CHIEF COMPLAINT: Patient found unresponsive/confused at home, brought to hospital

PRESENT ILLNESS: Mr. [**Known lastname 46366**] is a [**Age over 90 **] M with a medical history notable for COPD on
home oxygen, coronary artery disease, deep vein thrombosis s/p
IVC filter in [**2148**] (not on anticoagultion due to history of GI
bleed). At baseline, he lives independently, he pays his own
bills but he does not drive. He was last seen 1 week prior to
admission by his sister but his neighbors then noticed his
newpapers began collecting in his [**Last Name (un) **] lobby this week.

MEDICAL HISTORY: - HTN
- COPD - [**2143**] FVC 74% of predicted, FEV1 67% of predicted,
FEV1/FVC 90% of predicted, TLC 111% of predicted, RV 145% of
predicted. Intermitent home supplemental O2 use.
- BPH
- Anemia
- GERD, past +H.pylori
- Gout
- Inguinal hernia
- DVT ([**2148**]) s/p IVC filter
- CAD - stable angina

MEDICATION ON ADMISSION: Medications per OMR:
Tylenol prn
Aspirin 81mg PO
Combivent 2 puffs q6 hours prn
Colace 100mg PO BID prn
Doxazosin 2mg PO daily
Fiber laxative PO daily
Golytely prn
Metoprolol 25mg PO BID
Nasal saline
Nitroglycerin prn
Oxybutynin 20mg PO daily
Ranitidine 150mg PO BID

ALLERGIES: Penicillins

PHYSICAL EXAM: Physical exam on arrival to the floor:
- Vital signs: T 99.2, P 92, BP 120/60, 96% on 4LNC.
- Gen: Thin, elderly male sleeping when I enter the room. When I
wake him he is pleasant and alert. He does not participate in
the exam though and he is oriented x 1.
- HEENT: Oropharynx is dry.
- Neck: Supple. No nuchal rigidity.
- Chest: Breathing comfortably on 4LNC. I appreciate no wheezes
or rhonchi but he has bilateral rales in mid-lung fields.
- CV: PMI normal size and not displaced. Has PA lift with no
apprecaible RV heave. On my exam he is tachycardic. Regular
rhythm. Regular pulses. Normal S1, S2. III/VI HSM at LSB. JVP 12
cm when sitting upright in bed (90 degrees).
- Abdomen: Normal bowel sounds. Soft, nontender, nondistended.
No pulsatile liver appreciated.
- Extremities: 2+ ankle edema to the mid-calf.
- MSK: Joints with no redness, swelling, warmth, tenderness.
- Skin: Bruising on left side but no open areas of skin.
- Neuro: Alert, oriented x1. CN appear intact but he does no
cooperate with exam. His speech and language appear normal but
answers questions such as "where do you live" with a person's
name. He is smiling and appears comfortable.

FAMILY HISTORY: Significant for gout in his father.

SOCIAL HISTORY: Lives by himself, independent in IDLs, but not all IADLs (see
HPI). No current VNA/HHA. Tobacco - none currently, quit 40+
years ago. EtOH - none. Denies IV, illicit, or herbal drug use.
His wife passed away 2 years PTA, and family notes that he has
been more sad lately.
Pneumonitis due to inhalation of food or vomitus,Encephalopathy, unspecified,Acute on chronic diastolic heart failure,Atrial flutter,Other alteration of consciousness,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Esophageal reflux,Acute gouty arthropathy,Other and unspecified angina pectoris,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Other dependence on machines, supplemental oxygen,Personal history of venous thrombosis and embolism,Do not resuscitate status
Food/vomit pneumonitis,Encephalopathy NOS,Ac on chr diast hrt fail,Atrial flutter,Other alter consciousnes,Crnry athrscl natve vssl,Hypertension NOS,Esophageal reflux,Acute gouty arthropathy,Angina pectoris NEC/NOS,BPH w/o urinary obs/LUTS,Depend-supplement oxygen,Hx-ven thrombosis/embols,Do not resusctate status
Admission Date:  [**2150-12-6**]              Discharge Date:   [**2150-12-18**]


Service: MEDICINE

Allergies:
Penicillins

Attending:[**Doctor First Name 2080**]
Chief Complaint:
Patient found unresponsive/confused at home, brought to hospital

Major Surgical or Invasive Procedure:
None

History of Present Illness:
Mr. [**Known lastname 46366**] is a [**Age over 90 **] M with a medical history notable for COPD on
home oxygen, coronary artery disease, deep vein thrombosis s/p
IVC filter in [**2148**] (not on anticoagultion due to history of GI
bleed). At baseline, he lives independently, he pays his own
bills but he does not drive. He was last seen 1 week prior to
admission by his sister but his neighbors then noticed his
newpapers began collecting in his [**Last Name (un) **] lobby this week.

He was unable to provide further history, including ROS and
other events leading to the admission, due to delirium.  This
continued on admission to the medicine service.

He was found at home by EMS on [**12-6**]. On the initial evaluation
by EMS, he was minimally responsive, his temperature was 100.6,
and O2 sats were in the 70s on room air (improved to 90s on non
re-breather).

On arrival to the [**Hospital1 18**] ED he was initially hypertensive but his
blood pressures decreased to SBP 100 in the setting of a
temperature of 100.0. In the ED, he received 5L of normal saline
and had a normal head CT.

In the [**Hospital Unit Name 153**], his evaluation was notable for a left-sided opacity
on CXR of unclear etiology, a [**Name (NI) **] that revealed a dilated RV
with severe pulmonary hypertension (no [**Name (NI) **] available for
comparison), elevated cardiac biomarkers, and a PECT that
revealed no PE and did not reveal a left basilar pneumonia. In
the [**Hospital Unit Name 153**] he received levofloxacin, ceftriaxone, and was started
on Lasix for right heart failure. He was also evaluated by the
geriatrics team and recommended to start on Haldol for
agitation.

On arrival to the floor, he has no complaints. He is confused
and does not answer questions appropriately but is comfortable.


Past Medical History:
- HTN
- COPD - [**2143**] FVC 74% of predicted, FEV1 67% of predicted,
FEV1/FVC 90% of predicted, TLC 111% of predicted, RV 145% of
predicted. Intermitent home supplemental O2 use.
- BPH
- Anemia
- GERD, past +H.pylori
- Gout
- Inguinal hernia
- DVT ([**2148**]) s/p IVC filter
- CAD - stable angina

Social History:
Lives by himself, independent in IDLs, but not all IADLs (see
HPI). No current VNA/HHA. Tobacco - none currently, quit 40+
years ago. EtOH - none. Denies IV, illicit, or herbal drug use.
His wife passed away 2 years PTA, and family notes that he has
been more sad lately.


Family History:
Significant for gout in his father.

Physical Exam:
Physical exam on arrival to the floor:
- Vital signs: T 99.2, P 92, BP 120/60, 96% on 4LNC.
- Gen: Thin, elderly male sleeping when I enter the room. When I
wake him he is pleasant and alert. He does not participate in
the exam though and he is oriented x 1.
- HEENT: Oropharynx is dry.
- Neck: Supple. No nuchal rigidity.
- Chest: Breathing comfortably on 4LNC. I appreciate no wheezes
or rhonchi but he has bilateral rales in mid-lung fields.
- CV: PMI normal size and not displaced. Has PA lift with no
apprecaible RV heave. On my exam he is tachycardic. Regular
rhythm. Regular pulses. Normal S1, S2. III/VI HSM at LSB. JVP 12
cm when sitting upright in bed (90 degrees).
- Abdomen: Normal bowel sounds. Soft, nontender, nondistended.
No pulsatile liver appreciated.
- Extremities: 2+ ankle edema to the mid-calf.
- MSK: Joints with no redness, swelling, warmth, tenderness.
- Skin: Bruising on left side but no open areas of skin.
- Neuro: Alert, oriented x1. CN appear intact but he does no
cooperate with exam. His speech and language appear normal but
answers questions such as "where do you live" with a person's
name. He is smiling and appears comfortable.


Pertinent Results:
- [**12-6**] CXR with left basilar opacity, infection vs. atelectasis
- [**12-6**] PECT with centrilobular moderate emphysema, no PE, and
no evidence of pneumonia
- [**12-6**] Urine culture no growth to date
- [**12-6**] Urinary Legionella negative
- [**12-6**] Blood culture no growth to date
- [**12-7**]  Blood culture no growth to date

CT Head:
FINDINGS: The study is severely degraded by motion artifact.
Within this
limitation, there is no evidence of acute intracranial
hemorrhage or acute
major vascular territory infarction. Ventricles and sulci are
prominent
consistent with age-related involutional changes. There is some
low-attenuating regions within the periventricular white matter
consistent
with chronic small vessel ischemic disease. There is evidence of
left
maxillary sinus disease. No acute fractures are identified.
Bilateral
mastoid air cells are clear.

IMPRESSION:
1. No acute intracranial hemorrhage.
2. Left maxillary sinus disease.

CT C spine
IMPRESSION:
1. No evidence of acute fracture. Osseous fragment superior to
the odontoid
process appears well corticated and may represent either old
fracture or
degenerative changes; however, clinical correlation is
recommended.
2. Multilevel degenerative changes noted.

CTA Chest:
The study is extremely limited due to significant motion
artifacts. The
opacification of the pulmonary arteries is satisfactory, and in
the areas that
can be evaluated, no evidence of pulmonary embolism is
demonstrated including
the main pulmonary arteries, the lobar pulmonary arteries, and
the segmental
and subsegmental pulmonary arteries. Heart size is significantly
enlarged.
There is no pericardial effusion but there is bilateral
small-to-moderate
pleural effusion. Aorta is calcified but of normal diameter. No
pericardial
effusion is noted. No mediastinal gross abnormalities have been
demonstrated.
Coronary arteries are significantly calcified.

The imaged portion of the upper abdomen does not reveal any
abnormality.

There are no bone lesions worrisome for infection or neoplasm.
Degenerative
changes are seen throughout the thoracic spine.

Extensive calcifications of the mitral annulus are present.

The airways are patent till the level of subsegmental bronchi
bilaterally.
Centrilobular moderate emphysema affects upper lungs
bilaterally. Subpleural
interstitial changes are noted, diffuse, mostly affecting the
right lung but
extremely limited for evaluation due to motion artifacts, most
likely
representing chronic changes.

IMPRESSION:

Within the limitations of this technically challenging study, no
evidence of
pulmonary embolism is seen. Small bilateral pleural effusions
are present as
well as some degree of emphysema and chronic interstitial
changes with no
evidence of infectious process or other acute abnormalities that
might explain
patient's symptoms.

ECHO:
The left atrium is moderately dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity is unusually small.
Left ventricular systolic function is hyperdynamic (EF>75%).
There is no ventricular septal defect. The right ventricular
cavity is moderately dilated with moderate global free wall
hypokinesis. There is abnormal septal motion/position consistent
with right ventricular pressure/volume overload. The aortic root
is mildly dilated at the sinus level. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is severe pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.

CXR:
Enlargement of the cardiac silhouette is stable. Moderate to
large right and
small to moderate left pleural effusions have increased;
bibasilar opacities
have increased, a combination of increasing pleural effusions
and atelectasis,
superimposed infection cannot be excluded.. There is new mild
vascular
congestion. There is no pneumothorax.

Discharge Labs:
145 / 100 / 17 / 87
3.1 / 35 / 0.9
.
Ca: 9.3 Mg: 1.4 P: 2.4


Brief Hospital Course:
Delirium/Acute Encephalopathy: Likely a combination of
aspiration PNA, atrial fibrillation, and underlying
dementia/decline.  He initially required prn Haldol.  Geriatrics
was consulted.  Over time and with treatment he stabilized.  His
baseline on discharge was: NOT requiring haldol, lucid,
pleasant, conversant, occasionally oriented.

Atrial fibrillation with RVR: During hospitalization went into
Afib with RVR to 150s with low blood pressure.  He was started
on Diltiazem, requiring increasing doses and IV push.  Digoxin
was started as an adjunct.  He seemed to settle on diltiazem
90mg QID with Digoxin 0.125mg daily.  EKG did not show dig
effect.  We recommend continuing this regimen.  He may have
intermittent runs of afib with RVR to the 130s, this should
resolve.  WOuld allow it to correct on its own unless very
symptomatic.
- Consider transitioning to long acting dilt.  Monitor dig level
and adjust appropriately

Aspiration PNA:  Treated with full course of Levo/Flagyl.  S+S
eval improved during admission.  See current diet
recommendations.  Would recommend re-evaluation and advance if
tolerates.

Right sided heart failure, Pulm HTN, acute on chronic diastolic
CHF: Confirmed on echo and by exam with elevated JVD and
peripheral edema.  Diuresis was limited by low blood pressure
and afib.  He diuresed well to lasix 10mg IV and was
transitioned to 10mg daily maintenance, with Kcl supplement
- Adjust lasix, KCL prn based on exam and electrolytes
- rate control with dilt

h/o DVT/afib: Started lovenox. Consider transition to coumadin
based on family wishes

Constipation: Required aggressive bowel regimen

BPH: Held doxasozin given BP issues, oxybutynin given delirium.
Consider restarting at your discretion.

Sister involved in care, and in making medical decisions for
patient.  Patient is DNR/DNI, and would discuss with sister if
aggressive care short of resuscitation is needed.

Medications on Admission:
Medications per OMR:
Tylenol prn
Aspirin 81mg PO
Combivent 2 puffs q6 hours prn
Colace 100mg PO BID prn
Doxazosin 2mg PO daily
Fiber laxative PO daily
Golytely prn
Metoprolol 25mg PO BID
Nasal saline
Nitroglycerin prn
Oxybutynin 20mg PO daily
Ranitidine 150mg PO BID

Allergies: Penicillin


Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
3. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ML PO BID (2
times a day).
4. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. acetaminophen 650 mg Suppository Sig: [**2-7**] Suppositorys Rectal
Q6H (every 6 hours) as needed for pain.
7. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) injection
Subcutaneous QD (): afib, h/o DVT.
8. haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
9. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation every 4-6 hours as needed for SOB.
10. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).

11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO once a day as needed for constipation.
12. senna 8.6 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed for Constipation.
13. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
15. potassium chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO once a day: with lasix.
16. Outpatient Lab Work
Please check chem 7, magnesium within the next 3 days
17. medication adjustment
adjust lasix, KCL supplement based on peripheral edema and
potassium level
18. diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).


Discharge Disposition:
Extended Care

Facility:
[**First Name8 (NamePattern2) 3075**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for Living

Discharge Diagnosis:
Aspiration pneumonia
Delirium, acute encephalopathy
Atrial fibrillation/Flutter
CHF, right-sided, diastolic
Gout flare


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
Mr [**Known lastname 46366**],
It was a pleasure to care for you during this admission. You
were admitted when you were sick at home and confused. You were
found to have a pneumonia and this has improved. You also had a
fast heart rate, that needed medicine to slow it down. You got
confused, and this has also been getting better.  You were also
given diuretics to eliminate fluid.  You were started on Lovenox
as well for blood thinning.

Please take all medications as prescribed and keep all follow up
appointments

Followup Instructions:
Department: [**Hospital1 18**] [**Location (un) 2352**]
When: THURSDAY [**2151-1-14**] at 1:30 PM
With: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD [**Telephone/Fax (1) 1579**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS     Best Parking: Free Parking on Site
{'Pneumonitis due to inhalation of food or vomitus,Encephalopathy, unspecified,Acute on chronic diastolic heart failure,Atrial flutter,Other alteration of consciousness,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Esophageal reflux,Acute gouty arthropathy,Other and unspecified angina pectoris,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Other dependence on machines, supplemental oxygen,Personal history of venous thrombosis and embolism,Do not resuscitate status'}


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: Patient found unresponsive/confused at home, brought to hospital

PRESENT ILLNESS: Mr. [**Known lastname 46366**] is a [**Age over 90 **] M with a medical history notable for COPD on
home oxygen, coronary artery disease, deep vein thrombosis s/p
IVC filter in [**2148**] (not on anticoagultion due to history of GI
bleed). At baseline, he lives independently, he pays his own
bills but he does not drive. He was last seen 1 week prior to
admission by his sister but his neighbors then noticed his
newpapers began collecting in his [**Last Name (un) **] lobby this week.

MEDICAL HISTORY: - HTN
- COPD - [**2143**] FVC 74% of predicted, FEV1 67% of predicted,
FEV1/FVC 90% of predicted, TLC 111% of predicted, RV 145% of
predicted. Intermitent home supplemental O2 use.
- BPH
- Anemia
- GERD, past +H.pylori
- Gout
- Inguinal hernia
- DVT ([**2148**]) s/p IVC filter
- CAD - stable angina

MEDICATION ON ADMISSION: Medications per OMR:
Tylenol prn
Aspirin 81mg PO
Combivent 2 puffs q6 hours prn
Colace 100mg PO BID prn
Doxazosin 2mg PO daily
Fiber laxative PO daily
Golytely prn
Metoprolol 25mg PO BID
Nasal saline
Nitroglycerin prn
Oxybutynin 20mg PO daily
Ranitidine 150mg PO BID

ALLERGIES: Penicillins

PHYSICAL EXAM: Physical exam on arrival to the floor:
- Vital signs: T 99.2, P 92, BP 120/60, 96% on 4LNC.
- Gen: Thin, elderly male sleeping when I enter the room. When I
wake him he is pleasant and alert. He does not participate in
the exam though and he is oriented x 1.
- HEENT: Oropharynx is dry.
- Neck: Supple. No nuchal rigidity.
- Chest: Breathing comfortably on 4LNC. I appreciate no wheezes
or rhonchi but he has bilateral rales in mid-lung fields.
- CV: PMI normal size and not displaced. Has PA lift with no
apprecaible RV heave. On my exam he is tachycardic. Regular
rhythm. Regular pulses. Normal S1, S2. III/VI HSM at LSB. JVP 12
cm when sitting upright in bed (90 degrees).
- Abdomen: Normal bowel sounds. Soft, nontender, nondistended.
No pulsatile liver appreciated.
- Extremities: 2+ ankle edema to the mid-calf.
- MSK: Joints with no redness, swelling, warmth, tenderness.
- Skin: Bruising on left side but no open areas of skin.
- Neuro: Alert, oriented x1. CN appear intact but he does no
cooperate with exam. His speech and language appear normal but
answers questions such as "where do you live" with a person's
name. He is smiling and appears comfortable.

FAMILY HISTORY: Significant for gout in his father.

SOCIAL HISTORY: Lives by himself, independent in IDLs, but not all IADLs (see
HPI). No current VNA/HHA. Tobacco - none currently, quit 40+
years ago. EtOH - none. Denies IV, illicit, or herbal drug use.
His wife passed away 2 years PTA, and family notes that he has
been more sad lately. 

### Response:
{'Pneumonitis due to inhalation of food or vomitus,Encephalopathy, unspecified,Acute on chronic diastolic heart failure,Atrial flutter,Other alteration of consciousness,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Esophageal reflux,Acute gouty arthropathy,Other and unspecified angina pectoris,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Other dependence on machines, supplemental oxygen,Personal history of venous thrombosis and embolism,Do not resuscitate status'}
