CHIEF COMPLAINT: Hypoxia.

PRESENT ILLNESS: Patient is a 51 y/o woman with PMHx of T1-T2 paraplegia
following MVC [**1-4**], COPD and recent admission for PNA on
[**5-29**]-4/30 who presented to her PCP today with hypoxia, lethargy,
cough and increased work of breathing. Of note, she was
discharged on [**5-31**] after a two day hospital stay for PNA and
COPD exacerbation. She was treated with a short course of
Levofloxacin and steroid taper. Per husband, pt has been doing
well for the last week and has been out socializing and feeling
well. However, she was notably tachypneic, satting in the 80s
and requiring increased NC oxygen this morning. He brought her
in for evaluation in [**Company 191**] and they referred her into the ED for
further evaluation.

MEDICAL HISTORY: 1. T1-T2 paraplegia following MVC [**1-4**]
2. Recurrent UTIs: [**Month/Year (2) 40097**] klebsiella
3. HCV, viral load suppressed
4. H/o recurrent PNAs: MRSA, pan-sensitive Kleb
5. Anxiety
6. DVT in [**2142**] -IVC filter placed in [**2142**]
7. Pulmonary nodules
8. Hypothyroidism
9. Chronic pain
10. Chronic gastritis
11. H/o obstructive lung disease
12. Anemia of chronic disease
13. S/p PEA arrest during last hospitalization in [**2147-10-3**]

MEDICATION ON ADMISSION: - albuterol nebs q4-6h prn
- baclofen 10 mg up to 5 tabs daily
- citalopram 40 mg daily
- clonazepam 2mg qhs (occaisionally during the day for pain)
- Combivent 2 puffs tid
- levothyroxine 75 mcg qday
- lidocaine patch qday
- methadone 5 mg tid
- omeprazole 20 mg prn
- oxybutynin 5 mg up to five tabs daily
- pregabalin 150 mg tid
- sucralfate 1 g qid
- trazodone 200 mg qhs
- calcium carbonate 500 mg [**Hospital1 **]
- loratadine 10 mg daily prn
- nicotine patch 21 mg daily
- polyethylene glycol prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: BP 114/70 HR 80 Sats 99% on Face tent and 2L NC
General: NAD, sleepy but easily arousable
HEENT: Sclera anicteric, MMM, PERRLA
Lungs: CTAB, no wheezes, occaisional RLL rhonchi
CV: RRR no murmurs, rubs, gallops
Abdomen:  soft, NT/ND/NABS, no rebound tenderness or guarding
Ext: warm, 2+ pulses, trace edema bilaterally
Neuro: following commands, symmetric facial movement, squeezing
hands bilaterally

FAMILY HISTORY: No history of lung disease.

SOCIAL HISTORY: - Lives at home with her husband and 2 adolescent children
- Tobacco: 35 pack years, quit smoking after last
hospitalization
- etOH: Denies
- Illicits: Denies
Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Acidosis,Paraplegia,Obstructive chronic bronchitis with (acute) exacerbation,Unspecified viral hepatitis C without hepatic coma,Unspecified acquired hypothyroidism,Anxiety state, unspecified,Personal history of venous thrombosis and embolism,Atrophic gastritis, without mention of hemorrhage,Dysphagia, oropharyngeal phase,Anemia, unspecified
Food/vomit pneumonitis,Acute respiratry failure,Acidosis,Paraplegia NOS,Obs chr bronc w(ac) exac,Hpt C w/o hepat coma NOS,Hypothyroidism NOS,Anxiety state NOS,Hx-ven thrombosis/embols,Atrph gastrtis w/o hmrhg,Dysphagia, oropharyngeal,Anemia NOS
Admission Date:  [**2148-6-11**]              Discharge Date:   [**2148-6-15**]

Date of Birth:  [**2096-10-22**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
Hypoxia.

Major Surgical or Invasive Procedure:
Right femoral central venous line placement ([**6-11**]).
PICC line placement ([**6-13**]).

History of Present Illness:
Patient is a 51 y/o woman with PMHx of T1-T2 paraplegia
following MVC [**1-4**], COPD and recent admission for PNA on
[**5-29**]-4/30 who presented to her PCP today with hypoxia, lethargy,
cough and increased work of breathing. Of note, she was
discharged on [**5-31**] after a two day hospital stay for PNA and
COPD exacerbation. She was treated with a short course of
Levofloxacin and steroid taper. Per husband, pt has been doing
well for the last week and has been out socializing and feeling
well. However, she was notably tachypneic, satting in the 80s
and requiring increased NC oxygen this morning. He brought her
in for evaluation in [**Company 191**] and they referred her into the ED for
further evaluation.

In the ED, initial vs were: T 97.9 P 110 BP 109/84 R 24 O2 sat
97% on NRB. Pt underwent CXR which showed bilateral hazy
opacities at bases, essentially unchanged from prior film on
[**5-30**]. CTA was performed for hypoxia but did not show any PE,
there was bilateral atelectasis with RLL consolidations. Blood &
Urine Cx were sent and pt had right femoral line placed before
she was given 1L NS, Vanc and Zosyn for possible PNA. Per [**Name (NI) **], pt
became more somnolent with ABG showing pH 7.34 pCO2 64 pO2 62.
She was given Solumedrol 125mg IV, alb/atrovent and was placed
on BIPAP to treat a component of COPD exacerbation and CO2
retention.

On arrival to the ICU, pt was wearing BIPAP and complaining
about the discomfort of the mask. Overall, she was still
somnolent and husband provided most of the history.

Review of systems: as above, provided by husband. Denies fevers,
chills, nausea, vomiting, diarrhea, chest pain, med changes,
rash, cough. Husband did note increased somnolence while eating
and snoring while asleep.

Past Medical History:
1. T1-T2 paraplegia following MVC [**1-4**]
2. Recurrent UTIs: [**Month/Year (2) 40097**] klebsiella
3. HCV, viral load suppressed
4. H/o recurrent PNAs: MRSA, pan-sensitive Kleb
5. Anxiety
6. DVT in [**2142**] -IVC filter placed in [**2142**]
7. Pulmonary nodules
8. Hypothyroidism
9. Chronic pain
10. Chronic gastritis
11. H/o obstructive lung disease
12. Anemia of chronic disease
13. S/p PEA arrest during last hospitalization in [**2147-10-3**]

Social History:
- Lives at home with her husband and 2 adolescent children
- Tobacco: 35 pack years, quit smoking after last
hospitalization
- etOH: Denies
- Illicits: Denies

Family History:
No history of lung disease.

Physical Exam:
Vitals: BP 114/70 HR 80 Sats 99% on Face tent and 2L NC
General: NAD, sleepy but easily arousable
HEENT: Sclera anicteric, MMM, PERRLA
Lungs: CTAB, no wheezes, occaisional RLL rhonchi
CV: RRR no murmurs, rubs, gallops
Abdomen:  soft, NT/ND/NABS, no rebound tenderness or guarding
Ext: warm, 2+ pulses, trace edema bilaterally
Neuro: following commands, symmetric facial movement, squeezing
hands bilaterally

Pertinent Results:
Labs at Admission:
[**2148-6-11**] 02:45PM BLOOD WBC-18.3*# RBC-4.00* Hgb-10.7* Hct-35.0*
MCV-88 MCH-26.7* MCHC-30.4* RDW-15.5 Plt Ct-223
[**2148-6-11**] 02:45PM BLOOD Neuts-93.6* Lymphs-3.5* Monos-1.7*
Eos-1.0 Baso-0.3
[**2148-6-11**] 02:45PM BLOOD PT-12.2 PTT-27.4 INR(PT)-1.0
[**2148-6-11**] 02:45PM BLOOD Glucose-123* UreaN-11 Creat-0.3* Na-142
K-4.9 Cl-101 HCO3-32 AnGap-14
[**2148-6-11**] 02:45PM BLOOD Calcium-8.9 Phos-3.3 Mg-1.9

Lactate:
[**2148-6-11**] 03:10PM BLOOD Lactate-2.1* K-4.1
[**2148-6-11**] 11:40PM BLOOD Lactate-1.9
[**2148-6-12**] 02:47PM BLOOD Lactate-3.0*

Micro Data:
[**2148-6-12**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE- negative
[**2148-6-11**] URINE URINE CULTURE- negative
[**2148-6-11**] BLOOD CULTURE Blood Culture, Routine-
negative
[**2148-6-11**] BLOOD CULTURE Blood Culture, Routine-
negative

CTA chest ([**2148-6-11**]):
1. Assessment for pulmonary embolism within the segmental and
subsegmental pulmonary arterial branches is limited due to
suboptimal bolus timing. No
evidence of pulmonary embolism in the main pulmonary arteries.
2. Moderate-to-severe bibasilar atelectasis, predominately
within the right
lower lobe. A more consolidative element within the right lower
lobe along
with a new lingular patchy opacity may reflect an infectious
process.
3. Paraseptal emphysema.
4. Unchanged chronic rib cage deformities.

Brief Hospital Course:
51 y/o woman with PMHx of T1-T2 paraplegia, COPD and recurrent
PNAs who presents after recent discharge with respiratory
distress and somnolence, concern for new RLL infiltrate.

# Respiratory Distress: Mixed hypoxic/hypercarbic resp failure.
Pt with COPD and recurrent PNAs who developped tachypnea,
increased O2 requirement, cough and lethargy acutely this
morning. She was referred into the ED by her PCP and underwent [**Name Initial (PRE) **]
CTA that was negative for PE but revealed RLL consolidation,
unclear if new or resolving from prior admission. Pt became
increasingly somnolent in the ED with pCO2 in 60s. In the ED she
got steroids, alb/atrov and BIPAP, with improved mental status
and minimal O2 requirement. Given increased WBC and possible
consolidation and recent hospital admission, she was treated for
HAP with cefepime and vancomycin. A PICC line was placed so that
she could complete a 7-day course of antibiotics. There was
concern of recurrent aspiration. Patient underwent a speech and
swallow eval and passed. Her diet was restarted.  Her initial
PICC placed at the bedside went up the right IJ, so it was
removed and replaced by interventional radiology.  [**2148-6-12**] she
had hypotension and a low-grade fever to 100.7 at 1am.  She was
given fluids and looked well clinically.  Her CXR was unchanged,
U/A was negative and blood cultures had no growth at the time of
discharge. Her vancomycin was originally dosed 1250mg Q24 hours,
but a trough level was 3.8, so the dosing was changed to 1000mg
Q12 hours for the remainder of the course.

# T1-T2 Paraplegia with chronic pain: pt is maintained on
multiple sedating drugs for spasms and pain. She presented with
respiratory distress and progressive somnolence and hypercarbia.
Suspect a component of obesity hypoventilation with possible
aspiration PNA. During this admission, her clonazpeam,
pregabalin, and trazodone were initially held. Baclofen was
decreased to 5 mg tid. Methadone and oxybutynin were continued
at outpatient doses.  Her pregabalin and trazodone were added
back on, but her Baclofen was continued at 5mg TID with some
minor leg spasticity, but adequate pain control.  She was
switched to Ultram for breakthrough pain, but did not find this
effective, so she was switched back to Oxycodone.  She was
discharged, finally, on the same doses of methadone and
oxycodone, a reduced dose of baclofen, and off of Klonopin.  She
was given 2 weeks of methadone and oxycodone to last until she
can see Dr. [**Last Name (STitle) 665**] because she was supposed to get refills the
day of her admission but ended up being transferred to the ED.
.
# Possible UTI: Urine Cx from [**5-29**] grew out +enterococcus
>100,000 and this was not treated, possibly thought to be
contaminant. Repeat UAs appeared bland without WBCs and she
remained asymptomatic, so any possible UTI was probably treated
with vanco/cefepime.
.
# Access: She originally had a right femoral CVL, which was
pulled once she was stabilized.

Medications on Admission:
- albuterol nebs q4-6h prn
- baclofen 10 mg up to 5 tabs daily
- citalopram 40 mg daily
- clonazepam 2mg qhs (occaisionally during the day for pain)
- Combivent 2 puffs tid
- levothyroxine 75 mcg qday
- lidocaine patch qday
- methadone 5 mg tid
- omeprazole 20 mg prn
- oxybutynin 5 mg up to five tabs daily
- pregabalin 150 mg tid
- sucralfate 1 g qid
- trazodone 200 mg qhs
- calcium carbonate 500 mg [**Hospital1 **]
- loratadine 10 mg daily prn
- nicotine patch 21 mg daily
- polyethylene glycol prn

Discharge Medications:
1. Cefepime 2 gram Recon Soln [**Hospital1 **]: Two (2) grams Intravenous
every twelve (12) hours for 3 days.
Disp:*12 grams* Refills:*0*
2. Vancomycin in D5W 1 gram/200 mL Piggyback [**Hospital1 **]: One (1) gram
Intravenous Q 12H (Every 12 Hours).
Disp:*6 gram* Refills:*0*
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) treatment Inhalation Q6H (every 6
hours) as needed for wheeze.
4. Baclofen 10 mg Tablet [**Hospital1 **]: 0.5 Tablet PO TID (3 times a day).

5. Citalopram 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).

6. Combivent 18-103 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) puffs
Inhalation three times a day.
7. Levothyroxine 75 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain.
9. Methadone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a
day).
10. Oxybutynin Chloride 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID
(3 times a day).
11. Pregabalin 150 mg Capsule [**Hospital1 **]: One (1) Capsule PO once a
day.
12. Trazodone 100 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS (at
bedtime).
13. Calcium Carbonate 500 mg Tablet, Chewable [**Hospital1 **]: One (1)
Tablet, Chewable PO BID (2 times a day).
14. Loratadine 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
15. Nicotine 7 mg/24 hr Patch 24 hr [**Hospital1 **]: One (1) Patch 24 hr
Transdermal DAILY (Daily).
16. Polyethylene Glycol 3350 17 gram/dose Powder [**Hospital1 **]: One (1)
packet PO DAILY (Daily).
17. Ranitidine HCl 150 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily) as needed for heartburn.
18. Colace 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO twice a day.
19. Percocet 5-325 mg Tablet [**Hospital1 **]: One (1) Tablet PO every six
(6) hours as needed for pain: For breakthrough pain. Take
methadone as prescriped.


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 1474**] VNA

Discharge Diagnosis:
Aspiration pneumonia
Respiratory failure

Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.

Discharge Instructions:
You were admitted because you were having difficulty breathing.
We think that you had some contents from your stomach go into
your lungs because you were oversedated by your medications.
You went to the intensive care unit overnight, but your
breathing has now improved and we think you are safe to go home.
 We cut back on your medications to try to avoid having this
happen again.
.
- You should get 3 more days of antibiotics.  A visiting nurse
will come to give you the antibiotics through your PICC line.
- Please STOP taking Klonopin for at this time.
- Please DECREASE your Baclofen dose to 5mg every 8 hours. 5mg
is half of a 10mg dose.
- Please continue using methadone for pain control and percocet
for breakthrough pain.
- Please use ranitidine instead of omeprazole as needed for
heartburn.
- You can use colace and Miralax for constipation.  You should
take them every day unless you are having diarrhea.

Followup Instructions:
Please call Dr.[**Name (NI) 666**] office at [**Telephone/Fax (1) 250**] on Monday
morning to make an appointment for later next week or the week
after.

You had this appointment already made for you:
Department: SURGICAL SPECIALTIES
When: MONDAY [**2148-9-2**] at 3:30 PM
With: [**Name6 (MD) 161**] [**Name8 (MD) 6476**], MD [**Telephone/Fax (1) 921**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage


Completed by:[**2148-6-16**]
{'Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Acidosis,Paraplegia,Obstructive chronic bronchitis with (acute) exacerbation,Unspecified viral hepatitis C without hepatic coma,Unspecified acquired hypothyroidism,Anxiety state, unspecified,Personal history of venous thrombosis and embolism,Atrophic gastritis, without mention of hemorrhage,Dysphagia, oropharyngeal phase,Anemia, 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: Hypoxia.

PRESENT ILLNESS: Patient is a 51 y/o woman with PMHx of T1-T2 paraplegia
following MVC [**1-4**], COPD and recent admission for PNA on
[**5-29**]-4/30 who presented to her PCP today with hypoxia, lethargy,
cough and increased work of breathing. Of note, she was
discharged on [**5-31**] after a two day hospital stay for PNA and
COPD exacerbation. She was treated with a short course of
Levofloxacin and steroid taper. Per husband, pt has been doing
well for the last week and has been out socializing and feeling
well. However, she was notably tachypneic, satting in the 80s
and requiring increased NC oxygen this morning. He brought her
in for evaluation in [**Company 191**] and they referred her into the ED for
further evaluation.

MEDICAL HISTORY: 1. T1-T2 paraplegia following MVC [**1-4**]
2. Recurrent UTIs: [**Month/Year (2) 40097**] klebsiella
3. HCV, viral load suppressed
4. H/o recurrent PNAs: MRSA, pan-sensitive Kleb
5. Anxiety
6. DVT in [**2142**] -IVC filter placed in [**2142**]
7. Pulmonary nodules
8. Hypothyroidism
9. Chronic pain
10. Chronic gastritis
11. H/o obstructive lung disease
12. Anemia of chronic disease
13. S/p PEA arrest during last hospitalization in [**2147-10-3**]

MEDICATION ON ADMISSION: - albuterol nebs q4-6h prn
- baclofen 10 mg up to 5 tabs daily
- citalopram 40 mg daily
- clonazepam 2mg qhs (occaisionally during the day for pain)
- Combivent 2 puffs tid
- levothyroxine 75 mcg qday
- lidocaine patch qday
- methadone 5 mg tid
- omeprazole 20 mg prn
- oxybutynin 5 mg up to five tabs daily
- pregabalin 150 mg tid
- sucralfate 1 g qid
- trazodone 200 mg qhs
- calcium carbonate 500 mg [**Hospital1 **]
- loratadine 10 mg daily prn
- nicotine patch 21 mg daily
- polyethylene glycol prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: BP 114/70 HR 80 Sats 99% on Face tent and 2L NC
General: NAD, sleepy but easily arousable
HEENT: Sclera anicteric, MMM, PERRLA
Lungs: CTAB, no wheezes, occaisional RLL rhonchi
CV: RRR no murmurs, rubs, gallops
Abdomen:  soft, NT/ND/NABS, no rebound tenderness or guarding
Ext: warm, 2+ pulses, trace edema bilaterally
Neuro: following commands, symmetric facial movement, squeezing
hands bilaterally

FAMILY HISTORY: No history of lung disease.

SOCIAL HISTORY: - Lives at home with her husband and 2 adolescent children
- Tobacco: 35 pack years, quit smoking after last
hospitalization
- etOH: Denies
- Illicits: Denies 

### Response:
{'Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Acidosis,Paraplegia,Obstructive chronic bronchitis with (acute) exacerbation,Unspecified viral hepatitis C without hepatic coma,Unspecified acquired hypothyroidism,Anxiety state, unspecified,Personal history of venous thrombosis and embolism,Atrophic gastritis, without mention of hemorrhage,Dysphagia, oropharyngeal phase,Anemia, unspecified'}
