CHIEF COMPLAINT: Hypotension

PRESENT ILLNESS: 68 y.o.m. with T4 paraplegia, CAD, CHF, sacral decubitus ulcers,
UTIs, PE w/p IVC filter on anticoagulation who presents.

MEDICAL HISTORY: 1. Inflammatory disease of the spinal cord of uncertain

MEDICATION ON ADMISSION: Keppra 500mg [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: General Appearance: Well nourished, Overweight / Obese

FAMILY HISTORY: No stroke, aneurysm, no seizure, no AAA.

SOCIAL HISTORY: He moved here from [**Country 3594**] (after living in many different
countries) in the [**2068**].  He is retired from a job in the
maritime industry.  Divorced 24 years ago.  Three children.
Quit smoking [**2076**].  Quit drinking [**2080**].  No history of illicit
drug use or abuse.
Unspecified septicemia,Septic shock,Pneumonitis due to inhalation of food or vomitus,Urinary tract infection, site not specified,Paraplegia,Pressure ulcer, lower back,Chronic systolic heart failure,Severe sepsis,Esophageal reflux,Epilepsy, unspecified, without mention of intractable epilepsy,Neurogenic bladder NOS,Asthma, unspecified type, unspecified,Coronary atherosclerosis of native coronary artery,Aortocoronary bypass status,Unspecified accident
Septicemia NOS,Septic shock,Food/vomit pneumonitis,Urin tract infection NOS,Paraplegia NOS,Pressure ulcer, low back,Chr systolic hrt failure,Severe sepsis,Esophageal reflux,Epilep NOS w/o intr epil,Neurogenic bladder NOS,Asthma NOS,Crnry athrscl natve vssl,Aortocoronary bypass,Accident NOS
Admission Date:  [**2106-6-8**]              Discharge Date:   [**2106-6-11**]

Date of Birth:  [**2038-4-1**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
Hypotension

Major Surgical or Invasive Procedure:
none

History of Present Illness:
68 y.o.m. with T4 paraplegia, CAD, CHF, sacral decubitus ulcers,
UTIs, PE w/p IVC filter on anticoagulation who presents.

Presents from [**Hospital **] rehab with 5 days intermittent SSCP on
right side, abdominal discomfort, decreased appetite, nausea,
?emesis.  Also with shortness of breath over last couple of days
and increasing cough over last couple of weeks.  Abdominal pain
is chronic and has been present for years.  No fevers, chills.
EMS stated SBPs were 70s, responded to NS bolus.

.

In the ED vitals were 98, 92, 91/63, 28, 100% 2L.  BP decreased
to a low of 89/64, blood cultures and lactate drawn and given
vanc IV 1gm and zosyn IV 1 gm and 1LNS.  Guaiac negative.
Impression was for abdominal source [**3-13**] to sacral decub -> CT
Abd/Pelvis showed large infra sacral decub fluid collection with
possible abscess formation and associated rectal thickening.

.

Of note, that patient has had multiple admissions in the past,
the most recent from [**Date range (1) 45260**] for hypotension requiring
pressors.  Etiology unclear but felt to be either line vs. UTI
vs. sacral decub.  He was treated with meropenem, vancomycin,
flagyl, and ciprofloxacin, PICC removed, foley changed. Plastic
surgery evaluated sacral decubs and did not feel they were the
source of his sepsis.  Influenza negative.  Plan was to receive
two week course of meropenem and vancomycin given no clear
source of infection (completed [**5-27**]).   Discharge summary states
that pt should have serial blood and urine cultures, as well as
wound evaluation by plastic surgery, prior to initiating further
antibiotics as repeted episodes of hypotension with no culture
data to guide antibiotic therapy.  Prior discharge was after
admission for code stroke [**4-21**]--[**4-27**] which at the end, it was
thought to be a seizure episode. Prior to that, admitted
[**2106-4-6**]- [**2106-4-15**] for fever and hypotension treated for UTI and
wound infection with Vanc/Zosyn completed on [**4-21**].

Past Medical History:
1. Inflammatory disease of the spinal cord of uncertain

etiology.  MRA [**10-16**] negative for vascular malformation.  Initial


CSF analysis showed elevated protein (82) without oligoclonal

bands.  NMO blood titer negative, RPR negative, Lyme serology
negative, [**Doctor First Name **] negative, Ro and La negative, ACE level normal,
neuromyelitis IgG negative, ESR 70, CRP 66.8.  Ultimately
treated with broad spectrum antibiotics, corticosteroids (two
weeks of Solu-Medrol followed by a prednisone taper), and 5 days
of mannitol without improvement.  He is followed by neurology
for a dense paraplegia (T4) with neuropathic pain, restrictive
shoulder arthropathy, and a neurogenic bladder requiring a
chronic indwelling foley.

2. Chronic sacral decubitus ulcer, previously treated with a VAC
Dressing

3. Multiple UTI (including Pseudomonas)

4. Pulmonary embolus [**11-15**] s/p IVC filter placement

5. Asthma

6. Two-vessel coronary artery disease s/p CABG 4-5 years ago

7. Systolic CHF (EF 25-30% on [**2-15**] TTE)

8. Repaired liver laceration

9. Chronic back pain

10. Vitiligo

11. Feeding tube

12. Depression

13. MRSA from sacral swab and sputum

14. Prior transient episodes of leg paralysis

15. Right frontal lobe brain lesion biopsied [**11-15**] and c/w

gliosis; resolved on repeat imaging

16. Abnormal visual evoked potentials


Social History:
He moved here from [**Country 3594**] (after living in many different
countries) in the [**2068**].  He is retired from a job in the
maritime industry.  Divorced 24 years ago.  Three children.
Quit smoking [**2076**].  Quit drinking [**2080**].  No history of illicit
drug use or abuse.


Family History:
No stroke, aneurysm, no seizure, no AAA.

Physical Exam:
General Appearance: Well nourished, Overweight / Obese

Eyes / Conjunctiva: PERRL

Head, Ears, Nose, Throat: Normocephalic

Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,
(Murmur: No(t) Systolic, No(t) Diastolic)

Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)

Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Rhonchorous: throughout)

Abdominal: Soft, Tender: RUQ, Obese, no rebound or guarding

Extremities: Right: Trace, Left: Trace, mutlipidous boots

Skin:  Warm, No(t) Rash: , No(t) Jaundice, stage III-IV sacral
decubs bilateral ischial tuberosities, gluteal clefts

Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not
assessed


Pertinent Results:
IMPRESSION:
1. Tree-in-[**Male First Name (un) 239**] opacities in the right lower lobe concerning for
infectious process. Given the presence of copious secretions in
the airways aspiration should also be considered.
2. Large infra-sacral decubitus ulcer with possible abscess
formation. Associated rectal thickening could be representing
reactive changes or infectious involvement.
3. Left renal cyst.
4. IVC filter.
5. Cholelithiasis without cholecystitis.
--------------

URINE CULTURE (Final [**2106-6-9**]):
      ACINETOBACTER BAUMANNII COMPLEX.    >100,000
ORGANISMS/ML..
         "Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
         used, since therapeutic efficacy relies on intrinsic
activity of
         the sulbactam component".

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ACINETOBACTER BAUMANNII COMPLEX
                             |
AMPICILLIN/SULBACTAM--     4 S
CEFEPIME--------------  =>64 R
CEFTAZIDIME-----------  =>64 R
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------   <=1 S
IMIPENEM--------------  =>16 R
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----     2 S


Brief Hospital Course:
68-year-old man with severe shock (source most likely decub, but
UTI and PICC line also in DDx) on a background history of T4
paraplegia (?myelitis) complicated by decubiti, neurogenic
bladder, PEs and UTIs.
.

# Hypotension

History autonomic dysfunction with component likely urosepsis
with acinetobacter sensitive to tobramycin, patient completed 7
day course. Patient also was treated with a course of vancomycin
and cefepime to treat suspected underlying pneumonic process
given tree and [**Male First Name (un) 239**] opacities at right lower lobe on CTA chest.
MRI to evaluate for osteo prior to discharge to assess for
change in osteo was unrevealing. Cortstym test was appropriate.
PICC line was kept in place. Foley changed on admission. Patient
was off pressors with stable blood pressure, he was alert and
oriented and UOP was appropriate at the time of discharge.
.

# Decubitus ulcers

Evaluated by both plastic and general surgery who did not think
wound was actively infected. Stage IV documented sacral decubiti
ulcers which underwent debridement per surgery. MRI did not show
any evidence of new infection and did not warrant further
treatment with antibiotics.
.

# PE s/p IVC filter

Hold warfarin today; goal INR 2 ?????? 3.  Monitor closely.  If he
does not continue his rapid improvement, convert to heparin and
hold warfarin. Multiple abx on board likely affecting level.
.

# CAD/CHF (systolic, chronic)
No evidence of volume overload.  Hold antihypertensives;
continue aspirin.
His troponin is elevated, but appears to be chronically so (for
unclear reasons) ?????? does not appear to be ACS/unstable plaque.
Ruled out for ACS with 3 negative enzymes
.

Medications on Admission:
Keppra 500mg [**Hospital1 **]

Gabapentin 300mg [**Hospital1 **]

Citalopram 30mg daily

Baclofen 5mg PO TID

Lisinopril 2.5 mg daily

Carvedilol 3.25mg [**Hospital1 **]

Advair 250/50 [**Hospital1 **]

Albuterol 2 puffs Q6H

Ipratroprium 2 puffs Q6H

Aspirin 81 mg daily

Ursodiol 300mg PO BID

Vit D 800 daily

Vit B12 1000 daily

Calcium carb 500mg TID

Pantoprazole 40

Folic acid 1mg daily

Oxycodone 5mg Q6H prn

Warfarin 2mg daily

Meropenem (stopped [**5-27**])

Vancomycin (stopped [**5-27**])

Flagyl (stopped [**6-3**])


Discharge Medications:
1. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day).

6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
14. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
15. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Hexavitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).
17. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
18. Tobramycin Sulfate 40 mg/mL Solution Sig: Three Hundred
Forty (340) mg Injection Q24H (every 24 hours) for 4 days.
19. PICC line care per protocol
20. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) puff Inhalation every six (6) hours.


Discharge Disposition:
Expired

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

Discharge Diagnosis:
UTI

Discharge Condition:
Stable

Discharge Instructions:
You were admitted with hypoxia.  This resolved quickly and we
found a urinary tract infection, for which we are treating you
with intravenous antibiotics through your PICC line.  We got an
MRI to make sure there is no bone infection.  You will need to
have this followed up with your PCP.
.
Please return to the emergency room if you develop any fevers or
any other concerning symptoms.
.
Follow up as indicated below and take all of your medications as
directed.

Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at [**Telephone/Fax (1) 250**] within
the next two weeks to follow up your MRI results.
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7598**], MD Phone:[**Telephone/Fax (1) 5434**]
Date/Time:[**2106-7-16**] 9:30
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], [**First Name3 (LF) 3947**]. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2106-11-3**] 9:40
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2106-11-3**]
11:00
{'Unspecified septicemia,Septic shock,Pneumonitis due to inhalation of food or vomitus,Urinary tract infection, site not specified,Paraplegia,Pressure ulcer, lower back,Chronic systolic heart failure,Severe sepsis,Esophageal reflux,Epilepsy, unspecified, without mention of intractable epilepsy,Neurogenic bladder NOS,Asthma, unspecified type, unspecified,Coronary atherosclerosis of native coronary artery,Aortocoronary bypass status,Unspecified accident'}


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: 68 y.o.m. with T4 paraplegia, CAD, CHF, sacral decubitus ulcers,
UTIs, PE w/p IVC filter on anticoagulation who presents.

MEDICAL HISTORY: 1. Inflammatory disease of the spinal cord of uncertain

MEDICATION ON ADMISSION: Keppra 500mg [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: General Appearance: Well nourished, Overweight / Obese

FAMILY HISTORY: No stroke, aneurysm, no seizure, no AAA.

SOCIAL HISTORY: He moved here from [**Country 3594**] (after living in many different
countries) in the [**2068**].  He is retired from a job in the
maritime industry.  Divorced 24 years ago.  Three children.
Quit smoking [**2076**].  Quit drinking [**2080**].  No history of illicit
drug use or abuse. 

### Response:
{'Unspecified septicemia,Septic shock,Pneumonitis due to inhalation of food or vomitus,Urinary tract infection, site not specified,Paraplegia,Pressure ulcer, lower back,Chronic systolic heart failure,Severe sepsis,Esophageal reflux,Epilepsy, unspecified, without mention of intractable epilepsy,Neurogenic bladder NOS,Asthma, unspecified type, unspecified,Coronary atherosclerosis of native coronary artery,Aortocoronary bypass status,Unspecified accident'}
