CHIEF COMPLAINT: sepsis, PNA

PRESENT ILLNESS: Pt is a 67 yo m with ESRD (on HD MWF), ESLD [**2-8**] polycystic liver
disease who presented to [**Location (un) **] after 3 days of myalgias,
cough, SOB, and not able to get out of bed. He had been in his
USOH prior to this. At OSH, T 101.3, he was noted to have CXR
with LLL pna and received levaquin and 250cc IVF. At that time,
SBP 70-90's with normal BP 100's.
.
He was transferred to [**Hospital1 18**] due to bed shortages at OSH. In [**Hospital1 **]
ED, T98.7; HR 120-130's; BP 63-77/50's; RR89% RA and 100% NRB.
Lactate 1.3. Given low BP, a CVL was sterilely placed and he was
started on levophed. CVP was 15 once levophed on board. EKG with
afib and lateral ST depressions. He also received a dose of
clindamycin in ED.
.
Upon arrival to ICU, he is currently feeling comfortable in no
distress. he denies any chest pain, SOB, pleuritic pain,
abdominal pain, or any other symptoms. He does note that for
past few days he had orthopnea, which is new for him. Per his
wife, last week he also had one episode of severe lower
abdominal pain. he went to HD at that time and there was some
concern for a ruptured liver cyst; however, his wife does not
think he had any imaging at that time. This pain has since
resolved.

MEDICAL HISTORY: - atrial fibrillation
- ESRD: on HD, MWF
- ESLD: never had paracentesis
- s/p colectomy and ileostomy in place
- s/p parathyroidectomy
- hx of ? MI and arrhythmia requiring defibrillation (per wife)

MEDICATION ON ADMISSION: Warfarin 5 mg M/W/F/Sun; 4mg T/Th/Sat
Digoxin 0.125 daily
lomotil 0.25 daily prn
nephrocaps 2 daily
colchicine 0.6 daily
tums
folic acid
oxycodone QHS
neurontin 200 mg QHS

ALLERGIES: Penicillins / Enalapril

PHYSICAL EXAM: PE: 96.7  115-140's  101/72  25  97% NRB
Gen:  NAD, in very mild resp distress, but otherwise fairly
comfortable
HEENT: PERRL, Clear OP, MMM
NECK: Supple, No LAD, JVP difficult to assess as RIJ in place
CV: tachy, irreg, irreg; difficult to auscultate murmurs
LUNGS: CTA ant and laterally
ABD: Soft, area of hard, cystic masses on R
EXT: No edema. 2+ DP pulses BL. fistula in left with palp thrill

FAMILY HISTORY: Mother: d. pancreatic ca
Father: d. MI age 65
Brother: brain tumor
Sisters: DM

SOCIAL HISTORY: Married, retired printer
Smoking: quit 15 yrs ago, but prior has 80 pack year (5ppd since
age 8 until 50's)
EtOH: none for many years
Illicits: none
Septicemia due to hemophilus influenzae [H. influenzae],Pneumonia due to Hemophilus influenzae [H. influenzae],End stage renal disease,Septic shock,Congenital cystic disease of liver,Acute and subacute necrosis of liver,Pulmonary collapse,Acidosis,Paralytic ileus,Severe sepsis,Atrial fibrillation,Ileostomy status,Other sequelae of chronic liver disease,Chronic airway obstruction, not elsewhere classified,Obstructive sleep apnea (adult)(pediatric),Other chronic pulmonary heart diseases,Venous (peripheral) insufficiency, unspecified,Diverticulosis of colon (without mention of hemorrhage),Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Thrombocytopenia, unspecified
H. influenae septicemia,H.influenzae pneumonia,End stage renal disease,Septic shock,Cong cystic liver dis,Acute necrosis of liver,Pulmonary collapse,Acidosis,Paralytic ileus,Severe sepsis,Atrial fibrillation,Ileostomy status,Oth sequela, chr liv dis,Chr airway obstruct NEC,Obstructive sleep apnea,Chr pulmon heart dis NEC,Venous insufficiency NOS,Dvrtclo colon w/o hmrhg,Cholelithiasis NOS,Thrombocytopenia NOS
Admission Date:  [**2200-4-6**]              Discharge Date:   [**2200-4-17**]

Date of Birth:  [**2133-2-23**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Enalapril

Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
sepsis, PNA

Major Surgical or Invasive Procedure:
CVVH line placement, Left femoral vein
Intubation

History of Present Illness:
Pt is a 67 yo m with ESRD (on HD MWF), ESLD [**2-8**] polycystic liver
disease who presented to [**Location (un) **] after 3 days of myalgias,
cough, SOB, and not able to get out of bed. He had been in his
USOH prior to this. At OSH, T 101.3, he was noted to have CXR
with LLL pna and received levaquin and 250cc IVF. At that time,
SBP 70-90's with normal BP 100's.
.
He was transferred to [**Hospital1 18**] due to bed shortages at OSH. In [**Hospital1 **]
ED, T98.7; HR 120-130's; BP 63-77/50's; RR89% RA and 100% NRB.
Lactate 1.3. Given low BP, a CVL was sterilely placed and he was
started on levophed. CVP was 15 once levophed on board. EKG with
afib and lateral ST depressions. He also received a dose of
clindamycin in ED.
.
Upon arrival to ICU, he is currently feeling comfortable in no
distress. he denies any chest pain, SOB, pleuritic pain,
abdominal pain, or any other symptoms. He does note that for
past few days he had orthopnea, which is new for him. Per his
wife, last week he also had one episode of severe lower
abdominal pain. he went to HD at that time and there was some
concern for a ruptured liver cyst; however, his wife does not
think he had any imaging at that time. This pain has since
resolved.


Past Medical History:
- atrial fibrillation
- ESRD: on HD, MWF
- ESLD: never had paracentesis
- s/p colectomy and ileostomy in place
- s/p parathyroidectomy
- hx of ? MI and arrhythmia requiring defibrillation (per wife)

Social History:
Married, retired printer
Smoking: quit 15 yrs ago, but prior has 80 pack year (5ppd since
age 8 until 50's)
EtOH: none for many years
Illicits: none

Family History:
Mother: d. pancreatic ca
Father: d. MI age 65
Brother: brain tumor
Sisters: DM

Physical Exam:
PE: 96.7  115-140's  101/72  25  97% NRB
Gen:  NAD, in very mild resp distress, but otherwise fairly
comfortable
HEENT: PERRL, Clear OP, MMM
NECK: Supple, No LAD, JVP difficult to assess as RIJ in place
CV: tachy, irreg, irreg; difficult to auscultate murmurs
LUNGS: CTA ant and laterally
ABD: Soft, area of hard, cystic masses on R
EXT: No edema. 2+ DP pulses BL. fistula in left with palp thrill

SKIN: No lesions
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**1-8**]+ reflexes,
equal BL. Normal coordination.

Pertinent Results:
[**2200-4-6**] 11:25AM BLOOD WBC-10.4# RBC-3.55* Hgb-11.1* Hct-35.0*
MCV-99* MCH-31.2 MCHC-31.6 RDW-15.5 Plt Ct-158
[**2200-4-6**] 11:25AM BLOOD Neuts-93.8* Bands-0 Lymphs-3.5* Monos-2.3
Eos-0.2 Baso-0.1
[**2200-4-6**] 11:25AM BLOOD PT-27.1* PTT-43.3* INR(PT)-2.7*
[**2200-4-7**] 12:32AM BLOOD Fibrino-366
[**2200-4-6**] 11:25AM BLOOD Glucose-74 UreaN-41* Creat-6.5*# Na-135
K-5.6* Cl-97 HCO3-24 AnGap-20
[**2200-4-6**] 11:25AM BLOOD ALT-8 AST-10 CK(CPK)-158 AlkPhos-82
Amylase-57 TotBili-1.8*
[**2200-4-8**] 12:00AM BLOOD ALT-1710* AST-3118* LD(LDH)-2352*
AlkPhos-88 TotBili-2.8*
[**2200-4-9**] 04:04AM BLOOD ALT-1311* AST-1089* LD(LDH)-588*
AlkPhos-100 TotBili-3.2*
[**2200-4-10**] 09:52AM BLOOD ALT-859* AST-547* LD(LDH)-400*
AlkPhos-102 TotBili-3.4*
.
RADS

TTE [**4-6**]
The left atrium is markedly dilated. The right atrium is
markedly dilated. The left ventricular cavity is unusually
small. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function appears mildly depressed (LVEF= 50%), but
could not be fully evaluated because of technical limitations.
The right ventricular cavity is moderately dilated with severe
global free wall hypokinesis. There is abnormal septal
motion/position. The number of aortic valve leaflets cannot be
determined. The mitral valve leaflets are mildly thickened.
Tricuspid regurgitation is present but cannot be quantified.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.

IMPRESSION: Dilated right ventricle with severe RV systolic
dysfunction. Probable mild left ventricular systolic
dysfunction. Heavily calcified valves.

If clinically indicated, a full transthoracic study with Doppler
is recommended.
.
TTE [**4-7**]
The left ventricle is not well seen. The left ventricular cavity
is unusually small. Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is mildly depressed (LVEF= 45-50
%). The right ventricular cavity is moderately dilated with
severe global free wall hypokinesis. There is abnormal septal
motion/position. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension.

Compared with the prior study (images reviewed) of [**2200-4-6**],
the image quality is no better. The estimated pulmonary artery
systolic pressure is slightly lower but is probably unreliable
given poor image quality. The other findings are similar.
.
CTA [**4-7**]

IMPRESSION:
1. No evidence of pulmonary embolism.
2. Cardiomegaly with prominence of the right heart and
enlargement of the
main pulmonary artery suggestive of pulmonary hypertension.
3. Right lower lobe consolidation/volume loss. Left lower lobe
with
consolidation or volume loss and occluded left lower bronchus.
4. Diffuse emphysematous changes.
5. Small bilateral pleural effusions. Ascites. Anasarca.
6. Massively enlarged multicystic liver. Status post bilateral
nephrectomy.
7. Cystic changes in both femoral heads and acetabula.
Differential includes
changes secondary to secondary hyperparathyroidism. Comparison
is recommended
with old studies if available.
8. Mediastinal nodes, largest measuring 16mm.
9. Sigmoid diverticulosis without definite evidence of
diverticulitis.
10. Cholelithiasis without definite evidence of cholecystitis.
11. Right lower quadrant diverting ileostomy. No evidence of
obstruction.
12. NG tube and ET tube in proper placement.


Brief Hospital Course:
The patient is a 67 y/o M hx of ESRD on HD and ESLD [**2-8**]
polycystic liver/kindey disease who presented after 3 days of
myalgians, fever, cough, new infiltrate on CXR and hypotension
requiring pressors.

Brief Course:

He was transferred here on [**2200-4-6**] [**2-8**] bed shortages at OSH. He
arrived and was
stable but developed A fib to 140s and decompensated requiring
intubation, his AF was eventually controlled with amiodarone
bolus and drip as well as esmolol. Pt was found with influenza
A, c/b VAP. He was successfully extubated, but had persistent
oxygen requirement.  He was continued on broad spectrum
antibiotics for possible VAP. He was found to have severe RV
dilation and hypokinesis.  He was initiated on CVVH for fluid
overload which resulted initially in improved blood pressures.
He tolerated weaning from three pressors to one.
Throughout his hospitalization he had persistent pressor
requirement despite negative blood and sputum cultures.
In setting of patients grim overall prognosis a palliative care
consult was initiated to assist the family with end of life care
and transition to CMO status.  The patient was made CMO on [**4-17**],
pressors and CVVH were discontinued and expired shortly
thereafter.

Medications on Admission:
Warfarin 5 mg M/W/F/Sun; 4mg T/Th/Sat
Digoxin 0.125 daily
lomotil 0.25 daily prn
nephrocaps 2 daily
colchicine 0.6 daily
tums
folic acid
oxycodone QHS
neurontin 200 mg QHS

Discharge Medications:
expired

Discharge Disposition:
Expired

Discharge Diagnosis:
Expired

Discharge Condition:
Expired

Discharge Instructions:
Expired

Followup Instructions:
Expired
{'Septicemia due to hemophilus influenzae [H. influenzae],Pneumonia due to Hemophilus influenzae [H. influenzae],End stage renal disease,Septic shock,Congenital cystic disease of liver,Acute and subacute necrosis of liver,Pulmonary collapse,Acidosis,Paralytic ileus,Severe sepsis,Atrial fibrillation,Ileostomy status,Other sequelae of chronic liver disease,Chronic airway obstruction, not elsewhere classified,Obstructive sleep apnea (adult)(pediatric),Other chronic pulmonary heart diseases,Venous (peripheral) insufficiency, unspecified,Diverticulosis of colon (without mention of hemorrhage),Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Thrombocytopenia, unspecified'}


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: sepsis, PNA

PRESENT ILLNESS: Pt is a 67 yo m with ESRD (on HD MWF), ESLD [**2-8**] polycystic liver
disease who presented to [**Location (un) **] after 3 days of myalgias,
cough, SOB, and not able to get out of bed. He had been in his
USOH prior to this. At OSH, T 101.3, he was noted to have CXR
with LLL pna and received levaquin and 250cc IVF. At that time,
SBP 70-90's with normal BP 100's.
.
He was transferred to [**Hospital1 18**] due to bed shortages at OSH. In [**Hospital1 **]
ED, T98.7; HR 120-130's; BP 63-77/50's; RR89% RA and 100% NRB.
Lactate 1.3. Given low BP, a CVL was sterilely placed and he was
started on levophed. CVP was 15 once levophed on board. EKG with
afib and lateral ST depressions. He also received a dose of
clindamycin in ED.
.
Upon arrival to ICU, he is currently feeling comfortable in no
distress. he denies any chest pain, SOB, pleuritic pain,
abdominal pain, or any other symptoms. He does note that for
past few days he had orthopnea, which is new for him. Per his
wife, last week he also had one episode of severe lower
abdominal pain. he went to HD at that time and there was some
concern for a ruptured liver cyst; however, his wife does not
think he had any imaging at that time. This pain has since
resolved.

MEDICAL HISTORY: - atrial fibrillation
- ESRD: on HD, MWF
- ESLD: never had paracentesis
- s/p colectomy and ileostomy in place
- s/p parathyroidectomy
- hx of ? MI and arrhythmia requiring defibrillation (per wife)

MEDICATION ON ADMISSION: Warfarin 5 mg M/W/F/Sun; 4mg T/Th/Sat
Digoxin 0.125 daily
lomotil 0.25 daily prn
nephrocaps 2 daily
colchicine 0.6 daily
tums
folic acid
oxycodone QHS
neurontin 200 mg QHS

ALLERGIES: Penicillins / Enalapril

PHYSICAL EXAM: PE: 96.7  115-140's  101/72  25  97% NRB
Gen:  NAD, in very mild resp distress, but otherwise fairly
comfortable
HEENT: PERRL, Clear OP, MMM
NECK: Supple, No LAD, JVP difficult to assess as RIJ in place
CV: tachy, irreg, irreg; difficult to auscultate murmurs
LUNGS: CTA ant and laterally
ABD: Soft, area of hard, cystic masses on R
EXT: No edema. 2+ DP pulses BL. fistula in left with palp thrill

FAMILY HISTORY: Mother: d. pancreatic ca
Father: d. MI age 65
Brother: brain tumor
Sisters: DM

SOCIAL HISTORY: Married, retired printer
Smoking: quit 15 yrs ago, but prior has 80 pack year (5ppd since
age 8 until 50's)
EtOH: none for many years
Illicits: none 

### Response:
{'Septicemia due to hemophilus influenzae [H. influenzae],Pneumonia due to Hemophilus influenzae [H. influenzae],End stage renal disease,Septic shock,Congenital cystic disease of liver,Acute and subacute necrosis of liver,Pulmonary collapse,Acidosis,Paralytic ileus,Severe sepsis,Atrial fibrillation,Ileostomy status,Other sequelae of chronic liver disease,Chronic airway obstruction, not elsewhere classified,Obstructive sleep apnea (adult)(pediatric),Other chronic pulmonary heart diseases,Venous (peripheral) insufficiency, unspecified,Diverticulosis of colon (without mention of hemorrhage),Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Thrombocytopenia, unspecified'}
