CHIEF COMPLAINT: sepsis

PRESENT ILLNESS: 32 M with history of congenital adrenal hyperplasia presents
initially to LGH for nausea and vomiting x2 days.  He was
diagnosed with strep throat on [**2126-12-16**] via rapid swab, when he
presented with symptoms of sore throat and fevers to 102F at
home. He was started on azithromycin at that time and states
that he has been able to keep the antibiotics down despite
nausea/vomiting. However, he has not been able to keep down his
dexamethasone and florinef for last 2 days. Pt tried to increase
his steroid intake in the setting of illness, but was unable to.
He does not have emergency hydrocortisone/dexamethasone
injections at home. His vomiting has been nonbloody, somewhat
bilious, and he also reports very poor po intake due to his sore
throat.
.
While at LGH was noted to be vomiting, tachycardic to the 130's,
and acute renal failure with creatinine 1.7. Potassium also
noted to be 2.9. He received potassium IV repletion (80 mEq), 3L
NS, and hydrocortisone 100 mg IV x1 and IV azithromycin 500 mg
and was transferred here for further management.  OSH CXR
reported to be negative. He had not been noted to be
hypotensive.
.
In the ED inital vitals were, 98.8 128 108/66 24 100% 2L NP.
Patient received vancomycin 1 gram and ceftriaxone 1 gram for
concern for sepsis.  Initial labs notable for a white count of
17.5 with a left shift.  Creatinine improved at 0.9.  He
received another liter of IV fluids, but was persistently
tachycardic to 120-130s.  He received another 20 mEq of K.  Was
never noted to be hypotensive.  Vitals prior to transfer to the
floor were: HR 122, BP 112/70, RR 30, Sat 97%RA.
.
Review of systems:
(+) Per HPI: notable for fevers/chills, sore throat, cough,
odynophagia and n/v
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
shortness of breath, or wheezing. Denies chest pain, chest
pressure, palpitations, or weakness. Denies diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes.

MEDICAL HISTORY: Congenital adrenal hyperplasia
Bilateral knee surgeries

MEDICATION ON ADMISSION: Florinef 0.1 mg daily
Dexamethasone 0.25 mg daily

ALLERGIES: Augmentin

PHYSICAL EXAM: On admission:
Vitals: T: 98.3 BP: 132/69 P: 118 R: 18 O2: 100% RA
General: Alert, oriented, no acute distress
HEENT: PERRL, Conjunctival injection bilaterally with clear
discharge, mucous membranes dry, difficult to visualize the
oropharynx but ?exudates in the posterior oropharynx
Neck: supple, difficult to evaluate JVP given habitus, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: tachycardic but regular, normal S1 + S2, no
murmurs/rubs/gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. no rashes
Neuro: strength intact throughout

FAMILY HISTORY: Mother with DM, father with prostate CA diagnosed at age 62.

SOCIAL HISTORY: Works as a student loan collector, lives with wife and has 2
boys.
- Tobacco: occasional cigar
- Alcohol: denies
- Illicits: denies
Streptococcal septicemia,Acute kidney failure, unspecified,Acidosis,Sepsis,Streptococcal sore throat,Intestinal infection due to other organism, not elsewhere classified,Adrenogenital disorders,Acute conjunctivitis, unspecified
Streptococcal septicemia,Acute kidney failure NOS,Acidosis,Sepsis,Strep sore throat,Viral enteritis NOS,Adrenogenital disorders,Acute conjunctivitis NOS
Admission Date:  [**2126-12-17**]              Discharge Date:   [**2126-12-21**]

Date of Birth:  [**2094-1-14**]             Sex:   M

Service: MEDICINE

Allergies:
Augmentin

Attending:[**Doctor First Name 2080**]
Chief Complaint:
sepsis

Major Surgical or Invasive Procedure:
none

History of Present Illness:
32 M with history of congenital adrenal hyperplasia presents
initially to LGH for nausea and vomiting x2 days.  He was
diagnosed with strep throat on [**2126-12-16**] via rapid swab, when he
presented with symptoms of sore throat and fevers to 102F at
home. He was started on azithromycin at that time and states
that he has been able to keep the antibiotics down despite
nausea/vomiting. However, he has not been able to keep down his
dexamethasone and florinef for last 2 days. Pt tried to increase
his steroid intake in the setting of illness, but was unable to.
He does not have emergency hydrocortisone/dexamethasone
injections at home. His vomiting has been nonbloody, somewhat
bilious, and he also reports very poor po intake due to his sore
throat.
.
While at LGH was noted to be vomiting, tachycardic to the 130's,
and acute renal failure with creatinine 1.7. Potassium also
noted to be 2.9. He received potassium IV repletion (80 mEq), 3L
NS, and hydrocortisone 100 mg IV x1 and IV azithromycin 500 mg
and was transferred here for further management.  OSH CXR
reported to be negative. He had not been noted to be
hypotensive.
.
In the ED inital vitals were, 98.8 128 108/66 24 100% 2L NP.
Patient received vancomycin 1 gram and ceftriaxone 1 gram for
concern for sepsis.  Initial labs notable for a white count of
17.5 with a left shift.  Creatinine improved at 0.9.  He
received another liter of IV fluids, but was persistently
tachycardic to 120-130s.  He received another 20 mEq of K.  Was
never noted to be hypotensive.  Vitals prior to transfer to the
floor were: HR 122, BP 112/70, RR 30, Sat 97%RA.
.
Review of systems:
(+) Per HPI: notable for fevers/chills, sore throat, cough,
odynophagia and n/v
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
shortness of breath, or wheezing. Denies chest pain, chest
pressure, palpitations, or weakness. Denies diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes.

Past Medical History:
Congenital adrenal hyperplasia
Bilateral knee surgeries

Social History:
Works as a student loan collector, lives with wife and has 2
boys.
- Tobacco: occasional cigar
- Alcohol: denies
- Illicits: denies

Family History:
Mother with DM, father with prostate CA diagnosed at age 62.

Physical Exam:
On admission:
Vitals: T: 98.3 BP: 132/69 P: 118 R: 18 O2: 100% RA
General: Alert, oriented, no acute distress
HEENT: PERRL, Conjunctival injection bilaterally with clear
discharge, mucous membranes dry, difficult to visualize the
oropharynx but ?exudates in the posterior oropharynx
Neck: supple, difficult to evaluate JVP given habitus, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: tachycardic but regular, normal S1 + S2, no
murmurs/rubs/gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. no rashes
Neuro: strength intact throughout


Pertinent Results:
ADMISSION LABS:
[**2126-12-17**] 07:40PM BLOOD Neuts-92.0* Lymphs-4.1* Monos-3.0 Eos-0.7
Baso-0.1
[**2126-12-17**] 07:40PM BLOOD WBC-17.5*# RBC-4.83 Hgb-12.8*# Hct-37.5*
MCV-78* MCH-26.4* MCHC-34.1 RDW-12.5 Plt Ct-223
[**2126-12-17**] 07:40PM BLOOD Glucose-114* UreaN-13 Creat-0.9 Na-130*
K-3.9 Cl-95* HCO3-19* AnGap-20
[**2126-12-17**] 07:40PM BLOOD Osmolal-267*
[**2126-12-17**] 07:52PM BLOOD Glucose-111* Lactate-0.9 Na-129* K-3.7
Cl-96 calHCO3-19*

Brief Hospital Course:
32 M with CAH presents with concern for sepsis/adrenal
insufficiency and acute renal failure, thought to be from strep
throat, found to also have adenovirus.

#. Sepsis due to Strep pharyngitis vs. gastroenteritis: meeting
criteria for sepsis with tachycardia, fevers and leukocytosis,
with strep throat as source. Has only been treated for 2 days
with azithromycin, and given his n/v at home, concern for poor
absorption although patient reports taking his medications. He
got total of 8L NS and continued on IV azithromycin. For his
sepsis, he was converted to stress dosing steroids as below. His
UCx and BCx showed no growth. He was transferrd to the floor in
stable condition and complete a three day course of 500mg of IV
azithromycin.

#. Congenital Adrenal Hyperplasia/adrenal insufficiency: patient
unable to take his dexamethasone and florinef for x2 days in the
setting of his n/v and strep throat. s/p 100 mg IV
hydrocortisone at OSH. He was continued on stress dose
hydrocortisone IV 100 mg q8hrs for a day, and decreased to 50 mg
IV q8hrs. After discussion with his endocrinologist, he was
changed to po dexamethasone 2 mg qHS and florinef 0.1 mg daily.
He will continue this dose until he follows up with his
endocrinologist in the days following discharge.
.
#. Metabolic derangement: pt with hyponatremia and hypokalemia
on presentation, likely due to combination of missing his
dexamethasone/florinef, hypovolemia and vomiting. These resolved
with IVF and steroid replacement.

#. Mixed Anion gap/non anion gap metabolic acidosis: pt with
anion gap of 16, lactate 0.9. Unclear etiology of anion gap, as
pt's glucose is 114 and he has no known history of diabetes to
suggest ketoacidosis. THe AG compoenent was felt to be secondary
to his poor PO intahe as it resolved with nutrition. His NAGMA
was likley due to large volume diarrhea and large amounts of
normal saline.
.
#. Diarrhea/Adenovirus gastroenteritis: developed diarrhea
in-house, very liquid. C diff toxin negative, stool cultures
negative. Large volume and watery suggested small intestinal
source. He was found to have adenovirus which could cause
gasteroenteritis. Also could have been antibiotic related.
Resolving on discharge. He was started on immodium and
encouraged PO fluid intake.
.
#. Conjuctivitis: likely viral conjuctivitis, his respiratory
panel was positive for adenovirus. Could be cause of his
conjuctivitis and n/v/diarrhea. Symptomatic treatment.

#. ARF: baseline creatinine of 0.9-1.0.  On presentation to LGH
noted to have creatinine increased to 1.7, but following IV
fluids creatinine now back to 0.9.  Had been nauseous and
vomiting, likely creatinine bump from hypovolemia.

TRANSITIONAL ISSUES:
- Continue stress dose steroids with dexamethasone 2 mg po qHS
and florinef 0.1 mg po daily. Dr [**Last Name (STitle) 16258**] will tape rthe patient
after he sees him in follow up.
- Continue PO fluid replacement
- He shoudl have a chemistry panel checked in follow up as well

Medications on Admission:
Florinef 0.1 mg daily
Dexamethasone 0.25 mg daily

Discharge Medications:
1. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
Disp:*20 Tablet(s)* Refills:*2*
3. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
Disp:*28 Capsule(s)* Refills:*0*
4. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: [**12-23**] Tablet, Rapid
Dissolves PO every eight (8) hours as needed for nausea.
Disp:*24 Tablet, Rapid Dissolve(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Group A Strep pharyngitis
Congenital adrenal hyperplasia
Gastroenteritis


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
You were admitted to [**Hospital1 18**] for an episode of strep throat and
gastroenteritis in the setting of adrenal insufficiecny. You
were given antibiotics, steroids and fluids and you improved.
You will need to continue to drink PLENTY of water and follow up
with Dr. [**Last Name (STitle) 16258**] this week.
.
While youw ere here we made the following changes to your
medications.
We STARTED you on loperamide (Imodium)
We STARTED you on Zofran
We Increased your dexamethasone
.
Please take your other medications as prescribed

Followup Instructions:
Please call Dr.[**Name (NI) 16259**] office on Tuesday morning to schedule a
follow up appointment for this week.
{'Streptococcal septicemia,Acute kidney failure, unspecified,Acidosis,Sepsis,Streptococcal sore throat,Intestinal infection due to other organism, not elsewhere classified,Adrenogenital disorders,Acute conjunctivitis, 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

PRESENT ILLNESS: 32 M with history of congenital adrenal hyperplasia presents
initially to LGH for nausea and vomiting x2 days.  He was
diagnosed with strep throat on [**2126-12-16**] via rapid swab, when he
presented with symptoms of sore throat and fevers to 102F at
home. He was started on azithromycin at that time and states
that he has been able to keep the antibiotics down despite
nausea/vomiting. However, he has not been able to keep down his
dexamethasone and florinef for last 2 days. Pt tried to increase
his steroid intake in the setting of illness, but was unable to.
He does not have emergency hydrocortisone/dexamethasone
injections at home. His vomiting has been nonbloody, somewhat
bilious, and he also reports very poor po intake due to his sore
throat.
.
While at LGH was noted to be vomiting, tachycardic to the 130's,
and acute renal failure with creatinine 1.7. Potassium also
noted to be 2.9. He received potassium IV repletion (80 mEq), 3L
NS, and hydrocortisone 100 mg IV x1 and IV azithromycin 500 mg
and was transferred here for further management.  OSH CXR
reported to be negative. He had not been noted to be
hypotensive.
.
In the ED inital vitals were, 98.8 128 108/66 24 100% 2L NP.
Patient received vancomycin 1 gram and ceftriaxone 1 gram for
concern for sepsis.  Initial labs notable for a white count of
17.5 with a left shift.  Creatinine improved at 0.9.  He
received another liter of IV fluids, but was persistently
tachycardic to 120-130s.  He received another 20 mEq of K.  Was
never noted to be hypotensive.  Vitals prior to transfer to the
floor were: HR 122, BP 112/70, RR 30, Sat 97%RA.
.
Review of systems:
(+) Per HPI: notable for fevers/chills, sore throat, cough,
odynophagia and n/v
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
shortness of breath, or wheezing. Denies chest pain, chest
pressure, palpitations, or weakness. Denies diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes.

MEDICAL HISTORY: Congenital adrenal hyperplasia
Bilateral knee surgeries

MEDICATION ON ADMISSION: Florinef 0.1 mg daily
Dexamethasone 0.25 mg daily

ALLERGIES: Augmentin

PHYSICAL EXAM: On admission:
Vitals: T: 98.3 BP: 132/69 P: 118 R: 18 O2: 100% RA
General: Alert, oriented, no acute distress
HEENT: PERRL, Conjunctival injection bilaterally with clear
discharge, mucous membranes dry, difficult to visualize the
oropharynx but ?exudates in the posterior oropharynx
Neck: supple, difficult to evaluate JVP given habitus, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: tachycardic but regular, normal S1 + S2, no
murmurs/rubs/gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. no rashes
Neuro: strength intact throughout

FAMILY HISTORY: Mother with DM, father with prostate CA diagnosed at age 62.

SOCIAL HISTORY: Works as a student loan collector, lives with wife and has 2
boys.
- Tobacco: occasional cigar
- Alcohol: denies
- Illicits: denies 

### Response:
{'Streptococcal septicemia,Acute kidney failure, unspecified,Acidosis,Sepsis,Streptococcal sore throat,Intestinal infection due to other organism, not elsewhere classified,Adrenogenital disorders,Acute conjunctivitis, unspecified'}
