CHIEF COMPLAINT: Sepsis, DIC

PRESENT ILLNESS: 62y/o F with h/o COPD, CVA, + PPD [**12-27**] exposure to husband s/p
INH course x9 months, dementia, EtOH, hypertension presented to
OSH with increasing dyspnea. Was recently d/c'ed with COPD
exacerbation - treated with steroids and gatifloxacin. One week
later, c/o worsening dyspnea on [**12-29**]. She was confused, producing
thick yellow sputum, with chills.
Pt admitted to the floor. Desatted, with episode of a fib with
RVR - transferred to unit, treated with dig, lopressor, and dilt
- converted to normal sinus. Was hemodynamically stable.
At OSH, oriented to person and place, but not time. Sat 94% on
2L. WBC on arrival was 25.4, Hct 27.5, plt 35. She was found to
have a RLL infiltrate on CXR. Was on BiPAP initially, eventually
intubated [**12-27**] worsening respiratory failure. Had a chest CT with
loculated R effusion, 2.2 cm RML spiculated mass and R axillary
and supraclavicular LAD. Head CT performed [**12-27**] MS changes -
acute infarct in L frontal lobe. Head CT 4 days later showed no
change. Due to findings on chest CT, had a bronch on the AM of
admission - thick purulent secretions in RML, had cytology
brushings and quantitative cytology brushings sent. On the day
of admission, fibrinogen < 70, FDP > 20, plts 47, INR 1.9. Pt
rec'd 4 units of cryo, then 10 units cryo on [**1-1**], ? FFP, ?
platelets, vitamin K. Acute rise in LFTs - AST 275, ALT 260, alk
phos 82. Were normal on admission [**12-28**] - AST 31, ALT 15, alk phos
82, t bili 1.0.
Was treated with vanco and imipenem. Was transferred here for
expedited workup of RML mass.

MEDICAL HISTORY: h/o TB exposure - INH x9 months
lupus anticoagulant positive
hypertension
hyperlipidemia
h/o CVA
EtOH
tobacco use

MEDICATION ON ADMISSION: Meds on transfer:
decadron 8mg IV daily (rec'd 12mg IV [**12-30**])
vancomycin 1g x1 (10AM on am of transfer)
imipenem 500mg IV q8 (day 1)
colace 100mg daily
combivent q4h
diltiazem ? dose
albuterol nebs prn
lansoprazole 30mg [**Hospital1 **]
simvastatin 20mg qHS
haldol prn
ativan prn
milk of magnesia
SL ntg prn
morphine prn
phenergan prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 98.0 151/44 77 16 95% AC 450x16/7/0.5
Gen: not responsive to commands, intubated
HEENT: PERRL
CV: RRR, nl S1/S2, no m/r/g
Pulm: clear bilaterally
Abd: mildly distended, hypoactive bowel sounds
Ext: dusky R foot with non-dopplerable pulses, purple R 3rd
finger
Neuro: does not open eyes on command

FAMILY HISTORY: NC

SOCIAL HISTORY: lives with one of her daughters. [**Name (NI) 4906**] died about 1 year ago
[**12-27**] TB. In the past, pt drank EtoH daily, was a heavy smoker -
quit [**10-29**].
Malignant neoplasm of middle lobe, bronchus or lung,Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes,Unspecified septicemia,Acute respiratory failure,Chronic airway obstruction, not elsewhere classified,Defibrination syndrome,Cerebral artery occlusion, unspecified with cerebral infarction,Primary hypercoagulable state,Arterial embolism and thrombosis of lower extremity,Severe sepsis,Pneumonia, organism unspecified,Other pulmonary embolism and infarction,Other persistent mental disorders due to conditions classified elsewhere,Unspecified essential hypertension
Mal neo middle lobe lung,Mal neo lymph-intrathor,Septicemia NOS,Acute respiratry failure,Chr airway obstruct NEC,Defibrination syndrome,Crbl art ocl NOS w infrc,Prim hypercoagulable st,Lower extremity embolism,Severe sepsis,Pneumonia, organism NOS,Pulm embol/infarct NEC,Mental disor NEC oth dis,Hypertension NOS
Admission Date:  [**2154-1-2**]              Discharge Date:   [**2154-1-4**]

Date of Birth:  [**2091-1-28**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 8487**]
Chief Complaint:
Sepsis, DIC

Major Surgical or Invasive Procedure:
Endotracheal intubation (at OSH)

History of Present Illness:
62y/o F with h/o COPD, CVA, + PPD [**12-27**] exposure to husband s/p
INH course x9 months, dementia, EtOH, hypertension presented to
OSH with increasing dyspnea. Was recently d/c'ed with COPD
exacerbation - treated with steroids and gatifloxacin. One week
later, c/o worsening dyspnea on [**12-29**]. She was confused, producing
thick yellow sputum, with chills.
Pt admitted to the floor. Desatted, with episode of a fib with
RVR - transferred to unit, treated with dig, lopressor, and dilt
- converted to normal sinus. Was hemodynamically stable.
At OSH, oriented to person and place, but not time. Sat 94% on
2L. WBC on arrival was 25.4, Hct 27.5, plt 35. She was found to
have a RLL infiltrate on CXR. Was on BiPAP initially, eventually
intubated [**12-27**] worsening respiratory failure. Had a chest CT with
loculated R effusion, 2.2 cm RML spiculated mass and R axillary
and supraclavicular LAD. Head CT performed [**12-27**] MS changes -
acute infarct in L frontal lobe. Head CT 4 days later showed no
change. Due to findings on chest CT, had a bronch on the AM of
admission - thick purulent secretions in RML, had cytology
brushings and quantitative cytology brushings sent. On the day
of admission, fibrinogen < 70, FDP > 20, plts 47, INR 1.9. Pt
rec'd 4 units of cryo, then 10 units cryo on [**1-1**], ? FFP, ?
platelets, vitamin K. Acute rise in LFTs - AST 275, ALT 260, alk
phos 82. Were normal on admission [**12-28**] - AST 31, ALT 15, alk phos
82, t bili 1.0.
Was treated with vanco and imipenem. Was transferred here for
expedited workup of RML mass.


Past Medical History:
h/o TB exposure - INH x9 months
lupus anticoagulant positive
hypertension
hyperlipidemia
h/o CVA
EtOH
tobacco use


Social History:
lives with one of her daughters. [**Name (NI) 4906**] died about 1 year ago
[**12-27**] TB. In the past, pt drank EtoH daily, was a heavy smoker -
quit [**10-29**].

Family History:
NC

Physical Exam:
VS: 98.0 151/44 77 16 95% AC 450x16/7/0.5
Gen: not responsive to commands, intubated
HEENT: PERRL
CV: RRR, nl S1/S2, no m/r/g
Pulm: clear bilaterally
Abd: mildly distended, hypoactive bowel sounds
Ext: dusky R foot with non-dopplerable pulses, purple R 3rd
finger
Neuro: does not open eyes on command


Pertinent Results:
OSH Radiology Studies:

CT head without contrast [**12-31**] (OSH): c/w acute infarct, left
frontal; atrophy with additional small areas of decreased
attenuation c/w previous ischemic changes; R parietal temporal,
L posterior parietal, deep central R parietal - c/w areas of
previous infarct - no change from [**12-28**]
.
CT chest with contrast [**12-31**] (OSH): anteriorly at R base, 2.2cm
area of increased attenuation, possible rounded atelectasis but
cannot exclude lung mass in RML; soft tissue prominence in R
axilla, enhancing; soft tissue fullness in supraclavicular
region on R c/w adenopathy
.
CXR [**1-2**] (not official read): R sided diffuse infiltrate, could
not visualize discrete mass

[**Hospital1 18**] Radiology Studies:
[**1-3**] CXR:
1. Moderate loculated right pleural effusion.
2. Right paratracheal/suprahilar density, which may represent a
mass or
lymphadenopathy.
3. Patchy opacities in the right lung.
4. Further evaluation by chest CT is recommended.

[**1-3**] RLE U/S:
The right common femoral vein is patent and compressible, with
normal waveforms. The right common femoral artery is patent as
well, with a normal waveform, and without evidence of
pseudoaneurysm. Small amount of calcification is noted within
the right common femoral artery.

[**1-3**] Abdominal U/S:
1. Patent hepatic vasculature. No evidence of portal venous
thrombosis.
2. The gallbladder is fairly distended with sludge and possible
small amount shadowing stones within it. There is no gallbladder
wall thickening or edema, but there is a small amount of free
fluid in the gallbladder fossa. The appearance is not diagnostic
of cholecystitis, but the appearance is not entirely normal. If
there is clinical concern for cholecystitis, HIDA scan or
follow-up ultrasound may be helpful.
3. Right pleural effusion.

[**1-3**] Head CT:
There are multiple moderate size areas of hypodensity in the
cortex
and subajcent white matter of both cerebral hemispheres. These
are associated with loss of the [**Doctor Last Name 352**]-white matter
differentiation and are suggestive of subacute-chronic infarcts.
The abnormal areas are in the frontal and parietal lobes
bilaterally. The distribution is consistent with embolic
phenomenona but could be compatible with a watershed
distribution as well. There is no evidence of hemorrhagic
transformation. There is no hydrocephalus or shift of normally
midline structures. Note is made of septum cavum pellucidum et
vergae.


OSH Labs and Results:
Labs from AM of admission:
WBC 20.2 (90% PMNs), Hct 27.9, MCV 87, plt 47
Na 146 113 52 111
4.1 20 1.4
Ca 8.8 Mg 1.8
AST 275, ALT 260, alk phos 82, t bili 0.7, alb 2.9
dig 1.2
vanco 13.9
PT 22 PTT 37 INR 1.9
fibrinogen <70, FDP >20

Other labs - [**12-29**]:
AT III 78%
lupus anticoagulant positive
protein C 54%
homocysteine 10.4
anticardiolipin <7
protein S 71%
TSH 1.1
[**12-31**]: B12 326, folate 5.6
AFB neg x 1

[**Hospital1 18**] Labs:
BCx: Pending at time of death
UCx: Yeast
Urine Legionella negative

[**2154-1-2**] 11:30PM BLOOD WBC-17.7* RBC-3.82* Hgb-10.7* Hct-32.8*
MCV-86 MCH-28.1 MCHC-32.7 RDW-16.7* Plt Ct-95*
[**2154-1-3**] 04:29AM BLOOD WBC-22.9* RBC-3.69* Hgb-10.4* Hct-31.6*
MCV-86 MCH-28.2 MCHC-32.9 RDW-16.3* Plt Ct-76*
[**2154-1-3**] 06:05PM BLOOD WBC-16.1* RBC-2.79* Hgb-7.9* Hct-24.0*
MCV-86 MCH-28.4 MCHC-33.0 RDW-17.6* Plt Ct-70*
[**2154-1-2**] 11:30PM BLOOD Neuts-89* Bands-0 Lymphs-4* Monos-7 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-24*
[**2154-1-3**] 06:05PM BLOOD PT-15.8* PTT-24.1 INR(PT)-1.4*
[**2154-1-3**] 04:29AM BLOOD PT-18.1* PTT-25.8 INR(PT)-1.7*
[**2154-1-2**] 11:30PM BLOOD PT-17.6* PTT-25.1 INR(PT)-1.6*
[**2154-1-2**] 11:30PM BLOOD Fibrino-179
[**2154-1-2**] 11:30PM BLOOD FDP->1280*
[**2154-1-3**] 06:05PM BLOOD Fibrino-71*#
[**2154-1-2**] 11:30PM BLOOD Glucose-152* UreaN-55* Creat-1.5* Na-148*
K-3.8 Cl-110* HCO3-24 AnGap-18
[**2154-1-3**] 04:29AM BLOOD Glucose-139* UreaN-55* Creat-1.7* Na-146*
K-3.7 Cl-109* HCO3-21* AnGap-20
[**2154-1-3**] 06:05PM BLOOD Glucose-104 UreaN-49* Creat-1.1 Na-149*
K-3.2* Cl-117* HCO3-23 AnGap-12
[**2154-1-2**] 11:30PM BLOOD ALT-170* AST-108* LD(LDH)-686*
AlkPhos-110 Amylase-37 TotBili-0.9
[**2154-1-3**] 04:29AM BLOOD CK(CPK)-157*
[**2154-1-2**] 11:30PM BLOOD Lipase-20
[**2154-1-2**] 11:30PM BLOOD CK-MB-3 cTropnT-0.13*
[**2154-1-2**] 11:30PM BLOOD Albumin-3.5 Calcium-9.1 Phos-4.8* Mg-2.0
[**2154-1-3**] 06:05PM BLOOD Calcium-7.8* Phos-3.9 Mg-1.7
[**2154-1-2**] 11:30PM BLOOD Hapto-175
[**2154-1-3**] 06:05PM BLOOD Cortsol-2.7
[**2154-1-2**] 10:36PM BLOOD Type-ART pO2-91 pCO2-47* pH-7.34*
calHCO3-26 Base XS-0
[**2154-1-2**] 10:36PM BLOOD Lactate-1.8
[**2154-1-2**] 10:12PM URINE Color-DkAmb Appear-Clear Sp [**Last Name (un) **]-1.015
[**2154-1-2**] 10:12PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-15 Bilirub-SM  Urobiln-4* pH-5.0 Leuks-SM
[**2154-1-2**] 10:12PM URINE RBC-3* WBC-5 Bacteri-NONE Yeast-NONE
Epi-<1
[**2154-1-3**] 04:41PM URINE Hours-RANDOM UreaN-634 Creat-83 Na-41

Brief Hospital Course:
Ms. [**Known lastname 65506**] arrived to the ICU intubated. Initial labs
confirmed likelihood of DIC, probably [**12-27**] sepsis. There was no
evidence of acute bleeding, so FFP, platelets, and cryo were not
given. She was started on empiric vancomycin and meropenem for
PNA coverage, with the intention of d/c'ing vanc if no GPC on
blood or sputum cultures in 48h. She was also placed on steroid
taper since pt received decadron treatment at OSH. She was kept
on respiratory precautions due to h/o TB exposure, and sputum
cultures were ordered to r/o active pulmonary TB, given history.
On initial exam, a dusky blue right foot was seen, and pulses
were non-palpable in that foot. Vascular surgery was called
emergently, who saw the patient that night. It was thought that
the patient's DIC and lupus anticoagulant, in addition to
possibly being hypercoagulable [**12-27**] likely lung malignancy,
placed Ms. [**Known lastname 65506**] at very high risk for arterial thrombosis,
and vascular surgery recommended heparinization if possible. In
the context of recent stroke, it was decided to avoid heparin
until imaging of the brain could be done, and the neurology
service consulted.

Ms. [**Known lastname 65506**] was stable overnight until 6AM, when she became
hypertensive and tachycardic to 160s, with ECG demonstrating
afib with RVR. She was given diltiazem and metoprolol, which
slowed her HR somewhat. She also appeared agitated, and was
started on fentanyl and versed, after which she appeared more
comfortable, and more hemodynamically stable.

In the morning, a repeat head CT was done, which revealed
several large areas of hypoattenuation consistent with subacute
stroke. From the OSH head CT reports, which described small
areas of old CVAs, this was thought to possible represent a
progression with possible new or evolving infarcts. Neurology
was consulted, who recommended obtaining an MRI/MRA/MRV, given
hypercoagulable status, maintaining SBP>140, and holding heparin
in the context of possible ongoing stroke. She had q1h neuro
checks, and the head of her bed was elevated to 30 degrees. An
echocardiogram and carotid ultrasounds were also ordered, given
thromboembolic possibilities, and she was kept on ASA 325mg qD.

That evening, code status was discussed again with pt's daughter
and HCP. [**Name (NI) **] had previously been known to be DNR/DNI, but
had been intubated due to what was initially thought to be a
quickly reversible cause. Once Ms. [**Known lastname 65506**]' evolving and
deteriorating clinical course was discussed with her HCP, it was
decided to change the goals of care to comfort measures only.
Her other medications were d/c'ed, blood draws and radiology
tests were d/c'ed, and Ms. [**Known lastname 65506**] was placed on a morphine
drip. At midnight, her endotracheal tube was pulled. An hour
later, hosuestaff was called to the bedside to pronounce her
death. On auscultation, she had no respirations or heart sounds
for two minutes, and had no palpable pulse over this time
period. She had no corneal reflex. She was pronounced dead, and
an autopsy requested by the family.


Medications on Admission:
Meds on transfer:
decadron 8mg IV daily (rec'd 12mg IV [**12-30**])
vancomycin 1g x1 (10AM on am of transfer)
imipenem 500mg IV q8 (day 1)
colace 100mg daily
combivent q4h
diltiazem ? dose
albuterol nebs prn
lansoprazole 30mg [**Hospital1 **]
simvastatin 20mg qHS
haldol prn
ativan prn
milk of magnesia
SL ntg prn
morphine prn
phenergan prn


Discharge Medications:
None

Discharge Disposition:
Expired

Discharge Diagnosis:
DIC
Acute Stroke
Ischemic limb
Sepsis secondary to pneumonia
Lung mass


Discharge Condition:
Deceased

Discharge Instructions:
N/A

Followup Instructions:
N/A
{'Malignant neoplasm of middle lobe, bronchus or lung,Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes,Unspecified septicemia,Acute respiratory failure,Chronic airway obstruction, not elsewhere classified,Defibrination syndrome,Cerebral artery occlusion, unspecified with cerebral infarction,Primary hypercoagulable state,Arterial embolism and thrombosis of lower extremity,Severe sepsis,Pneumonia, organism unspecified,Other pulmonary embolism and infarction,Other persistent mental disorders due to conditions classified elsewhere,Unspecified essential hypertension'}


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, DIC

PRESENT ILLNESS: 62y/o F with h/o COPD, CVA, + PPD [**12-27**] exposure to husband s/p
INH course x9 months, dementia, EtOH, hypertension presented to
OSH with increasing dyspnea. Was recently d/c'ed with COPD
exacerbation - treated with steroids and gatifloxacin. One week
later, c/o worsening dyspnea on [**12-29**]. She was confused, producing
thick yellow sputum, with chills.
Pt admitted to the floor. Desatted, with episode of a fib with
RVR - transferred to unit, treated with dig, lopressor, and dilt
- converted to normal sinus. Was hemodynamically stable.
At OSH, oriented to person and place, but not time. Sat 94% on
2L. WBC on arrival was 25.4, Hct 27.5, plt 35. She was found to
have a RLL infiltrate on CXR. Was on BiPAP initially, eventually
intubated [**12-27**] worsening respiratory failure. Had a chest CT with
loculated R effusion, 2.2 cm RML spiculated mass and R axillary
and supraclavicular LAD. Head CT performed [**12-27**] MS changes -
acute infarct in L frontal lobe. Head CT 4 days later showed no
change. Due to findings on chest CT, had a bronch on the AM of
admission - thick purulent secretions in RML, had cytology
brushings and quantitative cytology brushings sent. On the day
of admission, fibrinogen < 70, FDP > 20, plts 47, INR 1.9. Pt
rec'd 4 units of cryo, then 10 units cryo on [**1-1**], ? FFP, ?
platelets, vitamin K. Acute rise in LFTs - AST 275, ALT 260, alk
phos 82. Were normal on admission [**12-28**] - AST 31, ALT 15, alk phos
82, t bili 1.0.
Was treated with vanco and imipenem. Was transferred here for
expedited workup of RML mass.

MEDICAL HISTORY: h/o TB exposure - INH x9 months
lupus anticoagulant positive
hypertension
hyperlipidemia
h/o CVA
EtOH
tobacco use

MEDICATION ON ADMISSION: Meds on transfer:
decadron 8mg IV daily (rec'd 12mg IV [**12-30**])
vancomycin 1g x1 (10AM on am of transfer)
imipenem 500mg IV q8 (day 1)
colace 100mg daily
combivent q4h
diltiazem ? dose
albuterol nebs prn
lansoprazole 30mg [**Hospital1 **]
simvastatin 20mg qHS
haldol prn
ativan prn
milk of magnesia
SL ntg prn
morphine prn
phenergan prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 98.0 151/44 77 16 95% AC 450x16/7/0.5
Gen: not responsive to commands, intubated
HEENT: PERRL
CV: RRR, nl S1/S2, no m/r/g
Pulm: clear bilaterally
Abd: mildly distended, hypoactive bowel sounds
Ext: dusky R foot with non-dopplerable pulses, purple R 3rd
finger
Neuro: does not open eyes on command

FAMILY HISTORY: NC

SOCIAL HISTORY: lives with one of her daughters. [**Name (NI) 4906**] died about 1 year ago
[**12-27**] TB. In the past, pt drank EtoH daily, was a heavy smoker -
quit [**10-29**]. 

### Response:
{'Malignant neoplasm of middle lobe, bronchus or lung,Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes,Unspecified septicemia,Acute respiratory failure,Chronic airway obstruction, not elsewhere classified,Defibrination syndrome,Cerebral artery occlusion, unspecified with cerebral infarction,Primary hypercoagulable state,Arterial embolism and thrombosis of lower extremity,Severe sepsis,Pneumonia, organism unspecified,Other pulmonary embolism and infarction,Other persistent mental disorders due to conditions classified elsewhere,Unspecified essential hypertension'}
