CHIEF COMPLAINT: New onset atrial fibrillation, poor urine output

PRESENT ILLNESS: 75 yo M h/o obesity, DM2, CRI (baseline cr 2.5), CHF,
chronically vent dependent [**1-17**] [**12-23**] PNA, presented from [**Hospital 671**]
Rehab after pt was noted to be in new atrial fibrillation. Pt's
available medical records are minimal at this time. Pt was
admitted to [**Location 1268**] VA in [**12-23**] for hypoxemic and subsequent
hypercarbic respiratory failure, ultimately requiring two
intubations.During that hospitalization, because of failure to
wean, pt was trached. Pt was diagnosed with VAP (microorganism
unknown), treated with cefepime. Pt was discharged ([**2-9**]) to
[**Hospital 671**] Hospital for longterm vent management/weaning. The
patient developed a gradual decline in his urine output. Labs at
the time revealed a cr elevated to 5.3. The patient was admitted
to [**Hospital6 **] on [**2-20**] for further evaluation of his
renal failure. During that admission the patient became volume
overloaded and was admitted to the MICU for initiation of HD.
The patient's course was complicated by citrobacter and VRE
bacteremia as well as acinetobacter growing from the sputum. The
pt was started on a 2 week course of linezolid and imipenem. The
pt's UOP improved to the point he no longer needed dialysis. He
was discharged [**3-4**]. Following discharge the pt was stable until
today when it was noted that his UOP had fallen to less than 20
130s (A fib) with stable BP. He was transferred to [**Hospital1 **] for futher
management.

MEDICAL HISTORY: # DM2
# CRI (baseline 2.5)
# CHF
# Trached and vent dependent [**1-17**] PNA
# Morbid obesity

MEDICATION ON ADMISSION: lantus 54 units QAM
pro-amatine 5 mg daily
aranesp 40 mcg
novolog sliding scale
lactulose 30 mL qid
combivent 4 puffs qid
silvadene
desenex
vitamin c
dulcolax
phoslo 667 mg tid
nexium 40 mg daiily
asa 81 mg daily
flagyl 500 mg tid
tylenol
bicitra 30 ml [**Hospital1 **]
heparin 5000 tid
zocor

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: # VS: T102.4, BP117/65, HR151, RR32, O2sat 91, PS 15/10 Fi 100%

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: lives with wife, who is HCP
Unspecified septicemia,Septic shock,Acute kidney failure with lesion of tubular necrosis,Acidosis,Urinary tract infection, site not specified,Pressure ulcer, lower back,Acute and chronic respiratory failure,Dependence on respirator, status,Severe sepsis,Venous (peripheral) insufficiency, unspecified,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Atrial fibrillation,Morbid obesity,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic kidney disease, unspecified,Tracheostomy status,Gastrostomy status
Septicemia NOS,Septic shock,Ac kidny fail, tubr necr,Acidosis,Urin tract infection NOS,Pressure ulcer, low back,Acute & chronc resp fail,Respirator depend status,Severe sepsis,Venous insufficiency NOS,Pseudomonas infect NOS,Atrial fibrillation,Morbid obesity,DMII wo cmp nt st uncntr,Chronic kidney dis NOS,Tracheostomy status,Gastrostomy status
Admission Date:  [**2150-3-15**]              Discharge Date:   [**2150-3-24**]

Date of Birth:  [**2075-1-1**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
New onset atrial fibrillation, poor urine output

Major Surgical or Invasive Procedure:
RIJ CVL placement and removal
Arterial line placement
RIJ temporary HD catheter placement
R PICC placement
Hemodialysis


History of Present Illness:
75 yo M h/o obesity, DM2, CRI (baseline cr 2.5), CHF,
chronically vent dependent [**1-17**] [**12-23**] PNA, presented from [**Hospital 671**]
Rehab after pt was noted to be in new atrial fibrillation. Pt's
available medical records are minimal at this time. Pt was
admitted to [**Location 1268**] VA in [**12-23**] for hypoxemic and subsequent
hypercarbic respiratory failure, ultimately requiring two
intubations.During that hospitalization, because of failure to
wean, pt was trached. Pt was diagnosed with VAP (microorganism
unknown), treated with cefepime. Pt was discharged ([**2-9**]) to
[**Hospital 671**] Hospital for longterm vent management/weaning. The
patient developed a gradual decline in his urine output. Labs at
the time revealed a cr elevated to 5.3. The patient was admitted
to [**Hospital6 **] on [**2-20**] for further evaluation of his
renal failure. During that admission the patient became volume
overloaded and was admitted to the MICU for initiation of HD.
The patient's course was complicated by citrobacter and VRE
bacteremia as well as acinetobacter growing from the sputum. The
pt was started on a 2 week course of linezolid and imipenem. The
pt's UOP improved to the point he no longer needed dialysis. He
was discharged [**3-4**]. Following discharge the pt was stable until
today when it was noted that his UOP had fallen to less than 20
130s (A fib) with stable BP. He was transferred to [**Hospital1 **] for futher
management.

Past Medical History:
# DM2
# CRI (baseline 2.5)
# CHF
# Trached and vent dependent [**1-17**] PNA
# Morbid obesity


Social History:
lives with wife, who is HCP

Family History:
Non-contributory

Physical Exam:
# VS: T102.4, BP117/65, HR151, RR32, O2sat 91, PS 15/10 Fi 100%

Gen: slightly anxious, mouthing answers to questions
appropriately
HEENT: MM dry
CV: irreg irreg, tachy, no murmurs
Chest: diffusely poor air movement, minimal at bases
Abd: obese, soft, NT, ND, +BS
Ext: brawny edema in LE, venous stasis changes
Neuro: following commands


Pertinent Results:
Admission Labs:

[**2150-3-15**] 09:05PM BLOOD WBC-10.7 RBC-3.73* Hgb-10.4* Hct-32.8*
MCV-88 MCH-27.9 MCHC-31.8 RDW-18.7* Plt Ct-174
[**2150-3-15**] 09:05PM BLOOD Neuts-86.2* Bands-0 Lymphs-8.9*
Monos-1.7* Eos-3.0 Baso-0.3
[**2150-3-15**] 09:05PM BLOOD PT-15.0* PTT-31.5 INR(PT)-1.3*
[**2150-3-15**] 09:05PM BLOOD Glucose-129* UreaN-129* Creat-4.4* Na-137
K-4.7 Cl-99 HCO3-24 AnGap-19
[**2150-3-15**] 09:05PM BLOOD ALT-5 AST-13 CK(CPK)-11* AlkPhos-169*
TotBili-0.3
[**2150-3-15**] 09:05PM BLOOD CK-MB-3 proBNP-[**Numeric Identifier **]*
[**2150-3-15**] 09:05PM BLOOD cTropnT-0.20*
[**2150-3-15**] 09:05PM BLOOD Albumin-2.6* Calcium-8.4 Phos-4.6* Mg-2.2
.
Studies:
CXR [**3-15**]: Markedly limited study. A PICC line from a right upper
extremity approach is evident with the line extending at least
to the superior vena cava. The exact tip is not seen. There is
diffuse interstitial and alveolar edema. A left lower lobe
consolidation cannot be excluded. Small bilateral pleural
effusions are noted
.
EKG [**3-15**]: afib, rate 127, VPCs, RBBB
.
Renal US [**3-17**]:
Note is made that this is an extremely limited ultrasound due to
the patient's body habitus. The left kidney was not visualized
on this examination. The right kidney measures 12.0 cm, and no
hydronephrosis is appreciated. Ultrasound is unable to further
characterize the kidney due to the poor visualization.
.
Bronchoscopy [**3-24**]:
No evidence of trauma, thin frothy pink secretions consistent
with pulmonary edema.

Brief Hospital Course:
A/P: 74M h/o morbid obesity, DM2, CRI, chronic vent dependency,
p/w poor UOP and A fib, now with clinical picture concerning for
sepsis
.
# Sepsis: Patient met SIRS criteria with temperature >102 and
hypotension with SBP 80s. He was given broad spectrum abx
including linezolid given his h/o VRE,
cefepime for broad gram neg coverage in this longterm rehab and
hospital resident, as well as his home flagyl.  His cefepime was
changed to meropenem per ID given his h/o resistant
acinetobacter.  A RIJ CVL was placed for pressors and CVP
monitoring.  He was given IVF to maintain CVP>8 and initially
required neo to maintain MAP >60.  Pressors were weaned off on
HD #2.  The patient was pan-cultured including urine, blood and
sputum.  In addition, his R PICC line was removed and tip was
sent for culture.  His urine was felt to be the source as
cultures returned positive for >100,000 colonies of
pan-sensitive pseudomonas.  He was continued on meropenem and
his flagyl and linezolid were discontinued.  Stool was c diff
negative.  In addition, the patient had 2 species of GNR in his
sputum, these were not identified at the time of transfer.  The
patient remained hemodynamically stable and afebrile for the
remainder of his hospital stay.  Blood cultures were negative at
the time of transfer.  He was continued on meropenem to cover
possible pulmonary infection as well as UTI, last dose to be
given [**2150-3-25**].
.
# Acute on chronic renal failure: Cr on admission was elevated
to 4.4 which was above his baseline of 1.9.  His acute renal
failure was felt to be in the setting of  sepsis. On prior admit
he required aggressive treatment with pressors to resume UOP
after being oliguric for a period.  A renal consult was obtained
who felt that his renal failure was [**1-17**] ischemic ATN in the
setting of sepsis.  A renal US was obtained that showed a normal
right kidney without hydronephrosis.  Left kidney was not
visualized due to body habitus.  His Cr continued to trend up
and was 4.8 on [**3-20**].  A trial of diuresis with diuril 500mg and
lasix 160mg was attempted per renal with only 60cc of UOP.
Given his volume overload and oliguria a temporary RIJ HD line
was placed by IR on [**3-20**] and HD was initiated the same day. His
last HD session was [**3-23**] which he tolerated well.  His
medications were renally dosed.
.
# Respiratory distress: Admission CXR showed possible b/l
infiltrates vs. pulmonary edema, however was extremely limited
due to body habitus.  Was on broad-spectrum antibiotics with GNR
in sputum.  He was primarily maintained on PS ventilation 12/5,
however patient was subjectively SOB and his pressure support
was increased to 15 on [**3-20**] despite stable O2 sats.  He was tried
on trach collar, however the patient requested to be placed back
on vent due to SOB.  He did not have a significant amount of
secretions and remained afebrile and his b/l infiltrates were
felt to be [**1-17**] pulmonary edema rather than infection.  He was
initiated on HD for fluid removal on [**3-20**].  Anxiety was felt to
be contibuting significantly to his inability to wean from the
vent.  He was started on Klonopin and Celexa on [**3-21**] to be
uptitrated as necessary. On [**3-23**] the patient developed some
bloody secretions from his trach in the setting of initiating
anticoagulation.  A bronch was performed on [**3-24**] that showed
****. His coumadin was held and decision to restart deferred
*****.
.
# Atrial fibrillation: new onset in the setting of sepsis.
Remained in afib throughout his hospital stay.  He was started
on low dose BB for rate control with good effect.  Once his PICC
and HD line were placed he was started on coumadin.  His BB was
uptitrated as his BP tolerated to a dose of 50mg tid.  His HR
remained well-controlled with HR 80s-90s. INR on day of
discharge was 2.5 on a dose of 5mg coumadin.  He should continue
his coumadin dose with close INR monitoring - every three days
for the first two weeks, and then prn for appropriate coumadin
dose adjustments to keep INR at goal of [**1-18**].
.
# hemoptysis: on the day of discharge the patient was having
scant hemoptysis and bronchoscopy was performed. He had pink
frothy secretions consistent with pulmonary edema and no
evidence of trauma. The etiology of his scant hemoptysis is
likely pulmonary edema only.
.
# DM2: He was maintained on his outpatient regimen of lantus
54units qam and RISS.
.
# FEN: He was continued on TFs per nutrition
.
# ppx: he was kept on PPI while in-house but this is
discontinued as of [**3-24**], no heparin to be given after discharge
as he is therapeutic on warfarin.
.
# Access: R IJ removed [**3-19**], R PICC placed [**3-19**], RIJ temp HD line
placed [**3-20**].
.
# Comm: son [**Name2 (NI) **] and wife/HCP [**Name (NI) 77789**] [**Telephone/Fax (1) 77790**]
.
# Code: Full (per discussion with wife and son)

Medications on Admission:
lantus 54 units QAM
pro-amatine 5 mg daily
aranesp 40 mcg
novolog sliding scale
lactulose 30 mL qid
combivent 4 puffs qid
silvadene
desenex
vitamin c
dulcolax
phoslo 667 mg tid
nexium 40 mg daiily
asa 81 mg daily
flagyl 500 mg tid
tylenol
bicitra 30 ml [**Hospital1 **]
heparin 5000 tid
zocor


Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q6H (every 6 hours).
3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4)
Puff Inhalation QID (4 times a day).
4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): Hold for SBP<100 or HR <65.
7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Titrate dose to goal INR [**1-18**].
8. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-17**] Sprays Nasal
QID (4 times a day) as needed.
9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID PRN ()
as needed for anxiety.
11. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
12. Meropenem 500 mg Recon Soln Sig: 500mg Recon Solns
Intravenous Q12H (every 12 hours) for 1 days.
13. Insulin Glargine 100 unit/mL Solution Sig: Fifty Four (54)
units Subcutaneous qam.
14. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale per sliding scale Injection with meals.


Discharge Disposition:
Extended Care

Discharge Diagnosis:
Sepsis
Acute on Chronic Kidney Disease
Atrial fibrillation, new onset
Pseudomonas UTI
Chronic respiratory failure, vent dependent
Diabetes
Morbid obesity


Discharge Condition:
Afebrile.  Vent dependent.


Discharge Instructions:
You were admitted to the medical ICU with rapid heart rate and
low urine output.  You were found to have an infection in your
urine that was likely causing your symptoms.  You were started
on an IV antibiotic called meropenem and will need to complete a
10-day course.  You have 1 more day of antibiotics.
.
You were also found to be in an irregular heart rate called
atrial fibrillation.  You were started on a medication called
metoprolol to help control your heart rate.  Given your
increased risk of stroke you were also started on a
blood-thinning medication called coumadin.  This will have to be
monitored closely by your doctor to keep the level between [**1-18**].
.
We also started you on two new medications for your anxiety.
These are called celexa and Klonopin.  Your doctors [**Name5 (PTitle) **] adjust
the doses of these to help with your anxiety.
.
Your kidney function declined in the setting of your infection
and the kidney doctors followed [**Name5 (PTitle) **] for this.  It was decided to
initiate dialysis and a temporary catheter was placed and you
were started on dialysis.  This will have to be continued
indefinitely or until your kidney function improves.
.
Please take all of your medications as prescribed.
.
Please keep you follow up appointments as below.


Followup Instructions:
Please follow up with your PCP for coumadin dosing, which will
be adjusted based on bloodwork.
.
Please follow up with nephrology regarding ongoing dialysis.
.
Please check INR in three days and every three days for the next
2 weeks, then as needed to monitor coumadin dosing.



Completed by:[**2150-3-24**]
{'Unspecified septicemia,Septic shock,Acute kidney failure with lesion of tubular necrosis,Acidosis,Urinary tract infection, site not specified,Pressure ulcer, lower back,Acute and chronic respiratory failure,Dependence on respirator, status,Severe sepsis,Venous (peripheral) insufficiency, unspecified,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Atrial fibrillation,Morbid obesity,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic kidney disease, unspecified,Tracheostomy status,Gastrostomy status'}


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: New onset atrial fibrillation, poor urine output

PRESENT ILLNESS: 75 yo M h/o obesity, DM2, CRI (baseline cr 2.5), CHF,
chronically vent dependent [**1-17**] [**12-23**] PNA, presented from [**Hospital 671**]
Rehab after pt was noted to be in new atrial fibrillation. Pt's
available medical records are minimal at this time. Pt was
admitted to [**Location 1268**] VA in [**12-23**] for hypoxemic and subsequent
hypercarbic respiratory failure, ultimately requiring two
intubations.During that hospitalization, because of failure to
wean, pt was trached. Pt was diagnosed with VAP (microorganism
unknown), treated with cefepime. Pt was discharged ([**2-9**]) to
[**Hospital 671**] Hospital for longterm vent management/weaning. The
patient developed a gradual decline in his urine output. Labs at
the time revealed a cr elevated to 5.3. The patient was admitted
to [**Hospital6 **] on [**2-20**] for further evaluation of his
renal failure. During that admission the patient became volume
overloaded and was admitted to the MICU for initiation of HD.
The patient's course was complicated by citrobacter and VRE
bacteremia as well as acinetobacter growing from the sputum. The
pt was started on a 2 week course of linezolid and imipenem. The
pt's UOP improved to the point he no longer needed dialysis. He
was discharged [**3-4**]. Following discharge the pt was stable until
today when it was noted that his UOP had fallen to less than 20
130s (A fib) with stable BP. He was transferred to [**Hospital1 **] for futher
management.

MEDICAL HISTORY: # DM2
# CRI (baseline 2.5)
# CHF
# Trached and vent dependent [**1-17**] PNA
# Morbid obesity

MEDICATION ON ADMISSION: lantus 54 units QAM
pro-amatine 5 mg daily
aranesp 40 mcg
novolog sliding scale
lactulose 30 mL qid
combivent 4 puffs qid
silvadene
desenex
vitamin c
dulcolax
phoslo 667 mg tid
nexium 40 mg daiily
asa 81 mg daily
flagyl 500 mg tid
tylenol
bicitra 30 ml [**Hospital1 **]
heparin 5000 tid
zocor

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: # VS: T102.4, BP117/65, HR151, RR32, O2sat 91, PS 15/10 Fi 100%

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: lives with wife, who is HCP 

### Response:
{'Unspecified septicemia,Septic shock,Acute kidney failure with lesion of tubular necrosis,Acidosis,Urinary tract infection, site not specified,Pressure ulcer, lower back,Acute and chronic respiratory failure,Dependence on respirator, status,Severe sepsis,Venous (peripheral) insufficiency, unspecified,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Atrial fibrillation,Morbid obesity,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic kidney disease, unspecified,Tracheostomy status,Gastrostomy status'}
