CHIEF COMPLAINT: Shortness of breath

PRESENT ILLNESS: Patient is a 70yo F w/ PMHx of critical AS, Rheumatic heart
disease, HTN HLD, hypothyroidism, UC, atrial fibrillation who
presented from OSH with shortness of breath.

MEDICAL HISTORY: --Rheumatic heart disease with mild mitral stenosis, mitral
regurgitation, moderate aortic insufficiency, preserved LV
function
--Paroxysmal atrial fibrillation, s/p two prior cardioversions
in [**2143**] and [**2145**], and most recently 1 week prior to admission.
--Diastolic CHF
--Hypertension
--Hyperlipidemia
--Ulcerative colitis
--s/p CcY
--Bipolar disorder

MEDICATION ON ADMISSION: --Meclizine 25mg [**Hospital1 **]
--Amiodarone 200mg daily
--Lisinopril 40mg daily
--Warfarin 3mg daily
--Crestor 20mg daily
--Amlodipine 5mg daily
--Levothyroxine 88mcg daily

ALLERGIES: Sulfa(Sulfonamide Antibiotics)

PHYSICAL EXAM: Admission physical exam:
VS: T 98.4, BP 152/82, HR 104, RR 18, SpO2 99% on RA
GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: There is no family history of hypertension, diabetes, heart
disease, or strokes.

SOCIAL HISTORY: She is divorced and lives alone.   She quit smoking in [**2130**] and
denies alcohol or illicit drug use.
Acute on chronic diastolic heart failure,Pneumonia, organism unspecified,Acute kidney failure, unspecified,Other pulmonary insufficiency, not elsewhere classified, following trauma and surgery,Acidosis,Unspecified pleural effusion,Mitral valve insufficiency and aortic valve stenosis,Atrial fibrillation,Other ill-defined heart diseases,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Benign paroxysmal positional vertigo,Personal history of other diseases of digestive system,Examination of participant in clinical trial
Ac on chr diast hrt fail,Pneumonia, organism NOS,Acute kidney failure NOS,Ot pul insuf fol trm/srg,Acidosis,Pleural effusion NOS,Mitral insuf/aort stenos,Atrial fibrillation,Ill-defined hrt dis NEC,Hypertension NOS,Hyperlipidemia NEC/NOS,Hypothyroidism NOS,Benign parxysmal vertigo,Prsnl hst ot spf dgst ds,Exam-clincal trial
Admission Date:  [**2152-4-29**]              Discharge Date:   [**2152-5-15**]

Date of Birth:  [**2081-12-30**]             Sex:   F

Service: CARDIOTHORACIC

Allergies:
Sulfa(Sulfonamide Antibiotics)

Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Shortness of breath

Major Surgical or Invasive Procedure:
Aortic valve replacement(#19 On-X), Mitral valve replacement
(#25/33 On-X), MAZE [**5-4**]


History of Present Illness:
Patient is a 70yo F w/ PMHx of critical AS, Rheumatic heart
disease, HTN HLD, hypothyroidism, UC, atrial fibrillation who
presented from OSH with shortness of breath.

Patient reports that she went for cardioveresion [**2152-4-26**]. The
day after cardioversion, the patient developed sharp pain
beneath her breast and in the back. The pain is described as
sharp. She also noticed worsening SOB; she could not sustain her
energy level for the same duration. The patient also reprots
that she has not been able to sleep at night secondary to her
heart bounding. She denies SOB keeping her up at night. She has
stable 3 pillow orthopnea. She denies LE edema or increased
abdominal girth. Because of these symptoms, the patient went to
see her PCP who them referred her to the ED.

Patient presented to OSH with increaseing SOB and mid-back pain.
She was noted to have bilateral interstitial opacities on
imaging with right greater than the left and minimal bluding of
the right costophrenic angle, suggestive of PNA. She was placed
on IV antibiotics with ceftriaxone and azithromycin. The patient
was noted to have low-grade fevers, of 100.7 on transfer to
[**Hospital1 18**]. The patient had blood cultures drawn at the OSH, that
were pending at the time of transfer, but have remained NGTD.
Upon transfer, the patient was noted to have an irregular beat,
satting 93% on 2.5L via NC.

Patient was seen by Dr. [**Last Name (STitle) **] [**2152-4-12**] to discuss options
related to her critical aortic stenosis. During that visit, the
patient was thought to be a good surgical candidate for AVR. But
at the time, the patient was not a candidate for transcatehter
aortic valve replacement. Dr. [**Last Name (STitle) **] planned to follow the
patient up in 3 months time to reassess her symptoms.

On arrival to the floor, patient reports shortness of breath.

REVIEW OF SYSTEMS:
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, hemoptysis,
black stools or red stools. She denies recent fevers, chills or
rigors. All of the other review of systems were negative.

Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope. Of note, she does report
vertigo.

Past Medical History:
--Rheumatic heart disease with mild mitral stenosis, mitral
regurgitation, moderate aortic insufficiency, preserved LV
function
--Paroxysmal atrial fibrillation, s/p two prior cardioversions
in [**2143**] and [**2145**], and most recently 1 week prior to admission.
--Diastolic CHF
--Hypertension
--Hyperlipidemia
--Ulcerative colitis
--s/p CcY
--Bipolar disorder

Social History:
She is divorced and lives alone.   She quit smoking in [**2130**] and
denies alcohol or illicit drug use.


Family History:
There is no family history of hypertension, diabetes, heart
disease, or strokes.


Physical Exam:
Admission physical exam:
VS: T 98.4, BP 152/82, HR 104, RR 18, SpO2 99% on RA
GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

NECK: Supple with JVD to the angle of the mandible.
CARDIAC: Ireegularly irregular, normal S1, but deminished S2.
Harsh 4/6 systolic cres/decres murmur best appreciated at the
RUSB. Holosystolic murmur radiating to the back as well. No
thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles at the bases
bilaterally, extending to [**12-24**] the lung fields posteriorly. No
wheezes.
ABDOMEN: BS+. Soft, ND. Diffusely tender throughout the abdomen.
No rebound or guarding. No HSM.
EXTREMITIES: No c/c. Trace pitting edema bilaterally to the
knees. No femoral bruits.
NEURO: CN II-XII tested and intact, strength 5/5 throughout,
sensation grossly normal. Gait not tested.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:  Right: DP 2+    Left: DP 2+

Pertinent Results:
Echocardiographic: [**2152-5-5**]
Conclusions
Overall left ventricular systolic function is normal (LVEF>55%).
There is abnormal septal motion/position. A mechanical aortic
valve prosthesis is present. The aortic valve prosthesis appears
well seated, with normal leaflet/disc motion and transvalvular
gradients. A mechanical mitral valve prosthesis is present. The
mitral prosthesis appears well seated, with normal leaflet/disc
motion and transvalvular gradients. The tricuspid valve leaflets
are mildly thickened. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion. There
are no echocardiographic signs of tamponade.
.

[**2152-5-14**] 06:35AM BLOOD WBC-6.5 RBC-2.93* Hgb-8.9* Hct-27.2*
MCV-93 MCH-30.3 MCHC-32.6 RDW-14.9 Plt Ct-272
[**2152-5-13**] 04:30AM BLOOD WBC-8.4 RBC-3.07* Hgb-9.1* Hct-28.5*
MCV-93 MCH-29.8 MCHC-32.1 RDW-15.0 Plt Ct-271
[**2152-5-15**] 04:56AM BLOOD PT-30.3* INR(PT)-2.9*
[**2152-5-14**] 06:35AM BLOOD PT-24.1* INR(PT)-2.3*
[**2152-5-13**] 12:50PM BLOOD PT-21.5* INR(PT)-2.0*
[**2152-5-13**] 04:30AM BLOOD PT-21.3* PTT-98.7* INR(PT)-2.0*
[**2152-5-12**] 08:55AM BLOOD PT-17.8* PTT-52.0* INR(PT)-1.7*
[**2152-5-11**] 04:42AM BLOOD PT-16.7* PTT-90.0* INR(PT)-1.6*
[**2152-5-10**] 10:30AM BLOOD PT-16.2* PTT-34.5 INR(PT)-1.5*
[**2152-5-9**] 05:24AM BLOOD PT-18.1* INR(PT)-1.7*
[**2152-5-8**] 02:25AM BLOOD PT-22.3* INR(PT)-2.1*
[**2152-5-15**] 04:56AM BLOOD UreaN-17 Creat-1.6* Na-137 K-3.7 Cl-94*
HCO3-34* AnGap-13
[**2152-5-14**] 06:35AM BLOOD Glucose-91 UreaN-18 Creat-1.5* Na-136
K-3.5 Cl-94* HCO3-32 AnGap-14
[**2152-5-13**] 04:30AM BLOOD Glucose-88 UreaN-19 Creat-1.4* Na-136
K-4.0 Cl-95* HCO3-31 AnGap-14

Brief Hospital Course:
MEDICINE COURSE:
.Patient is a 70yo F w/ PMHx of critical AS, Rheumatic heart
disease, HTN HLD, hypothyroidism, UC, atrial fibrillation who
presented from OSH with shortness of breath likely due to acute
on chronic diastolic CHF.

# Acute on Chronic diastolic CHF: Upon presentation, the patient
appeared volume overloaded with crackles [**12-24**] through the lung
fields posteriorly and elevated JVD to the angle of the
mandible. The patient was not on supplemental oxygen at
baseline, though was upon admission. She was ruled out for MI
with serial cardiac enzymes. Etiologies of the patient's acute
decompensation include worseing aortic stenosis versus atrial
fibrillation. She triggered for desaturation to 89% on 4L via NC
on evening of admission. Chest x-ray at the time showed
interstitial infiltrates concerning for pulmonary edema. She
received 10mg IV lasix initially and responded after the trigger
was called. The patient's volume status was assessed daily and
with diuresis 10mg IV lasix [**Hospital1 **], the patient's respiratory
status improved with her saturating well on room air and clear
lungs bilaterally.

# Aortic stenosis: Critical aortic stenosis with valve area of
0.8cm2. Patient has been seen by Dr. [**Last Name (STitle) **] as an outpatient for
evaluation. Per his note, patient is a good surgical candidate
and not a candidate for transcatehter aortic valve replacement.
Cardiac surgery was consulted and decided to prusue aortic valve
replacement pre-surgical work-up, which included TTE and carotid
ultrasound. The patient was taken to the operating room
Thursday, [**2152-5-4**].  There she underwent an aortic valve
replacement, mitral valve replacement, and MAZE procedure.  This
procedure was performed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].  Please see the
operative note for details.  She tolerated the procedure well
and was transferred in critical but stable condition to the
surgical intensive care unit.  She awoke neurologically intact
and extubated on the same day but became increasingly acidotic
and was therefore reintubated with resolution of the acidosis.
She extubated for a second time on post-operative day two and
remained as such.  She was in a junctional rhythm initially on
arrival to the intensive care unit and therefore was paced with
epicardial wires but converted to atrial fibrillation over the
next couple of days.  Milrinone was started for a question of
right ventricle stunning.

# Community-acquired pneumonia: The patient was noted to have
pulmonary opacities concerning for pneumonia at the outside
hospital, and she was started on antibiotics (ceftriaxone and
azithromycin). She spiked a temperature on Hospital Day 2 of
101.8. Infectious work-up was initiated, which included blood
cultures, urine analysis, and repeat chest x-ray. Chest x-ray
showed more focal areas of opacity within the lung bases on
hospital day 2. The patient completed a course of azithromycin
and ceftriaxone for treatment of community-acquired pneumonia.

# Hypertension: Patient's amlodipine was continued during the
admission, but lisinopril was initially held in light of
elevated serum creatinine and diuresis with IV lasix.  Patient's
systolic blood pressure remained stable in 120-130s during her
admission on the Cardiology service.   Post-operatively her
lopressor was titrated and lisinopril restarted for better blood
pressure control.

# Hyperlipidemia: Continued home Crestor.

# Atrial fibrillation: Patient status post recent cardioversion
on Wednesday prior to admission, which the patient failed.
Patient remained in atrial fibrillation during the admission.
Warfarin was initially continued during the admission, but then
discontinued per cardiac surgery recommendations in light of
up-coming aortic valve replacement. Amiodarone was continued at
home dosing. In light of elevated heart rates with accompanying
acute diastolic heart failure, the patient was started on
metoprolol which was titrated to acheive ventricular rate
control.

# Anticoagulation: Warfarin was restarted. Goal INR 2.5-3.5 for
atrial fibrillation and AVR/MVR (mechanical).

# Hypothyroidism: TSH was found to be within normal limits.
Continued home levothyroxine.

# Ulcerative colitis: Patient is not actively being treated for
UC and has not had regular follow-up. OSH CT abdomen/pelvis was
done that did not show an acute process. She denied bloody bowel
movements or black, tarry stools. Abdominal exam was trended
through the admission and remained benign.

# Vertigo: Likely due to BBPV as opposed to presyncope caused by
aortic stenosis as patient describes the room spinning.
Continued Meclizine 25mg [**Hospital1 **] at home dosing.

# Neuro: pain was well controlled with acetaminophen and ultram.


SURGICAL COURSE:
The patient was brought to the Operating Room on [**2152-5-4**] where
the patient underwent AVR (19mm On-X), MVR (25/33 On-X), Maze
with Dr. [**Last Name (STitle) **].  Overall the patient tolerated the procedure well
and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.  She was
extubated post-operatively, then re-intubated for acidosis and
hemodynamic instability.  This all resolved by POD 1 and the
patient was successfully extubated.  She was neurologically
intact.  Hemodynamics were supported with Neo and she was in
AFib. Coumadin was resumed for AFib and mechanical valves.  INR
became supratherapeutic quickly, coumadin was held and INR would
trend down.  Heparin bridge was initiated until INR became
therapeutica gain.  Beta blocker was initiated.  The patient was
aggressively diuresed toward the preoperative weight.  She did
suffer acute kidney injury and diuresis was tapered.  Creatinine
would trend down.  The patient was transferred to the telemetry
floor for further recovery.  Chest tubes and pacing wires were
discontinued without complication.  She did develop a right
sided pleural effusion.  Attempt will be made to diurese rather
than tap, as thoracentesis would require reversal of INR.  The
patient was evaluated by the physical therapy service for
assistance with strength and mobility.  By the time of discharge
on POD 11 the patient was ambulating freely, the wound was
healing and pain was controlled with oral analgesics.  The
patient was discharged to the [**Hospital 169**] Center in [**Location (un) **] in
good condition with appropriate follow up instructions.

Medications on Admission:
--Meclizine 25mg [**Hospital1 **]
--Amiodarone 200mg daily
--Lisinopril 40mg daily
--Warfarin 3mg daily
--Crestor 20mg daily
--Amlodipine 5mg daily
--Levothyroxine 88mcg daily

Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. levothyroxine 50 mcg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
6. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for coughing.
7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. ipratropium bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours).
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours).
11. acetazolamide 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 doses.
12. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
14. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
15. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
MD to dose daily for goal INR 2.5-3.5.
17. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO DAILY (Daily).
19. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] LivingCenter - [**Location (un) **]

Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Critical aortic stenosis
Acute on chronic diastolic heart failure
Mitral regurgitation

SECONDARY DIAGNOSIS:
Hypertension
Atrial fibrillation
Hypothyroidism
Hypertension

Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
trace edema, moderate right pleural effusion


Discharge Instructions:
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. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2152-6-15**] 1:00 in the
[**Hospital **] Medical Building [**Last Name (NamePattern1) **] [**Hospital Unit Name **]

Follow-up with Dr. [**Last Name (STitle) 11493**] Cardiologist [**Telephone/Fax (1) 62**]

Department: CARDIAC SERVICES
When: WEDNESDAY [**2152-7-19**] at 9:00 AM
With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: CARDIAC SERVICES: [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical [**Location (un) 3971**]
When: WEDNESDAY [**2152-7-19**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]

Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) 28949**] ([**Telephone/Fax (1) 99774**] for coumadin follow-up once
discharged from rehab.

**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
Coumadin for Atrial Fibrillation, AVR/MVR (mechanical)
Goal INR: 2.5-3.5
Please call Dr.[**Name (NI) 99775**] office for coumadin follow-up as
previoius
Results to phone [**Telephone/Fax (1) **] fax: [**Telephone/Fax (1) 28952**]



Completed by:[**2152-5-15**]
{'Acute on chronic diastolic heart failure,Pneumonia, organism unspecified,Acute kidney failure, unspecified,Other pulmonary insufficiency, not elsewhere classified, following trauma and surgery,Acidosis,Unspecified pleural effusion,Mitral valve insufficiency and aortic valve stenosis,Atrial fibrillation,Other ill-defined heart diseases,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Benign paroxysmal positional vertigo,Personal history of other diseases of digestive system,Examination of participant in clinical trial'}


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: Shortness of breath

PRESENT ILLNESS: Patient is a 70yo F w/ PMHx of critical AS, Rheumatic heart
disease, HTN HLD, hypothyroidism, UC, atrial fibrillation who
presented from OSH with shortness of breath.

MEDICAL HISTORY: --Rheumatic heart disease with mild mitral stenosis, mitral
regurgitation, moderate aortic insufficiency, preserved LV
function
--Paroxysmal atrial fibrillation, s/p two prior cardioversions
in [**2143**] and [**2145**], and most recently 1 week prior to admission.
--Diastolic CHF
--Hypertension
--Hyperlipidemia
--Ulcerative colitis
--s/p CcY
--Bipolar disorder

MEDICATION ON ADMISSION: --Meclizine 25mg [**Hospital1 **]
--Amiodarone 200mg daily
--Lisinopril 40mg daily
--Warfarin 3mg daily
--Crestor 20mg daily
--Amlodipine 5mg daily
--Levothyroxine 88mcg daily

ALLERGIES: Sulfa(Sulfonamide Antibiotics)

PHYSICAL EXAM: Admission physical exam:
VS: T 98.4, BP 152/82, HR 104, RR 18, SpO2 99% on RA
GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: There is no family history of hypertension, diabetes, heart
disease, or strokes.

SOCIAL HISTORY: She is divorced and lives alone.   She quit smoking in [**2130**] and
denies alcohol or illicit drug use. 

### Response:
{'Acute on chronic diastolic heart failure,Pneumonia, organism unspecified,Acute kidney failure, unspecified,Other pulmonary insufficiency, not elsewhere classified, following trauma and surgery,Acidosis,Unspecified pleural effusion,Mitral valve insufficiency and aortic valve stenosis,Atrial fibrillation,Other ill-defined heart diseases,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Benign paroxysmal positional vertigo,Personal history of other diseases of digestive system,Examination of participant in clinical trial'}
