CHIEF COMPLAINT: Bradycardia

PRESENT ILLNESS: 86 YO male presented to [**Hospital3 934**] ED in complete heart
block. He was at adult day care on the day of admission when
staff checked his vital signs around 12:00 noon and found him to
have a heart rate in the 30s. His daughter was called and picked
up the patient and took him to his PCP where [**Name Initial (PRE) **] 12 lead EKG
revealed him to be in complete heart block. He has had decreased
energy for several weeks and has been less active. Per his
daughter, he is pleasantly confused at baseline and was at his
baseline mental status on presentation to the ED and upon
transfer to [**Hospital1 18**]. He denies chest pain, SOB, nausea, vomiting,
diarrhea, syncope, lightheadeness. He does endorse mild
abdominal pain but denies any diarrhea or other [**Hospital1 **] symptoms.
.
At the [**Hospital **] Hospital ED, his VS were T 97.4, P 39, RR 16, BP
184/67, O2 sat 98% 02 on 3 L NC. He was transferred to [**Hospital1 18**] for
temporary transcutaneous pacemaker placement due to complete
heart block with wide ventricular escape at 35 bpm. A temporary
transcutaneous pacer was advanced to the RV apex via fluroscopic
guidance and position was confirmed with fluorscopy. V threshold
was set at 0.8 mA and V sensitivity threshold at >20 ms. [**First Name (Titles) **] [**Last Name (Titles) 78612**]s: VVI 70, V output 10 mA, V sensitivity 3 mV.
.

MEDICAL HISTORY: 1. Hypertension
2. Hypercholesterolemia
3. Dementia
4. CABG X4 vessels ([**2134**])
5. CVA ([**2137**])
6. CHF
7. Depression
8. Hypothyroidism
9. Barrett's esophabus
10.Eye surgery, unspecified
11. Elevated CRP, documented in PCP [**Name Initial (PRE) 626**] [**2148**] (3.8)

MEDICATION ON ADMISSION: 1. Reminyl 8 mg PO BID
2. Zoloft 100 PO daily
3. Altace 10 mg PO daily
4. Lasix 20 mg PO daily
5. Lipitor 10 mg PO daily
6. Plavix 75 mg PO daily
7. Hydtrin 5 mg PO daily
8. Synthroid 175 mcg PO daily
9. Ranitidine 150 mg PO daily
10. KDur 20 mg PO dialy

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 97.6, BP 137/31, HR 37, RR 23, O2 98% on 2L
Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with no appreciable JVD.
CV: 2/6 SEM at RUSB and LUSB. PMI located in 5th intercostal
space, midclavicular line. RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP

FAMILY HISTORY: FAMILY HISTORY
There is no family history of premature coronary artery disease
or sudden death. Mother: [**Name (NI) 5895**] (deceased, COD: pneumonia).
FAther: unknown [**Last Name **] problem (deceased).

SOCIAL HISTORY: SOCIAL HISTORY:
Social history is significant for the absence of current or
prior tobacco use. There is no history of alcohol abuse. Patient
is a retired pharmacist. Moved to [**Location (un) 86**] from [**State 108**] several
years ago to live with his daughter. Attends [**Name2 (NI) **] daycare.
.
Mobitz (type) II atrioventricular block,Systolic heart failure, unspecified,Unspecified essential hypertension,Pure hypercholesterolemia,Unspecified acquired hypothyroidism,Other persistent mental disorders due to conditions classified elsewhere,Coronary atherosclerosis of unspecified type of vessel, native or graft,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Depressive disorder, not elsewhere classified,Aortocoronary bypass status
Atrioven block-mobitz ii,Systolic hrt failure NOS,Hypertension NOS,Pure hypercholesterolem,Hypothyroidism NOS,Mental disor NEC oth dis,Cor ath unsp vsl ntv/gft,BPH w/o urinary obs/LUTS,Depressive disorder NEC,Aortocoronary bypass
Admission Date:  [**2153-6-7**]              Discharge Date:   [**2153-6-13**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 458**]
Chief Complaint:
Bradycardia

Major Surgical or Invasive Procedure:
Placement of pacemaker


History of Present Illness:
86 YO male presented to [**Hospital3 934**] ED in complete heart
block. He was at adult day care on the day of admission when
staff checked his vital signs around 12:00 noon and found him to
have a heart rate in the 30s. His daughter was called and picked
up the patient and took him to his PCP where [**Name Initial (PRE) **] 12 lead EKG
revealed him to be in complete heart block. He has had decreased
energy for several weeks and has been less active. Per his
daughter, he is pleasantly confused at baseline and was at his
baseline mental status on presentation to the ED and upon
transfer to [**Hospital1 18**]. He denies chest pain, SOB, nausea, vomiting,
diarrhea, syncope, lightheadeness. He does endorse mild
abdominal pain but denies any diarrhea or other [**Hospital1 **] symptoms.
.
At the [**Hospital **] Hospital ED, his VS were T 97.4, P 39, RR 16, BP
184/67, O2 sat 98% 02 on 3 L NC. He was transferred to [**Hospital1 18**] for
temporary transcutaneous pacemaker placement due to complete
heart block with wide ventricular escape at 35 bpm. A temporary
transcutaneous pacer was advanced to the RV apex via fluroscopic
guidance and position was confirmed with fluorscopy. V threshold
was set at 0.8 mA and V sensitivity threshold at >20 ms. [**First Name (Titles) **] [**Last Name (Titles) 78612**]s: VVI 70, V output 10 mA, V sensitivity 3 mV.
.


Past Medical History:
1. Hypertension
2. Hypercholesterolemia
3. Dementia
4. CABG X4 vessels ([**2134**])
5. CVA ([**2137**])
6. CHF
7. Depression
8. Hypothyroidism
9. Barrett's esophabus
10.Eye surgery, unspecified
11. Elevated CRP, documented in PCP [**Name Initial (PRE) 626**] [**2148**] (3.8)


Social History:
SOCIAL HISTORY:
Social history is significant for the absence of current or
prior tobacco use. There is no history of alcohol abuse. Patient
is a retired pharmacist. Moved to [**Location (un) 86**] from [**State 108**] several
years ago to live with his daughter. Attends [**Name2 (NI) **] daycare.
.


Family History:
FAMILY HISTORY
There is no family history of premature coronary artery disease
or sudden death. Mother: [**Name (NI) 5895**] (deceased, COD: pneumonia).
FAther: unknown [**Last Name **] problem (deceased).


Physical Exam:
VS: T 97.6, BP 137/31, HR 37, RR 23, O2 98% on 2L
Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with no appreciable JVD.
CV: 2/6 SEM at RUSB and LUSB. PMI located in 5th intercostal
space, midclavicular line. RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP

Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP



Pertinent Results:
[**2153-6-7**] 08:01PM   GLUCOSE-115* UREA N-26* CREAT-1.3* SODIUM-140
POTASSIUM-4.8 CHLORIDE-107 TOTAL CO2-24 ANION GAP-14
[**2153-6-7**] 08:01PM   estGFR-Using this
[**2153-6-7**] 08:01PM   CALCIUM-9.1 PHOSPHATE-3.3 MAGNESIUM-2.5
[**2153-6-7**] 08:01PM   TSH-7.4*
[**2153-6-7**] 08:01PM   WBC-6.2 RBC-3.32* HGB-10.6* HCT-31.0* MCV-93
MCH-31.8 MCHC-34.1 RDW-13.8
[**2153-6-7**] 08:01PM   PLT COUNT-229
.
STUDY: CT of the head without contrast. [**2153-6-8**]
There is a large area of encephalomalacia involving the left
occipital lobe, vascular territory of the left posterior
cerebral artery, multiple areas of low attenuation in the
periventricular white matter, indicating chronic microvascular
ischemic disease, there is no evidence of acute hemorrhagic
changes or shifting of the normally medial structures. Punctate
dense atherosclerotic calcifications are visualized in the left
medial cerebral artery, carotid siphons, and vertebral body
basilar systems. Prominence of the sulci and ventricles is also
noted, likely age related and involutional in nature. Prominence
of the tip of the basilar artery is also noted, the possibility
of arteriosclerotic changes versus aneurysmatic formation are
considerations, CTA of the head is recommended if clinically
warranted. The orbits appear grossly normal, the paranasal
sinuses demonstrate normal pneumatization, as well as the
mastoid air cells.
IMPRESSION: Chronic ischemic changes are visualized on the left
occipital
lobe with associated encephalomalacia and asymmetry of the left
occipital
ventricular [**Doctor Last Name 534**]. Multiple areas of low attenuation are
demonstrated in the periventricular white matter, likely
consistent with chronic microvascular ischemic changes. There is
no evidence of acute hemorrhage or subdural hematoma. Dense
arteriosclerotic calcifications are demonstrated in the carotid
siphons, left medial cerebral artery, and vertebrobasilar system
as described above. Prominent tip of the basilar artery is
demonstrated, possibly related with arteriosclerotic changes, a
small aneurysm cannot be completely excluded, CTA or MRA are
recommended for further characterization of these findings.
These findings were communicated to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at the time
of this interpretation.
.
CTA HEAD W&W/O C & RECONS Study Date of [**2153-6-10**]
Prominence of the ventricles and sulci is related to age-related
parenchymal atrophy. Periventricular white matter
hypoattenuation is consistent with chronic small vessel ischemic
disease.  There is again calcification of the middle cerebral
arteries, carotid siphons,
and vertebrobasilar arterial system. There is no hemorrhage,
edema, mass
effect, or shift of normally midline structures. There is ex
vacuo dilatation of the posterior [**Doctor Last Name 534**] of the left lateral
ventricle with surrounding encephalomalacia, consistent with
prior infarction.
CTA HEAD: There is prominence at the tip of the basilar artery,
which may
represent a patulous basilar artery or a small aneurysm. Poor
arterial
opacification and lack of processed imaging limits evaluation.
When processed images are become available, a separated addendum
will be provided.
IMPRESSION:
1. Prominence of tip of basilar artery may represent patulous
basilar artery versus small aneurysm. Poor arterial
opacification and lack of processed image limits evaluation, but
an addendum will be generated.
2. Calcifications of the intracranial vessels.
3. Age-related parenchymal atrophy.
4. Chronic small vessel ischemic disease.
5. Encephalomalacia of the left occipital lobe, likely from
prior infarction.
.
ECHO:
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). No masses or
thrombi are seen in the left ventricle. The aortic root is
mildly dilated at the sinus level. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. 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 aortic and mitral regurgitation. Mildly dilated thoracic
aorta.


Brief Hospital Course:
#Rhythm-The patient was transferred to [**Hospital1 18**] for temporary
transcutaneous pacemaker placement due to complete heart block
with wide ventricular escape at 35 bpm. A temporary
transcutaneous pacer was advanced to the RV apex via fluroscopic
guidance and position was confirmed with fluorscopy. V threshold
was set at 0.8 mA and V sensitivity threshold at >20 ms. [**First Name (Titles) **] [**Last Name (Titles) 78612**]s: VVI 70, V output 10 mA, V sensitivity 3 mV. Pt
subsequently had a pacemaker placed without complication.  He
did well and was monitored on telemetry x48 hours post
procedure.  He was started on Metoprolol 12.5mg [**Hospital1 **] after the
pacemkaer was placed for his known CAD.
.
# Pump: Overall EF 45% from [**2147**] with global hypokinesis
suggesting systolic dysfunction.  An echo was done which showed
mild symmetric left ventricular hypertrophy with normal cavity
size and regional/global systolic function (LVEF>55%).  He was
started on 40mg Lasix prior to discharge.
.
# CAD/Ischemia:  Pt ruled out for an MI. He was continued on his
lipitor, plavix, ramipril per home dosing. He was started on
Metoprolol twice daily and aspirin.
.
#. Hypothyroidism- Initially there was concern that the patient
may be hypothryoid which could contribute to heart block however
TSH was wnl. Endocrine consulted at first but pt was on adequate
synthroid replacement. He remained on his home synthroid dose
and appt made for endocrine followup on discharge.
.
# [**Name (NI) 78126**] Pt has dementia at baseline per daughter.
.
# Basilar artery aneurysm/Left posterior infarct. Given mental
status changes, there was initial concern for an intracerebral
abnormality (given history of fall at home) and thus CT head was
done. It showed no hemorrhage, but there was concern for a
basilar artery aneurysm. Thus, a CTA Head was done which showed
prominence of the tip of a basilar artery which may represent
patulous basilar artery versus small aneurysm.  Further followup
with the patient's PCP regarding this possible aneurysm is
recommended; however, no acute neurosurgical interventions were
deemed necessary. The patient was also noted to have a large
left posterior old infarct with associated encephalomalacia and
chronic SVID on this scan, likely related to ischemic dementia.

Medications on Admission:
1. Reminyl 8 mg PO BID
2. Zoloft 100 PO daily
3. Altace 10 mg PO daily
4. Lasix 20 mg PO daily
5. Lipitor 10 mg PO daily
6. Plavix 75 mg PO daily
7. Hydtrin 5 mg PO daily
8. Synthroid 175 mcg PO daily
9. Ranitidine 150 mg PO daily
10. KDur 20 mg PO dialy


Discharge Medications:
1. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Ramipril 5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily).

3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Galantamine 4 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for Alzheimer's Disease.
8. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
Primary
1. Mobitz Type II heart block
.
Secondary
1. Hypertension
2. Hypercholesterolemia
3. Dementia
4. Coronary artery disease
5. Hypothyroidism
6. Congestive heart failure


Discharge Condition:
Hemodynamically stable, afebrile


Discharge Instructions:
You were admitted to the hospital for an irregular heart rhythm.
 You had a temporary pacing wire placed and then had a pacemaker
placed to help control your heart rate.
.
There were changes made to your medications.  You were started
on new medications, including Metoprolol 12.5mg twice daily.
You were also started on Lasix 40mg daily to help maintain your
fluid status.
.
You will need to follow up with device clinic. An appointment
was made for you. In addition  you should be seen by
endocrinology as scheduled.

Followup Instructions:
Please followup with Dr. [**First Name (STitle) **], your PCP on [**7-3**] at 3:30 pm or
at least one week after patient leaves rehabilitation.  Phone
[**Telephone/Fax (1) 22468**].
.
A followup appointment has been made with endocronologist,
Provider: [**Name10 (NameIs) 16244**] [**Last Name (NamePattern4) 16245**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2153-7-16**] 1:40
.
***Provider:  [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**]
Date/Time:[**2153-6-18**] 1:30
{'Mobitz (type) II atrioventricular block,Systolic heart failure, unspecified,Unspecified essential hypertension,Pure hypercholesterolemia,Unspecified acquired hypothyroidism,Other persistent mental disorders due to conditions classified elsewhere,Coronary atherosclerosis of unspecified type of vessel, native or graft,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Depressive disorder, not elsewhere classified,Aortocoronary bypass status'}


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



### Clinical text :
CHIEF COMPLAINT: Bradycardia

PRESENT ILLNESS: 86 YO male presented to [**Hospital3 934**] ED in complete heart
block. He was at adult day care on the day of admission when
staff checked his vital signs around 12:00 noon and found him to
have a heart rate in the 30s. His daughter was called and picked
up the patient and took him to his PCP where [**Name Initial (PRE) **] 12 lead EKG
revealed him to be in complete heart block. He has had decreased
energy for several weeks and has been less active. Per his
daughter, he is pleasantly confused at baseline and was at his
baseline mental status on presentation to the ED and upon
transfer to [**Hospital1 18**]. He denies chest pain, SOB, nausea, vomiting,
diarrhea, syncope, lightheadeness. He does endorse mild
abdominal pain but denies any diarrhea or other [**Hospital1 **] symptoms.
.
At the [**Hospital **] Hospital ED, his VS were T 97.4, P 39, RR 16, BP
184/67, O2 sat 98% 02 on 3 L NC. He was transferred to [**Hospital1 18**] for
temporary transcutaneous pacemaker placement due to complete
heart block with wide ventricular escape at 35 bpm. A temporary
transcutaneous pacer was advanced to the RV apex via fluroscopic
guidance and position was confirmed with fluorscopy. V threshold
was set at 0.8 mA and V sensitivity threshold at >20 ms. [**First Name (Titles) **] [**Last Name (Titles) 78612**]s: VVI 70, V output 10 mA, V sensitivity 3 mV.
.

MEDICAL HISTORY: 1. Hypertension
2. Hypercholesterolemia
3. Dementia
4. CABG X4 vessels ([**2134**])
5. CVA ([**2137**])
6. CHF
7. Depression
8. Hypothyroidism
9. Barrett's esophabus
10.Eye surgery, unspecified
11. Elevated CRP, documented in PCP [**Name Initial (PRE) 626**] [**2148**] (3.8)

MEDICATION ON ADMISSION: 1. Reminyl 8 mg PO BID
2. Zoloft 100 PO daily
3. Altace 10 mg PO daily
4. Lasix 20 mg PO daily
5. Lipitor 10 mg PO daily
6. Plavix 75 mg PO daily
7. Hydtrin 5 mg PO daily
8. Synthroid 175 mcg PO daily
9. Ranitidine 150 mg PO daily
10. KDur 20 mg PO dialy

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 97.6, BP 137/31, HR 37, RR 23, O2 98% on 2L
Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with no appreciable JVD.
CV: 2/6 SEM at RUSB and LUSB. PMI located in 5th intercostal
space, midclavicular line. RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP

FAMILY HISTORY: FAMILY HISTORY
There is no family history of premature coronary artery disease
or sudden death. Mother: [**Name (NI) 5895**] (deceased, COD: pneumonia).
FAther: unknown [**Last Name **] problem (deceased).

SOCIAL HISTORY: SOCIAL HISTORY:
Social history is significant for the absence of current or
prior tobacco use. There is no history of alcohol abuse. Patient
is a retired pharmacist. Moved to [**Location (un) 86**] from [**State 108**] several
years ago to live with his daughter. Attends [**Name2 (NI) **] daycare.
. 

### Response:
{'Mobitz (type) II atrioventricular block,Systolic heart failure, unspecified,Unspecified essential hypertension,Pure hypercholesterolemia,Unspecified acquired hypothyroidism,Other persistent mental disorders due to conditions classified elsewhere,Coronary atherosclerosis of unspecified type of vessel, native or graft,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Depressive disorder, not elsewhere classified,Aortocoronary bypass status'}
