CHIEF COMPLAINT: S/P Pacemaker placement with pericardial effusion

PRESENT ILLNESS: (per admission note and patient):
87 yo female with history of HTN, atrial flutter, tachy/brady
syndrome, rheumatoid arthritis, who was transferred from an OSH
for atrial flutter ablation as she had failed sotalol and
amiodarone in the recent past.  The patient initially presented
with chest pain and near syncope, found to be in 2:1 conduction
at a rate of 150 on [**2160-2-29**] to an OSH.  Rate control was
attempted with digoxin which made her nauseous, and then Toprol.
She has complained of lightheadedness related to
bradyarrhythmia.  At that time she spontaneously converted to
sinus rhythm/brady with HR's ranging between 45-55.  There she
ruled out for an MI and her beta blocker was increased to 25
[**Hospital1 **].

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS:  HTN

MEDICATION ON ADMISSION: HOME MEDS:
Folic acid 1 mg daily
Methotrexate 2.5 mg (5 tabs) po daily
Metoprolol tartrate 25 mg [**Hospital1 **]
Prednisone 2.5 mg daily
Warfarin 2.5 mg QOD
Cclcium carbonate 500 mg po BID
MVI 1 daily

ALLERGIES: Sotalol / Amiodarone / Digoxin

PHYSICAL EXAM: VS:   T 97 HR 73 BP 135/64 RR 11 O2 100% on RA
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
Hard of hearing
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no elevation of JVP.
CARDIAC: RRR, normal S1, S2. 2/6 systolic murmur at apex, no
rubs/gallops.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi in anterior lung fields
ABDOMEN: NABS. Soft, NTND.
EXTREMITIES: No edema. ulnar deviation of BL hands, swan neck
deformity, swelling of MCP joints. WWP. 2+ DP, tibial pulses.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.

FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.

SOCIAL HISTORY: Pt lives with her brother
-[**Name (NI) 1139**] history: none
-ETOH: None
-Illicit drugs: None
Atrial fibrillation,Hemorrhage complicating a procedure,Other specified forms of effusion, except tuberculous,Iatrogenic pneumothorax,Unspecified essential hypertension,Anemia, unspecified,Osteoporosis, unspecified,Rheumatoid arthritis,Long-term (current) use of steroids,Other chest pain
Atrial fibrillation,Hemorrhage complic proc,Effusion NEC exc tb,Iatrogenic pneumothorax,Hypertension NOS,Anemia NOS,Osteoporosis NOS,Rheumatoid arthritis,Long-term use steroids,Chest pain NEC
Admission Date:  [**2160-3-4**]              Discharge Date:   [**2160-3-10**]


Service: MEDICINE

Allergies:
Sotalol / Amiodarone / Digoxin

Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
S/P Pacemaker placement with pericardial effusion

Major Surgical or Invasive Procedure:
-RA isthmus ablation for atypical atrial flutter
-Implantation of pacemaker


History of Present Illness:
(per admission note and patient):
87 yo female with history of HTN, atrial flutter, tachy/brady
syndrome, rheumatoid arthritis, who was transferred from an OSH
for atrial flutter ablation as she had failed sotalol and
amiodarone in the recent past.  The patient initially presented
with chest pain and near syncope, found to be in 2:1 conduction
at a rate of 150 on [**2160-2-29**] to an OSH.  Rate control was
attempted with digoxin which made her nauseous, and then Toprol.
She has complained of lightheadedness related to
bradyarrhythmia.  At that time she spontaneously converted to
sinus rhythm/brady with HR's ranging between 45-55.  There she
ruled out for an MI and her beta blocker was increased to 25
[**Hospital1 **].

She was transfered to [**Hospital1 18**] for RA isthmus ablation for atrial
flutter.  After the procedure she had a brief deterioration into
AF.  She was started on dofetilide on [**2160-3-5**].  The plan was to
monitor her for 6 doses of dofetilide, decrease her beta blocker
secondary to bradycardia and restart coumadin, then discharge
from [**Hospital Ward Name 121**] 3.

Today, she became persistently bradycardic into the 40's with a
prolonged QT on dofetelide.  A pacemaker was then placed to
treat her bradycardia.  After the procedure she developed chest
pain on the lower left chest wall, worse with inspiration,
reproducible to palpation.  When asked how long the pain has
been present for, she states intermittently for "days to weeks,
maybe even months."  The pain is mostly located in the upper
left abdomen, but sometimes migrates to her lower left chest,
but does not radiate.  The pain is not associated with SOB,
nausea, or diaphoresis.  The patient's vital signs were stable
during the episode in the EP lab.  A stat TTE was done in the EP
lab which showed questionable evidence of a small pleural
effusion.  She was transferred to the CCU for monitoring.

Past Medical History:
1. CARDIAC RISK FACTORS:  HTN

2. CARDIAC HISTORY:
Atrial flutter
Tachy/brady syndrome

3. OTHER PAST MEDICAL HISTORY:
Rheumatoid arthritis
Anemia
Osteoporosis


Social History:
Pt lives with her brother
-[**Name (NI) 1139**] history: none
-ETOH: None
-Illicit drugs: None

Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.


Physical Exam:
VS:   T 97 HR 73 BP 135/64 RR 11 O2 100% on RA
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
Hard of hearing
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no elevation of JVP.
CARDIAC: RRR, normal S1, S2. 2/6 systolic murmur at apex, no
rubs/gallops.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi in anterior lung fields
ABDOMEN: NABS. Soft, NTND.
EXTREMITIES: No edema. ulnar deviation of BL hands, swan neck
deformity, swelling of MCP joints. WWP. 2+ DP, tibial pulses.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.


Pertinent Results:
[**2160-3-4**] 12:56PM   GLUCOSE-98 UREA N-21* CREAT-1.0 SODIUM-135
POTASSIUM-5.0 CHLORIDE-93* TOTAL CO2-30 ANION GAP-17
[**2160-3-4**] 12:56PM   MAGNESIUM-2.3
[**2160-3-4**] 12:56PM   WBC-6.2 RBC-4.01* HGB-13.1 HCT-37.8 MCV-94
MCH-32.8* MCHC-34.8 RDW-14.4
[**2160-3-4**] 12:56PM   NEUTS-77.7* LYMPHS-18.5 MONOS-2.7 EOS-0.7
BASOS-0.4
[**2160-3-4**] 12:56PM   PLT COUNT-188
[**2160-3-4**] 12:56PM   PT-14.9* PTT-26.1 INR(PT)-1.3*

EKG: Atrial pacing at 70 beats per minute, early repolarization
of V5, V6, present on old EKG, no T wave changes, no QT
prolongation.

ECHO [**2160-3-7**]: (by cardiology fellow)  The estimated right atrial
pressure is 0-5 mmHg. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size is normal. with
normal free wall contractility. There is a trivial/physiologic
pericardial effusion. There is an anterior space which most
likely represents a fat pad. There are no echocardiographic
signs of tamponade.
IMPRESSION: Trivial pericardial effusion no signs of tamponade.

CXR: no acute cardopulmonary process


Brief Hospital Course:
# Chest pain:  Chronic issue.  Pleuritic, reproducible, located
in left lower chest, left upper abdomen.  Initial differential
included pneumothorax, pericarditis, pericardial effusion given
recent pacemaker placement, however the pain predated the
procedure and was later linked to patient throwing out the
garbage a few days ago.  Pulsus was wnl and tte showed only
trivial pericardial effusion.  Thought pain was most likely
either musculoskeletal or GI in origin.  On further review of
the chest xray following pacemaker placement a small
pneumothorax was appreciated.  The patient also had a Hct drop,
which pointed towards a hemothorax.  Likely pain was secondary
to both musculoskeletal and worsened by hemothorax.  The patient
was given ibuprofen which alleviated the pain.  The patient was
discharged to an acute rehab facility for physical therapy.

# Tachy/Brady Syndrome: S/P pacemaker placement with
questionable chest pain that was likely a chronic issue.  The
patient does not have any physicial or echocardiographic signs
of cardiac tamponade. A CXR taken after PPM placement showed a
small PTX and small pleural effusion. Repeat CXR showed small
progression of the PTX, likely with hemothorax as patient had
decrease in Hct as well. A TTE was done as well to confirm
placement of leads. This showed proper placement of the
pacemaker leads.  Coumadin was held during this time, and the
patient was instructed not to restart coumadin dosing until her
appointment with Dr. [**Last Name (STitle) 23246**] next week.  Cephalexin was to be
continued for a total of 5 days post pacemaker placement

# A flutter:  S/P right atrial isthmus ablation.  The patient
was initially restarted on coumadin, but then discontinued when
taken to the EP lab for pacemaker placement.  She was continued
on metoprolol and dofetilide, and discharged on this regimen. QT
was monitored with daily EKGs. She was started on daily
magnesium replacement.  Coumadin was not restarted this
admission as complication of hemothorax.  She was instructed to
discuss restarting coumadin with Dr. [**Last Name (STitle) 23246**] as an outpatient
next week.

# HTN: Continued metoprolol as above

# RA: Continued prednisone and resumed methotrexate at discharge


FEN: Heart healthy diet
ACCESS: PIVs
PROPHYLAXIS:
-DVT ppx with heparin SC TID
CODE: Full Code


Medications on Admission:
HOME MEDS:
Folic acid 1 mg daily
Methotrexate 2.5 mg (5 tabs) po daily
Metoprolol tartrate 25 mg [**Hospital1 **]
Prednisone 2.5 mg daily
Warfarin 2.5 mg QOD
Cclcium carbonate 500 mg po BID
MVI 1 daily

Medications on Transfer:
Maalox PRN
Calcium Carb 500mg [**Hospital1 **]
Cefazolin 2gm and 1gm X1 (start [**2160-3-7**])
Cephalexin 500mg PO Q8H X 3 days
Dofetilide 125mcg [**Hospital1 **]
Folic acid 1mg daily
Magnesium Oxide 400mg [**Hospital1 **]
Metoprolol tartrate 12.5mg [**Hospital1 **]
MVI PO daily
Prednisone 2.5mg daily
Simethicone 40-80mg QID PRN
Ambien 5-10mg QHS PRN

Discharge Medications:
1. FoLIC Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. PredniSONE 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Calcium Carbonate 500 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
4. Multivitamins     Tablet, Chewable Sig: One (1) Tablet PO
DAILY (Daily).
5. Methotrexate Sodium 2.5 mg Tablet Sig: Five (5) Tablet PO
once a week: every thursday.
6. Dofetilide 125 mcg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
7. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 3 days.
Disp:*8 Capsule(s)* Refills:*0*
9. Protonix 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Ibuprofen 200 mg Capsule Sig: [**11-30**] Capsules PO once a day.


Discharge Disposition:
Extended Care

Facility:
[**Location (un) 931**] House

Discharge Diagnosis:
Primary Diagnoses:
Atrial flutter
Right atrial isthmus ablation
Tachy/Brady Syndrome
s/p pacemaker implantation
Small hemothorax

Secondary Diagnoses:
Hypertension
Rheumatoid arthritis


Discharge Condition:
Ambulatory with cane.  Patient was afebrile and hemodynamically
stable prior to discharge.


Discharge Instructions:
You were admitted to [**Hospital1 18**] for evaluation of a fast heart rate.
You were found to be in atrial flutter.  You underwent a
procedure to ablate this rhythm.  You then had a very slow heart
rate, therefore a pacemaker was placed.  You had a complication
of blood collecting around your lung following the procedure.
It is important that you keep the incision and dressing dry
until you are evaluated in one week in the Device Clinic.

New medications:
- Dofetilide 125mg twice a day - A prescription for this
medication has been faxed to your CVS in [**Location (un) **] and your
mail-away pharmacy.
- Protonix 20mg daily - to protect your stomach from ulcers
while you are on prednisone.
- Cephalexin 500mg every eight hours for 3 more days
- Magnesium oxide 400mg twice a day

Please DO NOT take coumadin until you are seen by Dr.
[**Last Name (STitle) 82344**]. Recheck your INR lab on Monday [**2160-3-14**].

You can take the rest of your prescribed medications as
directed.

If you experience worsening chest pain, shortness of breath,
lightheadedness, dizziness, fever, chills or any other worrisome
symptoms please seek medical attention.

Followup Instructions:
Please follow up with your cardiologist, Dr. [**Last Name (STitle) 23246**], in
[**Location (un) **] on Tuesday [**3-18**] at 11:00am.  The phone number of
the office is [**Telephone/Fax (1) 82345**].

Please also follow up with the device clinic, if your
cardiologist recommends, on [**2160-3-20**] 1:00pm.  The phone number
of their office is [**Telephone/Fax (1) 62**]



Completed by:[**2160-3-10**]
{'Atrial fibrillation,Hemorrhage complicating a procedure,Other specified forms of effusion, except tuberculous,Iatrogenic pneumothorax,Unspecified essential hypertension,Anemia, unspecified,Osteoporosis, unspecified,Rheumatoid arthritis,Long-term (current) use of steroids,Other chest pain'}


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: S/P Pacemaker placement with pericardial effusion

PRESENT ILLNESS: (per admission note and patient):
87 yo female with history of HTN, atrial flutter, tachy/brady
syndrome, rheumatoid arthritis, who was transferred from an OSH
for atrial flutter ablation as she had failed sotalol and
amiodarone in the recent past.  The patient initially presented
with chest pain and near syncope, found to be in 2:1 conduction
at a rate of 150 on [**2160-2-29**] to an OSH.  Rate control was
attempted with digoxin which made her nauseous, and then Toprol.
She has complained of lightheadedness related to
bradyarrhythmia.  At that time she spontaneously converted to
sinus rhythm/brady with HR's ranging between 45-55.  There she
ruled out for an MI and her beta blocker was increased to 25
[**Hospital1 **].

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS:  HTN

MEDICATION ON ADMISSION: HOME MEDS:
Folic acid 1 mg daily
Methotrexate 2.5 mg (5 tabs) po daily
Metoprolol tartrate 25 mg [**Hospital1 **]
Prednisone 2.5 mg daily
Warfarin 2.5 mg QOD
Cclcium carbonate 500 mg po BID
MVI 1 daily

ALLERGIES: Sotalol / Amiodarone / Digoxin

PHYSICAL EXAM: VS:   T 97 HR 73 BP 135/64 RR 11 O2 100% on RA
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
Hard of hearing
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no elevation of JVP.
CARDIAC: RRR, normal S1, S2. 2/6 systolic murmur at apex, no
rubs/gallops.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi in anterior lung fields
ABDOMEN: NABS. Soft, NTND.
EXTREMITIES: No edema. ulnar deviation of BL hands, swan neck
deformity, swelling of MCP joints. WWP. 2+ DP, tibial pulses.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.

FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.

SOCIAL HISTORY: Pt lives with her brother
-[**Name (NI) 1139**] history: none
-ETOH: None
-Illicit drugs: None 

### Response:
{'Atrial fibrillation,Hemorrhage complicating a procedure,Other specified forms of effusion, except tuberculous,Iatrogenic pneumothorax,Unspecified essential hypertension,Anemia, unspecified,Osteoporosis, unspecified,Rheumatoid arthritis,Long-term (current) use of steroids,Other chest pain'}
