CHIEF COMPLAINT: Chest Pain

PRESENT ILLNESS: This 75 year old white male presented to [**Hospital3 417**] Hospital
ED on [**12-19**] with chest pain and shortness of breath for 1 week.
Upon presentation he had a new LBBB and his Troponin was 7.9.  A
TTE showed a depressed LVEF and global hypokinesis.  He was pain
free and then developed severe CP on [**12-21**] and was transferred
to [**Hospital1 18**].

MEDICAL HISTORY: Coronary Artery Disease
s/p Coronary Artery Bypass Graft x 4
recent Myocardial Infarction
Insulin dependent Diabetes Mellitus
Dyslipidemia
Hypertension
Chronid Kidney Disease stage 3-4
chronic lymphocytic leukemia
Congestive heart failure
Peripheral vascular disease
Chronic obstructive pulmonary disease
Peripheral neuropathy
Cataracts
Anxiety on Bupropion
Basal Cell skin ca s/p resection
s/p Appendectomy

MEDICATION ON ADMISSION: Cartia XT 300mg daily
furosemide 40mg daily
bupropin SR 150mg [**Hospital1 **]
Tricor 145mg daily
asa 81 daily
Diovan 80mg daily
Leukeran 2mg daily
procrit every 2 wks
lantus 26u sc qAM and qPM
Humalog SSI
clotrimazole cream prn basis
alevel prn
klonopin 0.1mg daily
On transfer:
Leukeran 2mg daily
ASA 325 dialy
Lipitor 80mg daily
Plavix 75mg daily
Aspart SSI
Levamir 26 U [**Hospital1 **]
Levaquin 500mg PO Q2days
Pepcid 20mg PO q2days
Procrit 10000u t/th/sat sc
prn meds:
tylenol
sl nt
morphine

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission:

FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory

SOCIAL HISTORY: -Tobacco history: 50 pack years, stopped 10 yrs ago.
-ETOH: no
-Illicit drugs: no
lives with wife. independent with ADLs.
Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Acute combined systolic and diastolic heart failure,End stage renal disease,Adhesive pericarditis,Chronic lymphoid leukemia, without mention of having achieved remission,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Coronary atherosclerosis of native coronary artery,Other chronic pulmonary heart diseases,Atherosclerosis of native arteries of the extremities, unspecified,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Anemia in chronic kidney disease,Other left bundle branch block,Other and unspecified hyperlipidemia,Chronic airway obstruction, not elsewhere classified,Anxiety state, unspecified,Disorders of phosphorus metabolism,Personal history of other malignant neoplasm of skin,Long-term (current) use of insulin
Subendo infarct, initial,Acute kidney failure NOS,Ac syst/diastol hrt fail,End stage renal disease,Adhesive pericarditis,Ch lym leuk wo achv rmsn,Hyp kid NOS w cr kid V,Crnry athrscl natve vssl,Chr pulmon heart dis NEC,Athscl extrm ntv art NOS,DMII neuro nt st uncntrl,Neuropathy in diabetes,Anemia in chr kidney dis,Left bb block NEC,Hyperlipidemia NEC/NOS,Chr airway obstruct NEC,Anxiety state NOS,Dis phosphorus metabol,Hx-skin malignancy NEC,Long-term use of insulin
Admission Date:  [**2138-12-22**]              Discharge Date:   [**2139-1-9**]

Date of Birth:  [**2063-7-15**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest Pain

Major Surgical or Invasive Procedure:
[**2138-12-25**] left heart cateterization, coronary angiography, left
ventriculogram
Perm-A-Cath placement [**2139-1-5**]
[**2138-12-29**] Coronary Artery Bypass Graft x 4 (Left internal mammary
artery to left anterior descending, Saphenous vein graft to
diagonal, Saphenous vein graft to obtuse marginal, Saphenous
vein graft to left posterior descending artery)


History of Present Illness:
This 75 year old white male presented to [**Hospital3 417**] Hospital
ED on [**12-19**] with chest pain and shortness of breath for 1 week.
Upon presentation he had a new LBBB and his Troponin was 7.9.  A
TTE showed a depressed LVEF and global hypokinesis.  He was pain
free and then developed severe CP on [**12-21**] and was transferred
to [**Hospital1 18**].

Past Medical History:
Coronary Artery Disease
s/p Coronary Artery Bypass Graft x 4
recent Myocardial Infarction
Insulin dependent Diabetes Mellitus
Dyslipidemia
Hypertension
Chronid Kidney Disease stage 3-4
chronic lymphocytic leukemia
Congestive heart failure
Peripheral vascular disease
Chronic obstructive pulmonary disease
Peripheral neuropathy
Cataracts
Anxiety on Bupropion
Basal Cell skin ca s/p resection
s/p Appendectomy

Social History:
-Tobacco history: 50 pack years, stopped 10 yrs ago.
-ETOH: no
-Illicit drugs: no
lives with wife. independent with ADLs.

Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory

Physical Exam:
Admission:

Pulse:64 Resp: 18 O2 sat: 99% 2 liters O2
B/P  Right: 107/62   Left:
Height: 68"   Weight: 79.5

General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck:  Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x]  Irregular []  Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x]  bowel sounds
+ []
Extremities: Warm [x], well-perfused [x]  Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral      Right: 2+ Left: 2+
DP           Right: 1+ Left: 1+
PT           [**Name (NI) 167**]: 1+ Left: 1+
Radial       Right: 2+ Left: 2+

Carotid Bruit        Right: no   Left: no

Pertinent Results:
[**2138-12-29**] Echo: PRE BYPASS The left atrium is moderately dilated.
The left atrium is elongated. Mild spontaneous echo contrast is
seen in the body of the left atrium. No mass/thrombus is seen in
the left atrium or left atrial appendage. Mild spontaneous echo
contrast is present in the left atrial appendage. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thicknesses are normal. The left ventricular cavity is
moderately dilated. There is severe regional left ventricular
systolic dysfunction with mild apical dyskinesis, lateral wall
akinesis, severe hypokinesis of all mid and distal sements, and
mild basal hypokinesis of all segments. Overall left ventricular
systolic function is severely depressed (LVEF= 15-20 %). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly to moderately thickened but aortic
stenosis is not present. There are filamentous strands on the
aortic leaflets consistent with Lambl's excresences (normal
variant). Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. Moderate [2+] tricuspid regurgitation is seen. There is a
small pericardial effusion. Stranding is visualized within the
pericardial space c/w organization. There are bilaqteral pleural
effusions. Dr. [**Last Name (STitle) **] was notified in person of the
results in the operating room at the time of the study. POST
BYPASS The patient is receiving milrinone and norepinephrine by
infusion. There is normal right ventricular systolic function.
The left ventricle displays apical akinesis with slight
improvement in all the rest of the segments. The mid and distal
segments are still severely hypokinetic with the basal segments
showing moderate hypokinesis. Overall EF is about 20%. Valvular
function appears unchanged from pre-bypass. The thoracic aorta
appears intact.


[**2139-1-9**] 06:02AM BLOOD WBC-12.0* RBC-3.64* Hgb-10.6* Hct-31.5*
MCV-87 MCH-29.0 MCHC-33.6 RDW-17.0* Plt Ct-191
[**2139-1-8**] 05:52AM BLOOD WBC-10.9 RBC-3.66* Hgb-10.5* Hct-31.6*
MCV-86 MCH-28.6 MCHC-33.2 RDW-17.1* Plt Ct-171
[**2138-12-29**] 11:45AM BLOOD Neuts-69.6 Lymphs-25.7 Monos-2.9 Eos-1.4
Baso-0.3
[**2139-1-9**] 06:02AM BLOOD Glucose-139* UreaN-74* Creat-5.0*# Na-136
K-5.4* Cl-97 HCO3-30 AnGap-14
[**2139-1-7**] 04:57AM BLOOD Glucose-123* UreaN-79* Creat-4.7*# Na-137
K-4.5 Cl-99 HCO3-27 AnGap-16
[**2139-1-6**] 04:26AM BLOOD Glucose-124* UreaN-69* Creat-3.3*# Na-138
K-4.0 Cl-100 HCO3-29 AnGap-13
[**2139-1-9**] 06:02AM BLOOD ALT-193* AST-307* LD(LDH)-409*
AlkPhos-172* Amylase-255* TotBili-12.9*
[**2139-1-8**] 05:52AM BLOOD TotBili-12.1* DirBili-10.0* IndBili-2.1
[**2139-1-7**] 04:57AM BLOOD ALT-135* AST-272* LD(LDH)-390*
AlkPhos-159* TotBili-13.6* DirBili-11.4* IndBili-2.2
[**2139-1-6**] 04:26AM BLOOD ALT-105* AST-232* LD(LDH)-380*
AlkPhos-141* Amylase-175* TotBili-13.6* DirBili-10.8*
IndBili-2.8
[**2138-12-22**] 03:10PM BLOOD ALT-17 AST-29 LD(LDH)-325* CK(CPK)-49
[**2138-12-25**] 04:35AM BLOOD ALT-63* AST-191* LD(LDH)-420*
CK(CPK)-361* AlkPhos-65 TotBili-0.7

Brief Hospital Course:
This 75 year old male presented with recent-onset chest pain,
shortness of breath and an acute infarction. He had recurrent
pain and was transferred here for further care. He remained
pain-free and was worked up cardiac surgery.  He was cleared by
hematology and subsequently was seen by the renal team and
dialysis was started preoperatively for his worsening renal
function.

He was taken to the Operating Room on [**12-29**] for coronary artery
bypass grafting. The initial plan was to proceed with off-pump
coronary artery bypass grafting, but in the Operating Room he
was found to have adhesive pericarditis and he was also becoming
hemodynamically unstable and it was decided to proceed with the
operation on full cardiopulmonary bypass. He underwent coronary
artery bypass grafting x4.
See operative note for full details.

He was transferred to the CVICU in stable condition on
Milrinone, Epinenphrine, Levophed and Vasopressin.  He was
started on a Lasix drip on POD#1 due to a low urine output.  He
was extubated on POD#2.  He was started on an Amiodarone drip
due to ventricular arrythmias and EP was consulted due to his
low EF.  Renal continued to monitor renal function and on POD#7
he was dialyzed when his BUN reached 110.    H estabilized and
vasoactive medications were weaned off and he was started on
Norvasc and low dose beta blockers.  He did have a bradycardic
episode and was atrial paced at 56 for a brief period.

Echocardiography on [**1-2**] showed an EF 15-25%, 1+ mitral
regurgitation and no pericardial effusion.  The patient also had
an increased total bilirubin to a peak of 16.  Right upper
quadrant ultrasound showed sludge but no evidence of biliary
obstruction or distention of the gall bladder or an acute
process.  Hepatology was finally consulted on [**1-8**] due to
persisitently elevated LFTs and hyperbilirubinemia. Multiple
serology studies were sent to evaluate for hepatitis and are
pending at discharge.

He was transferred to the step down unit on POD#6 in stable
condition.  He has had no further ventricular ectopy on
Amiodarone 200 mg daily.  He was dialyzed for the first time
post operatively on [**1-5**].  A tunnelled hemodialysis catheter
was placed for long term hemodialysis needs uneventfully.
Medications were adjusted for his renal failure and as he had
rhythm issues postoperatively and the LFTs rose before
Amiodarone was begun it was not discontinued completely.  He
continued M-W-F dialysis without problems. His urine output is
minimal and the Foley catheter was removed.  He may require
periodic straight catheterization after discharge.

He has been covered with sliding scale insulin postoperatively
and not been restarted on his long acting insulin (Lantus 26
units [**Hospital1 **]) at discharge as his oral intake and appetite have
been subpar.

He is very deconditioned and was transferred for further
recovery and continued dialysis before eventual discharge home.
Followup for his various medical providers will be as outlined
elsewhere.


Medications on Admission:
Cartia XT 300mg daily
furosemide 40mg daily
bupropin SR 150mg [**Hospital1 **]
Tricor 145mg daily
asa 81 daily
Diovan 80mg daily
Leukeran 2mg daily
procrit every 2 wks
lantus 26u sc qAM and qPM
Humalog SSI
clotrimazole cream prn basis
alevel prn
klonopin 0.1mg daily
On transfer:
Leukeran 2mg daily
ASA 325 dialy
Lipitor 80mg daily
Plavix 75mg daily
Aspart SSI
Levamir 26 U [**Hospital1 **]
Levaquin 500mg PO Q2days
Pepcid 20mg PO q2days
Procrit 10000u t/th/sat sc
prn meds:
tylenol
sl nt
morphine

Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
5. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
7. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) ml
Injection ASDIR (AS DIRECTED).
8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
12. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
14. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
15. Insulin Regular Human 100 unit/mL Cartridge Sig: as below
Injection ac and HS: 100-140:2 units SQ
141-180:4 units SQ
181-220:6 units SQ
221-260:8 units SQ
261-300:10units SQ.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 700**] - [**Location (un) 701**]

Discharge Diagnosis:
Coronary Artery Disease
s/p Coronary Artery Bypass Graft x 4
insulin dependent Diabetes Mellitus
Dyslipidemia
Hypertension
Chronid Kidney Disease stage 3-4
chronic lymphocytic leukemia
Congestive heart failure
Peripheral vascular disease
Chronic obstructive pulmonary disease
Peripheral neuropathy
Cataracts
Anxiety
s/p resection basal cell carcinoma
s/p Appendectomy


Discharge Condition:
Good

Discharge Instructions:
shower daily, no baths or swimming
no lotions, creams or powders to incisions
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
report any redness of, or drainage from incisions
report any fever greater than 100.5
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed

Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])- [**2139-2-9**] at 1pm
Dr. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] in 2 weeks ([**Telephone/Fax (1) 6699**]_
Dr. [**Last Name (STitle) 83624**] [**Name (STitle) 83625**] in 2 weeks ([**Telephone/Fax (1) 27174**])
Dr. [**Last Name (STitle) 21628**] in 4 weeks


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]

Completed by:[**2139-1-9**]
{'Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Acute combined systolic and diastolic heart failure,End stage renal disease,Adhesive pericarditis,Chronic lymphoid leukemia, without mention of having achieved remission,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Coronary atherosclerosis of native coronary artery,Other chronic pulmonary heart diseases,Atherosclerosis of native arteries of the extremities, unspecified,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Anemia in chronic kidney disease,Other left bundle branch block,Other and unspecified hyperlipidemia,Chronic airway obstruction, not elsewhere classified,Anxiety state, unspecified,Disorders of phosphorus metabolism,Personal history of other malignant neoplasm of skin,Long-term (current) use of insulin'}


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: Chest Pain

PRESENT ILLNESS: This 75 year old white male presented to [**Hospital3 417**] Hospital
ED on [**12-19**] with chest pain and shortness of breath for 1 week.
Upon presentation he had a new LBBB and his Troponin was 7.9.  A
TTE showed a depressed LVEF and global hypokinesis.  He was pain
free and then developed severe CP on [**12-21**] and was transferred
to [**Hospital1 18**].

MEDICAL HISTORY: Coronary Artery Disease
s/p Coronary Artery Bypass Graft x 4
recent Myocardial Infarction
Insulin dependent Diabetes Mellitus
Dyslipidemia
Hypertension
Chronid Kidney Disease stage 3-4
chronic lymphocytic leukemia
Congestive heart failure
Peripheral vascular disease
Chronic obstructive pulmonary disease
Peripheral neuropathy
Cataracts
Anxiety on Bupropion
Basal Cell skin ca s/p resection
s/p Appendectomy

MEDICATION ON ADMISSION: Cartia XT 300mg daily
furosemide 40mg daily
bupropin SR 150mg [**Hospital1 **]
Tricor 145mg daily
asa 81 daily
Diovan 80mg daily
Leukeran 2mg daily
procrit every 2 wks
lantus 26u sc qAM and qPM
Humalog SSI
clotrimazole cream prn basis
alevel prn
klonopin 0.1mg daily
On transfer:
Leukeran 2mg daily
ASA 325 dialy
Lipitor 80mg daily
Plavix 75mg daily
Aspart SSI
Levamir 26 U [**Hospital1 **]
Levaquin 500mg PO Q2days
Pepcid 20mg PO q2days
Procrit 10000u t/th/sat sc
prn meds:
tylenol
sl nt
morphine

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission:

FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory

SOCIAL HISTORY: -Tobacco history: 50 pack years, stopped 10 yrs ago.
-ETOH: no
-Illicit drugs: no
lives with wife. independent with ADLs. 

### Response:
{'Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Acute combined systolic and diastolic heart failure,End stage renal disease,Adhesive pericarditis,Chronic lymphoid leukemia, without mention of having achieved remission,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Coronary atherosclerosis of native coronary artery,Other chronic pulmonary heart diseases,Atherosclerosis of native arteries of the extremities, unspecified,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Anemia in chronic kidney disease,Other left bundle branch block,Other and unspecified hyperlipidemia,Chronic airway obstruction, not elsewhere classified,Anxiety state, unspecified,Disorders of phosphorus metabolism,Personal history of other malignant neoplasm of skin,Long-term (current) use of insulin'}
