CHIEF COMPLAINT: Hypoxia, hypotension and hypercarbia.

PRESENT ILLNESS: The patient is a 70-year-old
male with a history of chronic obstructive pulmonary disease,
status post intubation on [**2188-4-4**] and coronary artery
disease who presented to [**Hospital6 256**]
with hypoxia and hypercarbia requiring intubation, as well as
hypotension requiring pressors.  The patient presented
several times this year to the Emergency Department for
chronic obstructive pulmonary disease exacerbation, only once
requiring intubation ([**4-5**]).  The patient usually responds
well to steroids, antibiotics and bronchodilators.  At
baseline, the patient is functional and is not oxygen
dependent.

MEDICAL HISTORY: 1.  Chronic obstructive pulmonary disease - PFTs in [**7-6**]
were:  FVC equal to 85% expected, FEV1 equal to 52% expected
and FEV1/FVC equal to 60% expected.  These PFTs were improved
with bronchodilators.
2.  Coronary artery disease - ejection fraction equal to 55%
in [**2188-4-4**], 1+ mitral regurgitation, hypokinetic basal
half of the anterior septum and anterior wall on stress
echocardiogram, cardiac catheterization showed 40% occlusion
of the mid left anterior descending, 40% occlusion of the mid
circumflex, 20% occlusion of the left main with a normal
proximal left anterior descending and normal septal branches.
3.  Hypothyroidism.
4.  Depression.
5.  Question of hepatitis.

MEDICATION ON ADMISSION: 1.  Aspirin 325 mg q.d.
2.  Levoxyl 125 mcg q.d.
3.  Serevent.
4.  Albuterol/Atrovent.
5.  Flovent.
6.  Protonix 40 mg po q.d.
7.  Folate 1 mg po q.d.
8.  Paxil 20 mg po q.d.

ALLERGIES: Penicillin causes edema.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: In the chart, it is documented that the
patient smoked tobacco one pack per day times 40 years,
however, he tells me he only smoked for about 4-5 years while
in the service.  He denies alcohol use now.  There is
documented abuse in the past.  The patient is a retired
[**Location (un) **] police officer.
Obstructive chronic bronchitis with (acute) exacerbation,Congestive heart failure, unspecified,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Hypotension, unspecified
Obs chr bronc w(ac) exac,CHF NOS,Atrial fibrillation,Crnry athrscl natve vssl,Hypotension NOS
Admission Date:  [**2188-9-23**]     Discharge Date:  [**2188-9-27**]

Date of Birth:   [**2118-2-8**]     Sex:  M

Service:  [**Hospital1 **]

CHIEF COMPLAINT:  Hypoxia, hypotension and hypercarbia.

HISTORY OF PRESENT ILLNESS:  The patient is a 70-year-old
male with a history of chronic obstructive pulmonary disease,
status post intubation on [**2188-4-4**] and coronary artery
disease who presented to [**Hospital6 256**]
with hypoxia and hypercarbia requiring intubation, as well as
hypotension requiring pressors.  The patient presented
several times this year to the Emergency Department for
chronic obstructive pulmonary disease exacerbation, only once
requiring intubation ([**4-5**]).  The patient usually responds
well to steroids, antibiotics and bronchodilators.  At
baseline, the patient is functional and is not oxygen
dependent.

During his [**2188-4-4**] Medical Intensive Care Unit admission,
stress echocardiogram and cardiac catheterization were
performed to rule out ischemia as a cause of low O2
saturations.  The stress echocardiogram showed anterior
abnormalities and the cardiac catheterization showed mild to
moderate coronary artery disease with no flow limiting
lesions; normal filling pressures, left ventricular ejection
fraction equal to 55%.

On this admission, the patient states that he had had fevers
the night prior to admission and increased wheezing and
shortness of breath over the past week due to the "hot
weather."  On the night prior to admission, the patient
became very short of breath without relief from his albuterol
and Atrovent nebulizers.  The patient denies any chest pain,
hemoptysis, paroxysmal nocturnal dyspnea, orthopnea,
peripheral edema.  On the date of admission, the patient was
playing cards with friends, had an episode of nausea and
vomiting which was followed by the patient being found
outside gasping for air and asking for oxygen.  EMS arrived
on the scene and his O2 saturation was 70%.  The patient was
unable to speak, and he was diaphoretic.

In the Emergency Department, his O2 saturation was 84% on
nonrebreather with respiratory rate equal to 44.  Blood
pressure 120/palp and heart rate equal to 132.  The patient
was then intubated.  The patient then proceeded to seize
after receiving lidocaine/versed/Succinylcholine/etomidate
and resolved spontaneously.  Patient was given
albuterol/Atrovent nebulizers treatment, as well as
Solu-Medrol 125 mg intravenous times one, Fentanyl, and 750
cc of normal saline intravenously in the Emergency
Department.  His chest x-ray showed congestive heart failure.
 His electrocardiogram showed a left bundle branch block
which was intermittently seen on prior electrocardiograms
during his [**2188-4-4**] admission.  His arterial blood gases
was equal to 6.29/87/502 after intubation.  His blood
pressure dropped to 68/palp and the patient was then begun on
Levophed 4 mg/kg/minute and was transferred to the Medical
Intensive Care Unit.

Initial laboratories on admission include:  White blood cell
count 12.9, 58% neutrophils, 32% lymphocytes, 6% monocytes
and 3% eosinophils.  Hematocrit equal to 47.1, platelet count
304,000, PT equal to 14.4, PTT 31.9, INR 1.4.  Electrolytes:
Sodium was 143, potassium 4.9, chloride 103, bicarbonate 24,
BUN 15, creatinine 1.1, glucose 192. Repeat arterial blood
gas was 7.17/54/363.  All CKs were less than 200.  All CK-MBs
were less than 10 and initial troponin was less than 0.3.
Urinalysis was negative.

PAST MEDICAL HISTORY:
1.  Chronic obstructive pulmonary disease - PFTs in [**7-6**]
were:  FVC equal to 85% expected, FEV1 equal to 52% expected
and FEV1/FVC equal to 60% expected.  These PFTs were improved
with bronchodilators.
2.  Coronary artery disease - ejection fraction equal to 55%
in [**2188-4-4**], 1+ mitral regurgitation, hypokinetic basal
half of the anterior septum and anterior wall on stress
echocardiogram, cardiac catheterization showed 40% occlusion
of the mid left anterior descending, 40% occlusion of the mid
circumflex, 20% occlusion of the left main with a normal
proximal left anterior descending and normal septal branches.
3.  Hypothyroidism.
4.  Depression.
5.  Question of hepatitis.

MEDICATIONS ON ADMISSION:
1.  Aspirin 325 mg q.d.
2.  Levoxyl 125 mcg q.d.
3.  Serevent.
4.  Albuterol/Atrovent.
5.  Flovent.
6.  Protonix 40 mg po q.d.
7.  Folate 1 mg po q.d.
8.  Paxil 20 mg po q.d.

ALLERGIES:  Penicillin causes edema.

SOCIAL HISTORY:  In the chart, it is documented that the
patient smoked tobacco one pack per day times 40 years,
however, he tells me he only smoked for about 4-5 years while
in the service.  He denies alcohol use now.  There is
documented abuse in the past.  The patient is a retired
[**Location (un) **] police officer.

PHYSICAL EXAMINATION ON ADMISSION:  Temperature 97.  Heart
rate 131.  Blood pressure 118/61 (off pressors).  Oxygen
saturation was 100% on assist control with FIO2 of 60%, total
volume 600 and rate of 12.  In general, the patient is
sedated and intubated.  Head, eyes, ears, nose and throat:
Pupils are constricted bilaterally, both reactive, right
pupil approximately 1 mm, left was approximately 3 mm.
Lungs:  Severe expiratory wheezes throughout the chest
anteriorly.  Heart:  Tachycardiac with a normal S1, S2, no
murmurs, rubs or gallops.  Abdomen was soft, nontender,
nondistended, positive for hepatomegaly with the liver being
felt 3 cm below the costal margin. Extremities had poor
capillary refill.  No cyanosis, clubbing or edema.  2+
dorsalis pedis and posterior tibial pulses.  Neurological
exam:  The patient is moving all extremities spontaneously.

HOSPITAL COURSE:  The patient was admitted to the Medical
Intensive Care Unit Team to be intubated for his acute
respiratory failure, as well as the hypotension which
initially required pressors.  As per the Medical Intensive
Care Unit Teams evaluation, the patient likely experienced
acute respiratory failure in the setting of rate related
diastolic heart failure with likely demand ischemia, possibly
related to increased use of his albuterol.  The patient
rapidly responded to positive pressure ventilation and PEEP,
however, remaining tachycardiac while maintaining stable
blood pressure after being weaned from all pressors.  He was
extubated on [**9-24**] and did extremely well.  He did
require three, one liter boluses for systolic blood pressures
in the 70s.  He was found to be prerenal as per FeNA
calculation 0.11% and the patient received D5 normal saline
at 150 cc an hour for a low urine output on [**9-24**], which
is about 20 cc per hour throughout the day.  The patient's
urine output picked up to 40 cc per hour with hydration.
Follow-up chest x-ray on [**9-25**] showed clear lungs, no
effusions and no congestive heart failure.  The patient began
to have improved po intake with significantly increased urine
output.

By system:

1.  Pulmonary:  The patient is currently saturating well on
room air at 97% at rest and 93% with ambulation.  The patient
was begun on a prednisone taper at 60 mg q.d. times three, 40
mg q.d. times three, 20 mg q.d. times three and 10 mg q.d.
times three for a total of 12 days.  He received intravenous
steroids while in the Medical Intensive Care Unit and was
transitioned to prednisone when transferred to the regular
medicine floor.  The patient was begun on Singulair 10 mg po
q.d.  His MDI regimen was restarted with Serevent 2 puffs
b.i.d., Flovent 4 puffs b.i.d., Atrovent 4 puffs q.i.d. and
albuterol only 1-2 puffs q. 4 hours prn.  The patient should
not use albuterol nebulizers as he gets anginal symptoms and
tachycardic secondary to those nebulizers and likely becomes
ischemic due to demand.

2.  Cardiac:  The patient's troponin was found on [**9-25**]
to be 1.4.  This is likely related to his episode of
congestive heart failure.  The patient denies any chest pain
at this time.  The patient's hypotension improved throughout
his stay with hydration.  The patient's lipid profile looks
good, therefore, there is no need to start a statin for his
cholesterol level.  The patient continued on his aspirin.  It
was decided not to start a beta-blocker due to the patient's
significant bronchoreactivity.  Possibly consider beginning a
calcium channel blocker as an outpatient, as the patient's
blood pressure tolerates.  The patient has never been on a
cardiac regimen at all, so possibly consider Cardiology
Consult as an outpatient.

3.  Endocrine:  The patient was begun on a regular insulin
sliding scale due to the steroid taper.  His fingersticks
remained within normal limits.  This continued on [**9-26**].
The patient's TSH was found to be low at 0.15.  Free T4 and
T3 were sent and are still pending.  Albeit, in the setting
of acute illness, the patient will be discharged on slightly
lower dose of Levoxyl then he was getting previously and will
follow-up with his primary care physician regarding this
issue.  The patient will be discharged on Levoxyl 100 mcg po
q.d. as opposed to his dose he is currently taking which is
125 mcg po q.d.

4.  Psychiatric:  The patient has a history of depression and
anxiety.  The patient had been taking Paxil 20 mg po q.d.
until about a week prior to admission when he ran out of his
prescription.  The patient was restarted on Paxil during his
stay.

5.  Hematology:  The patient's hematocrit trended down from
47.1 on admission to 34.3 at time of discharge.  Rectal exam
showed guaiac negative stools.  This is likely dilutional as
the patient was hydrated aggressively due to his hypotension.
This should continue to be followed up by his primary care
provider upon discharge.

6.  Infectious Disease:  The patient was started on
levofloxacin 500 mg po q.d. for a ten day course for
treatment of the chronic obstructive pulmonary disease
exacerbation/bronchitis.  Sputum showed moderate
oropharyngeal flora, likely not a good sample.  Blood
cultures have been negative to date.

7.  Fluid, electrolytes and nutrition:  The patient is
currently on a cardiac diet as tolerated and we are
encouraging po intake.  The patient is doing well with this
at time of discharge.

CONDITION ON DISCHARGE:  Improved.  Good.

DISCHARGE STATUS:  To home without services.

DISCHARGE DIAGNOSES:
1.  Chronic obstructive pulmonary disease exacerbation with
associated hypotension/resolved.
2.  Chronic obstructive pulmonary disease.
3.  Coronary artery disease.
4.  Hypothyroidism.
5.  Depression.
6.  Question hepatitis.

MEDICATIONS ON DISCHARGE:
1.  Enteric coated aspirin 325 mg po q.d.
2.  Singulair 10 mg one tablet po q.d.
3.  Levofloxacin 500 mg po q.d. times six more days to
complete a ten day course.
4.  Prednisone taper.  Patient has completed the 60 mg times
three days, so the patient is discharged with 40 mg po q.d.
times three days, 20 mg po q.d. times three, then 10 mg po
q.d. times three.
5.  Serevent MDI 2 puffs b.i.d.
6.  Flovent 110 mcg MDI 4 puffs inhaled b.i.d.
7.  Atrovent MDI 4 puffs inhaled q.i.d.
8.  Albuterol MDI 1-2 puffs inhaled q. 4 hours prn.
9.  Paxil 20 mg po q.d.
10. Levoxyl 100 mcg po q.d.
11. Folate 1 mg po q.d.
12. Protonix 40 mg po q.d.

FOLLOW-UP:  The patient should follow-up with his primary
care provider, [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 410**], in one to two weeks.  The
patient is also seen by his pulmonary specialist, Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 217**], and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].  The patient should also
follow-up with them within the next one to two weeks for
follow-up of this hospitalization.






                          [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D.  [**MD Number(1) 1212**]

Dictated By:[**Last Name (NamePattern4) 26544**]

MEDQUIST36

D:  [**2188-10-3**]  16:25
T:  [**2188-10-3**]  16:25
JOB#:  [**Job Number 96129**]
{'Obstructive chronic bronchitis with (acute) exacerbation,Congestive heart failure, unspecified,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Hypotension, 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: Hypoxia, hypotension and hypercarbia.

PRESENT ILLNESS: The patient is a 70-year-old
male with a history of chronic obstructive pulmonary disease,
status post intubation on [**2188-4-4**] and coronary artery
disease who presented to [**Hospital6 256**]
with hypoxia and hypercarbia requiring intubation, as well as
hypotension requiring pressors.  The patient presented
several times this year to the Emergency Department for
chronic obstructive pulmonary disease exacerbation, only once
requiring intubation ([**4-5**]).  The patient usually responds
well to steroids, antibiotics and bronchodilators.  At
baseline, the patient is functional and is not oxygen
dependent.

MEDICAL HISTORY: 1.  Chronic obstructive pulmonary disease - PFTs in [**7-6**]
were:  FVC equal to 85% expected, FEV1 equal to 52% expected
and FEV1/FVC equal to 60% expected.  These PFTs were improved
with bronchodilators.
2.  Coronary artery disease - ejection fraction equal to 55%
in [**2188-4-4**], 1+ mitral regurgitation, hypokinetic basal
half of the anterior septum and anterior wall on stress
echocardiogram, cardiac catheterization showed 40% occlusion
of the mid left anterior descending, 40% occlusion of the mid
circumflex, 20% occlusion of the left main with a normal
proximal left anterior descending and normal septal branches.
3.  Hypothyroidism.
4.  Depression.
5.  Question of hepatitis.

MEDICATION ON ADMISSION: 1.  Aspirin 325 mg q.d.
2.  Levoxyl 125 mcg q.d.
3.  Serevent.
4.  Albuterol/Atrovent.
5.  Flovent.
6.  Protonix 40 mg po q.d.
7.  Folate 1 mg po q.d.
8.  Paxil 20 mg po q.d.

ALLERGIES: Penicillin causes edema.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: In the chart, it is documented that the
patient smoked tobacco one pack per day times 40 years,
however, he tells me he only smoked for about 4-5 years while
in the service.  He denies alcohol use now.  There is
documented abuse in the past.  The patient is a retired
[**Location (un) **] police officer. 

### Response:
{'Obstructive chronic bronchitis with (acute) exacerbation,Congestive heart failure, unspecified,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Hypotension, unspecified'}
