CHIEF COMPLAINT: Shortness of breath

PRESENT ILLNESS: Mrs [**Known lastname 81165**] is a 86 yo f with h/o HTN, CHF, COPD, Afib, and
aortic stenosis who presents for evaluation for possible AVR.
Patient presented to the hospital in [**3-13**] with shortness of
breath, fluid overload, and hypotension. She was found to have
critical aortic stenosis. She underwent valvuloplasty with
suboptimal results. Patient was discharged to rehab with
moderate improvement of her symptoms. After discharge patient
reevaluated her options and decided she was not content with her
quality of life. Her edematous legs and pulmonary edema has made
it impossible for her to be independently mobile. She requires
assistance for nearly all ADLs. She decided she was willing to
undergo surgical repair of her aortic valve in attempt to
improve her symptoms. She was seen by her physician who
recommended hospital admission for aggressive diuresis and a
complete preop evaluation.
.
On arrival to the floor, patient states she is comfortable and
without any pain. She thinks her shortness of breath has been
stable since her recent discharge but is unsure because she has
not been as mobile. She admits to significant increase in
bilateral lower extremity edema. She denies chest pain, nausea,
lightheadedness or diaphoresis. She denies any recent illness
with the exception of 1 day of diarrhea last week. She admits to
no other changes in her medical history since her last
admission.  The patient denies palpitations or syncope,
claudication-type symptoms, melena, rectal bleeding, or
transient neurologic deficits.  No change in weight or urinary
symptoms. No cough, fever, night sweats, arthralgias, myalgias,
headache or rash.  All other review of systems  negative.
.

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: 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

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 96.9 BP 104/66 HR 104 RR 24 SpO2 95% 4L
Gen: NAD, comfortable
HEENT: PERRL, EOMI, NCAT, mmm
NECK: large nontender goiter on R, no JVD visible
CV: holosystolic murmur with loss of S2 consistent
with severe AS, no delayed upstrokes
LUNGS: bibasilar crackles, good air movement
ABD: + bs, Soft, NTND
EXT: BLE 3+ pitting edema
Skin: warm, dry, weeping edematous BLE
Neurologic: no focal deficits, CN 2-12 grossly intact

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives at [**Hospital3 **]. Smoking: quit 40 years ago, but had 10
pack year priot to that
Acute on chronic systolic heart failure,Mixed acid-base balance disorder,Aortic valve disorders,Atrial fibrillation,Long-term (current) use of anticoagulants,Unspecified essential hypertension,Chronic airway obstruction, not elsewhere classified,Goiter, unspecified,Esophageal reflux,Osteoporosis, unspecified,Personal history of tobacco use,Encounter for palliative care,Kyphosis (acquired) (postural),Hypoxemia
Ac on chr syst hrt fail,Mixed acid-base bal dis,Aortic valve disorder,Atrial fibrillation,Long-term use anticoagul,Hypertension NOS,Chr airway obstruct NEC,Goiter NOS,Esophageal reflux,Osteoporosis NOS,History of tobacco use,Encountr palliative care,Kyphosis NOS,Hypoxemia
Admission Date:  [**2186-4-11**]              Discharge Date:   [**2186-4-19**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Shortness of breath

Major Surgical or Invasive Procedure:

PICC line placement and removal


History of Present Illness:
Mrs [**Known lastname 81165**] is a 86 yo f with h/o HTN, CHF, COPD, Afib, and
aortic stenosis who presents for evaluation for possible AVR.
Patient presented to the hospital in [**3-13**] with shortness of
breath, fluid overload, and hypotension. She was found to have
critical aortic stenosis. She underwent valvuloplasty with
suboptimal results. Patient was discharged to rehab with
moderate improvement of her symptoms. After discharge patient
reevaluated her options and decided she was not content with her
quality of life. Her edematous legs and pulmonary edema has made
it impossible for her to be independently mobile. She requires
assistance for nearly all ADLs. She decided she was willing to
undergo surgical repair of her aortic valve in attempt to
improve her symptoms. She was seen by her physician who
recommended hospital admission for aggressive diuresis and a
complete preop evaluation.
.
On arrival to the floor, patient states she is comfortable and
without any pain. She thinks her shortness of breath has been
stable since her recent discharge but is unsure because she has
not been as mobile. She admits to significant increase in
bilateral lower extremity edema. She denies chest pain, nausea,
lightheadedness or diaphoresis. She denies any recent illness
with the exception of 1 day of diarrhea last week. She admits to
no other changes in her medical history since her last
admission.  The patient denies palpitations or syncope,
claudication-type symptoms, melena, rectal bleeding, or
transient neurologic deficits.  No change in weight or urinary
symptoms. No cough, fever, night sweats, arthralgias, myalgias,
headache or rash.  All other review of systems  negative.
.


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:
VS: T 96.9 BP 104/66 HR 104 RR 24 SpO2 95% 4L
Gen: NAD, comfortable
HEENT: PERRL, EOMI, NCAT, mmm
NECK: large nontender goiter on R, no JVD visible
CV: holosystolic murmur with loss of S2 consistent
with severe AS, no delayed upstrokes
LUNGS: bibasilar crackles, good air movement
ABD: + bs, Soft, NTND
EXT: BLE 3+ pitting edema
Skin: warm, dry, weeping edematous BLE
Neurologic: no focal deficits, CN 2-12 grossly intact


Pertinent Results:
[**2186-4-11**]
Na 138 / K 3.5 / Cl 89 / CO2 42 / BUN 35 / Cr 1.2 / BG 118
ALT 13 / AST 27 / LDH 269 / Alk Phos 74 / TB 1.8
Alb 3.5 / Ca [**87**].2 / Mg 2.1 / Phos 2.8
WBC 7.9 / Hct 30.8 / Plt 222
INR 5.7
[**2186-4-13**] CXR - Marked widening of right superior mediastinal
contour is consistent with intrathoracic extension of a goiter
as reported on recent CT. Heart remains enlarged. Mild pulmonary
vascular engorgement and new perihilar haziness are likely due
to congestive heart failure. Multifocal patchy and linear
opacities in the left mid and both lower lungs favor
atelectasis. Small pleural effusions are present bilaterally.
[**2186-4-14**] Echo
The left atrium is moderately dilated. The right atrium is
markedly dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Overall left ventricular
systolic function is moderately depressed (LVEF= 35-40%). The
right ventricular cavity is moderately dilated with mild global
free wall hypokinesis. There is abnormal systolic septal
motion/position consistent with right ventricular pressure
overload. The ascending aorta is moderately dilated. The aortic
valve leaflets (3) are severely thickened/deformed. There is
severe aortic valve stenosis (area <0.8cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. The mitral valve shows characteristic rheumatic
deformity. There is mild valvular mitral stenosis (area
1.5-2.0cm2). Severe (4+) mitral regurgitation is seen. Moderate
[2+] tricuspid regurgitation is seen. There is severe pulmonary
artery systolic hypertension. The end-diastolic pulmonic
regurgitation velocity is increased suggesting pulmonary artery
diastolic hypertension. There is no pericardial effusion.
.
IMPRESSION: Mild LVH with moderate global systolic dysfunction.
Mild right ventricular systolic dysfunction. Severe aortic
stenosis. Mild aortic regurgitation. Mild valvular mitral
stenosis. Severe mitral regurgitation. Moderate tricuspid
regurgitation. Severe pulmonary hypertension.


Brief Hospital Course:
86 year old female with a history of HTN, CHF, COPD, Afib, and
aortic stenosis s/p valvuloplasty was admitted for evaluation of
aortic valve replacement.
.
1. Aortic Stenosis:
She was diagnosed with critical stenosis during a prior
admission. At that time, she was not interested in surgical
aortic valve repair but did agree to a cardiac catheterization
with valvuloplasty. She had minimal improvement in her aortic
valve after valvuloplasty. She tolerated the procedure well and
was discharged to rehab. Given her persistent symptoms, she did
ultimatly agree to surgery. Unfortunately she was thought to be
a very high risk for surgery due to likelihood of a difficult
extubation and prolonged ventilator wean, and she was no longer
a candidate for surgical aortic valve repair. Given her limited
other medical options, she was not interested in additional
therapy. She was made DNR/DNI/ Do not rehospitalize and was
discharged to rehab with plans to transition to hospice.
.
2. Congestive Heart Failure:
Ms. [**Known lastname 81165**] was in acute on chronic systolic heart failure upon
arrival to [**Hospital1 18**] likely worsened related to her severe aortic
stenosis. She was diuresed aggressively with a lasix drip and
then transitioned to oral lasix prior to discharge. She was
initially on 4L upon admission, required BiPap briefly, and was
back to 3-5L upon discharge. Her furosemide was transitioned
from a lasix drip to 120mg oral furosemide.
.
3. Hypoxia
Her hypoxia was likely multifactorial and related to her
congestive heart failure, valvular disease, kyphosis, and her
thyroid enlargement.
.
4. Atrial fibrillation
She has chronic atrial fibrillation and was maintained on a beta
blocker for rate control with coumadin for anticoagulation. She
was continued on her beta blocker and warfarin for symptomatic
control of her symptoms secondary to atrial fibrillation.
.
5. Goals of Care
Patient was initially full code upon admission to [**Hospital1 18**] in
anticipation of an aortic valve repair; however, when surgical
aortic valve repair was no longer an option, Ms. [**Known lastname 81165**] was
clear that she would not like any further interventions. She is
interested primarily in symptom control. She now has a do not
resuscitate, do not intubate, and do not rehospitalize order.
Her health care proxy, [**Name (NI) 3608**] [**Name (NI) 81166**], is aware of these wishes
and in full agreement. Palliative care was very helpful in
assisting with these discussions.

# CONTACT: [**Name (NI) 3608**] (daughter) (h) [**Telephone/Fax (1) 81167**] (c) [**Telephone/Fax (1) 81168**]


Medications on Admission:
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. Furosemide 20 mg Tablet Sig: One (3) Tablet PO DAILY
(Daily).


Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-3**] Sprays Nasal
QID (4 times a day) as needed.
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO Q6H
(every 6 hours).
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q4H (every 4 hours) as
needed.
6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
7. Furosemide 80 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
8. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
9. Morphine 10 mg/5 mL Solution Sig: 2.5-5 mg PO Q2H (every 2
hours) as needed for shortness of breath or wheezing.
10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).


Discharge Disposition:
Extended Care

Facility:
[**Last Name (un) 1848**]

Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Congestive Heart Failure
2. Aortic Stenosis s/p valvuloplasty
3. Atrial Fibrillation


Discharge Condition:
Stable. Patient is tolerating 3-5L of oxygen with adequate
saturations. She is alert and can speak clearly intermittently
throughout the day


Discharge Instructions:
You were admitted to the hospital with shortness of breath. This
was thought likely related to your heart failure and severe
valvular disease. Unfortunately you are not a candidate to have
surgical repair of your valve. Given that your symptoms will
likely not improve significantly without surgery, you were not
interested in further treatment of your medical problems in a
hospital setting. We fully support you in these brave and
difficult decisions and wish you the best of luck.
.
We have made several changes to your medications to align with
your current goals of care.
- raloxifene, lovastatin, calcium, aspirin - we have
discontinued these medications as they do not seem to be
treating your current symptoms.
- morphine - this is a medication you can use as you need for
pain control or shortness of breath.
- seroquel - this is a medication to help you sleep at night.


Followup Instructions:
Good luck to you in your future care.





Name:  [**Known lastname 13018**],[**Known firstname 4497**]                  Unit No:   [**Numeric Identifier 13019**]

Admission Date:  [**2186-4-11**]              Discharge Date:   [**2186-4-19**]

Date of Birth:  [**2099-7-14**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3780**]
Addendum:
Patient should be referred to Hospice of the [**Location (un) 95**] /
Palliative Care.

Discharge Disposition:
Extended Care

Facility:
[**Last Name (un) 13020**]

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3782**] MD [**MD Number(2) 3783**]

Completed by:[**2186-4-19**]
{'Acute on chronic systolic heart failure,Mixed acid-base balance disorder,Aortic valve disorders,Atrial fibrillation,Long-term (current) use of anticoagulants,Unspecified essential hypertension,Chronic airway obstruction, not elsewhere classified,Goiter, unspecified,Esophageal reflux,Osteoporosis, unspecified,Personal history of tobacco use,Encounter for palliative care,Kyphosis (acquired) (postural),Hypoxemia'}


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: Mrs [**Known lastname 81165**] is a 86 yo f with h/o HTN, CHF, COPD, Afib, and
aortic stenosis who presents for evaluation for possible AVR.
Patient presented to the hospital in [**3-13**] with shortness of
breath, fluid overload, and hypotension. She was found to have
critical aortic stenosis. She underwent valvuloplasty with
suboptimal results. Patient was discharged to rehab with
moderate improvement of her symptoms. After discharge patient
reevaluated her options and decided she was not content with her
quality of life. Her edematous legs and pulmonary edema has made
it impossible for her to be independently mobile. She requires
assistance for nearly all ADLs. She decided she was willing to
undergo surgical repair of her aortic valve in attempt to
improve her symptoms. She was seen by her physician who
recommended hospital admission for aggressive diuresis and a
complete preop evaluation.
.
On arrival to the floor, patient states she is comfortable and
without any pain. She thinks her shortness of breath has been
stable since her recent discharge but is unsure because she has
not been as mobile. She admits to significant increase in
bilateral lower extremity edema. She denies chest pain, nausea,
lightheadedness or diaphoresis. She denies any recent illness
with the exception of 1 day of diarrhea last week. She admits to
no other changes in her medical history since her last
admission.  The patient denies palpitations or syncope,
claudication-type symptoms, melena, rectal bleeding, or
transient neurologic deficits.  No change in weight or urinary
symptoms. No cough, fever, night sweats, arthralgias, myalgias,
headache or rash.  All other review of systems  negative.
.

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: 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

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 96.9 BP 104/66 HR 104 RR 24 SpO2 95% 4L
Gen: NAD, comfortable
HEENT: PERRL, EOMI, NCAT, mmm
NECK: large nontender goiter on R, no JVD visible
CV: holosystolic murmur with loss of S2 consistent
with severe AS, no delayed upstrokes
LUNGS: bibasilar crackles, good air movement
ABD: + bs, Soft, NTND
EXT: BLE 3+ pitting edema
Skin: warm, dry, weeping edematous BLE
Neurologic: no focal deficits, CN 2-12 grossly intact

FAMILY HISTORY: NC

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

### Response:
{'Acute on chronic systolic heart failure,Mixed acid-base balance disorder,Aortic valve disorders,Atrial fibrillation,Long-term (current) use of anticoagulants,Unspecified essential hypertension,Chronic airway obstruction, not elsewhere classified,Goiter, unspecified,Esophageal reflux,Osteoporosis, unspecified,Personal history of tobacco use,Encounter for palliative care,Kyphosis (acquired) (postural),Hypoxemia'}
