CHIEF COMPLAINT: respiratory distress

PRESENT ILLNESS: 87 y/o Cantonese M with PMHx of CHF, Atrial Fib, Metastatic
Prostate Ca with recent PNA who was discharged to NH from [**Hospital 3278**]
medical after a CHF exacerbation ([**Date range (1) 25250**])and now being
brought in by EMS with worsening shortness of breath. Pt was
felt to be in CHF by EMS providers and was given SL nitro and IV
lasix en route.
.
On arrival to the [**Name (NI) **], pt was in respiratory distress on a NRB
with sats of 83%. He was immediately placed on CPAP the next set
of vitals: P 80 BP 137/49 RR 34 O2 99% sat on CPAP of [**4-6**] with
100%. EKG did not show any acute ST-T wave changes and CXR
showed at LLL infiltrate with possible effusion. Pt was given
Levofloxacin 750mg IV, Ceftriaxone 1gram and Azithromycin 500mg
IV. Pt was given IVF at 250cc/hr with a total of approx 500cc.
Notes from [**Location (un) **] Health documenting clear DNR/DNI status.
.
On arrival to the ICU, pt was on CPAP and after transition to
high flow mask, he was notably more tachypneic.

MEDICAL HISTORY: -Rapidly progressive, treatment resistance prostate cancer
(started on Lupron '[**83**], Casodex added [**11-7**]
-Diastolic Heart Failure with EF of 55%
-h/o Urinary Retention (now s/p foley)
-Atrial Fibrillation
-Recent hospitalization ([**Date range (1) 30801**]/10) with Sepsis thought due to
PNA, managed with pressors but remained DNR/DNI. Pt was
re-admitted 10 days later with presumed CHF exacerbation,
diuresed and discharged to NH on [**5-18**].

MEDICATION ON ADMISSION: Medications from NH list:
Ducolax 10mg daily prn
Senna daily prn
Fleet enema prn
Amidarone 200mg daily
Dexamethasone 0.5mg [**Hospital1 **] (from taper after admission with sepsis)

ALLERGIES: No Drug Allergy Information on File

PHYSICAL EXAM: On admission
General Appearance: Thin, Anxious, Moderate to severe
respiratory distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, upper and lower
dentures
Cardiovascular: unable to hear
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Bronchial: , Rhonchorous: ), diffuse rhonci, paradoxical abd
movements
Abdominal: Soft, Non-tender; foley in place draining clear
yellow urine
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Skin:  Not assessed, No(t) Rash: , No(t) Jaundice
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): person, place, time, situation,
Movement: Not assessed, Tone: Not assessed

FAMILY HISTORY: NC

SOCIAL HISTORY: Pt was discharged from [**Hospital 3278**] Medical to [**Location (un) **] health NH on
[**5-18**]. Pt has a 60 pack year history of smoking. No ETOH or drug
use.
Acute respiratory failure,Pneumonia, organism unspecified,Acute kidney failure, unspecified,Acute on chronic systolic heart failure,Acute and subacute necrosis of liver,Acidosis,Unspecified pleural effusion,Hypoxemia,Retention of urine, unspecified,Other chronic pulmonary heart diseases
Acute respiratry failure,Pneumonia, organism NOS,Acute kidney failure NOS,Ac on chr syst hrt fail,Acute necrosis of liver,Acidosis,Pleural effusion NOS,Hypoxemia,Retention urine NOS,Chr pulmon heart dis NEC
Admission Date:  [**2199-5-21**]              Discharge Date:   [**2199-5-24**]


Service: MEDICINE

Allergies:
No Drug Allergy Information on File

Attending:[**First Name3 (LF) 603**]
Chief Complaint:
respiratory distress

Major Surgical or Invasive Procedure:
arterial line

History of Present Illness:
87 y/o Cantonese M with PMHx of CHF, Atrial Fib, Metastatic
Prostate Ca with recent PNA who was discharged to NH from [**Hospital 3278**]
medical after a CHF exacerbation ([**Date range (1) 25250**])and now being
brought in by EMS with worsening shortness of breath. Pt was
felt to be in CHF by EMS providers and was given SL nitro and IV
lasix en route.
.
On arrival to the [**Name (NI) **], pt was in respiratory distress on a NRB
with sats of 83%. He was immediately placed on CPAP the next set
of vitals: P 80 BP 137/49 RR 34 O2 99% sat on CPAP of [**4-6**] with
100%. EKG did not show any acute ST-T wave changes and CXR
showed at LLL infiltrate with possible effusion. Pt was given
Levofloxacin 750mg IV, Ceftriaxone 1gram and Azithromycin 500mg
IV. Pt was given IVF at 250cc/hr with a total of approx 500cc.
Notes from [**Location (un) **] Health documenting clear DNR/DNI status.
.
On arrival to the ICU, pt was on CPAP and after transition to
high flow mask, he was notably more tachypneic.


Past Medical History:
-Rapidly progressive, treatment resistance prostate cancer
(started on Lupron '[**83**], Casodex added [**11-7**]
-Diastolic Heart Failure with EF of 55%
-h/o Urinary Retention (now s/p foley)
-Atrial Fibrillation
-Recent hospitalization ([**Date range (1) 30801**]/10) with Sepsis thought due to
PNA, managed with pressors but remained DNR/DNI. Pt was
re-admitted 10 days later with presumed CHF exacerbation,
diuresed and discharged to NH on [**5-18**].


Social History:
Pt was discharged from [**Hospital 3278**] Medical to [**Location (un) **] health NH on
[**5-18**]. Pt has a 60 pack year history of smoking. No ETOH or drug
use.

Family History:
NC

Physical Exam:
On admission
General Appearance: Thin, Anxious, Moderate to severe
respiratory distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, upper and lower
dentures
Cardiovascular: unable to hear
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Bronchial: , Rhonchorous: ), diffuse rhonci, paradoxical abd
movements
Abdominal: Soft, Non-tender; foley in place draining clear
yellow urine
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Skin:  Not assessed, No(t) Rash: , No(t) Jaundice
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): person, place, time, situation,
Movement: Not assessed, Tone: Not assessed


Pertinent Results:
TTE
The left atrium is mildly dilated. The estimated right atrial
pressure is 10-20mmHg. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF>65%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are structurally
normal. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is an
anterior space which most likely represents a prominent fat pad.


IMPRESSION: Moderate pulmonary artery systolic hypertension.
Normal biventricular cavity sizes with preserved global
biventricular systolic function. Mild mitral regurgitation with
normal valve morphology.

CXR
There is opacity in the left mid and lower lung concerning for
aspiration or pneumonia with associated pleural effusion.
Blunting of the
right costophrenic angle is compatible with a small pleural
effusion. No
pneumothorax is seen. No pneumothorax.
.

[**2199-5-23**] 05:33AM BLOOD WBC-8.3# RBC-2.86* Hgb-9.3* Hct-27.4*
MCV-96 MCH-32.6* MCHC-34.0 RDW-19.4* Plt Ct-132*
[**2199-5-23**] 12:12AM BLOOD Hct-26.8*
[**2199-5-22**] 04:57PM BLOOD Hct-24.9*
[**2199-5-21**] 03:24PM BLOOD WBC-4.1 RBC-3.29* Hgb-10.4* Hct-31.8*
MCV-97 MCH-31.6 MCHC-32.7 RDW-19.1* Plt Ct-136*
[**2199-5-21**] 09:40AM BLOOD WBC-7.8 RBC-3.54* Hgb-11.3* Hct-34.7*
MCV-98 MCH-31.9 MCHC-32.5 RDW-19.1* Plt Ct-158
[**2199-5-23**] 05:33AM BLOOD Neuts-87.4* Lymphs-8.7* Monos-3.5 Eos-0.2
Baso-0.1
[**2199-5-21**] 09:40AM BLOOD Neuts-59 Bands-11* Lymphs-24 Monos-4
Eos-1 Baso-0 Atyps-0 Metas-1* Myelos-0 NRBC-1*
[**2199-5-23**] 09:52PM BLOOD PTT-81.7*
[**2199-5-23**] 10:48AM BLOOD PTT-60.4*
[**2199-5-23**] 05:33AM BLOOD Plt Ct-132*
[**2199-5-23**] 05:33AM BLOOD PT-18.1* PTT-82.0* INR(PT)-1.6*
[**2199-5-23**] 12:12AM BLOOD PTT-116.5*
[**2199-5-22**] 04:57PM BLOOD PT-20.9* PTT-104.9* INR(PT)-1.9*
[**2199-5-22**] 08:35AM BLOOD PTT-111.8*
[**2199-5-22**] 03:08AM BLOOD Plt Ct-110*
[**2199-5-22**] 03:08AM BLOOD PT-19.4* PTT-97.7* INR(PT)-1.8*
[**2199-5-21**] 03:24PM BLOOD Plt Ct-136*
[**2199-5-21**] 03:24PM BLOOD PT-16.3* PTT-31.8 INR(PT)-1.4*
[**2199-5-21**] 09:40AM BLOOD PT-15.3* PTT-27.5 INR(PT)-1.3*
[**2199-5-21**] 09:40AM BLOOD Plt Smr-NORMAL Plt Ct-158
[**2199-5-22**] 04:57PM BLOOD FDP-40-80*
[**2199-5-22**] 04:57PM BLOOD Fibrino-461*
[**2199-5-22**] 03:08AM BLOOD Fibrino-494*
[**2199-5-23**] 04:41PM BLOOD Glucose-92 UreaN-60* Creat-2.3* Na-133
K-4.5 Cl-100 HCO3-18* AnGap-20
[**2199-5-23**] 05:33AM BLOOD Glucose-91 UreaN-58* Creat-2.4* Na-132*
K-4.4 Cl-99 HCO3-17* AnGap-20
[**2199-5-22**] 04:57PM BLOOD Glucose-106* UreaN-56* Creat-2.5* Na-129*
K-4.4 Cl-98 HCO3-18* AnGap-17
[**2199-5-22**] 03:08AM BLOOD Glucose-77 UreaN-47* Creat-2.4* Na-130*
K-5.2* Cl-100 HCO3-13* AnGap-22*
[**2199-5-21**] 03:24PM BLOOD Glucose-91 UreaN-41* Creat-2.4* Na-130*
K-5.3* Cl-96 HCO3-17* AnGap-22*
[**2199-5-21**] 09:40AM BLOOD Glucose-127* UreaN-37* Creat-2.3* Na-133
K-5.3* Cl-99 HCO3-19* AnGap-20
[**2199-5-23**] 05:33AM BLOOD ALT-446* AST-326* LD(LDH)-554*
AlkPhos-159* TotBili-0.9
[**2199-5-22**] 04:57PM BLOOD LD(LDH)-868* TotBili-0.9
[**2199-5-21**] 03:24PM BLOOD CK(CPK)-300
[**2199-5-21**] 03:24PM BLOOD CK-MB-5 cTropnT-0.04* proBNP-[**Numeric Identifier 30802**]*
[**2199-5-23**] 04:41PM BLOOD Calcium-7.2* Phos-4.8*
[**2199-5-23**] 05:33AM BLOOD Calcium-7.1* Phos-4.7* Mg-2.4
[**2199-5-22**] 04:57PM BLOOD Calcium-6.9* Phos-5.1* Mg-2.4 Iron-149
[**2199-5-22**] 03:08AM BLOOD Calcium-6.6* Phos-6.2* Mg-1.8
[**2199-5-21**] 03:24PM BLOOD Calcium-7.0* Phos-5.7* Mg-1.9
[**2199-5-21**] 09:40AM BLOOD Calcium-7.2* Phos-6.0* Mg-2.0
[**2199-5-22**] 04:57PM BLOOD calTIBC-144 Hapto-280* Ferritn-[**Numeric Identifier 30803**]*
TRF-111*
[**2199-5-22**] 03:08AM BLOOD Hapto-305*
[**2199-5-22**] 03:23AM BLOOD Type-ART pO2-211* pCO2-30* pH-7.32*
calTCO2-16* Base XS--9
[**2199-5-21**] 09:16PM BLOOD Type-ART pO2-109* pCO2-31* pH-7.37
calTCO2-19* Base XS--5
[**2199-5-21**] 03:50PM BLOOD Type-ART pO2-90 pCO2-31* pH-7.35
calTCO2-18* Base XS--7 Comment-100% HIGH
[**2199-5-21**] 09:46AM BLOOD Type-ART Rates-/34 PEEP-5 FiO2-100 pO2-90
pCO2-36 pH-7.31* calTCO2-19* Base XS--7 AADO2-591 REQ O2-96
Intubat-NOT INTUBA Comment-GREEN TOP
[**2199-5-22**] 03:23AM BLOOD Lactate-3.3*
[**2199-5-21**] 09:16PM BLOOD Lactate-2.9*
[**2199-5-21**] 03:50PM BLOOD Lactate-3.1*
[**2199-5-21**] 09:46AM BLOOD Glucose-119* Lactate-3.3* K-5.0

Brief Hospital Course:
87 y/o M with PMHx of CHF, AF, Metastatic Prostate Ca and recent
OSH admission with PNA/sepsis/CHF who presents with respiratory
distress, LLL infiltrate and acute renal failure.
.
#. Respiratory Distress: Pt with recent admission with
sepsis/PNA followed by an admission for CHF who p/w tachypnea,
hypoxia and dense LLL infiltrate. Pt placed on BiPAP with
improvement in sats and decreased distress. After long
discussion with family/patient, DNR/DNI status confirmed.
Family/patient understand gravity of situation and additional
family being notified. Patient with hypoxia and tachypnea in the
setting of metabolic acidosis.  Was treated broadly with
vancomycin, cefepime and ciprofloxacin. Steroids were initiated
on admission, but discontinued on hospital day #2 given the
feeling that patient may become more agitated and provided
little benefit. Patient was empirically anticoagulated to treat
potential PE while in the ICU, which could not be further
evaluated with CTA due to renal failure. TTE revealed possible
volume overload on basis of IVC filling, so trialed lasix 40 mg
IV x1 with good output and some improvement in oxygenation.
Patient was called out of the ICU on [**5-23**] requiring 4L NC. A
family meeting was held prior to callout, and family decided to
keep DNR/I status. Palliative care was consulted on [**2199-5-24**] on
the floor and additional family updates/meetings were held. At
that time, family decided to make the patient CMO. They did not
want additional antibiotics or non-essential medications that
would not lead to comfort. They wanted him to be able to leave
the hospital to focus on comfort care. Per attached palliative
care note, pt's family has asked that patient not be
rehospitalized. Pt will be discharged on PO concentrated
morphine and sublingual ativan PRN dyspnea or pain.
.
#. Renal Failure: Pt with recent baseline creatinine of 1.3 and
presents now with PNA and creatinine of 2.3. Appears clinically
dry with low UOP and a tenuous respiratory status. Given known
prostate ca with chronic foley, will leave in place if promotes
patient comfort. If pt uncomfortable, foley can be removed.
.
# Metastatic Prostate Ca: End stage disease followed at [**Hospital1 3278**]
with new indwelling foley. Will hold off on removing foley,
suspect placed by urology during recent admission to [**Hospital1 3278**].
Recent admission documents discussion re goals of care and CMO
discussion. Pt is now written for PO oral concentrated morphine
for pain as per above.
.
# AFib: Currently in NSR, not anticoagulated per OSH records on
amiodarone 200mg daily as outpt. Pt may take amiodarone 200mg if
he would like.

.

Medications on Admission:
Medications from NH list:
Ducolax 10mg daily prn
Senna daily prn
Fleet enema prn
Amidarone 200mg daily
Dexamethasone 0.5mg [**Hospital1 **] (from taper after admission with sepsis)

Hydrochlorothiazide 12.5mg daily
Duonebs q8hr standing
Metoprolol 12.5mg [**Hospital1 **]
Folic Acid 1mg daily
.
Medications on transfer:
cefepime 1g q24h
ciprofloxacin 400 mg q24h
vancomycin 1 q48h (needs approval [**5-24**])
albuterol nebs prn
bisacodyl prn
famotidine 20 mg IV q24h
heparin SS
insulin SS
lorazepam .5 mg IV q4h:prn
metoprolol 2.5 mg IV q6h
morphine 2 mg IV q2h:prn


Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day): pt may refuse.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation: pt may refuse.
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q4H (every 4 hours) as
needed for SOB/Wheeze: for comfort only.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q4H (every 4 hours) as needed for SOB/Wheeze: for comfort only.

5. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal once a day as needed for secretions for 1 doses.
6. ativan
ativan 0.5-1mg sublingual Q3hrs prn dyspnea or anxiety
7. Morphine Concentrate 20 mg/mL Solution Sig: 5-10 mg PO q3-4
hours prn as needed for pain: pain or dyspnea.


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Healthcare Center - [**Location (un) **]

Discharge Diagnosis:
Major:
hypoxia related to nursing home associated pneumonia
acute systolic heart failure
metastatic prostate cancer
afib
.
Minor:
recent hospitalization for sepsis thought to be related to
pneumonia


Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
You were admitted with low oxygen levels, respiratory distress
and found to have heart failure and pneumonia. For this, you
were given IV antibiotics and trialed on lasix. You were also
found to have kidney impairment and liver impairment. You and
your family had discussions regarding your goals of care. After
meeting with palliative care, it was decided to continue your
current DNR/I status and to now focus your care on comfort
measures. After discussion with your family, it was decided that
all antibiotics and other treatments that did not focus on
comfort would be discontinued.
.
Medication changes: Pt may take the medications that he desires
according to comfort.

Followup Instructions:
Please contact your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 429**] [**Known lastname **] at [**Telephone/Fax (1) 16171**] at your
convenience as needed.
{'Acute respiratory failure,Pneumonia, organism unspecified,Acute kidney failure, unspecified,Acute on chronic systolic heart failure,Acute and subacute necrosis of liver,Acidosis,Unspecified pleural effusion,Hypoxemia,Retention of urine, unspecified,Other chronic pulmonary heart diseases'}


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 distress

PRESENT ILLNESS: 87 y/o Cantonese M with PMHx of CHF, Atrial Fib, Metastatic
Prostate Ca with recent PNA who was discharged to NH from [**Hospital 3278**]
medical after a CHF exacerbation ([**Date range (1) 25250**])and now being
brought in by EMS with worsening shortness of breath. Pt was
felt to be in CHF by EMS providers and was given SL nitro and IV
lasix en route.
.
On arrival to the [**Name (NI) **], pt was in respiratory distress on a NRB
with sats of 83%. He was immediately placed on CPAP the next set
of vitals: P 80 BP 137/49 RR 34 O2 99% sat on CPAP of [**4-6**] with
100%. EKG did not show any acute ST-T wave changes and CXR
showed at LLL infiltrate with possible effusion. Pt was given
Levofloxacin 750mg IV, Ceftriaxone 1gram and Azithromycin 500mg
IV. Pt was given IVF at 250cc/hr with a total of approx 500cc.
Notes from [**Location (un) **] Health documenting clear DNR/DNI status.
.
On arrival to the ICU, pt was on CPAP and after transition to
high flow mask, he was notably more tachypneic.

MEDICAL HISTORY: -Rapidly progressive, treatment resistance prostate cancer
(started on Lupron '[**83**], Casodex added [**11-7**]
-Diastolic Heart Failure with EF of 55%
-h/o Urinary Retention (now s/p foley)
-Atrial Fibrillation
-Recent hospitalization ([**Date range (1) 30801**]/10) with Sepsis thought due to
PNA, managed with pressors but remained DNR/DNI. Pt was
re-admitted 10 days later with presumed CHF exacerbation,
diuresed and discharged to NH on [**5-18**].

MEDICATION ON ADMISSION: Medications from NH list:
Ducolax 10mg daily prn
Senna daily prn
Fleet enema prn
Amidarone 200mg daily
Dexamethasone 0.5mg [**Hospital1 **] (from taper after admission with sepsis)

ALLERGIES: No Drug Allergy Information on File

PHYSICAL EXAM: On admission
General Appearance: Thin, Anxious, Moderate to severe
respiratory distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, upper and lower
dentures
Cardiovascular: unable to hear
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Bronchial: , Rhonchorous: ), diffuse rhonci, paradoxical abd
movements
Abdominal: Soft, Non-tender; foley in place draining clear
yellow urine
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Skin:  Not assessed, No(t) Rash: , No(t) Jaundice
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): person, place, time, situation,
Movement: Not assessed, Tone: Not assessed

FAMILY HISTORY: NC

SOCIAL HISTORY: Pt was discharged from [**Hospital 3278**] Medical to [**Location (un) **] health NH on
[**5-18**]. Pt has a 60 pack year history of smoking. No ETOH or drug
use. 

### Response:
{'Acute respiratory failure,Pneumonia, organism unspecified,Acute kidney failure, unspecified,Acute on chronic systolic heart failure,Acute and subacute necrosis of liver,Acidosis,Unspecified pleural effusion,Hypoxemia,Retention of urine, unspecified,Other chronic pulmonary heart diseases'}
