CHIEF COMPLAINT: Syncope.

PRESENT ILLNESS: This is a 79 year-old woman with
history of aortic stenosis and hypertension who presented
with an episode of syncope.  She was brushing her teeth when
she suddenly became light headed.  She tried to hold on for
support but then passed out.  She found herself on the floor.
She had a wound to her head which she reported copious
bleeding from.  She then came into the Emergency Room for
further evaluation.  She denied any symptoms of chest pain,
palpitations or shortness of breath.

MEDICAL HISTORY: Aortic stenosis with valve area of 0.7
by last echocardiogram, hypertension, status post cataract
surgery, status post total abdominal hysterectomy, bilateral
salpingo-oophorectomy, GERD, mild hypercholesterolemia.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: She lives at home with her husband.  She
denies any alcohol or tobacco use.
Atrioventricular block, complete,Aortic valve disorders,Unspecified essential hypertension,Anemia, unspecified,Esophageal reflux,Pure hypercholesterolemia
Atriovent block complete,Aortic valve disorder,Hypertension NOS,Anemia NOS,Esophageal reflux,Pure hypercholesterolem
Admission Date:  [**2135-7-5**]       Discharge Date:  [**2135-7-9**]


Service:  Progressive care unit

CHIEF COMPLAINT:  Syncope.

HISTORY OF PRESENT ILLNESS:  This is a 79 year-old woman with
history of aortic stenosis and hypertension who presented
with an episode of syncope.  She was brushing her teeth when
she suddenly became light headed.  She tried to hold on for
support but then passed out.  She found herself on the floor.
She had a wound to her head which she reported copious
bleeding from.  She then came into the Emergency Room for
further evaluation.  She denied any symptoms of chest pain,
palpitations or shortness of breath.

She did report a large black stool the day prior to admission
but also reports that she is on chronic iron and she also has
dark stools.

The head laceration was sutured in the Emergency Room and she
was admitted to the medicine floor for further evaluation.

Laboratories in the Emergency Room revealed hematocrit of 29
and per primary care physician it had been 39 one month
earlier.  She was noted to be in first degree AV block on her
electrocardiogram.

PAST MEDICAL HISTORY:  Aortic stenosis with valve area of 0.7
by last echocardiogram, hypertension, status post cataract
surgery, status post total abdominal hysterectomy, bilateral
salpingo-oophorectomy, GERD, mild hypercholesterolemia.

MEDICATIONS:  Adalat C 60 mg p.o. q. day, hydrochlorothiazide
5 mg p.o. q day, aspirin 81 mg p.o. q. day, multivitamins,
iron, Prilosec 40 mg p.o. q. day.

ALLERGIES:  No known drug allergies.

SOCIAL HISTORY:  She lives at home with her husband.  She
denies any alcohol or tobacco use.

PHYSICAL EXAMINATION:  Heart rate 60, blood pressure 160 to
190/50 to 70, respiratory rate 18, temperature 98.6, FAO2 96
percent on room air.  In general a thin elderly
African-American woman appears comfortable in no acute
distress.  Head, eyes, ears, nose and throat: there is a
laceration on the posterior right side of the head
approximately 3 cm in length which is well sutured.  Pupils
are surgical.  Oropharynx is clear.  Moist mucosal membranes.
Lungs are clear to auscultation bilaterally.  Heart is
regular rate and rhythm, normal S1 and S2.  There is a III/VI
systolic murmur which is loudest at the upper sternal border
that radiates throughout the precordium and also to the
carotid and subclavian arteries.  The carotid pulse is slow
and delayed.  Abdomen is soft, nontender, nondistended.
Extremities no edema.

LABORATORY DATA:  White count 5.8, hematocrit 29.3, platelets
265, INR 1.1, PTT 22.8.  Sodium 131, potassium 5.2, chloride
98, bicarb 24, BUN 23, creatinine 1.2, glucose 78, CK 121,
troponin less than 0.3.

Electrocardiogram normal sinus rhythm at 60 beats per minute,
first degree AV block, PR interval 355.  There is evidence of
left ventricular hypertrophy and left axis deviation.

Echocardiogram [**2134-12-24**]: left ventricular ejection
fraction 20%, left ventricular hypertrophy, mild mitral
regurgitation, mild mitral regurgitation, sclerotic aortic
valve with area of 0.7, mild to moderate aortic
regurgitation, moderate tricuspid regurgitation, increased PA
pressure.

HOSPITAL COURSE:  The patient was initially admitted to the
general medicine service for further evaluation.  Over the
course of the day she developed 2 to 1 AV block on telemetry
with episodes of complete heart block with pauses averaging 6
seconds.  She was seen by the cardiology consult service.
They suspected initially that this was an intra-Hissian block
and recommended that Atropine be avoided.  She was
asymptomatic and hemodynamically stable.  They recommended
that the electrophysiology service evaluate her for pacemaker
the following day.  However, later that night at
approximately 1 A.M. she began to have increased frequency of
pauses with one pause of 12 seconds.  She was symptomatic and
dizzy with this although her blood pressure remained stable.
She was transferred to the Cardiac Care Unit for closer
monitoring and temporary pacing wire placement.

The cardiology fellow came in to assist with the placing of a
line and the temporary wire placement.  It was attempted to
place a Cordis in the right internal jugular.  However,
access was difficult and line placement was unsuccessful.  As
she had remained in the Cardiac Care Unit at that time for
approximately three hours and actually remained in normal
sinus rhythm except for the first degree AV block that entire
time with no further pauses and was hemodynamically stable,
the decision was made to await the EP service to arrive to
place a permanent pacemaker.

However, later that morning on review of her medical history
and examination the patient reported that for quite some time
she had been having dyspnea on exertion and therefore it was
suspected that she actually did have symptomatic aortic
stenosis and may need a valve replacement.  Therefore,
permanent pacemaker placement was delayed as if she were to
need valve replacement this would need to be done first.
Therefore, she went to the catheterization laboratory where a
temporary pacing wire was placed to the right groin.  Of
note, again she was difficult access with three failed
attempts at right subclavian and one failed attempt at left
internal jugular.  A successful access was gained through the
right femoral vein.

She did well with the temporary pacer.

She continued to be hypertensive and was restarted on her
hydrochlorothiazide 25 mg p.o. q. day.  Of note, her calcium
channel blocker had been held ever since admission because of
the heart block.

The patient then underwent cardiac catheterization in
preparation for possible valve surgery.  On catheterization
she was found to have non-flow limiting single vessel disease
of the LAD with 80 percent stenosis.  Normal left main.
Normal left circumflex.  Normal RCA.

Evaluation of the aortic valve revealed a mean gradient of 32
and a calculated valve area of 0.8.  Therefore, this was felt
to be noncritical aortic stenosis, and it was felt that
surgery for valve replacement is not indicated at this time.

Therefore on the morning of [**7-8**] she was transferred to
the [**Hospital Ward Name 516**] electrophysiology laboratory for permanent
pacer placement.

A second issue during this hospitalization was her
hematocrit.  As noted in the History of Present Illness her
hematocrit in the emergency department is 29, but her primary
care physician two weeks later hematocrit was 39.  Then on
recheck of the hematocrit approximately 12 hours after her
admission when she was transferred to the Cardiac Care Unit
her hematocrit was 21.  Subsequent recheck of the hematocrit
revealed that it stabilized at about 22.  Initially the
patient refused blood transfusion, but eventually did
consent.  She was given two units of packed red blood cells
with bump in the hematocrit to 33.  Since the transfusion her
hematocrit had remained stable in the 31 to 33 range.

Hemolysis and DIC panels were sent, which were not worrisome
for hemolysis or DIC.  Iron studies were sent which were not
consistent with iron deficiency anemia and she has low iron
but elevated ferritin and low TIBC.

Her stools were repeatedly guaiac negative.  She had no
gastrointestinal symptoms and her BUN remained low normal,
which all of this is not consistent with gastrointestinal
bleed.  At this time it is not known why her hematocrit was
so low at 21.

If all other work up is negative, the possibility is that she
actually had a significant blood loss from her scalp
laceration as the patient does report that she bled enough
that she did actual mopping of the blood on her bathroom
floor.

However, it should not be discounted that further work up may
be necessary, including outpatient colonoscopy as well as
possible need for bone marrow biopsy to completely work up
this anemia with low MCV.

it is anticipated that if the hematocrit remained stable and
the patient did well after her pacemaker placement that she
will be discharged to home.  If there are any further events
there will be an addendum to this summary.

DISCHARGE DIAGNOSES:
1.      Aortic stenosis with valve area of 0.8.
2.      Hypertension.
3.      Anemia.

DISCHARGE MEDICATIONS:  Hydrochlorothiazide 25 mg p.o. q.
day, aspirin 325 mg p.o. q. day, Prilosec 20 mg p.o. b.i.d.,
multivitamin p.o. q. day, Cosopt eye drops.




                            [**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 5219**]

Dictated By:[**Last Name (NamePattern1) 18927**]
MEDQUIST36

D:  [**2135-7-8**]
T:  [**2135-7-8**]  13:25
JOB#:  [**Job Number 38663**]
{'Atrioventricular block, complete,Aortic valve disorders,Unspecified essential hypertension,Anemia, unspecified,Esophageal reflux,Pure hypercholesterolemia'}


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: This is a 79 year-old woman with
history of aortic stenosis and hypertension who presented
with an episode of syncope.  She was brushing her teeth when
she suddenly became light headed.  She tried to hold on for
support but then passed out.  She found herself on the floor.
She had a wound to her head which she reported copious
bleeding from.  She then came into the Emergency Room for
further evaluation.  She denied any symptoms of chest pain,
palpitations or shortness of breath.

MEDICAL HISTORY: Aortic stenosis with valve area of 0.7
by last echocardiogram, hypertension, status post cataract
surgery, status post total abdominal hysterectomy, bilateral
salpingo-oophorectomy, GERD, mild hypercholesterolemia.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: She lives at home with her husband.  She
denies any alcohol or tobacco use. 

### Response:
{'Atrioventricular block, complete,Aortic valve disorders,Unspecified essential hypertension,Anemia, unspecified,Esophageal reflux,Pure hypercholesterolemia'}
