CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
male with a past medical history of hypertension, atrial
fibrillation (status post pacemaker placement for symptomatic
bradycardia), obstructive sleep apnea, cor pulmonale, chronic
renal failure, and peripheral vascular disease who was
transferred from the Medical Intensive Care Unit to the floor
status post management of a hypercarbic respectively
decompensation.

MEDICAL HISTORY: 1.  Status post pituitary adenoma resection;
panhypopituitarism.
 2.  Paroxysmal atrial fibrillation.
 3.  Cor pulmonale.
 4.  Obstructive sleep apnea.
 5.  Asthma.
 6.  Chronic renal failure (with a baseline creatinine of 1.2
to 1.5).
 7.  Hypertension.
 8.  Status post pacemaker placement for symptomatic
bradycardia.
 9.  Benign prostatic hypertrophy.
10.  Peripheral vascular disease.
11.  Gastroesophageal reflux disease.
12.  Venous insufficiency.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient lives alone independently and is
capable of taking care of his activities of daily living.  He
denies alcohol and tobacco use.
Congestive heart failure, unspecified,Acidosis,Pneumonitis due to inhalation of food or vomitus,Panhypopituitarism,Atrial fibrillation,Acute kidney failure, unspecified,Mononeuritis of lower limb, unspecified,Hypotension, unspecified
CHF NOS,Acidosis,Food/vomit pneumonitis,Panhypopituitarism,Atrial fibrillation,Acute kidney failure NOS,Mononeuritis leg NOS,Hypotension NOS
Admission Date:  [**2166-3-26**]       Discharge Date:  [**2166-4-1**]


Service:  Medicine, [**Hospital1 139**] Firm

HISTORY OF PRESENT ILLNESS:  The patient is a [**Age over 90 **]-year-old
male with a past medical history of hypertension, atrial
fibrillation (status post pacemaker placement for symptomatic
bradycardia), obstructive sleep apnea, cor pulmonale, chronic
renal failure, and peripheral vascular disease who was
transferred from the Medical Intensive Care Unit to the floor
status post management of a hypercarbic respectively
decompensation.

The patient originally presented with knee pain on [**2166-3-26**].  He called Emergency Medical Service who found the
patient to be dyspneic and hypoxic with an oxygen saturation
of 70% on room air.

Of note, the patient had been complaining of increased lower
extremity edema and dysphagia for which he was seen in the
[**Hospital6 733**] Clinic on [**3-21**].

For his edema, the patient was told to double his Lasix dose.
His dysphagia was for solid foods, and the patient described
it as if "something was caught in my throat."  The patient
was referred for Ear/Nose/Throat and had a swallowing study
done on [**3-25**] (one day prior to admission) with a barium
esophagogram showing a nonspecific motor disorder of the
esophagus with one episode of aspiration.

In the Emergency Department, the patient's oxygen saturation
was 70% on room air and improved to 90% to 95% on a
nonrebreather.  His blood pressure was 96/50.  An arterial
blood gas revealed a pH of 7.41, a PCO2 of 46, and a PO2 of
98.  The patient did give a history of gradually increasing
dyspnea without chest pain.  His mental status deteriorated,
and he was only nodding to questions.  He received 40 mg of
intravenous Lasix, 120 mg of intravenously
methylprednisolone, albuterol and ipratropium nebulizers, and
aspirin 325 mg.

An electrocardiogram was done revealing ST elevations in
leads III and aVF and ST depressions in leads I and aVL.  He
was taken to the Cardiac Catheterization Laboratory and
catheterization showed clean coronary arteries.

In the Catheterization Laboratory, the patient developed
further deterioration of his mental status as well as
hypoxemia and respectively acidosis with an arterial blood
gas of 7.25/61/67.  He was placed on [**Hospital1 **]-level positive airway
pressure and transferred to the Medical Intensive Care Unit
for further management.

In the Medical Intensive Care Unit, the team felt that his
presentation was likely secondary to an aspiration event in
the setting of his lying flat in the Catheterization
Laboratory.  He was placed on levofloxacin and metronidazole
as well as [**Hospital1 **]-level positive airway pressure.  He was given
stress-dose steroids with intravenous hydrocortisone 50 mg
q.8h.  As of [**3-27**], the patient was off of [**Hospital1 **]-level positive
airway pressure since 4 a.m. and stable with an arterial
blood gas of 7.38/46/82.

PAST MEDICAL HISTORY:
 1.  Status post pituitary adenoma resection;
panhypopituitarism.
 2.  Paroxysmal atrial fibrillation.
 3.  Cor pulmonale.
 4.  Obstructive sleep apnea.
 5.  Asthma.
 6.  Chronic renal failure (with a baseline creatinine of 1.2
to 1.5).
 7.  Hypertension.
 8.  Status post pacemaker placement for symptomatic
bradycardia.
 9.  Benign prostatic hypertrophy.
10.  Peripheral vascular disease.
11.  Gastroesophageal reflux disease.
12.  Venous insufficiency.

MEDICATIONS ON TRANSFER:
 1.  Hydrocortisone 60 mg p.o. once per day.
 2.  Levofloxacin 250 mg p.o. every day.
 3.  Terazosin 5 mg p.o. q.h.s.
 4.  Levothyroxine 50 mcg p.o. once per day.
 5.  Albuterol as needed.
 6.  Amiodarone 200 mg p.o. once per day.
 7.  Protonix 40 mg p.o. once per day.
 8.  Regular insulin sliding-scale.
 9.  Flagyl 500 mg intravenously three times per day.
10.  Heparin 5000 units subcutaneously q.12h.

ALLERGIES:  No known drug allergies.

SOCIAL HISTORY:  The patient lives alone independently and is
capable of taking care of his activities of daily living.  He
denies alcohol and tobacco use.

PHYSICAL EXAMINATION ON PRESENTATION:  Physical examination
at the time of transfer revealed temperature was 96.1, blood
pressure was 114/49, heart rate was 60, respiratory rate was
25, and oxygen saturation was 95% on 5 liters nasal cannula.
In general, the patient was sitting upright in bed, in no
acute distress.  Head, eyes, ears, nose, and throat
examination revealed surgical pupils, 2 mm bilaterally.
Sclerae were anicteric.  The oral mucosa was moist.  The neck
was without lymphadenopathy and with normal jugular venous
pulsation.  Heart examination revealed a regular rate and
rhythm.  Normal first heart sounds and second heart sounds.
Distant heart sounds.  The lungs with occasional coarse
expiratory wheezes.  Fair air movement.  No rales.  The
abdomen was obese, soft, nontender, and nondistended.  Bowel
sounds were present in all four quadrants.  Extremity
examination revealed 1+ pitting lower extremity edema to the
knees bilaterally with venous stasis skin changes.
Neurologic examination revealed alert and oriented times
three.  Cranial nerves were grossly intact.  Extremities with
full range of motion.

PERTINENT LABORATORY VALUES ON PRESENTATION:  Laboratories on
transfer revealed white blood cell count was 13.9, hematocrit
was 36.7, and platelet count was 204.  Sodium was 145,
potassium was 3.4, chloride was 107, bicarbonate was 25,
blood urea nitrogen was 17, creatinine was 2.1, and blood
glucose was 170.  Calcium was 8.1, magnesium was 2, and
phosphate was 3.7.  Total bilirubin was 1.4 and direct
bilirubin was 0.4.  Creatine kinase was 104.  Troponin I was
0.5.  INR was 1.1 and partial thromboplastin time was 26.
Urinalysis revealed yellow/clear and small blood.  Negative
nitrites, ketones, bilirubin, leukocyte esterase, 30 mg/dL of
protein, 3 to 5 red blood cells, 0 to 2 white blood cells,
and a few bacteria.  Toxicology screen was negative for
aspirin, ethanol, acetaminophen, benzodiazepines,
barbiturates, and tricyclics.

PERTINENT RADIOLOGY/IMAGING:  A chest radiograph on [**3-26**]
revealed an increased density at the left base, right
hemidiaphragm less distinct, perihilar edema consistent with
heart failure.

A chest radiograph on [**3-27**] showed decreased heart failure,
no infiltrates, and decreased bibasilar atelectasis.

An echocardiogram on [**3-26**] was a suboptimal study with
normal left ventricular wall thickness and cavity size.  No
distinct wall motion abnormalities in the left ventricle.
The right ventricle was within normal limits.  Trace aortic
regurgitation.

Catheterization on [**3-26**] revealed no significant
obstructive disease.  No wall motion abnormalities.  Ejection
fraction was 60%.  Increased left ventricular end-diastolic
pressure at 17 mmHg.  Moderate pulmonary hypertension of 38
mmHg.

HOSPITAL COURSE BY ISSUE/SYSTEM:

1.  PULMONARY ISSUES:  Initially, after transfer from the
Medical Intensive Care Unit the patient continued to have a
4-liter to 5-liter of oxygen requirement to maintain his
oxygen saturation.  His episode of hypoxemia was felt to be
most likely secondary to an aspiration event followed by
flash pulmonary edema in the setting of diastolic cardiac
dysfunction.

With further diuresis, the patient's oxygen saturations were
improved and by [**4-1**] he was saturating greater than 92% on
room air.  His furosemide was held starting on the evening of
[**3-29**] because he started to appear hypovolemic on examination
with dry mucous membranes and poor skin turgor.

He received a video oropharyngeal swallowing study which
demonstrated an intact swallowing mechanism with no evidence
of aspiration.  A recommendation was made to avoid the use of
straws, however.

The patient continued to receive albuterol nebulizer
treatments while on the floor, and these were effective in
treating his episodic wheezing.

To rule out further heart failure, a chest radiograph was
obtained on [**3-31**] which demonstrated some bibasilar
atelectasis, but no evidence of heart failure.  The patient
was completing a 10-day course of levofloxacin and
metronidazole for aspiration pneumonia.

2.  LEG PAIN ISSUES:  The patient notably had persistent pain
in both his lower extremities below the knees throughout his
admission.  The legs were symmetrically slightly edematous
and tenderness to palpation anteriorly and posteriorly.
Lower extremity venous ultrasounds with Doppler studies were
obtained and revealed no deep venous thrombosis in either
lower extremity.

Given the patient's recent history of twisting his left
ankle, a plain film was obtained which revealed no evidence
of fracture or dislocation.

The patient described his pain as "tingling" as well as
"burning."  This was felt to be perhaps secondary to a
neuropathy; although the patient did not have known
conditions that would predispose to a neuropathy such as
diabetes.  Prior to discharge, the patient was empirically
started on low-dose gabapentin for treatment of presumed
neuropathy.

3.  RENAL ISSUES:  As aforementioned, at the time of transfer
from the Medical Intensive Care Unit, the patient had a
creatinine of 2.1.  His fractional excretion of sodium was
0.19%.  His acute-on-chronic renal failure was felt to be
secondary to prerenal azotemia in the setting of the
furosemide he was given as well as the dye load he received
in the Catheterization Laboratory.  Another condition of the
differential diagnosis was acute tubular necrosis secondary
to the dye load he received.

The patient maintained good urine output throughout his time
on the floor, and his creatinine improved to a level of 1.4
at the time of discharge.

4.  ENDOCRINE ISSUES:  The patient was continued on
hydrocortisone 60 mg once per day as well as levothyroxine
for his panhypopituitarism.  He had persistent mild
elevations in his fasting blood sugars which ranged between
150 and 200.  He received a regular insulin sliding-scale for
this.

DISCHARGE DIAGNOSES:
 1.  Status post aspiration event and heart failure
exacerbation in the setting of diastolic cardiac dysfunction.
 2.  Chronic renal failure; status post acute-on-chronic
renal failure.
 3.  Bilateral peripheral sensory neuropathy.
 4.  Hypoproliferative normocytic anemia of undetermined
etiology.
 6.  Panhypopituitarism.
 7.  Diffuse deconditioning.
 8.  Paroxysmal atrial fibrillation.
 9.  Hypertension.
10.  Chronic obstructive pulmonary disease.
11.  Cor pulmonale.
12.  History of pacemaker placement for symptomatic
bradycardia.
13.  Obstructive sleep apnea (requiring [**Hospital1 **]-level positive
airway pressure).
14.  Peripheral vascular disease.

CONDITION AT DISCHARGE:  Condition on discharge was fair.

DISCHARGE STATUS:   Discharge status was to [**Hospital3 94515**].

PRIMARY CARE PHYSICIAN:  [**Name10 (NameIs) **] patient's primary care physician
is [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] (telephone number [**Telephone/Fax (1) 250**]).

MEDICATIONS ON DISCHARGE:
 1.  Furosemide 40 mg p.o. q.a.m.
 2.  Gabapentin 100 mg p.o. q.h.s.
 3.  Albuterol nebulizer inhaled q.4-6h. as needed.
 4.  Atrovent nebulizer inhaled q.4-6h. as needed.
 5.  Vitamin D 400 units p.o. once per day.
 6.  Calcium carbonate 500 mg p.o. three times per day.
 7.  Flagyl 500 mg p.o. three times per day (through [**2166-4-4**]).
 8.  Levofloxacin 250 mg p.o. once per day (through [**2166-4-4**]).
 9.  Hydrocortisone 60 mg p.o. once per day.
10.  Terazosin 5 mg p.o. q.h.s.
11.  Levothyroxine 50 mcg p.o. once per day.
12.  Amiodarone 200 mg p.o. once per day.
13.  Protonix 40 mg p.o. once per day.
14.  Regular insulin sliding-scale.
15.  Heparin 5000 units subcutaneously q.12h.





                            [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D.  [**MD Number(1) 200**]

Dictated By:[**Last Name (NamePattern1) 5596**]
MEDQUIST36

D:  [**2166-4-1**]  15:13
T:  [**2166-4-1**]  15:37
JOB#:  [**Job Number 94516**]
{'Congestive heart failure, unspecified,Acidosis,Pneumonitis due to inhalation of food or vomitus,Panhypopituitarism,Atrial fibrillation,Acute kidney failure, unspecified,Mononeuritis of lower limb, unspecified,Hypotension, 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: 

PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
male with a past medical history of hypertension, atrial
fibrillation (status post pacemaker placement for symptomatic
bradycardia), obstructive sleep apnea, cor pulmonale, chronic
renal failure, and peripheral vascular disease who was
transferred from the Medical Intensive Care Unit to the floor
status post management of a hypercarbic respectively
decompensation.

MEDICAL HISTORY: 1.  Status post pituitary adenoma resection;
panhypopituitarism.
 2.  Paroxysmal atrial fibrillation.
 3.  Cor pulmonale.
 4.  Obstructive sleep apnea.
 5.  Asthma.
 6.  Chronic renal failure (with a baseline creatinine of 1.2
to 1.5).
 7.  Hypertension.
 8.  Status post pacemaker placement for symptomatic
bradycardia.
 9.  Benign prostatic hypertrophy.
10.  Peripheral vascular disease.
11.  Gastroesophageal reflux disease.
12.  Venous insufficiency.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient lives alone independently and is
capable of taking care of his activities of daily living.  He
denies alcohol and tobacco use. 

### Response:
{'Congestive heart failure, unspecified,Acidosis,Pneumonitis due to inhalation of food or vomitus,Panhypopituitarism,Atrial fibrillation,Acute kidney failure, unspecified,Mononeuritis of lower limb, unspecified,Hypotension, unspecified'}
