CHIEF COMPLAINT: 

PRESENT ILLNESS: Mr. [**Known firstname **] [**Known lastname **] is a
[**Age over 90 **]-year-old gentleman with a history of recent
cholecystostomy tube for cholecystitis, chronic obstructive
pulmonary disease, and panhypopituitarism who presented from
nursing home after being found to be short of breath this
morning with oxygen saturations of 77% on 2 liters.

MEDICAL HISTORY: 1.  Panhypopituitarism; status post pituitary adenoma
resection.
 2.  Paroxysmal atrial fibrillation.
 3.  Chronic obstructive pulmonary disease.
 4.  Cor pulmonale.
 5.  Obstructive sleep apnea.
 6.  Chronic renal insufficiency (with a baseline creatinine
of 1.2 to 1.5).
 7.  Hypertension.
 8.  Dual-mode, dual-pacing, dual-sensing pacemaker for
symptomatic bradycardia.
 9.  Benign prostatic hypertrophy.
10.  Peptic ulcer disease.
11.  Gastroesophageal reflux disease.
12.  History of cholecystitis in [**2166-4-27**]; status post
cholecystostomy tube placement which was removed in [**2166-4-27**].

MEDICATION ON ADMISSION: 1.  Hydrocortisone 60 mg by mouth once per day.
2.  Terazosin 5 mg by mouth once per day.
3.  Albuterol.
4.  Protonix 40 mg by mouth once per day.
5.  Synthroid 50 mcg once per day.
6.  Amiodarone 200 mg by mouth once per day.
7.  Insulin sliding-scale.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Streptococcal septicemia,Acute and chronic cholecystitis,Other pulmonary insufficiency, not elsewhere classified,Panhypopituitarism,Hyperosmolality and/or hypernatremia,Atrial fibrillation,Acute kidney failure, unspecified,Chronic obstructive asthma, unspecified
Streptococcal septicemia,Acte & chr cholecystitis,Other pulmonary insuff,Panhypopituitarism,Hyperosmolality,Atrial fibrillation,Acute kidney failure NOS,Chronic obst asthma NOS
Admission Date:  [**2166-8-25**]       Discharge Date:  [**2166-9-9**]


Service:

HISTORY OF PRESENT ILLNESS:   Mr. [**Known firstname **] [**Known lastname **] is a
[**Age over 90 **]-year-old gentleman with a history of recent
cholecystostomy tube for cholecystitis, chronic obstructive
pulmonary disease, and panhypopituitarism who presented from
nursing home after being found to be short of breath this
morning with oxygen saturations of 77% on 2 liters.

The patient was somnolent, tachypneic, and tachycardic on
arrival by Emergency Medical Service.  Emergency medical
technician was unable to obtain a blood pressure.

On arrival to the Emergency Department, the patient was
responsive only to noxious stimuli and was in respiratory
distress.  On arrival, his temperature was 100.8 degrees
Fahrenheit, his blood pressure was 60/20, and his heart rate
was 118.  The patient was started on dopamine and given
antibiotics of ceftriaxone and Flagyl as well as intravenous
fluids with an improvement in his blood pressure.  With
improved mental status, the patient reported increased
diffuse abdominal pain for two weeks associated with a poor
appetite.  He reported a precipitous increase in abdominal
pain on the day prior to admission.

PAST MEDICAL HISTORY:
 1.  Panhypopituitarism; status post pituitary adenoma
resection.
 2.  Paroxysmal atrial fibrillation.
 3.  Chronic obstructive pulmonary disease.
 4.  Cor pulmonale.
 5.  Obstructive sleep apnea.
 6.  Chronic renal insufficiency (with a baseline creatinine
of 1.2 to 1.5).
 7.  Hypertension.
 8.  Dual-mode, dual-pacing, dual-sensing pacemaker for
symptomatic bradycardia.
 9.  Benign prostatic hypertrophy.
10.  Peptic ulcer disease.
11.  Gastroesophageal reflux disease.
12.  History of cholecystitis in [**2166-4-27**]; status post
cholecystostomy tube placement which was removed in [**2166-4-27**].

ALLERGIES:  No known drug allergies.

MEDICATIONS ON ADMISSION:
1.  Hydrocortisone 60 mg by mouth once per day.
2.  Terazosin 5 mg by mouth once per day.
3.  Albuterol.
4.  Protonix 40 mg by mouth once per day.
5.  Synthroid 50 mcg once per day.
6.  Amiodarone 200 mg by mouth once per day.
7.  Insulin sliding-scale.

PHYSICAL EXAMINATION ON PRESENTATION:  Physical examination
revealed vital signs with a temperature of 100.5 degrees
Fahrenheit, his blood pressure was 105/17, his heart rate was
70 (paced), and his oxygen saturation was 100% on 2 liters.
In general, alert and oriented times three.  An ill-appearing
gentleman who was conversant and mildly tachypneic.  Head,
eyes, ears, nose, and throat examination revealed pupils were
equal, round, and reactive to light.  The mucous membranes
were dry.  Neck examination revealed jugular venous pulsation
was flat.  Cardiovascular examination revealed a regular
rate.  No murmurs, rubs, or gallops.  Respiratory examination
revealed the lungs were clear to auscultation bilaterally.
The abdomen was distended with diffuse tenderness to
palpation especially in the right upper quadrant without
rebound.  Positive guarding.  A small right upper quadrant
scar.  Extremity examination revealed the extremities were
cool.  Radial pulses were 1+.  Neurologic examination
revealed the patient alert and oriented times three.  The
patient  moved all extremities.

PERTINENT LABORATORY VALUES ON PRESENTATION:   Laboratories
revealed his white blood cell count was 19.4, his hematocrit
was 39.8, and his platelets were 239.  The differential
revealed neutrophils of 77%, lymphocytes of 18, and monocytes
of 5%.  Sodium was 144, potassium was 3.4, chloride was 107,
bicarbonate was 23, blood urea nitrogen was 29, creatinine
was 2.9, and his blood glucose was 95.  His amylase was 14,
his lipase was 9, ALT was 17, AST was 17, alkaline
phosphatase was 60, and his total bilirubin was 2.1.
Creatine kinase was 23.  Lactate was 4.4.  Urinalysis
revealed small blood, small leukocyte esterase, 0 to 2 red
blood cells, 6 to 10 white blood cells, and a few calcium
oxalate crystals.  Arterial blood gas was 7.38/34/98.

PERTINENT RADIOLOGY/IMAGING:  Abdominal ultrasound revealed a
markedly distended and edematous gallbladder consistent with
cholecystitis and adjacent areas of low attenuation in the
liver which were suspicious for extension of abscess of the
liver.

A chest x-ray revealed bilateral atelectasis.  No evidence of
congestive heart failure.  No acute infiltrate.

CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:

 1.  BILIARY SEPSIS ISSUES:  The patient was initially on
dopamine for pressure support which was changed to
norepinephrine with improvement of his blood pressures.

The patient had a percutaneous cholecystostomy tube placed by
Interventional Radiology.  Surgery was consulted.  Biliary
cultures grew methicillin-resistant Staphylococcus aureus and
enterococcus faecalis.  Blood cultures grew enterococcus
faecalis.  The patient was initially started on ceftriaxone
and Flagyl which were changed to vancomycin and Zosyn.  Once
blood cultures were obtained, Zosyn was discontinued.  The
patient was aggressively volume resuscitated with
approximately 15 liters of intravenous fluids.  His
norepinephrine was eventually weaned.  The patient was also
treated with stress-dose steroids.

The patient did well and was eventually called back to the
floor.  He was discharged to rehabilitation with his
cholecystostomy tube in place with plans for a possible
cholecystectomy in the future.

 2.  RESPIRATORY ISSUES:  The patient was in respiratory
distress upon admission, requiring noninvasive positive
pressure support.  This was felt to be multifactorial in
nature; although volume overload secondary to aggressive
intravenous fluids was felt to have played a significant
role.

A Renal Service consultation was obtained.  They recommended
continued aggressive diuresis with Lasix with metolazone and
Diuril as needed.  The patient slowly diuresed over his
hospitalization and was eventually doing well on room air
with no complaints.

An echocardiogram was requested prior to discharge and was
pending at the time of this dictation.  This may need to be
done as an outpatient for evaluation of the patient's
systolic function, and the possibility for an ACE inhibitor,
and congestive heart failure treatment as needed.  The
patient was felt to be euvolemic to slightly dry at the time
of discharge, so diuresis was discontinued.

 3.  CHRONIC OBSTRUCTIVE PULMONARY DISEASE ISSUES:  The
patient was continued on his home nebulizers and inhalers.

 4.  MENTAL STATUS CHANGE ISSUES:  This was felt secondary to
acute illness and resolved over his hospitalization.

 5.  PAROXYSMAL ATRIAL FIBRILLATION ISSUES:  The patient was
on no anticoagulation.  At the time of admission, his
amiodarone was secondary to hypotension.  This was restarted
on the day of discharge at a maintenance dose.

 6.  HYPONATREMIA ISSUES:  The patient was hyponatremic
throughout his Medical Intensive Care Unit course.  This was
felt to be secondary to an inability to take in free water.
He was free water bolused in his total parenteral nutrition
and defervesced.

 7.  NUTRITIONAL ISSUES:  The patient has a history of being
unable to swallow with straws.  A bedside swallow evaluation
was done which the patient failed.  A video swallowing study
was then performed.  Finally, the patient was safe to take
pills with purees, thin liquids, and have soft solids.  Basic
aspiration precautions were maintained.  The patient observed
to alternate between bites and sips and swallow twice between
bites and sips.

 8.  PANHYPOPITUITARISM ISSUES:  The patient was continued on
repletion with stress-dose steroids which were weaned to his
regular outpatient dose.

 9.  ANEMIA ISSUES:  The patient's iron studies were
consistent with anemia of chronic disease.  Stools were
guaiac-negative.  It was felt that his anemia was stable and
secondary to his chronic renal insufficiency.

10.  INFECTIOUS DISEASE ISSUES:  The patient had several
urine cultures growing yeast despite Foley catheter changes.
Given his multiple medical problems at this time, and
treatment with vancomycin, it was decided that antifungals
would be held and this would be addressed again as an
outpatient.

DISCHARGE STATUS:  Discharge status was to rehabilitation.

CONDITION AT DISCHARGE:  Condition on discharge was good.

DISCHARGE DIAGNOSES:
1.  Biliary sepsis.
2.  Volume overload with pulmonary edema.
3.  Chronic obstructive pulmonary disease.
4.  Panhypopituitarism.
5.  Anemia of chronic disease.

MEDICATIONS ON DISCHARGE:
 1.  Amiodarone 200 mg by mouth once per day.
 2.  Pantoprazole 40 mg by mouth once per day.
 3.  Multivitamin one tablet by mouth once per day.
 4.  Levothyroxine 75 mcg by mouth once per day
 5.  Hydrocortisone 40 mg by mouth twice per day.
 6.  Vitamin D 400 International Units by mouth twice per
day.
 7.  Vitamin C 500 mg by mouth twice per day.
 8.  Ipratropium meter-dosed inhaler 2 puffs inhaled q.4-6h.
as needed.
 9.  Albuterol 1 to 2 puffs inhaled q.4h. as needed.
10.  Albuterol ipratropium 1 to 2 puffs inhaled q.4h. as
needed.
11.  Insulin sliding-scale (as at home).
12.  Terazosin 5 mg by mouth once per day.
13.  Ipratropium nebulizer q.4-6h. as needed.

DISCHARGE INSTRUCTIONS/FOLLOWUP:   The patient was instructed
to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1266**] in rehabilitation.






                            [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 4263**]

Dictated By:[**Dictator Info **]
MEDQUIST36

D:  [**2166-9-9**]  13:26
T:  [**2166-9-9**]  13:45
JOB#:  [**Job Number 94517**]
{'Streptococcal septicemia,Acute and chronic cholecystitis,Other pulmonary insufficiency, not elsewhere classified,Panhypopituitarism,Hyperosmolality and/or hypernatremia,Atrial fibrillation,Acute kidney failure, unspecified,Chronic obstructive asthma, 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: Mr. [**Known firstname **] [**Known lastname **] is a
[**Age over 90 **]-year-old gentleman with a history of recent
cholecystostomy tube for cholecystitis, chronic obstructive
pulmonary disease, and panhypopituitarism who presented from
nursing home after being found to be short of breath this
morning with oxygen saturations of 77% on 2 liters.

MEDICAL HISTORY: 1.  Panhypopituitarism; status post pituitary adenoma
resection.
 2.  Paroxysmal atrial fibrillation.
 3.  Chronic obstructive pulmonary disease.
 4.  Cor pulmonale.
 5.  Obstructive sleep apnea.
 6.  Chronic renal insufficiency (with a baseline creatinine
of 1.2 to 1.5).
 7.  Hypertension.
 8.  Dual-mode, dual-pacing, dual-sensing pacemaker for
symptomatic bradycardia.
 9.  Benign prostatic hypertrophy.
10.  Peptic ulcer disease.
11.  Gastroesophageal reflux disease.
12.  History of cholecystitis in [**2166-4-27**]; status post
cholecystostomy tube placement which was removed in [**2166-4-27**].

MEDICATION ON ADMISSION: 1.  Hydrocortisone 60 mg by mouth once per day.
2.  Terazosin 5 mg by mouth once per day.
3.  Albuterol.
4.  Protonix 40 mg by mouth once per day.
5.  Synthroid 50 mcg once per day.
6.  Amiodarone 200 mg by mouth once per day.
7.  Insulin sliding-scale.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Streptococcal septicemia,Acute and chronic cholecystitis,Other pulmonary insufficiency, not elsewhere classified,Panhypopituitarism,Hyperosmolality and/or hypernatremia,Atrial fibrillation,Acute kidney failure, unspecified,Chronic obstructive asthma, unspecified'}
