CHIEF COMPLAINT: Respiratory distress

PRESENT ILLNESS: HPI: 86 year old female with tracheobronchiomalacia and chronic
respitory distress vent dependent, h/o UTI, h/o aspiration PNA,
DM type2, MR who presents from OSH after difficulty with
ventilation and found to have rapid atrial fibrillation. Patient
found at OSH to be in severe respitory distress with minimal.
EKG done which showed afib with RVR of 140-170. Patient given
solumedral 125mg and lasix 20mg at OSH for concern of CHF.
Patient transferred to ED were found to be in rapid afib,
hypotensive to SBP 60s and hypoxic with O2Sat in 80s. Patient
was cardioverted in the ED and returned to sinus rhythm,
decrease in HR and increase in BP. Patient given 4L IVF in the
ED with minimal urine output. Patient was also found to be
febrile with temp 104. Given flagyl,vanco,ceftriaxone in the ED.
On CXR in ED found that there was an overdistension of
tracheostomy cuff which was reduced in the ED.

MEDICAL HISTORY: 1. Diabetes mellitus type 2.
2. Hypertension.
3. Tracheobronchiomalacia
4. Anemia.
5. Moderate to severe mitral regurgitation.
6. PAF
7. COPD
8. CVA
9. C. diff being treated at OSH with flagyl and aztreonam

MEDICATION ON ADMISSION: 1) Lopressor 12.5 [**Hospital1 **]
2) Protonix 40mg qd
3) Modafonil 200mg qd
4) Albuterol 2puff q6 prn
5) Atrovent 2puff q6 prn
6) Heparin SC 5000units [**Hospital1 **]
7) Zoloft 75mg qd
8) Aranesp 25 mcg/qweek
9) Flagyl 500mg tid
10) Aztreonam 1g IV q12
11) Ferrlecit 62.5mg x3/week

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 104.2 HR 90-107 BP 96-100/34 RR 27 O2Sat 100% on vent. CMV
Vt450x RR 26 PEEP 6 FiO2 40%
Gen: Patient attached to vent via tracheostomy. Spontaneously
moving LE B/L. Patient responds to painful stimuli.
Heent: Pupils pinpoint, unable to get movement, MMM
Lungs: Course BS ant/lat, good airway entry
Cardiac: RRR S1/S2 hol
Abd: distended, decreased BS
Ext: no edema
Neuro: repsonsive to painful stimuli

FAMILY HISTORY: The patient is currently a resident at
[**Hospital3 672**] Hospital. No known tobacco or drug use

SOCIAL HISTORY: Unknown
Unspecified septicemia,Acute and chronic respiratory failure,Pneumonia, organism unspecified,Acute kidney failure, unspecified,Atrial fibrillation,Intestinal infection due to Clostridium difficile,Chronic airway obstruction, not elsewhere classified,Mitral valve disorders,Severe sepsis,Tracheostomy status,Candidiasis of other urogenital sites,Unspecified essential hypertension
Septicemia NOS,Acute & chronc resp fail,Pneumonia, organism NOS,Acute kidney failure NOS,Atrial fibrillation,Int inf clstrdium dfcile,Chr airway obstruct NEC,Mitral valve disorder,Severe sepsis,Tracheostomy status,Candidias urogenital NEC,Hypertension NOS
Admission Date:  [**2201-10-19**]              Discharge Date:   [**2201-10-22**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 7934**]
Chief Complaint:
Respiratory distress

Major Surgical or Invasive Procedure:
PICC line placement


History of Present Illness:
HPI: 86 year old female with tracheobronchiomalacia and chronic
respitory distress vent dependent, h/o UTI, h/o aspiration PNA,
DM type2, MR who presents from OSH after difficulty with
ventilation and found to have rapid atrial fibrillation. Patient
found at OSH to be in severe respitory distress with minimal.
EKG done which showed afib with RVR of 140-170. Patient given
solumedral 125mg and lasix 20mg at OSH for concern of CHF.
Patient transferred to ED were found to be in rapid afib,
hypotensive to SBP 60s and hypoxic with O2Sat in 80s. Patient
was cardioverted in the ED and returned to sinus rhythm,
decrease in HR and increase in BP. Patient given 4L IVF in the
ED with minimal urine output. Patient was also found to be
febrile with temp 104. Given flagyl,vanco,ceftriaxone in the ED.
On CXR in ED found that there was an overdistension of
tracheostomy cuff which was reduced in the ED.

Past Medical History:
1. Diabetes mellitus type 2.
2. Hypertension.
3. Tracheobronchiomalacia
4. Anemia.
5. Moderate to severe mitral regurgitation.
6. PAF
7. COPD
8. CVA
9. C. diff being treated at OSH with flagyl and aztreonam


Social History:
Unknown

Family History:
The patient is currently a resident at
[**Hospital3 672**] Hospital. No known tobacco or drug use


Physical Exam:
T 104.2 HR 90-107 BP 96-100/34 RR 27 O2Sat 100% on vent. CMV
Vt450x RR 26 PEEP 6 FiO2 40%
Gen: Patient attached to vent via tracheostomy. Spontaneously
moving LE B/L. Patient responds to painful stimuli.
Heent: Pupils pinpoint, unable to get movement, MMM
Lungs: Course BS ant/lat, good airway entry
Cardiac: RRR S1/S2 hol
Abd: distended, decreased BS
Ext: no edema
Neuro: repsonsive to painful stimuli


Pertinent Results:
[**2201-10-19**] 08:20PM   O2 SAT-99
[**2201-10-19**] 08:20PM   freeCa-1.11*
[**2201-10-19**] 08:20PM   TYPE-ART PO2-194* PCO2-36 PH-7.36 TOTAL
CO2-21 BASE XS--4
[**2201-10-19**] 08:20PM   LACTATE-1.4
[**2201-10-19**] 04:15PM URINE  COLOR-Amber APPEAR-Cloudy SP [**Last Name (un) 155**]-1.019
[**2201-10-19**] 04:15PM URINE  BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
[**2201-10-19**] 04:15PM URINE  RBC->50 WBC-[**12-6**]* BACTERIA-MANY
YEAST-MANY EPI-[**6-26**] TRANS EPI-[**6-26**]
[**2201-10-19**] 04:15PM URINE  GRANULAR-0-2 FINE GRANULAR CASTS
[**2201-10-19**] 02:58PM   TYPE-ART TEMP-40.0 RATES-/24 TIDAL VOL-600
O2-98 PO2-609* PCO2-74* PH-7.11* TOTAL CO2-25 BASE XS--7
AADO2-42 REQ O2-19 -ASSIST/CON INTUBATED-INTUBATED
[**2201-10-19**] 01:57PM   LACTATE-1.4
[**2201-10-19**] 01:30PM   GLUCOSE-237* UREA N-78* CREAT-1.6* SODIUM-134
POTASSIUM-5.1 CHLORIDE-101 TOTAL CO2-26 ANION GAP-12
[**2201-10-19**] 01:30PM   ALT(SGPT)-11 AST(SGOT)-19 CK(CPK)-50 ALK
PHOS-83 TOT BILI-0.2
[**2201-10-19**] 01:30PM   cTropnT-0.08*
[**2201-10-19**] 01:30PM   CK-MB-NotDone
[**2201-10-19**] 01:30PM   TOT PROT-7.5 CALCIUM-7.9* PHOSPHATE-5.0*
MAGNESIUM-2.4
[**2201-10-19**] 01:30PM   WBC-22.8*# RBC-2.99* HGB-9.0* HCT-29.9*
MCV-100*# MCH-30.0 MCHC-30.0*# RDW-14.3
[**2201-10-19**] 01:30PM   NEUTS-90* BANDS-3 LYMPHS-3* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-2* MYELOS-0
[**2201-10-19**] 01:30PM   HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-1+ STIPPLED-1+
[**2201-10-19**] 01:30PM   PLT COUNT-447*
[**2201-10-19**] 01:30PM   PT-15.2* PTT-88.5* INR(PT)-1.6
.
EKG: on arrival; atrial fibrillation @ RVR of 140, nl axis, no
ST changes
.
CXR: Marked overdistention of tracheostomy tube cuff, placing
the trachea at risk for perforation and fistula formation.
Probable pleural and parenchymal scarring at the lung bases,
although it
is difficult to fully exclude a pneumonia at the left lung base.

.
CXR [**10-21**]  1. Persistent tracheostomy cuff distention. 2.
Worsening mild congestive heart failure with mild cardiomegaly
and small bilateral pleural effusions.
.
[**2201-10-20**] 12:23 am SPUTUM     Site: ENDOTRACHEAL
   GRAM STAIN (Final [**2201-10-20**]):
      >25 PMNs and <10 epithelial cells/100X field.
      4+   (>10 per 1000X FIELD):   GRAM POSITIVE ROD(S).
      4+   (>10 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS, CHAINS, AND
CLUSTERS.
      4+   (>10 per 1000X FIELD):   GRAM NEGATIVE ROD(S).
NOTE: Culture data pending at time of discharge.
.
[**2201-10-20**] 12:30AM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2201-10-20**] 12:30AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.017
[**2201-10-20**] 12:30AM URINE RBC-21-50* WBC-[**12-6**]* Bacteri-MOD
Yeast-MOD Epi-[**3-21**]
.


Brief Hospital Course:
A/P: 86 y/o female with PMHx significant for
tracheobronchiomalacia and chronic respitory distress with
tracheostomy on chronic vent who presents from [**Hospital3 672**]
in severe respitory distress, afib with RVR, hypotension and
febrile.
.
1. Sepsis:  PNA vs Cdiff.  Pt came in with Positive Cdiff
cultures from OSH.  Cultures sent from [**Hospital1 18**] were subsequently
negative.  Will continue flagyl for complete course.  In
addition, gram stain revealed gram neg rods, gram + cocci in
pairs and cocci and gram + rods.  Speciation pending at time of
discharge.
- Will continue to keep patient on current vent setting and
titrate back to baseline as tolerated.
- Will conitnue vanco/zosyn/flagyl which could cover possible
VAP or aspiration PNA and CDIFF.  Should complete full course of
antibiotics at [**Hospital3 672**].  Vanco and zosyn started [**10-20**]
and flagyl started at OSH should continue until [**10-27**].
- Continue albuterol/atrovent nebs prn
- Patient with resp acidosis, would check daily ABG to make sure
correcting on current vent settings
- [**10-15**] Cdiff positive from [**10-15**] sample drawn at OSH.  Cdiff
negative at [**Hospital1 18**] [**10-20**].
.
2. Yeast infection- From urine cx.  Pulled foley on [**10-21**].
Should recheck U/A at [**Hospital3 672**] on [**10-23**] for persistent
fungal UTI.
.
3. PAF - Patient currently in sinus rhythm, atrial fibrillation
could have been exacerabted by infectious cause.
- Will hold off on BBlocker at this time as BP low.
- Consider repeat cardiovesion if returns back to atrial fib.
- Pt needs to be anticoagulated with Warfarin.  This was
communicated with physician at [**Hospital3 672**] on [**10-21**].
.
4. Acute Renal Failure - Patient with Cre 1.3, last Cre was 1.1
in [**2199**].  Could be ATN secondary to hypotensive episode.
Patient with minimal urine output.  Would continue to monitor
BUN/Cre and K+.  Trending down.  Probably [**2-18**] infection.
.
5. DM  RISS
.
6. Anemia: HCT improved but some guiaic + stool on last day of
admission in setting of heparin.  D/C'd heparin on final night
of admission.  Can reconsider anticoagulation at [**Hospital1 1099**].
.
7. Access: Femoral line
.
8. FEN: Continue IVF to maintain BP and UOP
.
9. PPx: Heparin SC, PPI, bowel regimine
.
10. Code: Full
.
11. Comm with daughter
.
12. Disp: To rehab



Medications on Admission:
1) Lopressor 12.5 [**Hospital1 **]
2) Protonix 40mg qd
3) Modafonil 200mg qd
4) Albuterol 2puff q6 prn
5) Atrovent 2puff q6 prn
6) Heparin SC 5000units [**Hospital1 **]
7) Zoloft 75mg qd
8) Aranesp 25 mcg/qweek
9) Flagyl 500mg tid
10) Aztreonam 1g IV q12
11) Ferrlecit 62.5mg x3/week

Discharge Disposition:
Extended Care

Facility:
[**Hospital3 672**] Hospital

Discharge Diagnosis:
Respiratory Distress/Pneumonia


Discharge Condition:
Stable


Discharge Instructions:
Pls administer all meds as indicated and call with any ?s.  Pt
to complete course of antibiotics with vanco, flagyl and zosyn
through newly place ([**10-21**]) PICC line.

Followup Instructions:
At OSH
{'Unspecified septicemia,Acute and chronic respiratory failure,Pneumonia, organism unspecified,Acute kidney failure, unspecified,Atrial fibrillation,Intestinal infection due to Clostridium difficile,Chronic airway obstruction, not elsewhere classified,Mitral valve disorders,Severe sepsis,Tracheostomy status,Candidiasis of other urogenital sites,Unspecified essential hypertension'}


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: Respiratory distress

PRESENT ILLNESS: HPI: 86 year old female with tracheobronchiomalacia and chronic
respitory distress vent dependent, h/o UTI, h/o aspiration PNA,
DM type2, MR who presents from OSH after difficulty with
ventilation and found to have rapid atrial fibrillation. Patient
found at OSH to be in severe respitory distress with minimal.
EKG done which showed afib with RVR of 140-170. Patient given
solumedral 125mg and lasix 20mg at OSH for concern of CHF.
Patient transferred to ED were found to be in rapid afib,
hypotensive to SBP 60s and hypoxic with O2Sat in 80s. Patient
was cardioverted in the ED and returned to sinus rhythm,
decrease in HR and increase in BP. Patient given 4L IVF in the
ED with minimal urine output. Patient was also found to be
febrile with temp 104. Given flagyl,vanco,ceftriaxone in the ED.
On CXR in ED found that there was an overdistension of
tracheostomy cuff which was reduced in the ED.

MEDICAL HISTORY: 1. Diabetes mellitus type 2.
2. Hypertension.
3. Tracheobronchiomalacia
4. Anemia.
5. Moderate to severe mitral regurgitation.
6. PAF
7. COPD
8. CVA
9. C. diff being treated at OSH with flagyl and aztreonam

MEDICATION ON ADMISSION: 1) Lopressor 12.5 [**Hospital1 **]
2) Protonix 40mg qd
3) Modafonil 200mg qd
4) Albuterol 2puff q6 prn
5) Atrovent 2puff q6 prn
6) Heparin SC 5000units [**Hospital1 **]
7) Zoloft 75mg qd
8) Aranesp 25 mcg/qweek
9) Flagyl 500mg tid
10) Aztreonam 1g IV q12
11) Ferrlecit 62.5mg x3/week

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 104.2 HR 90-107 BP 96-100/34 RR 27 O2Sat 100% on vent. CMV
Vt450x RR 26 PEEP 6 FiO2 40%
Gen: Patient attached to vent via tracheostomy. Spontaneously
moving LE B/L. Patient responds to painful stimuli.
Heent: Pupils pinpoint, unable to get movement, MMM
Lungs: Course BS ant/lat, good airway entry
Cardiac: RRR S1/S2 hol
Abd: distended, decreased BS
Ext: no edema
Neuro: repsonsive to painful stimuli

FAMILY HISTORY: The patient is currently a resident at
[**Hospital3 672**] Hospital. No known tobacco or drug use

SOCIAL HISTORY: Unknown 

### Response:
{'Unspecified septicemia,Acute and chronic respiratory failure,Pneumonia, organism unspecified,Acute kidney failure, unspecified,Atrial fibrillation,Intestinal infection due to Clostridium difficile,Chronic airway obstruction, not elsewhere classified,Mitral valve disorders,Severe sepsis,Tracheostomy status,Candidiasis of other urogenital sites,Unspecified essential hypertension'}
