CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 77 year old
male with a history of coronary artery disease, status post
coronary artery bypass graft in 05/98, left internal mammary
artery-D1, saphenous vein graft to left circumflex, saphenous
vein graft to right coronary artery, and bovine aortic valve
replacement, noninsulin dependent diabetes mellitus,
hyperlipidemia, peripheral vascular disease, who presents to
an outside hospital complaining of three week history of
substernal chest pain with minimal exertion, now increasing
at minimal exertion or at rest, increasing in frequency and
severity, requiring more frequent use of sublingual
Nitroglycerin as well as associated shortness of breath.  He
reported only intermittent stable angina since coronary
artery bypass graft in [**2150**], until now.  Just prior to
presentation at outside hospital, he took four to five
sublingual Nitroglycerin without significant relief of the
chest pain, and his wife drove him to the Emergency
Department.  He was found to have non ST elevation myocardial
infarction and was treated with Aspirin, beta blocker,
Nitroglycerin, Heparin, Plavix, but no IIB-IIIA.  Apparently
he then underwent a Persantine MIBI stress test showing fixed
defect in the septum and inferior and posterior wall and
moderately reduced left ventricular function.  He was then
transferred to [**Hospital1 69**] for
emergent cardiac catheterization.

MEDICAL HISTORY: 1.  Coronary artery disease, status post coronary artery
bypass graft as above in [**2150**], left internal mammary artery
to D1, saphenous vein graft to left circumflex, saphenous
vein graft to right coronary artery.
2.  Status post bovine aortic valve replacement in [**2150**].
3.  Peripheral vascular disease.
4.  Benign prostatic hypertrophy, status post transurethral
resection of prostate.
5.  Noninsulin dependent diabetes mellitus.
6.  Hyperlipidemia.
7.  Aortic stenosis/mitral regurgitation.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: He had a remote history of tobacco.  He quit
actually twenty years ago.  He admits to occasional alcohol.
No intravenous drug abuse.  He is a cartoonist.  He lives
with his wife.
Subendocardial infarction, initial episode of care,Cardiogenic shock,Iatrogenic cerebrovascular infarction or hemorrhage,Congestive heart failure, unspecified,Other complications due to other cardiac device, implant, and graft,Mitral valve disorders,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Coronary atherosclerosis of native coronary artery
Subendo infarct, initial,Cardiogenic shock,Iatrogen CV infarc/hmrhg,CHF NOS,Comp-oth cardiac device,Mitral valve disorder,DMII wo cmp nt st uncntr,Crnry athrscl natve vssl
Admission Date:  [**2156-1-14**]     Discharge Date:  [**2156-1-29**]

Date of Birth:   [**2078-9-28**]     Sex:  M

Service:  CCU

HISTORY OF PRESENT ILLNESS:  The patient is a 77 year old
male with a history of coronary artery disease, status post
coronary artery bypass graft in 05/98, left internal mammary
artery-D1, saphenous vein graft to left circumflex, saphenous
vein graft to right coronary artery, and bovine aortic valve
replacement, noninsulin dependent diabetes mellitus,
hyperlipidemia, peripheral vascular disease, who presents to
an outside hospital complaining of three week history of
substernal chest pain with minimal exertion, now increasing
at minimal exertion or at rest, increasing in frequency and
severity, requiring more frequent use of sublingual
Nitroglycerin as well as associated shortness of breath.  He
reported only intermittent stable angina since coronary
artery bypass graft in [**2150**], until now.  Just prior to
presentation at outside hospital, he took four to five
sublingual Nitroglycerin without significant relief of the
chest pain, and his wife drove him to the Emergency
Department.  He was found to have non ST elevation myocardial
infarction and was treated with Aspirin, beta blocker,
Nitroglycerin, Heparin, Plavix, but no IIB-IIIA.  Apparently
he then underwent a Persantine MIBI stress test showing fixed
defect in the septum and inferior and posterior wall and
moderately reduced left ventricular function.  He was then
transferred to [**Hospital1 69**] for
emergent cardiac catheterization.

PAST MEDICAL HISTORY:
1.  Coronary artery disease, status post coronary artery
bypass graft as above in [**2150**], left internal mammary artery
to D1, saphenous vein graft to left circumflex, saphenous
vein graft to right coronary artery.
2.  Status post bovine aortic valve replacement in [**2150**].
3.  Peripheral vascular disease.
4.  Benign prostatic hypertrophy, status post transurethral
resection of prostate.
5.  Noninsulin dependent diabetes mellitus.
6.  Hyperlipidemia.
7.  Aortic stenosis/mitral regurgitation.

ALLERGIES:  No known drug allergies.

MEDICATIONS ON TRANSFER:
1.  Zocor 40 mg once daily.
2.  Atenolol 25 mg once daily.
3.  Glyburide 5 mg once daily.
4.  Aspirin.
5.  Nitroglycerin sublingual p.r.n.
6.  Colace twice a day.

SOCIAL HISTORY:  He had a remote history of tobacco.  He quit
actually twenty years ago.  He admits to occasional alcohol.
No intravenous drug abuse.  He is a cartoonist.  He lives
with his wife.

Cardiac catheterization [**2156-1-14**], right heart catheterization
shows right atrial mean of 10, right ventricular pressure of
56/11, pulmonary artery pressure of 56/25, wedge mean 22.
Cardiac index is 2.7, SVR is 1192, PVR 289.  Left heart
catheterization shows three vessel disease and a right
dominant system, proximal right coronary artery with 90%
lesion, mid right coronary artery with diffuse disease.  His
left main has 100% lesion, proximal left anterior descending
100% lesion and his proximal circumflex has 100% lesion.
Meanwhile his saphenous vein graft one and two show 100%
lesions.  The patient subsequently underwent PCI to his
proximal right coronary artery lesion with two Hepacoat
stents.  He was unable to undergo PCI stent to mid right
coronary artery lesion and underwent percutaneous
transluminal coronary angioplasty with ultimately 30 to 40%
residual stenosis.  Post PCI for proximal right coronary
artery revealed TIMI-3 flow.

Transthoracic echocardiogram on [**2156-1-16**], showed ejection
fraction of 10 to 15%, normal left atrium and right atrium,
left ventricular wall thickness is normal with normal cavity
size with severe global left ventricular hypokinesis.  Right
ventricular cavity thickness and chamber size are within
normal limits but right ventricle does show depressed
systolic function.  Aortic valve prosthesis present without
aortic insufficiency.  Severe 3+ mitral regurgitation.  No
pericardial effusion.

HOSPITAL COURSE:
1.  Cardiovascular - Coronary artery disease - The patient
transferred from outside hospital, status post non ST
elevation myocardial infarction.  Cardiac catheterization
reveals native vessel disease with two out of three grafts
down.  He underwent intervention to his proximal and mid
right coronary artery lesion with stenting of proximal right
coronary artery and percutaneous transluminal coronary
angioplasty of mid right coronary artery lesion with 30 to
40% residual stenosis.  Post cardiac catheterization in CCU,
the patient underwent abbreviated course of Integrilin
secondary to episode of hemoptysis.  He was continued on
Aspirin and Plavix.  He was also continued on his statin. He
was also started on low dose beta blockade and ace inhibitor.
These final two medications had to be adjusted slowly as the
patient had marginal blood pressure and was felt to be in
moderate to severe congestive heart failure during his
hospital course.  His CKs trended until they peaked at 450,
and the patient denied having chest pain during the remainder
of his hospital course.

Pump Function - Transthoracic echocardiogram on hospital day
three showed severely depressed left ventricular function
with ejection fraction of 10 to 15% and with severe mitral
regurgitation.  His right heart catheterization also revealed
elevated filling pressures although reasonably normal cardiac
index. Post cardiac catheterization and CCU, the patient
initially underwent aggressive diuresis for his elevated
filling pressures.  He was negative approximately two to
three liters in his first day.  The patient subsequently
became hypotensive with the addition of ace inhibitor and
beta blockade.  His urine output began to decrease and his
cardiac index was decreased consistent with cardiogenic
shock.  Subsequently, he briefly required Dobutamine.  The
patient's pulmonary artery pressures and cardiac index were
followed continuously and the patient did show improved
cardiac function with the addition of low dose Dobutamine,
low dose ace inhibition and gentle diuresis.  By hospital day
four, his pulmonary artery diastolic pressures had decreased.
His cardiac index had improved and the patient had pulmonary
artery catheter subsequently discontinued.  By this time, the
patient was off Dobutamine.  He was continued on low dose ace
inhibition, continued on Lasix and also had Digoxin added for
additional inotropic support.  During the remainder of the
[**Hospital 228**] hospital course onto the floor, the patient was
continued to be gently diuresed 500 to 1000cc per day.  He
will be discharged on Lasix 20 mg once daily and will be
reassessed in one to two weeks by his cardiologist, Dr.
[**First Name8 (NamePattern2) **] [**Name (STitle) **].  Secondary to marginal blood pressure and
concern about a possible posterior cerebrovascular accident,
he had lower reserve for beta blockade and ace inhibition and
he was discharged on Coreg 1.56 mg twice a day and Lisinopril
2.5 mg once daily for his congestive heart failure.  He was
also continued on Digoxin throughout his course with his end
dose being 125 mcg once daily.

Hemodynamics - As mentioned above, the patient had marginal
blood pressure throughout his hospital course. He actually
became hypotensive early in the hospital course in the
setting of aggressive diuresis and combined beta blockade and
ace inhibition and briefly requiring inotropic support with
Dobutamine for cardiogenic shock.  His blood pressure did
improve slightly during his hospital course.  Later in his
hospital course, his marginal blood pressure prevented the
team from aggressively titrating his beta blockade and ace
inhibitor especially in the setting of a possible posterior
circulation cerebrovascular accident.   He did end up being
discharged on beta blockade and ace inhibitor as above.

Rhythm - The patient was initially tachycardic early in his
hospital course felt secondary to congestive heart failure.
His electrocardiogram does show an intraventricular
conduction delay.  Given his coronary artery disease and his
severe congestive heart failure, the team had considered
possibly having the patient evaluated for a biventricular
pacer and ICD.  This further evaluation did not take place
during his hospital course but may be initiated as an
outpatient at the discretion of his cardiologist.

2.  Pulmonary - Despite the patient's severe congestive heart
failure and ultimate cardiogenic shock, the patient remained
stable from respiratory standpoint.  He was briefly mildly
hypoxic requiring one to two liters of oxygen via nasal
cannula.  These oxygen requirements decreased with continued
diuresis.

3.  Neurologic - Later during his hospital course, the
patient began complaining of visual disturbances and was
found to have a left homonymous hemianopsia on examination.
Stroke team was consulted and magnetic resonance scan/MRA of
the head were obtained.  MRA showed acute right thalamus and
right posterior corpus callosum and right occipital infarct.
Magnetic resonance scan revealed normal anterior circulation
of [**Location (un) 431**], but posterior circulation was not seen.
Subsequent MRA of the aortic arch and neck vessels
demonstrates proximal occlusion bilaterally of the vertebral
arteries and eventual retrograde filling on venous phasing of
study.  Cerebral angiography was not obtained at this time.
Given his dilated vasculature, his decreased ejection
fraction and his recent cerebrovascular accident, it was
decided per neurology to begin anticoagulation for a goal INR
between 2.0 and 3.0.  He will be continued on Aspirin and
Plavix and team was cautious with any further blood pressure
control at this time.  He was to follow-up with neurology
clinic in two to three weeks time.

4.  Hematology - The patient did require two units of packed
red blood cells earlier during his CCU course in the setting
of his cardiac shock.  His hematocrit subsequently remained
stable during the remainder of his hospital course.   As
mentioned above, he was anticoagulated for his recent
cerebrovascular accident and depressed ejection fraction.
His goal INR is 2.0 to 3.0.  He was discharged on Coumadin 5
mg q.h.s. until [**2156-1-31**], and then was instructed to decrease
to 2.5 mg q.h.s.  His INR will be followed with Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) **].

5.  Infectious disease - The patient remained afebrile during
his hospital course.  He was treated prophylactically with
three days of Levaquin as prophylaxis following urethral
dilatation by urology for post cardiac catheterization Foley.

6.  Renal - The patient did have mild elevation in his
creatinine early in the CCU course in the setting of
cardiogenic shock.  He subsequently improved with mild
Dobutamine and the patient was able to tolerate ace
inhibition and gentle diuresis throughout his hospital
course.  Meanwhile, the patient was evaluated by urology post
cardiac catheterization with difficulty with placing a Foley
catheter.  He underwent urethral dilatation for presumed
stricture in the prostatic urethra.  Cystoscopy later
confirmed stricture in the bulbar urethra.  Foley was placed
following dilation and left in place for the first weeks of
his hospital course.  The patient was able to urinate after
removal of the Foley catheter.  However, subsequent
urinalysis did show residual hematuria.  As such, he was
instructed to follow-up with urology in one to two weeks.

7.  Endocrinology - The patient's Glyburide was increased to
7.5 mg for increased blood sugar during his hospital course.
He will need follow-up blood sugar control.

DISCHARGE DIAGNOSES:
1.  Coronary artery disease, status post non ST elevation
myocardial infarction and status post proximal right coronary
artery PCI/stent and percutaneous transluminal coronary
angioplasty of mid right coronary artery lesion.
2.  Congestive heart failure/cardiogenic shock, resolved.
3.  Status post acute right sided occipital cerebrovascular
accident with MRA evidence of complete occlusion of posterior
circulation.
4.  Urethral stricture/hematuria.
5.  Type 2 diabetes mellitus.

CONDITION ON DISCHARGE:  Good.

MEDICATIONS ON DISCHARGE:
1.  Aspirin 325 mg once daily.
2.  Plavix 75 mg once daily.
3.  Zocor 40 mg once daily.
4.  Digoxin 125 mcg once daily.
5.  Glyburide 7.5 mg once daily.
6.  Coreg 1.56 mg twice a day.
7.  Senokot twice a day.
8.  Colace twice a day.
9.  Lasix 20 mg once daily.
10. Lisinopril 1.25 mg once daily.
11. Coumadin 5 mg q.h.s. until [**2156-1-31**], and then 2.5 mg
q.h.s.

FOLLOW-UP PLANS:
1.  The patient was to call Dr. [**Last Name (STitle) **], cardiologist, for
appointment in one to two weeks and will be faxing over
results of INR.

2.  He was also instructed to call Dr. [**Last Name (STitle) 12544**] from neurology
stroke team for appointment in two to three weeks.

3.  He was to call the urologist, Dr. [**Last Name (STitle) 365**], in one to two
weeks for appointment for evaluation of his hematuria.




                          [**Name6 (MD) **] [**Last Name (NamePattern4) 5467**], M.D.  [**MD Number(1) 5468**]

Dictated By:[**Last Name (NamePattern1) 5539**]

MEDQUIST36

D:  [**2156-3-8**]  14:29
T:  [**2156-3-9**]  17:50
JOB#:  [**Job Number 23693**]
{'Subendocardial infarction, initial episode of care,Cardiogenic shock,Iatrogenic cerebrovascular infarction or hemorrhage,Congestive heart failure, unspecified,Other complications due to other cardiac device, implant, and graft,Mitral valve disorders,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: 

PRESENT ILLNESS: The patient is a 77 year old
male with a history of coronary artery disease, status post
coronary artery bypass graft in 05/98, left internal mammary
artery-D1, saphenous vein graft to left circumflex, saphenous
vein graft to right coronary artery, and bovine aortic valve
replacement, noninsulin dependent diabetes mellitus,
hyperlipidemia, peripheral vascular disease, who presents to
an outside hospital complaining of three week history of
substernal chest pain with minimal exertion, now increasing
at minimal exertion or at rest, increasing in frequency and
severity, requiring more frequent use of sublingual
Nitroglycerin as well as associated shortness of breath.  He
reported only intermittent stable angina since coronary
artery bypass graft in [**2150**], until now.  Just prior to
presentation at outside hospital, he took four to five
sublingual Nitroglycerin without significant relief of the
chest pain, and his wife drove him to the Emergency
Department.  He was found to have non ST elevation myocardial
infarction and was treated with Aspirin, beta blocker,
Nitroglycerin, Heparin, Plavix, but no IIB-IIIA.  Apparently
he then underwent a Persantine MIBI stress test showing fixed
defect in the septum and inferior and posterior wall and
moderately reduced left ventricular function.  He was then
transferred to [**Hospital1 69**] for
emergent cardiac catheterization.

MEDICAL HISTORY: 1.  Coronary artery disease, status post coronary artery
bypass graft as above in [**2150**], left internal mammary artery
to D1, saphenous vein graft to left circumflex, saphenous
vein graft to right coronary artery.
2.  Status post bovine aortic valve replacement in [**2150**].
3.  Peripheral vascular disease.
4.  Benign prostatic hypertrophy, status post transurethral
resection of prostate.
5.  Noninsulin dependent diabetes mellitus.
6.  Hyperlipidemia.
7.  Aortic stenosis/mitral regurgitation.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: He had a remote history of tobacco.  He quit
actually twenty years ago.  He admits to occasional alcohol.
No intravenous drug abuse.  He is a cartoonist.  He lives
with his wife. 

### Response:
{'Subendocardial infarction, initial episode of care,Cardiogenic shock,Iatrogenic cerebrovascular infarction or hemorrhage,Congestive heart failure, unspecified,Other complications due to other cardiac device, implant, and graft,Mitral valve disorders,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Coronary atherosclerosis of native coronary artery'}
