CHIEF COMPLAINT: s/p vfib arrest, transferred for continuous EEG monitoring

PRESENT ILLNESS: This is a 50 year old man with known CAD s/p STEMI in [**2146**] (with
LAD stents) and infrequent medical followup since that time who
was admitted to [**Hospital6 2561**] on [**2156-6-8**] following vfib
arrest. History is obtained from the medical records. He
reportedly had an unwitnessed (but heard) syncopal event at work
around 5:15pm on [**6-8**]. CPR was started within 2 minutes and 911
was called. AED was applied and a shock was given. On EMS
arrival, PEA was noted, and pt was given epi x2, atropine x2
with CPR continued. VF then noted again and shocked x2.
Lidocaine 100mg given, follwed by gtt. No BP was obtainable for
about 15 minutes. Peripheral dopamine started, after which SBP
108 noted. Pt was intubated en route to the hospital, and
sedated with versed. On arrival to the [**Last Name (un) 1724**] ED, rhythm was sinus
tachy 130s-150s with ST elevations V1-V3 noted.
.
Head CT was negative, and pt was then taken to the cath lab,
where multivessel disease was noted. DES x2 placed to LAD (prior
stents 100% occluded). Prox RCA was also noted to be chronically
occluded with L->R collaterals. IABP was inserted. Arctic Sun
cooling protocol was initiated. He was weaned off dopamine and
the IABP was discontinued 2 days prior to transfer.
.
On [**6-9**] he was noted to have some bleeding from his mouth. ENT
evaluated the patient and did not see any ongoing bleeding.
However, hct decreased from around 40 initially to 30 today.
.
The patient has also been spiking fevers and is currently on
vancomycin and ceftazidime for empiric treatment of VAP. He
reportedly has had H. flu and pan-sensitive staph growing from
sputum.
.
After re-warming, he has been noted to have LE>UE shaking
movements which are concerning for seizure activity in the
setting of possible anoxic brain injury. Neuro was consulted and
pt was loaded with Keppra. The patient is now transferred to
[**Hospital1 18**] for continuous EEG monitoring.
.
Currently unable to complete review of symptoms, as pt is
intubated and sedated. Medical records note that pt's wife
reported pt had L anterior chest pain radiating to his left arm
on the night prior to admission, but further details of this
history are unavailable at this time.

MEDICAL HISTORY: 1. Coronary artery disease, s/p STEMI in [**2146**] with stents to LAD

MEDICATION ON ADMISSION: aspirin 325
fondaparinux 2.5mg daily
capoten 6.25 tid
ceftazidime 2g q8h
HISS
keppra 1000mg [**Hospital1 **]
lipitor 80mg hs
metoprolol 25mg qid
plavix 75 mg daily
protonix 40mg IV daily
artificial tears
versed gtt
vancomycin 1250mg q12h

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 100.6, BP 131/93, HR 101, RR 24, O2 99% on 50% FiO2
Gen: WDWN middle aged male, unresponsive to verbal or painful
stimuli, no spontaneous movements. GCS 3.
HEENT: Normocephalic, superficial edema/evidence of trauma,
Sclera anicteric. PERRL, but variable baseline diameter.
Intermittent inferior deviation and rotational movements of both
eyes, mostly coordinated. Fundi could not be visualized. Corneal
reflex intact but sluggish, vestibular-ocular movements intact.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Lives at home with his wife. [**Name (NI) 1403**] as a graphic artist. Smokes
2ppd.
Paroxysmal ventricular tachycardia,Acute respiratory failure,Pneumonia, organism unspecified,Coma,Coronary atherosclerosis of native coronary artery,Subendocardial infarction, subsequent episode of care,Unspecified essential hypertension,Anemia, unspecified,Percutaneous transluminal coronary angioplasty status
Parox ventric tachycard,Acute respiratry failure,Pneumonia, organism NOS,Coma,Crnry athrscl natve vssl,Subendo infarct, subseq,Hypertension NOS,Anemia NOS,Status-post ptca
Admission Date:  [**2156-6-13**]              Discharge Date:   [**2156-6-24**]

Date of Birth:  [**2105-10-10**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
 s/p vfib arrest, transferred for continuous EEG monitoring

Major Surgical or Invasive Procedure:
Extubation, [**2156-6-17**]

History of Present Illness:
This is a 50 year old man with known CAD s/p STEMI in [**2146**] (with
LAD stents) and infrequent medical followup since that time who
was admitted to [**Hospital6 2561**] on [**2156-6-8**] following vfib
arrest. History is obtained from the medical records. He
reportedly had an unwitnessed (but heard) syncopal event at work
around 5:15pm on [**6-8**]. CPR was started within 2 minutes and 911
was called. AED was applied and a shock was given. On EMS
arrival, PEA was noted, and pt was given epi x2, atropine x2
with CPR continued. VF then noted again and shocked x2.
Lidocaine 100mg given, follwed by gtt. No BP was obtainable for
about 15 minutes. Peripheral dopamine started, after which SBP
108 noted. Pt was intubated en route to the hospital, and
sedated with versed. On arrival to the [**Last Name (un) 1724**] ED, rhythm was sinus
tachy 130s-150s with ST elevations V1-V3 noted.
.
Head CT was negative, and pt was then taken to the cath lab,
where multivessel disease was noted. DES x2 placed to LAD (prior
stents 100% occluded). Prox RCA was also noted to be chronically
occluded with L->R collaterals. IABP was inserted. Arctic Sun
cooling protocol was initiated. He was weaned off dopamine and
the IABP was discontinued 2 days prior to transfer.
.
On [**6-9**] he was noted to have some bleeding from his mouth. ENT
evaluated the patient and did not see any ongoing bleeding.
However, hct decreased from around 40 initially to 30 today.
.
The patient has also been spiking fevers and is currently on
vancomycin and ceftazidime for empiric treatment of VAP. He
reportedly has had H. flu and pan-sensitive staph growing from
sputum.
.
After re-warming, he has been noted to have LE>UE shaking
movements which are concerning for seizure activity in the
setting of possible anoxic brain injury. Neuro was consulted and
pt was loaded with Keppra. The patient is now transferred to
[**Hospital1 18**] for continuous EEG monitoring.
.
Currently unable to complete review of symptoms, as pt is
intubated and sedated. Medical records note that pt's wife
reported pt had L anterior chest pain radiating to his left arm
on the night prior to admission, but further details of this
history are unavailable at this time.


Past Medical History:
1. Coronary artery disease, s/p STEMI in [**2146**] with stents to LAD

2. HTN
3. SBO/strangulated internal hernia s/p small bowel resection in
[**8-/2149**]


Social History:
Lives at home with his wife. [**Name (NI) 1403**] as a graphic artist. Smokes
2ppd.

Family History:
Noncontributory

Physical Exam:
VS: T 100.6, BP 131/93, HR 101, RR 24, O2 99% on 50% FiO2
Gen: WDWN middle aged male, unresponsive to verbal or painful
stimuli, no spontaneous movements. GCS 3.
HEENT: Normocephalic, superficial edema/evidence of trauma,
Sclera anicteric. PERRL, but variable baseline diameter.
Intermittent inferior deviation and rotational movements of both
eyes, mostly coordinated. Fundi could not be visualized. Corneal
reflex intact but sluggish, vestibular-ocular movements intact.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.

Neck: Supple with JVP of 6 cm. CVL in place.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3, no murmurs.
Chest: On mechanical ventilation, pressure support. Exam limited
by supine positioning, but no crackles, wheeze, rhonchi
appreciated.
Abd: Positive bowel sounds. Obese, soft, non-distended, No HSM.
No abdominial bruits. Rectal tone somewhat diminished. Stool
guaiac negative.
Ext: No clubbing or cyanosis. Significant upper extremity
non-pitting edema, and 1+ lower extremity edeam. Peripheral
pulses 2+. UE reflexes 0-1+, Patellar reflexes 3+, no clonus,
Babinski with no response. No femoral bruits or hematomas.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP

Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP


Pertinent Results:
EKG on arrival to [**Hospital1 18**] demonstrated sinus rhythm, normal
intervals and axes, Q waves of [**10-27**] mm in V1-V3, and of [**1-14**] mm
in III and aVF, compared with OSH EKG which showed ST elevations
in V1-V3.
.
2D-ECHOCARDIOGRAM performed on [**2156-6-9**] demonstrated:
This was an extremely technically limited study due to poor echo
windows, the patient being intubated, hypothermic and having a
balloon pump in. There was no pericardial effusion seen. Overall
EF was moderately depressed. There was hypokinesis of the
anterior wall, apex and antero septum. Aortic valve is not well
visualized. There is mild MR. There is trace TR. Again, no
pericardial effusion is seen.
IMPRESSION: Moderately depressed EF. No evidence of pericardial
effusion. Recommendations made for a repeat echocardiogram for
better assessment of LV function when the patient has further
stabilized.
.
CARDIAC CATH performed on [**2156-6-8**] demonstrated:
1. Severe 2-vessel coronary artery disease with acute and
chronic occlusions.
2. Severe left ventricular systolic dysfunction.
3. No significant mitral regurgitation or aortic stenosis.
4. Successful balloon angioplasty and stenting (2 drug eluting
stents) of the left anterior descending coronary artery acute
proximal occlusion resulted in 0% residual stenosis.
5. Intra-aortic balloon pump placed for hemodynamic support.
.
[**2156-6-12**] Head CT:
1. Interval development of small low attenuation focus in the L
basal ganglia, which may represent a focus of ischemic injury.
2. Interval development of subcutaneous fluid collections over
the R parietal and L temporal bones, which most likely represent
hematomas if there is a history of recent trauma.
3. Interval worsening of sinus disease.
.
OSH LABORATORY DATA:
[**2156-6-13**]:
WBC 11.9, Hct 30.9, Plt 198
Na 132, K 3.4, Cl 100, CO2 26, BUN 15, Cr 0.9, glc 103. Ca 7.7,
Mg 2.0, Phos 2.9.
ALT 68, AST 103, AP 64, TB 0.4, Alb 2.0
.
CXR ([**6-13**] at [**Hospital1 **], prelim read): ET tube 7 cm above the carina.
Right line high in SVC. Hazy opacity in RLL.
.
EEG: (prelim read, during rhythmic movements) Slow, low
amplitude activity in all leads, no spikes or focal activity.
.


Brief Hospital Course:
# CAD/Ischemia:
The patient presented s/p MI with 100% lesion of LAD stented
with 2 drug-eluting stents. RCA was occluded but had L to R
colaterals; no intervention was undertaken during cath. Echo on
[**6-14**] showed severe anterior, septal, and apical hypokinesis.  The
patient was started on a beta-[**Last Name (LF) 7005**], [**First Name3 (LF) **], statin, and plavix.
.
# Pump:
The patient had TTE on [**6-14**] showed EF of 30-35%, severe anterior,
septal, and apical hypokinesis. The patient was not
anticoagulated with heparin for intraventricular thrombus
prophylaxis. He was diuresed with lasix and started on
Lisinopril 5mg daily.   He was sent home on 20mg lasix daily.
.
# Rhythm: s/p V-fib arrest, now sinus rhythm, monitored on
telemetry. Arrest appears to have been in the setting of MI vs
old scar; and he remained in sinus rhythm since AED
defibrillation.  Given his arrest he underwent an EP study which
showed inducible ventricular arrhythmia, and an ICD was placed.
He was given 2 days of Keflex post ICD placement. He had no
further events on telemetry.  He was discharged with follow up
in device clinic.

.
# Neurologic status: Per neuro, there was no evidence for
seizure, and EEG showed slow, low amplitude acitivity with no
foci. Patient was unresponsive initially, likely due to having
been without a blood pressure for 15 minutes with possible
anoxic brain injury. He did undergo cooling protocol at the
outside hospital. Patient became responsive on HD#3, and has had
steady improvement in neurological function since. MRI showed no
intracranial process.  Neuro followed throughout his course. Pt
is expected to have continued improvement in his MS up to 6
months; and will be followed as an outpatinet by Dr [**Last Name (STitle) **]
[**Name (STitle) **] who specializes in anoxic  brain injury.
.
# Respiratory failure: Paitent initially intubated on arrival
likely from pulmonary edema, poor mental status and pneumonia.
Pt extuabted on hospital day #2 and respiratory status improved;
able to oxygenate on room air.
.
# Fevers/Possible Pneumonia: Spiked fevers at OSH to 101 on
cooling protocol. WBC 11-->14. Started on vanco and ceftazidime.
Sputum culture from [**6-10**] at OSH grew MSSA, Haemophilus, but
continued to spike fevers, so antibiotics were initially
continued. Repeat sputum [**6-12**] grew Staph from OSH. CXR shows RLL
hazy opacity. His antibiotics were thus changed to
nafcillin/levo given two cultures and clindamycin was added for
aspiration pneumonia.  Pts fevers defervesced and he was changed
to an oral regiment which included dicloxacillin, levofloxacin
and clindaymycin.  CXR showed interval improvement.  Total abx
course 14 days, including 10 days of naf->diclox, levo, and
clinda.
.
# s/p fall: C-spine cleared via clinical evaluation and no
evidence of ligamentous injury/spinal cord injury on MRI.
.
# Anemia: Pts Hct was initially low on admission however it
remained stable and trended up throughout his stay.

Medications on Admission:
aspirin 325
fondaparinux 2.5mg daily
capoten 6.25 tid
ceftazidime 2g q8h
HISS
keppra 1000mg [**Hospital1 **]
lipitor 80mg hs
metoprolol 25mg qid
plavix 75 mg daily
protonix 40mg IV daily
artificial tears
versed gtt
vancomycin 1250mg q12h


Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily):
Total dose should be 125mg daily (in the morning).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day: Take
1 tablet each morning; total dose of Toprol XL is 125mg daily.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
6. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Primary diagnosis:
- Coronary artery disease
Secondary diagnosis:
- Ventricular arrhythmia
- Cognitive impairment


Discharge Condition:
Stable, ambulating without difficulty.


Discharge Instructions:
You were transferred here after being admitted at another
hospital after collasping at work. You were able to be
successfully extubated. You had a defibrillator (ICD) placed to
prevent any further cardiovascular collapses secondary to your
heart arrhythmia.
You have evidence of some cognitive impairment, and will need to
follow up closely with neurologist.
.
Please contact your cardiologist, primary care physician, [**Name10 (NameIs) **] go
to the emergency room if you experience any chest pain,
palpitations, difficulty breathing, dizziness, fevers, firing of
your ICD, or other concerning symptoms.
.
You have been started on a number of medications.
It is very important to continue these medications unless
directed by cardiologist. Your Plavix and Aspirin are extremely
important, as you are at risk for another heart attack or death
if you stop these.

Followup Instructions:
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the department of
behavioral neurology at an appointment made for you on [**7-8**]
at 10:30 AM. His office is located in [**First Name4 (NamePattern1) 40231**] [**Last Name (NamePattern1) **], [**Location (un) **],
[**Apartment Address(1) **], [**Hospital Ward Name 516**] (not in the [**Hospital Ward Name 23**] Building).
The number for the clinic is ([**Telephone/Fax (1) 1703**].
.
You should follow up at a cardiology appointment made for you
with Dr [**Last Name (STitle) **]. You have an appointment on [**7-22**] at 10:20am.
.
You will also need to follow up with the device clinic to check
the functioning of your ICD at an appointment: DEVICE CLINIC
Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2156-7-1**] 11:00

Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 2934**]
Date/Time:[**2156-7-22**] 10:20


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
{'Paroxysmal ventricular tachycardia,Acute respiratory failure,Pneumonia, organism unspecified,Coma,Coronary atherosclerosis of native coronary artery,Subendocardial infarction, subsequent episode of care,Unspecified essential hypertension,Anemia, unspecified,Percutaneous transluminal coronary angioplasty status'}


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: s/p vfib arrest, transferred for continuous EEG monitoring

PRESENT ILLNESS: This is a 50 year old man with known CAD s/p STEMI in [**2146**] (with
LAD stents) and infrequent medical followup since that time who
was admitted to [**Hospital6 2561**] on [**2156-6-8**] following vfib
arrest. History is obtained from the medical records. He
reportedly had an unwitnessed (but heard) syncopal event at work
around 5:15pm on [**6-8**]. CPR was started within 2 minutes and 911
was called. AED was applied and a shock was given. On EMS
arrival, PEA was noted, and pt was given epi x2, atropine x2
with CPR continued. VF then noted again and shocked x2.
Lidocaine 100mg given, follwed by gtt. No BP was obtainable for
about 15 minutes. Peripheral dopamine started, after which SBP
108 noted. Pt was intubated en route to the hospital, and
sedated with versed. On arrival to the [**Last Name (un) 1724**] ED, rhythm was sinus
tachy 130s-150s with ST elevations V1-V3 noted.
.
Head CT was negative, and pt was then taken to the cath lab,
where multivessel disease was noted. DES x2 placed to LAD (prior
stents 100% occluded). Prox RCA was also noted to be chronically
occluded with L->R collaterals. IABP was inserted. Arctic Sun
cooling protocol was initiated. He was weaned off dopamine and
the IABP was discontinued 2 days prior to transfer.
.
On [**6-9**] he was noted to have some bleeding from his mouth. ENT
evaluated the patient and did not see any ongoing bleeding.
However, hct decreased from around 40 initially to 30 today.
.
The patient has also been spiking fevers and is currently on
vancomycin and ceftazidime for empiric treatment of VAP. He
reportedly has had H. flu and pan-sensitive staph growing from
sputum.
.
After re-warming, he has been noted to have LE>UE shaking
movements which are concerning for seizure activity in the
setting of possible anoxic brain injury. Neuro was consulted and
pt was loaded with Keppra. The patient is now transferred to
[**Hospital1 18**] for continuous EEG monitoring.
.
Currently unable to complete review of symptoms, as pt is
intubated and sedated. Medical records note that pt's wife
reported pt had L anterior chest pain radiating to his left arm
on the night prior to admission, but further details of this
history are unavailable at this time.

MEDICAL HISTORY: 1. Coronary artery disease, s/p STEMI in [**2146**] with stents to LAD

MEDICATION ON ADMISSION: aspirin 325
fondaparinux 2.5mg daily
capoten 6.25 tid
ceftazidime 2g q8h
HISS
keppra 1000mg [**Hospital1 **]
lipitor 80mg hs
metoprolol 25mg qid
plavix 75 mg daily
protonix 40mg IV daily
artificial tears
versed gtt
vancomycin 1250mg q12h

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 100.6, BP 131/93, HR 101, RR 24, O2 99% on 50% FiO2
Gen: WDWN middle aged male, unresponsive to verbal or painful
stimuli, no spontaneous movements. GCS 3.
HEENT: Normocephalic, superficial edema/evidence of trauma,
Sclera anicteric. PERRL, but variable baseline diameter.
Intermittent inferior deviation and rotational movements of both
eyes, mostly coordinated. Fundi could not be visualized. Corneal
reflex intact but sluggish, vestibular-ocular movements intact.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Lives at home with his wife. [**Name (NI) 1403**] as a graphic artist. Smokes
2ppd. 

### Response:
{'Paroxysmal ventricular tachycardia,Acute respiratory failure,Pneumonia, organism unspecified,Coma,Coronary atherosclerosis of native coronary artery,Subendocardial infarction, subsequent episode of care,Unspecified essential hypertension,Anemia, unspecified,Percutaneous transluminal coronary angioplasty status'}
