CHIEF COMPLAINT: Shortness of breath, fever, hypoxia to 80% on RA.

PRESENT ILLNESS: 84 yo woman with dementia at [**Doctor Last Name **] presented to ED [**2154-6-10**] with
fever to 101, cough and hypoxia to 80s on RA. On arrival in the
ED VS: 97.5 127/61 107 30 80% RA BG 260. The ED confirmed full
code with family given dementia, so proceeded with intubation
out of concern for airway protection more than hypoxia. 1 hour
after intubation she was itnermitently hypoensive to 50s
systolic (?versed related) so a central line was placed and she
was started on minimal levophed (on arrival 0.06 mcg/kg/min).
She was given zosyn 4.5gm/vanco 1gm/levaquin 750mg iv, versed
2mg iv and got a CT torso/head. She was given total 3L NS. CVP
noted to be 16-19, her ekg showed STEMI in V2-V3 with tn of 0.12
so cardiology was consulted, no cath at this time, no heparin.
Cardiology did bedside TTE: Normal LV function, no WMA.

MEDICAL HISTORY: dementia: alzheimer's disease
hypertension
rectal surgery?

MEDICATION ON ADMISSION: lisinopril 5 daily
aspirin 81mg daily
memantine 10mg [**Hospital1 **]
razadyne ER 16mg daily
risperdal 0.5mg qhs
toprol xl 50mg daily
vitamin E 1,000u twice daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T: 97.1 BP 107/54 HR 82 RR 16 Sat 100% on AC 500/15/.[**5-11**]
GEN: NAD, intubated, responds to name, grimaces to pain, does
not follow commands
HEENT: AT, NC, PERRLA 4->3mm B, no conjuctival injection,
anicteric, OP clear, MMM
Neck: supple, no LAD, no carotid bruits, JVP to angle of jaw
CV: RRR, nl s1, s2, no m/r/g
PULM: diffusely rhonchorus throughout, rales left base
ABD: soft, NT, ND, + BS, no HSM
EXT: cool LE, dry, +2 distal pulses BL, trace B edema
NEURO: 1+ DTR's patellar, biceps, triceps, bracioradialis
bilaterally, grimaces to pain, conjugate gaze, PERRL

FAMILY HISTORY: Unknown.

SOCIAL HISTORY: Lives in [**Hospital3 **] in [**Location (un) **]: [**Telephone/Fax (1) 17732**], long-standing
dementia, thought to be Alzheimer's. Per children was out with
them to lunch last week, gets assistance with ADL's/iADL's and
has short term memory deficits but still very interactive, no
difficulty with aspiration when eating. No history of tobacco
use, etoh, or illicit drug use.
Unspecified septicemia,Acute respiratory failure,Dementia in conditions classified elsewhere with behavioral disturbance,Acute kidney failure, unspecified,Shock, unspecified,Pneumonia, organism unspecified,Subendocardial infarction, initial episode of care,Hyperosmolality and/or hypernatremia,Alzheimer's disease,Hypoxemia,Unspecified essential hypertension,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Severe sepsis,Atrial fibrillation,Other and unspecified complications of medical care, not elsewhere classified,Congestive heart failure, unspecified
Septicemia NOS,Acute respiratry failure,Dementia w behavior dist,Acute kidney failure NOS,Shock NOS,Pneumonia, organism NOS,Subendo infarct, initial,Hyperosmolality,Alzheimer's disease,Hypoxemia,Hypertension NOS,Cholelithiasis NOS,Severe sepsis,Atrial fibrillation,Complic med care NEC/NOS,CHF NOS
Admission Date:  [**2154-6-10**]              Discharge Date:   [**2154-7-5**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Shortness of breath, fever, hypoxia to 80% on RA.

Major Surgical or Invasive Procedure:
Endotracheal intubation
Central venous line placement


History of Present Illness:
84 yo woman with dementia at [**Doctor Last Name **] presented to ED [**2154-6-10**] with
fever to 101, cough and hypoxia to 80s on RA. On arrival in the
ED VS: 97.5 127/61 107 30 80% RA BG 260. The ED confirmed full
code with family given dementia, so proceeded with intubation
out of concern for airway protection more than hypoxia. 1 hour
after intubation she was itnermitently hypoensive to 50s
systolic (?versed related) so a central line was placed and she
was started on minimal levophed (on arrival 0.06 mcg/kg/min).
She was given zosyn 4.5gm/vanco 1gm/levaquin 750mg iv, versed
2mg iv and got a CT torso/head. She was given total 3L NS. CVP
noted to be 16-19, her ekg showed STEMI in V2-V3 with tn of 0.12
so cardiology was consulted, no cath at this time, no heparin.
Cardiology did bedside TTE: Normal LV function, no WMA.

ROS: Per children she c/o fatigue on saturday, was noted to
frequently clear her throat recently, but no other complaints
specifically.


Past Medical History:
dementia: alzheimer's disease
hypertension
rectal surgery?


Social History:
Lives in [**Hospital3 **] in [**Location (un) **]: [**Telephone/Fax (1) 17732**], long-standing
dementia, thought to be Alzheimer's. Per children was out with
them to lunch last week, gets assistance with ADL's/iADL's and
has short term memory deficits but still very interactive, no
difficulty with aspiration when eating. No history of tobacco
use, etoh, or illicit drug use.

Family History:
Unknown.

Physical Exam:
VS: T: 97.1 BP 107/54 HR 82 RR 16 Sat 100% on AC 500/15/.[**5-11**]
GEN: NAD, intubated, responds to name, grimaces to pain, does
not follow commands
HEENT: AT, NC, PERRLA 4->3mm B, no conjuctival injection,
anicteric, OP clear, MMM
Neck: supple, no LAD, no carotid bruits, JVP to angle of jaw
CV: RRR, nl s1, s2, no m/r/g
PULM: diffusely rhonchorus throughout, rales left base
ABD: soft, NT, ND, + BS, no HSM
EXT: cool LE, dry, +2 distal pulses BL, trace B edema
NEURO: 1+ DTR's patellar, biceps, triceps, bracioradialis
bilaterally, grimaces to pain, conjugate gaze, PERRL


Pertinent Results:
Admission labs:
[**Age over 90 **]|98|35 AG 9
-----------<279
4.3|34|1.1

estGFR: 47/57 (click for details)
CK: 100 MB: 7 Trop-T: 0.12
ALT: 140 AP: 122 Tbili: 0.4 AST: 162
13.4
7.4>--<200
40.5
N:75 Band:7 L:7 M:10 E:0 Bas:0 Myelos: 1
central venous o2 sat 96
PT: 12.5 PTT: 26.6 INR: 1.1

Micro:
blood cx [**6-10**] x4, no growth
stool cx [**6-10**] negative
urine culture negative
urine legionella antigen neg
sputum no growth [**6-10**], [**6-11**]

CXR PA and lat [**6-10**] FINAL: Hyperinflation with bilateral
hemidiaphragm flattening is not changed in appearance. No
effusion, consolidation or other opacity is identified within
the lungs. The aortic arch again demonstrates calcifications,
and there is no change in appearance of thoracic kyphosis with
vertebral body wedging.
.
ECG [**2154-6-10**]: Sinus tach (103), nl axis, nl intervals, 1mm ST
elevation V2-V3, Q III, TWI III, 1mm STE III, TW flattening aVF
(new). Improved on subsequent ECG's with slower rate.

CTA Chest, CT torso [**6-10**]: 1. No evidence of PE or thoracic or
abdominal aortic aneurysm.
2. No evidence of intra-abdominal abscess.
3. Some delay of passage of contrast from the great vessels,
which may represent pulmonary edema.
4. There is emphysema bilaterally. There is some atelectasis at
the bases.
5. There is a large non-obstructing gallstone in the
gallbladder.

CT Head [**6-10**]: 1. No evidence of infarction or hemorrhage. 2.
Likely chronic right maxillary sinusitis.

MRI Head ([**6-30**]):
1. No acute infarction.
2. Moderately extensive bilateral white matter FLAIR
hyperintense areas likely representing sequelae of chronic small
vessel occlusive disease, increased since [**2149**].
3. Patent major intracranial arteries, without focal
flow-limiting stenosis, occlusion, or aneurysm more than 3 mm,
within the resolution of MR angiogram.
4. Moderate diffusely increased signal, in the mastoid air
cells, representing fluid versus mucosal thickening.


Brief Hospital Course:
A/P: Mrs. [**Known lastname 12347**] is an 84F w/PMH dementia who initially
presented with fever, hypoxic respiratory failure, transient
hypotension, transaminitis, ARF and NSTEMI admitted to the
intensive care unit and intubated for respiratory distress. Her
course was complicated by NSTEMI, transaminitis and ARF, all of
which thought to be secondary to hypotensive shock in the
setting of sepsis. Patients mental status remained poor and
neurology as well as geriatric services were involved in
evaluation and treatment of her condition. All her psychotropic
medications were held (memantine, razadyne, risperdal) and her
mental status significantly improved. She remained alert and
cooperative, however with some confusion which remained stable.
.
Hospital course by problem:
.
.
# Pneumonia/Septic shock/VAP: Respiratory failure on admission
due to pneumonia in the setting of fever, cough, RLL infiltrate.
Course complicated by ventilator associated PNA. She had BAL on
[**2154-6-16**], no microorg identified. Levophed briefly required for
significant hypotension post intubation.  Vancomycin was d/c'd
[**6-19**] and she completed 10 day course of levofloxacin on [**6-20**] and
8 days of zosyn on [**6-23**]. She has completed all of her abx
courses.
.
# Respiratory failure:- Initially requiring intubation as above.
 Patient with pneumonia as above.  Respiratory status also
complicated by a component of pulmonary edema after aggressive
fluid resuscitation in the setting of sepsis. She was extubated
[**6-18**]. No formal diagnosis of COPD but emphysema on CXR, airway
resistance.  Once on the floor, she again required MICU transfer
due to hypercarbic respiratory failure and somnolence, likely
due to a combination of pulmonary edema, mucous plugging, and
oversedation. Now with good respiratory function on RA (O2Sat
97-100%)

.
# Paroxysmal Atrial fibrillation: She has been in and out of
Afib with RVR, rate to 150's since her admission. Seems to be
triggered by hypoxic episodes as above as well as by albuterol
neb treatments. CHADS2 score [**3-10**]. Afib seems also to trigger
pulm edema.  Albuterol/xopenex held.  Metoprolol uptitrated
significantly with improved rate control. Aspirin continued.
.
# ARF: Baseline creatinine 0.5, ARF on admission most likely due
to hypovolemia/pre-renal in setting of acute illness. Creatinine
came down and normalized. Lisinopril can be resumed in Rehab
with lower dose (2.5) and monitoring of renal function.
.
# Delirium/Dementia: Baseline dementia with intermittent
agitated delirium in the setting of acute illness and infection.
During her ICU stay she was tried on haldol with no effect,
zyprexa with short lasting effect, seroquel with best effect.
Memantine and razadyne restarted but pt became somnolent, hence
all psychotropic were held.  Geriatrics was consulted for
recommendations for behavioral control. Required 1:1 sitter at
times for safety.  Her post-discharge agitation plan includes
use of 0.25 mg haldol prn.
.
# NSTEMI: Troponin bump up to 0.12 with CK/CKMB not elevated,
most likely demand ischemia in the setting of relative
hypoperfusion from septic shock. Managed medically.  Aspirin,
statin, beta blocker continued and cardiology followed.  Stress
test as outpatient can be considered.   TTE initially showed
severe hypokinesis of the distal half of the inferior wall which
subsequently appeared to resolve on echo during MICU stay. Again
ruled out for MI with most recent episode of resp distress
requiring MICU transfer.
.
# FEN: seen by speech and swallow, approved for nectar thickened
liquids and ground solids, thin liqids between meals only,
replete lytes prn, speech and swallow re-eval in Rehab to clear
pt for solids.
.
# CODE: DNR, intubation okay.
.
# COMMUNICATION: Patient, son [**Name (NI) **] [**Name (NI) 12347**] (c) [**Telephone/Fax (1) 17733**]
(h)[**Telephone/Fax (1) 17734**] and daughter [**Name (NI) **] (c) [**Telephone/Fax (1) 17735**] and (h) [**Telephone/Fax (1) 17736**]-5400 (co-HCP's).


Medications on Admission:
lisinopril 5 daily
aspirin 81mg daily
memantine 10mg [**Hospital1 **]
razadyne ER 16mg daily
risperdal 0.5mg qhs
toprol xl 50mg daily
vitamin E 1,000u twice daily


Discharge Medications:
1. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Acetaminophen 160 mg/5 mL Solution Sig: One (1) Acetaminophen
(Oral) 160 mg/5 mL Solution PO Q6H (every 6 hours) as needed.
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
Two (2) puffs Inhalation [**Hospital1 **] (2 times a day).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
11. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day).
12. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation Q6H (every 6 hours) as needed.
13. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.



Discharge Disposition:
Extended Care

Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]

Discharge Diagnosis:
Septis
Respiratory failure
.
Ventilator associated pneumonia
Non ST elevation myocardial infarction
Agitation
Dementia
Afib with rapid ventricular response
COPD
Acute renal failure


Discharge Condition:
Stable


Discharge Instructions:
You were admitted with severe pneumonia and respiratory
difficulties with acute mental status changes.  We treated you
with antibiotics and you required a stay in the intensive care
unit. Your hospital course was complicated by mild myocardial
infarction (heart attack) and renal failure which recovered.
.
We changed and stopped some of you medication (see instructions
below).
.
Please return to the hospital or call your doctor if you or your
caregivers notice fever >101, further breathing difficulties,
agitation or difficult to control behavior, fast heart rate,
chest pain, or any new symptoms that you are concerned about.
.
Since you were admitted we have made the following changes to
your medications:
*

Followup Instructions:
Please see your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 311**], within 2
weeks of discharge.





Name:  [**Known lastname 2834**],[**Known firstname **]                  Unit No:   [**Numeric Identifier 2835**]

Admission Date:  [**2154-6-10**]              Discharge Date:   [**2154-7-5**]

Date of Birth:  [**2070-1-10**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1775**]
Addendum:
In the morning of her discharge patient's O2 saturation was
measurde to be 87% on room air, and increased with 2L O2 NC to
97%.
She had no respiratory complains.
On exam she had increase in bilateral crackles, and appeared
mildly volume overloaded. She was given 20 mg of IV Furosemide.
Her O2 saturation improved to 92% on room air, and she is being
discharged without supplemental O2 requirement.

Discharge Disposition:
Extended Care

Facility:
[**Hospital **] [**Hospital 345**] Nursing Home - [**Location (un) **]

                             [**First Name11 (Name Pattern1) 1034**] [**Last Name (NamePattern1) 1778**] MD [**MD Number(2) 1779**]

Completed by:[**2154-7-5**]
{"Unspecified septicemia,Acute respiratory failure,Dementia in conditions classified elsewhere with behavioral disturbance,Acute kidney failure, unspecified,Shock, unspecified,Pneumonia, organism unspecified,Subendocardial infarction, initial episode of care,Hyperosmolality and/or hypernatremia,Alzheimer's disease,Hypoxemia,Unspecified essential hypertension,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Severe sepsis,Atrial fibrillation,Other and unspecified complications of medical care, not elsewhere classified,Congestive heart failure, 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: Shortness of breath, fever, hypoxia to 80% on RA.

PRESENT ILLNESS: 84 yo woman with dementia at [**Doctor Last Name **] presented to ED [**2154-6-10**] with
fever to 101, cough and hypoxia to 80s on RA. On arrival in the
ED VS: 97.5 127/61 107 30 80% RA BG 260. The ED confirmed full
code with family given dementia, so proceeded with intubation
out of concern for airway protection more than hypoxia. 1 hour
after intubation she was itnermitently hypoensive to 50s
systolic (?versed related) so a central line was placed and she
was started on minimal levophed (on arrival 0.06 mcg/kg/min).
She was given zosyn 4.5gm/vanco 1gm/levaquin 750mg iv, versed
2mg iv and got a CT torso/head. She was given total 3L NS. CVP
noted to be 16-19, her ekg showed STEMI in V2-V3 with tn of 0.12
so cardiology was consulted, no cath at this time, no heparin.
Cardiology did bedside TTE: Normal LV function, no WMA.

MEDICAL HISTORY: dementia: alzheimer's disease
hypertension
rectal surgery?

MEDICATION ON ADMISSION: lisinopril 5 daily
aspirin 81mg daily
memantine 10mg [**Hospital1 **]
razadyne ER 16mg daily
risperdal 0.5mg qhs
toprol xl 50mg daily
vitamin E 1,000u twice daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T: 97.1 BP 107/54 HR 82 RR 16 Sat 100% on AC 500/15/.[**5-11**]
GEN: NAD, intubated, responds to name, grimaces to pain, does
not follow commands
HEENT: AT, NC, PERRLA 4->3mm B, no conjuctival injection,
anicteric, OP clear, MMM
Neck: supple, no LAD, no carotid bruits, JVP to angle of jaw
CV: RRR, nl s1, s2, no m/r/g
PULM: diffusely rhonchorus throughout, rales left base
ABD: soft, NT, ND, + BS, no HSM
EXT: cool LE, dry, +2 distal pulses BL, trace B edema
NEURO: 1+ DTR's patellar, biceps, triceps, bracioradialis
bilaterally, grimaces to pain, conjugate gaze, PERRL

FAMILY HISTORY: Unknown.

SOCIAL HISTORY: Lives in [**Hospital3 **] in [**Location (un) **]: [**Telephone/Fax (1) 17732**], long-standing
dementia, thought to be Alzheimer's. Per children was out with
them to lunch last week, gets assistance with ADL's/iADL's and
has short term memory deficits but still very interactive, no
difficulty with aspiration when eating. No history of tobacco
use, etoh, or illicit drug use. 

### Response:
{"Unspecified septicemia,Acute respiratory failure,Dementia in conditions classified elsewhere with behavioral disturbance,Acute kidney failure, unspecified,Shock, unspecified,Pneumonia, organism unspecified,Subendocardial infarction, initial episode of care,Hyperosmolality and/or hypernatremia,Alzheimer's disease,Hypoxemia,Unspecified essential hypertension,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Severe sepsis,Atrial fibrillation,Other and unspecified complications of medical care, not elsewhere classified,Congestive heart failure, unspecified"}
