CHIEF COMPLAINT: SOB, tremor

PRESENT ILLNESS: 72 yo male with severe COPD, on home oxygen and chronic
prednisone who presented with increasing SOB and oxygen sat per
VNA of 68%. He states he has been more SOB over past week, (at
baseline he is SOB but this has been worse). He has a cough but
no sputum. His wife also reports his speech was slurred this AM.
his wife notes that his tremors have been worse. This started
[**1-28**] mos ago, worse in R leg and that causes him to be unsteady
on his feet. He did fall on Sat and hurt his R foot. He denies
syncope with this event. He was admitted to [**Hospital1 2025**] in [**2163-12-28**] for
tremor and they thought it was from theophylline so that was
discontinued, however the tremors did not improve. Wife thinks
he had brain MRI and spine MRI that were normal. He also notes
hallucinations in the AM that they were told might be from
melatonin that he takes to help him sleep.

MEDICAL HISTORY: COPD - on home oxygen 2-6 liters at all times, PFTS [**2161**]
FEV1 1.09 (38% pred), FEV1/FVC 32 (48% pred). Followed at [**Hospital1 2025**],
pulmonologist is Dr. [**Last Name (STitle) 6376**]
Chronic constipation, sees [**Doctor Last Name 1940**]
Elev PSA s/p needle bx that were neg for malig in [**8-/2163**]
Hallucinations in AM
Tremors x [**1-28**] mos
S/P ulnar nerve redistribution in L arm.
bronchiectasis
hyperlipidemia
hypertension
depression
spinal stenosis
bladder cancer
kidney stones
childhood pyloric stenosis status post surgical repair.

MEDICATION ON ADMISSION: Advair discus 500/50 [**Hospital1 **]
Albuterol nebs Q4 hr
Atrovent nebs Q4 hr
Combivent IH
Atrvent IH
Flonase 50 mcg [**Hospital1 **]
Flovent IH
Lasix 40 mg PO
KCL slow rel 20 mg [**Hospital1 **]
Norvasc 5 mg QD
Pravachol 10 mg QD
Prednisone 20 mg QD
Protonix 40 mg QD
Bactrim DS 3 x / wk
Dyazide 37.5/25mg QD
Zoloft 250 mg QD
Mucinex 600 mg [**Hospital1 **]
Colace
Melatonin PRN
Fiber con
Iron 27 mg QD
There tears
Ipratoprium nasal spray 15 ml PRN

ALLERGIES: Sinemet-10/100

PHYSICAL EXAM: 97.1 80 116-140/61-70 100% venti mask, 15 L, 91-94%
GENL: somnolent, sleepy, in restaints, unable to assess mental
status, confused during code
HEENT: OP clear, PERL, EOMI, no elev JVP, no LAD
CV: RRR no MRG
Lung: profoundly decreased BS diffusely
Abd: soft, nt, nd, +bs
Ext: +ecchymises on R 4th and 5th metatarsal, tender to
palpation, +clubbing
Neuro: A&Ox3, +tremors, strength 5/5 diffusely
GU: with light pink urine slowly clearing, foley

FAMILY HISTORY: CAD in brother and father, [**Name (NI) 5895**] in father

SOCIAL HISTORY: married, 50 pack year smkr quit 4 yrs ago, no ETOH, no drugs
Obstructive chronic bronchitis with (acute) exacerbation,Acute and chronic respiratory failure,Pneumonitis due to inhalation of food or vomitus,Atrial fibrillation,Unspecified septicemia,Severe sepsis,Septic shock,Hyperosmolality and/or hypernatremia,Pneumonia due to Pseudomonas,Urinary tract infection, site not specified,Myoclonus,Long-term (current) use of steroids,Closed fracture of metatarsal bone(s),Fall from other slipping, tripping, or stumbling,Abnormality of gait,Delirium due to conditions classified elsewhere,Unspecified essential hypertension,Personal history of urinary calculi,Personal history of malignant neoplasm of bladder
Obs chr bronc w(ac) exac,Acute & chronc resp fail,Food/vomit pneumonitis,Atrial fibrillation,Septicemia NOS,Severe sepsis,Septic shock,Hyperosmolality,Pseudomonal pneumonia,Urin tract infection NOS,Myoclonus,Long-term use steroids,Fx metatarsal-closed,Fall from slipping NEC,Abnormality of gait,Delirium d/t other cond,Hypertension NOS,Prsnl hst urnr dsrd calc,Hx of bladder malignancy
Admission Date:  [**2164-2-7**]              Discharge Date:   [**2164-2-24**]

Date of Birth:  [**2092-1-11**]             Sex:   M

Service: MEDICINE

Allergies:
Sinemet-10/100

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
SOB, tremor

Major Surgical or Invasive Procedure:
Intubation
Central line placement

History of Present Illness:
72 yo male with severe COPD, on home oxygen and chronic
prednisone who presented with increasing SOB and oxygen sat per
VNA of 68%. He states he has been more SOB over past week, (at
baseline he is SOB but this has been worse). He has a cough but
no sputum. His wife also reports his speech was slurred this AM.
his wife notes that his tremors have been worse. This started
[**1-28**] mos ago, worse in R leg and that causes him to be unsteady
on his feet. He did fall on Sat and hurt his R foot. He denies
syncope with this event. He was admitted to [**Hospital1 2025**] in [**2163-12-28**] for
tremor and they thought it was from theophylline so that was
discontinued, however the tremors did not improve. Wife thinks
he had brain MRI and spine MRI that were normal. He also notes
hallucinations in the AM that they were told might be from
melatonin that he takes to help him sleep.


.
In summary, this is 72 yo M with severe COPD admitted with SOB
and tremors.
1. SOB: Likely COPD flare, will tx with prednisone, nebs,
azithormycin. Monitor on tele o/n. Calcium and vit D given
steroids. Sputum cx, gs, cont bactrim ppx for PCP
2. Tremors: DDX includes zoloft (but spoke to outpt psych who
said has been on this dose for 10yrs), Parkinsons, essential
tremor, hyperthyroidism, myclonus. CT head normal, [**Hospital1 2025**] MRI
showed micorangiopathic ischemic changes. TSH nl. Trying
klonopin per mvmt d/o team.
3. CV: Had TWI in one lead on EKG initially then infer STE, but
[**Last Name (un) **] neg, cont tele. COnt ASA, pravastatin, CE negative
4. Depression: cont zoloft
5. Hallucinations: ? if from melatonin, will follow, neuro
consult.
6. HTN: BP high in [**Last Name (LF) **], [**First Name3 (LF) **] increase norvasc
7. Foot fracture: comminuted fx in 5th metatarsal of R foot,
will wrap toes.
8. Urinary urgency - U/A negative. place foley
8. FEN: reg diet
9. PPX - PPI, Sq heparin
10. Full code


Past Medical History:
COPD - on home oxygen 2-6 liters at all times, PFTS [**2161**]
FEV1 1.09 (38% pred), FEV1/FVC 32 (48% pred). Followed at [**Hospital1 2025**],
pulmonologist is Dr. [**Last Name (STitle) 6376**]
Chronic constipation, sees [**Doctor Last Name 1940**]
Elev PSA s/p needle bx that were neg for malig in [**8-/2163**]
Hallucinations in AM
Tremors x [**1-28**] mos
S/P ulnar nerve redistribution in L arm.
bronchiectasis
hyperlipidemia
hypertension
depression
spinal stenosis
bladder cancer
kidney stones
childhood pyloric stenosis status post surgical repair.

Social History:
married, 50 pack year smkr quit 4 yrs ago, no ETOH, no drugs



Family History:
CAD in brother and father, [**Name (NI) 5895**] in father

Physical Exam:
97.1 80 116-140/61-70 100% venti mask, 15 L, 91-94%
GENL: somnolent, sleepy, in restaints, unable to assess mental
status, confused during code
HEENT: OP clear, PERL, EOMI, no elev JVP, no LAD
CV: RRR no MRG
Lung: profoundly decreased BS diffusely
Abd: soft, nt, nd, +bs
Ext: +ecchymises on R 4th and 5th metatarsal, tender to
palpation, +clubbing
Neuro: A&Ox3, +tremors, strength 5/5 diffusely
GU: with light pink urine slowly clearing, foley


Pertinent Results:
Studies
Foot xray - fx 5ht metatarsal
CXR: Aorta is tortuous. Heart size stable, allowing for
technical differences. There is lucency of both upper lung zones
consistent with patient's known emphysematous disease. Pulmonary
vasculature is unchanged. Lung parenchyma is unchanged compared
to the previous studies. Left costophrenic angle is not imaged.
Right costophrenic
angle is sharp. No evidence of pneumothorax. The right apex is
obscured by overlying breathing apparatus.
.
Head CT: No evidence of acute intracranial hemorrhage
.
EKG: SR, rate 76, nl axis, nl int, TWI in V1
.
MRI ([**Hospital1 2025**] [**2163-12-31**]) mult small scattered foci of T2/FLAIR
hyperintesity in subcort white matter, periventr regions and
pons. Nonspecific, likely from microangiopathic ischemic change.
Mineralziation in basal ganglia.
.


Brief Hospital Course:
Floor course: Pt was treated for COPD flare with 60 mg
prednisone, azithro, frequent nebs, and bactrim ppx. While on
the floor, pt's oxygen reuqirement appeared to be at baseline of
[**12-31**] L oxygen. Other VS stable, afebrile. Pt was seen by
neurology for evaluation of his tremor which was thought to be
myoclonus rel to COPD. Started on klonopin on [**2-9**] for help of
this tremor.
.
MICU was called for question of intubation. Pt was acutely
agitated. VS otherwise stable, sats 80% on 8 L oxygen. ABG
7.43/71/63/49 during event. Prior ABG in am. was 7.40/71/64/46.
Pt received a total of 4 mg haldol and 4 mg ativan during event.
Security called and pt placed in 4 pt leather restraints. A PIV
was placed. Pt was on 20% venti mask with sats in high 80's to
90's, increased to 40 % venti mask. Intubation was witheld as
earlier observed accessory muscle use and paradoxical breathing
improved, sats stable. Of note, when suctioned light pink
material noted.
.
# Septic shock/aspiration pneumonia/COPD
exacerbation/respiratory failure:  Transferred to the MICU for
hypoxia and closer monitoring.  The patient was continued on
steroids and MDIs for COPD exacerbation.  Once the patient
arrived to the MICU, he was noted to be hypoxic, hypotensive and
subsequently was intubated.  L IJ and a-line was placed.  The
patient was on a pressor briefly and  was weaned off. On CXR for
line placement showed a white out of the left lung.  Bronch was
done and ruled out complete collapse of the left lung and the
patient was started on vanco and cefepime for nosocomial
pneumonia on [**2-11**].  Cefepime was switched to Zosyn on [**2-13**] given
likelihood of aspiration pneumonia in the setting of mental
status changes.  The patient was difficult to wean off
ventilator, and to facilitate his weaning and decrease sedation,
standing haldol was started on [**2-15**]. Although goal was to
decrease sedation and wean off vent, because of his movement
disorder causing bruises on his legs and for pt safety, propofol
was restarted on [**2-18**] in addition to fentanyl and versed with
good result.   Patient remained aggitated once drips were weaned
despite increasing haldol.  Family thus decided not to escalate
further care.
Patient was subsequently started on morphine gtt on [**2-24**] AM and
extubated and expired soon afterwards.
.
# Atrial fibrillation: The patient developed a-fib with RVR to
130-160s on [**2-12**].  This was thought to be secondary to COPD and
new PNA.  The patient received diltiazem IV boluses and was
placed on drip for rate control but did not respond and dropped
his pressures.  Thus, amiodarone bolus and drip were started,
and pt converted to sinus and rate was controlled.  Pt also was
started on IV heparin but discontinued after 4 days as pt
remained in sinus on amiodarone, underlying PNA that likely
triggered afib was being treated and his high risk for fall as
an outpatient. Patient subsequently was controlled with PO
amiodarone and he remained in SR up until he expired.
.
# For neuro/myoclonus, neuro and psych both followed the
patients.  Neither neuro or psych had clear explaination for his
neuro abnormalities.  CT of head was negative. EEG or MRI were
considered but neuro thought they will not be revealing given
his metabolic disturbances and sepsis. For depression, pt was
off Zoloft initially in the MICU then was restarted and
continued on Zoloft 250mg qday on [**2-15**].
.
# Initially full code. After discussing with wife who is HCP, pt
was made DNR/DNI on [**2164-2-18**].  Patient did not tolerated the
lightening of sedation as he became acutely aggitated and
restless.  Family decided not to escalate any further care on
[**2-21**] while they contemplated further plan of care.  Patient was
started on morphine drip for comfort and was subsequently
extubation.  Patient was apnic and expired soon.

Medications on Admission:
Advair discus 500/50 [**Hospital1 **]
Albuterol nebs Q4 hr
Atrovent nebs Q4 hr
Combivent IH
Atrvent IH
Flonase 50 mcg [**Hospital1 **]
Flovent IH
Lasix 40 mg PO
KCL slow rel 20 mg [**Hospital1 **]
Norvasc 5 mg QD
Pravachol 10 mg QD
Prednisone 20 mg QD
Protonix 40 mg QD
Bactrim DS 3 x / wk
Dyazide 37.5/25mg QD
Zoloft 250 mg QD
Mucinex 600 mg [**Hospital1 **]
Colace
Melatonin PRN
Fiber con
Iron 27 mg QD
There tears
Ipratoprium nasal spray 15 ml PRN

Discharge Medications:
expired

Discharge Disposition:
Expired

Discharge Diagnosis:
expired

Discharge Condition:
expired

Discharge Instructions:
expired

Followup Instructions:
expired


Completed by:[**2164-2-25**]
{'Obstructive chronic bronchitis with (acute) exacerbation,Acute and chronic respiratory failure,Pneumonitis due to inhalation of food or vomitus,Atrial fibrillation,Unspecified septicemia,Severe sepsis,Septic shock,Hyperosmolality and/or hypernatremia,Pneumonia due to Pseudomonas,Urinary tract infection, site not specified,Myoclonus,Long-term (current) use of steroids,Closed fracture of metatarsal bone(s),Fall from other slipping, tripping, or stumbling,Abnormality of gait,Delirium due to conditions classified elsewhere,Unspecified essential hypertension,Personal history of urinary calculi,Personal history of malignant neoplasm of bladder'}


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: SOB, tremor

PRESENT ILLNESS: 72 yo male with severe COPD, on home oxygen and chronic
prednisone who presented with increasing SOB and oxygen sat per
VNA of 68%. He states he has been more SOB over past week, (at
baseline he is SOB but this has been worse). He has a cough but
no sputum. His wife also reports his speech was slurred this AM.
his wife notes that his tremors have been worse. This started
[**1-28**] mos ago, worse in R leg and that causes him to be unsteady
on his feet. He did fall on Sat and hurt his R foot. He denies
syncope with this event. He was admitted to [**Hospital1 2025**] in [**2163-12-28**] for
tremor and they thought it was from theophylline so that was
discontinued, however the tremors did not improve. Wife thinks
he had brain MRI and spine MRI that were normal. He also notes
hallucinations in the AM that they were told might be from
melatonin that he takes to help him sleep.

MEDICAL HISTORY: COPD - on home oxygen 2-6 liters at all times, PFTS [**2161**]
FEV1 1.09 (38% pred), FEV1/FVC 32 (48% pred). Followed at [**Hospital1 2025**],
pulmonologist is Dr. [**Last Name (STitle) 6376**]
Chronic constipation, sees [**Doctor Last Name 1940**]
Elev PSA s/p needle bx that were neg for malig in [**8-/2163**]
Hallucinations in AM
Tremors x [**1-28**] mos
S/P ulnar nerve redistribution in L arm.
bronchiectasis
hyperlipidemia
hypertension
depression
spinal stenosis
bladder cancer
kidney stones
childhood pyloric stenosis status post surgical repair.

MEDICATION ON ADMISSION: Advair discus 500/50 [**Hospital1 **]
Albuterol nebs Q4 hr
Atrovent nebs Q4 hr
Combivent IH
Atrvent IH
Flonase 50 mcg [**Hospital1 **]
Flovent IH
Lasix 40 mg PO
KCL slow rel 20 mg [**Hospital1 **]
Norvasc 5 mg QD
Pravachol 10 mg QD
Prednisone 20 mg QD
Protonix 40 mg QD
Bactrim DS 3 x / wk
Dyazide 37.5/25mg QD
Zoloft 250 mg QD
Mucinex 600 mg [**Hospital1 **]
Colace
Melatonin PRN
Fiber con
Iron 27 mg QD
There tears
Ipratoprium nasal spray 15 ml PRN

ALLERGIES: Sinemet-10/100

PHYSICAL EXAM: 97.1 80 116-140/61-70 100% venti mask, 15 L, 91-94%
GENL: somnolent, sleepy, in restaints, unable to assess mental
status, confused during code
HEENT: OP clear, PERL, EOMI, no elev JVP, no LAD
CV: RRR no MRG
Lung: profoundly decreased BS diffusely
Abd: soft, nt, nd, +bs
Ext: +ecchymises on R 4th and 5th metatarsal, tender to
palpation, +clubbing
Neuro: A&Ox3, +tremors, strength 5/5 diffusely
GU: with light pink urine slowly clearing, foley

FAMILY HISTORY: CAD in brother and father, [**Name (NI) 5895**] in father

SOCIAL HISTORY: married, 50 pack year smkr quit 4 yrs ago, no ETOH, no drugs 

### Response:
{'Obstructive chronic bronchitis with (acute) exacerbation,Acute and chronic respiratory failure,Pneumonitis due to inhalation of food or vomitus,Atrial fibrillation,Unspecified septicemia,Severe sepsis,Septic shock,Hyperosmolality and/or hypernatremia,Pneumonia due to Pseudomonas,Urinary tract infection, site not specified,Myoclonus,Long-term (current) use of steroids,Closed fracture of metatarsal bone(s),Fall from other slipping, tripping, or stumbling,Abnormality of gait,Delirium due to conditions classified elsewhere,Unspecified essential hypertension,Personal history of urinary calculi,Personal history of malignant neoplasm of bladder'}
