CHIEF COMPLAINT: Lightheadedness, slow pulse

PRESENT ILLNESS: Dr. [**Known lastname 3339**] is a 60 yoM with a history of myxomatous mitral
valve disease s/p annuloplasty '[**98**], paroxysmal atrial
fibrillation currently on Dronedarone and Coumadin, h/o
postoperative NSVT s/p ICD placement, and h/o nondilated
cardiomyopathy with EF  who presents with lightheadedness and
near-syncope in the context of recent undefined illness and
weight loss.
.
Pt reports history of 25lb weight loss in the past 6 weeks that
he attributes to losing his sense of taste due to his
Parkinson's meds. He denies any further focal symptoms during
this time frame. Then, today he was not feeling well while at
work in the ED here at [**Hospital1 18**]. He had been feeling lightheaded
all day. He went home then relates that he was laying on the
couch watching TV with his daughter and may have passed out for
some time, the only thing he remembers is his daughter waking
him up. He is unsure if he actually lost consciousness or not. A
family member took his pulse and found him to be in the 20's, so
brought him to the ED.
.
There his vitals were hr 31, 110/68, 18, 100% RA. He was found
to have elevated INR, hypokalemic and repleted. EKG showing
sinus bradycardia with intermittent ventricular escape beats and
Vpaced beats. He is admitted to CCU for pacer interrogation and
monitoring.
.
ROS is positive as above and also with worsening postural
hypoTN, which he ascribes to the Parkinson's meds, and lost of
taste, also attributed to Parkinson's meds
.
ROS is negative for f/c/ns, CP, SOB, diaphoresis, cough, PND,
orthopnea, syncope

MEDICAL HISTORY: 1.  Myxomatous mitral valve disease status post mitral valve
repair with an annuloplasty ring at the [**Hospital 3340**] Clinic in
[**2098**].
2.  Postoperative nonsustained VT status post single chamber
[**Company 1543**] ICD generator, changed in [**2108**].
3.  Atrial fibrillation, was previously on Amiodarone but now on
Dronedarone and also Coumadin
4.  Nonischemic dilated cardiomyopathy with an ejection fraction
of 30-40%
5. Parkinson disease, recently initiated on Aricept and
carbidopa
6. Progressive orthostasis with dizziness upon standing.
7. Small ASD or PFO not felt to be clinically significant

MEDICATION ON ADMISSION: Warfarin 1 mg or 5 mg daily (? med list unclear)
Metoprolol tartrate 50mg PO bid
Lisinopril 5mg po daily  (vs 20mg daily by medication list)
Dronedarone 400mg po BID
Azilect (Rasagiline) 1mg daily
Carbidopa/Levodopa 25/100 tid
Flomax 0.4mg qhs
Ambien 10 mg qhs prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 96.5   72   116/74   15   99% RA
Pleasant middle aged male in no distress, good historian.
JVD not elevated, no hepatojugular reflux noted
Lungs CTAB no w/c/r/r, good air movement, no accessory muscle
use, breathing comfortably on room air
RRR, no murmurs appreciated, heart sounds soft S1 S2, no S3 S4
Abd obese NT ND
No BLE edema noted but hyperpigmented macules noted
2+ bilateral radial pulses noted
CN 2-12 intact, no facial droop or dysarthria, spontaneously
moving all four extremities, no focal lesions noted.

FAMILY HISTORY: FH:
h/o colon CA

SOCIAL HISTORY: Lives at home with wife and two daughters
[**Name (NI) 1139**] Use: Never smoker
Alcohol Abuse: No history of alcohol abuse.
No drugs
Mechanical complication of automatic implantable cardiac defibrillator,Acute kidney failure, unspecified,Paroxysmal ventricular tachycardia,Other primary cardiomyopathies,Hypopotassemia,Long-term (current) use of anticoagulants,Automatic implantable cardiac defibrillator in situ,Paralysis agitans,Adult failure to thrive,Abnormal coagulation profile,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in other specified places
Mch cmp autm mplnt dfbrl,Acute kidney failure NOS,Parox ventric tachycard,Prim cardiomyopathy NEC,Hypopotassemia,Long-term use anticoagul,Status autm crd dfbrltr,Paralysis agitans,Failure to thrive-adult,Abnrml coagultion prfile,Abn react-procedure NEC,Accident in place NEC
Admission Date:  [**2110-5-21**]              Discharge Date:   [**2110-5-23**]

Date of Birth:  [**2050-3-18**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Lightheadedness, slow pulse

Major Surgical or Invasive Procedure:
None

History of Present Illness:
Dr. [**Known lastname 3339**] is a 60 yoM with a history of myxomatous mitral
valve disease s/p annuloplasty '[**98**], paroxysmal atrial
fibrillation currently on Dronedarone and Coumadin, h/o
postoperative NSVT s/p ICD placement, and h/o nondilated
cardiomyopathy with EF  who presents with lightheadedness and
near-syncope in the context of recent undefined illness and
weight loss.
.
Pt reports history of 25lb weight loss in the past 6 weeks that
he attributes to losing his sense of taste due to his
Parkinson's meds. He denies any further focal symptoms during
this time frame. Then, today he was not feeling well while at
work in the ED here at [**Hospital1 18**]. He had been feeling lightheaded
all day. He went home then relates that he was laying on the
couch watching TV with his daughter and may have passed out for
some time, the only thing he remembers is his daughter waking
him up. He is unsure if he actually lost consciousness or not. A
family member took his pulse and found him to be in the 20's, so
brought him to the ED.
.
There his vitals were hr 31, 110/68, 18, 100% RA. He was found
to have elevated INR, hypokalemic and repleted. EKG showing
sinus bradycardia with intermittent ventricular escape beats and
Vpaced beats. He is admitted to CCU for pacer interrogation and
monitoring.
.
ROS is positive as above and also with worsening postural
hypoTN, which he ascribes to the Parkinson's meds, and lost of
taste, also attributed to Parkinson's meds
.
ROS is negative for f/c/ns, CP, SOB, diaphoresis, cough, PND,
orthopnea, syncope


Past Medical History:
1.  Myxomatous mitral valve disease status post mitral valve
repair with an annuloplasty ring at the [**Hospital 3340**] Clinic in
[**2098**].
2.  Postoperative nonsustained VT status post single chamber
[**Company 1543**] ICD generator, changed in [**2108**].
3.  Atrial fibrillation, was previously on Amiodarone but now on
Dronedarone and also Coumadin
4.  Nonischemic dilated cardiomyopathy with an ejection fraction
of 30-40%
5. Parkinson disease, recently initiated on Aricept and
carbidopa
6. Progressive orthostasis with dizziness upon standing.
7. Small ASD or PFO not felt to be clinically significant

Social History:
Lives at home with wife and two daughters
[**Name (NI) 1139**] Use: Never smoker
Alcohol Abuse: No history of alcohol abuse.
No drugs

Family History:
FH:
h/o colon CA


Physical Exam:
96.5   72   116/74   15   99% RA
Pleasant middle aged male in no distress, good historian.
JVD not elevated, no hepatojugular reflux noted
Lungs CTAB no w/c/r/r, good air movement, no accessory muscle
use, breathing comfortably on room air
RRR, no murmurs appreciated, heart sounds soft S1 S2, no S3 S4
Abd obese NT ND
No BLE edema noted but hyperpigmented macules noted
2+ bilateral radial pulses noted
CN 2-12 intact, no facial droop or dysarthria, spontaneously
moving all four extremities, no focal lesions noted.


Pertinent Results:
CHEST (PORTABLE AP) Study Date of [**2110-5-21**] 10:47 PM
IMPRESSION: No acute intrathoracic process.

CBC
[**2110-5-23**] 06:45AM BLOOD WBC-4.1 RBC-4.09* Hgb-11.9* Hct-35.0*
MCV-86 MCH-29.2 MCHC-34.1 RDW-13.7 Plt Ct-180
[**2110-5-22**] 04:21AM BLOOD WBC-3.4* RBC-3.90* Hgb-11.7* Hct-33.2*
MCV-85 MCH-29.9 MCHC-35.2* RDW-13.8 Plt Ct-145*
[**2110-5-21**] 10:22PM BLOOD WBC-4.3 RBC-4.22* Hgb-12.3* Hct-35.9*
MCV-85 MCH-29.0 MCHC-34.1 RDW-13.7 Plt Ct-201

Coags
[**2110-5-23**] 06:45AM BLOOD PT-29.5* PTT-32.6 INR(PT)-2.9*
[**2110-5-22**] 04:21AM BLOOD PT-38.3* PTT-37.2* INR(PT)-4.0*
[**2110-5-21**] 10:22PM BLOOD PT-39.3* PTT-33.2 INR(PT)-4.1*

Chemistry
[**2110-5-23**] 01:28PM BLOOD K-4.2
[**2110-5-23**] 06:45AM BLOOD Glucose-90 UreaN-9 Creat-1.0 Na-142 K-4.0
Cl-107 HCO3-29 AnGap-10
[**2110-5-22**] 01:33PM BLOOD Glucose-93 UreaN-9 Creat-1.1 Na-140 K-4.7
Cl-106 HCO3-28 AnGap-11
[**2110-5-22**] 04:21AM BLOOD Glucose-83 UreaN-13 Creat-1.2 Na-142
K-3.1* Cl-106 HCO3-28 AnGap-11
[**2110-5-21**] 10:22PM BLOOD Glucose-98 UreaN-14 Creat-1.3* Na-142
K-3.1* Cl-102 HCO3-30 AnGap-13
[**2110-5-23**] 06:45AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.0
[**2110-5-22**] 01:33PM BLOOD Calcium-8.7 Phos-2.2* Mg-2.1
[**2110-5-22**] 04:21AM BLOOD Calcium-8.5 Phos-2.5* Mg-2.4 Iron-64
[**2110-5-21**] 10:22PM BLOOD Calcium-8.9 Phos-2.8 Mg-1.7

Cardiac Enzymes
[**2110-5-22**] 04:21AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2110-5-21**] 10:22PM BLOOD cTropnT-<0.01

Brief Hospital Course:
60 y/o M with a history of myxomatous mitral valve disease s/p
annuloplasty '[**98**], paroxysmal atrial fibrillation, h/o
postoperative NSVT s/p ICD placement, and h/o nondilated
cardiomyopathy who presents with lightheadedness and
near-syncope in the context of recent undefined illness and
weight loss, found to be bradycardic and admitted to CCU for
further management.
.
#. Presyncope/NSVT:  Pt had pacer evaluated by EP, which showed
a few episodes of NSVT which seem to correlate temporally with
his symptoms.  Also with runs of ventricular bigeminy with 1st
QRS complex paced and second complex a wide complex PVC, other
strips show bigeminy without pacing.  Runs of sinus rhythm with
junctional vs ventricular escape beats are also seen.  Patient
was followed closely by the EP service.  Possible etiology of
NSVT could be due to hypokalemia.  Patient had potassium
aggressively repleted.  Prior to discharge, his potassium level
was 4.2, for which he was repleted with an extra 40 mEq of
potassium for goal of 4.5.  Patient was continued on
dronedarone.  Metoprolol was stopped.  Lisinopril decreased to 5
mg daily.  Patient will also start daily potassium
supplementation.  He will follow up closely in device clinic
where he will have repeat CBC, lytes, and INR checked.
.
#. Failure to thrive: patient has had recent weight loss,
decrease in appetite, overall fatigue and malaise.  Sinamet is
the most recent addition to his outpatient medications.  His
neurologist did not think that these symptoms are due to
sinamet, although sinamet may cause some nausea, the treatment
of which would be to take an extra 25mg of carbidopa along with
his sinamet.  This was discussed with patient and a prescription
for carbidopa was provided to be taken as needed for nausea.
.
#. Pancytopenia: the etiology of this is unclear.  His
medications were reviewed with no offending medications found.
His neurologist did not think that this was being caused by any
of his parkinson's meds.  He will have a repeat CBC drawn on his
next visit at device clinic to follow up.
.
#. Acute renal failure - patient on admission had creatinine of
1.3 which trended down to baseline of 1.0 with gentle IV fluids.
.
#. Supratherapeutic INR - patient's albumin was normal which
suggests not a synthetic problem.  LFT's also normal.  Patient
had warfarin held during this admission, but on discharge his
INR was back within therapeutic range of 2.0-3.0 at 2.9.  He
will be restarted on warfarin as an outpatient, and will have
INR checked on his next visit to device clinic for further
management of his warfarin dosing.
.
#. Parkinson's - patient was continued on sinamet and azilect

Medications on Admission:
Warfarin 1 mg or 5 mg daily (? med list unclear)
Metoprolol tartrate 50mg PO bid
Lisinopril 5mg po daily  (vs 20mg daily by medication list)
Dronedarone 400mg po BID
Azilect (Rasagiline) 1mg daily
Carbidopa/Levodopa 25/100 tid
Flomax 0.4mg qhs
Ambien 10 mg qhs prn

Discharge Medications:
1. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day.
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Dronedarone 400 mg Tablet Sig: One (1) Tablet PO twice a day.

4. AZILECT 1 mg Tablet Sig: One (1) Tablet PO daily ().
5. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
7. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed for insomnia.
8. Carbidopa 25 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for nausea.
Disp:*90 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
10. Outpatient Lab Work
Please draw a CBC, Chemistry 10, PT, PTT, and INR drawn on
[**2110-5-27**] and have results faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at
[**Telephone/Fax (1) 3341**]


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnosis:
Presyncope/NSVT


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


Discharge Instructions:
You were admitted to [**Hospital1 69**] for
lightheadedness.  You were admitted to the cardiac intensive
care unit for close monitoring.  The electrophysiology service
evaluated you on this admission and changed some of the setting
on your pacemaker.  They found brief episodes of abnormal rhythm
when they interrogated your pacemaker.  You will need to
continue taking dronedarone.

We contact[**Name (NI) **] your neurologist in regards to your parkinson's
medications: sinemet and resegaline.  It does not appear that
they are the causes of your appetite or weight loss.  Sinemet
can cause nausea, and the treatment to that is to take an
additional 25mg of carbidopa along with the sinemet

You will also need to continue warfarin.  Your INR on discharge
is 2.9.  Please continue to have your INR checked periodically
in order to manage your warfarin dosage.

You will need to have your labs checked again.  Please have a
CBC, Chem 10, and an INR checked on [**5-27**].

Your medications have changed.  Please make note of the
following changes:
- please STOP taking metoprolol
- please DECREASE your lisinopril dosage to 5 mg daily
- new: Potassium chloride 20 mEq daily
- you are being given a prescription for carbidopa.  You can
take one tablet along with your sinamet, three times a day, as
needed if you are experiencing nausea that you think may be due
to the sinamet.

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.

Followup Instructions:
Provider:  [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2110-5-27**]
9:00

Dr.[**Name (NI) 1565**] office will contact you for an additional follow
up appointment in approximately 6 weeks' time.  If you do not
hear back from them soon, please call [**Telephone/Fax (1) 3342**] to make the
appointment.

Please continue to follow up with your neurologist Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **]
{'Mechanical complication of automatic implantable cardiac defibrillator,Acute kidney failure, unspecified,Paroxysmal ventricular tachycardia,Other primary cardiomyopathies,Hypopotassemia,Long-term (current) use of anticoagulants,Automatic implantable cardiac defibrillator in situ,Paralysis agitans,Adult failure to thrive,Abnormal coagulation profile,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in other specified places'}


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: Lightheadedness, slow pulse

PRESENT ILLNESS: Dr. [**Known lastname 3339**] is a 60 yoM with a history of myxomatous mitral
valve disease s/p annuloplasty '[**98**], paroxysmal atrial
fibrillation currently on Dronedarone and Coumadin, h/o
postoperative NSVT s/p ICD placement, and h/o nondilated
cardiomyopathy with EF  who presents with lightheadedness and
near-syncope in the context of recent undefined illness and
weight loss.
.
Pt reports history of 25lb weight loss in the past 6 weeks that
he attributes to losing his sense of taste due to his
Parkinson's meds. He denies any further focal symptoms during
this time frame. Then, today he was not feeling well while at
work in the ED here at [**Hospital1 18**]. He had been feeling lightheaded
all day. He went home then relates that he was laying on the
couch watching TV with his daughter and may have passed out for
some time, the only thing he remembers is his daughter waking
him up. He is unsure if he actually lost consciousness or not. A
family member took his pulse and found him to be in the 20's, so
brought him to the ED.
.
There his vitals were hr 31, 110/68, 18, 100% RA. He was found
to have elevated INR, hypokalemic and repleted. EKG showing
sinus bradycardia with intermittent ventricular escape beats and
Vpaced beats. He is admitted to CCU for pacer interrogation and
monitoring.
.
ROS is positive as above and also with worsening postural
hypoTN, which he ascribes to the Parkinson's meds, and lost of
taste, also attributed to Parkinson's meds
.
ROS is negative for f/c/ns, CP, SOB, diaphoresis, cough, PND,
orthopnea, syncope

MEDICAL HISTORY: 1.  Myxomatous mitral valve disease status post mitral valve
repair with an annuloplasty ring at the [**Hospital 3340**] Clinic in
[**2098**].
2.  Postoperative nonsustained VT status post single chamber
[**Company 1543**] ICD generator, changed in [**2108**].
3.  Atrial fibrillation, was previously on Amiodarone but now on
Dronedarone and also Coumadin
4.  Nonischemic dilated cardiomyopathy with an ejection fraction
of 30-40%
5. Parkinson disease, recently initiated on Aricept and
carbidopa
6. Progressive orthostasis with dizziness upon standing.
7. Small ASD or PFO not felt to be clinically significant

MEDICATION ON ADMISSION: Warfarin 1 mg or 5 mg daily (? med list unclear)
Metoprolol tartrate 50mg PO bid
Lisinopril 5mg po daily  (vs 20mg daily by medication list)
Dronedarone 400mg po BID
Azilect (Rasagiline) 1mg daily
Carbidopa/Levodopa 25/100 tid
Flomax 0.4mg qhs
Ambien 10 mg qhs prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 96.5   72   116/74   15   99% RA
Pleasant middle aged male in no distress, good historian.
JVD not elevated, no hepatojugular reflux noted
Lungs CTAB no w/c/r/r, good air movement, no accessory muscle
use, breathing comfortably on room air
RRR, no murmurs appreciated, heart sounds soft S1 S2, no S3 S4
Abd obese NT ND
No BLE edema noted but hyperpigmented macules noted
2+ bilateral radial pulses noted
CN 2-12 intact, no facial droop or dysarthria, spontaneously
moving all four extremities, no focal lesions noted.

FAMILY HISTORY: FH:
h/o colon CA

SOCIAL HISTORY: Lives at home with wife and two daughters
[**Name (NI) 1139**] Use: Never smoker
Alcohol Abuse: No history of alcohol abuse.
No drugs 

### Response:
{'Mechanical complication of automatic implantable cardiac defibrillator,Acute kidney failure, unspecified,Paroxysmal ventricular tachycardia,Other primary cardiomyopathies,Hypopotassemia,Long-term (current) use of anticoagulants,Automatic implantable cardiac defibrillator in situ,Paralysis agitans,Adult failure to thrive,Abnormal coagulation profile,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in other specified places'}
