CHIEF COMPLAINT: Sustained VT

PRESENT ILLNESS: 59 y/o F with history of COPD, CAD s/p angioplasty in '[**08**], AFib,
VT s/p ICD placement in '[**12**], admitted to [**Hospital1 1516**] on [**11-17**] because
of recurrent VT and ICD firing, now admitted to the CCU for
recurrent sustained VT and multiple ICD firing.
Pt was in USOH until the night PTA, when she was woken from
sleep by several ICD firings. Her ICD fired 3x at home with
shocks preceded by lightheadedness but no other sx.
When EP evaluated the pt in the ED, she was in NSR with PVCs and
interrogation revealed appropriate ICD firings for VT. Pt was
admitted to the floor, Toprol was increased to 50mg po and a
Lidocaine drip was started for recurrent sustained VT. On the
floor, the pt continued to have ICD firings for VT. At 3pm the
pt was noted to be in AFib with RVR that progressed to VT at
240bpm and a code was called. The pt was sedated and intubated
because of multiple ICD firings (17 in total) and was then
bolused with Amiodarone and started on amiodarone drip at
1mg/min with cessation of VTach. The pt's BP remained stable
throughout and on arrival in the CCU, the pt's vitals were
stable and EKG was in NSR with PVCs.
Of note, in advance of umbilical hernia repair, pt dc'd ASA on
[**11-8**] and coumadin on [**11-14**].

MEDICAL HISTORY: Cardiac:
- Coronary artery disease status post IMI [**2108**] + angioplasty
[**2108**] percutaneoustransluminal coronary angioplasty as above.
- s/p Defibrillator implantation [**4-/2113**] for susteined VT. EF at
that time 50% EPS with multiple inducible VT's not ablated.
[**Company 1543**] Gem ICD placed.
- A flutter [**2119**]
2. Gastroesophageal reflux disease.
3. Chronic obstructive pulmonary disease.
4. Claudication.
5. Depression.
6.Status post cesarean section.
7. Status post tonsillectomy.
8. Carpal tunnel syndrome.

MEDICATION ON ADMISSION: METOPROLOL SUCCINATE 25mg daily
DILTIAZEM HCL 360 mg daily
WARFARIN - recently held
ASPIRIN 325 mg daily- recently held
LISINOPRIL 10mg daily
FUROSEMIDE 20 mg daily
ISOSORBIDE MONONITRATE 30 mg daily
NITROGLYCERIN 0.4mg PRN
PRAVASTATIN 40 mg daily
RANITIDINE HCL 300 mg daily
ALBUTEROL 90 mcg Aerosol
FLUTICASONE-SALMETEROL 1 puff daily
TIOTROPIUM BROMIDE 18 mcg Capsule, w/Inhalation Device daily
PREDNISONE 10mg daily, prn
MVI daily
OMEGA-3 FATTY ACIDS 1,000 mg Capsule [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T-98.8    HR-64    BP-114/55   RR-18    O2-98%RA

FAMILY HISTORY: Mother died 9/199 v [**Name (NI) **]
Father Died [**2106**] [**Name2 (NI) 3730**]
Brother died [**2111**] V tachy

SOCIAL HISTORY: Married, one children. Lives on her own. 60 pack year smoking
history (quit in [**9-8**]).  No alcohol or IVDU.
Paroxysmal ventricular tachycardia,Infection and inflammatory reaction due to other vascular device, implant, and graft,Cellulitis and abscess of upper arm and forearm,Obstructive chronic bronchitis with (acute) exacerbation,Urinary tract infection, site not specified,Acute on chronic diastolic heart failure,Fitting and adjustment of automatic implantable cardiac defibrillator,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Esophageal reflux,Atherosclerosis of native arteries of the extremities with intermittent claudication,Depressive disorder, not elsewhere classified,Unspecified essential hypertension
Parox ventric tachycard,React-oth vasc dev/graft,Cellulitis of arm,Obs chr bronc w(ac) exac,Urin tract infection NOS,Ac on chr diast hrt fail,Ftng autmtc dfibrillator,Crnry athrscl natve vssl,Status-post ptca,Esophageal reflux,Ath ext ntv at w claudct,Depressive disorder NEC,Hypertension NOS
Admission Date:  [**2121-11-17**]              Discharge Date:   [**2121-11-26**]

Date of Birth:  [**2062-11-8**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 458**]
Chief Complaint:
Sustained VT

Major Surgical or Invasive Procedure:
ICD generator changed
Ventricular Tachycardia Ablation


History of Present Illness:
59 y/o F with history of COPD, CAD s/p angioplasty in '[**08**], AFib,
VT s/p ICD placement in '[**12**], admitted to [**Hospital1 1516**] on [**11-17**] because
of recurrent VT and ICD firing, now admitted to the CCU for
recurrent sustained VT and multiple ICD firing.
Pt was in USOH until the night PTA, when she was woken from
sleep by several ICD firings. Her ICD fired 3x at home with
shocks preceded by lightheadedness but no other sx.
When EP evaluated the pt in the ED, she was in NSR with PVCs and
interrogation revealed appropriate ICD firings for VT. Pt was
admitted to the floor, Toprol was increased to 50mg po and a
Lidocaine drip was started for recurrent sustained VT. On the
floor, the pt continued to have ICD firings for VT. At 3pm the
pt was noted to be in AFib with RVR that progressed to VT at
240bpm and a code was called. The pt was sedated and intubated
because of multiple ICD firings (17 in total) and was then
bolused with Amiodarone and started on amiodarone drip at
1mg/min with cessation of VTach. The pt's BP remained stable
throughout and on arrival in the CCU, the pt's vitals were
stable and EKG was in NSR with PVCs.
Of note, in advance of umbilical hernia repair, pt dc'd ASA on
[**11-8**] and coumadin on [**11-14**].


Past Medical History:
Cardiac:
- Coronary artery disease status post IMI [**2108**] + angioplasty
[**2108**] percutaneoustransluminal coronary angioplasty as above.
- s/p Defibrillator implantation [**4-/2113**] for susteined VT. EF at
that time 50% EPS with multiple inducible VT's not ablated.
[**Company 1543**] Gem ICD placed.
- A flutter [**2119**]
2. Gastroesophageal reflux disease.
3. Chronic obstructive pulmonary disease.
4. Claudication.
5. Depression.
6.Status post cesarean section.
7. Status post tonsillectomy.
8. Carpal tunnel syndrome.


Social History:
Married, one children. Lives on her own. 60 pack year smoking
history (quit in [**9-8**]).  No alcohol or IVDU.

Family History:
Mother died 9/199 v [**Name (NI) **]
Father Died [**2106**] [**Name2 (NI) 3730**]
Brother died [**2111**] V tachy


Physical Exam:
Vitals: T-98.8    HR-64    BP-114/55   RR-18    O2-98%RA

Gen: Obese middle aged woman.

Neck: JVP not appreciated due to large neck

CV: PMI not palpable. RRR, Nl S1, S2. no Murmurs, quiet HS

Chest: CTAB, no resp distress.

Abd: Obese, Soft, NTND.

Ext: warm, 2+ DPs, no edema

Skin: No stasis dermatitis, ulcers.

Neuro: Alert and oriented x 3, moving all extremities, answers
questions and follows directions appropriately.


Pertinent Results:
[**2121-11-25**] 05:20AM BLOOD WBC-13.4* RBC-4.24 Hgb-13.3 Hct-38.2
MCV-90 MCH-31.2 MCHC-34.7 RDW-15.0 Plt Ct-297
[**2121-11-17**] 07:00AM BLOOD WBC-7.7 RBC-4.56 Hgb-14.3 Hct-41.1 MCV-90
MCH-31.4 MCHC-34.9 RDW-15.1 Plt Ct-270
[**2121-11-25**] 05:20AM BLOOD Neuts-76.2* Lymphs-15.3* Monos-6.0
Eos-1.9 Baso-0.7
[**2121-11-25**] 05:20AM BLOOD PT-23.8* PTT-44.2* INR(PT)-2.3*
[**2121-11-25**] 05:20AM BLOOD Glucose-90 UreaN-21* Creat-0.8 Na-138
K-4.2 Cl-98 HCO3-30 AnGap-14
[**2121-11-17**] 07:00AM BLOOD ALT-25 AST-18 CK(CPK)-139 AlkPhos-91
TotBili-0.3
[**2121-11-17**] 07:00AM BLOOD CK-MB-4
[**2121-11-17**] 07:00AM BLOOD cTropnT-<0.01
[**2121-11-23**] 05:38AM BLOOD Calcium-9.1 Phos-3.9 Mg-1.8
[**2121-11-18**] 05:15AM BLOOD TSH-0.67
[**2121-11-19**] 02:48PM BLOOD Lactate-0.8

[**2121-11-18**] 02:07AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.015
[**2121-11-18**] 02:07AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
[**2121-11-18**] 02:07AM URINE RBC-3* WBC-54* Bacteri-MANY Yeast-NONE
Epi-1

Urine culture [**11-21**]: ESCHERICHIA COLI. >100,000 ORGANISMS/ML.
                             |
AMPICILLIN------------  =>32 R
AMPICILLIN/SULBACTAM--     8 S
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CEFUROXIME------------    16 I
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN--------  <=16 S
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----  =>16 R

BCx [**11-19**]: NGTD

Cardiac Cath [**11-18**]:
1. One vessel coronary artery disease.
2. Severe LV diastolic dysfunction.

ECHO [**11-18**]:
Suboptimal image quality. Mild symmetric left ventricular
hypertrophy with dilated left ventricle and focal regional
systolic dysfunction consistent with coronary artery disease.
Mildly dilated right ventricle with mild hypokinesis.


Brief Hospital Course:
59 yo woman with COPD, CAD s/p angioplasty, VT s/p ICD, admitted
to CCU for sustained VTach.

#. Rhythm: On presentation to CCU, pt was in normal sinus rhythm
on PO Amiodarone and Lopressor with improving PVCs. Pt had pacer
pads placed as ICD battery had been used up by the multiple
firings, but did not require any external shocking. Pt underwent
cardiac cath and echo (see results below) and then ablation of
left ventricular source. Following ablation, no arrythmias were
inducible. Pt underwent ICD change without complications,
however after had a recurrent run of ventricular tachycardia
afterwards. She was shocked by her ICD and restarted on
Amiodarone drip (in addition to PO) as well as started on
Mexilitine. Prior to discharge she was free of VT for several
days and was transitioned to PO Amiodarone and Mexilitine. She
is to have one more week of Amiodarone [**Hospital1 **] then to transition to
once daily. Pt had normal TFTs and LFTs, but will need PFTs done
as an outpt for baseline on Amiodarone. Will require twice
annual tfts and lfts, and an annual chest xray, pfts, and eye
exam.  Reviewed in detail potential amiodarone toxicities and
importance of f/u testing.  Pt understands.  These tests will be
deferred to pt's PCP and primary cardiologist.

#. CAD: Pt was continued on Lopressor, ASA, Pravastatin,
Lisinopril, Isosorbide Mononitrate and Lasix. She did not have
any EKG changes or cardiac enzyme elevations throughout her
hospitalization. ECHO showed "Suboptimal image quality. Mild
symmetric left ventricular hypertrophy with dilated left
ventricle and focal regional systolic dysfunction consistent
with coronary artery disease. Mildly dilated right ventricle
with mild hypokinesis." Cardiac Cath on [**11-18**] showed one vessel
coronary artery disease (not stented) and severe LV diastolic
dysfunction.

# ID: Pt developed an E Coli UTI, initially treated with Bactrim
DS. She was found to be resistent to Bactrim and switched to
Keflex to cover both the UTI and the ICD prophylaxis. On day of
discharge pt had developed some superficial cellulitis at sites
of blood draw and had an increasing WBC. She was restarted on
Bactrim to cover for possible MRSA (although earlier MRSA screen
was negative). At time of discharge pt was on day 6 of 7 of
Keflex and on day 2 of 10 of Bactrim. Blood cultures were neg on
[**11-19**] and were resent on [**11-25**] and were pending at time of
discharge.

# Respiratory: Pt was initially intubated due to multiple ICD
firings. She was extubated without complications. Given history
of COPD and copious secretions likely due to airway irritation,
pt was continued on Atrovent and Albuterol as needed and O2 was
weened to room air.


Medications on Admission:
METOPROLOL SUCCINATE 25mg daily
DILTIAZEM HCL 360 mg daily
WARFARIN - recently held
ASPIRIN 325 mg daily- recently held
LISINOPRIL 10mg daily
FUROSEMIDE 20 mg daily
ISOSORBIDE MONONITRATE 30 mg daily
NITROGLYCERIN 0.4mg PRN
PRAVASTATIN 40 mg daily
RANITIDINE HCL 300 mg daily
ALBUTEROL 90 mcg Aerosol
FLUTICASONE-SALMETEROL 1 puff daily
TIOTROPIUM BROMIDE 18 mcg Capsule, w/Inhalation Device daily
PREDNISONE 10mg daily, prn
MVI daily
OMEGA-3 FATTY ACIDS 1,000 mg Capsule [**Hospital1 **]


Discharge Medications:
1. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day.
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2*
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
6. Mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
Disp:*90 Capsule(s)* Refills:*2*
7. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) capsule Inhalation once a day.
8. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation 1 puff [**Hospital1 **] ().
9. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed for shortness of
breath, wheezing.
10. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO twice a
day.
11. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.

12. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day.
16. Outpatient Lab Work
Please check INR, CBC on [**2121-11-28**]. call results to covering
[**Provider Number 30083**]. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) as needed for ICD gen. change, UTI for 2 days: Last day
[**11-28**].
18. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: Two (2)
Tablet PO BID (2 times a day): last day [**2121-12-4**] for total 10 day
course.
19. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO twice a day:
For total 7 days until [**2121-12-5**], then decrease dose to once
daily.
20. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day:
To start [**2121-12-6**].
21. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: 1.5
Tablet Sustained Release 24 hrs PO once a day.
22. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for anxiety.


Discharge Disposition:
Extended Care

Facility:
[**Hospital **]Health Care

Discharge Diagnosis:
Primary:
Ventricular Tachycardia
Urinary Tract Infection
Bilateral arm cellulitis from IV sites
Secondary:
Atrial fibrillation
Coronary Artery disease
Chronic Obstructive Pulmonary Disease


Discharge Condition:
Stable
WBC 11.4
Hct 37
Na 138
K 3.9
Bun 14
Creat 0.8


Discharge Instructions:
You were admitted to the hospital because you had frequent
firing of your debrillator.  You were started on 2 medications
to help control your abnormal heart rhythm.  In addition, the
generator of your current ICD was changed and a catheterization
of your coronary arteries showed multiple small blockages. We
have started you on Clopodigrel to prevent blood clots. You had
a urinary tract infection and infections on both arms from IV
sites, you have been started on Bactrim and Keflex antibiotics
to treat these infections. Please keep both your arms elevated
on pillows when you are in bed or in a chair.
.
There were changes made to your medications:
New:
Toprol increased to 75mg daily
Amidarone started with load and tapering dose
Mexilitine started: this is a generic drug and might be
expensive.
Lorazepam: similar to Valium, may be taken as needed for anxiety
on a short term basis.

Changed:
discontinue taking diltiazem
.
You will need to follow up in device clinic as scheduled below.
.
Congratulations on quitting smoking. Information was given to
you on admission regarding smoking cessation and preventing
relapses.

Followup Instructions:
Provider:  [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2121-12-15**]
1:00
.
Primary Care:
[**Name6 (MD) **] [**Name8 (MD) 30084**], MD
[**Street Address(2) 30085**]
[**Location (un) 8117**], [**Numeric Identifier 30086**]
Phone: ([**Telephone/Fax (1) 30087**] Please make an appt to see him when you
get out of rehabilitation.
.
Cardiology:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 30088**], MD
[**Street Address(2) 30089**]
[**Location (un) 8117**], [**Numeric Identifier 30090**]
Phone: ([**Telephone/Fax (1) 30091**]
Date/time: [**12-10**] at 10:30am.



Completed by:[**2121-11-26**]
{'Paroxysmal ventricular tachycardia,Infection and inflammatory reaction due to other vascular device, implant, and graft,Cellulitis and abscess of upper arm and forearm,Obstructive chronic bronchitis with (acute) exacerbation,Urinary tract infection, site not specified,Acute on chronic diastolic heart failure,Fitting and adjustment of automatic implantable cardiac defibrillator,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Esophageal reflux,Atherosclerosis of native arteries of the extremities with intermittent claudication,Depressive disorder, not elsewhere classified,Unspecified essential hypertension'}


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: Sustained VT

PRESENT ILLNESS: 59 y/o F with history of COPD, CAD s/p angioplasty in '[**08**], AFib,
VT s/p ICD placement in '[**12**], admitted to [**Hospital1 1516**] on [**11-17**] because
of recurrent VT and ICD firing, now admitted to the CCU for
recurrent sustained VT and multiple ICD firing.
Pt was in USOH until the night PTA, when she was woken from
sleep by several ICD firings. Her ICD fired 3x at home with
shocks preceded by lightheadedness but no other sx.
When EP evaluated the pt in the ED, she was in NSR with PVCs and
interrogation revealed appropriate ICD firings for VT. Pt was
admitted to the floor, Toprol was increased to 50mg po and a
Lidocaine drip was started for recurrent sustained VT. On the
floor, the pt continued to have ICD firings for VT. At 3pm the
pt was noted to be in AFib with RVR that progressed to VT at
240bpm and a code was called. The pt was sedated and intubated
because of multiple ICD firings (17 in total) and was then
bolused with Amiodarone and started on amiodarone drip at
1mg/min with cessation of VTach. The pt's BP remained stable
throughout and on arrival in the CCU, the pt's vitals were
stable and EKG was in NSR with PVCs.
Of note, in advance of umbilical hernia repair, pt dc'd ASA on
[**11-8**] and coumadin on [**11-14**].

MEDICAL HISTORY: Cardiac:
- Coronary artery disease status post IMI [**2108**] + angioplasty
[**2108**] percutaneoustransluminal coronary angioplasty as above.
- s/p Defibrillator implantation [**4-/2113**] for susteined VT. EF at
that time 50% EPS with multiple inducible VT's not ablated.
[**Company 1543**] Gem ICD placed.
- A flutter [**2119**]
2. Gastroesophageal reflux disease.
3. Chronic obstructive pulmonary disease.
4. Claudication.
5. Depression.
6.Status post cesarean section.
7. Status post tonsillectomy.
8. Carpal tunnel syndrome.

MEDICATION ON ADMISSION: METOPROLOL SUCCINATE 25mg daily
DILTIAZEM HCL 360 mg daily
WARFARIN - recently held
ASPIRIN 325 mg daily- recently held
LISINOPRIL 10mg daily
FUROSEMIDE 20 mg daily
ISOSORBIDE MONONITRATE 30 mg daily
NITROGLYCERIN 0.4mg PRN
PRAVASTATIN 40 mg daily
RANITIDINE HCL 300 mg daily
ALBUTEROL 90 mcg Aerosol
FLUTICASONE-SALMETEROL 1 puff daily
TIOTROPIUM BROMIDE 18 mcg Capsule, w/Inhalation Device daily
PREDNISONE 10mg daily, prn
MVI daily
OMEGA-3 FATTY ACIDS 1,000 mg Capsule [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T-98.8    HR-64    BP-114/55   RR-18    O2-98%RA

FAMILY HISTORY: Mother died 9/199 v [**Name (NI) **]
Father Died [**2106**] [**Name2 (NI) 3730**]
Brother died [**2111**] V tachy

SOCIAL HISTORY: Married, one children. Lives on her own. 60 pack year smoking
history (quit in [**9-8**]).  No alcohol or IVDU. 

### Response:
{'Paroxysmal ventricular tachycardia,Infection and inflammatory reaction due to other vascular device, implant, and graft,Cellulitis and abscess of upper arm and forearm,Obstructive chronic bronchitis with (acute) exacerbation,Urinary tract infection, site not specified,Acute on chronic diastolic heart failure,Fitting and adjustment of automatic implantable cardiac defibrillator,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Esophageal reflux,Atherosclerosis of native arteries of the extremities with intermittent claudication,Depressive disorder, not elsewhere classified,Unspecified essential hypertension'}
