CHIEF COMPLAINT: dyspnea

PRESENT ILLNESS: Ms. [**Known lastname 1557**] is a 71 year-old female with history of atrial
fibrillation and CHF (since [**November 2178**] per pt) who presented to
[**Hospital3 **] last night for dyspnea. She reports that she had
been having increased dyspnea for the 2 days prior to admission;
of note, she ran out of her medications 4 days prior to
admission & was unable to refill them. She was found to be in
atrial fibrillation with RVR in the 150s per OSH report. EKG
showed atrial fibrillation w/ LBBB & no ischemic changes. Her
first troponin was 0.44, with an increase to 0.99 on her second.
INR on arrival to OSH was 12 and she was given 10 mg of vitamin
K; repeat INR today at 9. She was also given lipitor, 4 mg
morphine, ASA 325mg, and lasix 40mg IV & diltiazem 25mg IV. Beta
blocker was held [**3-3**] low BP. She was started on a diltiazem gtt
for HR control.

MEDICAL HISTORY: Primary diagnoses:
# Non-ST elevation myocardial infarction
# Atrial fibrillation with rapid ventricular response
# Ascending aortic aneurysm
# Pulmonary edema
# Acute renal failure
# Urinary tract infection
# Hypertension

MEDICATION ON ADMISSION: (called Rite-Aid pharmacy to verify as patient was unsure)
atenolol 25mg po qd
simvastatin 20mg po qhs
levothyroxine 75mcg po daily
coumadin 5mg po qhs
lisinopril 5mg po daily
imipramine 150mg po qhs
diazepam 5mg po qd prn
oxycodone 15mg q6h prn
allopurinol 100 po qd (last got 90-day supply in [**Month (only) **])
furosemide 40mg po qd (filled [**Month (only) **]-[**Month (only) **], then Rx had no more
refills)
actos 30mg po qd (last filled in [**October 2178**])

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM
VS: T: 97.5, BP: 125/62, HR: 115, RR: 16, O2 sat:  98%2L NC
GENERAL: WDWN female in no apparent respiratory distress.
Oriented x3, however, occ inattentive, mumbling & falling asleep
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: Mother w/ HTN, stroke; died at age 50. Father w/ emphysema; died
of cancer (site unknown) at age 70. No family history of early
MI, arrhythmia, cardiomyopathies, or sudden cardiac death;
otherwise non-contributory.

SOCIAL HISTORY: Lives at home with her boyfriend. [**Name (NI) **] a 50 year-old son. Worked
as a bookkeeper & accountant, now retired. Has a 5 pack-year
tobacco history. Drinks [**1-31**] glasses of wine every 6 months.
Denies any illicit drug use.
Subendocardial infarction, initial episode of care,Acute on chronic diastolic heart failure,Atrial flutter,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Thoracic aneurysm without mention of rupture,Mitral valve insufficiency and aortic valve insufficiency,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Coronary atherosclerosis of native coronary artery,Personal history of noncompliance with medical treatment, presenting hazards to health,Unspecified acquired hypothyroidism,Myalgia and myositis, unspecified
Subendo infarct, initial,Ac on chr diast hrt fail,Atrial flutter,Acute kidney failure NOS,Urin tract infection NOS,Thoracic aortic aneurysm,Mitral/aortic val insuff,Hypertension NOS,Hyperlipidemia NEC/NOS,DMII wo cmp nt st uncntr,Abnrml coagultion prfile,Adv eff anticoagulants,Crnry athrscl natve vssl,Hx of past noncompliance,Hypothyroidism NOS,Myalgia and myositis NOS
Admission Date:  [**2179-4-1**]              Discharge Date:   [**2179-4-13**]

Date of Birth:  [**2107-11-5**]             Sex:   F

Service: CARDIOTHORACIC

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
dyspnea

Major Surgical or Invasive Procedure:
[**4-2**] Direct current cardioversion
[**4-5**] Cardiac catheterization
[**4-8**] 1. Replacement of ascending and hemi-arch aorta aneurysm
with a
    32-mm Gelweave Dacron graft.
2. Aortic valve replacement with a 23-mm St. [**Male First Name (un) 923**] Epic
    tissue valve, model number ESP100-23-00.


History of Present Illness:
Ms. [**Known lastname 1557**] is a 71 year-old female with history of atrial
fibrillation and CHF (since [**November 2178**] per pt) who presented to
[**Hospital3 **] last night for dyspnea. She reports that she had
been having increased dyspnea for the 2 days prior to admission;
of note, she ran out of her medications 4 days prior to
admission & was unable to refill them. She was found to be in
atrial fibrillation with RVR in the 150s per OSH report. EKG
showed atrial fibrillation w/ LBBB & no ischemic changes. Her
first troponin was 0.44, with an increase to 0.99 on her second.
INR on arrival to OSH was 12 and she was given 10 mg of vitamin
K; repeat INR today at 9. She was also given lipitor, 4 mg
morphine, ASA 325mg, and lasix 40mg IV & diltiazem 25mg IV. Beta
blocker was held [**3-3**] low BP. She was started on a diltiazem gtt
for HR control.

She has a known abdominal aortic aneurysm measuring 6.8 cm (most
recently was 6.0 cm). She became confused after getting morphine
in the ED. A head CT was done which was normal.  Per report, her
mental status is improving as the morphine wears off.  Vitals
prior to transfer were BP 107/46, HR 80's, Sat 99-100% on 2L.

On arrival to the floor, VS 97.5 125/62 115 16 98%2L NC. Patient
appeared mildly diaphoretic, but comfortable. Currently
endorsing mild dyspnea.

REVIEW OF SYSTEMS
Per HPI; additionally, patient endorses mild dyspnea (all the
time, even at rest, not particularly exacerbated on exertion).
Also c/o fatigue, increased thirst & decreased appetite/PO
intake for the past 1-2 weeks. States that she has been drinking
lots of water & pineapple juice. C/o chronic back, joint &
muscle pain from fibromyalgia. R>L LE edema when she was volume
overloaded in the past (although not currently).

Denies any prior history of stroke, TIA, deep venous thrombosis,
pulmonary embolism, bleeding at the time of surgery, cough,
hemoptysis, black stools or red stools. She denies recent
fevers, chills or rigors. She denies exertional buttock or calf
pain. All of the other review of systems were negative.

Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope
or presyncope.

Past Medical History:
Primary diagnoses:
# Non-ST elevation myocardial infarction
# Atrial fibrillation with rapid ventricular response
# Ascending aortic aneurysm
# Pulmonary edema
# Acute renal failure
# Urinary tract infection
# Hypertension

Secondary diagnoses:
# Pre-diabetes
# Fibromyalgia


Social History:
Lives at home with her boyfriend. [**Name (NI) **] a 50 year-old son. Worked
as a bookkeeper & accountant, now retired. Has a 5 pack-year
tobacco history. Drinks [**1-31**] glasses of wine every 6 months.
Denies any illicit drug use.

Family History:
Mother w/ HTN, stroke; died at age 50. Father w/ emphysema; died
of cancer (site unknown) at age 70. No family history of early
MI, arrhythmia, cardiomyopathies, or sudden cardiac death;
otherwise non-contributory.

Physical Exam:
ADMISSION EXAM
VS: T: 97.5, BP: 125/62, HR: 115, RR: 16, O2 sat:  98%2L NC
GENERAL: WDWN female in no apparent respiratory distress.
Oriented x3, however, occ inattentive, mumbling & falling asleep
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

NECK: Supple with JVP of 5 cm. No cervical or supraclavicular
LAD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: bilateral crackles halfway up lungs, resp were unlabored,
no accessory muscle use. No wheezes or rhonchi. No chest wall
deformities, scoliosis or kyphosis.
ABDOMEN: Soft, obese, NTND.  No HSM or tenderness. No abdominial
bruits appreciated
EXTREMITIES: Trace edema. No c/c.
SKIN: forehead diaphoretic, no stasis dermatitis, ulcers, scars,
or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
NEURO: A+Ox3, CN II-XII intact with no focal deficits. Sensation
intact and symmetric. Gait deferred.
PSYCH: occasionally inattentive, mumbling & falling asleep

Pertinent Results:
# CARDIOLGY

[**2179-4-5**] Cardiac Cath
COMMENTS:
1. Selective coronary angiography of this right dominant system
demonstrated no obstructive coronary artery disease. There was
mild plaquing in the mid-LCA and first diagonal with maximal
stenoses of 40%. The remainder of the coronary arteries were
free of angiographically apparent disease.
2. Limited resting hemodynamics revealed normal resting central
aortic pressures.
FINAL DIAGNOSIS:
1. Non-obstructive coronary artery disease.
2. Ascending thoracic aortic aneurysm.

[**2179-4-2**] TTE
IMPRESSION: Large ascending aortic aneurysm with effacement of
sinotubular junction and moderate to severe functional aortic
valve regurgitation. Symmetric LVH with normal global and
regional biventricular systolic function. Moderate mitral and
tricuspid regurgitation. Moderate pulmonary hypertension.

# RADIOLOGY

[**2179-4-6**] CXR (PA/Lat)
FINDINGS: In comparison with study of [**5-2**], there is continued
enlargement of the cardiac silhouette. The pulmonary vascularity
is now essentially within normal limits. Tortuosity of the aorta
is again seen. No evidence of acute focal pneumonia or pleural
effusion.

# MICROBIOLOGY

[**2179-4-1**] Urine Culture (Final [**2179-4-2**]): NO GROWTH.
[**2179-4-2**] Staph aureus Screen (Final [**2179-4-5**]): NO STAPHYLOCOCCUS
AUREUS ISOLATED.

[**2179-4-13**] 05:23AM BLOOD WBC-9.2 RBC-3.62* Hgb-10.8* Hct-32.3*
MCV-89 MCH-29.8 MCHC-33.4 RDW-16.8* Plt Ct-242
[**2179-4-12**] 08:50AM BLOOD WBC-16.9* RBC-3.91* Hgb-11.4* Hct-34.8*
MCV-89 MCH-29.0 MCHC-32.6 RDW-16.3* Plt Ct-288#
[**2179-4-13**] 05:23AM BLOOD PT-36.2* INR(PT)-3.7*
[**2179-4-12**] 08:50AM BLOOD PT-32.5* INR(PT)-3.3*
[**2179-4-11**] 04:25PM BLOOD PT-24.9* INR(PT)-2.4*
[**2179-4-10**] 04:29AM BLOOD PT-15.8* PTT-30.1 INR(PT)-1.4*
[**2179-4-9**] 02:07AM BLOOD PT-15.7* PTT-34.0 INR(PT)-1.4*
[**2179-4-8**] 11:50AM BLOOD PT-19.4* PTT-150* INR(PT)-1.8*
[**2179-4-8**] 06:00AM BLOOD PT-15.9* PTT-112.4* INR(PT)-1.4*
[**2179-4-12**] 08:50AM BLOOD Glucose-163* UreaN-26* Creat-1.0 Na-134
K-4.9 Cl-98 HCO3-22 AnGap-19
[**2179-4-11**] 04:25PM BLOOD Glucose-124* UreaN-22* Creat-1.2* Na-130*
K-4.3 Cl-95* HCO3-24 AnGap-15

[**2179-4-8**]
Conclusions
Pre Bypass:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage.
No atrial septal defect is seen by 2D or color Doppler.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is low normal (LVEF 40 - 45%).
Right ventricular chamber size and free wall motion are normal.
The aortic root is mildly dilated at the sinus level. The
ascending aorta is severely dilated. The aortic arch is mildly
dilated. The descending thoracic aorta is moderately dilated.
There are simple atheroma in the descending thoracic aorta.
There are three aortic valve leaflets. There is no aortic valve
stenosis. Moderate (2+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**1-31**]+) mitral regurgitation is seen.
Dr. [**Last Name (STitle) **] was notified in person of the results.

Post Bypass:
The patient is on epinephrine and phenylephrine infussions,
being AV paced with cardiac index 2.8.
There is a well seated bioprosthetic valve in the aortic
position, there is no aortic regurgitation.
There is a tube graft in the ascending aorta position.
There is mild to moderate MR.
There is trivial TR.
The LV systolic function remains at an EF of 40- 45%.
The RV systolic function is moderately depressed.
The visible contours of the thoracic aorta are intact.
  I certify that I was present for this procedure in compliance
with HCFA regulations.

Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2179-4-9**] 09:00



Brief Hospital Course:
71 yo F with PMH of atrial fibrillation and CHF who present to
[**Hospital3 **] on the night prior to admission for dyspnea. She
was found to be in atrial fibrillation with RVR to 150s, also
with an NSTEMI. Likely went into RVR secondary to medication
noncompliance with resultant demand ischemia. Had cath [**4-5**] which
showed 40% non-obstructive CAD; plan is for AVR/repair of large
ascending aortic aneurysm tomorrow.

# Dyspnea: Secondary to pulmonary edema which resolved with
diuresis and improved rate control. Likely caused by medication
noncompliance leading to atrial fibrillation with RVR. The
patient received IV lasix as needed and her creatinine was
closely monitored as she presented in acute renal failure.
Additionally, patient was observed to desat at night while she
was sleeping, with rapid recovery of O2 sat

# Atrial fibrillation w/RVR: Likely secondary to medication
non-compliance as patient ran out of meds 4 days prior to
admission and started to experience symptoms 2 days later. Had
DCCV on [**4-2**] with successful conversion to sinus, however went
back into afib w/RVR on [**4-3**], and alternated between afib &
atrial flutter. She was on a heparin drip for anticoagulation
and metoprolol was uptitrated for rate control, although it was
difficult to achieve. Patient was also loaded with amiodarone IV
then PO.

# NSTEMI: Patient presented to [**Hospital3 **] with a troponin
of 0.44, which increased to 0.99. Possibly secondary to demand
ischemia in the context of afib w/RVR. Cardiac cath on [**4-5**]
showed non-obstructive CAD. She was maintained on a heparin drip
and received aspirin, metoprolol and atorvastatin.

# Ascending aortic aneurysm: Increased in size from 6.0 cm on
[**2179-2-18**], increased to 6.8 on [**2179-3-26**]. Given large & rapidly
changing size, there was significant concern for rupture.
Underwent an ascending aortic aneurysm repair on Thursday [**4-8**].
- tight BP control (goal SBP < 120)
- continue metoprolol dose to 125mg TID
- appreciate csurg recs

# Acute renal failure: Cr continues to improve, but still
slightly elevated from baseline. Likely pre-renal in the context
of decreased forward flow [**3-3**] afib & decreased PO intake.
- treat afib as above
- close monitoring of Cr in the context of diuresis
- hold lisinopril

# UTI: U/A with moderate leuks, 10 WBC, few bacteria & 0 epis.
Patient denies any dysuria, frequency or urgency now or prior to
admission. Final urine culture with no growth. Completed a 3-day
course of ciprofloxacin 250mg q12h.

# Hypertension: Blood pressures were low to normal. Given
presentation with acute renal failure, lisinopril was initially
held and the patient continued to receive metoprolol.

# Anemia: Baseline unclear, hematocrit currently stable at 34.
Hct 34 at OSH. Normocytic. Iron studies were with normal limits.

# Pre-Diabetes: Patient denies having pre-diabetes and is not
currently on any diabetes medications at home. Was previously
taking Actos, but per her pharmacy, prescription has not been
filled since [**11-8**]. During her admission she had fingersticks
before meals and bedtime and was a Humalog insulin sliding
scale. Blood glucose was well-controlled.

# Prophylaxis: Patient received heparin products during this
admission.

# Code status: Full code.

INACTIVE ISSUES
# Hyperlipidemia: Patient's home simvastatin was discontinued
and she was started on atorvastatin 80mg daily in the context of
an NSTEMI.

# Hypothyroidism: Continued home dose of levothyroxine 75mcg
daily.

# Fibromyalgia: Continued imipramine and patient received valium
& oxycodone as needed.

The patient was brought to the operating room on [**2179-4-8**] where
the patient underwent 1. Replacement of ascending and hemi-arch
aorta aneurysm with a
    32-mm Gelweave Dacron graft.
2. Aortic valve replacement with a 23-mm St. [**Male First Name (un) 923**] Epic
    tissue valve, model number ESP100-23-00.

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.  The patient
was transferred to the telemetry floor for further recovery.
She reverted to atrial fibrillation which was managed with
amiodarone, beta blocker titration and anti-coagulation was
initiated with coumadin.  Chest tubes and pacing wires were
discontinued without complication.  The patient was evaluated by
the physical therapy service for assistance with strength and
mobility.  By the time of discharge on POD 5, the patient was
ambulating with assistance, the wound was healing and pain was
controlled with oral analgesics.  The patient was discharged to
[**Hospital1 70671**] in good condition with appropriate follow
up instructions.

Medications on Admission:
(called Rite-Aid pharmacy to verify as patient was unsure)
atenolol 25mg po qd
simvastatin 20mg po qhs
levothyroxine 75mcg po daily
coumadin 5mg po qhs
lisinopril 5mg po daily
imipramine 150mg po qhs
diazepam 5mg po qd prn
oxycodone 15mg q6h prn
allopurinol 100 po qd (last got 90-day supply in [**Month (only) **])
furosemide 40mg po qd (filled [**Month (only) **]-[**Month (only) **], then Rx had no more
refills)
actos 30mg po qd (last filled in [**October 2178**])

Discharge Medications:
1. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. imipramine HCl 50 mg Tablet Sig: Three (3) Tablet PO at
bedtime.
3. diazepam 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for anxiety.
4. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours) for 7 days.

5. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
12. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.

13. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
14. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 1 week, then 400mg daily x 1 week, then
200mg daily until further instructed.
15. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: MD to dose daily for goal INR [**3-4**], dx: afib.
16. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]

Discharge Diagnosis:
Primary diagnoses:
# Non-ST elevation myocardial infarction
# Atrial fibrillation with rapid ventricular response
# Ascending aortic aneurysm
# Pulmonary edema
# Acute renal failure
# Urinary tract infection
# Hypertension

Secondary diagnoses:
# Pre-diabetes
# Fibromyalgia


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulating with assistance
Edema: 2+ LE


Discharge Instructions:
You were admitted to hospital with shortness of breath and found
to have atrial fibrillation with rapid heart rate. We gave you
medications to control your heart rate and diuresed you with
Lasix and your breathing improved. You occasionally had low
oxygen saturations at night, but this was rapidly corrected with
deep breaths and might be related to undiagnosed obstructive
sleep apnea (OSA).

On admission, you were found to have a mild heart attack, likely
from increased demand on your heart in the context of your
atrial fibrillation with rapid heart rate. You received aspirin,
atorvstatin, metoprolol and heparin to thin your blood. You had
a cardiac catheterization (cath) to evaluate the arteries that
supply blood to your heart for disease. It showed mild disease
that does not cause significant obstruction in your arteries.

We also attempted to convert you to a normal heart rhythm, but
you went back into atrial fibrillation with fast heart rates the
following day.

You were found to have an increase in the size of your ascending
aortic aneurysm. Given concern for the growing size of the
aneurysm and risk for rupture, you had surgery to repair the
aneurysm and replace your aortic valve.

When you were transferred to [**Hospital1 18**], you were found to have acute
kidney failure, likely from poor blood flow to your kidneys in
the context of atrial fibrillation. As we controlled your heart
rate and gave you fluids, your kidney function improved.

You had a mild urinary tract infection without any symptoms; we
treatd you with a 3-day course of ciprofloxacin given that you
were going to surgery.

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. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]  [**Telephone/Fax (1) 170**] Date/Time:[**2179-5-5**] 1:30

Cardiologist Dr. [**Last Name (STitle) **]. [**First Name8 (NamePattern2) **] [**Last Name (un) 39288**] ([**Hospital1 **]) [**5-13**] at 3:15pm

Please call to schedule the following:
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 15942**] [**Telephone/Fax (1) 60570**] in [**5-4**] weeks



Completed by:[**2179-4-13**]
{'Subendocardial infarction, initial episode of care,Acute on chronic diastolic heart failure,Atrial flutter,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Thoracic aneurysm without mention of rupture,Mitral valve insufficiency and aortic valve insufficiency,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Coronary atherosclerosis of native coronary artery,Personal history of noncompliance with medical treatment, presenting hazards to health,Unspecified acquired hypothyroidism,Myalgia and myositis, 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: dyspnea

PRESENT ILLNESS: Ms. [**Known lastname 1557**] is a 71 year-old female with history of atrial
fibrillation and CHF (since [**November 2178**] per pt) who presented to
[**Hospital3 **] last night for dyspnea. She reports that she had
been having increased dyspnea for the 2 days prior to admission;
of note, she ran out of her medications 4 days prior to
admission & was unable to refill them. She was found to be in
atrial fibrillation with RVR in the 150s per OSH report. EKG
showed atrial fibrillation w/ LBBB & no ischemic changes. Her
first troponin was 0.44, with an increase to 0.99 on her second.
INR on arrival to OSH was 12 and she was given 10 mg of vitamin
K; repeat INR today at 9. She was also given lipitor, 4 mg
morphine, ASA 325mg, and lasix 40mg IV & diltiazem 25mg IV. Beta
blocker was held [**3-3**] low BP. She was started on a diltiazem gtt
for HR control.

MEDICAL HISTORY: Primary diagnoses:
# Non-ST elevation myocardial infarction
# Atrial fibrillation with rapid ventricular response
# Ascending aortic aneurysm
# Pulmonary edema
# Acute renal failure
# Urinary tract infection
# Hypertension

MEDICATION ON ADMISSION: (called Rite-Aid pharmacy to verify as patient was unsure)
atenolol 25mg po qd
simvastatin 20mg po qhs
levothyroxine 75mcg po daily
coumadin 5mg po qhs
lisinopril 5mg po daily
imipramine 150mg po qhs
diazepam 5mg po qd prn
oxycodone 15mg q6h prn
allopurinol 100 po qd (last got 90-day supply in [**Month (only) **])
furosemide 40mg po qd (filled [**Month (only) **]-[**Month (only) **], then Rx had no more
refills)
actos 30mg po qd (last filled in [**October 2178**])

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM
VS: T: 97.5, BP: 125/62, HR: 115, RR: 16, O2 sat:  98%2L NC
GENERAL: WDWN female in no apparent respiratory distress.
Oriented x3, however, occ inattentive, mumbling & falling asleep
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: Mother w/ HTN, stroke; died at age 50. Father w/ emphysema; died
of cancer (site unknown) at age 70. No family history of early
MI, arrhythmia, cardiomyopathies, or sudden cardiac death;
otherwise non-contributory.

SOCIAL HISTORY: Lives at home with her boyfriend. [**Name (NI) **] a 50 year-old son. Worked
as a bookkeeper & accountant, now retired. Has a 5 pack-year
tobacco history. Drinks [**1-31**] glasses of wine every 6 months.
Denies any illicit drug use. 

### Response:
{'Subendocardial infarction, initial episode of care,Acute on chronic diastolic heart failure,Atrial flutter,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Thoracic aneurysm without mention of rupture,Mitral valve insufficiency and aortic valve insufficiency,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Coronary atherosclerosis of native coronary artery,Personal history of noncompliance with medical treatment, presenting hazards to health,Unspecified acquired hypothyroidism,Myalgia and myositis, unspecified'}
