CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 65-year-old
gentleman with known coronary artery disease, insulin-
dependent diabetes mellitus, chronic renal insufficiency, and
aortic stenosis who presented with worsening dyspnea on
exertion for one day prior to arrival.  At baseline, the
patient reports dyspnea on exertion with approximately one
flight of stairs, but over the past 24 hours, reported
minimal movement reproducing the same level of dyspnea, now
associated with chest tightness.  The patient denied any
diaphoresis or nausea associated with these episodes.  The
patient did report increasing orthopnea, but denied
paroxysmal nocturnal dyspnea or change in his chronic
bilateral lower extremity edema.  Initially, the patient was
evaluated in the emergency department of an outside hospital
and by report electrocardiograms revealed evidence of T-wave
inversion and ST-segment depression in the lateral leads.
The patient was administered low molecular weight heparin and
was transferred to [**Hospital1 69**] for
cardiac catheterization.  Upon obtaining this history from
the patient, there was no report of chest pain, and the
patient was without dyspnea.

MEDICAL HISTORY: Non-insulin-dependent diabetes
mellitus, hypercholesterolemia, hypertension, obstructive
sleep apnea, chronic renal insufficiency, gastroesophageal
reflux disease, coronary artery disease, status post CABG in
[**2148**], status post PTCA in [**2153**], aortic stenosis.  Cardiac
catheterization in [**3-4**] significant for severe native 3-
vessel disease pattern, SVG to OM1, distal LAD 60 percent
touchdown stenosis, LIMA to LAD, inferoposterior basal severe
hypokinesis and EF of 46 percent.  Echocardiogram in [**3-6**],
limited study with unassessed ejection fraction, otherwise
significant for mild-to-moderate aortic stenosis.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Subendocardial infarction, initial episode of care,Hematemesis,Congestive heart failure, unspecified,Aortic valve disorders,Unspecified gastritis and gastroduodenitis, with hemorrhage,Acute posthemorrhagic anemia,Other iatrogenic hypotension,Coronary atherosclerosis of native coronary artery
Subendo infarct, initial,Hematemesis,CHF NOS,Aortic valve disorder,Gstr/ddnts NOS w hmrhg,Ac posthemorrhag anemia,Iatrogenc hypotnsion NEC,Crnry athrscl natve vssl
Admission Date: [**2160-5-18**]        Discharge Date: [**2160-5-22**]

Date of Birth:  [**2094-10-7**]        Sex:  M

Service:  [**Hospital Unit Name 196**]


HISTORY OF PRESENT ILLNESS:  The patient is a 65-year-old
gentleman with known coronary artery disease, insulin-
dependent diabetes mellitus, chronic renal insufficiency, and
aortic stenosis who presented with worsening dyspnea on
exertion for one day prior to arrival.  At baseline, the
patient reports dyspnea on exertion with approximately one
flight of stairs, but over the past 24 hours, reported
minimal movement reproducing the same level of dyspnea, now
associated with chest tightness.  The patient denied any
diaphoresis or nausea associated with these episodes.  The
patient did report increasing orthopnea, but denied
paroxysmal nocturnal dyspnea or change in his chronic
bilateral lower extremity edema.  Initially, the patient was
evaluated in the emergency department of an outside hospital
and by report electrocardiograms revealed evidence of T-wave
inversion and ST-segment depression in the lateral leads.
The patient was administered low molecular weight heparin and
was transferred to [**Hospital1 69**] for
cardiac catheterization.  Upon obtaining this history from
the patient, there was no report of chest pain, and the
patient was without dyspnea.

REVIEW OF SYSTEMS:  On review of systems, there was absence
of fevers or productive cough.  There had been no recent
changes in medications or dietary indiscretion.

PAST MEDICAL HISTORY:  Non-insulin-dependent diabetes
mellitus, hypercholesterolemia, hypertension, obstructive
sleep apnea, chronic renal insufficiency, gastroesophageal
reflux disease, coronary artery disease, status post CABG in
[**2148**], status post PTCA in [**2153**], aortic stenosis.  Cardiac
catheterization in [**3-4**] significant for severe native 3-
vessel disease pattern, SVG to OM1, distal LAD 60 percent
touchdown stenosis, LIMA to LAD, inferoposterior basal severe
hypokinesis and EF of 46 percent.  Echocardiogram in [**3-6**],
limited study with unassessed ejection fraction, otherwise
significant for mild-to-moderate aortic stenosis.

ALLERGIES:  No known drug allergies.

MEDICATIONS:
1. Lovenox administered at the outside hospital.
2. Lasix 40 mg intravenously administered twice at the
   outside hospital.
3. Aspirin.
4. Lopressor 25 mg p.o. t.i.d.
5. Captopril 12.5 mg t.i.d.
6. Levoxyl 200 mg p.o. q.d.
7. Zoloft 100 mg p.o. q.d.
8. Allopurinol 100 mg p.o. q.d.
9. NPH 18 units subcutaneous b.i.d.
10.      Lipitor 40 mg p.o. q.d.


SOCIAL HISTORY AND HEALTH RELATED BEHAVIOUR:  Significant for
occasional alcohol use and no tobacco use.

PHYSICAL EXAMINATION:  Temperature 95.8, heart rate is 60,
respiratory rate 16, saturating 96 percent on room air, blood
pressure 110/68.  In general, well-appearing man in no acute
distress.  HEENT, extraocular movements are intact.  Pupils
are equal and round, reactive to light.  Oropharynx clear,
mucous membranes moist.  Neck, jugular venous distention not
assessed secondary to body habitus.  Respiratory, crackles
half way up posterior lung fields.  Cardiovascular, regular
rate and rhythm, 3/6 systolic murmur at the right upper
sternal border radiating to the carotids.  Abdomen soft,
obese, nontender, normoactive bowel sounds.  Extremities
significant for bilateral lower extremity pitting edema.
Palpable 1 plus dorsalis pedis and posterior tibialis pulses
bilaterally.  Neurologic exam, alert, conversant, grossly
nonfocal.

DIAGNOSTIC STUDIES:  ECG, normal sinus rhythm at 90, normal
axis, T-wave inversions in I, aVL, V4 through V6, [**Street Address(2) 4793**]
depressions in V6 and I.  Chest x-ray, cardiomegaly, no
evidence of CHF.  Cardiac enzymes in the outside hospital
were significant for troponin I of 28.4, CK of 82, MB
fraction 33.8.  Second CK 267, MB of 33.  Electrolytes,
sodium 139, potassium 3.9, chloride 112, bicarbonate 18, BUN
51, creatinine 1.6, glucose 174.  CBC, WBC 12, hematocrit 31,
platelets 202, INR 1.3.

HOSPITAL COURSE:  Non-ST-elevation myocardial infarction:
The patient was started on a heparin drip, a 2b/3a inhibitor
and was maintained on his beta-blocker, statin, and ACE
inhibitor with daily aspirin with a plan to take the patient
to cardiac catheterization the following morning.  Cardiac
catheterization was performed on [**2160-5-19**].  Please see
dictated report for further details.  Briefly, 3-vessel
coronary artery disease was demonstrated on cardiac
catheterization with moderate aortic stenosis. There was
successful stenting of the left main artery and diagonal
branches.  During the catheterization, markedly elevated
filling pressures were noticed on the hemodynamic monitoring
with an aortic valve gradient of 33 mmHg on dopamine.  The
patient was given an oral Plavix load and Lasix towards the end
of the procedure, after which the patient became severely
hypotensive with minimal amount of bloody emesis.  The
patient was then given aggressive intravenous fluids for
rehydration and transfused packed red blood cells with a
brief requirement for inotropes.  A CT of the abdomen was
obtained urgently to exclude a retroperitoneal hematoma.
This study revealed no evidence of such, and the patient was
transferred to the CCU for further monitoring and
postcatheterization care.  The patient remained
hemodynamically stable in the CCU and was transferred out to
the telemetry floor the following day.  The patient remained
hemodynamically stable and chest pain free throughout the
remainder of his hospital course and was discharged on the
cardiac medications detailed below.

Aortic stenosis:  The patient was noted to have aortic
stenosis on prior echocardiogram and was again evaluated with
hemodynamic measurements noted above on cardiac
catheterization.  It was the plan of the inpatient medical
team to further evaluate this stenosis with a stress
echocardiogram in the non-acute setting after the patient's
current acute illness had resolved.

Gastrointestinal bleed:  The CT scan of the abdomen mentioned
above obtained during the evaluation of the patient's
hypotensive episode during cardiac catheterization was
significant for a potential fundal abnormality of the stomach
consistent with gastric hematoma versus food contents versus
ingested pills.  Upon transfer to the telemetry floor, the
patient was then noted to have heme-positive maroon stool
with negative nasogastric lavage.  His hematocrit nadir was
24 from the baseline of 33 with appropriate response to
further transfusion.  The gastrointestinal consultation
service was asked to evaluate the patient, at which time an
esophagogastroduodenoscopy was performed, which demonstrated
findings consistent with a small healing ulcer in the
duodenal bulb and gastritis.  The patient was started on a
proton pump inhibitor, and his serial hematocrits remained
stable throughout the remainder of his hospitalization.

Chronic renal insufficiency:  The patient's baseline
hematocrit was relatively unchanged throughout this
hospitalization.  Proper precautions were taken given the dye
load administered by the cardiac catheterization and peri-
procedure hydration and Mucomyst was given in the usual
fashion.

Obstructive sleep apnea:  The patient continued to use his
CPAP nocturnally as he does as an outpatient.

Diabetes mellitus:  The patient was maintained on a modified
version of his NPH regimen and Regular Insulin sliding scale
as appropriate per inpatient diet and fingerstick blood
glucose.

Congestive heart failure:  The patient was symptomatically
improved by the time of discharge and was evaluated for
cardiac rehabilitation, at which time he was able to climb a
flight of stairs without significant dyspnea on exertion.
Prior to being released from the hospital, the patient was
restarted on his outpatient dose of oral Lasix.

CONDITION ON DISCHARGE:  Good.

DISCHARGE STATUS:  To home.

DISCHARGE DIAGNOSES:  Non-ST-elevation myocardial infarction.

Congestive heart failure.

Aortic stenosis.

Gastrointestinal bleeding.

Gastritis.

Duodenal ulcer.

Anemia.

DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q.d.
2. Levothyroxine 100 mg 2 tablets p.o. q.d.
3. Atorvastatin 40 mg 2 tablets p.o. q.d.
4. Sertraline 50 mg 2 tablets p.o. q.d.
5. Allopurinol 100 mg 1 tablet p.o. q.d.
6. Plavix 75 mg 1 tablet p.o. q.d.
7. Furosemide 40 mg 1 tablet p.o. q.d.
8. Pantoprazole 40 mg 1 tablet p.o. b.i.d. times 8 weeks;
   thereafter 1 tablet p.o. q.d.
9. Metoprolol 50 mg sustained release 1 tablet p.o. q.d.
10.Lisinopril 5 mg 1 tablet p.o. q.d.


FOLLOW-UP PLANS:  Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**] on [**2160-5-23**] at 9:30; Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2160-6-20**] at 12 noon.  Dr. [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] on [**2160-5-28**] at 12:40 p.m.  Pulmonary function tests
on [**2160-6-20**] at 11:45 a.m.  Dr. [**Last Name (STitle) 21140**], Gastroenterology, was
to call the patient within 2 to 3 days to arrange an
outpatient follow-up appointment.



                        [**Name6 (MD) **] [**Name8 (MD) 1911**], [**MD Number(1) 10456**]

Dictated By:[**Doctor Last Name 21141**]
MEDQUIST36
D:  [**2160-8-6**] 23:09:33
T:  [**2160-8-7**] 04:58:47
Job#:  [**Job Number 21142**]
{'Subendocardial infarction, initial episode of care,Hematemesis,Congestive heart failure, unspecified,Aortic valve disorders,Unspecified gastritis and gastroduodenitis, with hemorrhage,Acute posthemorrhagic anemia,Other iatrogenic hypotension,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: 

PRESENT ILLNESS: The patient is a 65-year-old
gentleman with known coronary artery disease, insulin-
dependent diabetes mellitus, chronic renal insufficiency, and
aortic stenosis who presented with worsening dyspnea on
exertion for one day prior to arrival.  At baseline, the
patient reports dyspnea on exertion with approximately one
flight of stairs, but over the past 24 hours, reported
minimal movement reproducing the same level of dyspnea, now
associated with chest tightness.  The patient denied any
diaphoresis or nausea associated with these episodes.  The
patient did report increasing orthopnea, but denied
paroxysmal nocturnal dyspnea or change in his chronic
bilateral lower extremity edema.  Initially, the patient was
evaluated in the emergency department of an outside hospital
and by report electrocardiograms revealed evidence of T-wave
inversion and ST-segment depression in the lateral leads.
The patient was administered low molecular weight heparin and
was transferred to [**Hospital1 69**] for
cardiac catheterization.  Upon obtaining this history from
the patient, there was no report of chest pain, and the
patient was without dyspnea.

MEDICAL HISTORY: Non-insulin-dependent diabetes
mellitus, hypercholesterolemia, hypertension, obstructive
sleep apnea, chronic renal insufficiency, gastroesophageal
reflux disease, coronary artery disease, status post CABG in
[**2148**], status post PTCA in [**2153**], aortic stenosis.  Cardiac
catheterization in [**3-4**] significant for severe native 3-
vessel disease pattern, SVG to OM1, distal LAD 60 percent
touchdown stenosis, LIMA to LAD, inferoposterior basal severe
hypokinesis and EF of 46 percent.  Echocardiogram in [**3-6**],
limited study with unassessed ejection fraction, otherwise
significant for mild-to-moderate aortic stenosis.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Subendocardial infarction, initial episode of care,Hematemesis,Congestive heart failure, unspecified,Aortic valve disorders,Unspecified gastritis and gastroduodenitis, with hemorrhage,Acute posthemorrhagic anemia,Other iatrogenic hypotension,Coronary atherosclerosis of native coronary artery'}
