CHIEF COMPLAINT: Urosepsis

PRESENT ILLNESS: [**Age over 90 **] yo man with h/o multiple medical problems (including CHF,
HTN, [**Name (NI) 5895**], hypothyroid, Wenckebach heart block s/p DDD
pacer, pernicious anemia, blindness, urinary retention with
indwelling suprapubic catheter) who presents with altered mental
status & hypotension to [**Hospital1 18**]-[**Location (un) 620**], found to have urosepsis
and hydronephrosis, transferred for IR drainage of hydro &
further treatment of his urosepsis.

MEDICAL HISTORY: CHF, LVEF 45%, mild AR, HTN, Parkinson's, hypothyroid,
Wenckebach heart block s/p DDD pacer, pernicious anemia,
bilateral cataracts and blindness, peripheral neuropathy,
psoriasis, gynecomastia, s/p appendectomy, distant C. difficile
colitis, BPH, urinary retention with a chronic indwelling
suprapubic catheter

MEDICATION ON ADMISSION: Meds on transfer:

ALLERGIES: Levofloxacin / Penicillins

PHYSICAL EXAM: VS - 97.6, 71, 109/51 (on levophed drip), 20, 95%-RA
Gen - thin, elderly male, non-verbal & minimally responsive
HEENT - blind, MMM, OP clear
Neck - no JVD, no LAD
CV - RRR, no m/r/g
Pulm - decreased BS at bases, + crackles at bases
Abd - no suprapubic tenderness, suprapubic catheter site c/d/i,
+BS
Ext - L femoral line c/d/i, +1 DP pulse bilat, no c/c/e
Neuro - moves all 4 extremities

FAMILY HISTORY: Unable to obtain from patient.

SOCIAL HISTORY: Per OSH records, pt lives at home with 24-hour caregiver as he
is minimally ambulatory and minimally verbal. Unable to obtain
review of systems on admission. He has obtained the flu vaccine
this season.
Other specified septicemias,Septic shock,Pneumonitis due to inhalation of food or vomitus,Defibrination syndrome,Acute respiratory failure,Acute kidney failure with lesion of tubular necrosis,Chronic systolic heart failure,Acute pyelonephritis without lesion of renal medullary necrosis,Hydronephrosis,Thrombocytopenia, unspecified,Calculus of kidney,Paralysis agitans,Unspecified essential hypertension,Severe sepsis,Pseudomonas infection in conditions classified elsewhere and of unspecified site
Septicemia NEC,Septic shock,Food/vomit pneumonitis,Defibrination syndrome,Acute respiratry failure,Ac kidny fail, tubr necr,Chr systolic hrt failure,Ac pyelonephritis NOS,Hydronephrosis,Thrombocytopenia NOS,Calculus of kidney,Paralysis agitans,Hypertension NOS,Severe sepsis,Pseudomonas infect NOS
Admission Date:  [**2154-12-13**]              Discharge Date:   [**2154-12-21**]


Service: MEDICINE

Allergies:
Levofloxacin / Penicillins

Attending:[**First Name3 (LF) 104950**]
Chief Complaint:
Urosepsis

Major Surgical or Invasive Procedure:
Percutaneous nephrostomy tube placement by IR
Central venous line placement

History of Present Illness:
[**Age over 90 **] yo man with h/o multiple medical problems (including CHF,
HTN, [**Name (NI) 5895**], hypothyroid, Wenckebach heart block s/p DDD
pacer, pernicious anemia, blindness, urinary retention with
indwelling suprapubic catheter) who presents with altered mental
status & hypotension to [**Hospital1 18**]-[**Location (un) 620**], found to have urosepsis
and hydronephrosis, transferred for IR drainage of hydro &
further treatment of his urosepsis.

Past Medical History:
CHF, LVEF 45%, mild AR, HTN, Parkinson's, hypothyroid,
Wenckebach heart block s/p DDD pacer, pernicious anemia,
bilateral cataracts and blindness, peripheral neuropathy,
psoriasis, gynecomastia, s/p appendectomy, distant C. difficile
colitis, BPH, urinary retention with a chronic indwelling
suprapubic catheter

Social History:
Per OSH records, pt lives at home with 24-hour caregiver as he
is minimally ambulatory and minimally verbal. Unable to obtain
review of systems on admission. He has obtained the flu vaccine
this season.


Family History:
Unable to obtain from patient.

Physical Exam:
VS - 97.6, 71, 109/51 (on levophed drip), 20, 95%-RA
Gen - thin, elderly male, non-verbal & minimally responsive
HEENT - blind, MMM, OP clear
Neck - no JVD, no LAD
CV - RRR, no m/r/g
Pulm - decreased BS at bases, + crackles at bases
Abd - no suprapubic tenderness, suprapubic catheter site c/d/i,
+BS
Ext - L femoral line c/d/i, +1 DP pulse bilat, no c/c/e
Neuro - moves all 4 extremities


Pertinent Results:
[**2154-12-13**] 07:40PM BLOOD WBC-18.4*# RBC-3.88* Hgb-13.1* Hct-40.2
MCV-104* MCH-33.7* MCHC-32.5 RDW-13.6 Plt Ct-133*
[**2154-12-13**] 07:40PM BLOOD Neuts-92.6* Bands-0 Lymphs-3.5* Monos-2.9
Eos-0.8 Baso-0.1
[**2154-12-14**] 05:57PM BLOOD WBC-15.8*# RBC-3.23* Hgb-10.9* Hct-33.4*
MCV-103* MCH-33.8* MCHC-32.7 RDW-13.7 Plt Ct-61*
[**2154-12-14**] 05:57PM BLOOD Neuts-89* Bands-10* Lymphs-1* Monos-0
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2154-12-13**] 07:40PM BLOOD PT-15.7* PTT-37.7* INR(PT)-1.5
[**2154-12-14**] 11:45AM BLOOD Fibrino-592* D-Dimer-9886*
[**2154-12-14**] 11:45AM BLOOD FDP-40-80
[**2154-12-13**] 07:40PM BLOOD Glucose-98 UreaN-24* Creat-1.2 Na-141
K-3.8 Cl-109* HCO3-22 AnGap-14
[**2154-12-13**] 07:40PM BLOOD ALT-13 AST-23 LD(LDH)-216 AlkPhos-75
TotBili-0.4
[**2154-12-16**] 08:55AM BLOOD CK-MB-4 cTropnT-0.06*
[**2154-12-13**] 07:40PM BLOOD Albumin-3.0* Calcium-7.5* Phos-2.1*
Mg-1.7
[**2154-12-13**] 08:13PM BLOOD Lactate-2.2*

RADIOLOGY:

[**2154-12-13**]:
CXR - Extensive multifocal patchy consolidations, consistent
with aspiration or pneumonia. Mild congestive heart failure with
a small right pleural effusion.
CT ABD - Severe right hydronephrosis secondary to large
obstructing ureteropelvic junction stone. Two other
non-obstructing right kidney stones are present. Patchy
consolidation in the right lung, concerning for pneumonia.
[**2154-12-14**]:
CXR - Increased interstitial markings in both apices with
clearing of patchy opacity at the right base. While this may
represent congestive failure, the heart is normal in size and
this more likely represents focal infiltrates or aspiration.
IR NEPHROGRAM/NEPHROSTOMY - Antegrade nephrostogram revealed
moderate hydronephrosis with multiple filling defects in the
renal pelvis consistent with one or more stones or clot.
Contrast passes beyond the area of obstruction into the urinary
bladder, where there is a suprapubic catheter present.
Successful placement of an 8 French percutaneous nephrostomy
tube via a right upper pole calyx. The tip of the catheter is
present in the renal pelvis. The catheter was placed to external
bag drainage.
[**2154-12-15**]:
CXR - Since previous exam yesterday morning, there is now
confluent density in the right upper lobe with bilateral pleural
effusions. This suggests aspiration. Patient also appears to be
in failure.

Brief Hospital Course:
SUMMARY OF HOSPITAL COURSE @ [**Hospital1 18**]-[**Location (un) **]:

1. Sepsis: The patient was admitted to the ICU after receiving
      ceftriaxone and ceftazidime in the emergency department.
He quickly
      became increasingly hypotensive and a groin line was
placed in the left
      femoral artery.  Overnight physician notes an art stick
occurred while
      attempting to place femoral catheter in the right groin.
There were no
      hematomas noted.
      After IV access was obtained, the patient was started on
Levophed for
      pressure support.  He also received aggressive fluid
resuscitation  with
      a total of 4 liters of IV fluids.  The patient was
continued on
      ceftazidime for IV antibiotics.  ID consult was obtained
and agreed with
      this for now pending further culture data.  The patient's
temperature
      curve continued to go down, however, repeat white count
was 22,000.
2. UTI: Due to the likelihood that UTI was the source of his
bacteremia,
      urologic consultation was obtained. The suprapubic
catheter was flushed
      and irrigated easily.  Abdominal ultrasound was obtained,
which reveals
      marked right hydronephrosis. Initial plan after speaking
with in town
      urology was to proceed with CT to assess for level of
obstruction.
      However, once Dr. [**First Name (STitle) 391**] could be reached, given the
patient's  poor
      respiratory status and DNR/DNI status, a decision was made
to transfer
      into [**Location (un) 86**] for IR placement of percutaneous drain to
drain infection
      and to avoid CT scan at this point. This was discussed
with the
      patient's family and they were in agreement with the plan.
3. Respiratory status: The patient, after aggressive fluid
      resuscitation, chest x-ray shows some mild pulmonary
edema. He continues
      to sat well with a face mask of oxygen on 10 liters of the
Venti-mask.
      His volume status should be watched closely as he is
DNR/DNI.
4. Acute renal failure: The patient's baseline creatinine is
1.1. On
      admission labs, his creatinine was 1.4 and the following
morning,
      remains elevated at 1.5. There is concern for development
of ATN (acute
      tubular necrosis) due to an hour or so of hypotension.
However, the
      patient remains with good urine output at this point.
5.  FEN (fluids, electrolytes, nutrition): Due the patient's
poor
      mental status, NG tube was placed to provide PO
medications. Tube feeds
      have not been begun and he has remained NPO. His
electrolytes have been
      repleted.

SUMMARY OF HOSPITAL COURSE @ [**Hospital1 18**]:

Pt admitted to MICU on [**2154-12-13**] with urosepsis secondary to
urinary obstruction, hypotension requiring pressors, aspiration
pneumonia, & coagulopathy.  Pt was continued on broad spectrum
antibiotics, received fluids & pressors for hypotension,
transfusion of blood products for coagulopathy, had central
venous line placed, and IR placement of nephrostomy tube to
relieve urinary obstruction.  On [**2154-12-15**], the MICU team met
with the pt's family & PCP [**Name Initial (PRE) **] [**Name10 (NameIs) **] aggressive treatment, there
had been no significant improvement in pt's condition, at this
time the family decided to change treatment to comfort measures
only (CMO), discontinuing pressors & aggressive treatment
although continuing with antibiotics.  Pt transferred to the
medicine wards on [**2154-12-16**] with CMO, d/c'ing antibiotics & IVF,
morphine boluses prn.  Pt continued to become more unresponsive
over the next couple days.  Discussed option of home hospice
with family, but it had been pt's desire to remain in hospital.
Pt expired & was pronounced dead on [**2154-12-21**] at 0920.  Pt's
family declined autopsy & made arrangements for body to be
donated to the medical school per pt's wishes.

Medications on Admission:
Meds on transfer:

Xalatan 0.005 percent one drop left eye at night, Lacrilube to
both eyes
t.i.d., Levophed drip, Nystatin powder to groin t.i.d.,
ceftazidime 1
gram q.12, subcutaneous heparin 5000 b.i.d., Isopto Carbachol
drop 0.75
percent left eye t.i.d., Cosopt drop one drop left eye b.i.d.,
aspirin
81 mg a day, Lactulose b.i.d., multivitamin 1 a day, Provigil
200 per G
tube q.a.m., carbidopa 25/100 one PO t.i.d., carbidopa 25/100
[**1-18**] 7 PM,
Ritalin 2.5 mg b.i.d., Tylenol p.r.n.


Discharge Medications:
n/a

Discharge Disposition:
Expired

Discharge Diagnosis:
Urosepsis
Urolithiasis with obstruction & hydronephrosis
Aspiration pneumonia
Coagulopathy
Renal failure
CHF
Parkinson's

Discharge Condition:
Deceased

Discharge Instructions:
n/a

Followup Instructions:
n/a
{'Other specified septicemias,Septic shock,Pneumonitis due to inhalation of food or vomitus,Defibrination syndrome,Acute respiratory failure,Acute kidney failure with lesion of tubular necrosis,Chronic systolic heart failure,Acute pyelonephritis without lesion of renal medullary necrosis,Hydronephrosis,Thrombocytopenia, unspecified,Calculus of kidney,Paralysis agitans,Unspecified essential hypertension,Severe sepsis,Pseudomonas infection in conditions classified elsewhere and of unspecified site'}


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: Urosepsis

PRESENT ILLNESS: [**Age over 90 **] yo man with h/o multiple medical problems (including CHF,
HTN, [**Name (NI) 5895**], hypothyroid, Wenckebach heart block s/p DDD
pacer, pernicious anemia, blindness, urinary retention with
indwelling suprapubic catheter) who presents with altered mental
status & hypotension to [**Hospital1 18**]-[**Location (un) 620**], found to have urosepsis
and hydronephrosis, transferred for IR drainage of hydro &
further treatment of his urosepsis.

MEDICAL HISTORY: CHF, LVEF 45%, mild AR, HTN, Parkinson's, hypothyroid,
Wenckebach heart block s/p DDD pacer, pernicious anemia,
bilateral cataracts and blindness, peripheral neuropathy,
psoriasis, gynecomastia, s/p appendectomy, distant C. difficile
colitis, BPH, urinary retention with a chronic indwelling
suprapubic catheter

MEDICATION ON ADMISSION: Meds on transfer:

ALLERGIES: Levofloxacin / Penicillins

PHYSICAL EXAM: VS - 97.6, 71, 109/51 (on levophed drip), 20, 95%-RA
Gen - thin, elderly male, non-verbal & minimally responsive
HEENT - blind, MMM, OP clear
Neck - no JVD, no LAD
CV - RRR, no m/r/g
Pulm - decreased BS at bases, + crackles at bases
Abd - no suprapubic tenderness, suprapubic catheter site c/d/i,
+BS
Ext - L femoral line c/d/i, +1 DP pulse bilat, no c/c/e
Neuro - moves all 4 extremities

FAMILY HISTORY: Unable to obtain from patient.

SOCIAL HISTORY: Per OSH records, pt lives at home with 24-hour caregiver as he
is minimally ambulatory and minimally verbal. Unable to obtain
review of systems on admission. He has obtained the flu vaccine
this season. 

### Response:
{'Other specified septicemias,Septic shock,Pneumonitis due to inhalation of food or vomitus,Defibrination syndrome,Acute respiratory failure,Acute kidney failure with lesion of tubular necrosis,Chronic systolic heart failure,Acute pyelonephritis without lesion of renal medullary necrosis,Hydronephrosis,Thrombocytopenia, unspecified,Calculus of kidney,Paralysis agitans,Unspecified essential hypertension,Severe sepsis,Pseudomonas infection in conditions classified elsewhere and of unspecified site'}
