CHIEF COMPLAINT: hypotension

PRESENT ILLNESS: Ms. [**Known lastname **] is a 54 year old G2P2 lady, with a past medical
history of symptomatic uterine fibroids and multinodular goiter
(euthyroid), who was admitted for an elective TAH, complicated
by hypotension,  ventricular tachycardia and cardiac arrest.
Patient presented on [**2184-10-4**].  Following induction of
anesthesia and intubation, Kefzol was administered.  While
antibiotics were being given, patient developed hypotension to
40/20s, and was given 1 mg epinephrine IV, out of concern for
anaphylaxis, which resulted in narrow-complex tachycardia.  EKG
at the time showed ST segment elevation in the inferior leads.
Bedside TEE performed showing hyperdynamic ventricle with poor
filling. At 15:10, the patient's rhythm degenerated to VT/VF.
After a first DC shock of 200J, there was initial return of
sinus bradycardia, which degenerated into VT again.  Patient
received another dose of epinephrine 1 mg IV and lidocaine 100
mg, followed by amiodarone 300 mg.  Second DC shock of 300J
failed to convert patient out of VT/VF.  The patient then was
noted to be pulseless and received CPR for 3-5 minutes with
resultant ROSC.  EKG
following the arrest showed sinus tachycardia, with less then
1mm ST elevations in inferior leads and persistent ST
depressions in anterior precordial leads.  Repeat bedside TEE
with ?inferior wall hypokinesis.  At that time, the patient was
noted to have a potassium of 2.4 as well.  During this episode,
the patient
developed a diffuse pink, blanching rash.  For her rash, patient
was given diphenhydramine 25 mg and famotidine 30 mg.  Due to
these complications, TAH was cancelled.  In the OR, patient at
17 cc of urine output, and was given 2200 cc IV fluids.
.
Full ROS was not obtained on admission to ICU as pt was
intubated and sedated.
.

MEDICAL HISTORY: 1.) Symptomatic uterine fibroids: had caused pain in the past,
and patient was recommended to have TAH due to size of fibroids
2.) Endometrial polyp
3.) Multinodular thyroid: found on physical exam in [**2171**],
asymptomatic, TSH and T4 normal
4.) G2P2
5.) Hyperlipidemia

MEDICATION ON ADMISSION: Vitamin D

ALLERGIES: Cephalosporins / Kefzol

PHYSICAL EXAM: On Admission to ICU

FAMILY HISTORY: Mother, still living, with DM and HTN.  No family history of
cardiovascular disease or anaphylaxis.  No family history of
sudden cardiac death.

SOCIAL HISTORY: Lives at home in [**Location (un) 86**] with two daughters.
[**Name (NI) 1403**] in a factory on assembly line.  No known chemical
exposures.  No history of tobacco, alcohol or drug use.
Leiomyoma of uterus, unspecified,Ventricular fibrillation,Acute respiratory failure,Other anaphylactic reaction,Cephalosporin group causing adverse effects in therapeutic use,Other iatrogenic hypotension,Polyp of corpus uteri,Nontoxic multinodular goiter,Surgical or other procedure not carried out because of contraindication
Uterine leiomyoma NOS,Ventricular fibrillation,Acute respiratry failure,Other anaphylactic react,Adv eff cephalosporin,Iatrogenc hypotnsion NEC,Polyp of corpus uteri,Nontox multinodul goiter,No proc/contraindication
Admission Date:  [**2184-10-4**]              Discharge Date:   [**2184-10-6**]

Date of Birth:  [**2130-7-23**]             Sex:   F

Service: MEDICINE

Allergies:
Cephalosporins / Kefzol

Attending:[**First Name3 (LF) 2291**]
Chief Complaint:
hypotension

Major Surgical or Invasive Procedure:
Intubation
CPR
defibrillation


History of Present Illness:
Ms. [**Known lastname **] is a 54 year old G2P2 lady, with a past medical
history of symptomatic uterine fibroids and multinodular goiter
(euthyroid), who was admitted for an elective TAH, complicated
by hypotension,  ventricular tachycardia and cardiac arrest.
Patient presented on [**2184-10-4**].  Following induction of
anesthesia and intubation, Kefzol was administered.  While
antibiotics were being given, patient developed hypotension to
40/20s, and was given 1 mg epinephrine IV, out of concern for
anaphylaxis, which resulted in narrow-complex tachycardia.  EKG
at the time showed ST segment elevation in the inferior leads.
Bedside TEE performed showing hyperdynamic ventricle with poor
filling. At 15:10, the patient's rhythm degenerated to VT/VF.
After a first DC shock of 200J, there was initial return of
sinus bradycardia, which degenerated into VT again.  Patient
received another dose of epinephrine 1 mg IV and lidocaine 100
mg, followed by amiodarone 300 mg.  Second DC shock of 300J
failed to convert patient out of VT/VF.  The patient then was
noted to be pulseless and received CPR for 3-5 minutes with
resultant ROSC.  EKG
following the arrest showed sinus tachycardia, with less then
1mm ST elevations in inferior leads and persistent ST
depressions in anterior precordial leads.  Repeat bedside TEE
with ?inferior wall hypokinesis.  At that time, the patient was
noted to have a potassium of 2.4 as well.  During this episode,
the patient
developed a diffuse pink, blanching rash.  For her rash, patient
was given diphenhydramine 25 mg and famotidine 30 mg.  Due to
these complications, TAH was cancelled.  In the OR, patient at
17 cc of urine output, and was given 2200 cc IV fluids.
.
Full ROS was not obtained on admission to ICU as pt was
intubated and sedated.
.

Past Medical History:
1.) Symptomatic uterine fibroids: had caused pain in the past,
and patient was recommended to have TAH due to size of fibroids
2.) Endometrial polyp
3.) Multinodular thyroid: found on physical exam in [**2171**],
asymptomatic, TSH and T4 normal
4.) G2P2
5.) Hyperlipidemia


Social History:
Lives at home in [**Location (un) 86**] with two daughters.
[**Name (NI) 1403**] in a factory on assembly line.  No known chemical
exposures.  No history of tobacco, alcohol or drug use.

Family History:
Mother, still living, with DM and HTN.  No family history of
cardiovascular disease or anaphylaxis.  No family history of
sudden cardiac death.


Physical Exam:
On Admission to ICU

VS T35.3 HR 59 BP 109/92 RR 14 O2 sat 100 on the vent
Vent settings: TV 500, RR 14 PEEP 5, FiO2 50%
Gen: Intubated, responds to voice, follows commands
HEENT: PERRL, EOMI, anicteric
CV: RRR, S1/S2, no m/r/g
Pulm: Good air entry b/l
Abd:soft, NT, ND, normal BS
Ext: no edema, clubbing, cyanosis
Skin: rash resolved
Neuro: awakens to voice and follows commands
Access: femoral A-line, peripheral IV's

Pertinent Results:
[**2184-10-4**] 05:10PM BLOOD WBC-16.7*# RBC-5.18 Hgb-16.6*# Hct-47.8#
MCV-92# MCH-32.1*# MCHC-34.7# RDW-12.9 Plt Ct-231
[**2184-10-5**] 04:18AM BLOOD WBC-15.3* RBC-4.54 Hgb-14.0 Hct-40.8
MCV-90 MCH-30.9 MCHC-34.4 RDW-13.2 Plt Ct-226
[**2184-10-6**] 06:25AM BLOOD WBC-7.6# RBC-3.72* Hgb-11.3* Hct-33.7*
MCV-91 MCH-30.5 MCHC-33.7 RDW-13.0 Plt Ct-180
[**2184-10-6**] 12:55PM BLOOD WBC-6.8 RBC-3.69* Hgb-11.6* Hct-34.0*
MCV-92 MCH-31.3 MCHC-34.0 RDW-13.0 Plt Ct-182
[**2184-10-4**] 05:10PM BLOOD PT-14.9* PTT-33.0 INR(PT)-1.3*
[**2184-10-4**] 05:10PM BLOOD Glucose-155* UreaN-15 Creat-0.6 Na-138
K-3.3 Cl-106 HCO3-17* AnGap-18
[**2184-10-5**] 04:18AM BLOOD Glucose-144* UreaN-12 Creat-0.7 Na-138
K-4.9 Cl-107 HCO3-20* AnGap-16
[**2184-10-6**] 06:25AM BLOOD Glucose-85 UreaN-8 Creat-0.6 Na-141 K-4.1
Cl-108 HCO3-30 AnGap-7*
[**2184-10-4**] 05:10PM BLOOD ALT-48* AST-56* LD(LDH)-186 CK(CPK)-84
AlkPhos-39 TotBili-0.6
[**2184-10-5**] 04:18AM BLOOD ALT-35 AST-29 LD(LDH)-151 AlkPhos-39
TotBili-0.8
[**2184-10-4**] 05:10PM BLOOD CK-MB-3 cTropnT-0.05*
[**2184-10-5**] 04:18AM BLOOD CK-MB-5 cTropnT-0.02*
[**2184-10-5**] 11:41AM BLOOD CK-MB-4 cTropnT-<0.01
[**2184-10-4**] 05:10PM BLOOD Calcium-7.9* Phos-3.3 Mg-1.6
[**2184-10-5**] 04:18AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.0
[**2184-10-6**] 06:25AM BLOOD Calcium-8.0* Phos-2.1* Mg-2.1
[**2184-10-4**] 05:10PM BLOOD TRYPTASE-PND
[**2184-10-5**] 11:42AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.023
[**2184-10-5**] 11:42AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-80 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2184-10-5**] 11:42AM URINE RBC-77* WBC-14* Bacteri-NONE Yeast-NONE
Epi-0
[**2184-10-5**] 11:42AM URINE CastHy-10*
.
Microbiology
Catheter tip culture ([**2184-10-5**]): pending, NGTD
Urine culture ([**2184-9-25**]): pending, NGTD
Blood culture ([**2184-10-5**]): pending, NGTD
MRSA screening ([**2184-10-4**]): pending
.
PCXR ([**2184-10-4**]):
IMPRESSION: AP chest reviewed in the absence of prior chest
radiographs:
Lungs are low in volume but clear. No pneumothorax or pleural
effusion.
Normal cardiomediastinal silhouette. Tip of the endotracheal
tube is no less than 22 mm above the carina, with the head in
neutral or extension.
Withdrawal 15 mm is recommended.
.
PCXR ([**2184-10-5**]):
FINDINGS: In comparison with the study of [**10-4**], the
endotracheal tube has
been removed. No evidence of acute pneumonia or vascular
congestion.
.
Echo ([**2184-10-5**]):
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
.
EKG [**2184-10-4**] (#1): sinus tach with inferior and lateral ST
elevations
EKG [**2184-10-4**] (#2): sinus tach with new Q-waves in inferior leads

Brief Hospital Course:
Briefly, the pt is a 54 yo F who presented initially on day of
admission for an elective hysterectomy for symptomatic uterine
fibroids.  Prior to surgery, following intubation and
administration of IV Cefazolin, the patient developed
hypotension to the 40's/20's. Then given IV epinephrine with
subsequent development of narrow-complex tachycardia, which
degenerated into VT/VF, with  unsuccessful debibrillation,
subsequent PEA arrest, received CPR for approximately 4 minutes
and return of spontaneous circulation.  TAH was cancelled and pt
was then transferred from the OR to the ICU, kept intubated.  Of
note, during this incident, pt had 2 bedside echocardiograms
done showing some inferior wall hypokinesis, and EKG's showed
initially some ST elevations that resolved but with some new
inferior Q waves.  During the episode, the pt was noted to have
a diffuse body rash, which responded to Benadryl and famotidine.
 Pt was successfully extubated the following day on [**10-5**] and
transferred to the medical floor in stable condition.
.
Acute Medical Issues:
.
# Anaphylactic Shock: given the patient's acute hypotension and
rash following administration of IV cefazolin, the pt is
presumed to have a severe allergy to cephlasporins.  Following
the acute episode in the OR, the patiet remained hemodynamically
stable without any pressors or aggressive IVF.  She remained
hemodynamically stable on the floor after transfer to the
medical floor.  The patient and her daughter were informed that
she has a severe allergic, potentially fatal, reaction to
cephlasporins.  She has been instructed to abstain from
cephlasporins and penicillins, and to avoid antibiotics in
general if possible for now, until she follows-up in [**Hospital 9039**]
Clinic after discharge.  She may need further allergen testing
once the acute phase of her anaphylaxis has resolved.  She also
received a prescription  for Epipen's, and was instructed on how
to administer and also given an informational handout.  With
regards to concern for the epinephrine potentially triggering
her arrhythmia and cardiac arrest, this was discussed with
Cardiology, and felt that the low dose of Epinephrine would make
this very unlikely and was not contraindicated.  The epinephrine
administered during the hypotensive shock had been given IV and
at a much higher dose.  Furthermore, if she did have symptoms
consistent with anaphylactic shock, Epipen would be the
appropriate immediate treatment.  A tryptase level is currently
still pending.
.
# VT arrest:  The patient developed VT/VF following her
anaphylactic shock and administration of IV epinephrine, and was
noted to have some wall motion abnormality on bedside Echo, EKG
changes, and elevated troponin.  As such, Cardiology Consult was
asked to see the patient.  Her follow-up echocardiogram showed
resolution of the wall motion abnormality, her EKG returned to
baseline, and her troponin quickly downtrended to within normal
range.  As such, Cardiology felt it was very unlikely for the
patient to have underlying coronary artery or structural heart
disease.  They also did not think that her EKG was concerning
for risk factors of sudden cardiac death.  Overall, they felt
that vasospasm due to epinephrine most likely caused transient
ischemia.  However, they did recommend that she be on an Aspirin
for the next 2 weeks and to have a follow-up Exercise-stress
echocardiogram in 2 weeks with appropriate Cardiology follow-up.
 She may also need to have her lipids rechecked in the
outpatient setting given a reported prior history of
dyslipidemia.
.
# Uterine Fibroids:  Unfortunately, given the pt's pre-operative
course, the pt's TAH was cancelled.  Given that it was an
elective surgery, the pt and her Gynecologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**],
have opted to postpone the surgery indefinitely until she has
further Cardiac and Allergy follow-up.
.
Transitional Issues:
1.  She will need to continue on Aspirin for 2 weeks and have a
outpt exercise-stress echocardiogram, which has already been
scheduled, and follow-up with Cardiology after the stress
testing.
2.  She will follow-up with [**Hospital 9039**] Clinic for possible further
allergen testing.  She also has a pending tryptase level that
may aid in the confirmation of her diagnosis of anaphylaxis
reaction to cephlasporins.
3.  She will follow-up with her PCP, [**Name10 (NameIs) **] she has pending culture
data, including a MRSA screen, blood culture, urine culture, and
catheter-tip culture.
4.  She will follow-up with her Gynecologist to determine when
to pursue her hysterectomy that was originally scheduled for
this admission.
.
Pending Studies:
1. Tryptase level
2. Urine culture, blood culture, catheter tip culture ([**10-5**])
3. MRSA screen ([**10-4**])
.

Medications on Admission:
Vitamin D

Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 2 weeks: please continue for 2 weeks till [**10-20**].
Disp:*14 Tablet(s)* Refills:*0*
2. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) injection
Intramuscular once as needed for anaphylaxis - shortness of
breath, tongue swelling, rash, low blood pressure: please keep 1
injection on you at all times or in your purse, keep 1 in your
car or your house. please call your doctor or 911 after using.
Disp:*2 injectors* Refills:*1*


Discharge Disposition:
Home

Discharge Diagnosis:
Anaphylactic allergic reaction medication
Ventricular Tachycardia


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


Discharge Instructions:
You presented to the hospital for an elective GYN surgery for
fibroids, however, prior to your sugery, your developed an
anaphylactic allergic reaction with low blood pressure to an
antibiotic (cefazolin) and also developed a cardiac arrest,
requiring CPR and electric shocks.  You were kept intubated and
monitored in the ICU.  You did well in the hospital, but your
surgery has been deferred indefinitely at this time.   There
were some mild abnormalities seen on ultrasound of the heart, so
the cardiologists recommend that you take Aspirin for the next 2
weeks.  You will then have follow-up testing of your heart and
will follow-up with Cardiology outpatient.  You will also have a
referral to [**Hospital 9039**] Clinic.  You will also follow-up with your
Gynecologist and PCP.
[**Name10 (NameIs) 357**] note the following medication changes:
1.  Aspirin was STARTED.
2.  Epipen is being PRESCRIBED
.
Please follow-up with all the appointments listed below.
.
The Epipen is to be used if you develop any reaction similar to
what you experienced here in the hospital, with low blood
pressure, difficulty breathing, shortness of breath, rash.
Please carry one in your purse or on you at all times, and keep
one in your car if you drive or at home if you don't.  We also
recommend that you also avoid any antibiotics until you are seen
in follow-up by the Allergy Specialists, especially the class of
antibiotics known as penicillins and cephlasporins.
.

Followup Instructions:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 4094**]: INTERNAL MEDICINE
Address: [**Last Name (un) 4805**], [**Location (un) **],[**Numeric Identifier 2900**]
Phone: [**Telephone/Fax (1) 4806**]
Appointment: WEDNESDAY [**10-13**] AT 1:30PM
.
Department: CARDIAC SERVICES
When: THURSDAY [**2184-11-4**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: ALLERGY AND [**Hospital **] CLINIC
Address: ONE [**Location (un) **] PLACE, [**Apartment Address(1) **] [**Location (un) **], [**Numeric Identifier 103822**]
Phone: [**Telephone/Fax (1) 9316**]
**We are working on a follow up appointment with the Allergy and
[**Hospital **] clinic within 2-4 weeks. You will be called at home
with the appointment. If you have not heard from the office
within 2 days or have any questions, please call the number
above.**
.
You will need to have a stress echo test performed prior to your
appointment with Dr. [**Last Name (STitle) **] in Cardiology.  The test has been
scheduled for [**10-27**] (Wed) at 9AM at [**Hospital Ward Name 23**] Building [**Location (un) 436**].
Please call [**Telephone/Fax (1) 62**] if you have questions, need to
reschedule, or need directions.  You should receive additional
instructions in the mail 1 week prior to your study.
.
Please keep your previously scheduled follow-up appointment with
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**] for next Tuesday ([**10-12**]).
{'Leiomyoma of uterus, unspecified,Ventricular fibrillation,Acute respiratory failure,Other anaphylactic reaction,Cephalosporin group causing adverse effects in therapeutic use,Other iatrogenic hypotension,Polyp of corpus uteri,Nontoxic multinodular goiter,Surgical or other procedure not carried out because of contraindication'}


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: hypotension

PRESENT ILLNESS: Ms. [**Known lastname **] is a 54 year old G2P2 lady, with a past medical
history of symptomatic uterine fibroids and multinodular goiter
(euthyroid), who was admitted for an elective TAH, complicated
by hypotension,  ventricular tachycardia and cardiac arrest.
Patient presented on [**2184-10-4**].  Following induction of
anesthesia and intubation, Kefzol was administered.  While
antibiotics were being given, patient developed hypotension to
40/20s, and was given 1 mg epinephrine IV, out of concern for
anaphylaxis, which resulted in narrow-complex tachycardia.  EKG
at the time showed ST segment elevation in the inferior leads.
Bedside TEE performed showing hyperdynamic ventricle with poor
filling. At 15:10, the patient's rhythm degenerated to VT/VF.
After a first DC shock of 200J, there was initial return of
sinus bradycardia, which degenerated into VT again.  Patient
received another dose of epinephrine 1 mg IV and lidocaine 100
mg, followed by amiodarone 300 mg.  Second DC shock of 300J
failed to convert patient out of VT/VF.  The patient then was
noted to be pulseless and received CPR for 3-5 minutes with
resultant ROSC.  EKG
following the arrest showed sinus tachycardia, with less then
1mm ST elevations in inferior leads and persistent ST
depressions in anterior precordial leads.  Repeat bedside TEE
with ?inferior wall hypokinesis.  At that time, the patient was
noted to have a potassium of 2.4 as well.  During this episode,
the patient
developed a diffuse pink, blanching rash.  For her rash, patient
was given diphenhydramine 25 mg and famotidine 30 mg.  Due to
these complications, TAH was cancelled.  In the OR, patient at
17 cc of urine output, and was given 2200 cc IV fluids.
.
Full ROS was not obtained on admission to ICU as pt was
intubated and sedated.
.

MEDICAL HISTORY: 1.) Symptomatic uterine fibroids: had caused pain in the past,
and patient was recommended to have TAH due to size of fibroids
2.) Endometrial polyp
3.) Multinodular thyroid: found on physical exam in [**2171**],
asymptomatic, TSH and T4 normal
4.) G2P2
5.) Hyperlipidemia

MEDICATION ON ADMISSION: Vitamin D

ALLERGIES: Cephalosporins / Kefzol

PHYSICAL EXAM: On Admission to ICU

FAMILY HISTORY: Mother, still living, with DM and HTN.  No family history of
cardiovascular disease or anaphylaxis.  No family history of
sudden cardiac death.

SOCIAL HISTORY: Lives at home in [**Location (un) 86**] with two daughters.
[**Name (NI) 1403**] in a factory on assembly line.  No known chemical
exposures.  No history of tobacco, alcohol or drug use. 

### Response:
{'Leiomyoma of uterus, unspecified,Ventricular fibrillation,Acute respiratory failure,Other anaphylactic reaction,Cephalosporin group causing adverse effects in therapeutic use,Other iatrogenic hypotension,Polyp of corpus uteri,Nontoxic multinodular goiter,Surgical or other procedure not carried out because of contraindication'}
