CHIEF COMPLAINT: dyspnea

PRESENT ILLNESS: This 63 year old male presented to an outside ED on [**2156-9-23**] for
4 weeks of gradually worsening dyspnea and chest discomfort and
was noted to be in heart failure. He was given ASA, sl
nitroglycerin, Bumex and Avalox. He was transferred to [**Hospital1 18**] for
futher treatment after his dyspnea improved.He underwent right
and left cardiac catheterization. He was noted to be in flutter
after  DCCV. [**9-29**]. Echocardiography showed severe aortic
stenosis ([**Location (un) 109**] 0.7 cm2, mean gradient 27 mmHg, peak gradient 42
mmHg).

MEDICAL HISTORY: None known
no medical care in "years"

MEDICATION ON ADMISSION: None

ALLERGIES: Penicillins

PHYSICAL EXAM: VS: T=97.4 BP=122/94 HR=127 RR=22 O2 sat=100,2L Wt: 86kg
GENERAL: WDWN male in NAD. Mood, affect appropriate.
HEENT: MMM.
NECK: Supple with JVP of [**10-12**] cm.
CARDIAC: Rapid regular rhythm, 2/6 systolic murmur at RUSB. No
S3 or S4 appreciated.
LUNGS: Appears mildly dyspneic. CTAB, no crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. +BS.
EXTREMITIES: 2+ edema to knees, trace to mid thighs. 2+ radial
pulses.

FAMILY HISTORY: Brother died of CHF age 62, mother had PPM.
estranged from son

SOCIAL HISTORY: Unemployed, lives alone in a rooming house.
-Tobacco history: none
-ETOH: ~10 drinks/wk
-Illicit drugs: none
Acute systolic heart failure,Acute kidney failure, unspecified,Atrial flutter,Congenital insufficiency of aortic valve,Unspecified pleural effusion,Traumatic pneumothorax without mention of open wound into thorax,Other primary cardiomyopathies,Alcohol withdrawal delirium,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Thoracic aneurysm without mention of rupture,Other chronic pulmonary heart diseases,Other and unspecified alcohol dependence, unspecified,Other accidents,Oliguria and anuria
Ac systolic hrt failure,Acute kidney failure NOS,Atrial flutter,Cong aorta valv insuffic,Pleural effusion NOS,Traum pneumothorax-close,Prim cardiomyopathy NEC,Delirium tremens,Crnry athrscl natve vssl,Old myocardial infarct,Thoracic aortic aneurysm,Chr pulmon heart dis NEC,Alcoh dep NEC/NOS-unspec,Accident NEC,Oliguria & anuria
Admission Date:  [**2156-9-23**]              Discharge Date:   [**2156-10-8**]

Date of Birth:  [**2093-3-1**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Penicillins

Attending:[**First Name3 (LF) 165**]
Chief Complaint:
dyspnea

Major Surgical or Invasive Procedure:
[**2156-9-24**] right and left heart catheterization, coronary
angiogram,left ventriculogram
[**2156-9-30**] Aortic valve replacement(21 St. [**Male First Name (un) 923**] Regent mechanical
valve),Ascending aortic aneurysm resection and interposition
tube graft(28 Gelweave graft),Coronary artery bypass graft
x1(saphenous vein graft to posterior descending artery).


History of Present Illness:
This 63 year old male presented to an outside ED on [**2156-9-23**] for
4 weeks of gradually worsening dyspnea and chest discomfort and
was noted to be in heart failure. He was given ASA, sl
nitroglycerin, Bumex and Avalox. He was transferred to [**Hospital1 18**] for
futher treatment after his dyspnea improved.He underwent right
and left cardiac catheterization. He was noted to be in flutter
after  DCCV. [**9-29**]. Echocardiography showed severe aortic
stenosis ([**Location (un) 109**] 0.7 cm2, mean gradient 27 mmHg, peak gradient 42
mmHg).

On catheterization he was noted to have 100% distal RCA
occlusion with left to right collaterals to distal vessel, LAD
30% proximal stenosis, otherwise diffuse disease distally with
probable distal occlusion of apical LAD.  30% stenosis of OM1.
Aortic valve with peak aortic gradient of 40 mmHg, area 0.6 cm2.
Right heart cath with PASP 51 mmHg, PCWP 23 mmHg, RVEDP 21 mmHg.
Consultation for evaluation of coronary bypass and aortic valve
replacement was obtained.

Past Medical History:
None known
no medical care in "years"

Social History:
Unemployed, lives alone in a rooming house.
-Tobacco history: none
-ETOH: ~10 drinks/wk
-Illicit drugs: none

Family History:
Brother died of CHF age 62, mother had PPM.
estranged from son

Physical Exam:
VS: T=97.4 BP=122/94 HR=127 RR=22 O2 sat=100,2L Wt: 86kg
GENERAL: WDWN male in NAD. Mood, affect appropriate.
HEENT: MMM.
NECK: Supple with JVP of [**10-12**] cm.
CARDIAC: Rapid regular rhythm, 2/6 systolic murmur at RUSB. No
S3 or S4 appreciated.
LUNGS: Appears mildly dyspneic. CTAB, no crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. +BS.
EXTREMITIES: 2+ edema to knees, trace to mid thighs. 2+ radial
pulses.

Pertinent Results:
[**2156-9-30**] Echo Pre CPB: Mild spontaneous echo contrast is seen in
the body of the left atrium. No mass/thrombus is seen in the
left atrium or left atrial appendage. Mild spontaneous echo
contrast is seen in the body of the right atrium. No atrial
septal defect is seen by 2D or color Doppler.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. Overall left
ventricular systolic function is severely depressed (LVEF= 15
%). The right ventricular cavity is mildly dilated with
borderline normal free wall function. The ascending aorta is
moderately dilated. There are simple atheroma in the descending
thoracic aorta. The aortic valve is bicuspid. There is critical
aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. There are bilateral pleural effusions.
The cardiac output is 2.0L/min. Dr. [**Last Name (STitle) **] was notified
in person of the results. Post CPB: The cardiac output is
4.0L/min. The patient is on an epinephrine infusion. There is a
well seated mechanical valve in the aortic position. There is a
tube graft in the ascending aorta. The visible contours of the
thoracic aorta are intact. The aortic valve has a mean gradient
of 7mmHg and no insufficiency. There is trace/mild MR, which
appears slightly improved.
The left ventricular ejection fraction is improved at 25-30%.
[**2156-10-6**] 08:30AM BLOOD WBC-7.4 RBC-3.05* Hgb-10.1* Hct-29.7*
MCV-97 MCH-33.0* MCHC-33.9 RDW-14.5 Plt Ct-252
[**2156-9-30**] 12:15PM BLOOD WBC-10.2 RBC-3.23* Hgb-11.1* Hct-31.2*
MCV-97 MCH-34.3* MCHC-35.6* RDW-14.1 Plt Ct-198
[**2156-9-23**] 01:15AM BLOOD WBC-7.9 RBC-4.32* Hgb-15.0 Hct-43.5
MCV-101* MCH-34.6* MCHC-34.4 RDW-13.7 Plt Ct-361
[**2156-10-6**] 08:30AM BLOOD PT-48.9* PTT-43.8* INR(PT)-5.3*
[**2156-10-5**] 05:24AM BLOOD PT-34.5* PTT-37.1* INR(PT)-3.5*
[**2156-10-4**] 04:24AM BLOOD PT-22.5* PTT-56.5* INR(PT)-2.1*
[**2156-10-3**] 08:27PM BLOOD PT-20.6* PTT-47.7* INR(PT)-1.9*
[**2156-10-3**] 11:42AM BLOOD PT-20.3* PTT-91.4* INR(PT)-1.9*
[**2156-10-3**] 01:30AM BLOOD PT-17.9* PTT-33.1 INR(PT)-1.6*
[**2156-10-6**] 08:30AM BLOOD Glucose-82 UreaN-23* Creat-1.0 Na-133
K-4.1 Cl-96 HCO3-29 AnGap-12
[**2156-9-23**] 01:15AM BLOOD Glucose-98 UreaN-17 Creat-0.9 Na-139
K-4.3 Cl-101 HCO3-24 AnGap-18

Brief Hospital Course:
He underwent right and left cardiac catheterizations  for
evaluation of his disease. He was noted to be in atrial flutter.
 Echocardiography showed severe aortic stenosis ([**Location (un) 109**] 0.7 cm2,
mean gradient 27 mmHg, peak gradient 42 mmHg. Catheterization
noted  100% distal RCA occlusion with left to right collaterals
to distal vessel, LAD 30% proximal stenosis, otherwise diffuse
disease distally with probable distal occlusion of apical
LAD,30% stenosis of OM1. Aortic valve with peak aortic gradient
of 40 mmHg, area 0.6 cm2. Right heart cath with PASP 51 mmHg,
PCWP 23 mmHg, RVEDP 21 mmHg. He was referred for surgical
evaluation.

After preoperative workup, he was taken to the Operating Room
where surgery as noted was performed. See operative note for
details. He weaned from bypass on Neo-Synephrine and Propofol.
He weaned from these and was extubated on POD 1.  He became very
agitated and confused, pulling out his mediastinal and right
chest tubes resulting in a pneumothorax. A right tube was
replaced due to a pneumothorax.  Valium was administered for
alcohol withdrawal treatment and he his agitation subsided.
Sedation was decreased, he remained stable and CTs were removed
on [**10-5**]. Sedation was stopped on [**10-6**].

Diuresis was institued and beta blockers were resumed.
Metoprolol was changed to Carvedilol due to his low ejection
fraction. Anticoagulation with coumadin was started for
mechcanical AVR. He also experienced post-operative atrial
fibrillation and was treated with amiodarone.

As he lives alone in a rooming house and has no social support,
is anticoagulated for mechcanical AVR and recovering from
surgery, a stay at rehabilitation was deemed appropriate.  He
will need an INR of 2.5-3.5 as a target. His wounds were clean
and healing well at discharge.

[**2156-10-8**] INR 2.7- needs to 2mg coumadin today.
NEXT INR draw [**2156-10-9**]


Medications on Admission:
None

Discharge Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
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. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 2 weeks: then decrease to 200mg daily.
6. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain for 4 weeks.
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever or pain.
9. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a day.

10. Outpatient Lab Work
daily INR/PT until stable, then as needed
11. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Coumadin 1 mg Tablet Sig: as directed for mech AVR Tablet PO
once a day: Goal INR for mech AVR 2.5-3.5. Tablet(s)


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 2222**] - [**Location (un) 538**]

Discharge Diagnosis:
Acute Heart Failure
Atrial Flutter
Severe aortic stenosis
s/p Aortic valve replacement
Ascending aortic aneurysm
s/p resection of ascending aorta
Coronary artery disease
s/p Coronary artery bypass graft
alcohol abuse


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


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 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**

Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**First Name (STitle) **] on [**11-1**] at 1:15 PM ([**Telephone/Fax (1) 170**])
Cardiologist: Dr. [**Last Name (STitle) **] on  [**10-25**] at 9:20 AM


**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 MECH AVR/AFib
Goal INR 2.5-3.5
First draw [**2156-10-9**]



                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]

Completed by:[**2156-10-8**]
{'Acute systolic heart failure,Acute kidney failure, unspecified,Atrial flutter,Congenital insufficiency of aortic valve,Unspecified pleural effusion,Traumatic pneumothorax without mention of open wound into thorax,Other primary cardiomyopathies,Alcohol withdrawal delirium,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Thoracic aneurysm without mention of rupture,Other chronic pulmonary heart diseases,Other and unspecified alcohol dependence, unspecified,Other accidents,Oliguria and anuria'}


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: This 63 year old male presented to an outside ED on [**2156-9-23**] for
4 weeks of gradually worsening dyspnea and chest discomfort and
was noted to be in heart failure. He was given ASA, sl
nitroglycerin, Bumex and Avalox. He was transferred to [**Hospital1 18**] for
futher treatment after his dyspnea improved.He underwent right
and left cardiac catheterization. He was noted to be in flutter
after  DCCV. [**9-29**]. Echocardiography showed severe aortic
stenosis ([**Location (un) 109**] 0.7 cm2, mean gradient 27 mmHg, peak gradient 42
mmHg).

MEDICAL HISTORY: None known
no medical care in "years"

MEDICATION ON ADMISSION: None

ALLERGIES: Penicillins

PHYSICAL EXAM: VS: T=97.4 BP=122/94 HR=127 RR=22 O2 sat=100,2L Wt: 86kg
GENERAL: WDWN male in NAD. Mood, affect appropriate.
HEENT: MMM.
NECK: Supple with JVP of [**10-12**] cm.
CARDIAC: Rapid regular rhythm, 2/6 systolic murmur at RUSB. No
S3 or S4 appreciated.
LUNGS: Appears mildly dyspneic. CTAB, no crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. +BS.
EXTREMITIES: 2+ edema to knees, trace to mid thighs. 2+ radial
pulses.

FAMILY HISTORY: Brother died of CHF age 62, mother had PPM.
estranged from son

SOCIAL HISTORY: Unemployed, lives alone in a rooming house.
-Tobacco history: none
-ETOH: ~10 drinks/wk
-Illicit drugs: none 

### Response:
{'Acute systolic heart failure,Acute kidney failure, unspecified,Atrial flutter,Congenital insufficiency of aortic valve,Unspecified pleural effusion,Traumatic pneumothorax without mention of open wound into thorax,Other primary cardiomyopathies,Alcohol withdrawal delirium,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Thoracic aneurysm without mention of rupture,Other chronic pulmonary heart diseases,Other and unspecified alcohol dependence, unspecified,Other accidents,Oliguria and anuria'}
