CHIEF COMPLAINT: aspiration

PRESENT ILLNESS: This is a [**Age over 90 **] yo female with history of severe COPD on home
oxygen(4L), diastolic heart failure, and kyphoscoliosis who was
recently discharged to [**Hospital1 **] after admission for aspiration
pna/pneumonitis who now presents with increasing shortness of
breath after aspirating. She was being treated at her [**Hospital 4382**] for Pneumonia with Vanc/Zosyn through PICC, however she
had an aspiration event during dinner, unable to take meds and
possibly in need of NG tube prompting transfer to the ED. There
she was placed on a NRB and unable to wean down, so admitted to
ICU.

MEDICAL HISTORY: Diastolic Heart Failure
Atrial Fibrillation on coumadin
Remote h/o TIAs
COPD on home O2 (3-4L at baseline)
Scoliosis
Osteoarthritis
L hip/R pelvis fx managed nonoperatively
Recent LLE cellulitis
Anxiety
Chronic Anemia (baseline hct 32)

MEDICATION ON ADMISSION: Heparin 5,000 U TID
Famotidine 20 mg daily
Ipratropium Nebs Q6H.
Digoxin 125 mcg EVERY OTHER DAY
Buspirone 10 mg TID
Citalopram 20 mg DAILY
Ferrous Gluconate 325 mg DAILY
Senna 8.6 mg HS
Bisacodyl 10 mg daily
Metoprolol Tartrate 12.5 mg [**Hospital1 **]
Ascorbic Acid 500 mg Daily
Albuterol Neb Q4H PRN SOB, wheezing.
Prednisone 20 mg daily
Aspirin 325 mg DAILY
Furosemide 40 mg DAILY
Furosemide 60 mg Q4PM.
Vancomycin 1000 mg IV Q48H First dose [**2196-5-4**]
Piperacillin-Tazobactam 2.25 g IV Q6H First dose [**2196-5-4**]
Ondansetron 4 mg IV Q8H:PRN nausea
Cardizem CD 180 mg Daily.
Insulin Lispro QACHS: sliding scale, w/ meals start at BS 160 -
2units, go up by 2 units for every increase in 40 of BS. At HS,
start at BS 200 same scale.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 96.7 BP: 113/61 P: 89  R: 14  O2: 100% on NRB
General: Easily arousible, follows commands, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple
Lungs: Diminished breath sounds on Right side, but otherwise
clear.
CV: Irregularly irreg, 2/6 SEM at LUSB
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: 2+ pulses, no clubbing, cyanosis. No edema at ankles.
Neuro: Asking questions, AOx2.

FAMILY HISTORY: Positive for hypertension and type II diabets.  Given age
non-contributory to current illness.

SOCIAL HISTORY: From chart, limited [**12-28**] BIPAP Lives at nursing home.  Ambulates
with a walker at baseline.  Alert and oriented x 3 at baseline.
On home oxygen 3-4L.  Past smoker but quit 30 years ago.  No
ethanol or illict drugs.  Son and daughter live nearby and are
involved.
Pneumonitis due to inhalation of food or vomitus,Acute on chronic diastolic heart failure,Chronic obstructive asthma with (acute) exacerbation,Pulmonary collapse,Other persistent mental disorders due to conditions classified elsewhere,Anxiety state, unspecified,Atrial fibrillation,Long-term (current) use of anticoagulants,Scoliosis [and kyphoscoliosis], idiopathic,Unspecified late effects of cerebrovascular disease,Anemia, unspecified,Personal history of tobacco use,Surgical or other procedure not carried out because of contraindication
Food/vomit pneumonitis,Ac on chr diast hrt fail,Ch obst asth w (ac) exac,Pulmonary collapse,Mental disor NEC oth dis,Anxiety state NOS,Atrial fibrillation,Long-term use anticoagul,Idiopathic scoliosis,Late effect CV dis NOS,Anemia NOS,History of tobacco use,No proc/contraindication
Admission Date:  [**2196-5-10**]              Discharge Date:   [**2196-5-13**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
aspiration

Major Surgical or Invasive Procedure:
None

History of Present Illness:
This is a [**Age over 90 **] yo female with history of severe COPD on home
oxygen(4L), diastolic heart failure, and kyphoscoliosis who was
recently discharged to [**Hospital1 **] after admission for aspiration
pna/pneumonitis who now presents with increasing shortness of
breath after aspirating. She was being treated at her [**Hospital 4382**] for Pneumonia with Vanc/Zosyn through PICC, however she
had an aspiration event during dinner, unable to take meds and
possibly in need of NG tube prompting transfer to the ED. There
she was placed on a NRB and unable to wean down, so admitted to
ICU.

In the ED, initial vs were: T 100.3 HR 89 afib BP 118/72 RR 28
POx 100% on NRB. CXR showed worsening Right effusion and [**Name6 (MD) **]
[**Name8 (MD) **] MD, family would be okay with feeding tube in setting
of chronic aspiration.

On floor she appears comfortable on 100% face mask.  She denies
SOB and does not recall why she is here.  She is confused when
we attempt to explain what has happened and cannot re-iterate
the consequences of chronic aspiration or a PEG tube when
explained to her.

Review of systems:
(+) She does state she has some belly pain and has not stooled
in several days.
(-) Denies chest pain, nausea, vomiting, diarrhea.


Past Medical History:
Diastolic Heart Failure
Atrial Fibrillation on coumadin
Remote h/o TIAs
COPD on home O2 (3-4L at baseline)
Scoliosis
Osteoarthritis
L hip/R pelvis fx managed nonoperatively
Recent LLE cellulitis
Anxiety
Chronic Anemia (baseline hct 32)

Social History:
From chart, limited [**12-28**] BIPAP Lives at nursing home.  Ambulates
with a walker at baseline.  Alert and oriented x 3 at baseline.
On home oxygen 3-4L.  Past smoker but quit 30 years ago.  No
ethanol or illict drugs.  Son and daughter live nearby and are
involved.


Family History:
Positive for hypertension and type II diabets.  Given age
non-contributory to current illness.

Physical Exam:
Vitals: T: 96.7 BP: 113/61 P: 89  R: 14  O2: 100% on NRB
General: Easily arousible, follows commands, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple
Lungs: Diminished breath sounds on Right side, but otherwise
clear.
CV: Irregularly irreg, 2/6 SEM at LUSB
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: 2+ pulses, no clubbing, cyanosis. No edema at ankles.
Neuro: Asking questions, AOx2.

Pertinent Results:
[**2196-5-10**] 10:17PM   PT-16.0* PTT-31.3 INR(PT)-1.4*
[**2196-5-10**] 12:32PM   PO2-54* PCO2-68* PH-7.46* TOTAL CO2-50* BASE
XS-20 COMMENTS-GREEN TOP
[**2196-5-10**] 12:32PM   LACTATE-1.7
[**2196-5-10**] 12:25PM   GLUCOSE-77 UREA N-26* CREAT-1.0 SODIUM-140
POTASSIUM-3.6 CHLORIDE-91* TOTAL CO2-47* ANION GAP-6*
[**2196-5-10**] 12:25PM   DIGOXIN-0.9
[**2196-5-10**] 12:25PM   WBC-9.3 RBC-3.26* HGB-9.6* HCT-30.1* MCV-92
MCH-29.4 MCHC-31.9 RDW-17.6*
[**2196-5-10**] 12:25PM   NEUTS-91.0* LYMPHS-6.3* MONOS-2.2 EOS-0.4
BASOS-0.1
[**2196-5-10**] 12:25PM   PLT COUNT-173
.
[**2196-5-10**] CXR - poor baseline with kyphoscoliosis, interval
increase in right sided effusion, increased pulmonary vascular
congestion as compared w/ prior, final read pending
.
EKG: A-fib rate 96, nl axis, LVH, old TWI in lateral leads,
unchaged from prior.
.
BEDSIDE SWALLOW EVAL:
1. Suggest determining goals of care with planned family
meeting.
2. If the family wishes to continue to allow the pt to eat,
understanding the risks of intermittent aspiration, I would
suggest the following:
a) PO diet of thin liquids and moist ground solids
b) strict supervision for meals- pt needs to be fed to reduce
risk of aspiration
c) slow rate of increase - take breaks during intake to allow RR
to return to baseline
d) take down high flow mask and then return after each bite and
sip
e) pills crushed with puree
f) alternate between bites and sips
g) sit upright for 30 minutes after meals
3. If the family wishes to get a more objective view of her
swallowing, we can certainly take her for a video swallow, but I
do not feel it will be representative of a full meal and may not
reveal the occasional aspiration episodes that are occurring.


Brief Hospital Course:
# Aspiration: Patient with known chronic aspiration risk, unable
to take PO meds at [**Hospital1 **].  She gets confused during attempts
to explain what has happened during her aspiration events likely
due to her baseline dementia. Had S&S study in [**3-3**] with
recommendation for soft dysphagia diet. HCP and grandson met
with palliative care, social work, and with ICU team regarding
peg tube placement. Decided NO PEG tube but are not ready to
make decision re: no further hospitalizations/hospice.

# Hypoxia/Hypercarbia - Baseline PO2 in 60s with PCO2 in 70s.
Etiology is most likely worsening right pleural effusion vs.
aspiration pneumonitis/pneumonia. Underlying COPD,
kyphoscoliosis contributing. ABG with improved hypercarbia from
baseline - PCO2 68. Had lactate of 1.7.  Was receiving coverage
for health-care associated with vanc/zosyn (Day 1=[**2196-5-4**] on
previous admission).  We continued these abx here and she
remained afebrile. Was kept on Non-invasive ventilation when
sleeping to keep sats 89-92%.
- Vanc and Zosyn to end on [**2196-5-15**]

# COPD  and restrictive lung disease from severe
scoliosis/kyphosis on home O2 (3-4L at baseline): On admission
bicarb was at her baseline suggesting no CO2 retention.
She was continued on atrovent/albuterol nebs.

# A fib on coumadin: Last INR was [**2196-5-6**] 2.3 and she was
initially rate-controlled although off home beta blocker she had
HRs in 100s. She was restarted on Diltiazem with good rate
control.  Long-term anticoagulation with coumadin would not be
beneficial, so she was kept on a full dose aspirin.

# Acute on chronic Diastolic heart failure: ECHO from [**10/2195**]
showed EF of 70-80% with Mild PAH and significant pulmonic
regurg. IV lasix was given PRN while NPO.

# Prophylaxis: Subcutaneous heparin

# Goals of Care: The family will discuss further what things
would constitute most
important "quality of life" for Ms. [**Known lastname 54770**], and clinical plans
will be guided by that.  For now she will continue IV
antibiotics, other meds as needed for her chronic illnesses, and
efforts will be made to wean her from the mask that she does not
like.

# Code: DNR/DNI per nursing home records and confirmed with HCP
# Communication: [**Name (NI) **] (son/power of attorney)
[**Telephone/Fax (5) 81861**]. [**Doctor First Name **] (daughter)
[**Telephone/Fax (3) 81862**], [**Doctor First Name 1494**] (daughter): [**Telephone/Fax (1) 81863**].


Medications on Admission:
Heparin 5,000 U TID
Famotidine 20 mg daily
Ipratropium Nebs Q6H.
Digoxin 125 mcg EVERY OTHER DAY
Buspirone 10 mg TID
Citalopram 20 mg DAILY
Ferrous Gluconate 325 mg DAILY
Senna 8.6 mg HS
Bisacodyl 10 mg daily
Metoprolol Tartrate 12.5 mg [**Hospital1 **]
Ascorbic Acid 500 mg Daily
Albuterol Neb Q4H PRN SOB, wheezing.
Prednisone 20 mg daily
Aspirin 325 mg DAILY
Furosemide 40 mg DAILY
Furosemide 60 mg Q4PM.
Vancomycin 1000 mg IV Q48H First dose [**2196-5-4**]
Piperacillin-Tazobactam 2.25 g IV Q6H First dose [**2196-5-4**]
Ondansetron 4 mg IV Q8H:PRN nausea
Cardizem CD 180 mg Daily.
Insulin Lispro QACHS: sliding scale, w/ meals start at BS 160 -
2units, go up by 2 units for every increase in 40 of BS. At HS,
start at BS 200 same scale.


Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. Famotidine 20 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO twice a day.
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO every other
day.
5. Buspirone 10 mg Tablet Sig: One (1) Tablet PO three times a
day.
6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. Ferrous Gluconate 325 mg Tablet Sig: One (1) Tablet PO once a
day.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
10. Diltiazem HCl 30 mg Tablet Sig: 1.5 Tablets PO QID (4 times
a day).
11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a
day.
12. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization
Sig: [**11-27**] neb Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
13. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO once a
day.
14. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
15. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day.
16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
17. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO QPM.
18. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gm Intravenous Q 24H (Every 24 Hours) for 2 days: to end on
[**2196-5-15**].
19. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: 2.25 grams
Intravenous Q6H (every 6 hours) for 2 days: To end on [**2196-5-15**].
20. Ondansetron 4 mg IV Q8H:PRN nausea
21. Insulin Lispro 100 unit/mL Solution Sig: as directed units
Subcutaneous QACHS: Insulin Lispro QACHS: sliding scale, w/
meals start at BS 160 -
2units, go up by 2 units for every increase in 40 of BS. At HS,
start at BS 200 same scale.
22. Lorazepam 2 mg/mL Syringe Sig: 0.5 mg Injection Q6H (every 6
hours) as needed for agitation.
23. Polyethylene Glycol 3350 100 % Powder Sig: Seventeen (17) gm
PO DAILY (Daily) as needed for constipation.
24. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Health Care Center

Discharge Diagnosis:
Primary:
- Chronic aspiration
- Aspiration pneumonia
- COPD/resrictive lung disease


Discharge Condition:
Hemodynamically stable, on stable O2 requirement of [**1-27**] L with
CPAP at night.


Discharge Instructions:
You came to the hospital after an aspiration event and possible
need for a PEG tube.  It was decided that a PEG tube would not
prevent aspiration and would be an unnecessary risk.  YOU ARE AT
HIGH RISK FOR CONTINUED INTERMITENT ASPIRATION.  You had a
swallow evaluation and we recommend the following:
a) PO diet of thin liquids and moist ground solids
b) strict supervision for meals- pt needs to be fed to reduce
risk of aspiration
c) slow rate of increase - take breaks during intake to allow RR
to return to baseline
d) take down high flow mask and then return after each bite and
sip
e) pills crushed with puree
f) alternate between bites and sips
g) sit upright for 30 minutes after meals
.
Medication changes:
- Your cardizem was changed to short acting diltiazem
- Your prednisone was weaned to 10 mg daily.
- You should continue the Vanc/Zosyn until [**2196-5-15**].
.
Please call your doctor or return to the ED if you have
shortness of breath, fevers, chills, chest pain, abdominal pain,
nausea, vomiting or other concerns.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:

Followup Instructions:
Please see your [**First Name8 (NamePattern2) **] [**Last Name (Titles) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 608**] in the next
1-2 weeks.



Completed by:[**2196-5-13**]
{'Pneumonitis due to inhalation of food or vomitus,Acute on chronic diastolic heart failure,Chronic obstructive asthma with (acute) exacerbation,Pulmonary collapse,Other persistent mental disorders due to conditions classified elsewhere,Anxiety state, unspecified,Atrial fibrillation,Long-term (current) use of anticoagulants,Scoliosis [and kyphoscoliosis], idiopathic,Unspecified late effects of cerebrovascular disease,Anemia, unspecified,Personal history of tobacco use,Surgical or other procedure not carried out because of contraindication'}


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: aspiration

PRESENT ILLNESS: This is a [**Age over 90 **] yo female with history of severe COPD on home
oxygen(4L), diastolic heart failure, and kyphoscoliosis who was
recently discharged to [**Hospital1 **] after admission for aspiration
pna/pneumonitis who now presents with increasing shortness of
breath after aspirating. She was being treated at her [**Hospital 4382**] for Pneumonia with Vanc/Zosyn through PICC, however she
had an aspiration event during dinner, unable to take meds and
possibly in need of NG tube prompting transfer to the ED. There
she was placed on a NRB and unable to wean down, so admitted to
ICU.

MEDICAL HISTORY: Diastolic Heart Failure
Atrial Fibrillation on coumadin
Remote h/o TIAs
COPD on home O2 (3-4L at baseline)
Scoliosis
Osteoarthritis
L hip/R pelvis fx managed nonoperatively
Recent LLE cellulitis
Anxiety
Chronic Anemia (baseline hct 32)

MEDICATION ON ADMISSION: Heparin 5,000 U TID
Famotidine 20 mg daily
Ipratropium Nebs Q6H.
Digoxin 125 mcg EVERY OTHER DAY
Buspirone 10 mg TID
Citalopram 20 mg DAILY
Ferrous Gluconate 325 mg DAILY
Senna 8.6 mg HS
Bisacodyl 10 mg daily
Metoprolol Tartrate 12.5 mg [**Hospital1 **]
Ascorbic Acid 500 mg Daily
Albuterol Neb Q4H PRN SOB, wheezing.
Prednisone 20 mg daily
Aspirin 325 mg DAILY
Furosemide 40 mg DAILY
Furosemide 60 mg Q4PM.
Vancomycin 1000 mg IV Q48H First dose [**2196-5-4**]
Piperacillin-Tazobactam 2.25 g IV Q6H First dose [**2196-5-4**]
Ondansetron 4 mg IV Q8H:PRN nausea
Cardizem CD 180 mg Daily.
Insulin Lispro QACHS: sliding scale, w/ meals start at BS 160 -
2units, go up by 2 units for every increase in 40 of BS. At HS,
start at BS 200 same scale.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 96.7 BP: 113/61 P: 89  R: 14  O2: 100% on NRB
General: Easily arousible, follows commands, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple
Lungs: Diminished breath sounds on Right side, but otherwise
clear.
CV: Irregularly irreg, 2/6 SEM at LUSB
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: 2+ pulses, no clubbing, cyanosis. No edema at ankles.
Neuro: Asking questions, AOx2.

FAMILY HISTORY: Positive for hypertension and type II diabets.  Given age
non-contributory to current illness.

SOCIAL HISTORY: From chart, limited [**12-28**] BIPAP Lives at nursing home.  Ambulates
with a walker at baseline.  Alert and oriented x 3 at baseline.
On home oxygen 3-4L.  Past smoker but quit 30 years ago.  No
ethanol or illict drugs.  Son and daughter live nearby and are
involved. 

### Response:
{'Pneumonitis due to inhalation of food or vomitus,Acute on chronic diastolic heart failure,Chronic obstructive asthma with (acute) exacerbation,Pulmonary collapse,Other persistent mental disorders due to conditions classified elsewhere,Anxiety state, unspecified,Atrial fibrillation,Long-term (current) use of anticoagulants,Scoliosis [and kyphoscoliosis], idiopathic,Unspecified late effects of cerebrovascular disease,Anemia, unspecified,Personal history of tobacco use,Surgical or other procedure not carried out because of contraindication'}
