CHIEF COMPLAINT: 

PRESENT ILLNESS: Mr. [**Known lastname 102172**] is an 87 year old
male, status post a fall in which he tripped over a flower
pot on a stair case and fell back and hit is head and his
right elbow.  He was noted to have right arm numbness and
weakness and was seen at an outside hospital.  CT of his neck
showed a non displaced C6 laminar fracture.  The patient was
transferred from an outside hospital to [**Hospital1 190**] for further care.  He was initially admitted
to the trauma service.  Later, on the day of admission, the
patient was found slumped over his bed with his cervical
collar in place, with possible airway obstruction.  He was
witnessed to have labored breathing, with little or no air
movement and his oxygen saturation at that time was 86% but
improved to 96% to 100% on two liters nasal cannula. At that
time, his blood pressure was 140/70 and his heart rate was in
the 100's.  An arterial blood gases was 7.41, 33, 90.

MEDICAL HISTORY: Hypertension, hyperlipidemia.

MEDICATION ON ADMISSION: Atenolol.
Aspirin.
Lipitor.
Norvasc.
Avalid.

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Closed fracture of C5-C7 level with unspecified spinal cord injury,Atrial fibrillation,Accidental fall on or from other stairs or steps,Pure hypercholesterolemia,Unspecified essential hypertension,Hypotension, unspecified
C5-c7 fx-cl/cord inj NOS,Atrial fibrillation,Fall on stair/step NEC,Pure hypercholesterolem,Hypertension NOS,Hypotension NOS
Admission Date:  [**2123-7-27**]       Discharge Date:  [**2123-7-29**]

Date of Birth:                    Sex:

Service:

HISTORY OF PRESENT ILLNESS:  Mr. [**Known lastname 102172**] is an 87 year old
male, status post a fall in which he tripped over a flower
pot on a stair case and fell back and hit is head and his
right elbow.  He was noted to have right arm numbness and
weakness and was seen at an outside hospital.  CT of his neck
showed a non displaced C6 laminar fracture.  The patient was
transferred from an outside hospital to [**Hospital1 190**] for further care.  He was initially admitted
to the trauma service.  Later, on the day of admission, the
patient was found slumped over his bed with his cervical
collar in place, with possible airway obstruction.  He was
witnessed to have labored breathing, with little or no air
movement and his oxygen saturation at that time was 86% but
improved to 96% to 100% on two liters nasal cannula. At that
time, his blood pressure was 140/70 and his heart rate was in
the 100's.  An arterial blood gases was 7.41, 33, 90.

A portable chest x-ray at that time showed findings consistent
with L basilar atelectasis and his electrocardiogram showed
atrial fibrillation with ST depressions in V4 through V6. At that
time, the patient was transferred to the trauma Surgical
Intensive Care Unit.  A CPK was done which was 1,500.  The MB
fraction was 19 and troponin was 0.02.  Overnight on [**7-27**], the patient became less responsive.

Early in the day on [**2123-7-28**], the patient was noted
to be hypotensive with systolic blood pressure by peripheral
cuff of 70 to 80 while still in atrial fibrillation, with
heart rate in the 100's.  However, he had poor wave form on
the arterial line at the time.

The patient's blood pressure was extremely variable but
appeared to initially respond to a 500 cc bolus of fluids and
was not correlating with his arrhythmia of atrial
fibrillation because he was coming in and out of atrial
fibrillation.  He was seen by cardiology.  Cardiology
recommended stopping the patient's Norvasc and try for
aggressive rate control.  It was felt that the elevated CPK was
not indicative of ischemia because the MB fraction and troponin
levels were not elevated. In addition, the patient was seen
by neurology for the change in mental status. They were
considering a differential diagnosis which included brain
concussion, status post fall and residual effects of morphine
sedation.

The patient was then transferred to the medical Intensive
Care Unit team for further management and close monitoring in the
afternoon of [**7-28**] (around 5 pm).

PAST MEDICAL HISTORY:  Hypertension, hyperlipidemia.

PAST SURGICAL HISTORY:  Excision of chest wall mass.

MEDICATIONS ON ADMISSION:
Atenolol.
Aspirin.
Lipitor.
Norvasc.
Avalid.

PHYSICAL EXAMINATION:  Upon admission to the medical
Intensive Care Unit, physical examination revealed a pulse of
81; range from 67 to 90; blood pressure 126/33, ranging from
80 to 50 over 153/67.  Respiration 22, ranging from 15 to 29.
Input and output over the last 12 hours, prior to transfer,
1,590 over 2,030.  On examination, the patient appeared to be
in no acute distress.  His mucous membranes were moist. There
was no jugular venous distention. Large ecchymosis on the
back of his neck. Few inspiratory crackles anteriorly on
lung examination.  Heart:  irregularly irregular. No murmurs,
rubs or gallops.  Abdomen:  Soft, nontender, nondistended,
positive bowel sounds.  Extremities:  Warm, 1+ posterior
tibial and dorsalis pedis pulses bilaterally.  Neurologic:
Alert and oriented times two.

LABORATORY DATA:  Slow drop trending down hematocrit from
34.8 to 27.4 on day of transfer to medical Intensive Care
Unit.  White count of 8.5.  Electrolytes were within normal
limits.  CK from 1,313 to 1,504; MB of 19 to 16; third set
was pending at this time.  Troponin was 0.02 to 0.04 and
third set was pending.  TSH was pending. Toxicology screen
was negative.  Head CT done on [**7-27**] showed no mass
effect or hemorrhage.  Magnetic resonance scan of the spine
on [**7-27**] showed C4-5 edema.  Fluid at C5-6, consistent
with possible ligamentous injury. Mild anterior compression
of T-1.

An echocardiogram on [**7-28**] showed an ejection
fraction of greater than 60% with no segmental wall motion
defects and 1 to 2+ mitral regurgitation.

HOSPITAL COURSE:  After admission to the Intensive Care Unit,
the patient was found to be hypotensive.  This was likely
multifactorial in etiology.  Baseline blood pressure appears to
be 140/80.  The patient had a recent drop in hematocrit with no
obvious source of bleed.  In addition, he was in atrial
fibrillation which causes a loss in atrial kick and less
filling of ventricles.  The patient was given fluid
resuscitation in the goal to keep mean arterial pressure
greater than 60.  The plan was to follow his hematocrit and
to make sure that it did not drop any further.  In addition,
medication was implemented to control the rate while the
patient was in atrial fibrillation. CT scans of the abdomen and
neck area were ordered to determine if there was any
retroperitoneal bleed or an expanding hematoma to explain the
drop in hematocrit.  A discussion between the MICU team, the
patient (who was oriented to place and person at that point), and
the patient's wife ensued at the bedside regarding code status.
Both patient and his wife expressed wishes that in the event of a
cardiac arrest, no CPR be performed.

Through the evening of [**7-28**], the patient continued to have
hypotensive episodes despite aggressive fluid challenges . He was
dropping into the systolics of the 70's and the patient became
less responsive.  A left subclavian central line was attempted by
trauma surgery. However, the patient's oxygen saturations dropped
during line attempt placement so the procedure was aborted .
Oxygen saturation improved with 100% oxygen and the patient was
placed in upright position.  Possible fluid overload secondary to
aggressive intravenous hydration was entertained, but stat chest
x- ray showed new multilobar infiltrates in the left mid and
lower lung zones, consistent with a pneumonia. Antibiotics for
hospital-acquired pneumonia were ordered. The patient received a
unit of packed red blood cells to keep his mean arterial pressure
greater than 60, as well as intravenous fluids.  His blood
pressure stabilized for a short period of time.  Cardiogenic
shock,vs sepsis, vs hypovolemia secondary to bleeding were
considered. The CT scans of the abdomen and neck did not show any
evidence for fluid collections or hematoma.

The MICU team continued to have ongoing discussions with the
family members (wife and one daughter) who were present at the
bedside. The plan to insert a central line (femoral) and starting
vasopressors, and this was discussed with the patient's family.
They stated that they did not want Mr. [**Known lastname 102172**] to undergo another
line placement attempt and did not want pressors used. Thus, the
plan was to continue with resuscitative efforts with intravenous
fluids at that time. Therefore, no central line was placed and
the DNR status was confirmed again.  The MICU attending and the
surgical team was made aware of these discussions with the
family. The patient was closely monitored and approximately at 10
p.m., the patient had an acute drop in his systolic blood
pressure, measured by both the cuff and the arterial line with
good arterial line wave, despite running intravenous fluids wide
open and packed red blood cells transfusion.

The patient also became extremely bradycardiac at this time.
Atropine was given twice with no effect. Another discussion with
the patient's family took place . At this time, it was Mr.
[**Known lastname 102173**] wife and two daughters who were present and the decision
was made to make the patient comfort measures only. Pros and cons
of starting morphine for comfort were discussed with the family.
At first, the family was hesitant to start morphine but after the
discussion, they decided it was for Mr. [**Known lastname 102173**] benefit that it
be started. Potential causes of patient's deterioration
(cardiogenic shock, sepsis from pneumonia) were discussed with
patient's family through the night. Dr. [**Last Name (STitle) 102174**], who was covering
for primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 14069**], was made aware of
impending death. Patient died at 12:15 a.m. on [**2123-7-29**].


                            [**Name6 (MD) 2467**] [**Last Name (NamePattern4) 10404**], M.D.  [**MD Number(1) 10405**]

Dictated By:[**Last Name (NamePattern1) 17526**]
MEDQUIST36

D:  [**2123-8-26**]  05:04
T:  [**2123-8-26**]  10:47
JOB#:  [**Job Number 102175**]
{'Closed fracture of C5-C7 level with unspecified spinal cord injury,Atrial fibrillation,Accidental fall on or from other stairs or steps,Pure hypercholesterolemia,Unspecified essential hypertension,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: 

PRESENT ILLNESS: Mr. [**Known lastname 102172**] is an 87 year old
male, status post a fall in which he tripped over a flower
pot on a stair case and fell back and hit is head and his
right elbow.  He was noted to have right arm numbness and
weakness and was seen at an outside hospital.  CT of his neck
showed a non displaced C6 laminar fracture.  The patient was
transferred from an outside hospital to [**Hospital1 190**] for further care.  He was initially admitted
to the trauma service.  Later, on the day of admission, the
patient was found slumped over his bed with his cervical
collar in place, with possible airway obstruction.  He was
witnessed to have labored breathing, with little or no air
movement and his oxygen saturation at that time was 86% but
improved to 96% to 100% on two liters nasal cannula. At that
time, his blood pressure was 140/70 and his heart rate was in
the 100's.  An arterial blood gases was 7.41, 33, 90.

MEDICAL HISTORY: Hypertension, hyperlipidemia.

MEDICATION ON ADMISSION: Atenolol.
Aspirin.
Lipitor.
Norvasc.
Avalid.

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Closed fracture of C5-C7 level with unspecified spinal cord injury,Atrial fibrillation,Accidental fall on or from other stairs or steps,Pure hypercholesterolemia,Unspecified essential hypertension,Hypotension, unspecified'}
