CHIEF COMPLAINT: dyspnea on exertion

PRESENT ILLNESS: 67 yo F with h/o aortic stenosis followed by serial
echocardiograms with complaints of dyspnea on exertion and
occasional dizziness.

MEDICAL HISTORY: 1.  aortic stenosis
2.  hypertension
3.  hypercholesterolemia
4.  hypothyroidism
5.  s/p incisional hernia repair
6.  retroperitoneal mass resected in [**10-17**], found to be a 15cm
cystic mass most consistent with paraganglioma on pathology
7.  obesity
8. osteoarthritis
9. osteoporosis

MEDICATION ON ADMISSION: Alendronate 70 mg Tablet once weekly (Not Taking as Prescribed:
patient not able to take a full glass of water so has not taken
the med for 3 months )
Atorvastatin [Lipitor] 40 mg daily
Cyanocobalamin 1,000 mcg/mL Solution IM injection once a month
Levothyroxine [Levoxyl] 100 mcg daily
Lisinopril 20 mg Tablet TID
Calcium Citrate-Vitamin D3 [Calcium Citrate + D] 315 mg-200 unit
Tablet 2 Tablet(s) by mouth twice a day

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Physical Exam

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Lives with husband.  Denies tobacco, alcohol, or IVDU.
Aortic valve disorders,Occlusion and stenosis of carotid artery with cerebral infarction,Aphasia,Cardiac complications, not elsewhere classified,Atrial fibrillation,Unspecified essential hypertension,Pure hypercholesterolemia,Unspecified acquired hypothyroidism,Obesity, unspecified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Osteoporosis, unspecified,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation
Aortic valve disorder,Ocl crtd art w infrct,Aphasia,Surg compl-heart,Atrial fibrillation,Hypertension NOS,Pure hypercholesterolem,Hypothyroidism NOS,Obesity NOS,Osteoarthros NOS-unspec,Osteoporosis NOS,Abn react-surg proc NEC
Admission Date:  [**2130-6-12**]              Discharge Date:   [**2130-6-25**]

Date of Birth:  [**2062-11-26**]             Sex:   F

Service: CARDIOTHORACIC

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
dyspnea on exertion

Major Surgical or Invasive Procedure:
aortic valve replacement (#23mm porcine), aortic root
enlargement and pericardial patch [**2130-6-12**]


History of Present Illness:
67 yo F with h/o aortic stenosis followed by serial
echocardiograms with complaints of dyspnea on exertion and
occasional dizziness.

Past Medical History:
1.  aortic stenosis
2.  hypertension
3.  hypercholesterolemia
4.  hypothyroidism
5.  s/p incisional hernia repair
6.  retroperitoneal mass resected in [**10-17**], found to be a 15cm
cystic mass most consistent with paraganglioma on pathology
7.  obesity
8. osteoarthritis
9. osteoporosis

Social History:
Lives with husband.  Denies tobacco, alcohol, or IVDU.


Family History:
Noncontributory

Physical Exam:
Physical Exam

Pulse:75 Resp:14  O2 sat: 97% RA
B/P  Right:150/81    Left:145/68
Height:5'0"     Weight:182 lbs

General:
Skin: Dry [x] intact []
HEENT: PERRLA [x] EOMI [x]
Neck:  Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x]  Irregular []  Murmur [**3-20**] blowing SEM
Abdomen: Soft [x] non-distended [x] non-tender [x]  bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]  No Edema Varicosities:
bilat spider veins and PVD color changes
Neuro: Grossly intact [x]
Pulses:
Femoral      Right: cath site Left: 2+
DP           Right: 2+  Left: 2+
PT           [**Name (NI) 167**]: 2+  Left: 2+
Radial       Right: 2+  Left: 2+

Carotid Bruit: Right: radiated murmur   Left: radiated murmur


Pertinent Results:
[**2130-6-15**] 05:45AM BLOOD WBC-11.6* RBC-2.68* Hgb-8.4* Hct-25.2*
MCV-94 MCH-31.3 MCHC-33.3 RDW-15.1 Plt Ct-163
[**2130-6-16**] 05:45AM BLOOD Hct-35.2*#
[**2130-6-12**] 12:10PM BLOOD PT-13.4 PTT-39.6* INR(PT)-1.1
[**2130-6-16**] 05:45AM BLOOD Glucose-140* UreaN-29* Creat-0.7 Na-138
K-4.5 Cl-102 HCO3-25 AnGap-16
[**2130-6-16**] 05:45AM BLOOD Mg-2.4
PRE-BYPASS:
1. The left atrium is moderately dilated. Mild spontaneous echo
contrast is present in the left atrial appendage. No atrial
septal defect is seen by 2D or color Doppler.
2. There is severe symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the descending thoracic aorta.
There are three aortic valve leaflets. The aortic valve leaflets
are moderately thickened. There is critical aortic valve
stenosis (valve area <0.8cm2). Mild to moderate ([**12-16**]+) aortic
regurgitation is seen.
5. The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral regurgitation is seen.
6. Moderate [2+] tricuspid regurgitation is seen.
7. There is no pericardial effusion.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and is
being A paced.
1. A well-seated bioprosthetic valve is seen in the Aortic
position with normal leaflet motion and gradients (mean gradient
= 10 mmHg). Trace central aortic regurgitation is seen.
2. Biventricular function is normal.
3. MR appears improved.
4. Other findings are unchanged

[**Known lastname 26148**],[**Known firstname **] [**Age over 90 26149**] F  67  [**2062-11-26**]

Radiology Report CTA NECK W&W/OC & RECONS Study Date of [**2130-6-17**]
7:33 PM


[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG CSRU [**2130-6-17**] 7:33 PM
CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS   Clip #
[**Clip Number (Radiology) 26150**]
Reason: (L)MCA infarct/(L)ICA embolic occlusion
Contrast: OPTIRAY Amt: 80



[**Hospital 93**] MEDICAL CONDITION:
   67 year old woman with (R)sided weakness/facial droop/slurred
speech
REASON FOR THIS EXAMINATION:
   (L)MCA infarct/(L)ICA embolic occlusion
CONTRAINDICATIONS FOR IV CONTRAST:
   None.



Wet Read: JKSd SAT [**2130-6-17**] 10:09 PM
Small amount of contrast now seen in the left common carotid
artery, but flow
stops at level of carotid canal. Minimal flow in left MCA as
before. Bilateral
pleural effusions, unchanged.


Final Report
CT ANGIOGRAPHY OF THE NECK AND HEAD

HISTORY: Right-sided weakness, facial droop, and slurred speech.


TECHNIQUE: Bolus intravenously enhanced imaging of the neck and
head with
multiplanar reconstructions.

COMPARISON STUDY ON PACS ARCHIVE: CT angiography of the neck and
head
performed eight hours previously.

PRELIMINARY FINDINGS: Provided by Dr. [**Name (NI) 402**] [**Last Name (NamePattern1) **], who
indicated "small
amount of contrast is now seen in the left common carotid
artery, but flow
stops at the level of the carotid canal. Minimal flow in left
middle cerebral
artery as before."

FINDINGS:

Comparison with the prior CT angiogram does reveal slightly
increased quantity
of contrast material within the intracervical portion of the
left internal
carotid artery. Both studies did reveal flow within the left
common carotid
artery, with essentially complete occlusion suspected on the
prior CT
angiogram. Upon meticulous review of the source data, the
original study
revealed the internal carotid artery, but appeared to show
negligible flow
beyond its origin. The present study appears to show some flow
within this
vessel extending to the carotid foramen, but again there is
negligible flow
more distally. The poor flow is substantiated by review of the
source images
intracranially, with this absence of flow also involving the
left internal
carotid bifurcation, as well as a portion of the A1 segment of
the left
anterior cerebral artery and proximal M1 segment of the left
middle cerebral
artery. Given this pattern of occlusions, flow to the left
middle cerebral
artery likely depends upon retrograde filling from contiguous
vascular
territories.

There is redemonstration of a moderate right and smaller
left-sided pleural
effusion, incompletely delineated on this study.

CONCLUSION: Some minor improvement in intracervical blood flow
in the left
internal carotid artery, but continued negligible flow in the
intracranial
portion of this vessel.


The study and the report were reviewed by the staff radiologist.


DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9987**]
Approved: SUN [**2130-6-18**] 1:33 PM

  Imaging Lab



Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2130-6-12**] where she underwent aortic valve
replacement as well as aortic root enlargement with a
pericardial patch as detailed in the operative note.  Overall
the patient tolerated the procedure well and post-operatively
was transferred to the CVICU in critical but stable condition
for observation and recovery.  At this time hemodynamics were
maintained with phenylephrine.  She awoke neurologically intact
and was extubated without difficulty on POD#1. Pressors were
weaned off and Beta- Blocker and diuresis was initiated.All
lines and drains were discontinued in a timely fashion.  She did
develop atrial fibrillation which was rate controlled  with
amiodarone and lopressor. Physical therapy was consulted for
post-operative strength and mobility assistance.
On the morning of [**6-17**], she became aphasic with right-sided
weakness. Code Stroke was called and she was evaluated by
neurology. A CT scan showed [**Doctor First Name 3098**] occlusion and likely embolic
CVA. She was transferred back to the CVICU and an IV heparin
bridge was initiated per neurology recommendations.  She
continued to make a good recovery with a slight residual right
facial droop and mild right upper and lower extremity weakness.
Coumadin was started. She was transferred back to the step down
floor on POD #7 to begin increasing her activity level. She went
into rapid A Fib on POD #7 and was treated with amiodarone and
titrated beta blockade. She was cleared for discharge to home on
POD # 13, The first INR blood draw with VNA should be on [**6-26**]
with results to be called to the office of Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] at
phone ([**Telephone/Fax (1) 1921**]/fax ([**Telephone/Fax (1) 23341**].  The target INR is [**1-17**]
per neurology.  Pt then set up with [**Hospital 197**] clinic. They will
contact her [**6-27**]

Medications on Admission:
Alendronate 70 mg Tablet once weekly (Not Taking as Prescribed:
patient not able to take a full glass of water so has not taken
the med for 3 months )
Atorvastatin [Lipitor] 40 mg daily
Cyanocobalamin 1,000 mcg/mL Solution IM injection once a month
Levothyroxine [Levoxyl] 100 mcg daily
Lisinopril 20 mg Tablet TID
Calcium Citrate-Vitamin D3 [Calcium Citrate + D] 315 mg-200 unit
Tablet 2 Tablet(s) by mouth twice a day


Discharge Medications:
1. Coumadin 2 mg Tablet Sig: Two (2) Tablet PO once a day: ING
goal is [**1-17**] for afibrillation. [**Hospital 197**] clinic to follow INR.
Disp:*60 Tablet(s)* Refills:*2*
2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): Take 400 [**Hospital1 **] x 1 week, Then 200 [**Hospital1 **] x 1 week, Then 200
qd afterwards.
Disp:*120 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
Disp:*30 Suppository(s)* Refills:*0*
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Packet Sig: One (1)  PO twice a
day for 7 days.
Disp:*14 20 mEq Packet* Refills:*0*
11. Aspirin 325 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*
12. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
PER PCP.
13. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain: prn for pain.
Disp:*30 Tablet(s)* Refills:*0*
14. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO once
a month: per PCP.


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
aortic stenosis s/p AVR
-Left Internal carotid artery embolic occlusion/ left middle
cerebral artery infarct
postop A Fib
HTN
hypercholesterolemia
hypothyroidism
obesity
oesteoartritis
osteoporosis


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, and while taking
narcotics
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]


Followup Instructions:
Dr. [**Last Name (STitle) **] (cardiac surgeon) in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] (PCP) [**Telephone/Fax (1) 250**] in [**12-16**] weeks.
Dr. [**Last Name (STitle) **] (cardiology) in [**1-17**] weeks
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (neurology) follow up in [**1-17**] weeks- please call
for appt.
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])

First INR blood draw with VNA [**6-26**] with results to be called to
the office of Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] at phone ([**Telephone/Fax (1) 1921**]/fax
([**Telephone/Fax (1) 23341**].  Plan confirmed with [**Doctor First Name 16883**] on [**6-22**].  Target INR
2-3 per neurology.

You will also be contact[**Name (NI) **] by the coumadiinclinic on [**6-27**]..
They will then moniter your INR



Completed by:[**2130-6-25**]
{'Aortic valve disorders,Occlusion and stenosis of carotid artery with cerebral infarction,Aphasia,Cardiac complications, not elsewhere classified,Atrial fibrillation,Unspecified essential hypertension,Pure hypercholesterolemia,Unspecified acquired hypothyroidism,Obesity, unspecified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Osteoporosis, unspecified,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}


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: 67 yo F with h/o aortic stenosis followed by serial
echocardiograms with complaints of dyspnea on exertion and
occasional dizziness.

MEDICAL HISTORY: 1.  aortic stenosis
2.  hypertension
3.  hypercholesterolemia
4.  hypothyroidism
5.  s/p incisional hernia repair
6.  retroperitoneal mass resected in [**10-17**], found to be a 15cm
cystic mass most consistent with paraganglioma on pathology
7.  obesity
8. osteoarthritis
9. osteoporosis

MEDICATION ON ADMISSION: Alendronate 70 mg Tablet once weekly (Not Taking as Prescribed:
patient not able to take a full glass of water so has not taken
the med for 3 months )
Atorvastatin [Lipitor] 40 mg daily
Cyanocobalamin 1,000 mcg/mL Solution IM injection once a month
Levothyroxine [Levoxyl] 100 mcg daily
Lisinopril 20 mg Tablet TID
Calcium Citrate-Vitamin D3 [Calcium Citrate + D] 315 mg-200 unit
Tablet 2 Tablet(s) by mouth twice a day

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Physical Exam

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Lives with husband.  Denies tobacco, alcohol, or IVDU. 

### Response:
{'Aortic valve disorders,Occlusion and stenosis of carotid artery with cerebral infarction,Aphasia,Cardiac complications, not elsewhere classified,Atrial fibrillation,Unspecified essential hypertension,Pure hypercholesterolemia,Unspecified acquired hypothyroidism,Obesity, unspecified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Osteoporosis, unspecified,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}
