CHIEF COMPLAINT: SHORTNESS OF BREATH

PRESENT ILLNESS: Ms [**Known lastname 12130**] is a 71 year old woman with history of insulin
dependent diabetes, peripheral [**Known lastname 1106**] disease, hyperthyroidism
and CAD, s/p recent STEMI, s/p CABG x 4 in [**10-17**] (LIMA to LAD,
SVG to OM1, OM2 and RCA), s/p left ventricular aneurysm repair,
presenting with shortness for the last four days.
.
Patient repors she has been feeling short of breath with normal
daily activities (making her bed, going to the kitchen) that was
new. She also describes rhinorrhea, watery eyes and a dry cough.
She presented to her PCP with these complaints and she was
empirically treated for a community acquired pneumonia. Cardiac
enzymes were also drawn and patient was called to present to ED
after these returned elevated (per report 1.5, unclear if Tn T
or I).
.
Patient denies any chest pain, nausea, vomiting, dizziness,
light headedness, palpitations, syncope or pre-syncope. She does
point out however that she has never had symptoms with any of
her heart attacks but rather that these present with URI
symptoms.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism. She does report
excessive bleeding previously after a cardiac cath performed at
[**Hospital1 336**] complicated by RP bleed. No excessive bleeding after recent
bypass however. Denies any hemoptysis, black stools or red
stools.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
but does report chronic bilateral ankle edema. Denies
palpitations, syncope or presyncope.
.
In the ED, VS 97.1, Bp 140/84, HR 108, RR24. patient given ASA,
BB, and started on IV heparin. Admitted for further evaluation.

MEDICAL HISTORY: - MI in [**2103**] c/b ventricular aneurysm
- CABG: in [**2116-10-31**] x4
LIMA to LAD, SVG to OM1, SVG to OM2, SVG to RCA, LCx
endarterectomy
- s/p left ventricular aneurysm repair (Dor procedure?)
PAST MEDICAL HISTORY:
-- PAD s/p left SFA angioplasty and stent
-- DM2
-- HTN
-- OA
-- spinal stenosis
-- Hyperthyroidism
-- s/p cholecystectomy
-- s/p appendectomy
-- s/p TAH
.
CARDIAC RISK FACTORS: (+) Diabetes, (+) Dyslipidemia,
(+)Hypertension

MEDICATION ON ADMISSION: ASA 325mg
Lipitor 80mg
Lisinopril 10mg
Metoprolol 50mg
Plavix
Protonix
Tapazole 10mg
Insulin
-- Levemir 34 units at night
-- Humalog 8 with breakfast, 14 with dinner.
Clorazepate 3.75 mg qday

ALLERGIES: Bactrim

PHYSICAL EXAM: VS: 97.9 112/70 83 18 98% 2L NC
GENERAL: Anxious elderly woman in NAD. Oriented x3. Affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: No family history of early MI, otherwise non-contributory.

SOCIAL HISTORY: Lives with her husband in [**Name (NI) 392**], [**Name6 (MD) **] is NP and is very
involved in her care. Denies tobacco, EtOH
Subendocardial infarction, initial episode of care,Acute on chronic systolic heart failure,Coronary atherosclerosis of autologous vein bypass graft,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Pure hypercholesterolemia
Subendo infarct, initial,Ac on chr syst hrt fail,Crn ath atlg vn bps grft,DMII wo cmp nt st uncntr,Hypertension NOS,Pure hypercholesterolem
Admission Date:  [**2116-12-26**]              Discharge Date:   [**2117-1-4**]

Date of Birth:  [**2045-10-30**]             Sex:   F

Service: MEDICINE

Allergies:
Bactrim

Attending:[**First Name3 (LF) 1436**]
Chief Complaint:
SHORTNESS OF BREATH

Major Surgical or Invasive Procedure:
cardiac catheterization

History of Present Illness:
Ms [**Known lastname 12130**] is a 71 year old woman with history of insulin
dependent diabetes, peripheral [**Known lastname 1106**] disease, hyperthyroidism
and CAD, s/p recent STEMI, s/p CABG x 4 in [**10-17**] (LIMA to LAD,
SVG to OM1, OM2 and RCA), s/p left ventricular aneurysm repair,
presenting with shortness for the last four days.
.
Patient repors she has been feeling short of breath with normal
daily activities (making her bed, going to the kitchen) that was
new. She also describes rhinorrhea, watery eyes and a dry cough.
She presented to her PCP with these complaints and she was
empirically treated for a community acquired pneumonia. Cardiac
enzymes were also drawn and patient was called to present to ED
after these returned elevated (per report 1.5, unclear if Tn T
or I).
.
Patient denies any chest pain, nausea, vomiting, dizziness,
light headedness, palpitations, syncope or pre-syncope. She does
point out however that she has never had symptoms with any of
her heart attacks but rather that these present with URI
symptoms.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism. She does report
excessive bleeding previously after a cardiac cath performed at
[**Hospital1 336**] complicated by RP bleed. No excessive bleeding after recent
bypass however. Denies any hemoptysis, black stools or red
stools.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
but does report chronic bilateral ankle edema. Denies
palpitations, syncope or presyncope.
.
In the ED, VS 97.1, Bp 140/84, HR 108, RR24. patient given ASA,
BB, and started on IV heparin. Admitted for further evaluation.



Past Medical History:
- MI in [**2103**] c/b ventricular aneurysm
- CABG: in [**2116-10-31**] x4
LIMA to LAD, SVG to OM1, SVG to OM2, SVG to RCA, LCx
endarterectomy
- s/p left ventricular aneurysm repair (Dor procedure?)
PAST MEDICAL HISTORY:
-- PAD s/p left SFA angioplasty and stent
-- DM2
-- HTN
-- OA
-- spinal stenosis
-- Hyperthyroidism
-- s/p cholecystectomy
-- s/p appendectomy
-- s/p TAH
.
CARDIAC RISK FACTORS: (+) Diabetes, (+) Dyslipidemia,
(+)Hypertension


Social History:
Lives with her husband in [**Name (NI) 392**], [**Name6 (MD) **] is NP and is very
involved in her care. Denies tobacco, EtOH

Family History:
No family history of early MI, otherwise non-contributory.

Physical Exam:
VS: 97.9 112/70 83 18 98% 2L NC
GENERAL: Anxious elderly woman in NAD. Oriented x3. Affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

NECK: Supple with JVP of 16 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, distant heart sounds with normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c, 3+ bilateral lower extremity edema. No
femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+


Pertinent Results:
EKG: ([**2116-12-26**])
NSR at 87 with incomplete right bundle branch block, TWI at aVL,
I and V2, with 1mm ST elevation in V2-V3.
.
2D-ECHOCARDIOGRAM: ([**2116-12-26**])
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. Overall left ventricular systolic function
is severely depressed (LVEF= 20-30 %) secondary to severe
hypokinesis of the anterior septum and anterior free wall, with
extensive apical akinesis and focal apical dyskinesis (no
definite apical thrombus seen but cannot exclude with
certainty). There is no ventricular septal defect. Right
ventricular chamber size is normal. with focal hypokinesis of
the apical free wall. The aortic arch is mildly dilated. There
are focal calcifications in the aortic arch. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2116-10-5**], the left ventricular ejection fraction is
further depressed, secondary to extensive hypokinesis of the
anterior septum and anterior free wall.
.
ETT: ([**2116-12-23**])
Ramping cycle ergometer protocol, 3 mins
INTERPRETATION: This 71 yo woman (h/o silent NSTEMI and s/p CABG
on
[**2116-10-12**]) was referrred to the lab for evaluation. The patient

completed 3.75 minutes on a ramping cycle ergometer protocol and
was
stopped due to marked shortness of breath and fatigue. This
represents a limited exercise tolerance for her age (~ 3.5
METS). The patient denied any neck, chest, arm or back
discomfort throughout the study. No significant ST segment
changes were noted from baseline. The rhythm was sinus with one
single VPB noted in recovery. Appropriate increased in blood
pressure noted with exercise. Blunted heart rate response to
exercise in the presence of beta-blockade therapy.
IMPRESSION: Marked shortness of breath noted at a low workload.
No
ischemic EKG changes noted.
.
CARDIAC CATH: ([**2116-12-29**])
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Severe systolic ventricular dysfunction.
3. Occluded SVG-OM venous conduits
4. Moderate mitral regurgitation.
.
CARDIAC CATH: ([**2116-12-31**])
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Successful placement of an IABP via the left femoral artery.
3. Successful PTCA and stenting of the left main - proximal left

circumflex with a Xience drug eluting stent.
4.  Successful PTCA of the proximal left anterior descending
artery.
.
CHEST X-RAY:
Personal review demonstrates partially rotated film with blunted
left costophrenic angle and right lower lobe opacity, with
minimal change from prior in [**10-17**] (with exception of left
sublavian line which not present now).
.
RENAL ULTRASOUND: [**2116-12-30**]
Bilateral simple renal cysts. Otherwise normal renal ultrasound.
.
LABS:
[**2116-12-26**] 01:30AM   WBC-9.8 RBC-4.08* HGB-11.9* HCT-35.5* MCV-87
MCH-29.1 MCHC-33.5 RDW-15.3
[**2116-12-26**] 01:30AM   NEUTS-82.6* LYMPHS-10.2* MONOS-3.5 EOS-3.4
BASOS-0.3
[**2116-12-26**] 01:30AM   PLT COUNT-216
[**2116-12-26**] 01:30AM   CK(CPK)-117
[**2116-12-26**] 01:30AM   cTropnT-0.44*
[**2116-12-26**] 01:30AM   CK-MB-11* MB INDX-9.4*
[**2116-12-26**] 09:15AM   CK(CPK)-140
[**2116-12-26**] 09:15AM   CK-MB-13* MB INDX-9.3* cTropnT-0.47*
[**2116-12-26**] 05:25PM   CK(CPK)-143*
[**2116-12-26**] 05:25PM   CK-MB-12* MB INDX-8.4* cTropnT-0.49*

Brief Hospital Course:
71 year old woman with insulin dependent diabetes, 3 vessel CAD
s/p CABG, presenting with dyspnea and NSTEMI found to have
occlusion of 3 of 4 by-pass grafts now s/p LCX stenting and PTCA
of the LAD now transferred to the CCU with IABP.
.
# ACS/ NSTEMI: Initial cardiac catherization showed restenosis
of bypass grafts (except SVG-RCA) not felt to be repeat surgical
candidate and thus underwent LCX stenting and PTCA to LAD.  She
had an intra-aortic baloon pump placed overnight and was
transferred to the ccu.  There her balloon pump was weaned
easily over the first day.  Medical management of CAD including
heparin gtt, plavix, ASA, statin were continued.
.
# Acute SYSTOLIC HEART FAILURE: Admitted with systolic heart
failure and s/p diuresis with lasix gtt. Patient improved after
diuresis and was without dyspnea.  ACEI and beta blocker were
continued.  In the ccu, no further diuresis was required. She
was evaluated by PT and her ambulatory O2 sats were 93% on room
air.
.
# RHYTHM: She remained in normal sinus rhythm.
.
# DIABETES: Her insulin regimen was uptitrated to improve blood
sugar control.
.
# HYPERTHYROIDISM: TSH was normal; methimazole was continued




Medications on Admission:
ASA 325mg
Lipitor 80mg
Lisinopril 10mg
Metoprolol 50mg
Plavix
Protonix
Tapazole 10mg
Insulin
-- Levemir 34 units at night
-- Humalog 8 with breakfast, 14 with dinner.
Clorazepate 3.75 mg qday


Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Methimazole 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Levemir 100 unit/mL Solution Sig: Forty Two (42) units
Subcutaneous at bedtime.
8. Humalog 100 unit/mL Cartridge Sig: as directed  Subcutaneous
twice a day: please take 4 units before breakfast and 10 units
before dinner. .
9. Clorazepate Dipotassium 3.75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily) as needed for anxiety.
10. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: 1.5
Tablet Sustained Release 24 hrs PO once a day.
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2*
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 86**] VNA

Discharge Diagnosis:
NSTEMI
Systolic Heart Failure, Acute on chronic

Secondary Issues:
Peripheral [**Location (un) 1106**] disease
Hypertension
Hypothyroidism
osteoarthritis
Spinal stenosis


Discharge Condition:
Stable.  Ambulating without assistance.  Breathing comfortably
on room air.


Discharge Instructions:
You were admitted with shortness of breath.  You were found to
have a small heart attack (NSTEMI).  You were treated with
medications to prevent further damage to your heart.  You
underwent cardiac catheterization and found to have blockages in
multiple arteries including the grafts that were created during
your recent CABG.  Your heart function was evaluated and you
were found to have slightly worse heart function.  You were
given medications to remove excess fluid from your body. You had
a second catheterization and had stents placed in some of your
blocked arteries.

Please keep all of your follow-up appointments.

Please continue your medications as prescribed.  We made the
following changes to your medicaiton regimen.
1. We increased the dose of your Toprolol.  Please take Toprolol
XL 50 mg tablets, take 1.5 tablets by mouth daily
2. We decreased the dose of your Lisinopril.  Please take
lisinopril 5 mg daily instead of 10 mg daily.
3. We increased the dose of your levemir to 42 units at bedtime.
 We decreased the dose of your Humalog to 4 units before
breakfast and 10 units before dinner.  Please check your blood
sugars before breakfast and before dinner.

Please contact your doctor or go to the emergency room if you
experience any of the following symptoms: chest pain or
pressure, worsening shortness of breath, difficulty breathing
with minimal exertion, lightheadedness/dizziness or other
concerning symtpoms.

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: none

Followup Instructions:
We recommend that you follow up with your cardiologist, Dr.
[**Last Name (STitle) **], next week.  We have made an appointment for you on
Monday, [**2117-1-11**] at 2:45pm in the [**Location (un) 620**] office.  The
office phone number is ([**Telephone/Fax (1) 4105**] if you have questions.

Please make an appointment to follow up with your Diabetes
Doctor in the next 1-2 weeks to follow up on your blood sugar
control.

Please make an appointment to see your primary care physcian, Dr
[**Last Name (STitle) **] [**Name (STitle) 75782**], in the next 1-2 weeks.  His telephone number is
[**Telephone/Fax (1) 7164**].

You had the following appointments scheduled previously:
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2117-6-14**]
11:00
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2117-6-14**] 11:30



Completed by:[**2117-1-10**]
{'Subendocardial infarction, initial episode of care,Acute on chronic systolic heart failure,Coronary atherosclerosis of autologous vein bypass graft,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Pure hypercholesterolemia'}


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: SHORTNESS OF BREATH

PRESENT ILLNESS: Ms [**Known lastname 12130**] is a 71 year old woman with history of insulin
dependent diabetes, peripheral [**Known lastname 1106**] disease, hyperthyroidism
and CAD, s/p recent STEMI, s/p CABG x 4 in [**10-17**] (LIMA to LAD,
SVG to OM1, OM2 and RCA), s/p left ventricular aneurysm repair,
presenting with shortness for the last four days.
.
Patient repors she has been feeling short of breath with normal
daily activities (making her bed, going to the kitchen) that was
new. She also describes rhinorrhea, watery eyes and a dry cough.
She presented to her PCP with these complaints and she was
empirically treated for a community acquired pneumonia. Cardiac
enzymes were also drawn and patient was called to present to ED
after these returned elevated (per report 1.5, unclear if Tn T
or I).
.
Patient denies any chest pain, nausea, vomiting, dizziness,
light headedness, palpitations, syncope or pre-syncope. She does
point out however that she has never had symptoms with any of
her heart attacks but rather that these present with URI
symptoms.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism. She does report
excessive bleeding previously after a cardiac cath performed at
[**Hospital1 336**] complicated by RP bleed. No excessive bleeding after recent
bypass however. Denies any hemoptysis, black stools or red
stools.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
but does report chronic bilateral ankle edema. Denies
palpitations, syncope or presyncope.
.
In the ED, VS 97.1, Bp 140/84, HR 108, RR24. patient given ASA,
BB, and started on IV heparin. Admitted for further evaluation.

MEDICAL HISTORY: - MI in [**2103**] c/b ventricular aneurysm
- CABG: in [**2116-10-31**] x4
LIMA to LAD, SVG to OM1, SVG to OM2, SVG to RCA, LCx
endarterectomy
- s/p left ventricular aneurysm repair (Dor procedure?)
PAST MEDICAL HISTORY:
-- PAD s/p left SFA angioplasty and stent
-- DM2
-- HTN
-- OA
-- spinal stenosis
-- Hyperthyroidism
-- s/p cholecystectomy
-- s/p appendectomy
-- s/p TAH
.
CARDIAC RISK FACTORS: (+) Diabetes, (+) Dyslipidemia,
(+)Hypertension

MEDICATION ON ADMISSION: ASA 325mg
Lipitor 80mg
Lisinopril 10mg
Metoprolol 50mg
Plavix
Protonix
Tapazole 10mg
Insulin
-- Levemir 34 units at night
-- Humalog 8 with breakfast, 14 with dinner.
Clorazepate 3.75 mg qday

ALLERGIES: Bactrim

PHYSICAL EXAM: VS: 97.9 112/70 83 18 98% 2L NC
GENERAL: Anxious elderly woman in NAD. Oriented x3. Affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: No family history of early MI, otherwise non-contributory.

SOCIAL HISTORY: Lives with her husband in [**Name (NI) 392**], [**Name6 (MD) **] is NP and is very
involved in her care. Denies tobacco, EtOH 

### Response:
{'Subendocardial infarction, initial episode of care,Acute on chronic systolic heart failure,Coronary atherosclerosis of autologous vein bypass graft,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Pure hypercholesterolemia'}
