CHIEF COMPLAINT: shortness of breath; chest pain with radiation to left arm

PRESENT ILLNESS: This patient is an 80 year old
female with severe aortic stenosis and history significant of
CAD
s/p CABG, atrial fibrillation on Coumadin, pulmonary
hypertension, hyperlipidemia, sleep apnea, and worsening renal
insufficiency stage III.  The patient was seen by Dr [**Last Name (STitle) 51681**]
for
follow up of her worsening dyspnea, now having to sit after
walking as little as 3 steps.  This is a marked decrease to what
she could do 3-6 months ago.  She fatigues more easily and has
cut back on her activities wanting to sleep all the time.  She
also notes LUE pain that starts in the left arm and radiates
upward to the heart happens when she is short of breath.  She
also does have some chest pain that is exertional.  She sits
down
and it gets better rather quickly.  The patient is unable to
perform pulmonary function tests because of her difficulty with
performing the test.  An echocardiogram on [**2164-1-25**] revealed
severe aortic stenosis with peak transalvular velocity of 4.44
m/sec, peak/mean pressure gradiesnt of 79/45 mmHg, and
calculated
[**Location (un) 109**] by continuity equation of 0.5-0.6 cm2.  LVEF was 50-55%.
Cardiac catheterization revealed mild-moderate coronary artery
disease which will be managed medically.  She presents
pre-operatively for heparin prior to redo sternotomy.

MEDICAL HISTORY: Aortic Stenosis, s/p Aortic Valve Replacement
PMH:
CAD: s/p CABG [**2155**] at [**Hospital3 8834**]
Atrial fibrillation, on Coumadin
Pulmonary HTN
Hypertension
Hyperlipidemia
Sleep apnea, unable to tolerate CPAP
Stage III renal insufficiency
Hypothyroid
Cancer-skin of face
Difficulty swallowing
Anxiety
Depression
Mild dementia
Rhinitis
Tinnitus
Spinal stenosis
S/P gallstone
GERD
Past Surgical History:
S/P C-section x4
Right Knee replacement

MEDICATION ON ADMISSION: Allopurinol 100mg daily, aricept 2.5mg am, 5mg pm, aspirin 81mg
daily, calcium 500mg tid, centrum mvi daily, cranberry caps [**Hospital1 **],
crestor 5mg daily, digoxin 0.125 QOD (LD [**4-27**]), diltiazem cd 180
daily, enablex 7.5mg daily, fluoxeetine 40mg daily, fluticasone
nasal spray daily, folic acid 1mg daily, furosemide 40mg daily,
levothyroxine 100mcg daily, losartan 25mg daily, metoprolol 25mg
[**Hospital1 **], nicobid 250mg daily, ntg prn, omeprazole 20mg daily,k
vitamin d 400 u daily, warfarin 3mg daily (LD [**2164-4-25**]), claritin

ALLERGIES: Penicillins

PHYSICAL EXAM: Pulse: 62 Resp: 20  O2 sat: 99%RA
B/P  Right:    Left: 115/55
Height: 5'3"    Weight: 170lb

FAMILY HISTORY: Mother had CAD in her 70's

SOCIAL HISTORY: Lives with son and daughter-in-law.  Retired
clerical worker at unemployment office in [**Location (un) **].
Discharge contact:  [**Name (NI) 16883**] [**Name (NI) 18199**], daughter.  C:  [**Telephone/Fax (1) 101696**]
[**Name2 (NI) **] Care Services:  Housekeeper once per week.  Companion [**2-10**]
Aortic valve disorders,Chronic diastolic heart failure,Other chronic pulmonary heart diseases,Unspecified pleural effusion,Acquired cardiac septal defect,Chronic kidney disease, Stage III (moderate),Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Aortocoronary bypass status,Atrial fibrillation,Unspecified acquired hypothyroidism,Other and unspecified hyperlipidemia,Knee joint replacement,Obstructive sleep apnea (adult)(pediatric),Examination of participant in clinical trial,Long-term (current) use of anticoagulants,Anemia, unspecified,Abnormal coagulation profile
Aortic valve disorder,Chr diastolic hrt fail,Chr pulmon heart dis NEC,Pleural effusion NOS,Acq cardiac septl defect,Chr kidney dis stage III,Hy kid NOS w cr kid I-IV,Aortocoronary bypass,Atrial fibrillation,Hypothyroidism NOS,Hyperlipidemia NEC/NOS,Joint replaced knee,Obstructive sleep apnea,Exam-clincal trial,Long-term use anticoagul,Anemia NOS,Abnrml coagultion prfile
Admission Date:  [**2164-4-29**]              Discharge Date:   [**2164-5-10**]

Date of Birth:  [**2083-6-2**]             Sex:   F

Service: CARDIOTHORACIC

Allergies:
Penicillins

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
shortness of breath; chest pain with radiation to left arm

Major Surgical or Invasive Procedure:
Redo Sternotomy, Aortic Valve Replacement (21mm Biocore Epic)
[**2164-5-1**]


History of Present Illness:
This patient is an 80 year old
female with severe aortic stenosis and history significant of
CAD
s/p CABG, atrial fibrillation on Coumadin, pulmonary
hypertension, hyperlipidemia, sleep apnea, and worsening renal
insufficiency stage III.  The patient was seen by Dr [**Last Name (STitle) 51681**]
for
follow up of her worsening dyspnea, now having to sit after
walking as little as 3 steps.  This is a marked decrease to what
she could do 3-6 months ago.  She fatigues more easily and has
cut back on her activities wanting to sleep all the time.  She
also notes LUE pain that starts in the left arm and radiates
upward to the heart happens when she is short of breath.  She
also does have some chest pain that is exertional.  She sits
down
and it gets better rather quickly.  The patient is unable to
perform pulmonary function tests because of her difficulty with
performing the test.  An echocardiogram on [**2164-1-25**] revealed
severe aortic stenosis with peak transalvular velocity of 4.44
m/sec, peak/mean pressure gradiesnt of 79/45 mmHg, and
calculated
[**Location (un) 109**] by continuity equation of 0.5-0.6 cm2.  LVEF was 50-55%.
Cardiac catheterization revealed mild-moderate coronary artery
disease which will be managed medically.  She presents
pre-operatively for heparin prior to redo sternotomy.

Past Medical History:
Aortic Stenosis, s/p Aortic Valve Replacement
PMH:
CAD: s/p CABG [**2155**] at [**Hospital3 8834**]
Atrial fibrillation, on Coumadin
Pulmonary HTN
Hypertension
Hyperlipidemia
Sleep apnea, unable to tolerate CPAP
Stage III renal insufficiency
Hypothyroid
Cancer-skin of face
Difficulty swallowing
Anxiety
Depression
Mild dementia
Rhinitis
Tinnitus
Spinal stenosis
S/P gallstone
GERD
Past Surgical History:
S/P C-section x4
Right Knee replacement


Social History:
Lives with son and daughter-in-law.  Retired
clerical worker at unemployment office in [**Location (un) **].
Discharge contact:  [**Name (NI) 16883**] [**Name (NI) 18199**], daughter.  C:  [**Telephone/Fax (1) 101696**]
[**Name2 (NI) **] Care Services:  Housekeeper once per week.  Companion [**2-10**]

Tobacco:  Never
ETOH:  None
Recreational drug use:  Denies


Family History:
Mother had CAD in her 70's

Physical Exam:
Pulse: 62 Resp: 20  O2 sat: 99%RA
B/P  Right:    Left: 115/55
Height: 5'3"    Weight: 170lb

General: NAD, pleasant, forgetful, poor historian
Skin: Dry [x] intact [x] well healed sternotomy
HEENT: PERRLA [x] EOMI [x]
tympanic membranes in tact bilaterally without evidence of
erythema or fluid
Neck:  Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR []  Irregular [x]  Murmur [x] grade __3/6__
Abdomen: Soft [x] non-distended [x] non-tender [x]  bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]  Edema [] trace
(wearing
compression stockings), well healed incisions of endoscopic vein
harvest of LLE, with incision of open harvest in thigh.
well-healed incision of right TKA
Varicosities: None []
Neuro: Grossly intact [x]
Pulses:
Femoral      Right: 2+  Left:2+
DP           Right: 1+  Left:1+
PT           [**Name (NI) 167**]:     Left:
Radial       Right:     Left:

Carotid Bruit        Right:    Left:
bruits vs. radiation of cardiac murmur


Pertinent Results:
[**2164-5-1**] ECHO
PREBYPASS

A patent foramen ovale is present. There is a bidirectional
shunt across the interatrial septum at rest. Left ventricular
wall thicknesses are normal. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is mildly
depressed (LVEF= 45 %). The right ventricular cavity is
moderately dilated with moderate global free wall hypokinesis.
There are complex (>4mm) 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. There is a minimally increased gradient consistent with
trivial mitral stenosis. Mild (1+) mitral regurgitation is seen.
The main pulmonary artery is dilated. Dr. [**Last Name (STitle) **] was notified
in person of the results on [**2164-5-1**] at 930 am.

POSTBYPASS

Patient is AV paced and receiving an infusion of phenylephrine.
Biventricular systolic function is unchanged. Bioprosthetic
valve seen in the aortic position. It appears to be well seated.
There is mild aortic insufficiency noted at the junction of the
native non and right coronary cusps. 1- 2+ mitral regurgitation
present. Aorta is intact post decannulation. Rest of the
examination is unchanged.

Very poor transgastric views.

Brief Hospital Course:
The patient was brought to the operating Room on [**2164-5-1**] where
she underwent redo sternotomy, and aortic valve replacement by
Dr. [**Last Name (STitle) **]. Please see operative note for details. Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition. She was left
intubated and sedated overnight. She required packed red blood
cells for a postoperative anemia. On postoperative day one, she
awoke neurologically intact and was extubated without incident.
She initially experienced intermittent hypertension which
responded well to Nicardipine drip. Warfarin was resumed for
atrial fibrillation but held after one dose due to
supratherapeutic INR. Over several days, beta blockade and
Diltiazem were titrated accordingly with much improved blood
pressure and rate control. However required titration down due
to bradycardia.  She responded well to Lasix, and dose adjusted
for diuresis. INR gradually improved, and low dose Warfarin was
resumed. She continued to progress and physical therapy worked
with her on strength and mobility.  On post-op day number 7, her
INR was 2.5, the coumadin dose was help on [**2164-5-8**].  On post-op
day 9, the patient's INR is stable at 2.6.  She will be advised
to take Coumadin 0.5mg on [**2164-5-10**], and INR will be followed
every other day until a steady therapeutic INR is achieved.  It
is now felt that the patient is safe to be discharged to
rehabilitation center on post-op day #9.

Medications on Admission:
Allopurinol 100mg daily, aricept 2.5mg am, 5mg pm, aspirin 81mg
daily, calcium 500mg tid, centrum mvi daily, cranberry caps [**Hospital1 **],
crestor 5mg daily, digoxin 0.125 QOD (LD [**4-27**]), diltiazem cd 180
daily, enablex 7.5mg daily, fluoxeetine 40mg daily, fluticasone
nasal spray daily, folic acid 1mg daily, furosemide 40mg daily,
levothyroxine 100mcg daily, losartan 25mg daily, metoprolol 25mg
[**Hospital1 **], nicobid 250mg daily, ntg prn, omeprazole 20mg daily,k
vitamin d 400 u daily, warfarin 3mg daily (LD [**2164-4-25**]), claritin

Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. warfarin 1 mg Tablet Sig: 0.5 mg PO DAILY (Daily): please
draw INR on [**2164-5-11**].
7. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever.
9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
10. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**1-9**]  Inhalation Q6H (every 6 hours) as needed
for dypsnea.
12. ipratropium bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed for dyspnea.
13. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
14. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily).
15. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. donepezil 5 mg Tablet Sig: 0.5 Tablet PO QAM (once a day (in
the morning)).
17. donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
18. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
19. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

20. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
21. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
22. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 7 days: Then after 7 days, decrease Lasix to 40mg by
mouth daily.
23. potassium chloride 20 mEq Packet Sig: One (1)  PO twice a
day for 7 days: after 7 days, decrease KCL to 20mEq by mouth
daily.
24. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).


Discharge Disposition:
Extended Care

Facility:
[**Location (un) 14468**] Nursing & Rehabilitation Center - [**Location (un) 1456**]

Discharge Diagnosis:
Aortic Stenosis, s/p Aortic Valve Replacement
PMH:
CAD: s/p CABG [**2155**] at [**Hospital3 8834**]
Atrial fibrillation, on Coumadin
Pulmonary HTN
Hypertension
Hyperlipidemia
Sleep apnea, unable to tolerate CPAP
Stage III renal insufficiency
Hypothyroid
Cancer-skin of face
Difficulty swallowing
Anxiety
Depression
Mild dementia
Rhinitis
Tinnitus
Spinal stenosis
S/P gallstone
GERD
Past Surgical History:
S/P C-section x4
Right Knee replacement


Discharge Condition:
Alert and oriented x ***** nonfocal
Ambulating, deconditioned
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage


Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge

Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr. [**Last Name (STitle) **]  [**2164-6-6**] at 1:30pm [**Telephone/Fax (1) 170**]
Cardiologist Dr. [**Last Name (STitle) **] [**2164-5-23**] at 11:00am
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] E. [**Telephone/Fax (1) 101697**] in [**4-12**] 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
Coumadin for atrial fibrillation
Goal INR 2.0 - 2.5
First draw day after discharge
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr.
[**Last Name (STitle) 24307**] to phone fax



Completed by:[**2164-5-10**]
{'Aortic valve disorders,Chronic diastolic heart failure,Other chronic pulmonary heart diseases,Unspecified pleural effusion,Acquired cardiac septal defect,Chronic kidney disease, Stage III (moderate),Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Aortocoronary bypass status,Atrial fibrillation,Unspecified acquired hypothyroidism,Other and unspecified hyperlipidemia,Knee joint replacement,Obstructive sleep apnea (adult)(pediatric),Examination of participant in clinical trial,Long-term (current) use of anticoagulants,Anemia, unspecified,Abnormal coagulation profile'}


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; chest pain with radiation to left arm

PRESENT ILLNESS: This patient is an 80 year old
female with severe aortic stenosis and history significant of
CAD
s/p CABG, atrial fibrillation on Coumadin, pulmonary
hypertension, hyperlipidemia, sleep apnea, and worsening renal
insufficiency stage III.  The patient was seen by Dr [**Last Name (STitle) 51681**]
for
follow up of her worsening dyspnea, now having to sit after
walking as little as 3 steps.  This is a marked decrease to what
she could do 3-6 months ago.  She fatigues more easily and has
cut back on her activities wanting to sleep all the time.  She
also notes LUE pain that starts in the left arm and radiates
upward to the heart happens when she is short of breath.  She
also does have some chest pain that is exertional.  She sits
down
and it gets better rather quickly.  The patient is unable to
perform pulmonary function tests because of her difficulty with
performing the test.  An echocardiogram on [**2164-1-25**] revealed
severe aortic stenosis with peak transalvular velocity of 4.44
m/sec, peak/mean pressure gradiesnt of 79/45 mmHg, and
calculated
[**Location (un) 109**] by continuity equation of 0.5-0.6 cm2.  LVEF was 50-55%.
Cardiac catheterization revealed mild-moderate coronary artery
disease which will be managed medically.  She presents
pre-operatively for heparin prior to redo sternotomy.

MEDICAL HISTORY: Aortic Stenosis, s/p Aortic Valve Replacement
PMH:
CAD: s/p CABG [**2155**] at [**Hospital3 8834**]
Atrial fibrillation, on Coumadin
Pulmonary HTN
Hypertension
Hyperlipidemia
Sleep apnea, unable to tolerate CPAP
Stage III renal insufficiency
Hypothyroid
Cancer-skin of face
Difficulty swallowing
Anxiety
Depression
Mild dementia
Rhinitis
Tinnitus
Spinal stenosis
S/P gallstone
GERD
Past Surgical History:
S/P C-section x4
Right Knee replacement

MEDICATION ON ADMISSION: Allopurinol 100mg daily, aricept 2.5mg am, 5mg pm, aspirin 81mg
daily, calcium 500mg tid, centrum mvi daily, cranberry caps [**Hospital1 **],
crestor 5mg daily, digoxin 0.125 QOD (LD [**4-27**]), diltiazem cd 180
daily, enablex 7.5mg daily, fluoxeetine 40mg daily, fluticasone
nasal spray daily, folic acid 1mg daily, furosemide 40mg daily,
levothyroxine 100mcg daily, losartan 25mg daily, metoprolol 25mg
[**Hospital1 **], nicobid 250mg daily, ntg prn, omeprazole 20mg daily,k
vitamin d 400 u daily, warfarin 3mg daily (LD [**2164-4-25**]), claritin

ALLERGIES: Penicillins

PHYSICAL EXAM: Pulse: 62 Resp: 20  O2 sat: 99%RA
B/P  Right:    Left: 115/55
Height: 5'3"    Weight: 170lb

FAMILY HISTORY: Mother had CAD in her 70's

SOCIAL HISTORY: Lives with son and daughter-in-law.  Retired
clerical worker at unemployment office in [**Location (un) **].
Discharge contact:  [**Name (NI) 16883**] [**Name (NI) 18199**], daughter.  C:  [**Telephone/Fax (1) 101696**]
[**Name2 (NI) **] Care Services:  Housekeeper once per week.  Companion [**2-10**] 

### Response:
{'Aortic valve disorders,Chronic diastolic heart failure,Other chronic pulmonary heart diseases,Unspecified pleural effusion,Acquired cardiac septal defect,Chronic kidney disease, Stage III (moderate),Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Aortocoronary bypass status,Atrial fibrillation,Unspecified acquired hypothyroidism,Other and unspecified hyperlipidemia,Knee joint replacement,Obstructive sleep apnea (adult)(pediatric),Examination of participant in clinical trial,Long-term (current) use of anticoagulants,Anemia, unspecified,Abnormal coagulation profile'}
