CHIEF COMPLAINT: Transfer for respiratory failure

PRESENT ILLNESS: Mr. [**Known lastname 39602**] is a 51 yo man with a diagnosis of pulmonary
alveolar proteinosis who presents in transfer from [**Location 75548**] for treatment of pneumonia and respiratory
failure. Per H&P from OSH, the patient was in his usual state of
health until [**9-28**] when he developed URI symptoms, dyspnea,
cough, fever and chills. He presented to the hospital today and
was found to have a large LLL/lingular pneumonia on chest X-ray.
He was afebrile on admission there with RR 49, HR 143, BP
111/75. He was started on IV linezolid and levofloxacin and
admitted to the ICU. O2 sat on arrival to the ICU was 88% on
FiO2 70%. ABG was 7.48/33/51. His RR increased to 50, his HR
remained 130s and his temp increased to 100.4, and he was
intubated at that time. he was placed on ventilator support -
assist control, tidal volume 600, FiO2 100% and RR 12. He was
placed on a propofol drip for sedation. He was suctioned for
thick yellow brownish-colored sputum, blood-tinged. Gram stain
showed <10 epis, 1+ gram positive cocci. BP dropped to 89/40 and
he received a NS bolus and started on neosynephrine. Repeat ABG
was 7.43/39/222. High A-a gradient of 442. He was transferred to
[**Hospital1 18**] for further management.

MEDICAL HISTORY: - Pulmonary alveolar proteinosis, diagnosed [**5-10**] by open lung bx
-follow-up 11/08 per OSH report almost complete resolution of
infiltrates
- IBD s/p colon resection and colostomy
- Hashimoto's thyroiditis
- Hx of sinus surgery

MEDICATION ON ADMISSION: - LEVOTHYROXINE - 200mcg po daily

ALLERGIES: Amoxicillin

PHYSICAL EXAM: VS: T: 99.4 HR: 91 BP: 102/60 RR: 16 O2: 98% on FiO2 100%, PEEP
5
Gen: Intubated sedated
HEENT: PEERL, MM dry
Neck: Supple, no LAD, no JVD
Heart:RRR, nl S1/2, no murmurs
Lung: clear breath sounds b/l anteriorly
Abd: Colostomy with midline scar
Extrem: Warm, no edema, 2+ dp, radial pulses
Skin: no rashes
Neuro: No clonus, toes downgoing

FAMILY HISTORY: Father deceased - kidney CA. Mother is alive and healthy

SOCIAL HISTORY: Occasional ETOH use, does not and has never smoked. Married, two
children.  Works as a mechanical engineer in an office setting.
Has no known exposure to asbestos.  Mother grew up on a farm in
[**State 23924**] and patient would visit often as a child.  No known
exposure to any chemicals or solvents. Married with two
children/
Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Acute kidney failure, unspecified,Acute respiratory failure,Pulmonary alveolar proteinosis,Unspecified disease of pericardium,Foreign body in main bronchus,Hypotension, unspecified,Unspecified acquired hypothyroidism,Foreign body accidentally entering other orifice
Pneumococcal pneumonia,Acute kidney failure NOS,Acute respiratry failure,Pul alveolar proteinosis,Pericardial disease NOS,Foreign body bronchus,Hypotension NOS,Hypothyroidism NOS,FB entering oth orifice
Admission Date:  [**2165-10-1**]              Discharge Date:   [**2165-10-9**]

Date of Birth:  [**2114-6-3**]             Sex:   M

Service: MEDICINE

Allergies:
Amoxicillin

Attending:[**First Name3 (LF) 1928**]
Chief Complaint:
Transfer for respiratory failure

Major Surgical or Invasive Procedure:
bronchoscopy *2

History of Present Illness:
Mr. [**Known lastname 39602**] is a 51 yo man with a diagnosis of pulmonary
alveolar proteinosis who presents in transfer from [**Location 75548**] for treatment of pneumonia and respiratory
failure. Per H&P from OSH, the patient was in his usual state of
health until [**9-28**] when he developed URI symptoms, dyspnea,
cough, fever and chills. He presented to the hospital today and
was found to have a large LLL/lingular pneumonia on chest X-ray.
He was afebrile on admission there with RR 49, HR 143, BP
111/75. He was started on IV linezolid and levofloxacin and
admitted to the ICU. O2 sat on arrival to the ICU was 88% on
FiO2 70%. ABG was 7.48/33/51. His RR increased to 50, his HR
remained 130s and his temp increased to 100.4, and he was
intubated at that time. he was placed on ventilator support -
assist control, tidal volume 600, FiO2 100% and RR 12. He was
placed on a propofol drip for sedation. He was suctioned for
thick yellow brownish-colored sputum, blood-tinged. Gram stain
showed <10 epis, 1+ gram positive cocci. BP dropped to 89/40 and
he received a NS bolus and started on neosynephrine. Repeat ABG
was 7.43/39/222. High A-a gradient of 442. He was transferred to
[**Hospital1 18**] for further management.

Upon arrival to the ICU, the patient was intubated, sedated, on
neo gtt. Central line and R radial A-line placed. Bronchoscopy
performed showing large mucus plug on the left.

On transfer to the floor, he felt that his shortness of breath
had improved, but was still requring supplemental oxygen.  He
reported feeling tired, but was improved since his admission


Past Medical History:
- Pulmonary alveolar proteinosis, diagnosed [**5-10**] by open lung bx
-follow-up 11/08 per OSH report almost complete resolution of
infiltrates
- IBD s/p colon resection and colostomy
- Hashimoto's thyroiditis
- Hx of sinus surgery


Social History:
Occasional ETOH use, does not and has never smoked. Married, two
children.  Works as a mechanical engineer in an office setting.
Has no known exposure to asbestos.  Mother grew up on a farm in
[**State 23924**] and patient would visit often as a child.  No known
exposure to any chemicals or solvents. Married with two
children/


Family History:
Father deceased - kidney CA. Mother is alive and healthy


Physical Exam:
VS: T: 99.4 HR: 91 BP: 102/60 RR: 16 O2: 98% on FiO2 100%, PEEP
5
Gen: Intubated sedated
HEENT: PEERL, MM dry
Neck: Supple, no LAD, no JVD
Heart:RRR, nl S1/2, no murmurs
Lung: clear breath sounds b/l anteriorly
Abd: Colostomy with midline scar
Extrem: Warm, no edema, 2+ dp, radial pulses
Skin: no rashes
Neuro: No clonus, toes downgoing

Pertinent Results:
EKG: Sinus rhythm at 88 with PVC. nl intervals, nl axis, J point
elevation in lateral leads, changed from prior

HEMATOLOGY
[**2165-10-1**] 09:45PM BLOOD WBC-10.3 RBC-3.79* Hgb-11.7* Hct-35.6*
MCV-94 MCH-31.0 MCHC-33.0 RDW-13.9 Plt Ct-241
[**2165-10-4**] 03:04AM BLOOD WBC-13.0* RBC-3.16* Hgb-9.7* Hct-29.2*
MCV-93 MCH-30.6 MCHC-33.0 RDW-14.5 Plt Ct-237
[**2165-10-7**] 04:08AM BLOOD WBC-11.2* RBC-3.13* Hgb-9.7* Hct-29.2*
MCV-93 MCH-31.0 MCHC-33.2 RDW-14.2 Plt Ct-381
[**2165-10-9**] 08:40AM BLOOD WBC-9.4 RBC-3.64* Hgb-10.8* Hct-33.8*
MCV-93 MCH-29.6 MCHC-31.9 RDW-14.6 Plt Ct-677*
[**2165-10-5**] 02:36AM BLOOD Neuts-92.1* Lymphs-4.7* Monos-2.5 Eos-0.5
Baso-0.2

COAGS
[**2165-10-4**] 03:04AM BLOOD PT-13.9* PTT-30.3 INR(PT)-1.2*

CHEMISTRY
[**2165-10-1**] 09:45PM BLOOD Glucose-114* UreaN-23* Creat-1.4* Na-141
K-3.7 Cl-107 HCO3-23 AnGap-15
[**2165-10-5**] 02:36AM BLOOD Glucose-100 UreaN-16 Creat-0.9 Na-146*
K-3.2* Cl-112* HCO3-26 AnGap-11
[**2165-10-9**] 08:40AM BLOOD Glucose-80 UreaN-7 Creat-0.9 Na-137 K-4.8
Cl-106 HCO3-22 AnGap-14
[**2165-10-9**] 08:40AM BLOOD Calcium-8.8 Phos-2.8 Mg-2.2

LFTS
[**2165-10-1**] 09:45PM BLOOD ALT-14 AST-39 LD(LDH)-303* AlkPhos-60
TotBili-1.6*

CARDIAC ENZYMES
[**2165-10-2**] 03:16AM BLOOD CK(CPK)-53
[**2165-10-3**] 11:00AM BLOOD CK(CPK)-435*
[**2165-10-2**] 03:16AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2165-10-3**] 11:00AM BLOOD CK-MB-5 cTropnT-<0.01
[**2165-10-3**] 06:00PM BLOOD cTropnT-<0.01

ENDOCRINE/IRON
[**2165-10-6**] 05:11AM BLOOD calTIBC-133* Ferritn-749* TRF-102*
[**2165-10-4**] 03:04AM BLOOD TSH-1.4
[**2165-10-4**] 03:04AM BLOOD T4-2.1* T3-44* calcTBG-0.95 TUptake-1.05
T4Index-2.2* Free T4-0.44*
[**2165-10-3**] 11:00AM BLOOD Cortsol-11.9
[**2165-10-2**] 03:23AM BLOOD Lactate-1.6

URINE:
U/A: negative glucose, small bili, neg ketones, neg nitrates,
trace blood, negative leuk esterase, protein >=300, [**6-12**] WBC, 3+
bacteria, 1+ amorphous crystals
Influenza antigen screen - negative

CULTURE DATA:
BAL: GRAM STAIN (Final [**2165-10-2**]):
      >25 PMNs and <10 epithelial cells/100X field.
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.
   RESPIRATORY CULTURE (Final [**2165-10-3**]):
      SPARSE GROWTH Commensal Respiratory Flora.
   FUNGAL CULTURE (Preliminary):
      MOLD.

BAL: GRAM STAIN (Final [**2165-10-2**]):
      >25 PMNs and <10 epithelial cells/100X field.
      NO MICROORGANISMS SEEN.
   RESPIRATORY CULTURE (Final [**2165-10-4**]):
      RARE GROWTH Commensal Respiratory Flora.
   FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.

Legionella Urinary Antigen  (Final [**2165-10-2**]):
      NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.

CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2165-10-7**]):
      Feces negative for C.difficile toxin A & B by EIA.

BLOOD AND URINE CULTURES AT [**Hospital1 18**] NEGATIVE TO DATE

CT CHEST [**2165-10-2**] - IMPRESSION: Confluent consolidation involving
nearly the entire left lung with either bronchocentric or
vascular dissemination to the right lung with assoicated
mediastinal and hilar lymphadenopathy most suggestive of
infection. Alternatively, consolidative forms of
bronchoaleveolar carcinoma or lymphoma could have a similar
appearance.
Review of the outside CT from [**2161**] and [**2164**] shows near
resolution of previous extensive ground glass opacity, diagnosed
as pulmonary alveloar proteinosis which may be idiopathic or
related to inhalational exposure.  Extensive mediastinal soft
tissue and lymphadenopathy.


Brief Hospital Course:
51 yo man with IBD, pulmonary alveolar proteinosis who presented
from [**Hospital6 19155**] with pneumonia and respiratory
failure.

# Respiratory failure/Pneumococcal Pneumonia: In the setting of
an acute pulmonary process, this was initially attributed to
bacterial pneumonia, likely community acquired, supported by
intial GPC's on sputum at [**Hospital6 19155**].  However,
PCP and Nocardia were also considered given known diagnosis of
PAP and labs were sent accordingly. CXR demonstrated unilateral
disease, not c/w PAP flare and more concerning for an acute
process. Patient was intubated and intially started on an ARDS
type ventilation with low tidal volumes. Patient was also
underwent bronchoscopy with aspiration of large, thick mucus
cast. Legionella Ag was sent and was negative. The patient was
initially started on vancomycin and aztreonam.  He was
subsequently switched to levaquin after cultures (blood and
sputum) from [**Location (un) **] returned possitive for Streptococcus
Pneumoniae. On [**10-3**], patient grew agitated in the evening and
self-extubated.  He was maintained with adequate saturations on
highflow facemask.  Patient's mental status rapidly improved
over the next several days. His CXR also rapidly improved with
increased oxygenation of the RL fields.  F/u of the nocardia
culture was negative to date and PCP smear was never done in the
lab. On transfer to the floor, his oxygen requirement was
initially 4L.  Levaquin was continued.  He had no acute events
on the floor, and O2 saturation was 94% on RA on day of
discharge.  Physical Therapy evaluated him during his admission
and recommended [**1-4**] further visits.  He still had dyspnea on
exertion so home oxygen was arranged for him.

FOLLOW-UP: PCP [**Last Name (NamePattern4) **] 1 week (their office will contact patient to
arrange appointment) and repeat chest imaging in [**4-8**] weeks.

# Acute Renal Failure - On transfer, patient had elevated
creatinine of 1.4, given 3L NS bolus in setting of hypotension
and pressors.  Responded appropriately.  Discharged with
creatinine 0.8-0.9.

# Hypotension - Patient experienced hypotension prior to
transfer from OSH.  He was transferred to [**Hospital1 18**] on a
neosynephrine (phenylephrine) drip.  Chem-7 showed elevated
creatinine which likely indicated pre-renal state.  Responded to
3L NS bolus and pressors were discontinued.  Patient maintained
normal blood pressure for rest of admission.

# Pulmonary Alveolar Proteinosis - Not an acute issue during
admission, however, may have been contributing factor to his
illness.  Instructed patient to follow-up with his pulmonologist
within 4 weeks of discharge.

# Hypothyroidism - TSH within normal limits.  Continued home
dose of Levoxyl.

Medications on Admission:
- LEVOTHYROXINE - 200mcg po daily


Discharge Medications:
1. Oxygen
O2 at 2 to 4 L continuous, Pulse dose for portability.
2. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Company 1519**]

Discharge Diagnosis:
Primary Diagnosis:
1. Pneumonia
2. Respiratory Failure
3. Hypotension
4. Acute Renal Failure

Secondary Diagnosis:
1. Pulmonary Alveolar Proteinosis
2. Hypothyroidism


Discharge Condition:
Hemodynamically Stable.  Tolerating PO intake.  Stable on oral
antibiotics.


Discharge Instructions:
You were transferred to [**Hospital1 18**] from [**Hospital6 19155**] for
further management of your pneumonia.  When you arrived, you
were sedated and had a tube down your throat to help you
breathe.  You also needed medication to help your body maintain
your blood pressure.  After recieving IV fluids, the medication
to help you maintain your blood pressure was discontinued.  You
pulled the breathing tube out of your mouth while in the
Intensive Care Unit, however it was not inserted.  Oxygen was
required for most of your hospitalization to help you breath.
Antibiotics were continued while you were in the hospital.
Please complete your course of antibiotics after discharge.  It
is important that you follow-up with your PCP and your
Pulmonologist after discharge.   You were given both a flu and
pneumococcal vaccine prior to discharge to help prevent flu and
pneumonia.

Oxygen has been arranged for you to have at home.  It is
intended to be used during exertion for the next 2-3 days or at
anytime that you are experiencing shortness of breath.

Changes in Medication
START Levofloxacin 750 mg by mouth daily for 5 days
CONTINUE Levothyroxine 200 mcg by mouth daily

If you experience fever > 101, worsening shortness of breath,
chest pain, pain when you breathe, coughing up blood, nausea or
vomitting, headaches, confusion or any other symptom that
concerns you, please contact your PCP or go to the nearest
emergency room for evaluation.


Followup Instructions:
Please follow-up with your PCP within one week of discharge.
Dr. [**Last Name (STitle) **] is no longer at the practice site your prevoiusly
went to and they stated your new PCP is [**Last Name (NamePattern4) **]. [**First Name (STitle) 1887**].  Dr. [**Name (NI) 77520**] nurse will contact you to arrange an appointment.

Additionally, you should follow-up with your pulmonologist
within 4-6 weeks for evaluation.
{'Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Acute kidney failure, unspecified,Acute respiratory failure,Pulmonary alveolar proteinosis,Unspecified disease of pericardium,Foreign body in main bronchus,Hypotension, unspecified,Unspecified acquired hypothyroidism,Foreign body accidentally entering other orifice'}


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: Transfer for respiratory failure

PRESENT ILLNESS: Mr. [**Known lastname 39602**] is a 51 yo man with a diagnosis of pulmonary
alveolar proteinosis who presents in transfer from [**Location 75548**] for treatment of pneumonia and respiratory
failure. Per H&P from OSH, the patient was in his usual state of
health until [**9-28**] when he developed URI symptoms, dyspnea,
cough, fever and chills. He presented to the hospital today and
was found to have a large LLL/lingular pneumonia on chest X-ray.
He was afebrile on admission there with RR 49, HR 143, BP
111/75. He was started on IV linezolid and levofloxacin and
admitted to the ICU. O2 sat on arrival to the ICU was 88% on
FiO2 70%. ABG was 7.48/33/51. His RR increased to 50, his HR
remained 130s and his temp increased to 100.4, and he was
intubated at that time. he was placed on ventilator support -
assist control, tidal volume 600, FiO2 100% and RR 12. He was
placed on a propofol drip for sedation. He was suctioned for
thick yellow brownish-colored sputum, blood-tinged. Gram stain
showed <10 epis, 1+ gram positive cocci. BP dropped to 89/40 and
he received a NS bolus and started on neosynephrine. Repeat ABG
was 7.43/39/222. High A-a gradient of 442. He was transferred to
[**Hospital1 18**] for further management.

MEDICAL HISTORY: - Pulmonary alveolar proteinosis, diagnosed [**5-10**] by open lung bx
-follow-up 11/08 per OSH report almost complete resolution of
infiltrates
- IBD s/p colon resection and colostomy
- Hashimoto's thyroiditis
- Hx of sinus surgery

MEDICATION ON ADMISSION: - LEVOTHYROXINE - 200mcg po daily

ALLERGIES: Amoxicillin

PHYSICAL EXAM: VS: T: 99.4 HR: 91 BP: 102/60 RR: 16 O2: 98% on FiO2 100%, PEEP
5
Gen: Intubated sedated
HEENT: PEERL, MM dry
Neck: Supple, no LAD, no JVD
Heart:RRR, nl S1/2, no murmurs
Lung: clear breath sounds b/l anteriorly
Abd: Colostomy with midline scar
Extrem: Warm, no edema, 2+ dp, radial pulses
Skin: no rashes
Neuro: No clonus, toes downgoing

FAMILY HISTORY: Father deceased - kidney CA. Mother is alive and healthy

SOCIAL HISTORY: Occasional ETOH use, does not and has never smoked. Married, two
children.  Works as a mechanical engineer in an office setting.
Has no known exposure to asbestos.  Mother grew up on a farm in
[**State 23924**] and patient would visit often as a child.  No known
exposure to any chemicals or solvents. Married with two
children/ 

### Response:
{'Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Acute kidney failure, unspecified,Acute respiratory failure,Pulmonary alveolar proteinosis,Unspecified disease of pericardium,Foreign body in main bronchus,Hypotension, unspecified,Unspecified acquired hypothyroidism,Foreign body accidentally entering other orifice'}
