CHIEF COMPLAINT: Atrial fibrillation and congestive heart
failure.

PRESENT ILLNESS: A 47-year-old woman with a
possible history of rheumatic heart disease as a child, and
an atrial septal defect repair in [**2133**], had a history of
palpitations and was diagnosed with atrial fibrillation.  In
[**2156-10-14**], she underwent transesophageal
echocardiogram cardioversion and was started on sotalol.  In
[**2156-11-13**], she was admitted to an outside hospital
with congestive heart failure, and the sotalol was
discontinued at that time.  The patient underwent cardiac
catheterization which showed no significant coronary artery
disease.  An echocardiogram showed a normal ejection fraction
with severe mitral regurgitation, moderate left atrial
dilatation, and mild-to-moderate tricuspid regurgitation.
She was started on Lasix, a beta blocker, and a calcium
channel blocker at that time.  She was also seen by
Dr. [**Last Name (STitle) **] from the Cardiology Service who suggested that
she should undergo a mitral valve replacement.

MEDICAL HISTORY: (The patient's past medical history is
significant for)
1.  Atrial septal defect repair in [**2133**].
2.  Atrial fibrillation times four to five years, status post
transesophageal echocardiogram cardioversion.
3.  Congestive heart failure.

MEDICATION ON ADMISSION: Medications prior to admission
included verapamil 240 mg p.o. q.d., Lasix 40 mg p.o. b.i.d.,
metoprolol 50 mg p.o. b.i.d., Coumadin 5 mg p.o. q.d. (which
was discontinued on [**2-5**], two days prior to
admission).

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: Mother died at 32 of MPS.

SOCIAL HISTORY: She is married with adult children.  Rare
alcohol use.  Smokes two to three cigarettes per day for
tobacco use.
Rheumatic mitral insufficiency,Diseases of tricuspid valve,Cardiac complications, not elsewhere classified,Atrioventricular block, complete,Urinary tract infection, site not specified,Atrial fibrillation,Other specified disease of white blood cells,Acquired hemolytic anemia, unspecified
Rheumatic mitral insuff,Tricuspid valve disease,Surg compl-heart,Atriovent block complete,Urin tract infection NOS,Atrial fibrillation,Wbc disease NEC,Acq hemolytic anemia NOS
Admission Date:  [**2157-2-7**]       Discharge Date:  [**2157-3-1**]

Date of Birth:   [**2109-3-22**]       Sex:  F

Service:  Cardothoracic Service

CHIEF COMPLAINT:  Atrial fibrillation and congestive heart
failure.

HISTORY OF PRESENT ILLNESS:  A 47-year-old woman with a
possible history of rheumatic heart disease as a child, and
an atrial septal defect repair in [**2133**], had a history of
palpitations and was diagnosed with atrial fibrillation.  In
[**2156-10-14**], she underwent transesophageal
echocardiogram cardioversion and was started on sotalol.  In
[**2156-11-13**], she was admitted to an outside hospital
with congestive heart failure, and the sotalol was
discontinued at that time.  The patient underwent cardiac
catheterization which showed no significant coronary artery
disease.  An echocardiogram showed a normal ejection fraction
with severe mitral regurgitation, moderate left atrial
dilatation, and mild-to-moderate tricuspid regurgitation.
She was started on Lasix, a beta blocker, and a calcium
channel blocker at that time.  She was also seen by
Dr. [**Last Name (STitle) **] from the Cardiology Service who suggested that
she should undergo a mitral valve replacement.

The patient was admitted preoperatively to discontinue her
Coumadin, to be started on heparin, and an amiodarone load.
In addition, to a mitral valve replacement she has a possible
tricuspid valve replacement as well as a Maze procedure and
plus or minus tieing off of a left atrial appendage.

PAST MEDICAL HISTORY:  (The patient's past medical history is
significant for)
1.  Atrial septal defect repair in [**2133**].
2.  Atrial fibrillation times four to five years, status post
transesophageal echocardiogram cardioversion.
3.  Congestive heart failure.

SOCIAL HISTORY:  She is married with adult children.  Rare
alcohol use.  Smokes two to three cigarettes per day for
tobacco use.

FAMILY HISTORY:  Mother died at 32 of MPS.

MEDICATIONS ON ADMISSION:  Medications prior to admission
included verapamil 240 mg p.o. q.d., Lasix 40 mg p.o. b.i.d.,
metoprolol 50 mg p.o. b.i.d., Coumadin 5 mg p.o. q.d. (which
was discontinued on [**2-5**], two days prior to
admission).

PHYSICAL EXAMINATION ON PRESENTATION:   Examination at the
time of admission revealed vital signs with temperature
of 98.1, blood pressure of 103/67, heart rate of 70,
respiratory rate of 18, oxygen saturation of 99% on room air.
In general, alert and oriented, pleasant, well-appearing.
Head, eyes, ears, nose, and throat revealed pupils were
equally round and reactive to light.  Extraocular movements
were intact.  Mucous membranes were moist.  Neck revealed no
jugular venous distention, no lymphadenopathy, supple.
Cardiovascular examination revealed irregularly irregular, a
[**1-19**] holosystolic murmur heard best at the apex.  Lungs were
clear to auscultation bilaterally.  The abdomen was soft,
nontender, and nondistended, with positive bowel sounds.
Extremities were warm with no edema.

RADIOLOGY/IMAGING:  Echocardiogram from [**1-11**] showed a
normal ejection fraction with 4+ mitral regurgitation, mild
left atrial dilatation, dilated right ventricle, hypokinetic
right ventricular systolic dysfunction, 3+ tricuspid
regurgitation, mild pulmonary hypertension.  No atrial septal
defect.

Electrocardiogram at the time of admission showed atrial
fibrillation with a rate of 55, normal axis, T wave flipped
in III and F, T wave inversions in V1 through V3, and flipped
in V4 and V5.

PERTINENT LABORATORY DATA ON PRESENTATION:  Laboratory data
on admission revealed a sodium of 141, potassium of 3.6,
chloride of 102, bicarbonate of 30, blood urea nitrogen of
20, creatinine of 0.6, glucose of 110.  White blood cell
count of 9.4, hematocrit of 33.2, platelets of 377.  PT
of 13.3, PTT of 69.4, INR of 1.2.

HOSPITAL COURSE:  On [**2-10**], the patient was brought to
the operating room at which time she underwent a mitral valve
replacement and a tricuspid valve repair.  Please see the
Operative Note for full details.

In summary, she had a mitral valve replacement with #28 St.
[**Male First Name (un) 923**] and a tricuspid valve repair with a #30
.................... ring.  She tolerated the operation well
and was transferred from the operating room to the
Cardiothoracic Intensive Care Unit.

The patient did well in the immediate postoperative period.
Her anesthesia was reversed, and she was weaned from the
ventilator and successfully extubated.  During the night of
on postoperative day one, she was noted to be in first-degree
atrioventricular heart block until about 2 in the morning
when it was noted that she had a paced rhythm at 60.
Checking her underlying rhythm at that time showed only P
waves with no ventricular escape.

On the morning of postoperative one, in checking the
patient's underlying rhythm it was noted that she was in
complete heart block with a ventricular escape in the 30s.
She remained hemodynamically stable with a paced rhythm.
Because she had no underlying rhythm, she remained in the
Intensive Care Unit.

On the morning of postoperative two, the patient remained
hemodynamically stable, in complete heart block.  It was
noted that her hematocrit was 22, and her urine output was
somewhat diminished; and, therefore, she received 2 units of
packed red blood cells.

On postoperative day three, it was noted that the patient was
in atrial fibrillation with a ventricular response in the
80s.  She remained hemodynamically stable in that rhythm.
However, it was noted that her respiratory status had
diminished.  She was begun on Lasix, and an echocardiogram
was done to check her valvular function.  The echocardiogram
showed normal valvular function with no evidence of
pericardial effusion at that time.

Over the next two days, the patient remained hemodynamically
stable.  She continued to have difficulty with oxygenation,
continued to be vigorously diuresed.  Her hematocrit was
noted, on postoperative day five, to be 19.7.  She was
transfused with 2 additional units of packed red blood cells.
The Electrophysiology Service was contact[**Name (NI) **] to evaluate for
permanent pacemaker, and Hematology was consulted to evaluate
anemia without any obvious bleeding source.

The Electrophysiology Service wanted to wait until the
patient's respiratory and hematologic issues were resolved,
and the Hematology Service felt that her anemia was possibly
due to a delayed transfusion reaction.

Over the next several days, the patient remained in the
Cardiothoracic Intensive Care Unit as she continued to have
complete heart block while awaiting for evaluation for a
permanent pacemaker.

The patient was also noted to have a climb in a white blood
cell count.  On postoperative day eight, it had risen to
30,000.  This was felt to be due to her delayed transfusion
reaction; however, Infectious Disease was consulted.  There
was no obvious source of infection.  The patient was
pan-cultured at that time, but all cultures returned
negative.

On postoperative day 12, the patient lost capture from her
epicardial pacing wires, and on postoperative day 13 she was
brought to the Electrophysiology Laboratory where she
underwent permanent pacemaker implantation.  Please see
Operative Note for full details.

In summary, the patient had a dual-mode, dual-pacing,
dual-sensing pacemaker placed without complication.

Following pacemaker placement, she was transferred from the
catheterization laboratory for [**Hospital Ward Name 121**] Six for continuing
postoperative care and cardiac rehabilitation.  She was
restarted on her heparin and was also started on Coumadin at
that time.  The patient remained on the Cardiothoracic
Recovery Floor for the next several days while awaiting for
her INR to get into therapeutic range.  Over the course of
that time, she continued working with Physical Therapy and
with the nursing staff to increase her activity level.  She
had an uneventful recovery from her permanent pacemaker
implantation.

On postoperative day 18, it was felt that the patient was
stable and ready for discharge to home as soon as her INR was
therapeutic; at that time it was 1.9 with the cutoff being 2.
An additional INR will be checked on the afternoon on
postoperative day 18.  If, at that time, it comes back
greater than 2, she will be discharged to home on this day.
Otherwise, she will be discharged to home on postoperative
day 19.

PHYSICAL EXAMINATION AT THE TIME OF DISCHARGE:  Vital signs
revealed temperature of 97.9, heart rate of 83, blood
pressure of 104/62, respiratory rate of 18, oxygen saturation
of 95% on room air.  Weight preoperatively was 72.9 kg, at
discharge weight was 66.9 kg.  Physical examination revealed
alert and oriented times three, moved all extremities,
conversant.  Respiratory was clear to auscultation
bilaterally.  Heart sounds were regular in rate and rhythm.
First heart sound and second heart sound with a loud click.
The sternum was stable.  The incision with Steri-Strips, open
to air, clean and dry.  Left shoulder incision with
Steri-Strips, open to air, clean and dry.  The abdomen was
soft, nontender, and nondistended, normal active bowel
sounds.  Extremities were warm and well perfused with no
clubbing, cyanosis or edema.

LABORATORY DATA ON DISCHARGE:  White blood cell count
of 10.9, hematocrit of 28.3, platelets of 575.  Sodium
of 137, potassium of 4.6, chloride of 95, bicarbonate of 31,
blood urea nitrogen of 31, creatinine of 0.8, glucose of 78.
INR was pending.

MEDICATIONS ON DISCHARGE:  (Discharge medications include)
1.  Niferex 150 mg p.o. q.d.
2.  Folate 1 mg p.o. q.d.
3.  Lopressor 50 mg p.o. b.i.d.
4.  Amiodarone 400 mg p.o. t.i.d. times one then; and then
every day.
5.  Coumadin 5 mg p.o. q.d. (to keep INR between 2.5 and 3).
6.  Percocet 5/325 one to two tablets p.o. q.4h. p.r.n.

DISCHARGE STATUS:  The patient was to be discharged to home.

DI[**Last Name (STitle) 408**]E FOLLOWUP:  A follow-up appointment in the
Electrophysiology Clinic in one week.  To follow up with
Dr. [**Last Name (Prefixes) **] in one month. To follow up in the [**Hospital 409**]
Clinic in two weeks.




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

Dictated By:[**Name8 (MD) 415**]
MEDQUIST36

D:  [**2157-3-1**]  15:31
T:  [**2157-3-1**]  14:46
JOB#:  [**Job Number 37070**]
{'Rheumatic mitral insufficiency,Diseases of tricuspid valve,Cardiac complications, not elsewhere classified,Atrioventricular block, complete,Urinary tract infection, site not specified,Atrial fibrillation,Other specified disease of white blood cells,Acquired hemolytic anemia, unspecified'}


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: Atrial fibrillation and congestive heart
failure.

PRESENT ILLNESS: A 47-year-old woman with a
possible history of rheumatic heart disease as a child, and
an atrial septal defect repair in [**2133**], had a history of
palpitations and was diagnosed with atrial fibrillation.  In
[**2156-10-14**], she underwent transesophageal
echocardiogram cardioversion and was started on sotalol.  In
[**2156-11-13**], she was admitted to an outside hospital
with congestive heart failure, and the sotalol was
discontinued at that time.  The patient underwent cardiac
catheterization which showed no significant coronary artery
disease.  An echocardiogram showed a normal ejection fraction
with severe mitral regurgitation, moderate left atrial
dilatation, and mild-to-moderate tricuspid regurgitation.
She was started on Lasix, a beta blocker, and a calcium
channel blocker at that time.  She was also seen by
Dr. [**Last Name (STitle) **] from the Cardiology Service who suggested that
she should undergo a mitral valve replacement.

MEDICAL HISTORY: (The patient's past medical history is
significant for)
1.  Atrial septal defect repair in [**2133**].
2.  Atrial fibrillation times four to five years, status post
transesophageal echocardiogram cardioversion.
3.  Congestive heart failure.

MEDICATION ON ADMISSION: Medications prior to admission
included verapamil 240 mg p.o. q.d., Lasix 40 mg p.o. b.i.d.,
metoprolol 50 mg p.o. b.i.d., Coumadin 5 mg p.o. q.d. (which
was discontinued on [**2-5**], two days prior to
admission).

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: Mother died at 32 of MPS.

SOCIAL HISTORY: She is married with adult children.  Rare
alcohol use.  Smokes two to three cigarettes per day for
tobacco use. 

### Response:
{'Rheumatic mitral insufficiency,Diseases of tricuspid valve,Cardiac complications, not elsewhere classified,Atrioventricular block, complete,Urinary tract infection, site not specified,Atrial fibrillation,Other specified disease of white blood cells,Acquired hemolytic anemia, unspecified'}
