CHIEF COMPLAINT: chest pain

PRESENT ILLNESS: 63 y/o man with PMH significant for traumatic brain injury
following fall in [**2124**]; trach in [**4-10**] and Peg [**7-11**] secondary
to failure to thrive; siezure disorder admitted from OSH for
PICC placement and further eval of the above. Pt was in his
usual state of health at his nursing home until [**2132-10-20**] at
which time he developed a temperature of 102.7 and oxygen
saturation of 79 percent on room air. He was sent to the [**Hospital1 18**]
[**Location (un) 620**] for futher care. There, a CXR showed left lower lobe
infiltrate and 5 posterior left sided rib fracutres. By report,
pt had recently fallen backward twice at the nursing home. In
addition, he was being treated with clindamycin (since [**2132-10-10**])
and levofloxacin ([**2132-10-15**]) for a question of pneumonia.

MEDICAL HISTORY: 1. Traumatic brain injury s/p fall in [**2124**]
2. Peg tube placement in [**7-11**]
3. Trach placed in [**4-10**] for post-intubation subglottic tracheal
stenosis per [**Hospital1 2025**] records.  Currently has T-tube.
4. HIstory of DVT on coumadin with IVC filter
5. Multiple aspiration pneumonia
6. S/P multiple abdominal surgeries for hernia repair
7. Past seizure disorder
8. Anemia
9. History of fungemia

MEDICATION ON ADMISSION: Linezolid 600 mg [**Hospital1 **]
Ciprofloxacin 500 mg [**Hospital1 **]
Zoloft 100 mg po qd
Albuterol nebs q4h prn
Dilaudid prn
Prilosec 20 mg qd
Valproic acid (250 mg in 5 ml syrup) 15 cc qAM, 20 cc qpm

ALLERGIES: Penicillins / Morphine / Demerol

PHYSICAL EXAM: T: 96.6  BP: 127/50  P: 54  RR: 24, O2 sat 95% on 50% TC (pt
does not desaturate with nasal cannula, but just prefers not to
wear it)
Gen: awake, alert, sitting up in chair
Skin: warm and dry
HEENT: + copious secretions from tracheostomy
Heart: bradycardic, regular rhythm, no murmurs, rubs, or gallops
Lungs: coarse throughout, moving air much better on the left
Abd: soft, nontender, nondistended.  Ventral hernia nontender,
easily reducible.  +bs.
Ext: no edema, 2+ distal pulses bilaterally.

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: Married.  Polish immigrant (speaks some English).  Used to be a
heavy smoker.  Has been a nursing home resident for many years
since his TBI.  Has several children who are closely involved,
one daughter is a CCU nurse at [**Hospital3 **].
Methicillin susceptible pneumonia due to Staphylococcus aureus,Closed fracture of five ribs,Other convulsions,Other emphysema,Pulmonary collapse,Fall from other slipping, tripping, or stumbling,Tracheostomy status
Meth sus pneum d/t Staph,Fracture five ribs-close,Convulsions NEC,Emphysema NEC,Pulmonary collapse,Fall from slipping NEC,Tracheostomy status
Admission Date:  [**2132-10-25**]              Discharge Date:   [**2132-10-30**]

Date of Birth:  [**2069-4-29**]             Sex:   M

Service: MED

Allergies:
Penicillins / Morphine / Demerol

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
chest pain

Major Surgical or Invasive Procedure:
bronchoscopy

History of Present Illness:
63 y/o man with PMH significant for traumatic brain injury
following fall in [**2124**]; trach in [**4-10**] and Peg [**7-11**] secondary
to failure to thrive; siezure disorder admitted from OSH for
PICC placement and further eval of the above. Pt was in his
usual state of health at his nursing home until [**2132-10-20**] at
which time he developed a temperature of 102.7 and oxygen
saturation of 79 percent on room air. He was sent to the [**Hospital1 18**]
[**Location (un) 620**] for futher care. There, a CXR showed left lower lobe
infiltrate and 5 posterior left sided rib fracutres. By report,
pt had recently fallen backward twice at the nursing home. In
addition, he was being treated with clindamycin (since [**2132-10-10**])
and levofloxacin ([**2132-10-15**]) for a question of pneumonia.

At [**Hospital1 18**] [**Name (NI) 620**], pt was admitted for treatment of his pneumonia
and hypernatremia. Initial vital signs included temperature of
102.2, blood pressure 100/68, oxygen saturation 98% on
nonrebreather, and respiratory rate of 36. Labs were significant
for a WBC count of 14.9 and a sodium of 160. ECG is reported as
Sinus tachycardia with no ST or T wave abnormalities. Pt was
started on vancomycin and ceftazidime for his pneumonia. Sputum
cultures from [**2132-10-23**] grew MRSA and pan resisitent pseudomonas.
On [**2132-10-23**], the pt lost IV access and attempts to replace it
were unsuccesful. Therefore, his antibiotics were changed to
linezolid and ciprofloxacin(wanted to cover gram negatives). By
[**2132-10-23**], the patient had also developed complete collapse of
the left lung. Pulmonary service was consulted at that time but
could not bronch the pt as he had no IV access. Pt often became
tachypnic at the outside hospital and required frequent
suctioning. Hypernatremia resolved with treatment with free
water. On [**2132-10-24**], the pt was sent to [**Hospital1 18**] to have a PICC
placed.

During PICC placement in IR, the pt developed nausea and CP at
approximately 3:30 PM. He was sent to the [**Hospital1 18**] ED for futher
evaluation. In the [**Name (NI) **], pt's VS were initially 98.2, 70, 101/53,
18, and 98% on 70% face tent. Pt received vancomycin 1 gm IV and
1 L of NS. ECG in the ED showed mildly [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] at 470-480 and T
wave inversion in V1-V4. Pt was evaluated by cardiology and plan
was made for medical management. He was placed on a heparin drip
for pain control. The first set of cardiac enzymes were
negative.


Past Medical History:
1. Traumatic brain injury s/p fall in [**2124**]
2. Peg tube placement in [**7-11**]
3. Trach placed in [**4-10**] for post-intubation subglottic tracheal
stenosis per [**Hospital1 2025**] records.  Currently has T-tube.
4. HIstory of DVT on coumadin with IVC filter
5. Multiple aspiration pneumonia
6. S/P multiple abdominal surgeries for hernia repair
7. Past seizure disorder
8. Anemia
9. History of fungemia

Social History:
Married.  Polish immigrant (speaks some English).  Used to be a
heavy smoker.  Has been a nursing home resident for many years
since his TBI.  Has several children who are closely involved,
one daughter is a CCU nurse at [**Hospital3 **].

Family History:
noncontributory

Physical Exam:
T: 96.6  BP: 127/50  P: 54  RR: 24, O2 sat 95% on 50% TC (pt
does not desaturate with nasal cannula, but just prefers not to
wear it)
Gen: awake, alert, sitting up in chair
Skin: warm and dry
HEENT: + copious secretions from tracheostomy
Heart: bradycardic, regular rhythm, no murmurs, rubs, or gallops
Lungs: coarse throughout, moving air much better on the left
Abd: soft, nontender, nondistended.  Ventral hernia nontender,
easily reducible.  +bs.
Ext: no edema, 2+ distal pulses bilaterally.


Pertinent Results:
[**2132-10-29**] 04:04AM BLOOD WBC-5.3 RBC-2.93* Hgb-8.4* Hct-25.7*
MCV-88 MCH-28.7 MCHC-32.7 RDW-17.3* Plt Ct-382
[**2132-10-28**] 04:00AM BLOOD WBC-7.3 RBC-2.92* Hgb-8.4* Hct-25.9*
MCV-89 MCH-28.9 MCHC-32.6 RDW-16.4* Plt Ct-358
[**2132-10-27**] 07:35AM BLOOD WBC-5.6 RBC-3.07*# Hgb-8.7*# Hct-26.9*
MCV-88# MCH-28.4 MCHC-32.4 RDW-16.6* Plt Ct-381
[**2132-10-27**] 04:51AM BLOOD WBC-4.7 RBC-2.31* Hgb-6.6* Hct-22.1*
MCV-96# MCH-28.6 MCHC-29.9*# RDW-16.0* Plt Ct-312
[**2132-10-26**] 03:50AM BLOOD WBC-7.6 RBC-2.97* Hgb-8.8* Hct-25.8*
MCV-87 MCH-29.8 MCHC-34.3# RDW-16.8* Plt Ct-397
[**2132-10-25**] 05:30PM BLOOD Hct-25.0*
[**2132-10-25**] 06:03AM BLOOD WBC-8.3 RBC-3.10* Hgb-8.6* Hct-27.7*
MCV-89 MCH-27.8 MCHC-31.1 RDW-16.2* Plt Ct-397
[**2132-10-24**] 04:25PM BLOOD WBC-7.0 RBC-2.97* Hgb-8.5* Hct-26.0*
MCV-88 MCH-28.5 MCHC-32.5 RDW-15.9* Plt Ct-319
[**2132-10-28**] 04:00AM BLOOD Neuts-71.0* Lymphs-23.2 Monos-4.0 Eos-1.6
Baso-0.2
[**2132-10-29**] 04:04AM BLOOD Plt Ct-382
[**2132-10-29**] 04:04AM BLOOD PT-13.7* PTT-32.5 INR(PT)-1.2
[**2132-10-28**] 04:00AM BLOOD PT-15.6* PTT-36.5* INR(PT)-1.5
[**2132-10-27**] 07:35AM BLOOD PT-16.9* PTT-37.6* INR(PT)-1.8
[**2132-10-27**] 04:51AM BLOOD PT-17.4* PTT-41.8* INR(PT)-1.9
[**2132-10-26**] 03:50AM BLOOD PT-15.2* PTT-35.3* INR(PT)-1.5
[**2132-10-25**] 06:03AM BLOOD PT-14.2* PTT-53.1* INR(PT)-1.3
[**2132-10-24**] 10:14PM BLOOD PT-14.7* PTT-119.1* INR(PT)-1.4
[**2132-10-24**] 04:25PM BLOOD PT-13.1 PTT-30.2 INR(PT)-1.1
[**2132-10-28**] 04:00AM BLOOD Glucose-109* UreaN-14 Creat-1.1 Na-146*
K-3.6 Cl-111* HCO3-27 AnGap-12
[**2132-10-27**] 07:35AM BLOOD Glucose-86 UreaN-15 Creat-1.0 Na-149*
K-3.5 Cl-114* HCO3-28 AnGap-11
[**2132-10-27**] 04:51AM BLOOD Glucose-732* UreaN-13 Creat-0.9 Na-137
K-3.0* Cl-107 HCO3-25 AnGap-8
[**2132-10-25**] 08:30PM BLOOD K-4.1
[**2132-10-25**] 06:03AM BLOOD Glucose-101 UreaN-28* Creat-1.1 Na-148*
K-3.3 Cl-110* HCO3-28 AnGap-13
[**2132-10-24**] 10:14PM BLOOD Glucose-437* UreaN-30* Creat-1.1 Na-145
K-3.4 Cl-108 HCO3-28 AnGap-12
[**2132-10-24**] 04:25PM BLOOD Glucose-69* UreaN-32* Creat-1.2 Na-150*
K-4.0 Cl-111* HCO3-30* AnGap-13
[**2132-10-25**] 06:03AM BLOOD ALT-73* AST-32 CK(CPK)-97 AlkPhos-66
TotBili-0.2
[**2132-10-24**] 10:14PM BLOOD CK(CPK)-91
[**2132-10-24**] 04:25PM BLOOD ALT-93* AST-40 LD(LDH)-211 CK(CPK)-113
AlkPhos-65 Amylase-30 TotBili-0.3
[**2132-10-25**] 06:03AM BLOOD CK-MB-2 cTropnT-<0.01
[**2132-10-24**] 10:14PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2132-10-24**] 04:25PM BLOOD CK-MB-1 cTropnT-<0.01
[**2132-10-24**] 04:25PM BLOOD Lipase-14
[**2132-10-29**] 04:04AM BLOOD Calcium-7.4* Phos-3.7 Mg-2.0
[**2132-10-28**] 04:00AM BLOOD Calcium-7.3* Phos-3.7 Mg-1.8
[**2132-10-27**] 07:35AM BLOOD Calcium-7.3* Phos-3.7 Mg-2.0
[**2132-10-27**] 04:51AM BLOOD Calcium-6.0* Phos-3.0 Mg-1.7
[**2132-10-26**] 03:50AM BLOOD Calcium-7.2* Phos-2.4* Mg-2.1
[**2132-10-25**] 06:03AM BLOOD Calcium-7.9* Phos-2.6* Mg-1.9
[**2132-10-24**] 10:14PM BLOOD Calcium-6.9* Phos-2.9 Mg-1.9
[**2132-10-24**] 04:25PM BLOOD Albumin-2.3* Calcium-8.0* Phos-3.3 Mg-2.1
[**2132-10-29**] 04:04AM BLOOD Valproa-38*
[**2132-10-27**] 07:35AM BLOOD Valproa-5*
[**2132-10-26**] 03:50AM BLOOD Valproa-4*
[**2132-10-24**] 04:25PM BLOOD Valproa-20*
[**2132-10-30**] 04:33PM BLOOD Hct-28.8*

Brief Hospital Course:
1. Respiratory:  Mr. [**Known lastname 57453**] presented to the OSH with a
pneumonia which grew 3 different bacteria: MRSA and 2 strains of
pseudomonas.  One strain of pseudomonas was pan-resistant, and
the other one was resistant to everything except ceftazidime and
pipercillin.  While here, the pt remained afebrile and his blood
pressure was stable.  His oxygen requirement remained the same.
He had copious secretions and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 57454**]-out left lung on CXR, and
so underwent bronchoscopy on [**10-27**].  It revealed quite a bit of
secretions in his upper airways, as well as a 95% dynamic
collapse of his trachea distal to the t-tube.  In this area
there was also what appeared to extrinsic compression of his
trachea, and the pulmonary attending recommended a CT scan to
evaluate this in the future.  After the bronch, he did well with
aggressive chest PT, positioning, and guafenesin.  He had a
vibrating vest placed on his chest which helped break up
secretions, but the pt did not tolerate this.  He also had
scheduled nebs while he was here, as he was wheezing on exam
initially.  His CXR looked better on discharge although he still
has some degree of collapse on his left side.  For his
pneumonia, given his hx of MRSA and pseudomonas (one of which
was sensitive to ceftaz), he was treated with vancomycin and
ceftazidime, discharged to finish a 10-day course, 1st day =
[**2132-10-24**].  He also had a chest CT done to evaluate the
possibility of his trachea being extrinsically compressed, which
showed:
1) Narrowed intrathoracic trachea and narrowed right and left
main bronchi consistent with tracheomalacia, 2) Enlarged thyroid
with slight heterogeneous attenuation of the right thyroid lobe,
3) Bilateral moderate-sized pleural effusions, 4) Right lower
lobe atelectasis, 5) Left upper lobe and left lower lobe
opacities. There is likely a combination of atelectasis and
pneumonia, 6) Left posterior 9th and 10th rib fractures, likely
acute, 7) Emphysema.

2. Cardiovascular:  On [**10-24**], during placement of a PICC line by
interventional radiology the pt developed chest pain.  He had an
EKG done at that time which showed T wave inversions in V1-V4
but no ST-T changes (none available for comparison).  He was
begun on a heparin gtt, and his pain resolved.  He had negative
cardiac enzymes x3 sets.  He was begun on an ASA and a statin.
His heparin gtt was discontinued the next morning.  We attempted
to start a beta blocker on him, but his pulse was often in the
40s-50s (sinus bradycardia) and so he did not tolerate it.  He
was evaluated by cardiology who felt that he could have an echo
or ETT as an outpatient to evaluate EF and wall motion
abnormalities.  It was felt that his chest pain was likely [**3-10**]
his 5 broken ribs sustained in a fall 2 weeks ago at the nursing
home.  For this reason, his ASA, statin, and beta-blocker were
all discontinued as we have no evidence that he actually has any
coronary artery disease.
In terms of his hx of DVT, he takes coumadin 10 mg qd at the
nursing home.  Coumadin was not one of his medications listed on
transfer from [**Hospital1 **]-[**Location (un) 620**].  In our ED, he was begun on a heparin
gtt [**3-10**] his chest pain.  His coumadin was restarted on [**2132-10-28**]
at his home dose.

3. GI: Pt was begun on tube feeds, which were cycled at night
per his NH protocol.  He tolerated these well and they were
quickly advanced to goal without complication.  His abd pain
that he had in IR had resolved by the time he was admitted to
the [**Hospital Unit Name 153**].

4. Hematology:  Pt was anemic on admission at 26.  He carries a
diagnosis of chronic anemia, and his crit was stable throughout
his stay.  He received one unit of PRBCs the evening of
admission (given the possibility of CAD), but basically hovered
in the 25-27 range throughout his stay.  He had no signs of
active bleeding, and it's recommended that this be followed up
as an outpt.  His hematocrit was 24.6 at its lowest point, and
was 28 on discharge.

5. Neuro:  He has been on Depakote for a hx of seizure disorder,
and when he came in his level was 20 (goal 50-100).  He was
placed on his home dosing of depakote ([**Hospital1 **]) but apparently it
was only given in the AM, and so his level dropped to 5.  This
was corrected, and his level should be followed up as an outpt.
His level prior to discharge was 35.  He had no seizure activity
while he was here.

6. Musculoskeletal:  He has 5 left-sided posterior rib fractures
sustained in a fall at the nursing home 2 weeks ago.  For this,
his pain was controlled with subcutaneous dilaudid.


Medications on Admission:
Linezolid 600 mg [**Hospital1 **]
Ciprofloxacin 500 mg [**Hospital1 **]
Zoloft 100 mg po qd
Albuterol nebs q4h prn
Dilaudid prn
Prilosec 20 mg qd
Valproic acid (250 mg in 5 ml syrup) 15 cc qAM, 20 cc qpm

Discharge Medications:
1. Valproate Sodium (Bulk) 250 mg/5 mL Syrup Sig: Twenty (20) cc
PO QPM (once a day (in the evening)).
2. Valproate Sodium (Bulk) 250 mg/5 mL Syrup Sig: Twenty (20) cc
PO QAM (once a day (in the morning)).
3. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q4-6H (every 4 to 6 hours) as needed for fever, pain.
4. Sertraline HCl 50 mg Tablet Sig: Two (2) Tablet PO QD (once a
day).
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing. neb
6. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheezing, sob.
7. Hydromorphone HCl 2 mg/mL Syringe Sig: 0.5-1 mg Injection Q6H
(every 6 hours) as needed.
8. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
9. Warfarin Sodium 5 mg Tablet Sig: Two (2) Tablet PO QD (once a
day).
10. Vancomycin HCl 1,000 mg Recon Soln Sig: One (1) gram
Intravenous  every twelve (12) hours for 4 days: Last dose 9/26
for a total 10 days treatment.
11. Ceftazidime 1 g Recon Soln Sig: One (1) gram Intravenous
every eight (8) hours for 4 days: Last dose on [**11-2**], for a total
10 days treatment.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 **] Hospital - [**Location (un) 701**]

Discharge Diagnosis:
Pneumonia with left lung collapse


Discharge Condition:
Stable

Discharge Instructions:
Please take your medications as directed.  Please use aggressive
chest physical therapy (pt tolerates, despite broken ribs),
suctioning, and expectorants (i.e. guaifenesin or humibid).

Followup Instructions:
please be evaluated by your PCP upon arrival at the NH.  Please
have your valproic acid level checked 2-3x/wk.  Please have your
INR checked at the same time, as we have restarted your
coumadin.
{'Methicillin susceptible pneumonia due to Staphylococcus aureus,Closed fracture of five ribs,Other convulsions,Other emphysema,Pulmonary collapse,Fall from other slipping, tripping, or stumbling,Tracheostomy status'}


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: chest pain

PRESENT ILLNESS: 63 y/o man with PMH significant for traumatic brain injury
following fall in [**2124**]; trach in [**4-10**] and Peg [**7-11**] secondary
to failure to thrive; siezure disorder admitted from OSH for
PICC placement and further eval of the above. Pt was in his
usual state of health at his nursing home until [**2132-10-20**] at
which time he developed a temperature of 102.7 and oxygen
saturation of 79 percent on room air. He was sent to the [**Hospital1 18**]
[**Location (un) 620**] for futher care. There, a CXR showed left lower lobe
infiltrate and 5 posterior left sided rib fracutres. By report,
pt had recently fallen backward twice at the nursing home. In
addition, he was being treated with clindamycin (since [**2132-10-10**])
and levofloxacin ([**2132-10-15**]) for a question of pneumonia.

MEDICAL HISTORY: 1. Traumatic brain injury s/p fall in [**2124**]
2. Peg tube placement in [**7-11**]
3. Trach placed in [**4-10**] for post-intubation subglottic tracheal
stenosis per [**Hospital1 2025**] records.  Currently has T-tube.
4. HIstory of DVT on coumadin with IVC filter
5. Multiple aspiration pneumonia
6. S/P multiple abdominal surgeries for hernia repair
7. Past seizure disorder
8. Anemia
9. History of fungemia

MEDICATION ON ADMISSION: Linezolid 600 mg [**Hospital1 **]
Ciprofloxacin 500 mg [**Hospital1 **]
Zoloft 100 mg po qd
Albuterol nebs q4h prn
Dilaudid prn
Prilosec 20 mg qd
Valproic acid (250 mg in 5 ml syrup) 15 cc qAM, 20 cc qpm

ALLERGIES: Penicillins / Morphine / Demerol

PHYSICAL EXAM: T: 96.6  BP: 127/50  P: 54  RR: 24, O2 sat 95% on 50% TC (pt
does not desaturate with nasal cannula, but just prefers not to
wear it)
Gen: awake, alert, sitting up in chair
Skin: warm and dry
HEENT: + copious secretions from tracheostomy
Heart: bradycardic, regular rhythm, no murmurs, rubs, or gallops
Lungs: coarse throughout, moving air much better on the left
Abd: soft, nontender, nondistended.  Ventral hernia nontender,
easily reducible.  +bs.
Ext: no edema, 2+ distal pulses bilaterally.

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: Married.  Polish immigrant (speaks some English).  Used to be a
heavy smoker.  Has been a nursing home resident for many years
since his TBI.  Has several children who are closely involved,
one daughter is a CCU nurse at [**Hospital3 **]. 

### Response:
{'Methicillin susceptible pneumonia due to Staphylococcus aureus,Closed fracture of five ribs,Other convulsions,Other emphysema,Pulmonary collapse,Fall from other slipping, tripping, or stumbling,Tracheostomy status'}
