CHIEF COMPLAINT: Bradycardia

PRESENT ILLNESS: This 88 yo male with a history of CAD presented after a syncopal
episode. He was sitting outside on his porch when he felt warm
and came inside to sit in his lounge chair. The next thing he
remembers is being awakened by his wife shaking him. She had
called 911 and they brought him here for evaluation. He was not
feeling lightheaded before this episode although he does note
that he has been a little lightheaded in the mornings on and
off. He had no evidence of seizure and awoke without any
lethargy after the episode. He has never had an episode like
this in the past. He has generally been feeling well prior to
this with no fevers or chills. He is followed closely by his PCP
[**Last Name (NamePattern4) **]. [**First Name (STitle) 1395**] who he last saw 4-5 months ago, he last saw his
cardiologist Dr. [**Last Name (STitle) **] 6 months ago. He says his heart rate is
generally 51-59.
.
In the ED his vitals were; Temp 93.2, Pulse 60s, BP 158/88, RR
20, 100% on 6L. In the ED pacer pads were placed and 4mg Zofran
was given.
.
He generally feels well with no chest pain, shortness of breath,
palpitations. His one complaint is hot flashes since his
testicular operation.
.

MEDICAL HISTORY: 1. Glaucoma - completely blind
2. CAD s/p 4 heart catheterizations, no stents or heart surgery

MEDICATION ON ADMISSION: Cosopt 2%-0/5% Eye Drops
Restasis 0.05% Eye Drops
Pilocarpine eye drops
Acyclovir Ointment
Lopressor 125mg PO daily
Aspirin 81 mg
Flomax 0.4mg oral
.

ALLERGIES: Penicillins

PHYSICAL EXAM: VS - Temp 92.8, Pulse 46, BP 157/58, RR 16, 100% on 3L
Gen: alert middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: His mother died of an MI at 81, his brother died of an MI at 41,
his father died at 51 of a pneumonia.

SOCIAL HISTORY: He used to smoke one pack per day, he quit 45 years ago. He
lives with his wife, he used to work as a manager for a
manufacturing plant. He rarely has wine
.
Other specified cardiac dysrhythmias,Hematoma complicating a procedure,Hemorrhage of gastrointestinal tract, unspecified,Coronary atherosclerosis of native coronary artery,Unspecified glaucoma,Profound impairment, both eyes, impairment level not further specified,Other left bundle branch block,Mitral valve disorders,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation
Cardiac dysrhythmias NEC,Hematoma complic proc,Gastrointest hemorr NOS,Crnry athrscl natve vssl,Glaucoma NOS,Both eyes blind-who def,Left bb block NEC,Mitral valve disorder,Abn react-artif implant
Admission Date:  [**2103-6-22**]              Discharge Date:   [**2103-6-28**]


Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 4071**]
Chief Complaint:
Bradycardia

Major Surgical or Invasive Procedure:
Pacemaker placement


History of Present Illness:
This 88 yo male with a history of CAD presented after a syncopal
episode. He was sitting outside on his porch when he felt warm
and came inside to sit in his lounge chair. The next thing he
remembers is being awakened by his wife shaking him. She had
called 911 and they brought him here for evaluation. He was not
feeling lightheaded before this episode although he does note
that he has been a little lightheaded in the mornings on and
off. He had no evidence of seizure and awoke without any
lethargy after the episode. He has never had an episode like
this in the past. He has generally been feeling well prior to
this with no fevers or chills. He is followed closely by his PCP
[**Last Name (NamePattern4) **]. [**First Name (STitle) 1395**] who he last saw 4-5 months ago, he last saw his
cardiologist Dr. [**Last Name (STitle) **] 6 months ago. He says his heart rate is
generally 51-59.
.
In the ED his vitals were; Temp 93.2, Pulse 60s, BP 158/88, RR
20, 100% on 6L. In the ED pacer pads were placed and 4mg Zofran
was given.
.
He generally feels well with no chest pain, shortness of breath,
palpitations. His one complaint is hot flashes since his
testicular operation.
.


Past Medical History:
1. Glaucoma - completely blind
2. CAD s/p 4 heart catheterizations, no stents or heart surgery

3. Prostate cancer for which he has never had a positive biopsy
but was treated with orchiectomy 4 years ago. No prostate
surgery or radiation.
4. Hemorrhoids
5. "Immune deficiency" diagnosed at [**Hospital 13128**].
.


Social History:
He used to smoke one pack per day, he quit 45 years ago. He
lives with his wife, he used to work as a manager for a
manufacturing plant. He rarely has wine
.


Family History:
His mother died of an MI at 81, his brother died of an MI at 41,
his father died at 51 of a pneumonia.

Physical Exam:
VS - Temp 92.8, Pulse 46, BP 157/58, RR 16, 100% on 3L
Gen: alert middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

Neck: Supple with JVP of 5 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
Bradycardic, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.


Pertinent Results:
EKG demonstrated left bundle branch block, sinus bradycardia at
60, 1st degree AV block, no old to compare.
.
Labs:
[**2103-6-22**] 04:30PM BLOOD WBC-6.3 RBC-4.14* Hgb-14.1 Hct-41.9
MCV-101* MCH-34.0* MCHC-33.5 RDW-13.5 Plt Ct-208
[**2103-6-22**] 04:30PM BLOOD Neuts-67.9 Lymphs-22.3 Monos-4.4 Eos-4.9*
Baso-0.5
[**2103-6-22**] 04:30PM BLOOD Plt Ct-208
[**2103-6-22**] 04:30PM BLOOD PT-11.6 PTT-29.5 INR(PT)-1.0
[**2103-6-22**] 04:30PM BLOOD Glucose-124* UreaN-11 Creat-0.7 Na-141
K-4.3 Cl-107 HCO3-23 AnGap-15
[**2103-6-22**] 04:30PM BLOOD Calcium-9.4 Phos-4.2 Mg-2.0
[**2103-6-23**] 09:20AM BLOOD TSH-3.0
[**2103-6-22**] 04:30PM BLOOD CK(CPK)-36*
[**2103-6-23**] 12:30AM BLOOD CK(CPK)-38
[**2103-6-23**] 09:20AM BLOOD CK(CPK)-48
[**2103-6-22**] 04:30PM BLOOD cTropnT-<0.01
[**2103-6-23**] 12:30AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2103-6-23**] 09:20AM BLOOD CK-MB-NotDone cTropnT-<0.01
.
CHEST (PORTABLE AP) [**2103-6-22**]:
Single bedside AP examination labeled "semi-erect at 1715 PM"
with
excessive lordotic positioning and no comparisons on record.
Allowing for the factors above, as well as low lung volumes with
elevation of the right
hemidiaphragm, the lungs are grossly clear. There is prominence
of the right paratracheal soft tissues which may represent
ectatic brachiocephalic vessels, as the aorta appears tortuous;
the cardiomediastinal silhouette is otherwise unremarkable with
no evidence of CHF.
.
TTE [**2103-6-26**]:
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. There is mild global left ventricular
hypokinesis. Overall left ventricular systolic function is
mildly depressed (LVEF= 45-50 %). Right ventricular chamber size
and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. There is no aortic valve stenosis.
Mild (1+) aortic regurgitation is seen. Moderate (2+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. The pulmonary artery systolic
pressure could not be determined. There is an anterior space
which most likely represents a fat pad.
IMPRESSION: Suboptimal quality. Mildly depressed global left
ventricular systolic function. Mild aortic regurgitation.
Moderate mitral regurgitation.
.
CT HEAD W/O CONTRAST [**2103-6-27**]:
There is no hemorrhage, edema, mass effect, or
shift of normally midline structures. Detection of a mass is
limited given
the lack of IV contrast administration and slight patient
motion. There is
periventricular hypoattenuation consistent with chronic small
vessel ischemic
disease. The ventricles and sulci are prominent, related to
age-expected
parenchymal atrophy. Incidental note is made of a left scleral
band. The
visualized paranasal sinuses are clear.
IMPRESSION:
1. No hemorrhage, edema, or mass effect.
2. Chronic small vessel ischemic disease and age-related
parenchymal atrophy.
.
CHEST (PA & LAT) [**2103-6-27**]:
The pacemaker leads terminate in right atrium and right
ventricle. The
cardiomediastinal silhouette is stable. The lungs are clear.
There is no
pleural effusion or pneumothorax.
IMPRESSION: Standard position of the pacemaker leads. No
evidence of
complications.
.

Brief Hospital Course:
Patient is a 88 year old gentleman who was admitted with
syncopal episode and bradycardia.
.
#. Syncope/Rhythm: His syncopal episode is likely related to his
bradycardia/complete heart block.  He was admitted with sinus
bradycardia, first degree AV block and left bundle branch block.
No evidence of seizure activity.  He was ruled out for
myocardial Infarction with negative cardiac enzymes.  His
metoprolol was discontinued.  His TSH was 3.  Patient went into
complete heart block with escape rhythm to high teens on
[**2103-6-25**].  He received a total of atropine 2.5 mg IV.  His
systolic blood pressure decreased from 100s to 70s.  He was
started on dopamine drip with heart rate increased to 90s.
Temporary pacing wire was placed through right femoral approach
but patient did not require pacing.  Patient was transfered to
CCU.  He received a pacemaker on [**6-26**]. His metoprolol was
restarted at low dose 25 mg twice a day given questionable
history of tachycardia. Patient had small pocket hematoma which
was stable at discharge.  He received 3 doses of IV vancomycin
periprocedure.  His antibiotic was switched to clindamycin for 5
days on discharge given penicllin allergy.  Patient was
recommended rehabilition facility by physical therapy but he
refused.  Physical therapy worked with him for two session while
in hospital.  He will go home with VNA and home physical therapy
services.
.
#. Pump: He did not have signs/symptoms of heart failure.
Transthoracic echocardiogram showed mild systolic dysfunction
(LVEF 45-50%), diastolic dysfunction and moderate mitral
regurgitation.  Patient was started on low dose lisinopril 5 mg
daily and tolerated this well.  Metoprolol as above.
.
#. Increased bowel movements: Patient experienced increased
bowel movements after getting milk of magnesia for acid reflux
symptoms on day after admission. This resolved with
discontinuing milk of magnesia.
.
#. GI Bleed: Patient had 1 episode of hematemesis on [**2103-6-25**]. He
was otherwise asymptomatic during event and denies any abdominal
pain or discomfort. He was started on IV pantoprazole twice a
day.  He has had occasional guaic positive stools in his stay
here.  His hematocrit was stable during this stay. He was
recommended discussing colonscopy as out patient with his
primary care provider.  [**Name10 (NameIs) **] will be discharged on pantoprazole 40
mg daily.
.
#. Blindness: He was continued on home eye drops.  Pilocarpine
drops were transiently held prior to pacemaker palcement.
.
# Patient received subcutaneous heparin for DVT prophylaxis.
.
#. Contact: Pt prefers that his daughter [**Name (NI) **] [**Name (NI) 78620**], who
lives in RI, be the contact person. [**Name2 (NI) **] cell [**Telephone/Fax (1) 78621**]; work
[**Telephone/Fax (1) 78622**]. Alternative contact is his wife, [**Name (NI) 78623**], who has
Parkinsons [**Telephone/Fax (1) 78624**].
.

Medications on Admission:
Cosopt 2%-0/5% Eye Drops
Restasis 0.05% Eye Drops
Pilocarpine eye drops
Acyclovir Ointment
Lopressor 125mg PO daily
Aspirin 81 mg
Flomax 0.4mg oral
.


Discharge Medications:
1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
4. Cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette
Ophthalmic [**Hospital1 **] (2 times a day).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Pilocarpine HCl 0.5 % Drops Sig: One (1)  Ophthalmic once a
day.
8. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO three
times a day for 5 days.
Disp:*15 Capsule(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services

Discharge Diagnosis:
Primary:
Sinus bradycardia
Episode of complete heart block with escape rhythm status post
pacemaker placement
Moderate Mitral Regurgitation
Occasional guaic positive stool
.
Secondary:
Coronary artery disease
Glaucoma


Discharge Condition:
Asymptomatic and hemodynamically stable.


Discharge Instructions:
You were admitted to [**Hospital1 69**] after
passing out.  Your symptoms are most likely due to abnormal
electrical conduction in your heart called complete heart block.
 You had a pacemaker placed.
.
Please take all of the medicaitons as written.  Your metoprolol
was reduced to 25 mg twice a day.  You were started on
lisinopril 5 mg daily.  You were started on antibiotic called
clindamycin three times a day for 5 days to prevent infection
around your pacemaker site.  You were started on pantoprazole 40
mg daily.
.
Please keep all of the follow up appointments.
.
If you develop chest pain, shortness of breath or any other
concerning symptoms, please call your primary care doctor or
come to the Emergency Department.
.
It was recommended that you go to a rehabilitation facility to
improve your function.  You refused to go there and wanted to go
home.  It was also recommended that you stay in hospital to get
2 to 3 more physical therapy session.  You also refused to stay
and wanted to go home.  You understood the risks and benefits of
going home against this advise.

Followup Instructions:
Cardiology follow up:
Dr.[**Last Name (STitle) **] was notified regarding your stay here.  He asked you
to call him next Monday [**7-2**] to schedule a follow up
appointment.  His telephone number is [**Telephone/Fax (1) 78625**].
.
Device Clinic follow up (electrophysiology):
Provider:  [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2103-7-5**]
10:30
.
Primary Care follow up:
Dr. [**First Name4 (NamePattern1) 487**] [**Last Name (NamePattern1) **] office will call you on Monday [**7-2**] to
let you know the date and time of your follow up appointment.
If you do not hear from them, please call [**Telephone/Fax (1) 78626**] to find
the date and time.  Please discuss getting an outpatient
colonscopy with your primary care doctor.


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4074**]

Completed by:[**2103-6-29**]
{'Other specified cardiac dysrhythmias,Hematoma complicating a procedure,Hemorrhage of gastrointestinal tract, unspecified,Coronary atherosclerosis of native coronary artery,Unspecified glaucoma,Profound impairment, both eyes, impairment level not further specified,Other left bundle branch block,Mitral valve disorders,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation'}


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: Bradycardia

PRESENT ILLNESS: This 88 yo male with a history of CAD presented after a syncopal
episode. He was sitting outside on his porch when he felt warm
and came inside to sit in his lounge chair. The next thing he
remembers is being awakened by his wife shaking him. She had
called 911 and they brought him here for evaluation. He was not
feeling lightheaded before this episode although he does note
that he has been a little lightheaded in the mornings on and
off. He had no evidence of seizure and awoke without any
lethargy after the episode. He has never had an episode like
this in the past. He has generally been feeling well prior to
this with no fevers or chills. He is followed closely by his PCP
[**Last Name (NamePattern4) **]. [**First Name (STitle) 1395**] who he last saw 4-5 months ago, he last saw his
cardiologist Dr. [**Last Name (STitle) **] 6 months ago. He says his heart rate is
generally 51-59.
.
In the ED his vitals were; Temp 93.2, Pulse 60s, BP 158/88, RR
20, 100% on 6L. In the ED pacer pads were placed and 4mg Zofran
was given.
.
He generally feels well with no chest pain, shortness of breath,
palpitations. His one complaint is hot flashes since his
testicular operation.
.

MEDICAL HISTORY: 1. Glaucoma - completely blind
2. CAD s/p 4 heart catheterizations, no stents or heart surgery

MEDICATION ON ADMISSION: Cosopt 2%-0/5% Eye Drops
Restasis 0.05% Eye Drops
Pilocarpine eye drops
Acyclovir Ointment
Lopressor 125mg PO daily
Aspirin 81 mg
Flomax 0.4mg oral
.

ALLERGIES: Penicillins

PHYSICAL EXAM: VS - Temp 92.8, Pulse 46, BP 157/58, RR 16, 100% on 3L
Gen: alert middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: His mother died of an MI at 81, his brother died of an MI at 41,
his father died at 51 of a pneumonia.

SOCIAL HISTORY: He used to smoke one pack per day, he quit 45 years ago. He
lives with his wife, he used to work as a manager for a
manufacturing plant. He rarely has wine
. 

### Response:
{'Other specified cardiac dysrhythmias,Hematoma complicating a procedure,Hemorrhage of gastrointestinal tract, unspecified,Coronary atherosclerosis of native coronary artery,Unspecified glaucoma,Profound impairment, both eyes, impairment level not further specified,Other left bundle branch block,Mitral valve disorders,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation'}
