CHIEF COMPLAINT: palpitations x1 week

PRESENT ILLNESS: 62 yo male with history of atrial fibrillation on Coumadin
presenting with palpitations for one week. He reports being on
amiodarone through [**Month (only) 404**] of this year, but then stopping it
until the past three weeks. Three weeks ago, he resumed his
prior amiodarone dose of 200mg daily. He reports one week of
palpitations, DOE, and diaphoresis with any exertion. He
eventually presented to the ED with presyncope and diffuse
weakness. In addition, he reports one episode of left sided
nonradiating chest pain that was self limited after last 10
minutes. He reports PND without orthopnea. He also reports a
ferocious appetite without any weight gain.
.
Returning to [**Hospital1 614**] on Friday, and has a follow up
appointment with his cardiologist next Monday. He reports being
followed in a coumadin clinic, but notes his last INR was 1.1 on
[**1-26**], at which point they kept his dose at 5mg.
.
In the ED, Initial Vitals: 98.3 78 129/88 16 100% RA
- EKG: Likely atrial fibrillation RVR versus atrial flutter
- Portable chest x-ray was done
- Diltiazem 20 mg IV was given then he was loaded with 60 po
dilt.
- Labs including troponin
- Chest pain resolved
- Cardiology consulted: Recommended TEE cardioversion tomorrow.
For tonight start heparin without bolus and double up on the
evening Coumadin.
Most recent vitals prior to transfer: 110, 125/85, 18, 98% on 2
L NC
.
Currently, he feels well, but is tired from a long day. He
denies any current CP or SOB.
.
REVIEW OF SYSTEMS:
Positive for Chronic Low back pain
He denies any fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, abdominal pain,
nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.

MEDICAL HISTORY: Paroxysmal Afib s/p prior cardioversion, on warfarin and
amiodarone
sCHF with EF 35-40%
HTN
Hypertensive Cardiomyopathy

MEDICATION ON ADMISSION: Warfarin 5mg daily
Diltiazem 30mg tid
Amiodarone 200mg daily
lasix 40mg [**Hospital1 **]
spironolactone 25mg daily
carvedilol 6.25mg [**Hospital1 **]
rosuvastatin 20mg qhs

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS - 97.5 149/91 108 20 100% on RA 116.3kg
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, JVP at 6mmHg, no carotid bruits
HEART - PMI non-displaced, irregularly tachycardic, slight [**12-26**]
murmur at apex
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - +BS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, 1+ bilateral LE edema, 2+ peripheral pulses
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**3-25**] throughout, steady gait

FAMILY HISTORY: Not reviewed.

SOCIAL HISTORY: Doesn't smoke, quit 3-4 months ago, used to smoke 1 pack over 4
days for 35 years. Occaisional EtOH, no drug use. Lives alone,
fully independent, drives, works as a high school teacher in the
culinary arts. Lives in [**Hospital1 614**], visiting his mother with his
family in the [**Name (NI) 86**] area.
Atrial flutter,Chronic systolic heart failure,Cardiac complications, not elsewhere classified,Unspecified hypertensive heart disease with heart failure,Cardiomyopathy in other diseases classified elsewhere,Long-term (current) use of anticoagulants,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Atrial flutter,Chr systolic hrt failure,Surg compl-heart,Hyp ht dis NOS w ht fail,Cardiomyopath in oth dis,Long-term use anticoagul,Abn react-procedure NEC
Admission Date:  [**2130-2-20**]              Discharge Date:   [**2130-2-23**]

Date of Birth:  [**2067-7-22**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
palpitations x1 week

Major Surgical or Invasive Procedure:
Cardioversion for Aflutter


History of Present Illness:
62 yo male with history of atrial fibrillation on Coumadin
presenting with palpitations for one week. He reports being on
amiodarone through [**Month (only) 404**] of this year, but then stopping it
until the past three weeks. Three weeks ago, he resumed his
prior amiodarone dose of 200mg daily. He reports one week of
palpitations, DOE, and diaphoresis with any exertion. He
eventually presented to the ED with presyncope and diffuse
weakness. In addition, he reports one episode of left sided
nonradiating chest pain that was self limited after last 10
minutes. He reports PND without orthopnea. He also reports a
ferocious appetite without any weight gain.
.
Returning to [**Hospital1 614**] on Friday, and has a follow up
appointment with his cardiologist next Monday. He reports being
followed in a coumadin clinic, but notes his last INR was 1.1 on
[**1-26**], at which point they kept his dose at 5mg.
.
In the ED, Initial Vitals: 98.3 78 129/88 16 100% RA
- EKG: Likely atrial fibrillation RVR versus atrial flutter
- Portable chest x-ray was done
- Diltiazem 20 mg IV was given then he was loaded with 60 po
dilt.
- Labs including troponin
- Chest pain resolved
- Cardiology consulted: Recommended TEE cardioversion tomorrow.
For tonight start heparin without bolus and double up on the
evening Coumadin.
Most recent vitals prior to transfer: 110, 125/85, 18, 98% on 2
L NC
.
Currently, he feels well, but is tired from a long day. He
denies any current CP or SOB.
.
REVIEW OF SYSTEMS:
Positive for Chronic Low back pain
He denies any fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, abdominal pain,
nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.


Past Medical History:
Paroxysmal Afib s/p prior cardioversion, on warfarin and
amiodarone
sCHF with EF 35-40%
HTN
Hypertensive Cardiomyopathy

Social History:
Doesn't smoke, quit 3-4 months ago, used to smoke 1 pack over 4
days for 35 years. Occaisional EtOH, no drug use. Lives alone,
fully independent, drives, works as a high school teacher in the
culinary arts. Lives in [**Hospital1 614**], visiting his mother with his
family in the [**Name (NI) 86**] area.

Family History:
Not reviewed.

Physical Exam:
 VS - 97.5 149/91 108 20 100% on RA 116.3kg
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, JVP at 6mmHg, no carotid bruits
HEART - PMI non-displaced, irregularly tachycardic, slight [**12-26**]
murmur at apex
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - +BS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, 1+ bilateral LE edema, 2+ peripheral pulses
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**3-25**] throughout, steady gait

DISCHARGE EXAM:
VSS, BP 135/70, HR 75
Gen: AOx3
Heart: RRR, widely split S2, 2/6 systolic murmur at apex with
radiation into axilla
Lungs: CTAB

Pertinent Results:
ADMISSION LABS

[**2130-2-20**] 07:45PM BLOOD WBC-10.2 RBC-5.22 Hgb-13.0* Hct-44.8
MCV-86 MCH-25.0* MCHC-29.1* RDW-15.8* Plt Ct-268
[**2130-2-20**] 07:45PM BLOOD Neuts-61.8 Lymphs-30.9 Monos-3.4 Eos-3.1
Baso-0.8
[**2130-2-20**] 07:45PM BLOOD PT-15.6* PTT-35.6 INR(PT)-1.5*
[**2130-2-20**] 07:45PM BLOOD Glucose-111* UreaN-31* Creat-1.5* Na-139
K-4.4 Cl-100 HCO3-28 AnGap-15
[**2130-2-22**] 06:15AM BLOOD ALT-39 AST-38 AlkPhos-146* TotBili-0.7
[**2130-2-21**] 06:30PM BLOOD Lipase-20
[**2130-2-20**] 07:45PM BLOOD proBNP-1803*
[**2130-2-20**] 07:45PM BLOOD cTropnT-<0.01
[**2130-2-21**] 07:15AM BLOOD CK-MB-5 cTropnT-<0.01
[**2130-2-21**] 06:30PM BLOOD CK-MB-4 cTropnT-<0.01
[**2130-2-20**] 07:45PM BLOOD Calcium-9.9 Phos-4.0 Mg-2.3
[**2130-2-20**] 08:05PM BLOOD Lactate-1.6

DISCHARGE LABS:

[**2130-2-23**] 06:15AM BLOOD WBC-8.9 RBC-5.03 Hgb-12.8* Hct-42.5
MCV-85 MCH-25.4* MCHC-30.0* RDW-16.2* Plt Ct-195
[**2130-2-23**] 06:15AM BLOOD PT-22.0* PTT-77.2* INR(PT)-2.1*
[**2130-2-23**] 06:15AM BLOOD Glucose-113* UreaN-38* Creat-1.7* Na-138
K-4.3 Cl-101 HCO3-29 AnGap-12
[**2130-2-23**] 06:15AM BLOOD Calcium-9.2 Phos-3.9 Mg-2.4
[**2130-2-21**] 02:55AM BLOOD %HbA1c-6.4* eAG-137*
[**2130-2-20**] 07:45PM BLOOD TSH-5.5*
[**2130-2-21**] 06:30PM BLOOD Free T4-1.6

===================
EKG: There appears to be atrial flutter with variable block.
Intraventricular conduction delay. Non-specific ST-T wave
changes. No previous tracing available for comparison.
===================
TTE:
The left atrium is mildly dilated. The right atrium is markedly
dilated. No atrial septal defect is seen by 2D or color Doppler.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is moderately dilated. There is severe global
left ventricular hypokinesis (LVEF = 25 %). No masses or thrombi
are seen in the left ventricle. There is no ventricular septal
defect. The right ventricular cavity is moderately dilated with
moderate global free wall hypokinesis. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Moderate
(2+) mitral regurgitation is seen. The left ventricular inflow
pattern suggests a restrictive filling abnormality, with
elevated left atrial pressure. The tricuspid valve leaflets are
mildly thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
=====================
CXR:
Cardiomegaly is substantial, unchanged. Mediastinum is
unremarkable. Lungs are essentially clear with no evidence of
pulmonary edema or increased in pleural effusion. Pneumothorax
is not seen.


Brief Hospital Course:
62 yo M with hypetensive cardiomyopathy presented with dyspnea
on exertion, found to be in aflutter, cardioverted but course
complicated by myocardial stunning.
.
1. Atrial Flutter: The patient was cardioverted out of atrial
flutter into NSR after a TEE did not demonstrate intra-atrial
clot. Post-procedure, the patient developed hypotension and
bradycardia requiring atropine and dopamine for pressor support.
 This likely developed in the setting of anesthesia, and
multiple medications given during his rapid ventricular rate
(diltizem and beta blockers).  Additionally, the patient
developed a similar reaction while cardioverted in the past.  In
the CCU, the patient was gradually weaned off dopamine. He
remained in sinus with a short run of NSVT noted on telemetry
overnight.  It was recommended that the patient's primary
cardiologist in [**Hospital1 614**] consider ablation to prevent future
episodes of atrial flutter.  Additionally, amiodarone was
recommended at 200mg daily.  The patient did not exhibit signs
of heart failure. The patient will need to remain on coumadin
for at least 1 month after cardioversion.
.
2. Hypertensive Chronic Systolic Failure: TTE here showed
moderate MR, global LV hypokinesis, and an EF 25-35%. The
patient had previously been on lasix 40mg [**Hospital1 **], diltiazem,
spironolactone, and coreg. These medications were held in the
setting od the patient's recent hypotension and bradycardia. The
patient should be restarted on these medications as an
outpatient. Also, the patient should be started on an ACEI if
indicated as determined by the patient's PCP/Cardiologist.
.
3. Elevated Glucose: A1C of 6.4% on admission labs. This should
be followed as an outpatient.
.
TRANSITIONAL ISSUES:
- Adjust patient's HF medications. These were held on discharge
due to recent hypotension.
- Add an ACEI
- Establish cardiology follow-up
- Control sugars
- Discuss role for aflutter ablation in the near future

Medications on Admission:
Warfarin 5mg daily
Diltiazem 30mg tid
Amiodarone 200mg daily
lasix 40mg [**Hospital1 **]
spironolactone 25mg daily
carvedilol 6.25mg [**Hospital1 **]
rosuvastatin 20mg qhs

Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
5. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for weight gain: If your weight is increasing, please
take 1 tab [**Hospital1 **] and [**Name6 (MD) 138**] your MD. .
6. Outpatient Lab Work
INR bloodwork needs to be drawn on Monday [**2-27**]


Discharge Disposition:
Home

Discharge Diagnosis:
Atrial Flutter with Variable Conduction
Non-Ischemic Chronic Systolic Heart Failure
Myocardidal Stunning after cardioversion


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
You were admitted to the hospital because you felt shortness of
breath and fatigue. In the ED, we found that you had a fast
heart rate. In order to help you feel better, we performed a
procedure called a cardioversion after ensuring that there were
no blood clots in the heart. After the procedure, you had some
stunning of the heart muscle, which required a quick stay in the
ICU for monitoring. Your heart muscle recovered and your Blood
pressure and heart rate returned to [**Location 213**]. You now have a
normal heart rhythm as well. Please follow-up with your
cardiologist in [**Hospital1 614**] on Monday. You should also have your
coumadin level checked on Monday as well. This is very important
to ensure that you do not have a stroke.
.
MEDICATION CHANGES INCLUDE:
HOLD Carvedilol, Spironolactone, and Diltiazem (These will need
to be restarted as an outpatient)
TAKE Lasix 40mg one-two times per day as needed for weight gain
(Please weigh yourself every day and take lasix if your weight
is going up by [**11-22**] pounds)
TAKE aspirin 81mg once a day by mouth
SAME: No change to Warfarin, Amiodarone, and Crestor

Followup Instructions:
Dr. [**Last Name (STitle) **] [**Name (STitle) 1256**] [**Hospital 15866**] Hospital [**Telephone/Fax (1) 15867**]. Please make sure that
you follow-up with this cardiologist on Monday and also have
your INR checked as well.

Weigh yourself everyday. Eat a low salt diet.
{'Atrial flutter,Chronic systolic heart failure,Cardiac complications, not elsewhere classified,Unspecified hypertensive heart disease with heart failure,Cardiomyopathy in other diseases classified elsewhere,Long-term (current) use of anticoagulants,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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: palpitations x1 week

PRESENT ILLNESS: 62 yo male with history of atrial fibrillation on Coumadin
presenting with palpitations for one week. He reports being on
amiodarone through [**Month (only) 404**] of this year, but then stopping it
until the past three weeks. Three weeks ago, he resumed his
prior amiodarone dose of 200mg daily. He reports one week of
palpitations, DOE, and diaphoresis with any exertion. He
eventually presented to the ED with presyncope and diffuse
weakness. In addition, he reports one episode of left sided
nonradiating chest pain that was self limited after last 10
minutes. He reports PND without orthopnea. He also reports a
ferocious appetite without any weight gain.
.
Returning to [**Hospital1 614**] on Friday, and has a follow up
appointment with his cardiologist next Monday. He reports being
followed in a coumadin clinic, but notes his last INR was 1.1 on
[**1-26**], at which point they kept his dose at 5mg.
.
In the ED, Initial Vitals: 98.3 78 129/88 16 100% RA
- EKG: Likely atrial fibrillation RVR versus atrial flutter
- Portable chest x-ray was done
- Diltiazem 20 mg IV was given then he was loaded with 60 po
dilt.
- Labs including troponin
- Chest pain resolved
- Cardiology consulted: Recommended TEE cardioversion tomorrow.
For tonight start heparin without bolus and double up on the
evening Coumadin.
Most recent vitals prior to transfer: 110, 125/85, 18, 98% on 2
L NC
.
Currently, he feels well, but is tired from a long day. He
denies any current CP or SOB.
.
REVIEW OF SYSTEMS:
Positive for Chronic Low back pain
He denies any fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, abdominal pain,
nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.

MEDICAL HISTORY: Paroxysmal Afib s/p prior cardioversion, on warfarin and
amiodarone
sCHF with EF 35-40%
HTN
Hypertensive Cardiomyopathy

MEDICATION ON ADMISSION: Warfarin 5mg daily
Diltiazem 30mg tid
Amiodarone 200mg daily
lasix 40mg [**Hospital1 **]
spironolactone 25mg daily
carvedilol 6.25mg [**Hospital1 **]
rosuvastatin 20mg qhs

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS - 97.5 149/91 108 20 100% on RA 116.3kg
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, JVP at 6mmHg, no carotid bruits
HEART - PMI non-displaced, irregularly tachycardic, slight [**12-26**]
murmur at apex
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - +BS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, 1+ bilateral LE edema, 2+ peripheral pulses
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**3-25**] throughout, steady gait

FAMILY HISTORY: Not reviewed.

SOCIAL HISTORY: Doesn't smoke, quit 3-4 months ago, used to smoke 1 pack over 4
days for 35 years. Occaisional EtOH, no drug use. Lives alone,
fully independent, drives, works as a high school teacher in the
culinary arts. Lives in [**Hospital1 614**], visiting his mother with his
family in the [**Name (NI) 86**] area. 

### Response:
{'Atrial flutter,Chronic systolic heart failure,Cardiac complications, not elsewhere classified,Unspecified hypertensive heart disease with heart failure,Cardiomyopathy in other diseases classified elsewhere,Long-term (current) use of anticoagulants,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
