CHIEF COMPLAINT: non ST elevation mycardial infarction, acute.

PRESENT ILLNESS: This 60 year old male with ESRD on HD (MWF), and known bicuspid
aortic valve with AS (1.0 [**Location (un) 109**]) presented to [**Location (un) **] with
paroxysmal nocturnal dyspnea. The patient reports that 1 week
prior, after "skidooing", he became acutely short of breath and
feeling his heart pounding. EMS was called and they gave him O2
and monitored his VS. with resolution of his symptoms. The day
prior to admission, after dialysis, the patient reports that
prior to dinner he had substernal burning sensation with some
radiation into the right shoulder. The pain was [**10-2**] and lasted
4 hours. It was not associated with excertion and simialar to
his prior heart-burn. The patient had run out of his PPI. The
pain resolved on its own and he was able to eat dinner. He then
went to sleep and awoke several hours later acutely SOB and
again gasping for air. He also felt his "heart beating out of
his chest." EMS was called and he went to [**Hospital3 7569**]. He
was tachycardiac in the ED and thought to either be in sinus
tach vs V-tach. He was given 10mg IV dilt, 40mg IV lasix and
carotid massage. BNP:3120, CPK:152, Trop:1.04. He was
transferred here for further management. It was thought he most
likely has sinus tachycardia with a left bundle branch.
.
In the ED VS: 97.9 104 129/77 18 97%RA. The patient was in NAD.
CK: 355 MB: 53 MBI: 14.9 Trop-T: 0.44. He was started on a
heparin infusion and ordered for plavix which was not given. He
was  also given levofloxacin 250mg IV x1 for possible RLL
pneumonia.

MEDICAL HISTORY: hepatitis C
hypertension
end stage renal disease on HD
hypercholesterolemia
secondary hyperparathyroidism
congenital bicuspid aortic valve
aortic stenosis
chronic, systolic heart failure
aortic insufficiency
homocysteinemia
anemia of chronic disease

MEDICATION ON ADMISSION: Epo @ dialysis
ASA 81mg daily
Sensipar 120mg
Docusate 100mg [**Hospital1 **]
Flomax 0.8mg daily
Lisinopril 20mg [**Hospital1 **]
Methadone 10mg TID
Protonix 40mg [**Hospital1 **]
Renagel 800mg QC
Dialyvite 800

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 98.8, 120/69, 94SR, 18, 93%RA
General: NAD, WG, chronically ill appearing [**First Name5 (NamePattern1) 4746**]
[**Last Name (NamePattern1) 4459**]: unremarkable
Lungs: CTAB
CV: RRR, no murmur or rub
Abd: +BS, soft, non-tender, non-distended
Ext: warm, no edema
Sternal Incision: c/d/i without erythema or drainage
Neuro: grossly intact

FAMILY HISTORY: Brother MI at age 62
Mother had some type of cancer

SOCIAL HISTORY: married, 1 ppd x 45 years, no alcohol, no drugs
Subendocardial infarction, initial episode of care,Pneumonia, organism unspecified,Congenital insufficiency of aortic valve,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Chronic systolic heart failure,Primary pulmonary hypertension,Secondary hyperparathyroidism (of renal origin),Aortic valve disorders,Coronary atherosclerosis of native coronary artery,Cirrhosis of liver without mention of alcohol,Anemia, unspecified
Subendo infarct, initial,Pneumonia, organism NOS,Cong aorta valv insuffic,Hyp kid NOS w cr kid V,End stage renal disease,Chr systolic hrt failure,Prim pulm hypertension,Sec hyperparathyrd-renal,Aortic valve disorder,Crnry athrscl natve vssl,Cirrhosis of liver NOS,Anemia NOS
Admission Date:  [**2162-1-16**]              Discharge Date:   [**2162-1-26**]

Date of Birth:  [**2101-6-19**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**Known firstname 922**]
Chief Complaint:
non ST elevation mycardial infarction, acute.

Major Surgical or Invasive Procedure:
Aortic Valve replacement (27mm Tissue) [**2162-1-22**]
left heart catheterization, coronary angiography


History of Present Illness:
This 60 year old male with ESRD on HD (MWF), and known bicuspid
aortic valve with AS (1.0 [**Location (un) 109**]) presented to [**Location (un) **] with
paroxysmal nocturnal dyspnea. The patient reports that 1 week
prior, after "skidooing", he became acutely short of breath and
feeling his heart pounding. EMS was called and they gave him O2
and monitored his VS. with resolution of his symptoms. The day
prior to admission, after dialysis, the patient reports that
prior to dinner he had substernal burning sensation with some
radiation into the right shoulder. The pain was [**10-2**] and lasted
4 hours. It was not associated with excertion and simialar to
his prior heart-burn. The patient had run out of his PPI. The
pain resolved on its own and he was able to eat dinner. He then
went to sleep and awoke several hours later acutely SOB and
again gasping for air. He also felt his "heart beating out of
his chest." EMS was called and he went to [**Hospital3 7569**]. He
was tachycardiac in the ED and thought to either be in sinus
tach vs V-tach. He was given 10mg IV dilt, 40mg IV lasix and
carotid massage. BNP:3120, CPK:152, Trop:1.04. He was
transferred here for further management. It was thought he most
likely has sinus tachycardia with a left bundle branch.
.
In the ED VS: 97.9 104 129/77 18 97%RA. The patient was in NAD.
CK: 355 MB: 53 MBI: 14.9 Trop-T: 0.44. He was started on a
heparin infusion and ordered for plavix which was not given. He
was  also given levofloxacin 250mg IV x1 for possible RLL
pneumonia.

On the floor he was  chest pain free, breathing comfortably
without any complaints. He reports SOB with walking short
distances (down the [**Doctor Last Name **]). No orthopnea, lower extremety edema.



Past Medical History:
hepatitis C
hypertension
end stage renal disease on HD
hypercholesterolemia
secondary hyperparathyroidism
congenital bicuspid aortic valve
aortic stenosis
chronic, systolic heart failure
aortic insufficiency
homocysteinemia
anemia of chronic disease

Social History:
married, 1 ppd x 45 years, no alcohol, no drugs

Family History:
Brother MI at age 62
Mother had some type of cancer


Physical Exam:
VS: 98.8, 120/69, 94SR, 18, 93%RA
General: NAD, WG, chronically ill appearing [**First Name5 (NamePattern1) 4746**]
[**Last Name (NamePattern1) 4459**]: unremarkable
Lungs: CTAB
CV: RRR, no murmur or rub
Abd: +BS, soft, non-tender, non-distended
Ext: warm, no edema
Sternal Incision: c/d/i without erythema or drainage
Neuro: grossly intact

Pertinent Results:
[**2162-1-25**] 11:53AM BLOOD WBC-6.5 RBC-2.61* Hgb-8.5* Hct-24.0*
MCV-92 MCH-32.6* MCHC-35.4* RDW-15.6* Plt Ct-129*
[**2162-1-26**] 08:50AM BLOOD Hct-27.5*
[**2162-1-25**] 11:53AM BLOOD Glucose-196* UreaN-36* Creat-6.0* Na-136
K-5.0 Cl-99 HCO3-25 AnGap-17
[**2162-1-26**] 08:50AM BLOOD K-4.4

Cardiology Report ECG Study Date of [**2162-1-16**]  5:25:08 AM
Sinus rhythm. Left bundle-branch block. Compared to the previous
tracing
of [**2158-1-24**] left bundle-branch block is new.

CXR [**1-16**]
IMPRESSION:
1. Hyperinflation consistent with chronic lung disease.
2. Small bilateral pleural effusions.
3. Interstitial pulmonary edema.
4. Probable right lower lobe pneumonia.

RUQ U/S [**1-17**]
IMPRESSION:
1. Slightly coarsened echotexture of the liver.
2. Patent portal venous and hepatic veins with normal flow in
terms of
directions and velocity.
3. Main hepatic artery normal in terms of waveform.
4. Bilaterally small kidneys consistent with chronic renal
disease

Cath [**1-18**]
COMMENTS:
1. Coronary angiography of this right dominant system revealed
single
vessel branch CAD with diffuse atherosclerosis.  The LMCA had
mild
distal tapering.  The LAD was heavily calcified with a tubular
35%
stenosis in the mid vessel; the D1 origin had a 70% stenosis.
The LCx
had a 40% proximal taper.  The RCA had a 30% mid vessel
stenosis.
2. Resting hemodynamics revealed mildly elevated right sided
filling
pressures with RVEDP of 10 mm Hg.  Left sided filling pressures
were
severely elevated with LVEDP of 37 mm Hg.  Moderate to severe
pulmonary
arterial hypertension was present; mean PCWP was elevated at 30
mm Hg.
Systemic arterial pressures were elevated with aortic systolic
pressure
of 155 mm Hg.  Cardiac index was preserved at 3.1 l/min/m2.
3. Peak to peak gradient across the aortic valve was 46 mm Hg.
Mean
aortic valve area was calculated to be 0.5 cm2.
4. Left ventriculography was not performed.
5. The right common femoral and right common iliac arteries were
heavily
calcified, causing some initial difficulty in advancing the J
wire into
the abdominal aorta.
6. 20-30 mm pulsus alternans was present after crossing with a
double
lumen pigtail catheter in to the left ventricle.


FINAL DIAGNOSIS:
1. Single vessel branch CAD with diffuse atherosclerosis.
2. Moderate-severe pulmonary arterial hypertension.
3. Severe LV diastolic dysfunction.
4. Moderate to severe aortic stenosis; calculated [**Location (un) 109**]
underestimated in
setting of know 3+ AI and cannot be accurately computed using
estimated
O2 consumption due to need for supplemental O2.
5. Calcified peripheral arterial atherosclerosis.
6. Pulsus alternans consistent with aortic regurgitation and/or
LV
systolic dysfunction.
7. No evidence of intracardiac shunting.

TTE [**1-19**]
The left atrium is moderately dilated. The left atrium is
elongated. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity is mildly dilated. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50 %). Right ventricular
chamber size and free wall motion are normal. The aortic root is
moderately dilated at the sinus level. The number of aortic
valve leaflets cannot be determined. The aortic valve leaflets
are severely thickened/deformed. There is severe aortic valve
stenosis (area <0.8cm2). Mild to moderate ([**12-25**]+) aortic
regurgitation is seen. The aortic regurgitation jet is
eccentric, directed toward the anterior mitral leaflet. [Due to
acoustic shadowing, the severity of aortic regurgitation may be
significantly UNDERestimated.] The mitral valve leaflets are
severely thickened/deformed. There is moderate thickening of the
mitral valve chordae. Mild (1+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.

IMPRESSION: Severe aortic stenosis. Mild to moderate aortic
regurgitation. Low-normal left ventricular systolic function.
Moderate pulmonary hypertension. Moderate aortic root dilation.

Compared with the prior study (images reviewed) of [**2158-1-23**],
left ventricular systolic function is mildly reduced, the left
ventricular cavity size is larger and the severity of aortic
stenosis has progressed.


Brief Hospital Course:
The patient has a history of hepatitis C and therefore was
evaluated and cleared by hepatology prior to surgery.  He was
brought to the operating room on [**2162-1-22**] where he underwent
aortic valve replacement (27mm [**Company 1543**] mosaic tissue).
Overall he tolerated the procedure well and postoperatively was
transferred to the CVICU on epi, vasopressin, and levo.  He was
extubated within 24 hours and all drips were weaned.  Chest
tubes and pacing wires were discontinued without complication.
He was transferred to the telemetry floor for further recovery.
The patient was dialyzed according to the recommendations of the
renal service.  Postoperative course was uneventful.  The
patient made excellent progress with physical therapy, showing
good strength and balance prior to discharge.  By the time of
discharge on POD 4 the patient was ambulating freely, the wound
was healing and pain was controlled with oral analgesics.  He
was discharged home with VNA services.

Medications on Admission:
Epo @ dialysis
ASA 81mg daily
Sensipar 120mg
Docusate 100mg [**Hospital1 **]
Flomax 0.8mg daily
Lisinopril 20mg [**Hospital1 **]
Methadone 10mg TID
Protonix 40mg [**Hospital1 **]
Renagel 800mg QC
Dialyvite 800


Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
Disp:*100 Tablet(s)* Refills:*0*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Cinacalcet 30 mg Tablet Sig: Four (4) Tablet PO QPM (once a
day (in the evening)).
9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
10. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
11. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
13. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day:
200mg twice daily for 2 weeks, then 200mg daily until further
instructed.
Disp:*56 Tablet(s)* Refills:*0*
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
Disp:*60 Capsule(s)* Refills:*0*
15. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Location (un) **] Nursing Service

Discharge Diagnosis:
acute myocardial infarction (NSTEMI)
Bicuspid aortic valve
chronic systolic heart failure
aortic stenosis
aortic insufficiency
s/p aortic valve replacement
end stage renal disease on hemodialysis
hypertension
hypercholesterolemia
secondary hyperparathyroidism
Hepatitis C
homocysteinemia
anemia of chronic disease


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 weight gain greater than 2 pounds a day or 5 pounds a
week
report any fever greater than 100.5
report any redness of, or drainage from incisions
take all medications as directed

Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr.[**Known firstname **] [**Last Name (NamePattern1) 19334**] in [**12-25**] weeks ([**Telephone/Fax (1) 41354**])
Dr. [**First Name (STitle) 3459**] at VAH in 2 weeks
[**Wardname 5010**] wound clinic in 2 weeks
Please call for appointments



Completed by:[**2162-1-26**]
{'Subendocardial infarction, initial episode of care,Pneumonia, organism unspecified,Congenital insufficiency of aortic valve,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Chronic systolic heart failure,Primary pulmonary hypertension,Secondary hyperparathyroidism (of renal origin),Aortic valve disorders,Coronary atherosclerosis of native coronary artery,Cirrhosis of liver without mention of alcohol,Anemia, unspecified'}


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: non ST elevation mycardial infarction, acute.

PRESENT ILLNESS: This 60 year old male with ESRD on HD (MWF), and known bicuspid
aortic valve with AS (1.0 [**Location (un) 109**]) presented to [**Location (un) **] with
paroxysmal nocturnal dyspnea. The patient reports that 1 week
prior, after "skidooing", he became acutely short of breath and
feeling his heart pounding. EMS was called and they gave him O2
and monitored his VS. with resolution of his symptoms. The day
prior to admission, after dialysis, the patient reports that
prior to dinner he had substernal burning sensation with some
radiation into the right shoulder. The pain was [**10-2**] and lasted
4 hours. It was not associated with excertion and simialar to
his prior heart-burn. The patient had run out of his PPI. The
pain resolved on its own and he was able to eat dinner. He then
went to sleep and awoke several hours later acutely SOB and
again gasping for air. He also felt his "heart beating out of
his chest." EMS was called and he went to [**Hospital3 7569**]. He
was tachycardiac in the ED and thought to either be in sinus
tach vs V-tach. He was given 10mg IV dilt, 40mg IV lasix and
carotid massage. BNP:3120, CPK:152, Trop:1.04. He was
transferred here for further management. It was thought he most
likely has sinus tachycardia with a left bundle branch.
.
In the ED VS: 97.9 104 129/77 18 97%RA. The patient was in NAD.
CK: 355 MB: 53 MBI: 14.9 Trop-T: 0.44. He was started on a
heparin infusion and ordered for plavix which was not given. He
was  also given levofloxacin 250mg IV x1 for possible RLL
pneumonia.

MEDICAL HISTORY: hepatitis C
hypertension
end stage renal disease on HD
hypercholesterolemia
secondary hyperparathyroidism
congenital bicuspid aortic valve
aortic stenosis
chronic, systolic heart failure
aortic insufficiency
homocysteinemia
anemia of chronic disease

MEDICATION ON ADMISSION: Epo @ dialysis
ASA 81mg daily
Sensipar 120mg
Docusate 100mg [**Hospital1 **]
Flomax 0.8mg daily
Lisinopril 20mg [**Hospital1 **]
Methadone 10mg TID
Protonix 40mg [**Hospital1 **]
Renagel 800mg QC
Dialyvite 800

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 98.8, 120/69, 94SR, 18, 93%RA
General: NAD, WG, chronically ill appearing [**First Name5 (NamePattern1) 4746**]
[**Last Name (NamePattern1) 4459**]: unremarkable
Lungs: CTAB
CV: RRR, no murmur or rub
Abd: +BS, soft, non-tender, non-distended
Ext: warm, no edema
Sternal Incision: c/d/i without erythema or drainage
Neuro: grossly intact

FAMILY HISTORY: Brother MI at age 62
Mother had some type of cancer

SOCIAL HISTORY: married, 1 ppd x 45 years, no alcohol, no drugs 

### Response:
{'Subendocardial infarction, initial episode of care,Pneumonia, organism unspecified,Congenital insufficiency of aortic valve,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Chronic systolic heart failure,Primary pulmonary hypertension,Secondary hyperparathyroidism (of renal origin),Aortic valve disorders,Coronary atherosclerosis of native coronary artery,Cirrhosis of liver without mention of alcohol,Anemia, unspecified'}
