CHIEF COMPLAINT: Hypoxia.

PRESENT ILLNESS: This is a 73-year-old male with
multiple medical problems including a history of COPD and
recent craniotomy with resection of a glioblastoma multiforme
in [**2110-1-20**], with initial XRT in [**2110-2-20**], who presented
to the ED last evening following XRT treatment with increased
shortness of breath and hypoxia.  The patient states that
shortness of breath has been times one month since starting
chemo and XRT, which has gradually been worsening.  He was
seen in clinic on [**2110-3-9**] with fatigue, decreased p.o., and
increased shortness of breath.  At that point, temozolomide
was stopped and Dilantin was stopped.  He had a chest x-ray,
which was negative.  No cough, no orthopnea, no chest pain,
no nausea or vomiting, diarrhea or dysuria, no abdominal
pain, no fevers or chills.  No sick contacts, and no recent
travel.  In the ED, ABG showed 7.50/31/35 on room air.  CTA
was negative for PE and nonspecific ground-glass opacities.
The patient was started on Bactrim and increased steroids for
question of PCP.  [**Name10 (NameIs) **], ABGs with continued hypoxia with
increasing lactates, he was transferred to the unit for
closer monitoring.

MEDICAL HISTORY: CAD status post CABG in [**2093**].

MEDICATION ON ADMISSION: 

ALLERGIES: MORPHINE AND CODEINE CAUSE NAUSEA AND VOMITING.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Pneumonia, organism unspecified,Acute respiratory failure,Chronic airway obstruction, not elsewhere classified,Malignant neoplasm of brain, unspecified,Hyposmolality and/or hyponatremia,Congestive heart failure, unspecified,Nonspecific low blood pressure reading,Coronary atherosclerosis of unspecified type of vessel, native or graft,Unspecified essential hypertension
Pneumonia, organism NOS,Acute respiratry failure,Chr airway obstruct NEC,Malig neo brain NOS,Hyposmolality,CHF NOS,Low blood press reading,Cor ath unsp vsl ntv/gft,Hypertension NOS
Admission Date: [**2110-3-28**]        Discharge Date: [**2110-4-7**]

Date of Birth:  [**2036-2-14**]        Sex:  M

Service:  OMED


CHIEF COMPLAINT:  Hypoxia.

HISTORY OF PRESENT ILLNESS:  This is a 73-year-old male with
multiple medical problems including a history of COPD and
recent craniotomy with resection of a glioblastoma multiforme
in [**2110-1-20**], with initial XRT in [**2110-2-20**], who presented
to the ED last evening following XRT treatment with increased
shortness of breath and hypoxia.  The patient states that
shortness of breath has been times one month since starting
chemo and XRT, which has gradually been worsening.  He was
seen in clinic on [**2110-3-9**] with fatigue, decreased p.o., and
increased shortness of breath.  At that point, temozolomide
was stopped and Dilantin was stopped.  He had a chest x-ray,
which was negative.  No cough, no orthopnea, no chest pain,
no nausea or vomiting, diarrhea or dysuria, no abdominal
pain, no fevers or chills.  No sick contacts, and no recent
travel.  In the ED, ABG showed 7.50/31/35 on room air.  CTA
was negative for PE and nonspecific ground-glass opacities.
The patient was started on Bactrim and increased steroids for
question of PCP.  [**Name10 (NameIs) **], ABGs with continued hypoxia with
increasing lactates, he was transferred to the unit for
closer monitoring.

PAST MEDICAL HISTORY:  CAD status post CABG in [**2093**].

Right upper lobe resection secondary to abscess in [**2094**] later
found to be Aspergillus

Prostate cancer in [**2106**] status post XRT.

Left hip fracture.

Hyperlipidemia

Hypertension.

COPD.

Basal cell carcinoma on nose.

Right frontal glioblastoma multiforme status post resection
[**1-23**] with XRT on steroids.

MEDICATIONS AT HOME:
1. Keppra.
2. Decadron.
3. Cardizem.
4. Protonix.
5. Neurontin.
6. Lipitor.
7. Quinine 325.
8. Aspirin.


MEDICATIONS ON TRANSFER:
1. Albuterol and Atrovent nebulizers.
2. Tylenol p.r.n.
3. Regular insulin sliding scale.
4. Senokot.
5. Colace.
6. Heparin subcutaneous t.i.d.
7. Levofloxacin 500 once daily.
8. Quinine 325.
9. Atorvastatin 20 once daily.
10.      Neurontin 300 once daily.
11.      Diltiazem 300 once daily.
12.      Protonix 40 once daily.
13.      Bactrim 400 IV q.8.
14.      Decadron 6 mg b.i.d.
15.      Keppra 500 in a.m. and 1000 in p.m.


ALLERGIES:  MORPHINE AND CODEINE CAUSE NAUSEA AND VOMITING.

PHYSICAL EXAMINATION:  Vital signs:  Afebrile.  Blood
pressure 166/89, pulse 77, pulse ox 98 on 100 percent
nonrebreather.  General:  Mild shortness of breath, but is
able to speak in full sentences.  HEENT:  PERRLA.  EOMI.
White coat on palate.  Cardiovascular:  S1, S2.  Regular.
Pulmonary:  Crackles left greater than right.  Bronchial
breath sounds throughout.  Abdomen:  Soft, nontender, and
nondistended.  Extremities:  No clubbing, cyanosis, edema.
Neurologic:  Grossly intact.

LABORATORY DATA:  Laboratory on admission to the SICU, white
count 18.9, hematocrit 45, platelets 151, differential is 91
neutrophils, 2 bands, 5 lymphs.  PT 12.4, INR 12.4.
Chemistry is sodium 131, potassium 4.3, chloride 96,
bicarbonate 21, BUN 30, creatinine 1.3, glucose 132, ALT 38,
AST 23, amylase 70, lipase 23, total bilirubin 0.4, alkaline
phosphatase 72, albumin 3.3.  ABG pH 7.5, CO2 26, oxygen 50,
and lactate 4.6.  Microbiology shows, induced sputum, no
growth to date, urine culture no growth to date, and blood
culture [**12-23**], no growth to date.

CTA from [**3-27**] shows no PA emphysematous changes, nonspecific
ground-glass opacity to both lungs consistent with infectious
or inflammatory disease or pulmonary edema.

Echocardiogram shows EF of 35 percent with akinesis and
thinning of anterior septal, inferior septum, inferior wall.
Normal PA pressures, no effusion, dilated left and right
atrium.

HOSPITAL COURSE:  Hypoxia/respiratory failure:  The patient
is admitted to SICU for further evaluation of his
hypoxia/respiratory failure.  The patient had been
empirically treated for a possible pneumonia.  Given his
history of malignancy and steroids, he was felt to be at
increased risk for PCP.  [**Name10 (NameIs) **] was subsequently started on
Bactrim and was placed on increased doses of steroids.
Meanwhile, he was also treated for possible bacterial process
with broad spectrum antibiotics including Levaquin and
Ceftaz.  The cause of the patient's respiratory demise
remained unclear throughout his hospital course.  However, he
progressively worsened in terms of his oxygen requirements.
By [**4-1**], he was placed on BiPAP for increased respiratory
distress.  When he was not continuing to improve and had an
increased hypoxia, he was emergently intubated on the evening
of [**2110-4-3**].  Initially, there were concerns about PCP as
mentioned above.  Family and team were hesitant to
bronchoscope the patient secondary to requirements for
intubation.  Initial discussions with the family stressed
that the patient and family would not be interested in
aggressive long-term measures such as intubation.
Ultimately, after the patient was intubated a bronchoscopy
was performed.  Bronchoscopy stains were negative for PCP and
fungal cultures were pending.  His sputum ultimately grew out
staph aureus and the patient was later changed to oxacillin.
Infectious disease was consulted for further evaluation.  He
was placed on voriconazole empirically secondary to concerns
about occult infections with fungus.  His condition failed to
improve, however.  There were also some thoughts that
possibly CHF could be an etiology of the patient's hypoxia.
He was gently diuresed, but did not respond well, resulted in
hypotension and increased renal insufficiency.  Family had
been offered a Swan at one  point, but refused.  Secondary to
the patient's response with hypotension and increased renal
insufficiency, CHF was not felt to be a large component of
his respiratory demise.  Cardiothoracic surgery was consulted
for evaluation of a possible VATS for further evaluation of
the patient's pulmonary demise.  Again, the family was not
interested in any aggressive measures.  Later during end of
hospital course, the patient has spiked fever and since
sputum grew out staph, oxacillin was added for possible
ventilator associated pneumonia.  At onset of the patient's
care in the ICU, the patient and family had expressed
reservations about long-term management on ventilators
particularly if situation was not promising.  After multiple
discussions with family during the [**Hospital 228**] hospital course,
it was ultimately decided that the patient's prognosis was
extremely poor, especially given his unclear etiology of
respiratory demise in the setting of a known CNS malignancy.
It was decided that the patient would be extubated on [**4-7**],
in the evening.  He expired several minutes later.

CHF:  The patient had echo from [**3-28**], showing EF of 35
percent as mentioned above, the patient's respiratory demise
was unclear in etiology.  There were some concern that CHF
may have been playing a role.  However, the patient had less
than adequate response to diuresis involving hypotension and
renal insufficiency.  Family had declined a Swan at one
point.  Given the patient's persistent hypotension with
diuresis, it was felt that CHF was not the etiology for his
respiratory failure.  His ACE was given cautiously secondary
to hypotension and renal failure.

CAD:  The patient was maintained on aspirin and low-dose
Lipitor.

Hypotension:  As mentioned above unclear in etiology.  The
patient responded to IV fluids on several occasions.  It was
felt that some of the hypotension may have been diuresed
induced.

Glioblastoma multiforme:  The patient had been in the midst
of receiving XRT during his hospitalization.  After his
respiratory status worsened, he was unable to continue with
further XRT.  Ultimately, his poor prognosis involving his
respiratory failure and his glioblastoma multiforme was the
key factor in the patient's family deciding to withdraw care.

Thrombocytopenia:  Unclear etiology.  Heparin induced
antibodies were sent and still pending at the time of death.

Acute renal insufficiency:  The patient developed mild renal
insufficiency with creatinines up to 1.5 and 1.6.  It was
thought that possibly over-diuresis may have been the
possible culprit.  Special care was used in order to renally
dose his medications.

DISPOSITION:  As mentioned above, the patient failed to show
significant improvement throughout his hospital course and in
fact his oxygen requirements increased.  After multiple
discussions with the family and primary ICU team, it was
decided to withdraw care of the patient and extubate him on
the evening of [**4-7**].  He passed away shortly at 08:32 in
the evening with the family at bed side.

DISCHARGE DIAGNOSES:  Death.

Respiratory failure/hypoxia of unclear etiology.

Glioblastoma multiforme.

Transient hypotension.

Acute renal insufficiency.

Thrombocytopenia.



                        [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55220**]

Dictated By:[**Last Name (NamePattern1) 11267**]
MEDQUIST36
D:  [**2110-8-5**] 16:48:57
T:  [**2110-8-6**] 04:13:02
Job#:  [**Job Number 55221**]
{'Pneumonia, organism unspecified,Acute respiratory failure,Chronic airway obstruction, not elsewhere classified,Malignant neoplasm of brain, unspecified,Hyposmolality and/or hyponatremia,Congestive heart failure, unspecified,Nonspecific low blood pressure reading,Coronary atherosclerosis of unspecified type of vessel, native or graft,Unspecified essential hypertension'}


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: Hypoxia.

PRESENT ILLNESS: This is a 73-year-old male with
multiple medical problems including a history of COPD and
recent craniotomy with resection of a glioblastoma multiforme
in [**2110-1-20**], with initial XRT in [**2110-2-20**], who presented
to the ED last evening following XRT treatment with increased
shortness of breath and hypoxia.  The patient states that
shortness of breath has been times one month since starting
chemo and XRT, which has gradually been worsening.  He was
seen in clinic on [**2110-3-9**] with fatigue, decreased p.o., and
increased shortness of breath.  At that point, temozolomide
was stopped and Dilantin was stopped.  He had a chest x-ray,
which was negative.  No cough, no orthopnea, no chest pain,
no nausea or vomiting, diarrhea or dysuria, no abdominal
pain, no fevers or chills.  No sick contacts, and no recent
travel.  In the ED, ABG showed 7.50/31/35 on room air.  CTA
was negative for PE and nonspecific ground-glass opacities.
The patient was started on Bactrim and increased steroids for
question of PCP.  [**Name10 (NameIs) **], ABGs with continued hypoxia with
increasing lactates, he was transferred to the unit for
closer monitoring.

MEDICAL HISTORY: CAD status post CABG in [**2093**].

MEDICATION ON ADMISSION: 

ALLERGIES: MORPHINE AND CODEINE CAUSE NAUSEA AND VOMITING.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Pneumonia, organism unspecified,Acute respiratory failure,Chronic airway obstruction, not elsewhere classified,Malignant neoplasm of brain, unspecified,Hyposmolality and/or hyponatremia,Congestive heart failure, unspecified,Nonspecific low blood pressure reading,Coronary atherosclerosis of unspecified type of vessel, native or graft,Unspecified essential hypertension'}
