CHIEF COMPLAINT: DOE, lethargy

PRESENT ILLNESS: 59y/o F with severe COPD on home O2 of 4L NC, DM2, Asthma,
Dperession, recently admitted to ICU here at [**Hospital1 18**] and intubated
([**Date range (2) 92815**]), discharged to [**Hospital3 672**] Hospital on 3L
of NC O2, then to [**Hospital3 **]. Now comes back with increased
cough, sputum production, sob and lethargy.

MEDICAL HISTORY: 1. COPD (intubated in the past), on home O2 of 4L NC
2. Asthma
3. DM type 2
4. Depression
5. hx of + PPD treated
6. history of MVC
7. h/o MAT on diltiazem

MEDICATION ON ADMISSION: 1. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE:
T:99 HR: 90 BP:113/47 RR:23 Sats:97%
GEN: more alert than on presentation to the ED, prior to BIPAP
was somnolent unarousable to voice commands, would wake up with
physical stimulus, speaks in broken sentences, desats with
talking.
HEENT:NC/AT, EOMI, PERRL, mmdry, o/p clear
CV: RRR with PACs, no m/r/g
PULM: Bibasilar crackles, no wheezes, min-mod air movement,
barrel chested,
ABD: +bs, soft, NT/ND, no rebound or gaurding
Ext: edema present in both lower extremities 1+ up to knees, no
c/c
NEURO: CN II-XII grossly intact, alert and oriented x 3,
strenght: [**5-31**] in upper and lower ext, sensation intact to light
touch,

FAMILY HISTORY: no heart and lung disease
Mother died of CVA

SOCIAL HISTORY: h/o of tobacco abuse, 40pyrs, quit this year, no ETOH, lives
alone, has one daughter, was at [**Hospital3 672**] Hospital
Acute and chronic respiratory failure,Obstructive chronic bronchitis with (acute) exacerbation,Atrial flutter,Congestive heart failure, unspecified,Diabetes with unspecified complication, type II or unspecified type, uncontrolled,Retention of urine, unspecified,Chronic kidney disease, unspecified,Pneumonia due to respiratory syncytial virus,Coronary atherosclerosis of native coronary artery,Iron deficiency anemia, unspecified,Long-term (current) use of steroids,Constipation, unspecified,Lumbago,Depressive disorder, not elsewhere classified,Asthma, unspecified type, unspecified
Acute & chronc resp fail,Obs chr bronc w(ac) exac,Atrial flutter,CHF NOS,DMII unspf uncntrld,Retention urine NOS,Chronic kidney dis NOS,Resp syncyt viral pneum,Crnry athrscl natve vssl,Iron defic anemia NOS,Long-term use steroids,Constipation NOS,Lumbago,Depressive disorder NEC,Asthma NOS
Admission Date:  [**2199-2-8**]              Discharge Date:   [**2199-3-8**]

Date of Birth:  [**2139-12-11**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 465**]
Chief Complaint:
DOE, lethargy

Major Surgical or Invasive Procedure:
Intubation

History of Present Illness:
59y/o F with severe COPD on home O2 of 4L NC, DM2, Asthma,
Dperession, recently admitted to ICU here at [**Hospital1 18**] and intubated
([**Date range (2) 92815**]), discharged to [**Hospital3 672**] Hospital on 3L
of NC O2, then to [**Hospital3 **]. Now comes back with increased
cough, sputum production, sob and lethargy.

In ED initial ABG was 7.21/118/51, placed on continuous nebs,
ICU team did repeat gas one hour later: 7.26/103/57 patient was
still lethargic and unable to speak. ICU team then place patient
on BIPAP with improvement in mental status.

Past Medical History:
1. COPD (intubated in the past), on home O2 of 4L NC
2. Asthma
3. DM type 2
4. Depression
5. hx of + PPD treated
6. history of MVC
7. h/o MAT on diltiazem

Social History:
h/o of tobacco abuse, 40pyrs, quit this year, no ETOH, lives
alone, has one daughter, was at [**Hospital3 672**] Hospital


Family History:
no heart and lung disease
Mother died of CVA

Physical Exam:
PE:
T:99 HR: 90 BP:113/47 RR:23 Sats:97%
GEN: more alert than on presentation to the ED, prior to BIPAP
was somnolent unarousable to voice commands, would wake up with
physical stimulus, speaks in broken sentences, desats with
talking.
HEENT:NC/AT, EOMI, PERRL, mmdry, o/p clear
CV: RRR with PACs, no m/r/g
PULM: Bibasilar crackles, no wheezes, min-mod air movement,
barrel chested,
ABD: +bs, soft, NT/ND, no rebound or gaurding
Ext: edema present in both lower extremities 1+ up to knees, no
c/c
NEURO: CN II-XII grossly intact, alert and oriented x 3,
strenght: [**5-31**] in upper and lower ext, sensation intact to light
touch,


Pertinent Results:
3.52pm: pH 7.26/103/57/48

2:34p pH 7.21/118/51/50 Lactate:0.6
Trop-*T*: <0.01

136  89  12  146    AGap=7

4.6  45  0.4

CK: 21  MB: Notdone
Ca: 9.1 Mg: 1.8 P: 5.5
ALT:  AP: 45 Tbili: 0.1 Alb: 4.4
AST: 23 LDH:  Dbili:  TProt:
[**Doctor First Name **]: 51 Lip: 17

Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative

Urine Benzos, Barbs, Opiates, Cocaine, Amphet, Mthdne Negative


12.1  9.5  260

 31.4
 N:88.2 L:9.9 M:1.5 E:0.3 Bas:0.2

PT: 11.6  PTT: 27.5  INR: 0.9

UA: normal.

ECHO [**2-11**]: Conclusions:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
and cavity size are normal. There is mild global left
ventricular hypokinesis. [Intrinsic left ventricular systolic
function is likely more depressed given the severity of valvular
regurgitation.] Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Moderate
(2+) mitral regurgitation is seen. There is mild pulmonary
artery systolic  Hypertension. There is no pericardial effusion.


IMPRESSION: Mild global left ventricular hypokinesis c/w diffuse
process
(tocxin, metabolic, multivessel CAD, etc.). Moderate mitral
regurgiattion. Mild pulmonary artery systolic hypertension. Mild
aortic regurgitation.

CXR: : Left lower lobe opacity possibly representing atelectasis
or
pneumonia, Follow up PA and lateral study would be helpful in
further
evaluating this area.

[**2199-2-22**] CXR: IMPRESSION: Small left effusion. Hyperinflated
lungs. Left lower lobe atelectasis/consolidation.


Brief Hospital Course:
59y/o F with severe COPD on home O2 of 4L NC, DM2, Asthma,
Depression, recently admitted to [**Hospital1 18**] and intubated
([**Date range (2) 92815**]) for COPD exacerbation, discharged to [**Hospital1 1099**] then home, came in with increased sputum production,
cough and SOB.
.
# COPD/hypercarbic respiratory failure: In the ED, she was found
to be in respiratory distress, hypercarbic respiratory failure
with intubation on [**2-10**] in am.  Nasal aspirate notable for RSV
positive, neg dfa for other resp viruses. She was given
Azithromycin 500mg x1 then 250mg for 4 days. She was treated for
COPD exacerbation initially, but her ICU course was complicated.
 The primary complications included 1) Ventilator-associated PNA
and 2) paroxyms of atrial flutter while intubated.  She was
treated with Zosyn/Vanc for the PNA, and was initially
heparinized for A flutter and put on amiodarone instead of
diltiazem.  Her long-acting diltiazem was originally converted
to short acting b/c it could be crushed; this was felt to have
precipitated her atrial flutter thus she was put on amiodarone.
She progressively improved and was extubated [**2-21**]; this was in
the setting of many prior failed attempts to wean PS.  She
subsequently improved and was able to be extubated.  Pt was
transfered to the floor for further managment. The pt continued
to improved on the floor and came back to her baseline O2
requirement of 1-2L, and her prednisone was tapered slowly off.
.
## Tachycardia: Pt has history of MAT and has been on dilt.
During intubation, Dilt CR was changed to qid dosing.  The pt
was receiving frequent nebulizers, in addition, she was found to
be auto-peeping.  She developed a rapid, regular, narrow complex
tachycardia that was found to have underlying fib waves (atrial
fibrillation).  Diltiazem was pushed IV x 2 overnight and an
additional PO dose of 30 was given.  Initially, with
tachycardias c/w MAT, BP was stable, however, at a rate of 150,
BP began to decrease such that MAP's were in the 50's.  After
de-recruitment with ventilator detachment, the pt's BP returned.
Albuterol was held and the pt was started on Amiodarone instead
of Diltiazem for rate control. On the floor, she subsequently
had one more episode of hypotension with tachycardia in the
context of getting up for the first time. She responded well to
fluids and had no other hypotensive events. Amiodarone was
switched back to dilt over concern for lung toxicity given her
pre-existing lung disease. However, on [**2-26**] she had an episode
of atrial flutter for about 45 minutes and spontaneously
converted back to normal rhythm. An EP consult was requested for
management of her arrhythmia, and they recommended staying off
amiodarone and increasing the dose of dilt. This was deferred
over concern for her low EF seen on echo [**2-12**], however, and a
repeat echo was obtained, which still showed a depressed EF at
30-40%. Given that the etiology of this was unclear, cardiology
recommended a pMIBI which showed mild reversible defects on the
anterior and lateral walls. Because this likely indicates 3VD
given involvement of 2 distributions and the defects are mild,
cardiology did not recommend urgent cath, as this may be
deferred to the outpatient setting if the patient so desires.
The patient should follow up with a cardiologist and has an
appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
.
## Anemia:  Low iron with normal TIBC and low normal Ferritin.
Component of anemia of chronic disease and iron deficiency. Iron
supplements as outpatient. However intially had hct drop 5
points from baseline most likely in the context of fluid
resuscitation for hypotension. Subsequently recovered without
transfusion and came back to baseline.
.
## Peripheral fluid overload: The patient was on 20mg PO Lasix
QD at home started during last admission. However, by [**2-24**], she
was autodiuresing and did not require any further Lasix. By day
of discharge, she was maintaining approximately even net fluid
balance on her own with baseline O2 sat in the mid-90s on 1-2L
O2 NC.
.
## DM2: Diabetes, usually controlled with diet, started on
Glyburide 1.25mg [**Hospital1 **] during last admission, last hemoglobin A1c
6.5. On FS QID while on steroids. Covered with ISSC while on
steroids, finger sticks were under control.
.
## Depression, Anxiety: Continue Seroquel, Trazadone, and Zoloft
at out-patient doses. Clonazepam TID increased to 1mg, but she
became intermittently disoriented and agitated so it was tapered
down to 0.5mg [**Hospital1 **] to good effect.
.
## Lower back pain/constipation: no open lesion, focal, no
radiation. Reports prior pain in that region, appears chronic.
Rectal pain likely related to constipation, possible
hemorrhoids, stool in vault on rectal. Pt maintained on Tylenol
1g qid w/ oxycodone 2.5mg q4-6h prn for breakthrough (decreased
from 5 to avoid oversedation) and aggressive bowel regimen as
long as no diarrhea: senna, colace, dulcolax, MOM.
[**3-3**] C. diff (sent for diarrhea) was negative. Diltiazem may have
contributed to constipation, it was d/c'ed as above.
Constipation may have contributed to urinary retention
experienced during her hospitalization but improved w/ treatment
of constipation.
.
## Dispo: to skilled nursing facility, expected length of stay
less than 30 days.

Medications on Admission:
1. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a

day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2

times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
5. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
8. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig: One

(1) Spray Nasal [**Hospital1 **] (2 times a day).
9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed: do not exceed 4g/d.
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): continue until ambulating > 3x/d.
11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:

One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
12. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-28**] Sprays Nasal
QID (4 times a day) as needed.
13. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 6 days.
14. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
15. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
16. Prednisone 40mg q day
17. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times

a day).
18. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
19. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
20. Glyburide 1.25 mg Tablet Sig: One (1) Tablet PO BID (2 times

a day).
21. Lasix 20 mg Tablet Sig: 0.5 Tablet PO once a day.
22. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)

Capsule, Sustained Release PO DAILY (Daily).
23. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.


Discharge Medications:
1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
2. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-28**] Sprays Nasal
QID (4 times a day) as needed.
5. Quetiapine 100 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q2H (every 2 hours) as needed. neb
8. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
12. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
13. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
sliding scale Injection ASDIR (AS DIRECTED).
14. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed.
15. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day) as needed for pain.
16. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day) as needed.
17. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

18. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
20. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for constipation.
21. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
22. Sodium Chloride 0.9%  Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
23. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
24. Warfarin 3 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).



Discharge Disposition:
Extended Care

Facility:
[**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**]

Discharge Diagnosis:
COPD
CHF
chronic back pain


Discharge Condition:
good, stable, O2 sat 94% on RA, ambulating with assistance


Discharge Instructions:
If you have fevers, chills, worsening shortness of breath,
lightheadedness, or chest pain, tell your doctor or seek medical
attention immediately.

Followup Instructions:
You should have your INR checked at rehab in 2 days. The doctor
there will adjust your coumadin dose accordingly to a goal INR
of [**3-1**].

Follow up with your PCP (VALIZADEH, [**Last Name (un) **]  [**Telephone/Fax (1) **]) within
1-2 weeks after being discharged from the rehab facility.

It is very important that you follow up with a cardiologist as
an outpatient. You have an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
on [**2199-3-25**] at 4pm on the [**Location (un) 436**] of the [**Hospital Ward Name 23**] building. Call
[**Telephone/Fax (1) 2934**] to register and for more information.


                             [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
{'Acute and chronic respiratory failure,Obstructive chronic bronchitis with (acute) exacerbation,Atrial flutter,Congestive heart failure, unspecified,Diabetes with unspecified complication, type II or unspecified type, uncontrolled,Retention of urine, unspecified,Chronic kidney disease, unspecified,Pneumonia due to respiratory syncytial virus,Coronary atherosclerosis of native coronary artery,Iron deficiency anemia, unspecified,Long-term (current) use of steroids,Constipation, unspecified,Lumbago,Depressive disorder, not elsewhere classified,Asthma, unspecified type, 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: DOE, lethargy

PRESENT ILLNESS: 59y/o F with severe COPD on home O2 of 4L NC, DM2, Asthma,
Dperession, recently admitted to ICU here at [**Hospital1 18**] and intubated
([**Date range (2) 92815**]), discharged to [**Hospital3 672**] Hospital on 3L
of NC O2, then to [**Hospital3 **]. Now comes back with increased
cough, sputum production, sob and lethargy.

MEDICAL HISTORY: 1. COPD (intubated in the past), on home O2 of 4L NC
2. Asthma
3. DM type 2
4. Depression
5. hx of + PPD treated
6. history of MVC
7. h/o MAT on diltiazem

MEDICATION ON ADMISSION: 1. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE:
T:99 HR: 90 BP:113/47 RR:23 Sats:97%
GEN: more alert than on presentation to the ED, prior to BIPAP
was somnolent unarousable to voice commands, would wake up with
physical stimulus, speaks in broken sentences, desats with
talking.
HEENT:NC/AT, EOMI, PERRL, mmdry, o/p clear
CV: RRR with PACs, no m/r/g
PULM: Bibasilar crackles, no wheezes, min-mod air movement,
barrel chested,
ABD: +bs, soft, NT/ND, no rebound or gaurding
Ext: edema present in both lower extremities 1+ up to knees, no
c/c
NEURO: CN II-XII grossly intact, alert and oriented x 3,
strenght: [**5-31**] in upper and lower ext, sensation intact to light
touch,

FAMILY HISTORY: no heart and lung disease
Mother died of CVA

SOCIAL HISTORY: h/o of tobacco abuse, 40pyrs, quit this year, no ETOH, lives
alone, has one daughter, was at [**Hospital3 672**] Hospital 

### Response:
{'Acute and chronic respiratory failure,Obstructive chronic bronchitis with (acute) exacerbation,Atrial flutter,Congestive heart failure, unspecified,Diabetes with unspecified complication, type II or unspecified type, uncontrolled,Retention of urine, unspecified,Chronic kidney disease, unspecified,Pneumonia due to respiratory syncytial virus,Coronary atherosclerosis of native coronary artery,Iron deficiency anemia, unspecified,Long-term (current) use of steroids,Constipation, unspecified,Lumbago,Depressive disorder, not elsewhere classified,Asthma, unspecified type, unspecified'}
