CHIEF COMPLAINT: Hypoxic respiratory failure and hypotension

PRESENT ILLNESS: 73 y.o. man who presents for respiratory distress.  History is
limited and is from son and [**Name (NI) **] notes.  He was apparently feeling
ok yesterday.  This morning, per his living facility, he was
less responsive and in respiratory distress.  O2 sat was in the
50s.  He may have had a mild cough over the last few days.  He
was brought to the ED. He was intubated on arrival for
unresponsiveness, cyanosis.  Subsequently, he was hypotensive
with SBP to 60s.  A CVL was placed, he was given 2.25 L NS and
started on levophed with response in SBP up to 110s.  He was
started on vanco, levo, flagyl for pneumonia after infiltrate
was seen on CXR.  Then transported to [**Hospital Unit Name 153**].

MEDICAL HISTORY: 1) AAA repair--R common iliac aneursym repair in [**7-12**] with
endovascular stent
2) COPD--on home O2
3) CAD with cardiomyopathy:  last TTE in [**7-12**] showed nml EF,
impaired relaxation.
4) HTN
5) CRI (bl Cr=1.2)
6) Anemia
7) chronic UTI
8) dementia
9) depression

MEDICATION ON ADMISSION: Trazadone 25mg q6h prn
APAP prn
Flovent 110mcg 2puffs [**Hospital1 **]
Combivent 2 puffs q4h
Lopressor 25mg tid
Levaquin 500mg daily (since [**2-4**])
Flagyl 500mg tid (since [**2-4**])

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS:  Tm 102 (Tc 101.3) -- BP 110/80 --- HR 90-100s -- RR 20
(set) --- 100% on AC 500 x 20  FiO2 0.6  PEEP 5  PIP 37.
GEN:  intubated, but opens eyes and follows simple commands.
HEENT:  NCAT, Pupils 3mm and min reactive but equal.  Anicteric.
 OP with ETT, dry MM.
Neck:  supple, JVP not appreciated due to habitus.
Lungs:  coarse BS b/l with anterior rhonchi and left sided
expiratory wheezing.
CV:  distant HS, RRR, nml S1S2, no m/r/g appreaciated
ABD:  soft, mod distended, NT, naBS, no masses.
EXT:  no c/c/e.
NEURO:  resting cogwheel tremor of hands R>L.
SKIN:  no wounds or ulcers.

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: Spanish speaking, lives in a nursing home, ex-smoker and alcohol
user.
Unspecified septicemia,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Septic shock,Chronic airway obstruction, not elsewhere classified,Congestive heart failure, unspecified,Acute kidney failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Pneumonia due to Pseudomonas,Other primary cardiomyopathies,Hypovolemia,Infection and inflammatory reaction due to other vascular device, implant, and graft,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Other persistent mental disorders due to conditions classified elsewhere,Severe sepsis
Septicemia NOS,Acute respiratry failure,Food/vomit pneumonitis,Septic shock,Chr airway obstruct NEC,CHF NOS,Acute kidney failure NOS,Hyp kid NOS w cr kid V,Pseudomonal pneumonia,Prim cardiomyopathy NEC,Hypovolemia,React-oth vasc dev/graft,Crnry athrscl natve vssl,Hypertension NOS,Mental disor NEC oth dis,Severe sepsis
Admission Date:  [**2123-2-11**]              Discharge Date:   [**2123-3-5**]

Date of Birth:  [**2049-10-4**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Hypoxic respiratory failure and hypotension

Major Surgical or Invasive Procedure:
1.  s/p Intubation
2.  s/p Tracheostomy


History of Present Illness:
73 y.o. man who presents for respiratory distress.  History is
limited and is from son and [**Name (NI) **] notes.  He was apparently feeling
ok yesterday.  This morning, per his living facility, he was
less responsive and in respiratory distress.  O2 sat was in the
50s.  He may have had a mild cough over the last few days.  He
was brought to the ED. He was intubated on arrival for
unresponsiveness, cyanosis.  Subsequently, he was hypotensive
with SBP to 60s.  A CVL was placed, he was given 2.25 L NS and
started on levophed with response in SBP up to 110s.  He was
started on vanco, levo, flagyl for pneumonia after infiltrate
was seen on CXR.  Then transported to [**Hospital Unit Name 153**].

Pt had CXR on [**2-4**] which showed bibasilar infiltrates.  He was
started on levaquin and flagyl.

Past Medical History:
1) AAA repair--R common iliac aneursym repair in [**7-12**] with
endovascular stent
2) COPD--on home O2
3) CAD with cardiomyopathy:  last TTE in [**7-12**] showed nml EF,
impaired relaxation.
4) HTN
5) CRI (bl Cr=1.2)
6) Anemia
7) chronic UTI
8) dementia
9) depression


Social History:
Spanish speaking, lives in a nursing home, ex-smoker and alcohol
user.


Family History:
noncontributory

Physical Exam:
VS:  Tm 102 (Tc 101.3) -- BP 110/80 --- HR 90-100s -- RR 20
(set) --- 100% on AC 500 x 20  FiO2 0.6  PEEP 5  PIP 37.
GEN:  intubated, but opens eyes and follows simple commands.
HEENT:  NCAT, Pupils 3mm and min reactive but equal.  Anicteric.
 OP with ETT, dry MM.
Neck:  supple, JVP not appreciated due to habitus.
Lungs:  coarse BS b/l with anterior rhonchi and left sided
expiratory wheezing.
CV:  distant HS, RRR, nml S1S2, no m/r/g appreaciated
ABD:  soft, mod distended, NT, naBS, no masses.
EXT:  no c/c/e.
NEURO:  resting cogwheel tremor of hands R>L.
SKIN:  no wounds or ulcers.

Pertinent Results:
[**2123-2-11**] 07:56AM   WBC-15.2* RBC-3.67* HGB-10.9* HCT-33.7*
MCV-92
PLT COUNT-215
.
[**2123-2-11**] 08:27AM   GLUCOSE-291* LACTATE-3.4* NA+-146 K+-4.3
CL--106
[**2123-2-11**] 08:27AM   freeCa-1.11*
[**2123-2-11**] 09:10AM   CALCIUM-7.8* PHOSPHATE-4.6* MAGNESIUM-2.2
.
[**2123-2-11**] 09:51AM   LACTATE-3.9*
[**2123-2-11**] 10:47AM   LACTATE-2.4*
.
[**2123-2-11**] 08:30AM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2123-2-11**] 08:30AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2123-2-11**] 08:30AM URINE  RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2 TRANS EPI-0-2
.
[**2123-2-11**] 08:27AM   ABG#1:  O2-100 PO2-277* PCO2-94* PH-7.21*
[**2123-2-11**]
ABG#2:  RATES-/16 O2-100 PO2-253* PCO2-64* PH-7.29*
.
CXR:  RLL patchy opacity
ECG:  porr baseline but appears SR at 96bpm, nml axis, ints.
PRWP.  TWI in V2, no acute ST-T changes (c/w [**7-12**])
.
[**2123-2-11**]- abdominal x-ray -  No evidence of bowel obstruction.
Nasogastric tube in satisfactory position.
.
Echo [**2123-2-15**] - Suboptimal image quality. Left ventricular wall
thicknesses and cavity size  are normal. Overall left
ventricular systolic function is probably mildly  depressed. The
basal septum appears hypokinetic. Right ventricular chamber
size and free wall motion appear normal. The aortic valve
leaflets (3) are  mildly thickened but aortic stenosis is not
present. No aortic regurgitation  is seen. The mitral valve
leaflets are mildly thickened. No mitral  regurgitation is seen.
There is mild pulmonary artery systolic hypertension.  There is
no pericardial effusion.
Compared with the report of the prior study (tape unavailable
for review) of  [**2122-8-5**], the degree of pulmonary hypertension
detected has increased. A  mildly depressed LVEF is now
suggested, but not conclusive (poor image  quality). If
clinically indicated, a repeat TTE with echo contrast (Definity)
 may better define regional/global LV systolic function.
.
CT abdomen - [**2123-2-22**] - IMPRESSION:
1. No findings to explain patient's bacteremia within the chest,
abdomen, or pelvis. No abscesses.
2. Extensive bullous emphysema within the lungs. Bilateral
pleural effusions, findings to suggest loculation. Bibasilar
consolidation has the appearance of more of atelectasis. Nodules
within the lungs should be followed up by CT in [**4-12**] months after
the patient's current condition has resolved.
3. The pancreatic head cystic lesion and small pancreatic neck
cystic lesion are unchanged in appearance from [**2122-5-14**]. These
likely represent cysts, however IPMT cannot be excluded, and
attention should be paid to this on follow-up.
4. Decreased size of right common iliac artery aneurysm after
graft placement. No evidence of superinfection of this aneurysm.
No change in the aortic, left common iliac, or bilateral common
femoral aneurysms. No evidence of infection of these aneurysms.
5. Gastrostomy tube tip is within the second/third portion of
the duodenum.
6. Persistent atrophic left kidney.
.
CXR [**2123-3-4**]- No change in comparison to the prior study. No
evidence for new infiltrate

Brief Hospital Course:
73 y.o. man with h/o severe COPD, pneumonias, HTN who presents
with hypoxic respiratory failure, unresponsiveness, and
hypotension.  Given fevers, infiltrate on CXR, most likely
etiology of respiratory failure is pneumonia, and this is also
the most likely cause of his hypotension/septic shock.  There is
no evidence of ACS or CHF.
..
..
## Hypoxic respiratory failure:  Intuabated on AC mode on
admission.  Given his history of recurrent aspiration pneumonias
with MRSA and Pseudomonas he was started on broad comverate
antibiotics with vanc, zosyn and azithromycin.  Urine legionella
was negative.  DFA for influenza also negative.  Sputum cultures
returned with MSSA and pesudeomonas ([**Last Name (un) 36**] to zosyn).  He was
treated with Vanc, Zosyn and azithro for 14 day course.  He was
also given albuterol/atrovent nebs given history of COPD.  He
did not have much improvement in lung mechanics with 20 puffs of
bronchodilator trial and was given burst of IV steroids
(methylpred 80 IV for 7 days).  Daily RSBIs were checked with
not much improvement in his respiratory status.  With attempts
of weaning pt became tachycardic and tachypneic and pressure
support was unable to be weaned off.  He was evaluated by
Interventional pulmonary who planned on placing a trach, this
was delayed given positive blood culture with klebsiella, see
below.  After cultures were negative for 6 days, IP placed a
bedside trach.  He will need to have continued mechanical
ventilation for now which should be weaned at a vent facility as
tolerated.  The trach should also help pt with preventing
aspiration as he's had multiple admissions for aspiration
pneumonias.
.
## Septic shock:  Likely due to pneumonia.  Treated with abx as
above.  Given IVF and levophed initially, with goals of CVP
10-12 corrected for PEEP, MAP>60, and UOP>30 cc/hr.  [**Last Name (un) **] stim
showed appropriate response. Levophed was weaned off and he did
not require pressors thereafter.
.
## CAD/CHF:  No indication of acute process.  Held
antihypertensives on admission. His blood pressure remained
stable and he was not restarted on his anithypertensives.  Given
his CAD, inquired with PCP and started him asa, statin.
..
## Bacteremia: Few days after admission pt had temp spike and
had blood cultures done which later grew Klebsiella.  There was
no clear source of infection.  So CT scan of abdomen was done
without clear source.  His central line was changed and cultures
were negative thereafter.  he should be treated for total 2 week
course with levofloxacin (start date [**2123-2-24**]).

## [**Doctor First Name 48**]/CRI:  Likely pre-renal from sepsis and hypotension.  This
resolved with initial ivf.  Creatinine remained around 1.4-1.7
during the rest of the admission.
..
## Abd distention:  nontender, LFTs were checked on admission
and several times during the admission and were unremakable.
KUB was done which showed no evidence of obstuction only stool
in colon.  Given persistent distension he also had a CT scan of
abdomen, results above.  His distention improved with prn
Lactulose during the admission.
..
## F/E/N:  He was continued on TFs during the hospitilization.
Nutrition also followed pt while he was in the ICU.  He was
placed on insulin gtt initially and was changed over to basal
insulin + RISS.
..
## PPx:  Maintained on SC heparin, PPI. bowel regimen.

Medications on Admission:
Trazadone 25mg q6h prn
APAP prn
Flovent 110mcg 2puffs [**Hospital1 **]
Combivent 2 puffs q4h
Lopressor 25mg tid
Levaquin 500mg daily (since [**2-4**])
Flagyl 500mg tid (since [**2-4**])

Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection Q8H (every 8 hours).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) ml PO DAILY (Daily).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Eight (8)
Puff Inhalation Q4H (every 4 hours).
8. Albuterol 90 mcg/Actuation Aerosol Sig: Eight (8) Puff
Inhalation Q4H (every 4 hours).
9. Albuterol 90 mcg/Actuation Aerosol Sig: Eight (8) Puff
Inhalation Q4H (every 4 hours) as needed.
10. Levofloxacin in D5W 250 mg/50 mL Piggyback Sig: Two Hundred
Fifty (250) mg Intravenous  Q24H (every 24 hours) for 8 days:
Please continue until [**2123-3-10**].  thank you.
11. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every
6 hours) as needed.
12. Acetaminophen 160 mg/5 mL Solution Sig: [**6-16**] ml PO Q4-6H
(every 4 to 6 hours) as needed.
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical  [**Hospital1 **]
(2 times a day) as needed.
14. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
15. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale Please see attached list for details Injection four times
a day: Please see attached list for details.
16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous  DAILY (Daily) as needed.
17. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Ten
(10) units Subcutaneous twice a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] - [**Location (un) 86**]

Discharge Diagnosis:
Primary:
1.  Sepsis due to PNA
2.  COPD
3.  Acute renal failure on baseline chronic renal failure

Secondary:
1.  CAD
2.  CHF
3.  AAA repair
4.  HTN
5.  Dementia


Discharge Condition:
Stable


Discharge Instructions:
Please follow up with all of your doctors.

Please take all of your medications as instructed.  Please note,
several changes have been made in your medications including
antibiotics which should be continued for two weeks.  See below
for details:
1.  Please continue the antibiotic Levofloxacin until [**2123-3-10**]
2.  Please continue the albuterol and atrovent nebulizers 8
puffs Q 4hours.  Your flovent and combivent has been
discontinued and replaced with the albuterol and atrovent IH.
3.  Please continue to hold the antihypertensive medications
until his blood pressure shows signs of hypertension.  At this
point, the pt can be started on metoprolol 12.5mg three times a
day and titrated up to 25mg three times a day.


Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **] 2 weeks after discharge.


                             [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

Completed by:[**2123-3-7**]
{'Unspecified septicemia,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Septic shock,Chronic airway obstruction, not elsewhere classified,Congestive heart failure, unspecified,Acute kidney failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Pneumonia due to Pseudomonas,Other primary cardiomyopathies,Hypovolemia,Infection and inflammatory reaction due to other vascular device, implant, and graft,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Other persistent mental disorders due to conditions classified elsewhere,Severe sepsis'}


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: Hypoxic respiratory failure and hypotension

PRESENT ILLNESS: 73 y.o. man who presents for respiratory distress.  History is
limited and is from son and [**Name (NI) **] notes.  He was apparently feeling
ok yesterday.  This morning, per his living facility, he was
less responsive and in respiratory distress.  O2 sat was in the
50s.  He may have had a mild cough over the last few days.  He
was brought to the ED. He was intubated on arrival for
unresponsiveness, cyanosis.  Subsequently, he was hypotensive
with SBP to 60s.  A CVL was placed, he was given 2.25 L NS and
started on levophed with response in SBP up to 110s.  He was
started on vanco, levo, flagyl for pneumonia after infiltrate
was seen on CXR.  Then transported to [**Hospital Unit Name 153**].

MEDICAL HISTORY: 1) AAA repair--R common iliac aneursym repair in [**7-12**] with
endovascular stent
2) COPD--on home O2
3) CAD with cardiomyopathy:  last TTE in [**7-12**] showed nml EF,
impaired relaxation.
4) HTN
5) CRI (bl Cr=1.2)
6) Anemia
7) chronic UTI
8) dementia
9) depression

MEDICATION ON ADMISSION: Trazadone 25mg q6h prn
APAP prn
Flovent 110mcg 2puffs [**Hospital1 **]
Combivent 2 puffs q4h
Lopressor 25mg tid
Levaquin 500mg daily (since [**2-4**])
Flagyl 500mg tid (since [**2-4**])

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS:  Tm 102 (Tc 101.3) -- BP 110/80 --- HR 90-100s -- RR 20
(set) --- 100% on AC 500 x 20  FiO2 0.6  PEEP 5  PIP 37.
GEN:  intubated, but opens eyes and follows simple commands.
HEENT:  NCAT, Pupils 3mm and min reactive but equal.  Anicteric.
 OP with ETT, dry MM.
Neck:  supple, JVP not appreciated due to habitus.
Lungs:  coarse BS b/l with anterior rhonchi and left sided
expiratory wheezing.
CV:  distant HS, RRR, nml S1S2, no m/r/g appreaciated
ABD:  soft, mod distended, NT, naBS, no masses.
EXT:  no c/c/e.
NEURO:  resting cogwheel tremor of hands R>L.
SKIN:  no wounds or ulcers.

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: Spanish speaking, lives in a nursing home, ex-smoker and alcohol
user. 

### Response:
{'Unspecified septicemia,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Septic shock,Chronic airway obstruction, not elsewhere classified,Congestive heart failure, unspecified,Acute kidney failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Pneumonia due to Pseudomonas,Other primary cardiomyopathies,Hypovolemia,Infection and inflammatory reaction due to other vascular device, implant, and graft,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Other persistent mental disorders due to conditions classified elsewhere,Severe sepsis'}
