CHIEF COMPLAINT: Shortness of breath.

PRESENT ILLNESS: The patient is a 77-year-old
female nursing home resident who reportedly developed acute
onset of shortness of breath on the morning of admission.
Her oxygen saturation was found to be 77% on room air and
increased to 88% with 2 or 3 L of oxygen by nasal cannula.
The patient was also found to be diaphoretic and was sent to
the [**Hospital6 256**] Emergency Department
for further evaluation.

MEDICAL HISTORY: 1.  Atrial fibrillation.  2.  Prior
cerebrovascular accident complicated by aphasia.  3.
Congestive heart failure.  4.  Depression.  5.  Hypertension.
6.  Dementia.

MEDICATION ON ADMISSION: 

ALLERGIES: NO KNOWN DRUG ALLERGIES.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient is a nursing home resident.  Her
brother lives in [**Name (NI) 108**].  She has two nieces that live in
the [**Location (un) 86**] area.
Pneumonia, organism unspecified,Acute respiratory failure,Atrial fibrillation,Congestive heart failure, unspecified,Urinary tract infection, site not specified,Hyperosmolality and/or hypernatremia,Cerebral artery occlusion, unspecified with cerebral infarction,Unspecified essential hypertension
Pneumonia, organism NOS,Acute respiratry failure,Atrial fibrillation,CHF NOS,Urin tract infection NOS,Hyperosmolality,Crbl art ocl NOS w infrc,Hypertension NOS
Admission Date:  [**2178-12-21**]       Discharge Date:  [**2178-12-29**]

Date of Birth:   [**2101-4-19**]       Sex:  F

Service:  ACOVE

CHIEF COMPLAINT:  Shortness of breath.

HISTORY OF PRESENT ILLNESS:  The patient is a 77-year-old
female nursing home resident who reportedly developed acute
onset of shortness of breath on the morning of admission.
Her oxygen saturation was found to be 77% on room air and
increased to 88% with 2 or 3 L of oxygen by nasal cannula.
The patient was also found to be diaphoretic and was sent to
the [**Hospital6 256**] Emergency Department
for further evaluation.

In the Emergency Department, a head CT demonstrated a
moderate sized subacute to chronic-appearing infarct of the
left parietal lobe, fairly prominent supratentorial
hydrocephalus, somewhat nodular-appearing LMCA, and
considerable thickening within the anterior aspect of the
left nasal cavity.

A chest x-ray demonstrated cardiomegaly and pulmonary
vascular congestion, so the patient was given Furosemide 40
mg IV.  Following diuresis, her respiratory rate decreased,
and her oxygen saturation improved to the mid 90s on 6 L of
oxygen by nasal cannula.

She was subsequently given Metoprolol 5 mg IV for a blood
pressure of 181/106; she also received 1 in of Nitropaste and
an Aspirin.

She was transferred to the floor after receiving an
additional 25 mg of Captopril p.o.

PAST MEDICAL HISTORY:  1.  Atrial fibrillation.  2.  Prior
cerebrovascular accident complicated by aphasia.  3.
Congestive heart failure.  4.  Depression.  5.  Hypertension.
6.  Dementia.

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

MEDICATIONS:  Warfarin 2 mg p.o. q.h.s., Alendronate 70 mg
p.o. q.Monday, Atenolol 50 mg p.o. q.d., Furosemide 60 mg
p.o. q.d., Lisinopril 5 mg p.o. q.d., Docusate 100 mg p.o.
b.i.d., Senna 2 tab p.o. b.i.d., Acetaminophen, Milk of
Magnesia, Calcium Carbonate, Potassium Chloride.

SOCIAL HISTORY:  The patient is a nursing home resident.  Her
brother lives in [**Name (NI) 108**].  She has two nieces that live in
the [**Location (un) 86**] area.

PHYSICAL EXAMINATION:  Vital signs:  On initial exam,
temperature was 96.9??????, heart rate 80, blood pressure 185/110,
respirations 48, oxygen saturation 97% on 50% face.  General:
The was lying in bed at 45??????, tachypneic and arousable but did
not answer any questions.  HEENT:  Pupils equal, round and
reactive to light.  No obstructing lesions in the left nasal
cavity per report.  There was no cervical lymphadenopathy.
Her neck was soft and supple.  There was accessory muscle
use, and there was jugular venous distention to 10 cm.
Heart:  Heart rate was irregular, and there were very distant
heart sounds.  Chest:  She had minimal air movement
bilaterally with coarse breath sounds, wheezes, and rhonchi.
Abdomen:  Benign.  Back:  Not assessed.  Extremities:  She
had 2+ bipedal edema, 1+ bilateral lower extremity edema from
the ankle to mid shin and 2+ dorsalis pedal pulses.  She had
no skin lesions.  Neurological:  She was not oriented to
place or time.  She did not follow commands.  She did not
respond to questions appropriately.

LABORATORY DATA:  On initial laboratory evaluation, white
count was 12.4, hematocrit 47.3, platelet count 196,000,
white count differential demonstrated 89.9 segs, no bands,
6.4 lymphs, 3 monocytes, 0.2 eosinophils, 0.5 basophils; PT
21.3, PTT 30.9, INR 3.0; initial serum chemistries
demonstrated a sodium of 144, potassium 3.5, chloride 103,
bicarb 25, BUN 22, creatinine 1.1, glucose 202; initial CK
was 115, MB fraction 5, troponin 0.5; initial urinalysis
demonstrated large blood, greater than 300 protein, [**4-27**] red
cells, [**1-20**] white cells, many bacteria, no yeast, 0-2
epithelial cells.

Chest x-ray and head CT were as noted above.
Electrocardiogram demonstrated atrial fibrillation versus
atrial flutter at 70 beats per minute, slight right axis,
normal QRS and QT intervals, Q-waves in leads AVL and V1, and
no ST segment or T-wave changes.

HOSPITAL COURSE:  The patient was initially admitted to the
ACOVE Service.  Although she appeared to have an element of
pulmonary edema on her chest x-ray, she did not have a
diuretic response to Furosemide, and she remained in
respiratory distress.  Given her persistent respiratory
distress, the patient was transferred to the Intensive Care
Unit for further monitoring and treatment.

On transfer to the Intensive Care Unit, the patient was found
to be in hypercapnic respiratory failure, and a repeat chest
x-ray demonstrated a left-sided infiltrate consistent with
pneumonia.  The patient was therefore treated with
Levofloxacin for her pneumonia.  She was also started on
BIPAP for her respiratory failure which was subsequently used
as needed for respiratory distress.

On [**2178-12-22**], the patient had an episode of
respiratory distress with decreased oxygen saturations and
increased respiratory rate.  She was given BIPAP, intravenous
steroids, and Nitroglycerin sublingually, Furosemide, and
nebulizer treatments.  In addition, Ceftriaxone was added for
broader coverage of her pneumonia.  She was subsequently
found to have E. coli resistant to Levofloxacin on a urine
culture, so her Ceftriaxone was continued.

While in the Intensive Care Unit, and echocardiogram was done
that demonstrated an ejection fraction of 70%, small left
ventricle, RVHK, left ventricular hypertrophy, and moderate
pulmonary hypertension.  She was therefore continued on her
antihypertensive medications and her other outpatient
medications as noted above.  Of note, she also ruled out for
myocardial infarction by cardiac enzymes.

Given her subacute stroke, a cholesterol panel was sent that
demonstrated a cholesterol of 179, triglycerides of 129, HDL
34, and LDL of 119.  Her LFTs were normal, and the patient
was subsequently started on Atorvastatin.  Given her impaired
neurologic status, a swallowing evaluation was done.

The Speech Pathology Department subsequently recommended a
diet of very moist, ground, and pureed foods with thin
liquids.  They also recommended crushing her medications in
pureed foods.  She should not be given any solids or mixed
consistencies.  Finally, her oral cavity should be checked at
the end of each meal, and any residue should be removed.

The patient also subsequently developed hypernatremia that
was likely thought to be due to a partial central diabetes
insipidus.

Also of note, following several family meetings, the decision
was finally made to make the patient DNR/DNI.

On [**2178-12-25**], the patient was transferred back to the
ACOVE Service from the Intensive Care Unit.  On transfer, she
continued to breath at a respiratory rate of 40 but appeared
clinically comfortable.  The thought was that the patient had
an elevated respiratory rate most likely as a consequence of
her recent subacute cerebrovascular accident.  As noted
above, she was started on Atorvastatin.

Her blood pressure remained elevated ranging between 160-190
systolic throughout her time on the Medicine Floor;
therefore, her blood pressure medications were titrated up as
noted below.  From a pulmonary point of view, she continued
to breath easily as her underlying pneumonia was treated.

Of note, the patient was found to have MRSA in her sputum
from a sputum culture sent while she was in the Intensive
Care Unit.  While this finding was though to most likely
represent contamination and not true infection, and given
that the patient was clinically improving with a combination
of Levofloxacin and Ceftriaxone, the decision was made to not
treat the patient for her MRSA in her sputum; however, should
the patient clinically decompensate in the future, treatment
of her MRSA should clearly be considered.

CONDITION ON DISCHARGE:  Stable.

DISCHARGE PLACEMENT:  To nursing home.

DISCHARGE DIAGNOSIS:
1.  Hypercapnic respiratory failure.
2.  Pneumonia.
3.  Urinary tract infection.
4.  Subacute cerebrovascular accident.
5.  Hypertension.
6.  Atrial fibrillation.
7.  Dementia.
8.  Depression.
9.  Congestive heart failure.

DISCHARGE MEDICATIONS:  Docusate 100 mg p.o. b.i.d., Senna 1
tab p.o. b.i.d., Acetaminophen 325-650 mg p.o. q.4-6 hours
p.r.n. pain, Calcium Carbonate 500 mg p.o. t.i.d., Aspirin 81
mg p.o. q.d., Levofloxacin 250 mg p.o. q.d. through [**2179-1-4**], Ranitidine 150 mg p.o. b.i.d., Fluticasone 2 puffs
b.i.d., Warfarin 2 mg p.o. q.h.s., Metoprolol 75 mg p.o.
b.i.d., Albuterol 1-2 puffs q.4-6 hours p.r.n. wheezing,
Ipratropium 2 puffs q.i.d., Captopril 75 mg p.o. t.i.d.,
Atorvastatin 10 mg p.o. q.d., Furosemide 40 mg p.o. q.d.

FOLLOW-UP:  The patient should follow-up with her primary
care physician at the nursing home following her discharge
from the hospital.






                            [**Name6 (MD) **] [**Name8 (MD) **], M.D.

Dictated By:[**Name8 (MD) 2507**]
MEDQUIST36

D:  [**2178-12-28**]  15:47
T:  [**2178-12-28**]  15:53
JOB#:  [**Job Number 35357**]
{'Pneumonia, organism unspecified,Acute respiratory failure,Atrial fibrillation,Congestive heart failure, unspecified,Urinary tract infection, site not specified,Hyperosmolality and/or hypernatremia,Cerebral artery occlusion, unspecified with cerebral infarction,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: Shortness of breath.

PRESENT ILLNESS: The patient is a 77-year-old
female nursing home resident who reportedly developed acute
onset of shortness of breath on the morning of admission.
Her oxygen saturation was found to be 77% on room air and
increased to 88% with 2 or 3 L of oxygen by nasal cannula.
The patient was also found to be diaphoretic and was sent to
the [**Hospital6 256**] Emergency Department
for further evaluation.

MEDICAL HISTORY: 1.  Atrial fibrillation.  2.  Prior
cerebrovascular accident complicated by aphasia.  3.
Congestive heart failure.  4.  Depression.  5.  Hypertension.
6.  Dementia.

MEDICATION ON ADMISSION: 

ALLERGIES: NO KNOWN DRUG ALLERGIES.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient is a nursing home resident.  Her
brother lives in [**Name (NI) 108**].  She has two nieces that live in
the [**Location (un) 86**] area. 

### Response:
{'Pneumonia, organism unspecified,Acute respiratory failure,Atrial fibrillation,Congestive heart failure, unspecified,Urinary tract infection, site not specified,Hyperosmolality and/or hypernatremia,Cerebral artery occlusion, unspecified with cerebral infarction,Unspecified essential hypertension'}
