CHIEF COMPLAINT: shortness of breath and chest pain

PRESENT ILLNESS: 61m with IPF on 2L home o2, HTN, CAD s/p MI and PTCA [**2150**], PTSD
who developed increasing dyspnea, hypoxemia, and chest pressure
at home. About three weeks prior to admission, he was on a trip
to [**State 108**] when he developed increasing dyspnea, cough, and
sputum production, no fevers or chills; a prescription for
levofloxacin was called in, and he took it for ten days. Upon
returning to [**Location (un) 86**], he felt about the same and came to the
pulmonary clinic where a chest CT showed worsened [**Last Name (LF) **], [**First Name3 (LF) **] his
levofloxacin course as extended another tend days, and
azithromycin was added. He said he was beginning to feel better
by the end of the course (2d prior to admit), but then one day
before admit began to feel worn down and noticed he was
requiring more oxygen when he exerted himself. He says his
exertional dyspnea was coming on more easily and was taking
longer to resolve. At 2:30am on the morning of admission, he
awoke with the sudden onset of dyspnea that improved while
sitting up in a chair. He routinely checks his home oximetry and
noted that he was desaturating to the low 80's on 5L-nc. He's
also developed intermittent chest pressure, mainly during
desaturations that was relieved temporarily with one sublingual
ntg. After a few hours of symptoms, he went to [**Hospital3 24012**]
by EMS, where he was given ceftriaxone and asa; he was
transferred to [**Hospital1 18**] and given levofloxacin.
A CTA at [**Hospital1 18**] showed no pulmonary embolism but significant,
diffuse worsening of ground-glass opacities. In the ED he was
put onto a 100%-nrb mask and maintained sats in the mid-high
90's at rest, but continued to desat to the 70's-80's with even
minimal exertion. At the time of admission, he said he was
feeling a bit better than he had that morning.
Otherwise, he says his weight has been stable, and he's had no
lower extremity edema. He denies fevers or chills, significant
cough, sputum, hemoptysis, wheeze, abdominal pain, n/v/d/c, or
urinary symptoms.
.

MEDICAL HISTORY: -IPF: diagnosed [**8-/2162**] after developing one yr of progressive
dyspnea with negative cardiac eval; chest CT with subpleural
honeycombing, [**Year (4 digits) **]'s; bx with evidence of UIP; enrolled in
Capacity trial (on pirfenidone, anti-tgf-b1 and anti-pdgf); last
pft's [**2-/2163**] FVC 58%, FEV1 64%, TLC 58%, DLCO 42%, DL/VA 82%.
-HTN
-CAD: MI and PTCA to LCX [**2150**]
-Prior etoh abuse
-PTSD
-Bipolar disorder

MEDICATION ON ADMISSION: Meds:
-Pirfenidone
-Rosuvastatin 40mg daily
-ASA 81mg daily
-Atenolol 100mg [**Hospital1 **]
-Ezetimibe 10mg daily
-Trileptal 300mg 4x/daily
-Esomeprazole 40mg daily

ALLERGIES: Percocet

PHYSICAL EXAM: t 100.6, bp 91/70, hr 92, rr 26, spo2 94% on 100%NRB
gen- lying nearly flat in bed, nrb mask on, pleasant,
interactive, seems in mod resp distress
heent- anicteric, op clear with mmm
neck- no jvd, lad, or thyromegaly
cv- tachy but reg, no m/r/g
pul- mod resp distress, intermittenly breathing in midst of
sentences, positive accesory muscle use, fair air movement,
diffuse dry rales loudest at bases, no wheeze
abd- soft, nt, nd, nabs, no hsm
back- no cva/vert tendrn
extrm- no cyanosis/edema, warm/dry
nails- mild clubbing, no pitting/color change/indentn
neuro- a&ox3, no focal cn/motor defct

FAMILY HISTORY: No known fhx of lung disease. Mother with [**Name2 (NI) 499**] cancer, sister
with breast cancer.

SOCIAL HISTORY: Pt a retired quality engineer, married, lives with his wife. [**Name (NI) **]
smoked [**3-20**] ppd x 30-40yrs, quit in [**2150**].
Postinflammatory pulmonary fibrosis,Pneumonia, organism unspecified,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Unspecified essential hypertension,Posttraumatic stress disorder,Bipolar I disorder, most recent episode (or current) unspecified,Old myocardial infarction,Hypoxemia
Postinflam pulm fibrosis,Pneumonia, organism NOS,Crnry athrscl natve vssl,Status-post ptca,Hypertension NOS,Posttraumatic stress dis,Bipolor I current NOS,Old myocardial infarct,Hypoxemia
Admission Date:  [**2163-6-8**]              Discharge Date:   [**2163-6-10**]

Date of Birth:  [**2101-12-2**]             Sex:   M

Service: MEDICINE

Allergies:
Percocet

Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
shortness of breath and chest pain

Major Surgical or Invasive Procedure:
none

History of Present Illness:
61m with IPF on 2L home o2, HTN, CAD s/p MI and PTCA [**2150**], PTSD
who developed increasing dyspnea, hypoxemia, and chest pressure
at home. About three weeks prior to admission, he was on a trip
to [**State 108**] when he developed increasing dyspnea, cough, and
sputum production, no fevers or chills; a prescription for
levofloxacin was called in, and he took it for ten days. Upon
returning to [**Location (un) 86**], he felt about the same and came to the
pulmonary clinic where a chest CT showed worsened [**Last Name (LF) **], [**First Name3 (LF) **] his
levofloxacin course as extended another tend days, and
azithromycin was added. He said he was beginning to feel better
by the end of the course (2d prior to admit), but then one day
before admit began to feel worn down and noticed he was
requiring more oxygen when he exerted himself. He says his
exertional dyspnea was coming on more easily and was taking
longer to resolve. At 2:30am on the morning of admission, he
awoke with the sudden onset of dyspnea that improved while
sitting up in a chair. He routinely checks his home oximetry and
noted that he was desaturating to the low 80's on 5L-nc. He's
also developed intermittent chest pressure, mainly during
desaturations that was relieved temporarily with one sublingual
ntg. After a few hours of symptoms, he went to [**Hospital3 24012**]
by EMS, where he was given ceftriaxone and asa; he was
transferred to [**Hospital1 18**] and given levofloxacin.
A CTA at [**Hospital1 18**] showed no pulmonary embolism but significant,
diffuse worsening of ground-glass opacities. In the ED he was
put onto a 100%-nrb mask and maintained sats in the mid-high
90's at rest, but continued to desat to the 70's-80's with even
minimal exertion. At the time of admission, he said he was
feeling a bit better than he had that morning.
Otherwise, he says his weight has been stable, and he's had no
lower extremity edema. He denies fevers or chills, significant
cough, sputum, hemoptysis, wheeze, abdominal pain, n/v/d/c, or
urinary symptoms.
.


Past Medical History:

-IPF: diagnosed [**8-/2162**] after developing one yr of progressive
dyspnea with negative cardiac eval; chest CT with subpleural
honeycombing, [**Year (4 digits) **]'s; bx with evidence of UIP; enrolled in
Capacity trial (on pirfenidone, anti-tgf-b1 and anti-pdgf); last
pft's [**2-/2163**] FVC 58%, FEV1 64%, TLC 58%, DLCO 42%, DL/VA 82%.
-HTN
-CAD: MI and PTCA to LCX [**2150**]
-Prior etoh abuse
-PTSD
-Bipolar disorder


Social History:
Pt a retired quality engineer, married, lives with his wife. [**Name (NI) **]
smoked [**3-20**] ppd x 30-40yrs, quit in [**2150**].

Family History:
No known fhx of lung disease. Mother with [**Name2 (NI) 499**] cancer, sister
with breast cancer.

Physical Exam:
t 100.6, bp 91/70, hr 92, rr 26, spo2 94% on 100%NRB
gen- lying nearly flat in bed, nrb mask on, pleasant,
interactive, seems in mod resp distress
heent- anicteric, op clear with mmm
neck- no jvd, lad, or thyromegaly
cv- tachy but reg, no m/r/g
pul- mod resp distress, intermittenly breathing in midst of
sentences, positive accesory muscle use, fair air movement,
diffuse dry rales loudest at bases, no wheeze
abd- soft, nt, nd, nabs, no hsm
back- no cva/vert tendrn
extrm- no cyanosis/edema, warm/dry
nails- mild clubbing, no pitting/color change/indentn
neuro- a&ox3, no focal cn/motor defct


Pertinent Results:
Labs:

[**2163-6-8**] 06:20PM   WBC-14.9*# RBC-4.34* HGB-13.3* HCT-37.6*
MCV-87 MCH-30.6 MCHC-35.3* RDW-13.7
[**2163-6-8**] 06:20PM   PLT SMR-NORMAL PLT COUNT-216
[**2163-6-8**] 06:20PM   NEUTS-90.9* BANDS-0 LYMPHS-4.8* MONOS-3.7
EOS-0.3 BASOS-0.3
[**2163-6-8**] 06:20PM   GLUCOSE-94 UREA N-12 CREAT-0.8 SODIUM-134
POTASSIUM-3.9 CHLORIDE-97 TOTAL CO2-27 ANION GAP-14
cTropnT-<0.01 x 3
.
Imaging:
ECG: nsr, nl axis, nl intervals, probable laa, no lvh, no q's,
0.5-1mm st-depr v2-v5, twi in III and v1; no major change from
prior.
.
Lung biopsy [**8-/2162**]: Features are consistent with usual
interstitial pneumonia (UIP) with associated moderate chronic
interstitial inflammation and areas of organizing pneumonitis.
.
[**2163-6-8**] - CTA chest:
1. Study limited by motion with no evidence of pulmonary
embolism or thoracic aortic dissection.
2. Continued demonstration of peripheral honeycombing and
interlobular septal thickening with marked interval worsening of
diffuse ground-glass opacity as well as interstitial thickening.
The rapidity of progression would favor an acute process such as
infection as opposed to purely an acute exacerbation of chronic
lung disease. The absence of pleural effusions and may weigh
against pulmonary edema.
3. Stable mediastinal and hilar lymph nodes.


Brief Hospital Course:
In brief, the patient is a 61 male with IPF, HTN, CAD, PTSD here
with sudden onset worsening dyspnea, hypoxemia, and chest
pressure occuring about two weeks after a pneumonia treated with
levofloxacin.
.
#Dyspnea and hypoxemia -- Leading diagnoses included infectious
> progressive IPF >> CHF. This was felt to unlikely to be CHF
given relatively low BNP and no improvement with >1L of
diuresis.  The patient was treated with broad spectrum
antibiotics for possible infectious sources, steroids (per his
pulmonologist's recommendations) and pirfenidone for his IPF.
Despite the above and being on large amounts of oxygen the
patient continued to become more hypoxic and a decision was made
to make the patient CMO.  These were discussions held with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2168**], the patient's primary pulmonologist, present.
The patient was never intubated and never on non-invasive
ventilation, based on his preferences.  He was placed on a
morphine drip and expired of respiratory distress.
.
#IPF -- It was felt that the patient's hypoxia could have been
caused by his IPF that has significantly worsened or is the
substrate upon which another process is acting. As above he was
treated with prednisone and continued his pirfenidone study
assigned medication.
.
#CAD -- The patient has a history of CAD, so given his dyspnea
and chest pressure (relieved by SL nitro) a work-up was pursued.
 His cardiac enzymes were negative x 2 and ECG was without
significant changes.  He was continued on his beta-blocker,
aspirin, and lipid lowering agents.
.
#HTN -- No issues continued on atenolol
.
#Leukocytosis -- The patient had leukocytosis with no fever.
Infectious evaluation including urine cultures, blood cultures
and legionella were sent. As above the patient was treated with
broad spectrum antibiotics and his wbc count followed.
.
# Agitation -- The patient was agitated though had intact
mentation, which did not appear to track with his low O2 sat.
His agitation was likely related to bipolar and underlying
personality trait, that was exacerbated by profound dyspnea.  He
was treated for his dyspnea, continued on home mood stabilizers
and given standing lorazepam as well.
.
# Code status -- Given the patient continued to deteriorate he
was made DNR/DNI and CMO and expired of respiratory distress.



Medications on Admission:
Meds:
-Pirfenidone
-Rosuvastatin 40mg daily
-ASA 81mg daily
-Atenolol 100mg [**Hospital1 **]
-Ezetimibe 10mg daily
-Trileptal 300mg 4x/daily
-Esomeprazole 40mg daily


Discharge Medications:
none

Discharge Disposition:
Expired

Discharge Diagnosis:
1. Hypoxemia
2. IPF
3. CAD
4. Leukocytosis

Discharge Condition:
expired

Discharge Instructions:
NA

Followup Instructions:
NA
{'Postinflammatory pulmonary fibrosis,Pneumonia, organism unspecified,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Unspecified essential hypertension,Posttraumatic stress disorder,Bipolar I disorder, most recent episode (or current) unspecified,Old myocardial infarction,Hypoxemia'}


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 and chest pain

PRESENT ILLNESS: 61m with IPF on 2L home o2, HTN, CAD s/p MI and PTCA [**2150**], PTSD
who developed increasing dyspnea, hypoxemia, and chest pressure
at home. About three weeks prior to admission, he was on a trip
to [**State 108**] when he developed increasing dyspnea, cough, and
sputum production, no fevers or chills; a prescription for
levofloxacin was called in, and he took it for ten days. Upon
returning to [**Location (un) 86**], he felt about the same and came to the
pulmonary clinic where a chest CT showed worsened [**Last Name (LF) **], [**First Name3 (LF) **] his
levofloxacin course as extended another tend days, and
azithromycin was added. He said he was beginning to feel better
by the end of the course (2d prior to admit), but then one day
before admit began to feel worn down and noticed he was
requiring more oxygen when he exerted himself. He says his
exertional dyspnea was coming on more easily and was taking
longer to resolve. At 2:30am on the morning of admission, he
awoke with the sudden onset of dyspnea that improved while
sitting up in a chair. He routinely checks his home oximetry and
noted that he was desaturating to the low 80's on 5L-nc. He's
also developed intermittent chest pressure, mainly during
desaturations that was relieved temporarily with one sublingual
ntg. After a few hours of symptoms, he went to [**Hospital3 24012**]
by EMS, where he was given ceftriaxone and asa; he was
transferred to [**Hospital1 18**] and given levofloxacin.
A CTA at [**Hospital1 18**] showed no pulmonary embolism but significant,
diffuse worsening of ground-glass opacities. In the ED he was
put onto a 100%-nrb mask and maintained sats in the mid-high
90's at rest, but continued to desat to the 70's-80's with even
minimal exertion. At the time of admission, he said he was
feeling a bit better than he had that morning.
Otherwise, he says his weight has been stable, and he's had no
lower extremity edema. He denies fevers or chills, significant
cough, sputum, hemoptysis, wheeze, abdominal pain, n/v/d/c, or
urinary symptoms.
.

MEDICAL HISTORY: -IPF: diagnosed [**8-/2162**] after developing one yr of progressive
dyspnea with negative cardiac eval; chest CT with subpleural
honeycombing, [**Year (4 digits) **]'s; bx with evidence of UIP; enrolled in
Capacity trial (on pirfenidone, anti-tgf-b1 and anti-pdgf); last
pft's [**2-/2163**] FVC 58%, FEV1 64%, TLC 58%, DLCO 42%, DL/VA 82%.
-HTN
-CAD: MI and PTCA to LCX [**2150**]
-Prior etoh abuse
-PTSD
-Bipolar disorder

MEDICATION ON ADMISSION: Meds:
-Pirfenidone
-Rosuvastatin 40mg daily
-ASA 81mg daily
-Atenolol 100mg [**Hospital1 **]
-Ezetimibe 10mg daily
-Trileptal 300mg 4x/daily
-Esomeprazole 40mg daily

ALLERGIES: Percocet

PHYSICAL EXAM: t 100.6, bp 91/70, hr 92, rr 26, spo2 94% on 100%NRB
gen- lying nearly flat in bed, nrb mask on, pleasant,
interactive, seems in mod resp distress
heent- anicteric, op clear with mmm
neck- no jvd, lad, or thyromegaly
cv- tachy but reg, no m/r/g
pul- mod resp distress, intermittenly breathing in midst of
sentences, positive accesory muscle use, fair air movement,
diffuse dry rales loudest at bases, no wheeze
abd- soft, nt, nd, nabs, no hsm
back- no cva/vert tendrn
extrm- no cyanosis/edema, warm/dry
nails- mild clubbing, no pitting/color change/indentn
neuro- a&ox3, no focal cn/motor defct

FAMILY HISTORY: No known fhx of lung disease. Mother with [**Name2 (NI) 499**] cancer, sister
with breast cancer.

SOCIAL HISTORY: Pt a retired quality engineer, married, lives with his wife. [**Name (NI) **]
smoked [**3-20**] ppd x 30-40yrs, quit in [**2150**]. 

### Response:
{'Postinflammatory pulmonary fibrosis,Pneumonia, organism unspecified,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Unspecified essential hypertension,Posttraumatic stress disorder,Bipolar I disorder, most recent episode (or current) unspecified,Old myocardial infarction,Hypoxemia'}
