CHIEF COMPLAINT: SOB, nausea, diarrhea

PRESENT ILLNESS: 46M h/o CAD s/p CABG [**2127**] (LIMA->LAD; SVG->D1,OM1), HTN, DM2,
hyperlipidemia, CRI, obesity presents with progressive weakness,
nausea, SOB, diaphoresis, non-bloody diarrhea, and
lightheadedness x 24 hours. Denies CP, vomiting, fevers, or
chills. Endorses cough. No sick contacts. [**Name (NI) 25122**] all meds.
.
In the ED, vitals were T 97.0, HR 40, BP 125/50, RR 21, SaO2
100%, and FSBG 350. ECG revealed ventricular escape rhythm with
new wide QRS and peaked T-waves. K+ 5.9, AG 14, lactate 7, Cre
2.1 (baseline 1.7), and WBC 17. Given 8U insulin sc, 2.5L NS,
and 1mg IV glucagon given concern for BB toxicity. Intubated and
sent to cath lab for emergent placement of temp pacer wire where
he was started on dopamine gtt for bradycardia and given
calcium, bicarb, insulin for hyperkalemia and presumed DKA. Temp
wire set at 80bpm. Transferred to CCU for further management.

MEDICAL HISTORY: CAD s/p CABG [**2127**] (LIMA->LAD; SVG->D1,OM1)
DM2 with gastroparesis
HTN
Hyperlipidemia
CRI (baselin Cre 1.7; renal bx [**2138**] c/w diabetic etiology)
BPPV
OSA on BiPAP
Obesity

MEDICATION ON ADMISSION: Aspirin
Plavix 75mg qd
Lisinopril 30mg [**Hospital1 **]
Atenolol 50mg qd
Verapamil SR 240mg [**Hospital1 **]
HCTZ 25mg qMWF
Metformin 1g [**Hospital1 **]
Glyburide 5mg [**Hospital1 **]
Meclizine 12.5mg q8h
Protonix 40mg qd
Cozaar 25mg qD
Crestor 20mg qD
Clonidine 0.1mg qD

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 95.2 HR 64 BP 120/49 RR 19 SaO2 100% on AC/600/12/5/100%
General: Intubated, NAD
HEENT: PERRL, EOMi, anicteric sclera, conjunctivae pink
Neck: supple, trachea midline, +ET tube, right IJ temp wire
Cardiac: RRR, s1s2 normal, no m/r/g, unable to assess JVD
Pulmonary: coarse BS b/l
Abdomen: +BS, soft, nontender, obese
Extremities: warm, 1+ DP/PT pulses, 1+ bilateral ankle edema
Neuro: Intubated and sedated, follows commands appropriately,
moves all extremities

FAMILY HISTORY: mother with CAD s/p CABG at age 70, mother with DM, no cancer,
no strokes

SOCIAL HISTORY: Lives at home with wife. [**Name (NI) 1403**] in office. No tobacco, no EtOH.
Other specified cardiac dysrhythmias,Acute kidney failure, unspecified,Chronic kidney disease, unspecified,Hyperpotassemia,Diabetes with neurological manifestations, type I [juvenile type], uncontrolled,Hypertensive heart and chronic kidney disease, unspecified, without heart failure and with chronic kidney disease stage I through stage IV, or unspecified,Aortocoronary bypass status,Anemia in chronic kidney disease,Other and unspecified hyperlipidemia,Gastroparesis,Obstructive sleep apnea (adult)(pediatric),Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Cardiac dysrhythmias NEC,Acute kidney failure NOS,Chronic kidney dis NOS,Hyperpotassemia,DMI neuro uncntrld,Hy ht/kd NOS I-IV w/o hf,Aortocoronary bypass,Anemia in chr kidney dis,Hyperlipidemia NEC/NOS,Gastroparesis,Obstructive sleep apnea,Abn react-procedure NEC
Admission Date:  [**2138-12-23**]              Discharge Date:   [**2138-12-29**]

Date of Birth:  [**2091-2-24**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 10842**]
Chief Complaint:
SOB, nausea, diarrhea

Major Surgical or Invasive Procedure:
Central venous line with temporary pacer wire placement


History of Present Illness:
46M h/o CAD s/p CABG [**2127**] (LIMA->LAD; SVG->D1,OM1), HTN, DM2,
hyperlipidemia, CRI, obesity presents with progressive weakness,
nausea, SOB, diaphoresis, non-bloody diarrhea, and
lightheadedness x 24 hours. Denies CP, vomiting, fevers, or
chills. Endorses cough. No sick contacts. [**Name (NI) 25122**] all meds.
.
In the ED, vitals were T 97.0, HR 40, BP 125/50, RR 21, SaO2
100%, and FSBG 350. ECG revealed ventricular escape rhythm with
new wide QRS and peaked T-waves. K+ 5.9, AG 14, lactate 7, Cre
2.1 (baseline 1.7), and WBC 17. Given 8U insulin sc, 2.5L NS,
and 1mg IV glucagon given concern for BB toxicity. Intubated and
sent to cath lab for emergent placement of temp pacer wire where
he was started on dopamine gtt for bradycardia and given
calcium, bicarb, insulin for hyperkalemia and presumed DKA. Temp
wire set at 80bpm. Transferred to CCU for further management.

Past Medical History:
CAD s/p CABG [**2127**] (LIMA->LAD; SVG->D1,OM1)
DM2 with gastroparesis
HTN
Hyperlipidemia
CRI (baselin Cre 1.7; renal bx [**2138**] c/w diabetic etiology)
BPPV
OSA on BiPAP
Obesity

Social History:
Lives at home with wife. [**Name (NI) 1403**] in office. No tobacco, no EtOH.


Family History:
mother with CAD s/p CABG at age 70, mother with DM, no cancer,
no strokes


Physical Exam:
T 95.2 HR 64 BP 120/49 RR 19 SaO2 100% on AC/600/12/5/100%
General: Intubated, NAD
HEENT: PERRL, EOMi, anicteric sclera, conjunctivae pink
Neck: supple, trachea midline, +ET tube, right IJ temp wire
Cardiac: RRR, s1s2 normal, no m/r/g, unable to assess JVD
Pulmonary: coarse BS b/l
Abdomen: +BS, soft, nontender, obese
Extremities: warm, 1+ DP/PT pulses, 1+ bilateral ankle edema
Neuro: Intubated and sedated, follows commands appropriately,
moves all extremities

Pertinent Results:
ECG ([**12-23**]): ventricular escape, 40bpm, axis normal, wide QRS,
peaked T-waves
.
ECG ([**12-24**]): Sinus rhythm. Since tracing #2, sinus rhythm has
resumed and the rate has increased. QRS complexes are now narrow
and there are non-specific T wave abnormalities.
.
CXR, portable ([**12-23**]): No obvious pulmonary edema or
consolidating pulmonary infiltrates.
.
Echo ([**12-24**]):
1. The left atrium is mildly dilated. The left atrium is
elongated.
2.There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).

3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
6.There is no pericardial effusion.
.
Renal U/S with doppler ([**12-26**]):
1.  Normal renal ultrasound study.  No stones or hydronephrosis
on either side.
2.  Normal Doppler evaluation bilaterally.
.
Prior studies -
.
ETT ([**2-5**]):
INTERPRETATION: This patient is a 44 year old man with a history
of
CABG and diabetes mellitus who was referred for atypical chest
pain.
The patient exercised for 10.5 minutes on a modified [**Doctor First Name **]
protocol and stopped for fatigue. This represents a good
physical capacity. There were 0.5 mm horizontal/upsloping ST
depressions beginning at peak exercise (0.0 minutes of recovery)
in leas V4-V5. At minute 1.0 of recovery there were 1.0 mm
horizontal/upsloping ST depressions in leads II, III, aVF, V4,
and V5. At minute 3.0 of recovery there were 1.[**Street Address(2) 27090**]
depressions in leads II, III, aVF, V4, V5, and lead I. The ST
deviations resolved at minute 15.0 of recovery. The rhythm was
sinus with no ectopy. The blood pressure response was good.
IMPRESSION: No anginal symptoms and borderline ischemic ECG
changes at the acheived workload. Nuclear report sent
separately.
Stress images show a moderate-to-severe perfusion defect of the
lateral wall.
.
MIBI ([**2-5**]):
Resting perfusion images show this defect to be predominantly
reversible. Ejection fraction calculated from gated wall motion
images obtained after exercise is 55%, with normal wall motion.

IMPRESSION:  At the level of exercise achieved, a
moderate-to-severe,
predominantly reversible, lateral wall defect with EF 55%.

Brief Hospital Course:
46M h/o CAD s/p CABG, DM2, HTN, CRI presents with GI symptoms,
SOB, malaise x 1 day found to have symptomatic bradycardia,
hyperkalemia with ECG changes and anion-gap metabolic acidosis
in the setting of acute-on-chronic renal insufficiency s/p temp
pacemaker wire placement and intubation, transiently on dopamine
gtt, now extubated and hemodynamically stable.
.
1.) Rhythm:
Patient was admitted with symptomatic bradycardia with
ventricular escape rhythm and ECG changes suggestive of
bradycardia. ECG not suggestive of CHB. Patient's bradycardia
was thought likely secondary to his hyperkalemia in the setting
of acute renal failure and possibly further complicated by beta
blocker toxicity from atenolol (given renal clearance of
atenolol). Patient was initially placed on dopamine and
intubated, then had temporary pacemaker wire placed, and was
then weaned off dopamine drip and extubated as mental status and
rhythm improved. As hyperkalemia resolved, patient's HR somewhat
improved and patient had 100% native pacing. The temp wire was
discontinued one day after admission and patient's rhythm
remained stable for the duration of his admission.
.
2.) Ischemia:
Patient has a history of coronary artery disease s/p CABG.
Patient had elevations of CK with mildly elevated Troponin T,
thought likely secondary to his acute renal failure on
presentation. Patient had an episode of isolated rising CK with
stable CK-MB and Troponin T, thought likely secondary to
myositis. Patient's medication regimen upon discharge includes
aspirin, plavix, statin, beta blocker, imdur, hydralazine,
lisinopril, and hydrochlorothiazide. Patient was recommended to
discuss with his outpatient cardiologist the usefulness of
taking plavix as the patient has no clear indication.
.
3.) Pump:
Echo demonstrated a preserved EF of greater than 55% and
appeared slightly volume overloaded on initial exam. Upon
discharge, patient was stabilized on a regimen of beta blocker,
ACEI, imdur, and HCTZ for blood pressure control.
.
4.) Hyperkalemia:
Etiology of patient's hyperkalemia thought likely secondary to
acute renal failure. Etiology of acute renal failure thought
likely secondary to pre-renal etiology after patient's history
of diarrhea. Potassium peaked at 7.2 with ECG changes suggestive
of hyperkalemia. Patient was treated with calcium, bicarb,
insulin, and kayexalate on admission and potassium remained
stable throughout the admission.
.
5.) Anion-gap metabolic acidosis:
Patient with elevated lactate and serum glucose on admission
with trace urine ketones. Etiology of anion gap metabolic
acidosis thought likely secondary to elevated lactate, perhaps
secondary to metformin and renal failure.
.
6.) Type 2 Diabetes Mellitus
Patient hyperglycemic on admission and had been stabilized on
metformin and glyburide at home. Upon admission, patient was
converted to a regimen of glyburide and insulin with input from
[**Last Name (un) **]. Patient to be discharged with follow-up with [**Last Name (un) **].
.
7.) Anemia:
Patient with a normocytic anemia of unclear etiology. Baseline
hematocrit appears to be between 30-32 with iron studies
consistent with anemia of chronic disease. Patient had an
attempted transfusion which was discontinued due to a
transfusion reaction with fevers and rigors. Patient recommended
to follow-up with his primary care doctor regarding his anemia.
.
8.) Hematuria:
Patient had several episodes of hematuria during this
hospitalization thought most likely secondary to trauma from
Foley insertion. Hematuria had much improved during the
hospitalization, but patient recommended to follow-up with his
PCP and consider an outpatient urology consult if hematuria does
not improve.
.

9.) Respiratory: Intubated initially for airway protection,
successfully extubated [**12-24**]. Overnight CPAP stable settings. He
was encouraged to discuss with his primary physician pursuing [**Name Initial (PRE) **]
sleep study as an outpatient if he develops concerns.
.
10.) CRI: s/p biopsy [**2138**] c/w diabetic etiology. elevated Cre at
presentation, pre-renal ARF [**3-6**] diarrhea and osmotic diuresis
from hyperglycemia resolved. After his presentation with the
elevated creatinine, his creatinine had some mild daily
variation but none clearly out of his baseline.  He should have
his chemitries repeated in outpatient follow-up.
.
11.) Myositis: mildly elevated CKs, possibly due to
immobilization or statin however on home regimen. no evidence
cardiac etiology. By time of discharge, his CK had resolved to
normal.  He remained without symptom of muscle pain.  Should the
elevations, persist or recurr there could be a consideration for
changing his statin dose or brand.

.
12.) FEN: cardiac/[**Doctor First Name **] diet, replete 'lytes prn
.
13.) PPX: heparin sc tid, PPI, bowel regimen
.
14.) Code: FULL
.
15.) Dispo: home with VNA for insulin teaching with PCP and
[**Name9 (PRE) **] [**Name9 (PRE) 702**]


Medications on Admission:
Aspirin
Plavix 75mg qd
Lisinopril 30mg [**Hospital1 **]
Atenolol 50mg qd
Verapamil SR 240mg [**Hospital1 **]
HCTZ 25mg qMWF
Metformin 1g [**Hospital1 **]
Glyburide 5mg [**Hospital1 **]
Meclizine 12.5mg q8h
Protonix 40mg qd
Cozaar 25mg qD
Crestor 20mg qD
Clonidine 0.1mg qD

Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*120 Tablet(s)* Refills:*2*
8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a
day.
Disp:*45 Tablet(s)* Refills:*2*
10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
11. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO Q8H (every
8 hours).
Disp:*270 Tablet(s)* Refills:*2*
12. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Insulin Lisp & Lisp Prot (Hum) 100 unit/mL (75-25)
Suspension Sig: as directed as directed Subcutaneous once a day:
As directed.
Disp:*1 vial* Refills:*2*
14. Insulin Syringe Ultrafine [**2-3**] mL 29 x [**2-3**]   Syringe Sig: One
(1) ea Miscell.  three times a day: as directed.
Disp:*200 ea* Refills:*2*
15. Humalog Pen 300 unit/3 mL Insulin Pen Sig: as directed units
Subcutaneous twice a day: see attached sliding scale for dosing.
Disp:*3 pens* Refills:*2*
16. One Touch Ultra Test     Strip Sig: One (1) strip Miscell.
four times a day.
Disp:*120 strips* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:

Primary:
Bradycardia
Hyperkalemia
Hyperglycemia
Acute on chronic renal failure


Discharge Condition:

Stable to be discharged home. stable vital signs. ambulating
unassisted. tolerating oral medications and nutrition.


Discharge Instructions:
Please follow up as below and take all medications as
prescribed.
.
New medications: metoprolol, imdur, hydralazine,
hydrochlorothiazide (dose change), insulin
Discontinued medications: atenolol, verapamil, cozaar,
metformin, clonidine
.
If you develop any chest pain, shortness of breath,
lightheadedness, passing out or fainting, or any other
concerning symptom, please call Dr. [**Last Name (STitle) 1147**] or report to the
nearest ER.
.
Please check your blood sugars at least 3 times per day and
record them in a notebook so you and your regular physicians can
adjust the insulin as needed.

Followup Instructions:
You have an appointment scheduled with Dr. [**Last Name (STitle) 1147**] on Monday
[**1-5**], at 3:30pm in the [**Location (un) 4628**] office.  Please call
[**0-0-**] with questions.
.
Please discuss with your primary care physician regarding any
further work-up needed for your anemia. Also, please let your
primary care physician know if you continue to have hematuria
(blood in your urine).
.
You have an appointment with Dr. [**First Name (STitle) 10083**] at the [**Hospital **] Clinic on
[**1-28**] at 9am.  Please call ([**Telephone/Fax (1) 3537**] with questions.
{'Other specified cardiac dysrhythmias,Acute kidney failure, unspecified,Chronic kidney disease, unspecified,Hyperpotassemia,Diabetes with neurological manifestations, type I [juvenile type], uncontrolled,Hypertensive heart and chronic kidney disease, unspecified, without heart failure and with chronic kidney disease stage I through stage IV, or unspecified,Aortocoronary bypass status,Anemia in chronic kidney disease,Other and unspecified hyperlipidemia,Gastroparesis,Obstructive sleep apnea (adult)(pediatric),Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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: SOB, nausea, diarrhea

PRESENT ILLNESS: 46M h/o CAD s/p CABG [**2127**] (LIMA->LAD; SVG->D1,OM1), HTN, DM2,
hyperlipidemia, CRI, obesity presents with progressive weakness,
nausea, SOB, diaphoresis, non-bloody diarrhea, and
lightheadedness x 24 hours. Denies CP, vomiting, fevers, or
chills. Endorses cough. No sick contacts. [**Name (NI) 25122**] all meds.
.
In the ED, vitals were T 97.0, HR 40, BP 125/50, RR 21, SaO2
100%, and FSBG 350. ECG revealed ventricular escape rhythm with
new wide QRS and peaked T-waves. K+ 5.9, AG 14, lactate 7, Cre
2.1 (baseline 1.7), and WBC 17. Given 8U insulin sc, 2.5L NS,
and 1mg IV glucagon given concern for BB toxicity. Intubated and
sent to cath lab for emergent placement of temp pacer wire where
he was started on dopamine gtt for bradycardia and given
calcium, bicarb, insulin for hyperkalemia and presumed DKA. Temp
wire set at 80bpm. Transferred to CCU for further management.

MEDICAL HISTORY: CAD s/p CABG [**2127**] (LIMA->LAD; SVG->D1,OM1)
DM2 with gastroparesis
HTN
Hyperlipidemia
CRI (baselin Cre 1.7; renal bx [**2138**] c/w diabetic etiology)
BPPV
OSA on BiPAP
Obesity

MEDICATION ON ADMISSION: Aspirin
Plavix 75mg qd
Lisinopril 30mg [**Hospital1 **]
Atenolol 50mg qd
Verapamil SR 240mg [**Hospital1 **]
HCTZ 25mg qMWF
Metformin 1g [**Hospital1 **]
Glyburide 5mg [**Hospital1 **]
Meclizine 12.5mg q8h
Protonix 40mg qd
Cozaar 25mg qD
Crestor 20mg qD
Clonidine 0.1mg qD

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 95.2 HR 64 BP 120/49 RR 19 SaO2 100% on AC/600/12/5/100%
General: Intubated, NAD
HEENT: PERRL, EOMi, anicteric sclera, conjunctivae pink
Neck: supple, trachea midline, +ET tube, right IJ temp wire
Cardiac: RRR, s1s2 normal, no m/r/g, unable to assess JVD
Pulmonary: coarse BS b/l
Abdomen: +BS, soft, nontender, obese
Extremities: warm, 1+ DP/PT pulses, 1+ bilateral ankle edema
Neuro: Intubated and sedated, follows commands appropriately,
moves all extremities

FAMILY HISTORY: mother with CAD s/p CABG at age 70, mother with DM, no cancer,
no strokes

SOCIAL HISTORY: Lives at home with wife. [**Name (NI) 1403**] in office. No tobacco, no EtOH. 

### Response:
{'Other specified cardiac dysrhythmias,Acute kidney failure, unspecified,Chronic kidney disease, unspecified,Hyperpotassemia,Diabetes with neurological manifestations, type I [juvenile type], uncontrolled,Hypertensive heart and chronic kidney disease, unspecified, without heart failure and with chronic kidney disease stage I through stage IV, or unspecified,Aortocoronary bypass status,Anemia in chronic kidney disease,Other and unspecified hyperlipidemia,Gastroparesis,Obstructive sleep apnea (adult)(pediatric),Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
