CHIEF COMPLAINT: Pericardial effusion

PRESENT ILLNESS: Please see original Neurology Admission Note and MICU [**Location (un) **]
Transfer Note for details.
.
Briefly, 47 y/o man with long standing history of epilepsy s/p
right temporal lobectomy (at age 19) and VNS placement (7 years
ago), h/o EtOH and cocaine abuse who was having increased
seizure frequency in the setting of VNS malfunction. He was
admitted on [**1-28**] for elective replacement of the vagus nerve
stimulator generator.  The procedure went without complication.
Overnight he developed AF with RVR to the 180s with hypotension
to the 80s.  CIWA was 17 with last drink approximately 72 hours
prior. Patient was also noted to be [**Doctor Last Name **] with a CIWA of 17
and is thought that last EtOH drink was 72 hours ago.  He
received 2mg IV ativan with somnolence and apenea afterwards.
He was subsequently transferred to the MICU.
.
His MICU course was notable for an echocardiogram which showed a
large pericardial effusion on [**1-29**].  He was seen by the
cardiology fellow and subsequently underwent pericardial window.
450cc of bloody pericardial fluid was drained. Patient developed
SVT in the cath lab and was treated with 9 mg IV metoprolol. He
was transferred to CCU postprocedurally for monitoring.
.
On arrival, patient complained of spinal back pain from lying on
the operating table. He also reports that his lungs feel
"collapsed" but denied shortness of breath.
.
Review of systems was otherwise negative.

MEDICAL HISTORY: - epilepsy and nonelectrographic seizures (petite mal with rare
secondary generalization)
- s/p right temporal lobectomy
- s/p VNS placement
- Mood disorder and likely borderline personality organization
- Multiple suicide attempts in past (largely overdose)
- DM due to medication, now apparently resolved
- cervical strain
- Rosacea
- [**Last Name (un) 865**] esophagus
- Polysubstance abuse: EtOH, MJ, cocaine/crack binges with
resultant unsafe sexual practices
- h/o atrial fibrillation (not on medication)

MEDICATION ON ADMISSION: - Clonazepam 1 mg QID
- Divalproex 250 mg Sustained Release qAM
- Depakote ER 500 mg tab- tabs qAM, 3 tabs in the afternoon and
3
tabs qPM
- Omeprazole 20 mg delayed release daily
- Oxcarbazepine 600 mg [**Hospital1 **]
- ASA 81 mg daily (not taking as prescribed)

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ON TRANSFER TO CCU:
VS: HR:90 BP:128/82 O2sat:93% 2L(NC)
GEN: agitated, in fetal position, not tachypneic
HEENT: PERRL. MM dry.
NECK: neck supple. Left neck dressing with dried blood. No
active bleeding or discharge. Mild tenderness on palpation.
PULM: Moving air appropriately, diffuse crackles. Left upper
chest (VNS) site c/d/i.
CARD: Soft heart sound, RRR, s1/s2 present, no m/g/r, with
pericardial window draining frank blood
ABD: +bs, soft, NT/ND
EXT: wwp, no edema, 2+PD bilaterally
SKIN: warm
BACK: tenderness to palpation along the spine
NEURO: AOx3, agitated, but agreeable.

FAMILY HISTORY: States has FH of diabetes and 'cancer in everyone' but no FH of
CAD, HTN, sudden death or cardiac dysrhythmias

SOCIAL HISTORY: Unemployed, lives alone. Smokes 1pk/day, occasional
ETOH and OMR records indicate some history of Crack Cocaine use.
Mechanical complication of nervous system device, implant, and graft,Other pulmonary embolism and infarction,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Generalized nonconvulsive epilepsy, with intractable epilepsy,Secondary malignant neoplasm of other specified sites,Malignant neoplasm of upper lobe, bronchus or lung,Alcohol withdrawal,Drug-induced delirium,Atrial flutter,Injury to bladder and urethra, without mention of open wound into cavity,Physical restraints status,Other and unspecified anticonvulsants causing adverse effects in therapeutic use,Unspecified episodic mood disorder,Borderline personality disorder,Unspecified accident
Malfun neuro device/graf,Pulm embol/infarct NEC,Ac DVT/emb prox low ext,Gen nonconv ep w intr ep,Secondary malig neo NEC,Mal neo upper lobe lung,Alcohol withdrawal,Drug-induced delirium,Atrial flutter,Bladder/urethra inj-clos,Physical restrain status,Adv eff antconvl NEC/NOS,Episodic mood disord NOS,Borderline personality,Accident NOS
Admission Date:  [**2196-1-28**]              Discharge Date:   [**2196-2-7**]

Date of Birth:  [**2148-11-11**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Pericardial effusion

Major Surgical or Invasive Procedure:
vagus nerve stimulator generator replacement [**2196-1-28**]
pericardiocentesis with pericardial drain [**2196-1-29**]

History of Present Illness:
Please see original Neurology Admission Note and MICU [**Location (un) **]
Transfer Note for details.
.
Briefly, 47 y/o man with long standing history of epilepsy s/p
right temporal lobectomy (at age 19) and VNS placement (7 years
ago), h/o EtOH and cocaine abuse who was having increased
seizure frequency in the setting of VNS malfunction. He was
admitted on [**1-28**] for elective replacement of the vagus nerve
stimulator generator.  The procedure went without complication.
Overnight he developed AF with RVR to the 180s with hypotension
to the 80s.  CIWA was 17 with last drink approximately 72 hours
prior. Patient was also noted to be [**Doctor Last Name **] with a CIWA of 17
and is thought that last EtOH drink was 72 hours ago.  He
received 2mg IV ativan with somnolence and apenea afterwards.
He was subsequently transferred to the MICU.
.
His MICU course was notable for an echocardiogram which showed a
large pericardial effusion on [**1-29**].  He was seen by the
cardiology fellow and subsequently underwent pericardial window.
450cc of bloody pericardial fluid was drained. Patient developed
SVT in the cath lab and was treated with 9 mg IV metoprolol. He
was transferred to CCU postprocedurally for monitoring.
.
On arrival, patient complained of spinal back pain from lying on
the operating table. He also reports that his lungs feel
"collapsed" but denied shortness of breath.
.
Review of systems was otherwise negative.


Past Medical History:
- epilepsy and nonelectrographic seizures (petite mal with rare
secondary generalization)
- s/p right temporal lobectomy
- s/p VNS placement
- Mood disorder and likely borderline personality organization
- Multiple suicide attempts in past (largely overdose)
- DM due to medication, now apparently resolved
- cervical strain
- Rosacea
- [**Last Name (un) 865**] esophagus
- Polysubstance abuse: EtOH, MJ, cocaine/crack binges with
resultant unsafe sexual practices
- h/o atrial fibrillation (not on medication)

Social History:
Unemployed, lives alone. Smokes 1pk/day, occasional
ETOH and OMR records indicate some history of Crack Cocaine use.

Family History:
States has FH of diabetes and 'cancer in everyone' but no FH of
CAD, HTN, sudden death or cardiac dysrhythmias

Physical Exam:
ON TRANSFER TO CCU:
VS: HR:90 BP:128/82 O2sat:93% 2L(NC)
GEN: agitated, in fetal position, not tachypneic
HEENT: PERRL. MM dry.
NECK: neck supple. Left neck dressing with dried blood. No
active bleeding or discharge. Mild tenderness on palpation.
PULM: Moving air appropriately, diffuse crackles. Left upper
chest (VNS) site c/d/i.
CARD: Soft heart sound, RRR, s1/s2 present, no m/g/r, with
pericardial window draining frank blood
ABD: +bs, soft, NT/ND
EXT: wwp, no edema, 2+PD bilaterally
SKIN: warm
BACK: tenderness to palpation along the spine
NEURO: AOx3, agitated, but agreeable.

On discharge:
VS: 96.6 118/62 (94-130/64-90) 64 16 97% RA
Tele: HR in 160s yesterday afternoon, otherwise 60s, sinus this
morning, short runs of SVT to 130s <30 seconds
GEN: AOx3, NAD
HEENT: PERRLA, MMM
NECK: neck supple
PULM: CTAB
CARD: RRR, normal s1/s2, no m/g/r
ABD: soft, nontender, nondistended
EXT: wwp no edema. L calf TTP, no swelling or cords noted.


Pertinent Results:
ADMISSION LABS:
.
[**2196-1-28**] 07:11PM BLOOD WBC-9.3# RBC-4.12* Hgb-13.3* Hct-40.2
MCV-98 MCH-32.3* MCHC-33.1 RDW-14.2 Plt Ct-189
[**2196-1-28**] 07:11PM BLOOD Glucose-115* UreaN-25* Creat-1.1 Na-138
K-4.4 Cl-102 HCO3-27 AnGap-13
[**2196-1-28**] 07:11PM BLOOD Calcium-9.0 Phos-4.7* Mg-2.2
[**2196-1-29**] 06:27AM BLOOD T4-4.7
[**2196-1-29**] 06:27AM BLOOD TSH-5.8*

CARDIAC BIOMARKERS
.
[**2196-1-29**] 05:55AM BLOOD CK-MB-2 cTropnT-<0.01
[**2196-1-29**] 06:27AM BLOOD CK-MB-2 cTropnT-<0.01
.
MICRO:
.
-Urine cx [**1-29**]: neg
-Pericardial fluid culture [**1-29**]: NGTD, but pending as of
transfer to MICU
-Pericardial fluid cytology: PND

STUDIES:
.
ECHO [**2196-1-28**]:
.
LEFT ATRIUM: Normal LA size.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Increased IVC diameter (>2.1cm)
with 35-50% decrease during respiration (estimated RA pressure
(10-15mmHg).

LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Suboptimal technical quality, a focal LV wall motion abnormality
cannot be fully excluded. Depressed LVEF. No resting LVOT
gradient. No VSD.

RIGHT VENTRICLE: Borderline normal RV systolic function.

AORTIC VALVE: No AS.

MITRAL VALVE: No MS. [**Name13 (STitle) **] MR.

TRICUSPID VALVE: Indeterminate PA systolic pressure.

PERICARDIUM: Moderate to large pericardial effusion. No RA
diastolic collapse. No RV diastolic collapse.

GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
The rhythm appears to be atrial flutter. Echocardiographic
patient.

Poor image quality.The estimated right atrial pressure is
10-15mmHg with IVC dilation (2.5 cm). Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. LV systolic function
appears mildly depressed. There is no ventricular septal defect.
RV with borderline normal free wall function. There is no aortic
valve stenosis. No mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is a
moderate to large sized pericardial effusion (greatest
anteriorly and best seen in the subcostal view). No right atrial
diastolic collapse is seen. No right ventricular diastolic
collapse is seen (mild RV compression in the subcostal view is
suggestive of elevated intrapericardial pressure).
.
Cardiac cath [**1-29**]:
COMMENTS:
Under fluoroscopic guidance, 450 CC of bloody pericardial fluid
was
obtained through subxiphoid approach. Intrapericardial origin of
fluid
was confirmed with contrast injection and intrapericardial
pressure
measurement. Initial pericardial pressure was elevated at 21 mm
Hg and
dropped to 3 mm Hg after remorval of fluid. Pericaridal drain
was
sutured in place for 24 hours.

FINAL DIAGNOSIS:
1. Successful urgent pericardiocentesis through subxiphoid
approach for
impending pericardial temponade
.
ECHO [**2196-1-30**]
IMPRESSION: Small amount of echodense pericardial material/fluid
is seen. No evidence of tamponade. Probable regional LV systolic
dysfunction. Moderately dilated and hypokinetic right ventricle.

Compared with the prior studies (images reviewed) of [**2196-1-29**]
and [**2194-7-23**], the appearance of the pericardium is similar to
that of the post-tap echo yesterday. The basal to mid
inferior/inferolateral hypokinesis was probably present in [**2194**]
but image quality is poor on all studies. The right ventricle
appears dilated on studies from yesterday and today - it was
probably normal in [**2194**].

.
LENI'S [**2196-2-1**]
BILATERAL LOWER EXTREMITY ULTRASOUND: Grayscale, color, and
Doppler images of the bilateral common femoral, superficial and
deep femoral, and popliteal veins were obtained. There is
non-occlusive thrombus in the mid left popliteal vein and left
peroneal veins, as well as the right posterior tibial vein. The
bilateral common femoral, superficial femoral, and right
popliteal veins demonstrated normal compressibility and
wall-to-wall color flow.

IMPRESSION: Non-occlusive thrombus in left popliteal, left
peroneal, and
right posterior tibial veins.
.
CT TORSO [**2196-2-1**] (PRELIM)
1. Pulmonary embolism involving right lower [**Month/Day/Year 3630**] posterior basal
segmental
and subsegmental branches, and subsegmental branch of left lower
[**Month/Day/Year 3630**] anterior
basal pulmonary artery.
2. Bilateral moderate-sized pleural effusions with adjacent
atelectasis.
3. Evidence of right heart strain, manifest as reflux of IV
contrast into the
IVC and hepatic veins.
4. Mediastinal and right hilar adenopathy with right hilar soft
tissue
causing some narrowing of the airways and vessels, concerning
for malignancy.  Bronchial wall thickening noted, particularly
along right middle [**Month/Day/Year 3630**] and right lower [**Month/Day/Year 3630**] bronchi.
5. Perifissural consolidation in posteromedial right middle
[**Last Name (LF) 3630**], [**First Name3 (LF) **]
represent atelectasis or infection; however, underlying tumor or
extension of right hilar mass not excluded.
6. 11 mm spiculated nodule in the right upper [**First Name3 (LF) 3630**] is suspicious
for
malignancy.
7. Predominantly paraseptal emphysema in the right upper [**First Name3 (LF) 3630**]
with largest
bulla measuring 3.5 x 5.9 cm.
8. Tiny pericardial fluid and possible pericardial thickening.
9. No evidence of malignancy in the abdomen and pelvis.
10. Intraabdominal findings include aortic and iliac artery
calcifications, colonic diverticulosis, and tiny bubble of gas
within the urinary bladder, which could be due to recent
catheterization (correlate clinically).
11. No bony destruction concerning for malignancy.
12. Evidence of right femoral head avascular necrosis, without
significant
collapse.
.

CT HEAD [**2-2**]
No evidence of an acute intracranial process. Postoperative
changes of right temporal lobectomy.
.
Pathology, pericardial effusion:
 POSITIVE FOR MALIGNANT CELLS,
  Consistent with metastatic adenocarcinoma. \

Repeat echo, [**2-2**]:
LV systolic function appears depressed. The right ventricular
cavity is borderline dilated with mild global free wall
hypokinesis. There is a small pericardial effusion. The effusion
is echo dense, consistent with blood, inflammation or other
cellular elements. There are no echocardiographic signs of
tamponade.


Brief Hospital Course:
47 yo M with history of epilepsy admitted for elective vagal
nerve stimulator replacement, transferred to MICU for management
of tachycardia, hypotension, and hypoxia, found to have
pericardial effusion, now s/p pericardiocentiesis with drain in
place, transferred to CCU for post-operative monitoring, with
frequent agitation, now found to have bilateral PEs
.
# Pericardial effusion:  In the MICU, pt noted to be tachycardic
with hypotension, and found to have pericardial effusion.  He
underwent pericardiocentesis with drain placement with drainage
of bloody fluid.  Hct stable despite profuse bloody drainage.
Etiology is likely malignancy given that CT torso showing RUL
lung spiculated nodule. Effusion cytology and micro showed cells
c/w metastatic lung adenocarcinoma.  Drain was eventually pulled
without complication and without any further hemodynamic
instability.  Pulsus checked for several days after drain pulled
and resolved effusion on Echo, was ~8 mmHg on discharge.
.
# PE/DVT:  Pt noted to have enlarged RV on repeat echo [**1-31**], so
CTA was obtained for concern of PEs which confirmed b/l
subsegmental PEs.  LENIs also positive for b/l DVTs.  He was
started on heparin ggt in house and transitioned to an
anticoagulation regimen of coumadin, with a lovenox bridge.  He
will f/u with his PCP on [**Name9 (PRE) 2974**] [**2-12**] after discharge.
.
#  Agitation: Patient with history of EtOH, marijuana,
cocaine/crack binges. He was significantly agitated throughout
admission which was initially thought to be secondary to ETOH
withdrawal.  He was maintained on a valium CIWA and klonipin 1mg
TID.  However, agitation persisted despite being well out of the
acute withdrawal window.  He had several code purples called for
him and was often violent towards nurses. Of note, pt would be
lucid and engaging often during the day with decompensation at
night.  Psych was consulted who felt that this was less likely
to be withdrawal and instead a behavioral issue/delerium, likely
in setting of supratherapeutic valproate level.  They
recommended haldol for his agitation which was continued 5mg PRN
along with 10mg QHS standing, these were discontinued on
discharge, takes no psych meds at home and delirium apparently
cleared.  Evaluated by psychiatry prior to discharge, appeared
to understand importance of f/u.  He was started on MVI,
thiamine, folate.
.
# Afib with RVR: Patient oscillates between HR of 70s ?????? 170s
with frequent episodes of RVR on tele, asymptomatic. Based on
old records, has a history of Afib with RVR, a flutter, was
treated with diltiazem and flecainide, and was supposed to be on
Metoprolol.  Increased metoprolol to 75 mg po qid standing which
has controlled rate well, though still with frequent episodes of
rapid ventricular response that respond to IV lopressor 5 mg x
1.  Because of continued episodes of RVR (likely in the setting
of pericardial effusion and multiple PEs) pt started on
diltiazem drip, weaned off and started on diltiazem ER 120 mg
daily, and metoprolol changed to 200 mg of metoprolol succinate
on discharge.  HR in the 60s with these changes, with short
bursts of SVT to 130s prior to discharge.  Would consider
uptitrating rate control as an outpatient.
.
#. h/o epilepsy and seizure activity: VNS placed and was
re-activated about 1 week after placement.  He was continued
home AEDs.   Depakote ER 1250/1500/1500 and Oxcarbazepine 600 mg
[**Hospital1 **] which was often given IV due to inability to take POs from
agitation.  Depakote level was found to be elevated in setting
of delirium, however unclear if this was true trough.  Was
discharged on home meds and advised to f/u with his outpatient
neurologist for management of his depakote.
.
# Foley self-d/c:  Pt pulled own foley overnight [**1-30**].  Of note
there was blood around the uerethral meatus after he pulled it.
Urine output was monitored and foley ended up being replaced on
[**2-2**] given that he was put back into 4pt restraints.  Foley
dc'ed and was able to void on his own with no hematuria for
remaineder of admission.


Medications on Admission:
- Clonazepam 1 mg QID
- Divalproex 250 mg Sustained Release qAM
- Depakote ER 500 mg tab- tabs qAM, 3 tabs in the afternoon and
3
tabs qPM
- Omeprazole 20 mg delayed release daily
- Oxcarbazepine 600 mg [**Hospital1 **]
- ASA 81 mg daily (not taking as prescribed)

Discharge Medications:
1. Lovenox 100 mg/mL Syringe Sig: One (1)  Subcutaneous twice a
day for 10 days.
Disp:*20 syringe* Refills:*0*
2. oxcarbazepine 600 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. clonazepam 1 mg Tablet Sig: One (1) Tablet PO four times a
day.
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
6. diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
7. divalproex 250 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO QAM: use in addition to the
depakote 500 mg strength tabs for total dose of 1250/1500/1500
mg .
8. divalproex 500 mg Tablet Sustained Release 24 hr Sig: Three
(3) Tablet Sustained Release 24 hr PO QAFTERNOON ().
9. divalproex 500 mg Tablet Sustained Release 24 hr Sig: Three
(3) Tablet Sustained Release 24 hr PO QHS (once a day (at
bedtime)).
10. divalproex 500 mg Tablet Sustained Release 24 hr Sig: Two
(2) Tablet Sustained Release 24 hr PO QAM: take in addition to
250 mg dose for a total 1250 mg every morning.
11. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
12. metoprolol succinate 200 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
13. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Home

Discharge Diagnosis:
Seizure disorder
Atrial fibrillation
Lung adenocarcinoma, pericardial effusion
Deep vein thrombosis, pulmonary embolism


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


Discharge Instructions:
You were seen in the hospital to have your vagal nerve
stimulator replaced, which has been turned on again, for your
seizures.

You were also found to have a very fast heart rate from your
atrial fibrillation (irregular heart rate) and for this we
started diltiazem and metoprolol, which slow your heart rate.

In addition, you were found to have a pericardial effusion
(fluid around your heart) which is likely due to spreading of
lung cancer, which was discovered on a CT scan.  You were seen
by the oncologists here who recommended that you go to clinic
for follow up to discuss further workup and treatment.

You were also found to have a pulmonary embolism and deep vein
thrombosis (blood clots in your lung and legs) for which you
were started a blood thinner.  You will be taking a blood
thinner called Coumadin to prevent more clots from forming and
to treat the ones you already have, and you should take this
medication every day.  You will be taking Lovenox, another blood
thinner which works immediately, temporarily until your blood
level of Coumadin reaches the therapeutic range.

Changes to your medications:
START diltiazem 120 mg every day
START taking metoprolol 200 mg daily
START taking warfarin 5 mg daily
START taking lovenox shots twice a day until you are told to
stop by your doctor

Followup Instructions:
In addition to the appointments below, the oncologists are
trying to schedule you an appointment in clinic.  The phone
number to call with questions is [**0-0-**].

Department: [**Hospital3 249**]
When: FRIDAY [**2196-2-12**] at 4:00 PM
With: MARK [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], LICSW [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: [**Hospital3 249**]
When: FRIDAY [**2196-2-19**] at 3:00 PM
With: MARK [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], LICSW [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: [**Hospital3 249**]
When: THURSDAY [**2196-3-17**] at 4:50 PM
With: [**First Name11 (Name Pattern1) 1980**] [**Last Name (NamePattern4) 1981**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage



Completed by:[**2196-2-7**]
{'Mechanical complication of nervous system device, implant, and graft,Other pulmonary embolism and infarction,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Generalized nonconvulsive epilepsy, with intractable epilepsy,Secondary malignant neoplasm of other specified sites,Malignant neoplasm of upper lobe, bronchus or lung,Alcohol withdrawal,Drug-induced delirium,Atrial flutter,Injury to bladder and urethra, without mention of open wound into cavity,Physical restraints status,Other and unspecified anticonvulsants causing adverse effects in therapeutic use,Unspecified episodic mood disorder,Borderline personality disorder,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: Pericardial effusion

PRESENT ILLNESS: Please see original Neurology Admission Note and MICU [**Location (un) **]
Transfer Note for details.
.
Briefly, 47 y/o man with long standing history of epilepsy s/p
right temporal lobectomy (at age 19) and VNS placement (7 years
ago), h/o EtOH and cocaine abuse who was having increased
seizure frequency in the setting of VNS malfunction. He was
admitted on [**1-28**] for elective replacement of the vagus nerve
stimulator generator.  The procedure went without complication.
Overnight he developed AF with RVR to the 180s with hypotension
to the 80s.  CIWA was 17 with last drink approximately 72 hours
prior. Patient was also noted to be [**Doctor Last Name **] with a CIWA of 17
and is thought that last EtOH drink was 72 hours ago.  He
received 2mg IV ativan with somnolence and apenea afterwards.
He was subsequently transferred to the MICU.
.
His MICU course was notable for an echocardiogram which showed a
large pericardial effusion on [**1-29**].  He was seen by the
cardiology fellow and subsequently underwent pericardial window.
450cc of bloody pericardial fluid was drained. Patient developed
SVT in the cath lab and was treated with 9 mg IV metoprolol. He
was transferred to CCU postprocedurally for monitoring.
.
On arrival, patient complained of spinal back pain from lying on
the operating table. He also reports that his lungs feel
"collapsed" but denied shortness of breath.
.
Review of systems was otherwise negative.

MEDICAL HISTORY: - epilepsy and nonelectrographic seizures (petite mal with rare
secondary generalization)
- s/p right temporal lobectomy
- s/p VNS placement
- Mood disorder and likely borderline personality organization
- Multiple suicide attempts in past (largely overdose)
- DM due to medication, now apparently resolved
- cervical strain
- Rosacea
- [**Last Name (un) 865**] esophagus
- Polysubstance abuse: EtOH, MJ, cocaine/crack binges with
resultant unsafe sexual practices
- h/o atrial fibrillation (not on medication)

MEDICATION ON ADMISSION: - Clonazepam 1 mg QID
- Divalproex 250 mg Sustained Release qAM
- Depakote ER 500 mg tab- tabs qAM, 3 tabs in the afternoon and
3
tabs qPM
- Omeprazole 20 mg delayed release daily
- Oxcarbazepine 600 mg [**Hospital1 **]
- ASA 81 mg daily (not taking as prescribed)

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ON TRANSFER TO CCU:
VS: HR:90 BP:128/82 O2sat:93% 2L(NC)
GEN: agitated, in fetal position, not tachypneic
HEENT: PERRL. MM dry.
NECK: neck supple. Left neck dressing with dried blood. No
active bleeding or discharge. Mild tenderness on palpation.
PULM: Moving air appropriately, diffuse crackles. Left upper
chest (VNS) site c/d/i.
CARD: Soft heart sound, RRR, s1/s2 present, no m/g/r, with
pericardial window draining frank blood
ABD: +bs, soft, NT/ND
EXT: wwp, no edema, 2+PD bilaterally
SKIN: warm
BACK: tenderness to palpation along the spine
NEURO: AOx3, agitated, but agreeable.

FAMILY HISTORY: States has FH of diabetes and 'cancer in everyone' but no FH of
CAD, HTN, sudden death or cardiac dysrhythmias

SOCIAL HISTORY: Unemployed, lives alone. Smokes 1pk/day, occasional
ETOH and OMR records indicate some history of Crack Cocaine use. 

### Response:
{'Mechanical complication of nervous system device, implant, and graft,Other pulmonary embolism and infarction,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Generalized nonconvulsive epilepsy, with intractable epilepsy,Secondary malignant neoplasm of other specified sites,Malignant neoplasm of upper lobe, bronchus or lung,Alcohol withdrawal,Drug-induced delirium,Atrial flutter,Injury to bladder and urethra, without mention of open wound into cavity,Physical restraints status,Other and unspecified anticonvulsants causing adverse effects in therapeutic use,Unspecified episodic mood disorder,Borderline personality disorder,Unspecified accident'}
