CHIEF COMPLAINT: septic shock

PRESENT ILLNESS: This is a 67 y/o female with a h/o HTN, NIDDM, persistent left
UPJ stone, s/p left ureteral stent placement and ESWL [**1-29**] with
incomplete fragmentation and demonstration of the renal stone in
the inferior calyx of the left kidney, who underwent a left
ureteroscopy, left retrograde pyelography, laser lithotripsy,
left ureteral stent removal and replacement yesterday, and now
presents with hypotension, fever, tachycardia, and septic shock.

MEDICAL HISTORY: HTN, DM, Breast Ca, Thyroid Ca - Thyroidectomy, TAH/SBO,
Appendectomy, SBOs

MEDICATION ON ADMISSION: 1. Metformin 500 mg [**Hospital1 **]
2. Lasix 40 mg qd
3. Atenolol 50 mg qd
4. Levoxyl 75 mcg qd

ALLERGIES: Vancomycin And Derivatives / Tetracyclines / Penicillins /
Sulfonamides

PHYSICAL EXAM: VS: T 98.9, BP 139/81, HR 102, RR 18, SaO2 97%/AC 550 x 18, FiO2
100%, PEEP 8, SvO2 81, CVP 25
General: Intubated, partially sedated but withdraws to pain.
HEENT: NC/AT, pupils minimally reactive. ETT and NGT in place.
Neck: supple, R IJ in place
Chest: diffuse rhonchi throughout
CV: RRR, s1 s2 normal but distant, no m/g/r
Abd: soft, NT/ND, few BS
Ext: no c/c/e, warm, pulses 1+ b/l
Neuro: Sedated, withdraws to pain, moves all 4 extremities

FAMILY HISTORY: NC

SOCIAL HISTORY: Rare EtOH
, no tobacco
Septicemia due to escherichia coli [E. coli],Other pulmonary insufficiency, not elsewhere classified,Septic shock,Acidosis,Urinary tract infection, site not specified,Acute kidney failure, unspecified,Calculus of ureter,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic kidney disease, unspecified,Thrombocytopenia, unspecified,Severe sepsis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other encephalopathy,Postsurgical hypothyroidism,Anemia, unspecified,Other nonspecific abnormal serum enzyme levels,Asbestosis,Esophageal reflux,Personal history of malignant neoplasm of breast,Personal history of malignant neoplasm of thyroid
E coli septicemia,Other pulmonary insuff,Septic shock,Acidosis,Urin tract infection NOS,Acute kidney failure NOS,Calculus of ureter,Hyp kid NOS w cr kid V,Chronic kidney dis NOS,Thrombocytopenia NOS,Severe sepsis,DMII wo cmp nt st uncntr,Encephalopathy NEC,Postsurgical hypothyroid,Anemia NOS,Abn serum enzy level NEC,Asbestosis,Esophageal reflux,Hx of breast malignancy,Hx of thyroid malignancy
Admission Date:  [**2196-8-31**]              Discharge Date:   [**2196-9-9**]

Date of Birth:  [**2128-12-29**]             Sex:   F

Service: MEDICINE

Allergies:
Vancomycin And Derivatives / Tetracyclines / Penicillins /
Sulfonamides

Attending:[**First Name3 (LF) 7934**]
Chief Complaint:
septic shock

Major Surgical or Invasive Procedure:
1. Lumbar puncture
2. Central line placement
3. Left nephrostomy tube placement.


History of Present Illness:
This is a 67 y/o female with a h/o HTN, NIDDM, persistent left
UPJ stone, s/p left ureteral stent placement and ESWL [**1-29**] with
incomplete fragmentation and demonstration of the renal stone in
the inferior calyx of the left kidney, who underwent a left
ureteroscopy, left retrograde pyelography, laser lithotripsy,
left ureteral stent removal and replacement yesterday, and now
presents with hypotension, fever, tachycardia, and septic shock.

.
Per op note, no complications were noted at the time of
procedure. Patient was sent home in stable condition yesterday.
However, she began developing left flank pain and difficulty
breathing last night. Her daughter brought her into the [**Name (NI) **] this
morning and the patient was found to be febrile, tachycardic,
and hypotensive.
.
In the ED, her VS were T 101.7, BP 58/36, HR 95, RR 39, SaO2
86%/RA. Lactate was 7.3. She was intubated for hypoxic
respiratory distress. She was given 6 L of NS for resuscitation,
however she remained hypotensive and was started on levophed,
dopamine (added when levo maxed out), and neo (added when levo
and dopa maxed). She was also given 500 mg IV levofloxacin, 500
mg IV flagyl, 10 mg IV decadron, and fentanyl/versed for
sedation. She was also evaluated by both surgery and urology -
no surgical intervention required at this time. CT abd/pelvis
demonstrated diffuse perinephric stranding with ?active
bleeding. Pt was transferred to the MICU for further management.



Past Medical History:
HTN, DM, Breast Ca, Thyroid Ca - Thyroidectomy, TAH/SBO,
Appendectomy, SBOs

Social History:
Rare EtOH
, no tobacco


Family History:
NC

Physical Exam:
VS: T 98.9, BP 139/81, HR 102, RR 18, SaO2 97%/AC 550 x 18, FiO2
100%, PEEP 8, SvO2 81, CVP 25
General: Intubated, partially sedated but withdraws to pain.
HEENT: NC/AT, pupils minimally reactive. ETT and NGT in place.
Neck: supple, R IJ in place
Chest: diffuse rhonchi throughout
CV: RRR, s1 s2 normal but distant, no m/g/r
Abd: soft, NT/ND, few BS
Ext: no c/c/e, warm, pulses 1+ b/l
Neuro: Sedated, withdraws to pain, moves all 4 extremities


Pertinent Results:
[**2196-8-31**] 09:38AM   PT-12.9 PTT-26.8 INR(PT)-1.1
[**2196-8-31**] 09:38AM   PLT SMR-NORMAL PLT COUNT-265
[**2196-8-31**] 09:38AM   NEUTS-67 BANDS-21* LYMPHS-2* MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-7* MYELOS-3*
[**2196-8-31**] 09:38AM   WBC-19.4*# RBC-3.75* HGB-10.8* HCT-31.6*
MCV-84 MCH-28.7 MCHC-34.0 RDW-14.4
[**2196-8-31**] 09:38AM   CALCIUM-8.2* PHOSPHATE-2.7# MAGNESIUM-1.2*
[**2196-8-31**] 09:38AM   CK-MB-13* MB INDX-1.5 cTropnT-0.03*
[**2196-8-31**] 09:38AM   CK(CPK)-864*
[**2196-8-31**] 09:38AM   CK(CPK)-864*
[**2196-8-31**] 09:38AM   GLUCOSE-206* UREA N-42* CREAT-3.5*#
SODIUM-135 POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-17* ANION GAP-24
[**2196-8-31**] 09:46AM   LACTATE-7.3*

Brief Hospital Course:
ASSESSMENT/PLAN - 67 y/o female with HTN, NIDDM, s/p recent
urologic procedure, now presenting with shock.
.
# Shock - On admission, patient was found to have fever,
leukocytosis and left shift with a positive U/a.  This was
consistent with likely urinary source, especially given recent
urologic instrumentation and lithotripsy.  On further cultures,
we found E. Coli in blood and urine.  Given her shock, she
initially required fluid resussitation and pressors.  She was
transfused with 2 units PRBC.  She demonstrated evidence of
end-organ damage with elevated lactate, elevated Cr, troponin
leak.
Pt with h/o multiple abx allergies and resistant organisms
during past septic shock hospitalization.  Given likely renal
source, left nephrostomy tube was placed under IR for drainage
of kidney.
.
She also had cardiac evaluation with Echo which showed:
.
Conclusions:
The left atrium is moderately dilated. Left ventricular wall
thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The aortic
valve leaflets are mildly thickened. There is no valvular aortic
stenosis. The
increased transaortic gradient is likely related to high cardiac
output. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened.
No mitral regurgitation is seen. There is no pericardial
effusion.
.
CT Evaluation of Chest and pelvis for identification of source
of infection/renal imaging showed:
.
IMPRESSION:
1.  Status post placement of left percutaneous nephrostomy tube.
 Left
ureteral stent remains in place.  Interval improvement in left
perinephric
stranding and fascial thickening.  No significant
hydronephrosis.
2.  Persistent small bilateral pleural effusions and generalized
edema
consistent with anasarca.
3.  Small fat-containing paraumbilical hernia.
.
# Hypoxic respiratory distress - We felt respiratory distress
was most likely caused by ARDS in setting of sepsis.  Patient
was intubated for ~24 hrs during hospitalization.  WIth
treatment of sepsis, she quickly weaned from mechanical
ventilation.  On discharge she is currently requiring only nasal
cannula.
.
# Metabolic acidosis - Patient presented with severe metabolic
acidosis, [**2-25**] lactic acidosis. Continued high minute ventilation
for compensation. Given Bicarb.  Resolved after resolution of
septic shock.
.
# ARF on CRI - Patient presented with elevated creatinine to 3.5
[**2-25**] hypoperfusion +/- ATN. Her medications were renally dosed.
Creatinine on discharge was back to 1.1.
.
# Elevated CE's - patient presented with elevated cardiac
enzymes likely [**2-25**] hypoperfusion and demand ischemia.  Echo
results above revealed normal cardiac function.
.
# NIDDM - Patient was known diabetic and was covered with
insulin gtt and ISS while in the hospital.
.
# PPx - For prophylaxis, patient was on IV PPI, heparin SC,
insulin gtt


Medications on Admission:
1. Metformin 500 mg [**Hospital1 **]
2. Lasix 40 mg qd
3. Atenolol 50 mg qd
4. Levoxyl 75 mcg qd


Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation. Tablet, Delayed Release (E.C.)(s)
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
4. Meropenem 1 g Recon Soln Sig: One (1) Recon Soln Intravenous
Q12H (every 12 hours): Please continue for 3 week course. .
5. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a
day.
6. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
7. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
1. E. Coli sepsis


Discharge Condition:
Good.


Discharge Instructions:
Please return if you have any fever, chills, increased headache,
chest pain, faintness, difficulty swallowing, pain with
urination, blood in urine or stool, or any other concerning
symptoms.

Followup Instructions:
Please follow up with your PCP [**Name Initial (PRE) 176**] 3 days of discharge.
{'Septicemia due to escherichia coli [E. coli],Other pulmonary insufficiency, not elsewhere classified,Septic shock,Acidosis,Urinary tract infection, site not specified,Acute kidney failure, unspecified,Calculus of ureter,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic kidney disease, unspecified,Thrombocytopenia, unspecified,Severe sepsis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other encephalopathy,Postsurgical hypothyroidism,Anemia, unspecified,Other nonspecific abnormal serum enzyme levels,Asbestosis,Esophageal reflux,Personal history of malignant neoplasm of breast,Personal history of malignant neoplasm of thyroid'}


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: This is a 67 y/o female with a h/o HTN, NIDDM, persistent left
UPJ stone, s/p left ureteral stent placement and ESWL [**1-29**] with
incomplete fragmentation and demonstration of the renal stone in
the inferior calyx of the left kidney, who underwent a left
ureteroscopy, left retrograde pyelography, laser lithotripsy,
left ureteral stent removal and replacement yesterday, and now
presents with hypotension, fever, tachycardia, and septic shock.

MEDICAL HISTORY: HTN, DM, Breast Ca, Thyroid Ca - Thyroidectomy, TAH/SBO,
Appendectomy, SBOs

MEDICATION ON ADMISSION: 1. Metformin 500 mg [**Hospital1 **]
2. Lasix 40 mg qd
3. Atenolol 50 mg qd
4. Levoxyl 75 mcg qd

ALLERGIES: Vancomycin And Derivatives / Tetracyclines / Penicillins /
Sulfonamides

PHYSICAL EXAM: VS: T 98.9, BP 139/81, HR 102, RR 18, SaO2 97%/AC 550 x 18, FiO2
100%, PEEP 8, SvO2 81, CVP 25
General: Intubated, partially sedated but withdraws to pain.
HEENT: NC/AT, pupils minimally reactive. ETT and NGT in place.
Neck: supple, R IJ in place
Chest: diffuse rhonchi throughout
CV: RRR, s1 s2 normal but distant, no m/g/r
Abd: soft, NT/ND, few BS
Ext: no c/c/e, warm, pulses 1+ b/l
Neuro: Sedated, withdraws to pain, moves all 4 extremities

FAMILY HISTORY: NC

SOCIAL HISTORY: Rare EtOH
, no tobacco 

### Response:
{'Septicemia due to escherichia coli [E. coli],Other pulmonary insufficiency, not elsewhere classified,Septic shock,Acidosis,Urinary tract infection, site not specified,Acute kidney failure, unspecified,Calculus of ureter,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic kidney disease, unspecified,Thrombocytopenia, unspecified,Severe sepsis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other encephalopathy,Postsurgical hypothyroidism,Anemia, unspecified,Other nonspecific abnormal serum enzyme levels,Asbestosis,Esophageal reflux,Personal history of malignant neoplasm of breast,Personal history of malignant neoplasm of thyroid'}
