CHIEF COMPLAINT: dyspnea on exertion

PRESENT ILLNESS: 77 y/o man with a history of diabetes, coronary disease s/p CABG
[**2162**] and several subsequent PCI, chronic renal failure, copd,
and atrial fibrillation on coumadin presents as a transfer from
[**Hospital **] hospital with chest pain.

MEDICAL HISTORY: # Coroary Artery Disease: CABG [**2152**]. PCI in [**4-/2170**], [**5-/2170**], and
10/[**2170**].
-PCI [**4-/2170**]: Atritic LIMA, occluded SVG to OM1/OM2, patent
SVG-Diag, unsucessful attempt at PCI of OM1 for placement of DES
to graft. Lcx dissection
-PCI [**5-/2170**]: succesful PCI of SVG to OM
-PCI [**9-/2171**]: patnet SVG-D2, patent SVG OM1-OM2, no intervention

MEDICATION ON ADMISSION: Allopurinol 300mg po qday
Imdur 120mg po Qday
Coumadin 5mg po Qday
Novolog prior to meals
zocor 80mg po qday
atroven nebs ih q4-6h prn
albuterol nebs ih q4-6h prn
metoprolol tartrate 50mg po BID
prilosec 20mg po BID
furosemide 40mg po qday
tramadol prn
aricept 10mg po qhs
glucotrol XL 5mg po qday
zestril 10mg po qday
NTG sL prn
aspirin 81mg po qday

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 98.3 160/63 62 18 97%RA
GEN: elderly male, not in any acute distress, obese
HEENT: moist mucus membranes
CV: RRR s1, s2, no M/G/R
RESP: course bs bialterally, low-pitched expiratory wheezes, no
crackles
ABD: soft, obese, several lumps palpated (?sub-cu scar tissue)
midline scar noted and laparoscope scars noted left and right of
midline.
EXT: no edema

FAMILY HISTORY: There is no family history of premature coronary artery disease
or sudden death

SOCIAL HISTORY: Lives in [**Location **] by himself. divorced, currently in a
relationship. Had 5 children, 1 passed away in [**2164**]. Former part
time police officer and welder, retired. Quit smoking most
recently 2 weeks ago, no etoh use.
Paroxysmal ventricular tachycardia,Acute kidney failure, unspecified,Intermediate coronary syndrome,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Long-term (current) use of anticoagulants,Tobacco use disorder,Chronic airway obstruction, not elsewhere classified,Other late effects of cerebrovascular disease,Aortocoronary bypass status,Coronary atherosclerosis of native coronary artery,Chronic kidney disease, unspecified,Other and unspecified hyperlipidemia,Gout, unspecified,Esophageal reflux,Old myocardial infarction,Other musculoskeletal symptoms referable to limbs
Parox ventric tachycard,Acute kidney failure NOS,Intermed coronary synd,DMII wo cmp nt st uncntr,Hy kid NOS w cr kid I-IV,Long-term use anticoagul,Tobacco use disorder,Chr airway obstruct NEC,Late effect CV dis NEC,Aortocoronary bypass,Crnry athrscl natve vssl,Chronic kidney dis NOS,Hyperlipidemia NEC/NOS,Gout NOS,Esophageal reflux,Old myocardial infarct,Muscskel sympt limb NEC
Admission Date:  [**2174-5-30**]              Discharge Date:   [**2174-6-10**]

Date of Birth:  [**2096-12-29**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2880**]
Chief Complaint:
dyspnea on exertion

Major Surgical or Invasive Procedure:
Cardiac catheterization
Electrophysiologic study
ICD implant placement


History of Present Illness:
77 y/o man with a history of diabetes, coronary disease s/p CABG
[**2162**] and several subsequent PCI, chronic renal failure, copd,
and atrial fibrillation on coumadin presents as a transfer from
[**Hospital **] hospital with chest pain.

He was admitted last week to [**Hospital **] hospital with chest pain
and ruled out for acute MI. He refused catheritization at that
time and was discharged. He was re-admitted sunday [**5-28**] with
recurrent chest pressure, diaphoresis, which began while at
dinner saturday night. He was found with a HR in the field of
160, BP 90s systolic. In the emergency department an EKG showed
an SVT, interpreted as atrial flutter. He had a blood pressure
in the 70s and attempts at chemical cardioversion with lopressor
IV and adenosine were unsuccesful. He then received amiodarone
and versed and became unresponsive with a BP in the 40s. He was
DC cardioverted with apparent return of atrial fibrillation the
60s and SBP 130. (pre and post-cardioversion telemetric strips
are not available).
.
He was admitted to [**Hospital **] hospital. His hospital course was
complicated by recurrent chest pain and a troponin elevation
wtihout CK elevation. It was presumed secondary to cardioversion
as EKGs were without ischemic changes. At some point he
converted to normal sinus rhythym with a markedly prolonged PR
interval. His metoprolol dose was increased to 100mg twice
daily, but this was decreased subsequently as he developed 2:1
wenkebach. He was evaluated by cardiology and was transfered to
[**Hospital1 18**] for consideration of cardiac cath and/or flutter ablation.
His coumadin was held, INR was 1.8 on transfer.


Past Medical History:
# Coroary Artery Disease: CABG [**2152**]. PCI in [**4-/2170**], [**5-/2170**], and
10/[**2170**].
-PCI [**4-/2170**]: Atritic LIMA, occluded SVG to OM1/OM2, patent
SVG-Diag, unsucessful attempt at PCI of OM1 for placement of DES
to graft. Lcx dissection
-PCI [**5-/2170**]: succesful PCI of SVG to OM
-PCI [**9-/2171**]: patnet SVG-D2, patent SVG OM1-OM2, no intervention

# Diabetes Mellitus
# Atrial Fibrillation, on coumadin
# Stroke with residual left hand dysfunction
# Hyperlipidemia
# Diverticulitis with partial bowel resection, colostomy s/p
reversal
# Chronic Renal Failure, b/l 1.5-2
# COPD
# Hypertension
# Tobacco Use, active
# Gout
# GERD


Social History:
Lives in [**Location **] by himself. divorced, currently in a
relationship. Had 5 children, 1 passed away in [**2164**]. Former part
time police officer and welder, retired. Quit smoking most
recently 2 weeks ago, no etoh use.


Family History:
There is no family history of premature coronary artery disease
or sudden death

Physical Exam:
98.3 160/63 62 18 97%RA
GEN: elderly male, not in any acute distress, obese
HEENT: moist mucus membranes
CV: RRR s1, s2, no M/G/R
RESP: course bs bialterally, low-pitched expiratory wheezes, no
crackles
ABD: soft, obese, several lumps palpated (?sub-cu scar tissue)
midline scar noted and laparoscope scars noted left and right of
midline.
EXT: no edema


Pertinent Results:
[**2174-5-31**] 06:25AM BLOOD WBC-11.8* RBC-3.99* Hgb-11.9*# Hct-35.7*
MCV-89 MCH-29.7 MCHC-33.2 RDW-17.8* Plt Ct-221
[**2174-6-10**] 09:00AM BLOOD WBC-10.5 RBC-3.52* Hgb-10.5* Hct-32.7*
MCV-93 MCH-29.8 MCHC-32.1 RDW-17.5* Plt Ct-173
[**2174-5-31**] 06:25AM BLOOD Neuts-69.4 Lymphs-21.7 Monos-6.1 Eos-2.2
Baso-0.5
[**2174-6-10**] 09:00AM BLOOD PT-13.1 PTT-30.8 INR(PT)-1.1
[**2174-6-10**] 09:00AM BLOOD Glucose-192* UreaN-40* Creat-1.9* Na-139
K-4.6 Cl-108 HCO3-24 AnGap-12
[**2174-5-31**] 06:25AM BLOOD Glucose-120* UreaN-43* Creat-1.7* Na-143
K-4.7 Cl-109* HCO3-22 AnGap-17
[**2174-6-1**] 06:55AM BLOOD cTropnT-0.28*
[**2174-5-31**] 06:25AM BLOOD TSH-2.7
[**2174-5-31**] 06:25AM BLOOD CK(CPK)-41

Brief Hospital Course:
1. Ventricular tachycardia
Patient presented for cardiac cath, and after admission
presented with a new wide-complex tachycardia, which was
interpretted as non-sustained VT with rate 150. He underwent
cardiac catherization on [**6-1**] in order to identify any ischemic
cause of arrhythmia or conduction delays. Cath showed patent
grafts and ostial stenosis of both right and left main
coronaries, not ammenable to intervention. Patient likely
perfuses via retrograde filling of LAD from diagonal stent and
collaterals. Patient then had EP study on [**6-6**]. However, the
clinical NSVT could not be induced. Two other VT patterns were
induced, and patient became unstable with these. In order to
prevent these unstable VTs, and also to allow adequate drug
therapy without inducing bradycardia, a dual chamber [**Company 1543**]
ICD was therefore placed on [**6-7**]. The ICD was set to pace VT at
a rate of 180. The evening after ICD placement, patient
developed sustained VT with hypotension (SBP 80) and slowed
mentation. He spontaneously converted to NSR, but VT recurred
within minutes. EP was called and ICD was adjusted to threshold
HR 160. Patient was transferred to CCU overnight on [**6-7**] and
received bolus of amiodarone and continued on metoprolol.
Patient then remained in NSR with occasional non-sustained VT
without symptoms terminated with anti-tachycardia pacing by the
ICD. Last run was 11:30 pm on [**6-7**]. He remained hemodynamically
stable. Per EP rec's, patient was started on mexelitine on [**6-8**],
but it was held on [**6-9**] after CNS changes including mental
inattention and sluggishness. His mental faculties returned to
baseline after Mexilitine was held and he had no further
episodes of arrythmia. Based on discussion with the cardiology
attending the plan is to continue on Metoprolol and not start an
anti-arrhythmic and allow the ICD to pace Mr. [**Known lastname 4027**] out of his
Ventricular Tachycardia. If he requires frequent defibrillations
however anti-arrhythmic therapy would have to be reconsidered.
- Mr. [**Known lastname 4027**] will need to follow up with his device clinic
appointment
- The Electrophysiology clinic was notifed of pt's discharge and
contact rehab centre for an appointment with Dr. [**Last Name (STitle) **] at
[**Hospital1 18**], if you have not heard from them by Wednesday please call
his office [**Telephone/Fax (1) 62**]

2. Coronary disease
Cath demonstrated patent grafts from prior CABG, with no
significant change since prior PCI on [**9-13**]. Patient was
continued on home metoprolol and Imdur. He was restarted on ASA,
Statin and Lisinopril.

3. Atrial fibrillation
Patient has chronic a fib, with complications including previous
stroke. He is chronically anticoagulated and rate controlled.
Coumadin was held and heparin drip started due to procedures and
tenous course. Following his ICD placement, he was restarted
directly on to Coumadin without Heparin bridge. Rate control
with metoprolol was continued.
- Please continue to check PT/INR every Monday and Friday and
titrate his Warfarin dose for a goal INR of 2.0-3.0.

4. Acute on chronic renal failure:
Patient has baseline creatinine 1.8-2.0, was 1.6-2.0 during
hospitalization. Urine output remained stable. Prior to
discharge pt's Lisinopril was restarted but his Furosemide
dosing was held.

5. Pain control
Patient complained of pain over the ICD site and shoulder pain
following EP study and ICD placement. Pain is likely due to the
ICD and not cardiac event, pain was controlled on Tylenol with
Codeine and lidocaine patch.

6. DM
Patient's home glucotrol and Zestril was held, and patient was
controlled on insulin sliding scale. Fingersticks were well
controlled.

7. Hypertension
Patient was continued on home Metoprolol and Imdur. His home
Lisinopril was briefly held due to an elevated Creatinine but
restarted prior to discharge. His blood pressure improved
significantly during his hospitalization.

8. COPD
Patient was started on Albuterol, Atrovent and Advair for
wheezing. His wheezing improved markedly with this regimen. He
was encouraged to quit smoking. Outpatient PFT's are
recommended.

9. Gout
Patient had no evidence of acute flare, he was continued on
renally dosed allopurinol.

10. GERD
Home PPI was held on admission to the CCU to avoid increasing
pneumonia risk, but was restarted after episodes of severe
reflux with drinking.


Medications on Admission:
Allopurinol 300mg po qday
Imdur 120mg po Qday
Coumadin 5mg po Qday
Novolog prior to meals
zocor 80mg po qday
atroven nebs ih q4-6h prn
albuterol nebs ih q4-6h prn
metoprolol tartrate 50mg po BID
prilosec 20mg po BID
furosemide 40mg po qday
tramadol prn
aricept 10mg po qhs
glucotrol XL 5mg po qday
zestril 10mg po qday
NTG sL prn
aspirin 81mg po qday


Discharge Medications:
1. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).
3. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).

4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**12-10**]  Inhalation Q6H (every 6 hours) as needed
for dyspnea.
5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).

9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Daily at 4pm.
12. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Zestril 10 mg Tablet Sig: One (1) Tablet PO once a day.
14. Glucotrol XL 5 mg Tablet Extended Rel 24 hr (2) Sig: One (1)
Tablet Extended Rel 24 hr (2) PO once a day.
15. Atrovent HFA 17 mcg/Actuation Aerosol Sig: 1-2 puffs
Inhalation four times a day.
16. Acetaminophen-Codeine 300-15 mg Tablet Sig: One (1) Tablet
PO q8H:PRN as needed for pain for 7 days.
17. Insulin Lispro 100 unit/mL Solution Sig: One (1) unit
Subcutaneous ASDIR (AS DIRECTED): per sliding scale.
18. Stockings
Please wear compression stockings for you lower extremity edema
19. Outpatient Lab Work
Pleae have your blood drawn every Monday and Friday to check
your PT, INR. Your Coumadin medication will be titrated by the
rehab doctors based on this lab


Discharge Disposition:
Extended Care

Facility:
[**Location (un) 931**] House Nursing & Rehabilitation Center - [**Location (un) 932**]

Discharge Diagnosis:
Primary: Ventricular tachycardia, Hypertension, COPD, A.
Fibrillation, Diabetes Mellitus, Coronary Disease
Secondary: Hyperlipidemia, h.o. Stroke, GERD


Discharge Condition:
Improved, Stable.


Discharge Instructions:
You were admitted to the hospital after an episode of chest pain
that was found to be an abnormal heart rhythm. You were first
taken to [**Hospital **] Hospital, where the abnormal heart rhythm was
converted to a normal rhythm using an electrical impulse to your
heart. You continued to have chest pain, however, so you were
taken to the [**Hospital3 **] [**Hospital 1225**] Medical Center. While you
were here, you continued to have episodes of this unstable heart
rhythm. As a result, the Cardiology team placed a pacemaker and
defibrillator device into your left chest to prevent further
arrythmias from occurring.

If you experience another episode of chest pain, sweating,
dizziness, lightheadedness, nausea, vomiting, or feel like you
might pass out, please call your primary care doctor or go to
the nearest emergency room.

Medications:
1. While you were in the hospital, your Allopurinol dose was
decreased from 300mg once daily to 100mg once daily due to your
chronic kidney disease. Please continue to take this medication
as directed.

2. Several of your blood pressure medications were changed based
on your improved hypertension. Your Imdur dose was decreased
from 120mg once daily to 90mg once daily. Please take this
decreased dose was directed. In addition, your Lasix dose was
stopped. Please do not continue taking this medication until you
see your primary care physician.

3. You had some wheezing in the hospital that did not resolve
with your home dose of Albuterol and Atrovent. As a result,
another medication was added, called Advair. Please continue to
take this medication as directed.


Followup Instructions:
Please follow-up in the Cardiology DEVICE CLINIC on [**2174-6-15**] at 10:00AM. Phone:[**Telephone/Fax (1) 62**].

Please follow-up with your cardiologist: Dr. [**First Name (STitle) **] Gaca at
[**Hospital **] Hospital in the next two weeks. You can make an
appointment by calling [**Telephone/Fax (1) 44655**].

Please also follow-up with your primary care provider: [**Last Name (NamePattern4) **].
[**Last Name (STitle) 31446**] [**Name (STitle) 8521**] at [**Hospital **] Hospital within the next month. You may
schedule an appointment at [**Telephone/Fax (1) 54268**].

You will be contact[**Name (NI) **] by the cardiology office at the [**Hospital 61**] Deaconness for follow-up with Dr. [**Last Name (STitle) **]. If you do
not hear from them by Wednesday [**6-15**], please call
[**Telephone/Fax (1) 62**] to schedule an appointment.

Please check your INR level every Monday & Friday for a goal of
[**1-11**].


                             [**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**]
{'Paroxysmal ventricular tachycardia,Acute kidney failure, unspecified,Intermediate coronary syndrome,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Long-term (current) use of anticoagulants,Tobacco use disorder,Chronic airway obstruction, not elsewhere classified,Other late effects of cerebrovascular disease,Aortocoronary bypass status,Coronary atherosclerosis of native coronary artery,Chronic kidney disease, unspecified,Other and unspecified hyperlipidemia,Gout, unspecified,Esophageal reflux,Old myocardial infarction,Other musculoskeletal symptoms referable to limbs'}


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: dyspnea on exertion

PRESENT ILLNESS: 77 y/o man with a history of diabetes, coronary disease s/p CABG
[**2162**] and several subsequent PCI, chronic renal failure, copd,
and atrial fibrillation on coumadin presents as a transfer from
[**Hospital **] hospital with chest pain.

MEDICAL HISTORY: # Coroary Artery Disease: CABG [**2152**]. PCI in [**4-/2170**], [**5-/2170**], and
10/[**2170**].
-PCI [**4-/2170**]: Atritic LIMA, occluded SVG to OM1/OM2, patent
SVG-Diag, unsucessful attempt at PCI of OM1 for placement of DES
to graft. Lcx dissection
-PCI [**5-/2170**]: succesful PCI of SVG to OM
-PCI [**9-/2171**]: patnet SVG-D2, patent SVG OM1-OM2, no intervention

MEDICATION ON ADMISSION: Allopurinol 300mg po qday
Imdur 120mg po Qday
Coumadin 5mg po Qday
Novolog prior to meals
zocor 80mg po qday
atroven nebs ih q4-6h prn
albuterol nebs ih q4-6h prn
metoprolol tartrate 50mg po BID
prilosec 20mg po BID
furosemide 40mg po qday
tramadol prn
aricept 10mg po qhs
glucotrol XL 5mg po qday
zestril 10mg po qday
NTG sL prn
aspirin 81mg po qday

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 98.3 160/63 62 18 97%RA
GEN: elderly male, not in any acute distress, obese
HEENT: moist mucus membranes
CV: RRR s1, s2, no M/G/R
RESP: course bs bialterally, low-pitched expiratory wheezes, no
crackles
ABD: soft, obese, several lumps palpated (?sub-cu scar tissue)
midline scar noted and laparoscope scars noted left and right of
midline.
EXT: no edema

FAMILY HISTORY: There is no family history of premature coronary artery disease
or sudden death

SOCIAL HISTORY: Lives in [**Location **] by himself. divorced, currently in a
relationship. Had 5 children, 1 passed away in [**2164**]. Former part
time police officer and welder, retired. Quit smoking most
recently 2 weeks ago, no etoh use. 

### Response:
{'Paroxysmal ventricular tachycardia,Acute kidney failure, unspecified,Intermediate coronary syndrome,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Long-term (current) use of anticoagulants,Tobacco use disorder,Chronic airway obstruction, not elsewhere classified,Other late effects of cerebrovascular disease,Aortocoronary bypass status,Coronary atherosclerosis of native coronary artery,Chronic kidney disease, unspecified,Other and unspecified hyperlipidemia,Gout, unspecified,Esophageal reflux,Old myocardial infarction,Other musculoskeletal symptoms referable to limbs'}
