CHIEF COMPLAINT: Chief complaint is dyspnea.

PRESENT ILLNESS: This is a 58-year-old female
with a history of coronary artery disease, status post
5-vessel coronary artery bypass graft, poorly controlled type
2 diabetes, hypertension, and increased cholesterol who
presents with a 2-month history of malaise, increased
shortness of breath, cough, and now fevers and chills at home
for the past two days.

MEDICAL HISTORY: 1.  Type 2 diabetes; poorly controlled, complicated by
nephropathy.
2.  Hypertension.
3.  Coronary artery disease; status post 5-vessel coronary
artery bypass graft in [**2179**].
4.  Hypercholesterolemia.
5.  Status post hip fracture in [**2182-5-31**].
6.  Depression.

MEDICATION ON ADMISSION: Medications on admission included
Toprol-XL 100 mg p.o. q.d., Paxil 20 mg p.o. q.d.,
Evista 60 mg p.o. q.d., Procardia 60 mg p.o. q.d.,
lisinopril 40 mg p.o. q.d., aspirin 81 mg p.o. q.d.,
Lasix 20 mg p.o. b.i.d., Colace 100 mg p.o. b.i.d.,
insulin 40 units subcutaneous q.a.m. and 26 units NPH
subcutaneous q.p.m., and regular insulin 30 units q.a.m. and
20 units q.p.m.

ALLERGIES: The patient has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Family history is significant for coronary
artery disease and diabetes.

SOCIAL HISTORY: The patient denies any tobacco or alcohol
use.  She works as a secretary.
Bacterial pneumonia, unspecified,Acute kidney failure, unspecified,Nephrotic syndrome in diseases classified elsewhere,Coronary atherosclerosis of native coronary artery,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Anemia, unspecified,Candidiasis of skin and nails
Bacterial pneumonia NOS,Acute kidney failure NOS,Nephrotic syn in oth dis,Crnry athrscl natve vssl,DMII renl nt st uncntrld,Anemia NOS,Cutaneous candidiasis
Admission Date:  [**2183-10-19**]     Discharge Date:  [**2183-10-31**]

Date of Birth:   [**2125-3-28**]     Sex:  F

Service:  [**Company 191**] East

CHIEF COMPLAINT:  Chief complaint is dyspnea.

HISTORY OF PRESENT ILLNESS:  This is a 58-year-old female
with a history of coronary artery disease, status post
5-vessel coronary artery bypass graft, poorly controlled type
2 diabetes, hypertension, and increased cholesterol who
presents with a 2-month history of malaise, increased
shortness of breath, cough, and now fevers and chills at home
for the past two days.

Over the past two months she has been fatigued with a mild
cough.  She has been treated with erythromycin for a upper
respiratory infection approximately one and a half months
ago.  She continues with cough productive with brown sputum,
pleuritic chest pain with cough, and has been feeling better
than over the past week.  She has had increased fatigue and
increased sputum with blood tinges in the sputum.

Two days ago, she became significantly short of breath and
febrile at home.  She was seen in the clinic on Friday "doing
better" and then acutely worsened during the night.

In the Emergency Department, a blood gas was drawn which
revealed 7.44/39/68.  She was ill-appearing and received
ceftriaxone, azithromycin, and Lasix, and a nitroglycerin
drip for hypertension.

PAST MEDICAL HISTORY:
1.  Type 2 diabetes; poorly controlled, complicated by
nephropathy.
2.  Hypertension.
3.  Coronary artery disease; status post 5-vessel coronary
artery bypass graft in [**2179**].
4.  Hypercholesterolemia.
5.  Status post hip fracture in [**2182-5-31**].
6.  Depression.

ALLERGIES:  The patient has no known drug allergies.

MEDICATIONS ON ADMISSION:   Medications on admission included
Toprol-XL 100 mg p.o. q.d., Paxil 20 mg p.o. q.d.,
Evista 60 mg p.o. q.d., Procardia 60 mg p.o. q.d.,
lisinopril 40 mg p.o. q.d., aspirin 81 mg p.o. q.d.,
Lasix 20 mg p.o. b.i.d., Colace 100 mg p.o. b.i.d.,
insulin 40 units subcutaneous q.a.m. and 26 units NPH
subcutaneous q.p.m., and regular insulin 30 units q.a.m. and
20 units q.p.m.

SOCIAL HISTORY:  The patient denies any tobacco or alcohol
use.  She works as a secretary.

FAMILY HISTORY:   Family history is significant for coronary
artery disease and diabetes.

PHYSICAL EXAMINATION ON PRESENTATION:  Blood pressure
was 155/60, pulse was 90, breathing at 35, oxygen saturation
was 93% on a nonrebreather mask.  In general, she appeared
ill.  A feverish female who spoke in full sentences.  Head,
eyes, ears, nose, and throat examination revealed the
oropharynx was dry but clear.  Pale right periorbital edema.
Cardiovascular examination revealed a regular heart rate.
Normal first heart sound and second heart sound.  No murmurs.
No jugular venous distention.  Pulmonary examination revealed
decreased breath sounds at the left base.  No wheezes.  No
egophony.  Dullness to percussion at the left base.
Abdominal examination revealed obese, soft, nontender, and
nondistended.  Extremities revealed 2 to 3+ edema, pale,
warm, and dry.  No clubbing.  Neurologic examination revealed
alert and oriented times three.

PERTINENT LABORATORY DATA ON PRESENTATION:  Laboratory data
revealed white blood cell count was 20.1 (with 88%
neutrophils, 4% bands, 3% lymphocytes), hematocrit was 35.4,
platelets were 385.  Sodium was 138, potassium was 4.4,
chloride was 101, bicarbonate was 22, blood urea nitrogen
was 40, creatinine was 1.8, and blood glucose was 210.
Creatine phosphokinase was 258, MB fraction was 2, troponin
was 0.6.  Urinalysis was leukocyte esterase negative,
moderate blood, nitrite positive, greater than 300 protein,
250 glucose, negative for ketones, 3 to 5 white blood cells,
no bacteria, 3 to 5 epithelial cells.

RADIOLOGY/IMAGING:   A chest x-ray revealed a left lower lobe
infiltrate.  No effusion, and no cephalization.

Electrocardiogram revealed a normal sinus rhythm at 100 beats
per minute, normal axis, and normal intervals.  T wave
flattening in II, III, and aVF.  Q wave in I.  Poor R wave
progression, and 1-mm ST elevations in V1 through V3, and
0.5-mm ST depressions in II.  New T wave flattening since
[**2182-5-31**].

HOSPITAL COURSE:

1.  PULMONARY SYSTEM:  The patient was diagnosed with a left
lower lobe pneumonia.  She was placed on ceftriaxone and
levofloxacin which were appropriately renally dosed.  A
sputum Gram stain revealed 4+ gram-positive cocci in pairs,
chains, and clusters as well as greater than 25
polymorphonuclear leukocytes per high powered field.  The
respiratory culture did not reveal any significant organisms
at this time.

Her oxygen requirements continued to improve over her
hospital course, and she was given aggressive chest physical
therapy.  On hospital day nine, ceftriaxone was discontinued.
She was continued on levofloxacin which was appropriately
dosed per her creatinine clearance.  The patient to complete
a full 14-day course of levofloxacin and was to follow up
with her primary care physician.

2.  CARDIOVASCULAR SYSTEM:  The patient was noted to have
electrocardiogram changes compared to her previous
electrocardiogram back in [**2182-5-31**].  Serial cardiac
enzymes were drawn which revealed a peak creatine
phosphokinase of 490, and a peak troponin level of 12.6 on
hospital day two.

It was felt that this troponin leak in the setting of hypoxia
and tachycardia was most likely a rate work related response
and not necessarily thrombotic.  A further workup of her
troponin leak was not performed secondary to her pneumonia
and will need to be followed up for possible outpatient
stress test for further evaluation.

3.  RENAL SYSTEM:  The patient was noted to have a baseline
creatinine of around 1 and was noted to have an elevation in
her creatinine and blood urea nitrogen ratio on admission.
It was felt initially that she was dehydrated on admission
and was given fluids.

Her lung examination deteriorated with fluids and was then
aggressively diuresed.  A urine sodium was drawn which
revealed a value of 14; suggesting a prerenal picture.  Her
FENa was calculated at less than 0.3.  Her creatinine was
noted to increase to a maximum of 2.9.  Her ACE inhibitor was
held.  She was given gentle fluid hydration again which
notably improved her renal function.

She was then aggressively diuresed which continued to improve
her renal function, and she stated that she was approximately
20 pounds over her baseline weight.  Her lower extremity
edema continued to improve.  A 24-hour urine was collected to
measure the amount of protein and albumin excreted which
revealed an elevated albumin to creatinine ratio; suggesting
that nephrotic syndrome may have been contributing to her
lower extremity edema.  She was managed with ACE inhibitors
and continued with aggressive diuresis to which she was
clinically responding and was to be discharged on both an
aggressive regimen of Lasix 80 mg p.o. b.i.d. and
lisinopril 20 mg p.o. q.d.   She was to have close followup
with her primary care physician within the next two weeks to
further monitor her renal function.

4.  ENDOCRINE SYSTEM:  The patient was noted to have very
poorly controlled diabetes.  She was placed on standing
NPH 40 units in the morning and 26 units in the evening with
a regular insulin sliding-scale with fingerstick checks four
times per day.  This regimen seemed to control her sugars
well.  The Learning Center was consulted to instruct the
patient on optimal blood sugar management and was to be
discharged home on this regimen.

5.  HEMATOLOGY:  The patient was noted to have an abrupt drop
in her hematocrit after hydration from a value of 35.4 down
to a nadir of 26.6.  She was transfused one units of packed
red blood cells to which she responded appropriately.  There
was no indication of hemolysis during this decrease in her
hematocrit, and no further issues were seen with regard to
her anemia.

CONDITION AT DISCHARGE:  Condition on discharge was stable.

DISCHARGE STATUS:  Discharge status was to home.

DISCHARGE FOLLOWUP:
1.  The patient to follow up with her primary care physician
within two weeks; at which time her renal function will again
be monitored, as well as further evaluation of her lower
extremity edema and volume status.
2.  She will also need a Cardiology evaluation for her
troponin leak.

MEDICATIONS ON DISCHARGE:
1.  Toprol-XL 150 mg p.o. q.d.
2.  Paxil 20 mg p.o. q.d.
3.  Evista 60 mg p.o. q.d.
4.  Lisinopril 20 mg p.o. q.d.
5.  Aspirin 81 mg p.o. q.d.
6.  Lasix 80 mg p.o. q.d.
7.  Colace 100 mg p.o. b.i.d.
8.  Insulin 40 units NPH subcutaneously q.a.m. and 26 units
subcutaneously q.p.m.
9.  Levofloxacin 500 mg p.o. q.d. (times five days).

DISCHARGE DIAGNOSES:
1.  Pneumonia; requiring Intensive Care Unit hospitalization.
2.  Cardiac ischemia.
3.  Acute renal failure secondary to dehydration.
4.  Anemia.




                          [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8873**] [**Name8 (MD) **], M.D.  [**MD Number(1) 8874**]

Dictated By:[**Name8 (MD) 5406**]

MEDQUIST36

D:  [**2183-10-31**]  10:37
T:  [**2183-10-31**]  11:02
JOB#:  [**Job Number 18984**]
{'Bacterial pneumonia, unspecified,Acute kidney failure, unspecified,Nephrotic syndrome in diseases classified elsewhere,Coronary atherosclerosis of native coronary artery,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Anemia, unspecified,Candidiasis of skin and nails'}


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: Chief complaint is dyspnea.

PRESENT ILLNESS: This is a 58-year-old female
with a history of coronary artery disease, status post
5-vessel coronary artery bypass graft, poorly controlled type
2 diabetes, hypertension, and increased cholesterol who
presents with a 2-month history of malaise, increased
shortness of breath, cough, and now fevers and chills at home
for the past two days.

MEDICAL HISTORY: 1.  Type 2 diabetes; poorly controlled, complicated by
nephropathy.
2.  Hypertension.
3.  Coronary artery disease; status post 5-vessel coronary
artery bypass graft in [**2179**].
4.  Hypercholesterolemia.
5.  Status post hip fracture in [**2182-5-31**].
6.  Depression.

MEDICATION ON ADMISSION: Medications on admission included
Toprol-XL 100 mg p.o. q.d., Paxil 20 mg p.o. q.d.,
Evista 60 mg p.o. q.d., Procardia 60 mg p.o. q.d.,
lisinopril 40 mg p.o. q.d., aspirin 81 mg p.o. q.d.,
Lasix 20 mg p.o. b.i.d., Colace 100 mg p.o. b.i.d.,
insulin 40 units subcutaneous q.a.m. and 26 units NPH
subcutaneous q.p.m., and regular insulin 30 units q.a.m. and
20 units q.p.m.

ALLERGIES: The patient has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Family history is significant for coronary
artery disease and diabetes.

SOCIAL HISTORY: The patient denies any tobacco or alcohol
use.  She works as a secretary. 

### Response:
{'Bacterial pneumonia, unspecified,Acute kidney failure, unspecified,Nephrotic syndrome in diseases classified elsewhere,Coronary atherosclerosis of native coronary artery,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Anemia, unspecified,Candidiasis of skin and nails'}
