CHIEF COMPLAINT: Multifocal pneumonia, Acute renal failure

PRESENT ILLNESS: [**Age over 90 **] y.o. male with dementia, prior left frontotemporal CVA,
atrial fibrillation on warfarin, COPD by radiograph who presents
from nursing home with dyspnea and found to have multifocal
pneumonia on chest radiograph new from prior admission 12 days
ago. According to patient's wife, he was in his normal state of
health the day prior, which is demented, unable to walk and or
perform ADLs, but had eaten a full meal. He reportedly has had
problems with swallowing his foods and has been noted to cough
after eating and drinking. To the best of the wife's knowledge,
he has not had any sick contacts. Today, he was noted to have a
dyspnea and a low-grade fever and was thus brought in to the ED
for further evaluation.
.
In the ED, initial vs were: 100.8, 124/104, 137, 28-40, 99% NRB
(89% RA), blood pressure dipped to 78/29 at 2100 prior to
transfer and lactate was elevated to 6.2. CXR showed multifocal
PNA and patient was given vancomycin 1g, zosyn 4.5g, and 650mg
tylenol along with 1 liter normal saline. After discussion with
patient's wife and HCP, it was clarified that patient is
DNR/DNI. Additionally, the patient's wife expressed a desire to
have no central access or pressors. Given his dyspnea and
tachypnea, BiPAP was started and the patient was more calm. He
was admitted to the ICU for further management.
.
On the floor, patient appeared comfortable and denied pain. He
was able to follow commands. The patient's wife and son were
engaged in a lengthy conversation during which the wife revealed
that she is confident that the patient would not want anything
to prolong his life given his current mental status and quality
of life. She and her son expressed a goal of keeping him
comfortable with BiPAP since it had been started and morphine if
necessary for air hunger. The wife eventually expressed an
interest in discontinuing antibiotics since she felt that they
were counterproductive in the goal of not prolonging his life.
It was also decided to hold IVF.  See above.

MEDICAL HISTORY: CVA 9 years ago, had TPA at [**Hospital3 **]
Dementia
Atrial Fibrillation on coumadin
BPH
Cataracts
COPD by radiograph
Anemia

MEDICATION ON ADMISSION: Coumadin 3.75 mg PO QD
Aspirin 81 mg PO QD

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 100.2, BP: 120/36, P: 87, R: 17, O2: 93% BiPAP
General: Arousable, able to follow commands, oriented to self
HEENT: NC/AT; PERRLA, EOMI; OP clear, nonerythematous
Neck: supple, JVP not elevated, no LAD
Lungs: Decreased BS bilaterally
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses; + clubbing and 2+ pitting
edema b/l.

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives at [**Location 35689**] house, married.
Unspecified septicemia,Septic shock,Pneumonitis due to inhalation of food or vomitus,Urinary tract infection, site not specified,Acute kidney failure, unspecified,Severe sepsis,Atrial fibrillation,Chronic kidney disease, Stage III (moderate),Anemia, unspecified,Unspecified cataract,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Long-term (current) use of anticoagulants,Chronic airway obstruction, not elsewhere classified,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits
Septicemia NOS,Septic shock,Food/vomit pneumonitis,Urin tract infection NOS,Acute kidney failure NOS,Severe sepsis,Atrial fibrillation,Chr kidney dis stage III,Anemia NOS,Cataract NOS,Alzheimer's disease,Dementia w/o behav dist,Long-term use anticoagul,Chr airway obstruct NEC,Hx TIA/stroke w/o resid
Admission Date:  [**2187-4-10**]              Discharge Date:   [**2187-4-13**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Multifocal pneumonia, Acute renal failure

Major Surgical or Invasive Procedure:
none

History of Present Illness:
[**Age over 90 **] y.o. male with dementia, prior left frontotemporal CVA,
atrial fibrillation on warfarin, COPD by radiograph who presents
from nursing home with dyspnea and found to have multifocal
pneumonia on chest radiograph new from prior admission 12 days
ago. According to patient's wife, he was in his normal state of
health the day prior, which is demented, unable to walk and or
perform ADLs, but had eaten a full meal. He reportedly has had
problems with swallowing his foods and has been noted to cough
after eating and drinking. To the best of the wife's knowledge,
he has not had any sick contacts. Today, he was noted to have a
dyspnea and a low-grade fever and was thus brought in to the ED
for further evaluation.
.
In the ED, initial vs were: 100.8, 124/104, 137, 28-40, 99% NRB
(89% RA), blood pressure dipped to 78/29 at 2100 prior to
transfer and lactate was elevated to 6.2. CXR showed multifocal
PNA and patient was given vancomycin 1g, zosyn 4.5g, and 650mg
tylenol along with 1 liter normal saline. After discussion with
patient's wife and HCP, it was clarified that patient is
DNR/DNI. Additionally, the patient's wife expressed a desire to
have no central access or pressors. Given his dyspnea and
tachypnea, BiPAP was started and the patient was more calm. He
was admitted to the ICU for further management.
.
On the floor, patient appeared comfortable and denied pain. He
was able to follow commands. The patient's wife and son were
engaged in a lengthy conversation during which the wife revealed
that she is confident that the patient would not want anything
to prolong his life given his current mental status and quality
of life. She and her son expressed a goal of keeping him
comfortable with BiPAP since it had been started and morphine if
necessary for air hunger. The wife eventually expressed an
interest in discontinuing antibiotics since she felt that they
were counterproductive in the goal of not prolonging his life.
It was also decided to hold IVF.  See above.

Past Medical History:
CVA 9 years ago, had TPA at [**Hospital3 **]
Dementia
Atrial Fibrillation on coumadin
BPH
Cataracts
COPD by radiograph
Anemia

Social History:
Lives at [**Location 35689**] house, married.


Family History:
NC

Physical Exam:
Vitals: T: 100.2, BP: 120/36, P: 87, R: 17, O2: 93% BiPAP
General: Arousable, able to follow commands, oriented to self
HEENT: NC/AT; PERRLA, EOMI; OP clear, nonerythematous
Neck: supple, JVP not elevated, no LAD
Lungs: Decreased BS bilaterally
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses; + clubbing and 2+ pitting
edema b/l.

Pertinent Results:
[**2187-4-10**] 07:30PM   NEUTS-85.5* LYMPHS-11.5* MONOS-2.5 EOS-0.3
BASOS-0.3
[**2187-4-10**] 07:30PM   WBC-7.4 RBC-3.65* HGB-11.6* HCT-36.5*#
MCV-100* MCH-31.8 MCHC-31.8 RDW-13.9
[**2187-4-10**] 07:30PM   CK-MB-6 cTropnT-0.03*
[**2187-4-10**] 07:30PM   LIPASE-66*
[**2187-4-10**] 07:30PM   ALT(SGPT)-29 AST(SGOT)-30 CK(CPK)-115 ALK
PHOS-133* TOT BILI-0.6
[**2187-4-10**] 07:49PM   COMMENTS-GREEN TOP
[**2187-4-10**] 07:50PM URINE  RBC-0-2 WBC->50 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2187-4-10**] 07:50PM URINE  COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.011

[**2187-4-10**] CXR
IMPRESSION: Patchy opacities, mainly at the mid to lower right
and left
lungs, which may represent multifocal pneumonia or central
pulmonary edema.


Brief Hospital Course:
Patient a [**Age over 90 **] year old male with dementia, prior left
frontotemporal CVA, atrial fibrillation on warfarin, COPD by
radiograph here with multifocal pneumonia, UTI, acute renal
failure and septic shock.
.
# Multifocal PNA: On presetntation, patient was septic with
urinary and pulmonary source requiring ICU care. History
suggests aspiration, though CXR is not entirely consistent with
this given left-sided infiltrates, though it certainly doesn't
rule out aspiration. While in the ICU, patient was given a
single dose of vanc/levo/zosyn. A family meeting was done, and
goals of care were determined to be comfort only and the
antibiotics were discontinued. Given goals of care, explicitly
discussed with patient's HCP, will focus management on comfort
and forego management otherwise of sepsis with CVL, pressors,
IVF and cultures. See above. Patient refused oxygen once on the
floor, but while CMO, the patient improved spontanously. At the
time of discharge, his conditioned had improved so much, vital
signs were stable and he was satting 96% RA. Family meeting was
done and he was started of cefepoxidime.
.
# Code status - While in the ICU, he appeared septic and family
wanted CMO. On the floor, there was a significant improvement in
his condition and he was made DNR/DNI with PO antibiotic
administration.
.
# ARF: Baseline Cr 1.2-1.3. Elevated to 1.7, likely pre-renal.
Will hold on IVF in accordance to goals of care.  Further labs
were not done.
.
# Atrial fibrillation: Not currently tachycardic. On
anticoagulation with coumadin.
- holding anticoagulation whlie CMO, family may consider
resuming as outpatient if they want lab draws.
.
# Code status: confirmed DNR/DNI; no central or arterial lines,
no vasopressors , see above
.
# Communication: [**Name (NI) **] wife [**Name (NI) 382**] [**Name (NI) 31250**] [**Name (NI) **] [**Telephone/Fax (1) 102636**],
son [**Name (NI) **] [**Telephone/Fax (1) 102637**]


Medications on Admission:
Coumadin 3.75 mg PO QD
Aspirin 81 mg PO QD

Discharge Medications:
1. Morphine Concentrate 20 mg/mL Solution Sig: One (1)  PO Q2H
(every 2 hours) as needed for discomfort.
2. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q6H (every 6 hours) as needed for agitation.
3. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 7 days.
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for warm.
5. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Extended Care

Facility:
[**Location (un) 169**] of Heathwood

Discharge Diagnosis:
Primary:
multifocal pneumonia
sepsis, resolved
urinary tract infection
acute on chronic renal failure, stage 3

Seconadry:
atrial fibrillation


Discharge Condition:
stable, on PO antibiotics


Discharge Instructions:
You were admitted for multifocal pneumonia and sepsis and you
were initially managed in the intensive care unit with IV
antibiotics. A family meeting was held and a decision was made
to do comfort measures only and antibiotics were stopped. You
were taken care of on the floor where you improved without
intervention. Another family meeting was held a decision was
made to start antibiotic pills. You are to continue these
medications as an outpatient.
.
Please take all medications as precribed. You are to continue
your baby aspirin and your coumadin was stopped since your
family did not want blood draws. This medication can be resumed
as an outpatient.
.
Please return to ED or contact your physician pending goals of
care as determined by your family.

Followup Instructions:
none, to be determined as per goals of care


                             [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

Completed by:[**2187-4-13**]
{"Unspecified septicemia,Septic shock,Pneumonitis due to inhalation of food or vomitus,Urinary tract infection, site not specified,Acute kidney failure, unspecified,Severe sepsis,Atrial fibrillation,Chronic kidney disease, Stage III (moderate),Anemia, unspecified,Unspecified cataract,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Long-term (current) use of anticoagulants,Chronic airway obstruction, not elsewhere classified,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits"}


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: Multifocal pneumonia, Acute renal failure

PRESENT ILLNESS: [**Age over 90 **] y.o. male with dementia, prior left frontotemporal CVA,
atrial fibrillation on warfarin, COPD by radiograph who presents
from nursing home with dyspnea and found to have multifocal
pneumonia on chest radiograph new from prior admission 12 days
ago. According to patient's wife, he was in his normal state of
health the day prior, which is demented, unable to walk and or
perform ADLs, but had eaten a full meal. He reportedly has had
problems with swallowing his foods and has been noted to cough
after eating and drinking. To the best of the wife's knowledge,
he has not had any sick contacts. Today, he was noted to have a
dyspnea and a low-grade fever and was thus brought in to the ED
for further evaluation.
.
In the ED, initial vs were: 100.8, 124/104, 137, 28-40, 99% NRB
(89% RA), blood pressure dipped to 78/29 at 2100 prior to
transfer and lactate was elevated to 6.2. CXR showed multifocal
PNA and patient was given vancomycin 1g, zosyn 4.5g, and 650mg
tylenol along with 1 liter normal saline. After discussion with
patient's wife and HCP, it was clarified that patient is
DNR/DNI. Additionally, the patient's wife expressed a desire to
have no central access or pressors. Given his dyspnea and
tachypnea, BiPAP was started and the patient was more calm. He
was admitted to the ICU for further management.
.
On the floor, patient appeared comfortable and denied pain. He
was able to follow commands. The patient's wife and son were
engaged in a lengthy conversation during which the wife revealed
that she is confident that the patient would not want anything
to prolong his life given his current mental status and quality
of life. She and her son expressed a goal of keeping him
comfortable with BiPAP since it had been started and morphine if
necessary for air hunger. The wife eventually expressed an
interest in discontinuing antibiotics since she felt that they
were counterproductive in the goal of not prolonging his life.
It was also decided to hold IVF.  See above.

MEDICAL HISTORY: CVA 9 years ago, had TPA at [**Hospital3 **]
Dementia
Atrial Fibrillation on coumadin
BPH
Cataracts
COPD by radiograph
Anemia

MEDICATION ON ADMISSION: Coumadin 3.75 mg PO QD
Aspirin 81 mg PO QD

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 100.2, BP: 120/36, P: 87, R: 17, O2: 93% BiPAP
General: Arousable, able to follow commands, oriented to self
HEENT: NC/AT; PERRLA, EOMI; OP clear, nonerythematous
Neck: supple, JVP not elevated, no LAD
Lungs: Decreased BS bilaterally
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses; + clubbing and 2+ pitting
edema b/l.

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives at [**Location 35689**] house, married. 

### Response:
{"Unspecified septicemia,Septic shock,Pneumonitis due to inhalation of food or vomitus,Urinary tract infection, site not specified,Acute kidney failure, unspecified,Severe sepsis,Atrial fibrillation,Chronic kidney disease, Stage III (moderate),Anemia, unspecified,Unspecified cataract,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Long-term (current) use of anticoagulants,Chronic airway obstruction, not elsewhere classified,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits"}
