CHIEF COMPLAINT: Shortness of breath

PRESENT ILLNESS: [**Age over 90 **] YO F with CAD, AF (not on anti-coagulation), UTIs and prior
multiloculated parapneumonic effusion presenting with shortness
of breath. She is a very poor historian but reports feeling well
until the day of admission when she developed acute SOB at home.
EMS was called and brought the patient into the ED. She reports
a minor non-productive cough and denies sob, fever, chills, or
dysuria. Her daughter does report that her birthday was the
other day and she has been eating out alot. Also, with the
recent warm weather, she has been drinking alot of water.
.
In the ED, initial vs were: 104.8 rectally 87 101/57 26 88% on
RA. Exam was notable for a very tachypneic woman in severe
respiratory distress. Her lung exam was notable for wheezing
with decreased air movement. Labs were notable for WBC to 21,
lactate 2.2. CXR was without clear infiltrate or effusion. EKG
showed RBBB and LAD which was c/w priors. She was placed on
non-invasive BiPAP 15/5 FiO2 100%. The patient was given
methylpred 125mg IV once, nebs, APAP and ibuprofen, levofloxacin
750mg IV and ceftriaxone 1g IV. 20g and an 18g PIV were placed.
VS prior to transfer were: HR 103 138/70s 20 98%; however just
prior to transport the patient's SBP dropped to the 70s. She was
taken off BiPap and given gentle fluids with recovery of her SBP
to the 90s and O2 sat 96% on 4L NC.
.
Upon arrival to the MICU, the patient reports feeling well aside
from some difficult breathing and feeling as though something is
"on" her chest.

MEDICAL HISTORY: Frequent Falls
CAD - s/p MI [**00**] years ago
HTN
CHF - ? last ECHO [**7-12**] EF 70%
Atrial fibrillation
Chronic venous stasis with b/l lower extremity edema
Constipation
orthostatic hypotension
trigeminal zoster
Hernia repair
s/p appy
Degenerative disc disease followed by ortho

MEDICATION ON ADMISSION: Donepezil 5 mg Tablet [**Age over 90 **]: Two (2) Tablet PO HS (at bedtime).
Omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Age over 90 **]: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Metoprolol Tartrate 25 mg Tablet [**Age over 90 **]: 0.5 Tablet PO BID (2 times
a day).
Aspirin 81 mg Tablet [**Age over 90 **]: One (1) Tablet PO DAILY (Daily).
Gabapentin 100 mg Capsule [**Age over 90 **]: Two (2) Capsule PO TID (3 times a
day).
Venlafaxine 75 mg Tablet [**Age over 90 **]: One (1) Tablet PO BID (2 times a
day).
.
Her medication list was confirmed with her PCP.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
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: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives in [**Location **] with husband. Previous husband died 10 [**Name2 (NI) 1686**]
ago. Has two children, both of whom live in [**State 531**], and three
grandchildren. She used to smoke a PPD for 40 [**State 1686**] stopped
roughly 20 [**State 1686**] ago after her MI. daily glass of wine. No other
drugs.
Pneumonia, organism unspecified,Acute respiratory failure,Urinary tract infection, site not specified,Cellulitis and abscess of leg, except foot,Chronic diastolic heart failure,Obstructive chronic bronchitis with (acute) exacerbation,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Venous (peripheral) insufficiency, unspecified,Orthostatic hypotension,Degeneration of lumbar or lumbosacral intervertebral disc,Anisocoria,Other constipation,Senile dementia, uncomplicated,Personal history of tobacco use,Old myocardial infarction
Pneumonia, organism NOS,Acute respiratry failure,Urin tract infection NOS,Cellulitis of leg,Chr diastolic hrt fail,Obs chr bronc w(ac) exac,Atrial fibrillation,Crnry athrscl natve vssl,Hypertension NOS,Venous insufficiency NOS,Orthostatic hypotension,Lumb/lumbosac disc degen,Anisocoria,Constipation NEC,Senile dementia uncomp,History of tobacco use,Old myocardial infarct
Admission Date:  [**2191-7-3**]              Discharge Date:   [**2191-7-8**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Shortness of breath

Major Surgical or Invasive Procedure:
PICC Line placement


History of Present Illness:
 [**Age over 90 **] YO F with CAD, AF (not on anti-coagulation), UTIs and prior
multiloculated parapneumonic effusion presenting with shortness
of breath. She is a very poor historian but reports feeling well
until the day of admission when she developed acute SOB at home.
EMS was called and brought the patient into the ED. She reports
a minor non-productive cough and denies sob, fever, chills, or
dysuria. Her daughter does report that her birthday was the
other day and she has been eating out alot. Also, with the
recent warm weather, she has been drinking alot of water.
.
In the ED, initial vs were: 104.8 rectally 87 101/57 26 88% on
RA. Exam was notable for a very tachypneic woman in severe
respiratory distress. Her lung exam was notable for wheezing
with decreased air movement. Labs were notable for WBC to 21,
lactate 2.2. CXR was without clear infiltrate or effusion. EKG
showed RBBB and LAD which was c/w priors. She was placed on
non-invasive BiPAP 15/5 FiO2 100%. The patient was given
methylpred 125mg IV once, nebs, APAP and ibuprofen, levofloxacin
750mg IV and ceftriaxone 1g IV. 20g and an 18g PIV were placed.
VS prior to transfer were: HR 103 138/70s 20 98%; however just
prior to transport the patient's SBP dropped to the 70s. She was
taken off BiPap and given gentle fluids with recovery of her SBP
to the 90s and O2 sat 96% on 4L NC.
.
Upon arrival to the MICU, the patient reports feeling well aside
from some difficult breathing and feeling as though something is
"on" her chest.


Past Medical History:
Frequent Falls
CAD - s/p MI [**00**] years ago
HTN
CHF - ? last ECHO [**7-12**] EF 70%
Atrial fibrillation
Chronic venous stasis with b/l lower extremity edema
Constipation
orthostatic hypotension
trigeminal zoster
Hernia repair
s/p appy
Degenerative disc disease followed by ortho

Social History:
Lives in [**Location **] with husband. Previous husband died 10 [**Name2 (NI) 1686**]
ago. Has two children, both of whom live in [**State 531**], and three
grandchildren. She used to smoke a PPD for 40 [**State 1686**] stopped
roughly 20 [**State 1686**] ago after her MI. daily glass of wine. No other
drugs.


Family History:
NC

Physical Exam:
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
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: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

Pertinent Results:
LOWER EXTREMITY U/S:
IMPRESSION: No evidence of DVT in the left lower extremity.
.
CTA CHEST:
1. No evidence of pulmonary embolism.
2. Cicatricial atelectasis in the right lower lobe is not
concerning for
malignancy.
3. New left lower lobe consolidation.
4. Interval decrease in size of segment VIII liver cyst.
.
ECHO:
Suboptimal image quality. Mild symmetric left ventricular
hypertrophy with preserved global biventricular systolic
function. Mild pulmonary artery systolic hypertension.
Compared with the report of the prior study (images unavailable
for review) of [**2190-6-30**], the severity of mitral regurgitation
and the estimated pulmonary artery systolic pressure are lower.
.
CT head [**2191-7-6**]: No acute intracranial hemorrhage or large
hypodensity to suggest infarct. If continued concern for carotid
dissection or skull base lesion to explain pupil asymmetry,
consider MRI andMRA to better evaluate, if there are no
contraindications.
.
[**2191-7-3**] 11:30 pm URINE     Site: CATHETER

                            **FINAL REPORT [**2191-7-6**]**

   URINE CULTURE (Final [**2191-7-6**]):
      ESCHERICHIA COLI.    >100,000 ORGANISMS/ML..
         PRESUMPTIVE IDENTIFICATION.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ESCHERICHIA COLI
                             |
AMPICILLIN------------  =>32 R
AMPICILLIN/SULBACTAM--  =>32 R
CEFAZOLIN-------------     8 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN--------  <=16 S
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S
.
Admission Lab
[**2191-7-3**] 10:50PM BLOOD WBC-21.5*# RBC-4.70 Hgb-13.8 Hct-42.5
MCV-91 MCH-29.3 MCHC-32.4 RDW-15.0 Plt Ct-224
[**2191-7-3**] 10:50PM BLOOD PT-12.2 PTT-25.9 INR(PT)-1.0
[**2191-7-3**] 10:50PM BLOOD Glucose-119* UreaN-19 Creat-0.9 Na-145
K-4.0 Cl-108 HCO3-26 AnGap-15
[**2191-7-3**] 10:50PM BLOOD Calcium-9.3 Phos-2.4* Mg-1.9
[**2191-7-4**] 03:14AM BLOOD Type-ART pO2-104 pCO2-35 pH-7.38
calTCO2-22 Base XS--3
[**2191-7-3**] 10:57PM BLOOD Lactate-2.2*
Discharge Labs
[**2191-7-8**] 09:45AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.2
[**2191-7-8**] 09:45AM BLOOD Glucose-59* UreaN-17 Creat-0.9 Na-141
K-4.2 Cl-106 HCO3-25 AnGap-14
[**2191-7-8**] 09:45AM BLOOD WBC-10.3 RBC-4.42 Hgb-13.0 Hct-40.0
MCV-91 MCH-29.4 MCHC-32.5 RDW-15.1 Plt Ct-256

Brief Hospital Course:
[**Age over 90 **]yo F with AFib not on anticoagulation who presents with SOB
and hypoxia. Initially requiring BiPAP, saturating well on RA at
the time of discharge. She was treated for for CAP with h/o
MRSA, E. coli UTI, and cellulitis.
.
#HYPOTENSION: She was initially hypotensive with an elevated
lactate and admitted to the ICU for further management. Given
her fever and leukocytosis there was strong suspicion that this
was a distributive process with likely either urinary vs
pulmonary source. She was started on broad spectrum intravenous
antibiotics. Her hypotension was fluid responsive and she did
not require vasopressors. She was transfered to the medical
floor on HD 3 where she was hemodynamically stable.
.
# URINARY TRACT INFECTION: She was found to have a fever,
leukocytosis, and urine culture growing >100,000 colonies of
E.Coli. She was initially on broad spectum IV therapy in the
MICU. When she came to the medical floor, she was started on po
levofloxacin. The E. coli was sensative to ciprofloxacin so she
was continued on levofloxacin for coverage of UTI and PNA. Will
be discharged on levofloxacin for 5 more days for her UTI as
given her age and having had a foley in the MICU, she should be
covered for a complicated UTI.
.
#Community Acquired Pneuonia: She presented with a new oxygen
requirement, cough, and fever. She was evaluated with a CTA
chest that showed no evidence of pulmonary embolism but revealed
consolidation. She was given broad spectrum antibiotics for
pneumonia. There was a LLL infiltrate present on both CT and
CXR. As noted above, she was started on po levofloxacin when she
came to the medical floor, and this was chosen so that one
antibiotic could cover both community-aquired pneumonia and her
UTI. IV vancomycin was continued for LLE cellulitis as well as
for treatment of PNA given her need for ICU admission and
history of MRSA PNA in the past. She was unable to provide a
sputum to determine whether or not it was still present. Given
this history, her iniital need for ICU level of care, and her
improvement on vacomycin, the decision was made to continue
vancomycin on the medical floor and for 5 more days.
.
#L LOWER EXTEMITY SWELLING/ERYTHEMA: She was evaluated with
lower extremity ultrasound, which revealed no evidence of DVT.
The redness, swelling, tenderness, and warmth of her left ankle
was concerning for cellulitis. The degree and extent of redness
and swelling improved with vancomycin. She will be discharged
with vancomycin for 5 days to complete a 10 day course of
therapy for cellulitis.
.
# ATRIAL FIBRILLATION: Her metoprolol was initially held in the
setting of hypotension but was restarted on hospital day two for
rate control for atrial fibrillation. Per the patient's PCP she
had been on coumadin in the past, but was inconsistant with
taking her medicines and has had multiple falls. The patient was
intermittently in a fib during this admission. Her asprin dose
was increased to 325mg daily.
.
# ANISOCORIA: Her pulpils were noted to be unequal by her nurse.
The left pupil measured approximate 4mm while the right pupil
was 1mm. They were minimally reactive to light. There were no
other neurological findings. Head CT showed no evidence of
bleed, ischemic event, or mass effect. Neurology was consulted
and recommended continuing to monitor clinically. The anisocoria
resolved spontaneously. Neruology had previously been consulted
for this same issue during a prior admission. At that time, it
was attributed to tiotropium nebulizer treatments getting into
the eye. It should be noted that the patient had recieved an
Atrovent neb treatment a few hours before the abnormality was
noted this admission.
.
# DEMENTIA: She was continued on venlafaxine and Aricept.
.
CODE: DNR/DNI

Medications on Admission:
Donepezil 5 mg Tablet [**Age over 90 **]: Two (2) Tablet PO HS (at bedtime).
Omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Age over 90 **]: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Metoprolol Tartrate 25 mg Tablet [**Age over 90 **]: 0.5 Tablet PO BID (2 times
a day).
Aspirin 81 mg Tablet [**Age over 90 **]: One (1) Tablet PO DAILY (Daily).
Gabapentin 100 mg Capsule [**Age over 90 **]: Two (2) Capsule PO TID (3 times a
day).
Venlafaxine 75 mg Tablet [**Age over 90 **]: One (1) Tablet PO BID (2 times a
day).
.
Her medication list was confirmed with her PCP.


Discharge Medications:
1. Donepezil 5 mg Tablet [**Age over 90 **]: Two (2) Tablet PO HS (at bedtime).

2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Age over 90 **]: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Acetaminophen 650 mg Tablet [**Age over 90 **]: One (1) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
4. Aspirin 325 mg Tablet [**Age over 90 **]: One (1) Tablet PO DAILY (Daily).
5. Gabapentin 100 mg Capsule [**Age over 90 **]: Two (2) Capsule PO TID (3
times a day).
6. Venlafaxine 75 mg Tablet [**Age over 90 **]: One (1) Tablet PO BID (2 times
a day).
7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Age over 90 **]:
1-2 puffs Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
8. Heparin, Porcine (PF) 10 unit/mL Syringe [**Age over 90 **]: One (1) flush
Intravenous PRN (as needed) as needed for line flush.
9. Vancomycin in D5W 1 gram/200 mL Piggyback [**Age over 90 **]: One (1) gram
Intravenous Q 12H (Every 12 Hours) for 5.5 days.
10. Levofloxacin 750 mg Tablet [**Age over 90 **]: One (1) Tablet PO once a day
for 5 days.
11. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
[**Age over 90 **]: One (1) Tablet Sustained Release 24 hr PO once a day.
12. Ipratropium Bromide 0.02 % Solution [**Age over 90 **]: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheezing, SOB.


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Healthcare Center - [**Location (un) **]

Discharge Diagnosis:
Primary:
community acquired pneumonia
urinary tract infection
cellulitis
Secondary:
atrial fibrilation


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
You were admitted to [**Hospital1 18**] for trouble breathing and not getting
enough oxygen. A machine called BiPAP was used at first to help
your breathing but you were given antibiotics and your symptoms
improved. You first went to the medical ICU, but when you were
off the breathing machine and doing better, you came to the
medicine floor.
.
You did not have any blood clots in your lungs. We gave you
antibiotics for pneumonia. You also were found to have a urinary
tract infection. The antibiotic levofloxacin will treat both of
these infections and the vancomycin will treat the infection in
your lungs as well as a possibe skin infection on your ankle.
The vancomycin goes through the PICC line that is in your left
arm. The nurses at rehab will give you this medicine. You will
take each of these medicines for 5 more days and then the PICC
line should be removed.
.
We made the following changes to your medications:
1) Start taking levofloxacin 750mg daily for 5 more days.
2) You will be getting vancomycin 1000mg twice a day through the
PICC line. Your dose may be adjusted based on the level
3) You may use an albuterol inhaler 2 puff every 4-6 hours as
needed for shortness of breath or wheezing.
4) Please increase your aspirin dose to 325mg as this is the
dose you should be on for your abnormal heart rhythm.
5) Please stop your lasix (furosemide)
6) Please start ipratropium and albuterol as needed


Followup Instructions:
Please make an appointment to see your primary care doctor, Dr.
[**Last Name (STitle) 2204**] when you go home from rehab.
{'Pneumonia, organism unspecified,Acute respiratory failure,Urinary tract infection, site not specified,Cellulitis and abscess of leg, except foot,Chronic diastolic heart failure,Obstructive chronic bronchitis with (acute) exacerbation,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Venous (peripheral) insufficiency, unspecified,Orthostatic hypotension,Degeneration of lumbar or lumbosacral intervertebral disc,Anisocoria,Other constipation,Senile dementia, uncomplicated,Personal history of tobacco use,Old myocardial infarction'}


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: Shortness of breath

PRESENT ILLNESS: [**Age over 90 **] YO F with CAD, AF (not on anti-coagulation), UTIs and prior
multiloculated parapneumonic effusion presenting with shortness
of breath. She is a very poor historian but reports feeling well
until the day of admission when she developed acute SOB at home.
EMS was called and brought the patient into the ED. She reports
a minor non-productive cough and denies sob, fever, chills, or
dysuria. Her daughter does report that her birthday was the
other day and she has been eating out alot. Also, with the
recent warm weather, she has been drinking alot of water.
.
In the ED, initial vs were: 104.8 rectally 87 101/57 26 88% on
RA. Exam was notable for a very tachypneic woman in severe
respiratory distress. Her lung exam was notable for wheezing
with decreased air movement. Labs were notable for WBC to 21,
lactate 2.2. CXR was without clear infiltrate or effusion. EKG
showed RBBB and LAD which was c/w priors. She was placed on
non-invasive BiPAP 15/5 FiO2 100%. The patient was given
methylpred 125mg IV once, nebs, APAP and ibuprofen, levofloxacin
750mg IV and ceftriaxone 1g IV. 20g and an 18g PIV were placed.
VS prior to transfer were: HR 103 138/70s 20 98%; however just
prior to transport the patient's SBP dropped to the 70s. She was
taken off BiPap and given gentle fluids with recovery of her SBP
to the 90s and O2 sat 96% on 4L NC.
.
Upon arrival to the MICU, the patient reports feeling well aside
from some difficult breathing and feeling as though something is
"on" her chest.

MEDICAL HISTORY: Frequent Falls
CAD - s/p MI [**00**] years ago
HTN
CHF - ? last ECHO [**7-12**] EF 70%
Atrial fibrillation
Chronic venous stasis with b/l lower extremity edema
Constipation
orthostatic hypotension
trigeminal zoster
Hernia repair
s/p appy
Degenerative disc disease followed by ortho

MEDICATION ON ADMISSION: Donepezil 5 mg Tablet [**Age over 90 **]: Two (2) Tablet PO HS (at bedtime).
Omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Age over 90 **]: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Metoprolol Tartrate 25 mg Tablet [**Age over 90 **]: 0.5 Tablet PO BID (2 times
a day).
Aspirin 81 mg Tablet [**Age over 90 **]: One (1) Tablet PO DAILY (Daily).
Gabapentin 100 mg Capsule [**Age over 90 **]: Two (2) Capsule PO TID (3 times a
day).
Venlafaxine 75 mg Tablet [**Age over 90 **]: One (1) Tablet PO BID (2 times a
day).
.
Her medication list was confirmed with her PCP.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
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: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives in [**Location **] with husband. Previous husband died 10 [**Name2 (NI) 1686**]
ago. Has two children, both of whom live in [**State 531**], and three
grandchildren. She used to smoke a PPD for 40 [**State 1686**] stopped
roughly 20 [**State 1686**] ago after her MI. daily glass of wine. No other
drugs. 

### Response:
{'Pneumonia, organism unspecified,Acute respiratory failure,Urinary tract infection, site not specified,Cellulitis and abscess of leg, except foot,Chronic diastolic heart failure,Obstructive chronic bronchitis with (acute) exacerbation,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Venous (peripheral) insufficiency, unspecified,Orthostatic hypotension,Degeneration of lumbar or lumbosacral intervertebral disc,Anisocoria,Other constipation,Senile dementia, uncomplicated,Personal history of tobacco use,Old myocardial infarction'}
