CHIEF COMPLAINT: Hypotension s/p atrial fibrillation ablation

PRESENT ILLNESS: HPI: 49 year old woman with history of atrial fibrillation and
atrial flutter that was diagnosed in [**2169-7-19**]. She
underwent flutter ablation in [**12/2169**] that was successful,
although atrial fibrillation was noted during the procedure. She
has been managed on Propafenone 425mg twice a day, Cartia 180mg
twice a day and Coumadin. Patient reports that since her flutter
ablation she has been completely asymptomatic. However, she
wants to stop taking Coumadin and presents today for a A Fib
ablation.
.
Following the procedure in the PACU patient became hypotensive.
She complained of back pain and abdominal pain. She had
descreased urine output. She received 6 L of LR and
phenylephrine drip (total I/O 6000/1045). She remained
hypotensive in the 80-90s and consequently CCU was consulted.
Her HCT dropped 12 points (38.2 -> 25.4). Consequently, we were
concerned regarding RP bleed and patient was sent for stat CT
abdomen. Stat ECHO also ordered to rule out tamponade due to
ablation procedure. Of note in PACU received morphine, dilaudid
and ativan for anxiety/pain.

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: Diltiazem 180mg twice a day
Vicodin 5mg-500mg one tablet every 4-6 hours prn pain
Propafenone 425mg one capsule twice a day, last dose [**2170-9-14**]
Coumadin 10mg as directed, last dose [**2170-9-13**]
Citalopram 20mg daily
Xanax 2.5 mg prn

ALLERGIES: Aspirin

PHYSICAL EXAM: PHYSICAL EXAMINATION:
VS: T= 99.1 BP= 105/76 HR= 85 RR= 14 O2 sat= 99% RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: No JVD.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Firm, tenderness to palpation in all quadrants (lower >
upper). No gaurding and no rebound. Abd aorta not enlarged by
palpation. No abdominial bruits. + BS. No flank ecchymoses
noted.
EXTREMITIES: No c/c/e. No femoral bruits.
Groin: B/L: dressing c/d/i. No bruit. Tenderness to touch.
SKIN: No stasis dermatitis, ulcers, scars.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+

FAMILY HISTORY: No family history of early cardiac death.

SOCIAL HISTORY: Patient is going through a divorce. She has two children ages 7
and 10 whom she lives with. Works as a career coach. Smoked for
10 years 1.5 ppd, quit 20 years ago. Glass of wine every few
days. Denies IV drug use.
Hemorrhage complicating a procedure,Atrial flutter,Urinary complications, not elsewhere classified,Acute posthemorrhagic anemia,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Retention of urine, unspecified
Hemorrhage complic proc,Atrial flutter,Surg compl-urinary tract,Ac posthemorrhag anemia,Abn react-procedure NEC,Retention urine NOS
Admission Date:  [**2170-9-17**]              Discharge Date:   [**2170-9-20**]

Date of Birth:  [**2121-5-24**]             Sex:   F

Service: MEDICINE

Allergies:
Aspirin

Attending:[**Doctor First Name 1402**]
Chief Complaint:
Hypotension s/p atrial fibrillation ablation

Major Surgical or Invasive Procedure:
Atrial fibrillation ablation.


History of Present Illness:
HPI: 49 year old woman with history of atrial fibrillation and
atrial flutter that was diagnosed in [**2169-7-19**]. She
underwent flutter ablation in [**12/2169**] that was successful,
although atrial fibrillation was noted during the procedure. She
has been managed on Propafenone 425mg twice a day, Cartia 180mg
twice a day and Coumadin. Patient reports that since her flutter
ablation she has been completely asymptomatic. However, she
wants to stop taking Coumadin and presents today for a A Fib
ablation.
.
Following the procedure in the PACU patient became hypotensive.
She complained of back pain and abdominal pain. She had
descreased urine output. She received 6 L of LR and
phenylephrine drip (total I/O 6000/1045). She remained
hypotensive in the 80-90s and consequently CCU was consulted.
Her HCT dropped 12 points (38.2 -> 25.4). Consequently, we were
concerned regarding RP bleed and patient was sent for stat CT
abdomen. Stat ECHO also ordered to rule out tamponade due to
ablation procedure. Of note in PACU received morphine, dilaudid
and ativan for anxiety/pain.


Social History:
Patient is going through a divorce. She has two children ages 7
and 10 whom she lives with. Works as a career coach. Smoked for
10 years 1.5 ppd, quit 20 years ago. Glass of wine every few
days. Denies IV drug use.

Family History:
No family history of early cardiac death.

Physical Exam:
PHYSICAL EXAMINATION:
VS: T= 99.1 BP= 105/76 HR= 85 RR= 14 O2 sat= 99% RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: No JVD.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Firm, tenderness to palpation in all quadrants (lower >
upper). No gaurding and no rebound. Abd aorta not enlarged by
palpation. No abdominial bruits. + BS. No flank ecchymoses
noted.
EXTREMITIES: No c/c/e. No femoral bruits.
Groin: B/L: dressing c/d/i. No bruit. Tenderness to touch.
SKIN: No stasis dermatitis, ulcers, scars.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+


Pertinent Results:
Pre-op labs:
CHEM-7: 140 / 103 / 15 107 AGap=14
---------------
3.8 / 27 / 0.8
WBC 7.7 Hgb 13.1 HCT 38.2 Platelets 315
PT: 13.5 INR: 1.2
Post-op Labs:
Chem- 7 140 / 111 / 12 / 136 AGap=8
-----------------
4.1 / 25 / 0.7
Ca: 8.0 Mg: 1.5 P: 2.9
WBC 9.1 Hgb 8.7 HCT 25.4 Platelets 263
Repeat:
HCT 24.9 PT: 13.3 PTT: 26.4 INR: 1.1
.
Imaging:
 [**2170-9-18**] CT PELVIS/ABD WITHOUT CONTRAST: The previously
described large retroperitoneal hematoma is again seen, now
measures 85 x 106 mm compared to the previous 88 x 114 mm,
essentially unchanged in size. Again seen is a hematocrit level.
The hematoma tracks along the left psoas muscle and iliac
vessels. There is persistent mass effect on the right-displaced
bladder, which has an indwelling Foley catheter. There is
expected soft tissue stranding from the presumed entry of the
left femoral access.

.
ECHO: no tamponade. patent IVC. good output.

------------
[**2170-9-17**] 07:40PM   HCT-24.9*
[**2170-9-17**] 07:40PM   PT-13.3 PTT-26.4 INR(PT)-1.1
[**2170-9-17**] 06:56PM   GLUCOSE-136* UREA N-12 CREAT-0.7 SODIUM-140
POTASSIUM-4.1 CHLORIDE-111* TOTAL CO2-25 ANION GAP-8
[**2170-9-17**] 06:56PM   CALCIUM-8.0* PHOSPHATE-2.9 MAGNESIUM-1.5*
[**2170-9-17**] 06:56PM   WBC-9.1 RBC-2.58*# HGB-8.7*# HCT-25.4*#
MCV-98 MCH-33.7* MCHC-34.2 RDW-12.8
[**2170-9-17**] 06:56PM   PLT COUNT-263
[**2170-9-17**] 08:30AM   GLUCOSE-107* UREA N-15 CREAT-0.8 SODIUM-140
POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-27 ANION GAP-14
[**2170-9-17**] 08:30AM   WBC-7.7 RBC-3.97* HGB-13.1 HCT-38.2 MCV-96
MCH-32.9* MCHC-34.3 RDW-13.0
[**2170-9-17**] 08:30AM   PLT COUNT-315
[**2170-9-17**] 08:30AM   PT-13.5* INR(PT)-1.2*
[**2170-9-17**] 08:00AM   INR(PT)-0.9

[**2170-9-19**] - Hct 30.9

Brief Hospital Course:
In summary, patient is a 49 year old woman with atrial
fibrillation who was referred for an elective Atrial
Fibrillation ablation procedure. Unfortunately, the patient
became hypotensive in PACU following the procedure despite 6 L
of Lactated Ringers IV fluid. She required a phenylephrine drip
as pressure support for a brief interval. Overall she had a 12
point HCT drop and a STAT Abdomen CT demonstrated significant RP
bleed which was noted as a complication of her surgery.
.
# RP bleed: As noted, the patient received a total of 6L LR and
3 units of blood.  Hematoma stable with no interval change seen
on consecutive CTs. HCT was checked q4hours initially and then
q12 once it was clear that her Hct had been stable for 24+ hrs.
The patient's diet was advanced to regular and she had good PO
intake despite some complaints of abdominal and flank pain. The
team initially held Coumadin and ASA secondary to bleed, but
restarted her Coumadin at a lower 5mg daily dose on [**2170-9-19**] per
EP team's recommendations to protect the patient from adverse
CVA risks given her atrial fibrillation and flutter histories.
She has remained in NSR since procedure. The patient continued
to have her BP and HR closely monitored. After hospital day 1
she was advanced from bedrest to light activity as she tolerated
and orthostatics were monitored. Discharged on 5 mg coumadin qhs
and to follow INR at [**Hospital1 112**] coumadin clinic.
.
# Urinary Retention: This was felt to be secondary to RP bleed
mechanically compressing bladder. The patient's symptoms have
improved since volume resuscitation and she has had healthy,
appropriate urine output throughout the remainder of her
hospitalization. 2-3L on average daily. The patient was closely
monitored with a foley but it was discontinued on [**2170-9-19**]. She
had some mild dysuria complaints on [**2170-9-19**] and a UA was sent to
assess for any infections and labs appeared unremarkable for any
UTIs. Patient denied suprapubic pain, urgency, frequency and was
afebrile.
.
# Rhythm: As aformentioned the patient had atrial-fib ablation.
She is currently in sinus. The patient's Diltiazem, Propafenone
and Coumadin were all held and she was
re-started on 5mg Coumadin once her Hct and CT appeared stable
for over 2 days.
She will plan for [**Doctor Last Name **] of Hearts monitoring for 3 mos with no
sign of Afib as a goal prior to considering full discontinuation
of her coumadin. Patient to follow up with Dr. [**Last Name (STitle) **].
.
# Pleuritic pain: No changes on EKG, no acute process on CXR.
Most likely related to pericardium irritation secondary to A Fib
ablation.
.
# Pain: Standing order of tylenol and Oxycodone 5-10 mg prn pain
was given and the patient's Oxycodone was titrated up to 10-15mg
PO q4hours on [**2170-9-19**] for better pain control as patient had
some breakthrough abdominal and flank discomfort. For pain
control discharged on oxydone 5 mg 2 tablets q4hr for pain
(total 40 tablets, no refills). Patient informed not to drive
while taking oxycodone.
.
# Anxiety: She was continued on her Citalopram 20 mg qd and her
Alprazolam 0.25 mg PO TID as needed as well as Zolpidem Tartrate
5-10 mg PO HS.



Medications on Admission:
Diltiazem 180mg twice a day
Vicodin 5mg-500mg one tablet every 4-6 hours prn pain
Propafenone 425mg one capsule twice a day, last dose [**2170-9-14**]
Coumadin 10mg as directed, last dose [**2170-9-13**]
Citalopram 20mg daily
Xanax 2.5 mg prn


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
Atrial fibrillation ablation
Retroperitoneal bleed

Seconadry:
atrial flutter, s/p ablation [**12-26**]


Discharge Condition:
Good, stable HCT, ambulating with stable vitals.


Discharge Instructions:
You had an Atrial Fibrillation ablation. You developed a
retroperitoneal bleed complication secondary to the ablation.
You were admitted to the CCU and transfused 3 units of blood. On
discharge your blood counts are stable. You are being discharged
on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor. Important to follow up with Dr.
[**Last Name (STitle) **] and your primary care doctor.

Made the following changes to your medications:
1) Stopped Diltiazem, Propafenone.
2) Take Coumadin 5 mg every night until directed by your primary
care doctor
3) Oxycodone 10 mg every 4 hours as needed for pain. Do not
drive when taking.
4) Have your INR checked at [**Hospital1 112**] [**2170-9-21**], adjust your coumadin as
needed.

Return to the ER if you experience worsening abdominal pain,
dizziness, shortness of breath, slurred speech, weakness,
bleeding or any other concerning symptoms.


Followup Instructions:
1) PT/INR on [**2170-9-21**] at [**Hospital1 112**]. Adjust Coumadin dose per primary
care doctor.
2) Call Dr. [**First Name (STitle) 1726**] [**Telephone/Fax (1) 74684**] and schedule an appointment in 1
week
3) Dr. [**Last Name (STitle) **] office will call you tomorrow to schedule an
appointment. If you do not hear from them in 2 days call the
office. ([**Telephone/Fax (1) 2037**].



Completed by:[**2170-9-24**]
{'Hemorrhage complicating a procedure,Atrial flutter,Urinary complications, not elsewhere classified,Acute posthemorrhagic anemia,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Retention of urine, unspecified'}


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: Hypotension s/p atrial fibrillation ablation

PRESENT ILLNESS: HPI: 49 year old woman with history of atrial fibrillation and
atrial flutter that was diagnosed in [**2169-7-19**]. She
underwent flutter ablation in [**12/2169**] that was successful,
although atrial fibrillation was noted during the procedure. She
has been managed on Propafenone 425mg twice a day, Cartia 180mg
twice a day and Coumadin. Patient reports that since her flutter
ablation she has been completely asymptomatic. However, she
wants to stop taking Coumadin and presents today for a A Fib
ablation.
.
Following the procedure in the PACU patient became hypotensive.
She complained of back pain and abdominal pain. She had
descreased urine output. She received 6 L of LR and
phenylephrine drip (total I/O 6000/1045). She remained
hypotensive in the 80-90s and consequently CCU was consulted.
Her HCT dropped 12 points (38.2 -> 25.4). Consequently, we were
concerned regarding RP bleed and patient was sent for stat CT
abdomen. Stat ECHO also ordered to rule out tamponade due to
ablation procedure. Of note in PACU received morphine, dilaudid
and ativan for anxiety/pain.

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: Diltiazem 180mg twice a day
Vicodin 5mg-500mg one tablet every 4-6 hours prn pain
Propafenone 425mg one capsule twice a day, last dose [**2170-9-14**]
Coumadin 10mg as directed, last dose [**2170-9-13**]
Citalopram 20mg daily
Xanax 2.5 mg prn

ALLERGIES: Aspirin

PHYSICAL EXAM: PHYSICAL EXAMINATION:
VS: T= 99.1 BP= 105/76 HR= 85 RR= 14 O2 sat= 99% RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: No JVD.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Firm, tenderness to palpation in all quadrants (lower >
upper). No gaurding and no rebound. Abd aorta not enlarged by
palpation. No abdominial bruits. + BS. No flank ecchymoses
noted.
EXTREMITIES: No c/c/e. No femoral bruits.
Groin: B/L: dressing c/d/i. No bruit. Tenderness to touch.
SKIN: No stasis dermatitis, ulcers, scars.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+

FAMILY HISTORY: No family history of early cardiac death.

SOCIAL HISTORY: Patient is going through a divorce. She has two children ages 7
and 10 whom she lives with. Works as a career coach. Smoked for
10 years 1.5 ppd, quit 20 years ago. Glass of wine every few
days. Denies IV drug use. 

### Response:
{'Hemorrhage complicating a procedure,Atrial flutter,Urinary complications, not elsewhere classified,Acute posthemorrhagic anemia,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Retention of urine, unspecified'}
