CHIEF COMPLAINT: Hypoxic respiratory failure

PRESENT ILLNESS: HPI: Pt is a 58 y/o f with htn, dm2, hypercholesterolemia who
presented to an OSH with increasing sob and cxr/chest CT
infiltrates felt to respresent an ILD, was transferred to [**Hospital1 18**]
floor for further work-up, underwent VATS 1 day prior to MICU
admission, and developed hypoxemia and respiratory distress on
the night of admission, prompting micu transfer and intubation.
Apparently she first began developing sx one month prior to
presenting to the OSH with increasing sob, attributed at first
to a pneumonia that did not respond to antibiotics. Her sx
worsened and her doctor got a chest CT with diffuse bilateral
interstitial and ground glass opacities. At OSH, was ruled-out
for MI, negative stress test, echo with decreased e/a ratio, cta
without pe. She was transferred to [**Hospital1 18**] and underwent VATS one
night prior to MICU transfer, with the chest tube removed the
day of transfer. Overnight, she was seen by the nightfloat for
hypoxia and tachypnea, transferred to the MICU, and intubated.
.

MEDICAL HISTORY: 1.)HTN
2.)DM2
3.)Hypercholesterolemia
4.)Hypothyroidism

MEDICATION ON ADMISSION: Levothyroxine 100mcg QD
Glyburide 5mg [**Hospital1 **]
Glucophage 500mg [**Hospital1 **]
ASA 325 QD
Cozaar 50mg QD (per pt, on Diovan?)
?Detrol LA (per patient. Not per doctor)
?Lipitor 10mg QD (per doctor. Not per patient)
recent Levaquin

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE: t 97.8, bp 96/50, hr 88, rr 20, spo2 97%
vent- a/c vt 400/rr 16/peep 10/fio2 1.00
gen- anxious-appearing female, looks age, mod distress
cv- rrr, s1s2, no m/r/g
pul- moves air well, clear anteriorly, velcro rales [**12-18**] way both
lung fields
abd- soft, nd, nabs
extrm- no cyanosis/edema, warm/dry
nails- no clubbing, painted
neuro- sedated, intubated, perrl

FAMILY HISTORY: Fhx: Mother had MI in her 70's - now with a pacemaker, also
currently being treated for lymphoma. Father has died, but had
lupus and had CABG at age 70. Brother had an MI and CABG at age
55.

SOCIAL HISTORY: SocHx: Married. Lives with her husband and children. Works as a
manager for an outside vendor at [**Company 22916**] company. Quit smoking
20 years ago, had smoked 1ppd x 10 years. No hx EtOH or drug
abuse.
Other specified alveolar and parietoalveolar pneumonopathies,Acute and chronic respiratory failure,Pneumocystosis,Methicillin susceptible pneumonia due to Staphylococcus aureus,Congestive heart failure, unspecified,Hyposmolality and/or hyponatremia,Postinflammatory pulmonary fibrosis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Pure hypercholesterolemia,Unspecified acquired hypothyroidism,Anxiety state, unspecified,Anemia of other chronic disease,Constipation, unspecified
Alveol pneumonopathy NEC,Acute & chronc resp fail,Pneumocystosis,Meth sus pneum d/t Staph,CHF NOS,Hyposmolality,Postinflam pulm fibrosis,DMII wo cmp nt st uncntr,Hypertension NOS,Pure hypercholesterolem,Hypothyroidism NOS,Anxiety state NOS,Anemia-other chronic dis,Constipation NOS
Admission Date:  [**2108-9-5**]              Discharge Date:   [**2108-10-6**]

Date of Birth:  [**2049-12-26**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 7934**]
Chief Complaint:
Hypoxic respiratory failure

Major Surgical or Invasive Procedure:
Intubation, esophageal baloon

History of Present Illness:
HPI: Pt is a 58 y/o f with htn, dm2, hypercholesterolemia who
presented to an OSH with increasing sob and cxr/chest CT
infiltrates felt to respresent an ILD, was transferred to [**Hospital1 18**]
floor for further work-up, underwent VATS 1 day prior to MICU
admission, and developed hypoxemia and respiratory distress on
the night of admission, prompting micu transfer and intubation.
Apparently she first began developing sx one month prior to
presenting to the OSH with increasing sob, attributed at first
to a pneumonia that did not respond to antibiotics. Her sx
worsened and her doctor got a chest CT with diffuse bilateral
interstitial and ground glass opacities. At OSH, was ruled-out
for MI, negative stress test, echo with decreased e/a ratio, cta
without pe. She was transferred to [**Hospital1 18**] and underwent VATS one
night prior to MICU transfer, with the chest tube removed the
day of transfer. Overnight, she was seen by the nightfloat for
hypoxia and tachypnea, transferred to the MICU, and intubated.
.


Past Medical History:
1.)HTN
2.)DM2
3.)Hypercholesterolemia
4.)Hypothyroidism


Social History:
SocHx: Married. Lives with her husband and children. Works as a
manager for an outside vendor at [**Company 22916**] company. Quit smoking
20 years ago, had smoked 1ppd x 10 years. No hx EtOH or drug
abuse.


Family History:
Fhx: Mother had MI in her 70's - now with a pacemaker, also
currently being treated for lymphoma. Father has died, but had
lupus and had CABG at age 70. Brother had an MI and CABG at age
55.


Physical Exam:
PE: t 97.8, bp 96/50, hr 88, rr 20, spo2 97%
vent- a/c vt 400/rr 16/peep 10/fio2 1.00
gen- anxious-appearing female, looks age, mod distress
cv- rrr, s1s2, no m/r/g
pul- moves air well, clear anteriorly, velcro rales [**12-18**] way both
lung fields
abd- soft, nd, nabs
extrm- no cyanosis/edema, warm/dry
nails- no clubbing, painted
neuro- sedated, intubated, perrl


Pertinent Results:
DATA:
.
Non Contrast CT chest [**9-6**]
IMPRESSION: Diffuse lung disease with a basal predominance. The
differential diagnosis include NSIP, UIP, or COP. The less
likely differentials are chronic hypersensitivity pneumonitis,
sarcoidosis and drug related lung disease. If the patient is
immunocompromised, atypical infection such as PCP could be [**Name Initial (PRE) **]
possibility.
2) Mediastinal lymphadenopathy.
3) Innumerable small sub cm axillary lymph nodes and a 10 mm
right
prepectoral enlarged node.Clinical correlation recommended.
.
Bronch [**9-10**]:  showed no DAH and had no complications.
.
VATS DATA ([**9-7**]):
Right middle lobe, wedge biopsy:
a. Acute and organizing interstitial pneumonitis with features
of bronchiolitis obliterans/organizing pneumonitis (BOOP).
b. Intraparenchymal lymph node.
Right lower lobe biopsy:
a. Acute and organizing interstitial pneumonitis with features
of bronchiolitis obliterans/organizing pneumonitis (BOOP).
b. Subpleural fibrosis and pleural adhesions.
Note: Stains for bacteria and fungi are negative.
.
Other Lab Data:  +[**Doctor First Name **] (1:80), -ANCA, Neg Anti GBM.
.
CT Scan of Chest [**10-4**]
There are multiple subcentimeter right and left paratracheal,
prevascular, precarinal, and subcarinal lymph nodes measuring up
to 7 mm in diameter that do not individually meet criteria for
pathologic enlargement. There are no pathologically enlarged
axillary lymph nodes. There is a tiny left pleural effusion,
decreased in size from the previous examination. In comparison
with the examination of [**2108-9-17**], there is mild increase
in consolidative opacity within the airspaces at the lung bases
bilaterally and within the superior segment of the left lower
lobe. There is additional increase in air space consolidation at
the lung apices bilaterally, with patchy foci of dense
consolidation at the right lung apex and in left perihilar and
apical location. The distribution and extent of patchy
geographic ground-glass opacity throughout the remainder of the
lungs is probably not significantly changed in the interval.
Sutures are again seen at the right lung base. There is no
pneumothorax. Limited images of the liver, spleen, adrenal
glands, upper poles of the kidneys, appear unremarkable. There
is a small amount of dependent density within the gallbladder
suggestive of small stones or milk of calcium. BONE WINDOWS:
Bone windows demonstrate multiple right-sided rib deformities
consistent with old healed fractures. No suspicious lytic or
sclerotic osseous lesions are identified. IMPRESSION: 1.
Interval progression of bilateral airspace consolidation, most
prominent at the lung bases and within the superior segment of
the left lower lobe, and additionally involving the lung apices
and central perihilar regions. The geographic patchy ground
glass opacity appears approximately unchanged in distribution.
2. Decrease in size of small left pleural effusion. 3. Probable
gallstones or milk of calcium.


Brief Hospital Course:
AA/P: 58 y/o f with htn, DM2 and newly diagnosed ILD 1 day s/p
[**Hospital **] transferred to MICU and intubated for hypoxic respiratory
failure.  Extubated and improved for 5 days, then required
reintubation and remains intubated with increasing O2
requirements with a diagnosis of PCP [**Name Initial (PRE) 11091**] (by BAL) superimposed
on her BOOP diagnosis.
.
1) Hypoxic respiratory failure -- Chest x-ray, discussed with
radiology, had appearance of progressive disease.  Final results
of VATS consistent with organizing interstitial pneumonitis with
features of BOOP.  She progressed on antibiotics in the past,
had no fever/wbc, all making an overlying infectious process
seem unlikely at the time.  Pt had fairly normal echo at the
OSH, making failure also seem to be an unlikely candidate.  Pt
was on high dose solumedrol during this time.  Pts repiratory
function improved, and she was extubted on [**9-12**].  She remained
on high flow mask until [**9-18**] but was very anxious with
occasional desats and CT chest on [**9-17**] showed worsening
bilateral infiltrates.  BAL was done [**9-18**] and she was paralyzed
with cisatracurium at 0.16mg/kg/hr and an esopageal baloon was
placed and she was reintubated on APRV and then PC ventillation.
 BAL micro data grew PCP pneumonia and IV Bactrim was started.
The question remains whether this was in the setting of high
dose steroids (only short course prior to diagnosis) or due to
an underlying immunocompromised condition.  ID was consulted
after several days of continued inability to wean with high
loading pressures (>30).  Several fungal studies were negative
as were autoimmune serologies except for [**Doctor First Name **] which was positive
(RF negative).   Steroids were dosed at 60mg IV BID starting
[**9-20**].  On [**9-25**], she was reintubated over a guidewire for cuff
leak.  For the next several days, all attempts to wean
ventillation were unsuccessful. The patient remained fluid
overloaded and daily I/O goals were net negative.  She received
fluids with antibiotics, etc. that made this difficult to attain
and lasix drip was used intermittently.  In addition, the
patient has an underlying anxiety disorder and required
increasing amounts of sedation of both Fentanyl and Versed.  As
soon as sedation began to wean, BP was >185 systolic with
apparant distress.  Several times, during daily sedation weans,
we asked the pt to report on any pain.  She responded with head
nods or shakes appropriately to questions and denied any pain or
other known sources of what could have been contributing to her
elevated BP.  She did admit to being anxious.  Starting around
[**9-30**], discussions about trach began with the family.  Per IP,
given her high PEEP requirement on AC (>10), a surgical should
be considered as well. Between [**Date range (1) 11301**], she required
occasional increased in FiO2 requirement and on the morning of
[**10-5**], on 100% FiO2 and PEEP of 12, O2 sats were in the mid 80's
after one desat to the mid 70s.  Bronch revealed no plugging.
Given high FiO2, no BAL was performed.  Secretions have been
bloody at times, but no visible trauma on BAL.  In addition,
occasional blood in NG residuals had persisted since [**10-3**], but
negative NG lavages.  At this time, discussions with the family
re: this turn for the worse began.  On [**10-5**], Md. [**Known lastname 1637**] is on
PC with an FiO2 of 100%, PEEP 18, PIP 33, RR 20, MAP 22.  Her
CXRs for the past few days have been significantly worse.  We
started vancomycin and meropenam on [**10-4**] for Coag + Staph
aureus in the sputum from [**10-2**] ([**Last Name (un) 36**] pending) and worsening
CXRs.  CT done yesterday was consistent with worsening
infiltrates.
.
2) PCP [**Name Initial (PRE) **]:  Pts repiratory function took a turn for the
worse several days ago requiring re-intubation due to PCP PNA
determined to have PCP PNA on BAL.
- IV Bactrim Q8 dosing for PCP PNA in setting of steroids.
.
3) Anxiety and sedation:  Underlying anxiety disorder.  There is
a clear relationship between elevated BP and anxiety.  Sedation
resolves both issues for now.
Sedation switched a few times during the admission from
fentanyl/versed to propofol.  Most recently, this is being done
on [**10-5**].
.
4) DM -- Ins gtt.
.
5) Anemia - HCT stable in mid 20's.  Had anemia of chronic dz
per data this admission.
.
6) Hyponatremia- persists.  Changed bactrim to be loaded in NS
instead of D5 (>1L daily fluid) on [**10-4**] with some improvement.
Had ranged 128-134.
.
7) Gut immobilization/FEN-  For several weeks, the patient has
had high rediduals with tube feeding.  She has had enemas QID
with lactulose as well as a full complement of PO bowel
medications and IV erythromycin (due to residuals on PO).  TPN
was commenced on [**10-4**].  See hyponatremia above.  Repleating
other lytes as necessary.  She had a contraction alkalosis with
hypochloridia due to diuresis as well.
.
8) Ppx -- Sc heparin, pneumoboots, PPI
.
9) Access -- R subclavian (placed [**9-17**]), peripherals, A line
(placed [**2108-9-21**])
.
10) Comm -- with husband and PCP(Dr. [**Last Name (STitle) 48223**]
.
11) Code -- full
.
12) Disp -- On [**10-6**], due to a family meeting where the fact
that the patient had previously expressed no desire to be in a
long term ventillated state was revealed, she was made CMO and
died quickly after she was extubated.  Morphine was titrated to
comfort.  The family was present for the extubation.

Medications on Admission:
Levothyroxine 100mcg QD
Glyburide 5mg [**Hospital1 **]
Glucophage 500mg [**Hospital1 **]
ASA 325 QD
Cozaar 50mg QD (per pt, on Diovan?)
?Detrol LA (per patient. Not per doctor)
?Lipitor 10mg QD (per doctor. Not per patient)
recent Levaquin


Discharge Disposition:
Expired

Discharge Diagnosis:
Expired

Discharge Condition:
Expired

Discharge Instructions:
Expired

Followup Instructions:
Expired
{'Other specified alveolar and parietoalveolar pneumonopathies,Acute and chronic respiratory failure,Pneumocystosis,Methicillin susceptible pneumonia due to Staphylococcus aureus,Congestive heart failure, unspecified,Hyposmolality and/or hyponatremia,Postinflammatory pulmonary fibrosis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Pure hypercholesterolemia,Unspecified acquired hypothyroidism,Anxiety state, unspecified,Anemia of other chronic disease,Constipation, unspecified'}


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

PRESENT ILLNESS: HPI: Pt is a 58 y/o f with htn, dm2, hypercholesterolemia who
presented to an OSH with increasing sob and cxr/chest CT
infiltrates felt to respresent an ILD, was transferred to [**Hospital1 18**]
floor for further work-up, underwent VATS 1 day prior to MICU
admission, and developed hypoxemia and respiratory distress on
the night of admission, prompting micu transfer and intubation.
Apparently she first began developing sx one month prior to
presenting to the OSH with increasing sob, attributed at first
to a pneumonia that did not respond to antibiotics. Her sx
worsened and her doctor got a chest CT with diffuse bilateral
interstitial and ground glass opacities. At OSH, was ruled-out
for MI, negative stress test, echo with decreased e/a ratio, cta
without pe. She was transferred to [**Hospital1 18**] and underwent VATS one
night prior to MICU transfer, with the chest tube removed the
day of transfer. Overnight, she was seen by the nightfloat for
hypoxia and tachypnea, transferred to the MICU, and intubated.
.

MEDICAL HISTORY: 1.)HTN
2.)DM2
3.)Hypercholesterolemia
4.)Hypothyroidism

MEDICATION ON ADMISSION: Levothyroxine 100mcg QD
Glyburide 5mg [**Hospital1 **]
Glucophage 500mg [**Hospital1 **]
ASA 325 QD
Cozaar 50mg QD (per pt, on Diovan?)
?Detrol LA (per patient. Not per doctor)
?Lipitor 10mg QD (per doctor. Not per patient)
recent Levaquin

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE: t 97.8, bp 96/50, hr 88, rr 20, spo2 97%
vent- a/c vt 400/rr 16/peep 10/fio2 1.00
gen- anxious-appearing female, looks age, mod distress
cv- rrr, s1s2, no m/r/g
pul- moves air well, clear anteriorly, velcro rales [**12-18**] way both
lung fields
abd- soft, nd, nabs
extrm- no cyanosis/edema, warm/dry
nails- no clubbing, painted
neuro- sedated, intubated, perrl

FAMILY HISTORY: Fhx: Mother had MI in her 70's - now with a pacemaker, also
currently being treated for lymphoma. Father has died, but had
lupus and had CABG at age 70. Brother had an MI and CABG at age
55.

SOCIAL HISTORY: SocHx: Married. Lives with her husband and children. Works as a
manager for an outside vendor at [**Company 22916**] company. Quit smoking
20 years ago, had smoked 1ppd x 10 years. No hx EtOH or drug
abuse. 

### Response:
{'Other specified alveolar and parietoalveolar pneumonopathies,Acute and chronic respiratory failure,Pneumocystosis,Methicillin susceptible pneumonia due to Staphylococcus aureus,Congestive heart failure, unspecified,Hyposmolality and/or hyponatremia,Postinflammatory pulmonary fibrosis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Pure hypercholesterolemia,Unspecified acquired hypothyroidism,Anxiety state, unspecified,Anemia of other chronic disease,Constipation, unspecified'}
