CHIEF COMPLAINT: confusion

PRESENT ILLNESS: 77F with sleep apnea on home O2 recently discharged from [**Hospital1 2025**] s/p
treatment of LE cellulitis and increasing LE edema.  CXR @ [**Hospital1 2025**]
revelaed worsening pulmonary edema, and she had a positive UA.
She received both CTX and Vancomycin.  She also received bolus
fluids for hypotension. Patient discharged on Dicloxicillin on
[**2184-6-24**]

MEDICAL HISTORY: HTN
Hyperlipidemia
Dm2
Afib on Coumadin
Gout
Sleep Apnea

MEDICATION ON ADMISSION: Allopurinol 300 daily
Atorvastatin 10 daily
Diltiazem 360 daily
Gabapentin 300 [**Hospital1 **]
Valsartan 80 mg daily
Warfarin 5 mg daily
Lasix 100 mg [**Hospital1 **]
Glyburide 2.5 [**Hospital1 **]
Eucerin Cream
Nystatin Poweder
Dicloxacillin 250 mg q8h x 14 days (Day 1 [**2184-6-23**])
.

ALLERGIES: Lisinopril

PHYSICAL EXAM: Vitals - T:95.5  BP:110/60  HR:90  RR:18  02 sat: 88RA
GENERAL: somnolent
SKIN: bruise on L flank
HEENT: large neck, AT/NC, EOMI, PERRLA, anicteric sclera, pink
conjunctiva, patent nares, MMM, supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB
ABDOMEN: obese, +BS, nontender in all quadrants, no
rebound/guarding, no appreciable hepatosplenomegaly
M/S: lower extremity venous stasis changes, 2+ edema bilaterally
PULSES: 2+ DP pulses bilaterally
NEURO: unable to assess

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: denies smoking, etoh use
Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Pure hypercholesterolemia,Undiagnosed cardiac murmurs,Other dependence on machines, supplemental oxygen,Long-term (current) use of anticoagulants,Acute respiratory failure,Obstructive chronic bronchitis with (acute) exacerbation,Atrial fibrillation,Cellulitis and abscess of leg, except foot,Intestinal infection due to Clostridium difficile,Unspecified pleural effusion,Other and unspecified coagulation defects,Urinary tract infection, site not specified,Obstructive sleep apnea (adult)(pediatric),Coronary atherosclerosis of native coronary artery,Gout, unspecified,Obesity, unspecified
DMII wo cmp nt st uncntr,Pure hypercholesterolem,Cardiac murmurs NEC,Depend-supplement oxygen,Long-term use anticoagul,Acute respiratry failure,Obs chr bronc w(ac) exac,Atrial fibrillation,Cellulitis of leg,Int inf clstrdium dfcile,Pleural effusion NOS,Coagulat defect NEC/NOS,Urin tract infection NOS,Obstructive sleep apnea,Crnry athrscl natve vssl,Gout NOS,Obesity NOS
Admission Date:  [**2184-6-26**]              Discharge Date:   [**2184-6-30**]

Date of Birth:  [**2107-1-31**]             Sex:   F

Service: MEDICINE

Allergies:
Lisinopril

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
confusion

Major Surgical or Invasive Procedure:
None

History of Present Illness:
77F with sleep apnea on home O2 recently discharged from [**Hospital1 2025**] s/p
treatment of LE cellulitis and increasing LE edema.  CXR @ [**Hospital1 2025**]
revelaed worsening pulmonary edema, and she had a positive UA.
She received both CTX and Vancomycin.  She also received bolus
fluids for hypotension. Patient discharged on Dicloxicillin on
[**2184-6-24**]

Patient returned to our ED on [**2184-6-25**] with change in mental
status. and increased LE pain, as noticed by family.  Vitals on
admission were 96.6 72 112/58 20 100NRB (88 RA).  CXR was
negative for any focal infiltrate.  She was given Solumedrol 125
iv x 1 for presumed COPD exacerbation.  ABG: 7.42/54/363.
Patient had facemask removed and transitioned to NC.  She was
also given Vanc/Levo.  Patient remained asleep for 4 hours
without internvention and sent to the floor.  On the floor
patinet was somnolent and ABG was 7.31/65/135 and patinet was
transferred to the MICU for CPAP for presumed hypercarbic
respiratory failure.


Past Medical History:
HTN
Hyperlipidemia
Dm2
Afib on Coumadin
Gout
Sleep Apnea

Social History:
denies smoking, etoh use

Family History:
Noncontributory

Physical Exam:
Vitals - T:95.5  BP:110/60  HR:90  RR:18  02 sat: 88RA
GENERAL: somnolent
SKIN: bruise on L flank
HEENT: large neck, AT/NC, EOMI, PERRLA, anicteric sclera, pink
conjunctiva, patent nares, MMM, supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB
ABDOMEN: obese, +BS, nontender in all quadrants, no
rebound/guarding, no appreciable hepatosplenomegaly
M/S: lower extremity venous stasis changes, 2+ edema bilaterally
PULSES: 2+ DP pulses bilaterally
NEURO: unable to assess

Pertinent Results:
Imaging:
CXR: IMPRESSION:  Limited examination.  Moderate cardiomegaly.
No pulmonary abnormality.
.
CT Head
FINDINGS:  There is no hemorrhage, mass effect, shift of the
normally midline structures, or major vascular territorial
infarct.  The [**Doctor Last Name 352**]-white matter differentiation is preserved.
There is no hydrocephalus.  Cysts are seen within the choroid
plexus.  Osseous structures demonstrate mild upper hyperostosis
of the walls of the right maxillary sinus.  The paranasal
sinuses and mastoid air cells are well aerated.
IMPRESSION:
1.  No hemorrhage or mass effect.
.
CT CHEST
CTA CHEST:  There are coronary artery calcifications and
calcifications of the mitral and aortic annuli.  Scattered
mediastinal lymph nodes do not meet CT criteria for enlargement.
 While the examination is technically limited, there are no main
or segmental pulmonary artery emboli.  There are small bilateral

pleural effusions and mild diffuse ground-glass opacity as well
as mild cardiomegaly, suggestive of mild pulmonary edema.
IMPRESSION:
1.  Moderate cardiomegaly with small bilateral pleural effusions
and
ground-glass opacities suggestive of mild pulmonary edema.

Brief Hospital Course:
77F with known COPD on home O2 with possible COPD exacerbation
and resultant hypercarbin respiratory failure

Hypercarbic respiratory failure: Cause is unclear, though may
have had some element of CHF.  Patient was found to have c02 in
the mid 60s and was somnolent and thus was taken to the MICU for
non-invasive ventilation.  This intervention improved mental
status.  Additionally was initially diuresed, but this was
complicated by hypotension. Cause was also likely secondary to
obesity hypoventilation given patient's habitus.  As well
patient has OSA and was started on CPAP.  Should increase CPAP
as tolerated and patient if possible should have a repeat sleep
study.  Improved CO2 and mental status after CPAP.  There is
very little evidence in chart that patient actually has COPD.
Night prior to discharge tolerated 10 CPAP.  This should be
continued and a sleep consult should be done at some point.

Hypotension: Found to have SBPs in the 80s, however always able
to mentate and had adequate urine output.  Hypotension was
likely a combination of difficulty in measuring, given habitus,
hypovolemia given diarrhea and high doses of diltiazem (thought
to be home doses, but possible patient was non-adherant).    BPs
stable prior to discharge in the 100-130s range.  Given that the
patient has baseline hypertension, suspect that diovan will
likely have to be restarted, as well as diltiazem.

C diff: diagnosed during this admission.  Started on flagyl for
14 day course.  Symptoms improved at time of diagnosis

Cellulitis - Patient recently discharged from [**Hospital1 2025**] s/p treatment
for cellulitis on dicloxacillin, on presentation was treated
wtih vancomycin.  However, by HD # 2 was clearly improved and
antibiotics were discontinued.

Atrial fibrillation: had episodes of tachycardia and was started
on diltiazem at 1/2 home dose, was hypotensive (though as above,
difficult to get accurate BP) but also intermittently
tachycardic.  Rate control was significantly improved with
digoxin load.  The level of digoxin should be checked in [**11-25**]
days to ensure patient not toxic at time of steady state.

Coagulopathy: patient with increased INR during admission.  This
is likely secondary to coumadin dosing at slightly higher (5 mg
versus 2.5 in some notes) as well as poor intake and diarrhea.
Additionally is on metronidazole that can increase it.  This
level should be followed with coumadin restarted when level <3.
Though it is possible that the patient has developed another
cause for hypocoagulibility, it seems less likely in the setting
of previously normal coags.  Nonetheless, if this should
continue to increase, mixing studies as well as hematology
evaluation may be necessary.

Medications on Admission:
Allopurinol 300 daily
Atorvastatin 10 daily
Diltiazem 360 daily
Gabapentin 300 [**Hospital1 **]
Valsartan 80 mg daily
Warfarin 5 mg daily
Lasix 100 mg [**Hospital1 **]
Glyburide 2.5 [**Hospital1 **]
Eucerin Cream
Nystatin Poweder
Dicloxacillin 250 mg q8h x 14 days (Day 1 [**2184-6-23**])
.


Discharge Medications:
1. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO twice a day.
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
3. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.

4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
7. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily):
please check level [**7-1**] or [**7-2**].
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
Hypercarbic respiratory failure
Obstructive sleep apnea
Atrial fibrillation
C diff
CAD


Discharge Condition:
improved


Discharge Instructions:
You were admitted with trouble breathing and recovering
infection.  While you were here your breathing improved with the
use of CPAP.  Additionally you now have c diff infection in your
bowels for which you should take antibiotics for 10 more days.

Please return to the ER if you have fever, chills, chest pain,
shortness of breath, vomiting, worsening diarrhea, abdominal
pain or any other concerning symptoms

Followup Instructions:
Please follow up with you primary care physician or with Dr.
[**Last Name (STitle) **] at [**Telephone/Fax (1) 1579**].

Additionally you should be seen by a pulmonologist.  If you
would like to be seen by Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 513**]


                             [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
{'Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Pure hypercholesterolemia,Undiagnosed cardiac murmurs,Other dependence on machines, supplemental oxygen,Long-term (current) use of anticoagulants,Acute respiratory failure,Obstructive chronic bronchitis with (acute) exacerbation,Atrial fibrillation,Cellulitis and abscess of leg, except foot,Intestinal infection due to Clostridium difficile,Unspecified pleural effusion,Other and unspecified coagulation defects,Urinary tract infection, site not specified,Obstructive sleep apnea (adult)(pediatric),Coronary atherosclerosis of native coronary artery,Gout, unspecified,Obesity, 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: confusion

PRESENT ILLNESS: 77F with sleep apnea on home O2 recently discharged from [**Hospital1 2025**] s/p
treatment of LE cellulitis and increasing LE edema.  CXR @ [**Hospital1 2025**]
revelaed worsening pulmonary edema, and she had a positive UA.
She received both CTX and Vancomycin.  She also received bolus
fluids for hypotension. Patient discharged on Dicloxicillin on
[**2184-6-24**]

MEDICAL HISTORY: HTN
Hyperlipidemia
Dm2
Afib on Coumadin
Gout
Sleep Apnea

MEDICATION ON ADMISSION: Allopurinol 300 daily
Atorvastatin 10 daily
Diltiazem 360 daily
Gabapentin 300 [**Hospital1 **]
Valsartan 80 mg daily
Warfarin 5 mg daily
Lasix 100 mg [**Hospital1 **]
Glyburide 2.5 [**Hospital1 **]
Eucerin Cream
Nystatin Poweder
Dicloxacillin 250 mg q8h x 14 days (Day 1 [**2184-6-23**])
.

ALLERGIES: Lisinopril

PHYSICAL EXAM: Vitals - T:95.5  BP:110/60  HR:90  RR:18  02 sat: 88RA
GENERAL: somnolent
SKIN: bruise on L flank
HEENT: large neck, AT/NC, EOMI, PERRLA, anicteric sclera, pink
conjunctiva, patent nares, MMM, supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB
ABDOMEN: obese, +BS, nontender in all quadrants, no
rebound/guarding, no appreciable hepatosplenomegaly
M/S: lower extremity venous stasis changes, 2+ edema bilaterally
PULSES: 2+ DP pulses bilaterally
NEURO: unable to assess

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: denies smoking, etoh use 

### Response:
{'Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Pure hypercholesterolemia,Undiagnosed cardiac murmurs,Other dependence on machines, supplemental oxygen,Long-term (current) use of anticoagulants,Acute respiratory failure,Obstructive chronic bronchitis with (acute) exacerbation,Atrial fibrillation,Cellulitis and abscess of leg, except foot,Intestinal infection due to Clostridium difficile,Unspecified pleural effusion,Other and unspecified coagulation defects,Urinary tract infection, site not specified,Obstructive sleep apnea (adult)(pediatric),Coronary atherosclerosis of native coronary artery,Gout, unspecified,Obesity, unspecified'}
