CHIEF COMPLAINT: respiratory failure

PRESENT ILLNESS: Mr. [**Known lastname **] is an 83 y/o man with PMH of COPD, prior NSTEMI,
and hypertension who presented with respiratory failure. Patient
was at home with increasing respiratory symptoms (productive
cough, fever) X 3 days. He was noted by his daughter (who is RN
case manager at [**Hospital1 18**]) to be cyanotic while having his breakfast
on the morning of admission. Decided to take him to [**Hospital1 18**]; on
the way to car, the patient collapsed and was placed in the car
by his daughter & son-in-law. [**Name (NI) **] was en route to [**Hospital1 18**] with his
daughter when his breathing became acutely worse; she then took
him to [**Hospital3 1443**] hospital as she was near the exit. She
reports that he became pulseless in the car. On the ED
physician's initial evaluation, the patient was noted to be
cyanotic, unresponsive with very low respirations, and without a
pulse. With bagging, reportedly his cyanosis improved as did his
bradycardia and blood pressure. Initial vitals at [**Hospital1 487**] were
rectal temp 97, oxygen sats 90 with bagging (pulse noted in
nursing note and HR 40 in sinus brady). After intubated, copious
amounts of greenish sputum were suctioned. He was treated with
avelox IV X 1 as well as ativan for agitation.
.
On arrival to our ED, initial vitals with BP 80/50, T 99.9, HR
80, and O2 sat 100% (on vent). Central venous access was placed
(right subclavian) and the patient was placed on dopamine with
increase in blood pressures to 120s-130s systolic. He received
zosyn 4.5 g X 1, clindamycin 600 mg IV X 1, solumedrol 125 mg IV
X 1, and versed 2 mg. Noted to be guaiac negative. He received a
total of 3 L NS and 1 L LR.
.
He is noted by his PCP to serially refuse influenza vaccination
but did have the pnuemococcal vaccine in [**2-6**]. Recent PCP visit
in [**2-7**] notes oxygen saturation 83% on room air at rest and 79%
on room air with ambulation. He was previously on home oxygen
which was recently reinstituted at 1 L/min at night

MEDICAL HISTORY: HTN
hypercholesterolemia
NQWMI ca. [**2182**]
TIA/aphasia [**10-2**]
s/p L CEA [**2-1**]
COPD (FEV1 1.57 per [**7-2**] PFTs)
BPH s/p TURP [**6-1**]
balanitis s/p circumcision [**6-1**]
remote nephrolithiasis
former tobacco use (80 pack/year Hx)

MEDICATION ON ADMISSION: advair diskus 100/50 [**Hospital1 **]
lasix 20 mg daily
lipitor 10 mg daily
lorazepam 0.5 mg [**Hospital1 **] prn
prednisone 10 mg daily
spiriva daily
oxygen via NC 1 L/min

ALLERGIES: Beta-Adrenergic Blocking Agents

PHYSICAL EXAM: Admission PE:
PE: T: 98.3 BP: 98/52 HR: 82 RR: 19 O2 97% on AC FiO2 50, Tv
520, RR 26, PEEP 10
Gen: intubated, sedated, moving all extremities minimally with
noxious stimuli
HEENT: pupils small but reactive bilaterally (R slightly larger
than L), no scleral icterus, ET tube & NG tube in place
NECK: Supple, No LAD palpable.
CV: regular rate & rhythm, heart sounds distant, no appreciable
murmur
LUNGS: rhonchi bilaterally, no wheezing
ABD: normoactive bowel sounds, nontender to palpation, no masses
palpated
EXT: no lower extremity edema, DP pulses 1+ bilaterally, toes
cool but feet warm, hands warm
SKIN: scattered ecchymoses on bilateral upper extremities with
small areas of skin breakdown, scratches on left posterior calf

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Prior smoker (> 80 pack years). Lives with wife in [**Name (NI) 33165**]. Daughter lives three streets away. No alcohol, no IVDU.
Still working.
Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Acute respiratory failure,Unspecified septicemia,Septic shock,Acute kidney failure, unspecified,Severe sepsis,Hyperosmolality and/or hypernatremia,Chronic diastolic heart failure,Chronic airway obstruction, not elsewhere classified,Unspecified essential hypertension,Pure hypercholesterolemia,Coronary atherosclerosis of native coronary artery
Pneumococcal pneumonia,Acute respiratry failure,Septicemia NOS,Septic shock,Acute kidney failure NOS,Severe sepsis,Hyperosmolality,Chr diastolic hrt fail,Chr airway obstruct NEC,Hypertension NOS,Pure hypercholesterolem,Crnry athrscl natve vssl
Admission Date:  [**2197-4-16**]              Discharge Date:   [**2197-4-26**]


Service: MEDICINE

Allergies:
Beta-Adrenergic Blocking Agents

Attending:[**First Name3 (LF) 10370**]
Chief Complaint:
respiratory failure

Major Surgical or Invasive Procedure:
Mechanical Ventilation, Central Venous Cannulation


History of Present Illness:
Mr. [**Known lastname **] is an 83 y/o man with PMH of COPD, prior NSTEMI,
and hypertension who presented with respiratory failure. Patient
was at home with increasing respiratory symptoms (productive
cough, fever) X 3 days. He was noted by his daughter (who is RN
case manager at [**Hospital1 18**]) to be cyanotic while having his breakfast
on the morning of admission. Decided to take him to [**Hospital1 18**]; on
the way to car, the patient collapsed and was placed in the car
by his daughter & son-in-law. [**Name (NI) **] was en route to [**Hospital1 18**] with his
daughter when his breathing became acutely worse; she then took
him to [**Hospital3 1443**] hospital as she was near the exit. She
reports that he became pulseless in the car. On the ED
physician's initial evaluation, the patient was noted to be
cyanotic, unresponsive with very low respirations, and without a
pulse. With bagging, reportedly his cyanosis improved as did his
bradycardia and blood pressure. Initial vitals at [**Hospital1 487**] were
rectal temp 97, oxygen sats 90 with bagging (pulse noted in
nursing note and HR 40 in sinus brady). After intubated, copious
amounts of greenish sputum were suctioned. He was treated with
avelox IV X 1 as well as ativan for agitation.
.
On arrival to our ED, initial vitals with BP 80/50, T 99.9, HR
80, and O2 sat 100% (on vent). Central venous access was placed
(right subclavian) and the patient was placed on dopamine with
increase in blood pressures to 120s-130s systolic. He received
zosyn 4.5 g X 1, clindamycin 600 mg IV X 1, solumedrol 125 mg IV
X 1, and versed 2 mg. Noted to be guaiac negative. He received a
total of 3 L NS and 1 L LR.
.
He is noted by his PCP to serially refuse influenza vaccination
but did have the pnuemococcal vaccine in [**2-6**]. Recent PCP visit
in [**2-7**] notes oxygen saturation 83% on room air at rest and 79%
on room air with ambulation. He was previously on home oxygen
which was recently reinstituted at 1 L/min at night


Past Medical History:
HTN
hypercholesterolemia
NQWMI ca. [**2182**]
TIA/aphasia [**10-2**]
s/p L CEA [**2-1**]
COPD (FEV1 1.57 per [**7-2**] PFTs)
BPH s/p TURP [**6-1**]
balanitis s/p circumcision [**6-1**]
remote nephrolithiasis
former tobacco use (80 pack/year Hx)


Social History:
Prior smoker (> 80 pack years). Lives with wife in [**Name (NI) 33165**]. Daughter lives three streets away. No alcohol, no IVDU.
Still working.

Family History:
Non-contributory

Physical Exam:
Admission PE:
PE: T: 98.3 BP: 98/52 HR: 82 RR: 19 O2 97% on AC FiO2 50, Tv
520, RR 26, PEEP 10
Gen: intubated, sedated, moving all extremities minimally with
noxious stimuli
HEENT: pupils small but reactive bilaterally (R slightly larger
than L), no scleral icterus, ET tube & NG tube in place
NECK: Supple, No LAD palpable.
CV: regular rate & rhythm, heart sounds distant, no appreciable
murmur
LUNGS: rhonchi bilaterally, no wheezing
ABD: normoactive bowel sounds, nontender to palpation, no masses
palpated
EXT: no lower extremity edema, DP pulses 1+ bilaterally, toes
cool but feet warm, hands warm
SKIN: scattered ecchymoses on bilateral upper extremities with
small areas of skin breakdown, scratches on left posterior calf

NEURO: sedated, no response to voice, moves extremities to
noxious stimuli


Pertinent Results:
LABS at OSH:
initial ABG 7.01/100/256 (on ventilator)
D dimer 0.7 (positive > 0.5)
Na 145, K 3.4, Cl 113, CO2 18, BUN 49, creatinine 1.3, glucose
160
calcium 5.5
total protein 4.2
albumin 2.2
total bili 0.4
alk phos 64
ALT 9
AST 10
CK 14
Mg 1.8
trop 0.03
.

MICROBIOLOGY:
[**2197-4-17**] 8:28 pm SPUTUM      Source: Endotracheal.
   GRAM STAIN (Final [**2197-4-18**]):
      >25 PMNs and <10 epithelial cells/100X field.
      NO MICROORGANISMS SEEN.
   RESPIRATORY CULTURE (Final [**2197-4-20**]):    NO GROWTH.
[**2197-4-17**]  Influenza A/B by DFA NEGATIVE
[**2197-4-17**] 12:21 am SPUTUM      Source: Endotracheal.
   GRAM STAIN (Final [**2197-4-17**]):
      >25 PMNs and <10 epithelial cells/100X field.
      3+  (5-10 per 1000X FIELD):   GRAM POSITIVE COCCI IN
PAIRS.
   RESPIRATORY CULTURE (Final [**2197-4-20**]):
      OROPHARYNGEAL FLORA ABSENT.
      STREPTOCOCCUS PNEUMONIAE.    SPARSE GROWTH.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
                             STREPTOCOCCUS PNEUMONIAE
                             |
CEFTRIAXONE-----------<=0.06 S
ERYTHROMYCIN----------   =>1 R
LEVOFLOXACIN----------     1 S
PENICILLIN------------  0.25 I
TETRACYCLINE----------   <=1 S
TRIMETHOPRIM/SULFA----  =>16 R
VANCOMYCIN------------   <=1 S
[**2197-4-16**]  URINE Legionella Urinary Antigen -FINAL NEGATIVE
[**2197-4-16**]  BLOOD CULTURE Blood Culture, Routine-PENDING
[**2197-4-16**]  URINE URINE CULTURE-NO GROWTH

.
STUDIES:
EKG from OSH: (1358) wide complex at rate of 130, right bundle
branch block, elevated upsloping ST segments in V1-V6,
EKG from OSH (1417): sinus rhythm at rate 100, right bundle
morphology, inverted T waves in V1-4, Q wave in 3, PR
prolongation (similar to prior from [**2-6**])
.
ECG Study Date of [**2197-4-16**]  5:09:26 PM
Sinus rhythm  First degree A-V delay Inferior infarct - age
undetermined may be old  Low limb lead QRS voltages
Delayed R wave progression with late precordial QRS transition -
is nonspecific; ST-T wave abnormalities - are nonspecific but
cannot exclude in part ischemia - clinical correlation is
suggested
Since previous tracing of [**2196-2-2**], precordial lead T waves
slight less prominent
    Intervals Axes
Rate PR QRS QT/QTc P QRS T
83 238 102 380/420 70 -99 41
.
ECG Study Date of [**2197-4-17**]  1:02:58 AM Sinus rhythm First degree
AV delay Inferior infarct, age indeterminate - may be old
Low limb lead QRS voltages Delayed R wave progression with late
precordial QRS transition - is nonspecific; ST-T wave
abnormalities - are nonspecific but cannot exclude in part
ischemia - clinical correlation is suggested Since previous
tracing of [**2197-4-16**], no significant change
  Intervals Axes
Rate PR QRS QT/QTc P QRS T
86 222 98 374/419 75 -88 37
.
[**4-16**] CXR: The patient has been intubated with the distal tip of
the
endotracheal tube approximately 5.4 cm from the carina. There is
widening of the mediastinum, likely due to underlying body
habitus and aortic tortuosity. However, in the setting of
trauma, mediastinal vascular injury cannot be entirely excluded.
The cardiac silhouette is within normal limits for size. No
definite consolidation is noted, however, subtle increased
density is seen along the lateral aspects of the right lung,
likely due to overlying soft tissue. In the more superior
aspect, there is an abnormal density resembling a reverse "P"
which may be extrinsic to the patient. Minimal left basilar
atelectasis is also evident. No definite effusion or
pneumothorax is seen.
IMPRESSION: Endotracheal tube in satisfactory position as above.

.
[**4-17**] portable CXR:  Interval placement of nasogastric tube with
the proximal side hole near the GE junction.  Otherwise, stable
radiographic appearance of the chest with left lower lobe
atelectasis.
.
[**4-18**] portable CXR: In the interim, the upper mediastinal vessels
including the azygos vein are less engorged on today's
examination.  The pulmonary opacification seen in both lungs
predominantly at the lung bases has decreased with better
identification of the pulmonary vessels.  Scarcity of the
vessels in the upper lobes reflects underlying emphysematous
lung changes.  The pulmonary arteries are prominent in keeping
with patient's pulmonary arterial hypertension.  The heart is
not enlarged.  There is no pleural effusion. The endotracheal
tube is approximately 4.2 cm above the carina.  A right
central line ends in the upper SVC.  A feeding tube tip is out
of view on this examination. IMPRESSION: 1.  Gradual decrease of
the volume overload. 2.  Emphysema.
.
[**4-21**] portable CXR: The patient has been extubated showing
persistent interstitial opacities seen in both lungs.  The
cardiac silhouette size is maintained slightly prominent.  No
newly occurred parenchymal opacities suggestive of pneumonia.
No pleural effusion or pneumothorax are noted. IMPRESSION: 1.
Stable radiographic findings including interstitial opacities in
both lungs, stable mild cardiomegaly, status post extubation.
.
[**4-24**] CXRIMPRESSION:
1. Stable mild cardiomegaly.
2. No focal consolidation.
.

Brief Hospital Course:
MICU COURSE: On arrival to the MICU, the patient was found
intubated and sedated.  He was initially continued on broad
spectrum antibiotics (cefepime, levofloxacin, vancomycin), vanc
d/c'd on [**4-18**], cefepime d/c'd on [**4-20**] as sputum culture came
back pneumococcus sensitive to levofloxacin. DFA fr flu was
negative. He was weaned off of a dopamine drip by [**4-17**]. He
received a steroid pulse and began a taper on [**4-18**]. He was
extubated on [**4-20**] without complication. He had acute renal
failure which resolved with fluids.  Patient was transferred to
the floor on [**2197-4-21**] in stable condition.
.
.
.
# PNA/COPD/Respiratory failure: Likely related to underlying
poor pulmonary status (COPD) and pneumonia. Patient had a
similar episode last year per his daughter when diagnosed with
Strep pneumoniae. Sputum culture +S. pneumo. DFA for flu
negative. S/p extubation [**4-20**], satting at 90% 3L.  Patient was
continued on Levofloxacin for which a 14 course will be
completed.  He will also remain on neb treatments and his home
prednisone.  All of his home medications were re-added back to
his regimen prior to discharge.  he idd have one episode of
hypoxia that was thought to be due to mucus plugging and
resolved quickly.

.
# Acute renal failure: Likely was volume depleted versus ATN in
setting of sepsis. Resolved with aggessive fluid hydration. His
urine output remained adequate while on the floor
.
# h/o NSTEMI: Patient was continued on statin, aspirin
.
.
After discussion with the patient, the patient's daughter and
the attending, all were in agreement that he was a suitable
candidate for discharge.

Medications on Admission:
advair diskus 100/50 [**Hospital1 **]
lasix 20 mg daily
lipitor 10 mg daily
lorazepam 0.5 mg [**Hospital1 **] prn
prednisone 10 mg daily
spiriva daily
oxygen via NC 1 L/min


Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety.
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 5 days.
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
14. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
15. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q2H PRN ().
16. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1)  Inhalation Q2H (every 2 hours) as needed for SOB.


Discharge Disposition:
Expired

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
Primary Diagnosis: Streptococcus pneumonia pneumonia
.
Secondary Diagnoses:
* H/o multilobar Strep pneumo pneumonia in [**2-6**] requiring
intubation at [**Hospital1 18**]
* HTN
* hypercholesterolemia
* Non-STEMI ([**2182**])
* TIA/aphasia [**10-2**]
* s/p L CEA [**2-1**]
* COPD - PFTs [**2190**] FVC 2.95 (76%), FEV1 1.57 (62%), FEV1/FVC 53
(82%)
* BPH s/p TURP [**6-1**]
* balanitis s/p circumcision [**6-1**]
* remote nephrolithiasis
* former tobacco use (80 pack/year Hx)


Discharge Condition:
Afebrile, stable vital signs, tolerating POs, ambulating without
assistance.


Discharge Instructions:
You were initially admitted to the intensive care unit after
requiring mechanical ventilation for what was found to be a
serious pneumonia.  You were extubated successfully and continue
on antibiotics, for which you will continue for a total of 14
days.  You also had an episode of hypoxiz while on the floor
which was likely due to a mucus plug.
.
1. Please take all medication as prescribed.
2. Please make all medical appointments.
3. Please return to the Emergency Room if you have any
concerning symptoms.

Followup Instructions:
Dr. [**Last Name (STitle) 5717**] will contact you regarding a follow-up appointment.
{'Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Acute respiratory failure,Unspecified septicemia,Septic shock,Acute kidney failure, unspecified,Severe sepsis,Hyperosmolality and/or hypernatremia,Chronic diastolic heart failure,Chronic airway obstruction, not elsewhere classified,Unspecified essential hypertension,Pure hypercholesterolemia,Coronary atherosclerosis of native coronary artery'}


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: respiratory failure

PRESENT ILLNESS: Mr. [**Known lastname **] is an 83 y/o man with PMH of COPD, prior NSTEMI,
and hypertension who presented with respiratory failure. Patient
was at home with increasing respiratory symptoms (productive
cough, fever) X 3 days. He was noted by his daughter (who is RN
case manager at [**Hospital1 18**]) to be cyanotic while having his breakfast
on the morning of admission. Decided to take him to [**Hospital1 18**]; on
the way to car, the patient collapsed and was placed in the car
by his daughter & son-in-law. [**Name (NI) **] was en route to [**Hospital1 18**] with his
daughter when his breathing became acutely worse; she then took
him to [**Hospital3 1443**] hospital as she was near the exit. She
reports that he became pulseless in the car. On the ED
physician's initial evaluation, the patient was noted to be
cyanotic, unresponsive with very low respirations, and without a
pulse. With bagging, reportedly his cyanosis improved as did his
bradycardia and blood pressure. Initial vitals at [**Hospital1 487**] were
rectal temp 97, oxygen sats 90 with bagging (pulse noted in
nursing note and HR 40 in sinus brady). After intubated, copious
amounts of greenish sputum were suctioned. He was treated with
avelox IV X 1 as well as ativan for agitation.
.
On arrival to our ED, initial vitals with BP 80/50, T 99.9, HR
80, and O2 sat 100% (on vent). Central venous access was placed
(right subclavian) and the patient was placed on dopamine with
increase in blood pressures to 120s-130s systolic. He received
zosyn 4.5 g X 1, clindamycin 600 mg IV X 1, solumedrol 125 mg IV
X 1, and versed 2 mg. Noted to be guaiac negative. He received a
total of 3 L NS and 1 L LR.
.
He is noted by his PCP to serially refuse influenza vaccination
but did have the pnuemococcal vaccine in [**2-6**]. Recent PCP visit
in [**2-7**] notes oxygen saturation 83% on room air at rest and 79%
on room air with ambulation. He was previously on home oxygen
which was recently reinstituted at 1 L/min at night

MEDICAL HISTORY: HTN
hypercholesterolemia
NQWMI ca. [**2182**]
TIA/aphasia [**10-2**]
s/p L CEA [**2-1**]
COPD (FEV1 1.57 per [**7-2**] PFTs)
BPH s/p TURP [**6-1**]
balanitis s/p circumcision [**6-1**]
remote nephrolithiasis
former tobacco use (80 pack/year Hx)

MEDICATION ON ADMISSION: advair diskus 100/50 [**Hospital1 **]
lasix 20 mg daily
lipitor 10 mg daily
lorazepam 0.5 mg [**Hospital1 **] prn
prednisone 10 mg daily
spiriva daily
oxygen via NC 1 L/min

ALLERGIES: Beta-Adrenergic Blocking Agents

PHYSICAL EXAM: Admission PE:
PE: T: 98.3 BP: 98/52 HR: 82 RR: 19 O2 97% on AC FiO2 50, Tv
520, RR 26, PEEP 10
Gen: intubated, sedated, moving all extremities minimally with
noxious stimuli
HEENT: pupils small but reactive bilaterally (R slightly larger
than L), no scleral icterus, ET tube & NG tube in place
NECK: Supple, No LAD palpable.
CV: regular rate & rhythm, heart sounds distant, no appreciable
murmur
LUNGS: rhonchi bilaterally, no wheezing
ABD: normoactive bowel sounds, nontender to palpation, no masses
palpated
EXT: no lower extremity edema, DP pulses 1+ bilaterally, toes
cool but feet warm, hands warm
SKIN: scattered ecchymoses on bilateral upper extremities with
small areas of skin breakdown, scratches on left posterior calf

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Prior smoker (> 80 pack years). Lives with wife in [**Name (NI) 33165**]. Daughter lives three streets away. No alcohol, no IVDU.
Still working. 

### Response:
{'Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Acute respiratory failure,Unspecified septicemia,Septic shock,Acute kidney failure, unspecified,Severe sepsis,Hyperosmolality and/or hypernatremia,Chronic diastolic heart failure,Chronic airway obstruction, not elsewhere classified,Unspecified essential hypertension,Pure hypercholesterolemia,Coronary atherosclerosis of native coronary artery'}
