CHIEF COMPLAINT: Initially admitted for complaints of
shortness of breath.

PRESENT ILLNESS: This is a 72 year old female
with a history of chronic obstructive pulmonary disease,
hypertension, hyperlipidemia; strong tobacco history; now
being evaluated for increased shortness of breath and dyspnea
on exertion.  The patient reports usual state of health until
one day prior to admission when she developed increased
shortness of breath and wheezing, dyspnea on exertion.  She
reports increased productive cough.  Shortness of breath not
worse when supine. Increased nasal congestion.  No headaches,
no fevers, chills, nausea and vomiting.  Denies chest pain,
palpitations, lower extremity edema.  No paroxysmal nocturnal
dyspnea. No orthopnea. No immediate sick contacts.  The
patient does attend a community center with elderly
individuals and some have had colds.  She denies any weight
gain, bowel or urinary changes, no abdominal pain.

MEDICAL HISTORY: 1.) Chronic obstructive pulmonary
disease. Intubated once.  No home oxygen.  The patient
reports severe dyspnea at baseline.  2.) Hypertension.  3.)
Hyperlipidemia.  4.) Status post total abdominal hysterectomy
in [**2079**].  5.) Status post hernia repair in [**2081**].  6.)
Irritable bowel syndrome.  7.) Questionable diastolic
dysfunction.  8.) Borderline pulmonary hypertension.

MEDICATION ON ADMISSION: lopressor 100 mg three times a day.
Captopril 12.5 mg three times a day.
Lipitor 20 mg q.o.d.
Procardia 30 mg q. day.
Albuterol prn.
Atrovent prn.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: She lives alone at the [**Location (un) 4398**].  She
reports 80 pack year of tobacco.  She is still smoking at the
time of admission.  She denies any alcohol or intravenous
drug abuse.
Obstructive chronic bronchitis with (acute) exacerbation,Subendocardial infarction, initial episode of care,Pneumonitis due to inhalation of food or vomitus,Acute diastolic heart failure,Acute respiratory failure,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia
Obs chr bronc w(ac) exac,Subendo infarct, initial,Food/vomit pneumonitis,Ac diastolic hrt failure,Acute respiratry failure,Crnry athrscl natve vssl,Hyperlipidemia NEC/NOS
Admission Date:  [**2118-2-6**]       Discharge Date:  [**2118-2-16**]

Date of Birth:                    Sex:

Service:

CHIEF COMPLAINT:  Initially admitted for complaints of
shortness of breath.

HISTORY OF PRESENT ILLNESS:  This is a 72 year old female
with a history of chronic obstructive pulmonary disease,
hypertension, hyperlipidemia; strong tobacco history; now
being evaluated for increased shortness of breath and dyspnea
on exertion.  The patient reports usual state of health until
one day prior to admission when she developed increased
shortness of breath and wheezing, dyspnea on exertion.  She
reports increased productive cough.  Shortness of breath not
worse when supine. Increased nasal congestion.  No headaches,
no fevers, chills, nausea and vomiting.  Denies chest pain,
palpitations, lower extremity edema.  No paroxysmal nocturnal
dyspnea. No orthopnea. No immediate sick contacts.  The
patient does attend a community center with elderly
individuals and some have had colds.  She denies any weight
gain, bowel or urinary changes, no abdominal pain.

She arrived in the Emergency Room where chest x-ray revealed
mild congestive heart failure.  She was found to be afebrile.
Hemodynamically stable with oxygen saturations in the low
90's on room air.  97% on four liters.  The patient denies
any home oxygen at baseline. The patient received intravenous
Solu-Medrol, nebs and reported symptomatic improvement in her
shortness of breath and wheezing.

PAST MEDICAL HISTORY:  1.) Chronic obstructive pulmonary
disease. Intubated once.  No home oxygen.  The patient
reports severe dyspnea at baseline.  2.) Hypertension.  3.)
Hyperlipidemia.  4.) Status post total abdominal hysterectomy
in [**2079**].  5.) Status post hernia repair in [**2081**].  6.)
Irritable bowel syndrome.  7.) Questionable diastolic
dysfunction.  8.) Borderline pulmonary hypertension.

ALLERGIES:  No known drug allergies.

MEDICATIONS ON ADMISSION:
lopressor 100 mg three times a day.
Captopril 12.5 mg three times a day.
Lipitor 20 mg q.o.d.
Procardia 30 mg q. day.
Albuterol prn.
Atrovent prn.

SOCIAL HISTORY:  She lives alone at the [**Location (un) 4398**].  She
reports 80 pack year of tobacco.  She is still smoking at the
time of admission.  She denies any alcohol or intravenous
drug abuse.

PHYSICAL EXAMINATION:  On admission, she is afebrile at 98;
blood pressure 124/70; pulse 88; 16 respiratory rate; 97% on
four liters.  In general, she is an elderly female, sitting
on the bed, legs dangling.  Pleasant. HEAD, EYES, EARS, NOSE
AND THROAT:  Significant for dry mucous membranes but no
jugular venous distention appreciated. Cardiovascular is
significant for faint heart sounds, S1 and S2 audible.
Pulmonary shows scattered wheezing, rhonchi. Abdominal
examination:  Obese, mildly distended, positive bowel sounds,
nontender.  Extremities showed no edema.

LABORATORY DATA:  White count of 6.5; hematocrit of 49;
platelets 129.  Chemistry 7 is remarkable.  Chest x-ray
showed mild congestive heart failure, no infiltrates.  Echo
from [**11-19**] shows ejection fraction of 70% and impaired
relaxation; borderline pulmonary hypertension; mild 1+ aortic
insufficiency; 1+ mitral regurgitation.  She had a stress
test in [**2114**] which showed mixed arteriosclerotic disease and
irreversible inferior apical perfusion defect.  Ejection
fraction was 67%.  Her electrocardiogram from admission
showed sinus rhythm at 75 beats per minute; normal axis;
borderline left atrial abnormality; normal intervals; no
signs of ischemia.

HOSPITAL COURSE:   1.) Cardiovascular:  The patient came in
for presumed chronic obstructive pulmonary disease
exacerbation without any cardiac symptoms.  Of note, she had
cardiac risk factors of tobacco, hypertension,
hyperlipidemia.  On hospital day number two, the patient
reports several episodes of chest pain, resolving with
nitroglycerin.  These episodes continued to persist, however,
and electrocardiogram showed evidence of ST depression in
lateral leads, V4 through V6.  It was felt at this point,
that the patient had unstable angina. Cardiology was
consulted.  The patient was started on heparin drip and was
transferred to the cardiac floor for nitroglycerin drip.  The
patient had difficulty in terms of somewhat low blood
pressures and difficulty titrating up beta blocker and ace
inhibitor.

The patient went to the cardiac  catheterization laboratory
on hospital day number three. Catheterization at that time
showed a complex, eccentric 90% lesion in her left anterior
descending, level of D-1. She underwent subsequent left
anterior descending stent successfully.  In addition, she had
a 60% proximal lesion in her left circumflex, in the region
of the obtuse marginal one and total occlusion of the left
circumflex after obtuse marginal two.  Fortunately, stent was
not able to be placed in this diseased left circumflex;
rather, she did receive percutaneous angioplasty via balloon.
It was thought that the left circumflex would not be a good
candidate for stenting, due to the fact that it was an
extremely long lesion and a very small caliber vessel.
Following procedure, she did have bumps in her CK's and
Troponins.  CK's were trending down after several days.  She
was continued on aspirin and started on Plavix and had her
Lipitor dose increased.  Overall, the patient did report
improvement in her chest pressure; however, further along in
her hospital course, she was still complaining of jaw and
tongue numbness, which was thought to be somewhat of an
anginal equivalent.  For this reason, cardiology was
reconsulted.

At this time, they recommended basic medical management of
her symptoms.  The patient's Lipitor dose was increased to 40
mg q. day.  She was continued on aspirin and Plavix. She was
started on low dose beta blockade and calcium channel
blockade as possible ways to improve rate control and
possible causes of ischemia.  She was maintained on a low
dose ace inhibitor as her pressures hovered in the high 90's,
low 100's.  It was felt at this time that the patient does
have coronary artery disease but, at this point, medical
management appears to be the best option as her catheter
report showed limited ability to intervene on small caliber
vessels.

As the patient's respiratory status declined, it was
sometimes unclear as whether the patient was in heart failure
versus severe chronic obstructive pulmonary disease
exacerbation.  She was diuresed with Lasix and responded with
excellent urinary output.  She ended up having a follow-up
transthoracic echocardiogram on [**2-9**], showing an ejection
fraction of greater than 55% with normal left atrium and mild
left ventricular hypertrophy with focal HK of her basilar
inferior wall.  Otherwise, from a cardiovascular standpoint,
the patient remained persistently tachycardiac during her
hospital course into the low 90's and low 100's.  This was
somewhat difficult to control, given the patient's need for
nebulizers, possibly clouding the picture.  Per cardiology
recommendations, low dose beta blockade was started, as well
as calcium channel blocker so as not to worsen her chronic
obstructive pulmonary disease exacerbation. These could be
considered to changing to longer acting preparations once her
doses are stabilized.

2.) Pulmonary:  The patient was initially admitted with a
chronic obstructive pulmonary disease exacerbation and
initially treated with intravenous Solu-Medrol and Levaquin.
Of note, the patient denies home oxygen prior to her
admission, although she admits to relatively poor functional
status, reporting severe dyspnea on exertion with minimal
amounts of activity.  By hospital day number two, the
patient's respiratory status showed signs of worsening.  This
was confounded by the fact of her unstable angina and, at
times, it was difficult to ascertain whether the patient was
in congestive heart failure versus chronic obstructive
pulmonary disease exacerbation.  As mentioned above, the
patient had been diuresed with small amounts of Lasix with
excellent urinary output.

Following her cardiac catheterization, however, the patient's
respiratory status continued to decline.  Arterial blood
gases at that time showed pH of 7.42, PC02 of 44 and P02 of
50.  At this time, the patient became increasingly hypoxic
despite increased oxygen supply and was found to be becoming
increasingly lethargic.  Chest x-ray at that point had shown
a left lower lobe infiltrate and the patient was transferred
to the Medical Intensive Care Unit for worsening respiratory
status.  The patient was not intubated but was trialed on
Bi-Pap which she did not tolerate very well.  However, she
was able to be weaned off bi-pap onto face mask.

At this point, the patient was continued on her intravenous
Solu-Medrol.  She was continued on aggressive nebs and was
switched from Bactrim as initial choice for chronic
obstructive pulmonary disease exacerbation as the initial
antibiotic to Levaquin.  By hospital day number six, the
patient's respiratory status had improved.  She had been
switched to p.o. Prednisone taper and was continued on
Levaquin.  At this point, she was transferred to the floor.
There was initial concern that the patient had a left sided
pleural effusion; however, interventional pulmonary performed
an ultrasound at the bedside which revealed minimal amounts
of fluid.  Follow-up CT scan on the next day showed
predominance in the posterior aspects of her lung, with no
evidence of any pleural effusions.  Also of note, were
multiple small nodules in the right lung base, in particular
at the periphery.

The patient's respiratory status continued to improve slowly
during the remainder of her time on the hospital [**Hospital1 **].  She
was continued on Levaquin and switched to a Prednisone taper
and was transitioned from Albuterol and Atrovent nebs to
Albuterol and Atrovent inhalers.  Meanwhile, her oxygen
requirements decreased at the time of discharge and she was
now on four liters of oxygen.  Pulmonary was consulted for
further
assistance and the management of her severe hypoxia and
severe and tenuous respiratory status.  They recommended
completing a 14 day course of Levaquin and also adding Flagyl
for increased anaerobic coverage, given the very large size
of her infiltrate on CT scan.  As well, they recommended
continuing a Prednisone taper which will be weaned off in the
next two weeks and having close pulmonary follow-up with Dr.
[**Last Name (STitle) **] in several weeks for repeat chest x-ray, pulmonary
function test and possible repeat CT later on to assess her
pulmonary nodules.

At this point, it is felt that the patient has severe chronic
obstructive pulmonary disease, probably from prior to her
admission.  It is felt that she will likely require home
oxygen.  At this point, plans are being arranged for her to
go to pulmonary rehabilitation with close pulmonary follow-up
as mentioned above.

3.) Gastrointestinal:  The patient was maintained on a PPI as
prophylaxis for her longstanding steroid taper.

4.) Infectious disease:  As described above, the patient was
admitted for chronic obstructive pulmonary disease
exacerbation and was later found to have large left lower
lobe infiltrate. The patient will be completing a 14 day
course of Levaquin and Flagyl was added on [**2-15**] which
also will be finished at the time of the Levaquin. It is
hoped that this addition of Flagyl with add additional
antibiotic coverage for this large infiltrate. The patient
remained afebrile with stable vital signs during her hospital
course.

5.)  Renal:  The patient's electrolytes and left renal
function remained stable during her hospital course.

6.)  Endocrinology:  The patient was maintained on sliding
scale insulin for her Prednisone.  She was also started on
Calcium and Vitamin D as prophylaxis for a long steroid
taper.  The patient is probably at risk for osteoporosis
given her strong tobacco history and probably decreased
activity at baseline.

7.) Disposition:  At this point, the patient remains full
code.  She is likely to be transferred to pulmonary
rehabilitation.

DISCHARGE DIAGNOSES:
Severe chronic obstructive pulmonary disease exacerbation/
left lower lobe pneumonia, improving.
Coronary artery disease with unstable angina; questionable
non Q wave myocardial infarction.
Status post left anterior descending stent and percutaneous
transluminal coronary angioplasty to left circumflex artery.

DISCHARGE MEDICATIONS:
Vitamin D 400 mg q. day.
Calcium carbonate 500 mg three times a day.
Tylenol prn.
Senna prn.
Colace 100 mg twice a day.
Aspirin 325 mg q. day.
Nitroglycerin sublingual prn.
Folic acid q. day.
Plavix 75 mg q. day times nine months.
Protonic 40 mg q. day.
Metoprolol 12.5 mg twice a day.
Diltiazem 30 mg four times a day (This may be changed to long
acting once the dose is stabilized).
Lipitor 40 mg q. day.
Lisinopril 2.5 mg q day.
Combivent inhaler, two puffs q. six hours.
Flovent two puffs twice a day.
Levaquin 500 mg q. day for an additional eight days, to
complete on [**2117-2-25**].
Flagyl 500 mg three times a day for an additional nine days,
to complete on [**2117-2-25**].
Prednisone taper, to be completed 40/30/20/10, to complete on
[**3-2**].

She will be discharged to pulmonary rehabilitation and the
name will be dictated at a later date.  She will need close
follow-up with pulmonary, Dr. [**Last Name (STitle) **].


                     DR.[**Last Name (STitle) 5538**],[**First Name3 (LF) **] 11-965

[**First Name3 (LF) 5538**]  31-565

Dictated By:[**Last Name (NamePattern1) 5539**]
MEDQUIST36

D:  [**2118-2-15**]  06:50
T:  [**2118-2-15**]  19:12
JOB#:  [**Job Number 5540**]
{'Obstructive chronic bronchitis with (acute) exacerbation,Subendocardial infarction, initial episode of care,Pneumonitis due to inhalation of food or vomitus,Acute diastolic heart failure,Acute respiratory failure,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia'}


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: Initially admitted for complaints of
shortness of breath.

PRESENT ILLNESS: This is a 72 year old female
with a history of chronic obstructive pulmonary disease,
hypertension, hyperlipidemia; strong tobacco history; now
being evaluated for increased shortness of breath and dyspnea
on exertion.  The patient reports usual state of health until
one day prior to admission when she developed increased
shortness of breath and wheezing, dyspnea on exertion.  She
reports increased productive cough.  Shortness of breath not
worse when supine. Increased nasal congestion.  No headaches,
no fevers, chills, nausea and vomiting.  Denies chest pain,
palpitations, lower extremity edema.  No paroxysmal nocturnal
dyspnea. No orthopnea. No immediate sick contacts.  The
patient does attend a community center with elderly
individuals and some have had colds.  She denies any weight
gain, bowel or urinary changes, no abdominal pain.

MEDICAL HISTORY: 1.) Chronic obstructive pulmonary
disease. Intubated once.  No home oxygen.  The patient
reports severe dyspnea at baseline.  2.) Hypertension.  3.)
Hyperlipidemia.  4.) Status post total abdominal hysterectomy
in [**2079**].  5.) Status post hernia repair in [**2081**].  6.)
Irritable bowel syndrome.  7.) Questionable diastolic
dysfunction.  8.) Borderline pulmonary hypertension.

MEDICATION ON ADMISSION: lopressor 100 mg three times a day.
Captopril 12.5 mg three times a day.
Lipitor 20 mg q.o.d.
Procardia 30 mg q. day.
Albuterol prn.
Atrovent prn.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: She lives alone at the [**Location (un) 4398**].  She
reports 80 pack year of tobacco.  She is still smoking at the
time of admission.  She denies any alcohol or intravenous
drug abuse. 

### Response:
{'Obstructive chronic bronchitis with (acute) exacerbation,Subendocardial infarction, initial episode of care,Pneumonitis due to inhalation of food or vomitus,Acute diastolic heart failure,Acute respiratory failure,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia'}
