CHIEF COMPLAINT: tachypnea and altered mental status

PRESENT ILLNESS: 55 year old man with reported h/o lung CA and with EtOH
dependence found on the street by EMS.  He was brought in to ED,
mainly complaining of HA. Initial vitals were WNL; however,
after 2 hours in the ED, the patient spiked a temperature of
103, and had a HR 110, SBP 170s, RR 40s and decreased O2 sat.
The ED staff were concerned for PE, infectious process, COPD,
vs. EtOH withdrawl. He was treated with valium (10 mg IV once),
solumedrol, nebs, magnesium, levo/flagyl/ceftriaxone (2gx1) and
vanc.  A CTA was negative for PE (but found lung nodules).  He
also got a head CT, abd/pelvic CT which were pending at the time
of admission to the MICU.  When called to see pt (4h after above
interventions) the patient was snoring, 99%on 4L, RR22, with ABG
7.36/41/105.

MEDICAL HISTORY: Depression
Lung CA (metastatic adenocarcinoma of unknown primary)
EtOH dependence

MEDICATION ON ADMISSION: Zoloft

ALLERGIES: Penicillins

PHYSICAL EXAM: T = 100.9; BP = 127/70; HR = 109
GEN: snoring, somnolent, NAD, arousable, following simple
commands
HEENT: PERRL 3-->2 mm bilaterally
CV: tachy, no mumurs
RESP: diffuse bilateral wheezing
ABD: NABS, no grimacing with palpation
EXT: 2 + edema of the hands bilaterally; no pedal edema

FAMILY HISTORY: unknown

SOCIAL HISTORY: homeless, EtOH dependence([**12-30**] gallon vodka daily), tobacco use.
Pneumonia, organism unspecified,Obstructive chronic bronchitis with (acute) exacerbation,Alcohol withdrawal,Other and unspecified alcohol dependence, continuous,Acidosis,Secondary malignant neoplasm of lung,Other malignant neoplasm without specification of site,Lack of housing
Pneumonia, organism NOS,Obs chr bronc w(ac) exac,Alcohol withdrawal,Alcoh dep NEC/NOS-contin,Acidosis,Secondary malig neo lung,Malignant neoplasm NOS,Lack of housing
Admission Date:  [**2115-4-9**]              Discharge Date:   [**2115-4-10**]

Date of Birth:  [**2059-4-24**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
tachypnea and altered mental status

Major Surgical or Invasive Procedure:
None


History of Present Illness:
55 year old man with reported h/o lung CA and with EtOH
dependence found on the street by EMS.  He was brought in to ED,
mainly complaining of HA. Initial vitals were WNL; however,
after 2 hours in the ED, the patient spiked a temperature of
103, and had a HR 110, SBP 170s, RR 40s and decreased O2 sat.
The ED staff were concerned for PE, infectious process, COPD,
vs. EtOH withdrawl. He was treated with valium (10 mg IV once),
solumedrol, nebs, magnesium, levo/flagyl/ceftriaxone (2gx1) and
vanc.  A CTA was negative for PE (but found lung nodules).  He
also got a head CT, abd/pelvic CT which were pending at the time
of admission to the MICU.  When called to see pt (4h after above
interventions) the patient was snoring, 99%on 4L, RR22, with ABG
7.36/41/105.


Past Medical History:
Depression
Lung CA (metastatic adenocarcinoma of unknown primary)
EtOH dependence

Social History:
homeless, EtOH dependence([**12-30**] gallon vodka daily), tobacco use.


Family History:
unknown

Physical Exam:
T = 100.9; BP = 127/70; HR = 109
GEN: snoring, somnolent, NAD, arousable, following simple
commands
HEENT: PERRL 3-->2 mm bilaterally
CV: tachy, no mumurs
RESP: diffuse bilateral wheezing
ABD: NABS, no grimacing with palpation
EXT: 2 + edema of the hands bilaterally; no pedal edema


Pertinent Results:
[**2115-4-8**] 10:50PM BLOOD WBC-14.7* RBC-4.81 Hgb-15.1 Hct-45.0
MCV-93 MCH-31.3 MCHC-33.5 RDW-15.3 Plt Ct-278
[**2115-4-8**] 10:50PM BLOOD Neuts-80.4* Lymphs-12.2* Monos-5.9
Eos-1.3 Baso-0.3
[**2115-4-8**] 10:50PM BLOOD Plt Ct-278
[**2115-4-8**] 10:50PM BLOOD PT-13.5 PTT-27.9 INR(PT)-1.2
[**2115-4-8**] 10:50PM BLOOD Glucose-63* UreaN-10 Creat-0.6 Na-140
K-4.1 Cl-100 HCO3-23 AnGap-21*
[**2115-4-8**] 10:50PM BLOOD ALT-62* AST-43* CK(CPK)-99 AlkPhos-105
Amylase-67 TotBili-0.9
[**2115-4-8**] 10:50PM BLOOD Lipase-23
[**2115-4-8**] 10:50PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2115-4-8**] 10:50PM BLOOD Albumin-4.4 Calcium-10.1 Phos-4.0 Mg-1.9
[**2115-4-8**] 10:50PM BLOOD ASA-NEG Ethanol-146* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2115-4-9**] 03:23AM BLOOD Lactate-1.9
[**2115-4-9**] 05:11AM BLOOD Lactate-1.5
[**2115-4-9**] 06:11AM BLOOD Lactate-0.9
*
CT HEAD W/O CONTRAST  [**2115-4-9**] 5:15 AM
FINDINGS: There is no overt sign for the presence of an
intracranial mass. There is a tiny area of low density within
the body of the left caudate nucleus, likely representing a
chronic lacunar infarct. There is mild prominence of the
ventricles and cortical sulci of the brain, suggesting mild
atrophic change. There is no shift of normally midline
structures. There is a symmetric irregular lucent appearance of
the occipital bone, on either side of the midline. It would be
helpful to know if there was any prior surgery in this area, as
in the evaluation and treatment of craniosynostosis. The
remaining osseous and soft tissue structures are notable for
discontinuity of the bony nasal septum, raising the question of
a fracture, of indeterminate age.
*
CTA CHEST W&W/O C &RECONS  [**2115-4-9**] 3:05 AM
CT ANGIOGRAM CHEST: There are no filling defects within the
pulmonary artery, proximal, or distal branches to suggest the
presence of a pulmonary embolism. There are coronary artery
calcifications, and arthrosclerotic plaque along the aorta.
There is no pleural, or pericardial effusion. There is no
significant axillary, mediastinal, or hilar lymphadenopathy.
Lung windows reveal panacinar emphysema, with a 1.8 x 0.9 mm
spiculated nodule within the left lower lobe anteriorly, as well
as a 9 x 9 mm spiculated nodule within the right middle lobe,
with surrounding peribronchial thickening. Additionally, a 7 x 6
mm rounded nodule is seen within the right upper lobe. Finally,
within the right middle lobe, anteriorly, there is a 5 x 9 mm
spiculated nodule, with surrounding acinar, and paraseptal
thickening. The airways are patent to the level of the segmental
bronchi bilaterally. Limited imaging through the abdomen
demonstrates diffuse atherosclerotic disease, and calcifications
within the pancreas consistent with chronic pancreatitis.
BONE WINDOWS: There are no suspicious lytic or sclerotic osseous
abnormalities. Degenerative changes are seen along the thoracic
spine.
Coronal and sagittal reformatted images confirm the axial
findings. MPR value grade 3.
IMPRESSION:
1) No evidence of pulmonary embolism.
2) Multiple spiculated nodules within the right upper lobe,
right middle lobe, and left lower lobe.
3) Panacinar emphysema.
4) Diffuse atherosclerotic disease.
*
CT ABDOMEN W/O CONTRAST  [**2115-4-9**] 5:16 AM
CT ABDOMEN WITH ORAL, WITHOUT IV CONTRAST: Lung bases
demonstrate focal opacities within the right posterior and
anterior lung bases. There is atherosclerotic disease, with mild
coronary artery calcifications. Imaging the abdomen is limited
secondary to the lack of intravenous contrast. Allowing for
this, the liver is normal attenuation. Gallbladder, pancreas,
spleen, both adrenals, and the kidneys are normal. Both kidneys
excrete contrast symmetrically from prior exam. There is diffuse
atherosclerotic disease along the abdominal aorta, and iliacs.
Intra-abdominal loops of large and small bowel are normal in
contour and caliber. There are no intra- abdominal fluid
collections, or masses. There is no mesenteric or
retroperitoneal lymphadenopathy. There is no free air and no
free fluid.
CT PELVIS WITHOUT ORAL, WITHOUT INTRAVENOUS CONTRAST: Contrast
is seen filling the bladder. There is a Foley catheter. The
distal ureters, sigmoid, and rectum are normal. Right-sided
central venous catheter is seen extending from a right femoral
vein to the level of the iliac crest. There is no inguinal or
pelvic lymphadenopathy. There is no free air and no free fluid.
Multiple prosthetic calcifications are noted.
BONE WINDOWS: There are no suspicious lytic or sclerotic osseous
abnormalities.
IMPRESSION:
1) No intra-abdominal fluid collections. No free air. No
evidence of obstruction.
2) Multifocal opacities within bilateral lung bases consistent
with patient's history of lung cancer, and possibly representing
lymphangitic spread versus multifocal pneumonia. Clinical
correlation is requested.
3) Atherosclerotic disease, without evidence of aneurysmal
dilatation.
*
CHEST (PA & LAT)  [**2115-4-9**] 1:59 AM
There are vague linear opacities in the right and left lower
lung zones, consistent with the patient's CT scan showing
spiculated nodules in these regions. Flattening of both
diaphragms, increased AP diameter and retrosternal clear space,
and attenuation of vascular markings in the upper lobes indicate
emphysematous changes. The cardiac, mediastinal, and hilar
contours are within normal limits.
IMPRESSION: Patchy opacities in bilateral lower lung zones,
consistent with the patient's CT scan showing spiculated nodules
in those areas. No acute cardiopulmonary process identified.


Brief Hospital Course:
Mr. [**Known lastname 7049**] is a 55 year old homeless man with h/o lung CA
(metastatic adenocarcinoma of unknown primary) and EtOH
dependence who was admitted after being found on the street by
EMS.  It appeared that he began to show signs and symptoms of
alcohol withdrawal in the ED with increase in heart rate, blood
pressure, and respiratory rate.  He also spiked a temprature and
became short of breath. Since there was concern for PE,
infectious process, COPD, vs. EtOH withdrawl in the ED, was
treated with valium (10 mg IV once), solumedrol, nebs,
magnesium, levo/flagyl/ceftriaxone (2gx1) and vanc.  A CTA was
negative for PE, head CT was negative for bleed, and abd/pelvic
CT was negative for intra-abdominal source for infection.
Although he had a fever with headache, the patient refused an
LP.  He was admitted to the MICU for further monitoring.
.
In the MICU, he was monitored on a CIWA scale with PRN valium.
He did well overnight with improvement in his mental status and
minimal valium requriments.  The following day, the ceftriaxone
and vancomycin were discontinued because there was a very low
suspicion for meningitis in this patient.  Given his altered
mental status on admission, there was some concern for
aspiration so he was continued on levofloxacin.  He was also
continued on a very short prednisone taper for the possibility
of COPD exacerbation given wheezes on exam.
.
The day following admission, the patient was markedly clinically
improved.  The decision was made to discharge the patient from
the hospital given his stable condition.  He was offered social
support for alcohol detox several times; however, refused
stating that he would go to AA after discharge.  A follow up
appointment was set up for Mr. [**Known lastname 7049**] to be seen with his
provider [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 75571**], [**Hospital1 93429**] within one week of discharge.

Medications on Admission:
Zoloft

Discharge Medications:
1. Multivitamin     Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
5. Prednisone 10 mg Tablet Sig: As directed Tablet PO once a day
for 4 days: Day 1 - take 4 tabs
Day 2 - take 3 tabs
Day 3 - take 2 tabs
Day 4 - take 1 tab.
Disp:*10 Tablet(s)* Refills:*0*
6. Albuterol 90 mcg/Actuation Aerosol Sig: One (1)  Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
Disp:*1 INH* Refills:*2*
7. Wellbutrin 75 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
1) Alcohol Withdrawal
2) COPD exacerbation
3) Pneumonia


Discharge Condition:
Stable

Discharge Instructions:
Please take your medications as prescribed.  Please return to
the Emergency Room if you experience difficulty breathing, chest
pain, or fever/chills.

Followup Instructions:
Please follow as follows:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 75571**], NP
[**Last Name (LF) 766**], [**4-15**] at 9:30AM
[**Hospital3 1563**] Hosp; [**Doctor Last Name **] Building [**Apartment Address(1) 101515**]


                             [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
{'Pneumonia, organism unspecified,Obstructive chronic bronchitis with (acute) exacerbation,Alcohol withdrawal,Other and unspecified alcohol dependence, continuous,Acidosis,Secondary malignant neoplasm of lung,Other malignant neoplasm without specification of site,Lack of housing'}


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: tachypnea and altered mental status

PRESENT ILLNESS: 55 year old man with reported h/o lung CA and with EtOH
dependence found on the street by EMS.  He was brought in to ED,
mainly complaining of HA. Initial vitals were WNL; however,
after 2 hours in the ED, the patient spiked a temperature of
103, and had a HR 110, SBP 170s, RR 40s and decreased O2 sat.
The ED staff were concerned for PE, infectious process, COPD,
vs. EtOH withdrawl. He was treated with valium (10 mg IV once),
solumedrol, nebs, magnesium, levo/flagyl/ceftriaxone (2gx1) and
vanc.  A CTA was negative for PE (but found lung nodules).  He
also got a head CT, abd/pelvic CT which were pending at the time
of admission to the MICU.  When called to see pt (4h after above
interventions) the patient was snoring, 99%on 4L, RR22, with ABG
7.36/41/105.

MEDICAL HISTORY: Depression
Lung CA (metastatic adenocarcinoma of unknown primary)
EtOH dependence

MEDICATION ON ADMISSION: Zoloft

ALLERGIES: Penicillins

PHYSICAL EXAM: T = 100.9; BP = 127/70; HR = 109
GEN: snoring, somnolent, NAD, arousable, following simple
commands
HEENT: PERRL 3-->2 mm bilaterally
CV: tachy, no mumurs
RESP: diffuse bilateral wheezing
ABD: NABS, no grimacing with palpation
EXT: 2 + edema of the hands bilaterally; no pedal edema

FAMILY HISTORY: unknown

SOCIAL HISTORY: homeless, EtOH dependence([**12-30**] gallon vodka daily), tobacco use. 

### Response:
{'Pneumonia, organism unspecified,Obstructive chronic bronchitis with (acute) exacerbation,Alcohol withdrawal,Other and unspecified alcohol dependence, continuous,Acidosis,Secondary malignant neoplasm of lung,Other malignant neoplasm without specification of site,Lack of housing'}
