CHIEF COMPLAINT: Fatigue

PRESENT ILLNESS: Mr [**Known lastname 4020**] is an 85 year old male with history of CAD s/p CABG
x2 and s/p AVR with bioprosthetic valve (not on
anticoagulation), transferred from [**Hospital1 **] [**Location (un) 620**] with complete
heart block. He has been experiencing recurrent episodes of
lightheadedness upon standing and falls for the past two weeks.
He has been generally asymptomatic when lying still, but
repeatedly feels lightheaded when standing. Has not had any
nausea, diaphoresis, or chest pain. Hit head softly one week
ago, but denies loss of consciousness.
.
On presentation to [**Hospital1 **] [**Location (un) 620**], initial VS were 97.3, 152/73,
37, 16, 100% 2l NC. Labs there showed hct 39.3, BUN/creat
54/1.4, INR 1.1, Alk phos 234, AST 147 (ALT 51), and normal
CK/MB/trop. ECG showed complete heart block with wide-QRS
complex escape beats. CXR showed no acute processes. He was seen
by cardiology who recommended transfer to [**Hospital1 18**].
.
In the ED, initial VS were 98.0, 132/63 22 100% 2L NC.
Ventricular rate was consistently in the 30s. ECG showed
complete heart block, with ventricular escape beats, rate in the
30s. Labs revealed hct 34.7 (baseline high 20s-low 30s),
elevated BUN/creat 56/1.2, negative troponin, and normal
potassium, magnesium, and other electrolytes. Pacer pads were
placed on his chest but were not employed.
.
Upon arrival to the CCU, the patient is without significant
complaints. He is awake, alert, and appears comfortable. He is
persistently bradycardic to the 30s, with occasional runs of
hemodynamically insignificant NSVT.
.
On review of systems, he endorses only chronic polyarticular
arthralgias. He denies any prior history of deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, cough, hemoptysis, black stools or red stools. He
denies recent fevers, chills or rigors. He denies exertional
buttock or calf pain. All of the other review of systems were
negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, or
ankle edema.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension

MEDICATION ON ADMISSION: -metoprolol 12.5 mg PO daily
-simvastatin 20 mg PO daily
-aspirin 325 mg PO daily
-docusate 100 mg PO BID
-ropinorole 1 mg PO QID
-carbidopa-levodopa 25-100 PO 5x/day
-vitamin C, E, B12, D, Calcium

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS: T=97.1 BP=132/108 HR=43 RR=16 O2 sat=99% 4L NC
GENERAL: Elderly caucasian gentleman with Parkinsonian features.
NAD. Oriented x3. Mood, affect appropriate.
HEENT: Masked facies. NCAT. Sclera anicteric. PERRL, EOMI.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 7 cm H20.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Regular rhythm, bradycardic. Absent S1, prominent S2.
+Holosystolic murmur most prominent at LUSB. No rubs or lifts.
LUNGS: CTAB, no W/R/R. No accessory muscle use
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: +High frequency, low amplitude upper extremity
tremor, which decreases with purposeful movements. No c/c/e. No
femoral bruits.
SKIN: No rashes
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
VS: T=97.1 BP=128/88 HR=56 RR=16 O2 sat=98%2L
GENERAL: Elderly caucasian gentleman with Parkinsonian features.
NAD. Oriented x3. Mood, affect appropriate.
HEENT: Masked facies. NCAT. Sclera anicteric. PERRL, EOMI.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 7 cm H20.
CHEST: Pacemaker site without tenderness or erythema
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Regular rhythm, bradycardic. Absent S1, prominent S2.
+Holosystolic murmur most prominent at LUSB. No rubs or lifts.
LUNGS: CTAB, no W/R/R. No accessory muscle use
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: +High frequency, low amplitude upper extremity
tremor, which decreases with purposeful movements. No c/c/e. No
femoral bruits.
SKIN: No rashes
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+

FAMILY HISTORY: - No family history of arrhythmia, cardiomyopathies, or sudden
cardiac death
- Mother:  [**Name (NI) 5895**] disease
- Father:  Alcoholism, ?MI at age 40
- Son: tourette's disease

SOCIAL HISTORY: Retired engineer. Denies any tobacco history or significant
alcohol intake. Wife passed away in [**2179**]. Lives home alone, but
has several children and friends visit him daily.
Atrioventricular block, complete,Delirium due to conditions classified elsewhere,Paralysis agitans,Other abnormal blood chemistry,Spinal stenosis, lumbar region, without neurogenic claudication,Diverticulosis of colon (without mention of hemorrhage),Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Heart valve replaced by transplant,Aortocoronary bypass status,Cardiac pacemaker in situ,Personal history of Methicillin resistant Staphylococcus aureus,Personal history of venous thrombosis and embolism,Personal history of colonic polyps
Atriovent block complete,Delirium d/t other cond,Paralysis agitans,Abn blood chemistry NEC,Spin sten,lumbr wo claud,Dvrtclo colon w/o hmrhg,BPH w/o urinary obs/LUTS,Heart valve transplant,Aortocoronary bypass,Status cardiac pacemaker,Hx Methicln resist Staph,Hx-ven thrombosis/embols,Prsnl hst colonic polyps
Admission Date:  [**2187-5-8**]              Discharge Date:   [**2187-5-10**]

Date of Birth:  [**2101-6-24**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2880**]
Chief Complaint:
Fatigue

Major Surgical or Invasive Procedure:
DDD pacemaker implantation


History of Present Illness:
Mr [**Known lastname 4020**] is an 85 year old male with history of CAD s/p CABG
x2 and s/p AVR with bioprosthetic valve (not on
anticoagulation), transferred from [**Hospital1 **] [**Location (un) 620**] with complete
heart block. He has been experiencing recurrent episodes of
lightheadedness upon standing and falls for the past two weeks.
He has been generally asymptomatic when lying still, but
repeatedly feels lightheaded when standing. Has not had any
nausea, diaphoresis, or chest pain. Hit head softly one week
ago, but denies loss of consciousness.
.
On presentation to [**Hospital1 **] [**Location (un) 620**], initial VS were 97.3, 152/73,
37, 16, 100% 2l NC. Labs there showed hct 39.3, BUN/creat
54/1.4, INR 1.1, Alk phos 234, AST 147 (ALT 51), and normal
CK/MB/trop. ECG showed complete heart block with wide-QRS
complex escape beats. CXR showed no acute processes. He was seen
by cardiology who recommended transfer to [**Hospital1 18**].
.
In the ED, initial VS were 98.0, 132/63 22 100% 2L NC.
Ventricular rate was consistently in the 30s. ECG showed
complete heart block, with ventricular escape beats, rate in the
30s. Labs revealed hct 34.7 (baseline high 20s-low 30s),
elevated BUN/creat 56/1.2, negative troponin, and normal
potassium, magnesium, and other electrolytes. Pacer pads were
placed on his chest but were not employed.
.
Upon arrival to the CCU, the patient is without significant
complaints. He is awake, alert, and appears comfortable. He is
persistently bradycardic to the 30s, with occasional runs of
hemodynamically insignificant NSVT.
.
On review of systems, he endorses only chronic polyarticular
arthralgias. He denies any prior history of deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, cough, hemoptysis, black stools or red stools. He
denies recent fevers, chills or rigors. He denies exertional
buttock or calf pain. All of the other review of systems were
negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, or
ankle edema.


Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension

2. CARDIAC HISTORY:
[**2177-8-19**]: CABG x4:
-in-situ LIMA to diagonal
-reversed SVG to distal LAD
-reversed SVG to OM1
-reversed SVG to PDA
[**2184-1-15**]:
-Redo CABG x2: SVG to LAD, SVG to PDA
-AVR with 23 mm Biocor porcine valve.
-Endoscopic vein harvesting
-c/b post-operative atrial fibrillation requiring amiodarone
.
OTHER PAST MEDICAL HISTORY:
- Unresponsive episode in [**2187-3-6**] believed [**2-7**] TIA vs seizure
- L3-L4 spinal stenosis
- L basilic vein thrombosis [**8-6**]
- Parkinson's disease
- BPH
- diverticulosis
- arthritis
- s/p cataract surgery
- s/p tonsillectomy


Social History:
Retired engineer. Denies any tobacco history or significant
alcohol intake. Wife passed away in [**2179**]. Lives home alone, but
has several children and friends visit him daily.

Family History:
- No family history of arrhythmia, cardiomyopathies, or sudden
cardiac death
- Mother:  [**Name (NI) 5895**] disease
- Father:  Alcoholism, ?MI at age 40
- Son: tourette's disease


Physical Exam:
VS: T=97.1 BP=132/108 HR=43 RR=16 O2 sat=99% 4L NC
GENERAL: Elderly caucasian gentleman with Parkinsonian features.
NAD. Oriented x3. Mood, affect appropriate.
HEENT: Masked facies. NCAT. Sclera anicteric. PERRL, EOMI.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 7 cm H20.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Regular rhythm, bradycardic. Absent S1, prominent S2.
+Holosystolic murmur most prominent at LUSB. No rubs or lifts.
LUNGS: CTAB, no W/R/R. No accessory muscle use
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: +High frequency, low amplitude upper extremity
tremor, which decreases with purposeful movements. No c/c/e. No
femoral bruits.
SKIN: No rashes
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
VS: T=97.1 BP=128/88 HR=56 RR=16 O2 sat=98%2L
GENERAL: Elderly caucasian gentleman with Parkinsonian features.
NAD. Oriented x3. Mood, affect appropriate.
HEENT: Masked facies. NCAT. Sclera anicteric. PERRL, EOMI.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 7 cm H20.
CHEST: Pacemaker site without tenderness or erythema
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Regular rhythm, bradycardic. Absent S1, prominent S2.
+Holosystolic murmur most prominent at LUSB. No rubs or lifts.
LUNGS: CTAB, no W/R/R. No accessory muscle use
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: +High frequency, low amplitude upper extremity
tremor, which decreases with purposeful movements. No c/c/e. No
femoral bruits.
SKIN: No rashes
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+


Pertinent Results:
Lab Trends:
.
CBC:
[**2187-5-8**] 06:00PM BLOOD WBC-7.4 RBC-3.57* Hgb-11.8*# Hct-34.7*#
MCV-97 MCH-33.2* MCHC-34.2 RDW-13.4 Plt Ct-161#
[**2187-5-9**] 02:24AM BLOOD WBC-7.6 RBC-3.51* Hgb-11.5* Hct-34.0*
MCV-97 MCH-32.9* MCHC-34.0 RDW-13.2 Plt Ct-143*
[**2187-5-10**] 12:40AM BLOOD WBC-8.0 RBC-3.60* Hgb-11.8* Hct-34.2*
MCV-95 MCH-32.8* MCHC-34.5 RDW-13.3 Plt Ct-163
.
INR
[**2187-5-8**] 06:00PM BLOOD PT-13.8* PTT-27.7 INR(PT)-1.2*
.
Chemistry:
[**2187-5-8**] 06:00PM BLOOD Glucose-93 UreaN-56* Creat-1.2 Na-141
K-4.5 Cl-107 HCO3-27 AnGap-12
[**2187-5-9**] 02:24AM BLOOD Glucose-105* UreaN-54* Creat-1.3* Na-140
K-4.7 Cl-107 HCO3-26 AnGap-12
[**2187-5-10**] 12:40AM BLOOD Glucose-91 UreaN-38* Creat-1.2 Na-139
K-4.7 Cl-107 HCO3-26 AnGap-11
.
LFTs:
[**2187-5-8**] 06:00PM BLOOD ALT-60* AST-125* CK(CPK)-90 AlkPhos-171*
TotBili-0.4
[**2187-5-9**] 02:24AM BLOOD ALT-34 AST-105* AlkPhos-160* TotBili-0.6
[**2187-5-10**] 12:40AM BLOOD ALT-22 AST-66* AlkPhos-146* TotBili-0.5
.
CXR [**5-10**]
FINDINGS: Sternotomy wires are midline. The first sternotomy
wire is
fractured, but unchanged since [**2184-2-6**]. A left
pacemaker device is noted with leads terminating appropriately
in the right atrium and right ventricle. Mediastinal surgical
clips are noted. Bilateral lungs show changes consistent with
chronic lung disease; however, no focal consolidation, pleural
effusion, or pneumothorax is noted. The cardiac, mediastinal and
hilar contours are within normal limits.
IMPRESSION: No consolidation, pleural effusion, or pneumothorax.

.
ECG [**5-8**]: Sinus rhythm with complete heart block and ventricular
escape rhythm. Compared to the previous tracing of [**2184-2-4**]
complete heart block is new. TRACING #1
- Prior ECG ([**2184-2-4**]): Sinus rhythm. Left bundle-branch block.
Baseline artifact. Compared to the previous tracing of [**2184-1-20**]
the lateral T waves are upright. The inferior T waves are still
inverted. These changes may be non-specific but clinical
correlation is suggested
.
ECG [**5-9**]: Ventricular paced rhythm. Compared to the previous
tracing pacing is now present. TRACING #2


Brief Hospital Course:
85 y/o M with hx CAD s/p CABG x2, AS s/p AVR, LBBB, Htn, HL,
presenting with several episodes of presyncope and syncope over
the past several weeks, found to be in complete heart block now
s/p successful pacemaker placement
.
ACTIVE ISSUES:
.
# Complete heart block/syncope: Presenting EKG showed complete
heart block. The patient underwent placement of PPM without
complication. The etiology of the patient's heartblock was
thought to be sick-sinus syndrome; CEs were serially negative
and there were no ischemic changes on serial EKGs although a
missed ischemic event was considered; TSH was within normal
limits; lyme serologies were negative. BB was initially held in
the acute setting then restarted after PPM placement when the
patient became hypertensive. The patient was discharged on
12.5mg daily metoprolol succinate at his home dose and follow-up
with the device clinic as well as antibiotics for 48h.
.
# HTN: Became hypertensive after placement of PPM in the setting
of holding BB. Became normotensive after restarting home dose
metoprolol as above.
.
# Elevated LFTs: LFTs were found to be mildly elevated from
baseline, in particular the patient's AP. Further work-up was
deferred for the outpatient setting.
.
# Delirium: The patient had an episode of delirium after
placement of PPM attributed to medical stressors and
environmental change in the setting of low cognitive reserve due
to Parkinson's and advanced age. The episode resolved with
Trazodone. There was no clear toxic-metabolic etiology of the
delirium; he remained hemodynamically stable.
.
INACTIVE ISSUES:
.
# CAD s/p CABG: Presented with symptoms of ACS. Continued
outpatient regimen. Became hypertensive off of BB, which was
then restarted at home dose.
.
# Parkinsons disease: Continued on sinemet, ropinorole
.
# Spinal stenosis: Presented with chronic paresthesias and
tingling in lower extremities; no changes were made to home
regimen.
.
# BPH: Remained stable. No changes were made to home regimen.
.
TRANSITIONAL ISSUES:
.
# PPM: Follow-up with device clinic as detailed below.
.
# Elevated LFTs: Patient will require further work-up after
discharge, starting with a RUQ ultrasound.

Medications on Admission:
-metoprolol 12.5 mg PO daily
-simvastatin 20 mg PO daily
-aspirin 325 mg PO daily
-docusate 100 mg PO BID
-ropinorole 1 mg PO QID
-carbidopa-levodopa 25-100 PO 5x/day
-vitamin C, E, B12, D, Calcium

Discharge Medications:
1. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
0.5 Tablet Extended Release 24 hr PO DAILY (Daily).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
4. ropinirole 1 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
5. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
5X/DAY (5 Times a Day).
7. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) as needed for post-pacemaker for 2 days.
Disp:*6 Capsule(s)* Refills:*0*


Discharge Disposition:
Extended Care

Facility:
[**Hospital 38**] Rehab Hospital at [**Hospital1 **]

Discharge Diagnosis:
Third degree AV block


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Dear Mr [**Known lastname 4020**] it was a pleasure taking care of you.
.
You were admitted due to weakness and repeated episodes of
fainting in recent weeks. You were found to have very slow heart
rate. A pacemaker was implanted in your chest in order to help
your heart beat at a normal rate.
.
You are discharged with the following new medication:
.
Cephalexin  500 mg Capsule, take One (1) Capsule PO Q8H (every 8
hours) for 2 days to prevent infection.
.
No other changes were made to your medications, please continue
to take your regular medications as prescribed.
.
For the next week please avoid lifting or other strenous
activity involving your left arm. Also avoid raising your left
arm about above the level of the shoulder.

Followup Instructions:
please keep the following appointments:
.
Name: [**Last Name (LF) **],[**First Name3 (LF) 35386**] I. MD
Location: [**Location (un) **] [**University/College **] FAMILY MEDICINE
Address: [**Street Address(2) **], [**Apartment Address(1) 35387**], [**Location (un) 35388**],[**Numeric Identifier **]
Phone: [**Telephone/Fax (1) 17203**]
Appointment: Wednesday [**2187-5-16**] 10:30am

Department: CARDIAC SERVICES
When: THURSDAY [**2187-5-17**] at 10:00 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


                             [**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**]
{'Atrioventricular block, complete,Delirium due to conditions classified elsewhere,Paralysis agitans,Other abnormal blood chemistry,Spinal stenosis, lumbar region, without neurogenic claudication,Diverticulosis of colon (without mention of hemorrhage),Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Heart valve replaced by transplant,Aortocoronary bypass status,Cardiac pacemaker in situ,Personal history of Methicillin resistant Staphylococcus aureus,Personal history of venous thrombosis and embolism,Personal history of colonic polyps'}


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: Fatigue

PRESENT ILLNESS: Mr [**Known lastname 4020**] is an 85 year old male with history of CAD s/p CABG
x2 and s/p AVR with bioprosthetic valve (not on
anticoagulation), transferred from [**Hospital1 **] [**Location (un) 620**] with complete
heart block. He has been experiencing recurrent episodes of
lightheadedness upon standing and falls for the past two weeks.
He has been generally asymptomatic when lying still, but
repeatedly feels lightheaded when standing. Has not had any
nausea, diaphoresis, or chest pain. Hit head softly one week
ago, but denies loss of consciousness.
.
On presentation to [**Hospital1 **] [**Location (un) 620**], initial VS were 97.3, 152/73,
37, 16, 100% 2l NC. Labs there showed hct 39.3, BUN/creat
54/1.4, INR 1.1, Alk phos 234, AST 147 (ALT 51), and normal
CK/MB/trop. ECG showed complete heart block with wide-QRS
complex escape beats. CXR showed no acute processes. He was seen
by cardiology who recommended transfer to [**Hospital1 18**].
.
In the ED, initial VS were 98.0, 132/63 22 100% 2L NC.
Ventricular rate was consistently in the 30s. ECG showed
complete heart block, with ventricular escape beats, rate in the
30s. Labs revealed hct 34.7 (baseline high 20s-low 30s),
elevated BUN/creat 56/1.2, negative troponin, and normal
potassium, magnesium, and other electrolytes. Pacer pads were
placed on his chest but were not employed.
.
Upon arrival to the CCU, the patient is without significant
complaints. He is awake, alert, and appears comfortable. He is
persistently bradycardic to the 30s, with occasional runs of
hemodynamically insignificant NSVT.
.
On review of systems, he endorses only chronic polyarticular
arthralgias. He denies any prior history of deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, cough, hemoptysis, black stools or red stools. He
denies recent fevers, chills or rigors. He denies exertional
buttock or calf pain. All of the other review of systems were
negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, or
ankle edema.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension

MEDICATION ON ADMISSION: -metoprolol 12.5 mg PO daily
-simvastatin 20 mg PO daily
-aspirin 325 mg PO daily
-docusate 100 mg PO BID
-ropinorole 1 mg PO QID
-carbidopa-levodopa 25-100 PO 5x/day
-vitamin C, E, B12, D, Calcium

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS: T=97.1 BP=132/108 HR=43 RR=16 O2 sat=99% 4L NC
GENERAL: Elderly caucasian gentleman with Parkinsonian features.
NAD. Oriented x3. Mood, affect appropriate.
HEENT: Masked facies. NCAT. Sclera anicteric. PERRL, EOMI.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 7 cm H20.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Regular rhythm, bradycardic. Absent S1, prominent S2.
+Holosystolic murmur most prominent at LUSB. No rubs or lifts.
LUNGS: CTAB, no W/R/R. No accessory muscle use
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: +High frequency, low amplitude upper extremity
tremor, which decreases with purposeful movements. No c/c/e. No
femoral bruits.
SKIN: No rashes
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
VS: T=97.1 BP=128/88 HR=56 RR=16 O2 sat=98%2L
GENERAL: Elderly caucasian gentleman with Parkinsonian features.
NAD. Oriented x3. Mood, affect appropriate.
HEENT: Masked facies. NCAT. Sclera anicteric. PERRL, EOMI.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 7 cm H20.
CHEST: Pacemaker site without tenderness or erythema
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Regular rhythm, bradycardic. Absent S1, prominent S2.
+Holosystolic murmur most prominent at LUSB. No rubs or lifts.
LUNGS: CTAB, no W/R/R. No accessory muscle use
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: +High frequency, low amplitude upper extremity
tremor, which decreases with purposeful movements. No c/c/e. No
femoral bruits.
SKIN: No rashes
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+

FAMILY HISTORY: - No family history of arrhythmia, cardiomyopathies, or sudden
cardiac death
- Mother:  [**Name (NI) 5895**] disease
- Father:  Alcoholism, ?MI at age 40
- Son: tourette's disease

SOCIAL HISTORY: Retired engineer. Denies any tobacco history or significant
alcohol intake. Wife passed away in [**2179**]. Lives home alone, but
has several children and friends visit him daily. 

### Response:
{'Atrioventricular block, complete,Delirium due to conditions classified elsewhere,Paralysis agitans,Other abnormal blood chemistry,Spinal stenosis, lumbar region, without neurogenic claudication,Diverticulosis of colon (without mention of hemorrhage),Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Heart valve replaced by transplant,Aortocoronary bypass status,Cardiac pacemaker in situ,Personal history of Methicillin resistant Staphylococcus aureus,Personal history of venous thrombosis and embolism,Personal history of colonic polyps'}
