CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 76-year-old
male who was transferred from an outside hospital with
initial complaints of increasing shortness of breath and
dyspnea on exertion times four days.  He also had bilateral
shoulder pain with exertion but never at rest.  Positive for
a productive cough.  The patient had an echocardiogram
revealing an ejection fraction of 45-50% with inferior wall
hypokinesis, moderate mitral regurgitation.  A stress ETT was
elected and the patient had ST depression and 2:1 type AV
block.

MEDICAL HISTORY: 1.  Hypertension.
2.  Alcohol abuse.
3.  Alcoholic cirrhosis.
4.  GERD.
5.  Portal hypertension.
6.  Ascites.
7.  History of GI bleed.
8.  Ventral hernia.
9.  History of seizure.
10. Thirty pack year smoking history, quit 30 years ago.

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Coronary atherosclerosis of native coronary artery,Other and unspecified angina pectoris,Atrioventricular block, complete,Other and unspecified alcohol dependence, unspecified,Alcohol withdrawal,Alcoholic cirrhosis of liver,Thrombocytopenia, unspecified,Unspecified pleural effusion,Atherosclerosis of other specified arteries
Crnry athrscl natve vssl,Angina pectoris NEC/NOS,Atriovent block complete,Alcoh dep NEC/NOS-unspec,Alcohol withdrawal,Alcohol cirrhosis liver,Thrombocytopenia NOS,Pleural effusion NOS,Atherosclerosis NEC
Admission Date:  [**2186-1-26**]     Discharge Date:  [**2186-2-15**]

Date of Birth:                  Sex:  M

Service:

ADMISSION DIAGNOSIS:  Coronary artery disease.

DISCHARGE DIAGNOSIS:
1.  Coronary artery disease.
2.  Alcohol withdrawal.
3.  Childs A cirrhosis.
4.  Status post coronary artery bypass graft times four.
5.  Right subclavian stenosis.
6.  Status post AICD implantation.
7.  Left pleural effusion.

HISTORY OF THE PRESENT ILLNESS:  The patient is a 76-year-old
male who was transferred from an outside hospital with
initial complaints of increasing shortness of breath and
dyspnea on exertion times four days.  He also had bilateral
shoulder pain with exertion but never at rest.  Positive for
a productive cough.  The patient had an echocardiogram
revealing an ejection fraction of 45-50% with inferior wall
hypokinesis, moderate mitral regurgitation.  A stress ETT was
elected and the patient had ST depression and 2:1 type AV
block.

The patient did have a cardiac catheterization performed on
[**2186-1-26**] which revealed 50-70% diffuse disease of the LAD,
60% distal of the LM, 50% of the proximal circumflex, 90% of
the posterior circumflex after the OM.

The patient was transferred to [**Hospital1 18**] for CABG.

PAST MEDICAL HISTORY:
1.  Hypertension.
2.  Alcohol abuse.
3.  Alcoholic cirrhosis.
4.  GERD.
5.  Portal hypertension.
6.  Ascites.
7.  History of GI bleed.
8.  Ventral hernia.
9.  History of seizure.
10. Thirty pack year smoking history, quit 30 years ago.

ADMISSION MEDICATIONS:
1.  Protonix 40 mg q.d.
2.  Aldactone 100 mg q.d.
3.  Aspirin.
4.  Norvasc 5 mg q.d.

PHYSICAL EXAMINATION ON ADMISSION:  The patient is an elderly
gentleman in no acute distress.  Vital signs:  Temperature
98.0 degrees Fahrenheit, blood pressure 140/52, heart rate
77, respirations 18, 97% on 2 liters nasal cannula.  HEENT:
Normocephalic, atraumatic.  EOMI, PERRL, anicteric.  The
throat was clear.  There is a left eye prosthesis noted.
Neck:  Supple, midline, without masses or lymphadenopathy.
Chest:  Clear to auscultation bilaterally.  Cardiovascular:
Regular rate and rhythm without murmurs, rubs, or gallops.
Abdomen:  Soft, nontender, nondistended, without masses or
organomegaly.  There does not appear to be any fluid wave.
Extremities:  Warm, noncyanotic, nonedematous times four.
There is noted to be a decreased pulse in the right extremity
versus left.  This is still palpable, however.  Neurological:
Grossly intact.

LABORATORY DATA ON ADMISSION:  CBC:  8.5/12.8/36.1/103.
Chemistries:  128/4.3/92/31/25/1.2/119.  CK 87, troponin less
than 0.04.  ALT 21, AST 32, alkaline phosphatase 64, total
bilirubin 1.2.

HOSPITAL COURSE:  The patient was transferred with initial
intent for coronary artery bypass grafting.  After his
arrival, however, his preoperative course was complicated
first by agitation consistent with alcohol withdrawal.

A Psychiatry consultation was obtained.  They recommended
sedation and empiric treatment with thiamine and folate.  The
Hepatology Service was also consulted.  A liver ultrasound
was obtained which was ultimately unhelpful.  The patient was
sedated using benzodiazepines and transferred to the
Intensive Care Unit for respiratory monitoring.  The patient
was seen to have some respiratory difficulty and was
eventually placed on BIPAP.

The patient was also started on vancomycin for coagulase
positive Staphylococcus from the sputum culture and a
temperature of 106.9.  A liver biopsy was performed using a
transjugular approach on [**2186-1-31**] which confirmed the
diagnosis of cirrhosis.  The patient was diagnosed as a class
A, Childs cirrhotic.

On hospital day number seven, the patient was transferred
back to the floor.  The patient was noted to have unequal
pressures and pulse examination across the upper extremities
with the left greater than the right and Vascular Surgery
consultation was obtained.  On further examination, the
patient was seen to have some mild right upper extremity
claudication symptoms in a right-handed patient.  It did not
appear to be life-limiting at that time.

There were no clinical symptoms consistent with a subclavian
steal.  Ultrasound and ultimately angiographic studies,
however, did reveal total occlusion of the right subclavian
artery with a moderate heavy calcification.  Patency of the
left subclavian artery.  The right internal carotid artery
had a mild 30% lesion and the right external carotid had
eccentric 70% lesion.  The right common carotid artery was
normal.  The left common carotid artery was also normal, with
a 30% lesion of the left internal carotid and the left
vertebral artery having a 50% lesion at its origin.

The patient was subsequently cleared for CABG.  The patient
did also have an episode of AV block which progressed to
paroxysmal advanced AV block with complete dissociation.  The
patient was transferred back to the CCU for closer monitoring
and temporary pacing wires were placed.  The patient was
paced and seen by the EP Service.

The patient was temporarily paced and cleared for coronary
artery bypass grafting by the EP Service with the
recommendation that he would probably need a permanent
dual-chamber pacemaker after coronary issues were resolved.

The patient ultimately had coronary artery bypass grafting
times four performed on [**2186-2-7**].  The patient was
transferred to the unit for close monitoring.  He tolerated
extubation on postoperative day number one with the aid of
Precedex.  The patient was transfused 1 unit of packed red
blood cells for a hematocrit of 24.4.

The patient continued to be in 2:1 AV block with V pacing and
continued to be V paced.  The EP Service continued to follow
along and help manage his arrhythmias.  The patient continued
also to have a great deal of mucus secretions.

A permanent dual-chamber pacer was implanted on [**2186-2-10**],
postoperative day number three.  The patient remained V paced
after this.  The patient was subsequently transferred to the
floor.

On postoperative day number four, he was on the floor and
continued to work with Physical Therapy.  On the evening of
postoperative day number four, the patient had a chest x-ray
which revealed a large left-sided pleural effusion.  There
was consideration made to tap this effusion.

On postoperative day number five, a repeat chest x-ray showed
improvement of the lesion with aggressive chest PT and
diuresis.  The patient continued on the floor stay on V
pacing and without any other significant events.  He
continued with diuresis and physical therapy and was
eventually discharged to rehabilitation for further
strengthening and conditioning.

DISCHARGE CONDITION:  Stable.

DISPOSITION:  To rehabilitation.

DIET:  Cardiac.

DISCHARGE MEDICATIONS:
1.  Lasix 40 mg b.i.d.
2.  Spironolactone 25 mg q.d.
3.  Protonix 40 mg q.d.
4.  Potassium chloride 20 mEq b.i.d.
5.  Captopril 50 mg t.i.d.
6.  Thiamine 100 mg q.d.
7.  Folate 1 mg q.d.
8.  Aspirin 325 mg q.d.
9.  Multivitamin.
10. Percocet 5/325 one to two tablets q. four hours p.r.n.
11. Colace 100 mg b.i.d.

DI[**Last Name (STitle) 408**]E INSTRUCTIONS:  The patient should continue to
receive aggressive physical therapy as well as aggressive
chest physical therapy to clear secretions.  The patient
should follow-up with his cardiologist in one to two weeks to
address the need for continued diuresis as well as adjustment
of other cardiac medications.  The patient should follow-up
with EP for pacemaker maintenance per protocol.  The patient
should follow-up with Dr. [**Last Name (Prefixes) **] in four weeks time.




                              [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D.  [**MD Number(1) 414**]


Dictated By:[**Last Name (NamePattern1) 5745**]

MEDQUIST36

D:  [**2186-2-14**]  01:34
T:  [**2186-2-16**]  12:59
JOB#:  [**Job Number 46067**]
{'Coronary atherosclerosis of native coronary artery,Other and unspecified angina pectoris,Atrioventricular block, complete,Other and unspecified alcohol dependence, unspecified,Alcohol withdrawal,Alcoholic cirrhosis of liver,Thrombocytopenia, unspecified,Unspecified pleural effusion,Atherosclerosis of other specified arteries'}


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 a 76-year-old
male who was transferred from an outside hospital with
initial complaints of increasing shortness of breath and
dyspnea on exertion times four days.  He also had bilateral
shoulder pain with exertion but never at rest.  Positive for
a productive cough.  The patient had an echocardiogram
revealing an ejection fraction of 45-50% with inferior wall
hypokinesis, moderate mitral regurgitation.  A stress ETT was
elected and the patient had ST depression and 2:1 type AV
block.

MEDICAL HISTORY: 1.  Hypertension.
2.  Alcohol abuse.
3.  Alcoholic cirrhosis.
4.  GERD.
5.  Portal hypertension.
6.  Ascites.
7.  History of GI bleed.
8.  Ventral hernia.
9.  History of seizure.
10. Thirty pack year smoking history, quit 30 years ago.

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Coronary atherosclerosis of native coronary artery,Other and unspecified angina pectoris,Atrioventricular block, complete,Other and unspecified alcohol dependence, unspecified,Alcohol withdrawal,Alcoholic cirrhosis of liver,Thrombocytopenia, unspecified,Unspecified pleural effusion,Atherosclerosis of other specified arteries'}
