CHIEF COMPLAINT: hypoxemia, hypotension

PRESENT ILLNESS: Ms. [**Name13 (STitle) 2819**] is a 55 yo woman with a Hodgkin's lymphoma s/p chemotx
x2, hypothyroidism and a h/o chemo-induced cardiomyopathy (now
resolved) who presents as a transfer from an OSH after being
found delirious at home.
.
Per the pt's son and daughter, she seemed abnormal on the phone
2 days prior to admission, but was not confused. On the day
prior to admission, the family reports that she was quite
confused on the phone, not knowing her address. As the family
did not know her exact address, they enlisted the help of others
to find her. Her landlord was eventually reached, and she called
EMS.
.
Upon EMS arrival, the pt was found in her bed as though she had
been there for a few days. She had been incontinent of urine and
there was a bucket ofvomit. She was A&Ox2. She was taken to an
OSH, where she was intubated for hypoxemic respiratory failure
(O2 sat 87% on 15L NC). She was not febrile, but was tachycardic
and hypotensive to the 80s systolic. A CXR demonstrated diffuse
R-sided infiltrate and LLL infiltrate. An initial CBC revealed
pancytopenia (WBC 2.9, Hct 17, Plt 34). She recieved 2 units
PRBCs, azithromycin, ceftriaxone and methylprednisolone. Her
blood pressure was maintained with dopamine. She was transferred
to the [**Hospital Unit Name 153**] for further management.

MEDICAL HISTORY: Hodkin's lymphoma
Hypothyroidism
h/o chemo-induced cardiomyopathy, resolved

MEDICATION ON ADMISSION: On transfer:
Dopamine gtt
Ceftriaxone
Azithromycin
Methylprednisolone

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 97.1 BP: 54/31 P: 107 R: 16 SaO2: 100%, ventilated
General: sedated, intubated, opens eyes to command, does not
squeeze hands to command
HEENT: Pupils small but reactive 1->0.5, no scleral icterus, MM
dry
Neck: no LAD, supple
Pulmonary: Lungs CTA anteriorly bilaterally
Cardiac: tachycardic, nl S1 S2, no murmurs, rubs or gallops
appreciated
Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or
organomegaly noted
Extremities: No edema, 2+ radial, DP pulses b/l
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted
Skin: no rashes or lesions noted.
.

FAMILY HISTORY: n/c

SOCIAL HISTORY: Lives by herself, recently moved from [**State **], former
substitute teacher, former smoker (quit 15-25 years ago), no h/o
EtOH abuse.
Pneumococcal septicemia [Streptococcus pneumoniae septicemia],Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Septic shock,Acute respiratory failure,Hyperosmolality and/or hypernatremia,Acute kidney failure, unspecified,Other candidiasis of other specified sites,Severe sepsis,Thrombocytopenia, unspecified,Other abnormal glucose,Other alteration of consciousness,Unspecified acquired hypothyroidism,Other specified disorders of liver,Personal history of hodgkin's disease,Personal history of tobacco use,Fitting and adjustment of vascular catheter,Procedure not carried out for other reasons
Pneumococcal septicemia,Pneumococcal pneumonia,Septic shock,Acute respiratry failure,Hyperosmolality,Acute kidney failure NOS,Candidiasis site NEC,Severe sepsis,Thrombocytopenia NOS,Abnormal glucose NEC,Other alter consciousnes,Hypothyroidism NOS,Liver disorders NEC,Hx-hodgkin's disease,History of tobacco use,Fit/adj vascular cathetr,No proc for reasons NEC
Admission Date:  [**2160-2-13**]              Discharge Date:   [**2160-2-19**]

Date of Birth:  [**2104-6-13**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
hypoxemia, hypotension


Major Surgical or Invasive Procedure:
Mechanical ventilation


History of Present Illness:
Ms. [**Name13 (STitle) 2819**] is a 55 yo woman with a Hodgkin's lymphoma s/p chemotx
x2, hypothyroidism and a h/o chemo-induced cardiomyopathy (now
resolved) who presents as a transfer from an OSH after being
found delirious at home.
.
Per the pt's son and daughter, she seemed abnormal on the phone
2 days prior to admission, but was not confused. On the day
prior to admission, the family reports that she was quite
confused on the phone, not knowing her address. As the family
did not know her exact address, they enlisted the help of others
to find her. Her landlord was eventually reached, and she called
EMS.
.
Upon EMS arrival, the pt was found in her bed as though she had
been there for a few days. She had been incontinent of urine and
there was a bucket ofvomit. She was A&Ox2. She was taken to an
OSH, where she was intubated for hypoxemic respiratory failure
(O2 sat 87% on 15L NC). She was not febrile, but was tachycardic
and hypotensive to the 80s systolic. A CXR demonstrated diffuse
R-sided infiltrate and LLL infiltrate. An initial CBC revealed
pancytopenia (WBC 2.9, Hct 17, Plt 34). She recieved 2 units
PRBCs, azithromycin, ceftriaxone and methylprednisolone. Her
blood pressure was maintained with dopamine. She was transferred
to the [**Hospital Unit Name 153**] for further management.


Past Medical History:
Hodkin's lymphoma
Hypothyroidism
h/o chemo-induced cardiomyopathy, resolved

Social History:
Lives by herself, recently moved from [**State **], former
substitute teacher, former smoker (quit 15-25 years ago), no h/o
EtOH abuse.


Family History:
n/c

Physical Exam:
Vitals: T: 97.1 BP: 54/31 P: 107 R: 16 SaO2: 100%, ventilated
General: sedated, intubated, opens eyes to command, does not
squeeze hands to command
HEENT: Pupils small but reactive 1->0.5, no scleral icterus, MM
dry
Neck: no LAD, supple
Pulmonary: Lungs CTA anteriorly bilaterally
Cardiac: tachycardic, nl S1 S2, no murmurs, rubs or gallops
appreciated
Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or
organomegaly noted
Extremities: No edema, 2+ radial, DP pulses b/l
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted
Skin: no rashes or lesions noted.
.


Pertinent Results:
From OSH:
152 | 113 | 94 /
3.7 |  20 | 1.3\ 236
.
2.9\_5.9 _/
   / 17   \34
Diff: Neuts 96%; Lymphs 3%; Monos 1%; 0 Eos, 0 Basos
.
Total protein 6.5, Albumin 2.4, Globulin 4.1, Tbili 1.4, Dbili
0.5, AST 37, ALT 24, Alk phos 113; Amylase 70, Lipase 37.
.
LDH 445
CK 54
.
Selected [**Hospital1 18**] labs
[**2160-2-13**] 10:41PM   HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc
Ab-NEGATIVE HAV Ab-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
HCV Ab-NEGATIVE
[**2160-2-13**] 10:41PM   FDP-40-80 FIBRINOGEN-1316*# D-DIMER-9619*
[**2160-2-13**] 03:59PM   FIBRINOGE-1138* D-DIMER-8857*
[**2160-2-13**] 09:23PM   LACTATE-2.4*
[**2160-2-13**] 04:15PM   LACTATE-2.5*
[**2160-2-13**] 03:59PM   HAPTOGLOB-552*
.
[**2160-2-13**] 03:59PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
.
[**2160-2-13**] 03:59PM   WBC-1.8* RBC-1.84* HGB-6.4* HCT-19.4*
MCV-105* MCH-34.7* MCHC-33.0 RDW-19.4*
[**2160-2-13**] 03:59PM   NEUTS-60 BANDS-18* LYMPHS-14* MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-6* MYELOS-2*
[**2160-2-13**] 03:59PM   PARST SMR-NEGATIVE
[**2160-2-13**] 03:59PM   RET MAN-.9
.
[**2160-2-13**] 03:59PM   GLUCOSE-209* UREA N-86* CREAT-1.7*
SODIUM-155* POTASSIUM-3.8 CHLORIDE-119* TOTAL CO2-25 ANION
GAP-15
[**2160-2-13**] 03:59PM   ALT(SGPT)-18 AST(SGOT)-29 LD(LDH)-330*
CK(CPK)-49 ALK PHOS-90 AMYLASE-62 TOT BILI-1.3
[**2160-2-13**] 03:59PM   CALCIUM-7.4* PHOSPHATE-3.2 MAGNESIUM-2.6

Brief Hospital Course:
55 yo woman with h/o Hodgkin's lymphoma s/p chemo x2 and
persistent pancytopenia presents with profound pancytopenia,
hypoxemic respiratory failure and sepsis.
.
Ms [**Name13 (STitle) 2819**] arrived to the MICU brought by [**Company 16410**] helicopter
from [**Hospital6 8283**]. She required ventilatory
support and pressors, starting with norepinephrine, and using a
low tidal-volume ventilatory strategy. Blood cultures ultimately
revealed strep pneumonia, E. coli, and [**Female First Name (un) **] albicans; she had
been broadly treated from the beginning and was ultimately
treated with levofloxacin (vancomycin was discontinued once
sensitivities on strep came back from MVH showing pan-sensitive
organism), cefepime, and caspofungin.
.
She was mildly responsive at different times in the first [**3-9**]
days of her stay but was not significantly responsive
thereafter. She required increasing levels of ventilatory
support, requiring frequent up-titrations of FiO2, increased
PEEP, and showing increasingly dire P/F ratios suggesting
advancing and refractory ARDS. Though she was started on a
single pressor for the last days of her admission she was
requiring three. Again, doses varied, but in the last two days
here she was so exquisitely dependent on pressors that her
pressures would drop precipitously even as nurses changed from
one bag of a pressor to the next.

The primary insult appeared to be a set of large consolidative
regions of her lungs, likely secondary to strep pneumonia, and
followed by sepsis and ARDS. Incidental note was made of
hypodensities on the liver (of unknown etiology), and cysts in
the lungs (likely non-pathologic given location of some in
healthy-appearing portions of lung). Though an abdominal process
could have contributed to her septic presentation, further
abdominal imaging was not possible because for most of her
admission the patient was not stable enough to take to CT scan
and ultrasound was minimally helpful given abdominal distension.
.
In sum, it appears that Ms [**Name13 (STitle) 2819**] acquired an infection in the
setting of pancytopenia and bone marrow fibrosis; was unable to
fight that infection (likely strep pneumo was the original
culprit); and then began having altered mental status and
vomiting, along with superimposed infections. She became septic,
and came to us with unrelenting sepsis and ARDS.
.
Ultimately after 7 days of attempting to improve her health, it
was clear that despite occasional gains, overall we were losing
ground. Her prospects of recovery were extremely slim. The team
discussed this with her son and daughter who had been present
and involved in her care, and together all agreed on stopping
her pressors and pulling back from aggressive interventions,
emphasizing comfort instead. It was clearly understood by all
that this would mean a hastened time of death compared to
pressing on with our prior life-sustaining but not life-saving
interventions.

She died about an hour-and-a-half after pressors were
discontinued, with her children present. She was kept on a
ventilator at this time to minimize respiratory discomfort
during the last period of her life, with the assessment that
removing the ventilator and subjecting the patient to sustained
respiratory distress would likely be more difficult for patient
and family than maintaining the ventilator while discontinuing
the pressors.
.
The family refused an autopsy.

Medications on Admission:
On transfer:
Dopamine gtt
Ceftriaxone
Azithromycin
Methylprednisolone


Discharge Medications:
n/a

Discharge Disposition:
Expired

Discharge Diagnosis:
Sepsis/ARDS

Discharge Condition:
expired


Discharge Instructions:
n/a

Followup Instructions:
n/a
{"Pneumococcal septicemia [Streptococcus pneumoniae septicemia],Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Septic shock,Acute respiratory failure,Hyperosmolality and/or hypernatremia,Acute kidney failure, unspecified,Other candidiasis of other specified sites,Severe sepsis,Thrombocytopenia, unspecified,Other abnormal glucose,Other alteration of consciousness,Unspecified acquired hypothyroidism,Other specified disorders of liver,Personal history of hodgkin's disease,Personal history of tobacco use,Fitting and adjustment of vascular catheter,Procedure not carried out for other reasons"}


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: hypoxemia, hypotension

PRESENT ILLNESS: Ms. [**Name13 (STitle) 2819**] is a 55 yo woman with a Hodgkin's lymphoma s/p chemotx
x2, hypothyroidism and a h/o chemo-induced cardiomyopathy (now
resolved) who presents as a transfer from an OSH after being
found delirious at home.
.
Per the pt's son and daughter, she seemed abnormal on the phone
2 days prior to admission, but was not confused. On the day
prior to admission, the family reports that she was quite
confused on the phone, not knowing her address. As the family
did not know her exact address, they enlisted the help of others
to find her. Her landlord was eventually reached, and she called
EMS.
.
Upon EMS arrival, the pt was found in her bed as though she had
been there for a few days. She had been incontinent of urine and
there was a bucket ofvomit. She was A&Ox2. She was taken to an
OSH, where she was intubated for hypoxemic respiratory failure
(O2 sat 87% on 15L NC). She was not febrile, but was tachycardic
and hypotensive to the 80s systolic. A CXR demonstrated diffuse
R-sided infiltrate and LLL infiltrate. An initial CBC revealed
pancytopenia (WBC 2.9, Hct 17, Plt 34). She recieved 2 units
PRBCs, azithromycin, ceftriaxone and methylprednisolone. Her
blood pressure was maintained with dopamine. She was transferred
to the [**Hospital Unit Name 153**] for further management.

MEDICAL HISTORY: Hodkin's lymphoma
Hypothyroidism
h/o chemo-induced cardiomyopathy, resolved

MEDICATION ON ADMISSION: On transfer:
Dopamine gtt
Ceftriaxone
Azithromycin
Methylprednisolone

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 97.1 BP: 54/31 P: 107 R: 16 SaO2: 100%, ventilated
General: sedated, intubated, opens eyes to command, does not
squeeze hands to command
HEENT: Pupils small but reactive 1->0.5, no scleral icterus, MM
dry
Neck: no LAD, supple
Pulmonary: Lungs CTA anteriorly bilaterally
Cardiac: tachycardic, nl S1 S2, no murmurs, rubs or gallops
appreciated
Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or
organomegaly noted
Extremities: No edema, 2+ radial, DP pulses b/l
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted
Skin: no rashes or lesions noted.
.

FAMILY HISTORY: n/c

SOCIAL HISTORY: Lives by herself, recently moved from [**State **], former
substitute teacher, former smoker (quit 15-25 years ago), no h/o
EtOH abuse. 

### Response:
{"Pneumococcal septicemia [Streptococcus pneumoniae septicemia],Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Septic shock,Acute respiratory failure,Hyperosmolality and/or hypernatremia,Acute kidney failure, unspecified,Other candidiasis of other specified sites,Severe sepsis,Thrombocytopenia, unspecified,Other abnormal glucose,Other alteration of consciousness,Unspecified acquired hypothyroidism,Other specified disorders of liver,Personal history of hodgkin's disease,Personal history of tobacco use,Fitting and adjustment of vascular catheter,Procedure not carried out for other reasons"}
