CHIEF COMPLAINT: hypoxia

PRESENT ILLNESS: 89 yo M with pna treansferred to MICU for hypoxia. Found
unresponsive at nursing home and found to have O2 sat 66% on RA.
The patient had an asymptomatic pna about a week ago which was
not treated. The daughter noticed that his mental status has
decreased over the past 2 days with decreased po intake.
.
In the ED, patient given vanc, ctx, azith. Received lasix by
EMT. ED physician spoke with daughter who confirmed DNR/DNI.
.
On arrival to the floor, the patient was stable on 2.5L NC. He
awoke to voice but was confused and could not answer questions.

MEDICAL HISTORY: Right sided stroke [**2163**] with residual L-sided weakness.
HTN
Atrial fibrillation
Dementia
Depression
Failure to Thrive
Frequent Falls
BPH
Urine/Stool incontinence

MEDICATION ON ADMISSION: Rivastigmine 1.5mg [**Hospital1 **]
asa 325 mg qday
tylenol prn
nexium
memantine 10mg [**Hospital1 **]
proscar 5mg qday
citalopram 20mg qday
terazosin 2mg qhs
metoprolol 100mg [**Hospital1 **]

ALLERGIES: Aricept

PHYSICAL EXAM: VS - 97.3 54 142/67 18 96% on 2.5L
GEN - confused, somnolent
HEENT - OP clear, PERRL
NECK - supple, no LAD
COR - irreg, irreg
CHEST - uncooperative on exam, loud upper airway sounds,
decreased BS on right
ABD - s/nt/bd +BS
EXT - w/wp, no edmema
NEURO - uncooperative, moving all ext

FAMILY HISTORY: Distant cigar smoker. No alcohol. Retired accountant. Nursing
home resident.

SOCIAL HISTORY: Mother with breast cancer at age 58.
Father with lung cancer at age 68.
Pneumonitis due to inhalation of food or vomitus,Hypoxemia,Bacteremia,Unspecified pleural effusion,Mitral valve insufficiency and aortic valve insufficiency,Rheumatic heart failure (congestive),Atrial fibrillation,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Other late effects of cerebrovascular disease,Unspecified essential hypertension
Food/vomit pneumonitis,Hypoxemia,Bacteremia,Pleural effusion NOS,Mitral/aortic val insuff,Rheumatic heart failure,Atrial fibrillation,BPH w/o urinary obs/LUTS,Late effect CV dis NEC,Hypertension NOS
Admission Date:  [**2165-3-21**]              Discharge Date:   [**2165-3-22**]


Service: MEDICINE

Allergies:
Aricept

Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
hypoxia

Major Surgical or Invasive Procedure:
PICC placement


History of Present Illness:
89 yo M with pna treansferred to MICU for hypoxia. Found
unresponsive at nursing home and found to have O2 sat 66% on RA.
The patient had an asymptomatic pna about a week ago which was
not treated. The daughter noticed that his mental status has
decreased over the past 2 days with decreased po intake.
.
In the ED, patient given vanc, ctx, azith. Received lasix by
EMT. ED physician spoke with daughter who confirmed DNR/DNI.
.
On arrival to the floor, the patient was stable on 2.5L NC. He
awoke to voice but was confused and could not answer questions.


Past Medical History:
Right sided stroke [**2163**] with residual L-sided weakness.
HTN
Atrial fibrillation
Dementia
Depression
Failure to Thrive
Frequent Falls
BPH
Urine/Stool incontinence


Social History:
Mother with breast cancer at age 58.
Father with lung cancer at age 68.


Family History:
Distant cigar smoker. No alcohol. Retired accountant. Nursing
home resident.

Physical Exam:
VS - 97.3 54 142/67 18 96% on 2.5L
GEN - confused, somnolent
HEENT - OP clear, PERRL
NECK - supple, no LAD
COR - irreg, irreg
CHEST - uncooperative on exam, loud upper airway sounds,
decreased BS on right
ABD - s/nt/bd +BS
EXT - w/wp, no edmema
NEURO - uncooperative, moving all ext

Pertinent Results:
EKG - afib 65 bpm, RBBB, no change from prior
.
CXR - Large right pleural effusion.  Significant atelectasis in
the
right lung with rightward shift of mediastinal contents.  Abrupt
cutoff of the right main stem bronchus.  Chest CT or
bronchoscopy is recommended for further evaluation.
.
[**10-17**] Chest CT - 1.  Right middle lobe consolidation.
2.  Moderately large right pleural effusion with fluid-like
density, and likely adjacent compressive atelectasis.
3.  Coronary artery calcifications.
4.  Small aneurysm of the ascending aorta to 4.4 cm in
dilatation.
5.  Calcified granuloma in the left upper lobe, with no other
lung nodules identified.
6.  Likely hepatic cyst, incompletely evaluated and visualized
here.
.
[**10-17**] Echo - Mild regional left ventricular systolic dysfunction.
Mild global right ventricular systolic dysfunction. Moderate
mitral regurgitation.  Mild-moderate aortic regurgitation.
Moderate pulmonary hypertension.  EF 50%
.
Admission Labs:
141  105  37
--------------< 162
6.5  30  1.5
*hemolyzed*
Trop 0.02
CK: 91  MB: Notdone
Ca: 8.7 Mg: 2.3 P: 5.2 D
proBNP: 5808
.
      13.9
11.2 >----<  199
      42.4
N:91.0 L:5.8 M:2.9 E:0.2 Bas:0.1
PT: 13.5  PTT: 30.1  INR: 1.2
.
Trends:
[**2165-3-21**] 01:45AM BLOOD WBC-11.2* RBC-4.15* Hgb-13.9* Hct-42.4
MCV-102*# MCH-33.4* MCHC-32.7 RDW-15.0 Plt Ct-199
[**2165-3-22**] 04:57AM BLOOD WBC-9.0 RBC-3.69* Hgb-12.5* Hct-37.8*
MCV-102* MCH-34.0* MCHC-33.2 RDW-14.7 Plt Ct-171
[**2165-3-21**] 01:45AM BLOOD Glucose-162* UreaN-37* Creat-1.5* Na-141
K-6.5* Cl-105 HCO3-30 AnGap-13
[**2165-3-22**] 04:57AM BLOOD Glucose-81 UreaN-38* Creat-1.3* Na-147*
K-3.4 Cl-108 HCO3-31 AnGap-11
[**2165-3-21**] 01:45AM BLOOD CK(CPK)-91
[**2165-3-22**] 04:57AM BLOOD CK(CPK)-35*
[**2165-3-21**] 01:45AM BLOOD cTropnT-0.02*
[**2165-3-21**] 10:15AM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2165-3-22**] 04:57AM BLOOD CK-MB-3 cTropnT-0.05*
[**2165-3-21**] 01:41AM BLOOD Lactate-2.4*
.
Micro:
[**2165-3-21**] 1:45 am BLOOD CULTURE

   AEROBIC BOTTLE (Preliminary):
      [**2165-3-21**] REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 38653**] AT 11:40 PM.
      GRAM POSITIVE COCCUS(COCCI).    IN CLUSTERS.  BEING
ISOLATED.
         FURTHER IDENTIFICATION TO FOLLOW.

   ANAEROBIC BOTTLE (Preliminary):
      GRAM POSITIVE COCCUS(COCCI).    IN CLUSTERS.
         BEING ISOLATED FURTHER IDENTIFICATION TO FOLLOW.


Brief Hospital Course:
89 yo M with pna.  Hospital course by problem:
.
# Hypoxia - Profound hypoxia on admission with complete white
out of right lung on CXR.  This prompted an admission to the
MICU.  CT scan significant for large effusion and diffuse mucous
plugging.  Differential includes post-obstructive pneumonia from
mucous plugging, lymphadenopathy, or mass.  Prior chest CT
showed right middle lobe consolidation in [**10-17**], making
malignancy more concerning.  he had gm pos cocci in clusters
which grew out of his blood cultures.  We treated him initially
with vanco and zosyn to cover broadly for possible MRSA and
pseudomonas.  These were started on [**3-21**] and we recommend
completion of a 14 day course.
.
# Goals of care: The patient had a questionable mass seen on the
right lung concerning for tumor with postobstructive changes.
We met with the family.  The family does not want to be
aggressive with care (i.e. no bronchoscopy for fear of need for
intubation, thoracentesis, etc.).  Would like to maintain
treatment with antibiotics, pulmonary toilet and chest PT.  If
decompensates the desire is to make the patient comfortable.
.
# Afib: Rate controlled, no anticoagulation given past history
of falls and supratherapeutic INR.  Continued ASA.  We also
decreased lopressor from 100 TID to 25 [**Hospital1 **] given bradycardia.
This may need to be adjusted further.
.
# CHF: The patient was dry initially so we did not treat him
with lasix.  In fact, he required fluid boluses on occasion.  He
aimed to keep I=O.
.
# HTN - continued lopressor
.
# Dementia/Depression - We initially held his home meds given
aspiration risk.  but as the patient requested food and our
goals of care were somewhat shifted as above, we restarted his
meds.  A speech and swallow study suggested nectar thickened
liquids with soft consistency solids.
.
# BPH - we initially held terazosin and proscar while asp risk.
These were restarted.
.
# FEN - patient on nectar thick diet with ensure
.
# PPx - hep sc, PPI
.
# Access: A PICC was placed [**3-22**] for access given prolonged abx
course.
.
# Communication - daughter, [**Name (NI) **] [**Name (NI) 8494**] (HCP) - [**Telephone/Fax (1) 67575**]
.
# Status - DNR/DNI, form from NH in chart, conf with daughter

Medications on Admission:
Rivastigmine 1.5mg [**Hospital1 **]
asa 325 mg qday
tylenol prn
nexium
memantine 10mg [**Hospital1 **]
proscar 5mg qday
citalopram 20mg qday
terazosin 2mg qhs
metoprolol 100mg [**Hospital1 **]


Discharge Medications:
1. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours) for 10 days: may adjust for
renal function.
2. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q6H (every 6 hours) for 10 days.
3. Rivastigmine 1.5 mg Capsule Sig: One (1) Capsule PO bid ().
4. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
6. Nexium 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. Memantine 5 mg Tablet Sig: Two (2) Tablet PO bid ().
8. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

10. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): may need to titrate up as tolerated.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
Primary:
- Pneumonia
- bacteremia
- hypoxia
- pleural effusion
- atrial fibrillation
Secondary:
- CHF
- HTN
- Dementia/depression
- BPH
- FEN


Discharge Condition:
fair


Discharge Instructions:
You were admitted with a pneumonia.  We treated you with IV
antibiotics and you improved.
.
Please take your abx as instructed.  Please take your other
medications as instructed.
.
Please followup with your PCP within the next 2 weeks.
.
Please return to the ED or contact your PCP if you experience
worsening shortness of breath, chest pain, abdominal pain,
fevers, or chills.

Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 658**], M.D. Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2165-5-21**] 9:00
{'Pneumonitis due to inhalation of food or vomitus,Hypoxemia,Bacteremia,Unspecified pleural effusion,Mitral valve insufficiency and aortic valve insufficiency,Rheumatic heart failure (congestive),Atrial fibrillation,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Other late effects of cerebrovascular disease,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: hypoxia

PRESENT ILLNESS: 89 yo M with pna treansferred to MICU for hypoxia. Found
unresponsive at nursing home and found to have O2 sat 66% on RA.
The patient had an asymptomatic pna about a week ago which was
not treated. The daughter noticed that his mental status has
decreased over the past 2 days with decreased po intake.
.
In the ED, patient given vanc, ctx, azith. Received lasix by
EMT. ED physician spoke with daughter who confirmed DNR/DNI.
.
On arrival to the floor, the patient was stable on 2.5L NC. He
awoke to voice but was confused and could not answer questions.

MEDICAL HISTORY: Right sided stroke [**2163**] with residual L-sided weakness.
HTN
Atrial fibrillation
Dementia
Depression
Failure to Thrive
Frequent Falls
BPH
Urine/Stool incontinence

MEDICATION ON ADMISSION: Rivastigmine 1.5mg [**Hospital1 **]
asa 325 mg qday
tylenol prn
nexium
memantine 10mg [**Hospital1 **]
proscar 5mg qday
citalopram 20mg qday
terazosin 2mg qhs
metoprolol 100mg [**Hospital1 **]

ALLERGIES: Aricept

PHYSICAL EXAM: VS - 97.3 54 142/67 18 96% on 2.5L
GEN - confused, somnolent
HEENT - OP clear, PERRL
NECK - supple, no LAD
COR - irreg, irreg
CHEST - uncooperative on exam, loud upper airway sounds,
decreased BS on right
ABD - s/nt/bd +BS
EXT - w/wp, no edmema
NEURO - uncooperative, moving all ext

FAMILY HISTORY: Distant cigar smoker. No alcohol. Retired accountant. Nursing
home resident.

SOCIAL HISTORY: Mother with breast cancer at age 58.
Father with lung cancer at age 68. 

### Response:
{'Pneumonitis due to inhalation of food or vomitus,Hypoxemia,Bacteremia,Unspecified pleural effusion,Mitral valve insufficiency and aortic valve insufficiency,Rheumatic heart failure (congestive),Atrial fibrillation,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Other late effects of cerebrovascular disease,Unspecified essential hypertension'}
