CHIEF COMPLAINT: transferred from OSH after airway compromise following CABG
[**2138-5-11**] for eval of TBM seen on bronchoscopy.

PRESENT ILLNESS: 68 yo male s/p CABG [**2138-5-11**] c/b inominate artery compromise.
Post op had airway compromise and bronch revealed
TBM-transferred for eval.

MEDICAL HISTORY: PAST MEDICAL HISTORY:
CRI, baseline Cr 1.2
Diabetes with peripheral neuropathy.
paroxysmal A-fib on coumadin
H/O multiple myeloma(Dr. [**Last Name (STitle) 66059**], last chemo 3 weeks ago); ?left
femur
hypertension
CAD-stentx2 [**2135**]

MEDICATION ON ADMISSION: NPH 48units QAM, 20units Q10pm; Novolog 12units QAM, 20units
Q5pm; Coumadin 7.5mg QHS  -Patient and wife deny that pt is
taking coumadin. I have called his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
[**Telephone/Fax (1) 73038**]-awaiting call back.
Tricor 160'
Metoprolol 50"
ASA 81'
Temazepam 30 QHS PRN
Procrit PRN
Velcade? (Chemo Every other week)
Zometta?

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PHYSICAL EXAMINATION:
T96.9 P87 BP107/44 R18 97% 4L
Gen- pleasant Caucasian male in no apparent distress
HEENT- anicteric, PERRLA, moist mucus membrane, normal
oropharynx, neck supple
CV- regular, no r/m/g
RESP- clear bilaterally(anterior)
ABDOMEN- soft, nontender, nondistended
EXT- no edema
NEUROLOGICAL:
.
Mental status: AAOx2. He thinks that this is [**2108**]. Able to say
month of year forward but not backward. Comprehension intact;
follows commands. Speech fluent. Normal affect.
.
Cranial Nerves:
I: Not tested
II: PERRL, 2->1 mm
III, IV, VI: EOMI
V: Facial sensation intact and symmetric to PP, LT.
VII: Face symmetric with intact strength.
VIII: Hearing intact bilaterally to finger rub
IX, X: Palatal elevation symmetric
[**Doctor First Name 81**]: SCM, trapezius strength intact
XII: Tongue midline without fasciculations
.
Motor: Normal bulk. No pronator drift.
.
Delt Tri [**Hospital1 **] WE FE FF IP QD Ham DF PF [**Last Name (un) 938**] EDB
RT: 5 4 5 5 5 5 5 5 5 5 5 5 5
LEFT: 5 4 5 5 5 5 5 4 4 5 5 5 5
.
Sensation: decreased sensation in lower extremities bilaterally
up to level of ankle, decreased proprioception in lower
extremity, normal sensation and proprioception in upper
extremity
.
Reflexes: Bic T Br Pa Ac
Right 0 0 0 0 0
Left 0 0 0 0 0
Toes equivocal
.
Coordination: FNF, H->S intact
.
Gait: Deferred because patient is very afraid to stand.
.

FAMILY HISTORY: CAD in family

SOCIAL HISTORY: smoke [**1-21**] ppd for 30-40 years, quit 20 y ago, used to drink but
quit in his 30s. Was in the navy once, then became meat cutter.
now retired. no drug use. currently lives with wife.
Unspecified disorder of autonomic nervous system,Subendocardial infarction, initial episode of care,Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled,Chronic kidney disease, unspecified,Multiple myeloma, without mention of having achieved remission,Congestive heart failure, unspecified,Background diabetic retinopathy,Aortocoronary bypass status,Polyneuropathy in diabetes,Atrial fibrillation,Long-term (current) use of anticoagulants,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified
Autonomic nerve dis NEC,Subendo infarct, initial,DMII ophth nt st uncntrl,Chronic kidney dis NOS,Mult mye w/o achv rmson,CHF NOS,Diabetic retinopathy NOS,Aortocoronary bypass,Neuropathy in diabetes,Atrial fibrillation,Long-term use anticoagul,Hy kid NOS w cr kid I-IV
Admission Date:  [**2138-5-28**]              Discharge Date:   [**2138-6-4**]

Date of Birth:  [**2069-9-11**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 281**]
Chief Complaint:
transferred from OSH after airway compromise following CABG
[**2138-5-11**] for eval of TBM seen on bronchoscopy.

Major Surgical or Invasive Procedure:
bronchoscopy


History of Present Illness:
68 yo male s/p CABG [**2138-5-11**] c/b inominate artery compromise.
Post op had airway compromise and bronch revealed
TBM-transferred for eval.

Past Medical History:
PAST MEDICAL HISTORY:
CRI, baseline Cr 1.2
Diabetes with peripheral neuropathy.
paroxysmal A-fib on coumadin
H/O multiple myeloma(Dr. [**Last Name (STitle) 66059**], last chemo 3 weeks ago); ?left
femur
hypertension
CAD-stentx2 [**2135**]


Social History:
smoke [**1-21**] ppd for 30-40 years, quit 20 y ago, used to drink but
quit in his 30s. Was in the navy once, then became meat cutter.
now retired. no drug use. currently lives with wife.

Family History:
CAD in family

Physical Exam:
PHYSICAL EXAMINATION:
T96.9 P87 BP107/44 R18 97% 4L
Gen- pleasant Caucasian male in no apparent distress
HEENT- anicteric, PERRLA, moist mucus membrane, normal
oropharynx, neck supple
CV- regular, no r/m/g
RESP- clear bilaterally(anterior)
ABDOMEN- soft, nontender, nondistended
EXT- no edema
NEUROLOGICAL:
.
Mental status: AAOx2. He thinks that this is [**2108**]. Able to say
month of year forward but not backward. Comprehension intact;
follows commands. Speech fluent. Normal affect.
.
Cranial Nerves:
I: Not tested
II: PERRL, 2->1 mm
III, IV, VI: EOMI
V: Facial sensation intact and symmetric to PP, LT.
VII: Face symmetric with intact strength.
VIII: Hearing intact bilaterally to finger rub
IX, X: Palatal elevation symmetric
[**Doctor First Name 81**]: SCM, trapezius strength intact
XII: Tongue midline without fasciculations
.
Motor: Normal bulk. No pronator drift.
.
Delt Tri [**Hospital1 **] WE FE FF IP QD Ham DF PF [**Last Name (un) 938**] EDB
RT: 5 4 5 5 5 5 5 5 5 5 5 5 5
LEFT: 5 4 5 5 5 5 5 4 4 5 5 5 5
.
Sensation: decreased sensation in lower extremities bilaterally
up to level of ankle, decreased proprioception in lower
extremity, normal sensation and proprioception in upper
extremity
.
Reflexes: Bic T Br Pa Ac
Right 0 0 0 0 0
Left 0 0 0 0 0
Toes equivocal
.
Coordination: FNF, H->S intact
.
Gait: Deferred because patient is very afraid to stand.
.


Pertinent Results:
CT trachea
1. No evidence of tracheobronchomalacia or stenosis.

2. Findings that may be consistent with recent median sternotomy
and thoracic surgery if sternotomy was performed within the past
15 days. Please correlate with time of surgical procedure.

3. Several slightly enlarged mediastinal nodes which are likely
hyperplastic but could be followed to ensure resolution or
stability if warranted clinically.

4. Bilateral small pleural effusions with likely lower lobe
atelectasis.

5. Splenic hypodensity which could represent a hemangioma or
possibly an infarct. Consider ultrasound for further
characterization, if warranted clinically.

[**2138-5-30**]: ECHO
Conclusions:
Technically suboptimal study due to poor image quality.
The left atrium is mildly dilated. There is mild symmetric left
ventricular
hypertrophy with normal cavity size and systolic function
(LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. The
aortic valve is not well seen, but Doppler does not suggeste
aortic stenosis.
No aortic regurgitation is seen. The mitral valve is not well
seen. No
definite mitral regurgitation is seen. The pulmonary artery
systolic pressure
could not be determined. No pericardial effusion is seen.


Brief Hospital Course:
Pt was admitted to the ICU from OSH after reportedly suffering
V-fib arrests prior to transfer. Once stabilized, pt underwent a
bronchoscopy [**2138-5-29**] that showed no evidence of TBM. CTA
confirmed no TBM. transferred from ICU on HD #3.  Evaluated by
neurology for autonomic dysfxn. Recommended Tilt table and other
recommendations: Evidence of autonomomic dysfunction on formal
testing (full report to follow).  Pt. had labile blood
pressures,
which if sustained, may cause symptoms of orthostatic
intolerance.  Autonomic dysfunction may be secondary to DM
and/or
multiple myeloma.  With regards to his neuropathy, this may be
related to DM, multiple myeloma, and/or Velcade.
Treatment recommendations:
For treatment we recommend ample hydration and salt intake.
Generally, we recommend 2L of fluid and 10gm of salt per day.
Given his recent cardiac history, this may not be possible to
achieve, but maximize therapy as can be tolerated.  Avoid
medications that may worsen orthostatic hypotension.
Deconditioning will also contribute to this problem and we
recommend physical therapy as tolerated.  Light compression
stockings and an abdominal binder may help prior to physical
therapy.  It may be necessary to avoid heavy compression given
his diabetic neuropathy.  If he remains orthostatic and is
unable
to tolerate physical therapy, it may be necessary to start low
dose midodrine, 2.5mg at 7am, noon, and 4pm.  This can be
titrated up as needed by 2.5mg per dose.  As it may contribute
to
supine hypertension, it should not be given after 4pm or prior
to
the patient lying supine.  Another option would be to dose
midodrine prior to physical therapy.  If midodrine is started,
it
would be best to check orthostatic blood pressures 1/2 hour
before the dose, and [**1-21**] after the dose.


Medications on Admission:
NPH 48units QAM, 20units Q10pm; Novolog 12units QAM, 20units
Q5pm; Coumadin 7.5mg QHS  -Patient and wife deny that pt is
taking coumadin. I have called his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
[**Telephone/Fax (1) 73038**]-awaiting call back.
Tricor 160'
Metoprolol 50"
ASA 81'
Temazepam 30 QHS PRN
Procrit PRN
Velcade? (Chemo Every other week)
Zometta?


Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
Daily ().
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. NPH insulin
48 units sq aqm, 20units q10pm
8. novolog
12 units qam, 20 nuits q5pm
9. finger stick
ac and qhs


Discharge Disposition:
Extended Care

Facility:
Rehab Hospital of [**Doctor Last Name **]

Discharge Diagnosis:
autonomic dysfunction


Discharge Condition:
deconditioned


Discharge Instructions:
Follow up with your primary care doctor and cardiologist after
you leave rehab. for medication review.

Followup Instructions:
Follow up your cardiologist and your primary care doctor after
you leave rehab.


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]

Completed by:[**2138-6-4**]
{'Unspecified disorder of autonomic nervous system,Subendocardial infarction, initial episode of care,Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled,Chronic kidney disease, unspecified,Multiple myeloma, without mention of having achieved remission,Congestive heart failure, unspecified,Background diabetic retinopathy,Aortocoronary bypass status,Polyneuropathy in diabetes,Atrial fibrillation,Long-term (current) use of anticoagulants,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or 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: transferred from OSH after airway compromise following CABG
[**2138-5-11**] for eval of TBM seen on bronchoscopy.

PRESENT ILLNESS: 68 yo male s/p CABG [**2138-5-11**] c/b inominate artery compromise.
Post op had airway compromise and bronch revealed
TBM-transferred for eval.

MEDICAL HISTORY: PAST MEDICAL HISTORY:
CRI, baseline Cr 1.2
Diabetes with peripheral neuropathy.
paroxysmal A-fib on coumadin
H/O multiple myeloma(Dr. [**Last Name (STitle) 66059**], last chemo 3 weeks ago); ?left
femur
hypertension
CAD-stentx2 [**2135**]

MEDICATION ON ADMISSION: NPH 48units QAM, 20units Q10pm; Novolog 12units QAM, 20units
Q5pm; Coumadin 7.5mg QHS  -Patient and wife deny that pt is
taking coumadin. I have called his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
[**Telephone/Fax (1) 73038**]-awaiting call back.
Tricor 160'
Metoprolol 50"
ASA 81'
Temazepam 30 QHS PRN
Procrit PRN
Velcade? (Chemo Every other week)
Zometta?

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PHYSICAL EXAMINATION:
T96.9 P87 BP107/44 R18 97% 4L
Gen- pleasant Caucasian male in no apparent distress
HEENT- anicteric, PERRLA, moist mucus membrane, normal
oropharynx, neck supple
CV- regular, no r/m/g
RESP- clear bilaterally(anterior)
ABDOMEN- soft, nontender, nondistended
EXT- no edema
NEUROLOGICAL:
.
Mental status: AAOx2. He thinks that this is [**2108**]. Able to say
month of year forward but not backward. Comprehension intact;
follows commands. Speech fluent. Normal affect.
.
Cranial Nerves:
I: Not tested
II: PERRL, 2->1 mm
III, IV, VI: EOMI
V: Facial sensation intact and symmetric to PP, LT.
VII: Face symmetric with intact strength.
VIII: Hearing intact bilaterally to finger rub
IX, X: Palatal elevation symmetric
[**Doctor First Name 81**]: SCM, trapezius strength intact
XII: Tongue midline without fasciculations
.
Motor: Normal bulk. No pronator drift.
.
Delt Tri [**Hospital1 **] WE FE FF IP QD Ham DF PF [**Last Name (un) 938**] EDB
RT: 5 4 5 5 5 5 5 5 5 5 5 5 5
LEFT: 5 4 5 5 5 5 5 4 4 5 5 5 5
.
Sensation: decreased sensation in lower extremities bilaterally
up to level of ankle, decreased proprioception in lower
extremity, normal sensation and proprioception in upper
extremity
.
Reflexes: Bic T Br Pa Ac
Right 0 0 0 0 0
Left 0 0 0 0 0
Toes equivocal
.
Coordination: FNF, H->S intact
.
Gait: Deferred because patient is very afraid to stand.
.

FAMILY HISTORY: CAD in family

SOCIAL HISTORY: smoke [**1-21**] ppd for 30-40 years, quit 20 y ago, used to drink but
quit in his 30s. Was in the navy once, then became meat cutter.
now retired. no drug use. currently lives with wife. 

### Response:
{'Unspecified disorder of autonomic nervous system,Subendocardial infarction, initial episode of care,Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled,Chronic kidney disease, unspecified,Multiple myeloma, without mention of having achieved remission,Congestive heart failure, unspecified,Background diabetic retinopathy,Aortocoronary bypass status,Polyneuropathy in diabetes,Atrial fibrillation,Long-term (current) use of anticoagulants,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified'}
