CHIEF COMPLAINT: Shortness of breath, hypoxia.

PRESENT ILLNESS: This is a 74 year old man with a medical history of COPD, A-fib
and lung CA who presents from OSH with increasing hypoxia three
weeks after a right pneumonectomy. Patient started having cough
and shortness of breath while at rehab aproximately three to
four days prior to admission.  Initially it was with exertion
then progressed to being at rest.  He noted subjective fevers
and chills.  He had a cough which became worse and occasionally
had some blood tinged sputum.  He had an incresing oxygen
requirement and started to desat on a Non-reBreather (NRB). On
[**4-19**] a chest XR was concerning for a Left Lower Lobe pneumonia
and he was started on emperic Vamcomycin and Meropenum. He was
evaluated at [**Hospital1 882**] ED and found to have a left lower lobe
pneumonia. He was given Zosyn. He was going to be admitted to an
ICU as he required a NRB, however there were no beds available.
He was transferred to the [**Hospital1 **] ED for further care. Of note, at
[**Hospital 100**] Rehab he had a sputum culture which had sparse MRSA
growth.

MEDICAL HISTORY: Lung CA: SCC (T2, N1, Mx) s/p R lung pneumonectomy
COPD
A-Fib with RVR

MEDICATION ON ADMISSION: Lovenox 40mg sc q24
atrovent nebs q4
albuterol q2
Xopenex q6
salmeterol INH q12
robitussin
amiodarone 200 daily (until [**5-2**])
Metoprolol 37.5 TID
Aspirin 81mg daily
Simvastatin 20mg daily
Furosemide 20mg daily
MVI
Omeprazole 20mg daily
oxycodone 5mg q4 prn
lactulose 10mg qHS

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Pt expired

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Hx Tob use quit 23 yrs ago
Hx of EtOH use quit 33
No IVDA
Lives with son [**Name (NI) 382**]
Unspecified septicemia,Acute respiratory failure,Acute kidney failure, unspecified,Pneumonia, organism unspecified,Persistent postoperative fistula,Primary pulmonary hypertension,Other pulmonary embolism and infarction,Severe sepsis,Chronic airway obstruction, not elsewhere classified,Atrial fibrillation,Personal history of malignant neoplasm of bronchus and lung
Septicemia NOS,Acute respiratry failure,Acute kidney failure NOS,Pneumonia, organism NOS,Persist postop fistula,Prim pulm hypertension,Pulm embol/infarct NEC,Severe sepsis,Chr airway obstruct NEC,Atrial fibrillation,Hx-bronchogenic malignan
Admission Date:  [**2184-4-20**]              Discharge Date:   [**2184-4-23**]

Date of Birth:  [**2109-12-5**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Shortness of breath, hypoxia.

Major Surgical or Invasive Procedure:
Chest tube placement ([**4-22**])
Central venous line placement to right subclavian vein ([**4-22**])
Arterial line placement to right brachial artery ([**4-22**])
Intubation

History of Present Illness:
This is a 74 year old man with a medical history of COPD, A-fib
and lung CA who presents from OSH with increasing hypoxia three
weeks after a right pneumonectomy. Patient started having cough
and shortness of breath while at rehab aproximately three to
four days prior to admission.  Initially it was with exertion
then progressed to being at rest.  He noted subjective fevers
and chills.  He had a cough which became worse and occasionally
had some blood tinged sputum.  He had an incresing oxygen
requirement and started to desat on a Non-reBreather (NRB). On
[**4-19**] a chest XR was concerning for a Left Lower Lobe pneumonia
and he was started on emperic Vamcomycin and Meropenum. He was
evaluated at [**Hospital1 882**] ED and found to have a left lower lobe
pneumonia. He was given Zosyn. He was going to be admitted to an
ICU as he required a NRB, however there were no beds available.
He was transferred to the [**Hospital1 **] ED for further care. Of note, at
[**Hospital 100**] Rehab he had a sputum culture which had sparse MRSA
growth.

At [**Hospital 100**] Rehab he had LENI without DVT ([**4-20**]); CXR with LLL
suspicious for PNA ([**4-19**]); TTE with normal EF (65%), septal
dysrythmia, mild - mod pulm HTN

In ED, vitals were afebrile, HR: 120, BP: 107/69, RR: 25-30, O2
Sat:90-92%% on NRB and 84% when on Nebs. Patient recieved
vamcomycin at 11am today and Zosyn at [**Hospital1 882**] ED at 5:30pm. His
last dose of Meropenum was 1 day PTA. At the [**Hospital1 **] ED he recieved
Albuterol and Ipratroprium nebs x3 and Salumedrol 125mg x1.

Past Medical History:
Lung CA: SCC (T2, N1, Mx) s/p R lung pneumonectomy
COPD
A-Fib with RVR

Social History:
Hx Tob use quit 23 yrs ago
Hx of EtOH use quit 33
No IVDA
Lives with son [**Name (NI) 382**]

Family History:
Noncontributory

Physical Exam:
Pt expired

Pertinent Results:
Labs at Admission:
[**2184-4-20**] 09:30PM BLOOD WBC-11.4* RBC-4.10* Hgb-11.6* Hct-34.7*
MCV-85 MCH-28.2 MCHC-33.3 RDW-14.6 Plt Ct-579*
[**2184-4-20**] 09:30PM BLOOD Neuts-84.3* Lymphs-9.8* Monos-4.4 Eos-1.1
Baso-0.3
[**2184-4-20**] 09:30PM BLOOD PT-15.9* PTT-28.6 INR(PT)-1.4*
[**2184-4-20**] 09:30PM BLOOD Glucose-142* UreaN-23* Creat-0.8 Na-138
K-4.4 Cl-101 HCO3-27 AnGap-14
[**2184-4-20**] 09:30PM BLOOD CK(CPK)-62
[**2184-4-21**] 04:46AM BLOOD Calcium-9.0 Phos-3.7 Mg-2.5
[**2184-4-22**] 12:09PM BLOOD Hapto-275*
[**2184-4-22**] 12:09PM BLOOD D-Dimer-[**Numeric Identifier 82559**]*
[**2184-4-23**] 05:32AM BLOOD Cortsol-111.2*
[**2184-4-23**] 05:55AM BLOOD Vanco-49.8*
[**2184-4-20**] 09:42PM BLOOD Glucose-135* Lactate-1.6 Na-138 K-4.1
Cl-98* calHCO3-28

Imaging Studies:

Transthoracic echocardiogram ([**4-20**]):
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is dilated with depressed free wall contractility. There
is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened with trivial mitral regurgitation.
The tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is at least moderate to
severe pulmonary artery systolic hypertension. There is a very
small pericardial effusion. There are no echocardiographic signs
of tamponade. (Echocardiographic signs of tamponade may be
absent in the presence of elevated right sided pressures.)

CTA chest ([**4-22**]):
IMPRESSION:
1. Very minimal questionable subsegmental pulmonary embolism in
the left
upper lobe.
2. Right pneumonectomy, new loculated air collection with
internal septations, worrisome for bronchopleural fistula and
potentially empyema.
3. Severe emphysema on the left. Diffuse left lower lobe opacity
with interstitial thickening and denser areas of ground-glass
opacity and consolidation in dependent portions of the left
lung, could be related to aspiration or pneumonia.
4. Moderate hiatal hernia.
5. One liver cyst and one liver hypodensity too small to
characterize.

Renal ultrasound ([**4-22**]):
No evidence of renal obstruction or other abnormality.

Bilateral lower extremity doppler ultrasound ([**4-23**]):
1. Technically limited exam, with non-compressibility and
absence of flow within the right superficial femoral vein at its
mid portion, concerning or thrombus but not definitive. The
right common femoral and popliteal veins are patent. Repeat
examination recommended but declined by the family, in the
process of initiating CMO status.
2. No left lower extremity DVT.

Brief Hospital Course:
A 74 year-old man with COPD, s/p right pneumonectomy 3 weeks
prior to this, now presenting with increasing dyspnea and
worsening O2 requirement who was found to have a LLL
consolidation at rehab and was admitted to ICU for hypoxemia
requiring non-rebreather.

# Hypoxemia/respiratory distress
He has poor pulmonary reserve given the recent right
pneumonectomy and underlying COPD. The clinical picture and
imaging studies were consistent with pneumonia. We started
empiric treatment for HAP with vancomycin and Zosyn. In addition
we treated for possible COPD flare with standing nebs and
solu-medrol. His respiratory status continued to decline and he
was intubated in the late morning on the first hospital day.
Once intubated, he maintained good oxygen saturations. We
ordered a CTA on the first hospital night to further assess the
pneumonia and pneumonectomy site; in addition, there was concern
for PE given his post-operative status and rapid respiratory
decline. There were air fluid levels in the right thoracic
cavity, concerning for broncho-pneumonectomy fistula. CT surgery
was consulted and placed a right-sided chest tube, immediately
draining 1L of exudative fluid. This was sent for culture. He
also underwent bronchoscopy; there was no evidence of air leak.
The final read from the CTA returned positive for PE and he was
started on heparin drip. Despite these interventions, his
oxygenation, ventilation, and overall clinical status continued
to decline and his code status was changed to CMO, he expired a
few hours after (time of death 2:10pm [**2184-4-23**])

# Hypotension
On the first hospital day, he maintained SBPs in the 80s. His
clinical picture was felt to be consistent with evolving
pneumonia, possibly progressing to sepsis, and thus on the
second hospital night he was bolused with IVF for total of 5L.
Initially, his systolic BP improved to 90s with fluids; however,
over the course of the night and into the following morning, the
blood pressure dropped to 70s. At this time, dopamine was
started through his left midline. A right subclavian CVL was
placed and he was started on levophed. Blood pressure continued
to decline despite the levophed, requiring addition of
vasopressin to maintain MAPs >60.  Patient was eventually on
three pressors with a MAP in the 20s.  At that point he was made
CMO per above.

# Transaminitis and coagulaopathy
This developed in the setting of evolving sepsis. In addition,
he was noted on TTE to have moderate TR and moderate to severe
pulmonary hypertension, and it is not clear if congestive
hepatopathy from right-sided heart failure might also be
contributing to the severe transaminitis (ALT 5200 and AST 6700
with TB 1.6). Likely this was shock liver from hypoperfusion.

# Acute renal failure
His creatinine rose from 0.8 at admission to 2.2 to 3.7 just
prior to death. The ARF was likely the result of sepsis and
renal hypoperfusion. As above, there was no response to IVF or
pressors.

# Atrial fibrillation
This was a recent diagnosis per patient, occurring
perioperatively. He was continued on amiodorone at home dose.
Metoprolol was held due to hypotension. Anticoagulation with ASA
and Lovenox was held when his clinical status worsened.  He was
started on an amio gtt for rate control.

# Lung cancer
He was recently diagnosed with squameous cell lung cancer, s/p
right pneumonectomy.

# Patient expired on [**2184-4-23**].

Medications on Admission:
Lovenox 40mg sc q24
atrovent nebs q4
albuterol q2
Xopenex q6
salmeterol INH q12
robitussin
amiodarone 200 daily (until [**5-2**])
Metoprolol 37.5 TID
Aspirin 81mg daily
Simvastatin 20mg daily
Furosemide 20mg daily
MVI
Omeprazole 20mg daily
oxycodone 5mg q4 prn
lactulose 10mg qHS

Discharge Medications:
Deceased.

Discharge Disposition:
Expired

Discharge Diagnosis:
Deceased.

Discharge Condition:
Deceased.

Discharge Instructions:
Deceased.

Followup Instructions:
Deceased.
{'Unspecified septicemia,Acute respiratory failure,Acute kidney failure, unspecified,Pneumonia, organism unspecified,Persistent postoperative fistula,Primary pulmonary hypertension,Other pulmonary embolism and infarction,Severe sepsis,Chronic airway obstruction, not elsewhere classified,Atrial fibrillation,Personal history of malignant neoplasm of bronchus and lung'}


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: Shortness of breath, hypoxia.

PRESENT ILLNESS: This is a 74 year old man with a medical history of COPD, A-fib
and lung CA who presents from OSH with increasing hypoxia three
weeks after a right pneumonectomy. Patient started having cough
and shortness of breath while at rehab aproximately three to
four days prior to admission.  Initially it was with exertion
then progressed to being at rest.  He noted subjective fevers
and chills.  He had a cough which became worse and occasionally
had some blood tinged sputum.  He had an incresing oxygen
requirement and started to desat on a Non-reBreather (NRB). On
[**4-19**] a chest XR was concerning for a Left Lower Lobe pneumonia
and he was started on emperic Vamcomycin and Meropenum. He was
evaluated at [**Hospital1 882**] ED and found to have a left lower lobe
pneumonia. He was given Zosyn. He was going to be admitted to an
ICU as he required a NRB, however there were no beds available.
He was transferred to the [**Hospital1 **] ED for further care. Of note, at
[**Hospital 100**] Rehab he had a sputum culture which had sparse MRSA
growth.

MEDICAL HISTORY: Lung CA: SCC (T2, N1, Mx) s/p R lung pneumonectomy
COPD
A-Fib with RVR

MEDICATION ON ADMISSION: Lovenox 40mg sc q24
atrovent nebs q4
albuterol q2
Xopenex q6
salmeterol INH q12
robitussin
amiodarone 200 daily (until [**5-2**])
Metoprolol 37.5 TID
Aspirin 81mg daily
Simvastatin 20mg daily
Furosemide 20mg daily
MVI
Omeprazole 20mg daily
oxycodone 5mg q4 prn
lactulose 10mg qHS

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Pt expired

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Hx Tob use quit 23 yrs ago
Hx of EtOH use quit 33
No IVDA
Lives with son [**Name (NI) 382**] 

### Response:
{'Unspecified septicemia,Acute respiratory failure,Acute kidney failure, unspecified,Pneumonia, organism unspecified,Persistent postoperative fistula,Primary pulmonary hypertension,Other pulmonary embolism and infarction,Severe sepsis,Chronic airway obstruction, not elsewhere classified,Atrial fibrillation,Personal history of malignant neoplasm of bronchus and lung'}
