CHIEF COMPLAINT: ventricular tachycardia arrest/dyspnea on exertion

PRESENT ILLNESS: The patient is a 63 male with multiple medical problems
including critical aortic stenosis who is admitted to CCU
following ventricular tachycardia arrest during cardiac
catheterization. He was in his normal state of health until this
past fall when he developed progressive dyspnea with exertion.
He denies symptoms concerning for angina. On exam, he was noted
to have a murmur consistent with aortic stenosis. He underwent a
surface echocardiogram that revealed aortic valve area by
continuity equation of 0.7 cm2 (trileaflet). He was referred to
[**Hospital1 18**] cardiac surgery for evaluation for aortic valve
replacment.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
3. OTHER PAST MEDICAL HISTORY:
-Aortic stenosis
-Hyperlipidemia
-Hypertension
-Morbid obesity
-Asthma
-GERD
-Cholelithiasis
-Degenerative joint disease
-Arthritis
-Anxiety
-Cholecystectomy [**77**] years ago

MEDICATION ON ADMISSION: -Protonix 40mg once daily
-albuterol every 6 hours prn
-Lisinopril 20mg once daily
-Zocor 40mg once daily
-Aspirin 81mg daily

ALLERGIES: Heparin Agents

PHYSICAL EXAM: Admission exam:
VS: BP:89/62  HR: 82  RR: 14  100%
Vent settings: AC 550  RR:14 PEEP: 8 cm/h2o FIO2: 100
GENERAL: Intubated, raising both hands
HEENT: NCAT. Sclera anicteric. pupils 2mm -> 1mm bilaterally,
EOMI. Conjunctiva were pink, no pallor of the oral mucosa. No
xanthalesma.
NECK: Supple with JVP of 6 cm.
CARDIAC: S1, S2 appreciated, ejection click not appreciated,
loud, nearly holosystolic murmur RUSB radiate to carotids
LUNGS: No chest wall deformities, faint crackles at bases
bilaterally
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits, right groin venous
access sheath in place
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+

FAMILY HISTORY: - No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Mother:  died CAD in early 60s
- Father:  died CAD, heart failure in mid 60s
- Brother: diagnosis of peripheral artery disease

SOCIAL HISTORY: -Marine biology teacher [**Location (un) 1411**] high school
-Former smoker during college
-several drinks per week
-denies illicit drug use
Aortic valve disorders,Cardiac arrest,Acute kidney failure with lesion of tubular necrosis,Acidosis,Other chronic pulmonary heart diseases,Other pulmonary insufficiency, not elsewhere classified, following trauma and surgery,Body Mass Index 40.0-44.9, adult,Congestive heart failure, unspecified,Heparin-induced thrombocytopenia (HIT),Chronic passive congestion of liver,Postoperative shock, cardiogenic,Cardiac complications, not elsewhere classified,Acute posthemorrhagic anemia,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Coronary atherosclerosis of native coronary artery,Morbid obesity,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Esophageal reflux,Asthma, unspecified type, unspecified,Anxiety state, unspecified,Family history of ischemic heart disease,Duane's syndrome,Injury to other specified nerve(s) of shoulder girdle and upper limb,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation
Aortic valve disorder,Cardiac arrest,Ac kidny fail, tubr necr,Acidosis,Chr pulmon heart dis NEC,Ot pul insuf fol trm/srg,BMI 40.0-44.9, adult,CHF NOS,Heparin-indu thrombocyto,Chr passiv congest liver,Postop shock,cardiogenic,Surg compl-heart,Ac posthemorrhag anemia,Abn react-cardiac cath,Crnry athrscl natve vssl,Morbid obesity,Hyperlipidemia NEC/NOS,Hypertension NOS,Esophageal reflux,Asthma NOS,Anxiety state NOS,Fam hx-ischem heart dis,Duane's syndrome,Inj nerve shldr/arm NEC,Abn react-anastom/graft
Admission Date:  [**2174-11-9**]              Discharge Date:   [**2174-12-2**]

Date of Birth:  [**2111-3-30**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Heparin Agents

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
ventricular tachycardia arrest/dyspnea on exertion

Major Surgical or Invasive Procedure:
[**2174-11-11**] - Aortic valve replacement with 19-mm St. [**Hospital 923**] Medical
Regent mechanical heart valve, aortic root enlargement with
bovine pericardium.
[**2174-11-9**] - Cardiac catheterization


History of Present Illness:
The patient is a 63 male with multiple medical problems
including critical aortic stenosis who is admitted to CCU
following ventricular tachycardia arrest during cardiac
catheterization. He was in his normal state of health until this
past fall when he developed progressive dyspnea with exertion.
He denies symptoms concerning for angina. On exam, he was noted
to have a murmur consistent with aortic stenosis. He underwent a
surface echocardiogram that revealed aortic valve area by
continuity equation of 0.7 cm2 (trileaflet). He was referred to
[**Hospital1 18**] cardiac surgery for evaluation for aortic valve
replacment.

On the day of admission, he underwent left heart catheterization
to evaluate coronary anatomy. He was in his normal state of
health before case. Arterial access obtained through right
radial without issue (3:10PM).  He then started to complain of
his right arm hurting him and became very anxious and said he
felt claustrophobic. His systolic blood pressure drifted down to
the 60s with heart rate in the fifties (3:16PM). He was given
atropine and started on dopamine.
He felt warm, diaphoretic, and restless. His blood pressure and
heart rate were variable, with narrow complex tachycardia up to
140s. The left circulation was injected (3:28).  He was noted to
have increasing PVCs on telemetry and then at 4:02PM developed
polymorphic ventricular tachycardia with loss of pulse. CPR was
initiated and he was shocked x2 with return of pressure.  CPR
done for approximately 1 minute.  He was intubated w/ fent/midaz
and still agitated so paralyzed. Initial ABG 7.17/46/180/18.
Catheterization showed no significant CAD, mean wedge 16,
cardiac index of 3.92.  Right groin venous sheath placed. TTE
w/out effusion. Repeat ABG 7.22/40/290/17. He was given at least
1.4L IVF during the case. Given dose of Ancef.

On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.

Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.

Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
3. OTHER PAST MEDICAL HISTORY:
-Aortic stenosis
-Hyperlipidemia
-Hypertension
-Morbid obesity
-Asthma
-GERD
-Cholelithiasis
-Degenerative joint disease
-Arthritis
-Anxiety
-Cholecystectomy [**77**] years ago

Social History:
-Marine biology teacher [**Location (un) 1411**] high school
-Former smoker during college
-several drinks per week
-denies illicit drug use

Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Mother:  died CAD in early 60s
- Father:  died CAD, heart failure in mid 60s
- Brother: diagnosis of peripheral artery disease

Physical Exam:
Admission exam:
VS: BP:89/62  HR: 82  RR: 14  100%
Vent settings: AC 550  RR:14 PEEP: 8 cm/h2o FIO2: 100
GENERAL: Intubated, raising both hands
HEENT: NCAT. Sclera anicteric. pupils 2mm -> 1mm bilaterally,
EOMI. Conjunctiva were pink, no pallor of the oral mucosa. No
xanthalesma.
NECK: Supple with JVP of 6 cm.
CARDIAC: S1, S2 appreciated, ejection click not appreciated,
loud, nearly holosystolic murmur RUSB radiate to carotids
LUNGS: No chest wall deformities, faint crackles at bases
bilaterally
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits, right groin venous
access sheath in place
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+

Pertinent Results:
Admission labs:
[**2174-11-9**] 12:56PM BLOOD WBC-7.7 RBC-4.34* Hgb-12.9* Hct-37.5*
MCV-86 MCH-29.8 MCHC-34.5 RDW-13.2 Plt Ct-244
[**2174-11-9**] 12:56PM BLOOD Neuts-65.2 Lymphs-27.8 Monos-5.6 Eos-1.0
Baso-0.5
[**2174-11-9**] 12:56PM BLOOD PT-12.6* PTT-150* INR(PT)-1.2*
[**2174-11-9**] 12:56PM BLOOD Glucose-85 UreaN-21* Creat-0.9 Na-140
K-4.0 Cl-106 HCO3-22 AnGap-16
[**2174-11-9**] 12:56PM BLOOD ALT-27 AST-35 AlkPhos-53 TotBili-0.7
[**2174-11-9**] 12:56PM BLOOD %HbA1c-5.5 eAG-111
[**2174-11-9**] 04:37PM BLOOD Type-ART Rates-/14 Tidal V-550 PEEP-5
FiO2-1 pO2-180* pCO2-46* pH-7.17* calTCO2-18* Base XS--11
Intubat-INTUBATED
[**2174-11-9**] 05:03PM BLOOD Type-ART Rates-/14 Tidal V-550 PEEP-5
FiO2-100 pO2-290* pCO2-40 pH-7.22* calTCO2-17* Base XS--10
AADO2-402 REQ O2-69 Intubat-INTUBATED
[**2174-11-9**] 09:37PM BLOOD Type-ART pO2-200* pCO2-34* pH-7.39
calTCO2-21 Base XS--3

Imaging/procedures:
-Cardiac cath ([**2174-11-9**]) - 1. Coronary angiography of this right
dominant system demonstrated one
vessel coronary artery disease. The LMCA was short and patent.
The LAD
had a proximal 40 % and 50% D1 stenosis. The LCX had a mid 30%
stenosis.
The RCA had a proximal 30% and distal 40% stenosis.
2. Resting hemodynamics revealed mildly elevated right and left
sided
filling pressures, with RVEDP 14 mmHg and PCW 16 mmHg. There was

moderate pulmonary arterial hypertension at rest, with PASP 46
mmHg. The
cardiac output was preserved at rest, with cardiac index 3.9
L/min/m2.
3. Event summary: Initial access obtained in right radial artery
using a
5 F sheath. After passing catheter centrally to ascending aorta,
patient
started feeling very estless, and felt hot and non-specifically
agitated. Denied chest pain or SOB, but initial central BP low
with SBP
88 mmHg, and then dropping down to 65 mmHg despite IV fluid
boluses.
Patient diaphoretic and HR 55/min. Given 0.5 mgIV atropine, with

increase HR but no improvement in BP. Then dopamine infusion was

started. Patient became intermittently agitated and tachycardic
with HR
increase to 150 bpm transiently and associated drops in BP to
SBP 70's.
When he would calm down, HR would decrease and SBP would improve
even
off dopamine. Initial angiography left coronary selective in the
LCX,
but no evient LMCA disease or dissection in thoracic aorta on
limited
contrast puffs. Decided to withdraw catheter from body, and
stabilize
patient clinically. He has no other feature to suggest allergic
response, but still very anxious. Called Dr [**Last Name (STitle) 45821**] of Ct
surgery to
discuss situation. Patient still too agitated to perform
coronary
angiography. While monitoring patient, he developed some mild
chest
tightness and PVC's and then had VF cardiac arrest. CPR
immediately
initiated and then quickly underwent successful DC cardioversion
with
restoration of pulse. With CPR and cardioversion, sheath
dislodged from
right radial artery, and TR band placed over the site. After [**12-5**]

minutes, he had another VF cardiac arrest with very brief CPR
and almost
inmmediate cardioversion. Anesthesia called stat, and patient
sedated
and intubated. Now more hemodynamically stable with better BP,
and
dopamine stopped. Access then obtained in right CFA and CFV and
coronary
angiography and RHC performed. At end of case, patient
hemodynamically
quite stable with BP 140/80 off pressors, good cardiac output,
and PCWP
16. Right CFA access site closed using AngioSeal device.
FINAL DIAGNOSIS:
1. one vessel coronary artery disease.
2. Hypotension and VF cardiac arrest likely secondary to
vasovagal
episode in the context of severe aortic stenosis. Echocardiogram

performed stat at end of case showed preseved LVEF and no
pericardial
effusion. He is s/p DC cardioversion x 2 and CPR. Intubated and
ventilated.
3. Moderate pulmonary hypertension.

-TTE ([**2174-11-9**]) - There is mild regional left ventricular
systolic dysfunction with probable hypokinesis of the distal
anterior septum. Right ventricular chamber size and free wall
motion are normal. Significant aortic stenosis is present (not
quantified). Moderate (2+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Aortic stenosis is probably severe. At least
moderate aortic regurgitation. Image quality is suboptimal. The
mid to distal anterior septum is probably mildly hypokinetic.

-CXR ([**2174-11-9**]) - The tip of the endotracheal tube projects 3.5
cm above the carina.  The nasogastric tube shows a normal
course. Moderate cardiomegaly with mild pulmonary edema. No
pleural effusions. No pneumonia. Minimal retrocardiac
atelectasis. There is no evidence of rib fractures on the
current radiograph. If clinically relevant, a dedicated rib
series should be obtained.

-CXR ([**2174-11-10**]) - As compared to the previous radiograph, there
is no relevant change. Low lung volumes, intubation, moderate
cardiomegaly, and mild fluid overload. No pleural effusions. No
evidence of pneumonia.

- ECHO [**2174-11-11**]
PRE-BYPASS: No spontaneous echo contrast is seen in the body of
the left atrium or left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is mildly
depressed (LVEF= 40-45 %). Right ventricular chamber size and
free wall motion are normal. There are simple atheroma in the
aortic arch. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets are severely
thickened/deformed. There is critical aortic valve stenosis
(valve area <0.8cm2). Moderate (2+) aortic regurgitation is
seen. The mitral valve leaflets are moderately thickened. Mild
to moderate ([**12-5**]+) mitral regurgitation is seen. There is no
pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the
results at time of surgery.

POST-BYPASS: The patient is in sinus rhythm. The patient is on
an epinephrine infusion. Right ventricular function on initial
post-bypass images appears moderately depressed, then improves
back to baseline after chest closure. Left ventricular function
is unchanged. There is a well-seated, well-positioned mechanical
prosthetic valve in the aortic position. No paravalvular leak is
seen. Characteristic washing jets are seen. There is a mean
gradient of 21 mmHg at a cardiac output of 4.1 L/min. Mitral
regurgitation is unchanged. The aorta is intact
post-decannulation.

- Abdominal U/S
Extremely limited ultrasound due to the patient's body habitus.
Despite diligent effort, the gallbladder could not be
identified. If further evaluation of the gallbladder is
indicated, CT, MR, or nuclear medicine scan could be obtained.


Brief Hospital Course:
The patient is a 63 male with multiple medical problems
including critical aortic stenosis who is admitted to CCU
following ventricular tachycardia arrest during cardiac
catheterization. Due to the initial complexity of his
hospitalization, his course will be broken down into systems
until the time of his aortic valve replacement.

#VT ARREST: Patient developed hemodynamically unstable
polymorphic ventricular during cardiac catheterization. EKG from
earlier in the day with normal QT interval with no conduction
abnormalities. Postulated mechanism his ventricular arrhythmia
include ischemia, excess catecholamines, of vagal event during
procedure causing hypotension resulting in ischemia.  Upon
admission to the CCU, he was initially requiring dopamine which
was weaned at the same time he was extubated and sedation was
turned off.

#RESPIRATORY FAILURE: Patient intubated in the setting of VT
arrest. ABG with increased A-a gradient most likely due to VQ
mismatch from atelactasis and mild/moderate pulmonary vascular
congestion. He was extubated without difficulty on ICU day 2 and
maintained good oxygen saturation.

#AORTIC STENOSIS: Patient with progressive dyspnea on exertion
found to have trileaflet aortic valve with aortic valve area of
0.7 by continuity equation on recent echocardiogram.

#RIGHT ARM PROXIMAL WEAKNESS - After he was extubated and
sedation wore off, he was unable to lift his right arm but had
intact hand movement.  This was presumed to be from a brachial
plexus injury which may have occurred during his cardiac cath
which was performed through the right radial artery.  Neurology
was consulted and felt that there was no evidence of a central
process.  He will follow up as an outpatient with neurology and
had his arm placed in a sling during this admission.

On [**2174-11-10**], Mr. [**Known lastname 13257**] [**Last Name (Titles) 5058**] neurologically intact and the
decision was made to proceed with his surgery. On [**2174-11-11**], Mr.
[**Known lastname 13257**] was taken to the operating room where he underwent
enlargement of his aortic root with replacement of his aortic
valve using a 19mm St. [**Male First Name (un) 923**] mechanical valve. Please see
operative note for details. Postoperatively he was taken to the
intensive care unit for monitoring. He required blodd
transfusions for postoperative anemia. He developed right heart
failure and remained intubated, sedated and on inotropes. He was
diuresed aggressively. He developed hepatic congestion with
elevation of his LFT's. A right upper quadrant ultrasound was
negative. His creatinine gradually increased and the renal
service was consulted for evaluation of an acute kidney injury.
Acute tubular necrosis in the setting of hypoperfusion was
suspected and he was started on CVVHD for fluid removal. His
creatinine slowly improved. He also became thrombocytopenic and
a hematology consult was obtained. Argatroban was started and
all heparin products were stopped. An original HIT screen was
negative but a serotonin assay was sent which returned positive.
Leukocytosis was noted and vancomycin and zosyn were started for
broad coverage. A central line culture grew coag negative staph
and the infectious disease service was consulted.  He will
continue on Vancomycin only until the 8 AM dose on [**12-3**]. Tube
feeds were started for nutritional support. Coumadin started
[**11-23**] for mechanical valve while bridged with argatroban. An MRI
of the brain was ordered for lingering right sided weakness of
both the upper and lower extremities and for limited horizontal
gaze. It showed multiple small white matter infarctions, but
neurology felt these findings did not explain Mr. [**Known lastname **]
deficits. Over the next week he began to make slow neurologic
improvement.  By post-operative day 21 he was ready for
discharge to [**Hospital3 **].


Medications on Admission:
-Protonix 40mg once daily
-albuterol every 6 hours prn
-Lisinopril 20mg once daily
-Zocor 40mg once daily
-Aspirin 81mg daily

Discharge Medications:
1. vancomycin in D5W 1 gram/200 mL Piggyback [**Hospital3 **]: One (1) gm
Intravenous Q 12H (Every 12 Hours): for coad negative staph in
IV line. last dose 12/31 at 8AM.
2. simvastatin 10 mg Tablet [**Hospital3 **]: One (1) Tablet PO HS (at
bedtime).
3. lisinopril 5 mg Tablet [**Hospital3 **]: One (1) Tablet PO DAILY (Daily).

4. metoprolol tartrate 25 mg Tablet [**Hospital3 **]: Three (3) Tablet PO TID
(3 times a day).
5. aspirin 81 mg Tablet, Delayed Release (E.C.) [**Hospital3 **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily). Tablet, Delayed
Release (E.C.)(s)
6. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
8. docusate sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2
times a day).
9. magnesium hydroxide 400 mg/5 mL Suspension [**Last Name (STitle) **]: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
10. warfarin 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO ONCE (Once) for
1 doses: Continue coumadin dosing for goal INR of [**1-6**] for a
mechanical aortic valve.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **]

Discharge Diagnosis:
Aortic stenosis
Hyperlipidemia
acute renal failure
heparin-induced thrombocytopenia
Hypertension
Morbid obesity
Asthma
GERD
Cholelithiasis
Degenerative joint disease
Arthritis
Anxiety
Cardiac arrest


Discharge Condition:
Alert and oriented x3 nonfocal
Stands with max assist
Right sided weakness 4/5 both upper and lower extremities,
limited horizontal gaze
Incisional pain managed with tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Edema trace lower extremity


Discharge Instructions:
1) 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.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]

*Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**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. [**Last Name (STitle) **] on [**1-11**] at 1PM
Cardiologist: Dr. [**Last Name (STitle) **] on [**12-28**] at 9:10AM

Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] in [**3-8**] weeks

**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 mechanical aortic valve
Goal INR 2-3.0
First draw [**12-3**]



Completed by:[**2174-12-2**]
{"Aortic valve disorders,Cardiac arrest,Acute kidney failure with lesion of tubular necrosis,Acidosis,Other chronic pulmonary heart diseases,Other pulmonary insufficiency, not elsewhere classified, following trauma and surgery,Body Mass Index 40.0-44.9, adult,Congestive heart failure, unspecified,Heparin-induced thrombocytopenia (HIT),Chronic passive congestion of liver,Postoperative shock, cardiogenic,Cardiac complications, not elsewhere classified,Acute posthemorrhagic anemia,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Coronary atherosclerosis of native coronary artery,Morbid obesity,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Esophageal reflux,Asthma, unspecified type, unspecified,Anxiety state, unspecified,Family history of ischemic heart disease,Duane's syndrome,Injury to other specified nerve(s) of shoulder girdle and upper limb,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation"}


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: ventricular tachycardia arrest/dyspnea on exertion

PRESENT ILLNESS: The patient is a 63 male with multiple medical problems
including critical aortic stenosis who is admitted to CCU
following ventricular tachycardia arrest during cardiac
catheterization. He was in his normal state of health until this
past fall when he developed progressive dyspnea with exertion.
He denies symptoms concerning for angina. On exam, he was noted
to have a murmur consistent with aortic stenosis. He underwent a
surface echocardiogram that revealed aortic valve area by
continuity equation of 0.7 cm2 (trileaflet). He was referred to
[**Hospital1 18**] cardiac surgery for evaluation for aortic valve
replacment.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
3. OTHER PAST MEDICAL HISTORY:
-Aortic stenosis
-Hyperlipidemia
-Hypertension
-Morbid obesity
-Asthma
-GERD
-Cholelithiasis
-Degenerative joint disease
-Arthritis
-Anxiety
-Cholecystectomy [**77**] years ago

MEDICATION ON ADMISSION: -Protonix 40mg once daily
-albuterol every 6 hours prn
-Lisinopril 20mg once daily
-Zocor 40mg once daily
-Aspirin 81mg daily

ALLERGIES: Heparin Agents

PHYSICAL EXAM: Admission exam:
VS: BP:89/62  HR: 82  RR: 14  100%
Vent settings: AC 550  RR:14 PEEP: 8 cm/h2o FIO2: 100
GENERAL: Intubated, raising both hands
HEENT: NCAT. Sclera anicteric. pupils 2mm -> 1mm bilaterally,
EOMI. Conjunctiva were pink, no pallor of the oral mucosa. No
xanthalesma.
NECK: Supple with JVP of 6 cm.
CARDIAC: S1, S2 appreciated, ejection click not appreciated,
loud, nearly holosystolic murmur RUSB radiate to carotids
LUNGS: No chest wall deformities, faint crackles at bases
bilaterally
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits, right groin venous
access sheath in place
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+

FAMILY HISTORY: - No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Mother:  died CAD in early 60s
- Father:  died CAD, heart failure in mid 60s
- Brother: diagnosis of peripheral artery disease

SOCIAL HISTORY: -Marine biology teacher [**Location (un) 1411**] high school
-Former smoker during college
-several drinks per week
-denies illicit drug use 

### Response:
{"Aortic valve disorders,Cardiac arrest,Acute kidney failure with lesion of tubular necrosis,Acidosis,Other chronic pulmonary heart diseases,Other pulmonary insufficiency, not elsewhere classified, following trauma and surgery,Body Mass Index 40.0-44.9, adult,Congestive heart failure, unspecified,Heparin-induced thrombocytopenia (HIT),Chronic passive congestion of liver,Postoperative shock, cardiogenic,Cardiac complications, not elsewhere classified,Acute posthemorrhagic anemia,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Coronary atherosclerosis of native coronary artery,Morbid obesity,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Esophageal reflux,Asthma, unspecified type, unspecified,Anxiety state, unspecified,Family history of ischemic heart disease,Duane's syndrome,Injury to other specified nerve(s) of shoulder girdle and upper limb,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation"}
