CHIEF COMPLAINT: 

PRESENT ILLNESS: This is an 81 year-old man with
a past medical history significant for coronary artery
disease status post coronary artery bypass graft in [**2167**] with
left internal mammary coronary artery to left anterior
descending coronary artery, saphenous vein graft to obtuse
marginal, saphenous vein graft to distal right coronary
artery, also with a past medical history significant for high
cholesterol, status post bilateral TKR, with actinic
keratosis, and aortic stenosis with a valve area of 1 by
catheterization and echocardiogram 9/[**2173**].  Also with
hypertension and chronic vertigo.

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: 

ALLERGIES: Penicillin, lobster, lamb and pork.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Mitral valve insufficiency and aortic valve stenosis,Coronary atherosclerosis of native coronary artery,Intermediate coronary syndrome,Congestive heart failure, unspecified,Hemorrhage complicating a procedure,Pure hypercholesterolemia,Unspecified essential hypertension
Mitral insuf/aort stenos,Crnry athrscl natve vssl,Intermed coronary synd,CHF NOS,Hemorrhage complic proc,Pure hypercholesterolem,Hypertension NOS
Admission Date:  [**2176-1-18**]     Discharge Date:  [**2176-1-25**]


Service:  CARDIOTHORACIC

HISTORY OF PRESENT ILLNESS:  This is an 81 year-old man with
a past medical history significant for coronary artery
disease status post coronary artery bypass graft in [**2167**] with
left internal mammary coronary artery to left anterior
descending coronary artery, saphenous vein graft to obtuse
marginal, saphenous vein graft to distal right coronary
artery, also with a past medical history significant for high
cholesterol, status post bilateral TKR, with actinic
keratosis, and aortic stenosis with a valve area of 1 by
catheterization and echocardiogram 9/[**2173**].  Also with
hypertension and chronic vertigo.

ALLERGIES:  Penicillin, lobster, lamb and pork.

MEDICATIONS ON TRANSFER:  Axid 150 mg, aspirin 81 mg,
Pravachol 10, Flomax, Lasix 40, Lopresor 25, Zocor 5 and
Ditropan at 5.

HOSPITAL COURSE:  This is an 81 year-old mildly demented male
with a history of coronary artery disease status post
coronary artery bypass graft times three with aortic stenosis
who presented after a syncopal episode with associated
congestive heart failure.  Prior to this episode he gave a
history of progressive dyspnea on exertion.  He denies
cerebrovascular accident, transient ischemic attack,
claudication or diabetes.

The patient underwent a re-do coronary artery bypass graft
times, one supraventricular tachycardia to old posterior
descending coronary artery graft and acute marginal and an
AVR with 21 mm pericardial valve on [**2176-1-22**].  The
patient left the Operating Room in sinus rhythm at 109 on
Vasopressin, epi, Milrinone, Dobutamine and Amiodarone.  The
patient was transferred to the Cardiac Surgery Intensive Care
Unit.

On physical examination postoperatively that day the patient
remained sedated.  Dobutamine was decreased to 3 mics per
kilogram.  Epi, Vasopressin, Milrinone and Amiodarone were
all maintained.  Respiratory wise there was an unsuccessful
attempt to wean.  There was bloody fluid leaking from the
chest dressing as well as left femoral dressing with bloody
drainage.  Postoperative day one the patient was febrile with
a temperature max of 101.3, temperature current of 100.9 and
sinus tachycardia at 110 on an SIMV of 800 and 16.  The
patient on balloon pump one to one on Amiodarone, epi,
insulin, Milrinone, morphine drip, Nimbex, dressings.  On
physical examination the patient was as stated paralyzed with
an open chest.

Laboratories, white blood cell count 5.6, hematocrit 26.1,
platelet count 111, sodium 142, potassium 4.1, BUN 16,
creatinine 1.3.

The plan was to continue vent support.  When he arrived to
the Intensive Care Unit he arrived with his chest open.
Postoperative day one [**2176-1-23**] the plan was to
continue dressing cardiovascular wise, keep the patient NPO,
continue insulin drip, continue antibiotics and correct the
patient's coagulopathy aggressively and to continue following
the patient's BUN and creatinine.  Postoperative day two the
patient on Vanco with an intra-aortic balloon pump at one to
one, Amiodarone, Dobutamine, epi, insulin, Lasix, Milrinone,
morphine, Nimbex, aspirin, Protamine.  The patient is still
febrile at 102 in sinus at 91, still intubated and sedated.
On physical examination the patient still with an open chest
and the rest of examination unchanged.  White count up to
10.3 with a hematocrit of 28.9, platelet count down from 88
to 77, sodium 140, potassium 4.2, BUN 17, creatinine 1.4.
Glucose of 117 with a mixed venous of 57%.  The plan was to
continue the patient on support, continue Lasix drip.  With
the patient NPO start levo intravenous.

The patient remained sedated that day on Vasopressin, neo,
Milrinone, Dobutamine unchanged, intra-aortic balloon pump
later that day at 1.1 to 2 with improved blood pressure, but
increased PA pressures.  Output and index were stable.
Echocardiogram was requested by Dr. [**Last Name (STitle) 1537**], which showed mild
aortic insufficiency with preserved left ventricular
function.  The patient was underfilled, 4+ MR and a clot was
noted around the heart.  There were no signs or symptom of
tamponade.  Lasix was increased at 10 mics per hour with mild
increased diuresis.  The patient was then decided to be taken
to the Operating Room.  The daughter was med flighted and
consent was obtained via the phone from Dr. [**Last Name (STitle) 1537**] and
anesthesia.  The patient received a dose of Levaquin and last
dose of Vanco prior to transfer to the Operating Room.  The
plan was to have a mitral valve repair verus replacement.

Postoperative day three from the AVR re-do coronary artery
bypass graft and postoperative day zero from the mitral valve
regurgitation, the patient returned from the Operating Room
late [**1-24**].  A mitral valve replacement was done with a
#25 Bioprosthetic.  The patient still remained on the same
preop drip.  The Levophed drip, however, was added in the
Operating Room with the transthoracic intra-aortic balloon
pump at one to one, the patient had no distal pulses, feet
were cool and the doctor was made aware.  The chest was still
open with the new left pleural chest tube added in the
Operating Room.  The patient respiratory wise was on 100%
FIO2, 12.5 PEEP rate of 18, poor sats 57 to 71%, multiple
amps of bicarb were given for metabolic acidosis, sats were
in the 90 to 96.  There was still a large amount of chest
tube drainage with multiple blood products, Protamine and
Amicar were also given.  The abdomen was distended and firm.
OG tube draining a small amount of green bilious material.
The patient was still sedated on intravenous propofol and
morphine and paralyzed with Nimbex drip.  They were unable to
assess the pupils and open the patient's eyes due to the
patient's swelling.

On [**2176-1-25**] at 11:47 a.m. postoperative day one
status post mitral valve regurgitation, postoperative day
four status post AVR re-do coronary artery bypass graft, the
patient's daughter was spoken to regarding her father's grave
status.  The patient's daughter and mother have chosen to not
come in.  Neurologically, the patient's propofol was turned
off and Valium was given in small increments.  Cardiovascular
wise the patient was still on levo, epi, Vasopressin,
Dobutamine, Milrinone, Amiodarone with a Amicar bolus and
drip ending at 11:00 a.m.  The patient with a heart rate in
sinus rhythm with first degree AV block with runs of
ventricular bigeminy unable to pace with epicardial wires or
ground skin leads.  The Ioban was removed from the chest and

Dr. [**Last Name (STitle) 1537**] with the assistance of Dr. [**Last Name (STitle) 14968**] expelled a large
amount of clot and blood from the chest cavity with minimal
improvement in hemodynamics.  The area was then flushed with
warm saline.  2 units of packed red blood cells were given.
The patient with massive total body fluid overload.  They
were able to obtain weak signals posterior tibial pulses via
doppler early in the morning.  The feet were cool and modeled
left greater then right.  The patient's acidosis was treated
with multiple amps of bicarb.  Abdomen was still large,
distended and firm with no bowel sounds.  The patient
remained anuretic.  Lasix drip was stopped.  The skin with
multiple fluid blisters all over the [**Doctor Last Name **], right groin
draining serous, left groin clips draining serosanguinous
fluid.  The plan was still currently full code.

At 4:26 p.m. the patient's condition continued to deteriorate
with dropping sats, blood pressure and cardiac output and
severe acidosis despite maximum inotropic counter pulsation
and vasopressor support.  Blood pressure was unresponsive to
doubled pitressin with continued downward spiral.  The rhythm
appeared occasionally water with loss of P waves.  At 5:59
the patient was on maximal drips and vent support overnight
and throughout the day.  Dr. [**Last Name (STitle) 1537**] had several discussions
with the family over the past 24 hours describing the
patient's grave condition.  It was mutually decided to make
the patient comfort measures only.  The drips were
discontinued and the patient died within five minutes,
asystolic with no blood pressure at 5:55 p.m.






                          [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D.  [**MD Number(1) 1540**]

Dictated By:[**Doctor Last Name 182**]

MEDQUIST36

D:  [**2176-3-12**]  13:01
T:  [**2176-3-13**]  09:44
JOB#:  [**Job Number 15382**]
{'Mitral valve insufficiency and aortic valve stenosis,Coronary atherosclerosis of native coronary artery,Intermediate coronary syndrome,Congestive heart failure, unspecified,Hemorrhage complicating a procedure,Pure hypercholesterolemia,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: 

PRESENT ILLNESS: This is an 81 year-old man with
a past medical history significant for coronary artery
disease status post coronary artery bypass graft in [**2167**] with
left internal mammary coronary artery to left anterior
descending coronary artery, saphenous vein graft to obtuse
marginal, saphenous vein graft to distal right coronary
artery, also with a past medical history significant for high
cholesterol, status post bilateral TKR, with actinic
keratosis, and aortic stenosis with a valve area of 1 by
catheterization and echocardiogram 9/[**2173**].  Also with
hypertension and chronic vertigo.

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: 

ALLERGIES: Penicillin, lobster, lamb and pork.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Mitral valve insufficiency and aortic valve stenosis,Coronary atherosclerosis of native coronary artery,Intermediate coronary syndrome,Congestive heart failure, unspecified,Hemorrhage complicating a procedure,Pure hypercholesterolemia,Unspecified essential hypertension'}
