CHIEF COMPLAINT: Dyspnea on exertion / Diminished exercise tolerance

PRESENT ILLNESS: 48 year old gentleman with past medical history signicicant for
triple vessel coronary artery bypass grafting in [**2118-9-9**]
followed by a redo sternotomy with a bioprosthetic mitral valve
replacement in [**2118-11-9**]. In [**2123-9-9**], he developed
dyspnea on exertion with diminished exercise tolerance. An echo
at that time did reveal that his mitral valve bioprosthesis had
begun to degenerate by way of mitral stenosis. Over the winter,
his symptoms have been progressive and worsening prompting a
repeat echocardiogram this [**Month (only) 547**] which showed severe mitral
stenosis and moderate mitral regurugitation. An exercise
tolerance test was positive and a cardiac catheterization
revealed severe three vessel native disease with severe vein
graft disease. The left internal mammary artery had a patent
touch down stent. Given the severity of his disease, he has been
referred for a redo, redo stenotomy with mitral valve
replacement
and coronary artery bypass grafting.

MEDICAL HISTORY: Coronary artery disease s/p coronary artery bypass graft x 3
(PCI
and cypher stenting of SVG-OM, LIMA-LAD [**2118-9-9**])
Mitral regurgitation s/p Mitral valve replacement [**11-11**]
Biopresthetic Mitral valve stenosis/regurgitation
Ischemic cardiomyopathy LVEF 40-45% by echo [**2124-3-9**]
Dyslipidemia
Hypertension
Sleep apnea (no c-pap)

MEDICATION ON ADMISSION: Metoprolol Succinate ER 50mg daily
Lisinopril 10mg daily
Buproprion SR 150mg daily
**Plavix 75mg Daily**
Lovaza 1gram TID
Zetia 10mg daily
Tricor 145mg daily
Folic acid
Calcium with vitamin D
Multivitamins
Niacin 500mg TID
Aspirin 325mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Pulse: 79 Resp: 16 O2 sat: 99%
B/P  Right: 125/90   Left: 134/105
Height: 5'9"   Weight: 190 lbs

FAMILY HISTORY: Brothers with CAD (1 underwent CABG, another w/ stents)

SOCIAL HISTORY: Race: Caucasian
Last Dental Exam: many yrs ago, edentulous
Lives with: Wife and daughter
Occupation: rug salesman
Tobacco: 30+ pack yr history, currently smoking several cigs/day
ETOH: several beers/week
Mechanical complication due to heart valve prosthesis,Coronary atherosclerosis of autologous vein bypass graft,Mitral valve disorders,Unspecified essential hypertension,Fitting and adjustment of automatic implantable cardiac defibrillator,Long-term (current) use of anticoagulants,Other iatrogenic hypotension,Obstructive sleep apnea (adult)(pediatric),Percutaneous transluminal coronary angioplasty status,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Other and unspecified hyperlipidemia,Tobacco use disorder
Malfunc prosth hrt valve,Crn ath atlg vn bps grft,Mitral valve disorder,Hypertension NOS,Ftng autmtc dfibrillator,Long-term use anticoagul,Iatrogenc hypotnsion NEC,Obstructive sleep apnea,Status-post ptca,Abn react-artif implant,Hyperlipidemia NEC/NOS,Tobacco use disorder
Admission Date:  [**2124-3-29**]              Discharge Date:   [**2124-4-3**]

Date of Birth:  [**2075-8-18**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion / Diminished exercise tolerance

Major Surgical or Invasive Procedure:
Second time redo (third time heart operation) for mitral valve
replacement with a [**Street Address(2) 7163**]. [**Hospital 923**] Medical mechanical valve and
coronary artery bypass grafting x1 with reverse saphenous vein
graft to the marginal graft.


History of Present Illness:
48 year old gentleman with past medical history signicicant for
triple vessel coronary artery bypass grafting in [**2118-9-9**]
followed by a redo sternotomy with a bioprosthetic mitral valve
replacement in [**2118-11-9**]. In [**2123-9-9**], he developed
dyspnea on exertion with diminished exercise tolerance. An echo
at that time did reveal that his mitral valve bioprosthesis had
begun to degenerate by way of mitral stenosis. Over the winter,
his symptoms have been progressive and worsening prompting a
repeat echocardiogram this [**Month (only) 547**] which showed severe mitral
stenosis and moderate mitral regurugitation. An exercise
tolerance test was positive and a cardiac catheterization
revealed severe three vessel native disease with severe vein
graft disease. The left internal mammary artery had a patent
touch down stent. Given the severity of his disease, he has been
referred for a redo, redo stenotomy with mitral valve
replacement
and coronary artery bypass grafting.


Past Medical History:
Coronary artery disease s/p coronary artery bypass graft x 3
(PCI
and cypher stenting of SVG-OM, LIMA-LAD [**2118-9-9**])
Mitral regurgitation s/p Mitral valve replacement [**11-11**]
Biopresthetic Mitral valve stenosis/regurgitation
Ischemic cardiomyopathy LVEF 40-45% by echo [**2124-3-9**]
Dyslipidemia
Hypertension
Sleep apnea (no c-pap)


Social History:
Race: Caucasian
Last Dental Exam: many yrs ago, edentulous
Lives with: Wife and daughter
Occupation: rug salesman
Tobacco: 30+ pack yr history, currently smoking several cigs/day
ETOH: several beers/week


Family History:
Brothers with CAD (1 underwent CABG, another w/ stents)


Physical Exam:
Pulse: 79 Resp: 16 O2 sat: 99%
B/P  Right: 125/90   Left: 134/105
Height: 5'9"   Weight: 190 lbs

General: Well-developed male in no acute distress
Skin: Dry [X] intact [X] well-healed sternotomy and right
thoracotomy incision
HEENT: PERRLA [X] EOMI [X]
Neck:  Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur 1-2/6 systolic murmur
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema/Varicosities:
None
[X] healed EVH incision right leg
Neuro: Grossly intact [X]
Pulses:
Femoral      Right: 2+ (healing cath site) Left: 2+
DP           Right: 2+  Left: 2+
PT           [**Name (NI) 167**]: 2+  Left: 2+
Radial       Right: 2+  Left: 2+

Carotid Bruit      Right/Left: -


Pertinent Results:
[**2124-3-29**]: TTE
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is mildly depressed (LVEF= 40 %) with mild
hypokinesis in the mid and apical inferior wma. The right
ventricular cavity is moderately dilated with borderline normal
free wall function. There are focal calcifications in the aortic
arch. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation.
A bioprosthetic mitral valve prosthesis is present. The
prosthetic mitral valve leaflets are thickened. The gradients
are higher than expected for this type of prosthesis. There is
severe valvular mitral stenosis (area <1.0cm2). Moderate to
severe (3+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is no pericardial
effusion.
Dr. [**Last Name (STitle) **]/[**Doctor First Name **] was notified in person of the results on
Mr.[**Known lastname 58103**] before surgical incision.
Post_Bypass;
Mild global RV hypokinesis.
Mild global LV dysfunction with added focalities in the mid and
apical inferior walls (similar to prebypass)
There is a bileaflet metallic prosthesis in the mitral position,
stable, both leaflets moving, typical washing jets present.
Thoracic aorta is itnact.
Mild TR.
[**2124-4-3**] 05:50AM BLOOD Hct-28.1*
[**2124-4-1**] 07:00AM BLOOD WBC-9.9 RBC-3.28* Hgb-9.9* Hct-28.9*
MCV-88 MCH-30.2 MCHC-34.3 RDW-14.8 Plt Ct-257
[**2124-4-3**] 05:50AM BLOOD UreaN-15 Creat-0.9 K-4.0
[**2124-4-1**] 07:00AM BLOOD Glucose-121* UreaN-17 Creat-1.0 Na-134
K-3.6 Cl-95* HCO3-32 AnGap-11
[**2124-4-3**] 05:50AM BLOOD PT-27.6* INR(PT)-2.7*
[**2124-4-2**] 05:35AM BLOOD PT-31.7* PTT-32.9 INR(PT)-3.2*
[**2124-4-1**] 08:45PM BLOOD PT-22.4* PTT-32.6 INR(PT)-2.1*
[**2124-4-1**] 07:00AM BLOOD PT-21.0* PTT-28.0 INR(PT)-1.9*
[**2124-3-31**] 02:46AM BLOOD PT-15.1* INR(PT)-1.3*

Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2124-3-29**] where the patient underwent a second
time redo (third time heart operation) for mitral valve
replacement with a [**Street Address(2) 7163**]. [**Hospital 923**] Medical mechanical valve and
coronary artery bypass grafting x1 with reverse saphenous vein
graft to the marginal graft. 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 on no inotropic or 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.  Chest tubes and
pacing wires were discontinued without complication.  The
patient was evaluated by the physical therapy service for
assistance with strength and mobility. He was started on
Coumadin on [**2124-3-31**] for his mechanical mitral valve replacement
and anticoagulated for a goal INR 2.5-3.5. By the time of
discharge on POD 5 the patient was ambulating freely, the wound
was healing and pain was controlled with oral analgesics.  The
patient was discharged post operative day 5 in good condition
with appropriate follow up instructions.  He is to be followed
by Dr. [**Last Name (STitle) 32255**] for Coumadin dosing and visiting nurses is to draw
INR on [**2124-4-4**] and call results to [**Telephone/Fax (1) 6256**] for goal INR
2.5-3.5. He is to receive 5 mg of Coumadin [**2124-4-3**] prior to
discharge.

Medications on Admission:
Metoprolol Succinate ER 50mg daily
Lisinopril 10mg daily
Buproprion SR 150mg daily
**Plavix 75mg Daily**
Lovaza 1gram TID
Zetia 10mg daily
Tricor 145mg daily
Folic acid
Calcium with vitamin D
Multivitamins
Niacin 500mg TID
Aspirin 325mg daily


Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO twice a day as needed
for constipation.
Disp:*60 Tablet(s)* Refills:*0*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Warfarin 2 mg Tablet Sig: 1-2 Tablets PO once a day: Goal INR
2.5-3.5 - take as instructed.
Disp:*100 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 1110**] VNA

Discharge Diagnosis:
Severe prosthetic mitral valve stenosis and recurrent coronary
artery disease, status post coronary artery bypass surgery and
status post mitral valve replacement.


Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with  steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.


Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
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 until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
***NO MOTORCYCLE DRIVING 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**


Followup Instructions:
You are scheduled for the following appointments
Surgeon:  Dr [**Last Name (STitle) **] on     at [**Hospital1 **] [**Telephone/Fax (1) 6256**] for wound
check and post-op follow-up
Please call to schedule appointments with your
Primary Care Dr [**Last Name (STitle) 12300**] in [**12-11**] weeks
Cardiologist Dr. [**Last Name (STitle) 32255**] in [**12-11**] weeks ([**Telephone/Fax (1) 20259**]
Labs: PT/INR for Coumadin ?????? indication mechanical mitral valve
replacement
Goal INR 2.5-3.5
First draw [**2124-4-4**]
Results to Dr [**Last Name (STitle) 32255**]
phone [**Telephone/Fax (1) 6256**]              fax [**Telephone/Fax (1) 31080**]

**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:[**2124-4-3**]

Name:  [**Known lastname 10778**],[**Known firstname **]               Unit No:   [**Numeric Identifier 10779**]

Admission Date:  [**2124-3-29**]              Discharge Date:   [**2124-4-3**]

Date of Birth:  [**2075-8-18**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 741**]
Addendum:
Lipitor not covered by insurance company therefore medication
changed to Zocor 10 mg po daily.
Also added to discharge medications:
Wellbutrin 150 mg SR daily
Tricor 145 mg daily
Zetia 10 mg daily
Folic Acid 2 mg daily
Lisinopril 10 mg daily
Niacin 500 mg three times a day

Patient instructed to restart Omega-3 acid tablets once home

Discharge Disposition:
Home With Service

Facility:
[**Location (un) 437**] VNA

                             [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]

Completed by:[**2124-4-3**]
{'Mechanical complication due to heart valve prosthesis,Coronary atherosclerosis of autologous vein bypass graft,Mitral valve disorders,Unspecified essential hypertension,Fitting and adjustment of automatic implantable cardiac defibrillator,Long-term (current) use of anticoagulants,Other iatrogenic hypotension,Obstructive sleep apnea (adult)(pediatric),Percutaneous transluminal coronary angioplasty status,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Other and unspecified hyperlipidemia,Tobacco use disorder'}


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 / Diminished exercise tolerance

PRESENT ILLNESS: 48 year old gentleman with past medical history signicicant for
triple vessel coronary artery bypass grafting in [**2118-9-9**]
followed by a redo sternotomy with a bioprosthetic mitral valve
replacement in [**2118-11-9**]. In [**2123-9-9**], he developed
dyspnea on exertion with diminished exercise tolerance. An echo
at that time did reveal that his mitral valve bioprosthesis had
begun to degenerate by way of mitral stenosis. Over the winter,
his symptoms have been progressive and worsening prompting a
repeat echocardiogram this [**Month (only) 547**] which showed severe mitral
stenosis and moderate mitral regurugitation. An exercise
tolerance test was positive and a cardiac catheterization
revealed severe three vessel native disease with severe vein
graft disease. The left internal mammary artery had a patent
touch down stent. Given the severity of his disease, he has been
referred for a redo, redo stenotomy with mitral valve
replacement
and coronary artery bypass grafting.

MEDICAL HISTORY: Coronary artery disease s/p coronary artery bypass graft x 3
(PCI
and cypher stenting of SVG-OM, LIMA-LAD [**2118-9-9**])
Mitral regurgitation s/p Mitral valve replacement [**11-11**]
Biopresthetic Mitral valve stenosis/regurgitation
Ischemic cardiomyopathy LVEF 40-45% by echo [**2124-3-9**]
Dyslipidemia
Hypertension
Sleep apnea (no c-pap)

MEDICATION ON ADMISSION: Metoprolol Succinate ER 50mg daily
Lisinopril 10mg daily
Buproprion SR 150mg daily
**Plavix 75mg Daily**
Lovaza 1gram TID
Zetia 10mg daily
Tricor 145mg daily
Folic acid
Calcium with vitamin D
Multivitamins
Niacin 500mg TID
Aspirin 325mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Pulse: 79 Resp: 16 O2 sat: 99%
B/P  Right: 125/90   Left: 134/105
Height: 5'9"   Weight: 190 lbs

FAMILY HISTORY: Brothers with CAD (1 underwent CABG, another w/ stents)

SOCIAL HISTORY: Race: Caucasian
Last Dental Exam: many yrs ago, edentulous
Lives with: Wife and daughter
Occupation: rug salesman
Tobacco: 30+ pack yr history, currently smoking several cigs/day
ETOH: several beers/week 

### Response:
{'Mechanical complication due to heart valve prosthesis,Coronary atherosclerosis of autologous vein bypass graft,Mitral valve disorders,Unspecified essential hypertension,Fitting and adjustment of automatic implantable cardiac defibrillator,Long-term (current) use of anticoagulants,Other iatrogenic hypotension,Obstructive sleep apnea (adult)(pediatric),Percutaneous transluminal coronary angioplasty status,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Other and unspecified hyperlipidemia,Tobacco use disorder'}
