CHIEF COMPLAINT: Shortness of Breath

PRESENT ILLNESS: The patient is a 58 year old female with a history of HTN and
tobacco use was presented to an OSH ED ([**Hospital3 51058**] ([**Telephone/Fax (1) 86711**]) from her PCPs office with hypotension in the 70s. The
patient is currently intubated, so most information was gained
from the medical records. She presented to her PCPs office with
complaints of 3 days of severe shortness of breath, cough,
congestion, and general malaise. Her symptoms [**Doctor Last Name **] also noted be
associate with subjetive fevers/chills, poor PO intake, and
loose stool. At the OSH ED, she was noted to be hypotensive
76/45, HR 103, T 99.4, satting 86% on RA. She was noted to have
new ARF with Cr to 4.5m Depsite receiving 2L. She was given a
dose of levofloxacin, placed on a NRB, and transfered to the
[**Hospital1 18**] for further manegement.
.
On arrival to the ED, patient's 92/40, HR 100, RR 24, satting
98% on 15L. She remained hypotensive throughout her ED course
with SBPs in the 70s and 80s, and was uptitrated on levo, neo,
and dopamine to maximal doses with continued hypotension. She
recieved an additional 7L of NS. She was given vancoymcyin and
clindamycin with concern of a PCN allergy. With continued
hypoxia with O2 sats to low 80s, she was intubated. No ABG or A
line oculd be placed. The patinet continued to have low O2 sats,
and had her FiO2 increased to 100%, PEEP increased to 15. She as
transfered to the floor for further care.
.
On arrival to the floor, an ABG was checked showing a gas of pH

MEDICAL HISTORY: Hypertension
Back pain (new since 3 days PTA)

MEDICATION ON ADMISSION: ASA prn headache
Benicar 20mg daily

ALLERGIES: Peanut / Penicillins / Cephalosporins

PHYSICAL EXAM: General Appearance: Intubated, unresponsive, critically ill
Eyes / Conjunctiva: Pupils dilated, unresponsive
Head, Ears, Nose, Throat: Endotracheal tube, OG tube
Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Diminished), (Left
radial pulse: Diminished), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Resonant : ), (Breath Sounds: Clear : )
Abdominal: Soft, Non-tender, No(t) Bowel sounds present,
Distended
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Skin:  Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed, Unresponive, sedated, paralyzed

FAMILY HISTORY: non contributory

SOCIAL HISTORY: The patient is married and has children. Smokes [**11-27**] PPD for many
years. No alcohol or drug use
Pneumococcal septicemia [Streptococcus pneumoniae septicemia],Septic shock,Acute kidney failure, unspecified,Acute respiratory failure,Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Severe sepsis,Unspecified essential hypertension,Anemia, unspecified,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction
Pneumococcal septicemia,Septic shock,Acute kidney failure NOS,Acute respiratry failure,Pneumococcal pneumonia,Severe sepsis,Hypertension NOS,Anemia NOS,Cholelithiasis NOS
Admission Date:  [**2179-12-15**]              Discharge Date:   [**2179-12-30**]

Date of Birth:  [**2120-12-29**]             Sex:   F

Service: MEDICINE

Allergies:
Peanut / Penicillins / Cephalosporins

Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Shortness of Breath

Major Surgical or Invasive Procedure:
Intubation
Central line placement


History of Present Illness:
The patient is a 58 year old female with a history of HTN and
tobacco use was presented to an OSH ED ([**Hospital3 51058**] ([**Telephone/Fax (1) 86711**]) from her PCPs office with hypotension in the 70s. The
patient is currently intubated, so most information was gained
from the medical records. She presented to her PCPs office with
complaints of 3 days of severe shortness of breath, cough,
congestion, and general malaise. Her symptoms [**Doctor Last Name **] also noted be
associate with subjetive fevers/chills, poor PO intake, and
loose stool. At the OSH ED, she was noted to be hypotensive
76/45, HR 103, T 99.4, satting 86% on RA. She was noted to have
new ARF with Cr to 4.5m Depsite receiving 2L. She was given a
dose of levofloxacin, placed on a NRB, and transfered to the
[**Hospital1 18**] for further manegement.
.
On arrival to the ED, patient's 92/40, HR 100, RR 24, satting
98% on 15L. She remained hypotensive throughout her ED course
with SBPs in the 70s and 80s, and was uptitrated on levo, neo,
and dopamine to maximal doses with continued hypotension. She
recieved an additional 7L of NS. She was given vancoymcyin and
clindamycin with concern of a PCN allergy. With continued
hypoxia with O2 sats to low 80s, she was intubated. No ABG or A
line oculd be placed. The patinet continued to have low O2 sats,
and had her FiO2 increased to 100%, PEEP increased to 15. She as
transfered to the floor for further care.
.
On arrival to the floor, an ABG was checked showing a gas of pH

6.91 pCO2 77 pO2 67 HCO3 17. 2 amps of HCO3 were given and a
HCO3 drip was started. Vasopressin was started. Her pressors
were weened over the course of her first hour, to low levels of
levophed and vasopressin. Her CVP was 15, and fluid
ressusitation was held. With high peak pressures and ? partial
right mainstem intubation, her ET tube was pulled back 1 cm. An
A line was placed, her PEEP increased from 15 to 20. With absent
bowel sounds on exam and marked leukocytosis with a history of
loose stool, flagyl was given. 4g of Ca were given for iCa of
0.7. Paralytics were started. She was placed on droplet
precautions and tamiflu was given. An A line was placed and
oxygention improved


Past Medical History:
Hypertension
Back pain (new since 3 days PTA)

Social History:
The patient is married and has children. Smokes [**11-27**] PPD for many
years. No alcohol or drug use

Family History:
non contributory

Physical Exam:
General Appearance: Intubated, unresponsive, critically ill
Eyes / Conjunctiva: Pupils dilated, unresponsive
Head, Ears, Nose, Throat: Endotracheal tube, OG tube
Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Diminished), (Left
radial pulse: Diminished), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Resonant : ), (Breath Sounds: Clear : )
Abdominal: Soft, Non-tender, No(t) Bowel sounds present,
Distended
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Skin:  Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed, Unresponive, sedated, paralyzed


Pertinent Results:
==================
  ADMISSION LABS
==================

[**2179-12-14**] 11:20PM BLOOD WBC-37.4* RBC-3.29* Hgb-10.1* Hct-30.2*
MCV-92 MCH-30.8 MCHC-33.6 RDW-14.3 Plt Ct-346
[**2179-12-14**] 11:20PM BLOOD Neuts-85* Bands-9* Lymphs-3* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-1*
[**2179-12-14**] 11:20PM BLOOD PT-12.2 PTT-31.3 INR(PT)-1.0
[**2179-12-14**] 11:20PM BLOOD Glucose-81 UreaN-90* Creat-2.8* Na-135
K-4.9 Cl-104 HCO3-16* AnGap-20
[**2179-12-16**] 04:01AM BLOOD Lipase-12
[**2179-12-14**] 11:20PM BLOOD Calcium-5.7* Phos-4.7* Mg-2.0
[**2179-12-16**] 04:01AM BLOOD Cortsol-38.0*
[**2179-12-15**] 03:26AM BLOOD Type-ART pO2-67* pCO2-77* pH-6.91*
calTCO2-17* Base XS--20
[**2179-12-14**] 11:44PM BLOOD Lactate-1.9
[**2179-12-15**] 03:26AM BLOOD O2 Sat-82
[**2179-12-15**] 03:59AM BLOOD freeCa-0.72*

=============
  RADIOLOGY
=============

CHEST X-RAY
CHEST, UPRIGHT PORTABLE AP VIEW: The right IJ catheter
terminates in the
right atrium. Diffuse airspace consolidation, most severely
involving the
right upper and lower lobes is concerning for pneumonia. Left
hilar
lymphadenopathy may be reactive, although an underlying mass
cannot be
excluded.
IMPRESSION:
1. Right IJ catheter terminating in right atrium.
2. Extensive bilateral airspace consolidation and left hilar
lymphadenopathy. As noted on the previous study, this should be
followed to resolution to exclude an underlying mass.

ECHO ([**2179-12-15**])
The estimated right atrial pressure is 10-20mmHg. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). There is a mild resting
left ventricular outflow tract obstruction. The aortic root is
mildly dilated at the sinus level. The aortic valve is not well
seen. There is no aortic valve stenosis. No aortic regurgitation
is seen. The mitral valve appears structurally normal with
trivial mitral regurgitation. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.

CT CHEST ([**2179-12-15**])
IMPRESSION:
1. Dense parenchymal multifocal airspace consolidation, most
compatible with multifocal pneumonia.
2. Distended gallbladder with small amount of pericholecystic
fluid and
gallbladder stone seen in the region of the neck. Mild
mesenteric stranding adjacent to gallbladder tip. Recommend
clinical correlation, and right upper quadrant ultrasound to
exclude possibility of cholecystitis.
3. No discrete fluid collections that would be concerning for
abscess
formation.
4. Mild wall thickening seen in several regions of the colon,
though is more likely secondary to collapsed bowel from
underdistension as no associated mesenteric stranding to suggest
active colitis.



Brief Hospital Course:
# Hypoxia/ARDS/Pneumonia:  The patient presented with 3 days of
fever, cough, SOB and congestion.  She presented to an OSH
hypoxic and hypotensive.  She was given levofloxacin, placed on
a NRB and transferred to [**Hospital1 18**].  IN the ED she continued to be
hypoxic to the low 80's and hypotensive requiring pressors
(levophed, neo, dopamine). She was intubated for respiratory
failure.  She was also given Vancomycin, clindamycin and
tamiflu.  She was transferred to the ICU for further management.
 The patient had a CXR that showed multifocal opacities and was
venilated based on ARDS protocol.  The patient's flu came back
negative from the State Lab and tamiflu was d/c.  However, blood
cultures from [**Hospital1 15331**] returned with S. pneumo (pan-sensitive)
and he was continued on meropenem/vancomycin.  The patient was
eventually narrowed to a 14 day course of levofloxacin.  The
sputum cultures have only grown yeast and all blood cultures
remained negative.  The patient was aggressively diuresed given
volume overload on a lasix gtt and eventually was able to be
extubated on [**12-25**].  Following extubation, patient did well with
oxygen via nasal canula. It was weaned as tolerated.  On
discharge, Mrs. [**Known lastname 86712**] was satting 95% on 2-3L by NC.
.
#Hypotension- On admission the patient was hypotensive and
required pressors including levophed, neo, and dopamine.  He
received approx 7L of IVF for hypotension.  In the ICU the
patient's pressors were able to be weaned to levophed and
vasopressin overnight.  The patient was able to be weaned off
levophed on [**12-18**], but remained on vasopressin intermittently
until [**12-25**] while being diuresed.  Aside from one episode of
hypotension while on lasix/ ambien, Mrs.[**Known lastname 86713**] blood
pressure was stable throughout the rest of the admission.
.
# Acute Renal Failure: At the OSH the patient's creatinine was
found to be 4.5.  On admission to [**Hospital1 18**] her creatinine was 2.0
and improved with IVF and blood pressure management.  It was
likely a combination of pre-renal leading to ATN.  The patient's
renal function improved and returned to baseline prior to
discharge
.
# Fevers: Patient with continued fevers throughout her course
likely from pan-sensitive strep pneumo bacteremia isolated at
the OSH hospital.  The patient was treated for pneumonia as
above with broad spectrum antibiotics.  Her urine cultures
remained negative and only growing yeast. Patient underwent RUQ
that showed some dilation of the CBD, but evaluated by surgery
who did not feel it was the cause of her fevers. She also
underwent MRI of the T/L/S spine that was negative for abscess.
She was continued on levofloxacin for a planned 14 day course.

.
# Nausea/Vomiting: Following extubation, Mrs. [**Known lastname 86712**] had
difficulty tolerating PO's.  She had several episodes of nausea
and vomiting.  She was evaluated by speech and swallow and there
was no evidence of aspiration.  The nausea and vomiting quickly
resolved on its own without further intervention.  On discharge
she was tolerating a regular diet.
.
# Weakness: Lower extremity weakness noted once patient
extubated and awake.  This was thought to be secondary to
deconditioning. Physical therapy was initiated and her weakness
was improving throughout her admission.  By discharge she was
ambulating with a walker though remains significantly
deconditioned.


Medications on Admission:
ASA prn headache
Benicar 20mg daily


Discharge Medications:
1. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*14 Patch 24 hr(s)* Refills:*2*
2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain: 12 hours on, 12 hours off.
Disp:*15 Adhesive Patch, Medicated(s)* Refills:*0*
3. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime). Tablet(s)
4. incentive spirometry  Sig: One (1)   use 10 times per hour:
when awake.
Disp:*1 1* Refills:*2*
5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**11-27**]  Inhalation q2hours as needed for shortness of breath or
wheezing.


Discharge Disposition:
Extended Care

Facility:
[**Hospital 86714**]Healthcare

Discharge Diagnosis:
Strep Pneumococcus Bacteremia, Pneumonia
Sepsis
ARDS


Discharge Condition:
Mental Status:Confused - sometimes
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)


Discharge Instructions:
You were diagnosed with a severe pneumonia.  You had a long
course in the ICU requiring intubation and completed a course of
antibiotics.  You will not need to take any antibiotics after
discharge.
.
When you came in you had very low blood pressure, thus we did
not give you your blood pressure medication while you were here.
 You should discuss this with your primary care physician before
restarting the medication.
.
You should continue to use your incentive spirometry 10 times
per hour while you are awake.  This will help with your
oxygenation.

Followup Instructions:
You will be discharged to a rehabilitation facility.

You should follow up with your primary care doctor 2-4 weeks
after discharge from the rehabilitation facility.



Completed by:[**2179-12-30**]
{'Pneumococcal septicemia [Streptococcus pneumoniae septicemia],Septic shock,Acute kidney failure, unspecified,Acute respiratory failure,Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Severe sepsis,Unspecified essential hypertension,Anemia, unspecified,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction'}


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: The patient is a 58 year old female with a history of HTN and
tobacco use was presented to an OSH ED ([**Hospital3 51058**] ([**Telephone/Fax (1) 86711**]) from her PCPs office with hypotension in the 70s. The
patient is currently intubated, so most information was gained
from the medical records. She presented to her PCPs office with
complaints of 3 days of severe shortness of breath, cough,
congestion, and general malaise. Her symptoms [**Doctor Last Name **] also noted be
associate with subjetive fevers/chills, poor PO intake, and
loose stool. At the OSH ED, she was noted to be hypotensive
76/45, HR 103, T 99.4, satting 86% on RA. She was noted to have
new ARF with Cr to 4.5m Depsite receiving 2L. She was given a
dose of levofloxacin, placed on a NRB, and transfered to the
[**Hospital1 18**] for further manegement.
.
On arrival to the ED, patient's 92/40, HR 100, RR 24, satting
98% on 15L. She remained hypotensive throughout her ED course
with SBPs in the 70s and 80s, and was uptitrated on levo, neo,
and dopamine to maximal doses with continued hypotension. She
recieved an additional 7L of NS. She was given vancoymcyin and
clindamycin with concern of a PCN allergy. With continued
hypoxia with O2 sats to low 80s, she was intubated. No ABG or A
line oculd be placed. The patinet continued to have low O2 sats,
and had her FiO2 increased to 100%, PEEP increased to 15. She as
transfered to the floor for further care.
.
On arrival to the floor, an ABG was checked showing a gas of pH

MEDICAL HISTORY: Hypertension
Back pain (new since 3 days PTA)

MEDICATION ON ADMISSION: ASA prn headache
Benicar 20mg daily

ALLERGIES: Peanut / Penicillins / Cephalosporins

PHYSICAL EXAM: General Appearance: Intubated, unresponsive, critically ill
Eyes / Conjunctiva: Pupils dilated, unresponsive
Head, Ears, Nose, Throat: Endotracheal tube, OG tube
Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Diminished), (Left
radial pulse: Diminished), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Resonant : ), (Breath Sounds: Clear : )
Abdominal: Soft, Non-tender, No(t) Bowel sounds present,
Distended
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Skin:  Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed, Unresponive, sedated, paralyzed

FAMILY HISTORY: non contributory

SOCIAL HISTORY: The patient is married and has children. Smokes [**11-27**] PPD for many
years. No alcohol or drug use 

### Response:
{'Pneumococcal septicemia [Streptococcus pneumoniae septicemia],Septic shock,Acute kidney failure, unspecified,Acute respiratory failure,Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Severe sepsis,Unspecified essential hypertension,Anemia, unspecified,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction'}
