CHIEF COMPLAINT: DOE/worsening fatigue

PRESENT ILLNESS: 65 yo female with RHD and recurrent AFib. Episode of CHF in
[**1-4**]. Known AI, MS, MR [**First Name (Titles) **] [**Last Name (Titles) **] by echo and cath. Referred for
surgery.

MEDICAL HISTORY: rheumatic heart disease
Atrial fibrillation (s/p ablation/PVI [**2134**] and mult. DCCVs)
chronic diastolic heart failure
depression
hypothyroidism
GI bleed secondary to ASA in past
history of amiodarone toxicity ( hypothyroid/neuropathy)
hiatal hernia
TIA [**2135**]
DVT left foot [**2127**]
varicose veins

MEDICATION ON ADMISSION: Coumadin 4 mg daily (LD [**2-2**])
digoxin 0.25 mg daily
verapamil 240 mg [**Hospital1 **]
synthroid 25 mcg daily
neurontin 300 mg TID
nortriptyline 10-40 mg daily
lasix 20 mg daily
protonix 20 mg daily
fluoxetine 40 mg daily
ambien 10 mg QHS
fluticasone spray 50 mcg

ALLERGIES: Amiodarone

PHYSICAL EXAM: (from thoracic surgery and cardiac pre-op)
68"  79.3 kg
97% RA sat RR 22  HR 70-100 afib  130-180/70
bowel sounds present in chest
HEENT unremarkable
1+ edema left leg
2/6 systolic murmur at RUSB, 1/6 systolic murmur at left mid-ax.
line, [**Last Name (un) **]
neuro unremarkable
no lymphadenopathy
skin unremarkable
2+ bil. fems/radials
1+ bil. DP/PTs
no carotid bruits appreciated

FAMILY HISTORY: non contributory

SOCIAL HISTORY: lives alone
retired
social ETOH only
remote tobacco
Multiple involvement of mitral and aortic valves,Acute respiratory failure,Chronic diastolic heart failure,Delirium due to conditions classified elsewhere,Atrial flutter,Diseases of tricuspid valve,Unspecified congenital anomaly of heart,Diaphragmatic hernia without mention of obstruction or gangrene,Depressive disorder, not elsewhere classified,Personal history of venous thrombosis and embolism,Acute post-thoracotomy pain,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Anemia, unspecified,Other iatrogenic hypothyroidism,Polyneuropathy due to drugs,Cardiac rhythm regulators causing adverse effects in therapeutic use
Mitr/aortic mult involv,Acute respiratry failure,Chr diastolic hrt fail,Delirium d/t other cond,Atrial flutter,Tricuspid valve disease,Cong heart anomaly NOS,Diaphragmatic hernia,Depressive disorder NEC,Hx-ven thrombosis/embols,Acute post-thoracot pain,Abn react-artif implant,Anemia NOS,Iatrogen hypothyroid NEC,Neuropathy due to drugs,Adv eff card rhyth regul
Admission Date:  [**2137-2-5**]              Discharge Date:   [**2137-2-21**]

Date of Birth:  [**2071-9-17**]             Sex:   F

Service: CARDIOTHORACIC

Allergies:
Amiodarone

Attending:[**First Name3 (LF) 922**]
Chief Complaint:
DOE/worsening fatigue

Major Surgical or Invasive Procedure:
[**2137-2-7**] Aortic Valve Replacement (23 mm CE pericardial)/ Mitral
Valve Replacment ([**Street Address(2) 44058**]. [**Male First Name (un) 923**] porcine)/ Tricuspid Valve
repair
(28 mm [**Doctor Last Name **] MC3 annuloplasty ring)/ Maze with left atrial
appendage ligation

History of Present Illness:
65 yo female with RHD and recurrent AFib. Episode of CHF in
[**1-4**]. Known AI, MS, MR [**First Name (Titles) **] [**Last Name (Titles) **] by echo and cath. Referred for
surgery.

Past Medical History:
rheumatic heart disease
Atrial fibrillation (s/p ablation/PVI [**2134**] and mult. DCCVs)
chronic diastolic heart failure
depression
hypothyroidism
GI bleed secondary to ASA in past
history of amiodarone toxicity ( hypothyroid/neuropathy)
hiatal hernia
TIA [**2135**]
DVT left foot [**2127**]
varicose veins

Social History:
lives alone
retired
social ETOH only
remote tobacco

Family History:
non contributory

Physical Exam:
(from thoracic surgery and cardiac pre-op)
68"  79.3 kg
97% RA sat RR 22  HR 70-100 afib  130-180/70
bowel sounds present in chest
HEENT unremarkable
1+ edema left leg
2/6 systolic murmur at RUSB, 1/6 systolic murmur at left mid-ax.
line, [**Last Name (un) **]
neuro unremarkable
no lymphadenopathy
skin unremarkable
2+ bil. fems/radials
1+ bil. DP/PTs
no carotid bruits appreciated

Pertinent Results:
[**2137-2-21**] 05:52AM BLOOD WBC-12.8* RBC-2.84* Hgb-8.8* Hct-26.3*
MCV-93 MCH-31.0 MCHC-33.4 RDW-15.3 Plt Ct-426
[**2137-2-21**] 05:52AM BLOOD Glucose-92 UreaN-22* Creat-1.4* Na-135
K-4.5 Cl-103 HCO3-23 AnGap-14
[**2137-2-21**] 05:52AM BLOOD Mg-1.6

[**2-7**] Echo: PRE-CPB:1. The left atrium is markedly dilated.
Moderate to severe spontaneous echo contrast is seen in the body
of the left atrium. No mass/thrombus is seen in the left atrium
or left atrial appendage. No atrial septal defect is seen by 2D
or color Doppler. 2. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular systolic function is mildly depressed (LVEF= 45%).
3. Right ventricular chamber size and free wall motion are
normal. 4. There are simple atheroma in the ascending aorta.
There are simple atheroma in the descending thoracic aorta. 5.
There are three aortic valve leaflets. The aortic valve leaflets
are mildly thickened. There is no aortic valve stenosis.
Moderate (2+) aortic regurgitation is seen. The aortic annulus
is 22 cm. 6. The mitral valve leaflets are severely
thickened/deformed. The mitral valve shows characteristic
rheumatic deformity. There is moderate valvular mitral stenosis
(area 1.0-1.5cm2). Mild (1+) mitral regurgitation is seen. 7.
The tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. The tricuspid annulus is 3.2
cm. Dr. [**Last Name (STitle) 914**] was notified in person of the results. POST-CPB:
On infusion of milrinone, phenylephrine. Apacing for slow sinus
rhythm. Preserved biventricular systolic function. LVEF now 50 %
on inotropic support. 1. Well-seated bioprosthetic valve in the
mitral position. No MR, no paravalvular leak. Transmitral
gradient is 11 mmHg with a mean of 6 at the time the cardiac
output is 7.6 L/min. 2. Well-seated bioprosthetic valve in the
aortic position with no AI, no paravalvular leak. Good flow is
seen in the left main coronary artery. Unable to obtain
transgastric views due to a hiatal hernia, so unable to
calculate gradients across the aortic valve. 3. Well-seated ring
in the tricuspid position with trace TR. 4. Descending aortic
contour appears normal post decannulation.
[**2-6**] CT: 1. Enlarged left atrium. 2. Large hiatal hernia
involving almost all the stomach and part of the colonic splenic
flexure, with the left inferior pulmonary vein sitting just
above it. 3. Grade I anterolisthesis of L4 on L5 and scoliosis.
4. 1-mm left upper lobe nodule, does not warrant further
followup if the patient has no risk factor for malignancy.
5. Bibasilar ground-glass opacity, could be atelectasis or
chronic aspiration given the history of large hiatus hernia.
[**2137-2-15**] 05:47AM BLOOD WBC-10.5 RBC-3.05* Hgb-9.5* Hct-28.4*
MCV-93 MCH-31.1 MCHC-33.4 RDW-15.2 Plt Ct-331
[**2137-2-5**] 10:20PM BLOOD WBC-6.2 RBC-3.64* Hgb-12.0 Hct-33.7*
MCV-93 MCH-33.0* MCHC-35.7* RDW-14.9 Plt Ct-215
[**2137-2-15**] 05:47AM BLOOD PT-14.7* INR(PT)-1.3*
[**2137-2-5**] 10:20PM BLOOD PT-16.7* PTT-133.9* INR(PT)-1.5*
[**2137-2-15**] 05:47AM BLOOD Glucose-93 UreaN-22* Creat-1.0 Na-143
K-3.0* Cl-99 HCO3-35* AnGap-12
[**2137-2-5**] 10:20PM BLOOD Glucose-106* UreaN-22* Creat-0.8 Na-142
K-4.1 Cl-108 HCO3-25 AnGap-13
    [**Known lastname **],[**Known firstname **] F. [**Medical Record Number 45942**] F  65  [**2071-9-17**]

Radiology Report CHEST PORT. LINE PLACEMENT Study Date of
[**2137-2-14**] 12:57 PM


[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] CSRU [**2137-2-14**] 12:57 PM
CHEST PORT. LINE PLACEMENT   Clip # [**Clip Number (Radiology) 45943**]
Reason: please check PICC tip 43 cm left basilic please page
with w



[**Hospital 93**] MEDICAL CONDITION:
   65 year old woman with
REASON FOR THIS EXAMINATION:
   please check PICC tip 43 cm left basilic please page with wet
read thanks
   [**Doctor First Name **] [**8-/2571**]



Final Report
INDICATION: PICC placement.

FINDINGS: A new left-sided PICC terminates in the SVC. As
compared to
[**2137-2-12**], there has been marked improvement of now only
mild
pulmonary edema. Large left lower lobe atelectasis and small
pleural effusion
are unchanged. The patient is status post aortic valve, mitral
valve, and
tricuspid valvular repair.

IMPRESSION: PICC in SVC.

The study and the report were reviewed by the staff radiologist.


DR. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 16277**]
DR. [**First Name (STitle) **] [**Initials (NamePattern5) 3250**] [**Last Name (NamePattern5) 3251**]
Approved: [**Doctor First Name **] [**2137-2-14**] 4:19 PM

  Imaging Lab



Brief Hospital Course:
Admitted [**2-5**] for IV heparin for Afib and to complete pre-op
workup. CT chest/abd done with thoracic surgery consult to
evaluate large hiatal hernia. On [**2-7**] she underwent Aortic valve
replacement (#23 mm [**Doctor Last Name **] pericardial )/Mitral Valve
Replacement (#29mm St.[**Male First Name (un) 923**] tissue valve)/Tricuspid Valve repair
(#28,,[**Doctor Last Name **] MC3 annuloplasty)/MAZE. Cross clamp time: 137
minutes,Cardiopulmonary bypass time: 179 minutes.Please see
Dr[**Last Name (STitle) 5305**] operative report for further surgical details.
Following surgery she was transferred to the CVICU for invasive
monitoring in stable but critical condition. Within 24 hours she
was weaned from sedation, awoke neurologically intact and was
extubated. She was initially requiring inotropic/pressor support
to optimise her cardiac output. She remained hemodynamically
stable and was successfully weaned off Milrinone and Neo drips.
All lines and drains were discontinued in a timely fashion. She
was transfused with red blood cells for postoperative anemia.
Ms.[**Known lastname 19849**] did complain of severe pain which was treated with a
dilaudid infusion. Aggressive diuresis was initiated. She had
moments of extreme aggitation which was treated with haldol and
ativan. As her daughter had reported she consumed daily alcohol,
thiamine and folic acid were started. Multiple inhalers were
used for worsening atelectasis and a high oxygen requirement.
Postoperatively, Beta-blocker and aspirin were initiated. [**2-10**]
anticoagulation was initiated with Coumadin for her MAZE
procedure. Her INR levels subsequently increased to 7.5.
Ms.[**Known lastname 19849**] was given vitamin K and fresh frozen plasma to correct
this level and Coumadin was held. On [**2-13**] her rhythm went into
atrial fibrillation. Given her continued  her confusion, a
swallow evaluation was performed which she failed due to her
altered mental status. Tube feeds were started for nutritional
support.  Due to Ms.[**Known lastname 45944**] extreme state of confusion and
agitation, it was not until POD#7 that she was transferred to
the step down unit for further monitoring and progression. Her
mental status improved to full orientation on [**2-15**] with
continued low dose Haldol. Per Dr.[**Last Name (STitle) **], Ms.[**Known lastname 19849**] was started
on heparin drip to bridge her subtherapeutic INR and low dose
Coumadin restarted. She continued to progress, diet was advanced
with improving mental status, and she was ready for discharge to
home on POD 14.  She was advised of all follow up appointments.

Medications on Admission:
Coumadin 4 mg daily (LD [**2-2**])
digoxin 0.25 mg daily
verapamil 240 mg [**Hospital1 **]
synthroid 25 mcg daily
neurontin 300 mg TID
nortriptyline 10-40 mg daily
lasix 20 mg daily
protonix 20 mg daily
fluoxetine 40 mg daily
ambien 10 mg QHS
fluticasone spray 50 mcg


Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. Magnesium Hydroxide 400 mg/5 mL Suspension [**Hospital1 **]: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
3. Sodium Chloride 0.65 % Aerosol, Spray [**Hospital1 **]: Two (2) Spray
Nasal QID (4 times a day) as needed.
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1)  Inhalation Q4H (every 4 hours) as
needed.
5. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [**Hospital1 **]: Two
(2) Puff Inhalation Q4H (every 4 hours).
6. Fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
7. Bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal
DAILY (Daily).
8. Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).

9. Ibuprofen 100 mg/5 mL Suspension [**Hospital1 **]: Three (3)  PO Q8H
(every 8 hours) as needed for pain.
10. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1)  PO BID (2
times a day).
12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
13. Thiamine HCl 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
14. Multivitamin     Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
15. Levothyroxine 25 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
16. Warfarin 2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day for 1
doses: titrate as directed by the office of Dr. [**Last Name (STitle) 45945**].  .
Disp:*30 Tablet(s)* Refills:*2*
17. Outpatient Lab Work
INR to be drawn on [**2137-2-22**] with results faxed to the office of
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 45945**] at ([**Telephone/Fax (1) 45946**].  Phone ([**Telephone/Fax (1) 45947**].
18. Lasix 20 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
19. Fluoxetine 20 mg Capsule [**Telephone/Fax (1) **]: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*0*
20. Nortriptyline 10 mg Capsule [**Telephone/Fax (1) **]: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*0*
21. Gabapentin 300 mg Capsule [**Telephone/Fax (1) **]: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
22. Metoprolol Tartrate 50 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
23. Ciprofloxacin 500 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO Q12H
(every 12 hours) for 7 days: through Thursday, [**2-28**].
Disp:*14 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital3 **] VNA

Discharge Diagnosis:
Rheumatic heart disease s/p Aortic Valve Replacement, Mitral
Valve Replacment, Tricuspid Valve repair
Atrial fibrillation (s/p ablation/PVI [**2134**] and mult. DCCVs) s/p
MAZE procedure with left atrial appendage ligation
Chronic diastolic heart failure
Secondary: Depression, Hypothyroidism, GI bleed secondary to ASA
in past, history of amiodarone toxicity (
hypothyroid/neuropathy)

Discharge Condition:
deconditioned


Discharge Instructions:
no lotions, creams or powders on any incision
shower daily and pat incisions dry
no driving for one month
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100.5, redness, drainage or weight
gain of 2 pounds in 2 days

Followup Instructions:
see Dr. [**Last Name (STitle) **] in [**12-28**] weeks
see Dr. [**Last Name (STitle) 23651**] in [**1-29**] weeks
see Dr. [**Last Name (STitle) 914**] in 4 weeks  [**Telephone/Fax (1) 170**]
please call for all appts.


Completed by:[**2137-2-21**]
{'Multiple involvement of mitral and aortic valves,Acute respiratory failure,Chronic diastolic heart failure,Delirium due to conditions classified elsewhere,Atrial flutter,Diseases of tricuspid valve,Unspecified congenital anomaly of heart,Diaphragmatic hernia without mention of obstruction or gangrene,Depressive disorder, not elsewhere classified,Personal history of venous thrombosis and embolism,Acute post-thoracotomy pain,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Anemia, unspecified,Other iatrogenic hypothyroidism,Polyneuropathy due to drugs,Cardiac rhythm regulators causing adverse effects in therapeutic use'}


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/worsening fatigue

PRESENT ILLNESS: 65 yo female with RHD and recurrent AFib. Episode of CHF in
[**1-4**]. Known AI, MS, MR [**First Name (Titles) **] [**Last Name (Titles) **] by echo and cath. Referred for
surgery.

MEDICAL HISTORY: rheumatic heart disease
Atrial fibrillation (s/p ablation/PVI [**2134**] and mult. DCCVs)
chronic diastolic heart failure
depression
hypothyroidism
GI bleed secondary to ASA in past
history of amiodarone toxicity ( hypothyroid/neuropathy)
hiatal hernia
TIA [**2135**]
DVT left foot [**2127**]
varicose veins

MEDICATION ON ADMISSION: Coumadin 4 mg daily (LD [**2-2**])
digoxin 0.25 mg daily
verapamil 240 mg [**Hospital1 **]
synthroid 25 mcg daily
neurontin 300 mg TID
nortriptyline 10-40 mg daily
lasix 20 mg daily
protonix 20 mg daily
fluoxetine 40 mg daily
ambien 10 mg QHS
fluticasone spray 50 mcg

ALLERGIES: Amiodarone

PHYSICAL EXAM: (from thoracic surgery and cardiac pre-op)
68"  79.3 kg
97% RA sat RR 22  HR 70-100 afib  130-180/70
bowel sounds present in chest
HEENT unremarkable
1+ edema left leg
2/6 systolic murmur at RUSB, 1/6 systolic murmur at left mid-ax.
line, [**Last Name (un) **]
neuro unremarkable
no lymphadenopathy
skin unremarkable
2+ bil. fems/radials
1+ bil. DP/PTs
no carotid bruits appreciated

FAMILY HISTORY: non contributory

SOCIAL HISTORY: lives alone
retired
social ETOH only
remote tobacco 

### Response:
{'Multiple involvement of mitral and aortic valves,Acute respiratory failure,Chronic diastolic heart failure,Delirium due to conditions classified elsewhere,Atrial flutter,Diseases of tricuspid valve,Unspecified congenital anomaly of heart,Diaphragmatic hernia without mention of obstruction or gangrene,Depressive disorder, not elsewhere classified,Personal history of venous thrombosis and embolism,Acute post-thoracotomy pain,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Anemia, unspecified,Other iatrogenic hypothyroidism,Polyneuropathy due to drugs,Cardiac rhythm regulators causing adverse effects in therapeutic use'}
