CHIEF COMPLAINT: Transfer for EP study/VT ablation

PRESENT ILLNESS: 48 yo M with hx of CAD, MI x2, CABG x4 [**1-13**], EF 15-20%, hx of VT
s/p ICD, multiple ICD shocks and noted slow VT, admitted to
[**Hospital3 17921**] Center in NH on [**2110-11-1**] after having his ICD
fire 10 times followed by few seconds of syncope despite being
on amiodarone and quinidine.  He has been having recurrent VT
which was treated with amiodarone dose, quinidine, and increased
Beta-blocker.  He reports that he could feel the PVC's and slow
VT's and could tell the threshold before having the syncopal
episode.  He was recently cathed on [**9-12**] to rule out ischemic
component of dysrrhythmia which showed patent grafts.  Since he
was discharged, he has had several ICD shocks and was treated
with increasing dose of B-blocker.  On the day of admission to
[**Hospital3 17921**] Center, he had 10 ICD firings, one of which was
associtated with loss of consciousness for few seconds.  At
[**Hospital3 17921**], pt was started on amiodarone and lidocaine
drips.  ICD interrogation revealed a slow VT which was
terminated with pacing.  He was also found to have another fast
VT.  Now with AV (atrial/biventricular) pacing after device
reprogramming.  Pt was transferred to [**Hospital1 18**] for VT ablation.

MEDICAL HISTORY: -CAD-remote IMI, anterior MI [**1-13**], s/p CABG [**1-13**]: LIMA-LAD,
SVG-ramus+PDA, SVG-OM.
-Cath [**2110-9-12**]: 100% LAD; 100% LCx; 100% RCA; LIMA-LAD patent;
AO-OM patent; AO-ramus-PDA patent.
-CHF: Echo [**7-19**] w/ EF 15-20% regional wall motion abnl c/w
ischemic dz, mod biatrial enlargement, mild MR, LVH. RVH w/
hypokinesis
-HTN
-Hypothyroidism
-CRI (baseline 1.6-1.8 in [**2-16**])
-Obstructive sleep apnea
-Obesity
-Hypercholesterolemia
-COPD
-Paroxismal a-fib

MEDICATION ON ADMISSION: Meds on Transfer:
Amiodarone 400 mg po qd
Spironolactone 25 mg po bid
Synthroid 100 mcg po qd
Flovent 110 mcg 2 puffs [**Hospital1 **]
Combivent 3 puffs prn
Zocor 40 mg po qhs
ASA 325 mg po qd
Coreg 12.5 mg po bid
Toresmide 50 mg po qd
Amiodarone drip 0.5 mg/hr
Lidocaine drip 1 mg/min

ALLERGIES: Erythromycin Estolate / Penicillins

PHYSICAL EXAM: VS: T 99.6 BP 110/61 HR 60 RR 18 O2sat 93% RA
GEN: Obese, cheerful male lying in bed post-cath in NAD
HEENT: NC/AT, PERRL, EOMI, MMM, no visible JVP
COR: RRR, distant S1, S2, no audible murmurs or rubs
LUNGS: CTA on anterior exam
ABD: +BS, obese, soft, NTND
EXT: R groin with no hematoma or eccymosis, no femoral bruits,
2+DP bilaterally, no edema
NEURO: A+Ox3, CN intact, nonfocal.

FAMILY HISTORY: Pt was adopted, and does not know about his biological
paterents.

SOCIAL HISTORY: Pt lives in [**Location 5450**], NH with his wife, has 7 kids (2 step
kids, 2 adopted kids, and 3 biological kids), 35 yr of smoking 1
pack/day and quit 1 yr ago, occasional EtOH, no recreational
drug
Paroxysmal ventricular tachycardia,Chronic airway obstruction, not elsewhere classified,Congestive heart failure, unspecified,Pure hypercholesterolemia,Unspecified sleep apnea,Aortocoronary bypass status,Old myocardial infarction,Diverticulitis of colon (without mention of hemorrhage),Unspecified acquired hypothyroidism,Unspecified essential hypertension,Automatic implantable cardiac defibrillator in situ
Parox ventric tachycard,Chr airway obstruct NEC,CHF NOS,Pure hypercholesterolem,Sleep apnea NOS,Aortocoronary bypass,Old myocardial infarct,Dvrtcli colon w/o hmrhg,Hypothyroidism NOS,Hypertension NOS,Status autm crd dfbrltr
Admission Date:  [**2110-11-4**]              Discharge Date:   [**2110-11-12**]

Date of Birth:  [**2061-11-11**]             Sex:   M

Service: MEDICINE

Allergies:
Erythromycin Estolate / Penicillins

Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Transfer for EP study/VT ablation

Major Surgical or Invasive Procedure:
EP study s/p mapping/ablation

History of Present Illness:
48 yo M with hx of CAD, MI x2, CABG x4 [**1-13**], EF 15-20%, hx of VT
s/p ICD, multiple ICD shocks and noted slow VT, admitted to
[**Hospital3 17921**] Center in NH on [**2110-11-1**] after having his ICD
fire 10 times followed by few seconds of syncope despite being
on amiodarone and quinidine.  He has been having recurrent VT
which was treated with amiodarone dose, quinidine, and increased
Beta-blocker.  He reports that he could feel the PVC's and slow
VT's and could tell the threshold before having the syncopal
episode.  He was recently cathed on [**9-12**] to rule out ischemic
component of dysrrhythmia which showed patent grafts.  Since he
was discharged, he has had several ICD shocks and was treated
with increasing dose of B-blocker.  On the day of admission to
[**Hospital3 17921**] Center, he had 10 ICD firings, one of which was
associtated with loss of consciousness for few seconds.  At
[**Hospital3 17921**], pt was started on amiodarone and lidocaine
drips.  ICD interrogation revealed a slow VT which was
terminated with pacing.  He was also found to have another fast
VT.  Now with AV (atrial/biventricular) pacing after device
reprogramming.  Pt was transferred to [**Hospital1 18**] for VT ablation.

In the EP lab here, aggressive attempts were made to induce the
sustained VT but only short runs of short VT were induced.
Mapping and ablation of multiple foci of slow VT were done.
Fast monomorphic VT w/ LBBB/L axis occurred (not induced) which
were not pace terminable requiring shock 360 J x3 and then
converted to sinus rhythm.

EP History:
History of VT '[**08**] s/p ICD placement, hx of multiple recurrent
ICD shock between [**2108**]-[**2109**], hx of slow monophasic VT (580-590
msec) noted in 4/'[**09**], which was pace terminated and ICD
reprogrammed, upgrade to biventricular ICD [**2110-7-30**], VT ablation
[**2110-8-5**].  EP study on [**2110-9-10**] after having ICD firing after
rapid VT 320-360 msec which failed to terminate with pacing.
Study showed 4 episodes of sustained monomorphic VT (320-340
msec), series of ATP algorithms tested but no successful
termination + was ultimatley terminated with shock.


Past Medical History:
-CAD-remote IMI, anterior MI [**1-13**], s/p CABG [**1-13**]: LIMA-LAD,
SVG-ramus+PDA, SVG-OM.
-Cath [**2110-9-12**]: 100% LAD; 100% LCx; 100% RCA; LIMA-LAD patent;
AO-OM patent; AO-ramus-PDA patent.
-CHF: Echo [**7-19**] w/ EF 15-20% regional wall motion abnl c/w
ischemic dz, mod biatrial enlargement, mild MR, LVH. RVH w/
hypokinesis
-HTN
-Hypothyroidism
-CRI (baseline 1.6-1.8 in [**2-16**])
-Obstructive sleep apnea
-Obesity
-Hypercholesterolemia
-COPD
-Paroxismal a-fib

Social History:
Pt lives in [**Location 5450**], NH with his wife, has 7 kids (2 step
kids, 2 adopted kids, and 3 biological kids), 35 yr of smoking 1
pack/day and quit 1 yr ago, occasional EtOH, no recreational
drug

Family History:
Pt was adopted, and does not know about his biological
paterents.

Physical Exam:
VS: T 99.6 BP 110/61 HR 60 RR 18 O2sat 93% RA
GEN: Obese, cheerful male lying in bed post-cath in NAD
HEENT: NC/AT, PERRL, EOMI, MMM, no visible JVP
COR: RRR, distant S1, S2, no audible murmurs or rubs
LUNGS: CTA on anterior exam
ABD: +BS, obese, soft, NTND
EXT: R groin with no hematoma or eccymosis, no femoral bruits,
2+DP bilaterally, no edema
NEURO: A+Ox3, CN intact, nonfocal.

Pertinent Results:
[**2110-11-4**] WBC-11.9* RBC-3.58* Hgb-9.9* Hct-31.2* MCV-87 MCH-27.7
MCHC-31.8 RDW-17.3* Plt Ct-216
[**2110-11-7**] WBC-14.0* RBC-3.35* Hgb-9.5* Hct-29.1* MCV-87 MCH-28.4
MCHC-32.8 RDW-17.5* Plt Ct-205
[**2110-11-8**] WBC-11.9* RBC-3.32* Hgb-9.6* Hct-28.8* MCV-87 MCH-28.8
MCHC-33.2 RDW-17.4* Plt Ct-245
[**2110-11-9**] WBC-9.7 RBC-3.53* Hgb-9.9* Hct-31.5* MCV-89 MCH-27.9
MCHC-31.3 RDW-16.9* Plt Ct-250
[**2110-11-12**] WBC-13.2* RBC-3.84* Hgb-10.6* Hct-34.0* MCV-89 MCH-27.5
MCHC-31.1 RDW-16.6* Plt Ct-391

[**2110-11-6**] Neuts-85* Bands-9* Lymphs-2* Monos-4 Eos-0 Baso-0
Atyps-0 Metas-0 Myelos-0
[**2110-11-9**] Neuts-89.7* Lymphs-4.9* Monos-3.6 Eos-1.7 Baso-0.1

[**2110-11-4**] PT-18.6* PTT-54.7* INR(PT)-2.2
[**2110-11-8**] PT-16.5* PTT-36.7* INR(PT)-1.7
[**2110-11-12**] PT-22.9* PTT-73.4* INR(PT)-3.3

[**2110-11-4**] Glucose-108* UreaN-32* Creat-1.9* Na-138 K-4.4 Cl-101
HCO3-25
[**2110-11-6**] UreaN-45* Creat-2.9* Na-135 K-4.8 Cl-99
[**2110-11-6**] Glucose-89 UreaN-52* Creat-3.9* Na-137 K-4.9 Cl-99
HCO3-26 [**2110-11-8**] Glucose-101 UreaN-49* Creat-2.2* Na-140 K-4.7
Cl-104 HCO3-25
[**2110-11-10**] Glucose-84 UreaN-29* Creat-1.7* Na-140 K-4.3 Cl-104
HCO3-27 [**2110-11-12**] Glucose-104 UreaN-15 Creat-1.3* Na-138 K-4.4
Cl-103 HCO3-22

[**2110-11-6**] ALT-25 AST-24 AlkPhos-64 Amylase-28 TotBili-0.9

[**2110-11-4**] CK(CPK)-218* CK-MB-16* MB Indx-7.3* cTropnT-2.06*

[**2110-11-7**] Calcium-8.9 Phos-4.8*# Mg-2.2
[**2110-11-12**] Calcium-9.3 Phos-3.9 Mg-2.0
[**2110-11-4**] Calcium-8.2* Phos-3.0 Mg-1.9
[**2110-11-8**] VitB12-203* Folate-7.3
[**2110-11-7**] Iron-26* calTIBC-281 Hapto-447* Ferritn-459* TRF-216

AEROBIC BOTTLE (Final [**2110-11-11**]):    NO GROWTH.

   ANAEROBIC BOTTLE (Final [**2110-11-11**]):    NO GROWTH.

URINE CULTURE (Final [**2110-11-6**]):    <10,000 organisms/ml.

FECAL CULTURE (Final [**2110-11-8**]):    NO SALMONELLA OR SHIGELLA
FOUND.

   CAMPYLOBACTER CULTURE (Final [**2110-11-8**]):    NO CAMPYLOBACTER
FOUND.

   CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2110-11-6**]):
      FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
      Reference Range:  Negative.

CXR [**11-5**]:  There is moderate cardiomegaly in a patient with
dual lead pacemaker insertion. The pacemaker chips overlie the
right atrium and ventricle. Patient has undergone prior CABG.
There is bilateral moderate pulmonary vascular redistribution
and perihilar haziness. The osseous structures are unremarkable.

CXR [**11-6**]:  Stable moderate-to-severe cardiomegaly in a patient
status post CABG. The dual-lead pacemaker tips overlie the right
atrium and ventricle. There is a slightly improved pulmonary
vascular redistribution and interstitial edema. The osseous
structures are unremarkable.
IMPRESSION:
Slight interval improvement in CHF.

[**11-6**]:  CT OF THE ABDOMEN WITHOUT CONTRAST: Patchy opacity is
present within the right lung base which could represent
atelectasis. The liver, spleen, pancreas, gallbladder, adrenal
glands, kidneys, and small bowel are normal in appearance. No
pathologically enlarged retroperitoneal or mesenteric lymph
nodes are seen.

CT OF THE PELVIS WITH CONTRAST: There is focal fat stranding
within the pelvic fat surrounding the sigmoid colon. There are
multiple diverticula. There is extraluminal gas adjacent to this
area of fat stranding. There is no drainable fluid collection.
Oral contrast reaches the transverse colon indicating no
evidence of obstruction.

Bone windows show no suspicious lytic or sclerotic lesions.

REFORMATTED IMAGING: Images reformatted in the coronal and
sagittal plane were essential in evaluating the patient's
abdomen and pelvis and show fat stranding within the deep pelvis
adjacent to the sigmoid colon, indicating diverticulitis.

IMPRESSION: Sigmoid diverticulitis with a suggestion of
microperforation. No drainable fluid collection present.

AXR [**11-6**]:  Left upper chest pacemaker device, sternal wires and
mediastinal clips are noted. The heart appears enlarged. There
is no free air. Images of the abdomen are of poor technical
quality. A nonspecific bowel gas pattern is noted.

AXR [**11-8**]:  Gaseous distention of stomach and moderate gaseous
distention of multiple loops of small bowel with retained
contrast in the rectosigmoid colon. Findings could be related to
ileus in the presence of intra-abdominal inflammatory process
but correlate clinically. The gaseous distention of the stomach
could be re- evaluated after passage of NG tube if clinically
indicated.


Brief Hospital Course:
1)Rhythm: As stated in HPI, pt underwent EP study with multiple
ablation of slow VT foci, but unable to map and ablate the focus
of fast VT.  Mapping and ablation of multiple foci of slow VT
were done.  Fast monomorphic VT w/ LBBB/L axis occurred (not
induced) which were not pace terminable requiring shock 360 J x3
and then converted to sinus rhythm.

VT occurred during the study which was not induced, not
terminable with pacing, and had to be shocked with 360 J x3.  Pt
was transferred to the CCU and to the floor with no significant
event.  Pt remained AV paced at a rate of 60 BPM, increased to
80 bpm subsequently.  Pt was initially scheduled to return to
NIPS and DFT.  However, pt developed fever and abdominal pain,
and therefore NIPS and DFT were canceled.  The EP team felt that
NIPS were not urgent, and they have spoken with his cardiologist
Dr. [**Last Name (STitle) 23246**] who will follow up with him in 4 weeks to do the
NIPS.  He was continued on amiodarone 400 mg po qd but quinidine
was discontinued.  Due to hypotention, Coreg was reduced to 12.5
mg [**Hospital1 **] from 50 mg [**Hospital1 **].  Pt was continued on coumadin for his
paroxysmal a-fib - he will need frequent INR checks while on
antibiotics for diverticulitis (see below).

2)Pump: Recent Echo 15-20%.  As above, pt will be discharged
with reduced dose of Coreg, and will be continued on his home
meds of lisinopril, torsemide, and spironolactone.  Pt appeared
euvolemic/hypovolemic clinically with hypotension to SBP 80's
but the CXR showed moderate CHF with increased interstitial
markings and vascular redistribution.  Pt got one dose of Lasix
which increased the creatinine from 1.9 to 2.9.  Pt later
received IVF which lowered the creatinine.  Additionally, his
torsemide was held during the hospitalization, as well as
spironolactone and lisinopril secondary to hypotension, and
rising creatinine.  He was started on digoxin 3 days before
discharge and had improvement in his blood pressure enough to
tolerate the lisinopril and spironolactone.  Additionally, his
creatinine had normalized, also allowing reintroduction of these
meds.  His creatinine had been stable at 1.3 for two days prior
to discharge, with SBP around 120.

3)CAD: Hx of prior inferior and anterior MI.  Patient was
continued on ASA, Zocor, Coreg, and lisinopril.

4)Diverticulitis: On the second day of admission, pt developed
fever of 102, abdominal pain, loose stools, and leukocytosis.
Patient had tender lower quadrant abdominal pain to palpation
but with no peritoneal signs.  Pt underwent CT abdomen which
showed sigmoid diverticulitis with possible microperforation.
An AXR did not demonstrate any free air.  He was made NPO, and
started on levaquin and flagyl.  His abdominal pain improved
significantly, and had completely resolved, with only residual
mild tenderness to palpation on discharge.  Reglan was started
when an AXR revealed gaseous distention of his stomach and
intestine.  His diet was slowly able to be advanced to low
residue, which he was tolerating prior to discharge.  His wbc
count rose on the day of discharge, however the patient remained
afebrile and was clinically improved; additionally, the hct and
platelets also rose, making it most likely secondary to
dehydration after restarting his diuretics.  The patient was
instructed to increase his fluid intake slightly over the next
couple of days while he isn't taking in a full diet.  He should
remain on a low residue, heart healthy diet until he sees a
gastroenterologist, at which time they may want to place him on
a high fiber diet.

5)HTN: Pt was continued on Coreg, lisinopril, Torsemide +
spironolactone.

6)Hypercholesterolemia: Pt was continued on Zocor.

7)COPD: initially, albuterol was held since it could potentially
trigger VT.  Pt was continued on Flovent and Atrovent, but
continued to have diffuse wheezing.  Pt was discharged with his
home meds of Comvient and Flovent.

8)Sleep apnea: Pt was continued on BIPAP 15 cm.  Overnight, pt
showed episodes of apnea and desaturation to the 70's and 80's.

7)Hypothyroid: Patient was continued on Synthroid.

8)CRI: Baseline Cr 1.6-1.8.  Creatinine on admission was 1.9 but
Creatinine increased to 2.9 after patient was NPO for planned
NIPS.  Pt also appeared intravscularly dry especially after
getting a dose of IV Lasix.  Pt got IVF bolus but creatinine
continued to be elevated.  His lisinopril and aldactone were
held, and as his diverticulitis resolved his creatinine returned
to baseline.  His renal insult may have been a combination from
his VT with hypoperfusion, as well as dehydration.  His
creatinine was 1.3 for two days prior to discharge.

Medications on Admission:
Meds on Transfer:
Amiodarone 400 mg po qd
Spironolactone 25 mg po bid
Synthroid 100 mcg po qd
Flovent 110 mcg 2 puffs [**Hospital1 **]
Combivent 3 puffs prn
Zocor 40 mg po qhs
ASA 325 mg po qd
Coreg 12.5 mg po bid
Toresmide 50 mg po qd
Amiodarone drip 0.5 mg/hr
Lidocaine drip 1 mg/min

Home Meds:
Amiodarone 400 mg po qd
QuinoGlute 324 mg po bid
Coreg 50 mg po bid
Lisinopril 10 mg po qd
Torsemide 50 mg po bid
Spironolactone 25 mg po bid
Lexapro 10 mg po qd
Combivent 14.7g 3 puffs PRN
Flovent 110 mcg 2 puffs [**Hospital1 **]
ASA 325 mg po qd
Warfarin 2.5 mh po qd
Zocor 40 mg po qd
Synthroid 100 mcg po qd

Discharge Medications:
1. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
3. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Combivent 103-18 mcg/Actuation Aerosol Sig: Three (3)
Inhalation Q4H:PRN.
10. Torsemide 20 mg Tablet Sig: 2.5 Tablets PO BID (2 times a
day).
11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Digoxin 250 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 9 days.
Disp:*9 Tablet(s)* Refills:*0*
14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 9 days.
Disp:*27 Tablet(s)* Refills:*0*
15. Warfarin Sodium 1 mg Tablet Sig: 1-2 Tablets PO DAILY
(Daily): 2.5 mg, except for Tues, Thurs, Sat. 1.5 mg, and as
dictated by your INR checks. Tablet(s)
16. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
VT s/p EP study
Diverticulitis
CAD
Congestive heart failure
COPD
Hypertension
Hypothyroidism


Discharge Condition:
Hemodynamcially stable, improved, having bowel movements,
urinating on his own.

Discharge Instructions:
Take all of your medications as directed - we have resumed all
of your previous medications - except for the QUINIDINE.  We
have decreased your dose of carvedilol to 12.5 mg twice a day
(instead of 50).

We have started two new medications: 1) digoxin - this is for
your heart.  2) Cyanocobalamin (Vitamin B12) - this is for your
anemia.

You will also be on two antibiotics called levaquin and flagyl
for the next 9 days.

Seek medical attention (PCP, [**Last Name (NamePattern4) **]) if you develop worsening
abdominal pain, nausea/vomiting, fever, chills, chest pain,
palpitation, ICD firing, SOB, or any other concerning symptoms.


You will need to follow up with your cardiologist Dr. [**First Name4 (NamePattern1) 30512**]
[**Last Name (NamePattern1) 23246**] in 4 weeks.  If she has any questions, she can reach
Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 285**].

You will also need to see Dr. [**Last Name (STitle) 519**] (surgery), or another
gastroenterologist in a couple of weeks to follow how your
diverticulitis is doing.  They will schedule you for a
colonoscopy in the next 2-3 months.  Dr. [**First Name4 (NamePattern1) 518**] [**Last Name (NamePattern1) **] number
is [**Telephone/Fax (1) 6554**].

You will need to have your INR checked on Friday, and every 3
days while you are on the antibiotics.

You will need to stay on a low residue diet until you see Dr.
[**Last Name (STitle) 519**] or another surgeon, at which time they should place you on
a high fiber diet which you should stay on to help avoid future
episodes of diverticulitis.

Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **]  [**Telephone/Fax (1) **].  Please make an
appointment with her in the next 2 weeks.

Please have your PCP make an appointment for you with a
gastroenterologist in your area.  If they have any questions, or
you would like to see a doctor here for your diverticulitis,
call Dr. [**Last Name (STitle) 519**] at [**Telephone/Fax (1) 6554**].  You will need a colonoscopy in
[**12-17**] months, which they can set you up with.

Please see your primary care doctor in the next week or two - he
should check your blood pressure, among other things, and
consider going back to your usual carvedilol dosage.
{'Paroxysmal ventricular tachycardia,Chronic airway obstruction, not elsewhere classified,Congestive heart failure, unspecified,Pure hypercholesterolemia,Unspecified sleep apnea,Aortocoronary bypass status,Old myocardial infarction,Diverticulitis of colon (without mention of hemorrhage),Unspecified acquired hypothyroidism,Unspecified essential hypertension,Automatic implantable cardiac defibrillator in situ'}


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: Transfer for EP study/VT ablation

PRESENT ILLNESS: 48 yo M with hx of CAD, MI x2, CABG x4 [**1-13**], EF 15-20%, hx of VT
s/p ICD, multiple ICD shocks and noted slow VT, admitted to
[**Hospital3 17921**] Center in NH on [**2110-11-1**] after having his ICD
fire 10 times followed by few seconds of syncope despite being
on amiodarone and quinidine.  He has been having recurrent VT
which was treated with amiodarone dose, quinidine, and increased
Beta-blocker.  He reports that he could feel the PVC's and slow
VT's and could tell the threshold before having the syncopal
episode.  He was recently cathed on [**9-12**] to rule out ischemic
component of dysrrhythmia which showed patent grafts.  Since he
was discharged, he has had several ICD shocks and was treated
with increasing dose of B-blocker.  On the day of admission to
[**Hospital3 17921**] Center, he had 10 ICD firings, one of which was
associtated with loss of consciousness for few seconds.  At
[**Hospital3 17921**], pt was started on amiodarone and lidocaine
drips.  ICD interrogation revealed a slow VT which was
terminated with pacing.  He was also found to have another fast
VT.  Now with AV (atrial/biventricular) pacing after device
reprogramming.  Pt was transferred to [**Hospital1 18**] for VT ablation.

MEDICAL HISTORY: -CAD-remote IMI, anterior MI [**1-13**], s/p CABG [**1-13**]: LIMA-LAD,
SVG-ramus+PDA, SVG-OM.
-Cath [**2110-9-12**]: 100% LAD; 100% LCx; 100% RCA; LIMA-LAD patent;
AO-OM patent; AO-ramus-PDA patent.
-CHF: Echo [**7-19**] w/ EF 15-20% regional wall motion abnl c/w
ischemic dz, mod biatrial enlargement, mild MR, LVH. RVH w/
hypokinesis
-HTN
-Hypothyroidism
-CRI (baseline 1.6-1.8 in [**2-16**])
-Obstructive sleep apnea
-Obesity
-Hypercholesterolemia
-COPD
-Paroxismal a-fib

MEDICATION ON ADMISSION: Meds on Transfer:
Amiodarone 400 mg po qd
Spironolactone 25 mg po bid
Synthroid 100 mcg po qd
Flovent 110 mcg 2 puffs [**Hospital1 **]
Combivent 3 puffs prn
Zocor 40 mg po qhs
ASA 325 mg po qd
Coreg 12.5 mg po bid
Toresmide 50 mg po qd
Amiodarone drip 0.5 mg/hr
Lidocaine drip 1 mg/min

ALLERGIES: Erythromycin Estolate / Penicillins

PHYSICAL EXAM: VS: T 99.6 BP 110/61 HR 60 RR 18 O2sat 93% RA
GEN: Obese, cheerful male lying in bed post-cath in NAD
HEENT: NC/AT, PERRL, EOMI, MMM, no visible JVP
COR: RRR, distant S1, S2, no audible murmurs or rubs
LUNGS: CTA on anterior exam
ABD: +BS, obese, soft, NTND
EXT: R groin with no hematoma or eccymosis, no femoral bruits,
2+DP bilaterally, no edema
NEURO: A+Ox3, CN intact, nonfocal.

FAMILY HISTORY: Pt was adopted, and does not know about his biological
paterents.

SOCIAL HISTORY: Pt lives in [**Location 5450**], NH with his wife, has 7 kids (2 step
kids, 2 adopted kids, and 3 biological kids), 35 yr of smoking 1
pack/day and quit 1 yr ago, occasional EtOH, no recreational
drug 

### Response:
{'Paroxysmal ventricular tachycardia,Chronic airway obstruction, not elsewhere classified,Congestive heart failure, unspecified,Pure hypercholesterolemia,Unspecified sleep apnea,Aortocoronary bypass status,Old myocardial infarction,Diverticulitis of colon (without mention of hemorrhage),Unspecified acquired hypothyroidism,Unspecified essential hypertension,Automatic implantable cardiac defibrillator in situ'}
