CHIEF COMPLAINT: Chest pain

PRESENT ILLNESS: 56 year old male ESRD s/p CABG [**5-/2155**] (3vd, 5-CABG with LIMA to
LAD double touchdown with endarterectomy from D1 to apex; SVG1
to OM1 and jump to OM2; and SVG2 to PDA) with a complicated post
CABG cardiac history who presents with chest pain to OSH. He
reports that he developed two episodes of chest pain prior to
admission that were relieved by SL NTG. First was while driving
to dialysis 4 days ago and relieved with SL nitro and second was
[**Year (4 digits) 2974**] morning at rest. He has not had chest pain since his
admission with PCI in [**Month (only) 404**] of this year. At outside hospital
a TTE was performed and revealed a markedly positive study for
symptoms at low work level associated with 2mm downsloping ST
depressions diffusely. The nuclear study demonstrated a large
severe reversible defect in the entire lateral wall compatible
with myocardial ischemia, in addition to global hypokinesis,
lateral akinesis, and a markedly decreased LVEF. He developed
chest pain on HD 3 (same day of above mentioned tests) and was
started on a heparin gtt and transferred to [**Hospital1 18**] for further
work-up, consideration for cardiac catheterization. Upon cardiac
catheterization he was found to have in stent restenosis of the
left main and is now being referred to cardiac surgery for redo
bypass surgery.

MEDICAL HISTORY: Coronary artery disease s/p Coronary artery bypass graft x 5
[**2155**]
ESRD on hemodialysis (at South Suburban, MWF)
Diabetes mellitus with renal complications
Neuropathy
Retinopathy
Obstructive Sleep Apnea (previously on CPAP, now resolved after
weight loss)
Cataract
Charcot foot due to diabetes mellitus
Hypothyroidism
Hyperlipidemia
Obesity s/p Lap Band ([**2154**])
Hyperparathyroidism [**3-17**] renal
Renal osteodystrophy
Pulmonary Nodule (Solitary)
History of Colonic Adenoma
Left arm fistula
s/p Lap Band ([**2154**])

MEDICATION ON ADMISSION: Aspirin 325mg daily
Lipitor 80mg daily
Plavix 75mg daily
NPH 10 units qAM, 30 units qPM
Regular insulin Sliding Scale
Synthroid 300mcg daily
Toprol XL 12.5mg [**Hospital1 **]
Sevelamer 2400mg TID - 2 packets with dinner one with BR and
lunch

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Pulse:75 Resp:16  O2 sat:100/RA
B/P  Right:99/60  Left: no BP d/t fistula
Height:5'6.5"     Weight:235 lbs

FAMILY HISTORY: Father with kidney disease. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death. Uncle
with cancer, NOS.

SOCIAL HISTORY: Tobacco history: 30 pack year history, quit at time of CABG ~1
year ago
ETOH: never
Illicit drugs: denies
Coronary atherosclerosis of native coronary artery,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Solitary pulmonary nodule,Background diabetic retinopathy,Unspecified acquired hypothyroidism,Other and unspecified hyperlipidemia,Anemia, unspecified,Bariatric surgery status,Renal dialysis status,Long-term (current) use of insulin,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Personal history of sudden cardiac arrest,Other iatrogenic hypotension,Hyperpotassemia,End stage renal disease,Thrombocytopenia, unspecified,Congestive heart failure, unspecified,Other complications due to other cardiac device, implant, and graft,Hypertensive chronic kidney disease, benign, with chronic kidney disease stage V or end stage renal disease,Intermediate coronary syndrome,Atrial fibrillation,Secondary hyperparathyroidism (of renal origin),Cardiac complications, not elsewhere classified,Polyneuropathy in diabetes
Crnry athrscl natve vssl,DMII neuro nt st uncntrl,Solitary pulmonry nodule,Diabetic retinopathy NOS,Hypothyroidism NOS,Hyperlipidemia NEC/NOS,Anemia NOS,Bariatric surgery status,Renal dialysis status,Long-term use of insulin,Abn react-artif implant,Hx sudden cardiac arrest,Iatrogenc hypotnsion NEC,Hyperpotassemia,End stage renal disease,Thrombocytopenia NOS,CHF NOS,Comp-oth cardiac device,Ben hyp kid w cr kid V,Intermed coronary synd,Atrial fibrillation,Sec hyperparathyrd-renal,Surg compl-heart,Neuropathy in diabetes
Admission Date:  [**2157-5-1**]              Discharge Date:   [**2157-5-9**]

Date of Birth:  [**2099-9-15**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain

Major Surgical or Invasive Procedure:
[**2157-5-2**] Cardiac cath
[**2157-5-3**] Redo sternotomy and coronary artery bypass graft x3,
saphenous vein graft to obtuse marginal 1, 2 and 3.

History of Present Illness:
56 year old male ESRD s/p CABG [**5-/2155**] (3vd, 5-CABG with LIMA to
LAD double touchdown with endarterectomy from D1 to apex; SVG1
to OM1 and jump to OM2; and SVG2 to PDA) with a complicated post
CABG cardiac history who presents with chest pain to OSH. He
reports that he developed two episodes of chest pain prior to
admission that were relieved by SL NTG. First was while driving
to dialysis 4 days ago and relieved with SL nitro and second was
[**Year (4 digits) 2974**] morning at rest. He has not had chest pain since his
admission with PCI in [**Month (only) 404**] of this year. At outside hospital
a TTE was performed and revealed a markedly positive study for
symptoms at low work level associated with 2mm downsloping ST
depressions diffusely. The nuclear study demonstrated a large
severe reversible defect in the entire lateral wall compatible
with myocardial ischemia, in addition to global hypokinesis,
lateral akinesis, and a markedly decreased LVEF. He developed
chest pain on HD 3 (same day of above mentioned tests) and was
started on a heparin gtt and transferred to [**Hospital1 18**] for further
work-up, consideration for cardiac catheterization. Upon cardiac
catheterization he was found to have in stent restenosis of the
left main and is now being referred to cardiac surgery for redo
bypass surgery.

Past Medical History:
Coronary artery disease s/p Coronary artery bypass graft x 5
[**2155**]
ESRD on hemodialysis (at South Suburban, MWF)
Diabetes mellitus with renal complications
Neuropathy
Retinopathy
Obstructive Sleep Apnea (previously on CPAP, now resolved after
weight loss)
Cataract
Charcot foot due to diabetes mellitus
Hypothyroidism
Hyperlipidemia
Obesity s/p Lap Band ([**2154**])
Hyperparathyroidism [**3-17**] renal
Renal osteodystrophy
Pulmonary Nodule (Solitary)
History of Colonic Adenoma
Left arm fistula
s/p Lap Band ([**2154**])

Social History:
Tobacco history: 30 pack year history, quit at time of CABG ~1
year ago
ETOH: never
Illicit drugs: denies

Family History:
Father with kidney disease. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death. Uncle
with cancer, NOS.

Physical Exam:
Pulse:75 Resp:16  O2 sat:100/RA
B/P  Right:99/60  Left: no BP d/t fistula
Height:5'6.5"     Weight:235 lbs

General:AAOx3
Skin: Dry [x] intact []
HEENT: PERRLA [x] EOMI [x]
Neck:  Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR []  Irregular []  Murmur [x] grade I/VI
Abdomen: Soft [x] non-distended [x] non-tender [x]
Extremities: Warm [x], well-perfused [x]  Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral      Right: IABP  Left: palp
DP           Right: dop   Left: dop
PT           [**Name (NI) 167**]: dop   Left: dop

Carotid Bruit        Right: none    Left: none

Pertinent Results:
CARDIAC CATH [**2157-5-2**]: 1. Selective coronary angiography of this
right dominant system revealed three vessel native coronary
artery disease. The LMCA had 80% instent restenosis distally.
The LAD had 70%ostial disease, 100% occlusion after S1 and 100%
occlusion after distal touchdown of LIMA. The LCx was a large
caliber vessel  with large territory. There was 95% ostial in
stent restenosis, 60% mid lesion; there was 100% occlusion of
OM1. The SVG-OM1 is flush occluded and the jump segment from
OM1-Om2 is patent and fills retrograde. The RCA is 100%
proximally occluded. 2. Limited resting hemodynamics revealed
borderline normal blood pressure (after sublingual nitroglycerin
given at start of case for chest pain) of 99/65 mmHg. 3.
Arterial conduit angiography showed a widely patent LIMA-LAD. 4.
Saphenous vein graft angiography showed  SVG-RPDA widely patent.
SVG-OM1-OM2 is known flush occluded. 5. Successful placement of
40cc IABP in RCFA under fluoroscopic guidance.
.
Echo [**2157-5-3**]: Transgastric views deferred due to increased
resistance upon gentle advancement of the probe into the stomach
(history of lap band surgery). Mild spontaneous echo contrast is
present in the left atrial appendage. The left atrial appendage
emptying velocity is depressed (<0.2m/s). No thrombus is seen in
the left atrial appendage. A patent foramen ovale is present. A
left-to-right shunt across the interatrial septum is seen at
rest. Left ventricular wall thicknesses are normal. Overall left
ventricular systolic function is mildly depressed (LVEF= 45-50
%). The right ventricular cavity is mildly dilated with normal
free wall contractility. There are simple atheroma in the aortic
arch. There are simple atheroma in the descending thoracic
aorta. There is an intraaortic balloon pump in good position
with the tip 2-3 cm distal to the takeoff of the left subclavian
artery. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Moderate
(2+) mitral regurgitation is seen. There is no pericardial
effusion. Dr. [**Last Name (STitle) **] was notified in person of the
results at time of surgery. POST-BYPASS: The patient is in sinus
rhythm. The patient is on no inotropes. Biventricular function
is unchanged. Mitral regurgitation is unchanged. The intraaortic
balloon pump remains in good position. The aorta is intact
post-decannulation. Valvular funciton is unchanged. No other
changes from prebypass examination.

Brief Hospital Course:
57 M with ESRD on Hemodialysis, HTN, insulin dependent diabetes,
hyperlipidemia, coronary artery disease s/p CABG [**5-/2155**]
complicated by stent restenosis s/p DES, now with recurrent LMCA
and ostial LCX restenosis. Admitted on [**2157-5-1**] and underwent
CABG X3 (SVG to OM1, OM2 and PDA) on [**2157-5-4**] after completing
pre-operative work up- see operative note for details. Off
bypass on vasopressin for hemodynamic support. Admitted to the
ICU immediately post-operatively for hemodyanamic monitoring and
management. Weaned off pressors readily. Weaned from sedation
and awoke neurologically intact and was weaned from the
ventilator and extubated. He was started on ASA, statin therapy,
and betablocker. Amiodarone was added for post-operative atrial
fibrillation. Plavix was resumed. His dialysis therapy was
resumed post-operatively. Chest tubes and temporary epicardial
wires were removed per protocol. He was evaluated by physical
therapy for strength and conditioning and was cleared for
discharge to home on POD#6. Ace-I was not resumed due to
borderline blood pressure. All follow up instructions and
appointments were advised.


Medications on Admission:
Aspirin 325mg daily
Lipitor 80mg daily
Plavix 75mg daily
NPH 10 units qAM, 30 units qPM
Regular insulin Sliding Scale
Synthroid 300mcg daily
Toprol XL 12.5mg [**Hospital1 **]
Sevelamer 2400mg TID - 2 packets with dinner one with BR and
lunch

Discharge Medications:
1. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. levothyroxine 100 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
10. sevelamer carbonate 2.4 gram Powder in Packet Sig: One (1)
PO 1 w/brkfst & lunch, 2 w/ dinner).
11. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY
(Daily) as needed for constipation.
12. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): twice daily for two weeks, then daily until directed to
discontinue.
Disp:*60 Tablet(s)* Refills:*2*
13. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 mls
PO every four (4) hours as needed for pain.
Disp:*720 mls* Refills:*0*
14. NPH insulin
10 units qam and 30 units qpm via pre-filled pen
15. regular insulin
regular insulin per sliding scale


Discharge Disposition:
Home With Service

Facility:
[**Hospital3 **] VNA

Discharge Diagnosis:
Coronary artery disease s/p Redo-sternotomy, Coronary artery
bypass x 3
Past medical history:
s/p Coronary artery bypass graft x 5 [**2155**]
ESRD on hemodialysis (at South Suburban, MWF)
Diabetes mellitus with renal complications
Neuropathy
Retinopathy
Obstructive Sleep Apnea (previously on CPAP, now resolved after
weight loss)
Cataract
Charcot foot due to diabetes mellitus
Hypothyroidism
Hyperlipidemia
Obesity s/p Lap Band ([**2154**])
Hyperparathyroidism [**3-17**] renal
Renal osteodystrophy
Pulmonary Nodule (Solitary)
History of Colonic Adenoma
Left arm fistula
s/p Lap Band ([**2154**])

Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema-trace


Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart

No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**

Followup Instructions:
You are scheduled for the following appointments
Wound check: [**Hospital Ward Name **] 2A on [**2157-5-17**] at 11am [**Telephone/Fax (1) 170**]
Surgeon: Dr. [**First Name (STitle) **]([**Telephone/Fax (1) 170**]) ON [**2157-6-7**] AT 1:15PM [**Hospital **]
medical office building, [**Doctor First Name **], [**Hospital Unit Name **]
Cardiologist: Dr.[**Name (NI) 90367**] OFFICE WILL CALL WITH APPOINTMENT

Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 46799**]([**Telephone/Fax (1) 17465**]) in [**5-19**] weeks

**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]

Completed by:[**2157-5-9**]
{'Coronary atherosclerosis of native coronary artery,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Solitary pulmonary nodule,Background diabetic retinopathy,Unspecified acquired hypothyroidism,Other and unspecified hyperlipidemia,Anemia, unspecified,Bariatric surgery status,Renal dialysis status,Long-term (current) use of insulin,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Personal history of sudden cardiac arrest,Other iatrogenic hypotension,Hyperpotassemia,End stage renal disease,Thrombocytopenia, unspecified,Congestive heart failure, unspecified,Other complications due to other cardiac device, implant, and graft,Hypertensive chronic kidney disease, benign, with chronic kidney disease stage V or end stage renal disease,Intermediate coronary syndrome,Atrial fibrillation,Secondary hyperparathyroidism (of renal origin),Cardiac complications, not elsewhere classified,Polyneuropathy in diabetes'}


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: Chest pain

PRESENT ILLNESS: 56 year old male ESRD s/p CABG [**5-/2155**] (3vd, 5-CABG with LIMA to
LAD double touchdown with endarterectomy from D1 to apex; SVG1
to OM1 and jump to OM2; and SVG2 to PDA) with a complicated post
CABG cardiac history who presents with chest pain to OSH. He
reports that he developed two episodes of chest pain prior to
admission that were relieved by SL NTG. First was while driving
to dialysis 4 days ago and relieved with SL nitro and second was
[**Year (4 digits) 2974**] morning at rest. He has not had chest pain since his
admission with PCI in [**Month (only) 404**] of this year. At outside hospital
a TTE was performed and revealed a markedly positive study for
symptoms at low work level associated with 2mm downsloping ST
depressions diffusely. The nuclear study demonstrated a large
severe reversible defect in the entire lateral wall compatible
with myocardial ischemia, in addition to global hypokinesis,
lateral akinesis, and a markedly decreased LVEF. He developed
chest pain on HD 3 (same day of above mentioned tests) and was
started on a heparin gtt and transferred to [**Hospital1 18**] for further
work-up, consideration for cardiac catheterization. Upon cardiac
catheterization he was found to have in stent restenosis of the
left main and is now being referred to cardiac surgery for redo
bypass surgery.

MEDICAL HISTORY: Coronary artery disease s/p Coronary artery bypass graft x 5
[**2155**]
ESRD on hemodialysis (at South Suburban, MWF)
Diabetes mellitus with renal complications
Neuropathy
Retinopathy
Obstructive Sleep Apnea (previously on CPAP, now resolved after
weight loss)
Cataract
Charcot foot due to diabetes mellitus
Hypothyroidism
Hyperlipidemia
Obesity s/p Lap Band ([**2154**])
Hyperparathyroidism [**3-17**] renal
Renal osteodystrophy
Pulmonary Nodule (Solitary)
History of Colonic Adenoma
Left arm fistula
s/p Lap Band ([**2154**])

MEDICATION ON ADMISSION: Aspirin 325mg daily
Lipitor 80mg daily
Plavix 75mg daily
NPH 10 units qAM, 30 units qPM
Regular insulin Sliding Scale
Synthroid 300mcg daily
Toprol XL 12.5mg [**Hospital1 **]
Sevelamer 2400mg TID - 2 packets with dinner one with BR and
lunch

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Pulse:75 Resp:16  O2 sat:100/RA
B/P  Right:99/60  Left: no BP d/t fistula
Height:5'6.5"     Weight:235 lbs

FAMILY HISTORY: Father with kidney disease. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death. Uncle
with cancer, NOS.

SOCIAL HISTORY: Tobacco history: 30 pack year history, quit at time of CABG ~1
year ago
ETOH: never
Illicit drugs: denies 

### Response:
{'Coronary atherosclerosis of native coronary artery,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Solitary pulmonary nodule,Background diabetic retinopathy,Unspecified acquired hypothyroidism,Other and unspecified hyperlipidemia,Anemia, unspecified,Bariatric surgery status,Renal dialysis status,Long-term (current) use of insulin,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Personal history of sudden cardiac arrest,Other iatrogenic hypotension,Hyperpotassemia,End stage renal disease,Thrombocytopenia, unspecified,Congestive heart failure, unspecified,Other complications due to other cardiac device, implant, and graft,Hypertensive chronic kidney disease, benign, with chronic kidney disease stage V or end stage renal disease,Intermediate coronary syndrome,Atrial fibrillation,Secondary hyperparathyroidism (of renal origin),Cardiac complications, not elsewhere classified,Polyneuropathy in diabetes'}
