CHIEF COMPLAINT: Shortness of breath

PRESENT ILLNESS: 63yo female with a h/o congenital heart defects (s/p repair
primum atrial septal defect, cleft mitral valve with an
endocardial cushion defect), afib on coumadin, pulmonary artery
HTN, DM, HLD who p/w 1mo shortness of breath, lower extremity
edema, and orthopnea.  On day of adission, patient presented to
Cardiology visit with Dr. [**First Name (STitle) 4135**] today for a scheduled
appointment regarding her pulmonary hypertension.  At the visit
patient reported the above symptoms, and under went a TTE for
evaluation of pHTN, which demonstrated PA pressure of 80mmHg
(prior was 36mmHg) and severe TR.  At the time, her vital signs
were HR45 BP150/60 99%RA.  Patient was sent to the [**Hospital1 18**] ED for
admission for treatment of heart failure and elevated pHTN.
.
In the ED, patient's initial vital signs were 99.1 42 164/48 20
100% 4LNC.  EKG showed afib at 46.  CXR c/w CHF. Labs were
significant for HCT 31.8, Cr 0.9, Trop<.01, BNP 2646 (no
baseline comparison).  Patient received 20mg IV lasix w good
urine output (not recorded).
.
Cardiac review of systems is notable for absence of chest pain,
palpitations, syncope or presyncope.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension

MEDICATION ON ADMISSION: ACARBOSE [PRECOSE]25 mg Tablet three times a day
AMOXICILLIN before dental procedure
ATENOLOL 25 mg Tablet once daily
GLYBURIDE 5 mg Tablet - two Tablets by mouth twice a day
LISINOPRIL 20 mg Tablet - 1 Tablet by mouth once a day
METFORMIN 1,000 mg Tablet - one Tablet by mouth twice a day
PIOGLITAZONE 15 mg Tablet - 1 Tablet by mouth once a day
SIMVASTATIN 20 mg Tablet - 1 Tablet by mouth daily
SITAGLIPTIN [JANUVIA] 100 mg Tablet - 1 Tablet by mouth once a
day
TAMOXIFEN 20 mg Tablet - 1 Tablet by mouth every day
ULTRAM 50MG Tablet - ONE TWICE A DAY
WARFARIN 5 mg Tablet - Take up to 2 tablets by mouth a day or as
directed by [**Hospital 191**] [**Hospital 197**] Clinic
Vitamin D 1000 mg twice daily.

ALLERGIES: Codeine

PHYSICAL EXAM: ON ADMISSION
VS: 98.2 150/50 46 22 100%2.5L
GENERAL: NAD, AOx3, Comfortable
HEENT: PERRL, EOMI, Conjunctiva were pink, no pallor or cyanosis
of the oral mucosa.
NECK: Supple with JVP of 6cm
CARDIAC: irregularly irregular, bradycardic, nlS1/S2, [**3-1**] late
peaking holosystolic murmur loudest at RUSB, [**3-1**] No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. Abd aorta not enlarged by palpation. No
abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+

FAMILY HISTORY: Mother is living (79 years; DM, lupus).
Father is deceased (30s or 40s years; MI); She has no siblings
and no children.

SOCIAL HISTORY: She lives in [**First Name11 (Name Pattern1) 392**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **] mother and works for a managed care
company.  Denies tobacco, denies ETOH.
Other chronic pulmonary heart diseases,Acute on chronic diastolic heart failure,Cardiac arrest,Hemorrhage of gastrointestinal tract, unspecified,Acute kidney failure, unspecified,Atrioventricular block, complete,Disorders of magnesium metabolism,Long-term (current) use of anticoagulants,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Mitral valve disorders,Other lymphedema,Unspecified nontoxic nodular goiter,Sickle-cell trait,Other and unspecified hyperlipidemia,Personal history of surgery to heart and great vessels, presenting hazards to health
Chr pulmon heart dis NEC,Ac on chr diast hrt fail,Cardiac arrest,Gastrointest hemorr NOS,Acute kidney failure NOS,Atriovent block complete,Dis magnesium metabolism,Long-term use anticoagul,DMII wo cmp nt st uncntr,Mitral valve disorder,Other lymphedema,Nontox nodul goiter NOS,Sickle-cell trait,Hyperlipidemia NEC/NOS,Hx-major cardiovasc surg
Admission Date:  [**2183-12-4**]              Discharge Date:   [**2183-12-17**]

Date of Birth:  [**2120-9-16**]             Sex:   F

Service: MEDICINE

Allergies:
Codeine

Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Shortness of breath

Major Surgical or Invasive Procedure:
Right Heart Catheterization on [**2183-12-8**] by Dr. [**Last Name (STitle) **]

History of Present Illness:
63yo female with a h/o congenital heart defects (s/p repair
primum atrial septal defect, cleft mitral valve with an
endocardial cushion defect), afib on coumadin, pulmonary artery
HTN, DM, HLD who p/w 1mo shortness of breath, lower extremity
edema, and orthopnea.  On day of adission, patient presented to
Cardiology visit with Dr. [**First Name (STitle) 4135**] today for a scheduled
appointment regarding her pulmonary hypertension.  At the visit
patient reported the above symptoms, and under went a TTE for
evaluation of pHTN, which demonstrated PA pressure of 80mmHg
(prior was 36mmHg) and severe TR.  At the time, her vital signs
were HR45 BP150/60 99%RA.  Patient was sent to the [**Hospital1 18**] ED for
admission for treatment of heart failure and elevated pHTN.
.
In the ED, patient's initial vital signs were 99.1 42 164/48 20
100% 4LNC.  EKG showed afib at 46.  CXR c/w CHF. Labs were
significant for HCT 31.8, Cr 0.9, Trop<.01, BNP 2646 (no
baseline comparison).  Patient received 20mg IV lasix w good
urine output (not recorded).
.
Cardiac review of systems is notable for absence of chest pain,
palpitations, syncope or presyncope.


Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension

2. CARDIAC HISTORY:
-Congenital heart disease: ASD, cleft mitral valve s/p mitral
valve repair and ASD repair ([**Hospital6 **] [**2145**])
-Moderate mitral regurgitation (TTE [**4-4**])
-Moderate to severe tricuspid regurgitation (TTE [**4-4**])
-Pulmonary hypertension - moderate echo [**4-3**] (severe echo [**12-5**])
-Tachy brady syndrome s/p pacemaker placement ([**2153**]), [**Company **]
spectrax s/p lead fracture in [**2164**] and generator explant
3. OTHER PAST MEDICAL HISTORY:
-Multinodular goiter
-Atypical lobular hyperplasia, right breast
-Chronic lymphedema, left leg
-Permanent atrial fibrillation, on warfarin
-Cervical hysterectomy with bilateral salpingo-oophorectomy
(fibroids, [**2169**])
-Thalassemia trait

Social History:
She lives in [**First Name11 (Name Pattern1) 392**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **] mother and works for a managed care
company.  Denies tobacco, denies ETOH.

Family History:
Mother is living (79 years; DM, lupus).
Father is deceased (30s or 40s years; MI); She has no siblings
and no children.

Physical Exam:
ON ADMISSION
VS: 98.2 150/50 46 22 100%2.5L
GENERAL: NAD, AOx3, Comfortable
HEENT: PERRL, EOMI, Conjunctiva were pink, no pallor or cyanosis
of the oral mucosa.
NECK: Supple with JVP of 6cm
CARDIAC: irregularly irregular, bradycardic, nlS1/S2, [**3-1**] late
peaking holosystolic murmur loudest at RUSB, [**3-1**] No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. Abd aorta not enlarged by palpation. No
abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+

ON DISCHARGE
VS: 97.8 96/69 71 18 100%RA 81.4kg
I/O: 0/[**2172**] (8hr) 1200/4600 (24hr)
GENERAL: NAD, AOx3, Comfortable
HEENT: PERRL, EOMI, OP clear, MMM, Conjunctiva pink.
NECK: Supple with JVP 4cm, prominent v-waves
CARDIAC: irregularly irregular, nlS1/S2, [**2-1**] late peaking
systolic murmur loudest at RUSB, no r/g. No thrills, lifts. No
S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND.
EXTREMITIES: trace pedal edema bilaterally, no c/c.
SKIN: No stasis dermatitis, ulcers, scars.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+

Pertinent Results:
Blood Counts
[**2183-12-4**] 01:31PM BLOOD WBC-5.8 RBC-4.49 Hgb-9.9* Hct-31.8*
MCV-71* MCH-22.0* MCHC-31.0 RDW-16.2* Plt Ct-170
[**2183-12-17**] 06:21AM BLOOD WBC-6.7 RBC-4.10* Hgb-9.1* Hct-28.5*
MCV-70* MCH-22.2* MCHC-31.9 RDW-15.9* Plt Ct-253

Coags
[**2183-12-5**] 01:55AM BLOOD PT-25.1* PTT-27.8 INR(PT)-2.4*
[**2183-12-17**] 06:21AM BLOOD PT-18.6* PTT-31.2 INR(PT)-1.7*

Chemistry
[**2183-12-4**] 01:31PM BLOOD Glucose-125* UreaN-18 Creat-0.9 Na-139
K-4.6 Cl-108 HCO3-21* AnGap-15
[**2183-12-13**] 04:59AM BLOOD Glucose-100 UreaN-20 Creat-1.1 Na-139
K-4.4 Cl-103 HCO3-26 AnGap-14
[**2183-12-16**] 06:00PM BLOOD Glucose-309* UreaN-26* Creat-1.6* Na-135
K-5.4* Cl-102 HCO3-24 AnGap-14
[**2183-12-17**] 06:21AM BLOOD Glucose-123* UreaN-23* Creat-1.4* Na-138
K-4.9 Cl-103 HCO3-26 AnGap-14

[**2183-12-4**]
TTE
The left atrium is moderately dilated. No thrombus/mass is seen
in the body of the left atrium. The right atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and global systolic function (LVEF>55%). There is no
ventricular septal defect. The right ventricular free wall is
hypertrophied. The right ventricular cavity is moderately
dilated with depressed free wall contractility. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The aortic valve leaflets
(3) are mildly thickened. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
moderately thickened. There is no mitral valve prolapse. There
is mild functional mitral stenosis (mean gradient 6 mmHg) due to
mitral annular calcification versus annular ring from prior
repair. Mild to moderate ([**12-28**]+) mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] The tricuspid valve
leaflets are mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2182-4-11**],
the RV appears enlarged with evidence of pressure/volume
overload. There is now severe pulmonary hypertension and the
degree of TR has increased. The mean transmitral gradient is
similar.

[**2183-12-8**]
CCath
1. Severe pulmonary arterial hypertension.
2. Moderate right ventricular diastolic heart failure.
3. Marked elevation in PCW consistent with severe left
ventricular
diastolic heart pressure, with giant V waves consistent with
significant
mitral regurgitation.
4. Mild improvement in PASP, mean PA and modest improvement in
PVR with
100% O2 and slightly further with addition of iNO, driven by
narrowing
of AV O2 difference.

[**2183-12-15**]
TEE
Mild spontaneous echo contrast but no thrombus is seen in the
body of the left atrium and left atrial appendage. The left
atrial appendage emptying velocity is depressed (<0.2m/s). No
spontaneous echo contrast or thrombus is seen in the body of the
right atrium or the right atrial appendage. The right atrial
appendage ejection velocity is depressed (<0.2m/s). No atrial
septal defect is seen by 2D or color Doppler. There are simple
atheroma in the aortic arch and descending thoracic aorta to 35
cm from the incisors. The aortic valve leaflets (3) are mildly
thickened. No aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened and there appears to be
prosthetic material in the mitral valve annulus consistent prior
surgery. There is a 3 mm Hg mean gradient across the mitral
valve, with an estimated valve area of 2.3 cm2, consistent with
trivial mitral stenosis. Mild (1+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened with moderate
[2+] tricuspid regurgitation. There is moderate pulmonary artery
systolic hypertension.
IMPRESSION: Trivial mitral stenosis. Mild mitral regurgitation.
Moderate tricuspid regurgitation. Moderate pulmonary artery
systolic hypertension. Mild spontaneous echo contrast without
thrombus in the left atrium and left atrial appendage. Simple
aortic atheroma in the arch and descending thoracic aorta.

[**2183-12-16**]
TTE
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF 75%). The mitral valve
leaflets are moderately thickened. There is no mitral valve
prolapse. The tricuspid valve leaflets are mildly thickened.
Moderate-to-severe [3+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension.
Compared with the findings of the prior study (images reviewed)
of [**2183-12-4**], the apparent pulmonary artery pressure is
significantly reduced


Brief Hospital Course:
HOSPITAL COURSE
This is a 63-year old female w a history of congenital heart
defects (s/p repair primum atrial septal defect, cleft mitral
valve with an endocardial cushion defect), a/w worsening severe
pHTN, hospital course c/b CCU stay for prolonged QT torsades and
VT/VF arrest s/p pacemaker placement, diuresed with follow-up
echocardiography demonstrating improved PA pressures.
.
ACTIVE
# Pulmonary hypertension: Patient was admitted with worsening
SOB and a TTE demonstrated pHTN.  A R heart cath demonstrated PA
pressures of 113/23, PCW 30 with V waves up to 60, moderately
responsive to supplemental O2.  Given elevated wedge with large
V waves, there was the question of mitral valve disease versus L
heart disease versus worsening primary process as the driving
process for this worsening pHTN (prior TTE in [**2181**] had estimated
pulm pressures in 30s).  Patient was aggresively diuresed with
torsemide and spironolactone.  TEE did not demonstrate evidence
of severe mitral valve disease, suggesting that large v waves
were artifact.  After diuresis of ~10kg, repeat TTE estimated PA
systolic pressures in the low 40s, suggesting that exacerbation
of pHTN was [**1-28**] to L sided failure.  Patient was discharged on
lasix and spironolactone, with set-up for home O2.
.
# Torsades and VT/VF arrest: Patient developed torsades leading
to VT/VF arrest on floor on [**12-8**].  She had ROSC after ACLS.  EP
was consulted who felt that a rate related prolonged QT was
responsible.  A single chamber pacemaker was placed on [**12-9**]
with normalization of the QT.  She was started on PO magnesium
and metoprolol for treatment of persistant ectopy.
.
# ARF: During diuresis, Cr rose to 1.6 (baseline 0.9).
Metformin was held.  Diuresis was slowed and at discharge Cr was
1.4.  Patient was instructed to discuss resuming metformin at
future PCP [**Name Initial (PRE) 648**].
.
#DM: Patient was continued on SS humalog, acarbose, glyburide,
metformin, and pioglitazone, with holding of oral hyperglycemics
in the setting of the cath and restarting afterwards.  Home
januvia was nonformulary and restarted at discharge.
.
#GI Bleed: Patient had a single episode of blood emesis in the
setting of her torsades episode.  She was started on PPI.  At
future outpatient follow-up, the patient could be evaluated for
stopping this medication.
.
# Afib: Patient's coumadin regimen was continued, but patient's
INR became subtherapeutic late in the admission.  With
consultation from the coumadin clinic, her coumadin was
increased to 5mg daily and she was bridged with lovenox.  She
discharged with script for lovenox and instructed to have her
INR checked by her VNA on [**12-22**] and faxed to the coumadin
clinic.
.
INACTIVE
#HLD: Patient was continued on home simvastatin.
.
#HTN: The patient was continued on home lisinopril
.
#h/o atypical lobular hyperplasia: Patient was continued on home
tamoxifen.
.
#Chronic Lymphedema: Patient was continued on home ultram.
.
TRANSITIONAL
1. Code status: Patient remained full code for the duration of
this admission
2. Pending: No labs pending at time of discharge
3. Transition of Care: Details of this admission were discussed
with PCP. [**Name10 (NameIs) **] was given follow-up appointments with PCP,
[**Name10 (NameIs) **], Pulmonary, and Device Clinic.  Patient was arranged
to have VNA and home O2.

Medications on Admission:
ACARBOSE [PRECOSE]25 mg Tablet three times a day
AMOXICILLIN before dental procedure
ATENOLOL 25 mg Tablet once daily
GLYBURIDE 5 mg Tablet - two Tablets by mouth twice a day
LISINOPRIL 20 mg Tablet - 1 Tablet by mouth once a day
METFORMIN 1,000 mg Tablet - one Tablet by mouth twice a day
PIOGLITAZONE 15 mg Tablet - 1 Tablet by mouth once a day
SIMVASTATIN 20 mg Tablet - 1 Tablet by mouth daily
SITAGLIPTIN [JANUVIA] 100 mg Tablet - 1 Tablet by mouth once a
day
TAMOXIFEN 20 mg Tablet - 1 Tablet by mouth every day
ULTRAM 50MG Tablet - ONE TWICE A DAY
WARFARIN 5 mg Tablet - Take up to 2 tablets by mouth a day or as
directed by [**Hospital 191**] [**Hospital 197**] Clinic
Vitamin D 1000 mg twice daily.

Discharge Medications:
1. acarbose 25 mg Tablet Sig: One (1) Tablet PO three times a
day: with meals.
2. metoprolol succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
3. glyburide 5 mg Tablet Sig: Two (2) Tablet PO twice a day.
4. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. pioglitazone 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day.
8. tamoxifen 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. tramadol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for pain.
10. warfarin 5 mg Tablet Sig: as directed Tablet PO Once Daily
at 4 PM: take as directed by coumadin clinic / primary care
doctor.
11. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO twice a day.
12. Oxygen
2-3 L NC
Continuous
Pulse dose for portability
Dx: pulmonary hypertension, heart failure
13. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
14. Lovenox 120 mg/0.8 mL Syringe Sig: One (1) 120mg
Subcutaneous once a day for 5 doses: Please continue until INR
at goal of [**1-29**].
Disp:*5 units* Refills:*0*
15. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
16. torsemide 20 mg Tablet Sig: 1.5 Tablets PO once a day.
Disp:*45 Tablet(s)* Refills:*0*
17. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
18. Outpatient Lab Work
At your [**2184-1-1**] doctors visit, please have have the following
labs checked:
Na, K, HCO3, Cl, BUN, Cr, Mg


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 86**] VNA

Discharge Diagnosis:
PRIMARY
Pulmonary Hypertension

SECONDARY
Congestive Heart Failure
Atrial Fibrillation


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
Ms. [**Known lastname 4553**],

It was a pleasure taking care of you at [**Hospital1 **].
You were admitted with shortness of breath and elevated
pulmonary artery pressures on an echocardiogram.  You were
treated with diuresis (to help remove some of the fluid), blood
pressure control (to help decrease the strain on your heart),
and oxygen therapy (to help decrease the strain on your heart).
Your symptoms improved and you were ready for discharge.

While you were here, your heart beat went into an irregular
rhythm, and you needed to have a pacemaker placed.

During your hospitalization the following changes were made to
your medications:
-STARTED torsemide (a diuretic)
-STARTED spironolactone (a diuretic)
-STARTED metoprolol (heart rate control)
-STARTED magnesium
-STARTED omeprazole
-STARTED home oxygen therapy
-STARTED lovenox
-INCREASED warfarin
-STOPPED metformin **please follow up with your primary care
doctor to discuss the possibility of restarting this
medication**

Please see below for your recommended follow-up appointments.

Followup Instructions:
DEVICE CLINIC
Thursday [**2183-12-18**] at 11AM - [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

PRIMARY CARE
When: THURSDAY [**2184-1-1**] at 10:00 AM
With: [**Doctor First Name **] FERN, RNC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

CARDIOLOGY
When: THURSDAY [**2184-2-5**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4135**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
You have been placed on a cancellation list. They will call you
at home with a sooner appointment.
{'Other chronic pulmonary heart diseases,Acute on chronic diastolic heart failure,Cardiac arrest,Hemorrhage of gastrointestinal tract, unspecified,Acute kidney failure, unspecified,Atrioventricular block, complete,Disorders of magnesium metabolism,Long-term (current) use of anticoagulants,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Mitral valve disorders,Other lymphedema,Unspecified nontoxic nodular goiter,Sickle-cell trait,Other and unspecified hyperlipidemia,Personal history of surgery to heart and great vessels, presenting hazards to health'}


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

PRESENT ILLNESS: 63yo female with a h/o congenital heart defects (s/p repair
primum atrial septal defect, cleft mitral valve with an
endocardial cushion defect), afib on coumadin, pulmonary artery
HTN, DM, HLD who p/w 1mo shortness of breath, lower extremity
edema, and orthopnea.  On day of adission, patient presented to
Cardiology visit with Dr. [**First Name (STitle) 4135**] today for a scheduled
appointment regarding her pulmonary hypertension.  At the visit
patient reported the above symptoms, and under went a TTE for
evaluation of pHTN, which demonstrated PA pressure of 80mmHg
(prior was 36mmHg) and severe TR.  At the time, her vital signs
were HR45 BP150/60 99%RA.  Patient was sent to the [**Hospital1 18**] ED for
admission for treatment of heart failure and elevated pHTN.
.
In the ED, patient's initial vital signs were 99.1 42 164/48 20
100% 4LNC.  EKG showed afib at 46.  CXR c/w CHF. Labs were
significant for HCT 31.8, Cr 0.9, Trop<.01, BNP 2646 (no
baseline comparison).  Patient received 20mg IV lasix w good
urine output (not recorded).
.
Cardiac review of systems is notable for absence of chest pain,
palpitations, syncope or presyncope.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension

MEDICATION ON ADMISSION: ACARBOSE [PRECOSE]25 mg Tablet three times a day
AMOXICILLIN before dental procedure
ATENOLOL 25 mg Tablet once daily
GLYBURIDE 5 mg Tablet - two Tablets by mouth twice a day
LISINOPRIL 20 mg Tablet - 1 Tablet by mouth once a day
METFORMIN 1,000 mg Tablet - one Tablet by mouth twice a day
PIOGLITAZONE 15 mg Tablet - 1 Tablet by mouth once a day
SIMVASTATIN 20 mg Tablet - 1 Tablet by mouth daily
SITAGLIPTIN [JANUVIA] 100 mg Tablet - 1 Tablet by mouth once a
day
TAMOXIFEN 20 mg Tablet - 1 Tablet by mouth every day
ULTRAM 50MG Tablet - ONE TWICE A DAY
WARFARIN 5 mg Tablet - Take up to 2 tablets by mouth a day or as
directed by [**Hospital 191**] [**Hospital 197**] Clinic
Vitamin D 1000 mg twice daily.

ALLERGIES: Codeine

PHYSICAL EXAM: ON ADMISSION
VS: 98.2 150/50 46 22 100%2.5L
GENERAL: NAD, AOx3, Comfortable
HEENT: PERRL, EOMI, Conjunctiva were pink, no pallor or cyanosis
of the oral mucosa.
NECK: Supple with JVP of 6cm
CARDIAC: irregularly irregular, bradycardic, nlS1/S2, [**3-1**] late
peaking holosystolic murmur loudest at RUSB, [**3-1**] No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. Abd aorta not enlarged by palpation. No
abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+

FAMILY HISTORY: Mother is living (79 years; DM, lupus).
Father is deceased (30s or 40s years; MI); She has no siblings
and no children.

SOCIAL HISTORY: She lives in [**First Name11 (Name Pattern1) 392**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **] mother and works for a managed care
company.  Denies tobacco, denies ETOH. 

### Response:
{'Other chronic pulmonary heart diseases,Acute on chronic diastolic heart failure,Cardiac arrest,Hemorrhage of gastrointestinal tract, unspecified,Acute kidney failure, unspecified,Atrioventricular block, complete,Disorders of magnesium metabolism,Long-term (current) use of anticoagulants,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Mitral valve disorders,Other lymphedema,Unspecified nontoxic nodular goiter,Sickle-cell trait,Other and unspecified hyperlipidemia,Personal history of surgery to heart and great vessels, presenting hazards to health'}
