CHIEF COMPLAINT: septic shock

PRESENT ILLNESS: 71 yo F with dementia, ESRD on HD, respiratory failure s/p
trach, s/p PEG, COPD, recurrent aspiration PNA, and hx of C.diff
colitis is transferred from the [**Hospital 100**] Rehab MACU after having
two hypotensive/unresponsive episodes during HD.  Rather than
take fluid off, they gave the patient 500 cc.  Per the patient's
son, the patient has been having difficulties for the past nine
weeks, with delerium that finally resolved after adding
phosphate binders, correcting lyte (hypercalcemia, hyperpphos)
abnormalities, and d/c'ing sedating medications.  Per rehab
records, she recently had recurrent C diff, and was treated with
Zosyn for PNA with cxs + for Providencia stuartii, Psuedomonas,
and Citrobacter.  She appeared to recover when she was noted
about 1 week prior to admission be increasingly hypotensive with
altered mental status.  She had blood and C diff cxs from [**6-11**]
which were negative.  Sputum cultures again grew Citrobacter and
Pseudomonas.  She was started on Levaquin for Citrobacter
(Pseudomonas was presumed to be a colonizer) but she was noted
to have worsening resp status with increasingly purulent sputum.
 On [**6-15**] her antibiotics were changed to Tobramycin and
Cefepime.  Her WBC has continued to rise, she had an episode of
atrial fibrillation, and then the above mentioned episodes at
HD.
.
In the ED, Patient's blood pressures were initially in the 90's
- 100's and the patient's mental status was at baseline per her
son.  [**Name (NI) **] [**Name2 (NI) **] count returned at 20.1 and her CXR came back as
having BL infiltrates concerning for multifocal PNA vs
aspiration.  She then began to drop her pressures into the 60's
systolic.  A code sepsis was called.  She received 2 liters of
fluid and was started on peripheral levophed.  A central lines
was placed and her initial CVP was 13 and her lactate was 1.5.
She appeared to be having significant oral secretions and
de-satting down to the 80's so she was placed on the ventilator.
 She was started on Vancomycin, Zosyn, Azithromycin and admitted
to MICU for further work-up and management.
.
Per her son, at baseline she is able to hold a coherent
conversation although she has some chronic deficits from her
previous CVA's including frequent altered mental status with
infections or lyte abnormalities, finding it difficult to
explain where her pain is in her body, and being easily
overstimulated (lights, sounds.)  She had some diarrhea at
[**Hospital 100**] Rehab today, and again in the ED, and one episode of
vomiting this AM.  Her baseline temp is 97.8 and she rarely gets
fevers when infected.

MEDICAL HISTORY: #. ESRD on HD of unclear etiology. ? d/t chronic pyelo and
uncontrolled HTN.
#. Respiratory failure s/p trach in [**2-11**], vent dependent until
[**2188-1-5**] when she was successfully weaned off
#. COPD
#chronic pleural effusions
#. Recurrent aspiration PNA
#. PVD, s/p R CEA, s/p bilateral iliac stents and gangrene of
toew bilaterally and autoamputating
#. HTN
#. Hypothyroidism
#. h/o GI bleeding
#. CHF no previous echo here, so unclear [**Name2 (NI) **]
#. h/o Cholesterol emboli syndrome
#. Paroxysmal AF
# Anemia
# s/p multiple embolic CVA
# Dementia
# Adenocarcinoma of the colon s/p resection in [**2186**]
# s/p PEG
# h/o MRSA colonization
# hx of pseudomonas colonization
# h/o VRE infection
# C.diff colitis

MEDICATION ON ADMISSION: 1. Hydromophone 0.75mg q2h/prn during HD sessions only
2. Vancomycin 125mg QID GT
3. Oxycodone 2.5mg q6h/prn GT
4. Benadryl 25mg [**Hospital1 **]/prn GT
5. Benadryl 25mg qhs GT
6. Tums 650mg po QID
7. colace 100mg [**Hospital1 **]/prn GT
8. Digoxin 0.125mg every other day GT, last dose given today at
the rehab
9. Mucomyst 200mg TId inh
10 Tylenol Q6h/prn GT
11. Albuterol 2 puffs q6h/prn inh
12. Synthroid 125 mcg daily GT
13. Aspirin 81mg qday Gt
14. Combivent 6 puffs q6h inh
15. Lactinex 1 tab [**Hospital1 **] GT
16. Prilosec 20mg GT
17. Reglan 10mg TID GT
18. Lidoderm patch top daily
19. Lactobacillus 1 tab [**Hospital1 **]
20. Epogen at HD

ALLERGIES: Proxy[**Name (NI) 67216**] / Caffeine / Butalbital / Barbiturates / Xanthines

PHYSICAL EXAM: VS: T: BP: 114/54 P: 66 RR: O2 sat: 100%
GEN: Lying in bed, NAD
HEENT: PERRL, cloudy cornea, Mouth open with dry tongue. no
obvious OP lesions
NECK: trach in place
CV: RRR, nl S1 and S2, no m/r/g
PULM: CTA bilaterally, no wheezes/rhonchi/crackles.
ABD: Soft, grimaces on palpation, mildly distended, active bowel
sounds. No hepatosplenomegaly
EXT: warm, no edema of LEs, no rashes, lidoderm patch on feet
bilaterally, dry gangrenous toes bilaterally and auto-amputated
toes on L. R great toe looks dry and auto-amputating. No signs
of infection in any toes, however.
NEURO: awake, opens eyes spontaneously, but does not follow any
commands.  Uncooperative with exam.

FAMILY HISTORY: # Siblings: MI in 60s. Schizophrenia.

SOCIAL HISTORY: # Personal: Lives at [**Hospital 100**] Rehab.  Divorced.  Three adult
children.
# Tobacco: Former smoker.  3 packs per day x 13 years.
# Alcohol: Occasional past use.
Other specified cardiac dysrhythmias,Unspecified acquired hypothyroidism,Abnormal coagulation profile,Other persistent mental disorders due to conditions classified elsewhere,Unspecified deficiency anemia,Gastrostomy status,Tracheostomy status,Personal history of malignant neoplasm of large intestine,Personal history of noncompliance with medical treatment, presenting hazards to health,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Other postprocedural status,Unspecified septicemia,Pneumonia due to Pseudomonas,Septic shock,End stage renal disease,Chronic respiratory failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Unspecified pleural effusion,Aphasia,Other and unspecified complications of medical care, not elsewhere classified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Severe sepsis,Chronic airway obstruction, not elsewhere classified,Peripheral vascular disease, unspecified
Cardiac dysrhythmias NEC,Hypothyroidism NOS,Abnrml coagultion prfile,Mental disor NEC oth dis,Deficiency anemia NOS,Gastrostomy status,Tracheostomy status,Hx of colonic malignancy,Hx of past noncompliance,Hx TIA/stroke w/o resid,Post-proc states NEC,Septicemia NOS,Pseudomonal pneumonia,Septic shock,End stage renal disease,Chronic respiratory fail,Hyp kid NOS w cr kid V,Pleural effusion NOS,Aphasia,Complic med care NEC/NOS,Abn react-procedure NEC,Severe sepsis,Chr airway obstruct NEC,Periph vascular dis NOS
Admission Date:  [**2188-6-16**]              Discharge Date:   [**2188-6-25**]

Date of Birth:  [**2116-10-30**]             Sex:   F

Service: MEDICINE

Allergies:
Proxy[**Name (NI) 67216**] / Caffeine / Butalbital / Barbiturates / Xanthines

Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
septic shock

Major Surgical or Invasive Procedure:
tunnelled line placement by IR

History of Present Illness:
71 yo F with dementia, ESRD on HD, respiratory failure s/p
trach, s/p PEG, COPD, recurrent aspiration PNA, and hx of C.diff
colitis is transferred from the [**Hospital 100**] Rehab MACU after having
two hypotensive/unresponsive episodes during HD.  Rather than
take fluid off, they gave the patient 500 cc.  Per the patient's
son, the patient has been having difficulties for the past nine
weeks, with delerium that finally resolved after adding
phosphate binders, correcting lyte (hypercalcemia, hyperpphos)
abnormalities, and d/c'ing sedating medications.  Per rehab
records, she recently had recurrent C diff, and was treated with
Zosyn for PNA with cxs + for Providencia stuartii, Psuedomonas,
and Citrobacter.  She appeared to recover when she was noted
about 1 week prior to admission be increasingly hypotensive with
altered mental status.  She had blood and C diff cxs from [**6-11**]
which were negative.  Sputum cultures again grew Citrobacter and
Pseudomonas.  She was started on Levaquin for Citrobacter
(Pseudomonas was presumed to be a colonizer) but she was noted
to have worsening resp status with increasingly purulent sputum.
 On [**6-15**] her antibiotics were changed to Tobramycin and
Cefepime.  Her WBC has continued to rise, she had an episode of
atrial fibrillation, and then the above mentioned episodes at
HD.
.
In the ED, Patient's blood pressures were initially in the 90's
- 100's and the patient's mental status was at baseline per her
son.  [**Name (NI) **] [**Name2 (NI) **] count returned at 20.1 and her CXR came back as
having BL infiltrates concerning for multifocal PNA vs
aspiration.  She then began to drop her pressures into the 60's
systolic.  A code sepsis was called.  She received 2 liters of
fluid and was started on peripheral levophed.  A central lines
was placed and her initial CVP was 13 and her lactate was 1.5.
She appeared to be having significant oral secretions and
de-satting down to the 80's so she was placed on the ventilator.
 She was started on Vancomycin, Zosyn, Azithromycin and admitted
to MICU for further work-up and management.
.
Per her son, at baseline she is able to hold a coherent
conversation although she has some chronic deficits from her
previous CVA's including frequent altered mental status with
infections or lyte abnormalities, finding it difficult to
explain where her pain is in her body, and being easily
overstimulated (lights, sounds.)  She had some diarrhea at
[**Hospital 100**] Rehab today, and again in the ED, and one episode of
vomiting this AM.  Her baseline temp is 97.8 and she rarely gets
fevers when infected.


Past Medical History:
#. ESRD on HD of unclear etiology. ? d/t chronic pyelo and
uncontrolled HTN.
#. Respiratory failure s/p trach in [**2-11**], vent dependent until
[**2188-1-5**] when she was successfully weaned off
#. COPD
#chronic pleural effusions
#. Recurrent aspiration PNA
#. PVD, s/p R CEA, s/p bilateral iliac stents and gangrene of
toew bilaterally and autoamputating
#. HTN
#. Hypothyroidism
#. h/o GI bleeding
#. CHF no previous echo here, so unclear [**Name2 (NI) **]
#. h/o Cholesterol emboli syndrome
#. Paroxysmal AF
# Anemia
# s/p multiple embolic CVA
# Dementia
# Adenocarcinoma of the colon s/p resection in [**2186**]
# s/p PEG
# h/o MRSA colonization
# hx of pseudomonas colonization
# h/o VRE infection
# C.diff colitis

Social History:
# Personal: Lives at [**Hospital 100**] Rehab.  Divorced.  Three adult
children.
# Tobacco: Former smoker.  3 packs per day x 13 years.
# Alcohol: Occasional past use.


Family History:
# Siblings: MI in 60s. Schizophrenia.

Physical Exam:
VS: T: BP: 114/54 P: 66 RR: O2 sat: 100%
GEN: Lying in bed, NAD
HEENT: PERRL, cloudy cornea, Mouth open with dry tongue. no
obvious OP lesions
NECK: trach in place
CV: RRR, nl S1 and S2, no m/r/g
PULM: CTA bilaterally, no wheezes/rhonchi/crackles.
ABD: Soft, grimaces on palpation, mildly distended, active bowel
sounds. No hepatosplenomegaly
EXT: warm, no edema of LEs, no rashes, lidoderm patch on feet
bilaterally, dry gangrenous toes bilaterally and auto-amputated
toes on L. R great toe looks dry and auto-amputating. No signs
of infection in any toes, however.
NEURO: awake, opens eyes spontaneously, but does not follow any
commands.  Uncooperative with exam.


Pertinent Results:
FINDINGS: A single frontal view of the chest labeled "PCXR
upright at 15:00 p.m." excludes the uppermost portion of the
left lung apex. A tracheostomy tube is in unchanged position.
The left-sided hemodialysis catheter again terminates at the
cavoatrial junction. Cardiomegaly is unchanged. Perihilar
opacities, probable small bilateral pleural effusions, and
Kerley B lines are consistent with mild CHF. In addition,
airspace opacities in the right upper
lobe abutting the major fissure and opacity in the right lower
lung field may represent pneumonia or aspiration. No
pneumothorax is evident.  Atherosclerotic calcifications are
again noted along the thoracic aorta. A tube overlying the left
upper abdomen is again seen. No rib fractures are seen.
IMPRESSION: Right-sided opacities may represent multifocal
pneumonia versus aspiration. These findings are superimposed on
underlying mild CHF.


Brief Hospital Course:
A/P: 71 yo F with dementia, CVAs, ESRD on HD, chronic
respiratory failure s/p trach, s/p PEG, COPD, recurrent
aspiration PNA, and recent hx of C diff colitis transferred from
[**Hospital 100**] Rehab MACU with septic shock.
.
1) Septic shock: Patient has infiltrates on CXR concerning for
PNA, infectious vs recurrent aspiration PNA.  At [**Hospital 100**] Rehab
grew out resistant Pseudomonas and Citrobacter in her sputum.
She was being treated for Citrobacter and Pseudomonas pneumonia
with Vancomycin, Zosyn, and Gentamycin.  When her cultures from
[**Hospital 100**] Rehab returned, the Pseudomonas was only intermediate
sensitive to the gentamycin and she was switched to Vanc, Zosyn,
and Amikacin which were dosed at various levels as her kidney
function fluctuated.  A sputum sample sent here grew out
Pseudomonas which was sensitive to gentamycin and Amikacin.
Patient was left on the Amikacin, dosed by level.  Additonal
possible sources for infection included her multiple lines.  She
had a PICC lines placed at [**Hospital 100**] Rehab on [**6-15**] and a tunneled
line catheter, which proved to be non-functioning and was
removed.  Cultures were sent from all her lines and were all
negative.  She is anuric.  She had no other localizing signs or
symptoms.  She initially required levophed and vasopressin,
titrated to systolic blood pressure rather than MAPs given her
chronically low diastolic blood pressure.  She was extremely
difficult to wean so she was started on stress dose steroids on
[**6-18**].  She came off both pressors by [**6-21**] and stress dose
steroids were d/c'd on [**6-22**].  Given her obvious pneumonia, lack
of signs of local infection, and negative blood cultures from
her lines, her PICC line was left in place.  She recovered from
her shock and tolerated fluid removal by intermittent HD prior
to discharge. Her antibiotics will be continued until [**2188-7-1**].
.
2) Respiratory failure: Patient has chronic trach but has not
been vent dependent since [**2188-1-5**] prior to this admission.  As
noted above she was vented in the ED for thick yellow secretions
and hypoxia to the 80's.  She continued to have thick pale
yellow secretions while on the vent.  She was placed on standing
albuterol and atrovent nebs, and QVAR for her history of COPD.
She received aggressive pulmonary toilet.
.
3) ESRD: Pt is on M-W-F HD schedule but was not able to receive
HD given her pressor-dependent septic shock.  Renal was
consulted.  CVVH was schedule to be initiated on but was
post-poned when it was discovered that her tunneled dialysis
catheter was not working.  The old line was removed and a new
one was placed by IR on [**6-19**].  The line placement was
complicated by some bleeding at the insertion site.  That day,
patient's PTT was greater than 150 depite not receiving any
systemic heparin.  The draw was repeated three times, two line
draws and a peripheral stick with peristently elevated PTT.  The
patient received a one time dose of DDAVP and the bleeding at
the line site  eventually resolved with additional sutures and a
fibrin injection.  CVVH was initiated late in the evening of
[**6-19**].  After her shock improved, she tolerated intermittent HD
last on [**2188-6-24**].  She will resume her prior M-W-F schedule. She
was discharged above her dry weight however she was requiring
minimal ventilatory support.  She can be re-assessed daily
should she need additional ultra-filtration sessions.
.
4) Bradycardia/Atrial Fibrillation: Previous ECG from [**12-12**]
shows normal rate.  ECG shows sinus brady with 1st degree block.
Her dignoxin level was checked multiple times and remained
sub-therapeutic. Nevertheless, it was held given her bradycardia
with rates in the 40's but dipping transiently as low as the
30's.  An Echocardiogram was performed which showed preserved
EF.  The etiology of her bradycardia was unclear.  On [**6-21**] she
was noted to be in atrial fibrillation with rates to the 80's.
Her ASA was increased from 81 mg to 325 mg PO daily. Her digoxin
was discontinued as she remained rate controlled without it.
.
5) G-tube fell out:  On arrival to the unit patient's G-tibe was
noted to be out and lying at her side.  A foley catheter was
placed and surgery was consulted.  Patient received her tube
feedings and PO medications through the foley cathter without
complication.  The G-tube was changed during her admission.
.
6) Anemia: Patient has chronic macrocytic anemia.  B12 and
folate levels were normal.  Her Hct drifted downwards until on
[**6-20**] it had trended down to 22.7.  As the patient was actively
oozing from the site of her new HD catheter, she received one
unit of PRBC with an appropriate rise in her HCT.  She has been
relatively stable at ~ 26 since that time with no further signs
of active bleeding.
.
7) Hypothyroidism: continue synthroid which was changed to IV.
This can be converted to G-tube administration once her Mid-line
is removed.
.
8) PVD: Followed by vascular surgery at rehab. Patient has dry
gangrene of toes and auto-amputating.  Per son, [**Last Name **] problem with
infection.  Lidoderm patches were applied to her feet.
.
9) FEN:
- TF via G-tube
- replete lytes PRN
.
10) PPX:
- heparin SC for DVT prophylaxis
- PPI
.
11) COMMUNICATIONS: [**Name (NI) **], [**First Name3 (LF) **] and HCP, [**Telephone/Fax (1) 67244**] (cell)
.
12) CODE: No compressions, no shocks.  Chemical code okay.
- confirmed with son [**Name (NI) **] (HCP)on [**6-16**]
.
13) Access: Midline (placed at HR [**6-15**]), tunnelled HD cath
(placed [**6-20**])
.
14) Dispo: transfered to MACU at [**Hospital1 100**] Senior Life

15) Ethical considerations: Pt seems very uncomfortable, resists
nursing care, usually noncommunicative during hospital course
but did mouth words to the nurses and doctors. Her only
communications were clearly mouthing "I want to die" and "help
me." [**Name (NI) 1094**] son argues that she doesn't mean that, or that she
only says those things when she is sick. Discussed with ethics
and social work.



Medications on Admission:
1. Hydromophone 0.75mg q2h/prn during HD sessions only
2. Vancomycin 125mg QID GT
3. Oxycodone 2.5mg q6h/prn GT
4. Benadryl 25mg [**Hospital1 **]/prn GT
5. Benadryl 25mg qhs GT
6. Tums 650mg po QID
7. colace 100mg [**Hospital1 **]/prn GT
8. Digoxin 0.125mg every other day GT, last dose given today at
the rehab
9. Mucomyst 200mg TId inh
10 Tylenol Q6h/prn GT
11. Albuterol 2 puffs q6h/prn inh
12. Synthroid 125 mcg daily GT
13. Aspirin 81mg qday Gt
14. Combivent 6 puffs q6h inh
15. Lactinex 1 tab [**Hospital1 **] GT
16. Prilosec 20mg GT
17. Reglan 10mg TID GT
18. Lidoderm patch top daily
19. Lactobacillus 1 tab [**Hospital1 **]
20. Epogen at HD


Discharge Medications:
1. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
2. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Ten (10) mL PO BID (2
times a day) as needed.
3. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Six (6)
Puff Inhalation QID (4 times a day).
4. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) mL
Injection [**Hospital1 **] (2 times a day).
5. Nystatin 100,000 unit/mL Suspension [**Hospital1 **]: Five (5) ML PO BID
(2 times a day).
6. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed.
7. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed.
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical QID
(4 times a day) as needed: apply to perineal area.
10. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: 2-15 Puffs
Inhalation Q6H (every 6 hours).
11. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: 2-15 Puffs
Inhalation Q2H (every 2 hours) as needed for SOB, wheeze.
12. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol [**Last Name (STitle) **]:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
13. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical 3X/WEEK (TU,TH,SA):
apply to intact skin of right foot.
14. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical 3X/WEEK (TU,TH,SA):
apply to intact skin of left foot.
15. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).

16. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: 0-10 units
Injection ASDIR (AS DIRECTED).
17. Levothyroxine 200 mcg Recon Soln [**Hospital1 **]: One (1) Recon Soln
Injection DAILY (Daily).
18. Fentanyl Citrate (PF) 50 mcg/mL Solution [**Hospital1 **]: 0.5-1 mL
Injection Q4H (every 4 hours) as needed for pain.
19. Amikacin 250 mg/mL Solution [**Hospital1 **]: 1.6 mL Injection QHD (each
hemodialysis): last dose on [**2188-7-1**].
20. Piperacillin-Tazobactam 2.25 gram Recon Soln [**Date Range **]: One (1)
Recon Soln Intravenous Q12H (every 12 hours): last dose on
[**2188-7-1**].


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
Primary diagnoses:
1)Sepsis secondary to Ventilator associated pneumonia
2)Respiratory failure
3)End stage renal disease

Secondary diagnoses:
1)Atrial fibrillation
2)Anemia
3)Hypothyroidism
4)Peripheral vascular disease


Discharge Condition:
Stable.
mouthing words. moving all 4 extremities.


Discharge Instructions:
1)You were admitted to the hospital with an infection, likely in
your lungs. You are currently on antibiotics for 2 weeks.

2)Please take all medications as listed in the discharge
instructions.

3)Please attend all appointments as listed below. Please
schedule an appointment with your primary care physician within
[**Name Initial (PRE) **] few weeks after being discharged from the hospital.

4)If you experience any fevers, chills, chest pain, shortness of
breath, dizziness, or any other concerning symptoms please
return to the emergency room.

Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 610**] [**Last Name (NamePattern4) 9001**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2188-7-4**] 2:00
{'Other specified cardiac dysrhythmias,Unspecified acquired hypothyroidism,Abnormal coagulation profile,Other persistent mental disorders due to conditions classified elsewhere,Unspecified deficiency anemia,Gastrostomy status,Tracheostomy status,Personal history of malignant neoplasm of large intestine,Personal history of noncompliance with medical treatment, presenting hazards to health,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Other postprocedural status,Unspecified septicemia,Pneumonia due to Pseudomonas,Septic shock,End stage renal disease,Chronic respiratory failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Unspecified pleural effusion,Aphasia,Other and unspecified complications of medical care, not elsewhere classified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Severe sepsis,Chronic airway obstruction, not elsewhere classified,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: septic shock

PRESENT ILLNESS: 71 yo F with dementia, ESRD on HD, respiratory failure s/p
trach, s/p PEG, COPD, recurrent aspiration PNA, and hx of C.diff
colitis is transferred from the [**Hospital 100**] Rehab MACU after having
two hypotensive/unresponsive episodes during HD.  Rather than
take fluid off, they gave the patient 500 cc.  Per the patient's
son, the patient has been having difficulties for the past nine
weeks, with delerium that finally resolved after adding
phosphate binders, correcting lyte (hypercalcemia, hyperpphos)
abnormalities, and d/c'ing sedating medications.  Per rehab
records, she recently had recurrent C diff, and was treated with
Zosyn for PNA with cxs + for Providencia stuartii, Psuedomonas,
and Citrobacter.  She appeared to recover when she was noted
about 1 week prior to admission be increasingly hypotensive with
altered mental status.  She had blood and C diff cxs from [**6-11**]
which were negative.  Sputum cultures again grew Citrobacter and
Pseudomonas.  She was started on Levaquin for Citrobacter
(Pseudomonas was presumed to be a colonizer) but she was noted
to have worsening resp status with increasingly purulent sputum.
 On [**6-15**] her antibiotics were changed to Tobramycin and
Cefepime.  Her WBC has continued to rise, she had an episode of
atrial fibrillation, and then the above mentioned episodes at
HD.
.
In the ED, Patient's blood pressures were initially in the 90's
- 100's and the patient's mental status was at baseline per her
son.  [**Name (NI) **] [**Name2 (NI) **] count returned at 20.1 and her CXR came back as
having BL infiltrates concerning for multifocal PNA vs
aspiration.  She then began to drop her pressures into the 60's
systolic.  A code sepsis was called.  She received 2 liters of
fluid and was started on peripheral levophed.  A central lines
was placed and her initial CVP was 13 and her lactate was 1.5.
She appeared to be having significant oral secretions and
de-satting down to the 80's so she was placed on the ventilator.
 She was started on Vancomycin, Zosyn, Azithromycin and admitted
to MICU for further work-up and management.
.
Per her son, at baseline she is able to hold a coherent
conversation although she has some chronic deficits from her
previous CVA's including frequent altered mental status with
infections or lyte abnormalities, finding it difficult to
explain where her pain is in her body, and being easily
overstimulated (lights, sounds.)  She had some diarrhea at
[**Hospital 100**] Rehab today, and again in the ED, and one episode of
vomiting this AM.  Her baseline temp is 97.8 and she rarely gets
fevers when infected.

MEDICAL HISTORY: #. ESRD on HD of unclear etiology. ? d/t chronic pyelo and
uncontrolled HTN.
#. Respiratory failure s/p trach in [**2-11**], vent dependent until
[**2188-1-5**] when she was successfully weaned off
#. COPD
#chronic pleural effusions
#. Recurrent aspiration PNA
#. PVD, s/p R CEA, s/p bilateral iliac stents and gangrene of
toew bilaterally and autoamputating
#. HTN
#. Hypothyroidism
#. h/o GI bleeding
#. CHF no previous echo here, so unclear [**Name2 (NI) **]
#. h/o Cholesterol emboli syndrome
#. Paroxysmal AF
# Anemia
# s/p multiple embolic CVA
# Dementia
# Adenocarcinoma of the colon s/p resection in [**2186**]
# s/p PEG
# h/o MRSA colonization
# hx of pseudomonas colonization
# h/o VRE infection
# C.diff colitis

MEDICATION ON ADMISSION: 1. Hydromophone 0.75mg q2h/prn during HD sessions only
2. Vancomycin 125mg QID GT
3. Oxycodone 2.5mg q6h/prn GT
4. Benadryl 25mg [**Hospital1 **]/prn GT
5. Benadryl 25mg qhs GT
6. Tums 650mg po QID
7. colace 100mg [**Hospital1 **]/prn GT
8. Digoxin 0.125mg every other day GT, last dose given today at
the rehab
9. Mucomyst 200mg TId inh
10 Tylenol Q6h/prn GT
11. Albuterol 2 puffs q6h/prn inh
12. Synthroid 125 mcg daily GT
13. Aspirin 81mg qday Gt
14. Combivent 6 puffs q6h inh
15. Lactinex 1 tab [**Hospital1 **] GT
16. Prilosec 20mg GT
17. Reglan 10mg TID GT
18. Lidoderm patch top daily
19. Lactobacillus 1 tab [**Hospital1 **]
20. Epogen at HD

ALLERGIES: Proxy[**Name (NI) 67216**] / Caffeine / Butalbital / Barbiturates / Xanthines

PHYSICAL EXAM: VS: T: BP: 114/54 P: 66 RR: O2 sat: 100%
GEN: Lying in bed, NAD
HEENT: PERRL, cloudy cornea, Mouth open with dry tongue. no
obvious OP lesions
NECK: trach in place
CV: RRR, nl S1 and S2, no m/r/g
PULM: CTA bilaterally, no wheezes/rhonchi/crackles.
ABD: Soft, grimaces on palpation, mildly distended, active bowel
sounds. No hepatosplenomegaly
EXT: warm, no edema of LEs, no rashes, lidoderm patch on feet
bilaterally, dry gangrenous toes bilaterally and auto-amputated
toes on L. R great toe looks dry and auto-amputating. No signs
of infection in any toes, however.
NEURO: awake, opens eyes spontaneously, but does not follow any
commands.  Uncooperative with exam.

FAMILY HISTORY: # Siblings: MI in 60s. Schizophrenia.

SOCIAL HISTORY: # Personal: Lives at [**Hospital 100**] Rehab.  Divorced.  Three adult
children.
# Tobacco: Former smoker.  3 packs per day x 13 years.
# Alcohol: Occasional past use. 

### Response:
{'Other specified cardiac dysrhythmias,Unspecified acquired hypothyroidism,Abnormal coagulation profile,Other persistent mental disorders due to conditions classified elsewhere,Unspecified deficiency anemia,Gastrostomy status,Tracheostomy status,Personal history of malignant neoplasm of large intestine,Personal history of noncompliance with medical treatment, presenting hazards to health,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Other postprocedural status,Unspecified septicemia,Pneumonia due to Pseudomonas,Septic shock,End stage renal disease,Chronic respiratory failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Unspecified pleural effusion,Aphasia,Other and unspecified complications of medical care, not elsewhere classified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Severe sepsis,Chronic airway obstruction, not elsewhere classified,Peripheral vascular disease, unspecified'}
