CHIEF COMPLAINT: unresponsiveness and PE

PRESENT ILLNESS: 77yo F w/hx of dementia, bipolar, anxiety, R hip fx [**2-27**] with
post-op PE and infected hematoma, s/p IVC filter, recurrent UTI
[**2-27**], advanced dementia who comes in from NH after being found
unresponsive. She was reportedly unresponsive for 5-10m and
hypoxic at 88%. Put on NRB and was 94% so was brought in.
Reportedly awoke to her baseline AAOx1 after 5m.
.
Of note: she had right ORIF [**2-27**] c/b postop PE (right lower
lobe) then hematoma. Anticoag stopped and IVC filter placed. She
also developed infection and pseudoanyeursm both treated.
.
In ED, 89% on RA then up to 96% on 2L. BP stable. HR 60-70. EKG
showed NSR, LAD, Q aVF, TWI III, TWF V3-V6 (no change). CTA
chest showed acute thrombus at bifurcation of right PA extending
into right middle lobe artery. No thrombus in left side. She was
started on heparin gtt without bolus. CE: CK flat but Trop 0.05.
Seen by vascular service who recommended bilat ultrasounds which
showed bilat lower ex DVTs. Hct at 36. Repeat HCT stable.
.
Currently, she feels well but difficult to assess related to
dementia. She denies pain anywhere. Denies CP or SOB. No leg
pain. Wants to be left alone to rest. ROS neg for fevers,
chills, or other systemic sx.
.

MEDICAL HISTORY: - R hip ORIF [**2117-3-8**] with course complicated by:
--- post-op PE (with bleeding complications requiring up to 14u
postop. Led to decision to stop anticoag and place IVC filter
([**2-27**] by Dr. [**Last Name (STitle) 1391**]
--- Morganella hip infection s/p IV abx (now on levaquin 500
daily)
--- pseudoaneurysm s/p correction [**5-6**]
- Bipolar
- Depression and anxiety
- HTN
- Pedal Edema
- Alzheimer's dementia with delusions and delirium, baseline MS

MEDICATION ON ADMISSION: Buproprion 75 [**Hospital1 **]
Citalopram 30 daily
Fentanyl patch 25
Metoprolol 12.5 [**Hospital1 **]
Olanzapine 5 [**Hospital1 **] prn
Famvir 500mg daily ???
levaquin 500 daily
asa 325
Oxycodone 2.5 prn
tylenol prn
Pantoprazole 40 daily
bisacodyl 10 qhs prn
Calcium/Vitamin D
Colace
MVI
Senna

ALLERGIES: Penicillins

PHYSICAL EXAM: Admission Exam:
==============
VS: 128/83 62 95% 2L RR12
Gen: frail, NAD, RR normal, no accessory muscles
HEENT: mm dry. JVP 7cm
Lungs: CTAB w no rales or wheeze
Heart: RRR iii/vi harsh early systolic murmur LUSB
Abd: BS+ mildly tender diffusely, no rebound or guarding
Ext: no rashes. 1+ pulses in feet bilat. 2+ edema bilat without
assymetry or pain. right hip does not feel particularly tense
Neuro: AAO to name but not otherwise. Can follow simple
commands.
- PERRLA, tongue midline. face symmetric
- toes down. FROM bilat upper/lower

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Lives in [**Hospital 745**] [**Hospital **] Nursing home.
Other pulmonary embolism and infarction,Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity,Dementia in conditions classified elsewhere with behavioral disturbance,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Anemia of other chronic disease,Alzheimer's disease,Bipolar disorder, unspecified,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits
Pulm embol/infarct NEC,Ac DVT/embl low ext NOS,Dementia w behavior dist,Hypertension NOS,Hyperlipidemia NEC/NOS,Anemia-other chronic dis,Alzheimer's disease,Bipolar disorder NOS,Hx TIA/stroke w/o resid
Admission Date:  [**2117-6-20**]              Discharge Date:   [**2117-6-25**]

Date of Birth:  [**2040-4-5**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 5129**]
Chief Complaint:
 unresponsiveness and PE

Major Surgical or Invasive Procedure:
none

History of Present Illness:
77yo F w/hx of dementia, bipolar, anxiety, R hip fx [**2-27**] with
post-op PE and infected hematoma, s/p IVC filter, recurrent UTI
[**2-27**], advanced dementia who comes in from NH after being found
unresponsive. She was reportedly unresponsive for 5-10m and
hypoxic at 88%. Put on NRB and was 94% so was brought in.
Reportedly awoke to her baseline AAOx1 after 5m.
.
Of note: she had right ORIF [**2-27**] c/b postop PE (right lower
lobe) then hematoma. Anticoag stopped and IVC filter placed. She
also developed infection and pseudoanyeursm both treated.
.
In ED, 89% on RA then up to 96% on 2L. BP stable. HR 60-70. EKG
showed NSR, LAD, Q aVF, TWI III, TWF V3-V6 (no change). CTA
chest showed acute thrombus at bifurcation of right PA extending
into right middle lobe artery. No thrombus in left side. She was
started on heparin gtt without bolus. CE: CK flat but Trop 0.05.
Seen by vascular service who recommended bilat ultrasounds which
showed bilat lower ex DVTs. Hct at 36. Repeat HCT stable.
.
Currently, she feels well but difficult to assess related to
dementia. She denies pain anywhere. Denies CP or SOB. No leg
pain. Wants to be left alone to rest. ROS neg for fevers,
chills, or other systemic sx.
.


Past Medical History:
- R hip ORIF [**2117-3-8**] with course complicated by:
--- post-op PE (with bleeding complications requiring up to 14u
postop. Led to decision to stop anticoag and place IVC filter
([**2-27**] by Dr. [**Last Name (STitle) 1391**]
--- Morganella hip infection s/p IV abx (now on levaquin 500
daily)
--- pseudoaneurysm s/p correction [**5-6**]
- Bipolar
- Depression and anxiety
- HTN
- Pedal Edema
- Alzheimer's dementia with delusions and delirium, baseline MS

per nursing home records is oriented to self only
- Hyperlipidemia
- h/o CVA [**2097**]


Social History:
Lives in [**Hospital 745**] [**Hospital **] Nursing home.

Son [**Name (NI) **].


Family History:
Noncontributory

Physical Exam:
Admission Exam:
==============
VS: 128/83 62 95% 2L RR12
Gen: frail, NAD, RR normal, no accessory muscles
HEENT: mm dry. JVP 7cm
Lungs: CTAB w no rales or wheeze
Heart: RRR iii/vi harsh early systolic murmur LUSB
Abd: BS+ mildly tender diffusely, no rebound or guarding
Ext: no rashes. 1+ pulses in feet bilat. 2+ edema bilat without
assymetry or pain. right hip does not feel particularly tense
Neuro: AAO to name but not otherwise. Can follow simple
commands.
- PERRLA, tongue midline. face symmetric
- toes down. FROM bilat upper/lower


Pertinent Results:
Admission labs:
==============
[**2117-6-20**] 11:30AM BLOOD WBC-5.1 RBC-4.08* Hgb-11.3* Hct-36.2
MCV-89 MCH-27.6 MCHC-31.2 RDW-14.6 Plt Ct-304
[**2117-6-20**] 11:30AM BLOOD Neuts-61.2 Lymphs-30.6 Monos-6.3 Eos-1.5
Baso-0.4
[**2117-6-20**] 11:30AM BLOOD PT-14.4* PTT-26.4 INR(PT)-1.2*
[**2117-6-20**] 11:30AM BLOOD Glucose-129* UreaN-13 Creat-0.5 Na-141
K-5.1 Cl-106 HCO3-28 AnGap-12
[**2117-6-20**] 11:30AM BLOOD CK(CPK)-103
[**2117-6-20**] 11:30AM BLOOD CK-MB-4
[**2117-6-20**] 11:30AM BLOOD cTropnT-0.05*
[**2117-6-20**] 08:00PM BLOOD cTropnT-0.07*
[**2117-6-21**] 01:52AM BLOOD CK-MB-4 cTropnT-0.06*
[**2117-6-21**] 01:52AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.9
[**2117-6-20**] 10:25AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2117-6-20**] 10:25AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG

[**2117-6-20**] BLOOD CULTURE Blood Culture, Routine - pending
[**2117-6-20**] URINE URINE CULTURE - no growth

Imaging:
========
[**6-20**] LE Duplex
1. Partially occlusive thrombus in the right superficial femoral
vein extending to the right popliteal vein.
2. Partially occlusive thrombus in the left common femoral vein,
which does not extend distally.
3. Thrombosed pseudoaneurysm in the left groin.

[**2117-6-20**] UE Duplex: No evidence of upper extremity DVT,
bilaterally

[**2117-6-21**] ECHO:
Left ventricular systolic function is hyperdynamic (EF>75%).
Right ventricular chamber size is normal. with normal free wall
contractility. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is borderline pulmonary artery systolic
hypertension.
IMPRESSION: Sub-optimal image quality. Right ventricular size
and systolic function is probably normal. Left ventricular
function is hyperdynamic. Mild mitral and tricuspid
regurgitation.
Compared with the prior study (images reviewed) of [**2117-3-12**],
the estimated pulmonary artery systolic pressure is lower on the
current study (however the TR jet velocity may be underestimated
on the current study).

[**2117-6-20**] CTA:
1. Acute pulmonary embolism in the right pulmonary artery at its
bifurcation, extending into the right middle lobe branches. More
chronic-appearing thrombus present in the right lower lobe
branches.
2. Compression deformity of T10 vertebral body, appears
unchanged, but not
completely visualized on the [**2117-3-11**] study.
3. No acute aortic abnormality. Stable atherosclerotic
calcification.

[**2117-6-20**] CT Head: No acute intracranial abnormalities.

[**2117-6-20**] CXR: Patient is quite kyphotic. There are low lung
volumes. There is plate-like atelectasis at the left lung base.
Lungs are otherwise grossly clear. Heart and mediastinum are
within normal limits. The bones are quite osteopenic.



Brief Hospital Course:
77 yo woman w hx of R hip ORIF [**2-27**] c/b post-op PE c/b hip
hematoma and hip infection. Patient had IVC filter placed and is
not on anticoagulation. Found unresponsive in NH and hypoxic
which improved now with only 2L. CTA shows large prox right pulm
artery PE. EKG without noticable strain. Mild trop leak.
.
# PE
No comment on RH strain seen on CT. Still given proximitiy,
likely this could be considered submassive. She is HD stable at
this point and has good resp status. Pt was anticoagulated with
IV heparin and also started on low dose coumadin (2.5-3mg/d).
Her INR today is 1.9. She was switched to lovenox on the day of
discharge and should overlap heparin with coumadin for at least
3 days more. Because this is recurrent PE despite IVC filter she
is a candidate for life-long anticoagulation. Goal INR should be
2 - 2.5
.
# Hx hematoma - H&H was monitored daily and was stable. There
was no clinical evidence of bleeding.
.
# dementia/psych:
Mental status improved over 24-48 hrs and returned to her
baseline. continue psych meds.
.
# ID:
Pt remained on the fluoroquinolone for her prior hip infection.
She developed low grade fever (<100.5) on [**6-24**] and ha d a chest
x-ray (negative except for improving atelectasis) and UA
(negative). No evidence of infection identified, and she
defervesced spontaneously, so likely secondary to atelectasis.
.
.
# Hypertension:
Initially Metoprolol was held given history of bleed and PE.
This was restarted [**6-22**] after heparin was therapeutic for >24
hours and she had no bleeding.

# FEN/GI - tolerating regular diet, puree solids, thin liquids


Medications on Admission:
Buproprion 75 [**Hospital1 **]
Citalopram 30 daily
Fentanyl patch 25
Metoprolol 12.5 [**Hospital1 **]
Olanzapine 5 [**Hospital1 **] prn
Famvir 500mg daily ???
levaquin 500 daily
asa 325
Oxycodone 2.5 prn
tylenol prn
Pantoprazole 40 daily
bisacodyl 10 qhs prn
Calcium/Vitamin D
Colace
MVI
Senna


Discharge Medications:
1. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
2. Citalopram 20 mg Tablet [**Hospital1 **]: 1.5 Tablets PO DAILY (Daily).
3. Fentanyl 25 mcg/hr Patch 72 hr [**Hospital1 **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
4. Olanzapine 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for agitation.
5. Levofloxacin 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q24H (every
24 hours).
6. Acetaminophen 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Calcium Carbonate 500 mg Tablet, Chewable [**Hospital1 **]: One (1)
Tablet, Chewable PO TID (3 times a day).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily).
10. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1)  PO BID (2
times a day).
11. Multivitamin     Tablet [**Hospital1 **]: One (1) Cap PO DAILY (Daily).
12. Bupropion 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
13. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID (2
times a day).
14. Miconazole Nitrate 2 % Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
15. Lactulose 10 gram/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO TID (3
times a day).
16. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
17. Senna 8.6 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily).
18. Warfarin 1 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO Once Daily at
4 PM as needed for Pulmonary embolism: Goal INR = 2-2.5.
19. Enoxaparin 80 mg/0.8 mL Syringe [**Last Name (STitle) **]: One (1) 70 Subcutaneous
Q12H (every 12 hours) for 3 days.


Discharge Disposition:
Extended Care

Facility:
[**Hospital 745**] Health Care Center

Discharge Diagnosis:
Pulmonary embolism
Alzheimer's dementia with delusions and delirium, baseline
mental status is oriented to self only
S/P R hip ORIF [**2117-3-8**] following hip fracture
Morganella hip infection post ORIF - on long-term Abx
Bipolar D/O
HTN
Depression and anxiety
Hyperlipidemia
S/P CVA [**2097**]
Chronic anemia

Discharge Condition:
Good


Discharge Instructions:
Continue Lovenox at treatment doses for Pulmonary embolism for 3
more days in addition to coumadin.

Goal INR = 2.0-2.5.

Patient will likely require life-long anticoagulation given
recurrent pulmonary embolism despite IVC filter.

Watch clinically for evidence of bleeding and monitor H & H
given history of significant bleeding after hip surgery.

Followup Instructions:
Follow up with physician in Nursing [**Name9 (PRE) **] in 1 week
{"Other pulmonary embolism and infarction,Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity,Dementia in conditions classified elsewhere with behavioral disturbance,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Anemia of other chronic disease,Alzheimer's disease,Bipolar disorder, unspecified,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: unresponsiveness and PE

PRESENT ILLNESS: 77yo F w/hx of dementia, bipolar, anxiety, R hip fx [**2-27**] with
post-op PE and infected hematoma, s/p IVC filter, recurrent UTI
[**2-27**], advanced dementia who comes in from NH after being found
unresponsive. She was reportedly unresponsive for 5-10m and
hypoxic at 88%. Put on NRB and was 94% so was brought in.
Reportedly awoke to her baseline AAOx1 after 5m.
.
Of note: she had right ORIF [**2-27**] c/b postop PE (right lower
lobe) then hematoma. Anticoag stopped and IVC filter placed. She
also developed infection and pseudoanyeursm both treated.
.
In ED, 89% on RA then up to 96% on 2L. BP stable. HR 60-70. EKG
showed NSR, LAD, Q aVF, TWI III, TWF V3-V6 (no change). CTA
chest showed acute thrombus at bifurcation of right PA extending
into right middle lobe artery. No thrombus in left side. She was
started on heparin gtt without bolus. CE: CK flat but Trop 0.05.
Seen by vascular service who recommended bilat ultrasounds which
showed bilat lower ex DVTs. Hct at 36. Repeat HCT stable.
.
Currently, she feels well but difficult to assess related to
dementia. She denies pain anywhere. Denies CP or SOB. No leg
pain. Wants to be left alone to rest. ROS neg for fevers,
chills, or other systemic sx.
.

MEDICAL HISTORY: - R hip ORIF [**2117-3-8**] with course complicated by:
--- post-op PE (with bleeding complications requiring up to 14u
postop. Led to decision to stop anticoag and place IVC filter
([**2-27**] by Dr. [**Last Name (STitle) 1391**]
--- Morganella hip infection s/p IV abx (now on levaquin 500
daily)
--- pseudoaneurysm s/p correction [**5-6**]
- Bipolar
- Depression and anxiety
- HTN
- Pedal Edema
- Alzheimer's dementia with delusions and delirium, baseline MS

MEDICATION ON ADMISSION: Buproprion 75 [**Hospital1 **]
Citalopram 30 daily
Fentanyl patch 25
Metoprolol 12.5 [**Hospital1 **]
Olanzapine 5 [**Hospital1 **] prn
Famvir 500mg daily ???
levaquin 500 daily
asa 325
Oxycodone 2.5 prn
tylenol prn
Pantoprazole 40 daily
bisacodyl 10 qhs prn
Calcium/Vitamin D
Colace
MVI
Senna

ALLERGIES: Penicillins

PHYSICAL EXAM: Admission Exam:
==============
VS: 128/83 62 95% 2L RR12
Gen: frail, NAD, RR normal, no accessory muscles
HEENT: mm dry. JVP 7cm
Lungs: CTAB w no rales or wheeze
Heart: RRR iii/vi harsh early systolic murmur LUSB
Abd: BS+ mildly tender diffusely, no rebound or guarding
Ext: no rashes. 1+ pulses in feet bilat. 2+ edema bilat without
assymetry or pain. right hip does not feel particularly tense
Neuro: AAO to name but not otherwise. Can follow simple
commands.
- PERRLA, tongue midline. face symmetric
- toes down. FROM bilat upper/lower

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Lives in [**Hospital 745**] [**Hospital **] Nursing home. 

### Response:
{"Other pulmonary embolism and infarction,Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity,Dementia in conditions classified elsewhere with behavioral disturbance,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Anemia of other chronic disease,Alzheimer's disease,Bipolar disorder, unspecified,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits"}
