CHIEF COMPLAINT: Prosthetic Mitral Valve thrombosis

PRESENT ILLNESS: 66 y/o F s/p CVA with hemorrhagic evolution ([**9-26**]) with prior
prosthetic Mitral valve and tricuspid ring transferred from OSH
with MV thrombosis and GI bleed with likely need for Cardiac
surgery.  Approx one month ago, patient was hospitalized for
CVA, receiving TPA which subsequently led to hemorrhagic
conversion of the infarct and worsening neurological status.
During that admission, the patient's coumadin was held and then
restarted prior to discharge to rehab. Pt was admitted on
[**2114-11-1**] at Good [**Hospital 57794**] hospital for a GI bleed after
restarting coumadin upon transfer to rehab.
Upon presentation to the OSH, patient was found to have blood in
her rectal vault. Her coumadin was held and she received IM
Vitamin K for her INR of 1.7 on admission. Her HCT on admission
was 39 and was 29 on transfer from OSH, she did not receive
blood products.
Cardiology was consulted and an echocardiogram was performed.
The echo showed mitral valve thrombosis and acute mtiral
stenosis. Fluroscopy was performed and showed that one of the
[**Last Name (un) 22837**] valve leaflets was immobile. Patient was transferred
initially for cardiac surgery, but was soon deemed to be a poor
candidate in the setting of a GI bleed and recent hemorrhagic
stroke.

MEDICAL HISTORY: - Atrial Fibrillation with multiple failed attempts at
cardioversion
- CAD
- PPM
- Hypothyroidism
s/p CVA with hemorrhagic conversion ([**9-26**])
h/o multiple CVAs in past
h/o GI bleed, unknown etiology.
h/o Anti-cardiolipin antibody
OSA with CPAP

MEDICATION ON ADMISSION: Paxil 30mg [**Hospital1 **]
Wellbutrin qdaily
Klonopin 0.5mg [**Hospital1 **]
Neurontin 300mg TID
Advair 250/50 [**Hospital1 **]
Coreg 3.125mg [**Hospital1 **]
Synthroid 25mcg qdaily
Aricept 5mg qHS
Zocor 40mg qHS
Nexium 40mg IV qdaily
SSI

ALLERGIES: Lasix / Codeine / Ceclor / Keflex / Voltaren / Penicillins

PHYSICAL EXAM: VS: 98.5, 83, 116/58, 71, 21, 98% 2L
GENERAL: 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: Noncontrib

SOCIAL HISTORY: Smokes 1ppd x 36 yrs
Other complications due to heart valve prosthesis,Acute diastolic heart failure,Hemorrhage of gastrointestinal tract, unspecified,Pneumonia, organism unspecified,Mitral valve stenosis and aortic valve stenosis,Unspecified acquired hypothyroidism,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Cardiac pacemaker in situ,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits
Comp-heart valve prosth,Ac diastolic hrt failure,Gastrointest hemorr NOS,Pneumonia, organism NOS,Mitral/aortic stenosis,Hypothyroidism NOS,Atrial fibrillation,Crnry athrscl natve vssl,Status cardiac pacemaker,Hx TIA/stroke w/o resid
Admission Date:  [**2114-11-2**]              Discharge Date:   [**2114-11-5**]

Date of Birth:  [**2048-4-3**]             Sex:   F

Service: MEDICINE

Allergies:
Lasix / Codeine / Ceclor / Keflex / Voltaren / Penicillins

Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Prosthetic Mitral Valve thrombosis

Major Surgical or Invasive Procedure:
None

History of Present Illness:

66 y/o F s/p CVA with hemorrhagic evolution ([**9-26**]) with prior
prosthetic Mitral valve and tricuspid ring transferred from OSH
with MV thrombosis and GI bleed with likely need for Cardiac
surgery.  Approx one month ago, patient was hospitalized for
CVA, receiving TPA which subsequently led to hemorrhagic
conversion of the infarct and worsening neurological status.
During that admission, the patient's coumadin was held and then
restarted prior to discharge to rehab. Pt was admitted on
[**2114-11-1**] at Good [**Hospital 57794**] hospital for a GI bleed after
restarting coumadin upon transfer to rehab.
Upon presentation to the OSH, patient was found to have blood in
her rectal vault. Her coumadin was held and she received IM
Vitamin K for her INR of 1.7 on admission. Her HCT on admission
was 39 and was 29 on transfer from OSH, she did not receive
blood products.
Cardiology was consulted and an echocardiogram was performed.
The echo showed mitral valve thrombosis and acute mtiral
stenosis. Fluroscopy was performed and showed that one of the
[**Last Name (un) 22837**] valve leaflets was immobile. Patient was transferred
initially for cardiac surgery, but was soon deemed to be a poor
candidate in the setting of a GI bleed and recent hemorrhagic
stroke.


Past Medical History:
- Atrial Fibrillation with multiple failed attempts at
cardioversion
- CAD
- PPM
- Hypothyroidism
s/p CVA with hemorrhagic conversion ([**9-26**])
h/o multiple CVAs in past
h/o GI bleed, unknown etiology.
h/o Anti-cardiolipin antibody
OSA with CPAP


Social History:
Smokes 1ppd x 36 yrs

Family History:
Noncontrib

Physical Exam:
VS: 98.5, 83, 116/58, 71, 21, 98% 2L
GENERAL: 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: No JVD
CARDIAC: RRR, prosthetic S1, with loud S2, crescendo-decrescendo
murmur at LUSB
LUNGS: CTAB in anterolateral chest.
ABDOMEN: Soft, NT/ND. No HSM. RLQ TTP.
EXTREMITIES: No c/c/e. No femoral bruits.
Neuro: CN II-X intact. Unable to assess, VII, IX, XII. [**2-21**]
Plantar flexion of L and R LE. [**3-24**] handgrip on R, [**1-23**] on L.
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:
CXR:
FINDINGS: In comparison with the earlier study of this date,
there is
continued elevation of pulmonary venous pressure consistent with
volume
overload. However, more coalescent areas at the left base and
both mid lung zones suggest superimposed multifocal pneumonia.

Tubes remain in place.
The study and the report were reviewed by the staff radiologist.

.
ECHO
The left atrium is dilated. Mild spontaneous echo contrast is
seen in the body of the left atrium. Moderate to severe
spontaneous echo contrast is present in the left atrial
appendage. The left atrial appendage emptying velocity is
depressed (<0.2m/s). A probable thrombus is seen in the tip of
the left atrial appendage. No atrial septal defect is seen by 2D
or color Doppler. There are simple atheroma in the ascending
aorta. There are simple atheroma in the aortic arch. There are
simple atheroma in the descending thoracic aorta up to 35cm from
the incisor. The aortic valve leaflets (3) are moderately
thickened. There is severe aortic valve stenosis (area 0.6cm2 by
planimetry). Trace aortic regurgitation is seen. [Due to
acoustic shadowing, the severity of aortic regurgitation may be
significantly UNDERestimated.] A mechanical mitral valve
prosthesis is present. There is extensive thrombus around the
ring of the prosthesis that measures at least 3.4cm by 1.1cm by
dimension. There is a highly mobile component of the thrombus
that measure 1.9cm x 0.5cm that prolapses through the mitral
valve orifice. The anterior/septal mitral valve leaflet is
completely immobile. The posterior/lateral leaflet moves well.
The gradients across the mitral valve is suggestive of severe
valvular mitral stenosis. A tricuspid valve annuloplasty ring is
present with trace tricuspid regurgitation. There is no
pericardial effusion.

Impression: Extensive thrombus around the mechanical mitral
prosthesis causing severe mitral stenosis. Severe aortic
stenosis (although may be OVERestimated given poor LV function).
Thrombus in the left atrial appendage.


Brief Hospital Course:
This is a 66 year old female with a history of AVR, MVR, atrial
fibrillation and recent stroke w/hemorrhagic conversion who
presented to an OSH with a GI bleed and found to have a new MV
thrombus.  The patient was urgently transferred to [**Hospital1 18**] for the
 treatment of the mitral valve thrombus that was presumed to
have formed since her recent discharge from [**Hospital 7348**] (when her coumadin was held in the setting of a
hemorrhagic conversion of a TPA treated embolic stroke).
Surgery was immediately consulted for possible intervention on
the thrombus, but given her active GI bleed, it was felt she was
not a good surgical candidate.  In addition, thrombolysis was
not an option given her recent stroke and the current GI bleed.

Initially, the patient was started on a heparin gtt to stabilize
the thrombus.  The risks/benefits of this were discussed with
the family at length.  The first few days of her stay, she was
transfused 2 U and GI was consulted.  A TEE was done which
showed a large thrombus overlying the mitral valve.   The
patient had a markedly elevated WBC as well as possible
pneumonia on CXR and was given broad spectrum antibiotics with
Vancomycin and Meropenem ([**1-20**] many drug allergies).  She was
diuresed as well for pulmonary edema.  Over the next 48 hours,
pt continued to have melena and the family (and health care
proxy) decided that the patient would be better served with
comfort measures and hospice care.  Her daughter is the health
care proxy and activated this option.  She was discharged to
hospice with plans to keep oral medications that would assist in
comfort only.  Her antibiotics were discontinued.  She was given
Morphine prn for comfort.


Medications on Admission:
Paxil 30mg [**Hospital1 **]
Wellbutrin qdaily
Klonopin 0.5mg [**Hospital1 **]
Neurontin 300mg TID
Advair 250/50 [**Hospital1 **]
Coreg 3.125mg [**Hospital1 **]
Synthroid 25mcg qdaily
Aricept 5mg qHS
Zocor 40mg qHS
Nexium 40mg IV qdaily
SSI


Discharge Medications:
1. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours) as
needed.
5. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed for PRN.
6. Bumetanide 2 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
9. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
11. Morphine 10 mg Capsule, Sust. Release Pellets Sig: One (1)
Capsule, Sust. Release Pellets PO every four (4) hours as needed
for pain.


Discharge Disposition:
Extended Care

Facility:
Life Care Center of [**Location (un) 5165**]

Discharge Diagnosis:
Mitral Valve Thrombus with acute mitral valve stenosis
Acute diastolic heart failure
Atrial Fibrillation
Lower GI bleed
Pneumonia

Discharge Condition:
Hospice level of care, alert and oriented x3

Discharge Instructions:
You were admitted to the hospital because a clot was found on
your mitral valve.  You also had some evidence of bleeding
coming from your gastrointestinal tract.  On discussion with
your family as well as with you, the decision was made to avoid
invasive procedures.  You were treated with comfort measures and
will continue this at the nursing home.

Followup Instructions:
None
{'Other complications due to heart valve prosthesis,Acute diastolic heart failure,Hemorrhage of gastrointestinal tract, unspecified,Pneumonia, organism unspecified,Mitral valve stenosis and aortic valve stenosis,Unspecified acquired hypothyroidism,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Cardiac pacemaker in situ,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits'}


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: Prosthetic Mitral Valve thrombosis

PRESENT ILLNESS: 66 y/o F s/p CVA with hemorrhagic evolution ([**9-26**]) with prior
prosthetic Mitral valve and tricuspid ring transferred from OSH
with MV thrombosis and GI bleed with likely need for Cardiac
surgery.  Approx one month ago, patient was hospitalized for
CVA, receiving TPA which subsequently led to hemorrhagic
conversion of the infarct and worsening neurological status.
During that admission, the patient's coumadin was held and then
restarted prior to discharge to rehab. Pt was admitted on
[**2114-11-1**] at Good [**Hospital 57794**] hospital for a GI bleed after
restarting coumadin upon transfer to rehab.
Upon presentation to the OSH, patient was found to have blood in
her rectal vault. Her coumadin was held and she received IM
Vitamin K for her INR of 1.7 on admission. Her HCT on admission
was 39 and was 29 on transfer from OSH, she did not receive
blood products.
Cardiology was consulted and an echocardiogram was performed.
The echo showed mitral valve thrombosis and acute mtiral
stenosis. Fluroscopy was performed and showed that one of the
[**Last Name (un) 22837**] valve leaflets was immobile. Patient was transferred
initially for cardiac surgery, but was soon deemed to be a poor
candidate in the setting of a GI bleed and recent hemorrhagic
stroke.

MEDICAL HISTORY: - Atrial Fibrillation with multiple failed attempts at
cardioversion
- CAD
- PPM
- Hypothyroidism
s/p CVA with hemorrhagic conversion ([**9-26**])
h/o multiple CVAs in past
h/o GI bleed, unknown etiology.
h/o Anti-cardiolipin antibody
OSA with CPAP

MEDICATION ON ADMISSION: Paxil 30mg [**Hospital1 **]
Wellbutrin qdaily
Klonopin 0.5mg [**Hospital1 **]
Neurontin 300mg TID
Advair 250/50 [**Hospital1 **]
Coreg 3.125mg [**Hospital1 **]
Synthroid 25mcg qdaily
Aricept 5mg qHS
Zocor 40mg qHS
Nexium 40mg IV qdaily
SSI

ALLERGIES: Lasix / Codeine / Ceclor / Keflex / Voltaren / Penicillins

PHYSICAL EXAM: VS: 98.5, 83, 116/58, 71, 21, 98% 2L
GENERAL: 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: Noncontrib

SOCIAL HISTORY: Smokes 1ppd x 36 yrs 

### Response:
{'Other complications due to heart valve prosthesis,Acute diastolic heart failure,Hemorrhage of gastrointestinal tract, unspecified,Pneumonia, organism unspecified,Mitral valve stenosis and aortic valve stenosis,Unspecified acquired hypothyroidism,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Cardiac pacemaker in situ,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits'}
