CHIEF COMPLAINT: 

PRESENT ILLNESS: A 57 year old male with a
history of chronic obstructive pulmonary disease and
pulmonary atresia on home oxygen, found unresponsive by
brother at home on [**2184-8-11**] in AM.  911 was called
and the patient was transported to the Emergency Department
of the outside hospital and then transferred here.  The
patient had reported increased shortness of breath times
several days prior to admission.  The night prior to
admission the patient reported to brother that he had some
shortness of breath but thought that he would be "okay."  The
morning of admission, the patient did not answer when brother
called, so brother went over to his house, found patient
unresponsive and called 911.  The patient was brought to the
outside hospital.

MEDICAL HISTORY: 1.  Chronic obstructive pulmonary
disease on home oxygen, 1 to 2 liters per minute, history of
multiple prior intubations; 2.  Cardiomyopathy with ejection
fraction of 20% and history of congestive heart failure; 3.
Prior inferior myocardial infarction; 4.  Status post right
lacunar cerebrovascular accident with residual left upper
extremity weakness; 5.  Atrial fibrillation; 6.  Pulmonary
artery atresia; 7.  Cholelithiasis; 8.  Legally blind,
secondary to moonshine ingestion; 9.  Peptic ulcer disease,
diagnosed in [**2181**]; 10. Idiopathic polyneuropathy.

MEDICATION ON ADMISSION: Medications as an outpatient
include - 1.  Digoxin 0.25 every day except Tuesday and
Friday when he receives 0.5; 2.  Lipitor 40 mg p.o. q.d.; 3.
Lasix 20 mg p.o. q.d.; 4.  Bisoprolol 5 mg p.o. q.d.; 5.
Coumadin; 6.  Combivent 2 puffs q.i.d.; 7.  Flovent 110 mcg 4
puffs b.i.d.; 8.  Multivitamin; 9.  Thiamine; 10.  Vitamin C;
11. Magnesium; 12. Albuterol metered dose inhaler prn.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: 75 Pack year history, quit two years ago.
Acute respiratory failure,Obstructive chronic bronchitis with (acute) exacerbation,Atrial fibrillation,Other shock without mention of trauma,Congestive heart failure, unspecified,Coronary atherosclerosis of native coronary artery,Anemia, unspecified
Acute respiratry failure,Obs chr bronc w(ac) exac,Atrial fibrillation,Shock w/o trauma NEC,CHF NOS,Crnry athrscl natve vssl,Anemia NOS
Admission Date:  [**2184-8-11**]       Discharge Date:  [**2184-8-19**]

Date of Birth:   [**2127-7-27**]       Sex:  M

Service:  MICU [**Location (un) **]

HISTORY OF PRESENT ILLNESS:  A 57 year old male with a
history of chronic obstructive pulmonary disease and
pulmonary atresia on home oxygen, found unresponsive by
brother at home on [**2184-8-11**] in AM.  911 was called
and the patient was transported to the Emergency Department
of the outside hospital and then transferred here.  The
patient had reported increased shortness of breath times
several days prior to admission.  The night prior to
admission the patient reported to brother that he had some
shortness of breath but thought that he would be "okay."  The
morning of admission, the patient did not answer when brother
called, so brother went over to his house, found patient
unresponsive and called 911.  The patient was brought to the
outside hospital.

Emergency medical services vital signs revealed blood
pressure 90/palpable, heartrate 120s, oxygen saturation 90%
on 1 to 2 liters (this was the patient's home oxygen level).
In the Emergency Department the patient was unresponsive and
so was intubated for airway protection.  The patient's blood
pressure decreased and he was started on intravenous fluids
and Dopamine drip.  Computerized tomography scan of his head
at the outside hospital was negative for an acute bleed.  The
patient had a CTA at the outside hospital which was read as
positive for segmental pulmonary embolism.

Laboratory studies at an outside hospital revealed white
blood cell count 19, INR 11.  The patient was given 2 mg of
Vitamin K in the Emergency Room, Ceftriaxone, and admitted.
The patient was then cultured and given a dose of Vancomycin
as well.  One set of cardiac enzymes were negative.  The
patient was given intravenous fluids but it is unclear the
amounts that were given.  The patient was transferred to the
[**Hospital6 256**] for further care
including evaluation for an inferior vena cava filter.

PAST MEDICAL HISTORY:  1.  Chronic obstructive pulmonary
disease on home oxygen, 1 to 2 liters per minute, history of
multiple prior intubations; 2.  Cardiomyopathy with ejection
fraction of 20% and history of congestive heart failure; 3.
Prior inferior myocardial infarction; 4.  Status post right
lacunar cerebrovascular accident with residual left upper
extremity weakness; 5.  Atrial fibrillation; 6.  Pulmonary
artery atresia; 7.  Cholelithiasis; 8.  Legally blind,
secondary to moonshine ingestion; 9.  Peptic ulcer disease,
diagnosed in [**2181**]; 10. Idiopathic polyneuropathy.

MEDICATIONS ON ADMISSION:  Medications as an outpatient
include - 1.  Digoxin 0.25 every day except Tuesday and
Friday when he receives 0.5; 2.  Lipitor 40 mg p.o. q.d.; 3.
Lasix 20 mg p.o. q.d.; 4.  Bisoprolol 5 mg p.o. q.d.; 5.
Coumadin; 6.  Combivent 2 puffs q.i.d.; 7.  Flovent 110 mcg 4
puffs b.i.d.; 8.  Multivitamin; 9.  Thiamine; 10.  Vitamin C;
11. Magnesium; 12. Albuterol metered dose inhaler prn.

ALLERGIES:  No known drug allergies.

SOCIAL HISTORY:  75 Pack year history, quit two years ago.

FAMILY HISTORY:  Non-contributory.

PHYSICAL EXAMINATION:  Vital signs revealed pulse 102, blood
pressure 98/64, respiratory 24 on assist control.  General:
Middle-aged male intubated and sedated, not following
commands.  Head, eyes, ears, nose and throat:  Pinpoint
pupils, oral mucosa moist without lesions, elevated
jugulovenous distension.  Cardiac:  Irregularly irregular,
normal S1 and S2, no murmurs, rubs or gallops.  Pulmonary:
Diffuse expiratory wheezes and squeaks with a prolonged
inspiratory to expiratory ratio, no crackles or rhonchi
appreciated.  Abdomen, soft with normoactive bowel sounds.
Nontender, nondistended.  Extremities, no cyanosis, clubbing
or edema, 1+ dorsalis pedis bilaterally.  Skin:  No skin
breakdown or rash noted.  Neurological:  Patient intubated
and sedated, responds to pain.

LABORATORY DATA:  Laboratory studies on admission revealed
white blood cell count 23.3, polys 93, bands 0, lymphs 5,
monos 2.  Hematocrit 36.5, platelets 264, sodium 142,
potassium 4.0, chloride 104, bicarbonate 30, BUN 35,
creatinine 1.0, anion gap 8.  Glucose 154, phosphorus 1.5,
magnesium 1.8, calcium 8.8, INR 2.9, PTT 39.2.  Urinalysis,
large blood, trace ketones, 12 to 50 red blood cells, no
white blood cells or bacteria.

Chest x-ray:  Hyperinflated lungs, bilateral upper lobe
opacities, flat diaphragm.  Electrocardiogram:  Atrial
flutter with variable block, normal axis and intervals.
Right R wave progression.  No ischemic changes.

HOSPITAL COURSE:  1.  Pulmonary - The patient was transferred
from an outside hospital for evaluation for inferior vena
cava filter placement for suspected pulmonary embolism in the
setting of Coumadin taken for atrial flutter.  The patient
initially started on therapeutic Lovenox and Coumadin was
held for supratherapeutic INR.  Repeat CTA showed no evidence
of pulmonary embolism.  It also showed pulmonary atresia
involving the left upper lobe and diffuse emphysematous
changes.  Given these results of the CTA, Lovenox was
discontinued.  The patient initially remained on assist
control ventilation.  This was changed to pressor support
which was gradually weaned and the patient was extubated on
[**2184-8-16**].  Following extubation, the patient was
placed on a Venturi mask with goal SPO2 of 88 to 93.  The
patient required q 2 hour nebulizer treatments.  The patient
was also continued on intravenous Solu-Medrol for suspected
chronic obstructive pulmonary disease exacerbation.  At the
time of discharge the patient was receiving 80 mg
intravenously q.d.  As the congestive heart failure may be a
component in the patient's respiratory failure, the patient's
Lasix was restarted and gentle diuresis was performed.

2.  Shock - Shock was felt likely due secondary to sepsis.
However, there was a cardiogenic component.  The patient
received urine cultures, blood cultures and sputum cultures
on admission and was started on broad spectrum antibiotics,
Vancomycin and Zosyn. Sputum cultures from [**2184-8-15**]
grew gram negative rods.  Those from the [**2184-8-12**]
grew rare oropharyngeal Flora.  The patient also had stool
sent for Clostridium difficile which was negative.  Blood
cultures from [**2184-8-11**] were negative and those from
[**2184-8-15**] pending at the time of discharge.  Urine
culture from [**2184-8-15**] were negative for growth.
Vancomycin and Zosyn were continued for a total of a seven
day course at which time they were discontinued as the
patient's white blood cell count began to normalize and the
patient remained afebrile.  The patient was titrated off of
Dopamine and Levophed was started.  Vasopressin was added as
needed.  In order to achieve increased inotrope a trial of
Dobutamine was begun, however, the patient did not tolerate
this with elevated heartrate in the 150s to 160s.  The
patient was started again on Levophed and Vasopressin which
were gradually weaned off to discontinue on [**2184-8-14**].  Following weaning of the pressors, the patient's blood
pressure remained stable.

3.  Cardiovascular - Given the patient's history of
cardiomyopathy with prior inferior myocardial infarction, the
patient had cardiac enzymes cycled.  Although creatinine
kinases were elevated to a peak of 471, troponins were less
than .01.  Elevated creatinine kinase was felt secondary to
muscle breakdown as the patient was found down.  The patient
had an echocardiogram on [**2184-8-12**] which showed an
ejection fraction of 10 to 15% with a dilated left atrium,
right atrium and left ventricle.  There was mild global right
ventricular free wall hypokinesis with 1+ mitral
regurgitation, 2+ tricuspid regurgitation and mild pulmonary
artery systolic hypertension.  The patient was noted to have
atrial fibrillation or atrial flutter throughout the hospital
stay.  The patient had several episodes of ventricular
response.  He was stated on a Nitroglycerin drip on the
evening of [**2184-8-16**] which was slowly weaned.  The
patient's outpatient Bisoprolol was restarted and the patient
was recycled for enzymes, all of which were negative.  The
patient was restarted on Digoxin and Lipitor at home doses
and restarted on standing Lasix with good urine output.  The
patient was also started on Captopril which was titrated up
to 25 mg p.o. b.i.d. for afterload reduction.  The patient's
Nitroglycerin drip was discontinued [**2184-8-17**].

4.  Hematology - The patient's Coumadin was held following
admission and initially the patient received therapeutic
doses of Lovenox for suspected pulmonary embolism.  When CTA
was negative for pulmonary embolism, the patient was changed
to Lovenox at deep vein thrombosis prophylactic doses.  The
patient's hematocrit drifted down over the course of the
Intensive Care Unit stay, although it eventually stabilized
at 30.  The patient had a small degree of hematuria likely
secondary to Foley catheter trauma, there were no other clear
sources of bleeding.  The patient will receive the first dose
of Coumadin on the day of discharge.  INR levels will need to
be monitored and the Coumadin doses adjusted as needed for  a
goal INR of 2 to 3.  The patient will also require periodic
hematocrit checks to ensure that it is not further drifting
down.  The patient was guaiac negative.

DISCHARGE STATUS:  To be discharged to acute rehabilitation
facility.

CONDITION ON DISCHARGE:  Fair, continuing blood loss is not
occurring.

DISCHARGE MEDICATIONS:
Captopril 25 mg p.o. t.i.d.
Bisoprolol 5 mg p.o. q.d.
Aspirin 325 mg p.o. q.d.
Atrovent nebulizer q. 4 hours with q. 2 hour prn
Albuterol nebulizers q. 4 hours with q. 2 hour prn
Coumadin 5 mg p.o. q.d.
Solu-Medrol 80 mg intravenously q.d. with plan for a slow
taper as an outpatient decreasing by 10 mg q.d. every four to
five days
Regular insulin sliding scale
Acetaminophen 325 to 650 mg p.o. q. 4-6 hours prn
Ativan 2 mg intravenously q. 4 hours prn
Flovent 110 mcg 4 puffs inhaled b.i.d.
Atorvastatin 40 mg p.o. q.h.s.
Digoxin 0.25 mg p.o. q.d.
Famotidine 20 mg intravenously q. 12 hours

FOLLOW UP:  The patient is to follow up with primary care
physician within one week of discharge from acute
rehabilitation facility.

DISCHARGE DIAGNOSIS:
1.  Chronic obstructive pulmonary disease exacerbation
2.  Pulmonary artery atresia
3.  Congestive heart failure
4.  Septic shock
5.  Atrial flutter/atrial fibrillation
6.  Blindness
7.  Peptic ulcer disease
8.  Coronary artery disease



                            [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D.  [**MD Number(1) 7585**]

Dictated By:[**Last Name (NamePattern1) 6008**]
MEDQUIST36

D:  [**2184-8-18**]  17:07
T:  [**2184-8-18**]  19:08
JOB#:  [**Job Number 51397**]
{'Acute respiratory failure,Obstructive chronic bronchitis with (acute) exacerbation,Atrial fibrillation,Other shock without mention of trauma,Congestive heart failure, unspecified,Coronary atherosclerosis of native coronary artery,Anemia, unspecified'}


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: 

PRESENT ILLNESS: A 57 year old male with a
history of chronic obstructive pulmonary disease and
pulmonary atresia on home oxygen, found unresponsive by
brother at home on [**2184-8-11**] in AM.  911 was called
and the patient was transported to the Emergency Department
of the outside hospital and then transferred here.  The
patient had reported increased shortness of breath times
several days prior to admission.  The night prior to
admission the patient reported to brother that he had some
shortness of breath but thought that he would be "okay."  The
morning of admission, the patient did not answer when brother
called, so brother went over to his house, found patient
unresponsive and called 911.  The patient was brought to the
outside hospital.

MEDICAL HISTORY: 1.  Chronic obstructive pulmonary
disease on home oxygen, 1 to 2 liters per minute, history of
multiple prior intubations; 2.  Cardiomyopathy with ejection
fraction of 20% and history of congestive heart failure; 3.
Prior inferior myocardial infarction; 4.  Status post right
lacunar cerebrovascular accident with residual left upper
extremity weakness; 5.  Atrial fibrillation; 6.  Pulmonary
artery atresia; 7.  Cholelithiasis; 8.  Legally blind,
secondary to moonshine ingestion; 9.  Peptic ulcer disease,
diagnosed in [**2181**]; 10. Idiopathic polyneuropathy.

MEDICATION ON ADMISSION: Medications as an outpatient
include - 1.  Digoxin 0.25 every day except Tuesday and
Friday when he receives 0.5; 2.  Lipitor 40 mg p.o. q.d.; 3.
Lasix 20 mg p.o. q.d.; 4.  Bisoprolol 5 mg p.o. q.d.; 5.
Coumadin; 6.  Combivent 2 puffs q.i.d.; 7.  Flovent 110 mcg 4
puffs b.i.d.; 8.  Multivitamin; 9.  Thiamine; 10.  Vitamin C;
11. Magnesium; 12. Albuterol metered dose inhaler prn.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: 75 Pack year history, quit two years ago. 

### Response:
{'Acute respiratory failure,Obstructive chronic bronchitis with (acute) exacerbation,Atrial fibrillation,Other shock without mention of trauma,Congestive heart failure, unspecified,Coronary atherosclerosis of native coronary artery,Anemia, unspecified'}
