CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
female who has a past medical history significant for
coronary artery disease, hypertension, dementia, recurrent
pneumonia and recent gastrectomy for peptic ulcer disease,
who presented to the emergency room with a complaint of
increasing shortness of breath.  The patient had been at home
for approximately 2 days following discharge from rehab
following gastrectomy when shortness of breath developed.
Emergency medical services were called and the patient was
found to have an oxygen saturation of 65% on room air and 85%
on 100% non-re-breather.

MEDICAL HISTORY: 1.  Hypothyroid.
2.  Coronary artery disease.
3.  Hypertension.
4.  Peptic ulcer disease status post gastrectomy for
perforated ulcer.
5.  Dementia.
6.  Esophageal motility disorder.
7.  Recurrent pneumonia.

MEDICATION ON ADMISSION: 

ALLERGIES: Sulfa.

PHYSICAL EXAM: 

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: Living situation - the patient at baseline
resides at home with 24 hour home health assistance.  There
is extensive family involvement.  The patient's code status
is DNR, DNI.
Pneumonitis due to inhalation of food or vomitus,Subendocardial infarction, initial episode of care,Congestive heart failure, unspecified,Nutritional marasmus,Status of other artificial opening of gastrointestinal tract,Other persistent mental disorders due to conditions classified elsewhere,Long-term (current) use of steroids,Coronary atherosclerosis of native coronary artery
Food/vomit pneumonitis,Subendo infarct, initial,CHF NOS,Nutritional marasmus,Enterostomy status NEC,Mental disor NEC oth dis,Long-term use steroids,Crnry athrscl natve vssl
Admission Date:  [**2188-11-1**]     Discharge Date:  [**2188-11-8**]


Service:  Medicine [**Hospital1 139**]

HISTORY OF PRESENT ILLNESS:  The patient is a [**Age over 90 **]-year-old
female who has a past medical history significant for
coronary artery disease, hypertension, dementia, recurrent
pneumonia and recent gastrectomy for peptic ulcer disease,
who presented to the emergency room with a complaint of
increasing shortness of breath.  The patient had been at home
for approximately 2 days following discharge from rehab
following gastrectomy when shortness of breath developed.
Emergency medical services were called and the patient was
found to have an oxygen saturation of 65% on room air and 85%
on 100% non-re-breather.

PAST MEDICAL HISTORY:
1.  Hypothyroid.
2.  Coronary artery disease.
3.  Hypertension.
4.  Peptic ulcer disease status post gastrectomy for
perforated ulcer.
5.  Dementia.
6.  Esophageal motility disorder.
7.  Recurrent pneumonia.

SOCIAL HISTORY:  Living situation - the patient at baseline
resides at home with 24 hour home health assistance.  There
is extensive family involvement.  The patient's code status
is DNR, DNI.

FAMILY HISTORY:  Noncontributory.

ALLERGIES:  Sulfa.

MEDICATIONS:
1.  Aricept 10 mg.
2.  Lasix 40 mg.
3.  Prevacid 30 mg.
4.  Lopressor 25 mg b.i.d.
5.  Multi-vitamin.
6.  Effexor 70 mg.
7.  Prednisone 25 mg.
8.  Zofran p.r.n.
9.  Synthroid 15 mg.

EXAM:  On presentation to the emergency department the
patient was found to have vital signs as follows:
Temperature 98.7, heart rate 82, blood pressure 160/62,
respiratory rate 25, oxygen saturation 87% on room air.  In
general, the patient is a well nourished but thin female in
respiratory distress.  There was no jugular venous distention
on examination of the neck.  Lung exam revealed decreased
breath sounds bilaterally.  Cardiovascular exam was
unremarkable.  The PEG site was clean, dry and intact.  The
patient was alert and oriented only to person.

LABORATORY STUDIES:  Admission CBC was unremarkable.
Admission SMA-7 was significant for an elevated BUN to
creatinine ratio consistent with dehydration.  Urinalysis was
unremarkable.  Cardiac enzymes were significant for an
isolated elevated troponin.  Coagulation studies were
unremarkable.  Arterial blood gas on 100% oxygen was
significant for a decreased pO2 of 70 and an elevated pCO2 of
59 with a normal pH.

RADIOLOGY:  Chest x-ray on admission revealed mild congestive
heart failure, markedly improved since the prior study of
[**2188-8-17**].  There was also bilateral lower lobe
opacification concerning for pneumonia.  CT angiogram
revealed consolidations at both lung bases consistent with
bibasilar pneumonia as well as subtle patchy opacifications
in the upper lobes with air fluid levels in the esophagus
suggesting possible aspiration.  There was no evidence of
pulmonary embolism.

CARDIAC STUDIES:  EKG on admission revealed sinus rhythm with
mild left axis deviation.  There was also felt to be possible
left anterior fascicular block.  The admitting MICU team
noted possible ST elevations in V3 through V6.
Echocardiogram revealed mild symmetric left ventricular
hypertrophy with normal left ventricular cavity size.
Overall left ventricular systolic function was normal.  There
was normal right ventricular systolic function.  There was
also moderate aortic regurgitation.  No pericardial effusion.

HOSPITAL COURSE:
1.  Respiratory distress:  On admission, the patient was felt
to have bilateral pneumonia, most likely secondary to
aspiration.  The patient was started on IV Levaquin, Flagyl
and Vancomycin to cover for likely aspiration in a setting of
recent nursing home admission.  The patient was kept on
supplemental oxygen to keep oxygen saturations above 92% and
was kept NPO on aspirations precautions.  On day of admission
antibiotics were changed to IV ceftazidine, Flagyl and
Vancomycin.  Vancomycin was dosed at 1 gram q24 hours in the
setting of patient's decreased renal function, age and body
size.  On day two of admission the patient was also felt to
be fluid over loaded and gentle diuresis was resumed.  On day
two of admission the patient was felt to be stable for
transfer to the floor.  On the floor, the patient was
initially continued on IV antibiotics.  On day five of
admission the patient had a follow up chest x-ray which
revealed marked improvement in bibasilar pneumonia.  The
patient also had improvement in oxygen saturation and was
able to tolerate room air.  As a result, the patient was
transitioned to p.o. antibiotics and was given Augmentin and
Flagyl through the PEG tube.  The patient was discharged home
on hospital day 9 with instructions to complete a 14 day
course of p.o. antibiotics for presumed aspiration pneumonia.

2.  Cardiovascular:  Elevated troponin as well as possible ST
elevations on admission were felt to reflect a demand
ischemia.  Cardiac enzymes and EKG changes stabilized.  The
patient was continued on aspirin, Lopressor throughout the
admission.  On day three of admission the patient had an
episode of sinus tachycardia likely secondary to dehydration
versus multi-focal atrial tachycardia secondary to pulmonary
disease.  This resolved following hydration.  The patient's
cardiovascular function remained stable for the rest of the
admission.

3.  Dementia:  The patient was continued on Aricept
throughout the admission.

4.  Gastrointestinal:  Following rehydration, the patient was
found to have a mildly decreased hematocrit.  As a result,
the patient was received an elevation by gastroenterology to
look for gastrointestinal bleeding as an etiology of
decreased hematocrit.  Given the patient's history of peptic
ulcer disease, gastroenterology service recommended H. pylori
serology, which was negative.  Iron studies were sent, which
revealed a decreased total iron binding capacity as well as
decreased iron suggestive of a combination of both blood loss
and chronic disease as etiologies of anemia.
Gastroenterology service felt, however, that EGD and
colonoscopy were not an option in setting of patient's recent
ischemic cardiac disease.  Furthermore, the patient refused
gastroenterology work up.  Gastroenterology service also
asked to evaluate patient for possible contribution of reflux
of jejunostomy tube feedings to development of aspiration
pneumonia.  Gastroenterology service felt that reflux of
J-tube feedings was unlikely, however, felt that patient's
long history of esophageal dysmotility could be contributing
to aspiration.  They recommended swallowing study.  The
patient received an oropharyngeal video fluoroscopic
swallowing evaluation on day five of admission.  This
revealed mild oral with moderate to severe pharyngoesophageal
dysphagia with significant impaired upper esophageal
sphincter opening leading to severe residue of solids in the
pharynx.  However, there was no aspiration.  Nevertheless,
swallowing service recommended the patient in future have
only thin liquids, pureed solids or very finely/minced meat
in p.o. diet.  They also recommended that the patient sit
bolt upright at meals and for 45 minutes after meals.  They
recommended the patient remain at 45 degrees in bed at all
times and should never lay flat in bed and recommended that
if patient must remain flat in bed that tube feedings be
discontinued for 30 minutes prior to patient laying flat in
bed.

5.  Endocrine:  The patient was continued on Levothyroxine
for hypothyroidism.

6.  GU:  The patient was placed on Foley catheter on
admission to the hospital.  On day seven of admission the
patient was ready for discharge from a medical standpoint,
but did not void in time status post discontinuation of the
Foley catheter.  As a result the patient remained in-house
for an additional day to ensure the patient could void
spontaneously following discontinuation of Foley catheter.

POST DISCHARGE MEDICATIONS:  Metronidazole 500 mg q8 hours x7
days, Augmentin 500/125 mg p.o. b.i.d. x7 days, furosemide 40
mg p.o. q.d., aspirin 325 mg p.o. q.d., metoprolol 25 mg p.o.
b.i.d., Venlafaxine HCL 75 mg capsule p.o. q.d.,
Levothyroxine 150 mcg p.o. q.d., donepezile hydrochloride 10
mg p.o. q.h.s., Lansoprazole 30 mg q.d., iron sulfate 325 mg
p.o. q.d., multi-vitamin.

DISPOSITION:  To home with visiting nurse as well as 24 hour
home health assistance.

DISCHARGE STATUS:  On day of discharge, the patient was
ambulating, voiding spontaneously and had oxygen saturation
of 97% on two liters.  The patient was demented in a manner
consistent with baseline.

DISCHARGE DIAGNOSES:
1.  Aspiration pneumonia.
2.  Coronary artery disease.
3.  Hypertension.
4.  Peptic ulcer disease status post gastrectomy.
5.  Hypothyroidism.
6.  Dementia.
7.  Esophageal dysmotility.
8.  Dehydration.

CODE STATUS:  DNR and DNI.

RECOMMENDED FOLLOW UP:  Follow up with Dr. [**First Name4 (NamePattern1) 140**] [**Last Name (NamePattern1) 141**]
[**Telephone/Fax (1) 142**] if new problems arise.






                          [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 143**], M.D.  [**MD Number(1) 144**]

Dictated By:[**Last Name (NamePattern1) 145**]

MEDQUIST36

D:  [**2188-12-13**]  16:12
T:  [**2188-12-15**]  06:37
JOB#:  [**Job Number 146**]
{'Pneumonitis due to inhalation of food or vomitus,Subendocardial infarction, initial episode of care,Congestive heart failure, unspecified,Nutritional marasmus,Status of other artificial opening of gastrointestinal tract,Other persistent mental disorders due to conditions classified elsewhere,Long-term (current) use of steroids,Coronary atherosclerosis of native coronary artery'}


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 [**Age over 90 **]-year-old
female who has a past medical history significant for
coronary artery disease, hypertension, dementia, recurrent
pneumonia and recent gastrectomy for peptic ulcer disease,
who presented to the emergency room with a complaint of
increasing shortness of breath.  The patient had been at home
for approximately 2 days following discharge from rehab
following gastrectomy when shortness of breath developed.
Emergency medical services were called and the patient was
found to have an oxygen saturation of 65% on room air and 85%
on 100% non-re-breather.

MEDICAL HISTORY: 1.  Hypothyroid.
2.  Coronary artery disease.
3.  Hypertension.
4.  Peptic ulcer disease status post gastrectomy for
perforated ulcer.
5.  Dementia.
6.  Esophageal motility disorder.
7.  Recurrent pneumonia.

MEDICATION ON ADMISSION: 

ALLERGIES: Sulfa.

PHYSICAL EXAM: 

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: Living situation - the patient at baseline
resides at home with 24 hour home health assistance.  There
is extensive family involvement.  The patient's code status
is DNR, DNI. 

### Response:
{'Pneumonitis due to inhalation of food or vomitus,Subendocardial infarction, initial episode of care,Congestive heart failure, unspecified,Nutritional marasmus,Status of other artificial opening of gastrointestinal tract,Other persistent mental disorders due to conditions classified elsewhere,Long-term (current) use of steroids,Coronary atherosclerosis of native coronary artery'}
