CHIEF COMPLAINT: Dyspnea on exertion

PRESENT ILLNESS: This 69 year old  male with cardiomyopathy, worsening dyspnea on
exertion and pedal edema, who has opted for medical management
in the past.  In [**Month (only) 956**] he had cardiac catheterization that
revealed severe three vessel disease coronary artery disease and
echocardiogram showed severe aortic stenosis, at which time he
was referred for surgical evaluation.

MEDICAL HISTORY: Cardiomyopathy
Congestive heart failure
noninsulin dependent Diabetes Mellitus
Benign prostatic hypertrophy
Gastric ulcers
s/p prostatectomy
s/p Tonsillectomy

MEDICATION ON ADMISSION: Aspirin 81mg qd, Advair 100/50 daily, Carvedilol 3.125mg [**Hospital1 **],
Glucophage 1000mg qAM and 500mg qPM, Lasix 80mg [**Hospital1 **], Zestril
40mg qd, Lanoxin 0.125mg [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission:
VS: 73 23 104/44 5'8" 156#
Gen: No acute distress
Skin: Unremarkable
HEENT: Unremarkable
Neck: Supple, full range of motion
Chest: Clear lungs bilaterally
Heart: Regular rate and rhythm 2/6 systolic murmur
Abd: Soft, non-tender, non-distended, +bowel sounds
Ext: Warm, well-perfused +3 edema
Neuro: Grossly intact, alert and oriented x 3

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Lives with: Family.
Occupation: Retired bookkeeper
Tobacco quit [**8-30**] 40 pack year history
ETOH: occassional
Aortic valve disorders,Acute on chronic systolic heart failure,Other primary cardiomyopathies,Cardiac complications, not elsewhere classified,Coronary atherosclerosis of native coronary artery,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled
Aortic valve disorder,Ac on chr syst hrt fail,Prim cardiomyopathy NEC,Surg compl-heart,Crnry athrscl natve vssl,Atrial fibrillation,DMII wo cmp nt st uncntr
Admission Date:  [**2125-1-24**]              Discharge Date:   [**2125-2-1**]

Date of Birth:  [**2055-11-25**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Dyspnea on exertion

Major Surgical or Invasive Procedure:
[**2121-1-24**] Aortic Valve Replacement (23mm CE Magna pericaridal),
Coronary Artery Bypass Graft x 4 (Saphenous vein graft to left
anterior descending, Saphenous vein graft to diagonal, Saphenous
vein graft to obtuse marginal, Saphenous vein graft to posterior
descending artery)

History of Present Illness:
This 69 year old  male with cardiomyopathy, worsening dyspnea on
exertion and pedal edema, who has opted for medical management
in the past.  In [**Month (only) 956**] he had cardiac catheterization that
revealed severe three vessel disease coronary artery disease and
echocardiogram showed severe aortic stenosis, at which time he
was referred for surgical evaluation.

Past Medical History:
Cardiomyopathy
Congestive heart failure
noninsulin dependent Diabetes Mellitus
Benign prostatic hypertrophy
Gastric ulcers
s/p prostatectomy
s/p Tonsillectomy

Social History:
Lives with: Family.
Occupation: Retired bookkeeper
Tobacco quit [**8-30**] 40 pack year history
ETOH: occassional

Family History:
Non-contributory

Physical Exam:
Admission:
VS: 73 23 104/44 5'8" 156#
Gen: No acute distress
Skin: Unremarkable
HEENT: Unremarkable
Neck: Supple, full range of motion
Chest: Clear lungs bilaterally
Heart: Regular rate and rhythm 2/6 systolic murmur
Abd: Soft, non-tender, non-distended, +bowel sounds
Ext: Warm, well-perfused +3 edema
Neuro: Grossly intact, alert and oriented x 3

Pertinent Results:
[**2125-2-1**] 09:20AM BLOOD WBC-7.6 RBC-3.88* Hgb-12.0* Hct-34.8*
MCV-90 MCH-31.1 MCHC-34.6 RDW-16.2* Plt Ct-121*
[**2125-1-24**] 01:11PM BLOOD WBC-15.5*# RBC-3.62* Hgb-11.0* Hct-32.9*
MCV-91 MCH-30.5 MCHC-33.6 RDW-15.5 Plt Ct-63*#
[**2125-2-1**] 09:20AM BLOOD Plt Ct-121*
[**2125-1-24**] 01:11PM BLOOD Plt Ct-63*#
[**2125-1-24**] 01:11PM BLOOD PT-26.4* PTT-150* INR(PT)-2.6*
[**2125-1-24**] 06:43PM BLOOD Fibrino-245#
[**2125-2-1**] 09:20AM BLOOD Glucose-217* UreaN-14 Creat-1.0 Na-135
K-4.3 Cl-101 HCO3-27 AnGap-11
[**2125-1-24**] 03:25PM BLOOD UreaN-61* Creat-1.7* Cl-118* HCO3-23
[**2125-1-30**] 06:13AM BLOOD ALT-22 AST-29 LD(LDH)-293* AlkPhos-68
Amylase-33 TotBili-1.4
[**2125-2-1**] 09:20AM BLOOD Calcium-7.9* Phos-2.0* Mg-1.7
[**2125-1-25**] 09:38PM BLOOD Calcium-8.2* Phos-4.2 Mg-2.0

[**Known lastname **],[**Known firstname **] JR [**Medical Record Number 101423**] M  69  [**2055-11-25**]

Radiology Report CHEST (PA & LAT) Study Date of [**2125-1-31**] 2:51 PM



[**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA6A [**2125-1-31**] 2:51 PM
CHEST (PA & LAT)   Clip # [**Clip Number (Radiology) 101424**]
Reason: evaluate effusion, atx



[**Hospital 93**] MEDICAL CONDITION:
   69 year old man with s/p avr, cabg
REASON FOR THIS EXAMINATION:
   evaluate effusion, atx



Final Report
REASON FOR EXAMINATION: Follow up of a patient after aortic
valve
replacement.

PA and lateral upright chest radiographs were compared to [**1-28**], [**2124**].

The right internal jugular line has been removed in the interum.
The
cardiomediastinal silhouette is stable. The position of the
replaced aortic
valve is unchanged. The bilateral pleural effusions are small to
moderate and
are unchanged as well. There is no evidence of pneumothorax.
There is no
evidence of failure. Bibasilar atelectasis most likely secondary
to pleural
effusion.

DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Approved: WED [**2125-1-31**] 4:07 PM

[**Known lastname **],[**Known firstname **] JR [**Medical Record Number 101423**] M  69  [**2055-11-25**]

Cardiology Report ECG Study Date of [**2125-1-27**]  12:03:02 PM


Sinus rhythm with ventricular premature complex
Probable left atrial abnormality
Left axis deviation may be due in part to left anterior
fascicular block and/or
possible prior inferior myocardial infarction
Delayed R wave progression with late precordial QRS transition
ST-T wave abnormalities
These findings are nonspecific but clinical correlation is
suggested
Since previous tracing of [**2125-1-24**], probably no significant
change


Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.

  Intervals Axes
Rate PR QRS QT/QTc P QRS T
71 0 100 400/419 0 -26 120

[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT

[**Known lastname **], [**Known firstname **]       [**Hospital1 18**] [**Numeric Identifier 101425**]Portable TTE
(Complete) Done [**2125-1-26**] at 11:00:00 AM      FINAL
Referring Physician     [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**]  Status: Inpatient DOB: [**2055-11-25**]
Age (years): 69 M  Hgt (in): 75
BP (mm Hg): 102/51  Wgt (lb): 176
HR (bpm): 75  BSA (m2): 2.08 m2
Indication: H/O cardiac surgery s/p AVR with bioprosthesis..
Left ventricular function
ICD-9 Codes: V42.2, 424.1, 424.0
Test Information
Date/Time: [**2125-1-26**] at 11:00    Interpret MD: [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD

Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) 4134**] [**Last Name (NamePattern1) 4135**],
RDCS
Doppler: Full Doppler and color Doppler Test Location: West
SICU/CTIC/VICU
Contrast: None Tech Quality: Suboptimal
Tape #: 2009W000-0:00 Machine: Vivid i-3
Echocardiographic Measurements
Results  Measurements  Normal Range
Left Atrium - Long Axis Dimension:  *4.3 cm  <= 4.0 cm
Left Atrium - Four Chamber Length:  5.2 cm  <= 5.2 cm
Left Atrium - Peak Pulm Vein S:  0.5 m/s
Left Atrium - Peak Pulm Vein D:  0.3 m/s
Left Atrium - Peak Pulm Vein A:  0.2 m/s  < 0.4 m/s
Right Atrium - Four Chamber Length:  *5.9 cm  <= 5.0 cm
Left Ventricle - Septal Wall Thickness:  0.8 cm  0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness:  0.8 cm  0.6 - 1.1 cm

Left Ventricle - Diastolic Dimension:  *5.9 cm  <= 5.6 cm
Left Ventricle - Systolic Dimension:  5.0 cm
Left Ventricle - Fractional Shortening:  *0.15  >= 0.29
Left Ventricle - Ejection Fraction:  20% to 30%  >= 55%
Left Ventricle - Lateral Peak E':  0.09 m/s  > 0.08 m/s
Left Ventricle - Septal Peak E':  *0.04 m/s  > 0.08 m/s
Left Ventricle - Ratio E/E':  9  < 15
Aorta - Sinus Level:  *3.9 cm  <= 3.6 cm
Aorta - Ascending:  *4.3 cm  <= 3.4 cm
Aorta - Arch:  *3.2 cm  <= 3.0 cm
Aortic Valve - Peak Velocity:  *2.2 m/sec  <= 2.0 m/sec
Aortic Valve - Peak Gradient:  *20 mm Hg  < 20 mm Hg
Aortic Valve - Mean Gradient:  12 mm Hg
Aortic Valve - LVOT diam:  2.0 cm
Mitral Valve - E Wave:  0.6 m/sec
Mitral Valve - A Wave:  0.5 m/sec
Mitral Valve - E/A ratio:  1.20
Mitral Valve - E Wave deceleration time:  *253 ms  140-250 ms
TR Gradient (+ RA = PASP):  *33 to 40 mm Hg  <= 25 mm Hg

Findings
This study was compared to the prior study of [**2124-12-28**].
LEFT ATRIUM: Mild LA enlargement.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter
or pacing wire is seen in the RA and extending into the RV.

LEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV
cavity. False LV tendon (normal variant). Severely depressed
LVEF. No resting LVOT gradient.

RIGHT VENTRICLE: Normal RV wall thickness. Mildly dilated RV
cavity. Mild global RV free wall hypokinesis.

AORTA: Mildly dilated aortic sinus. Moderately dilated ascending
aorta. Mildly dilated aortic arch.

AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR).
Normal AVR gradient.

MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild (1+) MR.

TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
to moderate [[**11-24**]+] TR. Moderate PA systolic hypertension.

PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.

GENERAL COMMENTS: Suboptimal image quality - poor parasternal
views. Suboptimal image quality - poor subcostal views.
Suboptimal image quality - bandages, defibrillator pads or
electrodes.

REGIONAL LEFT VENTRICULAR WALL MOTION:





     N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is mildly
dilated. Overall left ventricular systolic function is severely
depressed (LVEF= 20-30 %) secondary to hypokinesis of the
septum, anterior free wall, inferior wall, and apex; there is
relative sparing of the posterior and lateral walls. The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. The aortic root is mildly dilated at the sinus
level. The ascending aorta is moderately dilated. The aortic
arch is mildly dilated. A bioprosthetic aortic valve prosthesis
is present. The transaortic gradient is normal for this
prosthesis. The mitral valve leaflets are mildly thickened. Mild
(1+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. There is moderate pulmonary artery
systolic hypertension.

IMPRESSION: normal aortic bioprosthesis

Compared with the prior study (images reviewed) of [**2124-12-28**], the
aortic valve has been replaced; left ventricular ejection
fraction is similar, but the mitral regurgitation is reduced,
and there is evidence of reduced diastolic dysfunction of the
left ventricle; the pulmonary artery pressure is significantly
reduced.
  Electronically signed by [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2125-1-26**] 15:07






Brief Hospital Course:
Admitted same day and went to surgery.  Underwent coronary
artery bypass graft and aortic valve replacement.  See operative
report for further details.  He received Cefazolin for
perioperative antibiotics.  He was transferred to the intensive
care unit for hemodynamic management on Vasopressin, Levophed,
epinephrine and insulin infusions.  He received multiple blood
products and protamine for bleeding that resolved.  Medication
drips were weaned down and levophed was discontinued, he
remained hemodynamically stable. He was weaned from sedation,
awoke neurologically intact and was extubated without
complications.  Epinephrine and vasopressin were weaned off in
the afternoon on post operative day one but due to hypotension
the levophed was restarted.  He was gently diuresed toward
preoperative weight, beta blocker and ace inhibitor were held
due to pressor requirement.  On [**1-27**] he was weaned off levophed
but atrial paced for blood pressure.  He was noted for free air
under the diaphragm and dilated loops of bowel, but physical
exam benign.  He was followed clinically, narcotics
disconintued, and serial radiograph with resolution.
He was started on betablockers and ace inhibitors which he
tolerated.  Physical therapy worked with him on strength and
mobility.  He was ready for discharge home with services on post
operative day 8.  Plan for him to follow up with Dr [**Last Name (STitle) **] in
next seven to ten days to evaluate diuresis due to heart
failure.

Sternal incision: steri strips, no erythema no drainage, sternum
stable
Left EVH sites with no erythema no drainage.
Lower extremity edema +3 pitting, from knees down
Weight preoperative 76.5 kg discharge weight 74.6 kg

Medications on Admission:
Aspirin 81mg qd, Advair 100/50 daily, Carvedilol 3.125mg [**Hospital1 **],
Glucophage 1000mg qAM and 500mg qPM, Lasix 80mg [**Hospital1 **], Zestril
40mg qd, Lanoxin 0.125mg [**Hospital1 **]

Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*0*
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
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:*0*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
1 months.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*0*
9. Metformin 500 mg Tablet Sig: One (1) Tablet PO qpm: in
afternoon .
Disp:*30 Tablet(s)* Refills:*0*
10. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO once a day:
in am .
Disp:*30 Tablet(s)* Refills:*0*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 2
weeks.
Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
12. Furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day:
please take twice a day - follow up with cardiologist in next
7-10 days to evaluate diuresis .
Disp:*60 Tablet(s)* Refills:*0*
13. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
14. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a
day for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Aortic Stenosis s/p Aortic Valve Replacement
Coronary artery disease s/p coronary artery bypass graft surgery
Acute on chronic systolic heart failure
Post operative atrial fibrillation
Cardiomyopathy
Diabetes Mellitus
Benign prostatic hypertrophy
Gastric ulcers
s/p Prostate surgery
s/p Tonsillectomy


Discharge Condition:
Good


Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]

Followup Instructions:
Dr. [**First Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**6-1**] days
Dr. [**Last Name (STitle) 101422**] in 2 weeks ([**Telephone/Fax (1) 90222**])
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]

Completed by:[**2125-2-1**]
{'Aortic valve disorders,Acute on chronic systolic heart failure,Other primary cardiomyopathies,Cardiac complications, not elsewhere classified,Coronary atherosclerosis of native coronary artery,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}


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: Dyspnea on exertion

PRESENT ILLNESS: This 69 year old  male with cardiomyopathy, worsening dyspnea on
exertion and pedal edema, who has opted for medical management
in the past.  In [**Month (only) 956**] he had cardiac catheterization that
revealed severe three vessel disease coronary artery disease and
echocardiogram showed severe aortic stenosis, at which time he
was referred for surgical evaluation.

MEDICAL HISTORY: Cardiomyopathy
Congestive heart failure
noninsulin dependent Diabetes Mellitus
Benign prostatic hypertrophy
Gastric ulcers
s/p prostatectomy
s/p Tonsillectomy

MEDICATION ON ADMISSION: Aspirin 81mg qd, Advair 100/50 daily, Carvedilol 3.125mg [**Hospital1 **],
Glucophage 1000mg qAM and 500mg qPM, Lasix 80mg [**Hospital1 **], Zestril
40mg qd, Lanoxin 0.125mg [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission:
VS: 73 23 104/44 5'8" 156#
Gen: No acute distress
Skin: Unremarkable
HEENT: Unremarkable
Neck: Supple, full range of motion
Chest: Clear lungs bilaterally
Heart: Regular rate and rhythm 2/6 systolic murmur
Abd: Soft, non-tender, non-distended, +bowel sounds
Ext: Warm, well-perfused +3 edema
Neuro: Grossly intact, alert and oriented x 3

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Lives with: Family.
Occupation: Retired bookkeeper
Tobacco quit [**8-30**] 40 pack year history
ETOH: occassional 

### Response:
{'Aortic valve disorders,Acute on chronic systolic heart failure,Other primary cardiomyopathies,Cardiac complications, not elsewhere classified,Coronary atherosclerosis of native coronary artery,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}
