CHIEF COMPLAINT: Respiratory failure

PRESENT ILLNESS: Patient is a 66 yo f with pmh of stage iv renal cell ca, also
s/p recent colonic perforation with igmoid colectomy/Low
anterior resection with end colostomy and Hartmann's procedure,
who comes in with hypercarbic respiratory acidosis. She had a
recent admission for debulking nephrectomy for her RCC however,
it was never performed as she developed gram negative bacteremia
(B fragilis in [**12-5**] bottles) and subsequent bowel perforation.
Pt was treated broadly initially, then abx were tailored to
Levofloxacin, flagyl, and fluconazole. She was taken to the OR
for sigmoid colectomy/LAR with end colostomy and Hartmann's
procedure and jejunal feeding tube placement and then discharged
to [**Hospital **] rehab facility. For the past few days patient was
noted to be more hypoxic- and was treated with nebs and
prednisone. Finally today was sent into the ED for worsening
respiratory status.
.
In ED, VS were: p96.6, p105, 140/40, rr40, 87% 6L nc, 100% NRB.
Pt was found to have a increased pleural effusion (L>R), LLL
opacity. Lasix given without any improvement in respiratory
status. Pt was noted to be in severe respiratory distress with
RR in 50s ABG was found to be 7.21/104/200. Pt was urgently
intubated. Started on propofol drip, maintained good blood
pressures. Given cefepime, vanco, flagyl, lasix 20mg IV,
etomidate, succinylcholine, fentanyl, versed.

MEDICAL HISTORY: 1. emphysema/COPD
2. osteoporosis
3. fibrocystic breasts
4. s/p appendectomy
5. s/p ovarian cystectomy
6. s/p shoulder surgery
7. stage IV renal cell carcinoma

MEDICATION ON ADMISSION: Prednisone 60mg qd
ativan 0.5mg tid
atrovent neb q6h
levalbuterol neb q6h
ambien 10mg qhs
lopressor 50mg [**Hospital1 **]
benadryl
clotrimazole
lansoprazole 30mg qd
ondansetron prn
dalteparin 5000u qd
calcitonin
oxycodone 5-10mg
morphine 2mg
fentanyl 125mcg patch
lasix 20mg qd

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: vitals: tc 95.4, p78, 117/57, rr25, 94% AC 400/28/5/1
I/O: 1275/800
Gen: intubated, sedated, cachectic, chronically ill appearing
HEENT: PERRL
Lungs: diffuse expiratory rhonchi anteriorly
Heart: RRR, nl s1 s2, no m/g/r
Abd: soft, ND, J tube in place, large vertical incision,
colostomy bag in place with green stool
ext: 2+ edema bilaterally to hips

FAMILY HISTORY: Mother with cholangiocarcinoma. Father died of
complications of a peptic ulcer disease. Brother died at age 12

SOCIAL HISTORY: She is a widow. She lives alone in [**Location (un) 22287**]. She
shares a two-family house with her niece. She is retired. She
baby-sits two children. Tobacco, 1 pack a day, quit 7 months
ago. No alcohol.
Acute and chronic respiratory failure,Obstructive chronic bronchitis with (acute) exacerbation,Pneumonia, organism unspecified,Acute diastolic heart failure,Cardiac arrest,Acute kidney failure with lesion of tubular necrosis,Intestinal infection due to Clostridium difficile,Malignant neoplasm of kidney, except pelvis,Urinary tract infection, site not specified,Pressure ulcer, lower back,Unspecified pleural effusion,Other disorders of plasma protein metabolism,Edema,Unspecified essential hypertension,Intestinal bypass or anastomosis status,Anemia in chronic kidney disease,Attention to colostomy,Delirium due to conditions classified elsewhere
Acute & chronc resp fail,Obs chr bronc w(ac) exac,Pneumonia, organism NOS,Ac diastolic hrt failure,Cardiac arrest,Ac kidny fail, tubr necr,Int inf clstrdium dfcile,Malig neopl kidney,Urin tract infection NOS,Pressure ulcer, low back,Pleural effusion NOS,Dis plas protein met NEC,Edema,Hypertension NOS,Intestinal bypass status,Anemia in chr kidney dis,Atten to colostomy,Delirium d/t other cond
Admission Date:  [**2164-1-15**]              Discharge Date:   [**2164-2-1**]

Date of Birth:  [**2097-3-18**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 297**]
Chief Complaint:
Respiratory failure

Major Surgical or Invasive Procedure:
Thoracentesis x2
Tracheostomy


History of Present Illness:
Patient is a 66 yo f with pmh of stage iv renal cell ca, also
s/p recent colonic perforation with igmoid colectomy/Low
anterior resection with end colostomy and Hartmann's procedure,
who comes in with hypercarbic respiratory acidosis. She had a
recent admission for debulking nephrectomy for her RCC however,
it was never performed as she developed gram negative bacteremia
(B fragilis in [**12-5**] bottles) and subsequent bowel perforation.
Pt was treated broadly initially, then abx were tailored to
Levofloxacin, flagyl, and fluconazole. She was taken to the OR
for sigmoid colectomy/LAR with end colostomy and Hartmann's
procedure and jejunal feeding tube placement and then discharged
to [**Hospital **] rehab facility. For the past few days patient was
noted to be more hypoxic- and was treated with nebs and
prednisone. Finally today was sent into the ED for worsening
respiratory status.
.
In ED, VS were: p96.6, p105, 140/40, rr40, 87% 6L nc, 100% NRB.
Pt was found to have a increased pleural effusion (L>R), LLL
opacity. Lasix given without any improvement in respiratory
status. Pt was noted to be in severe respiratory distress with
RR in 50s ABG was found to be 7.21/104/200. Pt was urgently
intubated. Started on propofol drip, maintained good blood
pressures. Given cefepime, vanco, flagyl, lasix 20mg IV,
etomidate, succinylcholine, fentanyl, versed.


Past Medical History:
1. emphysema/COPD
2. osteoporosis
3. fibrocystic breasts
4. s/p appendectomy
5. s/p ovarian cystectomy
6. s/p shoulder surgery
7. stage IV renal cell carcinoma

Social History:
She is a widow. She lives alone in [**Location (un) 22287**]. She
shares a two-family house with her niece. She is retired. She
baby-sits two children. Tobacco, 1 pack a day, quit 7 months
ago. No alcohol.


Family History:
Mother with cholangiocarcinoma. Father died of
complications of a peptic ulcer disease. Brother died at age 12

of metastatic sarcoma.


Physical Exam:
vitals: tc 95.4, p78, 117/57, rr25, 94% AC 400/28/5/1
I/O: 1275/800
Gen: intubated, sedated, cachectic, chronically ill appearing
HEENT: PERRL
Lungs: diffuse expiratory rhonchi anteriorly
Heart: RRR, nl s1 s2, no m/g/r
Abd: soft, ND, J tube in place, large vertical incision,
colostomy bag in place with green stool
ext: 2+ edema bilaterally to hips


Pertinent Results:
[**2164-1-15**] 06:55PM   TYPE-ART TEMP-35.3 RATES-20/ TIDAL VOL-400
PEEP-5 O2-50 PO2-165* PCO2-52* PH-7.51* TOTAL CO2-43* BASE XS-16
-ASSIST/CON INTUBATED-INTUBATED
[**2164-1-15**] 05:41PM   TYPE-ART PO2-311* PCO2-47* PH-7.58* TOTAL
CO2-45* BASE XS-20 INTUBATED-INTUBATED
[**2164-1-15**] 05:41PM   LACTATE-1.9
[**2164-1-15**] 01:50PM   PO2-200* PCO2-104* PH-7.21* TOTAL CO2-44*
BASE XS-9
[**2164-1-15**] 01:50PM   LACTATE-2.3* K+-3.8
[**2164-1-15**] 01:50PM   HGB-10.6* calcHCT-32
[**2164-1-15**] 01:50PM   freeCa-1.28
[**2164-1-15**] 01:35PM   LACTATE-2.4*
[**2164-1-15**] 01:30PM   GLUCOSE-167* UREA N-15 CREAT-0.2* SODIUM-137
POTASSIUM-4.2 CHLORIDE-90* TOTAL CO2-39* ANION GAP-12
[**2164-1-15**] 01:30PM   ALT(SGPT)-17 AST(SGOT)-20 CK(CPK)-12* ALK
PHOS-175* AMYLASE-107* TOT BILI-0.2
[**2164-1-15**] 01:30PM   LIPASE-61*
[**2164-1-15**] 01:30PM   cTropnT-<0.01
[**2164-1-15**] 01:30PM   CK-MB-NotDone
[**2164-1-15**] 01:30PM   ALBUMIN-2.6* CALCIUM-9.1 PHOSPHATE-3.4
MAGNESIUM-1.9
[**2164-1-15**] 01:30PM   WBC-12.7* RBC-3.70*# HGB-10.7*# HCT-33.2*#
MCV-90# MCH-28.8 MCHC-32.2 RDW-15.5
[**2164-1-15**] 01:30PM   NEUTS-96.5* LYMPHS-2.4* MONOS-1.1* EOS-0
BASOS-0
[**2164-1-15**] 01:30PM   HYPOCHROM-2+
[**2164-1-15**] 01:30PM   PLT COUNT-447*
[**2164-1-15**] 01:30PM   PT-11.4 PTT-26.8 INR(PT)-1.0
[**2164-1-15**] 01:30PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2164-1-15**] 01:30PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2164-1-15**] 01:30PM URINE  RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2164-1-15**] 01:30PM URINE  GRANULAR-0-2 HYALINE-<1
[**2164-1-15**] 01:30PM URINE  AMORPH-FEW

Brief Hospital Course:
MICU course #1:
.
The patient was admitted to the MICU service for close
monitoring and ventilatory support.
.
# Hypercarbic respiratory failure. Thought to be multifactorial,
including pneumonia, CHF, and COPD exacerbation. The patient was
treated with cefipime and vancomycin for a CAP vs nosocomial
PNA. Solumedrol was given for COPD, as well as
albuterol/atrovent nebs. The patient was diuresed with lasix. A
thoracentesis was performed on HD2 for the large R pleural
effusion, with removal of approximately 700cc fluid which was
consistent with a transudate, and negative for malignant cells.
The patient remained intubated with RSBI scores around 150
suggesting she was a poor candidate for extubation, although
attempts were made to optimize the chances for her success by
diuresis and controlling her heart rate and blood pressure,
initially with labetalol gtt then PO labetalol. The patient
eventually did well with improved mechanics and was extubated on
[**2164-1-21**] and has since maintained her SaO2 on 4 L NC.
.
# Recent colonic perforation. Not an acute issue during this
hospitalization. Normal stool output through colostomy.
.
# RCC. Stage IV. Was scheduled for debulking surgery during
previous admission which did not occur [**12-22**] colonic perforation.
.
# Leukocytosis. Tests for c diff sent which were positive and
started Flagyl for treatment.
.
# Peripheral edema. Thought to be due to hypoalbuminemia.
Ultrasound of the lower extremities was negative for DVT. She
was diuresed.
.
# HTN. The patient's blood pressure was initially difficult to
control, requiring a labetalol gtt which was eventually
transitioned to PO.  However, after PEA arrest, her blood
pressure has been low, so discontinued all antihypertensives.
.
# FEN. Tube feedings through J-tube.
.
*****************
MICU Course #2
.
The patient was re-admitted to the MICU service [**2164-1-25**] after a
Code Blue was called for an apparent PEA arrest. The patient
while on Tele on the floor was found to be agonal and
bradycardic to the 30s without a palpable pulse; the patient was
quickly intubated, CPR was intiated, and she received one dose
of atropine with return of a palpable pulse and blood pressure.
An emergent femoral line was placed during the resuscitation;
this was removed once a R subclavian line was placed under
controlled circumstances in the MICU. A CTA was done and was
negative for PE and serial cardiac biomarkers were negative as a
possible etiology of the PEA arrest. A L pleural effusionw as
removed by thoracentesis at the bedside. The patient's mental
status returned to baseline quickly. After discussion with the
pt and the health care proxy, the patient underwent tracheostomy
[**2164-1-27**]. The patient is currently on CPAP/PS 12, FIO2 40%, TV
360s, and will need to be weaned off ventilator as tolerated to
trach mask.  For chronic obstructive lung disease, the patient
has been tapered off steroid from 60mg qday now to 20mg qday.
The patient is to take prednisone 10mg x 3days and off steroid.
It was then noted that the pt's urine output dropped and her
creatinine rose to 1.1, thought to be [**12-22**] contrast dye
nephropathy from the CTA done previously, as well as the cardiac
arrest/hypotension.  Renal u/s revealed new hematoma around her
foley, so a three-way foley was placed and continuous bladder
irrigation was done.  Renal Her creatinine slowly improved, and
her urine output increased slowly.  The patient still has a
foley currently and needs to be removed at rehab as the patient
has urinary tract infection that she is getting treated with
Ciprofloxacin which she will complete on [**2-9**].  For C.diff, she
has been getting Flagyl and will finish 10 day course on
[**2164-2-3**].  The patient will need to follow-up with her oncologist
for renal cell carcinoma and decide on the date for debulking
procedure.  Also, the patient passed video speech and swallow
and can take thick, pureed diet. Speech and swallow made the
following RECOMMENDATIONS: 1. Suggest starting a PO diet of
nectar thick liquids and pureed consistency solids when on
Pressure support vent settings or less and with PMV in place.
2. Pt must use a chin tuck for both the purees and the nectar
thick liquids.
3. Alternate between every bite and sip.
4. Continue with tube feedings for supplemental nutrition  and
hydration.
For her anemia, iron studies were consistent with anemia of
chornic disease likely [**12-22**] her renal cell carcinoma and was
started on Epogen.  The patient will need to follow-up with
oncologist and determine whether to continue on epogen.  The
patient developed delirium and suicidal ideation soon after
tracheostomy and psych was consulted and started haldol 1mg [**Hospital1 **].
The patient's delirium has cleared since the initiation of
haldol but still intermittently sundowns, so her mental status
needs to be monitored and follow-up with her primary care
physician and determine on whether to continue haldol or not.
Per psych, pt can take haldol/prn for delirium.  For
prophylaxis, the patient has been getting subcutaneous heparin,
and until ambulatory, pt will likely need subcutaneous heparin
given her high risk for DVT and PE due to her cancer.


Medications on Admission:
Prednisone 60mg qd
ativan 0.5mg tid
atrovent neb q6h
levalbuterol neb q6h
ambien 10mg qhs
lopressor 50mg [**Hospital1 **]
benadryl
clotrimazole
lansoprazole 30mg qd
ondansetron prn
dalteparin 5000u qd
calcitonin
oxycodone 5-10mg
morphine 2mg
fentanyl 125mcg patch
lasix 20mg qd


Discharge Medications:
1. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1)  PO BID (2
times a day).
2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
3. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q6H (every 6 hours).
4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q6H (every 6 hours).
5. Prednisone 10 mg Tablet Sig: One (1) Tablet PO daily () for 3
doses.
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
8. Haloperidol 0.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) as needed for 20 days: for delirium.
9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed.
10. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1)  Injection
QMOWEFR (Monday -Wednesday-Friday).
11. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 5 days: until [**2-6**].
12. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) mg Intravenous  Q8H (every 8 hours) as needed
for C diff + for 3 days: until [**2164-2-3**].
13. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day
for 1 days: on [**2-1**].
Disp:*1 Tablet(s)* Refills:*0*


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
Primary diagnoses:
Respiratory failure s/p tracheostomy
Pneumonia- treated
Chronic obstructive pulmonary disease
Acute renal failure
Urinary tract infection
C. Diff colitis
Secondary diagnoses:
Renal cell carcinoma
Anemia of chronic disease


Discharge Condition:
Stable


Discharge Instructions:
Return to the emergency department if you develop difficulty
breathing, chest pain, worsening shortness of breath, decreasing
urine output, or any other concerning symptoms.
.
Please follow up with your primary care physician [**Last Name (NamePattern4) **] 1 week and
follow-up with your oncologist to determine the date for
debulking and continuation of epogen.
.
Please take medications as instructed.

Followup Instructions:
Please follow-up with your primary care physician [**Last Name (NamePattern4) **] 1 week
after discharge.
Provider: [**Name10 (NameIs) 843**] [**Name8 (MD) 844**], MD Phone:[**Telephone/Fax (1) 10533**]
Date/Time:[**2164-3-1**] 1:00
{'Acute and chronic respiratory failure,Obstructive chronic bronchitis with (acute) exacerbation,Pneumonia, organism unspecified,Acute diastolic heart failure,Cardiac arrest,Acute kidney failure with lesion of tubular necrosis,Intestinal infection due to Clostridium difficile,Malignant neoplasm of kidney, except pelvis,Urinary tract infection, site not specified,Pressure ulcer, lower back,Unspecified pleural effusion,Other disorders of plasma protein metabolism,Edema,Unspecified essential hypertension,Intestinal bypass or anastomosis status,Anemia in chronic kidney disease,Attention to colostomy,Delirium due to conditions classified elsewhere'}


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: Patient is a 66 yo f with pmh of stage iv renal cell ca, also
s/p recent colonic perforation with igmoid colectomy/Low
anterior resection with end colostomy and Hartmann's procedure,
who comes in with hypercarbic respiratory acidosis. She had a
recent admission for debulking nephrectomy for her RCC however,
it was never performed as she developed gram negative bacteremia
(B fragilis in [**12-5**] bottles) and subsequent bowel perforation.
Pt was treated broadly initially, then abx were tailored to
Levofloxacin, flagyl, and fluconazole. She was taken to the OR
for sigmoid colectomy/LAR with end colostomy and Hartmann's
procedure and jejunal feeding tube placement and then discharged
to [**Hospital **] rehab facility. For the past few days patient was
noted to be more hypoxic- and was treated with nebs and
prednisone. Finally today was sent into the ED for worsening
respiratory status.
.
In ED, VS were: p96.6, p105, 140/40, rr40, 87% 6L nc, 100% NRB.
Pt was found to have a increased pleural effusion (L>R), LLL
opacity. Lasix given without any improvement in respiratory
status. Pt was noted to be in severe respiratory distress with
RR in 50s ABG was found to be 7.21/104/200. Pt was urgently
intubated. Started on propofol drip, maintained good blood
pressures. Given cefepime, vanco, flagyl, lasix 20mg IV,
etomidate, succinylcholine, fentanyl, versed.

MEDICAL HISTORY: 1. emphysema/COPD
2. osteoporosis
3. fibrocystic breasts
4. s/p appendectomy
5. s/p ovarian cystectomy
6. s/p shoulder surgery
7. stage IV renal cell carcinoma

MEDICATION ON ADMISSION: Prednisone 60mg qd
ativan 0.5mg tid
atrovent neb q6h
levalbuterol neb q6h
ambien 10mg qhs
lopressor 50mg [**Hospital1 **]
benadryl
clotrimazole
lansoprazole 30mg qd
ondansetron prn
dalteparin 5000u qd
calcitonin
oxycodone 5-10mg
morphine 2mg
fentanyl 125mcg patch
lasix 20mg qd

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: vitals: tc 95.4, p78, 117/57, rr25, 94% AC 400/28/5/1
I/O: 1275/800
Gen: intubated, sedated, cachectic, chronically ill appearing
HEENT: PERRL
Lungs: diffuse expiratory rhonchi anteriorly
Heart: RRR, nl s1 s2, no m/g/r
Abd: soft, ND, J tube in place, large vertical incision,
colostomy bag in place with green stool
ext: 2+ edema bilaterally to hips

FAMILY HISTORY: Mother with cholangiocarcinoma. Father died of
complications of a peptic ulcer disease. Brother died at age 12

SOCIAL HISTORY: She is a widow. She lives alone in [**Location (un) 22287**]. She
shares a two-family house with her niece. She is retired. She
baby-sits two children. Tobacco, 1 pack a day, quit 7 months
ago. No alcohol. 

### Response:
{'Acute and chronic respiratory failure,Obstructive chronic bronchitis with (acute) exacerbation,Pneumonia, organism unspecified,Acute diastolic heart failure,Cardiac arrest,Acute kidney failure with lesion of tubular necrosis,Intestinal infection due to Clostridium difficile,Malignant neoplasm of kidney, except pelvis,Urinary tract infection, site not specified,Pressure ulcer, lower back,Unspecified pleural effusion,Other disorders of plasma protein metabolism,Edema,Unspecified essential hypertension,Intestinal bypass or anastomosis status,Anemia in chronic kidney disease,Attention to colostomy,Delirium due to conditions classified elsewhere'}
