CHIEF COMPLAINT: Worsening shortness of breath for 6 months

PRESENT ILLNESS: Mrs [**Known lastname **] is a 65 year old woman female with h/o CAD/CABG, DM,
CHF, CVA, COPD, who is admitted to the CCU POD #1 following
CoreValve placement for critical Aortic Stenosis.
.
History obtained from OMR. Patient was diagnosed with AS at age
15. In the past 3-5 years she has developed progressive symptoms
of dyspnea and chest pain. She is primarily bed-bound, with
ambulation limited to ~ 10 feet without shortness of breath. In
the past a few weeks, with mild exertion, patient also felt mild
midsternal chest pain, described as "burning", with no
radiation. On admission she denied history of syncope.
Recent ECHO [**2132-4-25**] reveals LVEF 60% aortic valve area of
0.7cm2, mean gradient 81mmHg, and jet velocity of 5.5 m/sec.
Patient was evaluated by cardiothoracic surgery, and was deemed
high risk candidate for surgery and she was enrolled into the
Corevalve trial. Today, she was taken to the OR for CoreValve
placement under general anesthesia. Access through the right
femoral artery was obtained with a 18F sheath. A temporary pacer
wire was placed. Balloon aortic valvuloplasty was performed and
a 29mm Corevalve device was deployed. In the proceedure, the
patient developed hypotension to SBP 89 and was given IVNS, and
briefly on phenylephrine, intra operative HCT was 29.9 (down
from 32.3) she was transfused one unit PRBC. In total, she
received 3500cc IVNS intra operatively. Other medications given
intraop included Furosemide 80mg IV, cefazolin 2g, and
Vancomycin 1.5g. Following the proceedure, the patient was
transferred to the CCU for close monitoring.
The patient was received intubated in the CCU vitals were T:
97.1 BP 147/73 P:87 SaO2 97%, vent settings AC Vt600, rr16 Peep5
100% FiO2.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
(in the past, now hypotension)
2. CARDIAC HISTORY:
-CABG X3: [**2116**] with a LIMA to the [**Name Prefix (Prefixes) **]
- [**Last Name (Prefixes) **] [**1-/2132**] Patent LIMA->LAD, Patent SVG->OM1, occluded
SVG->PDA.
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
Diabetes on insulin & metformin
hypothyroidism
hiatal hernia
COPD (not on home O2, on Advair only)
Stroke [**2124**] --> mild gait imbalance after rehab
peripheral neuropathy
cholecystectomy [**2117**]
Hysterectomy
Surgery for disk herniation [**2105**], [**2106**], [**2107**].

MEDICATION ON ADMISSION: Lovastatin 40mg dialy
Pantoprozole a40mg daily
Asa 81 mg daily
Levothyroxine 175mcg daily
Furosemide 60mg [**Hospital1 **] (7a - 12p)
Lyrica 150mg q12 (8a-8p)
Advair diskus 500/50 1 puff q12 (8a-8p)
Ferrous gluconate 324mg tid (6a, 12p,6p)
Cardizem CD 360mg daily
Novolog 70/30 - 30units s/c qam, 60units s/c qhs
Metformin 1000mg [**Hospital1 **]
Xanax 0.25mg qhs prn insomnia
Meclizine 25mg po tid

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION PHYSICAL EXAMINATION:
T: 97.1 BP 147/73 P:87 SaO2 97%
GENERAL: obese woman intubated, arousable, uncomfortable, moving
all extremites.
HEENT: NCAT. Sclera anicteric. PERRLA, mucous membs dry, ET tube
in place.
NECK: Right IJ in place with surrounding clotted blood. JVP not
assessed due to habitus
CARDIAC: RRR, S1, soft S2 no murmurs/rubs/gallops
LUNGS: Transmitted breath sounds BL in anterior lung fields.
ABDOMEN: Overweight, midline sternotomy scar, and diagonal RUQ
scar, reducible periumbilical hernia.
EXTREMITIES: 1+ pitting edema to ankle bilaterally
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+

FAMILY HISTORY: Mother: DM, HTN, died from heart attack at age 67
Father: [**Name (NI) 11964**] disease, died from heart attack at age 84
22 biological siblings
Sister: diet from uremia [**12-19**] kidney failure
Sister: breast ca at age 40s
Sister: subarachnoid hemorrhage at age 49
Brother: subarachnoid hemorrhage at age 49
brother: lung cancer at age 66
brother: died from heart attack at age 67
brother: died from kidney and heart failure at age 67
sister: CAD s/p CABG at age 68

SOCIAL HISTORY: Worked at the social service at [**State 72929**], retired
after stroke in [**2124**]
One son, husband deceased
Currently lives with son's family in a duplex house in [**State 3914**]
-Tobacco history: 1 pky remote hx
-ETOH: none
-Illicit drugs: none
Aortic valve disorders,Acute on chronic diastolic heart failure,Coronary atherosclerosis of autologous vein bypass graft,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Chronic airway obstruction, not elsewhere classified,Obesity, unspecified,Esophageal reflux,Obstructive sleep apnea (adult)(pediatric),Long-term (current) use of insulin,Unspecified acquired hypothyroidism,Other left bundle branch block,Unspecified hereditary and idiopathic peripheral neuropathy,Examination of participant in clinical trial,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Iron deficiency anemia, unspecified,Dermatophytosis of the body,Constipation, unspecified
Aortic valve disorder,Ac on chr diast hrt fail,Crn ath atlg vn bps grft,DMII wo cmp nt st uncntr,Hypertension NOS,Hyperlipidemia NEC/NOS,Chr airway obstruct NEC,Obesity NOS,Esophageal reflux,Obstructive sleep apnea,Long-term use of insulin,Hypothyroidism NOS,Left bb block NEC,Idio periph neurpthy NOS,Exam-clincal trial,Hx TIA/stroke w/o resid,Iron defic anemia NOS,Dermatophytosis of body,Constipation NOS
Admission Date:  [**2132-5-26**]              Discharge Date:   [**2132-6-3**]

Date of Birth:  [**2066-7-15**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
Worsening shortness of breath for 6 months

Major Surgical or Invasive Procedure:
Transcatheter Aortic-Valve Implantation (CoreValve)

History of Present Illness:
Mrs [**Known lastname **] is a 65 year old woman female with h/o CAD/CABG, DM,
CHF, CVA, COPD, who is admitted to the CCU POD #1 following
CoreValve placement for critical Aortic Stenosis.
.
History obtained from OMR. Patient was diagnosed with AS at age
15. In the past 3-5 years she has developed progressive symptoms
of dyspnea and chest pain. She is primarily bed-bound, with
ambulation limited to ~ 10 feet without shortness of breath. In
the past a few weeks, with mild exertion, patient also felt mild
midsternal chest pain, described as "burning", with no
radiation. On admission she denied history of syncope.
Recent ECHO [**2132-4-25**] reveals LVEF 60% aortic valve area of
0.7cm2, mean gradient 81mmHg, and jet velocity of 5.5 m/sec.
Patient was evaluated by cardiothoracic surgery, and was deemed
high risk candidate for surgery and she was enrolled into the
Corevalve trial. Today, she was taken to the OR for CoreValve
placement under general anesthesia. Access through the right
femoral artery was obtained with a 18F sheath. A temporary pacer
wire was placed. Balloon aortic valvuloplasty was performed and
a 29mm Corevalve device was deployed. In the proceedure, the
patient developed hypotension to SBP 89 and was given IVNS, and
briefly on phenylephrine, intra operative HCT was 29.9 (down
from 32.3) she was transfused one unit PRBC. In total, she
received 3500cc IVNS intra operatively. Other medications given
intraop included Furosemide 80mg IV, cefazolin 2g, and
Vancomycin 1.5g. Following the proceedure, the patient was
transferred to the CCU for close monitoring.
The patient was received intubated in the CCU vitals were T:
97.1 BP 147/73 P:87 SaO2 97%, vent settings AC Vt600, rr16 Peep5
100% FiO2.

Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
(in the past, now hypotension)
2. CARDIAC HISTORY:
-CABG X3: [**2116**] with a LIMA to the [**Name Prefix (Prefixes) **]
- [**Last Name (Prefixes) **] [**1-/2132**] Patent LIMA->LAD, Patent SVG->OM1, occluded
SVG->PDA.
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
Diabetes on insulin & metformin
hypothyroidism
hiatal hernia
COPD (not on home O2, on Advair only)
Stroke [**2124**] --> mild gait imbalance after rehab
peripheral neuropathy
cholecystectomy [**2117**]
Hysterectomy
Surgery for disk herniation [**2105**], [**2106**], [**2107**].


Social History:
Worked at the social service at [**State 72929**], retired
after stroke in [**2124**]
One son, husband deceased
Currently lives with son's family in a duplex house in [**State 3914**]
-Tobacco history: 1 pky remote hx
-ETOH: none
-Illicit drugs: none


Family History:
Mother: DM, HTN, died from heart attack at age 67
Father: [**Name (NI) 11964**] disease, died from heart attack at age 84
22 biological siblings
Sister: diet from uremia [**12-19**] kidney failure
Sister: breast ca at age 40s
Sister: subarachnoid hemorrhage at age 49
Brother: subarachnoid hemorrhage at age 49
brother: lung cancer at age 66
brother: died from heart attack at age 67
brother: died from kidney and heart failure at age 67
sister: CAD s/p CABG at age 68


Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
T: 97.1 BP 147/73 P:87 SaO2 97%
GENERAL: obese woman intubated, arousable, uncomfortable, moving
all extremites.
HEENT: NCAT. Sclera anicteric. PERRLA, mucous membs dry, ET tube
in place.
NECK: Right IJ in place with surrounding clotted blood. JVP not
assessed due to habitus
CARDIAC: RRR, S1, soft S2 no murmurs/rubs/gallops
LUNGS: Transmitted breath sounds BL in anterior lung fields.
ABDOMEN: Overweight, midline sternotomy scar, and diagonal RUQ
scar, reducible periumbilical hernia.
EXTREMITIES: 1+ pitting edema to ankle bilaterally
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+

DISCHARGE PHYSICAL EXAM:
PHYSICAL EXAM:
Vitals - Tm/Tc: 98/97.4 BP: 82/41-121/67 HR:67-83 RR:18 02
sat:96\RA
Last 24H: 1180/2600
GENERAL: OOB in chair, in no acute distress. Speaking
comfortably.
HEENT: PERRLA, no pharyngeal erythemia, mucous membs moist, no
lymphadenopathy,
CHEST: CTABL no wheezes, no rales, no ronchi, decreased bases
CV: S1 S2 Normal in quality and intensity RRR, murmer LSB
ABD: soft, non-tender, non-distended, BS normoactive. no
rebound/guarding, neg HSM. neg [**Doctor Last Name 515**] sign. (+)visible hernia
with forceful cough), nontender
EXT: wwp, no edema. DPs, PTs 2+. 3+ lower extremity edema, taut,
shiny, left greater than right, no drainage, no lesions. Lower
calf erythema bilaterally, improved from admission, baseline
according to patient secondary to longterm stocking use.
NEURO: CNs II-XII intact. 5/5 strength in U/L extremities. DTRs
2+ BL (biceps, achilles, patellar). sensation intact to LT,
pain, temperature, vibration, proprioception. cerebellar fxn
intact (FTN, HTS). Ambulating indep with walker.
SKIN: Bilateral groin excoriations to skin fold, moist, clean in
appearance.
PSYCH: Verbalizing good understanding of discharge planning,
asking questions approp. Calm and receptive.


Pertinent Results:
ADMISSION LABS
==============
[**2132-5-26**] 05:20PM BLOOD WBC-11.2* RBC-4.32 Hgb-10.0* Hct-32.3*
MCV-75* MCH-23.2* MCHC-31.0 RDW-18.7* Plt Ct-213
[**2132-5-26**] 05:20PM BLOOD Neuts-72.7* Bands-0 Lymphs-17.4*
Monos-3.1 Eos-6.1* Baso-0.7
[**2132-5-26**] 09:35AM BLOOD PT-14.3* INR(PT)-1.2*
[**2132-5-26**] 05:20PM BLOOD Glucose-231* UreaN-41* Creat-1.0 Na-142
K-3.4 Cl-100 HCO3-31 AnGap-14
[**2132-5-26**] 05:20PM BLOOD ALT-12 AST-15 CK(CPK)-28* AlkPhos-73
TotBili-0.7
[**2132-5-26**] 05:20PM BLOOD Albumin-3.7
[**2132-5-27**] 02:43PM BLOOD Calcium-7.9* Phos-3.4 Mg-2.0
.
Cardiac Enzymes
===============
[**2132-5-26**] 05:20PM BLOOD CK-MB-2 proBNP-852*
[**2132-5-28**] 12:00AM BLOOD CK-MB-3
[**2132-5-28**] 05:05AM BLOOD CK-MB-3 cTropnT-0.01
[**2132-5-29**] 04:55AM BLOOD CK-MB-2 cTropnT-<0.01

PERTINENT STUDIES
# [**5-26**] Cardiac Cath
COMMENTS: Ascending aortogram was obtained using a sizing
Omniflush
catheter at 14/14 LAO/[**Last Name (un) **] projection to ensure that all the
cusps were
at the same level. Thereafter a 5 Fr sizing pigtail catheter was
used to
obtain the distal aortogram with visualization of bilateral
ileofemoral
arteries to assess feasibility of femoral access. At the end of
the
procedure TR band was applied to the left radial access site
with
excellent hemostasis. No immediate complications.
FINAL DIAGNOSIS:
1. Sinus of Valsalva diameter 30 mm ( adequate for Corevalve
placement)
2. Bilateral iliac and femoral diameter > 8 mm with minimal
tortuosity
3. Minimal aortic regurgitation by supravalvular aortography
.
# [**5-26**] CXR
IMPRESSION: PA and lateral chest reviewed in the absence of
prior chest
radiographs, but read in conjunction with CT imaging of the
chest on a torso CT examination performed elsewhere on [**2-1**]:

Pulmonary vascular plethora, mild interstitial abnormality,
moderate-to-severe cardiomegaly and pulmonary arterial
dilatation are all unchanged since [**Month (only) 958**].  There is no
pneumonia, interstitial pulmonary edema or pleural effusion. The
extent of central adenopathy and of calcification in the aortic
valve is much better demonstrated on CT images.
.
# [**5-27**] ECHO (TEE)
Pre valve implantation study
Very poor image quality overall.
No atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets are severely thickened/deformed. There is critical
aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. The mitral valve shows characteristic rheumatic
deformity. Moderate to severe (3+) mitral regurgitation is seen.
Drs [**Last Name (STitle) **] and [**Name5 (PTitle) **] was notified in person of the results on
[**2132-5-27**] at 900 am
Post implantation.
Stented valve seen in the aortic position. It appears well
seated. Two small perivalvular leaks noted. Mild aortic
insufficiency present. The mitral regurgitation is 2+.
.
# [**5-27**] CXR
FINDINGS: AP single view of the chest has been obtained with
patient in
sitting semi-upright position. Comparison is made with the next
preceding
similar study obtained on [**5-26**] at 20:14 hours. Frontal views
are compared.
Patient is now intubated, the ETT terminates in the trachea some
4 cm above the level of the carina. A right internal jugular
sheath has been placed, and a temporary pacing wire has been
advanced into the right ventricle. It projects into the apical
portion of the right ventricle. Special amended copy with high
contrast allows the delineation of a tubular network
superimposed on the aortic valve area and the proximal portion
of the ascending aorta. This is consistent with the appropriate
location of a CoreValve prosthesis.
Remarkable is that the cardiac contours including evidence of
previous bypass surgery and sternotomy have not undergone any
significant interval change. No pneumothorax has developed.
There is slightly more advanced perivascular haze in the
pulmonary circulation which may be related to temporary fluid
overload.
No new parenchymal abnormalities are seen, and the lateral
pleural sinuses
remain free from major fluid accumulations. No pneumothorax is
present in the apical area.
IMPRESSION: Satisfactory findings following CoreValve
replacement intervention.
.
# [**5-28**] ECHO (TTE)
Conclusions
The left atrium is elongated. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). An aortic CoreValve
prosthesis is present. The aortic valve prosthesis appears well
seated, with normal leaflet/disc motion and transvalvular
gradients. The mitral valve leaflets are mildly thickened. Mild
(1+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Corevalve well-seated with normal transvalvular
gradients and no regurgitation. Mild pulmonary hypertension.
Mild mitral regurgitation. Moderate symmetric left ventricular
hypertrophy with preserved global left ventricular systolic
function.
Compared with the prior study (images reviewed) of [**4-25**]/201, a
Corevalve prosthesis is now in place and aortic stenosis has
resolved.
.
# [**5-30**] CXR
FINDINGS: In comparison with study of [**5-27**], the monitoring and
support
devices have been removed. Continued enlargement of the cardiac
silhouette
with tortuosity of the aorta. There may be minimal elevation of
pulmonary
venous pressure. No evidence of acute focal pneumonia.
.
# [**6-3**] ECHO
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF>55%). There
is no ventricular septal defect. The right ventricular cavity is
mildly dilated with normal free wall contractility. The
diameters of aorta at the sinus, ascending and arch levels are
normal. An aortic CoreValve prosthesis is present. The aortic
valve prosthesis appears well seated, with normal leaflet/disc
motion and transvalvular gradients. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. There
is mild functional mitral stenosis (mean gradient 5 mmHg) due to
mitral annular calcification. Mild (1+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of [**2132-5-28**], no
change.

Labs @ discharge:
 COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2132-6-3**] 06:05    8.5 3.57* 8.5* 27.4* 77* 23.7* 30.9* 21.7*
234

  RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2132-6-3**] 06:05    105*1 27* 0.9 140 4.0 101 29 14


Brief Hospital Course:
Mrs [**Known lastname **] is a 65 year old female with PMH CAD/CABG, DM, CHF,
CVA, COPD, with severe aortic stenosis admitted for
transcatheter aortic-valve/Corevalve implantation.
.
ACTIVE ISSUES
.
# CoreValve placement
Patient has long history aortic stenosis.  Her functional status
exacerbated to be bed-bound most of time.  Pre-op Echo showed
aortic valve area of 0.7 cm2 and mean trans-aortic valve
gradient of 81 mmHg.  Patient's pre-op studies, including ECG,
aortography, ECHO, CXR and standard lab testings did not show
contraindications.  In addition, plavix 300 mg was provided.  On
HD#2, a 29 mm Corevalve was placed via transcatheter aortic
valve implantation (TAVI).  The procedure went smoothly, with
complete disappearance of trans-aortic valve pressure gradient.
There was no aortic regurgiation seen intra-op aortography
following valve replacement.  Transesophageal echo showed a 1+
paravalvular aortic regurgitation.  There was a new bundle
branch block observed on EKG after the deployment of the
CoreValve, with no angiographic evidence of coronary artery
compromise.  A temporary pacing wire was placed at the end of
procedure.  Patient remained hemodynamically stable throughout
the procedure.
.
# Post-op CoreValve placement
Patient was extubated successfully two hours post-op and was
transferred to CCU in stable condition.  Her EKG continued to
show the new LBBB, with no other changes.  There were no
elevation in cardiac enzymes within 24 hours postop.  She
continued to take Aspirin 81 mg, Clopidogrel 75 mg and
lovastatin 40 mg, and discontinued her Cardizam.  Patient
maintained stable blood pressure without additional pressors or
activation of pacer throughout the post-op recovery.  The pacing
wire and cordis were removed 48 hours after the procedure.  The
central line was removed at 72 hours post-op.  Patient was
transferred to regular floor afterwards, with standard care
including physical therapy.  ECHO one week post-op showed
Corevalve was well seated, normal gradients, no [**Last Name (LF) 3564**], [**First Name3 (LF) **] normal.
OUTPATIENT ISSUES
- STARTED plavix 75 mg daily
- STARTED lisinopril 2.5 mg once a day.
- Will get Cr check in two weeks, and consider up-titrating
lisinopril if blood pressure tolerates for nephroprotection in
the setting of diabetes.
.
# Left bundle branch block
A new left bundle branch block was observed after the placement
of CoreValve.  EKG changes did not meet Sgarbossa criteria for
acute MI.  New LBBB may have been induced in the proceedure
either by direct myocardial injury or by local tissue edema.  Of
note, there were no cardiac enzyme elevation.
OUTPATIENT ISSUES
- Will consider repeat EKG in two weeks for documentation
purpose.  There is a possibility that this LBBB will
spontaneously resolve.
.
# Diastolic dysfunction
Preop ECHO shows LVEF 55% with E/E' Ratio 30 suggesting
diastolic dysfunction.  This is most likely a result of chronic
aortic stenosis and might also be contributed by prior
hypertension.  Patient takes furosemide 60 mg daily at home
prior to the procedure.  Her I/Os and daily weight were clearly
monitored during the recovery and lasix was titrated to maintain
a slight negative fluid balance.
OUTPATIENT ISSUES
- Patient was discharged on home dose of furosemide 60 mg [**Hospital1 **].
Please adjust dose accordingly.
.
# Cornary artery disease
Patient had documented history of cornary artery disease s/p
CABG in [**2116**]. Cardiac cath in [**1-/2132**] performed in [**State 3914**] showed
95% mid LAD stenosis with patent LIMA->LAD, LCX with 90%
stenosis, SVG-OM1, occluded SVG->PDA. There was no angiographic
changes post-op.  The new LBBB was unlikely a result of acute
myocardial ischemia.  The home dose of her aspirin,and
lovastatin were continued.
.
# Anemia
On admission, patient had a Hct of 32.3, with MCV of 75, and
takes iron supplement at baseline.  She received one pRBC
post-op on the second hospital day, but otherwise maintain
stable Hct. She has slightly lower iron of 26, with otherwise
normal ferritin and transferrin.  There was no evidence of
hemolysis on lab.  We continued her ferrous sulfate at 324 mg
daily, but suspect that there could have been a secondary cause
to her microcytic anemia.
OUTPATIENT ISSUES
- Patient need PCP follow up on sustained microcytic anemia on
daily iron supplement.
.
CHRONIC ISSUES
# Peripheral neuropathy
Patient has a documented history of peripheral neuropathy.  We
continued her home dose of lyrica 150 mg [**Hospital1 **].
.
# Diabetes
Patient has documented history of diabetes, and was on insulin
prior to admssion.  Her metformin was discontinued.  She
received a combination of standing dose insulin at night and
sliding scale insulin during the day, which she tolerated fairly
well.  Blood glucose was monitored daily. Preop HgAic was 7.8 -
she will need to followup with her endocrinologist.
OUTPATIENT
- Patient will benefit from tighter glucose control.
.
# Hypothyroidism
Patient has a documented history of hypothyroidism.  She
received her home dose of synthroid 175 mcg daily. TSH 8.4/T4
5.9 in this hospitalization.  Patient by definition has
subclinical hypothyroidism, which could contribute to her
symptoms including weight gain, nonpitting edema.
OUTPATIENT ISSUES
- please follow up and consider increasing synthyroid dose.
.
# OSA
Patient has a documented history of OSA.  She used her home CPAP
during this hospitalization.
.
TRANSITIONAL ISSUES
- Patient maintained a full code throughout this admission
- Patient has a followup appointment with Dr. [**Last Name (STitle) **] on [**2132-6-20**]

Medications on Admission:
Lovastatin 40mg dialy
Pantoprozole a40mg daily
Asa 81 mg daily
Levothyroxine 175mcg daily
Furosemide 60mg [**Hospital1 **] (7a - 12p)
Lyrica 150mg q12 (8a-8p)
Advair diskus 500/50 1 puff q12 (8a-8p)
Ferrous gluconate 324mg tid (6a, 12p,6p)
Cardizem CD 360mg daily
Novolog 70/30 - 30units s/c qam, 60units s/c qhs
Metformin 1000mg [**Hospital1 **]
Xanax 0.25mg qhs prn insomnia
Meclizine 25mg po tid


Discharge Medications:
1. lovastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. furosemide 40 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
6. pregabalin 75 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
7. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. ferrous sulfate 300  mg (60 mg iron) Tablet Sig: One (1)
Tablet PO TID (3 times a day).
9. metformin 500 mg Tablet Extended Release 24 hr Sig: Two (2)
Tablet Extended Release 24 hr PO BID (2 times a day).
10. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for Insomnia.
11. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
14. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
15. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.

16. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
17. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: Thirty (30) UNITS Subcutaneous once a day: 30UNITS BEFORE
BREAKFAST, 60UNITS BEFORE DINNER.
18. Outpatient Lab Work
chem 7 and cbc on [**6-6**]


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 89431**]Rehab

Discharge Diagnosis:
1. Critical aortic stenosis - s/p Corevalve placement
2. coronary artery disease - s/p coronary artery bypass grafting
[**2116**]
3. Diabetes mellitus type II
4. Congestive heart failure, acute on chronic diastolic
dysfunction
5. Hypertension
6. Hperlipidemia
7. Obstructive sleep apnea
8. chronic obstructive pulmonary disorder
9. Obesity
10. Gastroesophageal reflux disease
11. Hypothyroid
12. Lymphedema


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).

Discharge Instructions:
Mrs. [**Known lastname **], you have undergone elective percutaneous aortic
valve placement with the Corevalve as treatment for your
symptomatic severe aortic stenosis. Your intraoperative course
went very well. You did have some bleeding at the vascular
access site for which you received one unit of blood. Your
postoperative course was uneventful. An [**Known lastname 461**] done at
your time of discharge showed the Aortic CoreValve with good
placement (well seated), normal leaflet/disc motion and normal
transvalvular gradients. Overall left ventricular systolic
function is normal (LVEF>55%).

You will receive a list of instructions which will include
weighing yourself every morning, call Dr [**Last Name (STitle) **] if weight goes up
more than 3 lbs in one day, or five pounds in 3 days.
.
We made the following changes to your medicines:
1. Your Cardizem Cd 360mg has been discontinued.
2. Lisinopril 2.5mg daily has been started instead to treat your
high blood pressure in patients who are diabetic.
3. clopidrogel (plavix)75 mg daily has been started as part of
the Corevalve protocol.
4. colace 100mg twice a day has been added to prevent
constipation.
5. Senna tab has been added of needed for constipation
6. miconazole powder to both groin areas has been added to treat
those excoriated areas - apply twice daily.
7. ultram 50mg every 6 hours if needed for pain has also been
added

Followup Instructions:
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2132-6-20**]
11:00
on [**Hospital Ward Name 517**] - [**Hospital Ward Name **]/[**Hospital Ward Name 121**] [**Location (un) 470**]
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2132-6-20**] 12:00 on [**Hospital Ward Name 516**] - [**Hospital Ward Name 23**] [**Location (un) 436**]
{'Aortic valve disorders,Acute on chronic diastolic heart failure,Coronary atherosclerosis of autologous vein bypass graft,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Chronic airway obstruction, not elsewhere classified,Obesity, unspecified,Esophageal reflux,Obstructive sleep apnea (adult)(pediatric),Long-term (current) use of insulin,Unspecified acquired hypothyroidism,Other left bundle branch block,Unspecified hereditary and idiopathic peripheral neuropathy,Examination of participant in clinical trial,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Iron deficiency anemia, unspecified,Dermatophytosis of the body,Constipation, unspecified'}


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: Worsening shortness of breath for 6 months

PRESENT ILLNESS: Mrs [**Known lastname **] is a 65 year old woman female with h/o CAD/CABG, DM,
CHF, CVA, COPD, who is admitted to the CCU POD #1 following
CoreValve placement for critical Aortic Stenosis.
.
History obtained from OMR. Patient was diagnosed with AS at age
15. In the past 3-5 years she has developed progressive symptoms
of dyspnea and chest pain. She is primarily bed-bound, with
ambulation limited to ~ 10 feet without shortness of breath. In
the past a few weeks, with mild exertion, patient also felt mild
midsternal chest pain, described as "burning", with no
radiation. On admission she denied history of syncope.
Recent ECHO [**2132-4-25**] reveals LVEF 60% aortic valve area of
0.7cm2, mean gradient 81mmHg, and jet velocity of 5.5 m/sec.
Patient was evaluated by cardiothoracic surgery, and was deemed
high risk candidate for surgery and she was enrolled into the
Corevalve trial. Today, she was taken to the OR for CoreValve
placement under general anesthesia. Access through the right
femoral artery was obtained with a 18F sheath. A temporary pacer
wire was placed. Balloon aortic valvuloplasty was performed and
a 29mm Corevalve device was deployed. In the proceedure, the
patient developed hypotension to SBP 89 and was given IVNS, and
briefly on phenylephrine, intra operative HCT was 29.9 (down
from 32.3) she was transfused one unit PRBC. In total, she
received 3500cc IVNS intra operatively. Other medications given
intraop included Furosemide 80mg IV, cefazolin 2g, and
Vancomycin 1.5g. Following the proceedure, the patient was
transferred to the CCU for close monitoring.
The patient was received intubated in the CCU vitals were T:
97.1 BP 147/73 P:87 SaO2 97%, vent settings AC Vt600, rr16 Peep5
100% FiO2.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
(in the past, now hypotension)
2. CARDIAC HISTORY:
-CABG X3: [**2116**] with a LIMA to the [**Name Prefix (Prefixes) **]
- [**Last Name (Prefixes) **] [**1-/2132**] Patent LIMA->LAD, Patent SVG->OM1, occluded
SVG->PDA.
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
Diabetes on insulin & metformin
hypothyroidism
hiatal hernia
COPD (not on home O2, on Advair only)
Stroke [**2124**] --> mild gait imbalance after rehab
peripheral neuropathy
cholecystectomy [**2117**]
Hysterectomy
Surgery for disk herniation [**2105**], [**2106**], [**2107**].

MEDICATION ON ADMISSION: Lovastatin 40mg dialy
Pantoprozole a40mg daily
Asa 81 mg daily
Levothyroxine 175mcg daily
Furosemide 60mg [**Hospital1 **] (7a - 12p)
Lyrica 150mg q12 (8a-8p)
Advair diskus 500/50 1 puff q12 (8a-8p)
Ferrous gluconate 324mg tid (6a, 12p,6p)
Cardizem CD 360mg daily
Novolog 70/30 - 30units s/c qam, 60units s/c qhs
Metformin 1000mg [**Hospital1 **]
Xanax 0.25mg qhs prn insomnia
Meclizine 25mg po tid

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION PHYSICAL EXAMINATION:
T: 97.1 BP 147/73 P:87 SaO2 97%
GENERAL: obese woman intubated, arousable, uncomfortable, moving
all extremites.
HEENT: NCAT. Sclera anicteric. PERRLA, mucous membs dry, ET tube
in place.
NECK: Right IJ in place with surrounding clotted blood. JVP not
assessed due to habitus
CARDIAC: RRR, S1, soft S2 no murmurs/rubs/gallops
LUNGS: Transmitted breath sounds BL in anterior lung fields.
ABDOMEN: Overweight, midline sternotomy scar, and diagonal RUQ
scar, reducible periumbilical hernia.
EXTREMITIES: 1+ pitting edema to ankle bilaterally
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+

FAMILY HISTORY: Mother: DM, HTN, died from heart attack at age 67
Father: [**Name (NI) 11964**] disease, died from heart attack at age 84
22 biological siblings
Sister: diet from uremia [**12-19**] kidney failure
Sister: breast ca at age 40s
Sister: subarachnoid hemorrhage at age 49
Brother: subarachnoid hemorrhage at age 49
brother: lung cancer at age 66
brother: died from heart attack at age 67
brother: died from kidney and heart failure at age 67
sister: CAD s/p CABG at age 68

SOCIAL HISTORY: Worked at the social service at [**State 72929**], retired
after stroke in [**2124**]
One son, husband deceased
Currently lives with son's family in a duplex house in [**State 3914**]
-Tobacco history: 1 pky remote hx
-ETOH: none
-Illicit drugs: none 

### Response:
{'Aortic valve disorders,Acute on chronic diastolic heart failure,Coronary atherosclerosis of autologous vein bypass graft,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Chronic airway obstruction, not elsewhere classified,Obesity, unspecified,Esophageal reflux,Obstructive sleep apnea (adult)(pediatric),Long-term (current) use of insulin,Unspecified acquired hypothyroidism,Other left bundle branch block,Unspecified hereditary and idiopathic peripheral neuropathy,Examination of participant in clinical trial,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Iron deficiency anemia, unspecified,Dermatophytosis of the body,Constipation, unspecified'}
