CHIEF COMPLAINT: Reason for admission: Chest pain
Reason for transfer to the MICU: hypercarbic respiratory failure

PRESENT ILLNESS: 87 y/o woman with CAD, Afib, presents with shortness of breath
and chest pain since morning of admission. She felt that her
shortness of breath has improved since getting to the hospital.
She can't elaborate as to what the extent of her activity level
is, but she cannot walk up one flight of stairs. She denied any
orthopnea or PND. On the morning of admission she was doing
regular housework, when she developed substernal pressure, as if
someone was sitting on her chest. She took one SL nitro and
called her friend to take her to the [**Name (NI) **]. On interview, she
denies any CP. She also c/o of having visual hallucinations at
night, she thinks it prob in her dreams.
.
On review of systems, the patient denied any chest pain,
shortness of breath, fevers, chills, weight loss, night sweats,
fatigue, headaches, dizziness, blurred vision, sore throat,
nausea, vomiting, abdominal pain, any new rashes, denies
dysuria, hematuria, increased urgency, diarrhea, constipation,
hematochezia, melena, epistaxis. All other systems were reviewed
in detail and were negative except for what has been mentioned
above.
.
In the ED, VS T 98.2 HR 80 BP 147/73 Sat 94 on RA increased to
98 on 3:. ECG with subtle ST dep/TW flattening anterior leads.
She was given ASA 325mg, combivent neb, plavix 600mg and lasic
40mg iv times 1. CXR showed vascular congestion. She had a foley
placed.
.
On the floor, patient was agitated requiring large amounts of
zyprexa and also Haldol was used. 1 Am [**6-12**] patient was found
unresponsive. ABG was performed with PH 7.15 pCO2 112 pO2 105.
Pt was electively intubated. Moving all four extremities,
responding to sternal rub. Suction of brown material, question
of aspiration. Pt to CT scan to assess for bleed, CVA and then
to MICU for further work up and management.

MEDICAL HISTORY: 1. Coronary artery disease, EF 45-50% in [**2157**].
2. Asthma.
3. Atrial fibrillation.
4. Hypertension.
5. Hepatosplenomegaly.
6. Anxiety.
7. Osteoarthritis.
8. Carpal tunnel syndrome.
9. Sciatica.
10. Status post total abdominal hysterectomy and bilateral
salpingo-oophorectomy.
11. Status post lumpectomy

MEDICATION ON ADMISSION: Tylenol
Coumadin 4mg po daily
Nitro SL
Namenda 10mg [**Hospital1 **]
Spironolactone 25mg qdaily
Furosemide 20mg daily
Isordil 10mg TID
Glucophage 500mg daily

ALLERGIES: Haldol

PHYSICAL EXAM: On admission to MICU
VS: 95/57. 62, 99.1, 100% on AC 450, 18/5 100 fio2
Gen: intubated, agitated, moving all extremities.
HEENT: Pupils pinpoint, ET tube in place.
CV: irregularly irregular
Lung:course breath sounds bilaterall, no wheezes noted.
Abdomen: Distended, hypoactive bowel sounds, but soft.
Ext: 1+ peripheral edema bilaterally, no clubbing, cyanosis, no
calf pain, DP pulses are 2+ bilaterally
Neuro: moving all extremities, unable to follow commands. DTR 2+
throughout, Toes downgoing
Skin: pink, warm, no rashes

FAMILY HISTORY: Father with heart problems.

SOCIAL HISTORY: Negative tobacco, occasional alcohol. Lives alone. Has two sons
and five grandchildren. Patient was born in Poland, Now lives
alone in [**Location (un) 583**] with daily care taker visits and [**1-23**]
times/week VNA.
Acute respiratory failure,Atrial fibrillation,Mitral valve stenosis and aortic valve stenosis,Chronic airway obstruction, not elsewhere classified,Congestive heart failure, unspecified,Pneumonia, organism unspecified,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Anxiety state, unspecified,Carpal tunnel syndrome,Hepatomegaly,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Dementia with lewy bodies,Dementia in conditions classified elsewhere without behavioral disturbance,Other specified disorders of pancreatic internal secretion,Adrenal cortical steroids causing adverse effects in therapeutic use,Long-term (current) use of anticoagulants,Other antipsychotics, neuroleptics, and major tranquilizers causing adverse effects in therapeutic use
Acute respiratry failure,Atrial fibrillation,Mitral/aortic stenosis,Chr airway obstruct NEC,CHF NOS,Pneumonia, organism NOS,Crnry athrscl natve vssl,Hypertension NOS,Anxiety state NOS,Carpal tunnel syndrome,Hepatomegaly,Osteoarthros NOS-unspec,Dementia w Lewy bodies,Dementia w/o behav dist,Pancreatic disorder NEC,Adv eff corticosteroids,Long-term use anticoagul,Adv eff antipsychotc NEC
Admission Date:  [**2162-6-10**]              Discharge Date:   [**2162-6-16**]


Service: MEDICINE

Allergies:
Haldol

Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Reason for admission: Chest pain
Reason for transfer to the MICU: hypercarbic respiratory failure



Major Surgical or Invasive Procedure:
Endotracheal intubation.
Arterial line placement.

History of Present Illness:
87 y/o woman with CAD, Afib, presents with shortness of breath
and chest pain since morning of admission. She felt that her
shortness of breath has improved since getting to the hospital.
She can't elaborate as to what the extent of her activity level
is, but she cannot walk up one flight of stairs. She denied any
orthopnea or PND. On the morning of admission she was doing
regular housework, when she developed substernal pressure, as if
someone was sitting on her chest. She took one SL nitro and
called her friend to take her to the [**Name (NI) **]. On interview, she
denies any CP. She also c/o of having visual hallucinations at
night, she thinks it prob in her dreams.
.
On review of systems, the patient denied any chest pain,
shortness of breath, fevers, chills, weight loss, night sweats,
fatigue, headaches, dizziness, blurred vision, sore throat,
nausea, vomiting, abdominal pain, any new rashes, denies
dysuria, hematuria, increased urgency, diarrhea, constipation,
hematochezia, melena, epistaxis. All other systems were reviewed
in detail and were negative except for what has been mentioned
above.
.
In the ED, VS T 98.2 HR 80 BP 147/73 Sat 94 on RA increased to
98 on 3:. ECG with subtle ST dep/TW flattening anterior leads.
She was given ASA 325mg, combivent neb, plavix 600mg and lasic
40mg iv times 1. CXR showed vascular congestion. She had a foley
placed.
.
On the floor, patient was agitated requiring large amounts of
zyprexa and also Haldol was used. 1 Am [**6-12**] patient was found
unresponsive. ABG was performed with PH 7.15 pCO2 112 pO2 105.
Pt was electively intubated. Moving all four extremities,
responding to sternal rub. Suction of brown material, question
of aspiration. Pt to CT scan to assess for bleed, CVA and then
to MICU for further work up and management.


Past Medical History:
1. Coronary artery disease, EF 45-50% in [**2157**].
2. Asthma.
3. Atrial fibrillation.
4. Hypertension.
5. Hepatosplenomegaly.
6. Anxiety.
7. Osteoarthritis.
8. Carpal tunnel syndrome.
9. Sciatica.
10. Status post total abdominal hysterectomy and bilateral
salpingo-oophorectomy.
11. Status post lumpectomy


Social History:
Negative tobacco, occasional alcohol. Lives alone. Has two sons
and five grandchildren. Patient was born in Poland, Now lives
alone in [**Location (un) 583**] with daily care taker visits and [**1-23**]
times/week VNA.

Family History:
Father with heart problems.

Physical Exam:
On admission to MICU
VS: 95/57. 62, 99.1, 100% on AC 450, 18/5 100 fio2
Gen: intubated, agitated, moving all extremities.
HEENT: Pupils pinpoint, ET tube in place.
CV: irregularly irregular
Lung:course breath sounds bilaterall, no wheezes noted.
Abdomen: Distended, hypoactive bowel sounds, but soft.
Ext: 1+ peripheral edema bilaterally, no clubbing, cyanosis, no
calf pain, DP pulses are 2+ bilaterally
Neuro: moving all extremities, unable to follow commands. DTR 2+
throughout, Toes downgoing
Skin: pink, warm, no rashes


Pertinent Results:
Echocardiography: EF 45% The left atrium is elongated. The right
atrium is moderately dilated. Left ventricular wall thicknesses
and cavity size are normal. Due to suboptimal technical quality,
a focal wall motion abnormality cannot be fully excluded.
There is mild global left ventricular hypokinesis. The right
ventricular
cavity is mildly dilated with mild global free wall hypokinesis.
The aortic valve leaflets appear structurally normal with good
leaflet excursion. No aortic stenosis is suggested. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild to moderate ([**12-22**]+) mitral regurgitation
is seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.

Compared with the prior study (images reviewed) of [**2158-9-28**],
the estimated pulmonary artery systolic pressure is now lower.
The severity of mitral regurgitation is slightly increased. Left
ventricular systolic function is similar.


Brief Hospital Course:
This is an 87 y/o woman with CAD, atrial fibrillation, Asthma,
who presented with acute onset of substernal chest pain and
altered mental status.  On [**6-12**] the floor she was found to be in
respiratory distress and found to be in hypercarbic respiratory
failure; this prompted emergent intubation and transfer to MICU.
 The patient was noted to be frequently agitated as well.  A
psychiatry consult was called and believed she had [**Last Name (un) **] body
dementia--notably the patient had received large dose.
The patient's hypercarbia resolved and the patient was extubated
on [**6-14**].  She was maintained on albuterol and atrovent
nebulizers.  Post extubation the patient was markedly less
agitated and her respiratory status remained stable.   She
passed a speech and swallow evaluation [**6-16**] and was subsequently
discharged.
.
In summary, this is an 87 year old woman with atrial
fibrillation, coronary artery disease and newly diagnosed with
[**Last Name (un) 309**] body dementia that was likely exacerbated by use of
antipsychotic medication.  This in turn may have led to
oversedation, hypoventilation and subsequent hypercarbic
respiratory failure.  She has been extubated for 48 h with nl
respiratory status and now appears again at her baseline mental
status.

Issues:
1) Reactive airway disease/respiratory failure, asthma vs. COPD
vs. sedative related hypoventilation.
-continue albuterol, atrovent nebulizers
-should get pulmonology followup with PFT's
-question component of aspiration, continue broad spectrum
antibiotics (vancomycin and zosyn) for two more days against
presumed hospital acquired pneumonia.
.
2) [**Last Name (un) 309**] Body dementia
-needs psychiatry and possibly neurology follow up
-avoid all antipsychotics
.
3) Atrial fibrillation, rate controlled without medications
-was on digoxin, but was bradycardic, would not continue digoxin
-continue coumadin, INR therapeutic.
.
4) CAD/chest pain
-continue aspirin.
-ruled out for MI
.
5) CHF, EF 40-45%
-held diuretics for low nl blood pressures
-diuresed cautiously, can restart PO lasix
.
6) Hyperglycemia, likely steroid related
-insulin sliding scale (humalog)
-consider A1c
.
FEN: Diabetic cardiac healthy diet.  Speech and swallow
evaluation cleared.
.
Ppx: Included heparin SC, bowel regimen and PPI
.
Code: Full
.
Disposition: Rehabilitation facility

Medications on Admission:
Tylenol
Coumadin 4mg po daily
Nitro SL
Namenda 10mg [**Hospital1 **]
Spironolactone 25mg qdaily
Furosemide 20mg daily
Isordil 10mg TID
Glucophage 500mg daily


Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
3. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
5. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
8. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation QID (4 times a day).
9. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q6H (every 6 hours).
10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
11. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
12. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours) as needed.
14. Warfarin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).

15. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed for constipation.
16. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
17. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
18. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q8H (every 8 hours): last day is [**2162-6-18**].
20. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous Q48H (every 48 hours): last day is [**2162-6-18**].
**got PRN lasix, consider restarting PO lasix, also was on
aldactone as outpatient

Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] - [**Location (un) 86**]

Discharge Diagnosis:
[**Last Name (un) 309**] Body Dementia
Reactive airway disease
Pneumonia
CAD


Discharge Condition:
Good,  mentating at baseline, normal respiratory status on 2L
NC.


Discharge Instructions:
Please have patient follow up with psychiatry for her [**Last Name (un) 309**] Body
Dementia
Please avoid all antipsychotics
Continue antibiotics for two more days
Continue prednisone and inhalers.

Followup Instructions:
Please have pt follow up with [**Hospital1 18**] Psychiatry, also consider
follow up with [**Hospital1 18**] Neurology.
Please have pt follow up with Dr. [**Last Name (STitle) 3707**] of [**Hospital1 18**] APG
practice.
{'Acute respiratory failure,Atrial fibrillation,Mitral valve stenosis and aortic valve stenosis,Chronic airway obstruction, not elsewhere classified,Congestive heart failure, unspecified,Pneumonia, organism unspecified,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Anxiety state, unspecified,Carpal tunnel syndrome,Hepatomegaly,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Dementia with lewy bodies,Dementia in conditions classified elsewhere without behavioral disturbance,Other specified disorders of pancreatic internal secretion,Adrenal cortical steroids causing adverse effects in therapeutic use,Long-term (current) use of anticoagulants,Other antipsychotics, neuroleptics, and major tranquilizers causing adverse effects in therapeutic use'}


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: Reason for admission: Chest pain
Reason for transfer to the MICU: hypercarbic respiratory failure

PRESENT ILLNESS: 87 y/o woman with CAD, Afib, presents with shortness of breath
and chest pain since morning of admission. She felt that her
shortness of breath has improved since getting to the hospital.
She can't elaborate as to what the extent of her activity level
is, but she cannot walk up one flight of stairs. She denied any
orthopnea or PND. On the morning of admission she was doing
regular housework, when she developed substernal pressure, as if
someone was sitting on her chest. She took one SL nitro and
called her friend to take her to the [**Name (NI) **]. On interview, she
denies any CP. She also c/o of having visual hallucinations at
night, she thinks it prob in her dreams.
.
On review of systems, the patient denied any chest pain,
shortness of breath, fevers, chills, weight loss, night sweats,
fatigue, headaches, dizziness, blurred vision, sore throat,
nausea, vomiting, abdominal pain, any new rashes, denies
dysuria, hematuria, increased urgency, diarrhea, constipation,
hematochezia, melena, epistaxis. All other systems were reviewed
in detail and were negative except for what has been mentioned
above.
.
In the ED, VS T 98.2 HR 80 BP 147/73 Sat 94 on RA increased to
98 on 3:. ECG with subtle ST dep/TW flattening anterior leads.
She was given ASA 325mg, combivent neb, plavix 600mg and lasic
40mg iv times 1. CXR showed vascular congestion. She had a foley
placed.
.
On the floor, patient was agitated requiring large amounts of
zyprexa and also Haldol was used. 1 Am [**6-12**] patient was found
unresponsive. ABG was performed with PH 7.15 pCO2 112 pO2 105.
Pt was electively intubated. Moving all four extremities,
responding to sternal rub. Suction of brown material, question
of aspiration. Pt to CT scan to assess for bleed, CVA and then
to MICU for further work up and management.

MEDICAL HISTORY: 1. Coronary artery disease, EF 45-50% in [**2157**].
2. Asthma.
3. Atrial fibrillation.
4. Hypertension.
5. Hepatosplenomegaly.
6. Anxiety.
7. Osteoarthritis.
8. Carpal tunnel syndrome.
9. Sciatica.
10. Status post total abdominal hysterectomy and bilateral
salpingo-oophorectomy.
11. Status post lumpectomy

MEDICATION ON ADMISSION: Tylenol
Coumadin 4mg po daily
Nitro SL
Namenda 10mg [**Hospital1 **]
Spironolactone 25mg qdaily
Furosemide 20mg daily
Isordil 10mg TID
Glucophage 500mg daily

ALLERGIES: Haldol

PHYSICAL EXAM: On admission to MICU
VS: 95/57. 62, 99.1, 100% on AC 450, 18/5 100 fio2
Gen: intubated, agitated, moving all extremities.
HEENT: Pupils pinpoint, ET tube in place.
CV: irregularly irregular
Lung:course breath sounds bilaterall, no wheezes noted.
Abdomen: Distended, hypoactive bowel sounds, but soft.
Ext: 1+ peripheral edema bilaterally, no clubbing, cyanosis, no
calf pain, DP pulses are 2+ bilaterally
Neuro: moving all extremities, unable to follow commands. DTR 2+
throughout, Toes downgoing
Skin: pink, warm, no rashes

FAMILY HISTORY: Father with heart problems.

SOCIAL HISTORY: Negative tobacco, occasional alcohol. Lives alone. Has two sons
and five grandchildren. Patient was born in Poland, Now lives
alone in [**Location (un) 583**] with daily care taker visits and [**1-23**]
times/week VNA. 

### Response:
{'Acute respiratory failure,Atrial fibrillation,Mitral valve stenosis and aortic valve stenosis,Chronic airway obstruction, not elsewhere classified,Congestive heart failure, unspecified,Pneumonia, organism unspecified,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Anxiety state, unspecified,Carpal tunnel syndrome,Hepatomegaly,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Dementia with lewy bodies,Dementia in conditions classified elsewhere without behavioral disturbance,Other specified disorders of pancreatic internal secretion,Adrenal cortical steroids causing adverse effects in therapeutic use,Long-term (current) use of anticoagulants,Other antipsychotics, neuroleptics, and major tranquilizers causing adverse effects in therapeutic use'}
