CHIEF COMPLAINT: Sepsis

PRESENT ILLNESS: This is a 72 year old female NH resident with Down's Syndrome,
alz dementia, diverticulosis, h/o VRE who presented from a NH
with respiratory distress, hypoxia with O2 and hypotension with
SBP 60-80. At NH, she had difficulty in breathing withouth
copious amounts of secretions being suctioned. Upon arrival to
the ED, her vitals were HR 92, BP of 70/46, RR of 28, O2sat of
80%/RA. Sats improved on CPAP and then was placed on NRB,
satting at 100%. Placed on levophed for support. Laboratories
notable for intial lactate 3.9, WBC of 42.6 and Cr of 4.4. K of
6.4 for which patient received calcium, insulin, bicarbonate,
and D50. Urinalysis notable for positive WBC and leucocyte
esterase. Pt received IV levofloxacin. Attempt at subclavian
central line unsuccessful, L femoral CVL placed.
.
Pt is DNR/[**Hospital 24351**] health care proxy was [**Name (NI) 653**] by [**Name (NI) **], she agreed
to pressors and antibiotics but confirmed DNR/DNI status.

MEDICAL HISTORY: Past Medical History:
- Down's Syndrome
- Alzheimer's dementia
- Sick sinus syndrome s/p dual chamber [**Name (NI) 4448**] in 7/00
- osteoporosis
- rosacea
- Raynauds
- OCD
- Diverticular disease
- Prior admission for pneumonia

MEDICATION ON ADMISSION: Tylenol 650 [**Hospital1 **]
Calcium Oyst 500 mg QD
Celecoxib 100 mg [**Hospital1 **]
MVI
Protonix 40 mg QD
Senna
Trazodone QHS
Vit D 400 units QD

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 97.3, 118/62 (76), 94, 17, 99%/NRB
Gen: in no acute distress, minimally verbal at baseline
HEENT: Dry mucus membranes, pupils with defects bilaterally,
sclerae anicteric.
Neck: Supple, no lymphadenopathy
CV: Normal S1/S2, RRR, II/VI HSM at apex.
Pul: bil exp coarse breath sounds
Abd: Soft, NT, distended, normoactive BS.
Ext: No edema, DP's full bilaterally.

FAMILY HISTORY: Unable to obtain/non-contributory.

SOCIAL HISTORY: Pt lives in nursing home ([**Last Name (un) 18355**] Center). Per chart no tobacco
or alcohol. The pt's guardian ([**Name (NI) **] ARC) in the past has made her
DNR/DNI.
Other septicemia due to gram-negative organisms,Urinary tract infection, site not specified,Pneumonia, organism unspecified,Acidosis,Acute kidney failure, unspecified,Acute respiratory failure,Septic shock,Down's syndrome,Fitting and adjustment of cardiac pacemaker,Severe sepsis,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Osteoporosis, unspecified,Other specified disorders of pancreatic internal secretion,Adrenal cortical steroids causing adverse effects in therapeutic use
Gram-neg septicemia NEC,Urin tract infection NOS,Pneumonia, organism NOS,Acidosis,Acute kidney failure NOS,Acute respiratry failure,Septic shock,Down's syndrome,Ftng cardiac pacemaker,Severe sepsis,Alzheimer's disease,Dementia w/o behav dist,Osteoporosis NOS,Pancreatic disorder NEC,Adv eff corticosteroids
Admission Date:  [**2160-12-24**]              Discharge Date:   [**2161-1-5**]

Date of Birth:  [**2088-7-13**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Sepsis

Major Surgical or Invasive Procedure:
Central line placement


History of Present Illness:
This is a 72 year old female NH resident with Down's Syndrome,
alz dementia, diverticulosis, h/o VRE who presented from a NH
with respiratory distress, hypoxia with O2 and hypotension with
SBP 60-80. At NH, she had difficulty in breathing withouth
copious amounts of secretions being suctioned. Upon arrival to
the ED, her vitals were HR 92, BP of 70/46, RR of 28, O2sat of
80%/RA. Sats improved on CPAP and then was placed on NRB,
satting at 100%. Placed on levophed for support. Laboratories
notable for intial lactate 3.9, WBC of 42.6 and Cr of 4.4. K of
6.4 for which patient received calcium, insulin, bicarbonate,
and D50. Urinalysis notable for positive WBC and leucocyte
esterase. Pt received IV levofloxacin. Attempt at subclavian
central line unsuccessful, L femoral CVL placed.
.
Pt is DNR/[**Hospital 24351**] health care proxy was [**Name (NI) 653**] by [**Name (NI) **], she agreed
to pressors and antibiotics but confirmed DNR/DNI status.


Past Medical History:
Past Medical History:
- Down's Syndrome
- Alzheimer's dementia
- Sick sinus syndrome s/p dual chamber [**Name (NI) 4448**] in 7/00
- osteoporosis
- rosacea
- Raynauds
- OCD
- Diverticular disease
- Prior admission for pneumonia


Social History:
Pt lives in nursing home ([**Last Name (un) 18355**] Center). Per chart no tobacco
or alcohol. The pt's guardian ([**Name (NI) **] ARC) in the past has made her
DNR/DNI.

Family History:
Unable to obtain/non-contributory.

Physical Exam:
VS: 97.3, 118/62 (76), 94, 17, 99%/NRB
Gen: in no acute distress, minimally verbal at baseline
HEENT: Dry mucus membranes, pupils with defects bilaterally,
sclerae anicteric.
Neck: Supple, no lymphadenopathy
CV: Normal S1/S2, RRR, II/VI HSM at apex.
Pul: bil exp coarse breath sounds
Abd: Soft, NT, distended, normoactive BS.
Ext: No edema, DP's full bilaterally.


Pertinent Results:
URINE CULTURE (Final [**2160-12-25**]):
      PROTEUS MIRABILIS.    10,000-100,000 ORGANISMS/ML..
         PRESUMPTIVE IDENTIFICATION.
         Trimethoprim/Sulfa sensitivity testing confirmed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             PROTEUS MIRABILIS
                             |
AMPICILLIN------------  =>32 R
AMPICILLIN/SULBACTAM--  =>32 R
CEFAZOLIN-------------     8 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CEFUROXIME------------   <=1 S
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------     8 I
LEVOFLOXACIN----------   =>8 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN----------    32 I
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------     8 I
TRIMETHOPRIM/SULFA----  =>16 R

[**2160-12-24**] 4:08 am SPUTUM      Source: Expectorated.

                            **FINAL REPORT [**2160-12-26**]**

   GRAM STAIN (Final [**2160-12-24**]):
      [**10-22**] PMNs and <10 epithelial cells/100X field.
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CHAINS.

   RESPIRATORY CULTURE (Final [**2160-12-26**]):
      SPARSE GROWTH OROPHARYNGEAL FLORA.
      BETA STREPTOCOCCI, NOT GROUP A.    SPARSE GROWTH.


Brief Hospital Course:
This is a 72 year old woman with Down's Syndrome, Alzheimer's
dementia, diverticular disease admitted with sepsis evidenced by
hemodynamic instability, high grade leucocytosis, lactic
acidosis and associated with renal failure and hyperkalemia,
Initially required Levophed, 100% FM. She is DNR/DNI.  She was
started on broad spectrum antibiotics including linezolid,
zosyn, and flagyl  The sources of infection appear to be UTI
secondary to proteus infection and RLL PNA given high amount of
secretions.  Given sensitivities of the proteus organism,
antibiotics were narrowed with vancomycin replacing linezolid
and continuation of zosyn.  She finished 10 days of flagyl.
.
The patient improved hemodynamically with pressors being weaned
off on hospital day 4.  Her acidosis and renal failure also
improved quickly.  She continued to have secretions and needed
oxygen support.  Secretions resolved fairly well by HD 7, she
continues to require oxygen support of 50% face mask.
.
In summary this is a 72 year old woman with Down's syndrom and
dementia admitted for sepsis secondary to proteus UTI and/or
pneumonia.  Sepsis is resolved.  She is DNR/DNI.  She has been
hemodynamically stable for over a week although she continues to
require oxygen support via facemask.
.
Issues and plan summarized below:
.
1) Sepsis: likely source UTI (from proteus) and PNA. metabolic
acidosis and renal failure reversed quickly at admission.
- volume repleted
- Levophed gtt off since [**12-28**]
- Vancomycin day 5, Zosyn day 11
- Completed steroids started [**12-27**] for continued pressor
requirement and inadequate [**Last Name (un) 104**] stim (total 5 days; ended [**11-30**])
.
2) Resp distress: likely from thick secretions from PNA,
secretions improved, continues to need oxygen support
- antibiotics as above.
- albuterol, mucomyst, added pulmicort
- chest PT, frequent suctioning
- lasix given cautiously as patient had been fluid overloaded.
.
3) Acute renal failure, now resolved after fluid resuscitation;
likely was from severe dehydration.
-hyperkalemic on admission, rec'd calcium/insulin/D50, now
resovled
.
4) Question adrenal insufficiency.
-was given steroids for continued adrenal insufficiency and
blunted [**Last Name (un) 104**] stim response (although [**Last Name (un) 104**] level was already high
in 30's)
-no need for steroids, consider repeat [**Last Name (un) 104**] stim
.
5) Hyperglycemia
-used regular insulin sliding scale while septic and on steroid
replacement
-likely does not need insulin any further, consider A1c level if
question of continued high glucose.
.
6) osteoporosis
- Continue Calcium, vitamin D
.
FEN: Tube feeds

PPX: Pt needs pneumoboots, heparin sq, famotidine, HOB
elevation,VRE precautions
.
Access: PICC placed [**12-26**], Left Fem VL d/c'd, 2 piv
.
Code: DNR/DNI, do not return pt to a MICU
.
Communication: HCP is [**Name (NI) **] [**Name (NI) **]/GBARC ([**Telephone/Fax (1) **] X15)
.
Disposition: Transfer to acute care facility

Medications on Admission:
Tylenol 650 [**Hospital1 **]
Calcium Oyst 500 mg QD
Celecoxib 100 mg [**Hospital1 **]
MVI
Protonix 40 mg QD
Senna
Trazodone QHS
Vit D 400 units QD

Discharge Medications:
1. Budesonide 0.25 mg/2 mL Solution for Nebulization Sig: Two
(2) ML Inhalation [**Hospital1 **] (2 times a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours).
7. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2)
ML Intravenous DAILY (Daily) as needed: and PRN for clogged
port.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection Q8H (every 8 hours).
9. Albuterol Sulfate 0.083 % Solution Sig: [**12-30**] nehulizers
Inhalation Q2H (every 2 hours) as needed for shortness of breath
or wheezing.
10. Famotidine in Normal Saline 20 mg/50 mL Piggyback Sig: Fifty
(50) mL Intravenous Q24H (every 24 hours).
11. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q6H (every 6 hours) for 3 days: last day is
[**2161-1-8**].
12. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous Q 12H (Every 12 Hours) for 9 days: Last day is
[**2160-1-15**].
13. Morphine 2 mg/mL Syringe Sig: 1-2 mg Injection Q4H (every 4
hours) as needed.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] - [**Location (un) 86**]

Discharge Diagnosis:
Urinary tract infection related sepsis


Discharge Condition:
Fair, still requiring some oxygen support but hemodynamically
stable.


Discharge Instructions:
Seek medical attention if secretions worsen.
Pulmonary toilet as needed.
Please continue antibiotics for 14 day course.
Please do not return patient to intensive care unit.

Followup Instructions:
Extended care facility
{"Other septicemia due to gram-negative organisms,Urinary tract infection, site not specified,Pneumonia, organism unspecified,Acidosis,Acute kidney failure, unspecified,Acute respiratory failure,Septic shock,Down's syndrome,Fitting and adjustment of cardiac pacemaker,Severe sepsis,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Osteoporosis, unspecified,Other specified disorders of pancreatic internal secretion,Adrenal cortical steroids causing adverse effects in therapeutic 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: This is a 72 year old female NH resident with Down's Syndrome,
alz dementia, diverticulosis, h/o VRE who presented from a NH
with respiratory distress, hypoxia with O2 and hypotension with
SBP 60-80. At NH, she had difficulty in breathing withouth
copious amounts of secretions being suctioned. Upon arrival to
the ED, her vitals were HR 92, BP of 70/46, RR of 28, O2sat of
80%/RA. Sats improved on CPAP and then was placed on NRB,
satting at 100%. Placed on levophed for support. Laboratories
notable for intial lactate 3.9, WBC of 42.6 and Cr of 4.4. K of
6.4 for which patient received calcium, insulin, bicarbonate,
and D50. Urinalysis notable for positive WBC and leucocyte
esterase. Pt received IV levofloxacin. Attempt at subclavian
central line unsuccessful, L femoral CVL placed.
.
Pt is DNR/[**Hospital 24351**] health care proxy was [**Name (NI) 653**] by [**Name (NI) **], she agreed
to pressors and antibiotics but confirmed DNR/DNI status.

MEDICAL HISTORY: Past Medical History:
- Down's Syndrome
- Alzheimer's dementia
- Sick sinus syndrome s/p dual chamber [**Name (NI) 4448**] in 7/00
- osteoporosis
- rosacea
- Raynauds
- OCD
- Diverticular disease
- Prior admission for pneumonia

MEDICATION ON ADMISSION: Tylenol 650 [**Hospital1 **]
Calcium Oyst 500 mg QD
Celecoxib 100 mg [**Hospital1 **]
MVI
Protonix 40 mg QD
Senna
Trazodone QHS
Vit D 400 units QD

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 97.3, 118/62 (76), 94, 17, 99%/NRB
Gen: in no acute distress, minimally verbal at baseline
HEENT: Dry mucus membranes, pupils with defects bilaterally,
sclerae anicteric.
Neck: Supple, no lymphadenopathy
CV: Normal S1/S2, RRR, II/VI HSM at apex.
Pul: bil exp coarse breath sounds
Abd: Soft, NT, distended, normoactive BS.
Ext: No edema, DP's full bilaterally.

FAMILY HISTORY: Unable to obtain/non-contributory.

SOCIAL HISTORY: Pt lives in nursing home ([**Last Name (un) 18355**] Center). Per chart no tobacco
or alcohol. The pt's guardian ([**Name (NI) **] ARC) in the past has made her
DNR/DNI. 

### Response:
{"Other septicemia due to gram-negative organisms,Urinary tract infection, site not specified,Pneumonia, organism unspecified,Acidosis,Acute kidney failure, unspecified,Acute respiratory failure,Septic shock,Down's syndrome,Fitting and adjustment of cardiac pacemaker,Severe sepsis,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Osteoporosis, unspecified,Other specified disorders of pancreatic internal secretion,Adrenal cortical steroids causing adverse effects in therapeutic use"}
