CHIEF COMPLAINT: hypotension, PEA/VF arrest

PRESENT ILLNESS: HPI: 67M with h/o HTN, hyperlipidemia, and depression presented
to an OSH on [**9-16**] after being found unresponsive at home.  He
complained of 1 week of weakness, fatigue, and increased
abdominal pain prior to presentation.  On the AM of [**9-16**], he was
found unresponsive by his wife.  EMS found him to be bradycardic
without a pulse, and received epinephrine/atropine and was
intubated in the field.  At the OSH, ECG showed inferior STE and
he was flown to [**Hospital1 18**] for cath.  His cath showed clean
coronaries.  He had VF arrest in the cath lab and was shocked
into NSR.  CXR showed large R pleural effusion with ?
mediastinal shift, so CT Surgery placed a chest tube, which
drained >1L mucinous fluid.  He was started on levophed and
vasopressin for SBP 70s.  LVgram showed .  Hemodynamics showed
CO 4.12, CI 1.93, elevated R and L-sided filling pressures (RA
14, PCWP 25).  He was admitted to the CCU for further
management.
.
In the CCU, his VS on arrival were T 97.8, HR 75, BP 98/30 on
levophed and vasopressin, O2sat 98% on AC 700x12/0/100%.
Cultures were sent including pleural fluid.  CT head showed SAH,
Neurosurgery was consulted, recommended MRI/A when stable.  CT
torso was performed to look for infectious source.  NG with
clots, transfused 1U PRBC, started on Protonix gtt.

MEDICAL HISTORY: Vitals- Tm 99.1/Tc 98.8, HR 62, BP 111/53 (MAP 70), RR 16, O2sat
98% on AC 600x16/FiO2 50%/PEEP 0; CVP 12, PAP 41/20, CO 6.6, CI
2.95, SVR 824
General- sedated and intubated
HEENT- pupils constricted b/l, ETT OGT
Neck- unable to assess for JVD [**1-13**] body habitus
Pulm- coarse breath sounds b/l, diffuse end-expiratory wheeze
CV- distant heart sounds
Abd- hypoactive bowel sounds, distended but soft, tympanitic on
percussion, grimaces to palpation of RUQ/epigastrium/RLQ
Extrem- 1+ ankle edema, 2 discrete erythematous patches on L
heel and R calf, unroofed blister on L inner thigh
Neuro- sedated and intubated, R pupil 2mm and reactive to light,
L eye opacified, does not open eyes to command or name, does not
track, withdraws all 4 extremities to noxious stimuli, toes
downgoing b/l

MEDICATION ON ADMISSION: [**Name (NI) 36173**] (wife held it 1wk ago)
Seroquel (wife held it 1wk ago)
Lisinopril
Crestor
Zyprexa 2.5mg qd (started 2d PTA)
Vicodin prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals- Tm 99.1/Tc 98.8, HR 62, BP 111/53 (MAP 70), RR 16, O2sat
98% on AC 600x16/FiO2 50%/PEEP 0; CVP 12, PAP 41/20, CO 6.6, CI
2.95, SVR 824
General- sedated and intubated
HEENT- pupils constricted b/l, ETT OGT
Neck- unable to assess for JVD [**1-13**] body habitus
Pulm- coarse breath sounds b/l, diffuse end-expiratory wheeze
CV- distant heart sounds
Abd- hypoactive bowel sounds, distended but soft, tympanitic on
percussion, grimaces to palpation of RUQ/epigastrium/RLQ
Extrem- 1+ ankle edema, 2 discrete erythematous patches on L
heel and R calf, unroofed blister on L inner thigh
Neuro- sedated and intubated, R pupil 2mm and reactive to light,
L eye opacified, does not open eyes to command or name, does not
track, withdraws all 4 extremities to noxious stimuli, toes
downgoing b/l

FAMILY HISTORY: lives with wife and grandson, worked as mechanic/welder,
currently on disability (family states for obesity?), family
states pt is independent in ADLs however poor hygiene evident on
admission; no EtOH/tob/IVDU per family

SOCIAL HISTORY: 1. HTN
2. Hyperlipidemia
3. Depression- for past 3y after son passed away
4. Glucose intolerance
5. L eye blindness
Unspecified septicemia,Septic shock,Acute myocardial infarction of other inferior wall, initial episode of care,Malignant neoplasm of lower lobe, bronchus or lung,Acute kidney failure, unspecified,Subarachnoid hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness,Hemorrhage of gastrointestinal tract, unspecified,Acute respiratory failure,Pneumonia, organism unspecified,Cardiac complications, not elsewhere classified,Ventricular fibrillation,Empyema without mention of fistula,Pressure ulcer, buttock,Chronic airway obstruction, not elsewhere classified,Unspecified fall,Severe sepsis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Delirium due to conditions classified elsewhere,Encounter for palliative care
Septicemia NOS,Septic shock,AMI inferior wall, init,Mal neo lower lobe lung,Acute kidney failure NOS,Traum subarachnoid hem,Gastrointest hemorr NOS,Acute respiratry failure,Pneumonia, organism NOS,Surg compl-heart,Ventricular fibrillation,Empyema w/o fistula,Pressure ulcer, buttock,Chr airway obstruct NEC,Fall NOS,Severe sepsis,DMII wo cmp nt st uncntr,Delirium d/t other cond,Encountr palliative care
Admission Date:  [**2191-9-16**]              Discharge Date:   [**2191-10-3**]

Date of Birth:  [**2124-2-7**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 99**]
Chief Complaint:
hypotension, PEA/VF arrest

Major Surgical or Invasive Procedure:
Endotracheal Intubation
Thoracostomy

History of Present Illness:
HPI: 67M with h/o HTN, hyperlipidemia, and depression presented
to an OSH on [**9-16**] after being found unresponsive at home.  He
complained of 1 week of weakness, fatigue, and increased
abdominal pain prior to presentation.  On the AM of [**9-16**], he was
found unresponsive by his wife.  EMS found him to be bradycardic
without a pulse, and received epinephrine/atropine and was
intubated in the field.  At the OSH, ECG showed inferior STE and
he was flown to [**Hospital1 18**] for cath.  His cath showed clean
coronaries.  He had VF arrest in the cath lab and was shocked
into NSR.  CXR showed large R pleural effusion with ?
mediastinal shift, so CT Surgery placed a chest tube, which
drained >1L mucinous fluid.  He was started on levophed and
vasopressin for SBP 70s.  LVgram showed .  Hemodynamics showed
CO 4.12, CI 1.93, elevated R and L-sided filling pressures (RA
14, PCWP 25).  He was admitted to the CCU for further
management.
.
In the CCU, his VS on arrival were T 97.8, HR 75, BP 98/30 on
levophed and vasopressin, O2sat 98% on AC 700x12/0/100%.
Cultures were sent including pleural fluid.  CT head showed SAH,
Neurosurgery was consulted, recommended MRI/A when stable.  CT
torso was performed to look for infectious source.  NG with
clots, transfused 1U PRBC, started on Protonix gtt.

Past Medical History:
Vitals- Tm 99.1/Tc 98.8, HR 62, BP 111/53 (MAP 70), RR 16, O2sat
98% on AC 600x16/FiO2 50%/PEEP 0; CVP 12, PAP 41/20, CO 6.6, CI
2.95, SVR 824
General- sedated and intubated
HEENT- pupils constricted b/l, ETT OGT
Neck- unable to assess for JVD [**1-13**] body habitus
Pulm- coarse breath sounds b/l, diffuse end-expiratory wheeze
CV- distant heart sounds
Abd- hypoactive bowel sounds, distended but soft, tympanitic on
percussion, grimaces to palpation of RUQ/epigastrium/RLQ
Extrem- 1+ ankle edema, 2 discrete erythematous patches on L
heel and R calf, unroofed blister on L inner thigh
Neuro- sedated and intubated, R pupil 2mm and reactive to light,
L eye opacified, does not open eyes to command or name, does not
track, withdraws all 4 extremities to noxious stimuli, toes
downgoing b/l

Social History:
1. HTN
2. Hyperlipidemia
3. Depression- for past 3y after son passed away
4. Glucose intolerance
5. L eye blindness

Family History:
lives with wife and grandson, worked as mechanic/welder,
currently on disability (family states for obesity?), family
states pt is independent in ADLs however poor hygiene evident on
admission; no EtOH/tob/IVDU per family

Physical Exam:
Vitals- Tm 99.1/Tc 98.8, HR 62, BP 111/53 (MAP 70), RR 16, O2sat
98% on AC 600x16/FiO2 50%/PEEP 0; CVP 12, PAP 41/20, CO 6.6, CI
2.95, SVR 824
General- sedated and intubated
HEENT- pupils constricted b/l, ETT OGT
Neck- unable to assess for JVD [**1-13**] body habitus
Pulm- coarse breath sounds b/l, diffuse end-expiratory wheeze
CV- distant heart sounds
Abd- hypoactive bowel sounds, distended but soft, tympanitic on
percussion, grimaces to palpation of RUQ/epigastrium/RLQ
Extrem- 1+ ankle edema, 2 discrete erythematous patches on L
heel and R calf, unroofed blister on L inner thigh
Neuro- sedated and intubated, R pupil 2mm and reactive to light,
L eye opacified, does not open eyes to command or name, does not
track, withdraws all 4 extremities to noxious stimuli, toes
downgoing b/l


Pertinent Results:
[**2191-9-16**] 01:15PM BLOOD WBC-14.6* RBC-3.28* Hgb-9.6* Hct-29.5*
MCV-90 MCH-29.3 MCHC-32.5 RDW-17.5* Plt Ct-434
[**2191-9-16**] 03:37PM BLOOD WBC-25.8* RBC-3.49* Hgb-10.3* Hct-30.8*
MCV-88 MCH-29.6 MCHC-33.5 RDW-17.5* Plt Ct-437
[**2191-9-16**] 03:37PM BLOOD Neuts-83* Bands-6* Lymphs-6* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 NRBC-6*
[**2191-9-16**] 03:37PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-1+
[**2191-9-16**] 03:37PM BLOOD PT-14.6* PTT-33.3 INR(PT)-1.3*
[**2191-9-16**] 03:37PM BLOOD Fibrino-463*
[**2191-9-16**] 01:15PM BLOOD Glucose-93 UreaN-50* Creat-1.5* Na-130*
K-3.7 Cl-92* HCO3-29 AnGap-13
[**2191-9-16**] 03:37PM BLOOD Glucose-200* UreaN-91* Creat-2.6*# Na-137
K-5.3* Cl-102 HCO3-25 AnGap-15
[**2191-9-16**] 01:15PM BLOOD ALT-11 CK(CPK)-1183* AlkPhos-29*
Amylase-28 TotBili-0.2
[**2191-9-16**] 03:37PM BLOOD ALT-22 AST-63* LD(LDH)-413* CK(CPK)-2927*
AlkPhos-62 TotBili-0.4
[**2191-9-16**] 01:15PM BLOOD Lipase-34
[**2191-9-16**] 03:37PM BLOOD CK-MB-20* MB Indx-0.7 cTropnT-0.17*
[**2191-9-16**] 03:37PM BLOOD TotProt-4.5* Albumin-2.2* Globuln-2.3
Calcium-6.8* Phos-6.8* Mg-2.2 UricAcd-10.6* Iron-PND
[**2191-9-16**] 01:15PM BLOOD Cortsol-26.6*
[**2191-9-16**] 03:37PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2191-9-16**] 02:43PM BLOOD Type-ART Tidal V-700 FiO2-100 pO2-138*
pCO2-53* pH-7.29* calTCO2-27 Base XS--1 AADO2-551 REQ O2-88
[**2191-9-16**] 05:47PM BLOOD Type-ART Temp-36.3 pO2-210* pCO2-49*
pH-7.35 calTCO2-28 Base XS-0
[**2191-9-16**] 12:59PM BLOOD Glucose-162* Lactate-8.6* Na-140 K-4.7
Cl-98*
[**2191-9-16**] 08:19PM BLOOD Lactate-1.5
[**2191-9-16**] 03:55PM BLOOD freeCa-1.05*
[**2191-9-16**] 03:39PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.030
[**2191-9-16**] 03:39PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-5.0 Leuks-NEG
[**2191-9-16**] 03:39PM URINE Hours-RANDOM Creat-143 Na-30 TotProt-72
Prot/Cr-0.5*
[**2191-9-16**] 03:39PM URINE Osmolal-423
[**2191-9-16**] 03:39PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2191-9-16**] 07:19PM PLEURAL WBC-1222* RBC-[**Numeric Identifier 69195**]* Polys-PND
Lymphs-PND Monos-PND
[**2191-9-16**] SEROLOGY/BLOOD LYME SEROLOGY-PENDING
[**2191-9-16**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING
[**2191-9-16**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING
[**2191-9-16**] PLEURAL FLUID GRAM STAIN-PENDING; FLUID
CULTURE-PENDING; ANAEROBIC CULTURE-PENDING; FUNGAL
CULTURE-PENDING; ACID FAST SMEAR-PENDING; ACID FAST
CULTURE-PENDING
[**2191-9-16**] PLEURAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-PENDING; ANAEROBIC CULTURE-PENDING; ACID FAST
CULTURE-PENDING; ACID FAST SMEAR-PENDING
[**2191-9-16**] URINE URINE CULTURE-PENDING
[**2191-9-16**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING


Brief Hospital Course:
# Shock: Pt had Septic physiology on admission to the CCU, and
the most likely source was felt to be postobstructive pneumonia
and parapneumonic effusion. His CI was high, so his hypotension
was not felt to be due to cardiogenic shock. He was initially
maintained on 3 pressors upon transfer to the MICU service, but
neosynephrine was weaned off quickly. He was given empiric Zosyn
and vancomycin to cover polymicrobial sepsis. Levophed was
gradually weaned the next day, and then vasopressin was stopped.
Levophed had to be restarted for a few hours on [**9-19**] for MAP<60,
but it was weaned off the next day.
.
# Respiratory failure: Pt was intubated during his first PEA
arrest. The R-sided chest tube initially drained a large volume
of mucinous fluid, then drained serosanguinous fluid. The fluid
was grossly exudative with LDH 4000 on a diluted specimen. The
pleural fluid amylase was also elevated, to 3x the serum value.
The Gram stain was negative, and cultures are no growth to date.
His noncontrast chest CT showed a RLL rounded opacity with no
air bronchograms but density consistent with lung parenchyma.
The differential was thought to include atelectasis vs.
postobstructive pneumonia vs. sequestration. He underwent a
bronchoscopy on [**9-18**] with mild secretions and no endobronchial
lesions visualized, and a BAL was sent. His ventilatory
requirements were gradually weaned, however he had trouble
ventilating adequately while on pressure support. CT chest with
contrast showed the RLL opacity was a large mass with
significant surrounding lymphadenopathy and marked pleural
tumor, with possible invasion into the chest wall. Pleural fluid
cytology returned suspicious for adenocarcinoma, and pt was
ultimately diagnosed with stage IIIA lung cancer.  Pt's
progressive respiratory failure was treated with BiPAP and nebs,
but he continually removed his BiPAP, leading to significantly
labored breathing and desaturation.  A family meeting concluded
that BiPAP should be deferred, and that pt should be made
DNR/DNI with a focus on full comfort measures.  Pt ultimately
died of respiratory failure likely due to a combination of COPD,
pneumonia and lung cancer on the morning of [**2191-10-3**].
.
# Altered mental status: She had a subarachnoid and
intracerebral hemorrhage on CT. Neurosurgery was consulted, and
felt that the bleed was likely an effect of reperfusion during
arrest. He had leukocytosis but no fever, and no history of
headache at home, so meningitis was thought to be unlikely and
LP was deferred. Tox screen was negative on admission. He was
able to follow commands and communicate effectively when his
sedation was weaned.  Pt maintained a waxing-[**Doctor Last Name 688**] course until
his death on [**2191-10-3**].
.
# ARF: It was thought likely secondary to hypoperfusion/ATN in
the setting of cardiac arrest and shock. His creatinine
gradually improved to normal.
.
# UGIB: His OG tube initially drained clots on admission. He was
felt to have an upper GI bleed in the setting of heparin and
integrilin in the cath lab, and it was self-resolved. Upon
transfer to the MICU, his OG tube was draining a thick white
chylous-appearing fluid. That also resolved spontaneously. His
CT was reviewed by Radiology who stated there was no evidence of
esophageal perforation. He was maintained on an IV PPI [**Hospital1 **], and
his HCT remained stable for the remainder of his course.
.
Pt was maintained on full comfort measures once a family meeting
concluded that he sould be made DNR/DNI w/o further aggressive
management of his progressive respiratory failure.  On the
morning of [**2191-10-3**], pt died a peaceful death due to
complications of progressive respiratory failure, likely
secondary to lung cancer, pneumonia, COPD and an expanding
malignant pleural effusion.  Pt's family was notified, and they
deferred autopsy.


Medications on Admission:
[**Name (NI) 36173**] (wife held it 1wk ago)
Seroquel (wife held it 1wk ago)
Lisinopril
Crestor
Zyprexa 2.5mg qd (started 2d PTA)
Vicodin prn


Discharge Medications:
N/A

Discharge Disposition:
Expired

Discharge Diagnosis:
Lung Cancer
COPD
Pneumonia
Intraparenchymal and subarachnoid hemorrhage

Discharge Condition:
Expired.

Discharge Instructions:
N/A

Followup Instructions:
N/A


Completed by:[**2191-10-5**]
{'Unspecified septicemia,Septic shock,Acute myocardial infarction of other inferior wall, initial episode of care,Malignant neoplasm of lower lobe, bronchus or lung,Acute kidney failure, unspecified,Subarachnoid hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness,Hemorrhage of gastrointestinal tract, unspecified,Acute respiratory failure,Pneumonia, organism unspecified,Cardiac complications, not elsewhere classified,Ventricular fibrillation,Empyema without mention of fistula,Pressure ulcer, buttock,Chronic airway obstruction, not elsewhere classified,Unspecified fall,Severe sepsis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Delirium due to conditions classified elsewhere,Encounter for palliative care'}


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: hypotension, PEA/VF arrest

PRESENT ILLNESS: HPI: 67M with h/o HTN, hyperlipidemia, and depression presented
to an OSH on [**9-16**] after being found unresponsive at home.  He
complained of 1 week of weakness, fatigue, and increased
abdominal pain prior to presentation.  On the AM of [**9-16**], he was
found unresponsive by his wife.  EMS found him to be bradycardic
without a pulse, and received epinephrine/atropine and was
intubated in the field.  At the OSH, ECG showed inferior STE and
he was flown to [**Hospital1 18**] for cath.  His cath showed clean
coronaries.  He had VF arrest in the cath lab and was shocked
into NSR.  CXR showed large R pleural effusion with ?
mediastinal shift, so CT Surgery placed a chest tube, which
drained >1L mucinous fluid.  He was started on levophed and
vasopressin for SBP 70s.  LVgram showed .  Hemodynamics showed
CO 4.12, CI 1.93, elevated R and L-sided filling pressures (RA
14, PCWP 25).  He was admitted to the CCU for further
management.
.
In the CCU, his VS on arrival were T 97.8, HR 75, BP 98/30 on
levophed and vasopressin, O2sat 98% on AC 700x12/0/100%.
Cultures were sent including pleural fluid.  CT head showed SAH,
Neurosurgery was consulted, recommended MRI/A when stable.  CT
torso was performed to look for infectious source.  NG with
clots, transfused 1U PRBC, started on Protonix gtt.

MEDICAL HISTORY: Vitals- Tm 99.1/Tc 98.8, HR 62, BP 111/53 (MAP 70), RR 16, O2sat
98% on AC 600x16/FiO2 50%/PEEP 0; CVP 12, PAP 41/20, CO 6.6, CI
2.95, SVR 824
General- sedated and intubated
HEENT- pupils constricted b/l, ETT OGT
Neck- unable to assess for JVD [**1-13**] body habitus
Pulm- coarse breath sounds b/l, diffuse end-expiratory wheeze
CV- distant heart sounds
Abd- hypoactive bowel sounds, distended but soft, tympanitic on
percussion, grimaces to palpation of RUQ/epigastrium/RLQ
Extrem- 1+ ankle edema, 2 discrete erythematous patches on L
heel and R calf, unroofed blister on L inner thigh
Neuro- sedated and intubated, R pupil 2mm and reactive to light,
L eye opacified, does not open eyes to command or name, does not
track, withdraws all 4 extremities to noxious stimuli, toes
downgoing b/l

MEDICATION ON ADMISSION: [**Name (NI) 36173**] (wife held it 1wk ago)
Seroquel (wife held it 1wk ago)
Lisinopril
Crestor
Zyprexa 2.5mg qd (started 2d PTA)
Vicodin prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals- Tm 99.1/Tc 98.8, HR 62, BP 111/53 (MAP 70), RR 16, O2sat
98% on AC 600x16/FiO2 50%/PEEP 0; CVP 12, PAP 41/20, CO 6.6, CI
2.95, SVR 824
General- sedated and intubated
HEENT- pupils constricted b/l, ETT OGT
Neck- unable to assess for JVD [**1-13**] body habitus
Pulm- coarse breath sounds b/l, diffuse end-expiratory wheeze
CV- distant heart sounds
Abd- hypoactive bowel sounds, distended but soft, tympanitic on
percussion, grimaces to palpation of RUQ/epigastrium/RLQ
Extrem- 1+ ankle edema, 2 discrete erythematous patches on L
heel and R calf, unroofed blister on L inner thigh
Neuro- sedated and intubated, R pupil 2mm and reactive to light,
L eye opacified, does not open eyes to command or name, does not
track, withdraws all 4 extremities to noxious stimuli, toes
downgoing b/l

FAMILY HISTORY: lives with wife and grandson, worked as mechanic/welder,
currently on disability (family states for obesity?), family
states pt is independent in ADLs however poor hygiene evident on
admission; no EtOH/tob/IVDU per family

SOCIAL HISTORY: 1. HTN
2. Hyperlipidemia
3. Depression- for past 3y after son passed away
4. Glucose intolerance
5. L eye blindness 

### Response:
{'Unspecified septicemia,Septic shock,Acute myocardial infarction of other inferior wall, initial episode of care,Malignant neoplasm of lower lobe, bronchus or lung,Acute kidney failure, unspecified,Subarachnoid hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness,Hemorrhage of gastrointestinal tract, unspecified,Acute respiratory failure,Pneumonia, organism unspecified,Cardiac complications, not elsewhere classified,Ventricular fibrillation,Empyema without mention of fistula,Pressure ulcer, buttock,Chronic airway obstruction, not elsewhere classified,Unspecified fall,Severe sepsis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Delirium due to conditions classified elsewhere,Encounter for palliative care'}
