CHIEF COMPLAINT: Dyspnea, cough

PRESENT ILLNESS: HPI: Pt is an 84F with emphysema, CAD, cardiomyopathy who
presents with 3-4 days subacute dyspnea, mildly productive
cough, and low grade fever.  She felt otherwise well until two
days prior to admission when she developed cough, worsening SOB,
and wheezing over the course of the day.  Her cough was
productive of yellow phlegm.  She uses 2L 02 at home at night,
but had to increase it to 3L.  She also admitted to increased
fatigue, being unable to ambulate as well with her walker.
Additionally, she described low grade fever as well but never
took her temp.  She denied sinus congestion, CP,
nausea/vomitting, abd pain, leg pain or swelling, orthopnea,
travel or sick contacts.  At baseline, patient lives alone and
is able to carry out ADLs and IALDs.  She denies anginal pain or
lightheadedness with exertion.  She denies symptoms of chronic
bronchitis but says that she has been admitted to the hospital
with pneumonia 3 times in the last six months.
.
In the ED, T 99.9, HR 96, BP 117/53, RR 26, 92% 3L.  BP ranged
from 90-105 systolic, given 2L NS.  HR improved to 80s.  Pt
given Levofloxacin 750mg IV x1 as well as nebulizers.  High
lactate eventually normalized after 2L fluids.  EKG unchanged
from prior.
.
On arrival to the floor, pt immediately triggered for BP 82/palp
bilat, HR 80s, RR 26.  Pt asymtpomatic, denying dizziness, CP,
worsened SOB or bleeding from anywhere.  Brief exam was notable
for dry MM, relatively clear lungs with prolonged exp phase,
cough.  With 500ml NS, BP improved to 96/40.  Labs/EKG redrawn.

MEDICAL HISTORY: 1. Emphysema previously followed by Dr. [**First Name (STitle) 9464**] at [**Hospital1 3372**], now seen by Dr. [**Last Name (STitle) 575**]
2. Coronary artery disease status post MI [**22**] years ago. EF
30-35%
3. History of polio.
4. History of falls.
5. Hyperlipidemia.
6. Osteoporosis.
7. Ischemic cardiomyopathy (EF 40% in [**3-10**])

MEDICATION ON ADMISSION: ALBUTEROL 1 q 4-6 hours as needed
ALENDRONATE-VITAMIN D3 70 mg-2,800 unit Tablet once a week
CITALOPRAM 20 mg once a day
FLUTICASONE-SALMETEROL 250 mcg-50 mcg/Dose Disk 1 puff twice a
day
IPRATROPIUM-ALBUTEROL Nebulization inhaled four times a day as
needed
SIMVASTATIN 20 mg Tablet once a day in the evening
VALSARTAN 80 mg once a day
ASPIRIN 81 mg once a day
CALCIUM-CHOLECALCIFEROL (D3) [CALCIUM 600 + D] - 600-125 mg-unit

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Physical Exam:
VS: T 99.4, BP 94/54 (94-100/50-58), HR 87, RR 24, 93% 3L
GEN: awake and alert, pleasant, talking in short/mid sentences,
NAD, coughing intermittently throughout exam
HEENT: EOMI, anicteric sclera, MM dry, no pallor
Neck: supple, no LAD, could not find JVP
Heart: RRR, no m/r/g
Lungs: scattered wheeze/rhonci with prolonged exp phase,
symmetric, no focal crackles or rales
Abd: soft NT/ND + BS no rebound or guarding
Ext: warm, no pitting edema or calf swelling/tenderness
Skin: no rashes
Neuro: awake and alert, appropriate, CN II-XII intact

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: The patient does not smoke now, but smoked significantly quit 20
years ago.  Today she said she smoked 3 pks/day for 20+ years.
Denies etoh or illicits. Lives in [**Location **], originally from
South [**Country 480**].
Methicillin susceptible pneumonia due to Staphylococcus aureus,Unspecified septicemia,Acute respiratory failure,Sepsis,Obstructive chronic bronchitis with (acute) exacerbation,Systolic heart failure, unspecified,Candidiasis of mouth,Atrial fibrillation,Volume depletion, unspecified,Infection with microorganisms resistant to penicillins,Esophageal reflux,Other specified forms of chronic ischemic heart disease,Old myocardial infarction,Encounter for palliative care,Osteoporosis, unspecified,Other and unspecified hyperlipidemia,Depressive disorder, not elsewhere classified,Personal history of poliomyelitis,History of fall
Meth sus pneum d/t Staph,Septicemia NOS,Acute respiratry failure,Sepsis,Obs chr bronc w(ac) exac,Systolic hrt failure NOS,Thrush,Atrial fibrillation,Volume depletion NOS,Inf mcrg rstn pncllins,Esophageal reflux,Chr ischemic hrt dis NEC,Old myocardial infarct,Encountr palliative care,Osteoporosis NOS,Hyperlipidemia NEC/NOS,Depressive disorder NEC,Prsnl hst poliomyelitis,Personal history of fall
Name:  [**Known lastname 4539**],[**Known firstname 732**]                    Unit No:   [**Numeric Identifier 4540**]

Admission Date:  [**2111-6-23**]              Discharge Date:   [**2111-7-2**]

Date of Birth:  [**2027-1-5**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 4541**]
Addendum:
# Aspiration Risk:  The patient's pneumonia raised concern for
risk of aspiration.  The patient underwent a video swallow-study
which showed no evidence of aspiration, but did demonstrate
delayed pharyngeal/esophageal transitioning and GERD.  The
patient was cleared for a regular diet with thin liquids, but
she was encouraged to take chin-tucked and full effort swallows.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 609**] for the Aged - [**Location (un) 1409**]

                             [**First Name11 (Name Pattern1) 2868**] [**Last Name (NamePattern4) 2869**] MD [**MD Number(1) 2870**]

Completed by:[**2111-7-2**]

Admission Date:  [**2111-6-23**]              Discharge Date:   [**2111-7-2**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 710**]
Chief Complaint:
Dyspnea, cough

Major Surgical or Invasive Procedure:
None

History of Present Illness:
HPI: Pt is an 84F with emphysema, CAD, cardiomyopathy who
presents with 3-4 days subacute dyspnea, mildly productive
cough, and low grade fever.  She felt otherwise well until two
days prior to admission when she developed cough, worsening SOB,
and wheezing over the course of the day.  Her cough was
productive of yellow phlegm.  She uses 2L 02 at home at night,
but had to increase it to 3L.  She also admitted to increased
fatigue, being unable to ambulate as well with her walker.
Additionally, she described low grade fever as well but never
took her temp.  She denied sinus congestion, CP,
nausea/vomitting, abd pain, leg pain or swelling, orthopnea,
travel or sick contacts.  At baseline, patient lives alone and
is able to carry out ADLs and IALDs.  She denies anginal pain or
lightheadedness with exertion.  She denies symptoms of chronic
bronchitis but says that she has been admitted to the hospital
with pneumonia 3 times in the last six months.
.
In the ED, T 99.9, HR 96, BP 117/53, RR 26, 92% 3L.  BP ranged
from 90-105 systolic, given 2L NS.  HR improved to 80s.  Pt
given Levofloxacin 750mg IV x1 as well as nebulizers.  High
lactate eventually normalized after 2L fluids.  EKG unchanged
from prior.
.
On arrival to the floor, pt immediately triggered for BP 82/palp
bilat, HR 80s, RR 26.  Pt asymtpomatic, denying dizziness, CP,
worsened SOB or bleeding from anywhere.  Brief exam was notable
for dry MM, relatively clear lungs with prolonged exp phase,
cough.  With 500ml NS, BP improved to 96/40.  Labs/EKG redrawn.


Past Medical History:
1. Emphysema previously followed by Dr. [**First Name (STitle) 9464**] at [**Hospital1 3372**], now seen by Dr. [**Last Name (STitle) 575**]
2. Coronary artery disease status post MI [**22**] years ago. EF
30-35%
3. History of polio.
4. History of falls.
5. Hyperlipidemia.
6. Osteoporosis.
7. Ischemic cardiomyopathy (EF 40% in [**3-10**])

Social History:
The patient does not smoke now, but smoked significantly quit 20
years ago.  Today she said she smoked 3 pks/day for 20+ years.
Denies etoh or illicits. Lives in [**Location **], originally from
South [**Country 480**].

Family History:
Noncontributory

Physical Exam:
Physical Exam:
VS: T 99.4, BP 94/54 (94-100/50-58), HR 87, RR 24, 93% 3L
GEN: awake and alert, pleasant, talking in short/mid sentences,
NAD, coughing intermittently throughout exam
HEENT: EOMI, anicteric sclera, MM dry, no pallor
Neck: supple, no LAD, could not find JVP
Heart: RRR, no m/r/g
Lungs: scattered wheeze/rhonci with prolonged exp phase,
symmetric, no focal crackles or rales
Abd: soft NT/ND + BS no rebound or guarding
Ext: warm, no pitting edema or calf swelling/tenderness
Skin: no rashes
Neuro: awake and alert, appropriate, CN II-XII intact

Pertinent Results:
EKG: sinus rhythm, 85bpm, nl axis, Q in III, poor R wave
progression, unchanged from prior
..
CXR [**6-23**]: Normal cardiac size, hyperinflation unchanged.  Ill
definied bibasilar opacities unchanged from prior exam, cannot
exclude infectious processes.


Brief Hospital Course:
# HYPOXIA/COPD EXACERBATION AND MRSA ASPIRATION PNA:
Patient was admitted for worsening SOB, fevers, and productive
cough. CXR showed an infiltrate at RLL. She was started on
Levaquin for presumed community aquired pneumonia. There was
also concern that she may have aspirated given her recent speech
and swallow evaluation. Based on physical exam and CXR, she did
not seem significantly fluid overloaded although her EF is ~40%.
She denied any chest pain and cardiac enzymes were negative and
her EKG was unchanged so this was unlikely an acute cardiac
event. Pulmonary embolism was also on the differential but low
on the differential since the patient was ambulatory at home and
had no other risk factors.  Although d-dimer was elevated in the
MICU, LE dopplers were negative for DVT.
.
She was started on vancomycin for MRSA in sputum in addition to
the levaquin she was receiving for empiric treatment of CAP.
She received albuterol and ipratropium nebs at standing order
doses, and was also written for acetylcysteine and guaifenesin.
During the hospital course, her oxygen requirements increased
and she was transferred to the MICU briefly for BiPAP.  At time
of transfer back to the floors, she was satting in mid 90s on 6L
nasal cannula.  She was gradually weaned off of 02 until time of
discharge, at which time her O2 sats were stable on 3L NC O2
with sats of 92-94%. Given her history of emphysema, the goal
for her would be to keep her O2 sat between 90-92%, and not
higher as she would be at risk for CO2 retaining. Her home
baseline NC O2 prior to hospitalization was 2L NC O2 at night.
.
During her time in the MICU, patient was started on IV
solumedrol for treatment of possible COPD exacerbation.  It was
also during this time that her abx regimen was broadened to
include vancomycin in addition to levoquin.  She finished her 7
day course of vancomycin/levaquin by discharge and was
discharged on a slow prednisone taper of 8 days duration.  The
patient should recieve:
40mg x 2 days
30mg x 2 days
20mg x 2 days
10mg x 2 days.
.
# Oral Thrush: The patient reported a slight sore throat and had
some evidence of oral [**Female First Name (un) **], she was started on lidocaine and
nystatin swish and spit. The nystatin can be discontinued in [**4-8**]
days or as symptoms resolve.
.
# BLOOD PRESSURE CONTROL:
On admission, patient was hypotensive with SBP 100s. Her BP
improved with IVF boluses. Baseline BP per OMR records is
120-130s/80. She likely had early sepsis physiology and met SIRS
criteria on admission. She never required pressors during time
in the MICU.  At time of transfer back to floors her SBP is
100-120s with hypotension resolved.  Her antihypertensives were
held in the ICU but as her BP normalized, she was restarted on
lisinopril which was slowly titrated up to 10mg PO daily at
discharge.
.
# AF WITH RVR:
While in the MICU, patient had brief period of atrial
fibrillation that resolved with electrical cardioversion and
digoxin loading. The likely cause was critical illness, unlikely
to be permanent (PAF) but her ECHO was repeated showing systolic
ventricular function of 40%. The patient was started on digoxin
after a load to improve her cardiac function. She would also
likely benefit from anticoagulation treatment with coumadin,
which the patient is amenable to. The patient was started on
coumadin 5mg PO daily and should be continued on this with INR
monitoring with follow up with an [**Hospital3 **]/PCP for
coumadin adjusting.
.
# CAD:
Continued home ASA.
.
# DEPRESSION:
Continued home Celexa,
.
# HYPERLIPIDEMIA:
Continued simvastatin at home dose.
.
# ACCESS:
Midline was placed in the MICU.  PICC was placed when placed for
anticipated IV antibiotics. However, as patient finished her
antibiotic course in the hospital, PICC line was discontinued at
discharge.
.
#. CODE STATUS: The patient was initially admitted with wishes
to be DNR/DNI per discussion on the floor with the patient.
After the patient had her episode of respiratory distress
leading to transfer to the ICU, a family discussion was held
including the patient and her sons, which led to her code status
to be reversed to full code. The patient was never intubated in
the ICU. After transfer back to the floor, code status and goals
of care were readdressed and the patient wishes to continue as
full code at this time. FULL CODE.

Medications on Admission:
ALBUTEROL 1 q 4-6 hours as needed
ALENDRONATE-VITAMIN D3 70 mg-2,800 unit Tablet once a week
CITALOPRAM 20 mg once a day
FLUTICASONE-SALMETEROL 250 mcg-50 mcg/Dose Disk 1 puff twice a
day
IPRATROPIUM-ALBUTEROL Nebulization inhaled four times a day as
needed
SIMVASTATIN 20 mg Tablet once a day in the evening
VALSARTAN 80 mg once a day
ASPIRIN 81 mg once a day
CALCIUM-CHOLECALCIFEROL (D3) [CALCIUM 600 + D] - 600-125 mg-unit

three times a day
ECHINACEA Dosage uncertain


Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours).
2. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO q6
hours:PRN as needed for cough.
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours).
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. Senna 8.6 mg Tablet Sig: Four (4) Tablet PO BID (2 times a
day) as needed.
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
7. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscellaneous Q6H (every 6 hours) as needed.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).

10. Lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane
TID (3 times a day) as needed.
11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Warfarin 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)): Dose to be adjusted per lab results.  Goal INR
[**1-4**].
13. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
14. Prednisone 10 mg Tablet Sig: 1-4 Tablets PO once a day for 8
days: Please give 40mg for 2 days then 30 mg for 2 days then
20mg for 2 days then 10mg for 2 days then stop.  Total of 8 days
of treatment.
15. Outpatient Lab Work
Please draw PT/PTT/INR on [**7-3**]. Adjust coumadin and repete labs
accordingly.

Please send results to Dr. [**First Name8 (NamePattern2) 712**] [**Name (STitle) 713**] MD
#[**Telephone/Fax (1) 716**]
16. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.



Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]

Discharge Diagnosis:
Community Acuired Pneumonia
COPD Exacerbation
Atrial fibrillation
Systolic Heart Failure
Oral Thrush


Discharge Condition:
The patient was hemodynamically stable, afebrile and without
pain.  She was comfortable with O2 sat of 92-94% on 3L NC.

Discharge Instructions:
You were admitted for shortness of breath which was felt to be
due to pneumonia.  You were started on antibiotics for your
infection and you have completed a 7 day course of antibiotics
or this infection.  Because of your emphysema, you were also
treated with steroids.  You will need to continue these steroids
for several more days.  You will need follow-up with Dr.
[**Last Name (STitle) 575**] from Pulmonology.  You will be contact[**Name (NI) **] regarding an
appointment in the next few weeks.

During your hospitalization you were found to have an irregular
heart rate which required electrical cardioversion and the
addition of new medication, Digoxin.  You will need to continue
this medication and to have lab values of the medication
monitored.  We have also started a medication called Coumadin.
This medication is used to thins your blood and prevents blood
clots and stroke in case your heart rate becomes irregular
again.  The dose of this medication may change overtime and your
blood will need to be closely monitored while you are on this
medication.

Studies of your heart showed that your heart does not pump as
effectively as it should.  In order to prevent damage to your
heart and to help control your blood pressure, we have started
you on a medication called Lisinopril.  You should take this
medication daily as directed.

You began to experience a sore throat and hoarse voice and this
appears to be due to a yeast infection in your mouth.  We have
started you on Nystatin, an antifungal medication which you will
need to use as a mouth rinse several times a day for the next
week.  You should also have your dentures cleaned.

You are being discharged into the care of [**Hospital1 100**] Rehabilition
Center.  Please alert your doctor if you develop worsening
shortness of breath, chest pain, change in cough or sputum,
fevers, chills, nausea, vomiting or any other symtom of concern.

Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2111-7-21**]
2:00.

Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2111-11-13**] 11:30

Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2111-11-13**] 11:30



Completed by:[**2111-7-2**]
{'Methicillin susceptible pneumonia due to Staphylococcus aureus,Unspecified septicemia,Acute respiratory failure,Sepsis,Obstructive chronic bronchitis with (acute) exacerbation,Systolic heart failure, unspecified,Candidiasis of mouth,Atrial fibrillation,Volume depletion, unspecified,Infection with microorganisms resistant to penicillins,Esophageal reflux,Other specified forms of chronic ischemic heart disease,Old myocardial infarction,Encounter for palliative care,Osteoporosis, unspecified,Other and unspecified hyperlipidemia,Depressive disorder, not elsewhere classified,Personal history of poliomyelitis,History of fall'}


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: Dyspnea, cough

PRESENT ILLNESS: HPI: Pt is an 84F with emphysema, CAD, cardiomyopathy who
presents with 3-4 days subacute dyspnea, mildly productive
cough, and low grade fever.  She felt otherwise well until two
days prior to admission when she developed cough, worsening SOB,
and wheezing over the course of the day.  Her cough was
productive of yellow phlegm.  She uses 2L 02 at home at night,
but had to increase it to 3L.  She also admitted to increased
fatigue, being unable to ambulate as well with her walker.
Additionally, she described low grade fever as well but never
took her temp.  She denied sinus congestion, CP,
nausea/vomitting, abd pain, leg pain or swelling, orthopnea,
travel or sick contacts.  At baseline, patient lives alone and
is able to carry out ADLs and IALDs.  She denies anginal pain or
lightheadedness with exertion.  She denies symptoms of chronic
bronchitis but says that she has been admitted to the hospital
with pneumonia 3 times in the last six months.
.
In the ED, T 99.9, HR 96, BP 117/53, RR 26, 92% 3L.  BP ranged
from 90-105 systolic, given 2L NS.  HR improved to 80s.  Pt
given Levofloxacin 750mg IV x1 as well as nebulizers.  High
lactate eventually normalized after 2L fluids.  EKG unchanged
from prior.
.
On arrival to the floor, pt immediately triggered for BP 82/palp
bilat, HR 80s, RR 26.  Pt asymtpomatic, denying dizziness, CP,
worsened SOB or bleeding from anywhere.  Brief exam was notable
for dry MM, relatively clear lungs with prolonged exp phase,
cough.  With 500ml NS, BP improved to 96/40.  Labs/EKG redrawn.

MEDICAL HISTORY: 1. Emphysema previously followed by Dr. [**First Name (STitle) 9464**] at [**Hospital1 3372**], now seen by Dr. [**Last Name (STitle) 575**]
2. Coronary artery disease status post MI [**22**] years ago. EF
30-35%
3. History of polio.
4. History of falls.
5. Hyperlipidemia.
6. Osteoporosis.
7. Ischemic cardiomyopathy (EF 40% in [**3-10**])

MEDICATION ON ADMISSION: ALBUTEROL 1 q 4-6 hours as needed
ALENDRONATE-VITAMIN D3 70 mg-2,800 unit Tablet once a week
CITALOPRAM 20 mg once a day
FLUTICASONE-SALMETEROL 250 mcg-50 mcg/Dose Disk 1 puff twice a
day
IPRATROPIUM-ALBUTEROL Nebulization inhaled four times a day as
needed
SIMVASTATIN 20 mg Tablet once a day in the evening
VALSARTAN 80 mg once a day
ASPIRIN 81 mg once a day
CALCIUM-CHOLECALCIFEROL (D3) [CALCIUM 600 + D] - 600-125 mg-unit

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Physical Exam:
VS: T 99.4, BP 94/54 (94-100/50-58), HR 87, RR 24, 93% 3L
GEN: awake and alert, pleasant, talking in short/mid sentences,
NAD, coughing intermittently throughout exam
HEENT: EOMI, anicteric sclera, MM dry, no pallor
Neck: supple, no LAD, could not find JVP
Heart: RRR, no m/r/g
Lungs: scattered wheeze/rhonci with prolonged exp phase,
symmetric, no focal crackles or rales
Abd: soft NT/ND + BS no rebound or guarding
Ext: warm, no pitting edema or calf swelling/tenderness
Skin: no rashes
Neuro: awake and alert, appropriate, CN II-XII intact

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: The patient does not smoke now, but smoked significantly quit 20
years ago.  Today she said she smoked 3 pks/day for 20+ years.
Denies etoh or illicits. Lives in [**Location **], originally from
South [**Country 480**]. 

### Response:
{'Methicillin susceptible pneumonia due to Staphylococcus aureus,Unspecified septicemia,Acute respiratory failure,Sepsis,Obstructive chronic bronchitis with (acute) exacerbation,Systolic heart failure, unspecified,Candidiasis of mouth,Atrial fibrillation,Volume depletion, unspecified,Infection with microorganisms resistant to penicillins,Esophageal reflux,Other specified forms of chronic ischemic heart disease,Old myocardial infarction,Encounter for palliative care,Osteoporosis, unspecified,Other and unspecified hyperlipidemia,Depressive disorder, not elsewhere classified,Personal history of poliomyelitis,History of fall'}
