CHIEF COMPLAINT: shortness of breath

PRESENT ILLNESS: Mr. [**Known lastname **] is a 65 yo Cantonese-speaking man w/hx of stage IV NSCLC
dx [**12-29**] who presented to the ED with acute onset SOB yesterday
with exertion.  He was found to have right mainste PE with
extension into apical RUL, RML, and RLL segemnt.  A head CT was
performed which showed stable brain mets.  He was started on
heparin.  On the OMED service, he was transitioned to lovenox.
On admission, his HR was 110s-120s in sinus.
.
Patient triggered on the floor for tachycardia to 150s at 9 PM
on the evening of his admission with a stable blood pressure.
He also had an increasing oxgyen requiring ment from 91% on RA
on admission to 92% on 4LNC and ultimately to a NRB.  His HR
remained stable between 92 - 146/69-103.  He given 1L NS and his
respiratory status worsened.  He was tachypneic to the 30s and
unable to speak in full sentences.  He denies chest pain, chest
pressure, fevers, chills, cough.

MEDICAL HISTORY: Past Oncologic History (per medical record):
- presented [**2179-12-21**] with SOB and was found to have stage IV
lung cancer with mets to the spine, sternum, ribs and basal
ganglia, with pathologic fractures of T2 and T5 and malignant
effusion on teh left. The primary lesion is in the left lung
apex with invasion into the anterior chest wall.
- thoracentesis [**2179-12-22**] showed adenocarcinoma with CK7 and TTF-1
positive, consistent with NSCLC. Bronchial biopsy [**2179-12-23**]
confirmed this diagnosis. EGFR testing reported L858R mutation
in exon 21 on [**1-20**] by [**Company 2475**].
- received WBXRT and XRT of C7-T6 spine, completed [**2180-1-11**]
.
Other Past Medical History:
none

MEDICATION ON ADMISSION: Home Medications (from bottles brought in from family):
Morphine 15mg PO 1 tab PO q4H PRN pain
MS Contin 15mg PO BID
Omeprazole 40mg PO qday
Acetaminophen PRN
Coalce 100mg PO daily
Vitamin D 50,000units PO weekly
Dexamethasone 2mg "as directed"
Fluconazole 150mg daily for 2 weeks starting [**2180-1-17**]
.
Transfer meds:
Furosemide 20 mg IV ONCE
Diltiazem 5-15 mg/hr IV INFUSION HR < 120
Omeprazole 40 mg PO DAILY
Morphine Sulfate IR 15 mg PO/NG Q4H:PRN pain
Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation
Docusate Sodium 100 mg PO BID
Morphine SR (MS Contin) 15 mg PO Q12H
Enoxaparin Sodium 60 mg SC Q12H

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: GEN: elderly male, in respiratory distress, tachypneic, unable
to speak in full sentences
VS: afebrile, HR 140s a. fib, BP 130
CV: tachycardic, irregular rate, no murmurs, rubs, gallops
PULM: increased work of breath, accessory muscle use, crackles
at bases bilaterally,
ABD: soft, non-tender, non-distended
LIMBS: no edema
SKIN: no rash

FAMILY HISTORY: Father - died of lung cancer
Mother - died of liver cancer

SOCIAL HISTORY: Home: lives with wife; immigrated from [**Country 651**] 18 years ago
Occupation: previously worked in markets
EtOH: Denies
Drugs: Denies
Tobacco: [**11-20**] PPD x 20 years
Other pulmonary embolism and infarction,Unspecified septicemia,Severe sepsis,Septic shock,Acute respiratory failure,Malignant neoplasm of other parts of bronchus or lung,Secondary malignant neoplasm of bone and bone marrow,Malignant pleural effusion,Other disorders of neurohypophysis,Pathologic fracture of vertebrae,Tobacco use disorder,Atrial fibrillation
Pulm embol/infarct NEC,Septicemia NOS,Severe sepsis,Septic shock,Acute respiratry failure,Mal neo bronch/lung NEC,Secondary malig neo bone,Malignant pleural effusn,Neurohypophysis dis NEC,Path fx vertebrae,Tobacco use disorder,Atrial fibrillation
Admission Date:  [**2180-1-27**]              Discharge Date:   [**2180-2-2**]

Date of Birth:  [**2114-3-23**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
shortness of breath

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Mr. [**Known lastname **] is a 65 yo Cantonese-speaking man w/hx of stage IV NSCLC
dx [**12-29**] who presented to the ED with acute onset SOB yesterday
with exertion.  He was found to have right mainste PE with
extension into apical RUL, RML, and RLL segemnt.  A head CT was
performed which showed stable brain mets.  He was started on
heparin.  On the OMED service, he was transitioned to lovenox.
On admission, his HR was 110s-120s in sinus.
.
Patient triggered on the floor for tachycardia to 150s at 9 PM
on the evening of his admission with a stable blood pressure.
He also had an increasing oxgyen requiring ment from 91% on RA
on admission to 92% on 4LNC and ultimately to a NRB.  His HR
remained stable between 92 - 146/69-103.  He given 1L NS and his
respiratory status worsened.  He was tachypneic to the 30s and
unable to speak in full sentences.  He denies chest pain, chest
pressure, fevers, chills, cough.


Past Medical History:
Past Oncologic History (per medical record):
- presented [**2179-12-21**] with SOB and was found to have stage IV
lung cancer with mets to the spine, sternum, ribs and basal
ganglia, with pathologic fractures of T2 and T5 and malignant
effusion on teh left. The primary lesion is in the left lung
apex with invasion into the anterior chest wall.
- thoracentesis [**2179-12-22**] showed adenocarcinoma with CK7 and TTF-1
positive, consistent with NSCLC. Bronchial biopsy [**2179-12-23**]
confirmed this diagnosis. EGFR testing reported L858R mutation
in exon 21 on [**1-20**] by [**Company 2475**].
- received WBXRT and XRT of C7-T6 spine, completed [**2180-1-11**]
.
Other Past Medical History:
none


Social History:
Home: lives with wife; immigrated from [**Country 651**] 18 years ago
Occupation: previously worked in markets
EtOH: Denies
Drugs: Denies
Tobacco: [**11-20**] PPD x 20 years

Family History:
Father - died of lung cancer
Mother - died of liver cancer

Physical Exam:
GEN: elderly male, in respiratory distress, tachypneic, unable
to speak in full sentences
VS: afebrile, HR 140s a. fib, BP 130
CV: tachycardic, irregular rate, no murmurs, rubs, gallops
PULM: increased work of breath, accessory muscle use, crackles
at bases bilaterally,
ABD: soft, non-tender, non-distended
LIMBS: no edema
SKIN: no rash

Pertinent Results:
ABG 7.44/24/93/19
.
.. \ 12.1  /
7.7 ------ 144
.. / 36.0 \
.
125 | 95 | 12 /
-------------- 104
4.5 | 16 | 0.6 \
.
Ca 8.3
Mg 1.7
Phos 3.9
.
Imaging:
CTA [**2180-1-27**] (prelim read): R main PE with extsn into apical RUL,
RML, and RLL segments
.
Head CT [**2180-1-27**] (prelim): no ICH
.
CXR.  [**2180-1-28**].
interval development of pulmonary edema with increased left
pleural effusion.

Lower extremity ultrasound [**2180-1-28**]:
IMPRESSION: No evidence of DVT in the bilateral lower
extremities.

CXR [**2180-1-30**]:
Increasing parenchymal opacity is seen at the right lung
diffusely,
particularly in the upper lobe as well as in the left lower and
mid lung
zones. The pattern is most consistent with a combination of
alveolar and
interstitial disease. There is a left-sided pleural effusion
that appears
similarly to the prior study. The heart size is not changed
substantially
since the prior study and there is no PTX.
IMPRESSION: Worsening airspace disease nonspecific - pneumonia,
CHF or ARDS should be considered.

CXR [**2180-2-1**]:
FINDINGS: In comparison with the study of [**1-31**], the monitoring
and support
devices remain in place. Diffuse bilateral pulmonary
opacifications have
somewhat decreased, especially in the upper zones. These are
superimposed
upon known pulmonary metastases.

[**2180-2-1**] 04:26AM BLOOD WBC-7.3 RBC-3.54* Hgb-10.2* Hct-31.3*
MCV-88 MCH-28.8 MCHC-32.6 RDW-17.0* Plt Ct-129*
[**2180-2-1**] 04:26AM BLOOD Neuts-56 Bands-26* Lymphs-3* Monos-1*
Eos-0 Baso-0 Atyps-1* Metas-8* Myelos-5* NRBC-1*
[**2180-2-1**] 04:26AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-1+ Ovalocy-1+ Schisto-1+
Burr-1+ Stipple-OCCASIONAL
[**2180-2-1**] 04:26AM BLOOD PT-18.5* PTT-87.1* INR(PT)-1.7*
[**2180-1-31**] 05:00PM BLOOD Glucose-240* UreaN-22* Creat-1.8*#
Na-131* K-4.0 Cl-98 HCO3-18* AnGap-19
[**2180-2-1**] 04:26AM BLOOD Glucose-194* UreaN-26* Creat-2.6* Na-126*
K-4.3 Cl-92* HCO3-19* AnGap-19
[**2180-2-1**] 02:41PM BLOOD Glucose-85 UreaN-30* Creat-3.0* Na-127*
K-4.8 Cl-92* HCO3-18* AnGap-22*
[**2180-2-1**] 04:26AM BLOOD ALT-1594* AST-2651* AlkPhos-268*
Amylase-86 TotBili-0.9
[**2180-2-1**] 02:41PM BLOOD Calcium-6.4* Phos-5.5* Mg-1.3*
[**2180-2-1**] 04:26AM BLOOD Cortsol-31.5*
[**2180-2-1**] 04:26AM BLOOD Digoxin-1.4
[**2180-2-1**] 11:14AM BLOOD Type-[**Last Name (un) **] Rates-34/0 Tidal V-420 PEEP-12
FiO2-90 pO2-46* pCO2-52* pH-7.21* calTCO2-22 Base XS--7
AADO2-557 REQ O2-90 -ASSIST/CON Intubat-INTUBATED
[**2180-2-1**] 12:03PM BLOOD Type-ART Temp-38.1 Rates-34/0 Tidal V-420
PEEP-12 FiO2-90 pO2-141* pCO2-42 pH-7.24* calTCO2-19* Base XS--8
AADO2-472 REQ O2-79 Intubat-INTUBATED Vent-CONTROLLED
[**2180-2-1**] 03:00PM BLOOD Type-ART Rates-34/ Tidal V-380 PEEP-12
FiO2-100 pO2-137* pCO2-44 pH-7.24* calTCO2-20* Base XS--8
AADO2-535 REQ O2-89 -ASSIST/CON Intubat-INTUBATED
[**2180-1-28**] 05:52AM BLOOD Lactate-1.9
[**2180-1-31**] 05:53AM BLOOD Lactate-1.6
[**2180-1-31**] 01:19PM BLOOD Lactate-5.2*
[**2180-2-1**] 03:00PM BLOOD Lactate-7.0*
[**2180-1-27**] 09:07PM URINE Hours-RANDOM Creat-43 Na-65
[**2180-1-27**] 09:07PM URINE Osmolal-508

[**2180-1-31**] 4:06 am SPUTUM      Source: Endotracheal.

   GRAM STAIN (Final [**2180-1-31**]):
      >25 PMNs and <10 epithelial cells/100X field.
      3+  (5-10 per 1000X FIELD):   GRAM POSITIVE ROD(S).
      1+    (<1 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.
      1+    (<1 per 1000X FIELD):   GRAM NEGATIVE ROD(S).
      1+    (<1 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CHAINS.

   RESPIRATORY CULTURE (Preliminary):    RESULTS PENDING.


Brief Hospital Course:
Mr. [**Known lastname **] is a 65 yo M w/hx of stage IV NSCLC admitted with large
right mainstem bronchus PE complicated by new onset atrial
fibrillation with RVR and respiratory distress.

1.  Respiratory Distress/ARDS.  Patient is known to have large
PE and was anticoagulated with lovenox.  On arrival to the ICU,
patient was in A. fib with RVR to 150s. CXR demonstrated
pulmonary edema likely secondary to fluids and rapid ventricular
rate.  ABG demonstrated respiratory alkalosis and hypoxia with
PAO2 of 93 on NRB. Additionally, Mr. [**Known lastname **] was noted on chest CT
to have worsening interstitial disease secondary to malignancy
progression. He was initially diuresed with lasix, rate
controlled with diltiazem and treated with BiPAP, his status
worsened and he required intubation. Subsequent CXRs were
consistent with ARDS.  Ventilator setting were titrated to
ARDSnet protocol low tidal volume ventilation.  He had
significant dyssynchrony, and was subsequently paralyzed.  His
hypoxia and acidemia gradually improved.

2. Tachycardia.  The patient initially in atrial fibrillation
with RVR and was started on a diltiazem drip with resolution of
his RVR.  It was thought that his new onset atrial fibrillation
was likely secondary to respiratory distress from known
pulmonary processes. He was switched to po digoxin and converted
to sinus rhythm.  As his respiratory status deteriorated, he
intermittently converted back to atrial fibrillation with rates
in the 150s.  This improved once he was mechanically ventilated

3.  Pulmonary Embolism.  Patient presented with large right
pulmonary artery PE. He was started on anticoagulation with
enoxaparin.  Bilateral LE ultrasounds were performed, to see if
patient warranted consideration of IVC filter placement, but
were negative for DVT. An TTE was done on [**2180-1-28**] to check for
heart strain and revealed: mild symmetric left ventricular
hypertrophy LVEF: >55%. Trivial MR, trace aortic regurg, and
mild pulmonary artery systolic hypertension. No pericardial
effusion.  He was switched from enoxaparin to weight based IV
heparin drip.

4. Septic Shock.  Once intubated, patient developed hypotension
with BP 80/60.  He was bolused NS IV initially with a good
response.  Over the course of the following 24 hours, he
required pressor support, initially with phenylephrine, then
with additionally vasopressin, and norepinephrine titrated to a
MAP of 60.  Mixed venous oxygen saturation was high, consistent
with sepsis.  He was started empirically on vancomycin, cefepime
and levofloxacin.  IVF boluses were continued.  Once a MAP of 60
could not be maintained with maximal doses of 3 pressors,
dopamine was added.  the patient subsequently converted to
atrial fibrillation with RVR with rates into the 150s and
dopamine was stopped.  His rhythm returned to sinus and his rate
decreased to 110.

4. NSCLC.  Patient NSCLC with primary left apical lesion and
mets to the spine, sternum, ribs and basal ganglia.  Patient was
treated for pain with long acting morphine.

5. Goals of care.  On admission patient was full code.  As his
clinical status deteriorated with ARDS and septic shock, a goals
of care discussion was had with the family and social work.
Given his persistent hypotension and respiratory failure, it was
considered highly unlikely that the patient would survive this
hospitalization with maximal medical treatment, and nearly
impossible that he could return to his prior level of
functionality if he did survive.  Per discussion with family, he
was initially made DNR, and subsequently made comfort measures
only.  He was extubated, and treatment was directed toward
patient comfort.  Patient expired at 12:30 am on [**2180-2-2**].


Medications on Admission:
Home Medications (from bottles brought in from family):
Morphine 15mg PO 1 tab PO q4H PRN pain
MS Contin 15mg PO BID
Omeprazole 40mg PO qday
Acetaminophen PRN
Coalce 100mg PO daily
Vitamin D 50,000units PO weekly
Dexamethasone 2mg "as directed"
Fluconazole 150mg daily for 2 weeks starting [**2180-1-17**]
.
Transfer meds:
Furosemide 20 mg IV ONCE
Diltiazem 5-15 mg/hr IV INFUSION HR < 120
Omeprazole 40 mg PO DAILY
Morphine Sulfate IR 15 mg PO/NG Q4H:PRN pain
Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation
Docusate Sodium 100 mg PO BID
Morphine SR (MS Contin) 15 mg PO Q12H
Enoxaparin Sodium 60 mg SC Q12H

Discharge Disposition:
Expired

Discharge Diagnosis:
Acute respiratory distress syndrome
Septic Shock
Pulmonary Embolism


Discharge Condition:
expired

Discharge Instructions:
expired

Followup Instructions:
expired
{'Other pulmonary embolism and infarction,Unspecified septicemia,Severe sepsis,Septic shock,Acute respiratory failure,Malignant neoplasm of other parts of bronchus or lung,Secondary malignant neoplasm of bone and bone marrow,Malignant pleural effusion,Other disorders of neurohypophysis,Pathologic fracture of vertebrae,Tobacco use disorder,Atrial fibrillation'}


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: shortness of breath

PRESENT ILLNESS: Mr. [**Known lastname **] is a 65 yo Cantonese-speaking man w/hx of stage IV NSCLC
dx [**12-29**] who presented to the ED with acute onset SOB yesterday
with exertion.  He was found to have right mainste PE with
extension into apical RUL, RML, and RLL segemnt.  A head CT was
performed which showed stable brain mets.  He was started on
heparin.  On the OMED service, he was transitioned to lovenox.
On admission, his HR was 110s-120s in sinus.
.
Patient triggered on the floor for tachycardia to 150s at 9 PM
on the evening of his admission with a stable blood pressure.
He also had an increasing oxgyen requiring ment from 91% on RA
on admission to 92% on 4LNC and ultimately to a NRB.  His HR
remained stable between 92 - 146/69-103.  He given 1L NS and his
respiratory status worsened.  He was tachypneic to the 30s and
unable to speak in full sentences.  He denies chest pain, chest
pressure, fevers, chills, cough.

MEDICAL HISTORY: Past Oncologic History (per medical record):
- presented [**2179-12-21**] with SOB and was found to have stage IV
lung cancer with mets to the spine, sternum, ribs and basal
ganglia, with pathologic fractures of T2 and T5 and malignant
effusion on teh left. The primary lesion is in the left lung
apex with invasion into the anterior chest wall.
- thoracentesis [**2179-12-22**] showed adenocarcinoma with CK7 and TTF-1
positive, consistent with NSCLC. Bronchial biopsy [**2179-12-23**]
confirmed this diagnosis. EGFR testing reported L858R mutation
in exon 21 on [**1-20**] by [**Company 2475**].
- received WBXRT and XRT of C7-T6 spine, completed [**2180-1-11**]
.
Other Past Medical History:
none

MEDICATION ON ADMISSION: Home Medications (from bottles brought in from family):
Morphine 15mg PO 1 tab PO q4H PRN pain
MS Contin 15mg PO BID
Omeprazole 40mg PO qday
Acetaminophen PRN
Coalce 100mg PO daily
Vitamin D 50,000units PO weekly
Dexamethasone 2mg "as directed"
Fluconazole 150mg daily for 2 weeks starting [**2180-1-17**]
.
Transfer meds:
Furosemide 20 mg IV ONCE
Diltiazem 5-15 mg/hr IV INFUSION HR < 120
Omeprazole 40 mg PO DAILY
Morphine Sulfate IR 15 mg PO/NG Q4H:PRN pain
Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation
Docusate Sodium 100 mg PO BID
Morphine SR (MS Contin) 15 mg PO Q12H
Enoxaparin Sodium 60 mg SC Q12H

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: GEN: elderly male, in respiratory distress, tachypneic, unable
to speak in full sentences
VS: afebrile, HR 140s a. fib, BP 130
CV: tachycardic, irregular rate, no murmurs, rubs, gallops
PULM: increased work of breath, accessory muscle use, crackles
at bases bilaterally,
ABD: soft, non-tender, non-distended
LIMBS: no edema
SKIN: no rash

FAMILY HISTORY: Father - died of lung cancer
Mother - died of liver cancer

SOCIAL HISTORY: Home: lives with wife; immigrated from [**Country 651**] 18 years ago
Occupation: previously worked in markets
EtOH: Denies
Drugs: Denies
Tobacco: [**11-20**] PPD x 20 years 

### Response:
{'Other pulmonary embolism and infarction,Unspecified septicemia,Severe sepsis,Septic shock,Acute respiratory failure,Malignant neoplasm of other parts of bronchus or lung,Secondary malignant neoplasm of bone and bone marrow,Malignant pleural effusion,Other disorders of neurohypophysis,Pathologic fracture of vertebrae,Tobacco use disorder,Atrial fibrillation'}
