CHIEF COMPLAINT: worsening shortness of breath

PRESENT ILLNESS: Patient is a [**Age over 90 **]yo male with hx CAD s/p CABG x1([**2173**]), PCI
([**2185**]), afib, dual chamber PPM, CVA, renal insufficiency s/p rt
renal artery stent, carotid disease, with known aortic stenosis
s/p valvuloplasy ([**8-/2197**]) who presents with symptoms of
shortness
of breath after slowly walking 1 block, inability to climb
stairs
without stopping due to shortness of breath. He denies chest
pain, lightheadedness. Past medical history includes B-cell
lymphoma for which he was treated with chemotherapy, no
radiation, now in remission ([**2192**]). He was seen 4 months prior
for evaluation for aortic treatment options and was found to be
of prohibitively high risk for surgical AVR. He was considered
for [**Year (4 digits) 10723**]/TAVR but did not meet criteria for available high
risk arm of study. He has been stable on medical management,
however, his family notes a decline in function and worsening
fatigue over the last 3 weeks. He admits to frequent naps, and
shortness of breath after walking 20 feet. He was again seen and
evaluated for conventional surgical AVR. He was deemed of
prohibitive surgical risk due to advance age and comorbidities.
After informed consent and extensive discussions with patient
and his son and daughter, he was screened for the [**Name (NI) 10723**]/TAVR
continued access extreme risk arm of the study. He met all
inclusion criteria, and did not meet any of the exclusion
criteria. He was screened and accepted and now returns for
elective [**Name (NI) 10723**]/TAVR.

MEDICAL HISTORY: CAD, s/p CABG in [**2173**]
[**2185**] s/p Cx stenting
Atrial fibrillation
[**Company 1543**] Adapta dual-chamber pacemaker
Aortic stenosis - s/p valvuloplasty [**8-/2197**]
Renal artery stenosis, s/p left renal artery stenting [**5-22**]
Hypertension
? Hyperlipidemia
Hypothyroidism
CVA, TIA x 2
s/p remote inguinal hernia repair
Cataract surgery
Hard of hearing
[**2192**]: Large cell Lymphoma, s/p R-CHOP (completed treatment in
[**9-21**]). Currently in remission
right axillary node dissection
tonsillectomy

MEDICATION ON ADMISSION: Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day). Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
Dipyridamole-aspirin 200-25 mg Cap, ER Multiphase 12 hr Sig: One
(1) Cap PO DAILY (Daily).
Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM -
discontinued 5 days ago

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Physical Exam on Admission:
Pulse: 66
B/P: 96/50(right) 90/50(left)
Resp: 18
O2 Sat: 99
Temp: 97.8
Height:  Weight: 170 lbs
General: alert, pleasant well-developed elderly male in NAD at
rest. Noticealbly SOB with ambulation
Skin: color pale pink, skin warm and dry, well healed sternal
incisional scar, no lesions.
HEENT: normocephalic, anicteric, good dentition, oropharynx
moist, upper bridge. Carotid bruits vs. referred murmer
Neck: supple, trachea midline, carotid bruits vs. referred
murmer
Chest: prominent clavicles, well healed sternotomy
Heart:  murmer throughout
Abdomen: soft, nontender,nondistended, (+)BS, 80%meal intake
Extremities: no peripheral edema, no obvious deformities
Neuro: pleasant, A+Ox3, gross FROM
Pulses: palpable peripheral pulses.

FAMILY HISTORY: Family History: Brother died of an MI in his late 50's-early
60s. Sister died of a heart condition her 60's.

SOCIAL HISTORY: Patient lives alone in [**Location (un) **], CT. He lives close to his
daughter, [**Name (NI) **] [**Name (NI) 24715**], who is his primary caretaker. [**Name (NI) **] denies
any hx of smoking, EtOH, or drug use
Aortic valve disorders,Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Delirium due to conditions classified elsewhere,Chronic diastolic heart failure,Acute posthemorrhagic anemia,Atherosclerosis of renal artery,Hematoma complicating a procedure,Atrial fibrillation,Unspecified renovascular hypertension,Unspecified acquired hypothyroidism,Other and unspecified hyperlipidemia,Constipation, unspecified,Lumbago,Aortocoronary bypass status,Cardiac pacemaker in situ,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Personal history of antineoplastic chemotherapy,Long-term (current) use of anticoagulants,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Aortic valve disorder,Oth lymp unsp xtrndl org,Delirium d/t other cond,Chr diastolic hrt fail,Ac posthemorrhag anemia,Renal artery atheroscler,Hematoma complic proc,Atrial fibrillation,Renovasc hypertension,Hypothyroidism NOS,Hyperlipidemia NEC/NOS,Constipation NOS,Lumbago,Aortocoronary bypass,Status cardiac pacemaker,Hx TIA/stroke w/o resid,Hx antineoplastic chemo,Long-term use anticoagul,Abn react-procedure NEC
Admission Date:  [**2199-4-29**]              Discharge Date:   [**2199-5-6**]


Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

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

Major Surgical or Invasive Procedure:
Cor Valve placement


History of Present Illness:
Patient is a [**Age over 90 **]yo male with hx CAD s/p CABG x1([**2173**]), PCI
([**2185**]), afib, dual chamber PPM, CVA, renal insufficiency s/p rt
renal artery stent, carotid disease, with known aortic stenosis
s/p valvuloplasy ([**8-/2197**]) who presents with symptoms of
shortness
of breath after slowly walking 1 block, inability to climb
stairs
without stopping due to shortness of breath. He denies chest
pain, lightheadedness. Past medical history includes B-cell
lymphoma for which he was treated with chemotherapy, no
radiation, now in remission ([**2192**]). He was seen 4 months prior
for evaluation for aortic treatment options and was found to be
of prohibitively high risk for surgical AVR. He was considered
for [**Year (4 digits) 10723**]/TAVR but did not meet criteria for available high
risk arm of study. He has been stable on medical management,
however, his family notes a decline in function and worsening
fatigue over the last 3 weeks. He admits to frequent naps, and
shortness of breath after walking 20 feet. He was again seen and
evaluated for conventional surgical AVR. He was deemed of
prohibitive surgical risk due to advance age and comorbidities.
After informed consent and extensive discussions with patient
and his son and daughter, he was screened for the [**Name (NI) 10723**]/TAVR
continued access extreme risk arm of the study. He met all
inclusion criteria, and did not meet any of the exclusion
criteria. He was screened and accepted and now returns for
elective [**Name (NI) 10723**]/TAVR.

NYHA Class: III


Past Medical History:
CAD, s/p CABG in [**2173**]
[**2185**] s/p Cx stenting
Atrial fibrillation
[**Company 1543**] Adapta dual-chamber pacemaker
Aortic stenosis - s/p valvuloplasty [**8-/2197**]
Renal artery stenosis, s/p left renal artery stenting [**5-22**]
Hypertension
? Hyperlipidemia
Hypothyroidism
CVA, TIA x 2
s/p remote inguinal hernia repair
Cataract surgery
Hard of hearing
[**2192**]: Large cell Lymphoma, s/p R-CHOP (completed treatment in
[**9-21**]). Currently in remission
right axillary node dissection
tonsillectomy


Social History:
Patient lives alone in [**Location (un) **], CT. He lives close to his
daughter, [**Name (NI) **] [**Name (NI) 24715**], who is his primary caretaker. [**Name (NI) **] denies
any hx of smoking, EtOH, or drug use


Family History:
Family History: Brother died of an MI in his late 50's-early
60s. Sister died of a heart condition her 60's.






Physical Exam:
Physical Exam on Admission:
Pulse: 66
B/P: 96/50(right) 90/50(left)
Resp: 18
O2 Sat: 99
Temp: 97.8
Height:  Weight: 170 lbs
General: alert, pleasant well-developed elderly male in NAD at
rest. Noticealbly SOB with ambulation
Skin: color pale pink, skin warm and dry, well healed sternal
incisional scar, no lesions.
HEENT: normocephalic, anicteric, good dentition, oropharynx
moist, upper bridge. Carotid bruits vs. referred murmer
Neck: supple, trachea midline, carotid bruits vs. referred
murmer
Chest: prominent clavicles, well healed sternotomy
Heart:  murmer throughout
Abdomen: soft, nontender,nondistended, (+)BS, 80%meal intake
Extremities: no peripheral edema, no obvious deformities
Neuro: pleasant, A+Ox3, gross FROM
Pulses: palpable peripheral pulses.

Physical Exam on Discharge:
Tmax/Tcurrent: 98.5/98.5 HR: 74 RR: 20 BP: 116-127/51-57O2 sat:
98% RA
I/O:
24h: 940/850
8H; none
General Appearance: No acute distress, AAOx2
Eyes / Conjunctiva: PERRL
Cardiovascular: [**1-21**] sys murmur with 3/6 diastolic murmur, +s1
and s2, no JVD seen
Peripheral Vascular: 2+ DP
Respiratory / Chest: CTAB
Abdominal: Soft, Non-tender
Extremities: no edema
Skin: intact
Neurologic: Attentive, Follows simple commands, strength 5/5
upper and lower extremeties, speech clear, no focal defecits.

Pertinent Results:
Labs on Admission:
[**2199-4-29**] 01:10PM   WBC-3.6* RBC-3.23* HGB-8.9* HCT-28.9* MCV-90
MCH-27.6 MCHC-30.8* RDW-17.2*
[**2199-4-29**] 01:10PM   GLUCOSE-72 UREA N-32* CREAT-1.6* SODIUM-136
POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-23 ANION GAP-13
[**2199-4-29**] 01:10PM   ALT(SGPT)-13 AST(SGOT)-22 CK(CPK)-32* ALK
PHOS-127 TOT BILI-0.7
[**2199-4-29**] 01:10PM   proBNP-6595*
[**2199-4-29**] 01:10PM   ALBUMIN-3.4*
[**2199-4-29**] 01:10PM   PT-14.6* PTT-31.7 INR(PT)-1.4*
[**2199-4-29**] 01:08PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2199-4-29**] 01:08PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG

Imaging:

Chest x-ray pre op
There is interval increase in right pleural effusion, currently
moderate.
Small amount of left pleural effusion is new as well.  Patient
is in mild
interstitial edema.  Heart size and mediastinum are
unremarkable.  Pacemaker leads terminate in the expected
location of right atrium and right ventricle.

TTE [**2199-4-30**]
There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size is normal. with mild global free wall hypokinesis.
An aortic [**Month/Day/Year **] prosthesis is present. The transaortic
gradient is normal for this prosthesis. A paravalvular aortic
valve leak is probably present. Moderate to severe (3+) aortic
regurgitation is seen (with holodiastolic flow reversal
demonstrated in the descending thoracic aorta in suprasternal
notch views). The mitral valve leaflets are mildly thickened.
Mild to moderate ([**12-17**]+) mitral regurgitation is seen. Moderate
[2+] tricuspid regurgitation is seen. There is borderline
pulmonary artery systolic hypertension. There is no pericardial
effusion

TTE [**2199-5-1**]
Overall left ventricular systolic function is normal (LVEF>55%).
An aortic [**Month/Day/Year **] prosthesis is present. The prosthesis is
well seated with thin/mobile leaflets and normal gradients. An
eccentric anterior perivalvular jet of at least mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**12-17**]+) mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is an anterior
space which most likely represents a prominent fat pad.
Compared with the prior study (images reviewed) of [**2199-4-30**],
the severity of aortic regurgitation is now reduced. The other
findings are similar.

TTE [**2199-5-2**]
Overall left ventricular systolic function is normal (LVEF 70%).
An aortic [**Month/Day/Year **] prosthesis is present. A paravalvular aortic
valve leak is present at the aorticopulmonic crux/septum. The
[**Month/Day/Year **] stent may not be fully expanded at the aorticopulmonic
crux/septum. A component of intravalvular regurgitation cannot
be excluded. The aortic regurgitation appears moderate (2+) by
color flow Doppler.
Compared with the findings of the prior study (images reviewed)
of [**2199-5-1**], the appearance of aortic regurgitation by color
flow Doppler is increased.

TTE [**2199-5-3**]
The right atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF>55%). An aortic
[**Month/Day/Year **] prosthesis is present. Mild to moderate ([**12-17**]+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild to moderate
([**12-17**]+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2199-5-2**], no
change.

TTE [**2199-5-6**]:
PRELIM: The estimated right atrial pressure is 0-5 mmHg. Overall
left ventricular systolic function is low normal (LVEF 50-55%).
Moderate (2+) aortic regurgitation is seen. Moderate (2+) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is no pericardial effusion.

DISCHARGE LABS:
[**2199-5-6**] 07:22AM BLOOD WBC-5.2 RBC-3.11* Hgb-8.7* Hct-29.0*
MCV-94 MCH-28.0 MCHC-29.9* RDW-18.3* Plt Ct-182
[**2199-5-6**] 07:22AM BLOOD PT-20.8* PTT-34.1 INR(PT)-2.0*
[**2199-5-6**] 07:22AM BLOOD Glucose-75 UreaN-31* Creat-1.2 Na-136
K-4.6 Cl-105 HCO3-22 AnGap-14
[**2199-5-4**] 04:42AM BLOOD ALT-11 AST-30 LD(LDH)-283* AlkPhos-147*
TotBili-0.9
[**2199-5-6**] 07:22AM BLOOD Calcium-8.0* Phos-3.0 Mg-2.2
[**2199-5-6**] 07:22AM BLOOD proBNP-2941*

Brief Hospital Course:
[**Age over 90 **] year old male with severe aortic stenosis s/p [**Age over 90 **]
placement x 2 c/b AR.

# Aortic stenosis s/p [**Age over 90 **]: 2 corevalves were placed due to
complicated aortic anatomy. He received 2 units PRBC during
procedure for bleeding. Patient was hemodynamically stable upon
arrival to CCU, briefly requiring phenylephrine. He received a
third unit PRBC on arrival to CCU for Hct 25 and bumped
appropriately, after which his Hct stabilized and he required no
further transfusions. He was extubated the same evening he
arrived to the CCU. Bedside echo post-procedure showed moderate
to severe aortic regurgitation. After groin hemostasis was
achieved, he was started on a heparin drip. CK and LFTs checked
8 hours post-procedure were normal. He was monitored for PAD
pressures with swan ganz catheter and gently diuresed for
pressures consistently > 25. HR optimized already by pacemaker.
blood pressure was optimized with nitro gtt (for HTN) and
phenylephrine gtt (for hypotension) per study protocol during
the post-op period. Pt was quickly weaned off the drips and
remained hemodynamically stable. Swan ganz removed on POD#2.
Repeat echo on POD#4 showed mild to mod aortic regurgitation and
on POD#6 showed mod AR. Pt felt well so was discharged. Per pt,
his son lives next door and visits daily, so would be able to
help out at home and with medications if needed.

# AR: expected to improved somewhat post-procedure as pt
stabilizes out. He remained hemodynamically stable and repeat
echo did show some improvement in AR. Immediately
post-procedure, AR was measured as mod to severe, while
subsequent measurements were graded as mild to mod vs mod.
Optimized BP and HR as above to manage this.

# Anemia: pt lost approximately one liter of blood during
procedure, received 3 units with appropriate increase to Hct
31.Pt also experienced some oozing at the site of his neck
catheter and was thought to have a hematoma there. patient was a
difficult cross match so 6 units were matched prior to his
arrival and another 3 after he required 3 units PRBC
post-procedure. He stabilized, however, so received only a total
of 3 units.

# CAD: s/p CABG in [**2173**] with patent LIMA-LAD: continued ASA.
restarted metoprolol on POD#1. held lisinopril due to contrast
load and expectation of contrast nephropathy. started 2.5mg
lisinopril daily on [**5-4**].

#  Afib/ pacemaker: held coumadin for procedure and started pt
on heparin drip after groin hemostasis achieved. When Hct stable
and there was no evidence of bleeding at the swan ganz catheter
site, coumadin was restarted at home dose with heparin subQ for
DVT ppx. pacemaker interrogated prior to procedure.

# confusion: pt intermittently experienced mild confusion at
night and in early AM in ICU, thought to be mild delirium [**1-17**] pt
not sleeping well at night. He cleared during the day as was
AAOx3. On the day of discharge, he admitted to feeling like he
"wasn't sure what was going on" and noted that his surroundings
just seemed unfamiliar. However, he was AAOx3 at this time and
could still say he was in the hospital for [**Month/Day (2) **]. Pt thought
to benefit most by getting home to familiar environment.
Assurances were made that family would be present and closely
monitor the patient once he went home (they live next door).

# Hypertension: restarted metoprolol on POD#2 as above

# Hyperlipidemia: continued pravastatin

# h/o renal artery stenosis: s/p stenting so pt started on
lisinopril as above for HTN/cardioprotection

# foley catheter: nurse had trouble getting foley out on POD#3.
It was lodged at urethral opening and balloon would not fully
deflate. called urology. they said to pull really hard on empty
syringe attached to balloon's port and if it would not deflate
to just pull the foley. said they would not do anything beyond
that so instructed them the primary team could go forward with
their suggestions. able to deflate the balloon a little more
with large empty syringe but it never fully deflated and a small
ridge persisted where the balloon was supposed to fully deflate.
pulled foley without any apparent complications. nurse filed
incident report on the device.

TRANSITIONAL ISSUES:
- follow up AR with hemodynamic monitoring and echo
- f/u with Dr. [**Last Name (STitle) **] re: [**Last Name (STitle) **] protocol s/p discharge
- f/u patient status at home for safety

Medications on Admission:
Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day). Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
Dipyridamole-aspirin 200-25 mg Cap, ER Multiphase 12 hr Sig: One
(1) Cap PO DAILY (Daily).
Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM -
discontinued 5 days ago


Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
2. escitalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.

3. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO once a
day.
4. pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
5. warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day.
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
8. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
VNA of Southeast [**State 2748**]

Discharge Diagnosis:
aortic stenosis
coronary artery disease
hypertension


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Dear Mr. [**Known lastname 24716**],

It was a pleasure caring for you.  You were admitted to the [**Hospital1 1535**] for treatment of your aortic
valve disease. You received a [**Hospital1 **] replacement of your
aortic valve and needed to have the new valve replaced within 24
hours. It now appears to be functioning well.

It is important for you to follow-up closely with your
cardiologist and to take all of your medications as prescribed.

Weigh yourself every morning, call Dr. [**Last Name (STitle) 24717**] if weight goes up
more than 3 lbs in 1 day or 5 pounds in 3 days. Please get your
INR checked when you see Dr. [**Last Name (STitle) 24717**] this week.
.
We have made the following changes to your medication regimen:
1. STOP taking Aggrenox
2. START taking a baby aspirin daily
3. Change metoprolol to a long acting version that you only need
to take once a day, stop taking the twice daily metoprolol
4. START lisinopril to lower your blood pressure and help your
heart pump better

Followup Instructions:
.
Department: CARDIAC SERVICES
When: MONDAY [**2199-6-17**] at 9:00 AM
With:  DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
.
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 24718**], MD
Specialty: Primary Care Provider
[**Name Initial (PRE) **]: Thursday [**5-9**] at 11:15am
Address: 27 [**Location (un) 24719**] DR, [**Location (un) **],[**Numeric Identifier 24720**]
Phone: [**Telephone/Fax (1) 24721**]
Please get your INR checked at this visit
.
Department: CARDIAC SERVICES
When: THURSDAY [**2199-5-30**] at 3:40 PM
With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Aortic valve disorders,Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Delirium due to conditions classified elsewhere,Chronic diastolic heart failure,Acute posthemorrhagic anemia,Atherosclerosis of renal artery,Hematoma complicating a procedure,Atrial fibrillation,Unspecified renovascular hypertension,Unspecified acquired hypothyroidism,Other and unspecified hyperlipidemia,Constipation, unspecified,Lumbago,Aortocoronary bypass status,Cardiac pacemaker in situ,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Personal history of antineoplastic chemotherapy,Long-term (current) use of anticoagulants,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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: worsening shortness of breath

PRESENT ILLNESS: Patient is a [**Age over 90 **]yo male with hx CAD s/p CABG x1([**2173**]), PCI
([**2185**]), afib, dual chamber PPM, CVA, renal insufficiency s/p rt
renal artery stent, carotid disease, with known aortic stenosis
s/p valvuloplasy ([**8-/2197**]) who presents with symptoms of
shortness
of breath after slowly walking 1 block, inability to climb
stairs
without stopping due to shortness of breath. He denies chest
pain, lightheadedness. Past medical history includes B-cell
lymphoma for which he was treated with chemotherapy, no
radiation, now in remission ([**2192**]). He was seen 4 months prior
for evaluation for aortic treatment options and was found to be
of prohibitively high risk for surgical AVR. He was considered
for [**Year (4 digits) 10723**]/TAVR but did not meet criteria for available high
risk arm of study. He has been stable on medical management,
however, his family notes a decline in function and worsening
fatigue over the last 3 weeks. He admits to frequent naps, and
shortness of breath after walking 20 feet. He was again seen and
evaluated for conventional surgical AVR. He was deemed of
prohibitive surgical risk due to advance age and comorbidities.
After informed consent and extensive discussions with patient
and his son and daughter, he was screened for the [**Name (NI) 10723**]/TAVR
continued access extreme risk arm of the study. He met all
inclusion criteria, and did not meet any of the exclusion
criteria. He was screened and accepted and now returns for
elective [**Name (NI) 10723**]/TAVR.

MEDICAL HISTORY: CAD, s/p CABG in [**2173**]
[**2185**] s/p Cx stenting
Atrial fibrillation
[**Company 1543**] Adapta dual-chamber pacemaker
Aortic stenosis - s/p valvuloplasty [**8-/2197**]
Renal artery stenosis, s/p left renal artery stenting [**5-22**]
Hypertension
? Hyperlipidemia
Hypothyroidism
CVA, TIA x 2
s/p remote inguinal hernia repair
Cataract surgery
Hard of hearing
[**2192**]: Large cell Lymphoma, s/p R-CHOP (completed treatment in
[**9-21**]). Currently in remission
right axillary node dissection
tonsillectomy

MEDICATION ON ADMISSION: Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day). Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
Dipyridamole-aspirin 200-25 mg Cap, ER Multiphase 12 hr Sig: One
(1) Cap PO DAILY (Daily).
Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM -
discontinued 5 days ago

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Physical Exam on Admission:
Pulse: 66
B/P: 96/50(right) 90/50(left)
Resp: 18
O2 Sat: 99
Temp: 97.8
Height:  Weight: 170 lbs
General: alert, pleasant well-developed elderly male in NAD at
rest. Noticealbly SOB with ambulation
Skin: color pale pink, skin warm and dry, well healed sternal
incisional scar, no lesions.
HEENT: normocephalic, anicteric, good dentition, oropharynx
moist, upper bridge. Carotid bruits vs. referred murmer
Neck: supple, trachea midline, carotid bruits vs. referred
murmer
Chest: prominent clavicles, well healed sternotomy
Heart:  murmer throughout
Abdomen: soft, nontender,nondistended, (+)BS, 80%meal intake
Extremities: no peripheral edema, no obvious deformities
Neuro: pleasant, A+Ox3, gross FROM
Pulses: palpable peripheral pulses.

FAMILY HISTORY: Family History: Brother died of an MI in his late 50's-early
60s. Sister died of a heart condition her 60's.

SOCIAL HISTORY: Patient lives alone in [**Location (un) **], CT. He lives close to his
daughter, [**Name (NI) **] [**Name (NI) 24715**], who is his primary caretaker. [**Name (NI) **] denies
any hx of smoking, EtOH, or drug use 

### Response:
{'Aortic valve disorders,Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Delirium due to conditions classified elsewhere,Chronic diastolic heart failure,Acute posthemorrhagic anemia,Atherosclerosis of renal artery,Hematoma complicating a procedure,Atrial fibrillation,Unspecified renovascular hypertension,Unspecified acquired hypothyroidism,Other and unspecified hyperlipidemia,Constipation, unspecified,Lumbago,Aortocoronary bypass status,Cardiac pacemaker in situ,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Personal history of antineoplastic chemotherapy,Long-term (current) use of anticoagulants,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
