CHIEF COMPLAINT: New onset of jaw and shoulder pain.

PRESENT ILLNESS: 67 year old male previously healthy until 5days ago when he
developed new onset bilateral jaw pain radiating to his arms,
lasting the the entire day. The following day he went to see his
PCP who sent him to the emergency room at MWMC. He ruled in for
NSTEMI. Trop 1.5. Cardiac catherization revealed coronary artery
disease and was transferred for surgical evaluation.

MEDICAL HISTORY: Tobacco

MEDICATION ON ADMISSION: Aspirin 325mg daily
plavix 300 mg (dose 7/23 only)

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Pulse: 74 Resp:  18 O2 sat: 99% on RA
B/P  Right:  127/66  Left:
Height:  74"   Weight: 103.6 kg

FAMILY HISTORY: None

SOCIAL HISTORY: Occupation:   stock portfolio manager
Lives with sister
[**Name (NI) 1139**]:  [**2-17**] PPD X 50 years - current smoker on admission
ETOH: none
Coronary atherosclerosis of native coronary artery,Cerebral embolism with cerebral infarction,Iatrogenic cerebrovascular infarction or hemorrhage,Hemiplegia, unspecified, affecting unspecified side,Atrial flutter,Unspecified protein-calorie malnutrition,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Constipation, unspecified,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms,Other alteration of consciousness,Foreign body in larynx,Foreign body accidentally entering other orifice,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism
Crnry athrscl natve vssl,Crbl emblsm w infrct,Iatrogen CV infarc/hmrhg,Unsp hemiplga unspf side,Atrial flutter,Protein-cal malnutr NOS,Abn react-anastom/graft,Constipation NOS,Oth gram negatv bacteria,Other alter consciousnes,Foreign body in larynx,FB entering oth orifice,Hypertension NOS,Hyperlipidemia NEC/NOS,Hypothyroidism NOS
Admission Date:  [**2125-9-9**]              Discharge Date:   [**2125-10-1**]

Date of Birth:  [**2058-6-10**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 165**]
Chief Complaint:
New onset of jaw and shoulder pain.

Major Surgical or Invasive Procedure:
[**2125-9-12**] - CABGx3(Left internal mammary artery->Left anterior
descending artery, Saphenous vein graft->Obtuse marginal artery,
Saphenous vein graft->Posterior descending artery)/Aortic Valve
Replacement(25mm [**Doctor Last Name **] Pericardial)/MV Repair(St. [**Male First Name (un) 923**] 32mm
saddle ring)
Cardioversion
[**2125-9-19**] PEG placement
[**2125-9-19**] Bronchoscopy
[**2125-9-26**] Tracheostomy #8 Portex
Cardioversion


History of Present Illness:
67 year old male previously healthy until 5days ago when he
developed new onset bilateral jaw pain radiating to his arms,
lasting the the entire day. The following day he went to see his
PCP who sent him to the emergency room at MWMC. He ruled in for
NSTEMI. Trop 1.5. Cardiac catherization revealed coronary artery
disease and was transferred for surgical evaluation.

Past Medical History:
Tobacco

Social History:
Occupation:   stock portfolio manager
Lives with sister
[**Name (NI) 1139**]:  [**2-17**] PPD X 50 years - current smoker on admission
ETOH: none


Family History:
None

Physical Exam:
Pulse: 74 Resp:  18 O2 sat: 99% on RA
B/P  Right:  127/66  Left:
Height:  74"   Weight: 103.6 kg

General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck:  Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x]  Irregular []  Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x]  bowel sounds
+ []
Extremities: Warm [x], well-perfused [x]  Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral      Right: +2 cath site  Left: +2
DP           Right:  +2 Left: +2
PT           [**Name (NI) 167**]: +2  Left:+2
Radial       Right:  +2 Left: +2

Carotid Bruit   none     Right: +2   Left:+2


Pertinent Results:
[**2125-9-12**] ECHO
Pre-CPB:
Patient had originally been planned as an off-pump CABG.
However, valve disorders were seen as significant enough to
warrant intervention.
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is mildly depressed
(LVEF= 45 - 50 %), with mild global free wall hypokinesis.
The aortic valve leaflets (3) are mildly thickened. Moderate
(2+) aortic regurgitation is seen.
There are non-mobile complex atheroma of the ascending and
descending aorta.
The mitral valve leaflets are mildly thickened. Severe (4+)
mitral regurgitation is seen.
There is no pericardial effusion.

Post- CPB:
The patient is AV-Paced and on low-dose NTG.
There is a mitral ring in placed with no MR. Residual mean
gradient = 3.
There is a prosthetic aortic valve with no leak and no AI.
Residual mean gradient = 13.
Good biventricular systolic fxn.
Aorta intact. Other parameters as pre-bypass.

[**2125-9-13**] Head CT

[**2125-9-20**] 02:41AM BLOOD WBC-20.6*# RBC-3.03* Hgb-9.6* Hct-29.8*
MCV-98 MCH-31.7 MCHC-32.3 RDW-13.7 Plt Ct-203
[**2125-9-9**] 03:26PM BLOOD WBC-9.7 RBC-3.95* Hgb-12.5* Hct-38.3*
MCV-97 MCH-31.5 MCHC-32.5 RDW-13.9 Plt Ct-140*
[**2125-9-20**] 02:41AM BLOOD PT-16.2* PTT-42.4* INR(PT)-1.4*
[**2125-9-9**] 03:26PM BLOOD PT-14.4* PTT-26.6 INR(PT)-1.2*
[**2125-9-20**] 02:41AM BLOOD Glucose-122* UreaN-32* Creat-1.2 Na-138
K-3.9 Cl-100 HCO3-26 AnGap-16
[**2125-9-9**] 03:26PM BLOOD Glucose-120* UreaN-22* Creat-0.9 Na-137
K-4.1 Cl-106 HCO3-21* AnGap-14
[**2125-9-30**] 03:19AM BLOOD WBC-14.3* RBC-2.51* Hgb-7.7* Hct-24.8*
MCV-99* MCH-30.5 MCHC-30.9* RDW-15.7* Plt Ct-201
[**2125-9-30**] 03:19AM BLOOD PT-21.5* PTT-33.6 INR(PT)-2.0*
[**2125-9-30**] 03:19AM BLOOD Glucose-120* UreaN-40* Creat-1.1 Na-148*
K-4.8 Cl-112* HCO3-29 AnGap-12

Brief Hospital Course:
He was admitted to the [**Hospital1 18**] for surgical management of his
coronary artery disease. He was worked-up in the usual
preoperative manner. As there was a positive Heparin Induced
Thrombocytopenia assay from [**Hospital6 1109**], a repeat
assay was obtained which was negative. A hematology consult was
obtained and he was cleared for surgery. On [**2125-9-12**], he taken to
the operating room were he underwent coronary artery bypass
grafting, aortic valve replacement, and a mitral valve repair.
Please see operative note for details. Postoperatively he was
taken to the intensive care unit for monitoring. He received
vancomycin for perioperative antibiotics because he was in the
hospital preoperatively.  On postoperative day one, left sided
weakness was noted, a CT scan was obtained which revealed a
right sided infarct. Neurology was consulted for assistance in
his care. He was extubated on post operative day two. dobhoff
was placed for nutrition due to loss of gaga and inability to
control secretions, speech therapy was consulted.  He had
episodes of atrial flutter that was treated with beta blockade,
amiodarone, calcium channel blockers and digoxin but unable to
control rate. EP was consulted for further management of atrial
flutter.  He was then cardioverted but within twenty four hours
returned to atrial flutter.   Reintubated electively for peg
placement at bedside and bronchoscopy was performed due to
secretions on post operative day seven, and he was extubated
after procedures complete.  He continued to be followed by
electrophysiology and medications were adjusted but he remained
in atrial flutter.  Repeat DCCV was performed on [**9-18**] with
conversion to NSR, in which he has remained.  Anticoagulation
was maintained for cardiac rhythm with heparin and coumadin.
His pulmonary status remained tenuous with his difficulty in
mobilizing thick, moderate to large amounts of secretions. On
[**9-25**] he was reintubated due to increased work of breathing and
the next day he had tracheostomy. Empiric antibiotics were
started for due to leukocytosis and secretions, and Infectious
disease was consulted.  All cultures negative except for sputum
which grew out rare growth Staph Aureus, coag +, gram negative
rods which is preliminary and urine with gram negative rods
~7000.  He received 8 days course of vancomycin and zosyn per
infections disease recommendations stopped [**10-1**].  He was started
on trach collar trials but requiring ventilator at night.
Physical therapy was consulted for strength and mobility.
Occupational therapy for work with left arm and leg.  On [**10-1**]
his tube feeds were adjusted due to free water deficit and water
added to tube feeds.  He was ready for discharge to rehab on
[**2125-10-1**].

Sternal incision healing no drainage no erythema, sternum stable

Left Leg EVH healing no erythema no drainage
Edema +1 lower extremity
Weight preoperative 103.8 kg  [**10-1**] - 97.2 kg
Neurologically alert, follows commands except left lower
extremity able to lift and hold off bed, left upper extremitiy
no movement when asked but has sponateously moved at times
Respiratory trach collar as tolerated but returns to ventilator
CPAP

Medications on Admission:
Aspirin 325mg daily
plavix 300 mg (dose 7/23 only)

Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous daily and PRN  as needed for line flush.
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. Temazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime) as needed for insomnia.
9. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. Ranitidine HCl 15 mg/mL Syrup Sig: One (1)  PO DAILY
(Daily).
11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Four (4) Puff Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
12. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day): while mechanically
ventilated.
13. Regular insulin Sliding Scale
Insulin SC Sliding Scale
  Q6H
Regular
Glucose Insulin Dose
0-60   mg/dL 4 oz. Juice
61-109   mg/dL 0   Units
110-130   mg/dL 3   Units
131-150   mg/dL 5   Units
151-180   mg/dL 7   Units
181-210   mg/dL 9   Units
211-240   mg/dL 11   Units
> 240   mg/dL Notify M.D.

14. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day:
please check INR monday, wednesday, and friday until on stable
dose - goal INR 2.0-2.5, medication adjustment with amidarone
and antibiotics in last few days that would effect INR level .
15. Outpatient Lab Work
please check CBC and Chem 7 weekly while in rehab

Please check sodium wednesday and friday this week to evaluate
free water deficit


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]

Discharge Diagnosis:
Coronary artery disease s/p CABG
Mitral Regurgitation s/p mitral valve repair
Aortic Insufficiency s/p AVR
right frontal infarction - acute stroke
Atrial fibrillation/flutter
Failed swallow with signs aspiration s/p PEG
Inability to manage secretions s/p tracheostomy
Acute renal failure
Non ST elevation myocardial infarction


Discharge Condition:
Good


Discharge Instructions:
1)  Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2)  Report any fever greater then 100.5.
3)  Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4)  No lotions, creams or powders to incision until it has
healed. 5) 5)  Please bathe daily and wash incisions with mild
soap and water, rinse with water and gently pat the wound dry.
6)  No bathing or swimming for 1 month. Use sunscreen on
incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks from date of
surgery.
6) No driving until cleared by PCP and cardiac [**Telephone/Fax (1) 5059**]
7) Call with any questions or concerns. [**Telephone/Fax (1) 170**]

Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **](for Dr. [**First Name (STitle) **] in 1 month at
[**Hospital1 **]  [**Telephone/Fax (1) 6256**]
Please follow-up with Dr. [**First Name (STitle) **] in [**2-16**] weeks.
Please follow-up with Dr. [**Last Name (STitle) 14334**] in [**3-20**] weeks.
Please follow up with Dr [**Last Name (STitle) **] (neurology) 3-4 weeks
Coumadin for atrial fibrillation with goal INR 2.0-2.5 - please
check INR monday - wednesday - friday until on stable dose and
with changes in amiodarone and discontinuation of antibiotics


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]

Completed by:[**2125-10-1**]
{'Coronary atherosclerosis of native coronary artery,Cerebral embolism with cerebral infarction,Iatrogenic cerebrovascular infarction or hemorrhage,Hemiplegia, unspecified, affecting unspecified side,Atrial flutter,Unspecified protein-calorie malnutrition,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Constipation, unspecified,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms,Other alteration of consciousness,Foreign body in larynx,Foreign body accidentally entering other orifice,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: New onset of jaw and shoulder pain.

PRESENT ILLNESS: 67 year old male previously healthy until 5days ago when he
developed new onset bilateral jaw pain radiating to his arms,
lasting the the entire day. The following day he went to see his
PCP who sent him to the emergency room at MWMC. He ruled in for
NSTEMI. Trop 1.5. Cardiac catherization revealed coronary artery
disease and was transferred for surgical evaluation.

MEDICAL HISTORY: Tobacco

MEDICATION ON ADMISSION: Aspirin 325mg daily
plavix 300 mg (dose 7/23 only)

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Pulse: 74 Resp:  18 O2 sat: 99% on RA
B/P  Right:  127/66  Left:
Height:  74"   Weight: 103.6 kg

FAMILY HISTORY: None

SOCIAL HISTORY: Occupation:   stock portfolio manager
Lives with sister
[**Name (NI) 1139**]:  [**2-17**] PPD X 50 years - current smoker on admission
ETOH: none 

### Response:
{'Coronary atherosclerosis of native coronary artery,Cerebral embolism with cerebral infarction,Iatrogenic cerebrovascular infarction or hemorrhage,Hemiplegia, unspecified, affecting unspecified side,Atrial flutter,Unspecified protein-calorie malnutrition,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Constipation, unspecified,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms,Other alteration of consciousness,Foreign body in larynx,Foreign body accidentally entering other orifice,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism'}
