CHIEF COMPLAINT: syncope

PRESENT ILLNESS: 68 year old male with hypertension,
diabetes, hyperlipidemia, obesity and COPD. Work up for history
of syncope included positive stress test at [**Hospital6 88998**].Cath revealed 3VD and he was transferred in for CABG.

MEDICAL HISTORY: Hypertension, hyperlipidemia, diabetes, MI [**2164**],  renal cancer
[**2172**], Obesity, obstructive sleep apnea with CPAP, left upper
lung
resection at [**Hospital1 2025**] [**2173**] s/p radiation in [**2173**], right foot plantar
fasciitis, CVA with right facial numbness, gastroparesis,
anxiety, gout, hard of hearing
Past Surgical History:
hiatal hernia repair x2, removal of gastric polyp, left upper
lung resection at [**Hospital1 2025**] [**2173**], right nephrectomy for renal cancer
[**2172**].

MEDICATION ON ADMISSION: diltiazem 180 mg daily, Isorbide mononitrate 30 mg daily, toprol
XL 12.5 daily, Dipyridamole 25mg [**Hospital1 **], lasiz 40mg daily,
omeprazole 40 mg daily, Januvia 100mg daily, Metformin 500mg
[**Hospital1 **],
simvastatin 80mg daily, ultram prn, spiriva 18mcgs daily, ASA
325
daily, genfibrozil 300mg [**Hospital1 **], allopurinol 300mg daily, xanax .25
hs.

ALLERGIES: OxyContin

PHYSICAL EXAM: Pulse: 63 Resp: 18 O2 sat: 98% RA
B/P  Right: 137/60   Left:
Height: 5'[**81**]"    Weight: 132.3 kg

FAMILY HISTORY: mother died at 91 with multiple CVAs, MI, and
Cancer. father died of MI at 71. Brothers alive at age 70 and 64
- older brother has cancer

SOCIAL HISTORY: Last Dental Exam: 2 years ago
Lives with: Widowed. Has girlfriend. Lives alone in [**Location (un) **]
Occupation: Gun store owner
Tobacco: smoked 3ppd of cigars for 30 years, quit [**2173**]
ETOH: none
Coronary atherosclerosis of native coronary artery,Intermediate coronary syndrome,Atrial fibrillation,Personal history of malignant neoplasm of kidney,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other and unspecified hyperlipidemia,Obstructive sleep apnea (adult)(pediatric),Other late effects of cerebrovascular disease,Disturbance of skin sensation,Gastroparesis,Personal history of malignant neoplasm of bronchus and lung,Obesity, unspecified,Body Mass Index 38.0-38.9, adult,Unspecified essential hypertension,Personal history of irradiation, presenting hazards to health
Crnry athrscl natve vssl,Intermed coronary synd,Atrial fibrillation,Hx of kidney malignancy,DMII wo cmp nt st uncntr,Hyperlipidemia NEC/NOS,Obstructive sleep apnea,Late effect CV dis NEC,Skin sensation disturb,Gastroparesis,Hx-bronchogenic malignan,Obesity NOS,BMI 38.0-38.9,adult,Hypertension NOS,Hx of irradiation
Name:  [**Known lastname **],[**Known firstname 126**] P             Unit No:   [**Numeric Identifier 14120**]

Admission Date:  [**2182-6-14**]              Discharge Date:   [**2182-6-23**]

Date of Birth:  [**2113-10-2**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
OxyContin

Attending:[**First Name3 (LF) 135**]
Addendum:
Amiodarone discontinued prior to discharge to avoid untoward
effects of 3 nodal agents. Afib is rate controlled.

Discharge Disposition:
Extended Care

Facility:
[**Location (un) 14121**] Nursing & Rehabilitation Center

                             [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**]

Completed by:[**2182-6-23**]

Admission Date:  [**2182-6-14**]              Discharge Date:   [**2182-6-23**]

Date of Birth:  [**2113-10-2**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
OxyContin

Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
syncope

Major Surgical or Invasive Procedure:
[**2182-6-18**] urgent CABG x5 ( LIMA to LAD, SVG to OM1, SVG to
OM2-seq. to OM3,SVG to RCA)


History of Present Illness:
68 year old male with hypertension,
diabetes, hyperlipidemia, obesity and COPD. Work up for history
of syncope included positive stress test at [**Hospital6 88998**].Cath revealed 3VD and he was transferred in for CABG.


Past Medical History:
Hypertension, hyperlipidemia, diabetes, MI [**2164**],  renal cancer
[**2172**], Obesity, obstructive sleep apnea with CPAP, left upper
lung
resection at [**Hospital1 2025**] [**2173**] s/p radiation in [**2173**], right foot plantar
fasciitis, CVA with right facial numbness, gastroparesis,
anxiety, gout, hard of hearing
Past Surgical History:
hiatal hernia repair x2, removal of gastric polyp, left upper
lung resection at [**Hospital1 2025**] [**2173**], right nephrectomy for renal cancer
[**2172**].


Social History:
Last Dental Exam: 2 years ago
Lives with: Widowed. Has girlfriend. Lives alone in [**Location (un) **]
Occupation: Gun store owner
Tobacco: smoked 3ppd of cigars for 30 years, quit [**2173**]
ETOH: none


Family History:
mother died at 91 with multiple CVAs, MI, and
Cancer. father died of MI at 71. Brothers alive at age 70 and 64
- older brother has cancer


Physical Exam:
Pulse: 63 Resp: 18 O2 sat: 98% RA
B/P  Right: 137/60   Left:
Height: 5'[**81**]"    Weight: 132.3 kg

General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck:  Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x]  Irregular []  Murmur 2/6 SEM
Abdomen: Soft [x] non-distended [x] non-tender [x]  bowel sounds
+ [x]obese
Extremities: Warm [x], well-perfused [x]  Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral      Right: 2+ cath site clean  Left: 2+
DP           Right: 2+   Left: 2+
PT           [**Name (NI) 167**]: 2+   Left: 2+
Radial       Right: 2+   Left: 2+

Carotid Bruit        Right: + bruit   Left: + bruit


Pertinent Results:
[**2182-6-23**] INR 1.1 (dose 2.5 mg coumadin)
[**2182-6-22**] WBC-12.4* RBC-3.20* Hgb-9.6* Hct-28.5 Plt Ct-310#
[**2182-6-14**] WBC-6.7 RBC-3.87* Hgb-11.3* Hct-33.9 Plt Ct-221
[**2182-6-22**] UreaN-25* Creat-1.2 Na-135 K-3.6 Cl-94*
[**2182-6-14**] Glucose-114* UreaN-22* Creat-1.0 Na-140 K-3.9 Cl-104
HCO3-25
[**2182-6-14**] ALT-38 AST-63* LD(LDH)-134 AlkPhos-60 TotBili-0.3
[**2182-6-14**] HbA1c-6.5* eAG-140*

CXR:
[**2182-6-20**]:
AP single view of the chest has been obtained with patient in
upright position. Comparison is made with the next preceding
supine
postoperative chest examination of [**2182-6-18**]. The patient is
now
extubated. Previously described sternotomy wires in place,
unchanged.
Previously described right internal jugular approach central
venous line
remains in place. The patient is now extubated and the
left-sided chest tube has been removed. Lungs remain ventilated
and no evidence of pneumothorax is seen on this portable chest
examination obtained in upright position.

Date of [**2182-6-17**]
SPIROMETRY Pre drug Post drug
      Actual Pred %Pred Actual %Pred %chg
FVC   3.77 4.57 82
FEV1  2.37 3.09 77
MMF   1.26 2.79 45
FEV1/FVC   63 68 93

LUNG VOLUMES 11:09 AM Pre drug Post drug
    Actual Pred %Pred Actual %Pred
TLC   5.61 7.15 78
FRC   2.61 4.07 64
RV    2.01 2.58 78
VC    3.60 4.57 79
IC    3.00 3.08 97
ERV   0.60 1.49 40
RV/TLC   36 36 99
He Mix Time   3.00
DLCO
    Actual Pred %Pred
DSB   21.24 25.64 83
VA(sb) 5.20 7.15 73
HB    11.30
DSB(HB) 23.80 25.64 93
DL/VA   4.58 3.59 128

Echocardiogram: [**2182-6-15**]
Left Atrium - Long Axis Dimension:  *4.4 cm  <= 4.0 cm
Left Atrium - Four Chamber Length:  4.8 cm  <= 5.2 cm
Left Atrium - Peak Pulm Vein S:  0.5 m/s
Left Atrium - Peak Pulm Vein D:  0.4 m/s
Left Atrium - Peak Pulm Vein A:  0.3 m/s  < 0.4 m/s
Right Atrium - Four Chamber Length:  4.7 cm  <= 5.0 cm
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:  5.1 cm  <= 5.6 cm
Left Ventricle - Ejection Fraction:  60%  >= 55%
Left Ventricle - Lateral Peak E':  *0.06 m/s  > 0.08 m/s
Left Ventricle - Septal Peak E':  *0.06 m/s  > 0.08 m/s
Left Ventricle - Ratio E/E':  12  < 15
Aorta - Sinus Level:  3.4 cm  <= 3.6 cm
Aorta - Ascending:  3.1 cm  <= 3.4 cm
Aortic Valve - Peak Velocity:  1.6 m/sec  <= 2.0 m/sec
Mitral Valve - E Wave:  0.7 m/sec
Mitral Valve - A Wave:  1.0 m/sec
Mitral Valve - E/A ratio:  0.70
Mitral Valve - E Wave deceleration time:  *301 ms  140-250 ms
TR Gradient (+ RA = PASP):  *26 mm Hg  <= 25 mm Hg
Findings
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Overall normal LVEF (>55%). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Focal calcifications in ascending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Normal mitral valve supporting structures. No MS. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal tricuspid valve supporting structures. No TS.
Borderline PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR. Normal main PA. No Doppler evidence for
PDA
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: REGIONAL LEFT VENTRICULAR WALL MOTION:
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 60%). The inferior wall appears hypokinetic. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.

[**2182-6-15**]: Chest CT
1. Moderate calcifications of the aortic arch. No calcification
of the
ascending aorta.
2. 1.7 cm right adrenal gland nodule, incompletely characterized
on this CT and MR is recommended for further work-up
3. Pathologically enlarged celiac axis lymph node which can be
further
assessed with MRI.
4. Cholelithiasis without cholecystitis.


Brief Hospital Course:
Transferred in [**6-14**] and preop w/u completed. Underwent surgery
with Dr. [**Last Name (STitle) **] on [**6-18**] and was transferred to the CVICU in stable
condition on titrated nitroglycerin and propofol drips.
Extubated later that day and transferred to the floor on POD #1
to begin increasing his activity level. Chest tubes and pacing
wires removed per protocol. Gently diuresed toward his preop
weight.

Respiratory: aggressive pulmonary toilet, nebs, ambulation his
oxygen requirement improved to 96% 3L via nasal cannula. He
continued CPAP overnight, saturations 98%
Home inhalers were continued.

Cardiac; Intermittent atrial fibrillation low 100's amiodarone
bolus, drip and PO was started. His beta-blocker was increased.
His Diltiazem was restarted.  He continued to rate control
atrial fibrillation. Hemodynamically stable BP 120-140's.
Statins were restarted ( at lower than home dose d/t
amiodarone). Coumadin was started for Afib on [**2182-6-22**]. he has
rec'd 2 doses of 2.5 mg couamdin and his INR was 1.1-  NO need
lovenox bridge)

GI: PPI & bowel regime.  Nutrition tolerated a regular diet

Renal: Renal function normal baseline CRE 1.0-1.2. He was gently
diuresed. Electrolytes repleted.  Foley removed with good urine
output. His gout medication continued.

Endocrine: Insulin while in CVICU, transitioned to SQ insulin
(regaulr insulin sliding scale and lantus) and once tolerating
PO his metformin was restarted to maintain blood sugars < 150.
He will require transitin back to januvia (home medication) and
off lantus.

Pain: well controlled with PO Dilaudid and acetaminophen

Disposition: he was seen by physical therapy, ambulates with a
rolling walker and would benefit from rehab.  He was discharged
on [**2182-6-23**] to [**Location (un) 13040**] Health Rehab

Medications on Admission:
diltiazem 180 mg daily, Isorbide mononitrate 30 mg daily, toprol
XL 12.5 daily, Dipyridamole 25mg [**Hospital1 **], lasiz 40mg daily,
omeprazole 40 mg daily, Januvia 100mg daily, Metformin 500mg
[**Hospital1 **],
simvastatin 80mg daily, ultram prn, spiriva 18mcgs daily, ASA
325
daily, genfibrozil 300mg [**Hospital1 **], allopurinol 300mg daily, xanax .25
hs.


Discharge Medications:
1. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours).
2. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
8. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
10. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
12. gemfibrozil 600 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
13. dipyridamole 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
400mg daily for 7 days then 200mg ongoing until d/c'd by
cardiologist.
15. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
16. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): home dose is 80mg-please increase to 80mg when off
amiodarone.
17. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day: home
dose is 40mg daily- decrease when at pre-op weight 132kg and
edema resolved.
18. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Indication afib
coumadin dose based on INR goal 2.0-2.5 .
19. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day:
Transition off lantus and back to Januvia.
20. lantus
lantus 65 units daily with breakfast.
transition off lantus to Januvia (home medication)
21. regular insulin
regular insulin per finger stick. See sliding scale
22. Outpatient Lab Work
Daily INR until INR stable at goal of 2.0-2.5 then twice weekly


Discharge Disposition:
Extended Care

Facility:
[**Location (un) 13040**] Nursing & Rehabilitation Center

Discharge Diagnosis:
Coronary artery disease s/p CABG x5
Post-operative afib
Hypertension, hyperlipidemia, diabetes, MI [**2164**],  renal cancer
[**2172**], Obesity, obstructive sleep apnea with CPAP, left upper
lung
resection at [**Hospital1 2025**] [**2173**] s/p radiation in [**2173**], right foot plantar
fasciitis, CVA with right facial numbness, gastroparesis,
anxiety, gout, hard of hearing
Past Surgical History:
hiatal hernia repair x2, removal of gastric polyp, left upper
lung resection at [**Hospital1 2025**] [**2173**], right nephrectomy for renal cancer
[**2172**].


Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.


Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart

No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]

Labs: PT/INR for Coumadin ?????? indication post-op afib
Goal INR 2.0-2.5
First draw [**2182-6-24**]
Coumdin follow up to be arranged with PCP upon discharge from
rehab. Thank you

**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**


Followup Instructions:
You are scheduled for the following appointments

Surgeon: Dr. [**Last Name (STitle) **] (for Dr. [**Last Name (STitle) **] at [**Hospital1 **], [**Telephone/Fax (1) 6256**])
Thursday, [**2182-7-18**] 9am

Cardiologist:Dr. [**First Name (STitle) **], [**2182-7-23**], 1:15pm
Primary Care Dr.[**Last Name (STitle) **] [**7-18**] at 2:00pm

Labs: PT/INR for Coumadin ?????? indication post-op afib
Goal INR 2.0-2.5
First draw [**2182-6-24**]
Coumdin follow up to be arranged with PCP upon discharge from
rehab. Thank you

**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**

Follow up with PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], regarding adrenal nodule noted on
CT scan- MRI recommended for follow up.



Completed by:[**2182-6-23**]
{'Coronary atherosclerosis of native coronary artery,Intermediate coronary syndrome,Atrial fibrillation,Personal history of malignant neoplasm of kidney,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other and unspecified hyperlipidemia,Obstructive sleep apnea (adult)(pediatric),Other late effects of cerebrovascular disease,Disturbance of skin sensation,Gastroparesis,Personal history of malignant neoplasm of bronchus and lung,Obesity, unspecified,Body Mass Index 38.0-38.9, adult,Unspecified essential hypertension,Personal history of irradiation, presenting hazards to health'}


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: syncope

PRESENT ILLNESS: 68 year old male with hypertension,
diabetes, hyperlipidemia, obesity and COPD. Work up for history
of syncope included positive stress test at [**Hospital6 88998**].Cath revealed 3VD and he was transferred in for CABG.

MEDICAL HISTORY: Hypertension, hyperlipidemia, diabetes, MI [**2164**],  renal cancer
[**2172**], Obesity, obstructive sleep apnea with CPAP, left upper
lung
resection at [**Hospital1 2025**] [**2173**] s/p radiation in [**2173**], right foot plantar
fasciitis, CVA with right facial numbness, gastroparesis,
anxiety, gout, hard of hearing
Past Surgical History:
hiatal hernia repair x2, removal of gastric polyp, left upper
lung resection at [**Hospital1 2025**] [**2173**], right nephrectomy for renal cancer
[**2172**].

MEDICATION ON ADMISSION: diltiazem 180 mg daily, Isorbide mononitrate 30 mg daily, toprol
XL 12.5 daily, Dipyridamole 25mg [**Hospital1 **], lasiz 40mg daily,
omeprazole 40 mg daily, Januvia 100mg daily, Metformin 500mg
[**Hospital1 **],
simvastatin 80mg daily, ultram prn, spiriva 18mcgs daily, ASA
325
daily, genfibrozil 300mg [**Hospital1 **], allopurinol 300mg daily, xanax .25
hs.

ALLERGIES: OxyContin

PHYSICAL EXAM: Pulse: 63 Resp: 18 O2 sat: 98% RA
B/P  Right: 137/60   Left:
Height: 5'[**81**]"    Weight: 132.3 kg

FAMILY HISTORY: mother died at 91 with multiple CVAs, MI, and
Cancer. father died of MI at 71. Brothers alive at age 70 and 64
- older brother has cancer

SOCIAL HISTORY: Last Dental Exam: 2 years ago
Lives with: Widowed. Has girlfriend. Lives alone in [**Location (un) **]
Occupation: Gun store owner
Tobacco: smoked 3ppd of cigars for 30 years, quit [**2173**]
ETOH: none 

### Response:
{'Coronary atherosclerosis of native coronary artery,Intermediate coronary syndrome,Atrial fibrillation,Personal history of malignant neoplasm of kidney,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other and unspecified hyperlipidemia,Obstructive sleep apnea (adult)(pediatric),Other late effects of cerebrovascular disease,Disturbance of skin sensation,Gastroparesis,Personal history of malignant neoplasm of bronchus and lung,Obesity, unspecified,Body Mass Index 38.0-38.9, adult,Unspecified essential hypertension,Personal history of irradiation, presenting hazards to health'}
