CHIEF COMPLAINT: Dyspnea on Exertion

PRESENT ILLNESS: This 77 year-old patient who has had previous bypass grafts in
[**2143**] with vein grafts to diagonal,obtuse marginal and posterior
descending artery and left
internal mammary artery to the left anterior descending artery
presented with increasing symptoms of dyspnea on exertion. He
was investigated and was found to have critical aortic stenosis
with preserved left ventricular function and patent coronary
grafts. His aortic valve was severely calcified with very
significant calcification in the region of the sinotubular
junction. He is also on Coumadin for preoperative atrial
fibrillation. He was electively admitted
for aortic valve replacement.

MEDICAL HISTORY: Coronary Artery Disease s/p Coronary Artery Bypass Graftx4
([**2143**])
Aortic Stenosis
Atrial Fibrillation (on Coumadin)
Hypertension
Diabetes Mellitus
Peripheral Vascular Disease s/p Femoral Artery Endarterectomy,
External Iliac to Perineal Bypass
Abdominal Aortic Aneurysm s/p Repair

MEDICATION ON ADMISSION: Atenolol, Norvasc, Warfarin, Lasix, Doxazosin, Lipitor,
Glucophage

ALLERGIES: Penicillins

PHYSICAL EXAM: VS: 64AF 16 128/61
General: 77 y/o male lying supine in bed in NAD
Skin: Well-healed Sternotomy Incision and Midline Abd Incision
HEENT: NC/AT, PERRL, EOMI, OP Benign
Neck: Supple, FROM, -Carotid Bruits
Lungs: CTAB -w/r/r
Heart: Irreg-Irreg +S1S2, 2/6 SEM
AbD: Soft, Protuberant, NT/ND, +BS
Ext: Warm, with healed open saph incision rle

FAMILY HISTORY: [**Name (NI) 2280**], Father [**Name (NI) **] CA

SOCIAL HISTORY: Quit smoking 40 yrs ago after approx. 1 ppd x 25 yrs.
Occ. ETOH
Aortic valve disorders,Atrial fibrillation,Congestive heart failure, unspecified,Unspecified essential hypertension,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Atherosclerosis of native arteries of the extremities, unspecified,Aortocoronary bypass status,Personal history of urinary calculi
Aortic valve disorder,Atrial fibrillation,CHF NOS,Hypertension NOS,DMII neuro nt st uncntrl,Neuropathy in diabetes,Athscl extrm ntv art NOS,Aortocoronary bypass,Prsnl hst urnr dsrd calc
Admission Date:  [**2158-2-12**]              Discharge Date:   [**2158-2-27**]

Date of Birth:  [**2080-7-15**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Penicillins

Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea on Exertion

Major Surgical or Invasive Procedure:
Redo-Sternotomy, Aortic Valve Replacement w/ [**Street Address(2) 11688**]. [**Male First Name (un) 923**]
Mechanical Valve [**2158-2-16**]

History of Present Illness:
This 77 year-old patient who has had previous bypass grafts in
[**2143**] with vein grafts to diagonal,obtuse marginal and posterior
descending artery and left
internal mammary artery to the left anterior descending artery
presented with increasing symptoms of dyspnea on exertion. He
was investigated and was found to have critical aortic stenosis
with preserved left ventricular function and patent coronary
grafts. His aortic valve was severely calcified with very
significant calcification in the region of the sinotubular
junction. He is also on Coumadin for preoperative atrial
fibrillation. He was electively admitted
for aortic valve replacement.

Past Medical History:
Coronary Artery Disease s/p Coronary Artery Bypass Graftx4
([**2143**])
Aortic Stenosis
Atrial Fibrillation (on Coumadin)
Hypertension
Diabetes Mellitus
Peripheral Vascular Disease s/p Femoral Artery Endarterectomy,
External Iliac to Perineal Bypass
Abdominal Aortic Aneurysm s/p Repair

Social History:
Quit smoking 40 yrs ago after approx. 1 ppd x 25 yrs.
Occ. ETOH

Family History:
[**Name (NI) 2280**], Father [**Name (NI) **] CA

Physical Exam:
VS: 64AF 16 128/61
General: 77 y/o male lying supine in bed in NAD
Skin: Well-healed Sternotomy Incision and Midline Abd Incision
HEENT: NC/AT, PERRL, EOMI, OP Benign
Neck: Supple, FROM, -Carotid Bruits
Lungs: CTAB -w/r/r
Heart: Irreg-Irreg +S1S2, 2/6 SEM
AbD: Soft, Protuberant, NT/ND, +BS
Ext: Warm, with healed open saph incision rle

Pertinent Results:
Chest CT [**2-16**]: 1. Diffuse atherosclerotic calcifications
involving all portions of the thoracic aorta, but with greater
involvement of the descending aorta and arch than the ascending
aorta. 2. Congestive failure with interstitial edema and small
right pleural effusion.

Echo [**2-17**]: No change in LV function LV EF 50-55%. RV with mild
to moderate hypokinesis, improved from intial moderate
hypokinesis immediately post bypass. MR remains high mild to
moderate range, TR remains mild to moderate. Mechanical #23
Aortic valve prosthesis in situ. No AI, No perivalvular leaks.
Peak gradient 10 mm Hg, Mean gradient 5 mm Hg, but views for cw
doppler suboptimal.

[**2158-2-27**] 06:30AM BLOOD WBC-6.7 RBC-2.80* Hgb-9.2* Hct-25.6*
MCV-91 MCH-33.0* MCHC-36.1* RDW-15.4 Plt Ct-285
[**2158-2-27**] 06:30AM BLOOD Plt Ct-285
[**2158-2-27**] 06:30AM BLOOD UreaN-19 Creat-0.9 K-4.0
[**2158-2-12**] 03:38PM BLOOD ALT-18 AST-26 AlkPhos-160* TotBili-1.1

[**2158-2-26**] CXR
PA and lateral chest radiographs demonstrate the patient to be
status post CABG. Sternal wires and surgical staples project
over the left basilar atelectasis that has improved. The lungs
are now clear. No effusion. Trachea is midline.

[**2158-2-23**] EKG
Atrial fibrillation with a mean ventricular response, rate 110.
Right
bundle-branch block. Left axis deviation. Left anterior
fascicular block.
Compared to the previous tracing of [**2158-2-13**] multiple
abnormalities persist
without major change.


[**Last Name (NamePattern4) 4125**]ospital Course:
As mentioned in the HPI, patient was electively admitted
pre-operatively secondary to his h/o Atrial Fibrillation and
being on Coumadin. Coumadin was discontinued and he was started
on Heparin. His INR was followed and awaited it to come down to
under 1.3 prior to surgery. Also prior to surgery he underwent a
chest CT to evaluate his calcified aortic valve/aorta (please
see pertinent results). He received Vit K and was eventually
brought to the operating room on [**2-17**]. He underwent a
Redo-Sternotomy, Aortic Valve Replacement with a Mechanical
Valve. Please see operative note for surgical details. He was
transferred to the CSRU in stable condition on Epi, Levo, and
Neo. Patient remained intubated until post-operative day two
when Propofol was weaned and patient awoke neurologically
intact. Warfarin therapy was resumed. Mechanical ventilation was
then weaned and he was extubated. Chest tubes were removed
post-op day two.  Patient also remained on multiple
Inotropes/Pressors through post-operative day three. Patient
continued to have improving hemodynamics and drips were slowly
weaned. Foley catheter and Swan were removed on post-op day
three and he was transferred to the cardiac step-down unit. He
was started on Heparin for a subtherapeutic prothrombin time. He
required several large doses of Warfarin before becoming
therapeutic. Given his history of atrial fibrillation and
mechanical valve, Warfarin was dosed for a goal INR between 2.0
- 3.0. Heparin was eventually discontinued on postoperative day
*****. He underwent a speech and swallow evaluation on
postoperative day four for a questionable episode of aspiration.
He experienced coughing and difficulty breathing. Evaluation
revealed no signs of aspiration but based on his history, there
was concern for laryngospasm of his vocal cords secondary to
regurgitation. He had no diet restrictions and tolerated a
regular diet for the rest of his hospital stay without further
difficulty. Over several days, he clinically improved with
diuresis and continued to make steady progress with physical
therapy. His INR slowly progressed towards a therapeutic range.
Medical therapy was optimized and he was cleared for discharge
on postoperative day ten. At discharge, his BP was  124/80 with
a HR of 84 atrial fibrillation. All surgical wounds were clean,
dry and intact. He will follow-up with Dr. [**Last Name (Prefixes) **], his
cardiologist and his primary care physician as an outpatient.
Dr. [**Last Name (STitle) 26033**] will manage his coumadin dosing for a target INR of
2.5-3.5. His first blood draw PT/INR will be [**2158-2-28**] at 10:30AM.
His INR on discharge was 2.6 and he was discharged with 5mg
tablets.

Medications on Admission:
Atenolol, Norvasc, Warfarin, Lasix, Doxazosin, Lipitor,
Glucophage

Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Take while taking pain medication to prevent
constipation.
Disp:*30 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*4*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
Disp:*60 Tablet(s)* Refills:*2*
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
11. Coumadin 5 mg Tablet Sig: as Instructed by Dr. [**Last Name (STitle) 26033**]
Tablet PO once a day: Take as instrcuted by Dr. [**Last Name (STitle) 26033**]. Please
note that dose will change based on your PT/INR blood levels.
Goal INR is 2.5-3.5.
Disp:*45 Tablet(s)* Refills:*0*
12. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily) for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
13. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
14. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
SOUTH [**State **] VNA

Discharge Diagnosis:
Aortic Stenosis s/p Aortic Valve Replacement (Mechanical Valve)
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
([**2143**])
Atrial fibrillation
Hypertension
Diabetes Mellitus
Peripheral Vascular Disease

Discharge Condition:
Good

Discharge Instructions:
1) You can take a shower. Wash incisions with water and gentle
soap. Gently pat dry. Do not take bath. Do not apply lotions,
creams, ointments or powders to incisions until they have
healed.
2) Do not drive for 1 month.
3) Do not lift greater than 10 pounds for 10 weeks.
4) Report any signs of infection. These include redness,
drainage or increased pain.
5) Report any fevers greater then 100.5.
6) Dr. [**Last Name (STitle) 26033**] will follow your PT/INR blood work and Coumadin
dosing. You will have your blood drawn on [**2158-2-28**], at Dr. [**Name (NI) 26034**] office at 10:30AM. Please take daily dose only as
instructed by Dr. [**Last Name (STitle) 26033**]. Your dose may change based on your
blood levels. Goal INR is 2.5-3.5 for atrial
fibrillation/Mechanical aortic valve.
7) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
8) Staples out on postoperative day 14 ->([**2158-3-3**])
9) Call with any questions or concerns.

[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (Prefixes) **] in 4 weeks
Dr. [**Last Name (STitle) 26033**](cardiologist)in [**1-30**] weeks. ([**Telephone/Fax (1) 26035**]
Dr. [**Last Name (STitle) **](PCP)in 2 weeks. ([**Telephone/Fax (1) 26036**]
Dr. [**Last Name (STitle) 26033**] will follow your INR and adjust your Coumadin as he
did preoperatively. You will have a PT/INR checked [**2158-2-28**] in
his office at 10:30 AM.
Please call all providers for appointments.



Completed by:[**2158-2-27**]
{'Aortic valve disorders,Atrial fibrillation,Congestive heart failure, unspecified,Unspecified essential hypertension,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Atherosclerosis of native arteries of the extremities, unspecified,Aortocoronary bypass status,Personal history of urinary calculi'}


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: This 77 year-old patient who has had previous bypass grafts in
[**2143**] with vein grafts to diagonal,obtuse marginal and posterior
descending artery and left
internal mammary artery to the left anterior descending artery
presented with increasing symptoms of dyspnea on exertion. He
was investigated and was found to have critical aortic stenosis
with preserved left ventricular function and patent coronary
grafts. His aortic valve was severely calcified with very
significant calcification in the region of the sinotubular
junction. He is also on Coumadin for preoperative atrial
fibrillation. He was electively admitted
for aortic valve replacement.

MEDICAL HISTORY: Coronary Artery Disease s/p Coronary Artery Bypass Graftx4
([**2143**])
Aortic Stenosis
Atrial Fibrillation (on Coumadin)
Hypertension
Diabetes Mellitus
Peripheral Vascular Disease s/p Femoral Artery Endarterectomy,
External Iliac to Perineal Bypass
Abdominal Aortic Aneurysm s/p Repair

MEDICATION ON ADMISSION: Atenolol, Norvasc, Warfarin, Lasix, Doxazosin, Lipitor,
Glucophage

ALLERGIES: Penicillins

PHYSICAL EXAM: VS: 64AF 16 128/61
General: 77 y/o male lying supine in bed in NAD
Skin: Well-healed Sternotomy Incision and Midline Abd Incision
HEENT: NC/AT, PERRL, EOMI, OP Benign
Neck: Supple, FROM, -Carotid Bruits
Lungs: CTAB -w/r/r
Heart: Irreg-Irreg +S1S2, 2/6 SEM
AbD: Soft, Protuberant, NT/ND, +BS
Ext: Warm, with healed open saph incision rle

FAMILY HISTORY: [**Name (NI) 2280**], Father [**Name (NI) **] CA

SOCIAL HISTORY: Quit smoking 40 yrs ago after approx. 1 ppd x 25 yrs.
Occ. ETOH 

### Response:
{'Aortic valve disorders,Atrial fibrillation,Congestive heart failure, unspecified,Unspecified essential hypertension,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Atherosclerosis of native arteries of the extremities, unspecified,Aortocoronary bypass status,Personal history of urinary calculi'}
