CHIEF COMPLAINT: dyspnea on exertion

PRESENT ILLNESS: Mr. [**Known lastname 16646**] is a 58 year old gentleman who underwent a
mechanical aortic valve replacement in [**2158**] after developing
subacute bacterial endocarditis.  He was recently noted to have
an ascending aortic aneurysm of 5.9 cm on chest CT scan dating
back to [**2174-1-17**].  Therefore, he was referred for
cardiac surgery.

MEDICAL HISTORY: history of bacterial endocarditis, hypertension, dyslipidemia,
nonischemic cardiomyopathy, history of atrial fibrillation,
status post cardioversion, prostate cancer, gastroesophageal
reflux disease,obesity, abdominal hernia, erectile dysfunction,
diverticular disease, and colon polyps.

MEDICATION ON ADMISSION: coumadin 5mg 6 days/week, 7.5 on sunday
captopril 25''
digoxin .25'
lasix 40'
lopressor 50''

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Skin: Dry [x] intact [x] no rash
HEENT: PERRLA [x] EOMI [x]
Neck:  Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x]  Irregular []  Murmur - audible mechanical cick
Abdomen: Soft [x] non-distended [x] non-tender [x]  bowel sounds
+ [x] small ventral hernia mid-upper abdomen
Extremities: Warm [x], well-perfused [x] no edema or
varicosities
Neuro: Grossly intact x
Pulses:
Femoral      Right: 2+  Left: 2+
DP           Right: 2+  Left: 2+
PT           [**Name (NI) 167**]: 2+  Left: 2+
Radial       Right: 2+  Left: 2+

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: Mr. [**Known lastname 16646**] lives with his wife.
[**Name (NI) **] quit smoking in [**2143**] with an 80 pack year history.
He denies drinking any alcohol in the past month.
Thoracic aneurysm without mention of rupture,Other primary cardiomyopathies,Atrial fibrillation,Unspecified essential hypertension,Esophageal reflux,Heart valve replaced by other means,Personal history of malignant neoplasm of prostate
Thoracic aortic aneurysm,Prim cardiomyopathy NEC,Atrial fibrillation,Hypertension NOS,Esophageal reflux,Heart valve replac NEC,Hx-prostatic malignancy
Admission Date:  [**2174-7-3**]              Discharge Date:   [**2174-7-11**]

Date of Birth:  [**2115-6-16**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
dyspnea on exertion

Major Surgical or Invasive Procedure:
s/p Redo Sternotomy/replacement of ascending aorta [**2174-7-5**]


History of Present Illness:
Mr. [**Known lastname 16646**] is a 58 year old gentleman who underwent a
mechanical aortic valve replacement in [**2158**] after developing
subacute bacterial endocarditis.  He was recently noted to have
an ascending aortic aneurysm of 5.9 cm on chest CT scan dating
back to [**2174-1-17**].  Therefore, he was referred for
cardiac surgery.

Past Medical History:
history of bacterial endocarditis, hypertension, dyslipidemia,
nonischemic cardiomyopathy, history of atrial fibrillation,
status post cardioversion, prostate cancer, gastroesophageal
reflux disease,obesity, abdominal hernia, erectile dysfunction,
diverticular disease, and colon polyps.


Social History:
Mr. [**Known lastname 16646**] lives with his wife.
[**Name (NI) **] quit smoking in [**2143**] with an 80 pack year history.
He denies drinking any alcohol in the past month.


Family History:
noncontributory

Physical Exam:
Skin: Dry [x] intact [x] no rash
HEENT: PERRLA [x] EOMI [x]
Neck:  Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x]  Irregular []  Murmur - audible mechanical cick
Abdomen: Soft [x] non-distended [x] non-tender [x]  bowel sounds
+ [x] small ventral hernia mid-upper abdomen
Extremities: Warm [x], well-perfused [x] no edema or
varicosities
Neuro: Grossly intact x
Pulses:
Femoral      Right: 2+  Left: 2+
DP           Right: 2+  Left: 2+
PT           [**Name (NI) 167**]: 2+  Left: 2+
Radial       Right: 2+  Left: 2+

Carotid Bruit        Right:    Left: no bruits- radiation of
mechanical click


Pertinent Results:
PA AND LATERAL CHEST

HISTORY: Replaced ascending aorta. New fever.

IMPRESSION: AP chest compared to [**7-7**]:

New opacification at the base of the left lung could be
pneumonia but is more
likely atelectasis. Pleural effusion, if any, is small.
Postoperative
widening of the mediastinum in the region of the ascending
aorta, which
improved between [**7-5**] and [**7-7**] is subsequently stable, heart
size is
mildly enlarged.

DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: SUN [**2174-7-10**] 10:51 AM

  Hematology                 WBC 7.3  HCT 24.4* , plt 345
  BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2174-7-11**] 06:05AM        345
[**2174-7-11**] 06:05AM    22.7* 63.3*   2.2*
BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino
[**2174-7-5**] 03:45PM    149*

Chemistry            Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2174-7-11**] 06:05AM    90 21* 0.9 139 4.2 104 26 13


 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT

[**Known lastname **], [**Known firstname 640**]       [**Hospital1 18**] [**Numeric Identifier 82665**] (Complete)
Done [**2174-7-5**] at 1:40:43 PM      PRELIMINARY
Referring Physician     [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**]  Status: Inpatient DOB: [**2115-6-16**]
Age (years): 59 M  Hgt (in): 72
BP (mm Hg): /  Wgt (lb): 225
HR (bpm):  BSA (m2): 2.24 m2
Indication: Intraoperative TEE for re-do sternotomy and Bental
procedure.
ICD-9 Codes: 440.0, 441.2, V43.3, 425.4
Test Information
Date/Time: [**2174-7-5**] at 13:40    Interpret MD: [**Name6 (MD) 928**]
[**Name8 (MD) 929**], MD, MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 929**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Suboptimal
Tape #: 2009AW05-: Machine:
Echocardiographic Measurements
Results  Measurements  Normal Range
Left Ventricle - Diastolic Dimension:  *6.0 cm  <= 5.6 cm
Left Ventricle - Ejection Fraction:  35% to 40%  >= 55%
Aorta - Sinus Level:  *5.1 cm  <= 3.6 cm
Aorta - Sinotubular Ridge:  *4.7 cm  <= 3.0 cm
Aorta - Ascending:  *5.5 cm  <= 3.4 cm
Aorta - Arch:  *3.5 cm  <= 3.0 cm
Aorta - Descending Thoracic:  *2.7 cm  <= 2.5 cm
Aortic Valve - Peak Velocity:  1.8 m/sec  <= 2.0 m/sec
Aortic Valve - Peak Gradient:  12 mm Hg  < 20 mm Hg

Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: Aneurysmal interatrial septum.
No ASD by 2D or color Doppler.

LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Dilated LV cavity. Moderate regional LV
systolic dysfunction. Moderately depressed LVEF.

RIGHT VENTRICLE: Borderline normal RV systolic function.

AORTA: Markedly dilated aortic sinus. Markedly dilated ascending
aorta. Mildly dilated aortic arch. Mildly dilated descending
aorta. Simple atheroma in descending aorta.

AORTIC VALVE: Bileaflet aortic valve prosthesis (AVR). AVR
leaflets move normally. Normal AVR gradient. No AS. No AR.

MITRAL VALVE: Mitral valve leaflets not well seen. Trivial MR.

TRICUSPID VALVE: Tricuspid valve not well visualized.
Physiologic TR.

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

PERICARDIUM: No 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. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient. See Conclusions for post-bypass data
The post-bypass study was performed while the patient was
receiving vasoactive infusions (see Conclusions for listing of
medications).
Conclusions
PRE-BYPASS:
1. The interatrial septum is aneurysmal. No atrial septal defect
is seen by 2D or color Doppler.
2. The left ventricular cavity is dilated. Overall left
ventricular systolic function is moderately depressed (LVEF=
35-40%).
3. RV with borderline normal free wall function.
4. The aortic root is markedly dilated at the sinus level. The
ascending aorta is markedly dilated The aortic arch is mildly
dilated. The descending thoracic aorta is mildly dilated. There
are simple atheroma in the descending thoracic aorta.
5. A bileaflet aortic valve prosthesis is present. The aortic
valve prosthesis leaflets appear to move normally. The
transaortic gradient is normal for this prosthesis. There is no
aortic valve stenosis. No aortic regurgitation is seen.
6. The mitral valve leaflets are not well seen. Trivial mitral
regurgitation is seen.
7. There is no pericardial effusion.

POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine.

1. LV function is unchanged.
2. Bileaflet Aortic prosthesis is functioning well.
3. An ascending aortic graft is seen.
4. Descending aorta is intact post decannulation.
5. Other findings are unchanged

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

Interpretation assigned to [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD,
Interpreting physician





Brief Hospital Course:
Mr. [**Known lastname 16646**] was admitted pre-operatively for intravenous
heparin.  On [**2174-7-5**] he underwent a redo sternotomy and
ascending aorta replacement and reapir of ventral hernia.
Please see the operative note for details.  He tolerated the
procedure well and was transferred in critical but stable
condition to the surgical intensive care unit.  By the following
day he was extubated and weaned from pressors.  He was
transferred to the step down floor.  His chest tubes and
epicardial wires were removed.  Coumadin and heparin were
initiated.  He was gently diuresed toward his pre-operative
weight. By post operative day #6 his INR was therapeutic at 2.2.
On the day of discharge  scant serosang drainage was noted at
the midpoint of his sternal incision. The sternum was srable and
the incision was w/o erythema. The WBC was 7.3 and he was
afebrile. He was started on po keflex and given instructions to
paint his wound with betadine and cover with a DSD daily after
showering. He is also sceduled to return for a wound check in 4
days on [**2174-7-15**]. He was also given instructions for examination
of his wound daily and to report any dreness, increased
drainage, fever or pain. The patient does not insurance coverage
for VNA. Dr. [**Last Name (STitle) **] was in agreement with the discharge plan.
Mr. [**Known lastname **] was discharged home on POD# 6.


Medications on Admission:
coumadin 5mg 6 days/week, 7.5 on sunday
captopril 25''
digoxin .25'
lasix 40'
lopressor 50''


Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. 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*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours). Tablet(s)
6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
Disp:*45 Tablet(s)* Refills:*2*
9. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: 5 mg
mon-thru sat and 7.5 mg on sunday.
For mechanical valve.
Disp:*30 Tablet(s)* Refills:*2*
10. Outpatient Lab Work
INR check [**2174-7-12**]
INR check daily until therapeutic on a stable dose of coumadin.
goal INR 2-3.0
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
13. Cephalexin 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) for 7 days.
Disp:*28 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Ascending aortic aneurysm
ventral hernia repair


Discharge Condition:
good


Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
After you shower, paint the sternal incision with betadine and
cover with a clean gauze daily.
take your antibiotic as directed.
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 100.5
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**]
Your INR should be drawn tomorrow [**2174-7-12**] at he VA.


Followup Instructions:
Wound check on [**Hospital Ward Name **] 6 friday [**2174-7-15**] [**Telephone/Fax (1) 170**]
Follow up with Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**], call for
appointment
Dr. [**First Name8 (NamePattern2) 11556**] [**Last Name (NamePattern1) 68250**] (PCP) [**Telephone/Fax (1) 82666**] in [**2-18**] weeks.
INR draws should be drawn at the outpatient coumadin clinic at
the VA [**Location (un) 12674**], who followed your INR previously.  Phone is
([**Telephone/Fax (1) 82667**], Fax ([**Telephone/Fax (1) 82668**].



Completed by:[**2174-7-11**]
{'Thoracic aneurysm without mention of rupture,Other primary cardiomyopathies,Atrial fibrillation,Unspecified essential hypertension,Esophageal reflux,Heart valve replaced by other means,Personal history of malignant neoplasm of prostate'}


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: Mr. [**Known lastname 16646**] is a 58 year old gentleman who underwent a
mechanical aortic valve replacement in [**2158**] after developing
subacute bacterial endocarditis.  He was recently noted to have
an ascending aortic aneurysm of 5.9 cm on chest CT scan dating
back to [**2174-1-17**].  Therefore, he was referred for
cardiac surgery.

MEDICAL HISTORY: history of bacterial endocarditis, hypertension, dyslipidemia,
nonischemic cardiomyopathy, history of atrial fibrillation,
status post cardioversion, prostate cancer, gastroesophageal
reflux disease,obesity, abdominal hernia, erectile dysfunction,
diverticular disease, and colon polyps.

MEDICATION ON ADMISSION: coumadin 5mg 6 days/week, 7.5 on sunday
captopril 25''
digoxin .25'
lasix 40'
lopressor 50''

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Skin: Dry [x] intact [x] no rash
HEENT: PERRLA [x] EOMI [x]
Neck:  Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x]  Irregular []  Murmur - audible mechanical cick
Abdomen: Soft [x] non-distended [x] non-tender [x]  bowel sounds
+ [x] small ventral hernia mid-upper abdomen
Extremities: Warm [x], well-perfused [x] no edema or
varicosities
Neuro: Grossly intact x
Pulses:
Femoral      Right: 2+  Left: 2+
DP           Right: 2+  Left: 2+
PT           [**Name (NI) 167**]: 2+  Left: 2+
Radial       Right: 2+  Left: 2+

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: Mr. [**Known lastname 16646**] lives with his wife.
[**Name (NI) **] quit smoking in [**2143**] with an 80 pack year history.
He denies drinking any alcohol in the past month. 

### Response:
{'Thoracic aneurysm without mention of rupture,Other primary cardiomyopathies,Atrial fibrillation,Unspecified essential hypertension,Esophageal reflux,Heart valve replaced by other means,Personal history of malignant neoplasm of prostate'}
