CHIEF COMPLAINT: worsening shortness of breath, chest pain

PRESENT ILLNESS: Ms. [**Known lastname 16905**] is a 70-year-old woman who was
referred with critical aortic stenosis.
In [**2173-10-18**], she suffered a syncopal episode and presented
to [**Hospital2 **] [**Hospital3 6783**] Hospital where evaluation documented critical
aortic stenosis by both catheterization as well as
echocardiography.  Coronary angiography at that time
demonstrated
an occluded proximal LAD, moderate diffuse disease in the LCx,
and an occluded RCA.  There was a patent SVG to the right
coronary and a patent SVG tot he LAD. Quantitation of her aortic
stenosis yielded a mean transvalvular gradient of 46 mmHg and a
valve area of 0.6 by Fick estimate. At that time, the patient
reportedly had a significantly elevated pulmonary arterial
pressure of systolic of 115mmHg, though no wedge pressure was
available in the report. She was evaluated by Dr. [**Last Name (STitle) 50180**] of
Cardiothoracic Surgery at [**Hospital2 **] [**Hospital3 6783**] and deemed to be
prohibitively high-risk candidate for traditional aortic valve
surgery.

MEDICAL HISTORY: 1. aortic stenosis
2. aortic valvuloplasty [**2174-3-24**]
3. CAD - s/p CABG x 2 ([**2159**]), PCI, chronic RBBB
4. COPD - home oxygen x 5 years
5. severe pulmonary hypertension
6. diabetes
7. hypertension
8. hyperlipidemia
9. obstructive sleep apnea  -has own CPAP machine
10. obesity
11. renal insufficiency
12. osteoarthritis
13. situational depression
14. presbyopia
15. gout
16. nasal fracture secondary to [**2159**]7. cholecystectomy
[**80**]. knee pain s/p [**2080**]9. ventral hernia

MEDICATION ON ADMISSION: ASA 81mg daily
metoprolol tartrate 12.5mg daily
simvastatin 20mg qhs
furosemide 20mg [**Hospital1 **]
metolazone 2.5mg 2x/week (qmon&fri)
insulin glargine (Lantus) 22units daily (pt regulates- varies)
insulin Lispro (humalog)3u bkfst,2u lunch,8u dinner, 3u hs
potassium chloride 20meq tid
ferrous sulfate 325mg daily
lansoprazole 30mg daily
MVI 1 tab daily
Allopurinol 150 daily
Buproprion HCL SR 200mg [**Hospital1 **]
clonazepam 2mg qhs
excitalopram Oxalate (Lexapro) 30mg daily
nitroglycerin SL 0.4mg SL prn chest pain
trazodone 100mg qhs prn insomnia
hydrocodone-acetaminophen 5/500mg 1-2 tabs q6h prn pain
oxygen 3L nasal cannula continuously
tolterodine (detrol) 2mg po bid

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADDMISSION EXAM:
Pulse: 46, B/P: Right 143/57, Resp: 18, O2 Sat: 95  (O2 2.5L),
Temp: 93.5 ax
Height: 160cm  Weight: 98.6kg
General: Elderly heavy set female in wheelchair with O2 notably
SOB with conversation.
Skin: Pale, skin warm and dry.
HEENT: Normocephalic. Anicteric.
Neck: Supple, trachea midline. Bilat. carotid bruit vs. murmer.
Chest: Able to speak in short phrases only.
Heart:murmer throughout
Abdomen: Rotund, soft, (+)bowel sounds.
Extremities: 2+ lower extremity edema bilaterally. Bilateral
knee
pain.
Neuro: A+O x 3, c/o pain to bilateral knees. Somnolent,
upperextremities. UE's muscle wasting.
Pulses: palpable peripheral pulses

FAMILY HISTORY: FAMILY HISTORY: Positive for diabetes and coronary artery
disease. Her father died in his 50s of an MI and her mother died
at 98 of a CVA.

SOCIAL HISTORY: SOCIAL HISTORY: She lives with her sister, [**Name (NI) 4248**]. She has another
sister, [**Name (NI) 37620**] who assists with her [**Name (NI) 5669**]. Ambulates at home
with
walker, uses wheelchair when out of house. Has 4 steps to enter
home, and chair lift once inside. Currently, physical therapy
sees her once weekly for her knee injury.
[**Name (NI) 37620**] [**Name (NI) **] (sister) [**Telephone/Fax (1) 88728**]
[**Doctor First Name **] (neice) [**Telephone/Fax (1) 88729**]
Aortic valve disorders,Cardiac arrest,Acute on chronic diastolic heart failure,Pneumonitis due to inhalation of food or vomitus,Acute kidney failure with lesion of tubular necrosis,Cardiac complications, not elsewhere classified,Atrioventricular block, complete,Other postoperative infection,Delirium due to conditions classified elsewhere,Acidosis,Cellulitis and abscess of trunk,Other chronic pulmonary heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Chronic airway obstruction, not elsewhere classified,Thrombocytopenia, unspecified,Obstructive sleep apnea (adult)(pediatric),Dysthymic disorder,Acute gouty arthropathy,Hypoxemia,Candidiasis of vulva and vagina,Leukocytosis, unspecified,Obesity, unspecified,Aortocoronary bypass status,History of fall,Acquired absence of both cervix and uterus,Long-term (current) use of insulin,Examination of participant in clinical trial,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation
Aortic valve disorder,Cardiac arrest,Ac on chr diast hrt fail,Food/vomit pneumonitis,Ac kidny fail, tubr necr,Surg compl-heart,Atriovent block complete,Other postop infection,Delirium d/t other cond,Acidosis,Cellulitis of trunk,Chr pulmon heart dis NEC,DMII wo cmp nt st uncntr,Chronic kidney dis NOS,Hy kid NOS w cr kid I-IV,Pseudomonas infect NOS,Chr airway obstruct NEC,Thrombocytopenia NOS,Obstructive sleep apnea,Dysthymic disorder,Acute gouty arthropathy,Hypoxemia,Candidal vulvovaginitis,Leukocytosis NOS,Obesity NOS,Aortocoronary bypass,Personal history of fall,Acq absnce cervix/uterus,Long-term use of insulin,Exam-clincal trial,Abn react-surg proc NEC
Admission Date:  [**2174-8-15**]              Discharge Date:   [**2174-9-2**]

Date of Birth:  [**2103-11-10**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
worsening shortness of breath, chest pain

Major Surgical or Invasive Procedure:
CoreValve on [**2174-8-16**]

History of Present Illness:
Ms. [**Known lastname 16905**] is a 70-year-old woman who was
referred with critical aortic stenosis.
In [**2173-10-18**], she suffered a syncopal episode and presented
to [**Hospital2 **] [**Hospital3 6783**] Hospital where evaluation documented critical
aortic stenosis by both catheterization as well as
echocardiography.  Coronary angiography at that time
demonstrated
an occluded proximal LAD, moderate diffuse disease in the LCx,
and an occluded RCA.  There was a patent SVG to the right
coronary and a patent SVG tot he LAD. Quantitation of her aortic
stenosis yielded a mean transvalvular gradient of 46 mmHg and a
valve area of 0.6 by Fick estimate. At that time, the patient
reportedly had a significantly elevated pulmonary arterial
pressure of systolic of 115mmHg, though no wedge pressure was
available in the report. She was evaluated by Dr. [**Last Name (STitle) 50180**] of
Cardiothoracic Surgery at [**Hospital2 **] [**Hospital3 6783**] and deemed to be
prohibitively high-risk candidate for traditional aortic valve
surgery.

Over the ensuing six months,  the patient has had recurrent
episodes of syncope as well as falls due to gait instability.
She
has continued to have exertional chest pressure, but no
palpitations and she has been hospitalized several times
following falls at home. She has profound dyspnea on exertion
(NYHA Class III) and has had several episodes of syncope per
month. She now reports onset of chest discomfort after 15 feet
of
walking.
     She has met inclusion criteria for Corevalve study and does
not meet exclusion criteria. Her findings have been reviewed,
submitted, and accepted for the Extreme arm Corevalve study.
     Since last seen in office, she is only able to ambulate
short distances (room to room) due to shortness of breath. She
comes in this am somewhat lethargic and diaphoretic, blood
glucose was 43, she was treated with 1/2 amp of D50w, and oral
juice, blood glucose 188. Patient somnolent, family reports she
took 2 doses of clorazepam at 2am. Patient reports she has been
anxious about procedure and has been unable to sleep. Answers
questions appropriately, somnolent unless verbally stimulated.
ABG done on baseline O2 3L nc. Acceptable findings.

NYHA Class: III-IV


Past Medical History:
1. aortic stenosis
2. aortic valvuloplasty [**2174-3-24**]
3. CAD - s/p CABG x 2 ([**2159**]), PCI, chronic RBBB
4. COPD - home oxygen x 5 years
5. severe pulmonary hypertension
6. diabetes
7. hypertension
8. hyperlipidemia
9. obstructive sleep apnea  -has own CPAP machine
10. obesity
11. renal insufficiency
12. osteoarthritis
13. situational depression
14. presbyopia
15. gout
16. nasal fracture secondary to [**2159**]7. cholecystectomy
[**80**]. knee pain s/p [**2080**]9. ventral hernia


Social History:
SOCIAL HISTORY: She lives with her sister, [**Name (NI) 4248**]. She has another
sister, [**Name (NI) 37620**] who assists with her [**Name (NI) 5669**]. Ambulates at home
with
walker, uses wheelchair when out of house. Has 4 steps to enter
home, and chair lift once inside. Currently, physical therapy
sees her once weekly for her knee injury.
[**Name (NI) 37620**] [**Name (NI) **] (sister) [**Telephone/Fax (1) 88728**]
[**Doctor First Name **] (neice) [**Telephone/Fax (1) 88729**]

Average Daily Living:
Live independently            Yes [x]   No [ ]
Bathing                [ ] Independent  [x] Dependent
Dressing               [ ] Independent  [x] Dependent
Toileting              [x] Independent  [ ] Dependent
Transferring           [ ] Independent  [x] Dependent
Continence             [x] Independent  [ ] Dependent
Feeding                [x] Independent  [ ] Dependent

Family History:
FAMILY HISTORY: Positive for diabetes and coronary artery
disease. Her father died in his 50s of an MI and her mother died
at 98 of a CVA.

Physical Exam:
ADDMISSION EXAM:
Pulse: 46, B/P: Right 143/57, Resp: 18, O2 Sat: 95  (O2 2.5L),
Temp: 93.5 ax
Height: 160cm  Weight: 98.6kg
General: Elderly heavy set female in wheelchair with O2 notably
SOB with conversation.
Skin: Pale, skin warm and dry.
HEENT: Normocephalic. Anicteric.
Neck: Supple, trachea midline. Bilat. carotid bruit vs. murmer.
Chest: Able to speak in short phrases only.
Heart:murmer throughout
Abdomen: Rotund, soft, (+)bowel sounds.
Extremities: 2+ lower extremity edema bilaterally. Bilateral
knee
pain.
Neuro: A+O x 3, c/o pain to bilateral knees. Somnolent,
upperextremities. UE's muscle wasting.
Pulses: palpable peripheral pulses

DISCHARGE EXAM:
Temp: 98 HR: 60 RR: 18 BP: 130/47 O2 sat 96% RA. Weight 83.3 kg.

.
GENERAL: 70 yo F in no acute distress
HEENT: PERRLA, no pharyngeal erythemia, mucous membs moist, no
lymphadenopathy, JVP non elevated.
CHEST: CTABL no wheezes, no rales, no rhonchi
CV: S1 S2, 1/6 systolic murmur at RUSB, Normal in quality and
intensity RRR no murmurs rubs or gallops
ABD: soft, non-tender, non-distended, BS normoactive. no
rebound/guarding.
EXT: feet warm, no edema, pulses palp. Left groin with large
open wound from surgical cutdown s/p bovine patch and staple
closure (staples now removed). Wound has dehiscence in the upper
proximal portion. Wound has circumferential redness and mild
yellow drainage and copious tan serous drainage from an
underlying seroma. See page 1 for dressing instructions.
NEURO: CNs II-XII intact. 4/5 strength in U/L extremities.
SKIN: no rash
PSYCH: appears calm today, A/O.


Pertinent Results:
Cardiac Catheterization: ([**2174-3-24**] [**Hospital1 112**] - valvuloplasty)
Diagnostic results-
Two Vessel CAD involving the LAD and RCA
s/p CABG: all grafts patent
s/p CABG: 2 patent of 2 total grafts
Elevated Right Heart Filling Pressures RA= 24 mmHg
Elevated Right Heart Filling Pressures RV= 102/20 mmHg
Elevated Right Heart Filling Pressures PA= 96/34 (57) mmHg
Elevated Left Heart Filling Pressures [**Last Name (un) 5767**] PCWP = 26 mmHg
Aortic stenosis: severe
Aortic calculated [**Location (un) 109**]: 0.59 cm2
Aortic mean gradient: 63.2
.
Echocardiogram: TTE (Complete) Done [**2174-7-8**] at 1:00:00 PM
FINAL
Echocardiographic Measurements
Results  Measurements  Normal Range

Left Ventricle - Ejection Fraction:  >= 55%
Left Ventricle - Stroke Volume:  63 ml/beat
Left Ventricle - Cardiac Output:  4.02 L/min
Left Ventricle - Cardiac Index:  2.19  >= 2.0 L/min/M2
Aortic Valve - Peak Velocity:  *4.2 m/sec  <= 2.0 m/sec
Aortic Valve - Mean Gradient:  37 mm Hg
Aortic Valve - Valve Area:  *0.6 cm2  >= 3.0 cm2
Findings
IMPRESSION: Critical calcific aortic stenosis. Symmetric LVH
with
normal global and regional systolic function. Mild to moderate
mitral regurgitation. Severe pulmonary hypertension.

EKG: [**2174-6-17**]  10:43:36 AM
ECG interpreted by ordering physician.
[**Name10 (NameIs) 357**] see corresponding office note for interpretation.
    Intervals Axes
Rate PR QRS QT/QTc P QRS T
63 130 150 488/493 59 86 21

CT: ([**2174-7-8**])
  IMPRESSION:
1. Evidence of known aortic stenosis. Measurements regarding the
aortic valve as well as iliac arteries will be provided
separately.
2. Extensive aortic calcifications with no evidence of
dilatation.
3. Anterior abdominal hernia containing part of the transverse
colon, with no evidence of obstruction at this point.
4. Pulmonary nodules that, based on the size, should be
reevaluated in one year.
5. Status post CABG with what appears to be patent bypass to
distal LAD and PDA.
6. Borderline mediastinal lymph nodes that might be reevaluated
on subsequent study.
7. Evidence of pulmonary hypertension.
8. Right hypodense kidney lesion as well as hypodense liver
lesion that should be correlated with ultrasound.
9. Diffuse enlargement of the thyroid with multiple nodules that
might be evaluated by thyroid ultrasound.

PFT's:
[**Hospital3 14325**];s Hospital at WMC

FVC  1.06 (39%)
FEV1 0.75 (36%)
FEV1/FVC 71 (92%)
TLC 2.45 (50%)
FRC 1.48 (53%)
IC 0.97 (46%)
RV 1.38 (64%)
RV/TLC 56 (130%)

DLCO 5.50 (24%)
DLCO/VA  3.82 (72%)
.
CTA AORTA/BIFEM/ILIAC RUNOFF [**8-31**]:
Impression:  Lung volumes demonstrate marked reduction in the
TLC, FRC, RV, and VC.  Spirometry demonstrates a much reduced
FVC
and FEV1 with a normal FEV1/FVC.  The DLCO is mildly reduced.
.
IMPRESSION:
1. Large postop seroma in the left inguinal region measuring 8.7
x 9.8 x 6.7 cm.
2. Diffuse soft tissue stranding and mild swelling of the left
leg compared to the right.
3. Right upper lobe tree-in-[**Male First Name (un) 239**] opacities concerning for
aspiration with
small bilateral simple pleural effusions.
4. Patent arterial system with no flow-limiting stenoses noted.

5. Grade 1 anterolisthesis of L4 on L5.
.
[**8-23**] ECHO:
The left atrium is moderately dilated. There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF 65%). The right ventricular free wall
is hypertrophied. Right ventricular chamber size is normal. with
borderline normal free wall function. The aortic root is mildly
dilated at the sinus level. An aortic CoreValve prosthesis is
present. The transaortic gradient is normal for this prosthesis.
A mild paravalvular aortic valve leak is present. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. There is severe mitral annular calcification. There is
a minimally increased gradient consistent with trivial mitral
stenosis. Moderate (2+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
.
ECG [**8-26**]:
Sinus rhythm with probable biventricular pacemaker. Intra-atrial
conduction defect with atrial tracking. Since the previous
tracing of [**2174-8-21**] atrial pacing is no longer present.
.
VS on discharge:
temp 98, HR 60, RR 18, BP 130/70, O2 sat 97% RA. Weight: 83.3
kg.
.
Exam on Discharge:
 GENERAL: 70 yo F in no acute distress
HEENT: PERRLA, no pharyngeal erythemia, mucous membs moist, no
lymphadenopathy, JVP non elevated.
CHEST: CTABL no wheezes, no rales, no rhonchi
CV: S1 S2, 1/6 systolic murmur at RUSB, Normal in quality and
intensity RRR no murmurs rubs or gallops
ABD: soft, non-tender, non-distended, BS normoactive. no
rebound/guarding.
EXT: feet warm, no edema, pulses palp. Left groin with mod tan
serous drainage r/t underlying wound seroma, decreasing today.
Also has mild circumferential redness that is improving with
small yellow purulent drainage.
NEURO: CNs II-XII intact. 4/5 strength in U/L extremities.
SKIN: no rash
PSYCH: appears calm today, A/O.


Brief Hospital Course:
IMPRESSION: 70yo female with severe symptomatic aortic stenosis
including chest pain and near syncope with significant COPD,
continuous home O2, and moderate to severe pulmonary
hypertension. h/o CABG x 2 with patent grafts.

1.Symptomatic Aortic Stenosis: Patient had a critical AS (area
0.6cm2) and received a percutaneous bioprosthetic aortic valve
replaement on [**8-16**]. She was started on  plavix and was
maintained on her 81 mg aspirin dose. Procedure was complicated
by AV dissociation with junctional escape rhythm and ventricular
tachycardia requiring cardioversion x2. A permanent pacemaker
was placed from the left subclavian and the patient was AV
sequentially paced at 80 bpm. Procedure was otherwise
successful. Post-operatively she required intubation and
pressure support for three days. Pt was also NO for pulm htn
after procedure and ultimately weaned to 100% O2.  Vent was
weaned and blood pressures improved and pt was extubated on [**8-19**].
 On [**2174-8-23**], a post-procedure echo showed a normal trans aortic
gradient. A mild paravalvular aortic valve leak was present. She
has had a slow recovery but reports decreased DOE with
ambulation, no chest pain and no episodes of syncope. She is
scheduled for cardiac f/u in 2 weeks.
.
2. COPD/pulmonary HTN/sleep apnea:  An admimssion ABG and CXR
were preformed which showed: 121/51/7.38/31. As mentioned above,
she required extended intubation post procedurally.  Pulmonary
was consulted and she was weaned off NO with 100%O2 and vent
settings were weaned.  Pt was extubated on [**8-19**] and tolerated
home O2 of 3L NC and CPAP for OSA. She needs to be encouraged to
bring in her CPAP machine from home to use.
.
3. Left femoral artery injury:  Iatrogenic left femoral injury
during fem-fem bypass was repaired with bovine pericardium,
closed [**8-17**] at bedside.  Staples were kept in place until [**8-30**].
Incision site was complicated by cellulitis and CTA with runoff
of lower extremity did not show evidence of infected graft. Gram
stain showed GNR, GPC, GPR, speciated pseudomonas.  She was
started on IV antibiotics and discharged on vancomycin and Zosyn
IV until [**9-12**] (total of 2 week course)and then needs to be
changed to ciprofloxacin PO for another 2 week course. Please
see page one for specific dressing changes and contact number
for concerns or questions. She was scheduled for a f/u appt with
Dr. [**Last Name (STitle) 22423**] in 2 weeks. Fluconazole was started to treat a
presumed vaginal yeast infection.
.
5. Complete heart block: Procedure was complicated by AV
dissociation with Vtach s/p two cardioversions and DDD PPM was
placed. On [**8-23**] device was interrogated revealing intrisic rhythm
of complete heart block without escape and PPM was A-V
sequential paced at rate of 60.
.
6. Diabetes: Pt was managed on insulin ss and home standing
insulin. HgbA1C was 6.2.
.
7. CKD: baseline Cr is 1.5.  After corevalve, cr elevated to 2.3
secondary to prerenal etiology, then decreased to under her
baseline at 1.3.
.
8. Depression/anxiety: Pt has a long history of depression and
had symptoms of impaired coping with her prolonged
hospitalization. She has an outpatient psychiatrist who sees her
frequently. Psych was consulted and did not recommend any
changes to her anti depressants but advised haldol at HS. This
was started but stopped at discharge because of mild tremor. Her
sleep has improved and anxiety decreased during her hospital
stay. She would benefit from a psychiatric consultation at
rehab.

Medications on Admission:
ASA 81mg daily
metoprolol tartrate 12.5mg daily
simvastatin 20mg qhs
furosemide 20mg [**Hospital1 **]
metolazone 2.5mg 2x/week (qmon&fri)
insulin glargine (Lantus) 22units daily (pt regulates- varies)
insulin Lispro (humalog)3u bkfst,2u lunch,8u dinner, 3u hs
potassium chloride 20meq tid
ferrous sulfate 325mg daily
lansoprazole 30mg daily
MVI 1 tab daily
Allopurinol 150 daily
Buproprion HCL SR 200mg [**Hospital1 **]
clonazepam 2mg qhs
excitalopram Oxalate (Lexapro) 30mg daily
nitroglycerin SL 0.4mg SL prn chest pain
trazodone 100mg qhs prn insomnia
hydrocodone-acetaminophen 5/500mg 1-2 tabs q6h prn pain
oxygen 3L nasal cannula continuously
tolterodine (detrol) 2mg po bid

Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. bupropion HCl 100 mg Tablet Extended Release Sig: Two (2)
Tablet Extended Release PO BID (2 times a day).
4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. furosemide 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
6. escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 2
weeks: Start only after IV antibiotics is done on [**9-12**], then
continue for 2 week course.
8. Vancomycin 1000 mg IV Q 24H
Monitor levels closely and dose based on goal peak and trough.
Please consult pharmacy for assistance in dosing.

9. Piperacillin-Tazobactam 4.5 g IV Q8H
Cont for total of two weeks, last day is [**2174-9-12**].
10. potassium chloride 20 mEq Packet Sig: One (1) packet PO once
a day.
11. ferrous sulfate 324 mg (65 mg iron) Tablet, Delayed Release
(E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a
day.
12. lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO once a day.
13. allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).

14. clonazepam 0.5 mg Tablet Sig: 1-2 Tablets PO at bedtime as
needed for anxiety.
15. trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime) as needed for insomnia.
16. hydrocodone-acetaminophen 5-500 mg Capsule Sig: [**12-19**] Capsules
PO three times a day as needed for pain.
17. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
18. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

19. Lantus 100 unit/mL Solution Sig: Twenty Two (22) units
Subcutaneous at bedtime.
20. Humalog 100 unit/mL Solution Sig: as per sliding scale units
Subcutaneous four times a day: see attached sliding scale.
21. fluconazole 100 mg Tablet Sig: 1.5 Tablets PO once a day for
2 weeks.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]

Discharge Diagnosis:
Aortic stenosis s/p corevalve placement
Complete heart block
Acute on Chronic Diastolic congestive heart failure
Coronary artery disease
Chronic Obstructive pulmonary disease on home oxygen
Diabetes mellitus
Obstructive sleep apnea
Acute on Chronic kidney injury


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
Dear Mrs. [**Known lastname 16905**],

You were admitted to the hospital for placement of a corevalve
prosthesis because of your aortic stenosis. You had some
hypotension after the procedure and needed medicine to keep your
blood pressure up. You developed some fluid overload and
required lasix to get rid of the extra fluid. You were on a
breathing tube that was removed on [**8-19**]. Your rhythm was slow and
a pacemaker was implanted. This will need to be followed every 6
months to make sure it is working properly. The left groin site
where the catheters were is slow to heal, has had a lot of
drainage and is mildly infected. You will need to continue
intravenous antibiotics for 2 weeks and get frequent dressing
changes.

Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes up
more than 3 lbs in 1 day or 5 pounds in 3 days.
.
We made the following changes to your medicines:
1. Start Zosyn and vancomycin for the infection in the groin
2. Metoprolol was changed to a long acting verson
3. Furosemide was increased to 40 mg twice daily
4. Start Plavix to decrease the chance of a blood clot on the
new valve
5. Metolazone was held for now
6. Decrease potassium to once daily
7. Decrease lexapro to 20 mg daily
8. discontinue Detrol
9. Start lisinopril 5 mg daily to lower your blood pressure and
help your heart pump better.
10. Start fluconazole to treat the vaginal yeast infection from
the antibiotics.

Followup Instructions:
Vascular:
Department: VASCULAR SURGERY
When: THURSDAY [**2174-9-15**] at 9:30 AM
With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
***Please have your pcp send an insurance referral to Dr
[**Last Name (STitle) 88730**] office before the visit. Fax to [**Telephone/Fax (1) 17352**]
.
Department: CARDIAC SERVICES
When: FRIDAY [**2174-9-16**] at 9:30 AM
With:  DEVICE CLINIC [**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
When: FRIDAY [**2174-9-16**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**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
When: FRIDAY [**2174-9-16**] at 11:00 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
{'Aortic valve disorders,Cardiac arrest,Acute on chronic diastolic heart failure,Pneumonitis due to inhalation of food or vomitus,Acute kidney failure with lesion of tubular necrosis,Cardiac complications, not elsewhere classified,Atrioventricular block, complete,Other postoperative infection,Delirium due to conditions classified elsewhere,Acidosis,Cellulitis and abscess of trunk,Other chronic pulmonary heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Chronic airway obstruction, not elsewhere classified,Thrombocytopenia, unspecified,Obstructive sleep apnea (adult)(pediatric),Dysthymic disorder,Acute gouty arthropathy,Hypoxemia,Candidiasis of vulva and vagina,Leukocytosis, unspecified,Obesity, unspecified,Aortocoronary bypass status,History of fall,Acquired absence of both cervix and uterus,Long-term (current) use of insulin,Examination of participant in clinical trial,Other specified surgical operations and procedures 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: worsening shortness of breath, chest pain

PRESENT ILLNESS: Ms. [**Known lastname 16905**] is a 70-year-old woman who was
referred with critical aortic stenosis.
In [**2173-10-18**], she suffered a syncopal episode and presented
to [**Hospital2 **] [**Hospital3 6783**] Hospital where evaluation documented critical
aortic stenosis by both catheterization as well as
echocardiography.  Coronary angiography at that time
demonstrated
an occluded proximal LAD, moderate diffuse disease in the LCx,
and an occluded RCA.  There was a patent SVG to the right
coronary and a patent SVG tot he LAD. Quantitation of her aortic
stenosis yielded a mean transvalvular gradient of 46 mmHg and a
valve area of 0.6 by Fick estimate. At that time, the patient
reportedly had a significantly elevated pulmonary arterial
pressure of systolic of 115mmHg, though no wedge pressure was
available in the report. She was evaluated by Dr. [**Last Name (STitle) 50180**] of
Cardiothoracic Surgery at [**Hospital2 **] [**Hospital3 6783**] and deemed to be
prohibitively high-risk candidate for traditional aortic valve
surgery.

MEDICAL HISTORY: 1. aortic stenosis
2. aortic valvuloplasty [**2174-3-24**]
3. CAD - s/p CABG x 2 ([**2159**]), PCI, chronic RBBB
4. COPD - home oxygen x 5 years
5. severe pulmonary hypertension
6. diabetes
7. hypertension
8. hyperlipidemia
9. obstructive sleep apnea  -has own CPAP machine
10. obesity
11. renal insufficiency
12. osteoarthritis
13. situational depression
14. presbyopia
15. gout
16. nasal fracture secondary to [**2159**]7. cholecystectomy
[**80**]. knee pain s/p [**2080**]9. ventral hernia

MEDICATION ON ADMISSION: ASA 81mg daily
metoprolol tartrate 12.5mg daily
simvastatin 20mg qhs
furosemide 20mg [**Hospital1 **]
metolazone 2.5mg 2x/week (qmon&fri)
insulin glargine (Lantus) 22units daily (pt regulates- varies)
insulin Lispro (humalog)3u bkfst,2u lunch,8u dinner, 3u hs
potassium chloride 20meq tid
ferrous sulfate 325mg daily
lansoprazole 30mg daily
MVI 1 tab daily
Allopurinol 150 daily
Buproprion HCL SR 200mg [**Hospital1 **]
clonazepam 2mg qhs
excitalopram Oxalate (Lexapro) 30mg daily
nitroglycerin SL 0.4mg SL prn chest pain
trazodone 100mg qhs prn insomnia
hydrocodone-acetaminophen 5/500mg 1-2 tabs q6h prn pain
oxygen 3L nasal cannula continuously
tolterodine (detrol) 2mg po bid

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADDMISSION EXAM:
Pulse: 46, B/P: Right 143/57, Resp: 18, O2 Sat: 95  (O2 2.5L),
Temp: 93.5 ax
Height: 160cm  Weight: 98.6kg
General: Elderly heavy set female in wheelchair with O2 notably
SOB with conversation.
Skin: Pale, skin warm and dry.
HEENT: Normocephalic. Anicteric.
Neck: Supple, trachea midline. Bilat. carotid bruit vs. murmer.
Chest: Able to speak in short phrases only.
Heart:murmer throughout
Abdomen: Rotund, soft, (+)bowel sounds.
Extremities: 2+ lower extremity edema bilaterally. Bilateral
knee
pain.
Neuro: A+O x 3, c/o pain to bilateral knees. Somnolent,
upperextremities. UE's muscle wasting.
Pulses: palpable peripheral pulses

FAMILY HISTORY: FAMILY HISTORY: Positive for diabetes and coronary artery
disease. Her father died in his 50s of an MI and her mother died
at 98 of a CVA.

SOCIAL HISTORY: SOCIAL HISTORY: She lives with her sister, [**Name (NI) 4248**]. She has another
sister, [**Name (NI) 37620**] who assists with her [**Name (NI) 5669**]. Ambulates at home
with
walker, uses wheelchair when out of house. Has 4 steps to enter
home, and chair lift once inside. Currently, physical therapy
sees her once weekly for her knee injury.
[**Name (NI) 37620**] [**Name (NI) **] (sister) [**Telephone/Fax (1) 88728**]
[**Doctor First Name **] (neice) [**Telephone/Fax (1) 88729**] 

### Response:
{'Aortic valve disorders,Cardiac arrest,Acute on chronic diastolic heart failure,Pneumonitis due to inhalation of food or vomitus,Acute kidney failure with lesion of tubular necrosis,Cardiac complications, not elsewhere classified,Atrioventricular block, complete,Other postoperative infection,Delirium due to conditions classified elsewhere,Acidosis,Cellulitis and abscess of trunk,Other chronic pulmonary heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Chronic airway obstruction, not elsewhere classified,Thrombocytopenia, unspecified,Obstructive sleep apnea (adult)(pediatric),Dysthymic disorder,Acute gouty arthropathy,Hypoxemia,Candidiasis of vulva and vagina,Leukocytosis, unspecified,Obesity, unspecified,Aortocoronary bypass status,History of fall,Acquired absence of both cervix and uterus,Long-term (current) use of insulin,Examination of participant in clinical trial,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}
