CHIEF COMPLAINT: Dyspnea

PRESENT ILLNESS: 80 year old female transferred from NH to [**Hospital1 18**] ED for
evaluation of hypoxia and dyspnea, found to have bilateral
pulmonary emboli, and is admitted to ICU due to ?right heart
strain. Per, report she had a peripheral saturation of 64% at
her NH. She was put on 4L NC and sats increased to 80s.
.
In the ED, initial VS were:  109/69, hr 62, rr20, sat 88 RA. bp
range 102-130/41-64. HR 65-94. 84-95% 3-4L NC.  A CTA confirmed
bilateral pulmonary emboli. Heparin gtt and bolus were started.
She also got a less than full dose of vancomycin (stopped as ct
showed no e/o pna) and a dose of ctx. Also ASA 325mg once. She
was given benadryl due to itching at the iv site during the
vancomycin infusion.
.
Transfer vitals af, hr 72, bp 102/61, rr 18, 94% 3L NC.  On
arrival to the MICU, she looked comfortable. She is demented.
Oriented to person only. She has no specific complaints but is
an unreliable historian.
.
Review of systems:  unable to obtain

MEDICAL HISTORY: -Frontal-temporal dementia:  Neurocognitive decline has been
tested at least three times consistent findings with frontal
lobe "dementia."
-Spinal stenosis: arthritis of lumbar spine with sciatica
diagnosed in [**2172**].
-Depression: currently on Fluoxetine
-Mild sleep apnea, although patient refuses to use equipment.
-Hypertension in past: subsequently had "low blood pressure"
treated with Florinef.
-Bilateral cataract surgeries in [**2170**].
-Surgery on both feet foot for bunions. Chronic foot pain.

MEDICATION ON ADMISSION: house diet pureed foods
omeprazole 20mg daily
citalopram 10mg daily
hctz 12.5mg daily
mv daily
risperidone .5mg daily
glucosamine/chondroitin
ibuprofen 600mg [**Hospital1 **]
buspirone 10mg [**Hospital1 **]
divalproex 125mg [**Hospital1 **]
senna
acetaminophen prn
bisacodyl prn
milk of mag prn
.
Allergies:  nkda

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
On discharge,
A&Ox1, pleasant
Lungs: CTA anteriorly
CV: RRR, no murmurs
Abd: soft, normoactive bs
Ext: warm and well-perfused, no edema
Neuro: EOMI, full strength in UE/LE bilaterally

FAMILY HISTORY: NC

SOCIAL HISTORY: In the past, the patient lived [**Street Address(1) 18292**] Senior Living
Center (adult
[**Doctor Last Name **] day care) in [**Location (un) 18293**] - currently lives in [**First Name4 (NamePattern1) 1188**]
[**Last Name (NamePattern1) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], the program
director at Bishop St., knows the patient well (contact #:
[**Telephone/Fax (1) 18294**]; [**Telephone/Fax (1) 18295**]). Continues to smoke less than one
pack per week.  Began
smoking in her 20's.  Previously drank alcohol, but none
currently.
Patient has a master's in music. She has had multiple
occupations in the past, including professional violinist at the
Other pulmonary embolism and infarction,Heart disease, unspecified,Spinal stenosis, lumbar region, without neurogenic claudication,Depressive disorder, not elsewhere classified,Unspecified sleep apnea,Unspecified essential hypertension,Esophageal reflux,Other frontotemporal dementia,Dementia in conditions classified elsewhere without behavioral disturbance,Do not resuscitate status
Pulm embol/infarct NEC,Heart disease NOS,Spin sten,lumbr wo claud,Depressive disorder NEC,Sleep apnea NOS,Hypertension NOS,Esophageal reflux,Frontotemp dementia NEC,Dementia w/o behav dist,Do not resusctate status
Name:  [**Known lastname **],[**Known firstname 3006**]                    Unit No:   [**Numeric Identifier 3007**]

Admission Date:  [**2181-3-1**]              Discharge Date:   [**2181-3-5**]

Date of Birth:  [**2100-6-30**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1824**]
Addendum:
Blood cultures - 1/4 bottles (anaerobic bottle) from [**3-1**] grew
gram-positive rods (corynebacterium or propionibacterium) on
[**3-6**] (5 days after culture) drawn. Patient was afebrile during
admission. This almost certainly represents a contaminant.

Discharge Disposition:
Extended Care

Facility:
[**First Name4 (NamePattern1) 3008**] [**Last Name (NamePattern1) **] - [**Location (un) 164**]

                             [**First Name11 (Name Pattern1) 634**] [**Last Name (NamePattern4) 1837**] MD [**MD Number(2) 1838**]

Completed by:[**2181-3-7**]

Admission Date:  [**2181-3-1**]              Discharge Date:   [**2181-3-5**]

Date of Birth:  [**2100-6-30**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Dyspnea

Major Surgical or Invasive Procedure:
None


History of Present Illness:
80 year old female transferred from NH to [**Hospital1 18**] ED for
evaluation of hypoxia and dyspnea, found to have bilateral
pulmonary emboli, and is admitted to ICU due to ?right heart
strain. Per, report she had a peripheral saturation of 64% at
her NH. She was put on 4L NC and sats increased to 80s.
.
In the ED, initial VS were:  109/69, hr 62, rr20, sat 88 RA. bp
range 102-130/41-64. HR 65-94. 84-95% 3-4L NC.  A CTA confirmed
bilateral pulmonary emboli. Heparin gtt and bolus were started.
She also got a less than full dose of vancomycin (stopped as ct
showed no e/o pna) and a dose of ctx. Also ASA 325mg once. She
was given benadryl due to itching at the iv site during the
vancomycin infusion.
.
Transfer vitals af, hr 72, bp 102/61, rr 18, 94% 3L NC.  On
arrival to the MICU, she looked comfortable. She is demented.
Oriented to person only. She has no specific complaints but is
an unreliable historian.
.
Review of systems:  unable to obtain


Past Medical History:
-Frontal-temporal dementia:  Neurocognitive decline has been
tested at least three times consistent findings with frontal
lobe "dementia."
-Spinal stenosis: arthritis of lumbar spine with sciatica
diagnosed in [**2172**].
-Depression: currently on Fluoxetine
-Mild sleep apnea, although patient refuses to use equipment.
-Hypertension in past: subsequently had "low blood pressure"
treated with Florinef.
-Bilateral cataract surgeries in [**2170**].
-Surgery on both feet foot for bunions. Chronic foot pain.


Social History:
In the past, the patient lived [**Street Address(1) 18292**] Senior Living
Center (adult
[**Doctor Last Name **] day care) in [**Location (un) 18293**] - currently lives in [**First Name4 (NamePattern1) 1188**]
[**Last Name (NamePattern1) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], the program
director at Bishop St., knows the patient well (contact #:
[**Telephone/Fax (1) 18294**]; [**Telephone/Fax (1) 18295**]). Continues to smoke less than one
pack per week.  Began
smoking in her 20's.  Previously drank alcohol, but none
currently.
Patient has a master's in music. She has had multiple
occupations in the past, including professional violinist at the

[**Location (un) 18296**] Symphony Orchestra, piano and violin teacher, and
caretaker. She is divorced and has no children. Reports that she

attends church regularly and has a community of friends in the
area. Hcp/[**Location (un) 18297**] [**First Name4 (NamePattern1) **] [**Name (NI) 18298**] [**Telephone/Fax (1) 18299**] home,
[**Telephone/Fax (1) 18300**] cell


Family History:
NC

Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
On discharge,
A&Ox1, pleasant
Lungs: CTA anteriorly
CV: RRR, no murmurs
Abd: soft, normoactive bs
Ext: warm and well-perfused, no edema
Neuro: EOMI, full strength in UE/LE bilaterally

Pertinent Results:
[**2181-3-1**] 06:29PM   PT-12.1 PTT-132.4* INR(PT)-1.1
[**2181-3-1**] 05:36PM   COMMENTS-GREEN TOP
[**2181-3-1**] 05:36PM   LACTATE-1.8
[**2181-3-1**] 11:25AM   D-DIMER-2898*
[**2181-3-1**] 09:04AM   LACTATE-3.8*
[**2181-3-1**] 09:00AM   GLUCOSE-138* UREA N-33* CREAT-0.9 SODIUM-142
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-26 ANION GAP-18
[**2181-3-1**] 09:00AM   estGFR-Using this
[**2181-3-1**] 09:00AM   cTropnT-<0.01
[**2181-3-1**] 09:00AM   CALCIUM-8.9 PHOSPHATE-4.1 MAGNESIUM-1.7
[**2181-3-1**] 09:00AM   WBC-12.8*# RBC-3.50* HGB-11.2* HCT-33.0*
MCV-94# MCH-31.9 MCHC-33.9 RDW-12.6
[**2181-3-1**] 09:00AM   NEUTS-80.9* LYMPHS-11.1* MONOS-5.8 EOS-1.7
BASOS-0.5
[**2181-3-1**] 09:00AM   PLT COUNT-338
[**2181-3-1**] 09:00AM   PT-11.7 PTT-27.9 INR(PT)-1.1
.
INR:
[**3-2**]: 1.1
[**3-3**]: 1.2
[**3-4**]: 1.3
[**3-5**]: 1.7
.
MICROBIOLOGY:
- [**2181-3-1**] MRSA screen: No MRSA isolated
- [**2181-3-1**] Blood culture: Pending at the time of discahrge (NGTD)
- [**2181-3-1**] Blood culture: Pending at the time of discahrge (NGTD)
- [**2181-3-4**] Urine culture: Pending at the time of discharge

CTA CHEST [**2181-3-1**]:
IMPRESSION: 1. Bilateral pulmonary emboli, the largest of which
is in the right main pulmonary artery with findings suggestive
of early right heart strain. Recommended correlation with
echocardiography. 2. Bilateral ground-glass opacities in the
upper lobes are nonspecific. 3. Small hiatal hernia. 4. 12-mm
subcarinal lymph node, likely reactive. 5. 8 mm subcutaneous
nodule within the left anterior chest wall, possibly a sebaceous
cyst, for which clinical correlation is recommended. 6.
Cholelithiasis.

CXR [**2181-3-1**]:
IMPRESSION: Low lung volumes with blunting of the left
costophrenic angle
suggestive of a small effusion.

TRANSTHORACIC ECHOCARDIOGRAM [**2181-3-1**]:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The right ventricular cavity is moderately
dilated with moderate global free wall hypokinesis. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion. IMPRESSION: Moderately dilated right
ventricle with moderate systolic dysfunction. Normal global and
regional left ventricular systolic functino. Moderate pulmonary
hypertension.


Brief Hospital Course:
HOSPITAL SUMMARY: Ms. [**Known lastname **] is an 80F who was transferred from
her care facility to [**Hospital1 18**] for evaluation of hypoxia and
shortness of breath. CTA demonstrated bilateral submassive
pulmonary emboli, and echocardiogram showed evidence of right
heart strain as above, so she was admitted to the medical ICU.
There, she remained hemodynamically stable and was started on
anticoagulation (initially with heparin gtt, then transitioned
to Lovenox therapeutic dosing; she was started on warfarin as
well for planned bridge). She was transferred to the general
medical [**Hospital1 **] on hospital day 2, where her breathing continued to
improve. She will likely require minimum of 6 months of
anticoagulation. Further work up for prothrombotic state
(malignancy, etc.) will be deferred to the outpatient setting.
She was discharged on a lovenox bridge (70 mg twice per day) to
be continued for 2 days after therapeutic INR. She was
discharged on coumadin 7.5 mg per day with instructions that
this is not a determined stable dose and will note close
monitoring - INR on discharge was 1.7. She did have a new oxygen
requirement upon discharge (84% on RA with ambulation).
.
CHRONIC ISSUES:
.
# DEPRESSION, FRONTOTEMPORAL DEMENTIA: Patient was alert and
pleasant but oriented only to self during this admission. She
was continued on her home doses of citalopram, divalproex,
buspirone, and risperdal.
.
# SLEEP APNEA: Patient unable to tolerate CPAP. No significant
complications were noted during this admission.
.
# HYPERTENSION: Hydrochlorothiazide was held during this
admission given concern for possible hemodynamic instability.
She remained normotensive throughout this admission so
hydrochlorothiazide was discontinued on discharge.
.
#GERD: Continued home dose of omeprazole.
.
TRANSITIONAL CARE:
- Patient will require overlap of warfarin and lovenox (70 mg
[**Hospital1 **]) for 2 days once an INR goal of [**3-16**] (measured twice at least
24 hrs apart) is reached
- Recommend 6-12 months minimum of anticoagulation therapy
- daily INRs until stable coumadin dose is established
- Thrombophilia workup will be deferred to the outpatient
setting; this may include age-appropriate cancer screening and
smoking cessation counselling depending on goals of care
- 12-mm subcarinal lymph node was noted on CTA imaging (likley
reactive); decision regarding follow up will be deferred to
outpatient providers
- Blood cultures x 2 sets from [**2181-3-1**] were pending at the time
of discharge (NGTD) as was urine culture (NGTD)
- Code status: DNR/DNI (confirmed with [**Month/Day/Year 18297**])
- [**Name (NI) **]: [**First Name5 (NamePattern1) **] [**Name (NI) 18298**] ([**Telephone/Fax (1) 18299**] home,
[**Telephone/Fax (1) 18300**] cell, fax [**Telephone/Fax (1) 18301**])


Medications on Admission:
house diet pureed foods
omeprazole 20mg daily
citalopram 10mg daily
hctz 12.5mg daily
mv daily
risperidone .5mg daily
glucosamine/chondroitin
ibuprofen 600mg [**Hospital1 **]
buspirone 10mg [**Hospital1 **]
divalproex 125mg [**Hospital1 **]
senna
acetaminophen prn
bisacodyl prn
milk of mag prn
.
Allergies:  nkda


Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. multivitamin     Tablet Sig: One (1) Tablet PO once a day.
4. risperidone 0.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. glucosamine-chondroitin  Oral
6. buspirone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. divalproex 125 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO once a day as needed for constipation.
10. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours as needed for fever or pain.
11. bisacodyl 5 mg Tablet Sig: 1-2 Tablets PO once a day as
needed for constipation.
12. enoxaparin 80 mg/0.8 mL Syringe Sig: Seventy (70) mg
Subcutaneous Q12H (every 12 hours): Please give lovenox twice
per day until INR is therapeutic for 2 days. Then discontinue
lovenox. .
13. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily
at 4 PM: This is not a stable dose of warfarin for this patient.
Please check daily INR until appropriate daily dose is
confirmed. .


Discharge Disposition:
Extended Care

Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**]

Discharge Diagnosis:
PRIMARY:
- Pulmonary emboli
- Right heart strain

SECONDARY:
- Frontotemporal dementia


Discharge Condition:
Mental Status: Confused - always (oriented only to self at
baseline)
Level of Consciousness: Alert and interactive.
Ambulates with a walker.


Discharge Instructions:
It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted to [**Hospital1 18**] with shortness of
breath and low oxygen levels. Imaging studies showed blood clots
in your lungs (pulmonary emboli) that were affecting your
heart's ability to pump blood. You were treated with blood
thinners and your breathing improved. You will need to continue
to use blood thinners until directed to stop by your physician.
[**Name10 (NameIs) **] will also need oxygen until the blood clots are stabilized
and absorbed by your body.

We have made the following changes to your medication regimen:
- BEGIN TAKING Lovenox injections (70 mg) twice daily until your
INR (blood test) is > 2 for 2 days. Then discontinue lovenox.
- BEGIN TAKING warfarin 7.5 mg by mouth daily (goal INR is [**3-16**]).
We have not yet determine what your final dose will be so you
will require frequent blood tests (INR monitoring) until we know
your proper long-term dose.
- STOP taking hydrochlorathiazide as your blood pressure was
normal
- STOP taking ibuprofen as this can increase your bleeding risk
while on anticoagulation
.
Please take your medications as prescribed and follow up with
your doctors as recommended below.

Followup Instructions:
Please follow up with your PCP ([**Last Name (LF) 251**],[**First Name3 (LF) **] G. [**Telephone/Fax (1) 608**]) or
the doctor at your extended care facility. You will need to have
your INR checked daily until your stable coumadin dose is known.
{'Other pulmonary embolism and infarction,Heart disease, unspecified,Spinal stenosis, lumbar region, without neurogenic claudication,Depressive disorder, not elsewhere classified,Unspecified sleep apnea,Unspecified essential hypertension,Esophageal reflux,Other frontotemporal dementia,Dementia in conditions classified elsewhere without behavioral disturbance,Do not resuscitate 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: Dyspnea

PRESENT ILLNESS: 80 year old female transferred from NH to [**Hospital1 18**] ED for
evaluation of hypoxia and dyspnea, found to have bilateral
pulmonary emboli, and is admitted to ICU due to ?right heart
strain. Per, report she had a peripheral saturation of 64% at
her NH. She was put on 4L NC and sats increased to 80s.
.
In the ED, initial VS were:  109/69, hr 62, rr20, sat 88 RA. bp
range 102-130/41-64. HR 65-94. 84-95% 3-4L NC.  A CTA confirmed
bilateral pulmonary emboli. Heparin gtt and bolus were started.
She also got a less than full dose of vancomycin (stopped as ct
showed no e/o pna) and a dose of ctx. Also ASA 325mg once. She
was given benadryl due to itching at the iv site during the
vancomycin infusion.
.
Transfer vitals af, hr 72, bp 102/61, rr 18, 94% 3L NC.  On
arrival to the MICU, she looked comfortable. She is demented.
Oriented to person only. She has no specific complaints but is
an unreliable historian.
.
Review of systems:  unable to obtain

MEDICAL HISTORY: -Frontal-temporal dementia:  Neurocognitive decline has been
tested at least three times consistent findings with frontal
lobe "dementia."
-Spinal stenosis: arthritis of lumbar spine with sciatica
diagnosed in [**2172**].
-Depression: currently on Fluoxetine
-Mild sleep apnea, although patient refuses to use equipment.
-Hypertension in past: subsequently had "low blood pressure"
treated with Florinef.
-Bilateral cataract surgeries in [**2170**].
-Surgery on both feet foot for bunions. Chronic foot pain.

MEDICATION ON ADMISSION: house diet pureed foods
omeprazole 20mg daily
citalopram 10mg daily
hctz 12.5mg daily
mv daily
risperidone .5mg daily
glucosamine/chondroitin
ibuprofen 600mg [**Hospital1 **]
buspirone 10mg [**Hospital1 **]
divalproex 125mg [**Hospital1 **]
senna
acetaminophen prn
bisacodyl prn
milk of mag prn
.
Allergies:  nkda

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
On discharge,
A&Ox1, pleasant
Lungs: CTA anteriorly
CV: RRR, no murmurs
Abd: soft, normoactive bs
Ext: warm and well-perfused, no edema
Neuro: EOMI, full strength in UE/LE bilaterally

FAMILY HISTORY: NC

SOCIAL HISTORY: In the past, the patient lived [**Street Address(1) 18292**] Senior Living
Center (adult
[**Doctor Last Name **] day care) in [**Location (un) 18293**] - currently lives in [**First Name4 (NamePattern1) 1188**]
[**Last Name (NamePattern1) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], the program
director at Bishop St., knows the patient well (contact #:
[**Telephone/Fax (1) 18294**]; [**Telephone/Fax (1) 18295**]). Continues to smoke less than one
pack per week.  Began
smoking in her 20's.  Previously drank alcohol, but none
currently.
Patient has a master's in music. She has had multiple
occupations in the past, including professional violinist at the 

### Response:
{'Other pulmonary embolism and infarction,Heart disease, unspecified,Spinal stenosis, lumbar region, without neurogenic claudication,Depressive disorder, not elsewhere classified,Unspecified sleep apnea,Unspecified essential hypertension,Esophageal reflux,Other frontotemporal dementia,Dementia in conditions classified elsewhere without behavioral disturbance,Do not resuscitate status'}
