CHIEF COMPLAINT: Septic shock
Left lower lobe pneumonia

PRESENT ILLNESS: 72 year old NH resident who presented with increased shortness
of breath and fever.  Patient comes with almost no information.
Per report from the nurse who found him this a.m., his temp was
104, systolic 95, HR 101.  He was given NEBs and transported to
[**Hospital1 18**] ED.

MEDICAL HISTORY: CVA
Organic brain syndrome
Bronchitis
Adenomatous polyps:  Colonoscopy [**8-5**] with adenomatous polyp,
removed.

MEDICATION ON ADMISSION: Deep Sea nasal spray TID
Paroxetine 30 mg PO [**Location (un) **]
Zyprexa 2.5 mg PO [**Name (NI) **]
MOM 30 ML QDay PRN
Guaifenesin 100mg Q6 hours PRN
Tylenol 650 mg PO Q4 hours PRN
Trazodone 50 mg PO [**Name (NI) **] PRN
Liquid vitamin Qday
Vitamin B12 1000mcg IM QMonth
Flonase 2 sprays QDay
Pseudoephedrine 30 mg PO QAM
Colace 100 mg PO BID

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Gen:  Slim asian male appearing tachypneic, with accessory
muscle use.
HEENT:  R pupil slightly larger than L, both minimally reactive.
 Anicteric sclerae.
Neck:  Distended EJ, IJ difficult to localize.  L IJ central
venous catheter in place.
Cor: RR, tachycardic, no m/r/g.
Lungs:  tachypneic, coarse, rhonchi b/l diffusely.
Abd: Hypoactive bowel sounds, soft, NT/ND.
Extr:  No c/c/e.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Resident of [**Hospital3 2558**].  Remainder unknown.  Per nurse, no
family.  Has a guardian.
Pneumonitis due to inhalation of food or vomitus,Congestive heart failure, unspecified,Acute kidney failure with lesion of tubular necrosis,Hematemesis,Hyperosmolality and/or hypernatremia,Urinary tract infection, site not specified,Nonspecific abnormal findings in stool contents,Other specified cardiac dysrhythmias,Unspecified nonpsychotic mental disorder following organic brain damage,Unspecified septicemia,Septic shock,Acute and chronic respiratory failure,Pneumonia, organism unspecified
Food/vomit pneumonitis,CHF NOS,Ac kidny fail, tubr necr,Hematemesis,Hyperosmolality,Urin tract infection NOS,Abn find-stool contents,Cardiac dysrhythmias NEC,Nonpsychot brain syn NOS,Septicemia NOS,Septic shock,Acute & chronc resp fail,Pneumonia, organism NOS
Admission Date:  [**2165-10-14**]              Discharge Date:   [**2165-11-1**]

Date of Birth:  [**2093-2-24**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 5827**]
Chief Complaint:
Septic shock
Left lower lobe pneumonia


Major Surgical or Invasive Procedure:
Central line placement in ED
Intubation


History of Present Illness:
72 year old NH resident who presented with increased shortness
of breath and fever.  Patient comes with almost no information.
Per report from the nurse who found him this a.m., his temp was
104, systolic 95, HR 101.  He was given NEBs and transported to
[**Hospital1 18**] ED.

In ED, vitals were T 104.8, P 161, BP 107/68, RR 36, 92% on 6L
NC. His labs were notable for a lactate of 5.3.  Pt. met
criteria for septic shock with the source mostly likely
pneumonia given his CXR demonstrated a LLL PNA.  Blood and urine
cultures were sent, and he was given flagyl, vanco, and levaquin
for empiric broad spectrum coverage.

An ABG in the ED came back 7.03/75/210; he was intubated with
etomidate and succinylcholine.  He subsequently dropped his
pressures to 50s systolic and was started on levophed and
subsequently vasopressin.  CVP was 18.  Pt. was in the MICU for
a week and zosyn was started.  Pt. was extubated successfuly.
Pt. was called out from the MICU on [**10-20**] to the floor and was
being diuresed for fluid overload, along with continued
treatment for pneumonia.


Past Medical History:
CVA
Organic brain syndrome
Bronchitis
Adenomatous polyps:  Colonoscopy [**8-5**] with adenomatous polyp,
removed.

Social History:
Resident of [**Hospital3 2558**].  Remainder unknown.  Per nurse, no
family.  Has a guardian.


Family History:
Non-contributory

Physical Exam:
Gen:  Slim asian male appearing tachypneic, with accessory
muscle use.
HEENT:  R pupil slightly larger than L, both minimally reactive.
 Anicteric sclerae.
Neck:  Distended EJ, IJ difficult to localize.  L IJ central
venous catheter in place.
Cor: RR, tachycardic, no m/r/g.
Lungs:  tachypneic, coarse, rhonchi b/l diffusely.
Abd: Hypoactive bowel sounds, soft, NT/ND.
Extr:  No c/c/e.


Pertinent Results:
Studies:
CXR ([**10-29**]): IMPRESSION: AP and lateral chest compared to earlier
on [**10-29**]: This study does not confirm the impression of
the bedside study that small nodules have developed in the
lungs. It does show persistent severe consolidation in the left
lower lobe due to partially resolved pneumonia. Heart is top
normal size, but there is no pulmonary edema or appreciable
right pleural effusion. Nasogastric tube passes into the upper
stomach. No pneumothorax
.
Swallow Study: profound oral defecits with silent aspiration
RECOMMENDATIONS:
1.NPO at this time with consideration for PEG tube for
nutrition and medications.
2.Follow up with palliative care team re: above issues.
3.Strongly consider use of nocturnal enteral nutrition
while maintaining small amounts of po's. At this time, if
this is pursued, would still suggest pureed solids and
nectar thick liquids. Avoid taking larger bites of purees.
Provide oral suctioning as needed. Pt should remain upright
for all po's and for 30 minutes after po feedings.
.
CXR ([**10-28**]): NGT in acceptable position, improvement in LLL
pneumonia and CHF
.
Repeat CXR ([**10-24**]) after NGT adjustment - tube in antrum of
stomach
.
CXR ([**10-24**]): NG tube has migrated proximally to the distal
esophagus. Mild congestive failure, bilateral small pleural
effusions, left lower lobe consolidation are not significantly
changed. There is no pneumothorax. Central venous line from left
internal jugular vein approach is in stable position.

CXR:LLL infiltrate
.
C. diff toxin - negative
Urine ctx ([**10-14**] and [**10-16**]) - no growth
Blood ctx ([**10-14**] and [**10-16**])- no growth in either aerobic/anaerobic
Urine serology ([**10-14**]) - no legionella antigen
.
ACID FAST SMEAR (Final [**2165-10-16**]):
      NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
      NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Pending):
.
Stool studies - No salmonella/shigella.
C. Diff negative ([**10-17**] and [**10-19**])

URINE:
[**2165-10-14**] URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.023 Blood-NEG
Nitrite-NEG Protein-30 Glucose-1000 Ketone-NEG Bilirub-NEG
Urobiln-NEG pH-5.0 Leuks-TR RBC-0-2 WBC-[**12-22**]* Bacteri-MOD
Yeast-NONE Epi-0

URINE CULTURE (Final [**2165-10-15**]):    NO GROWTH.

Legionella Urinary Antigen  (Final [**2165-10-15**]):
      NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.

BLOOD:
AEROBIC BOTTLE (Final [**2165-10-20**]):    NO GROWTH.

   ANAEROBIC BOTTLE (Final [**2165-10-20**]):    NO GROWTH.

SPUTUM:
GRAM STAIN (Final [**2165-10-14**]):
      >25 PMNs and <10 epithelial cells/100X field.
      4+   (>10 per 1000X FIELD):   BUDDING YEAST WITH
PSEUDOHYPHAE.
      3+  (5-10 per 1000X FIELD):   MULTIPLE ORGANISMS
CONSISTENT WITH
                                    OROPHARYNGEAL FLORA.

   RESPIRATORY CULTURE (Final [**2165-10-16**]):
      MODERATE GROWTH OROPHARYNGEAL FLORA.
      YEAST.    MODERATE GROWTH.
      GRAM NEGATIVE ROD(S).    SPARSE GROWTH.

   LEGIONELLA CULTURE (Preliminary):    NO LEGIONELLA ISOLATED.

   ACID FAST SMEAR (Final [**2165-10-16**]):
      NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
      NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.

   ACID FAST CULTURE (Pending):

STOOL:
FECAL CULTURE (Final [**2165-10-19**]):
      NO ENTERIC GRAM NEGATIVE RODS FOUND.
      NO SALMONELLA OR SHIGELLA FOUND.

   CAMPYLOBACTER CULTURE (Final [**2165-10-19**]):    NO CAMPYLOBACTER
FOUND.

   CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2165-10-17**]):
      FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
      Reference Range:  Negative.

CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2165-10-20**]):
      FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
      Reference Range:  Negative.

RADIOLOGY:
[**10-14**] PORTABLE CHEST:  There is a new large left lower lobe
airspace consolidation that likely represents pneumonia.

CHEST US:  IMPRESSION: Trace bilateral pleural effusions and
lower lobe
consolidation/atelectasis. The pleural effusions are too small
for
thoracentesis.

Brief Hospital Course:
72 year old male with unknown medical history, who presented
with fever, elevated lactate, tachypnea, PNA on CXR, and
hypotension.

1) Septic Shock:  Met criteria based on lactate, fever,
tachypnea and hypotension with presumed source being his large
LLL PNA.  He was placed on sepsis protocol in the ED with 2
pressor requirement after intubation, and admitted to the MICU.
His lactate trended down with continued aggressive fluid
resuscitation and he was able to come off pressors after 2 days.
 He had a cortisol stimulation test on arrival to which he did
not appropriately stim; he was therefore placed on a course of
hydrocortisone and fludrocortisone for 7 days.  Pt. was
successfully intubated on [**10-18**] and went to the floor on [**10-20**].

2) PNA:  He had a dense LLL consolidation on admission, and
received vanco, levaquin, and flagyl in the ED.  On arrival to
the MICU he was changed from flagyl to zosyn to provide broader
coverage given that he is a nursing home resident, and continued
on levaquin and vanco.  Levaquin was discontinued after his
urine legionella antigen was negative.  Vancomycin was
discontinued after sputum cultures failed to demonstrate any
gram positives.  He completed a 14 day course of zosyn in house.
 The resolution of his PNA on CXR lagged behind his clinical
improvement.  Pt. seemed to improve while he was on the floor,
but his xrays only moderately improved and pt. remained
tachypneic.  This may have also been due to fluid overload.

3) Volume status - Pt. had received over 22 liters during
aggressive resuscitation in the MICU.  When he came to the floor
he was diuresed.  CXRs showed gradual improvement, but pt.
continued to have some element of respiratory distress.

4) GI: Pt. had an episode of coffee ground emesis with guiac +
stool.  It was suspected that pt. had an UGI bleed, but given
his fragile state and respiratory compromise - discussion w/
guardian - decided not to get EGD or colonoscopy.  Pt. was on IV
PPI.and received 2 units PRBCs.  Pt's heparin was held at this
point to avoid lethal GI bleed.  Pt. had pneumoboots on.

5) CV - Pt. becames tachycardic on [**10-29**].  Was fluid challenged
b/c he looked dry, but this had no effect.  An EKG showed a
sinus tachycardia.  This along w/ respiratory distress led the
team to consider a PE. However, given pt's weakened condition
and discussion w/ guardian.  [**Name (NI) **] intervention or further studies
were performed.

6) Hypercarbic respiratory failure:  His A-a gradient on
admission was 395, and his hypercarbia was thought secondary to
VQ mismatch from his large LLL PNA.  He was intubated for 6 days
and successfully extubated on [**10-20**].  He unfortunately did not
have DNR/DNI papers with him on arrival to the ED prior to
intubation.  In discussion with his guardian he was indeed found
to be DNR/DNI and it was decided not to reintubate if he failed
his extubation.

7) Acute renal failure:  Creatinine was up to 2.1 on admission,
with recent baseline of around 1.1.  This was thought pre-renal
in the setting of sepsis and hypoperfusion, and his creatinine
returned to baseline with fluid resuscitation. this resolved on
the floor.

8) Swallow Evaluation:  Pt. failed two swallow studies and it
was decided that he need a PEG tube, however, given his
respiratory distress, GI did not want to do the procedure, so
pt. was given TF through an NG.  At the end of his hospital stay
it was decided that pt. was possibly having micro-aspirations
along with an episode of coffee ground emesis, so TF were held.

9) Hypernatremia:  He received free water boluses with tube
feeds, with normalization of his sodium.  This resolved on the
floor.

10) Troponin elevation:  His troponin was mildly elevated in the
setting of renal failure with a normal CK-MB and no EKG changes,
therefore it was felt unlikely to be an acute coronary syndrome.
 His troponin trended down.

11) On [**10-31**] per a discussion w/ patient's guardians and
continued complications including GI bleed, cont. resp.
distress, tachycardia, inability to place PEG, along with
possible PE, it was decided pt. would prefer to be comfort care
only. Pt. to be d/c to [**Location (un) **] house for end of life care.

Medications on Admission:
Deep Sea nasal spray TID
Paroxetine 30 mg PO [**Location (un) **]
Zyprexa 2.5 mg PO [**Name (NI) **]
MOM 30 ML QDay PRN
Guaifenesin 100mg Q6 hours PRN
Tylenol 650 mg PO Q4 hours PRN
Trazodone 50 mg PO [**Name (NI) **] PRN
Liquid vitamin Qday
Vitamin B12 1000mcg IM QMonth
Flonase 2 sprays QDay
Pseudoephedrine 30 mg PO QAM
Colace 100 mg PO BID


Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
2. Albuterol Sulfate 0.083 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
3. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q4-6H (every 4 to 6 hours) as needed for fever or pain.
4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for agitation.
5. Morphine Concentrate 20 mg/mL Solution Sig: One (1)  PO Q1-2H
() as needed for respiratory distress.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 2558**] - [**Location (un) **]

Discharge Diagnosis:
Septic shock
Pneumonia
Tachycardia
Fluid Overload
Hypernatremia
Gastrointestinal bleed


Discharge Condition:
Guarded


Discharge Instructions:
We have stopped all your medications except medications for
comfort.  If pt's disposition changes and pt. no longer is
comfort care he should go to the emergency room or call the
primary care physician for chest pain, shortness of breath,
nausea, vomitig, fevers, chills or any other changes in the
medical condition.

Followup Instructions:
Patient call follow up with Dr. [**Last Name (STitle) 6680**] as needed at [**Telephone/Fax (1) 5828**].
{'Pneumonitis due to inhalation of food or vomitus,Congestive heart failure, unspecified,Acute kidney failure with lesion of tubular necrosis,Hematemesis,Hyperosmolality and/or hypernatremia,Urinary tract infection, site not specified,Nonspecific abnormal findings in stool contents,Other specified cardiac dysrhythmias,Unspecified nonpsychotic mental disorder following organic brain damage,Unspecified septicemia,Septic shock,Acute and chronic respiratory failure,Pneumonia, organism unspecified'}


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: Septic shock
Left lower lobe pneumonia

PRESENT ILLNESS: 72 year old NH resident who presented with increased shortness
of breath and fever.  Patient comes with almost no information.
Per report from the nurse who found him this a.m., his temp was
104, systolic 95, HR 101.  He was given NEBs and transported to
[**Hospital1 18**] ED.

MEDICAL HISTORY: CVA
Organic brain syndrome
Bronchitis
Adenomatous polyps:  Colonoscopy [**8-5**] with adenomatous polyp,
removed.

MEDICATION ON ADMISSION: Deep Sea nasal spray TID
Paroxetine 30 mg PO [**Location (un) **]
Zyprexa 2.5 mg PO [**Name (NI) **]
MOM 30 ML QDay PRN
Guaifenesin 100mg Q6 hours PRN
Tylenol 650 mg PO Q4 hours PRN
Trazodone 50 mg PO [**Name (NI) **] PRN
Liquid vitamin Qday
Vitamin B12 1000mcg IM QMonth
Flonase 2 sprays QDay
Pseudoephedrine 30 mg PO QAM
Colace 100 mg PO BID

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Gen:  Slim asian male appearing tachypneic, with accessory
muscle use.
HEENT:  R pupil slightly larger than L, both minimally reactive.
 Anicteric sclerae.
Neck:  Distended EJ, IJ difficult to localize.  L IJ central
venous catheter in place.
Cor: RR, tachycardic, no m/r/g.
Lungs:  tachypneic, coarse, rhonchi b/l diffusely.
Abd: Hypoactive bowel sounds, soft, NT/ND.
Extr:  No c/c/e.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Resident of [**Hospital3 2558**].  Remainder unknown.  Per nurse, no
family.  Has a guardian. 

### Response:
{'Pneumonitis due to inhalation of food or vomitus,Congestive heart failure, unspecified,Acute kidney failure with lesion of tubular necrosis,Hematemesis,Hyperosmolality and/or hypernatremia,Urinary tract infection, site not specified,Nonspecific abnormal findings in stool contents,Other specified cardiac dysrhythmias,Unspecified nonpsychotic mental disorder following organic brain damage,Unspecified septicemia,Septic shock,Acute and chronic respiratory failure,Pneumonia, organism unspecified'}
