CHIEF COMPLAINT: Transfer from [**Hospital3 3583**] for pacemaker
placement.

PRESENT ILLNESS: An 87-year-old female, with a
history of myocardial infarction one week ago, refusing PTCA
at that time, with a history of paroxysmal atrial
fibrillation and sick sinus syndrome, who has had recent
pauses of up to 12 seconds at an outside hospital.  She has
refused a pacemaker in the past and was discharged to rehab.
At rehab on the day prior to admission to [**Hospital3 3583**],
she had some shortness of breath, and was again admitted to
[**Hospital3 3583**] with an elevated troponin of 0.17.  As she
was agreeable for pacemaker placement, she was transferred to
[**Hospital1 **].  She has had an attempt at a previous
pacemaker placement that was complicated by an anomalous
superior vena cava.

MEDICAL HISTORY: 1. Systolic CHF with an ejection fraction of 30%.
2. Paroxysmal atrial fibrillation.
3. Sick sinus syndrome.
4. Anomalous vena cava.
5. Coronary artery disease.
6. Myocardial infarction.
7. Ischemic cardiomyopathy.
8. Hypertension.
9. History of coagulopathy.
10.Chronic bilateral pleural effusions.

MEDICATION ON ADMISSION: 1. Lipitor 10 mg qd.
2. Amiodarone 200 mg qd.
3. Imdur 30 mg in the am.
4. Aspirin 81 mg qd.
5. Metoprolol 25 mg [**Hospital1 **].
6. Lasix 20 mg [**Hospital1 **].

ALLERGIES: Penicillin.

PHYSICAL EXAM: 

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: The patient was transferred from [**First Name5 (NamePattern1) 46**] [**Last Name (NamePattern1) **].
She does not smoke and does not drink alcohol.
Sinoatrial node dysfunction,Congestive heart failure, unspecified,Unspecified pleural effusion,Acute myocardial infarction of unspecified site, initial episode of care,Anomaly of great veins, unspecified,Other opiates and related narcotics causing adverse effects in therapeutic use
Sinoatrial node dysfunct,CHF NOS,Pleural effusion NOS,AMI NOS, initial,Great vein anomaly NOS,Adv eff opiates
Admission Date:  [**2151-7-26**]       Discharge Date:  [**2151-8-2**]


Service:  C-MED

CHIEF COMPLAINT:  Transfer from [**Hospital3 3583**] for pacemaker
placement.

HISTORY OF PRESENT ILLNESS:  An 87-year-old female, with a
history of myocardial infarction one week ago, refusing PTCA
at that time, with a history of paroxysmal atrial
fibrillation and sick sinus syndrome, who has had recent
pauses of up to 12 seconds at an outside hospital.  She has
refused a pacemaker in the past and was discharged to rehab.
At rehab on the day prior to admission to [**Hospital3 3583**],
she had some shortness of breath, and was again admitted to
[**Hospital3 3583**] with an elevated troponin of 0.17.  As she
was agreeable for pacemaker placement, she was transferred to
[**Hospital1 **].  She has had an attempt at a previous
pacemaker placement that was complicated by an anomalous
superior vena cava.

PAST MEDICAL HISTORY:
1. Systolic CHF with an ejection fraction of 30%.
2. Paroxysmal atrial fibrillation.
3. Sick sinus syndrome.
4. Anomalous vena cava.
5. Coronary artery disease.
6. Myocardial infarction.
7. Ischemic cardiomyopathy.
8. Hypertension.
9. History of coagulopathy.
10.Chronic bilateral pleural effusions.

ALLERGIES:  Penicillin.

MEDICATIONS ON ADMISSION:
1. Lipitor 10 mg qd.
2. Amiodarone 200 mg qd.
3. Imdur 30 mg in the am.
4. Aspirin 81 mg qd.
5. Metoprolol 25 mg [**Hospital1 **].
6. Lasix 20 mg [**Hospital1 **].

FAMILY HISTORY:  Noncontributory.

SOCIAL HISTORY:  The patient was transferred from [**First Name5 (NamePattern1) 46**] [**Last Name (NamePattern1) **].
She does not smoke and does not drink alcohol.

EXAMINATION:  The patient was afebrile, heart rate 110, blood
pressure 128/70, respiratory rate 20, oxygen saturation 92%
on 2 liters.
GENERAL:  Alert, oriented, no acute distress.
HEENT:  Supple neck.  Pupils equal, round and reactive to
light.
CARDIOVASCULAR EXAM:  Irregularly irregular, tachycardic.
RESPIRATORY EXAM:  Decreased breath sounds at the bases to
half way up bilaterally.
ABDOMEN:  Soft, nontender, nondistended.
EXTREMITIES:  Weak distal pulses bilaterally.  Extremities
warm.  No edema.
NEUROLOGICAL EXAM:  Alert and oriented.  Strength slightly
weak but symmetric and equal throughout.  Cranial nerves II
through XII grossly intact bilaterally.

EKG:  Atrial fibrillation, rate 137, right bundle branch
block, borderline right axis deviation.  Some ST-T wave
changes in leads V1 and V2 that are nonspecific.

LABS ON ADMISSION:  White blood cell count 13.5, hematocrit
36.8, platelets 448, sodium 138, potassium 4.3, chloride 100,
bicarb 29, BUN 37, creatinine 0.8, glucose 135, CK 20, CK-MB
1.4, calcium 9.0, AST 21, ALT 36.

ECHOCARDIOGRAM:  Ejection fraction less than 20%.  Left
atrium dilated.  Left ventricle - severe global LV
hypokinesis.  Severely depressed LV systolic function.  2+
mitral regurgitation.  No pericardial effusion.

HOSPITAL COURSE - 1) ATRIAL FIBRILLATION, SICK SINUS
SYNDROME:  The patient was taken to the EP Lab for pacemaker
placement which was again complicated by her anomalous
superior vena cava.  A ventricular lead was placed.  However,
an atrial lead was not obtained.  The patient was continued
on telemetry and was found to have episodes of rapid atrial
fibrillation followed by compensatory pauses, at which time
ventricular pacing would begin.

The patient was continued on a beta blocker; however, she was
changed over to carvedilol 6.25 mg [**Hospital1 **].  She was started on
Coumadin for anticoagulation at a loading dose of 5 mg once,
followed by 3 mg q hs.  Her amiodarone was increased from 200
to 400 mg which should be continued for the first four weeks,
at which time she should be changed over to 200 mg qd.

2) RESPIRATORY FAILURE, HYPOXIA:  Upon return from the
Electrophysiology Lab, the patient was found to be hypoxic
with an oxygen saturation in the 60% range.  In addition, her
respiratory rate was found to be two breaths per minute at
that time.  She was placed on high flow nonrebreather mask
with 100% FIO2, and responded to verbal stimulation, began
taking more breaths.  At that time, she was transferred to
the Intensive Care Unit for her respiratory failure where she
was started on a nesiritide drip, in addition to lasix for
effective diuresis of her congestive heart failure.  Her
decreased respiratory rate and hypoxia were felt to be
secondary to oversedation after her pacemaker placement, as
well as some component of congestive heart failure.  She
diuresed quickly in the CCU on the nesiritide drip and was
transferred back to the cardiology floor where the nesiritide
drip was continued for three days.  After discontinuing the
nesiritide, the patient was started on lasix po.

3) PLEURAL EFFUSIONS:  The patient has had chronic bilateral
pleural effusions that were felt to be secondary to her
congestive heart failure.  The effusions appeared stable on
multiple chest x-rays on this admission, and it is felt that
over time, with diuresis, the effusions will slowly resolve.

4) CONGESTIVE HEART FAILURE:  The patient's ejection fraction
was found to be 15%, with severe systolic left ventricular
dysfunction.  The patient was diuresed with nesiritide drip,
as well as IV lasix, and was restarted on scheduled [**Hospital1 **] po
lasix.  She was also placed on 1 liter of fluid restriction
and a 2 gm sodium diet.  The patient was started on a
low-dose ACE inhibitor for her congestive heart failure.

5) CORONARY ARTERY DISEASE:  The patient was continued on her
daily aspirin, beta blocker and Lipitor, and an ACE inhibitor
was started.

6) DEPRESSION:  During her admission, the patient at one
point refused all blood draws, and refused to take all PO
medication.  This was discussed with medical staff, as well
as with the patient and her grandniece.  The patient
continued to insist on refusing PO medications and blood
draws, and psychiatry was consulted to evaluate the patient's
mental status and depressed mood.

7) CODE STATUS:  The patient clearly expressed her wishes to
be DO NOT RESUSCITATE and DO NOT INTUBATE.  Her grandniece
was present at that time who agreed that that was the
patient's wishes.

CONDITION AT DISCHARGE:  Stable.

DISCHARGE INSTRUCTIONS:  The patient's I's and O's and daily
weights should be measured.  The patient's lasix may need to
be increased if she is not slowly diuresing, or if she gains
a significant amount of weight.  The patient's INR should be
checked 2-3 days after discharge, as her Coumadin dose may
need to be adjusted; her goal INR is between 2.0 and 3.0.
The patient should follow-up with her primary care doctor
within 1 week, and should follow-up with her cardiologist
within 1-2 weeks.

DISCHARGE DIAGNOSES:
1. Paroxysmal atrial fibrillation.
2. Sick sinus syndrome.
3. Systolic congestive heart failure.
4. Respiratory failure.
5. Coronary artery disease.
6. Ischemic cardiomyopathy.
7. Hypertension.
8. Bilateral pleural effusion.
9. Depression.




                            [**Doctor First Name 900**] [**Name8 (MD) 901**], M.D.  [**MD Number(1) 2144**]

Dictated By:[**Last Name (NamePattern1) 51445**]
MEDQUIST36

D:  [**2151-8-2**]  10:12
T:  [**2151-8-2**]  09:13
JOB#:  [**Job Number 51446**]


Name:  [**Known lastname 9573**], [**Known firstname 1683**]         Unit No:  [**Numeric Identifier 9574**]

Admission Date:  [**2151-7-26**]     Discharge Date:  [**2151-8-6**]

Date of Birth:   [**2063-11-5**]     Sex:  F

Service:  [**Hospital Unit Name 319**]

HOSPITAL COURSE:
1. Congestive heart failure:  The patient was continued on
nesiritide drip until the day of discharge.  In addition, she
was treated with daily IV Lasix and started on five days of
Diamox therapy.  She continued to have negative fluid balance
daily and was comfortable on low flow oxygen on the day of
discharge with oxygen saturations in the mid 90s.  She should
continue to have her daily Lasix, and she should complete
four more days of Diamox therapy.  Please check her weights
daily and follow her potassium as Lasix may cause
hypokalemia.  Please continue her daily digoxin at 0.125 and
check her digoxin level in one week.

2. Fall:  The patient fell on [**8-4**], while trying to
wipe herself on the commode.  She hit her head on the floor
and had a 3 cm in diameter superficial hematoma on her left
parietal scalp.  She had a nonfocal neurological examination.
Head CT scan, C spine films, and hips and pelvis x-rays
showed no acute trauma.  The patient is weak after her
extended hospital stay, and will need Physical Therapy in
rehab.  She continues to have a nonfocal examination and is
cleared for discharge.

3. Bilateral pleural effusions:  The patient has had chronic
bilateral pleural effusions that were being treated with
aggressive diuresis.  The right effusion has improved during
her hospital, however, the left side has had an interval
increase in size.  The patient refused an inpatient
thoracentesis despite having all of the benefits explained to
her.  She should be asked again as an outpatient and should
call the Interventional Pulmonary Department at [**Hospital1 960**] to schedule an outpatient
thoracentesis if she changes her mind.

4. Swallowing:  The patient passed her swallowing study, but
should have her medications crushed in apple sauce as she
refuses to take them if they are not prepared in that way.

5. Depression:  The patient was seen by Psychiatry during
this admission as she was refusing po medications.  She was
seen and it was determined that she was not clinically
depressed at this time.  She responds well to attention and
should be engaged in conversation and group activities, and
rehab as much as possible.

6. Atrial fibrillation:  She should continue to take her
daily Coumadin and have her INR checked every 2-3 days
initially.  Her goal INR is 2.0-3.0.  She should continue to
take 400 mg po of amiodarone daily for the next four weeks.
At that time, her dose should be adjusted to 200 mg daily.
Please check LFTs every 2-3 months.

7. Code status:  The patient has clearly expressed her wishes
to be DNR/DNI.  The family members were present, were in
agreement.

DISCHARGE MEDICATIONS:
1. Lipitor 10 mg po daily.
2. Carvedilol 6.25 mg [**Hospital1 **].
3. Captopril 6.25 mg tid.
4. Lasix 20 mg IV once daily.
5. Acetazolamide 250 mg one tablet po q day.
6. Digoxin 125 mcg po daily.
7. Amiodarone 400 mg po daily for 28 days, and then decrease
the dose to 200 mg po daily.
8. Aspirin 81 mg po daily.
9. Warfarin 3 mg daily, please check the patient's INR three
days after discharge and adjust the Coumadin dose to have a
goal INR of 2.0-3.0.



                          [**Doctor First Name 1332**] [**Name8 (MD) 1333**], M.D.  [**MD Number(1) 1334**]

Dictated By:[**Last Name (NamePattern1) 5373**]

MEDQUIST36

D:  [**2151-8-6**]  18:35
T:  [**2151-8-9**]  10:52
JOB#:  [**Job Number 9575**]
{'Sinoatrial node dysfunction,Congestive heart failure, unspecified,Unspecified pleural effusion,Acute myocardial infarction of unspecified site, initial episode of care,Anomaly of great veins, unspecified,Other opiates and related narcotics causing adverse effects in therapeutic use'}


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: Transfer from [**Hospital3 3583**] for pacemaker
placement.

PRESENT ILLNESS: An 87-year-old female, with a
history of myocardial infarction one week ago, refusing PTCA
at that time, with a history of paroxysmal atrial
fibrillation and sick sinus syndrome, who has had recent
pauses of up to 12 seconds at an outside hospital.  She has
refused a pacemaker in the past and was discharged to rehab.
At rehab on the day prior to admission to [**Hospital3 3583**],
she had some shortness of breath, and was again admitted to
[**Hospital3 3583**] with an elevated troponin of 0.17.  As she
was agreeable for pacemaker placement, she was transferred to
[**Hospital1 **].  She has had an attempt at a previous
pacemaker placement that was complicated by an anomalous
superior vena cava.

MEDICAL HISTORY: 1. Systolic CHF with an ejection fraction of 30%.
2. Paroxysmal atrial fibrillation.
3. Sick sinus syndrome.
4. Anomalous vena cava.
5. Coronary artery disease.
6. Myocardial infarction.
7. Ischemic cardiomyopathy.
8. Hypertension.
9. History of coagulopathy.
10.Chronic bilateral pleural effusions.

MEDICATION ON ADMISSION: 1. Lipitor 10 mg qd.
2. Amiodarone 200 mg qd.
3. Imdur 30 mg in the am.
4. Aspirin 81 mg qd.
5. Metoprolol 25 mg [**Hospital1 **].
6. Lasix 20 mg [**Hospital1 **].

ALLERGIES: Penicillin.

PHYSICAL EXAM: 

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: The patient was transferred from [**First Name5 (NamePattern1) 46**] [**Last Name (NamePattern1) **].
She does not smoke and does not drink alcohol. 

### Response:
{'Sinoatrial node dysfunction,Congestive heart failure, unspecified,Unspecified pleural effusion,Acute myocardial infarction of unspecified site, initial episode of care,Anomaly of great veins, unspecified,Other opiates and related narcotics causing adverse effects in therapeutic use'}
