CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 69-year-old
male with dilated cardiomyopathy with an ejection fraction of
approximately 10%, who presented with worsening orthopnea and
dyspnea.  He has had multiple recent admissions to the
Cardiovascular service.  In [**2134-4-14**], he was admitted with
complete heart block and a DDD pacemaker was placed.  Earlier
this month, in [**2134-5-15**], he was readmitted with acute
renal failure, hyperkalemia, and hypotension.  He was
transiently in the Coronary Care Unit on dopamine for one day
before being transferred to the floor when his heart failure
medications were gradually added back on.  He was just
discharged on [**2134-5-19**].  He has been followed closely by
his cardiologist, Dr. [**First Name (STitle) 2031**], who had been able to increase
his lasix back to his previous outpatient dose of 80 mg by
mouth twice a day.  Enalapril had been continued at 10 mg by
mouth once daily and Toprol XL had been held.  Today he
complains of dyspnea on exertion and progressive orthopnea
for the last three to five days.  He has had increasing
peripheral edema but, over the last two or three days, he
thinks this has improved.  His weight was 191 pounds
yesterday, although he claims his dry weight is approximately
180 pounds.  He felt extremely fatigued.  No fevers, chills,
nausea, vomiting or diarrhea.  No recent antibiotic use. No
dysuria, no chest pain.  He did have paroxysmal nocturnal
dyspnea and a mild cough.  He admitted to a decreased
appetite.  Because of his feeling generally unwell, he called
his niece to bring him into the Emergency Room.

MEDICAL HISTORY: 1.  Dilated cardiomyopathy, likely ethanol-induced; ejection
fraction of approximately 10%.  An echocardiogram in [**2134-5-15**] showed an ejection fraction of less than 20%, superior
left ventricular dilation, severe global right ventricular
and left ventricular hypokinesis, 3+ mitral regurgitation,
and 2+ tricuspid regurgitation.
2.  Coronary artery disease, although he had a normal cardiac
catheterization in [**2128**]
3.  Noninsulin dependent diabetes mellitus
4.  Asthma
5.  Complete heart block status post DDD pacemaker in [**2134-5-15**]
6.  Tophaceous gout, recently in the fourth toe on the left
foot
7.  Chronic renal insufficiency progressing to acute renal
failure in [**2134-5-15**], now resolved.  His baseline
creatinine is approximately 1.5 to 2.0.

MEDICATION ON ADMISSION: K-Dur 20 mEq by mouth once daily,
Vasotec 10 mg by mouth once daily, Coumadin 3 mg by mouth
once daily, Colace 100 mg by mouth once daily, lasix 80 mg by
mouth twice a day, aspirin 325 mg by mouth once daily,
Atrovent inhaler two puffs inhaled four times a day,
amiodarone 400 mg by mouth once daily, Toprol XL 12.5 mg by
mouth once daily that was on hold, Glyburide 10 mg by mouth
twice a day.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: He is a former iron worker, now retired. He
lives next door to his niece, who is his closest relative.
[**Name (NI) **] denies smoking or current drinking.  The niece's phone
number is [**Telephone/Fax (1) 108018**], name [**First Name4 (NamePattern1) **] [**Known lastname 11752**].
Congestive heart failure, unspecified,Alcoholic cardiomyopathy,Infection and inflammatory reaction due to other vascular device, implant, and graft,Other staphylococcal septicemia,Gouty tophi of other sites, except ear,Unspecified disorder of kidney and ureter,Coronary atherosclerosis of native coronary artery,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Asthma, unspecified type, unspecified
CHF NOS,Alcoholic cardiomyopathy,React-oth vasc dev/graft,Staphylcocc septicem NEC,Gouty tophi site NEC,Renal & ureteral dis NOS,Crnry athrscl natve vssl,DMII wo cmp nt st uncntr,Asthma NOS
Admission Date:  [**2134-5-30**]       Discharge Date:

Date of Birth:   [**2065-5-24**]       Sex:  M

Service:  CCU

Please note that this is an initial discharge summary that
will have an associated addendum dictated at a later time.

HISTORY OF PRESENT ILLNESS:  The patient is a 69-year-old
male with dilated cardiomyopathy with an ejection fraction of
approximately 10%, who presented with worsening orthopnea and
dyspnea.  He has had multiple recent admissions to the
Cardiovascular service.  In [**2134-4-14**], he was admitted with
complete heart block and a DDD pacemaker was placed.  Earlier
this month, in [**2134-5-15**], he was readmitted with acute
renal failure, hyperkalemia, and hypotension.  He was
transiently in the Coronary Care Unit on dopamine for one day
before being transferred to the floor when his heart failure
medications were gradually added back on.  He was just
discharged on [**2134-5-19**].  He has been followed closely by
his cardiologist, Dr. [**First Name (STitle) 2031**], who had been able to increase
his lasix back to his previous outpatient dose of 80 mg by
mouth twice a day.  Enalapril had been continued at 10 mg by
mouth once daily and Toprol XL had been held.  Today he
complains of dyspnea on exertion and progressive orthopnea
for the last three to five days.  He has had increasing
peripheral edema but, over the last two or three days, he
thinks this has improved.  His weight was 191 pounds
yesterday, although he claims his dry weight is approximately
180 pounds.  He felt extremely fatigued.  No fevers, chills,
nausea, vomiting or diarrhea.  No recent antibiotic use. No
dysuria, no chest pain.  He did have paroxysmal nocturnal
dyspnea and a mild cough.  He admitted to a decreased
appetite.  Because of his feeling generally unwell, he called
his niece to bring him into the Emergency Room.

PAST MEDICAL HISTORY:
1.  Dilated cardiomyopathy, likely ethanol-induced; ejection
fraction of approximately 10%.  An echocardiogram in [**2134-5-15**] showed an ejection fraction of less than 20%, superior
left ventricular dilation, severe global right ventricular
and left ventricular hypokinesis, 3+ mitral regurgitation,
and 2+ tricuspid regurgitation.
2.  Coronary artery disease, although he had a normal cardiac
catheterization in [**2128**]
3.  Noninsulin dependent diabetes mellitus
4.  Asthma
5.  Complete heart block status post DDD pacemaker in [**2134-5-15**]
6.  Tophaceous gout, recently in the fourth toe on the left
foot
7.  Chronic renal insufficiency progressing to acute renal
failure in [**2134-5-15**], now resolved.  His baseline
creatinine is approximately 1.5 to 2.0.

MEDICATIONS ON ADMISSION:  K-Dur 20 mEq by mouth once daily,
Vasotec 10 mg by mouth once daily, Coumadin 3 mg by mouth
once daily, Colace 100 mg by mouth once daily, lasix 80 mg by
mouth twice a day, aspirin 325 mg by mouth once daily,
Atrovent inhaler two puffs inhaled four times a day,
amiodarone 400 mg by mouth once daily, Toprol XL 12.5 mg by
mouth once daily that was on hold, Glyburide 10 mg by mouth
twice a day.

ALLERGIES:  No known drug allergies.

SOCIAL HISTORY:   He is a former iron worker, now retired. He
lives next door to his niece, who is his closest relative.
[**Name (NI) **] denies smoking or current drinking.  The niece's phone
number is [**Telephone/Fax (1) 108018**], name [**First Name4 (NamePattern1) **] [**Known lastname 11752**].

PHYSICAL EXAMINATION:  Afebrile, heart rate 80, blood
pressure 90/54 (this is his baseline blood pressure),
respirations 14, oxygen saturation 98% on room air.  In
general, an elderly male, lying in bed, comfortably, speaking
in full sentences, in no acute distress.  Head, eyes, ears,
nose and throat:  Pupils equal, round and reactive to light,
extraocular movements intact, normocephalic, atraumatic,
oropharynx clear, jugular venous distention approximately 10
cm.  Chest:  Bilateral basilar rales that he is known to have
at baseline, otherwise clear to auscultation bilaterally.
Cardiovascular:  Regular rate and rhythm, S1, S2, and S3 are
heard.  Abdomen:  Soft, nontender, nondistended, positive
bowel sounds.  Extremities:  2+ pitting edema bilaterally.

LABORATORY DATA:  White count 7.2,  with a normal
differential.  Hematocrit 33.8 with a mean cell volume of 79.
Platelets 235, INR 2.4, PTT 36.4.  Chem 7:  Sodium 134,
potassium 5.3, chloride 99, bicarbonate 20, BUN 53,
creatinine 2.3, glucose 182.  Initial CK was 73.
Electrocardiogram:  He was AV paced at 80 beats per minute
with a left bundle branch block.  There were no changes
compared to previous electrocardiogram.  Chest x-ray showed
cardiomegaly with mild upper zone redistribution.

IMPRESSION:  This is a 69-year-old man with dilated
cardiomyopathy, who presents with increasing dyspnea,
paroxysmal nocturnal dyspnea, and orthopnea, consistent with
fluid overload.

HOSPITAL COURSE BY SYSTEM:
1.  Cardiac:  Because of the patient's acute decompensated
congestive heart failure, the patient was ruled out for
myocardial infarction by enzymes.  Aspirin was continued.  In
order to more accurately assess the patient's fluid status in
light of his surprisingly clear lung examination, the patient
was taken to cardiac catheterization for a right heart
catheterization.  This showed marked increased pulmonary
capillary wedge pressure up to 30 mm Hg, with a mean right
atrial pressure of 25, consistent with marked fluid overload.
The cardiac index was depressed at 1.82.  Milrinone
intravenous was given, and the wedge pressure decreased to
22, with an increase in the cardiac output to 2.62.  He was
transferred to the Coronary Care Unit with his Swan-Ganz
catheter in place, for further management and aggressive
diuresis.  Initially this was attained with a milrinone drip
to improve cardiac output, and intravenous lasix to reduce
pre-load.  However, the patient's blood pressure did not
tolerate this regimen, so dopamine was added for pressor
support.  The lasix drip was increased to 40 mg/hour, and
Zaroxolyn was added, with good effect.  The patient diuresed
approximately 2 liters over two days on this regimen.

With hopes of weaning the dopamine, Natrecor was added as an
augmentation to the lasix.  The patient continued to diurese,
however, the dopamine was continued for low blood pressure.
It should be noted that we maintained the dopamine dose at 3
mcg/kg/minute because, at higher doses, the patient
experienced considerable ectopy.

By hospital day seven, the lasix drip had been converted to
twice a day lasix, the milrinone was turned off, Aldactone
was added, and Zaroxolyn was continued.  The patient was
given Enalapril 2.5 mg by mouth twice a day intermittently,
but this was often held for low blood pressure.  It was felt
that, by hospital day seven, the patient had returned to his
normal dry weight.

The patient's electrocardiogram showed evidence of
ventricular dyssynchrony.  Specifically, the QRS duration was
prolonged.  Therefore, the Electrophysiology service was
consulted to consider conversion  to biventricular leads
provide biventricular synchronization.  It was decided that
this would be performed once the patient was euvolemic.  As
of this dictation, the plan is to perform this procedure on
[**6-7**].

The patient's amiodarone was continued for his history of
atrial fibrillation.  The dose was decreased to 200 mg by
mouth once daily.  The patient was also anticoagulated both
for the history of atrial fibrillation as well as the low
ejection fraction.

2.  Pulmonary:  The patient had few pulmonary symptoms after
he was adequately diuresed.  Supplemental oxygen was
provided, and he had excellent oxygen saturation.

3.  Infectious Disease:  The patient had a temperature spike
to 102 on hospital day number seven.  Blood cultures and
urine cultures were taken, and the results were still pending
at the time of this dictation.  Empiric vancomycin,
levofloxacin and Flagyl were started.  The patient's central
line was discontinued to account for the possibility of line
sepsis.  These antibiotics should be continued until the
culture results are known, with tailoring of the antibiotic
regimen for the appropriate pathogen or, in the event of a
negative culture workup, the antibiotics should be
discontinued.

4.  Gastrointestinal:  The patient had a history of
constipation, and this was a problem for him during this
hospitalization.  He required an aggressive bowel regimen.
We also continued Protonix.

5.  Prophylaxis:  The patient received heparin subcutaneously
for deep venous thrombosis prophylaxis, as well as Protonix
as mentioned above.

6.  Code status:  The patient is full code.

DISPOSITION:  As of this dictation, the plan is for transfer
back to [**Hospital Unit Name 196**] after stabilization of the patient's blood
pressure and conversion of DDD pacer to biventricular mode.
The remainder of the hospital course will be dictated in a
separate dictation summary addendum.




                            [**First Name11 (Name Pattern1) 420**] [**Last Name (NamePattern4) 421**], M.D.  [**MD Number(1) 422**]

Dictated By:[**Name8 (MD) 2734**]
MEDQUIST36

D:  [**2134-6-6**]  00:02
T:  [**2134-6-6**]  04:02
JOB#:  [**Job Number 108019**]


Name:  [**Known lastname **], [**Known firstname **]            Unit No:  [**Numeric Identifier 17653**]

Admission Date:  [**2134-5-30**]     Discharge Date:   [**2134-6-16**]

Date of Birth:  [**2065-5-24**]      Sex:  M

Service:

ADDENDUM:

HOSPITAL COURSE:  This is a 69 year old Caucasian male with a
history of dilated cardiomyopathy with ejection fraction of
approximately 10% who was transferred from the CCU to the
[**Hospital Unit Name **] Service for further observation biventricular lead
placement and discharge.

HOSPITAL COURSE BY SYSTEM:
1.  Cardiac.  An echocardiogram was performed on the [**11-11**] which showed the following; the left atrium was
moderately dilated approximate 5.3 cm.  the left ventricular
cavity was severely dilated (7.8 cm).  There is severe global
left ventricular hypokinesis.  The right ventricular cavity
is moderately dilated.  There was moderate to severe global
right ventricular free wall hypokinesis.  The aortic root was
mildly dilated.  The aortic mitral leaflets are also mildly
dilated.  Mild +1 (aortic regurgitation was seen).  The
mitral valve leaflets are mildly thickened.  Moderate to
severe +3 (mitral regurgitation) was seen.  The interval
between the R-wave to the aortic valve opening was measured
at 245 milliseconds, 250 milliseconds and 250 milliseconds in
serial recordings, a pericardial short access view.  The
interval between the R-wave to aortic valve opening was
measured as 260 milliseconds in the parasternal long access
view.  The interval between the R-wave to pulmonic valve
opening was measured at 170 milliseconds, 185 milliseconds,
190 milliseconds and 185 in serial recordings in the
parasternal views.  In the parasternal RVOT view the interval
between the R-wave to the pulmonic valve opening was measured
at 190 milliseconds.  It was determined that it would be
beneficial to the patient to have a placement of a third
pacemaker lead wire to provide biventricular synchronization.
This procedure was successfully performed.  The patient
claimed that his symptoms were dramatically improved shortly
following the procedure.  While he was on the service, we
continued to restrict his fluids to a liter/day.  He was
continued to diurese on Lasix, Metolazone and Spirnalactone.
In addition, due to his congestive heart failure he was
placed on Enalapril and he remained on his Digoxin home
level.  Beta-blocker was held due to his low blood pressure.
The patient had a history of atrial fibrillation and he
remained on Amiodarone 200 mg p.o. q.d.
2.  Pulmonary.  The patient had no pulmonary symptoms after
he is adequately diuresed.  Occasionally the patient required
supplemental oxygen.
3.  Infectious Disease.  The patient completed his course of
treatment of Vancomycin, Levofloxacin and Flagyl.  The
patient's blood cultures 1/6 came back positive for a coag
negative Staph may be due to possible contamination.  The
patient, during his stay on [**Hospital Unit Name **] demonstrated no signs of
infection or sepsis.
4.  Diabetes.  The patient remained on his Glyburide and
sliding scale insulin regimen.  Glucophage was discontinued
due to his chronic renal insufficiency.
5.  Tophaceous gout.  The patient's gout was treated
superficially by joint aspiration.  The patient's improved
dramatically and the patient showed no symptoms of infection.

6.  Chronic renal insufficiency.  The patient's creatinine
remained around his baseline, approximately 1.5 to 2.0 during
his entire stay with [**Hospital Unit Name **].  It should be reminded that the
patient on presentation had a creatinine of 3.3 along with
hyperkalemia and hypertension.  He was aggressively treated
for that by the Coronary Care Unit Team in their dictation
summary.

DISCHARGE DIAGNOSIS:
1.  Dilated cardiomyopathy, likely ethanol induced, ejection
fraction less than 20%.
2.  Coronary artery disease.
3.  Noninsulin dependent diabetes mellitus.
4.  Asthma.
5.  Complete heart block status post DDD placement in [**2134-4-14**].
6.  Tophaceous gout.
7.  Chronic renal failure, baseline creatinine 1.5 to 2.0.
8.  Benign prostatic hypertrophy.

DISCHARGE MEDICATIONS:
1.  Lasix 60 mg p.o. b.i.d.
2.  Enalapril 2.5 mg p.o. q.d.
3.  Digoxin 0.125 mg p.o. q.d.
4.  Oxybutynin 5 mg p.o. t.i.d.
5.  Spirnalactone 6.25 mg p.o. q.d.
6.  Atrovent two puffs b.i.d.
7.  Amiodarone 200 mg p.o. q.d.
8.  Pantoprazole 40 mg p.o. q.d.
9.  Aspirin 325 mg q.d.
10. Lactulose 30 ml p.o. t.i.d.
11. Multi-vitamin.
12. Aluminum, magnesium, hydroxide 15 ml p.o. q.i.d. as
needed.
13. Glyburide 10 mg p.o. b.i.d.

DISCHARGE INSTRUCTIONS:  A follow-up with Dr. [**First Name (STitle) 1313**] in the
Congestive Heart Failure Clinic on the [**2134-7-5**] at
12 o'clock.  He was also to follow at the [**Hospital 8325**] Clinic on
the [**2134-6-28**] at 1:30 on the [**Location (un) **] of the [**Hospital **]
Clinic.  Finally, he was to follow-up with Dr. [**Last Name (STitle) 17654**] in the
next 2-3 weeks.  He was to discuss restarting Coumadin and
increasing his Enalapril with Dr. [**First Name (STitle) 1313**] at his next visit.
He was told to continue to restrict his fluids to
approximately one liter/day and avoid foods containing
sodium.  He was to be followed closely by a VNA Nurse on a
regular basis to follow his medications, his weight.  The
patient was to return to the Emergency Room or contact EMS if
he develops any further chest pain, shortness of breath,
heart palpitations or other cardiac related symptoms along
with gaining a significant amount of weight.




                          [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1600**], M.D.  [**MD Number(1) 1601**]

Dictated By:[**First Name3 (LF) 17655**]

MEDQUIST36

D:  [**2134-7-11**]  12:40
T:  [**2134-7-19**]  20:11
JOB#:  [**Job Number 17656**]
{'Congestive heart failure, unspecified,Alcoholic cardiomyopathy,Infection and inflammatory reaction due to other vascular device, implant, and graft,Other staphylococcal septicemia,Gouty tophi of other sites, except ear,Unspecified disorder of kidney and ureter,Coronary atherosclerosis of native coronary artery,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Asthma, unspecified type, unspecified'}


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: The patient is a 69-year-old
male with dilated cardiomyopathy with an ejection fraction of
approximately 10%, who presented with worsening orthopnea and
dyspnea.  He has had multiple recent admissions to the
Cardiovascular service.  In [**2134-4-14**], he was admitted with
complete heart block and a DDD pacemaker was placed.  Earlier
this month, in [**2134-5-15**], he was readmitted with acute
renal failure, hyperkalemia, and hypotension.  He was
transiently in the Coronary Care Unit on dopamine for one day
before being transferred to the floor when his heart failure
medications were gradually added back on.  He was just
discharged on [**2134-5-19**].  He has been followed closely by
his cardiologist, Dr. [**First Name (STitle) 2031**], who had been able to increase
his lasix back to his previous outpatient dose of 80 mg by
mouth twice a day.  Enalapril had been continued at 10 mg by
mouth once daily and Toprol XL had been held.  Today he
complains of dyspnea on exertion and progressive orthopnea
for the last three to five days.  He has had increasing
peripheral edema but, over the last two or three days, he
thinks this has improved.  His weight was 191 pounds
yesterday, although he claims his dry weight is approximately
180 pounds.  He felt extremely fatigued.  No fevers, chills,
nausea, vomiting or diarrhea.  No recent antibiotic use. No
dysuria, no chest pain.  He did have paroxysmal nocturnal
dyspnea and a mild cough.  He admitted to a decreased
appetite.  Because of his feeling generally unwell, he called
his niece to bring him into the Emergency Room.

MEDICAL HISTORY: 1.  Dilated cardiomyopathy, likely ethanol-induced; ejection
fraction of approximately 10%.  An echocardiogram in [**2134-5-15**] showed an ejection fraction of less than 20%, superior
left ventricular dilation, severe global right ventricular
and left ventricular hypokinesis, 3+ mitral regurgitation,
and 2+ tricuspid regurgitation.
2.  Coronary artery disease, although he had a normal cardiac
catheterization in [**2128**]
3.  Noninsulin dependent diabetes mellitus
4.  Asthma
5.  Complete heart block status post DDD pacemaker in [**2134-5-15**]
6.  Tophaceous gout, recently in the fourth toe on the left
foot
7.  Chronic renal insufficiency progressing to acute renal
failure in [**2134-5-15**], now resolved.  His baseline
creatinine is approximately 1.5 to 2.0.

MEDICATION ON ADMISSION: K-Dur 20 mEq by mouth once daily,
Vasotec 10 mg by mouth once daily, Coumadin 3 mg by mouth
once daily, Colace 100 mg by mouth once daily, lasix 80 mg by
mouth twice a day, aspirin 325 mg by mouth once daily,
Atrovent inhaler two puffs inhaled four times a day,
amiodarone 400 mg by mouth once daily, Toprol XL 12.5 mg by
mouth once daily that was on hold, Glyburide 10 mg by mouth
twice a day.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: He is a former iron worker, now retired. He
lives next door to his niece, who is his closest relative.
[**Name (NI) **] denies smoking or current drinking.  The niece's phone
number is [**Telephone/Fax (1) 108018**], name [**First Name4 (NamePattern1) **] [**Known lastname 11752**]. 

### Response:
{'Congestive heart failure, unspecified,Alcoholic cardiomyopathy,Infection and inflammatory reaction due to other vascular device, implant, and graft,Other staphylococcal septicemia,Gouty tophi of other sites, except ear,Unspecified disorder of kidney and ureter,Coronary atherosclerosis of native coronary artery,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Asthma, unspecified type, unspecified'}
