CHIEF COMPLAINT: Dyspnea on exertion

PRESENT ILLNESS: This is a 76 yo female w/ PMH of severe AS, MR secondary to
rheumatic heart disease presenting with progressive dyspnea on
exertion much worse since Monday. Pt. started noticing chest
discomfort which she is unable to characterize, tingling down
both arms and feeling of racing heart a/w dyspnea while walking
short distances on monday. These symptoms lasted about 5 minutes
and resolved after sitting down to rest. Pt. noticed these
symptoms came on this morning around 7:30 at rest and did not
resolve until around noon. These symptoms were not a/w
diaphoresis or nausea. Pt. had a minor heart attack while
hospitalized for elective knee surgery, she states that it did
not feel like these symptoms, she did not feel pain at that
time, she just had a sensation of not being able to get
comfortable in bed. Pt. also complains of a feeling of the room
spinning as she went to sleep last night, there was only one
episode of this. Pt. denies lightheadedness/syncope. Denies
orthopnea, PND, sleeps on 1 pillow. Her leg edema is at
baseline. She currently denies shortness of breath and chest
discomfort. She was admitted to the [**Hospital1 18**] under the cardiology
service.

MEDICAL HISTORY: Diabetes type 2, dx 5ya
CHF - EF 30% - Class I-II
h/o Rheumatic heart disease with mod-sev AS (peak gradient 60,
mean gradient 30, [**Location (un) 109**] 0.7 cm2), and mod MS (MVA 1.2cm2)
LBBB
Hypercholesterolemia.
Osteoarthritis.
Rotator cuff tear
Fibroid uterus.
Venous insufficiency.
Diverticulitis.
Aortic stenosis.
Atrial fibrillation on chronic anticoagulation

MEDICATION ON ADMISSION: ATORVASTATIN [LIPITOR] - 20 mg Tablet - 1 (One) Tablet(s) by
mouth once a day
DIGOXIN - 125 mcg Tablet - one tab by mouth once a day
FUROSEMIDE [LASIX] - 40 mg Tablet - 1 Tablet(s) by mouth once a

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS - 97.8, 124/83, 79, 18, 97% RA
Gen: Comfortable appearing women in NAD, breathing comfortably
HEENT: Mucous membranes mildly dry
Neck: JVD to earlobes
CV: High pitched crescendo/decrescendo murmur at ULSB radiating
to carotids.
Chest: Crackles to midlung, decreased resonance to percussion to
midlung bilaterally
Abd: Soft, NT, ND, ? hepatojugular reflux.
Ext: Chronic stasis changes in lower extremities bilaterally,
varicose veins in lower extremities.
Skin: stasis dermatitis

FAMILY HISTORY: Positive for CAD in several family members,
positive for an unknown malignancy in her father, and positive
for leukemia in her mother. [**Name (NI) **] family history of diabetes or
hypertension.

SOCIAL HISTORY: She is from [**Country 2559**], bilingual but speaks mostly
Italian. She is married, lives with her husband, has two grown
children. She is a retired cafeteria worker among others. No
tobacco use, no alcohol use, no drug use.
Multiple involvement of mitral and aortic valves,Acute on chronic systolic heart failure,Rheumatic heart failure (congestive),Paroxysmal ventricular tachycardia,Unspecified congenital anomaly of heart,Unspecified essential hypertension,Other chronic pulmonary heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other left bundle branch block,Pure hypercholesterolemia,Venous (peripheral) insufficiency, unspecified,Other diseases of lung, not elsewhere classified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Old myocardial infarction,Knee joint replacement,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Long-term (current) use of anticoagulants
Mitr/aortic mult involv,Ac on chr syst hrt fail,Rheumatic heart failure,Parox ventric tachycard,Cong heart anomaly NOS,Hypertension NOS,Chr pulmon heart dis NEC,DMII wo cmp nt st uncntr,Left bb block NEC,Pure hypercholesterolem,Venous insufficiency NOS,Other lung disease NEC,Osteoarthros NOS-unspec,Old myocardial infarct,Joint replaced knee,Abn react-surg proc NEC,Long-term use anticoagul
Admission Date:  [**2159-8-1**]              Discharge Date:   [**2159-8-12**]

Date of Birth:  [**2082-11-23**]             Sex:   F

Service: CARDIOTHORACIC

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on exertion

Major Surgical or Invasive Procedure:
[**2159-8-3**] Cardiac Catheterization
[**2159-8-7**] Aortic Valve Replacement(21mm Pericardial Valve) and
Mitral Valve Replacement(31mm Tissue Valve)


History of Present Illness:
This is a 76 yo female w/ PMH of severe AS, MR secondary to
rheumatic heart disease presenting with progressive dyspnea on
exertion much worse since Monday. Pt. started noticing chest
discomfort which she is unable to characterize, tingling down
both arms and feeling of racing heart a/w dyspnea while walking
short distances on monday. These symptoms lasted about 5 minutes
and resolved after sitting down to rest. Pt. noticed these
symptoms came on this morning around 7:30 at rest and did not
resolve until around noon. These symptoms were not a/w
diaphoresis or nausea. Pt. had a minor heart attack while
hospitalized for elective knee surgery, she states that it did
not feel like these symptoms, she did not feel pain at that
time, she just had a sensation of not being able to get
comfortable in bed. Pt. also complains of a feeling of the room
spinning as she went to sleep last night, there was only one
episode of this. Pt. denies lightheadedness/syncope. Denies
orthopnea, PND, sleeps on 1 pillow. Her leg edema is at
baseline. She currently denies shortness of breath and chest
discomfort. She was admitted to the [**Hospital1 18**] under the cardiology
service.

Past Medical History:
Diabetes type 2, dx 5ya
CHF - EF 30% - Class I-II
h/o Rheumatic heart disease with mod-sev AS (peak gradient 60,
mean gradient 30, [**Location (un) 109**] 0.7 cm2), and mod MS (MVA 1.2cm2)
LBBB
Hypercholesterolemia.
Osteoarthritis.
Rotator cuff tear
Fibroid uterus.
Venous insufficiency.
Diverticulitis.
Aortic stenosis.
Atrial fibrillation on chronic anticoagulation

PAST SURGICAL HISTORY:
1. Status post bowel resection for her diverticulitis.
2. Status post TAH/BSO.
3. Status post total knee replacement, bilateral


Social History:
She is from [**Country 2559**], bilingual but speaks mostly
Italian. She is married, lives with her husband, has two grown
children. She is a retired cafeteria worker among others. No
tobacco use, no alcohol use, no drug use.


Family History:
Positive for CAD in several family members,
positive for an unknown malignancy in her father, and positive
for leukemia in her mother. [**Name (NI) **] family history of diabetes or
hypertension.


Physical Exam:
VS - 97.8, 124/83, 79, 18, 97% RA
Gen: Comfortable appearing women in NAD, breathing comfortably
HEENT: Mucous membranes mildly dry
Neck: JVD to earlobes
CV: High pitched crescendo/decrescendo murmur at ULSB radiating
to carotids.
Chest: Crackles to midlung, decreased resonance to percussion to
midlung bilaterally
Abd: Soft, NT, ND, ? hepatojugular reflux.
Ext: Chronic stasis changes in lower extremities bilaterally,
varicose veins in lower extremities.
Skin: stasis dermatitis


Pertinent Results:
[**2159-8-1**] 05:45PM BLOOD WBC-9.9 RBC-3.52* Hgb-10.1* Hct-31.3*
MCV-89 MCH-28.8 MCHC-32.3 RDW-15.1 Plt Ct-368
[**2159-8-1**] 03:31PM BLOOD PT-25.6* INR(PT)-2.5*
[**2159-8-1**] 05:45PM BLOOD Glucose-132* UreaN-27* Creat-1.0 Na-141
K-4.7 Cl-106 HCO3-27 AnGap-13
[**2159-8-1**] 05:45PM BLOOD CK(CPK)-40
[**2159-8-1**] 05:45PM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2159-8-2**] 11:18AM BLOOD %HbA1c-6.4*
[**2159-8-2**] 07:10AM BLOOD Triglyc-115 HDL-35 CHOL/HD-3.5 LDLcalc-64
[**2159-8-1**] 05:45PM BLOOD TSH-1.0
[**2159-8-1**] EKG: Atrial fibrillation, mean ventricular rate 86. Left
bundle-branch block.
[**2159-8-1**] CXR: Since the prior study, the degree of pulmonary
vascular congestion and increased interstitial markings has
increased. There is no pneumothorax or pleural effusion. Severe
cardiomegaly persists.
[**2159-8-2**] ECHO:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
moderately dilated. There is moderate global left ventricular
hypokinesis (LVEF = 35 %) (Quantitative biplane EF 41%).
Transmitral Doppler and tissue velocity imaging are consistent
with Grade III/IV (severe) LV diastolic dysfunction. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic arch is mildly
dilated. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. There is severe aortic valve
stenosis (area <0.8cm2). Trace aortic regurgitation is seen. The
mitral valve leaflets are moderately thickened. There is mild
valvular mitral stenosis (area 1.5-2.0cm2). Moderate (2+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
[**2159-8-3**] Cardiac Cath:
1. Selective coronary angiography of this right dominant system
revealed
no angiographically apparent obstructive coronary disease.
2. Resting hemodynamics recorded during AF with a ventricular
rate of
90, demonstrated elevated left and right sided filling pressures
(mean
PCW 29 mmHg, RVSP 68 mmHg, RVEDP 12mmHg). There was moderately
severe
pulmonary hypertension (PA s/d/m = 66/30/47 mmHg). The
calculated
cardiac index was 2.6 l/min/m2. The catheter was not advanced to
the LV
to assess transaortic gradients or LV pressures as the main
purpose of
this limited study was to assess her coronary anatomy.
3. Left ventriculography was not performed.
[**2159-8-4**] Chest CT Scan:
1. Dense aortic valve and aortic root calcifications. Mild
calcifications
involving ascending aorta, and aortic arch. Mitral valve
calcifications.
2. 10-mm nodule in the left lower lobe, concerning for
malignancy. If no
prior studies are available for comparison, FDG - PET/CT can be
performed to further evaluate this nodule.
3. Diffuse predominantly perihilar ground-glass opacity, likely
reflecting
presence of congestive failure in the setting of cardiomegaly.

[**2159-8-12**] 07:00AM BLOOD WBC-7.9 RBC-2.83* Hgb-8.6* Hct-24.3*
MCV-86 MCH-30.5 MCHC-35.5* RDW-15.9* Plt Ct-229
[**2159-8-12**] 07:00AM BLOOD Plt Ct-229
[**2159-8-12**] 07:00AM BLOOD PT-18.1* PTT-30.6 INR(PT)-1.7*
[**2159-8-12**] 07:00AM BLOOD Glucose-116* UreaN-22* Creat-0.7 Na-136
K-3.9 Cl-100 HCO3-29 AnGap-11

Brief Hospital Course:
Mrs. [**Known lastname 45777**] was admitted under cardiology and started on a
Lasix drip for worsening heart failure. She ruled out for
myocardial infarction. She underwent right and left heart
catheterization which found minimal coronary artery disease and
revealed moderate pulmonary hypertension and moderate
biventricular diastolic dysfunction. Given the above findings,
cardiac surgery was consulted and further evaluation was
performed. Workup was notable for a one centimeter left lower
lobe non-calcified pulmonary nodule, concerning for malignancy.
This pulmonary nodule will be further evaluated as an outpatient
following surgery. Preoperative evaluation was otherwise
unremarkable and she was cleared for surgery. On [**8-7**],
Dr. [**Last Name (STitle) 914**] performed aortic and mitral valve replacments. For
surgical details, please see seperate dictated operative note.
She was transferred to the intensive for further hemodynamic
monitoring.  Amiodarone was started for ventricular tachycardia
post op which she converted after it was bolused. POD 1 she was
extubated with out complications and weaned from pressors.  She
continued to progress and was transferred to the floor POD 2.
Physical therapy worked with her on strength and mobility.  She
was transfused POD 4 for decreased hematocrit with no
complications.  She was ready to transfer to rehab on POD 5.


Medications on Admission:
ATORVASTATIN [LIPITOR] - 20 mg Tablet - 1 (One) Tablet(s) by
mouth once a day
DIGOXIN - 125 mcg Tablet - one tab by mouth once a day
FUROSEMIDE [LASIX] - 40 mg Tablet - 1 Tablet(s) by mouth once a

day as needed for as needed for swelling
LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth once a day
METFORMIN - 500 mg Tablet - 1 Tablet(s) by mouth twice a day
METOPROLOL SUCCINATE - 100 mg Tablet Sustained Release 24 hr -
one Tablet(s) by mouth twice a day
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)

by mouth qam Take on an empty stomach. Wait 15-20min prior to
eating or drinking anything.
WARFARIN - 3 mg Tablet - 1 Tablet(s) by mouth once a day as
prescribed

Medications - OTC
CYANOCOBALAMIN [VITAMIN B-12] - 1,000 mcg Tablet - 1 Tablet(s)
by
mouth once a day


Discharge Medications:
1. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day:
please check INR biweekly, goal INR 2-2.5 for atrial
fibrillation.
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours): twice a day for 1 week then decrease to daily, monitor
weight and edema .
9. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours): twice a day then decrease to daily with lasix.

10. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
14. medications
unable to start ACE inhibitor due to blood pressure - discussed
with Dr [**First Name (STitle) 437**] will start as outpatient


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]

Discharge Diagnosis:
Aortic and Mitral Valve Disease/Rheumatic Heart Disease
Chronic Atrial Fibrillation s/p LAA ligation
Acute on Chronic Systolic heart failure
Remote Myocardial Infarction
Dyslipidemia
Type II Diabetes Mellitus
Pulmonary Nodule


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. [**Last Name (STitle) 914**] in [**3-24**] weeks, call for appt
Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] in [**1-21**] weeks, call for appt
Dr. [**Last Name (STitle) **] in [**1-21**] weeks, call for appt
Currently scheduled appointments:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD Phone:[**Telephone/Fax (1) 1144**]
Date/Time:[**2159-12-4**] 10:30



Completed by:[**2159-8-12**]
{'Multiple involvement of mitral and aortic valves,Acute on chronic systolic heart failure,Rheumatic heart failure (congestive),Paroxysmal ventricular tachycardia,Unspecified congenital anomaly of heart,Unspecified essential hypertension,Other chronic pulmonary heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other left bundle branch block,Pure hypercholesterolemia,Venous (peripheral) insufficiency, unspecified,Other diseases of lung, not elsewhere classified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Old myocardial infarction,Knee joint replacement,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Long-term (current) use of anticoagulants'}


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 is a 76 yo female w/ PMH of severe AS, MR secondary to
rheumatic heart disease presenting with progressive dyspnea on
exertion much worse since Monday. Pt. started noticing chest
discomfort which she is unable to characterize, tingling down
both arms and feeling of racing heart a/w dyspnea while walking
short distances on monday. These symptoms lasted about 5 minutes
and resolved after sitting down to rest. Pt. noticed these
symptoms came on this morning around 7:30 at rest and did not
resolve until around noon. These symptoms were not a/w
diaphoresis or nausea. Pt. had a minor heart attack while
hospitalized for elective knee surgery, she states that it did
not feel like these symptoms, she did not feel pain at that
time, she just had a sensation of not being able to get
comfortable in bed. Pt. also complains of a feeling of the room
spinning as she went to sleep last night, there was only one
episode of this. Pt. denies lightheadedness/syncope. Denies
orthopnea, PND, sleeps on 1 pillow. Her leg edema is at
baseline. She currently denies shortness of breath and chest
discomfort. She was admitted to the [**Hospital1 18**] under the cardiology
service.

MEDICAL HISTORY: Diabetes type 2, dx 5ya
CHF - EF 30% - Class I-II
h/o Rheumatic heart disease with mod-sev AS (peak gradient 60,
mean gradient 30, [**Location (un) 109**] 0.7 cm2), and mod MS (MVA 1.2cm2)
LBBB
Hypercholesterolemia.
Osteoarthritis.
Rotator cuff tear
Fibroid uterus.
Venous insufficiency.
Diverticulitis.
Aortic stenosis.
Atrial fibrillation on chronic anticoagulation

MEDICATION ON ADMISSION: ATORVASTATIN [LIPITOR] - 20 mg Tablet - 1 (One) Tablet(s) by
mouth once a day
DIGOXIN - 125 mcg Tablet - one tab by mouth once a day
FUROSEMIDE [LASIX] - 40 mg Tablet - 1 Tablet(s) by mouth once a

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS - 97.8, 124/83, 79, 18, 97% RA
Gen: Comfortable appearing women in NAD, breathing comfortably
HEENT: Mucous membranes mildly dry
Neck: JVD to earlobes
CV: High pitched crescendo/decrescendo murmur at ULSB radiating
to carotids.
Chest: Crackles to midlung, decreased resonance to percussion to
midlung bilaterally
Abd: Soft, NT, ND, ? hepatojugular reflux.
Ext: Chronic stasis changes in lower extremities bilaterally,
varicose veins in lower extremities.
Skin: stasis dermatitis

FAMILY HISTORY: Positive for CAD in several family members,
positive for an unknown malignancy in her father, and positive
for leukemia in her mother. [**Name (NI) **] family history of diabetes or
hypertension.

SOCIAL HISTORY: She is from [**Country 2559**], bilingual but speaks mostly
Italian. She is married, lives with her husband, has two grown
children. She is a retired cafeteria worker among others. No
tobacco use, no alcohol use, no drug use. 

### Response:
{'Multiple involvement of mitral and aortic valves,Acute on chronic systolic heart failure,Rheumatic heart failure (congestive),Paroxysmal ventricular tachycardia,Unspecified congenital anomaly of heart,Unspecified essential hypertension,Other chronic pulmonary heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other left bundle branch block,Pure hypercholesterolemia,Venous (peripheral) insufficiency, unspecified,Other diseases of lung, not elsewhere classified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Old myocardial infarction,Knee joint replacement,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Long-term (current) use of anticoagulants'}
