CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is an 89 year old
female with a history of coronary artery disease status post
remote history of MI who presented to [**Hospital3 4527**] in the
a.m. of [**2-1**] with severe substernal chest pain radiating to
her back since [**46**]:00 p.m. the night before.  She reported
shortness of breath and orthopnea overnight.  She said that
her symptoms were reminiscent of her prior angina several
months ago.  At [**Hospital3 4527**] her heart rate was 115,
blood pressure 140/83.  EKG showed [**Street Address(2) 4793**] depression in lead
1 and questionable J point elevation in V2 and V3.  She also
had [**Street Address(2) 4793**] elevation in lead 3.  She was 91 to 92 percent on
4 liters nasal cannula at this time.  She received 5 mg of IV
Lopressor, aspirin, Lovenox, Integrilin, nitropaste, Benadryl
25 and prednisone 40.  She [**Street Address(2) 4351**] had relief of her pain
with these interventions.  Chest x-ray at [**First Name (Titles) 4527**]
[**Last Name (Titles) 4351**] showed no evidence of CHF or infiltrate.  She had
a CT of the thorax and abdomen which was negative for
dissection.  She was pain free on arrival to [**Hospital1 18**].

MEDICAL HISTORY: Spinal stenosis.  Abdominal aortic
aneurysm infra-renal approximately 4 cm.  Coronary artery
disease with a distant history of MI in [**2130**].
Hyperlipidemia.  Poor balance.  Borderline hypertension on no
medications.

MEDICATION ON ADMISSION: 

ALLERGIES: Bactrim, codeine, Naprosyn, apples, pears, tuna,
"antibiotics," fish, iodine.

PHYSICAL EXAM: 

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: The patient reports that her husband died
two weeks ago here in the MICU at [**Hospital1 18**].  She denies any
tobacco or drug use.  She reports occasional alcohol use.
Subendocardial infarction, initial episode of care,Diastolic heart failure, unspecified,Hyperosmolality and/or hypernatremia,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Other persistent mental disorders due to conditions classified elsewhere
Subendo infarct, initial,Diastolc hrt failure NOS,Hyperosmolality,Acute kidney failure NOS,Urin tract infection NOS,Atrial fibrillation,Crnry athrscl natve vssl,Mental disor NEC oth dis
Admission Date:  [**2140-2-1**]       Discharge Date:  [**2140-2-9**]


Service:  CCU

HISTORY OF PRESENT ILLNESS:  The patient is an 89 year old
female with a history of coronary artery disease status post
remote history of MI who presented to [**Hospital3 4527**] in the
a.m. of [**2-1**] with severe substernal chest pain radiating to
her back since [**46**]:00 p.m. the night before.  She reported
shortness of breath and orthopnea overnight.  She said that
her symptoms were reminiscent of her prior angina several
months ago.  At [**Hospital3 4527**] her heart rate was 115,
blood pressure 140/83.  EKG showed [**Street Address(2) 4793**] depression in lead
1 and questionable J point elevation in V2 and V3.  She also
had [**Street Address(2) 4793**] elevation in lead 3.  She was 91 to 92 percent on
4 liters nasal cannula at this time.  She received 5 mg of IV
Lopressor, aspirin, Lovenox, Integrilin, nitropaste, Benadryl
25 and prednisone 40.  She [**Street Address(2) 4351**] had relief of her pain
with these interventions.  Chest x-ray at [**First Name (Titles) 4527**]
[**Last Name (Titles) 4351**] showed no evidence of CHF or infiltrate.  She had
a CT of the thorax and abdomen which was negative for
dissection.  She was pain free on arrival to [**Hospital1 18**].

In the cath lab at [**Hospital1 18**] she received 20 mg of IV Lasix,
Integrilin and nitroglycerin drip.  Cardiac cath revealed
multivessel disease including left main coronary artery with
a mid 60 to 70 percent lesion, LAD with a proximal 70 percent
lesion, 90 percent mid-lesion, 40 percent mid-lesion.  Left
circumflex had a 60 percent ostial lesion and 60 to 70
percent mid-lesion.  She also had proximal RCA subtotal
occlusion.  Her cardiac index was 2.12.  Her PA pressures
were 45/27 with a wedge of 33.

PAST MEDICAL HISTORY:  Spinal stenosis.  Abdominal aortic
aneurysm infra-renal approximately 4 cm.  Coronary artery
disease with a distant history of MI in [**2130**].
Hyperlipidemia.  Poor balance.  Borderline hypertension on no
medications.

SOCIAL HISTORY:  The patient reports that her husband died
two weeks ago here in the MICU at [**Hospital1 18**].  She denies any
tobacco or drug use.  She reports occasional alcohol use.

FAMILY HISTORY:  Noncontributory.

ALLERGIES:  Bactrim, codeine, Naprosyn, apples, pears, tuna,
"antibiotics," fish, iodine.

MEDICATIONS:  Medications on transfer included Lopressor,
Lovenox, Integrilin drip, aspirin 325, prednisone 40 mg q.d.,
Benadryl, Lipitor, nitroglycerin drip, heparin drip,
Mucomyst.  Home medications included B-12, Lipitor at an
unknown dose, aspirin.

PHYSICAL EXAMINATION:  On presentation the patient had a
temperature of 95.5, heart rate 91, blood pressure 160/90,
respirations 18, oxygen saturation 96 percent on 100 percent
nonrebreather.  In general, she was in no acute distress,
alert and oriented times three.  HEENT exam revealed pupils
that were equally round and reactive to light.  Extraocular
muscles were intact.  Oropharynx was without lesions or
exudate and she had moist mucous membranes.  Neck exam
revealed JVP approximately half way to the angle of the jaw.
Lungs were clear anteriorly, however, she was not able to sit
up.  Abdomen was soft, nondistended, nontender.  There were
good bowel sounds.  She had a palpable pulsatile mass in the
mid-abdominal region consistent with abdominal aortic
aneurysm.  It was nontender to palpation, but pulsatile.
Stools were OB negative at [**Hospital3 4527**].  Heart was
regular and there was a 2/6 systolic ejection murmur heard
best at the left upper sternal border.  She had no gallop or
rubs.  Extremities were thin without cyanosis, clubbing or
edema.  She had 1 to 2+ dorsalis pedis pulses bilaterally.

LABORATORY DATA:  Laboratories at [**Hospital3 4527**]: CBC with
white count 6.5, hematocrit 33.3, platelets 170.  Chemistries
revealed sodium 138, potassium 4.7, chloride 103, bicarb 24,
BUN 22, creatinine 1.3, glucose 106.  She had an INR of 1.2,
PTT 27.  ALT 123, AST 85, t-bili 0.5, lipase 135, amylase 33.
CK 109, MB 8.9, MBI 8.2, troponin 5.2.  Cardiac cath results
are as mentioned above.  EKG at [**Hospital3 4527**] revealed
sinus tachycardia with a rate of 103 beats per minute.  She
had normal axis and normal intervals.  She had 1 mm S
elevations/J point elevations in leads V2 and V3.  She had
flipped T waves in V5 and V6.  She had [**Street Address(2) 4793**] depression in
lead 1.  She had [**Street Address(2) 4793**] elevation in lead 3 and a Q wave in
lead 3.

HOSPITAL COURSE:
1.  Cardiovascular.  In regard to ischemia and CAD, the
patient presented with unstable angina with three vessel
disease by cath with LAD lesion being the likely culprit of
her symptoms.  She was given aspirin, heparin, Integrilin and
subsequently started on a beta blocker after her congestive
heart failure improved.  She was also started on a statin.
She was initially resistant to the idea of CABG and there was
plan for PTCA of LAD the morning after admission.  Serial CKs
and troponins were followed which peaked and then began to
decline.  The night of admission she received 2 mg of Haldol
and 0.5 mg of Ativan and subsequently became very lethargic
and somewhat unarousable.  Her waxing and [**Doctor Last Name 688**] mental
status delayed her repeat cardiac cath, however, she
subsequently underwent cardiac cath on [**2140-2-5**] which revealed
90 percent mid-LAD lesion with mild proximal OM disease.  She
had successful PTCA and stenting of the LAD.  Final diagnosis
was three vessel coronary artery disease with successful
stenting of the mid-LAD.  As mentioned above, she was
continued on aspirin, a beta blocker, a statin and ACE
inhibitor was held due to elevated creatinine, however, it
was restarted on the day of discharge.

In regard to her pump function, she had evidence of elevated
filling pressures in the cath lab here.  She was diuresed
with Lasix overnight the first night of admission to
desaturate her wedge to 15 to 20.  She was continued on nitro
drip which was stopped the following morning.  She had a
chest film the day after admission which revealed evidence of
congestive heart failure.  She had an echo on [**2140-2-1**] which
revealed severe global left ventricular hypertrophy
consistent with multivessel CAD or another diffuse process.
She had mild aortic regurgitation.  Her pulmonary artery
systolic pressures were elevated.  She had mild mitral
regurgitation.  She had an ejection fraction of 20 percent.
She was subsequently diuresed for several days until she
became euvolemic.  At this time she experienced an elevation
in her creatinine to 2.2, which was felt to be a combination
of diuresis in the setting of two exposures to contrast.  She was
started on lisinopril 2.5 mg q.d. on the day of
discharge.

Rhythm.  The patient had no rhythm issues throughout
admission.

2.  Renal.  As mentioned above, the patient experienced some
renal failure during her admission with peak creatinine of
2.2.  It was felt this was most likely secondary to diuresis
in the setting of exposure to dye in someone with a known
iodine allergy.  She was premedicated prior to both
catheterizations with Benadryl and steroids as well as
Mucomyst.  Her creatinine continued to decline prior to
discharge as she began to auto-diurese.  It was felt safe to
start an ACE inhibitor with lisinopril 2.5 mg p.o. q.day on
the day of discharge.

3.  Neurologic.  As mentioned above, the patient was given
Haldol and Ativan the night of admission for agitation and
combativeness.  She was given a very small dose, however, in
the setting of likely renal failure, she became extremely
sedated and unresponsive on these medications.  A neurology
consult was obtained and it was felt that her mental status
changes were most likely multifactorial in the setting of
underlying dementia and poor substrate.  She had a CAT scan
of her head which was negative.  She had TSH which was
slightly elevated with normal free T4.  She had normal B-12
and folate.  It was not felt necessary to perform an LP,
given her improving mental status and lack of fever and white
cell count.  It was felt most likely that her mental status
changes were due to medication effect and sedating meds were
thereon avoided.  On the day of discharge she was awake,
alert and oriented times three intermittently with some
waxing and [**Doctor Last Name 688**] confusion.

4.  Musculoskeletal.  The patient became extremely weak
throughout admission and was seen by physical therapy the day
prior to discharge.  It was felt that she would most likely
benefit from subacute rehabilitation.

5.  Hypernatremia.  It was noted the day before discharge
that the patient was hypernatremic to 152.  It was felt that
this was most likely secondary to aggressive diuresis in the
setting of lack of access to free water.  Her free water dose
was adjusted and she was replaced with D5W with half of her
deficit being replaced in the first 24 hours.  It was also
felt that her hypernatremia was possibly responsible for some
of her mental status changes.

6.  Endocrine.  In the workup of the patient's mental status
changes, it was noted that she had an elevated TSH with a
normal free T4, possibly reflecting subclinical
hypothyroidism.  It was recommended that this be followed up
as an outpatient.

DISCHARGE DIAGNOSES:
1.  Coronary artery disease status post stent to LAD.
2.  Dementia.
3.  Hypernatremia.

DISCHARGE MEDICATIONS:
1.  Lisinopril 2.5 mg q.d.
2.  Toprol XL 100 mg q.d.
3.  Plavix 75 mg q.d.
4.  Lipitor 10 mg q.d.
5.  Aspirin 325 mg q.d.
6.  Multivitamin.

CONDITION ON DISCHARGE:  At the time of discharge the patient
was with improved spirits, was denying chest pain or
shortness of breath.  She was having waxing and [**Doctor Last Name 688**] mental
status changes with intermittently being confused and
disoriented to place.  However, she was in good spirits and
felt ready to go to rehab and then subsequently home
following rehab.

FOLLOWUP:  The patient will be discharged to [**Hospital **] Rehab
and will require followup with a cardiologist and with her
PCP at the time of discharge.






                      DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-426


Dictated By:[**Last Name (NamePattern1) 9820**]
MEDQUIST36

D:  [**2140-2-8**]  13:19
T:  [**2140-2-8**]  13:32
JOB#:  [**Job Number 49863**]
{'Subendocardial infarction, initial episode of care,Diastolic heart failure, unspecified,Hyperosmolality and/or hypernatremia,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Other persistent mental disorders due to conditions classified elsewhere'}


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 an 89 year old
female with a history of coronary artery disease status post
remote history of MI who presented to [**Hospital3 4527**] in the
a.m. of [**2-1**] with severe substernal chest pain radiating to
her back since [**46**]:00 p.m. the night before.  She reported
shortness of breath and orthopnea overnight.  She said that
her symptoms were reminiscent of her prior angina several
months ago.  At [**Hospital3 4527**] her heart rate was 115,
blood pressure 140/83.  EKG showed [**Street Address(2) 4793**] depression in lead
1 and questionable J point elevation in V2 and V3.  She also
had [**Street Address(2) 4793**] elevation in lead 3.  She was 91 to 92 percent on
4 liters nasal cannula at this time.  She received 5 mg of IV
Lopressor, aspirin, Lovenox, Integrilin, nitropaste, Benadryl
25 and prednisone 40.  She [**Street Address(2) 4351**] had relief of her pain
with these interventions.  Chest x-ray at [**First Name (Titles) 4527**]
[**Last Name (Titles) 4351**] showed no evidence of CHF or infiltrate.  She had
a CT of the thorax and abdomen which was negative for
dissection.  She was pain free on arrival to [**Hospital1 18**].

MEDICAL HISTORY: Spinal stenosis.  Abdominal aortic
aneurysm infra-renal approximately 4 cm.  Coronary artery
disease with a distant history of MI in [**2130**].
Hyperlipidemia.  Poor balance.  Borderline hypertension on no
medications.

MEDICATION ON ADMISSION: 

ALLERGIES: Bactrim, codeine, Naprosyn, apples, pears, tuna,
"antibiotics," fish, iodine.

PHYSICAL EXAM: 

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: The patient reports that her husband died
two weeks ago here in the MICU at [**Hospital1 18**].  She denies any
tobacco or drug use.  She reports occasional alcohol use. 

### Response:
{'Subendocardial infarction, initial episode of care,Diastolic heart failure, unspecified,Hyperosmolality and/or hypernatremia,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Other persistent mental disorders due to conditions classified elsewhere'}
