CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 49-year-old woman with a
longstanding vascular disease including coronary artery
disease status post MI, status post CABG, who was recently
admitted to [**Hospital6 256**] from
[**Date range (1) 33695**], at which time she was admitted for a non-ST
elevation myocardial infarction.  At that admission, the
patient had a cardiac catheterization which revealed a fresh
thrombus in her saphenous vein graft to D-1, and it was
decided that no intervention was undertaken at that time.
During this admission, her peak CK's rose to 910 and her
troponin was noted to be greater than 50.  Upon discharge,
she had been chest pain free for 48 hours and was ambulatory
at the time of discharge.  A follow-up echo at this time
revealed a relatively preserved left ventricular ejection
fraction of approximately 50% with 2+ mitral regurgitation.

MEDICAL HISTORY: 1.  Coronary artery disease status post MI [**5-31**], [**10-31**], [**2-1**],
[**9-1**], status post CABG [**2193**] with saphenous vein graft to RCA,
saphenous vein graft to D-1, status post cardiac
catheterization with RCA stent in [**2192**], left circumflex PTCA
in [**2192**], RCA stent in 11/00, and [**3-3**].
2.  Peripheral vascular disease status post bilateral
aorto-femoral bypass in 2/00, status post axillo-femoral
bypass in 5/00, status post left brachial stent in [**10-31**]
which was complicated by an aneurysm that required surgical
repair.
3.  Heparin induced thrombocytopenia.
4.  Hypothyroidism.
5.  Status post SDH with evacuation in [**4-1**].
6.  Seizures.

MEDICATION ON ADMISSION: 

ALLERGIES: 1.  Heparin, induced thrombocytopenia.
2.  Codeine.
3.  Sulfa.
4.  Ceclor.

PHYSICAL EXAM: 

FAMILY HISTORY: Significant for coronary artery and
peripheral vascular disease.
PHYSICAL EXAMINATION:  Upon arrival to the unit, general
exam: The patient was intubated and sedated on 30 of
dopamine.  Vital signs: Blood pressure 125/77, pulse of 122
and regular, temperature of 102 rectally.  The patient was on
a ventilator, FIMB at 814, 5, and 5.  HEENT: Pupils were
equally round and reacted to light and accommodation.
Cardiovascular exam: S1, S2, tachycardiac, no murmurs, rubs
or gallops.  There is a carotid bruit on the left side.
Chest: Clear to auscultation bilaterally.  Abdomen: Soft,
nontender, nondistended.  Positive bowel sounds in all four
quadrants.  Extremities: No dopplerable pulses, radial, DP,
PT, no edema, extremities cool to touch.  Neuro: Patient was
sedated.

SOCIAL HISTORY: Lives at home with husband in [**Name (NI) 3844**],
reformed tobacco smoker of one-and-a-half packs per day times
20 years.
Subendocardial infarction, initial episode of care,Cardiogenic shock,Bacteremia,Other convulsions,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Aortocoronary bypass status
Subendo infarct, initial,Cardiogenic shock,Bacteremia,Convulsions NEC,Crnry athrscl natve vssl,Hypertension NOS,Hypothyroidism NOS,Aortocoronary bypass
Admission Date:  [**2197-10-5**]     Discharge Date:  [**2197-10-14**]

Date of Birth:   [**2148-4-6**]     Sex:  F

Service:  CCU

PRESENT ILLNESS:  The patient is a 49-year-old woman with a
longstanding vascular disease including coronary artery
disease status post MI, status post CABG, who was recently
admitted to [**Hospital6 256**] from
[**Date range (1) 33695**], at which time she was admitted for a non-ST
elevation myocardial infarction.  At that admission, the
patient had a cardiac catheterization which revealed a fresh
thrombus in her saphenous vein graft to D-1, and it was
decided that no intervention was undertaken at that time.
During this admission, her peak CK's rose to 910 and her
troponin was noted to be greater than 50.  Upon discharge,
she had been chest pain free for 48 hours and was ambulatory
at the time of discharge.  A follow-up echo at this time
revealed a relatively preserved left ventricular ejection
fraction of approximately 50% with 2+ mitral regurgitation.

The following evening, at approximately 8 p.m., the patient
developed a sudden onset of [**9-9**] substernal chest pain.  The
pain was described as crushing pressure radiating to the
neck.  It was associated with nausea, though the patient
denied vomiting, palpitations or shortness of breath.  The
pain was unrelieved by sublingual nitroglycerin times three.
The patient called the EMS and was brought to the Emergency
Room where initial vital signs were stable.  The patient was
started on morphine p.r.n. with a nitroglycerin drip.  Her
EKG at presentation had no changes from her baseline.  With
these medications, her chest pain was reduced to [**2205-3-6**] and
the patient was started on hirudin.

The emergency course was remarkable for the sudden resurgence
of chest pain while on nitroglycerin and hirudin.
Subsequently, her blood pressure dropped to 60/30 for about
10 minutes and the patient was intubated secondary to
impending respiratory arrest.  Her blood pressure increased
with 1.5 liters of IV fluid and peripheral dopamine at 15
mcg/kg per minute.  The Emergency Room course was also
notable for spontaneous extubation for which she was
reintubated.  A right IJ was placed for access.  Her blood
pressure stabilized at 130/70 with a heart rate of 80 on 15
mcg/kg per minute of dopamine.  The patient did experience
another slight decrease in her blood pressure to 90's/60's
with administration of 100 mcg of fentanyl.  The patient was
then taken to the catheterization laboratory for emergent
cardiac catheterization.
Catheterization revealed a left main coronary artery of 40%
ostial lesion, left anterior descending with 70% ulcerated
stenosis proximally, and left circumflex with mild luminal
irregularities.  Interventional Cardiology and Cardiothoracic
Surgery reviewed these films and decision was made to
perform PTCA stenting of the left anterior lesion with 3.0
velocity at 18 mm, and 2.5 velocity 8 mm.

PAST MEDICAL HISTORY:
1.  Coronary artery disease status post MI [**5-31**], [**10-31**], [**2-1**],
[**9-1**], status post CABG [**2193**] with saphenous vein graft to RCA,
saphenous vein graft to D-1, status post cardiac
catheterization with RCA stent in [**2192**], left circumflex PTCA
in [**2192**], RCA stent in 11/00, and [**3-3**].
2.  Peripheral vascular disease status post bilateral
aorto-femoral bypass in 2/00, status post axillo-femoral
bypass in 5/00, status post left brachial stent in [**10-31**]
which was complicated by an aneurysm that required surgical
repair.
3.  Heparin induced thrombocytopenia.
4.  Hypothyroidism.
5.  Status post SDH with evacuation in [**4-1**].
6.  Seizures.

PAST SURGICAL HISTORY:  As above.

OUTPATIENT MEDICATIONS:
1.  Dilantin, 500 mg PO q d.
2.  Levoxyl, 125 mg PO q d.
3.  Folate, 1 gram PO q d.
4.  Pepcid, 20 mg PO b.i.d..
5.  Flexeril, 10 mg PO t.i.d..
6.  Metoprolol, 50 mg PO b.i.d..
7.  Aspirin, 325 mg PO q d.
8.  Accupril, 5 mg PO q d.
9.  Isordil, 10 mg PO t.i.d..
10. Tricor, 108 mg PO q d.
11. Zocor, 80 mg PO q d.
12. Senokot, two tabs q h.s..
13. Colace, 100 mg PO b.i.d..

ALLERGIES:
1.  Heparin, induced thrombocytopenia.
2.  Codeine.
3.  Sulfa.
4.  Ceclor.

SOCIAL HISTORY:  Lives at home with husband in [**Name (NI) 3844**],
reformed tobacco smoker of one-and-a-half packs per day times
20 years.

FAMILY HISTORY:  Significant for coronary artery and
peripheral vascular disease.
PHYSICAL EXAMINATION:  Upon arrival to the unit, general
exam: The patient was intubated and sedated on 30 of
dopamine.  Vital signs: Blood pressure 125/77, pulse of 122
and regular, temperature of 102 rectally.  The patient was on
a ventilator, FIMB at 814, 5, and 5.  HEENT: Pupils were
equally round and reacted to light and accommodation.
Cardiovascular exam: S1, S2, tachycardiac, no murmurs, rubs
or gallops.  There is a carotid bruit on the left side.
Chest: Clear to auscultation bilaterally.  Abdomen: Soft,
nontender, nondistended.  Positive bowel sounds in all four
quadrants.  Extremities: No dopplerable pulses, radial, DP,
PT, no edema, extremities cool to touch.  Neuro: Patient was
sedated.

LABORATORIES IN THE EMERGENCY ROOM:  Sodium 142, potassium
4.2, chloride 103, bicarbonate 24, BUN 16, creatinine 0.7,
glucose of 106.  White blood cell count of 9.1, hematocrit
29.8, platelets of 341, MCV of 92.  Differential: Neutrophils
54.3, lymphs 35.7, monos 5, eos 3, basos 0.1.  PT of 13.1,
INR of 1.2, PTT of 30.  Creatine kinase of 113 initially and
with repeat to 1381, with troponin unable to be interpreted
given previous troponin at discharge was greater than 50.
Calcium 9.1, phosphorus 5.8, magnesium 1.5.  TSH of 0.1.  ALT
29, AST 19, alkaline phosphatase 67, total bilirubin 0.3.  An
ABG on admission was 7.44, 27, 350.

EKG one at baseline revealed normal rate, rhythm, axis, and
intervals, first in the Emergency Room revealed ST
depressions in V3 through V5.  EKG number three corresponding
with hypotensive episode revealed 2 mm elevations in V2, 3 mm
elevation in V3, and 1 mm elevations in V4 and V5.

Chest x-ray revealed patchy opacities which may represent
developing pulmonary edema.

HOSPITAL COURSE:
1.  Coronary vascular system:  1. Coronary artery disease:
The patient was transferred to the CCU status post cardiac
catheterization with LAD stent times two.  The patient was
continued on aspirin and Integrilin with initial holding of
her beta blocker and ACE inhibitor secondary to pressor.
Plavix was initially held for possible upcoming CAB.  The
patient was continued on antihyperlipidemia medication.
Cardiac Thoracic Surgery was consulted and was aware of this
patient for determination of future need for CABG.  The
patient was weaned off dopamine and metoprolol and Captopril
were added as the patient tolerated.  The patient remained
chest pain free until hospital day number seven when the
patient began to experience [**4-9**] chest and jaw pressure after
she got up to go to the bathroom.  The pain was described as
[**6-9**] chest pressure with mild sternal and radiation to the
jaw, and patient states that this pain is similar to her
angina pain.  The patient received sublingual nitroglycerin
times three with decrease in the pain from [**6-9**] to [**2205-3-6**].
Vital signs remained stable, at this time.  An EKG revealed
nonspecific ST and T wave changes.  Nitro drip was started
and IV Lopressor was started for heart rate control, and CK's
were cycled.  The patient experienced pain episodic
throughout the day and, again, had no EKG changes, patient
had no increase in her creatine kinase enzyme.  Lopressor was
given as needed to control heart rate.  C-Surgery was
contact[**Name (NI) **] and the patient underwent pain MIBI to assess for
ischemia of anterior left ventricle.  MIBI revealed moderate
to severe perfusion defects anteriorly, inferiorly, and at
the apex, mild global hypokinesis, decreased ejection
fraction of 44%.  CT Surgery did not feel that this patient
is a candidate for surgical intervention at this time, given
risk-benefit ratio.  The goal for this patient was to
medically optimize cardiac risk factors and anti-anginal
medications prior to discharge.  Prior to discharge, the
patient was weaned off the nitro drip and started on Imdur 90
mg PO q d, and patient was started on Plavix prior to
discharge.  Integrilin was also DC'd at this time.  Please
see discharge medications for outpatient medications.

2.  Cardiovascular system:  An echocardiogram on [**10-3**] revealed
an ejection fraction of 55%.  A repeat echo revealed a
decrease in the ejection fraction to 35% following this
ischemic insult.  The patient was optimized on ACE inhibitor
and beta blockers prior to discharge.

3.  Cardiovascular system:  Rhythm:  The patient has no
history of arrhythmias, and patient remained arrhythmia free
throughout the hospital stay.

4.  Pulmonary:  Patient was ventilated for impending
respiratory arrest and was continued on ventilatory support
through hospital day number three.  Extubation was notable in
that, 15 minutes after extubation, the patient became
stridorous and was given racemic epinephrine and nebulizer
with resolution.  ENT was consulted to evaluate air rate.
ENT reports not evidence of airway obstruction, and felt
episode was possibly due to laryngospasm.  There was no
recurrence of the symptoms.  Patient remained extubated,
saturating well throughout the remainder of hospital stay.

5.  Infectious Disease:  On day of the admission, the patient
was noted to have high fevers which continued throughout the
first three days of hospital stay, and the patient's gram
stain was notable for gram positive cocci in pairs.  The
patient was started empirically on megalomicin and Levaquin
and treated for a 14 day course of antibiotics.  The patient
defervesced on hospital day number six and continued to
remain afebrile with a stable white blood cell count
throughout remainder of hospital stay.

6.  Musculoskeletal:  Given high fevers and increased
creatine kinase of greater than [**Numeric Identifier 389**] with an MB index of
less than 0.3, it was believed that the patient developed
muscle damage perhaps secondary to seizure experienced in the
Emergency Room or possible rhabdomyolysis given history of
peripheral vascular disease and hypotensive episode.  The
patient was hydrated during this time and enzymes continued
to down trend throughout the remainder of hospital stay.

7.  Neurology:  It is notable that the patient, while in the
Emergency Room, had an episode of shaking that was perhaps
consistent with seizure that had been controlled with Ativan.
Patient again had another shaking episode upon arriving to
the CCU that was also treated with Ativan and patient
experienced no other episode of seizure-like activity
throughout the remainder of the hospital stay.  The patient
was continued on Dilantin for her history of seizures.

8.  Endocrine:  The patient was continued on Synthroid for
history of hypothyroidism.

9.  Code status:  The patient signed a DNR-DNI prior to
discharge, as discussed with the attending.

CONDITION ON DISCHARGE:  Fair.

DISCHARGE STATUS:  To home.

DISCHARGE DIAGNOSES:
1.  ST elevation myocardial infarction.
2.  Cardiogenic shock.
3.  Seizure.
4.  Hypothyroidism.
5.  Bacteremia.

DISCHARGE MEDICATIONS:
1.  Aspirin, 325 mg PO q d.
2.  Imdur, 90 mg PO q d.
3.  Lipitor, 10 mg PO q d.
4.  Captopril, 25 mg PO t.i.d..
5.  Metoprolol, 50 mg PO b.i.d..
6.  Vancomycin, 1 gram q 12 hours times five days.
7.  Levaquin, 500 mg PO times six days.
8.  Levoxyl.
9.  Depakote, 500 mg PO q d.
10. Plavix, 75 mg PO q d.
11. Percocet, 5 mg/125 mg, one tab PO q 6 p.r.n. for pain.

FOLLOW-UP PLANS:
1.  Patient to follow-up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], patient's PCP, [**Name10 (NameIs) **]
two weeks.
2.  Vancomycin is to be continued via PICC line with home
nursing times five days after discharge.
3.  Patient to follow with ENT appointment to reassess
posterior vocal cords in one to two months after trauma has
resolved.  Follow-up with Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 41**].






                          [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D.  [**MD Number(1) 5211**]

Dictated By:[**Last Name (NamePattern1) 33696**]

MEDQUIST36

D:  [**2197-11-6**]  15:01
T:  [**2197-11-9**]  11:05
JOB#:  [**Job Number 33697**]
{'Subendocardial infarction, initial episode of care,Cardiogenic shock,Bacteremia,Other convulsions,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Aortocoronary bypass status'}


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 49-year-old woman with a
longstanding vascular disease including coronary artery
disease status post MI, status post CABG, who was recently
admitted to [**Hospital6 256**] from
[**Date range (1) 33695**], at which time she was admitted for a non-ST
elevation myocardial infarction.  At that admission, the
patient had a cardiac catheterization which revealed a fresh
thrombus in her saphenous vein graft to D-1, and it was
decided that no intervention was undertaken at that time.
During this admission, her peak CK's rose to 910 and her
troponin was noted to be greater than 50.  Upon discharge,
she had been chest pain free for 48 hours and was ambulatory
at the time of discharge.  A follow-up echo at this time
revealed a relatively preserved left ventricular ejection
fraction of approximately 50% with 2+ mitral regurgitation.

MEDICAL HISTORY: 1.  Coronary artery disease status post MI [**5-31**], [**10-31**], [**2-1**],
[**9-1**], status post CABG [**2193**] with saphenous vein graft to RCA,
saphenous vein graft to D-1, status post cardiac
catheterization with RCA stent in [**2192**], left circumflex PTCA
in [**2192**], RCA stent in 11/00, and [**3-3**].
2.  Peripheral vascular disease status post bilateral
aorto-femoral bypass in 2/00, status post axillo-femoral
bypass in 5/00, status post left brachial stent in [**10-31**]
which was complicated by an aneurysm that required surgical
repair.
3.  Heparin induced thrombocytopenia.
4.  Hypothyroidism.
5.  Status post SDH with evacuation in [**4-1**].
6.  Seizures.

MEDICATION ON ADMISSION: 

ALLERGIES: 1.  Heparin, induced thrombocytopenia.
2.  Codeine.
3.  Sulfa.
4.  Ceclor.

PHYSICAL EXAM: 

FAMILY HISTORY: Significant for coronary artery and
peripheral vascular disease.
PHYSICAL EXAMINATION:  Upon arrival to the unit, general
exam: The patient was intubated and sedated on 30 of
dopamine.  Vital signs: Blood pressure 125/77, pulse of 122
and regular, temperature of 102 rectally.  The patient was on
a ventilator, FIMB at 814, 5, and 5.  HEENT: Pupils were
equally round and reacted to light and accommodation.
Cardiovascular exam: S1, S2, tachycardiac, no murmurs, rubs
or gallops.  There is a carotid bruit on the left side.
Chest: Clear to auscultation bilaterally.  Abdomen: Soft,
nontender, nondistended.  Positive bowel sounds in all four
quadrants.  Extremities: No dopplerable pulses, radial, DP,
PT, no edema, extremities cool to touch.  Neuro: Patient was
sedated.

SOCIAL HISTORY: Lives at home with husband in [**Name (NI) 3844**],
reformed tobacco smoker of one-and-a-half packs per day times
20 years. 

### Response:
{'Subendocardial infarction, initial episode of care,Cardiogenic shock,Bacteremia,Other convulsions,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Aortocoronary bypass status'}
