CHIEF COMPLAINT: Pneumonia, sepsis

PRESENT ILLNESS: Mr. [**Known lastname 55406**] is a 58M with asplenia, anxiety/depression, s/p
[**Country **] dissection and L hemiparesis, who presents with 2-3 days
worsening productive cough, fever, and fatiuge. The patient was
in his usual state of health until the weekend when he noted
chest congestion, increasing productive cough, SOB and fatigue.
He denies any [**Last Name (LF) **], [**First Name3 (LF) **], sinus congestion, overt CP, n/v/d, rash,
or dysuria. He was so fatigued he tripped on his cat and fell,
without LOC. On sunday, he spiked a fever to 102. He denies sick
contacts or recent travel. He received his flu shot this year.
.
In the ED, VS T 103, HR 70, BP 108/52, RR 18, 95%NRB, 80s on RA.
The patient subsequently became tachy to 120s with BP 80s-90s.
Given 6L NS without improvement. RIJ was placed and started on
Levophed 0.06mcg/kg/min. ? PNA so given Levaquin but had
reaction. Changed to CTX/Azithro, and Vanco.

MEDICAL HISTORY: 1. Asplenia secondary to trauma incurred during Vietman, [**2144**],
pneumococcal vaccine given in [**2176**]. Does not remember if he
received H flu or meningococcus.
2. PTSD
3. ADHD
4. Depression/Anxiety
5. h/o Alcohol abuse
6. Migraine
7. Status post C5-C6 laminectomy and fusion several years ago by

MEDICATION ON ADMISSION: Amlodipine 2.5 mg Daily
Bupropion 200 mg qAM, 100mg qPM
Disulfiram 250 mg Daily
Gabapentin 600 mg qAM, 600mg qPM, 1200mg qHS
Ibuprofen 800 mg TID:PRN
Lisinopril 40 mg Daily
Methylphenidate 20 mg [**Hospital1 **]
Morphine [MS Contin] 30 mg [**Hospital1 **]
Nortriptyline 25-50 mg qHS:PRN
Oxycodone 5-10 mg q4-6 PRN
Aspirin 325 mg Daily

ALLERGIES: Levaquin

PHYSICAL EXAM: VS: T 98.8, 132/70, HR 104, RR 22, 97% NRB
Gen: Awake and alert but fatigued, talking in full sent over
mask
HEENT: EOMI, PERRL, anicteric sclera, MMM
Neck: supple, RIJ line intact, no LAD
Heart: Tachy ,regular, nl S1 S2 no m/r/g
Lungs: Coarse crackles heard bilat at bases
Abd: soft NT/ND +BS no rebound or guarding
Ext: warm well perfused,
Skin: R arm with scattered wheal, no bruising or ecchymoses
Neuro: CN II-XII intact, [**5-5**] strengh on R, [**3-5**] in L upper ext,
[**1-4**] in L lower ext, decreased sensation on L, preserved on R

FAMILY HISTORY: adopted

SOCIAL HISTORY: Married. 2 biologic and 1 adopted child. Works as a real estate
broker. Quit smoking a few years ago, former 1ppd. History of
alcohol abuse but no EtOH for 4 yrs. No drug use.
Unspecified septicemia,Methicillin susceptible pneumonia due to Staphylococcus aureus,Acute kidney failure, unspecified,Severe sepsis,Unspecified essential hypertension,Dysthymic disorder,Posttraumatic stress disorder
Septicemia NOS,Meth sus pneum d/t Staph,Acute kidney failure NOS,Severe sepsis,Hypertension NOS,Dysthymic disorder,Posttraumatic stress dis
Admission Date:  [**2183-3-24**]              Discharge Date:   [**2183-3-28**]

Date of Birth:  [**2124-11-17**]             Sex:   M

Service: MEDICINE

Allergies:
Levaquin

Attending:[**First Name3 (LF) 1828**]
Chief Complaint:
Pneumonia, sepsis

Major Surgical or Invasive Procedure:
None


History of Present Illness:
Mr. [**Known lastname 55406**] is a 58M with asplenia, anxiety/depression, s/p
[**Country **] dissection and L hemiparesis, who presents with 2-3 days
worsening productive cough, fever, and fatiuge. The patient was
in his usual state of health until the weekend when he noted
chest congestion, increasing productive cough, SOB and fatigue.
He denies any [**Last Name (LF) **], [**First Name3 (LF) **], sinus congestion, overt CP, n/v/d, rash,
or dysuria. He was so fatigued he tripped on his cat and fell,
without LOC. On sunday, he spiked a fever to 102. He denies sick
contacts or recent travel. He received his flu shot this year.
.
In the ED, VS T 103, HR 70, BP 108/52, RR 18, 95%NRB, 80s on RA.
The patient subsequently became tachy to 120s with BP 80s-90s.
Given 6L NS without improvement. RIJ was placed and started on
Levophed 0.06mcg/kg/min. ? PNA so given Levaquin but had
reaction. Changed to CTX/Azithro, and Vanco.


Past Medical History:
1. Asplenia secondary to trauma incurred during Vietman, [**2144**],
pneumococcal vaccine given in [**2176**]. Does not remember if he
received H flu or meningococcus.
2. PTSD
3. ADHD
4. Depression/Anxiety
5. h/o Alcohol abuse
6. Migraine
7. Status post C5-C6 laminectomy and fusion several years ago by

[**Doctor Last Name 1327**]
8. Diverticulitis, now status post partial colectomy
9. Multiple sharpnel injuries while in Vietmam, [**2142**] - NO MRI!!

10. Scrtoal Hematoma s/p R radical orchiectomy [**3-7**] with phantom
pain syndrome
11. Traumatic [**Country **] dissection with L hemiparesis [**11/2180**]


Social History:
Married. 2 biologic and 1 adopted child. Works as a real estate
broker. Quit smoking a few years ago, former 1ppd. History of
alcohol abuse but no EtOH for 4 yrs. No drug use.

Family History:
adopted

Physical Exam:
VS: T 98.8, 132/70, HR 104, RR 22, 97% NRB
Gen: Awake and alert but fatigued, talking in full sent over
mask
HEENT: EOMI, PERRL, anicteric sclera, MMM
Neck: supple, RIJ line intact, no LAD
Heart: Tachy ,regular, nl S1 S2 no m/r/g
Lungs: Coarse crackles heard bilat at bases
Abd: soft NT/ND +BS no rebound or guarding
Ext: warm well perfused,
Skin: R arm with scattered wheal, no bruising or ecchymoses
Neuro: CN II-XII intact, [**5-5**] strengh on R, [**3-5**] in L upper ext,
[**1-4**] in L lower ext, decreased sensation on L, preserved on R


Pertinent Results:
[**2183-3-24**] 09:50AM BLOOD WBC-7.9 RBC-4.68 Hgb-13.6* Hct-40.5
MCV-87 MCH-29.0 MCHC-33.5 RDW-13.2 Plt Ct-366
[**2183-3-27**] 05:50AM BLOOD WBC-16.0* RBC-4.39* Hgb-12.8* Hct-37.6*
MCV-86 MCH-29.2 MCHC-34.2 RDW-13.1 Plt Ct-426
[**2183-3-28**] 05:40AM BLOOD WBC-9.0 RBC-4.61 Hgb-13.4* Hct-39.6*
MCV-86 MCH-29.1 MCHC-33.9 RDW-13.4 Plt Ct-535*
[**2183-3-24**] 09:50AM BLOOD Glucose-159* UreaN-39* Creat-2.6*# Na-138
K-4.8 Cl-101 HCO3-23 AnGap-19
[**2183-3-28**] 05:40AM BLOOD Glucose-104 UreaN-9 Creat-0.8 Na-141
K-4.0 Cl-107 HCO3-23 AnGap-15
[**2183-3-24**] 03:42PM BLOOD Type-ART pO2-181* pCO2-47* pH-7.28*
calTCO2-23 Base XS--4
[**2183-3-24**] 08:35PM BLOOD Type-ART pO2-52* pCO2-44 pH-7.32*
calTCO2-24 Base XS--3 Intubat-NOT INTUBA

CXR ([**3-27**]):  FINDINGS: AP and lateral chest views were obtained
with patient in sitting upright position. The heart size is
normal, and no pulmonary vascular congestion is present. Again
demonstrated is a parenchymal density in the left lower lobe
posterior segment, similar in appearance as described on the
next preceding AP single chest view of [**3-26**]. Additional new
findings consist of some small fluffy poorly identified
parenchymal abnormalities suspected in the lateral portion of
the right upper lobe as well as in the mid left lung field. As
the technical differences of the two studies to be appreciated,
the latter findings are somewhat insecure. Considering, however,
the patient's sepsis status, a followup chest examination with
short interval is recommended.

IMPRESSION: Persistent left lower lobe pneumonic infiltrate,
suspicion for new small disseminated pulmonary parenchymal
densities. Follow up recommended.

Chest CT ([**3-27**]):  IMPRESSION:

1. Ground-glass opacities as well as centrilobular nodules in
the lower lobes, these findings are all consistent with
multifocal atypical infection.

2. Small bilateral pleural effusions.

3. Mediastinal lymphadenopathy as described above may be
reactive.

Followup imaging after treatment is recommended to ensure
resolution of these findings.

Brief Hospital Course:
Sepsis. : On admission, patients symptoms consistent with
sepsis, with hypotension, fever, and tachycardia.  His pressures
were supported with levophed, and patient was admitted to the
MICU.  The etiology of the patient's infection was attributed to
likely pneumonia, given hypoxia, cough, and concerning chest XR.
 He was initially started on vanc/levo, but due to drug induced
hives reaction, patient was switched to vanc/CTX/azithromycin.
Sputum culture grew out MSSA, and patient was switched to
nafcillin then diclocicilian on discharge.  Patients chest XR
showed developing disseminated pulmonary parencymal densities.
A chest CT was obtained, which showed ground glass opacitieis in
RUL and LML c/w multifocal atypical infection.  Given the
patients complaints of shortness of breath and URI type symptoms
in the 2-3 weeks prior to presentation, i is felt that the
patient had an atypical pneumonia then developed a secondary
superinfection with a staph pneumonia.  The patient was
afebrile, had a resolving WBC count, and normal vital signs
prior to discharge.  He was sent home on a twenty-one day course
of diclox as well as azythromycin to complete a 7 day course for
atypical pneumona.  The patient will follow up with his PCP [**Last Name (NamePattern4) **]
[**1-1**] weeks.  Follow up chest XR should be optained to evaluate
for resultuion of disseminated pumonary parencymal densities'
resolution.
.
ARF: The patient with a baseline Cr of 1, which was elevated to
2.6 on admission.  The patient's renal function resolved after
IVF resuscitation.
.
Asplenia: Underwent splenectomy in [**2144**] due to injury in
[**Country **]. Has not had severe infection in the past. Our records
indicate recent pneumo vax, flu shot, but no evidence of H. flu
or meningoccal vaccine.  On follow up with is his PCP, [**Name10 (NameIs) **]
patient should receivie these vaccinations for encapsulated
organisms.  Additionally, we would recommend consideration of
providing patient with prophylatic antibiotic to take of
immediate health care in not accessible.
.
s/p CVA: Occurred due to traumatic [**Country **] dissection s/p tPA. Had
subsequent anuerysm thought healing related change. Has L
hemiparesis as result. Not on anticoagulation anymore, hypercoag
work up neg
- Monitor clinically
.
Depresion/Anxiety: Continued outpatient Buproprion,
Nortriptyline.
.
Pain syndrome: Diagnosed with a phantom pain syndrome in the
setting of his orchiectomy. Has been seen by pain.  Continued
patients neuronti, oxycodone, nortiptyline, and MS contin.
.
HTN: Patient admitted with hypotension, and anti-hypertensives
were held.  Upon resolution, his outpatient BP meds were
restarted to good effect.

Medications on Admission:
Amlodipine 2.5 mg Daily
Bupropion 200 mg qAM, 100mg qPM
Disulfiram 250 mg Daily
Gabapentin 600 mg qAM, 600mg qPM, 1200mg qHS
Ibuprofen 800 mg TID:PRN
Lisinopril 40 mg Daily
Methylphenidate 20 mg [**Hospital1 **]
Morphine [MS Contin] 30 mg [**Hospital1 **]
Nortriptyline 25-50 mg qHS:PRN
Oxycodone 5-10 mg q4-6 PRN
Aspirin 325 mg Daily

Discharge Medications:
1. Nortriptyline 25 mg Capsule Sig: [**1-1**] Capsules PO HS (at
bedtime) as needed.
2. Disulfiram 250 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
4. Methylphenidate 20 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
5. Bupropion 100 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
6. Bupropion 100 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
7. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
8. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
9. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
10. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

13. Dicloxacillin 250 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) for 17 days.
[**Month/Day (2) **]:*68 Capsule(s)* Refills:*0*
14. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 days: start morning of [**3-29**].
[**Date Range **]:*2 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Dx:
Sepsis
Staphalococcous Pneumonia
Atypical Pneumonia

Secondary Dx:
Acute Renal Failure
Hyptertension
Asplenia


Discharge Condition:
Stable


Discharge Instructions:
     You are being discharged from the hospital after admission
for sepsis.  The etilogy of your infection is believed to be due
to a bacterial pneumonia.  You were started on antibiotics, and
should ocmplete the course as an outpatient.
     If you develop fevers, worsening shortness of breath,
cough, or any other concerning symptoms, you should call your
PCP.  [**Name10 (NameIs) **] should follow up with you PCP at the below listed time
for follow.

Followup Instructions:
Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 250**] to schedule a follow up
appointment in the next 1-2 weeks.
{'Unspecified septicemia,Methicillin susceptible pneumonia due to Staphylococcus aureus,Acute kidney failure, unspecified,Severe sepsis,Unspecified essential hypertension,Dysthymic disorder,Posttraumatic stress disorder'}


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: Pneumonia, sepsis

PRESENT ILLNESS: Mr. [**Known lastname 55406**] is a 58M with asplenia, anxiety/depression, s/p
[**Country **] dissection and L hemiparesis, who presents with 2-3 days
worsening productive cough, fever, and fatiuge. The patient was
in his usual state of health until the weekend when he noted
chest congestion, increasing productive cough, SOB and fatigue.
He denies any [**Last Name (LF) **], [**First Name3 (LF) **], sinus congestion, overt CP, n/v/d, rash,
or dysuria. He was so fatigued he tripped on his cat and fell,
without LOC. On sunday, he spiked a fever to 102. He denies sick
contacts or recent travel. He received his flu shot this year.
.
In the ED, VS T 103, HR 70, BP 108/52, RR 18, 95%NRB, 80s on RA.
The patient subsequently became tachy to 120s with BP 80s-90s.
Given 6L NS without improvement. RIJ was placed and started on
Levophed 0.06mcg/kg/min. ? PNA so given Levaquin but had
reaction. Changed to CTX/Azithro, and Vanco.

MEDICAL HISTORY: 1. Asplenia secondary to trauma incurred during Vietman, [**2144**],
pneumococcal vaccine given in [**2176**]. Does not remember if he
received H flu or meningococcus.
2. PTSD
3. ADHD
4. Depression/Anxiety
5. h/o Alcohol abuse
6. Migraine
7. Status post C5-C6 laminectomy and fusion several years ago by

MEDICATION ON ADMISSION: Amlodipine 2.5 mg Daily
Bupropion 200 mg qAM, 100mg qPM
Disulfiram 250 mg Daily
Gabapentin 600 mg qAM, 600mg qPM, 1200mg qHS
Ibuprofen 800 mg TID:PRN
Lisinopril 40 mg Daily
Methylphenidate 20 mg [**Hospital1 **]
Morphine [MS Contin] 30 mg [**Hospital1 **]
Nortriptyline 25-50 mg qHS:PRN
Oxycodone 5-10 mg q4-6 PRN
Aspirin 325 mg Daily

ALLERGIES: Levaquin

PHYSICAL EXAM: VS: T 98.8, 132/70, HR 104, RR 22, 97% NRB
Gen: Awake and alert but fatigued, talking in full sent over
mask
HEENT: EOMI, PERRL, anicteric sclera, MMM
Neck: supple, RIJ line intact, no LAD
Heart: Tachy ,regular, nl S1 S2 no m/r/g
Lungs: Coarse crackles heard bilat at bases
Abd: soft NT/ND +BS no rebound or guarding
Ext: warm well perfused,
Skin: R arm with scattered wheal, no bruising or ecchymoses
Neuro: CN II-XII intact, [**5-5**] strengh on R, [**3-5**] in L upper ext,
[**1-4**] in L lower ext, decreased sensation on L, preserved on R

FAMILY HISTORY: adopted

SOCIAL HISTORY: Married. 2 biologic and 1 adopted child. Works as a real estate
broker. Quit smoking a few years ago, former 1ppd. History of
alcohol abuse but no EtOH for 4 yrs. No drug use. 

### Response:
{'Unspecified septicemia,Methicillin susceptible pneumonia due to Staphylococcus aureus,Acute kidney failure, unspecified,Severe sepsis,Unspecified essential hypertension,Dysthymic disorder,Posttraumatic stress disorder'}
