CHIEF COMPLAINT: Bradycardia

PRESENT ILLNESS: 73M with CAD s/p DES to RCA and LCX, DMII, hyperlipidemia, LVH,
called EMS early this morning reporting two days of lethargy and
lightheadedness. On arrival EMS found him to have a neart rate
in the 30's.
.
The patient was recently started on atenolol 25mg two days ago
for treatment of CAD and frequent atrial and ventricular ectopy.
He was also told to decrease his diltiazem dosing. He took his
first dose of atenolol Monday, without decreasing his diltiazem.
He reports feeling normal and active during the day Monday and
feeling weak and lightheaded monday night.  He took his second
dose Tuesday morning and reports feeling fine all day tuesday as
well.  Tuesday night he reports feeling weak, lightheaded, and
almost fell.  He went to bed and then decided to call EMS at 4am
to bring him in to the ED.
.
On arrival to the ED he was in a regular junctional rhythm
without P waves at a rate of 34 and systolic blood pressure of
106. His Oxygen saturation was 100% RA. He was given Glucagon
5mg and Magnesium. His heart rate remained between 22 and 59,
mostly in 30's, during his stay in the ED and his blood pressure
ranged 84-121/43-60,  mostly 100/50.  He was given .5mg of
atropine when his HR dipped to 22 and blood pressure decreased
to 85.  Heart rate responded to 33 with blood pressure 105/57.
The first set of cardiac enzymes were negative.  Also with new
acute renal failure with creatiinne of 1.7 from baseline 1.2.
.
The patient underwent holter monitoring on [**7-3**] for evaluation of
non-sustained VT.  This evaluation showed sinus bradycardia with
episodes of junctional bradycardia with rates as low as 39. It
also showed an asymptomatic daytime pause of 3.3 seconds and
frequent atrial and ventricular ectopy.
.
He also reports a syncopal episode in [**Month (only) 404**].  He was evaluated
by Neurology and this was attributed to hypoglycemia or
parkinson's.
.
On arrival to the CCU he had a rate of 32 with blood pressure
100/60.  He was given 1mg of calcium chloride with increased
heart rate to 56 and increased blood pressure to 150/80.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
He sleeps on one pillow and has no PND, peripheral edema, weight
gain, syncope, or claudication.  He occasionally experiences
postural lightheadedness when standing up from a seated
position.

MEDICAL HISTORY: 1. CAD, status post stening x3, 1 drug-eluting, 2 non. He
was followed by a cardiologist at [**Hospital6 1708**].

MEDICATION ON ADMISSION: Atenolol 25 mg Tablet
1 Tablet(s) by mouth once a day
Atorvastatin [Lipitor] 10 mg Tablet 1 Tablet(s) by mouth twice
daily    Carbidopa-Levodopa [Sinemet] 10 mg-100 mg Tablet 1
Tablet(s) by mouth four times a day
Diltiazem HCl 180 mg Capsule, Sustained Release 1 Capsule(s) by
mouth every day
Gabapentin 300 mg Capsule [**12-3**] Capsule(s) by mouth Once or twice
daily  [**2180-5-3**]
Glyburide 5 mg Tablet Two Tablet(s) by mouth am  nr
LO DOSE INSULIN SYRINGES 1CC AS DIRECTED FOR INSULIN
ADMINISTRATION    Metformin [Glucophage XR] 500 mg Tablet
Sustained Release 24 hr three Tablet(s) by mouth daily
Valsartan [Diovan] 160 mg Tablet One Tablet(s) by mouth Daily

ALLERGIES: Corgard / Lasix

PHYSICAL EXAM: GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: Father - died MI in 50s
Mother - died of cancer at age 88
Brother - DM, Parkinsons

SOCIAL HISTORY: He is single and lives alone. He is a retired [**Location (un) 511**]
telephone worker. He has remote history of smoking cigars, quit
[**2170**] after 40 years of smoking, never smoked cigarettes. Drinks
1.75L whiskey a month.
Sinoatrial node dysfunction,Acute kidney failure, unspecified,Other and unspecified agents primarily affecting the cardiovascular system causing adverse effects in therapeutic use,Coronary atherosclerosis of native coronary artery,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Other and unspecified hyperlipidemia,Paralysis agitans,Spinal stenosis, unspecified region
Sinoatrial node dysfunct,Acute kidney failure NOS,Adv eff cardiovasc NEC,Crnry athrscl natve vssl,Hy kid NOS w cr kid I-IV,Chr kidney dis stage III,DMII neuro nt st uncntrl,Neuropathy in diabetes,Hyperlipidemia NEC/NOS,Paralysis agitans,Spinal stenosis NOS
Admission Date:  [**2180-7-19**]              Discharge Date:   [**2180-7-20**]

Date of Birth:  [**2107-6-27**]             Sex:   M

Service: MEDICINE

Allergies:
Corgard / Lasix

Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Bradycardia

Major Surgical or Invasive Procedure:
none

History of Present Illness:
73M with CAD s/p DES to RCA and LCX, DMII, hyperlipidemia, LVH,
called EMS early this morning reporting two days of lethargy and
lightheadedness. On arrival EMS found him to have a neart rate
in the 30's.
.
The patient was recently started on atenolol 25mg two days ago
for treatment of CAD and frequent atrial and ventricular ectopy.
He was also told to decrease his diltiazem dosing. He took his
first dose of atenolol Monday, without decreasing his diltiazem.
He reports feeling normal and active during the day Monday and
feeling weak and lightheaded monday night.  He took his second
dose Tuesday morning and reports feeling fine all day tuesday as
well.  Tuesday night he reports feeling weak, lightheaded, and
almost fell.  He went to bed and then decided to call EMS at 4am
to bring him in to the ED.
.
On arrival to the ED he was in a regular junctional rhythm
without P waves at a rate of 34 and systolic blood pressure of
106. His Oxygen saturation was 100% RA. He was given Glucagon
5mg and Magnesium. His heart rate remained between 22 and 59,
mostly in 30's, during his stay in the ED and his blood pressure
ranged 84-121/43-60,  mostly 100/50.  He was given .5mg of
atropine when his HR dipped to 22 and blood pressure decreased
to 85.  Heart rate responded to 33 with blood pressure 105/57.
The first set of cardiac enzymes were negative.  Also with new
acute renal failure with creatiinne of 1.7 from baseline 1.2.
.
The patient underwent holter monitoring on [**7-3**] for evaluation of
non-sustained VT.  This evaluation showed sinus bradycardia with
episodes of junctional bradycardia with rates as low as 39. It
also showed an asymptomatic daytime pause of 3.3 seconds and
frequent atrial and ventricular ectopy.
.
He also reports a syncopal episode in [**Month (only) 404**].  He was evaluated
by Neurology and this was attributed to hypoglycemia or
parkinson's.
.
On arrival to the CCU he had a rate of 32 with blood pressure
100/60.  He was given 1mg of calcium chloride with increased
heart rate to 56 and increased blood pressure to 150/80.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
He sleeps on one pillow and has no PND, peripheral edema, weight
gain, syncope, or claudication.  He occasionally experiences
postural lightheadedness when standing up from a seated
position.

Past Medical History:
1. CAD, status post stening x3, 1 drug-eluting, 2 non. He
was followed by a cardiologist at [**Hospital6 1708**].

2. Diabetes mellitus with diabetic neuropathy.
3. Dyslipidemia including hypertriglyceridemia.
4. Hypertension.
5. A history of multiple squamous skin cancers.
6. Proteinuria

Social History:
He is single and lives alone. He is a retired [**Location (un) 511**]
telephone worker. He has remote history of smoking cigars, quit
[**2170**] after 40 years of smoking, never smoked cigarettes. Drinks
1.75L whiskey a month.


Family History:
Father - died MI in 50s
Mother - died of cancer at age 88
Brother - DM, Parkinsons

Physical Exam:
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

NECK: Supple with no JVP.
CARDIAC: Bradycardic. normal S1, S2. No m/r/g. No thrills,
lifts. No S3 or S4.
LUNGS: CTAB, Bronchial breath sounds.
ABDOMEN: Obese, Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP and PT dopplerable
Left: DP and PT dopplerable


Pertinent Results:
EKG: [**7-19**]- Junctional bradycardia. Compared to the previous
tracing of [**2180-7-19**] right bundle-branch block is no longer
recorded. The Q-T interval is prolonged
.
[**2180-7-19**] 05:15AM BLOOD WBC-9.9 RBC-4.05* Hgb-13.1* Hct-39.0*
MCV-96 MCH-
32.4* MCHC-33.6 RDW-14.5 Plt Ct-245
[**2180-7-20**] 05:00AM BLOOD WBC-9.3 RBC-3.99* Hgb-12.9* Hct-37.8*
MCV-95 MCH-32.4* MCHC-34.1 RDW-14.3 Plt Ct-197
[**2180-7-19**] 05:15AM BLOOD Neuts-59.0 Lymphs-32.5 Monos-5.1 Eos-2.9
Baso-0.5
[**2180-7-19**] 05:15AM BLOOD PT-13.2 PTT-24.5 INR(PT)-1.1
[**2180-7-19**] 05:15AM BLOOD Plt Ct-245
[**2180-7-20**] 05:00AM BLOOD Plt Ct-197
[**2180-7-19**] 05:15AM BLOOD Glucose-268* UreaN-21* Creat-1.7* Na-132*
K-5.0 Cl-100 HCO3-22 AnGap-15
[**2180-7-19**] 03:15PM BLOOD Glucose-118* UreaN-24* Creat-1.7* Na-135
K-4.5 Cl-101 HCO3-26 AnGap-13
[**2180-7-20**] 05:00AM BLOOD Glucose-56* UreaN-22* Creat-1.2 Na-135
K-4.2 Cl-101 HCO3-27 AnGap-11
[**2180-7-19**] 05:15AM BLOOD CK(CPK)-52
[**2180-7-19**] 03:15PM BLOOD CK(CPK)-39
[**2180-7-19**] 05:15AM BLOOD cTropnT-0.01
[**2180-7-19**] 03:15PM BLOOD CK-MB-4 cTropnT-<0.01

Brief Hospital Course:
73 year old man with CAD, DMII, parkinson's disease, found to
have junctional bradycardia after recent initiation of atenolol,
likely sick sinus syndrome, in NSR after calcium chloride
administration.
.
# Bradycardia: presented with junctional rhythm with HR in 30s,
then in NSR with HR in 60s-70s with 1 amp calcium chloride
administration. It is thought that the recent addition of
atenolol to his home diltiazem regimen may have caused
suppression of AV node, with retrograde p waves causing a
simulated pacemeaker syndrome, when the atria and ventricle
contract simultaneously, causing increased vagal tone.  After
the calcium chloride administration, patient maintained HR in
60s-70s, with BP 150s-160s.  He was kept off atenolol (and all
beta blockers).  He was kept off diltiazem (and all calcium
channel blockers).  He is to not resume these classes of
medicines.  It was reviewed with patient that he likely has sick
sinus syndrome, for which he can only take diuretics/ACEi/ARBs
for blood pressure control.  He was discharged home with [**Doctor Last Name **] of
Hearts monitor and outpatient workup for sick sinus syndrome.
Dr. [**Last Name (STitle) **] will be getting the results of the [**Doctor Last Name **] of Hearts
monitor and will discuss them with patient on [**2180-8-9**].
.
# Acute on chronic Renal failure: Cr on presentation 1.7, which
improved to baseline 1.2.  Likely from poor cardiac output.
Patient's UOP was within normal limits on discharge.
.
# Diabetes II: metformin and glyburide were held.  Patient
continued on home dose insulin and insulin sliding scale.
.
# Hypertension: beta blockers and calcium channel blockers were
held.  SBP range was 150s-160s. Outpatient management will be
primarily ARBs, diuretics.  He is to continue valsartan and
hydrochlorothiazide (12.5 mg daily) as his new BP meds.
.
# Coronary Artery Disease: s/p two DES to RCA and LCX in [**2173**].
Patient was continued on aspirin 81mg and atorvastatin 10 mg.
He will be off BB and CCB due to likely sick sinus, as noted
above.
.
# Peripheral Neuropathy: from diabetes.  Continued on home dose
gabapentin.
.
# Spinal stenosis: pain control was adequate throughout
hospitalization.
.
# Parkinson's disease ?????? stable. Cont carbidopa-levodopa.

Medications on Admission:
Atenolol 25 mg Tablet
1 Tablet(s) by mouth once a day
Atorvastatin [Lipitor] 10 mg Tablet 1 Tablet(s) by mouth twice
daily    Carbidopa-Levodopa [Sinemet] 10 mg-100 mg Tablet 1
Tablet(s) by mouth four times a day
Diltiazem HCl 180 mg Capsule, Sustained Release 1 Capsule(s) by
mouth every day
Gabapentin 300 mg Capsule [**12-3**] Capsule(s) by mouth Once or twice
daily  [**2180-5-3**]
Glyburide 5 mg Tablet Two Tablet(s) by mouth am  nr
LO DOSE INSULIN SYRINGES 1CC AS DIRECTED FOR INSULIN
ADMINISTRATION    Metformin [Glucophage XR] 500 mg Tablet
Sustained Release 24 hr three Tablet(s) by mouth daily
Valsartan [Diovan] 160 mg Tablet One Tablet(s) by mouth Daily

Aspirin [Ecotrin Low Strength] 81 mg Tablet, Delayed Release
(E.C.)
one Tablet(s) by mouth daily
Blood Sugar Diagnostic [Accu-Chek Aviva] Strip Two Daily
Insulin NPH Human Recomb [Humulin N] 100 unit/mL Suspension
inject subcutaneously 60units in the morning
Multivitamin


Discharge Medications:
1. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*2*
3. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Carbidopa-Levodopa 10-100 mg Tablet Sig: One (1) Tablet PO
four times a day.
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Sixty
(60) units Subcutaneous once a day.
9. Glucophage XR 500 mg Tablet Sustained Release 24 hr Sig:
Three (3) Tablet Sustained Release 24 hr PO once a day.
10. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO once a day.
11. Outpatient Lab Work
chem 7 on [**2180-7-26**]. Call results to Dr. [**First Name (STitle) 216**] at [**Telephone/Fax (1) 250**]


Discharge Disposition:
Home

Discharge Diagnosis:
PRIMARY:
1. Bradycardia with junctional rhythm, medication induced
2. Sick sinus syndrome
3. Acute on Chronic Kidney disease, stage 3
4. Diabetes Mellitus Type 2
5. Hypertension
6. Coronary Artery Disease


Discharge Condition:
stable, with HR 70-80, SBP 150-160


Discharge Instructions:
You were admitted to the hospital with slow heart rate
(bradycardia) likely related to your atenolol and diltiazem
medications. You were given calcium chloride which increased
your heart rate into normal sinus rhythm. You are to not take
atenolol (or other beta blockers). You are to not take diltiazem
(or other calcium channel blockers). For blood pressure control,
you will take your valsartan (your home dose) and be started on
a medicine which does not affect heart rate
(hydrochlorothiazide). You will be wearing [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts
Monitor after you go home. Please follow instructions for use,
Dr. [**Last Name (STitle) **] will be getting the results and will discuss them
with you on [**2180-8-9**].
.
NEW MEDICATION:
-hydrochlorothiazide 12.5 mg daily
.
Please seek medical attention for lightheadedness, weakness,
fatigue, chest pain, palpitations, shortness of breath, fevers,
abdominal pain, or any other concerns.

Followup Instructions:
Cardiology:
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) **] Phone: [**Telephone/Fax (1) 62**]
Date/Time:[**2180-8-9**] 9:00
Primary Care:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2180-8-28**]
8:30
Nephrology:
Provider: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Phone:[**Telephone/Fax (1) 721**]
Date/Time:[**2180-11-2**] 1:00
Dermatology:
Provider: [**Name10 (NameIs) 28909**],[**Name11 (NameIs) 8754**] DERMATOLOGY GEN-[**Doctor First Name 8754**] (NHB)
Date/Time:[**2180-8-4**] 8:15



Completed by:[**2180-7-21**]
{'Sinoatrial node dysfunction,Acute kidney failure, unspecified,Other and unspecified agents primarily affecting the cardiovascular system causing adverse effects in therapeutic use,Coronary atherosclerosis of native coronary artery,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Other and unspecified hyperlipidemia,Paralysis agitans,Spinal stenosis, unspecified region'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: Bradycardia

PRESENT ILLNESS: 73M with CAD s/p DES to RCA and LCX, DMII, hyperlipidemia, LVH,
called EMS early this morning reporting two days of lethargy and
lightheadedness. On arrival EMS found him to have a neart rate
in the 30's.
.
The patient was recently started on atenolol 25mg two days ago
for treatment of CAD and frequent atrial and ventricular ectopy.
He was also told to decrease his diltiazem dosing. He took his
first dose of atenolol Monday, without decreasing his diltiazem.
He reports feeling normal and active during the day Monday and
feeling weak and lightheaded monday night.  He took his second
dose Tuesday morning and reports feeling fine all day tuesday as
well.  Tuesday night he reports feeling weak, lightheaded, and
almost fell.  He went to bed and then decided to call EMS at 4am
to bring him in to the ED.
.
On arrival to the ED he was in a regular junctional rhythm
without P waves at a rate of 34 and systolic blood pressure of
106. His Oxygen saturation was 100% RA. He was given Glucagon
5mg and Magnesium. His heart rate remained between 22 and 59,
mostly in 30's, during his stay in the ED and his blood pressure
ranged 84-121/43-60,  mostly 100/50.  He was given .5mg of
atropine when his HR dipped to 22 and blood pressure decreased
to 85.  Heart rate responded to 33 with blood pressure 105/57.
The first set of cardiac enzymes were negative.  Also with new
acute renal failure with creatiinne of 1.7 from baseline 1.2.
.
The patient underwent holter monitoring on [**7-3**] for evaluation of
non-sustained VT.  This evaluation showed sinus bradycardia with
episodes of junctional bradycardia with rates as low as 39. It
also showed an asymptomatic daytime pause of 3.3 seconds and
frequent atrial and ventricular ectopy.
.
He also reports a syncopal episode in [**Month (only) 404**].  He was evaluated
by Neurology and this was attributed to hypoglycemia or
parkinson's.
.
On arrival to the CCU he had a rate of 32 with blood pressure
100/60.  He was given 1mg of calcium chloride with increased
heart rate to 56 and increased blood pressure to 150/80.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
He sleeps on one pillow and has no PND, peripheral edema, weight
gain, syncope, or claudication.  He occasionally experiences
postural lightheadedness when standing up from a seated
position.

MEDICAL HISTORY: 1. CAD, status post stening x3, 1 drug-eluting, 2 non. He
was followed by a cardiologist at [**Hospital6 1708**].

MEDICATION ON ADMISSION: Atenolol 25 mg Tablet
1 Tablet(s) by mouth once a day
Atorvastatin [Lipitor] 10 mg Tablet 1 Tablet(s) by mouth twice
daily    Carbidopa-Levodopa [Sinemet] 10 mg-100 mg Tablet 1
Tablet(s) by mouth four times a day
Diltiazem HCl 180 mg Capsule, Sustained Release 1 Capsule(s) by
mouth every day
Gabapentin 300 mg Capsule [**12-3**] Capsule(s) by mouth Once or twice
daily  [**2180-5-3**]
Glyburide 5 mg Tablet Two Tablet(s) by mouth am  nr
LO DOSE INSULIN SYRINGES 1CC AS DIRECTED FOR INSULIN
ADMINISTRATION    Metformin [Glucophage XR] 500 mg Tablet
Sustained Release 24 hr three Tablet(s) by mouth daily
Valsartan [Diovan] 160 mg Tablet One Tablet(s) by mouth Daily

ALLERGIES: Corgard / Lasix

PHYSICAL EXAM: GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: Father - died MI in 50s
Mother - died of cancer at age 88
Brother - DM, Parkinsons

SOCIAL HISTORY: He is single and lives alone. He is a retired [**Location (un) 511**]
telephone worker. He has remote history of smoking cigars, quit
[**2170**] after 40 years of smoking, never smoked cigarettes. Drinks
1.75L whiskey a month. 

### Response:
{'Sinoatrial node dysfunction,Acute kidney failure, unspecified,Other and unspecified agents primarily affecting the cardiovascular system causing adverse effects in therapeutic use,Coronary atherosclerosis of native coronary artery,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Other and unspecified hyperlipidemia,Paralysis agitans,Spinal stenosis, unspecified region'}
