CHIEF COMPLAINT: Ventricular tachycardia

PRESENT ILLNESS: 81F with DM2, HTN, history of stroke on plavix, dementia
transferred from [**Hospital1 1516**] for closer monitoring in setting of
possible VTach.  Pt in usual state of health until yesterday.
Some SOB ascending stairs to bed last night, Daughter then heard
gurgling noise and noted pt to be difficult to arouse from
sleep, pt was confused and diaphoretic when awoken - pt stated
she was in "deep sleep".  Of note, clear fluid on shirt and
sheets thought to be from mouth, but reported to not look like
vomit. ? syncope.  EMS called, taken to [**Hospital3 4107**] where
troponin I 0.72, BNP 369, Creatinine 1.6, EKG NSR with sub-mm ST
elevations in III and aVF and reciprocal sub-mm depression in I
and aVL.  CXR with no acute process.  Recieved ASA 324mg and
heparin gtt, transferred to [**Hospital1 18**] for cath.  This am,
experienced 30s run of VT, self-limited.  Now with persistant
tachycardia, EP consulted and not sure if VT vs other
tachyarrhythmia - recommend transfer to CCU for further
monitoring.  Remained asymptommatic throughout.
.
She reports she is comfortable and never had any chest
discomfort or shortness of breath. Per son who accompanies her,
patient has baseline lower extremity edema, 2 pillow orthopnea
that is unchanged, and stable DOE w/ stairs. Has remote history
of fainting.
.
On review of systems, s/he denies any prior history of deep
venous thrombosis, pulmonary embolism, bleeding at the time of
surgery, myalgias, joint pains, cough, hemoptysis, black stools
or red stools. S/he denies recent fevers, chills or rigors. S/he
denies exertional buttock or calf pain. All of the other review
of systems were negative.
.
Cardiac review of systems is notable as above and for absence of
chest pain,  paroxysmal nocturnal dyspnea, palpitations.
.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: +Diabetes, -Dyslipidemia, +Hypertension

MEDICATION ON ADMISSION: Plavix 75 mg daily
Metoprolol Succinate 25 mg daily
Lantus 10 units SC daily
Vitamin B

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS: T= 97.5 BP= 67/50 HR= 123 RR= 21 O2 sat= 97%RA
.
DATE:  GENERAL: NAD. Oriented x2. Appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM, OP clear.
NECK: Supple, no LAD.  JVP minimally elevated above clavicle.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. tachycardic, regular, normal S1, S2. No m/r/g. No thrills,
lifts. no gallop.
LUNGS: Resp were unlabored, no accessory muscle use. bibasilar
wet crackles, no wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.  +BS.
EXTREMITIES: trace bilateral LE edema to ankle, No c/c.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+

FAMILY HISTORY: Unknown

SOCIAL HISTORY: Lives w/ daughter in [**Name (NI) 5110**]. Is from [**Location (un) **] and moved here
many decades ago.  Son is HCP/POA.
-Tobacco history: No current tobacco use. Smoked rarely in
remote past.
-ETOH: None currently. Rare in past.
-Illicit drugs: Never
Subendocardial infarction, initial episode of care,Acute systolic heart failure,Paroxysmal ventricular tachycardia,Acute kidney failure, unspecified,Coronary atherosclerosis of native coronary artery,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other persistent mental disorders due to conditions classified elsewhere,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Osteoporosis, unspecified,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Do not resuscitate status
Subendo infarct, initial,Ac systolic hrt failure,Parox ventric tachycard,Acute kidney failure NOS,Crnry athrscl natve vssl,DMII wo cmp nt st uncntr,Mental disor NEC oth dis,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Osteoporosis NOS,Hx TIA/stroke w/o resid,Do not resusctate status
Admission Date:  [**2128-9-27**]              Discharge Date:   [**2128-10-4**]

Date of Birth:  [**2046-11-9**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Ventricular tachycardia

Major Surgical or Invasive Procedure:
cardiac catheterization with no interventions


History of Present Illness:
81F with DM2, HTN, history of stroke on plavix, dementia
transferred from [**Hospital1 1516**] for closer monitoring in setting of
possible VTach.  Pt in usual state of health until yesterday.
Some SOB ascending stairs to bed last night, Daughter then heard
gurgling noise and noted pt to be difficult to arouse from
sleep, pt was confused and diaphoretic when awoken - pt stated
she was in "deep sleep".  Of note, clear fluid on shirt and
sheets thought to be from mouth, but reported to not look like
vomit. ? syncope.  EMS called, taken to [**Hospital3 4107**] where
troponin I 0.72, BNP 369, Creatinine 1.6, EKG NSR with sub-mm ST
elevations in III and aVF and reciprocal sub-mm depression in I
and aVL.  CXR with no acute process.  Recieved ASA 324mg and
heparin gtt, transferred to [**Hospital1 18**] for cath.  This am,
experienced 30s run of VT, self-limited.  Now with persistant
tachycardia, EP consulted and not sure if VT vs other
tachyarrhythmia - recommend transfer to CCU for further
monitoring.  Remained asymptommatic throughout.
.
She reports she is comfortable and never had any chest
discomfort or shortness of breath. Per son who accompanies her,
patient has baseline lower extremity edema, 2 pillow orthopnea
that is unchanged, and stable DOE w/ stairs. Has remote history
of fainting.
.
On review of systems, s/he denies any prior history of deep
venous thrombosis, pulmonary embolism, bleeding at the time of
surgery, myalgias, joint pains, cough, hemoptysis, black stools
or red stools. S/he denies recent fevers, chills or rigors. S/he
denies exertional buttock or calf pain. All of the other review
of systems were negative.
.
Cardiac review of systems is notable as above and for absence of
chest pain,  paroxysmal nocturnal dyspnea, palpitations.
.


Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, -Dyslipidemia, +Hypertension

2. OTHER PAST MEDICAL HISTORY:
Hypertension
Diabetes mellitus type II, on insulin
H/o stroke
Dementia (baseline oriented x2)
Osteoperosis
PVD
CKD - creatinine 1.8 in [**6-/2128**]

Social History:
Lives w/ daughter in [**Name (NI) 5110**]. Is from [**Location (un) **] and moved here
many decades ago.  Son is HCP/POA.
-Tobacco history: No current tobacco use. Smoked rarely in
remote past.
-ETOH: None currently. Rare in past.
-Illicit drugs: Never


Family History:
Unknown

Physical Exam:
VS: T= 97.5 BP= 67/50 HR= 123 RR= 21 O2 sat= 97%RA
.
DATE:  GENERAL: NAD. Oriented x2. Appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM, OP clear.
NECK: Supple, no LAD.  JVP minimally elevated above clavicle.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. tachycardic, regular, normal S1, S2. No m/r/g. No thrills,
lifts. no gallop.
LUNGS: Resp were unlabored, no accessory muscle use. bibasilar
wet crackles, no wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.  +BS.
EXTREMITIES: trace bilateral LE edema to ankle, No c/c.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+

Pertinent Results:
[**2128-9-27**] 05:49AM   PT-11.7 PTT-24.0 INR(PT)-1.0
[**2128-9-27**] 05:49AM   PLT COUNT-292
[**2128-9-27**] 05:49AM   NEUTS-65.1 LYMPHS-29.8 MONOS-3.1 EOS-1.5
BASOS-0.6
[**2128-9-27**] 05:49AM   WBC-7.4 RBC-3.43* HGB-10.5* HCT-30.2* MCV-88
MCH-30.7 MCHC-34.9 RDW-13.0
[**2128-9-27**] 05:49AM   CALCIUM-9.0 PHOSPHATE-2.7 MAGNESIUM-2.2
[**2128-9-27**] 05:49AM   CK-MB-4 cTropnT-0.43*
[**2128-9-27**] 05:49AM   CK(CPK)-73
[**2128-9-27**] 05:49AM   estGFR-Using this
[**2128-9-27**] 05:49AM   GLUCOSE-166* UREA N-29* CREAT-1.6* SODIUM-140
POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-23 ANION GAP-14
[**2128-9-27**] 12:00PM   PTT-61.7*
[**2128-9-27**] 04:55PM   CK-MB-3 cTropnT-0.43*
[**2128-9-27**] 04:55PM   CK(CPK)-63
.
Cardiac Cath [**2128-9-29**]
COMMENTS:
1.  Selective coronary angiography of this right-dominant system

demonstrated 3 vessel coronary artery disease.  The LMCA had no
angiographically apparent flow-limiting disease.  The LAD had a
90%
mid-vessel stenosis, and was otherwise diffusely disease.  The
D1 had an
80% stenosis.  The LCx had 80% stenosis at the origin, and OMB2
was
totally occluded and filled by left-to-left collaterals.  The
RCA was
totally occluded proximally and filled via left-to-right
collaterals.
2.  Resting hemodynamics revealed mildly elevated left- and
right-sided
filling pressures with an LVEDP of 20mmHg and an RVEDP of
16mmHg.  There
was no gradient across the aortic or mitral valve.  There was
mild
pulmonary venous hypertension with a PA pressure of 37/19 and a
normal
PVR.  Cardiac output was preserved at 5.5 L/min with an index of
3.2
L/min/m2.

FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Preserved cardiac output.
3. Mildly elevated left- and right-sided filling pressures
.
[**2128-9-27**]
echo
The left atrium and right atrium are normal in cavity size. No
atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses and cavity size are normal. There
is moderate regional left ventricular systolic dysfunction with
near akinesis of the basal inferior wall and distal halves of
the septum and anterior wall. The apex is mildly aneurysmal and
akinetic. The remaining segments contract normally (LVEF = 30-35
%). No masses or thrombi are seen in the left ventricle. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are structurally
normal. There is no mitral valve prolapse. Mild to moderate
([**1-11**]+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is an anterior space
which most likely represents a prominent fat pad.
.
IMPRESSION: Normal left ventricular cavity size with extensive
regional systolic dysfunction c/w multivessel CAD. Mild-moderate
mitral regurgitation.
.


Brief Hospital Course:
81F with history of previous stroke, DM and dementia admitted
with likely NSTEMI now with tachyarrythmia concerning for VT.
.
# NSTEMI/CAD:  no known history, multiple risk factors. q's in
III and aVF concerning for history of MI.  elevated troponin of
0.43, CK WNL.  Pt went for cardiac cath which showed extensive
3VD.  Goals of care discussion occured with pt and family and it
was determined not to pursue CABG.  Pt was continued on ASA,
plavix, metoprolol, lisinopril and atorvastatin.
.
# CHF:  On presentation to CCU, pt was found to have bibasilar
crackles on exam, however, no oxygen requirement and minimal
swelling in LE.  Pt was given one dose of lasix 10mg IV and
diuresed appropriately.  At time of discharge, she was not
requiring any diuretic.  She was discharged on lisinopril and
metoprolol.
.
# RHYTHM:  Pt was in stable monomorphic VT on transfer to CCU.
Etiology is likely secondary to scarring from previous event.
Pt was initially started on metoprolol 5mg IV and then lidocaine
bolus and drip.  She converted to 1st degree heart block.  On
[**9-30**] started amio 200TID for 14 days of loading, then 300 qday 4
weeks then 200mg qday.  EP was consulted and determined that pt
is not a good candidate for EP study given age and prior goals
of care discussion.
.
# HTN  - Pt was continued on metoprolol.  At time of discharge,
she was taking lisinopril and metoprolol.
.
# Diabetes - on lantus at home.  Was put on ISS during
hospitalization.
.
Transitional:
- Pt will need f/u care with Dr. [**Last Name (STitle) 8098**] per son's request for
management of CHF and CAD, unsuccessful attempt was made to
schedule before discharge
- DNR/DNI status initiated during this hospital stay
- Please check Chem-7 and CBC on Thursday [**10-7**]
- Please check fingersticks for one week with humalog sliding
scale, d/c after one week if FS consistantly < 150.
- Pt may need to transition to permanant 24 hour care according
to son.


Medications on Admission:
Plavix 75 mg daily
Metoprolol Succinate 25 mg daily
Lantus 10 units SC daily
Vitamin B

Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. trazodone 50 mg Tablet Sig: 0.25 Tablet PO HS (at bedtime) as
needed for insomnia.
4. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day) for 4 days: Change to 300 mg daily for 4 weeks, last day
[**11-4**], then change to 200 mg daily thereafter. .
5. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
7. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. insulin glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous once a day.
9. multivitamin     Capsule Sig: One (1) Capsule PO once a day.

10. Calcium Citrate + D 315-200 mg-unit Tablet Sig: One (1)
Tablet PO twice a day.


Discharge Disposition:
Extended Care

Facility:
Life Care Center of [**Location 15289**]

Discharge Diagnosis:
Severe coronary artery disease
Ventricular tachycardia
Acute systolic congestive heart failure
Diabetes
Hypertension
Dementia
History of stroke


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
YOu had a heart attack and needed a cardiac catheterization to
assess for blockages in your coronary arteries. There were
severe blockages found but none of the blockages were amenable
to treatment with balloons or stents. Instead, we have started
you on medicine to try to prevent the blockages from getting
worse. You had a irregular heart rhythm called ventricular
tachycardia, this was treated with a medicine called amiodarone
and it has not returned. Your heart is weak after the heart
attack. Weigh yourself every morning, call Dr. [**Last Name (STitle) 8098**] if weight
goes up more than 3 lbs in 1 day or 5 pounds in 3 days.
.
We made the following changes to your medicines:
1. Start aspirin to prevent another heart attack
2. Start lisinopril to help improve your heart function
3. STart trazadone to help you sleep
4. Start amiodarone to prevent ventricular tachycardia
5. Start atorvastatin to lower your cholesterol
6. STart calcium and vitamin D to treat your osteoporosis
7. STart a multivitamin to add to your diet.

Followup Instructions:
CV: A call was made to Dr.[**Name (NI) 39204**] office at [**Location 91435**], [**Numeric Identifier 34093**]
Phone:  ([**Telephone/Fax (1) 20481**]
Please call the office to schedule an appt
{'Subendocardial infarction, initial episode of care,Acute systolic heart failure,Paroxysmal ventricular tachycardia,Acute kidney failure, unspecified,Coronary atherosclerosis of native coronary artery,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other persistent mental disorders due to conditions classified elsewhere,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Osteoporosis, unspecified,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,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: Ventricular tachycardia

PRESENT ILLNESS: 81F with DM2, HTN, history of stroke on plavix, dementia
transferred from [**Hospital1 1516**] for closer monitoring in setting of
possible VTach.  Pt in usual state of health until yesterday.
Some SOB ascending stairs to bed last night, Daughter then heard
gurgling noise and noted pt to be difficult to arouse from
sleep, pt was confused and diaphoretic when awoken - pt stated
she was in "deep sleep".  Of note, clear fluid on shirt and
sheets thought to be from mouth, but reported to not look like
vomit. ? syncope.  EMS called, taken to [**Hospital3 4107**] where
troponin I 0.72, BNP 369, Creatinine 1.6, EKG NSR with sub-mm ST
elevations in III and aVF and reciprocal sub-mm depression in I
and aVL.  CXR with no acute process.  Recieved ASA 324mg and
heparin gtt, transferred to [**Hospital1 18**] for cath.  This am,
experienced 30s run of VT, self-limited.  Now with persistant
tachycardia, EP consulted and not sure if VT vs other
tachyarrhythmia - recommend transfer to CCU for further
monitoring.  Remained asymptommatic throughout.
.
She reports she is comfortable and never had any chest
discomfort or shortness of breath. Per son who accompanies her,
patient has baseline lower extremity edema, 2 pillow orthopnea
that is unchanged, and stable DOE w/ stairs. Has remote history
of fainting.
.
On review of systems, s/he denies any prior history of deep
venous thrombosis, pulmonary embolism, bleeding at the time of
surgery, myalgias, joint pains, cough, hemoptysis, black stools
or red stools. S/he denies recent fevers, chills or rigors. S/he
denies exertional buttock or calf pain. All of the other review
of systems were negative.
.
Cardiac review of systems is notable as above and for absence of
chest pain,  paroxysmal nocturnal dyspnea, palpitations.
.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: +Diabetes, -Dyslipidemia, +Hypertension

MEDICATION ON ADMISSION: Plavix 75 mg daily
Metoprolol Succinate 25 mg daily
Lantus 10 units SC daily
Vitamin B

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS: T= 97.5 BP= 67/50 HR= 123 RR= 21 O2 sat= 97%RA
.
DATE:  GENERAL: NAD. Oriented x2. Appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM, OP clear.
NECK: Supple, no LAD.  JVP minimally elevated above clavicle.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. tachycardic, regular, normal S1, S2. No m/r/g. No thrills,
lifts. no gallop.
LUNGS: Resp were unlabored, no accessory muscle use. bibasilar
wet crackles, no wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.  +BS.
EXTREMITIES: trace bilateral LE edema to ankle, No c/c.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+

FAMILY HISTORY: Unknown

SOCIAL HISTORY: Lives w/ daughter in [**Name (NI) 5110**]. Is from [**Location (un) **] and moved here
many decades ago.  Son is HCP/POA.
-Tobacco history: No current tobacco use. Smoked rarely in
remote past.
-ETOH: None currently. Rare in past.
-Illicit drugs: Never 

### Response:
{'Subendocardial infarction, initial episode of care,Acute systolic heart failure,Paroxysmal ventricular tachycardia,Acute kidney failure, unspecified,Coronary atherosclerosis of native coronary artery,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other persistent mental disorders due to conditions classified elsewhere,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Osteoporosis, unspecified,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Do not resuscitate status'}
