CHIEF COMPLAINT: Respiratory arrest

PRESENT ILLNESS: HPI - This is a 37 y/o male with relapsed AML, s/p unrelated
unmatched alloBMT day +59, course c/b VRE bacteremia ([**7-14**]),
aspergillus lung infection in [**2099**], GVHD, recent stay in [**Hospital Unit Name 153**]
for sepsis of unclear etiology (although grew pseudomonas and
enterococcus from pus from foley catheter) on long-standing
broad-spectrum abx, who was transferred to the ICU this
afternoon s/p code blue for respiratory arrest.
This afternoon, the patient was sitting in his chair and was
noted to become hypotensive from a lying to sitting position
(SBP drop to 70's) and suddenly unresponsive with hypoxia on 4L,
with sats of 80's on NRB. He was emergently intubated on the
floor and was started on Neo for a brief time when SBP's fell to
the 50's s/p intubation and sedation. By the time he arrived to
the ICU (approx 10 min later), his SBP had improved to the 90's
and he was weaned off the Neo gtt.
At the time of intubation, he was noted to have brown, copious
secretions at the back of his throat, requiring suctioning.

MEDICAL HISTORY: 1)ONCOLOGY HX -
- presented in [**7-30**] w/ new R sided neck discomfort, swelling,
fevers
- WBC in ED showed 20 K, 74% atypicals
- BM bx (sternal aspirate) showed AML FAB M2
- recieved induction w/ idarubicin and cytarabine, then hiDAC x2

MEDICATION ON ADMISSION: Tacrolimus suspension 2mg PO BID
Quetiapine 25mg PO QHS
Caphasol 30mL MM QID
Sucalfate 1gm PO QID
Nifedipine 10mg PO Q8
RISS + 15u Lantus QHS
Ambisome 500mg IV Q24
Metoprolol 25mg PO BID
Mycophenolate 750mg IV QAM (7), 500mg Qnoon (15), 750mg PO QPM
(23)
Fentanyl patch 75mcg TP Q72
Ursodiol 300mg PO QAM, 600mg PO QPM
Dental gel 1 app TP [**Hospital1 **]
Clotrimazole 1 troc PO QID
Mg, KPhos, Ca, KCl sliding scales
Methylprednisolone 50mg IV Q12
Cyclosporine cont infusion 180mg IV QD
Ciprofloxacin 250mg IV Q12 (started [**8-28**])
Daptomycin 450mg IV Q24 (started [**8-29**])
Lasix 40mg IV x1 on [**2101-8-28**]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS - T 95.7, BP 99/53, HR 76, RR 16, SaO2 97%/AC 900 x 16, FiO2
100%, PEEP 5
General: Obese male in respiratory distress, mentating enough to
say "help me".
HEENT: Sclera + significant icterus, tears are icteric. Pupils
small, but equal and reative bilaterally. OP clear, MM dry. ETT
in place.
Neck: Could not appreciate any JVD. No LAD.
CV: RRR, nl S1, S2, no m/r/g.
Pulm: dullness at bases b/l, with few anterior wheezes.
Abd: soft, obese, NT/ND. few BS.
Extrem: + anasarca. 2+ radial pulses, but weakly palpable DP
pulses bilaterally.
Neuro: moves all four extremities, sedated but opens voice to
tactile stimuli.

FAMILY HISTORY: No known history of leukemias or other cancers within the
family. His father had heart disease and multiple sclerosis. His
mother has type 1 diabetes.

SOCIAL HISTORY: He works in the real estate business and plans on going into
appraisals. He lives in [**Location 15427**] and is engaged. He has one
daughter from his prior marriage. He smoked 2 packs of
cigarettes per day prior to his diagnosis but is currently not
smoking. He does not drink alcohol.
Acute myeloid leukemia, without mention of having achieved remission,Acute respiratory failure,Cardiac arrest,Complications of transplanted bone marrow,Aspergillosis,Bacteremia,Hemorrhage of gastrointestinal tract, unspecified,Congestive heart failure, unspecified,Acute kidney failure, unspecified,Cellulitis and abscess of leg, except foot,Pneumonia, organism unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Other disorders of muscle, ligament, and fascia,Delirium due to conditions classified elsewhere,Infection with microorganisms without mention of resistance to multiple drugs,Unspecified essential hypertension,Other specified viral infection,Other specified disorders of liver,Other specified erythematous conditions
Ac myl leuk wo achv rmsn,Acute respiratry failure,Cardiac arrest,Compl marrow transplant,Aspergillosis,Bacteremia,Gastrointest hemorr NOS,CHF NOS,Acute kidney failure NOS,Cellulitis of leg,Pneumonia, organism NOS,DMII wo cmp nt st uncntr,Long-term use of insulin,Muscle/ligament dis NEC,Delirium d/t other cond,Inf mcr rst ot drg nt ml,Hypertension NOS,Oth specf viral infectn,Liver disorders NEC,Erythematous cond NEC
Admission Date:  [**2101-6-7**]              Discharge Date:   [**2101-9-18**]

Date of Birth:  [**2063-6-13**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 7934**]
Chief Complaint:
Respiratory arrest



Major Surgical or Invasive Procedure:
Central Line Placement
Transjugular liver biopsy

History of Present Illness:
HPI - This is a 37 y/o male with relapsed AML, s/p unrelated
unmatched alloBMT day +59, course c/b VRE bacteremia ([**7-14**]),
aspergillus lung infection in [**2099**], GVHD, recent stay in [**Hospital Unit Name 153**]
for sepsis of unclear etiology (although grew pseudomonas and
enterococcus from pus from foley catheter) on long-standing
broad-spectrum abx, who was transferred to the ICU this
afternoon s/p code blue for respiratory arrest.
This afternoon, the patient was sitting in his chair and was
noted to become hypotensive from a lying to sitting position
(SBP drop to 70's) and suddenly unresponsive with hypoxia on 4L,
with sats of 80's on NRB. He was emergently intubated on the
floor and was started on Neo for a brief time when SBP's fell to
the 50's s/p intubation and sedation. By the time he arrived to
the ICU (approx 10 min later), his SBP had improved to the 90's
and he was weaned off the Neo gtt.
At the time of intubation, he was noted to have brown, copious
secretions at the back of his throat, requiring suctioning.

Past Medical History:
1)ONCOLOGY HX -
- presented in [**7-30**] w/ new R sided neck discomfort, swelling,
fevers
- WBC in ED showed 20 K, 74% atypicals
- BM bx (sternal aspirate) showed AML FAB M2
- recieved induction w/ idarubicin and cytarabine, then hiDAC x2

- repeat BM bx showed complete remission
- admitted [**2100-12-6**] for autoBMT, conditioned w/
busulfan/cytoxan
- thrombocytopenia in [**1-31**] -> BM negative in [**2-28**]
- relapsed AML in [**3-31**] (94% blasts on smear)
- treated w/ MEC (last day [**2101-4-22**])
- prolonged neutropenia -> never recovered his counts
- BM at day 16 empty, then showed relapse in [**5-31**]
- admitted on [**2101-6-7**] with sepsis (VRE bacteremia)
- disease progressed
- went for unmatched, unrelated mini-alloBMT on [**2101-7-14**]
(conditioned w/ TBI, pentastatin)
- post-transplant course complicated by grade IV GVHD of gut,
skin, liver
-[**7-30**]: new right sided neck discomfort with fevers, painful
swelling
-WBC in ED showed 20 K, 74% atypicals
-BM bx (strenal aspirate) FAB M2
-recieved idarubicin and cytarabine
- Repeat BM bx showed complete remission
2. Left thigh furuncle s/p surgical debridement was on
daptomycin, metronidazole, and cipro.
3. DM 1, insulin dependent, on lantus
4.  VRE bacteremia


Social History:
He works in the real estate business and plans on going into
appraisals. He lives in [**Location 15427**] and is engaged. He has one
daughter from his prior marriage. He smoked 2 packs of
cigarettes per day prior to his diagnosis but is currently not
smoking. He does not drink alcohol.


Family History:
No known history of leukemias or other cancers within the
family. His father had heart disease and multiple sclerosis. His
mother has type 1 diabetes.


Physical Exam:
VS - T 95.7, BP 99/53, HR 76, RR 16, SaO2 97%/AC 900 x 16, FiO2
100%, PEEP 5
General: Obese male in respiratory distress, mentating enough to
say "help me".
HEENT: Sclera + significant icterus, tears are icteric. Pupils
small, but equal and reative bilaterally. OP clear, MM dry. ETT
in place.
Neck: Could not appreciate any JVD. No LAD.
CV: RRR, nl S1, S2, no m/r/g.
Pulm: dullness at bases b/l, with few anterior wheezes.
Abd: soft, obese, NT/ND. few BS.
Extrem: + anasarca. 2+ radial pulses, but weakly palpable DP
pulses bilaterally.
Neuro: moves all four extremities, sedated but opens voice to
tactile stimuli.


Pertinent Results:
Microbiology:
[**9-7**] - CMV negative
[**9-1**] - blood cx negative
[**8-31**] - urine cx negative
[**8-31**] - blood cx negative
[**8-29**] - blood cx negative
[**8-28**] - foley cath pus enterococcus/pseudomonas
GRAM STAIN (Final [**2101-8-28**]): 2+ PMNs, 4+ GNRs, 1+ GPC pairs.
[**8-22**] - CMV VL negative
[**8-18**] - HCV VL negative
[**8-18**] - HBV VL <60
[**8-16**] - duodenal tissue cx (prelim) negative for CMV
[**8-16**] - cath tip cx negative
[**8-15**] - CMV VL negative
[**8-8**] - CMV VL negative
[**8-6**] - C diff cx negative
[**8-4**] - C diff cx negative
[**8-4**] - stool viral cx negative

Relevant Imaging:
[**2101-7-27**] RUQ US: This study is somewhat limited by patient body
habitus.  The liver demonstrates diffuse increase in
echogenicity consistent with fatty infiltration.  No focal
hepatic lesions are identified. There is no intra- or
extra-hepatic biliary ductal dilatation.  The common duct
measures 6 mm.  The gallbladder contains shadowing stones and
sludge, but
there is no evidence of wall thickening, or pericholecystic
fluid.  There is no ascites.  Limited views of the right kidney
demonstrate no hydronephrosis. There is appropriate hepatopetal
portal vein blood flow.
[**2101-8-4**] Colonoscopy: scattered areas of ereythema throughout the
colon
[**2101-8-7**] CT Abdomen/pelvis: Diffuse wall thickening and luminal
narrowing of the entire large and small bowel, with segments of
small bowel demonstrating an intramural low attenuation rim;
these findings are suggestive of graft versus host disease given
the history of allogenic [**Month/Day/Year 3242**]. Other differential considerations
include other microvasculopathies and/or hypovolemic state. No
free intraperitoneal air.
Distended stomach with no contrast seen to pass past the antrum;
a delayed KUB could be obtained to ensure passage of barium and
exclude gastroparesis or obstruction.
Ground glass and tree-in-[**Male First Name (un) 239**] opacities involving the right
middle lobe and left lower lobes.  Small bilateral pleural
effusions.  Small pericardial effusion. 4-mm focal nodule at the
left lung base with a ground glass halo. Findings are
nonspecific, but most suggestive of an infectious process.
Cholelithiasis.
[**2101-8-16**] EGD: Erythema and nodularity in the whole duodenum
compatible with duodenitis (biopsy) Biopsies were taken from the
duodenum for viral culture and histology Otherwise normal EGD to
second part of the duodenum
[**2101-8-26**]: Duplex doppler US liver: Moderately distended
gallbladder with sludge and stones, but gallbladder wall
thickening not as prominent on today's study.  Cholecystitis is
not currently suspected, but if clinical suspicion persists or
increases, repeat ultrasound and/or HIDA scan can be performed.
Diminished flow within proximal left portal vein, with flow
distally.
[**2101-8-29**] CT abdomen: Diffuse ill-defined patchy pulmonary
opacities are diffuse infection versus asymmetric pulmonary
edema.  There are enlarging and moderate bilateral pleural
effusions.  New small fluid in the abdomen and pelvis secondary
to third spacing. Evaluation of the bowel is limited given lack
of IV contrast, but bowel wall thickening is again seen
suggestive of graft versus host disease.
[**9-12**] CXR - pulmonary edema, improved from CXR on [**2101-8-30**]

Brief Hospital Course:
A/P: Patient is a 38yo male w/ DM, relapsed AML neutropenic,
with acute respiratory failure

1. Respiratory distress/arrest: Pt emergently intubated on the
floor due to acute respiratory failure. Etiology for respiratory
arrest on admission continues to remain unclear, possible acute
worsening of pleural effusions secondary to GVHD versus
infection. Additionally mucous plugging versus aspiration
pneumonia should also be considered. Pt does have pleural
effusions on cxray but after [**Date Range 3242**] at this time is recommending
not to tap. Pt underwent bronchoscopy and continues to be
unrevealing for etiology, BAL cultures are NGTD. PCP and
legionella negative. He was continued on IV Methylprednisolone.
Pt was continued on broad spectrum antibiotics-Daptomycin,
Meropenem, Micofungin, and Vancomycin. The antibiotics were
slowly peeled off as the family progressed to comfort measures
only.

2. Hypotension: This was intermittent, occurring prior to
respiratory arrest and after intubation. Likely [**1-27**] aspiration
prior to arrest and [**1-27**] sedation. No clear infectious source
identified. Continued on broad spectrum antibiotics but were
d/c'ed as family came to decision to withdraw care. He was
intermittenly treated with Albumin, fluids, and Lasix since the
housestaff team was unsure about his volume status, despite him
being extremely edematous on exam.

3. Altered Mental Status: The patient did not wake from
sedation, despite being off off all sedation. The morning prior
to his death, pt went into vfib arrest, likely hypoxic for
approximately 10 minutes resulting in anoxic brain [**Month/Day (2) **].

4. Hyperbilirubinemia: The most likely cause of this conjugated
hyperbilirubinemia is acute hepatic GVHD. Pt underwent a
transjugular liver biopsy, as per hepatology,  but there was not
enough tissue sample to analyze. He also likely has a component
of hemolysis giving rise to indirect bilirubinemia [**1-27**]
mismatched allo. He was continued on Cyclosporing during his
stay, with close monitoring of the drug levels.

5. AML - Given mismatched alloBMT, has low grade hemolysis
contributing to his hyperbilirubinemia. He remained anemic and
thrombocytopenic during his stay in the [**Hospital Unit Name 153**] requiring multiple
RBC and platelet transfusions. [**Hospital Unit Name 3242**] followed him closely. He was
continued on empiric antibiotic therapy, Cyclosporine, and IV
steroids. The cyclosporine levels were followed closely.

6. GVHD: Likely affecting both the gut and liver - ongoing, with
intermittent GI bleed. He was continued on Cyclosporine, IV PPI
and sucralfate for his GI regimen.

7. Anemia/Thrombocytopenia: Likely [**1-27**] mismatched alloBMT, ACD,
and ongoing GIB. He required multiple RBC and platelet
transfusions.

8. DM: Continued on insulin in TPN along with ISS. .

9. F/E/N - TPN, NPO. Replete lytes prn.

10. Ppx - PPI, pneumoboots, bowel regimen, HOB at 30 degrees

11. Access - Right IJ Quad, R arterial radial line.

12. Communication - with pt, pt's girlfriend/HCP [**Name (NI) 1356**]
([**Telephone/Fax (1) 111400**])

Pt passed away on [**2101-9-18**] from respiratory failure after the
family decided to change code status to CMO. Full autopsy was
done.

Medications on Admission:
Tacrolimus suspension 2mg PO BID
Quetiapine 25mg PO QHS
Caphasol 30mL MM QID
Sucalfate 1gm PO QID
Nifedipine 10mg PO Q8
RISS + 15u Lantus QHS
Ambisome 500mg IV Q24
Metoprolol 25mg PO BID
Mycophenolate 750mg IV QAM (7), 500mg Qnoon (15), 750mg PO QPM
(23)
Fentanyl patch 75mcg TP Q72
Ursodiol 300mg PO QAM, 600mg PO QPM
Dental gel 1 app TP [**Hospital1 **]
Clotrimazole 1 troc PO QID
Mg, KPhos, Ca, KCl sliding scales
Methylprednisolone 50mg IV Q12
Cyclosporine cont infusion 180mg IV QD
Ciprofloxacin 250mg IV Q12 (started [**8-28**])
Daptomycin 450mg IV Q24 (started [**8-29**])
Lasix 40mg IV x1 on [**2101-8-28**]

Discharge Medications:
Pt died on [**2101-9-18**]

Discharge Disposition:
Home

Discharge Diagnosis:
Respiratory failure
Hepatic failure
AML


Discharge Condition:
Pt died on [**2101-9-18**]

Discharge Instructions:
Pt died on [**2101-9-18**]

Followup Instructions:
Pt died on [**2101-9-18**]
{'Acute myeloid leukemia, without mention of having achieved remission,Acute respiratory failure,Cardiac arrest,Complications of transplanted bone marrow,Aspergillosis,Bacteremia,Hemorrhage of gastrointestinal tract, unspecified,Congestive heart failure, unspecified,Acute kidney failure, unspecified,Cellulitis and abscess of leg, except foot,Pneumonia, organism unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Other disorders of muscle, ligament, and fascia,Delirium due to conditions classified elsewhere,Infection with microorganisms without mention of resistance to multiple drugs,Unspecified essential hypertension,Other specified viral infection,Other specified disorders of liver,Other specified erythematous conditions'}


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: Respiratory arrest

PRESENT ILLNESS: HPI - This is a 37 y/o male with relapsed AML, s/p unrelated
unmatched alloBMT day +59, course c/b VRE bacteremia ([**7-14**]),
aspergillus lung infection in [**2099**], GVHD, recent stay in [**Hospital Unit Name 153**]
for sepsis of unclear etiology (although grew pseudomonas and
enterococcus from pus from foley catheter) on long-standing
broad-spectrum abx, who was transferred to the ICU this
afternoon s/p code blue for respiratory arrest.
This afternoon, the patient was sitting in his chair and was
noted to become hypotensive from a lying to sitting position
(SBP drop to 70's) and suddenly unresponsive with hypoxia on 4L,
with sats of 80's on NRB. He was emergently intubated on the
floor and was started on Neo for a brief time when SBP's fell to
the 50's s/p intubation and sedation. By the time he arrived to
the ICU (approx 10 min later), his SBP had improved to the 90's
and he was weaned off the Neo gtt.
At the time of intubation, he was noted to have brown, copious
secretions at the back of his throat, requiring suctioning.

MEDICAL HISTORY: 1)ONCOLOGY HX -
- presented in [**7-30**] w/ new R sided neck discomfort, swelling,
fevers
- WBC in ED showed 20 K, 74% atypicals
- BM bx (sternal aspirate) showed AML FAB M2
- recieved induction w/ idarubicin and cytarabine, then hiDAC x2

MEDICATION ON ADMISSION: Tacrolimus suspension 2mg PO BID
Quetiapine 25mg PO QHS
Caphasol 30mL MM QID
Sucalfate 1gm PO QID
Nifedipine 10mg PO Q8
RISS + 15u Lantus QHS
Ambisome 500mg IV Q24
Metoprolol 25mg PO BID
Mycophenolate 750mg IV QAM (7), 500mg Qnoon (15), 750mg PO QPM
(23)
Fentanyl patch 75mcg TP Q72
Ursodiol 300mg PO QAM, 600mg PO QPM
Dental gel 1 app TP [**Hospital1 **]
Clotrimazole 1 troc PO QID
Mg, KPhos, Ca, KCl sliding scales
Methylprednisolone 50mg IV Q12
Cyclosporine cont infusion 180mg IV QD
Ciprofloxacin 250mg IV Q12 (started [**8-28**])
Daptomycin 450mg IV Q24 (started [**8-29**])
Lasix 40mg IV x1 on [**2101-8-28**]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS - T 95.7, BP 99/53, HR 76, RR 16, SaO2 97%/AC 900 x 16, FiO2
100%, PEEP 5
General: Obese male in respiratory distress, mentating enough to
say "help me".
HEENT: Sclera + significant icterus, tears are icteric. Pupils
small, but equal and reative bilaterally. OP clear, MM dry. ETT
in place.
Neck: Could not appreciate any JVD. No LAD.
CV: RRR, nl S1, S2, no m/r/g.
Pulm: dullness at bases b/l, with few anterior wheezes.
Abd: soft, obese, NT/ND. few BS.
Extrem: + anasarca. 2+ radial pulses, but weakly palpable DP
pulses bilaterally.
Neuro: moves all four extremities, sedated but opens voice to
tactile stimuli.

FAMILY HISTORY: No known history of leukemias or other cancers within the
family. His father had heart disease and multiple sclerosis. His
mother has type 1 diabetes.

SOCIAL HISTORY: He works in the real estate business and plans on going into
appraisals. He lives in [**Location 15427**] and is engaged. He has one
daughter from his prior marriage. He smoked 2 packs of
cigarettes per day prior to his diagnosis but is currently not
smoking. He does not drink alcohol. 

### Response:
{'Acute myeloid leukemia, without mention of having achieved remission,Acute respiratory failure,Cardiac arrest,Complications of transplanted bone marrow,Aspergillosis,Bacteremia,Hemorrhage of gastrointestinal tract, unspecified,Congestive heart failure, unspecified,Acute kidney failure, unspecified,Cellulitis and abscess of leg, except foot,Pneumonia, organism unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Other disorders of muscle, ligament, and fascia,Delirium due to conditions classified elsewhere,Infection with microorganisms without mention of resistance to multiple drugs,Unspecified essential hypertension,Other specified viral infection,Other specified disorders of liver,Other specified erythematous conditions'}
