CHIEF COMPLAINT: elective PVI complicated by pericardial tamponade

PRESENT ILLNESS: This is a 52 year old woman with history significant for
hypertrophic
cardiomyopathy, paroxysmal atrial fibrillation s/p multiple
prior
cardioversions, AF ablation in [**2170**], and PVI in [**2171-2-8**] who
is admitted to the CCU with pericardial tamponade status post
repeat pulmonary vein isolation procedure. Her most recent
cardioversion was in [**2172-3-10**] and at that time she
converted briefly to sinus rhythm and then went back into atrial
fibrillation and has remained in it since then, according to her
report. She experienced recurrent symptoms with fatigue and was
referred for redo pulmonary vein isolation procedure.
.
Patient presented for the procedure on the morning of admission
and underwent catheterization via the R femoral. Around 11:40
AM, she acutely dropped her blood pressures to systolics in the
40s. She was found to be in pericardial tamponade in the setting
of her supratherapeutic INR of 4.1. Bedside echo was performed
and showed a large anterior/apical pericardial effusion with RV
diastolic collapse c/w tamponade physiology. A large clot was
also visualized. The procedure was prematurely terminated, a
pericardial drain was placed. A Swan Ganz catheter was placed in
the left femoral vein for hemodynamic monitoring, and an
arterial line in the R femoral artery. She was hypotensive for
approximately 15 minutes, requiring neosynephrine briefly before
her pressures stabilized after drainage of 300 cc of blood. She
received 2 units of FFP. She was transferred to the CCU intubate
and sedated on propofol, hemodynamically stable off pressors,
for further management.
.
In the CCU, the patient was intubated and sedated and unable to
answer any questions.
.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia,
(-)Hypertension
2. CARDIAC HISTORY:
-HOCM
-atrial fibrillation s/p cardioversion 2 years ago
-hypercholesterolemia

MEDICATION ON ADMISSION: Disopyramide 400 mg TID
Seroquel 100-150 mg qhs prn for insomnia
Verapamil SR 120 mg daily
Coumadin 4.5 mg on all days except for 3 mg on Wednesday

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On Admission:
VS: T= 96.6 BP= 123/81 HR= 112 RR= 22 O2 sat= 100%
GENERAL: intubated, sedated
HEENT: Sclera anicteric. PERRL. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. Dry MMM.
NECK: Supple, JVP appx 15 cm at 30 degrees.
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: Wheezes bilaterally anteriorly, coarse BS; no rales
appreciated.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Numerous tattoos.
PULSES: 2+ radial, DPs and PTs b/l
.
On Discharge:
VS: T= 97.8 BP= 120/78 HR= 84 RR= 18 O2 sat= 100%
GENERAL: alert, oriented, NAD
HEENT: Sclera anicteric. PERRL. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. MMM.
NECK: Supple, JVP to mandible.
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: CTA anteriorly; no rales appreciated.
CHEST: tegaderm dressing over site of previous pericardial
drain: no erythema no discharge
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Numerous tattoos.
PULSES: 2+ radial, DPs and PTs b/l
.

FAMILY HISTORY: Father with MI at 38, died 12 years later in cath lab. Mother
with asthma but no cardiac disease. Five living brothers all
without heart disease. Otherwise non-contributory.

SOCIAL HISTORY: Married. Lives in [**Hospital1 **] with her husband.
Does not work; on unemployment.
Contact for discharge: Husband; Cell # [**Telephone/Fax (1) 109277**].
Tobacco: 5 cigarettes daily and marijuana on weekends
ETOH: NONE.
Denies IVDU since one episode in [**2147**]; rare and remote h/o
cocaine (~20yrs prior)
Acute respiratory failure,Cardiac complications, not elsewhere classified,Unspecified disease of pericardium,Acidosis,Accidental puncture or laceration during a procedure, not elsewhere classified,Procedure not carried out for other reasons,Atrial fibrillation,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution,Abnormal coagulation profile,Other chronic pulmonary heart diseases,Chronic airway obstruction, not elsewhere classified,Tobacco use disorder,Unspecified viral hepatitis C without hepatic coma
Acute respiratry failure,Surg compl-heart,Pericardial disease NOS,Acidosis,Accidental op laceration,No proc for reasons NEC,Atrial fibrillation,Abn react-cardiac cath,Accid in resident instit,Abnrml coagultion prfile,Chr pulmon heart dis NEC,Chr airway obstruct NEC,Tobacco use disorder,Hpt C w/o hepat coma NOS
Admission Date:  [**2172-6-17**]              Discharge Date:   [**2172-6-24**]

Date of Birth:  [**2119-10-17**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
elective PVI complicated by pericardial tamponade

Major Surgical or Invasive Procedure:
Pulmonary Vein Isolation
Pericardial Drain Placement
Right and left heart catheterization
Transesophageal echocardiogram and cardioversion


History of Present Illness:
This is a 52 year old woman with history significant for
hypertrophic
cardiomyopathy, paroxysmal atrial fibrillation s/p multiple
prior
cardioversions, AF ablation in [**2170**], and PVI in [**2171-2-8**] who
is admitted to the CCU with pericardial tamponade status post
repeat pulmonary vein isolation procedure. Her most recent
cardioversion was in [**2172-3-10**] and at that time she
converted briefly to sinus rhythm and then went back into atrial
fibrillation and has remained in it since then, according to her
report. She experienced recurrent symptoms with fatigue and was
referred for redo pulmonary vein isolation procedure.
.
Patient presented for the procedure on the morning of admission
and underwent catheterization via the R femoral. Around 11:40
AM, she acutely dropped her blood pressures to systolics in the
40s. She was found to be in pericardial tamponade in the setting
of her supratherapeutic INR of 4.1. Bedside echo was performed
and showed a large anterior/apical pericardial effusion with RV
diastolic collapse c/w tamponade physiology. A large clot was
also visualized. The procedure was prematurely terminated, a
pericardial drain was placed. A Swan Ganz catheter was placed in
the left femoral vein for hemodynamic monitoring, and an
arterial line in the R femoral artery. She was hypotensive for
approximately 15 minutes, requiring neosynephrine briefly before
her pressures stabilized after drainage of 300 cc of blood. She
received 2 units of FFP. She was transferred to the CCU intubate
and sedated on propofol, hemodynamically stable off pressors,
for further management.
.
In the CCU, the patient was intubated and sedated and unable to
answer any questions.
.


Past Medical History:
1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia,
(-)Hypertension
2. CARDIAC HISTORY:
-HOCM
-atrial fibrillation s/p cardioversion 2 years ago
-hypercholesterolemia

3. OTHER PAST MEDICAL HISTORY:
-Asthma/COPD
-GERD
-Hepatitis C, genotype IIIa; treated with interferon/ribavirin
-History of severe depression with suicide attempt, overdoses on
Seroquel, currently under good control
-h/o diverticulosis s/p colectomy
-Marijuana dependence
-Tobacco dependence

4. PAST SURGICAL HISTORY
- History of rotator cuff injury to the right shoulder
([**Doctor Last Name **])
- s/p cholecystectomy (per patient)
- s/p incisional hernia repair ([**6-/2167**])
- s/p colectomy for diverticulitis (~[**2159**])
- s/p appendectomy
- s/p ex-laparotomy [**9-/2167**] for epigastric and abdominal pain
(chronic cholecystitis) - found to be in afib during this
hospitalization

5. GYN HISTORY:
Currently going through menopause with active hot flashes as
above
LMP ~2 years ago


Social History:
Married. Lives in [**Hospital1 **] with her husband.
Does not work; on unemployment.
Contact for discharge: Husband; Cell # [**Telephone/Fax (1) 109277**].
Tobacco: 5 cigarettes daily and marijuana on weekends
ETOH: NONE.
Denies IVDU since one episode in [**2147**]; rare and remote h/o
cocaine (~20yrs prior)

Family History:
Father with MI at 38, died 12 years later in cath lab. Mother
with asthma but no cardiac disease. Five living brothers all
without heart disease. Otherwise non-contributory.

Physical Exam:
On Admission:
VS: T= 96.6 BP= 123/81 HR= 112 RR= 22 O2 sat= 100%
GENERAL: intubated, sedated
HEENT: Sclera anicteric. PERRL. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. Dry MMM.
NECK: Supple, JVP appx 15 cm at 30 degrees.
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: Wheezes bilaterally anteriorly, coarse BS; no rales
appreciated.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Numerous tattoos.
PULSES: 2+ radial, DPs and PTs b/l
.
On Discharge:
VS: T= 97.8 BP= 120/78 HR= 84 RR= 18 O2 sat= 100%
GENERAL: alert, oriented, NAD
HEENT: Sclera anicteric. PERRL. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. MMM.
NECK: Supple, JVP to mandible.
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: CTA anteriorly; no rales appreciated.
CHEST: tegaderm dressing over site of previous pericardial
drain: no erythema no discharge
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Numerous tattoos.
PULSES: 2+ radial, DPs and PTs b/l
.


Pertinent Results:
On Admission:

[**2172-6-17**] 07:15AM BLOOD WBC-7.3 RBC-4.81 Hgb-17.0* Hct-47.1
MCV-98 MCH-35.3* MCHC-36.1* RDW-14.5 Plt Ct-163
[**2172-6-17**] 10:00AM BLOOD PT-40.1* PTT-32.8 INR(PT)-4.1*
[**2172-6-17**] 07:15AM BLOOD Glucose-102* UreaN-10 Creat-0.7 Na-135
K-7.3* Cl-102 HCO3-25 AnGap-15
[**2172-6-17**] 03:00PM BLOOD Calcium-7.8* Phos-3.6 Mg-1.3*
.
On Discharge:
[**2172-6-24**] 04:22AM BLOOD WBC-5.1 RBC-3.23* Hgb-10.8* Hct-32.9*
MCV-102* MCH-33.5* MCHC-32.9 RDW-15.7* Plt Ct-123*
[**2172-6-24**] 04:22AM BLOOD PT-19.2* PTT-38.5* INR(PT)-1.7*
[**2172-6-24**] 04:22AM BLOOD Glucose-85 UreaN-7 Creat-0.6 Na-140 K-4.0
Cl-105 HCO3-28 AnGap-11
[**2172-6-24**] 04:22AM BLOOD Calcium-8.6 Phos-3.2 Mg-1.7
.
TFTs:
[**2172-6-22**] 04:28AM BLOOD TSH-5.7*
[**2172-6-22**] 04:28AM BLOOD T4-6.3
.
Anemia work-up
[**2172-6-22**] 04:28AM BLOOD VitB12-GREATER TH Folate-16.0
[**2172-6-23**] 05:43AM BLOOD Ret Aut-2.9
.
Lactate trend
[**2172-6-17**] 12:27PM BLOOD Glucose-88 Lactate-1.3 Na-140 K-3.7
Cl-110
[**2172-6-17**] 04:45PM BLOOD Lactate-1.0

Imaging:
SERIAL TTE
TTE [**6-17**]
Focused views during ablation procedure complicated by
tamponade.
There is a large pericardial effusion (2.2 cm). The effusion is
echo dense, consistent with blood, inflammation or other
cellular elements. The effusion is predominantly
anterior/apical. There is right ventricular diastolic collapse,
consistent with impaired fillling/tamponade physiology. There is
a catheter noted in the transatrial position, one in the
pericardial space and another in the IVC/RA.
After pericardial fluid drainage there is gradual improvement of
the size of the pericardial effusion (clip [**Clip Number (Radiology) **], measuring 1.1 cm)
and resolution of the tamponade physiology.
There was no significant resting LVOT gradient throughout the
procedure (patient has known hypertrophic cardiomyopathy).
.
TTE [**6-17**]: post-pericardiocenthesis
Focused views post pericardial drainage.
There is a small to moderate sized pericardial effusion. The
effusion is echo dense, consistent with blood, inflammation or
other cellular elements. There are no echocardiographic signs of
tamponade.
Compared with the post-pericardiocenthesis images of a few hours
ago, findings are similar.
.
TTE [**6-18**]
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There is a small pericardial effusion. The effusion is echo
dense, consistent with blood, inflammation or other cellular
elements.
Compared with the prior study (images reviewed) of [**2172-6-17**],
the amount of pericardial fluid is slightly less. It has similar
appearance (echo dense) and distribution (over the RV free wall
and apex).
.
TTE [**6-19**]
Overall left ventricular systolic function is normal (LVEF>55%).
There is a small pericardial effusion. The effusion is echo
dense, consistent with blood, inflammation or other cellular
elements. There are no echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2172-6-18**], no
change.
.
TTE [**6-20**]
There is a small pericardial effusion. The effusion appears
circumferential. The effusion is echo dense, consistent with
blood, inflammation or other cellular elements. No right atrial
or right ventricular diastolic collapse is seen.
IMPRESSION: Small echodense pericardial effusion without
echocardiographic evidence of significant hemodynamic impact.
Compared with the prior study (images reviewed) of [**2172-6-20**]
pericardial effusion is similar.
.
TEE: [**6-24**]
Mild spontaneous echo contrast is seen in the body of the left
atrium and the left atrial appendage. The left atrial appendage
emptying velocity is depressed (<0.2m/s). A large, nonmobile
thrombus is seen in the left atrial appendage. There is severe
symmetric left ventricular hypertrophy. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
free wall is hypertrophied. There are simple calcified atheroma
in the aortic arch and descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened without aortic stenosis.
There are filamentous strands on both the upstream and LVOT
sides of the aortic leaflets (probable noncoronary and left
coronary cusps), measuring 0.5-0.6 cm in length (clips 55, 58,
60, 72, 86, 87). The strands on the aortic valve side are
consistent with Lambl's excresences (normal variant). However,
thrombus or vegetation cannot be excluded. No aortic valve
abscess is seen. Trace central aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. Mild to moderate ([**2-9**]+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is a small pericardial effusion. There
are no echocardiographic signs of tamponade.

IMPRESSION: Large probable thrombus in the left atrial
appendage. Filamentous strands on the aortic valve, consistent
with Lambl's excresences (cannot exclude thrombus vs.
vegetation, in the appropriate clinical context). Trace aortic
regurgitation. Mild to moderate mitral regurgitation. Small
pericardial effusion without echocardiographic signs of
tamponade.
.
Cardiac Cath: [**6-22**]
COMMENTS:
1. Coronary angiography in this co-dominant system demonstrated
no
obstructive disease. The LMCA had no angiographically apparent
disease.
The LAD had up to 30% stenosis with otherwise minor lumen
irregularities. The LCx had minor lumen irregularities. The RCA
had up
to 30% stenosis in the mid vessel.
2. Resting hemodynamics revealed elevated right and left
ventricular
filling pressures with RVEDP 14 mmHg and LVEDP 24 mmHg. The
pulmonary
artery pressures were elevated with PASP 42 mmHg. The cardiac
index was
depressed at 1.8 L/min/m2. The pulmonary and systemic
resistances were
elevated at 347 and 2133 dyn-sec/cm5, respectively. There was
systemic
arterial normotension and no significant pressure gradient
across the
left ventricular outflow tract from apex to ascending aorta on
catheter
pullback despite the asymmetric septal hypertrophy. Simultaneous

pressure recordings showed no evidence of equalization of the
right and
left heart pressure recordings. There was no evidence of cardiac

tamponade.
FINAL DIAGNOSIS:
1. Coronary arteries are without obstructive disease.
2. Elevated biventricular filling pressures without evidence of
constriction/restriction or tamponade.
3. Moderate pulmonary artery hypertension.


Brief Hospital Course:
52 year old F w/ hypertrophic cardiomyopathy, HCV, and pAF
transferred to the CCU in for treatment of pericardial tamponade
in the setting of repeat PVI procedure.
.
# Pericardial Tamponade: Patient developed large pericardial
bleed and tamponade physiology in setting of pulmonary vein
isolation procedure in EP lab and supratherapeutic INR of 4.1.
Given onset of tamponade early in procedure and presence of
clot, concern for RV perf as etiology. Pericardiocentis
performed and drain placed. INR reversed with 5mg of vitamin K.
On transfer to CCU patient hemodynamically stable with stable
pericardial drain in place. Repeat echo with decreased effusion
and clot size without sign of active bleeding. Effusion
monitored with serial TTE to assess for resolution. Pericardial
drain pulled on HD3. Pain controlled with tylenol, tramadol and
colchicine. Pain improved and effusion stable but TTE. Concern
for lower extremity modeling and elevated JVD prompted right
heart catheterization to discern volume status in patient with
difficult hemodynamics (HOCM, effusion). Cardiac cath
demonstrated 1. Coronary arteries are without obstructive
disease. 2. Elevated biventricular filling pressures without
evidence of
constriction/restriction or tamponade. 3. Moderate pulmonary
artery hypertension. At time of discharge patient
hemodynamically stable without signs of tamponade physiology on
exam.
.
# Respiratory Failure: Patient was intubated and paralyzed for
the PVI procedure. On arrival to the CCU patient continued on AC
ventilation 500/12/50% with ABG pH7.25 pCO251 pO2132 c/w
respiratory acidosis. Current respiratory compromise may be more
related to COPD given she is currently HD stable. Patient
extubated shortly after arrival to the CCU. Home COPD
medications continued. Throughout stay patient complained of
dyspnea on exertion though remained with minimal oxygen
requirement. Patient saturating> 95% on Ra prior to discharge.
OUTPATIENT ISSUES:
-- Outpatient pulmonary consult.
.
# Paroxysmal AF: Patient admitted for PVI procedure which was
aborted [**3-11**] to pericardial effusion. EKG on admission showed
atrial tachycardia with variable block. Patient monitored on
telemetry with predominant rhythm: AF with rates in the low
100s. At home rate controlled with ... and anti-coagulated with
coumadin. On admission, coumadin held as INR supratherapeutic at
4.1. In house patient rate controlled with verapamil,
disopyramide and carvedilol 25mg PO BID. Home disopyuramide
decreased from 400mg TID -> 300mg TID. Attempted
TEE/cardioversion was deferred as TEE with evidence of atrial
clot. Decision made to continue anticoagulation and follow-up as
an outpatient. Prior to discharge patient transitioned from
Coumadin to Pradexa. At time of discharge patient adequately
rate controlled (HRs in 80s).
OUTPATIENT ISSUES
-- Continue rate control with Verapamil, disopyramide and
carvedilol
-- Continue anticoagulation with Pradexa
.
# Large probable thrombus in the left atrial appendage. Seen and
documented on [**6-24**] TEE. Cardioversion deferred in setting of
clot. Per EP appropriate to continue anticoagulation as planned
for treatment of atrial fibrillation.
OUTPATIENT ISSUES:
-- Continue to follow with TTE as outpatient
.
# COPD: Patient with moderate to severe emphysema on CT chest
from [**2171**]. No PFTs in our system. On admission and
intermittently during hospitalization patient with extensive
wheeze on exam. Patient not on standing COPD medications as an
outpatient. Treated with standing and prn nebulizers in house.
Smoking cessation strongly encourage.
OUTPATIENT ISSUES:
-- Pulmonary follow-up and PFTs as an outpatient
-- Continue to encourage smoking cessation
.
.
# Hypertrophic Cardiomyopathy- No signs of obstructive pathology
on serial TTE obtained in house. As an outpatient on verapamil.
Started beta blocker (carvedilol 25mg PO BID) in house.
.
# Hepatitis C. Per report has been treated with interferon in
the past. Stable and per record cleared.
OUTPATIENT ISSUES
-- Hepatology follow-up
.
# Insomnia. Continued on home Seroquel.
.
CODE: Full (confirmed with HCP, husband [**Name (NI) **] [**Name (NI) 15490**])
.
COMM: [**Name (NI) 4906**] [**Name (NI) **] [**Name (NI) 15490**]: [**Telephone/Fax (1) 109278**]; cell [**Telephone/Fax (1) 109279**]


Medications on Admission:
Disopyramide 400 mg TID
Seroquel 100-150 mg qhs prn for insomnia
Verapamil SR 120 mg daily
Coumadin 4.5 mg on all days except for 3 mg on Wednesday

Discharge Medications:
1. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. disopyramide 100 mg Capsule Sig: Three (3) Capsule PO Q8H
(every 8 hours).
3. verapamil 120 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q24H (every 24 hours).
4. Seroquel 100 mg Tablet Sig: 1-1.5 Tablets PO QHS as needed
for sleep.
5. carvedilol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*


Discharge Disposition:
Home

Discharge Diagnosis:
Pericardial Tamponade
Paroxsymal Atrial Fibrillation/Tachycardia
Hypertrophic Cardiomyopathy


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


Discharge Instructions:
Dear Ms. [**Known lastname 15490**],

You were admitted to the hospital after a complication of your
pulmonary vein isolation procedure. You had a bleed around your
heart for which you were treated with the placement of a
pericardial drain and close monitoring. While you were in the
hospital you underwent numerous ultrasounds of your heart as
well as heart catheterization which did not show further
accumulation of blood around your heart. You had a cardioversion
before you were discharged.
.
We have made the following changes to your medications:
- STOP taking coumadin for your atrial fibrillation
- START taking dabigatran 150mg tablet for your atrial
fibrillation, please take 1 tablet twice daily.
- CHANGE your dose of Disopyramide to 300 mg three times daily
for your atrial fibrillation
- START taking carvedilol 25 mg tablet for your atrial
fibrillation, please take one tablet twice daily
.
Please continue to take the rest of your regular medications
withou change.
It was a pleasure taking care of you at the [**Hospital1 18**]. We wish you a
speedy recovery.

Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] M.
Location: [**Hospital1 **] HEALTHCARE - UPPER FALLS
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 14512**]
Phone: [**Telephone/Fax (1) 3393**]
Appointment: Friday [**2172-7-3**] 11:45am

Department: CARDIAC SERVICES
When: THURSDAY [**2172-8-6**] at 9:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage



Completed by:[**2172-6-26**]
{'Acute respiratory failure,Cardiac complications, not elsewhere classified,Unspecified disease of pericardium,Acidosis,Accidental puncture or laceration during a procedure, not elsewhere classified,Procedure not carried out for other reasons,Atrial fibrillation,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution,Abnormal coagulation profile,Other chronic pulmonary heart diseases,Chronic airway obstruction, not elsewhere classified,Tobacco use disorder,Unspecified viral hepatitis C without hepatic coma'}


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: elective PVI complicated by pericardial tamponade

PRESENT ILLNESS: This is a 52 year old woman with history significant for
hypertrophic
cardiomyopathy, paroxysmal atrial fibrillation s/p multiple
prior
cardioversions, AF ablation in [**2170**], and PVI in [**2171-2-8**] who
is admitted to the CCU with pericardial tamponade status post
repeat pulmonary vein isolation procedure. Her most recent
cardioversion was in [**2172-3-10**] and at that time she
converted briefly to sinus rhythm and then went back into atrial
fibrillation and has remained in it since then, according to her
report. She experienced recurrent symptoms with fatigue and was
referred for redo pulmonary vein isolation procedure.
.
Patient presented for the procedure on the morning of admission
and underwent catheterization via the R femoral. Around 11:40
AM, she acutely dropped her blood pressures to systolics in the
40s. She was found to be in pericardial tamponade in the setting
of her supratherapeutic INR of 4.1. Bedside echo was performed
and showed a large anterior/apical pericardial effusion with RV
diastolic collapse c/w tamponade physiology. A large clot was
also visualized. The procedure was prematurely terminated, a
pericardial drain was placed. A Swan Ganz catheter was placed in
the left femoral vein for hemodynamic monitoring, and an
arterial line in the R femoral artery. She was hypotensive for
approximately 15 minutes, requiring neosynephrine briefly before
her pressures stabilized after drainage of 300 cc of blood. She
received 2 units of FFP. She was transferred to the CCU intubate
and sedated on propofol, hemodynamically stable off pressors,
for further management.
.
In the CCU, the patient was intubated and sedated and unable to
answer any questions.
.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia,
(-)Hypertension
2. CARDIAC HISTORY:
-HOCM
-atrial fibrillation s/p cardioversion 2 years ago
-hypercholesterolemia

MEDICATION ON ADMISSION: Disopyramide 400 mg TID
Seroquel 100-150 mg qhs prn for insomnia
Verapamil SR 120 mg daily
Coumadin 4.5 mg on all days except for 3 mg on Wednesday

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On Admission:
VS: T= 96.6 BP= 123/81 HR= 112 RR= 22 O2 sat= 100%
GENERAL: intubated, sedated
HEENT: Sclera anicteric. PERRL. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. Dry MMM.
NECK: Supple, JVP appx 15 cm at 30 degrees.
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: Wheezes bilaterally anteriorly, coarse BS; no rales
appreciated.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Numerous tattoos.
PULSES: 2+ radial, DPs and PTs b/l
.
On Discharge:
VS: T= 97.8 BP= 120/78 HR= 84 RR= 18 O2 sat= 100%
GENERAL: alert, oriented, NAD
HEENT: Sclera anicteric. PERRL. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. MMM.
NECK: Supple, JVP to mandible.
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: CTA anteriorly; no rales appreciated.
CHEST: tegaderm dressing over site of previous pericardial
drain: no erythema no discharge
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Numerous tattoos.
PULSES: 2+ radial, DPs and PTs b/l
.

FAMILY HISTORY: Father with MI at 38, died 12 years later in cath lab. Mother
with asthma but no cardiac disease. Five living brothers all
without heart disease. Otherwise non-contributory.

SOCIAL HISTORY: Married. Lives in [**Hospital1 **] with her husband.
Does not work; on unemployment.
Contact for discharge: Husband; Cell # [**Telephone/Fax (1) 109277**].
Tobacco: 5 cigarettes daily and marijuana on weekends
ETOH: NONE.
Denies IVDU since one episode in [**2147**]; rare and remote h/o
cocaine (~20yrs prior) 

### Response:
{'Acute respiratory failure,Cardiac complications, not elsewhere classified,Unspecified disease of pericardium,Acidosis,Accidental puncture or laceration during a procedure, not elsewhere classified,Procedure not carried out for other reasons,Atrial fibrillation,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution,Abnormal coagulation profile,Other chronic pulmonary heart diseases,Chronic airway obstruction, not elsewhere classified,Tobacco use disorder,Unspecified viral hepatitis C without hepatic coma'}
