CHIEF COMPLAINT: fever, hypotension, diarrhea, r/o sepsis

PRESENT ILLNESS: 47yo woman with h/o type II diabetes mellitus, ESRD on
hemodialysis, CAD, CHF (EF 20%), PVD presenting with fever,
hypotension, diarrhea, and left toe pain.  The patient presented
to [**Hospital1 18**] ED on [**2128-7-20**] with left toe pain, and was discharged to
home on a course of Augmentin for concern of developing
cellulitis and infected laceration.  She continued to have sharp
pain in her left foot.  She did not complete the 7day course,
however, developing worsening diarrhea and nausea after four
days of antibiotics.  Diarrhea was more frequent than her
baseline loose stools, and was nonbloody.  She denies having had
fevers or chills.  She continued to take her Coreg and Imdur
despite decreased po intake.  She has had chronic diarrhea at
baseline since starting hemodialysis in [**2125**] (MWF).  She missed
dialysis on Monday of this week, but was dialyzed Tuesday and
Wednesday.  She presented to [**Hospital 191**] clinic today and was found to
have temp of 101.7, pulse 104, and BP 86/62.  She was referred
to the ED for further evaluation.  On presentation to the ED, T
102.9 HR 112 BP 104/66 RR 16 98%RA.  Her blood pressure dropped
to 86/54, and she was treated with 3L NS.  She continued to be
hypotensive and was started on dopamine; however, he heart rate
was 120s.  A right IJ was placed, and she was started on
levophed. Blood pressure stabilized at 110/64.  She also
received vancomycin, levofloxacin, and metronidazole.  On review
of records, baseline blood pressure for this patient ranges
(80-100/60s).  She also denies having had recent chest pain or
tightness, shortness of breath, orthopnea, or PND.  At baseline
she is able to walk from one room to another without becoming
short of breath.
.
ROS:  significant for cough productive of yellow sputum.  She
denies headaches, dizziness, chest pain, tightness,
palpitations, SOB, orthopnea, PND, abdominal pain.

MEDICAL HISTORY: 1. CHF - EF 20-25%
2, h/o osteomyelitis
3. h/o VRE bacteremia
4. hypertension
5. hypercholesterolemia
6. ESRD from poorly controlled DM.
7. DM type 2- complicated by neuropathy, vascular disease,
retinopathy, gastropathy, and renal insufficiency; she does not
know her blood sugar ranges, although her A1C has been low at
5.8 mg/dL.
8. PVD- s/p PTCA of R superficial femoral and posterior tibial
arteries, complicated by VRE bacteremia. S/p TMA of R 5th
metatarsal with prolonged healing; + claudication symptoms.
9. CAD with ischemic cardiomyopathy- s/p MI in [**2124**] severe 3
vessel disease 1. Selective coronary angiography of this right
dominant system revealed diffuse three vessel disease. The LMCA
contained mild, diffuse disease. The LAD contained moderate
disease with total occlusion of the distal vessel. The LCX
contained moderate diffuse disease and supplied the distal LAD
via collaterals. The RCA contained severe, small vessel diffuse
disease. 2. Limited resting hemodynamics revealed a central
aortic pressure of 133/74.  TTE [**1-/2127**]: The left atrium is
moderately dilated. The right atrium is moderately dilated. No
atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. There is severe global left
ventricular hypokinesis (ejection fraction 20-30 percent). No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size is
normal. Right ventricular systolic function is borderline
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are structurally normal. There
is no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. Moderate [2+] tricuspid regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade.
10. Hx of VRE in BCx in [**12-18**]- sensitive to linezolid.
11. Osteoporosis

MEDICATION ON ADMISSION: Coreg 12.5mg [**Hospital1 **]
Imdur 60mg daily
Lipitor 80mg daily
Nephrocaps
Protonix 40mg daily
Neurontin 600mg QHS
Lisinopril 20mg daily
Calcium carbonate

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Pt deseased

FAMILY HISTORY: significant for diabetes, CAD

SOCIAL HISTORY: Came to US from [**Country **] in [**2116**].  Lives with her elderly
husband.  Their children are in [**Country **].  Very involved with her
church and is devout [**Doctor First Name **].
Denies tobacco, alcohol, or illicit drug use
Unspecified septicemia,Subendocardial infarction, initial episode of care,Congestive heart failure, unspecified,Septic shock,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Atherosclerosis of native arteries of the extremities with gangrene,Hyposmolality and/or hyponatremia,Other primary cardiomyopathies,Unspecified pleural effusion,Acute and subacute necrosis of liver,Intracerebral hemorrhage,Other and unspecified coagulation defects,Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as uncontrolled,Severe sepsis,Hypotension, unspecified,Coronary atherosclerosis of native coronary artery,Gastroparesis,Background diabetic retinopathy,Pure hypercholesterolemia,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Osteoporosis, unspecified,Long-term (current) use of insulin,Infection with microorganisms resistant to penicillins
Septicemia NOS,Subendo infarct, initial,CHF NOS,Septic shock,Hyp kid NOS w cr kid V,End stage renal disease,Ath ext ntv art gngrene,Hyposmolality,Prim cardiomyopathy NEC,Pleural effusion NOS,Acute necrosis of liver,Intracerebral hemorrhage,Coagulat defect NEC/NOS,DMII circ nt st uncntrld,Severe sepsis,Hypotension NOS,Crnry athrscl natve vssl,Gastroparesis,Diabetic retinopathy NOS,Pure hypercholesterolem,Mth sus Stph aur els/NOS,Osteoporosis NOS,Long-term use of insulin,Inf mcrg rstn pncllins
Admission Date:  [**2128-7-29**]              Discharge Date:   [**2128-8-24**]

Date of Birth:  [**2081-1-23**]             Sex:   F

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
fever, hypotension, diarrhea, r/o sepsis

Major Surgical or Invasive Procedure:
Open left fourth and fifth transmetatarsal amputation of the
toes

Left lower extremity arteriography and tibial angioplasty.

Angioplasty of left anterior tibial artery.

Left below-the-knee amputation.


History of Present Illness:
47yo woman with h/o type II diabetes mellitus, ESRD on
hemodialysis, CAD, CHF (EF 20%), PVD presenting with fever,
hypotension, diarrhea, and left toe pain.  The patient presented
to [**Hospital1 18**] ED on [**2128-7-20**] with left toe pain, and was discharged to
home on a course of Augmentin for concern of developing
cellulitis and infected laceration.  She continued to have sharp
pain in her left foot.  She did not complete the 7day course,
however, developing worsening diarrhea and nausea after four
days of antibiotics.  Diarrhea was more frequent than her
baseline loose stools, and was nonbloody.  She denies having had
fevers or chills.  She continued to take her Coreg and Imdur
despite decreased po intake.  She has had chronic diarrhea at
baseline since starting hemodialysis in [**2125**] (MWF).  She missed
dialysis on Monday of this week, but was dialyzed Tuesday and
Wednesday.  She presented to [**Hospital 191**] clinic today and was found to
have temp of 101.7, pulse 104, and BP 86/62.  She was referred
to the ED for further evaluation.  On presentation to the ED, T
102.9 HR 112 BP 104/66 RR 16 98%RA.  Her blood pressure dropped
to 86/54, and she was treated with 3L NS.  She continued to be
hypotensive and was started on dopamine; however, he heart rate
was 120s.  A right IJ was placed, and she was started on
levophed. Blood pressure stabilized at 110/64.  She also
received vancomycin, levofloxacin, and metronidazole.  On review
of records, baseline blood pressure for this patient ranges
(80-100/60s).  She also denies having had recent chest pain or
tightness, shortness of breath, orthopnea, or PND.  At baseline
she is able to walk from one room to another without becoming
short of breath.
.
ROS:  significant for cough productive of yellow sputum.  She
denies headaches, dizziness, chest pain, tightness,
palpitations, SOB, orthopnea, PND, abdominal pain.


Past Medical History:
1. CHF - EF 20-25%
2, h/o osteomyelitis
3. h/o VRE bacteremia
4. hypertension
5. hypercholesterolemia
6. ESRD from poorly controlled DM.
7. DM type 2- complicated by neuropathy, vascular disease,
retinopathy, gastropathy, and renal insufficiency; she does not
know her blood sugar ranges, although her A1C has been low at
5.8 mg/dL.
8. PVD- s/p PTCA of R superficial femoral and posterior tibial
arteries, complicated by VRE bacteremia. S/p TMA of R 5th
metatarsal with prolonged healing; + claudication symptoms.
9. CAD with ischemic cardiomyopathy- s/p MI in [**2124**] severe 3
vessel disease 1. Selective coronary angiography of this right
dominant system revealed diffuse three vessel disease. The LMCA
contained mild, diffuse disease. The LAD contained moderate
disease with total occlusion of the distal vessel. The LCX
contained moderate diffuse disease and supplied the distal LAD
via collaterals. The RCA contained severe, small vessel diffuse
disease. 2. Limited resting hemodynamics revealed a central
aortic pressure of 133/74.  TTE [**1-/2127**]: The left atrium is
moderately dilated. The right atrium is moderately dilated. No
atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. There is severe global left
ventricular hypokinesis (ejection fraction 20-30 percent). No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size is
normal. Right ventricular systolic function is borderline
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are structurally normal. There
is no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. Moderate [2+] tricuspid regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade.
10. Hx of VRE in BCx in [**12-18**]- sensitive to linezolid.
11. Osteoporosis

Social History:
Came to US from [**Country **] in [**2116**].  Lives with her elderly
husband.  Their children are in [**Country **].  Very involved with her
church and is devout [**Doctor First Name **].
Denies tobacco, alcohol, or illicit drug use


Family History:
significant for diabetes, CAD

Physical Exam:
Pt deseased


Pertinent Results:
RADIOLOGY  Final Report

CT HEAD W/O CONTRAST  [**2128-8-24**] 7:57 AM

CT HEAD W/O CONTRAST

Reason: ? bleed

[**Hospital 93**] MEDICAL CONDITION:
47 year old woman with ESRD/DM/CAD, coagulopathy now
unresponsive
REASON FOR THIS EXAMINATION:
? bleed
CONTRAINDICATIONS for IV CONTRAST: None.

NON-CONTRAST HEAD CT SCAN

HISTORY: End-stage renal disease, diabetes and coronary artery
disease, coagulopathy, now unresponsive.

TECHNIQUE: Non-contrast head CT scan.

COMPARISON STUDIES: None.

FINDINGS: There is a 2.5 x 4.2 cm lesion in the right frontal
lobe with hyperdense material, presumably hemorrhage,
sedimenting in the dependent portion as well as hyperdense
material marginating the lesion. This abnormality causes
extensive compression of the right frontal [**Doctor Last Name 534**]. There is a
moderately large quantity of blood sedimenting in the occipital
horns. The fourth ventricle is filled with blood and grossly
dilated as well. Blood is also seen in the region of the
vallecula, posterior to the medulla. Finally, there is probably
a small amount of blood within the posterior aspect of the third
ventricle. Though the scans are degraded by motion artifact,
there is likely a small quantity of subarachnoid blood overlying
the cerebral convexities bilaterally. There is no shift of
normally midline structures. Within the limitations of this
study, no definite major vascular territorial infarction is
noted. The right globe is shrunken and hyperdense, presumably
representing end-stage diabetic damage.

CONCLUSION: Probable unclotted right frontal hemorrhage with
extensive intraventricular hemorrhage, as well as hydrocephalus
and subarachnoid hemorrhage.

BRAIN SCAN

Reason: BRAIN HEMMORRHAGE BRAIN DEATH

RADIOPHARMECEUTICAL DATA:
24.7 mCi Tc-[**Age over 90 **]m Neurolite;
History: 47 year old woman with brain hemorrhage and absent gag
and corneal
reflexes on exam.

FINDINGS: Following injection of tracer, flow and static images
of the brain
were obtained in multiple projections showing no evidence of
perfusion to the
cerebral cortex.

The perfusion abnormalities noted above are consistent with
brain death.

IMPRESSION: No demonstrable intracerebral perfusion consistent
with brain death.


Brief Hospital Course:
47yoW with h/o TIIDM, 3vCAD, CHF (EF 20-25%), ESRD on HD
presenting with fever, left toe pain, diarrhea, and septic
shock.
.
Admitted to the MICU:
.
On admission hypotension was felt likely to be due to septic
shock given concurrent fever, leukocytosis, infected toe.
infection source likely necrotic left 4th/5th toes, concerning
for osteomyelitis and bactermia.  Less likely GI source with
diarrhea but lack of abdominal pain.
.
NSTEMI:  Likely demand ischemia in setting of hypotension in
patient with known 3v disease.  ECG showed lateral
ST-depressions. No heparin gtt was started as not likely due to
plaque rupture. She was continued on ASA, atorvastatin 80mg
daily.
Carvedilol and lisinopril were held given hypotension. An echo
was performed to evaluate for wall motion abnormalities, assess
cardiac function. An echo on [**7-30**] demonstrated interval
improvement in left ventricular systolic function (40%) from
prior studies (20-25%).
.
Diarrhea:  Patient reports having diarrhea at baseline, but
worsening this week.  Given concern for C.difficile, the patient
was treated empirically with metronidazole. C diff studies have
been negative. Stool cultures negative.
.
ESRD:  The patient was continued on M,W,F Hemodialysis untill
death

Hospital Course:
.
On [**7-30**] pt received TMA of her left 4th/5th digits. Pt initially
placed on levophed as above, switch to vasopressin [**7-31**]. Has now
been off pressors for > 36 hours. initially pt placed on [**Month/Year (2) **]
and zosyn. However, cultres have now grown out
enterobacter and klebsiella, both sensitive to levofloxacin, as
well as Coag pos staph and entercoccus ([**Last Name (un) 36**] pending). [**First Name9 (NamePattern2) **] [**Doctor Last Name **]
been continued. Per ID, who has been following, flagyl added to
regimen. Pt has been afebrile since [**7-31**].
.
Underwent angiogram with interventions x 2 to restore blood
flow. plavix started. It was decided that pt foot was source of
sepsis s/p TMA. It was decided to to a BKA.

Patient thenhad L BKA [**8-19**] and was transferred to the SICU for
cont. fevers and SBP in 60's. Patient was AAOx3 until [**8-24**] when
she had acute worsening of mental status at 6:15am.  A stat NS
consult obtained.

She was subsequently intubated for airway protection. On review
of labs,
PT 21.1, PTT 150, INR 2.0. Unclear etiology as patient was only
on SQ hep and hep flushes for CLs. Patient was also on ASA and
plavix.

Stat head CT showed large 4-5 cm intraparenchymal right frontal
bleed with bilateral intraventricular blood and in 3rd and 4th
ventricles.

Initial exam after aforementioned event:

PHYSICAL EXAM:
O: T: 99.3 BP: 96/52 HR: 99 R 14  99% O2Sats vented
CMV 14x500 FiO2 100% PEEP 5 CVP 27
Gen: Lying in bed bleeding from right ear from BS, oozing from
mouth, not awake.
HEENT: Pupils: L pupil sluggish 3mm -> 2.5mm EOMs
Neck: Supple
Lungs: breath sounds bilaterally.
Cardiac: tacyhcardic, regular rate. S1/S2.
Abd: Soft, NT, BS+
Extrem: left BKA staples c/d/i, right toe resection staples
c/d/i. hands warm, no cyanosis or edema.

Neuro: Exam performed without sedation.
Patient intubated, not awake or alert. Not responding to painful
stimuli in all 4 extremities, Left pupil sluggish 3->2.5mm and
eye midline, no corneal reflex, no gag.

Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors.

Reflexes: no DTRs
.
Pt made CMO
.
Pt deseased shortly after


Medications on Admission:
Coreg 12.5mg [**Hospital1 **]
Imdur 60mg daily
Lipitor 80mg daily
Nephrocaps
Protonix 40mg daily
Neurontin 600mg QHS
Lisinopril 20mg daily
Calcium carbonate


Discharge Medications:
n/a

Discharge Disposition:
Expired

Discharge Diagnosis:
n/a

Discharge Condition:
n/a

Discharge Instructions:
n/a

Followup Instructions:
n/a


Completed by:[**2129-5-21**]
{'Unspecified septicemia,Subendocardial infarction, initial episode of care,Congestive heart failure, unspecified,Septic shock,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Atherosclerosis of native arteries of the extremities with gangrene,Hyposmolality and/or hyponatremia,Other primary cardiomyopathies,Unspecified pleural effusion,Acute and subacute necrosis of liver,Intracerebral hemorrhage,Other and unspecified coagulation defects,Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as uncontrolled,Severe sepsis,Hypotension, unspecified,Coronary atherosclerosis of native coronary artery,Gastroparesis,Background diabetic retinopathy,Pure hypercholesterolemia,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Osteoporosis, unspecified,Long-term (current) use of insulin,Infection with microorganisms resistant to penicillins'}


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: fever, hypotension, diarrhea, r/o sepsis

PRESENT ILLNESS: 47yo woman with h/o type II diabetes mellitus, ESRD on
hemodialysis, CAD, CHF (EF 20%), PVD presenting with fever,
hypotension, diarrhea, and left toe pain.  The patient presented
to [**Hospital1 18**] ED on [**2128-7-20**] with left toe pain, and was discharged to
home on a course of Augmentin for concern of developing
cellulitis and infected laceration.  She continued to have sharp
pain in her left foot.  She did not complete the 7day course,
however, developing worsening diarrhea and nausea after four
days of antibiotics.  Diarrhea was more frequent than her
baseline loose stools, and was nonbloody.  She denies having had
fevers or chills.  She continued to take her Coreg and Imdur
despite decreased po intake.  She has had chronic diarrhea at
baseline since starting hemodialysis in [**2125**] (MWF).  She missed
dialysis on Monday of this week, but was dialyzed Tuesday and
Wednesday.  She presented to [**Hospital 191**] clinic today and was found to
have temp of 101.7, pulse 104, and BP 86/62.  She was referred
to the ED for further evaluation.  On presentation to the ED, T
102.9 HR 112 BP 104/66 RR 16 98%RA.  Her blood pressure dropped
to 86/54, and she was treated with 3L NS.  She continued to be
hypotensive and was started on dopamine; however, he heart rate
was 120s.  A right IJ was placed, and she was started on
levophed. Blood pressure stabilized at 110/64.  She also
received vancomycin, levofloxacin, and metronidazole.  On review
of records, baseline blood pressure for this patient ranges
(80-100/60s).  She also denies having had recent chest pain or
tightness, shortness of breath, orthopnea, or PND.  At baseline
she is able to walk from one room to another without becoming
short of breath.
.
ROS:  significant for cough productive of yellow sputum.  She
denies headaches, dizziness, chest pain, tightness,
palpitations, SOB, orthopnea, PND, abdominal pain.

MEDICAL HISTORY: 1. CHF - EF 20-25%
2, h/o osteomyelitis
3. h/o VRE bacteremia
4. hypertension
5. hypercholesterolemia
6. ESRD from poorly controlled DM.
7. DM type 2- complicated by neuropathy, vascular disease,
retinopathy, gastropathy, and renal insufficiency; she does not
know her blood sugar ranges, although her A1C has been low at
5.8 mg/dL.
8. PVD- s/p PTCA of R superficial femoral and posterior tibial
arteries, complicated by VRE bacteremia. S/p TMA of R 5th
metatarsal with prolonged healing; + claudication symptoms.
9. CAD with ischemic cardiomyopathy- s/p MI in [**2124**] severe 3
vessel disease 1. Selective coronary angiography of this right
dominant system revealed diffuse three vessel disease. The LMCA
contained mild, diffuse disease. The LAD contained moderate
disease with total occlusion of the distal vessel. The LCX
contained moderate diffuse disease and supplied the distal LAD
via collaterals. The RCA contained severe, small vessel diffuse
disease. 2. Limited resting hemodynamics revealed a central
aortic pressure of 133/74.  TTE [**1-/2127**]: The left atrium is
moderately dilated. The right atrium is moderately dilated. No
atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. There is severe global left
ventricular hypokinesis (ejection fraction 20-30 percent). No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size is
normal. Right ventricular systolic function is borderline
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are structurally normal. There
is no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. Moderate [2+] tricuspid regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade.
10. Hx of VRE in BCx in [**12-18**]- sensitive to linezolid.
11. Osteoporosis

MEDICATION ON ADMISSION: Coreg 12.5mg [**Hospital1 **]
Imdur 60mg daily
Lipitor 80mg daily
Nephrocaps
Protonix 40mg daily
Neurontin 600mg QHS
Lisinopril 20mg daily
Calcium carbonate

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Pt deseased

FAMILY HISTORY: significant for diabetes, CAD

SOCIAL HISTORY: Came to US from [**Country **] in [**2116**].  Lives with her elderly
husband.  Their children are in [**Country **].  Very involved with her
church and is devout [**Doctor First Name **].
Denies tobacco, alcohol, or illicit drug use 

### Response:
{'Unspecified septicemia,Subendocardial infarction, initial episode of care,Congestive heart failure, unspecified,Septic shock,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Atherosclerosis of native arteries of the extremities with gangrene,Hyposmolality and/or hyponatremia,Other primary cardiomyopathies,Unspecified pleural effusion,Acute and subacute necrosis of liver,Intracerebral hemorrhage,Other and unspecified coagulation defects,Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as uncontrolled,Severe sepsis,Hypotension, unspecified,Coronary atherosclerosis of native coronary artery,Gastroparesis,Background diabetic retinopathy,Pure hypercholesterolemia,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Osteoporosis, unspecified,Long-term (current) use of insulin,Infection with microorganisms resistant to penicillins'}
