CHIEF COMPLAINT: syncope/ hypotension

PRESENT ILLNESS: For full details please see full admission note from MICU. in
brief, the patient is a 59 year old male with history of ESRD on
HD< DM, CAD who was in his USOH until [**2167-9-25**] when he
experienced dizziness and lightheadedness with standing with
some resolution by the next morning. When walking the next day
he experienced some dyspnea and chest pressure. On arrival to
[**Last Name (un) **] that day for a planned appointment he syncopized in the
lobby. At that time the patient was found to he hypotensive to
70/30 for which he was taken to the E.D. immediately. There is
no report of aura prior to this episode, seizure, or post-ictal
state.
.
On arrival to the ED the patient was with following vitals:
T97.0, HR55, BP 84/53, O2 95%RA with ECG revealing a junctional
rhythm. IJ was placed and cardiology consulted with impression
that this was secondary to nodal effect of both Toprol and Dilt,
recommendation to monitor overnight holding BB and CCB. In the
ICU the patient regained sinus rhythm and pressure improved to
104/70 without other intervention. CXR unremarkable and lactate
WNL. The patient was monitored overnight and has remained
hemodynamically stable, had HD today. The patient had Metoprolol
Tartrate 37.5 PO tid started today and tolerating well thus far.
The patient is now transferred to the medical floor for ongoing
care.
.
On arrival to floor the patient feels well. He denies currently
chest pain, dyspnea, dizziness. He reports stable symptoms of
chest pressure with exertion, particularly climbing stairs, that
have stable over 1 year.

MEDICAL HISTORY: # ESRD - on HD (since '[**64**]) Tu/Th/Sat; failed kidney [**Year (2 digits) **]
attempted [**Year (2 digits) **] [**4-20**] from Hep C positive donor but aborted
[**1-16**] hypoxia. c/b wound dehiscence.
# Diabetes - followed by [**Last Name (un) **]
# Hep C - genotype 1 c hepatitis C viral load of 18,400,000 I.U.

MEDICATION ON ADMISSION: ASA 81mg daily
Citalopram 20mg daily
Dilt SR 360 daily
Valsartan 320 daily (patient not taking)
Gabapentin 100mg TID
Lantus 30 units
Reglan 10mg daily
Prilosec 20 mg daily
Vit B
Vit C
Folic acid
Cinacalcet 30mg daily
Toprol XL 100 daily
Allopurinol 100 daily
Calcium acetate
sevelamer 800 TID with meals
Mirapex 0.25 QHS

ALLERGIES: Iron Dextran Complex / Bupropion

PHYSICAL EXAM: Vitals: T- 98.9 lying: BP- 140/60 HR- 80 standing: BP 120/60  HR
80   RR-18  O2- 97% on RA
.
General: Patient is a well appearing African American Male,
pleasant, in NAD
HEENT: NCAT, EOMI, sclera muddy brown, conjunctiva WNL. OP: MMM,
no lesions
Neck: Obese, JVP difficult to assess [**1-16**] body habitus
Chest: Relatively clear to auscultation anterior and posterior,
few end expiratory course wheezes
Cor: RRR, normal S1/S2. No murmurs appreciated. + S4
Abdomen: Obese, mod distended. Soft, non-tender. + well healed
RLQ surgical scar
Ext: Trace lower extremity edema

FAMILY HISTORY: Father-died at age 52 from stroke
Mother-died in her 50s from cirrhosis
[**Name (NI) 12408**] DM
[**Name (NI) 30204**] addict
[**Name (NI) 30205**] at unknown age, due to problems with kidney and
pancreas

SOCIAL HISTORY: Mr. [**Known lastname 30197**] previously worked at Sheraton Hotel, retired in
[**2164**]. Currently lives with his sister
[**Name (NI) 1139**]: 80 pack-year history, quit [**2165-5-15**]
ETOH: history of 1 pint per week, quit [**2165-5-15**]
Illicits: Previous crack cocaine use, quit [**2165-5-15**].
Previous heroin use, quite 5-6 years ago. Member of NA, in
therapy for substance abuse.
Other specified cardiac dysrhythmias,End stage renal disease,Chronic diastolic heart failure,Sympatholytics [antiadrenergics] causing adverse effects in therapeutic use,Coronary vasodilators causing adverse effects in therapeutic use,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Chronic hepatitis C without mention of hepatic coma,Esophageal reflux,Personal history of malignant neoplasm of kidney
Cardiac dysrhythmias NEC,End stage renal disease,Chr diastolic hrt fail,Adv eff sympatholytics,Adv eff coronary vasodil,DMII renl nt st uncntrld,Chrnc hpt C wo hpat coma,Esophageal reflux,Hx of kidney malignancy
Admission Date:  [**2167-9-25**]              Discharge Date:   [**2167-9-27**]

Date of Birth:  [**2108-4-9**]             Sex:   M

Service: MEDICINE

Allergies:
Iron Dextran Complex / Bupropion

Attending:[**First Name3 (LF) 358**]
Chief Complaint:
syncope/ hypotension

Major Surgical or Invasive Procedure:
central line placement

History of Present Illness:
For full details please see full admission note from MICU. in
brief, the patient is a 59 year old male with history of ESRD on
HD< DM, CAD who was in his USOH until [**2167-9-25**] when he
experienced dizziness and lightheadedness with standing with
some resolution by the next morning. When walking the next day
he experienced some dyspnea and chest pressure. On arrival to
[**Last Name (un) **] that day for a planned appointment he syncopized in the
lobby. At that time the patient was found to he hypotensive to
70/30 for which he was taken to the E.D. immediately. There is
no report of aura prior to this episode, seizure, or post-ictal
state.
.
On arrival to the ED the patient was with following vitals:
T97.0, HR55, BP 84/53, O2 95%RA with ECG revealing a junctional
rhythm. IJ was placed and cardiology consulted with impression
that this was secondary to nodal effect of both Toprol and Dilt,
recommendation to monitor overnight holding BB and CCB. In the
ICU the patient regained sinus rhythm and pressure improved to
104/70 without other intervention. CXR unremarkable and lactate
WNL. The patient was monitored overnight and has remained
hemodynamically stable, had HD today. The patient had Metoprolol
Tartrate 37.5 PO tid started today and tolerating well thus far.
The patient is now transferred to the medical floor for ongoing
care.
.
On arrival to floor the patient feels well. He denies currently
chest pain, dyspnea, dizziness. He reports stable symptoms of
chest pressure with exertion, particularly climbing stairs, that
have stable over 1 year.


Past Medical History:
# ESRD - on HD (since '[**64**]) Tu/Th/Sat; failed kidney [**Year (2 digits) **]
attempted [**Year (2 digits) **] [**4-20**] from Hep C positive donor but aborted
[**1-16**] hypoxia. c/b wound dehiscence.
# Diabetes - followed by [**Last Name (un) **]
# Hep C - genotype 1 c hepatitis C viral load of 18,400,000 I.U.

Followed by Dr. [**Last Name (STitle) 497**]
# Diastolic CHF - last ECHO [**4-20**]: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3841**] dilated, RA
moderately dilated; LVEF>55%
# GERD
# Former Substance Abuse - alcohol, cocaine, heroine; clean
since '[**64**], 1 relapse with cocaine in '[**65**]; attends [**Hospital1 **] and NA

# Renal cell carcinoma s/p removal [**2162**] followed w/o recurrence

# Pericardial effusion [**2165**], presumed viral; required
pericardiocentesis for tamponade physiology
# Depression- no suicide attempts, +passive thoughts about
suicide with no plan
# Barrett's Esophagus (from OMR)c/b Anemia
# Carpal Tunnel Syndrome - used wrist splints
# Sleep Apnea


Social History:
Mr. [**Known lastname 30197**] previously worked at Sheraton Hotel, retired in
[**2164**]. Currently lives with his sister
[**Name (NI) 1139**]: 80 pack-year history, quit [**2165-5-15**]
ETOH: history of 1 pint per week, quit [**2165-5-15**]
Illicits: Previous crack cocaine use, quit [**2165-5-15**].
Previous heroin use, quite 5-6 years ago. Member of NA, in
therapy for substance abuse.


Family History:
Father-died at age 52 from stroke
Mother-died in her 50s from cirrhosis
[**Name (NI) 12408**] DM
[**Name (NI) 30204**] addict
[**Name (NI) 30205**] at unknown age, due to problems with kidney and
pancreas

Physical Exam:
Vitals: T- 98.9 lying: BP- 140/60 HR- 80 standing: BP 120/60  HR
80   RR-18  O2- 97% on RA
.
General: Patient is a well appearing African American Male,
pleasant, in NAD
HEENT: NCAT, EOMI, sclera muddy brown, conjunctiva WNL. OP: MMM,
no lesions
Neck: Obese, JVP difficult to assess [**1-16**] body habitus
Chest: Relatively clear to auscultation anterior and posterior,
few end expiratory course wheezes
Cor: RRR, normal S1/S2. No murmurs appreciated. + S4
Abdomen: Obese, mod distended. Soft, non-tender. + well healed
RLQ surgical scar
Ext: Trace lower extremity edema

Pertinent Results:
Trop: .02 - .03
WBC: 12.1

Imaging:
[**2167-9-25**] CXR - no acute process, line in place

Micro:
[**2167-9-25**] Blood - PENDING UPON DISCHARGE
[**2167-9-25**] Urine - PENDING UPON DISCHARGE
Catheter TIP culture: PENDING UPON DISCHARGE
ECG: Sinus Brady, LAD. Qs III, aVF. no acute ST/TW changes

[**2167-9-25**] 03:13PM   LACTATE-1.4
[**2167-9-25**] 12:45PM   K+-4.5
[**2167-9-25**] 12:35PM   GLUCOSE-100 UREA N-44* CREAT-8.3*# SODIUM-139
POTASSIUM-4.7 CHLORIDE-97 TOTAL CO2-27 ANION GAP-20
[**2167-9-25**] 12:35PM   CK(CPK)-119
[**2167-9-25**] 12:35PM   cTropnT-0.02*
[**2167-9-25**] 12:35PM   CK-MB-3
[**2167-9-25**] 12:35PM   WBC-11.6* RBC-3.99* HGB-11.2* HCT-35.6*
MCV-89 MCH-28.0 MCHC-31.5 RDW-20.7*
[**2167-9-25**] 12:35PM   NEUTS-58 BANDS-0 LYMPHS-23 MONOS-12* EOS-5*
BASOS-1 ATYPS-1* METAS-0 MYELOS-0 NUC RBCS-2*
[**2167-9-25**] 12:35PM   HYPOCHROM-OCCASIONAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-OCCASIONAL
POLYCHROM-1+ TEARDROP-OCCASIONAL
[**2167-9-25**] 12:35PM   PLT SMR-NORMAL PLT COUNT-374

Brief Hospital Course:
Bradycardia / Hypotension - Likely related to bradycardia with
possible contribution from volume depletion. No evidence by labs
or exam for infectious etiology.  Patient was on dilt 360mg po
daily and Toprol 100mg po daily.  His EKG showed marked sinus
bradycardia with a rate in the 20s and a junctional escape
rhythm with a rate in the high 50s.  He was hypotensive and
fluid resuscitated, his hypotension resolved and his rhythm
returned to sinus.  His medications were adjusted to Toprol 50mg
daily.  Diltiazem was discontinued.  EP was consulted and helped
direct the plan.  The patient's primary cardiologist was
notified of the changes.

Diabetes - blood glucoses well controlled as inpatient.

ESRD- on HD, rec'd HD as inpatient on Saturday [**9-26**].

Hep C - no active issues. Outpatient follow up.


Medications on Admission:
ASA 81mg daily
Citalopram 20mg daily
Dilt SR 360 daily
Valsartan 320 daily (patient not taking)
Gabapentin 100mg TID
Lantus 30 units
Reglan 10mg daily
Prilosec 20 mg daily
Vit B
Vit C
Folic acid
Cinacalcet 30mg daily
Toprol XL 100 daily
Allopurinol 100 daily
Calcium acetate
sevelamer 800 TID with meals
Mirapex 0.25 QHS

Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
4. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS
(3 TIMES A DAY WITH MEALS).
11. Insulin Glargine  Subcutaneous
12. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
13. Neurontin 100 mg Capsule Sig: Three (3) Capsule PO as
directed: take 3 pills after dialysis sessions.


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnosis:
Syncope
Sinus Bradycardia with junctional escape rhythm

Secondary Diagnosis:
ESRD on HD
HTN
DM II


Discharge Condition:
sinus rhythm, not symptomatically orthostatic, stable


Discharge Instructions:
You were admitted for a fall probably related to your
medications.  Please note the following medication changes:

PLEASE STOP TAKING YOUR DILTIAZEM.  ALSO, DECREASE YOUR TOPROL
XL DOSE TO 50MG DAILY.

Please call your doctor or go to the emergency room if you fall,
if you have lightheadedness, shortness of breath, chest pain, or
any other symptoms that concern you.

Followup Instructions:
Please follow up with your primary care physician and your
kidney doctors [**Name5 (PTitle) 176**] 4 weeks of your discharge.

You have the following appointments:

1. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2167-10-5**]
5:00

2. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8753**], MD Phone:[**Telephone/Fax (1) 1387**] Date/Time:[**2167-10-7**] 8:00

3. [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CENTER - NON BILLING
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2167-10-14**] 9:30
{'Other specified cardiac dysrhythmias,End stage renal disease,Chronic diastolic heart failure,Sympatholytics [antiadrenergics] causing adverse effects in therapeutic use,Coronary vasodilators causing adverse effects in therapeutic use,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Chronic hepatitis C without mention of hepatic coma,Esophageal reflux,Personal history of malignant neoplasm of kidney'}


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/ hypotension

PRESENT ILLNESS: For full details please see full admission note from MICU. in
brief, the patient is a 59 year old male with history of ESRD on
HD< DM, CAD who was in his USOH until [**2167-9-25**] when he
experienced dizziness and lightheadedness with standing with
some resolution by the next morning. When walking the next day
he experienced some dyspnea and chest pressure. On arrival to
[**Last Name (un) **] that day for a planned appointment he syncopized in the
lobby. At that time the patient was found to he hypotensive to
70/30 for which he was taken to the E.D. immediately. There is
no report of aura prior to this episode, seizure, or post-ictal
state.
.
On arrival to the ED the patient was with following vitals:
T97.0, HR55, BP 84/53, O2 95%RA with ECG revealing a junctional
rhythm. IJ was placed and cardiology consulted with impression
that this was secondary to nodal effect of both Toprol and Dilt,
recommendation to monitor overnight holding BB and CCB. In the
ICU the patient regained sinus rhythm and pressure improved to
104/70 without other intervention. CXR unremarkable and lactate
WNL. The patient was monitored overnight and has remained
hemodynamically stable, had HD today. The patient had Metoprolol
Tartrate 37.5 PO tid started today and tolerating well thus far.
The patient is now transferred to the medical floor for ongoing
care.
.
On arrival to floor the patient feels well. He denies currently
chest pain, dyspnea, dizziness. He reports stable symptoms of
chest pressure with exertion, particularly climbing stairs, that
have stable over 1 year.

MEDICAL HISTORY: # ESRD - on HD (since '[**64**]) Tu/Th/Sat; failed kidney [**Year (2 digits) **]
attempted [**Year (2 digits) **] [**4-20**] from Hep C positive donor but aborted
[**1-16**] hypoxia. c/b wound dehiscence.
# Diabetes - followed by [**Last Name (un) **]
# Hep C - genotype 1 c hepatitis C viral load of 18,400,000 I.U.

MEDICATION ON ADMISSION: ASA 81mg daily
Citalopram 20mg daily
Dilt SR 360 daily
Valsartan 320 daily (patient not taking)
Gabapentin 100mg TID
Lantus 30 units
Reglan 10mg daily
Prilosec 20 mg daily
Vit B
Vit C
Folic acid
Cinacalcet 30mg daily
Toprol XL 100 daily
Allopurinol 100 daily
Calcium acetate
sevelamer 800 TID with meals
Mirapex 0.25 QHS

ALLERGIES: Iron Dextran Complex / Bupropion

PHYSICAL EXAM: Vitals: T- 98.9 lying: BP- 140/60 HR- 80 standing: BP 120/60  HR
80   RR-18  O2- 97% on RA
.
General: Patient is a well appearing African American Male,
pleasant, in NAD
HEENT: NCAT, EOMI, sclera muddy brown, conjunctiva WNL. OP: MMM,
no lesions
Neck: Obese, JVP difficult to assess [**1-16**] body habitus
Chest: Relatively clear to auscultation anterior and posterior,
few end expiratory course wheezes
Cor: RRR, normal S1/S2. No murmurs appreciated. + S4
Abdomen: Obese, mod distended. Soft, non-tender. + well healed
RLQ surgical scar
Ext: Trace lower extremity edema

FAMILY HISTORY: Father-died at age 52 from stroke
Mother-died in her 50s from cirrhosis
[**Name (NI) 12408**] DM
[**Name (NI) 30204**] addict
[**Name (NI) 30205**] at unknown age, due to problems with kidney and
pancreas

SOCIAL HISTORY: Mr. [**Known lastname 30197**] previously worked at Sheraton Hotel, retired in
[**2164**]. Currently lives with his sister
[**Name (NI) 1139**]: 80 pack-year history, quit [**2165-5-15**]
ETOH: history of 1 pint per week, quit [**2165-5-15**]
Illicits: Previous crack cocaine use, quit [**2165-5-15**].
Previous heroin use, quite 5-6 years ago. Member of NA, in
therapy for substance abuse. 

### Response:
{'Other specified cardiac dysrhythmias,End stage renal disease,Chronic diastolic heart failure,Sympatholytics [antiadrenergics] causing adverse effects in therapeutic use,Coronary vasodilators causing adverse effects in therapeutic use,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Chronic hepatitis C without mention of hepatic coma,Esophageal reflux,Personal history of malignant neoplasm of kidney'}
