CHIEF COMPLAINT: hypoxic respiratory failure and hypotension

PRESENT ILLNESS: Mr. [**Known lastname 11679**] is an 87 year old male with a history of COPD on 3L
O2, lung cancer and congestive heart failure who is transferred
from [**Hospital **] [**Hospital 1459**] hospital for hypoxic respiratory failure
requiring intubation and hypotension. Per the patient's wife he
has been feeling poorly for the past week.  He has not had any
documented fevers but has felt chilled.  He has had a cough
productive of clear sputum.  He has had worsening dyspnea on
exertion and oxygen requirements.  He was reluctant to go to the
hospital but his breathing became worse and his wife encouraged
his to go.
.
On arrival to [**Location (un) **] [**Location (un) 1459**] he was reported as being alert
and oriented, cyanotic, with diminished air movement
bilaterally, using accessory muscles of respiration.  He was
immediately intubated for hypoxic respiratory failure.  He
received initially received solumedrol 125 mg IV x 1,
azithromycin 500 mg IV, ceftriaxone 1 gram IV, lasix 40 mg IV,
etomidate 20 mg IV, vecuronium 1 mg IV and succinyulcholine 100
mv IV.  He became hypotensive and he received 2 liters normal
saline and was started on a dopamine gtt.  He subsequently
developed multifocal atrial tachycardia and was started on a
diltiazem drip and his pressor was switched to neosynephrine.
He also was started on propofol for sedation.   Labs were
notable for a WBC count of 21.2 with 89.4 % neutrophils,,
hemoglobin of 13.1.  Initial ABG post intubation was
7.31/68.1/293 on 500 x 15, FiO2 100%, PEEP 5.  Prior to transfer
his blood pressures were ranging from the 70s to 90s systolic.
.
On arrival he was intubated, sedated and unresponsive to
questions.  His blood pressures were in the 80s systolic on
neosynephrine.  The diltiazem drip was discontinued and his
heart rates were in the 70s with wandering atrial pacemaker.  He
received 3 liters normal saline with improvement in his blood
pressures to the 110s systolic.  He had an arterial line and a
right sided IJ placed.  Review of systems unable to be obtained.

MEDICAL HISTORY: COPD on 3L home oxygen
Lung Cancer (unknown histology)
Congestive Heart Failure
Benign Prostatic Hypertrophy

MEDICATION ON ADMISSION: Albuterol 90 mcg 2 puffs Q4H:P$N
Albuterol nebulizers Q6H:PRN
Aspirin 81 mg daily
Bacitracin ointment [**Hospital1 **]
Clonazepam 1 mg [**Hospital1 **]
Cyanocopbalamin 250 mcg daily
Digoxin 0.25 mg daily
Ferrous Gluconate 325 mg [**Hospital1 **]
Formoterol Fumarate 12 mcg inhaler [**Hospital1 **]
Guaifenesin 600 mg SA Tab [**Hospital1 **]
Ipratropium 17 mcg 2 puffs QID
Lisinopril 2.5 mg daily
Methylprednisolone 4 mg daily
Metoprolol XL 12.5 mg daily
Mom[**Name (NI) 6474**] furoate 220 mcg inhaler 1 puff [**Hospital1 **]
Morphine SR 15 mg [**Hospital1 **]
Multivitamin
SL Nitroglycerin
Senna
Simvastatin 10 mg QHS

ALLERGIES: No Drug Allergy Information on File

PHYSICAL EXAM: Physical Exam:
Vitals: T: 98.8 HR: 67 BP: 98/43 RR: 20 O2: 100%
Vent Settings: 550 x 15, PEEP 5, FiO2 100%
HEENT: PERRL, EOMI, oropharynx clear, mucous membranes dry
Neck: JVP flat
Cardiac:  Irregular, s1 + s2, no murmurs, rubs, gallops
Lungs:  Coarse breath sounds bilaterally, no wheezez, rales
GI: soft, large midline scare, non-tender, non-distended, +BS
GU: foley draining clear urine
Ext: Warm and well perfused, 1+ pulses, + clubbing, cyanosis or
edema
Neurologic:  Intubated, sedated, withdraws all extremities to
pain

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Lives with his wife in [**Name (NI) 2199**]. Previous smoker but quit in the
60s. Used to be a heavy drinker but none currently. He has two
daughters and three sons.
Unspecified septicemia,Acute respiratory failure,Malignant neoplasm of upper lobe, bronchus or lung,Pneumonitis due to inhalation of food or vomitus,Septic shock,Cachexia,Glucocorticoid deficiency,Severe sepsis,Chronic airway obstruction, not elsewhere classified,Congestive heart failure, unspecified,Other specified cardiac dysrhythmias,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Body Mass Index between 19-24, adult
Septicemia NOS,Acute respiratry failure,Mal neo upper lobe lung,Food/vomit pneumonitis,Septic shock,Cachexia,Glucocorticoid deficient,Severe sepsis,Chr airway obstruct NEC,CHF NOS,Cardiac dysrhythmias NEC,BPH w/o urinary obs/LUTS,BMI between 19-24,adult
Admission Date:  [**2192-3-27**]              Discharge Date:   [**2192-3-29**]


Service: MEDICINE

Allergies:
No Drug Allergy Information on File

Attending:[**First Name3 (LF) 99**]
Chief Complaint:
hypoxic respiratory failure and hypotension


Major Surgical or Invasive Procedure:
None

History of Present Illness:
Mr. [**Known lastname 11679**] is an 87 year old male with a history of COPD on 3L
O2, lung cancer and congestive heart failure who is transferred
from [**Hospital **] [**Hospital 1459**] hospital for hypoxic respiratory failure
requiring intubation and hypotension. Per the patient's wife he
has been feeling poorly for the past week.  He has not had any
documented fevers but has felt chilled.  He has had a cough
productive of clear sputum.  He has had worsening dyspnea on
exertion and oxygen requirements.  He was reluctant to go to the
hospital but his breathing became worse and his wife encouraged
his to go.
.
On arrival to [**Location (un) **] [**Location (un) 1459**] he was reported as being alert
and oriented, cyanotic, with diminished air movement
bilaterally, using accessory muscles of respiration.  He was
immediately intubated for hypoxic respiratory failure.  He
received initially received solumedrol 125 mg IV x 1,
azithromycin 500 mg IV, ceftriaxone 1 gram IV, lasix 40 mg IV,
etomidate 20 mg IV, vecuronium 1 mg IV and succinyulcholine 100
mv IV.  He became hypotensive and he received 2 liters normal
saline and was started on a dopamine gtt.  He subsequently
developed multifocal atrial tachycardia and was started on a
diltiazem drip and his pressor was switched to neosynephrine.
He also was started on propofol for sedation.   Labs were
notable for a WBC count of 21.2 with 89.4 % neutrophils,,
hemoglobin of 13.1.  Initial ABG post intubation was
7.31/68.1/293 on 500 x 15, FiO2 100%, PEEP 5.  Prior to transfer
his blood pressures were ranging from the 70s to 90s systolic.
.
On arrival he was intubated, sedated and unresponsive to
questions.  His blood pressures were in the 80s systolic on
neosynephrine.  The diltiazem drip was discontinued and his
heart rates were in the 70s with wandering atrial pacemaker.  He
received 3 liters normal saline with improvement in his blood
pressures to the 110s systolic.  He had an arterial line and a
right sided IJ placed.  Review of systems unable to be obtained.



Past Medical History:
COPD on 3L home oxygen
Lung Cancer (unknown histology)
Congestive Heart Failure
Benign Prostatic Hypertrophy


Social History:
Lives with his wife in [**Name (NI) 2199**]. Previous smoker but quit in the
60s. Used to be a heavy drinker but none currently. He has two
daughters and three sons.

Family History:
 Non-contributory

Physical Exam:
Physical Exam:
Vitals: T: 98.8 HR: 67 BP: 98/43 RR: 20 O2: 100%
Vent Settings: 550 x 15, PEEP 5, FiO2 100%
HEENT: PERRL, EOMI, oropharynx clear, mucous membranes dry
Neck: JVP flat
Cardiac:  Irregular, s1 + s2, no murmurs, rubs, gallops
Lungs:  Coarse breath sounds bilaterally, no wheezez, rales
GI: soft, large midline scare, non-tender, non-distended, +BS
GU: foley draining clear urine
Ext: Warm and well perfused, 1+ pulses, + clubbing, cyanosis or
edema
Neurologic:  Intubated, sedated, withdraws all extremities to
pain


Pertinent Results:
[**2192-3-27**] 03:18PM   GLUCOSE-88 UREA N-21* CREAT-1.1 SODIUM-142
POTASSIUM-4.6 CHLORIDE-110* TOTAL CO2-26 ANION GAP-11
[**2192-3-27**] 03:18PM   MAGNESIUM-2.2
[**2192-3-27**] 12:24PM   TYPE-ART PO2-83* PCO2-48* PH-7.29* TOTAL
CO2-24 BASE XS--3
[**2192-3-27**] 12:24PM   GLUCOSE-73 K+-3.6
[**2192-3-27**] 12:24PM   O2 SAT-96
[**2192-3-27**] 07:30AM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.004
[**2192-3-27**] 07:30AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2192-3-27**] 07:30AM URINE  RBC-3* WBC-11* BACTERIA-FEW YEAST-NONE
EPI-0
[**2192-3-27**] 07:30AM URINE  HYALINE-5*
[**2192-3-27**] 07:30AM URINE  MUCOUS-RARE
[**2192-3-27**] 06:41AM   TYPE-ART PO2-117* PCO2-53* PH-7.30* TOTAL
CO2-27 BASE XS-0
[**2192-3-27**] 06:41AM   LACTATE-1.0
[**2192-3-27**] 06:08AM   GLUCOSE-78 UREA N-19 CREAT-0.9 SODIUM-142
POTASSIUM-3.5 CHLORIDE-110* TOTAL CO2-27 ANION GAP-9
[**2192-3-27**] 06:08AM   estGFR-Using this
[**2192-3-27**] 06:08AM   ALBUMIN-2.3* CALCIUM-6.5* PHOSPHATE-2.1*
MAGNESIUM-1.5*
[**2192-3-27**] 06:08AM   DIGOXIN-1.8
[**2192-3-27**] 06:08AM   WBC-26.3* RBC-4.07* HGB-11.0* HCT-35.7*
MCV-88 MCH-27.1 MCHC-30.8* RDW-14.7
[**2192-3-27**] 06:08AM   NEUTS-91.2* LYMPHS-6.2* MONOS-2.1 EOS-0.3
BASOS-0.1
[**2192-3-27**] 06:08AM   PLT COUNT-245
[**2192-3-27**] 06:08AM   PT-13.7* PTT-31.5 INR(PT)-1.2*

Echo [**3-27**]:
Conclusions
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
low normal (LVEF 50-55%). The right ventricular cavity is
moderately dilated with mild global free wall hypokinesis. The
aortic valve leaflets (3) are mildly thickened. There is a
minimally increased gradient consistent with minimal aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. Moderate [2+] tricuspid
regurgitation is seen. There is at least borderline pulmonary
artery systolic hypertension. A trivial pericardial effusion is
seen.
IMPRESSION: Suboptimal image quality. Low normal left
ventricular systolic function. Moderately dilated right
ventricle with mild hypokinesis. Moderate tricuspid
regurgitation. Minimal aortic stenosis. Borderline pulmonary
hypertension (may be underestimated).

CXR [**3-28**]:
Cardiomediastinal silhouette is unchanged as well as there is no
change in the right upper lobe mass highly suspicious for
neoplasm. Interval development of left lower lobe opacity is
consistent with aspiration. Bilateral pleural effusions are
present, small.


Brief Hospital Course:
Impression: 87 year old male with a history of COPD on 3L O2,
lung cancer and congestive heart failure who is transferred from
[**Hospital **] [**Hospital 1459**] hospital for hypoxic respiratory failure
requiring intubation and hypotension.

Shock:  Patient with subjective fevers at home, leukocytosis and
hypotension concerning for septic shock.  Other potential
etiologies for this patient include cardiogenic shock given his
history of congestive heart failure and adrenal insufficiency
given chronic steroids.  Less likely etiologies are hypovolemic,
hemorrhagic, or obstructive shock.  In terms of etiologies for
septic shock, pneumonia appears to be the most likely etiology
although we will cover him broadly for now.  After discussion
with family, goals of care clarified, no further escalation of
care wanted.  Patient extubated, abx and blood pressure support
withdrawn as patient made CMO.

Hypoxemic Respiratory Failure:  Patient with tenuous lung
function at baseline with known malignancy, home oxygen
requirement and obstructive lung disease.  PaO2/FiO2 = 117.
Given bilateral infiltrates and no clear evidence for congestive
heart failure meets criteria for ARDS.  CXR today with new LLL
infiltrate c/f aspiration PNA.  Patient extubated on [**3-28**],
pressors and abx withdrawn per CMO request.  Patient expired on
[**3-29**] after being made CMO the previous day.

Multifocal Atrial Tachycardia:  Likely related to underlying
lung disease.  Heart rate currently in the 70s off diltiazem.
Patient monitored on telemetry.

Lung Cancer:  Diagnosed approximately one year ago.  Unclear
what treatment he has had or degree of metastatic disease.

Congestive Heart Failure:  Ejection fraction 50% per echo on on
[**3-27**].  Low normal left ventricular systolic function. Moderately
dilated right ventricle with mild hypokinesis. Moderate
tricuspid regurgitation. Minimal aortic stenosis. Borderline
pulmonary hypertension

Code:  DNR/DNI.  Patient made CMO
Communication:  Wife [**Name (NI) **] [**Name (NI) 11679**] (phone number unknown
Disposition:  Patient made CMO per his previously stated wishes.
 He was placed on CMO status and expired on [**3-29**].




Medications on Admission:
Albuterol 90 mcg 2 puffs Q4H:P$N
Albuterol nebulizers Q6H:PRN
Aspirin 81 mg daily
Bacitracin ointment [**Hospital1 **]
Clonazepam 1 mg [**Hospital1 **]
Cyanocopbalamin 250 mcg daily
Digoxin 0.25 mg daily
Ferrous Gluconate 325 mg [**Hospital1 **]
Formoterol Fumarate 12 mcg inhaler [**Hospital1 **]
Guaifenesin 600 mg SA Tab [**Hospital1 **]
Ipratropium 17 mcg 2 puffs QID
Lisinopril 2.5 mg daily
Methylprednisolone 4 mg daily
Metoprolol XL 12.5 mg daily
Mom[**Name (NI) 6474**] furoate 220 mcg inhaler 1 puff [**Hospital1 **]
Morphine SR 15 mg [**Hospital1 **]
Multivitamin
SL Nitroglycerin
Senna
Simvastatin 10 mg QHS


Discharge Medications:
None

Discharge Disposition:
Expired

Discharge Diagnosis:
Lung cancer

Discharge Condition:
Death

Discharge Instructions:
None

Followup Instructions:
None
{'Unspecified septicemia,Acute respiratory failure,Malignant neoplasm of upper lobe, bronchus or lung,Pneumonitis due to inhalation of food or vomitus,Septic shock,Cachexia,Glucocorticoid deficiency,Severe sepsis,Chronic airway obstruction, not elsewhere classified,Congestive heart failure, unspecified,Other specified cardiac dysrhythmias,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Body Mass Index between 19-24, adult'}


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: hypoxic respiratory failure and hypotension

PRESENT ILLNESS: Mr. [**Known lastname 11679**] is an 87 year old male with a history of COPD on 3L
O2, lung cancer and congestive heart failure who is transferred
from [**Hospital **] [**Hospital 1459**] hospital for hypoxic respiratory failure
requiring intubation and hypotension. Per the patient's wife he
has been feeling poorly for the past week.  He has not had any
documented fevers but has felt chilled.  He has had a cough
productive of clear sputum.  He has had worsening dyspnea on
exertion and oxygen requirements.  He was reluctant to go to the
hospital but his breathing became worse and his wife encouraged
his to go.
.
On arrival to [**Location (un) **] [**Location (un) 1459**] he was reported as being alert
and oriented, cyanotic, with diminished air movement
bilaterally, using accessory muscles of respiration.  He was
immediately intubated for hypoxic respiratory failure.  He
received initially received solumedrol 125 mg IV x 1,
azithromycin 500 mg IV, ceftriaxone 1 gram IV, lasix 40 mg IV,
etomidate 20 mg IV, vecuronium 1 mg IV and succinyulcholine 100
mv IV.  He became hypotensive and he received 2 liters normal
saline and was started on a dopamine gtt.  He subsequently
developed multifocal atrial tachycardia and was started on a
diltiazem drip and his pressor was switched to neosynephrine.
He also was started on propofol for sedation.   Labs were
notable for a WBC count of 21.2 with 89.4 % neutrophils,,
hemoglobin of 13.1.  Initial ABG post intubation was
7.31/68.1/293 on 500 x 15, FiO2 100%, PEEP 5.  Prior to transfer
his blood pressures were ranging from the 70s to 90s systolic.
.
On arrival he was intubated, sedated and unresponsive to
questions.  His blood pressures were in the 80s systolic on
neosynephrine.  The diltiazem drip was discontinued and his
heart rates were in the 70s with wandering atrial pacemaker.  He
received 3 liters normal saline with improvement in his blood
pressures to the 110s systolic.  He had an arterial line and a
right sided IJ placed.  Review of systems unable to be obtained.

MEDICAL HISTORY: COPD on 3L home oxygen
Lung Cancer (unknown histology)
Congestive Heart Failure
Benign Prostatic Hypertrophy

MEDICATION ON ADMISSION: Albuterol 90 mcg 2 puffs Q4H:P$N
Albuterol nebulizers Q6H:PRN
Aspirin 81 mg daily
Bacitracin ointment [**Hospital1 **]
Clonazepam 1 mg [**Hospital1 **]
Cyanocopbalamin 250 mcg daily
Digoxin 0.25 mg daily
Ferrous Gluconate 325 mg [**Hospital1 **]
Formoterol Fumarate 12 mcg inhaler [**Hospital1 **]
Guaifenesin 600 mg SA Tab [**Hospital1 **]
Ipratropium 17 mcg 2 puffs QID
Lisinopril 2.5 mg daily
Methylprednisolone 4 mg daily
Metoprolol XL 12.5 mg daily
Mom[**Name (NI) 6474**] furoate 220 mcg inhaler 1 puff [**Hospital1 **]
Morphine SR 15 mg [**Hospital1 **]
Multivitamin
SL Nitroglycerin
Senna
Simvastatin 10 mg QHS

ALLERGIES: No Drug Allergy Information on File

PHYSICAL EXAM: Physical Exam:
Vitals: T: 98.8 HR: 67 BP: 98/43 RR: 20 O2: 100%
Vent Settings: 550 x 15, PEEP 5, FiO2 100%
HEENT: PERRL, EOMI, oropharynx clear, mucous membranes dry
Neck: JVP flat
Cardiac:  Irregular, s1 + s2, no murmurs, rubs, gallops
Lungs:  Coarse breath sounds bilaterally, no wheezez, rales
GI: soft, large midline scare, non-tender, non-distended, +BS
GU: foley draining clear urine
Ext: Warm and well perfused, 1+ pulses, + clubbing, cyanosis or
edema
Neurologic:  Intubated, sedated, withdraws all extremities to
pain

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Lives with his wife in [**Name (NI) 2199**]. Previous smoker but quit in the
60s. Used to be a heavy drinker but none currently. He has two
daughters and three sons. 

### Response:
{'Unspecified septicemia,Acute respiratory failure,Malignant neoplasm of upper lobe, bronchus or lung,Pneumonitis due to inhalation of food or vomitus,Septic shock,Cachexia,Glucocorticoid deficiency,Severe sepsis,Chronic airway obstruction, not elsewhere classified,Congestive heart failure, unspecified,Other specified cardiac dysrhythmias,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Body Mass Index between 19-24, adult'}
