CHIEF COMPLAINT: DOE

PRESENT ILLNESS: 75 yo F with increasing DOE over past several years, known AS
followed by serial echos, cath showed 3VD, referred for
AVR/CABG.

MEDICAL HISTORY: PMH: HTN, sleep apnea on CPAP, DM2, ^lipids, Diverticulitis, AS,
poor balance w/frequent falls, L4 & L5 fractures, subdural
hematoma
PSH: ccy, appendectomy, partial colectomy, knee arthroscopy x3,
pilonidal cyst excision

MEDICATION ON ADMISSION: glucophage 850", avandia 8', glipizide 10", dumex 2', asa 81'
spironolactone/hctz 25/25', , paxil 40', lipitor 20',
amitryptiline 25', lopressor 25''', ranitidine 150'', serevent
inh [**Hospital1 **], mvi, vit c 500", vit e 400', calcium + d 600",
methadone 5""

ALLERGIES: Tetracycline

PHYSICAL EXAM: Admission
HR 82 RR 16 BP 129/69
NAD
Lungs CTAB
Heart RRR, [**4-16**] HSM
Abdomen soft, NT, obese
Extrem 2+ edema

FAMILY HISTORY: father deceased from MI at age 41

SOCIAL HISTORY: retired lab tech
no tobacco
no etoh
Aortic valve disorders,Acute duodenal ulcer with perforation, without mention of obstruction,Unspecified peritonitis,Unspecified pleural effusion,Hematoma complicating a procedure,Hyperosmolality and/or hypernatremia,Other and unspecified mycoses,Pneumonia, organism unspecified,Other and unspecified infection due to central venous catheter,Coronary atherosclerosis of native coronary artery,Morbid obesity,Myocardial degeneration,Other diseases of trachea and bronchus,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Obstructive sleep apnea (adult)(pediatric),Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Aortic valve disorder,Ac duodenal ulcer w perf,Peritonitis NOS,Pleural effusion NOS,Hematoma complic proc,Hyperosmolality,Mycoses NEC & NOS,Pneumonia, organism NOS,Oth/uns inf-cen ven cath,Crnry athrscl natve vssl,Morbid obesity,Myocardial degeneration,Trachea & bronch dis NEC,DMII wo cmp nt st uncntr,Hypertension NOS,Obstructive sleep apnea,Abn react-procedure NEC
Admission Date:  [**2144-6-5**]              Discharge Date:   [**2144-7-9**]

Date of Birth:  [**2069-4-18**]             Sex:   F

Service: CARDIOTHORACIC

Allergies:
Tetracycline

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

Major Surgical or Invasive Procedure:
[**6-5**] AVR(21mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] porcine), CABGx2(SVG>PDA,LIMA>LAD)


History of Present Illness:
75 yo F with increasing DOE over past several years, known AS
followed by serial echos, cath showed 3VD, referred for
AVR/CABG.

Past Medical History:
PMH: HTN, sleep apnea on CPAP, DM2, ^lipids, Diverticulitis, AS,
poor balance w/frequent falls, L4 & L5 fractures, subdural
hematoma
PSH: ccy, appendectomy, partial colectomy, knee arthroscopy x3,
pilonidal cyst excision


Social History:
retired lab tech
no tobacco
no etoh

Family History:
father deceased from MI at age 41

Physical Exam:
Admission
HR 82 RR 16 BP 129/69
NAD
Lungs CTAB
Heart RRR, [**4-16**] HSM
Abdomen soft, NT, obese
Extrem 2+ edema

Discharge
VS T 99.3  HR 87 first degree AVB  BP 110/44  RR 22  O2sat 97%
50% PSV
Gen NAD
Neuro Alert/responsive. Follows commands, answers(shakes head)
appropriately
Pulm course rhonchi throughout
CV RRR, sternum stable. Incision small open area at base
w/fibrinous tissue minimal drainage
Abdm soft, NT/obese. Midline incision w/staples-CDI. J tube
site-CDI.
Ext warm, 4+ edema bilat
TLD J tube, foley, PIV, Trach, PICC-lft anticub

Pertinent Results:
[**2144-7-9**] 03:25AM BLOOD WBC-7.9 RBC-3.28*# Hgb-9.6*# Hct-28.4*
MCV-86 MCH-29.1 MCHC-33.7 RDW-18.7* Plt Ct-295
[**2144-7-8**] 08:59PM BLOOD Hct-28.7*
[**2144-7-8**] 03:03PM BLOOD Hct-24.7*
[**2144-7-8**] 06:37AM BLOOD Hct-22.2*
[**2144-7-9**] 03:25AM BLOOD PT-13.4 PTT-27.1 INR(PT)-1.1
[**2144-7-9**] 03:25AM BLOOD Glucose-170* UreaN-24* Creat-0.5 Na-138
K-3.8 Cl-104 HCCOMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC
RDW Plt Ct
[**2144-7-9**] 10:37AM          29.0*
O3-32 AnGap-6*

CHEST (PORTABLE AP)  [**2144-7-8**] 7:25 AM
CHEST (PORTABLE AP)
Reason: ?ptx
[**Hospital 93**] MEDICAL CONDITION:
75 year old woman with s/;p cabg
REASON FOR THIS EXAMINATION:
?ptx
INDICATION: 75-year-old woman with status post CABG; evaluate
for pneumothorax.
COMPARISON: [**2144-7-7**].
SINGLE AP UPRIGHT RADIOGRAPH OF THE CHEST AT 7:40 A.M.: There
are moderate bilateral pleural effusions, slightly worse than
prior study. There are associated bibasilar opacities which are
also worse and may reflect worsening atelectasis and/or
pneumonia. Left PICC is terminating at the upper SVC. There is
no pulmonary edema or pneumothorax.
IMPRESSION: No pneumothorax. Worsening moderate bilateral
pleural effusions and bibasilar consolidation.

CT ABDOMEN W/O CONTRAST  [**2144-7-8**] 4:38 PM
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST
Reason: r/o retroperitoneal bleed with drop in hct
[**Hospital 93**] MEDICAL CONDITION:
75 year old woman with s/p cabg
REASON FOR THIS EXAMINATION:
r/o retroperitoneal bleed with drop in hct
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 75-year-old female after cardiac surgery with falling
hematocrit and concern for retroperitoneal hematoma. The patient
has known right groin hematoma after removal of a femoral
catheter.
COMPARISON: Right groin ultrasound [**2144-7-1**].
TECHNIQUE: MDCT axial images of the abdomen and pelvis without
oral or IV contrast. Coronal and sagittal reformats were
obtained.
CT OF THE ABDOMEN WITHOUT IV CONTRAST: The patient is status
post sternotomy. There are small bilateral pleural effusions and
atelectasis of much of both lower lobes. Diffuse body wall edema
is noted. There are scattered pockets of ascites within the
abdomen. A drainage catheter enters the left upper abdomen and
terminates near the inferior liver edge. Evaluation of the solid
abdominal organs is limited without IV contrast. There is a
small subcentimeter hypodense focus of the left hepatic lobe,
too small to characterize. Gallbladder is not seen and may be
surgically absent or collapsed. Both kidneys are atrophic. The
pancreas, spleen, and adrenal glands are unremarkable. There are
numerous colonic diverticula, but no evidence of acute
diverticulitis. Oral contrast from prior examination is present
throughout the colon. There is no evidence of retroperitoneal
hematoma. There is extensive body wall edema.
CT OF THE PELVIS WITHOUT IV CONTRAST: Again seen is a large
right groin hematoma, which extends down the medial leg.
Assessment for change in size compared to recent ultrasound is
difficult due to differences in modalities. Today on greatest
axial dimension dimensions, it measures about 17 x 6 cm. The
hematoma has high-density component, suggesting more recent
hemorrhage. The bladder is decompressed by a Foley catheter. The
rectum, uterus, adnexa, and pelvic loops of bowel are
unremarkable.
BONE WINDOWS: No concerning bone lesions are seen. There are
degenerative changes of the spine. There is an old wedge
compression fracture deformity of L2 with hyperdense material
within it, probably from vertebroplasty.
IMPRESSION:
1. Right groin hematoma redemonstrated. Assessment for change in
size is difficult due to differences in modalities compared to
prior ultrasound [**2144-7-1**]. Maximal axial dimensions today are
17 x 6 cm. Presence of hyperdense material within the hematoma
suggest more recent hemorrhage into the hematoma. If clinically
indicated, further evaluation with a followup ultrasound to
assess for pseudoaneurysm is suggested.
2. Anasarca evidenced by small bilateral pleural effusions,
scattered pockets of intra-abdominal ascites and diffuse body
wall edema.
3. Atelectasis of a large portion of the lower lobes.
4. Atrophic kidneys.
5. Diverticulosis.

FEMORAL VASCULAR US RIGHT PORT  [**2144-7-8**] 5:24 PM
FEMORAL VASCULAR US RIGHT PORT
Reason: evaluation of rt groin hematoma if changes and
evaluation of
[**Hospital 93**] MEDICAL CONDITION:
75 year old woman with s/p cabg
REASON FOR THIS EXAMINATION:
evaluation of rt groin hematoma if changes and evaluation of
flow ? pseudoaneurysm - please compare to previous ultrasound
Right groin hematoma.
COMPARISON: [**2144-7-1**].
HISTORY: Hematoma.
FINDINGS: Panoramic images were obtained of the right groin to
assess the known complex fluid collection. This known complex
fluid collection measures 17.5 x 8.0 x 11.1 cm on today's
examination. Please note however that similar views were not
obtained on prior study and therefore not accurately comparable.
When comparing the most similar views from today's study to
prior study, the dimensions appear slightly decreased when
compared to prior exam. The right common femoral artery and vein
are patent with normal waveforms. There is no evidence of
pseudoaneurysm or AV fistula.
IMPRESSION: Large right groin hematoma, slightly decreased in
size as best can be compared to prior exam.

[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **]       [**Hospital1 18**] [**Numeric Identifier 77397**]TTE (Complete)
Done [**2144-6-29**] at 4:12:19 PM      FINAL
Referring Physician     [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**]  Status: Inpatient DOB: [**2069-4-18**]
Age (years): 75 F  Hgt (in): 66
BP (mm Hg): 124/66  Wgt (lb): 280
HR (bpm): 100  BSA (m2): 2.31 m2
Indication: Prosthetic valve function. Endocarditis.
ICD-9 Codes: 424.90, V43.3
Test Information
Date/Time: [**2144-6-29**] at 16:12    Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
MD
Test Type: TTE (Complete) Son[**Name (NI) 930**]: Cardiology Fellow
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Adequate
Tape #: 2008W9-9:9 Machine: Other
    Sedation: Versed: 1 mg
Fentanyl: 50 mcg
Patient was monitored by a nurse throughout the procedure
Echocardiographic Measurements
Results  Measurements  Normal Range
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness and cavity size.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Simple atheroma in aortic arch. Complex (>4mm) atheroma
in the descending thoracic aorta.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR
well seated, normal leaflet/disc motion and transvalvular
gradients. No masses or vegetations on aortic valve. No AS. No
AR.
MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**]
throughout the procedure. Local anesthesia was provided by
benzocaine topical spray. The patient was sedated for the TEE.
Medications and dosages are listed above (see Test Information
section). 0.1 mg of IV glycopyrrolate was given as an
antisialogogue prior to TEE probe insertion. No TEE related
complications. The patient appears to be in sinus rhythm.
Echocardiographic results were reviewed with the houseofficer
caring for the patient.
Conclusions
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses and cavity size are normal. Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the aortic arch. There are complex (>4mm)
atheroma in the descending thoracic aorta. A bioprosthetic
aortic valve prosthesis is present. No masses or vegetations are
seen on the aortic valve bioprosthesis. There is no aortic valve
stenosis or aortic regurgitation. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen.
Conclusions: Normal bioprosthetic aortic valve without
echocardiographic evidence of vegetation or mass present.


Brief Hospital Course:
She was taken to the operating room on [**6-5**] where she underwent
an AVR/CABG x 2. Please see operative note for details. She was
transferred to the ICU in stable condition. She underwent
bronchoscopy that night for thick secretions and airway
obstruction. She had low urine output and was started on
natrecor and lasix drips. She remained intubated for hemodynamic
instability on epinephrine and levophed. She developed a fever
and was cultured. She was seen by renal for continued low urine
output. She was seen by cardiology for continued hypotension and
ectopy and bundle branch block, and she was seen by infectious
diseases for ?sepsis. She continued on vanocmycin for CNS from
arterial line, and was started on cefepime and flagyl for ? of
VAP and empiric GI coverage. She was started on tube feeds.
Chest tube insertion was attempted for pleural effusion but was
unsuccessful secondary to body habitus. Meropenum was added and
flagyl was dc'd. She received free water for hypernatremia.
Repeat bronchoscopy on [**6-18**] showed significant secretions and
airway collapse. She underwent thoracentesis for left pleural
effusion. She was extubated on [**6-19**] but required BiPAP. She was
seen by cardiology for SVT that converted with adenosine and
medications (lopressor) were adjusted. She was reintubated on
[**6-22**] for respiratory failure. She was seen by thoracic surgery
for tracheostomy placement, and on [**6-23**] she underwent an open
tracheostomy, flexible bronchoscopy and open jejunostomy. She
developed an acute abdomen and new pressor requirement and On
[**6-26**] she was taken to the operating room for A duodenal ulcer
with perforation
and succus throughout the abdominal cavity and she underwent a
Exploratory laparotomy and washout, Lysis of adhesions, and
Duodenal ulcer [**Location (un) **] patch with [**Doctor Last Name 406**] drain placement.
Tube feeds were advanced to goal. She was started on caspofungin
for fungemia and positive fungal wound cultures. She was
transfused multiple times. PICC line was placed.
She was seen by vascular surgery for blue right toes. Right
femoral artery ultrasound showed complex fluid collection with
no evidence of pseudoaneurysm or AV fistula and she was followed
with serial HCTs which remained stable.
he did not tolerate passy-muir valve placement on [**7-2**]. She
tolerated trach mask trials. PICC line was replaced given
candidemia after previous PICC placed. She was started on bumex,
and then aldactone and HCTZ for diuresis. On [**7-7**] she underwent
left thoracentesis for 1200 cc serous fluid.
She developed guaiac positive stools and PPI was increased to
[**Hospital1 **]. HCT fell and she was transfused. She was started on vanco
for coag negative staph in blood cultures from [**7-5**], the vanco
was subsequently dc'd as only 1 bottle was positive. Subsequent
cultures remained negative.
HCT subsequently remained stable and she was ready for transfer
to rehab.

Medications on Admission:
glucophage 850", avandia 8', glipizide 10", dumex 2', asa 81'
spironolactone/hctz 25/25', , paxil 40', lipitor 20',
amitryptiline 25', lopressor 25''', ranitidine 150'', serevent
inh [**Hospital1 **], mvi, vit c 500", vit e 400', calcium + d 600",
methadone 5""

Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. Paroxetine HCl 10 mg/5 mL Suspension Sig: One (1)  PO DAILY
(Daily).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
7. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q4H (every 4 hours).
8. Docusate Sodium 50 mg/5 mL Liquid Sig: [**2-12**]  PO BID (2 times a
day).
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

10. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
11. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
14. Papain-Urea 830,000-10 unit/g-% Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day): to sternal and coccyx wounds .
15. Insulin Glargine 100 unit/mL Solution Sig: Twenty Five (25)
units Subcutaneous BREAKFAST (Breakfast).
16. Pantoprazole 40 mg IV Q12H
17. Meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg
Intravenous Q8H (every 8 hours): through [**7-10**].
18. Caspofungin 70 mg Recon Soln Sig: Fifty (50) mg Intravenous
Q24H (every 24 hours): Through [**7-12**].
19. Bumex 2 mg Tablet Sig: One (1) Tablet PO once a day: 30 min
after hctz.
20. Roxicet 5-325 mg/5 mL Solution Sig: 2.5-5 mls PO every [**5-17**]
hours as needed for pain.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 700**] - [**Location (un) 701**]

Discharge Diagnosis:
AS, CAD s/p AVR, CABG
Respiratory failure s/p tracheostomy, jejunostomy
Perforated duodenal ulcer s/p exploratory laparotomy, [**Location (un) **]
patch
PMH: HTN, sleep apnea on CPAP, DM2, ^lipids, Diverticulitis,
poor balance w/frequent falls, L4 & L5 fractures, subdural
hematoma
PSH: ccy, appendectomy, partial colectomy, knee arthroscopy x3,
pilonidal cyst excision


Discharge Condition:
Stable.


Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.

Followup Instructions:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8098**] [**Telephone/Fax (1) **] after discharge from rehab
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 77398**] after discharge from rehab
Dr. [**Last Name (STitle) **] after discharge from rehab
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2819**]/General surgery clinic in [**3-15**] weeks
Patient to call for all appointments



Completed by:[**2144-7-9**]
{'Aortic valve disorders,Acute duodenal ulcer with perforation, without mention of obstruction,Unspecified peritonitis,Unspecified pleural effusion,Hematoma complicating a procedure,Hyperosmolality and/or hypernatremia,Other and unspecified mycoses,Pneumonia, organism unspecified,Other and unspecified infection due to central venous catheter,Coronary atherosclerosis of native coronary artery,Morbid obesity,Myocardial degeneration,Other diseases of trachea and bronchus,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Obstructive sleep apnea (adult)(pediatric),Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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: DOE

PRESENT ILLNESS: 75 yo F with increasing DOE over past several years, known AS
followed by serial echos, cath showed 3VD, referred for
AVR/CABG.

MEDICAL HISTORY: PMH: HTN, sleep apnea on CPAP, DM2, ^lipids, Diverticulitis, AS,
poor balance w/frequent falls, L4 & L5 fractures, subdural
hematoma
PSH: ccy, appendectomy, partial colectomy, knee arthroscopy x3,
pilonidal cyst excision

MEDICATION ON ADMISSION: glucophage 850", avandia 8', glipizide 10", dumex 2', asa 81'
spironolactone/hctz 25/25', , paxil 40', lipitor 20',
amitryptiline 25', lopressor 25''', ranitidine 150'', serevent
inh [**Hospital1 **], mvi, vit c 500", vit e 400', calcium + d 600",
methadone 5""

ALLERGIES: Tetracycline

PHYSICAL EXAM: Admission
HR 82 RR 16 BP 129/69
NAD
Lungs CTAB
Heart RRR, [**4-16**] HSM
Abdomen soft, NT, obese
Extrem 2+ edema

FAMILY HISTORY: father deceased from MI at age 41

SOCIAL HISTORY: retired lab tech
no tobacco
no etoh 

### Response:
{'Aortic valve disorders,Acute duodenal ulcer with perforation, without mention of obstruction,Unspecified peritonitis,Unspecified pleural effusion,Hematoma complicating a procedure,Hyperosmolality and/or hypernatremia,Other and unspecified mycoses,Pneumonia, organism unspecified,Other and unspecified infection due to central venous catheter,Coronary atherosclerosis of native coronary artery,Morbid obesity,Myocardial degeneration,Other diseases of trachea and bronchus,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Obstructive sleep apnea (adult)(pediatric),Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
