CHIEF COMPLAINT: Syncope

PRESENT ILLNESS: 77M PMH COPD, HTN, hypertrophic CM--HOCM/IHSS, recently admitted
to [**Hospital3 417**] with syncope.  Pt notes that he was walking to
the bathroom when he felt SOB, then LOC x 1 min. No LH, CP,
palpitations.  Stayed home over the weekend, then continued to
feel increasing SOB, LH; and came in to [**Hospital3 **]. While in the
ED at [**Hospital3 **], he was noted to have SVT with stable vitals.  He
was give adenosine, then started on a dilt gtt overnight.  In
the AM on [**4-11**], he was noted on labs to have a trop increase
from 0.56 to 1.82 (CK 86-->115, MB 5.2-->6.6). He was medically
managed initially, then transferred to [**Hospital1 18**] for cath.
.
In the cath lab, he was noted to have a tortuous and heavily
calcified mid RCA that was unable to be expanded with the
balloon. Rotational atherectomy was performed, but still with
suboptimal balloon expansion.  Attempt to deliver an 18mm CYPHER
stent was unsuccessful, so 3 small bare metal stents were placed
overlapping, with good flow afterwards.

MEDICAL HISTORY: HCM--IHSS
     Squamous cell ca skin, mets to R hypopharynx, s/p XRT and
radical neck dissection [**9-5**].
     HTN
     Irregular heart beat
     Smoking history (60 pack-years)
     No family history of cardiac disease/sudden death

MEDICATION ON ADMISSION: Outpatient med list unavailable on admission

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: G: Elderly male, NAD
HEENT: MMM, Clear OP
Neck: No JVD
Lungs: Crackles BL at bases, No W/R]
CV: RRR, S1S2, No appreciable murmur
Abd: Soft, NT, BS+
Ext: No edema
Neuro: A&Ox3, appropriate. No focal deficits.

FAMILY HISTORY: NC

SOCIAL HISTORY: Current smoker
Subendocardial infarction, initial episode of care,Mitral stenosis,Other primary cardiomyopathies,Chronic airway obstruction, not elsewhere classified,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Other chronic pulmonary heart diseases,Unspecified disorder of kidney and ureter,Nonspecific abnormal findings in stool contents,Tobacco use disorder,Personal history of malignant neoplasm of other and unspecified oral cavity and pharynx
Subendo infarct, initial,Mitral stenosis,Prim cardiomyopathy NEC,Chr airway obstruct NEC,Atrial fibrillation,Crnry athrscl natve vssl,Chr pulmon heart dis NEC,Renal & ureteral dis NOS,Abn find-stool contents,Tobacco use disorder,Hx-oral/pharynx malg NEC
Admission Date:  [**2147-4-13**]              Discharge Date:   [**2147-4-18**]

Date of Birth:  [**2069-7-25**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2880**]
Chief Complaint:
Syncope

Major Surgical or Invasive Procedure:
Cardiac catheterization with rotational atherectomy of RCA and
bare metal stenting of proximal and mid right coronary artery.


History of Present Illness:
77M PMH COPD, HTN, hypertrophic CM--HOCM/IHSS, recently admitted
to [**Hospital3 417**] with syncope.  Pt notes that he was walking to
the bathroom when he felt SOB, then LOC x 1 min. No LH, CP,
palpitations.  Stayed home over the weekend, then continued to
feel increasing SOB, LH; and came in to [**Hospital3 **]. While in the
ED at [**Hospital3 **], he was noted to have SVT with stable vitals.  He
was give adenosine, then started on a dilt gtt overnight.  In
the AM on [**4-11**], he was noted on labs to have a trop increase
from 0.56 to 1.82 (CK 86-->115, MB 5.2-->6.6). He was medically
managed initially, then transferred to [**Hospital1 18**] for cath.
.
In the cath lab, he was noted to have a tortuous and heavily
calcified mid RCA that was unable to be expanded with the
balloon. Rotational atherectomy was performed, but still with
suboptimal balloon expansion.  Attempt to deliver an 18mm CYPHER
stent was unsuccessful, so 3 small bare metal stents were placed
overlapping, with good flow afterwards.

Past Medical History:
HCM--IHSS
     Squamous cell ca skin, mets to R hypopharynx, s/p XRT and
radical neck dissection [**9-5**].
     HTN
     Irregular heart beat
     Smoking history (60 pack-years)
     No family history of cardiac disease/sudden death

Social History:
Current smoker

Family History:
NC

Physical Exam:
G: Elderly male, NAD
HEENT: MMM, Clear OP
Neck: No JVD
Lungs: Crackles BL at bases, No W/R]
CV: RRR, S1S2, No appreciable murmur
Abd: Soft, NT, BS+
Ext: No edema
Neuro: A&Ox3, appropriate. No focal deficits.


Pertinent Results:
Admission Labs:
[**2147-4-13**] 07:30PM BLOOD WBC-9.3 RBC-3.79* Hgb-11.9* Hct-34.4*
MCV-91 MCH-31.5 MCHC-34.7 RDW-14.7 Plt Ct-266
[**2147-4-13**] 11:40AM BLOOD PT-13.2 INR(PT)-1.2
[**2147-4-13**] 07:30PM BLOOD Plt Ct-266
[**2147-4-13**] 10:39PM BLOOD Glucose-184* UreaN-15 Creat-0.8 Na-136
K-4.3 Cl-101 HCO3-29 AnGap-10
[**2147-4-13**] 10:39PM BLOOD CK(CPK)-54
[**2147-4-14**] 05:41AM BLOOD ALT-10 AST-15 LD(LDH)-158 CK(CPK)-47
AlkPhos-68 TotBili-0.8
[**2147-4-13**] 10:39PM BLOOD CK-MB-NotDone
[**2147-4-14**] 05:41AM BLOOD CK-MB-NotDone
[**2147-4-13**] 10:39PM BLOOD Calcium-8.2* Phos-3.3 Mg-1.6
[**2147-4-14**] 05:41AM BLOOD Albumin-3.4 Calcium-8.1* Phos-3.1 Mg-1.6
Cholest-129
[**2147-4-14**] 05:41AM BLOOD Triglyc-77 HDL-40 CHOL/HD-3.2 LDLcalc-74
[**2147-4-14**] 05:41AM BLOOD TSH-1.5
[**2147-4-14**] 05:41AM BLOOD Free T4-1.1
[**2147-4-13**] 03:12PM BLOOD Type-ART pO2-64* pCO2-37 pH-7.45
calHCO3-27 Base XS-1 Intubat-NOT INTUBA

Discharge Labs:
[**2147-4-18**] 07:12AM BLOOD WBC-6.9 RBC-3.92* Hgb-12.0* Hct-35.5*
MCV-91 MCH-30.7 MCHC-33.9 RDW-14.4 Plt Ct-294
[**2147-4-18**] 07:12AM BLOOD Plt Ct-294
[**2147-4-18**] 07:12AM BLOOD PT-12.7 PTT-25.1 INR(PT)-1.1
[**2147-4-18**] 07:12AM BLOOD Glucose-92 UreaN-22* Creat-0.9 Na-137
K-4.1 Cl-103 HCO3-23 AnGap-15
[**2147-4-18**] 07:12AM BLOOD Calcium-9.2 Phos-3.2 Mg-2.0

Cath Results: CO 4.21/CI 2.27
         PCW M/A/V: 31/30/38
         RA M/A/V: [**2153-9-12**]
         Ao: S/D/M: 210/79/126
         PA: S/D/M: 64/24/42
         LV: S/D/E: 209/13/26
         RV: S/D/E: [**2106-5-14**]
         HR 60s
         MV: Grad 9.27, Flow 149.4, area 1.30, index 0.70
         Fluoro x 125 min
         Contrast 465 cc
         LVgraphy: Not performed due to severe PA HTN
         R dom: LMCA, LAD, LCX non-obstructed
                OM: lower pole severe diffuse disease in a small
vessel
                RCA: 90% prox and mid vessels.
*
Echo: MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.9 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *6.0 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *6.0 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.8 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.6 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: >= 70% (nl >=55%)
Aorta - Valve Level: 3.2 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.2 cm (nl <= 3.4 cm)
Aorta - Arch: 2.8 cm (nl <= 3.0 cm)
Aortic Valve - Peak Velocity: *2.2 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 20 mm Hg
Aortic Valve - Mean Gradient: 10 mm Hg
Mitral Valve - Mean Gradient: 3 mm Hg
Mitral Valve - Pressure Half Time: 124 ms
Mitral Valve - MVA (P [**12-4**] T): 1.9 cm2
Mitral Valve - E Wave: 1.4 m/sec
Mitral Valve - A Wave: 1.0 m/sec
Mitral Valve - E/A Ratio: 1.40
Mitral Valve - E Wave Deceleration Time: 380 msec
TR Gradient (+ RA = PASP): *44 mm Hg (nl <= 25 mm Hg)

INTERPRETATION:

Findings:

LEFT ATRIUM: Mild LA enlargement.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.

LEFT VENTRICLE: Severe symmetric LVH. Normal regional LV
systolic function. No
resting or inducible LVOT gradient.

RIGHT VENTRICLE: Normal RV chamber size and free wall motion.

AORTA: Normal aortic root diameter. Normal ascending aorta
diameter. Normal
aortic arch diameter.

AORTIC VALVE: Mildly thickened aortic valve leaflets (3).
Minimally increased
gradient c/w minimal AS. Trace AR.

MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular
calcification. Mild thickening of mitral valve chordae. Mnimally
increased
gradient consistent with trivial MS. Mild to moderate ([**12-4**]+) MR.
[Due to
acoustic shadowing, the severity of MR may be significantly
UNDERestimated.]

TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Moderate PA
systolic hypertension.

PERICARDIUM: No pericardial effusion.

GENERAL COMMENTS: Suboptimal image quality - poor parasternal
views. Based on
[**2138**] AHA endocarditis prophylaxis recommendations, the echo
findings indicate
a moderate risk (prophylaxis recommended). Clinical decisions
regarding the
need for prophylaxis should be based on clinical and
echocardiographic data.

Conclusions:
The left atrium is mildly dilated. There is severe symmetric
left ventricular
hypertrophy with relative sparing of the inferior and
inferolateral walls and
normal cavity size.. Regional left ventricular wall motion is
normal. There is
no left ventricular outflow obstruction at rest or with
Valsalva. Right
ventricular chamber size and free wall motion are normal. The
aortic valve
leaflets (3) are mildly thickened. There is a minimally
increased gradient
consistent with minimal aortic valve stenosis. Trace aortic
regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
prominent
mitral annular calcification leading to minimal functional
mitral stenosis.
Mild to moderate ([**12-4**]+) mitral regurgitation is seen. [Due to
acoustic
shadowing, the severity of mitral regurgitation may be
significantly
UNDERestimated.] There is moderate pulmonary artery systolic
hypertension.
There is no pericardial effusion.

IMPRESSION: Hypertrophic non-obstructive cardiomyopathy with
preserved
regional systolic function. Pulmonary artery systolic
hypertension.
Mild-moderate mitral regurgitation. Minimal aortic stenosis and
minimal mitral
stenosis.



Brief Hospital Course:
CARDIAC:
.
A) Cor: NSTEMI, s/p rota atherectomy of RCA with placement of 3
bare metal stents.  Other coronary anatomy includes R dominant
system only otherwise significant for diffusely diseased OM. Pt
was started on aspirin, plavix, statin, beta blocker, and
integrillin x 18 hours post cath.  His ACEI was initially held
given concerns about dye nephropathy from prolonged exposure,
but this was restarted as his renal function was stable.
.
B) Pump: History of IHSS. Echo from OSH reveals severe septal
hypertrophy, mitral stenosis (peak 10, mean 5) mild MR [**First Name (Titles) **] [**Last Name (Titles) **],
EF > 75%, RVH, Peak LVOT gradient 14mmHg, mean 9, no evidence
[**Male First Name (un) **]. The patient was transferred to the floor with BPs in the
200 systolic.  He was started on a nitro drip, and oral
antihypertensives were gradually added back.  His echo was
significant for a lack of apparent LV outflow tract
obstruction/gradient, and his response to blood pressure
medications did not indicate that this was a significant issue.
He was eventually discharged on a regimen of HCTZ, lisinopril,
nifedipine, atenolol, all of which can be titrated as an
outpatient.
.
C) Rhythm: The patient continued to have brief episodes of
atrial fibrillation while on telemetry.  He was seen by EP, and
started on amiodarone (to be tapered as an outpatient) and well
as titrated up on nodal agents.  He was also without major risk
factors for sudden death, and was determined not to be a
candidate for ICD placement.  His heart rate was in the low 60s
on discharge.  He was also started on coumadin, after his
hematocrit was determined to be stable (see below), and can have
his INR followed as an OP.  He is discharged with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of
Hearts monitor.
*
RENAL: Pt exposed to large dye load (500cc) during the cath, and
there was a concern for dye nephropathy; however, his creatinine
remained stable throughout.  He was also given IV bicarbonate
and mucomyst post cath.
*
GI: The patient was noted to have had a decrease in Hct several
days post cath.  His stool was brown (not melanic or BRBPR), but
was guaiac positive.  An NGT lavage was clear with no blood or
bile. He was transfused 1 unit of PRBCs with a good response in
Hct, and remained stable throughout.  He should have a GI workup
for this as an outpatient.
*
NEURO: ? age indeterminant infarct on head CT, although pt not
aware of CVA. Neuro exam only notable for L facial droop.  No
active issues during this hospitalization. Continued on aspirin.
*
DERMATOLOGY: The patient had an extended cath time with fluoro
exposure lasting greater than 100 minutes.  He is to follow up
with dermatology as an outpatient.
*
COPD: No symptoms during this admission.
*


Medications on Admission:
Outpatient med list unavailable on admission

Discharge Medications:
1. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 4 weeks: After 4 weeks, you need to reduce your
dose to 1 tablet daily.
Disp:*56 Tablet(s)* Refills:*1*
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-4**]
Puffs Inhalation Q6H (every 6 hours) as needed.
5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
10. Atenolol 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Hypertrophic cardiomyopathy
Coronary artery disease
Supraventricular tachycardia


Discharge Condition:
Good

Discharge Instructions:
Take all of your medications as directed.

You need to quit smoking. This will not be easy, but it is the
most important thing you can do to protect your heart.  Please
talk with Dr. [**Last Name (STitle) 16004**] about nicotine replacement options.

Please have your blood drawn (Hct, PT/INR) in 3 days and follow
up the results with Dr. [**Last Name (STitle) 16004**].

Followup Instructions:
We recommend the following:



Please make an appointment with Dr. [**Last Name (STitle) 16004**] within 2-3 days of
discharge. You will need to have your blood pressure checked on
your new medication regimen. Dr. [**Last Name (STitle) 16004**] should also draw your
blood to check your INR after restarting your coumadin.



You should also have your liver enzymes, thyroid function tests
and pulmonary function tests monitored over time. You were
started on amiodarone which requires these tests.



Finally, Dr. [**Last Name (STitle) 16004**] should also schedule you to have another
colonoscopy given you were noted to have blood in your stool
during your hospital stay.



You will be sent home with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts Monitor to follow
your rhythm.



You need to call Dr.[**Name (NI) 33490**] office to schedule an appointment
with him. His number is ([**Telephone/Fax (1) 16005**]. He will receive the
results of your [**Doctor Last Name **] of hearts monitor.



You will need to return for followup with electrophysiology
within four weeks of discharge.



Provider: [**First Name8 (NamePattern2) 6715**] [**Last Name (NamePattern1) **] Where: [**Hospital6 29**] DERMATOLOGY
Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2147-5-15**] 2:30


                             [**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**]
{'Subendocardial infarction, initial episode of care,Mitral stenosis,Other primary cardiomyopathies,Chronic airway obstruction, not elsewhere classified,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Other chronic pulmonary heart diseases,Unspecified disorder of kidney and ureter,Nonspecific abnormal findings in stool contents,Tobacco use disorder,Personal history of malignant neoplasm of other and unspecified oral cavity and pharynx'}


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: Syncope

PRESENT ILLNESS: 77M PMH COPD, HTN, hypertrophic CM--HOCM/IHSS, recently admitted
to [**Hospital3 417**] with syncope.  Pt notes that he was walking to
the bathroom when he felt SOB, then LOC x 1 min. No LH, CP,
palpitations.  Stayed home over the weekend, then continued to
feel increasing SOB, LH; and came in to [**Hospital3 **]. While in the
ED at [**Hospital3 **], he was noted to have SVT with stable vitals.  He
was give adenosine, then started on a dilt gtt overnight.  In
the AM on [**4-11**], he was noted on labs to have a trop increase
from 0.56 to 1.82 (CK 86-->115, MB 5.2-->6.6). He was medically
managed initially, then transferred to [**Hospital1 18**] for cath.
.
In the cath lab, he was noted to have a tortuous and heavily
calcified mid RCA that was unable to be expanded with the
balloon. Rotational atherectomy was performed, but still with
suboptimal balloon expansion.  Attempt to deliver an 18mm CYPHER
stent was unsuccessful, so 3 small bare metal stents were placed
overlapping, with good flow afterwards.

MEDICAL HISTORY: HCM--IHSS
     Squamous cell ca skin, mets to R hypopharynx, s/p XRT and
radical neck dissection [**9-5**].
     HTN
     Irregular heart beat
     Smoking history (60 pack-years)
     No family history of cardiac disease/sudden death

MEDICATION ON ADMISSION: Outpatient med list unavailable on admission

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: G: Elderly male, NAD
HEENT: MMM, Clear OP
Neck: No JVD
Lungs: Crackles BL at bases, No W/R]
CV: RRR, S1S2, No appreciable murmur
Abd: Soft, NT, BS+
Ext: No edema
Neuro: A&Ox3, appropriate. No focal deficits.

FAMILY HISTORY: NC

SOCIAL HISTORY: Current smoker 

### Response:
{'Subendocardial infarction, initial episode of care,Mitral stenosis,Other primary cardiomyopathies,Chronic airway obstruction, not elsewhere classified,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Other chronic pulmonary heart diseases,Unspecified disorder of kidney and ureter,Nonspecific abnormal findings in stool contents,Tobacco use disorder,Personal history of malignant neoplasm of other and unspecified oral cavity and pharynx'}
