CHIEF COMPLAINT: Lethargy, hypoxia

PRESENT ILLNESS: Pt is a [**Age over 90 **] yo woman with dementia (non-verbal) brought in from
[**Hospital3 2558**] with lethargy and hypoxia (not on baseline O2)
noted this morning. She reportedly sounded congested. O2 sat
there was 69% RA, 79% on 5L NC, T 96.7, HR 120's, BP 129/73. On
arrival in the ED VS were T 99.9 HR 85 BP 130/54 RR 26 (28-30)
Sat 70->improved to high 84% on NRB. ABG showed 7.33/49/62. She
was started on CPAP with improvement to 94%. After 1 hour ABG
showed 7.31/45/74. She was DNR/DNI on arrival however her
daughter and HCP reversed this and requested intubation if
needed. She received 1L NS. Blood cultures were drawn but urine
culture was not sent. She was given 1gm ceftriaxone when CXR
revealed RML consolidation. She was ordered for additional 1gm
vanco iv and zosyn (not clear if they were given). Labs were
significant for troponin of 0.07, potassium 5.9 (on repeat 5.1),
WBC 13.9, lactate 2.6. ECG showed a. flutter at rate of 111. She
was transferred to the [**Hospital Unit Name 153**] for further management.
.
At baseline per daughter she opens eyes, eats (with assistance)
thick liquids and purees. She has had private nursing for the
past 3 years with no infectious complications or bed sores but
prior to that had frequent UTI's, aspiration PNA's and bed
sores. Additionally daughter notes baseline blood pressure 'runs
low.'

MEDICAL HISTORY: 1.  Dementia - non-verbal at baseline and dependent for all
activities of daily living and not ambulatory
2.  H/o Syncope
3.  Osteoporosis
4.  Depression
5.  Heel ulcer
6.  Incontinence
7.  Atrial fibrilation with RVR, not on anticoagulation
8.  ? CVA per daughter (multiple small contributing to dementia)

MEDICATION ON ADMISSION: Ipratropium Bromide neb Q6H
Acetaminophen 650 mg Suppository Rectal Q4-6H
Aspirin 81 mg PO DAILY
Metoprolol Tartrate 12.5mg PO BID
Lisinopril 2.5 mgPO DAILY
Natural Tears 1.4 % 1-2OU twice a day prn
Multi-Vitamin PO once a day.
Colace 100 mg PO twice a day
Senna 187 mg PO BID:PRN
mirtazipine 7.5mg po qhs
bisacodyl 10mg supp prn
MOM 30ml po prn
guituss prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: Tc: 100.2 HR: 84 BP: 120/73 RR: 36 Sat: 96% on 60% hiflow
face mask
Gen: Elderly women lying in bed in NAD. No diaphoresis, no
accessory muscle use.  Pt appears awake and alert but does not
communicate.
HEENT: PERRL, EOMI, mm dry
CV: Faint heart sounds, tachycardic, S1, S2, no murmurs, rubs,
gallops
Resp: coarse rhonchi bilaterally, ? RLL rales, no wheezes
Abd: Soft, NT, ND, BS hypoactive, no masses
Ext: No clubbing, cyanosis, edema
Neuro: Pt not moving any extremity spontaneously, withdraws to
pain, right eye with lateral deviation, has minimal gag, no
occulocephalic reflex noted, some spontaneous movement
Skin: intact, no pressure ulcers, echymosis left hand dorsum

FAMILY HISTORY: Unknown

SOCIAL HISTORY: Pt lives at [**Hospital3 2558**] is completely dependent for
activities of daily living. Pt is non-verbal at baseline. The
patient is widowed. She has two daughters, one of whom is the
health care proxy [**Name (NI) 16405**] [**Name (NI) 349**] ([**Telephone/Fax (1) 16406**]).  The other
daughter lives in [**Name (NI) 4565**].
Unspecified septicemia,Methicillin susceptible pneumonia due to Staphylococcus aureus,Septic shock,Acute respiratory failure,Congestive heart failure, unspecified,Dehydration,Subendocardial infarction, initial episode of care,Paroxysmal ventricular tachycardia,Other persistent mental disorders due to conditions classified elsewhere,Unspecified essential hypertension,Depressive disorder, not elsewhere classified,Osteoporosis, unspecified
Septicemia NOS,Meth sus pneum d/t Staph,Septic shock,Acute respiratry failure,CHF NOS,Dehydration,Subendo infarct, initial,Parox ventric tachycard,Mental disor NEC oth dis,Hypertension NOS,Depressive disorder NEC,Osteoporosis NOS
Admission Date:  [**2199-8-10**]              Discharge Date:   [**2199-8-16**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

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

Major Surgical or Invasive Procedure:
Intubation

History of Present Illness:
Pt is a [**Age over 90 **] yo woman with dementia (non-verbal) brought in from
[**Hospital3 2558**] with lethargy and hypoxia (not on baseline O2)
noted this morning. She reportedly sounded congested. O2 sat
there was 69% RA, 79% on 5L NC, T 96.7, HR 120's, BP 129/73. On
arrival in the ED VS were T 99.9 HR 85 BP 130/54 RR 26 (28-30)
Sat 70->improved to high 84% on NRB. ABG showed 7.33/49/62. She
was started on CPAP with improvement to 94%. After 1 hour ABG
showed 7.31/45/74. She was DNR/DNI on arrival however her
daughter and HCP reversed this and requested intubation if
needed. She received 1L NS. Blood cultures were drawn but urine
culture was not sent. She was given 1gm ceftriaxone when CXR
revealed RML consolidation. She was ordered for additional 1gm
vanco iv and zosyn (not clear if they were given). Labs were
significant for troponin of 0.07, potassium 5.9 (on repeat 5.1),
WBC 13.9, lactate 2.6. ECG showed a. flutter at rate of 111. She
was transferred to the [**Hospital Unit Name 153**] for further management.
.
At baseline per daughter she opens eyes, eats (with assistance)
thick liquids and purees. She has had private nursing for the
past 3 years with no infectious complications or bed sores but
prior to that had frequent UTI's, aspiration PNA's and bed
sores. Additionally daughter notes baseline blood pressure 'runs
low.'

Past Medical History:
1.  Dementia - non-verbal at baseline and dependent for all
activities of daily living and not ambulatory
2.  H/o Syncope
3.  Osteoporosis
4.  Depression
5.  Heel ulcer
6.  Incontinence
7.  Atrial fibrilation with RVR, not on anticoagulation
8.  ? CVA per daughter (multiple small contributing to dementia)

Social History:
Pt lives at [**Hospital3 2558**] is completely dependent for
activities of daily living. Pt is non-verbal at baseline. The
patient is widowed. She has two daughters, one of whom is the
health care proxy [**Name (NI) 16405**] [**Name (NI) 349**] ([**Telephone/Fax (1) 16406**]).  The other
daughter lives in [**Name (NI) 4565**].

Family History:
Unknown

Physical Exam:
VS: Tc: 100.2 HR: 84 BP: 120/73 RR: 36 Sat: 96% on 60% hiflow
face mask
Gen: Elderly women lying in bed in NAD. No diaphoresis, no
accessory muscle use.  Pt appears awake and alert but does not
communicate.
HEENT: PERRL, EOMI, mm dry
CV: Faint heart sounds, tachycardic, S1, S2, no murmurs, rubs,
gallops
Resp: coarse rhonchi bilaterally, ? RLL rales, no wheezes
Abd: Soft, NT, ND, BS hypoactive, no masses
Ext: No clubbing, cyanosis, edema
Neuro: Pt not moving any extremity spontaneously, withdraws to
pain, right eye with lateral deviation, has minimal gag, no
occulocephalic reflex noted, some spontaneous movement
Skin: intact, no pressure ulcers, echymosis left hand dorsum

Pertinent Results:
Admission labs:
[**2199-8-10**] 10:20AM   WBC-13.9* RBC-4.71 HGB-14.1 HCT-44.8 MCV-95
MCH-29.8 MCHC-31.4 RDW-14.8
[**2199-8-10**] 10:20AM   NEUTS-86* BANDS-5 LYMPHS-5* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2199-8-10**] 10:20AM   GLUCOSE-137* UREA N-38* CREAT-0.9 SODIUM-142
POTASSIUM-5.9* CHLORIDE-108 TOTAL CO2-24 ANION GAP-16
[**2199-8-10**] 10:20AM   CALCIUM-9.9 PHOSPHATE-4.3 MAGNESIUM-2.6
[**2199-8-10**] 10:20AM   CK-MB-5
[**2199-8-10**] 10:20AM   cTropnT-0.07*
[**2199-8-10**] 11:39AM   TYPE-ART O2 FLOW-100 PO2-74* PCO2-45 PH-7.31*
TOTAL CO2-24 BASE XS--3 INTUBATED-NOT INTUBA
[**2199-8-10**] 10:37AM   LACTATE-2.6*
.
Imaging:
ECHO Study Date of [**2199-8-12**]
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. There is moderate symmetric left
ventricular hypertrophy. There is mild regional left ventricular
systolic dysfunction with infero-lateral akinesis. No masses or
thrombi are seen in the left ventricle. Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg).  There is no ventricular septal defect. Right
ventricular systolic function is borderline normal. The aortic
root is mildly dilated at the sinus level. The ascending aorta
is mildly dilated. The aortic valve is not well seen. There is
no aortic valve stenosis. Mild (1+) aortic regurgitation is
seen. Trivial mitral regurgitation is seen. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.  Compared with the report of the prior
study (images unavailable for review) of [**2196-12-14**], a regional
wall motion abnormality is now detected.
.
CHEST (PORTABLE AP)  [**2199-8-14**] 4:50 AM
Pulmonary vascular congestion has improved since [**8-13**], while
small right pleural effusion has increased. Small left pleural
effusion may be present, also increased and left lower lobe
atelectasis remains unchanged. ET tube in standard placement,
nasogastric tube passes below the diaphragm and out of view and
a right-sided central venous catheter tip projects over the low
SVC. No pneumothorax.
.
ECG Study Date of [**2199-8-13**]  9:34:52 AM
Atrial fibrillation with rapid ventricular response
LVH with secondary ST-T changes

Brief Hospital Course:
Pt is a [**Age over 90 **] yo woman with dementia (non-verbal) brought in from
[**Hospital3 2558**] with lethargy and hypoxia and was found to have
paroxysmal atrial flutter with RVR, elevated troponin, MRSA
pneumonia, and pulmonary edema.  Pt was intubated and supported
by vasopressors.  Pt care shifted to comfort measures only on
[**8-15**] per family.
.
1.  Respiratory distress, likely due to PNA and pulmonary edema:
 CXR on admission suggested infiltrate in RML.  Pt had presented
with low-grade fevers and leukocytosis with L shift and
bandemia.  After IVFs for fluid resucitation in an effort to
keep her BP and UOP up, pt was found to have pulmonary edema on
repeat CXR and was intubated for hypoxic respiratory failure.
An ECHO showed new mild regional left ventricular systolic
dysfunction with infero-lateral akinesis with EF of 45% to 50%.
Prior to shifting to comfort care, pt was receiving vancomycin
and zosyn for MRSA pneumonia and furosemide as needed for
respiratory distress.  She was also extubated on [**8-15**].
.
2.  Hypotension, presumed septic shock from PNA + cardiogenic
component (decreased output during a fib, decreased LV function
on ECHO):  Pt required phenylephrine to keep MAP at goal of >60
prior to shifting to comfort care.  Upon discharge, she was
maintaining SBP 100s on her own.
.
3.  Paroxysmal atrial fibrillation:  This ranged from being
rate-controlled on her own to RVR.
.
4.  Elevated troponin on admission, likely due to demand
ischemia in the setting of dehydration, hypoxia, and a. fib with
RVR upon at that time:  ECG had some concerning changes though
not significantly changed from previous readings.  CK, CKMB
index were not elevated x4.
.
5.  Hypertension: Pt's SBP remained <120 during her hospital
stay.  Her home antihypertensives were held.
.
6.  Fluids/electroyltes/nutrition:  Pt's electrolytes were
repleted as necessary.  She did received tube feedings prior to
shifting to comfort care.

Medications on Admission:
Ipratropium Bromide neb Q6H
Acetaminophen 650 mg Suppository Rectal Q4-6H
Aspirin 81 mg PO DAILY
Metoprolol Tartrate 12.5mg PO BID
Lisinopril 2.5 mgPO DAILY
Natural Tears 1.4 % 1-2OU twice a day prn
Multi-Vitamin PO once a day.
Colace 100 mg PO twice a day
Senna 187 mg PO BID:PRN
mirtazipine 7.5mg po qhs
bisacodyl 10mg supp prn
MOM 30ml po prn
guituss prn

Discharge Medications:
1. Acetaminophen 160 mg/5 mL Solution Sig: [**1-29**]  PO Q6H (every 6
hours) as needed for fever.
2. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal ONCE (Once) as needed for secretions.
3. Morphine 10 mg/5 mL Solution Sig: [**1-29**]  PO Q6H (every 6 hours)
as needed for respiratory distress or pain.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 2558**] - [**Location (un) **]

Discharge Diagnosis:
Pneumonia
Shock
Atrial fibrillation


Discharge Condition:
Stable


Discharge Instructions:
You were admitted for lethargy and hypoxia.  You were found to
have pneumonia and to occasionally have an irregular heart
rhythm.  For a time, you required breathing assitance with a
ventilator and medications to support your blood pressure.
After a long discussion with your family members and the social
worker, it was decided that you wished to have your care
centered on comfort.
.
Please use the medications prescribed for your comfort as
needed.

Followup Instructions:
None
{'Unspecified septicemia,Methicillin susceptible pneumonia due to Staphylococcus aureus,Septic shock,Acute respiratory failure,Congestive heart failure, unspecified,Dehydration,Subendocardial infarction, initial episode of care,Paroxysmal ventricular tachycardia,Other persistent mental disorders due to conditions classified elsewhere,Unspecified essential hypertension,Depressive disorder, not elsewhere classified,Osteoporosis, unspecified'}


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: Lethargy, hypoxia

PRESENT ILLNESS: Pt is a [**Age over 90 **] yo woman with dementia (non-verbal) brought in from
[**Hospital3 2558**] with lethargy and hypoxia (not on baseline O2)
noted this morning. She reportedly sounded congested. O2 sat
there was 69% RA, 79% on 5L NC, T 96.7, HR 120's, BP 129/73. On
arrival in the ED VS were T 99.9 HR 85 BP 130/54 RR 26 (28-30)
Sat 70->improved to high 84% on NRB. ABG showed 7.33/49/62. She
was started on CPAP with improvement to 94%. After 1 hour ABG
showed 7.31/45/74. She was DNR/DNI on arrival however her
daughter and HCP reversed this and requested intubation if
needed. She received 1L NS. Blood cultures were drawn but urine
culture was not sent. She was given 1gm ceftriaxone when CXR
revealed RML consolidation. She was ordered for additional 1gm
vanco iv and zosyn (not clear if they were given). Labs were
significant for troponin of 0.07, potassium 5.9 (on repeat 5.1),
WBC 13.9, lactate 2.6. ECG showed a. flutter at rate of 111. She
was transferred to the [**Hospital Unit Name 153**] for further management.
.
At baseline per daughter she opens eyes, eats (with assistance)
thick liquids and purees. She has had private nursing for the
past 3 years with no infectious complications or bed sores but
prior to that had frequent UTI's, aspiration PNA's and bed
sores. Additionally daughter notes baseline blood pressure 'runs
low.'

MEDICAL HISTORY: 1.  Dementia - non-verbal at baseline and dependent for all
activities of daily living and not ambulatory
2.  H/o Syncope
3.  Osteoporosis
4.  Depression
5.  Heel ulcer
6.  Incontinence
7.  Atrial fibrilation with RVR, not on anticoagulation
8.  ? CVA per daughter (multiple small contributing to dementia)

MEDICATION ON ADMISSION: Ipratropium Bromide neb Q6H
Acetaminophen 650 mg Suppository Rectal Q4-6H
Aspirin 81 mg PO DAILY
Metoprolol Tartrate 12.5mg PO BID
Lisinopril 2.5 mgPO DAILY
Natural Tears 1.4 % 1-2OU twice a day prn
Multi-Vitamin PO once a day.
Colace 100 mg PO twice a day
Senna 187 mg PO BID:PRN
mirtazipine 7.5mg po qhs
bisacodyl 10mg supp prn
MOM 30ml po prn
guituss prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: Tc: 100.2 HR: 84 BP: 120/73 RR: 36 Sat: 96% on 60% hiflow
face mask
Gen: Elderly women lying in bed in NAD. No diaphoresis, no
accessory muscle use.  Pt appears awake and alert but does not
communicate.
HEENT: PERRL, EOMI, mm dry
CV: Faint heart sounds, tachycardic, S1, S2, no murmurs, rubs,
gallops
Resp: coarse rhonchi bilaterally, ? RLL rales, no wheezes
Abd: Soft, NT, ND, BS hypoactive, no masses
Ext: No clubbing, cyanosis, edema
Neuro: Pt not moving any extremity spontaneously, withdraws to
pain, right eye with lateral deviation, has minimal gag, no
occulocephalic reflex noted, some spontaneous movement
Skin: intact, no pressure ulcers, echymosis left hand dorsum

FAMILY HISTORY: Unknown

SOCIAL HISTORY: Pt lives at [**Hospital3 2558**] is completely dependent for
activities of daily living. Pt is non-verbal at baseline. The
patient is widowed. She has two daughters, one of whom is the
health care proxy [**Name (NI) 16405**] [**Name (NI) 349**] ([**Telephone/Fax (1) 16406**]).  The other
daughter lives in [**Name (NI) 4565**]. 

### Response:
{'Unspecified septicemia,Methicillin susceptible pneumonia due to Staphylococcus aureus,Septic shock,Acute respiratory failure,Congestive heart failure, unspecified,Dehydration,Subendocardial infarction, initial episode of care,Paroxysmal ventricular tachycardia,Other persistent mental disorders due to conditions classified elsewhere,Unspecified essential hypertension,Depressive disorder, not elsewhere classified,Osteoporosis, unspecified'}
