CHIEF COMPLAINT: Chest discomfort

PRESENT ILLNESS: [**Age over 90 **] year old female complaining of chest discomfort with
long-standing history of aortic stenosis followed by serial
echo's. Most recent echo showed severe aortic stenosis along
with mitral and tricuspid valve disease.

MEDICAL HISTORY: Aortic Stenosis
Mitral and tricupsid regurgitation
Hypertension
Glaucoma
Left breat cancer status post Mastectomy [**2101**]
Macular degeneration
Gastroesophageal reflux disease
Colon polyps
Surgery: Bilateral vein stripping, Tonsillectomy, Total hip
replacement, Appendectomy, Pacemaker implanted [**2144**] for
bradycardia

MEDICATION ON ADMISSION: Metoprolol 25mg [**Hospital1 **], Xalatan eye drops, Omeprazole, Lasix 20mg
daily, Irbesartan 150mg daily, Raloxifene 60mg daily, Aspirin
81mg daily, Vitamin D3, Multivitamin, Azopt eye drops

ALLERGIES: Penicillins / Ace Inhibitors

PHYSICAL EXAM: Vitals: 76 178/80 57" 54kg
General: Frail elderly female in no acute distress
Skin: Unremarkable
HEENT: Unremarkable
Neck: Supple, full range of motion
Chest: Clear to auscultation bilaterally. well healed pacemaker
and mastectomy scars
Heart: Regular rate and rhythm with 4/6 holosystolic murmur
Abd: Soft, non-tender, non-distended, +bowel sounds
Ext: Warm, well-perfused, -edema
Neuro: Grossly intact, non-focal

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Denies history of smoking. Denies alcohol use. Lives alone.
Multiple involvement of mitral and aortic valves,Acute on chronic diastolic heart failure,Atrioventricular block, complete,Intermediate coronary syndrome,Diseases of tricuspid valve,Coronary atherosclerosis of native coronary artery,Occlusion and stenosis of multiple and bilateral precerebral arteries without mention of cerebral infarction,Other chronic pulmonary heart diseases,Cardiac pacemaker in situ,Esophageal reflux,Macular degeneration (senile), unspecified,Personal history of malignant neoplasm of breast,Unspecified essential hypertension
Mitr/aortic mult involv,Ac on chr diast hrt fail,Atriovent block complete,Intermed coronary synd,Tricuspid valve disease,Crnry athrscl natve vssl,Ocl mlt bi art wo infrct,Chr pulmon heart dis NEC,Status cardiac pacemaker,Esophageal reflux,Macular degeneration NOS,Hx of breast malignancy,Hypertension NOS
Admission Date:  [**2145-5-18**]              Discharge Date:   [**2145-5-26**]


Service: CARDIOTHORACIC

Allergies:
Penicillins / Ace Inhibitors

Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest discomfort

Major Surgical or Invasive Procedure:
[**2145-5-20**] Aortic Valve Replacement (25 [**Company **] mosaic porcine)
[**2145-5-18**] Cardiac Catheterization


History of Present Illness:
[**Age over 90 **] year old female complaining of chest discomfort with
long-standing history of aortic stenosis followed by serial
echo's. Most recent echo showed severe aortic stenosis along
with mitral and tricuspid valve disease.

Past Medical History:
Aortic Stenosis
Mitral and tricupsid regurgitation
Hypertension
Glaucoma
Left breat cancer status post Mastectomy [**2101**]
Macular degeneration
Gastroesophageal reflux disease
Colon polyps
Surgery: Bilateral vein stripping, Tonsillectomy, Total hip
replacement, Appendectomy, Pacemaker implanted [**2144**] for
bradycardia

Social History:
Denies history of smoking. Denies alcohol use. Lives alone.

Family History:
non-contributory

Physical Exam:
Vitals: 76 178/80 57" 54kg
General: Frail elderly female in no acute distress
Skin: Unremarkable
HEENT: Unremarkable
Neck: Supple, full range of motion
Chest: Clear to auscultation bilaterally. well healed pacemaker
and mastectomy scars
Heart: Regular rate and rhythm with 4/6 holosystolic murmur
Abd: Soft, non-tender, non-distended, +bowel sounds
Ext: Warm, well-perfused, -edema
Neuro: Grossly intact, non-focal

Pertinent Results:
[**5-18**] Cath: 1.  Selective coronary angiography of this right
dominant system demonstrated moderate single vessel coronary
artery disease.  The LMCA had a 20% stenosis at the origin.  The
LAD was a tortuous vessel with slow flow consistent with
microvascular dysfunction.  The was plaquing in the proximal to
mid vessel up to 40%.  The D1-D4 were small in caliber. The LCX
had a high OM1 (functionally a ramus) with proximal 30%
plaquing, a patent high OM2.  The remainder of the LCX system
was absent.  The RCA was heavily calcified with a proximal 30%
stenosis. There was a modest RPDA with a stenosis at the origin
of 50%.  There were modest caliber RPL1 and RPL 2 with tortuous
terminal branches. There was slow flow consistent with
microvascular dysfunction. 2.  Resting hemodynamics revealed
elevated right and left ventricular filling pressures at 14 and
22 mmHg, respectively.  The mean PCWP was 21 mmHg.  The mean PA
pressure was 27 mmHg (phasic 50/20 mmHg).  The cardiac index was
mildly depressed at 2 L/min/m2. There was severe systemic
arterial hypertension with a mean pressure of 138 mmHg (phasic
200/98 mmHg).  There was sever aortic stenosis with a mean
gradient of 42 mmHg and a calculated aortic valve area of 0.5
cm2 (based on a measured VO2 and no known aortic insufficiency).
3.  Left ventriculography showed a mildly depressed EF of 51%.
There was anterolateral and apical hypokinesis. 4.
Hemodynamics: moderate pulmonary hypertension; severe systemic
systolic arterial hypertension; low cardiac output with severe
aortic stenosis by gradient and [**Location (un) 109**]; dobutamine not
administrated given severe systemic systolic arterial
hypertension.  Beat-to-beat variation in "PCW" tracing, many
without any end-diastolic gradient, but other beats with PA
morphology early; unable to confirm good PCW position by
oxymetry. 25-30 mmHg pulsus paradoxus. BP Rx metoprolol IV and
analgesics.
[**5-19**] Carotid U/S: Right ICA stenosis <40% Left ICA stenosis
<40%.
[**5-20**] Echo: PRE-BYPASS: The left atrium is normal in size. No
mass/thrombus is seen in the left atrium or left atrial
appendage. No atrial septal defect or patent foramen ovale is
seen by 2D, color Doppler or saline contrast with maneuvers.
There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. There
are simple atheroma in the aortic root. There are simple
atheroma in the ascending aorta. There are simple atheroma in
the descending thoracic aorta. There are three aortic valve
leaflets. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (area
<0.8cm2). No aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. Mild to moderate ([**2-5**]+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. The tricuspid regurgitation jet is
eccentric and may be underestimated. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion. POST-BYPASS: For the post-bypass study,
the patient was receiving phenylephrine infusion. A well-seated
bioprosthetic valve is seen in the aortic position. Peak
gradient = 18 mmHg. No aortic regurgitation is seen. Regional
and global left ventricular systolic function are normal. No
aortic dissection.

              WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2145-5-26**] PND PND PND PND PND PND PND   PND
[**2145-5-25**]                  29.3*
[**2145-5-25**] 11.3* 2.98* 9.3* 28.0* 94 31.2 33.3 14.7 496*#
[**2145-5-23**] 15.0* 3.17* 9.6* 29.1* 92 30.3 32.9 14.8 318
[**2145-5-22**] 17.5* 3.32* 10.4* 30.8* 93 31.2 33.7 15.1 295

            Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2145-5-26**] PND PND PND PND PND PND PND
[**2145-5-25**]      21* 1.1   4.4
[**2145-5-25**] 100 24* 1.1 135 4.1 99 30 10
[**2145-5-23**] 87 21* 1.1 135 4.3 98 28 13


Brief Hospital Course:
Mrs. [**Known lastname **] was admitted on [**2145-5-18**] following her cardiac
catheterization. In addition to her cardiac cath she underwent
echocardiogram, carotid ultrasound and usual pre-operative
work-up - please see result section for details. On [**2145-5-20**] she
was brought to the operating room where she underwent an aortic
valve replacement. Given that she was an inpatient for more than
24 hours prior to surgery, Vancomycin was given for
perioperative antibiotic coverage. Please see operative report
for surgical details. Following surgery she transferred to the
CVICU for invasive monitoring in stable condition. She was
weaned from sedation, awoke neurologically intact and extubated
on postoperative day two without incident. Later on this day she
appeared to be doing well and was transferred to the telemetry
floor for further care. Chest tubes and epicardial pacing wires
were removed per protocol and without complication. Over the
next several days she continued clinical improvements with
diuresis. She tolerated beta blockade and maintained stable
hemodynamics. She was medically cleared for discharge to rehab
facility on post-op day six. At discharge, her BP was
108-138/60-70 with HR 64(v-paced)) and room air oxygen
saturations of 95%. All surgical incisions appeared clean, dry
and intact. At discharge, she remained fluid overloaded and will
continue to require diuresis. Diuretics should be titrated
accordingly, with an ideal weight of approximately 52kg.

Medications on Admission:
Metoprolol 25mg [**Hospital1 **], Xalatan eye drops, Omeprazole, Lasix 20mg
daily, Irbesartan 150mg daily, Raloxifene 60mg daily, Aspirin
81mg daily, Vitamin D3, Multivitamin, Azopt eye drops

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. Dorzolamide 2 % Drops Sig: Two (2) Drop Ophthalmic [**Hospital1 **] (2
times a day).
4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 6-8 hours as needed for pain.
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day:
titrate according to weight/fluid status - ideal weight
approximately 52 kg - should remain on low dose Lasix at
discharge from rehab.
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.


Discharge Disposition:
Extended Care

Facility:
Aberjona Nursing Center - [**Hospital1 2436**]

Discharge Diagnosis:
Aortic Stenosis
Mild coronary artery disease
Mitral and tricupsid regurgitation
Hypertension
Glaucoma
Left breat cancer status post Mastectomy [**2101**]
Macular degeneration
Gastroesophageal reflux disease
Colon polyps
Surgery: Bilateral vein stripping, Tonsillectomy, Total hip
replacement, Appendectomy, Pacemaker implanted [**2144**] for
bradycardia

Discharge Condition:
Fair

Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]

Followup Instructions:
please call and sechedule the following appointments
Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
PCP ([**Last Name (un) 80939**]) in [**3-9**] weeks
Cardiologist ([**Doctor Last Name 1549**]) in [**2-5**] weeks

                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]

Completed by:[**2145-5-26**]

Admission Date:  [**2145-5-27**]              Discharge Date:   [**2145-5-27**]


Service: CARDIOTHORACIC

Allergies:
Penicillins / Ace Inhibitors

Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Twitching in abdomen

Major Surgical or Invasive Procedure:
None


History of Present Illness:
[**Age over 90 **] year old female who underwent an aortic valve replacement on
[**2145-5-20**] who did well postoperatively and was discharged to
rehabilitation on [**2145-5-26**]. Whiule at rehab, she developed a
single episode of abdominal "twitching". As there was a concern
for a pacemaker malfunction, she was returned to the [**Hospital1 18**] for
further evaluation.

Past Medical History:
Aortic Stenosis
Mitral and tricupsid regurgitation
Hypertension
Glaucoma
Left breat cancer status post Mastectomy [**2101**]
Macular degeneration
Gastroesophageal reflux disease
Colon polyps
Surgery: Bilateral vein stripping, Tonsillectomy, Total hip
replacement, Appendectomy, Pacemaker implanted [**2144**] for
bradycardia

Social History:
Denies history of smoking. Denies alcohol use. Lives alone.


Family History:
non-contributory

Physical Exam:
Vitals: 76 178/80 57" 54kg
General: Frail elderly female in no acute distress
Skin: Sternal incision clean/dry and intact
HEENT: Unremarkable
Neck: Supple, full range of motion
Chest: Clear to auscultation bilaterally. well healed pacemaker
and mastectomy scars
Heart: Regular rate and rhythm without murmur
Abd: Soft, non-tender, non-distended, +bowel sounds
Ext: Warm, well-perfused, trace edema
Neuro: Grossly intact, non-focal



Pertinent Results:
[**2145-5-26**] 10:35AM   WBC-14.8* RBC-3.53* HGB-10.9* HCT-33.8*
MCV-96 MCH-30.9 MCHC-32.3 RDW-14.6
[**2145-5-26**] 10:35PM   PT-14.5* PTT-28.0 INR(PT)-1.3*
[**2145-5-26**] 10:35PM   GLUCOSE-116* UREA N-20 CREAT-1.1 SODIUM-134
POTASSIUM-4.1 CHLORIDE-95* TOTAL CO2-29 ANION GAP-14
[**2145-5-26**] 10:35AM   PLT COUNT-762*#

Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2145-5-26**] for further
management of her pacemaker. The Electrophysiology service was
consulted. An interrogation was performed which showed no clear
indication of diaphragmatic stimulation. She was stable being
ventricular paced. Changes were made to the settings without
issue. A chest x-ray was obtained which likely showed that the
atrial lead was dislodged. As this had been a chronic and known
issue, no further intervention was recommended. She was thus
discharged back to rehabilitation on [**2145-5-27**].

Medications on Admission:
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. Dorzolamide 2 % Drops Sig: Two (2) Drop Ophthalmic [**Hospital1 **] (2
times a day).
4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at

bedtime).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 6-8 hours as needed for pain.
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every

4 hours) as needed.
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day:
titrate according to weight/fluid status - ideal weight
approximately 52 kg - should remain on low dose Lasix at
discharge from rehab.
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.


Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed.
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Extended Care

Facility:
Aberjona Nursing Center - [**Hospital1 2436**]

Discharge Diagnosis:
Aortic Stenosis staus post Aortic Valve Replacement
Mitral and tricupsid regurgitation
Hypertension
Glaucoma
Left breat cancer status post Mastectomy [**2101**]
Macular degeneration
Gastroesophageal reflux disease
Colon polyps
?diapragmatic stimulation from pacer
Surgery: Bilateral vein stripping, Tonsillectomy, Total hip
replacement, Appendectomy, Pacemaker implanted [**2144**] for
bradycardia


Discharge Condition:
Good


Discharge Instructions:
1)  Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2)  Report any fever greater then 100.5.
3)  Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4)  No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry.  Please shower daily.  No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks from date of
surgery.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.

Followup Instructions:
Please call and sechedule the following appointments
Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
PCP ([**Last Name (un) 80939**]) in [**3-9**] weeks
Cardiologist ([**Doctor Last Name 1549**]) in [**2-5**] weeks [**Telephone/Fax (1) 80940**]


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]

Completed by:[**2145-5-27**]
{'Multiple involvement of mitral and aortic valves,Acute on chronic diastolic heart failure,Atrioventricular block, complete,Intermediate coronary syndrome,Diseases of tricuspid valve,Coronary atherosclerosis of native coronary artery,Occlusion and stenosis of multiple and bilateral precerebral arteries without mention of cerebral infarction,Other chronic pulmonary heart diseases,Cardiac pacemaker in situ,Esophageal reflux,Macular degeneration (senile), unspecified,Personal history of malignant neoplasm of breast,Unspecified essential hypertension'}


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: Chest discomfort

PRESENT ILLNESS: [**Age over 90 **] year old female complaining of chest discomfort with
long-standing history of aortic stenosis followed by serial
echo's. Most recent echo showed severe aortic stenosis along
with mitral and tricuspid valve disease.

MEDICAL HISTORY: Aortic Stenosis
Mitral and tricupsid regurgitation
Hypertension
Glaucoma
Left breat cancer status post Mastectomy [**2101**]
Macular degeneration
Gastroesophageal reflux disease
Colon polyps
Surgery: Bilateral vein stripping, Tonsillectomy, Total hip
replacement, Appendectomy, Pacemaker implanted [**2144**] for
bradycardia

MEDICATION ON ADMISSION: Metoprolol 25mg [**Hospital1 **], Xalatan eye drops, Omeprazole, Lasix 20mg
daily, Irbesartan 150mg daily, Raloxifene 60mg daily, Aspirin
81mg daily, Vitamin D3, Multivitamin, Azopt eye drops

ALLERGIES: Penicillins / Ace Inhibitors

PHYSICAL EXAM: Vitals: 76 178/80 57" 54kg
General: Frail elderly female in no acute distress
Skin: Unremarkable
HEENT: Unremarkable
Neck: Supple, full range of motion
Chest: Clear to auscultation bilaterally. well healed pacemaker
and mastectomy scars
Heart: Regular rate and rhythm with 4/6 holosystolic murmur
Abd: Soft, non-tender, non-distended, +bowel sounds
Ext: Warm, well-perfused, -edema
Neuro: Grossly intact, non-focal

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Denies history of smoking. Denies alcohol use. Lives alone. 

### Response:
{'Multiple involvement of mitral and aortic valves,Acute on chronic diastolic heart failure,Atrioventricular block, complete,Intermediate coronary syndrome,Diseases of tricuspid valve,Coronary atherosclerosis of native coronary artery,Occlusion and stenosis of multiple and bilateral precerebral arteries without mention of cerebral infarction,Other chronic pulmonary heart diseases,Cardiac pacemaker in situ,Esophageal reflux,Macular degeneration (senile), unspecified,Personal history of malignant neoplasm of breast,Unspecified essential hypertension'}
