CHIEF COMPLAINT: Dyspnea on exertion

PRESENT ILLNESS: 64 year old woman with known rheumatic heart disease.
She has been more symptomatic lately, complaining of worsening
dyspnea on exertion and fatigue. Her most recent echocardiogram
showed severe aortic stenosis and regurgitation, moderate mitral
regurgitation with moderate to severe stenosis. She presents
today for surgical evaluation. In addition to her progressive
DOE, she also admits to two pillow orthopnea, persistent pedal
edema and intermittent palpitations. She denies chest pain,
syncope, and pre-syncope. It appears she has marked limitation
with routine ADL's.

MEDICAL HISTORY: Past Medical History
- Rheumatic Heart Disease, Chronic Diastolic Heart Failure
- Hypertension
- Dyslipidemia
- History of Asthma
- Hypothyroidism
- Anxiety
- Morbid Obesity
- Scattered pulmonary nodules on recent CT scan, ?sarcoidosis
- Eczema
Past Surgical History
- Bariatric surgery, 4 years ago

MEDICATION ON ADMISSION: Simvastatin 10mg daily,
Lasix 40mg twice daily,
Levothyroxine 75mcg daily,
Atenolol 25mg daily,
Flovent 220mcg prn,
Lorazepam prn,
Vitamin D and
Vitamin B12,
Omega 3,
Fish Oils

ALLERGIES: NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / propoxyphene

PHYSICAL EXAM: Admission:
Pulse: 64  Resp: 16   O2 sat: 99% room air
B/P  Right: 154/55   Left: 123/52
Height: 64 inches    Weight: approx 230 lbs per patient
General: Obese female in no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI []
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] - mixed diastolic and
systolic murmurs noted throughout precordium
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x]
Extremities: Warm [x], well-perfused [x]
Edema: 1+ bilaterally
Varicosities: Significant spider veins noted. Bilateral GSV
difficult to assess secondary to morbid obesity. No obvious
varicosities noted.
Neuro: Grossly intact [x]
Pulses:
Femoral      Right: 1+  Left: 1+
DP           Right: 1  Left: 1
PT           [**Name (NI) 167**]: 1  Left: 1
Radial       Right: 2  Left: 2
Carotid Bruit: transmitted murmurs bilaterally
Discharge:
 99.3   68 SR   132/86   18   94%-RA
Gen NAD
CV RRR, no murmur. Sternum stable -incision CDI
Pulm diminished in bases otherwise CTA
Abdm obese-soft, NT/ND/+BS
Ext warm 1+ bilat LE

FAMILY HISTORY: Family History: Denies premature coronary artery disease. Mother
had valve surgery in her 70's. Father had CABG in his 70's.

SOCIAL HISTORY: Race: Caucasian
Last Dental Exam: more than 6 months ago
Lives with: Sister
Occupation: Retired
Cigarettes: Denies
ETOH: Rare
Illicit drug use: Denies
Multiple involvement of mitral and aortic valves,Chronic diastolic heart failure,Atrial fibrillation,Asthma, unspecified type, unspecified,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Anxiety state, unspecified,Morbid obesity,Bariatric surgery status
Mitr/aortic mult involv,Chr diastolic hrt fail,Atrial fibrillation,Asthma NOS,Hyperlipidemia NEC/NOS,Hypertension NOS,Hypothyroidism NOS,Anxiety state NOS,Morbid obesity,Bariatric surgery status
Admission Date:  [**2154-1-24**]              Discharge Date:   [**2154-1-28**]

Date of Birth:  [**2089-9-11**]             Sex:   F

Service: CARDIOTHORACIC

Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / propoxyphene

Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on exertion

Major Surgical or Invasive Procedure:
1. Aortic valve replacement with a 21-mm St. [**Male First Name (un) 923**] Regent
mechanical valve.  Reference number [**Serial Number **].  Serial number
[**Serial Number 91977**].
2. Mitral valve replacement with a 29-mm St. [**Male First Name (un) 923**] mechanical
valve.  Reference number [**Serial Number 91951**].  Serial number [**Serial Number 91978**].
3. Pericardial reconstruction with core matrix product.
Reference number [**Serial Number 42232**].  Lot number [**Serial Number 42233**]


History of Present Illness:
64 year old woman with known rheumatic heart disease.
She has been more symptomatic lately, complaining of worsening
dyspnea on exertion and fatigue. Her most recent echocardiogram
showed severe aortic stenosis and regurgitation, moderate mitral
regurgitation with moderate to severe stenosis. She presents
today for surgical evaluation. In addition to her progressive
DOE, she also admits to two pillow orthopnea, persistent pedal
edema and intermittent palpitations. She denies chest pain,
syncope, and pre-syncope. It appears she has marked limitation
with routine ADL's.


Past Medical History:
Past Medical History
- Rheumatic Heart Disease, Chronic Diastolic Heart Failure
- Hypertension
- Dyslipidemia
- History of Asthma
- Hypothyroidism
- Anxiety
- Morbid Obesity
- Scattered pulmonary nodules on recent CT scan, ?sarcoidosis
- Eczema
Past Surgical History
- Bariatric surgery, 4 years ago


Social History:
Race: Caucasian
Last Dental Exam: more than 6 months ago
Lives with: Sister
Occupation: Retired
Cigarettes: Denies
ETOH: Rare
Illicit drug use: Denies


Family History:
Family History: Denies premature coronary artery disease. Mother
had valve surgery in her 70's. Father had CABG in his 70's.


Physical Exam:
Admission:
Pulse: 64  Resp: 16   O2 sat: 99% room air
B/P  Right: 154/55   Left: 123/52
Height: 64 inches    Weight: approx 230 lbs per patient
General: Obese female in no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI []
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] - mixed diastolic and
systolic murmurs noted throughout precordium
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x]
Extremities: Warm [x], well-perfused [x]
Edema: 1+ bilaterally
Varicosities: Significant spider veins noted. Bilateral GSV
difficult to assess secondary to morbid obesity. No obvious
varicosities noted.
Neuro: Grossly intact [x]
Pulses:
Femoral      Right: 1+  Left: 1+
DP           Right: 1  Left: 1
PT           [**Name (NI) 167**]: 1  Left: 1
Radial       Right: 2  Left: 2
Carotid Bruit: transmitted murmurs bilaterally
Discharge:
 99.3   68 SR   132/86   18   94%-RA
Gen NAD
CV RRR, no murmur. Sternum stable -incision CDI
Pulm diminished in bases otherwise CTA
Abdm obese-soft, NT/ND/+BS
Ext warm 1+ bilat LE

Pertinent Results:
Admission:
[**2154-1-24**] 07:40AM   HGB-12.0 calcHCT-36
[**2154-1-24**] 12:32PM   FIBRINOGE-188
[**2154-1-24**] 12:32PM   PT-14.5* PTT-27.3 INR(PT)-1.4*
[**2154-1-24**] 12:32PM   PLT COUNT-134*
[**2154-1-24**] 12:32PM   WBC-14.6*# RBC-3.10* HGB-9.0* HCT-27.4*
MCV-89 MCH-28.9 MCHC-32.6 RDW-14.2
[**2154-1-24**] 02:43PM   UREA N-22* CREAT-1.0 SODIUM-142 POTASSIUM-3.6
CHLORIDE-111* TOTAL CO2-25 ANION GAP-10
Discharge:
[**2154-1-27**] 05:06AM BLOOD WBC-10.4 RBC-3.70* Hgb-10.7* Hct-32.9*
MCV-89 MCH-28.9 MCHC-32.6 RDW-14.4 Plt Ct-134*
[**2154-1-28**] 04:54AM BLOOD PT-27.1* INR(PT)-2.6*
[**2154-1-27**] 05:53AM BLOOD PT-54.2* INR(PT)-5.4*
[**2154-1-26**] 04:18AM BLOOD PT-19.3* INR(PT)-1.8*
[**2154-1-28**] 04:54AM BLOOD UreaN-29* Creat-1.1 Na-137 K-3.9 Cl-103
[**2154-1-28**] 04:54AM BLOOD Mg-2.0

Radiology Report CHEST (PA & LAT) Study Date of [**2154-1-28**] 3:47 PM

Final Report
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Mild left pleural effusion, no noticeable right pleural
effusion.
Low lung volumes, areas of bilateral atelectasis. Status post
CABG and
valvular replacement. Right internal jugular vein catheter.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]

[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results  Measurements  Normal Range
Left Atrium - Four Chamber Length:  *5.3 cm  <= 5.2 cm
Right Atrium - Four Chamber Length:  4.7 cm  <= 5.0 cm
Left Ventricle - Septal Wall Thickness:  0.9 cm  0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness:  1.0 cm  0.6 - 1.1 cm

Left Ventricle - Diastolic Dimension:  *6.0 cm  <= 5.6 cm
Left Ventricle - Ejection Fraction:  55% to 60%  >= 55%
Left Ventricle - Stroke Volume:  104 ml/beat
Left Ventricle - Cardiac Output:  5.63 L/min
Left Ventricle - Cardiac Index:  2.75  >= 2.0 L/min/M2
Aorta - Annulus:  2.2 cm  <= 3.0 cm
Aorta - Sinus Level:  2.7 cm  <= 3.6 cm
Aorta - Sinotubular Ridge:  2.8 cm  <= 3.0 cm
Aorta - Ascending:  *4.2 cm  <= 3.4 cm
Aorta - Arch:  2.5 cm  <= 3.0 cm
Aorta - Descending Thoracic:  2.4 cm  <= 2.5 cm
Aortic Valve - Peak Velocity:  *4.6 m/sec  <= 2.0 m/sec
Aortic Valve - Peak Gradient:  *83 mm Hg  < 20 mm Hg
Aortic Valve - Mean Gradient:  40 mm Hg
Aortic Valve - LVOT pk vel:  1.40 m/sec
Aortic Valve - LVOT VTI:  41
Aortic Valve - LVOT diam:  1.8 cm
Aortic Valve - Valve Area:  *0.7 cm2  >= 3.0 cm2
Mitral Valve - Peak Velocity:  2.2 m/sec
Mitral Valve - Mean Gradient:  8 mm Hg
Mitral Valve - Pressure Half Time:  186 ms
Mitral Valve - MVA (P [**12-17**] T):  1.7 cm2
Findings
LEFT ATRIUM: No spontaneous echo contrast in the body of the [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **] LAA. Depressed LAA emptying velocity (<0.2m/s) No thrombus in
the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness. Moderately
dilated LV cavity. Normal regional LV systolic function. Overall
normal LVEF (>55%).
RIGHT VENTRICLE: Borderline normal RV systolic function.
AORTA: Normal aortic diameter at the sinus level. Mildly dilated
ascending aorta. No atheroma in ascending aorta. Normal aortic
arch diameter. No atheroma in aortic arch. Normal descending
aorta diameter.
AORTIC VALVE: Severely thickened/deformed aortic valve leaflets.
Critical AS (area <0.8cm2). Severe (4+) AR.
MITRAL VALVE: Severely thickened/deformed mitral valve leaflets.
Characteristic rheumatic deformity of the mitral valve leaflets
with fused commissures and tethering of leaflet motion. Severe
mitral annular calcification. Moderate valvular MS (MVA
1.0-1.5cm2) Moderate (2+) MR.
TRICUSPID VALVE: Moderate [2+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Mild PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Written informed consent was obtained from the
patient. The patient was under general anesthesia throughout the
procedure. No TEE related complications. The patient appears to
be in sinus rhythm. Results were personally reviewed with the MD
caring for the patient. See Conclusions for post-bypass data
Conclusions
PRE-BYPASS: No spontaneous echo contrast is seen in the body of
the left atrium or left atrial appendage. The left atrial
appendage emptying velocity is depressed (<0.2m/s). No thrombus
is seen in the left atrial appendage. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity is moderately dilated.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). with
borderline normal free wall function. The ascending aorta is
mildly dilated. The aortic valve leaflets are severely
thickened/deformed. There is critical aortic valve stenosis
(valve area <0.8cm2). Severe (4+) aortic regurgitation is seen.
The mitral valve leaflets are severely thickened/deformed. The
mitral valve shows characteristic rheumatic deformity. There is
severe mitral annular calcification. There is moderate valvular
mitral stenosis (area 1.0-1.5cm2). Moderate (2+) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is no pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified
in person of the results at time of surgery.
POST-BYPASS: The patient is in sinus rhythm. The patient is on
no inotropes. Right ventricular function is unchanged. Left
ventricular function is mildly depressed, with hypokinesis of
the basal inferior and inferoseptal walls. LVEF = 45 - 50%.
There is a well-seated, well-functioning mechanical valve in the
mitral position. Characteristic washing jets are seen. No mitral
regurgitation is seen. There is a mean gradient of 3 mmHg
through the valve at a cardiac output of 5.1 L/min. There is a
well-seated, well-functioning mechanical valve in the aortic
position. No aortic regurgitation is seen. There is a mean
gradient of 8 mmHg across the aortic valve at a cardiac output
of 5.5 L/min. The aorta is intact post-decannulation.
  I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 15425**] [**Name8 (MD) 15426**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2154-1-28**] 14:04


Brief Hospital Course:
Ms [**Known lastname **] was a same day admission to the operating room for
aortic and mitral valve surgery with Dr [**Last Name (STitle) 914**] on [**2154-1-23**].
Please see operative report for details, in summmary she had:
1. Aortic valve replacement with a 21-mm St. [**Male First Name (un) 923**] Regent
mechanical valve.  Reference number [**Serial Number **].  Serial number
[**Serial Number 91977**].
2. Mitral valve replacement with a 29-mm St. [**Male First Name (un) 923**] mechanical
valve.  Reference number [**Serial Number 91951**].  Serial number [**Serial Number 91978**].
3. Pericardial reconstruction with core matrix product.
Reference number [**Serial Number 42232**].  Lot number [**Serial Number 42233**].
Her CARDIOPULMONARY BYPASS TIME was 144 minutes, with a
CROSS-CLAMP TIME of 112 minutes. She tolerated the operation
well and post-operatively was transferred to the cardiac surgery
ICU in stable condition. In the immediate post-op period she was
hemodynamically stable, she woke neurologically intact and was
extubated. On POD1 she remained hemodynamically stable, she was
started on Bblockers and diuretics and  was transferred to the
stepdown floor. All tubes lines and drains were removed per
cardiac surgery protocol.
Once on the floor the patient was noted to have atrial
fibrillation which was treated with increased Bblockers,
amiodarone and she was started on anticoagulation.
The remainder of her hospital course was uneventful. She worked
with nursing and physical therapy to improve her strength and
mobility. On POD4 she was cleared for discharge home with
visiting nurses. She is to follow up w/Dr [**Last Name (STitle) **] in 1 month.

Medications on Admission:
Simvastatin 10mg daily,
Lasix 40mg twice daily,
Levothyroxine 75mcg daily,
Atenolol 25mg daily,
Flovent 220mcg prn,
Lorazepam prn,
Vitamin D and
Vitamin B12,
Omega 3,
Fish Oils

Discharge Medications:
1. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours).
Disp:*120 Tablet Extended Release(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
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:*2*
4. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
7. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. cyanocobalamin (vitamin B-12) 250 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. omega-3 fatty acids     Capsule Sig: One (1) Capsule PO
DAILY (Daily).
11. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
12. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for anxiety.
13. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
14. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
15. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
16. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 5days then 400mg daily x7days then 200mg
daily.
Disp:*60 Tablet(s)* Refills:*1*
17. warfarin 2 mg Tablet Sig: as directed by Dr [**Last Name (STitle) 60967**] Tablet PO
once a day: target INR 2-2.5.
Disp:*75 Tablet(s)* Refills:*2*
18. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
19. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day for 2
doses: take 2 mg coumadin on [**1-28**] and [**1-29**] then as directed by
Dr [**Last Name (STitle) 60967**].


Discharge Disposition:
Home With Service

Facility:
[**Company 1519**]

Discharge Diagnosis:
s/p [**First Name8 (NamePattern2) 6158**] [**Male First Name (un) 923**] Regent [**Male First Name (un) **] AVR/ [**First Name8 (NamePattern2) 44058**] [**First Name4 (NamePattern1) 923**] [**Last Name (NamePattern1) **] MVR
PMH:
Rheumatic Heart Disease,
Chronic Diastolic Heart Failure
Hypertension
Dyslipidemia
Asthma
Hypothyroidism
Anxiety
Morbid Obesity
Scattered pulmonary nodules on recent CT scan,
?sarcoidosis
Eczema,
Bariatric surgery 4 years ago


Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Edema 1+ bilat LE


Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
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**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**


Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**] on [**2154-2-25**] @1PM [**Telephone/Fax (1) 1504**]
Cardiologist: Dr [**First Name (STitle) **] [**Name (STitle) 2257**] office will call in 1 week
Wound check [**2-5**] @10:15 [**Telephone/Fax (1) 1504**]

Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) **],[**First Name3 (LF) **] B. [**Telephone/Fax (1) 2573**] in [**3-21**] 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 for Coumadin ?????? indication Atrial Fibrillation
Goal INR 2-2.5
First draw [**1-30**]
Results to phone [**Last Name (LF) **],[**First Name3 (LF) **] B. [**Telephone/Fax (1) 2573**]/Atrius



Completed by:[**2154-1-28**]
{'Multiple involvement of mitral and aortic valves,Chronic diastolic heart failure,Atrial fibrillation,Asthma, unspecified type, unspecified,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Anxiety state, unspecified,Morbid obesity,Bariatric surgery status'}


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: 64 year old woman with known rheumatic heart disease.
She has been more symptomatic lately, complaining of worsening
dyspnea on exertion and fatigue. Her most recent echocardiogram
showed severe aortic stenosis and regurgitation, moderate mitral
regurgitation with moderate to severe stenosis. She presents
today for surgical evaluation. In addition to her progressive
DOE, she also admits to two pillow orthopnea, persistent pedal
edema and intermittent palpitations. She denies chest pain,
syncope, and pre-syncope. It appears she has marked limitation
with routine ADL's.

MEDICAL HISTORY: Past Medical History
- Rheumatic Heart Disease, Chronic Diastolic Heart Failure
- Hypertension
- Dyslipidemia
- History of Asthma
- Hypothyroidism
- Anxiety
- Morbid Obesity
- Scattered pulmonary nodules on recent CT scan, ?sarcoidosis
- Eczema
Past Surgical History
- Bariatric surgery, 4 years ago

MEDICATION ON ADMISSION: Simvastatin 10mg daily,
Lasix 40mg twice daily,
Levothyroxine 75mcg daily,
Atenolol 25mg daily,
Flovent 220mcg prn,
Lorazepam prn,
Vitamin D and
Vitamin B12,
Omega 3,
Fish Oils

ALLERGIES: NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / propoxyphene

PHYSICAL EXAM: Admission:
Pulse: 64  Resp: 16   O2 sat: 99% room air
B/P  Right: 154/55   Left: 123/52
Height: 64 inches    Weight: approx 230 lbs per patient
General: Obese female in no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI []
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] - mixed diastolic and
systolic murmurs noted throughout precordium
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x]
Extremities: Warm [x], well-perfused [x]
Edema: 1+ bilaterally
Varicosities: Significant spider veins noted. Bilateral GSV
difficult to assess secondary to morbid obesity. No obvious
varicosities noted.
Neuro: Grossly intact [x]
Pulses:
Femoral      Right: 1+  Left: 1+
DP           Right: 1  Left: 1
PT           [**Name (NI) 167**]: 1  Left: 1
Radial       Right: 2  Left: 2
Carotid Bruit: transmitted murmurs bilaterally
Discharge:
 99.3   68 SR   132/86   18   94%-RA
Gen NAD
CV RRR, no murmur. Sternum stable -incision CDI
Pulm diminished in bases otherwise CTA
Abdm obese-soft, NT/ND/+BS
Ext warm 1+ bilat LE

FAMILY HISTORY: Family History: Denies premature coronary artery disease. Mother
had valve surgery in her 70's. Father had CABG in his 70's.

SOCIAL HISTORY: Race: Caucasian
Last Dental Exam: more than 6 months ago
Lives with: Sister
Occupation: Retired
Cigarettes: Denies
ETOH: Rare
Illicit drug use: Denies 

### Response:
{'Multiple involvement of mitral and aortic valves,Chronic diastolic heart failure,Atrial fibrillation,Asthma, unspecified type, unspecified,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Anxiety state, unspecified,Morbid obesity,Bariatric surgery status'}
