CHIEF COMPLAINT: left arm pain and atrial flutter

PRESENT ILLNESS: [**Age over 90 **] y/o lady with h/o aflutter presented to OSH with cold left
arm. She was found to be aflutter with RVR and was started on
dilt drip and heparin drip. She was transfered to [**Hospital1 18**] for
surgical eval. Patient underwent left brachial thrombectomy by
vascular surgery. During surgery her HR was in 60-70s per
Anesthesia however rebounded to 120s in PACU. She was given 15
mg IV dilt bolus and was started on a dilt drip in PACU. She was
transferd to the floor for further managment.
.
On arrival to the floor patient was found to be unresponsive to
verbal stimuli. She will occasionally open her eyes. She did not
have a gag reflex and had diffuse rhonchi. She was triggered.
She received 10 of IV morphine (total) and some dilaudid in
PACU. ABG was 7.24/58/236 c/w respiratory acidosis. She received
narcan IV 0.5 mg once and her mental status and gag reflex
improved. She was complaining of left upper extremity pain.
.
Patient was recently seen at OSH with a possible eye infection
and might have left AMA. The records are not available
currently. Patient has memory confusion problems at baseline,
however could ambulate and dress herself at home.
.
Patient is a poor historian and unable to give a good history.

MEDICAL HISTORY: CAD
H/o aflutter (per son, at least once ten years ago and another
episode in setting of ?eye infection)
Depression
Dementia
Trigeminal Neuralgia
Left eye infection
?S/p left eye surgery

MEDICATION ON ADMISSION: Aspirin 325 mg daily
Metoprolol 50 mg [**Hospital1 **]
Digoxin 0.125 mg daily
Cymbalta 40 mg daily
Gabapentin 300 mg [**Hospital1 **]
Erythromycin eye ointment

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On discharge:
VS: BP 148/64 HR 84 RR 16 O2 sat 95% RA
GENERAL: in NAD, difficult to understand speech, A and O x 1
HEENT: MMM, oropharynx clear
NECK: supple, no JVD
CARDIAC: S1S2 RRR
LUNGS: CTA bilaterally
ABDOMEN: Soft, NTND.
EXTREMITIES: LUE swollen, radial pulse 2+ on left, dressed with
erythema/ecchyosis over anterior aspect of LUE; 2+ pulses
throughout
NEURO: CN II-XII intact, moves all four extremites spontaneously

FAMILY HISTORY: N/C

SOCIAL HISTORY: Lives with son and daughter-in-law. Unattended during day when
family at work although a family member will usually check in at
lunchtime. H/o smoking, quit in her 60s. No EtOH or drug use.
Arterial embolism and thrombosis of upper extremity,Acute kidney failure with lesion of tubular necrosis,Atrial flutter,Nontraumatic compartment syndrome of upper extremity,Acidosis,Rhabdomyolysis,Other specified complications of procedures not elsewhere classified,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Altered mental status,Other specified analgesics and antipyretics causing adverse effects in therapeutic use,Nonspecific abnormal toxicological findings,Cardiotonic glycosides and drugs of similar action causing adverse effects in therapeutic use,Oliguria and anuria,Hypocalcemia,Malnutrition of mild degree,Senile dementia, uncomplicated,Conjunctivitis, unspecified,Coronary atherosclerosis of native coronary artery,Dysphagia, oropharyngeal phase,Trigeminal neuralgia,Depressive disorder, not elsewhere classified,Personal history of tobacco use
Upper extremity embolism,Ac kidny fail, tubr necr,Atrial flutter,Nontraum comp syn-up ext,Acidosis,Rhabdomyolysis,Oth spcf cmplc procd NEC,Abn react-surg proc NEC,Altered mental status,Adv eff analgesics NEC,Abn toxicologic finding,Adv eff cardiotonics,Oliguria & anuria,Hypocalcemia,Malnutrition mild degree,Senile dementia uncomp,Conjunctivitis NOS,Crnry athrscl natve vssl,Dysphagia, oropharyngeal,Trigeminal neuralgia,Depressive disorder NEC,History of tobacco use
Admission Date:  [**2161-8-11**]              Discharge Date:   [**2161-8-19**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
left arm pain and atrial flutter

Major Surgical or Invasive Procedure:
[**2161-8-11**] Left brachial thromboembolectomy
[**2161-8-11**] Right PICC placement
[**2161-8-12**] Left forearm fasciotomy

History of Present Illness:
[**Age over 90 **] y/o lady with h/o aflutter presented to OSH with cold left
arm. She was found to be aflutter with RVR and was started on
dilt drip and heparin drip. She was transfered to [**Hospital1 18**] for
surgical eval. Patient underwent left brachial thrombectomy by
vascular surgery. During surgery her HR was in 60-70s per
Anesthesia however rebounded to 120s in PACU. She was given 15
mg IV dilt bolus and was started on a dilt drip in PACU. She was
transferd to the floor for further managment.
.
On arrival to the floor patient was found to be unresponsive to
verbal stimuli. She will occasionally open her eyes. She did not
have a gag reflex and had diffuse rhonchi. She was triggered.
She received 10 of IV morphine (total) and some dilaudid in
PACU. ABG was 7.24/58/236 c/w respiratory acidosis. She received
narcan IV 0.5 mg once and her mental status and gag reflex
improved. She was complaining of left upper extremity pain.
.
Patient was recently seen at OSH with a possible eye infection
and might have left AMA. The records are not available
currently. Patient has memory confusion problems at baseline,
however could ambulate and dress herself at home.
.
Patient is a poor historian and unable to give a good history.

Past Medical History:
CAD
H/o aflutter (per son, at least once ten years ago and another
episode in setting of ?eye infection)
Depression
Dementia
Trigeminal Neuralgia
Left eye infection
?S/p left eye surgery

Social History:
Lives with son and daughter-in-law. Unattended during day when
family at work although a family member will usually check in at
lunchtime. H/o smoking, quit in her 60s. No EtOH or drug use.

Family History:
N/C

Physical Exam:
On discharge:
VS: BP 148/64 HR 84 RR 16 O2 sat 95% RA
GENERAL: in NAD, difficult to understand speech, A and O x 1
HEENT: MMM, oropharynx clear
NECK: supple, no JVD
CARDIAC: S1S2 RRR
LUNGS: CTA bilaterally
ABDOMEN: Soft, NTND.
EXTREMITIES: LUE swollen, radial pulse 2+ on left, dressed with
erythema/ecchyosis over anterior aspect of LUE; 2+ pulses
throughout
NEURO: CN II-XII intact, moves all four extremites spontaneously



Pertinent Results:
[**2161-8-19**] WBC-10.2 RBC-2.85* Hgb-8.9* Hct-26.4* MCV-93 MCH-31.3
MCHC-33.7 RDW-16.7* Plt Ct-309
[**2161-8-19**] Plt Ct-309
[**2161-8-19**] PT-24.7* PTT-31.2 INR(PT)-2.4*
[**2161-8-19**] Glucose-138* UreaN-86* Creat-3.3* Na-140 K-3.7 Cl-101
HCO3-25 AnGap-18
[**2161-8-12**] CK(CPK)-[**Numeric Identifier 83288**]*
[**2161-8-17**] CK(CPK)-1874*
[**2161-8-19**] Calcium-9.8 Phos-3.6 Mg-2.3 Iron-PND

TTE - Mild calcific aortic stenosis. Normal global biventricular
systolic function. Mild pulmonary hypertension.


Brief Hospital Course:
[**Age over 90 **] yo woman with history of dementia, coronary artery disease,
paroxysmal atrial flutter who was transferred to [**Hospital1 18**] for left
upper extremity thrombectomy and atrial flutter with rapid
ventricular response complicated by worsening renal failure,
rhabdomyolysis status post left upper extremity fasciotomy.

# Left brachial thrombus complicated by compartment syndrome,
Rhabdomyolysis
- The patient was found to have cool, pulseless left arm
extremity and taken to the operating room by Vascular Surgery on
[**2161-8-11**] for left brachial thromboembolectomy.  The patient
developed decreasing arm sensation and strength over [**2161-8-12**] with
development of compartment syndrome, likely due to reperfusion
injury, and was taken to the operating room by Plastics for
fasciotomy.  Following the fasciotomy, the patient was followed
by plastics for wound management, and received heparin for
anti-coagulation.  The patient was transitioned to oral
anti-coagulation, and INR at discharge was 2.4 on warfarin 2 mg
daily.  The patient will be followed by the hand clinic at
rehab.

# Atrial flutter
- The patient has a histroy of atrial flutter and was found to
be in rapid ventricular response prior to transfer to [**Hospital1 18**] and
was started on a diltiazem drip.  The rate improved in the
operating room on sedation; following transfer to the cardiac
unit post-operatively, the patient again had rapid ventricular
response.  The patient was transitioned back to home metoprolol
as rate controlled off diltiazem drip.  The patient's home
digoxin was discontinued as digoxin level rose to 2.8 in setting
of acute renal failure, and decreased to 2.4 after
discontinuation of digoxin.  Of note, digoxin reportedly was
started only 1 month ago and may have been supratherapeutic as
patient had described vision changes although dig level only 0.7
on admit.  The patient's rate remained well controlled following
transfer to the general medical floor on home metoprolol
regimen.

# Acute renal failure
- The patient's baseline was unknown but was 1.2 on admission.
The creatinine continued to rise with declining urine output
progressing to anuria in setting of difficulty obtaining
intravenous access and rhabdomyolysis from the compartment
syndrome.  The urine sediment consistent with ATN.  Duloxetine,
gabapentin, and digoxin was discontinued, and not restarted at
time of discharge.  Given rising creatinine despite initiation
of aggressive intravenous fluids once PICC was placed,
hemodialysis was considered and family amenable.  However, the
patient was responsive to diuresis with diuril and high dose
lasix with improvement in urine output that was greater than 100
cc/hour.  Following transfer from the ICU, intravenous fluids
and diuresis was discontinued, the patient was started on a
dysphagia diet, the creatinine continued to improve with
adequate urine output.  Creatinine at time of discharge was 3.3
and down-trending from a peak of 4.8.

# Rhabdomyolysis
- The patient reportedly was found in bed with left arm pain per
her son although circumstances leading up to this unclear.
Creatinine kinase was 1405 on admission but increased rapidly as
initially unable to obtain vascular access. Interventional
radiology-guided PICC was placed successfully, and the patient
was hydrated aggressively first with normal saline, then
switched to normal bicarbonate.  Peak creatinine kinase was
[**Numeric Identifier 83288**] on evening of [**2161-8-12**] and was downtrending at 1874 on
[**2161-8-17**].

# Hypocalcemia
- Patient had low calcium levels in the setting of
rhabdomyolysis, and calcium was repleted throughout the hospital
course.

# CAD Native Vessel
- The patient has an unspecified history of coronary artery
disease per her son.  It was felt that the elevated cardiac
enzymes were difficult to interpret in the setting of worsening
renal failure, and acute coronary syndrome was considered
unlikely.  The patient may have had some demand ischemia in the
setting of atrial flutter with rapid ventricular response.
Cardiac markers were decreasing during hospitalization,
metoprolol, aspirin, and heparin/coumadin were given, and
transthoracic echo showed no wall motion abnormalities with
preserved biventricular systolic function, with an estimated
ejection fraction of 55%.

# Delerium, Dementia - Senile
- The patientt has dementia at baseline, and there were no acute
findings on CT head.  The patient was thought to be somnolent in
setting of OR sedation with some improvement after receving
Narcan.  Again noted to be somnolent after second OR procedure
although improved back to baseline without Narcan and with
continued improvement of above medical problems.  The TSH was
normal.

# Conjunctivitis
- The patient had a purported eye infection and was continued on
the antibiotic ointment used prior to transfer.

# Mild Malnutrition
- Following nasogastric tube removal, a speech and swallow
evaluation 2 days prior to discharge cleared the patient for a
dysphagia diet with close one to one supervision.  The patient
was taking PO at discharge.

Medications on Admission:
Aspirin 325 mg daily
Metoprolol 50 mg [**Hospital1 **]
Digoxin 0.125 mg daily
Cymbalta 40 mg daily
Gabapentin 300 mg [**Hospital1 **]
Erythromycin eye ointment

Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Erythromycin 5 mg/g Ointment Sig: One (1)  Ophthalmic QID (4
times a day).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).


Discharge Disposition:
Extended Care

Facility:
Sea View Retreat

Discharge Diagnosis:
Primary Diagnoses:
left brachial thrombus s/p thrombectomy
compartment syndrome s/p fasciotomy
a. flutter with RVR
rhabdomyolysis
acute renal failure

Secondary Diagnoses:
CAD
H/o aflutter (per son, at least once ten years ago and another
episode in setting of ?eye infection)
Depression
Dementia
Trigeminal Neuralgia
Left eye infection


Discharge Condition:
stable and improved


Discharge Instructions:
You were admitted to the hospital for left arm pain.  A blood
clot was found in your arm, and you had surgery to remove the
clot.  During the recovery process, your arm developed high
pressures, and you had to have surgery to release that pressure.
 At this time, your kidney function declined, and you needed IV
fluids and medication.  You stayed in the ICU for a short amount
of time, and then you were transferred to the general medicine
floor.  There, you continued to improve, and you were discharged
on [**2161-8-19**] to an extended care facility for continued care.

You will follow up with the hand clinic, see appointment below.
Dr. [**Last Name (STitle) 8448**], your regular doctor, will see you in the rehab
center.
Please have the staff at the rehab center call Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 8448**] at [**Telephone/Fax (1) 83289**] to set up an appointment.

You were discharged on a new medication, coumadin, and your
cymbalta and neurontin were discontinued when you left the
hospital.

Please call or have your caretakers call if you develop left arm
pain/numbness/weakness or your arm becomes cold, fevers or
chills, or any other concerning medical symptoms.


Followup Instructions:
Please have the staff at the rehab center call Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 8448**] at [**Telephone/Fax (1) 83289**] to set up an appointment.

Dr.[**Name (NI) 27488**] appointment:
Specialty: Plastic Surgery Clinic

Date and time: [**8-28**] at 1pm

Location: [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **]

Phone number: [**Telephone/Fax (1) 4652**]

Special instructions if applicable:
{'Arterial embolism and thrombosis of upper extremity,Acute kidney failure with lesion of tubular necrosis,Atrial flutter,Nontraumatic compartment syndrome of upper extremity,Acidosis,Rhabdomyolysis,Other specified complications of procedures not elsewhere classified,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Altered mental status,Other specified analgesics and antipyretics causing adverse effects in therapeutic use,Nonspecific abnormal toxicological findings,Cardiotonic glycosides and drugs of similar action causing adverse effects in therapeutic use,Oliguria and anuria,Hypocalcemia,Malnutrition of mild degree,Senile dementia, uncomplicated,Conjunctivitis, unspecified,Coronary atherosclerosis of native coronary artery,Dysphagia, oropharyngeal phase,Trigeminal neuralgia,Depressive disorder, not elsewhere classified,Personal history of tobacco use'}


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: left arm pain and atrial flutter

PRESENT ILLNESS: [**Age over 90 **] y/o lady with h/o aflutter presented to OSH with cold left
arm. She was found to be aflutter with RVR and was started on
dilt drip and heparin drip. She was transfered to [**Hospital1 18**] for
surgical eval. Patient underwent left brachial thrombectomy by
vascular surgery. During surgery her HR was in 60-70s per
Anesthesia however rebounded to 120s in PACU. She was given 15
mg IV dilt bolus and was started on a dilt drip in PACU. She was
transferd to the floor for further managment.
.
On arrival to the floor patient was found to be unresponsive to
verbal stimuli. She will occasionally open her eyes. She did not
have a gag reflex and had diffuse rhonchi. She was triggered.
She received 10 of IV morphine (total) and some dilaudid in
PACU. ABG was 7.24/58/236 c/w respiratory acidosis. She received
narcan IV 0.5 mg once and her mental status and gag reflex
improved. She was complaining of left upper extremity pain.
.
Patient was recently seen at OSH with a possible eye infection
and might have left AMA. The records are not available
currently. Patient has memory confusion problems at baseline,
however could ambulate and dress herself at home.
.
Patient is a poor historian and unable to give a good history.

MEDICAL HISTORY: CAD
H/o aflutter (per son, at least once ten years ago and another
episode in setting of ?eye infection)
Depression
Dementia
Trigeminal Neuralgia
Left eye infection
?S/p left eye surgery

MEDICATION ON ADMISSION: Aspirin 325 mg daily
Metoprolol 50 mg [**Hospital1 **]
Digoxin 0.125 mg daily
Cymbalta 40 mg daily
Gabapentin 300 mg [**Hospital1 **]
Erythromycin eye ointment

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On discharge:
VS: BP 148/64 HR 84 RR 16 O2 sat 95% RA
GENERAL: in NAD, difficult to understand speech, A and O x 1
HEENT: MMM, oropharynx clear
NECK: supple, no JVD
CARDIAC: S1S2 RRR
LUNGS: CTA bilaterally
ABDOMEN: Soft, NTND.
EXTREMITIES: LUE swollen, radial pulse 2+ on left, dressed with
erythema/ecchyosis over anterior aspect of LUE; 2+ pulses
throughout
NEURO: CN II-XII intact, moves all four extremites spontaneously

FAMILY HISTORY: N/C

SOCIAL HISTORY: Lives with son and daughter-in-law. Unattended during day when
family at work although a family member will usually check in at
lunchtime. H/o smoking, quit in her 60s. No EtOH or drug use. 

### Response:
{'Arterial embolism and thrombosis of upper extremity,Acute kidney failure with lesion of tubular necrosis,Atrial flutter,Nontraumatic compartment syndrome of upper extremity,Acidosis,Rhabdomyolysis,Other specified complications of procedures not elsewhere classified,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Altered mental status,Other specified analgesics and antipyretics causing adverse effects in therapeutic use,Nonspecific abnormal toxicological findings,Cardiotonic glycosides and drugs of similar action causing adverse effects in therapeutic use,Oliguria and anuria,Hypocalcemia,Malnutrition of mild degree,Senile dementia, uncomplicated,Conjunctivitis, unspecified,Coronary atherosclerosis of native coronary artery,Dysphagia, oropharyngeal phase,Trigeminal neuralgia,Depressive disorder, not elsewhere classified,Personal history of tobacco use'}
