CHIEF COMPLAINT: passed out

PRESENT ILLNESS: This is a 21 year old woman with PMH of seizures who presents
following loss of consciousness in class. She reports being in
class and developing pleuritic chest pain for 10 minutes. She
says it was a sharp pain. The next thing she remembers is waking
up in the ED, naked. Per records, she was brought to the ED by
EMS and observed to have a episode of her eyes rolling back, and
her pupils were pinpoint. She received 2 mg iv narcan and
appeared to wake up. She had a positive D-dimer and was getting
her CTA and also became unresponsive. Head CT was unremarkable.
She got 2 mg more of Narcan and woke up somewhat again. Due to
concern for her becoming unresponsive repetitively and needing
more narcan, she was admitted to the MICU for observation.

MEDICAL HISTORY: palpitations
dysfunctional uterine bleeding(likely cyst rupture; seen at
ob/gyn clinic)
migraine

MEDICATION ON ADMISSION: Topomax- dose recently increased from 100 to 125.

ALLERGIES: Tylenol

PHYSICAL EXAM: : T98.3 BP 94/58 P70 R20 99% RA
Gen: slowed speech but appropriate responses. no apparent
distress
HEENT: pupils 4 mm and reactive bilaterally. OP clear. MMM
Resp: CTA bilaterally
CV: RRR nl s1s2 no MRG
Abd: soft NTND +BS
Gyn: deferred
Ext: no cyanosis, clubbing, or edema
Neuro: CN 2-12 intact, strength 5/5/ UE and LE. no pronator
drift.

FAMILY HISTORY: father and mother alive and well, 5 sisters without medical
problems.  [**Name (NI) **] history of childhood seizure/ epilepsy

SOCIAL HISTORY: college student, originally from [**Name (NI) 21380**], uncle who lives in
area, lives in [**Location **], denied smoking or drinking or IVDU.
Poisoning by other and unspecified anticonvulsants,Other convulsions,Poisoning by other opiates and related narcotics,Accidental poisoning by anticonvulsant and anti-parkinsonism drugs,Accidental poisoning by other opiates and related narcotics,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Adjustment disorder with mixed disturbance of emotions and conduct
Pois-anticonvul NEC/NOS,Convulsions NEC,Poisoning-opiates NEC,Acc poisn-anticonvulsant,Acc poison-opiates NEC,Migrne unsp wo ntrc mgrn,Adj dis-emotion/conduct
Admission Date:  [**2121-4-30**]              Discharge Date:   [**2121-5-2**]

Date of Birth:  [**2099-10-6**]             Sex:   F

Service: MEDICINE

Allergies:
Tylenol

Attending:[**First Name3 (LF) 4219**]
Chief Complaint:
passed out


Major Surgical or Invasive Procedure:
None

History of Present Illness:
This is a 21 year old woman with PMH of seizures who presents
following loss of consciousness in class. She reports being in
class and developing pleuritic chest pain for 10 minutes. She
says it was a sharp pain. The next thing she remembers is waking
up in the ED, naked. Per records, she was brought to the ED by
EMS and observed to have a episode of her eyes rolling back, and
her pupils were pinpoint. She received 2 mg iv narcan and
appeared to wake up. She had a positive D-dimer and was getting
her CTA and also became unresponsive. Head CT was unremarkable.
She got 2 mg more of Narcan and woke up somewhat again. Due to
concern for her becoming unresponsive repetitively and needing
more narcan, she was admitted to the MICU for observation.

Over the last few months, she remembers passing out over the
last few months. For example, she was evaluated at the [**Hospital1 112**] ED on
[**3-14**] with seizures. She reports some dizziness over the last few
days and a decreased appetitite over the last few weeks. She's
lost 15 pounds over the last 2 weeks. Denies night sweats,
diarrhea, fevers, chills, incontinence, tongue biting.
.
On ROS, she reports having a miscarriage 4 days ago with passing
of spongy material. Her last menstrual period was around [**3-17**] and she tested postive on a urine pregnancy test. She has
had some bleeding since that time, decreasing each day. She is
okay with the pregnancy terminating.


Past Medical History:
palpitations
dysfunctional uterine bleeding(likely cyst rupture; seen at
ob/gyn clinic)
migraine


Social History:
college student, originally from [**Name (NI) 21380**], uncle who lives in
area, lives in [**Location **], denied smoking or drinking or IVDU.


Family History:
father and mother alive and well, 5 sisters without medical
problems.  [**Name (NI) **] history of childhood seizure/ epilepsy

Physical Exam:
: T98.3 BP 94/58 P70 R20 99% RA
Gen: slowed speech but appropriate responses. no apparent
distress
HEENT: pupils 4 mm and reactive bilaterally. OP clear. MMM
Resp: CTA bilaterally
CV: RRR nl s1s2 no MRG
Abd: soft NTND +BS
Gyn: deferred
Ext: no cyanosis, clubbing, or edema
Neuro: CN 2-12 intact, strength 5/5/ UE and LE. no pronator
drift.


Pertinent Results:
EKG: NSR, no ST/T wave changes.
.
CXR: IMPRESSION:  Possible widening of the superior mediastinum.
 Please correlate with mechanism of injury.  No pneumothorax or
fracture identified.
.
CT head: IMPRESSION:  No evidence of intracranial hemorrhage.
.
CT chest with contrast:
IMPRESSION:  No evidence of pulmonary embolism or other acute
cardiopulmonary process.
.
TTE:
Conclusions:
1.The left atrium is normal in size.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity
size is normal. Overall left ventricular systolic function is
normal
(LVEF>55%).
3.Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic valve leaflets (3) appear structurally normal with
good leaflet
excursion. No aortic regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. No mitral
regurgitation is
seen.
6.There is no pericardial effusion.


Brief Hospital Course:
The patient was admitted to the MICU out of concern for repeated
unconsciousness. There was no history to suggest tongue biting,
bowel/bladder incontinence, shaking or other seizure activity.
She had a urine and serum tox screen in ED that was negative.
She was rehydrated with 1 liter of NS, was not found to be
orthostatic.  Neurology had evaluated her in the ED, initial
evaluation recommended outpatient follow-up with her
neurologist, however the next morning the neuro service
recommended an echo and an EEG.  The patient did not have any
further episodes of unresponsiveness while in the unit, remained
afebrile and hemodynamically stable.
.
She was restarted on her home dose of Topamax, and her outside
neurologist was trying to be reached.  She was transferred to a
medicine floor on the morning after admission.  The following
course by problem is summarized from the  time the pt was
transferred to the medicine service:
.
#) Loss of consciousness: The etiology of the pts syncopal
episode still remains unclear.  The differential diagnosis
included seizure vs. basilar migraine vs. opiate overdose per
neuro.  The pts story was somewhat inconsistent, given that she
had pinpoint pupils and responded to narcan, however her tox
screen was negative.  There is also a possibity of psychiatric
disturbance in the differential.   Apparently witnesses from the
original episode were not reachable, and the pt was unable to
recall the name of the woman who had helped her out of the
classroom. The pt was monitored on telemetry throughout her
stay, but there were no reported events on tele to suggest
cardiac etiology. TTE revealed no valvular abnormalities, EF
55%.  The pt was slightly orthostatic on the day of discharge,
but this resolved after she was given 1 L NS. The pt was seen by
psychiatry and was diagnosed with adjustment disorder and
anxiety disorder.  Psychiatry recommended the pt undergo
neuropsychological testing and follow up with a psychiatrist,
possibly under the referral of her primary neurologist, Dr.
[**Name (NI) **].  The pt was also given the phone number for [**Location (un) 44009**]Counseling Services by the psychiatric consultants.  EEG
was also perfromed prior to the pts discharge, revealing diffuse
slowing.  Neurology recommended discontinuation of the pts
Topamax as it was felt this medication could be the culprit of
the diffuse slowing.
.
#) History of recent preganacy with likely miscarriage: The pt
complained of mild vaginal bleeding throughout her stay.
Interestingly, the pts urine HCG was negative, although she
claimed she had a miscarriage 4 days prior to admission (however
serum bHCG levels were not checked).  Of note, the pt also has a
history of dysfunctional uterine bleeding noted in prior
discharge summaries.


Medications on Admission:
Topomax- dose recently increased from 100 to 125.

Discharge Medications:
none

Discharge Disposition:
Home

Discharge Diagnosis:
syncopal episode


Discharge Condition:
stable, no further episodes of syncope, no seizure activity
documented


Discharge Instructions:
1) Stop taking your Topamax
2) Follow up with your neurologist as scheduled below, you will
need an oupt eeg
3) Return to the ER or call your doctor [**First Name (Titles) **] [**Last Name (Titles) 16169**] episodes
of fainting, chest pain, worsening pelvic pain or vaginal
bleeding, loss of consciousness, or any other concerning
symptoms

Followup Instructions:
1) Please follow up with your neurologist Dr. [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) **] at
[**Telephone/Fax (1) 21076**] on Tuesday at 2 PM


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4231**]
{'Poisoning by other and unspecified anticonvulsants,Other convulsions,Poisoning by other opiates and related narcotics,Accidental poisoning by anticonvulsant and anti-parkinsonism drugs,Accidental poisoning by other opiates and related narcotics,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Adjustment disorder with mixed disturbance of emotions and conduct'}


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: passed out

PRESENT ILLNESS: This is a 21 year old woman with PMH of seizures who presents
following loss of consciousness in class. She reports being in
class and developing pleuritic chest pain for 10 minutes. She
says it was a sharp pain. The next thing she remembers is waking
up in the ED, naked. Per records, she was brought to the ED by
EMS and observed to have a episode of her eyes rolling back, and
her pupils were pinpoint. She received 2 mg iv narcan and
appeared to wake up. She had a positive D-dimer and was getting
her CTA and also became unresponsive. Head CT was unremarkable.
She got 2 mg more of Narcan and woke up somewhat again. Due to
concern for her becoming unresponsive repetitively and needing
more narcan, she was admitted to the MICU for observation.

MEDICAL HISTORY: palpitations
dysfunctional uterine bleeding(likely cyst rupture; seen at
ob/gyn clinic)
migraine

MEDICATION ON ADMISSION: Topomax- dose recently increased from 100 to 125.

ALLERGIES: Tylenol

PHYSICAL EXAM: : T98.3 BP 94/58 P70 R20 99% RA
Gen: slowed speech but appropriate responses. no apparent
distress
HEENT: pupils 4 mm and reactive bilaterally. OP clear. MMM
Resp: CTA bilaterally
CV: RRR nl s1s2 no MRG
Abd: soft NTND +BS
Gyn: deferred
Ext: no cyanosis, clubbing, or edema
Neuro: CN 2-12 intact, strength 5/5/ UE and LE. no pronator
drift.

FAMILY HISTORY: father and mother alive and well, 5 sisters without medical
problems.  [**Name (NI) **] history of childhood seizure/ epilepsy

SOCIAL HISTORY: college student, originally from [**Name (NI) 21380**], uncle who lives in
area, lives in [**Location **], denied smoking or drinking or IVDU. 

### Response:
{'Poisoning by other and unspecified anticonvulsants,Other convulsions,Poisoning by other opiates and related narcotics,Accidental poisoning by anticonvulsant and anti-parkinsonism drugs,Accidental poisoning by other opiates and related narcotics,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Adjustment disorder with mixed disturbance of emotions and conduct'}
