CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is an 83-year-old
white male with a history of CABG [**01**] years ago who presented
to an outside hospital with shortness of breath and CHF.  The
patient has a pacemaker for AV nodal disease which was placed
[**2185-11-16**].  The patient then had an echo which demonstrated
severe decrease in left ventricular function with an EF of
10% and moderate MR.  The patient also had an ultrasound of
the bilateral carotids which demonstrated bilateral disease
of approximately 80% stenosis on both sides.  The patient had
a Persantine stress test which demonstrated ischemia in the
lateral and basilar walls.  The patient was noted to be
hyponatremic at the outside hospital as well.

MEDICAL HISTORY: CABG [**01**] years ago, history of
myocardial infarction, status post cholecystectomy, status
post peptic ulcer disease surgery, ischemic cardiomyopathy,
mitral regurgitation, pacemaker placement secondary to AV
nodal disease, chronic renal insufficiency.

MEDICATION ON ADMISSION: 

ALLERGIES: The patient reports an allergy to Erythromycin
and to iodine.

PHYSICAL EXAM: 

FAMILY HISTORY: The patient's father died of a cancer at age
[**Age over 90 **].  The patient's mother died of pneumonia at age 86.  The
patient reports 10 siblings, one of whom has diabetes and
some of whom have "heart disease".  The patient lives with
his wife at home and prior to the last month has helped take
care of his wife.  [**Name (NI) **] has four children, two of whom live
close by and are very involved in his care.

SOCIAL HISTORY: The patient has a positive tobacco history
of 30 years but quit in [**2144**].  He denies any alcohol use.
Unspecified disorder of kidney and ureter,Anemia, unspecified,Staphylococcus infection in conditions classified elsewhere and of unspecified site, staphylococcus, unspecified,Subendocardial infarction, initial episode of care,Coronary atherosclerosis of autologous vein bypass graft,Congestive heart failure, unspecified,Other complications due to other cardiac device, implant, and graft,Hypotension, unspecified
Renal & ureteral dis NOS,Anemia NOS,Staphylococcus unspcfied,Subendo infarct, initial,Crn ath atlg vn bps grft,CHF NOS,Comp-oth cardiac device,Hypotension NOS
Admission Date:  [**2186-1-12**]       Discharge Date:


Service:  CCU

HISTORY OF PRESENT ILLNESS:  The patient is an 83-year-old
white male with a history of CABG [**01**] years ago who presented
to an outside hospital with shortness of breath and CHF.  The
patient has a pacemaker for AV nodal disease which was placed
[**2185-11-16**].  The patient then had an echo which demonstrated
severe decrease in left ventricular function with an EF of
10% and moderate MR.  The patient also had an ultrasound of
the bilateral carotids which demonstrated bilateral disease
of approximately 80% stenosis on both sides.  The patient had
a Persantine stress test which demonstrated ischemia in the
lateral and basilar walls.  The patient was noted to be
hyponatremic at the outside hospital as well.

The patient was admitted and treated with diuresis and
Dobutamine for two days with good result.  Over that time the
patient ruled in for myocardial infarction with elevated CPKs
but negative troponin.  The patient was therefore transferred
to [**Hospital1 69**] for a second opinion
regarding carotid endarterectomy as well as for
catheterization given his history of high risk surgery
candidate.

The outside hospital reported a 7 lb weight loss with
diuretics.  His Coumadin was held given his elevated INR of
3.25.  At time of transfer the patient denied any shortness
of breath, chest pain, nausea, vomiting, fevers, chills,
diarrhea, constipation.

PAST MEDICAL HISTORY:  CABG [**01**] years ago, history of
myocardial infarction, status post cholecystectomy, status
post peptic ulcer disease surgery, ischemic cardiomyopathy,
mitral regurgitation, pacemaker placement secondary to AV
nodal disease, chronic renal insufficiency.

MEDICATIONS:  Carvedilol 12.5 mg po bid, Colace 100 mg po
bid, Lasix 40 mg po q d, Aspirin 325 mg po q d, sublingual
Nitroglycerin po prn, Captopril 6.25 mg po tid, Serax 10 mg
po q h.s. prn, Heparin drip.

ALLERGIES:  The patient reports an allergy to Erythromycin
and to iodine.

SOCIAL HISTORY:  The patient has a positive tobacco history
of 30 years but quit in [**2144**].  He denies any alcohol use.

FAMILY HISTORY:  The patient's father died of a cancer at age
[**Age over 90 **].  The patient's mother died of pneumonia at age 86.  The
patient reports 10 siblings, one of whom has diabetes and
some of whom have "heart disease".  The patient lives with
his wife at home and prior to the last month has helped take
care of his wife.  [**Name (NI) **] has four children, two of whom live
close by and are very involved in his care.

PHYSICAL EXAMINATION:  Temperature 96.8, blood pressure
153/71, heart rate 40, respiratory rate 16, saturation 94% on
one liter O2, weight 45 kg.  HEENT:  Pupils equally round and
reactive to light, moist mucus membranes, full dentures,
extraocular movements intact, oropharynx clear.  Neck, no
cervical lymphadenopathy, no JVD.  Chest, clear to
auscultation bilaterally.  Cardiovascular, regular rate and
rhythm, normal S1 and S2, 2/6 systolic ejection murmur.
Abdomen, nontender, non distended, positive bowel sounds,
soft, positive scars, status post cholecystectomy and CABG.
Extremities, trace bilateral edema of the ankle, pulses full,
strength 5/5 bilaterally, trace pedal edema.

LABORATORY DATA:  White blood cell count 7.7, hemoglobin
32.4, platelet count 210,000, sodium 130, potassium 4.4,
chloride 92, CO2 31, BUN 19, creatinine 1.3, INR 1.35, PT
13.5, iron 42, TIBC 392.

EKG, old inferior/anterior MI with pacer spikes.

HOSPITAL COURSE:  The patient is an 83-year-old male with a
history of CABG, recent pacemaker placement, carotid artery
disease who presents for evaluation for carotid
endarterectomy as well as evaluation for possible
catheterization with stress changes on EKG.

The patient was originally admitted to C-Med firm for
evaluation for possible catheterization and evaluation by
vascular surgery for potential carotid endarterectomy.  Given
the patient's history of coronary artery disease he was
continued on his beta blocker, Aspirin and Captopril, as well
as Carvedilol.  A discussion was held with the patient's
family who agreed for cardiac catheterization to determine
patency of the patient's graft as well as to evaluate for any
potential intervention.  In the meantime an echocardiogram
was obtained on [**1-13**] which demonstrated a severely dilated
left ventricle, mildly dilated left atrium, severe global
hypokinesis of the left ventricle, moderate MR, no effusion.
At this time the patient was started on Digoxin and his ACE
inhibitor was titrated up as tolerated.

Cardiac catheterization was performed on [**2186-1-16**].
Catheterization demonstrated occluded CABG graft, with severe
three vessel coronary artery disease including a 40% stenosis
of the left main, 80% stenosis of the LAD, 50% stenosis of
the left circumflex with 50% stenosis of the diagonal, 100%
stenosis of RCA.  The patient had a stent placed in his LAD.
The patient's catheterization was complicated by hypotension
especially during the intervention of the LAD.  He briefly
required Milrinone therapy and was then stabilized on
Dopamine as well as an intra-aortic balloon pump.
Hemodynamics during the catheterization study demonstrated a
right atrial pressure of 11, right ventricle 62/5, PA
pressure 62/30 which was then 48/27 post intervention, PA sat
27%, then 62% post intervention, wedge pressure of 39, aortic
pressure 115/40.

Evaluation of catheterization results suggest that patient
did have surgical coronary artery disease, however, he was
not an operative candidate given his history of CABG and the
diffuseness of his disease.  Therefore he was admitted to the
CCU for further management post catheterization.  The patient
was continued on Aspirin and Plavix as well as his Heparin
drip.  A lipid panel was checked and the patient was
continued on Lipitor.  No 2B, 3A inhibitors were given
because the patient had demonstrated a low hematocrit over
the course of hospital stay and there had been a question of
some hemoptysis at time of admission.

The patient's LV function was significantly depressed based
on findings on the echocardiogram as well as catheterization.
It is likely that this low EF was not new and that this
revascularization would restore blood flow to hibernating
myocardium thus improving the cardiac function overall.  On
admission to the CCU the patient's intra-aortic balloon pump
was continued overnight and the patient was slowly weaned off
Dobutamine.




                             [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] M.D. [**MD Number(1) 7169**]

Dictated By:[**Name8 (MD) 8860**]
MEDQUIST36

D:  [**2186-1-18**]  10:47
T:  [**2186-1-18**]  12:24
JOB#:  [**Job Number 37528**]


Admission Date:  [**2186-1-12**]     Discharge Date:  [**2186-1-21**]


Service:

HISTORY OF PRESENT ILLNESS:  This is an 83-year-old male with
a history of coronary artery disease, status post coronary
artery bypass graft, with an ejection fraction of around 10%
due to ischemic cardiomyopathy, who presented to an outside
hospital with chest pain and was transferred to [**Hospital1 346**] for catheterization and carotid
evaluation as he was reported to have bilateral critical
carotid artery stenoses.

He arrived at the outside hospital on [**1-9**] with chest
pain, shortness of breath, and congestive heart failure
exacerbation.  He developed positive cardiac enzymes with a
peak creatine kinase of 962, and a MB of 24.6, with a MB
index of 2.7.  An echocardiogram revealed an ejection
fraction of 10% to 20%.  He was also noted to have bilateral
80% carotid stenoses and evidence of lateral ischemia on a
Persantine stress test.

Echocardiogram at [**Hospital1 69**]
confirmed significant left ventricular dilatation and
dysfunction, but carotid Doppler showed no significant
stenoses with 70% to 79% on the left and 40% to 49% on the
right.  He was deemed to not be a candidate for carotid
endarterectomy, but was taken to cardiac catheterization for
his non-Q-wave myocardial infarction.

Catheterization revealed significant native 3-vessel disease,
and none of his coronary artery bypass graft grafts were
patent.  He underwent percutaneous transluminal coronary
angioplasty and stenting of his proximal left anterior
descending artery lesion and had complications with
hypotension and high filling pressures during the
intervention.  He briefly required Milrinone and was
ultimately stabilized on dopamine and an intra-aortic balloon
pump.

After the case, he was transferred to the Coronary Care Unit
for further management.  Other positive findings on review of
systems included hemoptysis and anemia of unknown etiology.

PAST MEDICAL HISTORY:
1.  Coronary artery disease, status post coronary artery
bypass graft in [**2168**] at [**Hospital6 **] with unknown
graft anatomy.
2.  Ischemic cardiomyopathy with an ejection fraction of less
than 20%.
3.  Peripheral vascular disease.
4.  Type 2 diabetes mellitus complicated by chronic renal
insufficiency.
5.  His AV nodal disease, status post pacemaker placement.

MEDICATIONS ON TRANSFER:
1.  Carvedilol 12.5 mg p.o. b.i.d.
2.  Lasix 40 mg p.o. q.d.
3.  Aspirin 325 mg p.o. q.d.
4.  Captopril 12.5 mg p.o. t.i.d.
5.  Colace 100 mg p.o. b.i.d.
6.  Heparin drip.
7.  Digoxin 0.125 mg p.o. q.d.

ALLERGIES:  Allergy to ERYTHROMYCIN, IODINE, and PRONESTYL.

SOCIAL HISTORY:  He lives with his wife.  [**Name (NI) **] has four
children including two very involved daughters.  [**Name (NI) **] smoked
for 30 years but quit in [**2144**].  There is no alcohol use.

FAMILY HISTORY:  His father died at age [**Age over 90 **] of cancer.  His
mother died at age 86 of pneumonia.  He has one brother with
diabetes and nine of his other siblings are healthy.

PHYSICAL EXAMINATION ON PRESENTATION:  This is an elderly man
in no acute distress with a blood pressure of 153/71, a heart
rate of 39, a respiratory rate of 16, and oxygen saturation
of 95% on 1 liter nasal cannula.  He is afebrile and weighs
45 kg.  His head, ears, nose, eyes and throat examination was
unremarkable.  His neck was supple with no jugular venous
distention nor carotid bruits.  His lungs were clear except
for bibasilar rales.  His heart was regular with no murmurs.
His abdomen was benign.  His extremities were warm with no
edema.  His neurologic examination showed that he was awake
and oriented times three with intact cranial nerves.  He was
moving all four extremities spontaneously and had grossly
intact sensation.  His deep tendon reflexes were 1+
bilaterally.

PERTINENT LABORATORY DATA ON PRESENTATION:  Laboratories on
presentation included a white blood cell count of 7.7,
hematocrit of 32.4, and platelets of 210.  His Chem-7 was
within normal limits except for a blood urea nitrogen of 19
and a creatinine of 1.3.

RADIOLOGY/IMAGING:  Electrocardiogram before catheterization
showed a paced rhythm with a left bundle-branch block.  There
were no acute changes suggestive of ischemia.

HOSPITAL COURSE:  Mr. [**Known lastname **] was kept on aspirin, digoxin,
and captopril.  He was started on Lipitor and Plavix after
receiving his stent.  He was also placed on a heparin drip
for his low ejection fraction, but given his overall
functional status and that he was a poor candidate for
long-term anticoagulation it was stopped.

He was diuresed as he presented in failure and had great
improvement in his hemodynamics, especially his cardiac
output and his index to the point where he was able to be
weaned off of the balloon pump and off of pressors.  His
Swan-Ganz catheter was then removed.

Also of note, he had an increased creatine kinase after
intra-aortic balloon pump placement that peaked at around
5000 with negative MBs.  There was a concern for lower
extremity ischemia from the balloon exacerbating his
peripheral vascular disease.  This increased creatine kinase
was asymptomatic and continued to trend down during his
entire course.

From a pulmonary standpoint, a single chest x-ray on
[**1-19**] showed evidence of a tiny apical pneumothorax.
This was two days after right internal jugular placement for
a Swan.  This pneumothorax was not seen on repeat chest x-ray
on [**1-20**].

From an infectious disease standpoint, he spiked a fever in
the middle of his course and was started on empiric
vancomycin and levofloxacin to cover for line sepsis and
pneumonia.  There was a question of a left lower lobe
infiltrate on chest x-ray.  Blood and urine cultures were
negative.  After his sputum culture grew out Staphylococcus
aureus, his antibiotics were changed to dicloxacillin for a
10-day course.  He remained afebrile after initially starting
antibiotics.

For his anemia, he received multiple transfusions with an
increase in his hematocrit to 34 by the time of discharge.

He was briefly placed on Diamox for a metabolic alkalosis
that developed after his intervention.  This improved, and
the Diamox was stopped.  He was also on a 1.5-liter
restriction for his congestive heart failure.

He had occasional episodes of agitation and sundowning at
night that required Haldol.  From time to time he also
required Ativan for extreme agitation.

With regard to code status, he was full code on presentation
but as it became clear how long a recovery he would have and
the new limitations on his function status that were unlikely
to improve significantly with time, a frank discussion was
held with his very supportive family who decided to change
his code status to do not resuscitate/do not intubate/comfort
measures only and have him go home with hospice.

CONDITION AT DISCHARGE:  Condition on discharge was stable.

DISCHARGE STATUS:  To home with hospice.

DISCHARGE DIAGNOSES:
1.  Coronary artery disease, status post non-Q-wave
myocardial infarction, status post stent placement.
2.  Severe ischemic cardiomyopathy with an ejection fraction
of approximately 10%.
3.  Type 2 diabetes mellitus, diet controlled.
4.  AV nodal disease, status pacemaker placement.
5.  Peripheral vascular disease.

MEDICATIONS ON DISCHARGE:
 1.  Lasix 80 mg p.o. q.d.
 2.  Digoxin 0.125 mg p.o. q.d.
 3.  Aspirin 325 mg p.o. q.d.
 4.  Plavix 75 mg p.o. q.d.
 5.  Lisinopril 10 mg p.o. q.d.
 6.  Colace 100 mg p.o. b.i.d.
 7.  Dulcolax 10 mg p.o. q.d. p.r.n. for constipation.
 8.  Aldactone 25 mg p.o. q.d.
 9.  Haldol 2.5 mg p.o. q.h.s. p.r.n. for agitation.
10.  Ativan 0.5 mg to 1 mg p.o. q.4h. p.r.n. for extreme
agitation.
11.  Dicloxacillin 250 mg p.o. q.i.d. times 10 days.
12.  Tylenol 650 mg p.o. q.4-6h. p.r.n.
13.  Oxygen 3 liters nasal cannula p.r.n.
14.  Lasix 80 mg p.o. q.p.m. p.r.n. (weight greater than
52 kg).  This Lasix should be used whenever his weight goes
above 52 kg.  His weight on discharge was 50 kg.  Once his
weight returns to normal, p.r.n. Lasix can be stopped.




                          [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D.  [**MD Number(1) 7169**]

Dictated By:[**Name8 (MD) 1552**]

MEDQUIST36

D:  [**2186-1-21**]  15:24
T:  [**2186-1-25**]  07:52
JOB#:  [**Job Number 37529**]
{'Unspecified disorder of kidney and ureter,Anemia, unspecified,Staphylococcus infection in conditions classified elsewhere and of unspecified site, staphylococcus, unspecified,Subendocardial infarction, initial episode of care,Coronary atherosclerosis of autologous vein bypass graft,Congestive heart failure, unspecified,Other complications due to other cardiac device, implant, and graft,Hypotension, 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 an 83-year-old
white male with a history of CABG [**01**] years ago who presented
to an outside hospital with shortness of breath and CHF.  The
patient has a pacemaker for AV nodal disease which was placed
[**2185-11-16**].  The patient then had an echo which demonstrated
severe decrease in left ventricular function with an EF of
10% and moderate MR.  The patient also had an ultrasound of
the bilateral carotids which demonstrated bilateral disease
of approximately 80% stenosis on both sides.  The patient had
a Persantine stress test which demonstrated ischemia in the
lateral and basilar walls.  The patient was noted to be
hyponatremic at the outside hospital as well.

MEDICAL HISTORY: CABG [**01**] years ago, history of
myocardial infarction, status post cholecystectomy, status
post peptic ulcer disease surgery, ischemic cardiomyopathy,
mitral regurgitation, pacemaker placement secondary to AV
nodal disease, chronic renal insufficiency.

MEDICATION ON ADMISSION: 

ALLERGIES: The patient reports an allergy to Erythromycin
and to iodine.

PHYSICAL EXAM: 

FAMILY HISTORY: The patient's father died of a cancer at age
[**Age over 90 **].  The patient's mother died of pneumonia at age 86.  The
patient reports 10 siblings, one of whom has diabetes and
some of whom have "heart disease".  The patient lives with
his wife at home and prior to the last month has helped take
care of his wife.  [**Name (NI) **] has four children, two of whom live
close by and are very involved in his care.

SOCIAL HISTORY: The patient has a positive tobacco history
of 30 years but quit in [**2144**].  He denies any alcohol use. 

### Response:
{'Unspecified disorder of kidney and ureter,Anemia, unspecified,Staphylococcus infection in conditions classified elsewhere and of unspecified site, staphylococcus, unspecified,Subendocardial infarction, initial episode of care,Coronary atherosclerosis of autologous vein bypass graft,Congestive heart failure, unspecified,Other complications due to other cardiac device, implant, and graft,Hypotension, unspecified'}
