CHIEF COMPLAINT: Transfer from OSH for multiorgan system failure

PRESENT ILLNESS: The patient is a 33 yo M with h/o asthma (no attacks since
childhood) and oxycodone abuse (on methadone maintannce)
transferred from an OSH for for worsening respiratory failure
and multiorgan system failure. The patient presented to the OSH
2 days prior to transfer after waking up with resp distress and
looking cyanotic to his girlfriend. [**Name (NI) **] was driven to the
hospital and becamse unresponsive in the car. He was intubated
at the OSH and had a large aspiration event at the time
(received etomidate 25mg IV and succinochline 200mg IV). A
central line was placed at that time and was flushed with
heparin. At the OSH, vital signs on admission to the ICU were T
101.1, HR 119, BP 100/58, O2 100% on AC 600x12 PEEP 7 FIO2 100%.
Given his fevers and elevated WBC count on admission (WBC =
14.9), he was started on vancomycin, imipenom, and levofloxacin
to broadly cover for pneumonia. CXR revealed large left sided
aspiration PNA. He continued to need increasing levels of PEEP
and FIO2.
.
He was also found to be in acute renal failure at the time of
admission with a creatinine of 1.7 with a K of 6.0. His
creatinine continued to rise throughout his hospital course. He
was followed by the renal service at the OSH and it was felt to
be either pre-renal azotemia or ATN.
.
Also, of note, the patients central line was flused with heparin
at the time of presentation to the OSH ED. His platelets then
dropped from 190 to 67. All other heparin products were avoided.

MEDICAL HISTORY: -- Respiratory Distress (not requiring intubation) and ARF
(short term HD) in [**January 2191**]
-- HIT + [**January 2191**]
-- Oxycodone abuse; currently on methadone maintence

MEDICATION ON ADMISSION: Medications: (at the time of transfer)
Protonix 40mg IV daily
Propofol
Combivent
Levaquin
Primaxin
Vancomycin
Morphine
.
Home Medications:
Methadone 155mg per day

ALLERGIES: Heparin Agents / Codeine

PHYSICAL EXAM: Vitals - T96.8 HR86 BP115/70 O285% (FIO2 100% AC)
General - young man, sedated and paralyzed
HEENT - PERRL
Neck - supple, LIJ in place
CV - RRR, no murmur appreciated
Lungs - decreased breath sounds throughout L>R
Abdomen - soft, NT ND
Ext - no edema

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: Per family report patient has a history of oxycodone abuse and
has been on methadone maintanence for 3 years. ? of benzo abuse
as well. Family reports the patient did not use IV drugs. +
smoking. Lives with his girlfriend. Smokes 2ppd x years. Has 1
daugther.
Acute respiratory failure,Acute kidney failure, unspecified,Acute and subacute necrosis of liver,Pneumonitis due to inhalation of food or vomitus,Hyperpotassemia,Anticoagulants causing adverse effects in therapeutic use
Acute respiratry failure,Acute kidney failure NOS,Acute necrosis of liver,Food/vomit pneumonitis,Hyperpotassemia,Adv eff anticoagulants
Admission Date:  [**2191-11-4**]              Discharge Date:   [**2191-11-9**]

Date of Birth:  [**2158-6-15**]             Sex:   M

Service: MEDICINE

Allergies:
Heparin Agents / Codeine

Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Transfer from OSH for multiorgan system failure

Major Surgical or Invasive Procedure:
intubation from OSH
CVL from OSH
arterial line
right chest tube x2

History of Present Illness:
 The patient is a 33 yo M with h/o asthma (no attacks since
childhood) and oxycodone abuse (on methadone maintannce)
transferred from an OSH for for worsening respiratory failure
and multiorgan system failure. The patient presented to the OSH
2 days prior to transfer after waking up with resp distress and
looking cyanotic to his girlfriend. [**Name (NI) **] was driven to the
hospital and becamse unresponsive in the car. He was intubated
at the OSH and had a large aspiration event at the time
(received etomidate 25mg IV and succinochline 200mg IV). A
central line was placed at that time and was flushed with
heparin. At the OSH, vital signs on admission to the ICU were T
101.1, HR 119, BP 100/58, O2 100% on AC 600x12 PEEP 7 FIO2 100%.
Given his fevers and elevated WBC count on admission (WBC =
14.9), he was started on vancomycin, imipenom, and levofloxacin
to broadly cover for pneumonia. CXR revealed large left sided
aspiration PNA. He continued to need increasing levels of PEEP
and FIO2.
.
He was also found to be in acute renal failure at the time of
admission with a creatinine of 1.7 with a K of 6.0. His
creatinine continued to rise throughout his hospital course. He
was followed by the renal service at the OSH and it was felt to
be either pre-renal azotemia or ATN.
.
Also, of note, the patients central line was flused with heparin
at the time of presentation to the OSH ED. His platelets then
dropped from 190 to 67. All other heparin products were avoided.

.
Cardiac enzymes were also found to be positive with troponins
peaking at 4.228. An ECHO was significant for an EF of 40% and
hypokinetic right ventricle and septal area. Cardiology was
consulted and did not think this was a primary cardiac event,
but secondary to possible hypotension and pulmonary insults.
.
Given his continued respiratory failure and multiorgan system
failure, the patient was transferred to [**Hospital1 18**] on the evening of
[**2191-11-4**]. On arrival to the MICU, the patient was found to be
hypoxic with O2 sats in the high 80's on AC 380 x 26 100%FIO2
and a of PEEP 18. An ABG at that time was 7.27/53/52. His O2
sat's continued to drop to the 70's. Recruitment was attempted
without improvement in his oxygenation. He was tried on APRV at
P-high 38, P-low 10, T-high 1.5 and T-low 0.5 FIO2 100% and
continued to be hypoxic. A repeat gas was 7.19/62/46. A CXR was
obtained that showed LLL collapse and left sided infiltrate.
Because of concern for PE, the patient was started on
argatroban. His broad spectrum antibiotics were continued and he
was started on steroids for possible asthma exacerbation. He was
switched to pressure controlled ventilation at pressure 42, PEEP
22, rate 36 and FIO2 100% with mild improvement in his O2 sat's
to around 80. He was then tried on nitric oxide at 40ppm with
dramatic improvement of O2 sat's to the high 90's. His nitric
oxide was titrated down to 20ppm during the evening. Also, the
patient was found to have an elevated potassium thgouth due to
both his ARF and acidosis. An EKG did not show evidence of
peaked t waves. The patient received kayexalte, insulin,
glucose, and bicarb.
.


Past Medical History:
-- Respiratory Distress (not requiring intubation) and ARF
(short term HD) in [**January 2191**]
-- HIT + [**January 2191**]
-- Oxycodone abuse; currently on methadone maintence


Social History:
Per family report patient has a history of oxycodone abuse and
has been on methadone maintanence for 3 years. ? of benzo abuse
as well. Family reports the patient did not use IV drugs. +
smoking. Lives with his girlfriend. Smokes 2ppd x years. Has 1
daugther.

Family History:
noncontributory

Physical Exam:
Vitals - T96.8 HR86 BP115/70 O285% (FIO2 100% AC)
General - young man, sedated and paralyzed
HEENT - PERRL
Neck - supple, LIJ in place
CV - RRR, no murmur appreciated
Lungs - decreased breath sounds throughout L>R
Abdomen - soft, NT ND
Ext - no edema


Pertinent Results:
Outside hospital labs:
Initial ABG 7.02/111/82; repeat 7.2/58/72 (after intubation)
Urine Tox - + for methadone and benzos
BUN/Cr - 25/1.7
Hct 54 --> 40
WBC 14.9 (83%N/14%L) --> WBC 15.4 (34%N,44%B,9%L)
Platelets 190 (admit) --> 67
AST 1292 --> 5732
ALT 1377 --> 5275
INR 3.99 (on admission) --> 3.67 --> 2.49
Amylase 368 --> 103
Lipase 1439 --> 135
T Bili 1.1 --> 0.8
Hepatitis B and C - pending
Fibrinogen 693
D-Dimer >1050
Legionella antibody was negative
Urine ([**2191-11-3**]) - dark yellow, hazy, 1.015, 100 WBC, negative
nitrates, pH 5.0, 30 protein
Tylenol negative

Admission labs:
[**2191-11-4**] 06:59PM   TYPE-ART PO2-52* PCO2-53* PH-7.27* TOTAL
CO2-25 BASE XS--2
[**2191-11-4**] 08:04PM   FIBRINOGE-679*
[**2191-11-4**] 08:04PM   PT-17.2* PTT-29.5 INR(PT)-1.6*
[**2191-11-4**] 08:04PM   PLT COUNT-86*
[**2191-11-4**] 08:04PM   NEUTS-87.4* LYMPHS-10.0* MONOS-2.2 EOS-0.2
BASOS-0.2
[**2191-11-4**] 08:04PM   WBC-19.1* RBC-4.07* HGB-13.1* HCT-40.1 MCV-98
MCH-32.1* MCHC-32.7 RDW-15.3
[**2191-11-4**] 08:04PM   ALBUMIN-3.2* CALCIUM-8.0* PHOSPHATE-5.0*
MAGNESIUM-2.4
[**2191-11-4**] 08:04PM   CK-MB-17* MB INDX-0.9 cTropnT-0.30*
[**2191-11-4**] 08:04PM   ALT(SGPT)-2125* AST(SGOT)-726* LD(LDH)-532*
CK(CPK)-[**2135**]* ALK PHOS-67 AMYLASE-126* TOT BILI-1.0
[**2191-11-4**] 08:04PM   GLUCOSE-91 UREA N-81* CREAT-5.0* SODIUM-147*
POTASSIUM-5.5* CHLORIDE-112* TOTAL CO2-23 ANION GAP-18
.
Labs through course of hospitalization:
On [**2191-11-9**] his HCT dropped from 39.7 to 26. After receiving
over 5 units of PRBCs the HCT dropped further to 24.

[**2191-11-9**] 05:13AM BLOOD WBC-21.0* RBC-2.63* Hgb-8.3* Hct-24.0*
MCV-91 MCH-31.4 MCHC-34.5 RDW-15.5 Plt Ct-78*
[**2191-11-9**] 05:13AM BLOOD PT-31.8* PTT-77.7* INR(PT)-3.4*
[**2191-11-9**] 05:13AM BLOOD Glucose-211* UreaN-113* Creat-5.4* Na-145
K-6.9* Cl-111* HCO3-22 AnGap-19
[**2191-11-9**] 05:18AM BLOOD Type-MIX Temp-36.4 FiO2-100 pO2-40*
pCO2-63* pH-7.16* calTCO2-24 Base XS--8 AADO2-632 REQ O2-100
Intubat-INTUBATED

[**2191-11-8**] 03:46AM BLOOD ALT-132* AST-36 LD(LDH)-417* AlkPhos-48
TotBili-2.0*
[**2191-11-7**] 03:18AM BLOOD Lipase-53
[**2191-11-9**] 05:13AM BLOOD Calcium-7.3* Phos-11.4*# Mg-2.6
[**2191-11-6**] 03:59AM BLOOD Triglyc-161* HDL-29 CHOL/HD-4.2
LDLcalc-60
[**2191-11-4**] 08:00PM BLOOD ANCA-NEGATIVE B
[**2191-11-4**] 08:00PM BLOOD [**Doctor First Name **]-NEGATIVE


Brief Hospital Course:
33 yo M with h/o asthma as a child and drug abuse presented to
OSH with resp distress after being found down by his fiance. He
was intubated and found to have large aspiration PNA. Presented
to [**Hospital1 18**] with multiorgan system failure and difficult to
oxygenate despite mechanical ventilation. He presented in ARDS
with an unknown cause. The thought was that he had a severe
aspiration PNA. On arrival to [**Hospital1 18**] MICU, patient was
oxygenating in the low 80's then went down to the 70's s/p
recruitment manuveurs on FIO2 of 0.9. A bronch was not performed
given the high oxygen requirements (he had been bronched at the
OSH where they saw secretions but no evidence of hemorrhage).
His oxygenation did not improve with APRV, but he did respond to
nitric oxide. Later an oscillating bed was used to place the
patient in the prone position.  Given HIT and elevated heart
pressures, there was some concern for PE. LE dopplers negative
at OSH. Unable to get CTA given ARF, so he was started on
agatroban upon arrival to [**Hospital1 18**] for empiric therapy. He was
given broad spectrum antibiotics vancomycin/zosyn/cipro for
empiric coverage. All blood and sputum cultures were negative
during his hospitalization. Although less likely, pulm-renal
syndromes (wegners, goodpastures) were considered and [**First Name8 (NamePattern2) **]
[**Doctor First Name **]/ANCA were checked which were ultimately negative.
Throughout the hospitalization, despite all of the above
maneuvers, he remained very difficult to oxygenate and his
clinical status was not improving.

On the last day of the hospitalization, his blood pressure
dropped but responded to fluids. A routine CXR that night showed
a right pneumothorax. Surgery was called STAT to the bedside and
placed a chest tube. The tube was malpositioned and a second
tube was placed. During this procedure, he began to bleed (he
was on argatrogan as above, but this was turned off and he had
been given FFP periprocedure). His HCT dropped from 30 to 26.
He was given a total of 12 units of FFP and 5 units of PRBCs and
his HCT lowered further to 24. He was hypotensive and he was
given IVF and placed on 3 pressor agents.  Throughout his
hospitalization, his family had been updated to the grave nature
of his illness and the high likelihood of death. During this
last night, they decided not to pursue further agressive
treatment.  The patient passed away in the morning.

Other medical issues during the hospitalization included:
.
# ARF - on admission to the OSH patient had a creatinine of 1.7.
unknown what his baseline was. Per report the patient was
transiently hypotensive to the high 80's/low90's at the OSH.
Etiologies could be pre-renal with hypotension v. ATN v. ? Renal
vein thrombosis given HIT. Ultrasound was negative. Renal
consult felt this was likely ATN.
.
# Thrombocytopenia/HIT - h/o HIT + antibodies in [**January 2191**], was on
coumadin for unknown period of time. At OSH on [**11-2**] after
placement of CVL, got heparin flush. Platelets dropped from 190
to 67 at the OSH. He was placed on argatroban as described above
and heparin products were avoided.
.
# Cardiac -troponin elevated to 4 at OSH, had been trending
down. ECHO on [**11-3**] with EF 40% and a hypokinetic RV. Septal and
anterior wall also appear hypokinetic. Likely in the setting of
hypotension and poor oxygenation. EKG here fairly unremarkable.
ECHO was done for concern over PFO that opened with high PEEP
pressures.  It showed at least moderate pulmonary hypertension.
No ASD/PFO seen. Normal LVEF. Dilated RV with preserved RV
systolic function.
.
# Liver Failure - likely shock liver. other etiologies include
ingestions. tylenol levels negative at OSH. His INR elevated to
4 at OSH but 1.6 on arrival here; LFT's also trending down. His
hepatitis serologies all were negative.
.
# Fever/Elevated WBC - patient with elevated WBC on arrival to
the ED prior to the aspiration event. CXR with aspiration PNA,
UA negative, blood cultures negative to date from the OSH. He
was continued on broad spectrum antibiotics as above although
all his cultures were NGTD during the hospitalization.
.
# Substance abuse - continued on methadone to avoid withdrawal.
Per family, patient on 155mg per day of methadone as his
maintaince.
.
PPx - PPI, on agatroban, bowel regimen if needed
Access - left IJ (placed [**2191-11-2**] at OSH) and left a-line
(placed [**2191-11-4**] at [**Hospital1 18**])


Medications on Admission:
Medications: (at the time of transfer)
Protonix 40mg IV daily
Propofol
Combivent
Levaquin
Primaxin
Vancomycin
Morphine
.
Home Medications:
Methadone 155mg per day


Discharge Medications:
none

Discharge Disposition:
Expired

Discharge Diagnosis:
Expired

Discharge Condition:
Expired

Discharge Instructions:
None

Followup Instructions:
None


Completed by:[**2191-12-22**]
{'Acute respiratory failure,Acute kidney failure, unspecified,Acute and subacute necrosis of liver,Pneumonitis due to inhalation of food or vomitus,Hyperpotassemia,Anticoagulants causing adverse effects in therapeutic use'}


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 from OSH for multiorgan system failure

PRESENT ILLNESS: The patient is a 33 yo M with h/o asthma (no attacks since
childhood) and oxycodone abuse (on methadone maintannce)
transferred from an OSH for for worsening respiratory failure
and multiorgan system failure. The patient presented to the OSH
2 days prior to transfer after waking up with resp distress and
looking cyanotic to his girlfriend. [**Name (NI) **] was driven to the
hospital and becamse unresponsive in the car. He was intubated
at the OSH and had a large aspiration event at the time
(received etomidate 25mg IV and succinochline 200mg IV). A
central line was placed at that time and was flushed with
heparin. At the OSH, vital signs on admission to the ICU were T
101.1, HR 119, BP 100/58, O2 100% on AC 600x12 PEEP 7 FIO2 100%.
Given his fevers and elevated WBC count on admission (WBC =
14.9), he was started on vancomycin, imipenom, and levofloxacin
to broadly cover for pneumonia. CXR revealed large left sided
aspiration PNA. He continued to need increasing levels of PEEP
and FIO2.
.
He was also found to be in acute renal failure at the time of
admission with a creatinine of 1.7 with a K of 6.0. His
creatinine continued to rise throughout his hospital course. He
was followed by the renal service at the OSH and it was felt to
be either pre-renal azotemia or ATN.
.
Also, of note, the patients central line was flused with heparin
at the time of presentation to the OSH ED. His platelets then
dropped from 190 to 67. All other heparin products were avoided.

MEDICAL HISTORY: -- Respiratory Distress (not requiring intubation) and ARF
(short term HD) in [**January 2191**]
-- HIT + [**January 2191**]
-- Oxycodone abuse; currently on methadone maintence

MEDICATION ON ADMISSION: Medications: (at the time of transfer)
Protonix 40mg IV daily
Propofol
Combivent
Levaquin
Primaxin
Vancomycin
Morphine
.
Home Medications:
Methadone 155mg per day

ALLERGIES: Heparin Agents / Codeine

PHYSICAL EXAM: Vitals - T96.8 HR86 BP115/70 O285% (FIO2 100% AC)
General - young man, sedated and paralyzed
HEENT - PERRL
Neck - supple, LIJ in place
CV - RRR, no murmur appreciated
Lungs - decreased breath sounds throughout L>R
Abdomen - soft, NT ND
Ext - no edema

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: Per family report patient has a history of oxycodone abuse and
has been on methadone maintanence for 3 years. ? of benzo abuse
as well. Family reports the patient did not use IV drugs. +
smoking. Lives with his girlfriend. Smokes 2ppd x years. Has 1
daugther. 

### Response:
{'Acute respiratory failure,Acute kidney failure, unspecified,Acute and subacute necrosis of liver,Pneumonitis due to inhalation of food or vomitus,Hyperpotassemia,Anticoagulants causing adverse effects in therapeutic use'}
