CHIEF COMPLAINT: Dyspnea.

PRESENT ILLNESS: This is an 80 year old female
with severe chronic obstructive pulmonary disease with an
FEV1 of 0.59 and continued tobacco use, on two liters of home
O2.  The patient has had multiple admissions for chronic
obstructive pulmonary disease ([**2172-1-7**], [**2172-8-6**]).
She has been steroid dependent for several years and is
currently on 15 mg of Prednisone q. day.  The patient is well
usually at rest and requires oxygen when ambulating.

MEDICAL HISTORY: 1.  Chronic obstructive pulmonary disease with FEV1 equal to
0.59.
2.  Positive PPD with three negative sputum.
3.  Bipolar disorder.
4.  Hypertension.
5.  High cholesterol.
6.  Osteoporosis.
7.  Appendectomy.
8.  Hiatal hernia repair.
9.  Polycythemia.
10. Echocardiogram in [**2172-2-7**] with an ejection
fraction of 50% and decreased right ventricular function.
11. Epistaxis.

MEDICATION ON ADMISSION: 

ALLERGIES: Codeine, phenobarbital, lithium.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient is married with three children.
Husband cares for her.  Tobacco use greater than two packs
per day.  The patient uses wheelchair at home.  The patient
rarely ambulates at home.
Pneumonia, organism unspecified,Obstructive chronic bronchitis with (acute) exacerbation,Congestive heart failure, unspecified,Acute respiratory failure,Unspecified essential hypertension,Tobacco use disorder,Other specified disease of white blood cells,Bipolar I disorder, most recent episode (or current) unspecified
Pneumonia, organism NOS,Obs chr bronc w(ac) exac,CHF NOS,Acute respiratry failure,Hypertension NOS,Tobacco use disorder,Wbc disease NEC,Bipolor I current NOS
Admission Date:  [**2173-7-4**]     Discharge Date:  [**2173-7-7**]

Date of Birth:   [**2104-12-24**]     Sex:  F

Service:  MICU

CHIEF COMPLAINT:   Dyspnea.

HISTORY OF PRESENT ILLNESS:   This is an 80 year old female
with severe chronic obstructive pulmonary disease with an
FEV1 of 0.59 and continued tobacco use, on two liters of home
O2.  The patient has had multiple admissions for chronic
obstructive pulmonary disease ([**2172-1-7**], [**2172-8-6**]).
She has been steroid dependent for several years and is
currently on 15 mg of Prednisone q. day.  The patient is well
usually at rest and requires oxygen when ambulating.

She was at her baseline until five days prior to admission
when she began experiencing increased shortness of breath at
rest with increased respiratory rate and exhaustion.  In
addition, she has been nauseated and anorexic with abdominal
pain.  She says that symptoms correlate with the hot weather
and the air conditioner use.

REVIEW OF SYSTEMS:  Positive chronic cough with yellow
sputum, positive chronic back pain.  Denies fevers, chills,
chest pain or sick contacts.  Positive abdominal pain,
chronic.  Denies dysuria.

PAST MEDICAL HISTORY:
1.  Chronic obstructive pulmonary disease with FEV1 equal to
0.59.
2.  Positive PPD with three negative sputum.
3.  Bipolar disorder.
4.  Hypertension.
5.  High cholesterol.
6.  Osteoporosis.
7.  Appendectomy.
8.  Hiatal hernia repair.
9.  Polycythemia.
10. Echocardiogram in [**2172-2-7**] with an ejection
fraction of 50% and decreased right ventricular function.
11. Epistaxis.

ALLERGIES:   Codeine, phenobarbital, lithium.

SOCIAL HISTORY:   The patient is married with three children.
Husband cares for her.  Tobacco use greater than two packs
per day.  The patient uses wheelchair at home.  The patient
rarely ambulates at home.

MEDICATIONS AT HOME:
1.  Prednisone 15 mg q. day.
2.  Navane 4 mg q. h.s.
3.  Serax 10 mg four times a day.
4.  Tegretol 200 mg four times a day.
5.  Albuterol two puffs q. three to four hours.
6.  Atrovent two puffs q. two to four hours.
7.  Nebulizer at home with mask two liters.
8.  Flovent 220 micrograms twice a day.
9.  [**Doctor First Name **] 60 mg p.o. twice a day.
10. Zantac 150 mg twice a day.
11. Premarin 0.625 q. day.
12. Enteric-coated aspirin one p.o. q. day.
13. Senna one q. h.s.
14. Colace one q. day.
15. Volmax 4 mg q. day.
16. Centrum vitamin one q. day.

PHYSICAL EXAMINATION:   Vital signs were temperature 101.7
f.; heart rate 92; blood pressure 101/53; respiratory rate of
35; oxygen saturation 87% on two liters.  In general, the
patient was a thin ill appearing woman in some respiratory
distress, breathing at a fast respiratory rate and with clear
discomfort.  HEENT:  Her pupils are equal, round, and
reactive to light and accommodation.  Extraocular muscles are
intact.  She had dry mucous membranes.  Her lungs had
decreased breath sounds at the bases bilaterally with wheezes
on the right lung and some coarse breath sounds at the left
lung base.  Cardiac examination:  The patient was tachycardic
with a regular rhythm; no murmurs, rubs or gallops were
appreciated.  Abdomen was tender to palpation diffusely with
positive bowel sounds.  Extremities showed no cyanosis,
clubbing or edema.  Neurological examination showed the
patient to be alert and oriented times three with normal and
symmetric strength in the upper and lower extremities.  Skin
showed no rashes on examination.

LABORATORY:  An EKG showed sinus rhythm at a rate of 93 beats
per minute with normal intervals.  No T wave inversions,
however, ST changes were noted.

Her labs on admission were a sodium of 138, potassium of 4.2,
chloride of 101, bicarbonate of 25, BUN of 8.0, creatinine of
1.9, glucose of 145.  Blood gas with a pH of 7.32, a pCO2 of
54 and a pAO2 of 74.  White blood cell count of 18.6, with
67% neutrophils, 5% bands, a hematocrit of 44.2, and
platelets of 278.

The patient's blood gas was taken on two liters of oxygen.

Past spirometry has shown an FEV1 of 0.59 which is 33% of
predicted, vital capacity of 1.24 which is 49% predicted, and
an FEV1/FEC of 67% predicted.  These were done in [**2173-2-6**].

Chest x-ray on admission showed hyperinflated lungs with
flattened diaphragms bilaterally.  No signs of congestive
heart failure.  There was a question of a right lower lobe
pneumonia.

SUMMARY:  In summary, the patient is a 67 year old female
with severe chronic obstructive pulmonary disease with an
FEV1 of 0.59, bipolar disorder, hypertension, with multiple
admissions to this hospital for chronic obstructive pulmonary
disease exacerbations.  She presents now with a chronic
obstructive pulmonary disease exacerbation of unclear
etiology, a question of a right lower lobe pneumonia versus
the heat versus a viral upper respiratory infection.  The
patient presented with a temperature of 101.2 F, small
opacity in the right lower lobe on chest x-ray and some
yellow sputum that she states is at her baseline.

HOSPITAL COURSE:
1.  CHRONIC OBSTRUCTIVE PULMONARY DISEASE:  In the Emergency
Room, the patient required Bi-PAP mask in order to properly
oxygenate and increase her oxygen saturation greater than
90%.  She was placed on a Bi-PAP nasal mask with pressure
support of 8 and a PEEP of 5 and it was titrated to patient
comfort to keep her respiratory rate less than 30.  The
patient was continued on her Albuterol and Atrovent
nebulizers q. two hours.

The patient was started on Solu-Medrol 80 mg intravenously
three times a day.

On day two of admission, the patient was switched to p.o.
Prednisone but that afternoon was noted to have worsening
oxygenation on Bi-PAP.  She was then switched to a full face
mask with improvement in her oxygenation and her coordination
with the ventilator.  However, the patient was found to be
quite somnolent on day three of admission and blood bases a
that time showed a pH of 7.31, a pCO2 of 56, and a pO2 of 63,
which is probably very close to the patient's baseline.  It
was therefore decided that she was not hypercarbic but that
her mental status changes were due to her increased ativan
and morphine use for anxiety and back pain while in the
Medical Intensive Care Unit.

The patient continued to require Bi-PAP at a pressure support
of 8 and a PEEP of 5 with decreased oxygen saturations
throughout the day.  The patient, in addition, had increased
agitation requiring Ativan.

On the night prior to discharge, the patient was aggressively
suctioned with normal saline which yielded several brown and
bloody clots.  After aggressive suctioning, the patient
improved her saturation markedly with an oxygen saturation of
98% on three liters nasal cannula.  The patient continued to
saturate well on three liters nasal cannula overnight and
throughout the day and she became much more alert and
conversant.

By the time of discharge, the patient was saturating in the
high 90s on three liters nasal cannula.

2.  MENTAL STATUS CHANGES:  On admission to the Medical
Intensive Care Unit, the patient was extremely anxious with a
very high respiratory rate which calmed down with 2 mg of
Ativan.  On the second day of admission, the patient was
requiring ativan q. two and morphine q. two for back pain,
and was found to be quite lethargic, so the Ativan and
morphine were stopped.  The patient began to wake up at 8
p.m. on the third day of admission and by the next morning,
her mental status was back to baseline.

3.  PNEUMONIA:  The patient was admitted with a fever of
101.7 F., and increased white blood cell count of 18 with 5%
bands and a right lower lobe opacity was noted on the chest
x-ray.  The patient was therefore started on Levofloxacin and
continued on that coverage for assumed community acquired
pneumonia.  On the day of discharge, the patient was on day
four of a seven day course.

This is addendum to problem number one.  The patient was
transitioned to oral Prednisone 60 mg q. day with an
aggressive taper to 15 mg q. day over the course of two weeks
and she will need to have continued aggressive pulmonary
toilet.

4.  RENAL FUNCTION:  The patient was initially admitted with
a high creatinine of 1.7, up from her baseline of 1.2.  It
was assumed that the patient had prerenal insufficiency due
to hypovolemia with a sodium of 138.  The patient was
hydrated at 100 cc per hour of normal saline.  Nephrotoxic
drugs were avoided and the patient's renal function returned
to baseline on day two of admission and continued to stay at
baseline throughout her admission.

5.  CARDIAC STATUS:  The patient was complaining of chest
pain on the second day of admission.  She complained of chest
pain 10 out of 10 radiating to her left arm which improved
with sublingual Nitroglycerin and morphine times two.  The
cardiac enzymes were cycled and remained negative.  The
patient's chest pain resolved and was assumed to be secondary
to her pneumonia.

In addition, the patient was found to be hypertensive on the
second day of admission, with a blood pressure of 170/80.
Hypertension seemed to be secondary to her decreased oxygen
saturation and increased respiratory rate in addition to some
pain that she was having, and her hypertension improved
considerably once her ventilation was improved. The patient
did not need any hypertensive medications during this
admission.

6.  RENAL:  The patient was initially admitted with a
creatinine of 1.7 which was up from her baseline of 1.2 to
1.3.  Her prerenal insufficiency was considered to be
secondary to hypovolemia and prerenal failure.  The patient
was hydrated with 100 cc per hour of normal saline and by
discharge her creatinine had returned to its baseline of 1.3.

7.  PROPHYLAXIS:  The patient was maintained on subcutaneous
heparin and ranitidine.

8.  CODE STATUS:  The patient was "Do Not Resuscitate", "Do
Not Intubate".

Communication was maintained with the husband.  Several
family meetings were arranged to discuss the long term care
of the patient.  In addition, Palliative Care was involved
with the patient's care.  The patient lives with her husband.

9.  PAIN CONTROL:  The patient was complaining of
considerable back pain during this hospitalization,
requesting morphine.  On the day of discharge, the patient
was transitioned from morphine intravenously p.r.n. to
MS-Contin for longer acting pain control with MSIR for
breakthrough pain.

DISPOSITION:   The patient will be transferred to the Medical
Floor today.  Pulmonary consultation is to follow the patient
on the floor.  In addition, the patient should have
aggressive pulmonary toilet done by Respiratory Therapy.

MEDICATIONS ON TRANSFER:
1.  Albuterol nebulizer solution, one nebulizer q. two hours
p.r.n..
2.  Ipratropium bromide one nebulizer q. two hours p.r.n.
3.  Oxazepam 10 mg p.o. four times a day.
4.  [**Last Name (un) **] ...........4 mg p.o. q. h.s.
5.  Carbamazepine 200 mg p.o. four times a day.
6.  Docusate sodium 100 mg p.o. twice a day.
7.  Senna one tablet p.o. twice a day p.r.n.
8.  Multivitamin one p.o. q. day.
9.  Fexofenadine 60 mg p.o. twice a day.
10. Ranitidine 150 mg p.o. twice a day.
11. Heparin 5000 units subcutaneously q. 12.
12. Acetaminophen 325 mg p.o. q. four to six hours p.r.n.
13. Nicotine 14 mg transdermal patch q. day.
14. Nitroglycerin sublingual 0.3 mg p.r.n.
15. Aspirin 325 mg p.o. q. day.
16. Albuterol nebulizer solution, one nebulizer q. four
hours.
17. Ipratoprium bromide nebulizer solution, one nebulizer q.
six hours.
18. Levofloxacin 250 mg p.o. q. 24 hours.
19. Morphine sulfate IR 50 mg p.o. q. four to six hours
p.r.n. pain.
20. Morphine sulfate SR 50 mg p.o. q. 12 hours.
21. Prednisone taper to go as follows:  Prednisone 40 mg p.o.
q. day times two doses, then Prednisone 30 mg p.o. q. day
times two doses, then Prednisone 15 mg p.o. q. day
thereafter.

CONDITION ON DISCHARGE:   Condition on discharge to the floor
was stable.

DISCHARGE DIAGNOSES:
1.  Chronic obstructive pulmonary disease exacerbation with
pneumonia.



                          [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 4561**]

Dictated By:[**Last Name (NamePattern1) 5615**]

MEDQUIST36

D:  [**2173-7-7**]  11:48
T:  [**2173-7-11**]  15:04
JOB#:  [**Job Number 29661**]
{'Pneumonia, organism unspecified,Obstructive chronic bronchitis with (acute) exacerbation,Congestive heart failure, unspecified,Acute respiratory failure,Unspecified essential hypertension,Tobacco use disorder,Other specified disease of white blood cells,Bipolar I disorder, most recent episode (or current) 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: Dyspnea.

PRESENT ILLNESS: This is an 80 year old female
with severe chronic obstructive pulmonary disease with an
FEV1 of 0.59 and continued tobacco use, on two liters of home
O2.  The patient has had multiple admissions for chronic
obstructive pulmonary disease ([**2172-1-7**], [**2172-8-6**]).
She has been steroid dependent for several years and is
currently on 15 mg of Prednisone q. day.  The patient is well
usually at rest and requires oxygen when ambulating.

MEDICAL HISTORY: 1.  Chronic obstructive pulmonary disease with FEV1 equal to
0.59.
2.  Positive PPD with three negative sputum.
3.  Bipolar disorder.
4.  Hypertension.
5.  High cholesterol.
6.  Osteoporosis.
7.  Appendectomy.
8.  Hiatal hernia repair.
9.  Polycythemia.
10. Echocardiogram in [**2172-2-7**] with an ejection
fraction of 50% and decreased right ventricular function.
11. Epistaxis.

MEDICATION ON ADMISSION: 

ALLERGIES: Codeine, phenobarbital, lithium.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient is married with three children.
Husband cares for her.  Tobacco use greater than two packs
per day.  The patient uses wheelchair at home.  The patient
rarely ambulates at home. 

### Response:
{'Pneumonia, organism unspecified,Obstructive chronic bronchitis with (acute) exacerbation,Congestive heart failure, unspecified,Acute respiratory failure,Unspecified essential hypertension,Tobacco use disorder,Other specified disease of white blood cells,Bipolar I disorder, most recent episode (or current) unspecified'}
