CHIEF COMPLAINT: 

PRESENT ILLNESS: This is an 80 year old female
with a history of hypertension, hypercholesterolemia, mild
Raynaud's insufficiency and known aortic stenosis who
presented for cardiac catheterization on [**2116-2-6**],
to further assess her aortic valve.  She has been known to
have aortic stenosis since [**2105**] and has been followed by
serial echocardiograms.  The patient had an electrocardiogram
on [**1-16**], which showed normal left ventricular function,
aortic valve area of 0.5 cm squared, peak gradient of 9 mm of
mercury and a mean gradient of 54 with 1+ mitral
regurgitation, trace aortic regurgitation and 1+ tricuspid
regurgitation.

MEDICAL HISTORY: 1.  Hypertension; 2.
Hypercholesterolemia; 3.  Osteoarthritis; 4.  Depression; 5.
Mild renal insufficiency; 6.  Status post cesarean section
times two; 7.  Status post cholecystectomy; 8.  Status post
tonsillectomy; 9.  Status post hernia repair times three; 10.
Status post eye surgery; 11.  Status post BMT times two.

MEDICATION ON ADMISSION: 

ALLERGIES: Zephryn which gives her a rash.  Benadryl which
gives her a rash and Iodine which gives her a rash.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient lives with husband.  Denies
tobacco or ethyl alcohol use.
Rheumatic heart failure (congestive),Mitral valve insufficiency and aortic valve stenosis,Hemorrhage complicating a procedure,Peripheral vascular complications, not elsewhere classified,Hyperosmolality and/or hypernatremia,Cellulitis and abscess of trunk
Rheumatic heart failure,Mitral insuf/aort stenos,Hemorrhage complic proc,Surg comp-peri vasc syst,Hyperosmolality,Cellulitis of trunk
Admission Date:  [**2116-2-6**]       Discharge Date:  [**2116-3-2**]


Service:

HISTORY OF PRESENT ILLNESS:  This is an 80 year old female
with a history of hypertension, hypercholesterolemia, mild
Raynaud's insufficiency and known aortic stenosis who
presented for cardiac catheterization on [**2116-2-6**],
to further assess her aortic valve.  She has been known to
have aortic stenosis since [**2105**] and has been followed by
serial echocardiograms.  The patient had an electrocardiogram
on [**1-16**], which showed normal left ventricular function,
aortic valve area of 0.5 cm squared, peak gradient of 9 mm of
mercury and a mean gradient of 54 with 1+ mitral
regurgitation, trace aortic regurgitation and 1+ tricuspid
regurgitation.

PAST MEDICAL HISTORY:  1.  Hypertension; 2.
Hypercholesterolemia; 3.  Osteoarthritis; 4.  Depression; 5.
Mild renal insufficiency; 6.  Status post cesarean section
times two; 7.  Status post cholecystectomy; 8.  Status post
tonsillectomy; 9.  Status post hernia repair times three; 10.
Status post eye surgery; 11.  Status post BMT times two.

SOCIAL HISTORY:  The patient lives with husband.  Denies
tobacco or ethyl alcohol use.

ALLERGIES:  Zephryn which gives her a rash.  Benadryl which
gives her a rash and Iodine which gives her a rash.

PREOPERATIVE MEDICATIONS:
1.  Avapro 150 mg p.o. q. day
2.  Zoloft 50 mg p.o. q. day
3.  Tri-Chlor 160 mg p.o. q. day
4.  Occuvite one tablet p.o. q. day
5.  Aspirin 325 mg p.o. q. day

HOSPITAL COURSE:  The patient was admitted to [**Hospital6 1760**] on [**2116-2-6**] for
cardiac catheterization which showed mild diffuse distal left
anterior descending disease, 60 to 70% diagonal disease, 40%
circumflex disease, 90% proximal right coronary artery
disease, aortic valve with 100 mm gradient, aortic valve area
0.5 cm squared.  The patient was referred for evaluation by
the Cardiac Surgery Team.  In the Cardiac Catheterization
Laboratory the patient was noted to have a vagal response
post catheterization with a hematoma in the right groin.  The
patient underwent an ultrasound of the right groin which
showed an arteriovenous fistula without evidence of
pseudoaneurysm.  A vascular consult was obtained.  Vascular
recommended just observing and follow up in two to three
weeks as an outpatient.

On the evening of hospital day #2, Cardiac Surgery was
called.  The patient developed 5 out of 10 chest pain while
she was waiting to be discharged.  It was decided the patient
would remain in the hospital and be taken for surgery after
Vascular Surgery had decided to repair the arteriovenous
fistula.  On postoperative day #3, the patient had a dental
consult to evaluate her teeth preoperative for aortic valve
replacement.  It was determined there was no evidence of
infections noted and the patient was cleared for cardiac
surgery.  The patient had an episode of atrial fibrillation
while she had chest pain.  She was started on Amiodarone.  On
hospital day #4, the patient was found to have a hematocrit
of 26 for which she received 2 units of packed red blood cell
transfusion, and on [**2116-2-10**], she was taken to the
Operating Room by Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 1391**] for a coronary
artery bypass graft times one and an aortic valve replacement
with a 19 mm [**Company 1543**] Mosaic valve.  Please see operative
note for further details.  The patient also underwent a
repair of the right arteriovenous fistula by Dr. [**Last Name (STitle) 1391**] of
Vascular Surgery.

The patient was transferred to the Intensive Care Unit in
stable condition on Dobutamine infusion, epinephrine,
Levophed and Vasopressin.  Postoperatively the patient had a
large volume requirement, required aggressive fluid
resuscitation.  On postoperative day #2, the Vasopressin was
weaned off.  The patient continued on Epinephrine and
Dobutamine.  The patient had a cardiac index greater than 2.
By postoperative day #3, the epinephrine and the Dobutamine
had been weaned off with continued good hemodynamics.  The
pulmonary artery catheter was removed.  The patient was off
of all pressors.

Hypertensive and tachycardiac, the patient was started on
Lopressor which she tolerated well.  The patient was
attempted to be weaned from mechanical ventilation, however,
her work of breathing increased and her oxygen saturation
decreased.  On postoperative day #3, the patient' platelet
count was noted be 64.  Heparin antibodies were sent which
was subsequently negative.  The patient was able to be weaned
from mechanical ventilation.  She was started on enteral tube
feeds.  She was started on Lasix for diuresis.  Over the next
several days, the patient underwent aggressive diuretic
therapy as the patient was noted to be greater than 15 kg up
from her preoperative weight.  On postoperative day #5, the
patient was noted to have acute desaturations and the patient
underwent an urgent bronchoscopy which showed thick
secretions and tracheobronchitis.  The patient's oxygenation
improved after this.  The patient continued to have
difficulties weaning from mechanical ventilation.  The
patient had diuresed over 6 liters in three days developing a
metabolic alkalosis for which she was started on Diamox.  The
patient's baseline creatinine which was 1.4 was 1.5.  On
postoperative day #7, the patient was weaned to CPAP which
she tolerated during the day and was placed back on IMV
during the night.

On postoperative day #8, the patient continued on Diamox,
however, the patient did become hypernatremic to 150
requiring free water replacement.  She remained
hemodynamically stable during this time.  However, the
patient's respiratory status became more tenuous with
increased work of breathing and decreased oxygen saturation.
Chest x-rays showed a worsening diffuse interstitial pattern.
Sputum cultures were negative for any evidence of pneumonia,
however, the patient was started on antibiotics empirically.
A pulmonary consult was obtained who recommended reinserting
pulmonary artery catheter and obtaining an echocardiogram.
Echocardiogram showed mildly dilated left atrium, normal left
ventricular cavity size, slightly depressed left ventricular
systolic function, an aortic valve peak gradient of 53 mm of
mercury and severe 4+ mitral regurgitation.  Upon insertion
of the pulmonary artery catheter, the patient was found to
have significantly elevated pulmonary artery pressures and
wedge pressure.  With information, the patient underwent
aggressive diuresis with the significant findings of fluid
overload and inability to wean from mechanical ventilation.
General Surgery was consulted for a tracheostomy.  The
patient continued to receive aggressive diuresis.

On postoperative day #11, the patient's pulmonary catheter
was removed and the cordis was changed to a triple lumen.  On
postoperative day #11, it was noted that the right groin
incision had developed significant erythema and fluid
drainage.  The wound was opened and packed with wet to dry.
The culture subsequently grew coagulase negative
Staphylococcus, mild lactose-fermenting gram negative rods
and Peptostreptococcus.  The patient was started on Zosyn for
coverage and continued on Vancomycin.  On postoperative day
#12 the patient's epicardial pacing wires were removed
without incident.  By postoperative day #12, the patient was
able to be weaned to CPAP with pressor support during the
day, tolerating decreasing amounts of pressor support.  On
postoperative day #14, the patient underwent a tracheostomy
by Dr. [**Last Name (STitle) **] with a #8 [**Doctor Last Name 4726**]-Tex.  The patient tolerated
this procedure well.  By postoperative day #15, the patient
was able to remain on CPAP continuously with continued
significant diuresis.  By postoperative day #16, Pulmonary
Medicine had signed off and recommended continued diuretics,
a total of ten days of antibiotics for the
ventilator-associated pneumonia.

On postoperative day #16, the patient developed profuse
diarrhea with a rise in white count.  Specimens were sent for
Clostridium difficile which were subsequently, however, the
patient was empirically placed on Flagyl and the patient's
white blood cell count began to decrease.  The amount of
diarrhea began to decrease.  Also on postoperative day #16,
the patient was noted to have significant amount of bleeding
from around the trach site.  Surgery was consulted and it was
decided the patient had a skin bleeder, and the area was
approximated with a stitch and the bleeding subsequently
stopped.  The right groin wound appeared to be clean and a
wound vacuum-assisted closure dressing was applied.

On postoperative day #17, a repeat echocardiogram was
obtained which showed mild symmetric left ventricular
hypertrophy, mildly depressed left ventricular systolic
function and aortic valve gradient of 76 mm of mercury,
moderate to severe mitral regurgitation, study not
significantly changed from previous.  The patient also
underwent evaluation by the Speech and Swallow Team for her
ability to take p.o. and it was determined the patient was
safe to take thin liquids and pureed food which she tolerated
well.  She also tolerated a Passy-Muir valve and the patient
is preliminary scheduled to be discharged to rehabilitation
on [**3-2**].

The remainder of this discharge summary will be dictated at
that time.


                            [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 3113**]

Dictated By:[**Last Name (NamePattern1) 1541**]
MEDQUIST36

D:  [**2116-2-28**]  20:39
T:  [**2116-2-29**]  07:27
JOB#:  [**Job Number 53300**]


Name:  [**Known lastname 9941**], [**Known firstname **]                 Unit No:  [**Numeric Identifier 9942**]

Admission Date:  [**2116-2-6**]     Discharge Date:  [**2116-3-2**]

Date of Birth:   [**2036-7-2**]     Sex:  F

Service:

On postoperative day #2, the Vasopressin was weaned off.  The
patient continued on Epinephrine and Dobutamine.  The patient
had a cardiac index greater than 2.  By postoperative day #3,
the epinephrine and the Dobutamine had been weaned off with
continued good hemodynamics.  The pulmonary artery catheter
was removed.  The patient was off of all pressors.

Hypertensive and tachycardiac, the patient was started on
Lopressor which she tolerated well.  The patient was
attempted to be weaned from mechanical ventilation, however,
her work of breathing increased and her oxygen saturation
decreased.  On postoperative day #3, the patient' platelet
count was noted be 64.  Heparin antibodies were sent which
was subsequently negative.  The patient was able to be weaned
from mechanical ventilation.  She was started on enteral tube
feeds.  She was started on Lasix for diuresis.  Over the next
several days, the patient underwent aggressive diuretic
therapy as the patient was noted to be greater than 15 kg up
from her preoperative weight.  On postoperative day #5, the
patient was noted to have acute desaturations and the patient
underwent an urgent bronchoscopy which showed thick
secretions and tracheobronchitis.  The patient's oxygenation
improved after this.  The patient continued to have
difficulties weaning from mechanical ventilation.  The
patient had diuresed over 6 liters in three days developing a
metabolic alkalosis for which she was started on Diamox.  The
patient's baseline creatinine which was 1.4 was 1.5.  On
postoperative day #7, the patient was weaned to CPAP which
she tolerated during the day and was placed back on IMV
during the night.

On postoperative day #8, the patient continued on Diamox,
however, the patient did become hypernatremic to 150
requiring free water replacement.  She remained
hemodynamically stable during this time.  However, the
patient's respiratory status became more tenuous with
increased work of breathing and decreased oxygen saturation.
Chest x-rays showed a worsening diffuse interstitial pattern.
Sputum cultures were negative for any evidence of pneumonia,
however, the patient was started on antibiotics empirically.
A pulmonary consult was obtained who recommended reinserting
pulmonary artery catheter and obtaining an echocardiogram.
Echocardiogram showed mildly dilated left atrium, normal left
ventricular cavity size, slightly depressed left ventricular
systolic function, an aortic valve peak gradient of 53 mm of
mercury and severe 4+ mitral regurgitation.  Upon insertion
of the pulmonary artery catheter, the patient was found to
have significantly elevated pulmonary artery pressures and
wedge pressure.  With information, the patient underwent
aggressive diuresis with the significant findings of fluid
overload and inability to wean from mechanical ventilation.
General Surgery was consulted for a tracheostomy.  The
patient continued to receive aggressive diuresis.

On postoperative day #11, the patient's pulmonary catheter
was removed and the cordis was changed to a triple lumen.  On
postoperative day #11, it was noted that the right groin
incision had developed significant erythema and fluid
drainage.  The wound was opened and packed with wet to dry.
The culture subsequently grew coagulase negative
Staphylococcus, mild lactose-fermenting gram negative rods
and Peptostreptococcus.  The patient was started on Zosyn for
coverage and continued on Vancomycin.  On postoperative day
#12 the patient's epicardial pacing wires were removed
without incident.  By postoperative day #12, the patient was
able to be weaned to CPAP with pressor support during the
day, tolerating decreasing amounts of pressor support.  On
postoperative day #14, the patient underwent a tracheostomy
by Dr. [**Last Name (STitle) **] with a #8 [**Doctor Last Name 2320**]-Tex.  The patient tolerated
this procedure well.  By postoperative day #15, the patient
was able to remain on CPAP continuously with continued
significant diuresis.  By postoperative day #16, Pulmonary
Medicine had signed off and recommended continued diuretics,
a total of ten days of antibiotics for the
ventilator-associated pneumonia.

On postoperative day #16, the patient developed profuse
diarrhea with a rise in white count.  Specimens were sent for
Clostridium difficile which were subsequently, however, the
patient was empirically placed on Flagyl and the patient's
white blood cell count began to decrease.  The amount of
diarrhea began to decrease.  Also on postoperative day #16,
the patient was noted to have significant amount of bleeding
from around the trach site.  Surgery was consulted and it was
decided the patient had a skin bleeder, and the area was
approximated with a stitch and the bleeding subsequently
stopped.  The right groin wound appeared to be clean and a
wound vacuum-assisted closure dressing was applied.

On postoperative day #17, a repeat echocardiogram was
obtained which showed mild symmetric left ventricular
hypertrophy, mildly depressed left ventricular systolic
function and aortic valve gradient of 76 mm of mercury,
moderate to severe mitral regurgitation, study not
significantly changed from previous.  The patient also
underwent evaluation by the Speech and Swallow Team for her
ability to take p.o. and it was determined the patient was
safe to take thin liquids and pureed food which she tolerated
well.  She also tolerated a Passy-Muir valve and the patient
is preliminary scheduled to be discharged to rehabilitation
on [**3-2**].

The remainder of this discharge summary will be dictated at
that time.








                          [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 358**], M.D.  [**MD Number(1) 359**]

Dictated By:[**Last Name (NamePattern1) 5788**]

MEDQUIST36

D:  [**2116-2-28**]  21:04
T:  [**2116-2-29**]  07:41
JOB#:  [**Job Number 9943**]
{'Rheumatic heart failure (congestive),Mitral valve insufficiency and aortic valve stenosis,Hemorrhage complicating a procedure,Peripheral vascular complications, not elsewhere classified,Hyperosmolality and/or hypernatremia,Cellulitis and abscess of trunk'}


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: 

PRESENT ILLNESS: This is an 80 year old female
with a history of hypertension, hypercholesterolemia, mild
Raynaud's insufficiency and known aortic stenosis who
presented for cardiac catheterization on [**2116-2-6**],
to further assess her aortic valve.  She has been known to
have aortic stenosis since [**2105**] and has been followed by
serial echocardiograms.  The patient had an electrocardiogram
on [**1-16**], which showed normal left ventricular function,
aortic valve area of 0.5 cm squared, peak gradient of 9 mm of
mercury and a mean gradient of 54 with 1+ mitral
regurgitation, trace aortic regurgitation and 1+ tricuspid
regurgitation.

MEDICAL HISTORY: 1.  Hypertension; 2.
Hypercholesterolemia; 3.  Osteoarthritis; 4.  Depression; 5.
Mild renal insufficiency; 6.  Status post cesarean section
times two; 7.  Status post cholecystectomy; 8.  Status post
tonsillectomy; 9.  Status post hernia repair times three; 10.
Status post eye surgery; 11.  Status post BMT times two.

MEDICATION ON ADMISSION: 

ALLERGIES: Zephryn which gives her a rash.  Benadryl which
gives her a rash and Iodine which gives her a rash.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient lives with husband.  Denies
tobacco or ethyl alcohol use. 

### Response:
{'Rheumatic heart failure (congestive),Mitral valve insufficiency and aortic valve stenosis,Hemorrhage complicating a procedure,Peripheral vascular complications, not elsewhere classified,Hyperosmolality and/or hypernatremia,Cellulitis and abscess of trunk'}
