CHIEF COMPLAINT: Shortness of breath, Dyspnea on Exertion

PRESENT ILLNESS: Ms. [**Known lastname **] is a 72 yo F with known severe AI, diastolic [**Hospital 1902**]
transferred from an OSH with acute respiratory distress thought
due to flash pulmonary edema, infection +/- airway edema for
consideration of aortic valve replacement.

MEDICAL HISTORY: Chronic Diastolic Congestive Heart Failure
Aortic Valve Insufficiency
Mitral Regurgitation
Hypertension
Dyslipidemia
Cerebrovascular Disease - History of stroke
History of SVT
History of Syncope
Chronic LE Ulcers
Anemia
Anxiety
History of Vasculitis
Osteoarthritis
Glaucoma
History of Seizures
Appendectomy, Prior Hernia Repair

MEDICATION ON ADMISSION: At Home: Atorvastatin 10mg daily, Aspirin 81mg Daily, Metoprolol
25mg Three times daily, Norvasc 2.5mg Daily, Losartan 320mg
Daily, Timoptic 0.5% one drop each eye daily, Spiriva one
capsule daily, Claritin 10mg daily, Zoloft 100mg self-d/c'd
several weeks ago, Vitamins

ALLERGIES: Penicillins / Codeine / Iodine

PHYSICAL EXAM: ADMISSION PHYSICAL EXAMINATION:
VS: 99.7 79 137/60 AC FiO2 40% Vt 450 RR 10 PEEP 5
Gen: Well-appearing. Intubated.
CV: RRR. Normal S1 and S2. No M/R/G.
Pulm: CTA bilaterally listening anteriorly.
Abd: Soft, nontender.
Ext: No edema.
Neuro: A&Ox3.
Integumentary: Left lower extremity ulcer healing.

FAMILY HISTORY: No known family history of premature cardiac disease or sudden
death per outside hospital reports.

SOCIAL HISTORY: Remote tobacco use, rare ETOH. Divorced, lives independently.
Herpes simplex without mention of complication,Unspecified glaucoma,Mitral valve insufficiency and aortic valve insufficiency,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Urinary tract infection, site not specified,Hyposmolality and/or hyponatremia,Ulcer of other part of lower limb,Rheumatic heart failure (congestive),Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Other and unspecified hyperlipidemia
Herpes simplex NOS,Glaucoma NOS,Mitral/aortic val insuff,Acute respiratry failure,Food/vomit pneumonitis,Urin tract infection NOS,Hyposmolality,Ulcer oth part low limb,Rheumatic heart failure,Crnry athrscl natve vssl,Hypertension NOS,Hyperlipidemia NEC/NOS
Admission Date:  [**2186-1-16**]              Discharge Date:   [**2186-1-31**]

Date of Birth:  [**2113-12-18**]             Sex:   F

Service: CARDIOTHORACIC

Allergies:
Penicillins / Codeine / Iodine

Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Shortness of breath, Dyspnea on Exertion


Major Surgical or Invasive Procedure:
[**2186-1-19**] Cardiac Catheterization
[**2186-1-27**] Aortic Valve Replacement(21mm [**Doctor Last Name **] Pericardial
Valve), Mitral Valve Replacement(29mm St. [**Male First Name (un) 923**] Porcine Valve)
and Two Vessel Coronary Artery Bypass Grafting utilizing vein
grafts to first and second obtuse marginal arteries.


History of Present Illness:
Ms. [**Known lastname **] is a 72 yo F with known severe AI, diastolic [**Hospital 1902**]
transferred from an OSH with acute respiratory distress thought
due to flash pulmonary edema, infection +/- airway edema for
consideration of aortic valve replacement.

The patient called 911 at 7:42AM on [**2186-1-13**] with difficulty
breathing. She was found by EMT in a recliner unresponsive in
respiratory distress. Periorbital and peripheral cyanosis was
noted. Pulse ox at that time was 58%, pulse 120, bp 90/60. The
patient was bag-ventilated until she got to [**Hospital3 **]Hospital ED where she was emergently intubated. CXR at that time
revealed florid CHF by admission note report. The patient was
started on IV nitroglycerine and IV furosemide with good volume
output. EKG revealed no acute ischemic changes and cardiac
enzymes were negative. The patient had a maximum BNP of 100. The
patient transiently required a levophed drip for bp support. The
patient was extubated on [**2186-1-14**] after a successful SBT but she
required reintubation 6 hours later in the setting of
respiratory distress and ?respiratory stridor. On re-intubation,
the patient was noted to have vocal cord and larynx swelling
preventing requiring placement of a 6.5 ET tube (previous
intubation done with 7.5 ET tube). She was started on IV
solumedrol for treatment of airway edema. In the setting of
respiratory failure, possible infliltrates on CXR (bibasilar),
leukocytosis to 20 and staph growth in the sputum, the patient
was also started on vancomycin, levofloxacin for a possible
aspiration pneumonia.

On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.

By recent OMR notes, cardiac review of systems is notable for
occasional DOE and palpitations. Absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope or
presyncope.


Past Medical History:
Chronic Diastolic Congestive Heart Failure
Aortic Valve Insufficiency
Mitral Regurgitation
Hypertension
Dyslipidemia
Cerebrovascular Disease - History of stroke
History of SVT
History of Syncope
Chronic LE Ulcers
Anemia
Anxiety
History of Vasculitis
Osteoarthritis
Glaucoma
History of Seizures
Appendectomy, Prior Hernia Repair

Social History:
Remote tobacco use, rare ETOH. Divorced, lives independently.

Family History:
No known family history of premature cardiac disease or sudden
death per outside hospital reports.


Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 99.7 79 137/60 AC FiO2 40% Vt 450 RR 10 PEEP 5
Gen: Well-appearing. Intubated.
CV: RRR. Normal S1 and S2. No M/R/G.
Pulm: CTA bilaterally listening anteriorly.
Abd: Soft, nontender.
Ext: No edema.
Neuro: A&Ox3.
Integumentary: Left lower extremity ulcer healing.


Pertinent Results:
ADMISSION LABS:
[**2186-1-16**] 01:49PM BLOOD WBC-12.6* RBC-3.41* Hgb-10.2* Hct-30.0*
MCV-88 MCH-29.9 MCHC-33.9 RDW-13.8 Plt Ct-263
[**2186-1-16**] 01:49PM BLOOD PT-13.7* PTT-29.1 INR(PT)-1.2*
[**2186-1-16**] 01:49PM BLOOD Plt Ct-263
[**2186-1-16**] 01:49PM BLOOD Glucose-122* UreaN-11 Creat-0.7 Na-141
K-4.3 Cl-107 HCO3-25 AnGap-13
[**2186-1-16**] 01:49PM BLOOD CK(CPK)-55
[**2186-1-16**] 01:49PM BLOOD Calcium-8.8 Phos-1.7* Mg-2.2

[**2186-1-16**] TTE:
The left atrium is elongated. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%) [Intrinsic left ventricular systolic function is
likely more depressed given the severity of valvular
regurgitation.] Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No masses or
vegetations are seen on the aortic valve. There is no valvular
aortic stenosis. The increased transaortic velocity is likely
related to increased stroke volume due to aortic regurgitation.
At least moderate (2+) aortic regurgitation is seen. The mitral
valve leaflets and supporting structures are mildly thickened. A
vegetation cannot be excluded, but no definite vegetation is
seen (?artifact off MAC in clips #[**1-11**]). Moderate (2+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion. IMPRESSION: Suboptimal image quality.
At least moderate aortic regurgitation. Thickened mitral
leaflets with at least moderate mitral regurgitation. Preserved
global and regional biventricular systolic function.  If
clinically indicated, a TEE would be better able to define the
aortic and mitral valve morphology.

[**2186-1-17**] TEE:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Overall left ventricular systolic function is low
normal (LVEF 50-55%). [Intrinsic left ventricular systolic
function is likely more depressed given the severity of valvular
regurgitation.] Right ventricular function is normal with normal
free wall contractility. There are complex (>4mm) non-mobile
atheroma in the aortic arch and descending thoracic aorta (at 35
cm and 38 cm from the incisors). The aortic valve leaflets (3)
are mildly thickened. No masses or vegetations are seen on the
aortic valve. Moderate to severe (3+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild focal
mitral annular calcification is noted. No mass or vegetation is
seen on the mitral valve. An eccentric, posteriorly directed jet
of moderate to severe (3+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is mild to
moderate tricuspid regurgitation jet which is eccentric and may
be underestimated. No vegetation/mass is seen on the pulmonic
valve. There is no pericardial effusion.

[**2186-1-19**] Cardiac Catheterization:
1. Selective coronary angiography revealed a left dominant
system with
patent LMCA. LAD had mild plaqueing. LCX was dominant and had a
non-hemodynamically significant 30% lesion in its proximal
portion. RCA
was small non-dominant and without significant disease.
2. Left ventriculography and aortography was deferred.
3. Hemodynamic assessment showed mild systemic hypertension and
normal
left sided and right sided filling pressures. There was mild
pulmonary
hypertension. Cardiac index was preserved.
4. Selective renal arteriography showed bilaterally patent renal

arteries. Right accessory renal was also widely patent.

[**2186-1-19**] Carotid Ultrasound:
No significant (graded less than 40%) ICA stenoses on either
side.


Brief Hospital Course:
RESPIRATORY FAILURE
Ms. [**Known lastname **] had known diastolic CHF and was transferred from an
OSH intubated with acute respiratory distress thought due to
flash pulmonary edema.  A pneumonia was also suspected based
upon reports of pulmonary infiltrates, leukocytosis and staph
growth in the sputum.  She was started empirically on Vancomycin
and Levofloxacin.  She was also noted to have airway edema on
re-inutbation at the OSH and was started on Solumedrol.  On
[**2186-1-17**], she was successfully extubated and maintained oxygen
saturations in the upper 90's on 2 L NC.  She reported
improvement in her symptoms of dyspnea and SOB.

CONGESTIVE HEART FAILURE
Ms. [**Known lastname **] had known mild one-vessel disease on a prior
catheterization, but had no evidence of cardiac ischemia on EKG
or by cardiac enzymes.  A repeat catheterization was performed
on [**2186-1-19**] as part of a pre-op evaluation for CAD.  She was
continued on aspirin, metoprolol and atorvastatin throughout the
admission.  TTE on [**2186-11-16**] rasied concern for a mitral valve
vegetation, so TEE performed on [**2186-1-17**] and showed EF 55%, 3+ MR
and 3+ AI.

HSV 2 SKIN RASH:
On [**2186-1-23**], Ms. [**Known lastname **] was noted to have a vesciculated rash
on the posterior right thigh (not in a dermatomal distribution).
 Dermatology was consulted, and DFA of the lesion was positive
for HSV 2.  She was started on Valtrex for five days, and placed
on Acyclovir IV for 24 hours periop.  The lesion was monitored
clsoely, and she had no signs of a cellulitis superinfection.

URINARY TRACT INFECTION:
Urine culture from [**2186-1-23**] grew 10,000 - 100,000 CFU's of
Enteroccus and Corynebacterium, and urinalysis was consistent
with UTI.  The patient remained asymptomatic, but she was
treated with a short course of nitrofurantoin given her pending
MVR.

OTHER PREOPERATIVE WORKUP:
Carotid ultrasound showed less than 40% stenoses of both
internal carotid arteries. Vein mapping also revealed suitable
greater saphenous vein.

OPERATIVE COURSE:
On [**1-27**], Dr. [**Last Name (STitle) 914**] performed an aortic valve
replacement, mitral valve replacement, and coronary artery
bypass grafting surgery. For additional surgical details, please
see seperate dictated operative note.

POSTOPERATIVE COURSE:
Following the operation, she was brought to the CVICU for
invasive monitoring. Within 24 hours, she awoke neurologically
intact and was extubated without incident. Her CVICU course was
uneventful and she transferred to the SDU on postoperative day
two. She did well postoperatively and was ready for discharge to
[**Last Name (un) **] on POD #4. She was hyponatremia to 127 on POD #3, but
improved with free water restriction.

Medications on Admission:
At Home: Atorvastatin 10mg daily, Aspirin 81mg Daily, Metoprolol
25mg Three times daily, Norvasc 2.5mg Daily, Losartan 320mg
Daily, Timoptic 0.5% one drop each eye daily, Spiriva one
capsule daily, Claritin 10mg daily, Zoloft 100mg self-d/c'd
several weeks ago, Vitamins

At Transfer: Aspirin 325mg daily, Protonix 40mg IV daily,
Atorvastatin 10mg Daily, Timoptic 0.5% one drop each eye daily,
Metoprolol 25mg three times daily
Lovenox 40U subq daily, Vancomycin 500mg q12h, Levofloxacin
500mg Daily, day 1: [**2186-1-13**], Solu-medrol 125mg x1 on [**2186-1-16**],
now 30mg IV q6h, Bactroban ointment twice daily since [**2186-1-14**],
Propofol gtt, Zoloft 25mg Daily


Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4)
Puff Inhalation QID (4 times a day).
7. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q4H (every 4 hours) as needed.
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
10. Valacyclovir 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 4 days: through [**1-/2108**].
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
12. Zoloft 100 mg Tablet Sig: One (1) Tablet PO once a day.
13. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1)  Inhalation once a day.
14. Diovan 80 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]

Discharge Diagnosis:
Acute on Chronic Diastolic Congestive Heart Failure
Aortic Valve Insufficiency, Mitral Regurgitation
Coronary Artery Disease
Acute Respiratory Failure/Acute Pulmonary Edema
Preoperative Pneumonia(Aspiration vs Community Acquired)
Herpes Simplex Type II
Preoperative Urinary Tract Infection
Hypertension
Dyslipidemia
Cerebrovascular Disease - History of stroke
History of SVT
History of Syncope
Chronic LE Ulcers
Anemia


Discharge Condition:
Stable


Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call cardiac surgeon if there is concern for wound infection.
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
5)No driving for at least one month.

Followup Instructions:
Dr. [**Last Name (STitle) 914**] in [**3-11**] weeks, call for appt
Dr. [**Last Name (STitle) 11493**] in [**1-8**] weeks, call for appt
Dr. [**Last Name (STitle) 10208**] in [**1-8**] weeks, call for appt
Already scheduled appointment:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 16827**] Date/Time:[**2186-3-8**] 9:00



Completed by:[**2186-1-31**]
{'Herpes simplex without mention of complication,Unspecified glaucoma,Mitral valve insufficiency and aortic valve insufficiency,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Urinary tract infection, site not specified,Hyposmolality and/or hyponatremia,Ulcer of other part of lower limb,Rheumatic heart failure (congestive),Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Other and unspecified hyperlipidemia'}


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: Shortness of breath, Dyspnea on Exertion

PRESENT ILLNESS: Ms. [**Known lastname **] is a 72 yo F with known severe AI, diastolic [**Hospital 1902**]
transferred from an OSH with acute respiratory distress thought
due to flash pulmonary edema, infection +/- airway edema for
consideration of aortic valve replacement.

MEDICAL HISTORY: Chronic Diastolic Congestive Heart Failure
Aortic Valve Insufficiency
Mitral Regurgitation
Hypertension
Dyslipidemia
Cerebrovascular Disease - History of stroke
History of SVT
History of Syncope
Chronic LE Ulcers
Anemia
Anxiety
History of Vasculitis
Osteoarthritis
Glaucoma
History of Seizures
Appendectomy, Prior Hernia Repair

MEDICATION ON ADMISSION: At Home: Atorvastatin 10mg daily, Aspirin 81mg Daily, Metoprolol
25mg Three times daily, Norvasc 2.5mg Daily, Losartan 320mg
Daily, Timoptic 0.5% one drop each eye daily, Spiriva one
capsule daily, Claritin 10mg daily, Zoloft 100mg self-d/c'd
several weeks ago, Vitamins

ALLERGIES: Penicillins / Codeine / Iodine

PHYSICAL EXAM: ADMISSION PHYSICAL EXAMINATION:
VS: 99.7 79 137/60 AC FiO2 40% Vt 450 RR 10 PEEP 5
Gen: Well-appearing. Intubated.
CV: RRR. Normal S1 and S2. No M/R/G.
Pulm: CTA bilaterally listening anteriorly.
Abd: Soft, nontender.
Ext: No edema.
Neuro: A&Ox3.
Integumentary: Left lower extremity ulcer healing.

FAMILY HISTORY: No known family history of premature cardiac disease or sudden
death per outside hospital reports.

SOCIAL HISTORY: Remote tobacco use, rare ETOH. Divorced, lives independently. 

### Response:
{'Herpes simplex without mention of complication,Unspecified glaucoma,Mitral valve insufficiency and aortic valve insufficiency,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Urinary tract infection, site not specified,Hyposmolality and/or hyponatremia,Ulcer of other part of lower limb,Rheumatic heart failure (congestive),Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Other and unspecified hyperlipidemia'}
