CHIEF COMPLAINT: Fever, SOB, cough

PRESENT ILLNESS: 67 y/o F with a h/o HTN, T2DM, and hyperlipidemia who presented
to the ED with a 4 day h/o cough, SOB, and fever. Of note, the
patient recently returned from a trip to [**Country 3587**] to visit
relatives. The patient had been living in [**State 108**] for several
years and recently moved to the [**Location (un) 86**] area. She flew back from
[**Country 3587**] this past Friday and began to feel unwell on the
following Saturday. She had a productive cough of pink, frothy
sputum. She also had a fever at home (no exact measurement). She
also reported myalgias and decreased PO intake. She presented to
the ED for further evaluation of her symptoms.

MEDICAL HISTORY: 1. T2DM
2. HTN
3. Hyperlipidemia

MEDICATION ON ADMISSION: Lisinopril 40 mg PO daily
Tylenol PRN
Ibuprofen PRN
Ambien PRN
Metformin 500 mg PO BID
Crestor 20 mg PO daily
Atenolol 50 mg PO daily
ASA 81 mg PO daily

ALLERGIES: Penicillins

PHYSICAL EXAM: On transfer from MICU:

FAMILY HISTORY: NC

SOCIAL HISTORY: No tobacco or ethanol use
Unspecified septicemia,Acute respiratory failure,Septic shock,Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Acute kidney failure, unspecified,Atrial fibrillation,Rhabdomyolysis,Acute and subacute necrosis of liver,Severe sepsis,Critical illness myopathy,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled
Septicemia NOS,Acute respiratry failure,Septic shock,Pneumococcal pneumonia,Acute kidney failure NOS,Atrial fibrillation,Rhabdomyolysis,Acute necrosis of liver,Severe sepsis,Critical illness myopthy,Hypertension NOS,DMII wo cmp nt st uncntr
Admission Date:  [**2145-9-6**]              Discharge Date:   [**2145-9-23**]

Date of Birth:  [**2077-10-8**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Fever, SOB, cough

Major Surgical or Invasive Procedure:
Endotrachial intubation
Bronchoscopy
Foley catheter placement
Left subclavian line placement

History of Present Illness:
67 y/o F with a h/o HTN, T2DM, and hyperlipidemia who presented
to the ED with a 4 day h/o cough, SOB, and fever. Of note, the
patient recently returned from a trip to [**Country 3587**] to visit
relatives. The patient had been living in [**State 108**] for several
years and recently moved to the [**Location (un) 86**] area. She flew back from
[**Country 3587**] this past Friday and began to feel unwell on the
following Saturday. She had a productive cough of pink, frothy
sputum. She also had a fever at home (no exact measurement). She
also reported myalgias and decreased PO intake. She presented to
the ED for further evaluation of her symptoms.


Past Medical History:
1. T2DM
2. HTN
3. Hyperlipidemia

Social History:
No tobacco or ethanol use

Family History:
NC

Physical Exam:
On transfer from MICU:

Vitals: T 98.4 HR 81 BP 115/44 RR 22 94-100% on 2L NC
General: 67 F in NAD
HEENT: NC/AT. MM moist. OP clear.
Neck: No JVD.
CV: Regular rhythm. nl s1, s2; No m/r/g.
Pulm: CTAB, mildly decreased BS RUL.
Abd: Soft, non-distended, non-tender, with normoactive BS.
Ext: Feet cool. 2+ DP's bilaterally. 2+ edema around ankles
bilaterally, 1+ edema in UEs around wrists.
Skin: No rash.
Neuro: A/O x 3. Strength and sensation intact throughout.
Access: Left subclavian in place


Pertinent Results:
Initial Labs ([**9-6**]):

WBC 17.5 Hb 13.6 Hct 39.8 Plt 233
Diff - 66N + Dohle bodies, 21 Bands, 10 lymphs

NA 135 Chloride 96 BUn 41 Glucose 224
K 4.1  Bicarb 26   Cr 2.1

Lactate 3.0

Ck 1297 CK MB 7 Trop T < 0.01

ABG 7.29/53/83 21:07 [**9-6**]

ABG 7.26/63/70 06:00 [**9-7**]

Mixed Venous  7.43/55/169 [**9-16**]

Fe studies:
Iron 81 ug/dL 30 - 160
Iron Binding Capacity, Total 252* ug/dL 260 - 470
Ferritin 513* ng/mL 13 - 150
Transferrin 194* mg/dL 200 - 360

Micro:
BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL; LEGIONELLA CULTURE-FINAL; FUNGAL
CULTURE-PRELIMINARY; ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PENDING

CMV, EBV negative
Legionella negative
Mycoplasma IgG, IGM negative
Multiple blood culture, urine culture, respiratory culture
negative

Imaging:

[**9-6**] PA and Lateral: CHEST, TWO VIEWS: There is dense
opacification of the right upper lung with associated air
bronchograms. There is thickening of the right minor fissure
likely due to a small amount of fluid in the fissure. The right
posterior costophrenic sulcus is blunted consistent with a small
pleural effusion. The left lung is clear. The heart size is
normal. The aorta is tortuous.
IMPRESSION: Dense opacification of the right upper lobe, likely
representing a lobar pneumonia. An endobronchial obstructing
lesion cannot be excluded on these radiographs. Followup imaging
after treatment is suggested.

[**9-7**] ECHO Conclusions:
The left atrium is mildly dilated. There is mild symmetric left
ventricular
hypertrophy with normal cavity size and regional/global systolic
function
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion
abnormality cannot be fully excluded. The aortic valve leaflets
(3) are mildly thickened. There is no aortic valve stenosis. No
aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral

regurgitation. There is no mitral valve prolapse. The pulmonary
artery
systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved left ventricular systolic function. Mild valvular
thickening with no signifcant stenosis or regurgitation.

[**9-21**] PA and lateral chest compared to [**9-14**] through [**9-18**]:
A small amount of volume loss persists in the right upper lobe.
There is no good evidence of recurrent pneumonia. Mild
cardiomegaly is stable. Mediastinal vascular engorgement has
improved.
There is an unusual configuration to gas shadows in the upper
abdominal midline, probably unusual displacement of the gastric
antrum. If patient has referable symptoms to abdominal pathology
I would reevaluate with routine abdominal radiographs.
Tip of the left subclavian line projects over the upper SVC. No
pneumothorax. Medical student [**Last Name (un) 71534**] and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4887**]
were both paged to report these findings at the time of
dictation.


Brief Hospital Course:
In the ED, her vital signs were T 99.9 HR 120 BP 114/50 RR 32
95%NRB.  A chest x-ray [**Last Name (un) **] da RUL pneumonia, and ECG showed
afib with RVR. Her lactate was 3.0 and creatinine 2.1. She was
pan-cultured, given a dose of antibiotics, and transferred to
the MICU for presumed septic shock.
.
# Respiratory failure/Septic Shock:
In the MICU she quickly went into severe hypoxic hypercarbic
failure (7.26/59/63 on NRB) requiring intubation. She became
hypotensive, requiring transient pressors and a total of 13
liters net volume resuscitation. Culture data including EBV,
CMV, and TB were consistently negative, even after bronchoscopy.
She completed a ten day course of ceftriaxone and azithromycin,
but was also on vancomycin. By chest x-ray, her consolidation
resolved quickly after 5 days (post-bronchoscopy for cultures),
suggesting increased secretions were a major component of her
pulmonary dysfunction. She had a prolonged intubation ([**Date range (1) **])
with hypoxia during spontaneous breathing trials for many days.
She was extubated on [**9-18**] with steadily decreasing secretions and
O2 requirements.  She had an O2 requirement for 1-2 days on the
floor that improved with incentive spirometry and walking with
PT.
.
# Rhabdomyolysis
Upon presentation in the MICU, her CK was 1297 with large blood
and few RBCs in the urine suspicious for rhabdomyolysis. Her
troponins wer negative. Her CPKs peaked at [**Numeric Identifier 6235**] on [**9-15**] along
with transaminases in the 300's. She was treated by aggressive
volume resuscitation and lasix to achieve UO > 100cc/hr. She
never had any bump in her creatinine. Her last CK [**9-20**] was 3000,
and she continued to have a stable creatinine until discharge.
.
# Atrial fibrillation
The patient's MICU course was also complicated by atrial
fibrillation for 3-4 days not properly rate controlled on
metoprolol or diltiazem. Echocardiography showed a normal heart
with LVH and preserved EF (>55%). She was therefore begun on an
amiodarone drip, leading to documented conversion on [**9-10**], after
which the drip was D/Ced. She was anticoagulated for a total of
5 days.  In discussions with the cardiology consult service, it
was felt that the transient risk factor for atrial fibrillation
(septic shock) had resolved and that long-term anticoagulation
would not be warranted. She remained in sinus rhythm for 9 days
on telemetry after her cardioversion, after which telemetry was
discontinued. She reported no palpitations at any point in her
stay.
.
# Weakness
Ms. [**Known lastname 1001**] was initially weak while recovering from her extesnive
MICU course. She improved rapidly with hospital PT, however, and
was felt safe for discharge with home PT services to aid her
recovery.
.
# Anemia
She had a labile hematocrit during this admission, likely
consistent with a dilutional effect from high volume
resuscitation.  On discharge, she has borderline macrocytic
anemia with near-appropriate reticulocyte production and Fe
studies consistent with anemia of chronic disease. She was
guaiac negative. Further w/u as an outpt may be clinically
indicated.
.
# Hypertension
Her blood pressure was titrated with IV beta-blocker in the MICU
and switched oiver to PO beta-blocker once the patient was
taking good POs. ACE-I was D/Ced out of concern for renal
toxicity while rhabdomyolysis resolving.  Pt discharged on
stable regimen of metoprolol 75mg [**Hospital1 **] with BPs in the 120s -130s
except before morning meds. Outpt resumption of ACE-I can be
considered for this hypertensive patient with diabetes mellitus.
.
# DM2
Pt was on humalog sliding scale during the majority of this
admission. She was restarted on Metformin before discharge, and
had FSBG in the 100s without humalog support. Pt reports she ahs
always had normal blood sugars on metformin, and so she was sent
home on her home regimen.
.
#Hyperlipidemia
Crestor was held durign this admission out of concern for
potentially exacerbating rhabdomyolysis. Resumption of a statin
as an outpatient is likely clinically indicated.
.
# Nasal congestion
Ms. [**Known lastname 1001**] complained of nasal congestion post-intubation, which
was initially treated with Afrin x 3 days. She was sent home
with Ocean nasal spray.
.
The patient was discharged in good condition on [**2145-9-23**].

Medications on Admission:
Lisinopril 40 mg PO daily
Tylenol PRN
Ibuprofen PRN
Ambien PRN
Metformin 500 mg PO BID
Crestor 20 mg PO daily
Atenolol 50 mg PO daily
ASA 81 mg PO daily

Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for Pain.
2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
3. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*0*
4. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
5. Ocean Nasal 0.65 % Spray, Non-Aerosol Sig: Two (2) sprays
Nasal twice a day: each nostril.
Disp:*1 bottle* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
Americare at Home Inc

Discharge Diagnosis:
Primary:
Lobar pneumonia
Hypoxic and hypercarbic respiratory failure
Septic shock
Rhabdomyolysis
Atrial fibrillation
Critical illness myopathy

Secondary:
Hypertension
Diabetes mellitus type 2 controlled


Discharge Condition:
good. tolerating oral medications and nutrition. ambulating
without assist on room air.


Discharge Instructions:
You have been evaluated and treated for a severe pneumonia.
Your course was complicated by severe breathing difficutly
requiring a breathing machine to temporarily support your
breathing.  Also, there was evidence of temporary muscle
breakdown that was resolving by the time of discharge.  During
the most severe period of your illness, you developed a rapid
irregular heartbeat.  As this resolved as you recovered, no
direct therapy was started for this heartbeat.  Should you
notice a return of your irregular heartbeat, you should contact
your doctor as soon as possible.

Please take the medications as prescribed.
Some of your medications have been changed. You may want to
re-address these medications with your PCP at your next
appointment.

Please attend the recommended follow-up appointments.

Please continue to practice incentive spirometery at home until
your appointment with your PCP.

If you develop any new or concerning symptom such as shortness
of breath, chest pain, fevers to greater than 101F, or a fast
irregular heartbeat; please seek medical attention as soon as
possible.

Followup Instructions:
Primary care physician: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] 11:45AM Friday [**10-1**] [**Doctor Last Name 50531**]Health Center [**Telephone/Fax (1) 7976**]
{'Unspecified septicemia,Acute respiratory failure,Septic shock,Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Acute kidney failure, unspecified,Atrial fibrillation,Rhabdomyolysis,Acute and subacute necrosis of liver,Severe sepsis,Critical illness myopathy,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}


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: Fever, SOB, cough

PRESENT ILLNESS: 67 y/o F with a h/o HTN, T2DM, and hyperlipidemia who presented
to the ED with a 4 day h/o cough, SOB, and fever. Of note, the
patient recently returned from a trip to [**Country 3587**] to visit
relatives. The patient had been living in [**State 108**] for several
years and recently moved to the [**Location (un) 86**] area. She flew back from
[**Country 3587**] this past Friday and began to feel unwell on the
following Saturday. She had a productive cough of pink, frothy
sputum. She also had a fever at home (no exact measurement). She
also reported myalgias and decreased PO intake. She presented to
the ED for further evaluation of her symptoms.

MEDICAL HISTORY: 1. T2DM
2. HTN
3. Hyperlipidemia

MEDICATION ON ADMISSION: Lisinopril 40 mg PO daily
Tylenol PRN
Ibuprofen PRN
Ambien PRN
Metformin 500 mg PO BID
Crestor 20 mg PO daily
Atenolol 50 mg PO daily
ASA 81 mg PO daily

ALLERGIES: Penicillins

PHYSICAL EXAM: On transfer from MICU:

FAMILY HISTORY: NC

SOCIAL HISTORY: No tobacco or ethanol use 

### Response:
{'Unspecified septicemia,Acute respiratory failure,Septic shock,Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Acute kidney failure, unspecified,Atrial fibrillation,Rhabdomyolysis,Acute and subacute necrosis of liver,Severe sepsis,Critical illness myopathy,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}
