CHIEF COMPLAINT: Dyspnea

PRESENT ILLNESS: Briefly, this is a 53 year old woman with T1-T2 paraplegia s/p
MVC, recurrent UTI/PNA (recently d/ced for PNA on [**2149-11-17**],
treated for UTI [**2149-12-3**]), chronically on 2L of oxygen at home
for COPD who presents with SOB, productive cough and increased
home O2 requirement. One day prior to admission, pt started to
experience increased secretions with cough and sob. Her VNA came
over and symptoms progressed with desats to 80s. Used nebs x3
and sats did not improve. Increased O2 to 4L and sats improved
only to 90-91. Pt denies fevers, but reports chills. She reports
aspirating some of her breakfast in the AM.
.
She was recently admitted [**11-10**] to [**2149-11-17**] and finished a two
week course of vanc/[**Last Name (un) 2830**] for PNA and a UTI. [**12-3**] she was
diagnosed with a proteus UTI by her PCP and got 10 days of
cefpodoxime.
.
In the [**Name (NI) **], pt was tachypneic to 22-23, BP96/58 O2 sat 89% on 4L
NC with rectal temp of 102. Labs notable for WBC 13.5, Hct 31.1.
UA large leuks, negative nitrite and few bacteria. Lactate was
1.7 Patient was given Tylenol, albuterol/ipratropium nebs,
vanc/[**Last Name (un) 2830**]/Flagyl and 1L NS. Has port in place b/c of recurrent
admissions. Of note, pt also requires straight catheterization
at home due to urinary retention.
.
Pt was initially admitted to the MICU and started on vanc,
cefepime, flagyl and tobramycin. Pt's O2 sats improved and she
remained afebrile. At time of transfer to floor she was afebrile
sating well on 2L.
.
She denies any changes in urine frequency or color, no dysuria,
no myalgias, no chest pain or palpitations.

MEDICAL HISTORY: #T1 to T2 paraplegia status post a motor vehicle accident.
#Recurrent pneumonia (followed by pulm - Last [**2149-4-9**])
- Per pulm, recurrent pneumonia likely from pulmonary toilet
issues secondary to neuromuscular disease with improvement with
consistent and aggressive bronchopulmonary therapy.
- Prior sputum cultures + for MRSA, pan-sensitive Klebsiella,
and Pseudomonas.
#Recurrent UTIs in the setting of urinary retention requiring
straight catheterization
#COPD
#Hx Pres syndrome
#hepatitis C
#anxiety
#DVT in [**2142**] -IVC filter placed in [**2142**]
#Pulmonary nodules
#Hypothyroidism
#Chronic pain
#Chronic gastritis
#Anemia of chronic disease
#S/p PEA arrest during hospitalization in [**2147-10-3**]

MEDICATION ON ADMISSION: - albuterol 2.5mg nebs Q4-6hrs PRN
- baclofen 20mg QAM, 10mg Q4pm, 20mg QHS
- citalopram 40mg daily
- clonazepam 1mg TID
- Estradiol 0.01% cream twice weekly
- Combivent 18/103mcg 2puffs TID
- levothyroxine 112mcg daily
- lidocaine patch
- methadone 5mg TID
- omeprazole 20mg [**Hospital1 **]
- oyxbutynin 10mg QAM, 5mg Qafternoon, 10mg QPM
- oxycodone 5mg TID PRN
- pregabalin 100mg TID
- simvastatin 10mg daily
- sucralfate 1gm QID
- trazodone 100mg QHS
- calcium carbonate 500mg [**Hospital1 **]
- Miralax 17gm daily

ALLERGIES: Ativan

PHYSICAL EXAM: On admission: Vitals: T: BP: P: R: O2:
General: Drowsy but easily arousable, oriented x3, no acute
distress
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear

FAMILY HISTORY: Mother passed away with lung disease.

SOCIAL HISTORY: Lives at home with husband and 2 adolescent children.
- Tobacco: 35-pack-years, now quit.
- Alcohol: Denies.
- Illicits: Denies.
Pneumonia, organism unspecified,Paraplegia,Chronic airway obstruction, not elsewhere classified,Anemia of other chronic disease,Unspecified acquired hypothyroidism,Personal history of venous thrombosis and embolism
Pneumonia, organism NOS,Paraplegia NOS,Chr airway obstruct NEC,Anemia-other chronic dis,Hypothyroidism NOS,Hx-ven thrombosis/embols
Admission Date:  [**2149-12-18**]              Discharge Date:   [**2149-12-21**]

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

Service: MEDICINE

Allergies:
Ativan

Attending:[**First Name3 (LF) 71612**]
Chief Complaint:
Dyspnea

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Briefly, this is a 53 year old woman with T1-T2 paraplegia s/p
MVC, recurrent UTI/PNA (recently d/ced for PNA on [**2149-11-17**],
treated for UTI [**2149-12-3**]), chronically on 2L of oxygen at home
for COPD who presents with SOB, productive cough and increased
home O2 requirement. One day prior to admission, pt started to
experience increased secretions with cough and sob. Her VNA came
over and symptoms progressed with desats to 80s. Used nebs x3
and sats did not improve. Increased O2 to 4L and sats improved
only to 90-91. Pt denies fevers, but reports chills. She reports
aspirating some of her breakfast in the AM.
.
She was recently admitted [**11-10**] to [**2149-11-17**] and finished a two
week course of vanc/[**Last Name (un) 2830**] for PNA and a UTI. [**12-3**] she was
diagnosed with a proteus UTI by her PCP and got 10 days of
cefpodoxime.
.
In the [**Name (NI) **], pt was tachypneic to 22-23, BP96/58 O2 sat 89% on 4L
NC with rectal temp of 102. Labs notable for WBC 13.5, Hct 31.1.
UA large leuks, negative nitrite and few bacteria. Lactate was
1.7 Patient was given Tylenol, albuterol/ipratropium nebs,
vanc/[**Last Name (un) 2830**]/Flagyl and 1L NS. Has port in place b/c of recurrent
admissions. Of note, pt also requires straight catheterization
at home due to urinary retention.
.
Pt was initially admitted to the MICU and started on vanc,
cefepime, flagyl and tobramycin. Pt's O2 sats improved and she
remained afebrile. At time of transfer to floor she was afebrile
sating well on 2L.
.
She denies any changes in urine frequency or color, no dysuria,
no myalgias, no chest pain or palpitations.


Past Medical History:
#T1 to T2 paraplegia status post a motor vehicle accident.
#Recurrent pneumonia (followed by pulm - Last [**2149-4-9**])
- Per pulm, recurrent pneumonia likely from pulmonary toilet
issues secondary to neuromuscular disease with improvement with
consistent and aggressive bronchopulmonary therapy.
- Prior sputum cultures + for MRSA, pan-sensitive Klebsiella,
and Pseudomonas.
#Recurrent UTIs in the setting of urinary retention requiring
straight catheterization
#COPD
#Hx Pres syndrome
#hepatitis C
#anxiety
#DVT in [**2142**] -IVC filter placed in [**2142**]
#Pulmonary nodules
#Hypothyroidism
#Chronic pain
#Chronic gastritis
#Anemia of chronic disease
#S/p PEA arrest during hospitalization in [**2147-10-3**]


Social History:
Lives at home with husband and 2 adolescent children.
- Tobacco: 35-pack-years, now quit.
- Alcohol: Denies.
- Illicits: Denies.


Family History:
Mother passed away with lung disease.

Physical Exam:
On admission: Vitals: T: BP: P: R: O2:
General: Drowsy but easily arousable, oriented x3, no acute
distress
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear

Neck: supple, JVP not elevated, no LAD
Lungs: rhoncorus breath sounds anteriorly. Decreased breath
sounds at bilateral bases.
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
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly
intact in upper extremities. Does not have sensation or movement
of LEs.


Pertinent Results:
Labs on admission:

[**2149-12-18**] 12:50AM BLOOD WBC-13.5* RBC-3.68* Hgb-9.7* Hct-31.1*
MCV-85 MCH-26.3* MCHC-31.2 RDW-16.4* Plt Ct-170
[**2149-12-18**] 12:50AM BLOOD Neuts-92.4* Lymphs-4.1* Monos-1.7*
Eos-1.3 Baso-0.4
[**2149-12-18**] 12:50AM BLOOD Glucose-123* UreaN-9 Creat-0.5 Na-142
K-4.1 Cl-99 HCO3-34* AnGap-13
[**2149-12-18**] 05:47AM BLOOD Calcium-8.2* Phos-3.9 Mg-1.8
[**2149-12-18**] 01:02AM BLOOD Lactate-1.7

Other relevant labs:
Tobramycin level 1.4
.
Cultures:
                         **FINAL REPORT [**2149-12-22**]**

   GRAM STAIN (Final [**2149-12-18**]):
      >25 PMNs and <10 epithelial cells/100X field.
      2+   (1-5 per 1000X FIELD):   MULTIPLE ORGANISMS
CONSISTENT WITH
                                    OROPHARYNGEAL FLORA.

   RESPIRATORY CULTURE (Final [**2149-12-21**]):
      SPARSE GROWTH Commensal Respiratory Flora.
      STAPH AUREUS COAG +.    MODERATE GROWTH.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations.

         Rifampin should not be used alone for therapy.
      YEAST.    MODERATE GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------   =>8 R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
.
Urine: No growth
.
blood cultures [**2149-12-18**]: NGTD

.
CXR [**2149-12-18**]
1. Stable chronic bibasilar atelectasis with more focal rounded
atelectasis
in the right lung base.
2. Increasing right pleural effusion, now moderate.
3. No definite new superimposed consolidation.
4. Right central venous catheter terminating at the cavoatrial
junction.
.

[**2149-12-21**] 05:56AM BLOOD WBC-6.0 RBC-2.96* Hgb-7.8* Hct-24.7*
MCV-84 MCH-26.4* MCHC-31.6 RDW-15.9* Plt Ct-168
[**2149-12-21**] 05:56AM BLOOD Glucose-101* UreaN-5* Creat-0.2* Na-144
K-3.4 Cl-103 HCO3-38* AnGap-6*
[**2149-12-21**] 05:56AM BLOOD Calcium-8.8 Phos-2.1* Mg-1.8
[**2149-12-21**] 05:56AM BLOOD Vanco-17.7

Brief Hospital Course:
53 year old woman w/ T1-T2 paraplegia s/p MVC, recurrent
UTI/PNA, COPD on 2L home O2 who presents with worsening SOB and
wheezing.
.
#. HCAP: Initial CXR appeared similar to CXR from prior
admission for pna.  Pt reports that she believes that she
aspirated some of her food on the morning of admission.  She
then spiked a fever in the ED and had worsening SOB.  The time
course for aspiration event would favor chemical pneumonitis
because development of aspiration pna is days, not hours.
However, pt does appear to have PNA on CXR and was recently
hospitalized for PNA so she was initiated on broad spectrum
antibiotics for HCAP.  In the ICU she was started on
vanc/cefepime/tobramycin/flagyl.  Her O2 requirement improved to
her baseline of 2L and she was transferred to the floor.  On the
floor, pt remained afebrile and hemodynamically stable.  She
continued to saturate in high 90s on 2L O2.  Flagyl and
tobramycin were d/ced on the floor, and sputum ultimately grew
staph, so cefepime was d/ced as well.  She remained afebrile and
at baseline O2 requirement for 24hrs.  Pt was discharged with an
additional 6 days of vancomycin for ten day course.
.
COPD: Pt was continued on all of her home inhalers and given
standing and PRN nebs.  By the time she was transferred to the
floor she was sating well on home dose of o2 (2L).  On
discharge, no medication changes were made.
.
Hypothyroidism: Pt was continued on home synthroid
.
Hep C: stable, recent LFTs within normal limits.  No treatment
was initiated during this hospitalization.
.
Transitional:
- will need additional 6 days of IV abx
- follow up final culture data

Medications on Admission:
- albuterol 2.5mg nebs Q4-6hrs PRN
- baclofen 20mg QAM, 10mg Q4pm, 20mg QHS
- citalopram 40mg daily
- clonazepam 1mg TID
- Estradiol 0.01% cream twice weekly
- Combivent 18/103mcg 2puffs TID
- levothyroxine 112mcg daily
- lidocaine patch
- methadone 5mg TID
- omeprazole 20mg [**Hospital1 **]
- oyxbutynin 10mg QAM, 5mg Qafternoon, 10mg QPM
- oxycodone 5mg TID PRN
- pregabalin 100mg TID
- simvastatin 10mg daily
- sucralfate 1gm QID
- trazodone 100mg QHS
- calcium carbonate 500mg [**Hospital1 **]
- Miralax 17gm daily


Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) neb Inhalation q4-6hrs PRN as needed
for shortness of breath or wheezing.
2. citalopram 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).

3. baclofen 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times a
day).
4. baclofen 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
5. clonazepam 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a
day).
6. levothyroxine 112 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
7. trazodone 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
8. sucralfate 1 gram Tablet [**Hospital1 **]: One (1) Tablet PO QID (4 times
a day).
9. simvastatin 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
10. Combivent 18-103 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) puffs
Inhalation three times a day.
11. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
Two (2) Adhesive Patch, Medicated Topical DAILY (Daily): one
patch per leg .
12. oxybutynin chloride 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID
(2 times a day).
13. oxybutynin chloride 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
14. oxycodone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO three times a
day.
15. pregabalin 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO TID (3
times a day).
16. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
17. polyethylene glycol 3350 17 gram/dose Powder [**Hospital1 **]: Seventeen
(17) gram PO DAILY (Daily) as needed for constipation.
18. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
[**Hospital1 **]: One (1) Tablet, Chewable PO BID (2 times a day).
19. methadone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a
day).
20. vancomycin in D5W 1 gram/200 mL Piggyback [**Hospital1 **]: One (1) g
Intravenous Q 12H (Every 12 Hours) for 6 days: last day of abx
is [**2149-12-26**].
Disp:*12 g* Refills:*0*
21. Heparin Flush 10 unit/mL Kit [**Month/Day/Year **]: One (1)  Intravenous AS
DIRECTED: Indwelling Port, heparin dependent: flush with 10 mL
normal saline followed by heparin as above daily and PRN per
lumen.
Disp:**qs *qs* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 1474**] VNA

Discharge Diagnosis:
Hospital acquired pneumonia


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
Dear Mrs. [**Known lastname **],

It was a pleasure taking care of you.  You were admitted to the
hospital for a pneumonia.  We initially admitted to you to the
ICU because your oxygen requirement was high and your blood
pressure was borderline low.  We started you on broad spectrum
antibiotics and you improved.  We now think that you are safe to
go home.  You will need an additional 6 days of IV antibiotic
therapy.
.
We have made the following changes to your home medications:
START: Vancomycin 1 gram IV every 12 hrs for 6 days (last day
[**2149-12-26**])

Followup Instructions:
Please call your PCP (Dr. [**Last Name (STitle) 665**] at [**Telephone/Fax (1) 250**]) to schedule a
follow up appointment within one week after discharge.

Department: GASTROENTEROLOGY
When: THURSDAY [**2150-1-22**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4465**], MD [**Telephone/Fax (1) 463**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage
{'Pneumonia, organism unspecified,Paraplegia,Chronic airway obstruction, not elsewhere classified,Anemia of other chronic disease,Unspecified acquired hypothyroidism,Personal history of venous thrombosis and embolism'}


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: Dyspnea

PRESENT ILLNESS: Briefly, this is a 53 year old woman with T1-T2 paraplegia s/p
MVC, recurrent UTI/PNA (recently d/ced for PNA on [**2149-11-17**],
treated for UTI [**2149-12-3**]), chronically on 2L of oxygen at home
for COPD who presents with SOB, productive cough and increased
home O2 requirement. One day prior to admission, pt started to
experience increased secretions with cough and sob. Her VNA came
over and symptoms progressed with desats to 80s. Used nebs x3
and sats did not improve. Increased O2 to 4L and sats improved
only to 90-91. Pt denies fevers, but reports chills. She reports
aspirating some of her breakfast in the AM.
.
She was recently admitted [**11-10**] to [**2149-11-17**] and finished a two
week course of vanc/[**Last Name (un) 2830**] for PNA and a UTI. [**12-3**] she was
diagnosed with a proteus UTI by her PCP and got 10 days of
cefpodoxime.
.
In the [**Name (NI) **], pt was tachypneic to 22-23, BP96/58 O2 sat 89% on 4L
NC with rectal temp of 102. Labs notable for WBC 13.5, Hct 31.1.
UA large leuks, negative nitrite and few bacteria. Lactate was
1.7 Patient was given Tylenol, albuterol/ipratropium nebs,
vanc/[**Last Name (un) 2830**]/Flagyl and 1L NS. Has port in place b/c of recurrent
admissions. Of note, pt also requires straight catheterization
at home due to urinary retention.
.
Pt was initially admitted to the MICU and started on vanc,
cefepime, flagyl and tobramycin. Pt's O2 sats improved and she
remained afebrile. At time of transfer to floor she was afebrile
sating well on 2L.
.
She denies any changes in urine frequency or color, no dysuria,
no myalgias, no chest pain or palpitations.

MEDICAL HISTORY: #T1 to T2 paraplegia status post a motor vehicle accident.
#Recurrent pneumonia (followed by pulm - Last [**2149-4-9**])
- Per pulm, recurrent pneumonia likely from pulmonary toilet
issues secondary to neuromuscular disease with improvement with
consistent and aggressive bronchopulmonary therapy.
- Prior sputum cultures + for MRSA, pan-sensitive Klebsiella,
and Pseudomonas.
#Recurrent UTIs in the setting of urinary retention requiring
straight catheterization
#COPD
#Hx Pres syndrome
#hepatitis C
#anxiety
#DVT in [**2142**] -IVC filter placed in [**2142**]
#Pulmonary nodules
#Hypothyroidism
#Chronic pain
#Chronic gastritis
#Anemia of chronic disease
#S/p PEA arrest during hospitalization in [**2147-10-3**]

MEDICATION ON ADMISSION: - albuterol 2.5mg nebs Q4-6hrs PRN
- baclofen 20mg QAM, 10mg Q4pm, 20mg QHS
- citalopram 40mg daily
- clonazepam 1mg TID
- Estradiol 0.01% cream twice weekly
- Combivent 18/103mcg 2puffs TID
- levothyroxine 112mcg daily
- lidocaine patch
- methadone 5mg TID
- omeprazole 20mg [**Hospital1 **]
- oyxbutynin 10mg QAM, 5mg Qafternoon, 10mg QPM
- oxycodone 5mg TID PRN
- pregabalin 100mg TID
- simvastatin 10mg daily
- sucralfate 1gm QID
- trazodone 100mg QHS
- calcium carbonate 500mg [**Hospital1 **]
- Miralax 17gm daily

ALLERGIES: Ativan

PHYSICAL EXAM: On admission: Vitals: T: BP: P: R: O2:
General: Drowsy but easily arousable, oriented x3, no acute
distress
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear

FAMILY HISTORY: Mother passed away with lung disease.

SOCIAL HISTORY: Lives at home with husband and 2 adolescent children.
- Tobacco: 35-pack-years, now quit.
- Alcohol: Denies.
- Illicits: Denies. 

### Response:
{'Pneumonia, organism unspecified,Paraplegia,Chronic airway obstruction, not elsewhere classified,Anemia of other chronic disease,Unspecified acquired hypothyroidism,Personal history of venous thrombosis and embolism'}
