CHIEF COMPLAINT: Syncope.

PRESENT ILLNESS: Ms. [**Known lastname 4553**] is a 63 yo woman with history of hypothyroid,
lupus, non-hodgkin's lymphoma s/p xrt and chemotherapy 17 years
ago who presented to [**Hospital3 1443**] hospital earlier today
after a syncopal episode at home.

MEDICAL HISTORY: - Lupus, [**Doctor First Name **] supressed, manifests as pleural effusions, on
prednisone
- Hypothyroidism, s/p partial thyroidectomy w/ lymphoma of neck,
chemoradiation plus resection, on levothyroxine
- Hypertension
- Gastroesophageal reflux disease
- Fibromyalgia, on oxycodone 7.5 mg [**Hospital1 **]
- Sleep apnea, diagnosed, but has not wanted CPAP yet
- Depression, on fluoxetine
- Obesity
- Osteoporosis
- Cerebrovascular (small vessel) disease (on ASA and Plavix)

MEDICATION ON ADMISSION: - Alendronate 70 mg once weekly
- Alprazolam 2 mg qhs
- Atorvastatin 10 mg qday
- Clopidogrel 75 mg qday
- Ergocalciferol 50,000 unit qweek
- Fluoxetine 60 mg qday
- Levothyroxine 200 mcg qday
- Nystatin cream prn
- Percocet 7.5-500 qid prn
- Potassium chloride 20 mEq tid
- Prednisone 6 mg qday
- Propranolol 80 mg qday
- Trazodone 75 mg qhs
- ASA 325 qday
- Cyanocobalamin 100 mcg qday
- Multivitamin qday

ALLERGIES: Sulfonamides / Demerol / Haldol

PHYSICAL EXAM: General: morbidly obese woman
HEENT: Pupils symmetrically and markedly dilated (s/p atropine),
ears clear, tube in place, cannot inspect OP
Neck: Hematoma and echymosis on right lateral neck (later -
central line in place in right IJ), very thick neck, cannot
evaluate JVP.
Cardiac: Difficult to auscultate due to ventilator and habitus,
near tachycardic and regular.
Lungs: Symmetric air entry anteriorly with some transmitted
upper airway sound and ventilator noise.
Abdomen: Obese, non-tender to deep palpation.
Extremities: Trace edema, IO access in place at admission (later
removed). Extremities cool and dusky.
Skin: Echymosis on neck, [**Female First Name (un) **] under panus and breasts.
Pulses: Peripheral pulses barely palpable, but ulnar and radial
arteries were Dopplerable bilaterally.

FAMILY HISTORY: Family history of heart disease, but not of early onset.

SOCIAL HISTORY: -Tobacco history: None.
-ETOH: None.
-Illicit drugs: None.
Lives with husband in two family. Daughter and son-in-law live
upstairs with their son and a dog. Significant discord with
daughter and son-in-law at present. Also grandchildren upstairs.
Other specified cardiac dysrhythmias,Acute respiratory failure,Unspecified septicemia,Sepsis,Pneumonitis due to inhalation of food or vomitus,Hematoma complicating a procedure,Other respiratory complications,Unspecified transient mental disorder in conditions classified elsewhere,Atrioventricular block, complete,Unspecified acquired hypothyroidism,Systemic lupus erythematosus,Unspecified sleep apnea,Anemia, unspecified,Thrombocytopenia, unspecified,Osteoporosis, unspecified,Dysthymic disorder,Unspecified essential hypertension,Esophageal reflux,Myalgia and myositis, unspecified,Personal history of hodgkin's disease
Cardiac dysrhythmias NEC,Acute respiratry failure,Septicemia NOS,Sepsis,Food/vomit pneumonitis,Hematoma complic proc,Respiratory comp NEC,Transient mental dis NOS,Atriovent block complete,Hypothyroidism NOS,Syst lupus erythematosus,Sleep apnea NOS,Anemia NOS,Thrombocytopenia NOS,Osteoporosis NOS,Dysthymic disorder,Hypertension NOS,Esophageal reflux,Myalgia and myositis NOS,Hx-hodgkin's disease
Admission Date:  [**2149-4-10**]              Discharge Date:   [**2149-4-25**]

Date of Birth:  [**2085-6-26**]             Sex:   F

Service: MEDICINE

Allergies:
Sulfonamides / Demerol / Haldol

Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
Syncope.

Major Surgical or Invasive Procedure:
Permanent pacemaker placed.
Internal jugular central venous line placed.
Arterial line placed.

Procedures performed prior to arriving at [**Hospital1 18**]:
Endotracheal intubation
Subclavian central venous line
Transvenous pacing wires
Interosseous line


History of Present Illness:
  Ms. [**Known lastname 4553**] is a 63 yo woman with history of hypothyroid,
lupus, non-hodgkin's lymphoma s/p xrt and chemotherapy 17 years
ago who presented to [**Hospital3 1443**] hospital earlier today
after a syncopal episode at home.

  A couple of weeks ago, Mrs. [**Known lastname **] was in the bathroom
during the night. She awoke her husband and could not get off
the toilet. She felt faint. Her husband helped her up, noticing
that both of her legs and arms were cool. She lay back in her
recliner - in which she has slept since her radiotherapy and
lymphoma. Her husband asked if he should call EMS, but she
didn't think it necessary.

  Today, Mrs. [**Known lastname 4553**] was at home. Mr. [**Known lastname 4553**] went to work.
During the morning she felt faint and called EMS. They arrived
to find that she had fallen from her chair to the floor,
striking her head. Per [**Hospital3 1443**] ED, she was
unresponsive when the EMS arrived, unable to answer questions.
However, en route, she apparently complained of neck and back
pain. She was bradycardic to the 20s and transcutaneous pacing
was unsuccessful. Dopamine increased her heart rate and atropine
did little.

  On arrival the [**Hospital3 1443**] ED, she was described as
lethargic but communicative, but soon after became 'suddenly
ashen/cyanotic'. Dopamine gtt was started. Slow capillary refil
was noted. EKG was interpreted as 'complete heart block with AV
dissociation'. An echo was performed, per the Cardiology consult
note, which noted global hypokinesis and LVEF of 25-30% while
paced. Echos have previously been near normal.

  She was intubated for airway protection and sedation in the
setting of bradycardia and placement of the temp wire.
Tranvenous pacing wires were placed via a right subclavian line
under fluroscopy (the left actually has an adjacent 17-year-old
Port-A-Cath, still in place from treatment of her lymphoma).
Given likely necessity for a PPM/ICD and her hemodynamic
instability, she was transferred to [**Hospital1 18**] CCU.

  She arrived in a rigid neck collar - although CT head and neck
had been performed at [**Hospital1 487**], [**Location (un) 1131**] was not completed. Her
vitals on arrival were 98.7 F, 85 BPM, 21 RR, 100%. Blood
pressure messurements varied widely, but were typically from 80s
to 100s systolic.

Past Medical History:
- Lupus, [**Doctor First Name **] supressed, manifests as pleural effusions, on
prednisone
- Hypothyroidism, s/p partial thyroidectomy w/ lymphoma of neck,
chemoradiation plus resection, on levothyroxine
- Hypertension
- Gastroesophageal reflux disease
- Fibromyalgia, on oxycodone 7.5 mg [**Hospital1 **]
- Sleep apnea, diagnosed, but has not wanted CPAP yet
- Depression, on fluoxetine
- Obesity
- Osteoporosis
- Cerebrovascular (small vessel) disease (on ASA and Plavix)

Social History:
-Tobacco history: None.
-ETOH: None.
-Illicit drugs: None.
Lives with husband in two family. Daughter and son-in-law live
upstairs with their son and a dog. Significant discord with
daughter and son-in-law at present. Also grandchildren upstairs.



Family History:
Family history of heart disease, but not of early onset.

Physical Exam:
General: morbidly obese woman
HEENT: Pupils symmetrically and markedly dilated (s/p atropine),
ears clear, tube in place, cannot inspect OP
Neck: Hematoma and echymosis on right lateral neck (later -
central line in place in right IJ), very thick neck, cannot
evaluate JVP.
Cardiac: Difficult to auscultate due to ventilator and habitus,
near tachycardic and regular.
Lungs: Symmetric air entry anteriorly with some transmitted
upper airway sound and ventilator noise.
Abdomen: Obese, non-tender to deep palpation.
Extremities: Trace edema, IO access in place at admission (later
removed). Extremities cool and dusky.
Skin: Echymosis on neck, [**Female First Name (un) **] under panus and breasts.
Pulses: Peripheral pulses barely palpable, but ulnar and radial
arteries were Dopplerable bilaterally.

At the time of discharge, Mrs.[**Known lastname 20252**] physical exam was
unchanged but for the following: Hematoma and bandage over pacer
site, right subclavian, [**Female First Name (un) **] cleared, extremities well
perfused, alert, oriented and appropriate, although drowsy at
times.

Pertinent Results:
Labs at Admission
[**2149-4-10**] 05:24PM BLOOD WBC-10.9# RBC-4.37 Hgb-14.7 Hct-44.0
MCV-101* MCH-33.8* MCHC-33.5 RDW-12.3 Plt Ct-208
[**2149-4-10**] 05:24PM BLOOD Neuts-76.4* Lymphs-12.1* Monos-9.3
Eos-1.9 Baso-0.3
[**2149-4-10**] 05:24PM BLOOD PT-12.8 PTT-23.4 INR(PT)-1.1
[**2149-4-12**] 03:56AM BLOOD Ret Aut-1.2
[**2149-4-10**] 05:24PM BLOOD Glucose-120* UreaN-8 Creat-0.7 Na-140
K-3.8 Cl-103 HCO3-27 AnGap-14
[**2149-4-10**] 05:24PM BLOOD ALT-58* AST-90* LD(LDH)-488* CK(CPK)-299*
AlkPhos-62 TotBili-2.3*
[**2149-4-10**] 05:24PM BLOOD CK-MB-14* MB Indx-4.7 cTropnT-1.20*
[**2149-4-10**] 05:24PM BLOOD Albumin-3.6 Calcium-9.1 Phos-2.6* Mg-1.3*
[**2149-4-12**] 03:56AM BLOOD Hapto-18*
[**2149-4-15**] 05:39AM BLOOD VitB12-559 Folate-8.2
[**2149-4-10**] 05:24PM BLOOD T4-8.1
[**2149-4-11**] 06:14AM BLOOD Free T4-1.5
[**2149-4-13**] 05:00AM BLOOD C3-122 C4-23
[**2149-4-10**] 10:17PM BLOOD Type-ART pO2-142* pCO2-36 pH-7.44
calTCO2-25 Base XS-1
[**2149-4-10**] 10:17PM BLOOD Lactate-2.0
[**2149-4-10**] 10:17PM BLOOD O2 Sat-98
[**2149-4-12**] 10:47AM BLOOD freeCa-1.01*
[**2149-4-10**] 05:24PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG

Cardiac Enzymes and [**Doctor First Name **]
[**2149-4-10**] 05:24PM BLOOD CK-MB-14* MB Indx-4.7 cTropnT-1.20*
[**2149-4-11**] 12:49AM BLOOD cTropnT-1.02*
[**2149-4-11**] 06:14AM BLOOD CK-MB-7 cTropnT-0.56*
[**2149-4-14**] 08:45AM BLOOD [**Doctor First Name **]-NEGATIVE

Labs Prior to Discharge
[**2149-4-25**] 04:35AM BLOOD WBC-10.7 RBC-3.35* Hgb-11.4* Hct-35.2*
MCV-105* MCH-34.1* MCHC-32.5 RDW-15.0 Plt Ct-493*
[**2149-4-24**] 08:25AM BLOOD Neuts-77.2* Lymphs-13.1* Monos-6.3
Eos-3.2 Baso-0.2
[**2149-4-23**] 08:27AM BLOOD PT-15.5* PTT-27.0 INR(PT)-1.4*
[**2149-4-25**] 04:35AM BLOOD Glucose-91 UreaN-12 Creat-0.7 Na-140
K-3.4 Cl-98 HCO3-35* AnGap-10
[**2149-4-15**] 05:39AM BLOOD ALT-39 AST-45* AlkPhos-61 TotBili-1.4
[**2149-4-25**] 04:35AM BLOOD Calcium-8.9 Phos-4.0 Mg-2.2
[**2149-4-18**] 02:47PM BLOOD Lactate-1.4 K-3.9

Speech & Swallowing Assessment, [**4-21**]
Functional Oral Intake Scale (FOIS) rating of 6.
RECOMMENDATIONS:
1. Suggest a PO diet of thin liquids and soft, moist solids.
2. Small bites and sips.
3. Meds crushed w/ purees [**2-11**] esophageal strictures.
4. TID Oral care.

EKG [**2149-4-10**]
Sinus rhythm. Left axis deviation. Right bundle-branch block
with left anterior fascicular block. There are Q waves in the
inferior leads consistent with prior myocardial infarction.
There is lack of R waves in the anterior and anterolateral leads
consistent with possible prior myocardial infarction.
Non-specific ST-T wave changes. Low voltage in the precordial
leads. Compared to the previous tracing right bundle-branch
block, left anterior fascicular block and evidence of myocardial
infarction are new.
Rate PR QRS QT/QTc P QRS T
87 170 134 398/445 60 -63 105

Echo [**2149-4-11**]
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
is no aortic valve stenosis. No aortic regurgitation is seen.
The mitral valve leaflets are not well seen. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Very limited study. Grossly preserved biventricular
systolic function. Unable to comment on any valvular
vegetations. If clinical suspicion of endocarditis persists,
recommend obtaining a transesophageal study.

CT chest, abdomen, pelvis [**2149-4-12**]
IMPRESSION:
1. Markedly low lung volumes, with asymmetric left basilar
consolidation, with air bronchograms. This may represent
atelectasis, though pneumonia is certainly not excluded.
Clinical correlation is advised.
2. Adequate positioning of supportive and monitoring devices
including endotracheal tube, Swan-Ganz catheter, and NG tube.
3. Marked fatty infiltration of the liver.
4. Fatty involution of the pancreas.
5. Sigmoid diverticulosis without diverticulitis. Small bowel
diverticulosis.

EKG [**2149-4-19**]
Sinus rhythm. Left axis deviation. Anteroseptal, anterior and
inferior myocardial infarction. Intraventricular conduction
delay. Compared to the previous tracing of [**2149-4-17**] there is no
significant change.
Rate PR QRS QT/QTc P QRS T
81 174 108 426/[**Medical Record Number 20253**] 44

CXR [**2149-4-22**]
COMPARISON: Chest radiograph one day prior and multiple
previous.
Examination is somewhat limited by patient positioning and
difficulty penetration. However, there is persistent left
basilar atelectasis and pleural effusion with possible airspace
infectious consolidation superimposed. The right lung remains
clear. A right chest pacing device appears in unchanged position
since the most recent radiograph. The bony thorax is difficult
to evaluate.
IMPRESSION: Persistent left effusion with atelectasis and
possible superimposed airspace consolidation.

CT head [**2149-4-23**]
IMPRESSION:
1. No acute intracranial process.
2. Sequelae of small vessel disease and old lacunar infarcts in
the left basal ganglia.
3. Complete opacification of the sphenoid sinus with inspissated
secretions, essentially unchanged since [**8-/2139**], consistent with
chronic sinusitis, with possible contribution of fungal
colonization.

Brief Hospital Course:
In summary a 63 yo woman with h/o lupus, morbid obesity, h/o
large cell lymphoma and hypothyroidism who presented with
syncope in the setting of bradycardia and hypotension.

Syncope
  Likely due to bradycardia with conduction block. She has been
presyncopal numerous times recently, suggestive of intermittent
heart block. She was hypotensive and bradycardic in the OSH, and
tranvenous wires were required with restoration of blood
pressure by pacing to 70 BPM. Transcutaneous pacing was not
successful given habitus. EKG significant for large voltages and
prolonged QRS, normal PR, suggesting Hisian disease, rather than
calcific (CXR does not show marked calcification), infiltrative
disease (voltages only slightly low in precordial leads but
otherwise normal), or Rickettsial disease (intermittent rather
than progressive). However, past MI is suggested by EKG, which
may be responsible for block. EP planned to place a pacer, but
she became febrile and hypotensive briefly on HD2, delaying
placement.  Eventually a permanent pacemaker was placed.  She
was not pacemaker dependent during most of her admission, only
intermittantly engaging her device.  Pacemaker placement was
complicated by right subclavian hematoma - stable and without
pain (this does increase the risk of post-device infection,
however, so suspicion should remain for this if she develops a
fever and inflammation around the site). She will follow-up with
electrophysiology.

Head Injury upon Syncope
  She had a contusion on her occiput upon arrival. C-spine and
head cleared per OSH CT's - discussed with OSH radiologist.
Given delirium and recent fall, her head CT was repeated late in
the admission, for concern of slow subdural bleed. This repeat
head CT was also without any bleeding.

Respiratory failure
  Patient was intubated prior to arrival to secure airway and
also because of hypoxia.  Unclear etiology of hypoxia, but
despite negative sputum favor respiratory infection(see below).
However, primary cardiac process, including Hisian disease could
account for respiratory failure, hypotension, hypoxia.
Endocarditis was also considered given old hardware, arrhythmia,
and low grade temp. Very high doses of fentanyl, Versed and
proprofol were required for sedation, likely due to partitioning
into lipid in a very large volume of distribution.
Dexmedetomidine was used a bridge to extubation with
anesthesiology present. This was successful and she remained
comfortable on nasal cannula and then room air soon afterward.
Although not taking bronchodilators at home, she was given
ipratropium and albuterol nebulizer treatments in hospital -
these may later be discontinued.

Sedation, Mental Status, Delerium
  High doses of sedative medications were used, as described
above. She also takes both opioids and benzodiazepines at home
and has long suffered depression. As she recovered from
sedation, delirium was prominent, along with some hallucinations
and delusions. Psychiatry was consulted and recommended Zydis if
absolutely necessary (not needed) and restarting home
benzodiazepines (at a lower dose). During her early recovery
from sedation haloperidol was also required, particularly given
some outburst - she thumped her husband and grabbed the
respiratory therapist. However, she had QT prolongation in
response to this medication and it was discontinued.  By the
time of discharge she was pleasant, cooperative, without
delusions and hallucinations, was remebering environmental
events accurately, but was still drowsy at times during the day.


Coronary Artery Disease
  Evidenced by EKG changes, with impression of normal echo in a
limited study. Continued aspirin (also indicated by
cerebrovascular disease) and statin.

Consolidation on Chest X-ray
  No clinical correlate. Daily body temperature maximum was
typically 99s, but no infection was identified and pneumonia was
not suspected upon physical examination. However, breath sounds
are difficult to appreciate and she was intubated for several
days, so this should be followed. Yeast was found in sputum and
urine, but Infectious Diseases recommended not treating this as
they did not feel she clinically had an infection.

Hypotension and Hypertension
  In context of fever, mild leukocytosis, considered sepsis.
Swan-Ganz initially demonstrated increased calculated CO and
decreased SVR c/w sepsis. Treated broadly for seven days, with
suspicion much lower immediately after initiation of antibiotics
(vancomycin, cefepime, and flagyl) - however, given somewhat
fragile patient we felt that continuing treatement was most
prudent. Sites of infection considered included
endo/myocarditis, bacteremia, aspiration pneumonia/itis, along
with some infected hardware given placement of a Port-a-Cath
(left subclavian) that was never removed 17 years ago after
chemotherapy. Urine lytes and physiology was then most
consistent with a pre-renal, dehydrated state and blood
pressures overshot after fluid resuscitation was given (also in
the context of increase of steroids for lupus to stress-doses).
  Hypertension is treated at home with propranolol, likely given
desirable anxiolytic effects. This was restarted during the
admission and blood pressure will need to be followed.
Aggressive treatment did not occur as some hypertension was
likely secondary to steroids and there was still quite some
variation.

Leukocytosis
  Resolved now. Neutrophilia and leukocytosis, fever,
hypotension on HD2, together concerning for sepsis. She was
broadly covered with vancomycin, cefepime, metronidazole,
completing a seven day course despite spontaneous resolution of
fever (short latency, unlikely antibiotic effect).  Together
concerning for sepsis/occult infection. Could well be Gram
negative sepsis. Recrudescence of lymphoma seems unlikely.

Cardiac Enzyme Leak
  LDH could be cardiac, CK partially cardiac and TropT obviously
so. TropT and CKMB trended down, so we attributed this to pacing
in context of hypotension and hypoxia. However, recent missed MI
would be consistent with EKG findings and offer an explanation
for her heart block (EKG changes were also septal).

Sleep Apnea
  This has been diagnosed by sleep study in the past and noticed
again during the admission. We discussed this with her and Mr.
[**Known lastname 4553**] and recommended that they follow-up in the future with
Sleep Medicine to start CPAP at home.

Elevated Total Bilirubin
  Biliary and hemaptic processes were considered, RUQ ultrasound
negative. Most likely secondary to hemolysis within hematoma in
neck after central line placement on arrival.

Anemia
  Hct drop from 40 to 32. Elevated direct bili and decreased
haptoglobin, but felt to be more likely secondary to hemotoma
than hemolysis given resolution. However, did consider DIC in
septic picture, which later did not fit the clinical picture.
Most likely dilutional change plus blood breakdown in hematoma.

Lupus
  Manifested only as pleural effusions in past. Inactive during
the admission. Her Rheumatologist, Dr. [**Last Name (STitle) **], saw her
during the admission and explained that here [**Doctor First Name **] is supressed on
prednisone. She will follow-up with Dr. [**Last Name (STitle) **] in [**Month (only) **].
Complement also within normal limits. Insulin sliding scale was
used with stress dose steroids, but not needed when steroids
were reduced.

Nutrition
  Tube feeds were given while she was intubated. Speech and
Swallow deemed soft solids and thin liquids safe for her about
24 hours after extubation. This can likely be progressed soon,
however, she has long had difficulty swallowing, reports an
esophageal diverticulum and crushes pills at home.

Access
  Venous access was very difficult. A central line (internal
jugular) was placed and removed after pacer placement to reduce
chance of infection. A subclavian line (right) was placed at the
OSH for transvenous pacing. This was removed and right
subclavian access used for pacer wires and pacer pocket.
Port-a-Cath of 17 years standing occupies the left subclavian
position. Placement of arterial line was difficult also.
Peripheral venous access was maintained.

Hypothyroidism and Past Lymphoma
  Per Mrs. [**Known lastname 4553**]: Had a 'large cell' lymphoma of the neck
that was attached to the thyroid, resulting in partial
resection. Chemoradiotherapy was also given. She now requires
levothyroxine. TSH was suppressed at 0.16 during the admission,
suggesting that levothyroxine might be later adjusted downward
after

Chronic Pain
  Chronic low back pain and fibromyalgia were treated at home
with Percocet 7.5/500 mg up to four times daily (typically two).
We changed this to standing Tylenol with oxycodone breakthrough
on discharge, ensuring that her intake of Tylenol is controlled.


Depression and Anxiety
  Treated with fluoxetine throughout the admission. Trazadone is
also given at a dose with some antidepressant efficacy,
possibly, on the cusp of sedative/antidepressant doses (75 mg).
Trazadone, fluoxetine, propranalol and Xanax are her anxiolytic
medications.

Hemoptysis
  Brief self-limited hemoptysis after extubation was thought to
be due to endothelial scratch during ETT removal. There was only
one episode.

Hypokalemia
  Typically received 20-40 mEq per day in hospital. She is
written for 20 mEq daily, but this will need to be followed,
perhaps in three to four days.

DVT Prophylaxis
  Mrs. [**Known lastname 4553**] was given 7500 [**Location 20254**] heparins TID.

Code Status and Health Care Proxy
  She was full code throughout the admission. Her HCP is her
very helpful, nice and supportive husband, [**Name (NI) **] [**Name (NI) 4553**].

Osteoporosis
  Vitamin D and calcium were restarted at discharge. Alendronate
should be resumed as prior to the admission.

Hypercholesterolemia
  Atorvastatin was continued at home dose during the admission.
Given likely CAD, patient may warrant uptitration of this
medication as an outpatient.

Cerebrovascular Disease
  Continued Plavix and aspirin given CT evidence and history of
cerebrovascular disease and stroke.

Yeast Cutaneous Infection
  Resolved during the admission with cleansing and topical
antifungal.

GERD
  She was diagnosed with GERD in [**2146**], but without active
treatment. She was maintained on famotidine throughout the
admission, starting at intubation. This was stopped at
discharge.

Disposition
  She remained in the CCU throughout the admission for nursing
support and was transferred directly to acute rehabilitation for
physical therapy and to return to baseline before returning
home.

Medications on Admission:
- Alendronate 70 mg once weekly
- Alprazolam 2 mg qhs
- Atorvastatin 10 mg qday
- Clopidogrel 75 mg qday
- Ergocalciferol 50,000 unit qweek
- Fluoxetine 60 mg qday
- Levothyroxine 200 mcg qday
- Nystatin cream prn
- Percocet 7.5-500 qid prn
- Potassium chloride 20 mEq tid
- Prednisone 6 mg qday
- Propranolol 80 mg qday
- Trazodone 75 mg qhs
- ASA 325 qday
- Cyanocobalamin 100 mcg qday
- Multivitamin qday


Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 7500 (7500)
units Injection TID (3 times a day).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Therapeutic Multivitamin     Liquid Sig: Five (5) ML PO DAILY
(Daily).
6. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Prednisone 1 mg Tablet Sig: Six (6) Tablet PO DAILY (Daily).

8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day) as needed for constipation.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation every six (6) hours as
needed for shortness of breath, wheezing.
12. Acetaminophen 650 mg/20.3 mL Solution Sig: One (1)  PO Q8H
(every 8 hours).
13. Propranolol 80 mg Capsule,Sustained Action 24 hr Sig: One
(1) Capsule,Sustained Action 24 hr PO DAILY (Daily).
14. Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO daily ().

15. Oxycodone 5 mg/5 mL Solution Sig: 7.5 mg PO Q8H (every 8
hours) as needed for pain.
16. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week.
17. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for redness at skin folds.
18. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
19. Trazodone 50 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).

20. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
21. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
weekly on empty stomach with full 8oz of water, do not eat or
lie down for 30 min after taking .


Discharge Disposition:
Extended Care

Facility:
Courtyard - [**Location (un) 1468**]

Discharge Diagnosis:
Primary Diagnoses:
Syncope
Symptomatic bradycardia

Secondary Diagnoses:
- Lupus
- Hypothyroidism
- Hypertension
- Gastroesophageal reflux disease
- Fibromyalgia
- Sleep apnea
- Depression
- Obesity
- cerebro-vascular disease

Discharge Condition:
Mental Status: Confused - sometimes - patient is usually clear
during the day but sometimes becomes confused at night.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair. Patient requires assistance of a [**Doctor Last Name 9808**] to get out of
bed to chair.

Discharge Instructions:
You were admitted to the hospital because you fainted and were
found to have a very slow heart rate.  You had a permanent
pacemaker placed. You will need to follow-up in the pacemaker
device clinic and with an electrophysiologist (a cardiologist
who specializes in pacemakers).

Followup Instructions:
Please call the cardiology department at [**Telephone/Fax (1) 62**] on Tuesday
[**4-29**] to get the dates and times of your device clinic and
electrophysiology appointments.

Please attend these follow-up appointments with your primary
care doctor and your rheumatologist:

[**2149-5-26**]  02:45p   [**Last Name (LF) **],[**First Name3 (LF) **] W.
  [**Location (un) **] ([**Location (un) 2788**], MA), [**Location (un) **]
  [**Location (un) 2788**] INTERNAL MEDICINE (NHB)

[**2149-6-13**]  01:00p   [**Last Name (LF) 3310**],[**First Name3 (LF) **] (RHEUM LMOB)
  LM [**Hospital Unit Name **], [**Location (un) **]
  RHEUMATOLOGY LMOB WEST (SB)
{"Other specified cardiac dysrhythmias,Acute respiratory failure,Unspecified septicemia,Sepsis,Pneumonitis due to inhalation of food or vomitus,Hematoma complicating a procedure,Other respiratory complications,Unspecified transient mental disorder in conditions classified elsewhere,Atrioventricular block, complete,Unspecified acquired hypothyroidism,Systemic lupus erythematosus,Unspecified sleep apnea,Anemia, unspecified,Thrombocytopenia, unspecified,Osteoporosis, unspecified,Dysthymic disorder,Unspecified essential hypertension,Esophageal reflux,Myalgia and myositis, unspecified,Personal history of hodgkin's disease"}


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: Ms. [**Known lastname 4553**] is a 63 yo woman with history of hypothyroid,
lupus, non-hodgkin's lymphoma s/p xrt and chemotherapy 17 years
ago who presented to [**Hospital3 1443**] hospital earlier today
after a syncopal episode at home.

MEDICAL HISTORY: - Lupus, [**Doctor First Name **] supressed, manifests as pleural effusions, on
prednisone
- Hypothyroidism, s/p partial thyroidectomy w/ lymphoma of neck,
chemoradiation plus resection, on levothyroxine
- Hypertension
- Gastroesophageal reflux disease
- Fibromyalgia, on oxycodone 7.5 mg [**Hospital1 **]
- Sleep apnea, diagnosed, but has not wanted CPAP yet
- Depression, on fluoxetine
- Obesity
- Osteoporosis
- Cerebrovascular (small vessel) disease (on ASA and Plavix)

MEDICATION ON ADMISSION: - Alendronate 70 mg once weekly
- Alprazolam 2 mg qhs
- Atorvastatin 10 mg qday
- Clopidogrel 75 mg qday
- Ergocalciferol 50,000 unit qweek
- Fluoxetine 60 mg qday
- Levothyroxine 200 mcg qday
- Nystatin cream prn
- Percocet 7.5-500 qid prn
- Potassium chloride 20 mEq tid
- Prednisone 6 mg qday
- Propranolol 80 mg qday
- Trazodone 75 mg qhs
- ASA 325 qday
- Cyanocobalamin 100 mcg qday
- Multivitamin qday

ALLERGIES: Sulfonamides / Demerol / Haldol

PHYSICAL EXAM: General: morbidly obese woman
HEENT: Pupils symmetrically and markedly dilated (s/p atropine),
ears clear, tube in place, cannot inspect OP
Neck: Hematoma and echymosis on right lateral neck (later -
central line in place in right IJ), very thick neck, cannot
evaluate JVP.
Cardiac: Difficult to auscultate due to ventilator and habitus,
near tachycardic and regular.
Lungs: Symmetric air entry anteriorly with some transmitted
upper airway sound and ventilator noise.
Abdomen: Obese, non-tender to deep palpation.
Extremities: Trace edema, IO access in place at admission (later
removed). Extremities cool and dusky.
Skin: Echymosis on neck, [**Female First Name (un) **] under panus and breasts.
Pulses: Peripheral pulses barely palpable, but ulnar and radial
arteries were Dopplerable bilaterally.

FAMILY HISTORY: Family history of heart disease, but not of early onset.

SOCIAL HISTORY: -Tobacco history: None.
-ETOH: None.
-Illicit drugs: None.
Lives with husband in two family. Daughter and son-in-law live
upstairs with their son and a dog. Significant discord with
daughter and son-in-law at present. Also grandchildren upstairs. 

### Response:
{"Other specified cardiac dysrhythmias,Acute respiratory failure,Unspecified septicemia,Sepsis,Pneumonitis due to inhalation of food or vomitus,Hematoma complicating a procedure,Other respiratory complications,Unspecified transient mental disorder in conditions classified elsewhere,Atrioventricular block, complete,Unspecified acquired hypothyroidism,Systemic lupus erythematosus,Unspecified sleep apnea,Anemia, unspecified,Thrombocytopenia, unspecified,Osteoporosis, unspecified,Dysthymic disorder,Unspecified essential hypertension,Esophageal reflux,Myalgia and myositis, unspecified,Personal history of hodgkin's disease"}
