CHIEF COMPLAINT: pericardial effusion, chest pain

PRESENT ILLNESS: Mr. [**Known lastname 6515**] is a 37yo male with PMH s/f recent porcine AVR for
congenital bicuspid valve who is now being tranferred from and
OSH ED for evaluation for pericardial tamponade. Patient reports
having had a congenital bicuspid aortic valve repaired on
[**2197-11-21**]. There were no immediate complications of the surgery
although patient was noted to have two small PE's around time of
the surgery. Following the procedure he was maintained on
coumadin and aspirin with a goal INR of 2.5-3.5 (despite aortic
porcine valve). Patient had been in good health, although
tending to run high by INR since the surgery until this weekend
when he developed bilateral shoulder pain. He describes the pain
as very similar to a muscle aches, and that it radiates down
into his chest. Occasionally has radiated to the back as well.
Is pleuritic, but not exertional. This morning patient noted
marked exertional dyspnea with an exercise limitation of 20-30
yards which prompted him to present to the [**Hospital1 2436**] ED.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: (+)Hypertension
2. CARDIAC HISTORY:
-Bicuspid Aortic Valve Repair [**11/2197**]
-CABG: None.
-PERCUTANEOUS CORONARY INTERVENTIONS: None.
-PACING/ICD: None.
Additional PMH
-Pulmonary Emboli x 2 at time of surgery

MEDICATION ON ADMISSION: Metoprolol XL 50mg daily
Aspirin 81mg daily
Coumadin 5mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T97.8, 134/83, HR 103, 20, 100%2L, Pulsus 16-18mmHg
GENERAL: WDWN male 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.

FAMILY HISTORY: Father with CABG in his late 50's
Paternal GF and PGM w/ CABG in 60's. Mother died last month of
breast cancer. No h/o valvular disease. 3 healthy brothers

SOCIAL HISTORY: Moved from [**State 33977**] to [**Location (un) 86**] 1 year ago for work, he works for
Cintas uniform company.
-Tobacco history: chews 2 pack per day equivalent
-ETOH: social
-Illicit drugs: denies
Hemopericardium,Acute posthemorrhagic anemia,Anticoagulants causing adverse effects in therapeutic use,Heart valve replaced by transplant,Long-term (current) use of anticoagulants,Unspecified essential hypertension,Personal history of venous thrombosis and embolism
Hemopericardium,Ac posthemorrhag anemia,Adv eff anticoagulants,Heart valve transplant,Long-term use anticoagul,Hypertension NOS,Hx-ven thrombosis/embols
Admission Date:  [**2198-1-9**]              Discharge Date:   [**2198-1-11**]

Date of Birth:  [**2160-8-4**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
pericardial effusion, chest pain

Major Surgical or Invasive Procedure:
Pericardiocentesis with drain placement


History of Present Illness:
Mr. [**Known lastname 6515**] is a 37yo male with PMH s/f recent porcine AVR for
congenital bicuspid valve who is now being tranferred from and
OSH ED for evaluation for pericardial tamponade. Patient reports
having had a congenital bicuspid aortic valve repaired on
[**2197-11-21**]. There were no immediate complications of the surgery
although patient was noted to have two small PE's around time of
the surgery. Following the procedure he was maintained on
coumadin and aspirin with a goal INR of 2.5-3.5 (despite aortic
porcine valve). Patient had been in good health, although
tending to run high by INR since the surgery until this weekend
when he developed bilateral shoulder pain. He describes the pain
as very similar to a muscle aches, and that it radiates down
into his chest. Occasionally has radiated to the back as well.
Is pleuritic, but not exertional. This morning patient noted
marked exertional dyspnea with an exercise limitation of 20-30
yards which prompted him to present to the [**Hospital1 2436**] ED.

Patient initially seen at [**Hospital3 2783**] where VS were T98,
Bp 100/77, HR 136, RR 24, O2 sat 99%RA. Labs notable for anemia,
and INR 6.8. Bedside USD at that time showed no RV collapse and
ECG interpreted as nml (although shows electrical alternans). CT
chest showed no dissection but large pericardial effusion.
Impression was for pericarditis. Patient was given IVF bolus to
prevent progression to tamponade and transferred to [**Hospital1 18**] for
further evaluation

In the ED, initial vitals were: T98.2, HR 112, BP 121/83, RR 16,
O2 sat 100%RA. Exam notable for clear lungs, tachycardia. Labs
notable for Hct 28. CT A/P showed no RP bleed, but large
pericardial effusion. Bedside Echo showed some RV collapse.
Cards consulted as well as Cardiac Surgery. In the ED was given
4mg morphine IV, 10 units vitamin K, 2 units FFP and admitted to
[**Hospital Unit Name 196**] for management.

On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. He denies recent fevers, chills or rigors, sick
contacts, muscle aches, or other complaints. He denies
exertional buttock or calf pain. All of the other review of
systems were negative.

Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.


Past Medical History:
1. CARDIAC RISK FACTORS: (+)Hypertension
2. CARDIAC HISTORY:
-Bicuspid Aortic Valve Repair [**11/2197**]
-CABG: None.
-PERCUTANEOUS CORONARY INTERVENTIONS: None.
-PACING/ICD: None.
Additional PMH
-Pulmonary Emboli x 2 at time of surgery


Social History:
Moved from [**State 33977**] to [**Location (un) 86**] 1 year ago for work, he works for
Cintas uniform company.
-Tobacco history: chews 2 pack per day equivalent
-ETOH: social
-Illicit drugs: denies


Family History:
Father with CABG in his late 50's
Paternal GF and PGM w/ CABG in 60's. Mother died last month of
breast cancer. No h/o valvular disease. 3 healthy brothers


Physical Exam:
VS: T97.8, 134/83, HR 103, 20, 100%2L, Pulsus 16-18mmHg
GENERAL: WDWN male 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 [**1-22**] cm.
CARDIAC: RR, normal S1, S2. No m/g. No thrills, lifts. No S3 or
S4. Rub noted w/ausculatation, more prominent along left border.

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. Mild TTP in epigastrum/RUQ. Abd
aorta not enlarged by palpation.
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+


Pertinent Results:
ADMISSION LABS:
[**2198-1-8**] 08:40PM WBC-6.2 Hgb-8.9* Hct-28.2* Plt Ct-384
[**2198-1-8**] 08:40PM Neuts-59.6 Lymphs-33.0 Monos-5.7 Eos-1.4
Baso-0.3
[**2198-1-8**] 08:40PM PT-56.4* PTT-37.5* INR(PT)-6.3*
[**2198-1-8**] 08:40PM Glucose-91 UreaN-22* Creat-1.1 Na-138 K-4.2
Cl-103 HCO3-25 AnGap-14
[**2198-1-8**] 08:40PM CK(CPK)-72
[**2198-1-8**] 08:40PM CK-MB-NotDone
[**2198-1-8**] 08:40PM cTropnT-<0.01

OTHER PERTINENT LABS
[**2198-1-9**] 06:46AM Iron-15*
[**2198-1-9**] 06:46AM calTIBC-335 Ferritn-38 TRF-258

[**2198-1-8**] 08:40PM CK(CPK)-72
[**2198-1-9**] 06:46AM CK(CPK)-66
[**2198-1-8**] 08:40PM CK-MB-NotDone cTropnT-<0.01
[**2198-1-9**] 06:46AM CK-MB-NotDone cTropnT-<0.01

[**2198-1-9**] 06:13PM BLOOD ESR-20*

[**2198-1-8**] 08:40PM INR(PT)-6.3*
[**2198-1-9**] 07:42AM INR(PT)-1.8*
[**2198-1-9**] 06:13PM INR(PT)-1.4*
[**2198-1-10**] 03:07AM INR(PT)-1.4*
[**2198-1-11**] 06:10AM INR(PT)-1.4*

MICROBIOLOGY:
[**2198-1-9**] Pericardial effusion Cx: prelim negative

STUDIES:
[**2198-1-8**] ECHO:
There is mild symmetric left ventricular hypertrophy with normal
cavity size. Global left ventricular systolic function is good
(LVEF >40%). The right ventricular cavity is small. There is
dysnchronous septal motion (post-op). A a well-seated
bioprosthetic aortic valve prosthesis is present with mobile
leaflets. No aortic regurgitation is seen. The mitral valve
leaflets are grossly normal without mitral regurgitation. There
is a large circumferential pericardial effusion most prominent
inferior (4.0 cm) and lateral (3.2cm) to the left ventricle, but
also extending anteriorly around the right ventricle and right
atrium. There is right ventricular diastolic collapse,
consistent with impaired fillling/tamponade physiology.

IMPRESSION: Suboptimal image quality. Large circumferential
pericardial effusion with echocardiographic evidence c/w
tamponade physiology. Grossly normal aortic valve bioprosthesis.


[**2198-1-8**] CT abdomen/pelvis:
1. No evidence of retroperitoneal hematoma. Fluid in the abdomen
is of
intermediate attenuation and may represent hemoperitoneum. In
addition,
circumferential gallbladder mural thickening may represent mural
hemorrhage.
2. Large pericardial effusion, unchanged from the recent
comparison.
3. Calcified nodule in the right lower lobe.

[**2198-1-9**] Cardiac cath:
COMMENTS:
1. Hemodynamics revealed elevated pericardial pressure at 25
mmHg.
1050cc of bloody fluid was removed with resolution of effusion
and
tamponade by echocardiogram and normalization of pericardial
pressure.
The pericardial fluid was sent for laboratory studies.

FINAL DIAGNOSIS:
1. Severe pericardial tamponade.

[**2198-1-9**] ECHO:
There is symmetric left ventricular hypertrophy. Overall left
ventricular systolic function is mildly depressed (LVEF= 40-45
%). Right ventricular chamber size and free wall motion are
normal. A bioprosthetic aortic valve prosthesis is present which
was not fully assessed. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. There is a
residual moderate sized pericardial effusion (2 cm) after
drainage of 250 cc of fluid. After removal of 1050 cc of
additional pericardial fluid, there is a residual small
pericardial effusion (0.7 cm). The effusion appears
circumferential. There is brief right atrial diastolic collapse.

Compared with the report of the prior study (images unavailable
for review) of [**2198-1-8**], the pericardial effusion is smaller.


[**2198-1-10**] ECHO:
There is mild symmetric left ventricular hypertrophy. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is mildly depressed (LVEF= XX %). Right ventricular
chamber size and free wall motion are normal. A bioprosthetic
aortic valve prosthesis is present. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is mild pulmonary artery systolic
hypertension. There is a very small pericardial effusion. There
are no echocardiographic signs of tamponade.

Compared with the prior study (images reviewed) of [**2198-1-9**],
left ventricular systolic function appears slightly more
vigorous. The pericardial effusion is now slightly larger.

[**2198-1-11**] ECHO:
The estimated right atrial pressure is 0-5 mmHg. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is mildly dilated. There is mild global left ventricular
hypokinesis (LVEF = 45 %). Right ventricular chamber size and
free wall motion are normal. The aortic root is moderately
dilated at the sinus level. The ascending aorta is moderately
dilated. A bioprosthetic aortic valve prosthesis is present. The
aortic valve prosthesis appears well seated, with normal
leaflet/disc motion and transvalvular gradients. The estimated
pulmonary artery systolic pressure is normal. There is a very
small pericardial effusion.

Compared with the prior study (images reviewed) of [**2198-1-10**],
the size of the pericardial effusion remains very small. The
other findings are similar.

DISCHARGE LABS:
[**2198-1-11**] 06:10AM WBC-3.8* Hgb-8.6* Hct-26.2* Plt Ct-378
[**2198-1-11**] 06:10AM PT-15.6* PTT-25.4 INR(PT)-1.4*
[**2198-1-11**] 06:10AM Glucose-76 UreaN-12 Creat-0.8 Na-143 K-4.7
Cl-109* HCO3-28 AnGap-11
[**2198-1-11**] 06:10AM Calcium-8.7 Phos-3.5 Mg-2.4

Brief Hospital Course:
Mr. [**Known lastname 6515**] is a 37yo male with PMH s/p recent porcine AVR for
congenital bicuspid valve on [**11-21**] who was tranferred from OSH
ED for evaluation for pericardial tamponade. S/p 1050cc drainage
of bloody effusion and drain placement.

#. Pericardial Effusion s/p drain placement: Pt with tamponade
physiology seen on ECHO. He underwent removal of 1050cc of
bloody fluid and drain placement.  There was resolution of the
effusion after drain placement. The patient had a
super-therapeutic INR of 6.8.  Appears patient was on 3 months
of anti-coagulation for following valve vs PE. No history of URI
or infection to indicate viral pericarditis. Likely spontaneous
bleed from anti-coagulation. Repeat ECHOs showed a small amount
of residual effusion. AC was held as there is no clear
indication for it at this time, in addition to the patient's h/o
difficulty controlling INR. The patient should have a repeat
ECHO in [**2-10**] weeks to assess for resolution of pericardial
effusion.

#. s/p AVR with porcine valve: Pt with replacement of valve on
[**11-21**] and placed on anti-coagulation for 3 months. AC with
Coumadin was discontinued. The patient is on ASA 81mg PO daily.

#. Anemia: Hct 26. CT abdomen/pelvis did not show evidence of RP
bleed. Likely spontaneous bleeding from elevated INR. Pt with
>1000cc of bloody fluid removed from pericardium. Iron studies
show iron deficiency. The patient was started on an iron
supplement prior to discharge.

#H/o PEs: 2 PEs seen incidentally on CT chest 2-3 days after his
AVR surgery in [**State 33977**] on [**2197-11-21**].  No evidence of PE seen on
OSH CTA. Pt has been on coumadin since surgery. Coumadin has
been held, as above.


Medications on Admission:
Metoprolol XL 50mg daily
Aspirin 81mg daily
Coumadin 5mg daily

Discharge Medications:
1. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily): Use daily for 6 weeks, then decrease
to 14mg/day patch for 2 weeks. .
Disp:*30 Patch 24 hr(s)* Refills:*1*
2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
5. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain: Take if the Ibuprofen does not take
away the pain. .
Disp:*20 Tablet(s)* Refills:*0*
6. Outpatient Lab Work
Please check CBC on [**1-18**] and call results to Dr. [**Last Name (STitle) 12167**] at
[**Telephone/Fax (1) 56234**]


Discharge Disposition:
Home

Discharge Diagnosis:
Pericardial Effusion
Aortic Valve Disease s/p porcine AVR
Pulmonary Embolus


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


Discharge Instructions:
You had a large collection of blood around your heart that was
likely because your blood was too thin. Your Warfarin has been
stopped and a drain was placed in the space around your heart
that drained the blood. You had another echocardiogram that
showed that the blood has not reaccumulated. You will need
another Echocardiogram in about 2 weeks to check again. This can
be done by Dr. [**Last Name (STitle) 12167**]. You are quite anemic becaues of the
blood loss.
new medicines:
1. Aspirin 81 mg daily: this is for the valve replacement
2. Ferrous sulfate: to help your body make more red blood cells.
3. STOP taking Metoprolol and Warfain
4. Nicotine patch: take 21 mg for 6 weeks, then 14 mg for 2
weeks, then 7 mg for 2 weeks, then stop.
5. Ibuprofen: take as needed for the chest discomfort.
6. Vicodin: take as needed for chest discomfort if the ibuprofen
doesn't work.
.
You should not go back to work until after you see Dr. [**Last Name (STitle) 12167**].


Followup Instructions:
Cardiology:
Dr. [**Last Name (STitle) 12167**] Phone: [**Telephone/Fax (1) 56234**] Date/Time: [**1-26**] at 9:00am.
You will have an echocardiogram on that same date.
Primary Care:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone: ([**Telephone/Fax (1) 84060**] Date/time: Please
keep any regular scheduled appts.
{'Hemopericardium,Acute posthemorrhagic anemia,Anticoagulants causing adverse effects in therapeutic use,Heart valve replaced by transplant,Long-term (current) use of anticoagulants,Unspecified essential hypertension,Personal history of venous thrombosis and embolism'}


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: pericardial effusion, chest pain

PRESENT ILLNESS: Mr. [**Known lastname 6515**] is a 37yo male with PMH s/f recent porcine AVR for
congenital bicuspid valve who is now being tranferred from and
OSH ED for evaluation for pericardial tamponade. Patient reports
having had a congenital bicuspid aortic valve repaired on
[**2197-11-21**]. There were no immediate complications of the surgery
although patient was noted to have two small PE's around time of
the surgery. Following the procedure he was maintained on
coumadin and aspirin with a goal INR of 2.5-3.5 (despite aortic
porcine valve). Patient had been in good health, although
tending to run high by INR since the surgery until this weekend
when he developed bilateral shoulder pain. He describes the pain
as very similar to a muscle aches, and that it radiates down
into his chest. Occasionally has radiated to the back as well.
Is pleuritic, but not exertional. This morning patient noted
marked exertional dyspnea with an exercise limitation of 20-30
yards which prompted him to present to the [**Hospital1 2436**] ED.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: (+)Hypertension
2. CARDIAC HISTORY:
-Bicuspid Aortic Valve Repair [**11/2197**]
-CABG: None.
-PERCUTANEOUS CORONARY INTERVENTIONS: None.
-PACING/ICD: None.
Additional PMH
-Pulmonary Emboli x 2 at time of surgery

MEDICATION ON ADMISSION: Metoprolol XL 50mg daily
Aspirin 81mg daily
Coumadin 5mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T97.8, 134/83, HR 103, 20, 100%2L, Pulsus 16-18mmHg
GENERAL: WDWN male 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.

FAMILY HISTORY: Father with CABG in his late 50's
Paternal GF and PGM w/ CABG in 60's. Mother died last month of
breast cancer. No h/o valvular disease. 3 healthy brothers

SOCIAL HISTORY: Moved from [**State 33977**] to [**Location (un) 86**] 1 year ago for work, he works for
Cintas uniform company.
-Tobacco history: chews 2 pack per day equivalent
-ETOH: social
-Illicit drugs: denies 

### Response:
{'Hemopericardium,Acute posthemorrhagic anemia,Anticoagulants causing adverse effects in therapeutic use,Heart valve replaced by transplant,Long-term (current) use of anticoagulants,Unspecified essential hypertension,Personal history of venous thrombosis and embolism'}
