CHIEF COMPLAINT: Asystolic arrest

PRESENT ILLNESS: Patient is a [**Age over 90 **]yo M s/p asystolic arrest who presents from OSH
fro therapeutic hypothermia post cardiac arrest.

MEDICAL HISTORY: --CHF
--HTN
--BPH
--TIA
--Decubitus ulcer

MEDICATION ON ADMISSION: --ASA 325mg daily
--Carvedilol 12.5mg [**Hospital1 **]
--Digoxin 125mcg daily
--Lasix 10mg daily
--Levaquin 500mg daily
--Lisinopril 5mg daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission:
General: Unresponsive, diffusely cool, no pupilalry or corneal
reflexes
HEENT: ETT in place, pupils nonreactive
Cor: RRR, no murmurs
Lungs: CTAB anteriorly
Abd: soft, nondistended
Ext: cool

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Lives at home with his family being responsible for his care.
Non-smoker. No EtOH.
Unspecified septicemia,Acute respiratory failure,Septic shock,Pneumonitis due to inhalation of food or vomitus,Acute and subacute necrosis of liver,Pressure ulcer, stage IV,Anoxic brain damage,Acute kidney failure, unspecified,Chronic systolic heart failure,Hyposmolality and/or hyponatremia,Other and unspecified coagulation defects,Unspecified protein-calorie malnutrition,Severe sepsis,Cardiac arrest,Unspecified essential hypertension,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Thrombocytopenia, unspecified,Encounter for palliative care
Septicemia NOS,Acute respiratry failure,Septic shock,Food/vomit pneumonitis,Acute necrosis of liver,Pressure ulcer, stage IV,Anoxic brain damage,Acute kidney failure NOS,Chr systolic hrt failure,Hyposmolality,Coagulat defect NEC/NOS,Protein-cal malnutr NOS,Severe sepsis,Cardiac arrest,Hypertension NOS,BPH w/o urinary obs/LUTS,Thrombocytopenia NOS,Encountr palliative care
Admission Date:  [**2104-6-28**]              Discharge Date:   [**2104-7-4**]


Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
Asystolic arrest

Major Surgical or Invasive Procedure:
IJ CVL placement


History of Present Illness:
Patient is a [**Age over 90 **]yo M s/p asystolic arrest who presents from OSH
fro therapeutic hypothermia post cardiac arrest.

[**Name (NI) **] son reports that in the days prior to admission, he
was having more 'cold' (a productive cough). [**Name (NI) **] son also
reports vomiting and difficulty maintaining PO intake. Patient
was on Levaquinn for treatment of UTI; he completed a coure
approximately 2 days ago.

Per report the patient was last noted to have received a cup of
something to drink from a home health-aid and then went to bed.
Reportedly, 30 minutes later, the patient was found in his bed
unresponsive. His family began chest compressions and EMS was
called. He received epinephrine times 3 in the field and was
intubated. He was then transferred to [**Hospital3 **]. At [**Hospital1 **], he was started on Levophed. Upon starting Levophed,
the patient's SBP at OSH was noted to be in the 140s. He was
then transferred to [**Hospital1 18**] for therapeutic hypothermia post
cardiac arrest.

In the [**Hospital1 18**] ED, the patient was noted to be breathing over the
vent. He was given Fentanyl and midazolam boluses. A bedside
ECHO in the ED showed an EF of approximately 10%. Exam was
notable for a lack of corneal reflexes as well as a gag.  Pupils
were noted to be fixed and dialted.  Post-arrest team was
consulted in the ED. CXR in the ED was notable for right LL
opacity concerning for aspiration PNA. An A-line was placed in
the ED. For access: PIV in EJ, R femoral line, and Left IO.
Patient had a head CT that showed no evidence of acute bleed.
Levophed was able to be weaned to 0.03mcg/mg/min and dopamine
was started. The patient maintained MAPs in the 60s on the
combination of dopamine and Levophed.

On arrival to the MICU, the patient is intubated. He is on
Levophed 0.1mcg/kg/min.


Past Medical History:
--CHF
--HTN
--BPH
--TIA
--Decubitus ulcer


Social History:
Lives at home with his family being responsible for his care.
Non-smoker. No EtOH.

Family History:
Non-contributory

Physical Exam:
Admission:
General: Unresponsive, diffusely cool, no pupilalry or corneal
reflexes
HEENT: ETT in place, pupils nonreactive
Cor: RRR, no murmurs
Lungs: CTAB anteriorly
Abd: soft, nondistended
Ext: cool

Discharge: expired


Pertinent Results:
[**2104-6-28**] 11:15PM BLOOD WBC-6.5 RBC-3.42* Hgb-8.6* Hct-30.1*
MCV-88 MCH-25.2* MCHC-28.6* RDW-17.2* Plt Ct-159
[**2104-6-30**] 04:13AM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-2+
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Burr-2+ Acantho-1+
[**2104-6-28**] 11:15PM BLOOD PT-26.8* PTT-49.0* INR(PT)-2.6*
[**2104-6-28**] 11:15PM BLOOD Fibrino-219
[**2104-6-29**] 03:32AM BLOOD Glucose-126* UreaN-20 Creat-1.1 Na-126*
K-3.7 Cl-94* HCO3-17* AnGap-19
[**2104-6-29**] 03:32AM BLOOD ALT-113* AST-295* LD(LDH)-530*
CK(CPK)-545* AlkPhos-150* Amylase-128* TotBili-0.9
[**2104-6-28**] 11:15PM BLOOD Lipase-5
[**2104-6-28**] 11:15PM BLOOD cTropnT-0.33*
[**2104-6-29**] 03:32AM BLOOD CK-MB-25* MB Indx-4.6 cTropnT-0.41*
[**2104-6-29**] 10:15AM BLOOD CK-MB-36* MB Indx-5.6 cTropnT-0.41*
[**2104-6-29**] 10:10PM BLOOD CK-MB-49* MB Indx-7.7* cTropnT-0.35*
[**2104-6-30**] 04:13AM BLOOD CK-MB-50* MB Indx-9.7*
[**2104-7-1**] 02:45AM BLOOD CK-MB-20* MB Indx-10.5* cTropnT-0.38*
[**2104-6-29**] 03:32AM BLOOD Albumin-2.0* Calcium-7.4* Phos-2.6*
Mg-1.6
[**2104-7-1**] 03:28PM BLOOD Hapto-95
[**2104-6-29**] 03:32AM BLOOD Osmolal-267*
[**2104-6-29**] 10:15AM BLOOD TSH-1.5
[**2104-6-30**] 02:06PM BLOOD T3-49* Free T4-0.84*
[**2104-7-1**] 03:28PM BLOOD Cortsol-44.4*
[**2104-6-28**] 11:15PM BLOOD Digoxin-0.8*
[**2104-6-30**] 04:13AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2104-6-28**] 11:33PM BLOOD Type-ART Rates-20/10 PEEP-5 FiO2-100
pO2-46* pCO2-69* pH-7.10* calTCO2-23 Base XS--10 AADO2-604 REQ
O2-98 -ASSIST/CON Intubat-INTUBATED
[**2104-6-28**] 11:23PM BLOOD Glucose-139* Lactate-7.3* Na-125* K-4.6
Cl-97 calHCO3-21
[**2104-7-1**] 09:05PM URINE Hours-RANDOM Na-63 K-12 Cl-50
[**2104-7-1**] 09:05PM URINE Osmolal-162

[**2104-6-28**] 11:58 pm BLOOD CULTURE

   Blood Culture, Routine (Preliminary):
      STAPH AUREUS COAG +.
         Consultations with ID are recommended for all blood
cultures
         positive for Staphylococcus aureus, yeast or other
fungi.
         FINAL SENSITIVITIES.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations.

         Rifampin should not be used alone for therapy.
      ENTEROCOCCUS FAECALIS.    FINAL SENSITIVITIES.
         Daptomycin Sensitivity testing performed by Etest.
         Daptomycin = 1.0 MCG/ML.  BETA LACTAMASE NEGATIVE.
         HIGH LEVEL GENTAMICIN SCREEN: Resistant to 500 mcg/ml
of
         gentamicin. Screen predicts NO synergy with penicillins
or
         vancomycin. Consult ID for treatment options.
         HIGH LEVEL STREPTOMYCIN SCREEN: Resistant to 1000mcg/ml
of
         streptomycin. Screen predicts NO synergy with
penicillins or
         vancomycin.  Consult ID for treatment options.  .
      GRAM VARIABLE RODS.    ANAEROBIC.  UNABLE TO FURTHER
IDENTIFY.
      ANAEROBIC GRAM NEGATIVE ROD(S).

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |          ENTEROCOCCUS FAECALIS
                             |          |
AMPICILLIN------------              <=2 S
CLINDAMYCIN-----------   =>8 R
DAPTOMYCIN------------                  S
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
PENICILLIN G----------                8 S
RIFAMPIN-------------- <=0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------     1 S        1 S

TTE: The left atrium is normal in size. The interatrial septum
is bowed towards the left atrium c/w increased RA pressure.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is severe global left ventricular
hypokinesis. Quantitative (biplane) LVEF = 18 %. No masses or
thrombi are seen in the left ventricle.The right ventricular
cavity is mildly dilated with moderate global free wall
hypokinesis. There is abnormal diastolic septal motion/position
consistent with right ventricular volume overload. The number of
aortic valve leaflets cannot be determined. The aortic valve
leaflets are moderately thickened. The study is inadequate to
exclude significant aortic valve stenosis, but severe stenosis
is not suggested. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate ([**12-17**]+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. Symmetric left ventricular
hypertrophy and right ventricular cavity enlargement with global
biventricular hypokinesis. Mild-moderate mitral regurgitation.
Pulmonary artery hypertension.

NCHCT: 1.  No acute hemorrhage or mass effect. White matter
hypodense areas.
Subtle/equivocal loss of the [**Doctor Last Name 352**]-white matter differentiation
is compatible
with known history of prolonged cardiac arrest. Consider MRI if
not CI if
clinically indicated for better assessment of infarction.
2.  Moderate paranasal sinus disease.

EEG: This is an abnormal continuous ICU monitoring study because
of
burst suppression pattern. The bursts consist of [**12-16**].5 Hz high
amplitude
delta with superimposed [**4-20**] Hz theta activity lasting one to two
seconds and
the interburst interval varies from 10 seconds to several
minutes. In the
last few hours of the study, the bursts become more frequent
lasting four to
six seconds. These findings are indicative of very severe
diffuse cerebral
dysfunction likely due to anoxic insult to the brain in the
context of cardiac
arrest. No electrographic seizures are recorded. Compared to the
prior day's
EEG, the bursts have become frequent lasting four to six
seconds.

Renal U/S: Technically limited study showing no hydronephrosis
or stones in
the right kidney.  Views of the left kidney show no gross
hydronephrosis but
are technically inadequate.  Pelvic ascites is noted.


Brief Hospital Course:
[**Age over 90 **]yo M s/p asystolic arrest times 2 transferred from OSH for
hypothermic protocol and further management.

# s/p asystolic arrest: Likely developed in the setting of
aspiration PNA. The patient was hypothermic without active
cooling at admission and required active re-warming and
continued warming pads after re-warming to maintain physiologic
temp. Only evidence of neurologic activity was occasionally
overbreathing the vent, no pupillary or corneal reflexes upon
rewarming. CT head at admission showed possible early loss of
[**Doctor Last Name 352**] white matter differentiation. EEG showed at first burst
suppression but eventually showed no brainwave activity.
Multiple family meetings were held with the son and daughters
and the patient was eventually transitioned to focusing on
comfort and expired soon after pressors were withdrawn.

# Shock: Patient required [**1-18**] pressors throughout ICU admission,
likely multifactorial from cardiogenic shock with very low LVEF
and possible RV strain with [**Last Name (un) 13367**] sign, also with septic
shock component with multiple organisms in the blood. Femoral
line pulled and IJ CVL placed. He was put on broad spectrum
antibiotics with Vanc/Zosyn at admission for possile aspiration
PNA. He was empirically started on a heparin gtt for possible PE
based on RV findings on TTE. He was very sensitive to heparin
dosing and heme/onc was consulted and recommended Vit K to
improve therapeutic range of heparin, INR. He became immediately
hypotensive when pressors were stopped. Outpt. CHF regimen of
beta blocker, lasix, ACEI held. Endocrine consulted for concern
for hypothyroid causing myxedema given high TSH but felt this
likely represented sick euthyroid.

# [**Last Name (un) **]: Cr elevated and continued to trend up with minimal/no
urine output. Renal was consulted but he was not felt to be a
candidate for RRT.

# Decubitus ulcers: Patient with 3 stageable decubitus ulcers on
his sacrum, left heel, and right shin.  Wound was consulted.

# Foley trauma: Pt. required urology to place Foley under
cystoscopy using Seldinger technique. He developed worsening
penile and scrotal edema in setting of gross volume overload.

Medications on Admission:
--ASA 325mg daily
--Carvedilol 12.5mg [**Hospital1 **]
--Digoxin 125mcg daily
--Lasix 10mg daily
--Levaquin 500mg daily
--Lisinopril 5mg daily


Discharge Medications:
N/A

Discharge Disposition:
Expired

Discharge Diagnosis:
1. Asystolic arrest
2. Anoxic brain injury
3. Acute kidney injury
4. Sepsis

Discharge Condition:
Expired

Discharge Instructions:
N/A

Followup Instructions:
N/A
{'Unspecified septicemia,Acute respiratory failure,Septic shock,Pneumonitis due to inhalation of food or vomitus,Acute and subacute necrosis of liver,Pressure ulcer, stage IV,Anoxic brain damage,Acute kidney failure, unspecified,Chronic systolic heart failure,Hyposmolality and/or hyponatremia,Other and unspecified coagulation defects,Unspecified protein-calorie malnutrition,Severe sepsis,Cardiac arrest,Unspecified essential hypertension,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Thrombocytopenia, unspecified,Encounter for palliative care'}


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: Asystolic arrest

PRESENT ILLNESS: Patient is a [**Age over 90 **]yo M s/p asystolic arrest who presents from OSH
fro therapeutic hypothermia post cardiac arrest.

MEDICAL HISTORY: --CHF
--HTN
--BPH
--TIA
--Decubitus ulcer

MEDICATION ON ADMISSION: --ASA 325mg daily
--Carvedilol 12.5mg [**Hospital1 **]
--Digoxin 125mcg daily
--Lasix 10mg daily
--Levaquin 500mg daily
--Lisinopril 5mg daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission:
General: Unresponsive, diffusely cool, no pupilalry or corneal
reflexes
HEENT: ETT in place, pupils nonreactive
Cor: RRR, no murmurs
Lungs: CTAB anteriorly
Abd: soft, nondistended
Ext: cool

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Lives at home with his family being responsible for his care.
Non-smoker. No EtOH. 

### Response:
{'Unspecified septicemia,Acute respiratory failure,Septic shock,Pneumonitis due to inhalation of food or vomitus,Acute and subacute necrosis of liver,Pressure ulcer, stage IV,Anoxic brain damage,Acute kidney failure, unspecified,Chronic systolic heart failure,Hyposmolality and/or hyponatremia,Other and unspecified coagulation defects,Unspecified protein-calorie malnutrition,Severe sepsis,Cardiac arrest,Unspecified essential hypertension,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Thrombocytopenia, unspecified,Encounter for palliative care'}
