CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
female resident at a nursing home with advanced dementia who
presented to the Emergency Department on [**12-31**] in
respiratory distress.

MEDICAL HISTORY: 1.  Dementia; nonverbal at baseline and dependent for all
activities of daily living and not ambulatory.
2.  History of syncope.
3.  History of osteoporosis.
4.  History of depression.
5.  History of heel ulceration.
6.  History of incontinence.

MEDICATION ON ADMISSION: 1.  Aspirin 81 mg by mouth once per day.
2.  Multivitamin one tablet by mouth every day.
3.  Milk of Magnesia every other day.
4.  Tums twice per day.
5.  Remeron 15 mg by mouth at hour of sleep.
6.  Trazodone 25 mg by mouth at hour of sleep.
7.  Levaquin 500 mg by mouth once per day (started on
[**12-23**]).
8.  Flagyl 500 mg by mouth three times per day (started on
[**12-23**]).
9.  Promote twice per day.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient is widowed.  She has two
daughters.  She lives in a nursing home.  Her health care
proxy is her daughter [**Name (NI) 16405**] [**Name (NI) 349**] (telephone number
[**Telephone/Fax (1) 16406**]).
Pneumonitis due to inhalation of food or vomitus,Other pulmonary insufficiency, not elsewhere classified,Unspecified septicemia,Septic shock,Hyperosmolality and/or hypernatremia,Atrial fibrillation,Other persistent mental disorders due to conditions classified elsewhere
Food/vomit pneumonitis,Other pulmonary insuff,Septicemia NOS,Septic shock,Hyperosmolality,Atrial fibrillation,Mental disor NEC oth dis
Admission Date:  [**2195-12-31**]     Discharge Date:  [**2196-1-4**]


Service:  ACOVE Medicine Service

HISTORY OF PRESENT ILLNESS:  The patient is a [**Age over 90 **]-year-old
female resident at a nursing home with advanced dementia who
presented to the Emergency Department on [**12-31**] in
respiratory distress.

The patient had been her usual state of health until
approximately one week prior to admission when she developed
pneumonia.  She had been on day 7 of a 10-day course of
levofloxacin and Flagyl for a presumed aspiration pneumonia.
The patient was doing reasonably well until [**12-31**] when
she developed respiratory distress with a respiratory rate of
28, and an oxygen saturation of 90% on room air, and
hypotension with a blood pressure of 88/50.

She was transferred to the Emergency Department where she was
found to be in paroxysmal atrial fibrillation which was
treated with diltiazem.  She was also treated with several
liter intravenous fluid bolus for hypotension and was
subsequently admitted to the Medical Intensive Care Unit on
face mask oxygen.

PAST MEDICAL HISTORY:
1.  Dementia; nonverbal at baseline and dependent for all
activities of daily living and not ambulatory.
2.  History of syncope.
3.  History of osteoporosis.
4.  History of depression.
5.  History of heel ulceration.
6.  History of incontinence.

MEDICATIONS ON ADMISSION:
1.  Aspirin 81 mg by mouth once per day.
2.  Multivitamin one tablet by mouth every day.
3.  Milk of Magnesia every other day.
4.  Tums twice per day.
5.  Remeron 15 mg by mouth at hour of sleep.
6.  Trazodone 25 mg by mouth at hour of sleep.
7.  Levaquin 500 mg by mouth once per day (started on
[**12-23**]).
8.  Flagyl 500 mg by mouth three times per day (started on
[**12-23**]).
9.  Promote twice per day.

ALLERGIES:  No known drug allergies.

SOCIAL HISTORY:  The patient is widowed.  She has two
daughters.  She lives in a nursing home.  Her health care
proxy is her daughter [**Name (NI) 16405**] [**Name (NI) 349**] (telephone number
[**Telephone/Fax (1) 16406**]).

PHYSICAL EXAMINATION ON PRESENTATION:  Physical examination
on admission revealed the patient's temperature was 102
degrees Fahrenheit, her blood pressure was 96/56, her heart
rate was 57, her respiratory rate was 20, and her oxygen
saturation was 100% on nonrebreather with 12 liters.  In
general, this is an elderly female in moderate distress.  She
was not responsive to pain but awake and apparently alert.
Head, eyes, ears, nose, and throat examination revealed the
pupils were equal and reactive.  There were anicteric
sclerae.  The oropharynx was dry.  The patient was
edentulous.  The neck was supple.  No meningismus.  No
lymphadenopathy.  No thyromegaly.  Lung examination revealed
coarse breath sounds bilaterally, crackles at the bases, and
diffuse rhonchi.  Cardiovascular examination revealed the
heart was irregular.  There was a 2/6 systolic ejection
murmur.  The abdomen had decreased breath sounds.  The
abdomen was soft, nontender, and nondistended.  Extremity
examination revealed trace edema.  The dorsalis pedis pulses
were 1+ bilaterally.  The right toe with dry gangrene at the
tip.  There was a right heel grade 2 ulceration.  Neurologic
examination revealed the patient responded to pain and
occasionally to command but not reliable.  There were
contractures of the upper extremities.  The toes were
downgoing bilaterally.

PERTINENT LABORATORY VALUES ON PRESENTATION:   Laboratories
on admission revealed the patient's white blood cell count
was 15.5 (with 83% neutrophils and no bands), her hematocrit
was 46.2, and her platelets were 285.  Chemistry-7 revealed
the patient's sodium was 156, potassium was 4.2, chloride was
121, bicarbonate was 24, blood urea nitrogen was 52,
creatinine was 1, and blood glucose was 118.  Her lactate was
10.3.  Her troponin was 0.08.  Urinalysis was normal.

PERTINENT RADIOLOGY/IMAGING:  A chest x-ray showed a question
of a left lower lobe opacity and cardiomegaly.  No effusions.

An electrocardiogram revealed a normal sinus rhythm at 94.
There were T wave inversions in V1 through V6.  No old
electrocardiogram for comparison.

CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:  In the
Emergency Department, the patient was treated with
ceftriaxone 1 gram and azithromycin 500 mg intravenously.
She was placed on telemetry and found to be in atrial
fibrillation.  Her rapid atrial fibrillation was treated with
diltiazem 10 mg intravenously.  She subsequently became
hypotensive in the 70s and was treated with 2.5 liters of
intravenous fluids and transferred to the Intensive Care
Unit.

While in the Intensive Care Unit, she continued to need fluid
boluses overnight for blood pressures.  She was also given
additional vancomycin 1 gram given her septic picture.

1.  PNEUMONIA ISSUES:  Pneumonia thought to be secondary to
an aspiration event.  A sputum culture showed greater than 25
polymorphonuclear neutrophils and 2+ gram-positive cocci.  No
species were identified at this time.  She was placed on
broad coverage antibiotics including vancomycin to cover
methicillin-resistant Staphylococcus aureus or possible
Pseudomonas and Flagyl for anaerobes given concern for
aspiration.  On this regimen, she became afebrile and her
white blood cell count decreased.

She continued to have thick sputum production; however, she
was saturating well on nasal cannula.  Awaiting culture to
further narrow antibiotics.  Will treat for a full 14-day
course.

2.  HYPOTENSION ISSUES:  The patient's hypotension was felt
to be multifactorial; likely sepsis, and rapid atrial
fibrillation, and medications.  The hypotension resolved with
adequate fluid rehydration.

3.  ATRIAL FIBRILLATION ISSUES:  A new diagnosis of
paroxysmal atrial fibrillation.  This was stable.  The
patient was in a sinus rhythm after infectious process under
treatment.

4.  HYPERNATREMIA ISSUES:  Hypernatremia was likely secondary
to dehydration.  This was treated with free water repletion.

5.  QUESTION ADRENAL INSUFFICIENCY:  A.m. cortisol was 22.8;
however, the patient had been given stress-dose steroids
while in the [**Hospital Ward Name 332**] Intensive Care Unit.  Given normal
cortisol, this was discontinued.

6.  DEMENTIA ISSUES:  The patient is severely demented at
baseline with full dependence for activities of daily living.

7.  CODE STATUS ISSUES:  The patient's code status was
discussed with her family by the primary physician and
confirmed to be do not resuscitate/do not intubate.  However,
the family continued to wish for hospitalization and
aggressive management with those limitations.

DISCHARGE DIAGNOSES:
1.  Aspiration pneumonia.
2.  Hypernatremia.
3.  Hypotension.
4.  Dementia.
5.  Atrial fibrillation.

MEDICATIONS ON DISCHARGE:  To be included in an Addendum at a
later date.

DISCHARGE DISPOSITION:   The patient was to be discharged
back to her nursing home.

DISCHARGE INSTRUCTIONS/FOLLOWUP:
1.  The patient will need to continue the complete 14-day
course of intravenous antibiotics for which she has received
a peripherally inserted central catheter line.
2.  In addition, the patient will need close monitoring of
her electrolytes to insure adequate hydration and maintenance
of normal sodium.
3.  The patient's diet should be pureed or ground with
thickened liquids.






                DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] 12.AIY

Dictated By:[**Last Name (NamePattern1) 6765**]

MEDQUIST36

D:  [**2196-1-2**]  11:21
T:  [**2196-1-2**]  11:37
JOB#:  [**Job Number 16407**]
{'Pneumonitis due to inhalation of food or vomitus,Other pulmonary insufficiency, not elsewhere classified,Unspecified septicemia,Septic shock,Hyperosmolality and/or hypernatremia,Atrial fibrillation,Other persistent mental disorders due to conditions classified elsewhere'}


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: The patient is a [**Age over 90 **]-year-old
female resident at a nursing home with advanced dementia who
presented to the Emergency Department on [**12-31**] in
respiratory distress.

MEDICAL HISTORY: 1.  Dementia; nonverbal at baseline and dependent for all
activities of daily living and not ambulatory.
2.  History of syncope.
3.  History of osteoporosis.
4.  History of depression.
5.  History of heel ulceration.
6.  History of incontinence.

MEDICATION ON ADMISSION: 1.  Aspirin 81 mg by mouth once per day.
2.  Multivitamin one tablet by mouth every day.
3.  Milk of Magnesia every other day.
4.  Tums twice per day.
5.  Remeron 15 mg by mouth at hour of sleep.
6.  Trazodone 25 mg by mouth at hour of sleep.
7.  Levaquin 500 mg by mouth once per day (started on
[**12-23**]).
8.  Flagyl 500 mg by mouth three times per day (started on
[**12-23**]).
9.  Promote twice per day.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient is widowed.  She has two
daughters.  She lives in a nursing home.  Her health care
proxy is her daughter [**Name (NI) 16405**] [**Name (NI) 349**] (telephone number
[**Telephone/Fax (1) 16406**]). 

### Response:
{'Pneumonitis due to inhalation of food or vomitus,Other pulmonary insufficiency, not elsewhere classified,Unspecified septicemia,Septic shock,Hyperosmolality and/or hypernatremia,Atrial fibrillation,Other persistent mental disorders due to conditions classified elsewhere'}
