CHIEF COMPLAINT: Transfer from [**Hospital1 **]-[**Location (un) 620**] for possible tracheostomy

PRESENT ILLNESS: Ms. [**Known lastname **] is a 70 year old woman with morbid obesity, obesity
hypoventilation syndrome, atrial fibrillation, diabetes, and
diastolic heart failure who is transferred from [**Hospital1 **]-[**Location (un) 620**] for
tracheostomy placement. She was admitted to [**Hospital1 **]-[**Location (un) 620**] on [**2-2**]
with hypoxic and hypercarbic respiratory failure of unclear
etiology. She was admitted to the ICU for non-invasive
ventilation, which she could not tolerate; she was subsequently
intubated. She was substantially diuresed (~13 kg) with 100mg
[**Hospital1 **] Diamox. MRSA was found on sputum culture (but no white count
and no fever), and vancomycin was started (now day #5).
Piperacillin-tazobactam was added on the day of transfer. Her
vent settings at the time of transfer were SIMV 500 x 10, FiO2
0.4, PEEP 5.
.
The day prior to transfer, she developed a low-grade temperature
to 99.3 axillary with systolic blood pressures in the 80's. Her
beta blocker and calcium channel blocker (which she is on
because of atrial fibrillation with RVR) were discontinued, and
her rhythm converted into atrial fibrillation with RVR. She was
given 2 liters of IVF with improvement of her blood pressure to
the 110's, she was loaded with digoxin, and her beta blocker was
restarted (at a lower dose) on the day of transfer. Of note, her
sugars have been difficult to manage, so she was placed on an
insulin gtt.

MEDICAL HISTORY: 1. Morbid obesity.
2. Lymphedema.
3. Diabetes.
4. Mechanical aortic valve in [**2165**].
5. Atrial fibrillation.
6. Hypothyroidism.
7. History of decubitus ulcers.
8. Ankle fracture, status post fall in [**2177-9-25**] with long
rehabilitation.
9. Recent dig toxicity admitted to [**Hospital1 18**].
10. History of diastolic congestive heart failure (EF greater
than 55%
with mild LVH, pulmonary capillary wedge pressure of greater
than 18, 1+ MR).

MEDICATION ON ADMISSION: Levothyroxine 225mcg daily
ON TRANSFER:
Simvastatin 20mg daily
Insulin Drip
Docusate 100mg [**Hospital1 **]
Vancomycin 1g [**Hospital1 **] (day #1 [**2180-2-3**])
Zosyn 4.5 grams Q6H (day #1 [**2180-2-9**])
Escitalopram 20mg daily
Versed gtt
Coumadin 5mg daily
Free water boluses given Q8H
Metoprolol 25mg QID

ALLERGIES: Aspirin / Phenergan / Lorazepam

PHYSICAL EXAM: VITALS: T 98.6F, HR 100's, BP 105/59, RR 19, Sat 98%
VENT: A/C Tv 500, Rate 12 (overbreathing), PEEP 10, FiO2 0.5
GENERAL: Morbidly obese, ventilated, no acute distress
HEENT: EOMI, PERRL, MMM
NECK: Thick neck, unable to appreciate JVP
CARD: Irregularly irregular, normal S1/S2, 2/6 systolic murmur
heard loudest at apex
RESP: Clear to auscultation bilaterally anteriorly
ABD: Obese, non-distended. + bowel sounds.
BACK: Deferred
EXT: Warm, well-perfused, 2+ DP pulses bilaterally. Venous
stasis changes.
NEURO: Sedated.

FAMILY HISTORY: 2 brothers had [**Name (NI) 5290**] age 59, 66. Mother and brother with
emphysema, both smokers.

SOCIAL HISTORY: Lives at home with partner (health care proxy). Mostly [**Hospital1 **],
but can walk with assistance. Has nursing assistance 12 hours
daily. Denies alcohol, tobacco, other drugs. She was recently
discharged to [**Hospital6 **] after a stay at [**Hospital1 771**] for dig toxicity. She was discharged on
[**2180-1-31**]. She is mostly bed bound. She is dependent on
others for her activities of daily living. Prior to admission to
[**Location (un) 86**], she was living at home with her partner x 30 years who
is also her health care proxy.
Acute respiratory failure,Chronic diastolic heart failure,Morbid obesity,Heart valve replaced by other means,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled
Acute respiratry failure,Chr diastolic hrt fail,Morbid obesity,Heart valve replac NEC,Atrial fibrillation,DMII wo cmp nt st uncntr
Admission Date:  [**2180-2-10**]              Discharge Date:   [**2180-2-17**]

Date of Birth:  [**2109-5-11**]             Sex:   F

Service: MEDICINE

Allergies:
Aspirin / Phenergan / Lorazepam

Attending:[**First Name3 (LF) 492**]
Chief Complaint:
Transfer from [**Hospital1 **]-[**Location (un) 620**] for possible tracheostomy

Major Surgical or Invasive Procedure:
PEG and tracheostomy placement

History of Present Illness:
Ms. [**Known lastname **] is a 70 year old woman with morbid obesity, obesity
hypoventilation syndrome, atrial fibrillation, diabetes, and
diastolic heart failure who is transferred from [**Hospital1 **]-[**Location (un) 620**] for
tracheostomy placement. She was admitted to [**Hospital1 **]-[**Location (un) 620**] on [**2-2**]
with hypoxic and hypercarbic respiratory failure of unclear
etiology. She was admitted to the ICU for non-invasive
ventilation, which she could not tolerate; she was subsequently
intubated. She was substantially diuresed (~13 kg) with 100mg
[**Hospital1 **] Diamox. MRSA was found on sputum culture (but no white count
and no fever), and vancomycin was started (now day #5).
Piperacillin-tazobactam was added on the day of transfer. Her
vent settings at the time of transfer were SIMV 500 x 10, FiO2
0.4, PEEP 5.
.
The day prior to transfer, she developed a low-grade temperature
to 99.3 axillary with systolic blood pressures in the 80's. Her
beta blocker and calcium channel blocker (which she is on
because of atrial fibrillation with RVR) were discontinued, and
her rhythm converted into atrial fibrillation with RVR. She was
given 2 liters of IVF with improvement of her blood pressure to
the 110's, she was loaded with digoxin, and her beta blocker was
restarted (at a lower dose) on the day of transfer. Of note, her
sugars have been difficult to manage, so she was placed on an
insulin gtt.

Of note, she was recently discharged from [**Hospital1 18**] after an
admission for digoxin overdose, atrial fibrillation with RVR,
and UTI treated with 10 day course of levofloxacin.

Past Medical History:
1. Morbid obesity.
2. Lymphedema.
3. Diabetes.
4. Mechanical aortic valve in [**2165**].
5. Atrial fibrillation.
6. Hypothyroidism.
7. History of decubitus ulcers.
8. Ankle fracture, status post fall in [**2177-9-25**] with long
rehabilitation.
9. Recent dig toxicity admitted to [**Hospital1 18**].
10. History of diastolic congestive heart failure (EF greater
than 55%
with mild LVH, pulmonary capillary wedge pressure of greater
than 18, 1+ MR).

Social History:
Lives at home with partner (health care proxy). Mostly [**Hospital1 **],
but can walk with assistance. Has nursing assistance 12 hours
daily. Denies alcohol, tobacco, other drugs. She was recently
discharged to [**Hospital6 **] after a stay at [**Hospital1 771**] for dig toxicity. She was discharged on
[**2180-1-31**]. She is mostly bed bound. She is dependent on
others for her activities of daily living. Prior to admission to
[**Location (un) 86**], she was living at home with her partner x 30 years who
is also her health care proxy.

Family History:
2 brothers had [**Name (NI) 5290**] age 59, 66. Mother and brother with
emphysema, both smokers.

Physical Exam:
VITALS: T 98.6F, HR 100's, BP 105/59, RR 19, Sat 98%
VENT: A/C Tv 500, Rate 12 (overbreathing), PEEP 10, FiO2 0.5
GENERAL: Morbidly obese, ventilated, no acute distress
HEENT: EOMI, PERRL, MMM
NECK: Thick neck, unable to appreciate JVP
CARD: Irregularly irregular, normal S1/S2, 2/6 systolic murmur
heard loudest at apex
RESP: Clear to auscultation bilaterally anteriorly
ABD: Obese, non-distended. + bowel sounds.
BACK: Deferred
EXT: Warm, well-perfused, 2+ DP pulses bilaterally. Venous
stasis changes.
NEURO: Sedated.

Pertinent Results:
[**2180-2-10**] 08:25PM BLOOD WBC-10.7# RBC-3.33* Hgb-10.5* Hct-32.9*
MCV-99* MCH-31.3 MCHC-31.8 RDW-15.4 Plt Ct-356
[**2180-2-16**] 02:48AM BLOOD WBC-8.8 RBC-2.87* Hgb-9.0* Hct-28.1*
MCV-98 MCH-31.4 MCHC-32.0 RDW-15.4 Plt Ct-335
[**2180-2-16**] 02:48AM BLOOD PT-19.4* PTT-81.3* INR(PT)-1.8*
[**2180-2-10**] 08:25PM BLOOD Glucose-186* UreaN-19 Creat-0.8 Na-133
K-4.7 Cl-96 HCO3-34* AnGap-8
[**2180-2-16**] 02:48AM BLOOD Glucose-181* UreaN-11 Creat-0.9 Na-138
K-4.9 Cl-103 HCO3-28 AnGap-12
[**2180-2-10**] 08:25PM BLOOD ALT-16 AST-25 LD(LDH)-300* AlkPhos-81
Amylase-12 TotBili-0.6
[**2180-2-16**] 02:48AM BLOOD Calcium-10.0 Phos-3.5 Mg-2.8*
[**2180-2-16**] 03:04AM BLOOD Type-ART pO2-145* pCO2-60* pH-7.38
calTCO2-37* Base XS-8
.
CXR: This is compared with prior study from [**2180-2-14**].
There is some blunting of the left costophrenic angle suggestive
of a small effusion.  The cardiac size is somewhat enlarged.
The right PICC line has been removed. There has been a median
sternotomy with cerclage wires intact.  Large cardiac silhouette
with left-sided effusion, similar to
prior study.


Brief Hospital Course:
70yF with atrial fibrillation, aortic valve replacement,
admitted to [**Hospital1 **]-[**Location (un) 620**] with respiratory failure requiring
ventilation, now transferred to [**Hospital1 18**] for tracheostomy
placement.
.
#) Hypoxic/hypercarbic respiratory failure. This was thought to
be secondary to obesity hypoventilation syndrome with components
of CHF and possibly pneumonia. She had completed a course of
vancomycin at the OSH for MRSA in the sputum so her antibiotics
were stopped on admission and she remained afebrile.  She was
sent for a trach after her INR trended down to <1.5 and
tolerated this without difficulty.  Her sedation was weaned and
she tolerated a switch from AC ventilation to PS 15/10 FiO2 40%
TV ~500.  She was oxygenating and ventillating well on these
settings and was transfered to pulmonary rehab for further
weaning off the vent.  She was contined on nebs throughout her
admission.
.
#) Hypotension. She was initially hypotensive in the setting of
aggressive diuresis.  She remained afebrile and did not require
pressor support.  Her BP remained well controlled even with rate
control of her afib.
.
#) Atrial fibrillation. She was in poorly controlled atrial
fibrillation on admission and was intially treated with digoxin
given her borderline blood pressure.  As this improved with
hydration her home nodal agents were gradually reintroduced
(diltiazem and metoprolol).  She was rate controlled in the 70s
at the time of discharge.
.
#) Diabetes. She was intially managed with an insulin drip but
transitioned to long acting and sliding scale insulin prior to
discharge.  Her long acting insulin will need to be readjusted
in the future as needed.
.
#) Mechanical aortic valve. She was initally placed on a heparin
drip and her INR allowed to trend downwards for her trach/PEG.
After the procedure her heparin was restarted and she was
bridged to a therapeutic INR on coumadin.  Her INR was 2.0 on
the day of discharge and the heparin was stopped.  She should
have her coumadin titrated to maintain her INR between [**2-27**].
.
#) Hypothyroidism.  We continued levothyroxine.
.
#) Depression. We continued escitalopram.
.
#) F/E/N. She had a PEG tube placed and she was started on
Replete tube feeds at 60ml/hr continuously prior to discharge
which she tolerated well.


Medications on Admission:
Levothyroxine 225mcg daily
ON TRANSFER:
Simvastatin 20mg daily
Insulin Drip
Docusate 100mg [**Hospital1 **]
Vancomycin 1g [**Hospital1 **] (day #1 [**2180-2-3**])
Zosyn 4.5 grams Q6H (day #1 [**2180-2-9**])
Escitalopram 20mg daily
Versed gtt
Coumadin 5mg daily
Free water boluses given Q8H
Metoprolol 25mg QID

Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
6. Levothyroxine 75 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAYS
([**Doctor First Name **],MO,TU,WE,TH,FR,SA).
11. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): hold for sbp < 100 or rate < 60.
13. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day): hold for sbp < 100 or rate < 60.
14. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Fifty
Five (55) units Subcutaneous twice a day.
15. Insulin
sliding scale per attached scale


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]

Discharge Diagnosis:
Primary: Hypercarbic respiratory failure
.
Secondary: Mechanical AVR, Diabetes II, morbid obesity, atrial
fibrillation


Discharge Condition:
Stable on her vent settings, interactive, and tolerating PEG
feeds


Discharge Instructions:
Please follow the instructions at the rehab facility and take
your medications.

Please call your PCP for an appointment after discharge from
rehab

Followup Instructions:
Please follow-up with your PCP after discharge from rehab
([**Last Name (LF) **],[**First Name3 (LF) 2946**] S. [**Telephone/Fax (1) 2205**])


                             [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]

Completed by:[**2180-2-17**]
{'Acute respiratory failure,Chronic diastolic heart failure,Morbid obesity,Heart valve replaced by other means,Atrial fibrillation,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: Transfer from [**Hospital1 **]-[**Location (un) 620**] for possible tracheostomy

PRESENT ILLNESS: Ms. [**Known lastname **] is a 70 year old woman with morbid obesity, obesity
hypoventilation syndrome, atrial fibrillation, diabetes, and
diastolic heart failure who is transferred from [**Hospital1 **]-[**Location (un) 620**] for
tracheostomy placement. She was admitted to [**Hospital1 **]-[**Location (un) 620**] on [**2-2**]
with hypoxic and hypercarbic respiratory failure of unclear
etiology. She was admitted to the ICU for non-invasive
ventilation, which she could not tolerate; she was subsequently
intubated. She was substantially diuresed (~13 kg) with 100mg
[**Hospital1 **] Diamox. MRSA was found on sputum culture (but no white count
and no fever), and vancomycin was started (now day #5).
Piperacillin-tazobactam was added on the day of transfer. Her
vent settings at the time of transfer were SIMV 500 x 10, FiO2
0.4, PEEP 5.
.
The day prior to transfer, she developed a low-grade temperature
to 99.3 axillary with systolic blood pressures in the 80's. Her
beta blocker and calcium channel blocker (which she is on
because of atrial fibrillation with RVR) were discontinued, and
her rhythm converted into atrial fibrillation with RVR. She was
given 2 liters of IVF with improvement of her blood pressure to
the 110's, she was loaded with digoxin, and her beta blocker was
restarted (at a lower dose) on the day of transfer. Of note, her
sugars have been difficult to manage, so she was placed on an
insulin gtt.

MEDICAL HISTORY: 1. Morbid obesity.
2. Lymphedema.
3. Diabetes.
4. Mechanical aortic valve in [**2165**].
5. Atrial fibrillation.
6. Hypothyroidism.
7. History of decubitus ulcers.
8. Ankle fracture, status post fall in [**2177-9-25**] with long
rehabilitation.
9. Recent dig toxicity admitted to [**Hospital1 18**].
10. History of diastolic congestive heart failure (EF greater
than 55%
with mild LVH, pulmonary capillary wedge pressure of greater
than 18, 1+ MR).

MEDICATION ON ADMISSION: Levothyroxine 225mcg daily
ON TRANSFER:
Simvastatin 20mg daily
Insulin Drip
Docusate 100mg [**Hospital1 **]
Vancomycin 1g [**Hospital1 **] (day #1 [**2180-2-3**])
Zosyn 4.5 grams Q6H (day #1 [**2180-2-9**])
Escitalopram 20mg daily
Versed gtt
Coumadin 5mg daily
Free water boluses given Q8H
Metoprolol 25mg QID

ALLERGIES: Aspirin / Phenergan / Lorazepam

PHYSICAL EXAM: VITALS: T 98.6F, HR 100's, BP 105/59, RR 19, Sat 98%
VENT: A/C Tv 500, Rate 12 (overbreathing), PEEP 10, FiO2 0.5
GENERAL: Morbidly obese, ventilated, no acute distress
HEENT: EOMI, PERRL, MMM
NECK: Thick neck, unable to appreciate JVP
CARD: Irregularly irregular, normal S1/S2, 2/6 systolic murmur
heard loudest at apex
RESP: Clear to auscultation bilaterally anteriorly
ABD: Obese, non-distended. + bowel sounds.
BACK: Deferred
EXT: Warm, well-perfused, 2+ DP pulses bilaterally. Venous
stasis changes.
NEURO: Sedated.

FAMILY HISTORY: 2 brothers had [**Name (NI) 5290**] age 59, 66. Mother and brother with
emphysema, both smokers.

SOCIAL HISTORY: Lives at home with partner (health care proxy). Mostly [**Hospital1 **],
but can walk with assistance. Has nursing assistance 12 hours
daily. Denies alcohol, tobacco, other drugs. She was recently
discharged to [**Hospital6 **] after a stay at [**Hospital1 771**] for dig toxicity. She was discharged on
[**2180-1-31**]. She is mostly bed bound. She is dependent on
others for her activities of daily living. Prior to admission to
[**Location (un) 86**], she was living at home with her partner x 30 years who
is also her health care proxy. 

### Response:
{'Acute respiratory failure,Chronic diastolic heart failure,Morbid obesity,Heart valve replaced by other means,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}
