CHIEF COMPLAINT: Fever, abdominal pain

PRESENT ILLNESS: patient is a 71 y/o F with PMH of ESRD on HD, recent broncial
hemorrhage, respiratory failure with trach, hx of multiple GI
bleeds, nonresponsive at baseline presenting from [**Hospital **] rehab
with coffee ground emesis and fever.

MEDICAL HISTORY: 1)ESRD on HD of unclear etiology.
2)Respiratory failure s/p trach in [**2-11**], vent dependent until
[**1-11**] when she was successfully weaned
3)COPD
4)Chronic pleural effusions
5)Recurrent aspiration PNA
6)PVD, s/p R CEA, s/p bilateral iliac stents and gangrene of
toes bilaterally and autoamputating
7)HTN
8)Hypothyroidism
9)h/o GI bleeding
10)CHF no previous echo here, so unclear [**Name2 (NI) **]
11)h/o Cholesterol emboli syndrome
12)Paroxysmal AF
13)Anemia
14)s/p multiple embolic CVA
[**95**])Dementia
16)Adenocarcinoma of the colon s/p resection in [**2186**]
17)hx of C.diff colitis
18)Sepsis [**3-8**] to PNA d/c'd from MICU [**2188-6-25**]

MEDICATION ON ADMISSION: Tylenol, alumnium hydroxide 45ML per gtube, B12 1', colace,
Fluticasone proprionate, Folic acid, Heparin 2500 q12h,
dilauded 0.75mg PO at dialysis, Levothyroxine 200', Lidoderm 5%
2 patch once a dat topically, Nystatin 5mL QID, albterol q6h
nebs, Dulcolax 10PRN, Iartroprium q6hours, Zofran 4 TID

ALLERGIES: Proxy[**Name (NI) 67216**] / Caffeine / Butalbital / Barbiturates / Xanthines

PHYSICAL EXAM: vitals: T100.2 BP 93/39 P83 RR 19-28 98-100% on CPAP 50%
gen: resting, nad
pulm: diminished BS, no w/r/r
cv: hrrr, no m/r/g
abd: diffuse TTP, firm. hypoactive BS.
extr: multiple amputated toes, gangrene. No edema.

FAMILY HISTORY: Her parents lived until old age. One brother died of an MI in
his 60s. Another brother with schizophrenia. Son with
hypothyroidism.

SOCIAL HISTORY: # Personal: Lives at [**Hospital 100**] Rehab MACU. Divorced. Three adult
children. Son [**Name (NI) **] is her HCP and is very involved
# Tobacco: Former smoker. 3 packs per day x 13 years.
# Alcohol: Occasional past use.
Other specified septicemias,Septic shock,Acute vascular insufficiency of intestine,End stage renal disease,Unspecified pleural effusion,Kidney replaced by transplant,Intestinal infection due to Clostridium difficile,Ventilator associated pneumonia,Compression of vein,Acidosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Pneumonia due to Pseudomonas,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Severe sepsis,Renal dialysis status,Tracheostomy status,Gastrostomy status,Chronic airway obstruction, not elsewhere classified,Atrial fibrillation,Other toe(s) amputation status,Candidiasis of vulva and vagina,Other and unspecified infection due to central venous catheter,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other specified disorders resulting from impaired renal function
Septicemia NEC,Septic shock,Ac vasc insuff intestine,End stage renal disease,Pleural effusion NOS,Kidney transplant status,Int inf clstrdium dfcile,Ventltr assoc pneumonia,Compression of vein,Acidosis,Hyp kid NOS w cr kid V,Pseudomonal pneumonia,Food/vomit pneumonitis,Acute respiratry failure,Severe sepsis,Renal dialysis status,Tracheostomy status,Gastrostomy status,Chr airway obstruct NEC,Atrial fibrillation,Status amput othr toe(s),Candidal vulvovaginitis,Oth/uns inf-cen ven cath,Abn react-procedure NEC,Impair ren funct dis NEC
Admission Date:  [**2188-11-4**]              Discharge Date:   [**2188-11-28**]

Date of Birth:  [**2116-10-30**]             Sex:   F

Service: MEDICINE

Allergies:
Proxy[**Name (NI) 67216**] / Caffeine / Butalbital / Barbiturates / Xanthines

Attending:[**First Name3 (LF) 330**]
Chief Complaint:
Fever, abdominal pain

Major Surgical or Invasive Procedure:
CVL, a-line

History of Present Illness:
patient is a 71 y/o F with PMH of ESRD on HD, recent broncial
hemorrhage, respiratory failure with trach, hx of multiple GI
bleeds, nonresponsive at baseline presenting from [**Hospital **] rehab
with coffee ground emesis and fever.

The son reports that patient has been vomitting over the past
month, nonbloody until this morning. She was brought in from
rehab for evaluation of this. patient is unable to give review
of systems. Per the notes from [**Hospital 100**] rehab: at 8pm [**11-3**] she was
febrile to 101.2, she was diaphoretic and clammy, was given
250cc NS BPs were 80s/40s. stable overnight until 545 AM, when
she had hypotension to 88/32 again, was diaphoretic. Aspiration
of Gtube feeds showed 500cc of coffee ground fluid.

Per interview with the son, she is alert and speaks when not
infected and her electrolytes are normal. She has been having
emesis 3-4 times a day for the past month. This is been slowly
improving with change in admisteration of aluminum hydroxide
(daily instead of TID). Her Ca has also been high the past few
days. Her emesis also appeared more brown the past day instead
of the color of tube fees.

In the ED, her vitals were Tmax 101.4, BP: 116-149/60-70 (left
arm), HR 60-80, 96% on 100% BiPAP. Gtube aspirated 300-400cc of
coffee ground material. She was lavaged 7-800cc water which was
persistently coffee ground. Access was very difficult given her
vasculopathy; IJ was attempted but unable to thread and
eventually a 3inch 18 guage angiocath was placed. She has a 20
guage in her left arm. She was given 10mg IM morphine,
vancomycin 1gm IV, zosyn 4.5 mgIV, Ativan 1m, 2L NS, protonix
80mg IV once. She was put in BIPAP for reasons unclear, but
possibly in the setting of morphine and ativan.
Also of note her pressure should be checked from her left arm.


Past Medical History:
1)ESRD on HD of unclear etiology.
2)Respiratory failure s/p trach in [**2-11**], vent dependent until
[**1-11**] when she was successfully weaned
3)COPD
4)Chronic pleural effusions
5)Recurrent aspiration PNA
6)PVD, s/p R CEA, s/p bilateral iliac stents and gangrene of
toes bilaterally and autoamputating
7)HTN
8)Hypothyroidism
9)h/o GI bleeding
10)CHF no previous echo here, so unclear [**Name2 (NI) **]
11)h/o Cholesterol emboli syndrome
12)Paroxysmal AF
13)Anemia
14)s/p multiple embolic CVA
[**95**])Dementia
16)Adenocarcinoma of the colon s/p resection in [**2186**]
17)hx of C.diff colitis
18)Sepsis [**3-8**] to PNA d/c'd from MICU [**2188-6-25**]

Social History:
# Personal: Lives at [**Hospital 100**] Rehab MACU. Divorced. Three adult
children. Son [**Name (NI) **] is her HCP and is very involved
# Tobacco: Former smoker. 3 packs per day x 13 years.
# Alcohol: Occasional past use.


Family History:
Her parents lived until old age. One brother died of an MI in
his 60s. Another brother with schizophrenia. Son with
hypothyroidism.

Physical Exam:
vitals: T100.2 BP 93/39 P83 RR 19-28 98-100% on CPAP 50%
gen: resting, nad
pulm: diminished BS, no w/r/r
cv: hrrr, no m/r/g
abd: diffuse TTP, firm. hypoactive BS.
extr: multiple amputated toes, gangrene. No edema.


Pertinent Results:
[**2188-11-4**] CT ABDOMEN WITH INTRAVENOUS CONTRAST: The left lower
lobe is collapsed. There
are bilateral small pleural effusions. There is trace
pericardial fluid,
likely physiologic.

There are several segments of a bowel wall thickening, mucosal
enhancement,
and adjacent mesenteric edema, particularly at the distal ileum.
Some of
these bowel loops demonstrate pneumatosis.

The patient is post-resection of the right and the transverse
colon, with
ileocolic anastomosis. Small amount of perihepatic free fluid is
present.
Gallbladder is distended and contains numerous gallstones.
Kidneys are
atrophic. Pancreas and spleen are unremarkable. Gastrostomy tube
is in place.
There is no free air in the abdomen.

CT PELVIS WITH INTRAVENOUS CONTRAST: There is diverticulosis of
the sigmoid
colon without evidence of acute diverticulitis. The uterus is
atrophic. There
is a small amount of free fluid in the pelvis. The rectal wall
is thickened,
though may be in part due to nondistention.

Extensive vascular calcifications are noted in the abdomen and
pelvis. The
celiac axis and SMA are patent proximally, though there is
stenosis at the
origin of both vessels due to extensive atherosclerotic
calcification of the
abdominal aorta, which is normal in caliber. [**Female First Name (un) 899**] is not clearly
enhancing,
possibly secondary to atheroscleortic changes.

BONE WINDOWS: Demonstrate no concerning lytic or sclerotic
lesions.

IMPRESSION:

1. Findings highly concerning for mesenteric ischemia and
ischemic bowel in
the SMA territory.

2. Small amount of ascites.

3. Bilateral small pleural effusion, left lower lobe collapse.

4. Cholelithiasis; gallbladder distention can be related to the
fasting
state.
.
[**2188-11-9**] CT chest/abd/pelvis
FINDINGS:

The right brachiocephalic vein is markedly attenuated. The right
common
jugular vein appears to be normal caliber. However, there is a
clot in the
common jugular vein, series 2, image 127, which is eccentrically
positioned
and occupies approximately 50% of the lumen. The takeoff of the
right
subclavian vein is not well seen; however, an attenuated right
subclavian vein
is identified as it courses through the axilla. A left internal
jugular
central line is identified. The left brachiocephalic vein, left
internal
jugular, and left subclavian vein appear to be normal caliber.
There are
diffuse atherosclerotic changes of the arterial vessels without
evidence of
significant thrombus. The superior vena cava is slightly
attenuated in
caliber. The central line coursing through the SVC terminates at
the
SVC/right atrial junction.

There is no significant pericardial effusion. There are moderate
bilateral
pleural effusions with subjacent atelectasis, which appear to be
increased in
size from prior study dated [**2188-11-4**]. Shotty
mediastinal adenopathy
is noted. The tracheobronchial anatomy appears normal. There is
tracheostomy
tube identified. Esophagus appears unremarkable.

There is a distended gallbladder, which measures high normal in
diameter, at
4.9 cm, but is slightly decreased in diameter since the prior
study. Multiple
calcified dependent gallstones are identified. There is mild
amount of
perihepatic and perisplenic fluid. There is no focal lesion
identified in the
spleen or liver. There is no intrahepatic ductal dilatation.
There are
atrophic kidneys without evidence of hydronephrosis. The
pancreas appears
unremarkable.

There are atherosclerotic changes in the abdominal aorta, most
prominent at
series 2, image 60.

Patient is status post partial colonic resection and ileocolic
anastomosis. There are fluid filled loops of large and small
bowel with
air/fluid levels but no evidence of bowel wall thickening,
pneumotosis,
or acute transition point. There is free fluid in the right
lower quadrant as
well as the pouch of [**Location (un) **]. A gastrostomy tube is identified.
There is no
evidence of intraperitoneal free air. There is diverticulosis of
the sigmoid
colon. A right femoral venous line is identified.

There are mild degenerative changes in the thoracolumbar spine.

IMPRESSION:
1. Attenuated appearance of the right brachiocephalic vein with
poorly
delineated inflow from the right subclavian vein, possibly
representing
stenosis. Eccentric clot in a normal caliber common right
jugular vein.
Patent left brachiocephalic vein and SVC, with a left- sided
central venous
catheter coursing to the SVC/right atrial junction.
2. Ascites.
3. Increased bilateral effusions and bilateral lower lobe
atelectasis.
4. Findings suggestive of ileus, with no evidence of obstruction
or
pneumotosis.
5. Distended gallbladder with cholelithiasis.

The study and the report were reviewed by the staff radiologist.

.
CT Torso [**2188-11-25**]
CT TORSO WITH CONTRAST

INDICATION: 72-year-old woman with mesenteric ischemia, renal
failure, and
septic shock, please evaluate chest, abdomen and pelvis for
possible source of
infection and in light of clinical concern for SVC syndrome.

TECHNIQUE: MDCT-acquired axial images of the chest, abdomen and
pelvis were
obtained with hand injection of intravenous contrast via the
left femoral
central line. Early and late arterial images were obtained.
Coronal and
sagittal reformats were performed.

COMPARISON: [**2188-11-9**].

CT CHEST: The tracheostomy is in expected location. There is no
significant
axillary or hilar adenopathy. There are multiple small shotty
mediastinal
nodes. There are large bilateral pleural effusions, not
appreciably changed.
There is adjacent atelectasis. There are no pulmonary nodules.
There is a
central line in the left internal jugular vein. There is again
posterior non-
occlusive thrombus in the right internal jugular, which is not
completely
imaged. There is a highly stenotic but patent right
brachiocephalic vein,
which is diminutive but patent distally. The distal right
subclavian vein is
diminutive but patent. There is no evidence of SVC thrombosis,
although it is
somewhat attenuated in caliber. There are diffuse vascular
calcifications.
There is cardiomegaly without pericardial effusion.

CT ABDOMEN: The study is somewhat limited as the patient's arms
were down
causing streak artifact. There is trace perihepatic and
perisplenic fluid,
less than on prior study. There is focal atrophy in segments IV
A and B of the
liver that may represent prior insult. There is no intra- or
extra- hepatic
biliary ductal dilatation. The gallbladder is distended
containing gallstones.
The pancreas and adrenals are normal. The spleen is somewhat
nodular. The
kidneys are atrophic.

The patient had prior partial colonic resection and ileocolic
anastomosis.
There is a gastrostomy tube in place. The intra- abdominal small
and large
bowel is otherwise normal. There is no free air or adenopathy.

There is diffuse anasarca.

CT PELVIS: There is sigmoid diverticulosis. There is a rectal
tube. There
is a left femoral line. There is trace free fluid in the pelvis.

The skin nodules in the anterior abdominal wall are likely due
to sub-
cutaneous injections.

The abdominal aorta is atherosclerotic as are the iliac
arteries.
There is complete or near complete occlusion of the left
external iliac
artery, with epigastric arterial collaterals. There is complete
SFA thrombosis
on the right, with some flow in the profunda femoris.

IMPRESSION:
1. Posterior non- occlusive thrombus in right internal jugular,
again seen but
incompletely imaged. Distal right subclavian and brachiocephalic
veins
diminutive but patent. No evidence of SVC syndrome.

2. No evidence of intra-abdominal abscess

3. Slight interval decrease in ascites.

4. Bilateral effusions and atelectasis are not significantly
changed.

5. Severe atherosclerotic disease as described above.


Brief Hospital Course:
On admission tot he hospital the patient was placed on broad
spectrum antibiotic with vancomycin, flagyl, levofloxacin,
zosyn, and gentamicin for coverage of GI flora, given her bowel
ischemia. oral vancomycin was also added for empitric coverage
of C.Diff colitis, given her recent history of C.Diff. She was
placed on a norepinephrine drip for hypotension.  CVVH was
intiated given her hypotension.  Initial Abdomenal CT showed
extensive atherosclerotic disease and calcification of her SMA,
[**Female First Name (un) 899**], and celiac axis, along with bowel distension and
pneumatosis of her bowel wall.  After being hospitalized for 10
days she developed a vent associated pneumonia and was placed on
meropenem.  Chest CT revealed occlusion of the right subclavian,
and brachiocephalic veins.  As a result, the patient had
increased facial plethora and edema of the subcutaneous tissues
surrounding her neck. She continued to be hypotensive throughout
her hospitalization and vasopressin was added on [**2188-11-21**].  A
yeast infection was detected [**11-19**] and she was given fluconazole
IV for two days.  The patient's CVVH line became infected and it
was replaced over a wire.  She was placed on vancomycin and the
line was replaced.  The replacement line became infected two
days later.  Repeat CT Torso on [**11-25**] showed no radiographic
evidence of bowel ischemia, however the patient persisted with
intense abdominal pain with palpation.  By [**11-27**] the patient
continued to be dependent on two vasopressors to maintain her
blood pressure.  She was vent dependent, and on CVVH.  She was
developing increased respiratory and metabolic acidosis. On
[**11-27**], after family discussion, the patient was made CMO. her
antibiotics and vasopressors were stopped. Per her son's
request, the CVVH was continued.  The patient passed away at
9:40am on [**11-28**], of septic shock secondary to mesenteric
ischemia.

Medications on Admission:
Tylenol, alumnium hydroxide 45ML per gtube, B12 1', colace,
Fluticasone proprionate, Folic acid, Heparin 2500 q12h,
dilauded 0.75mg PO at dialysis, Levothyroxine 200', Lidoderm 5%
2 patch once a dat topically, Nystatin 5mL QID, albterol q6h
nebs, Dulcolax 10PRN, Iartroprium q6hours, Zofran 4 TID


Discharge Disposition:
Expired

Discharge Diagnosis:
mesenteric ischemia
septic shock

Discharge Condition:
expired
{'Other specified septicemias,Septic shock,Acute vascular insufficiency of intestine,End stage renal disease,Unspecified pleural effusion,Kidney replaced by transplant,Intestinal infection due to Clostridium difficile,Ventilator associated pneumonia,Compression of vein,Acidosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Pneumonia due to Pseudomonas,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Severe sepsis,Renal dialysis status,Tracheostomy status,Gastrostomy status,Chronic airway obstruction, not elsewhere classified,Atrial fibrillation,Other toe(s) amputation status,Candidiasis of vulva and vagina,Other and unspecified infection due to central venous catheter,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other specified disorders resulting from impaired renal function'}


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, abdominal pain

PRESENT ILLNESS: patient is a 71 y/o F with PMH of ESRD on HD, recent broncial
hemorrhage, respiratory failure with trach, hx of multiple GI
bleeds, nonresponsive at baseline presenting from [**Hospital **] rehab
with coffee ground emesis and fever.

MEDICAL HISTORY: 1)ESRD on HD of unclear etiology.
2)Respiratory failure s/p trach in [**2-11**], vent dependent until
[**1-11**] when she was successfully weaned
3)COPD
4)Chronic pleural effusions
5)Recurrent aspiration PNA
6)PVD, s/p R CEA, s/p bilateral iliac stents and gangrene of
toes bilaterally and autoamputating
7)HTN
8)Hypothyroidism
9)h/o GI bleeding
10)CHF no previous echo here, so unclear [**Name2 (NI) **]
11)h/o Cholesterol emboli syndrome
12)Paroxysmal AF
13)Anemia
14)s/p multiple embolic CVA
[**95**])Dementia
16)Adenocarcinoma of the colon s/p resection in [**2186**]
17)hx of C.diff colitis
18)Sepsis [**3-8**] to PNA d/c'd from MICU [**2188-6-25**]

MEDICATION ON ADMISSION: Tylenol, alumnium hydroxide 45ML per gtube, B12 1', colace,
Fluticasone proprionate, Folic acid, Heparin 2500 q12h,
dilauded 0.75mg PO at dialysis, Levothyroxine 200', Lidoderm 5%
2 patch once a dat topically, Nystatin 5mL QID, albterol q6h
nebs, Dulcolax 10PRN, Iartroprium q6hours, Zofran 4 TID

ALLERGIES: Proxy[**Name (NI) 67216**] / Caffeine / Butalbital / Barbiturates / Xanthines

PHYSICAL EXAM: vitals: T100.2 BP 93/39 P83 RR 19-28 98-100% on CPAP 50%
gen: resting, nad
pulm: diminished BS, no w/r/r
cv: hrrr, no m/r/g
abd: diffuse TTP, firm. hypoactive BS.
extr: multiple amputated toes, gangrene. No edema.

FAMILY HISTORY: Her parents lived until old age. One brother died of an MI in
his 60s. Another brother with schizophrenia. Son with
hypothyroidism.

SOCIAL HISTORY: # Personal: Lives at [**Hospital 100**] Rehab MACU. Divorced. Three adult
children. Son [**Name (NI) **] is her HCP and is very involved
# Tobacco: Former smoker. 3 packs per day x 13 years.
# Alcohol: Occasional past use. 

### Response:
{'Other specified septicemias,Septic shock,Acute vascular insufficiency of intestine,End stage renal disease,Unspecified pleural effusion,Kidney replaced by transplant,Intestinal infection due to Clostridium difficile,Ventilator associated pneumonia,Compression of vein,Acidosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Pneumonia due to Pseudomonas,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Severe sepsis,Renal dialysis status,Tracheostomy status,Gastrostomy status,Chronic airway obstruction, not elsewhere classified,Atrial fibrillation,Other toe(s) amputation status,Candidiasis of vulva and vagina,Other and unspecified infection due to central venous catheter,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other specified disorders resulting from impaired renal function'}
