CHIEF COMPLAINT: Transfer from outside hospital for carotid stenosis

PRESENT ILLNESS: This is a 84 year-old male with a history of dilated
cardiomyopathy with an EF of 15%, LBBB, and GI bleed who
presented to [**Hospital3 10377**] on [**2153-7-1**] with syncope.  He
states that he was in his usual state of health at the
drive-through for Honey Dew Donut when he fainted and hit a
wall.  The event was not preceded by any symptoms including CP,
SOB, dizziness, nausea, or diaphoresis.  He was initially going
to be referred to [**Hospital1 18**] for a biventricular ICD but an MRA of
the carotids showed 55-60% stenosis in the left internal
carotid.  However, carotid ultrasound showed high velocities in
the left internal carotid suggestive of an 80-95% stenosis.

MEDICAL HISTORY: systolic congestive heart failure with LVEF of 15%
Gastrointestinal bleed
Hiatal hernia
GERD

MEDICATION ON ADMISSION: Lasix 20 mg daily
KCL 20 mEq every other day
Lipitor 80 mg daily*
Aspirin 325 mg daily
Feosol 325 mg daily
Omeprazole 40 mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS - T 97.4, BP 122/71, P 65, RR 16, O2 sat 95% RA
Gen: WDWN elderly gentleman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. PERRL, EOMI. Conjunctiva were pink, no pallor or
cyanosis of the oral mucosa.
Neck: Supple, no carotid bruit.
CV: RR, normal S1, S2 but quiet. No m/r/g.
Chest: CTAB, no crackles, wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness.
Ext: No c/c/e.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
- Right: Carotid 2+ DP 2+ PT 2+
- Left: Carotid 2+ DP 2+ PT 2+

FAMILY HISTORY: He had two sons, but both passed away.  One had lymphoma, other
unknown.  There is no family history of premature coronary
artery disease or sudden death.

SOCIAL HISTORY: Social history is significant for 70 pack-year history of
tobacco use; patient stopped smoking 1.5 years ago when
diagnosed with congestive heart failure.  Pt used to have 1
alcoholic drink every 1-2 days but has also stopped.  There is
no history of illicit drug use. Pt used to do dry wall & plaster
but is retired.  He lives with wife (recovering from recent
admission for sciatica), is able to perform activities of daily
living.
Other specified cardiac dysrhythmias,Chronic systolic heart failure,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Other primary cardiomyopathies,Diaphragmatic hernia without mention of obstruction or gangrene,Esophageal reflux
Cardiac dysrhythmias NEC,Chr systolic hrt failure,Ocl crtd art wo infrct,Prim cardiomyopathy NEC,Diaphragmatic hernia,Esophageal reflux
Admission Date:  [**2153-7-8**]              Discharge Date:   [**2153-7-13**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Transfer from outside hospital for carotid stenosis

Major Surgical or Invasive Procedure:
Carotid angiography
Carotid stenting
Electrophysiology study
Biventricular pacemaker and ICD placement


History of Present Illness:
This is a 84 year-old male with a history of dilated
cardiomyopathy with an EF of 15%, LBBB, and GI bleed who
presented to [**Hospital3 10377**] on [**2153-7-1**] with syncope.  He
states that he was in his usual state of health at the
drive-through for Honey Dew Donut when he fainted and hit a
wall.  The event was not preceded by any symptoms including CP,
SOB, dizziness, nausea, or diaphoresis.  He was initially going
to be referred to [**Hospital1 18**] for a biventricular ICD but an MRA of
the carotids showed 55-60% stenosis in the left internal
carotid.  However, carotid ultrasound showed high velocities in
the left internal carotid suggestive of an 80-95% stenosis.

Pt states that he had only fainted once before, about 1.5 years
ago, when he was found to be in CHF.  He reports some increased
DOE over the past few months, becoming more SOB after walking up
1.5 flight of stairs.  He also denies chest pain, palpitations,
orthopnea, or PND.  He denies any headaches, lightheadedness or
vertigo, vision changes, difficulty speaking, or weakness.

Past Medical History:
systolic congestive heart failure with LVEF of 15%
Gastrointestinal bleed
Hiatal hernia
GERD

Social History:
Social history is significant for 70 pack-year history of
tobacco use; patient stopped smoking 1.5 years ago when
diagnosed with congestive heart failure.  Pt used to have 1
alcoholic drink every 1-2 days but has also stopped.  There is
no history of illicit drug use. Pt used to do dry wall & plaster
but is retired.  He lives with wife (recovering from recent
admission for sciatica), is able to perform activities of daily
living.


Family History:
He had two sons, but both passed away.  One had lymphoma, other
unknown.  There is no family history of premature coronary
artery disease or sudden death.

Physical Exam:
VS - T 97.4, BP 122/71, P 65, RR 16, O2 sat 95% RA
Gen: WDWN elderly gentleman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. PERRL, EOMI. Conjunctiva were pink, no pallor or
cyanosis of the oral mucosa.
Neck: Supple, no carotid bruit.
CV: RR, normal S1, S2 but quiet. No m/r/g.
Chest: CTAB, no crackles, wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness.
Ext: No c/c/e.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
- Right: Carotid 2+ DP 2+ PT 2+
- Left: Carotid 2+ DP 2+ PT 2+


Pertinent Results:
LABORATORY DATA at OSH:
BUN 20, Cr ranged from 1.3-1.6
Trop 0.05, 0.05
WBC 9, Hct 41, Plt 198
Urine positive for cannabinoids
.
Admission labs-
[**2153-7-8**] 05:25PM BLOOD WBC-6.5 RBC-4.14* Hgb-13.1* Hct-38.5*
MCV-93 MCH-31.7 MCHC-34.1 RDW-13.5 Plt Ct-189
[**2153-7-8**] 05:25PM BLOOD PT-12.8 PTT-26.3 INR(PT)-1.1
[**2153-7-8**] 05:25PM BLOOD Plt Ct-189
[**2153-7-8**] 05:25PM BLOOD Glucose-95 UreaN-25* Creat-1.4* Na-140
K-3.7 Cl-103 HCO3-23 AnGap-18
[**2153-7-10**] 06:13AM BLOOD CK(CPK)-158
[**2153-7-10**] 06:13AM BLOOD CK-MB-4 cTropnT-0.02*
[**2153-7-8**] 05:25PM BLOOD Calcium-9.0 Phos-3.1 Mg-2.2
.
Discharge labs-
.
[**2153-7-13**] 07:05AM BLOOD WBC-7.6 RBC-3.33* Hgb-10.7* Hct-31.2*
MCV-94 MCH-32.2* MCHC-34.4 RDW-14.3 Plt Ct-137*
[**2153-7-13**] 10:40AM BLOOD Hct-32.0*
[**2153-7-13**] 07:05AM BLOOD PT-13.0 PTT-29.2 INR(PT)-1.1
[**2153-7-13**] 07:05AM BLOOD Plt Ct-137*
[**2153-7-13**] 07:05AM BLOOD Glucose-94 UreaN-20 Creat-1.1 Na-138
K-3.8 Cl-106 HCO3-23 AnGap-13
[**2153-7-11**] 05:35AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.3
.
Studies-
.

.
TELEMETRY at OSH in [**6-17**]: No significant pauses, no VT.
.
2D-ECHOCARDIOGRAM at OSH in [**2152**]: Severe global hypokinesis with
EF of 15%.  Mild MR and Mild TR.

CAROTID DUPLEX at OSH on [**2153-7-3**]:
1. Severe heterogeneous calcified plaque in both carotid
systems, right greater than left
2. Flow velocities throughout the right ICA and common carotid
suggests an occlusion
3. Flow velocities within the left ICA suggest a high grade
80-95% stenosis.
4. Vertebral flow is antegrade bilaterally

MRA at OSH on [**2153-7-3**]: Examination degraded by patient motion.
Occlusion of the right carotid arterial system with
reconstitution primarily via the ophthalmic and right A1
segments.

MRI BRAIN at OSH on [**2153-7-3**]:
Examination degraded by patient motion.  Diffuse cerebral
atrophy and scattered small old supra and infratentorial
infarcts.  Focal encephalomalacia of the right frontoparietal
region probably represents an old watershed infarct.
.
EKG ([**2153-7-9**]):
Sinus bradycardia. Left atrial abnormality. Left bundle-branch
block.
Compared to the previous tracing of [**2153-7-9**] no diagnostic
interim change.
TRACING #2
.
EKG [**2153-7-10**]: rate of 54bpm
Sinus bradycardia. Left atrial abnormality. Left bundle-branch
block.
Compared to the previous tracing of [**2153-7-10**] sinus rhythm has
appeared.
.
Carotid Cath [**2153-7-9**]
COMMENTS:
1. Access: Retro RFA with catheter selective to LCCA.
2. Thoracic aorta: Type II arch with noted occlusion of RCCA.
3. Carotid/Vertebrals: The RCCA is occluded. The right vertebral
is
patent. The LCCA has mild orign disease without noted
significant
gradient. The ipsilateral CCA fills the ECA and ICA with the ICA
filling
the ipsilateral ACA and MCA with robust cross filling from a
patent ACOM
to the contralateral territories (right ACA and MCA).
4. Successful PTA/stent to left ICA with a [**6-17**] x40mm Acculink
stent
posted with a 4.0mm balloon. Excellent result with normal flow
down
vessel and 20% residual. Patient remained neurologically intact.

FINAL DIAGNOSIS:
1. 70% stenosis of left ICA.
2. Occluded right ICA.
3. Successful PTA/stent to left ICA with a 6-8x40mm
self-expanding stent
and posted with a 4.5mm balloon.
.
CXR [**2153-7-11**]
FRONTAL CHEST RADIOGRAPH: The pacemaker/AICD is seen overlying
the left chest wall, with one lead residing in the right atrium
and two overlying the expected location of the right ventricle.
The heart size is top normal. The pulmonary vasculature is
normal. Mild pleural thickening is seen, particularly along the
right lateral chest wall. There is no focal
consolidation or pneumothorax.
.
 CXR [**2153-7-12**]
FINDINGS: In comparison with the study of [**7-11**], there is no
interval change.  The cardiac silhouette remains at the upper
limits of normal in size. There is no change in the appearance
of the pacemaker lead. No acute pneumonia.
.


Brief Hospital Course:
#Carotid stenosis:
Pt gently hydrated with normal saline and then given bicarb
prior to carotid angiography, also given Mucomyst for renal
protection.  Behavioral Neurology evaluated patient, reported no
focal neurological findings before or after the procedure.
During the procedure patient had stenting of Left internal
carotid artery. Pt tolerated the procedure well and was observed
overnight in the CCU. Pt is now on plavix and aspirin.
.
# Syncope possibly secondary to dysrhythmia
Due to bradycardia and a recent syncopal episode, the patient
had an electophysiology study on [**2153-7-10**]. As a result it was
thought that the pt would benefit from Biventricular Implantable
Cardioverter and Defibrillator (BiICD) placement to prevent
bradycardia and future syncope. Pt had a known history of LBBB,
and atrial fibrillation, and while in the hospital he has had
sinus bradycardia into the 30's, rare PVCs and PACs. In the EP
lab atrial fibrillation was induced, the patient had
unsuccessful conversion with ibutelide, and later the patient
had 5 seconds of tachycardia to 120's. On [**2153-7-11**], patient had a
[**Company 1543**] BiV/ICD via cephalic and axillary, and before the
procedure had converted spontaneously into sinus rhythm. The
pacemaker's inferior lead briefly intermittently simulated the
phrenic nerve, but it was adjusted to resolve this issue. Pt had
a small hematoma in the area of the procedure, a pressure
dressing was applied and the pt was observed overnight.
Pacemaker was interrogated and was functioning appropriately the
day after insertion. Pt was not able to be anticoagulated due to
GI bleed. Pt received one dose of vancomycin and one dose of
levaquin for infection prevention after placement. On the
morning of discharge Dr. [**Last Name (STitle) **] found a small right femoral bruit on
exam which he wants the patient to have followed by Dr. [**Last Name (STitle) **] at
his next appointment. Dr. [**Last Name (STitle) **] informed Dr. [**Last Name (STitle) **] about this issue
for follow up care.
.
# Pump: Pt has dilated cardiomyopathy with class II chronic
systolic CHF, echo from an outside hospital showed that the
patient had an EF of 20%. Pt was restarted on lasix during his
stay and his congestive heart failure symptoms were well
controlled.
.
# CAD/Ischemia:
Pt has a left bundle branch block and an old inferior infarct
thus presumed coronary artery disease. Pt is on full dose
aspirin, lipitor, but not on a beta blocker due to bradycardia.
It was unclear why the pt was not on an [**Name (NI) **], and due to the
impaired renal function it was not started after his ICD
placement was completed. Pt was also placed on plavix for his
internal carotid stent. It was recommended to Dr. [**Last Name (STitle) **] to
consider adding an ACE-I as an out patient if his renal function
improves, unless there are other reasons the patient is not able
to tolerate the medication.
.
#Possible chronic renal failure- Creatinine was 1.5 on
admission, pt received gentle IV fluids and it dropped to 1.3.
Renal function was closely monitored before restarting the
patient's ACE-inhibitor, and should be followed after discharge.

.

# Prophylaxis/Hx of GI bleed: Pt was placed on pantoprazole 40mg
per day, and pt was not anticoagulated. Pt had pneumoboots for
DVT prophylaxis.
.
Pt was discharged hemodynamically stable, afebrile, and able to
ambulate.

Medications on Admission:
Lasix 20 mg daily
KCL 20 mEq every other day
Lipitor 80 mg daily*
Aspirin 325 mg daily
Feosol 325 mg daily
Omeprazole 40 mg daily

Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): for your cholesterol.
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): To pervent clots in your stent.
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
7. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Home With Service

Facility:
[**Hospital 2255**] [**Name (NI) 2256**]

Discharge Diagnosis:
Primary:
1. Carotid stenosis status post angiography and stenting
2. Sinus bradycardia status post biventricular ICD placement

Secondary:
1. Congestive heart failure due to dilated cardiomyopathy,
chronic systolic heart failure, EF 15%
2. GI bleed
3. Hiatal hernia
4. GERD


Discharge Condition:
Asymptomatic and hemodynamically stable.


Discharge Instructions:
You were admitted to [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) 2742**] and
treatment of your critical carotid stenosis.  You underwent
carotid angiography, and a stent was placed in your left
internal carotid artery.  You tolerated the procedure well, with
no worsening of your kidney function.

You had an irregular rhythm in your heart, and after testing it
was determined you would benefit from a pacemaker with ICD
(defibrillator). This device was implanted in you, and you
tolerated the procedure well.

You were started on the following medications: plavix (for your
stent), Toprolol XL (for your heart). Please take all
medications as prescribed.

Please follow up with your doctors for further [**Name5 (PTitle) **]. You will
need to see the device clinic to check on your pacemaker/ICD,
and your cardiologist and PCP.

If you experience chest pain, dizziness, weakness, vision loss,
difficulty speaking, please call 911 or come to the ER.

Followup Instructions:
Caridology:
Dr. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Monday [**8-6**] at 3:15
--please discuss starting ACE inhibitors with him.
--please ask him to evaluate your right femoral artery for a
small systolic bruit which was found on exam

Primary care provider:
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 17996**] (who works with Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3321**]) [**Numeric Identifier 73329**]
on [**7-20**] 12pm.  Please discuss your stay here during this
visit.

Pacemaker follow up:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2153-7-20**]
11:30



Completed by:[**2153-7-19**]
{'Other specified cardiac dysrhythmias,Chronic systolic heart failure,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Other primary cardiomyopathies,Diaphragmatic hernia without mention of obstruction or gangrene,Esophageal reflux'}


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: Transfer from outside hospital for carotid stenosis

PRESENT ILLNESS: This is a 84 year-old male with a history of dilated
cardiomyopathy with an EF of 15%, LBBB, and GI bleed who
presented to [**Hospital3 10377**] on [**2153-7-1**] with syncope.  He
states that he was in his usual state of health at the
drive-through for Honey Dew Donut when he fainted and hit a
wall.  The event was not preceded by any symptoms including CP,
SOB, dizziness, nausea, or diaphoresis.  He was initially going
to be referred to [**Hospital1 18**] for a biventricular ICD but an MRA of
the carotids showed 55-60% stenosis in the left internal
carotid.  However, carotid ultrasound showed high velocities in
the left internal carotid suggestive of an 80-95% stenosis.

MEDICAL HISTORY: systolic congestive heart failure with LVEF of 15%
Gastrointestinal bleed
Hiatal hernia
GERD

MEDICATION ON ADMISSION: Lasix 20 mg daily
KCL 20 mEq every other day
Lipitor 80 mg daily*
Aspirin 325 mg daily
Feosol 325 mg daily
Omeprazole 40 mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS - T 97.4, BP 122/71, P 65, RR 16, O2 sat 95% RA
Gen: WDWN elderly gentleman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. PERRL, EOMI. Conjunctiva were pink, no pallor or
cyanosis of the oral mucosa.
Neck: Supple, no carotid bruit.
CV: RR, normal S1, S2 but quiet. No m/r/g.
Chest: CTAB, no crackles, wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness.
Ext: No c/c/e.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
- Right: Carotid 2+ DP 2+ PT 2+
- Left: Carotid 2+ DP 2+ PT 2+

FAMILY HISTORY: He had two sons, but both passed away.  One had lymphoma, other
unknown.  There is no family history of premature coronary
artery disease or sudden death.

SOCIAL HISTORY: Social history is significant for 70 pack-year history of
tobacco use; patient stopped smoking 1.5 years ago when
diagnosed with congestive heart failure.  Pt used to have 1
alcoholic drink every 1-2 days but has also stopped.  There is
no history of illicit drug use. Pt used to do dry wall & plaster
but is retired.  He lives with wife (recovering from recent
admission for sciatica), is able to perform activities of daily
living. 

### Response:
{'Other specified cardiac dysrhythmias,Chronic systolic heart failure,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Other primary cardiomyopathies,Diaphragmatic hernia without mention of obstruction or gangrene,Esophageal reflux'}
