CHIEF COMPLAINT: Atrial Fibrillation, s/p pulmonary vein ablation

PRESENT ILLNESS: 55M Jehovah??????s Witness with a-fib who presented for an elective
a-fib ablation and developed a pericardial effusion association
with transient hypotension during the procedure.  Mr. [**Known lastname 62558**]
carries an 8 yr history of AF, undergoing a previous failed
ablation procedure in [**1-18**].  He is symptomatic almost daily;
most recently he was anticoagulated on coumadin and beta
blockade.  He was admitted for elective repeat a-fib ablation.
After all 4 pulmonary veins were identified and the ablations
were carried out successfully, the BP dropped to 68 systolic and
there arose concern for acute tamponade.  Protamine 15 IV was
given x2 to reverse the heparin.  Bedside echo was performed
which showed pericardial effusion although without evidence of
tamponade.  Mr. [**Known lastname 62558**] was monitored in the CCU for hemodynamic
changes and tamponade physiology.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for palpitations, fatigue,
dyspnea as per HPI. There is the absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope or
presyncope.

MEDICAL HISTORY: Atrial fibrillation
Hematuria in the setting of an elevated INR [**2189**]
Cellulitus [**9-18**]

MEDICATION ON ADMISSION: Toprol XL 100mg [**Hospital1 **]
Coumadin 1.5mg 5 days per week, 1mg 1 day per week, 2mg 1 day
per
week, last dose satuday [**9-24**]
Vitamin C 500mg daily
Vitamin E 400 IU daily
Magnesium and potassium 400mg daily

ALLERGIES: Propafenone

PHYSICAL EXAM: VS: T 97.9  BP 118/77  HR 75   RR 13  100 O2 % on 2L
Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. femoral sheaths in place
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP

FAMILY HISTORY: There is no family history of premature coronary artery disease
or sudden death.

SOCIAL HISTORY: Married and works as a house painter and has 5 children.
Wife will accompany him to the procedure. Patient is a Jehovah??????s
Witness and does not accept blood products.
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.
Atrial fibrillation,Cardiac complications, not elsewhere classified,Acute posthemorrhagic anemia,Unspecified disease of pericardium,Other iatrogenic hypotension
Atrial fibrillation,Surg compl-heart,Ac posthemorrhag anemia,Pericardial disease NOS,Iatrogenc hypotnsion NEC
Admission Date:  [**2191-9-28**]              Discharge Date:   [**2191-10-1**]

Date of Birth:  [**2136-4-10**]             Sex:   M

Service: MEDICINE

Allergies:
Propafenone

Attending:[**Doctor First Name 1402**]
Chief Complaint:
Atrial Fibrillation, s/p pulmonary vein ablation


Major Surgical or Invasive Procedure:
Atrial Fibrillation ablation, pulmonary vein isolation


History of Present Illness:
55M Jehovah??????s Witness with a-fib who presented for an elective
a-fib ablation and developed a pericardial effusion association
with transient hypotension during the procedure.  Mr. [**Known lastname 62558**]
carries an 8 yr history of AF, undergoing a previous failed
ablation procedure in [**1-18**].  He is symptomatic almost daily;
most recently he was anticoagulated on coumadin and beta
blockade.  He was admitted for elective repeat a-fib ablation.
After all 4 pulmonary veins were identified and the ablations
were carried out successfully, the BP dropped to 68 systolic and
there arose concern for acute tamponade.  Protamine 15 IV was
given x2 to reverse the heparin.  Bedside echo was performed
which showed pericardial effusion although without evidence of
tamponade.  Mr. [**Known lastname 62558**] was monitored in the CCU for hemodynamic
changes and tamponade physiology.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for palpitations, fatigue,
dyspnea as per HPI. There is the absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope or
presyncope.

Past Medical History:
Atrial fibrillation
Hematuria in the setting of an elevated INR [**2189**]
Cellulitus [**9-18**]

Social History:
Married and works as a house painter and has 5 children.
Wife will accompany him to the procedure. Patient is a Jehovah??????s
Witness and does not accept blood products.
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.

Family History:
There is no family history of premature coronary artery disease
or sudden death.

Physical Exam:
VS: T 97.9  BP 118/77  HR 75   RR 13  100 O2 % on 2L
Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. femoral sheaths in place
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP

Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP

Pertinent Results:
[**2191-9-28**] 07:25AM BLOOD WBC-6.9 RBC-4.88 Hgb-15.7 Hct-45.1 MCV-92
MCH-32.2* MCHC-34.8 RDW-13.5 Plt Ct-268
[**2191-9-30**] 05:38AM BLOOD WBC-10.5 RBC-3.56* Hgb-11.6* Hct-33.2*
MCV-93 MCH-32.6* MCHC-35.0 RDW-13.4 Plt Ct-152
[**2191-9-30**] 09:15PM BLOOD WBC-11.3* RBC-3.53* Hgb-11.5* Hct-32.9*
MCV-93 MCH-32.5* MCHC-34.9 RDW-13.3 Plt Ct-158
[**2191-10-1**] 07:50AM BLOOD WBC-9.5 RBC-3.61* Hgb-11.7* Hct-33.8*
MCV-94 MCH-32.3* MCHC-34.5 RDW-13.4 Plt Ct-172
[**2191-9-28**] 07:25AM BLOOD Glucose-101 UreaN-22* Creat-1.1 Na-138
K-7.0* Cl-101 HCO3-28 AnGap-16
[**2191-10-1**] 10:39AM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-8.0 Leuks-NEG
.
ECHO [**9-28**]
Left ventricular wall thickness, cavity size, and systolic
function are normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal.
There is a small circumferential pericardial effusion without
evidence of
hemodynamic compromise.
.
ECHO [**9-30**]
Indication: Pericardial effusion.
Height: (in) 70
Weight (lb): 183
BSA (m2): 2.01 m2
BP (mm Hg): 123/60
HR (bpm): 94
Status: Inpatient
Date/Time: [**2191-9-30**] at 08:43
Test: Portable TTE (Complete)
Doppler: Limited Doppler and color Doppler
Contrast: None
Tape Number: 2007W000-0:00
Test Location: West CCU
Technical Quality: Adequate

REFERRING DOCTOR: DR. [**First Name8 (NamePattern2) 251**] [**First Name8 (NamePattern2) 640**] [**Last Name (NamePattern1) **]

INTERPRETATION:

Findings:

This study was compared to the prior study of [**2191-9-29**].

RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (1.5-2.5cm)
with >50%
decrease during respiration (estimated RAP 5-10 mmHg).

LEFT VENTRICLE: Overall normal LVEF (>55%).

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

PERICARDIUM: Small pericardial effusion. No echocardiographic
signs of
tamponade.

Conclusions:
The estimated right atrial pressure is 5-10 mmHg. There is a
small pericardial
effusion. There are no echocardiographic signs of tamponade.




Brief Hospital Course:
55M Jehovah??????s Witness with a-fib who presented for an elective
a-fib ablation and developed a pericardial effusion association
with transient hypotension during the procedure.
.
Brief hospital course is divided by problem:
.
1) Atrial fibrillation
The isolation procedure was successful.  Afterwards the patient
remained in normal sinus rhythm except for frequent premature
atrial contractions.  Metoprolol was titrated up for
antiarrhythmic effect.  He was discharged on a lower dose than
previous to admission: 50 mg toprol q AM and 25 mg toprol q PM.
Coumadin was resumed to prevent thrombosis and stroke subsequent
to intracardiac ablation.  An INR will be checked on Mon [**10-3**]
before his outpt cardiology appt.
.
2) Pericardial effusion
During the end of the ablation procedure the patient was noted
to be hypotensive out of proportion to the isoproterenol
infusion and reactive tachycardia.  A swan was placed
intra-procedure which did not show diastolic equalization of RA
/RV / or PA pressures, however an echo was performed which
showed a pericardial effusion.  He was transferred to the unit
for observation.  No evidence for pericardial tamponade was
noted and within 2 days the effusion began to decrease in size.
The decision was made to not withdraw the remaining pericardial
fluid.  An echo will be performed Monday [**10-3**] as follow up
before outpatient cardiology appt.
.
3) Pericarditis
The night of the procedure Mr. [**Known lastname 62558**] noted positional chest
discomfort.  EKG initially showed no changes but then revealed
PR depression and diffuse ST elevation c/w pericarditis.  Low
grade temperatures were also reported with Tm of 101.6 F.
NSAIDS were not provided given the need for myocyte repair/
healing subsequent to the ablation.  Morphone and tylenol were
provided and by day 3 the pain had almost completely resolved.
.
After the ablation procedure, he remained hemodynamically
stable.  He did have low temperatures which trended down durin
the hospitalization.  His home dose of Toprol was lowered to 50
q AM and 25 q PM.  Coumadin was also reinitiated and an INR will
be checked as well as an echocardiogram prior to his next
appointment.

Medications on Admission:
Toprol XL 100mg [**Hospital1 **]
Coumadin 1.5mg 5 days per week, 1mg 1 day per week, 2mg 1 day
per
week, last dose satuday [**9-24**]
Vitamin C 500mg daily
Vitamin E 400 IU daily
Magnesium and potassium 400mg daily

Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Warfarin 1 mg Tablet Sig: 1.5 Tablets PO once a day: resume
your coumadin dose as it was before hospitalization; 1.5 mg 5
days a week, 1mg 1 day a week, 2 mg 1 day a week.
Disp:*45 Tablet(s)* Refills:*2*
3. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO QAM (once a day
(in the morning)).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
4. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO QPM (once a day
(in the evening)).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
5. Outpatient Lab Work
INR check
6. Echocardiogram
Echocardiogram, to evaluate pericardial effusion


Discharge Disposition:
Home

Discharge Diagnosis:
Pericarditis
Pericardial effusion
Atrial Fibrillation


Discharge Condition:
good


Discharge Instructions:
You were admitted to the hospital for ablation of atrial
fibrillation.  You were monitored in the cardiac care unit
afterwards for low blood pressure in the setting of fluid
surrounding your heart.  Afterwards you also had pericarditis
(inflammation of the fluid and tissue surrounding the heart)
which was treated with tylenol for pain.  You should continue to
take coumadin (warfarin) to thin your blood.  You will need your
blood checked (INR) by monday for your appointment with Dr.
[**Last Name (STitle) 12246**].  You should also continue
toprol XL, but at a new dose.  Take 50 mg Toprol Xl in the AM
and 25 mg Toprol Xl in the PM.

Followup Instructions:
Get your INR checked and get an echocardiogram on Monday [**10-3**]
for your appointment with Dr. [**Last Name (STitle) 12246**].  Call Dr.[**Last Name (un) 62559**]
office first thing Monday morning to schedule both the Echo and
INR check.
{'Atrial fibrillation,Cardiac complications, not elsewhere classified,Acute posthemorrhagic anemia,Unspecified disease of pericardium,Other iatrogenic hypotension'}


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 pulmonary vein ablation

PRESENT ILLNESS: 55M Jehovah??????s Witness with a-fib who presented for an elective
a-fib ablation and developed a pericardial effusion association
with transient hypotension during the procedure.  Mr. [**Known lastname 62558**]
carries an 8 yr history of AF, undergoing a previous failed
ablation procedure in [**1-18**].  He is symptomatic almost daily;
most recently he was anticoagulated on coumadin and beta
blockade.  He was admitted for elective repeat a-fib ablation.
After all 4 pulmonary veins were identified and the ablations
were carried out successfully, the BP dropped to 68 systolic and
there arose concern for acute tamponade.  Protamine 15 IV was
given x2 to reverse the heparin.  Bedside echo was performed
which showed pericardial effusion although without evidence of
tamponade.  Mr. [**Known lastname 62558**] was monitored in the CCU for hemodynamic
changes and tamponade physiology.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for palpitations, fatigue,
dyspnea as per HPI. There is the absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope or
presyncope.

MEDICAL HISTORY: Atrial fibrillation
Hematuria in the setting of an elevated INR [**2189**]
Cellulitus [**9-18**]

MEDICATION ON ADMISSION: Toprol XL 100mg [**Hospital1 **]
Coumadin 1.5mg 5 days per week, 1mg 1 day per week, 2mg 1 day
per
week, last dose satuday [**9-24**]
Vitamin C 500mg daily
Vitamin E 400 IU daily
Magnesium and potassium 400mg daily

ALLERGIES: Propafenone

PHYSICAL EXAM: VS: T 97.9  BP 118/77  HR 75   RR 13  100 O2 % on 2L
Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. femoral sheaths in place
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP

FAMILY HISTORY: There is no family history of premature coronary artery disease
or sudden death.

SOCIAL HISTORY: Married and works as a house painter and has 5 children.
Wife will accompany him to the procedure. Patient is a Jehovah??????s
Witness and does not accept blood products.
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. 

### Response:
{'Atrial fibrillation,Cardiac complications, not elsewhere classified,Acute posthemorrhagic anemia,Unspecified disease of pericardium,Other iatrogenic hypotension'}
