CHIEF COMPLAINT: Syncope

PRESENT ILLNESS: 74 yoM w/ MS presenting with hypotension, per his home health
aide he was hypotensive day prior to admission with possible
syncope.   SBP usually runs in the 130s.   The patient states
for the past 3 days or so he has had insomnia and the day prior
to admission he states he was in the car with his wife and was
extremely tired.  He then states he had "passed out" but may
have fallen asleep.  For 2 hours he was difficult to arouse then
a friend was able to wake him.  This was a period during which
he was witnessed and had no seizure activity, bowel or bladder
incontinence or tongue biting.  Since that event for the next 24
hours he has felt extremely fatigued and generally weak without
any focal new weakness.  No visual changes, no SOB, no CP, no
cough, no abd pain, no diarrhea, chronic constipation, no rashes
no F/C/NS.  Rest of ROS is negative.

MEDICAL HISTORY: -multiple sclerosis
-hypercholesterolemia
-HTN
-depression
-suprapubic catheter for MS-related bladder dysfunction
-History of aspiration PNA
-known vascular anomaly (AVM) in L parietal lobe by old imaging

MEDICATION ON ADMISSION: Norvasc 10mg daily
Prilosec 40mg po bid
Baclofen 30mg po qhs
Combegan 1 drop [**Hospital1 **]
Enablex 7.5mg po daily
Enalapril 30mg po bid
Excedrin prn
Neurontin 800mg po bid prn
Xalatan 0.005% 1 drop bedtime
Metadate ER (methylphenidate 20mg SR) qam
Miralax 1 daily
Simvastatin 10mg daily
Trimaterene-HCTZ (37.5-25mg po tiweek)
ASA 325mg daily
Dulcolax prn
Calcium + D
Colace 200mg po bid
MVI daily
Omega 3

ALLERGIES: Morphine / Coumadin

PHYSICAL EXAM: VITAL SIGNS: T 95.2 BP 104/49 HR 45 RR 12 O2 100% 2L
supine BP 104/49  HR 44  sitting BP 130/50  HR 46
GENERAL: Pleasant, well appearing male in NAD
HEENT: Normocephalic, atraumatic.  No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear.  Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, bradycardic. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].  JVP= 6cm
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND.  No HSM, suprapubic catheter site
w/o erythema, induration or discharge, no tenderness
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. RLE weakness (per pt is baseline)

FAMILY HISTORY: Per notes, daughter and cousin with MS, mother with AD, father
with leukemia, brother with arrhythmia

SOCIAL HISTORY: Lives with wife in [**Name (NI) **]. Former etoh, sober since [**2123**] via
Infection and inflammatory reaction due to indwelling urinary catheter,Unspecified septicemia,Sepsis,Hyposmolality and/or hyponatremia,Anomalies of cerebrovascular system,Urinary tract infection, site not specified,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Personal history of malignant neoplasm of prostate,Esophageal reflux,Multiple sclerosis,Other specified cardiac dysrhythmias,Attention to cystostomy,Unspecified hereditary and idiopathic peripheral neuropathy,Obstructive sleep apnea (adult)(pediatric),Depressive disorder, not elsewhere classified,Pure hypercholesterolemia,Unspecified essential hypertension,Neurogenic bladder NOS
React-indwell urin cath,Septicemia NOS,Sepsis,Hyposmolality,Cerebrovascular anomaly,Urin tract infection NOS,Klebsiella pneumoniae,Hx-prostatic malignancy,Esophageal reflux,Multiple sclerosis,Cardiac dysrhythmias NEC,Atten to cystostomy,Idio periph neurpthy NOS,Obstructive sleep apnea,Depressive disorder NEC,Pure hypercholesterolem,Hypertension NOS,Neurogenic bladder NOS
Admission Date:  [**2152-4-24**]              Discharge Date:   [**2152-4-27**]

Date of Birth:  [**2077-7-1**]             Sex:   M

Service: MEDICINE

Allergies:
Morphine / Coumadin

Attending:[**First Name3 (LF) 23347**]
Chief Complaint:
Syncope

Major Surgical or Invasive Procedure:
None

History of Present Illness:
74 yoM w/ MS presenting with hypotension, per his home health
aide he was hypotensive day prior to admission with possible
syncope.   SBP usually runs in the 130s.   The patient states
for the past 3 days or so he has had insomnia and the day prior
to admission he states he was in the car with his wife and was
extremely tired.  He then states he had "passed out" but may
have fallen asleep.  For 2 hours he was difficult to arouse then
a friend was able to wake him.  This was a period during which
he was witnessed and had no seizure activity, bowel or bladder
incontinence or tongue biting.  Since that event for the next 24
hours he has felt extremely fatigued and generally weak without
any focal new weakness.  No visual changes, no SOB, no CP, no
cough, no abd pain, no diarrhea, chronic constipation, no rashes
no F/C/NS.  Rest of ROS is negative.

In the ER his initial BP was 83/49 with a HR of 30-40 (sinus
brady) and was given zosyn for possible urosepsis and 3L of NS.

His VS prior to transfer to the floor were: T 98.2, BP 116/50,
HR of 41, RR 11, sating 100%on 2L.


Past Medical History:
-multiple sclerosis
-hypercholesterolemia
-HTN
-depression
-suprapubic catheter for MS-related bladder dysfunction
-History of aspiration PNA
-known vascular anomaly (AVM) in L parietal lobe by old imaging

-OSA on cpap at night
-peripheral neuropathy
-thoracic outlet syndrome
-spondylosis
-PE in [**2-20**]
-GERD
-bradycardia with 1st deg AV block
-BPH
-hx cellulitis
-h/o left foot fracture
-h/o MRSA
-Prostate Cancer - finished XRT for this.


Social History:
Lives with wife in [**Name (NI) **]. Former etoh, sober since [**2123**] via

AA. Quit cigars a few years ago. Retired judge (at age 68 due to

fatigue).


Family History:
Per notes, daughter and cousin with MS, mother with AD, father
with leukemia, brother with arrhythmia


Physical Exam:
VITAL SIGNS: T 95.2 BP 104/49 HR 45 RR 12 O2 100% 2L
supine BP 104/49  HR 44  sitting BP 130/50  HR 46
GENERAL: Pleasant, well appearing male in NAD
HEENT: Normocephalic, atraumatic.  No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear.  Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, bradycardic. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].  JVP= 6cm
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND.  No HSM, suprapubic catheter site
w/o erythema, induration or discharge, no tenderness
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. RLE weakness (per pt is baseline)

Pertinent Results:
Admission:
[**2152-4-24**] 05:39PM   HGB-11.9* calcHCT-36
[**2152-4-24**] 05:39PM   GLUCOSE-94 LACTATE-1.3 NA+-129* K+-4.5
CL--96* TCO2-24
[**2152-4-24**] 05:40PM   PT-12.3 PTT-29.6 INR(PT)-1.0
[**2152-4-24**] 05:40PM   NEUTS-69.2 LYMPHS-20.6 MONOS-6.3 EOS-3.4
BASOS-0.6
[**2152-4-24**] 05:40PM   WBC-7.7 RBC-3.92* HGB-12.1* HCT-35.3* MCV-90
MCH-30.9 MCHC-34.3 RDW-13.2
[**2152-4-24**] 05:40PM   OSMOLAL-273*
[**2152-4-24**] 05:40PM   CALCIUM-8.6 PHOSPHATE-3.0 MAGNESIUM-2.3
[**2152-4-24**] 05:40PM   cTropnT-<0.01
[**2152-4-24**] 05:40PM   GLUCOSE-97 UREA N-31* CREAT-1.3* SODIUM-128*
POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-23 ANION GAP-14
[**2152-4-24**] 05:45PM URINE  BLOOD-MOD NITRITE-POS PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-6.0
LEUK-LG
[**2152-4-24**] 05:45PM URINE  COLOR-Yellow APPEAR-SlHazy SP [**Last Name (un) 155**]-1.010
[**2152-4-24**] 07:17PM URINE  HOURS-RANDOM SODIUM-14

Labs during hospitalization:
[**2152-4-24**] 05:40PM BLOOD CK(CPK)-1158*
[**2152-4-25**] 04:09AM BLOOD ALT-32 AST-46* LD(LDH)-120 CK(CPK)-715*
AlkPhos-59 TotBili-0.5
[**2152-4-27**] 06:20AM BLOOD CK(CPK)-163

Labs on discharge:
[**2152-4-27**] 06:20AM BLOOD WBC-5.9 RBC-3.38* Hgb-10.5* Hct-30.2*
MCV-90 MCH-31.0 MCHC-34.7 RDW-13.3 Plt Ct-158
[**2152-4-27**] 06:20AM BLOOD Glucose-102 UreaN-17 Creat-0.9 Na-142
K-4.0 Cl-110* HCO3-23 AnGap-13
[**2152-4-27**] 06:20AM BLOOD Calcium-8.9 Phos-2.7 Mg-1.9

CXR [**2152-4-24**]: No acute cardiopulmonary process. Advanced
degenerative changes at the right glenohumeral joint and a bony
exostosis seen along the medial proximal shaft of the right
humerus are unchanged from the prior examination.

CXR [**2152-4-27**]:  Right PICC in place, tip in the lower SVC.

Ucx [**2152-4-24**]:
   URINE CULTURE (Final [**2152-4-29**]):
      KLEBSIELLA PNEUMONIAE.    >100,000 ORGANISMS/ML..
         WARNING! This isolate is an extended-spectrum
beta-lactamase
         (ESBL) producer and should be considered resistant to
all
         penicillins, cephalosporins, and aztreonam. Consider
Infectious
         Disease consultation for serious infections caused by
         ESBL-producing species.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             KLEBSIELLA PNEUMONIAE
                             |
AMIKACIN--------------     8 S
AMPICILLIN/SULBACTAM--  =>32 R
CEFAZOLIN-------------  =>64 R
CEFEPIME--------------       R
CEFTAZIDIME-----------  =>64 R
CEFTRIAXONE-----------       R
CEFUROXIME------------    32 R
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------     8 I
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- =>512 R
PIPERACILLIN/TAZO-----     8 S
TOBRAMYCIN------------  =>16 R
TRIMETHOPRIM/SULFA----  =>16 R


Brief Hospital Course:
Assessment and Plan: 74 yoM w/ a h/o MS, PE, and syncope
presents with hypotension and found to have UTI.

1. Hypotension/UTI:  Likely due to urosepsis. The patient's
blood pressure responded nicely to IV fluids in the ICU.  His
chronic bradycardia probably contributed to the overall picture
and inability to compensate.  His antihypertensives were
initially held and he was restarted on amlodipine and enalapril
prior to discharge.  He was treated with meropenem (given his
history of ESBL Klebsiella) for his UTI which was changed to
ertapenem at the time of discharge.  His suprapubic catheter was
changed.

2. Non responsiveness: He has a long history of vasovagal
syncope and has had multiple outpatient studies to work this up.
 This episode was unlikely a syncopal event given the duration
that he was non responsive. He had no witnessed seizure
activity.  This episode was more likely due to global cerebral
hypoperfusion in the setting of hypotension / UTI.  We discussed
at length that his family should bring him immediately to the ED
if he has an event like this in the future.  Pt to have
outpatient cognitive screening.

3. Bradycardia: Was seen by EP last year for recurrent syncopal
episodes, hypertension, and prolonged PR interval his syncope
was determined to be likely vasovagal given his prodrome of
diaphoresis, fatigue, and nausea.

4. Multiple sclerosis:  continued his home baclofen, enablex,
neurontin, methylphenidate, and remeron.  Has chronic
constipation and was continued on his bowel regimen.

5. Hypercholesterolemia: His statin was held due to an increased
Ck which trended down during his admission.  He should discuss
with his PCP whether to restart his statin.

6. Hyponatremia: Likely hypovolemic hyponatremia and responded
to hydration.

7. Renal failure: Cr 1.3 at admission and normalized during his
admission.

8. Ppx: heparin sc tid, bowel regimen prn, PPI blocker.

9. Full code


Medications on Admission:
Norvasc 10mg daily
Prilosec 40mg po bid
Baclofen 30mg po qhs
Combegan 1 drop [**Hospital1 **]
Enablex 7.5mg po daily
Enalapril 30mg po bid
Excedrin prn
Neurontin 800mg po bid prn
Xalatan 0.005% 1 drop bedtime
Metadate ER (methylphenidate 20mg SR) qam
Miralax 1 daily
Simvastatin 10mg daily
Trimaterene-HCTZ (37.5-25mg po tiweek)
ASA 325mg daily
Dulcolax prn
Calcium + D
Colace 200mg po bid
MVI daily
Omega 3

Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Baclofen 10 mg Tablet Sig: Three (3) Tablet PO QHS (once a
day (at bedtime)).
3. Enablex 7.5 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
5. Polyethylene Glycol 3350 100 % Powder Sig: One (1)  PO DAILY
(Daily).
6. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO at
bedtime.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. Gabapentin 800 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for pain.
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily): continue previous home dose.
10. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic TID (3 times a day).
12. Methylphenidate 20 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
13. Combigan 0.2-0.5 % Drops Sig: continue previous home dose
Ophthalmic [**Hospital1 **] (2 times a day).
14. Enalapril Maleate 10 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
15. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
16. Ertapenem 1 gram Recon Soln Sig: One (1) gram Intravenous
once a day as needed for complicated UTI for 6 days.
Disp:*qs gram* Refills:*0*
17. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
18. calcium
pls continue previous home dose
19. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Capsule PO 3 days a week: pls resume previous home dosing.
20. flush
Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Prmary Diagnosis:
-urosepsis
-suprapubic catheter for MS-related bladder dysfunction
.
Secondary Diagnosis:
-multiple sclerosis diagnosed in [**2122**]
-hypercholesterolemia
-HTN
-depression
-History of aspiration PNA
-known vascular anomaly (AVM) in L parietal lobe by old imaging

-OSA on cpap at night
-peripheral neuropathy
-thoracic outlet syndrome
-spondylosis
-PE in [**2-20**]
-GERD
-bradycardia with 1st deg AV block
-BPH
-hx cellulitis
-h/o left foot fracture
-h/o MRSA
-Prostate Cancer - had hormonal tx and spread past capsule


Discharge Condition:
Stable.


Discharge Instructions:
You were admitted to the intensive care unit with a urinary
tract infetion and decreased blood pressure.  You were started
on meropenem for broad spectrum antibiotic coverage which was
changed to ertapenem for once a day dosing.  A PICC line was
placed for antibiotic administration.
.
The following changes were made to your medications:
-ertapenem was started
.
The following medication was discontinued:
-simvastatin is being held due to your high CK suggesting the
statin could be negatively effecting your liver (pls talk to
your primary care doctor about whether to restart this)
.
No other changes were made to your medications.  Please take all
medications at their previously prescribed dose.
.
Please seek IMMEDIATE medical attention if you experience loss
of consciousness, dizziness, chest pain, redness around your
catheter site, shortness of breath, diarrhea, blood in your
stool, or any new concerning symptom.

Followup Instructions:
MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Specialty: Gerontology / PCP
Date and time: Tuesday, [**5-9**]  8:30am
Location: [**Hospital Unit Name **], [**Hospital Ward Name **] bldg
Phone number: [**Telephone/Fax (1) 719**]


                             [**Name6 (MD) **] [**Last Name (NamePattern4) 23348**] MD, [**MD Number(3) 23349**]

Completed by:[**2152-7-30**]
{"Infection and inflammatory reaction due to indwelling urinary catheter,Unspecified septicemia,Sepsis,Hyposmolality and/or hyponatremia,Anomalies of cerebrovascular system,Urinary tract infection, site not specified,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Personal history of malignant neoplasm of prostate,Esophageal reflux,Multiple sclerosis,Other specified cardiac dysrhythmias,Attention to cystostomy,Unspecified hereditary and idiopathic peripheral neuropathy,Obstructive sleep apnea (adult)(pediatric),Depressive disorder, not elsewhere classified,Pure hypercholesterolemia,Unspecified essential hypertension,Neurogenic bladder NOS"}


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: 74 yoM w/ MS presenting with hypotension, per his home health
aide he was hypotensive day prior to admission with possible
syncope.   SBP usually runs in the 130s.   The patient states
for the past 3 days or so he has had insomnia and the day prior
to admission he states he was in the car with his wife and was
extremely tired.  He then states he had "passed out" but may
have fallen asleep.  For 2 hours he was difficult to arouse then
a friend was able to wake him.  This was a period during which
he was witnessed and had no seizure activity, bowel or bladder
incontinence or tongue biting.  Since that event for the next 24
hours he has felt extremely fatigued and generally weak without
any focal new weakness.  No visual changes, no SOB, no CP, no
cough, no abd pain, no diarrhea, chronic constipation, no rashes
no F/C/NS.  Rest of ROS is negative.

MEDICAL HISTORY: -multiple sclerosis
-hypercholesterolemia
-HTN
-depression
-suprapubic catheter for MS-related bladder dysfunction
-History of aspiration PNA
-known vascular anomaly (AVM) in L parietal lobe by old imaging

MEDICATION ON ADMISSION: Norvasc 10mg daily
Prilosec 40mg po bid
Baclofen 30mg po qhs
Combegan 1 drop [**Hospital1 **]
Enablex 7.5mg po daily
Enalapril 30mg po bid
Excedrin prn
Neurontin 800mg po bid prn
Xalatan 0.005% 1 drop bedtime
Metadate ER (methylphenidate 20mg SR) qam
Miralax 1 daily
Simvastatin 10mg daily
Trimaterene-HCTZ (37.5-25mg po tiweek)
ASA 325mg daily
Dulcolax prn
Calcium + D
Colace 200mg po bid
MVI daily
Omega 3

ALLERGIES: Morphine / Coumadin

PHYSICAL EXAM: VITAL SIGNS: T 95.2 BP 104/49 HR 45 RR 12 O2 100% 2L
supine BP 104/49  HR 44  sitting BP 130/50  HR 46
GENERAL: Pleasant, well appearing male in NAD
HEENT: Normocephalic, atraumatic.  No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear.  Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, bradycardic. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].  JVP= 6cm
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND.  No HSM, suprapubic catheter site
w/o erythema, induration or discharge, no tenderness
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. RLE weakness (per pt is baseline)

FAMILY HISTORY: Per notes, daughter and cousin with MS, mother with AD, father
with leukemia, brother with arrhythmia

SOCIAL HISTORY: Lives with wife in [**Name (NI) **]. Former etoh, sober since [**2123**] via 

### Response:
{"Infection and inflammatory reaction due to indwelling urinary catheter,Unspecified septicemia,Sepsis,Hyposmolality and/or hyponatremia,Anomalies of cerebrovascular system,Urinary tract infection, site not specified,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Personal history of malignant neoplasm of prostate,Esophageal reflux,Multiple sclerosis,Other specified cardiac dysrhythmias,Attention to cystostomy,Unspecified hereditary and idiopathic peripheral neuropathy,Obstructive sleep apnea (adult)(pediatric),Depressive disorder, not elsewhere classified,Pure hypercholesterolemia,Unspecified essential hypertension,Neurogenic bladder NOS"}
