CHIEF COMPLAINT: Dyspnea on Exertion

PRESENT ILLNESS: 57 year old female with a history of dilated cardiomyopathy s/p
ICD implant in [**2125**], aortic insufficiency as well as chronic
kidney disease. She also has a
history of sickle cell anemia with her last crisis occurring in
[**2127-6-29**]. She has undergone yearly echocardiograms for
evaluation and follow up of her aortic insufficiency for the
past four years. Her most recent echo shows severe AI with
depressed EF. Presently, she reports she continues to feel mild
exertional dyspnea as well as occasional lightheadedness and
chest discomfort. Cardiac surgery consulted for surgical
correction.

MEDICAL HISTORY: Sickle cell anemia (last crisis in [**3-/2124**])
Nonischemic cardiomyopathy, diagnosed [**2121**]. ? Related to
recurrent sickle cell crises
AI, MR
Hypothyroidism
Renal insufficiency
s/p appendectomy
s/p oophorectomy

MEDICATION ON ADMISSION: CARVEDILOL PHOSPHATE XL 40 mg daily, DIPHENHYDRAMINE HCL 25
mgPRN, EPOETIN ALFA 20,000 unit/mL weekly, FUROSEMIDE 20 mg PRN,
LEVOTHYROXINE 75 mcg daily, LISINOPRIL 20 mg daily, MEPERIDINE
50 mg Q4 hours PRN, SPIRONOLACTONE 25 mg daily, CYANOCOBALAMIN
500 mcg daily, FOLIC ACID 0.4 mg daily, VITAMIN E 200 unit daily

ALLERGIES: Percocet

PHYSICAL EXAM: Physical Exam

FAMILY HISTORY: Patient endorses a positive family history of coronary artery
disease, mother with CAD at 68. Grandparents both with MI,
unknown age.

SOCIAL HISTORY: Social history is significant for the absence of current tobacco
use. She quit smoking in [**2120**], smoked for 30yrs prior. There is
no history of alcohol abuse. She lives with her husband in [**Name (NI) **].
They have 3 children.
Sickle-cell disease, unspecified,Thrombocytopenia, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Unspecified acquired hypothyroidism,Aortic valve disorders,Other primary cardiomyopathies,Atrioventricular block, complete,Automatic implantable cardiac defibrillator in situ
Sickle cell disease NOS,Thrombocytopenia NOS,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Hypothyroidism NOS,Aortic valve disorder,Prim cardiomyopathy NEC,Atriovent block complete,Status autm crd dfbrltr
Admission Date:  [**2128-2-4**]              Discharge Date:   [**2128-2-10**]

Date of Birth:  [**2070-12-6**]             Sex:   F

Service: CARDIOTHORACIC

Allergies:
Percocet

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

Major Surgical or Invasive Procedure:
PROCEDURES:
1. Aortic valve replacement with a 27-mm [**Company 1543**] Mosaic
    Ultra aortic valve bioprosthesis.
2. Reconstruction of the pericardium using CorMatrix
    xenograft.

[**2128-2-9**]:PPM placed for Complete heart block, [**Company 1543**]: DDD:[**Hospital1 **]-V
dual chamber PPM


History of Present Illness:
57 year old female with a history of dilated cardiomyopathy s/p
ICD implant in [**2125**], aortic insufficiency as well as chronic
kidney disease. She also has a
history of sickle cell anemia with her last crisis occurring in
[**2127-6-29**]. She has undergone yearly echocardiograms for
evaluation and follow up of her aortic insufficiency for the
past four years. Her most recent echo shows severe AI with
depressed EF. Presently, she reports she continues to feel mild
exertional dyspnea as well as occasional lightheadedness and
chest discomfort. Cardiac surgery consulted for surgical
correction.

Past Medical History:
Sickle cell anemia (last crisis in [**3-/2124**])
Nonischemic cardiomyopathy, diagnosed [**2121**]. ? Related to
recurrent sickle cell crises
AI, MR
Hypothyroidism
Renal insufficiency
s/p appendectomy
s/p oophorectomy


Social History:
Social history is significant for the absence of current tobacco
use. She quit smoking in [**2120**], smoked for 30yrs prior. There is
no history of alcohol abuse. She lives with her husband in [**Name (NI) **].
They have 3 children.


Family History:
Patient endorses a positive family history of coronary artery
disease, mother with CAD at 68. Grandparents both with MI,
unknown age.

Physical Exam:
Physical Exam

Pulse: 80 Resp: 16  O2 sat: 100%
B/P  Right:140/60
Height: 5'2.5"     Weight: 115 lbs

General: No acute distress, appears stated age
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck:  Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur [**1-4**] diastolic murmur
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] Edema - none
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral      Right: 2+  Left: 2+
DP           Right: 1+  Left: 1+
PT           [**Name (NI) 167**]: NP  Left: NP
Radial       Right: 2+  Left: 2+

Carotid Bruit    Right: -   Left: -


Pertinent Results:
[**2128-2-9**] 06:29AM BLOOD WBC-14.9* RBC-3.06* Hgb-9.1* Hct-26.7*
MCV-87 MCH-29.9 MCHC-34.3 RDW-15.8* Plt Ct-95*
[**2128-2-4**] 08:30AM BLOOD WBC-7.0 RBC-2.55*# Hgb-8.5* Hct-22.6*#
MCV-89 MCH-33.2* MCHC-37.5*# RDW-16.5* Plt Ct-69*
[**2128-2-7**] 03:16AM BLOOD PT-13.9* PTT-32.9 INR(PT)-1.2*
[**2128-2-4**] 01:50PM BLOOD PT-16.9* PTT-45.7* INR(PT)-1.5*
[**2128-2-9**] 06:29AM BLOOD Glucose-88 UreaN-26* Creat-1.2* Na-134
K-4.3 Cl-99 HCO3-27 AnGap-12
[**2128-2-4**] 03:25PM BLOOD UreaN-18 Creat-1.0 Na-138 K-4.7 Cl-108
HCO3-24 AnGap-11



[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT

[**Known lastname 41467**], [**Known firstname 41468**]       [**Hospital1 18**] [**Numeric Identifier 41469**] (Complete)
Done [**2128-2-4**] at 3:30:32 PM      FINAL
Referring Physician     [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**]  Status: Inpatient DOB: [**2070-12-6**]
Age (years): 57 F  Hgt (in):
BP (mm Hg): /  Wgt (lb):
HR (bpm):  BSA (m2):
Indication: Intraoperative TEE for AVR
ICD-9 Codes: 424.1, 424.2
Test Information
Date/Time: [**2128-2-4**] at 15:30    Interpret MD: [**First Name8 (NamePattern2) **] [**Name8 (MD) 17792**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 17792**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2011AW1-: Machine:
Echocardiographic Measurements
Results  Measurements  Normal Range
Right Atrium - Four Chamber Length:  *5.7 cm  <= 5.0 cm
Left Ventricle - Septal Wall Thickness:  *1.3 cm  0.6 - 1.1 cm
Left Ventricle - Ejection Fraction:  20% to 25%  >= 55%
Aorta - Annulus:  2.2 cm  <= 3.0 cm
Aorta - Sinus Level:  3.1 cm  <= 3.6 cm
Aorta - Sinotubular Ridge:  2.8 cm  <= 3.0 cm
Aorta - Ascending:  3.3 cm  <= 3.4 cm
Aortic Valve - Peak Gradient:  16 mm Hg  < 20 mm Hg
Aortic Valve - Mean Gradient:  9 mm Hg
Aortic Valve - LVOT diam:  2.4 cm

Findings
LEFT ATRIUM: Mild LA enlargement. No thrombus in the LAA.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter
or pacing wire is seen in the RA and extending into the RV. No
ASD by 2D or color Doppler.

LEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV
cavity. Severely depressed LVEF.

RIGHT VENTRICLE: Normal RV chamber size. Borderline normal RV
systolic function.

AORTA: Normal ascending aorta diameter. Mildly dilated
descending aorta. Simple atheroma in descending aorta. No
thoracic aortic dissection.

AORTIC VALVE: Three aortic valve leaflets. Moderately thickened
aortic valve leaflets. Bioprosthetic aortic valve prosthesis
(AVR). AVR leaflets move normally. Moderate to severe (3+) AR.

MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.

TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate to
severe [3+] TR.

PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
No PR.

GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications. Results were personally reviewed with the MD
caring for the patient.
Conclusions
PRE-CPB:
The left atrium is mildly dilated. No thrombus is seen in the
left atrial appendage.

There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is moderately dilated. Overall left
ventricular systolic function is severely depressed (LVEF= 20
%). The inferior wall hypokinesis appears most notable.

Right ventricular chamber size is normal with borderline normal
free wall function.

The descending thoracic aorta is mildly dilated. There are
simple atheroma in the descending thoracic aorta. No thoracic
aortic dissection is seen.

There are three aortic valve leaflets. The aortic valve leaflets
are moderately thickened, particularly at the tips. They do not
fully coapt. There is a central jet of moderate AI.

The mitral valve leaflets are structurally normal. Mild (1+)
mitral regurgitation is seen.

A moderate to severe [3+] eccentric jet of tricuspid
regurgitation is seen.

POST-CPB:
A porcine bioprosthetic aortic valve is present. The valve
appears to be well-seated. The aortic valve prosthesis leaflets
appear to move normally. There is no AI and no visible
paravalvular leak. The peak gradient across the prosthetic
aortic valve is 16mmHg, the mean gradient is 9mmHg.

The LV systolic function continues to be severely impaired with
the inferior wall appearing to be the most hypokinetic.
Estimated LV EF is 25%. (The patient is on a low dose
epinephrine infusion.)

RV systolic function appears improved. There is now severe TR,
with a similar eccentric direction as pre-bypass. This appears
to be due to failure of coaptation due to presence of pacing
wire and [**MD Number(3) 41470**].

There is no evidence of aortic dissection.

Dr.[**Last Name (STitle) 914**] was notified in person of the results at time of
study.
  I certify that I was present for this procedure in compliance
with HCFA regulations.

Electronically signed by [**First Name8 (NamePattern2) **] [**Name8 (MD) 17792**], MD, Interpreting physician [**Last Name (NamePattern4) **]
[**2128-2-4**] 16:55


?????? [**2119**] CareGroup IS. All rights reserved.


Brief Hospital Course:
The patient was brought to the operating room on [**2-4**] where she
underwent Aortic valve replacement with a 27-mm [**Company 1543**] Mosaic
Ultra aortic valve bioprosthesis and  Reconstruction of the
pericardium using CorMatrix xenograft with Dr.[**Last Name (STitle) 914**]. Please
refer to operative report for further surgical details. 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.
Postoperatively she did experience complete heart block. An
Electrophysiology consult was obtained. Mrs.[**Known lastname **] has a history
of dilated cardiomyopathy s/p ICD implant in [**2125**], with a
single chamber ICD implanted and programmed at VVI 40 for backup
rate. Temporary  Epicardial wires remained in place until
further EP eval of possible need for PPM.
She continued to progress and was transferred to the step down
unit for further recovery. The patient was evaluated by the
physical therapy service for assistance with strength and
mobility. Ep continued to follow and it was determined due to
persistant heart block, on [**2128-2-9**] Mrs.[**Known lastname **] underwent PPM
placement with the Electrophysiology team. Per EP's
recommendations, prophylaxis antibiotics were intiated post
placement. By the time of discharge on POD #6 the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. PPM interrogation was performed. She was
cleared by Dr.[**Last Name (STitle) 914**] for discharge to home with VNA on POD#6 in
good condition with appropriate follow up instructions advised.

Medications on Admission:
CARVEDILOL PHOSPHATE XL 40 mg daily, DIPHENHYDRAMINE HCL 25
mgPRN, EPOETIN ALFA 20,000 unit/mL weekly, FUROSEMIDE 20 mg PRN,
LEVOTHYROXINE 75 mcg daily, LISINOPRIL 20 mg daily, MEPERIDINE
50 mg Q4 hours PRN, SPIRONOLACTONE 25 mg daily, CYANOCOBALAMIN
500 mcg daily, FOLIC ACID 0.4 mg daily, VITAMIN E 200 unit daily


Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. meperidine 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
4. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO once a day for 5 days.
Disp:*5 Tablet Extended Release(s)* Refills:*0*
5. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5
days.
Disp:*5 Tablet(s)* Refills:*0*
6. Procrit 20,000 unit/mL Solution Sig: One (1)  Injection QOW.

7. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
10. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 7 days.
Disp:*21 Capsule(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 8300**] VNA and Hospice

Discharge Diagnosis:
PREOPERATIVE DIAGNOSES:
1. Aortic insufficiency.
2. Poor left ventricular function.
3. Sickle cell anemia.
4. Thrombocytopenia.
5. Complete Heart Block post AVR placement


Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage


Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.

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) 914**]:# [**Telephone/Fax (1) 170**]: [**2128-3-2**] at 1:45pm
-Cardiologist: Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] on [**2128-3-1**] at 3pm
-Provider DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2128-2-17**]
1:00
-Provider DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2128-2-24**]
1:30
-Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2128-2-24**] 2:00

Please call to schedule the following:
Primary Care Dr. [**Name (NI) **] [**Name (NI) 41471**]  in [**3-2**] 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:[**2128-2-10**]
{'Sickle-cell disease, unspecified,Thrombocytopenia, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Unspecified acquired hypothyroidism,Aortic valve disorders,Other primary cardiomyopathies,Atrioventricular block, complete,Automatic implantable cardiac defibrillator in situ'}


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: Dyspnea on Exertion

PRESENT ILLNESS: 57 year old female with a history of dilated cardiomyopathy s/p
ICD implant in [**2125**], aortic insufficiency as well as chronic
kidney disease. She also has a
history of sickle cell anemia with her last crisis occurring in
[**2127-6-29**]. She has undergone yearly echocardiograms for
evaluation and follow up of her aortic insufficiency for the
past four years. Her most recent echo shows severe AI with
depressed EF. Presently, she reports she continues to feel mild
exertional dyspnea as well as occasional lightheadedness and
chest discomfort. Cardiac surgery consulted for surgical
correction.

MEDICAL HISTORY: Sickle cell anemia (last crisis in [**3-/2124**])
Nonischemic cardiomyopathy, diagnosed [**2121**]. ? Related to
recurrent sickle cell crises
AI, MR
Hypothyroidism
Renal insufficiency
s/p appendectomy
s/p oophorectomy

MEDICATION ON ADMISSION: CARVEDILOL PHOSPHATE XL 40 mg daily, DIPHENHYDRAMINE HCL 25
mgPRN, EPOETIN ALFA 20,000 unit/mL weekly, FUROSEMIDE 20 mg PRN,
LEVOTHYROXINE 75 mcg daily, LISINOPRIL 20 mg daily, MEPERIDINE
50 mg Q4 hours PRN, SPIRONOLACTONE 25 mg daily, CYANOCOBALAMIN
500 mcg daily, FOLIC ACID 0.4 mg daily, VITAMIN E 200 unit daily

ALLERGIES: Percocet

PHYSICAL EXAM: Physical Exam

FAMILY HISTORY: Patient endorses a positive family history of coronary artery
disease, mother with CAD at 68. Grandparents both with MI,
unknown age.

SOCIAL HISTORY: Social history is significant for the absence of current tobacco
use. She quit smoking in [**2120**], smoked for 30yrs prior. There is
no history of alcohol abuse. She lives with her husband in [**Name (NI) **].
They have 3 children. 

### Response:
{'Sickle-cell disease, unspecified,Thrombocytopenia, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Unspecified acquired hypothyroidism,Aortic valve disorders,Other primary cardiomyopathies,Atrioventricular block, complete,Automatic implantable cardiac defibrillator in situ'}
