CHIEF COMPLAINT: Palpitations

PRESENT ILLNESS: 53 year old male who developed atrial flutter in [**2127**]. He
underwent an atrial fibrillation ablation in [**3-/2131**]; however,
had recurrence shortly thereafter. He then underwent pulmonary
vein isolation in 12/[**2130**]. He had been doing well until [**5-22**]
when he presented to [**Hospital1 18**] with two hours of left lower
extremity pain and pallor and was diagnosed with left leg
arterial clot. He was taken to the OR and underwent left iliac
and left femoral popliteal thrombectomy and placement of a left
common iliac stent. He also had left lower extremity four
compartment fasciotomies and evacuation and drainage of a left
medial calf hematoma. He was started on Coumadin and heparin. Of
note, the patient has a history of brain aneurysm in [**2117**] and
[**2127**] and had a subdural hematoma in [**2131**]. After the subdural
hematoma, he stopped Coumadin and remains off anticoagulation.
The patient is very reluctant to be on anticoagulation long term
given his past medical history but was on it short term after
recent left leg arterial clot. He currently reports episodes of
palpitations occurring two to three times per week. They come on
without apparent trigger and resolve spontaneously. The episodes
last approximately 5-10 minutes in total. Similar frequency to
prior. He has no associated chest pain, shortness of breath,
lightheadedness, dizziness, syncope or presyncope. He recently
had cardiac monitoring which showed primarily sinus rhythm and
sinus bradycardia with rates ranging  form 49 to 68bpm. There
were several short episodes of Atrial Fibrillation with the
longest 1 minute in duration. There were also PAC, and PAC pairs
as well as 1 PVC couplet. Given his palpitations, concern with
anticoagulation and recent cardiac study with documented atrial
fibrillation, he has been referred for consideration of MAZE and
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1916**] removal.

MEDICAL HISTORY: - Atrial fibrillation s/p AF ablation and PVI [**2130**]
- History of Cerebral Aneurysms
- Subdural hematoma s/p MVA in [**2131**]
- Chronic renal insufficiency, Polycystic Kidney Disease
- History of LLE Embolism
- Hypertension
- GERD
- Depression

MEDICATION ON ADMISSION: Celexa 20 mg daily
Metoprolol tartrate 50 mg TID
Pramipexole 0.25 mg daily
Omeprazole 20 mg daily
Propafenone 150 mg twice daily

ALLERGIES: Codeine

PHYSICAL EXAM: Pulse: 65  Resp: 16  O2 sat: 99% room air
B/P  Right: 133/87    Left: 137/91

FAMILY HISTORY: Significant for grandfather who died of MI at 76 and mother had
MI times two in her 70s

SOCIAL HISTORY: Lives with: Wife
Occupation: Retired police officer in [**2131**]
Tobacco: smokes [**12-11**] ppd, approx 30 PYH
ETOH: Quit 27 years ago
Coronary atherosclerosis of native coronary artery,Acute kidney failure with lesion of tubular necrosis,Metabolic encephalopathy,Polycystic kidney, unspecified type,Chronic kidney disease, Stage IV (severe),Ventilator associated pneumonia,Hyperosmolality and/or hypernatremia,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Hypoxemia,Atrial fibrillation,Long-term (current) use of anticoagulants,Personal history of venous thrombosis and embolism,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Esophageal reflux,Obstructive sleep apnea (adult)(pediatric),Depressive disorder, not elsewhere classified,Tobacco use disorder,Family history of other cardiovascular diseases
Crnry athrscl natve vssl,Ac kidny fail, tubr necr,Metabolic encephalopathy,Polycystic kidney NOS,Chr kidney dis stage IV,Ventltr assoc pneumonia,Hyperosmolality,MRSA elsewhere/NOS,Hypoxemia,Atrial fibrillation,Long-term use anticoagul,Hx-ven thrombosis/embols,Hy kid NOS w cr kid I-IV,Esophageal reflux,Obstructive sleep apnea,Depressive disorder NEC,Tobacco use disorder,Fam hx-cardiovas dis NEC
Admission Date:  [**2136-5-30**]              Discharge Date:   [**2136-6-14**]

Date of Birth:  [**2083-3-23**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Codeine

Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Palpitations


Major Surgical or Invasive Procedure:
[**2136-5-30**]
Coronary bypass grafting x2:  Left internal mammary artery to
left anterior descending coronary; reverse saphenous vein single
graft from aorta to distal right coronary artery.
Full left and right-sided maze procedure with a [**Company 1543**] Gemini
X Irrigated Bipolar device, as well as the cryo catheter.


History of Present Illness:
53 year old male who developed atrial flutter in [**2127**]. He
underwent an atrial fibrillation ablation in [**3-/2131**]; however,
had recurrence shortly thereafter. He then underwent pulmonary
vein isolation in 12/[**2130**]. He had been doing well until [**5-22**]
when he presented to [**Hospital1 18**] with two hours of left lower
extremity pain and pallor and was diagnosed with left leg
arterial clot. He was taken to the OR and underwent left iliac
and left femoral popliteal thrombectomy and placement of a left
common iliac stent. He also had left lower extremity four
compartment fasciotomies and evacuation and drainage of a left
medial calf hematoma. He was started on Coumadin and heparin. Of
note, the patient has a history of brain aneurysm in [**2117**] and
[**2127**] and had a subdural hematoma in [**2131**]. After the subdural
hematoma, he stopped Coumadin and remains off anticoagulation.
The patient is very reluctant to be on anticoagulation long term
given his past medical history but was on it short term after
recent left leg arterial clot. He currently reports episodes of
palpitations occurring two to three times per week. They come on
without apparent trigger and resolve spontaneously. The episodes
last approximately 5-10 minutes in total. Similar frequency to
prior. He has no associated chest pain, shortness of breath,
lightheadedness, dizziness, syncope or presyncope. He recently
had cardiac monitoring which showed primarily sinus rhythm and
sinus bradycardia with rates ranging  form 49 to 68bpm. There
were several short episodes of Atrial Fibrillation with the
longest 1 minute in duration. There were also PAC, and PAC pairs
as well as 1 PVC couplet. Given his palpitations, concern with
anticoagulation and recent cardiac study with documented atrial
fibrillation, he has been referred for consideration of MAZE and
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1916**] removal.


Past Medical History:
- Atrial fibrillation s/p AF ablation and PVI [**2130**]
- History of Cerebral Aneurysms
- Subdural hematoma s/p MVA in [**2131**]
- Chronic renal insufficiency, Polycystic Kidney Disease
- History of LLE Embolism
- Hypertension
- GERD
- Depression

Past Surgical History
- s/p Subdural Hematoma Evacuation [**2131**]
- s/p Intracranial aneurysm clipping x 2 ([**2117**], [**2127**])
- s/p Left iliac and left femoral popliteal thrombectomy, left
common iliac stent placement and lower extremity four
compartment
fasciotomies and evacuation and drainage of a left medial calf
hematoma
- s/p Bilateral wrist surgery
- s/p Bilateral shoulder surgery
- s/p Right knee arthroscopy
- s/p Right hand


Social History:
Lives with: Wife
Occupation: Retired police officer in [**2131**]
Tobacco: smokes [**12-11**] ppd, approx 30 PYH
ETOH: Quit 27 years ago


Family History:
Significant for grandfather who died of MI at 76 and mother had
MI times two in her 70s


Physical Exam:
Pulse: 65  Resp: 16  O2 sat: 99% room air
B/P  Right: 133/87    Left: 137/91

General: Middle aged male in no acute distress
Skin: Dry [X] intact [X] - no signficiant rash noted
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur - soft systolic
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema none
Varicosities: None [X]
Neuro: Grossly intact
Pulses:
Femoral      Right: 2  Left: 2
DP           Right: 1  Left: 1
PT           [**Name (NI) 167**]: 1  Left: 1
Radial       Right: 2  Left: -

Carotid Bruit     Right: none   Left: none


Pertinent Results:
[**2136-5-31**] 03:15AM BLOOD WBC-13.8* RBC-3.70* Hgb-11.8* Hct-35.7*
MCV-97 MCH-31.8 MCHC-32.9 RDW-14.2 Plt Ct-146*
[**2136-5-31**] 03:15AM BLOOD Glucose-138* UreaN-34* Creat-2.1* Na-141
K-5.1 Cl-112* HCO3-19* AnGap-15

[**2136-5-30**] TEE
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is low normal (LVEF
50-55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation.
The mitral valve appears structurally normal with trivial mitral
regurgitation.
There is no pericardial effusion.
3D echo reviewed the left atrial appendage prfe-procedure.
Post-CPB:
The patient is AV-Paced, on no inotropes.
Preserved biventricular systolic fxn.
No MR, no AI. Aorta intact.
LAA successfully ligated.


Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2136-5-30**] where the patient underwent  a
coronary bypass grafting x2:  Left internal mammary artery to
left anterior descending coronary; reverse saphenous vein single
graft from aorta to distal right coronary artery and full left
and right-sided maze procedure with a [**Company 1543**] Gemini X
Irrigated Bipolar device, as well as the cryo catheter. See
operative note for full details. Overall the patient tolerated
the procedure well and post-operatively was transferred to the
CVICU in stable condition for recovery and invasive monitoring.

The patient was extubated on post operative day 1 with hypoxia
after extubation requiring noninvasive ventilation. He was
hemodynamically stable on no inotropic or vasopressor support on
POD 1.  His chest tubes and temporary pacing wires were removed
per protocol. He was diuresed aggressively but his respiratory
status did not improve and he was reintubated. Attempts to
decrease sedation and wean from ventialtor resulted in agitation
which was managed with haldol. He developed a medication induced
ATN which improved when diuretics and other nephrotoxic agents
were d/c'd until renal function recovered. A leukocytosis
developed and was pan cultured and started on Cipro. Sputum
eventually grew out staph coag positive and cirpto was d/c'd and
he was started on IV Vanco. He was once again extubated
successfully. His mental status continued to improve over the
course of his hospital stay. He developed post-operative afib
and was started on betablockers for but developed a junctional
rhythm. EP service was consulted and amiodarone was started.
When his rhythm recovered betablocker was resumed. He was also
maintained on a statin. He was anticoagulated with coumadin for
afib and was sensitive to coumadin dosing. He was evaluated by
physical therapy for strength and conditoning. The wound was
healing and pain was controlled with oral analgesics.  The
patient was discharged home on POD# 15 in good condition with
appropriate follow up instructions.



Medications on Admission:
Celexa 20 mg daily
Metoprolol tartrate 50 mg TID
Pramipexole 0.25 mg daily
Omeprazole 20 mg daily
Propafenone 150 mg twice daily

Allergies: Codeine( GI upset) and midazolam (altered mental
status)


Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
3. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 mdi* Refills:*2*
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
6. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. pramipexole 0.125 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
9. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
12. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
13. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Coumadin 2.5 mg Tablet Sig: as directed Tablet PO once a
day: Based on INR for AFIB
Goal INR 2.0-2.5.
Disp:*90 Tablet(s)* Refills:*2*
17. Outpatient Lab Work
Check INR on [**2136-6-15**] and call results to Dr. [**Last Name (STitle) 27542**]
[**Telephone/Fax (1) 27541**]
Check INR daily  until off bactrim athen 3 times per week until
INR stable
INR daily Goal 2.0-2.5
please check bun/creat next week


Discharge Disposition:
Home With Service

Facility:
[**Location (un) **] Nursing Services

Discharge Diagnosis:
Coronary Artery Disease

Atrial fibrillation s/p AF ablation and PVI [**2130**] History of
Cerebral Aneurysms Subdural hematoma s/p MVA in [**2131**] Chronic
renal insufficiency, Polycystic Kidney Disease History of LLE
Embolism, Hypertension, GERD, Depression, s/p Subdural Hematoma
Evacuation [**2131**] s/p Intracranial aneurysm clipping x 2 ([**2117**],
[**2127**]) s/p Left iliac and left femoral popliteal thrombectomy,
left common iliac stent placement and lower extremity four
compartment fasciotomies and evacuation and drainage of a left
medial calf hematoma s/p Bilateral wrist surgery, s/p Bilateral
shoulder surgery s/p, Right knee arthroscopy


Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema - none



Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart

No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]

**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**


Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] on [**6-26**] at 3:30pm [**Telephone/Fax (1) 170**] in the [**Hospital **]
Medical office building [**Hospital Unit Name **]
Cardiology: Dr. [**Last Name (STitle) **] on [**7-4**] at 12:40pm

Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 27542**] in [**3-13**] weeks [**Telephone/Fax (1) 27541**]

Labs: PT/INR for Coumadin ?????? indication afib
Goal INR 2.0-2.5
First draw [**2136-6-15**] then daily until on a stable dose of coumadin
given bactrim interaction
Results to Dr. [**Last Name (STitle) 27542**] phone: [**Telephone/Fax (1) 27541**] fax: [**Telephone/Fax (1) 34527**]

**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**




Completed by:[**2136-6-14**]
{'Coronary atherosclerosis of native coronary artery,Acute kidney failure with lesion of tubular necrosis,Metabolic encephalopathy,Polycystic kidney, unspecified type,Chronic kidney disease, Stage IV (severe),Ventilator associated pneumonia,Hyperosmolality and/or hypernatremia,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Hypoxemia,Atrial fibrillation,Long-term (current) use of anticoagulants,Personal history of venous thrombosis and embolism,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Esophageal reflux,Obstructive sleep apnea (adult)(pediatric),Depressive disorder, not elsewhere classified,Tobacco use disorder,Family history of other cardiovascular diseases'}


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



### Clinical text :
CHIEF COMPLAINT: Palpitations

PRESENT ILLNESS: 53 year old male who developed atrial flutter in [**2127**]. He
underwent an atrial fibrillation ablation in [**3-/2131**]; however,
had recurrence shortly thereafter. He then underwent pulmonary
vein isolation in 12/[**2130**]. He had been doing well until [**5-22**]
when he presented to [**Hospital1 18**] with two hours of left lower
extremity pain and pallor and was diagnosed with left leg
arterial clot. He was taken to the OR and underwent left iliac
and left femoral popliteal thrombectomy and placement of a left
common iliac stent. He also had left lower extremity four
compartment fasciotomies and evacuation and drainage of a left
medial calf hematoma. He was started on Coumadin and heparin. Of
note, the patient has a history of brain aneurysm in [**2117**] and
[**2127**] and had a subdural hematoma in [**2131**]. After the subdural
hematoma, he stopped Coumadin and remains off anticoagulation.
The patient is very reluctant to be on anticoagulation long term
given his past medical history but was on it short term after
recent left leg arterial clot. He currently reports episodes of
palpitations occurring two to three times per week. They come on
without apparent trigger and resolve spontaneously. The episodes
last approximately 5-10 minutes in total. Similar frequency to
prior. He has no associated chest pain, shortness of breath,
lightheadedness, dizziness, syncope or presyncope. He recently
had cardiac monitoring which showed primarily sinus rhythm and
sinus bradycardia with rates ranging  form 49 to 68bpm. There
were several short episodes of Atrial Fibrillation with the
longest 1 minute in duration. There were also PAC, and PAC pairs
as well as 1 PVC couplet. Given his palpitations, concern with
anticoagulation and recent cardiac study with documented atrial
fibrillation, he has been referred for consideration of MAZE and
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1916**] removal.

MEDICAL HISTORY: - Atrial fibrillation s/p AF ablation and PVI [**2130**]
- History of Cerebral Aneurysms
- Subdural hematoma s/p MVA in [**2131**]
- Chronic renal insufficiency, Polycystic Kidney Disease
- History of LLE Embolism
- Hypertension
- GERD
- Depression

MEDICATION ON ADMISSION: Celexa 20 mg daily
Metoprolol tartrate 50 mg TID
Pramipexole 0.25 mg daily
Omeprazole 20 mg daily
Propafenone 150 mg twice daily

ALLERGIES: Codeine

PHYSICAL EXAM: Pulse: 65  Resp: 16  O2 sat: 99% room air
B/P  Right: 133/87    Left: 137/91

FAMILY HISTORY: Significant for grandfather who died of MI at 76 and mother had
MI times two in her 70s

SOCIAL HISTORY: Lives with: Wife
Occupation: Retired police officer in [**2131**]
Tobacco: smokes [**12-11**] ppd, approx 30 PYH
ETOH: Quit 27 years ago 

### Response:
{'Coronary atherosclerosis of native coronary artery,Acute kidney failure with lesion of tubular necrosis,Metabolic encephalopathy,Polycystic kidney, unspecified type,Chronic kidney disease, Stage IV (severe),Ventilator associated pneumonia,Hyperosmolality and/or hypernatremia,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Hypoxemia,Atrial fibrillation,Long-term (current) use of anticoagulants,Personal history of venous thrombosis and embolism,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Esophageal reflux,Obstructive sleep apnea (adult)(pediatric),Depressive disorder, not elsewhere classified,Tobacco use disorder,Family history of other cardiovascular diseases'}
