CHIEF COMPLAINT: Unresponsiveness, altered, intubated for airway protection found
to have urosepsis

PRESENT ILLNESS: 65 yo female with MS [**First Name (Titles) **] [**Last Name (Titles) 84078**] for questionable hx TMJ who was
sent in from her NSH after being found covered in vomit with
agonal breathing.  NSH notes reports "symptoms of seizure
activity" with patient subsequently unresponsive and found to be
hypoxic with sats <83% on 2L.  Per EMS, she was unresponsive en
route, still breathing but not withdrawing to pain.
.
In the ED, initial vitals were: no temp recorded, 118 135/71 34
100% on NRB.  She was easily intubated for airway protection
with a grade 1 view.  Head CT was unremarkable for bleed.  Neuro
was consulted and felt this was likely toxic metabolic if
seizure activity, but will continue to follow.  She has had
multiple episodes of UTI in the past.  Blood and urine cultures
were sent and she was given vanco/zosyn.  Foley was changed.
Per the ED resident, they were not aware of her potential
allergy but she did not have a rash prior to transfer to the
MICU.  When the patient was signed out she was currently doing
well on vent with most recent vitals prior to transfer being
afeb, 92, 103/60 with sats 100% on 400x18, 5x50%.  She dropped
her pressures prior to transfer to 67/41 with HR 94.  She was
given 2L of IVF and started on levophed.  Sedation was held.
.
Of note, per Dr.[**Name (NI) 84079**] note to her PCP, [**Name10 (NameIs) **] last admission was
for urinary tract infection, E. coli bacteremia, and sepsis, and
initially required admission to the ICU for vasopressor support.
She was also found to have an obstructing left renal stone and
had a percutaneous nephrostomy tube placed with improvement in
her infection. She was able to be taken of vasopressor agents
and was discharged to complete a 14 day total course of
antibiotics.  At that time, urology recommended to leave the
nephrostomy tube in the left renal system indefinitely with tube
changes every 3 months as she was high risk for both
nephrolithotomy and extracorporeal shock wave lithotripsy.  Her
hospital course was also notable for hypoxia with a 4L oxygen
requirement which was felt to be due to a combination of mild
volume overload, respiratory muscle weakness in the setting of
multiple sclerosis and infection, and intermittent aspiration.
Her oxygen requirement was stable and she was discharged to
rehab to have gentle diuresis as tolerated and tocontinue her
usual dysphagia diet.  She has been on 2L at her NSH with
unclear continued workup.
.

MEDICAL HISTORY: Multiple Sclerosis - about 14yrs, followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Location (un) 2274**]
 - wheelchair at baseline, lives in nursing home
 - has no use of her lower extremities, sometimes spastic
movements
 - bladder chronically contracted
UTI with ESBL E.coli--sensitive to zosyn, [**Last Name (un) 2830**], gent in past
[**Last Name (un) 8304**] Depression
Anxiety
PVD s/p lower extremity bypass
COPD
Osteoporosis
Hx of +PPD
bilateral femur supracondylar fractures [**2113**]
hx of Urosepsis - hospitalized about once/yr, per husband
Neurogenic bladder - indwelling foley x [**4-27**] [**Last Name (LF) 1686**], [**First Name3 (LF) **] husband
Recurrent C. Diff
Hx of Sacral Decub
LE spasticity
Hx of jaw pain -- ?TMJ, improved on [**First Name3 (LF) **]

MEDICATION ON ADMISSION: 1. methenamine hippurate 1 gram Tablet Sig: One (1) Tablet PO
bid
2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
3. carbamazepine 100 mg Tablet, Chewable Sig: one daily
4. Carbamazepine 100 mg Tablet, Chewable Sig: Three (3) Tablet
[**Hospital1 **]
5. baclofen 10 mg Tablet Sig: One (1) Tablet PO twice a day.
6. glatiramer 20 mg Kit Sig: Twenty (20) mg Subcutaneous Daily
7. Os-Cal 500 + D 500 mg(1,250mg) -200 unit Tablet daily
8. alendronate 70 mg Tablet PO once a week.
9. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

ALLERGIES: Zosyn / ceftriaxone

PHYSICAL EXAM: Admission exam
Vitals: 101.9 100 117/64 17 100% on 400x18, 5x50%
General: Intubated, sedated, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
blood around mouth, no lesions identified
Neck: supple, JVP not elevated, no LAD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: CTAB, no wheezes, rales, ronchi
Abdomen: +BS, soft, non-tender, non-distended, no organomegaly
Back: stage 2 sacral decub on right buttocks, stage 1 decub on
left hip, left perc neph tube in place and c/d/i
GU: +foley
Ext: cool, well perfused, 2+ pulses distally, no clubbing,
cyanosis or edema, moving her toes, PICC line in right upper arm
is c/d/i
Neuro: sedated

FAMILY HISTORY: No family members with Multiple Sclerosis.

SOCIAL HISTORY: Lives in nursing home for last 4 [**First Name3 (LF) 1686**].  Husband is HCP, lives
with one of their daughters.  [**Name (NI) **] daughter married and lives
in the area.  Nonambulatory and in wheelchair at baseline,
dependent for transfers and some of ADLs.  Has no use of lower
extremities at baseline.  On pureed thickened liquids at rehab.
Infection and inflammatory reaction due to other genitourinary device, implant, and graft,Septicemia due to pseudomonas,Acute myocardial infarction of other anterior wall, initial episode of care,Septic shock,Pressure ulcer, lower back,Hyperosmolality and/or hypernatremia,Paraplegia,Multiple sclerosis,Severe sepsis,Calculus of ureter,Wheelchair dependence,Neurogenic bladder NOS,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Chronic pyelonephritis without lesion of renal medullary necrosis,Urinary obstruction, unspecified,Other specified forms of chronic ischemic heart disease,Unspecified persistent mental disorders due to conditions classified elsewhere,Personal history, urinary (tract) infection,Chronic obstructive asthma, unspecified
React-oth genitourin dev,Pseudomonas septicemia,AMI anterior wall, init,Septic shock,Pressure ulcer, low back,Hyperosmolality,Paraplegia NOS,Multiple sclerosis,Severe sepsis,Calculus of ureter,Wheelchair dependence,Neurogenic bladder NOS,Abn react-procedure NEC,Chr pyelonephritis NOS,Urinary obstruction NOS,Chr ischemic hrt dis NEC,Mental disor NOS oth dis,Personal history UTI,Chronic obst asthma NOS
Admission Date:  [**2118-12-11**]              Discharge Date:   [**2118-12-20**]

Date of Birth:  [**2053-11-10**]             Sex:   F

Service: MEDICINE

Allergies:
Zosyn / ceftriaxone

Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
Unresponsiveness, altered, intubated for airway protection found
to have urosepsis

Major Surgical or Invasive Procedure:
intubated, mechanical ventilation

History of Present Illness:
65 yo female with MS [**First Name (Titles) **] [**Last Name (Titles) 84078**] for questionable hx TMJ who was
sent in from her NSH after being found covered in vomit with
agonal breathing.  NSH notes reports "symptoms of seizure
activity" with patient subsequently unresponsive and found to be
hypoxic with sats <83% on 2L.  Per EMS, she was unresponsive en
route, still breathing but not withdrawing to pain.
.
In the ED, initial vitals were: no temp recorded, 118 135/71 34
100% on NRB.  She was easily intubated for airway protection
with a grade 1 view.  Head CT was unremarkable for bleed.  Neuro
was consulted and felt this was likely toxic metabolic if
seizure activity, but will continue to follow.  She has had
multiple episodes of UTI in the past.  Blood and urine cultures
were sent and she was given vanco/zosyn.  Foley was changed.
Per the ED resident, they were not aware of her potential
allergy but she did not have a rash prior to transfer to the
MICU.  When the patient was signed out she was currently doing
well on vent with most recent vitals prior to transfer being
afeb, 92, 103/60 with sats 100% on 400x18, 5x50%.  She dropped
her pressures prior to transfer to 67/41 with HR 94.  She was
given 2L of IVF and started on levophed.  Sedation was held.
.
Of note, per Dr.[**Name (NI) 84079**] note to her PCP, [**Name10 (NameIs) **] last admission was
for urinary tract infection, E. coli bacteremia, and sepsis, and
initially required admission to the ICU for vasopressor support.
She was also found to have an obstructing left renal stone and
had a percutaneous nephrostomy tube placed with improvement in
her infection. She was able to be taken of vasopressor agents
and was discharged to complete a 14 day total course of
antibiotics.  At that time, urology recommended to leave the
nephrostomy tube in the left renal system indefinitely with tube
changes every 3 months as she was high risk for both
nephrolithotomy and extracorporeal shock wave lithotripsy.  Her
hospital course was also notable for hypoxia with a 4L oxygen
requirement which was felt to be due to a combination of mild
volume overload, respiratory muscle weakness in the setting of
multiple sclerosis and infection, and intermittent aspiration.
Her oxygen requirement was stable and she was discharged to
rehab to have gentle diuresis as tolerated and tocontinue her
usual dysphagia diet.  She has been on 2L at her NSH with
unclear continued workup.
.

Past Medical History:
Multiple Sclerosis - about 14yrs, followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Location (un) 2274**]
 - wheelchair at baseline, lives in nursing home
 - has no use of her lower extremities, sometimes spastic
movements
 - bladder chronically contracted
UTI with ESBL E.coli--sensitive to zosyn, [**Last Name (un) 2830**], gent in past
[**Last Name (un) 8304**] Depression
Anxiety
PVD s/p lower extremity bypass
COPD
Osteoporosis
Hx of +PPD
bilateral femur supracondylar fractures [**2113**]
hx of Urosepsis - hospitalized about once/yr, per husband
Neurogenic bladder - indwelling foley x [**4-27**] [**Last Name (LF) 1686**], [**First Name3 (LF) **] husband
Recurrent C. Diff
Hx of Sacral Decub
LE spasticity
Hx of jaw pain -- ?TMJ, improved on [**First Name3 (LF) **]


Social History:
Lives in nursing home for last 4 [**First Name3 (LF) 1686**].  Husband is HCP, lives
with one of their daughters.  [**Name (NI) **] daughter married and lives
in the area.  Nonambulatory and in wheelchair at baseline,
dependent for transfers and some of ADLs.  Has no use of lower
extremities at baseline.  On pureed thickened liquids at rehab.

-Tobacco: started at age 20, quit about 15yrs ago
-ETOH: social, occasional, per husband
-[**Name (NI) 3264**]: none


Family History:
No family members with Multiple Sclerosis.


Physical Exam:
Admission exam
Vitals: 101.9 100 117/64 17 100% on 400x18, 5x50%
General: Intubated, sedated, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
blood around mouth, no lesions identified
Neck: supple, JVP not elevated, no LAD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: CTAB, no wheezes, rales, ronchi
Abdomen: +BS, soft, non-tender, non-distended, no organomegaly
Back: stage 2 sacral decub on right buttocks, stage 1 decub on
left hip, left perc neph tube in place and c/d/i
GU: +foley
Ext: cool, well perfused, 2+ pulses distally, no clubbing,
cyanosis or edema, moving her toes, PICC line in right upper arm
is c/d/i
Neuro: sedated

Discharge Exam:
Afebrile
Gen: Alert, awake, responding appropriately to questions, soft
spoken with some slurring of speech
HEENT: dry MM
CV: RRR, no MRG
Lungs: poor inspiratory effort, no wheezes, crackles,
consolidations
Abd: +BS, soft, NT, surgical scars
Back: Decub
GU: Foley and left perc nephrostomy CDI
Neuro: baseline

Pertinent Results:
ADMISSION LABS:

[**2118-12-11**] 01:49PM   GLUCOSE-103* UREA N-16 CREAT-0.7 SODIUM-142
POTASSIUM-4.2 CHLORIDE-110* TOTAL CO2-25 ANION GAP-11
[**2118-12-11**] 01:49PM   CALCIUM-8.0* PHOSPHATE-2.7 MAGNESIUM-1.8
[**2118-12-11**] 06:23AM   CK-MB-7 cTropnT-0.50*
[**2118-12-11**] 06:23AM   ALT(SGPT)-30 AST(SGOT)-72* CK(CPK)-90 ALK
PHOS-183* TOT BILI-0.4
[**2118-12-11**] 06:23AM   WBC-14.7*# RBC-3.40* HGB-9.9* HCT-31.1*
MCV-91 MCH-29.0 MCHC-31.7 RDW-15.5

DISCHARGE LABS:

[**2118-12-20**] 06:07AM BLOOD WBC-6.0 RBC-3.09* Hgb-8.6* Hct-27.4*
MCV-89 MCH-27.7 MCHC-31.2 RDW-15.5 Plt Ct-407
[**2118-12-19**] 10:46AM BLOOD Neuts-67.6 Lymphs-22.0 Monos-4.6 Eos-5.1*
Baso-0.6
[**2118-12-20**] 06:07AM BLOOD Glucose-75 UreaN-7 Creat-0.4 Na-141 K-3.9
Cl-106 HCO3-31 AnGap-8
[**2118-12-13**] 05:54AM BLOOD ALT-16 AST-20 LD(LDH)-180 AlkPhos-130*
TotBili-0.2
[**2118-12-20**] 06:07AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.0

TTE:
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. There
is mild to moderate regional left ventricular systolic
dysfunction with hypokinesis of the distal half of the septum
and apical anterior and inferior walls. The remaining segments
contract well (LVEF 40%). The apex is not aneurysm and no apical
thrombus is seen. The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.

IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity size with regional systolic dysfunction c/w CAD (mid-LAD
distribution). Pulmonary artery hypertension.

CTAbd/pelvis:
IMPRESSION:
1. Foley catheter is now positioned with its distal tip seen in
the right
ureter. Repositioning is recommended. These findings were
discussed with Dr. [**Last Name (STitle) **] Dr. [**Last Name (STitle) **] by telephone at 12:10 a.m. on
[**2118-12-12**].

2. Left nephrostomy tube with small left subcapsular hematoma
and unchanged left ureteropelvic junction stone.

3. No evidence of small-bowel obstruction despite large amount
of stool seen within the rectum and sigmoid.

4. Unchanged right renal staghorn calculus.

Renal US:
IMPRESSION:

1. Right renal stones without hydronephrosis.

2. Unchanged mild left collecting system fullness.


Brief Hospital Course:
65 yo female with history of MS [**First Name (Titles) 151**] [**Last Name (Titles) **] indwelling foley
and left percutaneous nephrostomy tube found to be unresponsive
admitted to the MICU with septic shock secondary to Pseudomonas
urosepsis. The patient was started on Meropenem and did well on
the floor.
.
1. Sepsis:  Urosepsis due to pseudomonas in setting of
obstructing stone.  Pt with known obstructing staghorn in R, & L
percutaneous nephrostomy for ureteral stone. The patient had
been on suppressive ertapenem, but this was switched to
Meropenem 500mg IV Q6hr given ID recs and better urinary
penetration. ID evaluated the patient and felt she should
continue on this antibiotic until obstruction relieved.  The
patient was started on methemazine and ascorbic acid for
symptomatic relief. Pt will follow up with outpatient urology to
undergo intraoperative lithotripsy/stone extraction.
.
2. Elevated troponin/Possible NSTEMI: Pt's troponin found to be
elevated on admission.  This was likely secondary to demand
ischemia in the setting of hypotension.  An echo was formed that
showed wall motion abnormalities, the chronicity of which could
not be determined.  The patient's troponin trended down and she
was monitored on telemetry for several days with no events.
.
3. Multiple sclerosis: The patient had relapsing and remitting
MS treated with Glatimer. Our neuro colleagues were initially
consulted to determine whether her altered mental status was
neurological in origin. They determined that it was not and did
not change her treatment regimen. She remains on Baclofen,
Glatimer, and cyclobenzaprine.
.
4. Hyperlipidemia: Continue simvastatin
.
5. Depression: Continue citalopram
.
6. CODP: Respiratory status stable. Continue nebulizers/inhalers
.
7. Follow Up: The patient will follow up with urology for
elective stone removal.  She will continue on meropenem until
urinary obstruction is remedied.
.
Transitional Issues: The patient had yeast grow in 2 of 2 urine
cultures. With her h/o urosepsis and indwelling catheters, we
called her rehab facility and recommended starting Fluconazole.
As an outpatient, the patient should be started on a low dose
B-blocker given her NSTEMI. She should have outpatient
cardiology follow-up at some point as well.


Medications on Admission:
1. methenamine hippurate 1 gram Tablet Sig: One (1) Tablet PO
bid
2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
3. carbamazepine 100 mg Tablet, Chewable Sig: one daily
4. Carbamazepine 100 mg Tablet, Chewable Sig: Three (3) Tablet
[**Hospital1 **]
5. baclofen 10 mg Tablet Sig: One (1) Tablet PO twice a day.
6. glatiramer 20 mg Kit Sig: Twenty (20) mg Subcutaneous Daily
7. Os-Cal 500 + D 500 mg(1,250mg) -200 unit Tablet daily
8. alendronate 70 mg Tablet PO once a week.
9. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

10. donepezil 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
11. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS prn insomnia.
12. cranberry 250 mg Tablet Sig: One (1) Tablet PO once a day.
13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet daily
14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for nebs
q4h
15. ipratropium bromide 0.02 % Solution Sig: One (1) neg q6h
16. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six

(6) hours as needed for pain.
17. vitamin E 1,000 unit Capsule Sig: One (1) Capsule PO daily
18. senna 8.6 mg Tablet Sig: One (1) Tablet PO prn constipation
19. potassium chloride 20 mEq Packet Sig: One (1)daily
20. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1)  Rectal q
M/W/F.
21. docusate sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID
22. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff [**Hospital1 **]
23. Sodium Chloride 0.9%  Flush 3 mL IV Q8H:PRN line flush q8h
prn
24. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC
25. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO BID
26. meropenem 500 mg Recon Soln Sig: One (1)IV q8 hours for 5
days.

Discharge Medications:
1. methenamine hippurate 1 gram Tablet Sig: One (1) Tablet PO
BID (2 times a day).
2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. baclofen 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Other
glatiramer 20 mg Kit Sig: Twenty (20) mg Subcutaneous Daily

5. Os-Cal 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One (1)
Tablet PO once a day.
6. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.

7. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

8. donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).

9. Other
Trazodone 25 mg QHS PRN insomnia
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Nebulizer Inhalation every 4-6 hours
as needed for SOB, wheeze.
12. ipratropium bromide 0.02 % Solution Sig: One (1) Nebulizer
Inhalation every 6-8 hours as needed for shortness of breath or
wheezing.
13. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
14. vitamin E 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
15. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for Constipation.
16. potassium chloride 20 mEq Packet Sig: One (1) Packet PO once
a day.
17. Other
Fleet enema Q M/W/F
18. docusate sodium 50 mg/5 mL Liquid Sig: Two (2) Tablespoons
PO BID (2 times a day).
19. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puffs
Inhalation twice a day.
20. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
21. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
22. Meropenem 500 mg IV Q6H
Day 1 = [**12-11**]
23. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
24. carbamazepine 100 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day: Daily at noon.
25. carbamazepine 300 mg Cap, ER Multiphase 12 hr Sig: One (1)
Cap, ER Multiphase 12 hr PO twice a day.


Discharge Disposition:
Extended Care

Facility:
[**Location (un) 583**] House Rehab & Nursing Center

Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- Sepsis from a urinary source related to [**Location (un) **] partial
obstruction and [**Location (un) **] nephrolithiasis
- [**Location (un) 8304**] indwelling Foley and Perc nephrostomy tube on Left
- Demand cardiac ischemia

SECONDARY DIAGNOSES:
- Multiple Sclerosis


Discharge Condition:
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Mental Status: Confused - sometimes.


Discharge Instructions:
Ms. [**Known lastname **], it was a pleasure to participate in your care while
you were at [**Hospital1 18**]. You came to the hospital after you were found
unresponsive. You were admitted to the MICU where you were
ultimately found to have septic shock due to a urinary tract
infection and a large infected kidney stone. You were evaluated
by several specialists including the infectious disease team and
the urology team.  You antibiotics were changed while you were
here. You will need to follow up with your urologist for kidney
stone removal in the near future.

Followup Instructions:
It is recommended that you have a lithotripsy within the next
1-3 days. Please discuss with your urologist the best time to
have this done.
{'Infection and inflammatory reaction due to other genitourinary device, implant, and graft,Septicemia due to pseudomonas,Acute myocardial infarction of other anterior wall, initial episode of care,Septic shock,Pressure ulcer, lower back,Hyperosmolality and/or hypernatremia,Paraplegia,Multiple sclerosis,Severe sepsis,Calculus of ureter,Wheelchair dependence,Neurogenic bladder NOS,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Chronic pyelonephritis without lesion of renal medullary necrosis,Urinary obstruction, unspecified,Other specified forms of chronic ischemic heart disease,Unspecified persistent mental disorders due to conditions classified elsewhere,Personal history, urinary (tract) infection,Chronic obstructive asthma, 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: Unresponsiveness, altered, intubated for airway protection found
to have urosepsis

PRESENT ILLNESS: 65 yo female with MS [**First Name (Titles) **] [**Last Name (Titles) 84078**] for questionable hx TMJ who was
sent in from her NSH after being found covered in vomit with
agonal breathing.  NSH notes reports "symptoms of seizure
activity" with patient subsequently unresponsive and found to be
hypoxic with sats <83% on 2L.  Per EMS, she was unresponsive en
route, still breathing but not withdrawing to pain.
.
In the ED, initial vitals were: no temp recorded, 118 135/71 34
100% on NRB.  She was easily intubated for airway protection
with a grade 1 view.  Head CT was unremarkable for bleed.  Neuro
was consulted and felt this was likely toxic metabolic if
seizure activity, but will continue to follow.  She has had
multiple episodes of UTI in the past.  Blood and urine cultures
were sent and she was given vanco/zosyn.  Foley was changed.
Per the ED resident, they were not aware of her potential
allergy but she did not have a rash prior to transfer to the
MICU.  When the patient was signed out she was currently doing
well on vent with most recent vitals prior to transfer being
afeb, 92, 103/60 with sats 100% on 400x18, 5x50%.  She dropped
her pressures prior to transfer to 67/41 with HR 94.  She was
given 2L of IVF and started on levophed.  Sedation was held.
.
Of note, per Dr.[**Name (NI) 84079**] note to her PCP, [**Name10 (NameIs) **] last admission was
for urinary tract infection, E. coli bacteremia, and sepsis, and
initially required admission to the ICU for vasopressor support.
She was also found to have an obstructing left renal stone and
had a percutaneous nephrostomy tube placed with improvement in
her infection. She was able to be taken of vasopressor agents
and was discharged to complete a 14 day total course of
antibiotics.  At that time, urology recommended to leave the
nephrostomy tube in the left renal system indefinitely with tube
changes every 3 months as she was high risk for both
nephrolithotomy and extracorporeal shock wave lithotripsy.  Her
hospital course was also notable for hypoxia with a 4L oxygen
requirement which was felt to be due to a combination of mild
volume overload, respiratory muscle weakness in the setting of
multiple sclerosis and infection, and intermittent aspiration.
Her oxygen requirement was stable and she was discharged to
rehab to have gentle diuresis as tolerated and tocontinue her
usual dysphagia diet.  She has been on 2L at her NSH with
unclear continued workup.
.

MEDICAL HISTORY: Multiple Sclerosis - about 14yrs, followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Location (un) 2274**]
 - wheelchair at baseline, lives in nursing home
 - has no use of her lower extremities, sometimes spastic
movements
 - bladder chronically contracted
UTI with ESBL E.coli--sensitive to zosyn, [**Last Name (un) 2830**], gent in past
[**Last Name (un) 8304**] Depression
Anxiety
PVD s/p lower extremity bypass
COPD
Osteoporosis
Hx of +PPD
bilateral femur supracondylar fractures [**2113**]
hx of Urosepsis - hospitalized about once/yr, per husband
Neurogenic bladder - indwelling foley x [**4-27**] [**Last Name (LF) 1686**], [**First Name3 (LF) **] husband
Recurrent C. Diff
Hx of Sacral Decub
LE spasticity
Hx of jaw pain -- ?TMJ, improved on [**First Name3 (LF) **]

MEDICATION ON ADMISSION: 1. methenamine hippurate 1 gram Tablet Sig: One (1) Tablet PO
bid
2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
3. carbamazepine 100 mg Tablet, Chewable Sig: one daily
4. Carbamazepine 100 mg Tablet, Chewable Sig: Three (3) Tablet
[**Hospital1 **]
5. baclofen 10 mg Tablet Sig: One (1) Tablet PO twice a day.
6. glatiramer 20 mg Kit Sig: Twenty (20) mg Subcutaneous Daily
7. Os-Cal 500 + D 500 mg(1,250mg) -200 unit Tablet daily
8. alendronate 70 mg Tablet PO once a week.
9. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

ALLERGIES: Zosyn / ceftriaxone

PHYSICAL EXAM: Admission exam
Vitals: 101.9 100 117/64 17 100% on 400x18, 5x50%
General: Intubated, sedated, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
blood around mouth, no lesions identified
Neck: supple, JVP not elevated, no LAD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: CTAB, no wheezes, rales, ronchi
Abdomen: +BS, soft, non-tender, non-distended, no organomegaly
Back: stage 2 sacral decub on right buttocks, stage 1 decub on
left hip, left perc neph tube in place and c/d/i
GU: +foley
Ext: cool, well perfused, 2+ pulses distally, no clubbing,
cyanosis or edema, moving her toes, PICC line in right upper arm
is c/d/i
Neuro: sedated

FAMILY HISTORY: No family members with Multiple Sclerosis.

SOCIAL HISTORY: Lives in nursing home for last 4 [**First Name3 (LF) 1686**].  Husband is HCP, lives
with one of their daughters.  [**Name (NI) **] daughter married and lives
in the area.  Nonambulatory and in wheelchair at baseline,
dependent for transfers and some of ADLs.  Has no use of lower
extremities at baseline.  On pureed thickened liquids at rehab. 

### Response:
{'Infection and inflammatory reaction due to other genitourinary device, implant, and graft,Septicemia due to pseudomonas,Acute myocardial infarction of other anterior wall, initial episode of care,Septic shock,Pressure ulcer, lower back,Hyperosmolality and/or hypernatremia,Paraplegia,Multiple sclerosis,Severe sepsis,Calculus of ureter,Wheelchair dependence,Neurogenic bladder NOS,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Chronic pyelonephritis without lesion of renal medullary necrosis,Urinary obstruction, unspecified,Other specified forms of chronic ischemic heart disease,Unspecified persistent mental disorders due to conditions classified elsewhere,Personal history, urinary (tract) infection,Chronic obstructive asthma, unspecified'}
