CHIEF COMPLAINT: cough

PRESENT ILLNESS: Ms. [**Known lastname **] is a 52 year old type I diabetic, ESRD, admitted
with acute onset of shortness of breath and hemoptysis at 9AM.
She was nauseated and had vomiting and dry-heaved in the morning
with blood-tinged vomitus vs. emesis. She denied chest pain,
fevers, chills prior to admission. Per patient's daughter, she
had been noted to be coughing recently, however, did not
complain of fevers or chills to her daugher. No myalgias. No
sick contacts.

MEDICAL HISTORY: Type 1 DM
Non-ischemic Dilated cardiomyopathy, EF < 20% 4/08 by echo
Hypertension
CKD s/p transplant in [**2152**], undergoing evaluation for possible
second transplant
Chronic hepatitis C
Intracranial right ICA aneurysm; gets yearly imaging. 5mm [**2154**],
8mm on [**2159-2-7**] MRA.
H/o C4-5 and C5-6 anterior decompression and fusion after MVA
[**2157**], Dr. [**Last Name (STitle) 363**]
Ulnar nerve impingement bilaterally
S/p Rotator cuff repair
S/p release of right carpal tunnel

MEDICATION ON ADMISSION: Epo 100 units q MWF
Zemplar 2 mcg daily
Pravastatin 20 mg daily
Prednisone 5 mg daily
Sirolimus 8 mg daily
Ferrous Sulfate 325 mg daily
Colace 100 mg [**Hospital1 **]
Senna [**Hospital1 **] prn
Metoprolol Succinate 200 mg daily
Tacrolimus 3 mg q 12 hours
Ranitidine 75 mg daily
Nifedipine 90 mg daily
Insulin

ALLERGIES: Percocet

PHYSICAL EXAM: VS: HR 83, BP 111/70, RR 30, 93%
Vent settings: Fio2 100%, PEEP 10, TV 500, RRs 15 (patietn
breathing at 15)
Gen: sedated, intubated
HEENT: PERRL, 3mm--> 2mm, intbuated
CV: difficult to appreciate due to coarse breath sounds
Pulm: coarse rhonchi diffusely
Abd: soft, NT, ND, bowel sounds present
Ext: cool, distal pulses present
Neuro: sedated, PERRL, withdraws to pain

FAMILY HISTORY: Sister died of [**Name (NI) 101497**], many other family members on maternal side
with diabetes.

SOCIAL HISTORY: Divorced, has 2 children and 9 grandchildren. No tobacco, quit
12 years ago after having previously smoked 1ppd x27 years. No
EtOH although previously drank socially.
Acute respiratory failure,Pneumonia, organism unspecified,Acute on chronic systolic heart failure,Complications of transplanted kidney,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Other primary cardiomyopathies,Hyperosmolality and/or hypernatremia,Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled,Chronic hepatitis C without mention of hepatic coma,Anemia in chronic kidney disease
Acute respiratry failure,Pneumonia, organism NOS,Ac on chr syst hrt fail,Compl kidney transplant,Hyp kid NOS w cr kid V,End stage renal disease,Prim cardiomyopathy NEC,Hyperosmolality,DMI wo cmp nt st uncntrl,Chrnc hpt C wo hpat coma,Anemia in chr kidney dis
Admission Date:  [**2161-11-28**]              Discharge Date:   [**2161-12-7**]

Date of Birth:  [**2108-12-6**]             Sex:   F

Service: MEDICINE

Allergies:
Percocet

Attending:[**First Name3 (LF) 11552**]
Chief Complaint:
cough

Major Surgical or Invasive Procedure:
intubation, placement of temporary dialysis catheter

History of Present Illness:
Ms. [**Known lastname **] is a 52 year old type I diabetic, ESRD, admitted
with acute onset of shortness of breath and hemoptysis at 9AM.
She was nauseated and had vomiting and dry-heaved in the morning
with blood-tinged vomitus vs. emesis. She denied chest pain,
fevers, chills prior to admission. Per patient's daughter, she
had been noted to be coughing recently, however, did not
complain of fevers or chills to her daugher. No myalgias. No
sick contacts.

In the ED, vitasl were T 96.5F, BP 174/137, HR 96, RR 38, T
100.6, 97% on NRB. She was given lasix and nitroglycerin drip,
and placed on BIPAP. A chest x ray revealed RLL pneumonia, so
she was started on vanco/cefepime/levaquin, and so was intubated
because of concern for PNA. A right IJ was placed.


Past Medical History:
Type 1 DM
Non-ischemic Dilated cardiomyopathy, EF < 20% 4/08 by echo
Hypertension
CKD s/p transplant in [**2152**], undergoing evaluation for possible
second transplant
Chronic hepatitis C
Intracranial right ICA aneurysm; gets yearly imaging. 5mm [**2154**],
8mm on [**2159-2-7**] MRA.
H/o C4-5 and C5-6 anterior decompression and fusion after MVA
[**2157**], Dr. [**Last Name (STitle) 363**]
Ulnar nerve impingement bilaterally
S/p Rotator cuff repair
S/p release of right carpal tunnel


Social History:
Divorced, has 2 children and 9 grandchildren. No tobacco, quit
12 years ago after having previously smoked 1ppd x27 years. No
EtOH although previously drank socially.

Family History:
Sister died of [**Name (NI) 101497**], many other family members on maternal side
with diabetes.

Physical Exam:
VS: HR 83, BP 111/70, RR 30, 93%
Vent settings: Fio2 100%, PEEP 10, TV 500, RRs 15 (patietn
breathing at 15)
Gen: sedated, intubated
HEENT: PERRL, 3mm--> 2mm, intbuated
CV: difficult to appreciate due to coarse breath sounds
Pulm: coarse rhonchi diffusely
Abd: soft, NT, ND, bowel sounds present
Ext: cool, distal pulses present
Neuro: sedated, PERRL, withdraws to pain

Afebrile at discharge, O2 sats mid to high 90s on room air, lung
clear with slightly diminished air movement at bases

Pertinent Results:
Admission labs:

[**2161-11-28**] 11:30AM   WBC-5.5 RBC-3.68* HGB-9.7* HCT-30.0* MCV-82
MCH-26.4* MCHC-32.4 RDW-16.8*
[**2161-11-28**] 11:30AM   NEUTS-71.9* LYMPHS-24.4 MONOS-1.3* EOS-2.0
BASOS-0.5
[**2161-11-28**] 11:30AM   GLUCOSE-470* UREA N-80* CREAT-4.5* SODIUM-135
POTASSIUM-4.9 CHLORIDE-99 TOTAL CO2-20* ANION GAP-21
[**2161-11-28**] 11:30AM   CALCIUM-9.4 PHOSPHATE-6.6*# MAGNESIUM-2.0

Discharge Labs

[**2161-12-7**] 06:35AM BLOOD WBC-9.7 RBC-3.09* Hgb-8.5* Hct-25.4*
MCV-82 MCH-27.5 MCHC-33.5 RDW-18.3* Plt Ct-328
[**2161-12-7**] 06:35AM BLOOD Plt Ct-328
[**2161-12-7**] 06:35AM BLOOD Glucose-207* UreaN-74* Creat-4.4* Na-139
K-3.5 Cl-100 HCO3-27 AnGap-16
[**2161-12-7**] 06:35AM BLOOD Calcium-8.5 Phos-3.9 Mg-2.0

Other Lab Data
[**2161-11-29**] 04:45PM BLOOD WBC-11.8*# RBC-2.93* Hgb-7.7* Hct-23.3*
MCV-79* MCH-26.3* MCHC-33.1 RDW-17.4* Plt Ct-231
[**2161-11-30**] 01:46PM BLOOD WBC-17.4* RBC-2.88* Hgb-7.7* Hct-22.4*
MCV-78* MCH-26.7* MCHC-34.3 RDW-17.5* Plt Ct-254
[**2161-12-1**] 03:45PM BLOOD WBC-19.2* RBC-3.11* Hgb-8.5* Hct-24.4*
MCV-79* MCH-27.4 MCHC-34.8 RDW-18.0* Plt Ct-245
[**2161-12-3**] 02:01AM BLOOD WBC-14.1* RBC-3.32* Hgb-9.1* Hct-26.3*
MCV-79* MCH-27.3 MCHC-34.4 RDW-17.4* Plt Ct-204
[**2161-12-5**] 05:40AM BLOOD WBC-12.0* RBC-2.93* Hgb-8.2* Hct-24.3*
MCV-83 MCH-27.9 MCHC-33.6 RDW-17.8* Plt Ct-243
[**2161-11-30**] 09:50PM BLOOD Glucose-81 UreaN-113* Creat-7.1* Na-146*
K-3.9 Cl-109* HCO3-18* AnGap-23*
[**2161-12-2**] 03:25AM BLOOD Glucose-234* UreaN-124* Creat-7.3*
Na-148* K-2.1* Cl-104 HCO3-23 AnGap-23*
[**2161-12-3**] 02:01AM BLOOD Glucose-144* UreaN-112* Creat-6.0* Na-142
K-4.0 Cl-106 HCO3-23 AnGap-17
[**2161-12-5**] 05:40AM BLOOD Glucose-164* UreaN-97* Creat-5.3* Na-138
K-3.7 Cl-99 HCO3-25 AnGap-18
[**2161-11-30**] 01:46PM BLOOD ALT-26 AST-48* LD(LDH)-297* CK(CPK)-549*
AlkPhos-44 TotBili-0.5
[**2161-11-28**] 11:30AM BLOOD cTropnT-0.02*
[**2161-11-28**] 11:12PM BLOOD CK-MB-4 cTropnT-0.06*
[**2161-11-28**] 11:30AM BLOOD CK-MB-4 proBNP-[**Numeric Identifier **]*
[**2161-11-30**] 08:41AM BLOOD CK-MB-6 cTropnT-0.05*
[**2161-11-30**] 01:46PM BLOOD CK-MB-6 cTropnT-0.04*
[**2161-12-2**] 08:29AM BLOOD calTIBC-177* VitB12-1296* Folate-14.7
Ferritn-558* TRF-136*
[**2161-12-2**] 01:58PM BLOOD Hapto-310*
[**2161-11-28**] 11:30AM BLOOD Acetone-NEGATIVE
[**2161-12-2**] 03:20PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2161-11-30**] 01:56AM BLOOD rapmycn-3.8*
[**2161-12-6**] 05:25AM BLOOD rapmycn-3.8*
[**2161-12-1**] 04:48AM BLOOD Lactate-1.5
[**2161-12-2**] 03:20PM BLOOD HEPATITIS C - RIBA-Test
Test                          Result              Reference
Range/Units
HCV AB, RIBA                  POSITIVE  A         NEGATIVE

5-1-1 (P)/C100 (P)            REACTIVE  A         NONREACTIVE

C33C                          REACTIVE  A         NONREACTIVE

C22P                          REACTIVE  A         NONREACTIVE

NS5                           NONREACTIVE         NONREACTIVE

HSOD                          NONREACTIVE         NONREACTIVE


MICRO
Blood cx x 2 [**11-28**], [**12-6**] no growth
Urine cx [**11-28**] no growth; urine cx [**12-6**] 10-100L yeast
sputum cx [**11-28**] moraxella catarrhalis
BAL neg; legionella urinary ag neg
C diff neg x 2
CMV IgM neg, CMV VL not detected

IMAGING
Admission CXR: New large left lower lobe pneumonia.

TTE:The left atrium and right atrium are normal in cavity size.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated with severe global
hypokinesis. The basal inferolateral and anterior walls contract
best (LVEF = 20 %). The right ventricular cavity is mildly
dilated with hypokinesis of the distal half of the free wall.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis. Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. Significant pulmonic
regurgitation is seen. The end-diastolic pulmonic regurgitation
velocity is increased suggesting pulmonary artery diastolic
hypertension.
Compared with the prior study (images reviewed) of [**2161-4-17**],
the findings are similar.

CT neck: CONCLUSION: Extensive enlargement of the left
sternocleidomastoid muscle with heterogeneous density. In the
absence of obvious signs for infection, either clinically or
radiologically, the finding could potentially be either a
neoplastic or some other type of fibromatous process.
As we discussed by telephone, as it would be potentially
hazardous to
administer either iodinated contrast or gadolinium-DTPA
intravenously,
alternative imaging strategies could include a non-contrast MRI
scan of the neck, which can only be undertaken when there is
clarification that the aneurysm clip is MR compatible.
Additionally, [**Name (NI) 13416**] would offer a very efficacious means to
safely image this abnormality.

U/S Neck: Diffuse expansion and abnormal echogenicity and
hyperemia to the left sternocleidomastoid muscle. Findings could
be compatible with a myositis. Alternatively, hematoma would be
a differential consideration in the appropriate setting. If
there are no contraindications, MRI without contrast (given the
patient's history of end- stage renal disease) could potentially
assist with further characterization.

[**2161-12-3**] CXR
IMPRESSION: Left lower lobe opacity with air bronchograms,
consistent with LLL pneumonic infiltrate.


Brief Hospital Course:
Ms. [**Known lastname **] is a 52 year old female with Type 1 DM, ESRD s/p
failed transplant, admitted with respiratory failure secondary
to CHF versus pneumonia.

She was initially admitted to the MICU:
MICU Course
In the MICU, she was intubated upon admission [**11-28**] and
respiratory failure was thought to be a combination of pneumonia
and volume overload.  Sputum cultures grew Moraxella, and
levaquin was started.  The patient was intermittently
hypotensive but did not require pressors.  She was also volume
overloaded and was diuresed with IV lasix. Creatinine rose as
high as 7, and she underwent 1 session of HD.  Renal failure
improved thereafter.  She also had an anion gap acidosis briefly
requiring insulin gtt.  Subsequently her respiratory failure
improved, and she was extubated and then weaned off oxygen,
breathing comfortably on room air. Blood pressure rose into the
160s, and home BP meds were restarted.   Home lantus and ISS
were also restarted.  Central line was pulled.  She was
transferred to the [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] service.

Remainder of floor course summarized below by problem

#) Pneumonia: Oxygen saturations remained mid 90s on room air at
rest and with ambulation.  Levaquin was continued for a total 10
day course renally dosed.  She had intermittent low-grade fevers
but was afebrile x 24 hours prior to discharge with Tmax 99s.

#) CHF: EF was 20% [**2161-11-30**], no change since [**4-14**]. Initial
respiratory decompensation may have been in part flash pulmonary
edema in the setting of hypertension. However, she had no
further evidence of volume overload and did not require Lasix on
the floor. Remained euvolemic at time of discharge.

#) Neck mass: Patient was noted to have a nontender L neck mass.
CT without contrast (given her renal failure) was done, showing
SCM enlargement of unclear etiology.  Follow-up US was done,
showing similar findings. After discussion with her
nephrologist, it was felt that this was most likely a hematoma
since there was an attempted line placement at this site and the
pt did not have this mass prior to line placement. It should be
followed to resolution as an outpatient.

#) Hypertension: Home antihypertensive regimen was continued.
SBP was 140s at time of discharge.

#) ESRD s/p xplant: Creatinine continued to improve, and urine
output was high, consistent with resolving ATN.  She did not
require further HD sessions. Prednisone and sirolimus were
continued as well as Zemplar.  Tacrolimus was held per renal
recommendations.

#) Type 1 DM: [**Hospital1 **] Lantus and HISS were continued per home
regimen
.
#) Anemia: Erythropoeitin was continued at three times weekly
rather than twice weekly dosing.


Medications on Admission:
Epo 100 units q MWF
Zemplar 2 mcg daily
Pravastatin 20 mg daily
Prednisone 5 mg daily
Sirolimus 8 mg daily
Ferrous Sulfate 325 mg daily
Colace 100 mg [**Hospital1 **]
Senna [**Hospital1 **] prn
Metoprolol Succinate 200 mg daily
Tacrolimus 3 mg q 12 hours
Ranitidine 75 mg daily
Nifedipine 90 mg daily
Insulin


Discharge Medications:
1. Epoetin Alfa 4,000 unit/mL Solution Sig: 4000 (4000) units
Injection QMOWEFR (Monday -Wednesday-Friday).
Disp:*12 vials* Refills:*0*
2. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Sirolimus 2 mg Tablet Sig: Four (4) Tablet PO once a day.
4. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. Ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
8. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
9. Insulin
Please resume your outpatient lantus and insulin sliding scale.
10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
11. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
12. Zemplar 2 mcg Capsule Sig: One (1) Capsule PO once a day.


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] [**Hospital 2256**]

Discharge Diagnosis:
primary:  pneumonia, acute exacerbation of chronic systolic
heart failure
secondary: type 1 diabetes, hypertension, hepatitis C, chronic
kidlney disease s/p transplant [**2152**]


Discharge Condition:
hemodynamically stable, afebrile, shortness of breath improved,
ambulating without assist


Discharge Instructions:
You came to the hospital because you were short of breath.  This
was likely because you had pneumonia and fluid in your lungs
because of high blood pressure.  Your blood pressure was
treated, and you received antibiotics for your pneumonia.  Your
kidney function was worse for a short time, and you underwent
one session of dialysis.  You have completed your antibiotic
course for your pneumonia.

The following medications were changed in the hospital:
Tacrolimus was stopped
We changed your Epo dose to 4,000 units every Monday, Wednesday
and Friday. You were previously on 4000 units twice per week.

Please return to the emergency room if you have shortness of
breath, high fevers and chills, chest pain, or other symptoms
that are concerning to you.

Followup Instructions:
You are scheduled for a follow-up ultrasound of your neck next
Wednesday [**12-16**] at 2:45 pm. Please go to the [**Location (un) 10043**] of the
[**Hospital Ward Name 517**] to have this done.
Please follow up with Dr. [**First Name (STitle) 805**] on [**12-16**] at 1:30pm in clinic.
Provider: [**Name10 (NameIs) 72667**],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].  [**Telephone/Fax (1) 1260**]  Call to schedule
appointment
{'Acute respiratory failure,Pneumonia, organism unspecified,Acute on chronic systolic heart failure,Complications of transplanted kidney,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Other primary cardiomyopathies,Hyperosmolality and/or hypernatremia,Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled,Chronic hepatitis C without mention of hepatic coma,Anemia in chronic kidney disease'}


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: cough

PRESENT ILLNESS: Ms. [**Known lastname **] is a 52 year old type I diabetic, ESRD, admitted
with acute onset of shortness of breath and hemoptysis at 9AM.
She was nauseated and had vomiting and dry-heaved in the morning
with blood-tinged vomitus vs. emesis. She denied chest pain,
fevers, chills prior to admission. Per patient's daughter, she
had been noted to be coughing recently, however, did not
complain of fevers or chills to her daugher. No myalgias. No
sick contacts.

MEDICAL HISTORY: Type 1 DM
Non-ischemic Dilated cardiomyopathy, EF < 20% 4/08 by echo
Hypertension
CKD s/p transplant in [**2152**], undergoing evaluation for possible
second transplant
Chronic hepatitis C
Intracranial right ICA aneurysm; gets yearly imaging. 5mm [**2154**],
8mm on [**2159-2-7**] MRA.
H/o C4-5 and C5-6 anterior decompression and fusion after MVA
[**2157**], Dr. [**Last Name (STitle) 363**]
Ulnar nerve impingement bilaterally
S/p Rotator cuff repair
S/p release of right carpal tunnel

MEDICATION ON ADMISSION: Epo 100 units q MWF
Zemplar 2 mcg daily
Pravastatin 20 mg daily
Prednisone 5 mg daily
Sirolimus 8 mg daily
Ferrous Sulfate 325 mg daily
Colace 100 mg [**Hospital1 **]
Senna [**Hospital1 **] prn
Metoprolol Succinate 200 mg daily
Tacrolimus 3 mg q 12 hours
Ranitidine 75 mg daily
Nifedipine 90 mg daily
Insulin

ALLERGIES: Percocet

PHYSICAL EXAM: VS: HR 83, BP 111/70, RR 30, 93%
Vent settings: Fio2 100%, PEEP 10, TV 500, RRs 15 (patietn
breathing at 15)
Gen: sedated, intubated
HEENT: PERRL, 3mm--> 2mm, intbuated
CV: difficult to appreciate due to coarse breath sounds
Pulm: coarse rhonchi diffusely
Abd: soft, NT, ND, bowel sounds present
Ext: cool, distal pulses present
Neuro: sedated, PERRL, withdraws to pain

FAMILY HISTORY: Sister died of [**Name (NI) 101497**], many other family members on maternal side
with diabetes.

SOCIAL HISTORY: Divorced, has 2 children and 9 grandchildren. No tobacco, quit
12 years ago after having previously smoked 1ppd x27 years. No
EtOH although previously drank socially. 

### Response:
{'Acute respiratory failure,Pneumonia, organism unspecified,Acute on chronic systolic heart failure,Complications of transplanted kidney,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Other primary cardiomyopathies,Hyperosmolality and/or hypernatremia,Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled,Chronic hepatitis C without mention of hepatic coma,Anemia in chronic kidney disease'}
