CHIEF COMPLAINT: Respiratory distress.

PRESENT ILLNESS: 

MEDICAL HISTORY: 1.  Diabetes.  No further information available.
2.  Hypertension.
3.  Arthritis.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient drinks approximately one drink
per day, usually to help her sleep.  She denies any history
of tobacco or drug use per the family.  The patient lives
with her daughter and her family is very involved in her
care, especially her granddaughter, [**Name (NI) **] [**Name (NI) **],
[**Telephone/Fax (1) 46664**]. Patient's primary care physician is [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at
[**Telephone/Fax (1) 46665**].
Pneumonitis due to inhalation of food or vomitus,Acute and chronic respiratory failure,Acute kidney failure, unspecified,Unspecified septicemia,Hypotension, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled
Food/vomit pneumonitis,Acute & chronc resp fail,Acute kidney failure NOS,Septicemia NOS,Hypotension NOS,DMII wo cmp nt st uncntr
Name:  [**Known lastname **], [**Known firstname **] [**Known firstname 8588**]                        Unit No:  [**Numeric Identifier 8589**]

Admission Date:  [**2199-1-27**]     Discharge Date: [**2199-2-14**]

Date of Birth:   [**2114-11-5**]     Sex:  F

Service:

ADDENDUM:  Covering time since dictation of [**2199-2-10**].

HOSPITAL COURSE:  1.  Pulmonary - The patient was continued
on Vancomycin for the presumed gram positive cocci pneumonia.
She continued to necessitate mechanical ventilation up until
the time of this dictation.  She has remained on assist
control for most of this time, with unsuccessful episodes on
pressor support.  At the present time the plan is to continue
attempts to wean her onto pressor support.  The patient
underwent a tracheostomy towards the end of her hospital
stay, a procedure which she tolerated without any
complications.  Despite this, however, the patient still
could not be weaned off assist control at the time of this
dictation.  The patient also underwent removal of her
tracheal stent at the same time she was given the
tracheostomy; this also occurred without any complication.
The current plan is to discharge the patient to a
rehabilitation facility on intravenous antibiotics which she
will get through a PICC line.  The ultimate goal is for the
patient's respiratory status to be significantly improved and
for laboratory or radiographic evidence in the form of
cultures or chest x-rays to correlate with this improvement
prior to being taken off of her antibiotics.

2.  Cardiovascular - The patient remained on Telemetry
throughout her hospital stay.  She was successively weaned
off of the vasopressor and dopamine which she had been placed
on during her hospital stay.  On [**2-14**], the patient once
again began having increased blood pressure, most likely
secondary to volume depletion.  Her blood pressures responded
well to a fluid bolus of 500 cc.  At the time of this
dictation the plan is for the patient to be discharged to a
rehabilitation facility without any cardiac medications.

3.  Renal - The patient had no further increases in her
creatinine.  She did, however, have periods of decreased
urine output which were resolved by fluid boluses.  She also
responded well to being on pressors aimed at increasing her
urine output, and these were discontinued shortly after being
started once a good output was reached.

4.  Infectious disease - The patient was continued on
antibiotics for her pneumonia.  The patient underwent a
computerized tomography scan of the sinuses to rule out
sinusitis, and this computerized tomography scan revealed
marked left maxillary sinusitis for which she was started on
Ceftazidime, which she received in addition to her
Vancomycin.  The plan is for the patient to continue on these
medications for at least a period of 10 to 14 days.

5.  Nutrition - The patient had her nasogastric tube
discontinued as it was found to be coiled in her hypopharynx
on x-ray.  The patient underwent placement of a percutaneous
endoscopic gastrostomy at the same time that she underwent
her tracheostomy installation.  The patient tolerated
placement of the percutaneous endoscopic gastrostomy without
any problems.  She also tolerated tube feeds without any
problems.  The plan is to discharge the patient to the
rehabilitation facility with the percutaneous endoscopic
gastrostomy in place so she may continue to receive enteral
nutrition.

6.  Fluids and electrolytes - The patient's urine output as
noted earlier was low at times during the end of her hospital
stay, and this responded well to fluid boluses.  During her
hospital stay her electrolytes were repleted by intravenous.
The patient's net fluid balance is still approximately
positive 17 liters.  However, she seems to be intravascularly
depleted.  The plan is for the patient to continue to receive
tube feeds and for electrolytes to be checked occasionally.

7.  Prophylaxis - The patient will be continued on an H2
blocker through her feeding tube.  She will also be continued
on pneuma boots and heparin subcutaneously.

8.  Endocrine - The patient was changed to a sliding scale
insulin regimen, which covered her adequately during her
hospital stay.  The plan is for the patient to go to
rehabilitation on a regular insulin sliding scale.

CODE STATUS:  The patient continues to be full code.

CONDITION ON DISCHARGE:  Fair.

DISCHARGE STATUS:  To a rehabilitation facility.

DISCHARGE DIAGNOSIS:
1.  Tracheobronchomalacia, status post stenting with
subsequent stent removal and tracheostomy placement.
2.  Status post hypercarbic respiratory failure.
3.  Status post intubation, complicated by failure to wean.
4.  Right middle lobe pneumonia.
5.  Left maxillary sinusitis.
6.  History of hypertension.
7.  History of diabetes.
8.  Status post acute renal failure episode, resolved.

DISCHARGE MEDICATIONS:
1.  Bisacodyl 10 mg p.o. p.r. q.d. prn
2.  Senna one tablet p.o. b.i.d. prn
3.  Docusate sodium liquid 100 mg p.o. b.i.d.
4.  Lansoprazole 30 mg nasogastric q.d. through percutaneous
endoscopic gastrostomy
5.  Miconazole powder, 2% one application topically t.i.d.
prn
6.  Regular insulin sliding scale
7.  Albuterol 1 to 2 puffs inhaled q. 4 hours prn
bronchospasm
8.  Albuterol nebulizers
9.  Lorazepam 2 to 6 mg intravenously q. 2 hours prn
10. Desitin one application topically q.i.d. prn
11. Tylenol 325 to 650 mg p.o. q. 4-6 hours prn pain or fever
12. Nystatin oral suspension 5 ml p.o. q.i.d. prn
13. Heparin 5000 units subcutaneous q. 8 hours
14. Ceftazidime 1 gm intravenously q. 12 hours, currently day
#5 of 10 to 14 days.
15. Vancomycin 1000 mg intravenously q. 24 hours, day #8 of
10 to 14 days.  The too should be ended at the same time,
preferably on the last date of the Ceftazidime.

FOLLOW UP PLAN:  The patient should be discharged to a
rehabilitation facility where she will receive medical care.



                          [**Name6 (MD) 73**] [**Name8 (MD) 72**], M.D.  [**MD Number(1) 352**]

Dictated By:[**Last Name (NamePattern1) 2144**]

MEDQUIST36

D:  [**2199-2-14**]  17:40
T:  [**2199-2-14**]  18:32
JOB#:  [**Job Number 8590**]


Admission Date:  [**2199-1-27**]       Discharge Date:


Service:  MICU
This is a dictation summary from admission until [**2199-2-10**].  The rest will be completed by next intern.

CHIEF COMPLAINT:  Respiratory distress.

admitted with decreased responsiveness and respiratory
distress.  Patient's past history of present illness is not
well known except that the patient has been noted to have
increasing dyspnea over the past month or two, most notable
with exertion.  An exact number cannot be known.  The patient
gets short of breath after a block or so.  The family of the
patient also said that the patient had been coughing for a
unresponsiveness and very short of breath.  She was not noted
to have any fevers, chills, nausea, vomiting, abdominal pain,
diarrhea or constipation, rhinorrhea or sore throat prior to
admission.

EMS was called and the patient was brought to the Emergency
Department.  In the Emergency Department, she had a chest
x-ray which demonstrated right middle lobe pneumonia.
Arterial blood gas revealed 7.11/93/300.  Patient was placed
on BiPAP with minimal improvement in her gas.  Patient was
then intubated.  A thick sputum was also suctioned from her.
She also received Solu-Medrol and nebulizers in the Emergency
Department for a question of a chronic obstructive pulmonary
disease flare.

Patient's blood pressure was systolic 120s to 140s and
briefly dropped to 50/20.  Patient was started on dopamine,
however, increased to 190s.  Dopamine was changed to Neo with
improvement of the patient's rate and pressure.  She received
Ceftriaxone and Flagyl and 1400 cc of intravenous fluid and
sent to the Medical Intensive Care Unit for further
evaluation.

PAST MEDICAL HISTORY:
1.  Diabetes.  No further information available.
2.  Hypertension.
3.  Arthritis.

ALLERGIES:  No known drug allergies.

MEDICATIONS:
1.  Hydrochlorothiazide 25 mg po q.d.
2.  Lisinopril 40 mg po q.d.
3.  Tolazamide 250 mg po q.d.
4.  Naprosyn 500 mg po b.i.d.

SOCIAL HISTORY:  The patient drinks approximately one drink
per day, usually to help her sleep.  She denies any history
of tobacco or drug use per the family.  The patient lives
with her daughter and her family is very involved in her
care, especially her granddaughter, [**Name (NI) **] [**Name (NI) **],
[**Telephone/Fax (1) 46664**]. Patient's primary care physician is [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at
[**Telephone/Fax (1) 46665**].

PHYSICAL EXAMINATION:  Temperature 101.8, 104.  Blood
pressure 120/40.  General:  The patient is vented, sedated in
no acute distress.  Head, eyes, ears, nose and throat:
Pinpoint pupils, but received morphine in the Emergency
Department.  Normocephalic, atraumatic.  No icterus.  Small
hemorrhage in left conjunctivae.  Neck supple.  Heart:
Regular rate and rhythm, no murmurs, rubs or gallops.  Lungs:
Coarse rhonchi bilaterally.  Inspiratory and expiratory
wheeze with increased expiratory time.  Abdomen:  Soft,
nontender, nondistended with positive bowel sounds.
Extremities:  Cool, no edema.

LABORATORIES:  White blood cell count 22, hematocrit 47,
creatinine of 2.1.  Toxicology screen negative.
Electrocardiogram:  Sinus tachycardia at 132 with normal
axis, normal intervals, Qs in III and aVF.  Chest x-ray with
right middle lobe pneumonia.

HOSPITAL COURSE:

1.  Pulmonary:  The patient was admitted with possible
aspiration pneumonia given the questionable history of
alcohol use, although, upon further questioning, his history
of alcohol was less substantial.  Patient was started on
levofloxacin, Flagyl and vancomycin.  She was also started on
Combivent nebulizers and Solu-Medrol for question of chronic
obstructive pulmonary disease exacerbation given the
patient's wheezing on physical examination.  Patient remained
afebrile after a couple of days and the vancomycin was
discontinued.  As there appeared to be no indication of
flora, the patient was be treated for 14 days with
levofloxacin and Flagyl for a probable aspiration pneumonia.
Because the patient was noted to be noted to have severe
wheezing and also had an effusion on chest x-ray, CT was
performed of the chest which showed no change in her
pneumonia.  It did note small bilateral pleural effusions.
Patient was attempted several times to be weaned to pressure
support from AC ventilation, however, she did tolerate this
and she became very agitated and desynchronous with the
ventilator.

On hospital day six, the patient had a bronchoscopy to
further examine her wheezing as she had no history of chronic
obstructive pulmonary disease, smoking, and no clear reason
for her wheezing.  Bronchoscopy demonstrated very severe
tracheomalacia with 80-90% distal tracheal collapse, also severe
malacia of her RMST/RBI with complete obstruction of the bassilar
segments of the right lower lobe, moderate collapse of her left
main stem bronchus.  At this point, the patient's
steroids were discontinued and in house, the following day,
the patient was brought to the OR by Interventional Pulmonary for
stenting of her distal trachea and left mainstem were
performed.  Patient's wheezing did not improve and she
remained difficult to wean.  The plan was then to remove the
stents and to perform a tracheostomy,  to wean her off her AC and
ventilatory support.

On hospital day ten, the patient's temperature spiked and
grew gram positive cocci in her sputum.  The vancomycin was
restarted and awaiting final respiratory cultures.

2.  Cardiovascular:  The patient was initially brought to the
floor on Neo after her failure with dopamine.  Patient's
blood pressure remained somewhat tenuous and the patient's
Neo was changed to a vasopressin with good improvement.  She
remained on this for approximately two hospital day and then
was able to wean off her pressures altogether.  She underwent
cardiac echocardiogram which demonstrated normal ejection
fraction, moderate to severe mitral regurgitation.  Patient
remained off her blood pressure medications with minor
fluctuations in her blood pressure.

Patient became increasingly total volume overloaded during
her admission, up to 20 liters positive.  However, her
intervascular space remained volume depleted.  She was then
tried to be diuresed with Lasix, although, this tended to dry
her out.  On hospital day 12, the patient received 20 of
Lasix intravenously and dropped her pressures to the 70s.
She was restarted on vasopressin which provided only some
improvement in her blood pressure.

On hospital day 14, the patient was started on dopamine with
the hope of improving her profusion to her kidneys in hope of
auto-diuresis.

3.  Renal:  Patient was admitted with acute renal failure
with a creatinine of 2.0.  She was noted to have normal renal
function prior to admission.  Patient was treated with
intravenous fluids in the Emergency Department.  This slowly
resolved over several days until she came to a creatinine of
0.8 which was felt to be her baseline.

4.  Infectious Disease:  Patient was started on antibiotics
for her pneumonia as listed in the pulmonary section.  On
hospital day 14, the patient remained to have low grade
temperature spikes.  Patient will have CT of the sinuses to
rule out sinusitis.  She will be changed from Levaquin to
vancomycin and ceftazidime for a presumed sinusitis until the
CT scan results have returned.

5.  Nutrition:  Patient was started on tube feeds upon
admission.  Promote with fiber.  Patient tolerated these well
through her nasogastric or OT tube.  Due to patient's
inability to wean off the ventilator, the option of
percutaneous endoscopic gastrostomy was discussed with the
patient's family.  The agreed that percutaneous endoscopic
gastrostomy was wanted should the patient still have some
chance of recovery.  Gastrointestinal came to evaluate the
percutaneous endoscopic gastrostomy and once the patient is
off pressors, they will perform this procedure.

6.  Fluid and electrolytes:  The patient became increasingly
volume overloaded during the length of her stay up to 20
liters positive.  The reasoning for her inability to secrete
this fluid is not clear.  Should have normal renal function.
Patient does have a low abdomen which is likely contributing
to this problem.  >.....<pressors with diuresis may be
wanted.

7.  Prophylaxis:  The patient will remain on H2 blocker due
to lack of intravenous PPI availability.  Pneumoboots and
heparin subcutaneously.

8.  Code status:  Patient is full code.  Should the patient's
prognosis worsen, this should be readjusted with the family.

9.  Endocrine:  Patient was maintained on an insulin drip,
taken off her oral hypoglycemic.  Increase fingersticks as
well once the patient is off pressors and is doing better,
she will be returned to insulin or oral hypoglycemics.

DICTATION WILL BE CONTINUED BY INTERN TAKING OVER THIS
SERVICE.







                            [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D.  [**MD Number(1) 7585**]

Dictated By:[**First Name3 (LF) 46666**]
MEDQUIST36

D:  [**2199-2-10**]  01:23
T:  [**2199-2-10**]  13:30
JOB#:  [**Job Number 46667**]
{'Pneumonitis due to inhalation of food or vomitus,Acute and chronic respiratory failure,Acute kidney failure, unspecified,Unspecified septicemia,Hypotension, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}


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: 

MEDICAL HISTORY: 1.  Diabetes.  No further information available.
2.  Hypertension.
3.  Arthritis.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient drinks approximately one drink
per day, usually to help her sleep.  She denies any history
of tobacco or drug use per the family.  The patient lives
with her daughter and her family is very involved in her
care, especially her granddaughter, [**Name (NI) **] [**Name (NI) **],
[**Telephone/Fax (1) 46664**]. Patient's primary care physician is [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at
[**Telephone/Fax (1) 46665**]. 

### Response:
{'Pneumonitis due to inhalation of food or vomitus,Acute and chronic respiratory failure,Acute kidney failure, unspecified,Unspecified septicemia,Hypotension, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}
