CHIEF COMPLAINT: Chief Complaint: AMS
.
Reason for MICU transfer: Septic shock

PRESENT ILLNESS: History is limited as pt is not able to communicate with us on
arrival. Mrs. [**Known lastname 99445**] is a [**Age over 90 **]F w/ sign PMH for a.fib, dementia,
frequent UTIs was found slumped in chair by aide at home.
Unclear time frame of events as her aide did not accompany her
to the ED. On EMS arrival they found the pt breathing
spontaneously and minimally responsive able to follow simple
commands. She was not able to answer questions at that time. At
baseline she is known to have dementia, but is usually able to
have a conversation with intermittent confusion.
.
In the ED inital vitals were, 104.2 ??????F(Rectal), Pulse: 73, RR:
22, BP: 100/54, Rhythm: Sinus Arrythmia (w/ frequent PACs),
O2Sat: 98, O2Flow: 4lnc. She was noted to have food in her
mouth. Her labs were notable for WBC 15.6 q/ 86.5%PMNs, Cr of
1.2, lactate 2.0 and a grossly purulent UA. A CXR was obtained
which showed a RLL consolidation. She was given 3L IVF while
still becoming hypotensive. A central line was placed and
norepinephrine was started. She was given Vanc/Cefepime in the
ED.
.
On arrival to the ICU, the pt was not responding to questions,
off O2 and sating in the low 90s on RA. She was requiring
Norepinephrine to maintain her BP in low 100s.
.
Review of systems:
Not able to obtain due to MS

MEDICAL HISTORY: - CAD - s/p MI [**00**] years ago
- CHF - last ECHO [**6-/2191**] 55%
- Atrial fibrillation
- Chronic venous stasis with b/l lower extremity edema
- Constipation
- orthostatic hypotension
- trigeminal zoster
- s/p Hernia repair
- s/p appy
- Degenerative disc disease

MEDICATION ON ADMISSION: Citalopram 10mg daily
Donepezil 10mg daily
Furosemide 20mg daily
Gabapentin 200mg TID
Omeprazole 20mg daily
Venlafaxine 75mg [**Hospital1 **]
Folic Acid

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Physical Exam:
Vitals: T:97.4 BP:104/45 P:65 R:17 O2:93%RA
General: obtunded, not responding to commands, with drawal to
pain
HEENT: Sclera anicteric, dry MM, oropharynx clear, L pupil 3mm,
R pupil 2mm both sluggishly reactive
Neck: supple, no LAD
Lungs: on anterior exam Clear to auscultation bilaterally, no
wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, minimally tender over suprapubic area as pt
responded to pain, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU: foley
Ext: cool LE, 1+ pulses, no clubbing, cyanosis, 2+ edema to mid
calf

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives in [**Location **] with husband. Lives with health aid and
husband who is demented. Has two children, both of whom live in
[**State 531**], and three grandchildren. She used to smoke a PPD for
40 [**State 1686**] stopped roughly 20 [**State 1686**] ago. Daily glass of wine. No other
drugs.
Septicemia due to escherichia coli [E. coli],Septic shock,Urinary tract infection, site not specified,Acute kidney failure, unspecified,Chronic diastolic heart failure,Pulmonary collapse,Severe sepsis,Atrial fibrillation,Depressive disorder, not elsewhere classified,Coronary atherosclerosis of native coronary artery,Dementia, unspecified, without behavioral disturbance,Venous (peripheral) insufficiency, unspecified,Other constipation,Do not resuscitate status,Personal history of tobacco use,Encounter for palliative care
E coli septicemia,Septic shock,Urin tract infection NOS,Acute kidney failure NOS,Chr diastolic hrt fail,Pulmonary collapse,Severe sepsis,Atrial fibrillation,Depressive disorder NEC,Crnry athrscl natve vssl,Demen NOS w/o behv dstrb,Venous insufficiency NOS,Constipation NEC,Do not resusctate status,History of tobacco use,Encountr palliative care
Admission Date:  [**2193-3-17**]              Discharge Date:   [**2193-3-22**]


Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Chief Complaint: AMS
.
Reason for MICU transfer: Septic shock


Major Surgical or Invasive Procedure:
Central line placement [**2193-3-13**]


History of Present Illness:
History is limited as pt is not able to communicate with us on
arrival. Mrs. [**Known lastname 99445**] is a [**Age over 90 **]F w/ sign PMH for a.fib, dementia,
frequent UTIs was found slumped in chair by aide at home.
Unclear time frame of events as her aide did not accompany her
to the ED. On EMS arrival they found the pt breathing
spontaneously and minimally responsive able to follow simple
commands. She was not able to answer questions at that time. At
baseline she is known to have dementia, but is usually able to
have a conversation with intermittent confusion.
.
In the ED inital vitals were, 104.2 ??????F(Rectal), Pulse: 73, RR:
22, BP: 100/54, Rhythm: Sinus Arrythmia (w/ frequent PACs),
O2Sat: 98, O2Flow: 4lnc. She was noted to have food in her
mouth. Her labs were notable for WBC 15.6 q/ 86.5%PMNs, Cr of
1.2, lactate 2.0 and a grossly purulent UA. A CXR was obtained
which showed a RLL consolidation. She was given 3L IVF while
still becoming hypotensive. A central line was placed and
norepinephrine was started. She was given Vanc/Cefepime in the
ED.
.
On arrival to the ICU, the pt was not responding to questions,
off O2 and sating in the low 90s on RA. She was requiring
Norepinephrine to maintain her BP in low 100s.
.
Review of systems:
Not able to obtain due to MS


Past Medical History:
- CAD - s/p MI [**00**] years ago
- CHF - last ECHO [**6-/2191**] 55%
- Atrial fibrillation
- Chronic venous stasis with b/l lower extremity edema
- Constipation
- orthostatic hypotension
- trigeminal zoster
- s/p Hernia repair
- s/p appy
- Degenerative disc disease


Social History:
Lives in [**Location **] with husband. Lives with health aid and
husband who is demented. Has two children, both of whom live in
[**State 531**], and three grandchildren. She used to smoke a PPD for
40 [**State 1686**] stopped roughly 20 [**State 1686**] ago. Daily glass of wine. No other
drugs.


Family History:
NC

Physical Exam:
Physical Exam:
Vitals: T:97.4 BP:104/45 P:65 R:17 O2:93%RA
General: obtunded, not responding to commands, with drawal to
pain
HEENT: Sclera anicteric, dry MM, oropharynx clear, L pupil 3mm,
R pupil 2mm both sluggishly reactive
Neck: supple, no LAD
Lungs: on anterior exam Clear to auscultation bilaterally, no
wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, minimally tender over suprapubic area as pt
responded to pain, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU: foley
Ext: cool LE, 1+ pulses, no clubbing, cyanosis, 2+ edema to mid
calf

Discharge Exam:
VS- T 97.7 BP 127/67 HR 62 RR 22 O2 96%RA
CV- regular rate and rhythm, normal S1/S2, no m/r/g appreciated
Lungs- improved air movement bilaterally, no wheezes
Abd- +BS, soft, nontender, nondistended
Ext- WWP, 2+ edema to knee bilaterally, no cyanosis
Skin- skin tear in subclavian area on right, and left lower leg,
both well covered with mepilex, hyperpigmentation of lower
extremities, multiple areas of ecchymosis.
Neuro- A+Ox1, strength 4/5 bilaterally in u/l extremities


Pertinent Results:
PERTINENT LABS:
[**2193-3-17**] 05:00PM BLOOD WBC-15.6* RBC-4.51 Hgb-13.1 Hct-41.6
MCV-92 MCH-29.1 MCHC-31.5 RDW-14.6 Plt Ct-231
[**2193-3-17**] 09:26PM BLOOD WBC-19.6* RBC-4.30 Hgb-12.8 Hct-39.5
MCV-92 MCH-29.7 MCHC-32.3 RDW-14.5 Plt Ct-285
[**2193-3-18**] 04:50AM BLOOD WBC-16.2* RBC-4.00* Hgb-11.9* Hct-37.4
MCV-94 MCH-29.6 MCHC-31.7 RDW-14.6 Plt Ct-247
[**2193-3-19**] 04:07AM BLOOD WBC-10.0 RBC-4.14* Hgb-12.0 Hct-38.0
MCV-92 MCH-29.0 MCHC-31.5 RDW-14.6 Plt Ct-241
[**2193-3-17**] 05:00PM BLOOD Neuts-86.5* Lymphs-8.6* Monos-4.3 Eos-0.3
Baso-0.4
[**2193-3-17**] 09:26PM BLOOD Neuts-82.6* Lymphs-11.6* Monos-4.9
Eos-0.5 Baso-0.3
[**2193-3-18**] 04:50AM BLOOD Neuts-84.5* Lymphs-9.2* Monos-5.8 Eos-0.3
Baso-0.2
[**2193-3-17**] 05:00PM BLOOD PT-14.1* PTT-35.2 INR(PT)-1.3*
[**2193-3-17**] 05:00PM BLOOD Glucose-126* UreaN-24* Creat-1.2* Na-139
K-3.8 Cl-105 HCO3-25 AnGap-13
[**2193-3-17**] 05:00PM BLOOD ALT-13 AST-26 AlkPhos-88 TotBili-0.5
[**2193-3-17**] 05:00PM BLOOD cTropnT-<0.01
[**2193-3-18**] 04:50AM BLOOD CK-MB-3 cTropnT-0.02*
[**2193-3-17**] 05:00PM BLOOD Albumin-2.2* Calcium-8.3* Phos-3.5 Mg-1.9
[**2193-3-18**] 04:50AM BLOOD TSH-1.1
[**2193-3-17**] 09:10PM BLOOD freeCa-1.12
[**2193-3-17**] 05:14PM BLOOD Lactate-2.0
[**2193-3-17**] 09:10PM BLOOD Lactate-0.6
[**2193-3-17**] 06:00PM URINE Color-DkAmb Appear-Cloudy Sp [**Last Name (un) **]-1.013
[**2193-3-17**] 06:00PM URINE Blood-SM  Nitrite-POS Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
[**2193-3-17**] 06:00PM URINE RBC->182* WBC->182* Bacteri-FEW
Yeast-NONE Epi-0
[**2193-3-17**] 06:00PM URINE WBC Clm-OCC Mucous-MANY
[**2193-3-17**] 09:52PM URINE Hours-RANDOM UreaN-368 Creat-79 Na-50
K-57 Cl-67

Microbiology:
Blood culture [**2193-3-17**]- pending, NGTD
Blood culture [**2193-3-17**]- STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Urine culture [**2193-3-17**]- MIXED BACTERIAL FLORA ( >= 3 COLONY
TYPES), CONSISTENT WITH FECAL CONTAMINATION
Blood culture [**3-18**]- pending, NGTD
Blood culture [**3-19**]- pending NGTD

Imaging:
CHEST (PORTABLE AP) Study Date of [**2193-3-17**] 4:36 PM
No definite acute disease aside from patchy basilar opacities
suggestive of minor atelectasis.

CT HEAD W/O CONTRAST Study Date of [**2193-3-17**] 4:38 PM
No evidence of acute intracranial process; age-related atrophic
change and chronic small vessel ischemic disease. Focus of
chronic mastoid inflammation on the right.

CHEST (PORTABLE AP) Study Date of [**2193-3-17**] 7:08 PM
AP chest compared to [**3-17**] at 4:29 p.m.:
Tip of the new right internal jugular line projects over the mid
SVC. No
pneumothorax, mediastinal widening. A small, likely right
pleural effusion is unchanged since preceding line placement.
Opacification at the left lung base is new, probably due to
atelectasis, which is much milder but increased at the right
base as well.

CXR [**3-19**]-
Right internal jugular line is at the level of mid SVC. Heart
size and
mediastinum appear unchanged. There is unchanged left lower lobe

consolidation, that might reflect atelectasis, but pneumonia
cannot be
excluded. Mild vascular engorgement is noted and bilateral
pleural effusion is most likely present.

CXR [**3-20**]- The right IJ catheter has been removed. There are low
lung volumes and bibasilar atelectasis. There is no pulmonary
vascular congestion. The cardiomediastinal silhouette is not
well visualized. There is no confluent opacification. A pleural
effusion cannot be excluded.

Brief Hospital Course:
Mrs. [**Known lastname 99445**] is a [**Age over 90 **] yo F w/ significant hx of CAD, dementia and
multiple UTIs in the past presents to the ED with leukocytosis,
fever to 104 and altered mental status consistent with severe
sepsis.

# Septic Shock- She met this definition on arrival with
leukocytosis, febrile to 104 with altered mental status, acute
kidney injury and requiring pressors to maintain a perfusion
pressure. She had an overwhelmingly positive U/A on admission.
Prior urine cultures showed pan sensitive E.coli sensitive to
Ceftriaxone. She also was initially covered for community
acquired pneumonia with Vancomycin, Ceftriaxone and Azithromycin
as initally a respiratory source could not be ruled out,
however, with repeat CXRs and lack of respiratory symptoms, this
seem less likely so azithromycin was discontinued. She was given
IVF boluses for hypotension and was able to be weaned off
pressor support within hours of admission to the ICU. Her mental
status also improved quickly. By the next morning she was awake
and alert back to her baseline mental status.
    [**12-12**] blood cultures positive for GPCs in clusters, however
this was presumed to be a contaminant, and vancomycin was also
discontinued.  Urine cultures showed contamination.  Ceftriaxone
was transitioned to ciprofloxacin prior to discharge for planned
7 day course to treat UTI, ending [**2193-3-24**].
    Blood pressure remained stable throughout the remainder of
admission.

# [**Last Name (un) **]- BUN/Cr elevated on admission to 1.2 from baseline of
0.9-1.0. Urine lytes were consistent with a pre-renal etiology.
Her kidney function improved after IVF resuscitation. We
continued to treat her UTI with Ceftriaxone to complete a 7 day
course as above.  Creatinine remained at baseline for remainder
of admission.

# Atrial fibrillation with rapid ventricular response- Patient
in atrial fibrillation throughout ICU admission.  She has known
atrial fibrillation, and has not been on coumadin.  On arrival
to the floor, she developed rapid ventricular response, likely
triggered by sundowning, and perhaps over diuresis.  She
responded well to 30mg po diltiazem every 6 hours, and converted
to sinus rhythm.  She was continued on diltiazem XR 120mg po
daily on discharge to ensure that she remain in sinus rhythm.
However, this medication can be weaned if patient remains in
sinus rhythm.

# LE Edema- Patient chronically has bilateraly lower extremity
edema. Most recent echo showed preserved EF and no evidence of
diastolic dysfunction. Once she became hemodynamically stable,
she was restarted on home furosemide 20mg daily.

# [**Name (NI) **] pt has hx of prior MI in [**2170**]. She was admitted for chest
pain in [**12-19**] and was ruled out at that time. She was ruled out
for ACS with negative CE.Her EKG was unchanged from prior which
shows old RBBB and no evidence of acute ischemia.

# Altered Mental status- Patient was altered on arrival in
setting of septic shock.  She is alert, oriented to person only
at baseline. CT head obtained in the ED did not show an organic
cause for her AMS. She quickly became more alert after
initiation of antibiotics and IVF administration.
   On transfer to the floor, patient developed delerium with
poor attention.  She was given zyprexa 2.5mg qHS with good
results.  Donepezil was restarted on transfer to floor.  We
recommend continuing zyprexa on an as needed basis for agitation
at home.
   Gabapentin was held in setting of waxing/[**Doctor Last Name 688**] mental
status.

# Depression- Continued venlafaxine and citalopram

# Goals of care- Palliative care initiated discussions with
patient and family during admission.  Decision was made for no
further ICU transfers, but ok to hospitalize.  Family was still
considering hospice at time of discharge.  DNR/DNI paperwork was
completed.

# Transitional issues-
- please follow weights, weight on day of discharge 122.8lbs
- delerium is ongoing; improved with zyprexa 2.5mg po qHS
- ciprofloxacin to continue through [**2193-3-24**]
- blood cultures pending at time of discharge
- gabapentin held at time of discharge; should be restarted once
mental status stabilizes.
- DNR/DNI paperwork completed
- Family still considering hospice

Medications on Admission:
Citalopram 10mg daily
Donepezil 10mg daily
Furosemide 20mg daily
Gabapentin 200mg TID
Omeprazole 20mg daily
Venlafaxine 75mg [**Hospital1 **]
Folic Acid


Discharge Medications:
1. citalopram 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
2. venlafaxine 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day).
3. donepezil 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at
bedtime).
4. furosemide 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).

5. olanzapine 2.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at
bedtime) as needed for agitation/sundowning.
Disp:*15 Tablet(s)* Refills:*0*
6. diltiazem HCl 120 mg Capsule, Extended Release [**Hospital1 **]: One (1)
Capsule, Extended Release PO DAILY (Daily).
Disp:*30 Capsule, Extended Release(s)* Refills:*0*
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. folic acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
9. senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
Disp:*60 Tablet(s)* Refills:*0*
10. docusate sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1)  PO BID (2
times a day) as needed for constipation.
Disp:*60 * Refills:*0*
11. ciprofloxacin 250 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
Disp:*5 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary diagnosis:
# Septic shock
# Urinary tract infection
# Atrial fibrillation with rapid ventricular response

Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).

Discharge Instructions:
It was a pleasure taking care of you during your recent
admission.  You were admitted with altered mental status,
thought to be due to an infection in your urinary tract.  You
were given IV antibiotics and improved.

In addition, your heart was in an abnormal rhythm beating very
fast.  With medications, your heart went into a normal rhythm.

The following changes were made to your medication regimen:
- START ciprofloxacin twice a day through [**2193-3-24**]
- START diltiazem ER once a day
- STOP gabapentin 200mg three times day, restart once mental
status is stabilized
- for agitation at night, you can take one zyprexa
- for constipation, you should take senna and colace as
prescribed

Followup Instructions:
Department: [**State **]When: WEDNESDAY [**2193-3-27**] at 10:00 AM
With: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 6564**], MD [**Telephone/Fax (1) 2205**]
Building: [**State **] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS     Best Parking: On Street Parking
{'Septicemia due to escherichia coli [E. coli],Septic shock,Urinary tract infection, site not specified,Acute kidney failure, unspecified,Chronic diastolic heart failure,Pulmonary collapse,Severe sepsis,Atrial fibrillation,Depressive disorder, not elsewhere classified,Coronary atherosclerosis of native coronary artery,Dementia, unspecified, without behavioral disturbance,Venous (peripheral) insufficiency, unspecified,Other constipation,Do not resuscitate status,Personal history of tobacco use,Encounter for palliative care'}


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: Chief Complaint: AMS
.
Reason for MICU transfer: Septic shock

PRESENT ILLNESS: History is limited as pt is not able to communicate with us on
arrival. Mrs. [**Known lastname 99445**] is a [**Age over 90 **]F w/ sign PMH for a.fib, dementia,
frequent UTIs was found slumped in chair by aide at home.
Unclear time frame of events as her aide did not accompany her
to the ED. On EMS arrival they found the pt breathing
spontaneously and minimally responsive able to follow simple
commands. She was not able to answer questions at that time. At
baseline she is known to have dementia, but is usually able to
have a conversation with intermittent confusion.
.
In the ED inital vitals were, 104.2 ??????F(Rectal), Pulse: 73, RR:
22, BP: 100/54, Rhythm: Sinus Arrythmia (w/ frequent PACs),
O2Sat: 98, O2Flow: 4lnc. She was noted to have food in her
mouth. Her labs were notable for WBC 15.6 q/ 86.5%PMNs, Cr of
1.2, lactate 2.0 and a grossly purulent UA. A CXR was obtained
which showed a RLL consolidation. She was given 3L IVF while
still becoming hypotensive. A central line was placed and
norepinephrine was started. She was given Vanc/Cefepime in the
ED.
.
On arrival to the ICU, the pt was not responding to questions,
off O2 and sating in the low 90s on RA. She was requiring
Norepinephrine to maintain her BP in low 100s.
.
Review of systems:
Not able to obtain due to MS

MEDICAL HISTORY: - CAD - s/p MI [**00**] years ago
- CHF - last ECHO [**6-/2191**] 55%
- Atrial fibrillation
- Chronic venous stasis with b/l lower extremity edema
- Constipation
- orthostatic hypotension
- trigeminal zoster
- s/p Hernia repair
- s/p appy
- Degenerative disc disease

MEDICATION ON ADMISSION: Citalopram 10mg daily
Donepezil 10mg daily
Furosemide 20mg daily
Gabapentin 200mg TID
Omeprazole 20mg daily
Venlafaxine 75mg [**Hospital1 **]
Folic Acid

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Physical Exam:
Vitals: T:97.4 BP:104/45 P:65 R:17 O2:93%RA
General: obtunded, not responding to commands, with drawal to
pain
HEENT: Sclera anicteric, dry MM, oropharynx clear, L pupil 3mm,
R pupil 2mm both sluggishly reactive
Neck: supple, no LAD
Lungs: on anterior exam Clear to auscultation bilaterally, no
wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, minimally tender over suprapubic area as pt
responded to pain, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU: foley
Ext: cool LE, 1+ pulses, no clubbing, cyanosis, 2+ edema to mid
calf

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives in [**Location **] with husband. Lives with health aid and
husband who is demented. Has two children, both of whom live in
[**State 531**], and three grandchildren. She used to smoke a PPD for
40 [**State 1686**] stopped roughly 20 [**State 1686**] ago. Daily glass of wine. No other
drugs. 

### Response:
{'Septicemia due to escherichia coli [E. coli],Septic shock,Urinary tract infection, site not specified,Acute kidney failure, unspecified,Chronic diastolic heart failure,Pulmonary collapse,Severe sepsis,Atrial fibrillation,Depressive disorder, not elsewhere classified,Coronary atherosclerosis of native coronary artery,Dementia, unspecified, without behavioral disturbance,Venous (peripheral) insufficiency, unspecified,Other constipation,Do not resuscitate status,Personal history of tobacco use,Encounter for palliative care'}
