CHIEF COMPLAINT: 

PRESENT ILLNESS: This is a 52 year old woman
status post aortic valve replacement on [**2176-7-17**] who
presents with a subtherapeutic INR of 1.8.  The patient had a
longstanding aortic stenosis of uncertain etiology, which
became symptomatic in [**2176-3-5**].  On [**2176-7-17**], she
received a mechanical aortic valve transplant.  The patient
tolerated the procedure well, and was coumadinized after
surgery with a goal INR of 2.5 to 3.  Ms [**Known lastname 14738**] was discharged
on [**2176-7-25**] to home with [**First Name (Titles) 407**]
[**Last Name (Titles) 11807**] coming to check her INR frequently.  Her last INR
before discharge on [**2176-7-25**] was 3.6.  Her discharge
dose of Warfarin was 2 mg q.d.  On this dose, the patient's
INR drifted downward following discharge to 1.8 on [**2176-7-30**], at which time she was referred to [**Hospital6 649**] Emergency Department for management of her
anticoagulation.  Since her discharge from the hospital on
[**2176-7-25**], the patient has experienced no fever or
chills, no nausea or vomiting, no shortness of breath.  Her
only complaint is of some pain in her chest wall near the
surgical incision site.

MEDICAL HISTORY: 1.  History of aortic stenosis
(severe) of unknown etiology, status post aortic valve
replacement on [**2176-7-17**]; 2.  Asthma, no history of
systemic steroids, no intubation for asthma; 3.  Thyroiditis;
4.  Status post right oophorectomy.

MEDICATION ON ADMISSION: Lasix 40 mg p.o. b.i.d. times two weeks (day 8 of course on
admission)
Potassium chloride 20 mEq p.o. b.i.d. times two weeks (day 8
of course on admission)
Atenolol 75 mg p.o. q.d.
Flovent metered dose inhaler, 2 puffs t.i.d.
Atrovent 2 puffs b.i.d.
Albuterol metered dose inhaler, 2 puffs q. 4-6 hours prn
Percocet 5/325 one to two tablets p.o. q. 4 hours prn pain
Colace 100 mg p.o. b.i.d.
Coumadin (target INR 2.5 to 3)

ALLERGIES: Vioxx, rash

PHYSICAL EXAM: 

FAMILY HISTORY: Two sibling with coronary artery disease.

SOCIAL HISTORY: Widowed, lives with brother and grandson in
[**Name (NI) 16174**].  Reports they had been taking care of her "very
well" since surgery.  Employed as clean-up until late 70s
when she became a homemaker.  No smoking history.  No
alcohol.  No intravenous drug abuse.
Abnormal coagulation profile,Cardiac arrest,Acute and subacute necrosis of liver,Disruption of external operation (surgical) wound,Unspecified disease of pericardium,Other chronic pulmonary heart diseases,Long-term (current) use of anticoagulants,Asthma, unspecified type, unspecified
Abnrml coagultion prfile,Cardiac arrest,Acute necrosis of liver,Disrup-external op wound,Pericardial disease NOS,Chr pulmon heart dis NEC,Long-term use anticoagul,Asthma NOS
Admission Date:  [**2176-8-2**]       Discharge Date:  [**2176-8-4**]

Date of Birth:   [**2124-7-12**]       Sex:  F

Service:  [**Hospital1 **] A

HISTORY OF PRESENT ILLNESS:  This is a 52 year old woman
status post aortic valve replacement on [**2176-7-17**] who
presents with a subtherapeutic INR of 1.8.  The patient had a
longstanding aortic stenosis of uncertain etiology, which
became symptomatic in [**2176-3-5**].  On [**2176-7-17**], she
received a mechanical aortic valve transplant.  The patient
tolerated the procedure well, and was coumadinized after
surgery with a goal INR of 2.5 to 3.  Ms [**Known lastname 14738**] was discharged
on [**2176-7-25**] to home with [**First Name (Titles) 407**]
[**Last Name (Titles) 11807**] coming to check her INR frequently.  Her last INR
before discharge on [**2176-7-25**] was 3.6.  Her discharge
dose of Warfarin was 2 mg q.d.  On this dose, the patient's
INR drifted downward following discharge to 1.8 on [**2176-7-30**], at which time she was referred to [**Hospital6 649**] Emergency Department for management of her
anticoagulation.  Since her discharge from the hospital on
[**2176-7-25**], the patient has experienced no fever or
chills, no nausea or vomiting, no shortness of breath.  Her
only complaint is of some pain in her chest wall near the
surgical incision site.

PAST MEDICAL HISTORY:  1.  History of aortic stenosis
(severe) of unknown etiology, status post aortic valve
replacement on [**2176-7-17**]; 2.  Asthma, no history of
systemic steroids, no intubation for asthma; 3.  Thyroiditis;
4.  Status post right oophorectomy.

MEDICATIONS ON ADMISSION:
Lasix 40 mg p.o. b.i.d. times two weeks (day 8 of course on
admission)
Potassium chloride 20 mEq p.o. b.i.d. times two weeks (day 8
of course on admission)
Atenolol 75 mg p.o. q.d.
Flovent metered dose inhaler, 2 puffs t.i.d.
Atrovent 2 puffs b.i.d.
Albuterol metered dose inhaler, 2 puffs q. 4-6 hours prn
Percocet 5/325 one to two tablets p.o. q. 4 hours prn pain
Colace 100 mg p.o. b.i.d.
Coumadin (target INR 2.5 to 3)

ALLERGIES:  Vioxx, rash

SOCIAL HISTORY:  Widowed, lives with brother and grandson in
[**Name (NI) 16174**].  Reports they had been taking care of her "very
well" since surgery.  Employed as clean-up until late 70s
when she became a homemaker.  No smoking history.  No
alcohol.  No intravenous drug abuse.

FAMILY HISTORY:  Two sibling with coronary artery disease.

PHYSICAL EXAMINATION:  Vital signs, temperature 99.0, pulse
73, blood pressure 134/87, respiratory rate 18, oxygen
saturation 98% on room air.
General:  Lying comfortably, in no apparent distress, alert
and oriented times three.
Head, eyes, ears, nose and throat:  Normocephalic,
atraumatic.  Pupils equal, round and reactive to light,
extraocular muscles intact, no jugulovenous distension noted,
no lymphadenopathy.
Chest:  Clear to auscultation and percussion bilaterally, no
wheezes, no rales, no rhonchi.
Cardiovascular:  Regular rate and rhythm, click on S2,
particularly along the right upper sternal border.  No
murmurs, rubs or gallops appreciated.  Surgical scar, healing
well.
Abdomen:  Soft, obese, nontender, normoactive bowel sounds.
Extremities:  No edema bilaterally.  No clubbing, no
cyanosis.

LABORATORY DATA:  Pertinent laboratory studies on admission
revealed white blood cells 12.6, hematocrit 31.4, platelets
652.  PT 17.5, PTT 26.6, INR 2.0.  Sodium 137, potassium 4.9,
chloride 99, bicarbonate 28, BUN 15, creatinine 0.7, glucose
102.  Chest x-ray:  Cardiomegaly, no consolidations, no
congestive heart failure.

HOSPITAL COURSE:  1.  Anticoagulation - The patient received
a mechanical valve, therefore INR is 2.5 to 3.5.  INR
measured on admission was 2.0.  The patient was given a
Warfarin loading dose of 8 mg on the night of admission, and
given 4 mg Warfarin per day afterwards.  On the morning after
admission the patient's INR was 2.5, and stayed within the
therapeutic range for 24 hours, so the patient was discharged
on [**2176-8-4**].  The patient was discharged on Warfarin 4
mg q.d. and asked to have her INR checked the day after
discharge.  On admission before the INR was in target range,
the heparin intravenous drip was started based on
weight-based dosing.  The patient reached target PTT between
60 and 80 by the night of admission and stayed within that
range until the day of discharge, when heparin drip was
discontinued.

2.  Pain control - The patient complained of pain in her
chest near the surgical incision along the left lower sternal
border.  Pain appeared to be positional, and was not
associated with any symptoms that suggested it was cardiac in
origin.  There was no erythema, induration, or drainage of
the wound.  The patient reports that the pain has been slowly
decreasing since her surgery.  It seemed extremely likely
that the pain was normal post surgical pain.  For pain
control, the patient was given Percocet two tablets q. 4
hours, and Ibuprofen 600 mg q. 6 hours prn.

3.  Cardiovascular - During her hospital stay, the patient
had no symptoms or signs of cardiac ischemia or failure.  She
had no shortness of breath, no fevers or chills, no nausea or
vomiting.  As mentioned earlier, the chest pain that she had
did not appear to be cardiac in nature.  The patient was
maintained on her preadmission cardiac regimen of Lasix,
potassium chloride and Atenolol.

4.  Asthma - The patient was not wheezing on examination, and
did not complain of shortness of breath during her hospital
admission.  She continued on her preadmission regimen of
Flovent, Atrovent and Albuterol.

5.  Prophylaxis - The patient was given Colace because of her
narcotic pain medications.

CONDITION ON DISCHARGE:   The patient's condition on
discharge was good.  She was discharged to home with [**Hospital6 3429**] services.

DISCHARGE DIAGNOSIS:
1.  Subtherapeutic anticoagulation
2.  Status post aortic valve replacement
3.  Asthma

DISCHARGE MEDICATIONS:
1.  Lasix 40 mg p.o. b.i.d. times four days
2.  Potassium chloride 8 mEq p.o. b.i.d. times four days
3.  Atenolol 75 mg p.o. q.d.
4.  Flovent metered dose inhaler 2 puffs b.i.d.
5.  Atrovent 2 puffs b.i.d.
6.  Albuterol metered dose inhaler 2 puffs q. 4-6 hours prn
7.  Percocet 5/325 1 to 2 tablets q. 4 hours prn
8.  Colace 100 mg p.o. b.i.d. while on Percocet
9.  Coumadin 4 mg p.o. q.d. (target INR 2.5 to 3.5)

DISCHARGE INSTRUCTIONS:  The patient was discharged to home
with [**Hospital6 407**] services.  [**Hospital6 1587**] was to check INR the day after discharge, three
days after discharge and five days after discharge.  The INR
results would be monitored by her primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 13964**].  After one week, the patient was to have her INR
checked at [**Hospital 16175**] [**Hospital3 **].  The patient was
instructed to make an appointment with her primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 13964**] one week after discharge.



                          DR.[**Last Name (STitle) **],[**First Name3 (LF) 275**] 02-248

Dictated By:[**Name8 (MD) **]
MEDQUIST36

D:  [**2176-8-3**]  22:48
T:  [**2176-8-4**]  07:37
JOB#:  [**Job Number 16176**]

cc:[**Telephone/Fax (1) 16177**]

Admission Date:  [**2176-8-2**]       Discharge Date:  [**2176-8-15**]

Date of Birth:   [**2124-7-12**]       Sex:  F

Service:  CARDIOTHORACIC

HISTORY OF PRESENT ILLNESS:  The patient is a 52 year-old
female status post aortic valve replacement on [**2176-7-17**] who
presented with subtherapeutic INR of 1.8 to the Medicine
Service.  The patient had a long standing history of aortic
stenosis of uncertain etiology, which became symptomatic for
the first time in [**3-7**].  The patient began experiencing
dizziness and substernal burning with exercise.  An
echocardiogram on [**2176-6-13**] showed moderate [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 13385**],
moderate left ventricular hypertrophy, EF of 55%, severely
thickened/deformed aortic valve leaflets.  Cardiac
catheterization on [**2176-7-9**] showed severe AS with aortic valve
area of .5 cm squared, mean AV gradient of 49 mmHg, moderate
pulmonary hypertension with no significant mitral
regurgitation and no significant coronary artery disease.
Dr. [**Last Name (STitle) 1537**] performed minimally invasive aortic valve
replacement on [**2176-7-17**] with 21 mm Carbomedics mechanical
valve.  The patient tolerated the procedure well and recovery
in the hospital was complicated by only some wheezing, mild
shortness of breath that improved with aggressive diuresis
and bronchodilators.  The patient was Coumadinized after
surgery with a goal INR of 2.5 to 3.  The patient was
discharged to home on [**2176-7-25**] with visiting nurse coming on
[**7-27**] for INR checks.  INR was 3.6 predischarge and drifted to
2.7 on [**7-27**] while the patient was taken 2 mg of Warfarin q.d.
 Even with increased Warfarin dosage 2 mg to 4 mg alternating
the patient's INR drifted down to 1.8 on [**7-30**] at which time
she was referred to [**Hospital1 69**]
Emergency Department for management.  During the time after
her discharge from the hospital [**7-25**] the patient reports no
nausea, vomiting, fevers or chills, shortness of breath, only
some pain in chest near incision that was described as
positional.

PAST MEDICAL HISTORY:
1.  Aortic stenosis (severe), status post AVR [**2176-7-17**].  No
documented by tested valve or other congenital malformation.
No known history of rheumatic fever RA.
2.  Asthma, no systemic steroids, no intubations for asthma
in history.
3.  Thyroiditis.
4.  Status post right oophorectomy.

ALLERGIES:  Vioxx causes a rash.

MEDICATIONS ON ADMISSION:
1.  Lasix 40 mg b.i.d. times two weeks, day eight on day of
admission.
2.  Potassium chloride 20 milliequivalents b.i.d. times two
weeks, day eight on admission.
3.  Atenolol 75 mg q.d.
4.  Flovent MDI two puffs q.d.
5.  Atrovent two puffs q.d.
6.  Albuterol MDI two puffs.
7.  Percocet 5/325 one to two tabs q 4 prn, had been taking
about two tabs per day on admission.
8.  Colace 100 mg b.i.d. while on Percocet.
9.  Coumadin alternating 2 mg and 4 mg.

SOCIAL HISTORY:  The patient is a widow.  She lives with
brother and grandfather in [**Location (un) 686**] who have been taking
care of her "very well" since surgery.  Employed as a
cleaning nurse until late 70s when she quit to take care of
her children and then grandchildren.  No smoking history.  No
alcohol now, minimal in remote past.

FAMILY HISTORY:  Two brothers with coronary artery disease.
Three other siblings who are healthy.

PHYSICAL EXAMINATION ON ADMISSION:  Vital signs 99.0, 73,
139/87, 18, 95% on room air.  General, she was an obese
female lying comfortably in no acute distress, alert and
oriented times three.  HEENT examination normocephalic,
atraumatic female with pupils are equal, round, and reactive
to light and accommodation.  Extraocular movements intact.
No JVD.  Chest was clear to auscultation and percussion
bilaterally.  No rales, wheezes or rhonchi.  Cardiovascularly
the patient had a surgical scar well healing along sternum
approximately 12 cm long with regular rate and rhythm.  Loud
click on S2 especially on right upper sternal border.  No
murmurs, rubs or gallops.  Abdomen was soft, obese, nontender
with positive bowel sounds.  Extremities showed no edema
bilaterally.  No clubbing, cyanosis or edema.

LABORATORIES ON ADMISSION:  White blood cell count of 12.6,
hematocrit 31.4 and platelets 652.  [**Name (NI) 2591**] PT 17.5, PTT 26.6
and INR of 2.0.  Chest x-ray showed cardiomegaly without
consolidation without congestive heart failure.

HOSPITAL COURSE:  The patient was then admitted to the
Medicine Service and started on a heparin drip to increase
anticoagulation.  INR remained around 2 on hospital day one
and two, however, after 24 hours the patient was
anticoagulated and the patient was complaining of increasing
shortness of breath and hypotension on the floor.  Primary
team performed a transthoracic echocardiogram, which showed
well seated and functioning prosthetic valve and tamponade
physiology.  On conclusion of the echocardiogram the patient
became unresponsive and the patient arrested.
Cardiopulmonary resuscitation was performed and
cardiothoracic surgery was emergently called for
pericardiocentesis at the bedside.  The patient was
resuscitated for PEA arrest after the anterior pericardial
hematoma was seen on echocardiogram and cardiothoracic
surgery began to make a skin incision in order to perform the
pericardiocentesis.  Skin incision was made, however,
immediately femoral pulses were detected and the patient was
then wheeled directly to the Operating Room for emergent
pericardial window procedure via subxiphoid approach for
pericardia tamponade.  The patient tolerated the procedure
well.  One chest tube was placed postoperatively.  The
patient did well immediately postoperatively, however, blood
work at that time showed increasing liver function tests with
transaminases to the 1000 and INR of 66.  The liver was
deemed to be in shock.  Liver function tests began to fall on
their own and INR began to normalize spontaneously in the
ensuring days postoperatively.  By postoperative day three
the patient was extubated and INR was down to 30.

On postoperative day five the patient went slightly into
atrial fibrillation/atrial flutter, however, reverted with
beta blockade.  By postoperative day seven the patient's INR
was down to 2.5 on 3 mg of Coumadin a day and 2.1 on
postoperative day eight.  Coumadin doses were then adjusted
according to INR levels and the patient was continued on 3 mg
of Coumadin until postoperative day nine when she was
decreased to 2 mg of Coumadin and had INR steady of 2.4 for
postoperative days 10 and 11 the day of discharge.  The
patient did extremely well on the floor and was transferred
to the floor earlier on in hospital course on postoperative
day seven and was discharged on postoperative day 11 in no
acute distress.  The patient did have slight wound separation
in the subxiphoid pericardial window incision and was placed
on Levofloxacin 500 mg q day times six days for this.

DISCHARGE MEDICATIONS:
1.  Colace 100 mg po b.i.d.
2.  Percocet 5/325 mg tablet one to two tabs po q 4 hours prn
pain.
3.  Fluticasone propionate 110 micrograms areosol with
adapter six puff inhalation b.i.d.
4.  Ipratropium bromide 18 micrograms areosol with adapter
two puffs inhalation q 4 to 6 hours.
5.  Albuterol 90 micrograms areosol two puff inhalation q six
hours.
6.  Warfarin 2 mg one tablet oral one dose, please take in
the p.m. of [**8-15**] and the patient was instructed to have INR
drawn at [**Hospital3 **] at 10:45 on [**8-16**] and have
dose adjusted by then with target INR of 1.8 to 2.5.
7.  Lopressor 50 mg 1.5 tablets po b.i.d.
8.  Lasix 20 mg tablet one po q 12 hours times ten days.
9.  Singulair 10 mg tablet one po q.d.
10.  Protonix 40 mg tablet one po q.d.
11.  Potassium chloride two capsules po b.i.d. times ten
days.
12.  Levofloxacin 500 mg tablet one tablet po q day.
13.  Coumadin, the patient was instructed to take 2 mg in the
p.m. of [**8-15**].  Please keep appointment at [**Hospital 191**] [**Hospital3 **] at 10:25 on [**2176-8-16**] phone number [**Telephone/Fax (1) 2173**].  [**Location (un) 86**]
VNA was to check INR Monday, Wednesday and Friday of next
week after the week after discharge.  She was to follow up in
[**Company 191**] anticoagulation service for INR checks.  The patient's
primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] was notified and
was contact[**Name (NI) **] to follow results and then make any needed
adjustments for Warfarin doses.  Dr. [**Last Name (STitle) 911**] the patient's
cardiologist was also notified.

DISCHARGE STATUS:  Good.  Home with [**Location (un) 86**] VNA.

DISCHARGE DIAGNOSES:
1.  Subtherapeutic INR.
2.  Aortic stenosis status post aortic valve replacement.
3.  Asthma.
4.  Cardiac tamponade with cardiac arrest, emergent
pericardial window for evacuation of tamponade and
postoperative elevated liver enzymes.






                            [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D.  [**MD Number(1) 1540**]

Dictated By:[**Last Name (NamePattern4) 16178**]
MEDQUIST36

D:  [**2176-8-15**]  11:29
T:  [**2176-8-16**]  07:07
JOB#:  [**Job Number 16179**]

cc:[**Last Name (NamePattern4) 16180**]
{'Abnormal coagulation profile,Cardiac arrest,Acute and subacute necrosis of liver,Disruption of external operation (surgical) wound,Unspecified disease of pericardium,Other chronic pulmonary heart diseases,Long-term (current) use of anticoagulants,Asthma, unspecified type, 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: 

PRESENT ILLNESS: This is a 52 year old woman
status post aortic valve replacement on [**2176-7-17**] who
presents with a subtherapeutic INR of 1.8.  The patient had a
longstanding aortic stenosis of uncertain etiology, which
became symptomatic in [**2176-3-5**].  On [**2176-7-17**], she
received a mechanical aortic valve transplant.  The patient
tolerated the procedure well, and was coumadinized after
surgery with a goal INR of 2.5 to 3.  Ms [**Known lastname 14738**] was discharged
on [**2176-7-25**] to home with [**First Name (Titles) 407**]
[**Last Name (Titles) 11807**] coming to check her INR frequently.  Her last INR
before discharge on [**2176-7-25**] was 3.6.  Her discharge
dose of Warfarin was 2 mg q.d.  On this dose, the patient's
INR drifted downward following discharge to 1.8 on [**2176-7-30**], at which time she was referred to [**Hospital6 649**] Emergency Department for management of her
anticoagulation.  Since her discharge from the hospital on
[**2176-7-25**], the patient has experienced no fever or
chills, no nausea or vomiting, no shortness of breath.  Her
only complaint is of some pain in her chest wall near the
surgical incision site.

MEDICAL HISTORY: 1.  History of aortic stenosis
(severe) of unknown etiology, status post aortic valve
replacement on [**2176-7-17**]; 2.  Asthma, no history of
systemic steroids, no intubation for asthma; 3.  Thyroiditis;
4.  Status post right oophorectomy.

MEDICATION ON ADMISSION: Lasix 40 mg p.o. b.i.d. times two weeks (day 8 of course on
admission)
Potassium chloride 20 mEq p.o. b.i.d. times two weeks (day 8
of course on admission)
Atenolol 75 mg p.o. q.d.
Flovent metered dose inhaler, 2 puffs t.i.d.
Atrovent 2 puffs b.i.d.
Albuterol metered dose inhaler, 2 puffs q. 4-6 hours prn
Percocet 5/325 one to two tablets p.o. q. 4 hours prn pain
Colace 100 mg p.o. b.i.d.
Coumadin (target INR 2.5 to 3)

ALLERGIES: Vioxx, rash

PHYSICAL EXAM: 

FAMILY HISTORY: Two sibling with coronary artery disease.

SOCIAL HISTORY: Widowed, lives with brother and grandson in
[**Name (NI) 16174**].  Reports they had been taking care of her "very
well" since surgery.  Employed as clean-up until late 70s
when she became a homemaker.  No smoking history.  No
alcohol.  No intravenous drug abuse. 

### Response:
{'Abnormal coagulation profile,Cardiac arrest,Acute and subacute necrosis of liver,Disruption of external operation (surgical) wound,Unspecified disease of pericardium,Other chronic pulmonary heart diseases,Long-term (current) use of anticoagulants,Asthma, unspecified type, unspecified'}
