CHIEF COMPLAINT: Bradycardia

PRESENT ILLNESS: The pt is a 86y/o M with a PMH of biventricular CHF with EF 15%,
s/p CABG [**2167**] presenting with complete heart block.Recently
admitted [**Date range (1) 61817**] to BIDNH with dyspnea and was found to have
LLL PNA, treated with levaquin and azithromycin. He then
developed volume overload and was restarted on his home
diuretics. Of note, the patient declined a pacer placement.
Since discharge he reported feeling weak, not back to baseline
and with increased cough.The pt presented to BIDNH on [**2175-1-14**]
with complaints of weakness and CP. He was found to be in
complete heart block by EMS with HR 28 and BP 100 and was given
atropine en route to BIDNH ED. He became unresponsive in ED and
was intubated. Transcutaneous pacing started but he remained
hypotensive. Left SCL placed but no capture was obtained with
transvenous pacer. He was started on neosynephrien and dopamine
for hypotension. K 8.7 - hemolyzed and he was given calcium.
.
In the ED, initial vitals were HR: 80 [aced BP 144/47 RR 16
O2Sat: 92% RA. Patient received vancomycin 500mg IV, levaquin
750mg IV, Kayexelate 30g PR, Calcium gluconate 2gm IV, Insulin
10U IV and dextrose [**11-25**] amp for K of 6.1. Cardiology was called
and the patient had a transvenous pacer placed.

MEDICAL HISTORY: Biventricular Systolic Heart Failure EF 15-20% [**2174**]
Inferior myocardial infarction - [**2148**]
Cardiac History: CABG, in [**2168-1-9**] anatomy as follows: four
vessel coronary artery bypass graft was performed. LIMA to LAD,
SVG-diagonal, SVG - OM, SVG - PDA
Peptic ulcer disease.
History of diverticulitis
HTN
Hyperlipidemia
Mitral regurgitation/Aortic Stenosis
CKD
s/p transurethral resection of prostate

MEDICATION ON ADMISSION: Coreg 12.5mg [**Hospital1 **]
Centrum
Ecotrin 81mg daily
Allopurinol 100mg daily
Lasix 60mg daily
Lipitor 10mg daily
Metolazone 2.5mg every other day
Flomax 0.4mg daily
Potassium 10meq daily

ALLERGIES: Penicillins / Vasotec

PHYSICAL EXAM: Gen: WDWN elderly male, intubated and sedated
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: NC

SOCIAL HISTORY: Pt was widowed 2 years ago, has lived alone in [**Location (un) 620**] since and
was driving up until a few weeks ago. AFter first admission to
BIDN, he was discharged home with 24 hour non-skilled care and
was managing well with this help. Pt has 2 sone, one in Wash DC,
another in VT, who are very involved in patient's care and who
are concerned about his home situation after discharge. Pt has
been forgetful for a number of years but a formal dementia work
up has not been obtained per the son's knowledge. Pt is a
retired internist/cardiologist. Denies tobacco, occassional
EtOH.
Atrioventricular block, complete,Acute respiratory failure,Pneumonia, organism unspecified,Acute on chronic systolic heart failure,Delirium due to conditions classified elsewhere,Injury to bladder and urethra, without mention of open wound into cavity,Atrial flutter,Mitral valve insufficiency and aortic valve stenosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Diverticulosis of colon (without mention of hemorrhage),Peptic ulcer of unspecified site, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction,Other and unspecified hyperlipidemia,Hematuria, unspecified,Dysphagia, unspecified,Allergic urticaria,Acquired absence of organ, genital organs,Old myocardial infarction,Aortocoronary bypass status,Hyperpotassemia,Other specified forms of chronic ischemic heart disease,Unspecified accident
Atriovent block complete,Acute respiratry failure,Pneumonia, organism NOS,Ac on chr syst hrt fail,Delirium d/t other cond,Bladder/urethra inj-clos,Atrial flutter,Mitral insuf/aort stenos,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Dvrtclo colon w/o hmrhg,Peptic ulcer NOS,Hyperlipidemia NEC/NOS,Hematuria NOS,Dysphagia NOS,Allergic urticaria,Acq absnce genital organ,Old myocardial infarct,Aortocoronary bypass,Hyperpotassemia,Chr ischemic hrt dis NEC,Accident NOS
Admission Date:  [**2175-1-16**]              Discharge Date:   [**2175-1-20**]


Service: MEDICINE

Allergies:
Penicillins / Vasotec

Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Bradycardia

Major Surgical or Invasive Procedure:
Pacemaker Placement


History of Present Illness:
The pt is a 86y/o M with a PMH of biventricular CHF with EF 15%,
s/p CABG [**2167**] presenting with complete heart block.Recently
admitted [**Date range (1) 61817**] to BIDNH with dyspnea and was found to have
LLL PNA, treated with levaquin and azithromycin. He then
developed volume overload and was restarted on his home
diuretics. Of note, the patient declined a pacer placement.
Since discharge he reported feeling weak, not back to baseline
and with increased cough.The pt presented to BIDNH on [**2175-1-14**]
with complaints of weakness and CP. He was found to be in
complete heart block by EMS with HR 28 and BP 100 and was given
atropine en route to BIDNH ED. He became unresponsive in ED and
was intubated. Transcutaneous pacing started but he remained
hypotensive. Left SCL placed but no capture was obtained with
transvenous pacer. He was started on neosynephrien and dopamine
for hypotension. K 8.7 - hemolyzed and he was given calcium.
.
In the ED, initial vitals were HR: 80 [aced BP 144/47 RR 16
O2Sat: 92% RA. Patient received vancomycin 500mg IV, levaquin
750mg IV, Kayexelate 30g PR, Calcium gluconate 2gm IV, Insulin
10U IV and dextrose [**11-25**] amp for K of 6.1. Cardiology was called
and the patient had a transvenous pacer placed.


Past Medical History:
Biventricular Systolic Heart Failure EF 15-20% [**2174**]
Inferior myocardial infarction - [**2148**]
Cardiac History: CABG, in [**2168-1-9**] anatomy as follows: four
vessel coronary artery bypass graft was performed. LIMA to LAD,
SVG-diagonal, SVG - OM, SVG - PDA
Peptic ulcer disease.
History of diverticulitis
HTN
Hyperlipidemia
Mitral regurgitation/Aortic Stenosis
CKD
s/p transurethral resection of prostate


Social History:
Pt was widowed 2 years ago, has lived alone in [**Location (un) 620**] since and
was driving up until a few weeks ago. AFter first admission to
BIDN, he was discharged home with 24 hour non-skilled care and
was managing well with this help. Pt has 2 sone, one in Wash DC,
another in VT, who are very involved in patient's care and who
are concerned about his home situation after discharge. Pt has
been forgetful for a number of years but a formal dementia work
up has not been obtained per the son's knowledge. Pt is a
retired internist/cardiologist. Denies tobacco, occassional
EtOH.

Family History:
 NC

Physical Exam:
Gen: WDWN elderly male, intubated and sedated
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

Neck: Supple, no JVD
CV: RR, III/VI SM LUSB, No thrills, lifts.
Chest: No chest wall deformities, scoliosis or kyphosis. Clear
anteriorly, decreased BS L base, + bibasilar crackles
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No femoral bruits. no LE edema b/l
.
Pulses:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+


Pertinent Results:
[**2175-1-20**]:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2175-1-20**] 07:10AM    5.9 3.41* 10.5* 30.8* 90 30.8 34.0 15.9*
141*
  BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2175-1-20**] 07:10AM        141*
[**2175-1-20**] 07:10AM    15.6* 29.0   1.4*

Chemistry
  RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2175-1-20**] 07:10AM    128* 76* 2.5* 139 4.3 100 30 13
  CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron

[**2175-1-20**] 07:10AM          9.0 3.7 2.3

negative urine cx [**1-18**], negative sputum cx x2.

Brief Hospital Course:
#. Complete Heart Block - The patient has a history of
brady/tachy physiology per outpatient cardiologist most recently
in slow atrial flutter at 3:1 AV block. He has previously
declined pacer placement. Now presenting with CHB, most likely
representing progression of his underlying conduction disease.
Patient is s/p permanent pacemaker now off all pressor support.
PPM set at a rate of 60 currently. Completed 3 days of
clindamycin. F/U appt in device clinic on [**1-24**]. Right pacer
dressing will be changed at that appt.
.
# Acute Respiratory failure: now resolved ?????? patient was
intubated in the setting of complete heart block episode. Major
initial barrier to extubation was patient??????s mental status.
Initially concern for possible pnuemonia given sputum production
however patient afebrile without elevated white count and
previous treated for pneumonia. Has had 2 sputum samples that
show oropharangeal flora only.
.
#. Acute on chronic Severe Biventricular Systolic Heart Failure
?????? patient maintained on Coreg and low dose lipitor. Coreg was
restarted at lower dose and [**Last Name (un) **] was started on day of discharge.
Lasix at 60 mg daily (home dose)
.
#. Pleural Effusion - no clear evidence of PNA on CXR, likely
pulmonary edema related to severe CHF, no elevated WBC or fever,
recently treated for PNA with levaquin/azithromycin. Repeat
post-extubation CXR seems stable, no evidence of infection.
.
#. CAD - s/p CABG (4Vd in [**2167**])- No evidence that acute ischemia
led to CHB. Troponins on admission mildly elevated but flat in
the setting of renal failure.
Continue aspirin, beta blocker and statin
.
#. CKD - Cr 3.2 on admission, history of CKD with Cr ranging
from 2.5-3. Cr improved today to 2.5. Avoid nephrotoxins and
check lytes on Monday [**1-23**].
.
# Acute Delerium on Chronic Dementia- patient with underlying
dementia as per his son. [**Name (NI) **] has never had a dementia workup and
drove his car until recently. He is alert, calm, but with very
poor short term memory at this time. Has not needed Haldol in 24
hours. Pt will require fall precautions. An appt with a
geriatrician is scheduled at the memory clinic at [**Hospital1 18**] for
evaluation.
Please avoid benzodiazepines and anti-cholinergic medications
.
# Hematuria: resulting from foley trauma, no evidence of
infection. Bright red this am with tiny clots. Bladder scanned
and showed 165cc after 6 hours. Flomax restarted. Consider
continuous Foley irrigation if hematuria worsens. Push PO's of
thickened liquids.
.
#. HTN ?????? chronic. Well controlled on carvedilol and Losartan.
.
#. Hyperlipidemia - continue statin
.
#. Dysphagia: chronic cough concerning for silent aspiration.
Speech and swallow evaluation recommended ground solids with
nectar thick liquid, medications whole.
.
#. Uticaria: pt has macular red rash on lower back, thought to
be contact dermatitis. [**Name2 (NI) 6398**] lotion has been used successfully
for pruritis.
.
#. Disposition: Pt has 24 hour care at home, only set up in the
last week. Pt will need home safety evaluation by PT/OT to
assess level of care needed after discharge.


Medications on Admission:
Coreg 12.5mg [**Hospital1 **]
Centrum
Ecotrin 81mg daily
Allopurinol 100mg daily
Lasix 60mg daily
Lipitor 10mg daily
Metolazone 2.5mg every other day
Flomax 0.4mg daily
Potassium 10meq daily


Discharge Medications:
1. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Multivitamins     Tablet, Chewable Sig: One (1) Tablet PO
DAILY (Daily).
4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**11-25**] Sprays Nasal
QID (4 times a day).
7. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
9. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Ten
(10) ML PO Q6H (every 6 hours) as needed.
10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

13. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 700**] - [**Location (un) 701**]

Discharge Diagnosis:
Complete Heart Block
Acute on Chronic Congestive Heart Failure
Pneumonia
Acute Renal Failure
Uticaria


Discharge Condition:
stable.


Discharge Instructions:
You had complete heart block with a heart rate of 20 and became
unresponsive on [**1-16**] requiring intubation and pacemaker
placement. You were on pressors to increase your blood pressure
for a few days but your blood pressure is normal now. All of
your culture results are negative to date. Because of your new
pacemaker, you cannot lift more than 10 pounds for 6 weeks and
should refrain from lifting your left arm over your head for 6
weeks. You will come back to the device clinic here at [**Hospital1 18**]
next Tuesday to get your pacer checked and the dressing removed
over the pacer site.
New medicines:
1. Your carvedilol was decreased to 6.25 mg twice daily
2. You were started on Losartan to decrease your blood pressure\
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day
or 6 pounds in 3 days.
Adhere to 2 gm sodium diet
.
Please call provider if there is any increased bruising or
bleeding around the pacer site, if you have any fevers,
increased coughing, dizziness or chest pain.


Followup Instructions:
Cardiology:
DEVICE CLINIC [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **], [**Location (un) **] [**Location (un) 86**]. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2175-1-24**] 9:00am
.
Primary care and Cardiology:
Dr. [**Last Name (STitle) 29111**] [**Name (STitle) 11302**] Phone: ([**Telephone/Fax (1) 107816**] Date/Time: Tuesday
[**2-7**] at 11:15am
Gerontology/Memory clinic: [**Hospital Unit Name **], [**Hospital Unit Name **] [**Last Name (NamePattern1) 8028**], [**Location (un) 86**]
Provider: [**First Name8 (NamePattern2) 1439**] [**Last Name (NamePattern1) **], MD  Phone:[**Telephone/Fax (1) 719**] Date/Time: [**2-2**] at 11am.



Completed by:[**2175-1-20**]
{'Atrioventricular block, complete,Acute respiratory failure,Pneumonia, organism unspecified,Acute on chronic systolic heart failure,Delirium due to conditions classified elsewhere,Injury to bladder and urethra, without mention of open wound into cavity,Atrial flutter,Mitral valve insufficiency and aortic valve stenosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Diverticulosis of colon (without mention of hemorrhage),Peptic ulcer of unspecified site, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction,Other and unspecified hyperlipidemia,Hematuria, unspecified,Dysphagia, unspecified,Allergic urticaria,Acquired absence of organ, genital organs,Old myocardial infarction,Aortocoronary bypass status,Hyperpotassemia,Other specified forms of chronic ischemic heart disease,Unspecified accident'}


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: Bradycardia

PRESENT ILLNESS: The pt is a 86y/o M with a PMH of biventricular CHF with EF 15%,
s/p CABG [**2167**] presenting with complete heart block.Recently
admitted [**Date range (1) 61817**] to BIDNH with dyspnea and was found to have
LLL PNA, treated with levaquin and azithromycin. He then
developed volume overload and was restarted on his home
diuretics. Of note, the patient declined a pacer placement.
Since discharge he reported feeling weak, not back to baseline
and with increased cough.The pt presented to BIDNH on [**2175-1-14**]
with complaints of weakness and CP. He was found to be in
complete heart block by EMS with HR 28 and BP 100 and was given
atropine en route to BIDNH ED. He became unresponsive in ED and
was intubated. Transcutaneous pacing started but he remained
hypotensive. Left SCL placed but no capture was obtained with
transvenous pacer. He was started on neosynephrien and dopamine
for hypotension. K 8.7 - hemolyzed and he was given calcium.
.
In the ED, initial vitals were HR: 80 [aced BP 144/47 RR 16
O2Sat: 92% RA. Patient received vancomycin 500mg IV, levaquin
750mg IV, Kayexelate 30g PR, Calcium gluconate 2gm IV, Insulin
10U IV and dextrose [**11-25**] amp for K of 6.1. Cardiology was called
and the patient had a transvenous pacer placed.

MEDICAL HISTORY: Biventricular Systolic Heart Failure EF 15-20% [**2174**]
Inferior myocardial infarction - [**2148**]
Cardiac History: CABG, in [**2168-1-9**] anatomy as follows: four
vessel coronary artery bypass graft was performed. LIMA to LAD,
SVG-diagonal, SVG - OM, SVG - PDA
Peptic ulcer disease.
History of diverticulitis
HTN
Hyperlipidemia
Mitral regurgitation/Aortic Stenosis
CKD
s/p transurethral resection of prostate

MEDICATION ON ADMISSION: Coreg 12.5mg [**Hospital1 **]
Centrum
Ecotrin 81mg daily
Allopurinol 100mg daily
Lasix 60mg daily
Lipitor 10mg daily
Metolazone 2.5mg every other day
Flomax 0.4mg daily
Potassium 10meq daily

ALLERGIES: Penicillins / Vasotec

PHYSICAL EXAM: Gen: WDWN elderly male, intubated and sedated
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: NC

SOCIAL HISTORY: Pt was widowed 2 years ago, has lived alone in [**Location (un) 620**] since and
was driving up until a few weeks ago. AFter first admission to
BIDN, he was discharged home with 24 hour non-skilled care and
was managing well with this help. Pt has 2 sone, one in Wash DC,
another in VT, who are very involved in patient's care and who
are concerned about his home situation after discharge. Pt has
been forgetful for a number of years but a formal dementia work
up has not been obtained per the son's knowledge. Pt is a
retired internist/cardiologist. Denies tobacco, occassional
EtOH. 

### Response:
{'Atrioventricular block, complete,Acute respiratory failure,Pneumonia, organism unspecified,Acute on chronic systolic heart failure,Delirium due to conditions classified elsewhere,Injury to bladder and urethra, without mention of open wound into cavity,Atrial flutter,Mitral valve insufficiency and aortic valve stenosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Diverticulosis of colon (without mention of hemorrhage),Peptic ulcer of unspecified site, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction,Other and unspecified hyperlipidemia,Hematuria, unspecified,Dysphagia, unspecified,Allergic urticaria,Acquired absence of organ, genital organs,Old myocardial infarction,Aortocoronary bypass status,Hyperpotassemia,Other specified forms of chronic ischemic heart disease,Unspecified accident'}
