CHIEF COMPLAINT: tachycardia

PRESENT ILLNESS: 67 F with EtOH cirrhosis and ongoing EtOH abuse, previous
history of presumed alcoholic cardiomyopathy (EF as low as 30%,
most recently normalized LVEF), single previous episode of Afib,
history of breast cancer, admit to MICU for Afib with RVR and
concern for withdrawal.
.
Patient seen in liver clinic today with concerns about her
alcohol use and increased abdominal bloating and fullness.
Incidentally noted to be in Afib with HR to 130.  Sent to ED,
where HR noted to be as high as 180.  Received 15 IV dilt
followed by 25 IV dilt, then placed on dilt gtt.  SBPs in 130s.
Also received valium 15 mg for concern of EtOH withdrawal.  EtOH
level 130.  CT head done due to multiple recent falls.  In ED,
patient also had episode of transient desaturation.  Heparin gtt
started and D.dimer sent.  ED vitals 98.2, HR 171, BP 157/111,
R20, 96% on 4L.  eventually down to 2L and satting high 90s;
later with desat sown to 80s per report (notes with increasing
O2 requirement - 94% on 6L).
.
Patient has had a long standing history of alcoholism with
multiple attempts at detox. Last sober [**2133-3-21**]. Last drink
last night. Drinking a fifth vodka daily for the last several
weeks.  Attempts to detox herself; when she does this, she often
has episodes of bilious emesis and tremors. No seizures. Denies
fevers, chills, shortness of breath, chest pain, palpitations,
hematochezia, melena. + bilateral ankle swelling. Has not
noticed weight gain.  Admits to not taking her medications over
the past several days.

MEDICAL HISTORY: - EtOH cirrhosis.  Follows with Dr. [**Last Name (STitle) 497**].  No varices on EGD
last year.  Normal INR.
- EtOH abuse.  As per HPI.
- Breast cancer, stage IC.  Follows with Dr. [**Last Name (STitle) **].
Diagnosed [**2130**].  No past chemotherapy/anthracyclines.  s/p
lumpectomy and XRT and currently on arimidex.
- Cardiomyopathy in past, presumed due to EtOH.  Most recent (>1
year ago) EF 60% with borderline dilation.
- Single known episode of Afib in [**2130**], seen on holter monitor.
Briefly on coumadin, but difficulty with controlling INR.
Preumably in sinus since that time.
- HTN
- Osteoarthritis

MEDICATION ON ADMISSION: ARIMIDEX - 1MG Tablet - TAKE ONE PILL BY MOUTH EACH DAY
ATENOLOL -  50 mg - daily (patient unsure of dose - ?20 daily)
ATORVASTATIN - Dosage uncertain
BUPROPION [WELLBUTRIN SR] -   150 mg daily
ESCITALOPRAM [LEXAPRO] -   20 mg daily
ESOMEPRAZOLE MAGNESIUM [NEXIUM] - 40 mg daily
QUETIAPINE [SEROQUEL] -- 150 mg at bedtime
QUINAPRIL -  Dosage uncertain

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T 97.6F BP 115/71 HR 106 RR 20 O2Sat95%RA
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: Irregularly irregular, no M/G/R
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: A&O x 3, alert and appropriate. No asterixis.
SKIN: No jaundice, cyanosis, or gross dermatitis. Scattered
ecchymoses
============================
Physical exam not significantly changed at time of dicharge
except for HR which was in 70-80 range

FAMILY HISTORY: uterine ca, no bleeding d/o

SOCIAL HISTORY: Lives alone.  Good relationship with ex husband and adult
children.  EtOH use as above.  Denies methanol/antifreeze/other
alcohol ingestions.  Denies drug use and smoking.
Atrial fibrillation,Alcohol withdrawal,Urinary tract infection, site not specified,Alcoholic cirrhosis of liver,Other and unspecified alcohol dependence, continuous,Personal history of malignant neoplasm of breast,Other primary cardiomyopathies,Unspecified essential hypertension
Atrial fibrillation,Alcohol withdrawal,Urin tract infection NOS,Alcohol cirrhosis liver,Alcoh dep NEC/NOS-contin,Hx of breast malignancy,Prim cardiomyopathy NEC,Hypertension NOS
Admission Date:  [**2133-12-11**]              Discharge Date:   [**2133-12-15**]

Date of Birth:  [**2066-7-7**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 898**]
Chief Complaint:
tachycardia

Major Surgical or Invasive Procedure:
none

History of Present Illness:
67 F with EtOH cirrhosis and ongoing EtOH abuse, previous
history of presumed alcoholic cardiomyopathy (EF as low as 30%,
most recently normalized LVEF), single previous episode of Afib,
history of breast cancer, admit to MICU for Afib with RVR and
concern for withdrawal.
.
Patient seen in liver clinic today with concerns about her
alcohol use and increased abdominal bloating and fullness.
Incidentally noted to be in Afib with HR to 130.  Sent to ED,
where HR noted to be as high as 180.  Received 15 IV dilt
followed by 25 IV dilt, then placed on dilt gtt.  SBPs in 130s.
Also received valium 15 mg for concern of EtOH withdrawal.  EtOH
level 130.  CT head done due to multiple recent falls.  In ED,
patient also had episode of transient desaturation.  Heparin gtt
started and D.dimer sent.  ED vitals 98.2, HR 171, BP 157/111,
R20, 96% on 4L.  eventually down to 2L and satting high 90s;
later with desat sown to 80s per report (notes with increasing
O2 requirement - 94% on 6L).
.
Patient has had a long standing history of alcoholism with
multiple attempts at detox. Last sober [**2133-3-21**]. Last drink
last night. Drinking a fifth vodka daily for the last several
weeks.  Attempts to detox herself; when she does this, she often
has episodes of bilious emesis and tremors. No seizures. Denies
fevers, chills, shortness of breath, chest pain, palpitations,
hematochezia, melena. + bilateral ankle swelling. Has not
noticed weight gain.  Admits to not taking her medications over
the past several days.

Past Medical History:
- EtOH cirrhosis.  Follows with Dr. [**Last Name (STitle) 497**].  No varices on EGD
last year.  Normal INR.
- EtOH abuse.  As per HPI.
- Breast cancer, stage IC.  Follows with Dr. [**Last Name (STitle) **].
Diagnosed [**2130**].  No past chemotherapy/anthracyclines.  s/p
lumpectomy and XRT and currently on arimidex.
- Cardiomyopathy in past, presumed due to EtOH.  Most recent (>1
year ago) EF 60% with borderline dilation.
- Single known episode of Afib in [**2130**], seen on holter monitor.
Briefly on coumadin, but difficulty with controlling INR.
Preumably in sinus since that time.
- HTN
- Osteoarthritis


Social History:
Lives alone.  Good relationship with ex husband and adult
children.  EtOH use as above.  Denies methanol/antifreeze/other
alcohol ingestions.  Denies drug use and smoking.

Family History:
uterine ca, no bleeding d/o

Physical Exam:
Vitals: T 97.6F BP 115/71 HR 106 RR 20 O2Sat95%RA
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: Irregularly irregular, no M/G/R
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: A&O x 3, alert and appropriate. No asterixis.
SKIN: No jaundice, cyanosis, or gross dermatitis. Scattered
ecchymoses
============================
Physical exam not significantly changed at time of dicharge
except for HR which was in 70-80 range


Pertinent Results:
CXR:  cardiomegaly, no significant pulmonary edema or
infiltrate.
.
CT head: no bleed or mass effect.
.
Abd ultrasound: The liver appears heterogeneous and demonstrates
increased echogenicity and nodular contour consistent with
patient's known history of cirrhosis. No definite focal lesion
is identified; however, this is a limited study. No intrahepatic
biliary dilatation is noted. The common bile duct could not be
evaluated. The patient is status post cholecystectomy. The main
portal vein is patent with
appropriate hepatopetal flow. The spleen is within normal limits
and measures 9.4 cm. No ascites is seen.

.
TTE [**9-/2132**]: The left atrium is mildly dilated. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
top normal/borderline dilated. Regional left ventricular wall
motion is normal. Overall left ventricular systolic function is
normal (LVEF 60%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
[**2133-12-11**] 09:30AM BLOOD WBC-6.1 RBC-4.26 Hgb-14.3 Hct-43.2
MCV-102* MCH-33.6* MCHC-33.1 RDW-14.6 Plt Ct-134*#
[**2133-12-12**] 05:21PM BLOOD WBC-4.7 RBC-3.41* Hgb-12.2 Hct-35.2*
MCV-103* MCH-35.8* MCHC-34.6 RDW-15.0 Plt Ct-106*
[**2133-12-13**] 05:15AM BLOOD WBC-4.1 RBC-3.27* Hgb-11.6* Hct-34.5*
MCV-105* MCH-35.6* MCHC-33.8 RDW-14.7 Plt Ct-108*
[**2133-12-14**] 04:24AM BLOOD WBC-4.1 RBC-3.22* Hgb-11.3* Hct-34.3*
MCV-106* MCH-35.2* MCHC-33.0 RDW-14.7 Plt Ct-110*
[**2133-12-15**] 06:25AM BLOOD WBC-4.8 RBC-3.22* Hgb-11.6* Hct-33.8*
MCV-105* MCH-36.0* MCHC-34.3 RDW-15.0 Plt Ct-120*
[**2133-12-11**] 09:30AM BLOOD Neuts-79.9* Lymphs-13.2* Monos-5.5
Eos-0.8 Baso-0.6
[**2133-12-15**] 06:25AM BLOOD PT-12.8 PTT-36.6* INR(PT)-1.1
[**2133-12-15**] 06:25AM BLOOD Glucose-107* UreaN-7 Creat-0.8 Na-142
K-4.1 Cl-107 HCO3-28 AnGap-11
[**2133-12-15**] 06:25AM BLOOD Calcium-9.1 Phos-4.2 Mg-1.6
[**2133-12-12**] 03:27AM BLOOD VitB12-492 Folate-GREATER TH
[**2133-12-11**] 09:30AM BLOOD TSH-2.1

Brief Hospital Course:
In summary, Ms. [**Known lastname 11049**] is a 67 year old female with alcohol
cirrhosis, still consuming alcohol who presents with Afib with
RVR.
.
Afib with RVR.  Patient presented with A. fib with HR in the
180s, though hemodynamially stable.  Initially put on an esmolol
drip for rate control but then transitioned to oral atenolol.
She was anticoagulated with heparin for a. fib, but given her
ongoing alcohol abuse, falls risk, and history of
non-compliance, decision no to anticoagulate her with coumadin
was made.  Trigger for A. fib was thought to be alcohol
ingestion.  LENIs were negative and patient did not appear
hypovolemic on admission.

EtOH withdrawal.  Long history of alcohol abuse.  Patient had
moderate valium requirements for alcohol withdrawal in MICU.
She was evaluated by SW.

Depression.  She was continued on lexapro, wellbutrin, seroquel.
.
Cirrhosis/hepatitis.  Patient has alcoholic cirrhosis, still
drinking.  No evidence of decompensated cirrhosis.
.
UTI.  Patient treated with three days of Cipro for uncomplicated
UTI.
.
# Anemia/thrombocytopenia.  Likely EtOH and liver disease
related.
- folate, B12 normal
- trend  hct
.
# Anion gap metabolic acidosis.  Initial AG 25 and bicarb 19;
delta delta favoring both both metabolic acidosis and metabolic
alkalosis.  [**Month (only) 116**] have alkalosis due to dehydration. Lactate 2.6
(though liver failure patient), now <2.  Also had ketones in
urine, resolved.  No osmolar gap.  Likely some
alcoholic/starvation ketosis.  Now resolved.


Medications on Admission:
ARIMIDEX - 1MG Tablet - TAKE ONE PILL BY MOUTH EACH DAY
ATENOLOL -  50 mg - daily (patient unsure of dose - ?20 daily)
ATORVASTATIN - Dosage uncertain
BUPROPION [WELLBUTRIN SR] -   150 mg daily
ESCITALOPRAM [LEXAPRO] -   20 mg daily
ESOMEPRAZOLE MAGNESIUM [NEXIUM] - 40 mg daily
QUETIAPINE [SEROQUEL] -- 150 mg at bedtime
QUINAPRIL -  Dosage uncertain

Discharge Medications:
1. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily ().
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QAM (once a day (in the morning)).
4. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Quetiapine 100 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime)
as needed for insomnia.
6. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Atenolol 50 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily).
Disp:*75 Tablet(s)* Refills:*0*
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

11. CALCIUM 500+D 500 (1,250)-400 mg-unit Tablet, Chewable Oral


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
Atrial fibrillation with rapid ventricular rate

Secondary:
- Alcoholic cirrhosis
- Alcohol abuse
- Breast cancer
- History of cardiomyopathy
- Hypertension
- Osteoarthritis


Discharge Condition:
Afebrile, vital signs stable


Discharge Instructions:
You were admitted for a fast heart rhythm (atrial fibrillation).
 You have had this heart rhythm in the past.  We increased your
dose of atenolol to control your heart rate.  You should discuss
using a blood thinner with your primary care doctor to reduce
your risk of stroke in the future.

Please contact a physician or report to an emergency department
if you experience fevers, chills, chest pain, shortness of
breath, palpitations, or any other concerning symptoms.

Please take your medications as prescribed.
- Your atenolol was increased to 125 mg daily.
- You were started on aspirin 325 mg daily.
- Your quinapril was discontinued for blood pressure so that we
could increase the atenolol.

Followup Instructions:
You have an appointmet on [**12-29**] at 10:30am with Dr. [**Last Name (STitle) **].
Her phone number is [**Telephone/Fax (1) 3329**].

Please call your cardiologist to make an appointment as you have
not seen him for quite some time.

Previously scheduled appointments:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2134-2-19**] 11:00

[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4286**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2134-3-10**]
11:20



Completed by:[**2134-1-25**]
{'Atrial fibrillation,Alcohol withdrawal,Urinary tract infection, site not specified,Alcoholic cirrhosis of liver,Other and unspecified alcohol dependence, continuous,Personal history of malignant neoplasm of breast,Other primary cardiomyopathies,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: tachycardia

PRESENT ILLNESS: 67 F with EtOH cirrhosis and ongoing EtOH abuse, previous
history of presumed alcoholic cardiomyopathy (EF as low as 30%,
most recently normalized LVEF), single previous episode of Afib,
history of breast cancer, admit to MICU for Afib with RVR and
concern for withdrawal.
.
Patient seen in liver clinic today with concerns about her
alcohol use and increased abdominal bloating and fullness.
Incidentally noted to be in Afib with HR to 130.  Sent to ED,
where HR noted to be as high as 180.  Received 15 IV dilt
followed by 25 IV dilt, then placed on dilt gtt.  SBPs in 130s.
Also received valium 15 mg for concern of EtOH withdrawal.  EtOH
level 130.  CT head done due to multiple recent falls.  In ED,
patient also had episode of transient desaturation.  Heparin gtt
started and D.dimer sent.  ED vitals 98.2, HR 171, BP 157/111,
R20, 96% on 4L.  eventually down to 2L and satting high 90s;
later with desat sown to 80s per report (notes with increasing
O2 requirement - 94% on 6L).
.
Patient has had a long standing history of alcoholism with
multiple attempts at detox. Last sober [**2133-3-21**]. Last drink
last night. Drinking a fifth vodka daily for the last several
weeks.  Attempts to detox herself; when she does this, she often
has episodes of bilious emesis and tremors. No seizures. Denies
fevers, chills, shortness of breath, chest pain, palpitations,
hematochezia, melena. + bilateral ankle swelling. Has not
noticed weight gain.  Admits to not taking her medications over
the past several days.

MEDICAL HISTORY: - EtOH cirrhosis.  Follows with Dr. [**Last Name (STitle) 497**].  No varices on EGD
last year.  Normal INR.
- EtOH abuse.  As per HPI.
- Breast cancer, stage IC.  Follows with Dr. [**Last Name (STitle) **].
Diagnosed [**2130**].  No past chemotherapy/anthracyclines.  s/p
lumpectomy and XRT and currently on arimidex.
- Cardiomyopathy in past, presumed due to EtOH.  Most recent (>1
year ago) EF 60% with borderline dilation.
- Single known episode of Afib in [**2130**], seen on holter monitor.
Briefly on coumadin, but difficulty with controlling INR.
Preumably in sinus since that time.
- HTN
- Osteoarthritis

MEDICATION ON ADMISSION: ARIMIDEX - 1MG Tablet - TAKE ONE PILL BY MOUTH EACH DAY
ATENOLOL -  50 mg - daily (patient unsure of dose - ?20 daily)
ATORVASTATIN - Dosage uncertain
BUPROPION [WELLBUTRIN SR] -   150 mg daily
ESCITALOPRAM [LEXAPRO] -   20 mg daily
ESOMEPRAZOLE MAGNESIUM [NEXIUM] - 40 mg daily
QUETIAPINE [SEROQUEL] -- 150 mg at bedtime
QUINAPRIL -  Dosage uncertain

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T 97.6F BP 115/71 HR 106 RR 20 O2Sat95%RA
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: Irregularly irregular, no M/G/R
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: A&O x 3, alert and appropriate. No asterixis.
SKIN: No jaundice, cyanosis, or gross dermatitis. Scattered
ecchymoses
============================
Physical exam not significantly changed at time of dicharge
except for HR which was in 70-80 range

FAMILY HISTORY: uterine ca, no bleeding d/o

SOCIAL HISTORY: Lives alone.  Good relationship with ex husband and adult
children.  EtOH use as above.  Denies methanol/antifreeze/other
alcohol ingestions.  Denies drug use and smoking. 

### Response:
{'Atrial fibrillation,Alcohol withdrawal,Urinary tract infection, site not specified,Alcoholic cirrhosis of liver,Other and unspecified alcohol dependence, continuous,Personal history of malignant neoplasm of breast,Other primary cardiomyopathies,Unspecified essential hypertension'}
