CHIEF COMPLAINT: Tachycardia

PRESENT ILLNESS: 89F CAD, Afib, DM2 felt "strange" around 9pm last night with
malaise. Denies CP or SOB. Presented to [**Hospital3 4107**] ED,
where her HR was in 150s with question of SVT. She was given IV
dilt and HR came back to SR 60/min. Patient reported feeling
much better.  She denied any CP this time. She uses a walker to
ambulate but denied DOE. No N/V. Her ECG in at OSH showed ST
elevations in V2-V5 and III, w/ Q waves V2-V4,inferior. She was
transferred to [**Hospital1 18**] for further management.

MEDICAL HISTORY: Coronary Artery Disease s/p MI 15y ago s/p angioplasty
Afib on coumadin
Hypertension
Hypercholesterolemia
Upper GI [**Last Name (un) **] 10y ago
Osteoarthritis (primarily affecting knees)

MEDICATION ON ADMISSION: lasix 20 daily
aldactone 25 daily
lipitor 10 daily
MV
protonix 40 daily
coreg 25 [**Hospital1 **]
detrol 2 [**Hospital1 **]
coumadin 2.5 daily
glipizide 5 daily
cranberry caps daily
keflex q6h start [**9-2**] for 7 days

ALLERGIES: Aspirin / Adhesive Tape

PHYSICAL EXAM: VS: T97.1 , BP 114/66 , P86 , SaO298%2L at RR22
GENERAL: No apparent distress
HEENT: PERRLA, MMM
NECK: no JVD
CHEST: CTAB
CVS: irreg, 1/6 SEM
ABD: +BS. soft, NT/ND.
EXT: Warm, without edema.
SKIN: no rash
NEURO: AO3, moving all spontaneously

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Lives on her own in [**Hospital1 **], has family nearby, mostly
independent & takes care of herself, no tobacco, occ EtOH
Paroxysmal ventricular tachycardia,Acute on chronic systolic heart failure,Ulcer of other part of lower limb,Acute kidney failure, unspecified,Hypoxemia,Acute bronchitis,Pure hypercholesterolemia,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Percutaneous transluminal coronary angioplasty status,Dehydration,Long-term (current) use of anticoagulants,Mitral valve disorders,Diseases of tricuspid valve,Other chronic pulmonary heart diseases,Right bundle branch block
Parox ventric tachycard,Ac on chr syst hrt fail,Ulcer oth part low limb,Acute kidney failure NOS,Hypoxemia,Acute bronchitis,Pure hypercholesterolem,Osteoarthros NOS-unspec,Crnry athrscl natve vssl,Old myocardial infarct,Status-post ptca,Dehydration,Long-term use anticoagul,Mitral valve disorder,Tricuspid valve disease,Chr pulmon heart dis NEC,Rt bundle branch block
Admission Date:  [**2182-9-7**]              Discharge Date:   [**2182-9-18**]


Service: MEDICINE

Allergies:
Aspirin / Adhesive Tape

Attending:[**First Name3 (LF) 1436**]
Chief Complaint:
Tachycardia

Major Surgical or Invasive Procedure:
-Cardiopulmonary resuscitation
-Endotracheal intubation


History of Present Illness:
89F CAD, Afib, DM2 felt "strange" around 9pm last night with
malaise. Denies CP or SOB. Presented to [**Hospital3 4107**] ED,
where her HR was in 150s with question of SVT. She was given IV
dilt and HR came back to SR 60/min. Patient reported feeling
much better.  She denied any CP this time. She uses a walker to
ambulate but denied DOE. No N/V. Her ECG in at OSH showed ST
elevations in V2-V5 and III, w/ Q waves V2-V4,inferior. She was
transferred to [**Hospital1 18**] for further management.

Past Medical History:
Coronary Artery Disease s/p MI 15y ago s/p angioplasty
Afib on coumadin
Hypertension
Hypercholesterolemia
Upper GI [**Last Name (un) **] 10y ago
Osteoarthritis (primarily affecting knees)


Social History:
Lives on her own in [**Hospital1 **], has family nearby, mostly
independent & takes care of herself, no tobacco, occ EtOH

Family History:
non-contributory

Physical Exam:
VS: T97.1 , BP 114/66 , P86 , SaO298%2L at RR22
GENERAL: No apparent distress
HEENT: PERRLA, MMM
NECK: no JVD
CHEST: CTAB
CVS: irreg, 1/6 SEM
ABD: +BS. soft, NT/ND.
EXT: Warm, without edema.
SKIN: no rash
NEURO: AO3, moving all spontaneously


Pertinent Results:
Admission Labs:
[**2182-9-7**] 07:50AM   WBC-6.2 RBC-3.73* HGB-11.4* HCT-35.7* MCV-96
MCH-30.6 MCHC-32.0 RDW-14.6  PLT COUNT-156
[**2182-9-7**] TSH-1.9
[**2182-9-7**] CK-MB-24* MB INDX-15.7* cTropnT-1.23*
[**2182-9-7**] CK(CPK)-153*
[**2182-9-7**] GLUCOSE-146* UREA N-33* CREAT-1.3* SODIUM-142
POTASSIUM-5.1 CHLORIDE-110* TOTAL CO2-23 ANION GAP-14
.
Discharge Labs:
[**2182-9-18**] WBC-6.2 RBC-3.26* Hgb-9.8* Hct-31.2* MCV-96 MCH-30.1
MCHC-31.4 RDW-15.2 Plt Ct-269
[**2182-9-18**] PT-20.5* INR(PT)-2.0*
[**2182-9-18**] Glucose-99 UreaN-22* Creat-1.2* Na-140 K-4.8 Cl-106
HCO3-27 AnGap-12
[**2182-9-12**] -32 AST-40 LD(LDH)-199 AlkPhos-122* TotBili-0.9
[**2182-9-12**] CK-MB-NotDone cTropnT-0.37*
[**2182-9-17**] Calcium-8.4 Phos-3.0 Mg-2.2

Imaging:
[**2182-9-18**] CXR - FINDINGS:  In comparison with the study of [**9-12**],
there is again acute enlargement of the cardiac silhouette.
Although the retrocardiac area is poorly seen, there does appear
to be some increased opacification that would be consistent with
atelectatic change.  Mild prominence of the right hilar vessels,
though no definite increase in pulmonary venous pressure is
appreciated.
.
[**2182-9-9**] TTE: EF 30%.  The left atrium is mildly dilated. The
right atrium is moderately dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. There is
severe regional left ventricular systolic dysfunction with
septal, anterior and distal LV akinesis. No masses or thrombi
are seen in the left ventricle. Tissue Doppler imaging suggests
an increased left ventricular filling pressure (PCWP>18mmHg).
There is no ventricular septal defect. Right ventricular chamber
size is normal. Right ventricular systolic function is normal.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is moderate
thickening of the mitral valve chordae. Moderate (2+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is a small to moderate sized pericardial effusion. There
are no echocardiographic signs of tamponade.


Brief Hospital Course:
89yo F w/ CAD s/p MI, Afib, DM2, transferred to [**Hospital1 18**] here w/
wide complex tachycardia and elevated CEs.

* Wide complex tachycardia:  On admission, pt was thought to
have supraventricular tachycardia with right bundle branch
block.  She was given adenosine; however, the adenosine did not
break rhythm.  The rhythm lasted for a few hours and broke
spontaneously.  The pt was hemodynamically stable during the
event.  She noted only a mild discomfort in her interscapular
area.  Approximately 24hr after the rhythm broke she went into
it again, w/o hemodynamic compromise or symptoms.  Again, the
rhythm broke spontaneously after a few hours--metoprolol was
given during the event without apparent effect.
EP was consulted (Dr. [**Last Name (STitle) **] was initially EP attending, then Dr.
[**Last Name (STitle) **].  They determined that the rhythm was actually a
narrow, monomorphic ventricular tachycadia with RBBB and an
inferior axis, likely arising in/near the septum.  (Of note, the
official EKG readings in OMR do not describe the rhythm as
VT--see EKG from [**2182-9-7**] at 4:23 for an example of the VT.)
Pt had a third episode of VT, during which she was given
lidocaine with good response.  Discussion was had between the
team, the pt, and the pt's family about whether the pt should
undergo an EP study or start amiodarone empirically without an
EP study.  Given the patient's overall clinic picture and
wishes, amiodarone was started, no EP study was done.  She was
loaded with approximately 6grams of amiodarone.  She was then
continued on 200mg daily for maintenance.  The patient had no
further episodes of ventricular tachycardia after starting the
amiodarone.
Of note the patient had normal thyroid & liver function prior to
starting amiodarone.  She is scheduled to follow-up with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at his [**Hospital1 **] office on [**2182-10-15**] at 2:40pm.  She
will likely need baseline pulmonary function tests,
ophthomalogic exam, and repeat thyroid & liver function tests.

* PEA arrest: After the patient's third episode of VT broke, she
had a severe coughing fit, and became hypoxic with 02 into the
70s.  She then went into PEA arrest, presumably from hypoxia, as
no other cause was found.  CPR was performed for less than 5
minutes before a spontaneous rhythm was achieved.  However, the
patient was intubated given concern over her ability to proctect
her airway.  The patient was intubated for less than 48hr.

* Coronary artery disease:  Pt has a remote history of an MI
approximately 15yr, at which time she underwent angioplasty.
Prior to transfer to [**Hospital1 18**], she had diffuse ST elevations on EKG
at OSH.  These had resolved by time of admission here.  Pt was
without chest pain.  CE were elevated on admission & trended
down.  Her EKGs from OSH were reviewed and it was questioned
whether the ST elevations were from ischemia vs. repolarization
change or pericarditis.  Given her lack of CP and overall
clinical picture, it was felt that she did not need to go for
cardiac catheterization.  She was continued on her statin.  Her
b-blocker (coreg) was given until she was started on amiodarone,
at which time it was stopped due to bradycardia occasionally
into the 40s (without symptoms).  She is being discharged off of
coreg.  Caution should be used with b-blockers given she has
first degree AV block and is on amiodarone.  The pt refuses
aspirin due to prior bleeding with it.

* Atrial fibrillation: Rate controlled with amiodarone.  Coreg
discontinued due to bradycardia (hr 40-50s on amio).  Coumadin
dose decreased to 1.5mg daily (from 2.5mg) after starting
amiodarone.  INR on day of discharge was 2.  This should be
rechecked on [**2182-9-20**] and coumadin adjusted as necessary.

* Congestive heart failure: acute on chronic systolic heart
failure.  Echo during this stay showed an EF of 30% with
moderate mitral regurgitation moderate to severe tricuspid
regurgitation.  She was diuresed with IV lasix as necessary and
continued on home dose of lasix 20mg daily.  On day of
discharge, pt received a dose of 20mg IV lasix for slight volume
overload.  Her aldactone (25mg daily) was also restarted on
[**2182-9-18**].  An ACEi or [**Last Name (un) **] was not started during this hospital
stay due to relatively low BP (90-100); though pt would likely
benefit from one of these agents in future.

* Cough: Pt had a dry cough on admission, which ecame more
severe during hospital stay.  No clear pneumonia on imaging.  Pt
thought to likely have viral lower respiratory tract infection.
She was treated with standing anti-tussives and ipratropium
nebulizer (avoided albuterol because of arrythmias).  If cough
persists, consider further evaluation with her primary care
doctor.

* Acute renal failure: pt had episode of pre-renal failure early
in her hospital stay that was thought to be from dehydration.
Baseline crt unknown, though was as low as 1.2 and peaked at
1.5.  Discharge crt 1.2.

* LE ulcers: stable & appear to healing slowly.  Pt received 7d
course of abx for possible infection of LE ulcer.  Pt has two
ulcers, one on left leg & the other on the R leg.
Left lower leg is a traumatic ulcer approx 1.5 x 1 cm.  The
wound bed is 80% pink, 20% yellow.  The wound edges are
irregular.  The periwound tissue is intact with resolving
cellulitis.  Right lower extremity full thickness ulcer is
present on anterior tibialis, approx 7 x 5.5 cm, and the wound
bed is 60% yellow, 20% black, 20% pink.  There is a moderate
amount of serosanguinos yellow drainage with no odor.  The
periwound tissue is discolored, dark purple. Pt seen by wound
care nurse and plastic surgery.

* DM: type II, on low dose glipizide at home.  Was treated with
insulin sliding scale.  Sugars well controlled.  [**Month (only) 116**] continue
insulin sliding scale at rehab; however, pt can likely resume
home regimen in near future.

* PPx: Therapeutic INR
* Code: Full



Medications on Admission:
lasix 20 daily
aldactone 25 daily
lipitor 10 daily
MV
protonix 40 daily
coreg 25 [**Hospital1 **]
detrol 2 [**Hospital1 **]
coumadin 2.5 daily
glipizide 5 daily
cranberry caps daily
keflex q6h start [**9-2**] for 7 days


Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) for 7 days: Con't for 1 week or until cough
resolves.
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
5. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day): [**Month (only) 116**] stop when cough resolves.
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
11. Warfarin 1 mg Tablet Sig: 1.5 Tablets PO DAILY16 (Once Daily
at 16).
12. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: Ten (10) ML PO
Q4H (every 4 hours) as needed for cough: pt may refuse;
discontinue once cough resolves.
13. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Insulin Regular Human 100 unit/mL Solution Sig: Per sliding
scale  Injection ASDIR (AS DIRECTED).
15. Aldactone 25mg daily (restarted on [**2182-9-18**])


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] health care center

Discharge Diagnosis:
Primary:
- Monomorphic ventricular tachycardia with right bundle branch
block
- Cardiac arrest from pulseless electrical activity (in setting
of hypoxia)
- Bronchitis
- Lower extremity ulcers

Secondary:
Coronary artery disease s/p MI 15years ago s/p angioplasty
Atrial fibrillation on coumadin
Hypertension
Hypercholesterolemia
UGIB 10y ago
Osteoarthritis (primarily affecting knees)


Discharge Condition:
Good, ambulating with assistance, 02 saturation 97% on 2L NC.
Afebrile, BP 110-120/50-60s, HR 50-80s in atrial fibrillation.
No BM for 4 days--got suppository today ([**2182-10-18**])


Discharge Instructions:
You were admitted with ventricular tachycardia.  You were
started on a new medication for this called amiodarone.

You will need to have pulmonary function tests and an eye exam
now that you are on a new medication called amiodarone.
Additionally, you will need to have your liver function tests
followed from time to time.  Please discuss this with your
cardiologist and, or your primary care doctor.

Your dose of warfarin was decreased to 1.5mg.  Your new
medication amiodarone may cause your coumadin level to increase,
so your blood should be monitored closely and your coumadin dose
adjusted as needed.

Please call your doctor or 911 if you develop fever, chills,
shortness of breath, chest pain, lightheadedness, or any other
concerning change in your condition.

Followup Instructions:
Please call your PCP [**Name9 (PRE) 61898**],[**Name9 (PRE) 278**] [**Name Initial (PRE) **]. at [**Telephone/Fax (1) 61899**] to
schedule appointment
.
You have an appointment scheduled with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],
cardiologist and electrophysiologist, on [**2182-10-15**] at
2:40pm at his [**Hospital1 **] office.  See address below.
[**Hospital3 **] Internal Medicine
Address: [**Street Address(2) **]. # 300
[**Hospital1 **], [**Numeric Identifier 4474**]
Phone: ([**Telephone/Fax (1) 24747**]
{'Paroxysmal ventricular tachycardia,Acute on chronic systolic heart failure,Ulcer of other part of lower limb,Acute kidney failure, unspecified,Hypoxemia,Acute bronchitis,Pure hypercholesterolemia,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Percutaneous transluminal coronary angioplasty status,Dehydration,Long-term (current) use of anticoagulants,Mitral valve disorders,Diseases of tricuspid valve,Other chronic pulmonary heart diseases,Right bundle branch block'}


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: Tachycardia

PRESENT ILLNESS: 89F CAD, Afib, DM2 felt "strange" around 9pm last night with
malaise. Denies CP or SOB. Presented to [**Hospital3 4107**] ED,
where her HR was in 150s with question of SVT. She was given IV
dilt and HR came back to SR 60/min. Patient reported feeling
much better.  She denied any CP this time. She uses a walker to
ambulate but denied DOE. No N/V. Her ECG in at OSH showed ST
elevations in V2-V5 and III, w/ Q waves V2-V4,inferior. She was
transferred to [**Hospital1 18**] for further management.

MEDICAL HISTORY: Coronary Artery Disease s/p MI 15y ago s/p angioplasty
Afib on coumadin
Hypertension
Hypercholesterolemia
Upper GI [**Last Name (un) **] 10y ago
Osteoarthritis (primarily affecting knees)

MEDICATION ON ADMISSION: lasix 20 daily
aldactone 25 daily
lipitor 10 daily
MV
protonix 40 daily
coreg 25 [**Hospital1 **]
detrol 2 [**Hospital1 **]
coumadin 2.5 daily
glipizide 5 daily
cranberry caps daily
keflex q6h start [**9-2**] for 7 days

ALLERGIES: Aspirin / Adhesive Tape

PHYSICAL EXAM: VS: T97.1 , BP 114/66 , P86 , SaO298%2L at RR22
GENERAL: No apparent distress
HEENT: PERRLA, MMM
NECK: no JVD
CHEST: CTAB
CVS: irreg, 1/6 SEM
ABD: +BS. soft, NT/ND.
EXT: Warm, without edema.
SKIN: no rash
NEURO: AO3, moving all spontaneously

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Lives on her own in [**Hospital1 **], has family nearby, mostly
independent & takes care of herself, no tobacco, occ EtOH 

### Response:
{'Paroxysmal ventricular tachycardia,Acute on chronic systolic heart failure,Ulcer of other part of lower limb,Acute kidney failure, unspecified,Hypoxemia,Acute bronchitis,Pure hypercholesterolemia,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Percutaneous transluminal coronary angioplasty status,Dehydration,Long-term (current) use of anticoagulants,Mitral valve disorders,Diseases of tricuspid valve,Other chronic pulmonary heart diseases,Right bundle branch block'}
