CHIEF COMPLAINT: The patient was transferred from an outside
hospital for a cardiac catheterization because he ruled in
for a myocardial infarction.  He soon was transferred to the
Medical Intensive Care Unit for dyspnea, hypoxia, tachypnea,
and impending respiratory failure.

PRESENT ILLNESS: The patient is a 69-year-old
man with squamous cell carcinoma of the tongue, diagnosed in
[**2168-11-13**].  He is status post chemotherapy with
cisplatin and 5-fluorouracil as well as radiation therapy.
Over the past few weeks, he noted increasing dyspnea such
that he was unable to climb even a flight of stairs.  He also
noted occasional mild left-sided chest pain for which he went
to [**Hospital3 **] on [**2169-5-25**] where an EKG showed
diffuse ST depressions and where he ruled in for myocardial
infarction.

MEDICAL HISTORY: 1.  Hypertension.
2.  Hypercholesterolemia.
3.  Head and neck cancer.
4.  Per the patient, there is a question of a lung nodule on
a recent CT scan.

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: Mother with COPD.

SOCIAL HISTORY: He is currently unemployed.  He is a pipe
designer.  He has also worked in ship yards before.  He lives
in [**Hospital1 392**].  He is married and has three children.  He smoked
three packs per day of tobacco for 20 years but quit 33 years
ago.  He is also reported to have abused alcohol until he
quit in [**2169-3-14**].
Subendocardial infarction, initial episode of care,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Malignant neoplasm of base of tongue,Anemia, unspecified
Subendo infarct, initial,Food/vomit pneumonitis,Acute respiratry failure,Crnry athrscl natve vssl,Hypertension NOS,Mal neo tongue base,Anemia NOS
Admission Date:  [**2169-5-25**]     Discharge Date:  [**2169-5-30**]

Date of Birth:   [**2101-2-11**]     Sex:  M

Service:  MEDICAL INTENSIVE CARE UNIT

CHIEF COMPLAINT:  The patient was transferred from an outside
hospital for a cardiac catheterization because he ruled in
for a myocardial infarction.  He soon was transferred to the
Medical Intensive Care Unit for dyspnea, hypoxia, tachypnea,
and impending respiratory failure.

HISTORY OF THE PRESENT ILLNESS:  The patient is a 69-year-old
man with squamous cell carcinoma of the tongue, diagnosed in
[**2168-11-13**].  He is status post chemotherapy with
cisplatin and 5-fluorouracil as well as radiation therapy.
Over the past few weeks, he noted increasing dyspnea such
that he was unable to climb even a flight of stairs.  He also
noted occasional mild left-sided chest pain for which he went
to [**Hospital3 **] on [**2169-5-25**] where an EKG showed
diffuse ST depressions and where he ruled in for myocardial
infarction.

He was transferred to the [**Hospital6 2018**] where a cardiac catheterization was performed.  It
showed severe three vessel coronary artery disease.  PTCA was
attempted but was not successful.  Since arrival to the floor
on [**2169-5-25**], he was noted to be tachypneic to the 30s and
with complaints of dyspnea.  His oxygen saturation was around
90% on 4 liters nasal cannula 02.  His arterial blood gas was
7.47, 41, and 81 on arrival to the floor.

PAST MEDICAL HISTORY:
1.  Hypertension.
2.  Hypercholesterolemia.
3.  Head and neck cancer.
4.  Per the patient, there is a question of a lung nodule on
a recent CT scan.

FAMILY HISTORY:  Mother with COPD.

SOCIAL HISTORY:  He is currently unemployed.  He is a pipe
designer.  He has also worked in ship yards before.  He lives
in [**Hospital1 392**].  He is married and has three children.  He smoked
three packs per day of tobacco for 20 years but quit 33 years
ago.  He is also reported to have abused alcohol until he
quit in [**2169-3-14**].

PHYSICAL EXAMINATION ON ADMISSION:  Vital signs:  On [**2169-5-26**], the temperature was 98.4, pulse 90s, blood pressure
90s-150s/60s, respiratory rate 30s, 02 saturation 88-94% on
100% nonrebreather, 80% on room air.  General:  The patient
was a very pleasant, obese man, markedly tachypneic.  HEENT:
The oropharynx was dry.  Neck:  JVP 7-8 cm, no palpable
lymphadenopathy.  Chest:  Velcro-like crackles one-quarter up
bilaterally, otherwise clear to auscultation bilaterally with
decreased air movement.  There was a hematoma in the left
superior anterior chest.  It is mobile and about the size of
a small chicken egg.  Cardiovascular:  Regular rate and
rhythm, normal S1, S2, no murmur.  Abdomen:  Soft, nontender,
nondistended, with positive bowel sounds.  Extremities:  Warm
without edema.  There were chronic venostasis changes noted
at the right ankle.

LABORATORY/RADIOLOGIC DATA:  WBC 14.3, hematocrit 36.6,
platelets 271,000.  The differential revealed neutrophils
81%, bands 0%, lymphs 11%.  Sodium 134, K 3.9, CL 93, C02 28,
BUN 12, creatinine 0.6, glucose 112.  Troponins upon
admission were initially greater than 50, then 81.  The CKs
were 608, 467, and 409.

Chest x-ray on admission showed diffuse alveolar and
reticular infiltrates bilaterally, greatest at the bases.

HOSPITAL COURSE:  The patient is a 68-year-old man with head
and neck cancer diagnosed with three vessel coronary artery
disease as well as myocardial infarction on admission to the
hospital.  On arrival to the floor, he was noted to be
markedly tachypneic.  The tachypnea and dyspnea did not
improve even with 2.5 liters of Lasix diuresis.

He was transferred to the Medical Intensive Care Unit for
closer observation on [**2169-5-26**].  On [**2169-5-27**], he was noted to
be in increased respiratory distress and thus was electively
intubated.  A CT of the chest was performed.  It showed
multiple nodules throughout the lungs as well as interstitial
disease, especially at the bases.  There were diffuse ground
glass opacities in both lungs.

This clinical picture at this time was consistent with
respiratory failure secondary to likely a previously
undiagnosed interstitial lung disease vs. progressive
lymphangitic carcinomatosis. While he was intubated, he remained
difficult to oxygenate.  He also developed hypotension and
required Neo-Synephrine and two days later Vasopressin in order
to maintain a mean arterial pressure of 60 mmHg.  He also ruled
in for myocardial infarction again on [**2169-5-28**].  He was started
on heparin on [**2169-5-29**] given the myocardial infarction with EKG
changes in the inferior leads.

Throughout his ICU course, the patient's oxygenation was
tenuous.  His oxygen saturation was difficult to maintain at
90% even with increasing his positive end-expiratory
pressure.  Likewise, his hypotension did not show any
improvement during his ICU course.  Given these clinical
findings, the overall impression was that his prognosis was
very poor, especially given the interstitial lung disease
seen on CT scan.

On [**2169-5-30**], he was noted to have pupils that were fixed and
dilated as well.  There was no oculocephalic reflex noted and
he was also unresponsive even when he was off sedation.

Given the patient's extremely poor prognosis, especially with
the metastatic head and neck cancer, the interstitial lung
disease, and the multiple myocardial infarctions, as well as
other comorbidities, his family elected that he would be made
comfort measures only on [**2169-5-30**].  His pressors were stopped
and he was extubated.  He expired several hours later.

DISCHARGE DIAGNOSIS/PROCEDURES:
1.  Myocardial infarction times two.
2.  Cardiac catheterization, with attempted percutaneous
transluminal coronary angioplasty of coronary artery.
3.  Interstitial lung disease.
4.  Hypoxia.
5.  Respiratory failure requiring intubation.
6.  Shock, requiring pressor support.

DISPOSITION:  The patient expired on [**2169-5-30**] in the
afternoon.




                          [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D.  [**MD Number(1) 7585**]

Dictated By:[**Name8 (MD) 4123**]

MEDQUIST36

D:  [**2169-5-31**]  11:40
T:  [**2169-6-7**]  22:00
JOB#:  [**Job Number 48636**]


Admission Date:  [**2169-5-25**]     Discharge Date:  [**2169-5-30**]

Date of Birth:   [**2101-2-11**]     Sex:  M

Service:  MICU

HISTORY OF PRESENT ILLNESS:  The patient is a 69 year-old
male with a history of squamous cell carcinoma of the tongue
diagnosed in [**2168-11-13**] status post chemotherapy and
radiation therapy who had noticed dyspnea on climbing stairs
with occasional mild left sided chest pain over the past few
weeks prior to admission.  He went to [**Hospital3 **] on [**5-25**] after he woke up with chest pain.

Electrocardiogram showed sinus tachycardia to 115 beats per
minute with diffuse ST depressions that improved with rate
control and nitrates.  He ruled in for an myocardial
infarction at [**Hospital3 **] with a peak CK of 609 and a
troponin greater then 50.  Heparin was not given, because he
has had chronic bloody secretions and a hematoma at a recent
Port-A-Cath site.

He was transferred to [**Hospital1 69**]
where a cardiac catheterization was done, which showed three
vessel disease.  The patient was deemed to be a poor coronary
artery bypass graft candidate.  Percutaneous transluminal
coronary angioplasty was attempted, but not successful in the
cardiac catheterization laboratory.  The patient was
transferred to the floor and was observed to be tachypneic
and dyspneic.  Arterial blood gas performed at that time was
7.47, 41, 81.  The patient was given Lasix with 2.5 liters of
diuresis, but there was no change in his respiratory status.
The patient did complain of dyspnea, but did not complain of
chest pain upon transfer to the MICU.

PAST MEDICAL HISTORY:  Hypertension, hypercholesterolemia,
head and neck cancer diagnosed with cervical lymphadenopathy,
status post chemotherapy, 5FU and radiation therapy.  The
patient has chronic severe oral dryness.  T tube, Port-A-Cath
removed two weeks prior to admission.  The patient's daughter
believes he has a lung nodule of unclear etiology on CT scan
at outside hospital.

MEDICATIONS UPON TRANSFER:  Aspirin 325 mg po q.d.

FAMILY HISTORY:  Mother with chronic obstructive pulmonary
disease.

SOCIAL HISTORY:  Unemployed pipe designer.  He has worked in
shipyards before.  He is married with three children.  He
lives in [**Hospital1 392**].  He smoked three packs per day times twenty
years, quit thirty three years ago.  Alcohol abuse quit in
[**2169-3-14**].  Use of one bottle of alcohol per day.

PHYSICAL EXAMINATION:  Vital signs temperature 98.4.  Pulse
90. Blood pressure 90s to 150s/60s.  Respiratory rate in the
30s.  O2 sat 88 to 94%, 100% nonrebreather mask, 80% on room
air.  General, very pleasant obese man markedly tachypneic.
HEENT oropharynx is dry.  Neck JVP to 7 to 8 cm.  No palpable
lymphadenopathy.  Chest light crackles one fourth up
bilaterally, otherwise clear to auscultation.  Less apparent,
chest is mobile.  Hematoma approximately the size of a small
chicken egg.  Cardiovascular regular rate and rhythm.  Normal
S1 and S2.  No murmurs, rubs or gallops.  Abdomen obese,
soft, nontender, nondistended positive bowel sounds.
Extremities warm no edema. Chronic venous stasis changes
noted on right ankle.

LABORATORY:  White blood cell count 14.3, hematocrit 36.6,
platelets 271, PT/PTT 13.2/25.8, INR 1.2.  Neutrophils 81,
bands 0, lymphocytes 11.  Sodium 134, potassium 2.9, chloride
93, CO2 28, BUN 12, creatinine .6, glucose 112, ALT 23, AST
96, serial CKs 608, 467, 409.  Alkaline phosphatase 74, T
bili 0.9, serial troponins greater then 50, 8.1, calcium 9.4,
phos 3.2, magnesium 1.9, hematocrit 36.7.  Chest x-ray
diffuse alveolar and reticular infiltrates bilaterally,
greater at the bases.

INITIAL IMPRESSION:  The patient is a 68 year-old male with
head and neck cancer with coronary artery disease recent
myocardial infarction transferred to Medical Intensive Care
Unit for management and close observation of tachypnea and
hypoxia.

HOSPITAL COURSE:  The patient was initially treated with
Levofloxacin and Flagyl for suspected aspiration pneumonia.
Sputum was sent for culture.  It did not reveal any organisms
besides the oropharyngeal flora.  Chest x-ray suggested a
possible interstitial process.

The patient had a CT scan, which revealed no pulmonary
embolus, chronic interstitial process at the extreme bases
with diffuse ground glass opacities worrisome for an
underlying infectious or inflammatory process and multiple
pulmonary nodules consistent with the patient's metastasis or
perhaps primary lung tumor.

The patient's respiratory status became more tenuous in the
Intensive Care Unit and he was eventually intubated
electively.  The patient subsequently became more hypoxemic
and acidotic and became more and more difficult to ventilate
and oxygen properly.  The patient became hypertensive and
pressors were started neo-synephrine in particular.  The
patient proceeded to rule in for another myocardial
infarction after the pressor initiation.

The patient received an echocardiogram, which revealed a
global hypokinesis and a depressed ejection fraction about
40%.  He was started on heparin for myocardial infarction.

The patient on the morning of [**2169-5-30**] was noted to have
fixed dilated pupils and lack of oculocephalic reflex on
physical examination.  After family discussion given the
patient's grim prognosis and probably catastrophic brain
injury the family decided to withdraw life support and to
institute comfort measures.  The patient expired shortly
thereafter.  Pressors were withdrawn and he was then
extubated.

Postmortem examination requested and permission obtained.

DISCHARGE DIAGNOSES:
1.  Respiratory failure.
2.  Metastatic squamous cell carcinoma of the tongue.
3.  Coronary artery disease status post myocardial
infarction.

DISCHARGE CONDITION:  Expired.




                          [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D.  [**MD Number(1) 7585**]

Dictated By:[**Name8 (MD) 6867**]

MEDQUIST36

D:  [**2169-6-1**]  01:27
T:  [**2169-6-9**]  09:09
JOB#:  [**Job Number 48637**]
{'Subendocardial infarction, initial episode of care,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Malignant neoplasm of base of tongue,Anemia, 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: The patient was transferred from an outside
hospital for a cardiac catheterization because he ruled in
for a myocardial infarction.  He soon was transferred to the
Medical Intensive Care Unit for dyspnea, hypoxia, tachypnea,
and impending respiratory failure.

PRESENT ILLNESS: The patient is a 69-year-old
man with squamous cell carcinoma of the tongue, diagnosed in
[**2168-11-13**].  He is status post chemotherapy with
cisplatin and 5-fluorouracil as well as radiation therapy.
Over the past few weeks, he noted increasing dyspnea such
that he was unable to climb even a flight of stairs.  He also
noted occasional mild left-sided chest pain for which he went
to [**Hospital3 **] on [**2169-5-25**] where an EKG showed
diffuse ST depressions and where he ruled in for myocardial
infarction.

MEDICAL HISTORY: 1.  Hypertension.
2.  Hypercholesterolemia.
3.  Head and neck cancer.
4.  Per the patient, there is a question of a lung nodule on
a recent CT scan.

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: Mother with COPD.

SOCIAL HISTORY: He is currently unemployed.  He is a pipe
designer.  He has also worked in ship yards before.  He lives
in [**Hospital1 392**].  He is married and has three children.  He smoked
three packs per day of tobacco for 20 years but quit 33 years
ago.  He is also reported to have abused alcohol until he
quit in [**2169-3-14**]. 

### Response:
{'Subendocardial infarction, initial episode of care,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Malignant neoplasm of base of tongue,Anemia, unspecified'}
