CHIEF COMPLAINT: coronary artery disease

PRESENT ILLNESS: This 78 year old white male was being evaluated for claudication
and revascularization of his left leg.  During this workup he
was found to have an abnormal stress test and a catheterization
revealed significant double vessel disease.  he was referrred
for coronary revascularization, but had been given Plavix.  He
was admitted and begun on Heparin to allow clearance of the
Plavix.

MEDICAL HISTORY: Peripheral vascular disease
chronic renal insufficiency
s/p right carotid endarterectomy
hyperlipidemia
hypertension
renal artery stenosis

MEDICATION ON ADMISSION: Lisinopril 20mg/D,Plavix 75mg/D,ASA81,Zocor 20mg/D, ToprolXL
25mg/D

ALLERGIES: Latex

PHYSICAL EXAM: T 97.8  BP 139/68  HR 72  RR 20  96% RA  70.4 KG
Neuro: non-focal
Pulmonary: Lungs clear to auscultation bilaterally
Cardiac: regular rate and rhythm.
Sternal incision: sternum stable. No erythema or drainage.
Abdomen: soft and nontender without rebound or guarding.
Normoactive bowel sounds
Extremities: warm with 1+ edema

FAMILY HISTORY: No family history of early coronary artery disease or peripheral
vascular disease.

SOCIAL HISTORY: Ex-smoker having quit 25 years ago. Retired engineer. Lives at
home with his wife, Drinks 3-4 [**Name2 (NI) 17963**] a week.
Coronary atherosclerosis of native coronary artery,Pulmonary collapse,Atherosclerosis of renal artery,Tobacco use disorder,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Other iatrogenic hypotension
Crnry athrscl natve vssl,Pulmonary collapse,Renal artery atheroscler,Tobacco use disorder,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Iatrogenc hypotnsion NEC
Admission Date:  [**2124-8-18**]              Discharge Date:   [**2124-8-28**]

Date of Birth:  [**2046-8-3**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Latex

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
coronary artery disease

Major Surgical or Invasive Procedure:
Coronary artery bypass grafts x 3(LIMA-LAD, SVG-RCA,SVG-Cx)


History of Present Illness:
This 78 year old white male was being evaluated for claudication
and revascularization of his left leg.  During this workup he
was found to have an abnormal stress test and a catheterization
revealed significant double vessel disease.  he was referrred
for coronary revascularization, but had been given Plavix.  He
was admitted and begun on Heparin to allow clearance of the
Plavix.

Past Medical History:
Peripheral vascular disease
chronic renal insufficiency
s/p right carotid endarterectomy
hyperlipidemia
hypertension
renal artery stenosis

Social History:
Ex-smoker having quit 25 years ago. Retired engineer. Lives at
home with his wife, Drinks 3-4 [**Name2 (NI) 17963**] a week.

Family History:
No family history of early coronary artery disease or peripheral
vascular disease.

Physical Exam:
T 97.8  BP 139/68  HR 72  RR 20  96% RA  70.4 KG
Neuro: non-focal
Pulmonary: Lungs clear to auscultation bilaterally
Cardiac: regular rate and rhythm.
Sternal incision: sternum stable. No erythema or drainage.
Abdomen: soft and nontender without rebound or guarding.
Normoactive bowel sounds
Extremities: warm with 1+ edema

Pertinent Results:
Date of Birth:  [**2046-8-3**]        Sex:  M

Surgeon:  [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 6477**]

PREOPERATIVE DIAGNOSIS:  Coronary artery disease.

POSTOPERATIVE DIAGNOSIS:  Coronary artery disease.

PROCEDURE PERFORMED:  Coronary artery bypass grafting x3:
Left internal mammary artery grafted to the left anterior
descending with reverse saphenous vein graft to the posterior
descending artery and reverse saphenous vein graft to first
diagonal branch.

ASSISTANT:  [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 80112**], MD

ANESTHESIA:  General endotracheal anesthesia.

CLINICAL NOTE:  Mr. [**Known firstname 1726**] [**Known lastname **] is a 78-year-old male with
symptoms of chest tightness, shortness of breath, status post
right carotid endarterectomy, and known with peripheral
vascular disease with claudication and hypertension. He
underwent catheterization that showed severe 2-vessel disease
presenting for revascularization.

DESCRIPTION OF PROCEDURE:  After adequate anesthesia was
achieved and with the patient supine, he was prepped and
draped in the usual sterile manner. Median sternotomy was
performed through which the pericardium was exposed. The left
internal mammary artery was taken down to the level of the
left subclavian vein and divided distally after heparin was
given. Saphenous vein was harvested from the right lower
extremity using endoscopic vein harvesting system and
prepared in the usual fashion. The pericardium was exposed.
The patient was then heparinized. The ascending aorta was
cannulated with a soft-flow ascending aortic cannula. Three
stage venous cannula was placed through the right atrial
appendage. Retrograde coronary sinus cannula was placed
through the right atrial wall. He was placed on bypass and
the aorta was crossclamped. The heart was arrested with cold
antegrade blood cardioplegia followed by multiple retrograde
doses. The posterior descending artery was a small vessel but
was grafted to a segment of vein in end-to-side fashion with
running 7-0 Prolene. The first diagonal branch of the LAD was
a good size branch that was similarly grafted. The left
anterior descending artery was grafted to the mammary artery
in end-to-side fashion with a good size left internal mammary
artery. With the crossclamp in place, the 2 main grafts were
fashioned to the ascending aorta. Two punch aortotomies with
running 6-0 Prolene. Warm cardioplegia was given retrograde.
The crossclamp was released with the patient's head down
while de-airing the root. The grafts were de-aired and open
to flow. Epicardial pacing wires were placed. He was weaned
off bypass, decannulated after protamine administration and
once the field was dry, 1 left pleural and 2 mediastinal
tubes were left in place. The sternotomy was closed with
heavy steel wires and the presternal layers were closed with
Vicryl sutures. The skin was closed with subcuticular
closure. Dry dressing was applied. He tolerated the procedure
well and left the OR in stable condition.

                        [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]

Dictated By:[**Last Name (NamePattern4) 80113**]
[**Last Name (LF) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**]  Status: Inpatient DOB: [**2046-8-3**]
Age (years): 78 M  Hgt (in):
BP (mm Hg): /  Wgt (lb):
HR (bpm):  BSA (m2):
Indication: Intraop TEE for CABG
ICD-9 Codes: 402.90, 786.05, 786.51, 440.0
Test Information
Date/Time: [**2124-8-22**] at 13:21    Interpret MD: [**Name6 (MD) 928**]
[**Name8 (MD) 929**], MD, MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3319**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW2-: Machine: 2
Echocardiographic Measurements
Results  Measurements  Normal Range
Left Ventricle - Septal Wall Thickness:  1.1 cm  0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness:  1.0 cm  0.6 - 1.1 cm

Left Ventricle - Diastolic Dimension:  4.7 cm  <= 5.6 cm
Left Ventricle - Ejection Fraction:  35% to 40%  >= 55%
Aorta - Annulus:  2.0 cm  <= 3.0 cm
Aorta - Sinus Level:  2.8 cm  <= 3.6 cm
Aorta - Sinotubular Ridge:  2.4 cm  <= 3.0 cm
Aorta - Ascending:  2.4 cm  <= 3.4 cm
Aorta - Descending Thoracic:  2.2 cm  <= 2.5 cm
Aortic Valve - LVOT diam:  1.7 cm
Aortic Valve - Pressure Half Time:  143 ms

Findings
LEFT ATRIUM: Mild LA enlargement.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Lipomatous hypertrophy of the
interatrial septum. No ASD by 2D or color Doppler.

LEFT VENTRICLE: Normal LV cavity size. Moderate regional LV
systolic dysfunction.

RIGHT VENTRICLE: Mild global RV free wall hypokinesis.

AORTA: Normal ascending aorta diameter. Simple atheroma in
aortic arch. Complex (>4mm) atheroma in the descending thoracic
aorta.

AORTIC VALVE: Normal aortic valve leaflets (3). Mild to moderate
([**11-24**]+) AR.

MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.

TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.

PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.

GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient. See Conclusions for post-bypass data
The post-bypass study was performed while the patient was
receiving vasoactive infusions (see Conclusions for listing of
medications).

REGIONAL LEFT VENTRICULAR WALL MOTION:





     N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-BYPASS:
1. The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler.
2. The left ventricular cavity size is normal. There is moderate
regional left ventricular systolic dysfunction with anterior,
antero-septal and antero-lateral hypokinesis.
3. There are simple atheroma in the aortic arch. There are
complex (>4mm) atheroma in the descending thoracic aorta.
4. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. Mild to moderate ([**11-24**]+) aortic
regurgitation is seen.
5. The mitral valve leaflets are structurally normal. Mild (1+)
mitral regurgitation is seen.

Dr. [**Last Name (STitle) **] was notified in person of the results.

POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and is
being AV paced.
1. Biventricular function is unchanged.
2. Aorta is intact post decannulation.
3. Other findings are unchanged.
  I certify that I was present for this procedure in compliance
with HCFA regulations.

Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD,
Interpreting physician [**Last Name (NamePattern4) **] [**2124-8-22**] 14:20

[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2124-8-26**] SCHED
CHEST (PORTABLE AP)   Clip # [**Clip Number (Radiology) 80114**]
Reason: f/u atx, effusion



[**Hospital 93**] MEDICAL CONDITION:
   78 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
   f/u atx, effusion



Provisional Findings Impression: JRld SAT [**2124-8-26**] 8:33 PM
Increased bibasilar atelectasis more so in the left. Increased
bilateral
pleural effusions more so in the left.


Final Report
REASON FOR EXAM: Status post CABG, assess pleural effusion.

Comparison is made with prior study performed [**2124-8-23**].

Bibasilar atelectasis worse in the left side have increased.
Small bilateral
pleural effusions worse in the left side have also increased.
There is no
CHF. Cardiomediastinal silhouette is unchanged. Sternal wires
are aligned.

DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Approved: SUN [**2124-8-27**] 2:22 PM



Brief Hospital Course:
78 year old male who was transferred to [**Hospital1 18**] on [**2124-8-18**] for
CABG. He was being evaluated prior to Left fem-[**Doctor Last Name **] bypass. He
had failed a persantine-ett and cath showed severe ostial LAD
disease and 60% RCA disease.  He was brought to the OR with Dr
[**Last Name (STitle) **] on [**2124-8-22**] for 3-vessesl CAD (LIMA-LAD, SVG-D1,
SVG-PDA).  Please see operative report for full details.
Post-operatively he was transferred to the CVICU for invasive
monitoring.
Patient was noted to be in a junctional rhythm on POD 3 and
nodal blocking agents were held.  As a result, he was NOT
restarted on beta blockers.
He was transferred to the step down floor on post-op day 4. He
remained in sinus rhythm from post-op day 4 to discharge. He was
evaluated by PT and cleared to be discharged to home.

Medications on Admission:
Lisinopril 20mg/D,Plavix 75mg/D,ASA81,Zocor 20mg/D, ToprolXL
25mg/D

Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 5
days.
Disp:*10 Tablet(s)* Refills:*0*
5. Potassium Chloride 20 mEq Packet Sig: Two (2) Packet PO Q12H
(every 12 hours) for 5 days.
Disp:*20 Packet(s)* Refills:*0*
6. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Please take this as long as you take the narcotic
pain medicine.
Disp:*60 Capsule(s)* Refills:*0*
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 11485**] VNA

Discharge Diagnosis:
Coronary artery disease
s/p coronary artery bypass grafting
hypertension
peripheral vascular disease
s/p right carotid endarterectomy
hyperlipidemia
chronic renal insufficiency
renal artery stenosis


Discharge Condition:
good


Discharge Instructions:
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
shower daily, no baths or swimming
no lotions, creams or powders to incisions
report any fever greater than 100.5
report any redness or drainage from incisions
take all medications as directed

Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr [**Last Name (STitle) **] [**Last Name (STitle) **] [**12-26**] weeks
Dr [**Last Name (STitle) 17025**] 2 weeks



Completed by:[**2124-8-28**]

Name:  [**Known lastname **],[**Known firstname **] W.                 Unit No:   [**Numeric Identifier 12884**]

Admission Date:  [**2124-8-18**]              Discharge Date:   [**2124-8-28**]

Date of Birth:  [**2046-8-3**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Latex

Attending:[**First Name3 (LF) 741**]
Addendum:
As per patient request, T#3 prescription was not given. Darvocet
tabs 50/325 mg, 1/2 tabs po q 4hprn pain, dispensed #45 was
administered.

Discharge Disposition:
Home With Service

Facility:
[**Hospital1 12885**] VNA

                             [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]

Completed by:[**2124-8-28**]
{'Coronary atherosclerosis of native coronary artery,Pulmonary collapse,Atherosclerosis of renal artery,Tobacco use disorder,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Other iatrogenic hypotension'}


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: coronary artery disease

PRESENT ILLNESS: This 78 year old white male was being evaluated for claudication
and revascularization of his left leg.  During this workup he
was found to have an abnormal stress test and a catheterization
revealed significant double vessel disease.  he was referrred
for coronary revascularization, but had been given Plavix.  He
was admitted and begun on Heparin to allow clearance of the
Plavix.

MEDICAL HISTORY: Peripheral vascular disease
chronic renal insufficiency
s/p right carotid endarterectomy
hyperlipidemia
hypertension
renal artery stenosis

MEDICATION ON ADMISSION: Lisinopril 20mg/D,Plavix 75mg/D,ASA81,Zocor 20mg/D, ToprolXL
25mg/D

ALLERGIES: Latex

PHYSICAL EXAM: T 97.8  BP 139/68  HR 72  RR 20  96% RA  70.4 KG
Neuro: non-focal
Pulmonary: Lungs clear to auscultation bilaterally
Cardiac: regular rate and rhythm.
Sternal incision: sternum stable. No erythema or drainage.
Abdomen: soft and nontender without rebound or guarding.
Normoactive bowel sounds
Extremities: warm with 1+ edema

FAMILY HISTORY: No family history of early coronary artery disease or peripheral
vascular disease.

SOCIAL HISTORY: Ex-smoker having quit 25 years ago. Retired engineer. Lives at
home with his wife, Drinks 3-4 [**Name2 (NI) 17963**] a week. 

### Response:
{'Coronary atherosclerosis of native coronary artery,Pulmonary collapse,Atherosclerosis of renal artery,Tobacco use disorder,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Other iatrogenic hypotension'}
