CHIEF COMPLAINT: Shortness of Breath

PRESENT ILLNESS: Ms. [**Known lastname 84873**] is 63 yo female with a history of metastatic breat CA
on chemotherapy (Fulvestrant 500mg IM and a study drug). She
also has a history of mitral valve prolapse and 2+ MR based on
last echocardiogram. She presents with a few days of increasing
dyspnea on exertion. She notes progressive DOE limiting her
activities over 3-4 days, which started on Satuday when she was
walking a lot during her trip to [**State 531**]. She has noted an
occasional cough recently. She denies orthopnea or PND or chest
pain. She denies fevers, chills, n/v/d, hematuria, dysuria. She
denies peripheral edema. Her DOE has been progressive over the
past few days prompting her visit to the ED where her NT-proBNP
was noted to be elevated.

MEDICAL HISTORY: Mitral Regurgitation, s/p Mitral Valve Replacement
PMH:
Metastatic Breast Cancer on Fulvestrant and study drug
Degenerative Disk Disease
Mitral valve prolapse and severe mitral regurgitation
Depression
Hyperlipidemia
Neck pain
Osteoprosis
Past Surgical History:
right total mastectomy, sentinel node biopsy, and immediate
reconstruction with [**Last Name (un) 5884**] flap
removal of right ovarian cyst
Umbilical hernia repair
Right axillary lymph node dissection

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Venlafaxine XR 225 mg PO DAILY
2. zoledronic acid-mannitol&water *NF* unknown  Injection
unknown
3. Acetaminophen Dose is Unknown  PO Q6H:PRN pain
4. Calcium Citrate + D *NF* (calcium citrate-vitamin D3) 315-200
mg-unit Oral [**Hospital1 **]
5. Docusate Sodium Dose is Unknown  PO BID
6. Multivitamins 1 TAB PO DAILY
7. Naproxen Dose is Unknown  PO Q8H:PRN pain
8. Senna 1 TAB PO BID:PRN constipation

ALLERGIES: Percodan / simvastatin / Levaquin

PHYSICAL EXAM: VITALS: 98.9, 84-99/53-57, 104-114, 20, 97% RA
weight 60.6 kg
GENERAL: NAD, comfortable while lying on bed
HEENT: MMM, EOMI
NECK: JVP at 12 cm
LUNGS: CTABL, no crackles
HEART: [**4-10**] holosystolic murmur heard best at apex with radiation
across the precordium, RRR
ABDOMEN: Soft, NT, NABS, no organomegaly
EXTREMITIES: No c/c/e
NEUROLOGIC: A+OX3

FAMILY HISTORY: Breast Cancer: Mother
[**Name (NI) 3495**] Disease/MVP: Mother

SOCIAL HISTORY: No smoking, social alcohol use, lives alone in [**Location (un) 4628**].
Mitral valve disorders,Rupture of chordae tendineae,Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes,Secondary malignant neoplasm of bone and bone marrow,Malignant neoplasm of liver, secondary,Cardiac complications, not elsewhere classified,Congestive heart failure, unspecified,Diseases of tricuspid valve,Thrombocytopenia, unspecified,Atrial fibrillation,Examination of participant in clinical trial,Cervical spondylosis without myelopathy,Depressive disorder, not elsewhere classified,Other and unspecified hyperlipidemia,Personal history of malignant neoplasm of breast,Osteoporosis, unspecified,Family history of malignant neoplasm of breast,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Acquired absence of breast and nipple,Personal history of irradiation, presenting hazards to health,Personal history of antineoplastic chemotherapy,Long-term (current) use of other medications
Mitral valve disorder,Chordae tendinae rupture,Mal neo lymph-intrathor,Secondary malig neo bone,Second malig neo liver,Surg compl-heart,CHF NOS,Tricuspid valve disease,Thrombocytopenia NOS,Atrial fibrillation,Exam-clincal trial,Cervical spondylosis,Depressive disorder NEC,Hyperlipidemia NEC/NOS,Hx of breast malignancy,Osteoporosis NOS,Family hx-breast malig,Abn react-anastom/graft,Acq absnce breast/nipple,Hx of irradiation,Hx antineoplastic chemo,Long-term use meds NEC
Admission Date:  [**2196-7-4**]              Discharge Date:   [**2196-7-12**]

Date of Birth:  [**2132-9-21**]             Sex:   F

Service: CARDIOTHORACIC

Allergies:
Percodan / simvastatin / Levaquin

Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Shortness of Breath

Major Surgical or Invasive Procedure:
[**2196-7-8**]
1. Mediastinal thymic fat pad biopsy.
2. Mitral valve replacement with a St. [**Male First Name (un) 923**] Epic tissue
    valve, serial #[**Serial Number 103612**], reference #[**Serial Number 103613**].


History of Present Illness:
Ms. [**Known lastname 84873**] is 63 yo female with a history of metastatic breat CA
on chemotherapy (Fulvestrant 500mg IM and a study drug). She
also has a history of mitral valve prolapse and 2+ MR based on
last echocardiogram. She presents with a few days of increasing
dyspnea on exertion. She notes progressive DOE limiting her
activities over 3-4 days, which started on Satuday when she was
walking a lot during her trip to [**State 531**]. She has noted an
occasional cough recently. She denies orthopnea or PND or chest
pain. She denies fevers, chills, n/v/d, hematuria, dysuria. She
denies peripheral edema. Her DOE has been progressive over the
past few days prompting her visit to the ED where her NT-proBNP
was noted to be elevated.

In the ED, initial VS were: 98.4 99 107/67 98% 2L NC. EKG showed
SR HR 100. Q V1, V2. Lateral ST depressions. Inferior tWI.
Cardiology was consulted for evaluation of CHF. A bedside
cardiac ultrasound was performed with limited images that did
not show any obvious effusion or RV dysfunction. There was some
suggestion of apical LV dysfunction.

CXR showed nodular opacity in right lung field. Small bilateral
pleural effusions. CTA chest was performed but no prelim results
on arrival to floor. Patient received Levaquin, aspirin, and
20mg IV Lasix. 1st set of enzymes negative. Patient admitted to
floor for further workup of new onset volume overload.

REVIEW OF SYSTEMS:
+ fatigue
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.


Past Medical History:
Mitral Regurgitation, s/p Mitral Valve Replacement
PMH:
Metastatic Breast Cancer on Fulvestrant and study drug
Degenerative Disk Disease
Mitral valve prolapse and severe mitral regurgitation
Depression
Hyperlipidemia
Neck pain
Osteoprosis
Past Surgical History:
right total mastectomy, sentinel node biopsy, and immediate
reconstruction with [**Last Name (un) 5884**] flap
removal of right ovarian cyst
Umbilical hernia repair
Right axillary lymph node dissection


Social History:
No smoking, social alcohol use, lives alone in [**Location (un) 4628**].

Family History:
Breast Cancer: Mother
[**Name (NI) 3495**] Disease/MVP: Mother


Physical Exam:
VITALS: 98.9, 84-99/53-57, 104-114, 20, 97% RA
weight 60.6 kg
GENERAL: NAD, comfortable while lying on bed
HEENT: MMM, EOMI
NECK: JVP at 12 cm
LUNGS: CTABL, no crackles
HEART: [**4-10**] holosystolic murmur heard best at apex with radiation
across the precordium, RRR
ABDOMEN: Soft, NT, NABS, no organomegaly
EXTREMITIES: No c/c/e
NEUROLOGIC: A+OX3

Pertinent Results:
TTE [**2196-7-5**]:
The left atrium is markedly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 70%). 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 aortic regurgitation is
seen. The mitral valve leaflets are moderately thickened. The
mitral valve leaflets are myxomatous. There is moderate/severe
primarily posterior leaflet mitral valve prolapse. The P1 and/or
P2 mitral leaflet scallop is flail. An eccentric, anteriorly
directed jet of at least moderate to severe (3+) mitral
regurgitation is seen. Due to the eccentric nature of the
regurgitant jet, its severity may be significantly
underestimated (Coanda effect). The tricuspid valve leaflets are
mildly thickened. Tricuspid valve prolapse is present. Moderate
[2+] tricuspid regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.

Compared with the findings of the prior study (images reviewed)
of [**2196-5-26**], the posterior mitral leaflet is now flail, and
the mitral regurgitation is markedly increased (at least
moderate-to-severe, and likely frankly severe).

CTA [**7-4**]:
1.  No evidence of pulmonary embolism.
2.  Stable left hilar lymphadenopathy with central necrosis.
3.  Mild congestive heart failure with new small to moderate
sized bilateral
pleural effusions, right greater than left, with adjacent
compressive
atelectasis.
4.  New 10 x 12 mm nodule within the right upper lobe concerning
for
metastasis.
5.  Worsening hepatic metastatic disease.

Cardiac cath [**7-6**]:
1. No angiographically-apparent coronary artery disease.
2. Systemic arterial normotension.

PFTs [**7-6**]: no pulmonary function abnormalities

Intra-op TEE [**2196-7-8**]
Conclusions
Prebypass:
The left atrium is mildly dilated. No thrombus is seen in the
left atrial appendage. Left ventricular wall thicknesses are
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The ascending, transverse and descending thoracic
aorta are normal in diameter and free of atherosclerotic plaque.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. Trace aortic regurgitation is seen. The
mitral valve leaflets are severely thickened/deformed. The
mitral valve leaflets are myxomatous. There is moderate/severe
P2 leaflet mitral valve prolapse. There is partial P2 mitral
leaflet flail. The mitral valve leaflets do not fully coapt. An
eccentric, anteriorly directed jet of mitral valve. Severe (4+)
mitral regurgitation is seen. Due to the eccentric nature of the
regurgitant jet, its severity may be significantly
underestimated (Coanda effect). There is systolic flow reversal
in left upper pulmonary vein. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] distance is 2.9cm and the
A:P ratio is 1.03 as predictors for systolic anterior motion.
There is mild Tricuspid valve regurgitation with normal
appearing valves, the tricuspid annulus is 3cm. There is no
pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the
results on [**2196-7-8**] at 0830.

Postbypass:
There is a well seated, well functioining, bioprostetic in the
mitral position. Trace valvular mitral regurgitation is noted.
There is no evidence of aortic dissection. Left ventricular
function is grossly unchanged from prebypass.

[**2196-7-11**] 04:35AM BLOOD WBC-8.4 RBC-3.20* Hgb-9.7* Hct-28.5*
MCV-89 MCH-30.2 MCHC-33.9 RDW-14.4 Plt Ct-129*
[**2196-7-10**] 02:12AM BLOOD WBC-9.5 RBC-3.29*# Hgb-9.8*# Hct-29.4*
MCV-89 MCH-29.8 MCHC-33.3 RDW-14.6 Plt Ct-97*#
[**2196-7-9**] 11:44AM BLOOD Hct-29.1*
[**2196-7-11**] 04:35AM BLOOD Glucose-111* UreaN-12 Creat-0.5 Na-138
K-3.5 Cl-102 HCO3-28 AnGap-12
[**2196-7-10**] 02:12AM BLOOD Glucose-95 UreaN-10 Creat-0.6 Na-139
K-4.0 Cl-102 HCO3-30 AnGap-11
[**2196-7-9**] 11:44AM BLOOD Glucose-107* Na-133 K-3.5 Cl-98

Brief Hospital Course:
MEDICINE COURSE:
This is a 63 yo F with h/o metastatic breast cancer and Mitral
valve prolapse who presents with progressive shortness of
breath.

# SOB: Echo shows new mitral leaflet flail, with markedly
increased mitral regurg. The etiology of her SOB was [**1-7**]
worsening mitral regurg with resultant volume overload/heart
failure. Pulmonary embolism was ruled out with CTA. PFTs wnl.
Cardiac surgery evaluated the patient and recommended mitral
valve surgery (open heart). Cardiac cath was preformed before
surgery and showed clean coronary arteries.

# Breast Ca: CTA showed increasing size of metastasis in the
liver. Oncology followed the patient while in house, and
requested a biopsy of a metastatic lesion during open heart
surgery given her radiographic disease progression. The
patient's study drug was held during hospitalization, but she
did recieve Fulvestrant during admission.

SURGICAL COURSE: [**2196-7-8**]-Discharge

The patient was brought to the Operating Room on [**2196-7-8**] where
the patient underwent Mitral Valve Replacement and Thymectomy
with Dr. [**Last Name (STitle) **]. Overall the patient tolerated the procedure well
and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.

POD 1 found the patient extubated, alert and oriented and
breathing comfortably.  The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
developed atrial fibrillation which converted to Sinus Rhythm
with increase in beta blocker and Amiodarone. The patient was
transferred to the telemetry floor for further recovery. Chest
tubes and pacing wires were discontinued without complication.
The patient was evaluated by the physical therapy service for
assistance with strength and mobility. Oncology was consulted
and at this point all study medications other than Faslodex are
on hold. Planning of further breast cancer treatments with Dr.
[**Last Name (STitle) **] once patient recovers from mitral valve repair. At the
time of discharge, mitral valve and thymic fat pad biopsy were
pending - these results need to be followed up. By the time of
discharge on POD 4 the patient was ambulating freely, the wound
was healing and pain was controlled with oral analgesics. She
was evaluated by physical therapy and cleared for home.  The
patient was discharged home with VNA services in good condition
with appropriate follow up instructions.

Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Venlafaxine XR 225 mg PO DAILY
2. zoledronic acid-mannitol&water *NF* unknown  Injection
unknown
3. Acetaminophen Dose is Unknown  PO Q6H:PRN pain
4. Calcium Citrate + D *NF* (calcium citrate-vitamin D3) 315-200
mg-unit Oral [**Hospital1 **]
5. Docusate Sodium Dose is Unknown  PO BID
6. Multivitamins 1 TAB PO DAILY
7. Naproxen Dose is Unknown  PO Q8H:PRN pain
8. Senna 1 TAB PO BID:PRN constipation


Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain/temp
2. Docusate Sodium 100 mg PO BID
3. Venlafaxine XR 225 mg PO DAILY
4. Aspirin EC 81 mg PO DAILY
5. HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN pain
RX *Dilaudid 2 mg [**12-7**] tablet(s) by mouth every 4 hours Disp #*30
Tablet Refills:*0
6. Metoprolol Tartrate 25 mg PO TID
Hold for HR < 55 or SBP < 90 and call medical provider.
[**Last Name (NamePattern4) 9641**] *metoprolol tartrate 25 mg 1 tablet(s) by mouth every 8 hours
Disp #*90 Tablet Refills:*1
7. Potassium Chloride 20 mEq PO DAILY
Hold for K+ > 4.5
RX *Klor-Con M20 20 mEq 1 tablet by mouth once a day Disp #*5
Tablet Refills:*0
8. Ranitidine 150 mg PO BID
RX *Acid Reducer (ranitidine) 150 mg 1 tablet(s) by mouth Twice
a day Disp #*60 Tablet Refills:*0
9. Calcium Citrate + D *NF* (calcium citrate-vitamin D3) 315-200
mg-unit Oral [**Hospital1 **]
10. Multivitamins 1 TAB PO DAILY
11. Senna 1 TAB PO BID:PRN constipation
12. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*5
Tablet Refills:*0


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Mitral Regurgitation, s/p Mitral Valve Replacement
PMH:
Metastatic Breast Cancer on Fulvestrant and study drug
Degenerative Disk Disease
Mitral valve prolapse and severe mitral regurgitation
Depression
Hyperlipidemia
Neck pain
Osteoprosis
Past Surgical History:
right total mastectomy, sentinel node biopsy, and immediate
reconstruction with [**Last Name (un) 5884**] flap
removal of right ovarian cyst
Umbilical hernia repair
Right axillary lymph node dissection


Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema: none


Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge

Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**Last Name (STitle) **]  [**Telephone/Fax (1) 170**] [**2196-8-4**] at 1:15p
Dr. [**Last Name (STitle) **] [**2196-8-11**] at 3pm [**Hospital Ward Name 23**] 7
Oncologist: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2196-8-1**] at 10:00 AM
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 133**] in [**3-10**] weeks

**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**


Completed by:[**2196-7-12**]
{'Mitral valve disorders,Rupture of chordae tendineae,Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes,Secondary malignant neoplasm of bone and bone marrow,Malignant neoplasm of liver, secondary,Cardiac complications, not elsewhere classified,Congestive heart failure, unspecified,Diseases of tricuspid valve,Thrombocytopenia, unspecified,Atrial fibrillation,Examination of participant in clinical trial,Cervical spondylosis without myelopathy,Depressive disorder, not elsewhere classified,Other and unspecified hyperlipidemia,Personal history of malignant neoplasm of breast,Osteoporosis, unspecified,Family history of malignant neoplasm of breast,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Acquired absence of breast and nipple,Personal history of irradiation, presenting hazards to health,Personal history of antineoplastic chemotherapy,Long-term (current) use of other medications'}


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: Ms. [**Known lastname 84873**] is 63 yo female with a history of metastatic breat CA
on chemotherapy (Fulvestrant 500mg IM and a study drug). She
also has a history of mitral valve prolapse and 2+ MR based on
last echocardiogram. She presents with a few days of increasing
dyspnea on exertion. She notes progressive DOE limiting her
activities over 3-4 days, which started on Satuday when she was
walking a lot during her trip to [**State 531**]. She has noted an
occasional cough recently. She denies orthopnea or PND or chest
pain. She denies fevers, chills, n/v/d, hematuria, dysuria. She
denies peripheral edema. Her DOE has been progressive over the
past few days prompting her visit to the ED where her NT-proBNP
was noted to be elevated.

MEDICAL HISTORY: Mitral Regurgitation, s/p Mitral Valve Replacement
PMH:
Metastatic Breast Cancer on Fulvestrant and study drug
Degenerative Disk Disease
Mitral valve prolapse and severe mitral regurgitation
Depression
Hyperlipidemia
Neck pain
Osteoprosis
Past Surgical History:
right total mastectomy, sentinel node biopsy, and immediate
reconstruction with [**Last Name (un) 5884**] flap
removal of right ovarian cyst
Umbilical hernia repair
Right axillary lymph node dissection

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Venlafaxine XR 225 mg PO DAILY
2. zoledronic acid-mannitol&water *NF* unknown  Injection
unknown
3. Acetaminophen Dose is Unknown  PO Q6H:PRN pain
4. Calcium Citrate + D *NF* (calcium citrate-vitamin D3) 315-200
mg-unit Oral [**Hospital1 **]
5. Docusate Sodium Dose is Unknown  PO BID
6. Multivitamins 1 TAB PO DAILY
7. Naproxen Dose is Unknown  PO Q8H:PRN pain
8. Senna 1 TAB PO BID:PRN constipation

ALLERGIES: Percodan / simvastatin / Levaquin

PHYSICAL EXAM: VITALS: 98.9, 84-99/53-57, 104-114, 20, 97% RA
weight 60.6 kg
GENERAL: NAD, comfortable while lying on bed
HEENT: MMM, EOMI
NECK: JVP at 12 cm
LUNGS: CTABL, no crackles
HEART: [**4-10**] holosystolic murmur heard best at apex with radiation
across the precordium, RRR
ABDOMEN: Soft, NT, NABS, no organomegaly
EXTREMITIES: No c/c/e
NEUROLOGIC: A+OX3

FAMILY HISTORY: Breast Cancer: Mother
[**Name (NI) 3495**] Disease/MVP: Mother

SOCIAL HISTORY: No smoking, social alcohol use, lives alone in [**Location (un) 4628**]. 

### Response:
{'Mitral valve disorders,Rupture of chordae tendineae,Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes,Secondary malignant neoplasm of bone and bone marrow,Malignant neoplasm of liver, secondary,Cardiac complications, not elsewhere classified,Congestive heart failure, unspecified,Diseases of tricuspid valve,Thrombocytopenia, unspecified,Atrial fibrillation,Examination of participant in clinical trial,Cervical spondylosis without myelopathy,Depressive disorder, not elsewhere classified,Other and unspecified hyperlipidemia,Personal history of malignant neoplasm of breast,Osteoporosis, unspecified,Family history of malignant neoplasm of breast,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Acquired absence of breast and nipple,Personal history of irradiation, presenting hazards to health,Personal history of antineoplastic chemotherapy,Long-term (current) use of other medications'}
