CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
white male with a history of coronary artery disease with
three-vessel disease, diabetes mellitus, chronic renal
failure with recent acute renal failure admitted to outside
hospital on [**2166-5-29**] with hypoxia.  He was transferred to
[**Hospital1 69**] for further management
of respiratory failure.  In the early even of [**2166-5-29**] at
rehabilitation the patient complained of shortness of breath.
Oxygen saturations decreased to the 60s.  He was sent to an
outside hospital where he reportedly became unresponsive with
oxygen saturations of 80% on 100% face mask.  He was
intubated and sent to the intensive care unit.  He was
treated for presumed aspiration pneumonia with Levaquin and
started on vancomycin for one out of two blood cultures
positive for "staph".  No further isolation was noted.  White
blood cell count was 15.9.  There was no documented fever.
The patient was diuresed with Lasix 80 mg IV b.i.d. with a
pulmonary capillary wedge pressure of approximately 15.  He
was placed on a dopamine drip for hypotension with systolic
pressures in the 70s.  On the morning of transfer the patient
was noted to be in atrial fibrillation with a rate of 160s to
170s.  He was started on a diltiazem drip in addition to the
dopamine pressor for rate control as well as a heparin drip.
The wife requested transfer to [**Hospital1 188**] where he was recently hospitalized [**2166-4-7**] through
[**2166-4-19**] for left hip fracture, non-ST elevation myocardial
infarction, stent to the right coronary artery, acute renal
failure secondary to contrast dye requiring dialysis x 2, and
repair of hip fracture with a left open reduction and
internal fixation.  Upon transfer he was on SIMV
16-[**Medical Record Number 22113**], heparin drip, dopamine drip, diltiazem drip and
insulin drip.  Of note, in addition to his respiratory
failure he was in diabetic ketoacidosis with a metabolic
acidosis.  He had blood loss anemia with an hematocrit of 19
and he was in shock with a picture most consistent with
sepsis.

MEDICAL HISTORY: 1. Coronary artery disease status post
non-ST elevation myocardial infarction on [**2166-4-7**],
catheterization on [**2166-4-9**] with three-vessel disease, stent
right coronary artery.  2. Hypertension.  3.
Hypercholesterolemia.  4. Congestive heart failure with an
ejection fraction of approximately 25%.  5. Chronic renal
failure with acute renal failure [**4-10**] secondary to
catheterization dye load requiring hemodialysis x 2 sessions.
6. Anemia with decreased hematocrit to 20 with prior
hospitalization, source unknown.  7. Status post left open
reduction and internal fixation [**2166-4-15**].  8. Status post a
right THA.  9. Status post transurethral resection of the
prostate.  10. Gastroesophageal reflux disease.  11. History
of a seizure disorder, questionably four years ago.  12.
Status post appendectomy.  13. Urinary tract infection.  14.
Diabetes mellitus type 2 followed by the [**Hospital **] Clinic.

MEDICATION ON ADMISSION: 

ALLERGIES: The patient has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: He is a music composer.  He has been
recovering at [**Hospital **] Rehabilitation.  He has a very
involved wife.
Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Methicillin susceptible pneumonia due to Staphylococcus aureus,Congestive heart failure, unspecified,Subendocardial infarction, initial episode of care,Acute posthemorrhagic anemia,Acute cholecystitis,Acidosis,Unspecified septicemia
Acute respiratry failure,Food/vomit pneumonitis,Meth sus pneum d/t Staph,CHF NOS,Subendo infarct, initial,Ac posthemorrhag anemia,Acute cholecystitis,Acidosis,Septicemia NOS
Admission Date:  [**2166-6-3**]       Discharge Date:  [**2166-6-19**]


Service:

HISTORY OF PRESENT ILLNESS:  The patient is a [**Age over 90 **]-year-old
white male with a history of coronary artery disease with
three-vessel disease, diabetes mellitus, chronic renal
failure with recent acute renal failure admitted to outside
hospital on [**2166-5-29**] with hypoxia.  He was transferred to
[**Hospital1 69**] for further management
of respiratory failure.  In the early even of [**2166-5-29**] at
rehabilitation the patient complained of shortness of breath.
Oxygen saturations decreased to the 60s.  He was sent to an
outside hospital where he reportedly became unresponsive with
oxygen saturations of 80% on 100% face mask.  He was
intubated and sent to the intensive care unit.  He was
treated for presumed aspiration pneumonia with Levaquin and
started on vancomycin for one out of two blood cultures
positive for "staph".  No further isolation was noted.  White
blood cell count was 15.9.  There was no documented fever.
The patient was diuresed with Lasix 80 mg IV b.i.d. with a
pulmonary capillary wedge pressure of approximately 15.  He
was placed on a dopamine drip for hypotension with systolic
pressures in the 70s.  On the morning of transfer the patient
was noted to be in atrial fibrillation with a rate of 160s to
170s.  He was started on a diltiazem drip in addition to the
dopamine pressor for rate control as well as a heparin drip.
The wife requested transfer to [**Hospital1 188**] where he was recently hospitalized [**2166-4-7**] through
[**2166-4-19**] for left hip fracture, non-ST elevation myocardial
infarction, stent to the right coronary artery, acute renal
failure secondary to contrast dye requiring dialysis x 2, and
repair of hip fracture with a left open reduction and
internal fixation.  Upon transfer he was on SIMV
16-[**Medical Record Number 22113**], heparin drip, dopamine drip, diltiazem drip and
insulin drip.  Of note, in addition to his respiratory
failure he was in diabetic ketoacidosis with a metabolic
acidosis.  He had blood loss anemia with an hematocrit of 19
and he was in shock with a picture most consistent with
sepsis.

PAST MEDICAL HISTORY:  1. Coronary artery disease status post
non-ST elevation myocardial infarction on [**2166-4-7**],
catheterization on [**2166-4-9**] with three-vessel disease, stent
right coronary artery.  2. Hypertension.  3.
Hypercholesterolemia.  4. Congestive heart failure with an
ejection fraction of approximately 25%.  5. Chronic renal
failure with acute renal failure [**4-10**] secondary to
catheterization dye load requiring hemodialysis x 2 sessions.
6. Anemia with decreased hematocrit to 20 with prior
hospitalization, source unknown.  7. Status post left open
reduction and internal fixation [**2166-4-15**].  8. Status post a
right THA.  9. Status post transurethral resection of the
prostate.  10. Gastroesophageal reflux disease.  11. History
of a seizure disorder, questionably four years ago.  12.
Status post appendectomy.  13. Urinary tract infection.  14.
Diabetes mellitus type 2 followed by the [**Hospital **] Clinic.

SOCIAL HISTORY:  He is a music composer.  He has been
recovering at [**Hospital **] Rehabilitation.  He has a very
involved wife.

ALLERGIES:  The patient has no known drug allergies.

MEDICATIONS ON HOSPITAL TRANSFER:  1. Dopamine drip at 6.  2.
Diltiazem drip at 15.  3. Insulin drip at 2.  4. Heparin drip
at 400.  5. Coumadin 1 mg p.o. q.d.  6. Famotidine 20 mg q.
12.  7. Dilantin 200 mg b.i.d.  8. Levaquin 250 mg q.d. day
number five.  9. Vancomycin 1 gram q. 24, day unknown.  10.
Morphine 6 mg received in the AM.

MEDICATIONS AS AN OUTPATIENT:  1. Phenytoin 200 mg b.i.d.  2.
Colace 100 mg b.i.d.  3. Lente Insulin 20 units q.a.m. with a
Humalog sliding scale.  4. Metoprolol 50 mg b.i.d.  5. Plavix
75 mg q.d.  6. Trazodone 25 mg q.h.s.  7. Coumadin 1 mg q.d.
8. Aspirin 325 mg q.d.  9. Calcium carbonate 1 gram b.i.d.
10. Multivitamin q.d.  11. Lactulose p.r.n. constipation.
12. Lasix 100 mg p.o. q.a.m., 60 mg p.o. q.p.m.  13.
Lorazepam p.r.n.  14. Lansoprazole 30 mg q.d.  15. Combivent
2 puffs b.i.d.  16. Albuterol-Atrovent p.r.n.  17.
Amoxicillin ?  18. Cipro ?

PHYSICAL EXAMINATION:  Temperature 103 axillary, blood
pressure 90s/50s to 70s/30s, heart rate 100, vent AC at
600-6, FIO2 35%.  In general he was responsive to touch,
moved eyes to voice command.  HEENT showed pinpoint pupils.
Kyphoscoliosis.  Mucous membranes were dry.  heart was
regular rate and rhythm with a 1/6 systolic murmur at the
left sternal border.  Lungs had breath sounds somewhat
coarse, clear with suctioning.  Mild basilar crackles.
Abdomen soft, nontender, no stool in the vault.  Foley
catheter had yellow clear urine.  Extremities were warm and
well perfused.  Upper extremity edema was noted on hands.  No
lower extremity edema.  The patient had a right brachial line
with Swan in place, left radial arterial line, no stranding
erythema.  On neurological examination he moved all
extremities.  He had pinpoint pupils noted.

LABORATORY DATA:  White count was 1.1, hematocrit 23.4,
decreased from 27.4 on [**2166-6-1**].  Platelet count was 100.
Neutrophils 83.8, eosinophils 2, basos none.  Sodium was 127,
potassium 5.2 hemolyzed, chloride 95, bicarbonate 18, BUN 60,
creatinine 2.5, baseline 1.8, glucose 298, calcium 7.7,
magnesium 1.9, phosphorous 5.5.  PT 20, PTT 72.5, INR 2.7.
Vancomycin level was 25.1.  Cardiac enzymes were CK 80,
troponin less than 0.3.  Arterial blood gases were 7.45, 29,
114, 21.

Chest x-ray showed a Swan-Ganz catheter tip seen in the right
main pulmonary artery.  ETT 2 cm above the carina.  He had
improved pulmonary edema, no acute cardiopulmonary process
noted.

Echocardiogram from [**4-10**] showed left ventricular ejection
fraction of 25%, AK anterior septum, anterior free wall,
apex, moderate HK inferior septum and lateral free wall.
There was 1+ mitral regurgitation, trace aortic
regurgitation, moderate tricuspid regurgitation, moderate
pulmonary hypertension.

Catheterization on [**2166-4-9**] showed three-vessel disease with
left anterior descending coronary artery 70% proximal lesion,
100% mid with collaterals from PDA.  LCX 60% lesion, RCA 80%
x 2 with stent x 2 with good flow.

EKG showed normal sinus rhythm, rate 105, prolonged PR, left
axis, poor R wave progression, less than [**Street Address(2) 4793**] depression
noted in the inferior leads.  AVL with Q waves, T wave
inversion, new when compared to the EKG from [**2166-4-17**].

HOSPITAL COURSE:  1. Respiratory failure:  The patient was
admitted to an outside hospital with acute hypoxia, etiology
unknown, although aspiration pneumonia presumed, question
also of PE given recent surgery, question also of pulmonary
edema given history of severe congestive heart failure.  The
patient required ventilatory support for several days.
Initial wean was complicated by flash pulmonary edema and
agitation requiring reintubation.  At this time code status
was discussed at length with the wife.  She decided on DNI
after next extubation.  The patient was successfully
extubated on [**2166-6-10**] on a nitroglycerin drip and Lasix drip
with a bolus.  His respiratory status continued to improve
throughout the rest of his hospital stay.  At the time of
discharge he was consistently saturating 98-100% on a
two-liter nasal cannula and required minimal suctioning.

2. Shock:  On admission the patient had a blood
pressure of 70s/30s with a temperature of 103 consistent with
septic shock.  His brachial and Swan line were removed and
replaced with a subclavian line.  He was weaned off of his
diltiazem and dopamine drip with the initiation of Levophed.
After initiation of antibiotics as well as volume repletion
with blood products, he was weaned successfully off of his
Levophed.  Mild hypotension persisted until the patient was
extubated.  Since this time he has remained normotensive.

3. Congestive heart failure:  The patient had an ejection
fraction of 25% consistent per repeat echocardiogram done.
He received p.r.n. Lasix boluses and required a Lasix drip at
the time of extubation and given flash pulmonary edema.  He
was started on a nitroglycerin drip with hydralazine for
preload and afterload reduction.  His oxygen saturation
continued to improve.  At the time of discharge he received
20 of IV Lasix q.d. with goal I's and O's even.

4. Pneumonia:  The patient was under treatment for pneumonia
with Levaquin and questionably vancomycin at the time of
hospital transfer.  Both vancomycin and Levaquin were
continued for a 14-day course with interval improvement on
his chest x-ray and decreased leukocytosis.  Blood cultures
remained negative while in house.  Sputum culture did grow
MRSA for which he was placed on precautions.

While in house a swallow study was done and he was determined
to be at a high risk for aspiration pneumonia.  He was kept
n.p.o. for this reason.

5. Blood loss anemia:  On admission the patient's hematocrit
was 24.6 and rapidly decreased to 19.6 without clear source
of bleed.  Concurrently the patient experienced a demand
ischemia myocardial infarction.  He was transfused to an
hematocrit greater than 30.  After this event his hematocrit
remained stable with intermittent transfusions for iatrogenic
blood loss.  Of note the patient had a similar episode of
blood loss with his prior hospitalization.  He was guaiac
negative.  Hematocrit remained stable at the time of
discharge.

6. Coronary artery disease:  The patient has severe
three-vessel disease status post recent stent x 2 to right
coronary artery.  While in house he was followed by Dr.
[**Last Name (STitle) **], his outpatient cardiologist, who did not recommend
repeat catheterization at this time.  He was medically
managed with aspirin and beta blocker as tolerated.  At the
time of discharge he tolerated metoprolol 25 b.i.d.  He
should be started on a long-acting nitrate as tolerated as an
outpatient.

7. Atrial fibrillation:  Per hospital transfer notes the
patient had an initial episode of atrial fibrillation the
morning of [**2166-6-3**].  At the time of extubation he was noted
to be in rapid atrial fibrillation controlled with IV
Lopressor.  On standing Lopressor the patient remained in
sinus rhythm with a heart rate between 80 and 100.  He was
continued on aspirin.  No further anticoagulation was
initiated at this time.

8. Acute on chronic renal failure:  At the time of admission
the patient had elevated creatinine thought to be due to
decreased perfusion from sepsis.  Renal function improved
with increased systolic blood pressure and transfusion,
however after aggressive diuresis with pulmonary edema, the
patient's creatinine worsened.  Again, goal ins and outs are
to remain approximately even at this time.  His creatinine
should be followed closely.  He was started on Epogen.

9. Diabetes type 2:  The patient has a history of
poorly-controlled diabetes.  On admission he was noted to be
in diabetic ketoacidosis with a metabolic acidosis.  This was
controlled with IV hydration and insulin drip.  Throughout
the course of his stay he was continued on an insulin drip
for close glucose control.  At the time of discharge he was
switched to subcutaneous insulin with q. 4 hour fingersticks.
His sugars should be followed closely and after his new
insulin requirement is determined, he should be switched to a
long-acting insulin.  Of note, the patient previously was on
Lantus with Humalog sliding scale.

10. Fluids, electrolytes and nutrition:  As noted the patient
failed video swallow study and is noted to be at a high
aspiration risk.  The possibility of a PEG tube was discussed
with the patient's wife, however she is not ready to pursue
this at this time.  A Dobbhoff tube was placed per
fluoroscopy.  At the time of discharge he was on Nepro tube
feeds and receiving p.o. medicine through his Dobbhoff tube.

11. Constipation:  Of note, the patient's first bowel
movement throughout the course of the hospital stay was on
the day of discharge.  He should remain on stool softeners
and p.r.n. stimulants.

12. Code status:  After multiple family meetings it was
decided that his code status will be DNR/DNI.

13. Acute cholecystitis:  While intubated the patient was
noted to have increasing alkaline phosphatase with a positive
GGT, as well as a sensitive right upper quadrant.  Right
upper quadrant ultrasound was done which showed thickening of
the gallbladder wall as well as a stone in the cystic duct.
He was consulted by both general surgery and interventional
radiology who felt that his operative risk was too high given
his comorbidities.  He was started on Flagyl in addition to
Levaquin for acute cholecystitis and was kept n.p.o. on TPN.
He symptomatically improved with a decrease in his alkaline
phosphatase.  At the time of discharge he tolerated tube
feeds.

DISCHARGE STATUS:  To [**Hospital **] Rehabilitation.

CONDITION ON DISCHARGE:  Stable.

FOLLOW UP:  He will see his primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 22114**], in one to two weeks.

DISCHARGE DIAGNOSES:
1. Congestive heart failure.
2. Coronary artery disease.
3. Demand ischemia.
4. Blood loss anemia.
5. Aspiration pneumonia.
6. Diabetes mellitus type 2.
7. Diabetic ketoacidosis with metabolic acidosis.
8. Acute cholecystitis.
9. Septic shock.
10. Respiratory failure.
11. Atrial fibrillation.
12. Acute on chronic renal failure.

DISCHARGE MEDICATIONS:
1. Lansoprazole 30 mg p.o. q.d.
2. Hydralazine 10 mg p.o. q. 6 hours.
3. Metoprolol 25 mg p.o. b.i.d.
4. Aspirin 325 mg p.o. q.d.
5. Epogen 4,000 units subcutaneous biweekly.
6. Heparin 5,000 units subcutaneous b.i.d.
7. Insulin sliding scale with q. 4 hour fingersticks to be
converted to long-acting insulin per required dose.
8. Colace 100 mg p.o. b.i.d., liquid form.
9. Tylenol 325-650 mg p.o. q. 4-6 hours p.r.n. pain.
10. Dulcolax p.r. q.d. p.r.n. constipation.
11. Lasix 40 mg p.o. q.a.m. hold for creatinine increase,
goal I's and O's even.
12. Tube feeds - Nepro solution at 35 cc goal.
13. Two-liter nasal cannula titrated to oxygen saturation
greater than 92%.





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

Dictated By:[**Name8 (MD) 3219**]
MEDQUIST36

D:  [**2166-6-19**]  10:37
T:  [**2166-6-19**]  11:00
JOB#:  [**Job Number 22115**]
{'Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Methicillin susceptible pneumonia due to Staphylococcus aureus,Congestive heart failure, unspecified,Subendocardial infarction, initial episode of care,Acute posthemorrhagic anemia,Acute cholecystitis,Acidosis,Unspecified septicemia'}


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 [**Age over 90 **]-year-old
white male with a history of coronary artery disease with
three-vessel disease, diabetes mellitus, chronic renal
failure with recent acute renal failure admitted to outside
hospital on [**2166-5-29**] with hypoxia.  He was transferred to
[**Hospital1 69**] for further management
of respiratory failure.  In the early even of [**2166-5-29**] at
rehabilitation the patient complained of shortness of breath.
Oxygen saturations decreased to the 60s.  He was sent to an
outside hospital where he reportedly became unresponsive with
oxygen saturations of 80% on 100% face mask.  He was
intubated and sent to the intensive care unit.  He was
treated for presumed aspiration pneumonia with Levaquin and
started on vancomycin for one out of two blood cultures
positive for "staph".  No further isolation was noted.  White
blood cell count was 15.9.  There was no documented fever.
The patient was diuresed with Lasix 80 mg IV b.i.d. with a
pulmonary capillary wedge pressure of approximately 15.  He
was placed on a dopamine drip for hypotension with systolic
pressures in the 70s.  On the morning of transfer the patient
was noted to be in atrial fibrillation with a rate of 160s to
170s.  He was started on a diltiazem drip in addition to the
dopamine pressor for rate control as well as a heparin drip.
The wife requested transfer to [**Hospital1 188**] where he was recently hospitalized [**2166-4-7**] through
[**2166-4-19**] for left hip fracture, non-ST elevation myocardial
infarction, stent to the right coronary artery, acute renal
failure secondary to contrast dye requiring dialysis x 2, and
repair of hip fracture with a left open reduction and
internal fixation.  Upon transfer he was on SIMV
16-[**Medical Record Number 22113**], heparin drip, dopamine drip, diltiazem drip and
insulin drip.  Of note, in addition to his respiratory
failure he was in diabetic ketoacidosis with a metabolic
acidosis.  He had blood loss anemia with an hematocrit of 19
and he was in shock with a picture most consistent with
sepsis.

MEDICAL HISTORY: 1. Coronary artery disease status post
non-ST elevation myocardial infarction on [**2166-4-7**],
catheterization on [**2166-4-9**] with three-vessel disease, stent
right coronary artery.  2. Hypertension.  3.
Hypercholesterolemia.  4. Congestive heart failure with an
ejection fraction of approximately 25%.  5. Chronic renal
failure with acute renal failure [**4-10**] secondary to
catheterization dye load requiring hemodialysis x 2 sessions.
6. Anemia with decreased hematocrit to 20 with prior
hospitalization, source unknown.  7. Status post left open
reduction and internal fixation [**2166-4-15**].  8. Status post a
right THA.  9. Status post transurethral resection of the
prostate.  10. Gastroesophageal reflux disease.  11. History
of a seizure disorder, questionably four years ago.  12.
Status post appendectomy.  13. Urinary tract infection.  14.
Diabetes mellitus type 2 followed by the [**Hospital **] Clinic.

MEDICATION ON ADMISSION: 

ALLERGIES: The patient has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: He is a music composer.  He has been
recovering at [**Hospital **] Rehabilitation.  He has a very
involved wife. 

### Response:
{'Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Methicillin susceptible pneumonia due to Staphylococcus aureus,Congestive heart failure, unspecified,Subendocardial infarction, initial episode of care,Acute posthemorrhagic anemia,Acute cholecystitis,Acidosis,Unspecified septicemia'}
