CHIEF COMPLAINT: Shortness of breath

PRESENT ILLNESS: This 84 year old female has been followed for a history of
aortic stenosis.  An echo on [**2118-7-12**] showed heavily calcified
aortic valve leaflets  with a mean
aortic valve gradient of 60 mm Hg and [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 0.8 cm2.  She
has had increasing shortness of breath over the past week with
occasional episodes of dizziness and increased leg edema. She
underwent cardiac cath at [**Hospital6 5016**] today which
revealed severe AS, 80% ostial RCA lesion, and normal LV
function.  She was transferred to [**Hospital1 18**] for surgery.

MEDICAL HISTORY: CAD- s/p cardiac cath [**5-26**]
aortic stenosis
probable rheumatic heart disease
HTN
mitral valve prolapse
anxiety
colon cancer
NIDDM
Past Surgical History:
s/p appy
s/p choley
s/p s/p partial colectomy for colon ca [**2108**]
s/p bilat cataract surgery

MEDICATION ON ADMISSION: Nitro patch 0.4 mg top
Diltiazem CD 300 mg PO daily
Lescol XL 80 mg PO daily
Metformin 500 mg PO daily
ASA 81 mg PO daily
MVI 1 PO daily
Lisinopril 20 mg PO daily
Lasix 20 mg PO daily
KCl 10 mEq PO daily
Vitamin D 50,000 u PO once a week for 8 weeks

ALLERGIES: Penicillins / Vytorin [**9-26**] / Neosporin

PHYSICAL EXAM: Pulse:30s-40s Resp:10  O2 sat: 96%on RA
B/P  Right:160/90    Left:
Height:65"     Weight: 155

FAMILY HISTORY: no premature CAD

SOCIAL HISTORY: Lives with: daughter
Contact: [**Name (NI) **]                 Phone #([**Telephone/Fax (1) 90798**]
Occupation:housewife
Cigarettes: Smoked no [x] yes [] last cigarette _____ Hx:
Other Tobacco use:noen
ETOH: < 1 drink/week [x]  [**1-24**] drinks/week [] >8 drinks/week []
Illicit drug use none
Rheumatic aortic stenosis,Urinary tract infection, site not specified,Coronary atherosclerosis of native coronary artery,Atherosclerosis of aorta,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Unspecified disorder of lacrimal system,Other dental caries,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Personal history of malignant neoplasm of large intestine,Anxiety state, unspecified,Other second degree atrioventricular block,Altered mental status,Unspecified sedatives and hypnotics causing adverse effects in therapeutic use,Dysphagia, unspecified,Anemia, unspecified,Oliguria and anuria
Rheumat aortic stenosis,Urin tract infection NOS,Crnry athrscl natve vssl,Aortic atherosclerosis,Hypertension NOS,Hyperlipidemia NEC/NOS,Lacrimal syst dis NOS,Dental caries NEC,DMII wo cmp nt st uncntr,Hx of colonic malignancy,Anxiety state NOS,Av block-2nd degree NEC,Altered mental status,Adv eff sedat/hypnot NOS,Dysphagia NOS,Anemia NOS,Oliguria & anuria
Admission Date:  [**2118-7-21**]              Discharge Date:   [**2118-8-4**]

Date of Birth:  [**2034-3-10**]             Sex:   F

Service: CARDIOTHORACIC

Allergies:
Penicillins / Vytorin [**9-26**] / Neosporin

Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Shortness of breath

Major Surgical or Invasive Procedure:
[**2118-7-26**] AVR ( [**Street Address(2) 6158**]. [**Male First Name (un) 923**] Epic Supra porcine)/CABG x1 (SVG to
dRCA)


History of Present Illness:
This 84 year old female has been followed for a history of
aortic stenosis.  An echo on [**2118-7-12**] showed heavily calcified
aortic valve leaflets  with a mean
aortic valve gradient of 60 mm Hg and [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 0.8 cm2.  She
has had increasing shortness of breath over the past week with
occasional episodes of dizziness and increased leg edema. She
underwent cardiac cath at [**Hospital6 5016**] today which
revealed severe AS, 80% ostial RCA lesion, and normal LV
function.  She was transferred to [**Hospital1 18**] for surgery.


Past Medical History:
CAD- s/p cardiac cath [**5-26**]
aortic stenosis
probable rheumatic heart disease
HTN
mitral valve prolapse
anxiety
colon cancer
NIDDM
Past Surgical History:
s/p appy
s/p choley
s/p s/p partial colectomy for colon ca [**2108**]
s/p bilat cataract surgery


Social History:
Lives with: daughter
Contact: [**Name (NI) **]                 Phone #([**Telephone/Fax (1) 90798**]
Occupation:housewife
Cigarettes: Smoked no [x] yes [] last cigarette _____ Hx:
Other Tobacco use:noen
ETOH: < 1 drink/week [x]  [**1-24**] drinks/week [] >8 drinks/week []
Illicit drug use none


Family History:
no premature CAD

Physical Exam:
Pulse:30s-40s Resp:10  O2 sat: 96%on RA
B/P  Right:160/90    Left:
Height:65"     Weight: 155

Five Meter Walk Test #1_______ #2 _________  #3_________

General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck:  Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR []  Irregular [x]  Murmur [x] grade _4/6_____
Abdomen: Soft [x] non-distended [x] non-tender [x]  bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]  Edema [x] _Tr____
Varicosities: None [x]
Neuro: Oriented to person only-daughter states patient was
confused after she received versed, but is oriented and intact
at
baseline, exam is non-focal
Pulses:
Femoral      Right:fem stop-no hematoma   Left:2+
DP           Right:2+   Left:2+
PT           [**Name (NI) 167**]:2+   Left:2+
Radial       Right:2+   Left:2+

Carotid Bruit        Right:transmitted murmur
Left:transmitted
murmur


Pertinent Results:
Conclusions
PRE-BYPASS: No spontaneous echo contrast is seen in the body of
the left atrium. No spontaneous echo contrast is seen in the
left atrial appendage. 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. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are complex (>4mm) atheroma in the ascending aorta. There are
simple atheroma in the aortic arch. The descending thoracic
aorta is mildly dilated. There are complex (>4mm) atheroma in
the descending thoracic aorta. The aortic valve leaflets are
severely thickened/deformed. There is severe aortic valve
stenosis (valve area 0.8-1.0cm2). Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are moderately thickened.
Trivial mitral regurgitation is seen. There is no pericardial
effusion. Dr. [**Last Name (STitle) **] was notified in person of the
results prior to incision.

POST-BYPASS: The patient in on a phenylephrine infusion. There
is a well-seated, well-functioning bioprosthetic valve in the
aortic position. No aortic regurgitation is seen. There is a
mean gradient of 14 mmHg across the aortic valve. Biventricular
function is unchanged. There is no mitral regurgitation. The
ascending aorta, aortic arch, and descending aorta are intact.
Surgeon notified in person of the results at time of study.
  I certify that I was present for this procedure in compliance
with HCFA regulations.

Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting
physician

[**2118-8-4**] 05:50AM BLOOD WBC-11.1* RBC-3.51* Hgb-11.4* Hct-34.3*
MCV-98 MCH-32.5* MCHC-33.3 RDW-14.1 Plt Ct-451*
[**2118-8-3**] 08:10AM BLOOD WBC-11.6* RBC-3.78* Hgb-12.0 Hct-35.9*
MCV-95 MCH-31.8 MCHC-33.4 RDW-14.1 Plt Ct-419
[**2118-8-4**] 05:50AM BLOOD Glucose-136* UreaN-30* Creat-0.7 Na-148*
K-3.4 Cl-108 HCO3-33* AnGap-10
[**2118-8-3**] 08:10AM BLOOD Glucose-117* UreaN-27* Creat-0.5 Na-148*
K-4.0 Cl-107 HCO3-34* AnGap-11
[**2118-8-4**] 05:50AM BLOOD Mg-2.4
[**2118-8-3**] 08:10AM BLOOD Calcium-8.9 Phos-4.4 Mg-2.5

Brief Hospital Course:
Admitted [**7-21**] from OSH and pre-op work-up completed. Carotid
ultrasound revealed less than 40% stenosis in the [**Country **], 60-69%
stenosis on the left with antegrade vertebral flow.  The patient
was noted to have second degree heart block with bradycardia
that evening and was transferred to the CVICU for close
monitoring.  EP was consulted and noted Wenckebach rhythm, beta
blockers were held.   Noted to have periods of confusion and
agitation. L carotid disease noted on duplex. Dental extraction
completed [**7-24**].
On [**2118-7-26**] she was taken to the operating room and underwent
Aortic valve replacement with a size 21-mm St. [**Male First Name (un) 923**] Epic tissue
valve/Coronary artery bypass graft x1 with saphenous vein graft
to right coronary artery/Aortic endarterectomy with Dr. [**First Name (STitle) **].
She tolerated the procedure well and was transferred to the
CVICU in critical but stable condition, intubated and sedated
requiring pressor support. POD 1 found the patient extubated and
breathing comfortably.  The patient was sleepy, but easily
arousable and oriented to person and place.  She was
hemodynamically stable, weaned from vasopressor support.  Beta
blocker was not initited due to high grade heart block. EP
evaulated the patient and is following postoperatively.
Diuretics were initiated and the patient was gently diuresed
toward the preoperative weight. Norvasc and Lisinopril were
added for hypertension.  All lines and drains were discontinued
in a timely fashion with criteria met. On POD#4 she transferred
to the step down unit for further monitoring. Physical Therapy
was consulted for evaluation of strength and mobility. Her
mental status remained oriented to person and place, she follows
verbal commands, however she makes no effort to interact and
progress. All offending medications were discontinued so that
her mental status would not possibly be affected by narcotics.
On [**8-1**] she failed a speech and swallow study. A dobhoff tube
was placed for nutrition.  Diet was advanced to nectar thick
liquids and pureed solids with subsequent swallowing
evaluations.  She will remain on tube feeds until PO intake
improves.  The patient does have a history of a lacrimal duct
disorder and she does not open her eyes- this is her
pre-operative baseline.  She will maintain her Foley Catheter to
rehab.  Heart rhythm recovered and she was in sinus rhythm by
the the time of discharge.  Discussed with EP- and
recommendation is to follow up with her regular cardiologist.
On POD 9 she was cleared by Dr.[**First Name (STitle) **] for discharge to [**Hospital **] in [**Hospital1 3597**], NH.

Medications on Admission:
Nitro patch 0.4 mg top
Diltiazem CD 300 mg PO daily
Lescol XL 80 mg PO daily
Metformin 500 mg PO daily
ASA 81 mg PO daily
MVI 1 PO daily
Lisinopril 20 mg PO daily
Lasix 20 mg PO daily
KCl 10 mEq PO daily
Vitamin D 50,000 u PO once a week for 8 weeks


Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
2. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. fluvastatin 80 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

8. chlorhexidine gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. docusate sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).
11. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

12. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
13. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
14. potassium chloride 20 mEq Packet Sig: One (1) Packet PO once
a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7665**]

Discharge Diagnosis:
coronary artery disease
aortic stenosis
s/p aortic valve replacement,coronary artery bypass graft x1
probable rheumatic heart disease
hypertension
mitral valve prolapse
anxiety
h/o colon cancer
non-insulin dependent diabetes mellitus
s/p appendectomy
s/p cholecsytectomy
s/p s/p partial colectomy for colon carcinoma [**2108**]
s/p bilateral cataract surgery


Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema minimal


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 Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2118-9-5**] at 1:45pm
Cardiologist:Dr. [**Last Name (STitle) 5017**] on [**2118-8-24**] at 9:15am

Please call to schedule appointments with:
Primary Care Dr.[**Last Name (STitle) **] [**Name (STitle) **] ([**Telephone/Fax (1) 83705**]) in [**3-22**] 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**


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]

Completed by:[**2118-8-4**]
{'Rheumatic aortic stenosis,Urinary tract infection, site not specified,Coronary atherosclerosis of native coronary artery,Atherosclerosis of aorta,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Unspecified disorder of lacrimal system,Other dental caries,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Personal history of malignant neoplasm of large intestine,Anxiety state, unspecified,Other second degree atrioventricular block,Altered mental status,Unspecified sedatives and hypnotics causing adverse effects in therapeutic use,Dysphagia, unspecified,Anemia, unspecified,Oliguria and anuria'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: Shortness of breath

PRESENT ILLNESS: This 84 year old female has been followed for a history of
aortic stenosis.  An echo on [**2118-7-12**] showed heavily calcified
aortic valve leaflets  with a mean
aortic valve gradient of 60 mm Hg and [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 0.8 cm2.  She
has had increasing shortness of breath over the past week with
occasional episodes of dizziness and increased leg edema. She
underwent cardiac cath at [**Hospital6 5016**] today which
revealed severe AS, 80% ostial RCA lesion, and normal LV
function.  She was transferred to [**Hospital1 18**] for surgery.

MEDICAL HISTORY: CAD- s/p cardiac cath [**5-26**]
aortic stenosis
probable rheumatic heart disease
HTN
mitral valve prolapse
anxiety
colon cancer
NIDDM
Past Surgical History:
s/p appy
s/p choley
s/p s/p partial colectomy for colon ca [**2108**]
s/p bilat cataract surgery

MEDICATION ON ADMISSION: Nitro patch 0.4 mg top
Diltiazem CD 300 mg PO daily
Lescol XL 80 mg PO daily
Metformin 500 mg PO daily
ASA 81 mg PO daily
MVI 1 PO daily
Lisinopril 20 mg PO daily
Lasix 20 mg PO daily
KCl 10 mEq PO daily
Vitamin D 50,000 u PO once a week for 8 weeks

ALLERGIES: Penicillins / Vytorin [**9-26**] / Neosporin

PHYSICAL EXAM: Pulse:30s-40s Resp:10  O2 sat: 96%on RA
B/P  Right:160/90    Left:
Height:65"     Weight: 155

FAMILY HISTORY: no premature CAD

SOCIAL HISTORY: Lives with: daughter
Contact: [**Name (NI) **]                 Phone #([**Telephone/Fax (1) 90798**]
Occupation:housewife
Cigarettes: Smoked no [x] yes [] last cigarette _____ Hx:
Other Tobacco use:noen
ETOH: < 1 drink/week [x]  [**1-24**] drinks/week [] >8 drinks/week []
Illicit drug use none 

### Response:
{'Rheumatic aortic stenosis,Urinary tract infection, site not specified,Coronary atherosclerosis of native coronary artery,Atherosclerosis of aorta,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Unspecified disorder of lacrimal system,Other dental caries,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Personal history of malignant neoplasm of large intestine,Anxiety state, unspecified,Other second degree atrioventricular block,Altered mental status,Unspecified sedatives and hypnotics causing adverse effects in therapeutic use,Dysphagia, unspecified,Anemia, unspecified,Oliguria and anuria'}
