CHIEF COMPLAINT: 

PRESENT ILLNESS: Mr. [**Known lastname **] is a [**Age over 90 **] year old male
with a past medical history of diabetes, hypertension,
coronary artery disease status post myocardial infarction,
chronic renal insufficiency who presented to [**Hospital6 1760**] on [**2166-4-7**] for
catheterization for management of a non-ST elevation
myocardial infarction.  He presented from an outside
hospital.  He initially presented to an outside hospital in
St. [**Doctor Last Name **] while on vacation with a left hip fracture.  While
at this outside hospital he flashed, having pulmonary edema
requiring intubation times one day.  There he ruled in for
myocardial infarction with a positive troponin.  He denied
chest pain, palpitations and loss of consciousness, only
positive for shortness of breath.  He presented to [**Hospital Unit Name 196**] on
[**2166-4-7**] and was catheterized on [**2166-4-9**].  Right
atrium 12, mean right ventricle 55/14, pulmonary airway
55/25, wedge 27, mid right coronary artery discrete 80%,
distal right coronary artery discrete 80%, both of these
lesions had percutaneous transluminal coronary angioplasty
and stent.  Left main diffusely diseased 70%, mid left
anterior descending discrete 100%, collateral from an right
posterior descending artery.  Distal left anterior descending
diffusely diseased, collateral from an right posterior
descending artery.  Proximal circumflex discrete 60% lesion.
Overall impression, three vessel coronary artery disease,
status post successful stenting times two of the right
coronary artery, moderate systolic biventricular dysfunction,
elevated systolic pressure.  Echocardiogram on [**2166-4-9**],
sinus rhythm, prior anteroseptal infarct, ST segment
depression in 2, 3, and AVF, ST flattening in 1 and AVL, rate
sinus at 85, prolonged at 160, QRS at 70, QTC 416, normal
axis.  Also on the note of the patient's cardiac
catheterization, cardiac output was 3.3, index was 2, SVR was
1891.

MEDICAL HISTORY: Notable for diabetes, 12 year history,
very brittle.  Hypertension.  Coronary artery disease with
the posterior anteroseptal myocardial infarction.  Chronic
renal insufficiency.  Distant seizure disorder, has not had
seizure for 40 years, status post prostatectomy, status post
right hip replacement, gastroesophageal reflux disease.

MEDICATION ON ADMISSION: Medications at home include
Atenolol, Altace, Dilantin, Zantac and Insulin.  Medications
on transfer to CCU were Aspirin 325 q.d., Lopressor 25
b.i.d., Captopril 6.25 b.i.d., Dilantin 200 q. AM, 100 q. PM,
Protonix 40 q.d., Percocet, regular insulin sliding scale and
Mucomyst 600 b.i.d. times two days, insulin Lente 16 units q.
AM.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: He is a former composer of music.  He lives
with his wife at [**Name (NI) 8**].
Acute myocardial infarction of other anterior wall, initial episode of care,Congestive heart failure, unspecified,Other convulsions,Closed fracture of intertrochanteric section of neck of femur,Diseases of tricuspid valve,Acute kidney failure, unspecified,Hyperpotassemia,Urinary tract infection, site not specified,Other and unspecified angina pectoris
AMI anterior wall, init,CHF NOS,Convulsions NEC,Intertrochanteric fx-cl,Tricuspid valve disease,Acute kidney failure NOS,Hyperpotassemia,Urin tract infection NOS,Angina pectoris NEC/NOS
Admission Date:  [**2166-4-7**]       Discharge Date:  [**2166-4-19**]


Service:

HISTORY OF PRESENT ILLNESS:  Mr. [**Known lastname **] is a [**Age over 90 **] year old male
with a past medical history of diabetes, hypertension,
coronary artery disease status post myocardial infarction,
chronic renal insufficiency who presented to [**Hospital6 1760**] on [**2166-4-7**] for
catheterization for management of a non-ST elevation
myocardial infarction.  He presented from an outside
hospital.  He initially presented to an outside hospital in
St. [**Doctor Last Name **] while on vacation with a left hip fracture.  While
at this outside hospital he flashed, having pulmonary edema
requiring intubation times one day.  There he ruled in for
myocardial infarction with a positive troponin.  He denied
chest pain, palpitations and loss of consciousness, only
positive for shortness of breath.  He presented to [**Hospital Unit Name 196**] on
[**2166-4-7**] and was catheterized on [**2166-4-9**].  Right
atrium 12, mean right ventricle 55/14, pulmonary airway
55/25, wedge 27, mid right coronary artery discrete 80%,
distal right coronary artery discrete 80%, both of these
lesions had percutaneous transluminal coronary angioplasty
and stent.  Left main diffusely diseased 70%, mid left
anterior descending discrete 100%, collateral from an right
posterior descending artery.  Distal left anterior descending
diffusely diseased, collateral from an right posterior
descending artery.  Proximal circumflex discrete 60% lesion.
Overall impression, three vessel coronary artery disease,
status post successful stenting times two of the right
coronary artery, moderate systolic biventricular dysfunction,
elevated systolic pressure.  Echocardiogram on [**2166-4-9**],
sinus rhythm, prior anteroseptal infarct, ST segment
depression in 2, 3, and AVF, ST flattening in 1 and AVL, rate
sinus at 85, prolonged at 160, QRS at 70, QTC 416, normal
axis.  Also on the note of the patient's cardiac
catheterization, cardiac output was 3.3, index was 2, SVR was
1891.

REVIEW OF SYSTEMS:  The patient reports stable exertional
angina over several years, relieved with nitroglycerin.  He
has occasional nocturnal angina.  He has been chest pain free
since arrival.  Positive for fatigue.

PAST MEDICAL HISTORY:  Notable for diabetes, 12 year history,
very brittle.  Hypertension.  Coronary artery disease with
the posterior anteroseptal myocardial infarction.  Chronic
renal insufficiency.  Distant seizure disorder, has not had
seizure for 40 years, status post prostatectomy, status post
right hip replacement, gastroesophageal reflux disease.

ALLERGIES:  No known drug allergies.

SOCIAL HISTORY:  He is a former composer of music.  He lives
with his wife at [**Name (NI) 8**].

MEDICATIONS ON ADMISSION:  Medications at home include
Atenolol, Altace, Dilantin, Zantac and Insulin.  Medications
on transfer to CCU were Aspirin 325 q.d., Lopressor 25
b.i.d., Captopril 6.25 b.i.d., Dilantin 200 q. AM, 100 q. PM,
Protonix 40 q.d., Percocet, regular insulin sliding scale and
Mucomyst 600 b.i.d. times two days, insulin Lente 16 units q.
AM.

PHYSICAL EXAMINATION:  Physical examination on presentation
to the CCU, the patient was lying in bed in no acute
distress.  Extraocular movements intact.  Pupils equal,
round, and reactive to light and accommodation.  No oral
lesions.  Jugulovenous distension, angle of the mandible.
Lungs clear to auscultation, anteriorly in the upper lung
fields, decreased breathsounds laterally.  The patient was
unable to sit forward secondary to pain from his hip
fracture.  He had regular rate and rhythm, S1 and S2.  He had
a high-pitched systolic ejection murmur at the left sternal
border.  Normoactive bowel sounds.  Soft, nontender,
nondistended.  +1 dorsalis pedis pulses, no cyanosis,
clubbing or edema.  He has a deformity of the right hand.
Groin, no hematoma or bruit. Cranial nerves III through XII
intact.  Alert and oriented times three.  Good strength in
all of his extremities except for a broken leg, unable to
move it secondary to leg pain.

LABORATORY DATA:  On [**2166-4-8**], he had hematocrit of 32,
white blood cell count of 12.5, hemoglobin 10.6, platelets
152, sodium 135, potassium 4.8, chloride 100, bicarbonate 22,
BUN 57, creatinine 2.2.  His baseline seems to be
approximately 1.9 to 2.1, magnesium 1.9, calcium 8.3,
phosphorus 4.2, ALT 51, AST 21, alkaline phosphatase 201,
total bilirubin .3, INR 1.1.  On [**2166-4-8**], showed
ejection fraction 25%, gradient 41 mm of mercury, right
atrium normal size, left ventricular wall thickness was
normal, left ventricular cavity size was normal.  Overall
left ventricular function is severely depressed.  No resting
systolic outflow obstruction.  Right ventricular chamber
size, free wall motion is normal.  +1 mitral regurgitation,
although the acoustic shadow, the severity of this may be
significantly underestimated, 2+ tricuspid regurgitation,
moderate pulmonary artery systolic hypertension.

HOSPITAL COURSE:  So, the patient is a [**Age over 90 **] year old male with
a past medical history of coronary artery disease,
hypertension, hyperlipidemia, diabetes, chronic renal
insufficiency who presents from an outside hospital with left
hip fracture, non-ST elevation myocardial infarction,
resulting in congestive heart failure and status post
extubation, status post catheterization showing increased
filling pressures and right coronary artery with stent times
two.

1.  Cardiology - Coronary artery disease, the patient had two
right coronary artery stents.  His left system was totally
occluded.  He fills collaterals from the right system from
the posterior descending artery.  The patient in the future
may benefit from left-sided intervention to open up the left
anterior descending as he is dependent on a stented vessel
for flow of both his left and right systems.  The patient
will follow up with Dr. [**Last Name (STitle) **] as an outpatient, his
cardiologist.  The patient was continued on Aspirin, Plavix.
He was initially on Lopressor b.i.d.  This was ramped up to
50 b.i.d. with improved control of his heartrate going from
high 80s to 90s to mid 70s.  The patient initially was on
6.25 of Captopril.  This was increased as high as 37.5 but
then discontinued and the patient experienced acute renal
failure, thought secondary to dye-induced nephropathy
approximately 48 hours after his cardiac catheterization.
The patient initially was on the Nitroglycerin and Integrilin
drip status post catheterization.  These both were turned off
by 18 hours after the catheterization.

Congestive heart failure, the patient initially presented
from the Catheterization Laboratory in congestive heart
failure with recent intubation with elevated jugulovenous
pressure, pulmonary capillary wedge pressure in
Catheterization Laboratory and bilateral pleural effusions
with an ejection fraction of 25%.  He was diuresed with
Lasix, initially printing out to 80 intravenously.  Blood
pressure was said to be fine, overloaded and eventually did
not respond to further increasing doses of Lasix until again
he had initial course complicated by acute renal failure.
The patient had dialysis times two which helped remove fluid
and improve his volume status, greatly improving the
congestive heart failure that he had been experiencing.

Rhythm, the patient was on telemetry.  He for the most part
had a normal sinus rhythm but in the contest of hyperkalemia
he had a wide complex rhythm with PTT waves, flattened Ps and
a prolonged PR interval.  The patient received four gm of
intravenous calcium gluconate, 30 mg of Kayexalate and
insulin drip which reduced his potassium from a level of 7.2
to 5.6 and resolving his electrocardiogram changes.  The
patient had hemodialysis later that day which further
improved his potassium levels as well as his acidosis and his
volume status.  As outpatient has mitral regurgitation and
tricuspid regurgitation as per his echocardiogram.

Renal - As stated previously above, the patient had renal
failure with his creatinine to 4.9, baseline is 2.2 and his
potassium going to 7.2.  The patient had bicarbonate of 15 as
well.  Renal saw the patient, it was felt that his renal
dysfunction was the result of dye-induced nephropathy.  The
patient had Quinton catheter placed at the bedside.  This
improved and he had dialysis through his catheter.  This
improved his creatinine to 3.3 with further improvement to
2.9 and then 1.9 being 1.9 the night before discharge without
dialysis.  The patient only had dialysis twice and had
improvement of his renal function with resolution of the
temporary dye-induced nephropathy.  The patient had received
intravenous fluids, Mucomyst peri-catheterization but still
had dye-induced nephropathy.

Heme - The patient had hematocrit on [**4-8**] of 32.  He had a
hematocrit drop from 29.6 to 21.5 on [**4-13**].  The patient
was guaiac negative times two.  Post having his dialysis
placed as well as internal jugular Swan-Ganz catheter placed,
he had computerized axial tomography scan of the abdomen and
chest which showed no retroperitoneal or mediastinal bleed.
The patient received 2 units of packed red blood cells and
increased his hematocrit to 29 and with dialysis the patient
then received 2 more units prior to his hip surgery as well
as dialysis to remove excess fluid with increase in his
hematocrit to 39.  This decreased to 27.5 two days
postoperatively and he received 1 unit of packed red blood
cells on the night prior to discharge.

Orthopedics - The patient was followed by the Orthopedics
Team and greatly appreciated.  The patient had a left open
reduction and internal fixation of his fractured hip.  On
[**4-15**], he had this surgery by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 9694**].  The
patient tolerated this surgery well.  Prior to his renal
failure he had been on Lovenox 40 mg subcutaneously q. day as
well as pneuma boots for deep vein thrombosis prophylaxis
with renal failure.  This was discontinued and he was started
on 5000 units of subcutaneous heparin t.i.d., status post the
surgery as per Dr. [**Last Name (STitle) 9694**].  The patient was started on a low
dose Coumadin 2 mg q.h.s. with a goal INR of 1.5 to 2.  When
he reaches his goal INR of 1.5, the subcutaneous heparin will
be discontinued.  The patient currently is undergoing
physical therapy here in the CCU.  He will require [**Hospital 5735**]
rehabilitation for improvement of his mobility.  He is able
to bear weight on his leg.

Anticoagulation - The patient has apical AK on his
echocardiogram with an ejection fraction of less than 25%,
however, this is secondary to an old anterior myocardial
infarction and not an acute event, therefore he would not
benefit from anticoagulation as thrombus prevention as this
is an old lesion and the risk is in the acute setting of an
anterior myocardial infarction.  As per above, the patient
will be receiving the low dose Coumadin for deep vein
thrombosis prophylaxis.

Diabetes - The patient was seen by the [**Hospital1 **] Service who
assisted in the management of his very brittle diabetes.  The
patient was on an insulin drip prior to his surgery and
postoperative finally able to be removed from the drip on
[**2166-4-17**].  He is on a sliding scale as per [**Hospital1 **], a
little higher levels of Humalog.  This will be accompanying
his discharge paperwork.  The patient also is on Lente, now
starting on [**4-18**] through [**4-23**] in AM.  This will be
titrated up to 20 as he requires insulin control.  At the
current time, he ranged between 71 and 343, being very
brittle.  I just hope with titration as above his AM dose of
Lente, we can get better control.

Neurological - The patient has a very distant seizure
history.  His Dilantin level was .16 after dialysis.  He was
reloaded with 1 gm p.o. Dilantin divided in three doses and
then placed back on his 200 q. AM, 100 q.h.s. Dilantin with
no seizure activity witnessed.

Prophylaxis - The patient received initially Lovenox then
switched to subcutaneous heparin t.i.d. with pneuma boot as
well as being changed to low dose Coumadin when the patient
is above an INR of 1.5.  His .................. will be
discontinued in favor of the low dose Coumadin, it is helpful
that the patient is beginning to ambulate with physical
therapy.  He is also on Protonix for gastrointestinal
prophylaxis.  He is a full code.

The patient had agitation at night and was tried on 1 mg p.o.
b.i.d. of Haldol, the patient was very sedated.  When his
Haldol as well as Morphine was discontinued his mental status
improved.   He had Percocet for pain control related to
physical therapy but the patient should not receive more than
one pill at a time unless in extreme pain as he has had
decreased mental status and somnolence with narcotics and
Haldol.

DISCHARGE DIAGNOSIS:
1.  Non-ST elevation myocardial infarction, right coronary
artery distribution, status post stenting times two to the
right coronary artery
2.  Left hip fracture, status post open reduction and
internal fixation
3.  Acute renal failure secondary to diabetes and dye-induced
nephropathy
4.  Urinary tract infection
5.  Delirium
6.  Hypertension
7.  Coronary artery disease
8.  Distant seizure disorder
9.  Gastroesophageal reflux disease

RECOMMENDED FOLLOW UP:  The patient should call [**First Name8 (NamePattern2) **] [**Doctor Last Name **]
for follow up appointment, [**Telephone/Fax (1) 22111**], the patient is to
see Dr. [**Last Name (STitle) **] within two weeks status post discharge of
surgical procedures or open reduction and internal fixation
of the left hip on [**2166-4-15**].  Insertion of right
internal jugular Swan-Ganz catheter and insertion of right
groin temporary dialysis catheter, discontinued after
hemodialysis times two.

DISCHARGE CONDITION:  Good.

DISCHARGE MEDICATIONS:  ([**Month (only) 116**] be addended the morning of
discharge, and Page 1 which accompanies the patient's chart
will be the final say on the patient's discharge medications)
1.  Protonix 40 mg q.d.
2.  Dilantin 200 mg q. AM, 100 mg q. PM
3.  Ampicillin for his urinary tract infection, this
enterococcus sensitive to Ampicillin, he is on 5 mg b.i.d.
for five days, status post discharge
4.  Metoprolol
5.  Lopressor 50 mg p.o. b.i.d.
6.  Plavix 70 mg q.d.
7.  Aspirin 325 mg q.d.
8.  Lipitor 10 mg q.d.
9.  Heparin 5000 units subcutaneous q. 8 hours, this can be
discontinued when the patient's INR is between 1.5 and 2 with
Coumadin
10. Warfarin 2 mg q.d., his INR should be monitored daily or
at the worst q.o.d.  The patient is on many drugs including
the antibiotics which can affect his INR level as well as a
changing p.o. intake which is thankfully recently improved,
however, his INR will be labile, most likely and will require
monitoring.
11. Senna 1 tablet p.o. b.i.d. prn
12. Colace 100 mg p.o. b.i.d.
13. Sarna lotion topical t.i.d. as needed for pruritus
14. Bisacodyl 10 mg p.o. or p.r. q.d. as needed for
constipation
15. Percocet 5/325 mg tablets one to two tablets q. 4-6
hours, please use gingerly as the patient can become
oversedated with narcotics
16. Lente, at the current time the patient will be receiving
20 units in the morning, he is on a Humalog sliding scale
which will accompany this discharge
17. Hydrocortisone cream one q.i.d. to affected areas
18. Acetaminophen 325 mg tablets one to two tablets q. 4
hours prn for pain or fever.



                            [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D.  [**MD Number(1) 1014**]

Dictated By:[**Last Name (NamePattern1) 1659**]
MEDQUIST36

D:  [**2166-4-18**]  20:26
T:  [**2166-4-18**]  20:59
JOB#:  [**Job Number 22112**]
{'Acute myocardial infarction of other anterior wall, initial episode of care,Congestive heart failure, unspecified,Other convulsions,Closed fracture of intertrochanteric section of neck of femur,Diseases of tricuspid valve,Acute kidney failure, unspecified,Hyperpotassemia,Urinary tract infection, site not specified,Other and unspecified angina pectoris'}


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: Mr. [**Known lastname **] is a [**Age over 90 **] year old male
with a past medical history of diabetes, hypertension,
coronary artery disease status post myocardial infarction,
chronic renal insufficiency who presented to [**Hospital6 1760**] on [**2166-4-7**] for
catheterization for management of a non-ST elevation
myocardial infarction.  He presented from an outside
hospital.  He initially presented to an outside hospital in
St. [**Doctor Last Name **] while on vacation with a left hip fracture.  While
at this outside hospital he flashed, having pulmonary edema
requiring intubation times one day.  There he ruled in for
myocardial infarction with a positive troponin.  He denied
chest pain, palpitations and loss of consciousness, only
positive for shortness of breath.  He presented to [**Hospital Unit Name 196**] on
[**2166-4-7**] and was catheterized on [**2166-4-9**].  Right
atrium 12, mean right ventricle 55/14, pulmonary airway
55/25, wedge 27, mid right coronary artery discrete 80%,
distal right coronary artery discrete 80%, both of these
lesions had percutaneous transluminal coronary angioplasty
and stent.  Left main diffusely diseased 70%, mid left
anterior descending discrete 100%, collateral from an right
posterior descending artery.  Distal left anterior descending
diffusely diseased, collateral from an right posterior
descending artery.  Proximal circumflex discrete 60% lesion.
Overall impression, three vessel coronary artery disease,
status post successful stenting times two of the right
coronary artery, moderate systolic biventricular dysfunction,
elevated systolic pressure.  Echocardiogram on [**2166-4-9**],
sinus rhythm, prior anteroseptal infarct, ST segment
depression in 2, 3, and AVF, ST flattening in 1 and AVL, rate
sinus at 85, prolonged at 160, QRS at 70, QTC 416, normal
axis.  Also on the note of the patient's cardiac
catheterization, cardiac output was 3.3, index was 2, SVR was
1891.

MEDICAL HISTORY: Notable for diabetes, 12 year history,
very brittle.  Hypertension.  Coronary artery disease with
the posterior anteroseptal myocardial infarction.  Chronic
renal insufficiency.  Distant seizure disorder, has not had
seizure for 40 years, status post prostatectomy, status post
right hip replacement, gastroesophageal reflux disease.

MEDICATION ON ADMISSION: Medications at home include
Atenolol, Altace, Dilantin, Zantac and Insulin.  Medications
on transfer to CCU were Aspirin 325 q.d., Lopressor 25
b.i.d., Captopril 6.25 b.i.d., Dilantin 200 q. AM, 100 q. PM,
Protonix 40 q.d., Percocet, regular insulin sliding scale and
Mucomyst 600 b.i.d. times two days, insulin Lente 16 units q.
AM.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: He is a former composer of music.  He lives
with his wife at [**Name (NI) 8**]. 

### Response:
{'Acute myocardial infarction of other anterior wall, initial episode of care,Congestive heart failure, unspecified,Other convulsions,Closed fracture of intertrochanteric section of neck of femur,Diseases of tricuspid valve,Acute kidney failure, unspecified,Hyperpotassemia,Urinary tract infection, site not specified,Other and unspecified angina pectoris'}
