CHIEF COMPLAINT: altered MS, hypoxia

PRESENT ILLNESS: 81M w/ history of recent subdural hematoma s/p right sided
craniotomy/evacuation [**3-30**], chf thought secondary to MR/AR,
afib, aortic aneurysm, now being admitted to [**Hospital Unit Name **] for altered
mental status and hypoxia.
.
Recently discharged from [**Hospital1 18**] in late [**3-30**] after evaluation for
altered mental status and ultimate discovery of subdural
hematoma w/ subsequent evacuation of hematoma. Per OMR notes,
his mental status was back to baseline at time of discharge.
Also, he was found to have a UTI growing enterobacter and a
possible LLL pneumonia. He was treated with levofloxacin for a
short course.
.
At [**Hospital 100**] Rehab, he was in his USOH until late this morning when
he was noted to be delirious and had O2 sat of 88% on RA. He did
not appear to be in any respiratory distress, and the remainder
of his vitals were stable. He was then referred to the ED for
further evaluation.
.
In the ED, his initial vitals were T 101.2 BP 142/48 HR 85 RR 38
O2 sat 88%RA. He was oriented to self, pupils reactive, but he
was agitated, per ED notes. As pt became more agitated and less
responsive, he was given ativan 2mg iv and vecuronium 10mg iv x1
and intubated for airway protection. CXR taken to verify
position of ED tube revealed possible RML pna, and he was
treated empirically with levo/flagyl and vancomycin. However,
although this AP film was rotated, there was some concern
regarding possible aortic dissection - - he remained
hemodynamically stable, and his CXR was difficult to evaluate.
He also had a head CT w/o contrast to r/o ICH, edema, mass -
this showed residual hypodensity on the R subdural region. U/A
negative, EKG normal. He was then transferred to the [**Hospital Unit Name 153**] for
further management.

MEDICAL HISTORY: 1. CHF: [**2-27**] echo: mild symm LVH, EF 55% but likely
overestimation with degree of MR
2.  3+ mitral regurgitation
3. Atrial fibrillation
4. Ascending aortic aneurysm- [**11-27**] CTA: 5.7 x 5.4 cm stable
(pt. currently not interested in surgery)
5. DM2
6. Gout
7. Inflammatory Colitis (?)on chronic sulfasalazine.  No prior
surgeries or recent flares.
8. Hypertension
9. GERD
10. h/o Asbestosis
11. Recent B12 and Fe def. anemia

MEDICATION ON ADMISSION: Celexa 10 qd
Colace 100 [**Hospital1 **]
Combivent q6
Levoxyl 25mcg qd
Furosemide 40 qd
Senna
Colace
Protonix 40mg qd
Ferrous Sulfate 325 qd
metoprolol 50mg [**Hospital1 **]
seroquel 12.5mg qhs
ritalin 10mg qd
xanax

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 98.7 HR 85 BP 118/53 RR 14 O2 sat 100% on AC 450x14, FiO2
50% PEEP 5
Gen: sedated, intubated, NAD
Skin: warm, dry
HEENT: pupils reactive bilaterally, mucosa moist
Neck: elevated JVD
CV: RRR, no M/R/G
Pulm: CTA by anterior exam
Abd: soft, NT/ND, +BS
Ext: no pitting edema, 2+ DP pulses
Neuro: moving all extremities spontaneously

FAMILY HISTORY: no Alzhemer's or Parkinson's

SOCIAL HISTORY: Married, lives with wife, no prior [**Name (NI) **]/ETOH. Worked as a
salesman. h/o asbestosis exposure when in the service
(?shipyards).
Congestive heart failure, unspecified,Methicillin susceptible pneumonia due to Staphylococcus aureus,Unspecified pleural effusion,Acute respiratory failure,Infection with microorganisms resistant to penicillins,Atrial fibrillation,Mitral valve disorders,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other persistent mental disorders due to conditions classified elsewhere,Anemia, unspecified,Unspecified acquired hypothyroidism,Gout, unspecified,Depressive disorder, not elsewhere classified,Esophageal reflux,Abdominal aneurysm without mention of rupture
CHF NOS,Meth sus pneum d/t Staph,Pleural effusion NOS,Acute respiratry failure,Inf mcrg rstn pncllins,Atrial fibrillation,Mitral valve disorder,Hypertension NOS,DMII wo cmp nt st uncntr,Mental disor NEC oth dis,Anemia NOS,Hypothyroidism NOS,Gout NOS,Depressive disorder NEC,Esophageal reflux,Abdom aortic aneurysm
Admission Date:  [**2119-5-12**]              Discharge Date:   [**2119-5-19**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 905**]
Chief Complaint:
altered MS, hypoxia

Major Surgical or Invasive Procedure:
intubation
arterial line placement
lumbar puncture

History of Present Illness:
81M w/ history of recent subdural hematoma s/p right sided
craniotomy/evacuation [**3-30**], chf thought secondary to MR/AR,
afib, aortic aneurysm, now being admitted to [**Hospital Unit Name **] for altered
mental status and hypoxia.
.
Recently discharged from [**Hospital1 18**] in late [**3-30**] after evaluation for
altered mental status and ultimate discovery of subdural
hematoma w/ subsequent evacuation of hematoma. Per OMR notes,
his mental status was back to baseline at time of discharge.
Also, he was found to have a UTI growing enterobacter and a
possible LLL pneumonia. He was treated with levofloxacin for a
short course.
.
At [**Hospital 100**] Rehab, he was in his USOH until late this morning when
he was noted to be delirious and had O2 sat of 88% on RA. He did
not appear to be in any respiratory distress, and the remainder
of his vitals were stable. He was then referred to the ED for
further evaluation.
.
In the ED, his initial vitals were T 101.2 BP 142/48 HR 85 RR 38
O2 sat 88%RA. He was oriented to self, pupils reactive, but he
was agitated, per ED notes. As pt became more agitated and less
responsive, he was given ativan 2mg iv and vecuronium 10mg iv x1
and intubated for airway protection. CXR taken to verify
position of ED tube revealed possible RML pna, and he was
treated empirically with levo/flagyl and vancomycin. However,
although this AP film was rotated, there was some concern
regarding possible aortic dissection - - he remained
hemodynamically stable, and his CXR was difficult to evaluate.
He also had a head CT w/o contrast to r/o ICH, edema, mass -
this showed residual hypodensity on the R subdural region. U/A
negative, EKG normal. He was then transferred to the [**Hospital Unit Name 153**] for
further management.


Past Medical History:
1. CHF: [**2-27**] echo: mild symm LVH, EF 55% but likely
overestimation with degree of MR
2.  3+ mitral regurgitation
3. Atrial fibrillation
4. Ascending aortic aneurysm- [**11-27**] CTA: 5.7 x 5.4 cm stable
(pt. currently not interested in surgery)
5. DM2
6. Gout
7. Inflammatory Colitis (?)on chronic sulfasalazine.  No prior
surgeries or recent flares.
8. Hypertension
9. GERD
10. h/o Asbestosis
11. Recent B12 and Fe def. anemia

Social History:
Married, lives with wife, no prior [**Name (NI) **]/ETOH. Worked as a
salesman. h/o asbestosis exposure when in the service
(?shipyards).


Family History:
no Alzhemer's or Parkinson's

Physical Exam:
VS: T 98.7 HR 85 BP 118/53 RR 14 O2 sat 100% on AC 450x14, FiO2
50% PEEP 5
Gen: sedated, intubated, NAD
Skin: warm, dry
HEENT: pupils reactive bilaterally, mucosa moist
Neck: elevated JVD
CV: RRR, no M/R/G
Pulm: CTA by anterior exam
Abd: soft, NT/ND, +BS
Ext: no pitting edema, 2+ DP pulses
Neuro: moving all extremities spontaneously

Physical Exam Upon transfer to floor:
-VS: Tmax 98.2 HR 86-105 irreg irreg, BP 101/52 (SBP range
101-153), RR 15-22, O2 sat 100% on RA
-Gen: elderly M in NAD
-Skin: old surgical scars on head; o/w C/D/I; no rashes
appreciated
-HEENT: OP clear, MMM, EOMI, PERRLA
-Neck: JVD to mid-neck at 45 degrees
-CV: S1S2, RRR, no M/R/G
-Pulm: CTA anteriorly
-Abd: soft, NT, ND, NABS
-Ext: thin, no edema, 2+ DP pulses
-Neuro: A&Ox2 (person & "[**Hospital1 **]"), fluent speech, follows commands

Pertinent Results:
CT chest w/o contrast [**5-12**]:
1. CHF with large bilateral pleural effusions.
2. Noncalcified bilateral pulmonary nodules.
3. Right middle lobe consolidation, worrisome for pneumonia.
4. Ascending aorta measures 4.9 x 4.9 cm.
5. Calcified pleural plaques indicative of asbestosis exposure.

CXR AP [**5-12**] (#1):
Endotracheal tube in a standard position. Moderate congestive
heart failure with bilateral pleural effusions.

CT head w/o contrast [**5-12**]:
Persistent small hypodense subdural collection over the right
cerebral hemisphere. No evidence of mass effect, shift of
normally midline structures, or acute hemorrhage.

CXR AP [**5-12**] (#2):
1. ETT at top level of clavicles with room for advancement.
2. Possible right mid lung opacity for which a nonrotated
radiograph would provide further evaluation.

Sputum culture with MRSA sensitive to vancomycin

Brief Hospital Course:
81M w/recent subdural hematoma s/p evacuation in [**3-30**], CHF,
Afib, aortic aneurysm, initially admitted to [**Hospital Unit Name 153**] for altered
mental status and hypoxia. Found to be fluid overloaded & have
MRSA in sputum. Was intubated in ED, now stable on RA.

# Previous hypoxia: most likely combination of PNA & fluid
overload. BNP >30,000 in ED. Was intubated for tachypnea &
airway protection during agitated state. Diuresed with lasix and
pt was extubated successfully on [**5-16**]. Pt was weaned to room
air with further gentle diuresis.

# CHF: last echo ([**2119-4-3**]) w/EF >55%, 2+ MR, mod AR. Fluid
overloaded at admission as above. No EKG changes, CK-MB flat @
admission w/TropT slightly elevated but stable (likely related
to infection and increase HR).  Remained stable on ACE-I,
Bblocker, and PO lasix 40 daily.

# PNA: seen on CT in right middle lobe. No leukocytosis or high
fevers. Sputum grew MRSA ([**5-12**] & [**5-14**]), sensitive to vanco.
Respir status stable on RA within 24 hours of extubation. Plan
10 day course of vancomycin (started [**2119-5-16**]).

# Pleural effusions: thoracentesis done on [**5-13**] for evaluation
for infectious source revealed transudative fluid (pH 7.4, LDH
100, total protein 1.9), likely from congestive heart failure.

# Mental Status: agitated at admission, most likely related to
infection and acute illness. Also likely continued worsening
baseline dementia. Repeat CT showed small amount of residual
hypodensity over the R hemisphere, but no evidence of acute
hemorrhage. LP on [**2119-5-13**] showed 3 WBC. Apparently also had
recent changes in meds, including higher ritalin dose & starting
xanax. After extubation, pt's mental status remained stable.
Neuro consult followed patient & thought his mental status was
at recent baseline. Did not restart ritalin or Xanax.

# Subdural hematoma: no signif recurrance on head CT. Pt was
continued on Keppra for seizure prophylaxis post-craniotomy but
this was weaned slightly as it can cause agitation. Could
continue to wean by 250 mg q3days if pt becomes agitated. Plan
to continue this medication until neurology or neurosurgical
follow-up.

# AAA: ascending; measured >5cm in [**11-27**] & pt refused surgical
intervention at that time. There was question of widened
mediastinum on CXR in [**Hospital Unit Name 153**] but CT chest showed stable size.

# CRI: stable at baseline (creatinine 1.2-1.6)

# Paroxysmal Afib: remained rate-controlled on metoprolol.
Anticoagulation with warfarin was not used given recent subdural
hematoma and h/o frequent falls.

# DM2: remained stable. Pt was covered with RISS. Diabetic diet.

# Elevated LFTs @ admission: resolved. Pt dose have history of
hepatotoxicity due to dilantin. AST elevated at admission, but
remainder of liver enzymes normal. AST normalized within 1 day
of admission. No further S/Sx of liver dz during this
hospitalization.

# Anemia: iron studies most c/w chronic dz (ferritin 86). Hct
stable. Cont ferrous sulfate.
# Hypothyroidism: clinically euthyroid. Synthroid was continued
at home dose.
# Depression: remained stable. Celexa was continued @ home dose.
# FEN: tolerated POs well
# Prophylaxis: maintained on Protonix & pneumoboots
# Communication: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (daughter) [**Telephone/Fax (1) 15217**]
# Code: DNR/I, confirmed with family & ICU team

Medications on Admission:
Celexa 10 qd
Colace 100 [**Hospital1 **]
Combivent q6
Levoxyl 25mcg qd
Furosemide 40 qd
Senna
Colace
Protonix 40mg qd
Ferrous Sulfate 325 qd
metoprolol 50mg [**Hospital1 **]
seroquel 12.5mg qhs
ritalin 10mg qd
xanax


Discharge Medications:
1. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
5. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Ascorbic Acid 250 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO DAILY (Daily).
8. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram
Intravenous  Q 12H (Every 12 Hours) for 7 days.
9. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 2558**] - [**Location (un) **]

Discharge Diagnosis:
congestive heart failure
pneumonia
dementia
stable subdural hematoma


Discharge Condition:
medically stable; mental status stable


Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2 liters per day
Take all medications as directed

Followup Instructions:
--follow-up with your primary care physician (Dr. [**Last Name (STitle) 3649**] within 1
month

--follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6817**] of behavioral neurology
([**Telephone/Fax (1) 1690**]) within 1 month


                             [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

Completed by:[**2119-5-19**]
{'Congestive heart failure, unspecified,Methicillin susceptible pneumonia due to Staphylococcus aureus,Unspecified pleural effusion,Acute respiratory failure,Infection with microorganisms resistant to penicillins,Atrial fibrillation,Mitral valve disorders,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other persistent mental disorders due to conditions classified elsewhere,Anemia, unspecified,Unspecified acquired hypothyroidism,Gout, unspecified,Depressive disorder, not elsewhere classified,Esophageal reflux,Abdominal aneurysm without mention of rupture'}


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: altered MS, hypoxia

PRESENT ILLNESS: 81M w/ history of recent subdural hematoma s/p right sided
craniotomy/evacuation [**3-30**], chf thought secondary to MR/AR,
afib, aortic aneurysm, now being admitted to [**Hospital Unit Name **] for altered
mental status and hypoxia.
.
Recently discharged from [**Hospital1 18**] in late [**3-30**] after evaluation for
altered mental status and ultimate discovery of subdural
hematoma w/ subsequent evacuation of hematoma. Per OMR notes,
his mental status was back to baseline at time of discharge.
Also, he was found to have a UTI growing enterobacter and a
possible LLL pneumonia. He was treated with levofloxacin for a
short course.
.
At [**Hospital 100**] Rehab, he was in his USOH until late this morning when
he was noted to be delirious and had O2 sat of 88% on RA. He did
not appear to be in any respiratory distress, and the remainder
of his vitals were stable. He was then referred to the ED for
further evaluation.
.
In the ED, his initial vitals were T 101.2 BP 142/48 HR 85 RR 38
O2 sat 88%RA. He was oriented to self, pupils reactive, but he
was agitated, per ED notes. As pt became more agitated and less
responsive, he was given ativan 2mg iv and vecuronium 10mg iv x1
and intubated for airway protection. CXR taken to verify
position of ED tube revealed possible RML pna, and he was
treated empirically with levo/flagyl and vancomycin. However,
although this AP film was rotated, there was some concern
regarding possible aortic dissection - - he remained
hemodynamically stable, and his CXR was difficult to evaluate.
He also had a head CT w/o contrast to r/o ICH, edema, mass -
this showed residual hypodensity on the R subdural region. U/A
negative, EKG normal. He was then transferred to the [**Hospital Unit Name 153**] for
further management.

MEDICAL HISTORY: 1. CHF: [**2-27**] echo: mild symm LVH, EF 55% but likely
overestimation with degree of MR
2.  3+ mitral regurgitation
3. Atrial fibrillation
4. Ascending aortic aneurysm- [**11-27**] CTA: 5.7 x 5.4 cm stable
(pt. currently not interested in surgery)
5. DM2
6. Gout
7. Inflammatory Colitis (?)on chronic sulfasalazine.  No prior
surgeries or recent flares.
8. Hypertension
9. GERD
10. h/o Asbestosis
11. Recent B12 and Fe def. anemia

MEDICATION ON ADMISSION: Celexa 10 qd
Colace 100 [**Hospital1 **]
Combivent q6
Levoxyl 25mcg qd
Furosemide 40 qd
Senna
Colace
Protonix 40mg qd
Ferrous Sulfate 325 qd
metoprolol 50mg [**Hospital1 **]
seroquel 12.5mg qhs
ritalin 10mg qd
xanax

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 98.7 HR 85 BP 118/53 RR 14 O2 sat 100% on AC 450x14, FiO2
50% PEEP 5
Gen: sedated, intubated, NAD
Skin: warm, dry
HEENT: pupils reactive bilaterally, mucosa moist
Neck: elevated JVD
CV: RRR, no M/R/G
Pulm: CTA by anterior exam
Abd: soft, NT/ND, +BS
Ext: no pitting edema, 2+ DP pulses
Neuro: moving all extremities spontaneously

FAMILY HISTORY: no Alzhemer's or Parkinson's

SOCIAL HISTORY: Married, lives with wife, no prior [**Name (NI) **]/ETOH. Worked as a
salesman. h/o asbestosis exposure when in the service
(?shipyards). 

### Response:
{'Congestive heart failure, unspecified,Methicillin susceptible pneumonia due to Staphylococcus aureus,Unspecified pleural effusion,Acute respiratory failure,Infection with microorganisms resistant to penicillins,Atrial fibrillation,Mitral valve disorders,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other persistent mental disorders due to conditions classified elsewhere,Anemia, unspecified,Unspecified acquired hypothyroidism,Gout, unspecified,Depressive disorder, not elsewhere classified,Esophageal reflux,Abdominal aneurysm without mention of rupture'}
