CHIEF COMPLAINT: dyspnea

PRESENT ILLNESS: 88 y/o male with HTN, HLD, LE claudication, AF on coumadin, MDS,
moderate to severe AS, who initially presented on [**2159-2-24**] to
[**Hospital3 417**] Hospital via EMS with 2-3 days of nausea,
vomiting, diarrhea, diaphoresis, ? viral prodrome. During the
days up to admission, he also developed DOE and had
progressively more difficulty climbing stairs, requiring rest,
which was a change in baseline. In hindsight, he actually
reports progressive dyspnea while walking for the past several
months (4-6 months), when he was evaluated for LE claudication.
Functionally, he feels he can no longer walk 1 block or do 1
flight of stairs due to his breathing. He also reported weakness
and fatigue. En route, he received 4 aspirin tablets, 81 mg,
along with CPAP.
.
At [**Hospital3 417**] ED, his HR was 113, RR 30s, BP 149/109. He was
in tripod position while breathing. On ROS, he reported cough
for 3-4 days without fever or sputum. He denied abdominal pain
or headache. Denied dizziness. Denies syncope. He also reported
pressure in his epigastrium. He was noted to be tachypnic,
eventually requiring Bipap. X-ray confirmed acute CHF
exacerbation with ? RML infiltrate, and he was placed on nitro
gtt. He was also in rapid AF with ? rate related ST depressions,
requiring lopressor. Once nitro was weaned off, he again went
into flash pulmonary edema. On saturday, he again went into
rapid AF, and developed chest pressure with acute CHF
exacerbation. He has intermittently required Bipap, lasix, and
nitro gtt in CCU. Echo there showed critical AS with valve area
0.4 cm2, and he is transferred for consideration of aortic valve
intervention. Of note, cardiac enzymes were notable for negative
troponin x 2 and BNP 268 then 560.
.
Per review of [**Hospital3 417**] admission note, suspicion was for
congestive heart failure possibly triggered by early pneumonia.
He improved with Bipap, nitro gtt, lasix gtt. He also received
ceftriaxone and azithromycin, but this was discontinued prior to
transfer.
.
Vitals on transfer - afebrile, 95, 116/74, 16, 94% on 3L NC
.
On review of systems, patient reports that his baseline SBP is
110-120. He denies any prior history of stroke, TIA, deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, black stools or red stools. He denies recent fevers,
chills or rigors. All of the other review of systems were
negative.
.
Cardiac review of systems is positive for epigastric discomfort,
DOE, and PND. Reports sleeping on 1 pillow. Notable for absence
of palpitations, syncope or presyncope.

MEDICAL HISTORY: Aortic stenosis
Coronary artery disease
Mitral valve regurgitation
Dyslipidemia
Hypertension
Peripheral vascular disease (no interventions)
Atrial fibrillation on Coumadin
Myelodysplasia (no need for frequent transfusions, no prior
chemo)
Congestive heart failure
GERD
neuromuscular disorder affecting leg strength
arthritis

MEDICATION ON ADMISSION: HOME MEDICATIONS:
- digoxin 0.125 mg daily
- coumadin 10 mg MWF, 5 mg rest of days
- metoprolol 25 mg [**Hospital1 **]
- omeprazole 20 mg qAM
- B12 1000 mcg daily
.
Medications on transfer:
- coumadin (last dose Fri AM)
- maalox prn dyspepsia
- morphine sulfate 2 mg q2 hrs prn chest pain
- magnesium hydroxide prn
- lopressor 25 mg [**Hospital1 **]
- docusate
- aspirin 325 mg daily
- tylenol
- lasix gtt

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS: T=97.0 BP=91/68 HR=74 RR=18 O2 sat=93% 2L NC
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Does have L eye
ptosis. Conjunctiva were pink, no pallor or cyanosis of the oral
mucosa. No xanthalesma.
NECK: Supple with JVP of [**10-12**] cm
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. irregular rhythm. Grade III/VI holosystolic murmur heard
best at LSB. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Diffuse rhonchi and
crackles at bases, without wheezes.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c. Compression stockings present with trace
edema. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: AAOx3, CNII-XII intact, 5/5 strength UE and LE, 2+
reflexes biceps, brachioradialis, patellar, ankle.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+

FAMILY HISTORY: - No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Mother: died from "old age"
- Father: died from leukemia
- Brother: kidney cancer
- Daughter: colon cancer

SOCIAL HISTORY: - Tobacco history: quit smoking more than 40 years ago.
- ETOH: 1 drink per night
- Illicit drugs: denies
- Has one daughter. Very involved son and wife at bedside.
Mitral valve insufficiency and aortic valve stenosis,Pneumonia, organism unspecified,Acute on chronic diastolic heart failure,Acidosis,Hemorrhage complicating a procedure,Coronary atherosclerosis of native coronary artery,Other chronic pulmonary heart diseases,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Atrial fibrillation,Long-term (current) use of anticoagulants,Myelodysplastic syndrome, unspecified,Esophageal reflux,Myoneural disorders, unspecified,Arthropathy, unspecified, site unspecified,Peripheral vascular disease, unspecified,Examination of participant in clinical trial,Retention of urine, unspecified,Foreign body in larynx,Foreign body accidentally entering other orifice,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in residential institution
Mitral insuf/aort stenos,Pneumonia, organism NOS,Ac on chr diast hrt fail,Acidosis,Hemorrhage complic proc,Crnry athrscl natve vssl,Chr pulmon heart dis NEC,Hyperlipidemia NEC/NOS,Hypertension NOS,Atrial fibrillation,Long-term use anticoagul,Myelodysplastic synd NOS,Esophageal reflux,Myoneural disorders NOS,Arthropathy NOS-unspec,Periph vascular dis NOS,Exam-clincal trial,Retention urine NOS,Foreign body in larynx,FB entering oth orifice,Abn react-surg proc NEC,Accid in resident instit
Admission Date:  [**2159-2-26**]              Discharge Date:   [**2159-3-13**]


Service: CARDIOTHORACIC

Allergies:
No Known Allergies / Adverse Drug Reactions

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

Major Surgical or Invasive Procedure:
[**2159-3-6**] - 1. Urgent aortic valve replacement with a 25-mm Biocor
Epic tissue valve. 2. Mitral valve repair with a triangular
resection of middle scallop of the posterior leaflet P2 and a
mitral valve annuloplasty with a 30 mm [**Doctor Last Name 405**] annuloplasty
band. 3. Coronary artery bypass grafting times 1 with reverse
saphenous vein graft to the marginal branch.
[**2159-2-27**] - Cardiac Catheterization


History of Present Illness:
88 y/o male with HTN, HLD, LE claudication, AF on coumadin, MDS,
moderate to severe AS, who initially presented on [**2159-2-24**] to
[**Hospital3 417**] Hospital via EMS with 2-3 days of nausea,
vomiting, diarrhea, diaphoresis, ? viral prodrome. During the
days up to admission, he also developed DOE and had
progressively more difficulty climbing stairs, requiring rest,
which was a change in baseline. In hindsight, he actually
reports progressive dyspnea while walking for the past several
months (4-6 months), when he was evaluated for LE claudication.
Functionally, he feels he can no longer walk 1 block or do 1
flight of stairs due to his breathing. He also reported weakness
and fatigue. En route, he received 4 aspirin tablets, 81 mg,
along with CPAP.
.
At [**Hospital3 417**] ED, his HR was 113, RR 30s, BP 149/109. He was
in tripod position while breathing. On ROS, he reported cough
for 3-4 days without fever or sputum. He denied abdominal pain
or headache. Denied dizziness. Denies syncope. He also reported
pressure in his epigastrium. He was noted to be tachypnic,
eventually requiring Bipap. X-ray confirmed acute CHF
exacerbation with ? RML infiltrate, and he was placed on nitro
gtt. He was also in rapid AF with ? rate related ST depressions,
requiring lopressor. Once nitro was weaned off, he again went
into flash pulmonary edema. On saturday, he again went into
rapid AF, and developed chest pressure with acute CHF
exacerbation. He has intermittently required Bipap, lasix, and
nitro gtt in CCU. Echo there showed critical AS with valve area
0.4 cm2, and he is transferred for consideration of aortic valve
intervention. Of note, cardiac enzymes were notable for negative
troponin x 2 and BNP 268 then 560.
.
Per review of [**Hospital3 417**] admission note, suspicion was for
congestive heart failure possibly triggered by early pneumonia.
He improved with Bipap, nitro gtt, lasix gtt. He also received
ceftriaxone and azithromycin, but this was discontinued prior to
transfer.
.
Vitals on transfer - afebrile, 95, 116/74, 16, 94% on 3L NC
.
On review of systems, patient reports that his baseline SBP is
110-120. He denies any prior history of stroke, TIA, deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, black stools or red stools. He denies recent fevers,
chills or rigors. All of the other review of systems were
negative.
.
Cardiac review of systems is positive for epigastric discomfort,
DOE, and PND. Reports sleeping on 1 pillow. Notable for absence
of palpitations, syncope or presyncope.

Past Medical History:
Aortic stenosis
Coronary artery disease
Mitral valve regurgitation
Dyslipidemia
Hypertension
Peripheral vascular disease (no interventions)
Atrial fibrillation on Coumadin
Myelodysplasia (no need for frequent transfusions, no prior
chemo)
Congestive heart failure
GERD
neuromuscular disorder affecting leg strength
arthritis

Social History:
- Tobacco history: quit smoking more than 40 years ago.
- ETOH: 1 drink per night
- Illicit drugs: denies
- Has one daughter. Very involved son and wife at bedside.

Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Mother: died from "old age"
- Father: died from leukemia
- Brother: kidney cancer
- Daughter: colon cancer

Physical Exam:
VS: T=97.0 BP=91/68 HR=74 RR=18 O2 sat=93% 2L NC
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Does have L eye
ptosis. Conjunctiva were pink, no pallor or cyanosis of the oral
mucosa. No xanthalesma.
NECK: Supple with JVP of [**10-12**] cm
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. irregular rhythm. Grade III/VI holosystolic murmur heard
best at LSB. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Diffuse rhonchi and
crackles at bases, without wheezes.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c. Compression stockings present with trace
edema. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: AAOx3, CNII-XII intact, 5/5 strength UE and LE, 2+
reflexes biceps, brachioradialis, patellar, ankle.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+

Pertinent Results:
ECHO [**2159-3-6**]
The right atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). with normal free wall contractility. The ascending
aorta is mildly dilated. The aortic valve leaflets are severely
thickened/deformed. There is critical aortic valve stenosis
(valve area <0.8cm2). The mitral regurgitation vena contracta is
>=0.7cm. Severe (4+) mitral regurgitation is seen. Severe [4+]
tricuspid regurgitation is seen. There is no pericardial
effusion.
Post bypass
The patient is s/p Mitral valve repair with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] 30 ring
and an 25 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] bioprosthetic aortic valve replacement
The patient is on an Norepinephrine drip at 0.05 mcg/kg/min and
a milrinone drip at 0.5 mcg/kg/min
The cardiac index is 2.9
The mitral ring is well seated with no peri/paravalvular leaks
seen.The mean gradient across the mitral valve is 3 mmhg
The aortic valve is well seated with no peri/paravalvular
leaks.The mean gradient across the aortic valve is 11 mm hg
There is persistent moderate to severe tricuspid regurgitation
The aorta is intact post decannulation
LV function is preserved at an EF of>55%

Cardiac Catheterization [**2159-2-27**]
1.  Coronary angiography in this right dominant system
demonstrated two
vessel CAD. The LMCA was patent.  The LAD had diffuse mild
plaquing with
sever fal disease in the mid diagonal branch.  The Lcx had a
sever
proximal lesion with focal stenosis and diffuse mild to moderate

stenosis distally.  The RCA was mildly ectatic with diffuse mild

plaquing and TIMI 2 flow.
2. Resting hemodynamics demonstrated elevated left sided filling

pressures with a mean PCWP of 28mm Hg.  The was moderate to
severe
pulmonary pressure with a PASP of 58mm Hg and an elevate PVR.
The was
low normal systemic systolic pressure of 90mm HG with severely
depressed
cardiac index of 1.8 l/min/m2.

CTA [**2159-3-5**]
1. Bilateral pulmonary edema appears slightly increased compared
to the prior examination.
2. Bilateral pleural effusions, stable on the right and
decreased on the left compared to the prior examination.
3. Resolution of multifocal consolidative nodules.
4. Severe aortic valve calcification and atherosclerosis of the
coronary
vessels. Stable dilatation of the ascending thoracic aorta
measuring up to
4.7 cm in diameter.
5. Upper and lower pole left renal cysts.

[**2159-3-13**] 04:20AM BLOOD Hct-27.8*
[**2159-3-12**] 03:15PM BLOOD WBC-7.1 RBC-3.07* Hgb-10.5* Hct-29.7*
MCV-97 MCH-34.1* MCHC-35.2* RDW-15.7* Plt Ct-106*
[**2159-3-12**] 11:10AM BLOOD WBC-7.0 RBC-3.11* Hgb-10.4* Hct-30.1*
MCV-97 MCH-33.3* MCHC-34.5 RDW-15.7* Plt Ct-101*
[**2159-3-11**] 05:30AM BLOOD WBC-6.1 RBC-2.93* Hgb-9.9* Hct-28.2*
MCV-96 MCH-33.8* MCHC-35.2* RDW-15.3 Plt Ct-84*
[**2159-3-10**] 09:25AM BLOOD WBC-8.0 RBC-3.17* Hgb-10.6* Hct-30.3*
MCV-96 MCH-33.4* MCHC-35.0 RDW-15.6* Plt Ct-93*
[**2159-3-13**] 04:20AM BLOOD PT-23.8* INR(PT)-2.3*
[**2159-3-12**] 03:15PM BLOOD PT-25.1* INR(PT)-2.4*
[**2159-3-12**] 11:10AM BLOOD PT-23.4* PTT-26.3 INR(PT)-2.2*
[**2159-3-12**] 04:20AM BLOOD PT-22.9* INR(PT)-2.2*
[**2159-3-11**] 05:30AM BLOOD PT-17.8* INR(PT)-1.7*
[**2159-3-10**] 04:15AM BLOOD PT-16.5* INR(PT)-1.6*
[**2159-3-9**] 05:53AM BLOOD PT-15.8* PTT-28.7 INR(PT)-1.5*
[**2159-3-6**] 01:45PM BLOOD PT-18.1* PTT-27.9 INR(PT)-1.7*
[**2159-3-6**] 11:51AM BLOOD PT-25.7* PTT-38.4* INR(PT)-2.5*
[**2159-3-4**] 06:40AM BLOOD PT-17.0* PTT-81.7* INR(PT)-1.6*
[**2159-3-3**] 07:13AM BLOOD PT-16.5* INR(PT)-1.6*
[**2159-3-13**] 04:20AM BLOOD UreaN-30* Creat-0.9 Na-144 K-4.0 Cl-107
[**2159-3-12**] 04:20AM BLOOD Glucose-136* UreaN-33* Creat-0.9 Na-143
K-4.0 Cl-105 HCO3-28 AnGap-14
[**2159-3-11**] 05:30AM BLOOD Glucose-129* UreaN-33* Creat-0.9 Na-141
K-3.6 Cl-104 HCO3-30 AnGap-11

Brief Hospital Course:
Mr. [**Known lastname 3075**] was admitted to the [**Hospital1 18**] on [**2159-2-26**] via transfer
from [**Hospital3 417**] Hosipital. He initially presented on
[**2159-2-24**] to [**Hospital3 417**] Hospital with progressive dyspnea
and acute congestive heart failure exacerbation, and was thus
transferred for consideration of aortic valve intervention given
concern for critical/severe aortic stenosis. He was worked-up in
the usual preoperative manner which included a carotid duplex
ultrasound which shoed less then 40% stenosis of the bilateral
internal carotid arteries. A cardiac catheterization was
performed which showed single vessel coronary artery disease. A
chest CT scan was performed which showed a stable dilatation of
the ascending thoracic aorta measuring up to
4.7 cm in diameter and likely pneumonina. Levofloxacin was
started for pneumonia. Multifocal consolidative nodules were
also noted predominantly right upper lobe. As there was some
concern that these lesions could also represent bronchogenic
carcinoma, a repeat CT scan was done. This showed resolution of
the nodules. Heparin was continued for his atrial fibrillation.
He was diuresed for pulmonary edema. A dental consult was
obtained for oral clearance for surgery. No evidence of
infection was identified on exam or by panorex and he was
cleared for surgery from an oral standpoint.
On [**2159-3-6**], Mr. [**Known lastname 3075**] was taken to the operating room where he
underwent replacement of his aortic valve, a mitral valve repair
and cornary artery bypass grafting to one vessel. Please see
operative note for details. Postoperatively he was taken to the
intensive care unit for monitoring. Pressors and inotropes were
slowly weaned off. A mild acidosis was allowed to recover. On
postoperative day one, he was extubated. Mr. [**Known lastname 3075**] was noted
to have some difficulty swallowing. A speech and swallow consult
was obtained which showed evidence of aspiration with thin
liquids. A thickened liquid diet was recommended with moist
solids and continued aspiration precautions. Diuresis was
intiated.
On [**2159-3-8**], Mr. [**Known lastname 3075**] was transferred to the step down unit for
further recovery. The physical therapy service was consulted for
assistance with his postoperative strength and recovery.
Coumadin was resumed for his chronic atrial fibrillation.  The
patient developed ecchymosis at the vein harvest site of the
right lower extremity.  Keflex was started for this.  He
remained afebrile with a normal WBC count.  A copious amount of
dark blood and clot was milked from the vein harvest site on POD
6.  The leg was wrapped tightly with ACE.  Hematocrit remained
stable and bleeding stopped.
By the time of discharge on POD 7 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics.  The patient was discharged to [**Hospital 19771**] rehab in
[**Location (un) 2624**] in good condition with appropriate follow up
instructions.

Medications on Admission:
HOME MEDICATIONS:
- digoxin 0.125 mg daily
- coumadin 10 mg MWF, 5 mg rest of days
- metoprolol 25 mg [**Hospital1 **]
- omeprazole 20 mg qAM
- B12 1000 mcg daily
.
Medications on transfer:
- coumadin (last dose Fri AM)
- maalox prn dyspepsia
- morphine sulfate 2 mg q2 hrs prn chest pain
- magnesium hydroxide prn
- lopressor 25 mg [**Hospital1 **]
- docusate
- aspirin 325 mg daily
- tylenol
- lasix gtt

Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. docusate sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
5. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. amlodipine 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO Q12H (every 12 hours).
10. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
11. clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
12. multivitamin     Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. warfarin 1 mg Tablet Sig: One (1) Tablet PO ONCE (Once): MD
to dose daily for goal INR [**2-2**], dx: afib.


Discharge Disposition:
Extended Care

Facility:
Hellenic - [**Location (un) 2624**]

Discharge Diagnosis:
Aortic stenosis
Coronary artery disease
Mitral valve regurgitation
Dyslipidemia
Hypertension
Peripheral vascular disease (no interventions)
Atrial fibrillation on Coumadin
Myelodysplasia (no need for frequent transfusions, no prior
chemo)
Congestive heart failure
GERD
neuromuscular disorder affecting leg strength
arthritis


Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with assist
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
right leg- healing well, no erythema or drainage,right thigh
ecchymotic
trace edema left leg, 1+ edema right leg


Discharge Instructions:
1) 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.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) 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) **] [**Telephone/Fax (1) 170**] Date/Time:[**2159-4-11**] 1:15
Cardiologist: Dr. [**Last Name (STitle) 2262**] [**2159-3-26**] at 11:30a

Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 34561**] in [**4-5**] weeks [**Telephone/Fax (1) 3183**]

**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**

Labs: PT/INR for Coumadin ?????? indication a-fib
Goal INR 2-2.5
First draw day after discharge- [**2159-3-14**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr.
**Please arrange for coumadin follow-up on discharge from
rehab**



Completed by:[**2159-3-13**]
{'Mitral valve insufficiency and aortic valve stenosis,Pneumonia, organism unspecified,Acute on chronic diastolic heart failure,Acidosis,Hemorrhage complicating a procedure,Coronary atherosclerosis of native coronary artery,Other chronic pulmonary heart diseases,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Atrial fibrillation,Long-term (current) use of anticoagulants,Myelodysplastic syndrome, unspecified,Esophageal reflux,Myoneural disorders, unspecified,Arthropathy, unspecified, site unspecified,Peripheral vascular disease, unspecified,Examination of participant in clinical trial,Retention of urine, unspecified,Foreign body in larynx,Foreign body accidentally entering other orifice,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in residential institution'}


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: 88 y/o male with HTN, HLD, LE claudication, AF on coumadin, MDS,
moderate to severe AS, who initially presented on [**2159-2-24**] to
[**Hospital3 417**] Hospital via EMS with 2-3 days of nausea,
vomiting, diarrhea, diaphoresis, ? viral prodrome. During the
days up to admission, he also developed DOE and had
progressively more difficulty climbing stairs, requiring rest,
which was a change in baseline. In hindsight, he actually
reports progressive dyspnea while walking for the past several
months (4-6 months), when he was evaluated for LE claudication.
Functionally, he feels he can no longer walk 1 block or do 1
flight of stairs due to his breathing. He also reported weakness
and fatigue. En route, he received 4 aspirin tablets, 81 mg,
along with CPAP.
.
At [**Hospital3 417**] ED, his HR was 113, RR 30s, BP 149/109. He was
in tripod position while breathing. On ROS, he reported cough
for 3-4 days without fever or sputum. He denied abdominal pain
or headache. Denied dizziness. Denies syncope. He also reported
pressure in his epigastrium. He was noted to be tachypnic,
eventually requiring Bipap. X-ray confirmed acute CHF
exacerbation with ? RML infiltrate, and he was placed on nitro
gtt. He was also in rapid AF with ? rate related ST depressions,
requiring lopressor. Once nitro was weaned off, he again went
into flash pulmonary edema. On saturday, he again went into
rapid AF, and developed chest pressure with acute CHF
exacerbation. He has intermittently required Bipap, lasix, and
nitro gtt in CCU. Echo there showed critical AS with valve area
0.4 cm2, and he is transferred for consideration of aortic valve
intervention. Of note, cardiac enzymes were notable for negative
troponin x 2 and BNP 268 then 560.
.
Per review of [**Hospital3 417**] admission note, suspicion was for
congestive heart failure possibly triggered by early pneumonia.
He improved with Bipap, nitro gtt, lasix gtt. He also received
ceftriaxone and azithromycin, but this was discontinued prior to
transfer.
.
Vitals on transfer - afebrile, 95, 116/74, 16, 94% on 3L NC
.
On review of systems, patient reports that his baseline SBP is
110-120. He denies any prior history of stroke, TIA, deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, black stools or red stools. He denies recent fevers,
chills or rigors. All of the other review of systems were
negative.
.
Cardiac review of systems is positive for epigastric discomfort,
DOE, and PND. Reports sleeping on 1 pillow. Notable for absence
of palpitations, syncope or presyncope.

MEDICAL HISTORY: Aortic stenosis
Coronary artery disease
Mitral valve regurgitation
Dyslipidemia
Hypertension
Peripheral vascular disease (no interventions)
Atrial fibrillation on Coumadin
Myelodysplasia (no need for frequent transfusions, no prior
chemo)
Congestive heart failure
GERD
neuromuscular disorder affecting leg strength
arthritis

MEDICATION ON ADMISSION: HOME MEDICATIONS:
- digoxin 0.125 mg daily
- coumadin 10 mg MWF, 5 mg rest of days
- metoprolol 25 mg [**Hospital1 **]
- omeprazole 20 mg qAM
- B12 1000 mcg daily
.
Medications on transfer:
- coumadin (last dose Fri AM)
- maalox prn dyspepsia
- morphine sulfate 2 mg q2 hrs prn chest pain
- magnesium hydroxide prn
- lopressor 25 mg [**Hospital1 **]
- docusate
- aspirin 325 mg daily
- tylenol
- lasix gtt

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS: T=97.0 BP=91/68 HR=74 RR=18 O2 sat=93% 2L NC
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Does have L eye
ptosis. Conjunctiva were pink, no pallor or cyanosis of the oral
mucosa. No xanthalesma.
NECK: Supple with JVP of [**10-12**] cm
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. irregular rhythm. Grade III/VI holosystolic murmur heard
best at LSB. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Diffuse rhonchi and
crackles at bases, without wheezes.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c. Compression stockings present with trace
edema. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: AAOx3, CNII-XII intact, 5/5 strength UE and LE, 2+
reflexes biceps, brachioradialis, patellar, ankle.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+

FAMILY HISTORY: - No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Mother: died from "old age"
- Father: died from leukemia
- Brother: kidney cancer
- Daughter: colon cancer

SOCIAL HISTORY: - Tobacco history: quit smoking more than 40 years ago.
- ETOH: 1 drink per night
- Illicit drugs: denies
- Has one daughter. Very involved son and wife at bedside. 

### Response:
{'Mitral valve insufficiency and aortic valve stenosis,Pneumonia, organism unspecified,Acute on chronic diastolic heart failure,Acidosis,Hemorrhage complicating a procedure,Coronary atherosclerosis of native coronary artery,Other chronic pulmonary heart diseases,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Atrial fibrillation,Long-term (current) use of anticoagulants,Myelodysplastic syndrome, unspecified,Esophageal reflux,Myoneural disorders, unspecified,Arthropathy, unspecified, site unspecified,Peripheral vascular disease, unspecified,Examination of participant in clinical trial,Retention of urine, unspecified,Foreign body in larynx,Foreign body accidentally entering other orifice,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in residential institution'}
