CHIEF COMPLAINT: Pneumonia, dehydration

PRESENT ILLNESS: 37M 5 days s/p uncomplicated left L5 MDFH and left L4
foraminotomy for L4-L5 radiculopathy/herniation, discharged
[**2155-6-13**], presents to [**Hospital3 4107**] with 3 day h/o fevers and
chills to 103.7 as well as cough.

MEDICAL HISTORY: SVT ablation
hypertension
anxiety attack
s/p post discectomy

MEDICATION ON ADMISSION: Nebivolol Hcl (Bystolic) 50 MG PO DAILY
Venlafaxine 150 MG PO DAILY
Triamterene &  Hydrochlorothiaz 1 TAB PO DAILY 25 MG/37.5 MG CAP
Clonazepam (Klonopin) 2 MG PO BID PRN
Diazepam 5MG* (Valium 5MG*)10 MG PO 5XDAY PRN
Hydrocodone-Acetaminophen 1 TAB PO Q4H PRN 10 MG/650 MG
dicloxicillin
amlodipine/benazapril 5/20mg qday

ALLERGIES: scallops

PHYSICAL EXAM: 98, hr 62, 145/81, 20, 97% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, 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-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding

FAMILY HISTORY: Father has HTN
Mother MI at 62 yo
2 brothers are well
Maternal grandmother MI at 84 and grandfather at [**Age over 90 **] [**Name2 (NI) **]

SOCIAL HISTORY: Smokes 1 pack per day. Alcohol: occasional.
Recreational Drugs: none. Patient is a PhD in psychology, and
currently sees patients privately at a clinic.
Unspecified septicemia,Pneumonia, organism unspecified,Septic shock,Acute kidney failure, unspecified,Severe sepsis,Unspecified essential hypertension,Tobacco use disorder,Dysthymic disorder,Dehydration
Septicemia NOS,Pneumonia, organism NOS,Septic shock,Acute kidney failure NOS,Severe sepsis,Hypertension NOS,Tobacco use disorder,Dysthymic disorder,Dehydration
Admission Date:  [**2155-6-17**]              Discharge Date:   [**2155-6-18**]

Date of Birth:  [**2117-10-1**]             Sex:   M

Service: MEDICINE

Allergies:
scallops

Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Pneumonia, dehydration

Major Surgical or Invasive Procedure:
central venous line

History of Present Illness:
37M 5 days s/p uncomplicated left L5 MDFH and left L4
foraminotomy for L4-L5 radiculopathy/herniation, discharged
[**2155-6-13**], presents to [**Hospital3 4107**] with 3 day h/o fevers and
chills to 103.7 as well as cough.

On arrival to [**Hospital3 **], Pt was febrile to 103.7, with
initial SBP of 77/43, not responsive to 3L bolus of
crystalloids.  His lumbar incision was noted to be clean and
dry.  A chest xray obtained revealed RLL PNA.  His WBC was 12K,
with lactate of 2.1.  After additional L of NS, L of LR and
initiation of phenylephrine low dose, pt became normotensive
(100's/60's) and was mentating normally.  He was treated with
500mg PO flagyl, and 1 gm CTX at [**Hospital1 **].  He was subsequently
transferred to [**Hospital1 18**].  Pt reports that his radicular symptoms
have completely resolved s/p surgery.

ED Course:
In the ED, initial VS were: 98.6 72 104/63 20 98%
- trigger for transfer; 89/60 with neo gtt turned off
- EKG: Non-specific ST-T changes.  No significant change from
previous tracing of [**2155-6-9**].
[] labs: lactate 0.9, WBC 11.1, UA neg, chem7 wnl.
[] broadened abx to vanc and levaquin
[] CVL and pt started on levophed and phenylephrine stopped
[] repeat CXR - RLL PNA
[] total [**Hospital1 **] + [**Hospital1 18**] ED 7L IVF, now minimal levo and
pressures in 110s sbp.

On arrival to the MICU, patient's bp is 140/80.
He is on NS at 200/hr and making good urine.

Past Medical History:
SVT ablation
hypertension
anxiety attack
s/p post discectomy

Social History:
Smokes 1 pack per day. Alcohol: occasional.
Recreational Drugs: none. Patient is a PhD in psychology, and
currently sees patients privately at a clinic.


Family History:
Father has HTN
Mother MI at 62 yo
2 brothers are well
Maternal grandmother MI at 84 and grandfather at [**Age over 90 **] [**Name2 (NI) **]



Physical Exam:
98, hr 62, 145/81, 20, 97% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, 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-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding

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.



Pertinent Results:
[**Hospital1 **]

[**2155-6-17**] 0625 0619 Na 132 K 4.0 Cl93 HCO3 31  GLU 108  BUN 31 Cr
1.2 (1.2 on [**6-12**])  Ca 8.5

LACTATE VENOUS (LACTIC ACID)
[**2155-6-17**]  2.1

HEMOGRAM/PLT
[**2155-6-17**] 0625 WBC 12.9 HgB 11.4 HCT 32.0 L Plt185

URINALYSIS W/MICROSCOPIC
[**2155-6-17**] 0730 0619: Unremarkable

Micro: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 58343**] x 2- pending, Cdiff- pending

Images:
CXR ([**Hospital1 **]) [**2155-6-17**]
Chest 2 views, [**2155-6-17**].

No prior exams for comparison.

Infiltrate the right lung base compatible with pneumonitis. Left
lung
is clear. No evidence of CHF.

Impression:
 Right basilar infiltrate compatible with pneumonitis.
Radiographic
followup recommended.

EKG: Report from [**Hospital1 **]: Sinus rhythm.  Non-specific ST-T
changes.  No significant change from previous tracing of
[**2155-6-9**].

[**Hospital1 18**] admission

[**2155-6-17**] 11:52AM   LACTATE-0.9
[**2155-6-17**] 11:50AM   GLUCOSE-66* UREA N-21* CREAT-1.0 SODIUM-138
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-32 ANION GAP-10
[**2155-6-17**] 11:50AM   estGFR-Using this
[**2155-6-17**] 11:50AM   ALT(SGPT)-78* AST(SGOT)-41* ALK PHOS-89 TOT
BILI-0.2
[**2155-6-17**] 11:50AM   LIPASE-31
[**2155-6-17**] 11:50AM   ALBUMIN-3.2*
[**2155-6-17**] 11:50AM URINE  HOURS-RANDOM
[**2155-6-17**] 11:50AM URINE  GR HOLD-HOLD
[**2155-6-17**] 11:50AM   WBC-11.1* RBC-3.14* HGB-10.8* HCT-30.8*
MCV-98 MCH-34.4* MCHC-35.1* RDW-12.3
[**2155-6-17**] 11:50AM   NEUTS-68.5 LYMPHS-23.3 MONOS-5.1 EOS-2.9
BASOS-0.3
[**2155-6-17**] 11:50AM   PLT COUNT-199
[**2155-6-17**] 11:50AM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.004
[**2155-6-17**] 11:50AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG

CXR [**2155-6-17**]
Single portable view of the chest is compared to previous
outside
exam performed earlier the same day at 6:54 a.m.  There is new
right internal jugular venous catheter whose tip projects over
the upper SVC.  There is no visualized pneumothorax on this film
noting significant rotation.  Right lower lung consolidation is
again seen but better characterized on previous exam suspicious
for pneumonia.  Left lung is grossly clear.

IMPRESSION:  New right IJ line with tip in the upper SVC.  No
visualized
pneumothorax.  Persistent right lower lung consolidation
compatible with
pneumonia.

Micro:
blood cx x2 [**2155-6-17**]: pending

Discharge:

[**2155-6-18**] 05:12AM BLOOD WBC-9.1 RBC-3.48* Hgb-11.5* Hct-33.5*
MCV-96 MCH-32.9* MCHC-34.2 RDW-12.1 Plt Ct-219
[**2155-6-18**] 05:12AM BLOOD Neuts-65.3 Lymphs-21.5 Monos-8.2 Eos-4.9*
Baso-0
[**2155-6-18**] 05:12AM BLOOD Glucose-94 UreaN-15 Creat-0.9 Na-139
K-4.6 Cl-102 HCO3-33* AnGap-9
[**2155-6-18**] 05:12AM BLOOD Calcium-9.0 Phos-3.1 Mg-1.9
[**2155-6-18**] 05:29AM BLOOD Lactate-0.7

Brief Hospital Course:
37M 5 days s/p uncomplicated left L5 MDFH and left L4
foraminotomy for L4-L5 radiculopathy/herniation, discharged
[**2155-6-13**], presents to [**Hospital3 4107**] with 3 day h/o fevers and
chills to 103.7 and cough.

# Hospital Acquired Pneumonia:  Pt recently underwent spinal
surgery and presented to [**Hospital1 18**] with post-op fever and septic
shock.  His CXR showed a new RLL infiltrate and he complains of
cough, making pneumonia most likely diagnosis.  His U/A was
clear, surgical site is clean and he does not have any focal
neuro deficits.  Pt was recently intubated for his procedure,
and as [**First Name8 (NamePattern2) **] [**Hospital1 **] notes, it seems that he was over sedated at
one point requiring narcan, so the possibility of aspiration is
quite high.  Given that he was only intubated for procedure we
treated his pneumonia as a hospital acquired pneumonia, rather
than ventilator acquired pneumonia.  He was initially covered
with vancomycin and levaquin, and on HD2 he was narrowed to po
levaquin.  Pt remained afebrile without o2 requirement and his
leukocytosis resolved.  He was discharged with a 7 day
antibiotic course for hospital acquired pneumonia.

#Septic Shock:  secondary to pneumonia as above.  On
presentation, pt was febrile to 103F, with leukocytosis and
hypotensive to 70s systolic.  He had evidence of end organ
ischemia with lactate of 2.1 and acute kidney injury with
elevated BUN and cr.  He was treated with early goal directed
therapy and initially volume resuscitated with a total of 7
liters of crystalloid.  Initially his blood pressures did not
respond adequately, so he was started on phenylephrine and after
a central line was placed, he was started on norepinephrine.  By
the time he reached the [**Hospital Ward Name 332**] MICU, his blood pressure was
normotensive and vasopressors were discontinued.  His CVP
remained >10 so aggressive volume resuscitation was stopped.
His lactate came down to 0.9 and his acute kidney injury
resolved.  Pt remained normotensive for remainder of [**Hospital Unit Name 153**]
course.

# s/p Laminectomy - currently no neurological deficits,
radiculopathy is actually improved since surgery.  Incision site
was cdi and his dressing was changed as needed.  At time of
discharge, pt still had staples in place and will need to follow
up with his neuro-surgeon for post-op check and staple removal.
He was continued on post-surgical ppx antibiotics
(dicloxicillin) as prescribed by his surgeon.

HTN: Pt's antihypertensive medications were held during
hospitalization due to shock.  At time of discharge, he was
normotensive.  He was instructed to restart his
amlodipine/benazapril, but not to restart his triemtarine/HCTZ
given that he was normotensive at time of discharge.

SVT: bystolic was held as pt initially in shock.  It was
restarted at time of discharge.

Depression/anxiety: continued with venlafaxine and diazepam.

Transitional:
- f/u final blood cultures
- continue for total 7 day course of levaquin
- f/u with neurosurgeon for staple removal and post op check
- will need follow up with PCP within one week of discharge

Medications on Admission:
Nebivolol Hcl (Bystolic) 50 MG PO DAILY
Venlafaxine 150 MG PO DAILY
Triamterene &  Hydrochlorothiaz 1 TAB PO DAILY 25 MG/37.5 MG CAP
Clonazepam (Klonopin) 2 MG PO BID PRN
Diazepam 5MG* (Valium 5MG*)10 MG PO 5XDAY PRN
Hydrocodone-Acetaminophen 1 TAB PO Q4H PRN 10 MG/650 MG
dicloxicillin
amlodipine/benazapril 5/20mg qday

Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation: take for constipation while on
narcotic medications .
Disp:*60 Tablet(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day: take while on narcotic medications .
Disp:*60 Capsule(s)* Refills:*0*
3. methocarbamol 500 mg Tablet Sig: One (1) Tablet PO Q4HR () as
needed for muscle spasm.
4. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
5. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Two (2)
Capsule, Ext Release 24 hr PO DAILY (Daily).
6. clonazepam 2 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Bystolic  Oral
8. Levaquin 750 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
9. amlodipine-benazepril 5-20 mg Capsule Sig: One (1) Capsule PO
once a day.
10. dicloxacillin  Oral


Discharge Disposition:
Home

Discharge Diagnosis:
Septic [**Hospital 21020**]
Hospital Acquired Pneumonia


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


Discharge Instructions:
Dear Mr [**Known lastname **],

You were admitted to [**Hospital1 18**] for septic shock secondary to
pneumonia.  We treated you with aggressive IV fluids and
vasopressor medications to keep your blood pressure at a normal
level and we treated your pneumonia with antibiotics.  We think
that you are now safe to go home.  You will need to continue
antibiotics for an additional 5 days.

We have made the following changes to your home medications:
1. Start Levaquin 750mg by mouth once daily for five days
2. start tylenol 325mg 1-2 tablets every 6hrs for pain
3. hold triamterene/Hydrochlorothiazide 25/37.5mg daily until
you follow up with your primary care doctor
4. start taking senna and colace tablets to prevent narcotic
induced constipation.
5. continue taking dicloxicillin for post-surgical prophylaxis
as prescribed by your surgeon
6. continue with the rest of your home medications

Followup Instructions:
Please follow up with your neurosurgeon at your scheduled
post-op follow up appointment to have your staples removed

Name:[**Name6 (MD) **] [**Last Name (NamePattern4) 112271**], MD
Specialty: Primary Care
Location: COMMUNITY PHYSICIANS ASSOCIATES
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 70678**]
Phone: [**Telephone/Fax (1) 40833**]
When:The office is closed on Wednesdays so please call tomorrow
to set up an appointment in the next week


                             [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
{'Unspecified septicemia,Pneumonia, organism unspecified,Septic shock,Acute kidney failure, unspecified,Severe sepsis,Unspecified essential hypertension,Tobacco use disorder,Dysthymic disorder,Dehydration'}


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: Pneumonia, dehydration

PRESENT ILLNESS: 37M 5 days s/p uncomplicated left L5 MDFH and left L4
foraminotomy for L4-L5 radiculopathy/herniation, discharged
[**2155-6-13**], presents to [**Hospital3 4107**] with 3 day h/o fevers and
chills to 103.7 as well as cough.

MEDICAL HISTORY: SVT ablation
hypertension
anxiety attack
s/p post discectomy

MEDICATION ON ADMISSION: Nebivolol Hcl (Bystolic) 50 MG PO DAILY
Venlafaxine 150 MG PO DAILY
Triamterene &  Hydrochlorothiaz 1 TAB PO DAILY 25 MG/37.5 MG CAP
Clonazepam (Klonopin) 2 MG PO BID PRN
Diazepam 5MG* (Valium 5MG*)10 MG PO 5XDAY PRN
Hydrocodone-Acetaminophen 1 TAB PO Q4H PRN 10 MG/650 MG
dicloxicillin
amlodipine/benazapril 5/20mg qday

ALLERGIES: scallops

PHYSICAL EXAM: 98, hr 62, 145/81, 20, 97% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, 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-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding

FAMILY HISTORY: Father has HTN
Mother MI at 62 yo
2 brothers are well
Maternal grandmother MI at 84 and grandfather at [**Age over 90 **] [**Name2 (NI) **]

SOCIAL HISTORY: Smokes 1 pack per day. Alcohol: occasional.
Recreational Drugs: none. Patient is a PhD in psychology, and
currently sees patients privately at a clinic. 

### Response:
{'Unspecified septicemia,Pneumonia, organism unspecified,Septic shock,Acute kidney failure, unspecified,Severe sepsis,Unspecified essential hypertension,Tobacco use disorder,Dysthymic disorder,Dehydration'}
