CHIEF COMPLAINT: Fever and cough.

PRESENT ILLNESS: This is a 74 year old male with
a history of chronic obstructive pulmonary disease, alcohol
abuse, portal gastropathy, admitted for [**Hospital1 1680**] Psychiatric
Unit for the last five weeks. He presents with fever, cough
and chills with a temperature to 102.0.  He was referred to
the Emergency Department for further work-up.  He is not
forthcoming as a historian but denies any recent vomiting.

MEDICAL HISTORY: The patient's past medical history is
significant for the following:  The patient has alcohol
induced psychosis. Portal gastropathy.  Chronic obstructive
pulmonary disease.  Osteoarthritis. Status post partial
gastrectomy.  Cancer of the gums.  The patient has no known
drug allergies.

MEDICATION ON ADMISSION: The patient was on the following medications at the time of
admission to [**Hospital1 69**]:
Haldol 0.5 mg p.o. twice a day.
Vistaril 25 mg p.o. twice a day.
Zyprexa 10 mg p.o. twice a day.
Dietrol LA 4 mg p.o. q. day.

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient's social history is significant
for the following:  The patient has quit tobacco. He doesn't
remember his last drink.
Pneumonitis due to inhalation of food or vomitus,Hyperosmolality and/or hypernatremia,Alcohol abuse, unspecified,Obstructive chronic bronchitis with (acute) exacerbation,Acute respiratory failure,Unspecified protein-calorie malnutrition,Alcohol-induced persisting amnestic disorder,Osteoarthrosis, unspecified whether generalized or localized, site unspecified
Food/vomit pneumonitis,Hyperosmolality,Alcohol abuse-unspec,Obs chr bronc w(ac) exac,Acute respiratry failure,Protein-cal malnutr NOS,Alcohol amnestic disordr,Osteoarthros NOS-unspec
Admission Date:  [**2148-3-4**]     Discharge Date:  [**2148-3-18**]

Date of Birth:   [**2073-7-27**]     Sex:  M

Service:

CHIEF COMPLAINT:  Fever and cough.


HISTORY OF PRESENT ILLNESS:  This is a 74 year old male with
a history of chronic obstructive pulmonary disease, alcohol
abuse, portal gastropathy, admitted for [**Hospital1 1680**] Psychiatric
Unit for the last five weeks. He presents with fever, cough
and chills with a temperature to 102.0.  He was referred to
the Emergency Department for further work-up.  He is not
forthcoming as a historian but denies any recent vomiting.

REVIEW OF SYSTEMS:  Positive for fever, cough, paroxysmal
nocturnal dyspnea but no lower extremity edema.  He is unable
and unwilling to provide further history in regards to the
onset of these symptoms.  He denies any melena or bright red
blood per rectum.  It was noted by the nursing staff that he
has poor oral intake.

PAST MEDICAL HISTORY:   The patient's past medical history is
significant for the following:  The patient has alcohol
induced psychosis. Portal gastropathy.  Chronic obstructive
pulmonary disease.  Osteoarthritis. Status post partial
gastrectomy.  Cancer of the gums.  The patient has no known
drug allergies.

MEDICATIONS ON ADMISSION:
The patient was on the following medications at the time of
admission to [**Hospital1 69**]:
Haldol 0.5 mg p.o. twice a day.
Vistaril 25 mg p.o. twice a day.
Zyprexa 10 mg p.o. twice a day.
Dietrol LA 4 mg p.o. q. day.

SOCIAL HISTORY:  The patient's social history is significant
for the following:  The patient has quit tobacco. He doesn't
remember his last drink.

PHYSICAL EXAMINATION:   Physical examination at the time of
admission to [**Hospital1 69**] revealed
the following:  Temperature 100.7; blood pressure 189/83;
heart rate of 112; 83% on room air; 93% on six liters.  In
general, the patient is in no acute distress.  The patient is
alert and oriented times three.  HEAD, EYES, EARS, NOSE AND
THROAT:  Anicteric sclera.  Oropharynx is dry. Neck is
supple.  No lymphadenopathy.  Lungs:  Rhonchorus breath
sounds bilaterally. Slight decrease in breath sounds t the
right base with occasional expiratory wheezes.
Cardiovascular examination: S1 and S2, tachycardiac.
Abdominal examination:  Soft, nontender, nondistended with
bowel sounds present.  Extremities:  NO edema and warm.
Neurologic examination:  Alert, positive tremor.

LABORATORY DATA:  White count of 21.2; 90% neutrophils, 2%
bands, 3% lymphocytes.  Hematocrit of 40.6.  Platelets of
270.

Chemistry 7 revealed a sodium of 150; potassium of 4;
chloride of 110; C02 of 28; BUN 33; creatinine 1.1; glucose
149.

Urinalysis was yellow, clear, specific gravity of 1.025.
Small blood, 30 protein, trace ketones, small bilirubin, 0 to
2 white blood cells, rare bacteria.

Chest x-ray reveals no effusion, no congestive heart failure.
A right lower lobe infiltrate consistent with aspiration or
pneumonia.

Electrocardiogram revealed sinus tachycardia with a heart
rate of 113, normal axis and intervals and no ST or T wave
abnormalities.

HOSPITAL COURSE:  Aspiration pneumonia.  Based on his initial
chest x-ray, it appeared that his fevers were secondary to a
pneumonia, questionable aspiration pneumonia.  Further
history is obtained from the nursing home.  It was found that
he is on a mechanical soft diet with the nursing staff not
aware of any gross aspiration.

Blood and sputum cultures were obtained, of which the sputum
culture grew out moderate growth of coagulase positive staph
aureus which was Oxacillin sensitive.  He was initiated on
Levofloxacin 500 mg q. 24 hours as well as Flagyl 500 mg q.
24 hours with suspected aspiration pneumonia.

A bedside swallowing evaluation was obtained on hospital day
number two which revealed severe oral motor weakness and
difficulty initiating swallows, probable aspiration of apple
sauce and water and was, therefore, placed n.p.o. as a diet.

The neurology service was consulted for further evaluation of
the etiology of his oropharyngeal dysphagia. They recommended
performing an egrophonium test during a repeated speech and
swallow to evaluate for possible myasthenia [**Last Name (un) 2902**].  A repeat
speech and swallow evaluation with this tensilon was
performed with similar results to his initial evaluation --
namely considerable aspiration with inability to propel
pureed foods as well as inability to protect his airway.

Oxacillin was added to his antibiotic regimen for further
coverage of his aspiration pneumonia and his persistence of a
leukocytosis.  With this antibiotic regimen, he continued to
remain afebrile and completed a two week course in total of
these antibiotics.  However, his leukocytosis did not resolve
despite clinical improvement and it was felt that this was a
leukomoid reaction, unrelated to current infection.

On hospital day number ten, consent was obtained from his
legal guardian, [**Name (NI) **] [**Name (NI) **], phone #[**Telephone/Fax (1) 108932**] and a
percutaneous gastric jejunostomy tube was placed without
complications.  Tube feeds were initiated through this
gastrojejunostomy tube and the patient tolerated goal feeds
of Ultra-Cal at 75 cc an hour.

Repeat chest x-ray on hospital day number 14 revealed
improving bibasilar densities, consistent with improving
pneumonias.  However, he continued to sound somewhat
congested and may be chronically aspirating despite the
placement of the gastrojejunostomy tube.  He continues to
remain a chronic aspiration risk and was started on Bactrim
DS p.o. one tablet q. day for prophylaxis.

IN regards to further work-up of his oral and motor weakness,
an otorhinolaryngology consult was obtained to rule out
further involvement of his gingival cancer.  A biopsy was
taken one day prior to discharge with pathology results
pending at this time.

Alcohol induced psychosis.  It was difficult to determine the
baseline mental status of this patient and given the
possibility of neuroleptics causing dystonia, interfering
with his oral motor weakness, his psychiatric medications
were held, though upon further review of his history, he had
speech and swallowing difficulties prior to admission.

Despite the continuation of his neuroleptic, again his oral
and motor function did not improve.  The psychiatry service
was consulted in regards to further evaluation of his
dementia as well as recommended medications that would not
interfere with his oral and motor function.

Multiple laboratory studies were sent including liver
function tests, B-12, folate and TSH and RPR all of which
were normal and was started on Trilafon 8 mg by
gastrojejunostomy tube twice a day. The psychiatrist at
[**Hospital3 672**] Hospital was informed of his hospital course
and will continue further neuropsychiatric evaluation at this
facility.

Dyspnea.  On hospital day number four, the nursing staff
noticed that the patient was acutely dyspneic.  An arterial
blood gases was drawn during this event which revealed a pH
of 7.17, Pc02 of 87 and P02 of 104, indicative of a
respiratory acidosis. He was transferred to the Medical
Intensive Care Unit for a trial of mask ventilation.

He was also started on stress dose steroids, Solu-Medrol 80
mg intravenous three times a day as well as nebulizer
treatments.  It was thought that the etiology of his dyspnea
was secondary to a possible aspiration event, super imposed
on his chronic obstructive pulmonary disease.  Code status
was clarified with his legal guardian, stating that he is a
DNR/DNI patient.

After approximately 24 hours of mask ventilation, the patient
clinically improved with good oxygen saturations and was
significantly less labored in terms of his respiratory
status.  He was discharged from the Medical Intensive Care
Unit after a three day stay and sent back to the floor, with
continuation of treatment for aspiration pneumonia as
primary treatment of his dyspnea.

His oxygen requirements gradually tapered throughout the rest
of his hospital course, to a requirement of two liters nasal
cannula. His nebs were switched to an as needed basis and he
was quickly tapered off of steroids over a three day course
in total.

Hypernatremia.  The patient was noted to be hypernatremic
upon admission with a sodium level of 150.  His calculated
free water deficit was approximately three liters and,
throughout his hospital course, his sodium gradually
corrected with the supplementation of free water bolus.
However, upon discontinuation of his free water boluses, his
hyponatremia worsened.  Therefore, he will be discharged on a
standing order of 250 cc of free water every six hours
through his gastrojejunostomy tube to replenish his free
water.

DISCHARGE CONDITION:  Stable.

DISCHARGE STATUS:  The patient will be discharged to [**Hospital3 **] Hospital, Psychiatric Unit, where he will have
further evaluation of his mental status and indication for
Trilafon.

DISCHARGE DIAGNOSES:
Aspiration pneumonia, status post gastrojejunostomy tube
placement.
Alcohol induced psychosis.
Hypernatremia.
Gingival cancer.
Chronic obstructive pulmonary disease.

DISCHARGE MEDICATIONS:
Trilafon 80 mg by gastrojejunostomy tube twice a day.
Bactrim one tablet DS, by gastrojejunostomy tube q. day.
Colace 100 mg by gastrojejunostomy tube twice a day.
Dulcolax prn.
Lactulose prn.
Albuterol and Atrovent nebs prn.
Heparin 5,000 units subcutaneous q. 12 hours.
Miconazole powder 2% twice a day to intertrigonal areas.
Menzoprozole oral solution 30 mg in gastrojejunostomy tube q.
day.





                          [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D.  [**MD Number(1) 16316**]

Dictated By:[**Name8 (MD) 5406**]

MEDQUIST36

D:  [**2148-3-18**]  02:00
T:  [**2148-3-18**]  14:07
JOB#:  [**Job Number 108933**]

cc:[**Hospital3 **]
{'Pneumonitis due to inhalation of food or vomitus,Hyperosmolality and/or hypernatremia,Alcohol abuse, unspecified,Obstructive chronic bronchitis with (acute) exacerbation,Acute respiratory failure,Unspecified protein-calorie malnutrition,Alcohol-induced persisting amnestic disorder,Osteoarthrosis, unspecified whether generalized or localized, site 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: Fever and cough.

PRESENT ILLNESS: This is a 74 year old male with
a history of chronic obstructive pulmonary disease, alcohol
abuse, portal gastropathy, admitted for [**Hospital1 1680**] Psychiatric
Unit for the last five weeks. He presents with fever, cough
and chills with a temperature to 102.0.  He was referred to
the Emergency Department for further work-up.  He is not
forthcoming as a historian but denies any recent vomiting.

MEDICAL HISTORY: The patient's past medical history is
significant for the following:  The patient has alcohol
induced psychosis. Portal gastropathy.  Chronic obstructive
pulmonary disease.  Osteoarthritis. Status post partial
gastrectomy.  Cancer of the gums.  The patient has no known
drug allergies.

MEDICATION ON ADMISSION: The patient was on the following medications at the time of
admission to [**Hospital1 69**]:
Haldol 0.5 mg p.o. twice a day.
Vistaril 25 mg p.o. twice a day.
Zyprexa 10 mg p.o. twice a day.
Dietrol LA 4 mg p.o. q. day.

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient's social history is significant
for the following:  The patient has quit tobacco. He doesn't
remember his last drink. 

### Response:
{'Pneumonitis due to inhalation of food or vomitus,Hyperosmolality and/or hypernatremia,Alcohol abuse, unspecified,Obstructive chronic bronchitis with (acute) exacerbation,Acute respiratory failure,Unspecified protein-calorie malnutrition,Alcohol-induced persisting amnestic disorder,Osteoarthrosis, unspecified whether generalized or localized, site unspecified'}
