CHIEF COMPLAINT: Hypoxia, cyanosis

PRESENT ILLNESS: Ms. [**Known lastname 12347**] is an 84F with a PMH of alzheimer's dementia, HTN,
paroxysmal atrial fibrillation who was admitted from NH when she
was noted to have cyanotic lips, grey coloring and hypoxia with
O2 saturation 73-76%.  BP 151/82 HR 47, she was placed on O2 NC
at 4L with improvement in O2 sat to 98% on 4L NC, BP 107/83 P
80.  According to her family she had seemed a bit off over the
past several days, no more specific symptoms than that were
noted.
.
Of note she was recently admitted [**7-21**] - [**7-23**] for shaking and
altered mental status.  She was found to have a UTI and was
discharged on 7 day course of ciprofloxacin.  On review of her
culture data it appears that her urine culture grew morganella
morgani resistant to cipro.  She was also evaluated by neurology
during that admission for the shaking, felt to be a tremor, EEG
without evidence of seizure.
.
In addition, she was also admitted from [**2154-6-10**] -[**2154-7-5**] with
pneumonia and sepsis requiring intubation, complicated by acute
renal failure, suspected VAP, paroxysmal afib with RVR, NSTEMI,
and pulmonary edema.
.
In the ED T98.5 HR 92 BP 114/44 RR 26 98% 3L NC.  She was given
Ceftriaxone 1g IV, Vancomycin 1g IV, levofloxacin 750mg IV,
combineb x1, solumedrol 125mg IV.  She seemed to respond to neb
treatments intially however she was then noted to become
tachypnic and appeared to be in progressive respiratory
distress.  She was given etomidate 20, succinylcholine 100mg,
versed 2mg IV and fentanyl 50mcg IV and intubated.

MEDICAL HISTORY: - dementia: alzheimer's disease
- hypertension
- recent NSTEMI
- recent Hypercarbic respiratory failure c/b VAP
- Paroxysmal Atrial fibrillation
- Chronic obstructive pulmonary disease

MEDICATION ON ADMISSION: -Metoprolol Tartrate 100 mg Tablet PO BID
-Namenda 10mg [**Hospital1 **]
-EC Aspirin 81 mg Tablet daily
-Ipratropium Bromide nebs q6h prn
-Sennakot 1 [**Hospital1 **] prn
-colace 100mg [**Hospital1 **]
-tylenol 650mg q6prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
VS: T 96.1, HR 101, BP 110/35, RR 17, 96% on VC 100%/600/14/5
Gen: intubated, sedated, generalized tremors with stimulation,
opens eyes
HEENT: NC, AT, EOMI, PERRL, endotracheal tube in place
Neck: supple, no LAD
CV: RRR, soft 1/6 systolic murmur
Lungs: vented breath sounds, basilar crackles at right
ABD: soft, NT, ND BS + no guarding
Ext: cool, no pedal edema or cyanosis

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Prior to a prolonged hospitalization in [**6-/2154**] for pneumosepsis
the patient had lived in an [**Hospital3 **] facility where she
had some assistance with ADLs, but was still very interactive.
She is currently living in [**Hospital **] [**Hospital **] nursing home.
Pneumonia, organism unspecified,Acute respiratory failure,Urinary tract infection, site not specified,Hyposmolality and/or hyponatremia,Diastolic heart failure, unspecified,Pressure ulcer, lower back,Atrial fibrillation,Hypoxemia,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Unspecified essential hypertension,Chronic airway obstruction, not elsewhere classified
Pneumonia, organism NOS,Acute respiratry failure,Urin tract infection NOS,Hyposmolality,Diastolc hrt failure NOS,Pressure ulcer, low back,Atrial fibrillation,Hypoxemia,Alzheimer's disease,Dementia w/o behav dist,Hypertension NOS,Chr airway obstruct NEC
Admission Date:  [**2154-8-12**]              Discharge Date:   [**2154-8-21**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 8104**]
Chief Complaint:
Hypoxia, cyanosis


Major Surgical or Invasive Procedure:
Intubation

History of Present Illness:
Ms. [**Known lastname 12347**] is an 84F with a PMH of alzheimer's dementia, HTN,
paroxysmal atrial fibrillation who was admitted from NH when she
was noted to have cyanotic lips, grey coloring and hypoxia with
O2 saturation 73-76%.  BP 151/82 HR 47, she was placed on O2 NC
at 4L with improvement in O2 sat to 98% on 4L NC, BP 107/83 P
80.  According to her family she had seemed a bit off over the
past several days, no more specific symptoms than that were
noted.
.
Of note she was recently admitted [**7-21**] - [**7-23**] for shaking and
altered mental status.  She was found to have a UTI and was
discharged on 7 day course of ciprofloxacin.  On review of her
culture data it appears that her urine culture grew morganella
morgani resistant to cipro.  She was also evaluated by neurology
during that admission for the shaking, felt to be a tremor, EEG
without evidence of seizure.
.
In addition, she was also admitted from [**2154-6-10**] -[**2154-7-5**] with
pneumonia and sepsis requiring intubation, complicated by acute
renal failure, suspected VAP, paroxysmal afib with RVR, NSTEMI,
and pulmonary edema.
.
In the ED T98.5 HR 92 BP 114/44 RR 26 98% 3L NC.  She was given
Ceftriaxone 1g IV, Vancomycin 1g IV, levofloxacin 750mg IV,
combineb x1, solumedrol 125mg IV.  She seemed to respond to neb
treatments intially however she was then noted to become
tachypnic and appeared to be in progressive respiratory
distress.  She was given etomidate 20, succinylcholine 100mg,
versed 2mg IV and fentanyl 50mcg IV and intubated.


Past Medical History:
- dementia: alzheimer's disease
- hypertension
- recent NSTEMI
- recent Hypercarbic respiratory failure c/b VAP
- Paroxysmal Atrial fibrillation
- Chronic obstructive pulmonary disease


Social History:
Prior to a prolonged hospitalization in [**6-/2154**] for pneumosepsis
the patient had lived in an [**Hospital3 **] facility where she
had some assistance with ADLs, but was still very interactive.
She is currently living in [**Hospital **] [**Hospital **] nursing home.


Family History:
Non-contributory

Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 96.1, HR 101, BP 110/35, RR 17, 96% on VC 100%/600/14/5
Gen: intubated, sedated, generalized tremors with stimulation,
opens eyes
HEENT: NC, AT, EOMI, PERRL, endotracheal tube in place
Neck: supple, no LAD
CV: RRR, soft 1/6 systolic murmur
Lungs: vented breath sounds, basilar crackles at right
ABD: soft, NT, ND BS + no guarding
Ext: cool, no pedal edema or cyanosis

Pertinent Results:
Admission Labs:
WBC 10.9  23% bands, HCT 39.8, PLT 238
Na 148 K 4.5 Cl 106 HCO 35 BUN 20  Creat 0.8 Gluc 124
Lactate 2.6
UA: trace leuks, nitr pos, blood neg, [**12-26**] WBC, many bacteria

Micro:
[**8-12**] Blood Cx: P
[**8-12**] Urine Cx: P

Imaging:
[**2154-8-12**] CXR: Emphysema with small areas of opacity in the right
lung likely represent scarring or areas of bronchial wall
thickening, better seen on recent CT chest. No evidence of acute
intrathoracic process.

[**2154-8-12**] CXR post intubation (prelim):ETT terminates 5.3 cm above
carina, in satisfactory position. No change in emphysema and
parenchymal scarring since earlier same day.

[**2154-8-12**] EKG: NSR at 89 bpm, normal intervals, normal axis, no ST
segment or T wave changes, no significant change c/w prior
[**2154-7-21**].


Brief Hospital Course:
Mrs. [**Known lastname 12347**] is an 84 yo F with PMH of alzheimer's type
dementia, recent hospitalizations for PNA and UTI who was
admitted following episode of hypoxia and cyanosis.
.
#Hypoxic respiratory failure - unclear etiology.  She developed
heavy secretions so PNA seemed most likely.  Treated with vanco
/ piptazo / azithro and within 4d was extubated.  She required
positive pressure vent for 6h postextubation but then remained
stable thereafter.   Sputum cultures while intubated were
negative except for oropharyngeal flora. Her urine grew E. coli,
sensitive to Zosyn. She finished 5 days of azithro and continued
vanc and zosyn for at total of 14 days.
.
#Bandemia - She presented with a bandemia of 22, concerning for
acute infection and supportive of likely PNA.  Treated broadly
as above.  Ecoli grew out of the urine. This resolved with
antibiotic treatment.
.
#Hypotension - on arrival to ICU blood pressure decreased to SBP
80's - 90's, however she continued to have good urine output
with about 50-60cc's/hour after getting total of 4L IVF since
admission.  She then was diuresed peri-extubation.
.
#Hypernatremia - most likely hypovolemic hypernatremia likely
with component of free water defecit as well.  Improved with
free water bolusing
.
#Dementia/Delirium - she has had progressive decline since her
recent hospitalization in [**6-13**] with likely superimposed delirium
[**3-9**] acute medical illnesses. Namenda was held on admission and
restarted on [**8-17**]. Discontinuation of this medication should be
considered if [**Known firstname **] does not return to [**Hospital3 **]. Her
mental status after extubation was felt to be far below her
previous baseline. The geriatrics service was consulted and
discussed with the family that the patient's superimposed
delirium that has incurred likely to recurrent infections and
hospitalizations may take months to resolve, and that she may
never return to her previous level of functioning, and thus may
require a long-term facility that could provide full time care.
The family seemed to be in good understanding of this and will
make future plans accordingly. She will follow-up with her
behavioral neurologist Dr. [**Last Name (STitle) **] after discharge.  If needed,
she can also be seen by the gerontology outpatient service at
[**Hospital1 18**].

#h/o Hypertension - hypotensive on admission with good urine
output. Metoprolol was held and then restarted slowly after
fluid resuscitation.
.
#Paroxysmal atrial fibrillation - in NSR on admission. She
converted to afib while in the ICU, and she was re-loaded with
amiodarone in the ICU. Upon arrival to the floor on [**8-17**] she
went into afib with RVR. She was asympomatic and converted back
to normal sinus rhythm after 5mg IV and 12.5mg po metoprolol.
Her metoprolol dose was increased slowly due to intermittent
bradycardia at night until she was discharged on metoprolol 50
t.i.d. with good rate control. Coumadin 4mg was started as CHADS
score was 3. The risks and benefits of intitiating
anticoagulation were discussed with her son.  The plan is to
continue anticoagulation for now, and he will discuss the risks
and benefits with additional family members.  [**Name (NI) 227**] her
concomitant ASA, she was started on a PPI.

#Tremor - evaluated by neurology during her last admission, felt
most likely essential tremor.  No seizure activity on EEG.

#Code Status - DNR after speaking with her son and HCP as well
as her daughter.  Family is okay with reintubation if necessary
but are considering DNI.
.
#Contacts: Son [**Name (NI) 382**] [**Name (NI) **] [**Name (NI) 12347**] [**Telephone/Fax (1) 17733**]; daughter [**Name (NI) **]
[**Telephone/Fax (1) 17737**]

Medications on Admission:
-Metoprolol Tartrate 100 mg Tablet PO BID
-Namenda 10mg [**Hospital1 **]
-EC Aspirin 81 mg Tablet daily
-Ipratropium Bromide nebs q6h prn
-Sennakot 1 [**Hospital1 **] prn
-colace 100mg [**Hospital1 **]
-tylenol 650mg q6prn

Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Clotrimazole 1 % Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **] (2 times
a day).
3. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1)  Inhalation
Q6H (every 6 hours).
4. Memantine 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO bid ().
5. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID
(3 times a day).
6. Warfarin 2 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Once Daily at 4
PM.
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1)  Inhalation Q6H (every 6 hours).
8. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
9. Vancomycin 1,000 mg Recon Soln [**Hospital1 **]: One (1) gram Intravenous
once a day for 4 days: Last day is [**8-25**].
10. Zosyn 2.25 gram Recon Soln [**Month/Year (2) **]: One (1)  Intravenous every
six (6) hours for 4 days: **Last day is [**8-25**]**.
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day: **For prophylaxsis on
coumadin and ASA**.
12. Outpatient Lab Work
Please check INR on [**2154-8-23**]


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]

Discharge Diagnosis:
1) Pneumonia
2) urinary tract infection
3) atrial fibrillation
4) dementia
5) delirium


Discharge Condition:
Stable; Good


Discharge Instructions:
Please return to the hospital with fevers or shortness of breath
{"Pneumonia, organism unspecified,Acute respiratory failure,Urinary tract infection, site not specified,Hyposmolality and/or hyponatremia,Diastolic heart failure, unspecified,Pressure ulcer, lower back,Atrial fibrillation,Hypoxemia,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Unspecified essential hypertension,Chronic airway obstruction, not elsewhere classified"}


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: Hypoxia, cyanosis

PRESENT ILLNESS: Ms. [**Known lastname 12347**] is an 84F with a PMH of alzheimer's dementia, HTN,
paroxysmal atrial fibrillation who was admitted from NH when she
was noted to have cyanotic lips, grey coloring and hypoxia with
O2 saturation 73-76%.  BP 151/82 HR 47, she was placed on O2 NC
at 4L with improvement in O2 sat to 98% on 4L NC, BP 107/83 P
80.  According to her family she had seemed a bit off over the
past several days, no more specific symptoms than that were
noted.
.
Of note she was recently admitted [**7-21**] - [**7-23**] for shaking and
altered mental status.  She was found to have a UTI and was
discharged on 7 day course of ciprofloxacin.  On review of her
culture data it appears that her urine culture grew morganella
morgani resistant to cipro.  She was also evaluated by neurology
during that admission for the shaking, felt to be a tremor, EEG
without evidence of seizure.
.
In addition, she was also admitted from [**2154-6-10**] -[**2154-7-5**] with
pneumonia and sepsis requiring intubation, complicated by acute
renal failure, suspected VAP, paroxysmal afib with RVR, NSTEMI,
and pulmonary edema.
.
In the ED T98.5 HR 92 BP 114/44 RR 26 98% 3L NC.  She was given
Ceftriaxone 1g IV, Vancomycin 1g IV, levofloxacin 750mg IV,
combineb x1, solumedrol 125mg IV.  She seemed to respond to neb
treatments intially however she was then noted to become
tachypnic and appeared to be in progressive respiratory
distress.  She was given etomidate 20, succinylcholine 100mg,
versed 2mg IV and fentanyl 50mcg IV and intubated.

MEDICAL HISTORY: - dementia: alzheimer's disease
- hypertension
- recent NSTEMI
- recent Hypercarbic respiratory failure c/b VAP
- Paroxysmal Atrial fibrillation
- Chronic obstructive pulmonary disease

MEDICATION ON ADMISSION: -Metoprolol Tartrate 100 mg Tablet PO BID
-Namenda 10mg [**Hospital1 **]
-EC Aspirin 81 mg Tablet daily
-Ipratropium Bromide nebs q6h prn
-Sennakot 1 [**Hospital1 **] prn
-colace 100mg [**Hospital1 **]
-tylenol 650mg q6prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
VS: T 96.1, HR 101, BP 110/35, RR 17, 96% on VC 100%/600/14/5
Gen: intubated, sedated, generalized tremors with stimulation,
opens eyes
HEENT: NC, AT, EOMI, PERRL, endotracheal tube in place
Neck: supple, no LAD
CV: RRR, soft 1/6 systolic murmur
Lungs: vented breath sounds, basilar crackles at right
ABD: soft, NT, ND BS + no guarding
Ext: cool, no pedal edema or cyanosis

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Prior to a prolonged hospitalization in [**6-/2154**] for pneumosepsis
the patient had lived in an [**Hospital3 **] facility where she
had some assistance with ADLs, but was still very interactive.
She is currently living in [**Hospital **] [**Hospital **] nursing home. 

### Response:
{"Pneumonia, organism unspecified,Acute respiratory failure,Urinary tract infection, site not specified,Hyposmolality and/or hyponatremia,Diastolic heart failure, unspecified,Pressure ulcer, lower back,Atrial fibrillation,Hypoxemia,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Unspecified essential hypertension,Chronic airway obstruction, not elsewhere classified"}
