CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 65-year-old
male with a past medical history of CAD, NQWMI, status post
two vessel CABG plus AVR ([**2148**]) and DC cardioversion,
[**2161-5-14**], who presented to the ER with a two-day history of
dyspnea and PND.  The patient has a history of atrial
fibrillation and underwent DC cardioversion on [**2161-5-14**].  The
patient was hypotensive following the cardioversion and
required per report up to 7 liters of saline, accompanied by
a weight change of approximately 9 pounds (from 186 pounds to
195 pounds).  The patient states that he was feeling well
prior to the DC cardioversion and that subsequently had
dyspnea on exertion as well as shortness of breath at rest.
The patient stated that he had approximately 3-4 episodes of
PND over the 2 nights prior to admission.  He also had 1
brief episode of substernal chest pain that lasted 2-3
minutes the day prior to admission at 2:00 p.m. that began
when he went from a sitting to a standing position and
resolved spontaneously.

MEDICAL HISTORY: Status post coronary artery bypass
graft in [**2148**] at the [**Location (un) 511**] [**Hospital **] Hospital.  He had
an SVG to the LAD and SVG to the OM.  This procedure was done
in complement to an aortic valve replacement.  Per report,
the patient received a St. [**Male First Name (un) 1525**] number 23 mechanical valve
for treatment of the aortic value stenosis.  Per report, the
patient had non-Q wave MI in [**2143**].

MEDICATION ON ADMISSION: 1. Hydrochlorothiazide 25 mg (increased from 12.5 mg).
2. Atenolol 25 mg q.a.m.
3. Lisinopril 20 mg q.a.m.
4. Coumadin 5 mg every Tuesday, Thursday, Saturday; 6 mg
   every Sunday, Monday, Wednesday, Friday.
5. Lipitor 80 mg q.d.
6. Aspirin 81 mg q.d.
7. Zantac 150 mg p.r.n.

ALLERGIES: The patient has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: The patient is married and lives with his
wife.  [**Name (NI) **] is a former smoker with an approximate 20-pack year
history.  The patient quit several years ago.  He also drinks
up to 8-9 beers per day though he states that he has cut down
to 2 beers per day.  Denies any illicit drug use.  The
patient is a gambler and former boxer.  He won a lottery
several years ago.
Subendocardial infarction, initial episode of care,Diastolic heart failure, unspecified,Conduction disorder, unspecified,Atrial fibrillation,Alcohol abuse, continuous,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Heart valve replaced by other means
Subendo infarct, initial,Diastolc hrt failure NOS,Conduction disorder NOS,Atrial fibrillation,Alcohol abuse-continuous,Cor ath unsp vsl ntv/gft,Aortocoronary bypass,Heart valve replac NEC
Admission Date: [**2161-5-16**]        Discharge Date: [**2161-5-21**]

Date of Birth:  [**2096-2-18**]        Sex:  M

Service:  CME


HISTORY OF PRESENT ILLNESS:  The patient is a 65-year-old
male with a past medical history of CAD, NQWMI, status post
two vessel CABG plus AVR ([**2148**]) and DC cardioversion,
[**2161-5-14**], who presented to the ER with a two-day history of
dyspnea and PND.  The patient has a history of atrial
fibrillation and underwent DC cardioversion on [**2161-5-14**].  The
patient was hypotensive following the cardioversion and
required per report up to 7 liters of saline, accompanied by
a weight change of approximately 9 pounds (from 186 pounds to
195 pounds).  The patient states that he was feeling well
prior to the DC cardioversion and that subsequently had
dyspnea on exertion as well as shortness of breath at rest.
The patient stated that he had approximately 3-4 episodes of
PND over the 2 nights prior to admission.  He also had 1
brief episode of substernal chest pain that lasted 2-3
minutes the day prior to admission at 2:00 p.m. that began
when he went from a sitting to a standing position and
resolved spontaneously.

He describes the chest discomfort as central, substernal,
sharp, non-radiating, non-pleuritic and this is not
associated with diaphoresis, palpitations, nausea or
vomiting.  He does deny lower extremity edema and denies
having any significant history of angina since his CABG in
[**2148**].  On further review of systems, the patient admits to
having upper respiratory tract infection symptoms over the
past 3-4 days including cough productive of clear white
sputum.  There were no fever, chills, diarrhea, headache,
rash or arthralgia.  The patient, of note, has a significant
EtOH history and drinks up to 8 beers per day.  His last
drink was at 6:00 p.m. on the day prior to admission.

In the emergency department the patient received 40 mg of
Lasix, supplemental oxygen, 325 mg of aspirin and was started
on nitroglycerin drip.  His ECG showed sinus bradycardia with
PR prolongation, as well as left ventricular hypertrophy and
atrioventricular conduction delay and diffused ST and T-wave
changes, (there was no significant change in comparison with
the prior ECG of [**2161-5-14**]).  The patient's chest film was
consistent with mild CHF.  An echocardiogram revealed mild
symmetric LVH with an EF of 50 to 55 percent and mechanical
aortic valve prosthesis with 1 plus AR and 1 plus MR.

PAST MEDICAL HISTORY:  Status post coronary artery bypass
graft in [**2148**] at the [**Location (un) 511**] [**Hospital **] Hospital.  He had
an SVG to the LAD and SVG to the OM.  This procedure was done
in complement to an aortic valve replacement.  Per report,
the patient received a St. [**Male First Name (un) 1525**] number 23 mechanical valve
for treatment of the aortic value stenosis.  Per report, the
patient had non-Q wave MI in [**2143**].

Paroxysmal atrial fibrillation, status post DC cardioversion
on [**2161-5-14**] as well as on [**2161-2-26**].

Right parietal CVA in [**1-20**] with no residual symptoms.

Hyperlipidemia.

Diabetes mellitus, insulin dependent type 2 diabetic with
retinopathy.  He is followed by the [**Hospital **] Clinic.  The
patient reports that he checks sugars 6-7 times per day and
gives himself Regular though no longer, I think, insulin.  He
had an A1c at 8.3 on most recent check.

Status post herniorrhaphy

Meckel diverticulum.

GERD.

Significant ethanol use.

No history of DTs or seizures.

ALLERGIES:  The patient has no known drug allergies.

MEDICATIONS ON ADMISSION:
1. Hydrochlorothiazide 25 mg (increased from 12.5 mg).
2. Atenolol 25 mg q.a.m.
3. Lisinopril 20 mg q.a.m.
4. Coumadin 5 mg every Tuesday, Thursday, Saturday; 6 mg
   every Sunday, Monday, Wednesday, Friday.
5. Lipitor 80 mg q.d.
6. Aspirin 81 mg q.d.
7. Zantac 150 mg p.r.n.


SOCIAL HISTORY:  The patient is married and lives with his
wife.  [**Name (NI) **] is a former smoker with an approximate 20-pack year
history.  The patient quit several years ago.  He also drinks
up to 8-9 beers per day though he states that he has cut down
to 2 beers per day.  Denies any illicit drug use.  The
patient is a gambler and former boxer.  He won a lottery
several years ago.

FAMILY HISTORY:  Noncontributory.

PHYSICAL EXAMINATION ON ADMISSION:  Temperature is 97.5
degrees, heart rate is 50, blood pressure initially 171/71
and decreased to 129/69 with nitroglycerin, respiratory rate
16, oxygen saturation 95 percent on room air.  The patient is
found sitting in bed awake in no acute distress.  HEENT:
NC/AT.  Sclerae are anicteric.  Pupils are equally round and
reactive to light.  Extraocular muscles are intact.  Mucous
membranes are moist.  Oropharynx is clear.  Neck is supple,
there are no bruits.  JVD is 10-11 cm at 45 degrees.  2 plus
pulses bilaterally.  Heart:  Regular rate.  No bradycardiac
rhythm with a 1/6 systolic ejection murmur at the right upper
sternal border.  The patient has bilateral diminished breath
sounds at the bases, as well as bilateral rales at the bases
bilaterally.  There are no wheezes.  Abdomen is obese and
soft, nontender, nondistended.  Normoactive bowel sounds.
Liver is palpable.  The liver is approximately 10 cm to 11 cm
at the mid clavicular line.  Rectal examination reveals
guaiac-negative brown stool.  Extremities are warm and dry,
there is trace pitting edema at the ankles bilaterally.
Neurological Examination:  The patient is awake, alert and
oriented x3.  Speech is normal.  Cranial nerves II to XII are
intact.  Strength 5 plus in the upper and lower extremities.
Normal cerebellar examination.

LABORATORY DATA ON ADMISSION:  White count is 12.3,
hematocrit is 42, platelets are 291.  Sodium 136, potassium
3.8, chloride 92, bicarbonate 28.  BUN 18 creatinine 1.2,
glucose 210.  TSH 3.1, troponin T 0.19 with a CK of 295 and
MB of 6.  UA is nitrite negative.  ECG shows sinus
bradycardia, 45 beats per minute, normal axis.  PR interval
of 272 milliseconds, [**Street Address(2) 4793**] elevations in V1 and V2, Q-wave
inversions in V3, aVF, and V6.  Chest film demonstrates mild
CHF.

HOSPITAL COURSE:  CAD.  Serial cardiac enzymes were obtained
given the patient's history of chest pressure prior to
admission.  The patient's initial Troponin T was 0.19 and
increased subsequently to 0.21.  However, his CK was 295 and
subsequently decreased to 188.  His CK-MB was initially 6,
decreased to 4.  As the patient is status post recent
cardioversion and also has mild CRI, I felt that his troponin
elevation may well be due to both renal insufficiency as well
as recent cardioversion.  The patient underwent exercise
tolerance test in which he carried out a modified [**Last Name (un) 20758**]
treadmill test with a 70 percent target heart rate achieved
(heart rate reached at 109 with a blood pressure of 180/110).
There were no anginal symptoms or EKG changes with the
baseline abnormalities at maximum workload.  Nuclear imaging
revealed a mild reversible defect of the inferior wall.
Resting perfusion images did show resolution of this defect.
Ejection fraction was approximately 50 percent.  There was
lack of septal translation consistent with his prior CABG.
The patient was restarted on atenolol though at a lower dose
of 12.5 mg q.d.  He was maintained on atorvastatin 80 mg q.d.
as well as on the aspirin.  His lisinopril dose was increased
to 40 mg q.d.

Atrioventricular conduction delay.  The patient was noted to
have an elevated QT and QTc.  His magnesium and potassium
were repleted aggressively.  His QTc on the day of discharge
was 409 with a QT of 520.  His hydrochlorothiazide was
switched to Aldactazide.  He will take one-half tab q.d. for
a total of 12.5 mg of hydrochlorothiazide and 12.5 mg of
Aldactone.  He will also begin taking magnesium oxide 400 mg
q.d. supplementation.  The patient was asked and recommended
on several occasions to undergo Holter monitoring subsequent
to discharge.  However, the patient states that he is not
willing to have a Holter monitor over the next several weeks
and will consider undergoing Holter monitoring at his next
visit with his cardiologist.

CHF.  As mentioned in the HPI, the patient received
significant fluid resuscitation following his recent
cardioversion.  The patient was aggressively diuresed back to
his baseline weight.  The patient reported resolution of his
symptoms of shortness of breath, PND and dyspnea on exertion.
The patient's weight remained stable for several days prior
to discharge.

Atrial fibrillation.  The patient remained in sinus rhythm
during the hospitalization.  His is monitored on telemetry,
and he is noted to stay in sinus rhythm.  He was maintained
on anticoagulation with Coumadin both for his atrial
fibrillation and for his mechanical aortic valve with target
INR of 2.5 to 3.5.  The patient was begun on disopyramide, on
the day prior to discharge, he was loaded with 300 mg and EKG
on the day of discharge did not reveal any significant change
in QTc interval.  The patient did not appear to have any
adverse reactions to disopyramide and did have any urinary
retention.  The patient was explained at length in detail
every possible side effect of the disopyramide including
urinary retention and will contact his physician if he
experiences any of the side effects.

Bradycardia.  The patient was noted to be bradycardiac on
admission and on several occasions throughout his admission.
He improved off atenolol and his atenolol was restarted at
the lower dose of 12.5 mg q.d. which he will continue taking
after this hospitalization.

Diabetes mellitus.  The patient was maintained on a sliding
scale of Regular Insulin similar to his [**Last Name (un) **] dosing.  [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **] consult was obtained.  The patient was intermittently
maintained on NPH insulin as well though he prefers to only
take Regular Insulin and on several occasions refused with
NPH dosing.  The patient was noted to have labile blood
sugars over this hospitalization though did not allow changes
in general from his [**Last Name (un) **] sliding scale.

Ethanol abuse.  The patient was placed on a CIWA scale given
a significant drinking history.  However, his CIWAs remained
zero and required no Ativan.

Elevated LFTs.  The patient was noted to have significantly
elevated liver tests on admission.  His ALT was 217, his AST
was 192, alkaline phosphatase was 156 and his bilirubin total
was noted to be 0.8.  Subsequent LFTs revealed improvement in
these values.  LFTs diminished to 73 with an AST of 28 and
alkaline phosphatase of 112.  It is likely that these
abnormalities were related to his alcohol intake (though the
ALT greater than AST is somewhat atypical).  It is
recommended that the patient have followup LFTs on an
outpatient basis.  The patient is discharged in stable
condition.

DISCHARGE DIAGNOSES:  Coronary artery disease, status post
coronary artery bypass graft.

Aortic stenosis status post mechanical aortic valve
replacement.

Diabetes mellitus

Paroxysmal atrial fibrillation status post cardioversion.

Congestive heart failure.

Hyperlipidemia.

Atrioventricular conduction delay.

The patient will follow up with Dr. [**First Name (STitle) **] A. F. [**Doctor Last Name 73**] on
[**2161-6-15**] at 11:30 a.m.  He will also follow up with his
primary care physician, [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], in two weeks
if discharged and will also be the followed by the [**Hospital 197**]
Clinic.

MEDICATIONS ON DISCHARGE:
1. Ranitidine 150 mg b.i.d.
2. Lisinopril 40 q.d.
3. Atenolol 12.5 q.d.
4. Disopyramide 150 mg p.o. b.i.d.
5. Aldactazide 12.5/12.5 mg q.d.
6. Magnesium oxide 400 q.d.
7. Aspirin 81 q.d.
8. Humulin Insulin as directed per his [**Last Name (un) **] sliding scale.
9. Lipitor 80 mg q.d.
10.
   Coumadin 5 mg Tuesday, Thursday, Saturday; 6 mg on the other
   days.




                        [**Doctor First Name **] [**Initials (NamePattern4) **] [**Name8 (MD) **], [**MD Number(1) 20759**]

Dictated By:[**Last Name (NamePattern1) 8188**]
MEDQUIST36
D:  [**2161-5-21**] 16:06:49
T:  [**2161-5-23**] 03:44:04
Job#:  [**Job Number 11233**]
{'Subendocardial infarction, initial episode of care,Diastolic heart failure, unspecified,Conduction disorder, unspecified,Atrial fibrillation,Alcohol abuse, continuous,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Heart valve replaced by other means'}


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
male with a past medical history of CAD, NQWMI, status post
two vessel CABG plus AVR ([**2148**]) and DC cardioversion,
[**2161-5-14**], who presented to the ER with a two-day history of
dyspnea and PND.  The patient has a history of atrial
fibrillation and underwent DC cardioversion on [**2161-5-14**].  The
patient was hypotensive following the cardioversion and
required per report up to 7 liters of saline, accompanied by
a weight change of approximately 9 pounds (from 186 pounds to
195 pounds).  The patient states that he was feeling well
prior to the DC cardioversion and that subsequently had
dyspnea on exertion as well as shortness of breath at rest.
The patient stated that he had approximately 3-4 episodes of
PND over the 2 nights prior to admission.  He also had 1
brief episode of substernal chest pain that lasted 2-3
minutes the day prior to admission at 2:00 p.m. that began
when he went from a sitting to a standing position and
resolved spontaneously.

MEDICAL HISTORY: Status post coronary artery bypass
graft in [**2148**] at the [**Location (un) 511**] [**Hospital **] Hospital.  He had
an SVG to the LAD and SVG to the OM.  This procedure was done
in complement to an aortic valve replacement.  Per report,
the patient received a St. [**Male First Name (un) 1525**] number 23 mechanical valve
for treatment of the aortic value stenosis.  Per report, the
patient had non-Q wave MI in [**2143**].

MEDICATION ON ADMISSION: 1. Hydrochlorothiazide 25 mg (increased from 12.5 mg).
2. Atenolol 25 mg q.a.m.
3. Lisinopril 20 mg q.a.m.
4. Coumadin 5 mg every Tuesday, Thursday, Saturday; 6 mg
   every Sunday, Monday, Wednesday, Friday.
5. Lipitor 80 mg q.d.
6. Aspirin 81 mg q.d.
7. Zantac 150 mg p.r.n.

ALLERGIES: The patient has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: The patient is married and lives with his
wife.  [**Name (NI) **] is a former smoker with an approximate 20-pack year
history.  The patient quit several years ago.  He also drinks
up to 8-9 beers per day though he states that he has cut down
to 2 beers per day.  Denies any illicit drug use.  The
patient is a gambler and former boxer.  He won a lottery
several years ago. 

### Response:
{'Subendocardial infarction, initial episode of care,Diastolic heart failure, unspecified,Conduction disorder, unspecified,Atrial fibrillation,Alcohol abuse, continuous,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Heart valve replaced by other means'}
