CHIEF COMPLAINT: syncope and pleuritic chest pain upon waking

PRESENT ILLNESS: The patient is a 67 year old female with epilepsy, hypertension,
and pancreatic cancer s/p Whipple with positive margin who is
currently undergoing chemotherapy and radiation.  She had a
syncopal episode after returning home from a radiotherapy
session today and was initially seen at an OSH where she was
diagnosed with bilateral PEs.  She was transferred to [**Hospital1 18**] and
admitted to the ICU for further management.
.
After returning home from her radiotherapy session today, she
had a syncopal episode as she was entering her home.  Her
husband was next to her and managed to lower her to the ground
as she fell.  She did not strike her head or sustain any other
injuries.  She reports losing consciousness and waking up
several minutes later.  She reports that it was very different
than prior seizures and there was no evidence of seizure
activity.  After waking, she felt SOB with new bilateral chest
and back pain on inspiration.  She felt somewhat better after
resting, but once again felt SOB, weak, and dizzy later in the
day when getting up to the bathroom.  EMS was called and she was
brought to the [**Hospital3 417**] ED.  While there, she was tachy to
the 140s with BP in the 80s-90s, and CTA showed bilateral PEs
and evidence of right heart strain.  She was started on a
Heparin drip and received several liters of IV fluids.  She was
given Zofran 4 mg IV and Ativan 1 mg PO for nausea.  She was
transferred to [**Hospital1 18**] per patient request.
.
In the [**Hospital1 18**] ED, her initial vitals were T 98.3, HR 116, BP
103/67, RR 18, SpO2 98% on 3L.  She was on a Heparin drip at
1000 units/hr.  She complained of continued pleuritic chest pain
and back pain worse with inspiration.  EKG showed sinus
tachycardia at 113 bpm and slight ST depressions in the lateral
leads, as well as a mild S1Q3T3 pattern.  She was given
Acetaminophen 1000 mg, which she reports helped the pain
significantly.  Her Heparin drip was titrated and she was
admitted to the ICU for further management.
.
Once in the ICU, she reported feeling much better than earlier,
but with some continued pleuritic chest pain.  She reports
having a long history of varicose veins, but noted a recent
palpable vessel on her medial right thigh near the knee which
worsened and then improved a few days ago.  She has chronic LE
edema and venous stasis changes.  She has lost about 50 lbs
since her diagnosis with pancreatic cancer.  She has chronic
nausea, vomiting, and diarrhea related to her chemotherapy and
radiation.  She has had difficulty staying hydrated, requiring
periodic IV fluids in [**Hospital **] clinic.

MEDICAL HISTORY: # Pancreatic Cancer -- as below
# Epilepsy -- (Neurologist Dr [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] in [**Hospital1 1474**] MA)
-- No seizure in about 5 years
# Psoriasis
# Basal cell carcinoma of the skin, status post excision
# Hypertension -- now resolved
# Tonsillectomy History
.
ONCOLOGIC HISTORY:
# Pancreatic Cancer -- stage IIB (pT3, pN1, M0)
-- Summer [**2184**] developed epigastric discomfort
-- Few months later obstructive jaundice
-- [**2185-11-21**]: CT scan at [**Hospital1 18**] showed mass in the pancreatic
uncinate process
-- [**2185-12-8**]: Whipple procedure with Dr. [**Last Name (STitle) 468**]
-- Pathology showed a 2.4-cm moderately differentiated ductal
adenocarcinoma in the head of the pancreas.  One of the 11 lymph
nodes examined was positive, although it was noticed that the
single lymph node that contained carcinoma appeared to be
involved by direct contiguous tumor growth. The primary tumor
was extending beyond the pancreas, but without involvement of
the celiac axis or superior mesenteric artery.  The uncinate
process margin was positive for carcinoma.  There was no
vascular or lymphatic invasion but there was extensive
perineural invasion.
-- [**2186-1-12**]: Started cycle 1 of chemotherapy with Gemzar.
-- [**2186-2-2**]: Cyberknife therapy to positive margin.
-- [**2186-2-9**]: External beam radiation and concomitant XELODA.
-- [**2186-2-22**]: Xeloda held due to GI toxicity.

MEDICATION ON ADMISSION: Carbamazepine 200 mg PO TID
Levetiracetam 500 mg PO Q6H
Dexamethasone 2 mg PO daily
Lipase-protease-amylase [Zenpep] (20,000-68,000-109,000 units)
-- Take 3 capsules PO with meals and 2 capsules PO with snacks
Pantoprazole 40 mg PO daily
Potassium chloride 10 mEq PO BID
Lorazepam 0.5 mg PO Q6H PRN anxiety or nausea

ALLERGIES: Dilantin Kapseal / Calcipotriene / Lorazepam

PHYSICAL EXAM: VS: T 97.6, BP 95/67, HR 116, RR 21, SpO2 95-97% on 3L NC
Gen: Elderly female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM, OP benign.
Neck: Supple, full ROM.  JVP to jaw at 30 degree angle.  No
cervical lymphadenopathy.
CV: Tachycardia, regular with normal S1, S2.  No M/R/G.
Chest: Respiration unlabored, no accessory muscle use. CTAB
except for a few scattered crackles L>R.  No wheezes or rhonchi.
Abd: Active bowel sounds. Soft, NT, ND. No organomegaly or
masses. Well healed transverse surgical incision across upper
abdomen.
Ext: WWP.  Digital cap refill <2 sec.  Distal pulses intact
radial 2+, DP 1+.  LE edema 1+ bilaterally. Palpable cord right
medial thigh proximal to knee.  No calf tenderness.
Neuro: CN II-XII grossly intact. Moving all four limbs. Normal
speech.

FAMILY HISTORY: The patient is an only child.  She reports that the son and
grandson of her mother's sister died from pancreatic cancer, but
no more immediate family members.  She has five children.
# Mother -- Died at age 89 of leukemia and had a history of CHF.
# Father -- Died at age 63 of MI.

SOCIAL HISTORY: # Tobacco: Never smoked, but husband is a heavy smoker.
# Alcohol: Rare alcohol 1-2 drinks/month
# Drugs: None
Other pulmonary embolism and infarction,Malignant neoplasm of head of pancreas,Acute venous embolism and thrombosis of deep vessels of distal lower extremity,Acidosis,Atrial fibrillation,Epilepsy, unspecified, without mention of intractable epilepsy,Unspecified essential hypertension,Phlebitis and thrombophlebitis of superficial vessels of lower extremities
Pulm embol/infarct NEC,Mal neo pancreas head,Ac DVT/emb distl low ext,Acidosis,Atrial fibrillation,Epilep NOS w/o intr epil,Hypertension NOS,Superfic phlebitis-leg
Admission Date:  [**2186-3-16**]              Discharge Date:   [**2186-3-22**]

Date of Birth:  [**2118-6-9**]             Sex:   F

Service: MEDICINE

Allergies:
Dilantin Kapseal / Calcipotriene / Lorazepam

Attending:[**First Name3 (LF) 5141**]
Chief Complaint:
syncope and pleuritic chest pain upon waking

Major Surgical or Invasive Procedure:
None

History of Present Illness:
The patient is a 67 year old female with epilepsy, hypertension,
and pancreatic cancer s/p Whipple with positive margin who is
currently undergoing chemotherapy and radiation.  She had a
syncopal episode after returning home from a radiotherapy
session today and was initially seen at an OSH where she was
diagnosed with bilateral PEs.  She was transferred to [**Hospital1 18**] and
admitted to the ICU for further management.
.
After returning home from her radiotherapy session today, she
had a syncopal episode as she was entering her home.  Her
husband was next to her and managed to lower her to the ground
as she fell.  She did not strike her head or sustain any other
injuries.  She reports losing consciousness and waking up
several minutes later.  She reports that it was very different
than prior seizures and there was no evidence of seizure
activity.  After waking, she felt SOB with new bilateral chest
and back pain on inspiration.  She felt somewhat better after
resting, but once again felt SOB, weak, and dizzy later in the
day when getting up to the bathroom.  EMS was called and she was
brought to the [**Hospital3 417**] ED.  While there, she was tachy to
the 140s with BP in the 80s-90s, and CTA showed bilateral PEs
and evidence of right heart strain.  She was started on a
Heparin drip and received several liters of IV fluids.  She was
given Zofran 4 mg IV and Ativan 1 mg PO for nausea.  She was
transferred to [**Hospital1 18**] per patient request.
.
In the [**Hospital1 18**] ED, her initial vitals were T 98.3, HR 116, BP
103/67, RR 18, SpO2 98% on 3L.  She was on a Heparin drip at
1000 units/hr.  She complained of continued pleuritic chest pain
and back pain worse with inspiration.  EKG showed sinus
tachycardia at 113 bpm and slight ST depressions in the lateral
leads, as well as a mild S1Q3T3 pattern.  She was given
Acetaminophen 1000 mg, which she reports helped the pain
significantly.  Her Heparin drip was titrated and she was
admitted to the ICU for further management.
.
Once in the ICU, she reported feeling much better than earlier,
but with some continued pleuritic chest pain.  She reports
having a long history of varicose veins, but noted a recent
palpable vessel on her medial right thigh near the knee which
worsened and then improved a few days ago.  She has chronic LE
edema and venous stasis changes.  She has lost about 50 lbs
since her diagnosis with pancreatic cancer.  She has chronic
nausea, vomiting, and diarrhea related to her chemotherapy and
radiation.  She has had difficulty staying hydrated, requiring
periodic IV fluids in [**Hospital **] clinic.


Past Medical History:
# Pancreatic Cancer -- as below
# Epilepsy -- (Neurologist Dr [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] in [**Hospital1 1474**] MA)
-- No seizure in about 5 years
# Psoriasis
# Basal cell carcinoma of the skin, status post excision
# Hypertension -- now resolved
# Tonsillectomy History
.
ONCOLOGIC HISTORY:
# Pancreatic Cancer -- stage IIB (pT3, pN1, M0)
-- Summer [**2184**] developed epigastric discomfort
-- Few months later obstructive jaundice
-- [**2185-11-21**]: CT scan at [**Hospital1 18**] showed mass in the pancreatic
uncinate process
-- [**2185-12-8**]: Whipple procedure with Dr. [**Last Name (STitle) 468**]
-- Pathology showed a 2.4-cm moderately differentiated ductal
adenocarcinoma in the head of the pancreas.  One of the 11 lymph
nodes examined was positive, although it was noticed that the
single lymph node that contained carcinoma appeared to be
involved by direct contiguous tumor growth. The primary tumor
was extending beyond the pancreas, but without involvement of
the celiac axis or superior mesenteric artery.  The uncinate
process margin was positive for carcinoma.  There was no
vascular or lymphatic invasion but there was extensive
perineural invasion.
-- [**2186-1-12**]: Started cycle 1 of chemotherapy with Gemzar.
-- [**2186-2-2**]: Cyberknife therapy to positive margin.
-- [**2186-2-9**]: External beam radiation and concomitant XELODA.
-- [**2186-2-22**]: Xeloda held due to GI toxicity.


Social History:
# Tobacco: Never smoked, but husband is a heavy smoker.
# Alcohol: Rare alcohol 1-2 drinks/month
# Drugs: None

Married with 5 children and 5 grandchildren. Denies tobacco,
drinks beer occasionally.


Family History:
The patient is an only child.  She reports that the son and
grandson of her mother's sister died from pancreatic cancer, but
no more immediate family members.  She has five children.
# Mother -- Died at age 89 of leukemia and had a history of CHF.
# Father -- Died at age 63 of MI.


Physical Exam:
VS: T 97.6, BP 95/67, HR 116, RR 21, SpO2 95-97% on 3L NC
Gen: Elderly female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM, OP benign.
Neck: Supple, full ROM.  JVP to jaw at 30 degree angle.  No
cervical lymphadenopathy.
CV: Tachycardia, regular with normal S1, S2.  No M/R/G.
Chest: Respiration unlabored, no accessory muscle use. CTAB
except for a few scattered crackles L>R.  No wheezes or rhonchi.
Abd: Active bowel sounds. Soft, NT, ND. No organomegaly or
masses. Well healed transverse surgical incision across upper
abdomen.
Ext: WWP.  Digital cap refill <2 sec.  Distal pulses intact
radial 2+, DP 1+.  LE edema 1+ bilaterally. Palpable cord right
medial thigh proximal to knee.  No calf tenderness.
Neuro: CN II-XII grossly intact. Moving all four limbs. Normal
speech.


Pertinent Results:
ADMISSION LABS:

[**2186-3-16**] 02:35AM BLOOD WBC-8.1# RBC-3.36* Hgb-11.7* Hct-34.5*
MCV-103* MCH-34.8* MCHC-33.8 RDW-17.2* Plt Ct-136*
[**2186-3-16**] 02:35AM BLOOD Neuts-89.6* Lymphs-5.0* Monos-4.6 Eos-0.6
Baso-0.3
[**2186-3-16**] 02:35AM BLOOD PT-17.3* PTT-150* INR(PT)-1.6*
[**2186-3-16**] 02:35AM BLOOD Glucose-125* UreaN-9 Creat-0.7 Na-136
K-5.2* Cl-103 HCO3-21* AnGap-17
[**2186-3-16**] 02:35AM BLOOD ALT-38 AST-82* AlkPhos-169* TotBili-0.6
[**2186-3-16**] 02:35AM BLOOD cTropnT-0.32* proBNP-2404*
[**2186-3-16**] 02:35AM BLOOD Albumin-2.9*

IMAGING:
ECHO [**2186-3-16**]: Conclusions
The left atrium is normal in size. The left ventricular cavity
is unusually small. Left ventricular systolic function is
hyperdynamic (EF>75%). The right ventricular cavity is
moderately dilated with moderate global free wall hypokinesis.
There is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Severe [4+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. [In the setting of at least
moderate to severe tricuspid regurgitation, the estimated
pulmonary artery systolic pressure may be underestimated due to
a very high right atrial pressure.] There is a very small
pericardial effusion. There is an anterior space which most
likely represents a prominent fat pad.

CONCLUSIONS: Small underfilled hyperdynamic left ventricle.
Right ventricular systolic dysfunction with relative
preservation of the right ventricular apex consistent with acute
RV strain in the setting of her known PE. Likely severe
pulmonary artery systolic pressure.

BILATERAL LENIs [**2186-3-16**]:
IMPRESSION:
1. DVT involving the right peroneal vein. Superficial
thrombophlebitis of
the right great saphenous vein.
2. No DVT in the left lower extremity.

ABDOMINAL U/S [**2186-3-16**]:
FINDINGS: The liver is normal in echotexture, without focal
lesions. There
is no intra- or extra-hepatic biliary dilatation. The patient is
status post Whipple's procedure. The common hepatic duct is
normal, measuring 3 mm.  Main, right, and left portal veins
demonstrate normal directional flow and waveforms. The right,
middle,left hepatic veins and IVC demonstrate normal venous
waveforms. The main hepatic artery is patent. The spleen is not
visualized due to extensive bowel gas. There is no
intra-abdominal free fluid.

IMPRESSION: Normal liver, with patent hepatic vasculature. No
evidence for
portal vein thrombosis.

CXR [**2186-3-19**]:
One portable view. Comparison with [**2186-3-15**]. The lungs remain
clear. The
left hemidiaphragm is indistinct. The cardiac silhouette is
prominent but may be exaggerated by AP technique. The aorta is
mildly tortuous. Mediastinal structures appear stable. The bony
thorax is grossly intact.

IMPRESSION: No active pulmonary disease. The retrocardiac area
is
suboptimally evaluated and a lateral view is recommended if
further evaluation is clinically indicated.


Brief Hospital Course:
The patient is a 67 year old female with epilepsy, hypertension,
and pancreatic cancer s/p Whipple with positive margin who is
currently undergoing chemotherapy and radiation.  She presented
to OSH with syncope from bilateral PEs and was transferred to
[**Hospital1 18**] for further management.

# Pulmonary Embolism: She presented with syncope and then had
classic signs of PE including rapid onset SOB, pleurisy, and
tachycardia.  She was at high risk given her pancreatic cancer
and ongoing treatments.
- Found to have bilateral PEs on CTA at the OSH and was started
on a Heparin drip.
- Thrombolysis was considered given her initial low BP
(80-90??????s), low UOP (10-20cc/hr), and echo showing right heart
strain.
- She and her family initially opted for thrombolysis, but her
rectal guaiac was positive and she was unable to receive it.
- No IVC filter will be placed as the benefit does not outweigh
the risk.
- Her LE dopplers showed DVT involving the right peroneal vein
and superficial thrombophlebitis of the right great saphenous
vein.
- Her hepatic vessels were normal on RUQ US.
- She was transitioned to Enoxaparin on [**2186-3-18**] and her Heparin
drip was stopped.
- She will be continued on enoxaparin 70mg SQ Q12H.
- Once the patient was transferred to the floor on [**3-19**], she was
foudn to be hemodynamically stable with no episodes of oxygen
desaturation, pleurisy, or tachycardia
.
# Atrial Fibrillation: She had an episode of AFib with HR in the
140s overnight [**Date range (1) 88312**], but was asymptomatic and her BP
remained fairly stable.
- She was given Metoprolol 2.5 mg IV once, and converted back to
sinus rhythm shortly thereafter.
- She again went back into AFib the morning of [**3-19**], and was
given 15mg total of IV lopressor, and then 1 hour after her last
lopressor dose, she went back to NSR.
- We started her on 12.5mg metoprolol tartrate TID with good
achievement of rate control
.
# Anemia: Her Hct on admission was 34.5, which was at her recent
baseline, but then was dropping after admission to 26.6 on [**3-19**].

- Her MCV is elevated in the 100s with an increased RDW.
- Her B12 and folate levels on [**2186-3-7**] were normal at 1081 and
9.5 respectively.  Her Hct has fallen from 34.5 to 26.0 in the
setting of receiving some IVF, but not enough to account for the
observed fall in Hct.
- Her stools were guaiac positive and a mild GI bleed was
suspected given her treatment with Heparin
- She did not show any evidence of upper or lower GI bleeding
once transferred to the floor, and her hematocrit rose back up
to 30.5 on DOD
- Her hematocrit will be followed closely on her anticoagulation
treatment and any potential cessation of treatment or
intervention will be avoided while she is still in the subacute
phase of PE treatment

# Epilepsy: She has a history of epilepsy treated with
Carbamazepine and Levetiracetam, so we continued Carbamazepine
200 mg PO TID
and Levetiracetam 500 mg PO Q6H per her home dosing regimen.
.
# Pancreatic Cancer:  She has pancreatic adenocarcinoma stage
IIB and is s/p Whipple procedure with positive margins on
[**2185-12-6**].  She is currently being treated with radiation and
chemotherapy.  She was started on Dexamethasone [**2186-2-22**] for
nausea relief and improved appetite.  She has had chronic nausea
and diarrhea after her surgery and with her ongoing treatments.
She is also on pancreatic enzyme supplements.   She was briefly
placed on stress dose steroids due to concern that it may have
been contributing to her hypotension, however she was quickly
changed back to her home dexamethasone 2mg PO daily.  We
continued pancreatic enzyme supplements with meals, and
continued lorazepam 0.5mg PO Q6H PRN anxiety or nausea.


Medications on Admission:
Carbamazepine 200 mg PO TID
Levetiracetam 500 mg PO Q6H
Dexamethasone 2 mg PO daily
Lipase-protease-amylase [Zenpep] (20,000-68,000-109,000 units)
-- Take 3 capsules PO with meals and 2 capsules PO with snacks
Pantoprazole 40 mg PO daily
Potassium chloride 10 mEq PO BID
Lorazepam 0.5 mg PO Q6H PRN anxiety or nausea


Discharge Medications:
1. enoxaparin 80 mg/0.8 mL Syringe Sig: Seventy (70) mg
Subcutaneous twice a day.
Disp:*60 syringes* Refills:*2*
2. carbamazepine 200 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
3. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
4. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety or nausea.
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Zenpep 20,000-68,000 -109,000 unit Capsule, Delayed
Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO 3
caps with meals and 2 with snacks as needed for pancreas enzyme.

7. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
1.5 Tablet Extended Release 24 hrs PO once a day.
Disp:*45 Tablet Extended Release 24 hr(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital **] Home Health Care

Discharge Diagnosis:
Primary:
Pulmonary Emboli
Paroxysmal atrial fibrillation

Secondary:
Pancreatic Cancer


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


Discharge Instructions:
Dr. [**Last Name (STitle) **] [**Known lastname 1458**],

You were admitted to the [**Hospital1 18**] for evaluation and treatment of
blood clots that were found in your lungs.  You were intially
managed in the ICU, but recovered well and were able to be
transferred to the floor.  There you regained good functional
status, finished your radiation treatments, and continued
lovenox therapy for your blood clots.

Because of your blood clots, you had evidence of strain on your
heart. This also likely caused your heart to go into an
irregular rhythm called atrial fibrillation. You will need to
start taking a medication called metoprolol for your heart
rhythm. Also please start taking lisinopril for heart protective
effects and for blood pressure.

The following changes have been made with your medications:
1. START using lovenox shots twice a day
2. START metoprolol succinate 1.5 tablets once a day (for your
new irregular heart rhythm)
3. START lisinopril for blood pressure control and for
protective effects on your heart

Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2186-3-29**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2186-3-29**] at 11:30 AM
With: [**Name6 (MD) 5145**] [**Name8 (MD) 5146**], MD, PHD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: PSYCHIATRY
When: TUESDAY [**2186-4-4**] at 10:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 23908**], MD [**Telephone/Fax (1) 1387**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 551**]
Campus: EAST     Best Parking: Main Garage
{'Other pulmonary embolism and infarction,Malignant neoplasm of head of pancreas,Acute venous embolism and thrombosis of deep vessels of distal lower extremity,Acidosis,Atrial fibrillation,Epilepsy, unspecified, without mention of intractable epilepsy,Unspecified essential hypertension,Phlebitis and thrombophlebitis of superficial vessels of lower extremities'}


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 and pleuritic chest pain upon waking

PRESENT ILLNESS: The patient is a 67 year old female with epilepsy, hypertension,
and pancreatic cancer s/p Whipple with positive margin who is
currently undergoing chemotherapy and radiation.  She had a
syncopal episode after returning home from a radiotherapy
session today and was initially seen at an OSH where she was
diagnosed with bilateral PEs.  She was transferred to [**Hospital1 18**] and
admitted to the ICU for further management.
.
After returning home from her radiotherapy session today, she
had a syncopal episode as she was entering her home.  Her
husband was next to her and managed to lower her to the ground
as she fell.  She did not strike her head or sustain any other
injuries.  She reports losing consciousness and waking up
several minutes later.  She reports that it was very different
than prior seizures and there was no evidence of seizure
activity.  After waking, she felt SOB with new bilateral chest
and back pain on inspiration.  She felt somewhat better after
resting, but once again felt SOB, weak, and dizzy later in the
day when getting up to the bathroom.  EMS was called and she was
brought to the [**Hospital3 417**] ED.  While there, she was tachy to
the 140s with BP in the 80s-90s, and CTA showed bilateral PEs
and evidence of right heart strain.  She was started on a
Heparin drip and received several liters of IV fluids.  She was
given Zofran 4 mg IV and Ativan 1 mg PO for nausea.  She was
transferred to [**Hospital1 18**] per patient request.
.
In the [**Hospital1 18**] ED, her initial vitals were T 98.3, HR 116, BP
103/67, RR 18, SpO2 98% on 3L.  She was on a Heparin drip at
1000 units/hr.  She complained of continued pleuritic chest pain
and back pain worse with inspiration.  EKG showed sinus
tachycardia at 113 bpm and slight ST depressions in the lateral
leads, as well as a mild S1Q3T3 pattern.  She was given
Acetaminophen 1000 mg, which she reports helped the pain
significantly.  Her Heparin drip was titrated and she was
admitted to the ICU for further management.
.
Once in the ICU, she reported feeling much better than earlier,
but with some continued pleuritic chest pain.  She reports
having a long history of varicose veins, but noted a recent
palpable vessel on her medial right thigh near the knee which
worsened and then improved a few days ago.  She has chronic LE
edema and venous stasis changes.  She has lost about 50 lbs
since her diagnosis with pancreatic cancer.  She has chronic
nausea, vomiting, and diarrhea related to her chemotherapy and
radiation.  She has had difficulty staying hydrated, requiring
periodic IV fluids in [**Hospital **] clinic.

MEDICAL HISTORY: # Pancreatic Cancer -- as below
# Epilepsy -- (Neurologist Dr [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] in [**Hospital1 1474**] MA)
-- No seizure in about 5 years
# Psoriasis
# Basal cell carcinoma of the skin, status post excision
# Hypertension -- now resolved
# Tonsillectomy History
.
ONCOLOGIC HISTORY:
# Pancreatic Cancer -- stage IIB (pT3, pN1, M0)
-- Summer [**2184**] developed epigastric discomfort
-- Few months later obstructive jaundice
-- [**2185-11-21**]: CT scan at [**Hospital1 18**] showed mass in the pancreatic
uncinate process
-- [**2185-12-8**]: Whipple procedure with Dr. [**Last Name (STitle) 468**]
-- Pathology showed a 2.4-cm moderately differentiated ductal
adenocarcinoma in the head of the pancreas.  One of the 11 lymph
nodes examined was positive, although it was noticed that the
single lymph node that contained carcinoma appeared to be
involved by direct contiguous tumor growth. The primary tumor
was extending beyond the pancreas, but without involvement of
the celiac axis or superior mesenteric artery.  The uncinate
process margin was positive for carcinoma.  There was no
vascular or lymphatic invasion but there was extensive
perineural invasion.
-- [**2186-1-12**]: Started cycle 1 of chemotherapy with Gemzar.
-- [**2186-2-2**]: Cyberknife therapy to positive margin.
-- [**2186-2-9**]: External beam radiation and concomitant XELODA.
-- [**2186-2-22**]: Xeloda held due to GI toxicity.

MEDICATION ON ADMISSION: Carbamazepine 200 mg PO TID
Levetiracetam 500 mg PO Q6H
Dexamethasone 2 mg PO daily
Lipase-protease-amylase [Zenpep] (20,000-68,000-109,000 units)
-- Take 3 capsules PO with meals and 2 capsules PO with snacks
Pantoprazole 40 mg PO daily
Potassium chloride 10 mEq PO BID
Lorazepam 0.5 mg PO Q6H PRN anxiety or nausea

ALLERGIES: Dilantin Kapseal / Calcipotriene / Lorazepam

PHYSICAL EXAM: VS: T 97.6, BP 95/67, HR 116, RR 21, SpO2 95-97% on 3L NC
Gen: Elderly female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM, OP benign.
Neck: Supple, full ROM.  JVP to jaw at 30 degree angle.  No
cervical lymphadenopathy.
CV: Tachycardia, regular with normal S1, S2.  No M/R/G.
Chest: Respiration unlabored, no accessory muscle use. CTAB
except for a few scattered crackles L>R.  No wheezes or rhonchi.
Abd: Active bowel sounds. Soft, NT, ND. No organomegaly or
masses. Well healed transverse surgical incision across upper
abdomen.
Ext: WWP.  Digital cap refill <2 sec.  Distal pulses intact
radial 2+, DP 1+.  LE edema 1+ bilaterally. Palpable cord right
medial thigh proximal to knee.  No calf tenderness.
Neuro: CN II-XII grossly intact. Moving all four limbs. Normal
speech.

FAMILY HISTORY: The patient is an only child.  She reports that the son and
grandson of her mother's sister died from pancreatic cancer, but
no more immediate family members.  She has five children.
# Mother -- Died at age 89 of leukemia and had a history of CHF.
# Father -- Died at age 63 of MI.

SOCIAL HISTORY: # Tobacco: Never smoked, but husband is a heavy smoker.
# Alcohol: Rare alcohol 1-2 drinks/month
# Drugs: None 

### Response:
{'Other pulmonary embolism and infarction,Malignant neoplasm of head of pancreas,Acute venous embolism and thrombosis of deep vessels of distal lower extremity,Acidosis,Atrial fibrillation,Epilepsy, unspecified, without mention of intractable epilepsy,Unspecified essential hypertension,Phlebitis and thrombophlebitis of superficial vessels of lower extremities'}
