CHIEF COMPLAINT: 

PRESENT ILLNESS: Ms. [**Known lastname 13983**] is a 62 year-old
female with a past medical history significant for mitral
valve replacement secondary to rheumatic heart disease,
hypertension, high cholesterol, cerebrovascular accident in
[**2141**] and asthma who presented to the C-Med service with new
onset of congestive heart failure.  The patient had a mitral
valve stenosis secondary to rheumatic heart disease and had
this valve replaced with a St. Jude valve on [**2143-10-16**].  She
had been doing quite well until about four weeks prior to
admission when the patient noted an abrupt change in her
exercise capacity.  She noted dyspnea on exertion with
minimal activity and even at rest.  Her primary care
physician sent the patient for an echocardiogram which showed
a notable decrease in her ejection fraction from 50 percent
previously down to 10 to 20 percent with severe global left
ventricular hypokinesis.  After the echocardiogram the
patient's primary care sent her to the emergency department
for heparinization while the INR comes down in anticipation
of a cardiac catheterization to evaluate for ischemic
cardiomyopathy.  The patient was comfortable on admission
except for her dyspnea.

MEDICAL HISTORY: 1) Mitral valve replacement St. Jude
valve secondary to mitral valve stenosis for rheumatic heart
disease.  2) Hypertension.  3) High cholesterol.  4)
Cerebrovascular accident in [**2141**] leaving her with residual
right sided weakness and lastly asthma.  o known drug
allergies.

MEDICATION ON ADMISSION: Coumadin 3.5 alternating with 4.5
q.o.d., Lipitor 10 q.d., KayCiel 20 q.d., Lasix 20 b.i.d.,
Toprol XL 200 q.d., Diovan 80 b.i.d. and Lanoxicaps 0.2 q.d.

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: Was positive for coronary artery disease.
Sister had a coronary artery bypass graft at the age of 51.
Mother developed coronary artery disease in her 50s.

SOCIAL HISTORY: The patient quit smoking two years ago,
occasional alcohol use.
Acute systolic heart failure,Other primary cardiomyopathies,Endocarditis, valve unspecified, unspecified cause,Diseases of tricuspid valve,Hemorrhage complicating a procedure,Urinary tract infection, site not specified,Other chronic pulmonary heart diseases,Pure hypercholesterolemia
Ac systolic hrt failure,Prim cardiomyopathy NEC,Endocarditis NOS,Tricuspid valve disease,Hemorrhage complic proc,Urin tract infection NOS,Chr pulmon heart dis NEC,Pure hypercholesterolem
Admission Date:  [**2144-2-16**]       Discharge Date:  [**2144-3-5**]

Date of Birth:   [**2087-7-12**]       Sex:  F

Service:  C-MED

HISTORY OF PRESENT ILLNESS:  Ms. [**Known lastname 13983**] is a 62 year-old
female with a past medical history significant for mitral
valve replacement secondary to rheumatic heart disease,
hypertension, high cholesterol, cerebrovascular accident in
[**2141**] and asthma who presented to the C-Med service with new
onset of congestive heart failure.  The patient had a mitral
valve stenosis secondary to rheumatic heart disease and had
this valve replaced with a St. Jude valve on [**2143-10-16**].  She
had been doing quite well until about four weeks prior to
admission when the patient noted an abrupt change in her
exercise capacity.  She noted dyspnea on exertion with
minimal activity and even at rest.  Her primary care
physician sent the patient for an echocardiogram which showed
a notable decrease in her ejection fraction from 50 percent
previously down to 10 to 20 percent with severe global left
ventricular hypokinesis.  After the echocardiogram the
patient's primary care sent her to the emergency department
for heparinization while the INR comes down in anticipation
of a cardiac catheterization to evaluate for ischemic
cardiomyopathy.  The patient was comfortable on admission
except for her dyspnea.

PAST MEDICAL HISTORY:  1) Mitral valve replacement St. Jude
valve secondary to mitral valve stenosis for rheumatic heart
disease.  2) Hypertension.  3) High cholesterol.  4)
Cerebrovascular accident in [**2141**] leaving her with residual
right sided weakness and lastly asthma.  o known drug
allergies.

MEDICATIONS ON ADMISSION:  Coumadin 3.5 alternating with 4.5
q.o.d., Lipitor 10 q.d., KayCiel 20 q.d., Lasix 20 b.i.d.,
Toprol XL 200 q.d., Diovan 80 b.i.d. and Lanoxicaps 0.2 q.d.

SOCIAL HISTORY:  The patient quit smoking two years ago,
occasional alcohol use.

FAMILY HISTORY:  Was positive for coronary artery disease.
Sister had a coronary artery bypass graft at the age of 51.
Mother developed coronary artery disease in her 50s.

PHYSICAL EXAMINATION ON ADMISSION:  Afebrile, blood pressure
was 158/81, heart rate 83 and regular, respiratory rate 18,
saturation 99 percent on room air.  In general in no apparent
distress.  Neck: positive jugular venous pressure with pulse
noted at 10 cm, positive jugular venous distention.
Cardiovascular:  S1 mechanical, S2, irregularly irregular,
soft diastolic murmur at the right upper sternal border.
Lung clear to auscultation bilaterally.  Abdomen positive
bowel sounds, soft, nontender, nontender. Extremities:  no
clubbing, cyanosis or edema.  Neurologic examination: 4/5
strength in the right upper extremity, 5/5 strength
elsewhere. Cranial nerves intact.  Dysphagia which is
chronic, status post patient's cerebrovascular accident.

LABORATORY DATA:  Echocardiogram on [**2144-2-14**] showed a
moderately dilated left atrium, a mild symmetric left
ventricular hypertrophy, severe global left ventricular
hypokinesis with an ejection fraction estimated to be 10 to
20 percent, depressed right ventricular systolic function, no
aortic stenosis, trace aortic regurgitation, mitral valve
replacement well seated, severe mitral annular calcification,
3+ tricuspid regurgitation, moderate pulmonary hypertension,
significant pulmonic regurgitation.  Left ventricular
function significantly worse with ejection fraction noted to
be down from 50 percent on echocardiogram nine months prior
to this current echocardiogram.  Cardiac catheterization in
[**2141-10-25**] showed no significant coronary artery
disease, left ventriculogram showed no wall motion
abnormalities.  Hematocrit on admission 38.7, white count
6.8, platelet count 176,000.  Coagulation profile:  INR 2.6,
PTT 34.6, PT 19.7, creatinine 1.2, BUN 21, glucose 94.  Chest
x-ray showed mild cardiomegaly with cardiac enlargement, no
congestive heart failure, no infiltrate, pneumothorax or
effusion.  Electrocardiogram:  atrial flutter with variable
block at 75 beats per minute, biphasic T waves in 1 and AVL,
V4 through V6, ST depressions in V5 through V6, atrial
flutter was noted to be new since electrocardiogram from
[**2143-10-15**].

IMPRESSION:
This is a 62 year-old female with a history of mitral valve
replacement in [**2143-9-24**], hypertension, high cholesterol
and stroke with residual dysphagia admitted for cardiac
catheterization to evaluate for an ischemic cardiomyopathy.
he patient was also found to have new atrial flutter since
[**9-24**].

HOSPITAL COURSE:  1) New onset congestive heart failure with
marked decline in ejection fraction:  The patient's Coumadin
was held and the patient was started on intravenous heparin
so that she could be anticoagulated for both her valve and
atrial arrhythmia until cardiac catheterization.  The cause
of the new onset heart failure was thought to be either
secondary to 1) repeated microembolic events, 2) a large
embolus or thrombus in the LAD transiently during the
patient's mitral valve replacement, 3) the etiology was not
determined to be secondary to the mitral valve itself as the
echocardiogram showed the valve to be well seated, and 4) it
could be ischemic cardiomyopathy, or 5) a viral
cardiomyopathy.  The patient was continued on aspirin,
Diovan, Toprol and Lasix as well as well as the Torvastatin
prior to cardiac catheterization.  The patient had a TEE on
hospital day umber two.  This revealed a left appendage
thrombus.  Therefore, the patient was not a candidate for DC
cardioversion of the atrial flutter.  For management of the
atrial flutter she was rate controlled and kept on heparin.
The left atrial appendage thrombus was likely a complication
of the mitral valve replacement surgery and with time would
likely dissolve.  The patient was able to go for a cardiac
catheterization on [**2144-2-19**] after her INR had come down.  The
findings of cardiac catheterization were as follows.  Cardiac
output was 3.5 with a cardiac index of 2.12.  The pulmonary
capillary wedge pressure was a mean of 15, right atrial
pressure of 5, the PA pressure was 42/18 with a mean of 27,
left ventricular and diastolic pressure of 16, right
ventricular pressure 42/0 with an end of 5.  This was
interpreted as mild elevation of the pulmonary capillary
wedge and PA pressure.  Left ventriculography showed mitral
regurgitation, global left ventricular hypokinesis with no
mitral regurgitation.  Coronary angiography showed only a 10
to 20 percent plaque within the left main.  In the LAD there
were very minor irregularities, left circumferential minor
irregularities, RCA no significant abnormalities and there
was said to be no evidence of macro emboli in the coronary
arteries.  Therefore, based on the cardiac catheterization
the cardiomyopathy was not secondary to ischemia.  The
patient had no signs or symptoms of a viral cardiomyopathy
with no viral prodrome, no elevation of white blood count, no
history of fevers or chills.  Therefore, it was thought that
patient's global cardiomyopathy was likely secondary to
transient emboli to the LAD during her mitral valve
replacement surgery.  It was decided with Dr. [**Last Name (STitle) **] in the
heart failure service to have the patient sent for a
metabolic exercise stress test with Dr. [**Last Name (STitle) 4001**].  This was at
Dr.[**Name (NI) 13590**] request to 1) assess baseline function, and 2)
as part of a workup for possible future transplant surgery
depending on the results.  Regarding the patient's cardiac
left atrial appendage clot, cardiac surgery was contact[**Name (NI) **].
They felt that surgical ligation of this clot was risky and
would not decrease the risk of embolization from this clot.
On [**2144-2-20**] the patient was noted to have oozing of blood at
the cardiac catheterization site in he right groin.  This
resolved with compression.  The patient's PTT level was kept
tightly between 60 and 80 on the heparin drip.  The
cardiology fellow injected the groin with an epinephrine-
Lidocaine injection and this resulted in sensation of
bleeding.  On the morning of [**2144-2-21**] the patient was noted to
he light headed and hypotensive with blood pressures ranging
from 70 to 100 systolic.  The patient received two boluses of
normal saline with resultant increase in her blood pressure
to the low 100s.  The patient also was complaining of
abdominal pain at this time and on abdominal examination
there was noted to be a tense abdomen which was concerning
for a bleed from the patient's right groin.  The patient then
spiked a temperature to 101.1 so blood cultures were sent and
the patient was empirically started on Vancomycin.  The
patient was sent to the cardiac Intensive Care Unit for
further monitoring and her blood pressure continued to drop
and there was a notable drop in the patient's hematocrit to
26.4 when on the day previous to this her hematocrit was
37.2.  It was presumed that the patient likely had some type
of peritoneal or retroperitoneal bleed as a complication of
the cardiac catheterization a few days prior to this.  The
patient was sent to the unit.  During her stay there she had
a CT scan of the abdomen and pelvis with contrast.  She was
also immediately transfused two units of blood and heparin
was initially held.  The CT scan revealed a moderate sized
extraperitoneal hematoma with extension into the
retroperitoneum.  There were also noted to be inflammatory
changes within the right groin as well as an apparent
pseudoaneurysm of the right femoral artery.  Because of the
question of a pseudoaneurysm of the right femoral artery an
ultrasound was immediately ordered.  This showed no evidence
of a right groin pseudoaneurysm nor evidence of an
arteriovenous fistula.  Vascular surgery was consulted while
the patient was in the unit and they felt that based on these
findings no further intervention was recommended.  The
patient ended up receiving another unit of packed red cells
after the first two.  Her hematocrit stabilized at 33.4.  It
went from 26 to 33.4 after three units which was an
appropriate response.  The patient was restarted on a heparin
drip on [**2144-2-22**] with a goal PTT of 40 to 50 to prevent
expansion of the bleeding in the abdomen.  Physical therapy
saw the patient on [**2144-2-24**].  They felt that the patient was
safe for discharge to home once she was medically cleared and
did to require home physical therapy or short term
rehabilitation.  On [**2144-2-26**] the patient spiked a temperature
to 101.6.  She was pancultured.  Chest x-rays showed no
infiltrates.  Blood cultures had no growth.  A CT abdomen was
repeated to assess her increasing size of hematoma.  This
showed a decrease size of the abdominal hematoma and a
decrease in the inflammatory changes with no focal process.
The patient's urine culture did grow out proteus mirabilis.
The patient's urinalysis was significant for 11 red cells, 9
white cells and rare bacteria.  The patient was started
empirically on Levofloxacin 500 q.d.  Liver function tests
were also added on to assess for intra-abdominal infection,
even through the CT of the abdomen was negative they were
within normal limits.  The patient was restarted on Coumadin
and she was not to be discharged until her INR was greater
than 2.5 with both the mitral valve replacement and the left
atrial appendage.  The patient's Levofloxacin was
discontinued after three days of treatment.  Her blood
cultures had no growth and she did not spike any further
temperatures.  Her heart failure was well compensated and she
remained on the medication she was admitted with.  The
patient's hematocrit remained stable.  Her pain in the
abdomen and back secondary to the bleeding improved.  The
patient remained in house until [**3-5**] when her INR came back
at 3.0.  Her heparin was then discontinued.  The patient was
discharged to home to follow up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **].

DISCHARGE DIAGNOSES:
Cardiomyopathy, nonischemic, with an ejection fraction to 10
to 20 percent.

DISCHARGE MEDICATIONS:
1.      Torvastatin 10 q.d.
2.      Metoprolol 100 q.d.
3.      Valsartin 80 b.i.d.
4.      Tylenol p.r.n.
5.      Aspirin 81 q.d.
6.      Guaifenesin syrup q 6 hours p.r.n.
7.      Colace 100 b.i.d.
8.      Senna b.i.d. p.r.n.
9.      Benadryl 25 h.s. p.r.n. for insomnia.
10.     Digoxin .125 q.d.

The patient had the following follow up appointments:
1) Dr. [**Last Name (STitle) **] in Heart Failure Clinic on [**3-26**].
2) Dr. [**Last Name (STitle) **].
The patient was also to have her INR checked on the Monday
after discharge which is [**2144-3-9**] after [**Hospital 99514**] [**Hospital 107**]
Hospital.




                            [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern1) 24503**], M.D.  [**MD Number(1) 24504**]

Dictated By:[**Last Name (NamePattern1) 5851**]
MEDQUIST36

D:  [**2144-4-22**]  18:35
T:  [**2144-4-22**]  21:16
JOB#:  [**Job Number 99515**]
{'Acute systolic heart failure,Other primary cardiomyopathies,Endocarditis, valve unspecified, unspecified cause,Diseases of tricuspid valve,Hemorrhage complicating a procedure,Urinary tract infection, site not specified,Other chronic pulmonary heart diseases,Pure hypercholesterolemia'}


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: Ms. [**Known lastname 13983**] is a 62 year-old
female with a past medical history significant for mitral
valve replacement secondary to rheumatic heart disease,
hypertension, high cholesterol, cerebrovascular accident in
[**2141**] and asthma who presented to the C-Med service with new
onset of congestive heart failure.  The patient had a mitral
valve stenosis secondary to rheumatic heart disease and had
this valve replaced with a St. Jude valve on [**2143-10-16**].  She
had been doing quite well until about four weeks prior to
admission when the patient noted an abrupt change in her
exercise capacity.  She noted dyspnea on exertion with
minimal activity and even at rest.  Her primary care
physician sent the patient for an echocardiogram which showed
a notable decrease in her ejection fraction from 50 percent
previously down to 10 to 20 percent with severe global left
ventricular hypokinesis.  After the echocardiogram the
patient's primary care sent her to the emergency department
for heparinization while the INR comes down in anticipation
of a cardiac catheterization to evaluate for ischemic
cardiomyopathy.  The patient was comfortable on admission
except for her dyspnea.

MEDICAL HISTORY: 1) Mitral valve replacement St. Jude
valve secondary to mitral valve stenosis for rheumatic heart
disease.  2) Hypertension.  3) High cholesterol.  4)
Cerebrovascular accident in [**2141**] leaving her with residual
right sided weakness and lastly asthma.  o known drug
allergies.

MEDICATION ON ADMISSION: Coumadin 3.5 alternating with 4.5
q.o.d., Lipitor 10 q.d., KayCiel 20 q.d., Lasix 20 b.i.d.,
Toprol XL 200 q.d., Diovan 80 b.i.d. and Lanoxicaps 0.2 q.d.

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: Was positive for coronary artery disease.
Sister had a coronary artery bypass graft at the age of 51.
Mother developed coronary artery disease in her 50s.

SOCIAL HISTORY: The patient quit smoking two years ago,
occasional alcohol use. 

### Response:
{'Acute systolic heart failure,Other primary cardiomyopathies,Endocarditis, valve unspecified, unspecified cause,Diseases of tricuspid valve,Hemorrhage complicating a procedure,Urinary tract infection, site not specified,Other chronic pulmonary heart diseases,Pure hypercholesterolemia'}
