CHIEF COMPLAINT: shortness of breath

PRESENT ILLNESS: Mr. [**Known lastname 9035**] is an 80 year old male with a history of CAD s/p 5
vessel CABG and aortic stenosis (s/p dilation x 2 [**12-30**], [**12-29**])
who presents with worsening dyspnea. His shortness of breath has
gotten worse slowly over the course of two months. He now
becomes dypneic when supine in bed. He endorses PND and
orthopnea, using [**2-20**] pillows to sleep at night. However, most
nights he ends up sleeping flat, very uncomfortably. He has not
had chest pain, fevers or chills. He has a nonproductive cough
that has persisted over the same time period. After the
valvuloplasty in [**12/2173**], he was able to walk for 15 mintues
without stopping. He has not noticed swelling in his legs or
ankles.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
Aortic stenosis (Dilation [**12-30**], [**12-29**] at [**Hospital1 2025**]); valve area
0.7cm2 with peak gradient 76mmhg
CAD s/p 5-vessel CABG
Congestive Heart Failure with EF 30% in [**5-/2174**] by echo
3. OTHER PAST MEDICAL HISTORY:

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Allopurinol 100 mg PO DAILY
2. Ascorbic Acid 250 mg PO DAILY
3. Aspirin 162 mg PO DAILY
4. Bumetanide 1 mg PO BID
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Simvastatin 40 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY

ALLERGIES: Sulfa(Sulfonamide Antibiotics) / Torsemide

PHYSICAL EXAM: ADMISSION
VS: T=97.6 BP=106/55 HR=82 RR=21 O2 sat=100%
GENERAL: WDWN ** in NAD. Oriented x3. Mood, affect appropriate.

FAMILY HISTORY: Premature coronary artery disease- Mother CHF, died in 80s,
Father Died from MI at 62

SOCIAL HISTORY: He lives with his wife. Nonsmoker. Rarely drinks etoh. He is
retired and used to work as a manager at [**Company 2892**].
Aortic valve disorders,Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Other and unspecified hyperlipidemia,Other chronic pulmonary heart diseases,Dehydration,Thrombocytopenia, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate)
Aortic valve disorder,Ac on chr syst hrt fail,Acute kidney failure NOS,Cor ath unsp vsl ntv/gft,Aortocoronary bypass,Hyperlipidemia NEC/NOS,Chr pulmon heart dis NEC,Dehydration,Thrombocytopenia NOS,Hy kid NOS w cr kid I-IV,Chr kidney dis stage III
Admission Date:  [**2174-7-30**]              Discharge Date:   [**2174-8-7**]

Date of Birth:  [**2094-1-22**]             Sex:   M

Service: MEDICINE

Allergies:
Sulfa(Sulfonamide Antibiotics) / Torsemide

Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
shortness of breath

Major Surgical or Invasive Procedure:
Aortic Balloon Valvuloplasty


History of Present Illness:
Mr. [**Known lastname 9035**] is an 80 year old male with a history of CAD s/p 5
vessel CABG and aortic stenosis (s/p dilation x 2 [**12-30**], [**12-29**])
who presents with worsening dyspnea. His shortness of breath has
gotten worse slowly over the course of two months. He now
becomes dypneic when supine in bed. He endorses PND and
orthopnea, using [**2-20**] pillows to sleep at night. However, most
nights he ends up sleeping flat, very uncomfortably. He has not
had chest pain, fevers or chills. He has a nonproductive cough
that has persisted over the same time period. After the
valvuloplasty in [**12/2173**], he was able to walk for 15 mintues
without stopping. He has not noticed swelling in his legs or
ankles.

On admission, vitals were notable for a HR 89, R18, BP 96/55,
100% 3lnc. ACS was ruled out as the etiology of dyspnea and pt
improved with diuresis. He underwent an uncomplicated
valvoplasty today. During procedure, PAWP was elevated to 35 w/
a [**MD Number(3) 41999**]/47. He is transferred to the CCU for further
monitoring and diuresis. On arrival, patient only notes pain at
sheath site. He denies SOB, CP, fatigue, orthopnea,or weakness.


Past Medical History:
1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
Aortic stenosis (Dilation [**12-30**], [**12-29**] at [**Hospital1 2025**]); valve area
0.7cm2 with peak gradient 76mmhg
CAD s/p 5-vessel CABG
Congestive Heart Failure with EF 30% in [**5-/2174**] by echo
3. OTHER PAST MEDICAL HISTORY:


Social History:
He lives with his wife. Nonsmoker. Rarely drinks etoh. He is
retired and used to work as a manager at [**Company 2892**].

Family History:
Premature coronary artery disease- Mother CHF, died in 80s,
Father Died from MI at 62

Physical Exam:
ADMISSION
VS: T=97.6 BP=106/55 HR=82 RR=21 O2 sat=100%
GENERAL: WDWN ** in NAD. Oriented x3. Mood, affect appropriate.

HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

NECK: Supple with JVP of *** cm.
CARDIAC: Late peaking systolic murmur at R 2nd intercostal
space. [**3-25**] murmur 5 intercostal mid clavicular. RR, normal S1,
S2. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. B/L basilar crackles,
no wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
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+

DISCHARGE
VS 97.4 99/56-110/65 78-96 18 95% RA
Weight 70.6
I/O yesterday: -660/ -480
GENERAL- NAD, breathing comfortably when sitting upright at
rest. Oriented x3. Mood, affect appropriate.
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. MMM
NECK- no elevation in JVP
CARDIAC- PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. mid systolic high pitched murmur at the
upper sternal border radiating to carotids with a preserved s2;
more blowing sounding murmur at the apex, holosystolic, without
an s2. Parasternal heave. No S3 or S4.
LUNGS- No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN- Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES- No c/c/e. No femoral bruits.
SKIN- No stasis dermatitis or ulcers
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:
[**2174-7-30**] 04:50PM BLOOD WBC-8.1 RBC-3.90* Hgb-12.1* Hct-37.6*
MCV-97 MCH-31.1 MCHC-32.3 RDW-15.3 Plt Ct-148*
[**2174-7-30**] 04:50PM BLOOD Neuts-79.1* Lymphs-11.8* Monos-5.4
Eos-2.9 Baso-0.8
[**2174-7-30**] 04:50PM BLOOD PT-14.8* PTT-33.4 INR(PT)-1.4*
[**2174-7-30**] 04:50PM BLOOD Glucose-109* UreaN-51* Creat-1.9* Na-137
K-4.7 Cl-102 HCO3-22 AnGap-18
[**2174-7-30**] 04:50PM BLOOD proBNP-8430*
[**2174-7-30**] 04:50PM BLOOD cTropnT-0.03*
[**2174-7-31**] 07:00AM BLOOD CK-MB-4 cTropnT-0.02*
[**2174-7-31**] 07:00AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.6
.
Discharge Labs:
[**2174-8-6**] 08:25AM BLOOD WBC-7.7 RBC-4.03* Hgb-12.4* Hct-38.6*
MCV-96 MCH-30.7 MCHC-32.1 RDW-15.2 Plt Ct-173
[**2174-8-6**] 08:25AM BLOOD PT-12.9* PTT-33.7 INR(PT)-1.2*
[**2174-8-7**] 06:10AM BLOOD Glucose-155* UreaN-34* Creat-1.4* Na-136
K-4.0 Cl-101 HCO3-24 AnGap-15
[**2174-8-7**] 06:10AM BLOOD Calcium-9.1 Phos-3.3 Mg-2.3
.
Cardiac Cath with valvoplasty: [**2174-8-2**]:
Interventional details	
The indication for the procedure was refractory congestive heart
failure due to severe aortic stenosis (aortic valve area 0.52
cm2), severe 4+ mitral regurgitation, and severe pulmonary
hypertension.  He is a non operative candidate due to his
porcelain aorta.
.
Heparin (5000U, 2000U) was used for anticoagulation to maintain
an ACT > 250 seconds.
.
The procedure was performed using a Pre-close technique with a 6
Fr Proglide.  Femoral access was obtained with vascular
ultrasound guidance.
.
Right and left heart pressures are listed above with severe
pulmonary hypertension and a mixed venous saturation 51%.
.
Balloon aortic valvuloplasty was performed using a single
inflation using a 23 mm Tyshak-II balloon.  The patient became
profoundly hypotensive after the balloon inflation taking > 60
seconds to recovery his BP.
.
The mean aortic gradient decreased from 26.9 mmHg to 21.4 mmHg,
the cardiac output increased from 2.89 L/Min to 3.67 L/min, and
the aortic valve area increased from 0.53 cm2 to 0.80 cm2.  The
mixed venous increased from 51% to 60%.
.
The right femoral artery sheath was removed without difficulty.
Assessment & Recommendations
1.	Critical aortic stenosis
2.	s/p successful balloon aortic valvuloplasty with an increase
in the aortic valve area from 0.52 cm2 to 0.80 cm2
3.	CCU monitoring overnight with diuresis

.
TTE: [**2174-8-1**]:
The left atrium is markedly dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. Overall
left ventricular systolic function is severely depressed (LVEF=
25-30%). The right ventricular cavity is moderately dilated with
depressed free wall contractility. There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (valve
area 0.8-1.0cm2). Mild to moderate ([**12-20**]+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. The
mitral valve leaflets do not fully coapt. An eccentric,
posteriorly directed jet of severe mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is severe pulmonary
artery systolic hypertension. There is no pericardial effusion.
.
IMPRESSION: Mild symmetric LVH with severe left ventricular
systolic dysfunction. The inferior wall and distal septum are
near-akinetic. The basal lateral wall has relatively preserved
function. The other walls are moderately hypokinetic. There is
severe mitral regurgitation likely due to leaflet tethering.
Severe calcific aortic stenosis with mild to moderate aortic
regurgitation. Dilated, hypokinetic and pressure-volume
overloaded RV with severe pulmonary hypertension.
.
Compared with the prior study (images reviewed) of [**2174-6-28**],
findings are similar.
.
TTE: [**2174-8-2**]
Left ventricular systolic function is severely depressed. The
aortic valve leaflets are severely thickened/deformed. There is
significant aortic valve stenosis (probably severe). Moderate
(2+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Moderate to severe (3+) mitral regurgitation
is seen. The tricuspid valve leaflets are mildly thickened.
There is severe pulmonary artery systolic hypertension. There is
no significant pericardial effusion.
.
Compared with the prior study (images reviewed) of [**2174-8-1**],
estimated pulmonary artery systolic pressure is now lower. The
aortic valve gradient is now lower.
.
TTE: [**2174-8-3**]
Overall left ventricular systolic function is moderately
depressed (LVEF= 30-35 %) secondary to moderate global
hypokinesis and akinesis of the distal mid-anterior septum
(suboptimal image quality, LV apex was not well visualized).
There is severe aortic valve stenosis (valve area 0.8-1.0cm2).
Moderate (2+) aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. The mitral valve leaflets do
not fully coapt. Moderate to severe (3+) mitral regurgitation is
seen. Moderate [2+] tricuspid regurgitation is seen. There is
severe pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
Compared with the prior study dated [**2174-8-2**] (images reviewed),
pulmonary pressures are worse. The degree of aortic stenosis
remains severe based on visual assessment and continuity
equation (low gradients may be secondary to poor forward flow
and depressed LVEF). Aortic regurgitation and mitral
regurgitation are similar.

Brief Hospital Course:
Mr. [**Known lastname 9035**] is an 80 year old male with a history of CAD s/p 5
vessel CABG and aortic stenosis (s/p dilation x 2 [**12-30**], [**12-29**])
who presented with worsening dyspnea sedondary to his critical
AS and underwent valvuloplasty.
.
ACUTE
#) Symptomatic, Critical AS/CHF: Patient initially presented to
[**Hospital1 1516**] service with progressive dyspnea, poor activity tolerance
and fatigue most likely from his critical aortic stenosis. He
had valvoplasty on [**2174-8-2**] during which he was found to have
pulmonary artery pressure of 103/77 with pulmonary wedge
pressure of 35. Follwing the procedure the mean aortic gradient
decreased from 26.9 mmHg to 21.4 mmHg,the cardiac output
increased from 2.89 L/Min to 3.67 L/min, and the aortic valve
area increased from 0.53 cm2 to 0.80 cm2. Given his elevated
pressures during the procedure he was transfered to CCU for
further monitoring and aggressive diuresis. During his CCU stay
he was made 4L negative with several rounds of IV lasix.  His
symptoms greatly improved following procedure and diuresis.  He
was discahrged on furosemide 250 PO daily.  He will follow up
with Dr. [**Last Name (STitle) **] regarding possible AV replacement if CORE valve
trial permits in [**Month (only) **].
.
#) Acute on Chronic Kidney Injury: Patient baseline Cr is around
1.2.  He repsented with acute on chronic [**Last Name (un) **] with Cr of 1.9
likely secondary to poor forward flow in setting of aortic
stenosis.  After aggressive diuresis his Cr downtrended to 1.3,
near his baseline.
.
#) Cough:  On presentation he complained ofcough likely to be
related to AS with some degree of pulmonary edema. Findings on
the recent CT chest showed left upper lobe nodularities,
subcentimeter, that look infectious versus inflammatory with
recommended interval f/u imaging in 3 months. There is also a
1.2cm subcarinal lymph node in addition to left base calcified
granulomas. Patient will follow up with pcp and potentially
pulmonary for these findings.  HIs cough had resolved by
discharge.
.
CHRONIC
#) CAD: Continued aspirin, metoprolol, and simvastatin.  Started
on low-dose lisinopril while in house.
.
#) Hyperlipidemia: Continued on home simvastatin
.
TRANSITIONAL
#) Patient will follow up with Dr.[**Last Name (STitle) **] regarding possible AV
replacement if CORE valve trial permits in [**Month (only) **]
#) Follow up with PCP regarding CT Chest findings

Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Allopurinol 100 mg PO DAILY
2. Ascorbic Acid 250 mg PO DAILY
3. Aspirin 162 mg PO DAILY
4. Bumetanide 1 mg PO BID
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Simvastatin 40 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY


Discharge Medications:
1. Allopurinol 100 mg PO DAILY
2. Ascorbic Acid 250 mg PO DAILY
3. Aspirin 81 mg PO DAILY
RX *Adult Low Dose Aspirin 81 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
4. Multivitamins 1 TAB PO DAILY
5. Simvastatin 40 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Furosemide 240 mg PO DAILY
RX *furosemide 80 mg 3 tablet(s) by mouth daily in AM Disp #*120
Tablet Refills:*0
9. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
10. Outpatient Lab Work
Please have Chem 7 and Magnesium drawn on [**2174-8-9**] at your PCP's
office given you are on such a high dose of diuretics. Thank
you.


Discharge Disposition:
Home

Discharge Diagnosis:
Primary: Heart Failure, Aortic Stenosis
Secondary:  Hypertension, Hyperlipidemia, Coronary Artery
Disease

Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

Discharge Instructions:
Dear Mr [**Known lastname 9035**],
It was a pleasure taking care of you during your recent
admission to [**Hospital1 18**].  You were admitted because you were having
worsening shortness of breath.  We believe that this was because
of your aortic stenosis as well as fluid on your lungs.  As a
result, we diuresed you aggressively which improved your
symptoms.  You then went for aortic balloon valvuloplasty.  This
was accomplished without complication.  You were discharged with
followup to Dr. [**Last Name (STitle) **] and your PCP.  [**Name10 (NameIs) **] should also call Dr.
[**Last Name (STitle) **] for a f/u appointment.

Please have your electrolytes drawn on [**2174-8-9**] at you PCP's
office (this includes a "Chemistry 7 panel plus a magnesium
level"). Thank you

The following changes were made to your medication:
DISCONTINUE
Bumetanide
START
Lasix 240 mg daily
Lisinopril 2.5 mg daily
CHANGE
Aspirin to 81 mg daily


Followup Instructions:
Please call PCP for appointment within 1 week of discharge:
Name: [**Last Name (LF) 42000**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Location: [**Hospital1 **] PRIMARY CARE
Address: [**2174**] STE#441WHITE [**Last Name (LF) **], [**First Name3 (LF) **],[**Numeric Identifier 42001**]
Phone: [**Telephone/Fax (1) 9386**]
Fax: [**Telephone/Fax (1) 25663**]

Please call Dr. [**Last Name (STitle) **] for f/u cardiology appointment within [**12-20**]
weeks:
[**Location (un) 86**] West Cardiology
[**Street Address(2) 42002**]
[**Hospital1 **], [**Numeric Identifier **]
([**Telephone/Fax (1) 42003**] (Office)

Department: CARDIAC SERVICES
When: WEDNESDAY [**2174-9-7**] at 9:00 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
*Dr. [**Last Name (STitle) **] only sees patients at either 8am or 9am.
{'Aortic valve disorders,Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Other and unspecified hyperlipidemia,Other chronic pulmonary heart diseases,Dehydration,Thrombocytopenia, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate)'}


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: shortness of breath

PRESENT ILLNESS: Mr. [**Known lastname 9035**] is an 80 year old male with a history of CAD s/p 5
vessel CABG and aortic stenosis (s/p dilation x 2 [**12-30**], [**12-29**])
who presents with worsening dyspnea. His shortness of breath has
gotten worse slowly over the course of two months. He now
becomes dypneic when supine in bed. He endorses PND and
orthopnea, using [**2-20**] pillows to sleep at night. However, most
nights he ends up sleeping flat, very uncomfortably. He has not
had chest pain, fevers or chills. He has a nonproductive cough
that has persisted over the same time period. After the
valvuloplasty in [**12/2173**], he was able to walk for 15 mintues
without stopping. He has not noticed swelling in his legs or
ankles.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
Aortic stenosis (Dilation [**12-30**], [**12-29**] at [**Hospital1 2025**]); valve area
0.7cm2 with peak gradient 76mmhg
CAD s/p 5-vessel CABG
Congestive Heart Failure with EF 30% in [**5-/2174**] by echo
3. OTHER PAST MEDICAL HISTORY:

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Allopurinol 100 mg PO DAILY
2. Ascorbic Acid 250 mg PO DAILY
3. Aspirin 162 mg PO DAILY
4. Bumetanide 1 mg PO BID
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Simvastatin 40 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY

ALLERGIES: Sulfa(Sulfonamide Antibiotics) / Torsemide

PHYSICAL EXAM: ADMISSION
VS: T=97.6 BP=106/55 HR=82 RR=21 O2 sat=100%
GENERAL: WDWN ** in NAD. Oriented x3. Mood, affect appropriate.

FAMILY HISTORY: Premature coronary artery disease- Mother CHF, died in 80s,
Father Died from MI at 62

SOCIAL HISTORY: He lives with his wife. Nonsmoker. Rarely drinks etoh. He is
retired and used to work as a manager at [**Company 2892**]. 

### Response:
{'Aortic valve disorders,Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Other and unspecified hyperlipidemia,Other chronic pulmonary heart diseases,Dehydration,Thrombocytopenia, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate)'}
