CHIEF COMPLAINT: Urosepsis

PRESENT ILLNESS: Ms [**Known lastname 11622**] is a 79F with ESRD on HD (TThSa),sCHF (EF 20%) w/ LV
thrombus on coumadin, recent admission for altered mental status
now admitted with AMS. She was in her usual state of health at
rehab last night according to her daughter. When her daughter
saw her this morning, she was less awake and responsive than
usual, and complained of feeling generally unwell. The patient
took a nap, and after that was nearly unarousable. FSBS 23. EMS
was able to give glucagon and D50.

MEDICAL HISTORY: - dementia
- hypertension
- end-stage renal disease on hemodialysis, (TThSa via left
brachiocephalic AVF made in [**10/2131**])
- congestive heart failure EF 20%
- hyperlipidemia,
- osteoarthritis,
- depression,
- anemia,secondary versus tertiary hyperparathyroidism,
- recently developing dementia.
- hypothyroidism
- back pain
- Upper GI bleed
SURGERIES:
-TAH BSO
-appendectomy

MEDICATION ON ADMISSION: The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Levothyroxine Sodium 88 mcg PO DAILY
3. Losartan Potassium 100 mg PO DAILY
4. Metoprolol Tartrate 75 mg PO BID
5. Nephrocaps 1 CAP PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Sertraline 125 mg PO DAILY
8. Simvastatin 20 mg PO DAILY
9. Thiamine 100 mg PO DAILY
10. Sarna Lotion 1 Appl TP TID:PRN Itchying
11. Lidocaine-Prilocaine 1 Appl TP ONCE pain Duration: 1 Doses
apply to fistula site, 45 minutes prior to needle insertion
three times a week
12. Tucks *NF* (pramoxine-mineral oil-zinc;<br>starch;<br>witch
[**Female First Name (un) **]) 1-12.5 % Rectal apply daily
13. Warfarin 2 mg PO DAILY16

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM
GENERAL: pleasant, well appearing female, laying comfortably in
bed getting HD
HEENT: NC/AT, PERRLA, EOMI
NECK: supple, no thyromegaly, no JVD, no carotid bruits
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Came from rehab. Goes to [**Last Name (un) **] for HD. uses a walker
intermittently.
- Tobacco: denies
- Alcohol: denies
- Illicits: denies
Unspecified septicemia,End stage renal disease,Encephalopathy, unspecified,Acute and subacute necrosis of liver,Urinary tract infection, site not specified,Malignant neoplasm of kidney, except pelvis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic systolic heart failure,Acute kidney failure, unspecified,Acidosis,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Long-term (current) use of anticoagulants,Other ill-defined heart diseases,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Dementia with lewy bodies,Dementia in conditions classified elsewhere without behavioral disturbance,Anemia in chronic kidney disease,Sepsis
Septicemia NOS,End stage renal disease,Encephalopathy NOS,Acute necrosis of liver,Urin tract infection NOS,Malig neopl kidney,Hyp kid NOS w cr kid V,Chr systolic hrt failure,Acute kidney failure NOS,Acidosis,Abnrml coagultion prfile,Adv eff anticoagulants,Long-term use anticoagul,Ill-defined hrt dis NEC,Hyperlipidemia NEC/NOS,Hypothyroidism NOS,Dementia w Lewy bodies,Dementia w/o behav dist,Anemia in chr kidney dis,Sepsis
Admission Date:  [**2136-11-26**]              Discharge Date:   [**2136-11-30**]

Date of Birth:  [**2057-2-25**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
Urosepsis

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Ms [**Known lastname 11622**] is a 79F with ESRD on HD (TThSa),sCHF (EF 20%) w/ LV
thrombus on coumadin, recent admission for altered mental status
now admitted with AMS. She was in her usual state of health at
rehab last night according to her daughter. When her daughter
saw her this morning, she was less awake and responsive than
usual, and complained of feeling generally unwell. The patient
took a nap, and after that was nearly unarousable. FSBS 23. EMS
was able to give glucagon and D50.

  Initial vitals in the ED were 97 74 150/86 16 94% RA. Labs
were notable for WBC 5, HCT 35 83%, Plt 193, Cr 5.2, BUN 37 and
Lactate 15.7. UA showed >182 RBC and >182 WBC with no epithelial
cells. TropT 0.04 CKMB 2. She received cefepime and vancomycin
in the ED. Vitals on transfer were 96.8 66 134/62 24 97%RA.

  On arrival to the MICU, the patient appeared comfortable and
is without additional complaints.

Past Medical History:
- dementia
- hypertension
- end-stage renal disease on hemodialysis, (TThSa via left
brachiocephalic AVF made in [**10/2131**])
- congestive heart failure EF 20%
- hyperlipidemia,
- osteoarthritis,
- depression,
- anemia,secondary versus tertiary hyperparathyroidism,
- recently developing dementia.
- hypothyroidism
- back pain
- Upper GI bleed
SURGERIES:
-TAH BSO
-appendectomy


Social History:
Came from rehab. Goes to [**Last Name (un) **] for HD. uses a walker
intermittently.
- Tobacco: denies
- Alcohol: denies
- Illicits: denies


Family History:
non-contributory

Physical Exam:
ADMISSION PHYSICAL EXAM
GENERAL: pleasant, well appearing female, laying comfortably in
bed getting HD
HEENT: NC/AT, PERRLA, EOMI
NECK: supple, no thyromegaly, no JVD, no carotid bruits
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,

no accessory muscle use
HEART: RRR S1 S2, 3/6 SEM heard loudest at LUSB
ABDOMEN: NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding, no CVA
EXTREMITIES: warm, well perfused, no LE edema, 2+ DP pulses, dry

LE skin; LUE fistula with thrill and bruit
NEURO: alert and oriented x2 (not to time, year [**43**]-something,
c/w baseline), appropriate, no visual hallucinations. moving all

extremities spontaneously

DISCHARGE PHYSICAL EXAM
Vitals: T 98.3 BP 117/68 P 77 RR 20 97% RA
General:elderly woman sitting in bed in NAD, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV:[**3-5**] diastolic mummur  LSB, normal S1 + S2,
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, left AV fistula with palpable thrill
2+ pulses DP pulses, no clubbing, cyanosis or edema
Skin: no rashes or lesions noted
Neuro: Alert. Oriented to Person. Place ( knows she is in a
hosptial in [**Location (un) 86**]). does not know year. able to identify watch,
cup, and pen.

Pertinent Results:
ADMISSION LABS

[**2136-11-26**] 05:30PM BLOOD WBC-5.0 Hct-35.0* Plt Ct-193
[**2136-11-26**] 05:30PM BLOOD Neuts-83* Bands-1 Lymphs-14* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2136-11-26**] 05:30PM BLOOD Glucose-132* UreaN-37* Creat-5.2* Na-139
K-4.7 Cl-91* HCO3-8* AnGap-45*
[**2136-11-26**] 05:30PM BLOOD ALT-83* AST-128* CK(CPK)-50 AlkPhos-214*
TotBili-1.1
[**2136-11-26**] 05:30PM BLOOD cTropnT-0.04*
[**2136-11-26**] 05:30PM BLOOD Albumin-4.2 Calcium-10.1 Phos-7.5*#
Mg-2.4
[**2136-11-26**] 05:40PM BLOOD Glucose-104 Lactate-15.7* Na-142 K-4.7
Cl-105 calHCO3-11*
[**2136-11-26**] 07:05PM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-LG
[**2136-11-26**] 07:05PM URINE RBC->182* WBC->182* Bacteri-FEW
Yeast-NONE Epi-URINE CULTURE

RELEVANT LABS:

[**2136-11-26**] 05:30PM BLOOD ALT-83* AST-128* CK(CPK)-50 AlkPhos-214*
TotBili-1.1
[**2136-11-29**] 08:24AM BLOOD ALT-282* AST-356* AlkPhos-172*
TotBili-0.7
[**2136-11-27**] 11:38AM BLOOD Type-ART pO2-80* pCO2-26* pH-7.23*
calTCO2-11* Base XS--15

Discharge labs
[**2136-11-30**] 06:52AM BLOOD WBC-4.9 RBC-3.54* Hgb-10.6* Hct-34.6*
MCV-98 MCH-30.0 MCHC-30.7* RDW-18.2* Plt Ct-186
[**2136-11-30**] 11:40AM BLOOD PT-39.0* INR(PT)-3.6*
[**2136-11-30**] 06:52AM BLOOD Glucose-104* UreaN-19 Creat-3.5*# Na-135
K-4.7 Cl-99 HCO3-21* AnGap-20
[**2136-11-30**] 06:52AM BLOOD ALT-239* AST-257* AlkPhos-163*
TotBili-0.8
[**2136-11-30**] 06:52AM BLOOD Calcium-8.6 Phos-2.4* Mg-2.0
MICRO

URINE CULTRE(Final [**2136-11-27**]): MIXED BACTERIAL FLORA ( >= 3
COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL
CONTAMINATION.
[**2136-11-26**] 6:40 pm BLOOD CULTURE

Blood Culture [**2136-11-27**]", Routine (Preliminary): STAPHYLOCOCCUS,
COAGULASE NEGATIVE.
SENSITIVITIES PERFORMED ON REQUEST.. Isolated from only one set
in the previous five days.

IMAGING:
[**2136-11-26**]
CXR IMPRESSION:
1.  Patient is rotated to the right.  Moderate-to-marked
enlargement of the cardiac silhouette.
2.  Central pulmonary vascular engorgement.
3.  Areas of linear patchy bibasilar opacity most likely
represent
atelectasIS

[**2136-11-26**]- CT HEAD-IMPRESSION:  No acute intracranial process.
Chronic involutional changes.

[**2136-11-30**]
Right Upper quandrant ultrasound
1.  Sludge in the gallbladder with no evidence of gallbladder
wall edema to
suggest cholecystitis. No biliary dilation.
2.  Complex cystic lesion within the lower pole of the right
kidney measuring
2.3 x 2.3 x 2.7 cm. Recommend MRI for further evaluation as
malignancy cannot
be excluded.
3.  Additional bilateral simple renal cysts.
4.  Bilateral pleural effusions.

Brief Hospital Course:
79F w/ PMH of dementia, sCHF w/ LV thrombus, ESRD on HD who
presents with AMS, and elevated lactate

#Coagulase negative staph Bacteremia:The patient was growing
coagulase negative staph in [**1-30**] bottles. It was likley a
contaminant. She was empircally treated with vancomycin, which
was subsequently discontinued once the gram positive cocci were
speciated as coagulase negative staph.

# AMS/dementia: Patient has known dementia with recent worsening
of baseline. Patient was recently discharged on [**2136-11-13**] for
worsened dementia with increased hallucinations. Her acute
worsening of AMS likely related to hyoglycemic epidsode at home.
It is unclear why she was hypoglyemic. It is possible that she
has imparied gluconeogenesis from her congestive hepatopathy and
renal failure. Unclear if patient had an underlying infection,
leading to hypoglycemia. Her CXR was negative, blood cultures
were growing a contaminant. Her UA is difficult to interpret in
the setting of oliguira and urine Cx grew mixed bacterial flora.
She received a few doses of cefepime and levaquin for ?
urosepsis, although unclear if the patient has a true urinary
tract infection, and if an infection was the cause of her
hypglycemia. Given her improvement in mental status, after
receiving antibiotics, the patient will be discharged on
ciprofloxacin for treatment of complicated UTI.

# Complicated UTI-  ( see above) will treat with ciprofloxacin.
last day of antibiotics [**2136-12-5**]

# right kindey mass- On right upper quadrant ultrasound the
patient was  found to have a complex cystic lesion within the
lower pole of the right kidney measuring.2.3 x 2.3 x 2.7 cm.
Radiology recommend MRI for further evaluation as malignancy
cannot be excluded.

# Congestive hepatopathy- The patient has a history of
transaminitis with increased AST/ ALT, Alk [**Doctor Last Name **] and normal nl
bili noted inially in [**2136-9-29**].  LFTs reached almost 3x
baseline during this admission.  Her LFTs are consistent with
hepatocellular injury. Her work up for transaminities included
hepatitis serologies on a previous admission which were
negative. A RUQ ultrasound showed no evidence of CBD diliation
or cholecystitis. It likley that her transaminits is from
hepatic congestion if the setting of her systolic heart failture
with ( EF of 20%). Transminases will likley improve with
optimization of her heart failure regimen.
Will need to check LFTs on [**2136-12-3**]

# Coagulopathy: -The patient is on Coumadin for LV thrombus. She
was admitted with an elevated INR 5.0 ( goal [**3-2**]).  Her
supratherpeutic levels are likley related to here congestive
hepatopathy. Coumadin has been held during this h hospital
course, as her INRs have been persistently elevated.  INR at
time of discharge is 3.6. Her coumadin should be restarted on
[**12-1**] at 1mg and the patient should have her INR checked on [**12-3**]

# Systolic CHF ( EF 20%) with LV thrombus: Patient had recent
diagnosis of LV thrombus on prior admission. ( see above). Her
CHF is likley contributing to her transamnitis ( see above). Her
metoprolol was decreased form 75 mg [**Hospital1 **] to 25 [**Hospital1 **]  and she was
started on Isosorbide Mononitrate 30mg TID. She was continued on
losartan.  The patient has follow up with in Heart Failure
clinic with Dr. [**First Name (STitle) 437**] on discharge

# ESRD on HD: HD on T,Th,Sat schedule. Continued on nephrocaps
and typical HD schedule.


# Hypothyroid: Continued home levothyroxine.


# Hypertension: continued on and losartan. Isosrbide added to
help decrease afterload in setting of poor EF

# Hyperlipidemia- simvastatin was held in setting of
transmintis.  ( see above) can restart once AST and ALT less
than 100

TRANSITIONAL ISSUES
# follow up MRI for further evaluation of complex mass on  right
kidney mass
# recheck LFTs, restart simvastatin once AST and ALT are below
100
# restart Coumadin on [**12-1**] 1 mg daily
# recheck INR on [**2136-12-3**]
# full code

Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Levothyroxine Sodium 88 mcg PO DAILY
3. Losartan Potassium 100 mg PO DAILY
4. Metoprolol Tartrate 75 mg PO BID
5. Nephrocaps 1 CAP PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Sertraline 125 mg PO DAILY
8. Simvastatin 20 mg PO DAILY
9. Thiamine 100 mg PO DAILY
10. Sarna Lotion 1 Appl TP TID:PRN Itchying
11. Lidocaine-Prilocaine 1 Appl TP ONCE pain Duration: 1 Doses
apply to fistula site, 45 minutes prior to needle insertion
three times a week
12. Tucks *NF* (pramoxine-mineral oil-zinc;<br>starch;<br>witch
[**Female First Name (un) **]) 1-12.5 % Rectal apply daily
13. Warfarin 2 mg PO DAILY16


Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Levothyroxine Sodium 88 mcg PO DAILY
3. Lidocaine-Prilocaine 1 Appl TP ONCE pain Duration: 1 Doses
apply to fistula site, 45 minutes prior to needle insertion
three times a week
4. Losartan Potassium 100 mg PO DAILY
5. Metoprolol Tartrate 25 mg PO BID
6. Nephrocaps 1 CAP PO DAILY
7. Omeprazole 40 mg PO DAILY
8. Sarna Lotion 1 Appl TP TID:PRN Itchying
9. Sertraline 100 mg PO DAILY
10. Thiamine 100 mg PO DAILY
11. Tucks *NF* (pramoxine-mineral oil-zinc;<br>starch;<br>witch
[**Female First Name (un) **]) 1-12.5 % Rectal apply daily
12. Ciprofloxacin HCl 250 mg PO Q24H Duration: 5 Days
dose after HD
13. Warfarin 1 mg PO DAILY16
14. Isosorbide Mononitrate 20 mg PO TID


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - LTC

Discharge Diagnosis:
Altered Mental status
Coagulopathy
Congestive Heart Failure


Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Dear Ms. [**Known lastname 11622**],
It was pleasure participating in your care at [**Hospital1 18**]. You were
admitted to the hospital with altered mental status. You had a
CT scan of your head which was normal.  We found no evidence of
infection in your lung to causes a change in mental status. Your
blood cultures grew a bacteria (coagulase negative staph) which
is likely a contaminant. Your urine showed evidence of an
infection although the urine culture showed contaminants. We
will treat you empirically for urinary tract infection with
antibiotics (Ciprofloxacin). Your change in mental status was
likely from your low blood sugar, which may be related to a
urinary tract infection.

You were also admitted with an elevated INR. Your Coumadin has
been held since admission since your INR is still elevated.
Your INR will need to be re-checked on [**2136-12-3**] at rehab. You
should restart Coumadin on [**2136-12-1**] at a lower dose( 1mg).

You were found to have a mass on the right kidney that is
concerning for a cancer of the kidney. Please follow up with
your doctor at rehab and PCP to discuss these results further.

You were also found to have an increase in your liver function
tests. We think this may be related to your heart failure. We
made some changes to your medications, but it is important to
follow up in Heart Failure clinic at the appointment listed
below.

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.

Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2136-12-10**] at 3:30 PM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: COGNITIVE NEUROLOGY UNIT
When: FRIDAY [**2136-12-14**] at 2:00 PM
With: DR. [**Last Name (STitle) **] & DR. [**Last Name (STitle) 15661**] [**Telephone/Fax (1) 1690**]
Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST     Best Parking: Main Garage
{'Unspecified septicemia,End stage renal disease,Encephalopathy, unspecified,Acute and subacute necrosis of liver,Urinary tract infection, site not specified,Malignant neoplasm of kidney, except pelvis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic systolic heart failure,Acute kidney failure, unspecified,Acidosis,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Long-term (current) use of anticoagulants,Other ill-defined heart diseases,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Dementia with lewy bodies,Dementia in conditions classified elsewhere without behavioral disturbance,Anemia in chronic kidney disease,Sepsis'}


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: Urosepsis

PRESENT ILLNESS: Ms [**Known lastname 11622**] is a 79F with ESRD on HD (TThSa),sCHF (EF 20%) w/ LV
thrombus on coumadin, recent admission for altered mental status
now admitted with AMS. She was in her usual state of health at
rehab last night according to her daughter. When her daughter
saw her this morning, she was less awake and responsive than
usual, and complained of feeling generally unwell. The patient
took a nap, and after that was nearly unarousable. FSBS 23. EMS
was able to give glucagon and D50.

MEDICAL HISTORY: - dementia
- hypertension
- end-stage renal disease on hemodialysis, (TThSa via left
brachiocephalic AVF made in [**10/2131**])
- congestive heart failure EF 20%
- hyperlipidemia,
- osteoarthritis,
- depression,
- anemia,secondary versus tertiary hyperparathyroidism,
- recently developing dementia.
- hypothyroidism
- back pain
- Upper GI bleed
SURGERIES:
-TAH BSO
-appendectomy

MEDICATION ON ADMISSION: The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Levothyroxine Sodium 88 mcg PO DAILY
3. Losartan Potassium 100 mg PO DAILY
4. Metoprolol Tartrate 75 mg PO BID
5. Nephrocaps 1 CAP PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Sertraline 125 mg PO DAILY
8. Simvastatin 20 mg PO DAILY
9. Thiamine 100 mg PO DAILY
10. Sarna Lotion 1 Appl TP TID:PRN Itchying
11. Lidocaine-Prilocaine 1 Appl TP ONCE pain Duration: 1 Doses
apply to fistula site, 45 minutes prior to needle insertion
three times a week
12. Tucks *NF* (pramoxine-mineral oil-zinc;<br>starch;<br>witch
[**Female First Name (un) **]) 1-12.5 % Rectal apply daily
13. Warfarin 2 mg PO DAILY16

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM
GENERAL: pleasant, well appearing female, laying comfortably in
bed getting HD
HEENT: NC/AT, PERRLA, EOMI
NECK: supple, no thyromegaly, no JVD, no carotid bruits
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Came from rehab. Goes to [**Last Name (un) **] for HD. uses a walker
intermittently.
- Tobacco: denies
- Alcohol: denies
- Illicits: denies 

### Response:
{'Unspecified septicemia,End stage renal disease,Encephalopathy, unspecified,Acute and subacute necrosis of liver,Urinary tract infection, site not specified,Malignant neoplasm of kidney, except pelvis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic systolic heart failure,Acute kidney failure, unspecified,Acidosis,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Long-term (current) use of anticoagulants,Other ill-defined heart diseases,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Dementia with lewy bodies,Dementia in conditions classified elsewhere without behavioral disturbance,Anemia in chronic kidney disease,Sepsis'}
