CHIEF COMPLAINT: admitted for pre-op cath

PRESENT ILLNESS: 57 y/o F w/CAD s/p CABG [**2098**] (at [**Hospital1 112**], LIMA->LAD, SVG->RCA,
SVG->OM3), CHF [**1-28**] diastolic dysfxn w/EF 50%, and aortic
stenosis, admitted today for pre-op cath, prior to possible redo
CABG and possible AVR.  She was noted to have aortic stenosis on
a TTE from an OSH in [**7-30**], with a valve area 1.0 cm2, peak
gradient 59 mm Hg, 1+ MR, and mod pulm htn.  Her most recent adm
to the [**Hospital1 **] was [**8-30**], when she presented w/resting CP.  EKG at
that time demonstrated old lat TWI.  She underwent cath which
revealed patent LIMA->LAD, 80% mid LAD, 80% OM1, and 100% OM3
occlusions.   Her EF was noted to be 55%.  She had a PTCA of
OM1, c/b dissection with resulting overlying cypher stents
placed.
Since that intervention, she has noted no improvement in her
anginal symptoms, and has been having 3-6 episodes of angina
daily both at rest and with exertion (episodes resolve w/nitro
spray).  She also c/o orthopnea and increasing LE edema, but no
PND.

MEDICAL HISTORY: 1. CAD
2. Mitral regurg
3. Aortic stenosis
4. rheumatoid arthritis
5. osteoarthritis
6. fibromyalgia
7. hypothyroidism
8. htn
9. hypercholesterolemia
10. depression
11. iron def. anemia
12. s/p appy
13. s/p TAH

MEDICATION ON ADMISSION: crestor 10 mg po daily
nambutone 500 mg po bid
levoxyl 150 mcg po daily
imdur 120 mg po daily
norvasc 50 mg po tid
plavix 75 mg po daily
lopid 600 mg po daily
toprol XL 100 mg po daily
lisinopril 40 mg po daily
effexor XR 150 mg po daily
hydrocodone 7.5-750 2 tabs q4-6 hrs prn
duragesic patch 125 mcg q48hrs
trazodone 150-200mg po qhs
nitro sublingual prn
ASA 325 po daily
iron 325 mg po tid

ALLERGIES: Ambien / Percocet

PHYSICAL EXAM: T: 97.2  P: 67  BP: 127/53  RR: 12 O2 sat: 97%
Gen: alert & oriented anxious female, in NAD
HEENT: NCAT.  no conjunct. pallor.  MMM.
Lungs: CTA bilaterally
CV: RRR, III/VI mid-peaking systolic murmur heard throughout,
radiating to carotids
Abd: obese, nontender, nondistended.  normoactive bowel sounds.
Ext: no edema.  1+ dorsalis pedis pulses bilaterally.

FAMILY HISTORY: Mother had CABG at age 48, died of CAD at age 68
Father had DM, CAD, died of MI

SOCIAL HISTORY: single, has daughter, denies EtOH or tobacco
Coronary atherosclerosis of native coronary artery,Other and unspecified angina pectoris,Rheumatic heart failure (congestive),Mitral valve insufficiency and aortic valve stenosis,Other iatrogenic hypotension,Iron deficiency anemia, unspecified,Myalgia and myositis, unspecified,Unspecified acquired hypothyroidism,Unspecified essential hypertension,Aortocoronary bypass status
Crnry athrscl natve vssl,Angina pectoris NEC/NOS,Rheumatic heart failure,Mitral insuf/aort stenos,Iatrogenc hypotnsion NEC,Iron defic anemia NOS,Myalgia and myositis NOS,Hypothyroidism NOS,Hypertension NOS,Aortocoronary bypass
Admission Date:  [**2105-1-26**]              Discharge Date:   [**2105-2-4**]

Date of Birth:  [**2047-2-3**]             Sex:   F

Service: MEDICINE

Allergies:
Ambien / Percocet

Attending:[**First Name3 (LF) 134**]
Chief Complaint:
admitted for pre-op cath

Major Surgical or Invasive Procedure:
Cardiac Catheterization

History of Present Illness:
57 y/o F w/CAD s/p CABG [**2098**] (at [**Hospital1 112**], LIMA->LAD, SVG->RCA,
SVG->OM3), CHF [**1-28**] diastolic dysfxn w/EF 50%, and aortic
stenosis, admitted today for pre-op cath, prior to possible redo
CABG and possible AVR.  She was noted to have aortic stenosis on
a TTE from an OSH in [**7-30**], with a valve area 1.0 cm2, peak
gradient 59 mm Hg, 1+ MR, and mod pulm htn.  Her most recent adm
to the [**Hospital1 **] was [**8-30**], when she presented w/resting CP.  EKG at
that time demonstrated old lat TWI.  She underwent cath which
revealed patent LIMA->LAD, 80% mid LAD, 80% OM1, and 100% OM3
occlusions.   Her EF was noted to be 55%.  She had a PTCA of
OM1, c/b dissection with resulting overlying cypher stents
placed.
Since that intervention, she has noted no improvement in her
anginal symptoms, and has been having 3-6 episodes of angina
daily both at rest and with exertion (episodes resolve w/nitro
spray).  She also c/o orthopnea and increasing LE edema, but no
PND.

Prior to her cath today, she became hypotensive in the holding
area (72/41, pulse 61).  She received 2 L NS, 1 mg atropine,
with a pressure that responded to 108/52.  She was also somewhat
hypotensive during her cath, systolics 80s.  Today, she
underwent a cath which revealed patent LIMA->LAD, totally
occluded RCA/SVGs, 3+MR, posterobasal/inferior akinesis, and EF
40%. Her CO was 6.3, CI 3.2, PA 44/20, wedge 23, and RA mean 30.
 Aortic valve area 1.1 cm2, peak gradient 40 mm Hg (mean 28 mm
Hg).  She also had posterobasal and inferior akinesis on left
ventriculography.

Past Medical History:
1. CAD
2. Mitral regurg
3. Aortic stenosis
4. rheumatoid arthritis
5. osteoarthritis
6. fibromyalgia
7. hypothyroidism
8. htn
9. hypercholesterolemia
10. depression
11. iron def. anemia
12. s/p appy
13. s/p TAH


Social History:
single, has daughter, denies EtOH or tobacco

Family History:
Mother had CABG at age 48, died of CAD at age 68
Father had DM, CAD, died of MI

Physical Exam:
T: 97.2  P: 67  BP: 127/53  RR: 12 O2 sat: 97%
Gen: alert & oriented anxious female, in NAD
HEENT: NCAT.  no conjunct. pallor.  MMM.
Lungs: CTA bilaterally
CV: RRR, III/VI mid-peaking systolic murmur heard throughout,
radiating to carotids
Abd: obese, nontender, nondistended.  normoactive bowel sounds.
Ext: no edema.  1+ dorsalis pedis pulses bilaterally.


Pertinent Results:
Admit ECG:  NSR, q waves in II, III, avF, and TWI in V4-6.

Cardiac Cath:
COMMENTS:     1. Selective coronary angiography demonstrated
native
three vessel coronary artery disease in this right dominant
circulation.
The LMCA was a short vessel without flow limiting disease. The
LAD was
totally occluded after the first septal branch. The distal LAD
filled
via a patent LIMA graft. The LCX had a 50% tubular proximal
stenosis.
The OM2 had a 70% ostial stenosis and was a large vessel. A
patent stent
was seen between OM2 and OM3. OM3 was a large vessel without
flow
limiting disease. The RCA was totally occluded in the proximal
vessel
with left to right collaterals seen filling the distal vessel.
2. Graft angiography demonstrated a widely patent LIMA-LAD. The
SVG-RCA
and SVG-OM3 were known to be occluded and not engaged.
3. Resting hemodynamics from right and left heart
catheterization
revealed markedly elevated right and left sided filling
pressures
(RVEDP=28mmHg and LVEDP=26mmHg). Cardiac output and index were
preserved
at 6.3L/min and 3.2L/min/m2. There was a 40mmHg peak gradient
and 28mmHg
mean gradient across the aortic valve with calculated aortic
valve area
of 1.1cm2. Moderate pulmonary systolic pressures was seen.
4. Left ventriculography demonstrated posterobasal and inferior
akineses
with LVEF of 40%. 3+ mitral regurgitation was seen.

FINAL DIAGNOSIS:
1. Native three vessel coronary artery disease. Patent LIMA-LAD.

2. Moderate aortic stenosis.
3. Moderate to severe mitral regurgitation.
4. Focal LV systolic dysfunction.
5. Severe biventricular diastolic dysfunction.

TTE [**2105-1-29**]:
Left ventricular wall thicknesses are normal. The left
ventricular cavity size
is normal. Overall left ventricular systolic function is mildly
depressed
(ejection fraction 40-50 percent) secondary to hypokinesis of
the inferior
free wall. No masses or thrombi are seen in the left ventricle.
There is no
ventricular septal defect. The aortic valve is bicuspid. There
is moderate
aortic valve stenosis, with mild aortic regurgitation. The
mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. At least
mild mitral regurgitation is seen. There is no pericardial
effusion.

Compared with the findings of the prior study (tape reviewed) of
[**2105-1-27**], the transaortic valvular gradient is somewhat lower;
however, moderate
aortic stenosis is still present; otherwise no major change is
evident
(inferior hypokinesis present on prior study).

Pertinent lab results:
[**2105-1-26**] 01:45PM BLOOD WBC-3.1* RBC-3.70* Hgb-7.9* Hct-25.9*
MCV-70* MCH-21.4* MCHC-30.5* RDW-13.8 Plt Ct-215
[**2105-1-26**] 06:43PM BLOOD Hct-27.1*
[**2105-1-27**] 05:05AM BLOOD WBC-4.5 RBC-3.85* Hgb-8.1* Hct-27.2*
MCV-71* MCH-21.1* MCHC-29.9* RDW-14.2 Plt Ct-231
[**2105-1-28**] 06:02AM BLOOD WBC-5.7 RBC-3.81* Hgb-8.3* Hct-26.8*
MCV-70* MCH-21.8* MCHC-31.0 RDW-14.1 Plt Ct-211
[**2105-1-29**] 06:30AM BLOOD WBC-4.9 RBC-4.32 Hgb-9.6* Hct-30.6*
MCV-71* MCH-22.3* MCHC-31.4 RDW-15.3 Plt Ct-209
[**2105-1-30**] 06:10AM BLOOD Hct-29.2*
[**2105-1-31**] 06:50AM BLOOD Hct-29.7*
[**2105-2-1**] 06:40AM BLOOD Hct-30.8*
[**2105-2-2**] 07:00AM BLOOD Hct-30.8*
[**2105-1-26**] 01:45PM BLOOD Glucose-111* UreaN-17 Creat-0.9 Na-140
K-4.5 Cl-111* HCO3-25 AnGap-9
[**2105-1-26**] 06:43PM BLOOD Glucose-143* UreaN-15 Creat-0.8 Na-141
K-4.4 Cl-111* HCO3-26 AnGap-8
[**2105-1-27**] 05:05AM BLOOD Glucose-107* UreaN-12 Creat-0.8 Na-138
K-4.4 Cl-107 HCO3-24 AnGap-11
[**2105-1-28**] 06:02AM BLOOD Glucose-87 UreaN-15 Creat-0.9 Na-139
K-4.3 Cl-108 HCO3-23 AnGap-12
[**2105-1-29**] 06:30AM BLOOD Glucose-78 UreaN-15 Creat-0.7 Na-141
K-3.9 Cl-104 HCO3-26 AnGap-15
[**2105-1-26**] 01:45PM BLOOD ALT-22 AST-22 AlkPhos-108 TotBili-0.3
[**2105-1-29**] 06:30AM BLOOD Mg-1.7 Cholest-232*
[**2105-1-29**] 02:02PM BLOOD %HbA1c-6.4*
[**2105-1-28**] 06:02AM BLOOD TSH-1.5

Brief Hospital Course:
1. Cardiac:
-coronaries: She was continued on ASA, plavix, statin.  She was
evaluated by the CT surgery team regarding the possibility of
CABG/valve replacement, and they felt she could follow-up with
them as an outpatient.  It was not felt to be an urgent
inpatient matter and f/u was arranged with Dr. [**Last Name (STitle) **].
Throughout her stay, she had numerous episodes of chest pain
which she states were the typical chest pain she has at home
that wake her up at night.  EKGs were done for all of these
episodes, and never showed any signs of ischemia.  The pain
would resolve on its own or with sublingual nitroglycerin.  It
was unclear whether this pain represented angina or not, however
given the lack of EKG changes it seemed unlikely to be angina.
-pump:  She has an EF of 40%.  Because of her AS, she is
preload-dependent and so was not aggressively diuresed.  Her bp
was difficult to control and several medication adjustments were
made throughout her admission.  She was eventually discharged on
lisinopril, toprol, isosorbide mononitrate, and HCTZ.
-rhythm: remained in sinus throughout.

2. Hypotension:  She was admitted to the CCU for post-cath
hypotension, which resolved by the night of admission.  This was
felt to be most likely related to medications, as the patient
was given her meds on a different schedule than her home regimen
(she usually only takes her meds at night).

2. Heme:  She has a hx of iron-def anemia and was kept on her
iron supplementation.  She was transfused to a hematocrit of 30
given her CAD.

3. Hypothyroidism: continued on levoxyl.

4. Fibromyalgia/Osteoarthritis: She was continued on her home
pain regimen (duragesic, hydrocodone, nambutone).  She was also
given prn percocet.  However, this was attempted to be limited,
as the pt often appeared to be overly medicated on narcotics
(falling asleep during conversations, etc.)

5. PT:  The patient had difficulty ambulating secondary to her
chronic back/leg pain.  She was evaluated by PT, who felt she
was safe to go home w/home PT, which was arranged.

Medications on Admission:
crestor 10 mg po daily
nambutone 500 mg po bid
levoxyl 150 mcg po daily
imdur 120 mg po daily
norvasc 50 mg po tid
plavix 75 mg po daily
lopid 600 mg po daily
toprol XL 100 mg po daily
lisinopril 40 mg po daily
effexor XR 150 mg po daily
hydrocodone 7.5-750 2 tabs q4-6 hrs prn
duragesic patch 125 mcg q48hrs
trazodone 150-200mg po qhs
nitro sublingual prn
ASA 325 po daily
iron 325 mg po tid

Discharge Medications:
1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).

2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
3. Nabumetone 500 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
4. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QHS (once a day (at bedtime)).

6. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Venlafaxine HCl 75 mg Capsule, Sust. Release 24HR Sig: Two
(2) Capsule, Sust. Release 24HR PO QHS (once a day (at
bedtime)).
8. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)).
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO QHS (once
a day (at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
10. Trazodone HCl 50 mg Tablet Sig: 1-3 Tablets PO HS (at
bedtime) as needed.
11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
12. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
13. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) Patch 48HR
Transdermal Q48HRS ().
14. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 48HR
Transdermal Q48HRS ().
15. Rosuvastatin Calcium 20 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
16. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: 1.5 Tablet Sustained Release 24HRs PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2*
17. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
18. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 1474**] VNA

Discharge Diagnosis:
Coronary Artery Disease
Aortic Stenosis
Mitral Regurgitation


Discharge Condition:
stable

Discharge Instructions:
Please call your doctor or return to the emergency room for
worsening chest pain, chest pain that does not resolve with 5
minutes, shortness of breath, nausea, vomiting, abdominal pain,
lightheadedness, or any other concerns.
Please take all of your medications as prescribed.  If some of
your medications are supposed to be taken at intervals during
the day, it is important that you take them at those times.  Do
not just take all of your daily dose at night for medications
that are dosed more than once per day.

Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Last Name (Prefixes) 413**] CARDIAC SURGERY LMOB 2A Where: CARDIAC
SURGERY LMOB 2A Date/Time:[**2105-2-5**] 1:00

f/u with your PCP within one week

You have anemia, which we discussed.  You should talk with your
primary care physician about pursuing an upper endoscopy and a
colonoscopy.
{'Coronary atherosclerosis of native coronary artery,Other and unspecified angina pectoris,Rheumatic heart failure (congestive),Mitral valve insufficiency and aortic valve stenosis,Other iatrogenic hypotension,Iron deficiency anemia, unspecified,Myalgia and myositis, unspecified,Unspecified acquired hypothyroidism,Unspecified essential hypertension,Aortocoronary bypass 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: admitted for pre-op cath

PRESENT ILLNESS: 57 y/o F w/CAD s/p CABG [**2098**] (at [**Hospital1 112**], LIMA->LAD, SVG->RCA,
SVG->OM3), CHF [**1-28**] diastolic dysfxn w/EF 50%, and aortic
stenosis, admitted today for pre-op cath, prior to possible redo
CABG and possible AVR.  She was noted to have aortic stenosis on
a TTE from an OSH in [**7-30**], with a valve area 1.0 cm2, peak
gradient 59 mm Hg, 1+ MR, and mod pulm htn.  Her most recent adm
to the [**Hospital1 **] was [**8-30**], when she presented w/resting CP.  EKG at
that time demonstrated old lat TWI.  She underwent cath which
revealed patent LIMA->LAD, 80% mid LAD, 80% OM1, and 100% OM3
occlusions.   Her EF was noted to be 55%.  She had a PTCA of
OM1, c/b dissection with resulting overlying cypher stents
placed.
Since that intervention, she has noted no improvement in her
anginal symptoms, and has been having 3-6 episodes of angina
daily both at rest and with exertion (episodes resolve w/nitro
spray).  She also c/o orthopnea and increasing LE edema, but no
PND.

MEDICAL HISTORY: 1. CAD
2. Mitral regurg
3. Aortic stenosis
4. rheumatoid arthritis
5. osteoarthritis
6. fibromyalgia
7. hypothyroidism
8. htn
9. hypercholesterolemia
10. depression
11. iron def. anemia
12. s/p appy
13. s/p TAH

MEDICATION ON ADMISSION: crestor 10 mg po daily
nambutone 500 mg po bid
levoxyl 150 mcg po daily
imdur 120 mg po daily
norvasc 50 mg po tid
plavix 75 mg po daily
lopid 600 mg po daily
toprol XL 100 mg po daily
lisinopril 40 mg po daily
effexor XR 150 mg po daily
hydrocodone 7.5-750 2 tabs q4-6 hrs prn
duragesic patch 125 mcg q48hrs
trazodone 150-200mg po qhs
nitro sublingual prn
ASA 325 po daily
iron 325 mg po tid

ALLERGIES: Ambien / Percocet

PHYSICAL EXAM: T: 97.2  P: 67  BP: 127/53  RR: 12 O2 sat: 97%
Gen: alert & oriented anxious female, in NAD
HEENT: NCAT.  no conjunct. pallor.  MMM.
Lungs: CTA bilaterally
CV: RRR, III/VI mid-peaking systolic murmur heard throughout,
radiating to carotids
Abd: obese, nontender, nondistended.  normoactive bowel sounds.
Ext: no edema.  1+ dorsalis pedis pulses bilaterally.

FAMILY HISTORY: Mother had CABG at age 48, died of CAD at age 68
Father had DM, CAD, died of MI

SOCIAL HISTORY: single, has daughter, denies EtOH or tobacco 

### Response:
{'Coronary atherosclerosis of native coronary artery,Other and unspecified angina pectoris,Rheumatic heart failure (congestive),Mitral valve insufficiency and aortic valve stenosis,Other iatrogenic hypotension,Iron deficiency anemia, unspecified,Myalgia and myositis, unspecified,Unspecified acquired hypothyroidism,Unspecified essential hypertension,Aortocoronary bypass status'}
