CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is an 82-year-old
gentleman with a history of coronary artery disease (status
post myocardial infarction times two), hypertension, and
prior tobacco who was discharged from [**Hospital 792**]Hospital
this morning status post admission one week ago for a workup
of hemoptysis.

MEDICAL HISTORY: 1.  Coronary artery disease; status post prior myocardial
infarction times two.
2.  Questionable chronic obstructive pulmonary disease.
3.  Hypertension.
4.  Long smoking history.

MEDICATION ON ADMISSION: (Medications at home included)
1.  Protonix 40 mg by mouth once per day.
2.  Zocor 20 mg by mouth once per day.
3.  Enalapril 5 mg by mouth once per day.
4.  Lasix 40 mg by mouth once per day.
5.  Aspirin.
6.  Combivent.
7.  Prednisone (dose unknown but recent taper).

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: Tobacco times 66 years.  The patient now
smokes four cigarettes per day with a maximum of one pack per
day.  No alcohol use.  The patient lives with his wife of 52
years.  He has children and grandchildren.  He worked as
quality assurance in a medical allergic factory.  He reports
exposure to silicosis.  He reports that his daughter-in-law
converted to a positive purified protein derivative this
week.  She works in health care at an [**Hospital3 **]
facility.  Otherwise, no exposures.
Other pulmonary embolism and infarction,Obstructive chronic bronchitis with (acute) exacerbation,Acute kidney failure, unspecified,Congestive heart failure, unspecified,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Unspecified essential hypertension,Tobacco use disorder
Pulm embol/infarct NEC,Obs chr bronc w(ac) exac,Acute kidney failure NOS,CHF NOS,Crnry athrscl natve vssl,Old myocardial infarct,Hypertension NOS,Tobacco use disorder
Admission Date:  [**2186-1-12**]     Discharge Date:  [**2186-1-20**]


Service:  [**Hospital1 139**]

HISTORY OF PRESENT ILLNESS:  The patient is an 82-year-old
gentleman with a history of coronary artery disease (status
post myocardial infarction times two), hypertension, and
prior tobacco who was discharged from [**Hospital 792**]Hospital
this morning status post admission one week ago for a workup
of hemoptysis.

The patient developed recurrent hemoptysis and dyspnea at
home and returned with [**Hospital3 24768**] Emergency Room.  The
patient with new onset of cough after urinating upon return
home from hospitalization.  He brought up several clots of
bright red blood with associated dyspnea.  The symptoms were
not exertional.  He denied chest pain or diaphoresis.

On arrival to the Emergency Department, his temperature was
97.6 degrees Fahrenheit, his heart rate was 130, his
respiratory rate was 32, and his pulse oximetry was 87% on
room air.  The patient was put on continuous positive airway
pressure with increased oxygen saturations to 100%.  The
patient was started on a nitroglycerin drip, as well as
enalapril intravenously, with 2 mg of morphine.  The patient
had improved comfort and oxygenation, and he was quickly
weaned to 6 liters nasal cannula.  He continued to cough up
quarter-sized clots of bright red blood.

The patient reports one episode of hemoptysis one week ago,
prompting an admission to [**State 792**]Hospital this past
week.  A workup included a bronchoscopy that was reportedly
normal.  Also of note, the patient had an episode of
hemoptysis 20 years ago while being treated with Coumadin and
had a negative workup at that time.  He had been treated with
Coumadin for an myocardial infarction.

REVIEW OF SYSTEMS:  Review of systems revealed no weight
changes.  No tuberculosis exposure.  No fevers or chills.  No
lack of energy.  No rash.  No headaches.  No hematuria.  The
patient was recently diagnosed with inflammatory arthritis
and was treated with prednisone.

PAST MEDICAL HISTORY:
1.  Coronary artery disease; status post prior myocardial
infarction times two.
2.  Questionable chronic obstructive pulmonary disease.
3.  Hypertension.
4.  Long smoking history.

ALLERGIES:  No known drug allergies.

MEDICATIONS ON ADMISSION:  (Medications at home included)
1.  Protonix 40 mg by mouth once per day.
2.  Zocor 20 mg by mouth once per day.
3.  Enalapril 5 mg by mouth once per day.
4.  Lasix 40 mg by mouth once per day.
5.  Aspirin.
6.  Combivent.
7.  Prednisone (dose unknown but recent taper).

SOCIAL HISTORY:  Tobacco times 66 years.  The patient now
smokes four cigarettes per day with a maximum of one pack per
day.  No alcohol use.  The patient lives with his wife of 52
years.  He has children and grandchildren.  He worked as
quality assurance in a medical allergic factory.  He reports
exposure to silicosis.  He reports that his daughter-in-law
converted to a positive purified protein derivative this
week.  She works in health care at an [**Hospital3 **]
facility.  Otherwise, no exposures.

PHYSICAL EXAMINATION ON PRESENTATION:  Physical examination
upon admission revealed the patient's temperature was 97.9
degrees Fahrenheit, his heart rate was 90 to 100, his blood
pressure was 126/74, his respiratory rate was 26, and his
pulse oximetry was 98% on 6 liters.  In general, the patient
was mildly tachypneic, using some accessory muscles.
Positive abdominal breathing.  Head, eyes, ears, nose, and
throat examination revealed slightly dry oral mucosa.  No
visible blood.  No jugular venous distention.  Cardiovascular
examination revealed tachycardia, first heart sounds and
second heart sounds.  No murmurs.  Lung examination revealed
diffuse inspiratory and expiratory wheezing in all lung
fields.  No crackles.  The abdomen was soft and nontender.
There were positive bowel sounds.  Extremity examination
revealed trace lower extremity edema.  Distal pulses were 2+.

PERTINENT LABORATORY VALUES ON PRESENTATION:  Laboratories
upon admission revealed the patient's white blood cell count
was 16.6, his hematocrit was 42, and his platelets were 214.
His bicarbonate was 34.  His creatinine was 1.5.  Liver
function tests were normal.  Thyroid-stimulating hormone was
normal.

PERTINENT RADIOLOGY/IMAGING:  An electrocardiogram revealed a
normal sinus rhythm at 90.  Normal axis.  Positive premature
atrial contractions.  Positive premature ventricular
contractions.  No ST-T changes.

A chest x-ray was negative for infiltrate or effusion.  Tall
lung fields.  Flattened diaphragms.

CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:  The
patient was initially admitted to the Coronary Care Unit and
was quickly transfusion to the Medical Intensive Care Unit
within one day of admission.

The [**Hospital 228**] Medical Intensive Care Unit course was
completed on [**2186-1-18**] and he was transferred to the
General Medicine Service.

1.  HEMOPTYSIS ISSUES:  The patient had recurrent hemoptysis
prior to admission as well as during admission.  His
hematocrit remained stable as well as his oxygenation after
initial desaturation.

The etiology of the hemoptysis remained unclear at the time
of this dictation.  The patient underwent a rigid
bronchoscopy on day one of his admission which was negative.
Noted on the bronchoscopy were areas of bright red blood with
no clear focus.  A bronchoscopy done at [**Hospital 792**]Hospital
was also negative prior to admission to [**Hospital1 190**].

The patient had a chest computed tomography which showed
pulmonary emboli in the right middle lobe as well as
posterior right lower lobe; however, it was thought that this
did not cause the patient's hemoptysis.  There was no
necrosis noted on computed tomography, and this was thought
to be an unlikely source.  In addition, a 6-mm nodule was
noted on the computerized axial tomography of the chest.
However, this was also seen as unlikely to be the cause of
the patient's hemoptysis.

The patient underwent a transthoracic echocardiogram on day
one of his admission which revealed an ejection fraction of
45% to 50%, left ventricular abnormalities, 1+ aortic
regurgitation, and 1+ mitral regurgitation.

The patient also underwent an evaluation by Ear/Nose/Throat
which was negative.  The patient's computerized axial
tomography was negative for pneumonia.

A pulmonary angiogram was planned to further evaluate
vessels; however, the patient's hemoptysis resolved, and this
was put on hold.  The patient never required a blood
transfusion during this admission, and his respiratory status
was stabilized.  It was thought that if the patient
experienced recurrent bleed he would undergo a pulmonary
angiogram; however, this did not occur during this admission.

2.  PULMONARY EMBOLISM ISSUES:  The patient was started on a
heparin drip once the diagnosis of pulmonary embolus was
made.  The patient's heparin dosing was intermittently
decreased because of recurrent hemoptysis.  However, it was
thought that the patient needed to be anticoagulation.  He
has had complications with Coumadin in the past with
difficulty dosing as well as bleeding.  Therefore, it was
thought that low molecular weight heparin would be the best
choice for the patient's outpatient anticoagulation.

The patient was maintained on a dose of Lovenox 70 mg
subcutaneously twice per day.  The patient will need to be on
anticoagulation for at least six months and will need further
evaluation for longer therapy.  A hypercoagulable workup was
sent during this admission; however, the totality of these
tests was unknown in the setting of an acute pulmonary
embolus.  At the time of this dictation, protein C,
antithrombin III, and factor V Leiden were pending.  The
patient's cardiolipin IgG was normal as well as IgM.  The
patient will need followup with Pulmonary.

3.  CORONARY ARTERY DISEASE ISSUES:  The patient ruled out
for any acute coronary process.  He was maintained on his
regular cardiac medications as per his outpatient dosing.

A transthoracic echocardiogram was done with the results as
described above.  There were no acute cardiac issues;
although, when the patient was initially admitted, this was
thought to be the cause of the patient's dyspnea.

4.  CHRONIC OBSTRUCTIVE PULMONARY DISEASE ISSUES:  The
patient was thought to be in a chronic obstructive pulmonary
disease flare.  A prednisone taper was started during this
admission with continual meter-dosed inhalers.  The patient
was on nebulizer treatments but he disliked these and
reported they make him cough more.

5.  ACUTE RENAL FAILURE ISSUES:  The patient had mild acute
renal failure during this admission but maintained good urine
output.  It was thought this was prerenal, and the patient's
creatinine normalized prior to discharge.

6.  PURIFIED PROTEIN DERIVATIVE PLACEMENT ISSUES:  Due to the
patient's possible exposure with his daughter-in-law
converting to a positive purified protein derivative, a
purified protein derivative was placed and was negative.

7.  DISCHARGE DISPOSITION ISSUES:  Since the patient's
hemoptysis had resolved, he was to go home with his wife and
was to follow up closely with Pulmonary.  The patient was
told to return to an Emergency Department that is nearest to
his house if he re-bleeds and will need a pulmonary angiogram
as quickly as possible.

DISCHARGE DIAGNOSES:
1.  Hemoptysis of unknown etiology.
2.  Pulmonary embolism.
3.  Small lung nodule.
4.  Coronary artery disease.
5.  Hypertension.
6.  Smoker.

MEDICATIONS ON DISCHARGE:
1.  Protonix 40 mg by mouth once per day.
2.  Simvastatin 10 mg by mouth once per day.
3.  Prednisone taper (to be completed within two days of
discharge).
4.  Metoprolol 25 mg by mouth twice per day.
5.  Enoxaparin 70 mg subcutaneously q.12h.
6.  Enalapril 5 mg by mouth once per day.
7.  Aspirin 81 mg by mouth once per day.
8.  Combivent inhaler.
9.  Fluticasone.

DISCHARGE INSTRUCTIONS/FOLLOWUP:
1.  The patient was instructed to follow up with Pulmonary
within one week of discharge.
2.  The patient knew to return emergently to the hospital
nearest to his home if has recurrent hemoptysis.
3.  The patient was instructed to follow up with his primary
care physician within one to two weeks of discharge.





                          [**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D.  [**MD Number(1) 4521**]

Dictated By:[**Last Name (NamePattern1) 9244**]

MEDQUIST36

D:  [**2186-1-19**]  20:09
T:  [**2186-1-24**]  16:24
JOB#:  [**Job Number 53854**]
{'Other pulmonary embolism and infarction,Obstructive chronic bronchitis with (acute) exacerbation,Acute kidney failure, unspecified,Congestive heart failure, unspecified,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Unspecified essential hypertension,Tobacco use disorder'}


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 an 82-year-old
gentleman with a history of coronary artery disease (status
post myocardial infarction times two), hypertension, and
prior tobacco who was discharged from [**Hospital 792**]Hospital
this morning status post admission one week ago for a workup
of hemoptysis.

MEDICAL HISTORY: 1.  Coronary artery disease; status post prior myocardial
infarction times two.
2.  Questionable chronic obstructive pulmonary disease.
3.  Hypertension.
4.  Long smoking history.

MEDICATION ON ADMISSION: (Medications at home included)
1.  Protonix 40 mg by mouth once per day.
2.  Zocor 20 mg by mouth once per day.
3.  Enalapril 5 mg by mouth once per day.
4.  Lasix 40 mg by mouth once per day.
5.  Aspirin.
6.  Combivent.
7.  Prednisone (dose unknown but recent taper).

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: Tobacco times 66 years.  The patient now
smokes four cigarettes per day with a maximum of one pack per
day.  No alcohol use.  The patient lives with his wife of 52
years.  He has children and grandchildren.  He worked as
quality assurance in a medical allergic factory.  He reports
exposure to silicosis.  He reports that his daughter-in-law
converted to a positive purified protein derivative this
week.  She works in health care at an [**Hospital3 **]
facility.  Otherwise, no exposures. 

### Response:
{'Other pulmonary embolism and infarction,Obstructive chronic bronchitis with (acute) exacerbation,Acute kidney failure, unspecified,Congestive heart failure, unspecified,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Unspecified essential hypertension,Tobacco use disorder'}
