CHIEF COMPLAINT: Shortness of breath

PRESENT ILLNESS: This is a 74 year old male with a six month history of worsening
dyspnea on exertion. Several weeks prior to admission, he
admitted to rapid decrease in exercise capacity. For several
years, he had used two pillows for sleep. He has no history of
chest pain or PND. On [**6-6**], he presented to his
cardiologist with the above complaints. Office echocardiogram
showed an LVEF of 15-20%. He was subsequently admitted to [**Hospital 6451**] with congestive heart failure. BNP on admission was
1400. He was diuresed with IV Lasix with improvement in his
shortness of breath. He was stabilized on medical therapy and
transferred to the [**Hospital1 18**] for further evaluation and treatment.

MEDICAL HISTORY: Congestive Heart Failure, Hypertension, Hyperlipidemia, Type II
Diabetes Mellitus, Pulmonary Hypertension, Chronic Renal
Insufficiency, History of Atrial Fibrillation, GERD, History of
Urinary Sludge, Prior Tonsillectomy, Hidradenitis Suppurative
s/p Surgery

MEDICATION ON ADMISSION: Aspirin 325 qd, Zestril 20 qd, Toprol XL 50 qd, Lasix, KCL,
Nexium 40 qd, Plavix Load of 600mg

ALLERGIES: Dilaudid

PHYSICAL EXAM: PREOP EXAM - Vitals: 137/64, 79, 18, 95% RA
General: WDWN male in no acute distress
HEENT: Oropharynx benign, EOMI
Neck: Supple, no JVD
Lungs: CTA bilaterally
Heart: Regular rate and rhythm, normal s1s2, soft systolic
murmur
Abdomen: Soft, nontender with normoactive bowel sounds
Ext: Warm, no edema
Pulses: 2+ distally
Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal
deficits noted

FAMILY HISTORY: Denies premature coronary disease.

SOCIAL HISTORY: 15 pack year history of tobacco. Quit smoking over 25 years ago.
Admits to 3 ETOH drinks per month. Married, lives with spouse.
Mitral valve disorders,Acute on chronic systolic heart failure,Delirium due to conditions classified elsewhere,Paroxysmal ventricular tachycardia,Acute kidney failure, unspecified,Coronary atherosclerosis of native coronary artery,Other chronic pulmonary heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Esophageal reflux,Encounter for therapeutic drug monitoring,Long-term (current) use of anticoagulants,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in residential institution,Unspecified acquired hypothyroidism,Hidradenitis,Personal history of tobacco use
Mitral valve disorder,Ac on chr syst hrt fail,Delirium d/t other cond,Parox ventric tachycard,Acute kidney failure NOS,Crnry athrscl natve vssl,Chr pulmon heart dis NEC,DMII wo cmp nt st uncntr,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Esophageal reflux,Therapeutic drug monitor,Long-term use anticoagul,Abn react-surg proc NEC,Accid in resident instit,Hypothyroidism NOS,Hidradenitis,History of tobacco use
Admission Date:  [**2152-6-7**]              Discharge Date:   [**2152-6-23**]

Date of Birth:  [**2077-8-11**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Dilaudid

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath

Major Surgical or Invasive Procedure:
[**2152-6-7**] Cardiac Catheterization
[**2152-6-14**] Mitral Valve Repair(28mm Csgrove Annuloplasty Band) and
Four Vessel Coronary Artery Bypass Grafting(Left internal
mammary artery to left anterior descending, saphenous vein
grafts to diagonal, ramus, and posterior descending artery).


History of Present Illness:
This is a 74 year old male with a six month history of worsening
dyspnea on exertion. Several weeks prior to admission, he
admitted to rapid decrease in exercise capacity. For several
years, he had used two pillows for sleep. He has no history of
chest pain or PND. On [**6-6**], he presented to his
cardiologist with the above complaints. Office echocardiogram
showed an LVEF of 15-20%. He was subsequently admitted to [**Hospital 6451**] with congestive heart failure. BNP on admission was
1400. He was diuresed with IV Lasix with improvement in his
shortness of breath. He was stabilized on medical therapy and
transferred to the [**Hospital1 18**] for further evaluation and treatment.

Past Medical History:
Congestive Heart Failure, Hypertension, Hyperlipidemia, Type II
Diabetes Mellitus, Pulmonary Hypertension, Chronic Renal
Insufficiency, History of Atrial Fibrillation, GERD, History of
Urinary Sludge, Prior Tonsillectomy, Hidradenitis Suppurative
s/p Surgery


Social History:
15 pack year history of tobacco. Quit smoking over 25 years ago.
Admits to 3 ETOH drinks per month. Married, lives with spouse.

Family History:
Denies premature coronary disease.

Physical Exam:
PREOP EXAM - Vitals: 137/64, 79, 18, 95% RA
General: WDWN male in no acute distress
HEENT: Oropharynx benign, EOMI
Neck: Supple, no JVD
Lungs: CTA bilaterally
Heart: Regular rate and rhythm, normal s1s2, soft systolic
murmur
Abdomen: Soft, nontender with normoactive bowel sounds
Ext: Warm, no edema
Pulses: 2+ distally
Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal
deficits noted

Pertinent Results:
[**2152-6-7**] 10:20AM BLOOD WBC-6.8 RBC-3.99* Hgb-12.5* Hct-36.9*
MCV-93 MCH-31.5 MCHC-34.0 RDW-14.6 Plt Ct-264
[**2152-6-7**] 10:20AM BLOOD PT-13.9* PTT-28.4 INR(PT)-1.2*
[**2152-6-7**] 10:20AM BLOOD Glucose-147* UreaN-20 Creat-1.3* Na-140
K-3.6 Cl-105 HCO3-23 AnGap-16
[**2152-6-7**] 10:20AM BLOOD ALT-18 AST-19 AlkPhos-84 TotBili-0.9
[**2152-6-7**] 10:20AM BLOOD Albumin-4.3 Cholest-133
[**2152-6-7**] 10:20AM BLOOD %HbA1c-6.2*
[**2152-6-7**] 10:20AM BLOOD Triglyc-115 HDL-31 CHOL/HD-4.3 LDLcalc-79
[**2152-6-7**] Cardiac Catheterization
1.  Coronary angiography in this right-dominant system revealed
three-vessel disease:
--the LMCA had no angiographically apparent disease.
--the LAD had diffuse 80% stenosis in its mid-portion.  D1 was a
very
large vessel wrapping around the lateral wall, with an ostial
80%
stenosis.
--the LCX had an 80% proximal stenosis
--the RCA was occluded in its mid-portion and fills by
right-to-right
and left-to-right collaterals.
2.  Resting hemodynamics revealed elevated right- and left-sided
filling
pressures with RVEDP 10 mmHg and LVEDP 26 mmHg.  There was
moderate
pulmonary arterial hypertension with PASP 59 mmHg.  The cardiac
output
was low-normal with CI 2.1 L/min/m2.  The PCWP was elevated at
26 mmHg.
There was mild systemic arterial systolic hypertension with SBP
145
mmHg.  There was no gradient across the aortic valve upon
pullback of
the angled pigtail catheter from LV to ascending aorta.
[**2152-6-8**] Carotid Ultrasound: Bilateral less than 40% carotid
stenosis.
[**2152-6-8**] Echocardiogram: Left ventricular wall thicknesses are
normal. The left ventricular cavity is moderately dilated. There
is severe regional left ventricular systolic dysfunction with
near-akinesis of the inferior/inferolateral walls. There is
moderate-to-severe hypokinesis of the remaining segments (LVEF =
20%). No masses or thrombi are seen in the left ventricle. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.


Brief Hospital Course:
Mr. [**Known lastname **] was admitted under cardiology and [**Known lastname 1834**] cardiac
catheterization which revealed severe three vessel coronary
artery disease with moderate to severe pulmonary
hypertension(see result section). Cardiac surgery was consulted
and further evaluation was performed. Carotid ultrasound found
no significant disease of the internal carotid arteries. Repeat
echocardiogram was notable for an LVEF of 20% with mild mitral
regurgitation(see result section). Post catheterization, he had
a slight decline in renal function and his ACE inhibitor was
discontinued. His preoperative creatinine peaked to 1.7.
Creatinine just prior to surgery was 1.5. Preoperative course
was also notable for bouts of paroxysmal atrial
fibrillation/flutter for which he was maintained on intravenous
Heparin.

On [**6-14**], Mr. [**Known lastname **] [**Last Name (Titles) 1834**] coronary artery bypass
grafting and a mitral valve repair by Dr. [**Last Name (STitle) **]. For surgical
details, please see separate dictated operative note. Following
the operation, he was brought to the CVICU for invasive
monitoring. On postoperative day one, sedation was weaned and he
was extubated. However, due to severe agitation and confusion
associated with atrial fibrillation and low mixed venous
saturations, he was electively reintubated. While intubated and
sedated, cardioversion was performed but unsuccessful. He was
also given several units of PRBCs. On postoperative day three,
he self-extubated. He did not required reintubation but was
initially maintained on 100% shovel mask. Despite medical
therapy and multiple cardioversions, he continued to experience
atrial fibrillation. Given atrial fibrillation, he was
eventually started on Amiodarone and Warfarin. He temporarily
required a Heparin bridge. Postoperative renal function remained
relatively stable. His confusion and agitation gradually
improved with use of haldol. On [**2152-6-20**], Mr. [**Known lastname **] was
transferred to the step down unit for further recovery. He
continued to be gently diuresed towards his preoperative weight.
The physical therapy service worked with him daily to increase
his strength and mobility. Keflex was started for mild
incisional erythema. An ace inhibitor was started given his low
preoperative ejection fraction. Mr. [**Known lastname **] continued to make
steady progress and was discharged to Baypoint of [**Hospital1 1474**]. Dr. [**Name (NI) 38327**] coumadin clinic will assume management of his coumadin
dosing after discharge from rehabilitation. His goal INR is
2.0-2.5. He will also follow-up with Dr. [**Last Name (STitle) **] and Dr.
[**Last Name (un) **]. Amiodarone will be tapered to 200mg once daily.

Medications on Admission:
Aspirin 325 qd, Zestril 20 qd, Toprol XL 50 qd, Lasix, KCL,
Nexium 40 qd, Plavix Load of 600mg

Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
5. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 5 days.
6. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.

7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Warfarin 1 mg Tablet Sig: Adjust for goal INR 2.0-2.5 Tablets
PO DAILY (Daily): Adjust dose for goal INR of 2.0-2.5.
10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10
days.
11. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO once a day for 10 days:
Take with lasix and stop when/if lasix stopped.
12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): Take amiodarone 400mg twice daily for 2 more days.
Starting [**2152-6-26**], take 400mg once daily for 7 days and then
decrease to 200mg once daily therafter until seen by Dr.
[**Last Name (STitle) 7047**]. .
13. Senna Lax 8.6 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for constipation.
14. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
15. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
16. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Extended Care

Facility:
Baypointe - [**Hospital1 1474**]

Discharge Diagnosis:
Primary: Coronary Artery Disease, Mitral Regurgitation, Acute on
Chronic Systolic Heart Failure - s/p CABG and MV Repair
Secondary: Postoperative Atrial Fibrillation, Postoperative
Agitation, Hypertension, Hyperlipidemia, Type II Diabetes
Mellitus, Pulmonary Hypertension, Chronic Renal Insufficiency


Discharge Condition:
Stable


Discharge Instructions:
1)  Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2)  Report any fever greater then 100.5.
3)  Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4)  No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry.  Please shower daily.  No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) You are taking coumadin (a blood thinner) for atrial
fibrillation. You goal INR is 2.0-2.5. You coumadin dosing will
be managed by Dr. [**Last Name (STitle) 7047**] and you will need an appointment for
blood draw (PT/INR) when discharged from rhab for coumadin
management. [**Telephone/Fax (1) 8725**]
8) Take amiodarone 400mg twice daily for 2 more days. Starting
[**2152-6-26**], take 400mg once daily for 7 days and then (Starting
[**7-3**])decrease to 200mg once daily therafter until seen by Dr.
[**Last Name (STitle) 7047**].
9) Take lasix and potassium once daily for 10 days. Monitor
electrolytes and replete as needed. Monitor daily weights. Preop
weight 150lbs. You may need continued treatment with lasix but
will be determined per cardiologist or rehab physician.
10) Take Keflex for 5 days for sternal wound erythema.
11) Monitor renal function (BUN/CREAT)given history of chronic
renal insufficieny and currently on Ace and lasix. Preop Creat
1.3. [**6-23**] Creat 1.4.
12) Call with any questions or concerns.

Followup Instructions:
Dr. [**Last Name (STitle) **] in [**5-13**] weeks, call [**Telephone/Fax (1) 170**] for appt
Dr. [**Last Name (STitle) 7047**] in [**3-12**] weeks, call [**Telephone/Fax (1) 8725**] for appt
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 15369**] in [**3-12**] weeks, call [**Telephone/Fax (1) 6699**] for appt

****Coumadin management with Dr. [**Last Name (STitle) 7047**] via his coumadin
clinic. They are aware of patient (contact[**Name (NI) **] [**2152-6-23**]). Please
contact his office when discharged from rehab to schedule PT/INR
draw and appointment for coumadin management.****



Completed by:[**2152-6-23**]
{'Mitral valve disorders,Acute on chronic systolic heart failure,Delirium due to conditions classified elsewhere,Paroxysmal ventricular tachycardia,Acute kidney failure, unspecified,Coronary atherosclerosis of native coronary artery,Other chronic pulmonary heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Esophageal reflux,Encounter for therapeutic drug monitoring,Long-term (current) use of anticoagulants,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in residential institution,Unspecified acquired hypothyroidism,Hidradenitis,Personal history of tobacco 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: Shortness of breath

PRESENT ILLNESS: This is a 74 year old male with a six month history of worsening
dyspnea on exertion. Several weeks prior to admission, he
admitted to rapid decrease in exercise capacity. For several
years, he had used two pillows for sleep. He has no history of
chest pain or PND. On [**6-6**], he presented to his
cardiologist with the above complaints. Office echocardiogram
showed an LVEF of 15-20%. He was subsequently admitted to [**Hospital 6451**] with congestive heart failure. BNP on admission was
1400. He was diuresed with IV Lasix with improvement in his
shortness of breath. He was stabilized on medical therapy and
transferred to the [**Hospital1 18**] for further evaluation and treatment.

MEDICAL HISTORY: Congestive Heart Failure, Hypertension, Hyperlipidemia, Type II
Diabetes Mellitus, Pulmonary Hypertension, Chronic Renal
Insufficiency, History of Atrial Fibrillation, GERD, History of
Urinary Sludge, Prior Tonsillectomy, Hidradenitis Suppurative
s/p Surgery

MEDICATION ON ADMISSION: Aspirin 325 qd, Zestril 20 qd, Toprol XL 50 qd, Lasix, KCL,
Nexium 40 qd, Plavix Load of 600mg

ALLERGIES: Dilaudid

PHYSICAL EXAM: PREOP EXAM - Vitals: 137/64, 79, 18, 95% RA
General: WDWN male in no acute distress
HEENT: Oropharynx benign, EOMI
Neck: Supple, no JVD
Lungs: CTA bilaterally
Heart: Regular rate and rhythm, normal s1s2, soft systolic
murmur
Abdomen: Soft, nontender with normoactive bowel sounds
Ext: Warm, no edema
Pulses: 2+ distally
Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal
deficits noted

FAMILY HISTORY: Denies premature coronary disease.

SOCIAL HISTORY: 15 pack year history of tobacco. Quit smoking over 25 years ago.
Admits to 3 ETOH drinks per month. Married, lives with spouse. 

### Response:
{'Mitral valve disorders,Acute on chronic systolic heart failure,Delirium due to conditions classified elsewhere,Paroxysmal ventricular tachycardia,Acute kidney failure, unspecified,Coronary atherosclerosis of native coronary artery,Other chronic pulmonary heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Esophageal reflux,Encounter for therapeutic drug monitoring,Long-term (current) use of anticoagulants,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in residential institution,Unspecified acquired hypothyroidism,Hidradenitis,Personal history of tobacco use'}
