CHIEF COMPLAINT: Acute coronary artery dissection

PRESENT ILLNESS: The patient is a 61-year-old man who suffered inferior
myocardial infarction during attempt at right coronary
angioplasty. Dissection ensued and the right
coronary artery totally occluded. An intra-aortic balloon pump
was placed and he was referred for emergency bypass surgery.The
patient required pressor support with epinephrine and
neosynephrine  The patient was taken to the operating and
neosynephrine in the OR prior to surgery for hypotension.

MEDICAL HISTORY: CAD
MI
HTN
Hyperlipidemia
Hypogonadism s/p pituitary adenoma resection
Hypothyroid
Panhypopituitarism
Obesity

MEDICATION ON ADMISSION: ASA
Levothyroxine 100 daily
Lovastatin 80 daily
Toprol xl 25 daily
MVI
NTG prn
Norvasc 10 daily
Prednisone 5 daily
Pepcid OTC
Androgel 50/5 gel daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PRECATH

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: In process of quitting smoking. He has smoked 1.5-2ppd since the
age of 14. Married and works in management. Social alcohol use.
Coronary atherosclerosis of native coronary artery,Acute myocardial infarction of other inferior wall, initial episode of care,Accidental puncture or laceration during a procedure, not elsewhere classified,Cardiac complications, not elsewhere classified,Atrial fibrillation,Acidosis,Other iatrogenic hypotension,Anemia, unspecified,Other abnormal glucose,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Personal history of tobacco use
Crnry athrscl natve vssl,AMI inferior wall, init,Accidental op laceration,Surg compl-heart,Atrial fibrillation,Acidosis,Iatrogenc hypotnsion NEC,Anemia NOS,Abnormal glucose NEC,Hypertension NOS,Hyperlipidemia NEC/NOS,Hypothyroidism NOS,History of tobacco use
Admission Date:  [**2162-11-29**]              Discharge Date:   [**2162-12-7**]

Date of Birth:  [**2100-12-13**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Acute coronary artery dissection

Major Surgical or Invasive Procedure:
[**2162-11-29**] - Emergency coronary bypass grafting x3 (left internal
mammary artery to left anterior descending artery, saphenous
vein graft to diagonal branch, saphenous vein graft to posterior
descending coronary artery).
[**2162-11-29**] - Cardiac Catheterization


History of Present Illness:
The patient is a 61-year-old man who suffered inferior
myocardial infarction during attempt at right coronary
angioplasty. Dissection ensued and the right
coronary artery totally occluded. An intra-aortic balloon pump
was placed and he was referred for emergency bypass surgery.The
patient required pressor support with epinephrine and
neosynephrine  The patient was taken to the operating and
neosynephrine in the OR prior to surgery for hypotension.

Past Medical History:
CAD
MI
HTN
Hyperlipidemia
Hypogonadism s/p pituitary adenoma resection
Hypothyroid
Panhypopituitarism
Obesity

Social History:
In process of quitting smoking. He has smoked 1.5-2ppd since the
age of 14. Married and works in management. Social alcohol use.

Family History:
Noncontributory

Physical Exam:
PRECATH

AVSS
CV:RRR, No M/R?G
LUNGS: CTA
ABD: Benign
EXT: Pulsed [**1-19**]+ without carotid or femoral bruits.
NEURO: Nonfocal

Pertinent Results:
[**2162-12-6**] 09:10AM BLOOD WBC-11.3* RBC-3.43* Hgb-10.4* Hct-30.3*
MCV-88 MCH-30.2 MCHC-34.2 RDW-16.0* Plt Ct-310#
[**2162-11-29**] 12:40PM BLOOD WBC-9.0 RBC-4.24* Hgb-13.1* Hct-38.8*
MCV-92 MCH-31.0 MCHC-33.8 RDW-13.6 Plt Ct-259
[**2162-11-29**] 12:40PM BLOOD Neuts-74.9* Lymphs-18.4 Monos-3.0 Eos-3.2
Baso-0.5
[**2162-12-7**] 09:20AM BLOOD PT-13.2 INR(PT)-1.1
[**2162-12-6**] 09:10AM BLOOD Plt Ct-310#
[**2162-11-29**] 12:40PM BLOOD Plt Ct-259
[**2162-11-29**] 12:40PM BLOOD PT-12.9 PTT-150* INR(PT)-1.1
[**2162-11-29**] 05:35PM BLOOD Fibrino-131*
[**2162-12-6**] 09:10AM BLOOD Glucose-84 UreaN-17 Creat-1.0 Na-135
K-5.0 Cl-100 HCO3-24 AnGap-16
[**2162-11-29**] 12:40PM BLOOD Glucose-161* UreaN-17 Creat-0.9 Na-135
K-3.7 Cl-102 HCO3-25 AnGap-12
[**2162-12-3**] 03:27AM BLOOD ALT-83* AST-62* AlkPhos-48 Amylase-19
TotBili-0.4
[**2162-12-1**] 02:00AM BLOOD ALT-67* AST-102* LD(LDH)-512* AlkPhos-38*
Amylase-21 TotBili-0.4
[**2162-12-3**] 03:27AM BLOOD Lipase-12
[**2162-12-3**] 03:27AM BLOOD Mg-2.2
[**2162-11-29**] 12:40PM BLOOD %HbA1c-5.9

   RADIOLOGY  Final Report

CHEST (PORTABLE AP)  [**2162-12-3**] 9:41 AM

CHEST (PORTABLE AP)

Reason: assess for infiltrates/effusions

[**Hospital 93**] MEDICAL CONDITION:
61 year old man s/p cabg
REASON FOR THIS EXAMINATION:
assess for infiltrates/effusions
HISTORY: 61-year-old male status post CABG.

COMPARISON: Chest radiographs of [**2162-12-2**], dating back to
[**2162-11-29**].

PORTABLE UPRIGHT CHEST X-RAY: ET tube, left IJ Swan-Ganz
catheter, and NG tube are in unchanged positions. Counting from
the top, the sixth out of 7 sternal wires is newly broken and
the ends are distracted by approximately 2 cm. The lung volumes
remain low although there is resolution of right middle lung
atelectasis and improved aeration in the left lower lobe. No
pneumothorax or pleural effusions are present. Mild cardiomegaly
is stable. No new pulmonary infiltrates or pleural effusions are
identified.

IMPRESSION: No new pulmonary infiltrates or pleural effusions.
Interval improvement in lung aeration. New broken sternal wire.
Findings were discussed with [**First Name8 (NamePattern2) **] [**Doctor Last Name **] at the time of
dictation.

The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 95**] [**Last Name (NamePattern1) **]
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: SAT [**2162-12-4**] 9:41 AM

Baseline artifact. Atrial fibrillation. Since the previous
tracing
earlier on [**2162-11-29**] atrial fibrillation is new. ST-T wave
abnormalities are
more marked.
TRACING #2


Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A.

  Intervals Axes
Rate PR QRS QT/QTc P QRS T
98 0 94 368/434 0 -36 127

[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT

[**Known lastname **], [**Known firstname **]       [**Hospital1 18**] [**Numeric Identifier 99257**]
(Complete) Done [**2162-11-29**] at 4:40:42 PM      FINAL
Referring Physician     [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 1112**] W.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**]  Status: Inpatient DOB: [**2100-12-13**]
Age (years): 61 M  Hgt (in): 71
BP (mm Hg): /  Wgt (lb): 250
HR (bpm):  BSA (m2): 2.32 m2
Indication: Intraoperative TEE for CABG
ICD-9 Codes: 410.91, 440.0
Test Information
Date/Time: [**2162-11-29**] at 16:40    Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5740**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Suboptimal
Tape #: 2007AW4-: Machine: 4
Echocardiographic Measurements
Results  Measurements  Normal Range
Left Ventricle - Ejection Fraction:  55%  >= 55%
Aorta - Annulus:  2.2 cm  <= 3.0 cm
Aorta - Sinus Level:  *3.8 cm  <= 3.6 cm
Aorta - Sinotubular Ridge:  3.0 cm  <= 3.0 cm
Aorta - Ascending:  3.2 cm  <= 3.4 cm
Aorta - Descending Thoracic:  *2.8 cm  <= 2.5 cm

Findings
LEFT ATRIUM: Normal LA size.

RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. Normal interatrial
septum. No ASD by 2D or color Doppler.

LEFT VENTRICLE: Mild symmetric LVH. Overall normal LVEF (>55%).

RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic
function.

AORTA: Mildly dilated aortic sinus. Focal calcifications in
aortic root. Normal ascending aorta diameter. Normal aortic arch
diameter. Complex (>4mm) atheroma in the aortic arch. Normal
descending aorta diameter. Complex (>4mm) atheroma in the
descending thoracic aorta.

AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.


MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. No MS. Physiologic MR (within
normal limits).

TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.

PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.

GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. Suboptimal image
quality. The patient appears to be in sinus rhythm. Results were
Conclusions
PRE-BYPASS:
1. The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler.
2. There is mild symmetric left ventricular hypertrophy. Overall
left ventricular systolic function is normal (LVEF>55%).
3. The right ventricular cavity is mildly dilated. Right
ventricular systolic function is normal.
4. The aortic root is mildly dilated at the sinus level. There
are complex (>4mm) atheroma in the aortic arch. There are
complex (>4mm) atheroma in the descending thoracic aorta.
5. The aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen. T
6. he mitral valve leaflets are mildly thickened. Physiologic
mitral regurgitation is seen (within normal limits).

Post-bypass: On infusion of epi, phenylephrine. Pt with atrial
fibrillation requiring multiple cardioversions, amiodarone bolus
and infusion. Preserved LV systolic function. RV function
remains moderately depressed on inotropic support. Mild TR.
Trace MR.
I certify that I was present for this procedure in compliance
with HCFA regulations.

Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2162-11-29**] 18:20




Brief Hospital Course:
Mr. [**Known lastname 49346**] was admitted to the [**Hospital1 18**] on [**2162-11-29**] for a cardiac
catheterization. During his catheterization, he had an acute
dissection of his right coronary artery. An intra-aortic balloon
pump was placed and the cardiac surgical service was consulted.
Mr. [**Known lastname 49346**] was then taken to the OR emergently where he
underwent emergent coronary artery bypass grafting to three
vessels. Postoperatively he was taken to the cardiac surgical
intensive care unit for monitoring. He remained on pressors over
the next several days for poor hemodynamics. He developed atrial
fibrillation which was converted with amiodarone. He was
transfused with packed red blood cells for postoperative anemia.
He was aggressively diuresed for volume overload. His pressors
were slowly weaned over the next few days and his acidosis and
mixed venous saturations improved. On postoperative day four,
Mr. [**Known lastname 49346**] [**Last Name (Titles) 5058**] neurologically intact and was extubated. He
continued to be gently diuresed. The physical therapy service
was consulted for assistance with his postoperative strength and
mobility. He was transferred to the step down unit on
postoperative day six. Amiodarone was continued and started on
coumadin. Cleared for discharge to home with VNA services on POD
#8.
Coumadin follow up with [**Company 191**] coumadin clinic first draw [**12-10**]
call results to [**Telephone/Fax (1) 2173**]

Medications on Admission:
ASA
Levothyroxine 100 daily
Lovastatin 80 daily
Toprol xl 25 daily
MVI
NTG prn
Norvasc 10 daily
Prednisone 5 daily
Pepcid OTC
Androgel 50/5 gel daily

Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2
weeks.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): please take 400mg once a day for 6 days then decrease
to 200mg daily and follow with cardiology .
Disp:*40 Tablet(s)* Refills:*0*
9. Captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*0*
10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
12. Lovastatin 40 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*0*
13. AndroGel 1 %(50 mg/5 gram) Gel in Packet Sig: One (1)
Transdermal once a day.
Disp:*qs qs* Refills:*0*
14. Outpatient [**Name (NI) **] Work
PT/INR first draw [**12-10**] call results to [**Telephone/Fax (1) 2173**] [**Company 191**]
coumadin clinic for further dosing INR goal 2-2.5 Atrial
Fibrillation
15. Warfarin 1 mg Tablet Sig: goal INR 2-2.5 Tablets PO DAILY
(Daily): dosing by coumadin clinic [**Telephone/Fax (1) 2173**].
Disp:*90 Tablet(s)* Refills:*0*
16. Warfarin 2 mg Tablet Sig: goal INR 2-2.5  Tablets PO once a
day: dosing by coumadin clinic [**Telephone/Fax (1) 2173**].
Disp:*90 Tablet(s)* Refills:*0*
17. Coumadin
You have been given two different doses of coumadin
1mg and 2mg tablets
Please take 3mg on [**10-16**], [**12-9**] with [**Month/Year (2) **] draw [**11-30**] with
results to coumadin clinic for further dosing


Discharge Disposition:
Home With Service

Facility:
vna assoc. of [**Hospital3 635**]

Discharge Diagnosis:
CAD s/p emergency cabg
Post op atrial fibrillation
Coronary artery dissection
HTN
Hyperlipidemia


Discharge Condition:
Good


Discharge Instructions:
1)  Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2)  Report any fever greater then 100.5.
3)  Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4)  No lotions, creams or powders to incision until it has
healed. SHOWER daily and wash incision. Gently pat the wound
dry.   No bathing or swimming for 1 month. Use sunscreen on
incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns. [**Telephone/Fax (1) 170**]
8) Coumadin Dosing by [**Company 191**] coumadin clinic first draw [**12-10**] call
results to [**Telephone/Fax (1) 2173**] for further dosing INR goal 2-2.5 Atrial
Fibrillation


Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) 1016**] in [**1-19**] weeks. [**Telephone/Fax (1) 2386**]
Please follow-up with Dr. [**Last Name (STitle) 4844**] in 2 weeks. [**Telephone/Fax (1) 250**]
PT/INR first draw [**12-10**] call results to [**Telephone/Fax (1) 2173**] [**Company 191**]
coumadin clinic for further dosing INR goal 2-2.5 Atrial
Fibrillation
(spoke with [**Doctor First Name 16883**] in coumadin clinic)

Scheduled Appointments:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], M.D. Date/Time:[**2163-3-23**] 8:50



Completed by:[**2162-12-7**]
{'Coronary atherosclerosis of native coronary artery,Acute myocardial infarction of other inferior wall, initial episode of care,Accidental puncture or laceration during a procedure, not elsewhere classified,Cardiac complications, not elsewhere classified,Atrial fibrillation,Acidosis,Other iatrogenic hypotension,Anemia, unspecified,Other abnormal glucose,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Personal history of tobacco use'}


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: Acute coronary artery dissection

PRESENT ILLNESS: The patient is a 61-year-old man who suffered inferior
myocardial infarction during attempt at right coronary
angioplasty. Dissection ensued and the right
coronary artery totally occluded. An intra-aortic balloon pump
was placed and he was referred for emergency bypass surgery.The
patient required pressor support with epinephrine and
neosynephrine  The patient was taken to the operating and
neosynephrine in the OR prior to surgery for hypotension.

MEDICAL HISTORY: CAD
MI
HTN
Hyperlipidemia
Hypogonadism s/p pituitary adenoma resection
Hypothyroid
Panhypopituitarism
Obesity

MEDICATION ON ADMISSION: ASA
Levothyroxine 100 daily
Lovastatin 80 daily
Toprol xl 25 daily
MVI
NTG prn
Norvasc 10 daily
Prednisone 5 daily
Pepcid OTC
Androgel 50/5 gel daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PRECATH

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: In process of quitting smoking. He has smoked 1.5-2ppd since the
age of 14. Married and works in management. Social alcohol use. 

### Response:
{'Coronary atherosclerosis of native coronary artery,Acute myocardial infarction of other inferior wall, initial episode of care,Accidental puncture or laceration during a procedure, not elsewhere classified,Cardiac complications, not elsewhere classified,Atrial fibrillation,Acidosis,Other iatrogenic hypotension,Anemia, unspecified,Other abnormal glucose,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Personal history of tobacco use'}
