CHIEF COMPLAINT: AMS

PRESENT ILLNESS: 87 yo F with T2DM c/b peripheral neuropathy, CAD s/p stent,
chronic anemia, HTN, h/o PE on warfarin and other medical issues
presents from home with AMS.

MEDICAL HISTORY: Past Medical History:
Diabetes mellitus type 2
Hypertension
Peripheral vascular disease
Open wounds on the legs that are not healing
Peripheral neuropathy
Hyperthyroidism
History of pulmonary embolism, on warfarin
Urinary incontinence
Coronary artery disease s/p stent
Chronic anemia (baseline 30)
Chronic kidney disease (baseline 1.5)
Venous ulcers
LLE ulcer infection [**5-/2109**]

MEDICATION ON ADMISSION: - atenolol 50 mg daily
- Cosopt one gtt each eye at bedtime
- furosemide 40 mg daily
- mirtazapie 15 mg qHS
- warfarin 10 mg on Wednesday/Friday and 15 mg 5 other days
- Xalatan 0.005% 1 drop each eye at bedtime
- ASA 81 mg daily
- ferrous sulfate 325 mg daily
- MVI senior
- NPH 9 unit qAM and 7 unit qHS
- omeprazole

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM:
Vitals: HR 120, 152/100-> 69/48, RR 20, 15L on NR.  Unable to
get O2Sat
General: Alert, not oriented, does not answer questions but
grimace to pain
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: tachycardic, irregular, unable to appreciate m/r/g
Lungs: anterior left lower lung field has rhonchi, no
wheeze/crackles; otherwise clear to auscultation bilaterally
Abdomen: soft, tender to the left abd and suprapubic,
nondistended, BS+
GU: Foley draining pink thick urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Limited neurological exam given mental status, tracks to
voice, moves all upper extremities

FAMILY HISTORY: - mother died in her 80s [**1-17**] complication of Alzheimer's diease
- father had TB

SOCIAL HISTORY: Per d/c summary [**5-/2109**]
- in the process of getting Hospice involved
- married, lives with husband [**Name (NI) **]
- has 4 sons
- retired in [**2083**] from [**Hospital1 112**] as a OBGYN nurse
- quit smoking 20 yrs ago, about 20-30 years of smoking and no
more than 20-30 ppd
- rare EtOH
- denies illicit drugs
Unspecified septicemia,Septic shock,Acute pyelonephritis without lesion of renal medullary necrosis,Acute kidney failure, unspecified,Hyperosmolality and/or hypernatremia,Paroxysmal ventricular tachycardia,Ulcer of ankle,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Anemia, unspecified,Long-term (current) use of anticoagulants,Personal history of pulmonary embolism,Do not resuscitate status,Diabetes with neurological manifestations, type II or unspecified type, uncontrolled,Polyneuropathy in diabetes,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Personal history of tobacco use,Severe sepsis,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Peripheral vascular disease, unspecified
Septicemia NOS,Septic shock,Ac pyelonephritis NOS,Acute kidney failure NOS,Hyperosmolality,Parox ventric tachycard,Ulcer of ankle,Crnry athrscl natve vssl,Status-post ptca,Anemia NOS,Long-term use anticoagul,Hx pulmonary embolism,Do not resusctate status,DMII neuro uncntrld,Neuropathy in diabetes,Chronic kidney dis NOS,Hy kid NOS w cr kid I-IV,History of tobacco use,Severe sepsis,Abnrml coagultion prfile,Adv eff anticoagulants,Periph vascular dis NOS
Admission Date:  [**2109-10-16**]              Discharge Date:   [**2109-10-18**]

Date of Birth:  [**2022-7-8**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
AMS

Major Surgical or Invasive Procedure:
None

History of Present Illness:
87 yo F with T2DM c/b peripheral neuropathy, CAD s/p stent,
chronic anemia, HTN, h/o PE on warfarin and other medical issues
presents from home with AMS.

Touched base with patient's PCP who states that patient has not
been doing well with slow decline, and hospice option has been
entertained recently.  She is supposed to have hospice nurse
visiting for initial evaluation on Monday.  Patient has been
noted to be depressed but mentating well at baseline.

Per patient's husband, patient has not been eating well or
drinking well for the last few weeks.  Her mental status
declined significantly over the last week.  She has complained
about suprapubic pain for the last few days.  She had VNA on
Monday

Per EMS, patient is arousable with verbal stimuli, FSBS 311.
Patient appeared dry, cool to touch.

In the ED, inital VS were 97.8 72 148/104 22.  Per report, + red
blood on guaiac.  Rectal temp was thought to be 96.  Patient was
thought to be alert and oriented x 0.  Labs show WBC 15.4,
neutrophils 90%, H/H 12.5/39.6 (baseline 8-9/24-30), Na 148, K
7.5, Cl 108, bicarb 18, BUN 166, Crt 11.7 (baseline 0.8-0.9),
glucose 390, Trop 0.08, CK 145, MB 6, AG 22, normal LFTs,
albumin 2.8, Osm 388, PT 150, PTT 150, INR 13.8.  VBG
7.33/32/83/18, lactate 3.6.  UA is grossly positive with large
leuk, large blood, protein 300, glucose 100, > 182 RBC, > 182
WBC, few bacteria, and no epi.  Blood culture and urine culture
were sent.  CXR showed no acute cardiopulmonary process.  No CT
head was done.  No renal ultrasound was done.  EKG showed SR 86
1dAVB, LAD, IVCD, peaked T's with mild STE anteriorly, QRS 102.
Per ED, patient is DNR/DNI.  Nephrology was consulted for ? need
of urgent dialysis, and it was recommended to treat
conservatively with IVF, repeat electrolyes, head CT and abd
imaging.  Patient was given 3L of NS, calcium gluconate 2g IV
x1, CTX 2 g IV x1, vancomycin 1g IV x1, pantoprazole 40 mg IVx1,
insulin regular sc 10 unit x 1 and 7 uni/hr insulin gtt, sodium
bicarb 50 mEq IV x 1.  Upon transfer, VS 108 129/94 24 96%

Patient arrives to the MICU with VS HR 120, 152/100, RR 20, 15L
on NR.  Unable to get O2Sat.  Patient then dropped SBP to 69/48.


Past Medical History:
Past Medical History:
Diabetes mellitus type 2
Hypertension
Peripheral vascular disease
Open wounds on the legs that are not healing
Peripheral neuropathy
Hyperthyroidism
History of pulmonary embolism, on warfarin
Urinary incontinence
Coronary artery disease s/p stent
Chronic anemia (baseline 30)
Chronic kidney disease (baseline 1.5)
Venous ulcers
LLE ulcer infection [**5-/2109**]

PAST SURGICAL HISTORY:
Hysterectomy [**2070**]
Partial thyroidectomy
Cholecystectomy [**2090**]
Cataract surgery bilaterally
Removal fibroadenoma of right breast
Cardiac stent placement
Skin grafts to LE (didn't take)


Social History:
Per d/c summary [**5-/2109**]
- in the process of getting Hospice involved
- married, lives with husband [**Name (NI) **]
- has 4 sons
- retired in [**2083**] from [**Hospital1 112**] as a OBGYN nurse
- quit smoking 20 yrs ago, about 20-30 years of smoking and no
more than 20-30 ppd
- rare EtOH
- denies illicit drugs


Family History:
- mother died in her 80s [**1-17**] complication of Alzheimer's diease
- father had TB


Physical Exam:
ADMISSION EXAM:
Vitals: HR 120, 152/100-> 69/48, RR 20, 15L on NR.  Unable to
get O2Sat
General: Alert, not oriented, does not answer questions but
grimace to pain
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: tachycardic, irregular, unable to appreciate m/r/g
Lungs: anterior left lower lung field has rhonchi, no
wheeze/crackles; otherwise clear to auscultation bilaterally
Abdomen: soft, tender to the left abd and suprapubic,
nondistended, BS+
GU: Foley draining pink thick urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Limited neurological exam given mental status, tracks to
voice, moves all upper extremities

DISCHARGE EXAM: Death confirmed

Pertinent Results:
ADMISSION LABS:

[**2109-10-16**] 11:20AM BLOOD WBC-15.4*# RBC-4.24# Hgb-12.5# Hct-39.6#
MCV-94 MCH-29.5 MCHC-31.6 RDW-13.9 Plt Ct-239
[**2109-10-16**] 11:20AM BLOOD Neuts-90.1* Lymphs-5.8* Monos-3.9 Eos-0.1
Baso-0.1
[**2109-10-16**] 11:20AM BLOOD PT-150* PTT-150* INR(PT)-13.8*
[**2109-10-16**] 11:20AM BLOOD Glucose-390* UreaN-166* Creat-11.7*#
Na-148* K-7.5* Cl-108 HCO3-18* AnGap-30*
[**2109-10-16**] 11:20AM BLOOD ALT-14 AST-22 CK(CPK)-145 AlkPhos-59
TotBili-0.4
[**2109-10-16**] 11:20AM BLOOD CK-MB-6
[**2109-10-16**] 11:20AM BLOOD cTropnT-0.08*
[**2109-10-16**] 03:28PM BLOOD cTropnT-0.06*
[**2109-10-16**] 08:15PM BLOOD cTropnT-0.11*
[**2109-10-17**] 01:45AM BLOOD cTropnT-0.13*
[**2109-10-16**] 11:20AM BLOOD Albumin-2.8* Calcium-9.0 Phos-7.9*#
Mg-2.8*
[**2109-10-16**] 11:20AM BLOOD Osmolal-388*
[**2109-10-16**] 11:28AM BLOOD Type-[**Last Name (un) **] pO2-83* pCO2-32* pH-7.33*
calTCO2-18* Base XS--7 Comment-GREEN TOP
[**2109-10-16**] 11:28AM BLOOD Glucose-349* Lactate-3.6* Na-147* K-7.2*
Cl-109*
[**2109-10-16**] 11:28AM BLOOD Hgb-12.8 calcHCT-38
[**2109-10-16**] 04:15PM BLOOD freeCa-1.00*

MICRO:

[**2109-10-16**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
[**2109-10-16**] URINE URINE CULTURE-FINAL {YEAST} EMERGENCY
[**Hospital1 **]
[**2109-10-16**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]

IMAGING:

[**10-16**] CXR:
AP supine portable view of the chest was obtained.  The lungs
are clear
without focal consolidation.  No pleural effusion or
pneumothorax is seen.  The cardiac and mediastinal silhouettes
are unremarkable.  Linear lucency projecting over the right
humeral head extending to project over the right glenoid is felt
to be artifactual. IMPRESSION: No acute cardiopulmonary process.


[**10-16**] Renal U/s

IMPRESSION:

1.  Echogenic material layering in the bladder and right-sided
bladder
diverticulum, concerning for purulent material in the setting of
clinical
cystitis.  Circumferential wall thickening of the bladder is
consistent with
cystitis.

2.  Mild-to-moderate left hydronephrosis with left hydroureter
to the level of
the bladder.  Cause indeterminate on this study, but this raises
the
possibility of obstruction at the left ureterovesicular
junction.
Non-obstructing nephrolithiasis was seen in the left kidney.

3.  Foley catheter in the bladder but bladder is still partially
distended.
Clinical correlation for catheter patency is recommended.


Brief Hospital Course:
87 yo F with T2DM c/b peripheral neuropathy, CAD s/p stent,
chronic anemia, HTN, h/o PE on warfarin and other medical issues
presents from home with AMS and marked electolyte abnormalities.
Found to have septic shock with pyelonephritis as most likely
source.

ACTIVE ISSUES:

1. Goals of Care: On [**10-17**], patient's goals of care were
transitioned to CMO. She received morphine 1-4 mg IV q2H for
comfort. She died on the morning of [**10-18**].

2. Hypotension/Septic shock.  Pyelonephritis was the most likely
etiology given + UA, tender abdomen, and renal ultrasound
showing L pyelonephritis. Other possible sources included skin
given LLE ulcers and sacral ulcer. Given high mortality
associated with patient's presentation and family's desire to
maximize comfort, patient's goals of care were transitioned to
CMO. Pressors and antibiotics were discontinued and she died on
the morning of [**10-18**].

3. UTI/Pyelonephritis.  Patient presented with a grossly
positive UA with evidence of pyelo on renal u/s. She was
initially treated with Vancomycin and Cefepime, and Cefepime was
switched to Zosyn for pseudomonal coverage. Antibiotics were
discontinued when patient was made CMO.

4. AMS.  Likely multifactorial in the setting of significant
metabolic derrangements and septic shock. Her baseline was A&Ox3
per the PCP although functionally had been declining over the
preceeding weeks to months with signs of failure to thrive.
Upon arrival to the [**Hospital Unit Name 153**], patient was A&Ox0.

5. Supratherapeutic INR. Patient's INR was 13 upon admission.
Warfarin was held. She received FFP and Vit K and INR normalized
to 1.6.

6. [**Last Name (un) **]. Patient presented with new [**Last Name (un) **], which was most likely
secondary to intravascular depletion in the setting of septic
shock and which was complicated by decreased bicarb,
hyperkalemia, hypernatremia and increased urea. Patient was
treated with fluid resuscitation and free water replacement and
medications were renally dosed. Dialysis was considered but
determined not to be in line with goals of care, and patient was
not a candidate for HD.

7. Hyperglycemia/T2DM.  Patient presented with hyperglycemia and
an anion gap of 22. She was started on an insulin gtt and
transitioned to humalog. Medications were discontinued when
patient became CMO.

8. Hyperkalemia.  Secondary to [**Last Name (un) **]. Resolved s/p insulin gtt.

9. Hypernatremia. Hyperglycemia was corrected and patient's free
water deficit was calculated and repleted. Sodium remained
elevated. When goals of care transitioned to CMO, further
chemistries were not checked.

10. Metabolic acidosis. Anion gap. Most likely due to underlying
renal failure.

11. Atrial fibrillation with RVR.  New onset. Most likely due to
underlying infection. Anticoagulation was held given
supratherapeutic INR upon admission.

12. Elevated troponin. Most likely in the setting of AF with RVR
and ARF. Patient was monitored on telemetry

13. History of PE. Warfarin was held for supratherapeutic INR.


14. Sacral decubitus ulcer. Patient received wound care.

15. Leg ulcers: Followed by Dr. [**Last Name (STitle) 1391**] of vascular. Patient
received wound care

16. Ventricular ectopy: Intermittent runs of NSVT, likely due to
electrolyte derangements. Patient received calcium gluconate
sliding scale and electrolytes were monitored frequently.

Patient died on the morning of [**2109-10-18**].

Medications on Admission:
- atenolol 50 mg daily
- Cosopt one gtt each eye at bedtime
- furosemide 40 mg daily
- mirtazapie 15 mg qHS
- warfarin 10 mg on Wednesday/Friday and 15 mg 5 other days
- Xalatan 0.005% 1 drop each eye at bedtime
- ASA 81 mg daily
- ferrous sulfate 325 mg daily
- MVI senior
- NPH 9 unit qAM and 7 unit qHS
- omeprazole


Discharge Medications:
N/A

Discharge Disposition:
Expired

Discharge Diagnosis:
N/A

Discharge Condition:
Deceased

Discharge Instructions:
N/A

Followup Instructions:
N/A

                             [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
{'Unspecified septicemia,Septic shock,Acute pyelonephritis without lesion of renal medullary necrosis,Acute kidney failure, unspecified,Hyperosmolality and/or hypernatremia,Paroxysmal ventricular tachycardia,Ulcer of ankle,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Anemia, unspecified,Long-term (current) use of anticoagulants,Personal history of pulmonary embolism,Do not resuscitate status,Diabetes with neurological manifestations, type II or unspecified type, uncontrolled,Polyneuropathy in diabetes,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Personal history of tobacco use,Severe sepsis,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Peripheral vascular disease, 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: AMS

PRESENT ILLNESS: 87 yo F with T2DM c/b peripheral neuropathy, CAD s/p stent,
chronic anemia, HTN, h/o PE on warfarin and other medical issues
presents from home with AMS.

MEDICAL HISTORY: Past Medical History:
Diabetes mellitus type 2
Hypertension
Peripheral vascular disease
Open wounds on the legs that are not healing
Peripheral neuropathy
Hyperthyroidism
History of pulmonary embolism, on warfarin
Urinary incontinence
Coronary artery disease s/p stent
Chronic anemia (baseline 30)
Chronic kidney disease (baseline 1.5)
Venous ulcers
LLE ulcer infection [**5-/2109**]

MEDICATION ON ADMISSION: - atenolol 50 mg daily
- Cosopt one gtt each eye at bedtime
- furosemide 40 mg daily
- mirtazapie 15 mg qHS
- warfarin 10 mg on Wednesday/Friday and 15 mg 5 other days
- Xalatan 0.005% 1 drop each eye at bedtime
- ASA 81 mg daily
- ferrous sulfate 325 mg daily
- MVI senior
- NPH 9 unit qAM and 7 unit qHS
- omeprazole

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM:
Vitals: HR 120, 152/100-> 69/48, RR 20, 15L on NR.  Unable to
get O2Sat
General: Alert, not oriented, does not answer questions but
grimace to pain
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: tachycardic, irregular, unable to appreciate m/r/g
Lungs: anterior left lower lung field has rhonchi, no
wheeze/crackles; otherwise clear to auscultation bilaterally
Abdomen: soft, tender to the left abd and suprapubic,
nondistended, BS+
GU: Foley draining pink thick urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Limited neurological exam given mental status, tracks to
voice, moves all upper extremities

FAMILY HISTORY: - mother died in her 80s [**1-17**] complication of Alzheimer's diease
- father had TB

SOCIAL HISTORY: Per d/c summary [**5-/2109**]
- in the process of getting Hospice involved
- married, lives with husband [**Name (NI) **]
- has 4 sons
- retired in [**2083**] from [**Hospital1 112**] as a OBGYN nurse
- quit smoking 20 yrs ago, about 20-30 years of smoking and no
more than 20-30 ppd
- rare EtOH
- denies illicit drugs 

### Response:
{'Unspecified septicemia,Septic shock,Acute pyelonephritis without lesion of renal medullary necrosis,Acute kidney failure, unspecified,Hyperosmolality and/or hypernatremia,Paroxysmal ventricular tachycardia,Ulcer of ankle,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Anemia, unspecified,Long-term (current) use of anticoagulants,Personal history of pulmonary embolism,Do not resuscitate status,Diabetes with neurological manifestations, type II or unspecified type, uncontrolled,Polyneuropathy in diabetes,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Personal history of tobacco use,Severe sepsis,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Peripheral vascular disease, unspecified'}
