CHIEF COMPLAINT: DOE/CHF

PRESENT ILLNESS: The patient is an 80-year-old woman with diabetes and renal
failure who presented with recurrent congestive heart failure.
She was noted to have severe aortic stenosis. Catheterization
showed normal coronary arteries. It was elected to proceed with
aortic valve replacement with mechanical valve.

MEDICAL HISTORY: 1)History of GIB of unknown cause; numerous diverticula on
C-scope
2) L colectomy with transverse colostomy for GIB (D/C [**11-12**])
3) Diastolic CHF (EF 65-75%)
4) s/p trach placement after prolonged intubation in ICU (at
time
of colectomy)
5) Severe AS ([**Location (un) 109**] 0.7cm2, pk gradient 91mmHg, mean gradient
55mmHg
on [**6-13**] TTE
6) HTN
7) Elevated cholesterol
8) Diabetes type 2
9) CKD - baseline creat 2.5-3
10) Bilat total knee replacment
11) Multiple skin lesions removed by general and plastic surgery

MEDICATION ON ADMISSION: lasix 100", fluticasone 50', diovan 160", levothyroxine 75',
hydrazaline 50"', Labetolol 400", Procrit [**Numeric Identifier 961**] q mon, protonix
40', simvastatin 20', iron 325'

ALLERGIES: Protamine

PHYSICAL EXAM: 63 sr  18  150/61   68"  222lbs

FAMILY HISTORY: No colon CA, otherwise unremarkable. Has 3 sons and 1 dtr.

SOCIAL HISTORY: Lives at home with husband, [**Name (NI) **] 3 sons and 1 daughter. Is a
non-smoker, no alcohol use, no history of illicit drug use.
Retired, former manager. No h/o IVDU.
Aortic valve disorders,End stage renal disease,Chronic diastolic heart failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Pure hypercholesterolemia,Unspecified acquired hypothyroidism,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Other chronic pulmonary heart diseases,Knee joint replacement
Aortic valve disorder,End stage renal disease,Chr diastolic hrt fail,Hyp kid NOS w cr kid V,Pure hypercholesterolem,Hypothyroidism NOS,DMII renl nt st uncntrld,Chr pulmon heart dis NEC,Joint replaced knee
Admission Date:  [**2164-12-20**]              Discharge Date:   [**2164-12-25**]

Date of Birth:  [**2084-10-17**]             Sex:   F

Service: CARDIOTHORACIC

Allergies:
Protamine

Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
DOE/CHF

Major Surgical or Invasive Procedure:
[**2164-12-20**] - Aortic Valve Replacement (19mm St. [**Male First Name (un) 923**] Mechanical
Valve)


History of Present Illness:
The patient is an 80-year-old woman with diabetes and renal
failure who presented with recurrent congestive heart failure.
She was noted to have severe aortic stenosis. Catheterization
showed normal coronary arteries. It was elected to proceed with
aortic valve replacement with mechanical valve.

Past Medical History:
1)History of GIB of unknown cause; numerous diverticula on
C-scope
2) L colectomy with transverse colostomy for GIB (D/C [**11-12**])
3) Diastolic CHF (EF 65-75%)
4) s/p trach placement after prolonged intubation in ICU (at
time
of colectomy)
5) Severe AS ([**Location (un) 109**] 0.7cm2, pk gradient 91mmHg, mean gradient
55mmHg
on [**6-13**] TTE
6) HTN
7) Elevated cholesterol
8) Diabetes type 2
9) CKD - baseline creat 2.5-3
10) Bilat total knee replacment
11) Multiple skin lesions removed by general and plastic surgery

12) Hypothyroid


Social History:
Lives at home with husband, [**Name (NI) **] 3 sons and 1 daughter. Is a
non-smoker, no alcohol use, no history of illicit drug use.
Retired, former manager. No h/o IVDU.


Family History:
No colon CA, otherwise unremarkable. Has 3 sons and 1 dtr.

Physical Exam:
63 sr  18  150/61   68"  222lbs

GEN: NAD
SKIN: Unremarkable
HEENT: Unremarkable
NECK: Supple, FROM
LUNGS: CTA
HEART: RRR, Loud SEM, NlS1-S2
ABD: Soft, NT/ND, NABS
EXT: 2+ LE edema, Pulses palp except nonpalp DP.
NEURO: Nonfocal, unsteady gait


Pertinent Results:
[**2164-12-24**] 08:15AM BLOOD WBC-4.5 RBC-3.25* Hgb-10.1* Hct-31.3*
MCV-96 MCH-30.9 MCHC-32.1 RDW-16.3* Plt Ct-183
[**2164-12-20**] 11:06AM BLOOD WBC-9.2# RBC-3.11*# Hgb-9.8*# Hct-29.3*#
MCV-95 MCH-31.4 MCHC-33.2 RDW-17.1* Plt Ct-177
[**2164-12-20**] 11:06AM BLOOD Neuts-62.2 Lymphs-36.5 Monos-0.5* Eos-0.7
Baso-0.1
[**2164-12-25**] 05:42AM BLOOD PT-16.1* PTT-70.5* INR(PT)-1.4*
[**2164-12-24**] 08:15AM BLOOD PT-13.9* PTT-35.5* INR(PT)-1.2*
[**2164-12-23**] 01:10PM BLOOD PT-12.9 INR(PT)-1.1
[**2164-12-22**] 06:38AM BLOOD PT-13.7* PTT-30.9 INR(PT)-1.2*
[**2164-12-20**] 12:12PM BLOOD PT-14.8* PTT-47.3* INR(PT)-1.3*
[**2164-12-20**] 11:06AM BLOOD PT-15.7* PTT-48.0* INR(PT)-1.4*
[**2164-12-24**] 08:15AM BLOOD Glucose-109* UreaN-45* Creat-5.0*# Na-137
K-3.9 Cl-101 HCO3-27 AnGap-13
[**2164-12-20**] 12:12PM BLOOD UreaN-21* Creat-2.9* Cl-105 HCO3-28
[**2164-12-24**] 08:15AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.5
[**2164-12-24**] 09:00AM BLOOD PTH-290*

Cardiology Report ECG Study Date of [**2164-12-24**]  7:58:44 AM


Sinus rhythm. Compared to previous tracing of [**2164-12-20**] no
diagnostic
change.


Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**]

  Intervals Axes
Rate PR QRS QT/QTc P QRS T
79 124 104 422/455 57 20 71

RADIOLOGY  Final Report

CHEST (PORTABLE AP)  [**2164-12-24**] 2:59 PM

CHEST (PORTABLE AP)

Reason: evaluate effusion - in HD please check with RN that pt
on fl

[**Hospital 93**] MEDICAL CONDITION:
80 year old woman with s/p avr
REASON FOR THIS EXAMINATION:
evaluate effusion - in HD please check with RN that pt on floor
INDICATION: Followup.

FINDINGS: Comparison to [**2164-12-22**]. The right-sided
sheath in the jugular vein has been removed. All other invasive
and monitoring devices are in unchanged position. The effusions
are small and limited to the very area of the pleural sinuses.
In unchanged manner, the silhouette of the heart is enlarged.
Slight aortic calcification. Subtle signs of fluid overload.

IMPRESSION: Cardiomegaly with signs of fluid overload, unchanged
extent of bilateral pleural effusions.

DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: MON [**2164-12-24**] 5:14 PM

   RADIOLOGY   Preliminary Report

[**Numeric Identifier **] PICC W/O PORT  [**2164-12-24**] 12:01 PM

Reason: no IV access

[**Hospital 93**] MEDICAL CONDITION:
80 year old woman with s/p AVR w/ chronic renal failure, on HD
REASON FOR THIS EXAMINATION:
no IV access
PICC LINE PLACEMENT

INDICATION: IV access needed for antibiotics.

The procedure was explained to the patient. A timeout was
performed.

RADIOLOGISTS: Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 4686**] performed the
procedure. Dr. [**Last Name (STitle) 4686**], the Attending Radiologist, was present
and supervised the entire procedure.

TECHNIQUE: Using sterile technique and local anesthesia, the
right brachial vein was punctured under direct ultrasound
guidance using a micropuncture set. Hard copies of ultrasound
images were obtained before and immediately after establishing
intravenous access. A peel-away sheath was then placed over a
guidewire and a 5 French double-lumen PICC line measuring 35 cm
in length was then placed through the peel-away sheath with its
tip positioned in the SVC under fluoroscopic guidance. Position
of the catheter was confirmed by a fluoroscopic spot film of the
chest.

The peel-away sheath and guidewire were then removed. The
catheter was secured to the skin, flushed, and a sterile
dressing applied.

The patient tolerated the procedure well. There were no
immediate complications.

IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided
5 French double-lumen PICC line placement via the right brachial
venous approach. Final internal length is 35 cm, with the tip
positioned in SVC. The line is ready to use.

DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3904**]
DR. [**First Name (STitle) **] [**Name (STitle) **]
PreliminaryApproved: MON [**2164-12-24**] 4:48 PM

[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT

[**Known lastname **], [**Known firstname 2995**]       [**Hospital1 18**] [**Numeric Identifier 97470**] (Complete)
Done [**2164-12-20**] at 10:14:31 AM      FINAL
Referring Physician     [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 1112**] W.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**]  Status: Inpatient DOB: [**2084-10-17**]
Age (years): 80 F  Hgt (in):
BP (mm Hg): /  Wgt (lb):
HR (bpm):  BSA (m2):
Indication: Abnormal ECG. Aortic valve disease. Congestive heart
failure. Dizziness. Hypertension. Left ventricular function.
Pulmonary hypertension.
ICD-9 Codes: 428.0, 402.90, 786.05, 440.0, 424.1
Test Information
Date/Time: [**2164-12-20**] at 10:14    Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5209**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW2-: Machine:
Echocardiographic Measurements
Results  Measurements  Normal Range
Left Ventricle - Inferolateral Thickness:  *1.5 cm  0.6 - 1.1 cm

Left Ventricle - Ejection Fraction:  45% to 55%  >= 55%
Aorta - Ascending:  3.0 cm  <= 3.4 cm
Aortic Valve - Peak Velocity:  *3.0 m/sec  <= 2.0 m/sec
Aortic Valve - Peak Gradient:  *40 mm Hg  < 20 mm Hg
Aortic Valve - Valve Area:  *0.8 cm2  >= 3.0 cm2

Findings
LEFT ATRIUM: Mild LA enlargement.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color Doppler.

LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size.
Mildly depressed LVEF.

RIGHT VENTRICLE: RV hypertrophy. Mildly dilated RV cavity.
Borderline normal RV systolic function.

AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Simple atheroma in ascending aorta. Normal aortic arch diameter.
Simple atheroma in aortic arch. Normal descending aorta
diameter. Simple atheroma in descending aorta.

AORTIC VALVE: Three aortic valve leaflets. Moderately thickened
aortic valve leaflets. No masses or vegetations on aortic valve.
Moderate-severe AS (area 0.8-1.0cm2). Trace AR.

MITRAL VALVE: Moderately thickened mitral valve leaflets.
Moderate mitral annular calcification. Calcified tips of
papillary muscles. Mild (1+) MR.

TRICUSPID VALVE: Mild [1+] TR.

PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.

PERICARDIUM: Trivial/physiologic pericardial effusion.

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 patient received antibiotic prophylaxis. The
TEE probe was passed with assistance from the anesthesioology
staff using a laryngoscope. No TEE related complications.
patient.

REGIONAL LEFT VENTRICULAR WALL MOTION:





     N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-CPB:1. The left atrium is mildly dilated. No atrial septal
defect is seen by 2D or color Doppler.
2. There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is mildly depressed (LVEF= 45-50%).
3. The right ventricular free wall is hypertrophied. The right
ventricular cavity is mildly dilated. Right ventricular systolic
function is borderline normal.
4. There are simple atheroma in the ascending aorta. There are
simple atheroma in the aortic arch. There are simple atheroma in
the descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. No masses or vegetations are
seen on the aortic valve. There is moderate to severe aortic
valve stenosis (area 0.8-1.0cm2). Trace aortic regurgitation is
seen. The annulus is heavilyb calcified and measures 19 mm.
6. The mitral valve leaflets are moderately thickened. Mild (1+)
mitral regurgitation is seen.
7. There is a trivial/physiologic pericardial effusion.

POST-CPB: On infusions of epinephrine and levophed. Well-seated
mechanical valve in the aortic position. No AI. AS gradient 20
peak, 13 mean at Cardiac Output of 7 L/min. Preserved LV
systolic function on inotropic support. Mild inferior
hypokinesis. LVEF=50%. Flow seen in LMCA and RCA.
Protamine reaction with hypotension and CCO=8-9 L/min. Rx'd epi
boluses. LV SAX shows underfilled LV with good systolic
function. Aorta intact post decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.

Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2164-12-20**] 16:50




Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2164-12-20**] for surgical
management of her aortic valve disease. She was taken directly
to the operating room where she underwent an aortic valve
replacement using a 19mm St. [**Male First Name (un) 923**] Mechanical valve. Please see
operative note for details. Postoperatively she was taken to the
intensive care unit for monitoring. On postoperative day one,
she underwent dialysis to remove volume. On postoperative day
two, she awoke neurologically intact and was extubated. Coumadin
was started for anticoagulation. She was later transferred to
the step down unit for further recovery. The physical therapy
service was consulted for assistance with her postoperative
strength and mobility. The renal service continued to follow her
and she continued with hemodialysis as prior to surgery. She was
started on heparin while her INR was subtherapeutic. The heparin
should continue until her INR is 2. She is due for HD Wednesday
[**12-26**].

Medications on Admission:
lasix 100", fluticasone 50', diovan 160", levothyroxine 75',
hydrazaline 50"', Labetolol 400", Procrit [**Numeric Identifier 961**] q mon, protonix
40', simvastatin 20', iron 325'

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. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution Sig:
1000 (1000) units/hr Intravenous ASDIR (AS DIRECTED): goal PTT
60-80
do NOT bolus
discontinue when INR > 2.0 .
4. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1)  Injection
QMOWEFR (Monday -Wednesday-Friday).
5. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. PICC line
PICC line care per protocol
7. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Warfarin 1 mg Tablet Sig: goal INR 2.5-3.0 Tablets PO DAILY
(Daily) as needed for mech AVR: please dose based on INR result
- goal INR 2.5-3.0 with PT/INR checked daily until off heparin
and then mon/wed/fri for continued dosing .

She has received 3mg coumadin [**12-22**] and [**12-23**] 5mg coumadin
[**12-24**] and [**12-25**]


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 672**] Hospital/Radius

Discharge Diagnosis:
Aortic stenosis s/p avr
s/p Aortic valvuloplasty
CHF (Diastolic dysfunction LVEF 65%
Diabetes mellitus
CRI baseline creatinine 3.0
Hypothyroid
GIB
Obesity
s/p vein stripping


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.
6) No driving for 1 month.
7) Call with any questions or concerns [**Telephone/Fax (1) 170**]

Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with Dr. [**First Name (STitle) 437**] after discharge from rehab
Follow-up with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1266**] after discharge from rehab
[**Telephone/Fax (1) 608**]
Follow up with Dr [**Last Name (STitle) 4883**] [**Telephone/Fax (1) 20422**]
Please call all providers for appointments.

Scheduled Appointments:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. Phone:[**Telephone/Fax (1) 4451**]
Date/Time:[**2165-3-20**] 10:40

Dialysis - please refer back to [**Location (un) **] [**Location (un) **] when dc from
rehab
Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2165-1-3**] 9:20



Completed by:[**2164-12-25**]
{'Aortic valve disorders,End stage renal disease,Chronic diastolic heart failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Pure hypercholesterolemia,Unspecified acquired hypothyroidism,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Other chronic pulmonary heart diseases,Knee joint replacement'}


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: DOE/CHF

PRESENT ILLNESS: The patient is an 80-year-old woman with diabetes and renal
failure who presented with recurrent congestive heart failure.
She was noted to have severe aortic stenosis. Catheterization
showed normal coronary arteries. It was elected to proceed with
aortic valve replacement with mechanical valve.

MEDICAL HISTORY: 1)History of GIB of unknown cause; numerous diverticula on
C-scope
2) L colectomy with transverse colostomy for GIB (D/C [**11-12**])
3) Diastolic CHF (EF 65-75%)
4) s/p trach placement after prolonged intubation in ICU (at
time
of colectomy)
5) Severe AS ([**Location (un) 109**] 0.7cm2, pk gradient 91mmHg, mean gradient
55mmHg
on [**6-13**] TTE
6) HTN
7) Elevated cholesterol
8) Diabetes type 2
9) CKD - baseline creat 2.5-3
10) Bilat total knee replacment
11) Multiple skin lesions removed by general and plastic surgery

MEDICATION ON ADMISSION: lasix 100", fluticasone 50', diovan 160", levothyroxine 75',
hydrazaline 50"', Labetolol 400", Procrit [**Numeric Identifier 961**] q mon, protonix
40', simvastatin 20', iron 325'

ALLERGIES: Protamine

PHYSICAL EXAM: 63 sr  18  150/61   68"  222lbs

FAMILY HISTORY: No colon CA, otherwise unremarkable. Has 3 sons and 1 dtr.

SOCIAL HISTORY: Lives at home with husband, [**Name (NI) **] 3 sons and 1 daughter. Is a
non-smoker, no alcohol use, no history of illicit drug use.
Retired, former manager. No h/o IVDU. 

### Response:
{'Aortic valve disorders,End stage renal disease,Chronic diastolic heart failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Pure hypercholesterolemia,Unspecified acquired hypothyroidism,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Other chronic pulmonary heart diseases,Knee joint replacement'}
