CHIEF COMPLAINT: Atrial fibrillation and mitral regurgitation

PRESENT ILLNESS: Mr. [**Known lastname 38255**] is a 64 year old gentleman with a long standing
history of mitral regurge and atrial fibrillation despite
ablation therapy and multiple antiarrythmic drugs. His atrial
fibrillation is generally exacerbated by exercise and
accompanied by significant dyspnea. His most recent
echocardiogrma showed 2+ aortic regurgitation, 1+ mitral
regurgitation, 1+ tricuspid regurgitation, a dilated left and
right atrium, a mildly dilated aortic root and an ejection
fraction of 55%. A cardiac catheterization did not show any
significant coronary artery disease. Due to the progression of
his disease and debilitating symptoms, Mr. [**Known lastname 38255**] was referred
to Dr. [**Last Name (Prefixes) **] for surgical management.

MEDICAL HISTORY: Atrial Fibrillation
Mitral regurgitationPAst hernia repair

MEDICATION ON ADMISSION: Acebutolol 200mg twice daily
Lisinopril 10mg twice daily\
Paxil 10mg once daily
Dofetilide 500mg twice daily
Coumadin
xanax 0.25mg as needed

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VITAL SIGNS: HR 60 irregularly irregular  BP (L) 110/74 (R)
114/80
Ht 69" Wt 160 lbs
GENERAL: No apparent distress, well developed well nourished.
SKIN: warm, dry, no lesions
HEENT: PERRL, EOMI, anicteric sclera, oropharynx benign.
NECK: Supple, no lymphadenopathy, no thyromegally
CHEST: Clear lungs
HEART: Irregularly irregular rhythm, III?VI systolic murmur with
quiet diastolic murmur.
ABDOMEN: Soft, nontender, nondistended, normoactive bowel
sounds.
EXT: No clubbing, cyanosis or edema. No varicosities. 2+ pulses
throughout extremities. No femoral or carotid bruits.
NEURO: Cranial Nerve II-XII grossly intact, no focal deficits.

FAMILY HISTORY: Mother died at age 80 from an aortic aneurysm.
Father died at age 80 from congestive heart failure.
Sieter age 65 status post mitral valve replacement at age 60.
Sister age 67 with diabetes.

SOCIAL HISTORY: Mechanical engineer who lives in [**Location **] with wife. Quit
smoking 30 years ago. Rarely uses alcohol.
Mitral valve insufficiency and aortic valve insufficiency,Rheumatic heart failure (congestive),Acquired cardiac septal defect,Atrial fibrillation,Cardiac complications, not elsewhere classified,Dissection of aorta, thoracic,Pneumonitis due to inhalation of food or vomitus,Other diseases of vocal cords,Disruption of 24 hour sleep wake cycle, unspecified
Mitral/aortic val insuff,Rheumatic heart failure,Acq cardiac septl defect,Atrial fibrillation,Surg compl-heart,Dsct of thoracic aorta,Food/vomit pneumonitis,Vocal cord disease NEC,Irreg sleep-wake rhy NOS
Admission Date:  [**2121-12-22**]              Discharge Date:   [**2122-1-9**]

Date of Birth:  [**2057-2-11**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Atrial fibrillation and mitral regurgitation

Major Surgical or Invasive Procedure:
AVR (25mm [**Last Name (un) **]-[**Doctor Last Name **] pericardial tissue valve), MV
repair (28mm annuloplasty band),MAZE procedure, closure of
atrial septal defect and an ascending aorta replacement using a
28mm gelweave graft.


[**Last Name (NamePattern4) 15255**] of Present Illness:
Mr. [**Known lastname 38255**] is a 64 year old gentleman with a long standing
history of mitral regurge and atrial fibrillation despite
ablation therapy and multiple antiarrythmic drugs. His atrial
fibrillation is generally exacerbated by exercise and
accompanied by significant dyspnea. His most recent
echocardiogrma showed 2+ aortic regurgitation, 1+ mitral
regurgitation, 1+ tricuspid regurgitation, a dilated left and
right atrium, a mildly dilated aortic root and an ejection
fraction of 55%. A cardiac catheterization did not show any
significant coronary artery disease. Due to the progression of
his disease and debilitating symptoms, Mr. [**Known lastname 38255**] was referred
to Dr. [**Last Name (Prefixes) **] for surgical management.

Past Medical History:
Atrial Fibrillation
Mitral regurgitationPAst hernia repair

Social History:
Mechanical engineer who lives in [**Location **] with wife. Quit
smoking 30 years ago. Rarely uses alcohol.

Family History:
Mother died at age 80 from an aortic aneurysm.
Father died at age 80 from congestive heart failure.
Sieter age 65 status post mitral valve replacement at age 60.
Sister age 67 with diabetes.

Physical Exam:
VITAL SIGNS: HR 60 irregularly irregular  BP (L) 110/74 (R)
114/80
Ht 69" Wt 160 lbs
GENERAL: No apparent distress, well developed well nourished.
SKIN: warm, dry, no lesions
HEENT: PERRL, EOMI, anicteric sclera, oropharynx benign.
NECK: Supple, no lymphadenopathy, no thyromegally
CHEST: Clear lungs
HEART: Irregularly irregular rhythm, III?VI systolic murmur with
quiet diastolic murmur.
ABDOMEN: Soft, nontender, nondistended, normoactive bowel
sounds.
EXT: No clubbing, cyanosis or edema. No varicosities. 2+ pulses
throughout extremities. No femoral or carotid bruits.
NEURO: Cranial Nerve II-XII grossly intact, no focal deficits.


Pertinent Results:
Preop labs: WBC-4.0, HCT-34.3, PLT-168, Na- 138, K-4.1, BUN-0.7,
Creat-1.0. LFT's within normal limits
[**2122-1-8**] 06:35AM BLOOD WBC-9.4 RBC-3.35* Hgb-10.5* Hct-30.1*
MCV-90 MCH-31.4 MCHC-35.0 RDW-14.9 Plt Ct-566*
[**2122-1-9**] 09:35AM BLOOD PT-16.8* INR(PT)-1.8
[**2122-1-9**] 09:35AM BLOOD Glucose-185* UreaN-24* Creat-1.0 Na-137
K-4.4 Cl-105 HCO3-23 AnGap-13

[**2122-1-7**] CXR
Status post AVR. Cardiomegaly with bilateral pleural effusion.
Healed fracture of the ribs.

[**2122-1-6**] VIDEO OROPHARYNGEAL SWALLOW
Oral phase is notable for moderately impaired bolus formation
and control. There is premature spillover into the pharynx with
all consistencies. During the pharyngeal phase of swallowing,
there is a mild delay in swallow initiation. Laryngeal valve
closure was impaired causing penetration and aspiration.
Penetration occurred during and after the swallow and worsened
as the study went on. Aspiration of all consistencies occurred
after the swallow due to penetration. There was no spontaneous
cough.

[**2121-12-22**] PATHOLOGY
A. Aortic valve leaflets:
Valve leaflet with myxoid degeneration and calcification.
B. Aorta:
Segment of vessel wall with myxoid change.

[**2121-12-29**] ECHO
The left atrium is mildly dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses and cavity
size are normal. Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. Overall
systolic function is good (LVEF >40%). Right ventricular chamber
size is normal with mild global free wall hypokinesis. A
bioprosthetic aortic valve prosthesis is present. No definite
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. [Due
to acoustic shadowing, the severity of mitral regurgitation
maybe significantly underestimated.] There is a small (<=1.0cm)
circumferential pericardial effusion. No right ventricular
diastolic collapse is seen.

[**2121-12-26**] EKG
Atrial fibrillation 100. Modest nonspecific inferior T wave
changes. Since previous tracing of [**2121-12-25**], no significant
change



[**Last Name (NamePattern4) 4125**]ospital Course:
Mr. [**Known lastname 38255**] was admitted to the [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**] [**Last Name (NamePattern1) **] Medical
Center on [**2121-12-22**] for surgical management of his heart disease.
He was taken to the operating room where he underwent an aortic
valve replacement utilzing a 25mm [**Last Name (un) **] [**Doctor Last Name **] pericardial
prosthesis, a mitral valve repair using a 28mm annuloplasty
band, a MAZE procedure, an ascending aorta replacement using a
28mm gelweave graft and an atrial septal defect closure.
Postoperatively he was taken to the cardiac surgical intensive
care unit for monitoring. He was coagulopathic with a high chest
tube output requiring blood products. This slowly resolved
without issue. On postoperative day one, Mr. [**Known lastname 38255**] [**Last Name (Titles) 5058**]
neurologically intact and was extubated. The electrophysiology
service was consulted for assistance with his current rapid
rhythm of atrial fibrillation alternating with atrial flutter.
His previous antiarrythmic dofetilide was resumed but later
switched to beta blockade for rate control. A follow-up
appointment was scheduled in [**3-18**] weeks. Coumadin and heparin
were started for anticoagulation. Mr. [**Known lastname 38255**] remained
hypertensive neccessitating the use of intravenous nitroglycerin
which was slowly weaned off over three days. He developed thick,
copius secretions requiring large amounts of oxygen and BiPAP
therapy. He was however able to mobilize these secretions quite
well. The physical therapy service was consulted for assistance
with Mr. [**Known lastname 38256**] postoperative strength and mobility. His
secretions slowly decreased and his atrial fibrillation became
rate controlled. On postoperative day six, Mr. [**Known lastname 38255**] was
transferred to the cardiac surgical step down unit for further
recovery. He was gently diuresed towards his preoperative
weight. Mr. [**Known lastname 38255**] seemed to develop some coughing while
drinking thin liquids as well as a rsspy voice. He developed a
fever for which he was pancultured and placed on zosyn and
vancomycin. He developed respiratory distress in the setting of
rapid atrial fibrillation and was transferred back to the
cardiac surgical intensive care unit on [**2121-12-30**] for monitoring.
Natrecor was started for  adecreased urine output with good
effect. Dofetilide was resumed for rate control. Sputum cultures
returned positive for enterobacter suggesting an aspiration
pneumonia. His vancomycin was discontinued and zoysn was
continued with gradual improvement. A speech and swallow consult
was obtained and a bedside exam was suggestive of aspiration
with possible vocal chord paralysis. The otolaryngology service
was consulted and a video swallow study was obtained. This
revealed a small amount of granulomatous tissue on the vocal
chords and aspiration with thin and thick liquids likely due to
his deconditioned status. A nasogastric feeding tube was placed
and tube feeds were started. Mr. [**Known lastname 38255**] became somewhat
confused where he self removed his foley and intravenous lines.
A sitter was assigned to his bedside at night for close
observation. The neurology service was consulted who suspected a
toxic, metabolic or infectious source of his confusion. Seroquel
was started nightly for agitation however he had further
confusion with this and was thus was switched to librium with
good effect. Mr. [**Known lastname 38256**] nocturnal confusion continued to
improve thus confirming a likely sleep/wake cycle disturbance.
On [**2122-1-6**], a repeat video swallow was performed which showed
improvement of his swallowing ability however he continued to be
unable to fully protect his airway. With strict aspiration
precautions taken, Mr. [**Name14 (STitle) 38257**] was able to swallow and clear the
aspirated material during the study. A repeat video swallow was
recommended in 1 week to see if diet can be safely advanced.
Tube feeds and supervised oral intake was continued. As he
continued to do well with oral intake, his diet was slowly
advanced to include thin liquids. The ear, nose and throat
service performed a videostrobe study which showed incomplete
closure of the true vocal chords due to bowing. No granuloma was
seen. With teaching to cough following a swallow, all aspirates
were cleared. Voice therapy was recommened as an outpatient. Mr.
[**Known lastname 38256**] respiratory issues quickly improved. He was able to
tolerate oral intake with strict aspiration precautions. His
heart rate improved to a rate controlled atrial fibrillation.
Mr. [**Known lastname 38255**] continue dto make steady progress and was discharged
to his home on [**2122-1-9**]. He will follow-up with Dr. [**Last Name (Prefixes) **],
his cardiologist, the electrophysiology service, the speech and
swallow service and his primary care physician as an outpatient.


Medications on Admission:
Acebutolol 200mg twice daily
Lisinopril 10mg twice daily\
Paxil 10mg once daily
Dofetilide 500mg twice daily
Coumadin
xanax 0.25mg as needed


Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 MDI* Refills:*0*
4. Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Warfarin Sodium 1 mg Tablet Sig: Five (5) Tablet PO DAILY
(Daily) for 3 days: then VNA to draw INR and call results to Dr. [**Name (NI) 38258**] office Goal INR 2-2.5.
Disp:*100 Tablet(s)* Refills:*0*
7. Chlordiazepoxide HCl 5 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day).
Disp:*90 Capsule(s)* Refills:*2*
8. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
9. Dofetilide 500 mcg Capsule Sig: One (1) Capsule PO twice a
day.
Disp:*60 Capsule(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
s/p AVR(#25 CE Pericardial)/MV repair(#28 Annuloplasty
band)/MAZE/Ao dissection repair(#28 Gelweave graft)
Prolonged ICU stay, swallow dysfxn
PMH:MR, AR, Afib, hernia repair


Discharge Condition:
good

Discharge Instructions:
keep wounds clean and  dry. OK to shower, no bathing or
swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds

Followup Instructions:
Dr [**Last Name (STitle) 38259**] in [**1-15**] weeks
Dr [**Last Name (STitle) **] in [**1-15**] weeks
Dr [**Last Name (STitle) **] in 4 weeks
Repeat swallow [**Month (only) **]   (scheduled)



Completed by:[**2122-2-5**]
{'Mitral valve insufficiency and aortic valve insufficiency,Rheumatic heart failure (congestive),Acquired cardiac septal defect,Atrial fibrillation,Cardiac complications, not elsewhere classified,Dissection of aorta, thoracic,Pneumonitis due to inhalation of food or vomitus,Other diseases of vocal cords,Disruption of 24 hour sleep wake cycle, 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: Atrial fibrillation and mitral regurgitation

PRESENT ILLNESS: Mr. [**Known lastname 38255**] is a 64 year old gentleman with a long standing
history of mitral regurge and atrial fibrillation despite
ablation therapy and multiple antiarrythmic drugs. His atrial
fibrillation is generally exacerbated by exercise and
accompanied by significant dyspnea. His most recent
echocardiogrma showed 2+ aortic regurgitation, 1+ mitral
regurgitation, 1+ tricuspid regurgitation, a dilated left and
right atrium, a mildly dilated aortic root and an ejection
fraction of 55%. A cardiac catheterization did not show any
significant coronary artery disease. Due to the progression of
his disease and debilitating symptoms, Mr. [**Known lastname 38255**] was referred
to Dr. [**Last Name (Prefixes) **] for surgical management.

MEDICAL HISTORY: Atrial Fibrillation
Mitral regurgitationPAst hernia repair

MEDICATION ON ADMISSION: Acebutolol 200mg twice daily
Lisinopril 10mg twice daily\
Paxil 10mg once daily
Dofetilide 500mg twice daily
Coumadin
xanax 0.25mg as needed

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VITAL SIGNS: HR 60 irregularly irregular  BP (L) 110/74 (R)
114/80
Ht 69" Wt 160 lbs
GENERAL: No apparent distress, well developed well nourished.
SKIN: warm, dry, no lesions
HEENT: PERRL, EOMI, anicteric sclera, oropharynx benign.
NECK: Supple, no lymphadenopathy, no thyromegally
CHEST: Clear lungs
HEART: Irregularly irregular rhythm, III?VI systolic murmur with
quiet diastolic murmur.
ABDOMEN: Soft, nontender, nondistended, normoactive bowel
sounds.
EXT: No clubbing, cyanosis or edema. No varicosities. 2+ pulses
throughout extremities. No femoral or carotid bruits.
NEURO: Cranial Nerve II-XII grossly intact, no focal deficits.

FAMILY HISTORY: Mother died at age 80 from an aortic aneurysm.
Father died at age 80 from congestive heart failure.
Sieter age 65 status post mitral valve replacement at age 60.
Sister age 67 with diabetes.

SOCIAL HISTORY: Mechanical engineer who lives in [**Location **] with wife. Quit
smoking 30 years ago. Rarely uses alcohol. 

### Response:
{'Mitral valve insufficiency and aortic valve insufficiency,Rheumatic heart failure (congestive),Acquired cardiac septal defect,Atrial fibrillation,Cardiac complications, not elsewhere classified,Dissection of aorta, thoracic,Pneumonitis due to inhalation of food or vomitus,Other diseases of vocal cords,Disruption of 24 hour sleep wake cycle, unspecified'}
