CHIEF COMPLAINT: Syncope

PRESENT ILLNESS: [**Age over 90 **] year-old female with HTN, CAD s/p CABG presents with nausea,
vomiting and diarrhea since this morning.

MEDICAL HISTORY: 1. Coronary artery disease, status post CABG in [**2140**].
2. Peripheral arterial disease with status post right carotid
endarterectomy in [**2140**].
3. CVA [**2140**], status post right CEA.
4. Hypertension.
5. Dyslipidemia.
6. Pulmonary hypertension.
7. Severe tricuspid regurgitation.
8. Presyncope.
9. Depression

MEDICATION ON ADMISSION: Medications - Prescription
BUPROPION HCL [WELLBUTRIN] - 75 mg Tablet - 1 Tablet(s) by mouth
twice a day
CILOSTAZOL -  (Prescribed by Other Provider) - 50 mg Tablet - 1
Tablet(s) by mouth twice a day
LABETALOL - 100 mg Tablet - 1 Tablet by mouth twice a day
LISINOPRIL - 20 mg Tablet - 0.5 (One half) Tablet by mouth once
a
day
NIFEDIPINE - 30 mg Tablet Sustained Release - 1 Tablet(s) by
mouth once a day
PRAVASTATIN - 80 mg Tablet - 1 Tablet(s) by mouth qpm
.
Medications - OTC
ACETAMINOPHEN [TYLENOL] -  (OTC) - Dosage uncertain
ASPIRIN -  (OTC) - 81 mg Tablet, Chewable - 1 Tablet by mouth
once a day
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 1,000 unit Capsule - 1
Capsule(s) by mouth daily
SENNA -  (Prescribed by Other Provider) - 8.6 mg Capsule - 1
Capsule(s) by mouth every other night

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: Afebrile, BP 162/70, HR 86, 97% on 1 liter via nasal
canula
General: Alert and oriented; in good spirits
HEENT: Dry MM, oropharynx clear.
Neck: Right IJ in place.
Lungs: Rales at right base > left base; no wheezes
CV: Regular rate and rhythm; murmur at right lower sternal
border.
Abdomen: Non-tender and soft; mildly distended
GU: Foley in place
Ext: Warm, well perfused, palpable PT pulses; could not palplate
DP; no edema
.
Discharge:
VS 169/92 (140-172/58-90)  84  18  98RA
GEN: well appearing. NAD. Pleasant.
RESP: scattered dry insp rales B. Good AE.
Abd: benign.
Neuro/Psych: pleasant, interactive, moves all 4. Fluent speech.

FAMILY HISTORY: [**2-28**] children with HTN

SOCIAL HISTORY: Lives alone, family nearby. Uses cane with ambulation. Widowed
in [**2114**]. Worked subsequently in a bank. Has 6 living children -
children check on her daily. Has home health aide 2x/week. +
remote minor tobacco, occasional glass of wine with dinner, no
IVDU.
Unspecified septicemia,Acute kidney failure, unspecified,Septic shock,Unspecified vascular insufficiency of intestine,Infectious colitis, enteritis, and gastroenteritis,Malignant essential hypertension,Urinary tract infection, site not specified,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Severe sepsis,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Unspecified disorders of arteries and arterioles,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Other and unspecified hyperlipidemia,Other chronic pulmonary heart diseases,Depressive disorder, not elsewhere classified,Anemia of other chronic disease,Disorders of phosphorus metabolism,Hypopotassemia
Septicemia NOS,Acute kidney failure NOS,Septic shock,Vasc insuff intest NOS,Infectious enteritis NOS,Malignant hypertension,Urin tract infection NOS,Mth sus Stph aur els/NOS,Severe sepsis,Cor ath unsp vsl ntv/gft,Aortocoronary bypass,Arterial disease NOS,Hx TIA/stroke w/o resid,Hyperlipidemia NEC/NOS,Chr pulmon heart dis NEC,Depressive disorder NEC,Anemia-other chronic dis,Dis phosphorus metabol,Hypopotassemia
Admission Date:  [**2157-6-7**]              Discharge Date:   [**2157-6-14**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Syncope

Major Surgical or Invasive Procedure:
None

History of Present Illness:
[**Age over 90 **] year-old female with HTN, CAD s/p CABG presents with nausea,
vomiting and diarrhea since this morning.

Patient was in her usual state of health until this morning when
she awoke with nausea, bilious vomiting and diarrhea.  No blood
loss reported.  She was help to the toilet and then had the
first of two witnessed syncopal events (witnessed by caretaker).
 EMS was called.  She had another episode in front of EMS who
found her to be pale and hypotensive.  Each episode is reported
as less than 1 minute long with no seizure activity.  She was
brought to the [**Hospital1 18**] ED for further evaluation.

In the ED, she was found to be hypotensive to SBP in the 70s and
bradycardic to the 50s.  EKG showed RBBB with no ST changes.  On
exam, she was tender to palpation on abdominal exam.  CT scan
showed sigmoid thickening to descending colon consistent with
ischemic vs infectious colitis.  Surgical team was consulted but
after discussion between PCP and family, it was decided that
surgery would not be pursued.

She received 3L NS and had a right IJ placed.  Started on
levophed with improved in SBP to 110s.  Mental status also
improved.  She had more bilious emesis in the ED.  NG tube was
placed with 600cc of bilious emesis returned.  No further
episodes of diarrhea occured in the ED.  Of note, she had
isolated oral temp of 92.0.  Rectal probe placed with repeat
temp of 35.4.  CVP was 7.  Foley was in place and patient had
good UOP.  She was started on cipro/flagyl in the ED.

Goals of care discussion with famiy; she is DNR/DNI, but
pressors are okay to use.  No compressions.

On transfer to the floor, patient was afebrile with HR- 74, BP-
161/68, RR- 20, SaO2- 99% on 2L NC.

On the floor, patient was feeling better.  SBP was in the 160s
and patient's HR was in the 80s.  She continued to have
abdominal pain but mental status had improved.

Past Medical History:
1. Coronary artery disease, status post CABG in [**2140**].
2. Peripheral arterial disease with status post right carotid
endarterectomy in [**2140**].
3. CVA [**2140**], status post right CEA.
4. Hypertension.
5. Dyslipidemia.
6. Pulmonary hypertension.
7. Severe tricuspid regurgitation.
8. Presyncope.
9. Depression

Social History:
Lives alone, family nearby. Uses cane with ambulation. Widowed
in [**2114**]. Worked subsequently in a bank. Has 6 living children -
children check on her daily. Has home health aide 2x/week. +
remote minor tobacco, occasional glass of wine with dinner, no
IVDU.


Family History:
[**2-28**] children with HTN

Physical Exam:
Vitals: Afebrile, BP 162/70, HR 86, 97% on 1 liter via nasal
canula
General: Alert and oriented; in good spirits
HEENT: Dry MM, oropharynx clear.
Neck: Right IJ in place.
Lungs: Rales at right base > left base; no wheezes
CV: Regular rate and rhythm; murmur at right lower sternal
border.
Abdomen: Non-tender and soft; mildly distended
GU: Foley in place
Ext: Warm, well perfused, palpable PT pulses; could not palplate
DP; no edema
.
Discharge:
VS 169/92 (140-172/58-90)  84  18  98RA
GEN: well appearing. NAD. Pleasant.
RESP: scattered dry insp rales B. Good AE.
Abd: benign.
Neuro/Psych: pleasant, interactive, moves all 4. Fluent speech.


Pertinent Results:
HCT: 37 --> 27
WBC: 3.2 --> 28 --> 14

Cr: 1.3
Bicarb: 30 --> 18

LFTs normal

Troponin negative x3

TSH: 10 (recommend outpt follow up, recheck when pt not ill)

Lactate: 2.5 --> 1.9 --> 0.8

Urine culture:  MSSA

CTA ABD/PELVIS:
1. No definite signs of vascular occlusion though segments of
bowel wall
thickening in the distal descending and sigmoid colon raises
concern for
ischemic bowel versus infectious colitis. No free air or
evidence of
perforation. Abdominal ascites noted.
2. Small right pleural effusion, cardiomegaly, with evidence of
CHF.
3. Interstitial lung disease notable at the lung bases.
4. Cholelithiasis without evidence of cholecystitis.
5. NGT tip in distal esophagus. Recommend advancement.
6. Atrophic right kidney.

Discharge labs:

[**2157-6-12**] 05:11AM BLOOD WBC-7.5 RBC-3.18* Hgb-9.3* Hct-29.2*
MCV-92 MCH-29.4 MCHC-32.0 RDW-15.9* Plt Ct-212
[**2157-6-13**] 06:25AM BLOOD Glucose-82 UreaN-9 Creat-1.0 Na-142 K-3.4
Cl-110* HCO3-24 AnGap-11
[**2157-6-13**] 06:25AM BLOOD Calcium-8.2* Phos-2.4* Mg-1.9
[**2157-6-7**] 07:39PM BLOOD TSH-10*
[**2157-6-9**] 04:27AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017
[**2157-6-9**] 04:27AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD
[**2157-6-9**] 04:27AM URINE RBC-20* WBC-7* Bacteri-FEW Yeast-RARE
Epi-0 RenalEp-1

Urine culture:
                             STAPH AUREUS COAG +
                             |          STAPH AUREUS COAG +
                             |          |
GENTAMICIN------------ <=0.5 S    <=0.5 S
LEVOFLOXACIN----------<=0.12 S   <=0.12 S
NITROFURANTOIN--------    32 S       32 S
OXACILLIN-------------<=0.25 S   <=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S    <=0.5 S


Brief Hospital Course:
[**Age over 90 **] yo female with CAD s/p CABG, HTN admitted with syncope x2,
nausea, vomiting, diarrhea and hypotension. Found to have bowel
wall thickening, concerning for ischemic colitis vs ischemic
colitis. Also found to have MSSA UTI. Clinically improved.
.
.
# Sepsis / Septic shock / MSSA UTI (blood cultures negative).
The patient was initially admitted with hypotension and concern
for sepsis. Her hypotension resolved with fluid resuscitation.
She was briefly on pressure support medications but was weaned
from these upon arrival to the ICU. Her pressures remained
normotensive while in the ICU. Blood, urine, and stool cultures
were drawn. She was treated empirically with antibiotics for a
suspected GI source given her abdominal pain and history of
diarrhea.
- see colitis below
.
# Colitis, Ischemic vs Infectious.
CT Abd performed in the ED showed bowel wall thickening
concerning for ischemic vs. infectious colitis. The patient and
her family expressed that surgical management was not an option
and she was managed conservatively with antibiotics and fluid
resuscitation. Her diarrhea resolved and her pain was controlled
with morphine. She has remained abdominal pain-free on the
floor, and is now tolerating a regular diet.
Pt is being treated with Cipro/flagyl with plan for 10 day
course to end [**6-18**]. (Cipro dosing remains appropriate for renal
function)
Pt's diet was advanced, and she tolerated a regular diet without
difficulty.
.
# MSSA UTI
A urine culture grew MSSA and she was started on IV vancomycin.
This was later changed to dicloxacillin (avoided Bactrim d/t
potential renal toxicity). D1 of appropriate antibiotics was
[**6-8**]. Plan for 14 day course to complete [**6-22**].
.
# Coronary artery disease/Malignant hypertension.
The patient has a h/o CAD s/p CABG. Her blood pressure
medications were intially held out of concern for hypotension.
Pt became very hypertensive, with max SBP 220, but asymptomatic.
Her home BP medications were resumed, and her BP is under
improved control.
- Contin Labetolol to home dose 100 mg po bid
- contin Lisinopril 10 mg po q day
- Contin Nifedipine SR 30 mg po q day
- Want to avoid possible hypotension, as may have led to
ischemic colitis as possible inciting event.  It is important
for patient to maintain adequate hydration to avoid further
episodes.
- contin asprin / statin
.
# Acute renal failure.
The patient's creatinine improved with fluid resuscitation.
Renal function continues to improve.
- avoid renal toxins
.
# Goals of care. contin DNR/DNI. Dr. [**Last Name (STitle) 1007**] discussing possible
bridge to hospice.
.
# Hypophosphatemia.
- resolved with repletion
.
# Hypokalemia
- resolved with repletion
.
Prophylaxis: SubQ heparin.
Code: DNR/DNI; PCP planning to discuss possible bridge to
hospice as an outpt
DISP: d/c to Rehab, today.

Medications on Admission:
Medications - Prescription
BUPROPION HCL [WELLBUTRIN] - 75 mg Tablet - 1 Tablet(s) by mouth
twice a day
CILOSTAZOL -  (Prescribed by Other Provider) - 50 mg Tablet - 1
Tablet(s) by mouth twice a day
LABETALOL - 100 mg Tablet - 1 Tablet by mouth twice a day
LISINOPRIL - 20 mg Tablet - 0.5 (One half) Tablet by mouth once
a
day
NIFEDIPINE - 30 mg Tablet Sustained Release - 1 Tablet(s) by
mouth once a day
PRAVASTATIN - 80 mg Tablet - 1 Tablet(s) by mouth qpm
.
Medications - OTC
ACETAMINOPHEN [TYLENOL] -  (OTC) - Dosage uncertain
ASPIRIN -  (OTC) - 81 mg Tablet, Chewable - 1 Tablet by mouth
once a day
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 1,000 unit Capsule - 1
Capsule(s) by mouth daily
SENNA -  (Prescribed by Other Provider) - 8.6 mg Capsule - 1
Capsule(s) by mouth every other night

Discharge Medications:
1. Bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Cilostazol 50 mg Tablet Sig: One (1) Tablet PO twice a day.
3. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
6. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO q PM.
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO every other day.

11. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
12. Dicloxacillin 250 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) for 8 days.
13. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 5 days.
14. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 5 days.
15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) inj
Injection [**Hospital1 **] (2 times a day): (DVT Ppx).


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]

Discharge Diagnosis:
# Sepsis/Septic shock
# Syncope
# Colitis; Likely ischemic vs possible infectious
# Hypertension, malignant
# Acute renal failure


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


Discharge Instructions:
You were admitted after syncopal episodes, and were found to
have very low blood pressure.  You were admitted to the ICU, and
were found to have colitis, either due to ischemia or due to
infection. You are being treated with antibiotics, and you have
gotten better. You were also found to have a urinary tract
infection, for which you are being treated with antibiotics.

Followup Instructions:
Department: INTERNAL MEDICINE
When: TUESDAY [**2157-9-6**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**], MD [**Telephone/Fax (1) 10492**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 24**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: CARDIAC SERVICES
When: WEDNESDAY [**2157-10-12**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Unspecified septicemia,Acute kidney failure, unspecified,Septic shock,Unspecified vascular insufficiency of intestine,Infectious colitis, enteritis, and gastroenteritis,Malignant essential hypertension,Urinary tract infection, site not specified,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Severe sepsis,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Unspecified disorders of arteries and arterioles,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Other and unspecified hyperlipidemia,Other chronic pulmonary heart diseases,Depressive disorder, not elsewhere classified,Anemia of other chronic disease,Disorders of phosphorus metabolism,Hypopotassemia'}


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: Syncope

PRESENT ILLNESS: [**Age over 90 **] year-old female with HTN, CAD s/p CABG presents with nausea,
vomiting and diarrhea since this morning.

MEDICAL HISTORY: 1. Coronary artery disease, status post CABG in [**2140**].
2. Peripheral arterial disease with status post right carotid
endarterectomy in [**2140**].
3. CVA [**2140**], status post right CEA.
4. Hypertension.
5. Dyslipidemia.
6. Pulmonary hypertension.
7. Severe tricuspid regurgitation.
8. Presyncope.
9. Depression

MEDICATION ON ADMISSION: Medications - Prescription
BUPROPION HCL [WELLBUTRIN] - 75 mg Tablet - 1 Tablet(s) by mouth
twice a day
CILOSTAZOL -  (Prescribed by Other Provider) - 50 mg Tablet - 1
Tablet(s) by mouth twice a day
LABETALOL - 100 mg Tablet - 1 Tablet by mouth twice a day
LISINOPRIL - 20 mg Tablet - 0.5 (One half) Tablet by mouth once
a
day
NIFEDIPINE - 30 mg Tablet Sustained Release - 1 Tablet(s) by
mouth once a day
PRAVASTATIN - 80 mg Tablet - 1 Tablet(s) by mouth qpm
.
Medications - OTC
ACETAMINOPHEN [TYLENOL] -  (OTC) - Dosage uncertain
ASPIRIN -  (OTC) - 81 mg Tablet, Chewable - 1 Tablet by mouth
once a day
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 1,000 unit Capsule - 1
Capsule(s) by mouth daily
SENNA -  (Prescribed by Other Provider) - 8.6 mg Capsule - 1
Capsule(s) by mouth every other night

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: Afebrile, BP 162/70, HR 86, 97% on 1 liter via nasal
canula
General: Alert and oriented; in good spirits
HEENT: Dry MM, oropharynx clear.
Neck: Right IJ in place.
Lungs: Rales at right base > left base; no wheezes
CV: Regular rate and rhythm; murmur at right lower sternal
border.
Abdomen: Non-tender and soft; mildly distended
GU: Foley in place
Ext: Warm, well perfused, palpable PT pulses; could not palplate
DP; no edema
.
Discharge:
VS 169/92 (140-172/58-90)  84  18  98RA
GEN: well appearing. NAD. Pleasant.
RESP: scattered dry insp rales B. Good AE.
Abd: benign.
Neuro/Psych: pleasant, interactive, moves all 4. Fluent speech.

FAMILY HISTORY: [**2-28**] children with HTN

SOCIAL HISTORY: Lives alone, family nearby. Uses cane with ambulation. Widowed
in [**2114**]. Worked subsequently in a bank. Has 6 living children -
children check on her daily. Has home health aide 2x/week. +
remote minor tobacco, occasional glass of wine with dinner, no
IVDU. 

### Response:
{'Unspecified septicemia,Acute kidney failure, unspecified,Septic shock,Unspecified vascular insufficiency of intestine,Infectious colitis, enteritis, and gastroenteritis,Malignant essential hypertension,Urinary tract infection, site not specified,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Severe sepsis,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Unspecified disorders of arteries and arterioles,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Other and unspecified hyperlipidemia,Other chronic pulmonary heart diseases,Depressive disorder, not elsewhere classified,Anemia of other chronic disease,Disorders of phosphorus metabolism,Hypopotassemia'}
