CHIEF COMPLAINT: Syncope, apical perfusion defect on nuclear stress

PRESENT ILLNESS: 84F with HTN, HLD, DM2, newly diagnosed atrial fibrillation in
[**11/2144**] who was transferred to [**Hospital1 18**] from [**Hospital **] hospital for
cardiac catheterization after presentation there with syncopal
episode.  In summary, she has history of syncope & presyncope,
and was recently diagnosed with afib on [**2144-12-4**], CHADS2 score
of 3, and was started on a beta-blocker (metoprolol 50mg daily)
and coumadin.  Persantine thalium stress test showed severe
apical reversible perfusion defect consistent with ischemia
(LAD) and was scheduled for outpt Left heart catheterization
prior to presentation.  On [**2144-12-14**], she presented to [**Hospital **]
Hospital for syncope while sitting and talking on phone with her
neighbor. She was found sitting in chair with phone in hand,
conscious by her neighbor. She had not fallen, denies any CP,
palpitations, fluttering, LH or dizziness. At the OSH she was
noted to have 2.2 second pauses with heart rate in 40's. Ruled
out for MI with Trops less than .01 x3. Referred for [**Hospital1 18**] for
Left Heart Catheterization.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: +Diabetes diet controlled,
+Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
-persistent atrial fibrillation/atypical atrial flutter on
coumadin, diagnosed in 10/[**2144**]. CHADS-2 score is 3.
-GERD
-gastritis, duodenitis
-IBS
-thyroidectomy
-diabetes
-Parkinson's
-anxiety
-depression

MEDICATION ON ADMISSION: ASA 81 mg dialy
HCTZ 12.5 mg daily
metoprolol succinate ER 50 mg daily
ativan 0.5 mg a day at bed time
loperamide 2 mg every 6 hr prn
celexa 10 mg a day
meclizine 25 mg three times a day PRN
nexium 40 mg daily
ambien 10 mg a day
coumadin 3 mg

ALLERGIES: Codeine

PHYSICAL EXAM: Admission exam:
VS: 97.3  157/76 101 (irregular)  18   98%RA
GENERAL: Caucasian female in NAD, pleasant
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: father died of pancreatic cancer at 75. mother had diabetes,
peripheral vascular disease, s/p amputation and died of MI at
64. brother had CAD at 70. Maternal aunt died at 51 from heart
disease.

SOCIAL HISTORY: -Tobacco history: ex-smoker. quit at 40, smoked 1 PPD for 20
years.
-ETOH: none
-Illicit drugs: Denies
-lives alone, retired. Used to work at [**Location (un) 1411**] Court House as a
unit secretary. Has supportive family. Lives in senior housing,
but does all of her own ADLs.
-widowed. has 3 children. Health care proxy is the son [**Name (NI) **].
Coronary atherosclerosis of native coronary artery,Atrioventricular block, complete,Hematoma complicating a procedure,Acute kidney failure, unspecified,Cardiac complications, not elsewhere classified,Intermediate coronary syndrome,Atrial flutter,Long-term (current) use of anticoagulants,Paralysis agitans,Esophageal reflux,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution,Mitral stenosis with insufficiency,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Obesity, unspecified,Personal history of malignant neoplasm of ovary,Personal history of malignant neoplasm of thyroid,Personal history of malignant neoplasm of large intestine,Postsurgical hypothyroidism,Other drugs and medicinal substances causing adverse effects in therapeutic use,Other iatrogenic hypotension,Personal history of tobacco use,Dysthymic disorder
Crnry athrscl natve vssl,Atriovent block complete,Hematoma complic proc,Acute kidney failure NOS,Surg compl-heart,Intermed coronary synd,Atrial flutter,Long-term use anticoagul,Paralysis agitans,Esophageal reflux,Abn react-cardiac cath,Accid in resident instit,Mitral stenosis w insuff,DMII wo cmp nt st uncntr,Hypertension NOS,Hyperlipidemia NEC/NOS,Obesity NOS,Hx of ovarian malignancy,Hx of thyroid malignancy,Hx of colonic malignancy,Postsurgical hypothyroid,Adv eff medicinal NEC,Iatrogenc hypotnsion NEC,History of tobacco use,Dysthymic disorder
Admission Date:  [**2144-12-15**]              Discharge Date:   [**2144-12-24**]

Date of Birth:  [**2060-5-26**]             Sex:   F

Service: MEDICINE

Allergies:
Codeine

Attending:[**First Name3 (LF) 1436**]
Chief Complaint:
Syncope, apical perfusion defect on nuclear stress

Major Surgical or Invasive Procedure:
[**2144-12-15**] - Cardiac cath, diagnostic
[**2144-12-21**] - Cardiac cath with PCI; Cardiac catheterization x 2
s/p 2 DES to LAD, 1 DES to RCA
[**12-23**] - Dual chamber [**Company **] pacemaker placement with leads to
right atrium and right ventricle


History of Present Illness:
84F with HTN, HLD, DM2, newly diagnosed atrial fibrillation in
[**11/2144**] who was transferred to [**Hospital1 18**] from [**Hospital **] hospital for
cardiac catheterization after presentation there with syncopal
episode.  In summary, she has history of syncope & presyncope,
and was recently diagnosed with afib on [**2144-12-4**], CHADS2 score
of 3, and was started on a beta-blocker (metoprolol 50mg daily)
and coumadin.  Persantine thalium stress test showed severe
apical reversible perfusion defect consistent with ischemia
(LAD) and was scheduled for outpt Left heart catheterization
prior to presentation.  On [**2144-12-14**], she presented to [**Hospital **]
Hospital for syncope while sitting and talking on phone with her
neighbor. She was found sitting in chair with phone in hand,
conscious by her neighbor. She had not fallen, denies any CP,
palpitations, fluttering, LH or dizziness. At the OSH she was
noted to have 2.2 second pauses with heart rate in 40's. Ruled
out for MI with Trops less than .01 x3. Referred for [**Hospital1 18**] for
Left Heart Catheterization.

At [**Hospital1 18**], cath on [**2144-12-15**] showed 3VD (LMCA 20% ostial disease,
LAD: diffuse disease to a 80% focal,  two small diagonals
proximal 80% stenosis, LCX - 80% ostial disease, RCA ostial
70-80%, PLB w/ proximal 80% ostial stenosis.).  This was
complicated by 11x4x10 cm hematoma in the R groin with hct drop
from 32->27. She was given now 2u of prbc and anticoagulation
held and since that time hematocrit has been stable.  During the
hospitalization, telemetry was concerning for brady/tachy
syndrome.  She was evaluated by cardiac surgery and patient
opted for interventional approach.

She was taken to the cath lab for intervention in the AM with
plan for ppm placement in PM of [**2144-12-21**].  In the cath lab,
during intervention she became more bradycardic with rhythm
revealing complete heart block. Systolic blood pressure
transiently in 60s. She was given atropine and HR went to 120s
(afib) and blood pressure up to 180s. She was placed on nitro
gtt. Venous sheath and temporary pacing wire was placed. She had
2 [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 10157**] placed in LAD and 1 [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] in the RCA. She is
getting bicarb for renal protect as got 365cc of dye. She is
being transferred to CCU for further monitoring.

Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes diet controlled,
+Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
-persistent atrial fibrillation/atypical atrial flutter on
coumadin, diagnosed in 10/[**2144**]. CHADS-2 score is 3.
-GERD
-gastritis, duodenitis
-IBS
-thyroidectomy
-diabetes
-Parkinson's
-anxiety
-depression

PAST SURGICAL HISTORY:
-kyphoplasty
-resection of colon cancer
-thyroid surgery for thryoid cancer
-Stage IA granulosa cell tumor of ovary s/p TAH-BSO-left ankle
fracture
-cholecystectomy and appendectomy
-bladder repair after C section
-discectomy

Social History:
-Tobacco history: ex-smoker. quit at 40, smoked 1 PPD for 20
years.
-ETOH: none
-Illicit drugs: Denies
-lives alone, retired. Used to work at [**Location (un) 1411**] Court House as a
unit secretary. Has supportive family. Lives in senior housing,
but does all of her own ADLs.
-widowed. has 3 children. Health care proxy is the son [**Name (NI) **].

Family History:
father died of pancreatic cancer at 75. mother had diabetes,
peripheral vascular disease, s/p amputation and died of MI at
64. brother had CAD at 70. Maternal aunt died at 51 from heart
disease.

Physical Exam:
Admission exam:
VS: 97.3  157/76 101 (irregular)  18   98%RA
GENERAL: Caucasian female in NAD, pleasant
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

NECK: JVP difficult to assess [**2-26**] body habitus
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. irregular rhythm, normal S1 and S2.
LUNGS: No chest wall deformities, scoliosis or kyphosis.
Respirations were unlabored, no accessory muscle use. CTA
anteriorly
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: right groin ecchymosis, left groin sheath and temp wire in
place
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+

Discharge exam:
VS BP 147/73 P 71 RR 18 98% RA
PE: Unremarkable.  Still in atrial flutter.  No pauses.  CTA
bilaterally.  Large hematoma still present in right groin.  No
bruit  No pain anywhere.  Good pulses bilaterally.

Pertinent Results:
Admission labs:
[**2144-12-15**] 09:00PM BLOOD WBC-5.9 RBC-3.64* Hgb-10.9* Hct-31.7*
MCV-87 MCH-29.9 MCHC-34.4 RDW-13.9 Plt Ct-236
[**2144-12-15**] 09:00PM BLOOD PT-72.4* PTT->150* INR(PT)-8.2*
[**2144-12-15**] 09:00PM BLOOD Glucose-89 UreaN-16 Creat-1.0 Na-138
K-3.7 Cl-103 HCO3-25 AnGap-14
[**2144-12-15**] 09:00PM BLOOD ALT-9 AST-18 CK(CPK)-62 AlkPhos-58
Amylase-29 TotBili-0.5
[**2144-12-15**] 09:00PM BLOOD %HbA1c-6.3* eAG-134*
[**2144-12-16**] 06:50AM BLOOD Triglyc-142 HDL-39 CHOL/HD-5.1
LDLcalc-130* LDLmeas-147*

Thyroid Labs:
[**2144-12-19**] 04:50AM BLOOD TSH-5.9*
[**2144-12-19**] 04:50AM BLOOD Free T4-0.82*

Discharge Labs:
[**2144-12-24**] 08:00AM BLOOD WBC-6.2 RBC-3.37* Hgb-10.1* Hct-30.2*
MCV-90 MCH-29.9 MCHC-33.4 RDW-13.9 Plt Ct-274
[**2144-12-24**] 08:00AM BLOOD PT-12.9* PTT-31.8 INR(PT)-1.2*
[**2144-12-24**] 08:00AM BLOOD Glucose-120* UreaN-21* Creat-1.1 Na-138
K-4.3 Cl-101 HCO3-32 AnGap-9
[**2144-12-24**] 08:00AM BLOOD Calcium-8.6 Phos-3.9 Mg-2.3

Studies:
-Diagnostic cardiac cath ([**2144-12-15**]) - 1. Selective coronary
angiography of this right dominant system demonstrated three
vessel coronary artery disease. The LMCA had a 20% ostial
disease. The LAD had moderate diffuse disease that tapers to a
80% focal. Two small diagonals have proximal 80% stenosis. The
LCX had 80% ostial disease. The RCA had an ostial 70-80% that
did not improved with IC NTG. PLB had a proximal 80% ostial
stenosis. (RCA difficult to engage and require an AL1 catheter)
2. Limited resting hemodynamics revealed mildly elevated left
sided
filling pressures with LVEDP of 17 mmHg and severely elevated
systemic
arterial pressures with a central aortic pressure of 169/69
mmHg.
3. Left ventriculography was differred.

FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Left ventricular diastolic dysfunction.

-Carotid US ([**2144-12-16**]) - Right ICA <40% stenosis.  Left ICA
40-59% stenosis.

-Right femoral groin US ([**2144-12-19**]) - 11.4 x 3.9 x 10 cm
predominantly hypoechoic structure with a layering echogenic
material likely represents hematoma in the setting of
anticoagulation, however, underlying infectious process cannot
be completely excluded in the correct clinical setting.

-Cardiac cath with PCI ([**2144-12-21**]) - 2 DES to LAD and 1 DES to
RCA, became brady requiring atropine.  SUbsequently became tachy
to 120s and hypertensive to the 180s requiring nitro gtt.  Also
received temporary pacing wire.

-Dual chamber pacemaker ([**2144-12-23**])- [**Company 1543**] placed with leads
going to RA and RV.


Brief Hospital Course:
84 year old female with HTN, HLD, DM2, new atrial fibrillation
presented to OSH with syncope transferred to [**Hospital1 18**] from [**Hospital **]
hospital for cardiac catheterization found to have three vessel
disease (LM 20%, LAD 80%, CX 80%, DIAG 80%, RCA 80%) elected for
interventional management so s/p PCI (2 DES to LAD, 1 DES to
RCA) complicated by complete heart block and hypotension.

#Syncope - No evidence of carotid stenosis.  Given her apparent
tachy-brady syndrome, severely bradycardic episodes may have
caused her syncopal events as she had >2 s pauses visible on
tele.  She did not have any further syncopal events while
admitted to [**Hospital1 18**].  She had a PPM placed on [**12-23**] to prevent
future episodes of bradycardia.

#Coronaries/pump - Initial diagnostic cath showed triple vessel
disease.  Cardiac surgery was consulted and after discussion
with the patient, the decision was made to pursue PCI instead of
CABG.  She had 3 DES placed on [**12-21**] in the LAD and 1 in the
RCA.  She will continue on Plavix for at least 1 year and ASA
for lifetime.  She did not have any chest pain or other ischemic
symptoms during this admission.  Metoprolol was initially held
given her severe bradycardia, this was restarted after she
received her PPM.  She was also continued on atorvastatin 40mg
daily.

#Rhythm - Newly diagnosed with atrial fibrillation with episodes
of tachycardia and bradycardia, as above.  CHADS2 score is 3
(age, HTN, diabetes), however coumadin was held during workup
for cabg.  Pt was given heparin, however, after development of
groin hematoma this was stopped.  Pt was profoundly bradycardia
in the cath lab on [**12-21**] after PCI and received atropine, which
sibsequently made her tachycardic to the 120s and hypertensive.
This was suggestive of sick sinus syndrome and suggested that
she would need a PPM.  A temporary pacing wire was placed in the
cath lab and she was admitted to the CCU on [**12-21**] for closer
monitoring.  This wire was subsequently removed the same evening
as she was not requiring transvenous pacing.  The evening prior
to PPM placement, she was restarted on Coumadin for AF
anticoagulation without need for bridge.  Dual chamber [**Company **]
PPM placed on [**12-23**].  Pt given vancomycin while in house.  Will
need two days of keflex 500 mg TID.

#Groin hematoma - She had a significant right groin hematoma
after the initial diagnostic cath on [**12-15**] which resulted in a 5
point Hct drop and she required 2 units PRBCs.  Subsequently,
her Hct was stable although she continued to have significant
bruising at the right femoral access site.

#Hypertension - She briefly required a nitro drop for HTN after
leaving the cath lab on [**12-21**].  This was quickly weaned.  She
was continued on her home dose of HCTZ.  Her ACEi was held given
that her Cr rose after the initial cath on [**12-15**] and she
received over 300cc of contrast with her second cath.
Metoprolol was also held after admission to the CCU given her
bradycardia in the cath lab.

#[**Last Name (un) **] - Cr rose to 1.7 4 days after the initial diagnostic cath,
which returned to baseline of 1.0.  This is consistent with
contrast induced nephropathy.  After the second cath on [**12-21**],
Cr was stable.  ACEi was held and she received sodium bicarb
after the second cath during which she received ~350cc of
contrast.  We have continued to hold ACE-inhibitor and this can
be restarted at discretion of PCP.

#Hypothyroidism - Found to have elevated TSH with low free T4.
She was started on levothyroxine for hypothyroidism.  Pt was
found to have a palpable thyroid mass.  Pt should have follow up
with ultrasound and repeat TSH in [**4-29**] weeks.

#Diabetes - Diet controlled at home, was covered with an insulin
sliding scale during this admission.

#Depression/anxiety - Continued home Celexa and Ativan.

#GERD/gastritis - Given pantoprazole and maalox.

#Code status this admission - FULL CODE

#Transitional issues
-Will need Plavix for at least 1 year after her cath with PCI
([**2144-12-21**])
-Should continue on lifelong aspirin therapy
-Will need hypothyroidism followed-up as an outpatient and a
thyroid US
-Will need INR monitored while on Coumadin

Medications on Admission:
ASA 81 mg dialy
HCTZ 12.5 mg daily
metoprolol succinate ER 50 mg daily
ativan 0.5 mg a day at bed time
loperamide 2 mg every 6 hr prn
celexa 10 mg a day
meclizine 25 mg three times a day PRN
nexium 40 mg daily
ambien 10 mg a day
coumadin 3 mg

Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as
needed for constipation.
4. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. meclizine 12.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
6. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) as needed for anxiety: Please hold for sedation and
respiratory rate <12.
7. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
10. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for heartburn.
12. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
13. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM.
14. Ondansetron 4 mg IV Q8H:PRN nausea
15. Keflex 500 mg Capsule Sig: One (1) Capsule PO every eight
(8) hours for 2 days.
16. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
17. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.


Discharge Disposition:
Extended Care

Facility:
Charlwell House - [**Location (un) **]

Discharge Diagnosis:
Primary: CAD s/p stenting, atrial flutter and tachy-brady
syndrome s/p pacemaker placement, groin hematoma,
hypothyroidism, [**Last Name (un) **] now resolved

Secondary: HTN, GERD, DM II


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


Discharge Instructions:
Dear Ms. [**Known lastname 15716**],

It was a pleasure taking care of you at [**Hospital1 18**].

You were admitted for an abnormal stress test and an episode of
syncope which occurred after you were recently diagnosed with
atrial fibrillation/flutter.

You were found to have 3 vessel disease on cardiac
catheterization and after much discussion, you underwent
stenting with 2 drug eluting stents (DES) to the Left Anterior
Descending artery (LAD) and 1 DES to the Right coronary artery
(RCA).  During the procedure you went into heart block and
required pacing.

Subsequently, you had a dual chamber [**Company 1543**] pacemaker placed
which resolved the pauses you were previously experiencing.

You also had a large right groin hematoma after the first
cardiac catheterization.  You needed two units of blood due to
the significant amount of blood loss.  This stabalized over the
course of two days without any intervention.

Lastly, you were found to be hypothroid with a palpable thyroid
mass on the right side.  We started you on a new medication
called levothyoxine.  I also recommend that you follow up with
your PCP regarding your hypothyroidism and mass--he can obtain
an ultrasound which might be very useful given your previous
history of thyroid mass.

The following changes were made to your medications.  Please
take these everyday:
Started Atorvastatin to treat your high cholesterol
Started Clopidogrel (Plavix) to prevent stent occlusion
Started Levothyroxine to treat hypothyroidism.  Please take this
medication each morning on an empty stomach 1 hour before
breakfast.
Started Zofran as needed for nausea
Stopped Nexium and started on Pantoprazole
Decreased Metoprolol tartrate to 12.5 mg PO BID
Increase ASA 325mg orally daily
Sarted Keflex 500mg orally every 8 hours for a 2 days

Please wear your sling at night for the next week.  It is okay
to have it off during the day.

DO NOT STOP TAKING ASA AND PLAVIX unless you are told to do so
by your cardiologist.

Followup Instructions:
Dahlia will set up an appointment with Dr. [**Last Name (STitle) 23246**].

Dr. [**Last Name (STitle) 40075**] will see you at rehabilitation

You will need to have a thyroid ultrasound done for your low
thyroid level and evaluation of thyroid nodule



Completed by:[**2144-12-24**]
{'Coronary atherosclerosis of native coronary artery,Atrioventricular block, complete,Hematoma complicating a procedure,Acute kidney failure, unspecified,Cardiac complications, not elsewhere classified,Intermediate coronary syndrome,Atrial flutter,Long-term (current) use of anticoagulants,Paralysis agitans,Esophageal reflux,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution,Mitral stenosis with insufficiency,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Obesity, unspecified,Personal history of malignant neoplasm of ovary,Personal history of malignant neoplasm of thyroid,Personal history of malignant neoplasm of large intestine,Postsurgical hypothyroidism,Other drugs and medicinal substances causing adverse effects in therapeutic use,Other iatrogenic hypotension,Personal history of tobacco use,Dysthymic disorder'}


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, apical perfusion defect on nuclear stress

PRESENT ILLNESS: 84F with HTN, HLD, DM2, newly diagnosed atrial fibrillation in
[**11/2144**] who was transferred to [**Hospital1 18**] from [**Hospital **] hospital for
cardiac catheterization after presentation there with syncopal
episode.  In summary, she has history of syncope & presyncope,
and was recently diagnosed with afib on [**2144-12-4**], CHADS2 score
of 3, and was started on a beta-blocker (metoprolol 50mg daily)
and coumadin.  Persantine thalium stress test showed severe
apical reversible perfusion defect consistent with ischemia
(LAD) and was scheduled for outpt Left heart catheterization
prior to presentation.  On [**2144-12-14**], she presented to [**Hospital **]
Hospital for syncope while sitting and talking on phone with her
neighbor. She was found sitting in chair with phone in hand,
conscious by her neighbor. She had not fallen, denies any CP,
palpitations, fluttering, LH or dizziness. At the OSH she was
noted to have 2.2 second pauses with heart rate in 40's. Ruled
out for MI with Trops less than .01 x3. Referred for [**Hospital1 18**] for
Left Heart Catheterization.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: +Diabetes diet controlled,
+Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
-persistent atrial fibrillation/atypical atrial flutter on
coumadin, diagnosed in 10/[**2144**]. CHADS-2 score is 3.
-GERD
-gastritis, duodenitis
-IBS
-thyroidectomy
-diabetes
-Parkinson's
-anxiety
-depression

MEDICATION ON ADMISSION: ASA 81 mg dialy
HCTZ 12.5 mg daily
metoprolol succinate ER 50 mg daily
ativan 0.5 mg a day at bed time
loperamide 2 mg every 6 hr prn
celexa 10 mg a day
meclizine 25 mg three times a day PRN
nexium 40 mg daily
ambien 10 mg a day
coumadin 3 mg

ALLERGIES: Codeine

PHYSICAL EXAM: Admission exam:
VS: 97.3  157/76 101 (irregular)  18   98%RA
GENERAL: Caucasian female in NAD, pleasant
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: father died of pancreatic cancer at 75. mother had diabetes,
peripheral vascular disease, s/p amputation and died of MI at
64. brother had CAD at 70. Maternal aunt died at 51 from heart
disease.

SOCIAL HISTORY: -Tobacco history: ex-smoker. quit at 40, smoked 1 PPD for 20
years.
-ETOH: none
-Illicit drugs: Denies
-lives alone, retired. Used to work at [**Location (un) 1411**] Court House as a
unit secretary. Has supportive family. Lives in senior housing,
but does all of her own ADLs.
-widowed. has 3 children. Health care proxy is the son [**Name (NI) **]. 

### Response:
{'Coronary atherosclerosis of native coronary artery,Atrioventricular block, complete,Hematoma complicating a procedure,Acute kidney failure, unspecified,Cardiac complications, not elsewhere classified,Intermediate coronary syndrome,Atrial flutter,Long-term (current) use of anticoagulants,Paralysis agitans,Esophageal reflux,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution,Mitral stenosis with insufficiency,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Obesity, unspecified,Personal history of malignant neoplasm of ovary,Personal history of malignant neoplasm of thyroid,Personal history of malignant neoplasm of large intestine,Postsurgical hypothyroidism,Other drugs and medicinal substances causing adverse effects in therapeutic use,Other iatrogenic hypotension,Personal history of tobacco use,Dysthymic disorder'}
