CHIEF COMPLAINT: Hypertension.

PRESENT ILLNESS: (MICU Green Service)  This is a
78 year old woman with a history of congestive heart failure,
diastolic dysfunction, restrictive lung disease, who was in
her usual state of health until the afternoon of admission
when she woke up with mental status changes, increasing
lethargy, and abdominal discomfort.  The patient was noted to
be clammy and afebrile on arrival to the Emergency
Department.

MEDICAL HISTORY: 1.  Congestive heart failure, diastolic dysfunction with an
ejection fraction greater than 70%.
2.  Restrictive lung disease, FVC 0.6, 49% of predicted, FEV1
82% of predicted, FEV1/FVC ratio 69% of predicted.
3.  Hypertension.
4.  Gastroesophageal reflux disease.
5.  Hyperlipidemia.
6.  Mitral regurgitation.
7.  Chronic renal insufficiency with a baseline creatinine of
1.3.
8.  Degenerative joint disease/arthritis.
9.  Iron deficiency anemia.
10. History of breast cancer.
11. Urinary incontinence.
12. Osteoporosis.
13. Diverticulosis.
14. History of right sided hiatal hernia.

MEDICATION ON ADMISSION: 1.  Fosamax 70 mg q.week.
2.  TUMS 500 mg three times a day.
3.  Protonix 40 mg once daily.
4.  [**Doctor First Name **] 60 mg twice a day.
5.  Lasix 80 mg p.o. twice a day.
6.  Milk of Magnesia.
7.  Lipitor 10 mg q.h.s.
8.  Colace 100 mg twice a day.
9.  Enteric Coated Aspirin 81 mg once daily.
10. Atenolol 25 mg twice a day.
11. Tylenol.
12. Flovent.

ALLERGIES: Verapamil.

PHYSICAL EXAM: 

FAMILY HISTORY: Significant for pulmonary embolus.

SOCIAL HISTORY: The patient lives alone in [**Hospital3 **].
No history of tobacco and no history of alcohol.
Pneumonia, organism unspecified,Congestive heart failure, unspecified,Mitral valve disorders,Acute respiratory failure,Acidosis,Bacteremia,Cellulitis and abscess of leg, except foot,Acute kidney failure, unspecified
Pneumonia, organism NOS,CHF NOS,Mitral valve disorder,Acute respiratry failure,Acidosis,Bacteremia,Cellulitis of leg,Acute kidney failure NOS
Admission Date:  [**2109-3-21**]     Discharge Date:  [**2109-3-29**]

Date of Birth:   [**2030-6-1**]     Sex:  F

Service:

CHIEF COMPLAINT:   Hypertension.

HISTORY OF PRESENT ILLNESS:   (MICU Green Service)  This is a
78 year old woman with a history of congestive heart failure,
diastolic dysfunction, restrictive lung disease, who was in
her usual state of health until the afternoon of admission
when she woke up with mental status changes, increasing
lethargy, and abdominal discomfort.  The patient was noted to
be clammy and afebrile on arrival to the Emergency
Department.

On arrival, she had a temperature of 100.8, systolic blood
pressure 70s, heart rate 60 to 70s, and oxygen requirements
of 90% on two liters.  The patient was given two liters of
normal saline with good blood pressure response, however, the
patient had a desaturation to 70%.  The patient responded
with 100% nonrebreather.

In the Emergency Department, the patient was given two grams
of Ceftriaxone and 500 mg of Flagyl.  Despite intravenous
fluids, the patient's blood pressure continued to trend
downward and the patient was started on Levophed drip for
blood pressure control.  Chest x-ray showed right lower lobe
infiltrate.  The patient had right internal jugular central
line placed and the patient was transferred to the Intensive
Care Unit.

PAST MEDICAL HISTORY:
1.  Congestive heart failure, diastolic dysfunction with an
ejection fraction greater than 70%.
2.  Restrictive lung disease, FVC 0.6, 49% of predicted, FEV1
82% of predicted, FEV1/FVC ratio 69% of predicted.
3.  Hypertension.
4.  Gastroesophageal reflux disease.
5.  Hyperlipidemia.
6.  Mitral regurgitation.
7.  Chronic renal insufficiency with a baseline creatinine of
1.3.
8.  Degenerative joint disease/arthritis.
9.  Iron deficiency anemia.
10. History of breast cancer.
11. Urinary incontinence.
12. Osteoporosis.
13. Diverticulosis.
14. History of right sided hiatal hernia.

MEDICATIONS ON ADMISSION:
1.  Fosamax 70 mg q.week.
2.  TUMS 500 mg three times a day.
3.  Protonix 40 mg once daily.
4.  [**Doctor First Name **] 60 mg twice a day.
5.  Lasix 80 mg p.o. twice a day.
6.  Milk of Magnesia.
7.  Lipitor 10 mg q.h.s.
8.  Colace 100 mg twice a day.
9.  Enteric Coated Aspirin 81 mg once daily.
10. Atenolol 25 mg twice a day.
11. Tylenol.
12. Flovent.

ALLERGIES:  Verapamil.

SOCIAL HISTORY:  The patient lives alone in [**Hospital3 **].
No history of tobacco and no history of alcohol.

FAMILY HISTORY:  Significant for pulmonary embolus.

PHYSICAL EXAMINATION:  Temperature 100.8, pulse 65, blood
pressure 122/32, respiratory rate 20, 100% on nonrebreather.
General examination - The patient is a moderately obese
woman, lying in bed, in no acute distress.  Head, eyes, ears,
nose and throat examination - The oropharynx is clear.
Mucous membranes are moist.  Cushingoid appearance.
Cardiovascular is regular rate and rhythm, no murmurs, rubs
or gallops.  Lungs - decreased breath sounds at the base with
a few crackles bilaterally.   The abdomen is mildly
distended, mild suprapubic pain, no masses.  Extremities -
right lower extremity erythema and warmth, tender to
palpation, +1 pitting edema.  Neurologically, the patient
moves all four extremities.

LABORATORY DATA:   On admission, potassium 3.6, creatinine
2.0.  Urinalysis showed small leukocyte esterase.  Lactate
1.7.

Chest x-ray showed right sided hiatal hernia, evidence of
mild congestive heart failure, right lower lobe
consolidation.  CT of the abdomen and pelvis showed evidence
of diverticulosis without diverticulitis, large right sided
hiatal hernia, right lower lobe pneumonia.

HOSPITAL COURSE:
1.  Shock and hypotension - The patient was transferred to
the Medical Intensive Care Unit on Levophed pressor.  After
fluid resuscitation, blood pressure was stable and was weaned
off.  The patient was started on Ceftriaxone for possible
community acquired pneumonia.  The patient's respiratory
status continued to decline in the Medical Intensive Care
Unit.  The patient was thought to be in a moderate amount of
heart failure and given aggressive diuresis.  However, the
patient was found to be in ventilatory failure and she was
intubated for increased work of breathing and respiratory
failure on the second day of her Intensive Care Unit course.
After intubation, the patient was diuresed and echocardiogram
was performed and the patient was found to have ejection
fraction of 95% consistent with severe diastolic heart
failure.  The patient was rate controlled with calcium
channel blocker with good improvement of respiratory status.

2.  In regards to pneumonia, the patient was afebrile.  Since
three to four days of her hospital course, white blood cell
count trended downward from 15.0 to 8.0.  On Intensive Care
Unit stay day number six, the patient was extubated without
complications.  The patient was found to have moderate
respiratory acidosis which was thought to be chronic in
nature given her severe restrictive lung disease.  The
patient was comfortable and not tachypneic postextubation.

3.  The patient was also found to have Streptococcus G
bacteremia.  Cultures were growing four out of four bottles,
treated with Ceftriaxone.  Surveillance cultures after
antibiotics were negative.  The patient also presented with a
right lower extremity cellulitis which was thought to be the
source of the patient's bacteremia.  Cellulitis resolved
during hospital course.

4.  The patient was in acute renal failure on presentation
and creatinine was 2.0 from her baseline of 1.3.  Renal
failure resolved after intravenous hydration initially.  It
was thought to be prerenal in cause.

5.  The patient was also found to have new onset
supraventricular tachycardia.  On electrocardiogram, it
appears that the patient had atrial flutter with variable
block, paroxysmal in nature.  Anticoagulation was deferred at
this time given the setting of infection.  The risks of bleed
outweighed the risks of stroke.

6.  Secondary to the patient's severe right sided hiatal
hernia, she was thought to be at high risk for aspiration and
possible source of her right lower lobe pneumonia.  The
patient was given tube feeds but because of her anatomy,
postpyloric Dobbhoff was placed for tube feed and enteral
nutrition.

7.  On day seven of her Intensive Care Unit hospital stay,
the patient was noted to have a large tender and warm left
knee.  There was a concern that the knee appeared to be
septic.  X-ray and arthrocentesis was performed which showed
evidence of degenerative joint disease.  There was no
evidence of infection.  The patient's pain was treated with
Tylenol.

The patient was transferred to the Medicine service.  For
further details of hospital course and follow-up, please
refer to discharge addendum.




                          [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D.  [**MD Number(1) 7585**]

Dictated By:[**Name8 (MD) 10402**]

MEDQUIST36

D:  [**2109-3-29**]  14:27
T:  [**2109-3-30**]  14:12
JOB#:  [**Job Number 104832**]


Name:  [**Known lastname **], [**Known firstname 5872**]                      Unit No:  [**Numeric Identifier 17028**]

Admission Date:  [**2109-3-21**]       Discharge Date:  [**2109-4-4**]

Date of Birth:   [**2030-6-1**]       Sex:  F

Service:  Medicine, [**Location (un) **] Firm

ADDENDUM:

SUMMARY OF HOSPITAL COURSE (CONTINUED):

1.  PNEUMONIA ISSUES:  The patient continued to be treated
for pneumonia with ceftriaxone.  She was treated for a total
of 14 days.  She had no further fevers after being called out
from the Intensive Care Unit.  The patient did continue to
require supplemental oxygen.  However, she will likely be
weaned off of that over the coming days and weeks.

2.  STREP G BACTEREMIA ISSUES:  The patient had repeat
surveillance cultures and was continued on ceftriaxone for
two weeks.  She did not demonstrate any signs of recurrent
infection.

3.  ACUTE RENAL FAILURE ISSUES:  This resolved with
hydration.

4.  SUPRAVENTRICULAR TACHYCARDIA ISSUES:  This resolved, and
the patient was in a normal sinus rhythm after leaving the
Intensive Care Unit.  She was tachycardic for one to two
days; however, this was thought to be due to hypovolemia.
With rehydration, the patient's tachycardia resolved.

5.  DYSPHAGIA ISSUES:  The patient was evaluated for the risk
of aspiration by the Swallowing Service.  The evaluation
showed that the patient was a high risk for aspiration and
was aspirating all by mouth liquids.  At this point, the
patient was made nothing by mouth.  Tube feeds were continued
through her postpyloric Dobbhoff tube.

The plan was to re-evaluate her swallowing function in
approximately two weeks, and if there is no improvement the
patient was to have a video swallowing study done.  If this
showed continued swallowing difficulty and aspiration risk,
she was get a percutaneous endoscopic gastrostomy tube for
feeding.

6.  CELLULITIS ISSUES:  The patient developed right lower
extremity cellulitis.  This was treated with ceftriaxone.
The cellulitis gradually improved over a few days and by
discharge had resolved almost completely.  She was off
antibiotics at discharge.

DISCHARGE DIAGNOSES:
1.  ....................
2.  Heart failure.
3.  Dysphagia.
4.  Cellulitis.

MEDICATIONS ON DISCHARGE:
 1.  Colace.
 2.  Olanzapine 5 mg q.6-8h. as needed (for agitation).
 3.  Diltiazem 90 mg four times per day.
 4.  Lansoprazole 30 mg once per day.
 5.  Aspirin 300 mg per rectum once per day.
 6.  Dulcolax as needed.
 7.  Atrovent nebulizer q.4h. as needed.
 8.  Albuterol nebulizer q.6h. as needed.
 9.  Senna one tablet by mouth twice per day.
10.  Calcium carbonate 500 mg by mouth three times per day.
11.  Vitamin D 400 International Units once per day.
12.  Tramadol 25 mg q.6h. as needed.
13.  Ativan as needed (for agitation).
14.  Tylenol as needed.
15.  Subcutaneous heparin 5000 units subcutaneously q.8h.

DISCHARGE DISPOSITION:  The patient to be discharged to an
acute rehabilitation facility.

DISCHARGE INSTRUCTIONS/FOLLOWUP:
1.  She should continue her tube feeds at goal.
2.  She was to follow up with her primary care provider in
one to two weeks.





                    DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-207

Dictated By:[**Name8 (MD) 3520**]
MEDQUIST36

D:  [**2109-4-4**]  12:33
T:  [**2109-4-4**]  12:38
JOB#:  [**Job Number 17029**]
{'Pneumonia, organism unspecified,Congestive heart failure, unspecified,Mitral valve disorders,Acute respiratory failure,Acidosis,Bacteremia,Cellulitis and abscess of leg, except foot,Acute kidney 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: Hypertension.

PRESENT ILLNESS: (MICU Green Service)  This is a
78 year old woman with a history of congestive heart failure,
diastolic dysfunction, restrictive lung disease, who was in
her usual state of health until the afternoon of admission
when she woke up with mental status changes, increasing
lethargy, and abdominal discomfort.  The patient was noted to
be clammy and afebrile on arrival to the Emergency
Department.

MEDICAL HISTORY: 1.  Congestive heart failure, diastolic dysfunction with an
ejection fraction greater than 70%.
2.  Restrictive lung disease, FVC 0.6, 49% of predicted, FEV1
82% of predicted, FEV1/FVC ratio 69% of predicted.
3.  Hypertension.
4.  Gastroesophageal reflux disease.
5.  Hyperlipidemia.
6.  Mitral regurgitation.
7.  Chronic renal insufficiency with a baseline creatinine of
1.3.
8.  Degenerative joint disease/arthritis.
9.  Iron deficiency anemia.
10. History of breast cancer.
11. Urinary incontinence.
12. Osteoporosis.
13. Diverticulosis.
14. History of right sided hiatal hernia.

MEDICATION ON ADMISSION: 1.  Fosamax 70 mg q.week.
2.  TUMS 500 mg three times a day.
3.  Protonix 40 mg once daily.
4.  [**Doctor First Name **] 60 mg twice a day.
5.  Lasix 80 mg p.o. twice a day.
6.  Milk of Magnesia.
7.  Lipitor 10 mg q.h.s.
8.  Colace 100 mg twice a day.
9.  Enteric Coated Aspirin 81 mg once daily.
10. Atenolol 25 mg twice a day.
11. Tylenol.
12. Flovent.

ALLERGIES: Verapamil.

PHYSICAL EXAM: 

FAMILY HISTORY: Significant for pulmonary embolus.

SOCIAL HISTORY: The patient lives alone in [**Hospital3 **].
No history of tobacco and no history of alcohol. 

### Response:
{'Pneumonia, organism unspecified,Congestive heart failure, unspecified,Mitral valve disorders,Acute respiratory failure,Acidosis,Bacteremia,Cellulitis and abscess of leg, except foot,Acute kidney failure, unspecified'}
