CHIEF COMPLAINT: Shortness of breath

PRESENT ILLNESS: 78F with history of atrial fibrillation/flutter and
hypothyroidism who presented to the ED with complaint of
shortness of breath and low grade fever, associated with cough.
Patient states that she has been short of breath for the few
weeks since her recent admission on [**10-30**] at [**Hospital3 **] for
A. Fib with RVR.  Prior to that admission, PAF was well
controlled for 3 years.  During that admission, Rythmol dose was
doubled.  She subsequently followed up with her cardiologist,
Dr. [**Last Name (STitle) 10543**], last week at which time her Rythmol dose was
decreased back to her normal dose of 225 mg [**Hospital1 **] of SR
formulation and her pacemaker setting was decreased to 100.  The
next 24 hours she became so short of breath that she was unable
to carry out any activities, barely able to walk a few steps.
She returned to his office the next day and pacemaker was re-set
to 110, with some improvement in symptoms.  She then developed
worsening shortness of breath over last weekend with another
visit to her cardiologist 2 days prior to presentation.  She
reports a CXR showed fluid on her lungs, she declined lasix at
that time.  Since then, has had worsening shortness of breath,
non-productive cough and fever x 1 to 100.4 last night.
Overnight, she noted worsening shortness of breath, unable to
sleep and necessitating sitting up in a chair all night.  Also
noted belching, nausea, and substernal chest pain x 24 hours,
worse with coughing, non-radiating.  Of note, has had 3 pound
weight gain over past week.  Denies syncope, peripheral edema.
.
In the ED, initial VS were: 98.4  142/72  82  24  97%RA
Patient was given Zofran 4 mg for nausea, ASA 325 mg and NTG
0.4mg SL x 3 for chest discomfort.  After chest x-ray, due to
concern for CHF vs. PNA, was given Lasix 20 mg IV x 1 and
Cefepime 2g IV x 1.
.
On the floor, patient is in no acute distress.  She continues to
complain of some shortness of breath and occasional cough.

MEDICAL HISTORY: Atrial fibrillation- with multiples episode of palpitations in
the past
S/p pacemaker [**2139**]: s/p generator change [**2143**] at [**Hospital3 **]

MEDICATION ON ADMISSION: Levothyroxine 137 mcg qday
Metoprol Succinate 75 mg qday
Pantoprazole 40 mg qday
Propafenone 225 mg [**Hospital1 **]
Warfarin 2.5 mg MWF and 5mg T,Th,[**Last Name (LF) **],[**First Name3 (LF) **]

ALLERGIES: Penicillins / Keflex / Amoxicillin / Sulfa (Sulfonamide
Antibiotics) / Iodine-Iodine Containing

PHYSICAL EXAM: Pulse:63 Resp:18  O2 sat: 92/RA
B/P  136/84
Height:  66"   Weight: 87kgs

FAMILY HISTORY: Mother died of "tachycardia".  Father died of bladder/kidney
cancer.  Brother died of hodgkins lymphoma at 21.

SOCIAL HISTORY: Does not drink, no history of tobacco or drug use.
Divorced/retired, living alone in [**Location 1268**].
Independent in all ADLs.
Acute on chronic diastolic heart failure,Cerebral artery occlusion, unspecified with cerebral infarction,Pneumonia, organism unspecified,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Mitral valve disorders,Atrial fibrillation,Unspecified essential hypertension,Hip joint replacement,Postsurgical hypothyroidism,Cardiac pacemaker in situ,Diarrhea,Other speech disturbance,Other specified retention of urine,Esophageal reflux,Benign paroxysmal positional vertigo,Constipation, unspecified,Other chronic pulmonary heart diseases
Ac on chr diast hrt fail,Crbl art ocl NOS w infrc,Pneumonia, organism NOS,Acute kidney failure NOS,Hyposmolality,Mitral valve disorder,Atrial fibrillation,Hypertension NOS,Joint replaced hip,Postsurgical hypothyroid,Status cardiac pacemaker,Diarrhea,Speech disturbance NEC,Oth spcf retention urine,Esophageal reflux,Benign parxysmal vertigo,Constipation NOS,Chr pulmon heart dis NEC
Name:  [**Known lastname **],[**Known firstname **]                  Unit No:   [**Numeric Identifier 16189**]

Admission Date:  [**2144-11-18**]              Discharge Date:   [**2144-12-22**]

Date of Birth:  [**2066-11-9**]             Sex:   F

Service: CARDIOTHORACIC

Allergies:
Penicillins / Keflex / Amoxicillin / Sulfa (Sulfonamide
Antibiotics) / Iodine-Iodine Containing

Attending:[**First Name3 (LF) 741**]
Addendum:
ASA 81 mg discontinued, ASA 325 mg continued

Discharge Disposition:
Extended Care

Facility:
[**Location (un) **] AT [**Location (un) **]

                             [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]

Completed by:[**2144-12-22**]

Admission Date:  [**2144-11-18**]              Discharge Date:   [**2144-12-22**]

Date of Birth:  [**2066-11-9**]             Sex:   F

Service: CARDIOTHORACIC

Allergies:
Penicillins / Keflex / Amoxicillin / Sulfa (Sulfonamide
Antibiotics) / Iodine-Iodine Containing

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath


Major Surgical or Invasive Procedure:
[**2144-12-2**] Mitral valve repair with a 26-mm
annuloplasty ring (physio II).


History of Present Illness:
78F with history of atrial fibrillation/flutter and
hypothyroidism who presented to the ED with complaint of
shortness of breath and low grade fever, associated with cough.
Patient states that she has been short of breath for the few
weeks since her recent admission on [**10-30**] at [**Hospital3 **] for
A. Fib with RVR.  Prior to that admission, PAF was well
controlled for 3 years.  During that admission, Rythmol dose was
doubled.  She subsequently followed up with her cardiologist,
Dr. [**Last Name (STitle) 10543**], last week at which time her Rythmol dose was
decreased back to her normal dose of 225 mg [**Hospital1 **] of SR
formulation and her pacemaker setting was decreased to 100.  The
next 24 hours she became so short of breath that she was unable
to carry out any activities, barely able to walk a few steps.
She returned to his office the next day and pacemaker was re-set
to 110, with some improvement in symptoms.  She then developed
worsening shortness of breath over last weekend with another
visit to her cardiologist 2 days prior to presentation.  She
reports a CXR showed fluid on her lungs, she declined lasix at
that time.  Since then, has had worsening shortness of breath,
non-productive cough and fever x 1 to 100.4 last night.
Overnight, she noted worsening shortness of breath, unable to
sleep and necessitating sitting up in a chair all night.  Also
noted belching, nausea, and substernal chest pain x 24 hours,
worse with coughing, non-radiating.  Of note, has had 3 pound
weight gain over past week.  Denies syncope, peripheral edema.
.
In the ED, initial VS were: 98.4  142/72  82  24  97%RA
Patient was given Zofran 4 mg for nausea, ASA 325 mg and NTG
0.4mg SL x 3 for chest discomfort.  After chest x-ray, due to
concern for CHF vs. PNA, was given Lasix 20 mg IV x 1 and
Cefepime 2g IV x 1.
.
On the floor, patient is in no acute distress.  She continues to
complain of some shortness of breath and occasional cough.

ECHO was done revealing severe mitral regurg and moderate aortic
stenosis

Past Medical History:
Atrial fibrillation- with multiples episode of palpitations in
the past
S/p pacemaker [**2139**]: s/p generator change [**2143**] at [**Hospital3 **]

GERD
. Diverticulosis
hypertension
Cataract surgery
S/p TAH/BSO d/t bleeding endometriosis
Bilateral hip replacement
Benign positional vertigo
Urinary retention
Cyctocele/rectocele
Allergic Rhinitis
Esophageal strictures s/p dilation
S/p bladder suspension
Chest pain with normal coronaries by cath at [**Name (NI) **], pt
reports being "shocked" at the end of the case-
Osteoarthritis
Tonsillectomy
Appendectomy
Cholecystectomy
hypothyroidism/partial thyroidectomy

Social History:
Does not drink, no history of tobacco or drug use.
Divorced/retired, living alone in [**Location 1268**].
Independent in all ADLs.

Family History:
Mother died of "tachycardia".  Father died of bladder/kidney
cancer.  Brother died of hodgkins lymphoma at 21.

Physical Exam:
Pulse:63 Resp:18  O2 sat: 92/RA
B/P  136/84
Height:  66"   Weight: 87kgs

General:  NAD, alert, cooperative
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck:  Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally []few wheezes and scattered
rhonchi
Heart: RRR [x]  Irregular []  Murmur - I/VI systolic murmur 4th
LICS
Abdomen: Soft [x] non-distended [x] non-tender []x  bowel sounds
+ []
Extremities: Warm [x], well-perfused [x]  Edema Varicosities:
None []
Neuro: Grossly intact
Pulses:
Femoral      Right:   Left:
DP           Right:+2   Left:+2
PT           [**Name (NI) 167**]:+2   Left:+2
Radial       Right: +2  Left:+2

Carotid Bruit        Right: no bruit   Left: soft bruit


Pertinent Results:
Discharge
[**2144-12-15**] 04:45AM BLOOD WBC-10.5 RBC-3.81* Hgb-10.5* Hct-31.5*
MCV-83 MCH-27.5 MCHC-33.4 RDW-17.1* Plt Ct-353
[**2144-12-16**] 04:25AM BLOOD PT-16.6* INR(PT)-1.5*
[**2144-12-16**] 04:25AM BLOOD Na-132* K-4.9 Cl-89*
[**2144-12-15**] 04:45AM BLOOD Glucose-118* UreaN-29* Creat-1.2* Na-132*
K-4.0 Cl-91* HCO3-30 AnGap-15
[**2144-12-22**] INR 2.2 Na 133 BUN 23 Crea 1.0 K 3.8 WBC 7.0 Hct 29.8
ECHO [**2144-11-23**] - The left atrium is mildly dilated. The
estimated right atrial pressure is 10-20mmHg. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). [Intrinsic left ventricular
systolic function is likely more depressed given the severity of
valvular regurgitation.] Right ventricular chamber size is
mildly increased with preserved free wall motion. The diameters
of aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild to moderate ([**1-18**]+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Severe (4+) mitral
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. Significant pulmonic regurgitation is seen. There
is no pericardial effusion.
IMPRESSION: Mildly thickened mitral valve leaflets with severe
mitral regurgitation. Severe pulmlonary artery systolic
hypertension. Right ventricular cavity enlargement with
preserved systolic function. Normal left ventricular cavity size
with preserved regional and global systolic function.
Mild-moderate aortic regurgitation.

TEE [**2144-11-24**] - No atrial septal defect is seen by 2D or color
Doppler. Overall left ventricular systolic function is normal
(LVEF>55%). (Intrinisic LV function may be depressed given the
presence of significant mitral regurgitation). 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. Mild (1+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. There is no frank mitral
valve prolapse but there is some leaflet redundancy. Moderate to
severe (3+) central mitral regurgitation is seen. No reversal of
flow is identified in the pulmonary veins (4 seen entering the
left atrium). There is at least moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.

TEE (Complete) [**2144-12-2**] at 14:49
Echocardiographic Measurements
Results  Measurements  Normal Range
Left Ventricle - Septal Wall Thickness:  0.9 cm  0.6 - 1.1 cm
Left Ventricle - Ejection Fraction:  55%  >= 55%
Conclusions  Prebypass
The left atrium is dilated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thicknesses are
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF>55%).
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] 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 but aortic stenosis is
not present. Moderate (2+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Moderate to severe
(3+) mitral regurgitation is seen. There is no structural
abnormality seen with the mitral valve. The mitral regurgitation
is central with an annulus size of 3.8 cm. Moderate [2+]
tricuspid regurgitation is seen. There is no pericardial
effusion. Dr. [**Last Name (STitle) **] was notified in person of the results on
[**2144-12-2**] at 1330pm.
Post bypass
Patient is AV paced and receiving an infusion of phenylephrine
and epinephrine. Biventricular systolic function is unchanged.
Annuloplasty ring seen in the mitral position. It appears well
seated and there is no residual mitral regurgitation. Mean
gradient across the mitral valve is 4 mm Hg. Moderate aortic
insufficiency persists. There is also moderate tricuspid
regurgiation. Aorta appears intact post decannulation.

Radiology Report CHEST (PA & LAT) Study Date of [**2144-12-10**] 3:35 PM

[**Hospital 93**] MEDICAL CONDITION: 78 year old woman s/p MV repair
Final Report
In comparison with the study of [**12-6**], there are continued
bilateral pleural effusions with cardiomegaly and some probable
elevation of
pulmonary venous pressure. Mild bibasilar atelectasis persists.

[**2144-12-18**]
Head CT
There is no evidence for intracranial hemorrhage or large
territorial infarct. There is no large mass, mass effect, edema,
or
hydrocephalus. There is mild cortical atrophy, which is likely
secondary to patient's age. White matter hypodensity is likely
secondary to chronic small vessel ischemic disease.
Visualized bony structures are grossly unremarkable. The
visualized portions of the paranasal sinuses and mastoid air
cells are well aerated.
IMPRESSION: No evidence for acute intracranial process. However,
MR would be more sensitive for acute ischemia.

[**2144-12-19**]
Head CT
FINDINGS: There is no evidence of acute intracranial hemorrhage
or acute
major vascular territory infarction. There is no evidence of
large mass, mass effect, edema or hydrocephalus. Ventricles and
sulci are mildly prominent, consistent with age-related
involutional changes. Periventricular and subcortical white
matter low-attenuating lesions are likely sequelae of chronic
small vessel ischemic disease. Visualized osseous structures are
grossly unremarkable. The visualized portions of the paranasal
and mastoid air cells are well aerated.
IMPRESSION: No acute intracranial process. Although MRI would be
more
sensitive for acute ischemia, the patient has a pacemaker and
therefore MRI is contraindicated. Since the patient is also
allergic to CT contrast, repeat CT head without contrast is
recommended if clinical concern persists.

[**2144-12-22**]
Head CT
No evidence for acute intracranial process.




Brief Hospital Course:
78 Female with history of paroxysmal atrial fibrillation and
hypertension admitted with hypoxia, low-grade fever, and cough.
Transthoracic Echo showed severe MR (normal echo at OSH one year
ago).  Transesophogeal echo confirmed findings.  Symptoms were
controlled with diuresis and afterload reduction. CT surgery was
consulted and recommended mitral valve repair.

On [**2144-12-2**] Mrs. [**Known lastname 71227**] was taken to the operating room for
Mitral valve repair, please see operative report for details. In
summary she had: Mitral valve repair with a 26-mm annuloplasty
ring (physio II). Her bypass time was 54 minutes with a
crossclamp time of 40 minutes. She tolerated the surgery well
and upon completion of the procedure she was transferred to the
Cardiac surgery ICU. She awoke neurologically intact and was
weaned from the ventilator and extubated. On POD#1 she was
started on betablockers and she was aggressively diuresed toward
her preoperative weight. She was followed by the
electrophysiology department to assist with rhythm management
when she was in rapid atrial fibrillation. She was changed to
Amiodarone from Propafenone and Lopressor dose was adjusted.
She was rate controlled in sinus rhythm at the time of discharge
with occasional pacing from her permanent pacemaker. Her
Coumadin therapy was resumed for afib. Her chest tubes and
epicardial pacing wires were removed per cardiac surgery
protocol. On POD#3 she was transferred from the ICU to the step
down unit for continued post-operative care. On POD#7 she
developed serosanguinous drainage from her sternal incision, it
subsequently resolved. At that time she was prophylactically
started on Levaquin which produced some diarrhea, but C. Diff
was negative.  At the time of discharge she was afebrile and WBC
was WNL.

On [**2144-12-18**] she developed a sudden onset of vertigo while walking
the hallway. She described the feeling of nausea and thought she
was going to fall to the left. Vertigo has persisted and worsens
with any head movement, especially looking to the
left. She also complained of some slurred speech and left facial
paraesthesia. The neurology stroke team was consulted.  On exam,
awake, alert and oriented. Speech is fluent with normal language
functions. No obvious dysarthria. Head CT showed no hemorrhage
or early signs of infarction on [**12-18**]. Repeat [**12-19**] Head CT was
unchanged.  Based on clinical findings it was suspected she had
a new left inferior cerebellar infarction in the PICA territory
along with some lateral medullary involvement. She was continued
on Coumadin with Heparin bridge until she was therapeutic with
INR 2-2.5.  She was ambulating in the halls with assistance with
some gait instability and no other residual. On POD 20 she awoke
with left facial numbness and dizziness.  Repeat Head CT showed
no evidence for acute intracranial process. She was again
evaluated by the neurology stroke team with no recommended
changes in management.  She is to continue on Coumadin and
Aspirin with a goal INR 2-2.5.  She is scheduled for a follow up
appointment with Dr [**First Name8 (NamePattern2) 2530**] [**First Name8 (NamePattern2) **] [**1-26**] at 2 PM.

She did have urinary retention x 2 after Foley catheter removal.
She had a 900 cc residual after voiding with a bladder scan on
[**2144-12-21**] and Foley was replaced at this time. She is to be
discharged to rehab with a leg bag with plans for voiding trial
in the next 1-2 days. An urinalysis done [**12-21**] showed moderate
bacteria and [**6-25**] WBC and trace leukocytes and she was started
on Trimethaprime x 5 days.  Urine culture was pending at the
time of discharge and needs to be followed up with
discontinuation of antibiotics if culture is negative. If she
fails voiding trial once more, urology follow up is recommended.


She was evaluated by physical therapy for strength and
conditioning and rehab was recommended upon discharge. She was
discharged to rehabilitation at [**Location (un) 582**] at [**Location (un) 620**] on POD#20 in
stable condition. INR was 2.2 at the time of discharge and she
is to receive 5 mg of Coumadin on [**2144-12-22**] for INR goal 2-2.5.
Coumadin follow up is be arranged upon discharge from rehab to
[**Location (un) 582**] at [**Location (un) 620**].  All follow up appointments have been
arranged.


Medications on Admission:
Levothyroxine 137 mcg qday
Metoprol Succinate 75 mg qday
Pantoprazole 40 mg qday
Propafenone 225 mg [**Hospital1 **]
Warfarin 2.5 mg MWF and 5mg T,Th,[**Last Name (LF) **],[**First Name3 (LF) **]


Discharge Medications:
1. meclizine 12.5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for dizziness.
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain, fever.
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-18**]
Drops Ophthalmic PRN (as needed) as needed for dryness.
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day:
Continue until edema resolves.
8. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day: continue
while on lasix.
9. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO QID (4 times a day) as needed for
reflux.
10. warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY
(Daily): For afib
Dose based on INR 2.0-2.5.
Take 5 mg dose 12/7. Tablet(s)
11. acetaminophen-codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
12. Synthroid 150 mcg Tablet Sig: One (1) Tablet PO once a day.

13. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 4 weeks: 400 mg [**Hospital1 **] x 2 weeks then 400 mg daily x 2
weeks then dose to be determined by cardiologist. Tablet(s)
14. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
15. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

16. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
17. trimethoprim 100 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.


Discharge Disposition:
Extended Care

Facility:
[**Location (un) **] AT [**Location (un) **]

Discharge Diagnosis:
S/P Mitral valve repair(annuloplasty ring)
PMH: Severe MR
Hypothyroidism
Afib/flutter (Dx: [**2141**] per pt.)
S/p pacemaker [**2139**] s/p generator change [**2143**]/[**Hospital3 **]
([**Company 1543**] model #ADDR01P)
GERD
Hypertension
Benign positional vertigo
Urinary retention
Cyctocele/rectocele
Allergic Rhinitis
Esophageal strictures s/p dilation
Chest pain with normal coronaries by cath at [**Hospital3 **]
(~[**2141**]), pt reports being "shocked" at the end of the case
Osteoarthritis
PSH:
Tonsillectomy
Appendectomy
Cholecystectomy
S/p bladder suspension
Cataract surgery
S/p TAH/BSO d/t bleeding endometriosis
Bilateral hip replacement


Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with tylenol and ultram. sensitive to
narcotics
Incisions:
Sternal - healing well, no erythema or drainage
Edema 1+ lower extremity edema




Discharge Instructions:
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:
Recommended Follow-up:
You are scheduled for the following appointments:
Surgeon: Dr. [**Last Name (STitle) **] [**2145-1-21**] 1:15, [**Hospital **] Medical office
building [**Location (un) **] [**Telephone/Fax (1) 170**]
Cardiologist: Dr. [**Last Name (STitle) 171**] [**2144-12-30**] 9:40
Electrophysiologist: Dr [**Last Name (STitle) **] [**2145-1-11**] 10:00
Neurologist:
Dr [**First Name8 (NamePattern2) 2530**] [**First Name8 (NamePattern2) **] [**1-26**] at 2 PM [**Hospital Ward Name 23**] 5

Please call to schedule appointments with your
Primary Care Dr. [**First Name (STitle) 1877**] [**Telephone/Fax (1) 4475**] in [**4-20**] 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 afib
Goal INR 2-2.5
First draw [**2144-12-23**] Coumadin dose [**2144-12-22**] 5 mg
Will need coumadin follow up established upon discharge from
rehab



Completed by:[**2144-12-22**]
{'Acute on chronic diastolic heart failure,Cerebral artery occlusion, unspecified with cerebral infarction,Pneumonia, organism unspecified,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Mitral valve disorders,Atrial fibrillation,Unspecified essential hypertension,Hip joint replacement,Postsurgical hypothyroidism,Cardiac pacemaker in situ,Diarrhea,Other speech disturbance,Other specified retention of urine,Esophageal reflux,Benign paroxysmal positional vertigo,Constipation, unspecified,Other chronic pulmonary heart diseases'}


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: 78F with history of atrial fibrillation/flutter and
hypothyroidism who presented to the ED with complaint of
shortness of breath and low grade fever, associated with cough.
Patient states that she has been short of breath for the few
weeks since her recent admission on [**10-30**] at [**Hospital3 **] for
A. Fib with RVR.  Prior to that admission, PAF was well
controlled for 3 years.  During that admission, Rythmol dose was
doubled.  She subsequently followed up with her cardiologist,
Dr. [**Last Name (STitle) 10543**], last week at which time her Rythmol dose was
decreased back to her normal dose of 225 mg [**Hospital1 **] of SR
formulation and her pacemaker setting was decreased to 100.  The
next 24 hours she became so short of breath that she was unable
to carry out any activities, barely able to walk a few steps.
She returned to his office the next day and pacemaker was re-set
to 110, with some improvement in symptoms.  She then developed
worsening shortness of breath over last weekend with another
visit to her cardiologist 2 days prior to presentation.  She
reports a CXR showed fluid on her lungs, she declined lasix at
that time.  Since then, has had worsening shortness of breath,
non-productive cough and fever x 1 to 100.4 last night.
Overnight, she noted worsening shortness of breath, unable to
sleep and necessitating sitting up in a chair all night.  Also
noted belching, nausea, and substernal chest pain x 24 hours,
worse with coughing, non-radiating.  Of note, has had 3 pound
weight gain over past week.  Denies syncope, peripheral edema.
.
In the ED, initial VS were: 98.4  142/72  82  24  97%RA
Patient was given Zofran 4 mg for nausea, ASA 325 mg and NTG
0.4mg SL x 3 for chest discomfort.  After chest x-ray, due to
concern for CHF vs. PNA, was given Lasix 20 mg IV x 1 and
Cefepime 2g IV x 1.
.
On the floor, patient is in no acute distress.  She continues to
complain of some shortness of breath and occasional cough.

MEDICAL HISTORY: Atrial fibrillation- with multiples episode of palpitations in
the past
S/p pacemaker [**2139**]: s/p generator change [**2143**] at [**Hospital3 **]

MEDICATION ON ADMISSION: Levothyroxine 137 mcg qday
Metoprol Succinate 75 mg qday
Pantoprazole 40 mg qday
Propafenone 225 mg [**Hospital1 **]
Warfarin 2.5 mg MWF and 5mg T,Th,[**Last Name (LF) **],[**First Name3 (LF) **]

ALLERGIES: Penicillins / Keflex / Amoxicillin / Sulfa (Sulfonamide
Antibiotics) / Iodine-Iodine Containing

PHYSICAL EXAM: Pulse:63 Resp:18  O2 sat: 92/RA
B/P  136/84
Height:  66"   Weight: 87kgs

FAMILY HISTORY: Mother died of "tachycardia".  Father died of bladder/kidney
cancer.  Brother died of hodgkins lymphoma at 21.

SOCIAL HISTORY: Does not drink, no history of tobacco or drug use.
Divorced/retired, living alone in [**Location 1268**].
Independent in all ADLs. 

### Response:
{'Acute on chronic diastolic heart failure,Cerebral artery occlusion, unspecified with cerebral infarction,Pneumonia, organism unspecified,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Mitral valve disorders,Atrial fibrillation,Unspecified essential hypertension,Hip joint replacement,Postsurgical hypothyroidism,Cardiac pacemaker in situ,Diarrhea,Other speech disturbance,Other specified retention of urine,Esophageal reflux,Benign paroxysmal positional vertigo,Constipation, unspecified,Other chronic pulmonary heart diseases'}
