CHIEF COMPLAINT: Respiratory distress

PRESENT ILLNESS: 79 y/o M w/HTN, CHB s/p PPM, end-stage dementia, who was
admitted on [**2181-7-22**] after he presented from his nursing home
([**Hospital3 537**]) in respiratory distress. Per notes, he was found
to have O2 sats in the 70s, and he was sent here.
.
In the ED, he had temp of 101.4, HR of 60 (paced), BP of 150/90,
RR of 45-50, sats of 70s on RA -> 90% on NRB. He was given Lasix
100mg IV x1, and placed on BiPAP, along with a nitro gtt to
lower his BP. He was given Levaquin 500mg IV x1, Vanco 1g IV x1,
and Flagyl 500mg IV x1 for aspiration PNA vs NH-associated PNA.
His RR decreased down to the 20s and his BiPAP was discontinued
and switched back to a NRB. He was evaluated by cards for a
troponin of 0.08 who felt it was likely demand ischemia, no
indication for heparin. He had a bedside ultrasound, which was
negative for pericardial effusion. Per ED request, His nitro gtt
was d/c'ed prior to arrival to the floor.
.
On the floor, he was felt by the medicine team to have more of
an aspiration pneumonia and they did not feel he was in florid
CHF. He was kept on vanco/levo/flagyl. Per NH staff, he gets an
aspiration pna "every now and then". He was supposed to have a
speech and swallow today, but when they arrived to evaluate him,
he was clearly aspirating his oral secretions and they deferred.
He was made NPO. He was found to have a LUE DVT and was begun on
a heparin gtt. He was transfused 2U PRBCs for hypoxia and Hct
23. His O2 was weaned (from NRB to 2.5L earlier tonight).
.
On night of HD #1, respiratory was called to see him for
inability to clear secretions. He was audibly gurgling when they
arrived. They eventually got him to cough up some secretions, at
which point he respiratory arrested for approximately 3 minutes
(was bagged throughout). [**Name8 (MD) **] RN he was blue. He then began
breathing spontaenously with a RR in the mid 20s, pulse
110s-130s, bp 150s. He then grew very agitated and was
grimacing, so he received morphine 8 mg IV. His wife and son
were notified, and they confirmed that he was DNR/DNI on [**2181-7-23**].
He was transferred to the ICU for frequent suctioning.
.
Patient remained stable in the medicine ICU for two days with
normotensive BP, though he had frequent desats due to mucus
plugging and airway congestion. Per DNR/DNI status, he did not
get endotracheal suctioning, only what he could bring up on his
own after turnovers. He was transferred out of the ICU to the
medicine service on [**7-26**] after family meeting with palliative
care. It was decided that he would complete 10 day antibiotic
course, currently day 5, after which he will be on comfort
measures only. He will be discharged to [**Hospital3 537**] on [**7-27**].
Please note family discussion under dispo plans.

MEDICAL HISTORY: Frequent aspiration pnas (per wife, 6-7 times recently)
HTN
Cardiomyopathy
Complete heart block s/p pacer
Dementia
RA

MEDICATION ON ADMISSION: Prednisone 7.5
Duonebs
Lasix 20mg 3x/week
Prilosec 20
ASA 325
Plaquenil 400
Lisinopril 5
Zyprexa 5mg q1400
Depakaote 250
Exelon 3 [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T: 101.6 RR 24 BP:154/80 HR: 90 RR:28 O2sat: 90% 3L
GEN: Elderly male, awake&alert, not following commands
HEENT: MMM
RESP: coarse rhonchi throughout
CV: Regular, nml s1,s2. No murmurs.
ABD: Not distended. No HSM appreciated. +BS.
EXT: 2+ edema to mid-shins bilat. ext cool. LUE also with 1-2+
edema

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: No smoking, occasional alcohol, no drug use.
Unspecified septicemia,Septic shock,Hyperosmolality and/or hypernatremia,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Other primary cardiomyopathies,Severe sepsis,Rheumatoid arthritis,Cardiac pacemaker in situ,Unspecified essential hypertension,Other persistent mental disorders due to conditions classified elsewhere
Septicemia NOS,Septic shock,Hyperosmolality,Food/vomit pneumonitis,Acute respiratry failure,Prim cardiomyopathy NEC,Severe sepsis,Rheumatoid arthritis,Status cardiac pacemaker,Hypertension NOS,Mental disor NEC oth dis
Admission Date:  [**2181-7-22**]              Discharge Date:   [**2181-7-30**]

Date of Birth:  [**2102-3-14**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Respiratory distress

Major Surgical or Invasive Procedure:
None.


History of Present Illness:
79 y/o M w/HTN, CHB s/p PPM, end-stage dementia, who was
admitted on [**2181-7-22**] after he presented from his nursing home
([**Hospital3 537**]) in respiratory distress. Per notes, he was found
to have O2 sats in the 70s, and he was sent here.
.
In the ED, he had temp of 101.4, HR of 60 (paced), BP of 150/90,
RR of 45-50, sats of 70s on RA -> 90% on NRB. He was given Lasix
100mg IV x1, and placed on BiPAP, along with a nitro gtt to
lower his BP. He was given Levaquin 500mg IV x1, Vanco 1g IV x1,
and Flagyl 500mg IV x1 for aspiration PNA vs NH-associated PNA.
His RR decreased down to the 20s and his BiPAP was discontinued
and switched back to a NRB. He was evaluated by cards for a
troponin of 0.08 who felt it was likely demand ischemia, no
indication for heparin. He had a bedside ultrasound, which was
negative for pericardial effusion. Per ED request, His nitro gtt
was d/c'ed prior to arrival to the floor.
.
On the floor, he was felt by the medicine team to have more of
an aspiration pneumonia and they did not feel he was in florid
CHF. He was kept on vanco/levo/flagyl. Per NH staff, he gets an
aspiration pna "every now and then". He was supposed to have a
speech and swallow today, but when they arrived to evaluate him,
he was clearly aspirating his oral secretions and they deferred.
He was made NPO. He was found to have a LUE DVT and was begun on
a heparin gtt. He was transfused 2U PRBCs for hypoxia and Hct
23. His O2 was weaned (from NRB to 2.5L earlier tonight).
.
On night of HD #1, respiratory was called to see him for
inability to clear secretions. He was audibly gurgling when they
arrived. They eventually got him to cough up some secretions, at
which point he respiratory arrested for approximately 3 minutes
(was bagged throughout). [**Name8 (MD) **] RN he was blue. He then began
breathing spontaenously with a RR in the mid 20s, pulse
110s-130s, bp 150s. He then grew very agitated and was
grimacing, so he received morphine 8 mg IV. His wife and son
were notified, and they confirmed that he was DNR/DNI on [**2181-7-23**].
He was transferred to the ICU for frequent suctioning.
.
Patient remained stable in the medicine ICU for two days with
normotensive BP, though he had frequent desats due to mucus
plugging and airway congestion. Per DNR/DNI status, he did not
get endotracheal suctioning, only what he could bring up on his
own after turnovers. He was transferred out of the ICU to the
medicine service on [**7-26**] after family meeting with palliative
care. It was decided that he would complete 10 day antibiotic
course, currently day 5, after which he will be on comfort
measures only. He will be discharged to [**Hospital3 537**] on [**7-27**].
Please note family discussion under dispo plans.

Past Medical History:
Frequent aspiration pnas (per wife, 6-7 times recently)
HTN
Cardiomyopathy
Complete heart block s/p pacer
Dementia
RA

Social History:
No smoking, occasional alcohol, no drug use.

Family History:
non-contributory

Physical Exam:
VS: T: 101.6 RR 24 BP:154/80 HR: 90 RR:28 O2sat: 90% 3L
GEN: Elderly male, awake&alert, not following commands
HEENT: MMM
RESP: coarse rhonchi throughout
CV: Regular, nml s1,s2. No murmurs.
ABD: Not distended. No HSM appreciated. +BS.
EXT: 2+ edema to mid-shins bilat. ext cool. LUE also with 1-2+
edema

Pertinent Results:
[**2181-7-21**] 08:50PM BLOOD WBC-25.7* RBC-3.09* Hgb-10.1* Hct-30.1*
MCV-97 MCH-32.6* MCHC-33.5 RDW-16.4* Plt Ct-352
[**2181-7-24**] 01:39AM BLOOD WBC-12.8* RBC-3.77*# Hgb-11.8*#
Hct-34.7*# MCV-92 MCH-31.2 MCHC-33.9 RDW-17.1* Plt Ct-201
[**2181-7-21**] 08:50PM BLOOD Neuts-86.2* Lymphs-11.4* Monos-1.7*
Eos-0.6 Baso-0.1
[**2181-7-24**] 01:39AM BLOOD PT-16.6* PTT-141.4* INR(PT)-1.5*
[**2181-7-23**] 01:20PM BLOOD PT-20.6* PTT-150.0* INR(PT)-2.0*
[**2181-7-22**] 07:00PM BLOOD Ret Aut-2.9
[**2181-7-24**] 01:39AM BLOOD Glucose-197* UreaN-19 Creat-0.8 Na-145
K-3.4 Cl-108 HCO3-25 AnGap-15
[**2181-7-21**] 08:50PM BLOOD Glucose-287* UreaN-16 Creat-1.0 Na-146*
K-4.7 Cl-107 HCO3-26 AnGap-18
[**2181-7-22**] 07:00PM BLOOD LD(LDH)-260* TotBili-0.8
[**2181-7-22**] 05:27AM BLOOD LD(LDH)-319*
[**2181-7-21**] 08:50PM BLOOD CK-MB-NotDone cTropnT-0.08*
[**2181-7-24**] 01:39AM BLOOD Calcium-8.5 Phos-3.7 Mg-2.1
[**2181-7-21**] 08:50PM BLOOD Albumin-3.9 Calcium-8.4 Phos-6.3* Mg-2.4
[**2181-7-22**] 07:00PM BLOOD Hapto-99
[**2181-7-21**] 08:50PM BLOOD Valproa-18*
[**2181-7-23**] 08:20AM BLOOD Lactate-1.9
[**2181-7-21**] 11:04PM BLOOD Lactate-4.0*
                        WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2181-7-28**] 06:25AM    8.3 3.57* 11.2* 33.3* 93 31.4 33.7 15.9*
120*
                       Glucose UreaN Creat Na   K    Cl HCO3
AnGap
[**2181-7-29**] 06:30AM    111*    13     0.7  144 3.71 108  25
15
.
Imaging Studies:
.
CHEST (PORTABLE AP)  [**2181-7-21**] 8:56 PM
FINDINGS: Bibasilar costophrenic angles are blunted by small
bilateral pleural effusions. The left diaphragmatic border is
obscured by retrocardiac opacity, atelectasis versus pneumonia.
The heart and mediastinal contours are stable. The pulmonary
vasculature is engorged, and the septal lines indicate a small
degree of pulmonary edema.
.
IMPRESSION:
1. Mild pulmonary edema and bilateral pleural effusions.
2. Retrocardiac opacity is atelectasis versus pneumonia.
.
ECG Study Date of [**2181-7-21**]  10:59:50 PM
Normal sinus rhythm
AV nodal wenckebach block
Low voltage
Anterolateral ST-T wave changes, consider ischemia/myocardial
infarction
No previous tracing available for comparison
.
UNILAT UP EXT VEINS US LEFT  [**2181-7-22**] 12:35 PM
LEFT UPPER EXTREMITY ULTRASOUND: No prior studies for
comparison. [**Doctor Last Name **]-scale and color Doppler son[**Name (NI) 867**] was
performed of the left upper extremity including the internal
jugular, subclavian, axillary, brachial, basilic veins. There is
occlusive thrombus extending through one of the axillary veins,
as well as throughout the course of the basilic vein. These
veins are non- compressible and demonstrate no demonstrable
flow. The jugular vein is patent with normal compressibility and
waveforms. The subclavian vein is difficult to evaluate on this
study but is patent were visualized. There may be a collateral
vein that parallels the subclavian vein which contains clot.The
brachial veins are patent with normal compressibility, flow, and
waveforms. The cephalic vein compresses normally. The axillary
and subclavian veins on the contralateral right side demonstrate
normal flow, waveforms, and compressibility.
.
IMPRESSION: DVT involving the left axillary vein, basilic veins,
and possibly a small collateral paralleling the subclavian vein.
Findings discussed with the ordering physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **]
immediately after the study.
.
CHEST (PA & LAT)  [**2181-7-22**] 1:19 PM
IMPRESSION: PA and lateral chest compared to [**7-21**].
Bibasilar consolidation and small bilateral pleural effusions
have increased since [**7-21**], consistent with pneumonia. Heart
size is normal. Upper lungs show vascular engorgement, but are
otherwise clear. Transvenous right atrial and right ventricular
pacer leads are unchanged in their standard placements. A large
curvilinear calcification over the left ventricle is probably an
aneurysm.

Brief Hospital Course:
79 y/o M with PMHx of HTN, CM, s/p pacer, dementia, who
presented from NH today with resp distress.
.
# Resp Failure:
Most likely etiology was aspiration pna, given numerous episodes
of this in past, and witnessed aspiration of oral secretions
while on floor. Likely had mucus plug on floor causing prolonged
hypoxic event. Pt unable to clear secretions and protect airway
[**1-18**] dementia. Pt had not improved despite broad spectrum
antibiotics. ICU team had lengthy discussion with wife and son,
and they did not wish to pursue further aggressive measures.
They do not wish to continue oro-tracheal suctioning pt given
its obvious discomfort. They understood he was likely going to
continue aspirating, and they do not wish for him to be
sustained on mechanical ventilation or tube feeds. Patient
received morphine IV/elixer PRN for discomfort after transfer to
medicine floor from CCU. He was treated for aspiration pneumonia
with Vanco/Levaquin/Flagyl to complete 10 day course, though
there was no source of infection from blood or urine cultures.
Scopolamine patch was placed to aid clear secretions. He
received anti-pyretics for febrile episodes.
.
# Septic shock
Likely from aspiration pneumonia. No other clear source
identified. Pt with a lactate of 4.0 in the ED, received 1L NS
(limited by pulmonary edema). Currently, pt hemodynamically
stable. BP currently stable. Blood/urine cx after admission were
negative. Patient's urine culture on [**7-27**] was positive for
yeast. Blood pressure was stable with SBP in 120s-130s through
most of hospital stay, but declined to SBP 80-90s two days prior
to death.
.
# HTN
Held antihypertensives given hypotensive on arrival, although
likely due to morphine. He was administered IVF on admission for
resucitation efforts and also once he was made NPO by family
during his CCU course.
.
# CHB s/p pacer
Pt with paced rhythm in the 50s.
.
# Dementia
Unclear patient's baseline, here nonverbal and not responding to
verbal stimuli. On Zyprexa at baseline at NH. Per family, they
feel he sometimes recognizes them and interacts with them but
mental status waxes and wanes. Speech and swallow study
determined pt. to be aspiration risk with oral secretions as
well as PO nutrition. He was made NPO to prevent further
aspirations and CCU team discussed plan with family.
.
# DISPO:
Below is discussion summary between palliative care and family
regarding patient care plan:
Signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RNC on [**2181-7-26**]  Affiliation: [**Hospital1 18**] Met
with Mrs. [**Known lastname 69686**], daughter and son, Dr. [**Last Name (STitle) **], [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 805**], Sw to discuss plan of care for [**Known firstname **]. Family
understands [**Known firstname **] has a progressive dementia with frequent
episodes of asp. pneumonia. The last one was 2 wks ago. They do
not want him to recieve a PEG, they do not want further
hospitalizations. they like the care he receives at the [**Last Name (un) **]
Home [**Hospital1 1501**], he has been there for just over a year. We discussed
possible outcomes- clearly no matter what care he receives he is
in his dying phase, they understand that but are uncomfortable
with stopping all his meds and fluids right now. We agreed we
would continue IV abx and gentle IVF for a total 10 day course.
At the end of that period he would have either improved and be
able to take in some fluids and nurtrition- we discussed it
would never be enough to maintain life but would offer
pleasure/memories. If he deteriorates during the 10 day course
the decision to stop treatment sooner should be discussed. Once
this treatment course is finished, family agrees he should not
be hospitalized, or treated except for comfort when he
re-infects.
.
We discussed he may die tomorrow or in a few days, weeks or
months if he improves with antibiotics. His wife has made
funeral plans already. She is prepared for his death and wants
him to die peacefully. She is not interested in hospice care as
she feels hospice hastens death. We discussed this in detail-
she may be open to hearing from the individual hospice program
but he will not be eligible for hospice until
after abx are finished.
Patient was made DNR/DNI by family during hospital course in
CCU. After being transferred to medicine service on [**2181-7-26**],
plan was for him to be cared at the [**Hospital3 537**] as he
approached end-of-life and family would consider hospice
services. Patient at that time was in midst of completing
antibiotic course with 4 days remaining. In order to be
transferred to [**Hospital3 537**] with vancomycin, patient would need
a PICC line, instead of a peripheral IV. However, family did not
wish for him to have a PICC line but desired for him to complete
the full course of antibiotics. This would thus be done in the
hospital and they agreed that on Monday, [**7-30**] he could be
transferred to [**Hospital3 537**].
.
Over the course of the weekend, however, patient continued to
have desaturations in the 60s-70s and remained on 3-4L oxygen.
His BP had continued to decline with SBP in 80s. Per nursing
reports, patient was having respiratory distress and was made
comfortable with morphine drip and ativan. On morning of Monday
[**2181-7-30**], patient remained in respiratory failure and oxygen
saturations were staying in 60-70% range. Family was notified of
patient's deteriorating clinical condition. Morphine IV was
titrated up until patient appeared comfortable and not
tachypneic and ativan was also administered. Patient was in
peaceful state and he died at 10:23am on [**2181-7-30**]. Family
members were arrived to see the patient. Death report was filed
and submitted to Admitting Office. Cause of death was
respiratory failure secondary to aspiration pneumonia. [**Name (NI) **]
wife [**Name (NI) 53564**] [**Name (NI) 69686**] declined autopsy. Medical examiner
evaluation was not indicated.

Medications on Admission:
Prednisone 7.5
Duonebs
Lasix 20mg 3x/week
Prilosec 20
ASA 325
Plaquenil 400
Lisinopril 5
Zyprexa 5mg q1400
Depakaote 250
Exelon 3 [**Hospital1 **]

Discharge Medications:
1. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for fever.
2. Morphine Concentrate 20 mg/mL Solution Sig: [**12-18**]  PO Q3H
(every 3 hours) as needed for respiratory distress.
3. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 537**]- [**Location (un) 538**]

Discharge Diagnosis:
Primary diagnosis:
Respiratory distress secondary to pneumonia/mucus plugging
Hypotension secondary to sepsis
.
Secondary diagnoses:
Frequent aspiration pnas (per wife, 6-7 times recently)
HTN
Cardiomyopathy
Complete heart block s/p pacer
Dementia
RA


Discharge Condition:
Deceased.


Discharge Instructions:
None.

Followup Instructions:
None.
{'Unspecified septicemia,Septic shock,Hyperosmolality and/or hypernatremia,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Other primary cardiomyopathies,Severe sepsis,Rheumatoid arthritis,Cardiac pacemaker in situ,Unspecified essential hypertension,Other persistent mental disorders due to conditions classified elsewhere'}


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 distress

PRESENT ILLNESS: 79 y/o M w/HTN, CHB s/p PPM, end-stage dementia, who was
admitted on [**2181-7-22**] after he presented from his nursing home
([**Hospital3 537**]) in respiratory distress. Per notes, he was found
to have O2 sats in the 70s, and he was sent here.
.
In the ED, he had temp of 101.4, HR of 60 (paced), BP of 150/90,
RR of 45-50, sats of 70s on RA -> 90% on NRB. He was given Lasix
100mg IV x1, and placed on BiPAP, along with a nitro gtt to
lower his BP. He was given Levaquin 500mg IV x1, Vanco 1g IV x1,
and Flagyl 500mg IV x1 for aspiration PNA vs NH-associated PNA.
His RR decreased down to the 20s and his BiPAP was discontinued
and switched back to a NRB. He was evaluated by cards for a
troponin of 0.08 who felt it was likely demand ischemia, no
indication for heparin. He had a bedside ultrasound, which was
negative for pericardial effusion. Per ED request, His nitro gtt
was d/c'ed prior to arrival to the floor.
.
On the floor, he was felt by the medicine team to have more of
an aspiration pneumonia and they did not feel he was in florid
CHF. He was kept on vanco/levo/flagyl. Per NH staff, he gets an
aspiration pna "every now and then". He was supposed to have a
speech and swallow today, but when they arrived to evaluate him,
he was clearly aspirating his oral secretions and they deferred.
He was made NPO. He was found to have a LUE DVT and was begun on
a heparin gtt. He was transfused 2U PRBCs for hypoxia and Hct
23. His O2 was weaned (from NRB to 2.5L earlier tonight).
.
On night of HD #1, respiratory was called to see him for
inability to clear secretions. He was audibly gurgling when they
arrived. They eventually got him to cough up some secretions, at
which point he respiratory arrested for approximately 3 minutes
(was bagged throughout). [**Name8 (MD) **] RN he was blue. He then began
breathing spontaenously with a RR in the mid 20s, pulse
110s-130s, bp 150s. He then grew very agitated and was
grimacing, so he received morphine 8 mg IV. His wife and son
were notified, and they confirmed that he was DNR/DNI on [**2181-7-23**].
He was transferred to the ICU for frequent suctioning.
.
Patient remained stable in the medicine ICU for two days with
normotensive BP, though he had frequent desats due to mucus
plugging and airway congestion. Per DNR/DNI status, he did not
get endotracheal suctioning, only what he could bring up on his
own after turnovers. He was transferred out of the ICU to the
medicine service on [**7-26**] after family meeting with palliative
care. It was decided that he would complete 10 day antibiotic
course, currently day 5, after which he will be on comfort
measures only. He will be discharged to [**Hospital3 537**] on [**7-27**].
Please note family discussion under dispo plans.

MEDICAL HISTORY: Frequent aspiration pnas (per wife, 6-7 times recently)
HTN
Cardiomyopathy
Complete heart block s/p pacer
Dementia
RA

MEDICATION ON ADMISSION: Prednisone 7.5
Duonebs
Lasix 20mg 3x/week
Prilosec 20
ASA 325
Plaquenil 400
Lisinopril 5
Zyprexa 5mg q1400
Depakaote 250
Exelon 3 [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T: 101.6 RR 24 BP:154/80 HR: 90 RR:28 O2sat: 90% 3L
GEN: Elderly male, awake&alert, not following commands
HEENT: MMM
RESP: coarse rhonchi throughout
CV: Regular, nml s1,s2. No murmurs.
ABD: Not distended. No HSM appreciated. +BS.
EXT: 2+ edema to mid-shins bilat. ext cool. LUE also with 1-2+
edema

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: No smoking, occasional alcohol, no drug use. 

### Response:
{'Unspecified septicemia,Septic shock,Hyperosmolality and/or hypernatremia,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Other primary cardiomyopathies,Severe sepsis,Rheumatoid arthritis,Cardiac pacemaker in situ,Unspecified essential hypertension,Other persistent mental disorders due to conditions classified elsewhere'}
