CHIEF COMPLAINT: sepsis

PRESENT ILLNESS: 85F well known to the ACS service, transferred from [**Hospital 100**]
rehab, 12 days s/p ex-lap, right colectomy, and end ileostomy
for
lower GI bleeding localized to the cecum.  By report from the
facility, Ms. [**Known lastname 3647**] developed increasing abdominal pain
associated with minimal ileostomy output, one episode of
vomiting, and fever to 100.8 earlier today.  She had been NPO
secondary to nausea, but had a stable hematocrit and normal WBC
during her 5 day rehab stay.

MEDICAL HISTORY: Diabetes
Dyslipidemia
Hypertension
Atrial fibrillation
Hypothyroidism
Osteoarthritis, s/p bilateral knee replacements in [**2182**]
Depression
Asthma, diagnosed in [**2184**]
C-sections in past

MEDICATION ON ADMISSION: albuterol HFA 90 q4-6h PRN, cardiazem LA 240', diovan 160',
loratadine 10 PRN, pradaxa 150'', allopurinol 200', Vit D3
1000', lasix 40', glyburide 2.5', isosorbide mononitrate ER 30',
levothyroxine 112', metoprolol ER 100', oxybutynin 5',
pravastatin 40'

ALLERGIES: Lisinopril / Metformin

PHYSICAL EXAM: Vitals:  99.6 127 118/76 26 100%
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: Irregular, mildly tachycardic 110-120
PULM: Diminished bilaterally
ABD: Soft, mildly distended, +peristomal TTP in the RLQ, no
rebound or guarding, no palpable masses.  RLQ end ileostomy
flush
with abdominal skin, pink, small amount of watery brown
effluent, no flatus in bag.  Tender with digitalization.
Midline laparotomy incision with VAC in place, no erythema,
induration, drainage, or hernia. Left sided mucous fistula with
scant mucous output.
Ext: No LE edema, LE warm and well perfused

FAMILY HISTORY: Family history of CVA/CAD.

SOCIAL HISTORY: Husband died many years ago. Patient lives with her
granddaughter who is her proxy. Smoked 36 years x 1 ppd, quit in
[**2181**], remote social ETOH.
Other postoperative infection,Unspecified septicemia,Sepsis,Acute respiratory failure following trauma and surgery,Other digestive system complications,Perforation of intestine,Acute vascular insufficiency of intestine,Peritoneal abscess,Acute on chronic diastolic heart failure,Urinary tract infection, site not specified,Alkalosis,Delirium due to conditions classified elsewhere,Other and unspecified Escherichia coli [E. coli],Atrial fibrillation,Ileostomy status,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Abnormal sputum,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Peritoneal adhesions (postoperative) (postinfection),Unspecified acquired hypothyroidism,Depressive disorder, not elsewhere classified,Gout, unspecified,Asthma, unspecified type, unspecified,Knee joint replacement,Acquired absence of intestine (large) (small),Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Personal history of tobacco use
Other postop infection,Septicemia NOS,Sepsis,Ac resp flr fol trma/srg,Oth digestv system comp,Perforation of intestine,Ac vasc insuff intestine,Peritoneal abscess,Ac on chr diast hrt fail,Urin tract infection NOS,Alkalosis,Delirium d/t other cond,E.coli infection NEC/NOS,Atrial fibrillation,Ileostomy status,Chronic kidney dis NOS,Hy kid NOS w cr kid I-IV,Abnormal sputum,DMII wo cmp nt st uncntr,Peritoneal adhesions,Hypothyroidism NOS,Depressive disorder NEC,Gout NOS,Asthma NOS,Joint replaced knee,Acquire absnce intestine,Abn react-surg proc NEC,History of tobacco use
Admission Date:  [**2194-9-1**]              Discharge Date:   [**2194-9-12**]

Date of Birth:  [**2108-10-18**]             Sex:   F

Service: SURGERY

Allergies:
Lisinopril / Metformin

Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
sepsis

Major Surgical or Invasive Procedure:
[**8-20**] ex lap, extended right colectomy, end ileostomy

[**9-2**] redo ex lap, subtotal colectomy, mucous fistula


History of Present Illness:
85F well known to the ACS service, transferred from [**Hospital 100**]
rehab, 12 days s/p ex-lap, right colectomy, and end ileostomy
for
lower GI bleeding localized to the cecum.  By report from the
facility, Ms. [**Known lastname 3647**] developed increasing abdominal pain
associated with minimal ileostomy output, one episode of
vomiting, and fever to 100.8 earlier today.  She had been NPO
secondary to nausea, but had a stable hematocrit and normal WBC
during her 5 day rehab stay.

Past Medical History:
Diabetes
Dyslipidemia
Hypertension
Atrial fibrillation
Hypothyroidism
Osteoarthritis, s/p bilateral knee replacements in [**2182**]
Depression
Asthma, diagnosed in [**2184**]
C-sections in past

Social History:
Husband died many years ago. Patient lives with her
granddaughter who is her proxy. Smoked 36 years x 1 ppd, quit in
[**2181**], remote social ETOH.


Family History:
Family history of CVA/CAD.

Physical Exam:
Vitals:  99.6 127 118/76 26 100%
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: Irregular, mildly tachycardic 110-120
PULM: Diminished bilaterally
ABD: Soft, mildly distended, +peristomal TTP in the RLQ, no
rebound or guarding, no palpable masses.  RLQ end ileostomy
flush
with abdominal skin, pink, small amount of watery brown
effluent, no flatus in bag.  Tender with digitalization.
Midline laparotomy incision with VAC in place, no erythema,
induration, drainage, or hernia. Left sided mucous fistula with
scant mucous output.
Ext: No LE edema, LE warm and well perfused

Pertinent Results:
Admission
8.0 > 29.5 < 486

 N:65 Band:15 L:12 M:8 E:0 Bas:0

133  97  34 < 161   AGap=13
------------
4.3  27  1.5

Ca: 6.9 Mg: 1.8 P: 3.2
ALT: 23 AP: 125 Tbili: 0.5 Alb: 3.2
AST: 26
Lip: 26
Lactate:1.9

Admission CTAP
CT A/P:
1. SBO w/ transition pt at ileostomy exit site; cause appears to
be mass effect from herniated mesenteric fat adjacent to the
ileostomy.
2. s/p R colectomy w/ tiny locules of gas adjacent to colonic
staple line - may be post-operative although leak cannot be
excluded.
3. small amt of complex free fluid in abdomen/pelvis - ddx
includes [**Year (4 digits) **] or bowel leak contents - correlate w/ exam and
hct.

Discharge:

[**2194-9-8**] 6:33 am SPUTUM      Source: Endotracheal.

                            **FINAL REPORT [**2194-9-11**]**

   GRAM STAIN (Final [**2194-9-8**]):
      <10 PMNs and <10 epithelial cells/100X field.
      4+   (>10 per 1000X FIELD):   GRAM NEGATIVE ROD(S).
      1+    (<1 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND SINGLY.
      QUALITY OF SPECIMEN CANNOT BE ASSESSED.

   RESPIRATORY CULTURE (Final [**2194-9-11**]):
      RARE GROWTH Commensal Respiratory Flora.
      CULTURE WORKUP REQUESTED BY DR. [**First Name (STitle) **] [**Numeric Identifier 29695**].
      STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA.    MODERATE
GROWTH.
      KLEBSIELLA PNEUMONIAE.    SPARSE GROWTH.
         Cefazolin interpretative criteria are based on a dosage
regimen of
         2g every 8h.
         Piperacillin/tazobactam sensitivity testing available
on request.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STENOTROPHOMONAS (XANTHOMONAS)
MALTOPHILIA
                             |          KLEBSIELLA PNEUMONIAE
                             |          |
AMPICILLIN/SULBACTAM--                4 S
CEFAZOLIN-------------              <=4 S
CEFEPIME--------------              <=1 S
CEFTAZIDIME-----------              <=1 S
CEFTRIAXONE-----------              <=1 S
CIPROFLOXACIN---------           <=0.25 S
GENTAMICIN------------              <=1 S
MEROPENEM-------------           <=0.25 S
TOBRAMYCIN------------              <=1 S
TRIMETHOPRIM/SULFA----   <=1 S      <=1 S

[**2194-9-12**] 02:08AM [**Month/Day/Year 3143**] WBC-11.5* RBC-2.76* Hgb-8.2* Hct-25.6*
MCV-93 MCH-29.8 MCHC-32.0 RDW-16.3* Plt Ct-458*
[**2194-9-12**] 02:08AM [**Month/Day/Year 3143**] PT-13.6* PTT-28.2 INR(PT)-1.3*
[**2194-9-12**] 02:08AM [**Month/Day/Year 3143**] Glucose-131* UreaN-19 Creat-1.0 Na-131*
K-4.6 Cl-93* HCO3-29 AnGap-14
[**2194-9-12**] 02:08AM [**Month/Day/Year 3143**] Calcium-8.0* Phos-4.2 Mg-2.0

Brief Hospital Course:
Neuro:  On arrival, the patient was awake, but minimally alert
and seemed to be unaware of her surroundings. Over the course of
her stay, she was maintained on the minimum amount of pain
medication necessary to adequately control her pain. As a stay
progress, she became more alert and interactive, and after
extubation, was alert, oriented, and very interactive. At the
time of discharge, the patient was alert, oriented times three,
and had a nonfocal neurologic exam. She was moving all four
extremities, and complained only of tenderness of the abdomen.
Still sluggish with decreased interactiveness but appropriate.

CV: Initially, the patient was tachycardic ranging up to 140.
She initially required a diltiazem drip to control her
tachycardia, but as her stay progressed, the diltiazem drip was
weaned, and she was restarted on her home rate control
medications.  She also initially required some low doses of
Neo-Synephrine. This was weaned to fully off finally on hospital
day seven, and she did not require any more
pressors. She is now controlled well on an oral diltiazema and
metoprolol regimen. She has not yet restarted her isosorbide,
diovan, or pradaxa. Those are currently on hold. The patient has
atrial fibrillation at baseline and fluctuates from sinus
tachycardia into afib with rate control 90-115 and stable [**Month/Day/Year **]
pressures.

R: After her surgery, the patient was vent dependent for several
days. On post operative day two, she was weaned to pressure
support. She remained on these settings until postoperative day
nine, after which she was extubated. From that point on, she
tolerated minimal oxygen, and Room air.  After extubation, the
decision was made by the family, after a long family meeting, to
make the patient DNR/DNI. She is getting albuterol and
ipratropium inhalers as needed.

GI: On postoperative day two, she began to have stool from her
ostomy. Her tube feeds restarted on postoperative day four and
she continued to tolerate these throughout her stay. On
postoperative day 11, she failed a speech and swallow test,
after extubation, and had a dobhoff feeding tube placed, as she
had initially had an OGT while intubated.  On postoperative day
one, the patient had a wound VAC placed over the midline
laparotomy incision. Last change [**9-11**]. End ileostomy with stool
output, scant mucous output from mucous fistula. Two Jp drains
from OR removed prior to discharge. Famotidine prophylaxis
ongoing.

GU: The patient made adequate urine throughout her stay, which
was monitored with the catheter. On postoperative day six, she
began to have signs consistent with pulmonary edema. She was
started on a Lasix drip , But was only slightly negative for the
first several days. On postoperative day nine, she began to
diurese quite effectively, with no compromise of her hemodynamic
stability. On postoperative day 11, Lasix drip as stopped and
she was continued on intermittent Lasix. She continued to have
excellent output after this. She should continue to have close
monitoring of I's and O's and urine output.

Heme: In total, the patient received two units of packed red
[**Month/Year (2) **] cells. Her hematocrit was monitored frequently. After her
surgery, her hematocrit remained stable throughout her stay.
Pradaxa is being held at this time because it cannot be crushed
via the dophoff tube. The patient's PCP should determine the
patient's risk for stroke in setting of afib. For now no
anticoagulation. Heparin prophylaxis should continue 5000 units
sc TID.

ID:  During the perioperative period, the patient was initially
placed on vancomycin and Zosyn. The vancomycin was stopped
shortly after surgery. A culture from the wound on [**9-2**]
grew back pan sensitive E. coli, and the patient antibiotics
were changed to Bactrim.  She had two sputum, and two urine
cultures which grew back
only bacteria sensitive to Bactrim. She was discharged on a
two-week course of Bactrim. Her white [**Month (only) **] cell count was
monitored throughout her stay.

Medications on Admission:
albuterol HFA 90 q4-6h PRN, cardiazem LA 240', diovan 160',
loratadine 10 PRN, pradaxa 150'', allopurinol 200', Vit D3
1000', lasix 40', glyburide 2.5', isosorbide mononitrate ER 30',
levothyroxine 112', metoprolol ER 100', oxybutynin 5',
pravastatin 40'

Discharge Medications:
1. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
2. Diltiazem 60 mg PO QID
3. Famotidine 20 mg PO Q12H
4. Furosemide 20 mg PO BID
5. Heparin 5000 UNIT SC TID
6. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
7. Metoprolol Tartrate 25 mg PO BID
Hold for HR< 60
8. Ondansetron 4 mg IV Q8H:PRN nausea
9. Sodium Chloride 0.9%  Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
10. Sulfameth/Trimethoprim DS 3 TAB PO TID
12-15mg/kg/day trimethoprim component for tx Stenotrophomonas,
per pharmacy recs
11. Sodium Chloride 0.9%  Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
12. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q2H:PRN pain
13. Levothyroxine Sodium 112 mcg PO/NG DAILY
14.  Glargine 10 Units Q24H
Insulin SC Sliding Scale using REG Insulin
15. Ipratropium Bromide MDI 2 PUFF IH Q8H:PRN wheeze / dyspnea
16. Valsartan 160 mg PO/NG DAILY (not yet restarted)
17. Albuterol Inhaler [**12-16**] PUFF IH Q4H:PRN wheeze
18. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
(not yet restarted)
19. Oxybutynin 5 mg PO DAILY (not yet restarted)
20. Vitamin D 800 UNIT PO DAILY (not yet restarted)
21. Pravastatin 40 mg PO DAILY (not yet restarted)
22. Allopurinol 200 mg PO DAILY (not yet restarted)
23. GlyBURIDE 2.5 mg PO DAILY (not yet restarted)
24. Medication Alert
PLEASE NOTE MED REC -> MEDICATIONS THAT HAD NOT BEEN RESTARTED
AS OF DISCHARGE FROM [**Hospital1 18**] ON [**9-12**] WERE NOTED.

RESTART THESE MEDICATIONS AS APPROPRIATE IN CONVERSATION WITH
DR. [**First Name (STitle) **] PCP AND REHAB PHYSICIAN.

THE MEDICATIONS THAT THE PATIENT WAS GETTING DURING HER STAY
INCLUDE PO DILTIAZEM, PO METOPROLOL, PO LASIX, PO BACTRIM,
SYNTHROID, INSULIN SLIDING SCALE AND GLARGINE AS WRITTEN,
ELECTROLYTE REPLETION, HEPARIN PROPHYLAXIS. DILAUDID AND TYLENOL
AS NEEDED FOR PAIN AND ZOFRAN FOR NAUSEA.

THE OTHER LISTED MEDICATIONS THAT THE PATIENT WAS TAKING AT HOME
PRIOR TO ADMISSION WERE NOT RESTARTED.

THANK YOU.
25. Acetaminophen 325-650 mg PO/NG Q6H:PRN pain
26. Dabigatran Etexilate 150 mg PO BID (not yet restarted)

Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
anastamotic leak, colon necrosis

Discharge Condition:
good

Discharge Instructions:
Continue VAC dressing changes every 3 days and close wound
monitoring. Call the Acute Care Surgery Clinic if there are any
concerns about the wound appearance. Last VAC change was [**9-11**] at
[**Hospital1 18**].

The patient did have two JP drains which were removed during her
stay at [**Hospital1 18**]. Monitor those skin sites and use dry dressings as
needed.

Please continue ostomy teaching and management. The patient has
an end ileostomy and mucous fistula in place. Please call Acute
Care Clinic if concern with appearance or amount of ostomy
output, monitor for dehydration, bloody or melenic output.

Patient is on an antibiotic course with bactrim to cover for
klebsiella and stenotrophomonas in her sputum cultures.  She
will complete a two week total course of antibiotics. Her last
positive culture was on [**9-8**]. She will continue the bactrim
through [**9-21**].

The patient is taking diltiazem and metoprolol via the dophoff
tube to rate control her atrial fibrillation. Her pradaxa is
currently on hold. She should get prophylactic heparin 5000
units three times daily. Discussion should be had with Dr.
[**First Name (STitle) **], Ms. [**Known lastname **] primary care provider [**Last Name (NamePattern4) **]: anticoagulation.
Patient had been on coumadin in the past and one year ago was
transitioned to pradaxa. She is not on aspirin. Her initial
presentation in early [**Month (only) **] was with GI bleeding while on
pradaxa. Please discuss risks and benefits of anticoagulating
again once the patient passes speech and swallow. For now she
will remain with her dophoff tube, tube feeds, and oral
medications as possible. Pradaxa will be held. No coumadin or
aspirin to be started at this point. Discuss this issue with Dr.
[**First Name (STitle) **] in determining how to move forward with anticoagulating.

The patient did not pass her speech and swallow on [**9-11**] so a
dophoff tube was placed and tube feeds and medications have been
given through there. The dophoff should be flushed with 30cc q6
as well as additional flush as needed with crushed pills to
prevent clogging.

The patient is also being diruesed. Had been on a lasix drip for
over a week and was transitioned to lasix via the dophoff tube
on [**9-12**]. She is being discharged on 20mg lasix [**Hospital1 **] via dophoff,
please closely monitor electrolytes and BUN/Cr and back off on
diuresis as needed.

Continue other home medications as able to give via dophoff.
Continue reassessing speech and swallow ability to transition to
oral feeding and medications.

Call [**Hospital 2536**] clinic with concerns about ostomy output, inability to
tolerate tube feeds, increasing abdominal pain, or other
concerns.

Followup Instructions:
Provider: [**Name10 (NameIs) **] CARE CLINIC Phone:[**Telephone/Fax (1) 600**]
Date/Time:[**2194-9-18**] 1:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2010**]
Date/Time:[**2194-10-20**] 10:50



Completed by:[**2194-9-12**]
{'Other postoperative infection,Unspecified septicemia,Sepsis,Acute respiratory failure following trauma and surgery,Other digestive system complications,Perforation of intestine,Acute vascular insufficiency of intestine,Peritoneal abscess,Acute on chronic diastolic heart failure,Urinary tract infection, site not specified,Alkalosis,Delirium due to conditions classified elsewhere,Other and unspecified Escherichia coli [E. coli],Atrial fibrillation,Ileostomy status,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Abnormal sputum,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Peritoneal adhesions (postoperative) (postinfection),Unspecified acquired hypothyroidism,Depressive disorder, not elsewhere classified,Gout, unspecified,Asthma, unspecified type, unspecified,Knee joint replacement,Acquired absence of intestine (large) (small),Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Personal history of tobacco use'}


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: sepsis

PRESENT ILLNESS: 85F well known to the ACS service, transferred from [**Hospital 100**]
rehab, 12 days s/p ex-lap, right colectomy, and end ileostomy
for
lower GI bleeding localized to the cecum.  By report from the
facility, Ms. [**Known lastname 3647**] developed increasing abdominal pain
associated with minimal ileostomy output, one episode of
vomiting, and fever to 100.8 earlier today.  She had been NPO
secondary to nausea, but had a stable hematocrit and normal WBC
during her 5 day rehab stay.

MEDICAL HISTORY: Diabetes
Dyslipidemia
Hypertension
Atrial fibrillation
Hypothyroidism
Osteoarthritis, s/p bilateral knee replacements in [**2182**]
Depression
Asthma, diagnosed in [**2184**]
C-sections in past

MEDICATION ON ADMISSION: albuterol HFA 90 q4-6h PRN, cardiazem LA 240', diovan 160',
loratadine 10 PRN, pradaxa 150'', allopurinol 200', Vit D3
1000', lasix 40', glyburide 2.5', isosorbide mononitrate ER 30',
levothyroxine 112', metoprolol ER 100', oxybutynin 5',
pravastatin 40'

ALLERGIES: Lisinopril / Metformin

PHYSICAL EXAM: Vitals:  99.6 127 118/76 26 100%
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: Irregular, mildly tachycardic 110-120
PULM: Diminished bilaterally
ABD: Soft, mildly distended, +peristomal TTP in the RLQ, no
rebound or guarding, no palpable masses.  RLQ end ileostomy
flush
with abdominal skin, pink, small amount of watery brown
effluent, no flatus in bag.  Tender with digitalization.
Midline laparotomy incision with VAC in place, no erythema,
induration, drainage, or hernia. Left sided mucous fistula with
scant mucous output.
Ext: No LE edema, LE warm and well perfused

FAMILY HISTORY: Family history of CVA/CAD.

SOCIAL HISTORY: Husband died many years ago. Patient lives with her
granddaughter who is her proxy. Smoked 36 years x 1 ppd, quit in
[**2181**], remote social ETOH. 

### Response:
{'Other postoperative infection,Unspecified septicemia,Sepsis,Acute respiratory failure following trauma and surgery,Other digestive system complications,Perforation of intestine,Acute vascular insufficiency of intestine,Peritoneal abscess,Acute on chronic diastolic heart failure,Urinary tract infection, site not specified,Alkalosis,Delirium due to conditions classified elsewhere,Other and unspecified Escherichia coli [E. coli],Atrial fibrillation,Ileostomy status,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Abnormal sputum,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Peritoneal adhesions (postoperative) (postinfection),Unspecified acquired hypothyroidism,Depressive disorder, not elsewhere classified,Gout, unspecified,Asthma, unspecified type, unspecified,Knee joint replacement,Acquired absence of intestine (large) (small),Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Personal history of tobacco use'}
