CHIEF COMPLAINT: V-fib arrest

PRESENT ILLNESS: 74 yo male w/ hx of a fib (not on coumadin), COPD who was with
his wife at an appt in the [**Name (NI) 23**] building who had a witnessed
v fib arrest. Per PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2450**] - patient abruptly lost
consciousness and stopped breathing and (?) seized while sitting
in a chair. Code was called and chest compressions performed
until defibrillator available. Noted to be in VF and was shocked
(200 Joules) with rhythm return. He was intubated in the clinic
and transferred to the ED.
.
In the ED, vitals were t 98.6, hr 71, bp 129/59, rr 16, sat
100%. Soon began to move all 4 extremities and required bolus
sedation. EKG was obtained with a fib and new RBBB. Cards was
consulted and felt that his VF arrest was secondary to his
underlying pulmonary issues and recommended CTA to r/o PE and
echo in the am.
.
On arrival to the ICU, patient is intubated and sedated.
Minimally responsive to commands.

MEDICAL HISTORY: - Severe COPD - on home O2, FEV1 50%
- diastolic dysfunction with preserved left ventricular systolic
function and normal ejection fraction
- chronic leg edema -presumed to [**1-9**] R heart failure, on
torsemide
- chronic atrial fibrillation - not on anticoagulation by his
choice - hypertension
- Lung cancer - s/p RUL resection in [**2161**]
- prostate cancer - tx w/ Casodex and XRT at [**Company 2860**]
- 100-pack-year history of cigarette smoking
- Severe osteoarthritis involving both of his hips, s/p hip
surgery

MEDICATION ON ADMISSION: - torsemide alternating 50 mg/100mg every other day
- verapamil SR 240 mg daily
- aspirin 325 mg daily
- Combivent (albuterol/ipratropium) inhaler QD
- Advair (fluticasone/salmeterol) inhaler QD

ALLERGIES: Heparin Agents

PHYSICAL EXAM: On admission:
Vitals: t 96.3 ax, bp 148/66, hr 71, rr 18, sat 100%
AC 16/breathing 18 TV 600 PEEP 5 FiO2 1.0
Gen: intubated
HEENT: pupils reactive bilat, cataracts bilat
Resp: bibasilar crackles, no wheeze
Card: regular, no murmurs appreciated
Abd: + bs, soft, non-distended, no hsm
Ext: [**1-11**] lower ext edema, w/ erythema over lower ext consistent
with venous stasis changes, mild warmth, DP pulses [**12-9**]+
Neuro: sedated, moving all four extrmities

FAMILY HISTORY: NC

SOCIAL HISTORY: Patient lives with his wife. [**Name (NI) **] a 100 pack year smoking
history. No EtOH or illicits. Per recent CHF note, patient
severe SOB with
minimal exertion (ie walking 20-50 feet, bathing and dressing in
the morning). He continues to sleep in a recliner chair.
Ventricular fibrillation,Acute respiratory failure,Acute kidney failure, unspecified,Pathologic fracture of vertebrae,Diastolic heart failure, unspecified,Hyperosmolality and/or hypernatremia,Candidiasis of mouth,Pneumonia due to other gram-negative bacteria,Ankylosing spondylitis,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Thrombocytopenia, unspecified,Other and unspecified complications of medical care, not elsewhere classified
Ventricular fibrillation,Acute respiratry failure,Acute kidney failure NOS,Path fx vertebrae,Diastolc hrt failure NOS,Hyperosmolality,Thrush,Pneumo oth grm-neg bact,Ankylosing spondylitis,DMII wo cmp uncntrld,Thrombocytopenia NOS,Complic med care NEC/NOS
Admission Date:  [**2167-9-11**]              Discharge Date:   [**2167-10-16**]

Date of Birth:  [**2090-8-28**]             Sex:   M

Service: MEDICINE

Allergies:
Heparin Agents

Attending:[**First Name3 (LF) 99**]
Chief Complaint:
V-fib arrest

Major Surgical or Invasive Procedure:
spinal fixation

History of Present Illness:
74 yo male w/ hx of a fib (not on coumadin), COPD who was with
his wife at an appt in the [**Name (NI) 23**] building who had a witnessed
v fib arrest. Per PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2450**] - patient abruptly lost
consciousness and stopped breathing and (?) seized while sitting
in a chair. Code was called and chest compressions performed
until defibrillator available. Noted to be in VF and was shocked
(200 Joules) with rhythm return. He was intubated in the clinic
and transferred to the ED.
.
In the ED, vitals were t 98.6, hr 71, bp 129/59, rr 16, sat
100%. Soon began to move all 4 extremities and required bolus
sedation. EKG was obtained with a fib and new RBBB. Cards was
consulted and felt that his VF arrest was secondary to his
underlying pulmonary issues and recommended CTA to r/o PE and
echo in the am.
.
On arrival to the ICU, patient is intubated and sedated.
Minimally responsive to commands.

Past Medical History:
- Severe COPD - on home O2, FEV1 50%
- diastolic dysfunction with preserved left ventricular systolic
function and normal ejection fraction
- chronic leg edema -presumed to [**1-9**] R heart failure, on
torsemide
- chronic atrial fibrillation - not on anticoagulation by his
choice - hypertension
- Lung cancer - s/p RUL resection in [**2161**]
- prostate cancer - tx w/ Casodex and XRT at [**Company 2860**]
- 100-pack-year history of cigarette smoking
- Severe osteoarthritis involving both of his hips, s/p hip
surgery


Social History:
 Patient lives with his wife. [**Name (NI) **] a 100 pack year smoking
history. No EtOH or illicits. Per recent CHF note, patient
severe SOB with
minimal exertion (ie walking 20-50 feet, bathing and dressing in
the morning). He continues to sleep in a recliner chair.


Family History:
NC

Physical Exam:
On admission:
Vitals: t 96.3 ax, bp 148/66, hr 71, rr 18, sat 100%
AC 16/breathing 18 TV 600 PEEP 5 FiO2 1.0
Gen: intubated
HEENT: pupils reactive bilat, cataracts bilat
Resp: bibasilar crackles, no wheeze
Card: regular, no murmurs appreciated
Abd: + bs, soft, non-distended, no hsm
Ext: [**1-11**] lower ext edema, w/ erythema over lower ext consistent
with venous stasis changes, mild warmth, DP pulses [**12-9**]+
Neuro: sedated, moving all four extrmities

Pertinent Results:
EKG: hr 72, a fib, LAD, new RBBB, ST seg depression V4-V6
relatively unchanged from prior
.
Imaging:
CXR - [**2167-9-11**]: Cardiac silhouette is enlarged. There are
increased interstitial opacities with prominence and of the
pulmonary vasculature, consistent with interstitial edema. The
ET tube is in place, terminating 1 cm above the carina.
Defibrillator pad is in place on the right, partially obscuring
evaluation of the right lung. There is right lung volume loss
and post- surgical changes from right upper lobectomy,
unchanged.
.
Head CT - [**2167-9-11**]: (wet read)
no ICH, no mass effect, + loss of [**Doctor Last Name 352**]/white matter
differentiation in the L front/parietal area consistent w/
encephalomalacia
.
ECHO - [**4-12**]: Study is severely technically limited.
Biventricular systolic function appears grossly preserved in
suboptimal views. Regional wall motion could not be adequately
assessed. Mild aortic regurgitation is detected. The valves are
not well seen. Mitral and tricuspid regurgitation could not be
adequately assessed.


Brief Hospital Course:
Patient is a 77 year old male h/o COPD s/p R lung resection,
presumed diastolic heart failure, HTN, obesity, and likely
diabetes mellitus type 2, now status post cardiopulmonary
resuscitation given VF arrest, reintubated for worsening
respiratory status twice, [**1-9**] to mucus plugging, s/p spinal
fixation. Extubated two days ago, with increasing respiratory
distress.  Pt refuses reintubation.

# Respiratory failure: Pt with previous pulmonary history of
COPD and prior lung resection, was intubated s/p V fib arrest
and had multiple failed extubations.  He had previous been
extubated and reintubated twice for worsening acidemia and
hypercarbia, likely due to poor MS and possibly too much O2 use
causing CO2 retention. Pt has completed 2 steroid tapers for
possible COPD component, and has been diursed for many days. Pt
with Serratioa marrascens initially treated with unasyn and
changed to meropenem on [**9-26**] due to concern for
thrombocytopenia. Repeat sputum on [**9-12**] demonstrated
serratia as well, finished 8 day course of Meropenem on [**10-8**].
Further cultures continued to grow serratia. Patient was
extubated [**10-14**], and overnight felt fatigued at times, with some
difficulty clearing secretions.  Levofloxacin was started to
attempt to clear any remaining serratia.  Pt respiration assited
with bipap, diuresis, nebs, and chest PT.  Despite attempts, pt
continued to be unable to clear secretions, and retained CO2.
Multiple extensive discussions with patient and family, and in
end, pt refused re-intubation and was made CMO.  Pt died
approximatedly 1.5 days after third extubation.
.
# Code Status: Extensive discussions [**10-14**] and again [**10-15**].
Patient initially desired not to be re-intubated, however after
discussions with family, stated he would want to be intubated if
needed. After further discussions, pt again refused intubation
despite conversations with family, ICU staff and PCP.  [**Name10 (NameIs) **] was
not intubated, and eventually made CMO.
.
# S/p VF arrest: Contrast echo did not demonstrate any focal
wall motion abnormalities given suboptimal study. Per study, it
appears that systolic function is intact. Were planning for ICD
after stabilization, in consultation with EP.
.
# Thrombocytopenia- Dropped from 184 to 143 to 64 [**9-26**] am.
Extensive workup for variety of diagnosies including HIT, TTP,
ITP, sequestration etc including consultation of heme/onc.  Pt
continued to have plt < 20 and often < 10 despite transfusion
and removal of all thrombocytopenic drugs (including Diamox,
lasix, zosyn).  Heparin dependent Ab positive, serotonin release
assay negative so HIT very unlikely.  Pt was removed from all
heparin, and line was replaced with heparin free pic with no
resolution. Pt was treated with steroids and IVIG in event that
thrombocytopenia was immune mediated - no response.  U/S
revealed mildly enlarged spleen, no liver lesions making
sequestration unlikley.  DIC and hemoysis labs were negative as
well as fact that Upper and lower extremity ultrasounds negative
for DVT, and there were no schistocytes on smear. Patient
underwent BM biopsy which showed normal megakaryocytes. At this
time felt to be multifactorial, from medication effects, chronic
illness. In general, pt transfused 1 u of plt at at ime to keep
plt count above 10.  Plt count would initially bump, and then
return to low level.  No HLA antibodies, so that was not a
source of destroying plt.
.
# Atrial fibrillation: Patient frequently in atrial
fibrillation.  Rate was controlled with labetalol 50 mg PO TID.
(Atrial fibrillation is chronic, and patient had not been
previously anticoagulated; metoprolol had been stopped
previously as a home medication given patient's fatigue on
metoprolol as well as patient's COPD). Held any anticoagulation
given ongoing thrombocytopenia, anemia, bleeding difficulties.
Rate control at goal presently.
.
# Anemia: Previously anemic, now stable. Possible sources;
Stools guaiac positive, some serosangeous secretions, hematuria,
and general coagulopathy from decreased platlets.  Pt transfused
to maintain hct > 21
.
# Hypernatremia: Treated with free water boluses as needed
.
# Oral Thrush: Nystatin S&S.
.
# Hypertension: Had labile blood pressure ranging from
130s-170s, which responded well to labetaolol. Captopril was
added, and then transitioned to lisinopril 40 mg, with good
effect.  Hydralazine 10 mg was used prn for additional control.
.
# Renal failure: He was noted to have a minor creatinine bump
post op to 1.7, which quickly returned to [**Location 213**] range at 0.5.
Likely prerenal given urine Na<10, with good UOP
.
# Hyperglycemia: HbA1c 9.6, indicating poor glycemic control
over last two to three months. Insulin SS and NPH adjusted per
FSBGs.
.
# Spinal injury: s/p hardware fixation of t4-t10. Moving all
fours. Logroll precautions had been removed, and pt was sitting
up in chair with OT and PT consluts.  Heparin was [**Last Name (un) **] for
thrombocytopenia.
.
# COPD: Patient continued on albuterol and ipratropium
nebulizers standing, as well as albuterol PRN.
- Finished steroid taper x2.
.
# FEN: Tube feeds with Nutren Pulmonary at goal, with free water
boluses as needed for hypernatremia.
.
# PPX: PPI while intubated, eventually d/c to ensure not cause
of thrombocytopenia.  Had bowel regimin titrated as needed.
.
# Access: PICC line, A-line
.
# Communication: Wife [**Name (NI) **] [**Name (NI) **] cell [**Telephone/Fax (1) 111668**], home
[**Telephone/Fax (1) 111669**]

Medications on Admission:
- torsemide alternating 50 mg/100mg every other day
- verapamil SR 240 mg daily
- aspirin 325 mg daily
- Combivent (albuterol/ipratropium) inhaler QD
- Advair (fluticasone/salmeterol) inhaler QD

Discharge Medications:
None

Discharge Disposition:
Expired

Discharge Diagnosis:
deceased

Discharge Condition:
deceased

Discharge Instructions:
deceased

Followup Instructions:
deceased
{'Ventricular fibrillation,Acute respiratory failure,Acute kidney failure, unspecified,Pathologic fracture of vertebrae,Diastolic heart failure, unspecified,Hyperosmolality and/or hypernatremia,Candidiasis of mouth,Pneumonia due to other gram-negative bacteria,Ankylosing spondylitis,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Thrombocytopenia, unspecified,Other and unspecified complications of medical care, not elsewhere classified'}


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: V-fib arrest

PRESENT ILLNESS: 74 yo male w/ hx of a fib (not on coumadin), COPD who was with
his wife at an appt in the [**Name (NI) 23**] building who had a witnessed
v fib arrest. Per PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2450**] - patient abruptly lost
consciousness and stopped breathing and (?) seized while sitting
in a chair. Code was called and chest compressions performed
until defibrillator available. Noted to be in VF and was shocked
(200 Joules) with rhythm return. He was intubated in the clinic
and transferred to the ED.
.
In the ED, vitals were t 98.6, hr 71, bp 129/59, rr 16, sat
100%. Soon began to move all 4 extremities and required bolus
sedation. EKG was obtained with a fib and new RBBB. Cards was
consulted and felt that his VF arrest was secondary to his
underlying pulmonary issues and recommended CTA to r/o PE and
echo in the am.
.
On arrival to the ICU, patient is intubated and sedated.
Minimally responsive to commands.

MEDICAL HISTORY: - Severe COPD - on home O2, FEV1 50%
- diastolic dysfunction with preserved left ventricular systolic
function and normal ejection fraction
- chronic leg edema -presumed to [**1-9**] R heart failure, on
torsemide
- chronic atrial fibrillation - not on anticoagulation by his
choice - hypertension
- Lung cancer - s/p RUL resection in [**2161**]
- prostate cancer - tx w/ Casodex and XRT at [**Company 2860**]
- 100-pack-year history of cigarette smoking
- Severe osteoarthritis involving both of his hips, s/p hip
surgery

MEDICATION ON ADMISSION: - torsemide alternating 50 mg/100mg every other day
- verapamil SR 240 mg daily
- aspirin 325 mg daily
- Combivent (albuterol/ipratropium) inhaler QD
- Advair (fluticasone/salmeterol) inhaler QD

ALLERGIES: Heparin Agents

PHYSICAL EXAM: On admission:
Vitals: t 96.3 ax, bp 148/66, hr 71, rr 18, sat 100%
AC 16/breathing 18 TV 600 PEEP 5 FiO2 1.0
Gen: intubated
HEENT: pupils reactive bilat, cataracts bilat
Resp: bibasilar crackles, no wheeze
Card: regular, no murmurs appreciated
Abd: + bs, soft, non-distended, no hsm
Ext: [**1-11**] lower ext edema, w/ erythema over lower ext consistent
with venous stasis changes, mild warmth, DP pulses [**12-9**]+
Neuro: sedated, moving all four extrmities

FAMILY HISTORY: NC

SOCIAL HISTORY: Patient lives with his wife. [**Name (NI) **] a 100 pack year smoking
history. No EtOH or illicits. Per recent CHF note, patient
severe SOB with
minimal exertion (ie walking 20-50 feet, bathing and dressing in
the morning). He continues to sleep in a recliner chair. 

### Response:
{'Ventricular fibrillation,Acute respiratory failure,Acute kidney failure, unspecified,Pathologic fracture of vertebrae,Diastolic heart failure, unspecified,Hyperosmolality and/or hypernatremia,Candidiasis of mouth,Pneumonia due to other gram-negative bacteria,Ankylosing spondylitis,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Thrombocytopenia, unspecified,Other and unspecified complications of medical care, not elsewhere classified'}
