CHIEF COMPLAINT: Hypoxia

PRESENT ILLNESS: This is an 87-year-old woman with an extensive PMH including CAD
3 vessel, HTN, CHF, mod-severe AS who presented with acute
respiratory distress requiring intubation.  Ms. [**Known lastname 4602**]
developed increasing dyspnea at home since yesterday with
elevated blood pressure last evening (SBP > 200).  No history of
fever, chills, cough, increased sputum or chest pain.  Her
daughter found her this morning in acute respiratory distress
and consequently called EMS.  At the time she was ambulating to
the bathroom.
.
In the ED, initial vs were: T 97 P 60 BP 203/97 R 30 O2 sat 74%
bag mask. Ms. [**Known lastname 4602**] was emergently intubated.  She was given
lasix 60 mg IV once, per records diuresised 1150 L.  Patient
dropped pressure to 60 systolic with propofol, improved with 750
cc bolus and turning off propofol.  The patient was additionally
given versed and vecuronium.  She received a total of 1.5 L NS,
Ceftriaxone, and Levofloxacin (empiracally for PNA).  She was
transferred to the ICU.
.
Patient intubated and sedated unable to give history.

MEDICAL HISTORY: 1. CAD - 3 Vessel, told to have stress test but refused several

MEDICATION ON ADMISSION: meclizine 12.5mg [**Hospital1 **]
simvastatin 20 mg daily
levothyroxine 50 mcg daily
Lopressor 50 mg [**Hospital1 **],
Imdur 60 mg daily at noon
Amiodarone 200 mg daily
Aspirin 81 mg daily
Lasix 80 mg daily C
Clonidine 0.1 mg, 2 tablets in Am and 1 tablet in PM.

ALLERGIES: Morphine Sulfate

PHYSICAL EXAM: ON ADMISSION TO ED
T: 97 P: 60 BP: 203/97 R:30 SPO2 sat 74% bag mask
General Appearance: Intubated
Eyes / Conjunctiva: PERRL, No(t) Pupils dilated
Head, Ears, Nose, Throat: Endotracheal tube
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal),
(Murmur: Systolic)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Not assessed),
(Left DP pulse: Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Diminished: throughout)
Abdominal: Soft, Non-tender, Bowel sounds present, Obese
Extremities: Right lower extremity edema: 1+, Left lower
extremity edema: 1+
Skin:  Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Sedated, Tone: Not assessed

FAMILY HISTORY: CAD
Mother died of appendicitis
Four brothers died in [**Name (NI) 3106**]

SOCIAL HISTORY: Russian speaking.  Patient lives alone and is widowed. No h/o
tobacco, ETOH. Patient has help for cleaning and bathing, does
some cooking, daughter does
shopping. Walks without aid at baseline. Has frequent visitors,
Acute diastolic heart failure,Acute kidney failure, unspecified,Acute respiratory failure,Unspecified hypertensive heart disease with heart failure,Coronary atherosclerosis of native coronary artery,Aortic valve disorders,Atrial fibrillation,Unspecified acquired hypothyroidism,Cardiac pacemaker in situ
Ac diastolic hrt failure,Acute kidney failure NOS,Acute respiratry failure,Hyp ht dis NOS w ht fail,Crnry athrscl natve vssl,Aortic valve disorder,Atrial fibrillation,Hypothyroidism NOS,Status cardiac pacemaker
Admission Date:  [**2172-3-9**]              Discharge Date:   [**2172-3-14**]


Service: MEDICINE

Allergies:
Morphine Sulfate

Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Hypoxia

Major Surgical or Invasive Procedure:
1.  Intubation
2.  Right Radial Arterial Line

History of Present Illness:
This is an 87-year-old woman with an extensive PMH including CAD
3 vessel, HTN, CHF, mod-severe AS who presented with acute
respiratory distress requiring intubation.  Ms. [**Known lastname 4602**]
developed increasing dyspnea at home since yesterday with
elevated blood pressure last evening (SBP > 200).  No history of
fever, chills, cough, increased sputum or chest pain.  Her
daughter found her this morning in acute respiratory distress
and consequently called EMS.  At the time she was ambulating to
the bathroom.
.
In the ED, initial vs were: T 97 P 60 BP 203/97 R 30 O2 sat 74%
bag mask. Ms. [**Known lastname 4602**] was emergently intubated.  She was given
lasix 60 mg IV once, per records diuresised 1150 L.  Patient
dropped pressure to 60 systolic with propofol, improved with 750
cc bolus and turning off propofol.  The patient was additionally
given versed and vecuronium.  She received a total of 1.5 L NS,
Ceftriaxone, and Levofloxacin (empiracally for PNA).  She was
transferred to the ICU.
.
Patient intubated and sedated unable to give history.

Past Medical History:
1. CAD - 3 Vessel, told to have stress test but refused several

years ago, last catheterization about 12 years ago per patient's
 daughter.
2. HTN
3. Sick sinus syndrome s/p PPM [**2158**], replaced [**2169-5-9**]
4. CHF - last known echo EF >55% ([**10-12**])
5. Hypothyroidism
6. paced Afib - not anticoagulated
7. Chronic lung nodules
8. Moderate-severe aortic stenosis

Social History:
Russian speaking.  Patient lives alone and is widowed. No h/o
tobacco, ETOH. Patient has help for cleaning and bathing, does
some cooking, daughter does
shopping. Walks without aid at baseline. Has frequent visitors,

daughter (health care proxy) [**Name (NI) **] lives nearby: [**Telephone/Fax (1) 4603**].

Family History:
CAD
Mother died of appendicitis
Four brothers died in [**Name (NI) 3106**]

Physical Exam:
ON ADMISSION TO ED
T: 97 P: 60 BP: 203/97 R:30 SPO2 sat 74% bag mask
General Appearance: Intubated
Eyes / Conjunctiva: PERRL, No(t) Pupils dilated
Head, Ears, Nose, Throat: Endotracheal tube
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal),
(Murmur: Systolic)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Not assessed),
(Left DP pulse: Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Diminished: throughout)
Abdominal: Soft, Non-tender, Bowel sounds present, Obese
Extremities: Right lower extremity edema: 1+, Left lower
extremity edema: 1+
Skin:  Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Sedated, Tone: Not assessed

ON DISCHARGE:
Tm: 98.2, HR: 59, BP: 136/59, SP02: 99 2L
General:  Well appearing, sitting in chair eating breakfast
Neck:  Elevated JVP at about 7cm
Cardiac:  Regular rate and rhythm; 3/6 systolic ejection murmur
Lungs:  Crackles at bases bilaterally
Abdomen:  +BS, soft, non-tender, non-distended
Peripheral Vascular: + Peripheral pulses
Extremities: Trace edema bilaterally
Skin:  Warm and dry

Pertinent Results:
On admission:
[**2172-3-9**] 08:00AM BLOOD WBC-22.7* RBC-4.80 Hgb-14.7 Hct-44.8
MCV-93 MCH-30.5 MCHC-32.8 RDW-14.3 Plt Ct-181
[**2172-3-9**] 08:00AM BLOOD PT-12.9 PTT-24.6 INR(PT)-1.1
[**2172-3-9**] 08:00AM BLOOD Glucose-319* UreaN-17 Creat-1.2* Na-142
K-4.8 Cl-107 HCO3-21* AnGap-19
[**2172-3-9**] 08:00AM BLOOD ALT-32 AST-33 LD(LDH)-264* CK(CPK)-63
AlkPhos-95 TotBili-0.6
[**2172-3-9**] 08:00AM BLOOD Calcium-8.6 Phos-5.9* Mg-2.4
[**2172-3-9**] 08:43AM BLOOD Type-ART Tidal V-550 FiO2-60 pO2-67*
pCO2-46* pH-7.28* calTCO2-23 Base XS--4 -ASSIST/CON
Intubat-INTUBATED
[**2172-3-9**] 08:09AM BLOOD Glucose-289* Lactate-5.9* K-4.6
.
Cardiac Enzymes:
[**2172-3-9**] 08:00AM BLOOD cTropnT-<0.01
[**2172-3-9**] 08:00AM BLOOD CK-MB-NotDone
[**2172-3-9**] 02:49PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2172-3-9**] 07:46PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2172-3-10**] 09:31AM BLOOD proBNP-1430*
.
Cardiac Echo [**2172-3-9**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size is normal. The aortic valve leaflets are moderately
thickened. There is severe aortic valve stenosis (valve area
0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is mild pulmonary artery systolic
hypertension. There is an anterior space which most likely
represents a fat pad.
.
Compared with the prior study (images reviewed) of [**2170-7-16**], the
severity of aortic stenosis has progressed.
.
CXR [**2172-3-11**]
Lung volumes are maintained following tracheal extubation.
Extensive
bilateral pulmonary consolidation is heterogeneous and also has
varied in
radiodensity to different degrees in separate areas over the
past two days. I suspect much of the abnormality is edema, but
pulmonary hemorrhage and pneumonia could be making a
contribution. Moderate cardiomegaly is stable and small
bilateral pleural effusions have developed since the earliest
studies on [**3-9**]. Transvenous right atrial and right
ventricular pacer leads in standard placements. No pneumothorax.

.
EKG [**2172-3-12**]:
A-V sequentially paced rhythm with intrinsic A-V conduction and
right
bundle-branch block configuration. Compared to the previous
tracing of [**2172-3-9**] there is no diagnostic interim change.

Brief Hospital Course:
Ms. [**Known lastname 4602**] is a pleasant 87-year-old woman with CAD, CHF,
HTN, sick sinus syndrome s/p pacer, moderate-severe AS who
presented to [**Hospital1 18**] on [**2172-3-9**] with acute respiratory distress.
Due to her poor respiratory status she was intubated in the
emergency department and admitted to the medical intensive care
unit. On [**2172-3-10**], her respiratory status had improved and she was
successfully extubated. On [**2172-3-11**], she was transferred to the
cardiology service. Her brief hospital course was notable for:
.
# ACUTE RESPIRATORY DISTRESS:  Acute pulmonary edema was
suspected as the most likely etiology of the patient's acute
respiratory distress, in setting of diastolic dysfunction and
moderate-severe AS.  Initially, there was concern for myocardial
infarction however, she was ultimately ruled out with three sets
of negative cardiac enzymes. There was also concern for
pneumonia and initially Ms. [**Known lastname 4602**] was put on antibiotics.
However, due to lack of fever, leukocytosis, and marked clinical
improvement, antibiotics were discontinued on [**2172-3-11**].  In the
MICU, Ms. [**Known lastname 4602**] was diuresed with 60 IV lasix x 1, and on
[**2172-3-11**] was restarted on her home regimen of 80 mg PO lasix. An
arterial line was placed on [**2172-3-9**] without incident, for close
BP observation, and this was discontinued on [**2172-3-11**], prior to
transfer to the floor. She was successfully extubated on [**2172-3-11**].
.
Upon arrival on medicine floor, Ms. [**Known lastname 4602**] was started on
Torsemide (eventually uptitrated to 40mg [**Hospital1 **]) with good urine
output and diminishment of rales on lung exam.  (Patient was
diuresed with caution in light of mod-severe AS).  SP02
continued to be 92-95% on 2L nasal cannula.  She was also
started on Lisinopril 20mg QD for better BP control and
afterload reduction.  Better BP control will help with pulmonary
edema, but without valvular repair, this issue cannot be
entirely corrected.  Both the family and the patient are aware
of this.
.
# HYPERTENSION: During her hospitalization, the patient was
noted to have labile blood pressures ranging from hypo to
hypertensive. Hypotensive episodes occured in the setting of
getting propofol for sedation while intubated, and hypertensive
episodes occured primarily in the settings of anxiety, and after
extubation.  In the MICU, Ms. [**Known lastname 4602**] was initially started on
captopril, but this was changed to Lisinopril on the medicine
floor.  Her home clonadine was stopped; home Lopressor was
switched to Carvedilol for better alpha blockage.  Torsemide
40mg [**Hospital1 **] was started as above.  Ms. [**Known lastname 4602**] was also given
lorazepam prn anxiety.
.
# [**Last Name (un) **]: Creatinine increased to 1.2 from baseline 0.9 in the
setting of diuresis.  It trended down to 1.0 on day of
discharge.
.
# CAD: Patient with known 3 vessel disease. No history of chest
pain and cardiac biomarkers were present.  EKG did not reveal
any ST wave changes, though it did show some pacing
irregularities.  ASA and simvastatin were continued.  Ms.
[**Name14 (STitle) 4604**] was discharged on ASA, simvastatin, and ACE-I.
.
# MODERATE-SEVERE AORTIC STENOSIS:  Ms. [**Known lastname 4602**] had increasing
dyspnea prior to admission, but no known history of chest pain
or syncope.  And ECHO from [**2172-3-9**] shows an LVEF of 55% and an
aortic valve area of 0.8cm2.  Ms. [**Known lastname 4602**] prefers medical
management of AS and does not want surgery.  Her Imdur was
stopped during admission and she was diuresis cautiously as AS
makes her preload dependent.
.
# HYPOTHYROIDISM:  Levothyroxine was continued at 50mcg daily.
.
# RATE:  Ms. [**Known lastname 4602**] has a history of Afib and sick sinus
syndrome s/p PPM.  Pacemaker was interrogated by EP during
admission and some changes were made.  Ms. [**Known lastname 4602**] should
follow up with Device Clinic in 1 month and Dr. [**Last Name (STitle) **] on
[**2172-5-21**].  She was discharged on Amiodarone and Carvedilol.
.
#GOUT:  After aggressive diuresis, Ms. [**Known lastname 4602**] complained of
symptoms consistent with gouty flare in left big toe.
Colchicine was started at 0.6mg QD and pain begam to subside.
Colchicine was continued on discharge.  Outpatient management of
gout is deferred to PCP.

Medications on Admission:
meclizine 12.5mg [**Hospital1 **]
simvastatin 20 mg daily
levothyroxine 50 mcg daily
Lopressor 50 mg [**Hospital1 **],
Imdur 60 mg daily at noon
Amiodarone 200 mg daily
Aspirin 81 mg daily
Lasix 80 mg daily C
Clonidine 0.1 mg, 2 tablets in Am and 1 tablet in PM.

Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO twice a day.

10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain/fever.
12. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day.
13. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
14. Oxygen
Continue oxygen by nasal cannula (1-6L) as needed.  Call your
doctor [**First Name (Titles) **] [**Last Name (Titles) 4605**] worsens or your oxygen requirement
increases.

Discharge Disposition:
Extended Care

Facility:
[**Hospital1 599**] of [**Location (un) 55**]

Discharge Diagnosis:
Primary
1.  Acute pulmonary edema in the setting of high blood pressure

Secondary
1.  Coronary artery disease
2.  Diastolic heart failure
3.  Sick sinus syndrome s/p pace maker
4.  Hypothyroidism
6.  Atrial fibrillation
7.  Moderate-severe aortic stenosis

Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)


Discharge Instructions:
Dear Ms. [**Known lastname 4602**],

It was a pleasure taking care of you on this admission.  You
came to the hospital because you were having shortness of
breath.  In the Emergency Department your oxygen level was found
to be very low and your blood pressure very high.  You were
intubated (put on a ventilator) and sent to the intensive care
unit.  We think that you had trouble [**Known lastname 4605**] because your
blood pressure was high which, in relation to your other cardiac
issues, ultimately caused fluid to accumulate in your lungs.
.
The following changes were made to your medications in order to
ensure better control of your blood pressure in the setting of
your aortic stenosis.  We also started a medication to help with
your gout.
1.  STOP taking Imdur 60mg daily
2.  STOP taking Lopressor 50 mg twice a day
3.  STOP taking Lasix 80mg daily
4.  STOP taking Clonidine
5.  START taking Carvedilol 12.5mg twice a day
6.  START taking Lisinopril 20mg daily
7.  START colchicine 0.6mg daily (for gout)
8.  START Torsemide 40mg twice a day
.
At the rehab facility you will also receive Colace and Senna (to
help you move your bowels), Tylenol as needed for pain, oxygen,
and Heparin three times daily to prevent blood clots.
.
You will need to have your chemistry (electrolytes) checked in
one week because of some of the medications we are starting.
.
Please keep all of your doctors' appointments.  Please take all
of your medications as prescribed.
.
Weigh yourself every day and call your doctor if you gain more
than 3 pounds.
.
Call your doctor or return to the hospital if you develop
shortness of breath, chest pain, severe headache, bright red
blood in your stool, abdominal pain, nausea, vomiting, diarrhea,
fever or any other concerning symptoms.

Followup Instructions:
Please call your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3357**] at [**Telephone/Fax (1) 4606**] to make an
appointment in [**1-11**] weeks after you are discharged from the
rehabilitation facility.

You will be called by the Device Clinic for an outpatient
interrogation of your pacemaker one month after discharge.

Cardiology, Dr. [**Last Name (STitle) **]:  [**2172-5-21**]  09:20a
[**Hospital6 29**], [**Location (un) **]
CC7 CARDIOLOGY (SB)
{'Acute diastolic heart failure,Acute kidney failure, unspecified,Acute respiratory failure,Unspecified hypertensive heart disease with heart failure,Coronary atherosclerosis of native coronary artery,Aortic valve disorders,Atrial fibrillation,Unspecified acquired hypothyroidism,Cardiac pacemaker in situ'}


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 an 87-year-old woman with an extensive PMH including CAD
3 vessel, HTN, CHF, mod-severe AS who presented with acute
respiratory distress requiring intubation.  Ms. [**Known lastname 4602**]
developed increasing dyspnea at home since yesterday with
elevated blood pressure last evening (SBP > 200).  No history of
fever, chills, cough, increased sputum or chest pain.  Her
daughter found her this morning in acute respiratory distress
and consequently called EMS.  At the time she was ambulating to
the bathroom.
.
In the ED, initial vs were: T 97 P 60 BP 203/97 R 30 O2 sat 74%
bag mask. Ms. [**Known lastname 4602**] was emergently intubated.  She was given
lasix 60 mg IV once, per records diuresised 1150 L.  Patient
dropped pressure to 60 systolic with propofol, improved with 750
cc bolus and turning off propofol.  The patient was additionally
given versed and vecuronium.  She received a total of 1.5 L NS,
Ceftriaxone, and Levofloxacin (empiracally for PNA).  She was
transferred to the ICU.
.
Patient intubated and sedated unable to give history.

MEDICAL HISTORY: 1. CAD - 3 Vessel, told to have stress test but refused several

MEDICATION ON ADMISSION: meclizine 12.5mg [**Hospital1 **]
simvastatin 20 mg daily
levothyroxine 50 mcg daily
Lopressor 50 mg [**Hospital1 **],
Imdur 60 mg daily at noon
Amiodarone 200 mg daily
Aspirin 81 mg daily
Lasix 80 mg daily C
Clonidine 0.1 mg, 2 tablets in Am and 1 tablet in PM.

ALLERGIES: Morphine Sulfate

PHYSICAL EXAM: ON ADMISSION TO ED
T: 97 P: 60 BP: 203/97 R:30 SPO2 sat 74% bag mask
General Appearance: Intubated
Eyes / Conjunctiva: PERRL, No(t) Pupils dilated
Head, Ears, Nose, Throat: Endotracheal tube
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal),
(Murmur: Systolic)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Not assessed),
(Left DP pulse: Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Diminished: throughout)
Abdominal: Soft, Non-tender, Bowel sounds present, Obese
Extremities: Right lower extremity edema: 1+, Left lower
extremity edema: 1+
Skin:  Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Sedated, Tone: Not assessed

FAMILY HISTORY: CAD
Mother died of appendicitis
Four brothers died in [**Name (NI) 3106**]

SOCIAL HISTORY: Russian speaking.  Patient lives alone and is widowed. No h/o
tobacco, ETOH. Patient has help for cleaning and bathing, does
some cooking, daughter does
shopping. Walks without aid at baseline. Has frequent visitors, 

### Response:
{'Acute diastolic heart failure,Acute kidney failure, unspecified,Acute respiratory failure,Unspecified hypertensive heart disease with heart failure,Coronary atherosclerosis of native coronary artery,Aortic valve disorders,Atrial fibrillation,Unspecified acquired hypothyroidism,Cardiac pacemaker in situ'}
