CHIEF COMPLAINT: Unresponsiveness.

PRESENT ILLNESS: Mr. [**Known lastname 931**] is a [**Age over 90 **] year old gentleman wiht a PMH significant
for CAD, COPD on 2L nc at night, PE on coumadin, mild AS, and DM
2 transferred to the CCU for unresponsiveness. The patient was
initially admitted to an OSH for unresponsiveness and slurred
speech that spontaneously resolved. At that time, he denied any
chest pain, but does endorse dyspnea with exertion and
occasional exertional chest pain when walking from his bed to
the bathroom.  At the OSH, the patient had a CTH that was
negative and carotid dopplers that demonstrated severe bilateral
carotid stenosis. He was also noted to have a right foot ulcer
for which he received amp/sulbactam and was transfused 1 unit
pRBCs on the morning of [**2174-9-25**] for a hemoglobin of 10.0.  Of
note, the patient was scheduled for an outpatient
revascularization procedure of the RLE on [**2174-9-27**] prior to this
admission.
.
On initial arrival, the patient was noted to be mildly fluid
overloaded and noted that he had increased lower extremity edema
for the past 2 weeks. A CXR demonstrated mild pulmonary edema
and increased pulmonary vascular congestion with a BNP of 2200.
This morning, the patient was found to be unresponsive. On
initial exam, he was noted to have convulsions, which were not
tonic-clonic in nature.  ABG on 2L nc 7.40/62/91 and the patient
received 40 mg IV lasix.  He regained consciousness within
minutes, although remained confused and unable to follow
commands for several minutes without any stool incontinence (FC
in place).
.
Currently, he is resting comfortably without complaints. Denies
CP/SOB, f/c/s, n/v/d, abd pain, HA, palpitations, diaphoresis,
or pain radiating to jaw or arm.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope
or presyncope.

MEDICAL HISTORY: Coronary Artery Disease s/p cath [**6-23**] with occlusion of LAD and
collaterals, medically managed
Aortic stenosis - mild on cath ([**6-23**]), mean peak to peak
gradient of 28 mmHg.
PE ([**4-23**])
COPD - 2L supplemental oxygen at night
Restrictive lung disease (per report)
Diabetes Mellitus
Obesity
arthritis
Paralysed left hemi-diaphragm
Appendectomy
prior knee surgery

MEDICATION ON ADMISSION: Lipitor 80mg PO qday
Metoprolol 25mg PO BID
Ranitidine 150mg PO BID
Lorazepam .5mg PO qHS
Coumadin 5mg four days per week (per d/c summary, was M/T/W/F)
Coumadin 7.5mg 3 days per week (per d/c summary, was
Sat/Sun/[**Last Name (un) **])
Glipizide 10mg PO BID
Gabapentin 100mg PO TID
Isosorbide 60mg PO qday
Lasix 40mg PO qday
Atenolol 25mg PO qday
Insulin 20 units SC qday (type not specified)
Prednisone 10 [**Hospital1 **] (for hyper-eosinophilia)

ALLERGIES: Lisinopril / Zoloft

PHYSICAL EXAM: VS: 97 67 [**10/2119**] 89%1L nc
GENERAL: Age appropriate male in NAD
HEENT: Perrl, eomi, sclerae anicteric. MMM, OP clear without
lesions, exudate, or erythema.
CV: Nl S1+S2, II/VI systolic murmur throughout precordium
loudest at the base. Unable to ascertain JVP.
Pulm: Decreased breathsounds at left base. No wheezes.
Abd: S/NT/ND +bs
Ext: 1+ edema bilaterally. Unable to palpate dp/pt pulses
Neuro: Oriented to person and time. CN II-XII intact.
Skin: RLE bandaged. 2x2 cm ulcuer with eschar. No surrounding
erythema.

FAMILY HISTORY: Mother had a stroke, [**Name (NI) **] CHF, Daughter with leukemia, Son died
of "cancer".

SOCIAL HISTORY: He is a widower who lives with his daughter in [**Name (NI) 83153**].  Tobacco
history: history of 1 ppd x 2 years, quit in 60s
Disorders of diaphragm,Acute on chronic diastolic heart failure,Other specified septicemias,Sepsis,Acidosis,Ulcer of heel and midfoot,Pulmonary collapse,Other respiratory abnormalities,Adrenal cortical steroids causing adverse effects in therapeutic use,Obesity, unspecified,Other convulsions,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Coronary atherosclerosis of native coronary artery,Chronic airway obstruction, not elsewhere classified,Other dependence on machines, supplemental oxygen,Atherosclerosis of native arteries of the extremities with ulceration,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Personal history of venous thrombosis and embolism,Iron deficiency anemia, unspecified
Disorders of diaphragm,Ac on chr diast hrt fail,Septicemia NEC,Sepsis,Acidosis,Ulcer of heel & midfoot,Pulmonary collapse,Respiratory abnorm NEC,Adv eff corticosteroids,Obesity NOS,Convulsions NEC,Ocl crtd art wo infrct,Crnry athrscl natve vssl,Chr airway obstruct NEC,Depend-supplement oxygen,Ath ext ntv art ulcrtion,DMII wo cmp nt st uncntr,Long-term use of insulin,Hx-ven thrombosis/embols,Iron defic anemia NOS
Admission Date:  [**2174-9-25**]              Discharge Date:   [**2174-10-4**]


Service: MEDICINE

Allergies:
Lisinopril / Zoloft

Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
Unresponsiveness.

Major Surgical or Invasive Procedure:
Right lower extremity laser angioplasty on [**9-29**]/9.

History of Present Illness:
Mr. [**Known lastname 931**] is a [**Age over 90 **] year old gentleman wiht a PMH significant
for CAD, COPD on 2L nc at night, PE on coumadin, mild AS, and DM
2 transferred to the CCU for unresponsiveness. The patient was
initially admitted to an OSH for unresponsiveness and slurred
speech that spontaneously resolved. At that time, he denied any
chest pain, but does endorse dyspnea with exertion and
occasional exertional chest pain when walking from his bed to
the bathroom.  At the OSH, the patient had a CTH that was
negative and carotid dopplers that demonstrated severe bilateral
carotid stenosis. He was also noted to have a right foot ulcer
for which he received amp/sulbactam and was transfused 1 unit
pRBCs on the morning of [**2174-9-25**] for a hemoglobin of 10.0.  Of
note, the patient was scheduled for an outpatient
revascularization procedure of the RLE on [**2174-9-27**] prior to this
admission.
.
On initial arrival, the patient was noted to be mildly fluid
overloaded and noted that he had increased lower extremity edema
for the past 2 weeks. A CXR demonstrated mild pulmonary edema
and increased pulmonary vascular congestion with a BNP of 2200.
This morning, the patient was found to be unresponsive. On
initial exam, he was noted to have convulsions, which were not
tonic-clonic in nature.  ABG on 2L nc 7.40/62/91 and the patient
received 40 mg IV lasix.  He regained consciousness within
minutes, although remained confused and unable to follow
commands for several minutes without any stool incontinence (FC
in place).
.
Currently, he is resting comfortably without complaints. Denies
CP/SOB, f/c/s, n/v/d, abd pain, HA, palpitations, diaphoresis,
or pain radiating to jaw or arm.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope
or presyncope.

Past Medical History:
Coronary Artery Disease s/p cath [**6-23**] with occlusion of LAD and
collaterals, medically managed
Aortic stenosis - mild on cath ([**6-23**]), mean peak to peak
gradient of 28 mmHg.
PE ([**4-23**])
COPD - 2L supplemental oxygen at night
Restrictive lung disease (per report)
Diabetes Mellitus
Obesity
arthritis
Paralysed left hemi-diaphragm
Appendectomy
prior knee surgery

Social History:
He is a widower who lives with his daughter in [**Name (NI) 83153**].  Tobacco
history: history of 1 ppd x 2 years, quit in 60s

Family History:
Mother had a stroke, [**Name (NI) **] CHF, Daughter with leukemia, Son died
of "cancer".

Physical Exam:
VS: 97 67 [**10/2119**] 89%1L nc
GENERAL: Age appropriate male in NAD
HEENT: Perrl, eomi, sclerae anicteric. MMM, OP clear without
lesions, exudate, or erythema.
CV: Nl S1+S2, II/VI systolic murmur throughout precordium
loudest at the base. Unable to ascertain JVP.
Pulm: Decreased breathsounds at left base. No wheezes.
Abd: S/NT/ND +bs
Ext: 1+ edema bilaterally. Unable to palpate dp/pt pulses
Neuro: Oriented to person and time. CN II-XII intact.
Skin: RLE bandaged. 2x2 cm ulcuer with eschar. No surrounding
erythema.


Pertinent Results:
ECG: Sinus with 1:1 conduction. LBBB. NI. TWI in V1-V3 new
compared to [**2174-7-11**].
.
CXR ([**2174-9-25**]): Mild cardiomegaly is stable. The left
hemidiaphragm is elevated as before, but small bilateral pleural
effusions with adjacent basal atelectasis are new. There is mild
vascular congestion. There is no pneumothorax.
.
CXR ([**2174-9-26**]): New LLL/lingula collapse.
.
Carotid Artery U/S 10/2/9 from OSH:
FINDINGS: On the right, the common carotid artery peak systolic
velocity is 36, diastolic velocity 5, internal carotid artery
peak systolic velocity 143, diastolic velocity 15, external
carotid artery peak systolic velocity 216. The vertebral artery
is visualized with antegrade flow. The peak systolic velocity
ratio is 0, diastolic velocity ratio 3.0. B-mode imaging is
suboptimal, and not adequate to assess plaque morphology or
degree of occlusion; however, based on the velocities obtained,
the occlusion could range anywhere from 60-99%.
.
On the left, the common carotid artery peak systolic velocity is
75, diastolic velocity 12. Internal carotid artery peak systolic
velocity 168, diastolic velocity 61, external carotid artery
peak systolic elocity 220. The vertebral artery is visualized
with antegrade flow. The peak systolic velocity ratio is 2.2,
diastolic velocity ratio 5.1. Again, B- mode imaging is
suboptimal due to patient habitus and cooperation, and is not
adequate to assess the degree of occlusion or morphology of the
plaque. Velocity criteria would suggest occlusion in the range
of 60-99%.
.
Admission labs on [**9-25**]/9:
WBC-9.9 RBC-3.22* Hgb-9.8*# Hct-30.8* MCV-96 MCH-30.3 MCHC-31.6
RDW-15.1 Plt Ct-338#
PT-25.2* PTT-33.2 INR(PT)-2.4*
Glucose-188* UreaN-17 Creat-0.7 Na-144 K-4.0 Cl-105 HCO3-33*
AnGap-10
Calcium-8.2* Phos-2.2* Mg-2.0 Iron-17*
calTIBC-217* VitB12-349 Folate-6.7 Ferritn-110 TRF-167*
.
CXR [**9-28**]:
CHEST, AP UPRIGHT: There is similar moderate elevation of the
left
hemidiaphragm with confluent opacification of the left lower
chest, likely
reflecting extensive atelectasis of both the left lower lobe and
lingula.
Considerable leftward mediastinal shift is associated with
volume loss,
similar to slightly increased. Given confluent opacification, it
is difficult to exclude an associated pleural effusion. However,
unaffected portions of the lungs are essentially within normal
limits without evidence for pulmonary edema. The right lung
remains clear. There is no evidence of pneumothorax.
IMPRESSION: Persistent collapse of the left lower lobe and
lingula with
volume loss, including elevation of the left hemidiaphragm and
leftward
mediastinal shift, perhaps slightly increased.
.
CTA head/neck:
1. Approximately 80% stenoses of the distal common carotid and
proximal
internal carotid arteries bilaterally.
2. Mild plaque slightly narrowing the right vertebral artery
origin.
3. Mild narrowing of the cavernous and supraclinoid internal
carotid arteries due to atherosclerosis.
4. No evidence of acute intracranial abnormalities. Areas of
supratentorial white matter hypodensity are nonspecific, but
likely represent sequela of chronic microangiopathy, given the
patient's age.
5. Bilateral pleural effusions, left greater than right, with
associated
dependent atelectasis. Possible left upper lobe pneumonitis.
These findings are new since [**2174-7-5**].
5. Subluxation of the right temporomandibular joint.
.
Discharge labs [**10-4**]:
Glucose 81 UreaN 23 Creat 0.8 Na 143 K 4.0 Cl 94 HCO3 46 AnGap
WBC 10.6  RBC 2.79* Hgb 8.4* Hct 26.3* Plt 289
PMN 88.7* Bands 7.1* Lymphs 4.1 Monos 0 Eos 0.1
PT 19.0* PTT 63.0* INR 1.7*
.
EEG results: This is a mildly abnormal routine EEG due to mild
slowing
and disorganization of the background rhythm. These findings
suggest a
mild encephalopathy involving cortical and subcortical
structures.
Medication, toxic/metabolic disturbances, and infection are
among the
most common causes. There were no areas of prominent focal
slowing
although encephalopathies can obscure focal findings. There were
no
epileptiform discharges or electrographic seizures.
.
Cardiac cath [**9-29**]
COMMENTS:
1. Peripheral angiography of the right lower extremity
demonstrated
patent Iliac arteries bilaterally. The right common femoral had
no
hemodynamic angiographically apparent disease. The right SFA had
a
serial calcified 90% stenosis in the mid to distal vessel that
involved
the above knee popliteal. There was single vessel runoff via the
right
AT. The left lower extremity was not injected.
2. Successful PTA and Laser of the right mid to distal SFA and
above
knee popliteal with a 5.0 x 120mm Submarine balloon. Final
angiography
revealed a 20% residual stenosis, no angiographically apparent
dissection or perforation, and excellent flow distally via the
AT. (see
PTA comments for details)
FINAL DIAGNOSIS:
1. 90% serial calcified stenosis of the right SFA and [**Doctor Last Name **].
2. Successful PTA and Laser of the right SFA and [**Doctor Last Name **].


Brief Hospital Course:
Mr. [**Known lastname 931**] is a [**Age over 90 **] year old gentleman with a PMH significant
for CAD, COPD on 2L nc at night, PE on coumadin, mild AS, and DM
2 transferred to [**Hospital1 18**] and then subsequently to the CCU for
unresponsiveness. Called out to the floor after a few days
(following no further unresponsiveness episodes, and following
laser angioplasty to right lower extremity).
.
# Unresponsiveness: Most likely etioloigy at this time is LLL
collapse leading to transient hypoxia in setting of bilateral
carotid occlusive disease with supple/demand mismatch.  This may
have also represented a TIA from embolic source, although less
likely. Could also have been hyperventilation from anxiety as
patient did not receive his regular daily ativan in the morning.
From an obstructive lung disease standpoint, he appears to be at
baseline with minimal wheezing and an ABG on 2L nc with
appropriate pH and compensatory metabolic compensation in
setting of chronic CO2 retention. Additionally, this may
represent new seizure activity, although patient does not have a
history of seizure activity. Neurology was consulted. Based upon
the history, physical exam, imaging studies of the carotids, a
decision between neuro and cardiology was made to not intervene
on the carotid arteries during this admission.  Patient did not
have further episodes of unresponsiveness in-house.
.
# Femoral Artery Stenosis:  Patient had a planned
revascularization at OSH which the patient was unable to have,
as he was in-house on the day of the planned procedure.
In-house, he underwent catheterization which showed serial
calcified 90% stenosis in the mid to distal vessel extending to
the above knee popliteal artery.  Patient underwent balloon and
laser angioplasty of right SFA with restoration of excellent
flow to RLE.
.
# Carotid stenosis: Patient transferred for carotid
intervention. Based upon recommendations from neuro, the
patient's mental status, and the imaging studies (CTA head/neck
and reconstructions), a decision was made to not intervene on
his carotid arteries.
.
# Respiratory: Patient with known COPD on supplemental overnight
O2 at home. Based on physical exam, admission CXR, and elevated
BNP, he likely also had an element of volume overload secondary
to cardiogenic pulmonary edema. In addition, he was noted to
have elevated filling pressures on cardiac catheterization in
[**6-23**]. Patient was diuresed, given mucolytics, chest PT,
nebulizers. For potential COPD flare (wheezes on exam), patient
treated with Azithromycin and a prednisone burst which was then
transitioned to a taper, as the patient was on long-term
prednisone at home for hyper-IgE syndrome and eosinophil count
was downtrending. Patient had episode of desaturation while
lying flat during vascular procedure, but then responded to
upright position and Lasix and by the next morning he was
satting well on 1-2L NC; goal SpO2 in low 90's secondary to COPD
history.  Pulmonary was consulted and recommended nocturnal
BIPAP which the patient refused.  Pulmonary team also
recommended draining pt's pleural effusion only if it fails to
improve with antibiotics and BIPAP, in hopes of avoiding
invasive procedures if possible.  Patient's shortness of breath
and PO2 improved with Lasix, and PO2 is lower at night due to
patient refusing BIPAP at night.
.
# CAD: Patient continued on metoprolol, ASA, statin, imdur.
Patient has daily morning chest pressure that he reports is
typical for him. One night, he had chest pressure, during which
nitro, morphine, lasix, oxygen, and ativan were given for the
chest pressure and the SOB. This resolved. ECG had ST
depressions in V1, V2, and TWI, low suspicion for ACS, more
consistent with pulmonary edema and anxiety. After that episode,
no further episodes.  On telemetry for monitoring, and will be
discharged on telemetry for continued monitoring.
.
# Pump: Patient with preserved LVEF on last echo, although with
signs of volume overload initially. Patient was diuresed with
Lasix, and breathing improved.
.
# Rhythmn: Sinus with 1:1 conduction. No events on telemetry.
.
# Anemia: Unclear baseline, although patient received 1 unit
PRBC at OSH prior to transfer for hemoglobin 10.  Patient with
iron studies consistent with iron deficiency anemia.  Patient's
Hct stable while at [**Hospital1 18**]. No further transfusions. Would like
patient to have outpatient work-up for anemia, ie: colonoscopy
if appropriate, etc - recommend PCP [**Name9 (PRE) 702**] for this issue.
.
# Pulmonary embolism: Patient with history of PE in [**4-23**] on
coumadin. Unclear based on review of records if there was an
inciting event and need for continued anticoagulation. Plan to
anticoagulate at least 6 months nonetheless until [**2174-10-16**].
Patient on heparin gtt while inpatient as preparation for
potential procedure. Post-procedure, restarted coumadin at home
dose, with heparin bridge.
.
# DM: Held home glipizide. Continued HISS and accuchecks.
Patient hyperglycemia, beleived due to steroid course, so
treated with insulin sliding scale.  Will have this monitored at
rehab, given the patient is having his steroids tapered.
.
# Heel ulcer: Patient with non-healing ulcer in setting of PVD
and diabetes. On [**9-29**]/9 had right lower extremity laser
angioplasty, to increase vascular flow to this leg, in the hopes
to help decrease pain and help ulcer heel.
.
# Positive blood culture at outside hospital, 1 bottle of
[**Last Name (LF) 83154**], [**First Name3 (LF) **] treated with 7 day antibiotic course (first
unasyn IV, then augmentin PO).

Medications on Admission:
Lipitor 80mg PO qday
Metoprolol 25mg PO BID
Ranitidine 150mg PO BID
Lorazepam .5mg PO qHS
Coumadin 5mg four days per week (per d/c summary, was M/T/W/F)
Coumadin 7.5mg 3 days per week (per d/c summary, was
Sat/Sun/[**Last Name (un) **])
Glipizide 10mg PO BID
Gabapentin 100mg PO TID
Isosorbide 60mg PO qday
Lasix 40mg PO qday
Atenolol 25mg PO qday
Insulin 20 units SC qday (type not specified)
Prednisone 10 [**Hospital1 **] (for hyper-eosinophilia)

Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
puffs Inhalation four times a day.
7. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
8. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO 3X/WEEK
([**Doctor First Name **],TH,SA).
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO 4X/WEEK
(MO,TU,WE,FR).
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) vial Inhalation Q6H (every 6 hours) as
needed for Wheezing.
11. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
12. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily):
Hold SBP<90.
13. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
14. Prednisone 5 mg Tablet Sig: Two (2) Tablet PO daily () for 1
days: Last day [**10-5**].
15. Prednisone 5 mg Tablet Sig: 1.5 Tablets PO once a day for 3
days: last day [**10-8**].
16. Prednisone 5 mg Tablet Sig: One (1) Tablet PO daily () for 3
days: Last day [**10-11**].
17. Prednisone 2.5 mg Tablet Sig: 0.5 Tablet PO daily () for 3
days: Last day [**10-14**], then d/c.
18. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain/fever.
19. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
20. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
21. Heparin (Porcine) in NS (PF)  Intravenous
22. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: per sliding scale and PTT results units
Intravenous continuous: D/c once INR > 2.0.
23. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous at bedtime.


Discharge Disposition:
Extended Care

Facility:
lakes regional hospital

Discharge Diagnosis:
Hypoventilation syndrome
Anemia
Peripheral Artery Disease
Diabetes Mellitus type 2
Acute on chronic Diastolic congestive Heart Failure
Bilateral Carotid Stenosis


Discharge Condition:
stable

Na:143  CL=94
K=4.0  HCO3=46
Ca: 8.8 Mg: 2.4 P: 3.9
hct=26.3
PT: 19.0  PTT: Pnd  INR: 1.7


Discharge Instructions:
You had a procedure to open the arteries in your right leg. We
hope this will help your ulcer on your right foot to heal. You
also had a exacerbation of your lung disease and was treated
with antibiotics, nebulizers and prednisone.
Medication changes:
1. Stop Atenolol
2. Start Metoprolol Succinate to keep your heart rate low
3. START ATrovent to help with your breathing
4. Start a prednisone taper to help with your breathing
5. Restart Lasix to treat your fluid retention.
.


Followup Instructions:
Primary Care:
[**Last Name (LF) 83155**],[**First Name3 (LF) 2515**] W Phone: [**Telephone/Fax (1) 77350**] Please make an appt to see
once you are out of rehab
Cardiology:
[**First Name8 (NamePattern2) **] [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 11250**] Phone: ([**Telephone/Fax (1) 83156**] Date/time: Please
make an appt to see her in [**1-18**] weeks.
{'Disorders of diaphragm,Acute on chronic diastolic heart failure,Other specified septicemias,Sepsis,Acidosis,Ulcer of heel and midfoot,Pulmonary collapse,Other respiratory abnormalities,Adrenal cortical steroids causing adverse effects in therapeutic use,Obesity, unspecified,Other convulsions,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Coronary atherosclerosis of native coronary artery,Chronic airway obstruction, not elsewhere classified,Other dependence on machines, supplemental oxygen,Atherosclerosis of native arteries of the extremities with ulceration,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Personal history of venous thrombosis and embolism,Iron deficiency 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: Unresponsiveness.

PRESENT ILLNESS: Mr. [**Known lastname 931**] is a [**Age over 90 **] year old gentleman wiht a PMH significant
for CAD, COPD on 2L nc at night, PE on coumadin, mild AS, and DM
2 transferred to the CCU for unresponsiveness. The patient was
initially admitted to an OSH for unresponsiveness and slurred
speech that spontaneously resolved. At that time, he denied any
chest pain, but does endorse dyspnea with exertion and
occasional exertional chest pain when walking from his bed to
the bathroom.  At the OSH, the patient had a CTH that was
negative and carotid dopplers that demonstrated severe bilateral
carotid stenosis. He was also noted to have a right foot ulcer
for which he received amp/sulbactam and was transfused 1 unit
pRBCs on the morning of [**2174-9-25**] for a hemoglobin of 10.0.  Of
note, the patient was scheduled for an outpatient
revascularization procedure of the RLE on [**2174-9-27**] prior to this
admission.
.
On initial arrival, the patient was noted to be mildly fluid
overloaded and noted that he had increased lower extremity edema
for the past 2 weeks. A CXR demonstrated mild pulmonary edema
and increased pulmonary vascular congestion with a BNP of 2200.
This morning, the patient was found to be unresponsive. On
initial exam, he was noted to have convulsions, which were not
tonic-clonic in nature.  ABG on 2L nc 7.40/62/91 and the patient
received 40 mg IV lasix.  He regained consciousness within
minutes, although remained confused and unable to follow
commands for several minutes without any stool incontinence (FC
in place).
.
Currently, he is resting comfortably without complaints. Denies
CP/SOB, f/c/s, n/v/d, abd pain, HA, palpitations, diaphoresis,
or pain radiating to jaw or arm.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope
or presyncope.

MEDICAL HISTORY: Coronary Artery Disease s/p cath [**6-23**] with occlusion of LAD and
collaterals, medically managed
Aortic stenosis - mild on cath ([**6-23**]), mean peak to peak
gradient of 28 mmHg.
PE ([**4-23**])
COPD - 2L supplemental oxygen at night
Restrictive lung disease (per report)
Diabetes Mellitus
Obesity
arthritis
Paralysed left hemi-diaphragm
Appendectomy
prior knee surgery

MEDICATION ON ADMISSION: Lipitor 80mg PO qday
Metoprolol 25mg PO BID
Ranitidine 150mg PO BID
Lorazepam .5mg PO qHS
Coumadin 5mg four days per week (per d/c summary, was M/T/W/F)
Coumadin 7.5mg 3 days per week (per d/c summary, was
Sat/Sun/[**Last Name (un) **])
Glipizide 10mg PO BID
Gabapentin 100mg PO TID
Isosorbide 60mg PO qday
Lasix 40mg PO qday
Atenolol 25mg PO qday
Insulin 20 units SC qday (type not specified)
Prednisone 10 [**Hospital1 **] (for hyper-eosinophilia)

ALLERGIES: Lisinopril / Zoloft

PHYSICAL EXAM: VS: 97 67 [**10/2119**] 89%1L nc
GENERAL: Age appropriate male in NAD
HEENT: Perrl, eomi, sclerae anicteric. MMM, OP clear without
lesions, exudate, or erythema.
CV: Nl S1+S2, II/VI systolic murmur throughout precordium
loudest at the base. Unable to ascertain JVP.
Pulm: Decreased breathsounds at left base. No wheezes.
Abd: S/NT/ND +bs
Ext: 1+ edema bilaterally. Unable to palpate dp/pt pulses
Neuro: Oriented to person and time. CN II-XII intact.
Skin: RLE bandaged. 2x2 cm ulcuer with eschar. No surrounding
erythema.

FAMILY HISTORY: Mother had a stroke, [**Name (NI) **] CHF, Daughter with leukemia, Son died
of "cancer".

SOCIAL HISTORY: He is a widower who lives with his daughter in [**Name (NI) 83153**].  Tobacco
history: history of 1 ppd x 2 years, quit in 60s 

### Response:
{'Disorders of diaphragm,Acute on chronic diastolic heart failure,Other specified septicemias,Sepsis,Acidosis,Ulcer of heel and midfoot,Pulmonary collapse,Other respiratory abnormalities,Adrenal cortical steroids causing adverse effects in therapeutic use,Obesity, unspecified,Other convulsions,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Coronary atherosclerosis of native coronary artery,Chronic airway obstruction, not elsewhere classified,Other dependence on machines, supplemental oxygen,Atherosclerosis of native arteries of the extremities with ulceration,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Personal history of venous thrombosis and embolism,Iron deficiency anemia, unspecified'}
