CHIEF COMPLAINT: Unresponsive

PRESENT ILLNESS: 78 yo M w/ h/o seizure disorder, Parkinson's, dementia, recent
hospitalization for aspiration pneumonia and
encephalopathy/delirium presents to the ED with altered mental
status and hct drop from 28.4 upon discharge [**12-2**] to 21.7
(baseline appears to be 33-35).
.
He was recently dischared from [**Hospital1 18**] [**Date range (1) 52345**] hospitalization
for aspiration pneumonia and encephalopathy/delirium and went to
NH from there.  At the NH this am, [**Name8 (MD) **] RN report had acute onset
AMS and was found to be hypoxic with O2 sats in the mid 80s
which responded to O2 via nasal cannula (nml. O2 sats high 90s
on RA).  His wife reports that 1 day PTA, she noted that at the
NH, he had multiple large black stools; no bright red blood.
Upon tx to the ED, medics found him to have "low blood sugar"
although exact number is not known.  He received D50 en route to
the hospital.
.
In the ED, he was found to have the above mentioned hct drop and
had melanotic stool.  Gastric lavage was not performed in the
ED.  He received 2U prbcs.  He was found to have diffuse
pulmonary crackles and O2 requirement and CXR revealed e/o
pulmonary edema and b/l pleural effusion c/w heart failure.  BNP
was 1193.  Vitals on presentation revealed hypothermia, BP 94/65
RR 16 O2 sat was 100% (unclear in documentation on what
settings).  Bear hugger was applied and he was started on Bipap.
 Blood cultures were sent and he received vanco, ceftaz and
flagyl x1.  He received 3L IVF for persistent hypotension into
70s systolic to which his BP only transiently responded.
Discussion was had with his family by the ED staff and although
he is DNR/DNI, pressors are exceptable although they do not want
central line placement.  Thus, he was started on levophed and
was transferred to the [**Hospital Unit Name 153**] for further management.
.
During his most recent hospitalization [**Date range (1) 52345**], He was treated
with unasyn for aspiration pneumonia.  He was discharged on
augmentin to complete the course on [**12-9**].  Given his probable
aspiration pneumonia, he was evaluated by speech and swallow at
the bedside who recommended pureed solids and nectar thick
liquids.  He was also started on flagyl for C. diff colitis
which he is to complete on [**12-16**].  Additionally, pt. had
movements that were originally thought c/w seizure.  Neurology
evaluated him and thought movements were likely dyskinesis from
Parkinson's.  With the restarting of Parkinson's medication, he
became more responsive.

MEDICAL HISTORY: 1. Parkinsons Dx [**2136**] in [**Country 651**]
2. ? H/O Stroke
3. GERD
4. BPH
5. ? Seizures
6. Fatigue
7. Atypical chest pain, noncardiac

MEDICATION ON ADMISSION: 1. Acetaminophen 650 mg PO Q6H prn
2. Entacapone 200 mg q4h w/ sinemet
3. Carbidopa-Levodopa 25-250 mg 1 PO Q 3AM, 6AM, 9AM, NOON, 3PM,
6 PM
4. Carbidopa-Levodopa 50-200 mg 1 PO Q9PM
5. Pramipexole 0.25 mg Tablet 1 PO TID
6. Trihexyphenidyl 2 mg Tablet 1 PO BID
7. Tamsulosin 0.4 mg Capsule 1 PO QHS
8. Lactulose 10 g/15 mL Syrup 30ML PO Q8H prn
9. Albuterol Sulfate 0.083 % Solution 1 neb Q6H prn
10. Docusate Sodium 100 mg PO BID
11. Multivitamin,Tx-Minerals 1 PO daily
12. Aspirin 325 mg Tablet 1 PO daily
13. Pantoprazole 40 mg Tablet 1 PO qdaily
14. Calcium Carbonate 500 mg Tablet 1 PO TID
15. Cholecalciferol (Vitamin D3) 800 unit daily
16. Flagyl 500 mg Tablet 1 PO q8h (to complete on [**2149-12-16**])
17. Augmentin 875-125 mg Tablet 1 PO bid (to complete [**2149-12-9**])
.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T 95.0 ax BP 121/61 HR 61 RR 14 100% on 2L NC
Gen:  Unresponsive, nonverbal, does not follow commands
HEENT: PERRL, MMM, shallow wound on chin.
Neck:  supple, +JVD to angle of jaw
CV:  RRR, No mrg
Resp: rhonchorus anteriorly with intermittent exp wheeze right
anterior chest
Abd: Decreased bowel sounds.  Thin. No guarding. No
organomegaly.  Gastric lavage w/ sl. pink fluid
Ext: B/L upper extremity decorticate posturing.  Able to bend
arms but w/ resistance.  2+ b/l LE edema to mid shins.  When
attempt to bend left arm at elbow, pt. moans.
Neuro: 1+ patellar reflexes. Unable to get biceps reflexes [**12-26**]
to stiffness and extensor posturing.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Lives at [**Location **].  Children and wife live locally.  From [**Country 651**]
originally, Cantonese speaking.  Denies tobacco, ETOH, and drugs
Unspecified septicemia,Hemorrhage of gastrointestinal tract, unspecified,Pneumonitis due to inhalation of food or vomitus,Congestive heart failure, unspecified,Acute respiratory failure,Esophageal reflux,Paralysis agitans,Severe sepsis
Septicemia NOS,Gastrointest hemorr NOS,Food/vomit pneumonitis,CHF NOS,Acute respiratry failure,Esophageal reflux,Paralysis agitans,Severe sepsis
Admission Date:  [**2149-12-6**]              Discharge Date:   [**2149-12-6**]

Date of Birth:  [**2070-12-9**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Unresponsive

Major Surgical or Invasive Procedure:
None

History of Present Illness:
78 yo M w/ h/o seizure disorder, Parkinson's, dementia, recent
hospitalization for aspiration pneumonia and
encephalopathy/delirium presents to the ED with altered mental
status and hct drop from 28.4 upon discharge [**12-2**] to 21.7
(baseline appears to be 33-35).
.
He was recently dischared from [**Hospital1 18**] [**Date range (1) 52345**] hospitalization
for aspiration pneumonia and encephalopathy/delirium and went to
NH from there.  At the NH this am, [**Name8 (MD) **] RN report had acute onset
AMS and was found to be hypoxic with O2 sats in the mid 80s
which responded to O2 via nasal cannula (nml. O2 sats high 90s
on RA).  His wife reports that 1 day PTA, she noted that at the
NH, he had multiple large black stools; no bright red blood.
Upon tx to the ED, medics found him to have "low blood sugar"
although exact number is not known.  He received D50 en route to
the hospital.
.
In the ED, he was found to have the above mentioned hct drop and
had melanotic stool.  Gastric lavage was not performed in the
ED.  He received 2U prbcs.  He was found to have diffuse
pulmonary crackles and O2 requirement and CXR revealed e/o
pulmonary edema and b/l pleural effusion c/w heart failure.  BNP
was 1193.  Vitals on presentation revealed hypothermia, BP 94/65
RR 16 O2 sat was 100% (unclear in documentation on what
settings).  Bear hugger was applied and he was started on Bipap.
 Blood cultures were sent and he received vanco, ceftaz and
flagyl x1.  He received 3L IVF for persistent hypotension into
70s systolic to which his BP only transiently responded.
Discussion was had with his family by the ED staff and although
he is DNR/DNI, pressors are exceptable although they do not want
central line placement.  Thus, he was started on levophed and
was transferred to the [**Hospital Unit Name 153**] for further management.
.
During his most recent hospitalization [**Date range (1) 52345**], He was treated
with unasyn for aspiration pneumonia.  He was discharged on
augmentin to complete the course on [**12-9**].  Given his probable
aspiration pneumonia, he was evaluated by speech and swallow at
the bedside who recommended pureed solids and nectar thick
liquids.  He was also started on flagyl for C. diff colitis
which he is to complete on [**12-16**].  Additionally, pt. had
movements that were originally thought c/w seizure.  Neurology
evaluated him and thought movements were likely dyskinesis from
Parkinson's.  With the restarting of Parkinson's medication, he
became more responsive.


Past Medical History:
1. Parkinsons Dx [**2136**] in [**Country 651**]
2. ? H/O Stroke
3. GERD
4. BPH
5. ? Seizures
6. Fatigue
7. Atypical chest pain, noncardiac


Social History:
Lives at [**Location **].  Children and wife live locally.  From [**Country 651**]
originally, Cantonese speaking.  Denies tobacco, ETOH, and drugs


Family History:
Non-contributory

Physical Exam:
Vitals: T 95.0 ax BP 121/61 HR 61 RR 14 100% on 2L NC
Gen:  Unresponsive, nonverbal, does not follow commands
HEENT: PERRL, MMM, shallow wound on chin.
Neck:  supple, +JVD to angle of jaw
CV:  RRR, No mrg
Resp: rhonchorus anteriorly with intermittent exp wheeze right
anterior chest
Abd: Decreased bowel sounds.  Thin. No guarding. No
organomegaly.  Gastric lavage w/ sl. pink fluid
Ext: B/L upper extremity decorticate posturing.  Able to bend
arms but w/ resistance.  2+ b/l LE edema to mid shins.  When
attempt to bend left arm at elbow, pt. moans.
Neuro: 1+ patellar reflexes. Unable to get biceps reflexes [**12-26**]
to stiffness and extensor posturing.


Pertinent Results:
[**2149-12-6**] EKG:  NSR with rate 67. Nml axis. 1st degree AV delay.
No acute ST-T wave changes appreciated.
.
[**2149-12-6**] CXR:
1. Bilateral pleural effusions, fluid overload with interstitial
edema.  More confluent suprahilar opacities may be due to
dependent atelectasis component of edema or a superimposed
process such as acute aspiration.
2.  Likely left humeral fracture.  Dedicated shoulder
radiographs could be performed for further characterization.
.
[**2149-12-6**] Left shoulder x-ray: read pending
.
[**2149-12-6**] Head CT:
No acute intracranial hemorrhage or mass effect
.
[**2149-11-25**] MRA BRAIN:
1. 5-mm low signal intensity in the white matter of the right
frontal lobe consistent with hemosiderin and could represent a
cavernoma or trauma.
2. Diffuse abnormal bone marrow signal in the cervical spine
could represent anemia or other diffuse infiltrative process.
3. Normal circle of [**Location (un) 431**] MRA.
.
[**2149-11-21**] CT BRAIN: No intracranial hemorrhage or mass effect.
Unchanged appearance from [**2148-7-4**].
.
[**2149-11-21**] CT CSPINE:
1. No evidence of fracture or spondylolisthesis.
2. Multilevel degenerative change.
.
[**2150-11-21**] CXR:
Left basal and right infrahilar opacity concerning for evolving
pneumonia or aspiration.


Brief Hospital Course:
# GI bleed:  Significant hct drop from 28.4 on [**2149-12-2**] to 21.7 in
the ED on presentation, with elevated BUN where it was
previously was normal.  Unclear source.  Lavage with minimal
pinkish tinge p 200cc, but NGT at G-E junction.  Family did not
wish currently to pursue aggressive measures (EGD/[**Last Name (un) **]).  He was
transferred to the FIU as a DNI and after discussion with
family, he was made DNR/DNI.
.
# Sepsis: Probable pulmonary source given recent hospitalization
for aspiration pneumonia.  Patient was hypothermic with WBC >12
(12.3) w/ probable aspiration pneumonia as source.  He was not
tachycardic nor tachypneic.  He was hypotensive despite 3L fluid
resuscitation and required pressors to maintain his BP.
Currently on peripheral pressors started in the ED, but family
requested no central line placement.  He was continued on zosyn
to cover anaerobes, vanco given recent hospitalization, and
flagyl for known C. diff.  Above, family discussion was had
regarding their wishes and he was made DNR/DNI.  Despite
peripheral levophed, his BP continued to drop and he expired
within hours of [**Hospital Unit Name 153**] transfer.  Family was at bedside.
.
# Altered mental status:  Likely toxic metabolic in the setting
of sepsis and GIB.  CT head was negative for acute intracranial
process.
.
# Coagulopathy:  Elevated INR to 1.9 and has not been on any
anticoagulants.  Fibrinogen was normal, other DIC labs not sent.
 Likely largely nutrtional.  He was given vitamin K in setting
of GIB and elevated INR.
.
# CHF:  Has no previous h/o CAD nor CHF.  Last echo in [**6-28**] with
nml EF.  BNP 1193 w/ clear e/o fluid overload on CXR, elevated
JVD on exam nad peripheral edema.  CEs were negative x1.
.
# Parkinson's disease:  Plan was to continue sinemet,
entacapone, pramipaxole, and trihexyphenidyl.
.
# BPH:  Foley was placed, tamsulosin was held in setting of
severe hypotension.

Medications on Admission:
1. Acetaminophen 650 mg PO Q6H prn
2. Entacapone 200 mg q4h w/ sinemet
3. Carbidopa-Levodopa 25-250 mg 1 PO Q 3AM, 6AM, 9AM, NOON, 3PM,
6 PM
4. Carbidopa-Levodopa 50-200 mg 1 PO Q9PM
5. Pramipexole 0.25 mg Tablet 1 PO TID
6. Trihexyphenidyl 2 mg Tablet 1 PO BID
7. Tamsulosin 0.4 mg Capsule 1 PO QHS
8. Lactulose 10 g/15 mL Syrup 30ML PO Q8H prn
9. Albuterol Sulfate 0.083 % Solution 1 neb Q6H prn
10. Docusate Sodium 100 mg PO BID
11. Multivitamin,Tx-Minerals 1 PO daily
12. Aspirin 325 mg Tablet 1 PO daily
13. Pantoprazole 40 mg Tablet 1 PO qdaily
14. Calcium Carbonate 500 mg Tablet 1 PO TID
15. Cholecalciferol (Vitamin D3) 800 unit daily
16. Flagyl 500 mg Tablet 1 PO q8h (to complete on [**2149-12-16**])
17. Augmentin 875-125 mg Tablet 1 PO bid (to complete [**2149-12-9**])
.


Discharge Disposition:
Expired

Discharge Diagnosis:
Sepsis
GI bleed


Discharge Condition:
Expired


Followup Instructions:
None
{'Unspecified septicemia,Hemorrhage of gastrointestinal tract, unspecified,Pneumonitis due to inhalation of food or vomitus,Congestive heart failure, unspecified,Acute respiratory failure,Esophageal reflux,Paralysis agitans,Severe sepsis'}


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: Unresponsive

PRESENT ILLNESS: 78 yo M w/ h/o seizure disorder, Parkinson's, dementia, recent
hospitalization for aspiration pneumonia and
encephalopathy/delirium presents to the ED with altered mental
status and hct drop from 28.4 upon discharge [**12-2**] to 21.7
(baseline appears to be 33-35).
.
He was recently dischared from [**Hospital1 18**] [**Date range (1) 52345**] hospitalization
for aspiration pneumonia and encephalopathy/delirium and went to
NH from there.  At the NH this am, [**Name8 (MD) **] RN report had acute onset
AMS and was found to be hypoxic with O2 sats in the mid 80s
which responded to O2 via nasal cannula (nml. O2 sats high 90s
on RA).  His wife reports that 1 day PTA, she noted that at the
NH, he had multiple large black stools; no bright red blood.
Upon tx to the ED, medics found him to have "low blood sugar"
although exact number is not known.  He received D50 en route to
the hospital.
.
In the ED, he was found to have the above mentioned hct drop and
had melanotic stool.  Gastric lavage was not performed in the
ED.  He received 2U prbcs.  He was found to have diffuse
pulmonary crackles and O2 requirement and CXR revealed e/o
pulmonary edema and b/l pleural effusion c/w heart failure.  BNP
was 1193.  Vitals on presentation revealed hypothermia, BP 94/65
RR 16 O2 sat was 100% (unclear in documentation on what
settings).  Bear hugger was applied and he was started on Bipap.
 Blood cultures were sent and he received vanco, ceftaz and
flagyl x1.  He received 3L IVF for persistent hypotension into
70s systolic to which his BP only transiently responded.
Discussion was had with his family by the ED staff and although
he is DNR/DNI, pressors are exceptable although they do not want
central line placement.  Thus, he was started on levophed and
was transferred to the [**Hospital Unit Name 153**] for further management.
.
During his most recent hospitalization [**Date range (1) 52345**], He was treated
with unasyn for aspiration pneumonia.  He was discharged on
augmentin to complete the course on [**12-9**].  Given his probable
aspiration pneumonia, he was evaluated by speech and swallow at
the bedside who recommended pureed solids and nectar thick
liquids.  He was also started on flagyl for C. diff colitis
which he is to complete on [**12-16**].  Additionally, pt. had
movements that were originally thought c/w seizure.  Neurology
evaluated him and thought movements were likely dyskinesis from
Parkinson's.  With the restarting of Parkinson's medication, he
became more responsive.

MEDICAL HISTORY: 1. Parkinsons Dx [**2136**] in [**Country 651**]
2. ? H/O Stroke
3. GERD
4. BPH
5. ? Seizures
6. Fatigue
7. Atypical chest pain, noncardiac

MEDICATION ON ADMISSION: 1. Acetaminophen 650 mg PO Q6H prn
2. Entacapone 200 mg q4h w/ sinemet
3. Carbidopa-Levodopa 25-250 mg 1 PO Q 3AM, 6AM, 9AM, NOON, 3PM,
6 PM
4. Carbidopa-Levodopa 50-200 mg 1 PO Q9PM
5. Pramipexole 0.25 mg Tablet 1 PO TID
6. Trihexyphenidyl 2 mg Tablet 1 PO BID
7. Tamsulosin 0.4 mg Capsule 1 PO QHS
8. Lactulose 10 g/15 mL Syrup 30ML PO Q8H prn
9. Albuterol Sulfate 0.083 % Solution 1 neb Q6H prn
10. Docusate Sodium 100 mg PO BID
11. Multivitamin,Tx-Minerals 1 PO daily
12. Aspirin 325 mg Tablet 1 PO daily
13. Pantoprazole 40 mg Tablet 1 PO qdaily
14. Calcium Carbonate 500 mg Tablet 1 PO TID
15. Cholecalciferol (Vitamin D3) 800 unit daily
16. Flagyl 500 mg Tablet 1 PO q8h (to complete on [**2149-12-16**])
17. Augmentin 875-125 mg Tablet 1 PO bid (to complete [**2149-12-9**])
.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T 95.0 ax BP 121/61 HR 61 RR 14 100% on 2L NC
Gen:  Unresponsive, nonverbal, does not follow commands
HEENT: PERRL, MMM, shallow wound on chin.
Neck:  supple, +JVD to angle of jaw
CV:  RRR, No mrg
Resp: rhonchorus anteriorly with intermittent exp wheeze right
anterior chest
Abd: Decreased bowel sounds.  Thin. No guarding. No
organomegaly.  Gastric lavage w/ sl. pink fluid
Ext: B/L upper extremity decorticate posturing.  Able to bend
arms but w/ resistance.  2+ b/l LE edema to mid shins.  When
attempt to bend left arm at elbow, pt. moans.
Neuro: 1+ patellar reflexes. Unable to get biceps reflexes [**12-26**]
to stiffness and extensor posturing.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Lives at [**Location **].  Children and wife live locally.  From [**Country 651**]
originally, Cantonese speaking.  Denies tobacco, ETOH, and drugs 

### Response:
{'Unspecified septicemia,Hemorrhage of gastrointestinal tract, unspecified,Pneumonitis due to inhalation of food or vomitus,Congestive heart failure, unspecified,Acute respiratory failure,Esophageal reflux,Paralysis agitans,Severe sepsis'}
