CHIEF COMPLAINT: Post operative cardiac monitoring s/p pericardial effusion
drainage.

PRESENT ILLNESS: Ms. [**Known lastname **] is a 49 y.o woman with a h/o of smoking,
hypercholesterolemia, cardiomegaly, and emphysema with
pericardial effusion. On [**10-17**], the pt had an episode of RUQ
and epigastric pain. She was admitted at [**Hospital1 **] and found to
have a pericardial effussion and right atrial mass. Since that
time she has undergone consultation with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **]
who recommended surgery and has a tentative surgical date of
[**2158-12-4**]. She is also being followed by an oncologist, Dr.
[**Last Name (STitle) **] under who's recommendation is that she has had a
mammogram, a PET scan and cytology of her pericardial fluid.
.
Ms. [**Known lastname **] was admitted today for pericardial tap and Rt heart
cath. There are no perioperative complications. Rt heart cath
showed RA pr 10, PA pr 31/14/22, wedge 12, CO 3.9, CI 2.8, RV pr
31/7/11. Drained 360 cc straw colored fluid. She was transferred
to CCU for post op management.

MEDICAL HISTORY: hypercholesterolemia
Right atrial mass/pericardial effusion
GERD, esophagitis via EGD, s/p dilation
Hiatal hernia
Removal of vocal cord polyp [**2158-9-7**] ([**Hospital1 **])
Prior heavy ETOH, Drinks 2-3 beers per day several times a week

MEDICATION ON ADMISSION: Omeprazole 20mg twice a day
Lorazapam 0.5mg daily at bedtime
Advair diskus 100/50 one puff twice a day
Albuterol inhaler two puffs four times a day prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: vitals: bp 93/59 HR 68 RR 17 SpO2 96% on RA
Gen: Awake & alert, NAD, resting comfortably, reports post-op
pain with inspiration.
HEENT: EOMI, PERRLA, 2mm pupils, no rhinorrhea or lacrimation,
OP clear
Neck:soft & supple, no masses
Heart: distant heart sounds, RRR, S1 & S2 audible, no m/r/g
Lungs: CTAB, no wheezes, rales or rhonchi heard
Abdomen: soft, NT, ND, pericardial drain site C/D/I, no fluid
collection
Extremities: warm & well perfused, periph pulses intact (2+)

FAMILY HISTORY: Father had a CABG at age 56 with subsequent MI's.
He passed away in his late 70's

SOCIAL HISTORY: Patient is single and lives with her sister
[**Name (NI) 2048**] [**Name (NI) 36725**]. She has two children, ages 28 and 30. Her son
[**Name (NI) **] [**Name (NI) **] will accompany her to the hospital. His cell
phone number is [**Telephone/Fax (1) 68740**]. She works as a data entry
supervisor. Patient has smoked up to 2.5 packs a day x 39 years.
Had smoked a pack a day over the past year or two. Quit briefly
but restarted smoking in [**Month (only) **].
Ostium secundum type atrial septal defect,Other emphysema,Candidiasis of mouth,Lump or mass in breast,Cardiomegaly,Lipoma of other specified sites,Esophageal reflux,Other specified cardiac dysrhythmias,Retinal vascular occlusion, unspecified
Secundum atrial sept def,Emphysema NEC,Thrush,Lump or mass in breast,Cardiomegaly,Lipoma NEC,Esophageal reflux,Cardiac dysrhythmias NEC,Retinal vasc occlus NOS
Admission Date:  [**2158-11-30**]              Discharge Date:   [**2158-12-2**]

Date of Birth:  [**2109-9-19**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 11495**]
Chief Complaint:
Post operative cardiac monitoring s/p pericardial effusion
drainage.

Major Surgical or Invasive Procedure:
Pericardial tap and drain placement

History of Present Illness:
Ms. [**Known lastname **] is a 49 y.o woman with a h/o of smoking,
hypercholesterolemia, cardiomegaly, and emphysema with
pericardial effusion. On [**10-17**], the pt had an episode of RUQ
and epigastric pain. She was admitted at [**Hospital1 **] and found to
have a pericardial effussion and right atrial mass. Since that
time she has undergone consultation with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **]
who recommended surgery and has a tentative surgical date of
[**2158-12-4**]. She is also being followed by an oncologist, Dr.
[**Last Name (STitle) **] under who's recommendation is that she has had a
mammogram, a PET scan and cytology of her pericardial fluid.
.
Ms. [**Known lastname **] was admitted today for pericardial tap and Rt heart
cath. There are no perioperative complications. Rt heart cath
showed RA pr 10, PA pr 31/14/22, wedge 12, CO 3.9, CI 2.8, RV pr
31/7/11. Drained 360 cc straw colored fluid. She was transferred
to CCU for post op management.

ROS
Patient reports postop pleuritic pain near drain insertion site.

Denies headache, SOB, abd pain, hematuria, dysuria, N/V/D/C.


Past Medical History:
hypercholesterolemia
Right atrial mass/pericardial effusion
GERD, esophagitis via EGD, s/p dilation
Hiatal hernia
Removal of vocal cord polyp [**2158-9-7**] ([**Hospital1 **])
Prior heavy ETOH, Drinks 2-3 beers per day several times a week

Removal of a cyst on the left ovary
Ectopic pregnancy with removal of part of one tube
D&C
T&A
Emphysema
Migraine headaches


Social History:
Patient is single and lives with her sister
[**Name (NI) 2048**] [**Name (NI) 36725**]. She has two children, ages 28 and 30. Her son
[**Name (NI) **] [**Name (NI) **] will accompany her to the hospital. His cell
phone number is [**Telephone/Fax (1) 68740**]. She works as a data entry
supervisor. Patient has smoked up to 2.5 packs a day x 39 years.
Had smoked a pack a day over the past year or two. Quit briefly
but restarted smoking in [**Month (only) **].


Family History:
Father had a CABG at age 56 with subsequent MI's.
He passed away in his late 70's


Physical Exam:
vitals: bp 93/59 HR 68 RR 17 SpO2 96% on RA
Gen: Awake & alert, NAD, resting comfortably, reports post-op
pain with inspiration.
HEENT: EOMI, PERRLA, 2mm pupils, no rhinorrhea or lacrimation,
OP clear
Neck:soft & supple, no masses
Heart: distant heart sounds, RRR, S1 & S2 audible, no m/r/g
Lungs: CTAB, no wheezes, rales or rhonchi heard
Abdomen: soft, NT, ND, pericardial drain site C/D/I, no fluid
collection
Extremities: warm & well perfused, periph pulses intact (2+)


Pertinent Results:
[**2158-11-30**]
2:37p
139  108  10      AGap=9
-------------< 130
4.1  26  0.6
Ca: 8.5 Mg: 2.1 P: 3.3

 91
7.9 \ 13.1 / 219
    / 37.1 \


[**2158-11-30**]
09:49a
PERICARDIAL FLUID
Other Body Fluid Chemistry:
TotProt: 5.8
Glucose: 100
LD(LDH): 185
Amylase: 30
Albumin: 4.2

PERICARDIAL FLUID
Other Body Fluid Hematology:
WBC: 377
RBC: 385
Polys: 7
Lymphs: 24
Monos: 67
Other: 2

Initial echo:
Large pericardial effusion with tamponade physiology. Right
atrial
mass. Preserved biventricular global and regional biventricular
systolic
function.

Follow up echo:
Overall left ventricular systolic function is normal (LVEF>55%).
There is a
trivial/physiologic pericardial effusion. There are no
echocardiographic signs
of tamponade.

Compared with the prior study (images reviewed) of [**2158-11-30**]
post
pericardiocentesis, there is minimal change.


Brief Hospital Course:
pericardial effusion drainage: Pt had pericardial drainage with
pigtail catheter placement. over 400 cc pericardial fluid
drained total. Repeat echo showed improvement. The catheter was
removed and the patient was discharged home when she was feeling
better, with only slight pleuritic chest pain. EKG showed slight
evidence of pericarditis and she was put on standing ibuprofen.
She will follow up with cardiac surgery for myxoma removal in 2
days on [**2158-12-4**].


Medications on Admission:
Omeprazole 20mg twice a day
Lorazapam 0.5mg daily at bedtime
Advair diskus 100/50 one puff twice a day
Albuterol inhaler two puffs four times a day prn


Discharge Medications:
1. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
2. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours).
4. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*0*
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Company 1519**]

Discharge Diagnosis:
1)Pericardial effusion s/p tap and drain placement
2)Right atrial mass

Discharge Condition:
Stable

Discharge Instructions:
1)Please continue with your home medications.

2)Please return for surgery on Monday [**2158-12-4**] as you have been
instructed.

3)If you experience any chest pain, SOB, lightheadedness,
dizziness or any concerning symptoms, please return to the
Emergency department.

Followup Instructions:
You will be contact[**Name (NI) **] by Dr. [**Last Name (Prefixes) 68741**] or Dr. [**Last Name (STitle) **]
regarding further tests and appointments, likley surgery on
Monday [**2158-12-4**].




Admission Date:  [**2158-12-4**]              Discharge Date:   [**2158-12-12**]

Date of Birth:  [**2109-9-19**]             Sex:   F

Service: CARDIOTHORACIC

Allergies:
Codeine / Dilaudid

Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
49F with epigastric discomfort.

Major Surgical or Invasive Procedure:
s/p Resection of R atrial mass/PFO closure [**2158-12-4**]


History of Present Illness:
This 49F was recently hospitalized for abdominal pain.  The work
up revealed a large pericardial effusion and a R atrial mass.
Echo showed a 2x1 cm mass on the RA free wall and a lg.
posterior pericardial effusion. She underwent pericardiocentesis
on [**2158-11-30**].  She was asdmitted for surgical resection of the
mass.


Past Medical History:
hypercholesterolemia
Right atrial mass/pericardial effusion
GERD, esophagitis via EGD, s/p dilation
Hiatal hernia
Removal of vocal cord polyp [**2158-9-7**] ([**Hospital1 **])
Prior heavy ETOH, Drinks 2-3 beers per day several times a week

Removal of a cyst on the left ovary
Ectopic pregnancy with removal of part of one tube
D&C
T&A
Emphysema
Migraine headaches


Social History:
Patient is single and lives with her sister
[**Name (NI) 2048**] [**Name (NI) 36725**]. She has two children, ages 28 and 30. Her son
[**Name (NI) **] [**Name (NI) **] will accompany her to the hospital. His cell
phone number is [**Telephone/Fax (1) 68740**]. She works as a data entry
supervisor. Patient has smoked up to 2.5 packs a day x 39 years.
Had smoked a pack a day over the past year or two. Quit briefly
but restarted smoking in [**Month (only) **].


Family History:
Father had a CABG at age 56 with subsequent MI's.
He passed away in his late 70's


Physical Exam:
WDWNWF in NAD
HEENT: NC/AT, PERLA, EOMI, oropharynx benign
Neck: supple, FROM, no thyromegaly or lymphadenopathy, carotids
2+=bilat. throughout.
Lungs: Clear to A+P
CV: RRR without R/G/M, nl. S1, S2
Abd: +BS, soft, nontender, without masses or hepatosplenomegaly.
Ext: without C/C/E, pulses 2+=bilat. throughout.
Neuro: nonfocal

Pertinent Results:
[**2158-12-10**] 04:10AM BLOOD WBC-5.2 RBC-3.39*# Hgb-10.7*# Hct-30.5*#
MCV-90 MCH-31.4 MCHC-35.0 RDW-14.2 Plt Ct-225
[**2158-12-8**] 02:13AM BLOOD PT-12.8 PTT-32.4 INR(PT)-1.1
[**2158-12-10**] 04:10AM BLOOD Glucose-98 UreaN-9 Creat-0.5 Na-137 K-4.5
Cl-103 HCO3-28 AnGap-11
RADIOLOGY  Final Report

CHEST (PA & LAT)  [**2158-12-11**] 10:26 AM

CHEST (PA & LAT)

Reason: pleural effusion/pneumothorax - please do sometime this
am t

[**Hospital 93**] MEDICAL CONDITION:
49 year old woman s/p l atrial mass removal and PFO closure
REASON FOR THIS EXAMINATION:
pleural effusion/pneumothorax - please do sometime this am thank
you
COMPARISON: [**2158-12-5**].

INDICATION: Pleural effusion. Postop.

Right internal jugular vascular sheath has been removed, with no
evidence of pneumothorax. Small pleural effusions are now
present bilaterally where as previously there was only a minimal
left effusion present. Adjacent bibasilar opacities are likely
due to atelectasis. The remainder of the lungs are clear, and
cardiac and mediastinal contours are within normal limits for
postoperative status of the patient.

IMPRESSION: New small right and increasing small left pleural
effusion with adjacent basilar atelectasis.

DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
RADIOLOGY  Final Report

CHEST (PORTABLE AP)  [**2158-12-5**] 8:34 AM

CHEST (PORTABLE AP)

Reason: r/o ptx

[**Hospital 93**] MEDICAL CONDITION:
49 year old woman s/p res. R atrial mass/ closure PFO and ct
removal
REASON FOR THIS EXAMINATION:
r/o ptx
AP CHEST 8:40 A.M. ON [**12-5**].

HISTORY: Right atrial mass and PFO. Chest tube removed.

IMPRESSION: AP chest compared to [**11-29**] and 30:

Minimal left pleural effusion. No pneumothorax. Heart size
normal. Mediastinum midline. Right jugular sheath tip at the
thoracic inlet.

DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]








Brief Hospital Course:
The patient was admitted on [**12-4**] and underwent resection of R
atrial mass and closure of PFO.  Cross clamp time was 37 mins,
total bypass time was 53 mins.  She tolerated the procedure well
and was transferred to the CSRU in stable condition on Neo and
Propofol.  She was extubated on the post op night and had her
chest tubes removed on POD#1.  She was bradycardic and required
intermittent epicardial pacing.  She continued to be bradycardic
and required neo for several days.  EP evaluated her and
determined that she did not need pacer placement as she had good
AV conduction and her HR responded to exercise.  She was
transferred to the floor and continued to improve.  Her pacing
wires were d/c'd on POD#6. She went on to experience visual
defects, complaining of a "[**Doctor Last Name 352**] spot" in her vision. The
neurology and ophthalmology services were consulted. Her visual
deficit was most likely related to emboli and no further
recommendations were made as she was already on Aspirin therapy.
She will follow up with the eye clinic as an outpatient. The
rest of her hospital course was unremarkable and she was cleared
for discharge on postoperative day eight.

Medications on Admission:
Advair diskus
Albuterol
Prilosec 40 mg PO BID

Discharge Medications:
1. 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:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 inhaler* Refills:*0*
7. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 Disk with Device(s)* Refills:*0*
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
9. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO q8H:PRN as
needed for pain.
Disp:*2 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Company 1519**]

Discharge Diagnosis:
Right atrial mass - s/p removal, PFO - s/p closure, post op
bradycardia, Post op visual deficit


Discharge Condition:
Good.


Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use powders, lotions, or creams on wounds.
Call our office for sternal drainage, temp>101.5.

Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 32996**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 1290**] for 4 weeks.
Make an appointment with Dr. [**Last Name (STitle) **] (electrophysiology
cardiologist) in 3 months.



Completed by:[**2158-12-22**]
{'Ostium secundum type atrial septal defect,Other emphysema,Candidiasis of mouth,Lump or mass in breast,Cardiomegaly,Lipoma of other specified sites,Esophageal reflux,Other specified cardiac dysrhythmias,Retinal vascular occlusion, 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: Post operative cardiac monitoring s/p pericardial effusion
drainage.

PRESENT ILLNESS: Ms. [**Known lastname **] is a 49 y.o woman with a h/o of smoking,
hypercholesterolemia, cardiomegaly, and emphysema with
pericardial effusion. On [**10-17**], the pt had an episode of RUQ
and epigastric pain. She was admitted at [**Hospital1 **] and found to
have a pericardial effussion and right atrial mass. Since that
time she has undergone consultation with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **]
who recommended surgery and has a tentative surgical date of
[**2158-12-4**]. She is also being followed by an oncologist, Dr.
[**Last Name (STitle) **] under who's recommendation is that she has had a
mammogram, a PET scan and cytology of her pericardial fluid.
.
Ms. [**Known lastname **] was admitted today for pericardial tap and Rt heart
cath. There are no perioperative complications. Rt heart cath
showed RA pr 10, PA pr 31/14/22, wedge 12, CO 3.9, CI 2.8, RV pr
31/7/11. Drained 360 cc straw colored fluid. She was transferred
to CCU for post op management.

MEDICAL HISTORY: hypercholesterolemia
Right atrial mass/pericardial effusion
GERD, esophagitis via EGD, s/p dilation
Hiatal hernia
Removal of vocal cord polyp [**2158-9-7**] ([**Hospital1 **])
Prior heavy ETOH, Drinks 2-3 beers per day several times a week

MEDICATION ON ADMISSION: Omeprazole 20mg twice a day
Lorazapam 0.5mg daily at bedtime
Advair diskus 100/50 one puff twice a day
Albuterol inhaler two puffs four times a day prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: vitals: bp 93/59 HR 68 RR 17 SpO2 96% on RA
Gen: Awake & alert, NAD, resting comfortably, reports post-op
pain with inspiration.
HEENT: EOMI, PERRLA, 2mm pupils, no rhinorrhea or lacrimation,
OP clear
Neck:soft & supple, no masses
Heart: distant heart sounds, RRR, S1 & S2 audible, no m/r/g
Lungs: CTAB, no wheezes, rales or rhonchi heard
Abdomen: soft, NT, ND, pericardial drain site C/D/I, no fluid
collection
Extremities: warm & well perfused, periph pulses intact (2+)

FAMILY HISTORY: Father had a CABG at age 56 with subsequent MI's.
He passed away in his late 70's

SOCIAL HISTORY: Patient is single and lives with her sister
[**Name (NI) 2048**] [**Name (NI) 36725**]. She has two children, ages 28 and 30. Her son
[**Name (NI) **] [**Name (NI) **] will accompany her to the hospital. His cell
phone number is [**Telephone/Fax (1) 68740**]. She works as a data entry
supervisor. Patient has smoked up to 2.5 packs a day x 39 years.
Had smoked a pack a day over the past year or two. Quit briefly
but restarted smoking in [**Month (only) **]. 

### Response:
{'Ostium secundum type atrial septal defect,Other emphysema,Candidiasis of mouth,Lump or mass in breast,Cardiomegaly,Lipoma of other specified sites,Esophageal reflux,Other specified cardiac dysrhythmias,Retinal vascular occlusion, unspecified'}
