CHIEF COMPLAINT: Fever and hypoxemia

PRESENT ILLNESS: 86 year old male resident of [**Hospital 599**] Nursing home sent to [**Hospital1 **] for
w/up of fever w/ tachycardia, tachypnea and hypoxemia.
.
Pt reportedly transferred from dementia unit of nursing home to
sub-acute unit on [**2149-8-23**] for IVF for 'dehydration' due to
decreased PO intake. In sub acute unit pt noted to be SOB w/
T=102.2, R=36, BP 130/70, P132, O2 sat 71% on 3L NC. At that
time pt was noted to be alert and verbally responsive but
confused.  Pt was transferred to [**Hospital1 **] on [**8-24**] for further eval.
Per daughter, pts mental status has deteriorated over the past
two weeks.  Pt previously spoke in understandable sentances
whereas now he mumbles largely incoherently.
.
In ED VS 102.4  HR 129  BP 112/88  RR 30 sat 71% on 2L.  pt was
placed on BiPap.  CXR w/ finding of RLL pneumonia - pt given
vanco/ceftriaxone.

MEDICAL HISTORY: PMHx:
dementia
hx TIA
depression
psychosis
GERD
htn
Lumbosacral surgery
Urological disorder, details unknown
Chronic Diarrhea

MEDICATION ON ADMISSION: MEDS on admission:
Namenda 5mg po BID
zyprexa 2.5mg po BID prn agitation
acetominophen 1000 po tid
altace 5mg po daily
lasix 20 mg po MWF
loperamide 2mg po BID
plavix 75 mg po daily
tramadol hcl 25 mg po tid

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE: (Upon MICU arrival)
T:99.9 BP:103/82 P:104  RR:22 O2 sat:99% on BiPAP
gen: pt mumbling incoherently, awake
HEENT: NC/AT
Chest: Basilar crackles
Heart: tachycardic, regular rhythm, no M/R/G
Abd: soft, NT/ND
Ext: moves all 4 extremities
Skin: warm, well perfused, decreased turgor
neuro: pt follows occasional commands, mumbles incoherently

FAMILY HISTORY: Father with [**Name (NI) 2481**], Brother had a stroke

SOCIAL HISTORY: Lives in nursing home ([**Hospital1 599**] of [**Last Name (un) **] [**Doctor Last Name **]), daughter, [**Name (NI) **]
Pneumonitis due to inhalation of food or vomitus,Dehydration,Chronic kidney disease, unspecified,Acute kidney failure, unspecified,Hypoxemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Depressive disorder, not elsewhere classified,Esophageal reflux,Diarrhea,Other persistent mental disorders due to conditions classified elsewhere
Food/vomit pneumonitis,Dehydration,Chronic kidney dis NOS,Acute kidney failure NOS,Hypoxemia,Hy kid NOS w cr kid I-IV,Depressive disorder NEC,Esophageal reflux,Diarrhea,Mental disor NEC oth dis
Admission Date:  [**2149-8-24**]              Discharge Date:   [**2149-8-28**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 7455**]
Chief Complaint:
Fever and hypoxemia

Major Surgical or Invasive Procedure:
None


History of Present Illness:
86 year old male resident of [**Hospital 599**] Nursing home sent to [**Hospital1 **] for
w/up of fever w/ tachycardia, tachypnea and hypoxemia.
.
Pt reportedly transferred from dementia unit of nursing home to
sub-acute unit on [**2149-8-23**] for IVF for 'dehydration' due to
decreased PO intake. In sub acute unit pt noted to be SOB w/
T=102.2, R=36, BP 130/70, P132, O2 sat 71% on 3L NC. At that
time pt was noted to be alert and verbally responsive but
confused.  Pt was transferred to [**Hospital1 **] on [**8-24**] for further eval.
Per daughter, pts mental status has deteriorated over the past
two weeks.  Pt previously spoke in understandable sentances
whereas now he mumbles largely incoherently.
.
In ED VS 102.4  HR 129  BP 112/88  RR 30 sat 71% on 2L.  pt was
placed on BiPap.  CXR w/ finding of RLL pneumonia - pt given
vanco/ceftriaxone.

Past Medical History:
PMHx:
dementia
hx TIA
depression
psychosis
GERD
htn
Lumbosacral surgery
Urological disorder, details unknown
Chronic Diarrhea

Social History:
Lives in nursing home ([**Hospital1 599**] of [**Last Name (un) **] [**Doctor Last Name **]), daughter, [**Name (NI) **]

[**Name (NI) 66676**], is HCP ([**Telephone/Fax (1) 66677**], C [**Telephone/Fax (1) 66678**]), no tobacco, no
EtOH

Family History:
Father with [**Name (NI) 2481**], Brother had a stroke

Physical Exam:
PE: (Upon MICU arrival)
T:99.9 BP:103/82 P:104  RR:22 O2 sat:99% on BiPAP
gen: pt mumbling incoherently, awake
HEENT: NC/AT
Chest: Basilar crackles
Heart: tachycardic, regular rhythm, no M/R/G
Abd: soft, NT/ND
Ext: moves all 4 extremities
Skin: warm, well perfused, decreased turgor
neuro: pt follows occasional commands, mumbles incoherently


Pertinent Results:
ED labs/imaging:
ABG on cpap 7.35/36/259/21
lactate 1.9
trop T .08
Na 146/ K 4.8/Cl 112/HCO3 22/BUN 77/Cr 2.0/glucose 122
wbc 3.3/ hgb 11.8/ hct 36.7/ plt 281, diff N 86/0 bands/L 10/M 4
.
UA: mod blood, tr protein, occ bact, <1 epi, otherwise nl
.
EKG: sinus tachycardia
.
CXR: [**2149-8-24**]:
FINDINGS: The heart is normal in size. The aorta is mildly
ectatic. Large infiltrate can be seen within the right lower
lobe. Aside from the left basilar atelectasis, the remaining
lungs appear clear. There is a probable small right pleural
effusion. There is no left pleural effusion. There is no
pneumothorax. There is evidence of spinal fusion of the lower
lumbar vertebral bodies. Multiple tiny clips project along the
lateral aspects of the lower thoracic spine.
IMPRESSION: Right lower lobe pneumonia and small right pleural
effusion
.

Brief Hospital Course:
86 yo male w/ fever, tachycardia, tachypnea and hypoxia presents
from nursing home w/ RLL pneumonia.
.
# RLL pneumonia: In ED patient hypoxic to 70s, put on bipap. He
was able to transition to facemask upon MICU arrival.  His
respiratory distress was likely secondary to pneumonia given
clinical picture of fever, tachypnea and hypoxemia in light of
CXR finding of RLL infiltrate.  Given that he lives in nursing
home and was hospitalized recently ([**7-28**] - [**7-29**]), and may also
be at risk for aspiration pneumonia, he was covered for broad
spectrum pathogens w/ vanco and unasyn.  Sputum cultures were
taken but contaminated.  Blood cultures showed no growth to
date.  He was transitioned to oxygen by nasal cannula.  He was
able to go to the medical floor on [**8-27**] and is currently on
oxygen at 2L/min.  His antibiotics were changed to oral
levofloxacin and metronidazole, to complete a 10 day course.
Possible aspiration worked up as below.
.
# Comfort care measures: per family, care directed towards
comfort is most appropriate at this time. They have seen
progressive decline over the last few weeks and patient has not
been taking in good PO. He is DNR/DNI/no procedures/no lines. He
will likely become do not hospitalize following his discharge
with involvement of hospice.  We stopped restraints, IV fluids,
lab draws, and some medications.  He can resume PO intake for
comfort.
.
# Dehydration: His family reported very poor PO intake during
the last few weeks.  He was given IV fluid boluses and
maintenance fluids. Due to concern of aspiration, he was kept
NPO; bedside swallow studies were performed but were inadequate.
 He was going to have a video swallow study; however he was too
lethargic at the time and, after discussion with the family
regarding goals of care, this was not reattempted.  He was
allowed to eat pureed diet and thickened liquids as tolerated as
part of his comfort care measures.
.
# Renal Insufficiency: His Cr 2.0 at admission, up from 1.3 at
d/c on [**7-29**].  This was likely prerenal given recent decreased PO
intake, tachycardia, clinical exam and chronic diarrhea. He was
given IV fluids as above.  This improved to his most recent
value of 1.3.
.
# HTN - He was hypertensive to SBP 180s beginning on [**8-25**] w/
moderate tachycardia to 120.  He was restarted on home altace at
5 and also started on metoprolol 50 TID as well due to
inadequate control on altace only. His blood pressures have
improved with this regimen.
.
# Chronic Diarrhea: Has had diarrhea for months to years and
takes loperamide chronically.  No abd pain. Culture and C.diff
were negative.  Loperamide was restarted for comfort.
.
# Hypernatermia: pt w/ hypernatremia on admission. This resolved
with IV fluids.
.
# Code status: DNR/DNI/no central access or procedures. Likely
will become hospice and do not hospitalize.

Medications on Admission:

MEDS on admission:
Namenda 5mg po BID
zyprexa 2.5mg po BID prn agitation
acetominophen 1000 po tid
altace 5mg po daily
lasix 20 mg po MWF
loperamide 2mg po BID
plavix 75 mg po daily
tramadol hcl 25 mg po tid

ALL: NKDA

Discharge Medications:
1. Ramipril 5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily):
hold for SBP<100.
2. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day).

3. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for agitation: may substitute Zydis dissolvable
tablet .
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): hold for SBP<100 and HR<60  .
5. Loperamide 2 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
6. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days.
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain or fever.
9. Morphine Concentrate 20 mg/mL Solution Sig: 2-4 mg PO Q2H
(every 2 hours) as needed for pain, dyspnea, or anxiety.
10. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
inhalation Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 599**] of [**Location (un) 55**]

Discharge Diagnosis:
Pneumonia
Hypoxemia
Poor PO intake
Dementia


Discharge Condition:
Stable, comfortable, on oxygen by nasal cannula


Discharge Instructions:
You were admitted with low oxygen levels and found to have a
pneumonia.  You needed to stay in the intensive care unit for a
few days to support your oxygen levels.  You are still getting
oxygen for comfort.
.
We discussed the goals of your care with your family.  We are in
agreement that the focus should be on making you comfortable.
If these goals change, please discuss this with your primary
care doctor, Dr. [**Last Name (STitle) **].
.
We have made the following medication changes: We have stopped
some of your medications, including Plavix, Namenda, and Lasix.
We have added sublingual morphine for pain control and comfort.
We added metoprolol for your blood pressure.  We have also added
2 antibiotics, Levofloxacin and Metronidazole, for the treatment
of your pneumonia.  You can also use nebulizer treatments for
trouble breathing or wheezing if needed.

Followup Instructions:
Please followup with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **],
if you have any questions about your health or your care.  Your
care providers will also be giving your family more information
and involvement with Hospice services.
{'Pneumonitis due to inhalation of food or vomitus,Dehydration,Chronic kidney disease, unspecified,Acute kidney failure, unspecified,Hypoxemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Depressive disorder, not elsewhere classified,Esophageal reflux,Diarrhea,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: Fever and hypoxemia

PRESENT ILLNESS: 86 year old male resident of [**Hospital 599**] Nursing home sent to [**Hospital1 **] for
w/up of fever w/ tachycardia, tachypnea and hypoxemia.
.
Pt reportedly transferred from dementia unit of nursing home to
sub-acute unit on [**2149-8-23**] for IVF for 'dehydration' due to
decreased PO intake. In sub acute unit pt noted to be SOB w/
T=102.2, R=36, BP 130/70, P132, O2 sat 71% on 3L NC. At that
time pt was noted to be alert and verbally responsive but
confused.  Pt was transferred to [**Hospital1 **] on [**8-24**] for further eval.
Per daughter, pts mental status has deteriorated over the past
two weeks.  Pt previously spoke in understandable sentances
whereas now he mumbles largely incoherently.
.
In ED VS 102.4  HR 129  BP 112/88  RR 30 sat 71% on 2L.  pt was
placed on BiPap.  CXR w/ finding of RLL pneumonia - pt given
vanco/ceftriaxone.

MEDICAL HISTORY: PMHx:
dementia
hx TIA
depression
psychosis
GERD
htn
Lumbosacral surgery
Urological disorder, details unknown
Chronic Diarrhea

MEDICATION ON ADMISSION: MEDS on admission:
Namenda 5mg po BID
zyprexa 2.5mg po BID prn agitation
acetominophen 1000 po tid
altace 5mg po daily
lasix 20 mg po MWF
loperamide 2mg po BID
plavix 75 mg po daily
tramadol hcl 25 mg po tid

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE: (Upon MICU arrival)
T:99.9 BP:103/82 P:104  RR:22 O2 sat:99% on BiPAP
gen: pt mumbling incoherently, awake
HEENT: NC/AT
Chest: Basilar crackles
Heart: tachycardic, regular rhythm, no M/R/G
Abd: soft, NT/ND
Ext: moves all 4 extremities
Skin: warm, well perfused, decreased turgor
neuro: pt follows occasional commands, mumbles incoherently

FAMILY HISTORY: Father with [**Name (NI) 2481**], Brother had a stroke

SOCIAL HISTORY: Lives in nursing home ([**Hospital1 599**] of [**Last Name (un) **] [**Doctor Last Name **]), daughter, [**Name (NI) **] 

### Response:
{'Pneumonitis due to inhalation of food or vomitus,Dehydration,Chronic kidney disease, unspecified,Acute kidney failure, unspecified,Hypoxemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Depressive disorder, not elsewhere classified,Esophageal reflux,Diarrhea,Other persistent mental disorders due to conditions classified elsewhere'}
