CHIEF COMPLAINT: shortness of breath

PRESENT ILLNESS: The patient is an 86 yoM w/ a h/o afib (on coumadin) sent in
from home to [**Hospital3 4107**] as his VNA was unable to pass a
foley.  He was found to be in afib w/ a rate of 140s and
shortness of breath.  While in the [**Hospital3 4107**] ER the
patient was given ceftriaxone and vancomycin.  He was given 20mg
IV diltiazem and his BP had dropped- given this a IJ CVL was
placed and the patient was started on neo.  He was given 500cc
IVF in [**Hospital3 **].  He was guaiac negative, INR was 2.6 and
he was given 1 dose of protonix given a history his family had
provided of 2 episodes of dark emesis earlier in the day.

MEDICAL HISTORY: COPD
Atrial fibrillation
Dementia- mild per patients PCP (poor short term memory)
CHF ([**8-5**] echo EF 50%, severe HK of inf/post wall, no
significant valvular disease)
CAD s/p MI ([**6-5**])
BPH (intermittent indwelling foley given bilateral hydro and
ARF, recently discontinued w/ a plan to undergo TURP)

MEDICATION ON ADMISSION: Colace 100mg [**Hospital1 **]
Flexeril 10mg daily
Lopressor 12.5 mg [**Hospital1 **]
Simvastatin 40 mg daily
Tums 1000 mg q 4hrs prn
Senna
Miralx
Dulcolax
Coumdadin 5-7 mg daily
Vit C
Zinc Sulftae
MVI

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals - T: 97.3 BP: 109/67 HR: 86 RR: 30 02 sat: 94% RA
GENERAL: Elderly male, hard of hearing, alert, NAD
HEENT: EOMI, MMM, OP without lesions
NECK: JVD is elevated
CARDIAC: Irregular rhythm, normal rate, soft heart sounds, no
murmurs, rubs or gallops appreciated
LUNG: [**Last Name (un) 7016**] chest, bibasilar crackles, decreased lung sounds
ABDOMEN: soft, nontender, nondistended, +BS, no masses or
organomegaly appreciated
GU: large, R sided, hard scrotal mass
EXT: WWP, without cyanosis or edema, minimal clubbing of fingers

FAMILY HISTORY: unknown

SOCIAL HISTORY: EtOH: denies
Cigarette: denies
Illicits: denies
Septicemia due to escherichia coli [E. coli],Acute respiratory failure,Septic shock,Urinary tract infection, site not specified,Intestinal infection due to Clostridium difficile,Chronic diastolic heart failure,Old myocardial infarction,Coronary atherosclerosis of native coronary artery,Other persistent mental disorders due to conditions classified elsewhere,Atrial fibrillation,Long-term (current) use of anticoagulants,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Hydrocele, unspecified,Anemia, unspecified,Severe sepsis
E coli septicemia,Acute respiratry failure,Septic shock,Urin tract infection NOS,Int inf clstrdium dfcile,Chr diastolic hrt fail,Old myocardial infarct,Crnry athrscl natve vssl,Mental disor NEC oth dis,Atrial fibrillation,Long-term use anticoagul,BPH w/o urinary obs/LUTS,Hydrocele NOS,Anemia NOS,Severe sepsis
Admission Date:  [**2147-12-26**]              Discharge Date:   [**2148-1-3**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 348**]
Chief Complaint:
shortness of breath

Major Surgical or Invasive Procedure:
Intubation
Flexiseal
Foley Catheter
Central Line


History of Present Illness:
The patient is an 86 yoM w/ a h/o afib (on coumadin) sent in
from home to [**Hospital3 4107**] as his VNA was unable to pass a
foley.  He was found to be in afib w/ a rate of 140s and
shortness of breath.  While in the [**Hospital3 4107**] ER the
patient was given ceftriaxone and vancomycin.  He was given 20mg
IV diltiazem and his BP had dropped- given this a IJ CVL was
placed and the patient was started on neo.  He was given 500cc
IVF in [**Hospital3 **].  He was guaiac negative, INR was 2.6 and
he was given 1 dose of protonix given a history his family had
provided of 2 episodes of dark emesis earlier in the day.

The patient was then transferred to the [**Hospital1 18**] ER- in the
ambulance he was given 40mg IV lasix.

In the ED, initial VS: T 103.9 (improved to 101.6 w/ tylenol),
HR 110, BP 102/60.  Prior to transport VS were T 101.6 HR 84, BP
112/72, 100% on AC 500 x 16, PEEP 5 and FiO2 50%.  He was given
nearly 2 liters of fliud.  He was also given 4.5g IV zosyn. The
patient was intubated for tachypnea,

Currently, the patient is intubated, sedated and unable to
answer history questions.


Past Medical History:
COPD
Atrial fibrillation
Dementia- mild per patients PCP (poor short term memory)
CHF ([**8-5**] echo EF 50%, severe HK of inf/post wall, no
significant valvular disease)
CAD s/p MI ([**6-5**])
BPH (intermittent indwelling foley given bilateral hydro and
ARF, recently discontinued w/ a plan to undergo TURP)

Social History:
EtOH: denies
Cigarette: denies
Illicits: denies


Family History:
unknown

Physical Exam:
Vitals - T: 97.3 BP: 109/67 HR: 86 RR: 30 02 sat: 94% RA
GENERAL: Elderly male, hard of hearing, alert, NAD
HEENT: EOMI, MMM, OP without lesions
NECK: JVD is elevated
CARDIAC: Irregular rhythm, normal rate, soft heart sounds, no
murmurs, rubs or gallops appreciated
LUNG: [**Last Name (un) 7016**] chest, bibasilar crackles, decreased lung sounds
ABDOMEN: soft, nontender, nondistended, +BS, no masses or
organomegaly appreciated
GU: large, R sided, hard scrotal mass
EXT: WWP, without cyanosis or edema, minimal clubbing of fingers

DERM: tinea cruris


Pertinent Results:
[**2147-12-26**] 09:05PM   GLUCOSE-129* UREA N-38* CREAT-1.3* SODIUM-138
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-23 ANION GAP-16
[**2147-12-26**] 09:05PM   ALT(SGPT)-19 AST(SGOT)-33 CK(CPK)-253* ALK
PHOS-73 TOT BILI-0.3
[**2147-12-26**] 09:37PM   TYPE-ART PO2-338* PCO2-37 PH-7.41 TOTAL
CO2-24 BASE XS-0
[**2147-12-26**] 09:05PM   CALCIUM-8.5 PHOSPHATE-2.6* MAGNESIUM-1.9
[**2147-12-26**] 09:05PM   WBC-17.3* RBC-3.47* HGB-10.5* HCT-32.1*
MCV-92 MCH-30.3 MCHC-32.8 RDW-14.2
[**2147-12-26**] 09:05PM   PT-29.5* PTT-36.0* INR(PT)-2.9*
[**2147-12-26**] 08:44PM URINE  BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2147-12-26**] 08:44PM URINE  RBC-[**3-1**]* WBC->50 BACTERIA-MOD YEAST-NONE
EPI-0 RENAL EPI-0-2
.
[**2147-12-26**] EKG Sinus rhythm. Right bundle-branch block. Left
anterior fascicular block. No previous tracing available for
comparison.
.
[**2147-12-26**] CXR: UPRIGHT AP VIEW OF THE CHEST: Low inspiratory lung
volumes and slight patient rotation somewhat limit assessment.
The cardiac silhouette is mildly enlarged. The aorta is
tortuous. Left internal jugular central venous catheter tip
terminates at the confluence of brachiocephalic veins. There are
increased interstitial markings diffusely, findings suggestive
of mild interstitial pulmonary edema. Blunting of the right
costophrenic sulcus also suggest an element of pleural effusion
on the right. There is no pneumothorax. Subtle right inferior
anterior rib deformities suggest prior fractures in these
regions. Degenerative changes of both glenohumeral joints are
noted.
IMPRESSION: Cardiomegaly with mild pulmonary edema. Small right
pleural
effusion.
.
[**2147-12-26**] Scrotal US: IMPRESSION: Large heterogeneous collection
seen with associated rim calcification within the right scrotum,
measuring up to 10.6 cm, with no definitive right testis
identified. This may be post-traumatic in etiology and represent
a chronic hematoma. Normal left testicle. Extensive scrotal
edema.
.
[**2147-12-26**] CT abd/pel: 1. Large 6.0 x 6.6 cm rim-calcified cystic
lesion within the right scrotal sac thought to be likely
post-traumatic in nature with associated compression of the
right testis. No subcutaneous air to suggest necrotizing
fasciitis. 2. Bladder collapsed about the Foley catheter with
suggestion of possible bladder wall thickening, and mild
bilateral hydroureter with mild thickening and enhancement of
the urothelium. Findings are compatible with the patient's
history of known urosepsis. Multiple small subcentimeter
hypodensities scattered throughout both kidneys, too small to
accurately characterize and may represent simple cysts, however,
abscesses are not excluded, particularly a small ill-defined
hypodensity within the interpolar region of the left kidney. No
associated striated nephrogram to suggest pyelonephritis. 8mm
right sided renal calculus. 4. Distended gallbladder with
associated pericholecystic fluid. Recommend ultrasound for
further evaluation to exclude cholecystitis. 5. Infrarenal
abdominal aorta aneurysm measuring up to 3.3 cm, and aneurysmal
dilatation of the bilateral common iliac arteries. 6.
Diverticulosis without evidence of diverticulitis.
.
[**2147-12-26**] RUQ US: IMPRESSION: Gallbladder wall distention with
sludge but no stones. Mild wall edema and trace pericholecystic
fluid. Findings could be consistent with cholecystitis in the
appropriate clinical setting.
.
[**2147-12-27**] ECHO: The left atrium is dilated. The estimated right
atrial pressure is 0-5 mmHg. The ascending aorta may be dilated
but is not well visualized. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
[**2147-12-28**] 8:25 am STOOL     **FINAL REPORT [**2147-12-28**]**
   CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2147-12-28**]):
      REPORTED BY PHONE TO [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], R.N. ON [**2147-12-28**] AT
2300.
      CLOSTRIDIUM DIFFICILE.
         FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
           (Reference Range-Negative).
         A positive result in a recently treated patient is of
uncertain
         significance unless the patient is currently
symptomatic
         (relapse).
.
[**2147-12-26**] 8:44 pm URINE     Site: CATHETER   **FINAL REPORT
[**2147-12-28**]**
   URINE CULTURE (Final [**2147-12-28**]):
      ESCHERICHIA COLI.    >100,000 ORGANISMS/ML..
         PRESUMPTIVE IDENTIFICATION.
                              SENSITIVITIES: MIC expressed in
MCG/ML
                      ESCHERICHIA COLI
                             |
AMPICILLIN------------  =>32 R
AMPICILLIN/SULBACTAM--    16 I
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN--------  <=16 S
PIPERACILLIN/TAZO-----     8 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----     2 S


Brief Hospital Course:
86M with h/o COPD, CHF, afib RVR on warfarin p/w urosepsis,
subsequently developed respirtory distress requiring intubation,
pressor support and MICU admission. He has since been
successfully extubation and weaned from pressors and is
hemodynamicaly stable. He is currently getting antibiotics for
urosepsis and C. difficile.
.
#. Sepsis: The patient was found to have E. Coli urinary tract
infection with positive blood cultures. He was started on IV
antibiotics including zosyn, which was changed to cefepime. He
received 5 days of zosyn and cefepime and then was changed to PO
cefpodoxime after comparing sensativities from [**Hospital3 **]
and [**Hospital1 18**]. He will receive a total of 14 days of antibiotics.
The patient originally required vasopressor support and
intubation in the ICU. His vasopressors were quickly weaned and
he was extubated without difficulty. He had a TTE which was
negative for valvular pathology. The patient remained afebrile
and was hemodynamically stable prior to discharge.
.
#. C. Difficile: The patient had multiple bowel movements with a
very elevated leukocytosis. A C. difficile stool toxin assay was
sent which returned positive. He was started on PO flagyl and
then changed to PO vancomycin because he was classified as
having severe C. difficile (not lack of response). His first
dose was on [**2147-12-27**]. He will receive 7 days after her stops
taking cefpodoxime (21 day course total). His WBC trended down
and number of bowel movements decreased as well.
.
#. Atrial Fibrillation with rapid ventricular response: The
patient likely had rapid ventricular rate secondary to his
infection. He was controlled with IVF and metoprolol. The
patient is currently on warfarin and metoprolol. His INR goal is
[**1-31**]. His dose of warfarin was increased to 4mg daily and will
need to be followed at the extended care facility and as an
outpatient. He was continued on metoprolol 12.5mg daily with
rates in the 70-90s.
.
#. Shortness of breath: The patient became short of breath in
the emergency department after receiving 2.5 liters of IV fluids
prior to presentation. He was tachypnic and short of breath
requiring intubation. He looked fluid overload on exam. He was
given IV lasix and diuresed well with improvement of his
respiratory status. He was extubated without difficulty. He has
COPD on baseline and had PRN duonebs. He was saturating well on
room air at discharge and had not received lasix in multiple
days with no evidence of fluid overload.
.
#. Scrotal mass: He has a calcified mass. It was evaluated by
urology who thinks it is most likely a calcified hydrocele. This
will need to be followed up as an outpatient.
.
#. BPH: The patient has an indwelling foley in place. It is
changed every thirty days. He will need to have a TURP in the
future. He will follow up with his urologist as an outpatient.
This will need to be changed every 30 days or as per his
urologist.
.
#. Anemia: No evidence of acute bleed but the patient was noted
to be guaiac positive, which may be related to his c. difficile
colitis. He was maintined on a PPI and had an active T+S at all
times. His hematocrit remained stable throughout his stay.
.


Medications on Admission:
Colace 100mg [**Hospital1 **]
Flexeril 10mg daily
Lopressor 12.5 mg [**Hospital1 **]
Simvastatin 40 mg daily
Tums 1000 mg q 4hrs prn
Senna
Miralx
Dulcolax
Coumdadin 5-7 mg daily
Vit C
Zinc Sulftae
MVI

Discharge Medications:
1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
2. Metoprolol Tartrate 25 mg Tablet Sig: [**12-30**] Tablet PO twice a
day.
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. Tums 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO
every four (4) hours as needed for indigestion.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
6. Miralax 17 gram Powder in Packet Sig: One (1)  PO once a day
as needed for constipation.
7. Vitamin C  Oral
8. Zinc Sulfate  Oral
9. Multivitamin  Oral
10. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO Once Daily at 4
PM.
11. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: [**12-30**]
Tablet, Delayed Release (E.C.)s PO once a day as needed for
constipation.
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**4-2**]
hours as needed for pain.
13. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO three
times a day as needed for knee pain.
14. Miconazole Nitrate 2 % Powder Sig: One (1)  Topical twice a
day for 14 days.
15. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours for 6 days: to end after [**2148-1-8**].
16. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO every six
(6) hours for 13 days: to end after [**2148-1-15**].


Discharge Disposition:
Extended Care

Facility:
Meadowbrook - [**Location (un) 2624**]

Discharge Diagnosis:
Primary Diagnosis:
1. Urinary sepsis
2. C. Difficile
3. Pulmonary edema
4. Atrial fibrillation
.
Secondary Diagnosis:
1. COPD
2. CAD
3. BPH
4. Dementia
5. Scrotal Mass


Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent


Discharge Instructions:
You were admitted with a bacterial infection of your bladder and
blood. You required intubation and blood pressure support. You
were started on antibiotics. You also had an infection of your
gut. You were given another antibiotic for that as well. You
tolerated these medications well and you improved significantly.
You will be discharged on oral antibiotics. You will also need
to follow up with your primary care physician and urologist as
an outpatient.
.
The following changes were made to your medications:
1. START Cefpodoxime 200mg by mouth every 12 hours for 8 days.
This is treating your blood and urinary tract infection.
2. START Vancomycin 125mg by mouth every 6 hours for 15 days.
This is treating the infection in your gut.
.
Please attend your follow up appointments as listed below. They
are important for your future health.

Followup Instructions:
MD: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
Specialty: PCP
[**Name Initial (PRE) 2897**]/ Time: [**Hospital3 **] INTERNAL MEDICINE ASSOCIATES, [**Street Address(2) 83561**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 9331**]
Location: Tuesday, [**1-16**] at 11:30am
Phone number: [**Telephone/Fax (1) 4475**]

You will need to see your urologist within 2 weeks.
{'Septicemia due to escherichia coli [E. coli],Acute respiratory failure,Septic shock,Urinary tract infection, site not specified,Intestinal infection due to Clostridium difficile,Chronic diastolic heart failure,Old myocardial infarction,Coronary atherosclerosis of native coronary artery,Other persistent mental disorders due to conditions classified elsewhere,Atrial fibrillation,Long-term (current) use of anticoagulants,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Hydrocele, unspecified,Anemia, unspecified,Severe sepsis'}


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 an 86 yoM w/ a h/o afib (on coumadin) sent in
from home to [**Hospital3 4107**] as his VNA was unable to pass a
foley.  He was found to be in afib w/ a rate of 140s and
shortness of breath.  While in the [**Hospital3 4107**] ER the
patient was given ceftriaxone and vancomycin.  He was given 20mg
IV diltiazem and his BP had dropped- given this a IJ CVL was
placed and the patient was started on neo.  He was given 500cc
IVF in [**Hospital3 **].  He was guaiac negative, INR was 2.6 and
he was given 1 dose of protonix given a history his family had
provided of 2 episodes of dark emesis earlier in the day.

MEDICAL HISTORY: COPD
Atrial fibrillation
Dementia- mild per patients PCP (poor short term memory)
CHF ([**8-5**] echo EF 50%, severe HK of inf/post wall, no
significant valvular disease)
CAD s/p MI ([**6-5**])
BPH (intermittent indwelling foley given bilateral hydro and
ARF, recently discontinued w/ a plan to undergo TURP)

MEDICATION ON ADMISSION: Colace 100mg [**Hospital1 **]
Flexeril 10mg daily
Lopressor 12.5 mg [**Hospital1 **]
Simvastatin 40 mg daily
Tums 1000 mg q 4hrs prn
Senna
Miralx
Dulcolax
Coumdadin 5-7 mg daily
Vit C
Zinc Sulftae
MVI

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals - T: 97.3 BP: 109/67 HR: 86 RR: 30 02 sat: 94% RA
GENERAL: Elderly male, hard of hearing, alert, NAD
HEENT: EOMI, MMM, OP without lesions
NECK: JVD is elevated
CARDIAC: Irregular rhythm, normal rate, soft heart sounds, no
murmurs, rubs or gallops appreciated
LUNG: [**Last Name (un) 7016**] chest, bibasilar crackles, decreased lung sounds
ABDOMEN: soft, nontender, nondistended, +BS, no masses or
organomegaly appreciated
GU: large, R sided, hard scrotal mass
EXT: WWP, without cyanosis or edema, minimal clubbing of fingers

FAMILY HISTORY: unknown

SOCIAL HISTORY: EtOH: denies
Cigarette: denies
Illicits: denies 

### Response:
{'Septicemia due to escherichia coli [E. coli],Acute respiratory failure,Septic shock,Urinary tract infection, site not specified,Intestinal infection due to Clostridium difficile,Chronic diastolic heart failure,Old myocardial infarction,Coronary atherosclerosis of native coronary artery,Other persistent mental disorders due to conditions classified elsewhere,Atrial fibrillation,Long-term (current) use of anticoagulants,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Hydrocele, unspecified,Anemia, unspecified,Severe sepsis'}
