CHIEF COMPLAINT: Syncope, torsades de pointes

PRESENT ILLNESS: Ms. [**Known lastname **] is a 69 yo woman with ESRD secondary to DM and HTN,
CHF, hx of TIA, presented to ED after syncopal episode. She had
been in her usual state of health until she began having
syncopal episodes about 1.5 weeks ago. Prior to today, she has
had 2 episodes of passing out for a few seconds, once at home
and once at her son's. Of note, she also felt lightheaded after
dialysis on Monday, which resolved later in the day with rest.
She denies any recent medication changes, except for switch to
Celexa from Lexapro more than 6 months ago.
.
This morning, patient had left in the morning around 6am for a
nephrology appointment at [**Hospital1 18**]. She felt well upon awakening
but had not eaten breakfast. She was sitting in the backseat of
the T Ride when she suddenly lost consciousness for [**11-10**]
minutes. Her daughter was with her at the time and did not note
any head trauma or shaking. Denies any chest pain, numbness or
tingling in her arms, palpitations, diaphoresis, or shortness of
breath prior to or after the syncope episode. Patient awoke in
the ambulance and was transported to the [**Hospital1 18**] ED.
.
On review of systems, patient has had TIA x 2 without residual
neuro deficits. S/he denies any prior history of stroke, deep
venous thrombosis, pulmonary embolism, bleeding at the time of
surgery, myalgias, joint pains, cough, hemoptysis, black stools
or red stools. S/he denies recent fevers, chills or rigors. S/he
denies exertional buttock or calf pain. All of the other review
of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations.  Positive for syncope and
lightheadedness.
.
In the ED, initial vitals were HR 70s, BP 90s/50s, AF. EKG on
admission showed QT prolongation. Patient had torsades de
pointes x 2, lasting < 1 min each and was unresponsive. Prior to
torsades, she was eating lunch and felt slightly lightheaded.
Central line was placed in R femoral and Mag 5 mg IV was given.
Neuro was consulted and felt cause of syncope is unlikely
neurogenic given head CT that was negative for bleed and more
likely cardiac or from hypoperfusion.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
- CHF
- A-fib
- Hypercholesterolemia
3. OTHER PAST MEDICAL HISTORY:
- ESRD, on M/W/F HD
- DM2 x >20 yrs
- HTN
- hx of uterine CA, s/p TAH-BSO in [**2098**]
- TIA x 2
- L AV graft

MEDICATION ON ADMISSION: - coumadin 5 mg daily
- levothyroxine
- ASA 81 mg
- Celexa
- Acidophilus
- PhosLo 3 tabs qac
- simvastatin 40 mg daily
- nifedepine on T/R/Sat/Sun
- renal vitamins

ALLERGIES: Sulfa (Sulfonamides) / Morphine Sulfate

PHYSICAL EXAM: VS: T=98 BP=104/61 HR=74 RR=15 O2 sat=96% on RA
GENERAL: WDWN female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Poor dentition.
NECK: Supple with JVP to angle of jaw. No carotid bruits
CARDIAC: RR, normal S1, S2. 2/6 systolic cresc-decresc murmur.
No thrills, lifts. No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, mild
bibasilayr crackles.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits. Large, reducible
ventral hernia
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Radial 2+ DP 1+ PT 1+
Left: Radial 2+ DP 1+ PT 1+

FAMILY HISTORY: Mother and GM died of cancer in their 80's. DM in grandfather.
Daughter had [**Name2 (NI) **] CA and son had oral CA. No family history of
early MI, arrhythmia, cardiomyopathies, or sudden cardiac death;
otherwise non-contributory.

SOCIAL HISTORY: -Tobacco history:  rarely
-ETOH:  ocassional (<1 drink/wk)
-Illicit drugs:  denies
Lives with daughter, daughter's boyfriend, and grandson. [**Name (NI) **]
good support system at home for ADL's.
Paroxysmal ventricular tachycardia,Subendocardial infarction, initial episode of care,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Chronic systolic heart failure,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Renal dialysis status,Other and unspecified hyperlipidemia,Long-term (current) use of anticoagulants,Unspecified acquired hypothyroidism,Personal history of malignant neoplasm of other parts of uterus,Depressive disorder, not elsewhere classified,Aortic valve disorders,Diseases of tricuspid valve,Anemia in chronic kidney disease,Hypotension, unspecified,Hyperpotassemia
Parox ventric tachycard,Subendo infarct, initial,Hyp kid NOS w cr kid V,End stage renal disease,Chr systolic hrt failure,DMII renl nt st uncntrld,Renal dialysis status,Hyperlipidemia NEC/NOS,Long-term use anticoagul,Hypothyroidism NOS,Hx-uterus malignancy NEC,Depressive disorder NEC,Aortic valve disorder,Tricuspid valve disease,Anemia in chr kidney dis,Hypotension NOS,Hyperpotassemia
Admission Date:  [**2112-10-13**]              Discharge Date:   [**2112-10-20**]

Date of Birth:  [**2043-7-2**]             Sex:   F

Service: MEDICINE

Allergies:
Sulfa (Sulfonamides) / Morphine Sulfate

Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Syncope, torsades de pointes

Major Surgical or Invasive Procedure:
Cardiac cath and drug-eluting stent placement [**2112-10-17**]

History of Present Illness:
Ms. [**Known lastname **] is a 69 yo woman with ESRD secondary to DM and HTN,
CHF, hx of TIA, presented to ED after syncopal episode. She had
been in her usual state of health until she began having
syncopal episodes about 1.5 weeks ago. Prior to today, she has
had 2 episodes of passing out for a few seconds, once at home
and once at her son's. Of note, she also felt lightheaded after
dialysis on Monday, which resolved later in the day with rest.
She denies any recent medication changes, except for switch to
Celexa from Lexapro more than 6 months ago.
.
This morning, patient had left in the morning around 6am for a
nephrology appointment at [**Hospital1 18**]. She felt well upon awakening
but had not eaten breakfast. She was sitting in the backseat of
the T Ride when she suddenly lost consciousness for [**11-10**]
minutes. Her daughter was with her at the time and did not note
any head trauma or shaking. Denies any chest pain, numbness or
tingling in her arms, palpitations, diaphoresis, or shortness of
breath prior to or after the syncope episode. Patient awoke in
the ambulance and was transported to the [**Hospital1 18**] ED.
.
On review of systems, patient has had TIA x 2 without residual
neuro deficits. S/he denies any prior history of stroke, deep
venous thrombosis, pulmonary embolism, bleeding at the time of
surgery, myalgias, joint pains, cough, hemoptysis, black stools
or red stools. S/he denies recent fevers, chills or rigors. S/he
denies exertional buttock or calf pain. All of the other review
of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations.  Positive for syncope and
lightheadedness.
.
In the ED, initial vitals were HR 70s, BP 90s/50s, AF. EKG on
admission showed QT prolongation. Patient had torsades de
pointes x 2, lasting < 1 min each and was unresponsive. Prior to
torsades, she was eating lunch and felt slightly lightheaded.
Central line was placed in R femoral and Mag 5 mg IV was given.
Neuro was consulted and felt cause of syncope is unlikely
neurogenic given head CT that was negative for bleed and more
likely cardiac or from hypoperfusion.

Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
- CHF
- A-fib
- Hypercholesterolemia
3. OTHER PAST MEDICAL HISTORY:
- ESRD, on M/W/F HD
- DM2 x >20 yrs
- HTN
- hx of uterine CA, s/p TAH-BSO in [**2098**]
- TIA x 2
- L AV graft

Social History:
-Tobacco history:  rarely
-ETOH:  ocassional (<1 drink/wk)
-Illicit drugs:  denies
Lives with daughter, daughter's boyfriend, and grandson. [**Name (NI) **]
good support system at home for ADL's.

Family History:
Mother and GM died of cancer in their 80's. DM in grandfather.
Daughter had [**Name2 (NI) **] CA and son had oral CA. No family history of
early MI, arrhythmia, cardiomyopathies, or sudden cardiac death;
otherwise non-contributory.

Physical Exam:
VS: T=98 BP=104/61 HR=74 RR=15 O2 sat=96% on RA
GENERAL: WDWN female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Poor dentition.
NECK: Supple with JVP to angle of jaw. No carotid bruits
CARDIAC: RR, normal S1, S2. 2/6 systolic cresc-decresc murmur.
No thrills, lifts. No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, mild
bibasilayr crackles.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits. Large, reducible
ventral hernia
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Radial 2+ DP 1+ PT 1+
Left: Radial 2+ DP 1+ PT 1+

Pertinent Results:
Labs on admission:
[**2112-10-13**] 08:55AM   PT-43.2* PTT-31.5 INR(PT)-4.6*
[**2112-10-13**] 08:55AM   PLT COUNT-208
[**2112-10-13**] 08:55AM   NEUTS-82.8* LYMPHS-12.2* MONOS-2.7 EOS-1.8
BASOS-0.6
[**2112-10-13**] 08:55AM   WBC-11.1* RBC-4.84# HGB-14.2 HCT-47.6# MCV-98
MCH-29.3 MCHC-29.8* RDW-17.2*
[**2112-10-13**] 08:55AM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2112-10-13**] 08:55AM   CALCIUM-9.0 PHOSPHATE-2.4*# MAGNESIUM-1.7
[**2112-10-13**] 08:55AM   CK-MB-NotDone
[**2112-10-13**] 08:55AM   cTropnT-0.20*
[**2112-10-13**] 08:55AM   CK(CPK)-96
[**2112-10-13**] 08:55AM   estGFR-Using this
[**2112-10-13**] 08:55AM   GLUCOSE-153* UREA N-28* CREAT-5.5* SODIUM-142
POTASSIUM-3.8 CHLORIDE-96 TOTAL CO2-29 ANION GAP-21*
[**2112-10-13**] 03:28PM   TSH-1.0
.
Labs on discharge:
COMPLETE BLOOD COUNT    WBC RBC   Hgb    Hct MCV MCH  MCHC RDW
Plt Ct
[**2112-10-20**] 04:49AM    7.1  3.30* 10.2* 32.5* 98 31.0 31.5 17.2*
160
                       Glucose UreaN Creat Na   K   Cl HCO3
AnGap
[**2112-10-20**] 04:49AM    86      31*   4.4*# 140 4.9 101 30 14
PT/INR 12.8/1.1

.
EKG [**2112-10-12**]: NSR @ 60bpm, no ectopy, LAD, PRWP (new since
[**2111-3-25**]), normal PR and QRS intervals, QTc prolonged at 620ms,
no LVH, no ST elevations/depresions.
.
TELEMETRY:  Episodes of R on T and torsades noted on tele.
.
CHEST XRAY [**2112-10-13**]:
PA and lateral chest radiograph. The mildly enlarged
cardiomediastinal silhouette is stable. Again noted are aortic
calcifications, most prominent at the aortic knob. There is
interval removal of the dual-lumen dialysis catheter. The
pulmonary vasculature is mildly engorged and increased
interstitial markings bilaterally are unchanged, compatible with
mild interstitial edema. There are no pleural effusions. The
lungs are otherwise grossly clear without new focal
consolidations. In the low thoracic spine there is an apparent
new anterior wedge deformity, which is not seen a year and a
half ago. Degenerative changes are noted in the thoracic spine.
IMPRESSION:
1. Mild interstitial pulmonary edema.
2. Mild anterior wedge deformity in a low thoracic vertebral
body, new in the interval.
.
HEAD CT [**2112-10-13**]:
There is no acute intracranial hemorrhage or fracture. No large
territorial infarct, edema or mass effect are noted. The midline
structures are normal. The ventricles and sulci are prominent,
compatible with age-appropriate atrophy. There is
periventricular and subcortical white matter disease, compatible
with chronic small vessel ischemia. Again noted is a punctate
calcific density in the right sylvian fissure, unchanged, and
may represent a calcified granuloma, sequela of prior
neurocysticercosis, or be vascular etiology. A non- aggressive-
appearing lucent lesion is unchanged in the left frontal bone,
previously thought to be a hemangioma.
There is significant calcification in the distal vertebral
arteries as well as the cavernous portions of the internal
carotid arteries bilaterally The visualized paranasal sinuses
and mastoid air cells are clear.
IMPRESSION: No acute intracranial process.
.
TTE [**2112-10-14**]:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is severely
depressed (LVEF= 20 %) secondary to extensive anterior, septal,
and apical akinesis. Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). There
is no left ventricular outflow obstruction at rest or with
Valsalva. There is no ventricular septal defect. Right
ventricular chamber size is normal. with depressed free wall
contractility. There are focal calcifications in the aortic
arch. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. There is moderate aortic
valve stenosis. Mild to moderate ([**1-29**]+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. There is severe mitral annular
calcification. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Impression: extensive anterior, septal, and apical akinesis with
moderate-to-severe tricuspid regurgitation and at least mild
mitral regurgitation; moderate aortic stenosis.
.
Cardiac Cath [**2112-10-18**]:
COMMENTS:
1. Selective coronary angiography in this right dominant system
demonstrated one vessel disease. The LMCA had no
angiographically
apparent disease. The LAD had a hazy 80& stenosis right after
the first
septal branch. D1 had a proximal 60% stenosis. The Cx had no
angiographically apparent disease. The RCA had a 50% stenosis in
the mid
portion of the vessel.
2. Successful PCI of the proximal LAD with a 3.0x18mm Promus
DES.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Successful PCI of the LAD with DES.


Brief Hospital Course:
Ms. [**Known lastname **] is a 69 yo woman with ESRD/HD secondary to DM and HTN,
CHF, paroxysmal atrial fibrillation, hx of TIA, who presented to
ED after a syncopal episode.  In the ED she was found to have
prolonged QTc with episodes of symptomatic torsades de pointes.
The patient was discharged home with appropriate cardiac
follow-up.
.
# RHYTHM: Syncope of recent onset was thought to be due to QT
prolongation and pause-dependent torsades de pointes of unclear
etiology. Given patient age and lack of syncope history prior to
recent episodes, prolonged QT syndrome was thought unlikely to
be purely secondary to congenital channelopathy. Due to concern
that torsades de pointes could be medication-induced, Celexa was
discontinued. Electrolyte imbalance was also considered due to
patient's ESRD and HD, although electrolytes were only
borderline low (K 3.8, Mg 1.7). Potassium was repleted prn in
diasylate with goal of 5.0, and magnesium repleted to goal of
high-normal. Ischemia from possible ACS may also have
contributed to [**Known lastname 74264**] (see below). Patient had brief recurrence of
torsades de pointes on [**2112-10-14**] during HD that self-terminated
and did not require isoproterenol or temp pacing. EKG was
monitored daily and showed persistent QT prolongation that did
improve over the course of her hospitalization from 620ms to
469ms. EP was consulted and recommended initiation of verapamil,
which the patient tolerated well. ICD placement was deferred due
to patient's ESRD, stable condition, and improvement with
medical mangement of prolonged QT. Other than episodes of [**Name (NI) 74264**],
pt was in NSR throughout hospitalization. Coumadin was initially
held due to supratherapeutic INR of 4.6 on admission but later
resumed for her history of atrial fibrillation.
.
# PUMP: Patient had unclear history of congestive heart failure
based on TTE and TEE done 3 yrs ago at OSH. TTE performed
[**2112-10-14**] showed LVEF of 20% with extensive anterior, septal, and
apical akinesis, moderate-to-severe tricuspid regurgitation, at
least mild mitral regurgitation, and moderate aortic stenosis.
Based on cardiac cath findings, wall motion abnormalities and
systolic heart failure was consistent with ischemic
cardiomyopathy. Patient was fluid restricted and kept on
low-salt diet. Daily weights and I/O's were monitored. No ACE-I
was given due to ESRD. On discharge, patient was 64.2kg and had
net fluid balance of about positive 600 mL.  She anuric and
dependent on HD for fluid removal.
.
# CORONARIES: Patient had no known coronary artery disease prior
to admission but had chemical stress test in [**2111-7-28**] that was
normal per patient history. EKG during admission showed loss of
R waves in in precordial leads and diffuse ST elevations that
were both new compared with EKG from 2/[**2111**]. Cardiac enzymes
were initially elevated and trended until peak of CK 1044, MB
50, TropT 4.50 on [**10-14**] afternoon. It was unclear whether the
cardiac enzyme leak was secondary to global ischemia from [**Month/Year (2) 74264**] or
due to primary ACS event that may have led to [**Month/Year (2) 74264**]. The patient
was treated with ASA 325, Plavix 75 mg, heparin gtt, and
continued on simvastatin 40 mg. She underwent non-emergent left
cardiac cath on [**2112-10-18**] that showed a hazy 80% stenosis in the
LAD just distal to takeoff of first septal, in addition to 60%
stenosis in proximal D1 and 50% stenosis in mid-RCA. Promus
drug-eluting stent was placed in LAD with good effect.
.
# ESRD: Patient continued to receive M/W/F hemodialysis via left
AV graft. Patient has been essentially anuric. Electrolytes have
been stable since admission. Dialysate adjusted to maintain
potassium around 5.0 due to [**Date Range 74264**] arrhythmia. Renal tabs and
PhosLo were continued. Patient is on Epo for anemia of chronic
disease.
.
# R FEMORAL HEMATOMA: Hematoma developed around R femoral line
placed emergently in ED, likely [**2-29**] supratherapeutic INR.
Resolved after administration of vitamin K and pressure
dressings. LFT's were not indicative of coagulopathy from liver
disease.
.
# HYPOTHYROIDISM: Due to concern of hypothyroidism contributing
to [**Month/Day (2) 74264**], TSH was checked and wnl (1.0). Levothyroxine was
continued at home dose throughout hospital stay.
.
# DM2: Blood sugars were well-controlled. Patient is not on any
insulin or oral hypoglycemics at home. Diabetic diet and
sliding-scale insulin was given for glycemic control.
.
# CODE: FULL

Medications on Admission:
- coumadin 5 mg daily
- levothyroxine
- ASA 81 mg
- Celexa
- Acidophilus
- PhosLo 3 tabs qac
- simvastatin 40 mg daily
- nifedepine on T/R/Sat/Sun
- renal vitamins

Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): You should take this medication for at least 12 months.
Disp:*30 Tablet(s)* Refills:*2*
2. Verapamil 40 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours): Please skip your morning dose on days you receive
hemodialysis.
Disp:*90 Tablet(s)* Refills:*2*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
4. Outpatient Lab Work
Please have your INR blood test done at your dialysis center on
Monday [**2112-10-24**] and have the results forwarded to Dr. [**Last Name (STitle) **] as
well as your Dr. [**Last Name (STitle) 74265**] (fax# [**Telephone/Fax (1) 74266**]) for monitoring
your Coumadin (warfarin) dose.
5. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day:
Please resume the 81 mg baby aspirin after you finish with 1
month of 325 mg aspirin.
Disp:*30 Tablet(s)* Refills:*2*
6. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO once a
day.
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
9. Calcium Acetate 667 mg Tablet Sig: Three (3) Tablet PO three
times a day: take with meals.
10. Acidophilus 500 million cell Tablet Sig: One (1) Tablet PO
once a day.


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnosis:
Ventricular Tachycardia with prolonged QTc
STEMI
.
Secondary Diagnoses:
End stage renal disease on HD (M,W,F)
Diabetes Mellitus
Hypertension
Chronic systolic CHF
Paroxysmal Atrial Fibrillation


Discharge Condition:
Good; hemodynamically stable and improved


Discharge Instructions:
You were admitted to the hospital with an abnormal heart rhythm,
called torsades de pointes, possibly related to some of your
home medications, as well as changes to your electrolytes. We
treated you by stopping some of your home medications (Celexa),
and repleting your electrolytes.  While you were an inpatient,
you had changes to your ECG and blood tests concerning for a
myocardial infarction (commonly known as a heart attack).
Consequently, you underwent a cardiac catheterization and a
drug-eluting stent was placed in your LAD (one of the major
arteries supplying blood to your heart).
.
At your outpatient hemodialysis in the future, it is important
that they monitor your electrolytes closely and adjust dialysis
for a goal potassium greater than 4.5 and goal magnesium greater
than 2.
.
The following changes were made to your medications:
STOP Celexa
STOP Nifedepine
START Verapamil 40 mg three times daily. Do not take your
morning dose of verapamil on days you receive dialysis.
START Aspirin 325 mg once daily for 1 month then resume aspirin
81 mg once daily.
START Plavix 75 mg. You should take this medication for at least
12 months.
.
If you experience any further episodes of dizziness or "spells,"
chest pain, palpitations, shortness of breath, dark tarry
stools, abnormal bleeding or other concerning symptoms, please
call 911 or your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 74265**] at [**0-0-**].
.


Followup Instructions:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (Cardiology) on Tuesday, [**2112-11-8**] at
1:00 pm
[**Hospital1 18**] - Cardiac Services
[**Location (un) 830**], [**Hospital Ward Name 23**] 7
[**Location (un) 86**], [**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 62**]

Dr. [**First Name4 (NamePattern1) 24592**] [**Last Name (NamePattern1) 74265**] (PCP) on Thursday, [**2112-11-3**] at 9:15
am
Phone: [**0-0-**]

You should have your INR blood test drawn on Monday at your
dialysis clinic and have the results forwarded to Dr. [**Last Name (STitle) **]
for management of your coumadin dose.
{'Paroxysmal ventricular tachycardia,Subendocardial infarction, initial episode of care,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Chronic systolic heart failure,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Renal dialysis status,Other and unspecified hyperlipidemia,Long-term (current) use of anticoagulants,Unspecified acquired hypothyroidism,Personal history of malignant neoplasm of other parts of uterus,Depressive disorder, not elsewhere classified,Aortic valve disorders,Diseases of tricuspid valve,Anemia in chronic kidney disease,Hypotension, unspecified,Hyperpotassemia'}


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, torsades de pointes

PRESENT ILLNESS: Ms. [**Known lastname **] is a 69 yo woman with ESRD secondary to DM and HTN,
CHF, hx of TIA, presented to ED after syncopal episode. She had
been in her usual state of health until she began having
syncopal episodes about 1.5 weeks ago. Prior to today, she has
had 2 episodes of passing out for a few seconds, once at home
and once at her son's. Of note, she also felt lightheaded after
dialysis on Monday, which resolved later in the day with rest.
She denies any recent medication changes, except for switch to
Celexa from Lexapro more than 6 months ago.
.
This morning, patient had left in the morning around 6am for a
nephrology appointment at [**Hospital1 18**]. She felt well upon awakening
but had not eaten breakfast. She was sitting in the backseat of
the T Ride when she suddenly lost consciousness for [**11-10**]
minutes. Her daughter was with her at the time and did not note
any head trauma or shaking. Denies any chest pain, numbness or
tingling in her arms, palpitations, diaphoresis, or shortness of
breath prior to or after the syncope episode. Patient awoke in
the ambulance and was transported to the [**Hospital1 18**] ED.
.
On review of systems, patient has had TIA x 2 without residual
neuro deficits. S/he denies any prior history of stroke, deep
venous thrombosis, pulmonary embolism, bleeding at the time of
surgery, myalgias, joint pains, cough, hemoptysis, black stools
or red stools. S/he denies recent fevers, chills or rigors. S/he
denies exertional buttock or calf pain. All of the other review
of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations.  Positive for syncope and
lightheadedness.
.
In the ED, initial vitals were HR 70s, BP 90s/50s, AF. EKG on
admission showed QT prolongation. Patient had torsades de
pointes x 2, lasting < 1 min each and was unresponsive. Prior to
torsades, she was eating lunch and felt slightly lightheaded.
Central line was placed in R femoral and Mag 5 mg IV was given.
Neuro was consulted and felt cause of syncope is unlikely
neurogenic given head CT that was negative for bleed and more
likely cardiac or from hypoperfusion.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
- CHF
- A-fib
- Hypercholesterolemia
3. OTHER PAST MEDICAL HISTORY:
- ESRD, on M/W/F HD
- DM2 x >20 yrs
- HTN
- hx of uterine CA, s/p TAH-BSO in [**2098**]
- TIA x 2
- L AV graft

MEDICATION ON ADMISSION: - coumadin 5 mg daily
- levothyroxine
- ASA 81 mg
- Celexa
- Acidophilus
- PhosLo 3 tabs qac
- simvastatin 40 mg daily
- nifedepine on T/R/Sat/Sun
- renal vitamins

ALLERGIES: Sulfa (Sulfonamides) / Morphine Sulfate

PHYSICAL EXAM: VS: T=98 BP=104/61 HR=74 RR=15 O2 sat=96% on RA
GENERAL: WDWN female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Poor dentition.
NECK: Supple with JVP to angle of jaw. No carotid bruits
CARDIAC: RR, normal S1, S2. 2/6 systolic cresc-decresc murmur.
No thrills, lifts. No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, mild
bibasilayr crackles.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits. Large, reducible
ventral hernia
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Radial 2+ DP 1+ PT 1+
Left: Radial 2+ DP 1+ PT 1+

FAMILY HISTORY: Mother and GM died of cancer in their 80's. DM in grandfather.
Daughter had [**Name2 (NI) **] CA and son had oral CA. No family history of
early MI, arrhythmia, cardiomyopathies, or sudden cardiac death;
otherwise non-contributory.

SOCIAL HISTORY: -Tobacco history:  rarely
-ETOH:  ocassional (<1 drink/wk)
-Illicit drugs:  denies
Lives with daughter, daughter's boyfriend, and grandson. [**Name (NI) **]
good support system at home for ADL's. 

### Response:
{'Paroxysmal ventricular tachycardia,Subendocardial infarction, initial episode of care,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Chronic systolic heart failure,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Renal dialysis status,Other and unspecified hyperlipidemia,Long-term (current) use of anticoagulants,Unspecified acquired hypothyroidism,Personal history of malignant neoplasm of other parts of uterus,Depressive disorder, not elsewhere classified,Aortic valve disorders,Diseases of tricuspid valve,Anemia in chronic kidney disease,Hypotension, unspecified,Hyperpotassemia'}
