CHIEF COMPLAINT: Respiratory distress

PRESENT ILLNESS: 51M with hx of morbid obesity, HTN, HL, [**Hospital **] transferred from OSH
for CTA. He was in USOH, felt well and worked full day on day of
admission when he suddenly developed acute onset left sided
popliteal/calf pain radiating to L flank/abdomen and left arm
while driving. He did not have any other symptoms until he was
in the ED at [**Hospital3 26615**] when he developed shaking chills, SOB
with laying flat and nausea with emesis x 3. Only preceding
illness was toe infection for which he had completed antibiotics
1 week prior (Keflex and Doxy) and which has limited his
mobility the last month and a half. Wife denies recent illness,
fever, night sweats, sick contacts, although does report he had
complained of chills at night over the last week.

MEDICAL HISTORY: HTN
HL
No known h/o CAD or DM
PSH
s/p L slipped epiphyses repair as child with screws in left hip
s/p left shoulder surgery (no foreign body)
s/p knee arthroscopic procedures with no retained foreign body

MEDICATION ON ADMISSION: Lisinopril 40mg po daily
Norvasc 5mg po BID
Lasix 20mg po BID
Metoprolol
Allopurinol 300mg po daily
Clonidine
Simvastatin
ASA 81mg

ALLERGIES: Unasyn / Zosyn

PHYSICAL EXAM: Vitals: T: BP: P: R: 18 O2:
General: Intubated, sedated, no acute distress
HEENT: Sclera anicteric, MM dry with blood tinged nasopharynx
where nasotracheally intubated
Neck: Thick, supple, JVP not elevated, no LAD
Lungs: Coares rhonchorous vented BS bilaterally, no wheezes
CV: Distant. Regular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops appreciated
Abdomen: Obese. soft, tender diffusely over left side,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly appreciated
Ext: Warm, well perfused, RLE trace edema, LLE 1+ edema with
erythema and warmth. 2+ pulses, no clubbing, cyanosis or edema.
Erythematous intertriginous rash on groin. Small 1x1cm
superficial ulcers x 2 anterior shin, 1 1x1cm pustule left
anterior shin, tender. Right great toe with effaced nail, mild
purulent exudate

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Chef in family restaurant. Married. Lives with wife and 2
daughters.  [**Name (NI) **] tobacco. Occ ETOH. No drugs. 2 cats at home. No
known tick bites or other exposures. has camp in NH but does not
spend much time outside.
Streptococcal septicemia,Cellulitis and abscess of leg, except foot,Acute respiratory failure,Septic shock,Severe sepsis,Obstructive sleep apnea (adult)(pediatric),Other hyperalimentation,Unspecified essential hypertension,Dermatitis due to drugs and medicines taken internally,Penicillins causing adverse effects in therapeutic use,Dermatomycosis, unspecified
Streptococcal septicemia,Cellulitis of leg,Acute respiratry failure,Septic shock,Severe sepsis,Obstructive sleep apnea,Other hyperalimentation,Hypertension NOS,Drug dermatitis NOS,Adv eff penicillins,Dermatomycosis NOS
Admission Date:  [**2102-8-18**]              Discharge Date:   [**2102-8-30**]

Date of Birth:  [**2051-1-27**]             Sex:   M

Service: MEDICINE

Allergies:
Unasyn / Zosyn

Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
Respiratory distress

Major Surgical or Invasive Procedure:
Intubation
Central Venous Line
PICC


History of Present Illness:
51M with hx of morbid obesity, HTN, HL, [**Hospital **] transferred from OSH
for CTA. He was in USOH, felt well and worked full day on day of
admission when he suddenly developed acute onset left sided
popliteal/calf pain radiating to L flank/abdomen and left arm
while driving. He did not have any other symptoms until he was
in the ED at [**Hospital3 26615**] when he developed shaking chills, SOB
with laying flat and nausea with emesis x 3. Only preceding
illness was toe infection for which he had completed antibiotics
1 week prior (Keflex and Doxy) and which has limited his
mobility the last month and a half. Wife denies recent illness,
fever, night sweats, sick contacts, although does report he had
complained of chills at night over the last week.

At OSH, initial VS 99.3  139/83  103  22 93%RA. He received
Lovenox 150mg, Dilaudid, Zofran, spiked fever to 104 and was
transferred for CTA.

In our ED, he was tachycardic 130s, hypotensive to 70s, 87% on
NRB on arrival. Pt had portable CXR that revealed bibasilar
opacities consistent with aspiration vs atelectasis. labs
significant for WBC 14 with 24% bands. He was given Vanco 1g,
Zosyn 4.5g, and Dopamine was started peripherally for
hypotension. He was nasotracheally intubated for airway
protection and received Propofol and Versed/fentanyl. He
received duonebs. Tmax in ED 100.3.  EKG revealed R heart
strain, d-dimer was positive at 2120, and CTA was ordered and
performed on the way up to the MICU.
.
On arrival to the unit, he is intubated but alert and awake. He
had episode of bilious emesis which was suctioned.  He is unable
to provide further history other than above as obtained by his
wife.
.
Review of systems:
(+) Per HPI per wife. Otherwise negative. Denied recent rash,
illness, dysuria, change in bowel habits, travel, bug bites.

Past Medical History:
HTN
HL
No known h/o CAD or DM
PSH
s/p L slipped epiphyses repair as child with screws in left hip
s/p left shoulder surgery (no foreign body)
s/p knee arthroscopic procedures with no retained foreign body


Social History:
Chef in family restaurant. Married. Lives with wife and 2
daughters.  [**Name (NI) **] tobacco. Occ ETOH. No drugs. 2 cats at home. No
known tick bites or other exposures. has camp in NH but does not
spend much time outside.

Family History:
Non-contributory

Physical Exam:
Vitals: T: BP: P: R: 18 O2:
General: Intubated, sedated, no acute distress
HEENT: Sclera anicteric, MM dry with blood tinged nasopharynx
where nasotracheally intubated
Neck: Thick, supple, JVP not elevated, no LAD
Lungs: Coares rhonchorous vented BS bilaterally, no wheezes
CV: Distant. Regular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops appreciated
Abdomen: Obese. soft, tender diffusely over left side,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly appreciated
Ext: Warm, well perfused, RLE trace edema, LLE 1+ edema with
erythema and warmth. 2+ pulses, no clubbing, cyanosis or edema.
Erythematous intertriginous rash on groin. Small 1x1cm
superficial ulcers x 2 anterior shin, 1 1x1cm pustule left
anterior shin, tender. Right great toe with effaced nail, mild
purulent exudate

Pertinent Results:
Labs on Admission [**2102-8-18**]:
WBC-14.0* RBC-5.51 Hgb-15.5 Hct-49.6 MCV-90 RDW-14.5 Plt Ct-190
Neuts-73* Bands-23* Lymphs-2* Monos-2 Eos-0 Baso-0 Atyps-0
Metas-0 Myelos-0
PT-12.3 PTT-28.1 INR(PT)-1.0
Glucose-143* UreaN-26* Creat-1.0 Na-142 K-3.9 Cl-104 HCO3-31
AnGap-11
ALT-28 AST-26 LD(LDH)-223 CK(CPK)-126 AlkPhos-62 Amylase-30
TotBili-0.7
Lipase-19
Calcium-8.9 Phos-1.6* Mg-1.6
Lactate-2.4*
.
Other labs:
.
[**2102-8-18**] 08:55PM BLOOD cTropnT-<0.01
[**2102-8-19**] 04:49AM BLOOD CK-MB-4 cTropnT-<0.01 proBNP-1828*
[**2102-8-19**] 05:07PM BLOOD CK-MB-6 cTropnT-<0.01
.
Micro:
[**2102-8-18**] Blood cultures [**1-27**]: STREPTOCOCCUS DYSGALACTIAE SSP.
   EQUISIMILIS.
[**2102-8-19**] Sputum culture: oropharyngeal flora
[**2102-8-22**] Stool culture: C. diff negative
.
Other Studies:
.
[**2102-8-18**] EKG: Sinus tachycardia. Right axis deviation with
S1-Q3-T3 pattern consistent with acute or chronic right
ventricular strain. Diffuse non-diagnostic repolarization
abnormalities. No previous tracing available for comparison.
.
[**2102-8-18**] CXR: Bibasilar opacities may reflect atelectasis versus
aspiration/pneumonia. Please refer to CT chest performed
subsequently for
additional details.
.
[**2102-8-18**] CTA: 1. Exam extremely limited due to patient body
habitus and poor bolus timing. However, no evidence of central
or lobar pulmonary embolism. Subsegmental PE cannot be excluded
on this study. 2. Posterior bilateral consolidations concerning
for aspiration.
.
[**2102-8-19**] Echo: The left atrium is moderately dilated. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal for the patient's body size.
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Left ventricular systolic
function is hyperdynamic (EF>75%). There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened. There is no valvular aortic stenosis. The increased
transaortic velocity is likely related to high cardiac output.
No aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Hyperdynamic left
ventricle
.
[**2102-8-19**] LLE U/S: No evidence of left lower extremity DVT.
.
[**2102-8-19**] CT Abd/pelvis w/o: 1. Limited study due to patient body
habitus, but no evidence of nephrolithiasis, intra-abdominal
hemorrhage, or large abscess; these were the entities of
apparent clinical concern.
2. Nasogastric tube in stomach, but side port at or just above
GE junction. 3. Large left inguinal lymph node with adjacent
inflammatory stranding of unclear significance.
.
[**2102-8-19**] CT BLE w/o: Benign-appearing osseous lesion of distal
femoral diaphysis on the left.
.
[**2102-8-24**] CXR: As compared to the previous radiograph, nasogastric
tube and
endotracheal tube have been removed. Also removed is the
right-sided central venous access line. The lung volumes are
mildly increased. Better visible are bilateral basal and medial
opacities with air bronchograms that could both correspond to
aspiration. No other focal parenchymal opacities are present.
Unchanged size of the cardiac silhouette.
.
[**2102-8-28**] LLE U/S: No evidence of DVTs in left leg.

Brief Hospital Course:
This is a 51M with HTN, OSA, morbid obesity now with acute onset
of hypoxic hypercarbic respiratory failure and fever with
leukocytosis and bandemia.
.
.
#  Hypoxic Hypercarbic Respiratory failure: Pt admitted with
acute onset of hypoxic hypercarbic respiratory failure in the
setting of left leg pain and fever which is concerning for PE vs
infection/PNA. A CTA was obtained that was not suggestive of PE.
LENI's were done twice and were negative. Initial EKG was
suggestive of RV strain, but repeat EKGs and TTE showed no
evidence of RV strain.
.
The patient was intially started on empiric antibiotics of
pneumonia, but once the endotracheal sputum sample showed no
bacteria, his antibiotics were stopped.  His blood culture was
positive for STREPTOCOCCUS DYSGALACTIAE. The underlying cause of
most likely his lower extremity cellulitis rather than
pneumonia. He was treated with Unasyn and Clindamycin. His
respiratory failure was likely [**2-27**] to a toxic shock picture
related to his strep bacteremia. Chest imaging also suggested an
aspiration process, pneumonia vs. pneumonitis. He improved on
his antibiotic course and tolerated extubation well on [**8-23**].
However the patient had a high oxygen demand. He was on 5L NC
during the day and needed 60% high flow in addition at night.
The etiology of continued hypoxia was thought to be volume
overload on top of underlying Pickwickian syndrome. He improved
with physical and respiratory therapy, antibiotics, and diuresis
with Lasix. On discharge, he was 96% on room air and 92% on
ambulation/climbing stairs. He also has a history of CPAP and
was stabilized on hospital CPAP with O2 sats in 90's and no
awakenings. A sleep study is recommended for new CPAP mask for
home.
.
# Hypotension: Likely related to sepsis.  The patient was
initially managed with pressors, but this issue resolved with
antibiotics. An Echo was done that showed a preserved EF. An MI
was ruled out with cardiac enzymes. The patient was restarted on
his home antihypertensives.

#  Sepsis/Strep cellulitis: The patient presented with a septic
picture, with hypotension, respiratory failure as above. Blood
cultures grew Group C strep (STREPTOCOCCUS DYSGALACTIAE). The
source was thought to be left lower extremity cellulitis. A CT
of his lower extremeties was not suggestive of necrotizing
fascitis or osteomyelitis. The patient was treated with Unasyn
and Clindamycin. However, the patient developed a severe rash,
thought to be drug reaction to Unasyn. Urine showed rare
eosinophils. The rash improved when Unasyn stopped on [**8-26**]. The
patient was continued on IV clindamycin until day of discharge,
and was then switched to PO clindamycin to complete a 14 day
total course (last day [**2102-9-1**]).
.
#  Hyperglycemia: Likely related to infection. It was treated
with an insulin sliding scale. Normoglycemic for remainder of
course.

# ECG changes: Pt had lateral ST depressions when tachycardic,
likely demand related, have since have resolved with rate
improvement. An MI was ruled out with cardiac enzymes and
cardiology was consulted that agreed it was likely demand
ischemia.

# Hypertension: After his hypotension resolved the patient
started to gradually return to his baseline hypertensive state.
He was restarted on his home BP medications. His blood pressure
was within normal range on discharge.

Medications on Admission:
Lisinopril 40mg po daily
Norvasc 5mg po BID
Lasix 20mg po BID
Metoprolol
Allopurinol 300mg po daily
Clonidine
Simvastatin
ASA 81mg


Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
2. Clindamycin HCl 300 mg Capsule Sig: Two (2) Capsule PO Q8H
(every 8 hours) for 2 days: please continue until [**2102-9-1**].
Disp:*12 Capsule(s)* Refills:*0*
3. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
7. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.

8. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
Sepsis due to Bactermia and Cellulitis
Respiratory Failure
Sleep Apnea


Discharge Condition:
The patient was discharged in good condition, afebrile,
hemodynamically stable. Ambulating well with good oxygenation.


Discharge Instructions:
You were admitted to the hospital due to a severe infection. You
required intubation to support your breathing. You were treated
with antibiotics for the infection which came from your leg and
spread into your blood. You were treated with Lasix to improve
your breathing.  We treated your sleep apnea with CPAP.
.
The following changes were made to your home medications:
--> You will need to take clindamycin 3 times daily until
[**2102-9-1**].
.
You should call your PCP or seek medical attention if you
experience fevers, chills, shortness of breath, diarrhea, or any
other symptoms.

Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 13895**] from Infectious Disease to
ensure your leg infection is resolving and you do not need to
continue antibiotics for longer.
Location: [**Hospital 18**] [**Hospital **] Medical Office Bldg, [**Location (un) 83361**].
Phone number: [**Telephone/Fax (1) 457**]
You will be contact[**Name (NI) **] by the [**Hospital **] clinic regarding appointment
information. If you do not hear from them by Friday, [**9-1**], please
call.
.
Please follow-up with your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 72462**]
[**Name (STitle) **]
Date and time: [**Last Name (LF) 766**], [**9-11**] at 1:00PM
Location: [**Hospital 16848**] Medical Bldg.  Post Office Square,
[**Location (un) 16848**], MA Phone number: [**Telephone/Fax (1) 72461**]
.
MD: DRS. [**Last Name (STitle) **],[**Name5 (PTitle) **]
[**Name5 (PTitle) 4094**]: Pulmonary Sleep
Date and time: Tuesday, [**9-12**] @ 8:40am
Location: [**Hospital Ward Name 23**] 8
Phone number: ([**Telephone/Fax (1) 513**]
Special instructions if applicable: Please have pt bring current
CPAP prescription if possible
.
MD: DRS. [**Name5 (PTitle) **]/[**Doctor Last Name **]
[**Doctor Last Name 4094**]: Pulmonary
Date and time: Thursday, [**10-5**] @ 2pm for PFT, 2:30pm to
see the MDs above
Location: [**Hospital Ward Name 23**] 7
Phone number: [**Telephone/Fax (1) 612**]
{'Streptococcal septicemia,Cellulitis and abscess of leg, except foot,Acute respiratory failure,Septic shock,Severe sepsis,Obstructive sleep apnea (adult)(pediatric),Other hyperalimentation,Unspecified essential hypertension,Dermatitis due to drugs and medicines taken internally,Penicillins causing adverse effects in therapeutic use,Dermatomycosis, unspecified'}


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: 51M with hx of morbid obesity, HTN, HL, [**Hospital **] transferred from OSH
for CTA. He was in USOH, felt well and worked full day on day of
admission when he suddenly developed acute onset left sided
popliteal/calf pain radiating to L flank/abdomen and left arm
while driving. He did not have any other symptoms until he was
in the ED at [**Hospital3 26615**] when he developed shaking chills, SOB
with laying flat and nausea with emesis x 3. Only preceding
illness was toe infection for which he had completed antibiotics
1 week prior (Keflex and Doxy) and which has limited his
mobility the last month and a half. Wife denies recent illness,
fever, night sweats, sick contacts, although does report he had
complained of chills at night over the last week.

MEDICAL HISTORY: HTN
HL
No known h/o CAD or DM
PSH
s/p L slipped epiphyses repair as child with screws in left hip
s/p left shoulder surgery (no foreign body)
s/p knee arthroscopic procedures with no retained foreign body

MEDICATION ON ADMISSION: Lisinopril 40mg po daily
Norvasc 5mg po BID
Lasix 20mg po BID
Metoprolol
Allopurinol 300mg po daily
Clonidine
Simvastatin
ASA 81mg

ALLERGIES: Unasyn / Zosyn

PHYSICAL EXAM: Vitals: T: BP: P: R: 18 O2:
General: Intubated, sedated, no acute distress
HEENT: Sclera anicteric, MM dry with blood tinged nasopharynx
where nasotracheally intubated
Neck: Thick, supple, JVP not elevated, no LAD
Lungs: Coares rhonchorous vented BS bilaterally, no wheezes
CV: Distant. Regular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops appreciated
Abdomen: Obese. soft, tender diffusely over left side,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly appreciated
Ext: Warm, well perfused, RLE trace edema, LLE 1+ edema with
erythema and warmth. 2+ pulses, no clubbing, cyanosis or edema.
Erythematous intertriginous rash on groin. Small 1x1cm
superficial ulcers x 2 anterior shin, 1 1x1cm pustule left
anterior shin, tender. Right great toe with effaced nail, mild
purulent exudate

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Chef in family restaurant. Married. Lives with wife and 2
daughters.  [**Name (NI) **] tobacco. Occ ETOH. No drugs. 2 cats at home. No
known tick bites or other exposures. has camp in NH but does not
spend much time outside. 

### Response:
{'Streptococcal septicemia,Cellulitis and abscess of leg, except foot,Acute respiratory failure,Septic shock,Severe sepsis,Obstructive sleep apnea (adult)(pediatric),Other hyperalimentation,Unspecified essential hypertension,Dermatitis due to drugs and medicines taken internally,Penicillins causing adverse effects in therapeutic use,Dermatomycosis, unspecified'}
