CHIEF COMPLAINT: Hypoxia

PRESENT ILLNESS: This is a [**Age over 90 **] yo M with COPD, PAF, dementia, with a recently
diagnosed bilateral PNA at nursing home who presents with
hypoxia. He was started on levofloxacin at the NH, changed to
CTX today. The pt was initially hypoxic to 80's on RA, placed on
4L NC, desated again to 80's, and then was placed on NRB satting
91% at NH.
.
In the ED the pts vitals were: T98 HR 110 BP 108/72 RR 20-26 Sat
95-100% on NRB. The pt was noted to have rhonchi on exam, rales
left base, otherwise speaking in short sentences, somewhat
labored breathing, sinus tachy. CXR showed dense confluent
airspace opacities, air bronchograms, butterfly distribution, no
significant cardiac enlargement, no vascular congestion. He
received 1 L NS, Ceftaz, Clindamycin, and Vanc in the ED. In
addition, he was noted to have an NSTEMI with CK 471, MBI 7.9,
and Tpn T 1.88. BNP was 25,131. His EKG however had no clear
changes. He was given ASA but no BB.

MEDICAL HISTORY: 1. h/o Paroxysmal atrial fibrillation
2. HTN
3. h/o falls
4. BPH
5. L ear deafness
6. R eye cataracts s/p lens replacement
7. Arthritis bilateral knees and L hip
8. Mild dementia, unspecified type

MEDICATION ON ADMISSION: -Aricept 10mg qHS
-ASA 325mg daily
-Citalopram 10 mg daily
-Vitamin B12 q month
-Finasteride 5 mg daily
-Metamucil
-Tylenol 1g tid

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T: 97 BP 100/63 P 94 RR 31 Sat 94% on 100% NRB
General: This is a elderly male, sitting up in bed, tachyneic,
oriented x3
HEENT: anisocoria w/ right pupil 3->2 mm and left 2->1 mm. EOMI
without nystagmus, anicteric; MMM, no erythema/exudate
Neck: supple, no JVD
Pulmonary: diffuse rales with end expiratory wheezing
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: trace BL ankle edema, 2+ radial, 1+DP and PT pulses
b/l
Neurologic: AAOx3. CNII-XII grossly intact. MAFE

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: Mr. [**Known lastname 40370**] lives in the [**Hospital3 15333**]
facility.  Daughter [**Name (NI) **] (work: [**Telephone/Fax (1) 40371**]) is his HCP.
Smoked for 30 years, [**1-21**] pack/day. Denied EtOH use. No recent
smoking or alcohol.
Pneumonia due to escherichia coli [E. coli],Subendocardial infarction, initial episode of care,Hypoxemia,Atrial fibrillation,Acute kidney failure, unspecified,Congestive heart failure, unspecified,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Other persistent mental disorders due to conditions classified elsewhere,Unspecified hearing loss,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Diarrhea,Other chronic pulmonary heart diseases
Pneumonia e coli,Subendo infarct, initial,Hypoxemia,Atrial fibrillation,Acute kidney failure NOS,CHF NOS,Acute respiratry failure,Food/vomit pneumonitis,Mental disor NEC oth dis,Hearing loss NOS,BPH w/o urinary obs/LUTS,Diarrhea,Chr pulmon heart dis NEC
Admission Date:  [**2198-2-15**]              Discharge Date:   [**2198-2-23**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 5827**]
Chief Complaint:
Hypoxia

Major Surgical or Invasive Procedure:
R IJ central line placement
PICC line placement

History of Present Illness:
This is a [**Age over 90 **] yo M with COPD, PAF, dementia, with a recently
diagnosed bilateral PNA at nursing home who presents with
hypoxia. He was started on levofloxacin at the NH, changed to
CTX today. The pt was initially hypoxic to 80's on RA, placed on
4L NC, desated again to 80's, and then was placed on NRB satting
91% at NH.
.
In the ED the pts vitals were: T98 HR 110 BP 108/72 RR 20-26 Sat
95-100% on NRB. The pt was noted to have rhonchi on exam, rales
left base, otherwise speaking in short sentences, somewhat
labored breathing, sinus tachy. CXR showed dense confluent
airspace opacities, air bronchograms, butterfly distribution, no
significant cardiac enlargement, no vascular congestion. He
received 1 L NS, Ceftaz, Clindamycin, and Vanc in the ED. In
addition, he was noted to have an NSTEMI with CK 471, MBI 7.9,
and Tpn T 1.88. BNP was 25,131. His EKG however had no clear
changes. He was given ASA but no BB.

Past Medical History:
1. h/o Paroxysmal atrial fibrillation
2. HTN
3. h/o falls
4. BPH
5. L ear deafness
6. R eye cataracts s/p lens replacement
7. Arthritis bilateral knees and L hip
8. Mild dementia, unspecified type


Social History:
Mr. [**Known lastname 40370**] lives in the [**Hospital3 15333**]
facility.  Daughter [**Name (NI) **] (work: [**Telephone/Fax (1) 40371**]) is his HCP.
Smoked for 30 years, [**1-21**] pack/day. Denied EtOH use. No recent
smoking or alcohol.


Family History:
Noncontributory.

Physical Exam:
T: 97 BP 100/63 P 94 RR 31 Sat 94% on 100% NRB
General: This is a elderly male, sitting up in bed, tachyneic,
oriented x3
HEENT: anisocoria w/ right pupil 3->2 mm and left 2->1 mm. EOMI
without nystagmus, anicteric; MMM, no erythema/exudate
Neck: supple, no JVD
Pulmonary: diffuse rales with end expiratory wheezing
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: trace BL ankle edema, 2+ radial, 1+DP and PT pulses
b/l
Neurologic: AAOx3. CNII-XII grossly intact. MAFE

Pertinent Results:
[**2198-2-15**] 10:15AM   GLUCOSE-192* UREA N-31* CREAT-0.9 SODIUM-132*
POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-24 ANION GAP-13
[**2198-2-15**] 10:15AM   CK-MB-37* MB INDX-7.9* cTropnT-1.88*
proBNP-[**Numeric Identifier 32490**]*
[**2198-2-15**] 10:15AM   CK(CPK)-471*
[**2198-2-15**] 11:22AM   WBC-15.5*# RBC-4.38* HGB-13.1* HCT-40.4
MCV-92 MCH-29.8 MCHC-32.3 RDW-14.0
[**2198-2-15**] 11:22AM   NEUTS-86.2* LYMPHS-9.9* MONOS-3.9 EOS-0
BASOS-0.1
[**2198-2-15**] 06:54PM   CK-MB-18* MB INDX-6.2* cTropnT-2.94*
[**2198-2-15**] 06:54PM   WBC-12.7* RBC-3.98* HGB-12.4* HCT-36.9*
MCV-93 MCH-31.1 MCHC-33.5 RDW-14.1
[**2198-2-15**] 11:22AM   NEUTS-86.2* LYMPHS-9.9* MONOS-3.9 EOS-0
BASOS-0.1
.
ECHO:
Left Atrium - Long Axis Dimension: 3.5 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 5.1 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 4.4 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.3 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 2.7 cm
Left Ventricle - Fractional Shortening: 0.37 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 50% (nl >=55%)
Aorta - Valve Level: *3.9 cm (nl <= 3.6 cm)
Aortic Valve - Peak Velocity: 1.0 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 0.6 m/sec
Mitral Valve - E/A Ratio: 1.33
Mitral Valve - E Wave Deceleration Time: 250 msec
TR Gradient (+ RA = PASP): *26 mm Hg (nl <= 25 mm Hg)
Pulmonic Valve - Peak Velocity: 1.0 m/sec (nl <= 1.0 m/s)

INTERPRETATION:

Findings:

This study was compared to the report of the prior study (images
not
available) of [**2196-1-25**].


LEFT ATRIUM: Normal LA size.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.

LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. No
resting LVOT
gradient. No VSD.

RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic
function.
Paradoxic septal motion consistent with conduction
abnormality/ventricular
pacing.

AORTA: Mildly dilated aortic sinus.

AORTIC VALVE: ?# aortic valve leaflets. Mildly thickened aortic
valve
leaflets. No AS. No AR.

MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. Mild (1+) MR. [Due to acoustic shadowing, the
severity of MR
may be significantly UNDERestimated.]

TRICUSPID VALVE: Mild PA systolic hypertension.

PULMONIC VALVE/PULMONARY ARTERY: No PS.

PERICARDIUM: No pericardial effusion.

GENERAL COMMENTS: Suboptimal image quality - poor echo windows.


Conclusions:
Sub-optimal image quality. The left atrium is normal in size.
There is mild
symmetric left ventricular hypertrophy with normal cavity size.
The [**Year (4 digits) **]
wall appears hypokinetic in some views (limited by poor image
quality).
Overall LVEF is probably preserved/mildly reduced. There is no
ventricular
septal defect. The right ventricular cavity is mildly dilated.
Right
ventricular systolic function is normal. The aortic root is
mildly dilated at
the sinus level. The number of aortic valve leaflets cannot be
determined. The
aortic valve leaflets are mildly thickened. There is no aortic
valve stenosis.
No aortic regurgitation is seen. The mitral valve leaflets are
mildly
thickened. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing,
the severity of mitral regurgitation may be significantly
UNDERestimated.]
There is mild pulmonary artery systolic hypertension. There is
no pericardial
effusion.

Compared with the report of the prior study (images unavailable
for review) of
[**2196-1-25**], the [**Year (4 digits) **] wall now appears hypokinetic. If
clinically indicated, a
repeat study with echo contrast (Definity) may better
characterize
regional/global LV systolic function.
.
CXR:
There are dense, confluent air space
opacities, with prominent air bronchograms, involving both
parahilar regions
and the medial aspect of the right lung base, in a somewhat
"butterfly"
distribution.  However, there is no significant cardiac
enlargement and no
pleural effusion or gross pulmonary vascular congestion is
identified.  There
are atherosclerotic changes involving the thoracic aorta.

IMPRESSION:  Multifocal air space process with overall
appearance more
suggestive of extensive pneumonic consolidation than pulmonary
edema.


Brief Hospital Course:
Mr. [**Known lastname 40370**] is a [**Age over 90 **] year old male with COPD, PAF, dementia,
with a recently diagnosed bilateral PNA at nursing home who
presents with hypoxia and pneumonia vs. pulmonary edema and
found to have an NSTEMI.
.
1. Hypoxia: The patient's chest film findings were more
consistent with pneumonia than pulmonary edema. However, both
infection and heart failure were considered as etiologies for
his hypoxia. He initially required an non-rebreather for
adequate oxygenation.  He was given ceftriaxone and vancomycin
the emergency room and once in the MICU he was converted to
vancomycin and zosyn for broader coverage given his continued
hypoxia and hypotension.  He slowly improved and was weened down
to 4L NC.  Given his initially hypotension, he was given many
boluses of IVF and eventually developed pulmonary edema.  This
was treated with furosemide with good resolution. He was
discharged with a continued oxygen requirement of 3L nasal
cannula with oxygen saturation in the mid-90s%. Subsequent doses
of furosemide were not found to improve his oxygenation and
indeed may run the risk of dehydrating him. His hypoxia is
likely to resolve only as the pneumonia resolves. The patient
also was started on standing ipratropium nebulizer to improve
his respiratory status.
.
2. Pneumonia: As stated above, the patient was treated with
broad spectrum antibiotics on admission and in the ICU. His
blood cultures were negative, however, his sputum culture
contianed E.Coli that was broadly resistant (ESBL). See results
section for details. Although the culture was sensitive to
pipercillin/tazobactam, it was resistant to piperacillin alone,
and therefore there was a concern that it would develop
resistance to piperacillin alone. The patient was therefore
switch to meropenem, which he will require IV for at least a two
week course. Determination of the full length of course will be
determined by his primary physician, [**Name10 (NameIs) **] on his clinical
improvement. Because he had a highly resistant form of E.Coli,
he was switch to contact precautions while on the floor.
.
3. NSTEMI: Pt has elevated cardiac enzymes with CK 471-->291,
Tpn 1.88-->2.94. No clear EKG changes. Cardiology was consulted
and recommended starting a heparin gtt and giving a plavix load.
He was given aspirin and atorvastatin. It was thought that he
more likely had the NSTEMI in the setting of infection and
tachycardia causing a demand ischemia.  The heparin gtt was
stopped and he was not continued on plavix.  He was initially
not given a beta blocker or an ACEI given his hypotension.  Once
this resolved, his rate allowed for metoprolol 12.5mg TID, but
his blood pressures were still on the low side and for this
reason, an ACEI was not started.  He had an ECHO done which was
a poor study but showed 1+MR [**First Name (Titles) 151**] [**Last Name (Titles) **] wall hypokinesis and a
relatively preserved EF. He was continued on metoprolol,
aspirin, and statin.
.
4. PAF: patient had transient episodes of PAF.  The risks for
starting coumadin seem to outweigh the benefits of
anticoagulation in this demented elderly patient at high risk
for falls.
.
5. ARF: His creatinine rose after using furosemide to help with
his pulmonary edema.  Given this time course, his ARF was likely
secondary to this diuresis.  His Cr was continued to be
monitored. On discharge, his creatinine had returned to his
baseline level of 0.8.
.
6. GU: On the morning of discharge, the patient's urine was
noted to be quite concentrated. He had a foley in throughout his
stay. A U/A and urine culture was sent and results were pending
at time of discharge. The patient is being discharged on
meropenem, which is broadly active against urinary tract
pathogens. However, if a resistant bacteria is found on urine
culture, the [**Hospital 228**] nursing home will be contact[**Name (NI) **]. The
patient's foley was changed out. He failed to void after three
hours and in the interest of smooth transition of care, a foley
was replaced. However, a voiding trial should be considered as
soon as feasible at the [**Hospital 228**] nursing home. For the
patient's BPH he was continued on finasteride.
.
7. Lines: The patient has a right arm PICC line which was placed
on [**2198-2-23**]. The patient self-dc'd this PICC line earlier in his
stay. Thus, every attempt should be made to protect this PICC by
heavy wrapping with gauze. The patient's Foley was replaced on
[**2198-2-23**].
.
#Dementia/Psych: He was continued on his home doses of aricept,
celexa
.
#Speech and swallow: The patient had a speech and swallow eval
which found that he could tolerate thin liquids and ground
consistency solids. No straws. Dentures should not be worn
during meals given loose fit and risk of choking. Pills can be
given whole with puree. Finally, "if fixodent adhesive could be
brought for patient, he could be advanced to regular solids once
his pneumonia has cleared."
The patient was noted to have some trouble at times with whole
pills in puree and pills should be ground up if he demonstrates
ongoing aspiration risk.
.
#Contact: Daughter, [**Name (NI) **], [**Telephone/Fax (1) 40372**]
.
#DNR/DNI
.


Medications on Admission:
-Aricept 10mg qHS
-ASA 325mg daily
-Citalopram 10 mg daily
-Vitamin B12 q month
-Finasteride 5 mg daily
-Metamucil
-Tylenol 1g tid

Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.

2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day): Hold for SBP<100, HR<60.
10. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed: 10 ml NS followed by
2 ml of 100 Units/ml heparin (200 units heparin) each lumen
Daily and PRN. Inspect site every shift.
11. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q8H (every 8 hours) for 2 weeks: Full course to be
determined by covering physician.
12. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 537**]- [**Location (un) 538**]

Discharge Diagnosis:
Primary:
Pneumonia
Non-ST elevation myocardial infarction
.
Secondary:
Dementia
BPH


Discharge Condition:
Stable
Requires assistance ambulating
Require supplemental O2
Requires assistance taking pills.


Discharge Instructions:
The patient was hospitalized with pneumonia and coronary
ischemia. He improved with antibiotics, however he still
requires supplemental oxygen to maintain normal saturation. He
also will require an extended course of at least two weeks of
meropenem. Full extent of the course of antibiotics depends on
patient's clinical improvement, as determined by his clinician.


Followup Instructions:
Follow-up care will be managed by your primary care physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) **], or by other doctors in the [**Hospital3 4262**] Group.



Completed by:[**2198-2-23**]
{'Pneumonia due to escherichia coli [E. coli],Subendocardial infarction, initial episode of care,Hypoxemia,Atrial fibrillation,Acute kidney failure, unspecified,Congestive heart failure, unspecified,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Other persistent mental disorders due to conditions classified elsewhere,Unspecified hearing loss,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Diarrhea,Other chronic pulmonary heart diseases'}


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

PRESENT ILLNESS: This is a [**Age over 90 **] yo M with COPD, PAF, dementia, with a recently
diagnosed bilateral PNA at nursing home who presents with
hypoxia. He was started on levofloxacin at the NH, changed to
CTX today. The pt was initially hypoxic to 80's on RA, placed on
4L NC, desated again to 80's, and then was placed on NRB satting
91% at NH.
.
In the ED the pts vitals were: T98 HR 110 BP 108/72 RR 20-26 Sat
95-100% on NRB. The pt was noted to have rhonchi on exam, rales
left base, otherwise speaking in short sentences, somewhat
labored breathing, sinus tachy. CXR showed dense confluent
airspace opacities, air bronchograms, butterfly distribution, no
significant cardiac enlargement, no vascular congestion. He
received 1 L NS, Ceftaz, Clindamycin, and Vanc in the ED. In
addition, he was noted to have an NSTEMI with CK 471, MBI 7.9,
and Tpn T 1.88. BNP was 25,131. His EKG however had no clear
changes. He was given ASA but no BB.

MEDICAL HISTORY: 1. h/o Paroxysmal atrial fibrillation
2. HTN
3. h/o falls
4. BPH
5. L ear deafness
6. R eye cataracts s/p lens replacement
7. Arthritis bilateral knees and L hip
8. Mild dementia, unspecified type

MEDICATION ON ADMISSION: -Aricept 10mg qHS
-ASA 325mg daily
-Citalopram 10 mg daily
-Vitamin B12 q month
-Finasteride 5 mg daily
-Metamucil
-Tylenol 1g tid

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T: 97 BP 100/63 P 94 RR 31 Sat 94% on 100% NRB
General: This is a elderly male, sitting up in bed, tachyneic,
oriented x3
HEENT: anisocoria w/ right pupil 3->2 mm and left 2->1 mm. EOMI
without nystagmus, anicteric; MMM, no erythema/exudate
Neck: supple, no JVD
Pulmonary: diffuse rales with end expiratory wheezing
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: trace BL ankle edema, 2+ radial, 1+DP and PT pulses
b/l
Neurologic: AAOx3. CNII-XII grossly intact. MAFE

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: Mr. [**Known lastname 40370**] lives in the [**Hospital3 15333**]
facility.  Daughter [**Name (NI) **] (work: [**Telephone/Fax (1) 40371**]) is his HCP.
Smoked for 30 years, [**1-21**] pack/day. Denied EtOH use. No recent
smoking or alcohol. 

### Response:
{'Pneumonia due to escherichia coli [E. coli],Subendocardial infarction, initial episode of care,Hypoxemia,Atrial fibrillation,Acute kidney failure, unspecified,Congestive heart failure, unspecified,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Other persistent mental disorders due to conditions classified elsewhere,Unspecified hearing loss,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Diarrhea,Other chronic pulmonary heart diseases'}
