CHIEF COMPLAINT: Fevers and increased white blood cell
count.

PRESENT ILLNESS: This is an 85 year old female
with multiple medical problems who was sent in to the [**Hospital1 1444**] Emergency Room from her
nursing home for fevers and an increased white blood cell
count.  The patient was recently admitted to [**Hospital1 346**] from [**2146-3-17**] until [**2146-4-6**]
initially for shortness of breath and then had a prolonged
hospital course which included respiratory distress thought
secondary to a chronic obstructive pulmonary disease flare
from Pseudomonal pneumonia.

MEDICAL HISTORY: 1.  Status post pseudomonal pneumonia.
2.  Chronic obstructive pulmonary disease.
3.  Diverticulitis.
4.  Pancreatitis complicated by pseudocyst.
5.  Asthma.
6.  Gastroesophageal reflux disease.
7.  History of eosinophilia.
8.  Hypercholesterolemia.
9.  Atrial fibrillation, rate controlled.
10. Alzheimer's dementia.
11. Degenerative joint disease.
12. Coronary artery disease with a history of anterior
myocardial infarction and an ejection fraction of greater
than 55%.
13. T12 compression fracture.
14. Bronchiectasis.
15. Pancytopenia.
16. Sick euthyroid.
17. Steroid myopathy.
18. Status post PEG placement.

MEDICATION ON ADMISSION: 

ALLERGIES: Compazine / Tetracyclines / Aspirin / Sulfa (Sulfonamides) /
Darvocet-N 100 / Ultram / Flagyl / Clindamycin

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient has a significant history of
tobacco use.  She resides at the [**Hospital3 2732**] home for
the past week since her discharge from the hospital.
Methicillin susceptible Staphylococcus aureus septicemia,Severe sepsis,Urinary tract infection, site not specified,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Chronic obstructive asthma with (acute) exacerbation,Acute respiratory failure,Unspecified protein-calorie malnutrition,Gastrostomy status
Meth susc Staph aur sept,Severe sepsis,Urin tract infection NOS,Enterococcus group d,Ch obst asth w (ac) exac,Acute respiratry failure,Protein-cal malnutr NOS,Gastrostomy status
Admission Date:  [**2146-4-10**]       Discharge Date:  [**2146-4-14**]


Service:  [**Location (un) 259**] I

NOTE: Date of Discharge is expected to be [**2146-4-15**].

CHIEF COMPLAINT:   Fevers and increased white blood cell
count.

HISTORY OF PRESENT ILLNESS:  This is an 85 year old female
with multiple medical problems who was sent in to the [**Hospital1 1444**] Emergency Room from her
nursing home for fevers and an increased white blood cell
count.  The patient was recently admitted to [**Hospital1 346**] from [**2146-3-17**] until [**2146-4-6**]
initially for shortness of breath and then had a prolonged
hospital course which included respiratory distress thought
secondary to a chronic obstructive pulmonary disease flare
from Pseudomonal pneumonia.

Other etiologies were entertained including allergic
bronchopulmonary aspergillosis versus Turk-[**Doctor Last Name 3532**].  During
the patient's last admission she had intermittent shortness
of breath episodes that were treated with Lasix for pulmonary
edema.  She had also ruled out for an myocardial infarction
at that time.  Her hospital course at that time was also
complicated by a steroid induced myopathy, incidental thyroid
nodule with biochemically sick euthyroid, acute T12
compression fracture, ataxia attributed to steroid myopathy,
pancytopenia attributed to medication, and a PEG placement.

Upon evaluation for the current admission, the patient's
daughter stated that since her discharge, the patient's
mental status has been at baseline until the day prior to
admission when she became slightly more depressed.  She had
been calling out for her deceased mother.  The patient also
appeared confused and agitated.  At the nursing home, her
temperature was 101.1 F.; heart rate was 106 and respiratory
rate was 14.  She was saturating 94% on two liters and had
been placed on a nonrebreather by the EMS.

At the nursing home she had been given Ciprofloxacin,
Azithromycin and ceftazidime for one day.

Per the patient's daughter, the patient had not had any
headache, chest pain, change in her vision, diarrhea.  She
complained of mild abdominal diffuse pain.

PAST MEDICAL HISTORY:
1.  Status post pseudomonal pneumonia.
2.  Chronic obstructive pulmonary disease.
3.  Diverticulitis.
4.  Pancreatitis complicated by pseudocyst.
5.  Asthma.
6.  Gastroesophageal reflux disease.
7.  History of eosinophilia.
8.  Hypercholesterolemia.
9.  Atrial fibrillation, rate controlled.
10. Alzheimer's dementia.
11. Degenerative joint disease.
12. Coronary artery disease with a history of anterior
myocardial infarction and an ejection fraction of greater
than 55%.
13. T12 compression fracture.
14. Bronchiectasis.
15. Pancytopenia.
16. Sick euthyroid.
17. Steroid myopathy.
18. Status post PEG placement.

MEDICATIONS:
1.  Albuterol nebulizers q. six hours.
2.  Calcitriol 0.25 micrograms q. day.
3.  Salmeterol 50 micrograms q. 12 hours.
4.  Guaifenesin q. six hours p.r.n.
5.  Multivitamin.
6.  Tylenol p.r.n.
7.  Dulcolax suppositories p.r.n.
8.  Colace 100 mg p.o. twice a day.
9.  Flovent 110 micrograms, six puffs twice a day.
10. Alendronate 5 mg p.o. q. day.
11. Lidocaine patch p.r.n.
12. Calcium carbonate 1500 mg twice a day.
13. Prednisone 15 mg p.o. q. day.
14. Atrovent nebulizers q. six hours.
15. Nystatin swish and swallow.
16. Paxil 10 mg p.o. q. day.
17. Risperdal 0.5 mg p.o. twice a day p.r.n.
18. Zithromax 250 mg q. day.
19. Ciprofloxacin 500 mg q. day.
20. Ceftazidine one gram intravenously q. eight hours.
21. Lasix 20 mg p.o. q. day.
22. Diltiazem.

SOCIAL HISTORY:  The patient has a significant history of
tobacco use.  She resides at the [**Hospital3 2732**] home for
the past week since her discharge from the hospital.

PHYSICAL EXAMINATION:  On evaluation in the Emergency Room,
the patient was febrile with a temperature of 101.8 F.; blood
pressure 145/66; heart rate 110; respiratory rate 22; 99% on
a non-rebreather, 93% on room air at rest.  The patient
appeared sedated and was becoming agitated and combative at
times.  Her Pupils equally round and reactive to light.  Her
neck was supple without any lymphadenopathy or bruits.  Her
oropharynx was dry and her mucous membranes were moist
without exudates.  She had fine crackles half way up
bilaterally on her lung examination and had occasional
expiratory wheezes.  She had no accessory muscle use.  Her
heart was regular rate and rhythm with S1, S2.  Her abdomen
was soft, nontender to deep palpation.  She had normoactive
bowel sounds and no guarding.  Her PEG site was clean, dry
and intact without erythema or drainage.  Her legs were in
lambs wool boots.  She had trace edema to the ankles.  There
were no cords or erythema present.  On neurologic
examination, she responded to commands by opening her eyes,
but appeared sedated.  She had no point tenderness over her
spine.  She had no sacral decubitus ulcers and no skin
ulcers.

LABORATORY:   Her labs were as follows on admission, white
blood cell count 19.8, hematocrit 29.7, platelets 671.  She
had 70% neutrophils and 7% bands.  Her electrolytes were as
follows:  Sodium 139, potassium 3.8, chloride 99, bicarbonate
29, BUN 18, creatinine 0.5, glucose 143.  Her lactate was
0.9.

Her first set of cardiac enzymes revealed the following:  A
CK of 30, MB of 3, troponin of 0.13.  Her second troponin was
0.15.  Her INR was 1.2.  Two sets of blood cultures and a
urine culture were drawn.  Her ALT was 25, alkaline
phosphatase 82, total bilirubin 0.2, lipase 78, amylase 83.

On urinalysis she had moderate leukocytes and moderate blood.
She had a white blood cell count of greater than 50 in her
urine and many bacteria.  There were three to five epithelial
cells.

Chest x-ray showed increasing rounded but ill defined opacity
in the left upper lobe, same as in [**2146-2-17**].  There
was a question of cavitary worsening left upper lobe opacity.

An EKG was done which showed sinus tachycardia at 108 with
normal intervals and left axis deviation.

HOSPITAL COURSE BY PROBLEM:
1.  FEVERS:  Initially, the patient's fevers were thought to
be due to a urinary tract infection as seen on her urinalysis
upon admission.  She had been placed on Levaquin to treat for
the urinary tract infection, however, when the cultures came
back showing methicillin resistant Staphylococcus aureus, the
patient was switched to Vancomycin.  Also, blood cultures had
been drawn upon admission.  The first set of blood cultures
ended up growth enterococcus which was resistant to
Vancomycin; thus, the patient's Vancomycin was discontinued
and the Levaquin was discontinued as well.  She was then
started on Linezolid.

An Infectious Disease consultation was obtained.  They
recommended that the patient undergo possible transesophageal
echocardiogram; however, given the patient's agitated state,
this test was not done.  She was kept on the Linezolid and
she was also started on clindamycin.  Per Infectious Disease
recommendations, the patient was to be kept on the Linezolid
for a total of three or four weeks.

The patient continued to have occasional spikes in her
temperature.  Surveillance blood cultures were drawn daily.
The patient daily did not complain of any sort of symptoms;
however, it was difficult to obtain a history daily given
that the patient has a baseline dementia.

2.  PULMONARY NODULE:  Given the presence of this pulmonary
nodule on chest x-ray upon admission, a CT scan was
recommended by a pulmonary consultation that had been
obtained in the early part of the [**Hospital 228**] hospital course.
CT scan showed that the nodule had been present on a prior CT
scan but had slightly grown in size.  They were unable to
rule out whether this was TB versus aspergillosis.  Thus, the
patient was placed in isolation in order to have her ruled
out for tuberculosis.  Sputum was induced on multiple
occasions.  The first two sets of sputum cultures had no acid
fast bacilli on smear.  Cultures were pending.  The third set
at the time of this dictation has not been induced yet.

The patient had initially been placed on ceftazidime and
Ciprofloxacin in case this had been a recurrence of her
Pseudomonal pneumonia.  However, after an Infectious Disease
consultation had been obtained, they thought that this was
low suspicion and decided to place the patient on
Clindamycin.  The Pulmonary Team followed the patient
throughout her hospital course.

3.  ELEVATED TROPONIN:  Given that the patient's CK and MBs
were within normal limits, it was thought that the patient's
slightly elevated troponins were likely from demand ischemia.
She had no new EKG changes and the patient continued to be
asymptomatic.  She denied any chest pain or shortness of
breath throughout her hospital course.  She was placed on
Telemetry throughout her hospital course.  There were no
events up to the time of this dictation.

4.  DECREASED HEMATOCRIT:  The patient had a slightly
decreased hematocrit upon admission.  On hospital day two,
she was transfused one unit of blood.  Her hematocrit
remained stable throughout the remainder of her hospital
course.

5.  MENTAL STATUS:  The patient has baseline Alzheimer's
Disease dementia.  Initially she appeared improved since her
last admission, although at times she had periods of
agitation and depression.  She was placed on Risperdal twice
a day p.r.n. for agitation.

6.  NUTRITION:   The patient was continued on her tube feeds
for her PEG that had been placed at her prior admission.  A
swallow consultation was obtained to see if the patient was
at high risk for aspiration.  The patient refused to have
this test done, and given that she clearly had some risk of
aspiration, she was made NPO as her diet throughout her
hospital course.

7.  CODE STATUS;  The patient was a full code during her
hospital stay up until the point of this discharge summary.

8.  PROPHYLAXIS:  The patient was placed on Colace, Dulcolax,
heparin subcutaneously for deep venous thrombosis
prophylaxis, fall precautions, aspiration precautions.

9.  DIABETES MELLITUS:  The patient had her fingersticks
checked four times a day.  She was placed on a regular
insulin sliding scale due to the diabetes mellitus that had
developed from her long chronic use of Prednisone.  Her blood
sugars remained well controlled during her hospital stay.

The plan is for the patient to be discharged to a
rehabilitation facility after she is ruled out for
tuberculosis.  At the rehabilitation facility she will
receive the antibiotics, Linezolid and clindamycin up to a
total of three weeks.

DISCHARGE STATUS:  Discharged to a rehabilitation facility.

CONDITION AT DISCHARGE:   Stable.

DISCHARGE DIAGNOSES:
1.  VRE bacteremia.
2.  Methicillin resistant Staphylococcus aureus urinary tract
infection.
3.  Severe chronic obstructive pulmonary disease.
4.  Pulmonary nodule.
5.  Rule out tuberculosis.
6.  Asthma.
7.  Gastroesophageal reflux disease.
8.  Alzheimer's Disease dementia.
9.  T12 compression fracture.
10. Bronchiectasis.
11. Pancytopenia.
12. Steroid myopathy.

DISCHARGE INSTRUCTIONS:
1.  The patient was instructed to call her doctor or return
to the Emergency Room if she experienced any further chest
pain, increased shortness of breath, abdominal pain, fevers,
change in mental status, or other worrisome symptoms.
2.  She was also told to follow-up with the Infectious
Disease Clinic.
3.  She is to follow-up with her primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) **].
4.  In addition, the patient had been scheduled for certain
appointments during her prior hospital stay which were still
pending such as her appointment with Neurology and Pulmonary.


If there are any further events in the [**Hospital 228**] hospital
course, they will be dictated at a later time.




                            [**Name6 (MD) **] [**Name8 (MD) **], MD  [**MD Number(1) 21980**]

Dictated By:[**Name8 (MD) 4955**]
MEDQUIST36

D:  [**2146-4-14**]  14:44
T:  [**2146-4-14**]  17:38
JOB#:  [**Job Number 99483**]

cc:[**Last Name (NamePattern1) 99484**]

Name:  [**Known lastname 15941**],[**Known firstname 6532**] V              Unit No:   [**Numeric Identifier 15942**]

Admission Date:  [**2146-4-10**]              Discharge Date:   [**2146-4-21**]

Date of Birth:  [**2060-7-9**]             Sex:   F

Service: MED

Allergies:
Compazine / Tetracyclines / Aspirin / Sulfa (Sulfonamides) /
Darvocet-N 100 / Ultram / Flagyl / Clindamycin

Attending:[**First Name3 (LF) 8956**]
Chief Complaint:
Dyspnea, Respiratory Failure

Major Surgical or Invasive Procedure:
Non-invasive ventilation

Brief Hospital Course:
The patient was transferred to the [**Hospital Unit Name 1863**] with increasing O2
requirements and worsening respiratory status.  Over the course
of the next several days, neither the patient's mental status
nor respiratory status improved despite continued antibiotics,
agressive pulmonary toilet.  She continued to appear
uncomfortable and received prn pain medications. After
discussion with the family, the patient was made DNR/DNI but
continued to require non-invasive ventilation. After several
more days without any improvement, another family meeting was
held. The patient's son and daughter communicated that the
patient would have opted for comfort measures at this point.
The patient was made CMO and started on a morphine drip titrated
to the patient's comfort. Within 24 hours, the patient had
expired.  The patient's son was present at the time of her
death.  Family members requested a partial autopsy to
investigate the patient's dementia. The patient's primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 274**] continued to be in contact with the family
and to follow the patient in the ICU.

Discharge Disposition:
Extended Care

Discharge Diagnosis:
VRE bacteremia
MRSA uti
severe copd
pulmonary nodule
r/o TB
delirium


Discharge Condition:
deceased

                             [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 8958**] MD [**MD Number(1) 8825**]

Completed by:[**2146-8-27**]
{'Methicillin susceptible Staphylococcus aureus septicemia,Severe sepsis,Urinary tract infection, site not specified,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Chronic obstructive asthma with (acute) exacerbation,Acute respiratory failure,Unspecified protein-calorie malnutrition,Gastrostomy status'}


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: Fevers and increased white blood cell
count.

PRESENT ILLNESS: This is an 85 year old female
with multiple medical problems who was sent in to the [**Hospital1 1444**] Emergency Room from her
nursing home for fevers and an increased white blood cell
count.  The patient was recently admitted to [**Hospital1 346**] from [**2146-3-17**] until [**2146-4-6**]
initially for shortness of breath and then had a prolonged
hospital course which included respiratory distress thought
secondary to a chronic obstructive pulmonary disease flare
from Pseudomonal pneumonia.

MEDICAL HISTORY: 1.  Status post pseudomonal pneumonia.
2.  Chronic obstructive pulmonary disease.
3.  Diverticulitis.
4.  Pancreatitis complicated by pseudocyst.
5.  Asthma.
6.  Gastroesophageal reflux disease.
7.  History of eosinophilia.
8.  Hypercholesterolemia.
9.  Atrial fibrillation, rate controlled.
10. Alzheimer's dementia.
11. Degenerative joint disease.
12. Coronary artery disease with a history of anterior
myocardial infarction and an ejection fraction of greater
than 55%.
13. T12 compression fracture.
14. Bronchiectasis.
15. Pancytopenia.
16. Sick euthyroid.
17. Steroid myopathy.
18. Status post PEG placement.

MEDICATION ON ADMISSION: 

ALLERGIES: Compazine / Tetracyclines / Aspirin / Sulfa (Sulfonamides) /
Darvocet-N 100 / Ultram / Flagyl / Clindamycin

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient has a significant history of
tobacco use.  She resides at the [**Hospital3 2732**] home for
the past week since her discharge from the hospital. 

### Response:
{'Methicillin susceptible Staphylococcus aureus septicemia,Severe sepsis,Urinary tract infection, site not specified,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Chronic obstructive asthma with (acute) exacerbation,Acute respiratory failure,Unspecified protein-calorie malnutrition,Gastrostomy status'}
