CHIEF COMPLAINT: Sudden onset of shortness of breath.

PRESENT ILLNESS: The patient is a 76-year-old
female with a history of type 2 diabetes, 3-vessel coronary
artery disease, and a preserved ejection fraction of 60%, as
well as mild diastolic dysfunction who presents with the
above complaints as well as diaphoresis and nausea which
occurred suddenly while she was taking her morning
medications in her bathroom.  At this time she also felt her
heart was increased.  She called the Emergency Medical
Services who arrived and placed her on BiPAP with settings of
10 and 5, 1 inch of nitroglycerin paste, and gave her
morphine, oxygen, as well as 50 mg of Lasix with 300 cc of
urine output.

MEDICAL HISTORY: 1.  Insulin-dependent type 2 diabetes mellitus times 20
years.  Last hemoglobin A1c was 9.1.
 2.  Peripheral vascular disease including a right femoral to
peroneal bypass and transmetatarsal amputation in [**2123-12-20**] which was reportedly occluded in [**2124-8-18**].
She also has a left femoral to dorsalis pedis bypass which
was patent as of [**2124-8-18**].
 3.  History of mild chronic obstructive pulmonary disease.
She has no pulmonary function tests on record.  The only

MEDICATION ON ADMISSION: Medications include
lisinopril 20 mg p.o. q.d., Imdur 30 mg p.o. q.d.,
enteric-coated aspirin 325 mg p.o. q.d., Tums 500 mg p.o.
q.d., multivitamin p.o. q.d., NPH insulin 17 units q.a.m. and
10 units q.p.m., atenolol 75 mg p.o. q.d. (this was increased
from 50 mg p.o. q.d. one week prior to admission).

ALLERGIES: PENICILLIN gives her a rash, TETRACYCLINE gives
her gastrointestinal upset.  She has another nonspecific
allergy reported to TERBUTALINE.

PHYSICAL EXAM: 

FAMILY HISTORY: She has another sister with coronary artery
disease.  Her father died of a myocardial infarction at 69.
Her mother died of coronary artery disease at age 67, and she
has another brother with coronary artery disease.

SOCIAL HISTORY: The patient has never smoked.  Has had
distant social alcohol use, none currently.  Denied any other
substance use including intravenous drug abuse.  She lives
with her 80-year-old sister.
Congestive heart failure, unspecified,Chronic airway obstruction, not elsewhere classified,Coronary atherosclerosis of native coronary artery,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension
CHF NOS,Chr airway obstruct NEC,Crnry athrscl natve vssl,DMII wo cmp nt st uncntr,Hypertension NOS
Admission Date:  [**2126-6-17**]     Discharge Date:  [**2126-6-18**]


Service:  CCU

CHIEF COMPLAINT:  Sudden onset of shortness of breath.

HISTORY OF PRESENT ILLNESS:  The patient is a 76-year-old
female with a history of type 2 diabetes, 3-vessel coronary
artery disease, and a preserved ejection fraction of 60%, as
well as mild diastolic dysfunction who presents with the
above complaints as well as diaphoresis and nausea which
occurred suddenly while she was taking her morning
medications in her bathroom.  At this time she also felt her
heart was increased.  She called the Emergency Medical
Services who arrived and placed her on BiPAP with settings of
10 and 5, 1 inch of nitroglycerin paste, and gave her
morphine, oxygen, as well as 50 mg of Lasix with 300 cc of
urine output.

On arrival at the [**Hospital1 69**]
Emergency Room she received another 80 mg of Lasix, and her
BiPAP was weaned to 100% nonrebreather with saturations
greater than 99%.  She was admitted to the Medical Intensive
Care Unit on the Coronary Care Unit service where she was
rapidly weaned to 4 liters of nasal cannula without
desaturation and maintained a stable respiratory rate in the
low 20s.  At this time she denied any history of chest pain,
dietary indiscretion as far as salt intake, orthopnea or a
prior event similar to those which brought her to the
hospital.  With her prior cardiac ischemia she has had only
nausea in the past.  She has no history of paroxysmal
nocturnal dyspnea or cough, although she does report some
left lower extremity swelling which has been stable since
vascular surgery but is also reporting new onset right lower
extremity edema which she has not previously noticed.  She
also orthopnea but uses two pillows at home for comfort.

PAST MEDICAL HISTORY:
 1.  Insulin-dependent type 2 diabetes mellitus times 20
years.  Last hemoglobin A1c was 9.1.
 2.  Peripheral vascular disease including a right femoral to
peroneal bypass and transmetatarsal amputation in [**2123-12-20**] which was reportedly occluded in [**2124-8-18**].
She also has a left femoral to dorsalis pedis bypass which
was patent as of [**2124-8-18**].
 3.  History of mild chronic obstructive pulmonary disease.
She has no pulmonary function tests on record.  The only

description of this diagnosis is that it is mild.  She has no
tobacco history .
 4.  Recurrent lower extremity cellulitis.
 5.  Degenerative joint disease.
 6.  Hypertension.
 7.  Status post cholecystectomy.
 8.  Total abdominal hysterectomy.
 9.  Right hip fracture in [**2119**].
10.  Left hip fracture in [**2123**].
11.  Left humeral fracture in [**2121**].
12.  C4-C5 spinal stenosis.
13.  Coronary artery disease with 3-vessel disease previously
described as not amenable to coronary artery bypass graft.
Baseline electrocardiogram showed inferior and anterior
Q waves as well as ST elevation anteriorly.  Cardiac
catheterization in [**2126-3-19**] performed for an isolated
troponin leak showed an ejection fraction of 60%, apical
akinesis, a left ventricular end-diastolic pressure of 14,
right coronary arteries showed diffuse disease, left coronary
arteries in this left dominant system showed an left anterior
descending artery lesion of 80% proximally, 60% mid left
anterior descending artery, and 90% distally.  Left
circumflex showed a 50% lesion in the mid circumflex and a
70% lesion in the distal circumflex.  There was diffuse
disease in first obtuse marginal and second obtuse marginal
with up to 70% lesion.  The left posterior descending artery
was normal.  She had mild diastolic dysfunction.  An
echocardiogram performed in [**2126-3-19**] showed left atrial
enlargement.  Dimensions were 5.6 cm X 3.9 cm.  She had a
normal right atrium.  She had symmetric mild left ventricular
hypertrophy.  No wall motion abnormalities were described.
Delayed relaxation, trivial mitral regurgitation, and trivial
tricuspid regurgitation.  As well, mild thickening of the AV
was noted; however, this was a suboptimal study.

SOCIAL HISTORY:  The patient has never smoked.  Has had
distant social alcohol use, none currently.  Denied any other
substance use including intravenous drug abuse.  She lives
with her 80-year-old sister.

FAMILY HISTORY:  She has another sister with coronary artery
disease.  Her father died of a myocardial infarction at 69.
Her mother died of coronary artery disease at age 67, and she
has another brother with coronary artery disease.

ALLERGIES:  PENICILLIN gives her a rash, TETRACYCLINE gives
her gastrointestinal upset.  She has another nonspecific
allergy reported to TERBUTALINE.

MEDICATIONS ON ADMISSION:  Medications include
lisinopril 20 mg p.o. q.d., Imdur 30 mg p.o. q.d.,
enteric-coated aspirin 325 mg p.o. q.d., Tums 500 mg p.o.
q.d., multivitamin p.o. q.d., NPH insulin 17 units q.a.m. and
10 units q.p.m., atenolol 75 mg p.o. q.d. (this was increased
from 50 mg p.o. q.d. one week prior to admission).

REVIEW OF SYSTEMS:  She denies symptoms of urinary tract
infections.  She has been drinking seven to eight glasses of
water a day in an attempt to improve her health.  She denies
abdominal pain.  She does have nausea which is resolving.
She denies vomiting, diarrhea, and constipation.  She reports
some arthritic leg pain.  She denies rash.

PHYSICAL EXAMINATION ON ADMISSION:  On physical examination,
she was saturating 97% on 3 liters and 89% on room air.
Pulse was 66, blood pressure was 143/55, temperature was 97
degrees, respiratory rate was 18 to 20.  In general, she was
an obese elderly female in no acute distress.  HEENT
examination showed no jugular venous distention.  Mucous
membranes were moist.  The patient was edentulous.  Pupils
were sluggish but equal, round, and reactive to light.
Extraocular movements were intact.  Cranial nerves II through
XII were intact.  Cardiovascular examination was obscured by
her breath sounds but showed a regular rate and rhythm with
normal S1 and S2, and potentially a [**11-24**] murmur at her left
lower sternal border.  Lung examination showed good air
movement but loud coarse breath sounds including expiratory
grumbles and wheezes and some inspiratory crackles, right
greater than left, at the bases which were decreased since
evaluation in the Emergency Room.  Extremities showed a right
transmetatarsal amputation, several left toe amputations.
Surgical scars from her bypass procedures.  No cyanosis or
clubbing.  She had a good pulse in her left bypass graft but
none in her dorsalis pedis or posterior tibialis on either
side.  She had prominent pitting edema to slightly above her
knees.

LABORATORY ON ADMISSION:  White blood cell count was 11.6,
hemoglobin 15, hematocrit 45.8, platelets 237.  Sodium 139,
potassium 3.8, chloride 102, bicarbonate 24, BUN 16,
creatinine 0.7, glucose 277.  Calcium 8.8, magnesium 1.8,
phosphorous 4.9.  PT 12.3, INR 1, PTT 23.5.  Creatine kinase
was 58 on admission.  Troponin returned at less than 0.3.
Urinalysis was positive for nitrites, negative for white
blood cells and showed few bacteria.  Lipid profile obtained
in [**2126-3-19**] showed an LDL of 85, an HDL of 43, a
triglycerides of 60.

RADIOLOGY/IMAGING:  Chest x-ray was obtained in the lordotic
position and was also rotated which showed an elevated left
hemidiaphragm secondary to a large amount of gastric air.
There was left costophrenic angle blunting.  The right was
not included in the x-ray.  She had a central alveolar
pattern in her lung fields, consistent with congestive heart
failure.

Electrocardiogram at baseline the patient has Q waves and ST
elevations in V2 through V3 as well as T wave flattening in
V5 through V6 and I.  She also has Q waves in inferior leads
III and F as well as V1 and V4.  On admission she was in
sinus tachycardia at 111, had a normal axis, and had ST
elevations in V1 through V4, had T wave inversions and
flattening in the same leads, left atrial enlargement,
possibly a right atrial abnormality, Q waves in II, III, F,
V1 through V5; 40 minutes later the patient was in a sinus
rhythm at 81, axis was 0, ST elevations had decreased in V1
through V3, and she had one premature ventricular
contraction.

IMPRESSION:  Impression at that time was that this was a
76-year-old female with 3-vessel coronary artery disease,
diabetes, diastolic dysfunction with flash pulmonary edema
and rapid improvement with oxygenation and subjective
breathing while in the hospital.

HOSPITAL COURSE BY SYSTEM:

1.  CARDIOVASCULAR:  As far as her pump function, the patient
was continued on 1 inch of nitroglycerin paste.  She was
given supplemental oxygen by nasal cannula.  She was given
further Lasix 60 mg and 100 mg over the first night of her
admission as well as potassium repletion and diuresed
3 liters by discharge the following day.  By afternoon the
next day, she was feeling entirely well, was breathing at her
baseline, saturating 95% to 96% on room air, and had no
complaints.  She was taking a full diet.  The day after
admission the team increased her lisinopril to 30 mg q.d. and
put her on standing Lasix 60 mg p.o. q.d.   Her nitroglycerin
paste was switched to Imdur.  The possibility of excessive
volume intake or dietary indiscretion in terms of sodium were
discussed with the patient.  She was to decrease her fluid
intake to only when she is thirsty and to avoid high-salted
foods.

As far as her coronary artery disease, the patient ruled out
for myocardial infarction by enzymes; although, it was
impossible to rule an episode of ischemia which worsened her
diastolic dysfunction and precipitated this event.  Her beta
blocker, ACE inhibitor, and aspirin were continued.  In spite
of her acceptable lipid panel, no lipid lowering medications
were started.  She was seen by Cardiothoracic Surgery the day
after admission for consideration of possible coronary artery
bypass graft.  Surgery felt that she would be a acceptable,
but technically difficult, coronary artery bypass graft to
perform.

As far as her electrical issues, the patient was monitored on
telemetry and had no arrhythmias inhouse, but it was not
possible to exclude transient arrhythmia as a cause of her
flash pulmonary edema.  At discharge, her plan for management
of her coronary artery disease was to include medical
management at this time, follow up with her primary care
physician (Dr. [**First Name (STitle) **], as well as consideration for
dobutamine echocardiogram or stress nuclear perfusion imaging
should the patient have recurrent episodes with consideration
of coronary artery bypass graft in the future if required.

2.  ENDOCRINE:  The patient's diabetes was managed with
q.i.d. fingersticks and regular insulin sliding-scale with
good control.

3.  PULMONARY:  The diagnosis of her chronic obstructive
pulmonary disease was discussed with Dr. [**First Name (STitle) **] who was
uncertain why this had appeared in records and was unaware of
any data that suggested this diagnosis.  We therefore believe
that she had been misdiagnosed with chronic obstructive
pulmonary disease and was actually having an episode of heart
failure at the time this diagnosis was made.  There were no
pulmonary function tests to support the diagnosis of chronic
obstructive pulmonary disease.  The patient does not have a
history of tobacco use, and she is slightly old to be
presenting with alpha-1 antitrypsin disease.

4.  INFECTIOUS DISEASE:  Her urinalysis was repeated and was
entirely normal, and she was therefore not treated for the
nitrite-positive urinalysis on admission.

5.  HEMATOLOGY:  The day after admission, the patient was
noted to have a hematocrit of 33.4 which was greater than 10
points lower than her admission hematocrit of 45.8.  The
patient was heme-negative in the Emergency Room, and on
repeat examination after this hematocrit was obtained.  The
patient's prior hematocrits were reviewed and it was noted
that her admission hematocrit of 45.8 was markedly elevated
to her baseline which was in the middle 30s.  A repeat
hematocrit the day after admission was slightly increased
from that morning value, and it was therefore felt that the
elevated value of 45.8 was spurious.

6.  FLUIDS/ELECTROLYTES/NUTRITION:  The patient had potassium
repletion in the hospital and was placed on a low-sodium,
low-fat, heart-healthy diabetic diet.  She was to follow up
her potassium and diet with Dr. [**First Name (STitle) **] as an outpatient.

CONDITION AT DISCHARGE:  Stable.

CODE STATUS:  Full code.

MEDICATIONS ON DISCHARGE:
1.  Lisinopril 30 mg p.o. q.d. (increased from 20 mg).
2.  Atenolol 75 mg p.o. q.d.
3.  Lasix 60 mg p.o. q.d.
4.  Enteric-coated aspirin 325 mg p.o. q.d.
5.  NPH insulin 17 units q.a.m. and 10 units q.h.s.
6.  Imdur 30 mg p.o. q.d.
7.  Multivitamin p.o. q.d.

DISCHARGE FOLLOWUP:  Followup was arranged with Dr.[**Name (NI) 39123**]
nurse [**First Name (Titles) 96208**] [**Last Name (Titles) **] on [**6-25**] and with Dr. [**First Name (STitle) **] shortly
thereafter.

DISCHARGE DIAGNOSES:
1.  Flash pulmonary edema in the setting of normal systolic
function, diastolic dysfunction, and 3-vessel coronary artery
disease.
2.  Insulin-dependent diabetes mellitus.
3.  Peripheral vascular disease.
4.  Recurrent lower extremity cellulitis.
5.  Degenerative joint disease.
6.  Hypertension.



                          [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D.  [**MD Number(1) 1009**]

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

MEDQUIST36

D:  [**2126-6-19**]  10:48
T:  [**2126-6-21**]  06:28
JOB#:  [**Job Number 96209**]
{'Congestive heart failure, unspecified,Chronic airway obstruction, not elsewhere classified,Coronary atherosclerosis of native coronary artery,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension'}


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: Sudden onset of shortness of breath.

PRESENT ILLNESS: The patient is a 76-year-old
female with a history of type 2 diabetes, 3-vessel coronary
artery disease, and a preserved ejection fraction of 60%, as
well as mild diastolic dysfunction who presents with the
above complaints as well as diaphoresis and nausea which
occurred suddenly while she was taking her morning
medications in her bathroom.  At this time she also felt her
heart was increased.  She called the Emergency Medical
Services who arrived and placed her on BiPAP with settings of
10 and 5, 1 inch of nitroglycerin paste, and gave her
morphine, oxygen, as well as 50 mg of Lasix with 300 cc of
urine output.

MEDICAL HISTORY: 1.  Insulin-dependent type 2 diabetes mellitus times 20
years.  Last hemoglobin A1c was 9.1.
 2.  Peripheral vascular disease including a right femoral to
peroneal bypass and transmetatarsal amputation in [**2123-12-20**] which was reportedly occluded in [**2124-8-18**].
She also has a left femoral to dorsalis pedis bypass which
was patent as of [**2124-8-18**].
 3.  History of mild chronic obstructive pulmonary disease.
She has no pulmonary function tests on record.  The only

MEDICATION ON ADMISSION: Medications include
lisinopril 20 mg p.o. q.d., Imdur 30 mg p.o. q.d.,
enteric-coated aspirin 325 mg p.o. q.d., Tums 500 mg p.o.
q.d., multivitamin p.o. q.d., NPH insulin 17 units q.a.m. and
10 units q.p.m., atenolol 75 mg p.o. q.d. (this was increased
from 50 mg p.o. q.d. one week prior to admission).

ALLERGIES: PENICILLIN gives her a rash, TETRACYCLINE gives
her gastrointestinal upset.  She has another nonspecific
allergy reported to TERBUTALINE.

PHYSICAL EXAM: 

FAMILY HISTORY: She has another sister with coronary artery
disease.  Her father died of a myocardial infarction at 69.
Her mother died of coronary artery disease at age 67, and she
has another brother with coronary artery disease.

SOCIAL HISTORY: The patient has never smoked.  Has had
distant social alcohol use, none currently.  Denied any other
substance use including intravenous drug abuse.  She lives
with her 80-year-old sister. 

### Response:
{'Congestive heart failure, unspecified,Chronic airway obstruction, not elsewhere classified,Coronary atherosclerosis of native coronary artery,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension'}
