CHIEF COMPLAINT: respiratory distress

PRESENT ILLNESS: Mrs. [**Known lastname 44865**] is a [**Age over 90 **] year-old female with advanced dementia who
presented with respiratory distress, BIBA on bipap, tachypneic
and tachycardic, likely secondary to aspiration event; after
goals of care discussion, patient is now CMO.

MEDICAL HISTORY: - Advanced dementia, multi-infarct
- Diverticulosis
- Hearing loss
- Retinal detachment
- B12 deficiency
- Chronic abdominal pain
- Irritable bowel syndrome
- Spinal Stenosis

MEDICATION ON ADMISSION: Aspirin 81 mg daily
Vitamin D 400 U daily
Advil 600 mg daily

ALLERGIES: Zosyn

PHYSICAL EXAM: ADMISSION EXAM
General Appearance: No acute distress
Eyes / Conjunctiva: R>L pupil, both reactive (baseline)
Cardiovascular: (S1: Normal), (S2: Normal)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear :)
Abdominal: Soft, Non-tender
Extremities: Right lower extremity edema: 2+, Left lower
extremity edema: 2+
Skin: Stage V pressure ulcers bilateral calves
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: She was an English professor for many years. Lives with husband
who is her primary care giver. Had health aides that come to the
house 7 days a week. She has 2 sons. She has profound vascular
dementia, is dependent with all ADLs and is non verbal at
baseline.
Pneumonitis due to inhalation of food or vomitus,Pressure ulcer, stage IV,Other persistent mental disorders due to conditions classified elsewhere,Other vitamin B12 deficiency anemia
Food/vomit pneumonitis,Pressure ulcer, stage IV,Mental disor NEC oth dis,B12 defic anemia NEC
Admission Date:  [**2192-5-25**]              Discharge Date:   [**2192-5-29**]


Service: MEDICINE

Allergies:
Zosyn

Attending:[**First Name3 (LF) 2610**]
Chief Complaint:
respiratory distress

Major Surgical or Invasive Procedure:
None.

History of Present Illness:
Mrs. [**Known lastname 44865**] is a [**Age over 90 **] year-old female with advanced dementia who
presented with respiratory distress, BIBA on bipap, tachypneic
and tachycardic, likely secondary to aspiration event; after
goals of care discussion, patient is now CMO.

By report, patient was being fed by her caretaker, received some
advil and developed respiratory distress with a question of
aspiration. Patient's baseline function nonverbal and they use a
device to mobilize her from bed to chair. Spends day watching
TV, not interactive with people. In the ED it was discussed that
there would be no intubation, no compressions, no
defibrillation, no central line, no pressures. Medications by
vein and BiPap OK. Would not want cath.

Upon EMS arrival, tachypneic to 30-40, received nitropaste and
lasix en route with improvement. SBP 80-90 on arrival. Improved
off of bipap with SBP 140. Was taken off nitro paste in ED. Did
well on CPAP and then on NC, then shovel mask.

Labs significant for lactate 2.7, K 5.3, creatinine 0.9, trop
0.07, BNP 8751. WBC 21.7, Hct 42.4, Plate 493, N 88, band 1. UA
negative
She was given Ceftriaxone 1,250mg, Flagyl 500mg. CXR showed low
lung volumes, no focal consolidation or pleural effusion,
minimal left basilar atelectasis. EKG with ?STE I, avL. Blood
cultures were sent.

On the floor, does not appear to be in pain. She occassionally
tracks with her eyes but is nonverbal. She is not in respiratory
distress.

Past Medical History:
- Advanced dementia, multi-infarct
- Diverticulosis
- Hearing loss
- Retinal detachment
- B12 deficiency
- Chronic abdominal pain
- Irritable bowel syndrome
- Spinal Stenosis

Social History:
She was an English professor for many years. Lives with husband
who is her primary care giver. Had health aides that come to the
house 7 days a week. She has 2 sons. She has profound vascular
dementia, is dependent with all ADLs and is non verbal at
baseline.

Family History:
Non-contributory.

Physical Exam:
ADMISSION EXAM
General Appearance: No acute distress
Eyes / Conjunctiva: R>L pupil, both reactive (baseline)
Cardiovascular: (S1: Normal), (S2: Normal)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear :)
Abdominal: Soft, Non-tender
Extremities: Right lower extremity edema: 2+, Left lower
extremity edema: 2+
Skin: Stage V pressure ulcers bilateral calves
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed

DISCHARGE EXAM
GEN: no apparent distress
RESP: 14-20, anterior clear to auscultation
CV: RRR, nl S1, S2, no MRG
ABD: soft
EXT: stage V pressure ulcers bilateral posterior calves, R
appears with purulent discharge & foul-smelling odor, bilateral
large toes with ulcers

Pertinent Results:
 # LABORATORY DATA

Admission Labs
[**2192-5-25**] 06:00PM BLOOD WBC-21.7* RBC-4.66 Hgb-13.8 Hct-42.4
MCV-91 MCH-29.6 MCHC-32.5 RDW-14.1 Plt Ct-493*
[**2192-5-25**] 06:00PM BLOOD Neuts-88* Bands-1 Lymphs-6* Monos-5 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2192-5-25**] 06:00PM BLOOD PT-11.6 PTT-21.8* INR(PT)-1.0
[**2192-5-25**] 06:00PM BLOOD Glucose-218* UreaN-38* Creat-0.9 Na-135
K-5.3* Cl-97 HCO3-24 AnGap-19
[**2192-5-25**] 06:00PM BLOOD cTropnT-0.07* proBNP-8751*
[**2192-5-25**] 06:15PM BLOOD Lactate-2.7*

Discharge Labs: N/A.

 # IMAGING

[**5-25**] CHEST (Portable AP)
SEMI-UPRIGHT AP VIEW OF THE CHEST: The lung volumes are low. The
heart size is mildly enlarged with left ventricular
predominance. The aorta is mildly tortuous and diffusely
calcified. The pulmonary vascularity is normal. There may be
minimal left basilar atelectasis, but no focal consolidation is
seen. No pleural effusion or pneumothorax is present.
Degenerative changes are noted within the imaged thoracolumbar
spine, as well as involving both glenohumeral and
acromioclavicular joints.
IMPRESSION: Minimal left basilar atelectasis.

 # MICROBIOLOGY

[**5-25**] Blood cultures: Pending at discharge.

Brief Hospital Course:
[**Age over 90 **] year-old female with advanced dementia who presented with
respiratory distress, likely secondary to aspiration event.

# Goals of care: After multiple conversations the patient's
husband/HCP and son decided that care to prolong life was not
the priority and they would like to focus on comfort.
Antibiotics, lab draws & imaging studies were discontinued and
the patient was made comfort measures only. Palliative care was
consulted and helped the family arrange home hospice.

# Stage V pressure ulcers: Patient has stage V pressure ulcers
on her bilateral posterior calves inferiorly, as well as
bilateral ulcers on her 1st toes. Wound care was consulted and
made recommendations for appropriate wound care. At this point,
surgical debridement of the ulcers is not in line with the
patient's goal of care, which is comfort.

# Leukocytosis: With bands, most likely secondary to occult
infection versus stress response. See 'goals of care' above.

# Elevated troponin: Had been elevated in the past. No
significant EKG changes. See 'goals of care' above.

# Code status: Changed to comfort measures only (CMO) during
this admission.

Medications on Admission:
Aspirin 81 mg daily
Vitamin D 400 U daily
Advil 600 mg daily

Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day). Disp:*qs bottle* Refills:*2*
2. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation. Disp:*20
Suppository(s)* Refills:*1*
3. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig:
[**2-5**] mL PO q1h (every one (1) hour) as needed for pain or
respiratory distress. Disp:*30 mL* Refills:*0*

Discharge Disposition:
Home With Service

Facility:
circle of caring

Discharge Diagnosis:
Primary diagnosis:
# Aspiration pneumonitis
# End-stage dementia

Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.

Discharge Instructions:
# You were admitted to the hospital because you were having
difficulty breathing. You likely aspirated food or a pill (food
went down the wrong way, into your lungs rather than to your
stomach). You were initially taken to the intensive care unit,
but after discussion about goals of care, you were transferred
to the medical floor with comfort care as our primary goal.

# We made the following changes to your medications:
- STARTED morphine solution for pain
- STARTED docusate sodium liquid to soften stool
- STARTED bisacodyl suppositories as needed for constipation

- STOPPED aspirin
- STOPPED Advil (ibuprofen)
- STOPPED vitamin D

# For comfort, you should take morphine 30 minutes prior to your
dressing changes.

# You should take docusate sodium liquid twice a day to soften
your stools. Use the bisacodyl suppository as needed for
constipation.

# Follow up with hospice care as needed.

Followup Instructions:
Follow up with Circle of [**Hospital **] hospice as needed (tel:
[**Telephone/Fax (1) 77096**]).


Completed by:[**2192-5-29**]
{'Pneumonitis due to inhalation of food or vomitus,Pressure ulcer, stage IV,Other persistent mental disorders due to conditions classified elsewhere,Other vitamin B12 deficiency anemia'}


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: respiratory distress

PRESENT ILLNESS: Mrs. [**Known lastname 44865**] is a [**Age over 90 **] year-old female with advanced dementia who
presented with respiratory distress, BIBA on bipap, tachypneic
and tachycardic, likely secondary to aspiration event; after
goals of care discussion, patient is now CMO.

MEDICAL HISTORY: - Advanced dementia, multi-infarct
- Diverticulosis
- Hearing loss
- Retinal detachment
- B12 deficiency
- Chronic abdominal pain
- Irritable bowel syndrome
- Spinal Stenosis

MEDICATION ON ADMISSION: Aspirin 81 mg daily
Vitamin D 400 U daily
Advil 600 mg daily

ALLERGIES: Zosyn

PHYSICAL EXAM: ADMISSION EXAM
General Appearance: No acute distress
Eyes / Conjunctiva: R>L pupil, both reactive (baseline)
Cardiovascular: (S1: Normal), (S2: Normal)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear :)
Abdominal: Soft, Non-tender
Extremities: Right lower extremity edema: 2+, Left lower
extremity edema: 2+
Skin: Stage V pressure ulcers bilateral calves
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: She was an English professor for many years. Lives with husband
who is her primary care giver. Had health aides that come to the
house 7 days a week. She has 2 sons. She has profound vascular
dementia, is dependent with all ADLs and is non verbal at
baseline. 

### Response:
{'Pneumonitis due to inhalation of food or vomitus,Pressure ulcer, stage IV,Other persistent mental disorders due to conditions classified elsewhere,Other vitamin B12 deficiency anemia'}
