CHIEF COMPLAINT: SOB

PRESENT ILLNESS: [**Age over 90 **]F non-verbal with dementia  and NH resident who p/w several
days of hypoxia, fevers, and cough.  Pt was started on
levofloxacin and clindamycin for presumed aspiration PNA and
klebsiella UTI at NH 2 days ago.  Pt also received lasix 20 mg
po qd x 2 days for presumed CHF decompensation.  Pt was found to
be hypoxic at 89% on NRB and tachypnic to 38.  Pt received lasix
40mg iv x 1 and ntg paste and was x-ferred to [**Hospital1 18**].

MEDICAL HISTORY: 1.  Dementia - non-verbal at baseline and dependent for all
activities of daily living and not ambulatory
2.  Syncope
3.  Osteoporosis
4.  Depression
5.  Heel ulcer
6.  Incontinence

MEDICATION ON ADMISSION: 1.  ASA 81mg once daily
2.  Remeron 75mg QHS
3.  MVI once daily
4.  artificial tears
5.  tums [**Hospital1 **]
6.  Senna
7.  Colace
8.  Milk of Magnesia

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Physical Exam:
VS: Tc: 100.2   HR: 113   BP: 93/55   RR: 12   97% on 2L-5L NC
Gen: elderly women lying in bed in NAD.  no diaphoresis, no
accessory muscle use.  Pt appears awake and alert but does not
communicate in any manner - verbally, or by gesturing.
HEENT: PERRL, EOMI, mm dry
CV: faint heart sounds, tachycardic, S1, S2, no murmurs, rubs,
gallops
Chest: diffuse wheezing on expiration and coarse rhonchi
bilaterally
Abd: soft, NT, ND, BS hypoactive
Ext: no clubbing, cyanosis, edema, toes appear tonically down
going.
Neuro: Pt not moving any extremity spontaneously.

FAMILY HISTORY: 

SOCIAL HISTORY: Pt lives in a nursing home and is completely dependent for
activities of daily living.  Pt is non-verbal at baseline. The
patient is widowed.  She has two daughters, one of whom is the
health care proxy [**Name (NI) 16405**] [**Name (NI) 349**] ([**Telephone/Fax (1) 16406**]).
Atrial fibrillation,Hyperosmolality and/or hypernatremia,Acute kidney failure, unspecified,Retention of urine, unspecified,Diastolic heart failure, unspecified,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Other abnormal blood chemistry,Coronary atherosclerosis of native coronary artery,Other persistent mental disorders due to conditions classified elsewhere,Need for prophylactic vaccination and inoculation against influenza,Unspecified septicemia,Severe sepsis,Septic shock,Urinary tract infection, site not specified
Atrial fibrillation,Hyperosmolality,Acute kidney failure NOS,Retention urine NOS,Diastolc hrt failure NOS,Klebsiella pneumoniae,Abn blood chemistry NEC,Crnry athrscl natve vssl,Mental disor NEC oth dis,Vaccin for influenza,Septicemia NOS,Severe sepsis,Septic shock,Urin tract infection NOS
Admission Date:  [**2196-12-12**]              Discharge Date:   [**2196-12-19**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 5827**]
Chief Complaint:
SOB

Major Surgical or Invasive Procedure:
None


History of Present Illness:
   [**Age over 90 **]F non-verbal with dementia  and NH resident who p/w several
days of hypoxia, fevers, and cough.  Pt was started on
levofloxacin and clindamycin for presumed aspiration PNA and
klebsiella UTI at NH 2 days ago.  Pt also received lasix 20 mg
po qd x 2 days for presumed CHF decompensation.  Pt was found to
be hypoxic at 89% on NRB and tachypnic to 38.  Pt received lasix
40mg iv x 1 and ntg paste and was x-ferred to [**Hospital1 18**].

   In [**Name (NI) **], pt was febrile to 102 and tachypnic to 30's with SaO2
of 95% on 5L NC.  Pt was also found to have lactate of 2.5 with
WBC 16 and no bands.  ABG in ED showed the following:
7.46/37/78.  Pt received Levo, flagyl and Vanco prior to
receiving Blood Cx.  CXR was without obvious infiltrates and KUB
showed no dilated loops of bowel.  Later sensitivities from NH,
showed the Klebsiella to be Resistant to levo and cipro, but
Sensitive to Cefriaxone.  The patient subsequently got
Cefriaxone 1 g IV x 1. Patient also placed on levophed gtt. In
addition, the patient also went into afib with RVR at 170's,
which was subsequently slowed down to a ventricular rate of 120s
w/ IV Dilt.  Pt developed Troponin of 1.2 w/ nl CK in setting of
RVR, suggesting this was most likley demand ischemia.  Pt also
was found to have a sodium of 160 (hypovolemic hyperNa.

Patient was then admitted to the [**Hospital Unit Name 153**]. Patient subsequently
switched from levophed to vasopressin and dobutamine, with
disscontuation of pressors on [**12-14**] and had improvement of
oxygenation. Antibiotics therapy was changed from ceftriaxone
and Zosyn to Unasyn. Culture data from [**Hospital1 18**] remains negative to
date. Patient did have recurrent episode of Afib with RVR that
was treated with diltiazem, while on dobutamine, with no further
episodes while off B-agonists.

At time of transfer, patient remains non-verbal.

Past Medical History:
1.  Dementia - non-verbal at baseline and dependent for all
activities of daily living and not ambulatory
2.  Syncope
3.  Osteoporosis
4.  Depression
5.  Heel ulcer
6.  Incontinence


Social History:
Pt lives in a nursing home and is completely dependent for
activities of daily living.  Pt is non-verbal at baseline. The
patient is widowed.  She has two daughters, one of whom is the
health care proxy [**Name (NI) 16405**] [**Name (NI) 349**] ([**Telephone/Fax (1) 16406**]).

Physical Exam:
Physical Exam:
VS: Tc: 100.2   HR: 113   BP: 93/55   RR: 12   97% on 2L-5L NC
Gen: elderly women lying in bed in NAD.  no diaphoresis, no
accessory muscle use.  Pt appears awake and alert but does not
communicate in any manner - verbally, or by gesturing.
HEENT: PERRL, EOMI, mm dry
CV: faint heart sounds, tachycardic, S1, S2, no murmurs, rubs,
gallops
Chest: diffuse wheezing on expiration and coarse rhonchi
bilaterally
Abd: soft, NT, ND, BS hypoactive
Ext: no clubbing, cyanosis, edema, toes appear tonically down
going.
Neuro: Pt not moving any extremity spontaneously.

Pertinent Results:
[**2196-12-12**] 04:45PM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.023
[**2196-12-12**] 04:45PM URINE  BLOOD-NEG NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2196-12-12**] 04:45PM URINE  RBC-<1 WBC-[**4-1**] BACTERIA-MOD YEAST-NONE
EPI-[**4-1**]
.
[**2196-12-12**] 04:45PM   PT-14.1* PTT-23.1 INR(PT)-1.3
.
[**2196-12-12**] 04:45PM   WBC-16.1*# RBC-4.45# HGB-13.7# HCT-41.6#
MCV-94 MCH-30.8 MCHC-32.9 RDW-13.5
[**2196-12-12**] 04:45PM   NEUTS-87.6* LYMPHS-8.2* MONOS-3.6 EOS-0.3
BASOS-0.3
[**2196-12-12**] 11:05PM   WBC-14.3* RBC-3.57* HGB-10.7* HCT-33.5*
MCV-94 MCH-29.9 MCHC-31.8 RDW-13.5
.
[**2196-12-12**] 04:45PM BLOOD Glucose-167* UreaN-59* Creat-1.2* Na-162*
K-4.1 Cl-125* HCO3-25 AnGap-16
[**2196-12-12**] 07:58PM BLOOD Creat-1.1 Na-160* K-3.4 Cl-125* HCO3-26
AnGap-12
[**2196-12-12**] 11:05PM BLOOD Glucose-116* UreaN-44* Creat-0.9 Na-158*
K-3.2* Cl-122* HCO3-28 AnGap-11
[**2196-12-12**] 04:45PM BLOOD ALT-13 AST-24 LD(LDH)-340* CK(CPK)-191*
AlkPhos-106 TotBili-0.3
.
[**2196-12-12**] 04:45PM BLOOD CK(CPK)-185*
[**2196-12-12**] 07:58PM BLOOD CK(CPK)-164*
[**2196-12-12**] 11:05PM BLOOD CK(CPK)-159*
[**2196-12-12**] 04:45PM BLOOD CK-MB-2 cTropnT-1.20*
[**2196-12-12**] 04:45PM BLOOD CK-MB-2 cTropnT-1.16*
[**2196-12-12**] 11:05PM BLOOD CK-MB-2 cTropnT-0.69*
.
[**2196-12-12**] Abd X-Ray: "No dilated loops of bowel to suggest
obstruction or megacolon."
[**2196-12-12**]: CXR: "Cardiomegaly. Bibasilar atelectasis. No chf."


Brief Hospital Course:
[**Age over 90 **] yo demented female NH resident admitted to [**Hospital Unit Name 153**] with sepsis
protocol.

1. Sepsis: Most likely urosepsis, as patient admitted with UTI
and had no other evident source of infection (pt data from NH
showing Klebsiella sensitive to ceftriaxone).  Patient initially
treated with ceftriaxone, then Unasyn, given concern of
concomitant pneumonia and then to Augmentin once patient
tolerating pos.
Patient was weaned off of pressors and was stable
hemodynamically and afebrile for over 72 hours prior to
discharge.  She is to take Augmentin through [**2196-12-25**], to
complete a 2-week course of antibiotics.

2. Hypoxia: Likely [**2-29**] to increasd work of breathing and then
atelectasis or fluid overload.  Patient was titrated down from
Non-rebreather to oxygen supplementation via O2 nasal canula.
Her oxygenation remains stable on 2L and [**12-18**] has been stable
on room air.  Please follow RA sats, may require low level of
oxygen via nasal cannula to maintain O2 sat>92%.

3. Glucose control: Patient initiated on insulin in setting of
sepsis, with continued elevations in glucose. Patient was
started on QID FS and insulin sliding scale.  However, patients
finger stick glucoses were well controlled and she required no
insulin for several days prior to discharge.

4. Hypernatremia:  It is unclear how long the pt has been
hypernatremic and therefore was treated as though it had been
chronic. Peak sodium of 162 on admission, and was thought to be
secondary to dehydration.  She was given D5W with resolution of
her hypernatremia, though patients sodium returned from a low of
146 [**12-16**] to 150 [**12-17**], and was given an additional 2 liters of
D5W.  Serum Na was 143 on [**12-18**].  Given what appears to be
chronic hypernatremia presumably from dehydration, patients
serum sodium and hydration status should be followed
post-discharge, but should not be aggressively treated as pt
tolerates mild hypernatremia.

5.  Afib: Pt with episode of rapid ventricular response while in
ED which resolved with diltiazem and IV diltiazem PRN with
adequate control. Patient continued to experience paroxysmal
AFib while on floor and was initiated on low dose beta-blocker.
She thereafter converted back to normal sinus rhythm.  The
patients daughter and Health care proxy, [**Name (NI) 16405**] [**Name (NI) 349**]
([**Telephone/Fax (1) 16406**]) would like to discuss with the patient's primary
care physician possible initiation of coumadin for long-term
stroke prophylaxis, pending resolution of acute issues.

6.  Demand ischemia/coronary artery disease: Patient noted to
have dynamic ischemic EKG changes in setting of Atrial
fibrillation with rapid ventricular response and urosepsis. With
clinical improvement, patient's cardiac enzymes downtrending
(from CK maximum of 191 to 81, CK-MB maximum 4, Troponin T
maxiumum 1.20). Patient continued on ASA and beta-blocker.

7. hypokalemia - patient noted on several occasions to have
hypokalemia, with minimum serum potassium 3.2.  Potassium was
repleted as needed.

8. Prolonged Qt/Qtc interval - Has been noted to have prolonged
Qtc interval previously, and likely secondary to hypokalemia and
hypomagnesemia.  Electrolytes repleted as above.  Patient was
maintained on telemetry for much of her hospitalization, notable
only for occasional ectopy and intermittent atrial fibrillation.

9. MRSA+ sputum - sputum culture [**2196-12-15**] revealed sparse
Staphylococcus aureus that was oxacillin resistant.  However,
the patient did not appear to have pneumonia clinically (no
cough, adequate oxygen saturations on room air, afebrile, no
pneumonia suspected by physical examination).  Follow-up chest
film [**12-18**] did not show pneumonia.

10. Hypertension - patient was begun on low-dose metoprolol as
above, and also on low-dose lisinopril (2.5 mg daily).

11. influenza vaccination - patient received influenza vaccine
[**2196-12-18**] as she will be returning to an extended care facility.

12. Code: Patient's code status was DNR/DNI throughout
hospitalization.


Medications on Admission:
1.  ASA 81mg once daily
2.  Remeron 75mg QHS
3.  MVI once daily
4.  artificial tears
5.  tums [**Hospital1 **]
6.  Senna
7.  Colace
8.  Milk of Magnesia


Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours).
2. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q4-6H (every 4 to 6 hours) as needed.
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Amoxicillin-Pot Clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
6. oxygen supplementation via nasal canula. Please titrate to
maintain sats>94%
7. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Natural Tears 1.4 % Drops Sig: [**1-29**]  Ophthalmic  twice a day:
as needed.
9. Multi-Vitamin     Tablet Sig: One (1) Tablet PO once a day.
10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
11. Senna 187 mg Tablet Sig: One (1) Tablet PO BID:PRN.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 2558**] - [**Location (un) **]

Discharge Diagnosis:
1)Urosepsis
2)Urinary Tract infection
3)Atrial Fibrillation
4)Hypernatremia
5)Dehydration
6)Hypokalemia


Discharge Condition:
Fair


Discharge Instructions:
Please return to hospital for fevers, chills, worsening
shortness or of breath or other concerning symtpoms.

Followup Instructions:
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5351**].
Please phone to schedule your appointment.  Please discuss
possible initiation of coumadin for long-term stroke prophylaxis
(given your atrial fibrillation) with you PCP (patients daughter
and health care proxy, [**Name (NI) **] [**Name (NI) 349**], has requested to talk
with her PCP about this).
{"Atrial fibrillation,Hyperosmolality and/or hypernatremia,Acute kidney failure, unspecified,Retention of urine, unspecified,Diastolic heart failure, unspecified,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Other abnormal blood chemistry,Coronary atherosclerosis of native coronary artery,Other persistent mental disorders due to conditions classified elsewhere,Need for prophylactic vaccination and inoculation against influenza,Unspecified septicemia,Severe sepsis,Septic shock,Urinary tract infection, site not specified"}


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: SOB

PRESENT ILLNESS: [**Age over 90 **]F non-verbal with dementia  and NH resident who p/w several
days of hypoxia, fevers, and cough.  Pt was started on
levofloxacin and clindamycin for presumed aspiration PNA and
klebsiella UTI at NH 2 days ago.  Pt also received lasix 20 mg
po qd x 2 days for presumed CHF decompensation.  Pt was found to
be hypoxic at 89% on NRB and tachypnic to 38.  Pt received lasix
40mg iv x 1 and ntg paste and was x-ferred to [**Hospital1 18**].

MEDICAL HISTORY: 1.  Dementia - non-verbal at baseline and dependent for all
activities of daily living and not ambulatory
2.  Syncope
3.  Osteoporosis
4.  Depression
5.  Heel ulcer
6.  Incontinence

MEDICATION ON ADMISSION: 1.  ASA 81mg once daily
2.  Remeron 75mg QHS
3.  MVI once daily
4.  artificial tears
5.  tums [**Hospital1 **]
6.  Senna
7.  Colace
8.  Milk of Magnesia

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Physical Exam:
VS: Tc: 100.2   HR: 113   BP: 93/55   RR: 12   97% on 2L-5L NC
Gen: elderly women lying in bed in NAD.  no diaphoresis, no
accessory muscle use.  Pt appears awake and alert but does not
communicate in any manner - verbally, or by gesturing.
HEENT: PERRL, EOMI, mm dry
CV: faint heart sounds, tachycardic, S1, S2, no murmurs, rubs,
gallops
Chest: diffuse wheezing on expiration and coarse rhonchi
bilaterally
Abd: soft, NT, ND, BS hypoactive
Ext: no clubbing, cyanosis, edema, toes appear tonically down
going.
Neuro: Pt not moving any extremity spontaneously.

FAMILY HISTORY: 

SOCIAL HISTORY: Pt lives in a nursing home and is completely dependent for
activities of daily living.  Pt is non-verbal at baseline. The
patient is widowed.  She has two daughters, one of whom is the
health care proxy [**Name (NI) 16405**] [**Name (NI) 349**] ([**Telephone/Fax (1) 16406**]). 

### Response:
{"Atrial fibrillation,Hyperosmolality and/or hypernatremia,Acute kidney failure, unspecified,Retention of urine, unspecified,Diastolic heart failure, unspecified,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Other abnormal blood chemistry,Coronary atherosclerosis of native coronary artery,Other persistent mental disorders due to conditions classified elsewhere,Need for prophylactic vaccination and inoculation against influenza,Unspecified septicemia,Severe sepsis,Septic shock,Urinary tract infection, site not specified"}
