CHIEF COMPLAINT: 

PRESENT ILLNESS: This is an 82-year-old gentleman
with past medical history of hypertension, COPD,
hypercholesterolemia, and diabetes, who presents with acute
onset of shortness of breath at 1 a.m. that morning without
chest pain, but with associated nausea and diaphoresis.  He
presented to an outside hospital.  Initial vital signs by the
EMTs showed him to be tachypneic with a respiratory rate of
28-30 and O2 saturations to 91% on nonrebreather and cyanotic
nailbeds were noted.  At the outside hospital Emergency
Department, he was given CPAP and his O2 saturation increased
to 97% with resolution of his cyanosis.

MEDICAL HISTORY: 1. COPD without baseline O2 requirement.
2. Hypertension.
3. Hypercholesterolemia.
4. History of hemoptysis with pneumonia in [**2096**].
5. Diabetes.
6. Status post cholecystectomy.
7. Asthma.
8. History of diverticulosis status post partial colonic
resection 25 years ago.
9. Status post appendectomy.

MEDICATION ON ADMISSION: Doses not listed.
1. Lipitor.
2. Cartia XL.
3. Cozaar.
4. Hydrochlorothiazide.
5. Aspirin.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: Patient has 120 pack year history of
cigarette smoking.  He stopped approximately 20 years ago.
He is a former insurance salesman.  He has a fiancee.  His
son lives in the area and is involved in his care.
Subendocardial infarction, initial episode of care,Hemorrhage of gastrointestinal tract, unspecified,Cardiac complications, not elsewhere classified,Cardiac arrest,Congestive heart failure, unspecified,Methicillin susceptible pneumonia due to Staphylococcus aureus,Coronary atherosclerosis of native coronary artery,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled
Subendo infarct, initial,Gastrointest hemorr NOS,Surg compl-heart,Cardiac arrest,CHF NOS,Meth sus pneum d/t Staph,Crnry athrscl natve vssl,DMII wo cmp nt st uncntr
Admission Date:  [**2103-2-26**]       Discharge Date:  [**2103-3-29**]


Service:  [**Hospital Unit Name 196**]

HISTORY OF PRESENT ILLNESS:  This is an 82-year-old gentleman
with past medical history of hypertension, COPD,
hypercholesterolemia, and diabetes, who presents with acute
onset of shortness of breath at 1 a.m. that morning without
chest pain, but with associated nausea and diaphoresis.  He
presented to an outside hospital.  Initial vital signs by the
EMTs showed him to be tachypneic with a respiratory rate of
28-30 and O2 saturations to 91% on nonrebreather and cyanotic
nailbeds were noted.  At the outside hospital Emergency
Department, he was given CPAP and his O2 saturation increased
to 97% with resolution of his cyanosis.

EKG at that time showed [**Street Address(2) 1766**] elevations in V1 and V2 and
V5 and V5 had ST depressions.  Initial laboratories showed a
white count of 26.5.  ABG of 7.42/43/263/27.  Cardiac enzymes
were as follows:  CK 201, troponin less than 0.1.  Patient
was given aspirin at home and at the outside hospital.  He
was transferred to [**Hospital3 **] for further evaluation and
management.

An echocardiogram was done on presentation, which showed an
ejection fraction of 30-35% and wall motion abnormalities
including basal mid inferior and inferolateral and septal
hypo and akinesis.  There is focal hypokinesis of the apical
free wall of the right ventricle.  Aortic regurgitation 1+.

PAST MEDICAL HISTORY:
1. COPD without baseline O2 requirement.
2. Hypertension.
3. Hypercholesterolemia.
4. History of hemoptysis with pneumonia in [**2096**].
5. Diabetes.
6. Status post cholecystectomy.
7. Asthma.
8. History of diverticulosis status post partial colonic
resection 25 years ago.
9. Status post appendectomy.

MEDICATIONS ON ADMISSION:  Doses not listed.
1. Lipitor.
2. Cartia XL.
3. Cozaar.
4. Hydrochlorothiazide.
5. Aspirin.

ALLERGIES:  No known drug allergies.

SOCIAL HISTORY:  Patient has 120 pack year history of
cigarette smoking.  He stopped approximately 20 years ago.
He is a former insurance salesman.  He has a fiancee.  His
son lives in the area and is involved in his care.

PHYSICAL EXAM ON ADMISSION:  Vital signs:  Temperature 99.2,
blood pressure 118/66, heart rate 78, respiratory rate 20, O2
requirement 99% on nonrebreather to 96% on 5 liters.
General:  Elderly male with productive cough, purulent yellow
sputum.  HEENT:  EOMI.  Anicteric sclerae.  Oropharynx clear.
Neck is supple.  No JVD.  Lungs:  Coarse breath sounds with
rhonchi and scattered basilar rales.  Heart:  Regular rate
and rhythm, normal S1, S2.  Abdomen is soft, nontender, and
nondistended, positive bowel sounds.  Lower extremities:
Trace edema bilaterally.

LABORATORY DATA:  White count 26.6, 93.2% neutrophils, 0
bands, 5% lymphocytes, 1.7% monocytes, hematocrit 38.1,
platelet count 272.  INR 1.2.  Urinalysis is significant for
30 protein, otherwise negative.  Electrolytes:  Sodium 136,
potassium 4.2, chloride 96, bicarbonate 29, BUN 23,
creatinine 1.0.  CK 257, MB 14, MB index of 5.4, troponin
8.15.

Chest x-ray:  New bibasilar patchy opacities, which represent
pneumonia or possibly atelectasis.

EKG on admission:  Normal sinus rhythm, modest nonspecific
ST-T wave changes, rate at 83.

Echocardiogram results as reported above.

HOSPITAL COURSE:
1. Cardiovascular:  With regard to the patient's coronary
artery disease and presentation with elevated troponins, was
taken to cardiac catheterization laboratory on hospital day
#2, where proximal and mid RCA were found to be diffusely
diseased with discrete 70% stenosis of the left main and 50
and 60% stenoses of the mid LAD and distal LAD respectively.
Final diagnosis included left main coronary artery disease,
moderate systolic and diastolic ventricular dysfunction.
Recommendations were for ongoing medical therapy for this
non-ST segment myocardial infarction.

Patient was initiated on appropriate medications for medical
therapy for myocardial infarction including [**First Name8 (NamePattern2) **] [**Last Name (un) **],
metoprolol, aspirin, Lipitor.  The patient had been continued
on Plavix until the point of catheterization as described
above.

On [**2-27**], the Cardiac Surgery team was consulted for
intervention in regard to the patient's left main disease.
Subsequently, the patient was prepared for CABG off bypass
pump.  A LIMA to LAD bypass graft was accomplished on [**3-6**].  Patient's postoperative course was complicated by
pneumonia.  Sputum was positive for MRSA.  Patient's
shortness of breath did persist throughout much of his
hospital stay.  It was thought that further intervention at
the left main site may benefit the patient's ongoing
shortness of breath.

On [**3-26**], the patient underwent second cardiac
catheterization, which is 60% left main, 70% mid left circ,
and 80% PDA stenoses were observed.  The LM lesion was
assessed with a pressure wire.  This evaluation was
complicated by dissection/occlusion of the left circumflex
requiring two stents to be placed subsequently.  When flow
returned to this region, patient did have an episode of V-fib
arrest, which did resolve with one electric cardioversion 200
joules.  Patient's left main and PDA stenoses were also
stented.

Patient had a subsequent echocardiogram on [**2103-3-28**],
which showed an ejection fraction greater than 60%, normal
left ventricle wall thickness, cavity size, and systolic
function, mild aortic stenosis.

Following the patient's catheterization that had a
complication of V-fib arrest on [**3-26**], he was noted to
be in AFib transiently post catheterization, and was
therefore started on a course of amiodarone, which was
discontinued on [**3-29**] due to concerns of pulmonary
toxicity.  The patient did remain in normal sinus rhythm and
had no significant ectopy on telemetry monitoring
subsequently.

Medical management of his coronary disease was continued with
aspirin, Plavix with the addition of atorvastatin on [**3-28**], losartan and metoprolol for rate control.  The patient
was continued on Lasix for evidence of mild fluid overload by
chest x-rays on multiple occasions during his hospital stay.
At the time of discharge, the patient was in normal sinus
rhythm, hemodynamically stable with ongoing mild shortness of
breath and decreasing oxygen requirement.

2. Respiratory:  Patient was continued on albuterol,
Atrovent, and Advair inhalers throughout his hospital stay.
Chest PT was recommended.  His postoperative course was
complicated by pneumonia and was treated with Zosyn and
vancomycin in addition to a short course of Flagyl.  Patient
did have an elevated white blood cell count, which did
resolve.  His sputum cultures did reveal MRSA.  Patient's O2
requirement did slowly decrease throughout his hospital stay.
At the time of this dictation, his O2 requirement had fallen
to 1 liter.

During his hospital course on [**3-13**], the patient was
seen by the Pulmonary service, who recommended continuing
Atrovent and albuterol nebulizers, encouragement of
ambulation, chest PT, incentive spirometry, gentle diuresis
for the management of his lung disease.  Pulmonary function
tests were obtained during his hospital stay, which showed a
severe obstructive ventilatory defect and a suggestion of a
concurrent restrictive process.  Reduced diffusion capacity
was also seen consistent with emphysema.

3. Type 2 diabetes:  Patient was continued on repaglinide and
regular insulin-sliding scale during his hospital stay.  The
[**Last Name (un) **] Diabetes team followed his management throughout his
hospital stay.

4. Renal:  Patient's renal function was normal at the time of
presentation and throughout much of his hospital stay by
[**3-28**], it did increase to 1.5.  Prerenal etiology was
suspected.  Patient did receive a unit of blood during that
night and at the time of this dictation, his renal function
was improving to 1.3.  This mild elevation in his creatinine
may have also been the result of contrast nephropathy given
his recent cardiac catheterization.

5. Fluids, electrolytes, and nutrition:  Patient was
continued on [**First Name8 (NamePattern2) **] [**Doctor First Name **] 2-gram sodium fluid restricted diet,
cardiac prudent.

6. Infectious disease:  Patient was noted to have a pneumonia
postoperatively.  He was treated with a course of Zosyn,
vancomycin, and Flagyl per recommendations of the Infectious
Disease team were consulted during the hospital stay, and the
patient's sputum culture did grow MRSA, which required the
use of vancomycin course for coverage.  His white count
trended to normal slowly during his hospital stay gradually
reaching a point of 9.9 on [**3-24**].  It did increase again
to 14.6 shortly after his catheterization, but at the time of
this dictation, it had fallen to 11.9.  Blood cultures drawn
throughout this hospital stay were without growth.  At the
time of this dictation, serial Clostridium difficile samples
were negative.  All urine cultures were without growth.

7. Hematology:  Patient did require transfusions of PRBCs on
two incidences during his hospital stay, [**3-7**] and [**3-28**].  The GI team was consulted in regard to his hematocrit,
which remained near 30 throughout much of his hospital stay.
The GI fellow recommended outpatient evaluation with
colonoscopy/EGD for further evaluation of a possible GI
source to his ongoing anemia.

8. Disposition:  Physical Therapy service was consulted
during the hospital stay.  They recommended rehabilitation.

DISCHARGE CONDITION:  Afebrile, hemodynamically stable,
asymptomatic.

DISCHARGE STATUS:  To rehabilitation.

DISCHARGE DIAGNOSES:
1. Myocardial infarction.
2. Hypercholesterolemia.
3. Hypertension.
4. Type 2 diabetes.
5. Severe chronic obstructive pulmonary disease.
6. Congestive heart failure.
7. Hyponatremia.
8. Anemia.
9. Ventricular fibrillation arrest.
10. Atrial fibrillation.
11. Renal failure.
12. Pneumonia.

DISCHARGE MEDICATIONS:
1. Atorvastatin 10 mg p.o. q.d.
2. Losartan 50 mg p.o. q.d.
3. Plavix 75 mg p.o. q.d. for nine months.
4. Miconazole powder 2% topical b.i.d. to the coccyx.
5. Furosemide 80 mg p.o. t.i.d.
6. Repaglinide 2 mg p.o. t.i.d. with meals.
7. Trazodone 25 mg p.o. h.s. prn.
8. Advair Diskus one puff inhaled b.i.d.
9. Docusate sodium 100 mg p.o. b.i.d.
10. Mucinex 1200 mg p.o. b.i.d.
11. Atrovent nebulizer one nebulizer q.6h.
12. Ranitidine 150 mg p.o. b.i.d.
13. Aspirin enteric coated 325 mg p.o. q.d.
14. Albuterol nebulizer one nebulizer inhaled q.6h.
15. Regular insulin-sliding scale.

DISCHARGE INSTRUCTIONS:  Patient should follow up with his
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1266**] in the next week and
should follow up with his cardiologist in [**7-7**] days.



                        [**Name6 (MD) **] [**Name8 (MD) **], M.D.  [**MD Number(1) **]

Dictated By:[**Last Name (NamePattern1) 1615**]
MEDQUIST36

D:  [**2103-3-29**]  10:28
T:  [**2103-3-29**]  10:28
JOB#:  [**Job Number 23593**]
{'Subendocardial infarction, initial episode of care,Hemorrhage of gastrointestinal tract, unspecified,Cardiac complications, not elsewhere classified,Cardiac arrest,Congestive heart failure, unspecified,Methicillin susceptible pneumonia due to Staphylococcus aureus,Coronary atherosclerosis of native coronary artery,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}


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: 

PRESENT ILLNESS: This is an 82-year-old gentleman
with past medical history of hypertension, COPD,
hypercholesterolemia, and diabetes, who presents with acute
onset of shortness of breath at 1 a.m. that morning without
chest pain, but with associated nausea and diaphoresis.  He
presented to an outside hospital.  Initial vital signs by the
EMTs showed him to be tachypneic with a respiratory rate of
28-30 and O2 saturations to 91% on nonrebreather and cyanotic
nailbeds were noted.  At the outside hospital Emergency
Department, he was given CPAP and his O2 saturation increased
to 97% with resolution of his cyanosis.

MEDICAL HISTORY: 1. COPD without baseline O2 requirement.
2. Hypertension.
3. Hypercholesterolemia.
4. History of hemoptysis with pneumonia in [**2096**].
5. Diabetes.
6. Status post cholecystectomy.
7. Asthma.
8. History of diverticulosis status post partial colonic
resection 25 years ago.
9. Status post appendectomy.

MEDICATION ON ADMISSION: Doses not listed.
1. Lipitor.
2. Cartia XL.
3. Cozaar.
4. Hydrochlorothiazide.
5. Aspirin.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: Patient has 120 pack year history of
cigarette smoking.  He stopped approximately 20 years ago.
He is a former insurance salesman.  He has a fiancee.  His
son lives in the area and is involved in his care. 

### Response:
{'Subendocardial infarction, initial episode of care,Hemorrhage of gastrointestinal tract, unspecified,Cardiac complications, not elsewhere classified,Cardiac arrest,Congestive heart failure, unspecified,Methicillin susceptible pneumonia due to Staphylococcus aureus,Coronary atherosclerosis of native coronary artery,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}
