CHIEF COMPLAINT: Syncope

PRESENT ILLNESS: [**Age over 90 **]yo woman wwith a history of hypertension, congestive heart
failure (EF unknown), idiopathic emphysema, frequent PNAs in
last year, who presented with mental status change, bradycardia
(HR 20-30s), hypotension (SBP 60s), and hypothermia (T 92.3).
  Per report from her son (and HCP), the patient has appeared
tired & slightly off her baseline for few days PTA.  He noted
her speech was slowed, more deliberate & slightly slurred.  On
day of admission, after finishing [**Holiday 1451**] dinner, she was
noted to be fatigued.  Family members noted that she was unable
to get up from chair & walk.  She c/o "dizziness" & shooting
pain in neck.  She had increased confusion & followed by
LOC/episode of unresponsiveness (while sitting).  EMS was called
and, on their arrival, noted her HR was in 20-30s & SBP was in
60s.  She was transcutaneously paced by EMS.
Of note, pt reportedly coughing & appeared dyspneic for ~1wk
PTA.
.

MEDICAL HISTORY: # Hypertension
# Congestive Heart Failure - ef unknown
# Idiopathic emphysema
# Left mastectomy
# Left hand surgery
# Multiple recent hospitalizations for pneumonia ([**Hospital3 **],
[**Location (un) 5503**]; [**Hospital **] Hospital, [**Doctor Last Name **])

MEDICATION ON ADMISSION: # Furosemide 80 mg daily
# Metoprolol ER 25 mg daily
# Levothyroxine 75 mcg daily
# Aspirin 81 mg daily
# Ibuprofen PRN pain
# Guaifenesin PRN cough
.

ALLERGIES: Penicillins

PHYSICAL EXAM: VS: T 94.5, HR 68, BP 91.38, AC Vt 350 x RR 16, FiO2 100, PEEP
5/PS 0
Gen: Intubated, spontaneously moving, appears uncomfortable
HEENT: NCAT, PERRL, sclera anicteric, MMM
Neck: Supple, no LAD, no JVD
CV: Limited ascultation [**3-9**] vent sounds.  RRR S1/S2, no m/r/g
Resp: Coarse breath sounds B
Abdomen: Soft, NTND, BS+
Ext: BL and BUE edematous.  LUE atrophic.  DP pulses are 2+
bilaterally.
Neuro: Intubated and sedated, moving all extremities
spontaneously
Skin: Pink, cool, dry, scattered ecchymoses and hematomas at
blood draw sites.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: # Tobacco: Never
# Alcohol: Rare
# Personal: Lives independently.
# Professional: Retired nurse.
Unspecified septicemia,Septic shock,Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Intestinal infection due to Clostridium difficile,Pneumonia, organism unspecified,Acute respiratory failure,Unspecified pleural effusion,Severe sepsis,Other specified cardiac dysrhythmias,Other emphysema,Unspecified essential hypertension,Personal history of malignant neoplasm of breast
Septicemia NOS,Septic shock,Ac on chr syst hrt fail,Acute kidney failure NOS,Urin tract infection NOS,Int inf clstrdium dfcile,Pneumonia, organism NOS,Acute respiratry failure,Pleural effusion NOS,Severe sepsis,Cardiac dysrhythmias NEC,Emphysema NEC,Hypertension NOS,Hx of breast malignancy
Admission Date:  [**2170-12-27**]              Discharge Date:   [**2171-1-14**]


Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Syncope

Major Surgical or Invasive Procedure:
Right Internal Jugular Central Line


History of Present Illness:
[**Age over 90 **]yo woman wwith a history of hypertension, congestive heart
failure (EF unknown), idiopathic emphysema, frequent PNAs in
last year, who presented with mental status change, bradycardia
(HR 20-30s), hypotension (SBP 60s), and hypothermia (T 92.3).
  Per report from her son (and HCP), the patient has appeared
tired & slightly off her baseline for few days PTA.  He noted
her speech was slowed, more deliberate & slightly slurred.  On
day of admission, after finishing [**Holiday 1451**] dinner, she was
noted to be fatigued.  Family members noted that she was unable
to get up from chair & walk.  She c/o "dizziness" & shooting
pain in neck.  She had increased confusion & followed by
LOC/episode of unresponsiveness (while sitting).  EMS was called
and, on their arrival, noted her HR was in 20-30s & SBP was in
60s.  She was transcutaneously paced by EMS.
Of note, pt reportedly coughing & appeared dyspneic for ~1wk
PTA.
.



Past Medical History:
# Hypertension
# Congestive Heart Failure - ef unknown
# Idiopathic emphysema
# Left mastectomy
# Left hand surgery
# Multiple recent hospitalizations for pneumonia ([**Hospital3 **],
[**Location (un) 5503**]; [**Hospital **] Hospital, [**Doctor Last Name **])

Social History:
# Tobacco: Never
# Alcohol: Rare
# Personal: Lives independently.
# Professional: Retired nurse.

Family History:
Non-contributory

Physical Exam:
VS: T 94.5, HR 68, BP 91.38, AC Vt 350 x RR 16, FiO2 100, PEEP
5/PS 0
Gen: Intubated, spontaneously moving, appears uncomfortable
HEENT: NCAT, PERRL, sclera anicteric, MMM
Neck: Supple, no LAD, no JVD
CV: Limited ascultation [**3-9**] vent sounds.  RRR S1/S2, no m/r/g
Resp: Coarse breath sounds B
Abdomen: Soft, NTND, BS+
Ext: BL and BUE edematous.  LUE atrophic.  DP pulses are 2+
bilaterally.
Neuro: Intubated and sedated, moving all extremities
spontaneously
Skin: Pink, cool, dry, scattered ecchymoses and hematomas at
blood draw sites.


Pertinent Results:
Admission labs:
[**2170-12-27**] WBC-7.1 RBC-4.35 HGB-12.3 HCT-38.2  PLT COUNT-263
[**2170-12-27**]  GLUCOSE-100 UREA N-90* CREAT-2.3* SODIUM-141
POTASSIUM-5.7* CHLORIDE-103 TOTAL CO2-28
[**2170-12-27**] PT-11.0 PTT-30.0 INR(PT)-0.9
[**2170-12-27**] LACTATE-0.8
[**2170-12-27**] CORTISOL-8.2
[**2170-12-27**] cTropnT-0.03*  CK(CPK)-53
[**2170-12-27**] TSH-2.5
[**2170-12-27**]  ALT(SGPT)-81* AST(SGOT)-69* LD(LDH)-146 CK(CPK)-53 ALK
PHOS-33* TOT BILI-0.1
[**2170-12-27**] ABG PO2-250* PCO2-49* PH-7.20* TOTAL CO2-20*
.
[**2170-12-27**] URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008  BLOOD-LG
NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG
UROBILNGN-NEG PH-5.0 LEUK-MOD RBC-0-2 WBC->50 BACTERIA-FEW
YEAST-NONE EPI-0-2
.
[**12-27**] Urine cx: >100K E coli, pan-sensitive
[**1-7**] Urine cx: no growth
.
[**12-27**] Blood cx: no growth
[**1-7**] Blood cx: no growth
[**1-8**] Blood cx: pending
.
[**1-8**] C diff toxin: positive
.
CXR: Limited study. Endotracheal tube terminating just above the
carina. Cardiomegaly. Consolidation in the left lower lobe with
effusion, suspicious for pneumonia in the appropriate clinical
setting.
.
CT Head w/o contrast:  No bleed. Chronic small vessel ischemia
and atrophy.
.
EKG: NSR, rate ~75, LAD, Q's in I and aVL, V5 & V6. RBBB.  ST
depressions in V3-6.  Twave inversion I, aVL, V2-V6.
.
.
TTE [**12-28**]: The left atrium is moderately dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. There is mild regional left ventricular
systolic dysfunction with hypokinesis of the basal to mid
inferior septum and inferior wall. . Transmitral Doppler and
tissue velocity imaging are consistent with Grade I (mild) LV
diastolic dysfunction. Right ventricular chamber size and free
wall motion are normal. The number of aortic valve leaflets
cannot be determined. The aortic valve leaflets are mildly
thickened. There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The left
ventricular inflow pattern suggests impaired relaxation. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
[**12-28**] bilateral LENIs: no DVT
.
[**12-28**] pelvis xray: No acute fracture.
.
[**1-7**] CT abdomen/pelvis: Small right-sided retroperitoneal and
intramuscular hematoma, with diffuse soft tissue anasarca and
bilateral pleural effusions. Small pericardial effusion.
.


Brief Hospital Course:
[**Age over 90 **] year-old female admitted with bradycardia, hypotension,
hypothermia, and altered mental status, most likely secondary to
septic shock from E-coli UTI.
.
1. Septic shock:  The patient was admitted with bradycardia,
hypotension, hypothermia, and hypotension, all felt to be
manifestations of septic shock secondary to her E. coli UTI. She
was resuscitated with IVF and required pressors which were
eventually discontinued on [**1-1**]. She was initially treated with
ceftriaxone and azithromycin. Her urine culture revealed a
pan-sensitive E coli and thus azithromycin was discontinued.
While in the ICU, the decision was made to change her code
status to CMO on [**1-3**] and ceftriaxone was discontinued at that
time. She was transferred out to the regular medical floor.
.
2. Respiratory failure: She was initially intubated for airway
protection secondary to unstable mental status.  She was
diuresed to minimize pulmonary vascular congestion.  She was
extubated on [**2171-1-1**] without complication. CXR showed bilateral
pleural effusions, felt secondary to her CHF. She was diuresed
with lasix as her blood pressure tolerated. On discharge, she is
sat'ing well on 3L NC however she continues to complain of
shortness of breath and dyspnea with even minor movement.
.
3. UTI: The patient was admitted with septic shock secondary to
E. coli UTI. She was partially treated in the MICU with
ceftriaxone, which was discontinued on [**1-3**] when she was made
CMO. Antibiotics were re-initiated on the floor. She was treated
with PO levofloxacin with plan for a 14 day course. Last dose
will be on [**1-19**].
.
4. Clostridium dificile: The patient developed c diff infection
with positive stool toxin noted on [**1-8**]. She was started on PO
metronidazole for a 14 day course. Last day will be [**1-22**].
.
5. Bradycardia:  She was initially bradycardic to 20s
transiently with bundle branch block on EKG. Question of
beta-blocker toxicity with acute on chronic renal failure.  She
received glucagon 5mg x3 & calcium without significant response.
 To assess cardiac function, a TTE was obtained demonstrating EF
45-50%, mild regional L ventricular dysfunction, probable
diastolic dysfunction, and moderate pulmonary HTN.  EKG also
demonstrated old RBBB, old LAFB, and ST depressions in inferior
and lateral precordial leads.  Likely etiology was hypotension
leading to underperfusion of coronary artery and possible
conduction system abnormalities.  She was placed on a dopamine
drip transiently with good response and her bradycardia resolved
soon afterwards.
.
6. Acute renal failure: In the setting of septic shock and
hypotension, she developed acute renal failure. Her creatinine
was elevated to 2.3 on admission, felt likely to represent
pre-renal renal failure. Her creatinine returned to baseline by
[**1-7**].
.
7. ?Myocardial ischemia: There was concern initially for
ACS/ischemia in the setting of hypotension and EKG revealing ST
depressions.  However, she had not complained of CP (per family)
& 2 sets of cardiac enzymes were negative.  She was continued on
ASA with no BB given conduction disease.
.
8. CHF: Her home regimen of furosemide 80mg PO daily was
initially held because of hypotension and transient need for
pressors. Given amount of fluid pt given for resuscitation (9L)
she was eventually diuresed over the course of her MICU stay
with good results. Repeat CXR showed no change in her bilateral
pleural effusions, likely secondary to CHF. Diuresis was
continued on the floor, first with PO lasix and then IV lasix as
her blood pressure tolerated. She continued to have hypoxia
(requiring She will continue to receive PO lasix at hospice.
.
9. Mental status change:  Likely [**3-9**] hypotension & possible
sepsis. No evidence of seizures, CT negative for ICH.  No clear
toxic-metabolic insult.  Question of stroke.  Initially sedated
on vent with midazolam. MS improved eventually to her normal
baseline.
.
10. L breast mastectomy/L hand surgery: Avoided IV access at
LUE.
.
11. End-of-life: Palliative care was consulted on [**1-4**] after
family discussions the previous days with decision to withdraw
care. Morphine SL PRN SOB, ice packs to arms for edema, lasix
PRN SOB, regular diet. She was transferred to the regular floor
to a private room. Initially she was CMO, then the patient and
son requested to change her to DNR/DNI. After a week of more
aggressive therapy with IV lasix and little improvement in her
respiratory status, the decision was made to discharge to
hospice care.
.

Medications on Admission:
# Furosemide 80 mg daily
# Metoprolol ER 25 mg daily
# Levothyroxine 75 mcg daily
# Aspirin 81 mg daily
# Ibuprofen PRN pain
# Guaifenesin PRN cough
.

Discharge Medications:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
2. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-6**] Sprays Nasal
QID (4 times a day) as needed.
3. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed).
4. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed.
5. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days: last dose on [**1-19**].
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 9 days: last dose on [**1-22**].
8. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day.
9. Morphine
Morphine 50mg/ml; 0.1-0.2ml q2h prn dyspnea or pain; disp 30ml
10. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1)
Transdermal every seventy-two (72) hours as needed for oral
secretions.


Discharge Disposition:
Extended Care

Facility:
Ways

Discharge Diagnosis:
Primary:
Septicemia from urinary tract infection
Hypoxic respiratory failure
Acute blood loss anemia
Clostridium dificile
.
Secondary:
1) Acute systolic congestive heart failure
.


Discharge Condition:
Vital signs stable. Hematocrit stable. Sat'ing well on 3L O2.
.


Discharge Instructions:
You were admitted to the hospital for sepsis from a urinary
tract infection. You were initially in the intensive care unit,
where you received antibiotics, fluids and pressor medications.
You were also intubated until [**1-1**]. You were also found to have
c. diff., which is an infection of your intestines causing
diarrhea. You were treated with antibiotics for this.
.

Followup Instructions:
as needed
.
{'Unspecified septicemia,Septic shock,Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Intestinal infection due to Clostridium difficile,Pneumonia, organism unspecified,Acute respiratory failure,Unspecified pleural effusion,Severe sepsis,Other specified cardiac dysrhythmias,Other emphysema,Unspecified essential hypertension,Personal history of malignant neoplasm of breast'}


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: [**Age over 90 **]yo woman wwith a history of hypertension, congestive heart
failure (EF unknown), idiopathic emphysema, frequent PNAs in
last year, who presented with mental status change, bradycardia
(HR 20-30s), hypotension (SBP 60s), and hypothermia (T 92.3).
  Per report from her son (and HCP), the patient has appeared
tired & slightly off her baseline for few days PTA.  He noted
her speech was slowed, more deliberate & slightly slurred.  On
day of admission, after finishing [**Holiday 1451**] dinner, she was
noted to be fatigued.  Family members noted that she was unable
to get up from chair & walk.  She c/o "dizziness" & shooting
pain in neck.  She had increased confusion & followed by
LOC/episode of unresponsiveness (while sitting).  EMS was called
and, on their arrival, noted her HR was in 20-30s & SBP was in
60s.  She was transcutaneously paced by EMS.
Of note, pt reportedly coughing & appeared dyspneic for ~1wk
PTA.
.

MEDICAL HISTORY: # Hypertension
# Congestive Heart Failure - ef unknown
# Idiopathic emphysema
# Left mastectomy
# Left hand surgery
# Multiple recent hospitalizations for pneumonia ([**Hospital3 **],
[**Location (un) 5503**]; [**Hospital **] Hospital, [**Doctor Last Name **])

MEDICATION ON ADMISSION: # Furosemide 80 mg daily
# Metoprolol ER 25 mg daily
# Levothyroxine 75 mcg daily
# Aspirin 81 mg daily
# Ibuprofen PRN pain
# Guaifenesin PRN cough
.

ALLERGIES: Penicillins

PHYSICAL EXAM: VS: T 94.5, HR 68, BP 91.38, AC Vt 350 x RR 16, FiO2 100, PEEP
5/PS 0
Gen: Intubated, spontaneously moving, appears uncomfortable
HEENT: NCAT, PERRL, sclera anicteric, MMM
Neck: Supple, no LAD, no JVD
CV: Limited ascultation [**3-9**] vent sounds.  RRR S1/S2, no m/r/g
Resp: Coarse breath sounds B
Abdomen: Soft, NTND, BS+
Ext: BL and BUE edematous.  LUE atrophic.  DP pulses are 2+
bilaterally.
Neuro: Intubated and sedated, moving all extremities
spontaneously
Skin: Pink, cool, dry, scattered ecchymoses and hematomas at
blood draw sites.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: # Tobacco: Never
# Alcohol: Rare
# Personal: Lives independently.
# Professional: Retired nurse. 

### Response:
{'Unspecified septicemia,Septic shock,Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Intestinal infection due to Clostridium difficile,Pneumonia, organism unspecified,Acute respiratory failure,Unspecified pleural effusion,Severe sepsis,Other specified cardiac dysrhythmias,Other emphysema,Unspecified essential hypertension,Personal history of malignant neoplasm of breast'}
