CHIEF COMPLAINT: agitation, urosepsis, resp failure

PRESENT ILLNESS: 77F PMH HTN, osteoarthritis, R total hip 10yrs ago, depression
was vacationing in bermuda until [**2168-2-3**], returned home, did not
feel well on the night of return, tired, "did not seem self,"
appeared confused, acting strangely. C/O extremie thirst, no CP,
no SOB, no fevers, no URI-like sx, no nausea, no vomiting, no
dysuria. MS seemed worse on the next am with increased agitation
and confusion, incoherence, emotional changes, so brought to
[**Hospital 16843**] Hospital on [**2-5**]. Lyme negative, [**Doctor First Name **] negative. At LH,
dx'd with arf (cr 3.3) baseline 1.1-1.3, dx'd to have a e.coli
uti (10-15wbc, 3+ bacteria) (later found to be quinolone
resistant). BCx eventually grew out ecoli, resistant to
quinolones as well. The patient was started on abx (given levo
in the ed, then changed to cefazolin, then changed to ctx).
Improving MS on the 4th, but then in the afternoon agitated, +
restless, low sats, very emotionally upset, c/o abdominal and
back pain, moved bowels, got back into bed, but was agitated and
found to be hypoxic with sats in the low 80s abg 7.35/24/48/13
on 5L NC, intubated, xferrerd to ICU. HTN 140s-170s-->xferred to
ICU, ecoli in urine found to be R quinolones and sulfa,
sensitive to cephs and pcn. Started on heparin gtt, head ct neg.
CXR showed bilat fluffy infiltraes, concern for ARDS, concern
for PE (V/Q not done, could do CTA due to renal failure), placed
on NRB, satting 96%. Bcx x 2 from [**2-5**] GNRs (later to be found
E.coli).
.
Resp failure was attributed to ards, pt subsequentally intubated
on [**2168-2-8**]; started on versed+MSO4 for sedation, patient was
generally unresponsive, not following commands. Cr improved to
2.4 on [**2-8**]. Pt was tx'd with ctx. On [**2-9**]; pt was on cpap, doing
well, mental status improving. Echo performed [**2-9**]; normal LV fx,
small pericardial effusion. Pt was extubated on [**2-10**], within
12hrs required re-intubation for inability to protect airway.
She was doing well from resp mechanics point of view. Mental
status worsened, patient was more delirious with psychomotor
agitation, moving all 4 extremities at full strength, not able
to interact. Mutliple attemps were made to sedate the patient,
including propofol, which resulted in HTN, so it was stopped,
haldol, versed, ativan. She remained agitated, writhign in bed;
unresponsive to ativan. [**2-11**] CXR poor quality cxr, could not r/o
nosocomial pna, ID ocnsulted. The patient was started on vanc
1gm IV q 24 for hosp acquired PNA, zosyn 3.375 IV q 6 hrs were
started for urosepsis. She was also receiving lopressor 5mg IV q
4hrs for HTH, Morphine and ativan. Neuro consult was obtained
and dx'd pt with toxic metabolic encephalopathy [**1-8**] urosepsis
and resp failure. Psych consulted, dx'ed acute delirium,
recommended celexa and haldol PRN. Pt was never LP's and MRI was
not obtained.

MEDICAL HISTORY: HTN
osteoarthritis
hyperlipidemia
s/p hip replacement 10 yrs ago
s/p ccy 2 yrs ago
depression
DJD

MEDICATION ON ADMISSION: atenolol 100 p qd
buproprion ER 100 po bid
morphine sulfate 15mg 1 tab po bid
fluoxetine 20 mg 3 tabs daily
cyclobenzaprine 10mg 1 tab tid
protonix 40 po bid
celebrex 200 [**Hospital1 **] prn

ALLERGIES: Penicillins / Horse Blood Extract / Fentanyl

PHYSICAL EXAM: PE: T: 99.7 BP: 80-160/42-70  HR: 116 RR: 25 O2 %100 on CPAP+ PS
[**7-10**].
Gen: agitated, psychomotor delirium not following commands
HEENT: very dry muc membranes.  pupils reactive to light.
NECK: Supple, No LAD, No JVD. Large bulky thyroid on left.
Patient acutely agitated, unable to complete full neuro exam.
CV: tachycardic, nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**]
LUNGS: CTAB, mild bibasilar crackles. soft exp sounds
ABD: + bowel sounds. Soft, ND. NL BS.  No HSM. multiple bruises
on abdomen
EXT: WWP, NO CCE. 2+ DP pulses BL
SKIN: diffuse echymoses.
NEURO: psychomotor agitation.

FAMILY HISTORY: 

SOCIAL HISTORY: pt most likely a smoker, hides it from husband, husband not sure
how much she smokes.  2 glasses of wine q night.  lives at home
with husband. usually functions at a very high level
Septicemia due to escherichia coli [E. coli],Acute respiratory failure,Urinary tract infection, site not specified,Toxic encephalopathy,Pneumonia, organism unspecified,Acute kidney failure, unspecified,Pressure ulcer, lower back,Delirium due to conditions classified elsewhere,Severe sepsis,Unspecified essential hypertension,Diarrhea,Hip joint replacement,Tobacco use disorder,Other nonspecific abnormal serum enzyme levels,Osteoarthrosis, unspecified whether generalized or localized, site unspecified
E coli septicemia,Acute respiratry failure,Urin tract infection NOS,Toxic encephalopathy,Pneumonia, organism NOS,Acute kidney failure NOS,Pressure ulcer, low back,Delirium d/t other cond,Severe sepsis,Hypertension NOS,Diarrhea,Joint replaced hip,Tobacco use disorder,Abn serum enzy level NEC,Osteoarthros NOS-unspec
Admission Date:  [**2168-2-12**]              Discharge Date:   [**2168-2-27**]

Date of Birth:  [**2090-12-4**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Horse Blood Extract / Fentanyl

Attending:[**First Name3 (LF) 1974**]
Chief Complaint:
agitation, urosepsis, resp failure

Major Surgical or Invasive Procedure:
Intubation


History of Present Illness:
77F PMH HTN, osteoarthritis, R total hip 10yrs ago, depression
was vacationing in bermuda until [**2168-2-3**], returned home, did not
feel well on the night of return, tired, "did not seem self,"
appeared confused, acting strangely. C/O extremie thirst, no CP,
no SOB, no fevers, no URI-like sx, no nausea, no vomiting, no
dysuria. MS seemed worse on the next am with increased agitation
and confusion, incoherence, emotional changes, so brought to
[**Hospital 16843**] Hospital on [**2-5**]. Lyme negative, [**Doctor First Name **] negative. At LH,
dx'd with arf (cr 3.3) baseline 1.1-1.3, dx'd to have a e.coli
uti (10-15wbc, 3+ bacteria) (later found to be quinolone
resistant). BCx eventually grew out ecoli, resistant to
quinolones as well. The patient was started on abx (given levo
in the ed, then changed to cefazolin, then changed to ctx).
Improving MS on the 4th, but then in the afternoon agitated, +
restless, low sats, very emotionally upset, c/o abdominal and
back pain, moved bowels, got back into bed, but was agitated and
found to be hypoxic with sats in the low 80s abg 7.35/24/48/13
on 5L NC, intubated, xferrerd to ICU. HTN 140s-170s-->xferred to
ICU, ecoli in urine found to be R quinolones and sulfa,
sensitive to cephs and pcn. Started on heparin gtt, head ct neg.
CXR showed bilat fluffy infiltraes, concern for ARDS, concern
for PE (V/Q not done, could do CTA due to renal failure), placed
on NRB, satting 96%. Bcx x 2 from [**2-5**] GNRs (later to be found
E.coli).
.
Resp failure was attributed to ards, pt subsequentally intubated
on [**2168-2-8**]; started on versed+MSO4 for sedation, patient was
generally unresponsive, not following commands. Cr improved to
2.4 on [**2-8**]. Pt was tx'd with ctx. On [**2-9**]; pt was on cpap, doing
well, mental status improving. Echo performed [**2-9**]; normal LV fx,
small pericardial effusion. Pt was extubated on [**2-10**], within
12hrs required re-intubation for inability to protect airway.
She was doing well from resp mechanics point of view. Mental
status worsened, patient was more delirious with psychomotor
agitation, moving all 4 extremities at full strength, not able
to interact. Mutliple attemps were made to sedate the patient,
including propofol, which resulted in HTN, so it was stopped,
haldol, versed, ativan. She remained agitated, writhign in bed;
unresponsive to ativan. [**2-11**] CXR poor quality cxr, could not r/o
nosocomial pna, ID ocnsulted. The patient was started on vanc
1gm IV q 24 for hosp acquired PNA, zosyn 3.375 IV q 6 hrs were
started for urosepsis. She was also receiving lopressor 5mg IV q
4hrs for HTH, Morphine and ativan. Neuro consult was obtained
and dx'd pt with toxic metabolic encephalopathy [**1-8**] urosepsis
and resp failure. Psych consulted, dx'ed acute delirium,
recommended celexa and haldol PRN. Pt was never LP's and MRI was
not obtained.


Past Medical History:
HTN
osteoarthritis
hyperlipidemia
s/p hip replacement 10 yrs ago
s/p ccy 2 yrs ago
depression
DJD

Social History:
pt most likely a smoker, hides it from husband, husband not sure
how much she smokes.  2 glasses of wine q night.  lives at home
with husband. usually functions at a very high level

Physical Exam:
PE: T: 99.7 BP: 80-160/42-70  HR: 116 RR: 25 O2 %100 on CPAP+ PS
[**7-10**].
Gen: agitated, psychomotor delirium not following commands
HEENT: very dry muc membranes.  pupils reactive to light.
NECK: Supple, No LAD, No JVD. Large bulky thyroid on left.
Patient acutely agitated, unable to complete full neuro exam.
CV: tachycardic, nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**]
LUNGS: CTAB, mild bibasilar crackles. soft exp sounds
ABD: + bowel sounds. Soft, ND. NL BS.  No HSM. multiple bruises
on abdomen
EXT: WWP, NO CCE. 2+ DP pulses BL
SKIN: diffuse echymoses.
NEURO: psychomotor agitation.

Pertinent Results:
[**2168-2-14**] CXR: AP chest compared to [**2-12**] and 10:

Left lower lobe atelectasis is largely cleared. Mild pulmonary
edema has developed at the right lung base although heart size
is normal and there is no mediastinal vascular engorgement. No
pleural effusion or pneumothorax seen. ET tube, left subclavian
line, and nasogastric tube are in standard placements
respectively.
.
[**2168-2-15**] MR HEAD: 1) No evidence of infarction or other acute
process to explain the patient's symptoms.
2) Faint 2-mm contour abnormality off the left ICA at the
expected takeoff of the left opthalmic artery, seen only on the
reformatted MIP images, thought most likely to be artifactual.
If further workup is clinically indicated, a CT angiogram would
better assess this finding.
.
[**2168-2-18**] ABD U/S: Unremarkable abdominal ultrasound.
.
[**2168-2-20**] CXR: The cardiac silhouette is stable. There is
unchanged mild pulmonary edema. There is unchanged small right
pleural effusion with a new left small pleural effusion. There
is no pneumothorax.
.
[**2168-2-23**] ECG: Sinus rhythm
Atrial premature complex
Probable left atrial abnormality
Modest nonspecific T wave changes
Since previous tracing of [**2168-2-19**], sinus tachycardia absent,
delayed R wave
progression less prominent and ST-T wave changes decreased
.

FROM OSH:
[**2-11**] labs: wbc 12.8, hct 27.2, plt 314, 17% bands
INR: 1.0
ESR: 76-->110
chem 7 [**2-11**]
144
3.6
109
24
49
2.1(1.7 lowest it was at OSH)
.
alb 2.1
.
iron 40
tibc 289
.
bnp 1670 [**2168-2-7**]; decreased to 121 on [**2-11**]
.
LFTs [**2-10**] ([**2-5**])
t bili 0.4
alp 106
alt 31 (78)
ast 31  (133)
.
CE's negative
.
CXR: [**2-12**] [**Hospital1 18**]: retrocardiac opacity, increased vascular
markings R lung.
.
abg's: [**2-9**]: 7.43/27/102/18 FIO2 0.5/PEEP 10
.
Cx results:
blood [**2-5**] (4/4 bottles): ecoli ([**Last Name (un) 36**] to amp and cephazolin, R to
levo/cipro, [**Last Name (un) 36**] to zosyn, gent bactrim)/gpc's on gram stain.
.
still isolating gpc's seen on gram stain.
.
[**2168-2-5**] urine: ecoli: same resistance as above.
.
IMAGING:
From OSH: CXR: [**2168-2-9**]: new airspace disease in LLL
[**2168-2-10**]: improved aeration in lung fields. no infiltrates
appreciated
[**2168-2-8**]: significant improvement in interstitial and alveolar
opacities
[**2168-2-7**]: diffuse bilateral airspace disease
[**2168-2-5**]: CXR: normal
.
[**2168-2-7**]: CT head. normal.
.
[**2168-2-6**] abd us: intrahepatic dilatation. prominent CBD (can be
seen after surgery). kidneys ok.
.
Echo: small pericardial effusion; preserved ef (no report, just
per notes).


Brief Hospital Course:
1) DELERIUM:
On initial presentation, the patient was very agitated.  This
improved throughout admission especially after extubation in
ICU.  However, she remained confused and not at her baseline.
Both neurology and geriatrics were consulted.  Workup did not
reveal any organic cause and it was felt delerium was secondary
to acute illness and ICU hospitalization.  MRI was essentially
normal.  An LP was never performed as pt's mental status
improved.  Her mental status was improving slowly but
progressively.  She was started on zyprexa to prevent agitation
with success.  This can be slowly weaned as her delerium
improves.  Based upon discussion with PCP and family, there was
a possiblity of pre-existing underlying dementia which may
explain severity of delerium, but this will need to be formally
evaluated after delerium improves.  Her outpt meds which
included morphine, bupropion were eliminated.
.
2) SEPSIS:
See HPI for prior course.  Pt had resistant E. coli in urine
culture and completed a 14d course of antibiotics with
meropenem.  There was no recurrence of infectious signs or
symptoms after completion of antibiotics.
.
3) RESPIRATORY FAILURE:
Likely multifactorial with question of ARDS secondary to sepsis.
 After second extubation in ICU and completion of vanco for
pneumonia, pt's respiratory status was stable and normal.
.
4) ABNORMAL LFTs:
Pt had mildly elevated transaminases and alk phos.  She had no
abdominal pain and imaging did not show any hepatobiliary
pathology.  Hepatitis serologies were normal.  It may have been
secondary to sepsis.  Pt continued to have mild transaminitis
and should have rpt LFTs in [**12-8**] weeks to assure normalization.
.
5) HTN:
Well controlled on home dose of atenolol.


Medications on Admission:
atenolol 100 p qd
buproprion ER 100 po bid
morphine sulfate 15mg 1 tab po bid
fluoxetine 20 mg 3 tabs daily
cyclobenzaprine 10mg 1 tab tid
protonix 40 po bid
celebrex 200 [**Hospital1 **] prn


Discharge Medications:
1. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)).
3. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.


Discharge Disposition:
Extended Care

Facility:
[**Hospital 16844**] Hospital - [**Location (un) 1157**]

Discharge Diagnosis:
PRIMARY:
Urosepsis
Respiratory failure
Delerium
[**Hospital 7502**] hospital-acquired
.
SECONDARY:
Hypertension
Depression
Osteoarthritis


Discharge Condition:
Good--vital signs stable.


Discharge Instructions:
1.  Take medications as prescribed.
2.  Follow up as below.
3.  You can call Dr. [**Last Name (STitle) **] or physician at rehab if you have any
fevers, pain, shortness of breath, worsening confusion.

Followup Instructions:
1. DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2983**] Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2168-3-29**]
10:00, Memory Clinic

2. Please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (PCP) to schedule a follow-up
appointment once you leave rehab. [**Telephone/Fax (1) 4775**].
{'Septicemia due to escherichia coli [E. coli],Acute respiratory failure,Urinary tract infection, site not specified,Toxic encephalopathy,Pneumonia, organism unspecified,Acute kidney failure, unspecified,Pressure ulcer, lower back,Delirium due to conditions classified elsewhere,Severe sepsis,Unspecified essential hypertension,Diarrhea,Hip joint replacement,Tobacco use disorder,Other nonspecific abnormal serum enzyme levels,Osteoarthrosis, unspecified whether generalized or localized, site 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: agitation, urosepsis, resp failure

PRESENT ILLNESS: 77F PMH HTN, osteoarthritis, R total hip 10yrs ago, depression
was vacationing in bermuda until [**2168-2-3**], returned home, did not
feel well on the night of return, tired, "did not seem self,"
appeared confused, acting strangely. C/O extremie thirst, no CP,
no SOB, no fevers, no URI-like sx, no nausea, no vomiting, no
dysuria. MS seemed worse on the next am with increased agitation
and confusion, incoherence, emotional changes, so brought to
[**Hospital 16843**] Hospital on [**2-5**]. Lyme negative, [**Doctor First Name **] negative. At LH,
dx'd with arf (cr 3.3) baseline 1.1-1.3, dx'd to have a e.coli
uti (10-15wbc, 3+ bacteria) (later found to be quinolone
resistant). BCx eventually grew out ecoli, resistant to
quinolones as well. The patient was started on abx (given levo
in the ed, then changed to cefazolin, then changed to ctx).
Improving MS on the 4th, but then in the afternoon agitated, +
restless, low sats, very emotionally upset, c/o abdominal and
back pain, moved bowels, got back into bed, but was agitated and
found to be hypoxic with sats in the low 80s abg 7.35/24/48/13
on 5L NC, intubated, xferrerd to ICU. HTN 140s-170s-->xferred to
ICU, ecoli in urine found to be R quinolones and sulfa,
sensitive to cephs and pcn. Started on heparin gtt, head ct neg.
CXR showed bilat fluffy infiltraes, concern for ARDS, concern
for PE (V/Q not done, could do CTA due to renal failure), placed
on NRB, satting 96%. Bcx x 2 from [**2-5**] GNRs (later to be found
E.coli).
.
Resp failure was attributed to ards, pt subsequentally intubated
on [**2168-2-8**]; started on versed+MSO4 for sedation, patient was
generally unresponsive, not following commands. Cr improved to
2.4 on [**2-8**]. Pt was tx'd with ctx. On [**2-9**]; pt was on cpap, doing
well, mental status improving. Echo performed [**2-9**]; normal LV fx,
small pericardial effusion. Pt was extubated on [**2-10**], within
12hrs required re-intubation for inability to protect airway.
She was doing well from resp mechanics point of view. Mental
status worsened, patient was more delirious with psychomotor
agitation, moving all 4 extremities at full strength, not able
to interact. Mutliple attemps were made to sedate the patient,
including propofol, which resulted in HTN, so it was stopped,
haldol, versed, ativan. She remained agitated, writhign in bed;
unresponsive to ativan. [**2-11**] CXR poor quality cxr, could not r/o
nosocomial pna, ID ocnsulted. The patient was started on vanc
1gm IV q 24 for hosp acquired PNA, zosyn 3.375 IV q 6 hrs were
started for urosepsis. She was also receiving lopressor 5mg IV q
4hrs for HTH, Morphine and ativan. Neuro consult was obtained
and dx'd pt with toxic metabolic encephalopathy [**1-8**] urosepsis
and resp failure. Psych consulted, dx'ed acute delirium,
recommended celexa and haldol PRN. Pt was never LP's and MRI was
not obtained.

MEDICAL HISTORY: HTN
osteoarthritis
hyperlipidemia
s/p hip replacement 10 yrs ago
s/p ccy 2 yrs ago
depression
DJD

MEDICATION ON ADMISSION: atenolol 100 p qd
buproprion ER 100 po bid
morphine sulfate 15mg 1 tab po bid
fluoxetine 20 mg 3 tabs daily
cyclobenzaprine 10mg 1 tab tid
protonix 40 po bid
celebrex 200 [**Hospital1 **] prn

ALLERGIES: Penicillins / Horse Blood Extract / Fentanyl

PHYSICAL EXAM: PE: T: 99.7 BP: 80-160/42-70  HR: 116 RR: 25 O2 %100 on CPAP+ PS
[**7-10**].
Gen: agitated, psychomotor delirium not following commands
HEENT: very dry muc membranes.  pupils reactive to light.
NECK: Supple, No LAD, No JVD. Large bulky thyroid on left.
Patient acutely agitated, unable to complete full neuro exam.
CV: tachycardic, nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**]
LUNGS: CTAB, mild bibasilar crackles. soft exp sounds
ABD: + bowel sounds. Soft, ND. NL BS.  No HSM. multiple bruises
on abdomen
EXT: WWP, NO CCE. 2+ DP pulses BL
SKIN: diffuse echymoses.
NEURO: psychomotor agitation.

FAMILY HISTORY: 

SOCIAL HISTORY: pt most likely a smoker, hides it from husband, husband not sure
how much she smokes.  2 glasses of wine q night.  lives at home
with husband. usually functions at a very high level 

### Response:
{'Septicemia due to escherichia coli [E. coli],Acute respiratory failure,Urinary tract infection, site not specified,Toxic encephalopathy,Pneumonia, organism unspecified,Acute kidney failure, unspecified,Pressure ulcer, lower back,Delirium due to conditions classified elsewhere,Severe sepsis,Unspecified essential hypertension,Diarrhea,Hip joint replacement,Tobacco use disorder,Other nonspecific abnormal serum enzyme levels,Osteoarthrosis, unspecified whether generalized or localized, site unspecified'}
