CHIEF COMPLAINT: Tachycardia

PRESENT ILLNESS: The patient is a 47 yo man with h/o epilepsy s/p vagal nerve
stimulator, AFib, recent diagnosis of stage IV lung CA and PE on
Lovenox and Coumadin, and a recent pericardial effusion who
presents with one-week of worsening SOB, chest pain, and
abdominal pain. The patient was initially brought in by EMS
after being noted to be tachycardic to the 130's. He took 30mg
Diltiazem PO and was transferred to the BIED. In the ED, he
received Diltiazem 25 mg IV and 60 mg PO, and his HR remained in
the 180s. Bedside TTE demonstrated a moderate pericardial
effusion without evidence of tamponade and pulsus was difficult
to obtain secondary to tachycardia. CXR demonstrated a
right-sided pleural effusion.
.
Cards recomended amiodarone drip, with up escalation to dilt as
needed. He also received 5 L of NS. He was admitted to the MICU
for further management. His VS at the time of transfer were P
184, BP 98/83, 27, 98% on 3L.
.
On HD 1 the patient was taken for a pericardial window by csurg,
in which they removed 200cc of pericardial fluid and 1400cc of
fluid from his left lung. He returned intubated from the
pericardial window. Amio was stopped and metoprolol was
uptitrated. The patient d/c'd his own chest tube. Several times
the patient was agitated, requiring zydus 5 mg and haldol.
.
On HD 3 the decision was made to focus on comfort only.

MEDICAL HISTORY: - epilepsy and nonelectrographic seizures (petite mal with rare
secondary generalization)
- s/p right temporal lobectomy
- s/p VNS placement
- Mood disorder and likely borderline personality organization
- Multiple suicide attempts in past (largely overdose)
- DM due to medication, now apparently resolved
- cervical strain
- Rosacea
- [**Last Name (un) 865**] esophagus
- Polysubstance abuse: EtOH, MJ, cocaine/crack binges with
resultant unsafe sexual practices
- h/o atrial fibrillation (not on medication)

MEDICATION ON ADMISSION: Lovenox 100 mg/mL SQ [**Hospital1 **]
Oxcarbazepine 600 mg PO BID
Clonazepam 1 mg PO qid
Omeprazole 20 mg PO daily
Warfarin 5 mg PO daily
Diltiazem HCl 120 mg PO daily
Divalproex 1250/1500/1500 mg daily
Nicotine 14 mg/24 hr patch daily
Metoprolol Succinate 200 mg PO daily
ASA 81 mg daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Physical Exam
Vitals: BP: 115/73 P: 150's R: 20 O2:86%
General: Unresponsive
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Diffuse expiratory wheezes, R sided crackles
CV: distant heart sounds. pulsus of 16
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly

FAMILY HISTORY: States has FH of diabetes and 'cancer in everyone' but no FH of
CAD, HTN, sudden death or cardiac dysrhythmias

SOCIAL HISTORY: Unemployed, lives alone. Smokes 1pk/day, occasional
ETOH and OMR records indicate some history of Crack Cocaine use.
Secondary malignant neoplasm of other specified sites,Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial seizures, with intractable epilepsy,Malignant neoplasm of bronchus and lung, unspecified,Delirium due to conditions classified elsewhere,Atrial flutter,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants,Malignant pleural effusion,Personality change due to conditions classified elsewhere,Other emphysema,Tobacco use disorder,Do not resuscitate status
Secondary malig neo NEC,Psymotr epil w intr epil,Mal neo bronch/lung NOS,Delirium d/t other cond,Atrial flutter,Hx-ven thrombosis/embols,Long-term use anticoagul,Malignant pleural effusn,Personality chg oth dis,Emphysema NEC,Tobacco use disorder,Do not resusctate status
Admission Date:  [**2196-2-17**]              Discharge Date:   [**2196-2-22**]

Date of Birth:  [**2148-11-11**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
Tachycardia

Major Surgical or Invasive Procedure:
s/p Pericardial window for recurrent malignant pericardial
effusion and drainage of large right pleural effusion.


History of Present Illness:
The patient is a 47 yo man with h/o epilepsy s/p vagal nerve
stimulator, AFib, recent diagnosis of stage IV lung CA and PE on
Lovenox and Coumadin, and a recent pericardial effusion who
presents with one-week of worsening SOB, chest pain, and
abdominal pain. The patient was initially brought in by EMS
after being noted to be tachycardic to the 130's. He took 30mg
Diltiazem PO and was transferred to the BIED. In the ED, he
received Diltiazem 25 mg IV and 60 mg PO, and his HR remained in
the 180s. Bedside TTE demonstrated a moderate pericardial
effusion without evidence of tamponade and pulsus was difficult
to obtain secondary to tachycardia. CXR demonstrated a
right-sided pleural effusion.
.
Cards recomended amiodarone drip, with up escalation to dilt as
needed. He also received 5 L of NS. He was admitted to the MICU
for further management. His VS at the time of transfer were P
184, BP 98/83, 27, 98% on 3L.
.
On HD 1 the patient was taken for a pericardial window by csurg,
in which they removed 200cc of pericardial fluid and 1400cc of
fluid from his left lung. He returned intubated from the
pericardial window. Amio was stopped and metoprolol was
uptitrated. The patient d/c'd his own chest tube. Several times
the patient was agitated, requiring zydus 5 mg and haldol.
.
On HD 3 the decision was made to focus on comfort only.

Past Medical History:
- epilepsy and nonelectrographic seizures (petite mal with rare
secondary generalization)
- s/p right temporal lobectomy
- s/p VNS placement
- Mood disorder and likely borderline personality organization
- Multiple suicide attempts in past (largely overdose)
- DM due to medication, now apparently resolved
- cervical strain
- Rosacea
- [**Last Name (un) 865**] esophagus
- Polysubstance abuse: EtOH, MJ, cocaine/crack binges with
resultant unsafe sexual practices
- h/o atrial fibrillation (not on medication)

Social History:
Unemployed, lives alone. Smokes 1pk/day, occasional
ETOH and OMR records indicate some history of Crack Cocaine use.


Family History:
States has FH of diabetes and 'cancer in everyone' but no FH of
CAD, HTN, sudden death or cardiac dysrhythmias

Physical Exam:
Admission Physical Exam
Vitals: BP: 115/73 P: 150's R: 20 O2:86%
General: Unresponsive
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Diffuse expiratory wheezes, R sided crackles
CV: distant heart sounds. pulsus of 16
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly

Pertinent Results:
ECHO [**2-17**]:
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function cannot be reliably assessed. 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 is hypertrophied. with
borderline normal free wall function. There is a moderate sized
pericardial effusion. The effusion appears circumferential. The
effusion is echo dense, consistent with blood, inflammation or
other cellular elements. No right ventricular diastolic collapse
is seen.

IMPRESSION: Moderate-sized, organized circumferential
pericardial effusion without echocardiographic signs of
tamponade. Tachycardia with beat-to-beat variation in left
ventricular systolic function.

When compared to prior study ( images reviewed) from [**2196-2-2**],
the effusion is now larger. Atrial tachyarrhythmia is present.
.
ECHO [**2-18**]:
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function cannot be reliably assessed. There is
considerable beat-to-beat variability of the left ventricular
ejection fraction due to an irregular rhythm/premature beats.
There is a moderate sized pericardial effusion. The effusion
appears circumferential. The effusion is echo dense, consistent
with blood, inflammation or other cellular elements. No right
ventricular diastolic collapse is seen.

IMPRESSION: Limited study. Suboptimal quality. Moderate-sized
circumferential pericardial effusion containing echo dense
material consistent with blood, inflammation, or other cellular
elements. No echocardiographic evidence of tamponade. Left
pleural effusion.
Compared with the prior study (images reviewed) of [**2196-2-17**], the
size of the pericardial effusion remains moderate, but has
decreased minimally in size from 1.5 centimeters to 1.4
centimeters in greatest dimension.
.

[**2196-2-17**] 04:12PM BLOOD WBC-11.0# RBC-4.16* Hgb-13.4* Hct-39.4*
MCV-95 MCH-32.1* MCHC-33.9 RDW-13.9 Plt Ct-296
[**2196-2-20**] 03:57AM BLOOD WBC-5.8 RBC-3.40* Hgb-11.1* Hct-32.8*
MCV-96 MCH-32.7* MCHC-33.9 RDW-14.2 Plt Ct-219
[**2196-2-17**] 04:12PM BLOOD PT-15.4* PTT-25.4 INR(PT)-1.4*
[**2196-2-20**] 05:59PM BLOOD PT-42.0* PTT-44.5* INR(PT)-4.4*
[**2196-2-17**] 04:12PM BLOOD Glucose-104* UreaN-19 Creat-0.9 Na-133
K-4.5 Cl-95* HCO3-27 AnGap-16
[**2196-2-20**] 05:59PM BLOOD Glucose-70 UreaN-26* Creat-0.7 Na-138
K-4.4 Cl-107 HCO3-25 AnGap-10

Brief Hospital Course:
47 yo man with h/o epilepsy s/p vagal nerve stimulator, AFib,
recent diagnosis of stage IV lung CA and DVT/PE on Lovenox and
Coumadin, and a recent pericardial effusion who presents with
one-week of worsening SOB, chest pain, and abdominal pain.
.
#. Comfort care: Patient??????s family decided to make patient CMO,
patient when lucid yesterday evening also said that he did not
want any further procedures and just wanted his pain to be
controlled. All medications were discontinued. Patient passed
away on [**2196-2-22**] and was noted to be comfortable.
.
HOSPITAL COURSE
#. Tachycardia: AFib with RVR likely in the setting of
pericardial effusion and multiple PEs. Nl TSH and free T4 on
last admission at end of [**2196-1-9**]. Tox screen negative
except for ASA 4.1. Based on old records, has a history of Afib
with RVR, a flutter, was treated with diltiazem and flecainide,
and was supposed to be on Metoprolol. In ED, received Diltiazem
25 mg IV and 60 mg PO, and his HR remained in the 180s. Amio
drip started, HR 100-150s. All medications were discontinued
after patient was made CMO.
.
#. Pericardial Effusion: moderate size on echo in ED but no
evidence of tamponade. Prior pericardial effusion about one
month ago showed adenocarcinoma of lung, consistent with his
lung cancer diagnosis. Current effusion likely a malignant
effusion or blood. He was s/p pericardial window which he
tolerated well.
.
#. Pleural Effusion: Patient received 5L of fluids while in ED.
Chest xray shows R sided pleural effusion, new when compared to
xray at discharge 10 days prior to admission.
.
#. Lung cancer: Per our oncology team this patients condition
was end-stage.
.
#. h/o seizure disorder: VNS placed during last admission. He
was continued on his antiepileptics while be was CMO.

Medications on Admission:
Lovenox 100 mg/mL SQ [**Hospital1 **]
Oxcarbazepine 600 mg PO BID
Clonazepam 1 mg PO qid
Omeprazole 20 mg PO daily
Warfarin 5 mg PO daily
Diltiazem HCl 120 mg PO daily
Divalproex 1250/1500/1500 mg daily
Nicotine 14 mg/24 hr patch daily
Metoprolol Succinate 200 mg PO daily
ASA 81 mg daily

Discharge Medications:
N/A

Discharge Disposition:
Expired

Discharge Diagnosis:
Expired

Discharge Condition:
N/A

Discharge Instructions:
N/A

Followup Instructions:
N/A

                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
{'Secondary malignant neoplasm of other specified sites,Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial seizures, with intractable epilepsy,Malignant neoplasm of bronchus and lung, unspecified,Delirium due to conditions classified elsewhere,Atrial flutter,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants,Malignant pleural effusion,Personality change due to conditions classified elsewhere,Other emphysema,Tobacco use disorder,Do not resuscitate 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: Tachycardia

PRESENT ILLNESS: The patient is a 47 yo man with h/o epilepsy s/p vagal nerve
stimulator, AFib, recent diagnosis of stage IV lung CA and PE on
Lovenox and Coumadin, and a recent pericardial effusion who
presents with one-week of worsening SOB, chest pain, and
abdominal pain. The patient was initially brought in by EMS
after being noted to be tachycardic to the 130's. He took 30mg
Diltiazem PO and was transferred to the BIED. In the ED, he
received Diltiazem 25 mg IV and 60 mg PO, and his HR remained in
the 180s. Bedside TTE demonstrated a moderate pericardial
effusion without evidence of tamponade and pulsus was difficult
to obtain secondary to tachycardia. CXR demonstrated a
right-sided pleural effusion.
.
Cards recomended amiodarone drip, with up escalation to dilt as
needed. He also received 5 L of NS. He was admitted to the MICU
for further management. His VS at the time of transfer were P
184, BP 98/83, 27, 98% on 3L.
.
On HD 1 the patient was taken for a pericardial window by csurg,
in which they removed 200cc of pericardial fluid and 1400cc of
fluid from his left lung. He returned intubated from the
pericardial window. Amio was stopped and metoprolol was
uptitrated. The patient d/c'd his own chest tube. Several times
the patient was agitated, requiring zydus 5 mg and haldol.
.
On HD 3 the decision was made to focus on comfort only.

MEDICAL HISTORY: - epilepsy and nonelectrographic seizures (petite mal with rare
secondary generalization)
- s/p right temporal lobectomy
- s/p VNS placement
- Mood disorder and likely borderline personality organization
- Multiple suicide attempts in past (largely overdose)
- DM due to medication, now apparently resolved
- cervical strain
- Rosacea
- [**Last Name (un) 865**] esophagus
- Polysubstance abuse: EtOH, MJ, cocaine/crack binges with
resultant unsafe sexual practices
- h/o atrial fibrillation (not on medication)

MEDICATION ON ADMISSION: Lovenox 100 mg/mL SQ [**Hospital1 **]
Oxcarbazepine 600 mg PO BID
Clonazepam 1 mg PO qid
Omeprazole 20 mg PO daily
Warfarin 5 mg PO daily
Diltiazem HCl 120 mg PO daily
Divalproex 1250/1500/1500 mg daily
Nicotine 14 mg/24 hr patch daily
Metoprolol Succinate 200 mg PO daily
ASA 81 mg daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Physical Exam
Vitals: BP: 115/73 P: 150's R: 20 O2:86%
General: Unresponsive
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Diffuse expiratory wheezes, R sided crackles
CV: distant heart sounds. pulsus of 16
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly

FAMILY HISTORY: States has FH of diabetes and 'cancer in everyone' but no FH of
CAD, HTN, sudden death or cardiac dysrhythmias

SOCIAL HISTORY: Unemployed, lives alone. Smokes 1pk/day, occasional
ETOH and OMR records indicate some history of Crack Cocaine use. 

### Response:
{'Secondary malignant neoplasm of other specified sites,Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial seizures, with intractable epilepsy,Malignant neoplasm of bronchus and lung, unspecified,Delirium due to conditions classified elsewhere,Atrial flutter,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants,Malignant pleural effusion,Personality change due to conditions classified elsewhere,Other emphysema,Tobacco use disorder,Do not resuscitate status'}
