CHIEF COMPLAINT: Respiratory Distress

PRESENT ILLNESS: 79y/o F w/ dementia, non-verbal p/w respiratory distress and
diarrhea. Pt. was recently treated for recurrent respiratory
infection w/ augmentin and then developed diarrhea. She had been
having diarrhea for several days and then today her son noted
respiratory distress and brought her to [**Location (un) 620**] ED. At [**Location (un) **]
her VS were initially 116/66, 89, 21 and 100%. Labs came back w/
bicarb of 10 and then lactate of 9. She was given 5L NS, levo
and flagyl. U/A had >100 WBCs. WBC was 19 w/ 26% bands. Hct 36.
She was intubated after discussion w/ son re: goals of care
transferred to [**Hospital1 18**] ED and started on levophed at 0.8 for SBP
76. she got 2L more NS, cefepime and vanc IV. At [**Location (un) 620**] she had
hyperkalemia w/o EKG changes and got insulin, D50.

MEDICAL HISTORY: Dementia, nonverbal at baseline
Left hip decubitus ulcer
Sacral decubitus ulcer
diabetes
urinary retention
CVA 8 years ago
Recurrent pulmonary infections
Old necrotic left great toe

MEDICATION ON ADMISSION: Metformin 500mg QD
Jenuvia tube feed
MVI
Vit C oral
[**Name (NI) 10687**]
MOM
Artificial Tears
Tylenol

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: BP: 110/55 P: 98 R: 22 O2: 97% FiO2 100%, CMV TV 400,
PEEP 5
General: Unresponsive to stimuli, on vent and levophed drip at
0.8mcg/min. Extremities contracted.
HEENT: Sclera anicteric, MMM, oropharynx clear, TMs impacted w/
wax. Pupils equal and reactive to light.
Neck: Left triple lumen
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley present w/ cloudy urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, large decubitus ulcer/burn wound on L hip. L foot w/
necrotic great toe.

FAMILY HISTORY: NC

SOCIAL HISTORY: Living at home with the son. Immigrated from [**Country 651**] 18 years ago.
Dependent on all ADLs. No smoking, no alcohol known.
Unspecified septicemia,Acute respiratory failure,Pneumonia due to Pseudomonas,Pressure ulcer, stage III,Acute venous embolism and thrombosis of superficial veins of upper extremity,Acute kidney failure, unspecified,Acidosis,Mechanical complication of colostomy and enterostomy,Urinary tract infection, site not specified,Severe sepsis,Other persistent mental disorders due to conditions classified elsewhere,Do not resuscitate status,Retention of urine, unspecified,Anemia, unspecified,Diarrhea,Pseudomonas infection in conditions classified elsewhere and of unspecified site
Septicemia NOS,Acute respiratry failure,Pseudomonal pneumonia,Pressure ulcer,stage III,Ac embl suprfcl up ext,Acute kidney failure NOS,Acidosis,Colosty/enter comp-mech,Urin tract infection NOS,Severe sepsis,Mental disor NEC oth dis,Do not resusctate status,Retention urine NOS,Anemia NOS,Diarrhea,Pseudomonas infect NOS
Admission Date:  [**2123-10-16**]              Discharge Date:   [**2123-10-23**]

Date of Birth:  [**2044-1-1**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Respiratory Distress

Major Surgical or Invasive Procedure:
PEG tube exchange [**10-19**]

History of Present Illness:
79y/o F w/ dementia, non-verbal p/w respiratory distress and
diarrhea. Pt. was recently treated for recurrent respiratory
infection w/ augmentin and then developed diarrhea. She had been
having diarrhea for several days and then today her son noted
respiratory distress and brought her to [**Location (un) 620**] ED. At [**Location (un) **]
her VS were initially 116/66, 89, 21 and 100%. Labs came back w/
bicarb of 10 and then lactate of 9. She was given 5L NS, levo
and flagyl. U/A had >100 WBCs. WBC was 19 w/ 26% bands. Hct 36.
She was intubated after discussion w/ son re: goals of care
transferred to [**Hospital1 18**] ED and started on levophed at 0.8 for SBP
76. she got 2L more NS, cefepime and vanc IV. At [**Location (un) 620**] she had
hyperkalemia w/o EKG changes and got insulin, D50.

Past Medical History:
Dementia, nonverbal at baseline
Left hip decubitus ulcer
Sacral decubitus ulcer
diabetes
urinary retention
CVA 8 years ago
Recurrent pulmonary infections
Old necrotic left great toe

Social History:
Living at home with the son. Immigrated from [**Country 651**] 18 years ago.
Dependent on all ADLs. No smoking, no alcohol known.

Family History:
NC

Physical Exam:
Vitals: T: BP: 110/55 P: 98 R: 22 O2: 97% FiO2 100%, CMV TV 400,
PEEP 5
General: Unresponsive to stimuli, on vent and levophed drip at
0.8mcg/min. Extremities contracted.
HEENT: Sclera anicteric, MMM, oropharynx clear, TMs impacted w/
wax. Pupils equal and reactive to light.
Neck: Left triple lumen
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley present w/ cloudy urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, large decubitus ulcer/burn wound on L hip. L foot w/
necrotic great toe.

Pertinent Results:
[**2123-10-17**] 1:33 am URINE      Source: Catheter.

                            **FINAL REPORT [**2123-10-20**]**

   URINE CULTURE (Final [**2123-10-20**]):
      PSEUDOMONAS AERUGINOSA.    10,000-100,000 ORGANISMS/ML..
      GRAM NEGATIVE ROD(S).    ~6OOO/ML.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             PSEUDOMONAS AERUGINOSA
                             |
CEFEPIME--------------     4 S
CEFTAZIDIME-----------     4 S
CIPROFLOXACIN---------     2 I
GENTAMICIN------------     8 I
MEROPENEM-------------   0.5 S
PIPERACILLIN/TAZO-----    16 S
TOBRAMYCIN------------   <=1 S

[**2123-10-17**] 1:39 am SPUTUM      Source: Endotracheal.

                            **FINAL REPORT [**2123-10-21**]**

   GRAM STAIN (Final [**2123-10-17**]):
      >25 PMNs and <10 epithelial cells/100X field.
      4+   (>10 per 1000X FIELD):   BUDDING YEAST WITH
PSEUDOHYPHAE.
      SMEAR REVIEWED; RESULTS CONFIRMED.

   RESPIRATORY CULTURE (Final [**2123-10-21**]):
      Commensal Respiratory Flora Absent.
      PSEUDOMONAS AERUGINOSA.    MODERATE GROWTH.
         OF THREE COLONIAL MORPHOLOGIES.
      YEAST.    MODERATE GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             PSEUDOMONAS AERUGINOSA
                             |
CEFEPIME--------------     4 S
CEFTAZIDIME-----------     4 S
CIPROFLOXACIN---------   0.5 S
GENTAMICIN------------     8 I
MEROPENEM-------------     1 S
PIPERACILLIN/TAZO-----    16 S
TOBRAMYCIN------------   <=1 S

[**2123-10-17**] 1:33 am MRSA SCREEN      Source: Nasal swab.

                            **FINAL REPORT [**2123-10-18**]**

   MRSA SCREEN (Final [**2123-10-18**]):
      POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.

[**2123-10-23**] 03:38AM BLOOD WBC-6.1 RBC-2.83* Hgb-8.3* Hct-23.9*
MCV-85 MCH-29.5 MCHC-34.8 RDW-16.7* Plt Ct-339
[**2123-10-22**] 03:32AM BLOOD Neuts-75.4* Lymphs-18.3 Monos-4.3 Eos-1.8
Baso-0.2
[**2123-10-23**] 03:38AM BLOOD Glucose-181* UreaN-11 Creat-0.5 Na-140
K-4.2 Cl-106 HCO3-28 AnGap-10
[**2123-10-23**] 03:38AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.8
[**2123-10-22**] 03:58AM BLOOD Type-ART Temp-37.7 Rates-/16 O2 Flow-3
pO2-74* pCO2-35 pH-7.50* calTCO2-28 Base XS-3 Intubat-NOT INTUBA
[**2123-10-20**] 02:34AM BLOOD Lactate-0.9
[**2123-10-22**] 03:58AM BLOOD freeCa-1.16

Brief Hospital Course:
#Sepsis: Ms [**Known lastname **] was hypotensive and hypoxic on admission and was
intubated and required pressors.  Lactate was 9.1.  She was
treated empirically for hospital-acquired pneumonia with
cefepime and vancomycin; this was narrowed to cefepime after
sputum cultures returned positive for pseudomonas aeruginosa.
UA was positive and culture also grew pseudomonas.  A 14-day
course of cefepime was planned.

For some concern of c. diff colitis she was initially treated
with PO vancomycin, but this was discontinued after toxin assays
returned negative.  Other sources of infection considered
included her various decubitus ulcers, her burn-related ulcer,
and her necrotic great toe.

Pressors were weaned after 48 hours; her BP remained stable
throughout the remainder of her hospitalization.   Her
ventilator settings were gradually weaned and she was extubated
on HD#7, which she tolerated.

She was discharged with the plan to continue her IV antibiotics
via PICC for a 14-day course.

#Left upper extremity DVT: Ms. [**Known lastname **] was noted to have an
edematous left arm during hospitalization in the setting of a
left internal jugular catheter.  Ultrasound demonstrated a
cephalic vein DVT.  Heparin was begun and changed to lovanox on
HD#7, but it was then decided that the risks of anticoagulation
exceed the benefits, and this was discontinued.

#Nutrition: Ms. [**Known lastname 87266**] gastric tube was clogged after her son
administered a tube feeding.  The tube then fell out when it was
flushed.  It was then replaced by a gastrojejunal tube, selected
to decrease aspiration risk, which was sutured into place.

#[**Last Name (un) **]: Ms. [**Known lastname **] originally had a creatinine of 1.2 on admission
which was attributed to prerenal factors.  Creatinine decreased
to 0.4 with blood pressure support and fluids.

#Anemia: Hct trended down from 30 to 26, where it stabilized,
during hospitalization.

#DM: Ms. [**Known lastname **] was managed on an ISS, which was decreased on HD#3
following an episode of hypoglycemia.  On discharge, she was
returned to her home regimen of metformin.

#Goals of care: Ms. [**Known lastname **] was eventually made DNR/DNI after
discussions with her sons, and was discharged to home with
hospice services.

Medications on Admission:
Metformin 500mg QD
Jenuvia tube feed
MVI
Vit C oral
[**Name (NI) 10687**]
MOM
Artificial Tears
Tylenol

Discharge Medications:
1. cefepime 1 gram Recon Soln Sig: One (1) Recon Soln Injection
Q12H (every 12 hours) for 7 days: continue for 7 more days until
[**10-29**].
Disp:*14 Recon Soln(s)* Refills:*0*
2. sodium chloride 0.9 % 0.9 % Parenteral Solution Sig: Ten (10)
ML Intravenous PRN (as needed) as needed for line flush:
non-heparin-dependent PICC.
Disp:*1000 ML(s)* Refills:*0*
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
4. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
5. Januvia continuing at previous home dose (dose not known to
us at this time)


Discharge Disposition:
Home With Service

Facility:
VistaCare

Discharge Diagnosis:
1. Sepsis
2. Respiratory failure
3. Dementia
4. Acute renal failure


Discharge Condition:
Mental Status: Not interactive.
Level of Consciousness: Lethargic and not arousable.
Activity Status: Bedbound.


Discharge Instructions:
Dear Mr. [**Known lastname **],

It was a pleasure taking care of your mother in the ICU.  She
has now been extubated and is going home with hospice services.
She should receive IV antibiotics at home through her PICC line
and nutrition through her PEG tube.  Because she is [**Hospital 66537**]
hospice care, it is very important that if you are concerned
about any symptoms, you call Vistacare, the hospice company, for
assistance, rather than bringing her to the hospital.

Followup Instructions:
Home hospice services through VistaCare.
{'Unspecified septicemia,Acute respiratory failure,Pneumonia due to Pseudomonas,Pressure ulcer, stage III,Acute venous embolism and thrombosis of superficial veins of upper extremity,Acute kidney failure, unspecified,Acidosis,Mechanical complication of colostomy and enterostomy,Urinary tract infection, site not specified,Severe sepsis,Other persistent mental disorders due to conditions classified elsewhere,Do not resuscitate status,Retention of urine, unspecified,Anemia, unspecified,Diarrhea,Pseudomonas infection in conditions classified elsewhere and of unspecified site'}


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: Respiratory Distress

PRESENT ILLNESS: 79y/o F w/ dementia, non-verbal p/w respiratory distress and
diarrhea. Pt. was recently treated for recurrent respiratory
infection w/ augmentin and then developed diarrhea. She had been
having diarrhea for several days and then today her son noted
respiratory distress and brought her to [**Location (un) 620**] ED. At [**Location (un) **]
her VS were initially 116/66, 89, 21 and 100%. Labs came back w/
bicarb of 10 and then lactate of 9. She was given 5L NS, levo
and flagyl. U/A had >100 WBCs. WBC was 19 w/ 26% bands. Hct 36.
She was intubated after discussion w/ son re: goals of care
transferred to [**Hospital1 18**] ED and started on levophed at 0.8 for SBP
76. she got 2L more NS, cefepime and vanc IV. At [**Location (un) 620**] she had
hyperkalemia w/o EKG changes and got insulin, D50.

MEDICAL HISTORY: Dementia, nonverbal at baseline
Left hip decubitus ulcer
Sacral decubitus ulcer
diabetes
urinary retention
CVA 8 years ago
Recurrent pulmonary infections
Old necrotic left great toe

MEDICATION ON ADMISSION: Metformin 500mg QD
Jenuvia tube feed
MVI
Vit C oral
[**Name (NI) 10687**]
MOM
Artificial Tears
Tylenol

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: BP: 110/55 P: 98 R: 22 O2: 97% FiO2 100%, CMV TV 400,
PEEP 5
General: Unresponsive to stimuli, on vent and levophed drip at
0.8mcg/min. Extremities contracted.
HEENT: Sclera anicteric, MMM, oropharynx clear, TMs impacted w/
wax. Pupils equal and reactive to light.
Neck: Left triple lumen
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley present w/ cloudy urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, large decubitus ulcer/burn wound on L hip. L foot w/
necrotic great toe.

FAMILY HISTORY: NC

SOCIAL HISTORY: Living at home with the son. Immigrated from [**Country 651**] 18 years ago.
Dependent on all ADLs. No smoking, no alcohol known. 

### Response:
{'Unspecified septicemia,Acute respiratory failure,Pneumonia due to Pseudomonas,Pressure ulcer, stage III,Acute venous embolism and thrombosis of superficial veins of upper extremity,Acute kidney failure, unspecified,Acidosis,Mechanical complication of colostomy and enterostomy,Urinary tract infection, site not specified,Severe sepsis,Other persistent mental disorders due to conditions classified elsewhere,Do not resuscitate status,Retention of urine, unspecified,Anemia, unspecified,Diarrhea,Pseudomonas infection in conditions classified elsewhere and of unspecified site'}
