CHIEF COMPLAINT: Fever, dyspnea, sepsis

PRESENT ILLNESS: Ms. [**Known lastname **] is a 78 y.o. F with hypertension, atrial fibrillation
on coumadin, recurrent UTIs on suppressive therapy, s/p CVA with
residual L sided weakness, who presents with fever and shortness
of breath. The patient's symptoms started 5 days ago with
shortness of breath and fever 101-103. She also complained about
cough productive of white sputum. She tried treating with honey
for the cough. Also complained of nasal congestion but no
rhinorrhea. Denies myalgias. Denies sick contacts. [**Name (NI) **] recent
hospitalizations in the last 6 months. Per her husband, the
patient was more confused than her baseline dementia. From OMR
notes, on [**7-11**], husband called PCP and said patient was coughing
up "fluids" and requested [**Month/Year (2) 269**] evaluation. PCP [**Name (NI) 653**] [**Name (NI) 269**] for
evaluation on that day. Husband called again later that day to
say the patient's cough had improved with only edema over the
shins. At that time, no shortness of breath. PCP called
spironolactone 25 mg daily in that day. On [**2192-7-12**], [**Date Range 269**] visited
patient who stated fever 101 and sounded very congested. At that
point, PCP referred to [**Name9 (PRE) **] and she was brought in by EMS.

MEDICAL HISTORY: - s/p right MCA CVA - [**2189-7-18**] with left-sided hemiplegia
- Atrial fibrillation, on anticoagulation. Target INR 2.0-3.0
- Hypertension
- Hypercholesterolemia
- Glaucoma
- Seizure disorder - followed by Dr. [**Last Name (STitle) 631**]
- Recurrent urinary tract infections on macrodantin
- Depression
- Anemia
- Seborrheic dermatitis
.
PAST SURGICAL HISTORY:
None

MEDICATION ON ADMISSION: Amlodipine 5 mg po daily
Betamethasone dipropionate 0.05% cream [**Hospital1 **]
Cymbalta 30 mg po daily
Keppra 500 mg po BID
Lisinopril 20 mg po daily
Nitrofurantoin 25 mg po daily
Pantoprazole 20 mg po BID
Potassium Chloride 20 meq po daily
Lyrica 75 mg po BID
Simvastatin 40 mg po daily
Coumadin 3 mg po daily
Dulcolax 5 mg po daily
Spironolactone 25 mg po daily

ALLERGIES: Penicillins / Sulfa (Sulfonamides) / Erythromycin Ethylsuccinate
/ Zithromax / Zofran

PHYSICAL EXAM: VITAL SIGNS: T 100.2 HR 130 BP 132/48 RR 24 O2 89% 4 L NC
GEN: elderly obese female with facemask on, talking in full
sentences
HEENT: anicteric, EOMI, OP - no exudate, no erythema, no
cervical LAD, unable to assess JVP due to habitus
CHEST: scattered wheezes, decreased BS bilaterally at bases
CV: irreg irreg, no m/r/g
ABD: NDNT, soft, obese
EXT: [**1-20**]+ pitting edema to shins
NEURO: A&O x name, hospital, DOB
DERM: no rashes noted

FAMILY HISTORY: Brother with MI at 58.

SOCIAL HISTORY: Lives at home with husband. Wheelchair bound. Quit smoking 15
years ago, ~50 pack year history
Unspecified septicemia,Pneumonia, organism unspecified,Acute on chronic diastolic heart failure,Pneumonitis due to inhalation of food or vomitus,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Sepsis,Atrial fibrillation,Unspecified essential hypertension,Epilepsy, unspecified, without mention of intractable epilepsy,Long-term (current) use of anticoagulants,Dermatitis due to drugs and medicines taken internally,Cephalosporin group causing adverse effects in therapeutic use,Personal history of tobacco use,Unspecified glaucoma,Other persistent mental disorders due to conditions classified elsewhere,Anemia, unspecified,Right bundle branch block
Septicemia NOS,Pneumonia, organism NOS,Ac on chr diast hrt fail,Food/vomit pneumonitis,Late ef-hemplga side NOS,Sepsis,Atrial fibrillation,Hypertension NOS,Epilep NOS w/o intr epil,Long-term use anticoagul,Drug dermatitis NOS,Adv eff cephalosporin,History of tobacco use,Glaucoma NOS,Mental disor NEC oth dis,Anemia NOS,Rt bundle branch block
Name:  [**Known lastname **],[**Known firstname 779**] C                     Unit No:   [**Numeric Identifier 12069**]

Admission Date:  [**2192-7-12**]              Discharge Date:   [**2192-7-30**]

Date of Birth:  [**2113-9-9**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Sulfa (Sulfonamides) / Erythromycin Ethylsuccinate
/ Zithromax / Zofran

Attending:[**First Name3 (LF) 877**]
Addendum:
Hypertension: On admission the patient's home antihypertensives
were held and the patient was started on diltiazem for rate
control.  On discharge, the patient was kept on diltiazem for
rate control as her heart rate continued to be in the 80s-90s.
As her SBPs remained somewhat low in the 100-115 range her
previous antihypertensives (amlodipine, lisinopril, and
spironolactone) were not restarted.  If her BPs increase as an
outpatient consideration to restarting lisinopril given her
underlying CHF may be given.  Alternatively, if she develops
increasing edema at home a diuretic may also be considered.

Discharge Disposition:
Home With Service

Facility:
VN & Community Health

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 878**] MD, [**MD Number(3) 879**]

Completed by:[**2192-7-31**]

Admission Date:  [**2192-7-12**]              Discharge Date:   [**2192-7-30**]

Date of Birth:  [**2113-9-9**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Sulfa (Sulfonamides) / Erythromycin Ethylsuccinate
/ Zithromax / Zofran

Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Fever, dyspnea, sepsis


Major Surgical or Invasive Procedure:
RIJ Placement
PICC line placement


History of Present Illness:
Ms. [**Known lastname **] is a 78 y.o. F with hypertension, atrial fibrillation
on coumadin, recurrent UTIs on suppressive therapy, s/p CVA with
residual L sided weakness, who presents with fever and shortness
of breath. The patient's symptoms started 5 days ago with
shortness of breath and fever 101-103. She also complained about
cough productive of white sputum. She tried treating with honey
for the cough. Also complained of nasal congestion but no
rhinorrhea. Denies myalgias. Denies sick contacts. [**Name (NI) **] recent
hospitalizations in the last 6 months. Per her husband, the
patient was more confused than her baseline dementia. From OMR
notes, on [**7-11**], husband called PCP and said patient was coughing
up "fluids" and requested [**Month/Year (2) 269**] evaluation. PCP [**Name (NI) 653**] [**Name (NI) 269**] for
evaluation on that day. Husband called again later that day to
say the patient's cough had improved with only edema over the
shins. At that time, no shortness of breath. PCP called
spironolactone 25 mg daily in that day. On [**2192-7-12**], [**Date Range 269**] visited
patient who stated fever 101 and sounded very congested. At that
point, PCP referred to [**Name9 (PRE) **] and she was brought in by EMS.

In the ED, initial VS: T 99.1 HR 122 (120-140s) BP 128/80 RR 28
98% NRB. Labs drawn and significant for leukocytosis 25.8 and
INR 4.4. UA contaminated with epi. Blood Cultures and Urine
cultures pending. EKG with ? new RBBB. Portable CXR and CTA
completed. She was given aspirin 325 mg po x 1, levofloxacin 750
mg IV x 1, and vancomycin 1 gm IV x 1 (ordered, but not given).
2 L NS given. Foley catheter placed.

Review of systems:
(+) Per HPI, nausea
(-) Denies chest pain, abdominal pain, vomiting, constipation,
diarrhea.


Past Medical History:
- s/p right MCA CVA - [**2189-7-18**] with left-sided hemiplegia
- Atrial fibrillation, on anticoagulation. Target INR 2.0-3.0
- Hypertension
- Hypercholesterolemia
- Glaucoma
- Seizure disorder - followed by Dr. [**Last Name (STitle) 631**]
- Recurrent urinary tract infections on macrodantin
- Depression
- Anemia
- Seborrheic dermatitis
.
PAST SURGICAL HISTORY:
None


Social History:
Lives at home with husband. Wheelchair bound. Quit smoking 15
years ago, ~50 pack year history


Family History:
Brother with MI at 58.

Physical Exam:
VITAL SIGNS: T 100.2 HR 130 BP 132/48 RR 24 O2 89% 4 L NC
GEN: elderly obese female with facemask on, talking in full
sentences
HEENT: anicteric, EOMI, OP - no exudate, no erythema, no
cervical LAD, unable to assess JVP due to habitus
CHEST: scattered wheezes, decreased BS bilaterally at bases
CV: irreg irreg, no m/r/g
ABD: NDNT, soft, obese
EXT: [**1-20**]+ pitting edema to shins
NEURO: A&O x name, hospital, DOB
DERM: no rashes noted


Pertinent Results:
Admission Labs:
WBC 25.8 Hgb 10.2 Hct 34.2 Plt 308 MCV 74
N 91.7 L 4.3 M 3.7 E 0.1 Bas 0.2
PT 41.8 PTT 63.7 INR 4.4
.
CK 226 MB 3 Trop 0.02
.
Na 143 Cl 102 BUN 13 Gluc 128
K 3.7 Bicarb 30 Cr 1.0 AG 11
.
Lactate 1.7
.
UA amber, 4 urobili, small bili, neg leuk, lg blood, nitrite
neg, prot 30, tr ketones, RBC>50, WBC [**12-7**], few bacteria, 21-50
epis, [**6-27**] hyaline casts
.
MICROBIOLOGY:
[**2192-7-12**] Blood Cultures x 2: Negative
[**2192-7-12**] Urine Culture:  No growth
[**2192-7-12**] Urine legionella:  Negative
[**2192-7-13**] Sputum cx:   GRAM STAIN (Final [**2192-7-13**]):
      >25 PMNs and <10 epithelial cells/100X field.
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE ROD(S).

   RESPIRATORY CULTURE (Final [**2192-7-15**]):
      SPARSE GROWTH OROPHARYNGEAL FLORA.
.
Cardiac markers:
[**2192-7-12**] 01:40PM BLOOD CK-MB-3 proBNP-3784*
[**2192-7-12**] 01:40PM BLOOD CK(CPK)-226*
[**2192-7-12**] 01:40PM BLOOD cTropnT-0.02*
[**2192-7-13**] 03:35AM BLOOD CK(CPK)-246*
[**2192-7-13**] 03:35AM BLOOD CK-MB-3 cTropnT-0.02*
.
Dig load:
[**2192-7-16**] 05:20AM BLOOD Digoxin-2.6*
[**2192-7-17**] 04:16AM BLOOD Digoxin-2.4*
.
ABG trend:
[**2192-7-13**] 03:31AM BLOOD Type-ART pO2-74* pCO2-65* pH-7.27*
calTCO2-31* Base XS-0
[**2192-7-16**] 11:28AM BLOOD Type-ART pO2-77* pCO2-64* pH-7.40
calTCO2-41* Base XS-11
[**2192-7-16**] 02:43PM BLOOD Type-ART pO2-221* pCO2-64* pH-7.40
calTCO2-41* Base XS-12
[**2192-7-17**] 05:21PM BLOOD Type-ART pO2-82* pCO2-70* pH-7.39
calTCO2-44* Base XS-13
[**2192-7-19**] 12:27PM BLOOD Type-ART pO2-63* pCO2-62* pH-7.39
calTCO2-39* Base XS-9
.
STUDIES:
[**2192-7-12**] EKG: ? new RBBB, atrial fibrillation of 140s, nls axis,
no acute Q waves, TWI, ST changes. compared to previous in
10/[**2190**].
.
[**2192-7-12**] PORTABLE CXR (my read): RML and LLL infiltrates,
perihilar lymphadenopathy.
.
[**2192-7-12**] CTA (wet read): Limited study due to motion artifact.
Within limitation, no e/o PE to the segmental level. Multifocal
peribronchial opacities concerning for multifocal pneumonia or
aspiration. Hilar and mediastinal adenopathy likely reactive,
but some nodes measuring up to 12mm. Recommend repeat scan when
symptoms resolve and patient is able to perform breath hold to
ensure resolution.
.
[**2192-7-18**] CT CHEST:IMPRESSION: Increased small bilateral pleural
effusions and worsening bilateral lower lobe and lingular
atelectasis. Secretions are noted in the right main bronchus,
right bronchus intermedius and segemental branches.
.
[**2192-7-13**] ECHO:
The left atrium is mildly dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are
moderately thickened. There is mild aortic valve stenosis (valve
area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild calcific aortic stenosis. Moderate pulmonary hypertension.
.
[**2192-7-18**] ECHO WITH BUBBLE STUDY:
The left atrium is elongated. No intracardiac shunt is suggested
with intravenous saline contrast at rest x 2 (patient unable to
cooperate with maneuvers). There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. The aortic valve is not well seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is mild pulmonary artery systolic hypertension. There is
an anterior space which most likely represents a fat pad.
Compared with the prior study (images reviewed) of [**2192-7-16**],
the estimated pulmonary artery systolic pressure is lower.
.
[**2192-7-19**] EEG PORTABLE
IMPRESSION: Abnormal portable EEG due to the disorganized and
slow
background throughout. This indicates a widespread
encephalopathy.
Medications, metabolic disturbances, and infection are among the
most
common causes. There were no areas of prominent focal slowing,
but
encephalopathies may obscure focal findings. There were no
epileptiform
features.
.
[**2192-7-20**] CT HEAD: Preliminary Report !! WET READ !!
1. Minimally change of known encephalomalacia from prior R MCA
stroke. With ex vacuo effect. Minimall rightwarded shift of
normally midline structure.
2. No acute intracranial hemorrhage.
3. New sinus disease most evident in the right maxillary and
ethmoid sinus.
.
[**2192-7-23**] Chest X-ray - New left upper lobe opacity raises concern
for aspiration pneumonia. Persistent bibasilar opacities.
.
[**2192-7-23**] Abdominal X-ray - Unremarkable bowel pattern
.
[**2192-7-27**] Chest X-ray - There is interval improvement of the left
upper lobe opacity that may be suggestive of resolution of
atelectasis or aspiration
.
.
Discharge Labs:
[**2192-7-30**] 05:30AM BLOOD WBC-11.5* RBC-4.36 Hgb-9.7* Hct-31.0*
MCV-71* MCH-22.2* MCHC-31.2 RDW-19.7* Plt Ct-442*
[**2192-7-30**] 05:30AM BLOOD PT-20.9* PTT-28.5 INR(PT)-1.9*
[**2192-7-30**] 05:30AM BLOOD Glucose-126* UreaN-13 Creat-0.9 Na-138
K-4.1 Cl-101 HCO3-30
[**2192-7-30**] 05:30AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.4


Brief Hospital Course:
Mrs. [**Known lastname **] is a 78 year old female with hypertension, atrial
fibrillation on coumadin, recurrent UTIs on suppressive therapy,
s/p CVA with residual L sided weakness, who presented with a
multifocal pneumonia.

# Sepis secondary to Pneumonia: On admission the patient met
SIRS criteria with leukocytosis, tachycardia, and tachypnea. No
hypotension noted in ED.  She was septic on presentation
transiently requiring neosynephrine. Most likely infectious
etiology is multifocal pneumonia seen on both CXR and CTA.
Patient reported subjective fevers at home, low grade temp on
admission. Sputum culture and legionella urinary antigen were
negative.  Blood culture and urine culture also remained
negative.  She remained hypoxic despite good diuresis and
antibiotics.  It was thought she may have a shunt given pO2 82%
on 100% FiO2 after treatment of pneumonia.  She had increased
thick secretions with sats improved by suctioning.  No fever,
WBC elevated but stable.  Bubble study was without intracardiac
shunt.  CT chest showed small bilateral pleural effusions and
thick secretions.  Patient improved with frequent suctioning but
had a weak cough.  She completed a seven day course of
Ceftriaxone and Levofloxacin for pneumonia.  She was transferred
to the floor on [**7-21**].

Once on the floor the patient still exhibited signs of
infection/hypoxia.  Mental status remained below baseline.  PICC
placed on [**7-21**]. Thereafter, her wbc started to rise again, and on
[**7-23**], repeat CXR report mentioned a new LUL opacity suggestive of
a possible aspiration pneumonia on the final read. Her hypoxemia
remained. Blood, urine, and sputum cx sent. LFT were normal. C.
diff was negative. On [**7-24**], vancomycin, levofloxacin, and
metronidazole were started for possible pneumonia. On [**7-25**], the
patient had a temperature to 100.1.  WBC count was elevated from
13K to 20.4K.  Levofloxacin was switched to ciprofloxacin per ID
recommendations.  Flagyl and vancomycin remained for appropriate
coverage of hospital acquired pneumonia.  WBC began to trend
down (11.5 on [**7-30**]).  The patient remained afebrile while on the
floor.  Urine cultures were negative.  Blood cultures showed no
growth to date.  The patient's mental status also improved
tremendously.  Upon discharge, patient was afebrile with no
leukocytosis and her mental status had returned to her previous
baseline.

#. Hypoxia:  Most likely hypoxia was due to a combination of
heart failure and her previous pneumonia.  Patient initially
came to the floor requiring FM at 35%.  She was satting well and
denied any SOB except for on exertion.  Patient required
frequent diuresis with IV lasix with a fluid balance of -1L in
24hrs.  40mg IV lasix was the dose that provided the best
effect.  Nephrology was on-board and agreed with the plan to
diurese.  As her condition improved and mental status cleared
up, she was weaned.  On discharge she was on RA satting 91-93%
with no complaints of shortness of breath.

# Altered mental status:  In the ICU the patient was
intermittently somnolent and delerious.  No evidence of elevated
CO2 above her baseline hypercarbia.  She does have a history of
partial complex seizures for which she takes Keppra, but EEG in
the ICU showed widespread encephalopathy without focal seizures.
 A head CT showed encephalomalacia from prior R MCA stroke but
was without new bleed or other acute intracaranial process.  AMS
remained upon transfer to the floor for the first 5 days.  It
began to improve as her hypoxia improved.  There was an episode
on the morning of [**7-28**] when the patient was difficult to arouse
in the morning.  A trigger was called.  However, her vital signs
were stable, she had a normal blood glucose, and her ABG was
without significant hypercarbia.  She eventually did awake to
painful stimulus and remained alert the rest of the day and had
no further difficulties thereafter.

# Atrial fibrillation / diastolic CHF:  The patient was diuresed
in both the ICU and on the floor.  After extensive diuresis in
the ICU, her creatinine bumped to 1.2.  Diuretics were held and
then resumed on the floor.  Her creatinine had returned to 0.9
on discharge.  In the ICU the patient had afib with RVR and was
started on diltiazem for rate control.  She was also briefly
loaded on digoxin, but the latter was stopped in the setting of
acute decompensation.  Her other blood pressure medications were
held.

# Rash:  The patient developed a rash in the ICU that was
concerning for a drug rash.  She has known allergies to both
penicillins and sulfa drugs.  Ceftriaxone discontinued.

# Depression: Cymbalta was held in the setting of altered mental
status and resumed on discharge.

# Seizure disorder: EEG in the ICU was without signs of
seizures.  Keppra was continued.  Lyrica was temporarily held,
but continued on discharge.

# Recurrent UTIs: Initial UA contaminated with epithelial cells.
 The patient was restarted on nitrofurantoin for suppresive
therapy after her initial antibiotic course was completed

# Hypercholesterolemia:  The patient was continued on
simvastatin



Medications on Admission:
Amlodipine 5 mg po daily
Betamethasone dipropionate 0.05% cream [**Hospital1 **]
Cymbalta 30 mg po daily
Keppra 500 mg po BID
Lisinopril 20 mg po daily
Nitrofurantoin 25 mg po daily
Pantoprazole 20 mg po BID
Potassium Chloride 20 meq po daily
Lyrica 75 mg po BID
Simvastatin 40 mg po daily
Coumadin 3 mg po daily
Dulcolax 5 mg po daily
Spironolactone 25 mg po daily


Discharge Medications:
1. Betamethasone Dipropionate 0.05 % Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
2. Cymbalta 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. Levetiracetam 100 mg/mL Solution Sig: Five (5) ml PO BID (2
times a day): 500 mg twice a day.
4. Nitrofurantoin Macrocrystal 50 mg Capsule Sig: 0.5 Capsule PO
HS (at bedtime).
5. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day.
6. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day: do not give if
having diarrhea or loose stool.
9. Outpatient Lab Work
CBC with Diff, Chem 7, and INR on [**8-2**].  Please fax results to
Dr. [**Last Name (STitle) 6481**]
10. Outpatient Lab Work
Chest X-ray, PA and Lateral images, the week of [**9-1**].
Please fax report to Dr. [**Last Name (STitle) 6481**].
11. Diltiazem HCl 60 mg Capsule, Sust. Release 12 hr Sig: One
(1) Capsule, Sust. Release 12 hr PO every twelve (12) hours.
Disp:*60 Capsule, Sust. Release 12 hr(s)* Refills:*2*
12. Lyrica 75 mg Capsule Sig: One (1) Capsule PO twice a day.


Discharge Disposition:
Home With Service

Facility:
VN & Community Health

Discharge Diagnosis:
Primary Diagnoses:
1. Community acquired pneumonia
2. Aspiration pneumonia
3. Acute on chronic diastolic congestive heart failure

Secondary Diagnoses:
1. Status-post stroke
2. Atrial fibrillation
3. Hypertension
4. Seizure disorder
5. Glaucoma


Discharge Condition:
Vital signs stable, afebrile, mental status at baseline.


Discharge Instructions:
You were admitted to the hospital for evaluation of fevers and
shortness of breath.  You were treated for pneumonia in the ICU
and again on the hospital floor.  Your white blood cell count,
breathing, and alertness all improved.

The following changes were made to your medications:
1. Amlodipine, Lisinopril, and Spironolactone were all stopped.
2. You were started on diltiazem to better control your heart
rate.
3. Potassium was stopped

Please call your physician or return to the hospital if you
develop fevers, shortness of breath, chest pain, or other
concerning symptoms.

Followup Instructions:
Please get your blood counts, electrolytes, and INR checked in 3
days.

Please follow-up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6481**]
in [**2-21**] weeks ([**Telephone/Fax (1) 4775**]).

Please get a repeat chest x-ray in [**4-23**] weeks to ensure
resolution of your pneumonia.


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
{'Unspecified septicemia,Pneumonia, organism unspecified,Acute on chronic diastolic heart failure,Pneumonitis due to inhalation of food or vomitus,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Sepsis,Atrial fibrillation,Unspecified essential hypertension,Epilepsy, unspecified, without mention of intractable epilepsy,Long-term (current) use of anticoagulants,Dermatitis due to drugs and medicines taken internally,Cephalosporin group causing adverse effects in therapeutic use,Personal history of tobacco use,Unspecified glaucoma,Other persistent mental disorders due to conditions classified elsewhere,Anemia, unspecified,Right bundle branch block'}


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: Fever, dyspnea, sepsis

PRESENT ILLNESS: Ms. [**Known lastname **] is a 78 y.o. F with hypertension, atrial fibrillation
on coumadin, recurrent UTIs on suppressive therapy, s/p CVA with
residual L sided weakness, who presents with fever and shortness
of breath. The patient's symptoms started 5 days ago with
shortness of breath and fever 101-103. She also complained about
cough productive of white sputum. She tried treating with honey
for the cough. Also complained of nasal congestion but no
rhinorrhea. Denies myalgias. Denies sick contacts. [**Name (NI) **] recent
hospitalizations in the last 6 months. Per her husband, the
patient was more confused than her baseline dementia. From OMR
notes, on [**7-11**], husband called PCP and said patient was coughing
up "fluids" and requested [**Month/Year (2) 269**] evaluation. PCP [**Name (NI) 653**] [**Name (NI) 269**] for
evaluation on that day. Husband called again later that day to
say the patient's cough had improved with only edema over the
shins. At that time, no shortness of breath. PCP called
spironolactone 25 mg daily in that day. On [**2192-7-12**], [**Date Range 269**] visited
patient who stated fever 101 and sounded very congested. At that
point, PCP referred to [**Name9 (PRE) **] and she was brought in by EMS.

MEDICAL HISTORY: - s/p right MCA CVA - [**2189-7-18**] with left-sided hemiplegia
- Atrial fibrillation, on anticoagulation. Target INR 2.0-3.0
- Hypertension
- Hypercholesterolemia
- Glaucoma
- Seizure disorder - followed by Dr. [**Last Name (STitle) 631**]
- Recurrent urinary tract infections on macrodantin
- Depression
- Anemia
- Seborrheic dermatitis
.
PAST SURGICAL HISTORY:
None

MEDICATION ON ADMISSION: Amlodipine 5 mg po daily
Betamethasone dipropionate 0.05% cream [**Hospital1 **]
Cymbalta 30 mg po daily
Keppra 500 mg po BID
Lisinopril 20 mg po daily
Nitrofurantoin 25 mg po daily
Pantoprazole 20 mg po BID
Potassium Chloride 20 meq po daily
Lyrica 75 mg po BID
Simvastatin 40 mg po daily
Coumadin 3 mg po daily
Dulcolax 5 mg po daily
Spironolactone 25 mg po daily

ALLERGIES: Penicillins / Sulfa (Sulfonamides) / Erythromycin Ethylsuccinate
/ Zithromax / Zofran

PHYSICAL EXAM: VITAL SIGNS: T 100.2 HR 130 BP 132/48 RR 24 O2 89% 4 L NC
GEN: elderly obese female with facemask on, talking in full
sentences
HEENT: anicteric, EOMI, OP - no exudate, no erythema, no
cervical LAD, unable to assess JVP due to habitus
CHEST: scattered wheezes, decreased BS bilaterally at bases
CV: irreg irreg, no m/r/g
ABD: NDNT, soft, obese
EXT: [**1-20**]+ pitting edema to shins
NEURO: A&O x name, hospital, DOB
DERM: no rashes noted

FAMILY HISTORY: Brother with MI at 58.

SOCIAL HISTORY: Lives at home with husband. Wheelchair bound. Quit smoking 15
years ago, ~50 pack year history 

### Response:
{'Unspecified septicemia,Pneumonia, organism unspecified,Acute on chronic diastolic heart failure,Pneumonitis due to inhalation of food or vomitus,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Sepsis,Atrial fibrillation,Unspecified essential hypertension,Epilepsy, unspecified, without mention of intractable epilepsy,Long-term (current) use of anticoagulants,Dermatitis due to drugs and medicines taken internally,Cephalosporin group causing adverse effects in therapeutic use,Personal history of tobacco use,Unspecified glaucoma,Other persistent mental disorders due to conditions classified elsewhere,Anemia, unspecified,Right bundle branch block'}
