CHIEF COMPLAINT: Syncope

PRESENT ILLNESS: Ms. [**Known lastname 14738**] is a 61 y/o F with hx of mild dHF, HTN, bicuspid AV,
s/p mechanical AVR on coumadin (INR 2.4 on admission), severe
asthma (on prednisone) who was transferred to [**Hospital1 18**] for [**Hospital 16186**] after presenting there for syncope.  She has a hx of
severe asthma and has been on prednisone for the last 6-7 years
with inability to wean due to increased wheezing and SOB.  She
states that over the last 6 months she has had more frequent
episodes of "blacking out" that seem to occur after using her
asthma inhalers.  During each episode she denies CP, SOB, but
has some nausea.  Yesterday, while at her daughter's house she
was sitting on the couch and blacked out on two separate
occasions lasting a few seconds and then she came two.  She was
hospitalized [**2184-7-5**] year ago for similar c/o and was
monitored continuously on Tele, with no events detected.

MEDICAL HISTORY: PAST CARDIAC HISTORY:
.
1. CARDIAC RISK FACTORS: (+)Diabetes (borderline),
(-)Dyslipidemia, (+)Hypertension
2. CARDIAC HISTORY:
- Aortic valve replacement for critical AS/bicuspid aortic
valve, #21 Carbomedics mechanical valve c/b pericardial
tamponade and cardiac arrest ([**2175**])
.
OTHER PAST MEDICAL HISTORY:
- chronic anticoagulation w/ warfarin
- Hypertension, well controlled on meds
- Severe asthma, on multiple meds
- Allergic rhinitis
- Right lower quadrant hernia
- Osteoarthritis
- Chronically elevated CPK and bilateral calf pain
- Acid reflux
- Obesity
- DM2 (borderline, not on meds)
- Gout
- Gallstones
- H/o colonic ulcer [**2183**]

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Furosemide 60 mg PO DAILY
2. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB or Wheezing
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB or wheezing
4. Losartan Potassium 50 mg PO DAILY
5. Meclizine 25 mg PO BID:PRN Dizziness
6. Metoprolol Tartrate 25 mg PO BID
7. Montelukast Sodium 10 mg PO DAILY
8. Nystatin Cream 1 Appl TP [**Hospital1 **]
9. omalizumab *NF* 300 mg Subcutaneous Q2 weeks
10. Omeprazole 20 mg PO TID
11. PredniSONE 5 mg PO DAILY
Taper
Tapered dose - DOWN
12. TraMADOL (Ultram) 50 mg PO TID:PRN pain
13. Triamcinolone Acetonide 0.1% Cream 1 Appl TP [**Hospital1 **]
14. Colchicine 0.6 mg PO QOD
15. Fluticasone Propionate NASAL 2 SPRY NU DAILY
16. Artificial Tears 1-2 DROP BOTH EYES [**Hospital1 **]
17. Fish Oil (Omega 3) 1000 mg PO BID
18. Terbinafine 1% Cream 1 Appl TP [**Hospital1 **]
19. Verapamil SR 240 mg PO Q24H
20. Warfarin 4 mg PO DAILY16

ALLERGIES: Univasc / Amlodipine / Norvasc

PHYSICAL EXAM: ADMISSION:
VS: T=98.8 BP=133/65 HR=104 RR= 21 O2 sat= 97%RA
GENERAL: Overweight 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.

FAMILY HISTORY: FAMILY HISTORY: Daughter died of AML @ age 38 in [**2184-6-4**].
Older sister with breast cancer age 65. Strong family history of
DM2 & HTN. No family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
- Sister x 2 --> Breast Ca
- Sister --> Heart Block
- Brother --> CAD
- Brother --> Thyroid Ca

SOCIAL HISTORY: SOCIAL HISTORY:
- Tobacco history: denies
- EtOH: social, very rare
- Illicit drugs: denies
.
Atrioventricular block, complete,Chronic diastolic heart failure,Syncope and collapse,Heart valve replaced by other means,Other and unspecified hyperlipidemia,Long-term (current) use of anticoagulants,Asthma, unspecified type, unspecified,Unspecified essential hypertension,Other abnormal glucose
Atriovent block complete,Chr diastolic hrt fail,Syncope and collapse,Heart valve replac NEC,Hyperlipidemia NEC/NOS,Long-term use anticoagul,Asthma NOS,Hypertension NOS,Abnormal glucose NEC
Admission Date:  [**2185-8-8**]              Discharge Date:   [**2185-8-10**]

Date of Birth:  [**2124-7-12**]             Sex:   F

Service: MEDICINE

Allergies:
Univasc / Amlodipine / Norvasc

Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Syncope

Major Surgical or Invasive Procedure:
Permanent pacemaker

History of Present Illness:
Ms. [**Known lastname 14738**] is a 61 y/o F with hx of mild dHF, HTN, bicuspid AV,
s/p mechanical AVR on coumadin (INR 2.4 on admission), severe
asthma (on prednisone) who was transferred to [**Hospital1 18**] for [**Hospital 16186**] after presenting there for syncope.  She has a hx of
severe asthma and has been on prednisone for the last 6-7 years
with inability to wean due to increased wheezing and SOB.  She
states that over the last 6 months she has had more frequent
episodes of "blacking out" that seem to occur after using her
asthma inhalers.  During each episode she denies CP, SOB, but
has some nausea.  Yesterday, while at her daughter's house she
was sitting on the couch and blacked out on two separate
occasions lasting a few seconds and then she came two.  She was
hospitalized [**2184-7-5**] year ago for similar c/o and was
monitored continuously on Tele, with no events detected.

At OSH, VS 98.8, 121/48, 48, 21 98%RA.  EKG obtained at OSH was
c/w CHB with infranodal escape with RB at 43BPM.  She was
transferred to [**Hospital1 18**] for further evaluation.  Upon transfer in
the ED she had another syncopal episode and was apparently in
Sinus tachy to 110 at this point.  EKG at this time showed sinus
tachycardia with RBBB.  EP was called and was told to give
Metop, but it was not given.  They repleted his K and sent
admitted him to the CCU.

Upon admission to the CCU, initial EKG showed sinus tachycardic
with 1st degree AVB with a LBBB pattern.  During initial
evaluation, the patient had a 9 second pause on tele during
which time the patient reported "blacking out".  Her rhythm
returned spontaneously and repeat EKG at this time showed CHB
with RBBB pattern.  After which, emergent temporary pacer was
placed in the right ventricle via a right IJ Cordis.  The wires
are situated in the posterior RV, placement confirmed by CXR
post-procedure. She is currently being paced at 50bpm, MA 5mV.


Past Medical History:
PAST CARDIAC HISTORY:
.
1. CARDIAC RISK FACTORS: (+)Diabetes (borderline),
(-)Dyslipidemia, (+)Hypertension
2. CARDIAC HISTORY:
- Aortic valve replacement for critical AS/bicuspid aortic
valve, #21 Carbomedics mechanical valve c/b pericardial
tamponade and cardiac arrest ([**2175**])
.
OTHER PAST MEDICAL HISTORY:
- chronic anticoagulation w/ warfarin
- Hypertension, well controlled on meds
- Severe asthma, on multiple meds
- Allergic rhinitis
- Right lower quadrant hernia
- Osteoarthritis
- Chronically elevated CPK and bilateral calf pain
- Acid reflux
- Obesity
- DM2 (borderline, not on meds)
- Gout
- Gallstones
- H/o colonic ulcer [**2183**]

Social History:
SOCIAL HISTORY:
- Tobacco history: denies
- EtOH: social, very rare
- Illicit drugs: denies
.


Family History:
FAMILY HISTORY: Daughter died of AML @ age 38 in [**2184-6-4**].
Older sister with breast cancer age 65. Strong family history of
DM2 & HTN. No family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
- Sister x 2 --> Breast Ca
- Sister --> Heart Block
- Brother --> CAD
- Brother --> Thyroid Ca

Physical Exam:
ADMISSION:
VS: T=98.8 BP=133/65 HR=104 RR= 21 O2 sat= 97%RA
GENERAL: Overweight 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.

NECK: No JVD, right Cordis in place.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. 3/6 systolic ejection murmur with loud
S2. No thrills, lifts. No S3 or S4.
LUNGS: Bilateral expiratory wheezes over anterior chest.
ABDOMEN: Obese abdomen, soft, NTND. No HSM or tenderness. Abd
aorta not enlarged by palpation. No abdominial bruits.  RLQ
hernia.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+

DISCHARGE:

Pertinent Results:
ADMISSION:
[**2185-8-8**] 11:30AM BLOOD WBC-17.5*# RBC-4.26 Hgb-12.1 Hct-36.2
MCV-85 MCH-28.4 MCHC-33.4 RDW-16.0* Plt Ct-291
[**2185-8-8**] 11:30AM BLOOD Neuts-71.8* Lymphs-23.3 Monos-3.7 Eos-0.6
Baso-0.5
[**2185-8-8**] 11:30AM BLOOD PT-24.7* PTT-35.2 INR(PT)-2.4*
[**2185-8-8**] 11:30AM BLOOD Glucose-138* UreaN-20 Creat-0.8 Na-140
K-3.5 Cl-101 HCO3-28 AnGap-15
[**2185-8-8**] 11:30AM BLOOD ALT-75* AST-53* AlkPhos-105 TotBili-0.6
[**2185-8-8**] 11:30AM BLOOD Lipase-20
[**2185-8-8**] 11:30AM BLOOD cTropnT-0.01
[**2185-8-8**] 11:30AM BLOOD Albumin-3.8 Calcium-8.8 Phos-3.3 Mg-1.8

STUDIES:
CXR: Status post sternotomy and aortic valve replacement, newly
implanted permanent pacer, unremarkable position of electrode
termination and no pneumothorax.


Brief Hospital Course:
61 y/o F with hx of mild dHF, HTN, bicuspid AV, s/p mechanical
AVR on coumadin (INR 2.4 on admission), severe asthma (on
standing prednisone) who was transferred to [**Hospital1 18**] from OSH after
presenting with syncope found to be in CHB and 9-sec pause on
tele.
.
# SYNCOPE - likely due to arrhythmia septal disease in the area
involving the bundle of His, potentially exacerbated by
increased albuterol use (increased heart rate inducing prolonged
pausing at AV node). Initially had temporary pacer placed on
admission. Permanent pacermaker placed by EP on [**8-9**]. We started
metoprolol 25mg PO Q8H. Post op we started Vancomycin and then
switched to PO Clindamycing 450 q8 x 48 hours for prophylaxis.
Pt set up with EP follow up.
.
-------
CHRONIC
-------
# HTN - pt normotensive during admission. We continued losartan
50mg po daily, added metop 25mg PO Q8H for control of
arrhythmia.
.
# AV Replacement: Mechanical AVR in [**2175**] for bicuspid AV, recent
Echo ([**6-/2185**]) showed that valve with well seated with no
evidence of dehiscence. We continued Warfarin at home dose (4mg
PO daily)
.
#  ASTHMA: Patient has severe asthma in setting of possible mold
contamination in her home.  She has been on prednisone for last
6-7 years with inability to wean. We continued prednisone 10mg
PO daily, Ipratroprium/Budesonide nebs, Albuterol PRN
.
#  DM Type 2 vs Steroid Induced: Last A1C (7%, [**2185-7-28**]) not
currently on any home DM medications. We treated with Insulin SC

.
## TRANSITIONAL
- Follow up with EP


Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Furosemide 60 mg PO DAILY
2. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB or Wheezing
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB or wheezing
4. Losartan Potassium 50 mg PO DAILY
5. Meclizine 25 mg PO BID:PRN Dizziness
6. Metoprolol Tartrate 25 mg PO BID
7. Montelukast Sodium 10 mg PO DAILY
8. Nystatin Cream 1 Appl TP [**Hospital1 **]
9. omalizumab *NF* 300 mg Subcutaneous Q2 weeks
10. Omeprazole 20 mg PO TID
11. PredniSONE 5 mg PO DAILY
Taper
Tapered dose - DOWN
12. TraMADOL (Ultram) 50 mg PO TID:PRN pain
13. Triamcinolone Acetonide 0.1% Cream 1 Appl TP [**Hospital1 **]
14. Colchicine 0.6 mg PO QOD
15. Fluticasone Propionate NASAL 2 SPRY NU DAILY
16. Artificial Tears 1-2 DROP BOTH EYES [**Hospital1 **]
17. Fish Oil (Omega 3) 1000 mg PO BID
18. Terbinafine 1% Cream 1 Appl TP [**Hospital1 **]
19. Verapamil SR 240 mg PO Q24H
20. Warfarin 4 mg PO DAILY16


Discharge Medications:
1. Clindamycin 450 mg PO Q8H Duration: 2 Days
RX *clindamycin HCl 150 mg three capsule(s) by mouth three times
a day Disp #*27 Capsule Refills:*0
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB or wheezing
3. Artificial Tears 1-2 DROP BOTH EYES [**Hospital1 **]
4. Colchicine 0.6 mg PO QOD
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Furosemide 60 mg PO DAILY
7. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB or Wheezing
8. Losartan Potassium 50 mg PO DAILY
9. Montelukast Sodium 10 mg PO DAILY
10. Omeprazole 20 mg PO TID
11. Fish Oil (Omega 3) 1000 mg PO BID
12. Meclizine 25 mg PO BID:PRN Dizziness
13. Nystatin Cream 1 Appl TP [**Hospital1 **]
14. omalizumab *NF* 300 mg Subcutaneous Q2 weeks
15. Terbinafine 1% Cream 1 Appl TP [**Hospital1 **]
16. TraMADOL (Ultram) 50 mg PO TID:PRN pain
17. Triamcinolone Acetonide 0.1% Cream 1 Appl TP [**Hospital1 **]
18. Warfarin 4 mg PO DAILY16
Please take 2 mg today, [**8-10**], then resume 4mg daily
19. PredniSONE 10 mg PO DAILY
Tapered dose - DOWN
20. budesonide *NF* 0.5 mg/2 mL Inhalation every 4-5 hours
take with ipratroprium/albuterol
21. Metoprolol Tartrate 25 mg PO TID
22. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg one tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 8930**]

Discharge Diagnosis:
Cardiogenic Syncope
Mechanical aortic valve
Dyslipidemia


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


Discharge Instructions:
Dear Ms. [**Known lastname 14738**],

You were admitted for episodes of losing consciousness. Based on
multiple EKGs, we determined that the cause of these episodes is
due to problem with the rhythm of your heart. You were evaluated
by cardiology doctors who recommended a permanent pacemaker,
which was placed on [**2185-8-9**]. We also changed your metoprolol to
three times daily.

We have made an appointment for you with cardiology, please see
details below.
Please check your INR on [**2185-8-15**] when you are here for your
follow up visit. Call the [**Hospital3 **] if you have any
questions.

Followup Instructions:
Department: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**]
When: MONDAY [**2185-8-15**] at 3:20 PM
With: Dr [**Last Name (STitle) 16187**] [**Name (STitle) **]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Central [**Hospital **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: CARDIAC SERVICES
When: TUESDAY [**2185-8-16**] at 11:30 AM
With:  DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Atrioventricular block, complete,Chronic diastolic heart failure,Syncope and collapse,Heart valve replaced by other means,Other and unspecified hyperlipidemia,Long-term (current) use of anticoagulants,Asthma, unspecified type, unspecified,Unspecified essential hypertension,Other abnormal glucose'}


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: Ms. [**Known lastname 14738**] is a 61 y/o F with hx of mild dHF, HTN, bicuspid AV,
s/p mechanical AVR on coumadin (INR 2.4 on admission), severe
asthma (on prednisone) who was transferred to [**Hospital1 18**] for [**Hospital 16186**] after presenting there for syncope.  She has a hx of
severe asthma and has been on prednisone for the last 6-7 years
with inability to wean due to increased wheezing and SOB.  She
states that over the last 6 months she has had more frequent
episodes of "blacking out" that seem to occur after using her
asthma inhalers.  During each episode she denies CP, SOB, but
has some nausea.  Yesterday, while at her daughter's house she
was sitting on the couch and blacked out on two separate
occasions lasting a few seconds and then she came two.  She was
hospitalized [**2184-7-5**] year ago for similar c/o and was
monitored continuously on Tele, with no events detected.

MEDICAL HISTORY: PAST CARDIAC HISTORY:
.
1. CARDIAC RISK FACTORS: (+)Diabetes (borderline),
(-)Dyslipidemia, (+)Hypertension
2. CARDIAC HISTORY:
- Aortic valve replacement for critical AS/bicuspid aortic
valve, #21 Carbomedics mechanical valve c/b pericardial
tamponade and cardiac arrest ([**2175**])
.
OTHER PAST MEDICAL HISTORY:
- chronic anticoagulation w/ warfarin
- Hypertension, well controlled on meds
- Severe asthma, on multiple meds
- Allergic rhinitis
- Right lower quadrant hernia
- Osteoarthritis
- Chronically elevated CPK and bilateral calf pain
- Acid reflux
- Obesity
- DM2 (borderline, not on meds)
- Gout
- Gallstones
- H/o colonic ulcer [**2183**]

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Furosemide 60 mg PO DAILY
2. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB or Wheezing
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB or wheezing
4. Losartan Potassium 50 mg PO DAILY
5. Meclizine 25 mg PO BID:PRN Dizziness
6. Metoprolol Tartrate 25 mg PO BID
7. Montelukast Sodium 10 mg PO DAILY
8. Nystatin Cream 1 Appl TP [**Hospital1 **]
9. omalizumab *NF* 300 mg Subcutaneous Q2 weeks
10. Omeprazole 20 mg PO TID
11. PredniSONE 5 mg PO DAILY
Taper
Tapered dose - DOWN
12. TraMADOL (Ultram) 50 mg PO TID:PRN pain
13. Triamcinolone Acetonide 0.1% Cream 1 Appl TP [**Hospital1 **]
14. Colchicine 0.6 mg PO QOD
15. Fluticasone Propionate NASAL 2 SPRY NU DAILY
16. Artificial Tears 1-2 DROP BOTH EYES [**Hospital1 **]
17. Fish Oil (Omega 3) 1000 mg PO BID
18. Terbinafine 1% Cream 1 Appl TP [**Hospital1 **]
19. Verapamil SR 240 mg PO Q24H
20. Warfarin 4 mg PO DAILY16

ALLERGIES: Univasc / Amlodipine / Norvasc

PHYSICAL EXAM: ADMISSION:
VS: T=98.8 BP=133/65 HR=104 RR= 21 O2 sat= 97%RA
GENERAL: Overweight 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.

FAMILY HISTORY: FAMILY HISTORY: Daughter died of AML @ age 38 in [**2184-6-4**].
Older sister with breast cancer age 65. Strong family history of
DM2 & HTN. No family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
- Sister x 2 --> Breast Ca
- Sister --> Heart Block
- Brother --> CAD
- Brother --> Thyroid Ca

SOCIAL HISTORY: SOCIAL HISTORY:
- Tobacco history: denies
- EtOH: social, very rare
- Illicit drugs: denies
. 

### Response:
{'Atrioventricular block, complete,Chronic diastolic heart failure,Syncope and collapse,Heart valve replaced by other means,Other and unspecified hyperlipidemia,Long-term (current) use of anticoagulants,Asthma, unspecified type, unspecified,Unspecified essential hypertension,Other abnormal glucose'}
