CHIEF COMPLAINT: Palpitations

PRESENT ILLNESS: 44 yo male with history of HTN presented to his PCP today
complaining of weakness, intermittent fatigue, and occassional
cough for one week.  Over the past 2 days, he has had trouble
lying flat and has slept sitting in a chair.  He reports
palpitations; feels like his heart is "beating like racehorse,"
but denies dizziness, or lightheadedness.  Reports that
palpitations will last for few seconds and then self resolve.
He denies CP, but reports orthopnea.  Also reports worsening
dyspnea on exertion. In the past was able to walk long distances
without any SOB, but in the last few days the patient reports
that he has not been able walk more than ten minutes for the
last two days without stopping [**1-23**] shortness of breath.  The
patient denies ever having shortness of breath.  Of note, the
patient also reports developing a dry cough, mostly during the
day.  Started this past Wednesday.  Denies any recent
fevers/chills, no sick contacts.
.
Of note, he has not been taking lisinopril and HCTZ for past 6
months, as he reports not knowing he needed to continue these.
He reports occaisional NSAID/ibuprofen use for headache. Reports
that [**Last Name (un) **] has been his "second home."
.
Patient was first noted to have hypertension in [**2150**], initially
started on HCTZ 25 mg daily, and then lisinopril 10 mg added on.
 The patient has not been compliant with his medications; also
has had dietary indiscretions, even after being counseled about
the importance of low salt diet and exercise.
.
At [**Company 191**], he was found to have a HR in 150-160's with a narrow
complex SVT seen on EKG.  Vagal maneuvers were attempted but
were unsuccessful.  BP at the time was 150/100.  He was sent to
the ED for further evaluation of his tachycardia.
.
Upon arrival to the ED, initial vitals were 98.0 120
170/160-200/130 18 100% on unclear amt of oxygen.  Exam revealed
markedly elevated JVP, diffuse crackles, abdominal distension,
and [**12-23**]+ pitting edema.  EKG revealed a narrow compelx
tachycardia.  At 4pm, 12mg of adenosine was given through a
small right hand PIV, with conversion to sinus tachycardia at
140.  IVF were started for tachycardia with total 1.5L given.
At 6pm, he was still tachy to the 180's with another dose of
adenosine 12mg given.  He reverted to sinus brady at 50-60 for
10 seconds, then went back into sinus tachycardia.  CXR was
obtained and revealed volume overload so IVF were stopped.
Bedside TTE revealed no effusion.  EP was consulted and felt
this was likely acute heart failure [**1-23**] hypertension and SVT [**1-23**]
atrial stretch.  They recommended lasix 20mg x2, nitro gtt, and
bipap for recruitment.  RT started CPAP instead.  Vitals prior
to transfer: 139 142/102, 20, 100% on CPAP.
.
On review of systems, denies any abdominal pain, n/v/d, changes
in BM, denies any urinary sx, no blood in stool.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, +Hypertension

MEDICATION ON ADMISSION: ** Patient states that he had not been taking for at least 6
months prior to admission. **
1. Lisinopril 10 mg PO daily
2. Hydrochlorothiazide 25 mg PO daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission PE:
.
GENERAL: NAD. Oriented x3, tachypneic on NC, slightly flushed
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: DM, denies any cardiovascular disease, no h/o MIs.

SOCIAL HISTORY: Denies tobacco, EtOH, illicits, not currently sexually active.
Unspecified hypertensive heart disease with heart failure,Acute kidney failure, unspecified,Acute systolic heart failure,Other specified cardiac dysrhythmias,Personal history of noncompliance with medical treatment, presenting hazards to health,Cardiomyopathy in other diseases classified elsewhere
Hyp ht dis NOS w ht fail,Acute kidney failure NOS,Ac systolic hrt failure,Cardiac dysrhythmias NEC,Hx of past noncompliance,Cardiomyopath in oth dis
Admission Date:  [**2154-10-31**]              Discharge Date:   [**2154-11-6**]

Date of Birth:  [**2110-6-27**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

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

Major Surgical or Invasive Procedure:
EP study and mapping
Unsuccessful atrial tachycardia ablation

History of Present Illness:
44 yo male with history of HTN presented to his PCP today
complaining of weakness, intermittent fatigue, and occassional
cough for one week.  Over the past 2 days, he has had trouble
lying flat and has slept sitting in a chair.  He reports
palpitations; feels like his heart is "beating like racehorse,"
but denies dizziness, or lightheadedness.  Reports that
palpitations will last for few seconds and then self resolve.
He denies CP, but reports orthopnea.  Also reports worsening
dyspnea on exertion. In the past was able to walk long distances
without any SOB, but in the last few days the patient reports
that he has not been able walk more than ten minutes for the
last two days without stopping [**1-23**] shortness of breath.  The
patient denies ever having shortness of breath.  Of note, the
patient also reports developing a dry cough, mostly during the
day.  Started this past Wednesday.  Denies any recent
fevers/chills, no sick contacts.
.
Of note, he has not been taking lisinopril and HCTZ for past 6
months, as he reports not knowing he needed to continue these.
He reports occaisional NSAID/ibuprofen use for headache. Reports
that [**Last Name (un) **] has been his "second home."
.
Patient was first noted to have hypertension in [**2150**], initially
started on HCTZ 25 mg daily, and then lisinopril 10 mg added on.
 The patient has not been compliant with his medications; also
has had dietary indiscretions, even after being counseled about
the importance of low salt diet and exercise.
.
At [**Company 191**], he was found to have a HR in 150-160's with a narrow
complex SVT seen on EKG.  Vagal maneuvers were attempted but
were unsuccessful.  BP at the time was 150/100.  He was sent to
the ED for further evaluation of his tachycardia.
.
Upon arrival to the ED, initial vitals were 98.0 120
170/160-200/130 18 100% on unclear amt of oxygen.  Exam revealed
markedly elevated JVP, diffuse crackles, abdominal distension,
and [**12-23**]+ pitting edema.  EKG revealed a narrow compelx
tachycardia.  At 4pm, 12mg of adenosine was given through a
small right hand PIV, with conversion to sinus tachycardia at
140.  IVF were started for tachycardia with total 1.5L given.
At 6pm, he was still tachy to the 180's with another dose of
adenosine 12mg given.  He reverted to sinus brady at 50-60 for
10 seconds, then went back into sinus tachycardia.  CXR was
obtained and revealed volume overload so IVF were stopped.
Bedside TTE revealed no effusion.  EP was consulted and felt
this was likely acute heart failure [**1-23**] hypertension and SVT [**1-23**]
atrial stretch.  They recommended lasix 20mg x2, nitro gtt, and
bipap for recruitment.  RT started CPAP instead.  Vitals prior
to transfer: 139 142/102, 20, 100% on CPAP.
.
On review of systems, denies any abdominal pain, n/v/d, changes
in BM, denies any urinary sx, no blood in stool.

Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, +Hypertension

2. CARDIAC HISTORY:
- CABG:  none
- PERCUTANEOUS CORONARY INTERVENTIONS:  none
- PACING/ICD:  none
3. OTHER PAST MEDICAL HISTORY:  none

Social History:
Denies tobacco, EtOH, illicits, not currently sexually active.

Family History:
DM, denies any cardiovascular disease, no h/o MIs.

Physical Exam:
Admission PE:
.
GENERAL: NAD. Oriented x3, tachypneic on NC, slightly flushed
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

NECK: Supple with JVP to mid earlobe
CARDIAC: tachycardic, S1, S2, with S3, no murmurs appreciated
LUNGS: Poor air movement throughout, + wheezes throughout
ABDOMEN: Soft, slightly distended, +BS, no fluid wave
appreciated, non tender throughout
EXTREMITIES: warm well perfused, 2+ pitting edema b/l [**12-23**]
anterior shins
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Neuro: intact sensation/strength throughout, CN 2-12 grossly
intact
.
Discharge PE:
98.7 127/80 82 18 99 on RA
GENERAL: NAD. Oriented x3, tachypneic on NC, slightly flushed
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

NECK: Supple with JVP to mid earlobe
CARDIAC: tachycardic, S1, S2, with S3, no murmurs appreciated
LUNGS: Poor air movement throughout, + wheezes throughout
ABDOMEN: Soft, slightly distended, +BS, no fluid wave
appreciated, non tender throughout
EXTREMITIES: warm well perfused, 2+ pitting edema b/l [**12-23**]
anterior shins
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.

Pertinent Results:
Admission Labs:
[**2154-10-31**] 03:50PM BLOOD WBC-9.7# RBC-4.56* Hgb-13.9* Hct-40.6
MCV-89 MCH-30.5 MCHC-34.2 RDW-12.6 Plt Ct-238
[**2154-10-31**] 03:50PM BLOOD Neuts-69.3 Lymphs-23.9 Monos-5.3 Eos-1.2
Baso-0.3
[**2154-10-31**] 03:50PM BLOOD Glucose-126* UreaN-20 Creat-1.3* Na-137
K-4.2 Cl-99 HCO3-26 AnGap-16
[**2154-10-31**] 03:50PM BLOOD ALT-228* AST-114* AlkPhos-86 TotBili-0.7
[**2154-10-31**] 03:50PM BLOOD D-Dimer-753*
[**2154-10-31**] 03:50PM BLOOD %HbA1c-5.8 eAG-120
[**2154-10-31**] 03:50PM BLOOD Triglyc-115 HDL-45 CHOL/HD-2.9 LDLcalc-63
LDLmeas-69
[**2154-10-31**] 03:50PM BLOOD TSH-2.1
.
Cardiac Enzymes:
[**2154-10-31**] 03:50PM BLOOD cTropnT-<0.01
[**2154-11-1**] 03:22AM BLOOD CK-MB-2 cTropnT-<0.01
[**2154-11-1**] 02:04PM BLOOD CK-MB-1 cTropnT-<0.01
.
Relevant EKGs:
1. [**2154-10-31**]: Supraventricular tachycardia at 163 beats per
minute with a short R-P interval configuration. Left ventricular
hypertrophy with T wave inversions in  lead aVL and ST segment
sagging in leads I and V5-V6. Minimal J point elevation in the
inferior leads with inconsistent ST segment depression,
possibily artifactual in the inferior leads. ST segment
flattening in lead V4. No previous tracing available for
comparison.
2. [**2154-11-1**]: Sinus rhythm. Left ventricular hypertrophy. Left
atrial abnormality. Compared to the previous tracing of [**2154-10-31**]
sinus rhythm has replaced the supraventricular tachycardia. Left
ventricular hypertrophy is unchanged. T wave inversions in leads
I and aVL are improved. Non-specific ST segment flattening is
now prominent in the inferior leads and unchanged in the lateral
leads.  QRS morphology in the precordial leads is again
different consistent with alteration in precordial electrode
placement.
3. [**2154-11-2**]: Sinus tachycardia versus atrial tachycardia. Left
ventricular hypertrophy with secondary repolarization
abnormalities.
.
TTE ([**2154-11-1**]):
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity is moderately dilated.
There is moderate to severe global left ventricular hypokinesis
(LVEF = 30 %) with regional variation; the inferior free wall is
akinetic. The right ventricular free wall is hypertrophied. The
right ventricular cavity is dilated with depressed free wall
contractility. The number of aortic valve leaflets cannot be
determined. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. An eccentric,
posteriorly directed jet of moderate (2+) mitral regurgitation
is seen. Due to the eccentric nature of the regurgitant jet, its
severity may be significantly underestimated (Coanda effect).
The left ventricular inflow pattern suggests a restrictive
filling abnormality, with elevated left atrial pressure. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
Renal Artery Ultrasound ([**2154-11-2**]):
1. Patent main renal arteries. While the study is limited as the

intraparenchymal renal arteries could not be adequately assessed
due to the patient's inability to breath hold, there is no
definite stenosis.
2. No hydronephrosis or renal stone.
3. 3.2 cm lower pole simple left renal cyst.
4. Echogenic liver, suggestive of hepatosteatosis.
5. Left pleural effusion.
.
Discharge Labs:
[**2154-11-6**] 07:15AM BLOOD WBC-9.5 RBC-4.56* Hgb-13.8* Hct-41.3
MCV-91 MCH-30.3 MCHC-33.5 RDW-12.8 Plt Ct-256
[**2154-11-6**] 07:15AM BLOOD Glucose-106* UreaN-21* Creat-1.2 Na-137
K-4.1 Cl-99 HCO3-32 AnGap-10

Brief Hospital Course:
Brief Hospital Course:
44 y/o male with hypertension and h/o of medication
non-compliance (according to the patient) who presented with
palpitations, fatigue, orthopnea, PND and occassional cough to
PCP office and found to have new systolic CHF, tachycardia and
aucte diney injury.
.
# Atrial Tachycardia: Initially thought related to hypertension
and CHF but did not resolve after diuresis and BP control. Pt is
asymptomatic with the episodes.  Rates were 100-140's, increased
with activity. EP mapping and attempted ablation of AT was
unsuccessful so pt was started on amiodarone loading dose on day
of discharge with 300 mg [**Hospital1 **] for one month. He will f/u with EP
cardiology in 1 month at [**Hospital1 18**].
.
# Acute systolic heart failure: The patient initially presented
with signs and symptoms of heart failure, including severe
orthopnea, cardiac wheeze, 2+ peripheral edema and S3 on exam,
LVH on ECG and pulmonary edema on CXR. R/O'd by enzymes. His
blood pressure was controlled on nitroglycerin IV and furosemide
drip for diuresis. ECHO showed EF 30%, TR gradient of 39 and
global LV hypokinesis. Cardiac MR was done and results are
pending at the time of this summary. After a brisk diuresis, pt
was transitioned to carvedilol, torsemide and valsartan PO.
Weight at discharge was 180 pounds and all signs of CHF had
resolved. Teaching about medication complience, dietary Na
intake and daily weights was done but will need reinforcement.
.
# Hypertension: The patient was possibly having hypertensive
urgency with end organ ischemia evidenced by heart failure.
Blood pressure was controlled with vasartan (changed to
lisinopril after discharge because of insurance) and carvedilol.
Blood pressure should be followed as an outpatient for
medication adjustement.
.
# Acute Kidney Injury: Creat 1.3, baseline of 1.1 a year ago;
possibly end organ damage due to hypertension or decreased EF.
Creatinine had normalized to 1.2 at time
of discharge. Labs will be checked again as an outpatient.
.
Transitional Issues:
- Please follow up secondary hypertension work
up--metanephrines, aldosterone, and renin pending as of [**11-10**].
- Pt should be followed closely for complience to medicines as
this has been an issue in the past.
- Follow up cardiac MR results, pending as of [**11-10**].

Medications on Admission:
** Patient states that he had not been taking for at least 6
months prior to admission. **
1. Lisinopril 10 mg PO daily
2. Hydrochlorothiazide 25 mg PO daily


Discharge Medications:
1. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
2. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. amiodarone 200 mg Tablet Sig: 1.5 Tablets PO twice a day for
1 months.
Disp:*90 Tablet(s)* Refills:*1*
5. Outpatient Lab Work
Please check chem-7 on Friday [**2154-11-8**] and call results to Dr.
[**Last Name (STitle) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at Phone: [**Telephone/Fax (1) 250**]
Fax: [**Telephone/Fax (1) 3382**]


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Atrial tachycardia
Acute systolic congestive heart failure
Hypertension


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


Discharge Instructions:
You had a fast heart rate that made your heart weak. We tried to
stun the part of the electrical system of the heart that was
causing the fast heart rate but were unable to do this. Instead,
we are starting you on a mew medicine to help to slow your heart
rate. You will need to take this medicine twice daily for one
month and will come back in one month to see Dr. [**Last Name (STitle) **]. It
is very important you take you medicine every day to help keep
your heart working well. Weigh yourself every morning, call Dr.
[**Last Name (STitle) **] if weight goes up more than 3 lbs in 1 day or 5 pounds in
3 days. Also call Dr. [**Last Name (STitle) **] if you notice that you are having
trouble breathing or the swelling comes back. Please come to
[**Hospital Ward Name 23**] Clinical Center on Friday [**11-8**] to get your
blood checked, please bring the prescription with you.
.
We have started the following medicines:
1. START Carvedilol to lower your blood pressure and help your
heart pump better
2. START Valsartan to lower your blood pressure and help your
heart pump better
3. START Amiodarone to slow your heart rate. You will take this
dose for one month and will talk to Dr. [**Last Name (STitle) **] about changing
the dose after one month.
4. START Torsemide to get rid of extra fluid in your body.

Followup Instructions:
Test for consideration post-discharge: Aldosterone
.
Department: [**Hospital3 249**]
When: TUESDAY [**2154-11-12**] at 9:10 AM
With: DR [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]/[**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
**This appointment is with a hospital-based doctor as part of
your transition from the hospital back to your primary care
provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary
care doctor in follow up.**
.
Department: CARDIAC SERVICES
When: Friday [**12-13**] at 1:20 PM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Unspecified hypertensive heart disease with heart failure,Acute kidney failure, unspecified,Acute systolic heart failure,Other specified cardiac dysrhythmias,Personal history of noncompliance with medical treatment, presenting hazards to health,Cardiomyopathy in other diseases classified elsewhere'}


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: Palpitations

PRESENT ILLNESS: 44 yo male with history of HTN presented to his PCP today
complaining of weakness, intermittent fatigue, and occassional
cough for one week.  Over the past 2 days, he has had trouble
lying flat and has slept sitting in a chair.  He reports
palpitations; feels like his heart is "beating like racehorse,"
but denies dizziness, or lightheadedness.  Reports that
palpitations will last for few seconds and then self resolve.
He denies CP, but reports orthopnea.  Also reports worsening
dyspnea on exertion. In the past was able to walk long distances
without any SOB, but in the last few days the patient reports
that he has not been able walk more than ten minutes for the
last two days without stopping [**1-23**] shortness of breath.  The
patient denies ever having shortness of breath.  Of note, the
patient also reports developing a dry cough, mostly during the
day.  Started this past Wednesday.  Denies any recent
fevers/chills, no sick contacts.
.
Of note, he has not been taking lisinopril and HCTZ for past 6
months, as he reports not knowing he needed to continue these.
He reports occaisional NSAID/ibuprofen use for headache. Reports
that [**Last Name (un) **] has been his "second home."
.
Patient was first noted to have hypertension in [**2150**], initially
started on HCTZ 25 mg daily, and then lisinopril 10 mg added on.
 The patient has not been compliant with his medications; also
has had dietary indiscretions, even after being counseled about
the importance of low salt diet and exercise.
.
At [**Company 191**], he was found to have a HR in 150-160's with a narrow
complex SVT seen on EKG.  Vagal maneuvers were attempted but
were unsuccessful.  BP at the time was 150/100.  He was sent to
the ED for further evaluation of his tachycardia.
.
Upon arrival to the ED, initial vitals were 98.0 120
170/160-200/130 18 100% on unclear amt of oxygen.  Exam revealed
markedly elevated JVP, diffuse crackles, abdominal distension,
and [**12-23**]+ pitting edema.  EKG revealed a narrow compelx
tachycardia.  At 4pm, 12mg of adenosine was given through a
small right hand PIV, with conversion to sinus tachycardia at
140.  IVF were started for tachycardia with total 1.5L given.
At 6pm, he was still tachy to the 180's with another dose of
adenosine 12mg given.  He reverted to sinus brady at 50-60 for
10 seconds, then went back into sinus tachycardia.  CXR was
obtained and revealed volume overload so IVF were stopped.
Bedside TTE revealed no effusion.  EP was consulted and felt
this was likely acute heart failure [**1-23**] hypertension and SVT [**1-23**]
atrial stretch.  They recommended lasix 20mg x2, nitro gtt, and
bipap for recruitment.  RT started CPAP instead.  Vitals prior
to transfer: 139 142/102, 20, 100% on CPAP.
.
On review of systems, denies any abdominal pain, n/v/d, changes
in BM, denies any urinary sx, no blood in stool.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, +Hypertension

MEDICATION ON ADMISSION: ** Patient states that he had not been taking for at least 6
months prior to admission. **
1. Lisinopril 10 mg PO daily
2. Hydrochlorothiazide 25 mg PO daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission PE:
.
GENERAL: NAD. Oriented x3, tachypneic on NC, slightly flushed
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: DM, denies any cardiovascular disease, no h/o MIs.

SOCIAL HISTORY: Denies tobacco, EtOH, illicits, not currently sexually active. 

### Response:
{'Unspecified hypertensive heart disease with heart failure,Acute kidney failure, unspecified,Acute systolic heart failure,Other specified cardiac dysrhythmias,Personal history of noncompliance with medical treatment, presenting hazards to health,Cardiomyopathy in other diseases classified elsewhere'}
