CHIEF COMPLAINT: Atrial Flutter

PRESENT ILLNESS: 74 y/oM with PMH of CAD s/p CABG (5 vessel bypass) in [**2100**], COPD
present to ED with new onset afib prior to initiating stress
test.  Pt said that for the past month he has noticed increasing
shortness of breath both at rest and exertion and his exercise
tolerance was greatly diminished.  He can hardly walk 1 block
when he used to be able to walk.   He also noticed some
worsening lower extremity edema that comes and goes over the
past 2-3 weeks.  Otherwise the patient denies palpitations, CP,
Lightheadedness, dizziness, syncope, orthopnea, PND.  Pt was
sent to the ED for further evaluation.
.
In the ED VS were 98.5 132 130/89 16 98%RA.  Given lopressor 5 x
3 with minimal response and then 15 IV dilt HR dropped to 70s
with afib/ flutter with BP in 60s.  Pt was given 2L IVF and then
started dopamine 5-> 10 -> 6.  Pressures stablized with
systolics in the 100's.  His respiratory status remained stable.
 He was given 1 amp calcium gluconate.  Troponin was negative.
Repeat CXR was difficult to interpret as to change in position.
At the time of transfer HR was in the 120s and on 100%NRB with
BP to 81/60 (dopamine of 4)
.
On review of systems, he denies any prior history of TIA, deep
venous thrombosis, pulmonary embolism, myalgias, joint pains,
cough, hemoptysis, black stools or red stools. He denies recent
fevers, chills or rigors. He denies exertional buttock or calf
pain. All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: + Dyslipidemia, + Hypertension
2. CARDIAC HISTORY:
- CAD s/p CABG in [**2100**] (He underwent a five vessel
coronary artery bypass graft without any complications,
including the left internal mammary artery to the left
anterior descending, saphenous vein graft to the posterior
descending and the RPL and a radial to the obtuse marginal
artery and ramus intermedius)
.
3. OTHER PAST MEDICAL HISTORY:
- s/p subdural bleed in setting traumatic fall [**2106**]
- epilepsy
- s/p CVA
- celiac disease
- Dupuytren's contracture
- homocystinuria
- macular degeneration
- OSA
- obesity
- prostate CA
- alcoholic steatosis

MEDICATION ON ADMISSION: - aggrenox - 25 mg-200 mg Cap, ER 2 tabs daily
- fenofibrate - 145 mg tab daily
- folic acid 1 tab [**Hospital1 **]
- lisinopril 20mg daily
- metoprolol succinate - 50 mg Tablet Extended Release daily
- phenobarbital 120mg QHS
- simvastatin - 80 mg Tablet daily
- ASA 325mg daily
- multivitamin daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On admission:
VS: afebrile  BP=117/84 (Dopamine of 3) HR: 135, RR: 18, O2 sat=
93% 6L
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: - No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Father: PNA

SOCIAL HISTORY: Retired, used to work in [**University/College **]. in Lives with wife in
[**Name (NI) **]
- Tobacco history: denies
- ETOH: history of heavy use > 20 drinks per week. Quit 15 days
ago
- Illicit drugs: denies
Atrial flutter,Acute on chronic systolic heart failure,Other iatrogenic hypotension,Mitral valve disorders,Aortocoronary bypass status,Obesity, unspecified,Celiac disease,Personal history of malignant neoplasm of prostate,Epilepsy, unspecified, without mention of intractable epilepsy,Chronic airway obstruction, not elsewhere classified,Other primary cardiomyopathies
Atrial flutter,Ac on chr syst hrt fail,Iatrogenc hypotnsion NEC,Mitral valve disorder,Aortocoronary bypass,Obesity NOS,Celiac disease,Hx-prostatic malignancy,Epilep NOS w/o intr epil,Chr airway obstruct NEC,Prim cardiomyopathy NEC
Admission Date:  [**2111-4-27**]              Discharge Date:   [**2111-5-1**]

Date of Birth:  [**2036-6-28**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Atrial Flutter

Major Surgical or Invasive Procedure:
Atrial ablation

History of Present Illness:
74 y/oM with PMH of CAD s/p CABG (5 vessel bypass) in [**2100**], COPD
present to ED with new onset afib prior to initiating stress
test.  Pt said that for the past month he has noticed increasing
shortness of breath both at rest and exertion and his exercise
tolerance was greatly diminished.  He can hardly walk 1 block
when he used to be able to walk.   He also noticed some
worsening lower extremity edema that comes and goes over the
past 2-3 weeks.  Otherwise the patient denies palpitations, CP,
Lightheadedness, dizziness, syncope, orthopnea, PND.  Pt was
sent to the ED for further evaluation.
.
In the ED VS were 98.5 132 130/89 16 98%RA.  Given lopressor 5 x
3 with minimal response and then 15 IV dilt HR dropped to 70s
with afib/ flutter with BP in 60s.  Pt was given 2L IVF and then
started dopamine 5-> 10 -> 6.  Pressures stablized with
systolics in the 100's.  His respiratory status remained stable.
 He was given 1 amp calcium gluconate.  Troponin was negative.
Repeat CXR was difficult to interpret as to change in position.
At the time of transfer HR was in the 120s and on 100%NRB with
BP to 81/60 (dopamine of 4)
.
On review of systems, he denies any prior history of TIA, deep
venous thrombosis, pulmonary embolism, myalgias, joint pains,
cough, hemoptysis, black stools or red stools. He denies recent
fevers, chills or rigors. He denies exertional buttock or calf
pain. All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.


Past Medical History:
1. CARDIAC RISK FACTORS: + Dyslipidemia, + Hypertension
2. CARDIAC HISTORY:
- CAD s/p CABG in [**2100**] (He underwent a five vessel
coronary artery bypass graft without any complications,
including the left internal mammary artery to the left
anterior descending, saphenous vein graft to the posterior
descending and the RPL and a radial to the obtuse marginal
artery and ramus intermedius)
.
3. OTHER PAST MEDICAL HISTORY:
- s/p subdural bleed in setting traumatic fall [**2106**]
- epilepsy
- s/p CVA
- celiac disease
- Dupuytren's contracture
- homocystinuria
- macular degeneration
- OSA
- obesity
- prostate CA
- alcoholic steatosis

Social History:
Retired, used to work in [**University/College **]. in Lives with wife in
[**Name (NI) **]
- Tobacco history: denies
- ETOH: history of heavy use > 20 drinks per week. Quit 15 days
ago
- Illicit drugs: denies

Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Father: PNA

Physical Exam:
On admission:
VS: afebrile  BP=117/84 (Dopamine of 3) HR: 135, RR: 18, O2 sat=
93% 6L
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

NECK: Supple with JVP of 15 cm, no LAD.
CARDIAC: PMI 5/6th intercostal space at mid-clavicular line,
palpable hyperdynamic heart. tachycardic, normal S1, S2. No
m/r/g. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. crackles bibasilar
extending a little higher up on the right, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Warm to touch, No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Radial 2+ DP 2+ PT 2+
Left: Carotid 2+ Radial 2+ DP 2+ PT 2+
NEURO: A&Ox3, CNII_XII intact, sensation intact throughout,
strength 5/5 in all extremities, finger to noes intact
bilaterally, gait not assessed.
.
On Discharge:

Pertinent Results:
CBC:
[**2111-4-27**] 02:30PM BLOOD WBC-7.3 RBC-4.38* Hgb-15.2 Hct-42.8
MCV-98 MCH-34.7* MCHC-35.5* RDW-12.4 Plt Ct-234
[**2111-4-29**] 06:18AM BLOOD WBC-7.8 RBC-4.28* Hgb-14.7 Hct-41.7
MCV-98 MCH-34.4* MCHC-35.3* RDW-12.4 Plt Ct-229
[**2111-5-1**] 06:30AM BLOOD WBC-8.4 RBC-4.24* Hgb-14.5 Hct-40.7
MCV-96 MCH-34.3* MCHC-35.7* RDW-12.2 Plt Ct-230
.
COAGS:
[**2111-4-29**] 06:18AM BLOOD PT-14.0* PTT-55.8* INR(PT)-1.2*
[**2111-4-30**] 05:18AM BLOOD PT-14.2* PTT-75.4* INR(PT)-1.2*
[**2111-5-1**] 06:30AM BLOOD PT-14.3* PTT-33.5 INR(PT)-1.2*
.
CMP:
[**2111-4-27**] 02:30PM BLOOD Glucose-90 UreaN-31* Creat-1.2 Na-140
K-4.9 Cl-104 HCO3-26 AnGap-15
[**2111-4-29**] 06:18AM BLOOD Glucose-126* UreaN-24* Creat-1.3* Na-138
K-4.4 Cl-103 HCO3-26 AnGap-13
[**2111-4-29**] 02:44PM BLOOD Glucose-119* UreaN-21* Creat-1.3* Na-136
K-4.2 Cl-98 HCO3-28 AnGap-14
[**2111-5-1**] 06:30AM BLOOD Glucose-111* UreaN-17 Creat-1.3* Na-135
K-4.2 Cl-99 HCO3-27 AnGap-13
[**2111-4-28**] 01:51AM BLOOD Calcium-8.9 Phos-4.0 Mg-1.9
[**2111-4-29**] 02:44PM BLOOD Calcium-9.6 Phos-3.5 Mg-2.0
[**2111-5-1**] 06:30AM BLOOD Calcium-9.3 Phos-3.3 Mg-1.9
.
CARDIAC ENZYMES:
[**2111-4-27**] 02:30PM BLOOD cTropnT-<0.01
[**2111-4-28**] 01:51AM BLOOD CK-MB-3 cTropnT-<0.01
.
#######################################################
MRSA SCREEN (Final [**2111-4-30**]):    No MRSA isolated.
#######################################################
IMAGING:

Brief Hospital Course:
74 y/oM with PMH of CAD s/p CABG (5 vessel bypass) in [**2100**], COPD
present to ED with new onset afib prior to initiating stress
test who became hypotensive in the setting of multiple IV nodal
agents.
.
# a-flutter: Pt was found to be in a-flutter when he arrived for
ETT in the outpatient setting.  Overnight her was ruled out and
troponins were less than 0.01 x2.  He was given lasix 20mg PO on
Day 1 and nodal agents were held because he would likely require
high doses that may compromise his BP.  A heparin drip was
started.  TTE and TEE were done and he was monitored on
telemetry.  {atient was cardioverted successfully on day 2 and
then had atrial flutter ablation on Hospital day 4.  He
tolerated the procedure well and post cath check showed no
complications.  He was doing well and was discahrged on Day 5 of
admission with follow up.
.
# Hypotension:  Occured in the setting of multiple IV nodal
agents.  He was initially placed on a dopamine drip in the ED,
but was quickly weaned off of the drip once he came to the CCU.
His BP meds were initially held and his BP remained stable.  His
lisinopril was restarted while in the CCU and then his
metoprolol was restarted on the day of discharge.  He had no
other episodes of hypotension.
.
# New oxygen requirement:  Pt was placed on NRB after
administration of 2L IVF, but no documented hypoxic period.  He
was placed on 6L NC once he arrived to the CCU and was satting
95%.  He was diuresed lasix 20mg PO on day 1.  Overnight his
oxygen requirement decreased and on Day 2 he was satting 98% on
Nasal cannula 3L. He continued to be diuresed and was on room
air by the end of hospital day 3.  He continued to be slightly
short of breath, but that should improve as his heart regains
strength.  He was discharged with no oxygen requirement.
.
# CAD: Patient has a history of CAD s/p CABG in [**2100**] and has
been doing well with no recurrence of symptoms.  He was last
seen by Dr. [**Last Name (STitle) **] in [**2110-11-27**].  His BB and ACE-I were
initially held in the setting of hypotension, but as his BP
stabilized they were added back one at a time.  He was continued
on his ASA 325mg PO daily during the course of his hospital
stay.
.
# HLD: Pt last lipid panel in [**2109**] showed Tchol 175, HDL 73, LDL
62.  Pt is doing well, but will lower simvastatin given
increased risk of statin induced myopathy at 80mg as well as
increased risk of rhabdomyolysis while on both a statin and
fibrate.
We Held fenofibrate - 145 mg tab daily as not part of the
formulary.  Decreased simvastatin - 40mg PO Daily given
increased risk of myopathy on 80mg PO Daily.  he will be
discharged on simvastatin 40mg PO daily.
.
INACTIVE ISSUES:
.
# epilepsy: This was not an active issue during his hospital
stay.  Pt is followed by neurology.  Has not had a seizure in
over 12-15 years.  We will continue his home medications at this
time.  Continued phenobarbital 120mg QHS.  Initially held
aggrenox - 25 mg-200 mg Cap, ER 2 tabs daily in the setting of a
heparin drip.
.
# s/p CVA:  Pt has no neurologic defecits.  Held aggrenox for
now given heparin drip and aspirin.

# celiac disease: Continued Gluten free diet.  Has been stable.
.
# OSA: Documented in the past, but refusing CPAP, pt may desat
overnight.
.
# prostate CA: This was not an active issue.  s/p prostatectomy
about 12 years ago. Has appointment with Dr. [**Last Name (STitle) 33427**] next week.
Remains impotent, is not concerned about this. Denies genital
discomfort or trouble with urination.
.
# alcoholic steatosis: LFT have trended down and patient is
currently not drinking.  Has not had a drink for 15 days.  Will
continue to be followed in the outpatient setting.
.
# CODE: Full (CONFRIMED)
.
# COMM:Pt (wife [**Name (NI) 8513**] , HCP: [**Telephone/Fax (1) 98075**])


Medications on Admission:
- aggrenox - 25 mg-200 mg Cap, ER 2 tabs daily
- fenofibrate - 145 mg tab daily
- folic acid 1 tab [**Hospital1 **]
- lisinopril 20mg daily
- metoprolol succinate - 50 mg Tablet Extended Release daily
- phenobarbital 120mg QHS
- simvastatin - 80 mg Tablet daily
- ASA 325mg daily
- multivitamin daily

Discharge Medications:
1. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. phenobarbital 60 mg Tablet Sig: Two (2) Tablet PO at bedtime.

7. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
8. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. fenofibrate  Oral


Discharge Disposition:
Home With Service

Facility:
Home [**Hospital **] Hospice & Community Services

Discharge Diagnosis:
Primary Diagnosis:
Atrial Flutter
Acute on chronic systolic congestive heart failure

Secondary Diagnosis:
coronary artery disease
prior alcohol abuse


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
You were admitted to the hospital with shortness of breath
caused partially by atrial flutter, or an abnormal heart rhythm.
 You underwent an electric shock, or cardioversion, to convert
the heart to a regular rhythm.  You then underwent an ablation
to keep the heart from going back into atrial flutter.  You will
need to be on a blood thinner called dabigatran for at least 4
weeks following this procedure.  It is very important that stop
drinking alcohol, as it can lead to progression of your heart
disease.

Please make the following changes to your medication regimen:
1. START dabigatran 150mg twice daily
2. Stop Aggrenox
3. Decrease simvastatin to 40 mg daily

Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes up
more than 3 lbs in 1 day or 6 pounds in 3 days.

Followup Instructions:
Department: SURGICAL SPECIALTIES
When: THURSDAY [**2111-6-4**] at 8:00 AM
With: [**Known firstname 275**] [**Last Name (NamePattern4) 276**], M.D. [**Telephone/Fax (1) 277**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: [**Last Name (un) 12214**] [**Doctor Last Name **] MED GRP
When: THURSDAY [**2111-5-28**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], MD [**Telephone/Fax (1) 5068**]
Building: [**Location (un) **] ([**Location (un) 86**], MA) [**Location (un) **]
Campus: OFF CAMPUS     Best Parking: On Street Parking

Department: SLEEP UNIT NEUROLOGY
When: MONDAY [**2111-5-25**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6855**], M.D. [**Telephone/Fax (1) 6856**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Name: [**Last Name (LF) **],[**First Name3 (LF) **] G.
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **]
Address: [**Location (un) **], [**Apartment Address(1) 6850**], [**Location (un) **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 3329**]
When: MONDAY [**2111-5-11**] at 10:15 AM
{'Atrial flutter,Acute on chronic systolic heart failure,Other iatrogenic hypotension,Mitral valve disorders,Aortocoronary bypass status,Obesity, unspecified,Celiac disease,Personal history of malignant neoplasm of prostate,Epilepsy, unspecified, without mention of intractable epilepsy,Chronic airway obstruction, not elsewhere classified,Other primary cardiomyopathies'}


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: Atrial Flutter

PRESENT ILLNESS: 74 y/oM with PMH of CAD s/p CABG (5 vessel bypass) in [**2100**], COPD
present to ED with new onset afib prior to initiating stress
test.  Pt said that for the past month he has noticed increasing
shortness of breath both at rest and exertion and his exercise
tolerance was greatly diminished.  He can hardly walk 1 block
when he used to be able to walk.   He also noticed some
worsening lower extremity edema that comes and goes over the
past 2-3 weeks.  Otherwise the patient denies palpitations, CP,
Lightheadedness, dizziness, syncope, orthopnea, PND.  Pt was
sent to the ED for further evaluation.
.
In the ED VS were 98.5 132 130/89 16 98%RA.  Given lopressor 5 x
3 with minimal response and then 15 IV dilt HR dropped to 70s
with afib/ flutter with BP in 60s.  Pt was given 2L IVF and then
started dopamine 5-> 10 -> 6.  Pressures stablized with
systolics in the 100's.  His respiratory status remained stable.
 He was given 1 amp calcium gluconate.  Troponin was negative.
Repeat CXR was difficult to interpret as to change in position.
At the time of transfer HR was in the 120s and on 100%NRB with
BP to 81/60 (dopamine of 4)
.
On review of systems, he denies any prior history of TIA, deep
venous thrombosis, pulmonary embolism, myalgias, joint pains,
cough, hemoptysis, black stools or red stools. He denies recent
fevers, chills or rigors. He denies exertional buttock or calf
pain. All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: + Dyslipidemia, + Hypertension
2. CARDIAC HISTORY:
- CAD s/p CABG in [**2100**] (He underwent a five vessel
coronary artery bypass graft without any complications,
including the left internal mammary artery to the left
anterior descending, saphenous vein graft to the posterior
descending and the RPL and a radial to the obtuse marginal
artery and ramus intermedius)
.
3. OTHER PAST MEDICAL HISTORY:
- s/p subdural bleed in setting traumatic fall [**2106**]
- epilepsy
- s/p CVA
- celiac disease
- Dupuytren's contracture
- homocystinuria
- macular degeneration
- OSA
- obesity
- prostate CA
- alcoholic steatosis

MEDICATION ON ADMISSION: - aggrenox - 25 mg-200 mg Cap, ER 2 tabs daily
- fenofibrate - 145 mg tab daily
- folic acid 1 tab [**Hospital1 **]
- lisinopril 20mg daily
- metoprolol succinate - 50 mg Tablet Extended Release daily
- phenobarbital 120mg QHS
- simvastatin - 80 mg Tablet daily
- ASA 325mg daily
- multivitamin daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On admission:
VS: afebrile  BP=117/84 (Dopamine of 3) HR: 135, RR: 18, O2 sat=
93% 6L
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: - No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Father: PNA

SOCIAL HISTORY: Retired, used to work in [**University/College **]. in Lives with wife in
[**Name (NI) **]
- Tobacco history: denies
- ETOH: history of heavy use > 20 drinks per week. Quit 15 days
ago
- Illicit drugs: denies 

### Response:
{'Atrial flutter,Acute on chronic systolic heart failure,Other iatrogenic hypotension,Mitral valve disorders,Aortocoronary bypass status,Obesity, unspecified,Celiac disease,Personal history of malignant neoplasm of prostate,Epilepsy, unspecified, without mention of intractable epilepsy,Chronic airway obstruction, not elsewhere classified,Other primary cardiomyopathies'}
