CHIEF COMPLAINT: cardiac arrest, acute renal failure

PRESENT ILLNESS: 78 yoF presents from OSH with acute renal failure (Cr 9) and
hyperkalemia (K 8.3) s/p cardiac arrest. According to her
family, patient was in her usual state of health until yesterday
evening when she reported nausea, vomiting, and back pain.
Family had been at Foxwoods the weekend prior but otherwise no
travel. No sick contacts. [**Name (NI) **] exotic food but did eat at
Fudruckers. Patient had episodes of diarrhea on Friday which
resolve.
.
Patient reported to family that she vomited once the night prior
to presentation and felt somewhat improved. The following day
the patient reported to family that she continued to have
abdomen and back pain and ached all over. At ~ 6 pm on the
evening prior to transfer, she was found to be lethargic,
confused, and complaining of abdomen and back pain. EMS was
called.
.
Upon arrival, patient was found to be hypotensive. She was
transferred to an OSH where she developed a wide complex
bradycardia and then became pulseless. ? of whether patient was
briefly transcutaneously paced. Patient was intubated and
treated with epi/atropine and CPR and then evolved into VT. She
was then given amio. Dopamine was started for hypotension. At
the OSH, labs were notable for pH 6.65, lactate of 17.3, WBC
21.1 w/ 3% bands, 73% PMNs, Hct 37, plts 413, Cr 9.5, K 8.2,
bicarb 5. According to family, patient had been seen by her PCP
last week at which time her K was 5.5 and her Cr was normal (?
1.0).
.
She received 2 amps D50, 15 units insulin, 1 amp CaGluc, [**6-5**]
amps bicarb, and kayexalate. Also received 1 gram of Rocephin
for elevated WBC. She was then transferred to [**Hospital1 18**] via
[**Location (un) 7622**] for emergent dialysis. During [**Location (un) 7622**], patient
fluctuated between a narrow complex rhythm (? accelerated
junctional rhythm) and a wide complex tachycardia and was
intermittently hypotensive requiring dopamine.
.
Upon arrival to [**Hospital1 18**] ED, patient was hypotensive with SBP in
80s which quickly dropped to 50s. She was started on levophed
and dopamine with response in BPs to 120s. At that time she was
in a narrow complex rhythm. Due to reports of abdominal pain,
she was sent for a stat CT torso as well as a CT head and was
then transferred to the MICU for further management.
.

MEDICAL HISTORY: # NIDDM
# htn
# asthma
# h/o active TB s/p treatment in [**2062**]
# s/p laminectomy
.

MEDICATION ON ADMISSION: lisinopril
zocor
ativan prn
metformin
combivent

ALLERGIES: No Drug Allergy Information on File

PHYSICAL EXAM: T: 91.4 BP: 113/49 HR: 63 O2 100% on 1.0 FiO2
Gen: intubated, sedated, intermittently posturing
HEENT: Pupils fixed and dilated at 8 mm. ET tube in place
NECK: Stiff. No JVD
CV: RRR. nl S1, S2. No MRG
LUNGS: CTAB
ABD: hypoactive bowel sounds. distended.
EXT: Cool extremities. No edema.
SKIN: No rashes/lesions, ecchymoses
NEURO: Intubated and sedated. Pupils fixed and dilated. face
symmetric. Intermittent extensor posturing
.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: + smoking hx. Quit 8-9 years ago. Widowed. Retired. Lives alone.
Has supportive family
Unspecified septicemia,Septic shock,Hyperpotassemia,Acute kidney failure with lesion of tubular necrosis,Severe sepsis,Asthma, unspecified type, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension
Septicemia NOS,Septic shock,Hyperpotassemia,Ac kidny fail, tubr necr,Severe sepsis,Asthma NOS,DMII wo cmp nt st uncntr,Hypertension NOS
Admission Date:  [**2110-8-5**]              Discharge Date:   [**2110-8-6**]

Date of Birth:  [**2031-11-19**]             Sex:   F

Service: MEDICINE

Allergies:
No Drug Allergy Information on File

Attending:[**First Name3 (LF) 99**]
Chief Complaint:
cardiac arrest, acute renal failure

Major Surgical or Invasive Procedure:
dialysis

History of Present Illness:
78 yoF presents from OSH with acute renal failure (Cr 9) and
hyperkalemia (K 8.3) s/p cardiac arrest. According to her
family, patient was in her usual state of health until yesterday
evening when she reported nausea, vomiting, and back pain.
Family had been at Foxwoods the weekend prior but otherwise no
travel. No sick contacts. [**Name (NI) **] exotic food but did eat at
Fudruckers. Patient had episodes of diarrhea on Friday which
resolve.
.
Patient reported to family that she vomited once the night prior
to presentation and felt somewhat improved. The following day
the patient reported to family that she continued to have
abdomen and back pain and ached all over. At ~ 6 pm on the
evening prior to transfer, she was found to be lethargic,
confused, and complaining of abdomen and back pain. EMS was
called.
.
Upon arrival, patient was found to be hypotensive. She was
transferred to an OSH where she developed a wide complex
bradycardia and then became pulseless. ? of whether patient was
briefly transcutaneously paced. Patient was intubated and
treated with epi/atropine and CPR and then evolved into VT. She
was then given amio. Dopamine was started for hypotension. At
the OSH, labs were notable for pH 6.65, lactate of 17.3, WBC
21.1 w/ 3% bands, 73% PMNs, Hct 37, plts 413, Cr 9.5, K 8.2,
bicarb 5. According to family, patient had been seen by her PCP
last week at which time her K was 5.5 and her Cr was normal (?
1.0).
.
She received 2 amps D50, 15 units insulin, 1 amp CaGluc, [**6-5**]
amps bicarb, and kayexalate. Also received 1 gram of Rocephin
for elevated WBC. She was then transferred to [**Hospital1 18**] via
[**Location (un) 7622**] for emergent dialysis. During [**Location (un) 7622**], patient
fluctuated between a narrow complex rhythm (? accelerated
junctional rhythm) and a wide complex tachycardia and was
intermittently hypotensive requiring dopamine.
.
Upon arrival to [**Hospital1 18**] ED, patient was hypotensive with SBP in
80s which quickly dropped to 50s. She was started on levophed
and dopamine with response in BPs to 120s. At that time she was
in a narrow complex rhythm. Due to reports of abdominal pain,
she was sent for a stat CT torso as well as a CT head and was
then transferred to the MICU for further management.
.


Past Medical History:
# NIDDM
# htn
# asthma
# h/o active TB s/p treatment in [**2062**]
# s/p laminectomy
.


Social History:
+ smoking hx. Quit 8-9 years ago. Widowed. Retired. Lives alone.
Has supportive family

Family History:
non-contributory

Physical Exam:
T: 91.4 BP: 113/49 HR: 63 O2 100% on 1.0 FiO2
Gen: intubated, sedated, intermittently posturing
HEENT: Pupils fixed and dilated at 8 mm. ET tube in place
NECK: Stiff. No JVD
CV: RRR. nl S1, S2. No MRG
LUNGS: CTAB
ABD: hypoactive bowel sounds. distended.
EXT: Cool extremities. No edema.
SKIN: No rashes/lesions, ecchymoses
NEURO: Intubated and sedated. Pupils fixed and dilated. face
symmetric. Intermittent extensor posturing
.


Pertinent Results:
[**2110-8-5**] 11:44PM   TYPE-ART PO2-86 PCO2-46* PH-6.74* TOTAL
CO2-7* BASE XS--32
[**2110-8-5**] 11:34PM   LACTATE-21.7* K+-5.7*
[**2110-8-5**] 11:30PM   CK(CPK)-239*
[**2110-8-5**] 11:30PM   GLUCOSE-262* UREA N-76* CREAT-8.2*
SODIUM-152* POTASSIUM-5.8* CHLORIDE-99 TOTAL CO2-LESS THAN
[**2110-8-5**] 11:30PM   CK(CPK)-239*
[**2110-8-5**] 11:30PM   CK-MB-11* MB INDX-4.6
[**2110-8-5**] 11:30PM   CK-MB-11* MB INDX-4.6
[**2110-8-5**] 11:30PM   CALCIUM-9.3 PHOSPHATE-17.2* MAGNESIUM-2.8*
[**2110-8-5**] 11:30PM   WBC-21.8* HCT-32.0*
[**2110-8-5**] 11:30PM   NEUTS-61 BANDS-1 LYMPHS-36 MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-2* MYELOS-0
[**2110-8-5**] 11:30PM   HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-2+ MACROCYT-OCCASIONAL MICROCYT-NORMAL
POLYCHROM-NORMAL BURR-2+
[**2110-8-5**] 11:30PM   PLT SMR-NORMAL PLT COUNT-343
[**2110-8-5**] 11:20PM   UREA N-76* CREAT-8.0* SODIUM-152*
POTASSIUM-6.0* CHLORIDE-99 TOTAL CO2-5* ANION GAP-54*
[**2110-8-5**] 11:20PM   estGFR-Using this
[**2110-8-5**] 11:20PM   CK(CPK)-239* AMYLASE-131*
[**2110-8-5**] 11:20PM   CK-MB-12* MB INDX-5.0 cTropnT-0.24*
[**2110-8-5**] 11:20PM   CALCIUM-9.2 PHOSPHATE-17.1* MAGNESIUM-2.8*
[**2110-8-5**] 11:20PM   PT-18.7* PTT-55.1* INR(PT)-1.8*
[**2110-8-5**] 11:20PM   FIBRINOGE-286

CT torso ([**8-6**]):
1. No evidence of aortic dissection or aneurysm
2. apical [**Doctor Last Name **] and RUL traction bronchiectasis
3. L adrenal nodule: 1 cm
4. marked enhancement of small bowel and stranding of mesentery

5. sigmoid diverticula without stranding
.
EKG (OSH): per report, No clear p waves. ? prolonged PR. RBBB,
old IMI, diffuse ST changes
.
CXR (OSH): per report, old granulomas. borderline cardiomegaly.

.
CT head (OSH): 17 mm calcified meningioma R frontal lobe. No
shift
.
EKG ([**8-6**]): AIVR @ 100. Diffuse low voltage. QW in V2.
.


Brief Hospital Course:
A/P: 78 yoF with acute renal failure, hyperkalemia, s/p cardiac
arrest
.
# acute renal failure: unclear etiology. Ddx prerenal,
intrarenal, postrenal. No evidence of hydronephrosis on CT
abdomen. Suspect hypotension/ATN given remainder of
presentation. Hyperkalemia and cardiac arrhythmias indication
for emergent dialysis.
- HD line placed for emergent CVVH
- appreciate renal input
- hyperkalemia treated with CaGluc, 1 amp bicarb push with 3
amps in D5W, insulin gtt, kayexalate
- U/A, culture, microscopic exam
- urine lytes, eos
- No need for renal u/s given nl CT
.
# metabolic acidosis: severe acidosis with pH 6.7. Combined AG
acidosis and metabolic alkylosis. AG 48. delta bicarb 19. AG
acidosis likely lactic acidosis. Metabolic alkylosis likely
secondary to bicarb administration at OSH. ? contribution of
Metformin to lactic acidosis.
- 1 amp bicarb now
- D5W with 3 amps bicarb wide open
- hyperventilation
- CVVH against high bicarb bath
.
# hypotension: unclear cause. Likely sepsis given significant
leukocytosis although no clear source. Could explain renal
failure. Potential source most likely GI given symptoms. Must
also consider ischemic contribution given elevated cardiac
enzymes although less likely. Received dose of Rocephin.
- blood cultures
- U/A, culture
- stool cultures
- broad coverage with vanco, cefepime, flagyl
- cont volume resuscitation with D5W+3amps bicarb until CVVH
then switch to NS
- cont pressors: levophed/vasopressin. consider further pressors
for increased BP support.
.
# s/p cardiac arrest: suspect PEA secondary to hyperkalemia vs.
acidemia. Only briefly pulseless by report although current exam
concerning for CNS damage.
- hyperkalemia/acidemia treatment as above
- cont tele monitoring
.
# mental status: concerning neurologic findings on exam
including fixed dilated pupils and involuntary motor activity:
posturing vs. myoclonic seizures.
- maintained BP with fluids and pressors
- maintained hypothermia for neurologic protection
- likely Neuro consult
- consider MRI, EEG
- No need for seizure tx currently
.
# leukocytosis: as above, unclear source. Infectious vs. stress
response. Hypothermic currently. Suspect infectious given
hypotensive presentation.
- pan culture as above
- cont broad spectrum antibiotics
- trend WBC
.
# cardiac enzyme elevation: elevated troponin difficult to
interpret in setting of ARF but CKs also elevated with positive
MBI. However, not necessary unexpected s/p cardiac arrest, chest
compressions, and reported transcutaneous pacing.
- trend cardiac enzymes
- no anticoagulation, If enzymes trended up, would consider
heparin
- hold beta blocker, ace inhibitor
- hold statin until LFTs return with concern for shock liver
- hold aspirin given coagulopathy
.
# DM: on metformin at home.
- hold metformin
- insulin gtt for now. Can transition to sliding scale prn
.
# htn: hypotensive currently requiring pressors
- hold lisinopril
.
# asthma: albuterol/atrovent MDIs while ventilated
.
# FEN: NPO.
- hyperkalemia tx as above
- hypernatremia likely secondary to sodium bicarb resuscitation.
hoped to improve with CVVH so okay to resuscitate with NS
following CVVH. trend lytes
- hyperphosphatemia should also be treated with CVVH.
.
# PPx: H2 blocker. heparin sc held.
.
# ACCESS: R IJ. L femoral HD catheter
.
# CODE STATUS AND COMMUNICATION: Discussions were held with the
patient's family at the MICU once the patient was admitted. Upon
admission the patient was full code.  In the setting of
increasing pressor requirements, hypotension, and increasing
likely seizure activity, the family was called via telephone and
the patient's daughter decided to make the patient DNR per the
family's wishes. Upon arrival again at the MICU in the morning,
after seeing the patient and discussing the patient's poor
prognosis with the ICU team, the family decided to withdraw
aggressive support and made the patient "comfort measures only."
 The patient expired shortly thereafter upon the termination of
cardiopulmonary support.
.
# DISPO: expired in the ICU on the morning of [**2110-8-6**]


Medications on Admission:
lisinopril
zocor
ativan prn
metformin
combivent


Discharge Medications:
expired

Discharge Disposition:
Expired

Discharge Diagnosis:
expired

Discharge Condition:
expired

Discharge Instructions:
expired

Followup Instructions:
expired
{'Unspecified septicemia,Septic shock,Hyperpotassemia,Acute kidney failure with lesion of tubular necrosis,Severe sepsis,Asthma, unspecified type, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,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: cardiac arrest, acute renal failure

PRESENT ILLNESS: 78 yoF presents from OSH with acute renal failure (Cr 9) and
hyperkalemia (K 8.3) s/p cardiac arrest. According to her
family, patient was in her usual state of health until yesterday
evening when she reported nausea, vomiting, and back pain.
Family had been at Foxwoods the weekend prior but otherwise no
travel. No sick contacts. [**Name (NI) **] exotic food but did eat at
Fudruckers. Patient had episodes of diarrhea on Friday which
resolve.
.
Patient reported to family that she vomited once the night prior
to presentation and felt somewhat improved. The following day
the patient reported to family that she continued to have
abdomen and back pain and ached all over. At ~ 6 pm on the
evening prior to transfer, she was found to be lethargic,
confused, and complaining of abdomen and back pain. EMS was
called.
.
Upon arrival, patient was found to be hypotensive. She was
transferred to an OSH where she developed a wide complex
bradycardia and then became pulseless. ? of whether patient was
briefly transcutaneously paced. Patient was intubated and
treated with epi/atropine and CPR and then evolved into VT. She
was then given amio. Dopamine was started for hypotension. At
the OSH, labs were notable for pH 6.65, lactate of 17.3, WBC
21.1 w/ 3% bands, 73% PMNs, Hct 37, plts 413, Cr 9.5, K 8.2,
bicarb 5. According to family, patient had been seen by her PCP
last week at which time her K was 5.5 and her Cr was normal (?
1.0).
.
She received 2 amps D50, 15 units insulin, 1 amp CaGluc, [**6-5**]
amps bicarb, and kayexalate. Also received 1 gram of Rocephin
for elevated WBC. She was then transferred to [**Hospital1 18**] via
[**Location (un) 7622**] for emergent dialysis. During [**Location (un) 7622**], patient
fluctuated between a narrow complex rhythm (? accelerated
junctional rhythm) and a wide complex tachycardia and was
intermittently hypotensive requiring dopamine.
.
Upon arrival to [**Hospital1 18**] ED, patient was hypotensive with SBP in
80s which quickly dropped to 50s. She was started on levophed
and dopamine with response in BPs to 120s. At that time she was
in a narrow complex rhythm. Due to reports of abdominal pain,
she was sent for a stat CT torso as well as a CT head and was
then transferred to the MICU for further management.
.

MEDICAL HISTORY: # NIDDM
# htn
# asthma
# h/o active TB s/p treatment in [**2062**]
# s/p laminectomy
.

MEDICATION ON ADMISSION: lisinopril
zocor
ativan prn
metformin
combivent

ALLERGIES: No Drug Allergy Information on File

PHYSICAL EXAM: T: 91.4 BP: 113/49 HR: 63 O2 100% on 1.0 FiO2
Gen: intubated, sedated, intermittently posturing
HEENT: Pupils fixed and dilated at 8 mm. ET tube in place
NECK: Stiff. No JVD
CV: RRR. nl S1, S2. No MRG
LUNGS: CTAB
ABD: hypoactive bowel sounds. distended.
EXT: Cool extremities. No edema.
SKIN: No rashes/lesions, ecchymoses
NEURO: Intubated and sedated. Pupils fixed and dilated. face
symmetric. Intermittent extensor posturing
.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: + smoking hx. Quit 8-9 years ago. Widowed. Retired. Lives alone.
Has supportive family 

### Response:
{'Unspecified septicemia,Septic shock,Hyperpotassemia,Acute kidney failure with lesion of tubular necrosis,Severe sepsis,Asthma, unspecified type, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension'}
