CHIEF COMPLAINT: Hypoxemia and S/P fall

PRESENT ILLNESS: 84 yo M with h/o dementia, Parkinson's, CAD, CHF (EF 30%)
presents following a fall w/ 3 days of worsening shortness of
breath since his discharge from [**Hospital1 18**] on [**2139-1-9**].  He was
admitted at that time s/p probable mechanical fall and hypoxia.
He again presents following multiple falls since last discharge.
 He denies lightheadedness/dizziness, chest pain prior to the
falls and says that his walker slipped ahead of him.  He does,
however, note some confusion following the fall.  He does not
recall head trauma.
.
Also of note, his daughter reports that around the time of these
episodes he had significant sweats and chills. Since his
discharge, he has continued to be short of breath, even
[**Last Name (un) 6055**]-[**Doctor Last Name **] breathing according to his son-in-law (a
nephrologist).
.
In the ED, BNP was found to be [**Numeric Identifier 31854**], but CXR did not reveal
gross volume overload. Cardiac enzymes showed elevated troponin
(but this is at his baseline given his acute on chronic renal
failure) and CKs were flat.  His initial vitals revealed T 98.0
HR 120 BP 88/40 and RR in the 20s with O2 sats of 88% on RA.
Given his elevated lactate and recent h/o sweats and rigors, he
received vancomycin and zosyn for broad coverage although there
currently is no clear source of infection.

MEDICAL HISTORY: 1. CAD, h/o prior MIs with cath in [**2111**]
2. [**Last Name (un) 309**]-body dementia
3. Parkinson's
4. s/p ICD for history syncope
4. mild BPH
5. neurogenic bladder
7. h/o embolic CVA - on chronic coumadin
8. Moderate MR/TR
9. Compensated CHF, EF 30% in [**2136**]
10. ?aspiration
11. CRI, baseline Cr 1.4-1.5
12. Anemia (BL 34-36)
13. Recurrent falls
14. HTN
15. Atrial fibrillation
16. Hyperlipidemia

MEDICATION ON ADMISSION: 1. Donepezil 5 mg PO HS
2. Carbidopa-Levodopa 50-200 mg PO DAILY
3. Carbidopa-Levodopa 25-100 mg Tablet PO TID
4. Quetiapine 25 mg Tablet PO QHS
5. Nitroglycerin 0.2 mg/hr Patch 24HR (1) Patch Q24H
6. Furosemide 20 mg PO DAILY
7. Simvastatin 10 mg Tablet PO DAILY
8. Metoprolol Tartrate 25 mg Tablet PO DAILY
9. Aspirin 81 mg Tablet PO DAILY
10. Proscar 5mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 96.6 ax HR 112 V paced BP 123/88 RR 18 O2 sat 96% NRB
Gen: Alert and oriented to person, place, and time as [**Month (only) 404**],
[**2138**], not to day.
HEENT: PERRL
Neck: No JVD appreciated.  Supple.
CV: Tachycardic, V-paced, no mrg
Resp: [**Month (only) **]. BS left lung base, no wheezes/rales/rhonchi
Abd: +BS, soft, NT, ND
Ext: 1+ edema b/l, midfoot to toes b/l cool, b/l fingers cool,
cyanotic
Neuro:  + pill rolling tremor right hand > left, right foot with
tremor. Strength 5/5 b/l upper extremities.

FAMILY HISTORY: Father with MI, unknown age.

SOCIAL HISTORY: Lives at home with his wife. Uses a walker occasionally. Former
smoker, quit 20 years ago. No EtOH or illicits.
Hypoxemia,Acquired cardiac septal defect,Congestive heart failure, unspecified,Acute kidney failure, unspecified,Traumatic pneumothorax without mention of open wound into thorax,Closed fracture of one rib,Unspecified fall,Mitral valve disorders,Diseases of tricuspid valve,Atrial fibrillation,Chronic kidney disease, unspecified,Dementia with lewy bodies,Dementia in conditions classified elsewhere without behavioral disturbance,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Paralysis agitans,Fitting and adjustment of automatic implantable cardiac defibrillator
Hypoxemia,Acq cardiac septl defect,CHF NOS,Acute kidney failure NOS,Traum pneumothorax-close,Fracture one rib-closed,Fall NOS,Mitral valve disorder,Tricuspid valve disease,Atrial fibrillation,Chronic kidney dis NOS,Dementia w Lewy bodies,Dementia w/o behav dist,Hy kid NOS w cr kid I-IV,Paralysis agitans,Ftng autmtc dfibrillator
Admission Date:  [**2139-1-13**]              Discharge Date:   [**2139-1-19**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
Hypoxemia and S/P fall

Major Surgical or Invasive Procedure:
None

History of Present Illness:
84 yo M with h/o dementia, Parkinson's, CAD, CHF (EF 30%)
presents following a fall w/ 3 days of worsening shortness of
breath since his discharge from [**Hospital1 18**] on [**2139-1-9**].  He was
admitted at that time s/p probable mechanical fall and hypoxia.
He again presents following multiple falls since last discharge.
 He denies lightheadedness/dizziness, chest pain prior to the
falls and says that his walker slipped ahead of him.  He does,
however, note some confusion following the fall.  He does not
recall head trauma.
.
Also of note, his daughter reports that around the time of these
episodes he had significant sweats and chills. Since his
discharge, he has continued to be short of breath, even
[**Last Name (un) 6055**]-[**Doctor Last Name **] breathing according to his son-in-law (a
nephrologist).
.
In the ED, BNP was found to be [**Numeric Identifier 31854**], but CXR did not reveal
gross volume overload. Cardiac enzymes showed elevated troponin
(but this is at his baseline given his acute on chronic renal
failure) and CKs were flat.  His initial vitals revealed T 98.0
HR 120 BP 88/40 and RR in the 20s with O2 sats of 88% on RA.
Given his elevated lactate and recent h/o sweats and rigors, he
received vancomycin and zosyn for broad coverage although there
currently is no clear source of infection.


Past Medical History:
1. CAD, h/o prior MIs with cath in [**2111**]
2. [**Last Name (un) 309**]-body dementia
3. Parkinson's
4. s/p ICD for history syncope
4. mild BPH
5. neurogenic bladder
7. h/o embolic CVA - on chronic coumadin
8. Moderate MR/TR
9. Compensated CHF, EF 30% in [**2136**]
10. ?aspiration
11. CRI, baseline Cr 1.4-1.5
12. Anemia (BL 34-36)
13. Recurrent falls
14. HTN
15. Atrial fibrillation
16. Hyperlipidemia


Social History:
Lives at home with his wife. Uses a walker occasionally. Former
smoker, quit 20 years ago. No EtOH or illicits.

Family History:
Father with MI, unknown age.

Physical Exam:
T 96.6 ax HR 112 V paced BP 123/88 RR 18 O2 sat 96% NRB
Gen: Alert and oriented to person, place, and time as [**Month (only) 404**],
[**2138**], not to day.
HEENT: PERRL
Neck: No JVD appreciated.  Supple.
CV: Tachycardic, V-paced, no mrg
Resp: [**Month (only) **]. BS left lung base, no wheezes/rales/rhonchi
Abd: +BS, soft, NT, ND
Ext: 1+ edema b/l, midfoot to toes b/l cool, b/l fingers cool,
cyanotic
Neuro:  + pill rolling tremor right hand > left, right foot with
tremor. Strength 5/5 b/l upper extremities.


Pertinent Results:
[**2139-1-13**] 08:26PM BLOOD Type-ART Temp-36.7 pO2-52* pCO2-25*
pH-7.39 calTCO2-16* Base XS--7 Intubat-NOT INTUBA
[**2139-1-13**] 08:05PM BLOOD CK-MB-6 proBNP-[**Numeric Identifier 31854**]*
[**2139-1-13**] 08:05PM BLOOD cTropnT-0.13*
[**2139-1-13**] 08:05PM BLOOD Lipase-33
[**2139-1-13**] 08:05PM BLOOD ALT-57* AST-53* CK(CPK)-125 AlkPhos-126*
Amylase-88 TotBili-1.3
[**2139-1-13**] 08:05PM BLOOD Glucose-130* UreaN-37* Creat-1.9* Na-138
K-5.4* Cl-103 HCO3-17* AnGap-23*
[**2139-1-18**] 06:35AM BLOOD Glucose-83 UreaN-23* Creat-1.3* Na-140
K-3.8 Cl-105 HCO3-26 AnGap-13
[**2139-1-13**] 08:05PM BLOOD PT-16.1* PTT-30.9 INR(PT)-1.5*
[**2139-1-13**] 08:05PM BLOOD WBC-8.6# RBC-4.19* Hgb-13.8* Hct-41.8
MCV-100* MCH-33.0* MCHC-33.0 RDW-14.8 Plt Ct-134*
[**2139-1-18**] 06:35AM BLOOD WBC-4.8 RBC-3.55* Hgb-11.7* Hct-33.8*
MCV-95 MCH-32.8* MCHC-34.4 RDW-14.9 Plt Ct-116*
.
CHEST, AP: There is a dual lead pacemaker device in a similar
position. The heart is enlarged. The mediastinal and hilar
contours are unremarkable. There are no effusions. There is a
mildly displaced left lateral eighth rib fracture with air in
the adjacent subcutaneous tissues. In the absence of penetrating
trauma, this could possibly represent a small pneumothorax.
There is no evidence of pneumonia.
.
IMPRESSION: Left-sided rib fracture with question of small
pneumothorax
.

The left atrium is elongated. A left-to-right shunt across the
interatrial  septum is seen at rest c/w a small secundum atrial
septal defect. The  estimated right atrial pressure is 16-20
mmHg. Left ventricular wall thicknesses and cavity size are
normal. There is moderate to severe regional left ventricular
systolic dysfunction with akinesis/thinning of the inferior and
inferolateral walls. The remaining segments are hypokinetic. No
masses or thrombi are seen in the left ventricle. The right
ventricular cavity is moderately dilated with mild global free
wall hypokinesis. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. The
tricuspid valve leaflets are
mildly thickened. The pulmonary artery systolic pressure could
not be
determined. There is no pericardial effusion.
.
Compared with the report of the prior study (images unavailable
for review) of [**2137-10-2**], the right ventricular cavity now
appears dilated with free wall  hypokinesis. The severity of
mitral regurgitation is now incresaed. Overall left ventricular
systolic function may be more depressed.
.
V/Q:
IMPRESSION:
1. Low likelihood ratio for recent pulmonary embolism. 2.
Evidence of
activity in the arterial system as demonstrated by increased
activity in the brain and kidneys consistent with a right to
left shunt.
.
CXR [**1-16**]:
Moderate-to-severe cardiomegaly is chronic. Lungs are fully
expanded and clear. There is no pleural effusion or
pneumothorax. Left subclavian transvenous right atrial pacer and
right ventricular pacer defibrillator leads are in standard
placements, unchanged.


Brief Hospital Course:
# Hypoxemia: On admission, CXR did not reveal pulmonary edema
nor infiltrate to suggest CHF, despite elevated BNP, or
pneumonia as contributors to his hypoxemia.  Heparin gtt was
started in the ED given concern for PE.  He had, however, been
subtherapeutic for only approx. 3 days once his coumadin (for a.
fib) had been recently been stopped [**1-30**] to his fall risk.
However, TTE on [**2139-1-14**] revealed worsening RV function and L-->R
shunt via ASD.  Because of the worsening right heart function, a
V/Q scan was pursued given persistent concern for PE (renal
failure prevented CTPA).  V/Q scan performed [**1-15**] showed low
probability of PE so heparin gtt was d/c'd.  Additionally, V/Q
scan revealed e/o R-->L shunt, thus suggesting shunt as likely
cause of his transient, posititionally related hypoxemia.  O2
saturations have otherwise been normal on room air.  Left sided
pneumothorax from left 8th rib fracture was evaluated by
thoracics in the ED and remained stable on follow up imaging.
Repair of ASD discussed with family, declined.
.
# Pneumothorax: [**1-30**] to left 8th rib fracture.  Evaluated by
thoracics in the ED who did not feel that intervention would
benefit him at this point and recommended serial CXRs.  X-rays
have remained stable.
.
# CHF: [**2139-1-14**] EF was found to be depressed slightly to 25%
compared to EF 30% on echo [**10-2**].  He was found to have worsened
RV function on this echo, but as above, V/Q scan showed low
probability for PE.  Clinically and on CXR he did not appear to
be fluid overloaded and his lasix was held in the setting of
elevated creatinine from baseline and presumed prerenal picture
in the setting of persistent diuresis with lasix in setting of
poor PO just prior to admission.
.
# CAD:  Elevated troponin on admission, but this is within his
BL range in the setting of his acute on chronic renal failure.
EKG did not reveal e/o acute ischemic changes and CKs were flat.
 He was continued on beta blocker and statin.  ASA had recently
been held PTA [**1-30**] to his mulitiple falls. Coumadin held
(discussed with family) because of fall risk.
.
# Acute on chronic renal failure: Baseline creatinine appears
1.4-1.5; admission creatinine was 1.9.  As above, hct appeared
hemoconcentrated.  Despite elevated BNP, his pulm exam did not
reveal significant crackles and he did not appear grossly
overloaded.  Rather, in the setting of poor PO x several days
and continuation of his standing lasix dose, he appeared
prerenal and intravascularly dry.  Creatinine improved to his BL
(1.4).  Lasix was added back at 10 mg qd.
.
# S/P fall: By history, sounds to be mechanical as patient
reports walker sliding out from in front of him.  Echo and V/Q
raised the possiblity that he may be getting transiently
hypoxemic while ambulating if R-->L shunt occurs and this may be
contributing to his falls or causing the confusion at the time
of the fall.
.
#Tachy-brady: s/p pacemaker.  Given change in code status (see
below), EP was consulted and turned off ICD portion.
.
# Hyperlipidemia: He was continued on a statin.
.
# Parkinson's:  He was continued on his home doses of sinemet.
.
# [**Last Name (un) 309**] body dementia: Continued on aricept.
.
# HTN:  Had been largely normotensive in the ICU. Transitioned
back to Atenolol
.
# Code: DNR/DNI after code status w/ family.  EP to turn off ICD
while maintaining pacer.
.
The patient was doing well on the floor with no change in
clinical status.  However, on the evening of [**1-18**], pt expired.
He had awoken in the middle of night and walked to the bathroom
using his walker; his LPN was at his bedside and helped him.
About 30-60 seconds after sitting on the toilet, pt fell
forward, unconscious.  His aide caught him and laid him on the
floor.  He was found to be pulsesless and not breathing.  On the
monitor, he was still found to have a paced rhythm but again, no
pulse was palpated.  He could not be aroused and given his
DNR/DNI status, nothing was done to resuscitate him.  He was
pronounced dead and his family was notified along with his PCP's
office.

Medications on Admission:
1. Donepezil 5 mg PO HS
2. Carbidopa-Levodopa 50-200 mg PO DAILY
3. Carbidopa-Levodopa 25-100 mg Tablet PO TID
4. Quetiapine 25 mg Tablet PO QHS
5. Nitroglycerin 0.2 mg/hr Patch 24HR (1) Patch Q24H
6. Furosemide 20 mg PO DAILY
7. Simvastatin 10 mg Tablet PO DAILY
8. Metoprolol Tartrate 25 mg Tablet PO DAILY
9. Aspirin 81 mg Tablet PO DAILY
10. Proscar 5mg daily


Discharge Medications:
None

Discharge Disposition:
Expired

Discharge Diagnosis:
deceased


Discharge Condition:
deceased


Discharge Instructions:
none

Followup Instructions:
none
{'Hypoxemia,Acquired cardiac septal defect,Congestive heart failure, unspecified,Acute kidney failure, unspecified,Traumatic pneumothorax without mention of open wound into thorax,Closed fracture of one rib,Unspecified fall,Mitral valve disorders,Diseases of tricuspid valve,Atrial fibrillation,Chronic kidney disease, unspecified,Dementia with lewy bodies,Dementia in conditions classified elsewhere without behavioral disturbance,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Paralysis agitans,Fitting and adjustment of automatic implantable cardiac defibrillator'}


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: Hypoxemia and S/P fall

PRESENT ILLNESS: 84 yo M with h/o dementia, Parkinson's, CAD, CHF (EF 30%)
presents following a fall w/ 3 days of worsening shortness of
breath since his discharge from [**Hospital1 18**] on [**2139-1-9**].  He was
admitted at that time s/p probable mechanical fall and hypoxia.
He again presents following multiple falls since last discharge.
 He denies lightheadedness/dizziness, chest pain prior to the
falls and says that his walker slipped ahead of him.  He does,
however, note some confusion following the fall.  He does not
recall head trauma.
.
Also of note, his daughter reports that around the time of these
episodes he had significant sweats and chills. Since his
discharge, he has continued to be short of breath, even
[**Last Name (un) 6055**]-[**Doctor Last Name **] breathing according to his son-in-law (a
nephrologist).
.
In the ED, BNP was found to be [**Numeric Identifier 31854**], but CXR did not reveal
gross volume overload. Cardiac enzymes showed elevated troponin
(but this is at his baseline given his acute on chronic renal
failure) and CKs were flat.  His initial vitals revealed T 98.0
HR 120 BP 88/40 and RR in the 20s with O2 sats of 88% on RA.
Given his elevated lactate and recent h/o sweats and rigors, he
received vancomycin and zosyn for broad coverage although there
currently is no clear source of infection.

MEDICAL HISTORY: 1. CAD, h/o prior MIs with cath in [**2111**]
2. [**Last Name (un) 309**]-body dementia
3. Parkinson's
4. s/p ICD for history syncope
4. mild BPH
5. neurogenic bladder
7. h/o embolic CVA - on chronic coumadin
8. Moderate MR/TR
9. Compensated CHF, EF 30% in [**2136**]
10. ?aspiration
11. CRI, baseline Cr 1.4-1.5
12. Anemia (BL 34-36)
13. Recurrent falls
14. HTN
15. Atrial fibrillation
16. Hyperlipidemia

MEDICATION ON ADMISSION: 1. Donepezil 5 mg PO HS
2. Carbidopa-Levodopa 50-200 mg PO DAILY
3. Carbidopa-Levodopa 25-100 mg Tablet PO TID
4. Quetiapine 25 mg Tablet PO QHS
5. Nitroglycerin 0.2 mg/hr Patch 24HR (1) Patch Q24H
6. Furosemide 20 mg PO DAILY
7. Simvastatin 10 mg Tablet PO DAILY
8. Metoprolol Tartrate 25 mg Tablet PO DAILY
9. Aspirin 81 mg Tablet PO DAILY
10. Proscar 5mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 96.6 ax HR 112 V paced BP 123/88 RR 18 O2 sat 96% NRB
Gen: Alert and oriented to person, place, and time as [**Month (only) 404**],
[**2138**], not to day.
HEENT: PERRL
Neck: No JVD appreciated.  Supple.
CV: Tachycardic, V-paced, no mrg
Resp: [**Month (only) **]. BS left lung base, no wheezes/rales/rhonchi
Abd: +BS, soft, NT, ND
Ext: 1+ edema b/l, midfoot to toes b/l cool, b/l fingers cool,
cyanotic
Neuro:  + pill rolling tremor right hand > left, right foot with
tremor. Strength 5/5 b/l upper extremities.

FAMILY HISTORY: Father with MI, unknown age.

SOCIAL HISTORY: Lives at home with his wife. Uses a walker occasionally. Former
smoker, quit 20 years ago. No EtOH or illicits. 

### Response:
{'Hypoxemia,Acquired cardiac septal defect,Congestive heart failure, unspecified,Acute kidney failure, unspecified,Traumatic pneumothorax without mention of open wound into thorax,Closed fracture of one rib,Unspecified fall,Mitral valve disorders,Diseases of tricuspid valve,Atrial fibrillation,Chronic kidney disease, unspecified,Dementia with lewy bodies,Dementia in conditions classified elsewhere without behavioral disturbance,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Paralysis agitans,Fitting and adjustment of automatic implantable cardiac defibrillator'}
