CHIEF COMPLAINT: fever, cough

PRESENT ILLNESS: 78 yr old female with hx of Chrohn's disease, NSTEMI, bilateral
DVTs/saddle emboli who was in her usual state of health until
day of admission when she developed a fevere to 102.9.  Pt's
daughter reports that pt had [**1-31**] day hx of a cough but no hx of
chest pain, sob, n/v/d, abd pain, dysuria, neck stiffness.  Of
note, all family memebers have been ill with various URIs in the
past month.  Pt was brought to the ED and was found to have a
temp of 99 (after tylenol) and was intermittently hypotensive
with SBPs in the 70-80 range despite 5L fluids.  The MUST
protocol was initiated and the pt was started on Levophed and
given stress dose steroids after [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**]-stim.  Pt was
transferred to the MICU for further management.
.
In the MICU, pt was weaned off levophed (after only 5 hours) and
started on ceftriaxone/azithro for presumed CAP as source of
sepsis.  Pt had a abd CT scan that showed no evidence of abd
abscess.

MEDICAL HISTORY: 1. Crohns, last flare [**1-2**]
2. breast CA s/p s/p R lumpectomy and XRT 11 yrs ago
3. GERD
4. CAD s/p NSTEMI '[**89**] [stress [**4-2**]: mod, partially rev [**First Name (Titles) 15758**] [**Last Name (Titles) 99599**]t in apex w/ associated hypokinesis; ECHO [**4-2**]: EF 45-55%]
5. s/p CCY 10 yrs ago
6. HTN
7. hx of bilateral DVTs and saddle embolus in [**2190**]
8. CRI, baseline cr 1.5-1.8
9. Anemia

MEDICATION ON ADMISSION: asacol 9 pills per day
Cipro 250mg [**Hospital1 **]
Prednisone 5mg [**Hospital1 **]
Coumadin 3mg qd
Prilosec
Metoprolol 12.5mg qd
lasix 10mg qd

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: tmax 97.3, tc 96.0, BP 142/67 (118-145/49-71), HR 77 (69-88), R
24, O2 96% on 2L
Gen: NAD, sitting up in bed, not dyspneic on talking
HEENT: PERRL, EOMI
Neck: JVD flat
CV: RRR, 3/6 systolic murmur at RUSB
Chest: poor air movement, crackles at left base; thick upper
airway sounds
Abd: +BS, soft, NT
Ext: 3+ lower ext edema, L>R, painful to palpation
Neuro: alert, grossly nonfocal

FAMILY HISTORY: NC

SOCIAL HISTORY: lives at home, daughter is very involved
Unspecified septicemia,Pneumonia, organism unspecified,Sepsis,Long-term (current) use of steroids,Unspecified essential hypertension,Regional enteritis of unspecified site,Old myocardial infarction,Esophageal reflux,Personal history of malignant neoplasm of breast,Adrenal cortical steroids causing adverse effects in therapeutic use
Septicemia NOS,Pneumonia, organism NOS,Sepsis,Long-term use steroids,Hypertension NOS,Regional enteritis NOS,Old myocardial infarct,Esophageal reflux,Hx of breast malignancy,Adv eff corticosteroids
Admission Date:  [**2190-7-1**]              Discharge Date:   [**2190-7-5**]

Date of Birth:  [**2112-2-19**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 898**]
Chief Complaint:
fever, cough

Major Surgical or Invasive Procedure:
1. Left Internal Jugular Central Line


History of Present Illness:
78 yr old female with hx of Chrohn's disease, NSTEMI, bilateral
DVTs/saddle emboli who was in her usual state of health until
day of admission when she developed a fevere to 102.9.  Pt's
daughter reports that pt had [**1-31**] day hx of a cough but no hx of
chest pain, sob, n/v/d, abd pain, dysuria, neck stiffness.  Of
note, all family memebers have been ill with various URIs in the
past month.  Pt was brought to the ED and was found to have a
temp of 99 (after tylenol) and was intermittently hypotensive
with SBPs in the 70-80 range despite 5L fluids.  The MUST
protocol was initiated and the pt was started on Levophed and
given stress dose steroids after [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**]-stim.  Pt was
transferred to the MICU for further management.
.
In the MICU, pt was weaned off levophed (after only 5 hours) and
started on ceftriaxone/azithro for presumed CAP as source of
sepsis.  Pt had a abd CT scan that showed no evidence of abd
abscess.

Past Medical History:
1. Crohns, last flare [**1-2**]
2. breast CA s/p s/p R lumpectomy and XRT 11 yrs ago
3. GERD
4. CAD s/p NSTEMI '[**89**] [stress [**4-2**]: mod, partially rev [**First Name (Titles) 15758**] [**Last Name (Titles) 99599**]t in apex w/ associated hypokinesis; ECHO [**4-2**]: EF 45-55%]
5. s/p CCY 10 yrs ago
6. HTN
7. hx of bilateral DVTs and saddle embolus in [**2190**]
8. CRI, baseline cr 1.5-1.8
9. Anemia

Social History:
lives at home, daughter is very involved


Family History:
NC

Physical Exam:
tmax 97.3, tc 96.0, BP 142/67 (118-145/49-71), HR 77 (69-88), R
24, O2 96% on 2L
Gen: NAD, sitting up in bed, not dyspneic on talking
HEENT: PERRL, EOMI
Neck: JVD flat
CV: RRR, 3/6 systolic murmur at RUSB
Chest: poor air movement, crackles at left base; thick upper
airway sounds
Abd: +BS, soft, NT
Ext: 3+ lower ext edema, L>R, painful to palpation
Neuro: alert, grossly nonfocal

Pertinent Results:
*** admit labs ***
[**2190-6-30**] 09:26PM   LACTATE-1.9
.
[**2190-6-30**] 09:40PM   WBC-14.4*# HCT-29.6* MCV-122*#
[**2190-6-30**] 09:40PM   NEUTS-43* BANDS-35* LYMPHS-6* MONOS-2 EOS-0
BASOS-0 ATYPS-1* METAS-10* MYELOS-3*
[**2190-6-30**] 09:40PM   PLT COUNT-266
[**2190-6-30**] 09:40PM   PT-15.4* PTT-23.2 INR(PT)-1.6
.
[**2190-6-30**] 09:40PM   CRP-5.05*
[**2190-6-30**] 09:40PM   CORTISOL-18.3
[**2190-6-30**] 09:40PM   GLUCOSE-99 UREA N-25* CREAT-1.6* SODIUM-137
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-22 ANION GAP-14
[**2190-6-30**] 09:40PM   ALT(SGPT)-10 AST(SGOT)-14 CK(CPK)-21* ALK
PHOS-84 AMYLASE-82 TOT BILI-0.5
[**2190-6-30**] 09:40PM   LIPASE-22
[**2190-6-30**] 09:40PM   CALCIUM-8.0* PHOSPHATE-2.0*# MAGNESIUM-1.3*
.
[**2190-6-30**] 11:00PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2190-6-30**] 11:00PM URINE  RBC-0 WBC-0 BACTERIA-RARE YEAST-NONE
EPI-<1
.
** on transfer to floor from MICU **
[**2190-7-3**] 04:03AM BLOOD WBC-9.2 Hct-32.6* MCV-109*#
[**2190-7-3**] 04:03AM BLOOD Plt Ct-228
[**2190-7-3**] 04:03AM BLOOD PT-17.1* PTT-75.6* INR(PT)-1.9
.
[**2190-7-3**] 04:03AM BLOOD Glucose-126* UreaN-29* Creat-1.6* Na-142
K-4.2 Cl-110* HCO3-22 AnGap-14
[**2190-7-3**] 04:03AM BLOOD Calcium-8.2* Phos-3.4 Mg-2.5
.
** CXR:
1) Left IJ line with its tip in the brachiocephalic vein in the
midline; no pneumothorax.
2) Faint right base/perihilar opacity, consistent with
atelectasis versus early pneumonic infiltrate.
.

** abd CT:
1. No evidence of intraabdominal abscess.
2. Chronic changes consistent with Crohn's disease. A few mildly
thickened loops of small bowel could be related to flare.
3. Small bilateral pleural effusions. Bibasilar atelectasis.


Brief Hospital Course:
Assessment: 78 y/o female with crohns disease on chronic
steroids presenting with cough and fever. Had persistent
hypotension in ED and was enrolled in MUST protocol, now stable
so being transferred to floor
.
1. Sepsis:  Pt's sepsis was likely secondary to pneumonia and
mild element of adrenal insufficiency (in setting of chronic
steroids for Crohn's disease) causing transient hypotensions
requiring pressors esp given bandemia, infiltrate on CXR and
rapid improvement with abx.  Pressors were discontinued soon
after arrival to the ICU with the help of fluids, initiation of
abx and steroids.  PCP was also considered given pt's
immunosuppression but unlikely given an LDH of 194.  An induced
sputum was sent for PCP and was pending at the time of
discharge.  UA negative and abd CT negative for acute pathology.
 Pt was started on Azithro/Ceftriaxone for community acquired
pneumonia.  She was given high dose steroids in the setting of
her hypotension and these were weaned down to her home dose by
the day of discharge.  She was continued on albuterol and
atrovent nebs.  Blood cx were negative.  Pt was sent home on
cefpodoxime and azithro for a total of a 10 day course.
.
2. Hypoxia: Pt required oxygen in the ICU but was never
intubated.  It was difficult to wean the pt's oxygen on the
floor due to persistent hypoxia.  A CXR showed some evidence of
failure so she was diuresed gently.  She continued to desaturate
to 87-89% on ambulation so she was discharged with home oxygen
which she will use until she is able to maintain sats >92%.
.
3. DVT/ saddle embolus: Pt with subtherapeutic INR on admission
likely secondary to missed coumadin doses during acute illness.
She was started on a heparin drip until her INR was therapeutic.
 She should have her INR closely monitored for the first several
days following discharge due to fluctuating values.  Pt's legs
have chronically been swollen since her DVTs but she was given a
few doses of lasix to aid in diuresis given the large amount
fluid the pt received while she was hypotensive.
.
4. CAD with h/o NSTEMI: Pt ruled out for MI with 3 sets of
negative cardiac enzymes.
Fasting lipids were checked and a low dose statin was started
for an LDL of 117.  Her beta blocker was titrated up as her BP
would allow.
.
5. Crohn's: Pt's steroids were tapered down to home dose of 5mg
[**Hospital1 **].  She was continued on asacol.  She was started on calcium
and vitamin D given the chronic steroids.


Medications on Admission:
asacol 9 pills per day
Cipro 250mg [**Hospital1 **]
Prednisone 5mg [**Hospital1 **]
Coumadin 3mg qd
Prilosec
Metoprolol 12.5mg qd
lasix 10mg qd

Discharge Medications:
1. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Four
(4) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
2. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).

5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TIDAC (3 times a day (before meals)).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Warfarin Sodium 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
8. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
Disp:*45 Tablet(s)* Refills:*2*
10. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Azithromycin 250 mg Capsule Sig: Two (2) Capsule PO Q24H
(every 24 hours) for 9 days: last dose on [**7-14**].
Disp:*18 Capsule(s)* Refills:*0*
12. Cefpodoxime Proxetil 200 mg Tablet Sig: One (1) Tablet PO
Q24H (every 24 hours) for 9 days: last dose on [**7-14**].
Disp:*9 Tablet(s)* Refills:*0*
13. Home Oxygen
Pt desats to 87-89% on ambulation.  Needs continuous O2 via
nasal cannula at 2L/min to maintain O2 sats>92%.
14. Outpatient Lab Work
Please check daily INR and call results to Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] L
at [**Telephone/Fax (1) 4606**]
15. Prednisone 5 mg Tablet Sig: One (1) Tablet PO twice a day.


Discharge Disposition:
Home With Service

Facility:
VNA

Discharge Diagnosis:
Primary Diagnoses:
1. Sepsis
2. Hypotension
3. Pneumonia
4. Adrenal Insufficiency

Secondary Diagnoses:
1. Hypertension
2. DVT
3. Pulmonary Embolism
4. Crohn's Disease
5. Anemia
6. Chronic Renal Insufficiency
7. Coronary Artery Disease


Discharge Condition:
stable on room air, afebrile, hemodynamically stable, tolerating
diet

Discharge Instructions:
Please take all medications as perscribed. Please report to the
emergency room with any chest pain, shortness of breath, nausea,
vomiting, increasing lower extremity edema, fevers, chills, pain
with urination.

Followup Instructions:
Please follow up with your primary care physician [**Name Initial (PRE) 108324**] 1 week
of discharge.
{'Unspecified septicemia,Pneumonia, organism unspecified,Sepsis,Long-term (current) use of steroids,Unspecified essential hypertension,Regional enteritis of unspecified site,Old myocardial infarction,Esophageal reflux,Personal history of malignant neoplasm of breast,Adrenal cortical steroids causing adverse effects in therapeutic use'}


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: fever, cough

PRESENT ILLNESS: 78 yr old female with hx of Chrohn's disease, NSTEMI, bilateral
DVTs/saddle emboli who was in her usual state of health until
day of admission when she developed a fevere to 102.9.  Pt's
daughter reports that pt had [**1-31**] day hx of a cough but no hx of
chest pain, sob, n/v/d, abd pain, dysuria, neck stiffness.  Of
note, all family memebers have been ill with various URIs in the
past month.  Pt was brought to the ED and was found to have a
temp of 99 (after tylenol) and was intermittently hypotensive
with SBPs in the 70-80 range despite 5L fluids.  The MUST
protocol was initiated and the pt was started on Levophed and
given stress dose steroids after [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**]-stim.  Pt was
transferred to the MICU for further management.
.
In the MICU, pt was weaned off levophed (after only 5 hours) and
started on ceftriaxone/azithro for presumed CAP as source of
sepsis.  Pt had a abd CT scan that showed no evidence of abd
abscess.

MEDICAL HISTORY: 1. Crohns, last flare [**1-2**]
2. breast CA s/p s/p R lumpectomy and XRT 11 yrs ago
3. GERD
4. CAD s/p NSTEMI '[**89**] [stress [**4-2**]: mod, partially rev [**First Name (Titles) 15758**] [**Last Name (Titles) 99599**]t in apex w/ associated hypokinesis; ECHO [**4-2**]: EF 45-55%]
5. s/p CCY 10 yrs ago
6. HTN
7. hx of bilateral DVTs and saddle embolus in [**2190**]
8. CRI, baseline cr 1.5-1.8
9. Anemia

MEDICATION ON ADMISSION: asacol 9 pills per day
Cipro 250mg [**Hospital1 **]
Prednisone 5mg [**Hospital1 **]
Coumadin 3mg qd
Prilosec
Metoprolol 12.5mg qd
lasix 10mg qd

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: tmax 97.3, tc 96.0, BP 142/67 (118-145/49-71), HR 77 (69-88), R
24, O2 96% on 2L
Gen: NAD, sitting up in bed, not dyspneic on talking
HEENT: PERRL, EOMI
Neck: JVD flat
CV: RRR, 3/6 systolic murmur at RUSB
Chest: poor air movement, crackles at left base; thick upper
airway sounds
Abd: +BS, soft, NT
Ext: 3+ lower ext edema, L>R, painful to palpation
Neuro: alert, grossly nonfocal

FAMILY HISTORY: NC

SOCIAL HISTORY: lives at home, daughter is very involved 

### Response:
{'Unspecified septicemia,Pneumonia, organism unspecified,Sepsis,Long-term (current) use of steroids,Unspecified essential hypertension,Regional enteritis of unspecified site,Old myocardial infarction,Esophageal reflux,Personal history of malignant neoplasm of breast,Adrenal cortical steroids causing adverse effects in therapeutic use'}
