CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 77-year-old
man with a long history of intermittent lower GI bleed
believed secondary to diverticulosis and hemorrhoids (as seen
on colonoscopy in [**2177-4-2**]) who had been having some
rectal bleeding.  His hematocrit dropped to 27.  He then
received 2 units of packed red blood cells at his
rehabilitation facility on the day of admission.  At this
time, he was noted to become more dyspneic.  The patient was
given Lasix, however, did not respond.  He was, therefore,
sent to the Emergency Department.

MEDICAL HISTORY: 1.  Type 2 diabetes.
2.  Hypertension.
3.  Diverticulosis and grade III hemorrhoids causing a
chronic lower GI bleed with the patient intermittently
requiring transfusion.
4.  Congestive heart failure with diastolic dysfunction. An
echocardiogram in [**2177-5-3**] showed an ejection fraction of
greater than 5%, trace aortic regurgitation, trace mitral
regurgitation, trivial tricuspid regurgitation.
5.  Paroxysmal atrial fibrillation, status post DCCV in [**2177-5-3**].
6.  Stress MIBI in [**2177-7-3**] showed a reversible
inferior wall defect, inferior wall hypokinesis.
7.  Spinal stenosis, status post laminectomy in [**2177-7-3**].
8.  Right hip fracture, status post ORIF in [**2177-12-3**].
9.  TIAs in [**2169**] and [**2177-3-3**] leading to garbled speech.
10. Prostate cancer, status post radiation therapy in [**2170**].
11. Status post appendectomy complicated by peritonitis in
[**2140**].
12. COPD with most recent pulmonary function tests in [**2168**]
showing an FEV1 of 50% of predicted and FVC 63% of predicted
and FEV1 to FVC ratio 80% of predicted.
13. Melanoma, status post excision.
14. Radiation proctitis.

MEDICATION ON ADMISSION: 1.  Amiodarone 200 mg p.o. q.d.
2.  Lasix 40 mg p.o. q.d.
3.  Verapamil CR 180 mg p.o. q.d.
4.  Moexipril 7.5 mg q.a.m., 11.25 mg q.p.m.
5.  Cilium one packet p.o. q.d.
6.  Zoloft 75 mg p.o. q.d.
7.  Lovenox 30 mg subcutaneously q. 12 hours.
8.  Regular insulin sliding scale.
9.  Tylenol 975 mg p.o. b.i.d.
10. Vitamin C 500 mg p.o. b.i.d.
11. Multivitamin.
12. Melatonin 1 mg p.o. q.h.s.
13. Glyburide 2.5 mg p.o. q.d.
14. Niferex 150 mg p.o. b.i.d.
15. Vioxx 25 mg p.o. q.d.
16. Senna two tablets p.o. q.h.s.
17. Atenolol 37.5 mg p.o. q.d.
18. Sublingual nitroglycerin p.r.n.
19. Milk of magnesia p.r.n.
20. Dulcolax p.r.n.
21. Anusol one per rectum b.i.d.
22. Colace 100 mg p.o. b.i.d.

ALLERGIES: The patient has no known drug allergies.
However, Percocet and codeine cause delirium and confusion.

PHYSICAL EXAM: 

FAMILY HISTORY: Positive for myocardial infarction.

SOCIAL HISTORY: The patient was working part-time as an
accountant up until his hip fracture in [**2177-12-3**].  He
has a 70 pack year history of smoking and quit in [**2141**].  The
patient rarely drinks alcohol.  He is married.  His health
care proxy is his son in-law, [**Name (NI) **] [**Last Name (NamePattern1) 8732**], phone number
[**Telephone/Fax (1) 8733**].  He currently was at rehabilitation at [**Hospital1 5595**] and
his family is looking into long-term care options as his
mobility is severely limited since his hip fracture.
Pneumonitis due to inhalation of food or vomitus,Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Atrial fibrillation,Chronic obstructive asthma, unspecified,Unspecified protein-calorie malnutrition
Food/vomit pneumonitis,Ac on chr diast hrt fail,Acute kidney failure NOS,Atrial fibrillation,Chronic obst asthma NOS,Protein-cal malnutr NOS
Admission Date:  [**2178-2-25**]     Discharge Date:  [**2178-3-7**]

Date of Birth:   [**2100-5-11**]     Sex:  M

Service:  ACOVE MEDICINE

ADMITTING DIAGNOSIS:  Shortness of breath.

HISTORY OF THE PRESENT ILLNESS:  The patient is a 77-year-old
man with a long history of intermittent lower GI bleed
believed secondary to diverticulosis and hemorrhoids (as seen
on colonoscopy in [**2177-4-2**]) who had been having some
rectal bleeding.  His hematocrit dropped to 27.  He then
received 2 units of packed red blood cells at his
rehabilitation facility on the day of admission.  At this
time, he was noted to become more dyspneic.  The patient was
given Lasix, however, did not respond.  He was, therefore,
sent to the Emergency Department.

In the Emergency Department, an initial ABG was 7.23/80/49.
There was a trial of noninvasive positive pressure
ventilation but the patient did not improve.  Therefore, he
was intubated.  A chest x-ray taken at this time showed
congestive heart failure with a right lower lobe effusion.
The patient was suctioned and this revealed thick pus.  In
the Emergency Department, the patient was given ceftriaxone 1
gram and azithromycin 1 gram.  He was also given 15 mg of
Kayexalate for a potassium of 5.5 in the setting of acute
renal failure with a BUN of 55 and creatinine of 2.3 up from
a baseline of 1.2.  A subclavian line was placed in the
Emergency Department.

After intubation, the patient's blood pressure dropped
briefly to a systolic of 70s.  It increased with 100 cc bolus
of normal saline.  The patient was admitted to the ICU for
further management.  The patient also received 120 mg of
Lasix IV in the Emergency Department.

PAST MEDICAL HISTORY:
1.  Type 2 diabetes.
2.  Hypertension.
3.  Diverticulosis and grade III hemorrhoids causing a
chronic lower GI bleed with the patient intermittently
requiring transfusion.
4.  Congestive heart failure with diastolic dysfunction. An
echocardiogram in [**2177-5-3**] showed an ejection fraction of
greater than 5%, trace aortic regurgitation, trace mitral
regurgitation, trivial tricuspid regurgitation.
5.  Paroxysmal atrial fibrillation, status post DCCV in [**2177-5-3**].
6.  Stress MIBI in [**2177-7-3**] showed a reversible
inferior wall defect, inferior wall hypokinesis.
7.  Spinal stenosis, status post laminectomy in [**2177-7-3**].
8.  Right hip fracture, status post ORIF in [**2177-12-3**].
9.  TIAs in [**2169**] and [**2177-3-3**] leading to garbled speech.
10. Prostate cancer, status post radiation therapy in [**2170**].
11. Status post appendectomy complicated by peritonitis in
[**2140**].
12. COPD with most recent pulmonary function tests in [**2168**]
showing an FEV1 of 50% of predicted and FVC 63% of predicted
and FEV1 to FVC ratio 80% of predicted.
13. Melanoma, status post excision.
14. Radiation proctitis.

MEDICATIONS ON ADMISSION:
1.  Amiodarone 200 mg p.o. q.d.
2.  Lasix 40 mg p.o. q.d.
3.  Verapamil CR 180 mg p.o. q.d.
4.  Moexipril 7.5 mg q.a.m., 11.25 mg q.p.m.
5.  Cilium one packet p.o. q.d.
6.  Zoloft 75 mg p.o. q.d.
7.  Lovenox 30 mg subcutaneously q. 12 hours.
8.  Regular insulin sliding scale.
9.  Tylenol 975 mg p.o. b.i.d.
10. Vitamin C 500 mg p.o. b.i.d.
11. Multivitamin.
12. Melatonin 1 mg p.o. q.h.s.
13. Glyburide 2.5 mg p.o. q.d.
14. Niferex 150 mg p.o. b.i.d.
15. Vioxx 25 mg p.o. q.d.
16. Senna two tablets p.o. q.h.s.
17. Atenolol 37.5 mg p.o. q.d.
18. Sublingual nitroglycerin p.r.n.
19. Milk of magnesia p.r.n.
20. Dulcolax p.r.n.
21. Anusol one per rectum b.i.d.
22. Colace 100 mg p.o. b.i.d.

ALLERGIES:  The patient has no known drug allergies.
However, Percocet and codeine cause delirium and confusion.

SOCIAL HISTORY:  The patient was working part-time as an
accountant up until his hip fracture in [**2177-12-3**].  He
has a 70 pack year history of smoking and quit in [**2141**].  The
patient rarely drinks alcohol.  He is married.  His health
care proxy is his son in-law, [**Name (NI) **] [**Last Name (NamePattern1) 8732**], phone number
[**Telephone/Fax (1) 8733**].  He currently was at rehabilitation at [**Hospital1 5595**] and
his family is looking into long-term care options as his
mobility is severely limited since his hip fracture.

FAMILY HISTORY:  Positive for myocardial infarction.

PHYSICAL EXAMINATION ON ADMISSION:  Vital signs:  Temperature
95.2, blood pressure 133/45, heart rate 50, respiratory rate
22, saturating 60% on room air.  The patient was then
intubated and had a blood pressure of 111/49, heart rate 55,
respiratory rate 12, saturating 100% on AC 500 times 12 with
a PEEP of 5.  General:  The patient was sedated and
intubated.  He responded only to pain.  HEENT:  The pupils
were 2 mm and reactive bilaterally.  The head was
normocephalic, atraumatic.  JVD 10 cm at 30 degrees.  The
tympanic membranes were normal.  There was no lymphadenopathy
in the head or neck.  Pulmonary:  Coarse bronchial breath
sounds and rhonchi scattered bilaterally.  Heart:  The heart
rate was bradycardiac.  The rate was regular.  There was a
summation gallop.  There were no murmurs.  Abdomen: Soft,
nontender, nondistended.  Bowel sounds were present.  There
was ecchymoses bilaterally in the lower quadrants likely from
Lovenox.  Extremities:  There was 2+ pitting edema.  There
was no clubbing or cyanosis.  The dorsalis pedis pulses were
2+ bilaterally.  The patient had a sacral decubitus ulcer.
The right hip surgical scar was well healed.

LABORATORY DATA:  White count 15.9, hematocrit 40.0,
platelets 218,000.  Sodium 139, potassium 5.5, chloride 98,
bicarbonate 30, BUN 55, creatinine 2.3, glucose 108.  PT
13.1, INR 1.1, PTT 32.4.

The urinalysis showed a small amount of blood, 30 protein,
negative glucose, negative ketones, negative leukocyte
esterase, negative nitrates.  The pH was 5.0.  There were [**2-4**]
red blood cells, 0 white blood cells, and occasional
bacteria.

An EKG showed sinus bradycardia at 50 beats per minute.
There was left axis deviation.  There was a possible old MI
with Q in V1.  There was T wave flattening in III and aVF.
There was a prolonged QT interval of 500.  There were U waves
in the precordium.

Chest x-ray showed bilateral patchy opacities with a right
pleural effusion with the diagnosis of congestive heart
failure versus multifocal pneumonia.

HOSPITAL COURSE:  1.  PULMONARY:  The patient was initially
intubated and transferred to the ICU.  His respiratory
failure was felt to be multifactorial.  However, pneumonia
seemed most likely.  The patient was also noted to have
impaired pulmonary function at baseline secondary to COPD.
The patient was initially started on vancomycin, ceftriaxone
and azithromycin for treatment of pneumonia.  Sputum culture
eventually grew out MRSA.  The patient's effusion was not
amenable to tap.  It was evaluated by ultrasound and felt to
be nontappable.  Therefore, the patient did not have a
thoracentesis.

The patient was maintained on intubation and ventilation.  He
was also maintained on inhalers for his COPD.  The patient
was extubated on [**2178-2-27**] and did well from a pulmonary
point of view.  He was called out to the floor on [**2178-2-28**].

That evening, the patient was given his evening medications
and was noted to aspirate.  The patient desatted to the 60s
on a nonrebreather mask.  He became unresponsive.  The
patient was then intubated for likely aspiration and
transferred back to the ICU.  The patient was maintained on
his antibiotics.  He did well in the ICU from a pulmonary
point of view and was then extubated on [**2178-3-3**].

He was transferred to the floor on [**2178-3-4**].  The
patient's mental status was noted to be quite changed after
his second extubation.  He failed a swallow study and was
kept n.p.o.  He seemed to be doing well from a pulmonary
point of view.  However, the patient, after much discussion
with his family, was made DNR/DNI.  He was then found
deceased in the early morning of [**2178-3-7**].  It is
thought that he may have passed away from a pulmonary event.

2.  RENAL:  The patient was noted to be in acute renal
failure on admission.  This was felt to be secondary to
overdiuresis.  The patient was given IV normal saline and his
renal function improved somewhat.  By the time that he was
called out to the floor, the patient's creatinine was down to
his baseline of 0.8.

However, when the patient was intubated a second time, his
blood pressure dropped again to the 60s to 70s and he
transiently required dopamine.  After that, the patient's
renal function worsened.  This was felt to be secondary to
ATN from hypotension.  His creatinine continued to climb up
to as high as 1.7 on the day of his death.

3.  ATRIAL FIBRILLATION:  The patient came in in sinus
rhythm.  He intermittently went into atrial fibrillation
while in the ICU.  However, the patient then spontaneously
converted to sinus rhythm.  The patient was maintained on
Amiodarone and it was felt that as he had returned to sinus
rhythm that he did not require anticoagulation.

4.  GASTROINTESTINAL:  The patient has a long history of GI
bleeding.  This was not a factor during this admission.  The
patient's crits were followed q.d. and remained relatively
stable in the mid 30s.

5.  DIABETES:  The patient has a history of type 2 diabetes.
He was maintained on a regular insulin sliding scale.  The
patient was unable to take p.o.  He was not kept on his oral
hypoglycemics.

6.  NEUROLOGY:  After his first extubation, the patient
appeared to be doing well from a neurological point of view.
He was somewhat confused but was able to converse normally.
However, after his second extubation, the patient's mental
status was significantly worse.  He was not oriented to
place, time, or person.  He was unable to converse and was
very agitated.  This may have been secondary to hypoxia at
the time of his second intubation.

7.  NUTRITION:  The patient was maintained on tube feeds
while in the ICU and intubated.  After his second transfer to
the floor, the patient's mental status was such that he was
unable to take p.o.  The patient failed a bedside swallow
evaluation and was not oriented enough to undergo a video
swallow study.  After much discussion with the patient's wife
as well as his health care proxy, his son in-law, [**Name (NI) **]
[**Last Name (NamePattern1) 8732**], the family decided against placement of a PEG tube.

The family at that time wished to maintain the patient on IV
fluids for hydration and to see if his mental status
improved.  At that time, the family made the patient DNR/DNI.
The patient then passed away before any final decisions could
be made about his nutrition.

8.  PROPHYLAXIS:  The patient was maintained on either a
proton pump inhibitor or an H2 blocker throughout his stay in
the hospital.  The patient was not on subcutaneous heparin
prophylactically as he was HIT antibody positive.  He was
maintained on pneumoboots throughout his stay in the
hospital.

9.  CODE STATUS:  The patient was initially a full code.
However, after his second transfer to the floor and his
worsened mental status, the family made the decision to have
the patient made DNR/DNI.  The patient was then found
deceased on the floor the next day and was not coded.

DISCHARGE DIAGNOSIS:
1.  Methicillin-resistant Staphylococcus aureus pneumonia
complicated by respiratory arrest.
2.  Aspiration leading to respiratory arrest.
3.  Pleural effusions.
4.  Acute renal failure secondary to dehydration.
5.  Acute renal failure secondary to acute tubular necrosis,
secondary to hypotension.
6.  Confusion, likely secondary to hypoxic brain injury.
7.  Atrial fibrillation.
8.  Type 2 diabetes.
9.  Hypertension.
10. History of gastrointestinal bleed secondary to
diverticulosis and grade III hemorrhoids.
11. Congestive heart failure with diastolic dysfunction.
12. Spinal stenosis, status post laminectomy.
13. Right hip fracture, status post open reduction and
internal fixation.
14. History of transient ischemic attacks in [**2169**] and [**2176**].
15. Prostate cancer, status post radiation therapy.
16. Status post appendectomy complicated by peritonitis in
[**2140**].
17. Chronic obstructive pulmonary disease.
18. Melanoma, status post excision.
19. Radiation proctitis.

DISCHARGE:  The patient was pronounced dead at 3:20 a.m. on
[**2178-3-7**].




                          [**Name6 (MD) 251**] [**Name8 (MD) **], M.D.  [**MD Number(1) 910**]

Dictated By:[**Last Name (NamePattern1) 222**]

MEDQUIST36

D:  [**2178-3-16**]  10:22
T:  [**2178-3-16**]  12:13
JOB#:  [**Job Number 8734**]


Name:  [**Known lastname **], [**Known firstname **]                     Unit No:  [**Numeric Identifier 1169**]

Admission Date:  [**2178-2-25**]     Discharge Date:  [**2178-3-8**]

Date of Birth:   [**2100-5-11**]     Sex:  M

Service:  ACOVE

ADDENDUM:  This is an Addendum to the Discharge Summary
covering the admission from [**2178-2-25**] until [**2178-3-8**].

The patient died on [**2178-3-8**].  The previous Discharge
Summary improperly stated the date of death as [**2178-3-7**].




                          [**Name6 (MD) 116**] [**Name8 (MD) 117**], M.D.  [**MD Number(1) 118**]

Dictated By:[**Last Name (NamePattern1) 1170**]

MEDQUIST36

D:  [**2178-5-21**]  15:52
T:  [**2178-5-21**]  15:54
JOB#:  [**Job Number 1171**]
{'Pneumonitis due to inhalation of food or vomitus,Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Atrial fibrillation,Chronic obstructive asthma, unspecified,Unspecified protein-calorie malnutrition'}


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: The patient is a 77-year-old
man with a long history of intermittent lower GI bleed
believed secondary to diverticulosis and hemorrhoids (as seen
on colonoscopy in [**2177-4-2**]) who had been having some
rectal bleeding.  His hematocrit dropped to 27.  He then
received 2 units of packed red blood cells at his
rehabilitation facility on the day of admission.  At this
time, he was noted to become more dyspneic.  The patient was
given Lasix, however, did not respond.  He was, therefore,
sent to the Emergency Department.

MEDICAL HISTORY: 1.  Type 2 diabetes.
2.  Hypertension.
3.  Diverticulosis and grade III hemorrhoids causing a
chronic lower GI bleed with the patient intermittently
requiring transfusion.
4.  Congestive heart failure with diastolic dysfunction. An
echocardiogram in [**2177-5-3**] showed an ejection fraction of
greater than 5%, trace aortic regurgitation, trace mitral
regurgitation, trivial tricuspid regurgitation.
5.  Paroxysmal atrial fibrillation, status post DCCV in [**2177-5-3**].
6.  Stress MIBI in [**2177-7-3**] showed a reversible
inferior wall defect, inferior wall hypokinesis.
7.  Spinal stenosis, status post laminectomy in [**2177-7-3**].
8.  Right hip fracture, status post ORIF in [**2177-12-3**].
9.  TIAs in [**2169**] and [**2177-3-3**] leading to garbled speech.
10. Prostate cancer, status post radiation therapy in [**2170**].
11. Status post appendectomy complicated by peritonitis in
[**2140**].
12. COPD with most recent pulmonary function tests in [**2168**]
showing an FEV1 of 50% of predicted and FVC 63% of predicted
and FEV1 to FVC ratio 80% of predicted.
13. Melanoma, status post excision.
14. Radiation proctitis.

MEDICATION ON ADMISSION: 1.  Amiodarone 200 mg p.o. q.d.
2.  Lasix 40 mg p.o. q.d.
3.  Verapamil CR 180 mg p.o. q.d.
4.  Moexipril 7.5 mg q.a.m., 11.25 mg q.p.m.
5.  Cilium one packet p.o. q.d.
6.  Zoloft 75 mg p.o. q.d.
7.  Lovenox 30 mg subcutaneously q. 12 hours.
8.  Regular insulin sliding scale.
9.  Tylenol 975 mg p.o. b.i.d.
10. Vitamin C 500 mg p.o. b.i.d.
11. Multivitamin.
12. Melatonin 1 mg p.o. q.h.s.
13. Glyburide 2.5 mg p.o. q.d.
14. Niferex 150 mg p.o. b.i.d.
15. Vioxx 25 mg p.o. q.d.
16. Senna two tablets p.o. q.h.s.
17. Atenolol 37.5 mg p.o. q.d.
18. Sublingual nitroglycerin p.r.n.
19. Milk of magnesia p.r.n.
20. Dulcolax p.r.n.
21. Anusol one per rectum b.i.d.
22. Colace 100 mg p.o. b.i.d.

ALLERGIES: The patient has no known drug allergies.
However, Percocet and codeine cause delirium and confusion.

PHYSICAL EXAM: 

FAMILY HISTORY: Positive for myocardial infarction.

SOCIAL HISTORY: The patient was working part-time as an
accountant up until his hip fracture in [**2177-12-3**].  He
has a 70 pack year history of smoking and quit in [**2141**].  The
patient rarely drinks alcohol.  He is married.  His health
care proxy is his son in-law, [**Name (NI) **] [**Last Name (NamePattern1) 8732**], phone number
[**Telephone/Fax (1) 8733**].  He currently was at rehabilitation at [**Hospital1 5595**] and
his family is looking into long-term care options as his
mobility is severely limited since his hip fracture. 

### Response:
{'Pneumonitis due to inhalation of food or vomitus,Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Atrial fibrillation,Chronic obstructive asthma, unspecified,Unspecified protein-calorie malnutrition'}
