CHIEF COMPLAINT: Respiratory distress.

PRESENT ILLNESS: This is an 84-year-old woman
with a history of tracheobronchiomalacia and chronic
respiratory failure who was transferred to the [**Hospital1 346**] from [**Hospital3 672**] Hospital.  The
patient originally had her respiratory failure following an
episode of aspiration pneumonia back in [**Month (only) 404**], at which
time she had failed attempts at stenting of her
tracheobronchiomalacia and required tracheostomy and PEG tube
placement for her chronic respiratory failure.  She has been
at [**Hospital3 672**] Hospital since that time and has been
unable to wean from the ventilator.  Her usual vent settings
are SIMV, respiratory rate of 8, tidal volume of 500,
pressure support of 15, PEEP of 5, FIO2 of 0.3.  The patient
had been doing well and had been gradually weaned off the
ventilator until the day of admission.  At that time she was
noted to be in respiratory distress.  She was tachypneic and
short of breath.  Two saturations decreased to 90%.  She went
from CPAP back to IMV.  Arterial blood gas was
7.23/70/123/30/96%.  Breath sounds were noted to be distant
and chest x-ray could not be obtained for a significant
period so she was sent to [**Hospital1 188**] for further evaluation.

MEDICAL HISTORY: 1. Diabetes mellitus type 2.  2.
Hypertension.  3. Tracheobronchiomalacia as above.  4.
Anemia.  5. Moderate to severe mitral regurgitation.

MEDICATION ON ADMISSION: 

ALLERGIES: The patient has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Unknown.

SOCIAL HISTORY: The patient is currently a resident at
[**Hospital3 672**] Hospital.  She has some family members who
are involved in her care.  She has no known history of
tobacco or drug use.
Pneumonia, organism unspecified,Other pulmonary insufficiency, not elsewhere classified,Multiple involvement of mitral and aortic valves,Urinary tract infection, site not specified,Occlusion and stenosis of carotid artery with cerebral infarction,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus
Pneumonia, organism NOS,Other pulmonary insuff,Mitr/aortic mult involv,Urin tract infection NOS,Ocl crtd art w infrct,Abn react-procedure NEC,Other staphylococcus
Admission Date:  [**2199-5-26**]       Discharge Date:  [**2199-5-28**]


Service:  MICU

CHIEF COMPLAINT:  Respiratory distress.

HISTORY OF PRESENT ILLNESS:  This is an 84-year-old woman
with a history of tracheobronchiomalacia and chronic
respiratory failure who was transferred to the [**Hospital1 346**] from [**Hospital3 672**] Hospital.  The
patient originally had her respiratory failure following an
episode of aspiration pneumonia back in [**Month (only) 404**], at which
time she had failed attempts at stenting of her
tracheobronchiomalacia and required tracheostomy and PEG tube
placement for her chronic respiratory failure.  She has been
at [**Hospital3 672**] Hospital since that time and has been
unable to wean from the ventilator.  Her usual vent settings
are SIMV, respiratory rate of 8, tidal volume of 500,
pressure support of 15, PEEP of 5, FIO2 of 0.3.  The patient
had been doing well and had been gradually weaned off the
ventilator until the day of admission.  At that time she was
noted to be in respiratory distress.  She was tachypneic and
short of breath.  Two saturations decreased to 90%.  She went
from CPAP back to IMV.  Arterial blood gas was
7.23/70/123/30/96%.  Breath sounds were noted to be distant
and chest x-ray could not be obtained for a significant
period so she was sent to [**Hospital1 188**] for further evaluation.

In the Emergency Department the patient was bagged and
suctioned.  No obvious mucous plugs were removed and Lasix 60
mg IV x 1 was given.  The patient's symptoms improved and she
was transferred to the medical intensive care unit for
further evaluation.

PAST MEDICAL HISTORY:  1. Diabetes mellitus type 2.  2.
Hypertension.  3. Tracheobronchiomalacia as above.  4.
Anemia.  5. Moderate to severe mitral regurgitation.

ALLERGIES:  The patient has no known drug allergies.

MEDICATIONS:  1. Protonix 40 mg p.o. q.d.  2. Ritalin 5 mg
p.o. q.d.  3. Zoloft 50 mg p.o. q.d.  4. Albuterol p.r.n.  5.
Subcutaneous heparin 5,000 mg subcutaneous b.i.d.  6. Ativan
0.25 mg p.o. q. 8 hours p.r.n.  7. Lasix 40 mg p.o. q.d. on
hold x 1 week.

FAMILY HISTORY:  Unknown.

SOCIAL HISTORY:  The patient is currently a resident at
[**Hospital3 672**] Hospital.  She has some family members who
are involved in her care.  She has no known history of
tobacco or drug use.

PHYSICAL EXAMINATION:  Vital signs were 98.8, heart rate 82,
blood pressure 92/47, respiratory rate 18, 100% bagged.  In
general she was an obese, confused woman who was in no acute
distress at the time of the medical intensive care unit
evaluation.  HEENT:  Left eye cataract with some ptosis.
Oropharynx was noted to have thrush, otherwise dry.  Neck:
No jugular venous distension, no lymphadenopathy.
Tracheostomy in place.  Cardiac:  Regular rate and rhythm, no
murmurs, gallops, or rubs.  Lungs:  Rhonchi noted diffusely
with decreased breath sounds at the bases bilaterally,
occasional expiratory wheezes.  Abdomen:  Soft, nontender,
distended abdomen, positive bowel sounds.  PEG in place with
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1356**] clamp.  Extremities:  No cyanosis, clubbing or edema,
warm with good pulses, no calf tenderness, no palpable cord.
Neurological:  The patient was able to move all extremities,
decreased hearing and unable to communicate or take p.o.

LABORATORY DATA:  White blood count 18.2, hematocrit 36.4,
platelet count 425, and 87.5, no bands.  Sodium 132, BUN 49,
creatinine 1.1, glucose 231.  Urinalysis had large blood,
greater than 50 white blood cells, [**12-5**] red blood cells,
nitrite negative, leukocyte esterase moderate.

HOSPITAL COURSE:  1. Pulmonary:  The patient was admitted
with respiratory distress of unclear etiology.  She was given
Lasix initially for congestive heart failure, although this
was unlikely to be congestive heart failure.  The patient was
thought to have a mucous plug given the rapid improvement of
her symptoms after suctioning.  The patient had follow-up
chest x-ray which demonstrated right middle lobe pneumonia
and question of pneumonia at the left base.  The patient was
initially started on ceftriaxone and azithromycin in the
Emergency Department, but was then changed to vancomycin and
Zosyn to cover a ventilator-associated pneumonia.  The
patient was then put back on her [**Hospital3 672**] Hospital
ventilator settings and her white count decreased.  She
continued to have low-grade temperatures which were thought
to be due to her lack of adequate antibiotics.  Sputum
culture showed greater than 25 polys, less than 10 epithelial
cells with mixed flora and final culture is pending at the
time of this dictation.

2. Cardiac:  The patient was treated empirically in the
Emergency Department for congestive heart failure.  She
underwent transthoracic echocardiogram to evaluate her
ejection fraction given possible congestive heart failure.
This demonstrated left atrium with moderate dilatation, right
atrium with moderate dilatation, mild left ventricular
hypertrophy, minimal aortic stenosis, 1+ aortic
regurgitation, mild to moderate mitral regurgitation,
impaired ventricular relaxation.  It was not clear if the
patient was in any congestive heart failure and she was not
given Lasix.  This can be restarted should her symptoms
worsen.

3. Weakness:  On hospital day number one the patient was
noted to have some left-sided weakness.  It is unclear
exactly what her baseline is.  She was able to move all four
extremities, however she had some flaccidity and
hyperreflexia in the left upper and lower extremities.  She
underwent CT scan of the head which demonstrated no acute
changes but chronic microvascular changes and atherosclerosis
of the internal carotid and vertebral arteries.  Given the
patient's condition and unclear age of her findings, no
additional work-up was undertaken.

4. Endocrine:  The patient was maintained on fingersticks
q.i.d. and a Regular Insulin sliding scale for her diabetes
mellitus.  This should be maintained at her discharge for
optimal blood sugar control during her time of infection.

5. Anemia:  The patient's blood counts decreased from
admission of 36 down to 26 on hospital day number two.  Some
of this was thought to be dilution as the patient did receive
some intravenous fluids during her admission.  She was guaiac
negative and did not have any signs of active bleeding.
Blood count is stable at the time of her discharge.  She did
not have a history of coronary artery disease so no packed
cells were given.  Should her hematocrit decreased to less
than 24, blood transfusion may be of benefit to her.

6. Access:  The patient had a PICC line placed for
intravenous antibiotics to complete a 14-day course of
vancomycin and Zosyn.

CONDITION ON DISCHARGE:  Stable.

DISCHARGE STATUS:  The patient was discharged back to [**Hospital3 **] Hospital for continued weaning and intravenous
antibiotic therapy.

DISCHARGE DIAGNOSES:
1. Ventilator-associated pneumonia.
2. Cerebrovascular accident of unclear duration.
3. Mitral regurgitation.
4. Anemia.
5. Diabetes mellitus.
6. Urinary tract infection:  Positive urinary tract infection
with Gram-negative rods and beta streptococcus.

DISCHARGE MEDICATIONS:
1. Vancomycin 1 gram q. 48 hours started on [**2199-5-27**] to
receive a 14-day course.
2. Zosyn 2.25 grams IV q. 6 hours started on [**2199-5-27**] to
complete a 14-day course.
3. Sertraline 50 mg p.o. q.d.
4. Methylphenidate 5 mg p.o. b.i.d.
5. Albuterol nebulizer inhaled q. 6 hours p.r.n.
6. Atrovent 2 puffs inhaled q.i.d.
7. Heparin 5,000 mg subcutaneous b.i.d.
8. Fluticasone 110, 2 puffs inhaled b.i.d.
9. Regular Insulin sliding scale.
10. Fluconazole 100 mg p.o. q. 24 hours for thrush to
complete four additional doses.
11. Lansoprazole 30 mg via nasogastric tube q.d.
12. Ativan 0.25 mg p.o./IV t.i.d. p.r.n.





                            [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 3795**]

Dictated By:[**Name8 (MD) 17420**]
MEDQUIST36

D:  [**2199-5-28**]  10:50
T:  [**2199-5-28**]  11:03
JOB#:  [**Job Number 46668**]
{'Pneumonia, organism unspecified,Other pulmonary insufficiency, not elsewhere classified,Multiple involvement of mitral and aortic valves,Urinary tract infection, site not specified,Occlusion and stenosis of carotid artery with cerebral infarction,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus'}


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: Respiratory distress.

PRESENT ILLNESS: This is an 84-year-old woman
with a history of tracheobronchiomalacia and chronic
respiratory failure who was transferred to the [**Hospital1 346**] from [**Hospital3 672**] Hospital.  The
patient originally had her respiratory failure following an
episode of aspiration pneumonia back in [**Month (only) 404**], at which
time she had failed attempts at stenting of her
tracheobronchiomalacia and required tracheostomy and PEG tube
placement for her chronic respiratory failure.  She has been
at [**Hospital3 672**] Hospital since that time and has been
unable to wean from the ventilator.  Her usual vent settings
are SIMV, respiratory rate of 8, tidal volume of 500,
pressure support of 15, PEEP of 5, FIO2 of 0.3.  The patient
had been doing well and had been gradually weaned off the
ventilator until the day of admission.  At that time she was
noted to be in respiratory distress.  She was tachypneic and
short of breath.  Two saturations decreased to 90%.  She went
from CPAP back to IMV.  Arterial blood gas was
7.23/70/123/30/96%.  Breath sounds were noted to be distant
and chest x-ray could not be obtained for a significant
period so she was sent to [**Hospital1 188**] for further evaluation.

MEDICAL HISTORY: 1. Diabetes mellitus type 2.  2.
Hypertension.  3. Tracheobronchiomalacia as above.  4.
Anemia.  5. Moderate to severe mitral regurgitation.

MEDICATION ON ADMISSION: 

ALLERGIES: The patient has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Unknown.

SOCIAL HISTORY: The patient is currently a resident at
[**Hospital3 672**] Hospital.  She has some family members who
are involved in her care.  She has no known history of
tobacco or drug use. 

### Response:
{'Pneumonia, organism unspecified,Other pulmonary insufficiency, not elsewhere classified,Multiple involvement of mitral and aortic valves,Urinary tract infection, site not specified,Occlusion and stenosis of carotid artery with cerebral infarction,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus'}
