CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 68-year-old
male with severe dilated cardiomyopathy with an ejection
fraction of 10%, coronary artery disease (with a remote
history of myocardial infarction), non-insulin-dependent
diabetes mellitus, hypertension, and asthma who presented
with progressive fatigue, weakness, and abdominal fullness.

MEDICAL HISTORY: 1.  Dilated cardiomyopathy with an ejection fraction of 10%.
2.  Coronary artery disease, status post myocardial
infarction in [**2128**].
3.  Non-insulin-dependent diabetes mellitus.
4.  Hypertension.
5.  Asthma.
6.  History of alcohol abuse.
7.  Gout.
8.  Anxiety.

MEDICATION ON ADMISSION: Amiodarone 400 mg p.o. t.i.d.,
Toprol-XL 12.5 mg p.o. q.d., Keflex 500 mg p.o. q.i.d. (this
had just been completed), Lasix 80 mg p.o. b.i.d., Percocet
p.o. p.r.n., Coumadin 5 mg p.o. q.h.s., Klonopin 0.24 mg to
0.5 mg p.o. q.h.s. p.r.n., enalapril 7.5 mg p.o. b.i.d.,
glyburide 10 mg p.o. b.i.d., Atrovent 2 puffs inhaled q.i.d.,
lactulose 15 cc to 30 cc p.o. q.d. p.r.n. for constipation,
metformin 850 mg p.o. b.i.d., potassium chloride 25 mEq p.o.
q.d., Robitussin p.r.n., enteric-coated aspirin 325 mg p.o.
q.d., and sulfate 325 mg p.o. b.i.d.

ALLERGIES: He has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: He lives with his brother.  [**Name (NI) **] alcohol or
tobacco.
Acute kidney failure, unspecified,Mitral valve insufficiency and aortic valve insufficiency,Diseases of tricuspid valve,Other primary cardiomyopathies,Gout, unspecified,Asthma, unspecified type, unspecified,Old myocardial infarction
Acute kidney failure NOS,Mitral/aortic val insuff,Tricuspid valve disease,Prim cardiomyopathy NEC,Gout NOS,Asthma NOS,Old myocardial infarct
Admission Date:  [**2134-5-12**]       Discharge Date:  [**2134-5-19**]

Date of Birth:   [**2065-5-24**]       Sex:  M

Service:

HISTORY OF PRESENT ILLNESS:  The patient is a 68-year-old
male with severe dilated cardiomyopathy with an ejection
fraction of 10%, coronary artery disease (with a remote
history of myocardial infarction), non-insulin-dependent
diabetes mellitus, hypertension, and asthma who presented
with progressive fatigue, weakness, and abdominal fullness.

The patient was recently admitted with complete heart block
the week prior to this admission and had a pacemaker placed
on [**2134-5-8**].  He was discharged on [**5-10**].  Over the past
week, he has developed fatigue, weakness, and decreased oral
intake.  He attributes this to early satiety and abdominal
bloating.  The patient reports mild shortness of breath but
denied chest pain, palpitations, fevers, or chills.

On the night prior to admission, he had two-pillow orthopnea,
paroxysmal nocturnal dyspnea, and increasing abdominal
discomfort.  Therefore, he was taken to the hospital where
initial laboratories showed acute renal failure,
hyperkalemia, and hypotension.  He was started on a dopamine
drip peripherally in the Emergency Room.  He was given
Kayexalate times two, insulin, and D-50, and calcium.

PAST MEDICAL HISTORY:
1.  Dilated cardiomyopathy with an ejection fraction of 10%.
2.  Coronary artery disease, status post myocardial
infarction in [**2128**].
3.  Non-insulin-dependent diabetes mellitus.
4.  Hypertension.
5.  Asthma.
6.  History of alcohol abuse.
7.  Gout.
8.  Anxiety.

MEDICATIONS ON ADMISSION:  Amiodarone 400 mg p.o. t.i.d.,
Toprol-XL 12.5 mg p.o. q.d., Keflex 500 mg p.o. q.i.d. (this
had just been completed), Lasix 80 mg p.o. b.i.d., Percocet
p.o. p.r.n., Coumadin 5 mg p.o. q.h.s., Klonopin 0.24 mg to
0.5 mg p.o. q.h.s. p.r.n., enalapril 7.5 mg p.o. b.i.d.,
glyburide 10 mg p.o. b.i.d., Atrovent 2 puffs inhaled q.i.d.,
lactulose 15 cc to 30 cc p.o. q.d. p.r.n. for constipation,
metformin 850 mg p.o. b.i.d., potassium chloride 25 mEq p.o.
q.d., Robitussin p.r.n., enteric-coated aspirin 325 mg p.o.
q.d., and sulfate 325 mg p.o. b.i.d.

ALLERGIES:  He has no known drug allergies.

SOCIAL HISTORY:  He lives with his brother.  [**Name (NI) **] alcohol or
tobacco.

PHYSICAL EXAMINATION ON PRESENTATION:  Vital signs on
admission revealed a temperature of 95.1, pulse of 80, blood
pressure of 94/60, respiratory rate of 10, oxygen saturation
of 98% on room air.  He was on a dopamine drip while this
blood pressure was taken.  In general, he was a pale,
chronically ill-appearing gentleman, alert and oriented times
three.  Head, eyes, ears, nose, and throat revealed pupils
were equal, round, and reactive to light.  Extraocular
movements were intact.  His sclerae were anicteric.  His
oropharynx was clear.  The mucous membranes were moist.  The
neck was supple with jugular venous pressure elevated to
11 cm to 12 cm.  The chest was notable for bibasilar rales,
and otherwise clear to auscultation bilaterally.  The
cardiovascular examination revealed a regular normal first
heart sound and second heart sound, distant heart sounds.
There was a 2/6 systolic murmur heard at the apex.  There
were no gallops or rubs.  The abdomen was soft, nontender,
and nondistended, with normal active bowel sounds.
Extremities were cool.  The was 1+ pedal edema.  The left
fourth toe was erythematous.  Neurologic examination revealed
alert and oriented times three.  Cranial nerves II through
XII were intact.  Strength was [**4-18**] in the upper and lower
extremities bilaterally.  Sensation was intact to light
touch.  The gait was not assessed.

PERTINENT LABORATORY DATA ON PRESENTATION:  Laboratories on
admission revealed a sodium of 128, potassium of 6, chloride
of 91, bicarbonate of 20, blood urea nitrogen of 76,
creatinine of 3.3 (his baseline when he was discharged from
the hospital on [**5-12**] was 1.7), blood glucose of 150.  The
anion gap was calculated at 17.  His digoxin level was 0.4.
Calcium was 8.9, magnesium of 2.6, and phosphate of 6.4.
Troponin of less than 0.3, and creatine kinase was 119, with
a MB fraction of 4.  The white blood cell count was 8.5 (with
a differential of 88% neutrophils, 5% lymphocytes, and
6% monocytes.  His hematocrit was 34.7, and platelets
were 233.  The INR was elevated at 5.3.  Urinalysis was
negative.

RADIOLOGY/IMAGING:   A chest x-ray showed cardiomegaly with
pacemaker leads in place.

Electrocardiogram showed a ventricularly paced rhythm with a
rate in the 80s.  There was complete heart block when he was
not paced.

An echocardiogram performed on [**5-5**] showed an ejection
fraction of less than 20%, left ventricle severely dilated,
global left ventricular hypokinesis, right ventricle
moderately dilated with free wall hypokinesis.  There was 3+
mitral regurgitation, 2+ tricuspid regurgitation, and 1+
aortic regurgitation.

IMPRESSION:  This is a 68-year-old male with a history of
severe dilated cardiomyopathy, non-insulin-dependent diabetes
mellitus, and coronary artery disease who presented with
acute renal failure, and hyperkalemia, as well as a
supracervical INR.

HOSPITAL COURSE BY SYSTEM:

1.  CARDIOVASCULAR:  The patient was initially admitted to
the Cardiothoracic Intensive Care Unit for blood pressure
support.  His dopamine was weaned to off over the first 24
hours of his admission.  He was able to be transferred
uneventfully to the General Medicine floor.

He was felt to be severely volume depleted and was given
intravenous fluids.  We held his Lasix, beta blocker, and ACE
inhibitor initially.  With this treatment, his creatinine
slowly decreased to 1.7 and stabilized.  He ruled out for a
myocardial infarction by negative creatine kinases times
three.  Gradually, as he became more euvolemic, we added
standing Lasix at half his prior dose; specifically, 40 mg
p.o. b.i.d.   We also restarted his ACE inhibitor at a lower
dose that previously; specifically, enalapril 10 mg p.o. q.d.
These should be gradually titrated back up to their prior
levels as an outpatient.  In addition, Toprol-XL should be
restarted as an outpatient.

It should be noted that throughout his time on the General
Medicine floor, his blood pressure remained in the middle
90s.  His blood pressure did not drop once we added his
medications for heart failure.

From an electrophysiology standpoint, the patient was seen by
the Electrophysiology Service and a quick look of his
pacemaker revealed a normally functioning pacemaker.  In
addition, he was noted to have a small hematoma at the
pacemaker wound site that was felt to be clinically
insignificant.  Finally, we continued the patient on
amiodarone at 400 mg p.o. b.i.d.  This should be gradually
titrated down as an outpatient.

2.  RENAL:  Given the patient's renal failure and
hyperkalemia, we hydrated the patient and his kidney function
subsequently improved.  Therefore, it seemed almost certain
that his renal failure was secondary to prerenal cause.  His
potassium normalized with the treatment mentioned above in
the History of Present Illness and remained within normal
limits for the remainder of his hospitalization.

3.  PULMONARY:  The patient had no acute pulmonary issues
during this hospitalization.  He oxygenated well.  The chest
x-ray revealed no pulmonary or vascular engorgement, and he
did not have any signs or symptoms of overt congestive heart
failure from a pulmonary standpoint.

4.  HEMATOLOGY:  The patient presented with an elevated INR.
This was probably secondary to malnutrition and dehydration.
Coumadin was initially held, and once his INR reached 2.2 we
re-initiated Coumadin therapy at 3 mg p.o. q.h.s.  On the day
prior to discharge, his INR was 1.9, and this should be
followed closely as an outpatient to keep his INR at
approximately 2 for his severely hypokinetic left ventricle.
There was no evidence of acute bleeding despite the elevated
INR.

5.  RHEUMATOLOGY:  The patient's left fourth toe was found to
have some warmth and erythema for which he had been on
Keflex.  He was seen by the Rheumatology Service who felt
that his signs and symptoms were most consistent with gout.
An x-ray was performed that suggested the possibility of
osteomyelitis; however, this was not supported by the
clinical presentation.  Rather, it was felt that the patient
had tophaceous gout.  An outpatient Rheumatology followup was
arranged, and there was no specific anti-gout therapy
instituted the fact that the warmth and erythema resolved
spontaneously, and the patient was asymptomatic.

6.  GASTROINTESTINAL:  The patient had mild gastrointestinal
distress on admission which was probably secondary to uremia
and past hepatic congestion.  His gastrointestinal distress
resolved, and we continued him on Protonix and lactulose
p.r.n.

7.  ENDOCRINE:  Initially, we held the patient's glyburide
and Glucophage and covered the patient with a regular insulin
sliding-scale.  On the day prior to discharge, we
reinstituted glyburide.  We recommend holding Glucophage
given the patient's continued elevated creatinine.

MEDICATIONS ON DISCHARGE:
 1.  Aspirin 325 mg p.o. q.d.
 2.  Atrovent 2 puffs inhaled q.i.d.
 3.  Glyburide 10 mg p.o. b.i.d.
 4.  Amiodarone 400 mg p.o. b.i.d.
 5.  Klonopin 0.25 mg to 0.5 mg p.o. q.h.s. p.r.n. for
insomnia.
 6.  Lasix 40 mg p.o. b.i.d.
 7.  Enalapril 10 mg p.o. q.d.
 8.  Coumadin 3 mg p.o. q.h.s.
 9.  Colace 100 mg p.o. b.i.d.
10.  Lactulose 15 cc to 30 cc p.o. q.d. p.r.n. for
constipation.
11.  Potassium chloride 20 mEq p.o. q.d.

DISCHARGE FOLLOWUP:   The patient should follow up with his
primary care physician (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]).  The patient had
followup arranged with the Heart Failure Clinic,
Rheumatology, and the Electrophysiology Clinic.

DISCHARGE STATUS:  He was discharged to home with [**Hospital6 3429**] and home physical therapy.

CONDITION AT DISCHARGE:  Condition on discharge was good.

DISCHARGE DIAGNOSES:
 1.  Dehydration.
 2.  Acute renal failure.
 3.  Chronic renal insufficiency.
 4.  Congestive heart failure.
 5.  Gout.
 6.  Diabetes mellitus.
 7.  Asthma.
 8.  Supracervical INR.
 9.  Hyperkalemia.
10.  Complete heart block, status post pacemaker placement.





                          DR.[**Last Name (STitle) **],[**Known firstname **] 12-153

Dictated By:[**Name8 (MD) 2734**]
MEDQUIST36

D:  [**2134-5-18**]  14:11
T:  [**2134-5-18**]  14:55
JOB#:  [**Job Number 96412**]
{'Acute kidney failure, unspecified,Mitral valve insufficiency and aortic valve insufficiency,Diseases of tricuspid valve,Other primary cardiomyopathies,Gout, unspecified,Asthma, unspecified type, unspecified,Old myocardial infarction'}


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 68-year-old
male with severe dilated cardiomyopathy with an ejection
fraction of 10%, coronary artery disease (with a remote
history of myocardial infarction), non-insulin-dependent
diabetes mellitus, hypertension, and asthma who presented
with progressive fatigue, weakness, and abdominal fullness.

MEDICAL HISTORY: 1.  Dilated cardiomyopathy with an ejection fraction of 10%.
2.  Coronary artery disease, status post myocardial
infarction in [**2128**].
3.  Non-insulin-dependent diabetes mellitus.
4.  Hypertension.
5.  Asthma.
6.  History of alcohol abuse.
7.  Gout.
8.  Anxiety.

MEDICATION ON ADMISSION: Amiodarone 400 mg p.o. t.i.d.,
Toprol-XL 12.5 mg p.o. q.d., Keflex 500 mg p.o. q.i.d. (this
had just been completed), Lasix 80 mg p.o. b.i.d., Percocet
p.o. p.r.n., Coumadin 5 mg p.o. q.h.s., Klonopin 0.24 mg to
0.5 mg p.o. q.h.s. p.r.n., enalapril 7.5 mg p.o. b.i.d.,
glyburide 10 mg p.o. b.i.d., Atrovent 2 puffs inhaled q.i.d.,
lactulose 15 cc to 30 cc p.o. q.d. p.r.n. for constipation,
metformin 850 mg p.o. b.i.d., potassium chloride 25 mEq p.o.
q.d., Robitussin p.r.n., enteric-coated aspirin 325 mg p.o.
q.d., and sulfate 325 mg p.o. b.i.d.

ALLERGIES: He has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: He lives with his brother.  [**Name (NI) **] alcohol or
tobacco. 

### Response:
{'Acute kidney failure, unspecified,Mitral valve insufficiency and aortic valve insufficiency,Diseases of tricuspid valve,Other primary cardiomyopathies,Gout, unspecified,Asthma, unspecified type, unspecified,Old myocardial infarction'}
