CHIEF COMPLAINT: atrial fibrillation s/p ablation, unable to extubate

PRESENT ILLNESS: This patient is 48 yo male with a past medical history of
paroxysmal afib, hyperlipidemia, mitochondrial muscular disorder
with gait instability who presented today for an atrial
fibrillation ablation following which he was difficult to
extubate and hypotensive.
The patient was diagnosed with paroxysmal atrial fibrillation in
[**2174**], was cardioverted, started on aspirin and rate controlled.
Next, in [**2177**] he went into afib, was again cardioverted and
started on Propafenone. He had a recent episode of atrial
fibrillation/flutter and was started on Coumadin. He underwent
cardioversion for a third time in [**2181-3-4**]. He saw Dr.
[**Last Name (STitle) **] in electrophysiology consultation on [**2181-3-27**] for
treatment of his atrial fibrillation. He is not felt to be a
good candidate for long-term Coumadin therapy due to his history
of falls secondary to the neuromuscular disorder, and had
pulmonary vein isolation today. In terms of symptoms, per CMI
note, he is reports feeling more fatigued and short of breath
when he is in atrial fibrillation. He denies chest pain,
dizziness or syncope.
Today, the patient had afib ablation. At the end of the case he
was given protamine to reverse his anticoagulation and systolic
blood pressure dropped to the 60's after the protamine requiring
bolused vasopressors. He was also difficult to extubate, likely
secondary to the neuromuscular disorder. An ECHO at the bedside
in the lab showed no effusion. The patient has 3 femoral sheaths
still in place for access until the AM.
.
On floor, patient was intubated and sedated, unable to do review
of systems.

MEDICAL HISTORY: - Paroxysmal atrial fibrillation (first in [**2174**] s/p
cardioversion, [**2177**] cardioverted and on propafenone, now more
often recently)
- mitochondrial myotonic dystrophy
- Hyperlipidemia

MEDICATION ON ADMISSION: Atenolol 12.5mg daily
Propafenone 225mg twice daily
simvastatin 40mg daily
Warfarin 5mg everyday except 7mg on MWF
Aspirin 81mg

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 98.4 hr 79, 91/72, rr 15, 95% on 100% Fi02
GENERAL: intubated and sedated
HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. OG tube and ET tube in
place
NECK: supple, no LAD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: clear anteriorly and laterally.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. 2 left femoral sheaths, 1 right femoral
sheath.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: b/l pedal pulses palpable

FAMILY HISTORY: He claims his both parents may have arrhythmias, they are alive
into their 70s. His father may also have a neuromuscular
disorder. He has one sister age 44. [**Name2 (NI) 6419**] his father and his
sister apparently have a slow heart rate, although they do not
have pacemakers at this time.

SOCIAL HISTORY: He is married with no children. He does not smoke but
drinks socially. He is currently on medical disability. He is
from [**Country **], but has been living in america for >10 years.
Atrial fibrillation,Other pulmonary insufficiency, not elsewhere classified,Disorders of mitochondrial metabolism,Myotonic muscular dystrophy,Other iatrogenic hypotension,Disorders of diaphragm,History of fall,Other and unspecified hyperlipidemia
Atrial fibrillation,Other pulmonary insuff,Dis mitochondrial metab,Myotonic musclr dystrphy,Iatrogenc hypotnsion NEC,Disorders of diaphragm,Personal history of fall,Hyperlipidemia NEC/NOS
Admission Date:  [**2181-4-25**]              Discharge Date:   [**2181-4-30**]

Date of Birth:  [**2133-2-22**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
atrial fibrillation s/p ablation, unable to extubate

Major Surgical or Invasive Procedure:
Atrial Fibrillation s/p ablation
Cardioversion
Intubation


History of Present Illness:
This patient is 48 yo male with a past medical history of
paroxysmal afib, hyperlipidemia, mitochondrial muscular disorder
with gait instability who presented today for an atrial
fibrillation ablation following which he was difficult to
extubate and hypotensive.
The patient was diagnosed with paroxysmal atrial fibrillation in
[**2174**], was cardioverted, started on aspirin and rate controlled.
Next, in [**2177**] he went into afib, was again cardioverted and
started on Propafenone. He had a recent episode of atrial
fibrillation/flutter and was started on Coumadin. He underwent
cardioversion for a third time in [**2181-3-4**]. He saw Dr.
[**Last Name (STitle) **] in electrophysiology consultation on [**2181-3-27**] for
treatment of his atrial fibrillation. He is not felt to be a
good candidate for long-term Coumadin therapy due to his history
of falls secondary to the neuromuscular disorder, and had
pulmonary vein isolation today. In terms of symptoms, per CMI
note, he is reports feeling more fatigued and short of breath
when he is in atrial fibrillation. He denies chest pain,
dizziness or syncope.
Today, the patient had afib ablation. At the end of the case he
was given protamine to reverse his anticoagulation and systolic
blood pressure dropped to the 60's after the protamine requiring
bolused vasopressors. He was also difficult to extubate, likely
secondary to the neuromuscular disorder. An ECHO at the bedside
in the lab showed no effusion. The patient has 3 femoral sheaths
still in place for access until the AM.
.
On floor, patient was intubated and sedated, unable to do review
of systems.


Past Medical History:
- Paroxysmal atrial fibrillation (first in [**2174**] s/p
cardioversion, [**2177**] cardioverted and on propafenone, now more
often recently)
- mitochondrial myotonic dystrophy
- Hyperlipidemia

CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, - Hypertension


CARDIAC HISTORY:
-CABG: no
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: no



Social History:
He is married with no children. He does not smoke but
drinks socially. He is currently on medical disability. He is
from [**Country **], but has been living in america for >10 years.


Family History:
He claims his both parents may have arrhythmias, they are alive
into their 70s. His father may also have a neuromuscular
disorder. He has one sister age 44. [**Name2 (NI) 6419**] his father and his
sister apparently have a slow heart rate, although they do not
have pacemakers at this time.

Physical Exam:
VS: 98.4 hr 79, 91/72, rr 15, 95% on 100% Fi02
GENERAL: intubated and sedated
HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. OG tube and ET tube in
place
NECK: supple, no LAD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: clear anteriorly and laterally.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. 2 left femoral sheaths, 1 right femoral
sheath.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: b/l pedal pulses palpable


Pertinent Results:
Admission Labs
[**2181-4-25**] 10:58AM BLOOD WBC-7.0 RBC-5.21 Hgb-16.4 Hct-49.4 MCV-95
MCH-31.5 MCHC-33.2 RDW-14.1 Plt Ct-172
[**2181-4-25**] 10:58AM BLOOD PT-28.5* PTT-35.7* INR(PT)-2.9*
[**2181-4-25**] 10:58AM BLOOD Glucose-109* UreaN-14 Creat-0.7 Na-144
K-4.2 Cl-105 HCO3-32 AnGap-11
[**2181-4-25**] 10:04PM BLOOD Type-ART pO2-95 pCO2-52* pH-7.40
calTCO2-33* Base XS-5
.
[**2181-4-26**]
CT chest with contrast:

1. No evidence of pulmonary embolism.

2. Unchanged low lung volumes and atelectasis.

3. Improved visualization of a 6-mm nodular opacity at the right
upper lobe.
Three-month CT followup is recommended.

4. Heterogeneous left thyroid nodule. Consider ultrasound if
warranted
clinically.
.
[**2181-4-26**] Ct chest without contrast:
1. Enlarged left lobe of the thyroid with some low-attenuation
foci.
Consider ultrasound if warranted clinically.
2. Low lung volumes. Parenchymal opacities at the bases are
associated with
volume loss and most suggestive of atelectasis.
3. Minimal retained secretions within the trachea.
4. Mild thickening of the anterior trachea wall, which is
nonspecific
but could potentially be due to a sequelae or prior intubation
or tracheostomy
placement.
5. Mild enlargement of the main pulmonary artery.
.
[**2181-4-28**] Echo:
The left atrium is mildly dilated. No left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). The
right atrium is moderately dilated. The estimated right atrial
pressure is 10-20mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). Transmitral and tissue Doppler imaging suggests normal
diastolic function, and a normal left ventricular filling
pressure (PCWP<12mmHg). The right ventricular cavity is mildly
dilated with normal free wall contractility. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.

IMPRESSION: Mild right ventricular cavity enlargement with
preserved global free wall motion. Biatrail enlargement.

CLINICAL IMPLICATIONS:
Based on [**2179**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
[**4-27**] CXR:
Lung volumes are lower with increased bibasilar atelectasis.
Bilateral
pleural effusions, if any, would still be tiny. There is no
other overall
change.


Brief Hospital Course:
48M with history of neuromuscular disorder, paroxysmal atrial
fibrillation s/p ablation complicated by hypotension and
difficulty with extubation.

#Respiratory distress: Patient was difficult to extubate after
case. Extubation was attempted briefly, but since patient was
hypotensive, was sent to CCU. He received 2L IVF in EP lab.
Apparently in prior intubation O2sats had been low likely due to
underlying neuromuscular disorder and baseline as wife said
patient has a lot of am secretions. Patient appeared volume
overloaded on xray so was diuresed with good response. He
tolerated extubation well on [**4-26**] but remained hypoxic. Chest CT
was negative for PE but was consistent with low lung volumes and
atelectasis. Pulm was consulted and reported low NIF consistant
with decreased diaphragmatic weakensss likely [**3-5**] to underlying
neuromuscular disorder. He continued to be hypoxic with
ambulation requring 4L by nasal canula to keep sats at 94%.
Patient will get PFTS and be followed by pulm as outpatient as
his disorder is likely progressing and will need home oxygen at
the very least for now.

#Hypotension: Patient hypotensive after receiving protamine in
the EP lab. Likely protamine reaction, since it can cause
sudden, transient drop in blood pressure. Required minimal
phenylephrine which was weaned off. Afebrile and no white count
so sepsis unlikely. Resolved and beta blocker was restarted.

#Atrial fibrillation: s/p ablation. Has been in sinus since.
Continue coumadin, propafenone and atenolol. Followed INR.
Follow up with EP.

#Mitochondrial Neuromuscular disorder: Likely reason why low
sats with intubation and weak cough post intubation. Should
follow up with neurology as outpatient.  Evaluate my physical
therapy who believe he is safe to go home but should get home PT
eval.

Medications on Admission:
Atenolol 12.5mg daily
Propafenone 225mg twice daily
simvastatin 40mg daily
Warfarin 5mg everyday except 7mg on MWF
Aspirin 81mg


Discharge Medications:
1. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Propafenone 225 mg Capsule, Sust. Release 12 hr Sig: One (1)
Capsule, Sust. Release 12 hr PO twice a day.
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO DAYS
(MO,WE,FR).
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAYS
([**Doctor First Name **],TU,TH,SA).
6. Home Oxygen
3-4L continuous pulsed dose for portability, O2 sat 86% on RA.
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
8. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 932**] VNA

Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Atrial Fibrillation
2. Mitochondrial Myotonic Dystrophy
3. Hypoxia
.
SECONDARY DIAGNOSIS:
1. Hyperlipidemia


Discharge Condition:
Stable. Patient is ambulating, tolerating oral intake, and has
returned to his baseline condition.


Discharge Instructions:
You were admitted to the hospital for treatment of your atrial
fibrillation. You underwent a procedure to return your heart to
normal rhythm. You had some difficulty breathing after your
procedure and you were monitored in the intensive care unit for
2 days after your procedure. You are now in a normal sinus
rhythm. We made an appt with Dr. [**First Name (STitle) **] from pulmonology to get
breathing tests. These appts are listed below.
.
We made the following changes to your medication:
1. Increase your aspirin to 325 mg daily
2. Take Ibuprofen for any chest burning or ache that you may
have. If the ibuprofen does not alleviate the symptoms, call Dr.
[**Last Name (STitle) **].
.
Please seek immediate medical care if you develop shortness of
breath, light-headedness, dizziness, loss of consciousness,
fevers, shaking chills, night sweats, abdominal pain, back pain,
or pain in your lower extremities.
.
You will be going home on a monitor to evaluate your heart
rhythm. Please follow the instructions given to you. You will
send strips daily and the monitor will trigger if you go back
into atrial fibrillation.

Followup Instructions:
Please follow-up with your cardiologist [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD on
[**2181-5-28**] 3:40.
.
Pulmonology:
Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]  Phone: ([**Telephone/Fax (1) 513**]
Date/time: Wednesday [**5-16**] at 3:30 with Dr. [**Last Name (STitle) 18309**] on
[**Hospital Ward Name 23**] 7
Pulmonary function tests before the appt at 2:30pm on [**Hospital Ward Name 23**] 7,
Clinical Center, [**Hospital Ward Name 516**], [**Location (un) **]
.
Primary Care:
[**Last Name (LF) **],[**First Name3 (LF) **] Phone: [**Telephone/Fax (1) 74550**] Date/time: [**5-14**] at 3:30pm.




Completed by:[**2181-4-30**]
{'Atrial fibrillation,Other pulmonary insufficiency, not elsewhere classified,Disorders of mitochondrial metabolism,Myotonic muscular dystrophy,Other iatrogenic hypotension,Disorders of diaphragm,History of fall,Other and unspecified hyperlipidemia'}


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: atrial fibrillation s/p ablation, unable to extubate

PRESENT ILLNESS: This patient is 48 yo male with a past medical history of
paroxysmal afib, hyperlipidemia, mitochondrial muscular disorder
with gait instability who presented today for an atrial
fibrillation ablation following which he was difficult to
extubate and hypotensive.
The patient was diagnosed with paroxysmal atrial fibrillation in
[**2174**], was cardioverted, started on aspirin and rate controlled.
Next, in [**2177**] he went into afib, was again cardioverted and
started on Propafenone. He had a recent episode of atrial
fibrillation/flutter and was started on Coumadin. He underwent
cardioversion for a third time in [**2181-3-4**]. He saw Dr.
[**Last Name (STitle) **] in electrophysiology consultation on [**2181-3-27**] for
treatment of his atrial fibrillation. He is not felt to be a
good candidate for long-term Coumadin therapy due to his history
of falls secondary to the neuromuscular disorder, and had
pulmonary vein isolation today. In terms of symptoms, per CMI
note, he is reports feeling more fatigued and short of breath
when he is in atrial fibrillation. He denies chest pain,
dizziness or syncope.
Today, the patient had afib ablation. At the end of the case he
was given protamine to reverse his anticoagulation and systolic
blood pressure dropped to the 60's after the protamine requiring
bolused vasopressors. He was also difficult to extubate, likely
secondary to the neuromuscular disorder. An ECHO at the bedside
in the lab showed no effusion. The patient has 3 femoral sheaths
still in place for access until the AM.
.
On floor, patient was intubated and sedated, unable to do review
of systems.

MEDICAL HISTORY: - Paroxysmal atrial fibrillation (first in [**2174**] s/p
cardioversion, [**2177**] cardioverted and on propafenone, now more
often recently)
- mitochondrial myotonic dystrophy
- Hyperlipidemia

MEDICATION ON ADMISSION: Atenolol 12.5mg daily
Propafenone 225mg twice daily
simvastatin 40mg daily
Warfarin 5mg everyday except 7mg on MWF
Aspirin 81mg

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 98.4 hr 79, 91/72, rr 15, 95% on 100% Fi02
GENERAL: intubated and sedated
HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. OG tube and ET tube in
place
NECK: supple, no LAD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: clear anteriorly and laterally.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. 2 left femoral sheaths, 1 right femoral
sheath.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: b/l pedal pulses palpable

FAMILY HISTORY: He claims his both parents may have arrhythmias, they are alive
into their 70s. His father may also have a neuromuscular
disorder. He has one sister age 44. [**Name2 (NI) 6419**] his father and his
sister apparently have a slow heart rate, although they do not
have pacemakers at this time.

SOCIAL HISTORY: He is married with no children. He does not smoke but
drinks socially. He is currently on medical disability. He is
from [**Country **], but has been living in america for >10 years. 

### Response:
{'Atrial fibrillation,Other pulmonary insufficiency, not elsewhere classified,Disorders of mitochondrial metabolism,Myotonic muscular dystrophy,Other iatrogenic hypotension,Disorders of diaphragm,History of fall,Other and unspecified hyperlipidemia'}
