CHIEF COMPLAINT: Bilateral pulmonary emboli and COPD flare

PRESENT ILLNESS: 74 yo male NH resident, h/o COPD (on O2), type 2 DM, presenting
with lethargy, hypoglycemia, and SOB; pt was 83-84% with
FSBG=59.  Pt improved with dextrose, O2, and sat's went up to
91%.  Given pt's lethargy, HCT was performed which was negative
for mass effect or bleed.  CXR on admission showed possible
RUL/RML PNA, but was concerning for endobronchial lesion.  F/U
Chest CT showed bilateral PE's, and patient was started on
anticoagulation with coumadin and lovenox.  Pt's vitals o/w
stable.  Pt was on Prednisone taper on admission and got
stress-dose solumedrol in ED.  Pt was initially stable on the
floor, but on hospital day [**1-13**], he had an acute desaturation,
was working hard to breathe/using accessory muscle, and was
transferred to the MICU at this time where he was stabilized
using non-invasive measures (O2 mask, frequent nebs).  Pt
transferred back to floor when he was more stable from a
respiratory standpoint.

MEDICAL HISTORY: PMH: COPD-on O2, type 2 DM, MRSA, prostate cancer,
diverticulitis, glaucoma, is legally blind,
hypercholesterolemia.

MEDICATION ON ADMISSION: Prednisone 30 mg (taper)
Humulin 70/30, 55 QAM, 28 QPM
Trisoptin drops
Alphagen drops
Colace
Albuterol
Xanax 0.25 TID
SQ heparin
Flutamide 250 TID
KCL
Zantac 150 [**Hospital1 **]
Effexor 75 QD
Verapamil 120 TID
Ambien 10 mg QHS
Vit C

ALLERGIES: Penicillins / Cephalosporins / Neurontin

PHYSICAL EXAM: VS: 97.9   103    138/64     22   97% 4L
Gen: mild respiratory distress, pleasant, slightly disoriented,
appropriate responses
HEENT: dilated pupils (bland)
CV: tachycardic S1/S2, no m/r/g
Lungs: prolonged expiratory phase, wheezing, rhonchi in right
base
Abd: soft, NT/ND, no HSM, NABS
Extr: no edema/cyanosis/clubbing, DP and PT intact bilaterally
Neuro: grossly intact

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: SH: married, has been in a NH for the past 2-3 weeks after a
recent hospital admission to [**Hospital1 336**], likely with MID.  No Etoh,
former smoker, was DNR/DNI in nursing home.
Other pulmonary embolism and infarction,Obstructive chronic bronchitis with (acute) exacerbation,Other pulmonary insufficiency, not elsewhere classified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension
Pulm embol/infarct NEC,Obs chr bronc w(ac) exac,Other pulmonary insuff,DMII wo cmp nt st uncntr,Hypertension NOS
Admission Date:  [**2178-6-27**]              Discharge Date:   [**2178-7-2**]

Date of Birth:  [**2104-1-2**]             Sex:   M

Service: MED

Allergies:
Penicillins / Cephalosporins / Neurontin

Attending:[**First Name3 (LF) 8684**]
Chief Complaint:
Bilateral pulmonary emboli and COPD flare

Major Surgical or Invasive Procedure:
none


History of Present Illness:
74 yo male NH resident, h/o COPD (on O2), type 2 DM, presenting
with lethargy, hypoglycemia, and SOB; pt was 83-84% with
FSBG=59.  Pt improved with dextrose, O2, and sat's went up to
91%.  Given pt's lethargy, HCT was performed which was negative
for mass effect or bleed.  CXR on admission showed possible
RUL/RML PNA, but was concerning for endobronchial lesion.  F/U
Chest CT showed bilateral PE's, and patient was started on
anticoagulation with coumadin and lovenox.  Pt's vitals o/w
stable.  Pt was on Prednisone taper on admission and got
stress-dose solumedrol in ED.  Pt was initially stable on the
floor, but on hospital day [**1-13**], he had an acute desaturation,
was working hard to breathe/using accessory muscle, and was
transferred to the MICU at this time where he was stabilized
using non-invasive measures (O2 mask, frequent nebs).  Pt
transferred back to floor when he was more stable from a
respiratory standpoint.


Past Medical History:
PMH: COPD-on O2, type 2 DM, MRSA, prostate cancer,
diverticulitis, glaucoma, is legally blind,
hypercholesterolemia.


Social History:
SH: married, has been in a NH for the past 2-3 weeks after a
recent hospital admission to [**Hospital1 336**], likely with MID.  No Etoh,
former smoker, was DNR/DNI in nursing home.

Family History:
non-contributory

Physical Exam:
VS: 97.9   103    138/64     22   97% 4L
Gen: mild respiratory distress, pleasant, slightly disoriented,
appropriate responses
HEENT: dilated pupils (bland)
CV: tachycardic S1/S2, no m/r/g
Lungs: prolonged expiratory phase, wheezing, rhonchi in right
base
Abd: soft, NT/ND, no HSM, NABS
Extr: no edema/cyanosis/clubbing, DP and PT intact bilaterally
Neuro: grossly intact

Pertinent Results:
[**2178-6-27**] 03:00AM   PT-13.4* PTT-28.5 INR(PT)-1.2
[**2178-6-27**] 03:00AM   PLT SMR-LOW PLT COUNT-144*
[**2178-6-27**] 03:00AM   WBC-9.0 RBC-3.39* HGB-9.9* HCT-33.0* MCV-97
MCH-29.3 MCHC-30.1* RDW-15.4
[**2178-6-27**] 03:00AM   GLUCOSE-196* UREA N-11 CREAT-0.7 SODIUM-143
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-35* ANION GAP-9

Brief Hospital Course:
1. Severe B PE.  Pt was initially put on Lovenox 70 [**Hospital1 **] with
coumadin when PE's discovered on chest CT.  Pt was stable for 2
days and then had an acute episode of desaturation, O2 sats
83-84% on 4L, minimal improvement with nebs and 50% facemask.
Chest X-ray did not show any acute process, but patient was
laboring to breathe, using accessory muscles, and was not moving
air very well.  ABG showed some CO2 retention, a normal pH, but
inadequate O2 sat given the amount of facemask O2.  He was
transferred to the MICU at this time where he was managed and
stabilized without intubation (frequent nebs, O2).  TTE showed
possible left mobile PA mass/clot; suggestion was patient was
throwing new clots even though on Lovenox.  Pt started on
Heparin drip, became more stable from a respiratory standpoint,
and he was transferred back to the floor where he has remained
stable on 2 L NC O2, nebs, hep gtt, antibiotics, and steroid
taper.  Heparin was discontinued after 48 hour overlap
(therapeutic on both coumadin and heparin), and patient
discharged on coumadin for lifelong anticoagulation.  IVC filter
should be considered if this anticoagulation is inadequate.

2.  COPD: Pt continued on a prednisone taper (2wks) for possible
COPD flare, likely one of the reasons for his respiratory
distress.  Pt also with frequent nebs and O2 as needed (pt has
baseline 2 L O2 requirement).

3.  ?PNA-normal cxr, afebrile, but did have bandemia on
admission and now with pseudomonas in sputum, resistent to
quinolones. Given allergy to pcn, ceph, wills start aztreonam
for presumptive coverage since he has poor respiratory status.
14-d course of Aztreonam with a 7-day course of Levo for
possible pneumonia with COPD flare.

4.  DM- restart 70/30 at 1/2 dose; will cover with SSI, and cked
FSBG in house.


5.  Psych: continue Effexor, give Ambien for insomnia; hold
Xanax, monitor for signs of benzo withdrawal

6.  FEN- gave boluses as necessary, no standing IVF

7.  PPX- Zantac, MRSA precautions

8.  Pt is now Full code; reversed code status in-house given
possibly reversible cause of respiratory distress.  This should
be reviewed upon return to rehab facility, for patient was
DNR/DNI prior to this admission.


Medications on Admission:
Prednisone 30 mg (taper)
Humulin 70/30, 55 QAM, 28 QPM
Trisoptin drops
Alphagen drops
Colace
Albuterol
Xanax 0.25 TID
SQ heparin
Flutamide 250 TID
KCL
Zantac 150 [**Hospital1 **]
Effexor 75 QD
Verapamil 120 TID
Ambien 10 mg QHS
Vit C

Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours).
2. Albuterol Sulfate 0.083 % Solution Sig: One (1)  Inhalation
Q2H (every 2 hours) as needed.
3. Dorzolamide HCl 2 % Drops Sig: One (1) Drop Ophthalmic  [**Hospital1 **]
(2 times a day).
4. Brimonidine Tartrate 0.2 % Drops Sig: One (1) Drop Ophthalmic
 [**Hospital1 **] (2 times a day).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO QD (once a day).
6. Flutamide 125 mg Capsule Sig: Two (2) Capsule PO TID (3 times
a day).
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Venlafaxine HCl 75 mg Tablet Sig: One (1) Tablet PO QD (once
a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
11. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
12. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-12**]
Puffs Inhalation Q6H (every 6 hours).
13. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO QD (once
a day).
14. Verapamil HCl 120 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours).
15. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO QD (once a
day) for 13 days: Take 60 mg until [**7-5**], take 40 mg until [**7-10**],
take 20 mg until [**7-14**], then off.
Disp:*23 Tablet(s)* Refills:*0*
16. Insulin 70/30 70-30 unit/mL Suspension Sig: 25 U
Subcutaneous QAC.
17. Insulin 70/30 70-30 unit/mL Suspension Sig: 15 U
Subcutaneous at bedtime.
18. Levofloxacin 500 mg IV Q24H   Duration: 1 Days
Continue until [**7-3**]
19. Aztreonam [**2173**] mg IV Q8H   Duration: 11 Days
Continue until [**7-13**]


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 672**] Hospital

Discharge Diagnosis:
Bilateral Pulmonary emboli, COPD flare


Discharge Condition:
Good

Discharge Instructions:
Please let staff at acute rehab know if you are experiencing
chest pain, shortness of breath, fevers, chills, or any other
concerns.
1.  Pt needs monitoring of his coumadin; pt found to have
bilateral severe PE's on chest CT, thought to be chronic.  He
will need lifelong anticoagulation with coumadin. His goal INR
is [**1-13**].  He will need an INR ck in the morning of [**7-3**]; pt
currently on 5mg coumadin each day.  If lifelong anticoagulation
proves to be inadequate, an IVC filter should be considered.
2.  Pt was DNR/DNI before this hospitalization; code status was
reversed given the possibly reversible nature of his pulmonary
emboli.  This should be rediscussed; it is reasonable to resume
patient's prior code status.
3.  Pt has a relatively new diagnosis of [**Name (NI) **] dementia
(from last 1-2 months).

Followup Instructions:
Will have f/u at rehabilitation facility
Need INR checks regularly for coumadin therapy
{'Other pulmonary embolism and infarction,Obstructive chronic bronchitis with (acute) exacerbation,Other pulmonary insufficiency, not elsewhere classified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension'}


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: Bilateral pulmonary emboli and COPD flare

PRESENT ILLNESS: 74 yo male NH resident, h/o COPD (on O2), type 2 DM, presenting
with lethargy, hypoglycemia, and SOB; pt was 83-84% with
FSBG=59.  Pt improved with dextrose, O2, and sat's went up to
91%.  Given pt's lethargy, HCT was performed which was negative
for mass effect or bleed.  CXR on admission showed possible
RUL/RML PNA, but was concerning for endobronchial lesion.  F/U
Chest CT showed bilateral PE's, and patient was started on
anticoagulation with coumadin and lovenox.  Pt's vitals o/w
stable.  Pt was on Prednisone taper on admission and got
stress-dose solumedrol in ED.  Pt was initially stable on the
floor, but on hospital day [**1-13**], he had an acute desaturation,
was working hard to breathe/using accessory muscle, and was
transferred to the MICU at this time where he was stabilized
using non-invasive measures (O2 mask, frequent nebs).  Pt
transferred back to floor when he was more stable from a
respiratory standpoint.

MEDICAL HISTORY: PMH: COPD-on O2, type 2 DM, MRSA, prostate cancer,
diverticulitis, glaucoma, is legally blind,
hypercholesterolemia.

MEDICATION ON ADMISSION: Prednisone 30 mg (taper)
Humulin 70/30, 55 QAM, 28 QPM
Trisoptin drops
Alphagen drops
Colace
Albuterol
Xanax 0.25 TID
SQ heparin
Flutamide 250 TID
KCL
Zantac 150 [**Hospital1 **]
Effexor 75 QD
Verapamil 120 TID
Ambien 10 mg QHS
Vit C

ALLERGIES: Penicillins / Cephalosporins / Neurontin

PHYSICAL EXAM: VS: 97.9   103    138/64     22   97% 4L
Gen: mild respiratory distress, pleasant, slightly disoriented,
appropriate responses
HEENT: dilated pupils (bland)
CV: tachycardic S1/S2, no m/r/g
Lungs: prolonged expiratory phase, wheezing, rhonchi in right
base
Abd: soft, NT/ND, no HSM, NABS
Extr: no edema/cyanosis/clubbing, DP and PT intact bilaterally
Neuro: grossly intact

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: SH: married, has been in a NH for the past 2-3 weeks after a
recent hospital admission to [**Hospital1 336**], likely with MID.  No Etoh,
former smoker, was DNR/DNI in nursing home. 

### Response:
{'Other pulmonary embolism and infarction,Obstructive chronic bronchitis with (acute) exacerbation,Other pulmonary insufficiency, not elsewhere classified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension'}
