CHIEF COMPLAINT: Respiratory Distress

PRESENT ILLNESS: Ms. [**Known lastname **] is an 89 year-old woman with CHF, atrial fibrillation
on coumadin, recent bilateral femur fractures s/p ORIFs at
[**Hospital6 1708**] complicated by pneumonia, and
recent discharge to rehab 2 weeks ago presents with 1 day of
respiratory distress at rehab.  Her roomate at rehab apparently
had a viral illness and then the patient started having similar
symptoms.  She desaturated to 79% on 2L, 86% on a
non-rebreather(no baseline O2 requirement).  She was brought to
the emergency department at [**Hospital1 1170**].
.
Upon arrival to the ED, vital signs were temperature 98.3, blood
pressure 159/59, HR 73, RR 36, SaO2 88% on room air 96% on 3 L
NC.  Patient tachypneic, short of breath with conversation, and
had audible gurgling.  She received Lasix 40 mg IV and was
started on a nitroglyercin drip which was later discontinued
when respiratory status immproved on BiPap.

MEDICAL HISTORY: # Congestive Heart Failure
# Atrial fibrillation on coumadin, s/p pacemaker placement
# Multiple pneumonias, including aspiration PNA
# Hypertension
# s/p Bilateral supracondylar femur fractures [**10-6**], s/p ORIF of
both distal femurs
# Dementia
# Remote history of TB
# History of Clostridium difficile
# Right foot drop secondary to peroneal injury
# Pulmonary nodule
# Thyromegaly

MEDICATION ON ADMISSION: Lasix 20mg PO every other day
Metoprolol 50mg PO TID
Coumadin 5.5mg daily
Prilosec 20mg daily
Lactulose 30ml PO BID
KCl 10 meq PO every other day
Calcium citrate 950mg PO BID
Zinc sulfate 220mg PO daily
Multivitamin
Vitamin B12 1000mg PO daily
Vitamin C 500mg PO daily
Oscal 1200mg PO BID
Acetaminophen prn
Dulcolax supp daily prn
Fleet enema pr prn

ALLERGIES: Prednisone / Penicillins

PHYSICAL EXAM: Physical Exam on Admission:
Vitals: t 96.9, bp 172/61, HR 90, RR 35, SaO2 96% on Hi Flow 15
L/M and FiO2 95%
General: chronically ill female, appears in mod resp distress
HEENT: pt refused to allow exam of pupils, EOM appear intact
CV: irreg irreg, no M/R/G over breath sounds
Pulm: v.loud upper airway sounds, b/l crackles throughout.
Abdomen: +BS, soft, non-tender
Extremities: mild LE edema b/l
Neuro: awakens to voice.  answers some questions.  Moves all
extremities but will not cooperate with full neuro exam
Skin: per nursing, stage II lumbar decub

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Previously lived with family but recently residing at rehab
facility after recent femur fractures with private care nurses
also attending.  Dementia at baseline. Family very involved with
care.
Acute and chronic respiratory failure,Pneumonitis due to inhalation of food or vomitus,Pneumonia due to other gram-negative bacteria,Chronic diastolic heart failure,Pressure ulcer, ankle,Unspecified protein-calorie malnutrition,Atrial fibrillation,Long-term (current) use of anticoagulants,Cardiac pacemaker in situ,Other persistent mental disorders due to conditions classified elsewhere,Unspecified essential hypertension
Acute & chronc resp fail,Food/vomit pneumonitis,Pneumo oth grm-neg bact,Chr diastolic hrt fail,Pressure ulcer, ankle,Protein-cal malnutr NOS,Atrial fibrillation,Long-term use anticoagul,Status cardiac pacemaker,Mental disor NEC oth dis,Hypertension NOS
Admission Date:  [**2194-12-19**]              Discharge Date:   [**2194-12-29**]


Service: MEDICINE

Allergies:
Prednisone / Penicillins

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Respiratory Distress

Major Surgical or Invasive Procedure:
Endotracheal intubation

History of Present Illness:
Ms. [**Known lastname **] is an 89 year-old woman with CHF, atrial fibrillation
on coumadin, recent bilateral femur fractures s/p ORIFs at
[**Hospital6 1708**] complicated by pneumonia, and
recent discharge to rehab 2 weeks ago presents with 1 day of
respiratory distress at rehab.  Her roomate at rehab apparently
had a viral illness and then the patient started having similar
symptoms.  She desaturated to 79% on 2L, 86% on a
non-rebreather(no baseline O2 requirement).  She was brought to
the emergency department at [**Hospital1 1170**].
.
Upon arrival to the ED, vital signs were temperature 98.3, blood
pressure 159/59, HR 73, RR 36, SaO2 88% on room air 96% on 3 L
NC.  Patient tachypneic, short of breath with conversation, and
had audible gurgling.  She received Lasix 40 mg IV and was
started on a nitroglyercin drip which was later discontinued
when respiratory status immproved on BiPap.


Past Medical History:
# Congestive Heart Failure
# Atrial fibrillation on coumadin, s/p pacemaker placement
# Multiple pneumonias, including aspiration PNA
# Hypertension
# s/p Bilateral supracondylar femur fractures [**10-6**], s/p ORIF of
both distal femurs
# Dementia
# Remote history of TB
# History of Clostridium difficile
# Right foot drop secondary to peroneal injury
# Pulmonary nodule
# Thyromegaly

Social History:
Previously lived with family but recently residing at rehab
facility after recent femur fractures with private care nurses
also attending.  Dementia at baseline. Family very involved with
care.

Family History:
Non-contributory

Physical Exam:
Physical Exam on Admission:
Vitals: t 96.9, bp 172/61, HR 90, RR 35, SaO2 96% on Hi Flow 15
L/M and FiO2 95%
General: chronically ill female, appears in mod resp distress
HEENT: pt refused to allow exam of pupils, EOM appear intact
CV: irreg irreg, no M/R/G over breath sounds
Pulm: v.loud upper airway sounds, b/l crackles throughout.
Abdomen: +BS, soft, non-tender
Extremities: mild LE edema b/l
Neuro: awakens to voice.  answers some questions.  Moves all
extremities but will not cooperate with full neuro exam
Skin: per nursing, stage II lumbar decub

Pertinent Results:
ECG [**2194-12-19**]-Atrial fibrillation with controlled ventricular
response. Right bundle-branch block with secondary ST-T wave
abnormalities. No previous tracing available for comparison.
.
ECG [**2194-12-23**]-Possible atrial fibrillation with bigeminal
ventricular premature beats.  Right bundle-branch block with
left anterior fascicular block. Compared to tracing of [**2194-12-20**]
bigeminal ventricular premature beats are present.
.
Chest X-ray [**2194-12-29**]-FINDINGS: In comparison with the study of
[**12-28**], there is little change. Again, there is huge stable
enlargement of the cardiac silhouette with relatively mild
vascular congestion, raising the possibility of pericardial
effusion or cardiomyopathy. Opacification at the right base
persists, consistent with pleural effusion and probable
underlying atelectasis. The left base is difficult to evaluate
due to obliquity of the patient. Single-channel pacemaker device
remains in place with its tip in the region of the apex of the
right ventricle.
.
Echo [**2194-12-23**]-Conclusions
The left atrium is moderately dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). The right ventricular cavity is
mildly dilated. Right ventricular systolic function is normal.
There are three aortic valve leaflets. The aortic valve leaflets
are moderately thickened. There is mild aortic valve stenosis
(area 1.2-1.9cm2). Moderate (2+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Mild to moderate ([**2-4**]+) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is a trivial/physiologic pericardial effusion.
Suboptimal image quality - patient unable to cooperate.
IMPRESSION: Mild symmetric hypertrophy with normal systolic
function. Mild aortic stenosis and moderate aortic
regurgitation. The study was limited due to lack of patient
cooperation.


Brief Hospital Course:
# Respiratory distress: Pt admitted to MICU given respiratory
distress thought to be due to CHF versus pneumonia. She was
stable on intubation and received multiple fluid boluses for low
blood pressure,  urine output.  She was started on vancomycin,
levofloxacin and metronidazole (pt has PCN allergy) for empiric
PNA treatment. She was extubated on HD4. When Sputum culture was
positive for moraxella she was changed to PO levofloxacin to
complete 10 day course [**12-30**] for 10 day course.  Given pulmonary
edema, she received furosemide PRN for goal 1L negative daily,
then returned to furosemide 20mg QOD (home regimen) as pt
appeared less fluid overloaded.  On [**12-25**], oxygen saturation
decreased to high 80s, received chest PT and increased O2 via NC
with improved O2sat.  Has intermittent Bipap which was later
weaned. She was continued on chest PT, with added guaifenesin
[**6-12**] ml PO Q6H to help mobilize secretions; xopenex 1.25-0.5
mg/mL inhalation Q6H PRN; and ipratropium bromide nebs IH Q4H
while awake. On the day of discharge she was awake and alert and
following commands. Her blood gas at time of discharge is pH
7.42, pCO2 61, pO2 76, HCO3 41 on 0.5L nasal cannula with
baseline optimal mental status (awake and alert).
.
# HTN: Home regimen for HTN metoprolol 50mg PO TID, furosemide
20mg QOD.  She was started on metoprolol IV pending swallow
evaluation and briefly tried on metoprolol.  Per patient's
previous cardiologist, she has marked orthostatic changes in
blood pressure and must tolerate elevated blood pressures in
sitting/recumbent position in order to prevent hypotension upon
standing.  Recommend continuing home regimen and outlined above
and increasing lasix to 20mg daily when evidence of fluid
overload exists.
.
# Atrial fibrillation: Pt returned to home dose of metoprolol 50
mg TID for rate control; warfarin restarted at 5.0mg daily (home
regimen is 5.5mg daily). Recommend regular INR monitoring.
.
# Decubitus ulcers: Pt has thoracic, chronic Achilles and
posterior calf decubitus ulcers.  Wound care consult obtained
and made the following recommendatios:
Thoracic: Full wound healing Achilles: Keep tendon moistened to
prevent dessication. Posterior calf: Moist wound therapy for
autolytic debridement.
.
# S/p bilateral  femur fx: Pt continues to be weight-bearing as
tolerated.
.
# FEN:  Pt initially placed on Nutren Pulmonary tube feeds but
returned to PO, with nectar prethickened liquids and ground
solids. HCP expressed opposition to NG tube placement.
Recommend calorie counts and nutritional supplements.
.
# Prophylaxis:  Pt continued on heparin 5000units SC TID,
pantoprazole 40mg PO daily, humalog ISS, and bowel regimen.
.
# Full Code
.
# Communication: HCP son [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 103134**]

Medications on Admission:
Lasix 20mg PO every other day
Metoprolol 50mg PO TID
Coumadin 5.5mg daily
Prilosec 20mg daily
Lactulose 30ml PO BID
KCl 10 meq PO every other day
Calcium citrate 950mg PO BID
Zinc sulfate 220mg PO daily
Multivitamin
Vitamin B12 1000mg PO daily
Vitamin C 500mg PO daily
Oscal 1200mg PO BID
Acetaminophen prn
Dulcolax supp daily prn
Fleet enema pr prn

Discharge Medications:
1. Insulin Lispro 100 unit/mL Solution [**Telephone/Fax (1) **]: Sliding scale per
sheet  Subcutaneous ASDIR (AS DIRECTED).
2. Senna 8.6 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO BID (2 times a
day) as needed.
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Telephone/Fax (1) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Cyanocobalamin 500 mcg Tablet [**Telephone/Fax (1) **]: Two (2) Tablet PO DAILY
(Daily).
5. Docusate Sodium 50 mg/5 mL Liquid [**Telephone/Fax (1) **]: One (1)  PO BID (2
times a day).
6. Warfarin 5 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY16 (Once
Daily at 16).
7. Olanzapine 5 mg Tablet, Rapid Dissolve [**Telephone/Fax (1) **]: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)) as needed for
insomnia, agitation.
8. Metoprolol Tartrate 50 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO TID
(3 times a day).
9. Furosemide 20 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO QOD ().
10. Ipratropium Bromide 0.02 % Solution [**Telephone/Fax (1) **]: One (1)  Inhalation
Q4H (every 4 hours).
11. Guaifenesin 100 mg/5 mL Syrup [**Telephone/Fax (1) **]: 5-10 MLs PO Q6H (every 6
hours) as needed for secretions.
12. Levalbuterol HCl 0.63 mg/3 mL Solution [**Telephone/Fax (1) **]: One (1) ML
Inhalation q 6 hr prn () as needed for SOB, wheezing.
13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
14. Lactulose 10 gram/15 mL Syrup [**Last Name (STitle) **]: Fifteen (15) ML PO BID (2
times a day).


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
Congestive Heart Failure
Pneumonia


Discharge Condition:
Good


Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet


Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] of cardiology. Call ([**Telephone/Fax (1) 1987**] to
make an appointment.
{'Acute and chronic respiratory failure,Pneumonitis due to inhalation of food or vomitus,Pneumonia due to other gram-negative bacteria,Chronic diastolic heart failure,Pressure ulcer, ankle,Unspecified protein-calorie malnutrition,Atrial fibrillation,Long-term (current) use of anticoagulants,Cardiac pacemaker in situ,Other persistent mental disorders due to conditions classified elsewhere,Unspecified essential hypertension'}


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: Ms. [**Known lastname **] is an 89 year-old woman with CHF, atrial fibrillation
on coumadin, recent bilateral femur fractures s/p ORIFs at
[**Hospital6 1708**] complicated by pneumonia, and
recent discharge to rehab 2 weeks ago presents with 1 day of
respiratory distress at rehab.  Her roomate at rehab apparently
had a viral illness and then the patient started having similar
symptoms.  She desaturated to 79% on 2L, 86% on a
non-rebreather(no baseline O2 requirement).  She was brought to
the emergency department at [**Hospital1 1170**].
.
Upon arrival to the ED, vital signs were temperature 98.3, blood
pressure 159/59, HR 73, RR 36, SaO2 88% on room air 96% on 3 L
NC.  Patient tachypneic, short of breath with conversation, and
had audible gurgling.  She received Lasix 40 mg IV and was
started on a nitroglyercin drip which was later discontinued
when respiratory status immproved on BiPap.

MEDICAL HISTORY: # Congestive Heart Failure
# Atrial fibrillation on coumadin, s/p pacemaker placement
# Multiple pneumonias, including aspiration PNA
# Hypertension
# s/p Bilateral supracondylar femur fractures [**10-6**], s/p ORIF of
both distal femurs
# Dementia
# Remote history of TB
# History of Clostridium difficile
# Right foot drop secondary to peroneal injury
# Pulmonary nodule
# Thyromegaly

MEDICATION ON ADMISSION: Lasix 20mg PO every other day
Metoprolol 50mg PO TID
Coumadin 5.5mg daily
Prilosec 20mg daily
Lactulose 30ml PO BID
KCl 10 meq PO every other day
Calcium citrate 950mg PO BID
Zinc sulfate 220mg PO daily
Multivitamin
Vitamin B12 1000mg PO daily
Vitamin C 500mg PO daily
Oscal 1200mg PO BID
Acetaminophen prn
Dulcolax supp daily prn
Fleet enema pr prn

ALLERGIES: Prednisone / Penicillins

PHYSICAL EXAM: Physical Exam on Admission:
Vitals: t 96.9, bp 172/61, HR 90, RR 35, SaO2 96% on Hi Flow 15
L/M and FiO2 95%
General: chronically ill female, appears in mod resp distress
HEENT: pt refused to allow exam of pupils, EOM appear intact
CV: irreg irreg, no M/R/G over breath sounds
Pulm: v.loud upper airway sounds, b/l crackles throughout.
Abdomen: +BS, soft, non-tender
Extremities: mild LE edema b/l
Neuro: awakens to voice.  answers some questions.  Moves all
extremities but will not cooperate with full neuro exam
Skin: per nursing, stage II lumbar decub

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Previously lived with family but recently residing at rehab
facility after recent femur fractures with private care nurses
also attending.  Dementia at baseline. Family very involved with
care. 

### Response:
{'Acute and chronic respiratory failure,Pneumonitis due to inhalation of food or vomitus,Pneumonia due to other gram-negative bacteria,Chronic diastolic heart failure,Pressure ulcer, ankle,Unspecified protein-calorie malnutrition,Atrial fibrillation,Long-term (current) use of anticoagulants,Cardiac pacemaker in situ,Other persistent mental disorders due to conditions classified elsewhere,Unspecified essential hypertension'}
