CHIEF COMPLAINT: shortness of breath

PRESENT ILLNESS: This is 91-year old female with little pmhx who was brought to
the ED today by her son after 1 week of increasing somnolence,
incontinence, s/p fall, and dyspnea.  Pt poor historian, most of
history obtained through son [**Name (NI) 518**], who is HCP. [**Name (NI) **] states
that pt had been in usual state of health up until about one
week prior when she began requesting to go to bed multiple times
throughout the day, was agitated, and had multiple episodes of
urinary incontinence. Pt has also had multiple episodes of
"heavy breathing" both at rest and with activity. Denies recent
fevers/ chills, pt has chronic cough, no recent change in sputum
production. Pt also w/ chronic LE edema and gout, but son feels
legs have recently looked "worse". Pt does not c/o pain, but son
reports she always denies any pain. No known sick contacts. At
baseline, pt is coherent and talkative; has significant hearing
loss but refuses hearing aid. Son denies any recent signs to
suggest confusion, no known dementia.
.
In [**Name (NI) **], pt was found to have hypothermic to 93.5 with elevated
WBC and lactate, code sepsis initiated. [**Name (NI) 1094**] son refused [**Name (NI) 14938**],
however, and pt made DNR/DNI. Pt became tachycardic with likely
a-fib rhythm, IV lopressor administered with resolution of HR to
100's. Pt also received 500 cc NS and dose of Nafcillin for
likely cellulitis of LE.

MEDICAL HISTORY: 1.  Atrial fibrillation
2.  Hypertension
3.  Peripheral Vascular Disease
4.  Peptic Ulcer Disease
5.  Iron deficiency anemia
6.  Umbilical hernia
7.  h/o ARF secondary to ACE inhibitors
8.  Chronic LE edema
9.  Gout
10. Hearing loss

MEDICATION ON ADMISSION: aspirin
pt recently self-d'c'd cardiac medication (? atenolol) for
unknown reasons per son.

ALLERGIES: Penicillins / A.C.E Inhibitors

PHYSICAL EXAM: Vitals: T 98 BP 120-126/70 P 94-99 R 22-24 Sat 97-98%3LNC
Gen: elderly woman, sitting up in bed, dyspneic and tachypneic,
unable to complete a full sentence
HEENT: NCAT, sclerae anicteric/noninjected, pupils equal, OP
clear, uvula midline, dry MM
Neck: JVP difficult to assess, no LAD
CV: irregular, tachycardic, distant heart sounds, no m/r/g noted

FAMILY HISTORY: non-contributory at present.

SOCIAL HISTORY: Lived alone up until this past [**Month (only) 205**], now lives with son and
nephew.  [**Name (NI) **] tobacco, no ETOH, no illicit drug use.
Pneumonitis due to inhalation of food or vomitus,Cellulitis and abscess of leg, except foot,Atrial fibrillation,Mitral valve disorders,Diseases of tricuspid valve,Other primary cardiomyopathies,Acute kidney failure, unspecified,Hyperosmolality and/or hypernatremia,Unspecified essential hypertension,Peripheral vascular disease, unspecified,Venous (peripheral) insufficiency, unspecified,Gout, unspecified,Acute duodenal ulcer without mention of hemorrhage or perforation, without mention of obstruction,Iron deficiency anemia, unspecified,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Senile dementia with delirium
Food/vomit pneumonitis,Cellulitis of leg,Atrial fibrillation,Mitral valve disorder,Tricuspid valve disease,Prim cardiomyopathy NEC,Acute kidney failure NOS,Hyperosmolality,Hypertension NOS,Periph vascular dis NOS,Venous insufficiency NOS,Gout NOS,Acute duodenal ulcer NOS,Iron defic anemia NOS,Gstr/ddnts NOS w/o hmrhg,Senile delirium
Admission Date:  [**2185-10-24**]              Discharge Date:   [**2185-10-31**]


Service: MEDICINE

Allergies:
Penicillins / A.C.E Inhibitors

Attending:[**First Name3 (LF) 898**]
Chief Complaint:
shortness of breath

Major Surgical or Invasive Procedure:
EGD.


History of Present Illness:
This is 91-year old female with little pmhx who was brought to
the ED today by her son after 1 week of increasing somnolence,
incontinence, s/p fall, and dyspnea.  Pt poor historian, most of
history obtained through son [**Name (NI) 518**], who is HCP. [**Name (NI) **] states
that pt had been in usual state of health up until about one
week prior when she began requesting to go to bed multiple times
throughout the day, was agitated, and had multiple episodes of
urinary incontinence. Pt has also had multiple episodes of
"heavy breathing" both at rest and with activity. Denies recent
fevers/ chills, pt has chronic cough, no recent change in sputum
production. Pt also w/ chronic LE edema and gout, but son feels
legs have recently looked "worse". Pt does not c/o pain, but son
reports she always denies any pain. No known sick contacts. At
baseline, pt is coherent and talkative; has significant hearing
loss but refuses hearing aid. Son denies any recent signs to
suggest confusion, no known dementia.
.
In [**Name (NI) **], pt was found to have hypothermic to 93.5 with elevated
WBC and lactate, code sepsis initiated. [**Name (NI) 1094**] son refused [**Name (NI) 14938**],
however, and pt made DNR/DNI. Pt became tachycardic with likely
a-fib rhythm, IV lopressor administered with resolution of HR to
100's. Pt also received 500 cc NS and dose of Nafcillin for
likely cellulitis of LE.


Past Medical History:
1.  Atrial fibrillation
2.  Hypertension
3.  Peripheral Vascular Disease
4.  Peptic Ulcer Disease
5.  Iron deficiency anemia
6.  Umbilical hernia
7.  h/o ARF secondary to ACE inhibitors
8.  Chronic LE edema
9.  Gout
10. Hearing loss


Social History:
Lived alone up until this past [**Month (only) 205**], now lives with son and
nephew.  [**Name (NI) **] tobacco, no ETOH, no illicit drug use.

Family History:
non-contributory at present.

Physical Exam:
Vitals: T 98 BP 120-126/70 P 94-99 R 22-24 Sat 97-98%3LNC
Gen: elderly woman, sitting up in bed, dyspneic and tachypneic,
unable to complete a full sentence
HEENT: NCAT, sclerae anicteric/noninjected, pupils equal, OP
clear, uvula midline, dry MM
Neck: JVP difficult to assess, no LAD
CV: irregular, tachycardic, distant heart sounds, no m/r/g noted

Lungs: unable to get pt to take deep breath, but pt has
decreased breath sounds at the bases, no rales or wheezing
Ab: soft, NTND, NABS, large umbilical hernia, no HSM by
percussion, no rebound or guarding
Extrem: wwp, 3+ pitting edema up to the knees bilaterally and
2+edema in the thighs; 1 +pitting edema LUE and trace pitting
edema RUE; erythema on BL calves symmetrically
Neuro: a and ox3, MAFE


Pertinent Results:
[**2185-10-24**] 03:30PM BLOOD WBC-16.0*# RBC-5.42* Hgb-15.2 Hct-45.4
MCV-84 MCH-28.2 MCHC-33.6 RDW-16.7* Plt Ct-276
[**2185-10-25**] 03:50AM BLOOD WBC-13.5* RBC-4.68 Hgb-13.3 Hct-39.6
MCV-85 MCH-28.3 MCHC-33.5 RDW-16.7* Plt Ct-204
[**2185-10-26**] 04:08AM BLOOD WBC-17.4* RBC-4.86 Hgb-13.6 Hct-40.7
MCV-84 MCH-27.9 MCHC-33.4 RDW-16.8* Plt Ct-203
[**2185-10-27**] 05:45AM BLOOD WBC-13.1* RBC-4.83 Hgb-13.2 Hct-41.4
MCV-86 MCH-27.2 MCHC-31.8 RDW-16.7* Plt Ct-167
[**2185-10-28**] 05:55AM BLOOD WBC-12.3* RBC-4.96 Hgb-13.6 Hct-41.5
MCV-84 MCH-27.5 MCHC-32.9 RDW-16.4* Plt Ct-193
[**2185-10-25**] 03:50AM BLOOD Neuts-89.3* Lymphs-6.5* Monos-3.7 Eos-0.5
Baso-0
[**2185-10-24**] 03:30PM BLOOD PT-14.7* PTT-27.0 INR(PT)-1.3*
[**2185-10-28**] 05:55AM BLOOD Glucose-82 UreaN-23* Creat-0.9 Na-143
K-3.7 Cl-108 HCO3-26 AnGap-13
[**2185-10-24**] 03:30PM BLOOD Glucose-120* UreaN-31* Creat-1.6* Na-141
K-4.9 Cl-104 HCO3-23 AnGap-19
[**2185-10-24**] 03:30PM BLOOD CK(CPK)-43
[**2185-10-24**] 03:30PM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier **]*
[**2185-10-24**] 03:30PM BLOOD cTropnT-0.02*
[**2185-10-27**] 05:45AM BLOOD CK-MB-3 cTropnT-0.02*
[**2185-10-24**] 03:30PM BLOOD Calcium-9.7 Phos-3.8 Mg-2.4
.
CXR [**10-24**] - IMPRESSION: Density at the right lung base, that
could represent airspace disease versus atelectasis, left-sided
pleural effusion.
.
Orophyaryngeal Swallow Study [**10-25**]:  Video oropharyngeal swallow
exam was performed in conjunction with the speech and swallow
therapy department. Various consistencies of barium were
administered under constant video fluoroscopic monitoring.
Several times, premature spillover of liquids from the oral
cavity into the valleculae, piriform sinuses, and airway was
noted. Aspiration did occur before the swallow of the
administered teaspoon of thin liquid due to premature spillover.
The patient did have a reflexive cough, however, was not
effective in clearing the aspirated material. Penetration was
also noted during the swallow of thin liquids. Of note,
evaluation of the esophagus revealed visible _____ of barium
material that did not readily pass into the stomach.
.
Echo: Moderate left ventricular and severe right ventricular
systolic
dysfunction. Moderate to severe mitral regurgitation. Moderate
tricuspid
regurgitation. Mild aortic regurgitation. Mild pulmonary
hypertension.
Moderately dilated ascending aorta.
.
CT chest: 1. Right middle and lower lobe consolidation with
moderate-sized
pleural effusion; no bronchial obstruction or [**Location (un) 21851**].
Right pleural
effusion may impinge on the esophagus.
2. Small left pleural effusion.
3. Atherosclerotic coronary and aortic calcification.
4. Moderate cardiomegaly.
.
EGD: EGD showed narrowing at GE junction without mucosal
abnormality.
Scope could traverse the GE junction.  Distal esophagus was
tortuous.  Upper esophagus had external pulsatile mass.  Stomach
had severe erosive gastritis and acute duodenal ulcer, neither
of
which were bleeding. Suggest; chest CT scan to exclude external
compression of both distal and proximal esophagus.  Continue
PPI.  Stop ASA if possible after discussion with Cardiology.  If
ASA is continued, she should take PPI lifelong because of
appearance of stomach at endoscopy.

Brief Hospital Course:
A/P: [**Age over 90 **] yo F with afib and gout who originally presented after
her son noted she had increased somnolence, SOB, and a fall.
Treated for community aqcuried and presumed aspiration PNA.
.
## Pneumonia: consolidation on right side on CT with. Subjective
dyspnea at baseline, but no home O2 requirement. Was treated
with levofloxacin (500 mg qd now that renal function has
improved) for a course that ios to end on [**11-6**] and
metronidazole 500 gm tid for a course that is to end [**11-6**]. She
was also treated with standing ipratropium nebs and prn
albuterol nebs.
.
## Cardiomyopathy: EF 30% by echo. She was diuresed slowly and
started on digoxin for her CMPY and a-fib. Her ACE inhibitor was
held due to renal dysfunction. She was started on metoprolol
short acting and then changed over to the long-acting
formulation on the day of discharge. Hydralazine was also begun
for blood pressure and afterload control. A long-acting nitrate
should be added to her regimen this week once she is tolerating
the change to long-acting metoprolol.
.
## Dementia: pt is currently at her baseline per son and
daughter.
.
## LE Cellulitis vs. venous stasis: concern in unit, primary
team here questioning presence of cellulitis.  Holding on vanco.
Findings c/w chronic venous stasis dermatitis.
.
## ARF: unsure of patient's baseline.  Cr 1.6 on admission,
currently 0.9. CrCl by MDRD is in mid-50s. Dosed meds
appropriately.
.
## Hypernatremia: pt's baseline may be elevated.  Primary
finding that does not support CHF component but likely effected
by decreased PO intake and possible intermittent contraction
alkalosis.
.
## Gout: Had a 5-day course of prednisone that has now been
stopped. She was without joint complaint on the day of
discharge.
.
## Atrial fibrillation: h/o afib, rate controlled. She was
maintained on short-acting metoprolol and then changed to
long-acting version for management of her CMPY and rate control.
Not on warfarin. Kept on aspirin.
.
## Impaired Swallowing: swallow evaluation performed twice in
past week with same results.  Nectar thick suggested.  EGD
revealed external compression of the esophagus, however, CT
chest not revealing in terms of etiology esophageal compression.

Medications on Admission:
aspirin
pt recently self-d'c'd cardiac medication (? atenolol) for
unknown reasons per son.

Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
2. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 6 days: To cease on [**11-6**] to complete 10 day
course for treatment of pneumonia.
Disp:*6 Tablet(s)* Refills:*0*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
5. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*6 Tablet(s)* Refills:*0*
8. Ipratropium Bromide 0.02 % Solution Sig: Two (2) puffs
Inhalation Q6H (every 6 hours).
Disp:*qs qs* Refills:*2*
9. Albuterol Sulfate 0.083 % Solution Sig: Two (2) puffs
Inhalation Q3-4H (Every 3 to 4 Hours) as needed for shortness of
breath or wheezing.
Disp:*qs qs* Refills:*2*
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Extended Care

Facility:
[**Location (un) 86**] Center

Discharge Diagnosis:
1.  Pneumonia
2.  Atrial fibrillation
3.  Hypertension
4.  Peripheral Vascular Disease
5.  Peptic Ulcer Disease
6.  Iron deficiency anemia
7.  Umbilical hernia
8.  ARF secondary to ACE inhibitors
9.  Chronic LE edema
10. Gout
11. Hearing loss


Discharge Condition:
Patient discharged to home in stable condition, tolerating foods
and fluids, without pain, and without fever with stable vital
signs.


Discharge Instructions:
Patient is advised to come to the emergency room if she
experiences chest pain, shortness of breath, lightheadedness,
fevers, chills, nausea, vomiting, or pain that is out of the
ordinary for her.
Patient is advised to take all of her prescriptions as
prescribed.


Followup Instructions:
1.  Patient is advised to follow-up with her primary care
physician [**Name Initial (PRE) 176**] 3-5 days to address these medical issues.
2.  Patient is advised to see a cardiologist - we have set up an
appointment for you - Friday, [**11-18**], 10am, Dr. [**Last Name (STitle) **],
[**Hospital Ward Name 23**] Clinical Center, [**Location (un) 436**].
{'Pneumonitis due to inhalation of food or vomitus,Cellulitis and abscess of leg, except foot,Atrial fibrillation,Mitral valve disorders,Diseases of tricuspid valve,Other primary cardiomyopathies,Acute kidney failure, unspecified,Hyperosmolality and/or hypernatremia,Unspecified essential hypertension,Peripheral vascular disease, unspecified,Venous (peripheral) insufficiency, unspecified,Gout, unspecified,Acute duodenal ulcer without mention of hemorrhage or perforation, without mention of obstruction,Iron deficiency anemia, unspecified,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Senile dementia with delirium'}


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: shortness of breath

PRESENT ILLNESS: This is 91-year old female with little pmhx who was brought to
the ED today by her son after 1 week of increasing somnolence,
incontinence, s/p fall, and dyspnea.  Pt poor historian, most of
history obtained through son [**Name (NI) 518**], who is HCP. [**Name (NI) **] states
that pt had been in usual state of health up until about one
week prior when she began requesting to go to bed multiple times
throughout the day, was agitated, and had multiple episodes of
urinary incontinence. Pt has also had multiple episodes of
"heavy breathing" both at rest and with activity. Denies recent
fevers/ chills, pt has chronic cough, no recent change in sputum
production. Pt also w/ chronic LE edema and gout, but son feels
legs have recently looked "worse". Pt does not c/o pain, but son
reports she always denies any pain. No known sick contacts. At
baseline, pt is coherent and talkative; has significant hearing
loss but refuses hearing aid. Son denies any recent signs to
suggest confusion, no known dementia.
.
In [**Name (NI) **], pt was found to have hypothermic to 93.5 with elevated
WBC and lactate, code sepsis initiated. [**Name (NI) 1094**] son refused [**Name (NI) 14938**],
however, and pt made DNR/DNI. Pt became tachycardic with likely
a-fib rhythm, IV lopressor administered with resolution of HR to
100's. Pt also received 500 cc NS and dose of Nafcillin for
likely cellulitis of LE.

MEDICAL HISTORY: 1.  Atrial fibrillation
2.  Hypertension
3.  Peripheral Vascular Disease
4.  Peptic Ulcer Disease
5.  Iron deficiency anemia
6.  Umbilical hernia
7.  h/o ARF secondary to ACE inhibitors
8.  Chronic LE edema
9.  Gout
10. Hearing loss

MEDICATION ON ADMISSION: aspirin
pt recently self-d'c'd cardiac medication (? atenolol) for
unknown reasons per son.

ALLERGIES: Penicillins / A.C.E Inhibitors

PHYSICAL EXAM: Vitals: T 98 BP 120-126/70 P 94-99 R 22-24 Sat 97-98%3LNC
Gen: elderly woman, sitting up in bed, dyspneic and tachypneic,
unable to complete a full sentence
HEENT: NCAT, sclerae anicteric/noninjected, pupils equal, OP
clear, uvula midline, dry MM
Neck: JVP difficult to assess, no LAD
CV: irregular, tachycardic, distant heart sounds, no m/r/g noted

FAMILY HISTORY: non-contributory at present.

SOCIAL HISTORY: Lived alone up until this past [**Month (only) 205**], now lives with son and
nephew.  [**Name (NI) **] tobacco, no ETOH, no illicit drug use. 

### Response:
{'Pneumonitis due to inhalation of food or vomitus,Cellulitis and abscess of leg, except foot,Atrial fibrillation,Mitral valve disorders,Diseases of tricuspid valve,Other primary cardiomyopathies,Acute kidney failure, unspecified,Hyperosmolality and/or hypernatremia,Unspecified essential hypertension,Peripheral vascular disease, unspecified,Venous (peripheral) insufficiency, unspecified,Gout, unspecified,Acute duodenal ulcer without mention of hemorrhage or perforation, without mention of obstruction,Iron deficiency anemia, unspecified,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Senile dementia with delirium'}
