CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is an 84-year-old
female with a history of rheumatoid arthritis and
hypertension who was in the process of preoperative
evaluation for a right knee replacement.  She was found to
have a urinary tract infection on routine urinalysis on
[**8-11**].  She was therefore started on Bactrim.  Since
then the patient reports nonspecific complaints including
increasing fatigue and occasional lightheadedness but denied
any chest pain, shortness of breath, nausea, vomiting, or
diaphoresis.  She does report that her urine did become
[**Location (un) 2452**] in color.  She experienced a decrease in urine output
times two days prior to admission without any dysuria or
hematuria.

MEDICAL HISTORY: 1.  Rheumatoid arthritis.
2.  Osteoporosis.
3.  Hypertension.
4.  History of vertigo.
5.  No history of coronary artery disease.

MEDICATION ON ADMISSION: Atenolol 25 mg p.o. q.d.,
Bactrim 1-week total (to be completed on [**10-20**]),
Fosamax 10 mg p.o. q.d., Plaquenil 200 mg p.o. b.i.d.,
Ultra-Cal, Vioxx 25 mg p.o. b.i.d., meclizine 25 mg p.o. q.d.
p.r.n.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient lives alone is very independent.
She walks regularly for exercise.  She denies any alcohol or
tobacco use.  Her daughter is her contact at phone
number [**Telephone/Fax (1) 32941**].
Acute glomerulonephritis with other specified pathological lesion in kidney,Dermatitis due to drugs and medicines taken internally,Sulfonamides causing adverse effects in therapeutic use,Acute kidney failure, unspecified,Postinflammatory pulmonary fibrosis,Iatrogenic pneumothorax,Urinary tract infection, site not specified
Acute nephritis NEC,Drug dermatitis NOS,Adv eff sulfonamides,Acute kidney failure NOS,Postinflam pulm fibrosis,Iatrogenic pneumothorax,Urin tract infection NOS
Admission Date:  [**2117-8-21**]     Discharge Date:  [**2117-9-6**]


Service:

HISTORY OF PRESENT ILLNESS:  The patient is an 84-year-old
female with a history of rheumatoid arthritis and
hypertension who was in the process of preoperative
evaluation for a right knee replacement.  She was found to
have a urinary tract infection on routine urinalysis on
[**8-11**].  She was therefore started on Bactrim.  Since
then the patient reports nonspecific complaints including
increasing fatigue and occasional lightheadedness but denied
any chest pain, shortness of breath, nausea, vomiting, or
diaphoresis.  She does report that her urine did become
[**Location (un) 2452**] in color.  She experienced a decrease in urine output
times two days prior to admission without any dysuria or
hematuria.

She had laboratories drawn at an outside hospital on
[**8-18**] which demonstrated an increased white blood cell
count with 3 bands.  In addition, her creatinine had
increased from a baseline of 1 to 2.7.  While she was at her
primary care physician's office getting her laboratories
drawn she continued to complain of lightheadedness and
dizziness.

She was seen in the clinic on [**8-20**] for followup.  She
was found to have a blood pressure of 110/64 and physical
examination revealed no bibasilar crackles.  Her
electrocardiogram showed no acute changes, and a chest x-ray
was negative by report.  Her creatine kinase enzymes and
creatinine were found to be elevated and she was sent to the
Emergency Department to evaluate for acute renal failure and
to rule out for myocardial infarction.

In the Emergency Department, the patient was afebrile with
stable vital signs.  Her creatine kinases were cycled, and
her troponin was negative.  Her second creatine kinase had an
elevated MB fraction.  The patient was questioned again about
chest pain, angina, shortness of breath, nausea, vomiting,
diaphoresis; and she denied all.  She was noted at that time
to have a maculopapular rash.

In the Emergency Department, she was given Lasix 20 mg, and
aspirin, as well as 1 unit of packed red blood cells.  She
was admitted for further evaluation of her acute renal
failure and to rule out myocardial infarction.

PAST MEDICAL HISTORY:
1.  Rheumatoid arthritis.
2.  Osteoporosis.
3.  Hypertension.
4.  History of vertigo.
5.  No history of coronary artery disease.

ALLERGIES:  No known drug allergies.

MEDICATIONS ON ADMISSION:  Atenolol 25 mg p.o. q.d.,
Bactrim 1-week total (to be completed on [**10-20**]),
Fosamax 10 mg p.o. q.d., Plaquenil 200 mg p.o. b.i.d.,
Ultra-Cal, Vioxx 25 mg p.o. b.i.d., meclizine 25 mg p.o. q.d.
p.r.n.

SOCIAL HISTORY:  The patient lives alone is very independent.
She walks regularly for exercise.  She denies any alcohol or
tobacco use.  Her daughter is her contact at phone
number [**Telephone/Fax (1) 32941**].

PHYSICAL EXAMINATION ON PRESENTATION:  Vital signs were blood
pressure 108/48, heart rate 58, respiratory rate 26, satting
97% on 2 liters oxygen.  In general, pleasant, in no acute
distress.  HEENT revealed extraocular muscles were intact.
Pupils were equal, round, and reactive to light.  The
oropharynx was without lesions.  Cardiovascular had a regular
rate and rhythm, a 2/6 systolic ejection murmur at the left
sternal border radiating to the axilla.  No jugular venous
distention.  Pulmonary revealed crackles appreciated at the
lower one-third on the left and lower one-half on the right.
Abdomen was distended and tympanitic with positive bowel
sounds, soft and nontender.  No suprapubic tenderness.  No
costovertebral angle tenderness.  Foley in place with light
yellow urine.  Extremities had 2+ pitting edema to the feet
bilaterally.  Skin had maculopapular rash over the chest,
arms, legs; nonpruritic.  Neurologically, nonfocal.

LABORATORY DATA ON PRESENTATION:  White blood cell count 6.9,
hematocrit 27.5, platelets 154.  Sodium 128, potassium 4.2,
chloride 95, bicarbonate 22, BUN 57, creatinine 3.5, glucose
of 111.  ALT 15, AST 30, alkaline phosphatase 79, total
bilirubin 0.2.  Creatine kinase 263 with an MB fraction
of 21, giving an index of 8%.  Urinalysis was nitrite
negative, protein negative, blood negative, 5 red blood
cells, 1 white blood cell, no bacteria, 1 epithelial cell.

RADIOLOGY/IMAGING:  Electrocardiogram revealed sinus rhythm
at 56 beats per minute, primary AV block, normal axis, T wave
inversions in leads III and aVF.

HOSPITAL COURSE:   The patient is an 84-year-old female with
rheumatoid arthritis with a recent bump in her creatinine and
a new rash following initiation of Bactrim therapy, who was
also presenting with a complaint of malaise, positive
creatine kinases, negative troponin.

Her acute renal failure seemed likely secondary to Bactrim
initiation as well as possibly having been contributed by
dehydration and Vioxx therapy.  The role of her positive
creatine kinase enzymes was unclear.  She also seemed to be
demonstrating a mild congestive heart failure at the time of
admission.

The patient was ruling in by myocardial enzymes for a
myocardial infarction given her elevated enzymes.  She was
therefore started on an aspirin and Lopressor, and her ACE
inhibitor was held.  The patient was started on telemetry,
and serial electrocardiograms were followed.

The patient was also suffering nonoliguric acute renal
failure which was thought secondary to Bactrim, possibly
exacerbated by dehydration.  Therefore, the Bactrim was held.
A Renal consultation was obtained, who said that the sediment
of the urine did show white cells.  They felt like her
symptomatology could be consistent with Bactrim-induced renal
insufficiency.  They recommended gentle hydration and
withholding of offending agents with consideration for
steroid treatment should her renal function worsen.

Over the course of the next few days the patient's creatinine
trended downward as the patient diuresed.  The patient
remained cardiovascularly stable with creatine kinase enzymes
trending downward as well.  She remained chest pain free over
the next few hospital days.  Her beta blocker, aspirin, and
nitrates were continued.

However, the patient's pulmonary function continued to worsen
over the next few days.  She continued to have low oxygen
saturations and required increasing amounts of oxygen to
maintain her saturation.  In addition, she continued to have
rales on examination despite avid diuresis.  Therefore, it
was felt that congestive heart failure was an unlikely reason
for the patient's pulmonary problems.  A CT scan was obtained
which was not consistent with pulmonary embolus.  As her
pulmonary situation continued to deteriorate, it was felt
that she was likely developing acute respiratory distress
syndrome.  She was therefore evaluated by the Medical
Intensive Care Unit team for possible transfer.

By [**8-27**], the patient was requiring 10 liters to 15
liters by face mask to maintain oxygen saturations of greater
than 90%.  As part of the workup of her hypoxia, an
echocardiogram revealed an ejection fraction of 50% with
moderate pulmonary hypertension, and her CT angiogram while
demonstrating no evidence of pulmonary embolus did
demonstrate increased interstitial infiltrates and areas of
ground-glass opacifications.  She was therefore transferred
to the Medical Intensive Care Unit on [**8-27**] for
management of what appeared to be a noncardiogenic
interstitial infiltrate of unclear etiology.  She was
continued on levofloxacin 250 mg p.o. q.d. and was started on
Solu-Medrol 60 mg intravenously q.8h.

A bronchoalveolar lavage was planned to evaluate for
infectious etiology of the patient's pulmonary issues as well
as to obtain a tissue sample for evaluation of possible
hypersensitivity pneumonitis.  Pending these results, the
patient was continued on empiric antibiotic therapy as well
as empiric Pneumocystis carinii pneumonia coverage and
empiric steroids.  Her saturations remained stable on a
nonrebreather over the next few days; however, the patient
did not show any improvement in her pulmonary situation.
Results from the bronchoalveolar lavage did not demonstrate
any etiology of the patient's pulmonary pathology.
Therefore, Thoracic Surgery was contact[**Name (NI) **] for evaluation for
possible open lung biopsy.

Over the course of the next few days the patient's pulmonary
situation continued to worsen.  On [**8-30**], it was felt
that the patient was becoming fatigued and could not longer
support her own breathing.  Therefore, she was intubated and
sedated to decrease her work of breathing.  Levofloxacin and
Solu-Medrol were continued.  The patient has remained
hemodynamically stable; however, after initiating sedatives
for placement of the endotracheal tube, her pressure dropped
and responded well to fluid boluses.

On [**9-1**], a central line was placed in preparation for a
lung biopsy.  This resulted in a subsequent pneumothorax
which was treated with chest tube placement.  The patient
tolerated the procedure without difficulty.  A lung biopsy
was performed later that afternoon.  Results from the lung
biopsy demonstrated extensive fibrosis with virtually no
pulmonary architecture remaining.  Therefore, it was felt
that the patient was suffering end-stage fibrosis possibly
secondary to a usual interstitial pneumonitis versus an acute
interstitial pneumonitis.

Over the course of the next few days the patient's oxygen
requirements and ventilatory support need increased.  A
family discussion was held to discuss the patient's poor
prognosis given the extent fibrosis found on lung biopsy.  It
was determined that the only possible course of treatment
left was a short course of intensive high-dose steroids.  The
patient's family agreed to this treatment, and the patient
was treated with 1 g of Solu-Medrol intravenously q.d. times
three days.  Over the course of those three days, the patient
remained hemodynamically stable but with decreasing blood
pressure and had to be started on pressors.  She also
required increasing ventilatory support and was kept sedated
as well as paralyzed.  Serial blood gases demonstrated
increasing acidosis.  In addition, the patient's peak
pressures increased to well over 40.

Therefore, at the end of three days of high-dose steroids it
was felt that the patient's pulmonary situation had not
improved.  This was discussed at length with the patient's
family who agreed that in this situation the patient would
not want to be on a ventilator for the rest of her life.
Therefore, the focus of care was switched to comfort measures
only.  The patient was provided with adequate sedation and
pain medication.

The patient was found to be unresponsive in the afternoon of
[**2117-9-6**].  Telemetry demonstrated no electrocardiac
activity.  The patient was found to have pupils fixed and
dilated with absent reflexes, absent heart sounds, and absent
breath sounds.  The patient was pronounced dead at 4:30 p.m.
on [**2117-9-6**].  The patient's family was in attendance
at the time of death.  The attending, Dr. [**First Name (STitle) **], and the
patient's covering primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], were
contact[**Name (NI) **].  The patient deferred an autopsy at the time of
death.




                          [**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D.  [**MD Number(1) 314**]

Dictated By:[**Name8 (MD) 8860**]

MEDQUIST36

D:  [**2117-10-14**]  17:06
T:  [**2117-10-17**]  10:08
JOB#:  [**Job Number **]

 (cclist)
{'Acute glomerulonephritis with other specified pathological lesion in kidney,Dermatitis due to drugs and medicines taken internally,Sulfonamides causing adverse effects in therapeutic use,Acute kidney failure, unspecified,Postinflammatory pulmonary fibrosis,Iatrogenic pneumothorax,Urinary tract infection, site not specified'}


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: 

PRESENT ILLNESS: The patient is an 84-year-old
female with a history of rheumatoid arthritis and
hypertension who was in the process of preoperative
evaluation for a right knee replacement.  She was found to
have a urinary tract infection on routine urinalysis on
[**8-11**].  She was therefore started on Bactrim.  Since
then the patient reports nonspecific complaints including
increasing fatigue and occasional lightheadedness but denied
any chest pain, shortness of breath, nausea, vomiting, or
diaphoresis.  She does report that her urine did become
[**Location (un) 2452**] in color.  She experienced a decrease in urine output
times two days prior to admission without any dysuria or
hematuria.

MEDICAL HISTORY: 1.  Rheumatoid arthritis.
2.  Osteoporosis.
3.  Hypertension.
4.  History of vertigo.
5.  No history of coronary artery disease.

MEDICATION ON ADMISSION: Atenolol 25 mg p.o. q.d.,
Bactrim 1-week total (to be completed on [**10-20**]),
Fosamax 10 mg p.o. q.d., Plaquenil 200 mg p.o. b.i.d.,
Ultra-Cal, Vioxx 25 mg p.o. b.i.d., meclizine 25 mg p.o. q.d.
p.r.n.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient lives alone is very independent.
She walks regularly for exercise.  She denies any alcohol or
tobacco use.  Her daughter is her contact at phone
number [**Telephone/Fax (1) 32941**]. 

### Response:
{'Acute glomerulonephritis with other specified pathological lesion in kidney,Dermatitis due to drugs and medicines taken internally,Sulfonamides causing adverse effects in therapeutic use,Acute kidney failure, unspecified,Postinflammatory pulmonary fibrosis,Iatrogenic pneumothorax,Urinary tract infection, site not specified'}
