CHIEF COMPLAINT: pre-syncope, rapid heart rate, BRBPR

PRESENT ILLNESS: 46 year old male from jail with a history of hypertension with
CP and SOB for 2 weeks off and on. He describes the pain as a
substernal punch that last for a few seconds. It may occur more
frequently when standing up although this is not clear. He is
unable to lie flat because he feels like he get the chest pain
at that time. The pain usually occurs 4-5 times per day. He was
in the shower and was almost past out although never lost
consciousness. He has been having lightheadedness for a few
weeks, most notable when in the bathroom or when standing. After
almost passing out he was brought the the ED where he was noted
to havea rapid heart rate (see below).
.
He notes that he has been on metoprolol, aspirin and hctz but
stopped the metoprolol this am (?) although he thinks his doctor
in jail had him stop it two weeks ago when he initially
complained of being lightheaded.
.
Patient also reports that he has had 15 years of bloody bowel
movements. He says that he has 15-20 bowel movements a day and
that most of them are bloody (both in the toilet bowel and on
the toilet paper). He has never had this worked up. It may occur
more frequently when he drinks alcohol although this is unclear.
[**Name2 (NI) **] does say that it has been getting worse in the past 2 weeks.

MEDICAL HISTORY: HTN
renal cyst removed
appendectomy

MEDICATION ON ADMISSION: Metoprolol
hctz
aspirin

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission:
VS afebrile, 79, 133/74, 100% RA
Gen: muscular young M in NAD. +pectus deformity.
HEENT: EOMI, PERRLA, MMM, OP clear
CV: no JVD. nl S1, S2. RRR no murmurs appreciated
LUNGS: CTAB/L no wheeze
ABD: +BS soft mild distention, NT. aorta was not enlarged by
palpation. No abdominal bruits.
EXT: no edema, R-groin site c/d/i, tender to palp
LUE erythema and tenderness over previous basilic vein IV site
NEURO: A&Ox3. CN 2-12 grossly intact. Preserved sensation
throughout. 5/5 strength throughout. [**11-28**]+ reflexes, equal BL.
Normal coordination. Gait assessment deferred.

FAMILY HISTORY: M died of MI at 54
F died of MI at 66
sister died in [**2102**]
No Hx of IBD or cancer

SOCIAL HISTORY: prior EtOH abuse (used to drink 1/5th vodka or scotch daily but
stopped 46 days ago), occasional cocaine use, once per month.
Sexually active with women.
HIV negative 2 months ago at [**Hospital1 2177**]
Currently incarcerated for aprox 1 month for armed robbery/
aggressive behaviour Tob: none
Atrial flutter,Respiratory arrest,Acute kidney failure, unspecified,Coarctation of aorta (preductal) (postductal),Acute venous embolism and thrombosis of superficial veins of upper extremity,Acute posthemorrhagic anemia,Internal hemorrhoids with other complication,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Alcohol abuse, in remission,Iron deficiency anemia, unspecified,Other vitamin B12 deficiency anemia,Hypertrophy of breast,Unspecified sedatives and hypnotics causing adverse effects in therapeutic use
Atrial flutter,Respiratory arrest,Acute kidney failure NOS,Coarctation of aorta,Ac embl suprfcl up ext,Ac posthemorrhag anemia,Int hemrrhoid w comp NEC,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Alcohol abuse-in remiss,Iron defic anemia NOS,B12 defic anemia NEC,Hypertrophy of breast,Adv eff sedat/hypnot NOS
Admission Date:  [**2112-3-29**]              Discharge Date:   [**2112-4-8**]

Date of Birth:  [**2065-4-12**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
pre-syncope, rapid heart rate, BRBPR

Major Surgical or Invasive Procedure:
Atrial flutter ablation
Trans-esophageal echo
Colonoscopy under monitored anesthesia care


History of Present Illness:
46 year old male from jail with a history of hypertension with
CP and SOB for 2 weeks off and on. He describes the pain as a
substernal punch that last for a few seconds. It may occur more
frequently when standing up although this is not clear. He is
unable to lie flat because he feels like he get the chest pain
at that time. The pain usually occurs 4-5 times per day. He was
in the shower and was almost past out although never lost
consciousness. He has been having lightheadedness for a few
weeks, most notable when in the bathroom or when standing. After
almost passing out he was brought the the ED where he was noted
to havea rapid heart rate (see below).
.
He notes that he has been on metoprolol, aspirin and hctz but
stopped the metoprolol this am (?) although he thinks his doctor
in jail had him stop it two weeks ago when he initially
complained of being lightheaded.
.
Patient also reports that he has had 15 years of bloody bowel
movements. He says that he has 15-20 bowel movements a day and
that most of them are bloody (both in the toilet bowel and on
the toilet paper). He has never had this worked up. It may occur
more frequently when he drinks alcohol although this is unclear.
[**Name2 (NI) **] does say that it has been getting worse in the past 2 weeks.

.
Finally, of note he was recently seen in [**Hospital1 2177**] (aprox 2 months
ago) for high blood pressure (to SBP 200).
.
He was brought to [**Location (un) 620**] initially and then send to [**Hospital1 **] ED.
.
[**Location (un) 620**] labs:
k: 5
BUN/Cr: 22/1.9
Alb: 3
hct: 41.3
Trop: <0.01
CK: 58
.
[**Location (un) 620**] CXR: normal.
.
[**Location (un) 620**]: ECG: flutter at 2:1 conduction, HR: 152
.
Neehdam ED course: AFlutter 150, rec'd Dilt 10 IV, PPI IV, 3 L
IV NS
.
In the ED, initial VS were: 97.3 156 113/91 18 100. No chest
pain. Was given 2 g ca (to prevent hypotension from excess
dilt), dilt 20mg IV last ECG with HR 60 in fib (not flutter)
Dilt 30 po x2.
.
Vitals on transfer were 91, 119.69, 96% RA.
.
On the floor, he was not having any symptoms. No chest pain, no
palpitations. Heart rate was in the 70s.

Past Medical History:
HTN
renal cyst removed
appendectomy

Social History:
prior EtOH abuse (used to drink 1/5th vodka or scotch daily but
stopped 46 days ago), occasional cocaine use, once per month.
Sexually active with women.
HIV negative 2 months ago at [**Hospital1 2177**]
Currently incarcerated for aprox 1 month for armed robbery/
aggressive behaviour Tob: none


Family History:
M died of MI at 54
F died of MI at 66
sister died in [**2102**]
No Hx of IBD or cancer


Physical Exam:
Admission:
VS afebrile, 79, 133/74, 100% RA
Gen: muscular young M in NAD. +pectus deformity.
HEENT: EOMI, PERRLA, MMM, OP clear
CV: no JVD. nl S1, S2. RRR no murmurs appreciated
LUNGS: CTAB/L no wheeze
ABD: +BS soft mild distention, NT. aorta was not enlarged by
palpation. No abdominal bruits.
EXT: no edema, R-groin site c/d/i, tender to palp
LUE erythema and tenderness over previous basilic vein IV site
NEURO: A&Ox3. CN 2-12 grossly intact. Preserved sensation
throughout. 5/5 strength throughout. [**11-28**]+ reflexes, equal BL.
Normal coordination. Gait assessment deferred.


Pertinent Results:
Admission labs:
[**2112-3-29**] 09:50PM BLOOD WBC-7.4 RBC-5.08 Hgb-12.1* Hct-37.5*
MCV-74* MCH-23.8* MCHC-32.2 RDW-14.1 Plt Ct-207
[**2112-3-29**] 09:50PM BLOOD PT-12.6 PTT-24.1 INR(PT)-1.1
[**2112-3-30**] 09:20AM BLOOD ESR-22*
[**2112-3-29**] 09:50PM BLOOD Glucose-93 UreaN-20 Creat-1.7* Na-143
K-4.6 Cl-110* HCO3-23 AnGap-15
[**2112-3-29**] 09:50PM BLOOD ALT-12 AST-17 AlkPhos-54 TotBili-0.2
[**2112-3-30**] 09:20AM BLOOD CK(CPK)-67
[**2112-3-29**] 09:50PM BLOOD cTropnT-<0.01
[**2112-3-30**] 09:20AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2112-3-29**] 09:50PM BLOOD Albumin-3.4* Calcium-8.8 Phos-3.1 Mg-1.8
[**2112-3-29**] 11:51PM BLOOD D-Dimer-417
[**2112-3-30**] 09:20AM BLOOD TSH-1.5
[**2112-3-30**] 09:20AM BLOOD CRP-16.4*
[**2112-3-30**] 09:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2112-4-5**] 01:35PM BLOOD Lactate-1.0
.
Anemia w/u:
[**2112-3-31**] 07:35AM BLOOD calTIBC-333 VitB12-323 Folate-12.8
Ferritn-45 TRF-256
.
Micro:
[**2112-3-30**] 6:35 am STOOL     CONSISTENCY: NOT APPLICABLE
      O & P ADDED ON [**2112-3-31**] AT 0130.

                            **FINAL REPORT [**2112-4-2**]**

   FECAL CULTURE (Final [**2112-4-2**]):    NO SALMONELLA OR SHIGELLA
FOUND.

   CAMPYLOBACTER CULTURE (Final [**2112-4-1**]):    NO CAMPYLOBACTER
FOUND.

   CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2112-3-30**]):
      Feces negative for C.difficile toxin A & B by EIA.
           (Reference Range-Negative).

   OVA + PARASITES (Final [**2112-3-31**]):
      NO OVA AND PARASITES SEEN.
      This test does not reliably detect Cryptosporidium,
Cyclospora or
      Microsporidium. While most cases of Giardia are detected
by routine
      O+P, the Giardia antigen test may enhance detection when
organisms
      are rare.
.
Micro:
[**2112-4-2**] 8:08 am STOOL     CONSISTENCY: WATERY      Source:
Stool.

                            **FINAL REPORT [**2112-4-5**]**

   FECAL CULTURE (Final [**2112-4-4**]):
      NO ENTERIC GRAM NEGATIVE RODS FOUND.
      NO SALMONELLA OR SHIGELLA FOUND.

   CAMPYLOBACTER CULTURE (Final [**2112-4-4**]):    NO CAMPYLOBACTER
FOUND.

   OVA + PARASITES (Final [**2112-4-5**]):
      NO OVA AND PARASITES SEEN.
      This test does not reliably detect Cryptosporidium,
Cyclospora or
      Microsporidium. While most cases of Giardia are detected
by routine
      O+P, the Giardia antigen test may enhance detection when
organisms
      are rare.

   FECAL CULTURE - R/O VIBRIO (Final [**2112-4-4**]):    NO VIBRIO
FOUND.

   FECAL CULTURE - R/O YERSINIA (Final [**2112-4-4**]):    NO YERSINIA
FOUND.

   FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2112-4-4**]):
      NO E.COLI 0157:H7 FOUND.

   CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2112-4-3**]):
      Feces negative for C.difficile toxin A & B by EIA.
           (Reference Range-Negative).
.
[**2112-3-30**] 12:04 pm URINE      Source: CVS.

                            **FINAL REPORT [**2112-3-31**]**

   URINE CULTURE (Final [**2112-3-31**]):    NO GROWTH.
.
u/a negative [**3-30**]
.
[**3-30**] echo:
The left atrium and right atrium are normal in cavity size. No
left atrial mass/thrombus seen (best excluded by transesophageal
echocardiography). The estimated right atrial pressure is 0-5
mmHg. There is mild symmetric left ventricular hypertrophy with
normal cavity size and regional/global systolic function
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The diameters of aorta at the sinus, ascending and
arch levels are normal. There appears to be a mild coarctation
of the distal aortic arch. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. Trace aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.

IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
?Mild coarctation of the distal aortic arch. If clinically
indicated a thoracic CT or MR or a TEE would be better able to
anatomically define the possible mild aortic coarctation.
.
[**3-30**] CXR:
IMPRESSION: PA and lateral chest reviewed in the absence of
prior chest
radiographs:

Mild-to-moderate cardiomegaly is exaggerated by a pectus
deformity of the
sternum. Aside from a band of linear atelectasis inferior to the
left hilus, the lungs are clear. There is no pulmonary edema and
no pleural effusion or evidence of central adenopathy and the
hila are normal size. Findings do not suggest pulmonary embolism
in order to exclude that diagnosis. Incidental note made of
healed left lower lateral rib fractures.
.
[**3-30**] CT abd/pelvis:
IMPRESSION:
1. Colonic wall thickening and mild surrounding inflammatory
change involving the ascending, transverse, and descending
colon. The sigmoid colon and rectum are difficult to evaluate as
they are collapsed. The terminal ileum also appears thickened.
Findings are likely inflammatory or infectious in nature.  There
are no secondary signs of ischemia, although this cannot be
fully excluded.

2. 6-mm non-obstructing proximal right ureteral stone with
proximal ureteral thickening, likely reactive. Mild dilatation
of the right ureter in its mid portion, which may be due to
prior passed stone.

3. Focal left renal cortical scarring and two punctate
non-obstructing
stones.
.
[**4-3**] renal u/s:
1. Non-obstructing 7-mm stone at the right UPJ, with a right
extrarenal
pelvis, with no evidence for right hydronephrosis.
2. Focal cortical thinning in the left kidney without
hydronephrosis or
obstructing nephrolithiasis on the left. Small cyst at the lower
pole of the left kidney.
.
[**4-4**]:
b/l UE u/s:
IMPRESSION: Occlusive thrombus seen within the basilic veins
bilaterally. On the right arm, the thrombus is in the forearm
below the antecubital fossa. In the left arm, the thrombus is in
the forearm and extends into the antecubital fossa.
.
[**4-5**]:
TEE: There is no pericardial effusion. There is left ventricular
hypertrophy. Left ventricular systolic function appears mildly
to moderately depressed (LVEF ?40%) in focused views.
TEE: No spontaneous echo contrast or thrombus in the left
atrium/left atrial appendage. Mildly to moderately depressed
global left ventricular systolic function. Depressed right
ventricular systolic function. Mild aortic regurgitation. Simple
atheroma in the aortic arch and descending thoracic aorta.
.
[**4-7**] COLONOSCOPY:
FINDINGS:
Lumen: Evidence of a previous end to side ileo-colonic
anastomosis was seen at the ascending colon.
Mucosa: Normal mucosa was noted in the whole examined colon, at
the anastomosis and in the neoterminal ileum.
Cold forceps biopsies were performed for histology at the small
bowel, Ileum.
Cold forceps random biopsies were performed for histology
throughout the whole colon.
Protruding Lesions Medium-sized internal hemorrhoids were noted.
IMPRESSION: Previous end to side ileo-colonic anastomosis of the
ascending colon
Normal mucosa in the colon and neo-terminal ileum. Internal
hemorrhoids (biopsy)
Otherwise normal colonoscopy to neoterminal ileum
Recommendations: Await biopsy results
F/U with inpatient GI consult team
.
[**4-7**] BIOPSIES pending
.

Brief Hospital Course:
46 yo M with h/o HTN presents with 2 weeks of increasing bloody
BMs, pre-syncope and found to have A-flutter/fib with RVR.
.
# A-fib/flutter: New diagnosis per patient. Patient in/out of
primarily flutter with variable conduction, mostly 2:1, (with
occasional NSR or afib, but after a couple of days was without
the afib episodes, and was only flutter/NSR).
Initially, went into sinus after IV and po dilt; then in/out of
fib/flutter with variable block and with variable HR from 40s to
140s, also sometimes in sinus rhythm. Then more persistently in
aflutter with HR in 140s, treated with uptitration of diltiazem,
then per cardiology transitioned to beta-blocker with
uptitration of metoprolol. Tried IV amiodarone load, but without
change from aflutter in 140s, discontinued amiodarone after the
load and went back to metoprolol for rate control, with doses
varying from 75 tid to 100 qid, with caution regarding BP
(mostly SBP 100-130) and concern for potential to throw a clot
if converted to sinus given not anticoagulating in setting of GI
bleed.
Thought that atrial arrhythmia may be due to volume loss from
bloody BM's and diarrhea, or from inflammatory state related to
IBD/colitis.
Felt that chest pain/pre-syncope/SOB were related to
tachycardia, as symptoms were worsen with rising HR (but often
even when tachycardic to 140s patient could be asymptomatic).
Given CHADS 2 score of 1 (hx of HTN), would likely only need to
be anticoagulated with aspirin, but held given GIB.
Ruled out MI with 2 sets of negative cardiac enzymes. Also
considered drugs as causative perhaps d/t cocaine-induced
hypertension and secondary arrhythmia, although he had a
negative tox screen on admission. Echo without CHF and also
without evidence of right heart strain plus with negative
d-dimer less likely PE. + aortic coarctation perhaps
contributing to hypertension and secondary atrial arrhythmia.
TSH wnl. Without pain or fever.
Cardiology and electrophysiology were consulted - without being
able to rate control the aflutter after multiple days and
medication regimens, then went to TEE to ensure no intracardiac
thrombus, which was followed by atrial flutter ablation. This
was complicated by a respiratory arrest due to oversedation with
medications, requiring Narcan and flumazenil for reversal and
monitoring overnight in the CCU post-procedure. On return to the
floor he was in normal sinus rhythm in the 50s-60s, with
hypertension to the 160s-180s. TEE with concern for
tachyarrhythmia-induced cardiomyopathy and depressed EF, so
medications were adjusted to include metoprolol tartrate 25mg
[**Hospital1 **] and lisinopril, which can continue to be adjusted as needed
as an outpatient. He will need follow-up of this cardiomyopathy
and his post-ablation care, and has been scheduled for an
outpatient appointment with cardiology here at [**Hospital1 18**]. He was
started on Lovenox and then Coumadin for bridging prior to
discharge, and he will have a goal INR of 2.0-3.0 for at least
three months post-ablation.
.
# BRBPR: Differential includes ischemic, inflammatory,
infectious; favor inflammatory given lack of pain and good
appetite point away from ischemic, given long duration seems
less likely to be infectious and also negative infectious w/u
thus far, including stool studies. Colitis seen on CT scan
abd/pelvis. Twice prepped for colonoscopy but failed attempts
due to tachycardia of aflutter in 150s and so discomfort on the
part of anesthesia to perform the colonoscopy in that setting.
Plan for attempt at colonoscopy after atrial arrhythmia ablated.
In the interim, GI was consulted, and patient was empirically
treated with antibiotics (ceftriaxone/flagyl). Although patient
continued with BRBPR, its frequency decreased, and his Hct
remained stable in 35-38 range without need for transfusion.
Colonoscopy ultimately did not show colitis, but did show
internal hemorrhoids, as well as a surprising finding of a prior
abdominal surgery. Felt hemorroids to be most likely source of
BRBPR. Biopsies taken to assess for microscopic colitis, which
are pending on discharge, and patient will need follow-up with
gastroenterology, which has been scheduled.
.
# Bilateral basilic vein clots: after amiodarone administration,
patient's b/l antecubital regions were TTP and erythematous, and
they worsened over 2 days. u/s of b/l UE's showed b/l basilic
vein clots. treated with warm compresses, but did not treat with
antibiotics as clinically appeared superficial thrombophlebitis
and not cellulitis. ultimately started on anti-coagulation for
post-ablation care, which may be helpful in treating these
superficial upper extremity vein thrombi.
.
# Respiratory arrest: Pt suffered a respiratory arrest in the
setting of excess sedation for his atrial flutter ablation.
Reversed easily with Narcan and flumazenil, but required
overnight observation in the CCU without further complication.
.
# ARF vs CRI: Unclear baseline. Perhaps pre-renal in setting of
bloody diarrhea; or could be [**12-29**] renal scarring seen on CT scan
as more of a chronic process; or could be [**12-29**] long-standing
hypertension in setting of h/o cocaine use & aortic coarctation.
Treated with IVF hydration, and saw Cr waver around 1.7-1.9
steadily. Improved after ablation, perhaps poor forward-flow was
partially causative, currently improved to 1.4 on discharge.
.
# Anemia: Fe and B12 deficient, started repletion of both,
thought that this could be d/t malabsorption in setting of
colitis, or due to malnutrition.
.
# Aortic coarctation: incidentally seen on echo; needs MRI
outpatient follow-up, per cardiology.
.
# Hypertension: Treated with metoprolol and lisinopril. Given
concern for tachycardia-induced cardiomyopathy, would like to
uptitrate lisinopril as tolerated.

Medications on Admission:
Metoprolol
hctz
aspirin


Discharge Medications:
1. Outpatient Lab Work
Please check CBC, Chem 7 panel, and PT/INR on Monday [**2112-4-11**].
Please check PT/INR as needed in the future to monitor for
therapeutic anticoagulation with Coumadin.
2. Lovenox 150 mg/mL Syringe Sig: 130mg injection Subcutaneous
once a day for 7 days: Continue until INR therapeutic for 24
hours (goal INR [**12-30**]).
Disp:*7 syringes* Refills:*1*
3. Coumadin 1 mg Tablet Sig: Five (5) Tablet PO once a day: Goal
INR [**12-30**].
Disp:*150 Tablet(s)* Refills:*1*
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day:
Hold for systolic blood pressure <110.
Disp:*30 Tablet(s)* Refills:*2*
5. Metoprolol Tartrate 25 mg Tablet Sig: Half Tablet PO BID (2
times a day): Hold for HR<60 or SBP<105.
Disp:*30 Tablet(s)* Refills:*2*
6. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
Disp:*80 Capsule(s)* Refills:*1*
7. Ferrous Sulfate 300  mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Cyanocobalamin 100 mcg Tablet Sig: 2.5 Tablets PO DAILY
(Daily).
Disp:*75 Tablet(s)* Refills:*2*


Discharge Disposition:
Extended Care

Facility:
[**Location 85622**] of Correction

Discharge Diagnosis:
Internal hemorrhoids
Atrial flutter
Atrial fibrillation
Aortic coarctation
Anemia
Bilateral basilic vein thrombi
Hypertension
Respiratory arrest


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


Discharge Instructions:
You were admitted to the hospital with a fast heart rate, bloody
stools, and lightheadedness. The bloody stools are likely due to
internal hemorroids, seen on colonoscopy. The associated blood
loss likely resulted in the lightheadedness and contributed to
the cardiac arrhythmia such that you felt chest pain, shortness
of breath, and a fast heart rate.
.
Controlling your heart rate was difficult to do with
medications, so you had an ablation to reset the heart rhythm,
which was successful.
.
You have a new set of medications to take, please see attached.
.
You will take lovenox (for approximately 5-7 days) to complete a
bridge while you start taking coumadin. Your goal INR is [**12-30**],
once you are at that goal for 24 hours, then you can discontinue
the coumadin. INR checks should ensure it is between [**12-30**], and
your coumadin dose should be titrated as needed.

Followup Instructions:
Please attend the following appointments:
.
Gastroenterology (for diarrhea & bloody stool follow-up, and to
review biopsy results):
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2112-4-27**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 10314**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST    Best Parking: Main Garage
.
Cardiology:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2112-5-4**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Atrial flutter,Respiratory arrest,Acute kidney failure, unspecified,Coarctation of aorta (preductal) (postductal),Acute venous embolism and thrombosis of superficial veins of upper extremity,Acute posthemorrhagic anemia,Internal hemorrhoids with other complication,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Alcohol abuse, in remission,Iron deficiency anemia, unspecified,Other vitamin B12 deficiency anemia,Hypertrophy of breast,Unspecified sedatives and hypnotics causing adverse effects in therapeutic use'}


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: pre-syncope, rapid heart rate, BRBPR

PRESENT ILLNESS: 46 year old male from jail with a history of hypertension with
CP and SOB for 2 weeks off and on. He describes the pain as a
substernal punch that last for a few seconds. It may occur more
frequently when standing up although this is not clear. He is
unable to lie flat because he feels like he get the chest pain
at that time. The pain usually occurs 4-5 times per day. He was
in the shower and was almost past out although never lost
consciousness. He has been having lightheadedness for a few
weeks, most notable when in the bathroom or when standing. After
almost passing out he was brought the the ED where he was noted
to havea rapid heart rate (see below).
.
He notes that he has been on metoprolol, aspirin and hctz but
stopped the metoprolol this am (?) although he thinks his doctor
in jail had him stop it two weeks ago when he initially
complained of being lightheaded.
.
Patient also reports that he has had 15 years of bloody bowel
movements. He says that he has 15-20 bowel movements a day and
that most of them are bloody (both in the toilet bowel and on
the toilet paper). He has never had this worked up. It may occur
more frequently when he drinks alcohol although this is unclear.
[**Name2 (NI) **] does say that it has been getting worse in the past 2 weeks.

MEDICAL HISTORY: HTN
renal cyst removed
appendectomy

MEDICATION ON ADMISSION: Metoprolol
hctz
aspirin

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission:
VS afebrile, 79, 133/74, 100% RA
Gen: muscular young M in NAD. +pectus deformity.
HEENT: EOMI, PERRLA, MMM, OP clear
CV: no JVD. nl S1, S2. RRR no murmurs appreciated
LUNGS: CTAB/L no wheeze
ABD: +BS soft mild distention, NT. aorta was not enlarged by
palpation. No abdominal bruits.
EXT: no edema, R-groin site c/d/i, tender to palp
LUE erythema and tenderness over previous basilic vein IV site
NEURO: A&Ox3. CN 2-12 grossly intact. Preserved sensation
throughout. 5/5 strength throughout. [**11-28**]+ reflexes, equal BL.
Normal coordination. Gait assessment deferred.

FAMILY HISTORY: M died of MI at 54
F died of MI at 66
sister died in [**2102**]
No Hx of IBD or cancer

SOCIAL HISTORY: prior EtOH abuse (used to drink 1/5th vodka or scotch daily but
stopped 46 days ago), occasional cocaine use, once per month.
Sexually active with women.
HIV negative 2 months ago at [**Hospital1 2177**]
Currently incarcerated for aprox 1 month for armed robbery/
aggressive behaviour Tob: none 

### Response:
{'Atrial flutter,Respiratory arrest,Acute kidney failure, unspecified,Coarctation of aorta (preductal) (postductal),Acute venous embolism and thrombosis of superficial veins of upper extremity,Acute posthemorrhagic anemia,Internal hemorrhoids with other complication,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Alcohol abuse, in remission,Iron deficiency anemia, unspecified,Other vitamin B12 deficiency anemia,Hypertrophy of breast,Unspecified sedatives and hypnotics causing adverse effects in therapeutic use'}
