CHIEF COMPLAINT: 

PRESENT ILLNESS: This is a [**Age over 90 **]-year-old woman
who is a resident of the [**Hospital3 1186**] who has a history of
Alzheimer's dementia, tardive dyskinesia, at baseline
nonverbal, and was noted at the nursing home to be having
increasing wheezing with 02 saturations in the 80s to low
90s.  Given Albuterol nebulizers and was still with wheezing.
Respiratory rate was noted to be in the 20-26 range, blood
pressure 112/60, heart rate 120s.  Of note, the patient was
on tube feeds.  She has stage III left heel ulcer and was on
morphine for pain management during dressing changes for
them.  Per son, the patient currently appears near her normal
self.

MEDICAL HISTORY: 1.  Cataracts.
2.  Alzheimer's dementia.
3.  Tardive dyskinesia secondary to Haldol.
4.  Status post PEG.
5.  Hypertension.
6.  Dysphagia.
7.  Esophagitis.
8.  History of duodenal ulcer.
9.  History of left hip fracture, status post ORIF.
10. Status post TAH.
11. History of urinary incontinence.

MEDICATION ON ADMISSION: 

ALLERGIES: The patient is allergic to Haldol.

PHYSICAL EXAM: 

FAMILY HISTORY: Unknown secondary to mental status.

SOCIAL HISTORY: She is a [**Hospital3 1186**] resident.
Unspecified septicemia,Urinary tract infection, site not specified,Ulcer of heel and midfoot,Congestive heart failure, unspecified,Pneumonia, organism unspecified,Septic shock,Alzheimer's disease,Sepsis
Septicemia NOS,Urin tract infection NOS,Ulcer of heel & midfoot,CHF NOS,Pneumonia, organism NOS,Septic shock,Alzheimer's disease,Sepsis
Admission Date:  [**2106-5-27**]       Discharge Date:  [**2106-6-1**]


Service:

HISTORY OF THE PRESENT ILLNESS:  This is a [**Age over 90 **]-year-old woman
who is a resident of the [**Hospital3 1186**] who has a history of
Alzheimer's dementia, tardive dyskinesia, at baseline
nonverbal, and was noted at the nursing home to be having
increasing wheezing with 02 saturations in the 80s to low
90s.  Given Albuterol nebulizers and was still with wheezing.
Respiratory rate was noted to be in the 20-26 range, blood
pressure 112/60, heart rate 120s.  Of note, the patient was
on tube feeds.  She has stage III left heel ulcer and was on
morphine for pain management during dressing changes for
them.  Per son, the patient currently appears near her normal
self.

While she was in the Emergency Room, the blood pressure was
in the 90s, temperature of 102 and the patient was started on
ceftriaxone and Flagyl for a urinary tract infection as she
was noted to have pus in her Foley.  She was continued on
nebulizers and Solu-Medrol was started while in the Emergency
Room.  She received fluids and had improvement in her blood
pressure.

PAST MEDICAL HISTORY:
1.  Cataracts.
2.  Alzheimer's dementia.
3.  Tardive dyskinesia secondary to Haldol.
4.  Status post PEG.
5.  Hypertension.
6.  Dysphagia.
7.  Esophagitis.
8.  History of duodenal ulcer.
9.  History of left hip fracture, status post ORIF.
10. Status post TAH.
11. History of urinary incontinence.

SOCIAL HISTORY:  She is a [**Hospital3 1186**] resident.

FAMILY HISTORY:  Unknown secondary to mental status.

ALLERGIES:  The patient is allergic to Haldol.

ADMISSION MEDICATIONS:
1.  Colace.
2.  Duragesic patch.
3.  Dulcolax p.r.
4.  Multivitamin with minerals.
5.  Oyster shell with vitamin D.
6.  Valproic acid.
7.  Tylenol.
8.  Morphine sulfate prior to dressing changes.

DIET:  ProMod with fiber times 18 hours.

PHYSICAL EXAMINATION:  Vital signs:  Temperature 99 going up
to 102.8 in the Emergency Room, blood pressure 94/66, pulse
122-125, respiratory rate 30, saturations 82% on room air,
100% later on 3 liters.  General:  The patient was alert,
opens eyes to pain and verbal stimuli.  HEENT:  Normocephalic
and atraumatic.  The extraocular muscles were grossly intact.
Neck: Supple.  Cardiovascular:  Tachycardiac, I/VI systolic
ejection murmur.  Respiratory:  Diffuse wheezing bilaterally,
upper airway sounds bilaterally.  Abdomen:  Soft, positive
bowel sounds, positive PEG.  No erythema.  Normal appearing
PEG site.  No pain around her left hip.  Extremities:  No
edema, stage III decubitus ulcer on the left foot of 5 cm by
7 cm.  Neurologic:  Contracted extremities, both arms and
legs.

LABORATORY AND RADIOLOGIC DATA: White count 12.4, 83%
neutrophils, 9% lymphs, hematocrit 31.5, platelets 449,000.
Chem-7 137, potassium 5.7, chloride 99, bicarbonate 27, BUN
44, creatinine 0.7, glucose 117, calcium 9.1, magnesium 2.2,
phosphorus 0.8.  INR 1.0.

The U/A on admission revealed a specific gravity of 1.014,
hazy, small leukocyte esterase, small blood, positive
nitrates, trace protein, negative glucose, negative ketones,
greater than 50 white blood cells and a few bacteria.

EKG was sinus tachycardia at 119.  Lactate of 3.0.

HOSPITAL COURSE:  This is a [**Hospital 93961**] nursing home
resident, at baseline nonverbal secondary to dementia, who
was initially admitted for hypoxia and UTI, initially found
to be in sepsis and transferred to the VICU on the day of
admission.

1.  SEPSIS:  The patient was stable and initially admitted
under sepsis protocol to the VICU where she received
aggressive hydration, transfused 2 units of blood for a
hematocrit less than 30.  She was temporarily on Levophed and
eventually this was weaned off. She also had a subclavian
line placed for access for neurosepsis protocol.  The
patient's CVPs were monitored and were otherwise stable.  The
patient initially had some respiratory distress after her
fluid hydration but this improved and was stable with minimal
02 by nasal cannula.

Under sepsis protocol, the patient was started on broad
antibiotics including ceftazidime and levofloxacin.  The
patient was noted to have gram-negative rods growing from her
urine culture and eventually this grew out Citrobacter
.................... which was sensitive to levofloxacin and
ceftazidime and was the likely source of her sepsis.  There
was also initial concern for pneumonia; however, the patient
continued to improve, had follow-up chest x-rays.  The chest
x-ray on [**2106-5-28**] showed just mild CHF and no evidence of
pneumothorax.  The patient had a follow-up chest x-ray on
[**2106-5-31**] which was also consistent with CHF versus pneumonia.
However, the patient's oxygenation improved with diuresis and
was otherwise stable.

The patient was adrenally insufficient on the admission to
the VICU and is to complete a five day course of
hydrocortisone and fludrocortisone for adrenal insufficiency.
The patient's blood pressure remained stable.  The patient
was weaned off pressors pretty quickly and did not require
further fluid boluses to maintain blood pressure.

2.  HYPOXIA:  Initially came in hypoxic on room air.  This
improved with 3 liters of 02 and then after aggressive
hydration for her blood pressure was in mild respiratory
distress, transferred to the VICU but remained respiratory
stable on 2 liters and a cool nebulizer face mask.  She had a
blood gas of 7.40/37/185 and was oxygenating well.  She was
continued on nebulizers throughout her admission and her
wheezing improved.  She did continue to have some upper
airway sounds, some cough to help mobilize some of her
airways.  Otherwise, she was stable from a respiratory
standpoint.  She was eventually transferred to the floor and
continued to wean down her 02.  She was on [**3-9**] liters of
nasal cannula, continued on Albuterol and Atrovent
nebulizers.  She was given three doses of 10 mg of IV Lasix
throughout her stay on the floor and was weaned off oxygen
and was saturating 97% on 1 liter with minimal 02
requirements, very comfortable respiratory rate.

However, the plans are to complete a ten day course of
levofloxacin for the urinary tract infection, discontinue the
ceftazidime.




                            [**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D.  [**MD Number(1) 3475**]

Dictated By:[**Name8 (MD) 264**]
MEDQUIST36

D:  [**2106-6-1**]  10:03
T:  [**2106-6-1**]  10:05
JOB#:  [**Job Number 93962**]


Name:  [**Known lastname **], [**Known firstname 14865**]                        Unit No:  [**Numeric Identifier 14866**]

Admission Date:  [**2106-5-27**]       Discharge Date:  [**2106-6-1**]

Date of Birth:   [**2013-12-22**]       Sex:  F

Service:  [**Company 112**]

ADDENDUM TO PROBLEM LIST - HYPOXIA (CON'T):  The patient
continued to wean off O2.  Planned to continue nebs prn for
wheezing.  Continue to follow oxygenation at nursing home and
only use prn doses of 10 mg of po lasix as needed, but
otherwise are not recommending standing doses of lasix for
discharge.

URINARY TRACT INFECTION:  The patient with chronic Foley
secondary to urinary incontinence, and was continued on
Foley.  However, this was changed during the course of her
stay.  Initially, UA positive, and urine culture grew out
Citrobacter koseri which is sensitive to levofloxacin and
ceftaz which she was double-covered on for the first 5 days,
and then will complete a course of levofloxacin to complete a
10-day course for her urinary tract infection, to which the
Citrobacter is sensitive to.

CONSTIPATION:  The patient was constipated initially, likely
secondary to her morphine that she gets for dressing changes.
She is status post an anal disimpaction, and continued on an
aggressive bowel regimen, to which she is to continue at her
nursing home to prevent further constipation.

DEMENTIA:  The patient was stable, at baseline mental status,
per her son, and she was continued on depakote here.

STAGE 3 LOWER EXTREMITY ULCER:  This was stable, followed by
the plastic service, and continued on [**Hospital1 **] wet-to-dry
dressings while in-house, and continued on frequent turns,
Podus boots, and air bed to help and to optimize nutritional
status, in hopes to help her ulcer heal.  The patient was
seen by the plastic surgery who are now recommending
transition to qd wet-to-dry dressing changes, and continue to
await granulation tissue and revitalization.  However, no
plans for skin graft at this time, as would like be more
complicated than continuing dressing changes at this time.
No evidence of osteomyelitis during her stay.  She had an
x-ray which was negative and was otherwise stable from her
ulcer perspective.

ANEMIA:  Stable.  The patient had iron studies and B12 and
folate which were done which were negative.  Guaiac negative
while here.  The patient's anemia most likely secondary to
chronic disease.  The patient did require 2 units transfusion
while in the VICU.  Unclear initial source of her hematocrit
drop except dilutional from aggressive hydration.  However,
in light of patient's septic picture, the patient was
transfused for a hematocrit of less than 27.  However, after
her transfusion, her hematocrit remained stable, and at the
time of discharge was 36.

NUTRITION:  The patient was continued NPO while here and
continued on tube feeds on a continuous basis.  She can
return to her home cycling doses once she returns back to her
nursing home.

DISCHARGE DIAGNOSES:
1. Sepsis.
2. Urinary tract infection.
3. Fluid overload.
4. Hypoxia.
5. Constipation.
6. Dementia.
7. Lower extremity decubitus ulcer.
8. Anemia.
9. Urinary incontinence.
10.Dysphagia.

DISCHARGE MEDICATIONS:
1. Tylenol 650 mg po q 4-6 h prn.
2. Fentanyl patch 50 mcg/h transdermal q 72 h.
3. Multivitamin 1 po qd.
4. Valproic acid 250 mg po q 12, elixir form.
5. Morphine sulfate oral solution 2 mg po bid prn dressing
changes.
6. Lansoprazole 30 mg po qd, liquid form.
7. Subcu heparin 5,000 U q 8.
8. Sliding scale insulin [**Hospital1 **].
9. Albuterol nebs 1 neb q 4 h prn wheezing.
10.Ipratropium nebs 1 neb q 6 h prn.
11.Colace 100 mg po bid.
12.Bisacodyl 10 mg PR qd prn.
13.Lactulose 30 ml po q 8 prn constipation.
14.Levofloxacin 250 mg po qd for 6 more days.

DISCHARGE CONDITION:  Good.  The patient at baseline,
nonverbal, comfortable.  No O2 requirement.  Bed bound.

DISCHARGE STATUS:  Discharge back to [**First Name4 (NamePattern1) 14703**] [**Last Name (NamePattern1) **].

DISCHARGE FOLLOW-UP:  The patient is to follow-up with her
PCP [**Last Name (NamePattern4) **] [**8-14**] days.




                            [**Name6 (MD) **] [**Last Name (NamePattern4) 424**], M.D.  [**MD Number(1) 425**]

Dictated By:[**Name8 (MD) 1404**]
MEDQUIST36

D:  [**2106-6-1**]  10:11
T:  [**2106-6-1**]  10:12
JOB#:  [**Job Number 14867**]
{"Unspecified septicemia,Urinary tract infection, site not specified,Ulcer of heel and midfoot,Congestive heart failure, unspecified,Pneumonia, organism unspecified,Septic shock,Alzheimer's disease,Sepsis"}


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: 

PRESENT ILLNESS: This is a [**Age over 90 **]-year-old woman
who is a resident of the [**Hospital3 1186**] who has a history of
Alzheimer's dementia, tardive dyskinesia, at baseline
nonverbal, and was noted at the nursing home to be having
increasing wheezing with 02 saturations in the 80s to low
90s.  Given Albuterol nebulizers and was still with wheezing.
Respiratory rate was noted to be in the 20-26 range, blood
pressure 112/60, heart rate 120s.  Of note, the patient was
on tube feeds.  She has stage III left heel ulcer and was on
morphine for pain management during dressing changes for
them.  Per son, the patient currently appears near her normal
self.

MEDICAL HISTORY: 1.  Cataracts.
2.  Alzheimer's dementia.
3.  Tardive dyskinesia secondary to Haldol.
4.  Status post PEG.
5.  Hypertension.
6.  Dysphagia.
7.  Esophagitis.
8.  History of duodenal ulcer.
9.  History of left hip fracture, status post ORIF.
10. Status post TAH.
11. History of urinary incontinence.

MEDICATION ON ADMISSION: 

ALLERGIES: The patient is allergic to Haldol.

PHYSICAL EXAM: 

FAMILY HISTORY: Unknown secondary to mental status.

SOCIAL HISTORY: She is a [**Hospital3 1186**] resident. 

### Response:
{"Unspecified septicemia,Urinary tract infection, site not specified,Ulcer of heel and midfoot,Congestive heart failure, unspecified,Pneumonia, organism unspecified,Septic shock,Alzheimer's disease,Sepsis"}
