CHIEF COMPLAINT: fever

PRESENT ILLNESS: Pt is a 71 yo F with Down's syndrome and Alzheimer's dementia,
also s/p [**First Name3 (LF) 4448**] who initally presented with fever, cough and
agitation for 2-3 days. Pt reported abdominal pain but no other
complaints. Per nursing home staff, she was eating and drinking
normally with no diarrhea. No known sick contacts. [**Name (NI) **] reports of
sputum. Pt otherwise has been in USOH.  Had swallow eval in [**9-2**]
which showed only microaspiration.
.
In the ED the pt was febrile to 101.2.  She had a KUB and
abdominal CT, as well as CXR. She was given IV fluids and
swallow study was ordered. She was started on vanco, levo, and
flagyl.

MEDICAL HISTORY: Down's Syndrome
Alzheimer's dementia
s/p [**Date Range 4448**]
osteoporosis
rosacea
Raynauds
OCD

MEDICATION ON ADMISSION: celexa 10 mg PO qday
tylenol 325mg PO prn
Ca carbonate 1000mg PO qday
ASA 81 mg PO qday
aricept 5mg PO qday
trazadone 25mg qhs
Zyprexa PRN
Zosyn
Vanco
Azithromycin

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE: T 96.5 ax BP 95/48, HR 71  RR 12  O2 96% shovel mask  wt
103lbs
Gen: sitting up in bed, not following commands, agonal
breathing, audible wheeze.
HEENT: PERRL, NCAT, MMM
Neck: no LAD, ? JVD (unable to assess fully due to mask
ventilation)
Cor: RRR, III/VI systolic murmur heard best at LUSB, s1s2
Pulm: difuse insp and exp wheezing. Poor air movement, decreased
BS at bilateral bases.
Abd: soft, NT, distended, small ventral hernia noted, no HSM,
hyperactive BS.
Ext: mild erythema of hands and wrists. Warm and well perfused.
Neuro: unable to examine

FAMILY HISTORY: Unable to obtain.

SOCIAL HISTORY: Pt lives in nursing home. Per chart no tobacco or alcohol. The
pt's guardian ([**Name (NI) **] ARC) from her group home changed her code
status to DNR/DNI for this admission.
Pneumonitis due to inhalation of food or vomitus,Congestive heart failure, unspecified,Down's syndrome,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Osteoporosis, unspecified,Cardiac pacemaker in situ
Food/vomit pneumonitis,CHF NOS,Down's syndrome,Alzheimer's disease,Dementia w/o behav dist,Osteoporosis NOS,Status cardiac pacemaker
Admission Date:  [**2159-9-18**]              Discharge Date:   [**2159-10-1**]

Date of Birth:  [**2088-7-13**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2605**]
Chief Complaint:
fever

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Pt is a 71 yo F with Down's syndrome and Alzheimer's dementia,
also s/p [**First Name3 (LF) 4448**] who initally presented with fever, cough and
agitation for 2-3 days. Pt reported abdominal pain but no other
complaints. Per nursing home staff, she was eating and drinking
normally with no diarrhea. No known sick contacts. [**Name (NI) **] reports of
sputum. Pt otherwise has been in USOH.  Had swallow eval in [**9-2**]
which showed only microaspiration.
.
In the ED the pt was febrile to 101.2.  She had a KUB and
abdominal CT, as well as CXR. She was given IV fluids and
swallow study was ordered. She was started on vanco, levo, and
flagyl.

Past Medical History:
Down's Syndrome
Alzheimer's dementia
s/p [**Date Range 4448**]
osteoporosis
rosacea
Raynauds
OCD

Social History:
Pt lives in nursing home. Per chart no tobacco or alcohol. The
pt's guardian ([**Name (NI) **] ARC) from her group home changed her code
status to DNR/DNI for this admission.

Family History:
Unable to obtain.

Physical Exam:
PE: T 96.5 ax BP 95/48, HR 71  RR 12  O2 96% shovel mask  wt
103lbs
Gen: sitting up in bed, not following commands, agonal
breathing, audible wheeze.
HEENT: PERRL, NCAT, MMM
Neck: no LAD, ? JVD (unable to assess fully due to mask
ventilation)
Cor: RRR, III/VI systolic murmur heard best at LUSB, s1s2
Pulm: difuse insp and exp wheezing. Poor air movement, decreased
BS at bilateral bases.
Abd: soft, NT, distended, small ventral hernia noted, no HSM,
hyperactive BS.
Ext: mild erythema of hands and wrists. Warm and well perfused.
Neuro: unable to examine

Pertinent Results:
Labs on admission:
[**2159-9-23**] 07:20AM BLOOD WBC-8.8 RBC-3.45* Hgb-11.1* Hct-32.7*
MCV-95 MCH-32.1* MCHC-33.8 RDW-13.6 Plt Ct-287
[**2159-9-23**] 07:20AM BLOOD Plt Ct-287
[**2159-9-22**] 07:05AM BLOOD Glucose-89 UreaN-4* Creat-0.6 Na-134
K-4.1 Cl-101 HCO3-26 AnGap-11
[**2159-9-23**] 07:20AM BLOOD Calcium-7.8* Phos-4.5 Mg-1.7
[**2159-9-23**] 01:33PM BLOOD Type-ART pO2-129* pCO2-52* pH-7.37
calHCO3-31* Base XS-3
[**2159-9-23**] 09:36AM BLOOD Type-ART pO2-55* pCO2-49* pH-7.39
calHCO3-31* Base XS-3
.
CXR: Persistent bilateral pulmonary opacities consistent with
pneumonia, possibly slightly increased right lung base and
decreased on the left side. No pneumothorax.
.
CT abdomen ([**9-19**]): Bibasilar airspace consolidations with small,
bilateral pleural effusions.  Otherwise, unremarkable CT of the
abdomen and pelvis.
.
KUB ([**9-19**]): fecal material demonstrated throughout the colon.
Limited study.  No definite evidence for bowel obstruction or
free intraperitoneal air.
.
TTE: The left atrium is elongated. There is mild symmetric LVH.
The LV cavity size is normal. Overall LV systolic function is
normal (LVEF>55%). RV chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened to
moderately. There is mild aortic valve stenosis. Mild to
moderate ([**12-31**]+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild to moderate ([**12-31**]+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
Based on [**2150**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate a moderate risk (prophylaxis
recommended).
.
.
CXR [**9-26**]: Mild-to-moderate pulmonary edema, largely basilar, has
improved and small-to-moderate bilateral pleural effusions are
also smaller compared to [**9-25**]. Severe cardiomegaly
and/or pericardial effusion is stable. A component of pneumonia
particularly in the severely congestive lower lungs cannot be
excluded. Transvenous right atrial and right ventricular pacer
leads in standard placements are unchanged. No pneumothorax.


Brief Hospital Course:
She was admitted, hydrated 3L NS, had KUB and abdominal CT (done
for c/o abd pain) which was neg. On the floor on the first
hospital day, the pt remained afebrile but became quite agitated
and had increased respiratory distress satting in the high 80s,
as well as hypotension to SBP 80/40. She was given 100% O2 by
face mask, and 1.5L fluid bolus, to which she did not respond. A
foley was placed and the patient immediately put out 1L of
yellow urine. Later that evening, she was transferred to the
[**Hospital Unit Name 153**] for increased nursing needs in the setting of low sat and
hypotension. ABG 7.43/30/54 on RA.  In the [**Hospital Unit Name 153**], the pt's
hypotension eventually resolved with fluids. She has been
saturating well first on O2 by nasal cannula and then on room
air.  She had no more complaints of abdominal pain since the
foley catheter was placed. She had nl BMs. The pt became very
agitated and inconsolably crying and was given zydis, with good
results.  The pt then desatted to the 80s on RA and was given
lasix and placed on a shovel mask, which returned her sats to
the high 90s. CXR at that time had revealed worsening CHF.
Repeat CXR the next AM showed improved pulmonary edema and
worsening LLL pneumonia. Pt was transferred back to [**Hospital Unit Name 153**] for
respiratory distress to receive Bipap.  Patient did not tolerate
BiPAP and was weaned to face mask.

On the floor her respiratory distress was thought to be PNA with
a component of CHF (and volume overload from 6+L of IVF).  For
her institutionally acquired (CAP in nursing home) vs aspiration
pneumonia completed a course of azithro, vanc x 2 days, zosyn  x
4 days, and then was transitioned to PO levo and flagyl.  She
received 2 days of steroids as well.  She received Q6 hour nebs.
 She needed soft restraints to keep her Nasal Cannula on.  She
also received 2 doses of IV lasix to diurese patient, after CXR
showed significant pulmonary edema.
.
The patient's low-grade fever resolved on the floor.  Her
leukocytosis worsened upon transfer so the patient was started
on flagyl IV on [**9-25**] for possible C.diff (loose BMs that morning
as well) and coverage for possible aspiration PNA.  The patient
was transitioned to PO levo and flagyl for pneumonia.  On
discharge she was satting well on 2L NC.  Stool cultures for
C.diff were negative.
.
The patient passed video swallow study on [**9-25**] and was able to
take pureed food and thin liquids. She had good PO intake on
discharge.  Aspiration precautions were maintained.
.
Her foley was removed on [**9-29**] with less than 100cc of post-void
residual.  On discharge the patient was urinating spontaneously.
.
The patient had a delicate fluid balance while on the floor,
requiring gentle diuresis with lasix.  CXR showed signs of
improving CHF.  TTE showed good EF and it was found that the
patient meets AHA criteria for endocarditis prophyllaxis.  On
the day prior to discharge the patient was over-diuresed and
became hypotensive to 80/50, requiring a 500cc bolus.
.
The patient's donepezil and celexa were restarted once the
patient was taking PO.
.
The patient was DNR/DNI for this admission per guardian.
Communication was with her GB ARC Guardian, [**Name (NI) **] at
[**Telephone/Fax (1) **].

Medications on Admission:
celexa 10 mg PO qday
tylenol 325mg PO prn
Ca carbonate 1000mg PO qday
ASA 81 mg PO qday
aricept 5mg PO qday
trazadone 25mg qhs
Zyprexa PRN
Zosyn
Vanco
Azithromycin

Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever, pain.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours).
4. Albuterol Sulfate 0.083 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed for sob, wheeze.
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily): please crush in pureed food.
6. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily):
please crush in pureed food.
7. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime):
please crush in pureed food.
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 4 days.
9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
10. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day) as needed for agitation.
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical  [**Hospital1 **]
(2 times a day).
13. Calcium 500 with Vitamin D 500-125 mg-unit Tablet Sig: Two
(2) Tablet PO once a day: please crush in pureed food.


Discharge Disposition:
Extended Care

Facility:
[**Last Name (un) 1687**] - [**Location (un) 745**]

Discharge Diagnosis:
Pneumonia
.........
Alzheimer's Dementia
Down's Syndrome

Discharge Condition:
stable - satting 94-99% on 4L NC.  tolerating PO well,
ambulating.

Discharge Instructions:
Please return with increased shortness of breath, decreased
blood pressure (SBP <90), fever > 101.5, or any other worrisome
symptoms.
.
Please take all medications as directed.

Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2159-10-4**]
12:00
.
Provider: [**Name10 (NameIs) **] CALL Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2159-10-18**]
11:45


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2608**] MD, [**MD Number(3) 2609**]
{"Pneumonitis due to inhalation of food or vomitus,Congestive heart failure, unspecified,Down's syndrome,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Osteoporosis, unspecified,Cardiac pacemaker in situ"}


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: fever

PRESENT ILLNESS: Pt is a 71 yo F with Down's syndrome and Alzheimer's dementia,
also s/p [**First Name3 (LF) 4448**] who initally presented with fever, cough and
agitation for 2-3 days. Pt reported abdominal pain but no other
complaints. Per nursing home staff, she was eating and drinking
normally with no diarrhea. No known sick contacts. [**Name (NI) **] reports of
sputum. Pt otherwise has been in USOH.  Had swallow eval in [**9-2**]
which showed only microaspiration.
.
In the ED the pt was febrile to 101.2.  She had a KUB and
abdominal CT, as well as CXR. She was given IV fluids and
swallow study was ordered. She was started on vanco, levo, and
flagyl.

MEDICAL HISTORY: Down's Syndrome
Alzheimer's dementia
s/p [**Date Range 4448**]
osteoporosis
rosacea
Raynauds
OCD

MEDICATION ON ADMISSION: celexa 10 mg PO qday
tylenol 325mg PO prn
Ca carbonate 1000mg PO qday
ASA 81 mg PO qday
aricept 5mg PO qday
trazadone 25mg qhs
Zyprexa PRN
Zosyn
Vanco
Azithromycin

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE: T 96.5 ax BP 95/48, HR 71  RR 12  O2 96% shovel mask  wt
103lbs
Gen: sitting up in bed, not following commands, agonal
breathing, audible wheeze.
HEENT: PERRL, NCAT, MMM
Neck: no LAD, ? JVD (unable to assess fully due to mask
ventilation)
Cor: RRR, III/VI systolic murmur heard best at LUSB, s1s2
Pulm: difuse insp and exp wheezing. Poor air movement, decreased
BS at bilateral bases.
Abd: soft, NT, distended, small ventral hernia noted, no HSM,
hyperactive BS.
Ext: mild erythema of hands and wrists. Warm and well perfused.
Neuro: unable to examine

FAMILY HISTORY: Unable to obtain.

SOCIAL HISTORY: Pt lives in nursing home. Per chart no tobacco or alcohol. The
pt's guardian ([**Name (NI) **] ARC) from her group home changed her code
status to DNR/DNI for this admission. 

### Response:
{"Pneumonitis due to inhalation of food or vomitus,Congestive heart failure, unspecified,Down's syndrome,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Osteoporosis, unspecified,Cardiac pacemaker in situ"}
