CHIEF COMPLAINT: Shortness of breath and hypoxia

PRESENT ILLNESS: Mrs. [**Known lastname 54770**] is a [**Age over 90 **] year old female with a history of severe
COPD on home oxygen, diastolic heart failure, and kyphoscoliosis
who presents from rehab with hypoxia and shortness of breath.
She was discharged from this hospital on [**2195-12-30**] at which time
she was requiring 60% face mask high flow O2 to maintain oxygen
saturations of 88-90%.  She was initially discharged to [**Hospital1 **]
where she showed rapid improvement with antibiotics and after
one month was discharged to [**Hospital1 2436**] and finally to Admiral
[**Doctor Last Name **] nursing home on [**2196-2-24**].  At that time she was requiring
between 3-4 liters nasal canula to maintain saturations in the
high 80s to low 90s at rest.  The events of today are unclear.
She reports that she was trying to get to the dining [**Doctor Last Name **] and
had to walk around the facility.  This was significantly more
exercise than she typically gets.  She sat down and felt short
of breath.  She was wearing her oxygen at the time.  Her oxygen
saturations were noted to be in the 70s on 5L nasal canula.  She
was not experiencing any fevers, chills, cough, congestion,
lightheadedness, dizziness or chest pain.  She was experiencing
significant nasal congestion.  She received a nebulizer therapy
by EMS and by the time of arrival at [**Hospital1 18**] here oxygen
saturation was 96%.
.
In the ED, initial vs were: T: 97.7 BP: 120/50 P: 60 R: 20 O2
sat: 96% on nebulizer. She had a CXR which showed bilateral
pleural effusions and possible bilateral pneumonia although not
significantly changed from her previous films.  She received
ceftriaxone, azithromycin and levofloxacin.  She also received
nebulizers and solumedrol.  She had an EKG which showed atrial
fibrillation but no acute ST segment changes.  She was satting
in the mid 90s on 50% facemask.  She was admitted to the ICU for
further managemen.
.
Upon arrival to the ICU she reports that she feels well.  She is
hungry.  She denies fevers, chills, chest pain, shortness of
breath, nausea, vomiting, abdominal pain, dysuria, hematuria,
leg pain or swelling. She endorses nasal congestion but no cough
or sore throat.  She does not completely recall the events of
today.  All other review of systems negative in detail.

MEDICAL HISTORY: Diastolic Heart Failure
Atrial Fibrillation on coumadin
Remote h/o TIAs
COPD on home O2 (3-4L at baseline)
Scoliosis
Osteoarthritis
L hip/R pelvis fx managed nonoperatively
Recent LLE cellulitis
Anxiety
Chronic Anemia (baseline hct 32)

MEDICATION ON ADMISSION: Milk of Magnesia
Dulcolax
Fleets
Tylenol PRN
Acetazolamide 250 mg [**Hospital1 **]
Albuterol nebulizer TID
Ascorbic Acid 500 mg [**Hospital1 **]
BuSpar 10 mg daily
Celexa 40 mg daily
Lasix 120 mg [**Hospital1 **]
Ipratropium nebulizers TID
Lidocaine patch 1 patch daily
Toprol XL 50 mg daily
Multivitamin daily
Omeprazole 20 mg daily
Micro-K 20 mg daily
Senna
Coumadin 2.5 alternating with 3 mg daily
Colace
Lorazepam 0.25 mg PRN

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Physical Examination
Vitals: T: 97.1 BP: 123/63 P: 74 R: 18 O2: 96% on 10L
aerosolized mask
General: Alert, oriented, no acute distress, breathing
comfortably
HEENT: Sclera anicteric, MMM, oropharynx clear, nasal passages
with erythema and congestion
Neck: supple, JVP not elevated, no LAD
Lungs: Decreased breath sounds at bases, dull to percussion at
bases, expiratory wheezes heard throughout lung fields
CV: irregular, s1 + s2, 2/6 SEM at RUSB, no rubs or gallops
Abdomen:  soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, 1+
edema bilaterally

FAMILY HISTORY: Positive for hypertension and type II diabets.  Given age
non-contributory to current illness.

SOCIAL HISTORY: Lives at nursing home.  Ambulates with a walker at baseline.
Alert and oriented x 3 at baseline.  On home oxygen 3-4L.  Past
smoker but quit 30 years ago.  No ethanol or illict drugs.  Son
and daughter live nearby and are involved.
Obstructive chronic bronchitis with (acute) exacerbation,Acute and chronic respiratory failure,Acute on chronic diastolic heart failure,Unspecified pleural effusion,Long-term (current) use of anticoagulants,Scoliosis [and kyphoscoliosis], idiopathic,Iron deficiency anemia, unspecified,Dysthymic disorder
Obs chr bronc w(ac) exac,Acute & chronc resp fail,Ac on chr diast hrt fail,Pleural effusion NOS,Long-term use anticoagul,Idiopathic scoliosis,Iron defic anemia NOS,Dysthymic disorder
Admission Date:  [**2196-3-4**]              Discharge Date:   [**2196-3-9**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Shortness of breath and hypoxia

Major Surgical or Invasive Procedure:
None

History of Present Illness:
Mrs. [**Known lastname 54770**] is a [**Age over 90 **] year old female with a history of severe
COPD on home oxygen, diastolic heart failure, and kyphoscoliosis
who presents from rehab with hypoxia and shortness of breath.
She was discharged from this hospital on [**2195-12-30**] at which time
she was requiring 60% face mask high flow O2 to maintain oxygen
saturations of 88-90%.  She was initially discharged to [**Hospital1 **]
where she showed rapid improvement with antibiotics and after
one month was discharged to [**Hospital1 2436**] and finally to Admiral
[**Doctor Last Name **] nursing home on [**2196-2-24**].  At that time she was requiring
between 3-4 liters nasal canula to maintain saturations in the
high 80s to low 90s at rest.  The events of today are unclear.
She reports that she was trying to get to the dining [**Doctor Last Name **] and
had to walk around the facility.  This was significantly more
exercise than she typically gets.  She sat down and felt short
of breath.  She was wearing her oxygen at the time.  Her oxygen
saturations were noted to be in the 70s on 5L nasal canula.  She
was not experiencing any fevers, chills, cough, congestion,
lightheadedness, dizziness or chest pain.  She was experiencing
significant nasal congestion.  She received a nebulizer therapy
by EMS and by the time of arrival at [**Hospital1 18**] here oxygen
saturation was 96%.
.
In the ED, initial vs were: T: 97.7 BP: 120/50 P: 60 R: 20 O2
sat: 96% on nebulizer. She had a CXR which showed bilateral
pleural effusions and possible bilateral pneumonia although not
significantly changed from her previous films.  She received
ceftriaxone, azithromycin and levofloxacin.  She also received
nebulizers and solumedrol.  She had an EKG which showed atrial
fibrillation but no acute ST segment changes.  She was satting
in the mid 90s on 50% facemask.  She was admitted to the ICU for
further managemen.
.
Upon arrival to the ICU she reports that she feels well.  She is
hungry.  She denies fevers, chills, chest pain, shortness of
breath, nausea, vomiting, abdominal pain, dysuria, hematuria,
leg pain or swelling. She endorses nasal congestion but no cough
or sore throat.  She does not completely recall the events of
today.  All other review of systems negative in detail.


Past Medical History:
Diastolic Heart Failure
Atrial Fibrillation on coumadin
Remote h/o TIAs
COPD on home O2 (3-4L at baseline)
Scoliosis
Osteoarthritis
L hip/R pelvis fx managed nonoperatively
Recent LLE cellulitis
Anxiety
Chronic Anemia (baseline hct 32)

Social History:
Lives at nursing home.  Ambulates with a walker at baseline.
Alert and oriented x 3 at baseline.  On home oxygen 3-4L.  Past
smoker but quit 30 years ago.  No ethanol or illict drugs.  Son
and daughter live nearby and are involved.


Family History:
Positive for hypertension and type II diabets.  Given age
non-contributory to current illness.

Physical Exam:
Physical Examination
Vitals: T: 97.1 BP: 123/63 P: 74 R: 18 O2: 96% on 10L
aerosolized mask
General: Alert, oriented, no acute distress, breathing
comfortably
HEENT: Sclera anicteric, MMM, oropharynx clear, nasal passages
with erythema and congestion
Neck: supple, JVP not elevated, no LAD
Lungs: Decreased breath sounds at bases, dull to percussion at
bases, expiratory wheezes heard throughout lung fields
CV: irregular, s1 + s2, 2/6 SEM at RUSB, no rubs or gallops
Abdomen:  soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, 1+
edema bilaterally


Brief Hospital Course:
Assessment and Plan: Mrs. [**Known lastname 54770**] is a [**Age over 90 **] year old female with a
history of severe COPD on home oxygen, diastolic heart failure,
and kyphoscoliosis who presents from rehab with hypoxia and
shortness of breath.

Shortness of Breath/Hypoxia:  While in the ICU patient appeared
not particularly far from baseline. It was suspected that her
relative respiratory decompensation was due to a large component
of COPD exacerbation possibly from viral upper respiratory tract
infection.  Condition exacerbated by known bilateral effusions,
chronic RLL collapse and restrictive lung disease from
kyphoscoliosis.  Her CXR was difficult to interpret but was not
significantly changed from prior films.  She had no fevers,
chills, or leukocytosis.  She does not have increased sputum
production.  She has no signs and symptoms of cardiac ischemia.
She did not appear significantly volume overloaded on exam.
Patient given dose of levofloxacin and then antibiotics were
discontinued as bacterial infection was not believed to be
driving force behind symptoms. She was initiated on prednisone
60mg qd with standing alb/ipratropium nebs.  A BNP was done
which was 1655 which was acually below her baseline.  She was
quickly able to be called out to the floor.  Her respiratory
symptoms gradually improved and she was tapered to 40mg
prednisone on day of discharge with plan to continue slow taper
on discharge.  She was continued on her home dose of lasix. Her
home acetazolamide was discontinued due to concerns about
increasing C02 production in a pt with already low reserve from
COPD. Her 02 sats were in high 80s to mid 90s, even during walks
with PT and she was stable on her home dose of 3.5L NC 02.

Diastolic Heart Failure:  Most recent echocardiogram in [**2194**]
actually with hyperdynamic left ventricle and normal LV wall
thickeness.  She was continued on her home dose of lasix,
acetazolamide discontinued as above.

Atrial Fibrillation:  Chronic, on coumadin and beta blockers at
home. Her INR was supratherapeutic while hospitalized, her
coumadin was held until day of discharge, at which time it was
restarted at home doses for INR of 2.0.  Her heart rate was
increased in AF necessitating increase in her beta blockade with
good effect, stable BP.

Anxiety: Stable.
- continued celexa
- continued buspar
- continued PRN ativan

Anemia:  Chronic, normocytic to macrocytic.  At baseline.
- monitored hematocrit, was stable.  Iron deficient by labs,
discharged on iron.
- B12, folate WNL

Seen by speech language pathology due to concerns about coughing
with meals, was placed on a soft dysphagia diet with thin
liquids.

After PT eval and recommendation, pt discharged with stable
vital signs and baseline oxygenation to short term rehab.

Communication: [**Name (NI) **] (son/power of attorney)
[**Telephone/Fax (5) 81861**].  [**Doctor First Name **] (daughter)
[**Telephone/Fax (3) 81862**], [**Doctor First Name 1494**] (daughter): [**Telephone/Fax (1) 81863**].


Medications on Admission:
Milk of Magnesia
Dulcolax
Fleets
Tylenol PRN
Acetazolamide 250 mg [**Hospital1 **]
Albuterol nebulizer TID
Ascorbic Acid 500 mg [**Hospital1 **]
BuSpar 10 mg daily
Celexa 40 mg daily
Lasix 120 mg [**Hospital1 **]
Ipratropium nebulizers TID
Lidocaine patch 1 patch daily
Toprol XL 50 mg daily
Multivitamin daily
Omeprazole 20 mg daily
Micro-K 20 mg daily
Senna
Coumadin 2.5 alternating with 3 mg daily
Colace
Lorazepam 0.25 mg PRN

Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).
2. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q4H (every 4
hours).
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q2H (every 2
hours) as needed for shortness of breath or wheezing.
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Buspirone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

9. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
10. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q4H (every 4 hours).
14. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day): Hold for SBP <90.
15. Warfarin 2 mg Tablet Sig: 1.5 Tablets PO 3X/WEEK (TU,TH,SA).

16. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO 4X/WEEK
([**Doctor First Name **],MO,WE,FR): Adjust dose as needed for goal INR [**12-29**].
17. Prednisone 20 mg Tablet Sig: as directed Tablet PO DAILY
(Daily): STEROID TAPER:
Take 2 tablets daily for 5 days; then 1 tablet daily for 5 days;
then [**11-27**] tablet daily for 5 days, then stop. .
18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
19. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
20. Ferrous Gluconate 225 mg (27 mg Iron) Tablet Sig: One (1)
Tablet PO once a day: Do not take with maalox.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 2436**] Nursing Center - [**Hospital1 2436**]

Discharge Diagnosis:
COPD exacerbation
Iron deficiency anemia
Dysphagia

Secondary Diagnoses:
Diastolic Congestive Heart Failure
Depression


Discharge Condition:
Stable vital signs, maintaining baseline oxygenation of 88-93%
on 3.5L while ambulating, tolerating an oral diet.

Discharge Instructions:
You were admitted with difficulty breathing and low oxygen
levels.  You were not found to have any evidence of infection.
You were treated for an exacerbation of your COPD with steroids
and nebulizers. You will need to complete a slow taper of these
steroids.  You were found to have an iron deficiency anemia, you
should take iron pills for this, will stool softeners if need be
as this can cause constipation.
Your metoprolol for your atrial fibrillation was increased to
control your heart rate.
Your coumadin was held briefly for elevated levels and restarted
prior to discharge. You should continue to get regular blood
draws to check on these levels and adjust dosing as needed.
Please take all medications as prescribed. Please follow up with
your primary care physician [**First Name8 (NamePattern2) 335**] [**Last Name (NamePattern1) 5351**] after discharge.
Call your doctor or return to the emergency room if you
experience worsening shortness of breath not responsive to
nebulizer treatment, fevers, chills, dizziness or loss of
consciousness or for any other concerning symptoms.

Followup Instructions:
Call your PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 608**] for a follow up
appointment within 1-2 weeks of discharge.




Name:  [**Known lastname 13127**],[**Known firstname 3038**]                   Unit No:   [**Numeric Identifier 13128**]

Admission Date:  [**2196-3-4**]              Discharge Date:   [**2196-3-9**]

Date of Birth:  [**2102-4-9**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1981**]
Addendum:
Patient stayed in hospital one additional day due to loss of
rehab bed.  On day of discharge she had some dyspnea that
improved with nebulizers and her morning medications, including
beta blockers and low dose benzodiazapines. Her oxygenation
remained at baseline in low 90s on 3L.  Wheezing is less of a
component of her respiratory status and frequent albuterol use
may only be acting to drive up her HR and worsen her sense of
dyspnea.  She should utilize bronchodilators only on an as
needed basis.

Discharge Disposition:
Extended Care

Facility:
[**Hospital1 8750**] Nursing Center - [**Hospital1 8750**]

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1983**] MD [**MD Number(2) 1984**]

Completed by:[**2196-3-9**]
{'Obstructive chronic bronchitis with (acute) exacerbation,Acute and chronic respiratory failure,Acute on chronic diastolic heart failure,Unspecified pleural effusion,Long-term (current) use of anticoagulants,Scoliosis [and kyphoscoliosis], idiopathic,Iron deficiency anemia, unspecified,Dysthymic disorder'}


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 and hypoxia

PRESENT ILLNESS: Mrs. [**Known lastname 54770**] is a [**Age over 90 **] year old female with a history of severe
COPD on home oxygen, diastolic heart failure, and kyphoscoliosis
who presents from rehab with hypoxia and shortness of breath.
She was discharged from this hospital on [**2195-12-30**] at which time
she was requiring 60% face mask high flow O2 to maintain oxygen
saturations of 88-90%.  She was initially discharged to [**Hospital1 **]
where she showed rapid improvement with antibiotics and after
one month was discharged to [**Hospital1 2436**] and finally to Admiral
[**Doctor Last Name **] nursing home on [**2196-2-24**].  At that time she was requiring
between 3-4 liters nasal canula to maintain saturations in the
high 80s to low 90s at rest.  The events of today are unclear.
She reports that she was trying to get to the dining [**Doctor Last Name **] and
had to walk around the facility.  This was significantly more
exercise than she typically gets.  She sat down and felt short
of breath.  She was wearing her oxygen at the time.  Her oxygen
saturations were noted to be in the 70s on 5L nasal canula.  She
was not experiencing any fevers, chills, cough, congestion,
lightheadedness, dizziness or chest pain.  She was experiencing
significant nasal congestion.  She received a nebulizer therapy
by EMS and by the time of arrival at [**Hospital1 18**] here oxygen
saturation was 96%.
.
In the ED, initial vs were: T: 97.7 BP: 120/50 P: 60 R: 20 O2
sat: 96% on nebulizer. She had a CXR which showed bilateral
pleural effusions and possible bilateral pneumonia although not
significantly changed from her previous films.  She received
ceftriaxone, azithromycin and levofloxacin.  She also received
nebulizers and solumedrol.  She had an EKG which showed atrial
fibrillation but no acute ST segment changes.  She was satting
in the mid 90s on 50% facemask.  She was admitted to the ICU for
further managemen.
.
Upon arrival to the ICU she reports that she feels well.  She is
hungry.  She denies fevers, chills, chest pain, shortness of
breath, nausea, vomiting, abdominal pain, dysuria, hematuria,
leg pain or swelling. She endorses nasal congestion but no cough
or sore throat.  She does not completely recall the events of
today.  All other review of systems negative in detail.

MEDICAL HISTORY: Diastolic Heart Failure
Atrial Fibrillation on coumadin
Remote h/o TIAs
COPD on home O2 (3-4L at baseline)
Scoliosis
Osteoarthritis
L hip/R pelvis fx managed nonoperatively
Recent LLE cellulitis
Anxiety
Chronic Anemia (baseline hct 32)

MEDICATION ON ADMISSION: Milk of Magnesia
Dulcolax
Fleets
Tylenol PRN
Acetazolamide 250 mg [**Hospital1 **]
Albuterol nebulizer TID
Ascorbic Acid 500 mg [**Hospital1 **]
BuSpar 10 mg daily
Celexa 40 mg daily
Lasix 120 mg [**Hospital1 **]
Ipratropium nebulizers TID
Lidocaine patch 1 patch daily
Toprol XL 50 mg daily
Multivitamin daily
Omeprazole 20 mg daily
Micro-K 20 mg daily
Senna
Coumadin 2.5 alternating with 3 mg daily
Colace
Lorazepam 0.25 mg PRN

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Physical Examination
Vitals: T: 97.1 BP: 123/63 P: 74 R: 18 O2: 96% on 10L
aerosolized mask
General: Alert, oriented, no acute distress, breathing
comfortably
HEENT: Sclera anicteric, MMM, oropharynx clear, nasal passages
with erythema and congestion
Neck: supple, JVP not elevated, no LAD
Lungs: Decreased breath sounds at bases, dull to percussion at
bases, expiratory wheezes heard throughout lung fields
CV: irregular, s1 + s2, 2/6 SEM at RUSB, no rubs or gallops
Abdomen:  soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, 1+
edema bilaterally

FAMILY HISTORY: Positive for hypertension and type II diabets.  Given age
non-contributory to current illness.

SOCIAL HISTORY: Lives at nursing home.  Ambulates with a walker at baseline.
Alert and oriented x 3 at baseline.  On home oxygen 3-4L.  Past
smoker but quit 30 years ago.  No ethanol or illict drugs.  Son
and daughter live nearby and are involved. 

### Response:
{'Obstructive chronic bronchitis with (acute) exacerbation,Acute and chronic respiratory failure,Acute on chronic diastolic heart failure,Unspecified pleural effusion,Long-term (current) use of anticoagulants,Scoliosis [and kyphoscoliosis], idiopathic,Iron deficiency anemia, unspecified,Dysthymic disorder'}
