CHIEF COMPLAINT: syncopal episode

PRESENT ILLNESS: Pt is 85 yr old female with Hx of AF/gastric AVMs/carotid
stenosis who fell from sitting position with +LOC. The patient
states that she was confused and thought she had been told that
there was rioting in [**Location (un) **] after the superbowl. She got up
very quickly to walk to the T.V. when she began feeling dizzy.
She felt as though she might lose consciousness, attempted to
sit down, and fell from the chair. The fall was witnessed by her
son who confirms LOC. Pt. denies any concommitant palpitations,
SOB, or CP. Patient denies the use of EtOH or any illegal
substances prior to the fall. The patient states that she has
been significantly SOB for the last 2-4 weeks, particularly in
the AM. She is unable to walk more than 15feet w/o becoming SOB.
The dyspnea usually resolves after a nebulizer Tx. She has also
been somewhat pale over the same time period. Pt. denies any
HA,F/C/N/V, changes in bowel or urinary habits, any melanotic
stools.
.
She was taken to [**Hospital3 **] & found to have SAH, & was
transferred to [**Hospital1 18**] where repeat CT scan showed left tempo
parietel SAH. Pt noted to have Hct of 22.2 and INR of 1.6 on
admission and had guaiac+ brown stool. Pt otherwise stable and
alert upon arrival to TICU.

MEDICAL HISTORY: AF with h/o embolic TIA
DM
GERD
HTN
carotid stenosis
hyperlipidemia
h/o duodenal ulcer [**2112**], stomach AVMs
hiatal hernia
mesenteric ischemia s/p small bowel resection [**12/2113**]
basal cell CA s/p excision [**5-22**]
legally blind

MEDICATION ON ADMISSION: ASA 325, digoxin, lipitor, imdur, lisinopril, glyburide, Plavix,
Metformin, Lopressor 50 TID, coumadin, protonix

ALLERGIES: Atenolol

PHYSICAL EXAM: T98.6, HR 84 (70-80s), BP 140/60, R20, O2sat 95RA
.
Gen: Thin appearing pleasant female appearing stated age, in NAD

FAMILY HISTORY: Mother died at 63 from blood clot
Father died at 70

SOCIAL HISTORY: Retired. Lives at home with her daughter. no tobacco, no EtOH x
many years.  She is no longer able to cook for herself and her
diet consists mostly of sandwiches and occassional fried foods.
She does not exercise.
Syncope and collapse,Subarachnoid hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration,Atrial fibrillation,Urinary tract infection, site not specified,Chronic airway obstruction, not elsewhere classified,Angiodysplasia of stomach and duodenum with hemorrhage,Acute posthemorrhagic anemia,Pulmonary collapse,Accidental fall from chair,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Esophageal reflux,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled
Syncope and collapse,Subarach hem-coma NOS,Atrial fibrillation,Urin tract infection NOS,Chr airway obstruct NEC,Angio stm/dudn w hmrhg,Ac posthemorrhag anemia,Pulmonary collapse,Fall from chair,Hyperlipidemia NEC/NOS,Hypertension NOS,Esophageal reflux,DMII wo cmp nt st uncntr
Admission Date:  [**2119-12-26**]              Discharge Date:   [**2120-1-8**]


Service: MEDICINE

Allergies:
Atenolol

Attending:[**First Name3 (LF) 783**]
Chief Complaint:
syncopal episode

Major Surgical or Invasive Procedure:
None


History of Present Illness:
Pt is 85 yr old female with Hx of AF/gastric AVMs/carotid
stenosis who fell from sitting position with +LOC. The patient
states that she was confused and thought she had been told that
there was rioting in [**Location (un) **] after the superbowl. She got up
very quickly to walk to the T.V. when she began feeling dizzy.
She felt as though she might lose consciousness, attempted to
sit down, and fell from the chair. The fall was witnessed by her
son who confirms LOC. Pt. denies any concommitant palpitations,
SOB, or CP. Patient denies the use of EtOH or any illegal
substances prior to the fall. The patient states that she has
been significantly SOB for the last 2-4 weeks, particularly in
the AM. She is unable to walk more than 15feet w/o becoming SOB.
The dyspnea usually resolves after a nebulizer Tx. She has also
been somewhat pale over the same time period. Pt. denies any
HA,F/C/N/V, changes in bowel or urinary habits, any melanotic
stools.
.
She was taken to [**Hospital3 **] & found to have SAH, & was
transferred to [**Hospital1 18**] where repeat CT scan showed left tempo
parietel SAH. Pt noted to have Hct of 22.2 and INR of 1.6 on
admission and had guaiac+ brown stool. Pt otherwise stable and
alert upon arrival to TICU.


Past Medical History:
AF with h/o embolic TIA
DM
GERD
HTN
carotid stenosis
hyperlipidemia
h/o duodenal ulcer [**2112**], stomach AVMs
hiatal hernia
mesenteric ischemia s/p small bowel resection [**12/2113**]
basal cell CA s/p excision [**5-22**]
legally blind

Social History:
Retired. Lives at home with her daughter. no tobacco, no EtOH x
many years.  She is no longer able to cook for herself and her
diet consists mostly of sandwiches and occassional fried foods.
She does not exercise.


Family History:
Mother died at 63 from blood clot
Father died at 70

Physical Exam:
T98.6, HR 84 (70-80s), BP 140/60, R20, O2sat 95RA
.
Gen: Thin appearing pleasant female appearing stated age, in NAD

HEENT: NC, 3x2 contusion lt. temporal region, sclera anicteric,
no conjunctival pallor
Neck: JVP 11cm, no LAD
Cardio: irrg, S1S2, no M/G/R
Lungs: min cracles R base
Abd: mid abdominal scar, soft, round non-tender non-distended,
+BS.
Ext: warm/well perfused
posNeuro: CN 3-12 intact, pt. legally blind


Pertinent Results:
Labs on admission
[**2119-12-26**] 04:35PM BLOOD WBC-6.9 RBC-2.71* Hgb-7.1*# Hct-22.2*#
MCV-82 MCH-26.1*# MCHC-31.9 RDW-16.6* Plt Ct-266#
[**2119-12-26**] 04:35PM BLOOD PT-17.2* PTT-25.7 INR(PT)-1.6*
[**2119-12-26**] 04:35PM BLOOD Glucose-177* UreaN-22* Creat-0.9 Na-144
K-4.1 Cl-107 HCO3-26 AnGap-15
[**2119-12-26**] 04:35PM BLOOD Iron-20*
.
[**2119-12-26**] CT angio of head
IMPRESSION: No evidence of aneurysm of the circle of [**Location (un) 431**],
within the limitations of this examination technique. Findings
were discussed with Dr. [**Last Name (STitle) 64602**] at time of exam by Dr. [**Last Name (STitle) **].
Tham.
.
[**2119-12-26**] CT head without contrast
FINDINGS: There is a small amount of subarachnoid blood within
the left Sylvian fissure. There is no significant mass effect or
shift of normally midline structures. There is no evidence of
hydrocephalus. Note is made of cavum septum pellucidum at
vergae. Mild hypodensity in the periventricular cerebral white
matter is consistent with chronic microvascular ischemia.
Osseous structures are unremarkable without evidence of skull
fracture. There is a prominent left frontal subgaleal hematoma.

IMPRESSION: Small amount of left-sided subarachnoid hemorrhage
as described above.
.
[**2119-12-27**] CT head without contrast
FINDINGS: Again seen is a small amount of subarachnoid blood
within the left sylvian fissure. The left frontal subgaleal
hematoma is again noted. No other significant changes are noted.
There is no evidence of shift of normally midline structures or
impending herniation.

IMPRESSION: Stable small left sylvian fissure subarachnoid
hemorrhage.

[**2119-12-27**] EKG
Atrial fibrillation
- frequent multifocal PVCs or aberrant ventricular conduction
Probable anteroseptal infarct - age undetermined
Inferior/lateral ST-T changes
Left anterior fascicular block
Since previous tracing, no significant change
.
[**2120-1-3**]
Chest X-ray PA & L
CONCLUSION:
1. Single intact lead terminating at expected location of tip of
right ventricle.
2. New left pleural effusion and parenchymal consolidation at
the left lung base. Parenchymal consolidation could represent
some atelectasis or pneumonia and radiographic followup to
complete clearing is recommended to assure no underlying lesion
exists.
3. COPD.
4. Atherosclerosis including severe coronary artery plaque.
.
[**2120-1-4**]
Chest X-ray PA & L
1. Residual streaky opacity in the retrocardiac region, most
likely representing atelectasis.
2. Left effusion has significantly decreased in the interim,
with residual blunting of the costophrenic angle.
3. COPD.
4. Atherosclerosis involving the aorta and coronary arteries.


Brief Hospital Course:
1. SAH
On admission the patient was found to have a small SAH in L
Sylvian fissure, w/o any evidence of aneurysm in the Circle of
[**Location (un) 431**]. Her INR on admission was 1.4. Repeat CT Head
demonstrated stable hemorrage.The pt. did not have any
neurological Sx on admission and continued to remain
neurologically stable and mentating appropriately.  Per
neurosurgical recs the patient was placed on Phenytoin 100mg TID
for seizure prophylaxis for a total of 2wks. Her Coumadin was
d/c and will be restarted as an outpatient in 4wks ([**2120-1-24**]).
Plavix was initially d/c and then restarted on HD4.
.
2. Syncope
Given the patients's Hx of gastric AVMs her syncopal episode may
have been precipitated by intravascular depletion secondary to a
slow GI bleed. The patient's Hct fell from 30.4 on her last
admission ([**11-7**]) to 22.2 on this admission. Given patient's
history of afib with RVR and bradycardia during this admission,
her syncope episode may have been secondary to a combination of
cardiac factors, in addition her Hx of DM may have also had
autonomic instability. The patient was ruled out for an MI x3.
Her troponins remained <0.01 and her EKG was unchanged from
previous exam. On transfer to the Medicine service the pt. was
orthostatic w/ a 20 point drop in SBP from supine to sitting.
There was no significant increase in HR given that the patient
was beta blocked.  The patient was monitored on telemetry
throughout her hospitalization.  She did have multiple
tachy/brady episodes, but did not have any syncopal episodes
during the admission.
.
3. Cardiovascular
.
Cor
The patient is s/p atherectomy to mid-LAD and distal LAD, DES to
the LAD 2.5 X 28mm. Coumadin was held due to SAH. Plavix was
also held by request of Neurosurgery but later restarted.  The
patient was maintained on aspirin and statin.
.
Pump
optimal BP control: The patient was maintained on captopril and
BB. Digoxin has been d/c because it is contraindicated for
patient's in this age range, and it is unnecessary given that
the patient remained rate controlled on BB and CCB.
.
Rhythm  (afib w/ RVR)
Pt. is in chronic Afib, and had some skipped beats and 3
episodes of bradycardia to 30s during her course, twice while
sleeping and once when awake. Pt. also had approx 4 episodes in
total of tachycardia with ambulation (150s) and at rest (170s).
On HD3 the pt. had two tachycardic events overnight HR 179, and
had 2 triggers called that AM.  10:30AM - asymptomatic
tachycardia HR 150, and 11:30am - asymptomatic bradycardia HR 29
while sleeping, then 38 when awake. During her tachycardia she
responded to 5 IV dilt. The bradycardic event did not require
any additional diagnositc tests or intervention, and resolved
spontaneously.  The patient was asymptomatic during all events
above mentioned events. EP was consulted and the patient was
scheduled placement of a single lead pacemaker on [**1-3**]. Her
Coumadin was d/c given her SAH and will be restarted on
[**2120-1-24**].  After pacemaker placement the pt. continued to have
episodes of asympotomatic tachycardia up to the 170s. Diltiazem
was added to her regimen for rate control.  The patient's HR
stablized to 100s on Metroprolol 75mg [**Hospital1 **] and Diltiazem XR 180mg
[**Hospital1 **].
.
4. Anemia  The patient's Hct was down to 22.2 from 30.4 on her
previous admission, she received 2U of PRBCs bringing her Hct up
to 29.5 which held stable for several days.  On HD10 The pt's
Hct dropped again down to 24.6 from 28.9 the previous day.  She
was transfused again with 2U of PRBCs with a goal of maintaining
her Hct >28. The patient underwent endoscopy, which identified a
duodenal bleed which was
cauterized. The patient was maintained on iron supplementation
throughout her admission.
.
5. UTI
The patient developed a Klebsiella UTI during her
hospitalization which was Tx with Ciprofloxacin.
.
6. DM
The patient was maintained on the following regimen FSBG QID,
ISS, and her at home regimen of Metformin 500mg po QD and
glyburide 5mg po TID.
.
7. FEN  Lytes were repleted as needed and the patient was
maintained, cardiac/diabetic low sodium diet, and was placed on
GI and DVT prophylaxis w/o event.
.
8. Dispo
Home w/ services.
.
In summary this is an 85yo woman w/ a hx of CAD s/p NSTEMI and
LAD stent placement ([**10-22**])/gastric AVMs/DM who presents w/ a
fall from sitting position +LOC and SAH.  Given the patient's Hx
of GIB, low Hct, and guaiac+ brown stool, it is likely that her
synope was partially attributable to orthostatic hypotension
secondary to intravascular depletion.  However given the
patient's Afib w/ tachy/brady sx during her hospital course
cardiovascular factors could not be ruled out.  The patient's
coumadin was d/c for 4 wks, and she was maintained on ASA and
plavix for anticthrombolytic therapy. Given the difficulty in
adequately controlling the patient's rate by medical management
only, EP was consulted. She received a single lead pacemaker and
her rate was further controlled w/ Metroprolol and Diltiazem.
She was also placed on an ACEi and a statin. .  The patient's
Hct was stabilized s/p blood transfusion, and her duodenal ulcer
was visualized on EGD and cauterized.  She was d/c home w/ in
stable condition with services.

Medications on Admission:
ASA 325, digoxin, lipitor, imdur, lisinopril, glyburide, Plavix,
Metformin, Lopressor 50 TID, coumadin, protonix

Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
Disp:*qs vials/ bottles* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*2*
8. Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 1474**] VNA

Discharge Diagnosis:
Syncopal episode secondary to anemia and cardiac arrythmias


Discharge Condition:
Good, vitals stable


Discharge Instructions:
Seek medical services immediately if you should have any chest
pain, fevers, lightheadness or any other worrisome symptom.
.
Please take your medications as prescribed and please keep all
of your appointments.

Followup Instructions:
Follow up with your PCP [**Name Initial (PRE) 176**] 1-2 weeks of discharge
.
Follow up with neurosurgery within 1-2 weeks of discharge.
.
Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 2934**]
Date/Time:[**2120-1-1**] 4:00


                             [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

Completed by:[**2120-1-9**]
{'Syncope and collapse,Subarachnoid hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration,Atrial fibrillation,Urinary tract infection, site not specified,Chronic airway obstruction, not elsewhere classified,Angiodysplasia of stomach and duodenum with hemorrhage,Acute posthemorrhagic anemia,Pulmonary collapse,Accidental fall from chair,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Esophageal reflux,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}


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: syncopal episode

PRESENT ILLNESS: Pt is 85 yr old female with Hx of AF/gastric AVMs/carotid
stenosis who fell from sitting position with +LOC. The patient
states that she was confused and thought she had been told that
there was rioting in [**Location (un) **] after the superbowl. She got up
very quickly to walk to the T.V. when she began feeling dizzy.
She felt as though she might lose consciousness, attempted to
sit down, and fell from the chair. The fall was witnessed by her
son who confirms LOC. Pt. denies any concommitant palpitations,
SOB, or CP. Patient denies the use of EtOH or any illegal
substances prior to the fall. The patient states that she has
been significantly SOB for the last 2-4 weeks, particularly in
the AM. She is unable to walk more than 15feet w/o becoming SOB.
The dyspnea usually resolves after a nebulizer Tx. She has also
been somewhat pale over the same time period. Pt. denies any
HA,F/C/N/V, changes in bowel or urinary habits, any melanotic
stools.
.
She was taken to [**Hospital3 **] & found to have SAH, & was
transferred to [**Hospital1 18**] where repeat CT scan showed left tempo
parietel SAH. Pt noted to have Hct of 22.2 and INR of 1.6 on
admission and had guaiac+ brown stool. Pt otherwise stable and
alert upon arrival to TICU.

MEDICAL HISTORY: AF with h/o embolic TIA
DM
GERD
HTN
carotid stenosis
hyperlipidemia
h/o duodenal ulcer [**2112**], stomach AVMs
hiatal hernia
mesenteric ischemia s/p small bowel resection [**12/2113**]
basal cell CA s/p excision [**5-22**]
legally blind

MEDICATION ON ADMISSION: ASA 325, digoxin, lipitor, imdur, lisinopril, glyburide, Plavix,
Metformin, Lopressor 50 TID, coumadin, protonix

ALLERGIES: Atenolol

PHYSICAL EXAM: T98.6, HR 84 (70-80s), BP 140/60, R20, O2sat 95RA
.
Gen: Thin appearing pleasant female appearing stated age, in NAD

FAMILY HISTORY: Mother died at 63 from blood clot
Father died at 70

SOCIAL HISTORY: Retired. Lives at home with her daughter. no tobacco, no EtOH x
many years.  She is no longer able to cook for herself and her
diet consists mostly of sandwiches and occassional fried foods.
She does not exercise. 

### Response:
{'Syncope and collapse,Subarachnoid hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration,Atrial fibrillation,Urinary tract infection, site not specified,Chronic airway obstruction, not elsewhere classified,Angiodysplasia of stomach and duodenum with hemorrhage,Acute posthemorrhagic anemia,Pulmonary collapse,Accidental fall from chair,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Esophageal reflux,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}
