CHIEF COMPLAINT: S/p unwitnessed fall/syncope

PRESENT ILLNESS: CC:[**CC Contact Info 99633**]
HPI: 88 y.o. male with h/o parkinson's, dementia, chf, multiple
myeloma and hypothyroidism sustained unwitnessed fall while on
toilet. Wife found him. He does not recall circumstances
initially but later reports his bottom "slipped off toilet."
Does feel he actually moved his bowels. Unclear if LOC. Denies
and assoc CP/SOB. No dizziness/lightheadedness. Per EMS sbp was
in 80s. EKG unchanged in ED. Head/neck CT negative. SBP in ED
100.

MEDICAL HISTORY: PMH:
1. Hypothryroidism
2. Parkinson's Disease
3. Glaucoma
4. Dementia
5. Cataracts
6. BPH s/p TURP [**2092**]
7. Chronic diarrhea
8. h/o adenomatous polyp [**2104**]
9. CHF
10. ? h/o multiple myeloma s/p tx with thalidomide
11. h/o squamous cell ca s/p deep resection with graft

MEDICATION ON ADMISSION: Home Medications:
1. Levothyroxine 75mcg daily
2. Aricept 10mg daily
3. Furosemide 20mg alt with 40mg daily
4. Namenda 10mg [**Hospital1 **]
5. levocarnitine 2 caps twice daily
6. Aspirin 81mg daily
7. Lumigan both eyes at bedtime
8. Timoptic both eyes morning/bedtime
9. Azopt left eye tid
10. Vitamin E 200 units daily
11. Vitamin D 1000 units daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Physical Exam on Admission:
VS: BP 123/84 HR 96 T 97 97% RA
General: Skin warm and dry. NAD. Alert, engaging.
Neuro: Oriented to person, hospital [**2112-3-24**].  HEENT: Neck
supple,
Resp: lungs with crackles at LLL, good insp effort and air
movement.
CV: heart rrr ap 90 + IV/VI holosystolic murmur best heard 3rd
ICS LSB radiates to axilla
GI: abd soft, non-tender, +bs, + ventral hernia, no guarding.
EXT: +pp no edema bilat, no hair on lower extremeties
Skin: Right shin with large scar (~4inx3in)
Rectal exam: vault full of stool, guiaic neg.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Social History:
Lives with his wife (second x 14 yrs). Wife is HCP but she often
defers to sons. [**Name (NI) **] two sons, [**Name (NI) **] who is local and [**Name (NI) **]
in [**State 4565**] is a ENT surgeon. Daighter in law [**Doctor Last Name 2048**] is also
very involved.  Prior worked as CPA x 40 yrs. Reports smoked
less than pack per day but quit >20 yrs ago. Reports occ etoh
use.
Hemorrhage of gastrointestinal tract, unspecified,Acute combined systolic and diastolic heart failure,Acute kidney failure, unspecified,Pneumonitis due to inhalation of food or vomitus,Acute posthemorrhagic anemia,Multiple myeloma, without mention of having achieved remission,Vascular dementia, with delirium,Delirium due to conditions classified elsewhere,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Syncope and collapse,Mitral valve disorders,Cerebral atherosclerosis,Unspecified glaucoma,Benign neoplasm of colon,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Diverticulum of esophagus, acquired,Paralysis agitans,Other specified retention of urine,Diarrhea,Unspecified acquired hypothyroidism
Gastrointest hemorr NOS,Ac syst/diastol hrt fail,Acute kidney failure NOS,Food/vomit pneumonitis,Ac posthemorrhag anemia,Mult mye w/o achv rmson,Vasc dementia w delirium,Delirium d/t other cond,Chronic kidney dis NOS,Hy kid NOS w cr kid I-IV,Syncope and collapse,Mitral valve disorder,Cerebral atherosclerosis,Glaucoma NOS,Benign neoplasm lg bowel,BPH w/o urinary obs/LUTS,Acq esophag diverticulum,Paralysis agitans,Oth spcf retention urine,Diarrhea,Hypothyroidism NOS
Admission Date:  [**2112-4-15**]              Discharge Date:   [**2112-4-25**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2234**]
Chief Complaint:
S/p unwitnessed fall/syncope

Major Surgical or Invasive Procedure:
Blood transfusions, four units
Speech and swallow evaluation
Video barium swallow evaluation [**4-20**]


History of Present Illness:
CC:[**CC Contact Info 99633**]
HPI: 88 y.o. male with h/o parkinson's, dementia, chf, multiple
myeloma and hypothyroidism sustained unwitnessed fall while on
toilet. Wife found him. He does not recall circumstances
initially but later reports his bottom "slipped off toilet."
Does feel he actually moved his bowels. Unclear if LOC. Denies
and assoc CP/SOB. No dizziness/lightheadedness. Per EMS sbp was
in 80s. EKG unchanged in ED. Head/neck CT negative. SBP in ED
100.

Family reports he has c/o increased urinary frequency over past
few days.

ROS: Denies pain. Denies weight loss. Denies prior falls. Feels
as though he needs to urinate even though catheter is in place.
Reports that he is at times forgetful and that his memory is
"fair." Reports good sleep. Nml bowel pattern is 2x/day. Sleeps
with two pillows at baseline Denies moist cough but often dry
cough. All other ROS negative.


Past Medical History:
PMH:
1. Hypothryroidism
2. Parkinson's Disease
3. Glaucoma
4. Dementia
5. Cataracts
6. BPH s/p TURP [**2092**]
7. Chronic diarrhea
8. h/o adenomatous polyp [**2104**]
9. CHF
10. ? h/o multiple myeloma s/p tx with thalidomide
11. h/o squamous cell ca s/p deep resection with graft

Home Medications:

1. Levothyroxine 75mcg daily
2. Aricept 10mg daily
3. Furosemide 20mg alt with 40mg daily
4. Namenda 10mg [**Hospital1 **]
5. levocarnitine 2 caps twice daily
6. Aspirin 81mg daily
7. Lumigan both eyes at bedtime
8. Timoptic both eyes morning/bedtime
9. Azopt left eye tid
10. Vitamin E 200 units daily
11. Vitamin D 1000 units daily


Social History:
Social History:
Lives with his wife (second x 14 yrs). Wife is HCP but she often
defers to sons. [**Name (NI) **] two sons, [**Name (NI) **] who is local and [**Name (NI) **]
in [**State 4565**] is a ENT surgeon. Daighter in law [**Doctor Last Name 2048**] is also
very involved.  Prior worked as CPA x 40 yrs. Reports smoked
less than pack per day but quit >20 yrs ago. Reports occ etoh
use.

Wife manages medications. Does cooking/finances. Prior level of
function is walker. Has chair lift in home. Lives in single
family two story home. Bedroom on [**Location (un) 1773**].  Has home health
aide 5x week to help him shower and dress, goes to adult day
care at [**Hospital 100**] Rehab 3x week.

Has bilateral hearing aides. Has glasses for [**Location (un) 1131**].


Family History:
non-contributory

Physical Exam:
Physical Exam on Admission:
VS: BP 123/84 HR 96 T 97 97% RA
General: Skin warm and dry. NAD. Alert, engaging.
Neuro: Oriented to person, hospital [**2112-3-24**].  HEENT: Neck
supple,
Resp: lungs with crackles at LLL, good insp effort and air
movement.
CV: heart rrr ap 90 + IV/VI holosystolic murmur best heard 3rd
ICS LSB radiates to axilla
GI: abd soft, non-tender, +bs, + ventral hernia, no guarding.
EXT: +pp no edema bilat, no hair on lower extremeties
Skin: Right shin with large scar (~4inx3in)
Rectal exam: vault full of stool, guiaic neg.

Physical exam on discharge:
109-128/70-80 98% ra afebrile
Skin warm and dry, NAD. voice strong. Oriented to situation "I
don't to stay in the hospital another day. I want to go to
rehab."
Lungs with trace bibasilar rales no wheezes/rhonchi
heart rrr ap 72, + IV/VI holosystolic murmur radiating to axilla
abd s, nt +bs
+pp no edema


Pertinent Results:
Admission Labs:
===============
[**2112-4-15**] 07:15AM   WBC-11.6*# RBC-3.12*# HGB-9.5*# HCT-29.3*#
MCV-94 MCH-30.5 MCHC-32.6 RDW-15.1
[**2112-4-15**] 07:15AM   NEUTS-84* BANDS-4 LYMPHS-9* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2112-4-15**] 07:15AM   HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
TEARDROP-OCCASIONAL
[**2112-4-15**] 07:15AM   PLT COUNT-178#
[**2112-4-15**] 07:14AM   GLUCOSE-163* UREA N-65* CREAT-1.6* SODIUM-142
POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-21* ANION GAP-21*
[**2112-4-15**] 07:14AM   estGFR-Using this
[**2112-4-15**] 07:14AM   CK(CPK)-28*
[**2112-4-15**] 07:14AM   cTropnT-<0.01
[**2112-4-15**] 07:14AM   CK-MB-NotDone proBNP-6187*
[**2112-4-15**] 07:14AM   PT-17.5* PTT-31.6 INR(PT)-1.6*

Discharge Labs:

COMPLETE BLOOD COUNT   WBC RBC   Hgb   Hct  MCV MCH  MCHC RDW
Plt Ct
[**2112-4-25**] 11:00AM    7.8 3.32* 10.5* 30.7* 92 31.5 34.1 15.2
119*
RENAL & GLUCOSE       Glu UreaN Creat Na  K   Cl  HCO3 AnGap
[**2112-4-25**] 11:00AM    104 24*  1.4*  137 3.7 105 23 13

Imaging:
========
CT C-SPINE WITHOUT IV CONTRAST: There is no acute malalignment,
prevertebral soft tissue swelling, or acute fracture. There are
severe degenerative changes throughout the cervical spine. The
C4 vertebral body demonstrates a large (approximately 5 mm)
round lucency, which likely represents a large subchondral cyst
with cortical breakthrough at the superior surface, however less
likely consideration is a lytic lesion. There is anterior and
posterior osteophyte formation at all levels, with disc height
loss throughout the cervical spine. At C6-C7, there is severe
disc height loss, with near bone- on-bone appearance. There is
no evidence of indentation of the thecal sac, although CT does
not provide the intrathecal detail comparable to MRI. The lung
apices demonstrate no nodule or other opacity. There is no
submandibular or cervical lymphadenopathy.

IMPRESSION:

1. No fracture or acute malalignment abnormality.
2. No prevertebral soft tissue swelling or other evidence of
acute injury.
3. Round lucency in C4 vertebral body with cortical breakthrough
at superior surface likely represents large subchondral cysts,
but lytic lesion is a less likely possibility.
4. Severe degenerative changes throughout the cervical spine.

CT HEAD WITHOUT IV CONTRAST: There is no hemorrhage, mass, mass
effect, edema, or shift of normally midline structures.
Prominence of the ventricles and sulci with increased bifrontal
CSF space are suggestive of age-related parenchymal atrophy. No
fracture or soft tissue injury is identified.

IMPRESSION: No evidence of hemorrhage, edema, or fracture.

Chest XRAY

FINDINGS: Portable AP upright chest radiograph is reviewed
without comparison. Cardiac silhouette is upper limits of
normal, with left ventricular prominence, which could suggest
underlying hypertension. Prominence of the pulmonary vascularity
may suggest pulmonary hypertension, but there is no pulmonary
vascular engorgement or other evidence of pulmonary edema. There
is ill-defined 1-cm nodular opacity in the right perihilar
region. There is no focal airspace opacity to suggest pneumonia.
There is no pleural effusion or pneumothorax.

IMPRESSION:
1. 1-cm ill-defined right mid lung nodular opacity, incompletely
evaluated. CT is recommended for further evaluation to exclude
underlying mass.
2. Prominent cardiac silhouette with left ventricular
configuration could suggest underlying hypertension. Prominence
of the pulmonary vasculature, but no evidence of pulmonary
edema.

Portable TTE (Complete) Done [**2112-4-19**] at 10:33:19 AM
Conclusions:
The left atrium is markedly dilated. The right atrium is
moderately dilated. The estimated right atrial pressure is
10-20mmHg. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF 60%). [Intrinsic
left ventricular systolic function is likely more depressed
given the severity of valvular regurgitation.] There is no
ventricular septal defect. The aortic root is moderately dilated
at the sinus level. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild to moderate
([**11-25**]+) aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. The mitral valve leaflets are myxomatous.
There is probable (partial) mitral leaflet flail. An eccentric,
anteriorly directed jet of severe (4+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is moderate pulmonary artery systolic hypertension. Significant
pulmonic regurgitation is seen. The end-diastolic pulmonic
regurgitation velocity is increased suggesting pulmonary artery
diastolic hypertension.

If clinically indicated, a transesophageal echocardiographic
examination is recommended to evaluate mitral valve morphology.

IMPRESSION: severe mitral regurgitation secondary to (probable)
partial flail leaflet

RENAL U.S.  [**2112-4-20**] 1:29 PM

FINDINGS: The left kidney measures 10.4 cm and the right kidney
measures 11.5 cm. Cortical echogenicity is within normal limits.
There is moderate dilatation of the collecting system on the
right. The right extrarenal pelvis is again noted.

There is a exophytic simple cyst arising from the upper pole of
the left kidney, measuring 3.3 x 1.9 x 1.8 cm. This is slightly
increased in size when compared to the prior study of [**2104**], when
it measured 2.8 cm. There is no mass or calculus in either
kidney. There is no left hydronephrosis.

Urinary bladder is collapsed.

IMPRESSION: Moderate right hydronephrosis.

VIDEO OROPHARYNGEAL SWALLOW  [**2112-4-20**] 11:04 AM

FINDINGS: Oral and pharyngeal swallowing videofluoroscopy was
performed today in collaboration with speech and language
pathology. Various consistencies of barium were administered.

ORAL PHASE: Moderate oral dysphagia is seen, with decreased
bolus formation, control and AP tongue movement, as well as
increased oral transit times. There is a premature spillover
into the larynx. Moderate oral residue remains after the
swallow.

PHARYNGEAL PHASE: Severely delayed initiation of this swallow
trigger is noted. There is mildly reduced anterior laryngeal
excursion and laryngeal valve closure. There is complete
epiglottic deflection. There is a posterior pooling of contrast
just below the upper esophageal sphincter, consistent with known
large Zenker's diverticulum, resulting in backflow of the
contrast above the upper esophageal sphincter into the piriform
sinuses and eventually aspiration.

IMPRESSION:
1. Mild-to-moderate oropharyngeal dysphagia.
2. Findings most consistent with Zenker's diverticulum, with
backflow of contrast into the pharynx and resulting in the
aspiration.


Brief Hospital Course:
88 y.o. male with CHF, BPH, dementia s/p unwitnessed fall.
Presented with elevated BNP and BUN, also with hgb drop
(12.5-9.5) over past 6 weeks and sx of UTI.
.
1. S/p fall: most likely multifactorial.  Vasovagal vs volume
depletion from GI bleed.
- Head and c-spine ct negative, urine culture negative for UTI.


2. Acute renal failure: in setting of diuresis after volume
administration.  Echo done which showed severe MR.  Lasix
currently on hold.  He was gently hydrated daily and Cr
decreased to baseline of 1.5. Creatinine on discharge 1.4.

3. Zenkers diverticulum: This is a long standing issue ([**2104**])
and the family has declined intervention in the past due to
risks involved. He has no known prior aspiration pneumonia. Of
note his son is an ENT surgeon in [**Name (NI) 4565**]. At baseline he
eats generally soft foods and cuts up other food into small
bites. He was felt to be aspirating and seen by speech and
swallow therapist who noted coughing and phonation changes with
foods at the bedside.  Video barium swallow evaluation showed
large Zenker's Diverticulum that collects and fills with po
throughout po trials and eventually results in aspiration due to
backflow of po into the pharynx.  He had a new finding on cxr
that was pna vs pneumonitis s/p barium swallow. He has slight
leukocytosis (12.3) and therefore was treated with a course of
levofloxacin.  He was made NPO for a few days, maintained with
intravenous fluids, and ENT was consulted for recommendations on
less invasive repair options.  After discussion with the family
it was decided that invasive surgery would not be ideal, but a
less invasive procedure would be appropriate given his good
functional status at home.  ENT saw the patient and at that
point his lethargy and delirium had improved, and they
recommended to trial oral feeds again.  He was started on a
honey thick puree diet and tolerated this well.  He has an
appointment with ENT [**5-4**].
.
4. Upper GI Bleed:
Developed melena on [**4-15**]. Received 4 units PRBC in ICU. He was
given IV PPI and ASA was held. Family and GI decided against EGD
given he was hemodynamically stable and HCT stabilized after
blood. Possible cause is aspirin retention in Zenkers. Will f/u
with ENT as outpatient. Discharge HCT 30.1. He was taking
Vitamin E over the counter at home.  This was discontinued
because of increased risk of bleeding.  Family members aware.

5. ? h/o multiple myeloma:
-History of monoclonal gammopathy. Last colonoscopy [**2104**] with
adenoma polyp removed and repeat suggested in three years,
family reports it was not done.  Oncologist Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 23509**] [**Telephone/Fax (1) 72711**].  Last seen 4/[**2111**].  He is currently
stable, received Reclast therapy for bone health over the
winter, and will follow up in [**2-28**] months.

5. Systolic and diastolic congestive heart failure
- Echo shows severe 4+ mitral regurgitation with prolapsed
leaflet.  Followed by Dr. [**Last Name (STitle) **] of the Lown group last seen
4/[**2111**].  He had acute congestive heart failure this admission in
the setting of fluid volume overload from blood products and
intravenous fluid in the ICU during GI bleed.  He was given
diuretics and diuresed to baseline.
- Goal weight is 163 lbs per cardiology records.
- Lasix restarted at 20 mg daily. Home dose is 40mg alternating
with 20 mg.
- Keep K >4.0 and Mg >2.0.
- Had short runs of NSVT upon admission but improved, monitor K
and Mg on lasix.
.
6. Urinary retention
- Foley catheter was inserted during ICU stay.  It was
discontinued on the general care unit and after 12 hours he
failed to void.  Bladder scan showed 700mL and foley was placed
for 800mL urine.  Urology was called and they recommended
keeping the foley in place and following up as an outpatient.
He has a history of BPH and had a TURP in [**2094**]. He has f/u [**4-28**].
Consider voiding trial in the am of [**4-26**] and if he fails starting
tamsulosin. Does have h/o BPH s/o TURP.
.
7. Dementia
- Followed by geriatric psychiatrist at [**Hospital 1191**] Hospital.
Assumed to be vascular dementia.  Maintained on aricept and
namenda.  He was also taking vitamin e at home but it was
advised that this be discontinued because of risk of bleeding.
He has short term memory deficits and has declined in function
over the last 6 months, now with incontinence and needing
assistance with ADLs/IADLs.  He has a home health aide 5x per
week for bathing and goes to adult day care 3 days per week.
His wife is increasingly more burdened by his needs and is
considering increasing day care to 5 days per week.  Family is
supportive as well.  Discussion with family about code status
and overall goals of care.  At this time they feel strongly that
he remain Full code and would prefer to discuss resuscitation at
the time of crisis.  They do however prefer less invasive
treatment options given his overall age and dementia.  Further
discussion about code status is ongoing given his poor survival
potential.
- He showed delirium during this hospitalization that slowly
resolved, improving to his baseline cognitive level.  He was
given low dose x1 IV haldol in the ICU.  He slowly improved and
has been without sitter for several days with no attempts to get
out of bed/chair.

FAMILY DOES NOT WANT FEEDING TUBE.

Medications on Admission:
Home Medications:
1. Levothyroxine 75mcg daily
2. Aricept 10mg daily
3. Furosemide 20mg alt with 40mg daily
4. Namenda 10mg [**Hospital1 **]
5. levocarnitine 2 caps twice daily
6. Aspirin 81mg daily
7. Lumigan both eyes at bedtime
8. Timoptic both eyes morning/bedtime
9. Azopt left eye tid
10. Vitamin E 200 units daily
11. Vitamin D 1000 units daily


Discharge Medications:
1. Bimatoprost 0.03 % Drops Sig: One (1)  Ophthalmic qhs ():
Both eyes.
2. Brinzolamide 1 % Drops, Suspension Sig: One (1)  Ophthalmic
TID (3 times a day): left eye.
3. Donepezil 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Memantine 10 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day): Both eyes.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
once a day as needed for constipation for 1 doses.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).


Discharge Disposition:
Extended Care

Facility:
[**Location (un) 582**] Of [**Location (un) 620**]

Discharge Diagnosis:
Upper gastroesophageal bleed
Urinary retention
Severe Mitral regurgitation
Glaucoma
benign prostatic hypertrophy s/p transurethral resection
hypothroidism
Parkinsonism
dementia
chronic diarrhea
congestive heart failure
colonic polyp


Discharge Condition:
Stable.  Alert to person, hospital, [**2111**].  Cooperative.  Uses
rolling walker for ambulation.


Discharge Instructions:
You were admitted after falling at home.  While you were in the
hospital you had bleeding from your upper gastroesophageal
system and were treated with blood transfusions and intravenous
fluids.

You will have follow up with an ENT doctor to help determine if
you need a procedure to fix your Zenkers Diverticulum, hopefully
it will improve without intervention.

Please do not take Vitamin E any longer, it may contribute to
gastrointestinal bleeding. Please also do not take aspirin until
instructed by your doctor.

Your lasix was held for several days but has been restarted at
discharge.

Followup Instructions:
Appointment scheduled with Dr. [**Last Name (STitle) 1837**] [**2112-5-4**] at 4:15pm
for evaluation of the zenker's divertivulum.

Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2112-4-28**] 11:15 Urologist, please follow up for
outpatient voiding trial, Dr. [**Last Name (STitle) 33427**] was unable to see you in
the near future.

Please follow up with your cardiologist Dr. [**Last Name (STitle) **] at [**Hospital1 **] 1-2 weeks after discharge from rehab.
([**Telephone/Fax (1) 41173**].

Please follow up with your primary care provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) 13183**] [**11-25**]
weeks after discharge from rehab ([**Telephone/Fax (1) 99634**].



Completed by:[**2112-4-25**]
{'Hemorrhage of gastrointestinal tract, unspecified,Acute combined systolic and diastolic heart failure,Acute kidney failure, unspecified,Pneumonitis due to inhalation of food or vomitus,Acute posthemorrhagic anemia,Multiple myeloma, without mention of having achieved remission,Vascular dementia, with delirium,Delirium due to conditions classified elsewhere,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Syncope and collapse,Mitral valve disorders,Cerebral atherosclerosis,Unspecified glaucoma,Benign neoplasm of colon,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Diverticulum of esophagus, acquired,Paralysis agitans,Other specified retention of urine,Diarrhea,Unspecified acquired hypothyroidism'}


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: S/p unwitnessed fall/syncope

PRESENT ILLNESS: CC:[**CC Contact Info 99633**]
HPI: 88 y.o. male with h/o parkinson's, dementia, chf, multiple
myeloma and hypothyroidism sustained unwitnessed fall while on
toilet. Wife found him. He does not recall circumstances
initially but later reports his bottom "slipped off toilet."
Does feel he actually moved his bowels. Unclear if LOC. Denies
and assoc CP/SOB. No dizziness/lightheadedness. Per EMS sbp was
in 80s. EKG unchanged in ED. Head/neck CT negative. SBP in ED
100.

MEDICAL HISTORY: PMH:
1. Hypothryroidism
2. Parkinson's Disease
3. Glaucoma
4. Dementia
5. Cataracts
6. BPH s/p TURP [**2092**]
7. Chronic diarrhea
8. h/o adenomatous polyp [**2104**]
9. CHF
10. ? h/o multiple myeloma s/p tx with thalidomide
11. h/o squamous cell ca s/p deep resection with graft

MEDICATION ON ADMISSION: Home Medications:
1. Levothyroxine 75mcg daily
2. Aricept 10mg daily
3. Furosemide 20mg alt with 40mg daily
4. Namenda 10mg [**Hospital1 **]
5. levocarnitine 2 caps twice daily
6. Aspirin 81mg daily
7. Lumigan both eyes at bedtime
8. Timoptic both eyes morning/bedtime
9. Azopt left eye tid
10. Vitamin E 200 units daily
11. Vitamin D 1000 units daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Physical Exam on Admission:
VS: BP 123/84 HR 96 T 97 97% RA
General: Skin warm and dry. NAD. Alert, engaging.
Neuro: Oriented to person, hospital [**2112-3-24**].  HEENT: Neck
supple,
Resp: lungs with crackles at LLL, good insp effort and air
movement.
CV: heart rrr ap 90 + IV/VI holosystolic murmur best heard 3rd
ICS LSB radiates to axilla
GI: abd soft, non-tender, +bs, + ventral hernia, no guarding.
EXT: +pp no edema bilat, no hair on lower extremeties
Skin: Right shin with large scar (~4inx3in)
Rectal exam: vault full of stool, guiaic neg.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Social History:
Lives with his wife (second x 14 yrs). Wife is HCP but she often
defers to sons. [**Name (NI) **] two sons, [**Name (NI) **] who is local and [**Name (NI) **]
in [**State 4565**] is a ENT surgeon. Daighter in law [**Doctor Last Name 2048**] is also
very involved.  Prior worked as CPA x 40 yrs. Reports smoked
less than pack per day but quit >20 yrs ago. Reports occ etoh
use. 

### Response:
{'Hemorrhage of gastrointestinal tract, unspecified,Acute combined systolic and diastolic heart failure,Acute kidney failure, unspecified,Pneumonitis due to inhalation of food or vomitus,Acute posthemorrhagic anemia,Multiple myeloma, without mention of having achieved remission,Vascular dementia, with delirium,Delirium due to conditions classified elsewhere,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Syncope and collapse,Mitral valve disorders,Cerebral atherosclerosis,Unspecified glaucoma,Benign neoplasm of colon,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Diverticulum of esophagus, acquired,Paralysis agitans,Other specified retention of urine,Diarrhea,Unspecified acquired hypothyroidism'}
