CHIEF COMPLAINT: Hypotension

PRESENT ILLNESS: 58 year old man with chronic leukopenia, who presents with
fevers, chills, and malaise 4 days following prostate biopsy.
Initially following his biopsy, he was treated with Levoquin,
then admitted to [**Hospital1 **] for tachycardia and fevers up to 105F.
At [**Hospital1 **], he was started on Ceftriaxone and Flagyl.  He also
recieved Vancomycin and was thought to have a rash reaction.
The patient was noted to have posterior EKG changes and was
transferred to [**Hospital1 18**] for cardiology follow-up and possible cath
on Heparin drip, Plavix and ASA.

MEDICAL HISTORY: PMH:
lichen planus
chronic leukopenia
.
PSH:
Nasal Polypoectomy years ago

MEDICATION ON ADMISSION: None

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On admission:
Vitals:  99.1 96/70 85 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVD elevated to clavicle, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact, no aterixis
.
On discharge:
Vitals:  98.6  108/69  83  18  97%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVD elevated to clavicle, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact, no aterixis

FAMILY HISTORY: no known family history of heart disease

SOCIAL HISTORY: [**Name6 (MD) **] is NP[**Hospital1 **].  Lives with wife.
- Tobacco:denies
- Alcohol: denies
- Illicits:denies
Other postoperative infection,Septicemia due to escherichia coli [E. coli],Septic shock,Severe sepsis,Acidosis,Other pancytopenia,Other and unspecified coagulation defects,Urinary tract infection, site not specified,Other neutropenia,Nonspecific abnormal results of function study of liver,Chest pain, unspecified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Other postop infection,E coli septicemia,Septic shock,Severe sepsis,Acidosis,Other pancytopenia,Coagulat defect NEC/NOS,Urin tract infection NOS,Neutropenia NEC,Abn liver function study,Chest pain NOS,Abn react-procedure NEC
Admission Date:  [**2185-6-28**]              Discharge Date:   [**2185-7-4**]

Date of Birth:  [**2126-10-1**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Doctor First Name 2080**]
Chief Complaint:
Hypotension


Major Surgical or Invasive Procedure:
PICC LINE
Central line
Cardiac catheterization without immediate complications


History of Present Illness:
58 year old man with chronic leukopenia, who presents with
fevers, chills, and malaise 4 days following prostate biopsy.
Initially following his biopsy, he was treated with Levoquin,
then admitted to [**Hospital1 **] for tachycardia and fevers up to 105F.
At [**Hospital1 **], he was started on Ceftriaxone and Flagyl.  He also
recieved Vancomycin and was thought to have a rash reaction.
The patient was noted to have posterior EKG changes and was
transferred to [**Hospital1 18**] for cardiology follow-up and possible cath
on Heparin drip, Plavix and ASA.

In [**Hospital1 18**] ED, initial vital signs 98.8 104 85/57 18 98% 2L Nasal
Cannula.  Right IJ was placed and 4 Liters of NS were given.
Norepinephrine was started for systolic pressure in the 80's.
Cardiology consult concluded no indication for cath as ST
changes resolved, but ASA, plavix, and heparin continued.
.
On arrival to the MICU, vital signs 99.1 96/70 85. Patient was
interactive and denied pain.  He denies syncope, palpitations,
nausea, vomiting, dyspnea.


Past Medical History:
PMH:
lichen planus
chronic leukopenia
.
PSH:
Nasal Polypoectomy years ago


Social History:
[**Name6 (MD) **] is NP[**Hospital1 **].  Lives with wife.
- Tobacco:denies
- Alcohol: denies
- Illicits:denies


Family History:
no known family history of heart disease

Physical Exam:
On admission:
Vitals:  99.1 96/70 85 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVD elevated to clavicle, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact, no aterixis
.
On discharge:
Vitals:  98.6  108/69  83  18  97%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVD elevated to clavicle, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact, no aterixis

Pertinent Results:
ADMISSION LABS:
[**2185-6-28**] 05:30PM [**Month/Day/Year 3143**] WBC-3.6* RBC-3.99* Hgb-12.2* Hct-36.4*
MCV-91 MCH-30.6 MCHC-33.6 RDW-12.3 Plt Ct-86*
[**2185-6-28**] 05:30PM [**Month/Day/Year 3143**] Neuts-76* Bands-14* Lymphs-9* Monos-0
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2185-6-28**] 05:30PM [**Month/Day/Year 3143**] Glucose-87 UreaN-12 Creat-1.2 Na-139
K-3.5 Cl-109* HCO3-19* AnGap-15
[**2185-6-29**] 04:58AM [**Month/Day/Year 3143**] ALT-48* AST-95* LD(LDH)-189 CK(CPK)-1064*
AlkPhos-121 TotBili-5.1* DirBili-3.0* IndBili-2.1
.
DISCHARGE LABS:
[**2185-7-4**] 05:54AM [**Month/Day/Year 3143**] WBC-6.4 RBC-4.14* Hgb-12.0* Hct-38.0*
MCV-92 MCH-29.0 MCHC-31.6 RDW-13.1 Plt Ct-228
[**2185-7-4**] 05:54AM [**Month/Day/Year 3143**] Glucose-107* UreaN-8 Creat-0.9 Na-140
K-4.2 Cl-104 HCO3-28 AnGap-12
[**2185-7-4**] 05:54AM [**Month/Day/Year 3143**] PT-9.9 PTT-29.1 INR(PT)-0.9
[**2185-7-4**] 05:54AM [**Month/Day/Year 3143**] Calcium-8.7 Phos-3.2 Mg-2.4
[**2185-7-3**] 06:10AM [**Month/Day/Year 3143**] ALT-52* AST-63* LD(LDH)-312* AlkPhos-292*
TotBili-1.4
.
URINE STUDIES:
[**2185-6-28**] 06:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.007
[**2185-6-28**] 06:00PM URINE [**Month/Day/Year **]-SM  Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
[**2185-6-28**] 06:00PM URINE RBC-1 WBC-28* Bacteri-FEW Yeast-NONE
Epi-<1
[**2185-6-28**] 06:00PM URINE CastHy-4*
.
MICRO DATA:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] cultures:
[**Last Name (NamePattern1) 3143**] CULTURE  ESCHERICHIA COLI.  ISOLATED FROM AEROBIC AND
ANAEROBIC BOTTLES.
                                      INTERP M.I.C.
                                      ------ ------
       AMIKACIN                         S        16
       AMPICILLIN                       R      >=32
       AMPICILLIN/SULBACTAM             R      >=32
       CEFAZOLIN                        S       <=4
       CEFOXITIN                        S       <=4
       CEFTAZIDIME                      S       <=1
       CEFTRIAXONE                      S       <=1
       GENTAMICIN                       S       <=1
       IMIPENEM                         S       <=1
       LEVOFLOXACIN                     R       >=8
       TOBRAMYCIN                       R      >=16
       TRIMETHOPRIM/SULFA               R     >=320

[**2185-6-28**] 5:15 pm [**Month/Day/Year 3143**] CULTURE, Routine (Final [**2185-7-4**]):    NO
GROWTH
[**2185-6-28**] 6:00 pm URINE CULTURE (Final [**2185-6-29**]):    NO GROWTH.
[**2185-6-28**] 5:30 pm [**Month/Day/Year 3143**] CULTURE (Final [**2185-7-4**]):    NO GROWTH.
[**2185-6-28**] 10:06 pm MRSA SCREEN POSITIVE FOR METHICILLIN RESISTANT
STAPH AUREUS.
[**2185-7-1**] 1:25 am URINE CULTURE (Final [**2185-7-2**]):    NO GROWTH.
[**2185-7-1**] 1:25 am [**Month/Day/Year 3143**] CULTURE, Routine (Pending):
[**2185-7-1**] 7:57 pm URINE CULTURE (Final [**2185-7-2**]):    NO GROWTH.
.
EKG OSH- ST depressions in II, III, AVF NSR tachycardic to
120's.
EKG [**2185-6-28**] - NSR , No acute ST elevations or depressions, some
T wave flattening in II, III, AVF, V4-V6
EKG [**2185-7-4**] - Sinus rhythm. T wave abnormalities. Since the
previous tracing of [**2185-6-28**] no significant change.
.
CXR [**2185-6-28**]: The right internal jugular central venous catheter
tip is malpositioned, with the catheter coursing across midline
through the left brachiocephalic vein, and terminating in the
region of the left subclavian vein.  No pneumothorax is
identified.  The remainder of the chest is unchanged.  No
pneumothorax is identified.
.
CXR [**2185-6-28**]:  Right internal jugular central venous catheter has
been repositioned, the tip now terminating in the proximal right
atrium.  No pneumothorax is identified.  The cardiac,
mediastinal and hilar contours are normal.  Lungs are clear.
There is no pleural effusion.
.
RUQ ultrasound [**2185-6-29**]: The liver is of normal echotexture.  No
focal hepatic lesion is noted.  There is no evidence of
intrahepatic or extrahepatic biliary ductal dilatation.  The
portal vein is patent demonstrating hepatopetal flow.  CBD is of
normal caliber measuring 3 mm.  The gallbladder is incompletely
distended.  There is no gallbladder wall edema or
pericholecystic fluid collection to suggest acute
inflammation.  The pancreas is largely obscured by overlying
bowel gas.  The spleen measures 11.7 cm and is normal in
appearance.  The left kidney measures 11.3 cm, and the right
kidney measures 10.9 cm.  There is no evidence of
hydronephrosis.  There is no ascites.  Imaged intra-abdominal
aorta and IVC are normal in caliber.
.
CXR Picc line placement [**2185-6-30**]: Bedside upright AP radiograph
of the chest demonstrates a new right PICC terminating at or 1
cm below the expected location of the cavoatrial junction.  The
lungs are clear.  The hilar and cardiomediastinal contours are
normal.  There is no pneumothorax or pleural effusion.  The
pulmonary vascularity is normal.
.
Cardiac cath [**2185-7-4**]: 1) Selective coronary angiography of this
left-dominant system demonstrated no angiographically-apparent
flow-limiting stenoses in the LMCA, LAD, LCx, or RCA systems.
2) Left ventriculography demonstrated normal wall motion with an
LVEF of
65% and no mitral regurgitation.
3) Limited resting hemodynamics revealed mildly-elevated
left-sided
filling pressures, with an LVEDP of 13mmHg.  The central aortic
pressure
was normal at 113/65 mmHg.
4) A TR band was applied to the right radial arteriotomy site.

Brief Hospital Course:
58 year old man with a history of chronic leukopenia admitted
with E. coli urosepsis following prostate biopsy; found to have
EKG changes in the setting of hypotension but clean cardiac
catheterization.
.
# E.coli sepsis/septicemia: The patient was admitted to the ICU
hypotensive and tachycardic. He was fluid resuscitated and a
central line was placed. He was briefly on Levophed to support
his [**Month/Day/Year **] pressure. The patient was started on vancomycin and
meropenem until E. coli cultured from [**Month/Day/Year **] and urine returned
sensitive to ceftriaxone. Pressors were weaned the day following
ICU admission. A PICC line was placed in anticipation of a
2-week course of antibiotics for bacteremia.  The patient was
continued on ceftriaxone and his fevers and hypotension
resolved.  He was discharged with PICC in place and VNA for 8
remaining days of ceftriaxone.  The patient will follow up with
his primary care physician and urology as an outpatient.
.
#Abnormal EKG- The patient presented to [**Hospital1 **] with chest
pressure and diffuse ST depressions with elevation in aVR. EKG
changes resolved on arrival to [**Hospital1 18**] and troponin peaked at
0.06.  These changes were likely due to tachycardia. Cardiology
was consulted, and the patient was briefly placed on a heparin
gtt, Plavix, and aspirin until he ruled out for myocardial
infarction.  On transfer to the medical floor, the patient
underwent cardiac catheterization that showed normal ejection
fraction and no evidence of significant coronary artery disease.
 The patient did not require preventative aspirin or cardiology
followup on discharge.
.
#Thrombocytopenia- Thought most likely to be related to sepsis.
Platelets were trended and returned to [**Location 213**].
.
#Abnormal LFT's -  Patient with mildly progressive transaminitis
throughout admission.  T.bili peaked on admission at 3.5 and
trended down to 1.4 the day prior to discharge.  The patient has
no known history of liver disorder or abnormal LFTs.  Abnormal
LFTs on admission likely related to bacteremia/sepsis. RUQ
returned negative for evidence of liver disease.  However,
slowly progressive transaminitis may represent drug-induced
cholestasis.  The patient should undergo repeat LFTs on [**7-8**].
Antibiotic regimen may need to be changed or further outpatient
workup of transaminitis may need to be performed if continues to
progress.
.
#Code status - full
===================================
TRANSITIONAL ISSUES
# Patient should follow up with PCP for CBC and LFT check 1 week
following discharge.  He may require further workup of
transaminitis
# Patient with 8 days of ceftriaxone remaining at discharge

Medications on Admission:
None


Discharge Medications:
1. CeftriaXONE 2 gm IV Q24H
RX *ceftriaxone 2 gram daily Disp #*8 Syringe Refills:*0
2. Outpatient Lab Work
Please check CBC, LFTs on [**2185-7-8**].  Fax results to [**Last Name (LF) 9468**],[**Known firstname **]
S.F.  Fax: [**Telephone/Fax (1) 84944**].  Phone: [**Telephone/Fax (1) 9470**].


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 511**] Home Therapies

Discharge Diagnosis:
Primary diagnosis:  Urosepsis
Secondary diagnosis:  Chest pain


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
Mr. [**Known lastname **],
.
You were admitted to the intensive care unit with a severe
urinary tract infection, compromising your [**Known lastname **] pressure.  You
were started on IV antibiotics, and your infection improved.
You will continue to receive IV ceftriaxone for 8 more days
through a PICC line as an outpatient.
.
While your [**Known lastname **] pressure was low on admission, you experienced
chest pain.  You received IV fluids and your [**Known lastname **] pressure
improved.  Your chest pain resolved.  You underwent cardiac
catheterization that showed no damage to your heart.  You do not
require special followup with a cardiologist on discharge.
.
MEDICATIONS CHANGED THIS ADMISSION:
START ceftriaxone 2gm daily for 8 days

Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] on Wednesday [**2185-7-6**] at 3:00pm.
{'Other postoperative infection,Septicemia due to escherichia coli [E. coli],Septic shock,Severe sepsis,Acidosis,Other pancytopenia,Other and unspecified coagulation defects,Urinary tract infection, site not specified,Other neutropenia,Nonspecific abnormal results of function study of liver,Chest pain, unspecified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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: Hypotension

PRESENT ILLNESS: 58 year old man with chronic leukopenia, who presents with
fevers, chills, and malaise 4 days following prostate biopsy.
Initially following his biopsy, he was treated with Levoquin,
then admitted to [**Hospital1 **] for tachycardia and fevers up to 105F.
At [**Hospital1 **], he was started on Ceftriaxone and Flagyl.  He also
recieved Vancomycin and was thought to have a rash reaction.
The patient was noted to have posterior EKG changes and was
transferred to [**Hospital1 18**] for cardiology follow-up and possible cath
on Heparin drip, Plavix and ASA.

MEDICAL HISTORY: PMH:
lichen planus
chronic leukopenia
.
PSH:
Nasal Polypoectomy years ago

MEDICATION ON ADMISSION: None

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On admission:
Vitals:  99.1 96/70 85 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVD elevated to clavicle, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact, no aterixis
.
On discharge:
Vitals:  98.6  108/69  83  18  97%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVD elevated to clavicle, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact, no aterixis

FAMILY HISTORY: no known family history of heart disease

SOCIAL HISTORY: [**Name6 (MD) **] is NP[**Hospital1 **].  Lives with wife.
- Tobacco:denies
- Alcohol: denies
- Illicits:denies 

### Response:
{'Other postoperative infection,Septicemia due to escherichia coli [E. coli],Septic shock,Severe sepsis,Acidosis,Other pancytopenia,Other and unspecified coagulation defects,Urinary tract infection, site not specified,Other neutropenia,Nonspecific abnormal results of function study of liver,Chest pain, unspecified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
