CHIEF COMPLAINT: Acute dyspnea.

PRESENT ILLNESS: This is a 74-year-old male with
no prior medical history except his first myocardial
infarction in [**2177-2-14**] in the setting of five days of
new onset of substernal chest pressure and was eventually
found to have 2-vessel disease by cardiac catheterization and
elevated right-sided pressures.

MEDICAL HISTORY: 1.  Coronary artery disease, status post myocardial
infarction in [**2177-2-14**].  Cardiac catheterization on
[**2177-2-21**] revealed 100% fresh proximal left circumflex
lesion which received percutaneous transluminal coronary
angioplasty and stent; 100% proximal right coronary artery
chronic occlusion with no action; the wedge was 25; the
pulmonary artery pressure was 54/21.  His cardiac risk
factors include a distant 50-pack-year history of smoking;
quit 10 years ago, hypertension, and age.
2.  Depressed ejection fraction of 25% with multiple region
wall motion abnormalities including inferoapical akinesis by
[**2177-2-24**] echocardiogram.

MEDICATION ON ADMISSION: (Medications on admission
included)
1.  Coumadin 5 mg p.o. q.d.
2.  Lipitor 10 mg p.o. q.d.
3.  Atenolol 25 mg p.o. q.d.
4.  Aspirin 325 mg p.o. q.d.
5.  Plavix 75 mg p.o. q.d.
6.  Trandolapril 1 mg p.o. q.d.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient is a widower for the last few
years.  He lives alone and does his own activities of daily
living, and he has a distant 50-pack-year history of tobacco;
he quit 10 years ago.  The patient did smoke unfiltered
cigarettes.
Subendocardial infarction, initial episode of care,Congestive heart failure, unspecified,Coronary atherosclerosis of native coronary artery,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Abnormal coagulation profile,Anemia, unspecified,Pure hypercholesterolemia,Unspecified essential hypertension,Old myocardial infarction
Subendo infarct, initial,CHF NOS,Crnry athrscl natve vssl,DMII wo cmp nt st uncntr,Abnrml coagultion prfile,Anemia NOS,Pure hypercholesterolem,Hypertension NOS,Old myocardial infarct
Admission Date:  [**2177-3-23**]     Discharge Date:  [**2177-3-27**]

Date of Birth:   [**2102-4-5**]     Sex:  M

Service:  CCU

CHIEF COMPLAINT:  Acute dyspnea.

HISTORY OF PRESENT ILLNESS:  This is a 74-year-old male with
no prior medical history except his first myocardial
infarction in [**2177-2-14**] in the setting of five days of
new onset of substernal chest pressure and was eventually
found to have 2-vessel disease by cardiac catheterization and
elevated right-sided pressures.

On that admission, the patient ruled in for a myocardial
infarction with a peak creatine kinase of 1665, a MB of 138,
and a troponin of greater than 50.  His echocardiogram
revealed an ejection fraction of 25% with significant
inferoapical akinesis and multiple basolateral hypokinetic
segments.

The patient was doing well after his myocardial infarction
and compliant with his medications (as per his report).
However, he was having two to three episodes of early a.m.
dyspnea with exertion, and the exertion was basically doing
household chores.

On the morning of admission, the patient again had an episode
of dyspnea while doing some household chores.  However,
unlike his prior episodes, this one did not resolve with rest
and continued to worsen.  There was no associated chest pain,
and no vagal symptoms.  There is no history of paroxysmal
nocturnal dyspnea, and the patient has stable three-pillow
orthopnea.  There is no history of infectious symptoms such
as fevers, chills or cough; and the patient reports no
dietary indiscretion.

In the Emergency Department the patient was observed to be
hypertensive to 211/116, with a heart rate of 128, satting
97% on 100% nonrebreather mask.  He was tachypneic with
paradoxical breathing motions, and speaking in single
syllables.  The patient was given Lasix, nitroglycerin,
morphine, and hydralazine.  An initial arterial blood gas
revealed a pH of 7.12, a PCO2 of 77, and a PAO2 of 78 on 100%
nonrebreather.  The patient was subsequently put on
noninvasive pressure ventilation.  The Coronary Care Unit was
then contact[**Name (NI) **] for management of presumed acute flash
pulmonary edema of unclear etiology.

PAST MEDICAL HISTORY:
1.  Coronary artery disease, status post myocardial
infarction in [**2177-2-14**].  Cardiac catheterization on
[**2177-2-21**] revealed 100% fresh proximal left circumflex
lesion which received percutaneous transluminal coronary
angioplasty and stent; 100% proximal right coronary artery
chronic occlusion with no action; the wedge was 25; the
pulmonary artery pressure was 54/21.  His cardiac risk
factors include a distant 50-pack-year history of smoking;
quit 10 years ago, hypertension, and age.
2.  Depressed ejection fraction of 25% with multiple region
wall motion abnormalities including inferoapical akinesis by
[**2177-2-24**] echocardiogram.

MEDICATIONS ON ADMISSION:  (Medications on admission
included)
1.  Coumadin 5 mg p.o. q.d.
2.  Lipitor 10 mg p.o. q.d.
3.  Atenolol 25 mg p.o. q.d.
4.  Aspirin 325 mg p.o. q.d.
5.  Plavix 75 mg p.o. q.d.
6.  Trandolapril 1 mg p.o. q.d.

ALLERGIES:  No known drug allergies.

SOCIAL HISTORY: The patient is a widower for the last few
years.  He lives alone and does his own activities of daily
living, and he has a distant 50-pack-year history of tobacco;
he quit 10 years ago.  The patient did smoke unfiltered
cigarettes.

PHYSICAL EXAMINATION ON PRESENTATION:   Admission physical
examination revealed vital signs with a blood pressure
of 140/60, temperature of 99.7, heart rate of 108,
respiratory rate of 25, oxygen saturation of 97% on BiPAP.
In general, alert and oriented times three, with significant
respiratory distress.  Head, eyes, ears, nose, and throat
revealed normocephalic and atraumatic.  Pupils were equal,
round, and reactive to light.  Extraocular movements were
intact.  The oropharynx was clear.  No jugular venous
distention.  The neck was supple.  Pulmonary revealed
bilateral expiratory wheezing, high-pitched rales heard
one-half of the way up the lung field.  Cardiovascular
examination revealed distant heart sounds, but no murmurs,
rubs or gallops.  No abnormal pulsus paradoxus.  The abdomen
was protuberant, nontender and nondistended, normal active
bowel sounds.  Paradoxical motions observed with
respirations.  Extremities revealed no clubbing, cyanosis or
edema, cool, and pink.  Neurologically intact on cranial
nerve and strength examination.

PERTINENT LABORATORY DATA ON PRESENTATION:  Admission
laboratories revealed a white blood cell count of 15.1,
hematocrit of 39.5, platelets of 297.  Coagulations revealed
PT of 21.4, PTT of 37.1, INR of 3.2.  SMA-7 revealed sodium
of 138, potassium of 4.7, chloride of 103, bicarbonate of 21,
blood urea nitrogen of 11, creatinine of 1.3, and glucose
of 383.  Creatine kinase of 110, MB of 3, troponin of 0.3.

RADIOLOGY/IMAGING:  Electrocardiogram revealed an old right
bundle-branch block, sinus tachycardia, old first heart sound
Q3-T3 pattern, and no acute ST-T wave abnormalities.

Chest x-ray obtained was notable for significant perihilar
edema, moderate-to-severe upper zone redistribution, and
bilateral small pleural effusions.  The left hemidiaphragm
was also obscured.

HOSPITAL COURSE:   The patient was admitted to the Coronary
Care Unit for management of poor respiratory status that was
felt to be secondary to flash pulmonary edema.  The cause of
this was not clear on presentation, but the leading
considerations were medication noncompliance leading to
hypertension, a hypertensive spike, and ischemic event
leading to worsening left ventricular compliance.

The patient was on BiPAP for the first several hours of
admission with significant improvement in his arterial blood
gas, and about 24 hours into his hospitalization he was on
nasal cannula oxygen with no ventilatory or oxygenation
abnormalities.

In terms of the patient's known coronary artery disease,
cardiac enzymes were cycled as were electrocardiograms.
Electrocardiograms revealed no new changes; however, the
patient did rule in for a myocardial infarction with a peak
creatine kinase of 186, and a peak MB index of 7.5.  The
patient's Plavix was discontinued on [**2177-3-25**] after a
30-day course following his stent placement, and the patient
was started on folate.

In terms of the patient's depressed ejection fraction, it was
unclear why the patient was not placed on Lasix prior to this
admission; however, he diuresed well to p.r.n. doses of 60 mg
intravenously of Lasix, and at the time of discharge he was
on 40 mg of Lasix p.o. q.d.  The patient's ACE inhibitor was
also titrated up.  He was initially started at 12.5 mg of
captopril, and eventually we were able to get him to 25 mg
p.o. t.i.d. of captopril.  He will be discharged on 2 mg of
trandolapril per day.

The patient's admission blood sugar was 383.  A hemoglobin
A1c noted in the OMR was 5.8.  This was all consistent with
worsening glucose intolerance.  However, once the patient's
acute stressor resolved, his blood sugars came down into the
normal range, and he did not need sliding-scale insulin.

Finally, the patient's INR was climbing for unclear reasons
from an admission INR of 3.2 to a maximum of 4.8 on the day
prior to discharge.  On the day of discharge, it was 2.5 with
no interventions made.  The patient's captopril had been held
throughout the hospitalization, and it will be restarted at
the time of discharge.

The patient's hematocrit also mysteriously dropped from 39
to 32; and, so, an anemia workup was initiated.  The
patient's reticulocyte count was 3, iron was 39, with a TIBC
of 260.  The mean cell volume was normal at 89.  The
hematocrit came up of its own [**Location (un) **] from 32 to 39, so no
further actions were taken.

On [**2177-3-27**], after a Physical Therapy consultation the
patient was felt to be stable for discharge home with home
physical therapy for medication monitoring and assistance
with arrangements of followup.

DISCHARGE DIAGNOSES:
1.  Non-ST elevation myocardial infarction.
2.  Flash pulmonary edema.
3.  Congestive heart failure; class I to II.
4.  Inferoapical akinesis.
5.  Worsening glucose intolerance.

MEDICATIONS ON DISCHARGE:
1.  Trandolapril 2 mg p.o. q.d.
2.  Lasix 40 mg p.o. q.d.
3.  Folate 1 mg p.o. q.d.
4.  Atenolol 25 mg p.o. q.d.
5.  Lipitor 10 mg p.o. q.d.
6.  Aspirin 325 mg p.o. q.d.
7.  Coumadin 5 mg p.o. q.d.

DISCHARGE FOLLOWUP:
1.  The patient will follow up with his primary care
physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], in one to two weeks.
2.  The patient will follow up in the [**Hospital 197**] Clinic in two
to three days for recheck of his INR.




                          [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 2057**]

Dictated By:[**Name8 (MD) 2653**]

MEDQUIST36

D:  [**2177-3-26**]  11:23
T:  [**2177-3-27**]  14:35
JOB#:  [**Job Number 38026**]

cc:[**Name8 (MD) **]
{'Subendocardial infarction, initial episode of care,Congestive heart failure, unspecified,Coronary atherosclerosis of native coronary artery,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Abnormal coagulation profile,Anemia, unspecified,Pure hypercholesterolemia,Unspecified essential hypertension,Old myocardial infarction'}


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: Acute dyspnea.

PRESENT ILLNESS: This is a 74-year-old male with
no prior medical history except his first myocardial
infarction in [**2177-2-14**] in the setting of five days of
new onset of substernal chest pressure and was eventually
found to have 2-vessel disease by cardiac catheterization and
elevated right-sided pressures.

MEDICAL HISTORY: 1.  Coronary artery disease, status post myocardial
infarction in [**2177-2-14**].  Cardiac catheterization on
[**2177-2-21**] revealed 100% fresh proximal left circumflex
lesion which received percutaneous transluminal coronary
angioplasty and stent; 100% proximal right coronary artery
chronic occlusion with no action; the wedge was 25; the
pulmonary artery pressure was 54/21.  His cardiac risk
factors include a distant 50-pack-year history of smoking;
quit 10 years ago, hypertension, and age.
2.  Depressed ejection fraction of 25% with multiple region
wall motion abnormalities including inferoapical akinesis by
[**2177-2-24**] echocardiogram.

MEDICATION ON ADMISSION: (Medications on admission
included)
1.  Coumadin 5 mg p.o. q.d.
2.  Lipitor 10 mg p.o. q.d.
3.  Atenolol 25 mg p.o. q.d.
4.  Aspirin 325 mg p.o. q.d.
5.  Plavix 75 mg p.o. q.d.
6.  Trandolapril 1 mg p.o. q.d.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient is a widower for the last few
years.  He lives alone and does his own activities of daily
living, and he has a distant 50-pack-year history of tobacco;
he quit 10 years ago.  The patient did smoke unfiltered
cigarettes. 

### Response:
{'Subendocardial infarction, initial episode of care,Congestive heart failure, unspecified,Coronary atherosclerosis of native coronary artery,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Abnormal coagulation profile,Anemia, unspecified,Pure hypercholesterolemia,Unspecified essential hypertension,Old myocardial infarction'}
