CHIEF COMPLAINT: Lethargy, abdominal pain.

PRESENT ILLNESS: Mrs. [**Known firstname **] [**Known lastname **] is a 61 yo F with PmHx significant for ESRD
on peritoneal dialysis, DMII, CAD, HTN, COPD, asthma, PVD s/p
bilateral AKA, s/p MVR, h/o PE, h/o MRSA bacteremia, h/o
endocarditis, breast ca s/p mastectomy, recently hospitalized
[**9-8**] - [**9-12**] with hypotension thought secondary to diarrhea and
poor PO intake, who presents to the ED with lethargy and
abdominal pain.  The patient is unable to provide history at the
time of ED presentation, but per her son who later arrived and
who lives with her, Mrs. [**Known lastname **] had been complaining of
abdominal pain for the past week.   Of note, she had been
administered 2g of vancomycin intraperitoneally [**9-13**] at [**Location (un) 4265**]
where she receives peritoneal dialysis (no gram stain or culture
data is available, and it is unclear from disucssions with the
renal fellow why antiobiotics were administered).  She
apparently only received one dose of IP antibiotics at [**Location (un) 4265**].
Per her son, Mrs. [**Known lastname **] was evaluated for abdominal pain and
fatigue at [**Hospital6 **] ED several days prior to this
presentation for abdominal pain and lethargy, was given fluids,
though was not admitted.  Mrs.[**Name (NI) 14386**] son also noted drainage
and irration around the PD exit site and was told to apply
antibiotic ointment to the area, which he did.  However, the
patient continued per report to experience abdominal pain.  The
morning of admission was noted to be increasingly lethargic,
with worsening abdominal pain, and was brought to the ED for
further evaluation.

MEDICAL HISTORY: ESRD, on peritoneal dialysis
DM II
CAD (no cardiac catheterizations), +stress test.
s/p MVR
PVD s/p bilateral AKA
DMII
HTN
COPD
asthma
DVT and PE
MRSA bacteremia
endocarditis
breast cancer, s/p mastectomy
s/p TAH/BSO

MEDICATION ON ADMISSION: Ipratropium inh
Albuterol inh
folic acid
Timolol eye drops
Midodrine 2.5 by mouth [**Hospital1 **]
Sevelamer 800 PO TID
Metoprolol PO 25 BID
Plavix 75 PO QD
Protonix 40 QD
Nephrocaps

ALLERGIES: Aspirin / Penicillins / Percocet / Benzodiazepines /
Cephalosporins

PHYSICAL EXAM: T=34.1, BP 97/55 (on 20 of Levophed), HR 117 RR 30 100% on RA
Patient found lying in semi-recumbant position, frequently
groaning, though laying still.
Anicteric, conjunctiva uninjected, MM dry, no sores or lesions
in OP
L EJ catheter in place.  No JVD.  No bruits
Irreg tachy rhythm, nl s1 s2, no M/R/G
CTA
s/p mastectomy
abd soft, diffusely tender to palpation, though without rebound
or guarding.  No [**Doctor Last Name 515**] sign.
bilateral AKA.
No rashes
L-sided forearm fistula without thrill, sclerotic in texture.
Awake, intermittently responds to questions, which she answers
with yes/no answers or short-sentences.  Oriented to person.  CN
exam limited (patient only occasionally responding to commands),
surgical R pupil, left reactive to light.  Neurological
examination appears non-focal.

FAMILY HISTORY: NC

SOCIAL HISTORY: patient has an approximate 60 pack-year tobacco history.
No EtoH or IVDU.
Lives with adult children.
Jehovas witness.
Infection and inflammatory reaction due to peritoneal dialysis catheter,Unspecified septicemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic obstructive asthma, unspecified,Paroxysmal ventricular tachycardia,Septic shock,Subendocardial infarction, initial episode of care,Severe sepsis,Anemia, unspecified,Kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
React-periton dialy cath,Septicemia NOS,Hyp kid NOS w cr kid V,Chronic obst asthma NOS,Parox ventric tachycard,Septic shock,Subendo infarct, initial,Severe sepsis,Anemia NOS,Abn react-renal dialysis
Admission Date:  [**2197-9-26**]              Discharge Date:   [**2197-9-27**]

Date of Birth:  [**2135-11-11**]             Sex:   F

Service: MED

Allergies:
Aspirin / Penicillins / Percocet / Benzodiazepines /
Cephalosporins

Attending:[**First Name3 (LF) 14385**]
Chief Complaint:
Lethargy, abdominal pain.

Major Surgical or Invasive Procedure:
L subclavian central line

History of Present Illness:
Mrs. [**Known firstname **] [**Known lastname **] is a 61 yo F with PmHx significant for ESRD
on peritoneal dialysis, DMII, CAD, HTN, COPD, asthma, PVD s/p
bilateral AKA, s/p MVR, h/o PE, h/o MRSA bacteremia, h/o
endocarditis, breast ca s/p mastectomy, recently hospitalized
[**9-8**] - [**9-12**] with hypotension thought secondary to diarrhea and
poor PO intake, who presents to the ED with lethargy and
abdominal pain.  The patient is unable to provide history at the
time of ED presentation, but per her son who later arrived and
who lives with her, Mrs. [**Known lastname **] had been complaining of
abdominal pain for the past week.   Of note, she had been
administered 2g of vancomycin intraperitoneally [**9-13**] at [**Location (un) 4265**]
where she receives peritoneal dialysis (no gram stain or culture
data is available, and it is unclear from disucssions with the
renal fellow why antiobiotics were administered).  She
apparently only received one dose of IP antibiotics at [**Location (un) 4265**].
Per her son, Mrs. [**Known lastname **] was evaluated for abdominal pain and
fatigue at [**Hospital6 **] ED several days prior to this
presentation for abdominal pain and lethargy, was given fluids,
though was not admitted.  Mrs.[**Name (NI) 14386**] son also noted drainage
and irration around the PD exit site and was told to apply
antibiotic ointment to the area, which he did.  However, the
patient continued per report to experience abdominal pain.  The
morning of admission was noted to be increasingly lethargic,
with worsening abdominal pain, and was brought to the ED for
further evaluation.

On ED admission, she was noted to be hypothermic (T=33.7 C),
hypotensive. (BP 92/50), tachycardic (HR 130s), and hypoxic,
tachypnic (RR in the 30s), with initial O2 sat 63% in the ED
(noted to be hypoxic in the field, started on NRB prior to ED
presentation).  Initial blood glucoses were in the 70s.
Unsuccessful attempts were made at placemet of femoral CVL, and
and left EJ IV was placed.  The patient was intubated for
respiratory failure.  She was given saline boluses for a total
of 4L of NS, with minimal increase in blood pressure.  Initial
serum lactate was 8.9.  The source of the sepsis was unknown,
though felt possibly to be a secondary to a peritoneal
infection, given her localizing symptom of abdominal pain:
pritoneal fluid was drained, revealing purulent fluid that on
analysis demonstrated 17,000 WBC, though negative gram stain.
The patient was given levofloxacin 500 mg IV, flagyl 500mg IV,
and vancomycin 1g IV (ceftriaxone was not given, as the patient
has a history of cephalosporin and PCN allergy). The renal team
was consulted, and the patient was also given intraperitoneally
2 grams of vancomycin and 30mg of gentamycin.  A surgerical
consult was obtained, with plans for removal of the PD catheter
when patient stable enough for the procedure.

As the patient remained hypotensive despite fluid challagnes,
she was started on Levophed.  A L subclavian central line was
placed. The patient was started on empiric dexamethasone as per
the sepsis protocol, and was also started on an insulin drip for
tight glycemic control.  Though an anion gap acidosis was
present, she was acetone negative.

As above, the decision was made by the ED staff to intubate the
patient for respiratory failure.  As initial attempts at
contacting family were unsuccessful, the patient was intubated
in the ED, and begun on CMV ventillation.  However, when contact
with family were acheived, the family (including HCP) stated
that patient had voiced a definite DNR/DNI advanced directive.
A family meeting was held between the ED staff and the family,
and at the wishes of the patient's family, the patient was
extubated.  Her post-extubation ABG was: pH
7.19/PaCo2=33/PaO2=66 (intubated ABG pH 7.20/
PaCO2=27/PaO2=470). The family (including HCP) again explained
that the patient was to be DNR/DNI, though they desired
otherwise aggressive medical therapy, including vasopressor
usage as necessary.

Mrs. [**Known lastname **] was also noted in the ED to have an irregular
atrial tachycardic rhythm that appeared to be new-onset atrial
fibrillation with rapid ventricular response (with rates up to
the 140-150s), with inferiolateral ischemic changes.   She ruled
in for myocardial infarction with a peak troponin I of 1.45,
peak CK of 704, peak CK-MB of 53, peak MB index of 8.7.
Attempts were made to wean off the Levophed as tolerated, given
its beta-agonistic effects, and she appeared to reconvert to NSR
with rates in the 90s-100s.  The patient was given further fluid
boluses (carefully, given the DNI status and ESRD), and
vasopressin was initiated to maintain adequate blood pressure.
As she has an aspirin allergy, no aspirin was administered (she
does however take Plavix).  Given her hypotension/sepsis, no
beta-blockers were initiated.

Past Medical History:
ESRD, on peritoneal dialysis
DM II
CAD (no cardiac catheterizations), +stress test.
s/p MVR
PVD s/p bilateral AKA
DMII
HTN
COPD
asthma
DVT and PE
MRSA bacteremia
endocarditis
breast cancer, s/p mastectomy
s/p TAH/BSO

Social History:
patient has an approximate 60 pack-year tobacco history.
No EtoH or IVDU.
Lives with adult children.
Jehovas witness.

Family History:
NC

Physical Exam:
T=34.1, BP 97/55 (on 20 of Levophed), HR 117 RR 30 100% on RA
Patient found lying in semi-recumbant position, frequently
groaning, though laying still.
Anicteric, conjunctiva uninjected, MM dry, no sores or lesions
in OP
L EJ catheter in place.  No JVD.  No bruits
Irreg tachy rhythm, nl s1 s2, no M/R/G
CTA
s/p mastectomy
abd soft, diffusely tender to palpation, though without rebound
or guarding.  No [**Doctor Last Name 515**] sign.
bilateral AKA.
No rashes
L-sided forearm fistula without thrill, sclerotic in texture.
Awake, intermittently responds to questions, which she answers
with yes/no answers or short-sentences.  Oriented to person.  CN
exam limited (patient only occasionally responding to commands),
surgical R pupil, left reactive to light.  Neurological
examination appears non-focal.


Pertinent Results:
[**2197-9-27**] 06:45AM BLOOD WBC-14.3* RBC-3.60*# Hgb-11.7*# Hct-35.6*
MCV-99* MCH-32.5* MCHC-32.9 RDW-15.7* Plt Ct-183

[**2197-9-27**] 02:55AM BLOOD Hct-39.6#
[**2197-9-26**] 05:10PM BLOOD WBC-13.6* RBC-2.63*# Hgb-8.4*# Hct-26.8*#
MCV-102*# MCH-31.9 MCHC-31.3 RDW-15.4 Plt Ct-175
[**2197-9-26**] 05:10PM BLOOD Neuts-94.1* Bands-0 Lymphs-4.7*
Monos-1.0* Eos-0.2 Baso-0
[**2197-9-26**] 05:10PM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Burr-1+
[**2197-9-27**] 06:45AM BLOOD Plt Ct-183
[**2197-9-27**] 06:45AM BLOOD PT-13.9* PTT-30.0 INR(PT)-1.2
[**2197-9-26**] 05:10PM BLOOD Plt Ct-175
[**2197-9-26**] 05:10PM BLOOD PT-15.2* PTT-36.0* INR(PT)-1.5
[**2197-9-26**] 05:00PM BLOOD PT-13.4 PTT-25.7 INR(PT)-1.1
[**2197-9-27**] 06:45AM BLOOD Glucose-170* UreaN-37* Creat-6.1* Na-141
K-3.8 Cl-108 HCO3-15* AnGap-22*
[**2197-9-27**] 02:55AM BLOOD Glucose-219* UreaN-38* Creat-6.2* Na-140
K-3.9 Cl-107 HCO3-10* AnGap-27*
[**2197-9-26**] 05:10PM BLOOD Glucose-384* UreaN-31* Creat-5.2* Na-147*
K-3.1* Cl-115* HCO3-10* AnGap-25*
[**2197-9-27**] 06:45AM BLOOD CK(CPK)-549*
[**2197-9-27**] 02:55AM BLOOD LD(LDH)-245 CK(CPK)-704*
[**2197-9-26**] 05:10PM BLOOD ALT-17 AST-23 CK(CPK)-171* AlkPhos-51
Amylase-37 TotBili-0.3
[**2197-9-26**] 05:10PM BLOOD Lipase-17
[**2197-9-27**] 06:45AM BLOOD CK-MB-48* MB Indx-8.7* cTropnT-1.45*
[**2197-9-27**] 02:55AM BLOOD CK-MB-53* MB Indx-7.5* cTropnT-1.15*
[**2197-9-26**] 05:10PM BLOOD CK-MB-9 cTropnT-0.31*
[**2197-9-27**] 06:45AM BLOOD Calcium-8.9 Phos-7.0* Mg-1.7
[**2197-9-27**] 02:55AM BLOOD Calcium-9.0 Phos-7.5* Mg-1.8
[**2197-9-26**] 05:10PM BLOOD Calcium-5.7* Phos-6.7* Mg-1.4*
[**2197-9-27**] 02:55AM BLOOD HoldBLu-HOLD
[**2197-9-27**] 02:55AM BLOOD RedHold-HOLD
[**2197-9-27**] 02:55AM BLOOD GreenHd-HOLD
[**2197-9-26**] 05:10PM BLOOD GreenHd-HOLD
[**2197-9-27**] 12:02AM BLOOD Glucose-236* Lactate-7.9* Na-138 K-3.9
Cl-110
[**2197-9-26**] 06:11PM BLOOD Lactate-8.9*
[**2197-9-26**] 05:16PM BLOOD Glucose-300* Na-138 K-6.6* Cl-105
calHCO3-14*

Brief Hospital Course:
Several minutes after transport from the emergency room to the
MICU, the patient abruptly became tachycardic (patient's rhythm
had returned to NSR in the ED, and ECG of 4:54am revealed NSR),
with a heart rate that abruptly increased from approximately 90
bpm to the 130s.  Shortly thereafter (within seconds), Mrs.
[**Known lastname **] was noted to have a wide complex regular rhythm that
appeared to be ventricular tachycardia, which then abruptly
degenerated into ventricular fibrillation.  No pulses could be
palpated, no BP could be detected.  As the patient's family,
including her health care proxy [**Name (NI) 14387**] [**Name (NI) **], had clearly
voiced DNR status for the patient, no attempt was made at
cardiac resuscitation (clearly stated wishes for no electrical
cardioversion, and patient had no perfusing rhythm to allow
administration of pharmacological agents).  Time of death was
11:20am.  Immediate cause of death was cardiac arrest.

Of note, three sets of blood cultures and peritoneal fluid
cultures, all obtained prior to administration to antibiotics
per ED records, did not grow any microorganisms.

Medications on Admission:
Ipratropium inh
Albuterol inh
folic acid
Timolol eye drops
Midodrine 2.5 by mouth [**Hospital1 **]
Sevelamer 800 PO TID
Metoprolol PO 25 BID
Plavix 75 PO QD
Protonix 40 QD
Nephrocaps

Discharge Medications:
n/A

Discharge Disposition:
Expired

Discharge Diagnosis:
Septic Shock
Peritonitis
atrial fibrillation with rapid ventricular response
anemia
myocardial infarction
End stage renal disease
Diabetes Mellitus
Coronary artery disease
chronic obstructive pulmonary disease
asthma
history of breast cancer, status post mastectomy
status post bilateral above the knee amputations

Discharge Condition:
deceased

Discharge Instructions:
n/a

Followup Instructions:
n/a


Completed by:[**2197-10-6**]
{'Infection and inflammatory reaction due to peritoneal dialysis catheter,Unspecified septicemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic obstructive asthma, unspecified,Paroxysmal ventricular tachycardia,Septic shock,Subendocardial infarction, initial episode of care,Severe sepsis,Anemia, unspecified,Kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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: Lethargy, abdominal pain.

PRESENT ILLNESS: Mrs. [**Known firstname **] [**Known lastname **] is a 61 yo F with PmHx significant for ESRD
on peritoneal dialysis, DMII, CAD, HTN, COPD, asthma, PVD s/p
bilateral AKA, s/p MVR, h/o PE, h/o MRSA bacteremia, h/o
endocarditis, breast ca s/p mastectomy, recently hospitalized
[**9-8**] - [**9-12**] with hypotension thought secondary to diarrhea and
poor PO intake, who presents to the ED with lethargy and
abdominal pain.  The patient is unable to provide history at the
time of ED presentation, but per her son who later arrived and
who lives with her, Mrs. [**Known lastname **] had been complaining of
abdominal pain for the past week.   Of note, she had been
administered 2g of vancomycin intraperitoneally [**9-13**] at [**Location (un) 4265**]
where she receives peritoneal dialysis (no gram stain or culture
data is available, and it is unclear from disucssions with the
renal fellow why antiobiotics were administered).  She
apparently only received one dose of IP antibiotics at [**Location (un) 4265**].
Per her son, Mrs. [**Known lastname **] was evaluated for abdominal pain and
fatigue at [**Hospital6 **] ED several days prior to this
presentation for abdominal pain and lethargy, was given fluids,
though was not admitted.  Mrs.[**Name (NI) 14386**] son also noted drainage
and irration around the PD exit site and was told to apply
antibiotic ointment to the area, which he did.  However, the
patient continued per report to experience abdominal pain.  The
morning of admission was noted to be increasingly lethargic,
with worsening abdominal pain, and was brought to the ED for
further evaluation.

MEDICAL HISTORY: ESRD, on peritoneal dialysis
DM II
CAD (no cardiac catheterizations), +stress test.
s/p MVR
PVD s/p bilateral AKA
DMII
HTN
COPD
asthma
DVT and PE
MRSA bacteremia
endocarditis
breast cancer, s/p mastectomy
s/p TAH/BSO

MEDICATION ON ADMISSION: Ipratropium inh
Albuterol inh
folic acid
Timolol eye drops
Midodrine 2.5 by mouth [**Hospital1 **]
Sevelamer 800 PO TID
Metoprolol PO 25 BID
Plavix 75 PO QD
Protonix 40 QD
Nephrocaps

ALLERGIES: Aspirin / Penicillins / Percocet / Benzodiazepines /
Cephalosporins

PHYSICAL EXAM: T=34.1, BP 97/55 (on 20 of Levophed), HR 117 RR 30 100% on RA
Patient found lying in semi-recumbant position, frequently
groaning, though laying still.
Anicteric, conjunctiva uninjected, MM dry, no sores or lesions
in OP
L EJ catheter in place.  No JVD.  No bruits
Irreg tachy rhythm, nl s1 s2, no M/R/G
CTA
s/p mastectomy
abd soft, diffusely tender to palpation, though without rebound
or guarding.  No [**Doctor Last Name 515**] sign.
bilateral AKA.
No rashes
L-sided forearm fistula without thrill, sclerotic in texture.
Awake, intermittently responds to questions, which she answers
with yes/no answers or short-sentences.  Oriented to person.  CN
exam limited (patient only occasionally responding to commands),
surgical R pupil, left reactive to light.  Neurological
examination appears non-focal.

FAMILY HISTORY: NC

SOCIAL HISTORY: patient has an approximate 60 pack-year tobacco history.
No EtoH or IVDU.
Lives with adult children.
Jehovas witness. 

### Response:
{'Infection and inflammatory reaction due to peritoneal dialysis catheter,Unspecified septicemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic obstructive asthma, unspecified,Paroxysmal ventricular tachycardia,Septic shock,Subendocardial infarction, initial episode of care,Severe sepsis,Anemia, unspecified,Kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
