CHIEF COMPLAINT: A-flutter with demand ischemia, hypotension

PRESENT ILLNESS: 76 year old female with a past medical history of amyloidosis
complicated by restrictive cardiomyopathy, ITP that likely
developed as a result of Revlimid dose being used to treat her
amyloidosis, ulcerative colitis, cholecystectomy, Urinary
incontinence, Hypohyroidism, subarachnoid hemorrhage, TIA, HLD,
and a recent pneumonia who presented to the [**Hospital1 18**] ED with chest
pain this AM. The pain occurred around 930 AM and was substernal
with radiation to her left arm and associated SOB. Of note she
has had a several month history of intermittent chest pain,
however it has never radiated to her left arm before. She notes
her pain is worse with exertion and better with rest. She takes
lopressor at home for "fast heart rate" and did not take her
morning dose of lopressor prior to arrival.  She was recently
treated on [**2152-6-28**] for a atypical pneumonia with a course of
azithromycin, with improvement of symptoms.

MEDICAL HISTORY: # PAST ONCOLOGIC HISTORY: She initially presented in the fall of
[**2149**] with four to five months of easy bruising and mild dyspnea
on exertion. In [**Month (only) **], she was diagnosed with amyloidosis by
bone marrow biopsy and an abnormal UPEP and was subsequently
started on treatment with Velcade, melphalan, and Decadron. She
completed six cycles of this with a plateau in her response. She
then started on subcutaneous Velcade due to her neuropathy and
GI intolerance. Shortly after she received this treatment, she
was admitted for hemianopsia and found to have a TIA, from which
she recovered without any sequelae. Further treatments with
Velcade was deferred given her TIA, but she was noted to have a
rise in her light chains and well as worsening kidney function
and hypercalcemia concerning for progression of her amyloidosis.
She was therefore started on Revlimid 15 mg daily for 21 day
cycle with aspirin for DVT prophylaxis in addition to 20 mg po
Decadron weekly.  In summary of recent events:
-[**11-12**]: D1 weekly rituxan for ITP, also steroids increased to
decadron 40 mg daily x8 from [**Date range (1) 92781**]
-[**11-25**]: D15 rituxan and platelets
-[**11-26**]: 10 minutes into platelet transfusion BP 87/49, temp
100.3.Given dex 40.
.
# PAST MEDICAL HISTORY:
-Amyloidosis with progressive restrictive amyloid cardiomyopathy

MEDICATION ON ADMISSION: ACYCLOVIR - acyclovir 400 mg tablet
1 Tablet(s) by mouth twice a day. Please dispense 3 month
supply.
LEVOTHYROXINE [LEVOXYL] - Levoxyl 75 mcg tablet
one Tablet(s) by mouth once a day No Substitution
LORAZEPAM - lorazepam 0.5 mg tablet
[**11-22**] Tablet(s) by mouth every 8 hrs as needed for nausea, sleep,
anxiety.
METOPROLOL TARTRATE - (Dose adjustment - no new Rx) - metoprolol
tartrate 25 mg tablet
0.5 (One half) Tablet(s) by mouth twice a day
PANTOPRAZOLE - pantoprazole 20 mg tablet,delayed release
1 (One) Tablet(s) by mouth daily
SIMVASTATIN - simvastatin 5 mg tablet
1 Tablet(s) by mouth once a day
TORSEMIDE - torsemide 20 mg tablet
one Tablet(s) by mouth daily in the morning
TROSPIUM [SANCTURA XR] - (Prescribed by Other Provider) (Not
Taking as Prescribed: not helpful; does not like the way it
makes her feel) - Dosage uncertain

ALLERGIES: lenalidomide

PHYSICAL EXAM: Admission Exam
VS: Temp = 97.4, HR = 162, BP = 109/64, RR = 22, O2sat = 100%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP elevated to clavicle in sitting position, no
LAD
CV: irregular rhythm, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, notable extremity bruising
Neuro: AOx3

FAMILY HISTORY: Son: had thyroid cancer
mother: HTN, DM, CVA and died at the age of 63
Father: had prostate cancer with metastasis to the bone

SOCIAL HISTORY: SOCIAL HISTORY/ FUNCTIONAL STATUS: I< 65
Cigarettes: [x ] never  [ ] ex-smoker
                       quit: ______
ETOH:       [x] No   [ ] Yes     drinks/day: _____
Drugs: none
Occupation: retired volunteer worker with the osteomy
association of [**Location (un) 86**]
Marital Status: [ x] Married  [] Single.  She has 3 children.
Two children live in MA.  One lives in [**Location **]. She has 8
grandchildren.
Lives:          [ ] Alone    [x] w/ family  [ ] Other:
Received influenza vaccination in the past 12 months [ x]Y [ ]N
Received pneumococcal vaccinationin the past  [ x]Y [ ]N
Atrial fibrillation,Other acute and subacute forms of ischemic heart disease, other,Immune thrombocytopenic purpura,Other amyloidosis,Peripheral autonomic neuropathy in disorders classified elsewhere,Acidosis,Acute kidney failure, unspecified,Nutritional and metabolic cardiomyopathy,Other drugs and medicinal substances causing adverse effects in therapeutic use,Nausea alone,Unspecified acquired hypothyroidism,Urinary incontinence, unspecified,Other and unspecified hyperlipidemia,Ileostomy status,Personal history of other diseases of digestive system,Personal history of tobacco use,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits
Atrial fibrillation,Ac ischemic hrt dis NEC,Immune thrombocyt purpra,Amyloidosis NEC,Aut neuropthy in oth dis,Acidosis,Acute kidney failure NOS,Metabolic cardiomyopathy,Adv eff medicinal NEC,Nausea alone,Hypothyroidism NOS,Urinary incontinence NOS,Hyperlipidemia NEC/NOS,Ileostomy status,Prsnl hst ot spf dgst ds,History of tobacco use,Hx TIA/stroke w/o resid
Admission Date:  [**2152-7-8**]              Discharge Date:   [**2152-7-11**]

Date of Birth:  [**2076-2-22**]             Sex:   F

Service: MEDICINE

Allergies:
lenalidomide

Attending:[**First Name3 (LF) 3063**]
Chief Complaint:
A-flutter with demand ischemia, hypotension

Major Surgical or Invasive Procedure:
none

History of Present Illness:
76 year old female with a past medical history of amyloidosis
complicated by restrictive cardiomyopathy, ITP that likely
developed as a result of Revlimid dose being used to treat her
amyloidosis, ulcerative colitis, cholecystectomy, Urinary
incontinence, Hypohyroidism, subarachnoid hemorrhage, TIA, HLD,
and a recent pneumonia who presented to the [**Hospital1 18**] ED with chest
pain this AM. The pain occurred around 930 AM and was substernal
with radiation to her left arm and associated SOB. Of note she
has had a several month history of intermittent chest pain,
however it has never radiated to her left arm before. She notes
her pain is worse with exertion and better with rest. She takes
lopressor at home for "fast heart rate" and did not take her
morning dose of lopressor prior to arrival.  She was recently
treated on [**2152-6-28**] for a atypical pneumonia with a course of
azithromycin, with improvement of symptoms.

  Also of note she sees Dr. [**First Name (STitle) **] [**Name (STitle) **] MD for her ITP
and amyloidosis for which she recieved IgG on [**2152-7-5**]. At that
time per her OMR note over the first 2 hours of the IVIG
infusion her BP droped as low as 72/50 without symptoms or
complaints. Her BP subsequently rose to 84/52 and the infusion
rate was increased to 60cc/hr x 1 hours. The infusion rate was
then increased to 120cc/hr to the completion of the IVIG. Prior
to discharge home her BP was 96/80 with HR 90. Her per
hemeatology notes her disease has become difficult to treat with
conventional therapy and they are considering exploring a [**Hospital1 2177**]
appointment to see what benefit their ongoing clinical trials
may have for her.

  On arrival to the ED her VS were Temp = 97.4, HR = 162, BP =
109/64, RR = 22, O2sat = 100%. EKG with narrow complex, regular
tachycardia in 160s, rhythm strip with atrial flutter in lead
II. Tachycardia broke with carotid massage. A bedside ultrasound
was negative for pericardial effusion. Her HR improved to 100's
after 5mg IV lopressor. Home dose of PO lopressor was given
prior to transfer. A D-dimer was negative and a CTA was not
perfromed given low probability of PE. She was given 1L NS.
Further IVF was held considering poor cardiac function. Her BP
while in the ED was stable in 80s-90s systolic over 60s
diastolic and she was asymptomatic. A initial trop was 0.09.

On arrival to the MICU, the patient's VS were HR = 82, BP =
95/62, O2sat = 97% RA, RR = 20. She was in no obvious distress
and was AOx3.

Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.


Past Medical History:
# PAST ONCOLOGIC HISTORY: She initially presented in the fall of
[**2149**] with four to five months of easy bruising and mild dyspnea
on exertion. In [**Month (only) **], she was diagnosed with amyloidosis by
bone marrow biopsy and an abnormal UPEP and was subsequently
started on treatment with Velcade, melphalan, and Decadron. She
completed six cycles of this with a plateau in her response. She
then started on subcutaneous Velcade due to her neuropathy and
GI intolerance. Shortly after she received this treatment, she
was admitted for hemianopsia and found to have a TIA, from which
she recovered without any sequelae. Further treatments with
Velcade was deferred given her TIA, but she was noted to have a
rise in her light chains and well as worsening kidney function
and hypercalcemia concerning for progression of her amyloidosis.
She was therefore started on Revlimid 15 mg daily for 21 day
cycle with aspirin for DVT prophylaxis in addition to 20 mg po
Decadron weekly.  In summary of recent events:
-[**11-12**]: D1 weekly rituxan for ITP, also steroids increased to
decadron 40 mg daily x8 from [**Date range (1) 92781**]
-[**11-25**]: D15 rituxan and platelets
-[**11-26**]: 10 minutes into platelet transfusion BP 87/49, temp
100.3.Given dex 40.
.
# PAST MEDICAL HISTORY:
-Amyloidosis with progressive restrictive amyloid cardiomyopathy

-TIA (suspected secondary to Velcade)
-Ulcerative colitis followed by total colectomy and ileostomy
since [**2108**]
-Dyslipidemia
-Cholecystectomy
-Left knee surgery
-Urinary incontinence
-Hypothyroidism

Social History:
SOCIAL HISTORY/ FUNCTIONAL STATUS: I< 65
Cigarettes: [x ] never  [ ] ex-smoker
                       quit: ______
ETOH:       [x] No   [ ] Yes     drinks/day: _____
Drugs: none
Occupation: retired volunteer worker with the osteomy
association of [**Location (un) 86**]
Marital Status: [ x] Married  [] Single.  She has 3 children.
Two children live in MA.  One lives in [**Location **]. She has 8
grandchildren.
Lives:          [ ] Alone    [x] w/ family  [ ] Other:
Received influenza vaccination in the past 12 months [ x]Y [ ]N
Received pneumococcal vaccinationin the past  [ x]Y [ ]N

>65
ADLS:
Independent of ADLS: [x ]dressing  [ x]ambulating [ x]hygiene [x
]eating  [x ]toileting
Requires assitance with:  [ [ ]dressing  [ ]ambulating [
]hygiene [ ]eating  [ ]toileting
IADLS:
Independent of all IADLS:
she does not have pre-existent home care services
At baseline walks: [x ]independently [ ] with a cane [
]wutwalker [ ]wheelchair at baseliine
H/o fall within past year: [x]Y  - no recent falls prior to the
fall on admission []N
Visual aides  [x ]Y [ ]N
Dentures  [ ]Y [x ]N
Hearing Aides  [ ]Y [x ] N


Family History:
Son: had thyroid cancer
mother: HTN, DM, CVA and died at the age of 63
Father: had prostate cancer with metastasis to the bone

Physical Exam:
Admission Exam
VS: Temp = 97.4, HR = 162, BP = 109/64, RR = 22, O2sat = 100%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP elevated to clavicle in sitting position, no
LAD
CV: irregular rhythm, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, notable extremity bruising
Neuro: AOx3

Discharge Exam:
VS: 98.4, 116, 100/62, 99% on RA
GEN Alert, oriented, no acute distress sitting up in bed
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, lungs CLTAB
CV RRR, normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions


Pertinent Results:
ADMISSION LABS:

[**2152-7-8**] 11:21AM   PT-12.0 PTT-24.8* INR(PT)-1.1
[**2152-7-8**] 11:21AM   PLT COUNT-63*
[**2152-7-8**] 11:21AM   NEUTS-75.4* LYMPHS-16.2* MONOS-6.8 EOS-1.3
BASOS-0.3
[**2152-7-8**] 11:21AM   WBC-8.1 RBC-4.34 HGB-13.3 HCT-40.2 MCV-93
MCH-30.7 MCHC-33.1 RDW-17.9*
[**2152-7-8**] 11:21AM   CK-MB-2
[**2152-7-8**] 11:21AM   cTropnT-0.09*
[**2152-7-8**] 11:21AM   CK(CPK)-18*
[**2152-7-8**] 11:21AM   estGFR-Using this
[**2152-7-8**] 11:21AM   GLUCOSE-169* UREA N-29* CREAT-1.4* SODIUM-139
POTASSIUM-4.0 CHLORIDE-109* TOTAL CO2-20* ANION GAP-14
[**2152-7-8**] 11:27AM   D-DIMER-390
[**2152-7-8**] 07:00PM   CK-MB-2 cTropnT-0.08*
[**2152-7-8**] 07:00PM   CK(CPK)-12*

Relevant Labs:
CPK ISOENZYMES 	CK-MB 	cTropnT 	proBNP
[**2152-7-9**] 03:43   	1 	0.10*1 	
FT4 TSH ADDED ON [**2152-7-9**]
[**2152-7-8**] 19:00   	2 	0.08*2 	
[**2152-7-8**] 11:21   	  	0.09*2

Discharge Labs:
RENAL & GLUCOSE 	Glucose 	UreaN 	Creat 	Na 	K 	Cl 	HCO3 	AnGap
[**2152-7-11**] 07:00   	971 	19 	1.2* 	141 	4.2 	112* 	19* 	14

CHEMISTRY 		Calcium 	Phos 	Mg 	
[**2152-7-10**] 06:50   	   8.6 	        2.7     	1.7

COMPLETE BLOOD COUNT 	WBC 	RBC 	Hgb 	Hct 	MCV 	MCH 	MCHC 	RDW
	Plt Ct
[**2152-7-10**] 06:50   	6.0 	3.56* 	10.7* 	32.9* 	93 	30.0 	32.4
	17.7* 	66*

Pertinent Micro/Path:
[**2152-7-9**] 1:23 am MRSA SCREEN      Source: Nasal swab.

                            **FINAL REPORT [**2152-7-11**]**

   MRSA SCREEN (Final [**2152-7-11**]):    No MRSA isolated.

Pertinent Imaging:
CXR [**2152-7-8**]:  IMPRESSION:  No significant interval change of
interstitial abnormality seen on the prior radiograph, with
perihilar and right mid lung opacities.

[**Known lastname **],[**Known firstname **]	[**Medical Record Number 97786**]	F  76  [**2076-2-22**]
Cardiovascular Report	ECG	Study Date of [**2152-7-8**]  11:12:10 AM

Probable atrial flutter with a rapid ventricular response and
2:1 A-V block.  Poor R wave progression. Low QRS voltage in the
limb leads. Compared to the previous tracing of [**2151-12-11**] rapid
atrial flutter and low limb lead voltage are new.


Brief Hospital Course:
Patient is 76 year old woman with amyloidosis resulting in
cardiomyopathy and idiopathic thrombocytopenic purpura (thought
to be result of Revlimid therapy) and history of Ulcerative
Colitis status post colectomy with iliostomy presenting with
changed chest pain and shortness of breath.

Active Diagnosis:

#. Atrial fib/flutter with RVR and demand Ischemia: Patient has
a history of Amyloidosis complicated by severe restrictive
cardiomyopathy with a hyperdynamic EF > 75% and left ventricular
hypertrophy and a NYH classification of II-III as of 2/[**2151**]. The
natural history of this disease predisposes her to several
adverse cardiac outcomes. Considering she has had anginal
symptoms for the past few months this is likely a combination of
distal cornary involvement of her disease compounded by demand
ischemia. Patient was up-titrated on metoprolol to 12.5 TID, and
required further PO doses of metoprolol to control her rate.
Cardiac markers were stable with Trop @ 0.09-0.08, flat CK-MB.
There was difficulty in managing the patient's metoprolol when
on the floor.  She was started on 12.5 QID, but was found to be
hypotensive to 86/50.  Eventually she was discharged on 25 mg
[**Hospital1 **] with the hope that this will control her rate without
dropping her pressure too much.  The discussion of potential
anticoagulation was introduced during the patient's
hospitalization and will be further discussed at her outpatient
cardiology follow-up appointment.

#. Hypotension: This is a common finding in patients with
restrictive cardiomyopathy and is secondary to low CO as well as
an interesting association with autonomic neuropathy that is
part of the diseases natural history. Her blood pressure
measurements have been low consistanently during her Nplate and
office visits.

#. CXR Findings:  CXR performed during recent outpatient
oncology clinic visit showed new parenchymal opacities, seen in
the right lung apex and the right upper lobe.  This will need to
be further addressed by the patient's outpatient oncology
providers.

Chronic Issues:

#. Amyloidosis: This is a chronic issue. She will continue with
her previously scheduled outpatient followup.

#. ITP: This is a chronic issue. The etiology of this patient's
ITP is attributed to her revlimid therapy. Her low platelets is
likely related to needing her N-Plate therapy soon.  She will
get next dose two days after discharge.

#. Hypothyroidism: This is a chronic stable issue.

#. Metabolic Acidosis: Likely secondary to high output from her
ostomey and loss of bicarb. Acidosis resolved with gentle fluid
resuscitation.

#. [**Last Name (un) **]: patient at baseline at time of discharge

#. Pneumonia: Resolved. Underwent IVIG therapy and ABX therapy
prior to admission.

#. Hyperlipidemia: This is a chronic stable issue.

#. Nausea: This is a stable chronic issue.
- Continue Zofran 8mg PRN for nausea
- Continue Ativan 0.5 PRN for nausea
- Continue PPI

Transitional Issues:
# There was difficulty in controlling heart rate while not
dropping pressures too much with metoprolol therapy.  This
should be further investigated in the outpatient setting.
# Anticoagulation should be discussed in the outpatient setting
as well (see above).
# CXR findings (see above) will need to be addressed.

Medications on Admission:
ACYCLOVIR - acyclovir 400 mg tablet
1 Tablet(s) by mouth twice a day. Please dispense 3 month
supply.
LEVOTHYROXINE [LEVOXYL] - Levoxyl 75 mcg tablet
one Tablet(s) by mouth once a day No Substitution
LORAZEPAM - lorazepam 0.5 mg tablet
[**11-22**] Tablet(s) by mouth every 8 hrs as needed for nausea, sleep,
anxiety.
METOPROLOL TARTRATE - (Dose adjustment - no new Rx) - metoprolol
tartrate 25 mg tablet
0.5 (One half) Tablet(s) by mouth twice a day
PANTOPRAZOLE - pantoprazole 20 mg tablet,delayed release
1 (One) Tablet(s) by mouth daily
SIMVASTATIN - simvastatin 5 mg tablet
1 Tablet(s) by mouth once a day
TORSEMIDE - torsemide 20 mg tablet
one Tablet(s) by mouth daily in the morning
TROSPIUM [SANCTURA XR] - (Prescribed by Other Provider) (Not
Taking as Prescribed: not helpful; does not like the way it
makes her feel) - Dosage uncertain

MEDICATIONS OTC:
CHOLECALCIFEROL (VITAMIN D3) - (OTC) - cholecalciferol (vitamin
D3) 1,000 unit capsule
1 (One) Capsule(s) by mouth once a day


Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. Levothyroxine Sodium 75 mcg PO DAILY
3. Pantoprazole 20 mg PO Q24H
4. Simvastatin 5 mg PO DAILY
5. Torsemide 20 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Lorazepam 0.5 mg PO Q8H:PRN nausea, sleep, anxiety
8. Metoprolol Tartrate 25 mg PO BID
hold for HR<60, SBP<90
(please page HO if holding)
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day
[**Month/Day (2) **] #*14 Tablet Refills:*0


Discharge Disposition:
Home

Discharge Diagnosis:
Atrial fibrillation with rapid ventricular response


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


Discharge Instructions:
Mrs. [**Known lastname 3273**],

It was a pleasure taking care of you in the hospital.  As you
know, you initially presented with chest pain that was not like
the pain you had been having over the last severaly months.  You
were found to have an elevated heart rate, up to the 170's, and
an irregular heart rhythm (atrial fibrillation).  We were able
to reduce your heart rate with medicines and your heart returned
to its normal rhythm at that time.  You were observed in the ICU
for one day and then on the regular medicine floor after that.

We were concerned that your blood pressure was dropping too low
(86/45) when we were giving you the medicine to keep your heart
rate in the healthy range (80's) so we asked the cardiologists
at the hospital to see you.  They recommended that you take 25
mg Metoprolol two times a day.  We know that you don't like to
take your Torsemide, but after talking it over we think that it
is an important medication for you.  If you still have concerns
you should make sure you bring them up with your cardiologist
Dr. [**First Name (STitle) 437**] when you meet with him next week.

We made the following changes to your home medications:
CHANGED metoprolol to 25 mg twice a day, you can take an extra
12.5mg if you feel your heart rate going fast

Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2152-7-17**] at 2:00 PM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: [**Hospital3 249**]
When: WEDNESDAY [**2152-7-26**] at 11:10 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Atrial fibrillation,Other acute and subacute forms of ischemic heart disease, other,Immune thrombocytopenic purpura,Other amyloidosis,Peripheral autonomic neuropathy in disorders classified elsewhere,Acidosis,Acute kidney failure, unspecified,Nutritional and metabolic cardiomyopathy,Other drugs and medicinal substances causing adverse effects in therapeutic use,Nausea alone,Unspecified acquired hypothyroidism,Urinary incontinence, unspecified,Other and unspecified hyperlipidemia,Ileostomy status,Personal history of other diseases of digestive system,Personal history of tobacco use,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits'}


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: A-flutter with demand ischemia, hypotension

PRESENT ILLNESS: 76 year old female with a past medical history of amyloidosis
complicated by restrictive cardiomyopathy, ITP that likely
developed as a result of Revlimid dose being used to treat her
amyloidosis, ulcerative colitis, cholecystectomy, Urinary
incontinence, Hypohyroidism, subarachnoid hemorrhage, TIA, HLD,
and a recent pneumonia who presented to the [**Hospital1 18**] ED with chest
pain this AM. The pain occurred around 930 AM and was substernal
with radiation to her left arm and associated SOB. Of note she
has had a several month history of intermittent chest pain,
however it has never radiated to her left arm before. She notes
her pain is worse with exertion and better with rest. She takes
lopressor at home for "fast heart rate" and did not take her
morning dose of lopressor prior to arrival.  She was recently
treated on [**2152-6-28**] for a atypical pneumonia with a course of
azithromycin, with improvement of symptoms.

MEDICAL HISTORY: # PAST ONCOLOGIC HISTORY: She initially presented in the fall of
[**2149**] with four to five months of easy bruising and mild dyspnea
on exertion. In [**Month (only) **], she was diagnosed with amyloidosis by
bone marrow biopsy and an abnormal UPEP and was subsequently
started on treatment with Velcade, melphalan, and Decadron. She
completed six cycles of this with a plateau in her response. She
then started on subcutaneous Velcade due to her neuropathy and
GI intolerance. Shortly after she received this treatment, she
was admitted for hemianopsia and found to have a TIA, from which
she recovered without any sequelae. Further treatments with
Velcade was deferred given her TIA, but she was noted to have a
rise in her light chains and well as worsening kidney function
and hypercalcemia concerning for progression of her amyloidosis.
She was therefore started on Revlimid 15 mg daily for 21 day
cycle with aspirin for DVT prophylaxis in addition to 20 mg po
Decadron weekly.  In summary of recent events:
-[**11-12**]: D1 weekly rituxan for ITP, also steroids increased to
decadron 40 mg daily x8 from [**Date range (1) 92781**]
-[**11-25**]: D15 rituxan and platelets
-[**11-26**]: 10 minutes into platelet transfusion BP 87/49, temp
100.3.Given dex 40.
.
# PAST MEDICAL HISTORY:
-Amyloidosis with progressive restrictive amyloid cardiomyopathy

MEDICATION ON ADMISSION: ACYCLOVIR - acyclovir 400 mg tablet
1 Tablet(s) by mouth twice a day. Please dispense 3 month
supply.
LEVOTHYROXINE [LEVOXYL] - Levoxyl 75 mcg tablet
one Tablet(s) by mouth once a day No Substitution
LORAZEPAM - lorazepam 0.5 mg tablet
[**11-22**] Tablet(s) by mouth every 8 hrs as needed for nausea, sleep,
anxiety.
METOPROLOL TARTRATE - (Dose adjustment - no new Rx) - metoprolol
tartrate 25 mg tablet
0.5 (One half) Tablet(s) by mouth twice a day
PANTOPRAZOLE - pantoprazole 20 mg tablet,delayed release
1 (One) Tablet(s) by mouth daily
SIMVASTATIN - simvastatin 5 mg tablet
1 Tablet(s) by mouth once a day
TORSEMIDE - torsemide 20 mg tablet
one Tablet(s) by mouth daily in the morning
TROSPIUM [SANCTURA XR] - (Prescribed by Other Provider) (Not
Taking as Prescribed: not helpful; does not like the way it
makes her feel) - Dosage uncertain

ALLERGIES: lenalidomide

PHYSICAL EXAM: Admission Exam
VS: Temp = 97.4, HR = 162, BP = 109/64, RR = 22, O2sat = 100%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP elevated to clavicle in sitting position, no
LAD
CV: irregular rhythm, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, notable extremity bruising
Neuro: AOx3

FAMILY HISTORY: Son: had thyroid cancer
mother: HTN, DM, CVA and died at the age of 63
Father: had prostate cancer with metastasis to the bone

SOCIAL HISTORY: SOCIAL HISTORY/ FUNCTIONAL STATUS: I< 65
Cigarettes: [x ] never  [ ] ex-smoker
                       quit: ______
ETOH:       [x] No   [ ] Yes     drinks/day: _____
Drugs: none
Occupation: retired volunteer worker with the osteomy
association of [**Location (un) 86**]
Marital Status: [ x] Married  [] Single.  She has 3 children.
Two children live in MA.  One lives in [**Location **]. She has 8
grandchildren.
Lives:          [ ] Alone    [x] w/ family  [ ] Other:
Received influenza vaccination in the past 12 months [ x]Y [ ]N
Received pneumococcal vaccinationin the past  [ x]Y [ ]N 

### Response:
{'Atrial fibrillation,Other acute and subacute forms of ischemic heart disease, other,Immune thrombocytopenic purpura,Other amyloidosis,Peripheral autonomic neuropathy in disorders classified elsewhere,Acidosis,Acute kidney failure, unspecified,Nutritional and metabolic cardiomyopathy,Other drugs and medicinal substances causing adverse effects in therapeutic use,Nausea alone,Unspecified acquired hypothyroidism,Urinary incontinence, unspecified,Other and unspecified hyperlipidemia,Ileostomy status,Personal history of other diseases of digestive system,Personal history of tobacco use,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits'}
