CHIEF COMPLAINT: Aspiration PNA

PRESENT ILLNESS: [**Age over 90 **] yo F with recent admission to an OSH for SDH [**Date range (1) 66732**] who is
being transferred from OSH for aspiration PNA c/b hypoxemic
respiratory failure s/p intubation.
.
Patient reportedly fell in [**Month (only) **] at home without LOC, and
started to develop fatigue over the past 2 weeks prior to
initial admission. His son noted garbled speech and brought him
in to the hospital where he was diagnosed with a SDH. Following
this prior admission, he was discharged to Rehab with plans to
return for an evacuation in one week for a plavix washout
scheduled for Wednesday, [**12-30**].
.
In rehab, he developed SOB and was found to have O2sats in the
70s. He was intubated upon arrival in the OSH ED. His labs at
that time were notable for Wbc: 10.4, Hct: 27, Cr 1.6. (cr
during prior admission: 1.3), lactate of 2.7. reportedly CXR
showed bilateral infiltrates. Diagnosed with sepsis due to
pneumonia. He was also diagnosed with NSTEMI with troponin peak
to 0.5.  He was treated with Vancomycin, Zosyb and plavix and
transferred to [**Hospital1 18**] intubated and sedated for neurosurgical
evaluation.

MEDICAL HISTORY: -- SDH, d/t mechanical fall in [**10-3**] per son
-- HLD
-- HTN
-- TIA x 3, last TIA 4-5 years ago. Carotids found to have
stenosis with 85% on one side. Per son's report carotids Since
has been taking lipitor and plavix, but recently d/c'd plavix
d/t SDH.
-- Right Inguinal Hernia Repair x2, Last 16 years prior
-- Zenkers Diverticulum

MEDICATION ON ADMISSION: Medications: on Transfer
- Phenylephrine (discontinued prior to transfer)
- pantoprazole 40 IV BID
- Propofol IV prn
- combivent 4 puff q 4h prn
- reglan 10 mg q6h prn
- zofran 4 mg q4H prn
- acetaminophen 650 mg q4H prn
- Vancomycin 1 gram
- Zosyn 2.25 mg IV q6H
- Lefaquin 250 mg daily
- Fentanyl 50 mcg q3H prn
.
Home Medications:
1. docusate sodium 100 mg Capsule [**Year (4 digits) **]: One (1) Capsule PO BID (2

ALLERGIES: Sulfa(Sulfonamide Antibiotics)

PHYSICAL EXAM: Vitals: T:100.4 BP:100/42 P: R: 26 O2:
General: intubated and sedated
HEENT: Sclera anicteric, MMM, ET tube in place,
Neck: supple, JVP not elevated,
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis.
Trace edema in lower extremities
Neuro: Sedated and responds to pain, once sedation is off, moves
all extremities
.

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives alone
Denies tobacco and EtOH use
Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Subendocardial infarction, initial episode of care,Subdural hemorrhage,Acute kidney failure, unspecified,Unspecified essential hypertension,Diverticulum of esophagus, acquired,Other convulsions,Encounter for palliative care,Other and unspecified hyperlipidemia,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits
Acute respiratry failure,Food/vomit pneumonitis,Subendo infarct, initial,Subdural hemorrhage,Acute kidney failure NOS,Hypertension NOS,Acq esophag diverticulum,Convulsions NEC,Encountr palliative care,Hyperlipidemia NEC/NOS,Hx TIA/stroke w/o resid
Admission Date:  [**2133-12-28**]              Discharge Date:   [**2134-1-1**]


Service: MEDICINE

Allergies:
Sulfa(Sulfonamide Antibiotics)

Attending:[**First Name3 (LF) 8263**]
Chief Complaint:
Aspiration PNA


Major Surgical or Invasive Procedure:
Extubation


History of Present Illness:
 [**Age over 90 **] yo F with recent admission to an OSH for SDH [**Date range (1) 66732**] who is
being transferred from OSH for aspiration PNA c/b hypoxemic
respiratory failure s/p intubation.
.
Patient reportedly fell in [**Month (only) **] at home without LOC, and
started to develop fatigue over the past 2 weeks prior to
initial admission. His son noted garbled speech and brought him
in to the hospital where he was diagnosed with a SDH. Following
this prior admission, he was discharged to Rehab with plans to
return for an evacuation in one week for a plavix washout
scheduled for Wednesday, [**12-30**].
.
In rehab, he developed SOB and was found to have O2sats in the
70s. He was intubated upon arrival in the OSH ED. His labs at
that time were notable for Wbc: 10.4, Hct: 27, Cr 1.6. (cr
during prior admission: 1.3), lactate of 2.7. reportedly CXR
showed bilateral infiltrates. Diagnosed with sepsis due to
pneumonia. He was also diagnosed with NSTEMI with troponin peak
to 0.5.  He was treated with Vancomycin, Zosyb and plavix and
transferred to [**Hospital1 18**] intubated and sedated for neurosurgical
evaluation.

Past Medical History:
-- SDH, d/t mechanical fall in [**10-3**] per son
-- HLD
-- HTN
-- TIA x 3, last TIA 4-5 years ago. Carotids found to have
stenosis with 85% on one side. Per son's report carotids Since
has been taking lipitor and plavix, but recently d/c'd plavix
d/t SDH.
-- Right Inguinal Hernia Repair x2, Last 16 years prior
-- Zenkers Diverticulum


Social History:
Lives alone
Denies tobacco and EtOH use


Family History:
NC

Physical Exam:
Vitals: T:100.4 BP:100/42 P: R: 26 O2:
General: intubated and sedated
HEENT: Sclera anicteric, MMM, ET tube in place,
Neck: supple, JVP not elevated,
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis.
Trace edema in lower extremities
Neuro: Sedated and responds to pain, once sedation is off, moves
all extremities
.


Pertinent Results:
[**2133-12-31**] 01:10AM BLOOD WBC-5.0 RBC-3.63* Hgb-11.6* Hct-34.4*
MCV-95 MCH-32.0 MCHC-33.8 RDW-14.2 Plt Ct-152
[**2133-12-28**] 04:12PM BLOOD PT-13.7* PTT-33.7 INR(PT)-1.3*
[**2133-12-31**] 01:10AM BLOOD PT-13.1* PTT-28.0 INR(PT)-1.2*
[**2133-12-28**] 04:12PM BLOOD Glucose-103* UreaN-30* Creat-1.8* Na-137
K-4.7 Cl-114* HCO3-16* AnGap-12
[**2133-12-31**] 01:10AM BLOOD Glucose-100 UreaN-34* Creat-1.8* Na-142
K-4.1 Cl-114* HCO3-17* AnGap-15
[**2133-12-28**] 04:12PM BLOOD ALT-31 AST-26 LD(LDH)-204 CK(CPK)-26*
AlkPhos-58 TotBili-0.7
[**2133-12-30**] 03:33AM BLOOD ALT-29 AST-24 AlkPhos-54 TotBili-0.7
[**2133-12-29**] 05:07AM BLOOD CK-MB-2 cTropnT-0.15*
[**2133-12-28**] 04:12PM BLOOD Calcium-7.5* Phos-2.9 Mg-1.8
[**2133-12-31**] 01:10AM BLOOD Calcium-8.2* Phos-3.2 Mg-1.9
[**2133-12-28**] 04:12PM BLOOD Vanco-20.6*
[**2133-12-29**] 06:26AM BLOOD Vanco-14.9
[**2133-12-28**] 05:00PM BLOOD Lactate-1.5
[**2133-12-28**] 11:15PM BLOOD Lactate-1.3
.
Chest Xray [**2133-12-28**]: Right mid lung and lower lobe consolidation
appears to be new and might reflect extensive pneumonia. Left
basilar opacity is noted and reflect another area of infection,
most likely . Small amount of bilateral pleural effusion is
present.
.
Chest Xray [**2133-12-30**]: FINDINGS: In comparison with the study of
[**12-29**], the tip of the endotracheal tube lies approximately 6.9 cm
above the carina. Nasogastric tube again extends well into the
stomach. There are again bilateral layering pleural effusions,
more prominent on the right with compressive atelectasis at the
bases. The possibility of supervening pneumonia, especially at
the right base, cannot be excluded in the appropriate clinical
setting.
.
TTE [**2133-12-29**]: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is mildly depressed with apical hypokinesis/akinesis
(LVEF= 40-45 %). A large round thrombus is seen in the left
ventricular apex approximately 1.7 cm in diameter. Right
ventricular chamber size is normal. with depressed free wall
contractility. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion.
.
Video Swallow: IMPRESSION: Large posterior diverticulum in the
upper esophagus consistent with a Zenker's diverticulum.
Regurgitation resulted in trace aspiration of all consistencies.
For full details, please see detailed speech and swallow note in
OMR.
.
CT HEAD non contrast [**2133-12-28**]: IMPRESSION:
1. Stable size of the large chronic left frontoparietal subdural
hematoma.
2. Minimal increase in the degree of subfalcine herniation, now
measuring 10 mm to the right as opposed 8 mm previously.
3. No evidence of transtentorial herniation.
4. No new intra- or extra-axial hemorrhage


Brief Hospital Course:
BRIEF HOSPITAL COURSE: This is a [**Age over 90 **] year old gentleman with a
history of TIAs, recent subdural hemorrhage complicated by
seizures who presents from rehab with pneumonia with associated
respiratory failure prior to transport here. He was transferred
to the ICU where he was initiated on antibiotic therapy for
health care acquired pneumonia and extubated. Following
extubation the decision was made to focus on comfort measures.
.
ACTIVE ISSUES
RESPIRATORY FAILURE: Bilateral infiltrates noted on chest xray.
He was intubated prior to transfer to [**Hospital1 18**]. Significant
aspiration risk given large zenkers diverticulum. He was
continued on zosyn and vancomycin. Ciprofloxacin was added for a
planned course of 8 days for treatment of health care aquired
pneumonia.  Gram stain of his sputum demonstrated budding yeast
with pseudohyphae, gram negative rods and gram positive cocci.
He was extubated on [**2133-12-29**] sucessfully and had no oxygen
requirement. His antibiotic course was simplified when medical
care was shifted to comfort care. Vancomycin and zosyn were
continued for management of fevers and secretions at the request
of the family. (day 8 = [**2134-1-4**]).
.
SUBDURAL HEMATOMA: Concerning for progressive hematoma based on
OSH CT. EKG concerning for cerebral T waves. Hemodynamics are
not consistent with ICP and patient moving all extremities.
Initial presentation was concerning for active seizures, keppra
was increased from 750 [**Hospital1 **] to 1000 [**Hospital1 **] dosing. A repeat CT head
here demonstrated stable size of his chronic left frotonparietal
subdural hematoma with a minimal increase in the defree of
subfalcine herniation. A continuous EEG demonstrated
epileptiform charges that improved over time and did not appear
consistent with ative seizures. A burr hole was considered by
neurosurgery for future management after completement of
treatment of pneumonia and sepsis.
.
NSTEMI: At OSH noted to have NSTEMI with peak troponin 0.5 and
cerebral T waves on EKG.  Troponins remained presistently
elevated throughout admission.  Antiplatelet medications were
stopped on admission to [**Hospital1 18**] secondary to subdural hematoma. He
was continued on atorvastatin which was discontinued on
discharge secondary to shift of care focus to comfort.
.
LV THROMBUS: Noted in an echo at outside hospital. Repeat echo
here demonstrated mild apical hypokinesis/akinesis with an
associated large round thrombus in the left ventricular apex of
1.7cm in diameter. Anticoagulation is not possible secondary to
sub dural hematoma.
.
ACUTE KIDNEY INJURY: Creatining 1.8-1.9 throughout admission.
Baseline creatinine 1.3.  Medications were renally dosed.
.
HYPERTENSION: Not an issue. Lisinopril and hydralazine were held
in the setting of sepsis and admission hypotension. They were
not restarted on discharge.
.
TACHYCARDIA: Multifocal atrial tachycardia, intermittant atrial
fibrillation of new onset on admission. In the ICU, he was
treated with IV metoprolol q4hrs. This was transitioned to
crushable PO metoprolol tartrate on transfer to the floor.
.
ZENKERS DIVERTICULUM: A swallow consult was made after
extubation. He was well known to the service. A video swallow
during his last admission on [**2133-12-23**] demonstrated a large
diverticulum with backflow and risk of aspiration with all
consistencies.  His mental status was clear on that admission
and the patient accepted the risk of aspiration having the
diverticulum for the past 13 years without complication.  After
extubation on this admission, he is notably below his baseline
with unclear contribution of delirium/encephalopathy
contributing to his mental status. He was transitioned to PO
crushable or liquid medications with diet modified to thin
liquids with ground consistency. He aspirated all these pills so
his medications were changed back to IV.  The family was aware
of his aspiration risk.
.
GOALS OF CARE: On transfer from the MICU to the general medical
floor, the patient was notably not at his baseline. It is
unclear at the time of discharge, how much of his mental status
changes could be attributed to delirium. He was able to complete
short sentences and respond occasionally appropriately to simple
commands. He appeared to recognize his family members.  The
decision was made by his son to transition him to comfort
focused care and transfer him to a nursing facility closer to
his home with hospice care. He was transitioned to liquid
morphine for pain. He did not seem to tolerate ativan for
agitation.  Anti-psychotics were not provided secondary to his
prolongued qtc 506 (489 after d/c of cipro).  Antibiotic therapy
was continued for management of respiratory secretions and
fever. Metoprolol was continued for heart rate control and
keppra for seizure prophylaxis.
.
TRANSITIONAL ISSUES
- comfort focused care

Medications on Admission:
Medications: on Transfer
- Phenylephrine (discontinued prior to transfer)
- pantoprazole 40 IV BID
- Propofol IV prn
- combivent 4 puff q 4h prn
- reglan 10 mg q6h prn
- zofran 4 mg q4H prn
- acetaminophen 650 mg q4H prn
- Vancomycin 1 gram
- Zosyn 2.25 mg IV q6H
- Lefaquin 250 mg daily
- Fentanyl 50 mcg q3H prn
.
Home Medications:
1. docusate sodium 100 mg Capsule [**Year (4 digits) **]: One (1) Capsule PO BID (2

times a day).
2. senna 8.6 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO HS (at bedtime).
3. multivitamin Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily).
4. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
[**Year (4 digits) **]: One (1) Tablet, Chewable PO TID (3 times a day).
5. lisinopril 5 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily).

6. simvastatin 10 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY
(Daily).
7. heparin (porcine) 5,000 unit/mL Solution [**Year (4 digits) **]: One (1)
Injection TID (3 times a day).
8. acetaminophen 325 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO Q6H (every

6 hours) as needed for pain.
9. Famotidine 20 mg IV Q12H
10. LeVETiracetam 750 mg IV BID
11. HydrALAzine 10 mg IV Q6H:PRN SBP>160


Discharge Medications:
1. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution [**Year (4 digits) **]: One
(1)  PO Q2H (every 2 hours) as needed for pain.
Disp:*qS * Refills:*0*
2. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
3. Piperacillin-Tazobactam 2.25 g IV Q6H
4. Vancomycin 1000 mg IV Q48H
5. metoprolol tartrate 5 mg/5 mL Solution [**Last Name (STitle) **]: One (1)
Intravenous every four (4) hours.
6. Senna Soft 15 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
7. Colace 60 mg/15 mL Syrup [**Last Name (STitle) **]: One (1)  PO once a day.
8. Keppra 100 mg/mL Solution [**Last Name (STitle) **]: Ten (10) mL PO twice a day:
Solution. Oral versus Per Rectal.


Discharge Disposition:
Extended Care

Facility:
Country Rehabilitation and Nursing Center - [**Location (un) 5028**]

Discharge Diagnosis:
1. Health Care associated pneumonia, Subdural Hematoma, Seizures


Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
You were admitted for management of respiratory distress. You
were continued on intravenous antibiotics for hospital acquired
pneumonia. Our neurosurgeons evaluated you and deferred surgical
intervention until management of your infection was completed.
You were transitioned to comfort focused care after discussion
with your loved ones resgarding your care. You were transitioned
to a nursing facility with hospice care.
.
The following changes were made to your medication list.
1. CONTINUE VANCOMYCIN for 3 additional days
2. CONTINUE ZOSYN for 3 additional days
3. INCREASE KEPPRA to 1000 mg IV BID
4. START LIQUID MORPHINE q6hrs prn
5. START LANSOPRAZOLE 30mg ODT
6. START METOPROLOL 5mg IV q4hrs
7. DISCONTINUE CALCIUM CARBONATE
8. DISCONTINUE MULTIVITAMIN
9. DISCONTINUE SIMVASTATIN daily
10. DISCONTINUE HEPARIN SUBQ
11. DISCONTINUE HYDRALAZINE 10mg IV
12. DISCONTINUE FAMOTIDINE daily
13. DISCONTINUE LISINOPRIL daily

Followup Instructions:
Please follow-up with the providers at the nursing facility that
you are being transferred to.





Name:  [**Known lastname 14451**],[**Known firstname **]                    Unit No:   [**Numeric Identifier 14452**]

Admission Date:  [**2133-12-28**]              Discharge Date:   [**2134-1-1**]

Date of Birth:  [**2042-9-2**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Sulfa(Sulfonamide Antibiotics)

Attending:[**First Name3 (LF) 40**]
Addendum:
Patient did have acute delirium/toxic metabolic encephalopathy

Discharge Disposition:
Extended Care

Facility:
Country Rehabilitation and Nursing Center - [**Location (un) 6451**]

                             [**Name6 (MD) **] [**Last Name (NamePattern4) 43**] MD [**MD Number(2) 44**]

Completed by:[**2134-3-2**]
{'Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Subendocardial infarction, initial episode of care,Subdural hemorrhage,Acute kidney failure, unspecified,Unspecified essential hypertension,Diverticulum of esophagus, acquired,Other convulsions,Encounter for palliative care,Other and unspecified hyperlipidemia,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits'}


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: Aspiration PNA

PRESENT ILLNESS: [**Age over 90 **] yo F with recent admission to an OSH for SDH [**Date range (1) 66732**] who is
being transferred from OSH for aspiration PNA c/b hypoxemic
respiratory failure s/p intubation.
.
Patient reportedly fell in [**Month (only) **] at home without LOC, and
started to develop fatigue over the past 2 weeks prior to
initial admission. His son noted garbled speech and brought him
in to the hospital where he was diagnosed with a SDH. Following
this prior admission, he was discharged to Rehab with plans to
return for an evacuation in one week for a plavix washout
scheduled for Wednesday, [**12-30**].
.
In rehab, he developed SOB and was found to have O2sats in the
70s. He was intubated upon arrival in the OSH ED. His labs at
that time were notable for Wbc: 10.4, Hct: 27, Cr 1.6. (cr
during prior admission: 1.3), lactate of 2.7. reportedly CXR
showed bilateral infiltrates. Diagnosed with sepsis due to
pneumonia. He was also diagnosed with NSTEMI with troponin peak
to 0.5.  He was treated with Vancomycin, Zosyb and plavix and
transferred to [**Hospital1 18**] intubated and sedated for neurosurgical
evaluation.

MEDICAL HISTORY: -- SDH, d/t mechanical fall in [**10-3**] per son
-- HLD
-- HTN
-- TIA x 3, last TIA 4-5 years ago. Carotids found to have
stenosis with 85% on one side. Per son's report carotids Since
has been taking lipitor and plavix, but recently d/c'd plavix
d/t SDH.
-- Right Inguinal Hernia Repair x2, Last 16 years prior
-- Zenkers Diverticulum

MEDICATION ON ADMISSION: Medications: on Transfer
- Phenylephrine (discontinued prior to transfer)
- pantoprazole 40 IV BID
- Propofol IV prn
- combivent 4 puff q 4h prn
- reglan 10 mg q6h prn
- zofran 4 mg q4H prn
- acetaminophen 650 mg q4H prn
- Vancomycin 1 gram
- Zosyn 2.25 mg IV q6H
- Lefaquin 250 mg daily
- Fentanyl 50 mcg q3H prn
.
Home Medications:
1. docusate sodium 100 mg Capsule [**Year (4 digits) **]: One (1) Capsule PO BID (2

ALLERGIES: Sulfa(Sulfonamide Antibiotics)

PHYSICAL EXAM: Vitals: T:100.4 BP:100/42 P: R: 26 O2:
General: intubated and sedated
HEENT: Sclera anicteric, MMM, ET tube in place,
Neck: supple, JVP not elevated,
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis.
Trace edema in lower extremities
Neuro: Sedated and responds to pain, once sedation is off, moves
all extremities
.

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives alone
Denies tobacco and EtOH use 

### Response:
{'Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Subendocardial infarction, initial episode of care,Subdural hemorrhage,Acute kidney failure, unspecified,Unspecified essential hypertension,Diverticulum of esophagus, acquired,Other convulsions,Encounter for palliative care,Other and unspecified hyperlipidemia,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits'}
