CHIEF COMPLAINT: mental status changes, sepsis

PRESENT ILLNESS: Ms. [**Known lastname 37559**] is a 53 y/o female with PMH significant for DM, ESRD
on HD s/p R proximal SFA to proximal AT bypass on [**2191-3-31**]
admitted with wound infection. She was discharged then
readmitted [**2195-4-6**] for volume overload. Subsequently, she
returned to rehab but then was readmitted to the Vascular
Surgery service on [**2191-4-19**] with purulent drainage from her
wound. She was initially treated with vanc/levo/flagyl, and
original wound culture grew pansensitive E coli. On [**4-22**], she
was taken back to the OR where subsequent cultures grew MRSA and
Klebsiella. Over her hospital course, the patient was
intermittently confused and disoriented. The patient tolerated
HD on [**4-25**], but could not tolerate HD on [**4-27**] [**12-31**] hypotension
(down to 59 systolic). On [**4-27**], ID was consulted who recommended
vancomycin, meropenem and gentamycin. EKG on admission to the
ICU showed new lateral TWI (no intervention, occurred in setting
of hypotension, peak troponin 0.9 and CK ~ 800). The patient was
bolused with IVF in the MICU (transfer on [**4-27**]) and antibiotics
were broadened per ID recs.

MEDICAL HISTORY: renal failure secondary to diabetes mellitus on HD
status post R nephrectomy for renal cell cancer
depression
cholecystectomy
gastric ulcer
PVD s/p Left SFA to dorsalis pedis artery bypass for L
gangrenous heel in [**2187**]; R proximal SFA to proximal AT bypass on
[**2191-3-31**]
OSA
Gastroparesis

MEDICATION ON ADMISSION: Meds on transfer from MICU:
ASA 81 mg daily
cinacalcet 60 mg daily
plavix 75 mg daily
gabapentin 300 mg daily
haldol 2 mg IV prn (agitation)
heparin SC TId
SSI, NPH insulin
iron 150 mg daily
ativan 0.5 mg prn agitation
Meropenem 500 mg IV daily
flagyl 500 mg Q12H
nephrocaps 1 daily
oxycodone prn pain
protonix 40 mg daily
sevelamer 2400 TID
simvastatin 20 mg daily
simethicone prn
vancomycin 500 mg at HD

ALLERGIES: Lisinopril

PHYSICAL EXAM: VS: T 99.1 HR 68 BP 95/59 RR 18 94% on 3L NC (home O2
requirement)
GENL: obese, cooperative, speaking clearly and in full
sentences, appropriate
HEENT: OP clear, MMM, no JVD, no icterus
CV: RRR, + II/VI systolic murmur at RSB, no rubs/gallops
Lungs: clear bilaterally
Abd: soft, nd, bs+ no masses. no HSM. obese.
Ext: R thigh wound with wound vac in place. No obvious drainage
from incisions in right lower leg. DP pulses 1+ bilaterally. No
peripheral edema.

FAMILY HISTORY: Multiple family members with [**Name (NI) 2320**] and HTN

SOCIAL HISTORY: lives in senior housing, 2 children, former tobacco, quit 7 yrs
ago, 1PPDx20 yrs, no ETOH, no drugs
Other postoperative infection,Methicillin susceptible Staphylococcus aureus septicemia,Sepsis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Acute posthemorrhagic anemia,Pressure ulcer, lower back,Infection with microorganisms resistant to penicillins,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Unspecified vascular insufficiency of intestine
Other postop infection,Meth susc Staph aur sept,Sepsis,Hyp kid NOS w cr kid V,End stage renal disease,Ac posthemorrhag anemia,Pressure ulcer, low back,Inf mcrg rstn pncllins,DMII renl nt st uncntrld,Vasc insuff intest NOS
Admission Date:  [**2191-4-19**]              Discharge Date:   [**2191-5-17**]

Date of Birth:  [**2138-3-6**]             Sex:   F

Service: MEDICINE

Allergies:
Lisinopril

Attending:[**First Name3 (LF) 3283**]
Chief Complaint:
mental status changes, sepsis

Major Surgical or Invasive Procedure:
Placement of right IJ central venous catheter
Placement of right peripherally inserted central catheter
Hemodialysis
Surgical debridement R thigh.

History of Present Illness:
Ms. [**Known lastname 37559**] is a 53 y/o female with PMH significant for DM, ESRD
on HD s/p R proximal SFA to proximal AT bypass on [**2191-3-31**]
admitted with wound infection. She was discharged then
readmitted [**2195-4-6**] for volume overload. Subsequently, she
returned to rehab but then was readmitted to the Vascular
Surgery service on [**2191-4-19**] with purulent drainage from her
wound. She was initially treated with vanc/levo/flagyl, and
original wound culture grew pansensitive E coli. On [**4-22**], she
was taken back to the OR where subsequent cultures grew MRSA and
Klebsiella. Over her hospital course, the patient was
intermittently confused and disoriented. The patient tolerated
HD on [**4-25**], but could not tolerate HD on [**4-27**] [**12-31**] hypotension
(down to 59 systolic). On [**4-27**], ID was consulted who recommended
vancomycin, meropenem and gentamycin. EKG on admission to the
ICU showed new lateral TWI (no intervention, occurred in setting
of hypotension, peak troponin 0.9 and CK ~ 800). The patient was
bolused with IVF in the MICU (transfer on [**4-27**]) and antibiotics
were broadened per ID recs.

In the ICU, an A line could not be placed but R IJ was placed on
[**4-28**]. She was transfused 1 U PRBCs on [**2191-4-29**]; she received
ativan and haldol for agitation thought [**12-31**] toxic metabolic
state as well as infection. Gentamycin d/c'd on [**4-29**] but patient
continues on vancomycin (d13), meropenem (d5), and flagyl (d3).
She was noted to have scant blood out of rectal tube but
hematocrit has been stable thus far and patient is on multiple
anticoagulants (ASA, plavix, SC heparin). Vascular surgery
continues to follow with next wound vac change is planned for
[**Last Name (LF) 766**], [**5-2**]. At the present time, the patient feels quite
well. She has no shortness of breath or chest pain. She has some
right leg pain which is overall quite improved from prior. She
denies any nausea or vomiting; she is having [**4-3**] diarrheal
stools per day, which is unchanged over the past few days.


Past Medical History:
renal failure secondary to diabetes mellitus on HD
status post R nephrectomy for renal cell cancer
depression
cholecystectomy
gastric ulcer
PVD s/p Left SFA to dorsalis pedis artery bypass for L
gangrenous heel in [**2187**]; R proximal SFA to proximal AT bypass on
[**2191-3-31**]
OSA
Gastroparesis


Social History:
lives in senior housing, 2 children, former tobacco, quit 7 yrs
ago, 1PPDx20 yrs, no ETOH, no drugs

Family History:
Multiple family members with [**Name (NI) 2320**] and HTN

Physical Exam:
VS: T 99.1 HR 68 BP 95/59 RR 18 94% on 3L NC (home O2
requirement)
GENL: obese, cooperative, speaking clearly and in full
sentences, appropriate
HEENT: OP clear, MMM, no JVD, no icterus
CV: RRR, + II/VI systolic murmur at RSB, no rubs/gallops
Lungs: clear bilaterally
Abd: soft, nd, bs+ no masses. no HSM. obese.
Ext: R thigh wound with wound vac in place. No obvious drainage
from incisions in right lower leg. DP pulses 1+ bilaterally. No
peripheral edema.


Pertinent Results:
Labs on admission:

Imaging:

Microbiology:

Labs on discharge:

Brief Hospital Course:
53 y/o F ESRD on HD, with large Right thigh wound at site of
saphenous vein harvest for CABG, originally admitted to the
hospital for wound infection and a question of sepsis.  She was
treated with meropenem and vanco on the floor until she was
found to be bleeding large amounts from rectum.

She was transferred to the MICU on [**2191-5-5**] for LGIB with
hypotension.
MICU course. Pt was readmitted to the ICU with hematochezia. Pt
was irgently brought to the ICU, where SBP dropped to the 60's.
Trauma line was placed, 4 units of PRBC, 2 bags of platelets,
and ddAVP 20 mcg given, and patient was brought to IR, where
angio was performed in hopes of embolization. Pressors were
initiated for a matter of minutes. The [**Female First Name (un) 899**] though located, could
not be cannulated due to its small caliber, calcification and
tortuosity. A generalized run was therefore performed adjacent
to the orifice of the [**Female First Name (un) 899**], and this demonstrated no active
extravasation, as well. Given no active site of bleed. Patient
was returned to the floor, with BP's continung in the 80's
systolic. MAP mantained above 60 by transfusion. Transfused to
crit>28. Surgery and GI consulted. GI performed NG lavage with
bilious material therefore endoscopy not performed. Surgery
consulted and deferred surgery given inability to localize bleed
and desire to avoid total colectomy in patient with numerous
comorbidities. Prep for colonoscopy was not initiated day one
given labile blood pressure and concern for hemodynamic
stability. Day two patient was prepped for colonoscopy. Only
sigmoidoscopy completed as linear ulcerations consistent with
ischemic colitis found. Deemed likely etiology of bleed.
Ischemic colitis in the setting of atheroschlerosis with
hypotension from sepsis leading to poor perfusion. Patient kept
NPO, with bowel rest, maintaining blood pressure, and [**Hospital1 **] PPI.
No hematochezia after day two in the MICU. Day prior to call out
pt developed hemoptysis in the setting of wretching. NG lavage
was negative for gross blood. GI informed. No EGD at that time.
Patient was called out of the MICU with stable hematocrit, and
BP on clear diet. No hematemesis, hematochezia, melena at time
of transfer to floor.

Angiography showed: Assessment of the celiac, SMA and [**Female First Name (un) 899**]
demonstrating no abnormal vasculature, no evidence of active
extravasation
.
On the floor, her right thigh wound was managed with a wound
vac, changed by vascular surgery on [**2191-5-10**].  She was taken to
the OR for debridement on [**5-12**]. She continued on vanco/meropenem
for 21 days.
.
Hemodynamically, she remained stable while on the floor after
transfusion of pRBCs, FFP and ddAVP, with a stable HCT.  Her
blood pressure, while difficult to obtain (right forearm only)
remained in the 95-105 range.  She did not have further GI
bleeding while on the floor.  Her diet was slowly advanced and
she toelrated it well.
.
While in the MICU, she was noted to have EKG Changes: ST
depressions in inferolateral distribution; however, recent Echo
and stress test were normal. Enzymes have peaked and are
trending down.
She was originally started on ASA, plavix, and a statin.  The
plavix was held in the setting of her GI Bleed.
A repeat EKG on [**5-10**] showed resolution of ST depressions. At no
time did she experience chest pain.
.
The patient was continued on her home diabetes regimen, and
insulin sliding scale added when needed.
.
ESRD: The renal team folowed the patient.  She had dialysis
every mon, wed, Fri while in house.  She had one episode of
hypotension during dialysis, requiring blood transfusion.
Electrolytes remained normal.  Subsequent dialysis was without
problems.
.
She was found to have a stage II sacral decubitus ulcer.  She
was transferred to a [**Doctor First Name **]-air bed, and a wound care nursing
consult was enacted.  Physical Therapy was also consulted.
.
During her initial hospital stay, she experienced Mental status
changes/Agitation: Likely result of toxic metabolic causes,
infection, in addition to encephalopathy from Uremia and use of
pain meds. Dilaudid in particular seemed to cause mental status
changes and agitation.  Upon transfer to the floor, she was
alert and oriented, without agitation.
.
Access: R IJ placed on [**2191-4-28**], d/ced in ICU.  R PICC placed.
She also has a left av fistula for dialysis use.
She was Full code
.
After the surgical debridement of her right thigh wound, the
patient remained stable and tolerated POs.  She was then
transferred to rehab for continued treatment.

Medications on Admission:
Meds on transfer from MICU:
ASA 81 mg daily
cinacalcet 60 mg daily
plavix 75 mg daily
gabapentin 300 mg daily
haldol 2 mg IV prn (agitation)
heparin SC TId
SSI, NPH insulin
iron 150 mg daily
ativan 0.5 mg prn agitation
Meropenem 500 mg IV daily
flagyl 500 mg Q12H
nephrocaps 1 daily
oxycodone prn pain
protonix 40 mg daily
sevelamer 2400 TID
simvastatin 20 mg daily
simethicone prn
vancomycin 500 mg at HD


Discharge Medications:
1. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
2. Sevelamer 800 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
7. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
8. Insulin Lispro (Human) 100 unit/mL Solution Sig: 1-20 units
Subcutaneous ASDIR (AS DIRECTED).
9. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
12. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
13. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours) for 3 days: Stop date [**5-19**].
Disp:*3 Recon Soln(s)* Refills:*0*
14. Vancomycin 1,000 mg Recon Soln Sig: One (1) dose Intravenous
QHD per protocol for 2 days: stop day [**5-19**].
Disp:*2 bags* Refills:*0*
15. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed: 10 ml NS followed by
2 ml of 100 Units/ml heparin (200 units heparin) each lumen
Daily and PRN. Inspect site every shift.
.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]

Discharge Diagnosis:
Right thigh wound with wound vac
Diabetes Mellitus
Right heel wound
Ischemic colitis
End Stage Renal Disease on Hemodialysis


Discharge Condition:
Fair


Discharge Instructions:
You have been in the hospital because the wound on your right
thigh was infected.  YOu are almost finished with a long course
of antibiotics.  The wound will heal over time, but will
continue to need a wound vac dressing for many weeks.

Please continue all medicines as prescibed.

Please continue hemodialysis as usual.

Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 2450**] in [**11-30**] weeks.  Call his office at
[**Telephone/Fax (1) 250**] to make an appointment

Please follow up with  Dr. [**Last Name (STitle) **] on [**5-27**] at 930 at [**Hospital1 **].
 call [**Telephone/Fax (1) 2395**] for directions
{'Other postoperative infection,Methicillin susceptible Staphylococcus aureus septicemia,Sepsis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Acute posthemorrhagic anemia,Pressure ulcer, lower back,Infection with microorganisms resistant to penicillins,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Unspecified vascular insufficiency of intestine'}


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: mental status changes, sepsis

PRESENT ILLNESS: Ms. [**Known lastname 37559**] is a 53 y/o female with PMH significant for DM, ESRD
on HD s/p R proximal SFA to proximal AT bypass on [**2191-3-31**]
admitted with wound infection. She was discharged then
readmitted [**2195-4-6**] for volume overload. Subsequently, she
returned to rehab but then was readmitted to the Vascular
Surgery service on [**2191-4-19**] with purulent drainage from her
wound. She was initially treated with vanc/levo/flagyl, and
original wound culture grew pansensitive E coli. On [**4-22**], she
was taken back to the OR where subsequent cultures grew MRSA and
Klebsiella. Over her hospital course, the patient was
intermittently confused and disoriented. The patient tolerated
HD on [**4-25**], but could not tolerate HD on [**4-27**] [**12-31**] hypotension
(down to 59 systolic). On [**4-27**], ID was consulted who recommended
vancomycin, meropenem and gentamycin. EKG on admission to the
ICU showed new lateral TWI (no intervention, occurred in setting
of hypotension, peak troponin 0.9 and CK ~ 800). The patient was
bolused with IVF in the MICU (transfer on [**4-27**]) and antibiotics
were broadened per ID recs.

MEDICAL HISTORY: renal failure secondary to diabetes mellitus on HD
status post R nephrectomy for renal cell cancer
depression
cholecystectomy
gastric ulcer
PVD s/p Left SFA to dorsalis pedis artery bypass for L
gangrenous heel in [**2187**]; R proximal SFA to proximal AT bypass on
[**2191-3-31**]
OSA
Gastroparesis

MEDICATION ON ADMISSION: Meds on transfer from MICU:
ASA 81 mg daily
cinacalcet 60 mg daily
plavix 75 mg daily
gabapentin 300 mg daily
haldol 2 mg IV prn (agitation)
heparin SC TId
SSI, NPH insulin
iron 150 mg daily
ativan 0.5 mg prn agitation
Meropenem 500 mg IV daily
flagyl 500 mg Q12H
nephrocaps 1 daily
oxycodone prn pain
protonix 40 mg daily
sevelamer 2400 TID
simvastatin 20 mg daily
simethicone prn
vancomycin 500 mg at HD

ALLERGIES: Lisinopril

PHYSICAL EXAM: VS: T 99.1 HR 68 BP 95/59 RR 18 94% on 3L NC (home O2
requirement)
GENL: obese, cooperative, speaking clearly and in full
sentences, appropriate
HEENT: OP clear, MMM, no JVD, no icterus
CV: RRR, + II/VI systolic murmur at RSB, no rubs/gallops
Lungs: clear bilaterally
Abd: soft, nd, bs+ no masses. no HSM. obese.
Ext: R thigh wound with wound vac in place. No obvious drainage
from incisions in right lower leg. DP pulses 1+ bilaterally. No
peripheral edema.

FAMILY HISTORY: Multiple family members with [**Name (NI) 2320**] and HTN

SOCIAL HISTORY: lives in senior housing, 2 children, former tobacco, quit 7 yrs
ago, 1PPDx20 yrs, no ETOH, no drugs 

### Response:
{'Other postoperative infection,Methicillin susceptible Staphylococcus aureus septicemia,Sepsis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Acute posthemorrhagic anemia,Pressure ulcer, lower back,Infection with microorganisms resistant to penicillins,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Unspecified vascular insufficiency of intestine'}
