CHIEF COMPLAINT: chest pain and dyspnea on exertion

PRESENT ILLNESS: 68 yo M with known CAD s/p PTCA in [**2173**], also with known AS.
Abnormal stress test led to cath which showed 3vd and AS.
Referred for surgery.

MEDICAL HISTORY: CAD(PTCA), HTN, ^chol, AS, Tonsillectomy, Gout, Asbestos
exposure

MEDICATION ON ADMISSION: Crestor 20', Diovan 320', ASA 325', Allopurinol 300', HCTZ 25'

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: HR 68 RR 20 BP 157/72
NAD flat after cath
Lungs CTAB ant/lat
Heart RRR 3/6 SEM at LSB
Abdomen benign
Extrem warm, no edema
1 varicose vein on left calf.
Carotids with transmitted murmur v. bruit.

FAMILY HISTORY: NC

SOCIAL HISTORY: works at golf course
quit tobacco 40 years ago
2-6 beers/day
Aortic valve disorders,Iatrogenic pulmonary embolism and infarction,Cellulitis and abscess of leg, except foot,Iatrogenic pneumothorax,Coronary atherosclerosis of native coronary artery,Congestive heart failure, unspecified,Unspecified essential hypertension,Pure hypercholesterolemia,Gout, unspecified,Percutaneous transluminal coronary angioplasty status,Personal history of contact with and (suspected) exposure to asbestos,Anemia, unspecified
Aortic valve disorder,Iatrogen pulm emb/infarc,Cellulitis of leg,Iatrogenic pneumothorax,Crnry athrscl natve vssl,CHF NOS,Hypertension NOS,Pure hypercholesterolem,Gout NOS,Status-post ptca,Hx-contct/expos asbestos,Anemia NOS
Admission Date:  [**2186-12-28**]              Discharge Date:   [**2187-1-10**]

Date of Birth:  [**2117-12-9**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest pain and dyspnea on exertion

Major Surgical or Invasive Procedure:
AVR(#23 CE Magna
pericardial)CABGx3(LIMA-LAD,SVG-OM,SVG-RCA)[**12-28**]


History of Present Illness:
68 yo M with known CAD s/p PTCA in [**2173**], also with known AS.
Abnormal stress test led to cath which showed 3vd and AS.
Referred for surgery.

Past Medical History:
CAD(PTCA), HTN, ^chol, AS, Tonsillectomy, Gout, Asbestos
exposure

Social History:
works at golf course
quit tobacco 40 years ago
2-6 beers/day

Family History:
NC

Physical Exam:
HR 68 RR 20 BP 157/72
NAD flat after cath
Lungs CTAB ant/lat
Heart RRR 3/6 SEM at LSB
Abdomen benign
Extrem warm, no edema
1 varicose vein on left calf.
Carotids with transmitted murmur v. bruit.

Pertinent Results:
[**2187-1-10**] 05:15AM BLOOD WBC-9.0 RBC-3.02* Hgb-9.3* Hct-27.3*
MCV-90 MCH-30.8 MCHC-34.1 RDW-15.7* Plt Ct-297
[**2187-1-9**] 06:00AM BLOOD WBC-11.8* RBC-3.29* Hgb-10.4* Hct-30.5*
MCV-93 MCH-31.5 MCHC-34.0 RDW-15.6* Plt Ct-324
[**2187-1-10**] 05:15AM BLOOD Plt Ct-297
[**2187-1-10**] 05:15AM BLOOD PT-35.3* INR(PT)-3.7*
[**2187-1-9**] 06:00AM BLOOD PT-37.6* INR(PT)-4.0*
[**2187-1-8**] 05:28AM BLOOD PT-37.3* INR(PT)-4.0*
[**2187-1-7**] 05:48AM BLOOD PT-38.6* INR(PT)-4.2*
[**2187-1-6**] 06:08AM BLOOD PT-47.5* PTT-48.3* INR(PT)-5.4*
[**2187-1-5**] 06:13AM BLOOD PT-46.2* PTT-42.5* INR(PT)-5.2*
[**2187-1-4**] 04:55PM BLOOD PT-56.4* PTT-39.5* INR(PT)-6.6*
[**2187-1-4**] 02:27PM BLOOD PT-62.5* PTT-150* INR(PT)-7.5*
[**2187-1-4**] 04:13AM BLOOD PT-37.2* PTT-87.0* INR(PT)-4.0*
[**2187-1-3**] 04:16AM BLOOD PT-18.3* PTT-55.2* INR(PT)-1.7*

CHEST (PA & LAT)  [**2187-1-7**] 1:02 PM

CHEST (PA & LAT)

Reason: ? effusion

[**Hospital 93**] MEDICAL CONDITION:
69 year old man s/p avr CABG
REASON FOR THIS EXAMINATION:
? effusion
Comparison to [**2187-1-3**]. Minimal increase of the
right-sided pleural effusion. All other radiographic findings
are unchanged as to the previous examination.

CHEST (PORTABLE AP)  [**2187-1-3**] 7:29 AM

CHEST (PORTABLE AP)

Reason: s/p AVR/CABG w/PE on heparin w/dropping HCT-r/o effusion


[**Hospital 93**] MEDICAL CONDITION:
69 year old man with
REASON FOR THIS EXAMINATION:
s/p AVR/CABG w/PE on heparin w/dropping HCT-r/o effusion
HISTORY: CABG with dropping hematocrit on heparin.

FINDINGS: In comparison with the study of [**1-2**], there is little
change. No definite pneumothorax with the right chest tube still
in place. Indeed, there is no change in the appearance of the
heart and lungs.

[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT

[**Known lastname **], [**Known firstname **]       [**Hospital1 18**] [**Numeric Identifier 41414**]Portable TTE
(Complete) Done [**2187-1-2**] at 10:15:00 AM      FINAL
Referring Physician     [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**]
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**]  Status: Inpatient DOB: [**2117-12-9**]
Age (years): 69 M  Hgt (in): 69
BP (mm Hg): 108/66  Wgt (lb): 216
HR (bpm): 74  BSA (m2): 2.14 m2
Indication: Left ventricular function. Aortic valve replacement.
CABG.
ICD-9 Codes: 410.92, 402.90, 423.9, V42.2, 424.0
Test Information
Date/Time: [**2187-1-2**] at 10:15    Interpret MD: [**First Name8 (NamePattern2) **] [**Name8 (MD) **],
MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4587**],
RDCS
Doppler: Full Doppler and color Doppler Test Location: West
SICU/CTIC/VICU
Contrast: None Tech Quality: Adequate
Tape #: 2007W043-0:20 Machine: Vivid [**8-6**]
Echocardiographic Measurements
Results  Measurements  Normal Range
Left Atrium - Long Axis Dimension:  3.8 cm  <= 4.0 cm
Left Atrium - Four Chamber Length:  *6.9 cm  <= 5.2 cm
Left Atrium - Peak Pulm Vein S:  0.3 m/s
Left Atrium - Peak Pulm Vein D:  0.2 m/s
Right Atrium - Four Chamber Length:  *6.9 cm  <= 5.0 cm
Left Ventricle - Septal Wall Thickness:  *1.3 cm  0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness:  1.1 cm  0.6 - 1.1 cm

Left Ventricle - Diastolic Dimension:  *5.8 cm  <= 5.6 cm
Left Ventricle - Ejection Fraction:  30% to 35%  >= 55%
Left Ventricle - Lateral Peak E':  *0.05 m/s  > 0.08 m/s
Left Ventricle - Septal Peak E':  *0.04 m/s  > 0.08 m/s
Left Ventricle - Ratio E/E':  *20  < 15
Aorta - Sinus Level:  2.7 cm  <= 3.6 cm
Aorta - Ascending:  *3.8 cm  <= 3.4 cm
Aortic Valve - Peak Velocity:  *2.1 m/sec  <= 2.0 m/sec
Aortic Valve - Peak Gradient:  17 mm Hg  < 20 mm Hg
Aortic Valve - Mean Gradient:  9 mm Hg
Mitral Valve - E Wave:  0.9 m/sec
Mitral Valve - A Wave:  0.9 m/sec
Mitral Valve - E/A ratio:  1.00
Mitral Valve - E Wave deceleration time:  201 ms  140-250 ms
TR Gradient (+ RA = PASP):  22 mm Hg  <= 25 mm Hg
Pulmonic Valve - Peak Velocity:  0.9 m/sec  <= 1.5 m/sec
Pericardium - Effusion Size:  1.3 cm

Findings
LEFT ATRIUM: Elongated LA.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.

LEFT VENTRICLE: Mild symmetric LVH. Mildly dilated LV cavity.
Suboptimal technical quality, a focal LV wall motion abnormality
cannot be fully excluded. Moderately depressed LVEF. TDI E/e'
>15, suggesting PCWP>18mmHg. No resting LVOT gradient.

RIGHT VENTRICLE: RV not well seen. Paradoxic septal motion
consistent with prior cardiac surgery.

AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Mildly dilated ascending aorta.
Focal calcifications in ascending aorta.

AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR).
Normal AVR gradient.

MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular calcification.

TRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic
TR. Normal PA systolic pressure.

PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.

PERICARDIUM: Small to moderate pericardial effusion. No
echocardiographic signs of tamponade.

GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality - bandages, defibrillator pads or
electrodes.
Conclusions
The left atrium is elongated. The right atrium is moderately
dilated. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity is mildly dilated. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
difficult to assess given limited images but appears to be
moderately depressed (LVEF= 30-35 %). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Interventricular septal motion is normal. The
ascending aorta is mildly dilated. A bioprosthetic aortic valve
prosthesis is present. The aortic valve prosthesis appears well
seated, with normal ltransvalvular gradients. Leaflet motion not
adequately visualized. The mitral valve leaflets are mildly
thickened. No mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is a small
to moderate sized pericardial effusion. There are no
echocardiographic signs of tamponade.

IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with mildly dilated cavity and probably
moderately depressed left ventricular systolic function.
Elevated LV filling pressure. Bioprosthetic AVR with normal
gradients and no visualized aortic regurgitation. Small
pericardial effusion.

CTA CHEST W&W/O C&RECONS, NON-CORONARY  [**2187-1-1**] 10:56 PM

CTA CHEST W&W/O C&RECONS, NON-

Reason: r/o pe
Field of view: 40 Contrast: OPTIRAY

[**Hospital 93**] MEDICAL CONDITION:
69 year old man s/p cabgg/avr now ^dyspnea/hypoxia
REASON FOR THIS EXAMINATION:
r/o pe
CONTRAINDICATIONS for IV CONTRAST: None.

CTA CHEST ON [**1-1**]

CLINICAL HISTORY: Recent CABG/AVR, now hypoxic. Question PE.

TECHNIQUE: Helical acquisition of CT images performed through
the thorax during dynamic infusion of approximately 80 cc of
intravenous nonionic contrast following departmental CTA
protocol. Comparison made to prior study of [**2186-12-22**].

FINDINGS: Since the prior study, there is has been interval
median sternotomy and three-vessel CABG, as well as aortic valve
replacement. There is a persistent anterior mediastinal
hematoma, and a moderate sized pericardial effusion, with
density measurements consistent with serosanguineous fluid.
Greatest thickness of fluid is approximately 1.5 cm.
The aorta opacifies thoroughly, and there is no evidence for
dissection. Main pulmonary arteries are well opacified, however,
there are multiple bilateral filling defects within the
segmental arteries, all compatible with small pulmonary emboli.
The largest is located in the right upper lobe apical segmental
artery (3,39).
There are small bibasilar pleural effusions and associated
atelectasis with near complete collapse of the posterior basal
segment of the right lower lobe. Tiny residual anterior
right-sided pneumothorax, with chest tube in place, its tip
located at the apex. Small amount of right-sided subcutaneous
emphysema is seen. There are healing posterior right rib
fractures of the 9th and 10th ribs. Stable bilateral extensive
calcified pleural plaques. Wedge-shaped foci of increased
density in the left upper lobe may represent small focal
infarcts.

Limited imaging below the diaphragm reveals no discrete
abnormality on early arterial phase imaging.
There has been decrease in the size of the previously described
phlegmonous tissue at the head of the right clavicle.

IMPRESSION:
1. Multiple segmental and subsegmental bilateral pulmonary
emboli with associated atelectasis and possible small left upper
lobe pulmonary infarct. No evidence for right heart strain
currently.
2. Postoperative changes from recent sternotomy, with residual
anterior mediastinal hematoma and partially sanguinous, moderat
sized pericardial effusion.
3. Small bibasilar pleural effusions and extensive calcified
pleural plaques, unchanged.
4. These findings were discussed with Dr. [**Last Name (STitle) **] by Dr. [**Last Name (STitle) 18936**] at
the time of initial interpretation.


Brief Hospital Course:
He was taken to the operating room on [**12-28**] where he underwent a
CABG x 3 and AVR (pericardial). He was transferred to the ICU in
critical but stable condition on neo and propofol. He was
extubated later that same day. He received 2 units PRBCs for HCT
24. He was transferred to the floor on POD #3. He was SOB and
was transferred back to the ICU. He was seen by ID and started
on vanco and ceftriaxone empirically for pneumonia. A right
chest tube was placed for pneumothorax. CTA showed bilateral PEs
and he was started on heparin and coumadin. His antibiotics were
dc'd.  He had atrial fibrillation but converted to NSR. He was
started on vencomycin for lower extremity cellulitis. His
cellulitis improved and his INR was therapeutic and he was ready
for discharge home on POD #13 with oral antiobitics. I spoke
with Dr. [**Last Name (STitle) 41415**] who will see him in [**1-11**] and manage his
coumadin.

Medications on Admission:
Crestor 20', Diovan 320', ASA 325', Allopurinol 300', HCTZ 25'

Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*0*
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
6. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
8. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.

9. Warfarin 1 mg Tablet Sig: 0.5 Tablet PO ONCE (Once) for 1
doses: INR to be checked [**1-11**] at Dr. [**Last Name (STitle) 41416**] office.
Disp:*30 Tablet(s)* Refills:*0*
10. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 2255**] [**Name (NI) 2256**]

Discharge Diagnosis:
CAD, AS now s/p CABG /AVR
post op PE
post op Cellulitis
PTCA, HTN, ^chol, Tonsillectomy, Gout, Asbestos exposure


Discharge Condition:
Good.


Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pouds or driving until follow up with
surgeon.
Follow up with Dr. [**Last Name (STitle) 41415**] when you arrive home, he will manage
your coumadin.

Followup Instructions:
Dr. [**Last Name (STitle) 41415**] (PCP) - please call him when you arrive home to make
an appointment for [**1-11**].
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (cardiologist) 2 weeks
Dr. [**Last Name (STitle) 914**] Wednesday [**1-17**] at 2:30, please get labwork drawn
before appointment.
Already scheduled appointments:
[**First Name4 (NamePattern1) 569**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2187-2-9**] 10:30
[**First Name4 (NamePattern1) 8826**] [**Last Name (NamePattern1) 17512**],MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2187-2-9**]
10:30



Completed by:[**2187-1-10**]
{'Aortic valve disorders,Iatrogenic pulmonary embolism and infarction,Cellulitis and abscess of leg, except foot,Iatrogenic pneumothorax,Coronary atherosclerosis of native coronary artery,Congestive heart failure, unspecified,Unspecified essential hypertension,Pure hypercholesterolemia,Gout, unspecified,Percutaneous transluminal coronary angioplasty status,Personal history of contact with and (suspected) exposure to asbestos,Anemia, unspecified'}


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: chest pain and dyspnea on exertion

PRESENT ILLNESS: 68 yo M with known CAD s/p PTCA in [**2173**], also with known AS.
Abnormal stress test led to cath which showed 3vd and AS.
Referred for surgery.

MEDICAL HISTORY: CAD(PTCA), HTN, ^chol, AS, Tonsillectomy, Gout, Asbestos
exposure

MEDICATION ON ADMISSION: Crestor 20', Diovan 320', ASA 325', Allopurinol 300', HCTZ 25'

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: HR 68 RR 20 BP 157/72
NAD flat after cath
Lungs CTAB ant/lat
Heart RRR 3/6 SEM at LSB
Abdomen benign
Extrem warm, no edema
1 varicose vein on left calf.
Carotids with transmitted murmur v. bruit.

FAMILY HISTORY: NC

SOCIAL HISTORY: works at golf course
quit tobacco 40 years ago
2-6 beers/day 

### Response:
{'Aortic valve disorders,Iatrogenic pulmonary embolism and infarction,Cellulitis and abscess of leg, except foot,Iatrogenic pneumothorax,Coronary atherosclerosis of native coronary artery,Congestive heart failure, unspecified,Unspecified essential hypertension,Pure hypercholesterolemia,Gout, unspecified,Percutaneous transluminal coronary angioplasty status,Personal history of contact with and (suspected) exposure to asbestos,Anemia, unspecified'}
