CHIEF COMPLAINT: dysnpnea

PRESENT ILLNESS: Mr. [**Known lastname **] is an 84yo man with h/o CAD, diastolic CHF c EF
55%, COPD on home O2 at 2LNC, and recent strep pneumo pna
requiring intubation (5d) one month ago, discharged to home from
[**Hospital **] rehab 1 week ago with new diagnosis of Cdiff now s/p
14d po vanco/flagyl. Yesterday he noted increased dyspnea and
his visiting nurse [**First Name (Titles) 33166**] [**Last Name (Titles) **] crackles. He seemed weak per his
daughter, and continued to have diarrhea.  Last night his edema
(usually trace only) and breathing began worsening and he had
increased lethargy and decreased mentation today, for which he
was brought by EMS to an OSH.
.
At [**Hospital3 1443**], ABG was 7.18/65/163 for which he was put
on bipap - repeat ABG was 7.26/60/444. He was treated for COPD
exacerbation with 125mg IV solumedrol, nebs, and was given 80mg
IV lasix x 1 after his BNP returned as 35,000 to which he put
out only 100cc, and was transferred to the [**Hospital1 18**].  On arrival
here his SBP was in the 70s-80 (per daughter his baseline is
high 80s-90s since last year).  He continued on bipap with O2
sats in the 90s. Femoral line was placed and he was initially
started on dopamine drip however this caused tachycardia and
drip was stopped before transfer to ICU with SBP remaining in
the 80s. He was given a dose of levoflox, despite CXR negative
for infiltrate (also no sign of pulmonary edema, but did show
underlying COPD and bronchiectasis). EKG was reportedly
unremarkable.  Repeat BNP here was pending at the time of
admission.
.
He denies having had CP, N/V/diaphoresis, dizziness, dysuria, or
any other symptoms besides shortness of breath and weakness as
above. No cough, no fever or chills.
.
ROS: currently states breathing feels better than earlier today,
no cp, abd pain, n/v.

MEDICAL HISTORY: - HTN, however per daughter no longer, and now hypotensive
- diastolic CHF with EF 55%
- hypercholesterolemia;
- CAD s/p IMI in [**2182**]
- TIA/aphasia [**10-2**]; s/p L CEA [**2-1**]
- COPD (FEV1 1.57 per [**7-2**] PFTs, ratio 82% due to poor
effort,but tracing appeared obstructive per report);  on home
2LNC O2
- BPH s/p TURP [**6-1**];
- balanitis s/p circumcision [**6-1**];
- remote nephrolithiasis;
- former tobacco use (80 pack/year Hx),
- S. pneumoniae pneumonia [**4-8**], intubated for hypercarbia
- C diff diagnosed [**5-9**]

MEDICATION ON ADMISSION: Aspirin 81 mg po qday
Atorvastatin 10 mg po DAILY
Fluticasone-Salmeterol 500-50 mcg inhale twice a day.
Furosemide 40 mg po DAILY
Lorazepam 0.5 mg twice a day
pepcid 20mg po qday
Prednisone 10 mg PO DAILY
Tiotropium 18 mcg Capsule, Inhalation DAILY
Florasta 250mg po bid
questran packet [**Hospital1 **]
finished 2w course of po vanco and flagyl yesterday

ALLERGIES: Beta-Adrenergic Blocking Agents

PHYSICAL EXAM: VS 96.4,  100,  86/47,  31,  95% on noninvasive bipap 15/8 at
FiO2 0.35
Gen: responds with hand gestures and nods to questions, wearing
bipap mask, uses abdominal muscles for exhalation
HEENT: Pupils small but minimally reactive
Neck: JVP mildly distended at 10cm
Cor: very decreased heart sounds, s1s2, no murmur
Pulm: R base with rales, Left lung clear
Abd: soft, NT, ND, +bs
Ext: [**3-5**]+ pitting edema bilateral LE to just below knees
Neuro: moves all four, responds to commands
Skin: obvious bruises and thin, fragile skin throughout
GU: concentrated brown/[**Location (un) 2452**] urine in foley

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: Before admission in [**Month (only) 958**] had lived alone with wife. For last
week since d/c from [**Hospital **] rehab he and wife have been living
iwth daughter, who is a nurse here at [**Hospital1 18**]. 80 pack years of
smoking, quit 5 years ago.
Other specified septicemias,Septic shock,Methicillin susceptible pneumonia due to Staphylococcus aureus,Acute respiratory failure,Aspergillosis,Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity,Other pulmonary embolism and infarction,Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Intestinal infection due to Clostridium difficile,Severe sepsis,Infection with microorganisms resistant to penicillins,Atrial fibrillation,Chronic airway obstruction, not elsewhere classified,Coronary atherosclerosis of unspecified type of vessel, native or graft,Unspecified essential hypertension,Hypotension, unspecified,Other chronic pulmonary heart diseases,Pure hypercholesterolemia,Hyperpotassemia,Anemia, unspecified,Leukocytosis, unspecified,Other dependence on machines, supplemental oxygen
Septicemia NEC,Septic shock,Meth sus pneum d/t Staph,Acute respiratry failure,Aspergillosis,Ac DVT/embl low ext NOS,Pulm embol/infarct NEC,Ac on chr diast hrt fail,Acute kidney failure NOS,Int inf clstrdium dfcile,Severe sepsis,Inf mcrg rstn pncllins,Atrial fibrillation,Chr airway obstruct NEC,Cor ath unsp vsl ntv/gft,Hypertension NOS,Hypotension NOS,Chr pulmon heart dis NEC,Pure hypercholesterolem,Hyperpotassemia,Anemia NOS,Leukocytosis NOS,Depend-supplement oxygen
Admission Date:  [**2197-5-27**]              Discharge Date:   [**2197-6-8**]


Service: CARDIOTHORACIC

Allergies:
Beta-Adrenergic Blocking Agents

Attending:[**First Name3 (LF) 492**]
Chief Complaint:
dysnpnea

Major Surgical or Invasive Procedure:
endotracheal intubation, thrombectomy, IVC filter placement,
central venous catheter placement

History of Present Illness:
Mr. [**Known lastname **] is an 84yo man with h/o CAD, diastolic CHF c EF
55%, COPD on home O2 at 2LNC, and recent strep pneumo pna
requiring intubation (5d) one month ago, discharged to home from
[**Hospital **] rehab 1 week ago with new diagnosis of Cdiff now s/p
14d po vanco/flagyl. Yesterday he noted increased dyspnea and
his visiting nurse [**First Name (Titles) 33166**] [**Last Name (Titles) **] crackles. He seemed weak per his
daughter, and continued to have diarrhea.  Last night his edema
(usually trace only) and breathing began worsening and he had
increased lethargy and decreased mentation today, for which he
was brought by EMS to an OSH.
.
At [**Hospital3 1443**], ABG was 7.18/65/163 for which he was put
on bipap - repeat ABG was 7.26/60/444. He was treated for COPD
exacerbation with 125mg IV solumedrol, nebs, and was given 80mg
IV lasix x 1 after his BNP returned as 35,000 to which he put
out only 100cc, and was transferred to the [**Hospital1 18**].  On arrival
here his SBP was in the 70s-80 (per daughter his baseline is
high 80s-90s since last year).  He continued on bipap with O2
sats in the 90s. Femoral line was placed and he was initially
started on dopamine drip however this caused tachycardia and
drip was stopped before transfer to ICU with SBP remaining in
the 80s. He was given a dose of levoflox, despite CXR negative
for infiltrate (also no sign of pulmonary edema, but did show
underlying COPD and bronchiectasis). EKG was reportedly
unremarkable.  Repeat BNP here was pending at the time of
admission.
.
He denies having had CP, N/V/diaphoresis, dizziness, dysuria, or
any other symptoms besides shortness of breath and weakness as
above. No cough, no fever or chills.
.
ROS: currently states breathing feels better than earlier today,
no cp, abd pain, n/v.


Past Medical History:
- HTN, however per daughter no longer, and now hypotensive
- diastolic CHF with EF 55%
- hypercholesterolemia;
- CAD s/p IMI in [**2182**]
- TIA/aphasia [**10-2**]; s/p L CEA [**2-1**]
- COPD (FEV1 1.57 per [**7-2**] PFTs, ratio 82% due to poor
effort,but tracing appeared obstructive per report);  on home
2LNC O2
- BPH s/p TURP [**6-1**];
- balanitis s/p circumcision [**6-1**];
- remote nephrolithiasis;
- former tobacco use (80 pack/year Hx),
- S. pneumoniae pneumonia [**4-8**], intubated for hypercarbia
- C diff diagnosed [**5-9**]

Social History:
Before admission in [**Month (only) 958**] had lived alone with wife. For last
week since d/c from [**Hospital **] rehab he and wife have been living
iwth daughter, who is a nurse here at [**Hospital1 18**]. 80 pack years of
smoking, quit 5 years ago.

Family History:
noncontributory

Physical Exam:
VS 96.4,  100,  86/47,  31,  95% on noninvasive bipap 15/8 at
FiO2 0.35
Gen: responds with hand gestures and nods to questions, wearing
bipap mask, uses abdominal muscles for exhalation
HEENT: Pupils small but minimally reactive
Neck: JVP mildly distended at 10cm
Cor: very decreased heart sounds, s1s2, no murmur
Pulm: R base with rales, Left lung clear
Abd: soft, NT, ND, +bs
Ext: [**3-5**]+ pitting edema bilateral LE to just below knees
Neuro: moves all four, responds to commands
Skin: obvious bruises and thin, fragile skin throughout
GU: concentrated brown/[**Location (un) 2452**] urine in foley


Pertinent Results:
WBC-21.1* RBC-4.58* HGB-13.7* HCT-42.4 MCV-93 MCH-30.0 MCHC-32.4
RDW-15.4
PLT COUNT-285
  - NEUTS-96.7* BANDS-0 LYMPHS-1.5* MONOS-1.5* EOS-0.1 BASOS-0.1
GLUCOSE-177* UREA N-38* CREAT-1.3* SODIUM-141 POTASSIUM-5.4*
CHLORIDE-105 TOTAL CO2-27  CALCIUM-8.8 PHOSPHATE-6.0*#
MAGNESIUM-1.9
CK(CPK)-19* ->17, cTropnT-0.03* ->0.03
proBNP-[**Numeric Identifier 33167**]*
PT-15.0* PTT-46.0* INR(PT)-1.3*

CXR: linear and tubular opacities and ring shadows R>L base
consistent with chronic bronchiectasis and scarring from COPD.
No new opacity, no significant pleural effusion or edema, but
prominent pulmonary arteries suggesting possible pulm artery
hypertension.
.
EKG: unclear baseline in ER. repeat on floor: afib at 83, poor R
wave progression, old Q in II, III, F, new TWI v1-4. Low
voltage. No STE.
.
echo [**2-6**]: The left atrium is elongated. There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%). The right ventricular free wall
is hypertrophied. The right ventricular cavity is dilated. There
is mild global right ventricular free wall hypokinesis. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. The mitral valve leaflets are mildly
thickened. No mitral regurgitation is seen. The left ventricular
inflow pattern suggests impaired relaxation.


Brief Hospital Course:
A/P: 84yo man with h/o CAD, diastolic CHF, COPD, recent strep
pna pneumonia s/p intubation and C diff colitis presented
acutely with respiratory failure, right heart failure from
massive PE, extensive LE DVT, new afib who developed MRSA
pneumonia and aspergilus. Given his lack of improvement in
respiration without mechanical ventilation or ability to
maintain blood pressure without pressors his family made the
decision to change goals of care to comfort. He passed away
comfortably with his family at the bedside shortly after.

1. Respiratory failure: This was due to massive PE with high
dead space fraction of 92. Fatigued so required intubation to
support ventilation. Initially requiring high minute-ventilation
(AC 700x32) because of high dead space fraction, tolerating high
rates despite COPD. Echocardiogram with RV strain on [**5-28**]. No
clear source of hypercoagulability such as known malignancy or
prolonged immobility. Unable to perform CTA due to hemodynamic
instability and anuric renal failure. He underwent lysis with
tPA on [**5-28**], without any bleeding complications and had
improvement in hemodynamics transiently. He then went for
catheter directed thrombectomy on [**5-29**], and was found to have
right-upper and left-lower main [**MD Number(3) 33168**] that were extracted
with Angiojet. These clots were thought to have been
embolizstion from lysis of larger main PA clot. LENI's were + so
had retractable ivc filter placed by IR [**5-30**]. He made only
minimal improvement in his respiratory failure, and developed
subsequent MRSA pneumonia, treated initially with vancomycin
then linezolid. He also had aspergilus in his BAL so was started
on voriconazole. Despite these measures he was not able to
tolerate even a pressure support mode of ventilation due to his
persistent high minute ventilation requirement.

2 Fever/Infection: Developed [**5-31**] despite tylenol, associated
with increased pressor requirement, difficulty with ventialation
(had to increase MV), CO2 increased and pH decreased. Suspected
nosocomial infection (MRSA VAP), UA + but culture just yeast,
repeat cx after foley change neg. His CVC was changed [**6-4**]
despite all negative blood cultures. His RUQ US showed gall
stone with gallbladder distension, but subsequent ultrasounds
showed improvement in this and the wall edema was attributed to
anasarca. His lungs were ultrasounded twice to look for pleural
effusions for thoracentesis but there was not enough fluid
present to sample. CT scan of head, torso showed only source of
infection likely was a RUL cavitation which was treated with
linezolid for mrsa and voriconazole for aspergilus. He was also
treated with zosyn empirically and po vanco given recent history
of c.diff colitis, despite negative c.diff toxin x3. ID was
consulted to exhaust all potential sources of infection. Amylase
and lipase were sampled periodically to assess for pancreatitis
but were normal.

3 Hypotension: Pt became markedly hypotensive peri-intubation
required maximizing levophed and addition of Neosynephrine.
Bedside echocardiogram with markedly dilated RV with hypokinesis
and +[**Last Name (un) 13367**] sign. Blood pressure and pressor requirement
transiently improved with systemic lysis but had another
deterioration on [**5-29**] in AM. Cardiology completed thrombectomy
on [**5-29**] with some improvement in hemodynamics. Neosynephrine
weaned [**Date range (1) 33169**]. However, worsening pressor requirement [**5-31**]
thought related to infection/sepsis. He remained on levophed and
vasopressin for hemodynamic support throughout his course. IVF
resuscitation and empiric steroids did not allow his pressors to
be weaned. Furthermore any manipulation such as turning or
cleaning caused him to drop his blood pressure despite pressor
support.

4 Pulmonary embolism: Echocardiogram with RV strain on [**5-28**]. No
clear source of hypercoagulability such as known malignancy or
prolonged immobility. Unable to perform CTA due to hemodynamic
instability and anuric renal failure. Underwent lysis with tPA
on [**5-28**]. Then went for catheter directed thrombectomy on [**5-29**],
found to have right-upper and left-lower main [**MD Number(3) 33168**]. He was
treated with heparin drip with goal ptt 60-80 with ivc filter
placement.
.
5 Leukocytosis: He was admitted with WBC of 30 from recent
baseline of 20. This was initially thought related to underlying
c.diff with stress reaction. His WBC rose with the development
of his MRSA VAP, but continued to climb despite antiobiotics and
improvement in fever. Given the severity of the leukocytosis and
the number of bands and nucleated red blood cells the smear was
reviewed by hem-on, with no unusal forms. This was thought to
reflect the response to severe stress.

6 ARF/ATN: He was initially in anuric renal failure but this
improved with early treatment of his obsturctive shock. His GFR
then remained stable.

7 New afib: Thought related to PE/right heart strain. He
returned to sinus rhythm with occaisional runs of NSVT.

8 CAD: His aspirin dose was decreased to 81mg daily, he was
continued on his statin.

9 COPD: home O2 2LNC. Will need to administer aggressive MDI to
decrease airway resistance. He was  restarted on hydrocort [**5-6**]
given elevated airway resistance, which subsequently improved.

10 PPX: on heparin drip, PPI, bowel regimen, insulin sliding
scale.



Medications on Admission:
Aspirin 81 mg po qday
Atorvastatin 10 mg po DAILY
Fluticasone-Salmeterol 500-50 mcg inhale twice a day.
Furosemide 40 mg po DAILY
Lorazepam 0.5 mg twice a day
pepcid 20mg po qday
Prednisone 10 mg PO DAILY
Tiotropium 18 mcg Capsule, Inhalation DAILY
Florasta 250mg po bid
questran packet [**Hospital1 **]
finished 2w course of po vanco and flagyl yesterday

Discharge Medications:
None.

Discharge Disposition:
Expired

Discharge Diagnosis:
Pulmonary embouls with severe obstructive shock, septic shock,
MRSA pneumonia, aspergilus pneumonia.

Discharge Condition:
Deceased.

                             [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
{'Other specified septicemias,Septic shock,Methicillin susceptible pneumonia due to Staphylococcus aureus,Acute respiratory failure,Aspergillosis,Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity,Other pulmonary embolism and infarction,Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Intestinal infection due to Clostridium difficile,Severe sepsis,Infection with microorganisms resistant to penicillins,Atrial fibrillation,Chronic airway obstruction, not elsewhere classified,Coronary atherosclerosis of unspecified type of vessel, native or graft,Unspecified essential hypertension,Hypotension, unspecified,Other chronic pulmonary heart diseases,Pure hypercholesterolemia,Hyperpotassemia,Anemia, unspecified,Leukocytosis, unspecified,Other dependence on machines, supplemental oxygen'}


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: dysnpnea

PRESENT ILLNESS: Mr. [**Known lastname **] is an 84yo man with h/o CAD, diastolic CHF c EF
55%, COPD on home O2 at 2LNC, and recent strep pneumo pna
requiring intubation (5d) one month ago, discharged to home from
[**Hospital **] rehab 1 week ago with new diagnosis of Cdiff now s/p
14d po vanco/flagyl. Yesterday he noted increased dyspnea and
his visiting nurse [**First Name (Titles) 33166**] [**Last Name (Titles) **] crackles. He seemed weak per his
daughter, and continued to have diarrhea.  Last night his edema
(usually trace only) and breathing began worsening and he had
increased lethargy and decreased mentation today, for which he
was brought by EMS to an OSH.
.
At [**Hospital3 1443**], ABG was 7.18/65/163 for which he was put
on bipap - repeat ABG was 7.26/60/444. He was treated for COPD
exacerbation with 125mg IV solumedrol, nebs, and was given 80mg
IV lasix x 1 after his BNP returned as 35,000 to which he put
out only 100cc, and was transferred to the [**Hospital1 18**].  On arrival
here his SBP was in the 70s-80 (per daughter his baseline is
high 80s-90s since last year).  He continued on bipap with O2
sats in the 90s. Femoral line was placed and he was initially
started on dopamine drip however this caused tachycardia and
drip was stopped before transfer to ICU with SBP remaining in
the 80s. He was given a dose of levoflox, despite CXR negative
for infiltrate (also no sign of pulmonary edema, but did show
underlying COPD and bronchiectasis). EKG was reportedly
unremarkable.  Repeat BNP here was pending at the time of
admission.
.
He denies having had CP, N/V/diaphoresis, dizziness, dysuria, or
any other symptoms besides shortness of breath and weakness as
above. No cough, no fever or chills.
.
ROS: currently states breathing feels better than earlier today,
no cp, abd pain, n/v.

MEDICAL HISTORY: - HTN, however per daughter no longer, and now hypotensive
- diastolic CHF with EF 55%
- hypercholesterolemia;
- CAD s/p IMI in [**2182**]
- TIA/aphasia [**10-2**]; s/p L CEA [**2-1**]
- COPD (FEV1 1.57 per [**7-2**] PFTs, ratio 82% due to poor
effort,but tracing appeared obstructive per report);  on home
2LNC O2
- BPH s/p TURP [**6-1**];
- balanitis s/p circumcision [**6-1**];
- remote nephrolithiasis;
- former tobacco use (80 pack/year Hx),
- S. pneumoniae pneumonia [**4-8**], intubated for hypercarbia
- C diff diagnosed [**5-9**]

MEDICATION ON ADMISSION: Aspirin 81 mg po qday
Atorvastatin 10 mg po DAILY
Fluticasone-Salmeterol 500-50 mcg inhale twice a day.
Furosemide 40 mg po DAILY
Lorazepam 0.5 mg twice a day
pepcid 20mg po qday
Prednisone 10 mg PO DAILY
Tiotropium 18 mcg Capsule, Inhalation DAILY
Florasta 250mg po bid
questran packet [**Hospital1 **]
finished 2w course of po vanco and flagyl yesterday

ALLERGIES: Beta-Adrenergic Blocking Agents

PHYSICAL EXAM: VS 96.4,  100,  86/47,  31,  95% on noninvasive bipap 15/8 at
FiO2 0.35
Gen: responds with hand gestures and nods to questions, wearing
bipap mask, uses abdominal muscles for exhalation
HEENT: Pupils small but minimally reactive
Neck: JVP mildly distended at 10cm
Cor: very decreased heart sounds, s1s2, no murmur
Pulm: R base with rales, Left lung clear
Abd: soft, NT, ND, +bs
Ext: [**3-5**]+ pitting edema bilateral LE to just below knees
Neuro: moves all four, responds to commands
Skin: obvious bruises and thin, fragile skin throughout
GU: concentrated brown/[**Location (un) 2452**] urine in foley

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: Before admission in [**Month (only) 958**] had lived alone with wife. For last
week since d/c from [**Hospital **] rehab he and wife have been living
iwth daughter, who is a nurse here at [**Hospital1 18**]. 80 pack years of
smoking, quit 5 years ago. 

### Response:
{'Other specified septicemias,Septic shock,Methicillin susceptible pneumonia due to Staphylococcus aureus,Acute respiratory failure,Aspergillosis,Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity,Other pulmonary embolism and infarction,Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Intestinal infection due to Clostridium difficile,Severe sepsis,Infection with microorganisms resistant to penicillins,Atrial fibrillation,Chronic airway obstruction, not elsewhere classified,Coronary atherosclerosis of unspecified type of vessel, native or graft,Unspecified essential hypertension,Hypotension, unspecified,Other chronic pulmonary heart diseases,Pure hypercholesterolemia,Hyperpotassemia,Anemia, unspecified,Leukocytosis, unspecified,Other dependence on machines, supplemental oxygen'}
