CHIEF COMPLAINT: Afib/flutter with RVR

PRESENT ILLNESS: Ms. [**Known lastname 2643**] is a 79 year old woman with recent diagnosis of
carcinoid lung mass with mets, atrial fibrillation on lovenox,
idiopathic cardiomyopathy (EF 45%), recently hospitalized for
initiation of chemotherapy (with carboplatin/etoposide, day#1
[**2200-5-7**]) [**Date range (1) 40354**], now presenting from rehab with afib with
RVR. She noticed palpitations today at rehab and asked to be
evaluated. She was noted to be in rapid Afib with rates 150s.
Aside from palpitations, she denies symptoms of associated chest
pain, shortness of breath, nausea, lightheadedness. She was sent
to [**Hospital1 18**] ED for further evaluation.
.
She was diagnosed with Afib in [**2-/2200**] with the workup resulting
in her neuroendocrine lung cancer diagnosis during [**4-/2200**]
hospitalization. Cancer was diagnosed when TTE showed [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 7388**] vs
external compression. Subsequent CT showed large mediastinal
mass. Afib has been difficult to control since middle of
[**Month (only) 404**], thought to be related to mass effect from tumor. She
had been on sotalol, switched to dronedarone, then back to
sotalol, which was changed to diltiazem and metoprolol during
recent hospitalization in 3/[**2200**]. She has been flipping in and
out of atrial fibrillation frequently in the last few months but
notes improved control of afib since that hospitalization. Can
feel palpitations with rates >140s. She was transitioned from
dabigatran to enoxaparin during that hospitalization in setting
of biopsy and was kept on enoxaparin in case she might need a
repeat procedure.
.
In the ED inital vitals were as follows: 97.4 140 90/64 18 100%
RA.
500cc NS bolus given which brought HR down to 108. She was then
given diltiazem 5mg IV push with BP 92/60, bringing HR down to
96. During ED stay, systolic BPs ranged 87-104, appeared to have
lower systolics with elevated HRs. She received another 10mg IV
diltiazem with 30mg po diltiazem in the ED as well as magnesium
repletion and total 2L IVF. She denied any chest pain, shortness
of breath. ECG showed Afib with NA NI, new ST depression lateral
leads; repeat EKG unchanged. CXR with stable right effusion vs
elevation of right hemidiaphragm. Troponin negative x1. Labs
also significant for WBC 1.3, Hct 35.3, Na 131. Vitals in ED
prior to transfer to floor were as follows: 104/66 114,afib 22
97% on 2L NC.
.
On arrival to the ICU, she feels overall well. Denies
palpitations currently. She does report generalized fatigue,
progressive since starting chemotherapy, worse in the last two
days, such that she needs to use a walker at Rehab to help her
move around. She denies fevers, chills, chest pain, shortness of
breath beyond her baseline. Her cough is unchanged from
baseline, no sputum production. No headache. Has very decreased
appetite for several days.
.
Review of systems:
(+) Per HPI . Groin rash.
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies chest pain, chest
pressure. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias.

MEDICAL HISTORY: PAST ONCOLOGIC HISTORY:
- Patient developed new onset atrial fibrillation in beginning
of [**2200**], initial TTE showed slightly depressed LVEF of 45%,
initially thought to be due to her chronic alcohol use. Her
atrial fibrillation worsened despite uptitration of medication
(sotalol and dronedarone)  and her repeat TTE showed a [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 2966**] vs. extrinsic mass compressing on LA. She was admitted
for evaluation and her biopsy showed neuroendocrine tumor
consistent with typical carcinoid.
- CT scan showing metastases to bone, lymph nodes and possibly
liver.
.
PAST MEDICAL HISTORY:
Atrial fibrillation [**1-/2200**] (diagnosed [**2-/2200**])
Idiopathic Cardiomyopathy, LVEF 45% (diagnosed [**2-/2200**])
Osteopenia
GERD
BPPV
Cataracts s/p lens replacements

MEDICATION ON ADMISSION: - filgrastim 300 mcg/0.5 mL - for 10 days (from discharge
[**2200-5-10**])
- allopurinol 300 mg Tablet daily
- multivitamin daily
- omeprazole 20 mg Capsule x 2 tabs daily
- enoxaparin 100 mg/mL Syringe sq daily
- calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable PO
QID PRN acid reflux.
- Diltia XT 240 mg Capsule,[**Month/Day/Year **] Release Degradable daily
- Toprol XL 100 mg Tablet Extended Release 24 hr daily
- docusate sodium 100 mg Capsule PO BID
- codeine sulfate 30 mg Tablet PRN cough.
- benzonatate 100 mg Capsule PO TID prn cough
- senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID prn constipation
- acetaminophen 325 mg Tablet x 2 tabs PO Q6H PRN pain/fever
- dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup PRN cough
- nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
- ranitidine HCl 150 mg Tablet [**Hospital1 **] PRN heartburn
- bisacodyl 10 mg Suppository PRN constipation
- Fleet Enema 19-7 gram/118 mL Enema PRN constipation
- Milk of Magnesia 400 mg/5 mL Suspension Sig: Five (5) mL PO
once a day PRN constipation
- Ensure Liquid TID with meals

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Physical Exam:
Vitals: T: 97.8 BP: 97/52 P: 110 R: 24 O2: 96% on 2L
General: Alert, oriented, thin woman in no acute distress
HEENT: Sclera anicteric, pale conjunctiva, dry mucus membranes,
oropharynx clear
Neck: JVP ~9cm
Lungs: Decreased breath sounds in Right lower base posteriorly,
no wheezes, rales, rhonchi
CV: Irregular rhythm, rapid rate, no murmurs appreciated
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU: no foley ; erythematous groin rash
[**Location (un) **]: warm, well perfused, 1+ peripheral edema

FAMILY HISTORY: Mother with MI at age 85, son with Afib, daughter with breast CA

SOCIAL HISTORY: Lives alone, son [**Name (NI) **] involved in care.
-Tobacco history: Smoked 1 pack/two weeks x8 years, quit [**2174**]
-ETOH: Lifetime drinker (1 [**Location (un) 21601**]/day with 2 shots of whisky)
until 3-4 weeks ago she stopped due to concern for ETOH
cardiomyopathy.
-Illicit drugs: Denies
Atrial fibrillation,Malignant carcinoid tumor of the bronchus and lung,Chronic systolic heart failure,Other primary cardiomyopathies,Hyposmolality and/or hyponatremia,Hypotension, unspecified,Drug induced neutropenia,Other secondary thrombocytopenia,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Long-term (current) use of anticoagulants,Esophageal reflux,Dermatophytosis of groin and perianal area,Do not resuscitate status,Disorder of bone and cartilage, unspecified,Personal history of tobacco use,Personal history of antineoplastic chemotherapy
Atrial fibrillation,Mal carcinoid bronc/lung,Chr systolic hrt failure,Prim cardiomyopathy NEC,Hyposmolality,Hypotension NOS,Drug induced neutropenia,Sec thrombocytpenia NEC,Adv eff antineoplastic,Long-term use anticoagul,Esophageal reflux,Dermatophytosis of groin,Do not resusctate status,Bone & cartilage dis NOS,History of tobacco use,Hx antineoplastic chemo
Admission Date:  [**2200-5-16**]              Discharge Date:   [**2200-5-23**]

Date of Birth:  [**2121-1-6**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 12**]
Chief Complaint:
Afib/flutter with RVR

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Ms. [**Known lastname 2643**] is a 79 year old woman with recent diagnosis of
carcinoid lung mass with mets, atrial fibrillation on lovenox,
idiopathic cardiomyopathy (EF 45%), recently hospitalized for
initiation of chemotherapy (with carboplatin/etoposide, day#1
[**2200-5-7**]) [**Date range (1) 40354**], now presenting from rehab with afib with
RVR. She noticed palpitations today at rehab and asked to be
evaluated. She was noted to be in rapid Afib with rates 150s.
Aside from palpitations, she denies symptoms of associated chest
pain, shortness of breath, nausea, lightheadedness. She was sent
to [**Hospital1 18**] ED for further evaluation.
.
She was diagnosed with Afib in [**2-/2200**] with the workup resulting
in her neuroendocrine lung cancer diagnosis during [**4-/2200**]
hospitalization. Cancer was diagnosed when TTE showed [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 7388**] vs
external compression. Subsequent CT showed large mediastinal
mass. Afib has been difficult to control since middle of
[**Month (only) 404**], thought to be related to mass effect from tumor. She
had been on sotalol, switched to dronedarone, then back to
sotalol, which was changed to diltiazem and metoprolol during
recent hospitalization in 3/[**2200**]. She has been flipping in and
out of atrial fibrillation frequently in the last few months but
notes improved control of afib since that hospitalization. Can
feel palpitations with rates >140s. She was transitioned from
dabigatran to enoxaparin during that hospitalization in setting
of biopsy and was kept on enoxaparin in case she might need a
repeat procedure.
.
In the ED inital vitals were as follows: 97.4 140 90/64 18 100%
RA.
500cc NS bolus given which brought HR down to 108. She was then
given diltiazem 5mg IV push with BP 92/60, bringing HR down to
96. During ED stay, systolic BPs ranged 87-104, appeared to have
lower systolics with elevated HRs. She received another 10mg IV
diltiazem with 30mg po diltiazem in the ED as well as magnesium
repletion and total 2L IVF. She denied any chest pain, shortness
of breath. ECG showed Afib with NA NI, new ST depression lateral
leads; repeat EKG unchanged. CXR with stable right effusion vs
elevation of right hemidiaphragm. Troponin negative x1. Labs
also significant for WBC 1.3, Hct 35.3, Na 131. Vitals in ED
prior to transfer to floor were as follows: 104/66 114,afib 22
97% on 2L NC.
.
On arrival to the ICU, she feels overall well. Denies
palpitations currently. She does report generalized fatigue,
progressive since starting chemotherapy, worse in the last two
days, such that she needs to use a walker at Rehab to help her
move around. She denies fevers, chills, chest pain, shortness of
breath beyond her baseline. Her cough is unchanged from
baseline, no sputum production. No headache. Has very decreased
appetite for several days.
.
Review of systems:
(+) Per HPI . Groin rash.
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies chest pain, chest
pressure. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias.


Past Medical History:
PAST ONCOLOGIC HISTORY:
- Patient developed new onset atrial fibrillation in beginning
of [**2200**], initial TTE showed slightly depressed LVEF of 45%,
initially thought to be due to her chronic alcohol use. Her
atrial fibrillation worsened despite uptitration of medication
(sotalol and dronedarone)  and her repeat TTE showed a [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 2966**] vs. extrinsic mass compressing on LA. She was admitted
for evaluation and her biopsy showed neuroendocrine tumor
consistent with typical carcinoid.
- CT scan showing metastases to bone, lymph nodes and possibly
liver.
.
PAST MEDICAL HISTORY:
Atrial fibrillation [**1-/2200**] (diagnosed [**2-/2200**])
Idiopathic Cardiomyopathy, LVEF 45% (diagnosed [**2-/2200**])
Osteopenia
GERD
BPPV
Cataracts s/p lens replacements

Social History:
Lives alone, son [**Name (NI) **] involved in care.
-Tobacco history: Smoked 1 pack/two weeks x8 years, quit [**2174**]
-ETOH: Lifetime drinker (1 [**Location (un) 21601**]/day with 2 shots of whisky)
until 3-4 weeks ago she stopped due to concern for ETOH
cardiomyopathy.
-Illicit drugs: Denies


Family History:
Mother with MI at age 85, son with Afib, daughter with breast CA

Physical Exam:
Physical Exam:
Vitals: T: 97.8 BP: 97/52 P: 110 R: 24 O2: 96% on 2L
General: Alert, oriented, thin woman in no acute distress
HEENT: Sclera anicteric, pale conjunctiva, dry mucus membranes,
oropharynx clear
Neck: JVP ~9cm
Lungs: Decreased breath sounds in Right lower base posteriorly,
no wheezes, rales, rhonchi
CV: Irregular rhythm, rapid rate, no murmurs appreciated
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU: no foley ; erythematous groin rash
[**Location (un) **]: warm, well perfused, 1+ peripheral edema

DISCHARGE PHYSICAL EXAM:
Vitals: 97.4, 108/60, 108, 22, 94% RA
General: Alert, oriented, thin woman in no acute distress
HEENT: Sclera anicteric, pale conjunctiva, dry mucus membranes,
oropharynx clear
Neck: JVP ~9cm
Lungs: Decreased breath sounds over right base and mid-lunk; no
wheezes, rales, rhonchi
CV: Irregular rhythm, no murmurs or rubs appreciated
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU: no foley; erythematous groin rash
[**Location (un) **]: warm, well perfused, 1+ peripheral edema


Pertinent Results:


[**2200-5-16**] 03:00PM BLOOD WBC-1.3*# RBC-4.07* Hgb-10.9* Hct-35.3*
MCV-87 MCH-26.8* MCHC-31.0 RDW-19.3* Plt Ct-113*#
[**2200-5-17**] 02:30AM BLOOD WBC-1.0* RBC-3.47* Hgb-9.3* Hct-29.5*
MCV-85 MCH-26.9* MCHC-31.6 RDW-19.2* Plt Ct-89*
[**2200-5-18**] 07:35AM BLOOD WBC-1.5* RBC-3.72* Hgb-10.0* Hct-32.7*
MCV-88 MCH-26.8* MCHC-30.5* RDW-19.2* Plt Ct-78*
[**2200-5-19**] 08:20AM BLOOD WBC-2.3*# RBC-3.73* Hgb-10.0* Hct-32.4*
MCV-87 MCH-26.7* MCHC-30.8* RDW-19.5* Plt Ct-71*
[**2200-5-20**] 08:25AM BLOOD WBC-5.0# RBC-3.68* Hgb-10.2* Hct-32.1*
MCV-87 MCH-27.6 MCHC-31.6 RDW-20.1* Plt Ct-68*
[**2200-5-21**] 08:30AM BLOOD WBC-8.5# RBC-3.59* Hgb-9.9* Hct-31.3*
MCV-87 MCH-27.6 MCHC-31.7 RDW-21.0* Plt Ct-63*
[**2200-5-22**] 08:15AM BLOOD WBC-6.4 RBC-3.64* Hgb-9.8* Hct-31.5*
MCV-87 MCH-26.8* MCHC-31.0 RDW-21.0* Plt Ct-60*
[**2200-5-23**] 08:33AM BLOOD WBC-8.5 RBC-3.76* Hgb-10.5* Hct-32.9*
MCV-88 MCH-27.9 MCHC-31.9 RDW-20.6* Plt Ct-76*
[**2200-5-22**] 08:15AM BLOOD Neuts-67 Bands-3 Lymphs-11* Monos-11
Eos-0 Baso-0 Atyps-2* Metas-2* Myelos-3* Promyel-1* NRBC-1*
[**2200-5-18**] 07:35AM BLOOD Gran Ct-460*
[**2200-5-19**] 08:20AM BLOOD Gran Ct-[**2216**]*
[**2200-5-20**] 08:25AM BLOOD Gran Ct-3762
[**2200-5-16**] 03:00PM BLOOD Glucose-114* UreaN-7 Creat-0.4 Na-131*
K-3.9 Cl-94* HCO3-29 AnGap-12
[**2200-5-17**] 02:30AM BLOOD Glucose-93 UreaN-6 Creat-0.4 Na-133 K-3.7
Cl-100 HCO3-25 AnGap-12
[**2200-5-18**] 07:35AM BLOOD Glucose-99 UreaN-7 Creat-0.4 Na-132*
K-3.9 Cl-97 HCO3-26 AnGap-13
[**2200-5-19**] 08:20AM BLOOD Glucose-91 UreaN-6 Creat-0.4 Na-130*
K-3.4 Cl-95* HCO3-25 AnGap-13
[**2200-5-20**] 08:25AM BLOOD Glucose-141* UreaN-7 Creat-0.5 Na-130*
K-3.2* Cl-94* HCO3-29 AnGap-10
[**2200-5-21**] 08:30AM BLOOD Glucose-82 UreaN-4* Creat-0.5 Na-129*
K-4.0 Cl-98 HCO3-25 AnGap-10
[**2200-5-22**] 08:15AM BLOOD Glucose-79 UreaN-4* Creat-0.6 Na-133
K-3.8 Cl-99 HCO3-30 AnGap-8
[**2200-5-23**] 08:33AM BLOOD Glucose-78 UreaN-7 Creat-0.5 Na-134 K-3.8
Cl-97 HCO3-30 AnGap-11
[**2200-5-19**] 08:20AM BLOOD ALT-31 AST-23 LD(LDH)-188 AlkPhos-120*
TotBili-0.6
[**2200-5-16**] 03:00PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-[**2151**]*
[**2200-5-17**] 02:30AM BLOOD CK-MB-2 cTropnT-<0.01
[**2200-5-17**] 02:30AM BLOOD TSH-5.3*

[**5-20**] TTE:
A large, ovoid mass is present in the posterior mediastinum
abutting the posterior wall of the left atrium and resulting in
extrinsic compression (erosion/infiltration into the wall of the
left atrium is possible but cannot be diagnosed or excluded on
the basis of this study). The mass measures approximately 7 cm
in its long axis and 5 cm in its short axis. Pulmonary vein
compression cannot be excluded but is possible based on the
location of the mass, as well as the pulmonary hypertension,
right ventricular enlargement, and tricuspid regurgitation. No
prior echocardiographic study is available for comparison.

The left atrium is normal in size. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF 65%). There is
considerable beat-to-beat variability of the left ventricular
ejection fraction due to an irregular rhythm/premature beats.
The right ventricular free wall thickness is normal. The right
ventricular cavity is dilated with depressed free wall
contractility. There are focal calcifications in the aortic
arch. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild to moderate ([**2-3**]+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. The mitral valve leaflets are myxomatous. The mitral
valve leaflets are elongated. There is moderate bileaflet mitral
valve prolapse. Mild to moderate ([**2-3**]+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened.
Tricuspid valve prolapse is present. Moderate to severe [3+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. [In the setting of at least
moderate to severe tricuspid regurgitation, the estimated
pulmonary artery systolic pressure may be underestimated due to
a very high right atrial pressure.] There is a
trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade.

Brief Hospital Course:
79 yo F with atrial fibrillation and lung carcinoid tumor with
neuroendocrine features, presenting with palpitations, admitted
to ICU for control of rapid Afib/Aflutter.

# Atrial fibrillation/ Aflutter:
Hemodynamically stable with HR in 70s-80s and SBPs 90s on
arrival after IV Diltiazem and IVF were administered. We
continued enoxaparin for anticoagulation. She was restarted on
her home dose of metoprolol and diltiazem was increased to 90mg
QID, which was not tolerated. She was transferred to the floor
where her rate control faltered; eventually she was loaded with
amiodarone with conversion to sinus rhythm per electrophysiology
recommendations.  Her diltiazem was discontinued and her
metoprolol was lowered.  She will be fitted with a cardionet
device for arrhythmia monitoring while at rehab (prescription
sent and address of rehab noted).

# Hypoxia
Mild hypoxia on presentation with 2L O2 requirement, perhaps in
the setting of receiving IVFs in the ED. She did not appear to
be grossly fluid overloaded on exam. A CXR showed a significant
mass present in the right lung with a small effusion present.
She was weaned off 02 prior to discharge from the ICU and
remained on room air throughout the admission.

# Lung carcinoid tumor with neuroendocrine features:
Followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Hospital1 18**] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10351**].
She was started last week on carboplatin and etoposide,
presented on day#1 [**2200-5-7**]. Allopurinol was continued.  She had a
repeat TTE that better clarified her cardiac sequelae from this
tumor; she is noted to have a normal EF but could have
compression of the pulmonary veins.  She will be readmitted on
[**5-27**] for her second cycle of chemo along with radiation.

# Neutropenia- On admission the pt's ANC was 130. She did not
have any signs of acute infection. Blood and urine cultures were
sent. She was continued on Neupogen at her home dose and placed
on neutropenic precautions.  By the time of discharge, her
counts had recovered for many days.

Transitional Issues:

- readmission on [**5-27**] for chemo/radiation
- cardionet measurements/fitting and delivery to rehab (to be
worn while at rehab)
- requests a [**Hospital1 18**] PCP and cardiologist; appointments not made
due to her planned readmission in a few days, at which point
follow-up appointments should be made.

Medications on Admission:
- filgrastim 300 mcg/0.5 mL - for 10 days (from discharge
[**2200-5-10**])
- allopurinol 300 mg Tablet daily
- multivitamin daily
- omeprazole 20 mg Capsule x 2 tabs daily
- enoxaparin 100 mg/mL Syringe sq daily
- calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable PO
QID PRN acid reflux.
- Diltia XT 240 mg Capsule,[**Month/Day/Year **] Release Degradable daily
- Toprol XL 100 mg Tablet Extended Release 24 hr daily
- docusate sodium 100 mg Capsule PO BID
- codeine sulfate 30 mg Tablet PRN cough.
- benzonatate 100 mg Capsule PO TID prn cough
- senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID prn constipation
- acetaminophen 325 mg Tablet x 2 tabs PO Q6H PRN pain/fever
- dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup PRN cough
- nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
- ranitidine HCl 150 mg Tablet [**Hospital1 **] PRN heartburn
- bisacodyl 10 mg Suppository PRN constipation
- Fleet Enema 19-7 gram/118 mL Enema PRN constipation
- Milk of Magnesia 400 mg/5 mL Suspension Sig: Five (5) mL PO
once a day PRN constipation
- Ensure Liquid TID with meals


Discharge Medications:
1. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. enoxaparin 100 mg/mL Syringe Sig: One (1) syringe
Subcutaneous Q24 ().
5. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for reflux.
6. Toprol XL 25 mg Tablet Extended Release 24 hr Sig: Three (3)
Tablet Extended Release 24 hr PO once a day.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. codeine sulfate 30 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for cough.
9. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
10. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
11. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q4H (every 4 hours) as needed for cough.
12. nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
13. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
14. dronabinol 2.5 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
15. amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day): with meals.
16. Ensure     Liquid Sig: One (1)  PO three times a day.


Discharge Disposition:
Extended Care

Facility:
Hellenic - [**Location (un) 2624**]

Discharge Diagnosis:
Atrial fibrillation/atrial flutter with rapid ventricular rate
Typical lung carcinoid with neuroendocrine features


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

Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 18**].

You were admitted for atrial fibrillation/atrial flutter with
rapid ventricular rate.  We attempted to control your rhythm
with the previously prescribed medications, but eventually
switched to another medication called amiodarone.  This
medication was successful at converting you back into a normal
rhythm with a normal rate.

You will be readmitted next week [**5-27**] for planned
chemotherapy and radiation therapy.

Please note the following changes to your medication list:

START amiodarone 200mg by mouth three times per day with meals
(for heart rate/rhythm)
START dronabinol 5mg by mouth twice per day (for appetite)

DECREASE toprol XL from 100mg to 75mg daily (decreased due to
change to amiodarone)

STOP diltiazem (you were switched to amiodarone)
STOP neupogen
STOP milk of magnesia
STOP fleet enema
STOP ranitidine

Otherwise please take all medications as prescribed.


Followup Instructions:
[**5-23**] at 3pm with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Location (un) 1411**] Cardiology.

Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2200-5-27**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2200-5-27**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12633**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2200-5-27**] at 12:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Atrial fibrillation,Malignant carcinoid tumor of the bronchus and lung,Chronic systolic heart failure,Other primary cardiomyopathies,Hyposmolality and/or hyponatremia,Hypotension, unspecified,Drug induced neutropenia,Other secondary thrombocytopenia,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Long-term (current) use of anticoagulants,Esophageal reflux,Dermatophytosis of groin and perianal area,Do not resuscitate status,Disorder of bone and cartilage, unspecified,Personal history of tobacco use,Personal history of antineoplastic chemotherapy'}


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: Afib/flutter with RVR

PRESENT ILLNESS: Ms. [**Known lastname 2643**] is a 79 year old woman with recent diagnosis of
carcinoid lung mass with mets, atrial fibrillation on lovenox,
idiopathic cardiomyopathy (EF 45%), recently hospitalized for
initiation of chemotherapy (with carboplatin/etoposide, day#1
[**2200-5-7**]) [**Date range (1) 40354**], now presenting from rehab with afib with
RVR. She noticed palpitations today at rehab and asked to be
evaluated. She was noted to be in rapid Afib with rates 150s.
Aside from palpitations, she denies symptoms of associated chest
pain, shortness of breath, nausea, lightheadedness. She was sent
to [**Hospital1 18**] ED for further evaluation.
.
She was diagnosed with Afib in [**2-/2200**] with the workup resulting
in her neuroendocrine lung cancer diagnosis during [**4-/2200**]
hospitalization. Cancer was diagnosed when TTE showed [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 7388**] vs
external compression. Subsequent CT showed large mediastinal
mass. Afib has been difficult to control since middle of
[**Month (only) 404**], thought to be related to mass effect from tumor. She
had been on sotalol, switched to dronedarone, then back to
sotalol, which was changed to diltiazem and metoprolol during
recent hospitalization in 3/[**2200**]. She has been flipping in and
out of atrial fibrillation frequently in the last few months but
notes improved control of afib since that hospitalization. Can
feel palpitations with rates >140s. She was transitioned from
dabigatran to enoxaparin during that hospitalization in setting
of biopsy and was kept on enoxaparin in case she might need a
repeat procedure.
.
In the ED inital vitals were as follows: 97.4 140 90/64 18 100%
RA.
500cc NS bolus given which brought HR down to 108. She was then
given diltiazem 5mg IV push with BP 92/60, bringing HR down to
96. During ED stay, systolic BPs ranged 87-104, appeared to have
lower systolics with elevated HRs. She received another 10mg IV
diltiazem with 30mg po diltiazem in the ED as well as magnesium
repletion and total 2L IVF. She denied any chest pain, shortness
of breath. ECG showed Afib with NA NI, new ST depression lateral
leads; repeat EKG unchanged. CXR with stable right effusion vs
elevation of right hemidiaphragm. Troponin negative x1. Labs
also significant for WBC 1.3, Hct 35.3, Na 131. Vitals in ED
prior to transfer to floor were as follows: 104/66 114,afib 22
97% on 2L NC.
.
On arrival to the ICU, she feels overall well. Denies
palpitations currently. She does report generalized fatigue,
progressive since starting chemotherapy, worse in the last two
days, such that she needs to use a walker at Rehab to help her
move around. She denies fevers, chills, chest pain, shortness of
breath beyond her baseline. Her cough is unchanged from
baseline, no sputum production. No headache. Has very decreased
appetite for several days.
.
Review of systems:
(+) Per HPI . Groin rash.
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies chest pain, chest
pressure. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias.

MEDICAL HISTORY: PAST ONCOLOGIC HISTORY:
- Patient developed new onset atrial fibrillation in beginning
of [**2200**], initial TTE showed slightly depressed LVEF of 45%,
initially thought to be due to her chronic alcohol use. Her
atrial fibrillation worsened despite uptitration of medication
(sotalol and dronedarone)  and her repeat TTE showed a [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 2966**] vs. extrinsic mass compressing on LA. She was admitted
for evaluation and her biopsy showed neuroendocrine tumor
consistent with typical carcinoid.
- CT scan showing metastases to bone, lymph nodes and possibly
liver.
.
PAST MEDICAL HISTORY:
Atrial fibrillation [**1-/2200**] (diagnosed [**2-/2200**])
Idiopathic Cardiomyopathy, LVEF 45% (diagnosed [**2-/2200**])
Osteopenia
GERD
BPPV
Cataracts s/p lens replacements

MEDICATION ON ADMISSION: - filgrastim 300 mcg/0.5 mL - for 10 days (from discharge
[**2200-5-10**])
- allopurinol 300 mg Tablet daily
- multivitamin daily
- omeprazole 20 mg Capsule x 2 tabs daily
- enoxaparin 100 mg/mL Syringe sq daily
- calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable PO
QID PRN acid reflux.
- Diltia XT 240 mg Capsule,[**Month/Day/Year **] Release Degradable daily
- Toprol XL 100 mg Tablet Extended Release 24 hr daily
- docusate sodium 100 mg Capsule PO BID
- codeine sulfate 30 mg Tablet PRN cough.
- benzonatate 100 mg Capsule PO TID prn cough
- senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID prn constipation
- acetaminophen 325 mg Tablet x 2 tabs PO Q6H PRN pain/fever
- dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup PRN cough
- nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
- ranitidine HCl 150 mg Tablet [**Hospital1 **] PRN heartburn
- bisacodyl 10 mg Suppository PRN constipation
- Fleet Enema 19-7 gram/118 mL Enema PRN constipation
- Milk of Magnesia 400 mg/5 mL Suspension Sig: Five (5) mL PO
once a day PRN constipation
- Ensure Liquid TID with meals

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Physical Exam:
Vitals: T: 97.8 BP: 97/52 P: 110 R: 24 O2: 96% on 2L
General: Alert, oriented, thin woman in no acute distress
HEENT: Sclera anicteric, pale conjunctiva, dry mucus membranes,
oropharynx clear
Neck: JVP ~9cm
Lungs: Decreased breath sounds in Right lower base posteriorly,
no wheezes, rales, rhonchi
CV: Irregular rhythm, rapid rate, no murmurs appreciated
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU: no foley ; erythematous groin rash
[**Location (un) **]: warm, well perfused, 1+ peripheral edema

FAMILY HISTORY: Mother with MI at age 85, son with Afib, daughter with breast CA

SOCIAL HISTORY: Lives alone, son [**Name (NI) **] involved in care.
-Tobacco history: Smoked 1 pack/two weeks x8 years, quit [**2174**]
-ETOH: Lifetime drinker (1 [**Location (un) 21601**]/day with 2 shots of whisky)
until 3-4 weeks ago she stopped due to concern for ETOH
cardiomyopathy.
-Illicit drugs: Denies 

### Response:
{'Atrial fibrillation,Malignant carcinoid tumor of the bronchus and lung,Chronic systolic heart failure,Other primary cardiomyopathies,Hyposmolality and/or hyponatremia,Hypotension, unspecified,Drug induced neutropenia,Other secondary thrombocytopenia,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Long-term (current) use of anticoagulants,Esophageal reflux,Dermatophytosis of groin and perianal area,Do not resuscitate status,Disorder of bone and cartilage, unspecified,Personal history of tobacco use,Personal history of antineoplastic chemotherapy'}
