CHIEF COMPLAINT: Shortness of breath

PRESENT ILLNESS: 64 year old female with a PMH of ESRD [**2-21**] IgA nephropathy,
a-fib/flutter (on coumadin in the past, recently being held for
hx of septic emboli), MSSA
bacteremia/endocarditis in [**9-/2198**] and hypertension who was
brought in from dialysis with a chief complaint of chest
tightness x 1 hour and shortness of breath for 1 day. She felt
well begninning of last week. However, she started having
dyspnea over night when she was trying to go to bed and had to
sit up. Also states that she was having dry cough. Overnight,
she had some anxiety given her dypsnea. When she was at dialysis
in the morning, she noticed some chest pressure/tightness, which
was substernal, without radiation or frank pain. She had
palpitations during the episode, however they have now resolved.
She denies fever or chills. Per report she was hypotensive
during the session, though her BP improved with stopping
dialysis and her symptoms of tightness resolved. She has been at
rehab since her discharge from hospital for MSSA
bacteremia/endocarditis and for shortness of breath (during
which she was found to be in afib and her amiodarone was
restarted). She is known to cardiac surgery
and being evaluated for a mitral valve replacement.

MEDICAL HISTORY: Mitral regurgitation- Mitral Valve Replacement [**2198-12-6**]
PMH:
1. Atrial fibrillation/flutter
2. End-stage renal disease on hemodialysis secondary to IgA
nephropathy s/p cadaveric kidney transplant in [**2173**] which has
eventually failed, and started on hemodialysis in [**2193**]. Dialysis
on Mo/We/Fri.
3. Upper GI bleeding in [**2195-2-20**] with evidence of
esophagitis, gastric ulcer, and bleeding duodenal vessel s/p
clipping, cauterization and PPI.
4. Diastolic heart failure supported by an echocardiography from
[**2195-12-21**].
5. History of malignant hypertension, which was complicated by
seizure on [**2193-5-20**]. Not on antiepileptic meds.
6. Depression.
7. Rheumatic fever in childhood

MEDICATION ON ADMISSION: 1. CefazoLIN 2 g IV MONDAY AND WEDNESDAY Give dose after HD
2. CefazoLIN 3 g IV Q FRIDAY Give dose after HD
3. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day)
4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY
6. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1)
Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours)
8. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
9. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2
times a day)
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation
13. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS
14. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day)
15. Nepro 0.08-1.80 gram-kcal/mL Liquid Sig: One [**Age over 90 **]y
(120) mL PO twice a day
16. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
17. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY

ALLERGIES: Dilantin Kapseal

PHYSICAL EXAM: Pulse:82 Resp:18  O2 sat: 94/RA
B/P  Right:127/60    Left:unable to obtain d/t fistula
Height:62"     Weight:36.6 kgs

FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. Her father died at the age of 80. Her
mother died at the age of 64 from lung CA. She has a sister with
breast CA. MI in uncle in his 60s.

SOCIAL HISTORY: Originally from [**Country 65588**], single, used to live by herself in
[**Location (un) 686**], and has no children. Has been in the rehab facility
or the hospital from [**Month (only) **] to [**Month (only) **] in [**2198**]. Ambulates w/walker at
rehab facility.
Aortic valve disorders,End stage renal disease,Acute respiratory failure following trauma and surgery,Cerebral embolism with cerebral infarction,Other postoperative infection,Bacteremia,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Atrial flutter,Iatrogenic cerebrovascular infarction or hemorrhage,Complications of transplanted kidney,Chronic diastolic heart failure,Cachexia,Body Mass Index less than 19, adult,Hyposmolality and/or hyponatremia,First degree atrioventricular block,Leukocytosis, unspecified,Aneurysm of artery of upper extremity,Anemia in chronic kidney disease,Depressive disorder, not elsewhere classified,Personal history of tobacco use,Renal dialysis status,Personal history of venous thrombosis and embolism,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation
Aortic valve disorder,End stage renal disease,Ac resp flr fol trma/srg,Crbl emblsm w infrct,Other postop infection,Bacteremia,Pseudomonas infect NOS,Hyp kid NOS w cr kid V,Atrial flutter,Iatrogen CV infarc/hmrhg,Compl kidney transplant,Chr diastolic hrt fail,Cachexia,BMI less than 19,adult,Hyposmolality,Atriovent block-1st degr,Leukocytosis NOS,Upper extremity aneurysm,Anemia in chr kidney dis,Depressive disorder NEC,History of tobacco use,Renal dialysis status,Hx-ven thrombosis/embols,Abn react-org transplant
Admission Date:  [**2198-12-6**]              Discharge Date:   [**2198-12-19**]

Date of Birth:  [**2134-9-9**]             Sex:   F

Service: CARDIOTHORACIC

Allergies:
Dilantin Kapseal

Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Shortness of breath

Major Surgical or Invasive Procedure:
[**2198-12-6**]:
1. Mitral valve replacement with a 25/33-mm  On-X mechanical
valve, reference number [**Serial Number 101277**], serial number [**Serial Number 101278**]. 2.
Pericardial reconstruction with CorMatrix pericardial closure
device, reference number [**Serial Number 42232**], lot number [**Serial Number 101279**].


History of Present Illness:
64 year old female with a PMH of ESRD [**2-21**] IgA nephropathy,
a-fib/flutter (on coumadin in the past, recently being held for
hx of septic emboli), MSSA
bacteremia/endocarditis in [**9-/2198**] and hypertension who was
brought in from dialysis with a chief complaint of chest
tightness x 1 hour and shortness of breath for 1 day. She felt
well begninning of last week. However, she started having
dyspnea over night when she was trying to go to bed and had to
sit up. Also states that she was having dry cough. Overnight,
she had some anxiety given her dypsnea. When she was at dialysis
in the morning, she noticed some chest pressure/tightness, which
was substernal, without radiation or frank pain. She had
palpitations during the episode, however they have now resolved.
She denies fever or chills. Per report she was hypotensive
during the session, though her BP improved with stopping
dialysis and her symptoms of tightness resolved. She has been at
rehab since her discharge from hospital for MSSA
bacteremia/endocarditis and for shortness of breath (during
which she was found to be in afib and her amiodarone was
restarted). She is known to cardiac surgery
and being evaluated for a mitral valve replacement.

Past Medical History:
Mitral regurgitation- Mitral Valve Replacement [**2198-12-6**]
PMH:
1. Atrial fibrillation/flutter
2. End-stage renal disease on hemodialysis secondary to IgA
nephropathy s/p cadaveric kidney transplant in [**2173**] which has
eventually failed, and started on hemodialysis in [**2193**]. Dialysis
on Mo/We/Fri.
3. Upper GI bleeding in [**2195-2-20**] with evidence of
esophagitis, gastric ulcer, and bleeding duodenal vessel s/p
clipping, cauterization and PPI.
4. Diastolic heart failure supported by an echocardiography from
[**2195-12-21**].
5. History of malignant hypertension, which was complicated by
seizure on [**2193-5-20**]. Not on antiepileptic meds.
6. Depression.
7. Rheumatic fever in childhood


Social History:
Originally from [**Country 65588**], single, used to live by herself in
[**Location (un) 686**], and has no children. Has been in the rehab facility
or the hospital from [**Month (only) **] to [**Month (only) **] in [**2198**]. Ambulates w/walker at
rehab facility.

She quit smoking 25 years ago (10-pack-years). She rarely drinks
alcohol, and denies illicit drug use. She used to work part-time
in a coffee shop, but currently does not work. She is Buddhist.


Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. Her father died at the age of 80. Her
mother died at the age of 64 from lung CA. She has a sister with
breast CA. MI in uncle in his 60s.

Physical Exam:
Pulse:82 Resp:18  O2 sat: 94/RA
B/P  Right:127/60    Left:unable to obtain d/t fistula
Height:62"     Weight:36.6 kgs

General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck:  Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x]  Irregular []  Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x]  bowel sounds
+ [x]
Extremities: Warm [x], well-perfused []  Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral      Right: palp  Left: palp
DP           Right: palp  Left: palp
PT           [**Name (NI) 167**]: palp  Left: dop
Radial       Right: plap  Left: palp

LUE AV fistula

Carotid Bruit        Right: none    Left: none


Pertinent Results:
[**2198-12-6**] ECHO
PRE-BYPASS: No spontaneous echo contrast is seen in the body of
the left atrium or 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. 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 aortic arch. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened. There is mild aortic valve
stenosis (valve area 1.2-1.9cm2). Mild (1+) aortic regurgitation
is seen. There is severe mitral annular calcification. There is
severe thickening of the mitral valve chordae. Posterior leaflet
motion is restricted due to heavy calcification. There is mild
valvular mitral stenosis (area 1.5-2.0cm2). An eccentric,
anteriorly directed jet of moderate (2+) mitral regurgitation is
seen. There is a small pericardial effusion. Bilateral pleural
effusions are seen. Dr. [**Last Name (STitle) 914**] was notified in person of the
results at time of surgery.

POST-BYPASS: The patient is AV paced. The patient is on no
inotropes. Biventricular function is unchanged. No regional wall
motion abnormalities are seen. There is a well-seated,
well-functioning mechanical prosthesis in the mitral position.
No mitral regurgitation is seen. No paravalvular leak is seen.
Characteristic washing jets are present. There is a mean
gradient of 3 mmHg at a cardiac output of 4.3 L/min. Aortic
regurgitation is unchanged. Tricuspid regurgitation is
unchanged. The aorta is intact post-decannulation.
.
MRA BRAIN W/O CONTRAST Study Date of [**2198-12-14**] 8:30 PM


[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2198-12-14**] 8:30 PM
MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST; MRA NECK W/O
CONTRAST   Clip # [**Clip Number (Radiology) 101280**]
Reason: infarct/rule out bleed



[**Hospital 93**] MEDICAL CONDITION:
   64 year old woman with hx bihemispheric small infarcts likely
due to MV
   vegetation. Now s/p MVR with change in MS
REASON FOR THIS EXAMINATION:
   infarct/rule out bleed
CONTRAINDICATIONS FOR IV CONTRAST:
   None.



Wet Read: GMSj FRI [**2198-12-14**] 11:54 PM
MRI Brain:
No intra- or extra- axial hemorrhage
No midline shift, no signs of herniation
New punctate areas of restricted diffusion in the right
parietal, left and
right frontal, and right occipital lobes and in the splenium of
the corpus
callosum on the left - findings concerning for embolic infarcts.

Chronicity is uncertain and some of these regions appear
hyperintense on FLAIR
sequences suggesting a subacute process - though others are not
clearly
delineated.

Preliminary findinds d/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] (cardiac surgery) at
11:30 pm on
[**2198-12-14**] by telephone. GSenapati [**Pager number 101281**]
Wet Read Audit # 1


Final Report
EXAM: MRI of the brain.

CLINICAL INFORMATION: Patient with bihemispheric small infarcts,
likely due
to mitral valve vegetation, now status post MVR with change in
mental status.

TECHNIQUE: T1 sagittal and FLAIR, T2 susceptibility and
diffusion axial
images of the brain were acquired. 3D time-of-flight MRA of the
circle of
[**Location (un) 431**] obtained. 2D time-of-flight MRA of the head and neck was
obtained.

Comparison was made with the previous MRI examination of
[**2198-11-13**].

FINDINGS:

BRAIN MRI:

There are several areas of restricted diffusion seen
predominantly in the deep
white matter of both cerebral hemispheres. In comparison to the
prior study
it demonstrates evolution of some of the previously seen
infarcts which are
now seen as T2 shine through. However, the other areas appear to
be
representing acute infarcts. Given the multiplicity as well as
the
involvement of both cerebral hemispheres and multiple vascular
territories
including the splenium of left side of the corpus callosum, the
findings are
suggestive of embolic infarcts. There is no evidence of acute or
chronic
hemorrhage seen. Moderate-to-severe changes of small vessel
disease and brain
atrophy identified. Soft tissue changes seen in the mastoid air
cells, right
greater than left side. Retention cyst is seen in the left
maxillary sinus.

IMPRESSION:

Multiple acute predominantly deep white matter infarcts are
identified which
are new since the previous MRI examination. Several previously
seen infarcts
have evolved. Small vessel disease and brain atrophy seen. No
midline shift.

MRA HEAD:

The head MRA demonstrates normal flow signal in the arteries of
anterior and
posterior circulation. No evidence of stenosis or occlusion of
the major
vascular structures seen. No evidence of aneurysm greater than 3
mm in size.

MRA NECK:

The neck MRA obtained with 2D time-of-flight study demonstrates
no vascular
occlusion or stenosis in the carotid or vertebral arteries.

IMPRESSION:

Normal MRA of the neck.

DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**]
Approved: SAT [**2198-12-15**] 1:28 PM

  Imaging Lab

.
LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Study Date of
[**2198-12-10**] 11:45 AM


[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] CSRU [**2198-12-10**] 11:45 AM
LIVER OR GALLBLADDER US (SINGL   Clip # [**Clip Number (Radiology) 101282**]
Reason: RUQ PAIN; ?CHOLECYSTITIS



[**Hospital 93**] MEDICAL CONDITION:
   64 year old woman with abd pain. S/p MVR for endocarditis.
Ess nl LFTs but
   fever yest w/ GNR in blood.
REASON FOR THIS EXAMINATION:
   ? cholecystitis



Final Report
INDICATION: 64-year-old female with abdominal pain status post
MVR for
endocarditis. Question cholecystitis.

COMPARISON: CT and ultrasound dated [**2198-10-7**].

FINDINGS: Evaluation is somewhat limited by presence of a
midline abdominal
dressing. Allowing for such, the liver demonstrates no focal or
textural
abnormality. There is no biliary dilatation. The common duct
measures 5 mm.
The gallbladder, however, appears to demonstrate slightly
increased wall
thickening as compared to [**2198-10-7**], with a suggestion
of trace
pericholecystic fluid. The gallbladder remains mildly distended,
with a few
sub-3-mm anterior wall polyps, of doubtful clinical
significance. Son[**Name (NI) 493**]
[**Name2 (NI) **] sign is negative. The spleen is 10 cm and within normal
appearance.
There is no appreciable abdominal ascites. Normal hepatopetal
flow is seen in
the portal vein.

IMPRESSION: 1. Persistent gallbladder distention with new wall
thickening as
compared with [**2198-10-7**], with trace pericholecystic
fluid in this
patient with normal albumin. Acute cholecystitis cannot be
excluded. If
there is a persistent clinical suspicion, a HIDA scan should be
performed for
further evaluation.

The study and the report were reviewed by the staff radiologist.


DR. [**First Name8 (NamePattern2) 8083**] [**Name (STitle) 8084**]
DR. [**First Name8 (NamePattern2) 7722**] [**Last Name (NamePattern1) 7723**]
Approved: MON [**2198-12-10**] 9:36 PM

  Imaging Lab

ECHO [**2198-12-17**]
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. There are prominent pectinate
muscles in the right atrial appendage. No atrial septal defect
or patent foramen ovale is seen by 2D, color Doppler or saline
contrast at rest. Left ventricular systolic function is
hyperdynamic (EF>75%). Right ventricular chamber size and free
wall motion are normal. There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened. No masses or vegetations are seen on the
aortic valve. Trace aortic regurgitation is seen. A bileaflet
mechanical mitral valve prosthesis is present. The mitral
prosthesis appears well seated, with normal disc motion and
transvalvular gradients. No mass or vegetation is seen on the
mitral valve. Mild (1+) mitral regurgitation is seen (normal for
this prosthesis). There is no pericardial effusion.

IMPRESSION: Well-seated, normally functioning bileaflet
mechanical mitral valve prosthesis. Mild mitral regurgitation.
No echocardiographic evidence of intracardiac thrombus or
endocarditis seen
  I certify that I was present for this procedure in compliance
with HCFA regulations.

Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2198-12-17**] 18:30



Brief Hospital Course:
Ms. [**Name13 (STitle) 101283**] was admitted to the [**Hospital1 18**] on [**2198-12-6**] for surgical
management of her mitral valve disease. She was taken to the
operating room where she underwent a mitral valve replacement
using an on-x mechanical valve. Please see operative note for
details. Postoperatively she was taken to the intensive care
unit for monitoring. Over the next several hours, she awoke
neurologically intact and was extubated. The renal service was
consulted given her history of IgA nephropathy and end stage
renal disease on hemodialysis. Hemodialysis was initiated for
volume removal.  She was initially dialyzed daily for volume
overload, and returned to her Monday, Wednesday, Friday schedule
when she stabilized.
 She remained in the unit for sinus bradycardia. The
electrophysiology service was consulted.  She was found to have
a ventricular escape rhythm with a rate of 40bpm.  EP felt that
her rhythm would recover and a pacer would not be necessary.
Anti-coagulation was initiated with Warfarin for the mechanical
Mitral Valve.
ID followed for endocarditis.  There was no growth on valve
tissue sent from OR.  She did develop Pseudomonas and Morganella
bacteremia.  Antibiotics were adjusted accordingly to Cefepime.
The patient improved on this and the course will complete on
[**2198-12-23**].  Ultrasound revealed gall-bladder wall thickening.
This will be pursued with HIDA if bacteremia does not resolve.
Transplant surgery was consulted to evaluate the left upper
extremity AV fistula as the possible source of bacteremia.  Dr.
[**Last Name (STitle) **] determined this was an unlikely source.  There are
aneurysmal areas of the fistula that will need to be evaluated
as an outpatient with Dr. [**Last Name (STitle) **], following discharge.  It is
recommended to avoid scabbed areas when accessing AVF for HD.
Left upper extremity was found to be edematous.  Ultrasound was
negative for DVT.
INR became supra-therapeutic quickly in the setting of poor
appetite and nutritional depletion.  She was given FFP and
Coumadin doses were very carefully titrated.  The patient
received a PICC on [**2198-12-10**] for continued IV antibiotic therapy.

Rapid atrial fibrillation developed.  The patient converted to
Sinus Rhythm with IV Amiodarone and IV Lopressor.  She remained
in Sinus Rhythm with 1st degree AV block on PO Amio and Coreg.
Amiodarone was discontinued for prolonged QTC. Chest tubes and
pacing wires were discontinued without complication.
The patient was transferred to the telemetry floor for further
recovery.  The patient was evaluated by the physical therapy
service for assistance with strength and mobility.  She did
develop some confusion in dialysis on [**12-14**].  MRA of the brain
revealed multiple embolic infarcts- acute/ and sub acute.
Neurology was consulted and felt it unlikely that the emboli are
septic.  On [**2198-12-16**] a TEE was done and cardiac thrombus was
ruled out emboli.  The patient's mental status cleared, and her
blood pressure was allowed to remain above 120mmHg systolic, as
she remained oriented under this condition.

  By the time of discharge on POD #13 the patient remained
deconditioned ambulating short distances with assistance, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged to the [**Hospital 100**] Rehab MACU in good
condition with appropriate follow up instructions.

Medications on Admission:
1. CefazoLIN 2 g IV MONDAY AND WEDNESDAY Give dose after HD
2. CefazoLIN 3 g IV Q FRIDAY Give dose after HD
3. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day)
4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY
6. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1)
Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours)
8. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
9. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2
times a day)
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation
13. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS
14. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day)
15. Nepro 0.08-1.80 gram-kcal/mL Liquid Sig: One [**Age over 90 **]y
(120) mL PO twice a day
16. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
17. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY

Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. B-complex with vitamin C     Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

8. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) for 9 days.
10. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain/temp.
11. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
12. Cepacol Sore Throat  Mucous membrane
13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours) as
needed for wheezing.
14. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
15. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
16. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
17. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
18. cefepime 1 gram Recon Soln Sig: One (1) Recon Soln Injection
Q24H (every 24 hours) for 4 days: end date [**2198-12-23**].
19. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

20. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

21. warfarin 1 mg Tablet Sig: dose based on INR Tablet PO Once
Daily at 4 PM: very sensitive to coumadin-has been on 0.5mg
coumadin.
22. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
Mitral regurgitation- Mitral Valve Replacement [**2198-12-6**]
PMH:
1. Atrial fibrillation/flutter
2. End-stage renal disease on hemodialysis secondary to IgA
nephropathy s/p cadaveric kidney transplant in [**2173**] which has
eventually failed, and started on hemodialysis in [**2193**]. Dialysis
on Mo/We/Fri.
3. Upper GI bleeding in [**2195-2-20**] with evidence of
esophagitis, gastric ulcer, and bleeding duodenal vessel s/p
clipping, cauterization and PPI.
4. Diastolic heart failure supported by an echocardiography from
[**2195-12-21**].
5. History of malignant hypertension, which was complicated by
seizure on [**2193-5-20**]. Not on antiepileptic meds.
6. Depression.
7. Rheumatic fever in childhood


Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Incisional pain managed with APAP
Incisions:
Sternal - healing well, no erythema or drainage
Edema -trace


Discharge Instructions:
1) 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.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) 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. [**Last Name (STitle) 914**], [**Telephone/Fax (1) 170**] Date/Time:[**2198-12-24**] 2:00pm in
the [**Hospital **] medical office building [**Doctor First Name **] [**Hospital Unit Name **]
Cardiologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) 62**] Date/Time:[**2198-12-19**]
11:40

Please call to schedule appointments with:
Transplant Surgery for AV fistula: [**Telephone/Fax (1) 673**] (Dr. [**Last Name (STitle) **] or
Dr. [**First Name (STitle) **]
Primary Care Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 250**] in [**4-24**] 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**

Labs: PT/INR for Coumadin ?????? indication- mechanical Mitral Valve
Goal INR 3.0-3.5
First draw [**2198-12-20**], then Monday Wednesday, Friday until
stabilized.  MD to dose daily



Completed by:[**2198-12-19**]
{'Aortic valve disorders,End stage renal disease,Acute respiratory failure following trauma and surgery,Cerebral embolism with cerebral infarction,Other postoperative infection,Bacteremia,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Atrial flutter,Iatrogenic cerebrovascular infarction or hemorrhage,Complications of transplanted kidney,Chronic diastolic heart failure,Cachexia,Body Mass Index less than 19, adult,Hyposmolality and/or hyponatremia,First degree atrioventricular block,Leukocytosis, unspecified,Aneurysm of artery of upper extremity,Anemia in chronic kidney disease,Depressive disorder, not elsewhere classified,Personal history of tobacco use,Renal dialysis status,Personal history of venous thrombosis and embolism,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}


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: 64 year old female with a PMH of ESRD [**2-21**] IgA nephropathy,
a-fib/flutter (on coumadin in the past, recently being held for
hx of septic emboli), MSSA
bacteremia/endocarditis in [**9-/2198**] and hypertension who was
brought in from dialysis with a chief complaint of chest
tightness x 1 hour and shortness of breath for 1 day. She felt
well begninning of last week. However, she started having
dyspnea over night when she was trying to go to bed and had to
sit up. Also states that she was having dry cough. Overnight,
she had some anxiety given her dypsnea. When she was at dialysis
in the morning, she noticed some chest pressure/tightness, which
was substernal, without radiation or frank pain. She had
palpitations during the episode, however they have now resolved.
She denies fever or chills. Per report she was hypotensive
during the session, though her BP improved with stopping
dialysis and her symptoms of tightness resolved. She has been at
rehab since her discharge from hospital for MSSA
bacteremia/endocarditis and for shortness of breath (during
which she was found to be in afib and her amiodarone was
restarted). She is known to cardiac surgery
and being evaluated for a mitral valve replacement.

MEDICAL HISTORY: Mitral regurgitation- Mitral Valve Replacement [**2198-12-6**]
PMH:
1. Atrial fibrillation/flutter
2. End-stage renal disease on hemodialysis secondary to IgA
nephropathy s/p cadaveric kidney transplant in [**2173**] which has
eventually failed, and started on hemodialysis in [**2193**]. Dialysis
on Mo/We/Fri.
3. Upper GI bleeding in [**2195-2-20**] with evidence of
esophagitis, gastric ulcer, and bleeding duodenal vessel s/p
clipping, cauterization and PPI.
4. Diastolic heart failure supported by an echocardiography from
[**2195-12-21**].
5. History of malignant hypertension, which was complicated by
seizure on [**2193-5-20**]. Not on antiepileptic meds.
6. Depression.
7. Rheumatic fever in childhood

MEDICATION ON ADMISSION: 1. CefazoLIN 2 g IV MONDAY AND WEDNESDAY Give dose after HD
2. CefazoLIN 3 g IV Q FRIDAY Give dose after HD
3. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day)
4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY
6. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1)
Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours)
8. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
9. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2
times a day)
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation
13. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS
14. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day)
15. Nepro 0.08-1.80 gram-kcal/mL Liquid Sig: One [**Age over 90 **]y
(120) mL PO twice a day
16. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
17. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY

ALLERGIES: Dilantin Kapseal

PHYSICAL EXAM: Pulse:82 Resp:18  O2 sat: 94/RA
B/P  Right:127/60    Left:unable to obtain d/t fistula
Height:62"     Weight:36.6 kgs

FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. Her father died at the age of 80. Her
mother died at the age of 64 from lung CA. She has a sister with
breast CA. MI in uncle in his 60s.

SOCIAL HISTORY: Originally from [**Country 65588**], single, used to live by herself in
[**Location (un) 686**], and has no children. Has been in the rehab facility
or the hospital from [**Month (only) **] to [**Month (only) **] in [**2198**]. Ambulates w/walker at
rehab facility. 

### Response:
{'Aortic valve disorders,End stage renal disease,Acute respiratory failure following trauma and surgery,Cerebral embolism with cerebral infarction,Other postoperative infection,Bacteremia,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Atrial flutter,Iatrogenic cerebrovascular infarction or hemorrhage,Complications of transplanted kidney,Chronic diastolic heart failure,Cachexia,Body Mass Index less than 19, adult,Hyposmolality and/or hyponatremia,First degree atrioventricular block,Leukocytosis, unspecified,Aneurysm of artery of upper extremity,Anemia in chronic kidney disease,Depressive disorder, not elsewhere classified,Personal history of tobacco use,Renal dialysis status,Personal history of venous thrombosis and embolism,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}
