CHIEF COMPLAINT: Shortness of Breath

PRESENT ILLNESS: 51 y.o. Female with h.o.T1-T2 paraplegia [**3-5**] MVA, multiple
admissions for PNA, [**Month/Day (2) 40097**] UTI requiring intubation,
hypothyroidism originally admitted to the ED for ?PNA.
Transferred to the unit for hypotension versus septic shock.
.
Unfortunately pt is a poor historian. Pt was diagnosed with a
UTI and started on Augementin on [**2148-2-6**] which she completed a
10 day course. Per pt's PCA they were at Foxwood yesterday, pt
had no symptoms when she went to bed last night at 8pm. Her PCA
stayed with her last night when the pt had acute onset of SOB at
midnight. Her O2 sat which was noted to be 77%, she was placed
on 4l of oxygen and her saturation improved to 93%. Her PCA
called [**Company 191**] and was referred to the ED. Pt has home oxygen which
she uses only when she is discharged from the hospital with PNA.

MEDICAL HISTORY: 1. T1-T2 paraplegia following MVC [**1-4**]
2. Recurrent UTIs: [**Month/Year (2) 40097**] klebsiella
3. HCV, viral load suppressed
4. H/o recurrent PNAs: MRSA, pan-sensitive Kleb
5. Anxiety
6. DVT in [**2142**] -IVC filter placed in [**2142**]
7. Pulmonary nodules
8. Hypothyroidism
9. Chronic pain
10. Chronic gastritis
11. H/o obstructive lung disease
12. Anemia of chronic disease
13. S/p PEA arrest during last hospitalization in [**2147-10-3**]

MEDICATION ON ADMISSION: Baby Wipes
Cranberry Extract 500mg [**Hospital1 **]
Citalopram 40mg daily
Lyrica 150mg TID
Combivent 18mcg-103mcg 2 puffs TID
Methadone 5mg TID
Calcium 500mg (1250mg) [**Hospital1 **]
Klonopin 1mg QID PRN
Albuterol 2.5mg/3ml (0.083%) nebs q4-6hr PRN
Omeprazole 20mg [**Hospital1 **]
Baclofen 10mg QID (2 tabs qAM, 1 tab midday, 2 tabs qHS)
Levothyroxine 75mcg daily
Trazadone 200mg qHS
Oxycodone 5mg q4-6hr PRN
Loratadine 10mg daily
Oxybutynin 10mg qAM, 5mg qafternoon, 10mg qHS
Carafate 100mg/ml 2 tsp QID
Miralax PRN
Lidoderm patch
Nicotine patch

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: GENERAL: Caucasian Female laying down in bed, tearful in NARD.
HEENT: No scleral icterus, EOMI.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: Diminished BS noted diffusely.
ABDOMEN: Soft, NT, ND. No HSM
EXTREMITIES: No edema noted.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3.
Appropriate. CN II-[**Last Name (LF) **],[**First Name3 (LF) 81**],XII intact on examination. Has
intermittent sensation in her lower extremities.
PSYCH: Tearful on examination, states she feels scared.

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: The patient currently lives at home wiht her husband and 2
children, ages 15 and 22. Former 35 packyear smoker. Denies
current tobacco or alcohol use.
Methicillin susceptible pneumonia due to Staphylococcus aureus,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Paraplegia,Chronic hepatitis C without mention of hepatic coma,Thrombocytopenia, unspecified,Tracheostomy status,Urinary tract infection, site not specified,Chronic airway obstruction, not elsewhere classified,Unspecified disorder of autonomic nervous system,Late effect of unspecified injury,Late effects of motor vehicle accident,Hypopotassemia,Disorders of phosphorus metabolism,Unspecified acquired hypothyroidism,Other diseases of lung, not elsewhere classified,Anemia of other chronic disease,Atrophic gastritis, without mention of hemorrhage,Other chronic pain,Panic disorder without agoraphobia,Other postprocedural status
Meth sus pneum d/t Staph,Pseudomonas infect NOS,Paraplegia NOS,Chrnc hpt C wo hpat coma,Thrombocytopenia NOS,Tracheostomy status,Urin tract infection NOS,Chr airway obstruct NEC,Autonomic nerve dis NEC,Late effect injury NOS,Late eff motor vehic acc,Hypopotassemia,Dis phosphorus metabol,Hypothyroidism NOS,Other lung disease NEC,Anemia-other chronic dis,Atrph gastrtis w/o hmrhg,Chronic pain NEC,Panic dis w/o agorphobia,Post-proc states NEC
Admission Date:  [**2148-2-24**]              Discharge Date:   [**2148-3-1**]

Date of Birth:  [**2096-10-22**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**Last Name (NamePattern1) 1136**]
Chief Complaint:
Shortness of Breath

Major Surgical or Invasive Procedure:
None


History of Present Illness:
51 y.o. Female with h.o.T1-T2 paraplegia [**3-5**] MVA, multiple
admissions for PNA, [**Month/Day (2) 40097**] UTI requiring intubation,
hypothyroidism originally admitted to the ED for ?PNA.
Transferred to the unit for hypotension versus septic shock.
.
Unfortunately pt is a poor historian. Pt was diagnosed with a
UTI and started on Augementin on [**2148-2-6**] which she completed a
10 day course. Per pt's PCA they were at Foxwood yesterday, pt
had no symptoms when she went to bed last night at 8pm. Her PCA
stayed with her last night when the pt had acute onset of SOB at
midnight. Her O2 sat which was noted to be 77%, she was placed
on 4l of oxygen and her saturation improved to 93%. Her PCA
called [**Company 191**] and was referred to the ED. Pt has home oxygen which
she uses only when she is discharged from the hospital with PNA.

.
She denies any cough, fever, nausea, vomiting, rhinorrhea,
abdominal pain, melena, hematemesis, expectorant. + chills.
.
In the ED initial vitals were noted to be T99.2, HR 86, BP
101/66, RR 18, Sat 97%. Initial labs were notablw for Plt 130,
WBC was 9.7, Neutrophillic predominance. Chem 10 panel was
unremarkable. A CTA was obtsined which showed no P. Embolism but
did show bibasilar consolidation which were thought to be
possible chronic atelectasis. Pt was originally on her way to
the medicine floor when she was hypotensive to with systolics in
the 80s asymptomatic. Pt was given 3-4 litres of fluid, lactate
was obtained and normal. BP prior to transfer was increased to
90/60.
.
Of note she was recently discharged on [**2148-1-3**] with a similar
presentation. She was noted to have similar symptoms with
hypotension, hypoxia and was intubated and placed on pressors.
She then developed PRES syndrome in the ICU.


Past Medical History:
1. T1-T2 paraplegia following MVC [**1-4**]
2. Recurrent UTIs: [**Month/Year (2) 40097**] klebsiella
3. HCV, viral load suppressed
4. H/o recurrent PNAs: MRSA, pan-sensitive Kleb
5. Anxiety
6. DVT in [**2142**] -IVC filter placed in [**2142**]
7. Pulmonary nodules
8. Hypothyroidism
9. Chronic pain
10. Chronic gastritis
11. H/o obstructive lung disease
12. Anemia of chronic disease
13. S/p PEA arrest during last hospitalization in [**2147-10-3**]


Social History:
The patient currently lives at home wiht her husband and 2
children, ages 15 and 22. Former 35 packyear smoker. Denies
current tobacco or alcohol use.


Family History:
Non-contributory.

Physical Exam:
GENERAL: Caucasian Female laying down in bed, tearful in NARD.
HEENT: No scleral icterus, EOMI.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: Diminished BS noted diffusely.
ABDOMEN: Soft, NT, ND. No HSM
EXTREMITIES: No edema noted.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3.
Appropriate. CN II-[**Last Name (LF) **],[**First Name3 (LF) 81**],XII intact on examination. Has
intermittent sensation in her lower extremities.
PSYCH: Tearful on examination, states she feels scared.

Pertinent Results:
[**2148-2-24**]
WBC 9.7 / Hct 35.5 / Plt 130
N 88 / L 8 / M 2 / E 1 / B 0
INR 1 / PTT 31
Na 141 / K 4.4 / Cl 101 / CO2 29 / BUN 9 / Cr .4 / BG 136
Ca 8.8 / Mg 2 / Phos 3.9
Lactate .8
.
Discharge Labs:
WBC-5.2 RBC-3.31* Hgb-9.7* Hct-28.9* MCV-87 MCH-29.2 MCHC-33.5
RDW-15.2 Plt Ct-144*
Glucose-97 UreaN-3* Creat-0.2* Na-145 K-3.9 Cl-104 HCO3-37*
AnGap-8
Calcium-8.9 Phos-2.8 Mg-2.2
.
MICROBIOLOGY:
[**2148-2-24**] Blood Cx - negative
[**2148-2-24**] Urine cx - Pseudomonas pan sensitive
[**2148-2-25**] Sputum Cx - staph aureus (sparse growth) and yeast
[**2148-2-25**] Urine legionella - negative
.
STUDIES:
[**2148-2-24**] CXR Focal opacity at the right heart border in the right
lower lung may represent focal pneumonia (favored) or
atelectasis.

[**2148-2-24**] CTA Chest
1. No pulmonary embolism or acute aortic pathology.
2. Improved bibasilar atelectasis and left lung ground-glass
opacities.
These chronic atelectatic findings may be secondary to chest
wall deformities and poor inspiratory efforts in the setting of
multiple chronic rib fractures.
3. Mucoid impaction in bilateral lower lobe bronchioles.

[**2148-2-27**] CXR
IMPRESSION: AP chest compared to [**2-24**]:
  Extensive opacification has developed in the perihilar regions
of both lungs, accompanied by a new small right pleural effusion
most consistent with pulmonary edema due to cardiac
decompensation. Tip of the left PIC line extends approximately a
centimeter beyond the wire, in the mid-to-upper SVC.  No
pneumothorax. Dr. [**Last Name (STitle) **] and venous access nurse were both
paged


Brief Hospital Course:
1. Hypotension: Pt originally admitted to the ICU given episode
of hypotension to the 80s. Given the patient's initial
presentation, she did not meet SIRS criteria given her WBC,
temp, RR, HR. Determined not to be septic shock.  On review of
her clinical notes her BP appears to be 95 in her prior Primary
Care visit, there is also a comment in a prior Neurology note of
possible dysautonomia from her thoracic lesion. Patient had
stable SBPs 80-90s with no evidence of end-organ ischemia,
mentating well, good urine output, during her hospitalization,
so was presumed to be at baseline and secondary to autonomic
dysfunction. Did not require IVF boluses and remained
hemodynamically stable.
.
2. Hypoxia: Pt noted to be hypoxic at home on room air that
corrected with 2L of oxygen. Given CXR LLL/retrocardiac
infiltrate lobar pneumonia was thought to be the cause of the
patient's hypoxia.  She was treated empirically for HAP with
levofloxacin and vancomycin.  Given sputum culture grew sparse
growth of staph aureus, the patient was continued on this
regimen, vancomycin for 7 days, levofloxacin for 10 days.
Ipratropium/Albuterol nebs treatments, chest PT, acapella and
incentive spirometer use improved the patient's symptoms.
.
3.  UTI: Pt also has history of frequent UTIs given that her
caregiver self-caths. She was started on Augmentin for [**Last Name (STitle) 40097**]
Klebsiella UTI diagnosed in Caritas. Her review of urine culture
data shows [**Last Name (STitle) 40097**] Klebsiella sensitive to Zosyn, Meropenem,
Bactrim, Unasyn. She also has a h.o. of Proteus sensitive to
Zosyn. Though [**Last Name (STitle) 40097**] Klebsiella appears to be sensitive to Zosyn
there may be a difference between in-[**Last Name (un) **] vs in-[**Last Name (un) 5153**]
sensitivity.  High rate of resistance with [**Last Name (un) 40097**] during Zosyn
therapy, thus was initially treated with Meropenem.  When the
culture data returned with pansensitive pseudomonas, Meropenem
was discontinued and levofloxacin was continued for total of 10
days.
.
4.  Thrombocytopenia: Pt on admission noted to have plt 130,
prior baseline has shown plt count in the 300s.  The patient's
platelet count dropped to 84 on her third hospital day.  Heparin
and omeprazole were discontinued as possible causes.  Her count
returned to 144 prior to discharge.  Omeprazole was held, and
the patient instructed to have a repeat platelet count as an
outpatient.
.
5. T1-T2 paraplegia s/p MVC: Pt was maintained on her home
regimen of Methadone, Lyrica, Baclofen, Lidocaine patch,
Klonopin, Trazadone.  Home oxycodone was discontinued given
hypotension and questionable mental status at times.  The
patient never requested oxycodone therapy.  She was asked to
refrain from restarting oxycodone as an outpatient if possible.

.
6.  h.o. PRES syndrome: Pt has history of PRES syndrome occured
in [**12/2147**] and thought to be due to a combination of pressors,
pt's underlying labile BP.  The patient's blood pressure
remained relatively stable during hospitalization, with
increases when the patient was anxious.
.
7. Hypothyroidism: Continued home regimen of levothyroxine.


Medications on Admission:
Baby Wipes
Cranberry Extract 500mg [**Hospital1 **]
Citalopram 40mg daily
Lyrica 150mg TID
Combivent 18mcg-103mcg 2 puffs TID
Methadone 5mg TID
Calcium 500mg (1250mg) [**Hospital1 **]
Klonopin 1mg QID PRN
Albuterol 2.5mg/3ml (0.083%) nebs q4-6hr PRN
Omeprazole 20mg [**Hospital1 **]
Baclofen 10mg QID (2 tabs qAM, 1 tab midday, 2 tabs qHS)
Levothyroxine 75mcg daily
Trazadone 200mg qHS
Oxycodone 5mg q4-6hr PRN
Loratadine 10mg daily
Oxybutynin 10mg qAM, 5mg qafternoon, 10mg qHS
Carafate 100mg/ml 2 tsp QID
Miralax PRN
Lidoderm patch
Nicotine patch


Discharge Medications:
1. Citalopram 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).

2. Pregabalin 75 mg Capsule [**Hospital1 **]: Two (2) Capsule PO TID (3 times
a day).
3. Combivent 18-103 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) puffs
Inhalation three times a day.
4. Methadone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a
day).
5. Calcium 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day.
6. Clonazepam 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO QID (4 times a
day) as needed for anxiety.
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1)  Inhalation every four (4) hours as
needed for shortness of breath or wheezing.
Disp:*4 Box* Refills:*0*
8. Baclofen 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO QAM (once a day
(in the morning)).
9. Baclofen 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO NOON (At Noon).

10. Baclofen 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO QHS (once a day
(at bedtime)).
11. Levothyroxine 75 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
12. Trazodone 100 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS (at
bedtime) as needed for anxiety.
13. Oxybutynin Chloride 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO QAM
(once a day (in the morning)).
14. Oxybutynin Chloride 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q1400
().
15. Oxybutynin Chloride 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS
(at bedtime).
16. Sucralfate 1 gram Tablet [**Hospital1 **]: One (1) Tablet PO QID (4 times
a day).
17. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
18. Loratadine 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO daily ().
19. Guaifenesin 100 mg/5 mL Syrup [**Hospital1 **]: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
Disp:*250 ML(s)* Refills:*0*
20. Levofloxacin 750 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day
for 4 days.
Disp:*4 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 1474**] VNA

Discharge Diagnosis:
Primary Diagnoses:
Community Acquired Pneumonia
Urinary Tract Infection
Thrombocytopenia
Autonomic dysfuction secondary to paraplegia
.
Secondary Diagnoses:
T1-2 Paraplegia
Depression/Anxiety
Hypothyroidism


Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Bedbound


Discharge Instructions:
You were admitted to [**Hospital1 18**] for evaluation of decrease oxygen
levels in your blood.  You were found to have a pneumonia.  You
were also incidentally found to have a urinary tract infection.
You were treated with IV antibiotics for these infections.  You
have completed your course of antibiotics during your
hospitalization.  Your platelet count was also found to be low
during your stay.  You were taken off heparin and omeprazole and
your platelets improved.  You should avoid these medications if
possible in the future.
.
Because of your confusion on arrival, you were not given
Oxycodone during your stay.  It seems your pain was well
controlled with methadone only.  You should refrain from using
Oxycodone in the future.
.
During your stay it was noted that you had decreased levels of
potassium and phosphorous.  You should have your labs checked
with your primary care physician in one week.

Followup Instructions:
Please follow up with your primary care physician
[**Last Name (NamePattern4) **]: [**First Name4 (NamePattern1) 2184**] [**Last Name (NamePattern1) 2185**] (covering for Dr. [**Last Name (STitle) 665**]
Specialty: Internal Medicine/ [**Company 191**] Post [**Hospital **] Clinic
Date/ Time: Thursday, [**3-7**], 8:10am
Location: [**Hospital Ward Name 23**] Building, [**Location (un) **] South Suite
Phone number: [**Telephone/Fax (1) 250**]



Completed by:[**2148-3-3**]
{'Methicillin susceptible pneumonia due to Staphylococcus aureus,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Paraplegia,Chronic hepatitis C without mention of hepatic coma,Thrombocytopenia, unspecified,Tracheostomy status,Urinary tract infection, site not specified,Chronic airway obstruction, not elsewhere classified,Unspecified disorder of autonomic nervous system,Late effect of unspecified injury,Late effects of motor vehicle accident,Hypopotassemia,Disorders of phosphorus metabolism,Unspecified acquired hypothyroidism,Other diseases of lung, not elsewhere classified,Anemia of other chronic disease,Atrophic gastritis, without mention of hemorrhage,Other chronic pain,Panic disorder without agoraphobia,Other postprocedural 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: Shortness of Breath

PRESENT ILLNESS: 51 y.o. Female with h.o.T1-T2 paraplegia [**3-5**] MVA, multiple
admissions for PNA, [**Month/Day (2) 40097**] UTI requiring intubation,
hypothyroidism originally admitted to the ED for ?PNA.
Transferred to the unit for hypotension versus septic shock.
.
Unfortunately pt is a poor historian. Pt was diagnosed with a
UTI and started on Augementin on [**2148-2-6**] which she completed a
10 day course. Per pt's PCA they were at Foxwood yesterday, pt
had no symptoms when she went to bed last night at 8pm. Her PCA
stayed with her last night when the pt had acute onset of SOB at
midnight. Her O2 sat which was noted to be 77%, she was placed
on 4l of oxygen and her saturation improved to 93%. Her PCA
called [**Company 191**] and was referred to the ED. Pt has home oxygen which
she uses only when she is discharged from the hospital with PNA.

MEDICAL HISTORY: 1. T1-T2 paraplegia following MVC [**1-4**]
2. Recurrent UTIs: [**Month/Year (2) 40097**] klebsiella
3. HCV, viral load suppressed
4. H/o recurrent PNAs: MRSA, pan-sensitive Kleb
5. Anxiety
6. DVT in [**2142**] -IVC filter placed in [**2142**]
7. Pulmonary nodules
8. Hypothyroidism
9. Chronic pain
10. Chronic gastritis
11. H/o obstructive lung disease
12. Anemia of chronic disease
13. S/p PEA arrest during last hospitalization in [**2147-10-3**]

MEDICATION ON ADMISSION: Baby Wipes
Cranberry Extract 500mg [**Hospital1 **]
Citalopram 40mg daily
Lyrica 150mg TID
Combivent 18mcg-103mcg 2 puffs TID
Methadone 5mg TID
Calcium 500mg (1250mg) [**Hospital1 **]
Klonopin 1mg QID PRN
Albuterol 2.5mg/3ml (0.083%) nebs q4-6hr PRN
Omeprazole 20mg [**Hospital1 **]
Baclofen 10mg QID (2 tabs qAM, 1 tab midday, 2 tabs qHS)
Levothyroxine 75mcg daily
Trazadone 200mg qHS
Oxycodone 5mg q4-6hr PRN
Loratadine 10mg daily
Oxybutynin 10mg qAM, 5mg qafternoon, 10mg qHS
Carafate 100mg/ml 2 tsp QID
Miralax PRN
Lidoderm patch
Nicotine patch

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: GENERAL: Caucasian Female laying down in bed, tearful in NARD.
HEENT: No scleral icterus, EOMI.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: Diminished BS noted diffusely.
ABDOMEN: Soft, NT, ND. No HSM
EXTREMITIES: No edema noted.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3.
Appropriate. CN II-[**Last Name (LF) **],[**First Name3 (LF) 81**],XII intact on examination. Has
intermittent sensation in her lower extremities.
PSYCH: Tearful on examination, states she feels scared.

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: The patient currently lives at home wiht her husband and 2
children, ages 15 and 22. Former 35 packyear smoker. Denies
current tobacco or alcohol use. 

### Response:
{'Methicillin susceptible pneumonia due to Staphylococcus aureus,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Paraplegia,Chronic hepatitis C without mention of hepatic coma,Thrombocytopenia, unspecified,Tracheostomy status,Urinary tract infection, site not specified,Chronic airway obstruction, not elsewhere classified,Unspecified disorder of autonomic nervous system,Late effect of unspecified injury,Late effects of motor vehicle accident,Hypopotassemia,Disorders of phosphorus metabolism,Unspecified acquired hypothyroidism,Other diseases of lung, not elsewhere classified,Anemia of other chronic disease,Atrophic gastritis, without mention of hemorrhage,Other chronic pain,Panic disorder without agoraphobia,Other postprocedural status'}
