CHIEF COMPLAINT: SOB

PRESENT ILLNESS: 82 yo male with episode of angioedema  a couple of weeks ago and
has had SOB since. ACE-I was discontinued and angioedema
resolved. Echo revealed worsening aortic stenosis, with [**Location (un) 109**] now
0.6 cm2 (1.4 cm2 2 years ago).Subsequent cath showed
siginificant 3 vessel disease. Transferred here for surgery.

MEDICAL HISTORY: insulin-dependent diabetes mellitus
severe dilated cardiomyopathy
macular degeneration (partially blind)
? emphysema
neuropathy left leg

MEDICATION ON ADMISSION: aspirin 81 mg daily
diovan 80 mg daily
glyburide 10 mg [**Hospital1 **]
insulin (unclear type) 15u QAM
lasix 80 mg daily
metformin 1500 mg daily
Kcl 10 mEq daily

ALLERGIES: Benadryl / Ace Inhibitors

PHYSICAL EXAM: HR 70 RR 12 126/70  5'9"  204#
skin intact
PERRLA, EOMI
neck supple with full ROM
CTAB
RRR
abd soft, NT, ND, + BS
warm, well-perfused
no edema or varicosities noted
neuro grossly intact
2+ bil. fem/DP/PT/radials
murmur transmits to both carotids
left leg skin tag

FAMILY HISTORY: NC

SOCIAL HISTORY: retired
lives alone
20 pack-years -quit many years ago
no recent ETOH use
Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Other primary cardiomyopathies,Unspecified transient mental disorder in conditions classified elsewhere,Aortic valve disorders,Coronary atherosclerosis of native coronary artery,Other acute postoperative pain,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Other nonspecific findings on examination of urine,Polyneuropathy in diabetes,Macular degeneration (senile), unspecified
Ac on chr syst hrt fail,Acute kidney failure NOS,Prim cardiomyopathy NEC,Transient mental dis NOS,Aortic valve disorder,Crnry athrscl natve vssl,Acute postop pain NEC,DMII neuro nt st uncntrl,Long-term use of insulin,Abn urine findings NEC,Neuropathy in diabetes,Macular degeneration NOS
Name:  [**Known lastname 13151**],[**Known firstname 126**] F               Unit No:   [**Numeric Identifier 13152**]

Admission Date:  [**2163-5-4**]              Discharge Date:   [**2163-5-17**]

Date of Birth:  [**2081-3-30**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Benadryl / Ace Inhibitors

Attending:[**First Name3 (LF) 1543**]
Addendum:
On admission baseline creatinine 1.4 with decrease
postoperatively due to volume.  However over the first few days
postoperatively his creatinine progressively increased and
peaked at 2.6 on [**5-10**].  He had received fluids and was on
multiple pressors to maintain blood pressure post operatively.
Due to oliguria he was treated with fluids and lasix for
diuresis with medication adjustment due to acute renal failure
that was resolving at discharge with creatinine decreased to
1.9.

Acute on Chronic systolic heart failure based on Echo with EF
10-20% [**2162-5-5**]. Due to renal function and blood pressure was not
started on ACE inhibitor or [**Last Name (un) **].

Although discharged on Ciprofloxacin for positive urinalysis,
final culture was no growth.

Discharge Disposition:
Extended Care

Facility:
[**Location (un) 13237**] [**Doctor Last Name **]

                             [**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]

Completed by:[**2163-5-26**]

Admission Date:  [**2163-5-4**]              Discharge Date:   [**2163-5-17**]

Date of Birth:  [**2081-3-30**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Benadryl / Ace Inhibitors

Attending:[**First Name3 (LF) 922**]
Chief Complaint:
SOB

Major Surgical or Invasive Procedure:
[**2163-5-5**]  AVR ( 25mm [**Company 1543**] Mosaic Ultra Porcine)/ CABG x3
(LIMA to LAD, SVG to OM, SVG to dRCA/PDA)


History of Present Illness:
82 yo male with episode of angioedema  a couple of weeks ago and
has had SOB since. ACE-I was discontinued and angioedema
resolved. Echo revealed worsening aortic stenosis, with [**Location (un) 109**] now
0.6 cm2 (1.4 cm2 2 years ago).Subsequent cath showed
siginificant 3 vessel disease. Transferred here for surgery.

Past Medical History:
insulin-dependent diabetes mellitus
severe dilated cardiomyopathy
macular degeneration (partially blind)
? emphysema
neuropathy left leg


Social History:
retired
lives alone
20 pack-years -quit many years ago
no recent ETOH use


Family History:
NC

Physical Exam:
HR 70 RR 12 126/70  5'9"  204#
skin intact
PERRLA, EOMI
neck supple with full ROM
CTAB
RRR
abd soft, NT, ND, + BS
warm, well-perfused
no edema or varicosities noted
neuro grossly intact
2+ bil. fem/DP/PT/radials
murmur transmits to both carotids
left leg skin tag

Pertinent Results:

[**2163-5-4**] 05:20PM   GLUCOSE-288* UREA N-33* CREAT-1.4* SODIUM-139
POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-29 ANION GAP-15
[**2163-5-4**] 05:20PM   ALT(SGPT)-14 AST(SGOT)-16 LD(LDH)-227 ALK
PHOS-97 TOT BILI-0.8
[**2163-5-4**] 05:20PM   ALBUMIN-4.1
[**2163-5-4**] 05:20PM   %HbA1c-9.7*
[**2163-5-4**] 05:20PM   WBC-8.8 RBC-3.80* HGB-11.3* HCT-34.4* MCV-91
MCH-29.7 MCHC-32.8 RDW-14.5
[**2163-5-15**] 06:15AM BLOOD WBC-13.4* RBC-3.47* Hgb-10.6* Hct-31.0*
MCV-89 MCH-30.5 MCHC-34.1 RDW-15.5 Plt Ct-459*
[**2163-5-15**] 06:15AM BLOOD Plt Ct-459*
[**2163-5-15**] 06:15AM BLOOD PT-14.9* INR(PT)-1.3*
[**2163-5-15**] 06:15AM BLOOD Glucose-81 UreaN-72* Creat-1.8* Na-138
K-5.1 Cl-99 HCO3-29 AnGap-15
[**2163-5-4**] 05:20PM BLOOD %HbA1c-9.7*

PRE BYPASS
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is severely dilated. There is severe regional left
ventricular systolic dysfunction with akinesis of the septal
walls and severe hypokinesis of the apex, mid to distal
anterior, inferior anterolateral and inferolateral walls. There
is sparing of the anterior, anterolateral, lateral base. Overall
left ventricular systolic function is severely depressed
(LVEF`10%). The RV is mildly to moderately depressed with apical
hypokinesis. There are complex (>4mm) atheroma in the descending
thoracic aorta. There are three aortic valve leaflets. The
aortic valve leaflets are moderately thickened. There is
critical aortic valve stenosis (valve area <0.8cm2). No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**12-31**]+) mitral regurgitation is seen.
Dr. [**Last Name (STitle) 914**] was notified in person of the results.
POST BYPASS
The patient is receiving IV dobutamine at 5 ucg/kg/min and
norepinephrine at 0.07 ucg/kg/min There is slight improvement of
the previously functioning basilar rim of mycocardium in the
setting of inotropes. LVEF~15%. There is slight improvement of
RV systolic function. There is a well seated, well functioning
bioprosthesis in the aortic position (#25 [**Company 1543**] mosaic)
There is no AI visualized. The MR now appears to me mild (1+).
The remaining study is unchanged from prebypass.
  I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2163-5-5**] 14:10
Radiology Report CHEST (PA & LAT) Study Date of [**2163-5-13**] 10:25
AM
 [**Hospital 93**] MEDICAL CONDITION:
   82 year old man s/p CABG x3
REASON FOR THIS EXAMINATION:
   interval chnage
HISTORY: Status post CABG.
IMPRESSION: AP chest compared to [**2163-5-10**]:
Small bilateral pleural effusions persist, left lower lobe
atelectasis is
improved. Postoperative widening of the cardiomediastinal
silhouette is
stable. No pneumothorax. No edema.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: FRI [**2163-5-13**] 12:51 PM

[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT

[**Known lastname 82102**], [**Known firstname **]       [**Hospital1 18**] [**Numeric Identifier 82103**]Portable TTE
(Complete) Done [**2163-5-16**] at 2:12:47 PM      FINAL
Referring Physician     [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**]  Status: Inpatient DOB: [**2081-3-30**]
Age (years): 82 M  Hgt (in): 69
BP (mm Hg): 112/63  Wgt (lb): 210
HR (bpm): 72  BSA (m2): 2.11 m2
Indication: Coronary artery disease. Valvular heart disease.
Aortic valve replacement. CABG.
ICD-9 Codes: 428.0, V43.3, 414.8, 424.1, 424.0
Test Information
Date/Time: [**2163-5-16**] at 14:12    Interpret MD: [**Name6 (MD) **] [**Name8 (MD) 4082**], MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1661**],
RDCS
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Suboptimal
Tape #: 2009W014-0:39 Machine: Vivid [**7-5**]
Echocardiographic Measurements
Results  Measurements  Normal Range
Left Atrium - Long Axis Dimension:  *5.7 cm  <= 4.0 cm
Left Atrium - Four Chamber Length:  *6.8 cm  <= 5.2 cm
Left Atrium - Peak Pulm Vein S:  0.4 m/s
Left Atrium - Peak Pulm Vein D:  0.7 m/s
Right Atrium - Four Chamber Length:  *7.2 cm  <= 5.0 cm
Left Ventricle - Septal Wall Thickness:  0.8 cm  0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness:  1.1 cm  0.6 - 1.1 cm

Left Ventricle - Diastolic Dimension:  *6.0 cm  <= 5.6 cm
Left Ventricle - Systolic Dimension:  5.7 cm
Left Ventricle - Fractional Shortening:  *0.05  >= 0.29
Left Ventricle - Ejection Fraction:  <= 20%  >= 55%
Aorta - Sinus Level:  2.0 cm  <= 3.6 cm
Aorta - Ascending:  2.2 cm  <= 3.4 cm
Aortic Valve - Peak Velocity:  *2.1 m/sec  <= 2.0 m/sec
Aortic Valve - Peak Gradient:  19 mm Hg  < 20 mm Hg
Aortic Valve - Mean Gradient:  12 mm Hg
Aortic Valve - LVOT diam:  2.0 cm
Mitral Valve - E Wave:  1.3 m/sec
Mitral Valve - E Wave deceleration time:  161 ms  140-250 ms

Findings
LEFT ATRIUM: Moderate LA enlargement.

LEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV
cavity. Severe global LV hypokinesis.

RIGHT VENTRICLE: Moderately dilated RV cavity. Severe global RV
free wall hypokinesis.

AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR
well seated, normal leaflet/disc motion and transvalvular
gradients. No AR.

MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild thickening of mitral valve
chordae. Calcified tips of papillary muscles. Mild to moderate
([**12-31**]+) MR.

TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Indeterminate PA systolic pressure.

PERICARDIUM: Small pericardial effusion.

GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Left pleural effusion.
Conclusions
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is mildly
dilated with severe global hypokinesis (LVEF <20 %). The right
ventricular cavity is moderately dilated with severe global free
wall hypokinesis. A bioprosthetic aortic valve prosthesis is
present. The aortic valve prosthesis appears well seated, with
normal transvalvular gradients. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**12-31**]+) mitral regurgitation is seen (may be underestimated). The
pulmonary artery systolic pressure could not be quantified.
There is a small pericardial effusion.

IMPRESSION: Suboptimal image quality. Biventricular cavity
enlargement with severe global hypokinesis. At least
mild-moderate mitral regurgitation. Normal functioning
bioprosthetic aortic valve.

CLINICAL IMPLICATIONS:
Based on [**2160**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis IS recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
  Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2163-5-16**] 17:15


?????? [**2156**] CareGroup IS. All rights reserved.


Brief Hospital Course:
Transfered [**5-4**] from OSH with known AS and 3 vessel coronary
artery disease for surgical evaluation. Brought to the operating
room and underwent Aortic Valve Replacement (#25mm [**Company 1543**]
Mosaic Ultraporcine) /Coronary artery bypass grafting (Left
internal mammary artery grafted to Left anterior descending
artery/Saphenous vein grafted to Obtuse Marginal/Posterior desc.
artery)with Dr. [**Last Name (STitle) 914**] on [**5-5**]. Cross clamp time = 139
minutes/Cardiopulmonary Bypass time =183 minutes. Please refer
to Dr[**Last Name (STitle) 5305**] operative report for further details. He
tolerated the operation well and was transferred to the CVICU in
stable condition on levophed, insulin, dobutamine and propofol
drips. He remained intubated while weaning off of vasoactive
infusions, and on POD#3 maintaining hemodynamic stability, he
awoke neurologically intact and was extubated. Mr.[**Known lastname **] became
increasingly confused after extubation and remained in ICU for
an additional 2 days with minimal narcotic coverage.All lines
and drains removed in a timely fashion. He began to clear
mentally and was transferred to the stepdown floor on POD6 for
further monitoring. The remainder of his postoperative course
was essentially uncomplicated. He was started on Amiodarone and
Anticoagulation with Coumadin for rate controlled Atrial
Fibrillation.  Once on the floor the patient's confusion
cleared, his physical activity was advanced with the assistance
of the nursing and physical therapy staff and on POD 12
Dr.[**Last Name (STitle) 914**] cleared Mr [**Known lastname **] for discharge to rehabilitation at
[**Hospital3 17921**] Center in [**Location (un) 5450**], NH. All follow up
appointments were advised. He will followup with Dr [**Last Name (STitle) 914**] in 2
weeks

Medications on Admission:
aspirin 81 mg daily
diovan 80 mg daily
glyburide 10 mg [**Hospital1 **]
insulin (unclear type) 15u QAM
lasix 80 mg daily
metformin 1500 mg daily
Kcl 10 mEq daily

Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**4-4**]
hours as needed for temp.
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
8. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
11. Ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q12H
(every 12 hours) for 5 days.
12. Furosemide 10 mg/mL Solution Sig: Forty (40) mg Injection
[**Hospital1 **] (2 times a day).
13. Potassium Chloride 20 mEq Packet Sig: Twenty (20) mEq PO
Q12H (every 12 hours).
14. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous once a day.
15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as
needed for wheezes.
16. Warfarin 1 mg Tablet Sig: as directed Tablet PO once a day
as needed for a fib: adjust dose daily to target INR 2-2.5***2mg
to be administered on [**5-17**].
Last 3 days recieved 5/5/5.* Tablet(s)* Refills:*0*
17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours).
18. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours).


Discharge Disposition:
Extended Care

Facility:
[**Location (un) 38640**] [**Doctor Last Name **]

Discharge Diagnosis:
s/p AVR(25 [**Company 1543**]
Ultra-porcine)CABGx3(LIMA-LAD,SVG-OM,SVG-dRCA)[**5-5**]
insulin-dependent diabetes mellitus
severe dilated cardiomyopathy
macular degeneration (partially blind)
? emphysema
neuropathy left leg


Discharge Condition:
stable


Discharge Instructions:
no lotions, creams or powders on any incision
shower daily and pat incisions dry
no driving for one month
no lifting greater than 10 pounds for 10 weeks
call for fever, redness, drainage, or weight gain of 2 pounds in
2 days or 5 pounds in one week
**Daily INR draw for Coumadin dose [**Name8 (MD) **] MD

Followup Instructions:
see Dr. [**Last Name (STitle) 914**] in 2 weeks [**Telephone/Fax (1) 170**]
see Dr.[**Last Name (STitle) 39975**] in 4 weeks
see Dr. [**Last Name (STitle) 76130**] in 6 weeks
please call for appts.



Completed by:[**2163-5-17**]

Name:  [**Known lastname 13151**],[**Known firstname 126**] F               Unit No:   [**Numeric Identifier 13152**]

Admission Date:  [**2163-5-4**]              Discharge Date:   [**2163-5-17**]

Date of Birth:  [**2081-3-30**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Benadryl / Ace Inhibitors

Attending:[**First Name3 (LF) 1543**]
Addendum:
Medication Adjustment on  discharge:

Lasix 40mg po BID (NOT IV)

Discharge Disposition:
Extended Care

Facility:
[**Location (un) 13237**] [**Doctor Last Name **]

                             [**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]

Completed by:[**2163-5-17**]
{'Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Other primary cardiomyopathies,Unspecified transient mental disorder in conditions classified elsewhere,Aortic valve disorders,Coronary atherosclerosis of native coronary artery,Other acute postoperative pain,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Other nonspecific findings on examination of urine,Polyneuropathy in diabetes,Macular degeneration (senile), 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: SOB

PRESENT ILLNESS: 82 yo male with episode of angioedema  a couple of weeks ago and
has had SOB since. ACE-I was discontinued and angioedema
resolved. Echo revealed worsening aortic stenosis, with [**Location (un) 109**] now
0.6 cm2 (1.4 cm2 2 years ago).Subsequent cath showed
siginificant 3 vessel disease. Transferred here for surgery.

MEDICAL HISTORY: insulin-dependent diabetes mellitus
severe dilated cardiomyopathy
macular degeneration (partially blind)
? emphysema
neuropathy left leg

MEDICATION ON ADMISSION: aspirin 81 mg daily
diovan 80 mg daily
glyburide 10 mg [**Hospital1 **]
insulin (unclear type) 15u QAM
lasix 80 mg daily
metformin 1500 mg daily
Kcl 10 mEq daily

ALLERGIES: Benadryl / Ace Inhibitors

PHYSICAL EXAM: HR 70 RR 12 126/70  5'9"  204#
skin intact
PERRLA, EOMI
neck supple with full ROM
CTAB
RRR
abd soft, NT, ND, + BS
warm, well-perfused
no edema or varicosities noted
neuro grossly intact
2+ bil. fem/DP/PT/radials
murmur transmits to both carotids
left leg skin tag

FAMILY HISTORY: NC

SOCIAL HISTORY: retired
lives alone
20 pack-years -quit many years ago
no recent ETOH use 

### Response:
{'Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Other primary cardiomyopathies,Unspecified transient mental disorder in conditions classified elsewhere,Aortic valve disorders,Coronary atherosclerosis of native coronary artery,Other acute postoperative pain,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Other nonspecific findings on examination of urine,Polyneuropathy in diabetes,Macular degeneration (senile), unspecified'}
