CHIEF COMPLAINT: Dyspnea on exertion

PRESENT ILLNESS: 81 year old gentleman with atrial fibrillation s/p cardioversion
in [**2133-7-21**] and [**Month (only) 205**]/[**2134**] presents for preoperative workup
for Minimally invasive vs
sternotomy MV repair vs replacement

MEDICAL HISTORY: hypertension, atrial fibrillation on
coumadin s/p cardioversion in [**2133-7-21**] and a repeat
cardioversion in [**2135-6-21**], benign prostatic hypertrophy s/p
TURP, s/p cholecystectomy, s/p tonsillectomy
Past Surgical History: s/p TURP, s/p cholecystectomy, s/p
tonsillectomy

MEDICATION ON ADMISSION: coumadin (for atrial fibrillation) 2-3mg -LD
[**5-5**], cyclosporine (eczematous dermatitis)75mg [**Hospital1 **], norvasc 5mg,
toprol XL 50mg, triamcinolone acetonide cream (eczematous
dermatitis), detrol LA 4mg

ALLERGIES: Lisinopril / Coumadin

PHYSICAL EXAM: Physical Exam

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: retired electrical engineer - Last Dental Exam [**2136-5-4**]
Mitral valve insufficiency and aortic valve stenosis,Diseases of tricuspid valve,Thrombocytopenia, unspecified,Atrial fibrillation,Chronic airway obstruction, not elsewhere classified,Long-term (current) use of anticoagulants,Unspecified essential hypertension,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Contact dermatitis and other eczema, unspecified cause
Mitral insuf/aort stenos,Tricuspid valve disease,Thrombocytopenia NOS,Atrial fibrillation,Chr airway obstruct NEC,Long-term use anticoagul,Hypertension NOS,BPH w/o urinary obs/LUTS,Dermatitis NOS
Admission Date:  [**2136-5-9**]              Discharge Date:   [**2136-5-16**]

Date of Birth:  [**2054-11-5**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Lisinopril / Coumadin

Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Dyspnea on exertion

Major Surgical or Invasive Procedure:
-status post Mitral Valve Replacement (#27mm Porcine)/Aortic
Valve Replacement ( #21 Pericardial)/Tricuspid Valve Repair [**5-11**]


History of Present Illness:
81 year old gentleman with atrial fibrillation s/p cardioversion
in [**2133-7-21**] and [**Month (only) 205**]/[**2134**] presents for preoperative workup
for Minimally invasive vs
sternotomy MV repair vs replacement


Past Medical History:
hypertension, atrial fibrillation on
coumadin s/p cardioversion in [**2133-7-21**] and a repeat
cardioversion in [**2135-6-21**], benign prostatic hypertrophy s/p
TURP, s/p cholecystectomy, s/p tonsillectomy
Past Surgical History: s/p TURP, s/p cholecystectomy, s/p
tonsillectomy


Social History:
retired electrical engineer - Last Dental Exam [**2136-5-4**]

Lives with companion   -Race caucasian

Tobacco:  Denies    -   ETOH: one glass of wine or beer nightly


Family History:
noncontributory

Physical Exam:
Physical Exam

Pulse:66 Resp: 18 O2 sat: 99 RA
B/P  Right:136/84
Height: 67 inches    Weight:66 kgs

General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck:  Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR []  Irregular [x]  Murmur IV/VI SEM
Abdomen: Soft [x] non-distended [x] non-tender [x]  bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]  Edema Varicosities:
None []
Neuro: Grossly intact[X]
Pulses:
Femoral      Right:2+   Left:2+
DP           Right:2+   Left:2+
PT           [**Name (NI) 167**]:2+   Left:2+
Radial       Right:2+   Left:2+

Carotid Bruit        Right:-    Left:-


Pertinent Results:
[**2136-5-15**] 05:30AM BLOOD WBC-7.0 RBC-2.64* Hgb-8.6* Hct-25.3*
MCV-96 MCH-32.6* MCHC-34.0 RDW-14.5 Plt Ct-84*
[**2136-5-9**] 09:30PM BLOOD WBC-4.9 RBC-3.88* Hgb-12.9* Hct-37.6*
MCV-97# MCH-33.1* MCHC-34.2 RDW-13.2 Plt Ct-142*
[**2136-5-14**] 05:30AM BLOOD PT-13.1 INR(PT)-1.1
[**2136-5-9**] 09:30PM BLOOD PT-18.0* PTT-28.0 INR(PT)-1.6*
[**2136-5-15**] 05:30AM BLOOD Glucose-100 UreaN-24* Creat-1.0 Na-140
K-4.2 Cl-106 HCO3-25 AnGap-13
[**2136-5-9**] 09:30PM BLOOD Glucose-113* UreaN-17 Creat-0.9 Na-139
K-3.8 Cl-106 HCO3-25 AnGap-12


[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT

[**Known lastname 58320**], [**Known firstname **]       [**Hospital1 18**] [**Numeric Identifier 58321**] (Complete)
Done [**2136-5-11**] at 10:34:52 AM      PRELIMINARY
Referring Physician     [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
[**Street Address(2) 15115**]
[**Location (un) 15116**], [**Numeric Identifier 15117**]  Status: Inpatient DOB: [**2054-11-5**]
Age (years): 81 M  Hgt (in): 69
BP (mm Hg): 104/52  Wgt (lb): 140
HR (bpm): 76  BSA (m2): 1.78 m2
Indication: Mitral valve regurgitation, aortic stenosis,
tricuspid regurgitation. Intraoperative management
ICD-9 Codes: 427.31, 786.05, 440.0, 424.1, 424.0, 424.2
Test Information
Date/Time: [**2136-5-11**] at 10:34    Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD

Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 168**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW2-: Machine: 2
Echocardiographic Measurements
Results  Measurements  Normal Range
Left Atrium - Long Axis Dimension:  *5.4 cm  <= 4.0 cm
Left Atrium - Four Chamber Length:  *6.3 cm  <= 5.2 cm
Left Ventricle - Septal Wall Thickness:  1.0 cm  0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness:  *1.2 cm  0.6 - 1.1 cm

Left Ventricle - Diastolic Dimension:  *6.4 cm  <= 5.6 cm
Left Ventricle - Systolic Dimension:  4.3 cm
Left Ventricle - Fractional Shortening:  0.33  >= 0.29
Left Ventricle - Ejection Fraction:  45% to 50%  >= 55%
Aorta - Annulus:  2.1 cm  <= 3.0 cm
Aorta - Sinus Level:  2.9 cm  <= 3.6 cm
Aorta - Sinotubular Ridge:  2.6 cm  <= 3.0 cm
Aorta - Ascending:  2.7 cm  <= 3.4 cm
Aorta - Arch:  2.5 cm  <= 3.0 cm
Aorta - Descending Thoracic:  2.2 cm  <= 2.5 cm
Aortic Valve - Peak Velocity:  *3.2 m/sec  <= 2.0 m/sec
Aortic Valve - Peak Gradient:  *21 mm Hg  < 20 mm Hg
Aortic Valve - Mean Gradient:  14 mm Hg
Aortic Valve - LVOT diam:  1.9 cm

Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
Good (>20 cm/s) LAA ejection velocity.

RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.

LEFT VENTRICLE: Normal LV wall thickness. Mildly depressed LVEF.


RIGHT VENTRICLE: Normal RV chamber size and free wall motion.

AORTA: Normal aortic arch diameter. Simple atheroma in aortic
arch. Normal descending aorta diameter. Simple atheroma in
descending aorta.

AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Critical AS (area
<0.8cm2). Mild (1+) AR.

MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild
mitral annular calcification. Moderate to severe (3+) MR. [**Name13 (STitle) 15110**] to
the eccentric MR jet, its severity may be underestimated (Coanda
effect).

TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate to
severe [3+] TR.

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

GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications. Results were personally reviewed with the MD
caring for the patient.
Conclusions
PRE-BYPASS:

1. No spontaneous echo contrast is seen in the left atrial
appendage.
2. No atrial septal defect is seen by 2D or color Doppler.
3. Left ventricular wall thicknesses are normal. Overall left
ventricular systolic function is globally mildly depressed
(LVEF= 45%). However intrinsic LV systolic function may be
further impaired given the degree of MR
4. Right ventricular chamber size is moderately dilated Free
wall motion is normal.
5. There are simple atheroma in the aortic arch and descending
thoracic aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets are severely thickened/deformed. There is critical
aortic valve stenosis (valve area <0.8cm2) with peak and mean
gradients 25 and 14 respectively. Mild (1+) aortic regurgitation
is seen.
7. The mitral valve leaflets are moderately thickened. Moderate
to severe (3+) mitral regurgitation is seen. Due to the
eccentric nature of the regurgitant jet, its severity may be
significantly underestimated (Coanda effect).
8. Moderate to severe [3+] tricuspid regurgitation is seen with
a dilated TV annulus 4.6cm.
9. Dr. [**Last Name (STitle) **] was notified in person of the results
during surgery on [**2136-5-11**] at 843.

POSTBYPASS
1. Patient is on phenylephrine and epinephrine infusions.
2. A well functioning, well seated tissue valve is noted in the
mitral position. A small perivalvular leak is noted. Max
pressure gradient 27 and mean PG 9 mmHg.
3. A well functioning, well seated tissue valve is noted in the
aortic valve. A small perivalvular leak is noted along the
anterior LVOT wall. Max pressure gradient is 19 with a mean
gradient of 9 mmHg.
4. A tricuspid annuloplasty ring is noted. Residual mild
tricuspid regurgitation is noted.
5. LV EF is similar to prebypass.
6. Aortic contour is smooth after decannulation.
  I certify that I was present for this procedure in compliance
with HCFA regulations.

Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting
physician


?????? [**2129**] CareGroup IS. All rights reserved.


Brief Hospital Course:
[**5-11**] Mr. [**Known lastname **] [**Last Name (Titles) 1834**] a Mitral Valve Replacement (#27mm
Porcine)/Aortic Valve Replacement (# 21mm Pericardial/ Tricuspid
Valve Repair with Dr.[**Last Name (STitle) **]. Cross clamp time= 143
minutes/ Cardiopulmonary bypass time = 166 minutes. Please refer
to Dr[**Doctor Last Name 14333**] operative report for further details. He
was transported to the CVICU on Phenylephrine/Epinephrine and
Propofol to augment hemodynamic stablity. He awoke
neurologically intact and was extubated on POD#1. All lines and
drains were discontinued in a timely fashion. POD#2 Mr.[**Known lastname **] was
transferred to the stepdown unit for further monitoring. A HIT
panel was sent for thrombocytopenia. Coumadin was started for
anticoagulation for chronic atrial fibrillation. Beta-blocker
was initiated to optimize heart rate and rhythm. Pacing wires
were discontinued POD# 4 per Dr.[**Last Name (STitle) **]. Mr.[**Known lastname **]
continued to progress, and the remainder of his postoperative
course was essentially uncomplicated. His platlet count showed
recovery. POD# 5 he was cleared by Dr.[**Last Name (STitle) **] for
discharge to home with VNA. All follow up appointments were
advised. Dr[**Doctor Last Name **] office was contact[**Name (NI) **]/agreed to resume
following Coumadin dosing/INR draws.

Medications on Admission:
coumadin (for atrial fibrillation) 2-3mg -LD
[**5-5**], cyclosporine (eczematous dermatitis)75mg [**Hospital1 **], norvasc 5mg,
toprol XL 50mg, triamcinolone acetonide cream (eczematous
dermatitis), detrol LA 4mg


Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg [**Hospital1 8426**] Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*45 [**Hospital1 8426**](s)* Refills:*0*
2. Aspirin 81 mg [**Hospital1 8426**], Delayed Release (E.C.) Sig: One (1)
[**Hospital1 8426**], Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 [**Hospital1 8426**], Delayed Release (E.C.)(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Tolterodine 2 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO BID (2 times a
day).
Disp:*60 [**Hospital1 8426**](s)* Refills:*2*
5. Warfarin 1 mg [**Hospital1 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] DAILY (Daily) as
needed for atrial fibrillation .
Disp:*90 [**Last Name (Titles) 8426**](s)* Refills:*0*
6. Metoprolol Tartrate 25 mg [**Last Name (Titles) 8426**] Sig: 0.5 [**Last Name (Titles) 8426**] PO BID (2
times a day).
Disp:*30 [**Last Name (Titles) 8426**](s)* Refills:*2*
7. Furosemide 20 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO BID (2 times a
day) for 5 days.
Disp:*10 [**Last Name (Titles) 8426**](s)* Refills:*0*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day)
for 5 days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. Warfarin 5 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO ONCE (Once) for 1
doses: tonight.
Disp:*1 [**Last Name (Titles) 8426**](s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
VNA of Southeastern Mass.

Discharge Diagnosis:
-status post Mitral Valve Replacement (#27mm Porcine)/Aortic
Valve Replacement ( #21 Pericardial)/Tricuspid Valve Repair
-HTN/AFib/Benign prostatic hypertrophy, s/p TURP, s/p CCY


Discharge Condition:
good


Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Resume INR checks for Coumadin with Dr.[**Last Name (STitle) 6700**]
*VNA to draw INR/Coumadin dosing per Dr.[**Last Name (STitle) 6700**]


Followup Instructions:
-Dr. [**Name (NI) **] in 4 weeks #([**Telephone/Fax (1) 170**]) please call for
appointment
-Dr [**Last Name (STitle) **],[**First Name3 (LF) **] M. in 1 week #([**Telephone/Fax (1) **]) please call
for appointment
-Dr [**Last Name (STitle) 1911**], [**First Name3 (LF) **] in [**1-24**] weeks please call for
appointment
-Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3071**])


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]

Completed by:[**2136-5-16**]
{'Mitral valve insufficiency and aortic valve stenosis,Diseases of tricuspid valve,Thrombocytopenia, unspecified,Atrial fibrillation,Chronic airway obstruction, not elsewhere classified,Long-term (current) use of anticoagulants,Unspecified essential hypertension,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Contact dermatitis and other eczema, unspecified cause'}


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: Dyspnea on exertion

PRESENT ILLNESS: 81 year old gentleman with atrial fibrillation s/p cardioversion
in [**2133-7-21**] and [**Month (only) 205**]/[**2134**] presents for preoperative workup
for Minimally invasive vs
sternotomy MV repair vs replacement

MEDICAL HISTORY: hypertension, atrial fibrillation on
coumadin s/p cardioversion in [**2133-7-21**] and a repeat
cardioversion in [**2135-6-21**], benign prostatic hypertrophy s/p
TURP, s/p cholecystectomy, s/p tonsillectomy
Past Surgical History: s/p TURP, s/p cholecystectomy, s/p
tonsillectomy

MEDICATION ON ADMISSION: coumadin (for atrial fibrillation) 2-3mg -LD
[**5-5**], cyclosporine (eczematous dermatitis)75mg [**Hospital1 **], norvasc 5mg,
toprol XL 50mg, triamcinolone acetonide cream (eczematous
dermatitis), detrol LA 4mg

ALLERGIES: Lisinopril / Coumadin

PHYSICAL EXAM: Physical Exam

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: retired electrical engineer - Last Dental Exam [**2136-5-4**] 

### Response:
{'Mitral valve insufficiency and aortic valve stenosis,Diseases of tricuspid valve,Thrombocytopenia, unspecified,Atrial fibrillation,Chronic airway obstruction, not elsewhere classified,Long-term (current) use of anticoagulants,Unspecified essential hypertension,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Contact dermatitis and other eczema, unspecified cause'}
