CHIEF COMPLAINT: Hypoxia and Hypotension.

PRESENT ILLNESS: Ms. [**Known lastname **] is a 50 year old female with paraplegia secondary to
traumatic injury with recurrent infections, noted by her husband
to be lethargic and hypoxic to 70s on RA at home.

MEDICAL HISTORY: 1. T1-T2 paraplegia following MVC [**1-5**]
2. Recurrent UTIs
3. HCV, viral load suppressed after 3 months of therapy
4. H/o recurrent PNAs
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

MEDICATION ON ADMISSION: Tylenol PRN
Oxycodone 5 mg prn
Pregabalin 150, 75, 150 mg
Calcium carbonate 500 mg [**Hospital1 **]
Baclofen 20, 10, 20 mg
Clonazepam 2 mg QID prn
Oxybutynin 10, 5, 10
Trazodone 100 mg qhs prn
Methadone 5 mg TID
Omeprazole 20 mg daily
Citalopram 40 mg
Levothyroxine 75 mcg daily
Nicotine 14 mg/24 hr daily
Ipratropium-Albuterol prn
Sucralfate 1 gram QID
Polyethylene Glycol 17 grams daily
Docusate Sodium 100 mg PO BID
Senna 8.6 mg [**Hospital1 **]
Ertapenem 1 gram daily completed [**2147-4-27**]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On admission:
Vitals: T 100.2, HR 99, BP 135/60, RR 24, 100% on 6LNC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: decreased breath sounds at right base, scattered wheezes,

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.
Unspecified septicemia,Pneumonia, organism unspecified,Other pulmonary insufficiency, not elsewhere classified,Septic shock,Urinary tract infection, site not specified,Chronic hepatitis C without mention of hepatic coma,Chronic airway obstruction, not elsewhere classified,Delirium due to conditions classified elsewhere,Paraplegia,Severe sepsis,Dysthymic disorder,Late effect of spinal cord injury,Late effects of motor vehicle accident,Other iatrogenic hypotension,Other diuretics causing adverse effects in therapeutic use,Atrophic gastritis, without mention of hemorrhage,Constipation, unspecified,Unspecified acquired hypothyroidism,Personal history of venous thrombosis and embolism,Personal history of tobacco use,Surgical or other procedure not carried out because of patient's decision
Septicemia NOS,Pneumonia, organism NOS,Other pulmonary insuff,Septic shock,Urin tract infection NOS,Chrnc hpt C wo hpat coma,Chr airway obstruct NEC,Delirium d/t other cond,Paraplegia NOS,Severe sepsis,Dysthymic disorder,Late eff spinal cord inj,Late eff motor vehic acc,Iatrogenc hypotnsion NEC,Adv eff diuretics NEC,Atrph gastrtis w/o hmrhg,Constipation NOS,Hypothyroidism NOS,Hx-ven thrombosis/embols,History of tobacco use,No proc/patient decision
Admission Date:  [**2147-4-30**]              Discharge Date:   [**2147-5-9**]

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

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
Hypoxia and Hypotension.


Major Surgical or Invasive Procedure:
None.

History of Present Illness:
Ms. [**Known lastname **] is a 50 year old female with paraplegia secondary to
traumatic injury with recurrent infections, noted by her husband
to be lethargic and hypoxic to 70s on RA at home.

In the ED, her vitals were T 98.6, HR 109, BP 113/79, RR 26, 79%
on 2lNC. She was given vancomycin and zosyn. SHe was given a
combivent neb as well. She was given lovenox for empiric
treatment of PE. A CTA was unable to be obtained due to lack of
peripheral IV. In the ED, her BP fell to to 79/39. She was given
1LNS.

Upon arrival to the MICU, patient denies shortness of breath.
She reports cough productive of green sputum. She denies fevers
at home. She denies chest pain, nausea, vomiting, diarrhea,
headache, neck stiffness or any other complaints. She denies
bladder pressure, dysuria, or urinary frequency. Per her
husband, her mental status is at 80%.

Of note, she had been recently discharged from [**Hospital1 18**] for UTI,
treated with irtapenem. Of note, patient hospitalized
[**Date range (1) 104917**] for PNA and was treated with 7 day course of
levaquin.

Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied chest pain or tightness, palpitations. Denied
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denied
arthralgias or myalgias.

Past Medical History:
1. T1-T2 paraplegia following MVC [**1-5**]
2. Recurrent UTIs
3. HCV, viral load suppressed after 3 months of therapy
4. H/o recurrent PNAs
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

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:
On admission:
Vitals: T 100.2, HR 99, BP 135/60, RR 24, 100% on 6LNC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: decreased breath sounds at right base, scattered wheezes,

CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, + b/l LE edema w/o erythema


Pertinent Results:
Labs on admission:
[**2147-4-30**] 12:20PM BLOOD WBC-20.3*# RBC-4.19*# Hgb-12.5# Hct-36.5#
MCV-87 MCH-29.8 MCHC-34.2 RDW-16.0* Plt Ct-171
[**2147-4-30**] 12:20PM BLOOD Neuts-92* Bands-0 Lymphs-6* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2147-4-30**] 01:45PM BLOOD PT-15.9* PTT-35.1* INR(PT)-1.4*
[**2147-4-30**] 01:45PM BLOOD Glucose-105 UreaN-14 Creat-0.4 Na-137
K-4.5 Cl-98 HCO3-31 AnGap-13
[**2147-4-30**] 01:45PM BLOOD CK(CPK)-36
[**2147-4-30**] 01:45PM BLOOD cTropnT-<0.01
[**2147-5-1**] 03:30AM BLOOD Calcium-7.7* Phos-1.9* Mg-1.8
[**2147-4-30**] 12:39PM BLOOD pO2-43* pCO2-53* pH-7.41 calTCO2-35* Base
XS-6
[**2147-4-30**] 02:08PM BLOOD Lactate-0.8

Chest x-ray [**2147-4-30**]:
Persistent opacity obscuring the right hemidiaphragm, could
reflect pleural effusion, consolidation or atelectasis.

Chest x-ray [**2147-5-1**]:
Minimal change in the cardiomegaly, bibasilar opacities, and
small right pleural effusion.


Brief Hospital Course:
This is a 50 year old female with paraplegia secondonary to MVA
in [**2142**], history of recurrent resistant infections, here with
pneumonia and hypotension.

#  pneumonia/sepsis: patient presented with hypotension and
radiographic evidence of bilateral pneumonia. She required
levophed for blood pressure support for a few days for SBP 70-90
range. She was given broad spectrum antibiotics for vancomycin
and zosyn. She was also worked up for other sources with a
negative urinalysis and culture, negative legionella urinary
antigen and two sputum cultures which were oral flora only. She
did come in with a PICC line in place and there was thought this
might be a source of infection but blood cultures remained
negative and the site was clean. In addition, the PICC was only
in for 10 days on admission. She completed a 7 day course of
antibiotics for healthcare associated pneumonia. She had
aggressive chest PT and incentive spirometry use.  She is being
discharged on 2L NC oxygen as her oxygen saturation declined to
the mid 80's on room air with activity. Of note she has required
oxygen at home on and off prior to this admission.

#  Anemia:
Baseline HCT 30-35. In the hospital she was stable at about
27-25 range. Prior studies have shown anemia of chronic disease.
Her HCT was closely monitored.

#  Delirium:
She was very anxious and delirius in the ICU and a psychiatric
consult was obtained. She likely was delirius from being in the
ICU and for polypharmacy and from her illness. Her medication
regimen was optimized and cut down to help prevent delirium. She
was offered an appointment with psychopharmacology to further
help with this, but she refused. She was provided with the
number at discharge if she changes her mind.

#  Chronic pain:
She was given her home methadone, baclofen, and lyrica. The
doses were lowered while she was delirius and then increased to
her home dose at discharge.  She complained of significant
chronic pain not controlled since [**2147-1-2**]. She was encouraged
to follow up with the psychopharmacologist for this which she
refused and also with her PCP and SW as we explained that pain
can be affected by many things including depression.

#  Hypothyroidism:
She was maintained on Levothyroxine.

#  Depression:
Home Citalopram 40 mg was continued. Psychiatry and social work
consults were following along.

#  Constipation:
She was on an aggressive bowel regimen to maintain her as
regular.

#  Access: PICC line which was removed prior to discharge.

Medications on Admission:
Tylenol PRN
Oxycodone 5 mg prn
Pregabalin 150, 75, 150 mg
Calcium carbonate 500 mg [**Hospital1 **]
Baclofen 20, 10, 20 mg
Clonazepam 2 mg QID prn
Oxybutynin 10, 5, 10
Trazodone 100 mg qhs prn
Methadone 5 mg TID
Omeprazole 20 mg daily
Citalopram 40 mg
Levothyroxine 75 mcg daily
Nicotine 14 mg/24 hr daily
Ipratropium-Albuterol prn
Sucralfate 1 gram QID
Polyethylene Glycol 17 grams daily
Docusate Sodium 100 mg PO BID
Senna 8.6 mg [**Hospital1 **]
Ertapenem 1 gram daily completed [**2147-4-27**]

Discharge Medications:
1. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for muscle spasms.
2. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

3. Methadone 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. Pregabalin 75 mg Capsule Sig: [**2-3**] Capsules PO TID (3 times a
day): Please take 150mg in the morning and at night. Please take
75mg in the afternoon.
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO three times a day.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Polyethylene Glycol 3350 100 % Powder Sig: One (1)  PO DAILY
(Daily).
11. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
pneumonia
sepsis
anxiety
anemia of chronic disease
chronic pain
paraplegia


Discharge Condition:
stable with resting oxygen saturation of 93% on RA but
ambulatory saturation of 86% on RA and 96% on 2L NC.


Discharge Instructions:
You were admitted with severe pneumonia causing sepsis (or low
blood pressure). You were treated with antibiotics and completed
the course. Your stay was complicated by delirium and anxiety
and a psychiatric consult helped us care for you.

You still require oxygen by nasal cannual at home. Please keep
2L on at all times.  You should continue aggressive chest
physical therapy three times a day. Continue to use your
incentive spirometer and get out of bed to a chair as much as
possible to help your lungs expand.

You should take your medications as prescribed.

We recommend that you keep all of your appointments as written
below. We also recommend that you see a psychopharmacologist.
This appointment was not made because you did not want it, but
the number is provided below if you change your mind. This is
recommended to help you develop a working medical regimen to
help control your pain and also keep you thinking clearly and
without side effects.

You should call your doctor or go to the emergency room if you
have fevers over 102, chills, chest pain, trouble breathing,
bleeding or any other symptoms which is concerning to you.

Followup Instructions:
Social work:
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 23482**], LICSW Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2147-5-12**] 12:00
[**Hospital Ward Name 23**] building [**Location (un) **] [**Hospital1 18**] [**Hospital Ward Name **]

Hepatology:
 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2147-5-12**] 1:20


Primary care:
 [**First Name8 (NamePattern2) 1409**] [**Last Name (NamePattern1) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**] Date/Time:[**2147-6-6**] 1:20
[**Hospital1 18**] [**Hospital Ward Name 23**] building [**Location (un) **]

Psychopharmacology:
[**Telephone/Fax (1) 1387**] We recommend you call and schedule an appointment.



Completed by:[**2147-5-10**]
{"Unspecified septicemia,Pneumonia, organism unspecified,Other pulmonary insufficiency, not elsewhere classified,Septic shock,Urinary tract infection, site not specified,Chronic hepatitis C without mention of hepatic coma,Chronic airway obstruction, not elsewhere classified,Delirium due to conditions classified elsewhere,Paraplegia,Severe sepsis,Dysthymic disorder,Late effect of spinal cord injury,Late effects of motor vehicle accident,Other iatrogenic hypotension,Other diuretics causing adverse effects in therapeutic use,Atrophic gastritis, without mention of hemorrhage,Constipation, unspecified,Unspecified acquired hypothyroidism,Personal history of venous thrombosis and embolism,Personal history of tobacco use,Surgical or other procedure not carried out because of patient's decision"}


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: Hypoxia and Hypotension.

PRESENT ILLNESS: Ms. [**Known lastname **] is a 50 year old female with paraplegia secondary to
traumatic injury with recurrent infections, noted by her husband
to be lethargic and hypoxic to 70s on RA at home.

MEDICAL HISTORY: 1. T1-T2 paraplegia following MVC [**1-5**]
2. Recurrent UTIs
3. HCV, viral load suppressed after 3 months of therapy
4. H/o recurrent PNAs
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

MEDICATION ON ADMISSION: Tylenol PRN
Oxycodone 5 mg prn
Pregabalin 150, 75, 150 mg
Calcium carbonate 500 mg [**Hospital1 **]
Baclofen 20, 10, 20 mg
Clonazepam 2 mg QID prn
Oxybutynin 10, 5, 10
Trazodone 100 mg qhs prn
Methadone 5 mg TID
Omeprazole 20 mg daily
Citalopram 40 mg
Levothyroxine 75 mcg daily
Nicotine 14 mg/24 hr daily
Ipratropium-Albuterol prn
Sucralfate 1 gram QID
Polyethylene Glycol 17 grams daily
Docusate Sodium 100 mg PO BID
Senna 8.6 mg [**Hospital1 **]
Ertapenem 1 gram daily completed [**2147-4-27**]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On admission:
Vitals: T 100.2, HR 99, BP 135/60, RR 24, 100% on 6LNC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: decreased breath sounds at right base, scattered wheezes,

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:
{"Unspecified septicemia,Pneumonia, organism unspecified,Other pulmonary insufficiency, not elsewhere classified,Septic shock,Urinary tract infection, site not specified,Chronic hepatitis C without mention of hepatic coma,Chronic airway obstruction, not elsewhere classified,Delirium due to conditions classified elsewhere,Paraplegia,Severe sepsis,Dysthymic disorder,Late effect of spinal cord injury,Late effects of motor vehicle accident,Other iatrogenic hypotension,Other diuretics causing adverse effects in therapeutic use,Atrophic gastritis, without mention of hemorrhage,Constipation, unspecified,Unspecified acquired hypothyroidism,Personal history of venous thrombosis and embolism,Personal history of tobacco use,Surgical or other procedure not carried out because of patient's decision"}
