CHIEF COMPLAINT: transferred for management of hypotension, dyspnea

PRESENT ILLNESS: This is a 79 yo man w/h/o PEs, [**First Name3 (LF) 7792**], COPD on 2-3LNC outpt, who
p/w 4-5days of SOB and nonproductive cough. Most of hx is given
by pt's son who notes that the SOB began ~2 weeks ago. At that
time, he was febrile w/productive cough. He was treated w/2
weeks of levofloxacin and a ZPak, course complete last Fri.
Since then, pt notes that his breathing was slightly better, but
upon following up with his PCP this past [**Name9 (PRE) **], she noted that he
was fluid overloaded. They had been increasing the outpt dose of
lasix, but both son and pt are unable to recall what the most
recent dose was. Pt's dry weight is ~210lbs, and most recently
he weighed 215lbs outpt. Pts son notes that [**Name (NI) 269**] has been
checking vitals daily and day PTA his father's O2 sat dropped to
mid 70's on 5L O2 which improved w/son's CPAP to 93%. He has
otherwise been afebrile. Denied recent CP/palpitations, notes +
orthopnea, PND, DOE. They presented to [**Hospital1 **] [**Location (un) 620**] where he
received Ceftriaxone and Levofloxacin and was started on
pressors for SBP 70s/50s.
.
In the ED, right IJ was placed to continue levophed. Vitals were
T 100.6 BP 96/56 HR 96 RR 28 sat 99% on NRB.
.
ROS: The patient denies any nausea, vomiting, abdominal pain,
diarrhea, constipation, melena, hematochezia, urinary frequency,
urgency, dysuria, lightheadedness, gait unsteadiness, focal
weakness, vision changes, headache, rash or skin changes.
.

MEDICAL HISTORY: # Dyslipidemia
# Hypertension
# Systolic heart failure- EF 35%
# Aortic stenosis- moderate to severe
# PE: junction right upper and right middle lob artery; also PE

MEDICATION ON ADMISSION: Coumadin as directed
metoprolol 12.5 mg twice a day
Plavix 75 mg daily
aspirin 81 mg daily
lisinopril 5 mg daily
Zocor 80 mg daily
folic acid
thiamine
protonix 40mg [**Hospital1 **]

ALLERGIES: Bacitracin

PHYSICAL EXAM: Tmax: 37.1 ??????C (98.7 ??????F)
Tcurrent: 35.8 ??????C (96.4 ??????F)
HR: 103 (93 - 109) bpm
BP: 66/39(50) {66/39(50) - 121/59(79)} mmHg
RR: 16 (11 - 31) insp/min
SpO2: 98%
Heart rhythm: ST (Sinus Tachycardia)
Wgt (current): 100 kg (admission): 100 kg

FAMILY HISTORY: FAMILY HISTORY:
No family history of early MI, otherwise non-contributory.

SOCIAL HISTORY: Positive for alcohol and tobacco use: 6beers and 2 shots/day,
60pack year hx. Lives with his son.
Acute on chronic combined systolic and diastolic heart failure,Pneumonia, organism unspecified,Acute respiratory failure,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Cardiogenic shock,Mitral valve insufficiency and aortic valve insufficiency,Subendocardial infarction, subsequent episode of care,Surgical or other procedure not carried out because of patient's decision,Personal history of malignant neoplasm of prostate,Chronic airway obstruction, not elsewhere classified,Alcohol abuse, continuous
Ac/chr syst/dia hrt fail,Pneumonia, organism NOS,Acute respiratry failure,Acute kidney failure NOS,Urin tract infection NOS,Cardiogenic shock,Mitral/aortic val insuff,Subendo infarct, subseq,No proc/patient decision,Hx-prostatic malignancy,Chr airway obstruct NEC,Alcohol abuse-continuous
Admission Date:  [**2181-10-24**]              Discharge Date:   [**2181-10-27**]

Date of Birth:  [**2102-3-8**]             Sex:   M

Service: MEDICINE

Allergies:
Bacitracin

Attending:[**First Name3 (LF) 22964**]
Chief Complaint:
transferred for management of hypotension, dyspnea


Major Surgical or Invasive Procedure:
Left arterial line placement
Right internal jugular central venous line placement.

History of Present Illness:
This is a 79 yo man w/h/o PEs, [**First Name3 (LF) 7792**], COPD on 2-3LNC outpt, who
p/w 4-5days of SOB and nonproductive cough. Most of hx is given
by pt's son who notes that the SOB began ~2 weeks ago. At that
time, he was febrile w/productive cough. He was treated w/2
weeks of levofloxacin and a ZPak, course complete last Fri.
Since then, pt notes that his breathing was slightly better, but
upon following up with his PCP this past [**Name9 (PRE) **], she noted that he
was fluid overloaded. They had been increasing the outpt dose of
lasix, but both son and pt are unable to recall what the most
recent dose was. Pt's dry weight is ~210lbs, and most recently
he weighed 215lbs outpt. Pts son notes that [**Name (NI) 269**] has been
checking vitals daily and day PTA his father's O2 sat dropped to
mid 70's on 5L O2 which improved w/son's CPAP to 93%. He has
otherwise been afebrile. Denied recent CP/palpitations, notes +
orthopnea, PND, DOE. They presented to [**Hospital1 **] [**Location (un) 620**] where he
received Ceftriaxone and Levofloxacin and was started on
pressors for SBP 70s/50s.
.
In the ED, right IJ was placed to continue levophed. Vitals were
T 100.6 BP 96/56 HR 96 RR 28 sat 99% on NRB.
.
ROS: The patient denies any nausea, vomiting, abdominal pain,
diarrhea, constipation, melena, hematochezia, urinary frequency,
urgency, dysuria, lightheadedness, gait unsteadiness, focal
weakness, vision changes, headache, rash or skin changes.
.


Past Medical History:
# Dyslipidemia
# Hypertension
# Systolic heart failure- EF 35%
# Aortic stenosis- moderate to severe
# PE: junction right upper and right middle lob artery; also PE

  of RML, RLL, LLL distal vessels
# Extensive mural thrombus of aortic arch and descending
  abdominal aorta
# RLE DVT
# Prostate CA s/p radiation
# Hypercholesterolemia
# COPD
# Hx of ETOH abuse

Social History:
Positive for alcohol and tobacco use: 6beers and 2 shots/day,
60pack year hx. Lives with his son.


Family History:
FAMILY HISTORY:
No family history of early MI, otherwise non-contributory.


Physical Exam:
Tmax: 37.1 ??????C (98.7 ??????F)
Tcurrent: 35.8 ??????C (96.4 ??????F)
HR: 103 (93 - 109) bpm
BP: 66/39(50) {66/39(50) - 121/59(79)} mmHg
RR: 16 (11 - 31) insp/min
SpO2: 98%
Heart rhythm: ST (Sinus Tachycardia)
Wgt (current): 100 kg (admission): 100 kg

General Appearance: sleeping and obtunded
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Rhonchorous: ), coarse
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: 2+, Left: 2+
Neurologic: No(t) Attentive, No(t) Follows simple commands,
Responds to: Verbal stimuli, Movement: Not assessed, Tone: Not
assessed


Pertinent Results:
[**2181-10-26**] 04:41AM BLOOD WBC-7.1 RBC-2.92* Hgb-9.2* Hct-27.9*
MCV-96 MCH-31.3 MCHC-32.8 RDW-14.6 Plt Ct-192
[**2181-10-24**] 08:50PM BLOOD Neuts-85.8* Lymphs-8.9* Monos-4.5 Eos-0.7
Baso-0.1
[**2181-10-26**] 04:41AM BLOOD PT-34.2* PTT-47.9* INR(PT)-3.5*
[**2181-10-26**] 04:41AM BLOOD Glucose-91 UreaN-52* Creat-2.1* Na-136
K-5.1 Cl-97 HCO3-29 AnGap-15
[**2181-10-25**] 04:24AM BLOOD ALT-19 AST-22 LD(LDH)-164 AlkPhos-38*
TotBili-1.9* DirBili-0.6* IndBili-1.3
[**2181-10-25**] 04:24AM BLOOD proBNP-[**Numeric Identifier 48936**]*
[**2181-10-26**] 04:41AM BLOOD Calcium-8.5 Phos-5.1*# Mg-2.1
[**2181-10-26**] 01:01PM BLOOD Type-ART pO2-69* pCO2-70* pH-7.28*
calTCO2-34* Base XS-3
[**2181-10-26**] 11:20AM BLOOD Type-ART Temp-37.0 Rates-/14 FiO2-50
pO2-91 pCO2-72* pH-7.28* calTCO2-35* Base XS-3 Intubat-NOT
INTUBA
[**2181-10-24**] 09:01PM BLOOD Glucose-134* Lactate-0.9 Na-136 K-5.0
Cl-94* calHCO3-32*
[**2181-10-25**] 10:02AM BLOOD O2 Sat-71
[**2181-10-24**] 09:01PM BLOOD freeCa-1.06*

TTE [**10-25**]
The left atrial volume is markedly increased (>32ml/m2). The
right atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. There is severe global left ventricular
hypokinesis (LVEF = XX %). There is no ventricular septal
defect. The right ventricular cavity is moderately dilated with
moderate global free wall hypokinesis. The aortic root is mildly
dilated at the sinus level. The number of aortic valve leaflets
cannot be determined. The aortic valve leaflets are moderately
thickened. There is moderate to severe aortic valve stenosis
(area 0.8-1.0cm2). Mild to moderate ([**1-10**]+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. Mild to moderate ([**1-10**]+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is a trivial/physiologic pericardial effusion. There are
no echocardiographic signs of tamponade.

IMPRESSION: Severe global LV hypokinesis with moderate LV
dilatation. Moderate to severe aortic stenosis. Mild to moderate
aortic and mitral regurgitation.

Compared with the prior study (images reviewed) of [**2181-7-16**], the
left ventricle is now dilated. The inferior and inferolateral
segments, which previously had relatively preserved function are
now hypokinetic. The valvular pathologies are similar. The
degree of pulmonary artery systolic hypertension is slightly
lower.

Brief Hospital Course:
Mr. [**Known lastname 2727**] is a 79 year old gentleman with a PMH significant for
COPD on 2-3L home O2, recent PE on coumadin s/p IVF filter
placement, and recent [**Known lastname 7792**] medically managed admitted for [**4-14**]
days of SOB, nonproductive cough, and hypotension.  The patient
was found to have decompensated heart failure and started on
dobutamine, dopamine, and lasix gtt. The patient's condition
continued to deteriorate and the decision was made in
conjunction with his entire family to make the patient Comfort
Measures Only and died shortly thereafter.

1. Hypotension: This most likely represents decompensated heart
failure/cardiogenic shock and less likely sepsis.  Pt ECHO shows
reduced EF (20-25%) and severe global hypokinesis.  BNP was
>36,000.  Cardiology was consulted and recommended diuresis and
attempting to wean pressors.  Pt negative 400cc yesterday.
Potential infectious sources include urosepsis versus pneumonia.
The patient had worsening CXR showing possible retrocardiac
opacity concerning for effusion versus pneumonia, although
patient with recently treated CAP as outpatient with
azithromycin.  The patient was continued on dobutaime and
dopamine.  He was diuresised on a lasix drip, but his output was
limited by his hypotension.  The patient was also started on
broad spectrum antibiotics for pneumonia, vancomycin, zosyn and
levofloxacin.  On [**10-26**] in the morning the patient was found to
be more lethargic and confused.  A blood gas showed that he had
hypercapneic respiratory failure and was placed on BiPAP.  The
patient refused intubation.  He did not improve on BiPAP and
given his clinical deterioration the patient and family decided
to pursue comfort measures only.  All additional interventions
and treatments were suspended and the patient was only given
morphine and placed on a NRB.  He died shortly thereafter.

2. Dyspnea: Likely multifactorial including fluid overload due
to decompensated systolic heart failure (BNP >36,000), possibly
secondary to ARF (Cr trending down from 2.1, baseline 1.0) and
baseline COPD although without signs of exacerbation including
wheezes.

3. CAD: Recent [**Month/Year (2) 7792**] that was medically managed.  ECG without
evidence of acute ischemia and patient without chest pain.

4. ARF: FeUrea 21.3%, suggesting that acute renal failure is due
to pre-renal azotemia consistent with decreased renal
perfusion/forward flow from decompensated heart failure.
Baseline creatinine 1-1.2.

5. UTI: Treated with ceftriaxone until patient made CMO.

6. Anemia: Baseline hct of 30-40, now with hct of 27.9 after 1U
pRBC with unknown etiology to acute decrease.  Pt haptoglobin
(230) and TBili mildly elevated.  LDH normal.

7. Pulmonary embolism: Patient with multiple PE in [**7-17**]
currently on coumadin with mildly supratherapeutic INR.
Continued on coumadin during admission.

8. EtOH abuse: Past history of EtOH use.  Continued on thiamine
and folate.

9. Code status: As above, patient made CMO after discussion with
family.

Medications on Admission:
Coumadin as directed
metoprolol 12.5 mg twice a day
Plavix 75 mg daily
aspirin 81 mg daily
lisinopril 5 mg daily
Zocor 80 mg daily
folic acid
thiamine
protonix 40mg [**Hospital1 **]


Discharge Medications:
Patiend died.

Discharge Disposition:
Expired

Discharge Diagnosis:
Patiend died.

Discharge Condition:
Patiend died.

Discharge Instructions:
Patiend died.

Followup Instructions:
Patiend died.


Completed by:[**2181-10-27**]
{"Acute on chronic combined systolic and diastolic heart failure,Pneumonia, organism unspecified,Acute respiratory failure,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Cardiogenic shock,Mitral valve insufficiency and aortic valve insufficiency,Subendocardial infarction, subsequent episode of care,Surgical or other procedure not carried out because of patient's decision,Personal history of malignant neoplasm of prostate,Chronic airway obstruction, not elsewhere classified,Alcohol abuse, continuous"}


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: transferred for management of hypotension, dyspnea

PRESENT ILLNESS: This is a 79 yo man w/h/o PEs, [**First Name3 (LF) 7792**], COPD on 2-3LNC outpt, who
p/w 4-5days of SOB and nonproductive cough. Most of hx is given
by pt's son who notes that the SOB began ~2 weeks ago. At that
time, he was febrile w/productive cough. He was treated w/2
weeks of levofloxacin and a ZPak, course complete last Fri.
Since then, pt notes that his breathing was slightly better, but
upon following up with his PCP this past [**Name9 (PRE) **], she noted that he
was fluid overloaded. They had been increasing the outpt dose of
lasix, but both son and pt are unable to recall what the most
recent dose was. Pt's dry weight is ~210lbs, and most recently
he weighed 215lbs outpt. Pts son notes that [**Name (NI) 269**] has been
checking vitals daily and day PTA his father's O2 sat dropped to
mid 70's on 5L O2 which improved w/son's CPAP to 93%. He has
otherwise been afebrile. Denied recent CP/palpitations, notes +
orthopnea, PND, DOE. They presented to [**Hospital1 **] [**Location (un) 620**] where he
received Ceftriaxone and Levofloxacin and was started on
pressors for SBP 70s/50s.
.
In the ED, right IJ was placed to continue levophed. Vitals were
T 100.6 BP 96/56 HR 96 RR 28 sat 99% on NRB.
.
ROS: The patient denies any nausea, vomiting, abdominal pain,
diarrhea, constipation, melena, hematochezia, urinary frequency,
urgency, dysuria, lightheadedness, gait unsteadiness, focal
weakness, vision changes, headache, rash or skin changes.
.

MEDICAL HISTORY: # Dyslipidemia
# Hypertension
# Systolic heart failure- EF 35%
# Aortic stenosis- moderate to severe
# PE: junction right upper and right middle lob artery; also PE

MEDICATION ON ADMISSION: Coumadin as directed
metoprolol 12.5 mg twice a day
Plavix 75 mg daily
aspirin 81 mg daily
lisinopril 5 mg daily
Zocor 80 mg daily
folic acid
thiamine
protonix 40mg [**Hospital1 **]

ALLERGIES: Bacitracin

PHYSICAL EXAM: Tmax: 37.1 ??????C (98.7 ??????F)
Tcurrent: 35.8 ??????C (96.4 ??????F)
HR: 103 (93 - 109) bpm
BP: 66/39(50) {66/39(50) - 121/59(79)} mmHg
RR: 16 (11 - 31) insp/min
SpO2: 98%
Heart rhythm: ST (Sinus Tachycardia)
Wgt (current): 100 kg (admission): 100 kg

FAMILY HISTORY: FAMILY HISTORY:
No family history of early MI, otherwise non-contributory.

SOCIAL HISTORY: Positive for alcohol and tobacco use: 6beers and 2 shots/day,
60pack year hx. Lives with his son. 

### Response:
{"Acute on chronic combined systolic and diastolic heart failure,Pneumonia, organism unspecified,Acute respiratory failure,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Cardiogenic shock,Mitral valve insufficiency and aortic valve insufficiency,Subendocardial infarction, subsequent episode of care,Surgical or other procedure not carried out because of patient's decision,Personal history of malignant neoplasm of prostate,Chronic airway obstruction, not elsewhere classified,Alcohol abuse, continuous"}
