CHIEF COMPLAINT: hypoxia, SOB

PRESENT ILLNESS: [**Age over 90 **] y/o F with PMHx of COPD on home O2 (baseline 90% on 2LNC),
Afib and Diastolic CHF who was noted to at nursing home resident
who was found today at NH SOB and desat 84% on 4LNC. She was
transferred to [**Hospital1 18**].
.
In the ED, initial vs were: T 100.5 P 98  BP 137/78  R28  80%RA,
92% NRB. Patient was given Ceftriaxone, Azithro, Solumedrol 125
IV X1, and nebs in ED. She was started on nasal bipap with sats
in 95%
.
On arrival to ICUs she is c/o mild non-productive cough, but
denies pain, fever, chills, chest discomfort, palpitatiosn,
muscle aches.

MEDICAL HISTORY: Diastolic Heart Failure
Atrial Fibrillation on coumadin
Remote h/o TIAs
COPD on home O2 (2L at baseline)
Scoliosis
Osteoarthritis
L hip/R pelvis fx managed nonoperatively
Recent LLE cellulitis

MEDICATION ON ADMISSION: Albuterol Sulfate q4hrs
Ascorbic Acid 500 mg [**Hospital1 **]
Buspirone 10 mg qdinner
Multivitamin daily
Docusate Sodium 100 mg prn
Omeprazole 20 mg daily
Lorazepam 0.5 mg qam
Citalopram 40 mg daily
Ipratropium Bromide q4hr
Furosemide 120 mg [**Hospital1 **]
CALCIUM 500+D 500 [**Hospital1 **]
Digoxin 125 mcg Tablet [**11-27**] tablet per day
Warfarin 2 mg daily
Metoprolol Succinate 50 mg daily
acetazolamide 250 mg [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE on admission:
Vitals: T: 98.7 BP: 147/84 P: 89 R: 95%bipap O2:
General: Alert, oriented to person, tremulous, tolerating nasal
mask
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: ronchi throughout with some scarce wheeses L>R, no
crackles
CV: irregular, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: +HTN, DM. overall non contributory to currently illness and
given her age.

SOCIAL HISTORY: Was coming from [**Hospital 100**] Rehab MACU. Normally ambulates with
walker. A&OX3 and functional at baseline. On oxygen 2L. Past
smoker, quit >30years ago. No etoh or illicits. Son/daughter are
nearby and  involved. DNR/DNI.
Obstructive chronic bronchitis with (acute) exacerbation,Acute respiratory failure,Acute kidney failure, unspecified,Alkalosis,Combined systolic and diastolic heart failure, unspecified,Other dependence on machines, supplemental oxygen,Atrial fibrillation,Long-term (current) use of anticoagulants
Obs chr bronc w(ac) exac,Acute respiratry failure,Acute kidney failure NOS,Alkalosis,Syst/diast hrt fail NOS,Depend-supplement oxygen,Atrial fibrillation,Long-term use anticoagul
Admission Date:  [**2195-12-24**]              Discharge Date:   [**2195-12-30**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
hypoxia, SOB

Major Surgical or Invasive Procedure:
none


History of Present Illness:
[**Age over 90 **] y/o F with PMHx of COPD on home O2 (baseline 90% on 2LNC),
Afib and Diastolic CHF who was noted to at nursing home resident
who was found today at NH SOB and desat 84% on 4LNC. She was
transferred to [**Hospital1 18**].
.
In the ED, initial vs were: T 100.5 P 98  BP 137/78  R28  80%RA,
92% NRB. Patient was given Ceftriaxone, Azithro, Solumedrol 125
IV X1, and nebs in ED. She was started on nasal bipap with sats
in 95%
.
On arrival to ICUs she is c/o mild non-productive cough, but
denies pain, fever, chills, chest discomfort, palpitatiosn,
muscle aches.

Past Medical History:
Diastolic Heart Failure
Atrial Fibrillation on coumadin
Remote h/o TIAs
COPD on home O2 (2L at baseline)
Scoliosis
Osteoarthritis
L hip/R pelvis fx managed nonoperatively
Recent LLE cellulitis


Social History:
Was coming from [**Hospital 100**] Rehab MACU. Normally ambulates with
walker. A&OX3 and functional at baseline. On oxygen 2L. Past
smoker, quit >30years ago. No etoh or illicits. Son/daughter are
nearby and  involved. DNR/DNI.


Family History:
+HTN, DM. overall non contributory to currently illness and
given her age.

Physical Exam:
PE on admission:
Vitals: T: 98.7 BP: 147/84 P: 89 R: 95%bipap O2:
General: Alert, oriented to person, tremulous, tolerating nasal
mask
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: ronchi throughout with some scarce wheeses L>R, no
crackles
CV: irregular, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema


Pertinent Results:
[**2195-12-24**] 11:30AM BLOOD WBC-6.4 RBC-3.79* Hgb-12.2 Hct-37.2
MCV-98 MCH-32.1* MCHC-32.8 RDW-14.4 Plt Ct-230
[**2195-12-25**] 05:20PM BLOOD WBC-2.7* RBC-3.33* Hgb-10.5* Hct-31.9*
MCV-96 MCH-31.5 MCHC-32.9 RDW-14.6 Plt Ct-190
[**2195-12-28**] 03:30AM BLOOD WBC-4.8 RBC-3.33* Hgb-10.3* Hct-32.1*
MCV-96 MCH-30.9 MCHC-32.1 RDW-14.2 Plt Ct-194
[**2195-12-30**] 04:12AM BLOOD WBC-7.0# RBC-3.63* Hgb-11.6* Hct-33.6*
MCV-93 MCH-31.8 MCHC-34.4 RDW-14.3 Plt Ct-189
[**2195-12-24**] 11:30AM BLOOD Glucose-112* UreaN-24* Creat-1.2* Na-143
K-3.7 Cl-99 HCO3-33* AnGap-15
[**2195-12-26**] 04:00AM BLOOD Glucose-149* UreaN-37* Creat-1.2* Na-145
K-4.6 Cl-105 HCO3-33* AnGap-12
[**2195-12-27**] 03:57PM BLOOD Glucose-173* UreaN-49* Creat-1.4* Na-146*
K-4.6 Cl-101 HCO3-42* AnGap-8
[**2195-12-29**] 04:29PM BLOOD Glucose-245* UreaN-30* Creat-1.0 Na-136
K-3.8 Cl-82* HCO3-44* AnGap-14
[**2195-12-30**] 06:12AM BLOOD K-3.7
[**2195-12-25**] 06:33AM BLOOD proBNP-5511*
[**2195-12-25**] 03:25AM BLOOD Calcium-8.4 Phos-4.6* Mg-2.0
[**2195-12-27**] 03:57PM BLOOD Calcium-9.2 Phos-3.2 Mg-2.2
[**2195-12-30**] 04:12AM BLOOD Calcium-8.7 Phos-2.9 Mg-2.2
[**2195-12-24**] 11:30AM BLOOD Digoxin-0.3*
[**2195-12-24**] 07:12PM BLOOD Type-ART pO2-139* pCO2-70* pH-7.21*
calTCO2-30 Base XS--1
[**2195-12-25**] 11:01AM BLOOD Type-ART pO2-60* pCO2-65* pH-7.29*
calTCO2-33* Base XS-2
[**2195-12-26**] 01:33PM BLOOD Type-[**Last Name (un) **] pO2-163* pCO2-86* pH-7.23*
calTCO2-38* Base XS-5 Comment-GREEN TOP
[**2195-12-28**] 03:42AM BLOOD Type-[**Last Name (un) **] Temp-36.5 Rates-/28 FiO2-40
pO2-52* pCO2-83* pH-7.32* calTCO2-45* Base XS-12 Intubat-NOT
INTUBA Vent-SPONTANEOU
[**2195-12-27**] 07:40PM BLOOD Lactate-2.6*
[**2195-12-28**] 03:42AM BLOOD Lactate-1.8

Imaging:
FINDINGS: A small right pleural effusion is seen which has
decreased in size since the prior study. Patchy opacities at the
right lung base are likely atelectasis, although infection
cannot be excluded. Linear density near the left lung base is
likely atelectasis. No other areas of focal consolidation are
noted. There is no pulmonary edema. The cardiomediastinal
silhouette is difficult to assess due to severe scoliosis;
however, cardiomegaly is stable and the mediastinal silhouette
is unchanged. There is calcification of the aorta. Visualized
osseous structures appear intact.

IMPRESSION: Decrease in size of small right pleural effusion.
Most likely
atelectasis in the right lower lobe, although infection cannot
be excluded. Stable cardiomegaly.


Brief Hospital Course:
[**Age over 90 **] y/o F with PMHx of COPD on home O2, Diastolic CHF who
presents with sob and hypoxia likely due to copd exacerbation
unable to wean from bipap.
The big picture is that she has multifactorial severe resp
failure including:

- Severe COPD
- Chronic diastolic heart failure, PH from that as well as cor
pulmonale, afib
- Restrictive ventilatory defect from severe kyphoscoliosis,
large hiatal hernia, pleural effusions, which also contributes
to atelectasis

She has not had a robust response to medical therapy. I am
concerned that though she is critically ill with high oxygen
requirement, this is probably her baseline and she may not
improve to the point of requiring less supplemental O2.

.
# Hypoxia:  likely secondary to COPD exaccerbation with or
without an underlying pneumonia.  Treated for COPD exaccerbation
with steroids and azithromycin.  Also started on ceftriaxone for
? CAP and vanco for ? HAP considering she was a nursing home
resident.  The first two days of her hospitalization she
required intermittent bipap treatment to maintain O2 sats with
goal btw 88-92.  Then she started to maintain good O2
saturations in the above mentioned goal on 60% face mask, which
is the amount of oxygen she was wearing in rehab before
readmission.  She was mentating well and not complaining of SOB
with this mask.  She was switched to levofloxacin after the
first doses of antibiotics mentioned above, and treated with a
course of this which was stopped on [**12-29**].  She completed a course
of azithromycin.  Initially for steroids she was on IV 125 mg
solumedrol, then switched to 40 mg IV bid dosing and then
transitioned to PO 40 steroids.  And we recommend 3 more days of
prednisone 40 mg daily, then 2 days of 20 mg daily, then 2 days
of 10 mg daily, then 2 days of 5 mg daily, then stopping.
.
# Diastolic Heart Failure:  continued toprol at home dose
initially.  Diuresed over the course of her hospitalization and
then started to appear clinically dry and develop a contraction
alkalosis.  We are continuing to hold her lasix and
acetazolamide.  It should be restarted based on her clinical
fluid status and resolution of her alkalosis.
.
# Atrial Fibrillation: was rate controlled and anticoagulated
with coumadin.  Went into afib with RVR during hospitalization
on [**12-27**].  Control with PO and IV metoprolol failed and Dilt gtt
was started.  She was weaned off the diltiazem gtt on [**12-29**] and
transitioned to PO diltiazem of 30 mg qid.  Her dose was
increased to 60 mg qid with good control and rates in the
80s-90s.  We did not restart her metoprolol.  It could be
restarted as needed for rate control.
.
# ARF: had increase in her creatinine to 1.4, likey due to
dehydration from over diuresis.  With holding of her diuretics,
it returned to her baseline around 1.0 or 0.9.  She made
appropriate urine throughout her hospitalization.
.
# FEN:  repleted electrolytes prn
.
# Prophylaxis: Subcutaneous heparin
.
# Access: PIVs
.
# Code: DNR/DNI
.
# Communication: Patient
   daughter: [**Name (NI) **] [**Numeric Identifier 81859**]; [**Last Name (un) **]
[**Telephone/Fax (5) 81860**]


Medications on Admission:
Albuterol Sulfate q4hrs
Ascorbic Acid 500 mg [**Hospital1 **]
Buspirone 10 mg qdinner
Multivitamin daily
Docusate Sodium 100 mg prn
Omeprazole 20 mg daily
Lorazepam 0.5 mg qam
Citalopram 40 mg daily
Ipratropium Bromide q4hr
Furosemide 120 mg [**Hospital1 **]
CALCIUM 500+D 500 [**Hospital1 **]
Digoxin 125 mcg Tablet [**11-27**] tablet per day
Warfarin 2 mg daily
Metoprolol Succinate 50 mg daily
acetazolamide 250 mg [**Hospital1 **]


Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Buspirone 10 mg Tablet Sig: One (1) Tablet PO DINNER
(Dinner).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
8. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatment
Inhalation Q6H (every 6 hours).
12. Warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
13. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
14. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 3 days: The complete taper with prednisone 20 mg for 2 days,
then 10 mg for 2 days, then 5 mg for 2 days, then stop.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
Primary Diagnosis:
1.  COPD exaccerbation
2.  Atrial fibrillation with rapid ventricular response
3.  Diastolic heart failure

Secondary Diagnosis:
1.  Hx of TIAs
2.  Scoliosis


Discharge Condition:
frail, afebrile, on 60% face mask high flow O2


Discharge Instructions:
You were admitted to the hospital for having low oxygen levels
at your [**Hospital1 **] center.  You came to the ICU and we
treated you with antibiotics, steroids and extra oxygen.  The
reason for your SOB and low oxygen level was likely an
exaccerbation of your COPD.

You will return to [**Hospital1 **] where they will continue to
use high flow oxygen to help you breath.  You will also be able
to do more physical therapy while there.

If you start feeling more SOB, the rehab staff starts noticing
fevers, chills, confusion or any other concerns, you should
return to the hospital.

Followup Instructions:
Please continue care with the doctors [**First Name (Titles) **] [**Last Name (Titles) **]
[**Name5 (PTitle) **].

Follow up with your PCP as needed after rehab.



Completed by:[**2195-12-30**]
{'Obstructive chronic bronchitis with (acute) exacerbation,Acute respiratory failure,Acute kidney failure, unspecified,Alkalosis,Combined systolic and diastolic heart failure, unspecified,Other dependence on machines, supplemental oxygen,Atrial fibrillation,Long-term (current) use of anticoagulants'}


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: hypoxia, SOB

PRESENT ILLNESS: [**Age over 90 **] y/o F with PMHx of COPD on home O2 (baseline 90% on 2LNC),
Afib and Diastolic CHF who was noted to at nursing home resident
who was found today at NH SOB and desat 84% on 4LNC. She was
transferred to [**Hospital1 18**].
.
In the ED, initial vs were: T 100.5 P 98  BP 137/78  R28  80%RA,
92% NRB. Patient was given Ceftriaxone, Azithro, Solumedrol 125
IV X1, and nebs in ED. She was started on nasal bipap with sats
in 95%
.
On arrival to ICUs she is c/o mild non-productive cough, but
denies pain, fever, chills, chest discomfort, palpitatiosn,
muscle aches.

MEDICAL HISTORY: Diastolic Heart Failure
Atrial Fibrillation on coumadin
Remote h/o TIAs
COPD on home O2 (2L at baseline)
Scoliosis
Osteoarthritis
L hip/R pelvis fx managed nonoperatively
Recent LLE cellulitis

MEDICATION ON ADMISSION: Albuterol Sulfate q4hrs
Ascorbic Acid 500 mg [**Hospital1 **]
Buspirone 10 mg qdinner
Multivitamin daily
Docusate Sodium 100 mg prn
Omeprazole 20 mg daily
Lorazepam 0.5 mg qam
Citalopram 40 mg daily
Ipratropium Bromide q4hr
Furosemide 120 mg [**Hospital1 **]
CALCIUM 500+D 500 [**Hospital1 **]
Digoxin 125 mcg Tablet [**11-27**] tablet per day
Warfarin 2 mg daily
Metoprolol Succinate 50 mg daily
acetazolamide 250 mg [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE on admission:
Vitals: T: 98.7 BP: 147/84 P: 89 R: 95%bipap O2:
General: Alert, oriented to person, tremulous, tolerating nasal
mask
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: ronchi throughout with some scarce wheeses L>R, no
crackles
CV: irregular, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: +HTN, DM. overall non contributory to currently illness and
given her age.

SOCIAL HISTORY: Was coming from [**Hospital 100**] Rehab MACU. Normally ambulates with
walker. A&OX3 and functional at baseline. On oxygen 2L. Past
smoker, quit >30years ago. No etoh or illicits. Son/daughter are
nearby and  involved. DNR/DNI. 

### Response:
{'Obstructive chronic bronchitis with (acute) exacerbation,Acute respiratory failure,Acute kidney failure, unspecified,Alkalosis,Combined systolic and diastolic heart failure, unspecified,Other dependence on machines, supplemental oxygen,Atrial fibrillation,Long-term (current) use of anticoagulants'}
