CHIEF COMPLAINT: Status post congestive heart failure
exacerbation requiring intubation.

PRESENT ILLNESS: This is a 75-year-old Caucasian
male with a history of congestive heart failure and moderate
to severe mitral regurgitation with worsening dyspnea on
exertion over the past week.  At baseline the patient climbs
24 stairs, but at that time could not complete this test.  He
was seen by his primary care physician on the morning of
admission with change from physical exam on week prior to
admission including increasing dyspnea and crackles.  At this
time, he was sent to the Emergency Department for further
evaluation.

MEDICAL HISTORY: 1.  Atrial fibrillation.  2.
Congestive heart failure with echocardiogram on [**2123-1-21**], showing mild regional left ventricular systolic
dysfunction, hypokinesis of the distal septum and apex, mild
AS, moderate to severe mitral regurgitation, and mild
pulmonary artery hypertension.  3.  Diabetes mellitus with
retinopathy and blindness, status post laser vitrectomy.  4.
Obesity.  5.  Blindness.  6.  Hypertension.

MEDICATION ON ADMISSION: Glucophage 1000 mg p.o. b.i.d.,
Amiodarone 200 mg p.o. q.d., Prinivil 30 mg p.o. q.d.,
Aspirin 325 mg p.o. q.d.

ALLERGIES: NO KNOWN DRUG ALLERGIES.

PHYSICAL EXAM: 

FAMILY HISTORY: Significant for father who had a myocardial
infarction and was obese.  Mother had cancer.

SOCIAL HISTORY: The patient has significant a smoking and
alcohol history; however, he quit smoking approximately three
years ago and quit alcohol approximately five years ago.  He
is retired and lives at home alone.
Rheumatic heart failure (congestive),Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Mitral valve insufficiency and aortic valve stenosis,Atrial fibrillation,Other chronic pulmonary heart diseases,Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled,Anemia, unspecified,Legal blindness, as defined in U.S.A.
Rheumatic heart failure,Acute respiratry failure,Food/vomit pneumonitis,Mitral insuf/aort stenos,Atrial fibrillation,Chr pulmon heart dis NEC,DMII ophth nt st uncntrl,Anemia NOS,Legal blindness-usa def
Admission Date:  [**2123-11-3**]       Discharge Date:  [**2123-11-9**]

Date of Birth:   [**2048-8-16**]       Sex:  M

Service:

CHIEF COMPLAINT:  Status post congestive heart failure
exacerbation requiring intubation.

HISTORY OF PRESENT ILLNESS:  This is a 75-year-old Caucasian
male with a history of congestive heart failure and moderate
to severe mitral regurgitation with worsening dyspnea on
exertion over the past week.  At baseline the patient climbs
24 stairs, but at that time could not complete this test.  He
was seen by his primary care physician on the morning of
admission with change from physical exam on week prior to
admission including increasing dyspnea and crackles.  At this
time, he was sent to the Emergency Department for further
evaluation.

He was sent to the East for further evaluation and
management.  He was given Lasix 40 mg IV x 1 and 20 mg IV x
3, Morphine 2 mg IV x 4, Aspirin, Lopressor 2.5 mg p.o. x 1,
and 5 mg IV x 2, and 1 sublingual Nitroglycerin.  Per note,
the patient put out 1200 cc in one hour.  Systolic blood
pressure decreased to 80 but was responsive to fluid bolus.
The patient became increasingly dyspneic.  He was intubated
for mechanical ventilation and transferred to the SICU/PACU
for further observation.  It was at this time that he was
transferred over to the West to the CCU for management.

In the CCU he was agitated and given 2 mg of IV Ativan x 2
and placed on Propofol drip.  His blood pressure decreased to
57/33 and responded poorly to IV bolus.  At this time, he was
placed on Dopamine drip with good result.

PAST MEDICAL HISTORY:  1.  Atrial fibrillation.  2.
Congestive heart failure with echocardiogram on [**2123-1-21**], showing mild regional left ventricular systolic
dysfunction, hypokinesis of the distal septum and apex, mild
AS, moderate to severe mitral regurgitation, and mild
pulmonary artery hypertension.  3.  Diabetes mellitus with
retinopathy and blindness, status post laser vitrectomy.  4.
Obesity.  5.  Blindness.  6.  Hypertension.

MEDICATIONS ON ADMISSION:  Glucophage 1000 mg p.o. b.i.d.,
Amiodarone 200 mg p.o. q.d., Prinivil 30 mg p.o. q.d.,
Aspirin 325 mg p.o. q.d.

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

FAMILY HISTORY:  Significant for father who had a myocardial
infarction and was obese.  Mother had cancer.

SOCIAL HISTORY:  The patient has significant a smoking and
alcohol history; however, he quit smoking approximately three
years ago and quit alcohol approximately five years ago.  He
is retired and lives at home alone.

PHYSICAL EXAMINATION:  General:  He was intubated and
sedated.  HEENT:  Pupils equal, round and reactive to light.
Cardiovascular:  Regular, rate and rhythm.  No rubs or
gallops.  There was a 3 out of 6 systolic murmur best heard
at the right upper sternal border and at the apex.  Lungs:
There were crackles bilaterally on anterior exam.  Abdomen:
Normoactive bowel sounds.  Nontender and nondistended.
Extremities:  Trace pretibial edema, right more than left.

LABORATORY DATA:  On admission white count 5.2, hematocrit
30.9, platelet count 189,000, differential with 75.5%
neutrophils, 15.5% lymphocytes, 5.5% monocytes, 2.5%
eosinophils, 0.9% basophils; PT on admission 12.3, PTT 27.2,
INR 1.1; CHEM7 revealed a sodium of 141, potassium 5.9,
chloride 108, bicarb 22, BUN 19, creatinine 1.1, blood sugar
157; urinalysis was negative with 30 proteins, 0-2 white
blood cells, few bacteria, 0-2 epis; CK #1 was 44, troponin
less than 0.3, CK #2 was 40, MB 3, troponin less than 0.3;
ALT 28, AST 37, alkaline phosphatase 93, total bilirubin 0.4,
total protein 6.8, albumin 3.6, ......... 3.2, calcium 9,
lactate 3.7; ABG prior to intubation was 7.23, 52, 72, ABG
shortly after intubation was 7.31, 47, 70.

Chest x-ray showed congestive heart failure with bilateral
pleural effusions.  Electrocardiogram showed ST depressions
and T-wave inversions in leads I and AVL, otherwise normal
sinus with left axis, heart rate 76, QS waves in V1-V3
suggesting possible old anterior myocardial infarction.

HOSPITAL COURSE:  As stated above the patient was transferred
to CCU for further observation and management.  He continued
to diurese well from the Lasix given to him earlier that day.
That night, central line access was attempted at the left
subclavian right IJ and left femoral areas.  Right femoral
access was finally completed.  Echocardiogram was completed
that night showing drastically reduced ejection fraction
around 20% and mild aortic stenosis.  He remained on Dopamine
throughout the night until the following morning.

1.  Coronary artery disease:  The patient ruled out for
myocardial infarction by serial CKs and flat troponins.  He
was placed on telemetry and started on Heparin; however,
after he ruled out for myocardial infarction, Heparin was
discontinued.  He was continued on his Aspirin.
The next morning, he received cardiac catheterization which
showed right atrial pressures of 13, right ventricular
pressure 50/12, pulmonary artery pressure 50/23, pulmonary
wedge 16, cardiac index 3, SVR [**2068**], PVR 427.  There was
three-vessel disease and a right dominant system.  The left
main was angiographically normal.  Left anterior descending
was totally occluded proximally with severely diffusely
disease distal vessel filling of the left circumflex and D1
collaterals.  The left circumflex had moderate diffuse
proximal disease, moderate diffuse marginal disease.  The
right coronary artery had a 70% ostial lesion with moderate
diffuse proximal ........... disease, 70% ostial posterior
descending artery stenosis, with sequential 90% stenosis
beyond the posterior descending artery.  There was also mild
aortic stenosis as noted from previous echocardiogram with
moderate left ventricular diastolic dysfunction.

During the intervening days, the patient was noted placed on
beta-blockers secondary to his blood pressure.  Instead, it
was felt that Amiodarone would have some beta-blocking
properties.  He was started on Lipitor on [**2123-11-9**],
with lipid panel pending.

From the catheterization results, it was determined that
medical management would be optimal.  CT Surgery was
consulted but did not want to operate at this time.

2.  Pump:  The patient underwent another echocardiogram on
the morning of [**2123-11-4**], showing overall left
ventricular systolic function severely depressed with severe
global left ventricular hypokinesis.  The following resting
regional left ventricular wall motion abnormalities were
seen:  Basal anterior hypokinesis, mid anterior hypokinesis,
basal anteroseptal hypokinesis, mid anteroseptal hypokinesis,
basal intraseptal hypokinesis, mid intraseptal hypokinesis,
basal inferior hypokinesis, mid inferior hypokinesis, mid
inferolateral hypokinesis, basal anterolateral hypokinesis,
mid anterolateral hypokinesis, anterior apex hypokinesis,
septal apex hypokinesis, inferior apex hypokinesis, lateral
apex hypokinesis, and apical hypokinesis.  Right ventricular
wall thickness was normal, as well as right ventricular
systolic function.  There was moderate aortic stenosis, 2+
mitral regurgitation, and no pericardial effusion.  The
mitral regurgitation was slightly less than in the study as
compared to previous studies from [**2122-12-28**].  Ejection
fraction was approximately 20%.

The patient continued to require Dopamine until the following
morning.  At that point, he was weaned off Dopamine and back
on his normal dose of Prinivil 30 mg p.o. q.d.; however, he
could not maintain normal blood pressure with this dose of
ACE inhibitor, and he was switched at this time to Captopril

6.25 mg p.o. t.i.d.  Unfortunately he could not maintain
blood pressure on this ACE inhibitor as well, and this was
discontinued.

The patient required intermittent use of pressors on the
morning of [**2123-11-6**]; however, this was weaned off
without difficulties.  The patient was finally placed back on
Captopril, and the dose was weaned up as tolerated.  The dose
at this time is 25 mg p.o. t.i.d.  The patient was started on
Digoxin on [**2123-11-7**], and is now on a dose of 0.125
mg p.o. q.o.d.

3.  Vascular:  The patient has a history of hypertension;
however, at this time, the hypertension was more of an issue.

Rhythm:  The patient was in normal sinus rhythm throughout.
He has a history of atrial fibrillation and was continued on
Amiodarone.

4.  Respiratory:  The patient was maintained on ventilation
from [**2123-11-3**], and was finally extubated on [**2123-11-3**].  Extubation was postponed secondary to profuse
thick, green sputum collection suctioned from his trach tube.
He had vomited on the night of [**2123-11-3**], after being
intubated.  Clindamycin was started on [**2123-11-5**], for
possible aspiration pneumonia.  Chest x-ray showed possible
retrocardiac infiltrate.  He was febrile to 101.6?????? with
increasing white blood cell count, and he was thus started on
Levaquin for additional gram-negative coverage.  Sputum
cultures grew out proteus and E. coli that were sensitive to
Levaquin.  He will be continued on Clindamycin and Levaquin
for a full 7-day course.

5.  Infectious disease:  The patient had 1 out of 4 blood
cultures from [**2123-11-4**], growing coag-negative
staphylococcus.  He was initially started on Vancomycin for
one day for possible Methicillin resistant Staphylococcus
aureus; however, this was discontinued upon firm speciation.

Renal:  The patient's creatinine was stable throughout.

6.  FEN:  The patient was NPO from [**2123-11-3**], to
[**2123-11-8**].  There was some question of possible
aspiration with water, but the patient did much better on a
thicker solution.  Nutrition was consulted, and they advised
to advance diet as tolerated to heart-healthy, [**Doctor First Name **] diet with
t.i.d. Ensure shakes.  Aspiration precautions were used
during this day.

7.  Lines:  The patient had a left radial arterial line and
right internal jugular access.  On [**2123-11-8**], he
pulled out the right IJ line, and no further central access
was attempted.

8.  Endocrine:  The patient was held NPO, and his daily
Glucophage was also held.  He was covered only with sliding
Insulin with q.i.d. fingersticks.  When he began to eat,
again Glucophage was decreased to 500 mg p.o. b.i.d.  His
hospital course at this time was significant for elevated
blood sugars up to 460.  He was covered with sliding scale
Insulin, and his Glucophage was increased to 1000 mg b.i.d.

DISPOSITION:  The patient was called out from the CCU on
[**2123-11-9**].  He will undergo Physical Therapy and
Occupational Therapy consult and likely go to rehabilitation
near [**Hospital1 **] where he lives.

DISCHARGE INSTRUCTIONS:  The patient will follow-up with Dr.
[**Last Name (STitle) 9671**] for diabetes.

DISCHARGE MEDICATIONS:  Glucophage 1000 mg p.o. b.i.d.,
Amiodarone 200 mg p.o. q.d., Digoxin 0.125 mg p.o. q.o.d.,
Aspirin 325 mg p.o. q.d., sliding scale Insulin, Lipitor 10
mg p.o. q.d., Tylenol 325-650 mg p.o. q.4-6 hours p.r.n.,
Clindamycin 450 mg p.o. q.i.d. until [**2123-10-12**],
Levaquin 500 mg p.o. q.d. until [**2123-11-14**], Colace 100
mg p.o. b.i.d., Senna [**12-29**] tab p.o. q.h.s. p.r.n., Captopril
current dose 25 mg p.o. t.i.d., as an outpatient should
titrate up to 50 mg p.o. t.i.d. per physician [**Name Initial (PRE) **].






                            [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 2057**]

Dictated By:[**Name8 (MD) 8073**]
MEDQUIST36

D:  [**2123-11-9**]  12:03
T:  [**2123-11-9**]  12:01
JOB#:  [**Job Number 19974**]


Name:  [**Known lastname 3329**], [**Known firstname **] J.                     Unit No:  [**Numeric Identifier 3330**]

Admission Date:  [**2123-11-3**]     Discharge Date:  [**2123-11-10**]

Date of Birth:   [**2048-8-16**]     Sex:  M

Service:

HOSPITAL COURSE:
Heme:  Mr. [**Known lastname **] was transfused two units of packed red
blood cells for a hematocrit of 26.8.  Hematocrit was
followed in the intervening days with no further need for
transfusion.

DISCHARGE INSTRUCTIONS:  Mr. [**Known lastname **] will also follow-up with
his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2118**].  A copy of this
discharge summary and the one previous should be forwarded to
Dr. [**Last Name (STitle) 2118**].

DISCHARGE MEDICATIONS:  Discharge medications will also
include, in addition to the ones stated before, Lasix 40 mg
po q day, Lopressor 12.5 mg po bid.



                          [**First Name8 (NamePattern2) 77**] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 715**]

Dictated By:[**Name8 (MD) 1037**]

MEDQUIST36

D:  [**2123-11-9**]  15:56
T:  [**2123-11-11**]  23:09
JOB#:  [**Job Number 3331**]

cc:[**Last Name (NamePattern4) 3332**]
{'Rheumatic heart failure (congestive),Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Mitral valve insufficiency and aortic valve stenosis,Atrial fibrillation,Other chronic pulmonary heart diseases,Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled,Anemia, unspecified,Legal blindness, as defined in U.S.A.'}


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: Status post congestive heart failure
exacerbation requiring intubation.

PRESENT ILLNESS: This is a 75-year-old Caucasian
male with a history of congestive heart failure and moderate
to severe mitral regurgitation with worsening dyspnea on
exertion over the past week.  At baseline the patient climbs
24 stairs, but at that time could not complete this test.  He
was seen by his primary care physician on the morning of
admission with change from physical exam on week prior to
admission including increasing dyspnea and crackles.  At this
time, he was sent to the Emergency Department for further
evaluation.

MEDICAL HISTORY: 1.  Atrial fibrillation.  2.
Congestive heart failure with echocardiogram on [**2123-1-21**], showing mild regional left ventricular systolic
dysfunction, hypokinesis of the distal septum and apex, mild
AS, moderate to severe mitral regurgitation, and mild
pulmonary artery hypertension.  3.  Diabetes mellitus with
retinopathy and blindness, status post laser vitrectomy.  4.
Obesity.  5.  Blindness.  6.  Hypertension.

MEDICATION ON ADMISSION: Glucophage 1000 mg p.o. b.i.d.,
Amiodarone 200 mg p.o. q.d., Prinivil 30 mg p.o. q.d.,
Aspirin 325 mg p.o. q.d.

ALLERGIES: NO KNOWN DRUG ALLERGIES.

PHYSICAL EXAM: 

FAMILY HISTORY: Significant for father who had a myocardial
infarction and was obese.  Mother had cancer.

SOCIAL HISTORY: The patient has significant a smoking and
alcohol history; however, he quit smoking approximately three
years ago and quit alcohol approximately five years ago.  He
is retired and lives at home alone. 

### Response:
{'Rheumatic heart failure (congestive),Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Mitral valve insufficiency and aortic valve stenosis,Atrial fibrillation,Other chronic pulmonary heart diseases,Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled,Anemia, unspecified,Legal blindness, as defined in U.S.A.'}
