CHIEF COMPLAINT: Shortness of breath, dyspnea on exertion

PRESENT ILLNESS: In brief, Pt is an 86 y/o with a PMH of afib on coumadin, CHF EF
45%, HTN, recently diagnosed COPD who presented with several
weeks of SOB and DOE.  She was admitted to the MICU and
underwent TTE which showed critical AS, with valve area 0.5 cm2
and mean gradient 78 and peak gradient 129.  She is being
transferred to CCU for further care.
.
With regards to the patient's DOE, it has been worsening over
the last few weeks.  Previously, the patient was able to walk
around the mall without much difficulty.  Her breathing has been
even worse over the last few days, to the point that she gets
short of breath even at rest. On the day of admission she was
seen to be very SOB by her daughter and was brought to her PCPs
office where her amb sat was 86% on RA and she was sent to ED.
.

MEDICAL HISTORY: # HTN
# CHF
# COPD: recently diagnosed by Dr. [**Last Name (STitle) 656**] at [**Last Name (un) 4199**]
# stable goiter
# afib on coumadin
# ? aortic stenosis
# GERD
# osteoporosis
# basal cell under left eye
# s/p resection of childhood tumor "behind heart"

MEDICATION ON ADMISSION: # enalapril 10 mg AM, 5 mg PM
# lasix 20 mg 2X /week
# ranitidine 150 [**Hospital1 **]
# evista 60 daily
# warfarin 2-3 mg daily
# lovastatin 40 mg daily
# os-cal 500 [**Hospital1 **]
# tylenol 2 daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 36.7 HR 92 BP 110/77 RR 18 SaO2 94% on RA
General Appearance: Well nourished
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: large goiter on R
Cardiovascular: holosystolic murmur with loss of S2 consistent
with severe AS, no delayed upstrokes
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Breath Sounds: Crackles : at bases)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: 2+, Left: 2+
Skin:  Not assessed
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Movement: Not assessed, Tone: Not assessed

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives at [**Hospital3 **]. Smoking: quit 40 years ago, but had 10
pack year priot to that
Mitral valve insufficiency and aortic valve stenosis,Rheumatic heart failure (congestive),Diseases of tricuspid valve,Other specified hypotension,Other chronic pulmonary heart diseases,Chronic airway obstruction, not elsewhere classified,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Unspecified essential hypertension,Atrial fibrillation,Goiter, unspecified,Other and unspecified hyperlipidemia,Anemia, unspecified,Esophageal reflux,Osteoporosis, unspecified,Personal history of other malignant neoplasm of skin
Mitral insuf/aort stenos,Rheumatic heart failure,Tricuspid valve disease,Hypotension NEC,Chr pulmon heart dis NEC,Chr airway obstruct NEC,Abnrml coagultion prfile,Adv eff anticoagulants,Hypertension NOS,Atrial fibrillation,Goiter NOS,Hyperlipidemia NEC/NOS,Anemia NOS,Esophageal reflux,Osteoporosis NOS,Hx-skin malignancy NEC
Admission Date:  [**2186-3-17**]              Discharge Date:   [**2186-3-28**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 10842**]
Chief Complaint:
Shortness of breath, dyspnea on exertion

Major Surgical or Invasive Procedure:
None

History of Present Illness:
In brief, Pt is an 86 y/o with a PMH of afib on coumadin, CHF EF
45%, HTN, recently diagnosed COPD who presented with several
weeks of SOB and DOE.  She was admitted to the MICU and
underwent TTE which showed critical AS, with valve area 0.5 cm2
and mean gradient 78 and peak gradient 129.  She is being
transferred to CCU for further care.
.
With regards to the patient's DOE, it has been worsening over
the last few weeks.  Previously, the patient was able to walk
around the mall without much difficulty.  Her breathing has been
even worse over the last few days, to the point that she gets
short of breath even at rest. On the day of admission she was
seen to be very SOB by her daughter and was brought to her PCPs
office where her amb sat was 86% on RA and she was sent to ED.
.

Past Medical History:
# HTN
# CHF
# COPD: recently diagnosed by Dr. [**Last Name (STitle) 656**] at [**Last Name (un) 4199**]
# stable goiter
# afib on coumadin
# ? aortic stenosis
# GERD
# osteoporosis
# basal cell under left eye
# s/p resection of childhood tumor "behind heart"

Social History:
Lives at [**Hospital3 **]. Smoking: quit 40 years ago, but had 10
pack year priot to that


Family History:
NC

Physical Exam:
T 36.7 HR 92 BP 110/77 RR 18 SaO2 94% on RA
General Appearance: Well nourished
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: large goiter on R
Cardiovascular: holosystolic murmur with loss of S2 consistent
with severe AS, no delayed upstrokes
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Breath Sounds: Crackles : at bases)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: 2+, Left: 2+
Skin:  Not assessed
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Movement: Not assessed, Tone: Not assessed




Pertinent Results:
 [**3-28**]: WBC: 5.5 3.18* HGB: 9.9* Hct: 30.3* 96 31.2 32.6 15.6*
Plt: 232
INR 1.8
      Gluc: 96 BUN: 29* Creat:1.0 Na:144 K:4.2 Cl:101 Bicarb:
36* AGAP:11
.
[**3-17**] CXR
Mild CHF. Right paratracheal density/mass. Left basal pneumonia.
No change
since the examination done one hour earlier. Ct scan of chest
suggested.

[**3-18**] ECHO
The left atrium is elongated. The right atrium is moderately
dilated. 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. There is mild regional left
ventricular systolic dysfunction with septal/inferior
hypokinesis. [Intrinsic left ventricular systolic function is
likely more depressed given the severity of valvular
regurgitation. There is no ventricular septal defect. with mild
global free wall hypokinesis. The ascending aorta is mildly
dilated. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (area
<0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are moderately thickened. The mitral valve shows
characteristic rheumatic deformity. There is moderate thickening
of the mitral valve chordae. There is a minimally increased
gradient consistent with trivial mitral stenosis. Moderate to
severe (3+) mitral regurgitation is seen. The tricuspid valve
leaflets are moderately thickened. Moderate [2+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
[**3-19**] CXR
Compared to the film from two days previous there continues to
be
cardiomegaly. There is increased pulmonary vascular
re-distribution and
increased bilateral effusions left greater than right suggesting
worsening
CHF. The prominence in the right paratracheal region is again
seen and it is unclear if this is due to tortuous vessel versus
a mass in this region. The opacity in the retrocardiac region
has also increased and it is unclear if this is due to pulmonary
edema or an infectious infiltrate. Pleural calcifications are
again noted.
.
IMPRESSION: Worsening CHF.
.
[**3-20**] CUS
IMPRESSION: Bilateral 1-39% ICA stenosis with blunted common
carotid
waveforms consistent with aortic stenosis. Antegrade vertebral
flow. Right
thyroid cyst as described above.
.

[**3-20**] CT CHEST
IMPRESSION:
1. The thyroid is markedly enlarged, with multiple masses. The
thyroid gland extends into the superior mediastinum, resulting
in mass effect on the great vessels, particularly the right
brachiocephalic artery, left common carotid and subclavian
arteries, and brachiocephalic veins. The origin and course of
the left common carotid artery cannot be delineated on this
study. The right brachiocephalic vein is sandwiched between the
first rib and goiter, with multiple collateral vessels seen in
the upper neck. Furthermore, at least one of the thyroid nodules
in the right superior mediastinum contains multiple thin flecks
of calcium, concerning for neoplasm. Multiple enlarged
mediastinal nodes are also seen. Further evaluation is
recommended, to evaluate for the possibility of a thyroid
cancer.
2. Cardiomegaly, coronary artery calcifications, aortic valve
and mitral
valve calcifications, and aortic atherosclerosis.
3. Small-to-moderate bilateral pleural effusions.
4. Mosaic attenuation in the lungs, possibly related to
airtrapping.
5. L1 compression fracture.
.

[**3-22**] SPIROMETRY
SPIROMETRY 1:20 PM Pre drug Post drug
    Actual Pred %Pred Actual %Pred %chg
FVC   0.74 2.10 35 0.78 37 +6
FEV1   0.56 1.34 41 0.65 48 +16
MMF   0.44 1.63 27 0.78 48 +78
FEV1/FVC   76 64 118 83 130 +10

LUNG VOLUMES 1:20 PM Pre drug Post drug
    Actual Pred %Pred Actual %Pred
TLC   1.76 3.93 45
FRC   1.03 2.41 43
RV   1.05 1.83 58
VC   0.71 2.10 34
IC   0.73 1.52 48
ERV   -0.03 0.58 -4
RV/TLC   60 47 128
He Mix Time   3.00

DLCO 1:20 PM
    Actual Pred %Pred
DSB   4.65 14.98 31
VA(sb)   1.52 3.93 39
HB   10.20
DSB(HB)   5.25 14.98 35
DL/VA   3.46 3.81 91
.
[**3-24**] CARDIAC CATH

COMMENTS:     1. Selective coronary angiography of this right
dominant
system did not reveal flow limiting coronary artery disease. The
LMCA
was normal. The LAD had mild disease. The LCx was small without
disease.
The mid-RCA had a 40% stenosis.
2. Resting hemodynamic measurement demonstrated moderately
elevated left
and right sided filling pressures with an LVEDP of 25mmHg and
RVEDP
24mmHg. An accurate PCWP was not obtainable after several
attempts. The
mean PAP was severely elevated at 62 mmHg. Simulatenous pressure

measurement in the LV and aorta demonstrated a mean 39mmHg
gradient. The
calculated fick cardiac index was preserved at 2.3 l/min/m2.
3. Valvuloplasty was performed.  We exchanged for a 8F sheath
with a
Amplatzer super stiff wire in LV and advanced a 20mm Tyshak 2
balloon.
With RV pacing at a rate of 160 we performed 4 inflations
manually with
a 30cc syringe.  The balloon would not fully inflate prior to
being
pushed into aorta but [**Location (un) 109**] did improve from .5 to .64 and peak to
peak
gradient fell by 20mmHG.  Heparin was used for anticoagulation.
4. Angioseal of the 8F RFA arteriotomy.

FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Critical AS
3. Severely elevated left and right sided filling pressures.
4. Severe pulmonary hypertension.



Brief Hospital Course:
In the ED, initial vs were: T 97.3, P 95, BP 114/52, R 24, 94%RA
O2 sat. EKG with ST depression in V5-6 c/w strain pattern, and
CXR c/w pulm edema and LLL infiltrate. She was given nebs,
levaquin and CTX. She became hypotensive intermittently to SBP
86/60 and got 250 NS b/c low BPs. Oxygen requirement increased
to 97% on 4L NC. She did not get lasix given hypotension.  She
was admitted to the MICU and reported feeling somewhat better.
She denied any chest pain, chest pressure, palpitations, fever,
chills, cough, sputum production, dysuria, or sick contacts
(although does live in [**Hospital3 **]). She noted progressive
orthopnea and possible PND. + LE swelling. She is unsure of
weight gain.

# Hypoxia: The primary cause for her hypoxia was likely
pulmonary edema in the settting of critical AS. Pt has known
critical AS from OSH records but per her primary Cardiologist
this has likely worsened.  Pt felt symptomatically improved
after being diuresed with 20mg IV Lasix but then dropped her
SBPs to 70-80s.  She was clearly very preload dependant but also
very sensitive to "fluid overload."  There was initially concern
for possible PNA given LLL infitrate on initial CXR, however she
was afebrile and without leukocytosis. While in the MICU, pt was
started on a 5-day course of Azithromycin.  This was
discontinued on transfer to the CCU due to lack of clinical
signs/sx of pna. PFT's were done which showed a restrictive
pattern, not obstructive, please see pertinent results section
for more details.  Given the high likelihood of the critical AS
contributing to pt's fluid overload and resultant shortness of
breath, pt was evaluated for AV repair, and decision was made to
proceed with valvuloplasty (see above) In addition, given
patient's pulmonary function tests, her outpatient COPD
medications were discontinued. Pt was satting 82% on RA on
discharge but 96% with 2L NP. It is hoped that hypoxia will be
improved with continued gentle diuresis. Patient was discharged
on 60 mg PO daily of standing Lasix and dose to be adjusted as
needed by outpatient cardiologist.
.
# Critical aortic stenosis: TTE on [**3-18**] revealed worsening of
her critical AS with a valve area of 0.5cm2. Pt discussed
options for treatment extensively with her family, primary
cardiologist, and the team, and decision was made to proceed
with valvoloplasty instead of aortic valve replacement given
higher risks of morbidity and mortality with surgery and with
the plan that if this failed to improve her symptoms she could
still undergo AVR in the future. Valvuloplasty was performed
with cardiac cath.  Cath showed 40% stenosis in RCA. AV area was
increased from 0.5->0.65cm2. Pt remained hemodyanamically stable
post-procedure. Pt will be following up further as outpt with
Dr. [**Last Name (STitle) 1147**], her primary cardiologist. Because of the critical
aortic stenosis and preload dependence patient's outpatient ACE
inhibitor was discontinued. Patient was restarted on outpatient
lasix dose.  Patient should follow up with Dr. [**Last Name (STitle) 1147**] on
discharge to discuss furthur management.  Patient underwent
pre-operative work-up including cardiac catherization, panorex
etc, so should patient require surgery she will be able to get
it in the future.
.
# Goiter: Pt has a large goiter on the right side of her neck
which she reports as being stable over the past 55 years.
Thyroid function tests, including TSH, T3, T4, were all wnl. In
the setting of possible AVR surgery, goiter was further
evaluated by CT, and was found to extend into the mediastinum.
Thoracics was consulted per request by CT Surgery, and it was
decided that pt could undergo future chest surgery if needed as
the mass was not invading the aortic arch. Endocrine was also
consulted, and advised against FNA/biopsy, as thyroid cancer is
unlikely given chronicity of mass and normal TFTs. Concern was
expressed over impingement on trachea by mass. As pt did not
show any clinical signs of respiratory airway compromise, she
closely monitored. Pt also preferred not to pursue any surgical
interventions for her goiter. She was monitored for signs of
thyrotoxicosis after cath. Pt continued to be hemodynamically
stable and asymptomatic from the mass on day of discharge. She
was advised to talk to her PCP if future symptoms associated
with her neck mass arise.
.
# Afib: Pt home coumadin 2 mg daily, except Sunday 3 mg.
Coumadin initially held in the setting of
pericath/valvuloplasty.  Patient was not reversed with vit K.
Patient was started on low dose beta blocker. Coumadin was held
pre-operatively and discharged on previous coumadin regimen,
with follow-up as outpt with her PCP/primary oncologist for
dosing adjustment.  Patient was not adequately rate controlled
however did not have room to increase her beta blocker given low
heart rate.
.
# Hypotension: Pt was transiently hypotensive in ED and
responded to a 500cc NS bolus. Also hypotensive in the unit
after diuresis with 20mg IV lasix.  Pt exquisitely sensitive to
fluid shifts given her critical AS.  ACEI was held in the unit
secondary hypotension and was not restarted in the setting of
critical aortic stenosis. Once hypotension resolved, was was
restarted on low dose beta blocker for afib rate control
.
# Hyperlipidemia: Pt continued on her home Lovastatin.
.
# GERD: Pt continued on her home ranitidine.
.
# Osteoporosis: Pt continued on calcium, vitamin D and evista.


Medications on Admission:
# enalapril 10 mg AM, 5 mg PM
# lasix 20 mg 2X /week
# ranitidine 150 [**Hospital1 **]
# evista 60 daily
# warfarin 2-3 mg daily
# lovastatin 40 mg daily
# os-cal 500 [**Hospital1 **]
# tylenol 2 daily

Discharge Medications:
1. Raloxifene 60 mg Tablet Sig: One (1) Tablet PO daily ().
2. Lovastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
3. Calcium 600 + D(3) 600 mg(1,500mg) -200 unit Tablet Sig: One
(1) Tablet PO twice a day.
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO four times a
day as needed for fever or pain.
6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: Every
day except Sunday.
7. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day: Take
Sunday only.
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
10. Outpatient Lab Work
Please check INR and Chem-7 on Thursday 26th
11. Furosemide 20 mg Tablet Sig: One (3) Tablet PO DAILY
(Daily).


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Rehab Ctr. of [**Location (un) 1121**]

Discharge Diagnosis:
Primary:
Severe aortic stenosis (valve area 0.5cm2)status psot
Valvuloplasty with valve area improved to 0.65
Acute Systolic Congestive heart failure
.
Secondary:
Atrial fibrillation
Hypertension


Discharge Condition:
Good, hemodynamically stable, shortness of breath improved
INR 1.8 [**3-28**]
Weight 81.4 kg [**3-28**]

Good, hemodynamically stable, shortness of breath improved
INR 1.8 [**3-28**]
Weight 81.4 kg [**3-28**]

Good, hemodynamically stable, shortness of breath improved
INR 1.8 [**3-28**]
Weight 81.4 kg [**3-28**]


Discharge Instructions:
You were admitted for shortness of breath and dyspnea on
exertion. You were evaluated by an echocardiogram, which showed
a very narrow aortic valve, likely contributing to your
symptoms. You were transferred to the CCU for closer blood
pressure monitoring. You were seen by cardiothoracic surgery for
valve repair but a valvuloplasty was performed instead as it was
thought to be easier to tolerate. You were seen by endocrine and
thoracic surgery who did not feel that your thyroid mass needed
to be removed or was affecting other major organs.
.
New medicines:
You were started on low dose Metoprolol 12.5 mg twice daily to
help your heart pump better
Your ACE inhibitor was discontinued in the setting of severe
aortic stenosis and marginal blood pressure
Please continue to take lasix 20mg daily. We stopped this
briefly in the hospital.
.
If you experience any recurrent shortness of breath, dyspnea on
exertion, or have chest pain, dizziness, fainting, or other
[**First Name4 (NamePattern1) 1258**] [**Last Name (NamePattern1) 69336**] if you have any questions or concerns about
your medicines or discharge instructions.

Followup Instructions:
Please follow-up with your cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1147**]
[**0-0-**] on [**4-20**] at 1:45pm. Please call the [**Doctor First Name 24606**] on
Tuesday at the [**Location (un) 4628**] office when you get home to schedule an
earlier appt.



Completed by:[**2186-3-28**]
{'Mitral valve insufficiency and aortic valve stenosis,Rheumatic heart failure (congestive),Diseases of tricuspid valve,Other specified hypotension,Other chronic pulmonary heart diseases,Chronic airway obstruction, not elsewhere classified,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Unspecified essential hypertension,Atrial fibrillation,Goiter, unspecified,Other and unspecified hyperlipidemia,Anemia, unspecified,Esophageal reflux,Osteoporosis, unspecified,Personal history of other malignant neoplasm of skin'}


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, dyspnea on exertion

PRESENT ILLNESS: In brief, Pt is an 86 y/o with a PMH of afib on coumadin, CHF EF
45%, HTN, recently diagnosed COPD who presented with several
weeks of SOB and DOE.  She was admitted to the MICU and
underwent TTE which showed critical AS, with valve area 0.5 cm2
and mean gradient 78 and peak gradient 129.  She is being
transferred to CCU for further care.
.
With regards to the patient's DOE, it has been worsening over
the last few weeks.  Previously, the patient was able to walk
around the mall without much difficulty.  Her breathing has been
even worse over the last few days, to the point that she gets
short of breath even at rest. On the day of admission she was
seen to be very SOB by her daughter and was brought to her PCPs
office where her amb sat was 86% on RA and she was sent to ED.
.

MEDICAL HISTORY: # HTN
# CHF
# COPD: recently diagnosed by Dr. [**Last Name (STitle) 656**] at [**Last Name (un) 4199**]
# stable goiter
# afib on coumadin
# ? aortic stenosis
# GERD
# osteoporosis
# basal cell under left eye
# s/p resection of childhood tumor "behind heart"

MEDICATION ON ADMISSION: # enalapril 10 mg AM, 5 mg PM
# lasix 20 mg 2X /week
# ranitidine 150 [**Hospital1 **]
# evista 60 daily
# warfarin 2-3 mg daily
# lovastatin 40 mg daily
# os-cal 500 [**Hospital1 **]
# tylenol 2 daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 36.7 HR 92 BP 110/77 RR 18 SaO2 94% on RA
General Appearance: Well nourished
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: large goiter on R
Cardiovascular: holosystolic murmur with loss of S2 consistent
with severe AS, no delayed upstrokes
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Breath Sounds: Crackles : at bases)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: 2+, Left: 2+
Skin:  Not assessed
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Movement: Not assessed, Tone: Not assessed

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives at [**Hospital3 **]. Smoking: quit 40 years ago, but had 10
pack year priot to that 

### Response:
{'Mitral valve insufficiency and aortic valve stenosis,Rheumatic heart failure (congestive),Diseases of tricuspid valve,Other specified hypotension,Other chronic pulmonary heart diseases,Chronic airway obstruction, not elsewhere classified,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Unspecified essential hypertension,Atrial fibrillation,Goiter, unspecified,Other and unspecified hyperlipidemia,Anemia, unspecified,Esophageal reflux,Osteoporosis, unspecified,Personal history of other malignant neoplasm of skin'}
