CHIEF COMPLAINT: dyspnea

PRESENT ILLNESS: Mr. [**Known lastname 104620**] is an 89 yo M with HTN, HLD, DMII, moderate AS (valve
area 1.0 cm^2) and CKD who presented with worsening chest pain,
and admitted for elective cardiac cath. Please see Dr. [**Initials (NamePattern4) 104621**] [**Last Name (NamePattern4) 196**] admission note for full details. In brief,
patient noted worsening exertional chest discomfort over the
past few months, with decreased exercise tolerance (unable to
walk ?????? mile without chest pain, and less resolution with rest).
He had a TTE with mildly depressed EF (50%) in [**6-26**], and an
exercise stress test showing a mild, fixed inferior wall defect
and global mild hypokinesis with a calculated left ventricular
ejection fraction is 46 %. As a result of his symptoms and the
above test results, he was admitted to [**Hospital1 18**] on [**2182-1-23**] for
pre-cath hydration prior to elective cardiac catherization.
.
In the cath lab today, patient received total fentanyl 82.5 mg
IV and midazolam 2 mg IV. Right and left heart cardiac
catherization was performed. Left heart cath revealed 2VD, with
a heavily calcified LAD 80% proximal, 90% serial mid, and 70%
distal disease, LCx 40% proximal stenosis and a 60% stenosis of
the ramus, and moderate aortic stenosis. Right heart cath
revealed both elevated left and right sided pressures. Rotablade
was performed on the LAD (2 more proximal lesions followed by
angioplasty). However, at that point, patient became confused,
stated his back was hurting and tried to move off of the cath
table despite requests to stay down, and contaminated the groin
site with his hand. At that point, the cardiac catherization was
stopped (no intervention on the distal lesion). He received 10
mg IV haldol total and 20 mg IV lasix, while in the cath lab.
Urine output unable to be measured due to condom cath being
pulled off by patient. An angioseal was placed for arterial
closure. He was started on integrillin and transferred to the
CCU for closer monitering.
.
In the CCU, he continued to be confused, and attempted to sit up
in bed despite having a venous sheath, and pull on his lines. He
received an extra 5 mg of IV haldol and was placed in 4 point
wrist restraints. He was able to follow most commands, but
unable to answer any review of systems.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension

MEDICATION ON ADMISSION: Lisinopril 40mg daily (on hold for past 2 days)
Glipizide 10mg daily
Actos 15mg daily
ASA 81mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T= afebrile BP= 133/59 HR= 75% RR=15 O2 sat= 95% on RA
GENERAL: agitated gentleman attempting to get out of bed and
pulling at lines.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: No know FH of cardiac disease, diabetes, no colon/proste/breast
cancer. Parents lived to 70s to 80s with no known medical
problems. Children in good health.

SOCIAL HISTORY: Patient was born in [**Country 4754**], moved to the US in [**2125**]. Worked in
construction as a labor foreman. Married x 54 years, with 3
children and 9 grandchildren. Denies tobacco or illicit drug
use. Occasional EtOH use
Coronary atherosclerosis of native coronary artery,Acute combined systolic and diastolic heart failure,Intermediate coronary syndrome,Chronic kidney disease, Stage IV (severe),Delirium due to conditions classified elsewhere,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Aortic valve disorders,Hyperpotassemia,Anemia, unspecified
Crnry athrscl natve vssl,Ac syst/diastol hrt fail,Intermed coronary synd,Chr kidney dis stage IV,Delirium d/t other cond,Hy kid NOS w cr kid I-IV,DMII wo cmp nt st uncntr,Aortic valve disorder,Hyperpotassemia,Anemia NOS
Admission Date:  [**2182-1-23**]              Discharge Date:   [**2182-1-28**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
dyspnea

Major Surgical or Invasive Procedure:
Cardiac Catheterization [**2182-1-24**]


History of Present Illness:
Mr. [**Known lastname 104620**] is an 89 yo M with HTN, HLD, DMII, moderate AS (valve
area 1.0 cm^2) and CKD who presented with worsening chest pain,
and admitted for elective cardiac cath. Please see Dr. [**Initials (NamePattern4) 104621**] [**Last Name (NamePattern4) 196**] admission note for full details. In brief,
patient noted worsening exertional chest discomfort over the
past few months, with decreased exercise tolerance (unable to
walk ?????? mile without chest pain, and less resolution with rest).
He had a TTE with mildly depressed EF (50%) in [**6-26**], and an
exercise stress test showing a mild, fixed inferior wall defect
and global mild hypokinesis with a calculated left ventricular
ejection fraction is 46 %. As a result of his symptoms and the
above test results, he was admitted to [**Hospital1 18**] on [**2182-1-23**] for
pre-cath hydration prior to elective cardiac catherization.
.
In the cath lab today, patient received total fentanyl 82.5 mg
IV and midazolam 2 mg IV. Right and left heart cardiac
catherization was performed. Left heart cath revealed 2VD, with
a heavily calcified LAD 80% proximal, 90% serial mid, and 70%
distal disease, LCx 40% proximal stenosis and a 60% stenosis of
the ramus, and moderate aortic stenosis. Right heart cath
revealed both elevated left and right sided pressures. Rotablade
was performed on the LAD (2 more proximal lesions followed by
angioplasty). However, at that point, patient became confused,
stated his back was hurting and tried to move off of the cath
table despite requests to stay down, and contaminated the groin
site with his hand. At that point, the cardiac catherization was
stopped (no intervention on the distal lesion). He received 10
mg IV haldol total and 20 mg IV lasix, while in the cath lab.
Urine output unable to be measured due to condom cath being
pulled off by patient. An angioseal was placed for arterial
closure. He was started on integrillin and transferred to the
CCU for closer monitering.
.
In the CCU, he continued to be confused, and attempted to sit up
in bed despite having a venous sheath, and pull on his lines. He
received an extra 5 mg of IV haldol and was placed in 4 point
wrist restraints. He was able to follow most commands, but
unable to answer any review of systems.


Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension

2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
Anemia
Chronic Kidney Disease (Baseline Cre 2.1)
Gout

Social History:
Patient was born in [**Country 4754**], moved to the US in [**2125**]. Worked in
construction as a labor foreman. Married x 54 years, with 3
children and 9 grandchildren. Denies tobacco or illicit drug
use. Occasional EtOH use

Family History:
No know FH of cardiac disease, diabetes, no colon/proste/breast
cancer. Parents lived to 70s to 80s with no known medical
problems. Children in good health.

Physical Exam:
VS: T= afebrile BP= 133/59 HR= 75% RR=15 O2 sat= 95% on RA
GENERAL: agitated gentleman attempting to get out of bed and
pulling at lines.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

NECK: Supple with JVP of 6 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, 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/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: AOX1 ('[**Known firstname **]', but unable to state location or date).
Unable to concentrate (cannot spell 'world' backwards). CN exam
limited due to inability to follow most fine commands, but no
gross deficiencies noted in [**3-1**]. squeezes both hands on
commands, dorsiflexes and plantar flexes feet on command.
appropriate gross sensation and proprioception on both arms and
legs. downgoing Babinski bilaterally. 1+ symmetric reflexes in
biceps and achilles tendons. unable to assess cerebellar
function or gait due to wrist restraints.
.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+


Pertinent Results:
===================
ADMISSION LABS:
===================
[**2182-1-24**] 05:55AM BLOOD WBC-6.0 RBC-3.00* Hgb-10.1* Hct-29.9*
MCV-100* MCH-33.6* MCHC-33.6 RDW-13.0 Plt Ct-224
[**2182-1-24**] 05:55AM BLOOD PT-14.7* PTT-31.4 INR(PT)-1.3*
[**2182-1-24**] 05:55AM BLOOD PT-14.7* PTT-31.4 INR(PT)-1.3*
[**2182-1-24**] 05:55AM BLOOD Glucose-77 UreaN-52* Creat-2.3* Na-138
K-5.2* Cl-108 HCO3-24 AnGap-11
[**2182-1-24**] 05:30PM BLOOD CK(CPK)-152
[**2182-1-24**] 05:55AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.1 Cholest-141
[**2182-1-24**] 05:55AM BLOOD Triglyc-111 HDL-27 CHOL/HD-5.2 LDLcalc-92
[**2182-1-25**] 03:09PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.029
[**2182-1-25**] 03:09PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-TR Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2182-1-25**] 03:09PM URINE RBC-2 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-<1 TransE-<1
[**2182-1-25**] 03:09PM URINE CastGr-1*
====================
DISCHARGE LABS:
====================
[**2182-1-28**] 05:20AM BLOOD WBC-7.4 RBC-2.77* Hgb-9.2* Hct-27.7*
MCV-100* MCH-33.2* MCHC-33.2 RDW-12.9 Plt Ct-214
[**2182-1-28**] 05:20AM BLOOD Glucose-149* UreaN-75* Creat-2.4* Na-138
K-5.0 Cl-106 HCO3-23 AnGap-14
[**2182-1-27**] 05:45AM BLOOD Calcium-8.4 Phos-4.9* Mg-2.2
.
====================
IMAGING/PROCEDURES:
====================
CARDIAC CATH [**2182-1-24**]:
1. Coronary angiography in this left dominant system
demonstrated two
vessel disease. The LMCA had no angiographically apparent
disease. The
LAD was diffusely calcified with a proximal 80% stenosis, 90%
mid
stenosis, and 70% distal stenosis. The LCx had a 40% proximal
stenosis
and a 60% stenosis of the ramus. The RCA was nondominant and had
no
angiographically apparent disease.
2. Resting hemodynamics revealed elevated right and left sided
filling
pressures with RVEDP 18mmHg and LVEDP 21mmHg. There was moderate
pulmonary arterial hypertension with PASP 61mmHg. The cardiac
index was
preserved at 2.33 L/min/m2. The SVR was normal at 1300
dynes-sec/cm5.
The systemic arterial blood pressure was normal with SBP 132mmHg
and DBP
63mmHg.
3. There was moderate aortic stenosis with valve area of 1.0cm2
with
mean gradient of 24.3mmHg.
4. Successful rotational atherectomy (1.5mm burr) and PTCA
(2.5mm
balloon) of the proximal and mid LAD.
5. Successful closure of the right femoral arteriotomy site with
a 6F
Angioseal device.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Serial LAD stenoses.
3. Moderate aortic stenosis.
4. Successful atherectomy and PTCA of the proximal and mid LAD.
.
CXR [**2182-1-26**]:The heart size is moderately enlarged, similar
compared to prior, and there are bilateral pleural effusions
with volume loss in both lower lobes. There is pulmonary
vascular re-distribution, but there is less
perihilar haze compared to prior. There is volume
loss/infiltrate in both
lower lobes.
IMPRESSION: Continued but slightly improved CHF.

Brief Hospital Course:
89 yo M with multiple CAD risk factors admitted for elective
cardiac cath for symptoms of unstable angina and mild systolic
dysfunction on TTE, found to have 2 vessel disease(including
severe LAD disease) and moderate aortic stenosis.
.
# CORONARIES:  The patient has multiple risk factors for CAD
including HTN, HLD, DM, CKD. He was directly admitted for
cardiac catheterization because of a reversible defect seen on
stress testing.  Cardiac catheterization showed 3 tight LAD
lesions and a 40% LCx stenosis.  Only 2 of 3 LAD lesions were
intervened on, when the patient became agitated and the
procedure was terminated with the patient sent to the CCU for
close monitoring.  He received integrilin post-procedure, and
was maintained on aspirin, plavix, high dose statin and
metoprolol.  Additionally, he completed a three day course of
Cefazolin because of contamination of the groin site during the
procedure secondary to the patient's agitation.
.
# Delerium: Peri-procedure, the patient exhibited symptoms of
delerium including difficulty with concentration. The patient's
neurologic exam was non-focal, and the CCU team felt the
delerium was multifactorial in the setting of medication effect
(benzodiazepines given peri-procedure), especially given CKD
with decreased medication clearance, age and lack of sleep in
the hospital prior to procedure. He received haldol with good
effect and the delerium resolved completely prior to discharge.
.
# PUMP: At admission, the patient had no signs or symptoms of
CHF.  However, he received prehydration with normal saline and
bicarbonate infusions.  During cardiac catheterisation, he was
found to have elevated right and left sided pressures consistent
with systolic and diastolic dysfunction.  Additionally, he was
found to have moderate aortic stenosis (aortic valve area 1.0
cm^2, mean gradient 24 mm Hg) with symptoms of [**2-20**] in the AS
triad (angina, CHF).  He was diuresed with low dose IV lasix,
with good effect.  He was continued on metoprolol, and
lisinopril held secondary to acute renal failure.
.
# RHYTHM: The patient remained in sinus rhythm throughout the
hospital stay, with PR prolongation seen on ECG.  He was
continued on metoprolol.
.
# Diabetes Mellitus: The patient's oral hypoglycemics were held
while in-house, and he was maintained on a regular insulin
sliding scale.
.
# Chronic Kidney Disease: Patient with Stage IV CKD, w/ Cre
clearance of 23. He received pre-cath hydration and IV mucomyst
before and after catherization.  His creatinine rose after cath
to a peak of 2.9, and then began to decline.  Lisinopril was
held for several days prior to hospitalization, and he was
instructed to continue to hold this medication until being
evaluated by his primary care physician.
.
# Hyperkalemia: The patient's potassium was elevated to 5.9 in
the CCU, likely secondary to Acute on chronic renal failure
after contrast load.  He received kayexalate, insulin and D5 and
had no ECG changes.  His potassium remained stable thereafter.
.
# HTN: Lisinopril was held, and the patient continued on
metoprolol.

# Deconditioning: The patient was evaluated by physical therapy
prior to discharge, who recommended VNA services with a home
physical therapy regimen. .
.

Medications on Admission:
Lisinopril 40mg daily (on hold for past 2 days)
Glipizide 10mg daily
Actos 15mg daily
ASA 81mg daily


Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. Actos 15 mg Tablet Sig: One (1) Tablet PO once a day.
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Final Diagnoses:
Coronary Artery Disease
Hypertension
Diabetes Mellitus type 2
Chronic Kidney Disease


Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent


Discharge Instructions:
You have a history of progressive chest dyscomfort with exertion
and were admitted for a cardiac catheterization to evaluate for
coronary artery disease.  You were admitted the night prior to
the procedure in order to give you intravenous hydration to
protect your kidneys from the dye involved in the procedure.
You underwent Cardiac Catheterization on [**2182-1-24**], which showed
narrowing of two of your coronary arteries.  You became confused
and agitated during the procedure, which we think was likely
because of sedating medications.

We made the following changes to your medications:
- START plavix: this is a medication to help prevent blockages
in your coronary arteries
- START metoprolol: this medication treats your elevated blood
pressure
- START Atorvastatin: This is a medication to treat your
elevated cholesterol, and helps to prevent blockages in your
coronary arteries
- STOP your lisinopril until you see your PCP at the end of the
week.  This medication was stopped prior to the catheterization
to help protect your kidneys.  Your PCP may choose to restart
this medication after checking your kidney function at your next
visit.
.
We did not make any further changes to your home medications.
Please take all medications as prescribed.

Followup Instructions:
You have a follow-up appointment with your PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 131**], MD
on Friday [**2182-2-1**] 1:15 PM.  Tel: [**Telephone/Fax (1) 133**]

Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2182-3-7**] 1:20
{'Coronary atherosclerosis of native coronary artery,Acute combined systolic and diastolic heart failure,Intermediate coronary syndrome,Chronic kidney disease, Stage IV (severe),Delirium due to conditions classified elsewhere,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Aortic valve disorders,Hyperpotassemia,Anemia, 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: dyspnea

PRESENT ILLNESS: Mr. [**Known lastname 104620**] is an 89 yo M with HTN, HLD, DMII, moderate AS (valve
area 1.0 cm^2) and CKD who presented with worsening chest pain,
and admitted for elective cardiac cath. Please see Dr. [**Initials (NamePattern4) 104621**] [**Last Name (NamePattern4) 196**] admission note for full details. In brief,
patient noted worsening exertional chest discomfort over the
past few months, with decreased exercise tolerance (unable to
walk ?????? mile without chest pain, and less resolution with rest).
He had a TTE with mildly depressed EF (50%) in [**6-26**], and an
exercise stress test showing a mild, fixed inferior wall defect
and global mild hypokinesis with a calculated left ventricular
ejection fraction is 46 %. As a result of his symptoms and the
above test results, he was admitted to [**Hospital1 18**] on [**2182-1-23**] for
pre-cath hydration prior to elective cardiac catherization.
.
In the cath lab today, patient received total fentanyl 82.5 mg
IV and midazolam 2 mg IV. Right and left heart cardiac
catherization was performed. Left heart cath revealed 2VD, with
a heavily calcified LAD 80% proximal, 90% serial mid, and 70%
distal disease, LCx 40% proximal stenosis and a 60% stenosis of
the ramus, and moderate aortic stenosis. Right heart cath
revealed both elevated left and right sided pressures. Rotablade
was performed on the LAD (2 more proximal lesions followed by
angioplasty). However, at that point, patient became confused,
stated his back was hurting and tried to move off of the cath
table despite requests to stay down, and contaminated the groin
site with his hand. At that point, the cardiac catherization was
stopped (no intervention on the distal lesion). He received 10
mg IV haldol total and 20 mg IV lasix, while in the cath lab.
Urine output unable to be measured due to condom cath being
pulled off by patient. An angioseal was placed for arterial
closure. He was started on integrillin and transferred to the
CCU for closer monitering.
.
In the CCU, he continued to be confused, and attempted to sit up
in bed despite having a venous sheath, and pull on his lines. He
received an extra 5 mg of IV haldol and was placed in 4 point
wrist restraints. He was able to follow most commands, but
unable to answer any review of systems.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension

MEDICATION ON ADMISSION: Lisinopril 40mg daily (on hold for past 2 days)
Glipizide 10mg daily
Actos 15mg daily
ASA 81mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T= afebrile BP= 133/59 HR= 75% RR=15 O2 sat= 95% on RA
GENERAL: agitated gentleman attempting to get out of bed and
pulling at lines.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: No know FH of cardiac disease, diabetes, no colon/proste/breast
cancer. Parents lived to 70s to 80s with no known medical
problems. Children in good health.

SOCIAL HISTORY: Patient was born in [**Country 4754**], moved to the US in [**2125**]. Worked in
construction as a labor foreman. Married x 54 years, with 3
children and 9 grandchildren. Denies tobacco or illicit drug
use. Occasional EtOH use 

### Response:
{'Coronary atherosclerosis of native coronary artery,Acute combined systolic and diastolic heart failure,Intermediate coronary syndrome,Chronic kidney disease, Stage IV (severe),Delirium due to conditions classified elsewhere,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Aortic valve disorders,Hyperpotassemia,Anemia, unspecified'}
