CHIEF COMPLAINT: cyanosis, hypoxemia

PRESENT ILLNESS: [**Age over 90 **]M with COPD on home O2, AFib on lovenox, DVT s/p IVC filter
admitted with hypoxemia and hypercapnia after being found to be
cyanotic, confused, and hypoxic at his nursing home. Discharged
yesterday after a 2 week admission for aspiration pneumonia,
treated with levo/flagyl, with delirium and also atrial
fibrillation with RVR.

MEDICAL HISTORY: - COPD - [**2143**] FVC 74% of predicted, FEV1 67% of predicted,
FEV1/FVC 90% of predicted, TLC 111% of predicted, RV 145% of
predicted. Intermitent home supplemental O2 use.
- AFib
- CAD
- DVT ([**2148**]) s/p IVC filter
- HTN
- BPH
- GERD
- H. pylori gastritis
- Gout
- Inguinal hernia

MEDICATION ON ADMISSION: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable

ALLERGIES: Penicillins

PHYSICAL EXAM: Admission Physical Exam:
General: Alert, oriented to name, knows he is in the hospital in
[**Location (un) **], MA, NOT oriented to time, no acute distress, using
muscles of respirations
HEENT: Sclera anicteric, mucus membranes dry, oropharynx clear
Neck: supple, JVP not elevated (but difficult to assess), no LAD

FAMILY HISTORY: NC

SOCIAL HISTORY: Prior to recent admission, lived home alone and was independent
with ADLs, lived on a one floor home no stairs, walked around
with oxygen intermittently (reportedly 50% of the time).
Resident of [**First Name8 (NamePattern2) 3075**] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **] since recent admission. Quit
tobacco quit 40+ years ago. No ETOH.
Pneumonia, organism unspecified,Acute on chronic diastolic heart failure,Alkalosis,Precipitous drop in hematocrit,Chronic respiratory failure,Other dependence on machines, supplemental oxygen,Chronic airway obstruction, not elsewhere classified,Atrial fibrillation,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Esophageal reflux,Gout, unspecified,Other chronic pulmonary heart diseases,Constipation, unspecified
Pneumonia, organism NOS,Ac on chr diast hrt fail,Alkalosis,Drop, hematocrit, precip,Chronic respiratory fail,Depend-supplement oxygen,Chr airway obstruct NEC,Atrial fibrillation,Hx-ven thrombosis/embols,Long-term use anticoagul,Crnry athrscl natve vssl,Hypertension NOS,BPH w/o urinary obs/LUTS,Esophageal reflux,Gout NOS,Chr pulmon heart dis NEC,Constipation NOS
Admission Date:  [**2150-12-19**]              Discharge Date:   [**2150-12-23**]


Service: MEDICINE

Allergies:
Penicillins

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
cyanosis, hypoxemia

Major Surgical or Invasive Procedure:
PICC placement [**2150-12-20**]

History of Present Illness:
[**Age over 90 **]M with COPD on home O2, AFib on lovenox, DVT s/p IVC filter
admitted with hypoxemia and hypercapnia after being found to be
cyanotic, confused, and hypoxic at his nursing home. Discharged
yesterday after a 2 week admission for aspiration pneumonia,
treated with levo/flagyl, with delirium and also atrial
fibrillation with RVR.

At [**Hospital1 1501**], he was hypoxic to 70s on 4L O2 by NC, looked cyanotic,
was increasingly confused and lethargic. Sats improved to mid
80s on 5L.

In the ED, initial vs 100 100 144/74 26 91%RA. ABG
7.47/53/63/40. CXR showed bilateral basalar opacities relatively
unchanged from prior. EKG showed Afib rate Given vanco, levo,
solumedrol, nebs. V/S prior to transfer 110 130/50 25 85% 6L VM.

On the floor, he appeared fatigued/sleepy but conversed
normally, oriented x2. Mild shortness of breath with cough
occasionally productive of sputum. No chest pain, no abdominal
pain. Stated he was having loose stools recently. No nausea or
vomitting. No fever, but felt occasional chills. No
lightheadedness. No dysuria. No myalgias.

Past Medical History:
- COPD - [**2143**] FVC 74% of predicted, FEV1 67% of predicted,
FEV1/FVC 90% of predicted, TLC 111% of predicted, RV 145% of
predicted. Intermitent home supplemental O2 use.
- AFib
- CAD
- DVT ([**2148**]) s/p IVC filter
- HTN
- BPH
- GERD
- H. pylori gastritis
- Gout
- Inguinal hernia


Social History:
Prior to recent admission, lived home alone and was independent
with ADLs, lived on a one floor home no stairs, walked around
with oxygen intermittently (reportedly 50% of the time).
Resident of [**First Name8 (NamePattern2) 3075**] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **] since recent admission. Quit
tobacco quit 40+ years ago. No ETOH.

Family History:
NC

Physical Exam:
Admission Physical Exam:
General: Alert, oriented to name, knows he is in the hospital in
[**Location (un) **], MA, NOT oriented to time, no acute distress, using
muscles of respirations
HEENT: Sclera anicteric, mucus membranes dry, oropharynx clear
Neck: supple, JVP not elevated (but difficult to assess), no LAD

Lungs: Crackles [**2-8**] way up at left base, decreased breath sounds
at right base, no wheezes, occasional anterior rhonchi
CV: afib, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, 2+
pitting edema LE b/l, 2+ pitting edema with ecchymosis left hand



Pertinent Results:
[**2150-12-21**] 1:58 pm URINE      Source: CVS.

                            **FINAL REPORT [**2150-12-22**]**

   Legionella Urinary Antigen  (Final [**2150-12-22**]):
      NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
           (Reference Range-Negative).
      Performed by Immunochromogenic assay.
      A negative result does not rule out infection due to other
L.
      pneumophila serogroups or other Legionella species.
Furthermore, in
      infected patients the excretion of antigen in urine may
vary.
.
[**2150-12-21**] 5:38 pm STOOL     CONSISTENCY: SOFT

                            **FINAL REPORT [**2150-12-22**]**

   CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2150-12-22**]):
      Feces negative for C.difficile toxin A & B by EIA.
           (Reference Range-Negative).
.
[**2150-12-21**] 12:55 pm SPUTUM

   GRAM STAIN (Final [**2150-12-21**]):
      >25 PMNs and <10 epithelial cells/100X field.
      1+    (<1 per 1000X FIELD):   YEAST(S).

   RESPIRATORY CULTURE (Preliminary):
      Further incubation required to determine the presence or
absence of
      commensal respiratory flora.
      YEAST.    MODERATE GROWTH.
.
[**2150-12-19**] Portable AP CXR
Fleeting opacities, now worsened in left perihilar region, but
slightly better on the right. Worsening opacity in the right
apical region as well. Edema is favored, although foci of
aspiration or pneumonia cannot be entirely excluded. Bilateral
pleural effusions again noted, right greater than left.
.
[**2150-12-20**] Portable AP CXR
Right PICC terminates in the superior vena cava. Heart is
enlarged.
Mediastinum is within normal limits. There is increased
consolidation of the right lower lobe with a moderate
right-sided pleural effusion. There is a moderate left pleural
effusion with left lower lobe consolidation. There is patchy
airspace opacification of the right upper lobe. There is
prominent interstitial marking. There is mild congestive
failure.
IMPRESSION:
Interval worsening of the appearance of the chest.
Right PICC terminates in the superior vena cava.
.











Brief Hospital Course:
[**Age over 90 **]M with COPD on home O2, AFib on lovenox, DVT s/p IVC filter
admitted with hypoxemia and hypercapnia after being found to be
cyanotic, confused, and hypoxic.

#Hospital-acquired pneumonia- Started on an 8 day course of
vancomycin and cefepime ([**Date range (1) 46367**]). PICC line placed [**12-20**]/
Cultures remained negative.

#Acute on chronic diastolic CHF - Treated with bolus diuresis
(furosemide 20 mg IV) with decrease in admission weight. Unable
to accurately measure urine output as the patient refused a
foley catheter.  Patient will need to have electrolytes followed
closely on Friday, [**2150-12-25**].  Will continue to diurese and to
replete electrolytes as needed.

#Atrial fibrillation - Rate controlled with diltiazem and
digoxin. Treated with aspirin instead of systemic
anticoagulation given his history of falls.

#COPD- Continued with albuterol and ipratropium nebulizer.  He
was started advair.

#Nutrition- After discussion with patient and his sister,
patient wishes to continue with diet knowing about his
aspiration risk.  He did have an episode of witnessed
aspiration.  Patient should adhere to the recommendations of
speech/swallow therapy from [**12-14**] (1. PO diet of nectar thick
liquids and pureed solids, 2. Full supervision with all PO
intake, 3. Encourage single sips of liquid and slow rate of
intake, 4. Meds crushed with purees).

#Goals of care- Confirmed DNR/DNI status with the patient and
his sister and healthcare proxy, [**Name (NI) 1743**] [**Name (NI) 17839**].  If
patient cannot adhere to the recommended diet above, please
consider "do not rehospitalize" order if it is still consistent
with his goals of care.


Medications on Admission:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable

PO DAILY (Daily).
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
3. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ML PO BID (2

times a day).
4. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath

or wheezing.
5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. acetaminophen 650 mg Suppository Sig: [**2-7**] Suppositorys Rectal

Q6H (every 6 hours) as needed for pain.
7. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) injection
Subcutaneous QD (): afib, h/o DVT.
8. haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
9. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:

One (1) neb Inhalation every 4-6 hours as needed for SOB.
10. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).

11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO once a day as needed for constipation.
12. senna 8.6 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed for Constipation.
13. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
15. potassium chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO once a day: with lasix.
16. Outpatient Lab Work
Please check chem 7, magnesium within the next 3 days
17. medication adjustment
adjust lasix, KCL supplement based on peripheral edema and
potassium level
18. diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).


Discharge Medications:
1. Outpatient Lab Work
Please check CBC, Electrolytes (sodium, potassium, chloride,
bicarb) as well as BUN and Creatining on Friday [**2150-12-25**].
Please fax the results to the on-call physician at the rehab.
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
3. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)  PO
DAILY (Daily) as needed for constipation: can hold for loose
stools.
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation: can hold for loose stools.
6. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
[**2-7**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day).
7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): can hold for loose stools.
9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**2-7**]  Inhalation Q4H (every 4 hours) as needed
for wheeze.
10. ipratropium bromide 0.02 % Solution Sig: One (1)  Inhalation
Q4H (every 4 hours) as needed for SOB.
11. acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for pain/fever.
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO every six
(6) hours.
14. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours) for 4 days.
15. cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q24H (every 24 hours) for 4 days.
16. magnesium sulfate 4 % Solution Sig: One (1)  Injection PRN
(as needed).
17. furosemide 10 mg/mL Syringe Sig: Two (2)  Injection once a
day.
18. potassium chloride 20 mEq/50 mL Piggyback Sig: One (1)
Intravenous PRN (as needed).


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]

Discharge Diagnosis:
Primary diagnoses
- Hospital Acquired Pneumonia
- Acute on Chronic Diastolic Congestive Heart Failure

Secondary diagnoses:
- Atrial Fibrillation
- Chronic Obstructive Pulmonary Disease
- Aspiration
- Gastroesophageal Reflux Disease


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
You are being discharged from the ICU at [**Hospital1 827**]. You were admitted for low oxygen levels because
you had fluid in your lungs and when you were eating, food would
be going down the wrong tube.  We also suspect you have
apneumonia that you acquired at your last hospitalization. We
gave you medications to help you get rid of the fluid and we
also watched you very closely when eating, but you had episodes
when your oxygen decreased because you swallowed food down the
wrong tube.  We discussed placing a PEG tube so food would not
go into your lungs, but you did not want this.  We spoke with
you and your sister who is your health care proxy and it was
decided that it is more important to make you comfortable and
have you eat what you want.  You will be discharged to [**Location (un) 1456**]
and they will continue to manage your medical problems.

You were started on the following medications:
Vancomycin 1gm IV every 24hours (need 4 more days of therapy)
Cefepime 2gms IV every 24 hours (need 4 more days of therapy)
Lasix 20mg IV daily
Potassium Chloride adjust as needed seocndary to lasix dosing

The following medication was changed:
Diltiazem 90mg by mouth four times a day --> diltiazem 60mg by
mouth four times a day.

The following medication was stoppped
enoxaparin

Please continue your other medications as prescribed.

Followup Instructions:
Make an appoinment after you are discharged from LTAC.


                             [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]



Name:  [**Known lastname 8527**],[**Known firstname **]                  Unit No:   [**Numeric Identifier 8528**]

Admission Date:  [**2150-12-19**]              Discharge Date:   [**2150-12-23**]

Date of Birth:  [**2055-5-5**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins

Attending:[**Last Name (NamePattern4) 3776**]
Addendum:
There was an additional discussion prior to the discharge of the
patient to [**Location (un) 4534**].  After speaking with the patient and his
sister who is his health care proxy, it was decided to
officially make the patient DO NOT REHOSPITALIZE.

Discharge Disposition:
Extended Care

Facility:
[**Hospital3 2215**] - [**Location (un) 95**] - [**Location (un) 4534**]

                             [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 593**] [**Name8 (MD) 304**] MD [**MD Number(1) 594**]

Completed by:[**2150-12-23**]
{'Pneumonia, organism unspecified,Acute on chronic diastolic heart failure,Alkalosis,Precipitous drop in hematocrit,Chronic respiratory failure,Other dependence on machines, supplemental oxygen,Chronic airway obstruction, not elsewhere classified,Atrial fibrillation,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Esophageal reflux,Gout, unspecified,Other chronic pulmonary heart diseases,Constipation, 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: cyanosis, hypoxemia

PRESENT ILLNESS: [**Age over 90 **]M with COPD on home O2, AFib on lovenox, DVT s/p IVC filter
admitted with hypoxemia and hypercapnia after being found to be
cyanotic, confused, and hypoxic at his nursing home. Discharged
yesterday after a 2 week admission for aspiration pneumonia,
treated with levo/flagyl, with delirium and also atrial
fibrillation with RVR.

MEDICAL HISTORY: - COPD - [**2143**] FVC 74% of predicted, FEV1 67% of predicted,
FEV1/FVC 90% of predicted, TLC 111% of predicted, RV 145% of
predicted. Intermitent home supplemental O2 use.
- AFib
- CAD
- DVT ([**2148**]) s/p IVC filter
- HTN
- BPH
- GERD
- H. pylori gastritis
- Gout
- Inguinal hernia

MEDICATION ON ADMISSION: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable

ALLERGIES: Penicillins

PHYSICAL EXAM: Admission Physical Exam:
General: Alert, oriented to name, knows he is in the hospital in
[**Location (un) **], MA, NOT oriented to time, no acute distress, using
muscles of respirations
HEENT: Sclera anicteric, mucus membranes dry, oropharynx clear
Neck: supple, JVP not elevated (but difficult to assess), no LAD

FAMILY HISTORY: NC

SOCIAL HISTORY: Prior to recent admission, lived home alone and was independent
with ADLs, lived on a one floor home no stairs, walked around
with oxygen intermittently (reportedly 50% of the time).
Resident of [**First Name8 (NamePattern2) 3075**] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **] since recent admission. Quit
tobacco quit 40+ years ago. No ETOH. 

### Response:
{'Pneumonia, organism unspecified,Acute on chronic diastolic heart failure,Alkalosis,Precipitous drop in hematocrit,Chronic respiratory failure,Other dependence on machines, supplemental oxygen,Chronic airway obstruction, not elsewhere classified,Atrial fibrillation,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Esophageal reflux,Gout, unspecified,Other chronic pulmonary heart diseases,Constipation, unspecified'}
