CHIEF COMPLAINT: Possible PEA Arrest

PRESENT ILLNESS: Mr. [**Known lastname **] is an 89 yo male with a history of DM2, HTN, slow
AFib, and poor functional capacity who presents to [**Hospital1 18**] after
sustaining a questionable PEA arrest at his opthomologist's
office on [**2145-3-8**]. Per the patient's daughter, after hurrying
him across the road because of oncoming traffic, he acutely
developed lethargy and went to sit down in a hunched over
position. He was apparently unresponsive for 2-3 minutes and
then [**Name8 (MD) **] RN came by and called EMS, which arrived within 3
minutes per the patient's daughter.
.
When EMS arrived, their initial documented HR [**Location (un) 1131**] was a
pulse of 26. After transfer to the stretcher, he was reportedly
pulseless and CPR was initiated (5 min), his monitor reported
pulse in the 20s and he was given atropine for presumed PEA. Per
report, he was also apneic, and hence was intubated int he
field. His HR subsequently rose to 58 and then was 110 on his
arrival to the [**Hospital1 18**] ED (AFib). He was reportedly also agitated
from his intubation.

MEDICAL HISTORY: CAD (s/p CABG) - unclear anatomy
Anticardiolipin (+) in past - no follow up antibody tests.
CHF (unclear if diastolic or systolic)
DM2
Hypertension
Hypothyroidism
Atrial Fibrillation - not on warfarin because he is a high fall
risk - per son ([**Name8 (MD) **] MD)
Hearing impairment
Prostate Cancer s/p prostatectomy
Retinopathy
b/l cataract surgery
OA of cervical and lumbar spine
Osteoporosis
Bladder cancer
Hyperlipidemia

MEDICATION ON ADMISSION: Benicar 20mg daily
Furosemide 40mg daily
Insulin:
AM: 20U Humalog and 40U Humulin N
PM: 20U Humalog and 20U Humulin N
Levothyroxine: 50mcg
ASA Alternates b/w 162mg/325mg
Fe
MVI
Zantac (? dose)
Lipitor 20 mg PO QHS
Zoladex Q 3 months

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
VS: T: 97.4 , BP: 161/83 , HR: 40s-50s (Irregular) , Intubated:
AC 550 x 18 with FiO2 of 50%, PEEP: 5 , 100% O2 % on
Gen: Elderly male who is sedated and intubated.
HEENT: NCAT. Sclera anicteric. Pupils irregular and equal and
minimally responsive to light, EOMI.
Neck: Supple with JVP to mid neck at 30 degrees.
CV: +s1+s2 irregularly irregular. No murmurs
Chest: No crackles, wheeze, rhonchi.
Abd: Soft, NTND, No HSM or tenderness. No abdominial bruits.
Ext: No c/c/e. R sheath in place. L groin line in place. Cool
feet, but with dopplerable pulses

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Family denied tobacco or alcohol abuse.  Recently moved in with
daughter. [**Name (NI) **] has low functional capacity; has difficulty walking
long distances; cannot climb a flight of stairs. Gets SOB with
moderate exertion. Has a walker, but does not use it to walk.
Other specified cardiac dysrhythmias,Acute respiratory failure,Anoxic brain damage,Pneumonitis due to inhalation of food or vomitus,Chronic diastolic heart failure,Other pulmonary embolism and infarction,Urinary tract infection, site not specified,Hyperosmolality and/or hypernatremia,Acute kidney failure, unspecified,Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled,Background diabetic retinopathy,Other chronic pulmonary heart diseases,Unspecified acquired hypothyroidism,Aortocoronary bypass status,Chronic kidney disease, unspecified,Personal history of malignant neoplasm of bladder,Personal history of malignant neoplasm of prostate,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified
Cardiac dysrhythmias NEC,Acute respiratry failure,Anoxic brain damage,Food/vomit pneumonitis,Chr diastolic hrt fail,Pulm embol/infarct NEC,Urin tract infection NOS,Hyperosmolality,Acute kidney failure NOS,DMII ophth nt st uncntrl,Diabetic retinopathy NOS,Chr pulmon heart dis NEC,Hypothyroidism NOS,Aortocoronary bypass,Chronic kidney dis NOS,Hx of bladder malignancy,Hx-prostatic malignancy,Hy kid NOS w cr kid I-IV
Admission Date:  [**2145-3-8**]              Discharge Date:   [**2145-3-19**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Possible PEA Arrest


Major Surgical or Invasive Procedure:
None

History of Present Illness:
Mr. [**Known lastname **] is an 89 yo male with a history of DM2, HTN, slow
AFib, and poor functional capacity who presents to [**Hospital1 18**] after
sustaining a questionable PEA arrest at his opthomologist's
office on [**2145-3-8**]. Per the patient's daughter, after hurrying
him across the road because of oncoming traffic, he acutely
developed lethargy and went to sit down in a hunched over
position. He was apparently unresponsive for 2-3 minutes and
then [**Name8 (MD) **] RN came by and called EMS, which arrived within 3
minutes per the patient's daughter.
.
When EMS arrived, their initial documented HR [**Location (un) 1131**] was a
pulse of 26. After transfer to the stretcher, he was reportedly
pulseless and CPR was initiated (5 min), his monitor reported
pulse in the 20s and he was given atropine for presumed PEA. Per
report, he was also apneic, and hence was intubated int he
field. His HR subsequently rose to 58 and then was 110 on his
arrival to the [**Hospital1 18**] ED (AFib). He was reportedly also agitated
from his intubation.

On arrival to [**Hospital1 18**], his HR was in the 80s. He was started on
propofol gtt (as he was not sedated in the field). His pressure
dropped to 75/25, and his HR dropped to 55. It was presumed that
his BP decrement was due to the bradycardia, and thus was given
atropine and the propofol discontinued. He was given a 2nd mg of
atropine because his HR was still in the 50s; and started on
fentanyl gtt and versed for sedation.

He had a femoral line placed and dopamine infusion was begun b/c
of of BP in the 80s-90s and hr in the 40s.
.
Cardiology was consulted in the ED; he had an ECHO which showed
R heart strain; however, a subsequent PE protocol CT did not
find evidence of an acute PE; evidence of chronic PE was found.
He was intubated for altered mental status and undertook a trip
to the cardiac catheterization laboratory which found him to
have:
- elevated RV and PA pressures.
- he was also started on heparin gtt and given ASA 325.
.
Of note, he was taken off of his ASA for 4 days prior to his
opthamologic surgery. He was also not being anticoagulated for
his known AFib.


Past Medical History:
CAD (s/p CABG) - unclear anatomy
Anticardiolipin (+) in past - no follow up antibody tests.
CHF (unclear if diastolic or systolic)
DM2
Hypertension
Hypothyroidism
Atrial Fibrillation - not on warfarin because he is a high fall
risk - per son ([**Name8 (MD) **] MD)
Hearing impairment
Prostate Cancer s/p prostatectomy
Retinopathy
b/l cataract surgery
OA of cervical and lumbar spine
Osteoporosis
Bladder cancer
Hyperlipidemia


Social History:
Family denied tobacco or alcohol abuse.  Recently moved in with
daughter. [**Name (NI) **] has low functional capacity; has difficulty walking
long distances; cannot climb a flight of stairs. Gets SOB with
moderate exertion. Has a walker, but does not use it to walk.


Family History:
Non-contributory

Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T: 97.4 , BP: 161/83 , HR: 40s-50s (Irregular) , Intubated:
AC 550 x 18 with FiO2 of 50%, PEEP: 5 , 100% O2 % on
Gen: Elderly male who is sedated and intubated.
HEENT: NCAT. Sclera anicteric. Pupils irregular and equal and
minimally responsive to light, EOMI.
Neck: Supple with JVP to mid neck at 30 degrees.
CV: +s1+s2 irregularly irregular. No murmurs
Chest: No crackles, wheeze, rhonchi.
Abd: Soft, NTND, No HSM or tenderness. No abdominial bruits.
Ext: No c/c/e. R sheath in place. L groin line in place. Cool
feet, but with dopplerable pulses


Pertinent Results:
ADMISSION LABS:
[**2145-3-8**] 11:25AM BLOOD WBC-12.9* RBC-3.32* Hgb-11.2* Hct-34.0*
MCV-103* MCH-33.7* MCHC-32.9 RDW-14.0 Plt Ct-102*
[**2145-3-8**] 11:25AM BLOOD Neuts-65.7 Lymphs-30.8 Monos-2.5 Eos-0.5
Baso-0.6
[**2145-3-8**] 11:25AM BLOOD Plt Ct-102*
[**2145-3-8**] 11:25AM BLOOD PT-14.4* PTT-52.5* INR(PT)-1.3*
[**2145-3-9**] 04:51AM BLOOD ACA IgG-28.5* ACA IgM-57.4*
[**2145-3-10**] 10:13AM BLOOD Heparin-0.29*
[**2145-3-8**] 11:25AM BLOOD Glucose-325* UreaN-37* Creat-2.0* Na-137
K-4.6 Cl-106 HCO3-16* AnGap-20
[**2145-3-8**] 06:10PM BLOOD ALT-38 AST-65* LD(LDH)-349* AlkPhos-140*
TotBili-1.7*
[**2145-3-8**] 11:25AM BLOOD CK(CPK)-135
[**2145-3-8**] 11:25AM BLOOD Calcium-9.0 Mg-2.8*
.
CARDIAC ENZYMES:
[**2145-3-8**] 11:09PM BLOOD CK-MB-13* MB Indx-5.2 cTropnT-0.31*
[**2145-3-9**] 02:06PM BLOOD CK-MB-6 cTropnT-0.38*
[**2145-3-12**] 05:00AM BLOOD CK-MB-5 cTropnT-0.13*
.
EKG : AFib with LBBB morphology. Diffuse TWI in inferior leads.
Also V1-V4 with TWI. STD in V3-V4. (A report from OSH [**7-17**]: AFib
with RBBB.
- [**11-16**]: Slow AFib with RBBB
.
TELEMETRY demonstrated: Slow Afib.
.
[**2145-3-8**] TTE:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is moderately dilated with moderate global free wall
hypokinesis. There is abnormal systolic septal motion/position
consistent with right ventricular pressure overload. The
ascending aorta is mildly dilated. The number of aortic valve
leaflets cannot be determined. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is severe
pulmonary artery systolic hypertension. There is no pericardial
effusion. IMPRESSION: Mild symmetric left ventricular
hypertrophy with normal systolic function. Moderately dilated
right ventricle with moderately depressed function and severe
estimated pulmonary artery systolic hypertension.
.
[**8-15**]: ECHO from [**Hospital3 **]
- EF: 65%
- PASP: 39mm Hg
- concentric LVH
.
ETT performed : NA
.
CARDIAC CATH performed on [**2145-3-8**]:
Pulm HTN and moderate elevation of PVR with moderate LV
diastolic dysfunction.
.
HEMODYNAMICS:
CO: 6.55 L/min    CI: 3.28 L/min/m^2
RA (mean) : 14
RV: 93/8
PCWP (mean) : 24mm Hg
PA : 93/24 (mean 49)
.
CTA [**2145-3-8**]:
1.  No acute PE.  Findings suggestive of chronic PE.
2.  Endotracheal tube terminates 1.5 cm from the carina.  Pull
black is recommended.
3.  Acute angulation of bilateral anterior ribs.  Recommend
clinical
correlation for acute injury possibly related to recent
resuscitative efforts.
4.  Extensive coronary artery disease.
5.  Possible interstitial lung disease versus interstitial
engorgement in the setting of recent cardiac arrest.  Followup
imaging may be useful once clinically stabilized.
.
[**3-17**] EEG:
Abnormal portable EEG due to the slow and disorganized
background and bursts of generalized slowing. These findings
indicate a
widespread encephalopathy affecting both cortical and
subcortical
structures. Anoxia is a possible explanation of the
encephalopathy.
Medications, infection, and metabolic disturbances can also
contribute.
There were no areas of persistent focal slowing, and there were
no
epileptiform features.


Brief Hospital Course:
(1) POSSIBLE PEA ARREST
From accounts from EMS, it appeared that Mr. [**Known lastname **] had a PEA
arrest while running across the street. However, it did not take
long to rescucitate the patient in the field, so it is unclear
whether he had an actual arrest.  Given his chronic PE and high
PA & RV pressures, it is likely that he could not match the
demand from his episode of exertion, leading to hypoxia which
may have been the predisposing factor to his PEA.  In addition,
the patient has poor functional status, and along with his known
CAD and DM, demand ischemia could have potentially led to his
PEA.  Given his CKD and dye load with CTA and right heart cath,
detailed inspection of his coronary anatomy was not pursued.
.
He was continued on aspirin and atrovastatin during his
hospitalization. ECHO showed moderately dilated right ventricle
with moderately depressed function and severe estimated
pulmonary artery systolic hypertension.

(2) HYPOXIC BRAIN INJURY
Mr.[**Known lastname **] suffered from severe neurologic impairment from his
cardiac event.  Once off sedation for intubation, he was
arousable to voice but otherwise not following commands or
communicating.  Neurology was consulted to advise on progrnosis,
and EEG showed encephalopathy c/w anoxic brain injury.
Neurology felt there was little probability of recovery to
baseline functioning.  The palliative care team was consulted,
and the patient was made comfort measures only on [**2145-3-18**].  On
the morning of [**2145-3-19**], Mr. [**Known lastname **] passed away in the CCU when
his heart went into asystole.

(3) CHRONIC PULMONARY EMBOLISM
Lovenox

(4) ACUTE ON CHRONIC RENAL FAILURE
Mr. [**Known lastname **] has long-standing diabetes mellitus with likely CKD,
although baseline creatinine is not known.  Cr was 2.0 on
admission and then 2.3 several days later, likely secondary to
ATN from hypoperfusion during his event and the dye load from
the catheterization and CTA.  Urine output remained good, and
creatinine slowly improved over the hospitalization.

(5) FEVER
Most likely source is pulmonary [**3-13**] aspiration at time of field
intubation; sputum with 3+ GPC and GNR.  He was placed on
vancomycin and zosyn for a seven day course, with improvement in
his fevers.  Blood cultures were negative except for one vial
which grew coag neg Staph, thought to be a contaminant.
Infection/sepsis was not thought to contribute to the immediate
cause of death.


Medications on Admission:
Benicar 20mg daily
Furosemide 40mg daily
Insulin:
AM: 20U Humalog and 40U Humulin N
PM: 20U Humalog and 20U Humulin N
Levothyroxine: 50mcg
ASA Alternates b/w 162mg/325mg
Fe
MVI
Zantac (? dose)
Lipitor 20 mg PO QHS
Zoladex Q 3 months


Discharge Disposition:
Expired

Discharge Diagnosis:
Primary Diagnoses:
Pulseless electrical activity
Anoxic brain injury


Discharge Condition:
Patient expired on [**2145-3-19**] in the CCU.

Discharge Instructions:
NA

Followup Instructions:
NA
{'Other specified cardiac dysrhythmias,Acute respiratory failure,Anoxic brain damage,Pneumonitis due to inhalation of food or vomitus,Chronic diastolic heart failure,Other pulmonary embolism and infarction,Urinary tract infection, site not specified,Hyperosmolality and/or hypernatremia,Acute kidney failure, unspecified,Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled,Background diabetic retinopathy,Other chronic pulmonary heart diseases,Unspecified acquired hypothyroidism,Aortocoronary bypass status,Chronic kidney disease, unspecified,Personal history of malignant neoplasm of bladder,Personal history of malignant neoplasm of prostate,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified'}


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: Possible PEA Arrest

PRESENT ILLNESS: Mr. [**Known lastname **] is an 89 yo male with a history of DM2, HTN, slow
AFib, and poor functional capacity who presents to [**Hospital1 18**] after
sustaining a questionable PEA arrest at his opthomologist's
office on [**2145-3-8**]. Per the patient's daughter, after hurrying
him across the road because of oncoming traffic, he acutely
developed lethargy and went to sit down in a hunched over
position. He was apparently unresponsive for 2-3 minutes and
then [**Name8 (MD) **] RN came by and called EMS, which arrived within 3
minutes per the patient's daughter.
.
When EMS arrived, their initial documented HR [**Location (un) 1131**] was a
pulse of 26. After transfer to the stretcher, he was reportedly
pulseless and CPR was initiated (5 min), his monitor reported
pulse in the 20s and he was given atropine for presumed PEA. Per
report, he was also apneic, and hence was intubated int he
field. His HR subsequently rose to 58 and then was 110 on his
arrival to the [**Hospital1 18**] ED (AFib). He was reportedly also agitated
from his intubation.

MEDICAL HISTORY: CAD (s/p CABG) - unclear anatomy
Anticardiolipin (+) in past - no follow up antibody tests.
CHF (unclear if diastolic or systolic)
DM2
Hypertension
Hypothyroidism
Atrial Fibrillation - not on warfarin because he is a high fall
risk - per son ([**Name8 (MD) **] MD)
Hearing impairment
Prostate Cancer s/p prostatectomy
Retinopathy
b/l cataract surgery
OA of cervical and lumbar spine
Osteoporosis
Bladder cancer
Hyperlipidemia

MEDICATION ON ADMISSION: Benicar 20mg daily
Furosemide 40mg daily
Insulin:
AM: 20U Humalog and 40U Humulin N
PM: 20U Humalog and 20U Humulin N
Levothyroxine: 50mcg
ASA Alternates b/w 162mg/325mg
Fe
MVI
Zantac (? dose)
Lipitor 20 mg PO QHS
Zoladex Q 3 months

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
VS: T: 97.4 , BP: 161/83 , HR: 40s-50s (Irregular) , Intubated:
AC 550 x 18 with FiO2 of 50%, PEEP: 5 , 100% O2 % on
Gen: Elderly male who is sedated and intubated.
HEENT: NCAT. Sclera anicteric. Pupils irregular and equal and
minimally responsive to light, EOMI.
Neck: Supple with JVP to mid neck at 30 degrees.
CV: +s1+s2 irregularly irregular. No murmurs
Chest: No crackles, wheeze, rhonchi.
Abd: Soft, NTND, No HSM or tenderness. No abdominial bruits.
Ext: No c/c/e. R sheath in place. L groin line in place. Cool
feet, but with dopplerable pulses

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Family denied tobacco or alcohol abuse.  Recently moved in with
daughter. [**Name (NI) **] has low functional capacity; has difficulty walking
long distances; cannot climb a flight of stairs. Gets SOB with
moderate exertion. Has a walker, but does not use it to walk. 

### Response:
{'Other specified cardiac dysrhythmias,Acute respiratory failure,Anoxic brain damage,Pneumonitis due to inhalation of food or vomitus,Chronic diastolic heart failure,Other pulmonary embolism and infarction,Urinary tract infection, site not specified,Hyperosmolality and/or hypernatremia,Acute kidney failure, unspecified,Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled,Background diabetic retinopathy,Other chronic pulmonary heart diseases,Unspecified acquired hypothyroidism,Aortocoronary bypass status,Chronic kidney disease, unspecified,Personal history of malignant neoplasm of bladder,Personal history of malignant neoplasm of prostate,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified'}
