CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 75 year old
female from a nursing home who was recently discharged from
[**Hospital1 18**] on [**2119-6-16**], now presenting with mental status
changes.  Her discharge diagnoses from the previous admission
consisted of pneumonia and UTI.  She was discharged back to
the nursing home on levofloxacin and Flagyl.  Patient did not
improve clinically in terms of her mental status changes and
was unable to tolerate p.o.  On the day of admission at the
nursing home she spiked a temperature and given that her
mental status had not improved, she was brought to the E.D.
She was found to be hypotensive and tachycardiac to the 140s.
She received 3 liters of IV fluids and 20 mg of IV diltiazem
times two.  Her blood pressure improved and her heart rate
slowed down to the low 100s.  She was also started on
ceftriaxone and vancomycin.

MEDICAL HISTORY: Seizure disorder.  History of atrial
fibrillation which is rate controlled on diltiazem.  She is
currently not on anticoagulation.  Osteoarthritis.
Osteoporosis.  History of dementia likely secondary to
alcohol abuse.  History of lower GI bleed from diverticula.
Type 2 diabetes mellitus.  Cerebrovascular accident of the
left frontal lobe resulting in ataxia and right hemiplegia.
History of fall.  History of cataracts.  History of decubitus
ulcerations on the right buttocks.  History of hyponatremia.
Total abdominal hysterectomy with bilateral
salpingo-oophorectomy.

MEDICATION ON ADMISSION: Diltiazem extended release 120 mg
p.o. b.i.d., potassium chloride 20 mEq p.o. b.i.d., trazodone
50 mg p.o. q.day, Dilantin 450 mg p.o. q.day, phenobarbital
60 mg p.o. q.day, folic acid 1 mg p.o. q.day, glyburide 10 mg
p.o. q.day, multivitamin q.day, Protonix 40 mg p.o. q.day,
calcium carbonate 500 mg p.o. b.i.d., senna q.day, Zyprexa
2.5 mg in the morning and 5 mg at night.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Unable to elicit.

SOCIAL HISTORY: The patient has a history of alcohol abuse.
Her smoking history is currently unknown.  She lives at the
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] which is a nursing facility.
Other specified alveolar and parietoalveolar pneumonopathies,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Atrial fibrillation,Congestive heart failure, unspecified,Other convulsions,Other venous embolism and thrombosis of unspecified site,Other pulmonary insufficiency, not elsewhere classified
Alveol pneumonopathy NEC,Pneumonia, organism NOS,Urin tract infection NOS,Atrial fibrillation,CHF NOS,Convulsions NEC,Venous thrombosis NOS,Other pulmonary insuff
Name:  [**Known lastname 183**], [**Known firstname **] MAE                 Unit No:  [**Numeric Identifier 17280**]

Admission Date:  [**2119-6-23**]     Discharge Date:  [**2119-7-9**]

Date of Birth:   [**2043-11-11**]     Sex:  F

Service:  [**Hospital1 248**] MED

ADDENDUM TO HOSPITAL COURSE:

The initial portion of the [**Hospital 1325**] hospital course was
dictated at an earlier time.

[**First Name8 (NamePattern2) 1693**] [**Known lastname **] is a 75 year old female with a history of
seizure disorder, atrial fibrillation, dementia and diabetes
mellitus who was admitted on [**2119-6-23**], with mental
status changes, urinary tract infection, dehydration,
hypotension and fevers, now being transferred from the
Medical Intensive Care Unit for further management of her
mental status changes and hypoxemia.

Hospital course is as follows:

1.  URINARY TRACT INFECTION:  The patient was treated with
Ceftazidime and then switched to Vancomycin and gentamicin.
Despite these antibiotics, the urinalysis continually showed
greater than 50 white blood cells with a urine culture always
only growing out yeast.

The patient was started on Diflucan bladder washes in the
Medical Intensive Care Unit, which did not seem to improve
her urinalyses.  On the [**Hospital1 **] Service, she was given
Fluconazole times three days.  A repeat urinalysis and urine
culture have yet to be collected.

2.  PULMONARY:  The Pulmonary Consultation Service has been
following this patient throughout her stay on the [**Hospital1 **]
Service and they attributed her recent chest CT scan changes
to either BOOP or bronchoalveolar cancer.  She was started on
a trial dose of Prednisone 60 mg p.o. q. day on [**7-9**] to
see if her chest x-ray findings would improve as they should
in BOOP.

Throughout her stay on the [**Hospital1 **] Service up until the time of
this dictation, the patient's oxygen saturations had remained
stable between 90 and 95% on 31% Ventimask.  As per the
Medical Intensive Care Unit Team, they felt that an oxygen
saturation in the low 90s worked best to maintain her
ventilatory drive.

3.  ATRIAL FIBRILLATION:  The patient was continued on
diltiazem and digoxin.  She was not on Telemetry.

4.  CONGESTIVE HEART FAILURE:  The patient was continued on
her daily Lasix dose.

5.  MENTAL STATUS CHANGES:  Neurological Consultation Service
continued to follow this patient while on the [**Hospital1 **].  Her
phenobarbital was discontinued and she was continued on
Dilantin with daily Dilantin level checks.  No seizures had
occurred by the time of this dictation.

6.  ANEMIA:  The patient continued to have low hematocrit in
the high 20s but remained stable throughout the remainder of
the hospital course.

7.  NUTRITION:  Since the patient's mental status did not
allow for good p.o. intake, she was started on nasogastric
tube feedings and was continued on these feedings throughout
her hospital course until the time of this dictation.

A family meeting was held to discuss whether a PEG tube
should be placed, but the family ultimately declined PEG tube
placement and she was continued on nasogastric tube feedings.


8.  DEEP VEIN THROMBOSIS:  Lower extremity Dopplers performed
in the Medical Intensive Care Unit showed bilateral deep vein
thromboses and the patient was continued on Lovenox
throughout her hospital course.

Discharge Diagnoses and Discharge Medications will be
dictated at a later time.


                          [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 872**]

Dictated By:[**Last Name (STitle) 3647**]

MEDQUIST36

D:  [**2119-7-9**]  18:14
T:  [**2119-7-9**]  20:17
JOB#:  [**Job Number 17281**]


Admission Date:  [**2119-6-23**]       Discharge Date:  [**2119-7-11**]

Date of Birth:   [**2043-11-11**]       Sex:  F

Service:  MEDICINE

HISTORY OF PRESENT ILLNESS:  The patient is a 75 year old
female from a nursing home who was recently discharged from
[**Hospital1 18**] on [**2119-6-16**], now presenting with mental status
changes.  Her discharge diagnoses from the previous admission
consisted of pneumonia and UTI.  She was discharged back to
the nursing home on levofloxacin and Flagyl.  Patient did not
improve clinically in terms of her mental status changes and
was unable to tolerate p.o.  On the day of admission at the
nursing home she spiked a temperature and given that her
mental status had not improved, she was brought to the E.D.
She was found to be hypotensive and tachycardiac to the 140s.
She received 3 liters of IV fluids and 20 mg of IV diltiazem
times two.  Her blood pressure improved and her heart rate
slowed down to the low 100s.  She was also started on
ceftriaxone and vancomycin.

PAST MEDICAL HISTORY:  Seizure disorder.  History of atrial
fibrillation which is rate controlled on diltiazem.  She is
currently not on anticoagulation.  Osteoarthritis.
Osteoporosis.  History of dementia likely secondary to
alcohol abuse.  History of lower GI bleed from diverticula.
Type 2 diabetes mellitus.  Cerebrovascular accident of the
left frontal lobe resulting in ataxia and right hemiplegia.
History of fall.  History of cataracts.  History of decubitus
ulcerations on the right buttocks.  History of hyponatremia.
Total abdominal hysterectomy with bilateral
salpingo-oophorectomy.

ALLERGIES:  No known drug allergies.

MEDICATIONS ON ADMISSION:  Diltiazem extended release 120 mg
p.o. b.i.d., potassium chloride 20 mEq p.o. b.i.d., trazodone
50 mg p.o. q.day, Dilantin 450 mg p.o. q.day, phenobarbital
60 mg p.o. q.day, folic acid 1 mg p.o. q.day, glyburide 10 mg
p.o. q.day, multivitamin q.day, Protonix 40 mg p.o. q.day,
calcium carbonate 500 mg p.o. b.i.d., senna q.day, Zyprexa
2.5 mg in the morning and 5 mg at night.

SOCIAL HISTORY:  The patient has a history of alcohol abuse.
Her smoking history is currently unknown.  She lives at the
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] which is a nursing facility.

FAMILY HISTORY:  Unable to elicit.

PHYSICAL EXAMINATION:  On admission vital signs temperature
101, pulse 140, blood pressure 126/80, respiratory rate 22,
oxygen saturation 94 percent on 2 liters of oxygen by nasal
cannula.  In general, this was an obtunded, elderly female.
HEENT had surgical pupils.  Lungs had crackles bilaterally at
the bases with decreased breath sounds throughout.  Heart was
tachycardiac with an irregular rhythm.  Abdomen soft,
nondistended, nontender with no hepatosplenomegaly and good
bowel sounds.  On neurologic exam she had right sided
hemiparesis.  Extremities had no cyanosis, clubbing or edema.
On rectal exam the patient was guaiac positive.

LABORATORY DATA:  On admission white count was 14.3 with
neutrophil predominance of 81.2 percent, hematocrit 37.1,
platelets 160.  Chem-7 sodium 149, potassium 3.9, chloride
118, bicarbonate 21, BUN 32, creatinine 0.9, glucose 334.
INR was elevated at 1.8, PTT 26.3.  ALT 11, AST 18, alka phos
108, total bili 0.5.  UA was cloudy, moderate leukocytes,
large blood, no nitrites, greater than 50 red blood cells,
greater than 50 white blood cells, many bacteria, no yeast, 3
to 5 epithelial cells.  Head CT scan was stable in appearance
with no evidence of hemorrhage or edema.  Chest x-ray showed
multifocal air space opacities which have worsened since
[**Month (only) 956**].  The differential diagnosis for these chest x-ray
findings is either multilobar pneumonia versus BOOP versus
aspiration pneumonia.  EKG showed atrial fibrillation with
RVR at 150 beats per minute, LAD, ST depressions in leads 1,
aVL, V2 through 6 which are old.

HOSPITAL COURSE:  The patient had a long complicated hospital
course, bouncing between the medicine floor, [**Hospital1 **] service and
the MICU.

1.  Pulmonary.  As it was unclear the exact cause of her
chest x-ray changes, she was initially started on antibiotics
for possible pneumonia.  She was treated with vancomycin and
eventually cefuroxime was added for further coverage.  A
pulmonary consult was obtained on [**6-27**] following a chest CT
which showed multifocal areas of consolidation as well as
ill-defined pulmonary nodules and masses, many of which
contained air bronchograms.  Pulmonary consult attributed
these chest CAT scan changes to either BOOP versus
bronchoalveolar cancer.  A trial of steroids was not started
initially due to the patient's persistent mental status
changes.  Patient also had multiple episodes of respiratory
distress requiring admission to the MICU.  She was originally
admitted to the [**Hospital1 **] service of medicine, but required
transfer to the MICU on [**6-29**] for closer monitoring and
respiratory distress causing respiratory acidosis.  She was
again transferred back to medicine to the [**Hospital1 **] service on
[**6-30**] after her respiratory status had improved, but then
required another transfer to the MICU on [**7-2**] for hypoxia
requiring BiPAP.  She was transferred back to medicine on the
[**Hospital1 **] service one final time on [**7-4**] after her
respiratory status had again stabilized.

2.  Urinary tract infection.  The patient was treated with
ceftazidime initially and then switched to vancomycin and
gentamicin on [**6-25**].  Despite these antibiotics, her
urinalysis continued to show greater than 50 white blood
cells.  Urine cultures from [**6-23**], [**6-25**], [**6-29**], [**6-30**] and [**7-2**] all showed yeast.  Patient was started on
Diflucan bladder washes in the MICU before her last transfer
to the medicine service.

3.  Atrial fibrillation.  The patient moved in and out of
atrial fibrillation, but was continued on diltiazem and
digoxin.

4.  Congestive heart failure.  Due to the patient's worsening
hypoxemia, the MICU team ordered an echo to evaluate cardiac
function on [**6-30**].  This showed an ejection fraction of 60
percent, 3+ tricuspid regurgitation, 2+ mitral regurgitation.
She was started on Lasix as it was felt that part of her
respiratory distress was due to a CHF component.

5.  Mental status changes.  Neurology was consulted to
further evaluate these mental status changes.  EEG showed
mild diffuse encephalopathy.  CSF studies were normal.  Head
CT was negative.  Neurology believed these mental status
changes to be due to a toxic metabolic cause.  Dilantin
levels were adjusted, but she continued to have waxing and
[**Doctor Last Name 688**] mental status.  MRI showed a focal lesion that did not
correlate with physical exam findings.  Patient was tapered
off phenobarbital.  At the time of this dictation, she
continued to have waxing and [**Doctor Last Name 688**] mental status of unknown
etiology.

6.  Anemia.  The patient had a low hematocrit, but no signs
of DIC.

7.  Nutrition.  Since the patient's mental status did not
allow for good p.o. intake, she was started on NG tube
feedings.  GI was consulted on [**6-30**] for possible PEG tube
placement, but it had not been placed at the time of this
dictation.

8.  Rheumatology.  There was a question of whether the
patient may have scleroderma due to skin changes on her hand
which are consistent with a picture of scleroderma.  Labs are
pending.

9.  Deep vein thrombosis.  Lower extremity Dopplers showed
bilateral DVTs and the patient was placed on Lovenox.

The remainder of the hospital course will be dictated at
another time.






                            [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 4263**]

Dictated By:[**Doctor Last Name 30585**]
MEDQUIST36

D:  [**2119-7-24**]  14:57
T:  [**2119-7-24**]  15:02
JOB#:  [**Job Number 106156**]


Name:  [**Known lastname 183**], [**Known firstname **] MAE                 Unit No:  [**Numeric Identifier 17280**]

Admission Date:  [**2119-6-23**]     Discharge Date:  [**2119-7-11**]

Date of Birth:   [**2043-11-11**]     Sex:  F

Service:

ADDENDUM:

HOSPITAL COURSE:  The patient remained on the floor.  Mental
status did not improve.  The patient continued to have oxygen
requirement of six liters with oxygen saturation in the 91 to
94% range.  On the evening of [**2119-7-10**], the patient removed
her own nasogastric tube.  Family had decided prior to this
not to place a percutaneous feeding tube.  In the afternoon
of [**2119-7-11**], the patient's respiratory rate increased to 36.
The patient was found in rapid atrial fibrillation with heart
rate in the 120s to 140s with initial blood pressure of
50/30.  The patient was administered 5 mg of Lopressor
intravenously with heart rate decreased to the 90s.  The
patient was administered a total one liter of normal saline
with blood pressure up to 80/50.  The family to bedside.
Discussion with attending Dr. [**Last Name (STitle) **], house staff and
family followed.  The family decided to make the patient
DNR/DNI and to withdraw care.  The patient's medications were
discontinued and the patient was given Morphine for pain
control.  Dr. [**Last Name (STitle) **] called to the patient's bedside at 3:50
p.m. [**2119-7-11**].  Upon arrival, the patient was unresponsive to
name, to sternal rub, no heart sounds were heard, no breath
sounds were heard.  The pupils were fixed and dilated.  No
reflexes were present.  Death was declared at 3:50 p.m. on
[**2119-7-11**].  The patient's family and attending physician were
notified.




                          [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 872**]

Dictated By:[**Last Name (NamePattern1) 2223**]

MEDQUIST36

D:  [**2119-7-11**]  16:38
T:  [**2119-7-11**]  20:33
JOB#:  [**Job Number 17282**]
{'Other specified alveolar and parietoalveolar pneumonopathies,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Atrial fibrillation,Congestive heart failure, unspecified,Other convulsions,Other venous embolism and thrombosis of unspecified site,Other pulmonary insufficiency, not elsewhere classified'}


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 a 75 year old
female from a nursing home who was recently discharged from
[**Hospital1 18**] on [**2119-6-16**], now presenting with mental status
changes.  Her discharge diagnoses from the previous admission
consisted of pneumonia and UTI.  She was discharged back to
the nursing home on levofloxacin and Flagyl.  Patient did not
improve clinically in terms of her mental status changes and
was unable to tolerate p.o.  On the day of admission at the
nursing home she spiked a temperature and given that her
mental status had not improved, she was brought to the E.D.
She was found to be hypotensive and tachycardiac to the 140s.
She received 3 liters of IV fluids and 20 mg of IV diltiazem
times two.  Her blood pressure improved and her heart rate
slowed down to the low 100s.  She was also started on
ceftriaxone and vancomycin.

MEDICAL HISTORY: Seizure disorder.  History of atrial
fibrillation which is rate controlled on diltiazem.  She is
currently not on anticoagulation.  Osteoarthritis.
Osteoporosis.  History of dementia likely secondary to
alcohol abuse.  History of lower GI bleed from diverticula.
Type 2 diabetes mellitus.  Cerebrovascular accident of the
left frontal lobe resulting in ataxia and right hemiplegia.
History of fall.  History of cataracts.  History of decubitus
ulcerations on the right buttocks.  History of hyponatremia.
Total abdominal hysterectomy with bilateral
salpingo-oophorectomy.

MEDICATION ON ADMISSION: Diltiazem extended release 120 mg
p.o. b.i.d., potassium chloride 20 mEq p.o. b.i.d., trazodone
50 mg p.o. q.day, Dilantin 450 mg p.o. q.day, phenobarbital
60 mg p.o. q.day, folic acid 1 mg p.o. q.day, glyburide 10 mg
p.o. q.day, multivitamin q.day, Protonix 40 mg p.o. q.day,
calcium carbonate 500 mg p.o. b.i.d., senna q.day, Zyprexa
2.5 mg in the morning and 5 mg at night.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Unable to elicit.

SOCIAL HISTORY: The patient has a history of alcohol abuse.
Her smoking history is currently unknown.  She lives at the
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] which is a nursing facility. 

### Response:
{'Other specified alveolar and parietoalveolar pneumonopathies,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Atrial fibrillation,Congestive heart failure, unspecified,Other convulsions,Other venous embolism and thrombosis of unspecified site,Other pulmonary insufficiency, not elsewhere classified'}
