CHIEF COMPLAINT: shortness of breath

PRESENT ILLNESS: This is a [**Age over 90 **] yo female with history of severe COPD on home
oxygen(4L), diastolic heart failure, and kyphoscoliosis who
presented to the [**Hospital 4199**] Hospital with increasing shortness of
breath the evening prior to admission. She was being treated at
her [**Hospital3 **] for heart failure exacerbation, however she
had an aspiration event in the dining room at dinner, desatted
to low 80s on 4liters, tachycardic prompting transfer to the ED.
There she was febrile to 102 and felt to have active acute on
chronic diastolic heart failure, copd flare, and pneumonia. She
also complained of chest pain, but details are unclear. She
received vanco/solumedrol/lasix and ntg paste at OSH prior to ED
to [**Hospital **] transfer to [**Hospital1 18**] for further management at the request of
the family. On arrival at [**Hospital1 18**], her room air sat was in the 80s
and she was tachypnic to 40s. She was started on bipap and
received cefepime and gentamycin and blood cultures were sent.
.
In the ED, initial vs were: T 102.2 HR 96afib BP 136/74 RR 26
POx 87. Prior to transfer to the floor HR 98 BP 135/71. Her IV
infiltrated and was removed. She was given 1gm Vanc, 125mg
solumedrol, and nitropaste at [**Last Name (un) 4199**] for SOB and ? chest pain.
At [**Hospital1 18**] ED

MEDICAL HISTORY: Diastolic Heart Failure
Atrial Fibrillation on coumadin
Remote h/o TIAs
COPD on home O2 (3-4L at baseline)
Scoliosis
Osteoarthritis
L hip/R pelvis fx managed nonoperatively
Recent LLE cellulitis
Anxiety
Chronic Anemia (baseline hct 32)

MEDICATION ON ADMISSION: prednisone 20 mg 1 tab(s) qd
Atrovent 0.02% 3 mL QID
Cardizem CD 180 mg/24 hours 1 cap(s) once a day
Lasix 80 mg 1 q am
Lasix 40 mg/60 mg 1 tab(s) q o 12 noon
Lanoxin 0.0625 mg 1 tab qod
Coumadin 2 mg as directed q pm
BuSpar 10 mg 1 tab(s) TID
Celexa 20 mg 1 tab(s) once a day
ferrous gluconate 1 qd
Prilosec 20 mg 1 cap(s) once a day
senna 8.6 mg 2 tab(s) once a day (at bedtime)
Bisac-Evac 5 mg 2 tab(s) once a day
Lopressor 12.5mg as directed Q12H
Vitamin C 500 mg 1 tab(s) once a day

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 96.2 BP: 152/71 P: 94 R: 27 O2: 93% on BiPAP 30%
FiO2, 14/8
General: Easily arousible, follows commands, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple
Lungs: Clear to auscultation bilaterally, no wheezes, diminished
breath sounds at Right base.
CV: Irregularly irreg, 2/6 SEM at LUSB without rubs, gallops
Abdomen: soft, non-tender, minimally distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 2+
edema at ankles.
Neuro: responds to verbal stimuli, unable to understand her
while on BiPAP, moving all 4 extremities equally.

FAMILY HISTORY: Positive for hypertension and type II diabets.  Given age
non-contributory to current illness.

SOCIAL HISTORY: From chart, limited [**12-28**] BIPAP Lives at nursing home.  Ambulates
with a walker at baseline.  Alert and oriented x 3 at baseline.
On home oxygen 3-4L.  Past smoker but quit 30 years ago.  No
ethanol or illict drugs.  Son and daughter live nearby and are
involved.
Pneumonitis due to inhalation of food or vomitus,Acute on chronic diastolic heart failure,Chronic airway obstruction, not elsewhere classified,Hypoxemia,Atrial fibrillation,Long-term (current) use of anticoagulants,Anemia, unspecified,Anxiety state, unspecified,Personal history of tobacco use,Scoliosis [and kyphoscoliosis], idiopathic,Secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or unspecified,Adrenal cortical steroids causing adverse effects in therapeutic use
Food/vomit pneumonitis,Ac on chr diast hrt fail,Chr airway obstruct NEC,Hypoxemia,Atrial fibrillation,Long-term use anticoagul,Anemia NOS,Anxiety state NOS,History of tobacco use,Idiopathic scoliosis,Sec DM wo cmp nt st uncn,Adv eff corticosteroids
Admission Date:  [**2196-5-5**]              Discharge Date:   [**2196-5-6**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
shortness of breath

Major Surgical or Invasive Procedure:
none

History of Present Illness:
This is a [**Age over 90 **] yo female with history of severe COPD on home
oxygen(4L), diastolic heart failure, and kyphoscoliosis who
presented to the [**Hospital 4199**] Hospital with increasing shortness of
breath the evening prior to admission. She was being treated at
her [**Hospital3 **] for heart failure exacerbation, however she
had an aspiration event in the dining room at dinner, desatted
to low 80s on 4liters, tachycardic prompting transfer to the ED.
There she was febrile to 102 and felt to have active acute on
chronic diastolic heart failure, copd flare, and pneumonia. She
also complained of chest pain, but details are unclear. She
received vanco/solumedrol/lasix and ntg paste at OSH prior to ED
to [**Hospital **] transfer to [**Hospital1 18**] for further management at the request of
the family. On arrival at [**Hospital1 18**], her room air sat was in the 80s
and she was tachypnic to 40s. She was started on bipap and
received cefepime and gentamycin and blood cultures were sent.
.
In the ED, initial vs were: T 102.2 HR 96afib BP 136/74 RR 26
POx 87. Prior to transfer to the floor HR 98 BP 135/71. Her IV
infiltrated and was removed. She was given 1gm Vanc, 125mg
solumedrol, and nitropaste at [**Last Name (un) 4199**] for SOB and ? chest pain.
At [**Hospital1 18**] ED

On the floor, she is comfortable on BiPAP, satting 92% on FiO2
30%, but does not remember what happened at dinner the previous
night.

Review of systems:
(+) Per HPI
(-) Denies any current pain, but unable to obtain further
information given pt on BiPAP mask.


Past Medical History:
Diastolic Heart Failure
Atrial Fibrillation on coumadin
Remote h/o TIAs
COPD on home O2 (3-4L at baseline)
Scoliosis
Osteoarthritis
L hip/R pelvis fx managed nonoperatively
Recent LLE cellulitis
Anxiety
Chronic Anemia (baseline hct 32)


Social History:
From chart, limited [**12-28**] BIPAP Lives at nursing home.  Ambulates
with a walker at baseline.  Alert and oriented x 3 at baseline.
On home oxygen 3-4L.  Past smoker but quit 30 years ago.  No
ethanol or illict drugs.  Son and daughter live nearby and are
involved.


Family History:
Positive for hypertension and type II diabets.  Given age
non-contributory to current illness.

Physical Exam:
Vitals: T: 96.2 BP: 152/71 P: 94 R: 27 O2: 93% on BiPAP 30%
FiO2, 14/8
General: Easily arousible, follows commands, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple
Lungs: Clear to auscultation bilaterally, no wheezes, diminished
breath sounds at Right base.
CV: Irregularly irreg, 2/6 SEM at LUSB without rubs, gallops
Abdomen: soft, non-tender, minimally distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 2+
edema at ankles.
Neuro: responds to verbal stimuli, unable to understand her
while on BiPAP, moving all 4 extremities equally.


Pertinent Results:
[**2196-5-5**] 04:41AM   TYPE-ART PO2-74* PCO2-76* PH-7.42 TOTAL
CO2-51* BASE XS-19
[**2196-5-5**] 04:41AM   LACTATE-1.7
[**2196-5-4**] 11:57PM   LACTATE-2.1*
[**2196-5-4**] 11:45PM   GLUCOSE-191* UREA N-29* CREAT-1.1 SODIUM-142
POTASSIUM-4.8 CHLORIDE-91* TOTAL CO2-42* ANION GAP-14
[**2196-5-4**] 11:45PM   CK(CPK)-61
[**2196-5-4**] 11:45PM   cTropnT-0.04*
[**2196-5-4**] 11:45PM   CK-MB-NotDone proBNP-2595*
[**2196-5-4**] 11:45PM   WBC-8.2 RBC-3.94* HGB-11.7* HCT-36.2 MCV-92
MCH-29.7 MCHC-32.3 RDW-17.2*
[**2196-5-4**] 11:45PM   NEUTS-94.9* LYMPHS-3.6* MONOS-1.3* EOS-0.1
BASOS-0.1
[**2196-5-4**] 11:45PM   PLT COUNT-232
[**2196-5-4**] 11:45PM   PT-18.9* PTT-22.7 INR(PT)-1.7*
[**2196-5-4**] 11:45PM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2196-5-4**] 11:45PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG

Brief Hospital Course:
This is a [**Age over 90 **] yo F with severe COPD, diastolic heart failure,
kyphoscoliosis who presents with acute on chronic diastolic
heart failure and aspiration pneumonia.

# Hypoxia - Presented with aspiration pneumonitis/pneumonia and
component of acute on chronic diastolic heart failure.
Underlying COPD, kyphoscoliosis contributing.  ABG with baseline
hypercarbia of PCO2 76.  Presented with lactate of 2.1, but down
to 1.7 after 1 L NS resuscitation. She was maintained at first
on Bipap with sats >92% so was then weaned to NC with sats in
the low 90s for most of the first hospital day. When she fell
asleep she did require CPAP with PS using full face mask set at
IPAP of 15 and EPAP of 5 with 2-4L oxygen to maintain oxygen
sats of 88-92%. She was started on vanc/zosyn on [**2196-5-5**] for
HCAP given that she lives in a [**Hospital3 **] and has had
multiple recent hospital admission and her CXR had evidence of
RLL infiltrate. She will complete an 10 day course on [**2196-5-15**].
She was maintained on her home dose of lasix which was increased
the day of admission (she takes 80mg PO at home and got 40mg IV
here) for goal fluid balance net negative 500mL daily.

# ECG changes:  [**First Name8 (NamePattern2) **] [**Hospital 4199**] hospital ED, patient was complaining
of chest pain and given nitro paste. Cardiac biomarkers were
flat (0.04->0.02), EKG in am was unchanged. She was started on
asa while awaiting results of ROMI. She had no further episodes
of chest pain and her cardiac enzymes were negative. Aspirin was
continued in place of coumadin for her atrial fibrillation.

# COPD on home O2 (3-4L at baseline): On admission bicarb was at
her baseline and her hypercarbia was at baseline with PCO2 of
76. Also was on prednisone for recent exacerbation and was given
125mg solumedrol at [**Hospital 4199**] hospital.  Kept O2 sats 89-92.
Received scheduled Nebs and PRN for SOB. Continued prednisone
20mg which should be tapered as she continues to improve. ABx as
above.

# A fib on coumadin: She had a sub therapeutic INR of 1.7 on
admission with good rate control with Cardizem and metoprolol.
She was switched to short acting dilt while hospitalized with
HRs in low 60s and switched back at the time of discharge. She
was continued on metoprolol for rate control. Given the
risk/benefit of coumadin in this patient, decision was made to
treat with aspirin alone.

# Acute on chronic Diastolic heart failure: ECHO from [**10/2195**]
showed EF of 70-80% with Mild PAH and significant pulmonic
regurg.  On admission appeared euvolemic.  She was given 1 L NS
in ED for lactate of 2.1 which improved to 1.7 after fluids. BNP
was mildly elevated at level it had been on past admissions. Her
CXR did not appear grossly fluid overloaded so lasix was
initially held but as above over the day she had some increasing
O2 requirements and she was given her recently increased home
dose of lasix. We recommend continuing with daily weights,
maitain goal I/O at negative 500cc /day, titrating lasix and
monitoring electrolytes as necessary.

# Chronic Aspiration - Patient should be maintain on aspiration
precautions and dysphagia diet of pureed solids and nectar
thickened liquids. The risk of future aspiration events
discussed with patient's family. It is their wish to continue
with feeding.

# Goals of Care - Family very interested in initiating
palliative care/home hospice when the time comes for her to
transition home and would like more information on this.

# hyperglycemia - In setting of steroids patient was noted to
have elevated blood sugars. A humalog sliding scale was started.

# Prophylaxis: Subcutaneous heparin and H2 blocker
# Access: peripherals
# Code: DNR/DNI per family and nursing home records
# Communication:  [**Name (NI) **] (son/power of attorney)
[**Telephone/Fax (5) 81861**].  [**Doctor First Name **] (daughter)
[**Telephone/Fax (3) 81862**], [**Doctor First Name 1494**] (daughter): [**Telephone/Fax (1) 81863**].


Medications on Admission:
prednisone 20 mg 1 tab(s) qd
Atrovent 0.02% 3 mL QID
Cardizem CD 180 mg/24 hours 1 cap(s) once a day
Lasix 80 mg 1 q am
Lasix 40 mg/60 mg 1 tab(s) q o 12 noon
Lanoxin 0.0625 mg 1 tab qod
Coumadin 2 mg as directed q pm
BuSpar 10 mg 1 tab(s) TID
Celexa 20 mg 1 tab(s) once a day
ferrous gluconate 1 qd
Prilosec 20 mg 1 cap(s) once a day
senna 8.6 mg 2 tab(s) once a day (at bedtime)
Bisac-Evac 5 mg 2 tab(s) once a day
Lopressor 12.5mg as directed Q12H
Vitamin C 500 mg 1 tab(s) once a day

Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours).
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
5. Buspirone 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) inhalation Inhalation Q4H (every 4
hours) as needed for SOB, wheezing.
13. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

15. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
16. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO Q4PM ().
17. Vancomycin 1000 mg IV Q48H
First dose [**2196-5-4**]
18. Piperacillin-Tazobactam 2.25 g IV Q6H
First dose [**2196-5-4**]
19. Ondansetron 4 mg IV Q8H:PRN nausea
20. Cardizem CD 180 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
21. Insulin Lispro 100 unit/mL Solution Sig: as directed units
Subcutaneous QACHS: sliding scale, w/ meals start at BS 160 -
2units, go up by 2 units for every increase in 40 of BS. At HS,
start at BS 200 same scale.
22. 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.


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
Primary
- Pneumonia
Secondary
- Acute on chronic diastolic heart failure
- Chronic obstructive pulmonary disease
- Atrial fibrillation


Discharge Condition:
Hemodynamically stable, O2 sats 88-92% on nasal cannula.


Discharge Instructions:
You were admitted with shortness of breath. This was thought to
be due a pneumonia with possible exacerbation of your congestive
heart failure. You were started on antibiotics with improvement.
You were continued on your pureed diet and thickened liquids as
was consistent with your goals of care. You also were started on
CPAP w/ IPAP of 15/EPAP of 5 ccH2O while you sleep with great
improvement in your respiratory status. You will be discharged
to Rehab for further care.

The following changes were made to your medications:
Your coumadin was discontinued and replaced with aspirin
You were started on vancomycin/zosyn for treatment of your
pneumonia with plan for total of 10 day course from [**2196-5-5**]
.
Please take all medications as prescribed.

Call your doctor or 911 if you develop chest pain, difficulty
breathing, fevers > 101, dizziness, change in mental status,
bleeding, or any other concerning symptoms.

Followup Instructions:
Please follow up with your PCP, [**First Name8 (NamePattern2) 335**] [**Last Name (NamePattern1) 5351**], within 1-2 weeks
of discharge. Her office number is [**Telephone/Fax (1) 608**].
{'Pneumonitis due to inhalation of food or vomitus,Acute on chronic diastolic heart failure,Chronic airway obstruction, not elsewhere classified,Hypoxemia,Atrial fibrillation,Long-term (current) use of anticoagulants,Anemia, unspecified,Anxiety state, unspecified,Personal history of tobacco use,Scoliosis [and kyphoscoliosis], idiopathic,Secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or unspecified,Adrenal cortical steroids causing adverse effects in therapeutic use'}


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: shortness of breath

PRESENT ILLNESS: This is a [**Age over 90 **] yo female with history of severe COPD on home
oxygen(4L), diastolic heart failure, and kyphoscoliosis who
presented to the [**Hospital 4199**] Hospital with increasing shortness of
breath the evening prior to admission. She was being treated at
her [**Hospital3 **] for heart failure exacerbation, however she
had an aspiration event in the dining room at dinner, desatted
to low 80s on 4liters, tachycardic prompting transfer to the ED.
There she was febrile to 102 and felt to have active acute on
chronic diastolic heart failure, copd flare, and pneumonia. She
also complained of chest pain, but details are unclear. She
received vanco/solumedrol/lasix and ntg paste at OSH prior to ED
to [**Hospital **] transfer to [**Hospital1 18**] for further management at the request of
the family. On arrival at [**Hospital1 18**], her room air sat was in the 80s
and she was tachypnic to 40s. She was started on bipap and
received cefepime and gentamycin and blood cultures were sent.
.
In the ED, initial vs were: T 102.2 HR 96afib BP 136/74 RR 26
POx 87. Prior to transfer to the floor HR 98 BP 135/71. Her IV
infiltrated and was removed. She was given 1gm Vanc, 125mg
solumedrol, and nitropaste at [**Last Name (un) 4199**] for SOB and ? chest pain.
At [**Hospital1 18**] ED

MEDICAL HISTORY: Diastolic Heart Failure
Atrial Fibrillation on coumadin
Remote h/o TIAs
COPD on home O2 (3-4L at baseline)
Scoliosis
Osteoarthritis
L hip/R pelvis fx managed nonoperatively
Recent LLE cellulitis
Anxiety
Chronic Anemia (baseline hct 32)

MEDICATION ON ADMISSION: prednisone 20 mg 1 tab(s) qd
Atrovent 0.02% 3 mL QID
Cardizem CD 180 mg/24 hours 1 cap(s) once a day
Lasix 80 mg 1 q am
Lasix 40 mg/60 mg 1 tab(s) q o 12 noon
Lanoxin 0.0625 mg 1 tab qod
Coumadin 2 mg as directed q pm
BuSpar 10 mg 1 tab(s) TID
Celexa 20 mg 1 tab(s) once a day
ferrous gluconate 1 qd
Prilosec 20 mg 1 cap(s) once a day
senna 8.6 mg 2 tab(s) once a day (at bedtime)
Bisac-Evac 5 mg 2 tab(s) once a day
Lopressor 12.5mg as directed Q12H
Vitamin C 500 mg 1 tab(s) once a day

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 96.2 BP: 152/71 P: 94 R: 27 O2: 93% on BiPAP 30%
FiO2, 14/8
General: Easily arousible, follows commands, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple
Lungs: Clear to auscultation bilaterally, no wheezes, diminished
breath sounds at Right base.
CV: Irregularly irreg, 2/6 SEM at LUSB without rubs, gallops
Abdomen: soft, non-tender, minimally distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 2+
edema at ankles.
Neuro: responds to verbal stimuli, unable to understand her
while on BiPAP, moving all 4 extremities equally.

FAMILY HISTORY: Positive for hypertension and type II diabets.  Given age
non-contributory to current illness.

SOCIAL HISTORY: From chart, limited [**12-28**] BIPAP Lives at nursing home.  Ambulates
with a walker at baseline.  Alert and oriented x 3 at baseline.
On home oxygen 3-4L.  Past smoker but quit 30 years ago.  No
ethanol or illict drugs.  Son and daughter live nearby and are
involved. 

### Response:
{'Pneumonitis due to inhalation of food or vomitus,Acute on chronic diastolic heart failure,Chronic airway obstruction, not elsewhere classified,Hypoxemia,Atrial fibrillation,Long-term (current) use of anticoagulants,Anemia, unspecified,Anxiety state, unspecified,Personal history of tobacco use,Scoliosis [and kyphoscoliosis], idiopathic,Secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or unspecified,Adrenal cortical steroids causing adverse effects in therapeutic use'}
