CHIEF COMPLAINT: OSH transfer for CABG

PRESENT ILLNESS: 68 F with morbid obesity, HTN, NIDDM, and hypercholersterolemia,
transfer from OSH with RP bleed s/p cath and for possible CABG,
now transferred to CCU service after surgery delayed due to
infectious issues.
.
Admitted to [**Hospital1 **] [**2129-8-25**] with intermittent CP, SOB and
fatigue for 3 weeks; had significant anteriolateral ST segment
depressions and was treated with heparin, integralin, aspirin,
and sublingual nitro. Pt underwent cardiac catheterization on
[**2129-8-25**], complicated by likely femoral artery lacteration.  This
caused a retroperitoneal bleed with hypotension treated with
fluids and transfusion of PRBCs and neo. Cath revealed 3 VD -
100% occlusion of proximal RCA, long 70% stenosis of mid LAD,
and long 80% stenosis of mid-LCx. On day of transfer ([**8-27**]) she
became hypotensive, dropped her HCT, and was intubated
(reportedly due to pulmonary edema). Received 1 unit PRBCs at
OSH and 4 units since admission to [**Hospital1 18**].  CT scan as below (6x6
cm hematoma with no evidence of active extravasation).
.
Troponin peak at OSH 0.51 (MB 13.6 on [**8-25**]; patient had another
bump in cardiac enzymes here peaking at troponin 9.45 with CKs
2429 (162).  Following transfer she developed fevers to 102 with
continued hypotension requiring pressor therapy.  Vanco/zosyn
started on [**2129-8-29**].  Now transfer to CCU service for further
managment of her cardiac and medical issues while surgery on
hold due to infection.
.
Review of symptoms deferred [**1-22**] patient intubation/sedation;
refer to prior admit note for further details.

MEDICAL HISTORY: - Obesity
- HTN
- Diabetes type II x 15 years (patient has refused multiple
treatments for this in the past)
- Peripheral neuropathy
- PVD (details unknown)
- Hyperlipidemia

MEDICATION ON ADMISSION: Amitryptiline
metformin
metoprolol
diovan

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On Transfer to CCU:
VS: Tc 100.1, Tm 101.1, BP 127/60 (85-132), HR 78, RR 13, O2 97%
on AC 0.5 FiO2, 700 x12 PEEP 8
Gen: obese female NAD, intubated and sedated
HEENT: NCAT. Sclera anicteric. PERRL 3->2. MMM. ETT in place
Neck: Supple with JVP of at least 5 cm ASA.
CV: RR, normal S1, S2. [**1-26**] SM at LUSB
Chest: Coarse on vent. No crackles, wheeze, rhonchi.  Decreased
at bases.
Abd: Obese, soft, +BS. NTND, No HSM.
Ext: Diffuse 1+ edema.  Bilat DP and PT pulses palbable but R PT
somewhat weak.  R groin ecchymotic, dressing in place. No
hematoma present.
Neuro: Sedated.  Withdraws to pain bilat LE and grimaces bilat
UE.

FAMILY HISTORY: There is no family history of premature coronary artery disease
or sudden death

SOCIAL HISTORY: Social history is significant for the absence of current tobacco
use. Alcohol/drug use unknown.
Subendocardial infarction, initial episode of care,Pneumonia due to other gram-negative bacteria,Hematoma complicating a procedure,Paroxysmal ventricular tachycardia,Cardiogenic shock,Unspecified septicemia,Severe sepsis,Acute respiratory failure,Acute kidney failure, unspecified,Acute systolic heart failure,Acute posthemorrhagic anemia,Hemorrhage of gastrointestinal tract, unspecified,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other and unspecified complications of medical care, not elsewhere classified,Hypovolemia,Unspecified essential hypertension,Morbid obesity,Pure hypercholesterolemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Coronary atherosclerosis of native coronary artery
Subendo infarct, initial,Pneumo oth grm-neg bact,Hematoma complic proc,Parox ventric tachycard,Cardiogenic shock,Septicemia NOS,Severe sepsis,Acute respiratry failure,Acute kidney failure NOS,Ac systolic hrt failure,Ac posthemorrhag anemia,Gastrointest hemorr NOS,Abn react-cardiac cath,Complic med care NEC/NOS,Hypovolemia,Hypertension NOS,Morbid obesity,Pure hypercholesterolem,DMII wo cmp nt st uncntr,Crnry athrscl natve vssl
Admission Date:  [**2129-8-27**]              Discharge Date:   [**2129-9-19**]

Date of Birth:  [**2061-8-7**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
OSH transfer for CABG

Major Surgical or Invasive Procedure:
-Placement of PICC line
-Cardiac Catheterization with placement of BMS to LCx and
placement of intra-aortic balloon pump

History of Present Illness:
68 F with morbid obesity, HTN, NIDDM, and hypercholersterolemia,
transfer from OSH with RP bleed s/p cath and for possible CABG,
now transferred to CCU service after surgery delayed due to
infectious issues.
.
Admitted to [**Hospital1 **] [**2129-8-25**] with intermittent CP, SOB and
fatigue for 3 weeks; had significant anteriolateral ST segment
depressions and was treated with heparin, integralin, aspirin,
and sublingual nitro. Pt underwent cardiac catheterization on
[**2129-8-25**], complicated by likely femoral artery lacteration.  This
caused a retroperitoneal bleed with hypotension treated with
fluids and transfusion of PRBCs and neo. Cath revealed 3 VD -
100% occlusion of proximal RCA, long 70% stenosis of mid LAD,
and long 80% stenosis of mid-LCx. On day of transfer ([**8-27**]) she
became hypotensive, dropped her HCT, and was intubated
(reportedly due to pulmonary edema). Received 1 unit PRBCs at
OSH and 4 units since admission to [**Hospital1 18**].  CT scan as below (6x6
cm hematoma with no evidence of active extravasation).
.
Troponin peak at OSH 0.51 (MB 13.6 on [**8-25**]; patient had another
bump in cardiac enzymes here peaking at troponin 9.45 with CKs
2429 (162).  Following transfer she developed fevers to 102 with
continued hypotension requiring pressor therapy.  Vanco/zosyn
started on [**2129-8-29**].  Now transfer to CCU service for further
managment of her cardiac and medical issues while surgery on
hold due to infection.
.
Review of symptoms deferred [**1-22**] patient intubation/sedation;
refer to prior admit note for further details.


Past Medical History:
- Obesity
- HTN
- Diabetes type II x 15 years (patient has refused multiple
treatments for this in the past)
- Peripheral neuropathy
- PVD (details unknown)
- Hyperlipidemia


Social History:
Social history is significant for the absence of current tobacco
use. Alcohol/drug use unknown.

Family History:
There is no family history of premature coronary artery disease
or sudden death

Physical Exam:
On Transfer to CCU:
VS: Tc 100.1, Tm 101.1, BP 127/60 (85-132), HR 78, RR 13, O2 97%
on AC 0.5 FiO2, 700 x12 PEEP 8
Gen: obese female NAD, intubated and sedated
HEENT: NCAT. Sclera anicteric. PERRL 3->2. MMM. ETT in place
Neck: Supple with JVP of at least 5 cm ASA.
CV: RR, normal S1, S2. [**1-26**] SM at LUSB
Chest: Coarse on vent. No crackles, wheeze, rhonchi.  Decreased
at bases.
Abd: Obese, soft, +BS. NTND, No HSM.
Ext: Diffuse 1+ edema.  Bilat DP and PT pulses palbable but R PT
somewhat weak.  R groin ecchymotic, dressing in place. No
hematoma present.
Neuro: Sedated.  Withdraws to pain bilat LE and grimaces bilat
UE.


Pertinent Results:
[**2129-9-5**] echo
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild regional left ventricular systolic
dysfunction with severe hypokinesis of the inferior and
inferolateral walls. The remaining segments contract normally
(LVEF = 40 %). Right ventricular chamber size and free wall
motion are normal. The aortic valve is normal. The mitral valve
leaflets are mildly thickened. There is no pericardial effusion.

Compared with the prior study (images reviewed) of [**2129-8-30**], left
ventricular function is similar.

[**2129-9-5**] CT torso
1. 7 x 7 cm right pelvic hematoma extending into the inguinal
region with
mild perihematoma stranding. No focal abscesses or fluid
collections to
explain patient's symptoms.
2. Distended sludge and stone-filled gallbladder, unchanged
since the
appearance on ultrasound yesterday.
3. Bilateral pleural effusions and atelectasis.
4. Multiple hypoattenuating renal lesions the largest in the
interpolar left
kidney may represent a simple cyst, others are too [**Known lastname **] to
characterize.
5. Residual contrast in the kidneys from a recent cardiac
catheterization
suggesting acute renal failure.

[**9-3**] c. cath
1. Three vessel coronary artery disease.
2. Elevated filling pressures of both ventricles, elevated
pulmonary
pressures consistent with LV failure.
3.  Successful PTCA and stenting of the proximal left circumflex
with a
bare metal stent.
4.  Successful placement of a 30cc IABP via the right femoral
artery.


Brief Hospital Course:
68 F with morbid obesity, DM II, HTN; transfer from OSH with 3VD
on cath and RP bleed due to femoral artery laceration. Now with
shock likely related to sepsis.
.
# CAD/Ischemia: Ruled in for MI at OSH. Recieved coronary
catheterization which showed 3vd and no intervenable culprit
lesion. She developed a retroperitoneal bleed secondary to
femoral artery laceration and was transfered to [**Hospital1 18**] for
possible CABG. While preparing for transfer she became
hypotensive and went into respiratory failure thought secondary
to pulmonary edema. She was intubated on arrival to [**Hospital1 18**]. She
was initially admitted to the cardiac surgery service but then
transferred to CCU after developing a VAP. While being treated
for her VAP she became hypotensive and an EKG showed new ST
elevations, she was taken to the cath lab and recieved a BMS to
the LCx and transfered back to CCU w/ balloon pump/pressors. She
was quickly weaned off of the balloon pump but remained on
pressors for several days for suspected concomitant septic
shock.
.
# Hypotension/shock. Mixed picture due to impaired cardiac
function (inferior HK) and sepsis/shock; also hypovolemic at
times with rapid bleeding. Appeared to be combination of
septic/cardiogenic shock as she had warm extremities and the
shock resolved gradually over several days w/ treatment of her
CAD and appropriate Abx. Several days after her stent she was
able to be weaned from pressors and then several days after that
she was able to be weaned from the ventilator and extubated.
After extubation she actually became hypertensive and required
antihypertensive medication.
.
# Pump: EF 40%, mild regional left ventricular systolic
dysfunction with severe hypokinesis of the inferior and
inferolateral walls. She appeared to be severely volume
overloaded w/ edema and wet lung exam and needed to be diuresed
several liters before she could be extubated. After extubation
she had several episodes of flash pulmonary edema precipitated
by either positional changes or systemic hypertension. It was
unknown as to whether the systemic hypertension had caused or
was caused by her flash pulmonary edema. Her pulmonary edema
responded reliably and quickly to IV nitro drip and she
continued to require diuresis for several days after extubation
but her functional status improved daily w/ diuresis.
.
# Rhythm: NSR, had several episodes of hypotensive VT which
required shocks, all of these occured during one night several
days after she was percutaneously revascularized. She was
initially started on amiodarone but once she clinically improved
and it was felt that she no longer had triggers for ectopy this
was stopped.
.
She should continue to be monitored on telemetry at the acute
rehab facility.  Although we believe that her risk of
ventricular tachycardia is minimal now that the ischemic insult
has been removed, she should continue to have close monitoring
of her heart rhythm.
.
# VAP: CXR/chest CT was not impressive for PNA, but when Abx
were stopped her WBC increased dramatically and she spiked
fevers. Her sputum eventually grew out multi resistant
Acinetobacter baumanii sensitive to high dose unasyn. High dose
unasyn was started and her fevers stopped, her hypotension began
to resolve and her WBC's gradually decreased to normal. Her
septic shock initially prompted concern for abdominal source as
she grimaced when pressure was applied to her RUQ and her labs
were concerning for cholestasis. RUQ u/s was negative and her
labs were attributed to intrahepatic cholestasis secondary to
systemic sepsis.
.
# ARF: Significant contrast exposure given cath, angios, CT with
contrast. Also consider atheroembolic, AIN from unknown new med,
prerenal or ATN from sepsis or hypovolemia. Her creatinine
continued to trend downward until several days before d/c at
which point it increased and it was decided that she had
probably been overdiuresed. On day of d/c her Cr was 1.9 still
up from baseline of around 1.
.
# Positive blood culture: [**12-24**] only, subsequents negative. Likely
contaminant. On vanco for GPCs in sputum.
.
# Hypertension: After extubation her blood pressure was
elevated, even after uptitration of her BB and ACEI.  We started
her on her home Lasix dose and added hydrochlorthiazide to
potentiate the loop diuretic.  This resulted in excellent
diuresis and blood pressure control.  Her current
antihypertensive regimen includes lisinopril,
hydrochlorthiazide, Lasix, and metoprolol.
.
# Diabetes: She currently has adequate glycemic control on
regular insulin sliding scale and 22U glargine qhs.  This can be
continued as outpatient.

Medications on Admission:
Amitryptiline
metformin
metoprolol
diovan

Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]

Discharge Diagnosis:
Primary
Coronary artery disease
Ventilator associated pneumonia, septic shock

Secondary

Obesity
Diabetes type II poorly controled


Discharge Condition:
Stable

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]

Completed by:[**2129-9-19**]
{'Subendocardial infarction, initial episode of care,Pneumonia due to other gram-negative bacteria,Hematoma complicating a procedure,Paroxysmal ventricular tachycardia,Cardiogenic shock,Unspecified septicemia,Severe sepsis,Acute respiratory failure,Acute kidney failure, unspecified,Acute systolic heart failure,Acute posthemorrhagic anemia,Hemorrhage of gastrointestinal tract, unspecified,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other and unspecified complications of medical care, not elsewhere classified,Hypovolemia,Unspecified essential hypertension,Morbid obesity,Pure hypercholesterolemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Coronary atherosclerosis of native coronary artery'}


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: OSH transfer for CABG

PRESENT ILLNESS: 68 F with morbid obesity, HTN, NIDDM, and hypercholersterolemia,
transfer from OSH with RP bleed s/p cath and for possible CABG,
now transferred to CCU service after surgery delayed due to
infectious issues.
.
Admitted to [**Hospital1 **] [**2129-8-25**] with intermittent CP, SOB and
fatigue for 3 weeks; had significant anteriolateral ST segment
depressions and was treated with heparin, integralin, aspirin,
and sublingual nitro. Pt underwent cardiac catheterization on
[**2129-8-25**], complicated by likely femoral artery lacteration.  This
caused a retroperitoneal bleed with hypotension treated with
fluids and transfusion of PRBCs and neo. Cath revealed 3 VD -
100% occlusion of proximal RCA, long 70% stenosis of mid LAD,
and long 80% stenosis of mid-LCx. On day of transfer ([**8-27**]) she
became hypotensive, dropped her HCT, and was intubated
(reportedly due to pulmonary edema). Received 1 unit PRBCs at
OSH and 4 units since admission to [**Hospital1 18**].  CT scan as below (6x6
cm hematoma with no evidence of active extravasation).
.
Troponin peak at OSH 0.51 (MB 13.6 on [**8-25**]; patient had another
bump in cardiac enzymes here peaking at troponin 9.45 with CKs
2429 (162).  Following transfer she developed fevers to 102 with
continued hypotension requiring pressor therapy.  Vanco/zosyn
started on [**2129-8-29**].  Now transfer to CCU service for further
managment of her cardiac and medical issues while surgery on
hold due to infection.
.
Review of symptoms deferred [**1-22**] patient intubation/sedation;
refer to prior admit note for further details.

MEDICAL HISTORY: - Obesity
- HTN
- Diabetes type II x 15 years (patient has refused multiple
treatments for this in the past)
- Peripheral neuropathy
- PVD (details unknown)
- Hyperlipidemia

MEDICATION ON ADMISSION: Amitryptiline
metformin
metoprolol
diovan

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On Transfer to CCU:
VS: Tc 100.1, Tm 101.1, BP 127/60 (85-132), HR 78, RR 13, O2 97%
on AC 0.5 FiO2, 700 x12 PEEP 8
Gen: obese female NAD, intubated and sedated
HEENT: NCAT. Sclera anicteric. PERRL 3->2. MMM. ETT in place
Neck: Supple with JVP of at least 5 cm ASA.
CV: RR, normal S1, S2. [**1-26**] SM at LUSB
Chest: Coarse on vent. No crackles, wheeze, rhonchi.  Decreased
at bases.
Abd: Obese, soft, +BS. NTND, No HSM.
Ext: Diffuse 1+ edema.  Bilat DP and PT pulses palbable but R PT
somewhat weak.  R groin ecchymotic, dressing in place. No
hematoma present.
Neuro: Sedated.  Withdraws to pain bilat LE and grimaces bilat
UE.

FAMILY HISTORY: There is no family history of premature coronary artery disease
or sudden death

SOCIAL HISTORY: Social history is significant for the absence of current tobacco
use. Alcohol/drug use unknown. 

### Response:
{'Subendocardial infarction, initial episode of care,Pneumonia due to other gram-negative bacteria,Hematoma complicating a procedure,Paroxysmal ventricular tachycardia,Cardiogenic shock,Unspecified septicemia,Severe sepsis,Acute respiratory failure,Acute kidney failure, unspecified,Acute systolic heart failure,Acute posthemorrhagic anemia,Hemorrhage of gastrointestinal tract, unspecified,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other and unspecified complications of medical care, not elsewhere classified,Hypovolemia,Unspecified essential hypertension,Morbid obesity,Pure hypercholesterolemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Coronary atherosclerosis of native coronary artery'}
