CHIEF COMPLAINT: 

PRESENT ILLNESS: 

MEDICAL HISTORY: 1. Congestive heart failure secondary to diastolic
dysfunction with ejection fraction greater than 60%, mild
left ventricular hypertrophy, 1+ mitral regurgitation, and 1+
aortic regurgitation.
2. Hypertension.
3. Peripheral vascular disease, status post right
femoral-popliteal bypass graft in [**2146-4-17**].
4. Hemorrhagic cerebrovascular accident in [**2137**] with
right-sided weakness and dysarthria.
5. Benign prostatic hypertrophy, status post TURP.
6. Osteoarthritis of the hip.
7. Recurrent pneumonia.
8. Tonsillectomy.
9. Right inguinal hernia repair.
10.Remote peptic ulcer disease.

MEDICATION ON ADMISSION: 

ALLERGIES: 1. Sulfa medications.
2. Ether.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient is a resident of [**Hospital3 1761**] for 8 years, since his hemorrhagic CVA.  He
quit tobacco 40 years ago.  He denies alcohol or drug use.
His healthcare proxy is his son, [**Name (NI) **], who lives close
by. The patient does not ambulate at baseline and is in a
wheelchair.  He is very active at [**Hospital3 **], and
is the head of the men's club, and is an activist for many of
the residents there.
Unspecified septicemia,Septic shock,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Methicillin susceptible pneumonia due to Staphylococcus aureus,Congestive heart failure, unspecified,Acidosis,Ulcer of heel and midfoot
Septicemia NOS,Septic shock,Food/vomit pneumonitis,Acute respiratry failure,Meth sus pneum d/t Staph,CHF NOS,Acidosis,Ulcer of heel & midfoot
Admission Date:  [**2146-12-5**]     Discharge Date:  [**2146-12-14**]


Service:  [**Hospital Unit Name 153**]

REPORT COVERS ICU COURSE FROM [**0-0-**]:  This is
a [**Age over 90 **]-year-old male, a resident of [**Hospital 100**] Rehab, who came to
the Emergency Room with chief complaint of nausea, vomiting,
shortness of breath and fever.  He was found to be hypoxic,
hypotensive and febrile by EMS with blood pressure of
80/palp, heart rate 130, respiratory rate 40, O2 sat 79% on 5
liters.  He has a history of chronic diarrhea, with a recent
admission in [**2146-9-17**], in which he was found to have
acute proctitis by EGD and colonoscopy, and was currently
scheduled to have a repeat sigmoidoscopy for recurrence of
this diarrhea.  On the day of admission, the patient vomited
and acutely became hypoxic and dyspneic after this.  At
baseline, he has no dementia and has clear mental status.  He
does have right-sided weakness and some dysarthria at
baseline.

Upon arrival to the ED, sepsis code was called, and the
patient received ceftriaxone, vancomycin, and a sepsis line,
as well as 4 liters of normal saline, and was started on
Levophed for his pressors.

PAST MEDICAL HISTORY:
1. Congestive heart failure secondary to diastolic
dysfunction with ejection fraction greater than 60%, mild
left ventricular hypertrophy, 1+ mitral regurgitation, and 1+
aortic regurgitation.
2. Hypertension.
3. Peripheral vascular disease, status post right
femoral-popliteal bypass graft in [**2146-4-17**].
4. Hemorrhagic cerebrovascular accident in [**2137**] with
right-sided weakness and dysarthria.
5. Benign prostatic hypertrophy, status post TURP.
6. Osteoarthritis of the hip.
7. Recurrent pneumonia.
8. Tonsillectomy.
9. Right inguinal hernia repair.
10.Remote peptic ulcer disease.

MEDICATIONS UPON ADMISSION:
1. Tylenol 650 mg q 4 h.
2. Norvasc 5 mg po qd.
3. Aspirin 81 mg po qd.
4. Enalapril 5 mg po bid.
5. Lasix 20 mg q Monday, Wednesday and Friday.
6. Lansoprazole 30 mg po qd.
7. Lopressor 12.5 mg [**Hospital1 **].
8. Multivitamin.
9. Oxybutynin 5 mg po tid.
10.Ambien 5 mg po q hs.
11.Nystatin swish and swallow.
12.Flagyl 500 mg po tid, scheduled to stop on [**2146-12-9**].

ALLERGIES:
1. Sulfa medications.
2. Ether.

SOCIAL HISTORY:  The patient is a resident of [**Hospital3 1761**] for 8 years, since his hemorrhagic CVA.  He
quit tobacco 40 years ago.  He denies alcohol or drug use.
His healthcare proxy is his son, [**Name (NI) **], who lives close
by. The patient does not ambulate at baseline and is in a
wheelchair.  He is very active at [**Hospital3 **], and
is the head of the men's club, and is an activist for many of
the residents there.

EXAM ON ADMISSION:  Temperature 101.8, pulse 100, blood
pressure 80/50, respirations 30, 93% saturation on nasal
cannula.  In general, he was an elderly male, ill-appearing,
dry mucous membranes, flat neck veins.  Lungs had bronchial
breath sounds over the left base anteriorly.  Heart was
tachycardic, regular, without murmurs.  Abdomen soft,
nontender, nondistended, with normoactive bowel sounds.
Extremities - no edema.  The patient was awake, moaning,
moving hands and feet to command.  Reflexes - trace at the
ankles, 1+ brachial.  Skin had no rashes.  A small foot
ulcer, dressed, over the ball of the right foot.  There was a
right scar from previous vascular surgery on his right leg.

LABS ON ADMISSION:  White blood count 27.4, hematocrit 36.4,
platelets 404, sodium 143, potassium 2.6, chloride 114,
bicarbonate 11, BUN 54, creatinine 2.4, glucose 175, anion
gap 18, change in his anion gap/change in his bicarbonate
equals less than 0.5, calcium 9.4, magnesium 1.6, phosphorus
1.7, ALT 9, AST 13, alk phos 95, total bilirubin 0.7, albumin
3.4, LDH 130, total protein 5.5, amylase 94, lipase 48, CK
20, troponin 0.05, PT 14.5, PTT 28, INR 1.4.  ABG initially
on room air 7.26/26/64/12, lactate 5.4.  Chest x-ray on
admission shows a left lower lobe infiltrate and a right IJ
central line in good position.  Urinalysis - specific gravity
1.021, small blood, [**1-20**] white cells, [**10-7**] red cells, 0
bacteria, positive hyaline casts.  EKG - sinus rhythm, 96,
normal axis, normal intervals, 0.[**Street Address(2) 1755**] depressions V1
through V3.

PERTINENT STUDIES THIS ADMISSION:  [**2146-12-5**], the patient
had a portable KUB to assess for ?bowel obstruction, and it
did show a possibility of early partial small bowel
obstruction, and recommended follow-up.  Follow-up study done
on [**2146-12-7**] showed no evidence for intestinal obstruction.
CT of the head without contrast done [**2146-12-9**]--this was
done for a history of prior CVA with now change in mental
status.  It showed no acute intracranial hemorrhage, and
tissue loss noted in the left thalamus consistent with his
old known hemorrhagic stroke.
Ultrasound of his right upper extremity done [**2146-12-12**] for
edematous right arm showed nonocclusive clot within the right
IJ and one of his two brachial veins thrombosed.

HOSPITAL COURSE FROM [**0-0-0**]:  This is a
[**Age over 90 **]-year-old male, with a history of chronic diarrhea, past
hemorrhagic CVA, who was admitted to the [**Hospital Ward Name 12573**] Intensive
Care Unit with an aspiration pneumonia after vomiting, and
subsequent development of sepsis and respiratory failure.
Postextubation, it was noted that the patient had new left
leg weakness and left facial droop with new dysarthria.

1) SEPTIC SHOCK:  This was likely secondary to a SIRS
reaction, status post severe aspiration pneumonia and
pneumonitis.  The patient was admitted on the MUST sepsis
protocol.  During his first hospital day, he was hypotensive
and required both Levophed and vasopressin to keep his mean
arterial pressure greater than 65, his lactic acidosis peaked
with a lactate level of 6.0, and he was placed on a
bicarbonate drip in the setting of both nongap and anion gap
acidosis.  He also required an insulin drip.  His cortisol
stimulation test was negative with a baseline cortisol of 100
in the setting of his sepsis which is an appropriate
response.  His aspiration pneumonia was treated with a 9-day
course of ceftazidime, vancomycin and Flagyl to cover
nosocomial aspiration.  The vancomycin was switched to
oxacillin after sensitivities came back on a Staph aureus
that grew out of his sputum that showed it to be sensitive to
oxacillin.

The patient improved rapidly after his early intervention in
sepsis therapy and was weaned off vasopressors by hospital
day #2.  He completed the remainder of his antibiotic course
and did not have any further temperature spikes for the
remainder of his ICU course.

2) RESPIRATORY FAILURE:  The patient required intubation for
respiratory distress in the setting of acute aspiration
pneumonia and pneumonitis, as well as increased respiratory
drive from two metabolic acidosis processes.  He was able to
be quickly weaned off his ventilator, as his sepsis also
rapidly improved.  He was extubated on [**2146-12-8**] after some
diuresis to remove volume that had been given during his
acute sepsis.  He remained extubated and has gradually had
improving pulmonary toilet over the past few days.  The
patient is currently on a scoop mask with 12 liters of flow
and has had stable O2 sats of 95% or greater since then.

3) NEUROLOGIC:  After extubation, it became apparent that Mr.
[**Known lastname 12574**] had a new left-sided facial droop, dysarthria,
dysphagia, and left leg weakness.  A head CT done to rule out
any acute bleed was negative and showed only has old known
hemorrhagic infarct, as well as multiple lacunar events.  His
neurologic deficits have been gradually improving over the
past few days, and currently his dysarthria is much improved.
He has 3/5 strength to the muscles in his left leg, and has
4/5 strength to muscles in his left arm, and his facial droop
is also improved.  He currently is requiring NG tube for
feeding, as he has failed his speech and swallow evaluation.
The plan will be to reevaluate him on Monday, [**12-19**], to
see if his swallowing has improved with his improved
dysarthria.  He will be continued on an aspirin a day for
stroke prophylaxis.  It is likely that this stroke occurred
in the setting of low-flow during his hypotensive episodes.

4) GI BLEEDING:  Upon admission, the patient had guaiac
positive NG output and stool, although there was no gross
blood, melena or coffee grounds from this output.  He did
have a total of 3 units of packed RBCs during his
hospitalization with a hematocrit drop from 34 down to 26,
and 3 units of blood required to get him above 30.  He was
initially started on Protonix and sucralfate for presumed
stress gastritis.  After this intervention, he had no further
signs of GI bleeding, and his hematocrit has remained stable
since [**2146-12-7**].  He was then changed to lansoprazole
therapy only.

5) CHRONIC DIARRHEA:  The patient did not have diarrhea while
NPO, and his diarrhea restarted in the setting of his tube
feeds.  He had no further nausea or vomiting on admission.
Cultures of his stool were negative.  C. difficile x 3 was
negative.  Stool Osm gap was also nondiagnostic.  He was seen
by his outpatient gastroenterologist, Dr. [**Last Name (STitle) 12575**], during this
hospitalization who feels that he will perform a flexible
sigmoidoscopy when his respiratory status is improved.  We
will currently continue Pepto-Bismol for symptomatic relief.
Current output is about 200 cc/D of stool.

6) METABOLIC ACIDOSIS:  The patient had both a lactic
acidosis and a nonanion gap acidosis on admission.  His
lactic acidosis was from his sepsis, and his nonanion gap
acidosis was likely from chronic diarrhea.  These both
improved with hydration and the bicarb drip, and are not
currently an issue.

7) ACUTE RENAL FAILURE:  This occurred also in the setting of
sepsis and hypotension.  This has resolved to the patient's
baseline creatinine after IV hydration, as well.

8) NON-ST ELEVATION MI:  The patient ruled in after admission
with a peak troponin of 0.2.  His CKs and MBs were never
positive.  This was likely a demand ischemia event in the
setting of sepsis.  He had his aspirin restarted and was kept
on beta blocker when his blood pressure tolerated this.  He
has had no signs of GI bleeding on the aspirin at this time.

9) RIGHT ARM VENOUS CLOT:  This occurred in the setting of a
right IJ central line.  The central line was pulled, and the
patient is now on Lovenox and Coumadin.  The plan is to
anticoagulate for 1 month in the setting of known intravenous
precipitant for the clot.  Edema of the right arm is now
resolved.

10) ENDOCRINE:  The patient has no known history of diabetes,
but has had increased blood sugars this entire
hospitalization, even after the sepsis has resolved.  He was
initially on insulin drip, and has now been converted to
insulin sliding scale.  He will likely need to be converted
to oral insulin therapy upon discharge.

11) FLUIDS, ELECTROLYTES AND NUTRITION:  The patient has been
maintained on Criticare tube feeds as a low-residue,
low-osmolar formula to help decrease his diarrhea.  His
volume status is currently still volume overloaded, and he is
being actively diuresed with lasix 40 mg IV bid.  His volume
status should be assessed daily for adjustment of this and
conversion to PO lasix.  Replete potassium to be greater than
4, and magnesium to be greater than 2.

12) ACCESS:  The patient has poor IV access after his right
IJ was discontinued.  He had a left midline PICC placed by IV
therapy on [**2146-12-14**] for purposes of blood draws, intravenous
lasix, and labs.

13) HYPERTENSION:  This is well-controlled on current
Lopressor, ACE inhibitor and Norvasc doses.

14) PROPHYLAXIS:  The patient is on lansoprazole for GI
prophylaxis and Risperdal 0.5 mg q hs for sleeping
medication.  Communication daily with son, [**Name (NI) **], and his
wife.

DISPOSITION:  The patient will be discharged to the medicine
team on the floor today to the geriatric service.  He is
currently also being screened for rehab versus return to
[**Hospital 100**] Rehab after improvement in his pulmonary toilets on
the floor.

DNR STATUS:  The patient is Do Not Resuscitate, but he would
like to be intubated in the event of respiratory
failure.

DISCHARGE DIAGNOSES:
1. Aspiration pneumonia.
2. Septic shock.
3. Respiratory failure.
4. Stroke.
5. Venous thrombosis.
6. Chronic diarrhea.
7. Congestive heart failure.
8. Non-ST elevation myocardial infarction.
9. Hypertension.
10.Diabetes mellitus.
11.Gastritis and gastrointestinal bleeding.
12.Acute renal failure.

DISCHARGE CONDITION:  Good.  The patient has better
management of his secretions, as his dysarthria is improving.

TRANSFER MEDICATIONS FROM ICU TO MEDICINE [**Hospital1 **] AS OF
[**2146-12-14**]:
1. Coumadin 5 mg po q hs.
2. Lasix 40 mg IV bid.
3. Bismuth salicylate 15 ml po tid.
4. Risperdal oral solution 0.5 mg po q hs.
5. Lovenox 80 mg subcutaneously q 12 h.
6. Aspirin 81 mg po qd.
7. Nystatin ointment qid prn.
8. Enalapril 5 mg po bid.
9. Amlodipine 5 mg po qd.
10.Miconazole powder.
11.Lansoprazole oral suspension 30 mg NG qd.
12.Insulin subcutaneously, sliding scale.
13.Metoprolol 25 mg po bid.
14.Zinc sulfate 220 mg po qd.
15.Vitamin C 500 mg po bid.
16.Zofran 4 mg IV q 6 prn.
17.Tylenol 325-650 mg po PR q 6 prn.
18.Ativan 0.5-1 mg po q 4 prn.

The patient is currently NPO and all medications are given
via his NG tube which is postpyloric at this time.  The
remainder of the [**Hospital 228**] hospital course will be dictated
by the floor team, as well as final disposition plan.



                         DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]   12-ADV


Dictated By:[**Last Name (NamePattern1) 12576**]

MEDQUIST36

D:  [**2146-12-14**]  13:42
T:  [**2146-12-14**]  13:53
JOB#:  [**Job Number 12577**]
{'Unspecified septicemia,Septic shock,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Methicillin susceptible pneumonia due to Staphylococcus aureus,Congestive heart failure, unspecified,Acidosis,Ulcer of heel and midfoot'}


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: 

MEDICAL HISTORY: 1. Congestive heart failure secondary to diastolic
dysfunction with ejection fraction greater than 60%, mild
left ventricular hypertrophy, 1+ mitral regurgitation, and 1+
aortic regurgitation.
2. Hypertension.
3. Peripheral vascular disease, status post right
femoral-popliteal bypass graft in [**2146-4-17**].
4. Hemorrhagic cerebrovascular accident in [**2137**] with
right-sided weakness and dysarthria.
5. Benign prostatic hypertrophy, status post TURP.
6. Osteoarthritis of the hip.
7. Recurrent pneumonia.
8. Tonsillectomy.
9. Right inguinal hernia repair.
10.Remote peptic ulcer disease.

MEDICATION ON ADMISSION: 

ALLERGIES: 1. Sulfa medications.
2. Ether.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient is a resident of [**Hospital3 1761**] for 8 years, since his hemorrhagic CVA.  He
quit tobacco 40 years ago.  He denies alcohol or drug use.
His healthcare proxy is his son, [**Name (NI) **], who lives close
by. The patient does not ambulate at baseline and is in a
wheelchair.  He is very active at [**Hospital3 **], and
is the head of the men's club, and is an activist for many of
the residents there. 

### Response:
{'Unspecified septicemia,Septic shock,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Methicillin susceptible pneumonia due to Staphylococcus aureus,Congestive heart failure, unspecified,Acidosis,Ulcer of heel and midfoot'}
