CHIEF COMPLAINT: Unstable angina status post myocardial
infarction

PRESENT ILLNESS: Mrs. [**Known lastname 46993**] is an 86-year-old
female with a past medical history significant for type II
diabetes mellitus, coronary artery disease status post
myocardial infarction and peptic ulcer disease who began
experiencing substernal chest pain upon exertion at the
beginning of [**2155-10-26**].  She was admitted to the [**Hospital6 1760**] on [**2155-10-30**] at which
time she ruled in for myocardial infarction by CK/MB cardiac
enzyme which was 12.3  She was also found to have an
electrocardiogram notable for ST depressions and flipped
T-waves.  During the aforementioned admission, the patient
underwent cardiac catheterization which showed significant
two vessel disease with a LAD which had a long 70% mid vessel
stenosis.

MEDICAL HISTORY: 1.  Type II diabetes mellitus which is diet controlled.
2.  Peptic ulcer disease
3.  Hiatal hernia
4.  Coronary artery disease

MEDICATION ON ADMISSION: 

ALLERGIES: THE PATIENT REPORTS AN ALLERGY TO CODEINE.

PHYSICAL EXAM: 

FAMILY HISTORY: Mrs.[**Known lastname 46994**] family history is significant of
her mother and a brother who died of myocardial infarctions,
both in their 70s.

SOCIAL HISTORY: The patient lives alone with home services.
She denies any prior use of tobacco, alcohol or illicit
drugs.
Coronary atherosclerosis of native coronary artery,Cardiac complications, not elsewhere classified,Atrial fibrillation,Subendocardial infarction, subsequent episode of care,Other ill-defined heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Esophageal reflux,Family history of ischemic heart disease
Crnry athrscl natve vssl,Surg compl-heart,Atrial fibrillation,Subendo infarct, subseq,Ill-defined hrt dis NEC,DMII wo cmp nt st uncntr,Esophageal reflux,Fam hx-ischem heart dis
Admission Date:  [**2155-11-21**]       Discharge Date:  [**2155-12-1**]


Service:  Cardiothoracic Surgery

CHIEF COMPLAINT:  Unstable angina status post myocardial
infarction

HISTORY OF PRESENT ILLNESS:  Mrs. [**Known lastname 46993**] is an 86-year-old
female with a past medical history significant for type II
diabetes mellitus, coronary artery disease status post
myocardial infarction and peptic ulcer disease who began
experiencing substernal chest pain upon exertion at the
beginning of [**2155-10-26**].  She was admitted to the [**Hospital6 1760**] on [**2155-10-30**] at which
time she ruled in for myocardial infarction by CK/MB cardiac
enzyme which was 12.3  She was also found to have an
electrocardiogram notable for ST depressions and flipped
T-waves.  During the aforementioned admission, the patient
underwent cardiac catheterization which showed significant
two vessel disease with a LAD which had a long 70% mid vessel
stenosis.

PAST MEDICAL HISTORY:
1.  Type II diabetes mellitus which is diet controlled.
2.  Peptic ulcer disease
3.  Hiatal hernia
4.  Coronary artery disease

PAST SURGICAL HISTORY:
1.  Repair of hiatal hernia
2.  Hysterectomy
3.  Partial gastrectomy

ADMISSION MEDICATIONS:
1.  Lopressor 25 mg by mouth twice per day
2.  Enteric coated aspirin 325 mg by mouth once per day
3.  Lansoprazole
4.  Calcium tablets 500 mg by mouth 3x per day
5.  Nitroglycerin ointment as needed for chest pain
6.  Multivitamin

ALLERGIES:  THE PATIENT REPORTS AN ALLERGY TO CODEINE.

SOCIAL HISTORY:  The patient lives alone with home services.
She denies any prior use of tobacco, alcohol or illicit
drugs.

FAMILY HISTORY:  Mrs.[**Known lastname 46994**] family history is significant of
her mother and a brother who died of myocardial infarctions,
both in their 70s.

PHYSICAL EXAMINATION:  On initial physical examination, Mrs.
[**Known lastname 46993**] was found to have a heart rate of 80 beats per minute in
sinus rhythm with a blood pressure of 155/66.  Her height was
4 feet 10 inches and her weight was 102 pounds.
GENERAL:  She was a pleasant and elderly woman in no acute
distress.
HEAD, EARS, EYES, NOSE AND THROAT:  Her pupils were equal,
round and reactive to light and accommodation.  Her
extraocular muscles were intact.
NECK:  Supple with trachea in the midline and no visible
jugular venous distention.  Her carotid arteries were 2+
palpable with no audible bruits.  There was no
lymphadenopathy.
CARDIAC:  She had a regular rate and rhythm with normal S1
and S2 heart sounds.  There were no murmurs, rubs or gallops
LUNGS:  Clear to auscultation bilaterally with good air entry
and movement.
ABDOMEN:  Soft, nontender, nondistended, with no
hepatosplenomegaly or other palpable masses.
EXTREMITIES:  Warm and dry with no peripheral edema.
NEUROLOGIC:  She was alert and oriented to person, place and
time and her motor and sensory systems were grossly intact.

LABORATORY DATA available from her prior admission in early
[**Month (only) 1096**] was significant for a hematocrit of 33.7, an INR of
1.3 and electrolytes.  Chem-7 showing a sodium of 140,
potassium of 4.5, chloride of 107, bicarbonate of 23, BUN of
14, creatinine of 0.8 with a blood glucose of 111.

RADIOLOGIC STUDIES:  Mrs. [**Known lastname 46993**] underwent a preoperative chest
x-ray which showed no apparent abnormalities.  She also had
undergone cardiac catheterization in early [**Month (only) 1096**] which
showed two vessel disease as previously mentioned in the
History of Present Illness.

HOSPITAL COURSE:  Mrs. [**Known lastname 46993**] was admitted to the Operating
Room on [**2155-11-21**] where she underwent a coronary
artery bypass graft x2.  Please see the dictated operative
note for details of this procedure, but in summary the
patient underwent a bypass graft x2 with the left internal
mammary artery anastomosed to the left anterior descending
and a saphenous vein graft of the coronary artery.  She also
underwent pericardial patch repair of the right atrium with
Bio-glue.  She was subsequently transferred to the Cardiac
Surgery Recovery Unit in stable condition, with a mean
arterial pressure of 95, A-paced, and on a propofol drip at
20 mcg per kg per minute.  On the night of her surgery, she
developed acute onset of a sinus tachycardia with a heart
rate in the 130s, which was refractory to adenosine and
intravenous metoprolol.  Pacing was also unable to decrease
her heart rate.

At this time, an electrophysiology consult was obtained, and
her heart rate was controlled using E and V pacing as well as
increase in her dosage of beta blocker, and antiinflammatory
medication for a pericardial rub which could be heard at this
time.  The laboratory results on postoperative day #1 were
significant for a hematocrit of 32 and a white blood cell
count of 8.6.  At this time, her electrolytes were
significant for a sodium of 146, potassium of 4.5, chloride
of 112, bicarbonate of 23, BUN 18, creatinine of 0.7.  Her
magnesium at the time was 2.4 and her INR was 1.0.  She also
had an arterial blood gas which showed a pH of 7.38, PCO2 46,
and a PO2 of 172.

Her blood pressure was held in control using a Neo-Synephrine
drip to combat the blood pressure lowing effects of her
increasing doses of beta blocker.  She was, at this time,
also started on esmolol, as the previously given Lopressor
had not been fully effective.  Her heart rhythm during this
time was at times sinus, but also at times atrial
fibrillation.  On postoperative day #3, she continued to be
tachycardic and in atrial fibrillation from time to time.
She was at this time on Lasix, Lopressor and aspirin.  Her
esmolol was weaned and she was started on oral amiodarone.
Her Lopressor was further increased on postoperative day #4
and she was started on captopril.  She continued to oscillate
between atrial fibrillation and sinus rhythm.  She was awake
and alert and doing well from the standpoint of her surgery.
Her episodes of tachycardia became shorter in duration, and
she spent more time in sinus rhythm.

At this time, a speech and swallowing evaluation was also
obtained as the patient was noted to have trouble swallowing
her pills.  She did not have any difficulty with any of the
diet attempts that were made including .................
puree and jello.  She was not found to aspirate, and her diet
was to be advanced as tolerated.  She was at this time also
on a diltiazem drip in order to help with rate control.  This
was stopped on postoperative day #5.  The patient was able to
maintain a sustained period of sinus rhythm.  By
postoperative day #6, she had been in normal sinus rhythm for
a full 24 hour period.  Her amiodarone was decreased now due
to bradycardia to 400 mg by mouth twice per day.  Her heart
rate at this time was 63 beats per minute and in sinus
rhythm.  She was subsequently transferred to the floor on
postoperative day #6 where she did quite well.  She continued
to improve from the standpoint of her diet and mobility.  Her
incision was healing well and she had good sternal stability.

She continued to slowly diurese and continues to have minimal
lower extremity edema.  On approximately postoperative day
#8, she began having multiple loose stools per day and was
empirically started on 500 mg of Flagyl by mouth 3x per day
and a stool sample was sent for Clostridium difficile toxin.
Her Lopressor and captopril were titrated according to her
heart rate and blood pressure to fully meet her heart rate
and blood pressure control needs.  Due to her age and living
situation, it was thought prudent that she spend a brief time
in a skilled care nursing facility, where she could be more
closely monitored.  She was screened and deemed ready for
discharge on postoperative day #10.

PHYSICAL EXAMINATION AT THE TIME OF DISCHARGE:
VITAL SIGNS:  Notable for a temperature of 96?????? Fahrenheit,
heart rate of 86 and sinus rhythm, blood pressure of 123/50,
with an oxygen saturation of 100% on room air.
GENERAL:  She was sitting in a chair, alert and oriented to
person, place and time.
HEART:  Regular rate and rhythm with normal S1, S2 and no
murmurs.
LUNGS:  Clear to auscultation bilaterally with good air entry
and movement.
CHEST:  Her sternal incision was healing quite nicely with
good sternal stability.
ABDOMEN:  Soft, nontender and nondistended.  Her incisions
were open to the air, clean and dry.
EXTREMITIES:  Warm and well perfuse with no evidence of pedal
edema.

DISCHARGE LABORATORIES:  A complete blood count with a white
blood cell count of 8.2, hematocrit of 31.1 and a platelet
count of 187,000.  Her Chem-7 showed a sodium of 137,
potassium of 5.2, chloride of 105, bicarbonate of 28, BUN of
21, creatinine of 0.9 with a blood glucose of 117.  Her
magnesium at the time is 1.5 for which she will be repleted
prior to discharge.

DISCHARGE MEDICATIONS:
1.  Lopressor 37.5 mg by mouth twice per day to be held for a
systolic blood pressure less than 100 or a heart rate less
than 60
2.  Captopril 6.25 mg by mouth 3x per day to be held for a
systolic blood pressure below 110
3.  Flagyl 500 mg by mouth 3x per day
4.  Amiodarone 400 mg by mouth once per day
5.  Protonix 40 mg by mouth once per day
6.  Enteric coated aspirin 325 mg by mouth once per day
7.  Colace 100 mg by mouth twice per day
8.  Lasix 20 mg by mouth once per day
9.  Dulcolax suppository 10 mg per rectum once per day as
needed for constipation
10. Benadryl 25 mg by mouth each night at the hour of sleep
as needed for sleep.
11. Milk of Magnesia 30 ml by mouth each night as needed for
constipation
12. Tylenol 650 mg by mouth 4x every four hours as needed for
pain

DIET:  Her diet should be a cardiac heart healthy diet.

ACTIVITY:  Her activity should be as tolerated, though she
would probably benefit from some further physical therapy in
order to increase her strength and mobility.

DISPOSITION:  Skilled nursing facility

FOLLOW UP:  Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] in four weeks time.




                            [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D.  [**MD Number(1) 414**]

Dictated By:[**Name (STitle) 46995**]
MEDQUIST36

D:  [**2155-12-1**]  09:55
T:  [**2155-12-1**]  11:01
JOB#:  [**Job Number 46996**]
{'Coronary atherosclerosis of native coronary artery,Cardiac complications, not elsewhere classified,Atrial fibrillation,Subendocardial infarction, subsequent episode of care,Other ill-defined heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Esophageal reflux,Family history of ischemic heart disease'}


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: Unstable angina status post myocardial
infarction

PRESENT ILLNESS: Mrs. [**Known lastname 46993**] is an 86-year-old
female with a past medical history significant for type II
diabetes mellitus, coronary artery disease status post
myocardial infarction and peptic ulcer disease who began
experiencing substernal chest pain upon exertion at the
beginning of [**2155-10-26**].  She was admitted to the [**Hospital6 1760**] on [**2155-10-30**] at which
time she ruled in for myocardial infarction by CK/MB cardiac
enzyme which was 12.3  She was also found to have an
electrocardiogram notable for ST depressions and flipped
T-waves.  During the aforementioned admission, the patient
underwent cardiac catheterization which showed significant
two vessel disease with a LAD which had a long 70% mid vessel
stenosis.

MEDICAL HISTORY: 1.  Type II diabetes mellitus which is diet controlled.
2.  Peptic ulcer disease
3.  Hiatal hernia
4.  Coronary artery disease

MEDICATION ON ADMISSION: 

ALLERGIES: THE PATIENT REPORTS AN ALLERGY TO CODEINE.

PHYSICAL EXAM: 

FAMILY HISTORY: Mrs.[**Known lastname 46994**] family history is significant of
her mother and a brother who died of myocardial infarctions,
both in their 70s.

SOCIAL HISTORY: The patient lives alone with home services.
She denies any prior use of tobacco, alcohol or illicit
drugs. 

### Response:
{'Coronary atherosclerosis of native coronary artery,Cardiac complications, not elsewhere classified,Atrial fibrillation,Subendocardial infarction, subsequent episode of care,Other ill-defined heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Esophageal reflux,Family history of ischemic heart disease'}
