CHIEF COMPLAINT: Syncope

PRESENT ILLNESS: 63 yo with ESRD, DM, CAD, CHF, who presents after an episode of
syncope today. The patient went to the commode today felling
fine, but then suddenly fell forward and hit her head and her
left arm. She thinks that she might have fallen asleep and only
recalls mild lightheadedness which is a common symptom for her
when she gets up to the commode. She did not loose consciousness
and recalls the event in detail. She was not able to get up from
the floor becaus eof the weakness in her legs at baseline until
her husband came to help her. She then had one episode of
non-bloody vomitus. Her husband called EMS who brought her to
[**Hospital6 **].
At [**Hospital1 34**] the patient reportedly was lethargic and a head CT was
done that was negative for bleed. The patient reported pain in
her L arm and a humerus XR showed a comminuted surgical neck
fracture with less than half shaft width of lateral
displacement. A CT of her spine was negative for fracture. A CXR
was read as CHF. The patient was transfered to [**Hospital1 18**] for further
management.
.
ED course: CXR was done and showed new R perihilar and RLL
infiltrate. The patient underwent a CTA that did not show any PE
but confirmed a right lower lobe as well as dependent right
upper lobe and medial left lower lobe infiltrate that was
concerning for infection. The pt was given Vanco, Levo and
Flagyl.
.
ROS: negative for CP, SOB, cough, secretions, abdominal pain,
diarrhea, constipation, f/c/ns, weight loss, dysuria, changes in
the color of the urine or stool. The patient reports that she
was feeling a little weaker since her recent admission for coag
neg bacteremia but had been feeling fine otherwise.

MEDICAL HISTORY: 1. DM2 since her 40s, dialysis since [**2-3**]
2. ESRD [**2-1**] DMII, on MWF HD, followed by Dr. [**First Name (STitle) 805**]
3. h/o MRSA cellulitis of bilateral LE
4. HTN
5. Hyperlipidemia
6. Hypothyroidism
7. CAD s/p CABG [**2179**], NSTEMI in [**9-2**] during admission; echo [**3-4**]
with EF 35%, moderate to severe MR
8. Anemia
9. Osteoporosis
10. Depression
11. h/o right hip fx s/o ORIF
12. PVD
13. Sleep apnea
14. On Home 3L O2, PFTs [**2186**] with restrictive pattern, pulmonary
HTN
15. R Charcot Foot
16. Restless Leg Syndrome
17. Pulmonary hypertension

MEDICATION ON ADMISSION: Amlodipine 5 mg once a day
Aspirin 81 mg once a day
B complex once a day
Cozaar 50mg 4 times a week
Digoxin 125mcg, [**1-1**] alternating with 1 tablet po Q4days
Gabapentin 200mg QHS
Klonopin 1mg, 1 tablet QHS, 2mg before dialysis
Lipitor 10 mg--1 tablet(s) by mouth at bedtime
Mirapex 0.125 mg--[**1-1**] tablet(s) by mouth at 6pm and again QHS
Nephrocaps 1 capsule(s) by mouth once a day
Synthroid 50 mcg--1 tablet(s) by mouth once a day
TOPROL XL 100 mg--1 tablet(s) by mouth at bedtime
ZOLOFT 100 mg--1 tablet(s) by mouth q am
Daypro 600mg, 2 tbl with food
Calcium Acetate 667 mg 2tb TID W/MEALS
Clopidogrel 75 mg Tablet
Sevelamer 800 mg 3 Tablet PO TID
Glargine 37U, HISS

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS T 97.5 BP 104/90  HR 71  RR 21 O2Sat 99% on NRB
Gen: NAD, AAOx3
HEENT: NC/AT, PERRLA, dry mm
NECK: no LAD, JVD not visulized, no carotid bruit
COR: S1S2, regular rhythm, SEM II/VI over LUSB, no r/g
PULM: limited due to patients limited ability to turn; decreased
breathsounds in R base, crackles b/l
ABD: + bowel sounds, soft, nd, nt, indurated area L lateral to
the umbilicus, umbilical hernia
Skin: warm extremities, no rash, 0.5cm dry open wound on L
malleolus,
EXT: dopplerable DP, charcot deformity of the R foot, trace
edema, no CVA tenderness
Neuro: following commands, PERRLA, reflexes 2+ b/l inupper
extremities, 1+ patella, absent achilles reflex

FAMILY HISTORY: Father - Deceased with MI at 60
Sister - Breast cancer
Mother - 60s, CAD
Son with DM

SOCIAL HISTORY: The patient lives with her husband who is her primary caregiver.
She denies past or present tobacco use. She denies alcohol or IV
drug use. Patient previously worked as a secretary.
Acute respiratory failure,Congestive heart failure, unspecified,Postinflammatory pulmonary fibrosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Primary pulmonary hypertension,Pneumonia, organism unspecified,End stage renal disease,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Syncope and collapse,Closed fracture of surgical neck of humerus,Unspecified fall,Malignant neoplasm of ovary,Sinoatrial node dysfunction,Hypotension, unspecified,Unspecified acquired hypothyroidism,Delirium due to conditions classified elsewhere,Aortocoronary bypass status,Old myocardial infarction,Encounter for palliative care
Acute respiratry failure,CHF NOS,Postinflam pulm fibrosis,Hyp kid NOS w cr kid V,Prim pulm hypertension,Pneumonia, organism NOS,End stage renal disease,DMII renl nt st uncntrld,Syncope and collapse,Fx surg nck humerus-clos,Fall NOS,Malign neopl ovary,Sinoatrial node dysfunct,Hypotension NOS,Hypothyroidism NOS,Delirium d/t other cond,Aortocoronary bypass,Old myocardial infarct,Encountr palliative care
Admission Date:  [**2188-8-19**]              Discharge Date:   [**2188-8-28**]

Date of Birth:  [**2125-3-28**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Syncope

Major Surgical or Invasive Procedure:
intubation
central line placement

History of Present Illness:
63 yo with ESRD, DM, CAD, CHF, who presents after an episode of
syncope today. The patient went to the commode today felling
fine, but then suddenly fell forward and hit her head and her
left arm. She thinks that she might have fallen asleep and only
recalls mild lightheadedness which is a common symptom for her
when she gets up to the commode. She did not loose consciousness
and recalls the event in detail. She was not able to get up from
the floor becaus eof the weakness in her legs at baseline until
her husband came to help her. She then had one episode of
non-bloody vomitus. Her husband called EMS who brought her to
[**Hospital6 **].
At [**Hospital1 34**] the patient reportedly was lethargic and a head CT was
done that was negative for bleed. The patient reported pain in
her L arm and a humerus XR showed a comminuted surgical neck
fracture with less than half shaft width of lateral
displacement. A CT of her spine was negative for fracture. A CXR
was read as CHF. The patient was transfered to [**Hospital1 18**] for further
management.
.
ED course: CXR was done and showed new R perihilar and RLL
infiltrate. The patient underwent a CTA that did not show any PE
but confirmed a right lower lobe as well as dependent right
upper lobe and medial left lower lobe infiltrate that was
concerning for infection. The pt was given Vanco, Levo and
Flagyl.
.
ROS: negative for CP, SOB, cough, secretions, abdominal pain,
diarrhea, constipation, f/c/ns, weight loss, dysuria, changes in
the color of the urine or stool. The patient reports that she
was feeling a little weaker since her recent admission for coag
neg bacteremia but had been feeling fine otherwise.

Past Medical History:
1. DM2 since her 40s, dialysis since [**2-3**]
2. ESRD [**2-1**] DMII, on MWF HD, followed by Dr. [**First Name (STitle) 805**]
3. h/o MRSA cellulitis of bilateral LE
4. HTN
5. Hyperlipidemia
6. Hypothyroidism
7. CAD s/p CABG [**2179**], NSTEMI in [**9-2**] during admission; echo [**3-4**]
with EF 35%, moderate to severe MR
8. Anemia
9. Osteoporosis
10. Depression
11. h/o right hip fx s/o ORIF
12. PVD
13. Sleep apnea
14. On Home 3L O2, PFTs [**2186**] with restrictive pattern, pulmonary
HTN
15. R Charcot Foot
16. Restless Leg Syndrome
17. Pulmonary hypertension

Social History:
The patient lives with her husband who is her primary caregiver.
She denies past or present tobacco use. She denies alcohol or IV
drug use. Patient previously worked as a secretary.

Family History:
Father - Deceased with MI at 60
Sister - Breast cancer
Mother - 60s, CAD
Son with DM

Physical Exam:
VS T 97.5 BP 104/90  HR 71  RR 21 O2Sat 99% on NRB
Gen: NAD, AAOx3
HEENT: NC/AT, PERRLA, dry mm
NECK: no LAD, JVD not visulized, no carotid bruit
COR: S1S2, regular rhythm, SEM II/VI over LUSB, no r/g
PULM: limited due to patients limited ability to turn; decreased
breathsounds in R base, crackles b/l
ABD: + bowel sounds, soft, nd, nt, indurated area L lateral to
the umbilicus, umbilical hernia
Skin: warm extremities, no rash, 0.5cm dry open wound on L
malleolus,
EXT: dopplerable DP, charcot deformity of the R foot, trace
edema, no CVA tenderness
Neuro: following commands, PERRLA, reflexes 2+ b/l inupper
extremities, 1+ patella, absent achilles reflex

Pertinent Results:
EKG: SR, LA, HR 70, borderline PR interval, intraventricular
conduction delay with QRS prolongation to 170ms. No change from
prior.
.
CTA:
1. No PE.
2. Marked cardiomegaly with evidence of right heart dysfunction
and
congestion.
3. Consolidation of much of right lower lobe, as well as
dependent right upper lobe and medial left lower lobe may be due
to aspiration or infection.
4. Small-moderate partially loculated right pleural effusion.
5. Chronic right hemidiaphragmatic elevation.
6. Evidence of pulmonary arterial hypertension.
.
CT head: negative for bleed, old left parietal infarct.
CT spine: negative for fracture
.
XR humerus L: comminuted surgical neck fracture with less than
half shaft width of lateral displacement.
CONCLUSION:

1. Consolidation in the right lower, right upper and medial left
lower lobe, slightly increased in extent compared to prior
examination, may be due to infection or aspiration.
2. Small right pleural effusion.
3. Pulmonary arterial hypertension.
4. Large pelvic cystic mass, probably arising from the right
adnexal region. This finding is concerning for ovarian
malignancy, considering presence of ascites and omental
nodularity.
5. Old fracture deformities of inferior right pubic ramus, right
lower posterior ribs. Impacted fracture of the left humeral neck
and fracture of the right humeral neck, dedicated films can be
obtained if clinically indicated.. L3 compression fracture new
since [**2186-8-31**].
6. Thyroid nodule.
7. Left adrenal nodule.

Brief Hospital Course:
A/P: 63 yo with ESRD, DM, CAD, CHF, s/p syncopal event
presenting with hypercarbic respiratory failure, mild fluid
overload and L humerus fracture.
.
# Hypercarbic respiratory failure.  Was intubated for airway
protection and hypercarbic respiratory failure thought to be due
to CHF and restrictive lung disease due to body habitus
(kyphoscoliosis/abdominal distention) and splinting from pain.
Patient has chronic CO2 retention at baseline and also O2
dependent with 3Lat baseline.  Was treated with dialysis and was
extubated on [**8-25**].  Patient breathing comfortably on [**3-2**] L NC at
time of discharge.
.
# Syncopal event. This was thought to be due to a vasovagal
episode after micturation. No evidence of carotid stenosis, no
significant aortic valve disease on recent ECHO.  Cardiac
enzymes were only mildly elevated with peak CK-MB of 12 on [**8-10**].
 Troponins peaked at 0.8 on [**8-25**].
.
# Abdominal mass/ascites.  This is likely be to ovarian cancer.
Elevated CEA and CA-125 are consistent with  malignancy. Patient
was seen by gyn oncology who felt she was not a surgical
candidate - this was discussed with the pt. and her family and
they understood this and the uncertain but likely very poor
prognosis.  They elected to treat symptomatically, and not
pursue specific further therapy.
.
# DM: Patient was treated with an insulin sliding scale during
ICU stay.  She will need to resume her home dose of 37 [**Location 18993**] at night if her po intake increases and her blood
sugars are elevated.   At the time of discharge she was being
managed on SSI alone.
.
# ESRD.  Patient received dialysis during hospitalization, and
should continue TIW as outpatient.
.
# Humerus fracture.  Patient suffered a humerus fracture during
syncopal episode.  There was a mild displacement.  She was
treated with Morphine prn and Tylenol RTC for pain control.  She
was seen by orthopedic surgery and her arm was placed in a sling
- they recommended nwb and maintenance of arm in sling with
outpatient follow up in 4 weeks.
.
# Code:Pt. and family elect DNR/DNI. No pressors per family.




Medications on Admission:
Amlodipine 5 mg once a day
Aspirin 81 mg once a day
B complex once a day
Cozaar 50mg 4 times a week
Digoxin 125mcg, [**1-1**] alternating with 1 tablet po Q4days
Gabapentin 200mg QHS
Klonopin 1mg, 1 tablet QHS, 2mg before dialysis
Lipitor 10 mg--1 tablet(s) by mouth at bedtime
Mirapex 0.125 mg--[**1-1**] tablet(s) by mouth at 6pm and again QHS
Nephrocaps 1 capsule(s) by mouth once a day
Synthroid 50 mcg--1 tablet(s) by mouth once a day
TOPROL XL 100 mg--1 tablet(s) by mouth at bedtime
ZOLOFT 100 mg--1 tablet(s) by mouth q am
Daypro 600mg, 2 tbl with food
Calcium Acetate 667 mg 2tb TID W/MEALS
Clopidogrel 75 mg Tablet
Sevelamer 800 mg 3 Tablet PO TID
Glargine 37U, HISS

Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed.
3. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO Q6pm and
QHS ().
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3
TIMES A DAY WITH MEALS).
9. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
11. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
neb Inhalation Q6H (every 6 hours) as needed.
12. Insulin Lispro 100 unit/mL Solution Sig: as per sliding
scale units, insulin Subcutaneous ASDIR (AS DIRECTED): see
attached sliding scale. units, insulin
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
14. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
17. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
18. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for Pain.
19. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
20. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).


Discharge Disposition:
Extended Care

Facility:
Life Care Center of [**Location 15289**]

Discharge Diagnosis:
Likely ovarian cancer
Lt. humeral fracture
Multilobar, community-acquired pneumonia
Hypercarbic respiratory failure requiring mechanical ventilation


Discharge Condition:
stable


Discharge Instructions:
Take all medications as prescribed.

Call the Orthopedic department at [**Hospital1 **] to arrange a follow up
appointment for four weeks from the time of discharge:
([**Telephone/Fax (1) 2007**]

Call the Gynecology Department at [**Hospital1 18**] to arrange follow up
should you elect to pursue further treatment for the abdominal
mass that was found during this admission:
([**Telephone/Fax (1) 18994**]

Call and arrange a follow up appointment with your primary
doctor for within one month of leaving the hospital

[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]


Followup Instructions:
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2188-9-16**] 11:10
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7380**],MD MPH[**MD Number(3) 708**]:[**Telephone/Fax (1) 457**]
Date/Time:[**2188-9-30**] 9:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2189-1-1**] 11:00
{'Acute respiratory failure,Congestive heart failure, unspecified,Postinflammatory pulmonary fibrosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Primary pulmonary hypertension,Pneumonia, organism unspecified,End stage renal disease,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Syncope and collapse,Closed fracture of surgical neck of humerus,Unspecified fall,Malignant neoplasm of ovary,Sinoatrial node dysfunction,Hypotension, unspecified,Unspecified acquired hypothyroidism,Delirium due to conditions classified elsewhere,Aortocoronary bypass status,Old myocardial infarction,Encounter for palliative care'}


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: 63 yo with ESRD, DM, CAD, CHF, who presents after an episode of
syncope today. The patient went to the commode today felling
fine, but then suddenly fell forward and hit her head and her
left arm. She thinks that she might have fallen asleep and only
recalls mild lightheadedness which is a common symptom for her
when she gets up to the commode. She did not loose consciousness
and recalls the event in detail. She was not able to get up from
the floor becaus eof the weakness in her legs at baseline until
her husband came to help her. She then had one episode of
non-bloody vomitus. Her husband called EMS who brought her to
[**Hospital6 **].
At [**Hospital1 34**] the patient reportedly was lethargic and a head CT was
done that was negative for bleed. The patient reported pain in
her L arm and a humerus XR showed a comminuted surgical neck
fracture with less than half shaft width of lateral
displacement. A CT of her spine was negative for fracture. A CXR
was read as CHF. The patient was transfered to [**Hospital1 18**] for further
management.
.
ED course: CXR was done and showed new R perihilar and RLL
infiltrate. The patient underwent a CTA that did not show any PE
but confirmed a right lower lobe as well as dependent right
upper lobe and medial left lower lobe infiltrate that was
concerning for infection. The pt was given Vanco, Levo and
Flagyl.
.
ROS: negative for CP, SOB, cough, secretions, abdominal pain,
diarrhea, constipation, f/c/ns, weight loss, dysuria, changes in
the color of the urine or stool. The patient reports that she
was feeling a little weaker since her recent admission for coag
neg bacteremia but had been feeling fine otherwise.

MEDICAL HISTORY: 1. DM2 since her 40s, dialysis since [**2-3**]
2. ESRD [**2-1**] DMII, on MWF HD, followed by Dr. [**First Name (STitle) 805**]
3. h/o MRSA cellulitis of bilateral LE
4. HTN
5. Hyperlipidemia
6. Hypothyroidism
7. CAD s/p CABG [**2179**], NSTEMI in [**9-2**] during admission; echo [**3-4**]
with EF 35%, moderate to severe MR
8. Anemia
9. Osteoporosis
10. Depression
11. h/o right hip fx s/o ORIF
12. PVD
13. Sleep apnea
14. On Home 3L O2, PFTs [**2186**] with restrictive pattern, pulmonary
HTN
15. R Charcot Foot
16. Restless Leg Syndrome
17. Pulmonary hypertension

MEDICATION ON ADMISSION: Amlodipine 5 mg once a day
Aspirin 81 mg once a day
B complex once a day
Cozaar 50mg 4 times a week
Digoxin 125mcg, [**1-1**] alternating with 1 tablet po Q4days
Gabapentin 200mg QHS
Klonopin 1mg, 1 tablet QHS, 2mg before dialysis
Lipitor 10 mg--1 tablet(s) by mouth at bedtime
Mirapex 0.125 mg--[**1-1**] tablet(s) by mouth at 6pm and again QHS
Nephrocaps 1 capsule(s) by mouth once a day
Synthroid 50 mcg--1 tablet(s) by mouth once a day
TOPROL XL 100 mg--1 tablet(s) by mouth at bedtime
ZOLOFT 100 mg--1 tablet(s) by mouth q am
Daypro 600mg, 2 tbl with food
Calcium Acetate 667 mg 2tb TID W/MEALS
Clopidogrel 75 mg Tablet
Sevelamer 800 mg 3 Tablet PO TID
Glargine 37U, HISS

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS T 97.5 BP 104/90  HR 71  RR 21 O2Sat 99% on NRB
Gen: NAD, AAOx3
HEENT: NC/AT, PERRLA, dry mm
NECK: no LAD, JVD not visulized, no carotid bruit
COR: S1S2, regular rhythm, SEM II/VI over LUSB, no r/g
PULM: limited due to patients limited ability to turn; decreased
breathsounds in R base, crackles b/l
ABD: + bowel sounds, soft, nd, nt, indurated area L lateral to
the umbilicus, umbilical hernia
Skin: warm extremities, no rash, 0.5cm dry open wound on L
malleolus,
EXT: dopplerable DP, charcot deformity of the R foot, trace
edema, no CVA tenderness
Neuro: following commands, PERRLA, reflexes 2+ b/l inupper
extremities, 1+ patella, absent achilles reflex

FAMILY HISTORY: Father - Deceased with MI at 60
Sister - Breast cancer
Mother - 60s, CAD
Son with DM

SOCIAL HISTORY: The patient lives with her husband who is her primary caregiver.
She denies past or present tobacco use. She denies alcohol or IV
drug use. Patient previously worked as a secretary. 

### Response:
{'Acute respiratory failure,Congestive heart failure, unspecified,Postinflammatory pulmonary fibrosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Primary pulmonary hypertension,Pneumonia, organism unspecified,End stage renal disease,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Syncope and collapse,Closed fracture of surgical neck of humerus,Unspecified fall,Malignant neoplasm of ovary,Sinoatrial node dysfunction,Hypotension, unspecified,Unspecified acquired hypothyroidism,Delirium due to conditions classified elsewhere,Aortocoronary bypass status,Old myocardial infarction,Encounter for palliative care'}
