CHIEF COMPLAINT: Septic/Cardiogenic Shock

PRESENT ILLNESS: 67 yo F with h/o CHF and amyloidosis receiving chemotherapy at
[**Hospital1 18**] presents with altered mental status and increasing LBP x 5
days with some new bowel/bladder incontinence and LE weakness.
.
Mrs. [**Known lastname **] started her first cycle of Velcade / Decadron
chemotherapy regimen 1 month ago and last dose was 10 days ago.
Over the last 5 days she experienced worsening back pain and
lower extremity weakness. She has become confused with an
altered mental status according to her husband and developed new
bowel and bladder incontinence 1 day prior to presentation.
.
The patient presented to [**Location (un) **] in a hypotensive state with
ARDS/pul edema on CXR. Initially, pneumonia vs CHF was
considered. The pt was given lasix, IVF, ceftazidime and
levaquin. Because of patients acute change in mental status, the
pt was given a full dose ASA and sent for head CT which was
negative. A U/A positive for blood. The pt was deemed to have
[**3-10**] BLE weakness and after decadron 10mg IV she was transferred
to [**Hospital1 **] for possible cauda equina vs. sepsis. The patient was
incontinent of stool en route.
.
In the ED, initial vs were: 99 76 85/41 18 100% on NRB.
Initially the patient was confused but A&Ox3 and complained only
of fatigue and aching in low back. Neuro exam revealed
weak-normal rectal tone and LE weakness, but normal reflexes and
sensation. CXR in ED was consistent with CHF. BNP was [**Numeric Identifier **]
(previously [**Numeric Identifier 890**] in [**2164**]). EKG V-paced but does not ST criteria
for STEMI. Troponin was 0.15 here (trop at [**Location (un) **] higher, but
they may be using a different assay). Because of concern for a
possible epidural abscess, the pt was sent for CT of full (C, T
and L) spine that showed no obvious fluid collections. The
patient cannot be sent for MRI because she has a pacemaker. She
started on vancomycin and received a 500cc NS bolus, had a right
IJ line place and was started on levophed. SBP rose to 110s with
an SpO2 98% on 4L NC with RR 20. She was transferred to [**Hospital Unit Name 153**] for
hemodynamic instability and concern for sepsis vs. cardiogenic
shock. On transfer, her vitals were 95.3F 61 102/59 19 95% on 5L
O2 by NC.
.
On the floor, pt is alert, but disoriented on 0.06mcg/kg/min
levophed with a warming blanket for hypothermia.

MEDICAL HISTORY: 1) Primary amyloidosis diagnosed in [**2163**]. Renal biopsy
showed a lambda light chain deposition and she had light chains
in her urine.  At that time, she has had marked lower extremity
edema and recurrent infections.  She ultimately had her stem
cells mobilized with Cytoxan and underwent autologous stem cell
transplant with melphalan as her conditioning regimen.
Transplant was complicated by GI bleed and ICU admission;
however, she was ultimately discharged and has been doing quite
well since transplant.
2) Pacemaker for symptomatic sinus block early [**2169-5-6**]
3) CHF
4) HTN
5) High cholesterol
6) Left wrist fracture
7) History of premature ventricular complexes
8) History of duodenal ulcer
9) Multiple bilateral breast cysts: Biopsies negative for
cancer.
10) tendon repair right leg in [**2139**]'s

MEDICATION ON ADMISSION: AMIODARONE -  (Prescribed by Other Provider) - 200 mg Tablet - 2
Tablet(s) by mouth once a day for 7 days then 1 tablet daily
ATORVASTATIN [LIPITOR] -  (Prescribed by Other Provider) - 20 mg
Tablet - 2 Tablet(s) by mouth once a day
CITALOPRAM -  (Prescribed by Other Provider) - 10 mg Tablet - 1
(One) Tablet(s) by mouth once a day
DEXAMETHASONE - 4 mg Tablet - 10 Tablet(s) by mouth once per day
for 4 days or as directed
FUROSEMIDE -  (Prescribed by Other Provider) - 40 mg Tablet - 1
(One) Tablet(s) by mouth twice a day
POTASSIUM CHLORIDE -  (Prescribed by Other Provider) - 20 mEq
Tab
Sust.Rel. Particle/Crystal - 2 Tab(s) by mouth once a day
RANITIDINE HCL -  (Prescribed by Other Provider) - 150 mg Tablet
- 1 Tablet(s) by mouth twice a day

ALLERGIES: Sulfa (Sulfonamide Antibiotics)

PHYSICAL EXAM: General: Appears ill, aware she is at [**Hospital1 18**], but disoriented to
time.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP 3cm above sternal angle, no LAD
Lungs: + upper airway transmitted sounds on expiration, a few
wheezes, inspiratory crackles.
CV: regular rate and rhythm, faint S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley draining clear fluid.
Ext: warm, well perfused, 2+ pulses, 1+ pedal edema bilat up to
knees.
Neuro: PERLA, good strength of facial muscles, normal tongue
movements, palate rises. strength 5/5 in ankles and elbows for
extension and flexion. strength 3/5 for hip flexion bilat. DTR
Patellar 3+ right, 1+ left. achilles 1+ bilat. biceps 3+ bilat.
-ve babinski bilat. good sensation and equal bilat in feet.
Skin: brownish discoloration above ankles bilaterally, macular
non blanching rash with confluent areas over inguinal/pubic
area.

FAMILY HISTORY: Unable to obtain secondary to confusion

SOCIAL HISTORY: She has been married for 47 years. She has three children and
five grandchildren who live locally.
- Tobacco: one to two cigarettes a day.
Unspecified septicemia,Acute respiratory failure,Septic shock,Acute on chronic combined systolic and diastolic heart failure,Acute kidney failure with lesion of tubular necrosis,Varicella (hemorrhagic) pneumonitis,Other amyloidosis,Nutritional and metabolic cardiomyopathy,Peripheral stem cells replaced by transplant,Hyposmolality and/or hyponatremia,Severe sepsis,Thrombocytopenia, unspecified,Cardiac pacemaker in situ,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere
Septicemia NOS,Acute respiratry failure,Septic shock,Ac/chr syst/dia hrt fail,Ac kidny fail, tubr necr,Varicella pneumonitis,Amyloidosis NEC,Metabolic cardiomyopathy,Trspl sts-perip stm cell,Hyposmolality,Severe sepsis,Thrombocytopenia NOS,Status cardiac pacemaker,Nephritis NOS in oth dis
Admission Date:  [**2169-10-12**]              Discharge Date:   [**2169-10-19**]

Date of Birth:  [**2102-6-12**]             Sex:   F

Service: MEDICINE

Allergies:
Sulfa (Sulfonamide Antibiotics)

Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Septic/Cardiogenic Shock

Major Surgical or Invasive Procedure:
endotracheal intubation

History of Present Illness:
67 yo F with h/o CHF and amyloidosis receiving chemotherapy at
[**Hospital1 18**] presents with altered mental status and increasing LBP x 5
days with some new bowel/bladder incontinence and LE weakness.
.
Mrs. [**Known lastname **] started her first cycle of Velcade / Decadron
chemotherapy regimen 1 month ago and last dose was 10 days ago.
Over the last 5 days she experienced worsening back pain and
lower extremity weakness. She has become confused with an
altered mental status according to her husband and developed new
bowel and bladder incontinence 1 day prior to presentation.
.
The patient presented to [**Location (un) **] in a hypotensive state with
ARDS/pul edema on CXR. Initially, pneumonia vs CHF was
considered. The pt was given lasix, IVF, ceftazidime and
levaquin. Because of patients acute change in mental status, the
pt was given a full dose ASA and sent for head CT which was
negative. A U/A positive for blood. The pt was deemed to have
[**3-10**] BLE weakness and after decadron 10mg IV she was transferred
to [**Hospital1 **] for possible cauda equina vs. sepsis. The patient was
incontinent of stool en route.
.
In the ED, initial vs were: 99 76 85/41 18 100% on NRB.
Initially the patient was confused but A&Ox3 and complained only
of fatigue and aching in low back. Neuro exam revealed
weak-normal rectal tone and LE weakness, but normal reflexes and
sensation. CXR in ED was consistent with CHF. BNP was [**Numeric Identifier **]
(previously [**Numeric Identifier 890**] in [**2164**]). EKG V-paced but does not ST criteria
for STEMI. Troponin was 0.15 here (trop at [**Location (un) **] higher, but
they may be using a different assay). Because of concern for a
possible epidural abscess, the pt was sent for CT of full (C, T
and L) spine that showed no obvious fluid collections. The
patient cannot be sent for MRI because she has a pacemaker. She
started on vancomycin and received a 500cc NS bolus, had a right
IJ line place and was started on levophed. SBP rose to 110s with
an SpO2 98% on 4L NC with RR 20. She was transferred to [**Hospital Unit Name 153**] for
hemodynamic instability and concern for sepsis vs. cardiogenic
shock. On transfer, her vitals were 95.3F 61 102/59 19 95% on 5L
O2 by NC.
.
On the floor, pt is alert, but disoriented on 0.06mcg/kg/min
levophed with a warming blanket for hypothermia.

Past Medical History:
1) Primary amyloidosis diagnosed in [**2163**]. Renal biopsy
showed a lambda light chain deposition and she had light chains
in her urine.  At that time, she has had marked lower extremity
edema and recurrent infections.  She ultimately had her stem
cells mobilized with Cytoxan and underwent autologous stem cell
transplant with melphalan as her conditioning regimen.
Transplant was complicated by GI bleed and ICU admission;
however, she was ultimately discharged and has been doing quite
well since transplant.
2) Pacemaker for symptomatic sinus block early [**2169-5-6**]
3) CHF
4) HTN
5) High cholesterol
6) Left wrist fracture
7) History of premature ventricular complexes
8) History of duodenal ulcer
9) Multiple bilateral breast cysts: Biopsies negative for
cancer.
10) tendon repair right leg in [**2139**]'s

Social History:
She has been married for 47 years. She has three children and
five grandchildren who live locally.
- Tobacco: one to two cigarettes a day.

Family History:
Unable to obtain secondary to confusion

Physical Exam:
General: Appears ill, aware she is at [**Hospital1 18**], but disoriented to
time.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP 3cm above sternal angle, no LAD
Lungs: + upper airway transmitted sounds on expiration, a few
wheezes, inspiratory crackles.
CV: regular rate and rhythm, faint S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley draining clear fluid.
Ext: warm, well perfused, 2+ pulses, 1+ pedal edema bilat up to
knees.
Neuro: PERLA, good strength of facial muscles, normal tongue
movements, palate rises. strength 5/5 in ankles and elbows for
extension and flexion. strength 3/5 for hip flexion bilat. DTR
Patellar 3+ right, 1+ left. achilles 1+ bilat. biceps 3+ bilat.
-ve babinski bilat. good sensation and equal bilat in feet.
Skin: brownish discoloration above ankles bilaterally, macular
non blanching rash with confluent areas over inguinal/pubic
area.


Pertinent Results:
[**2169-10-13**] 12:00AM   TYPE-MIX PO2-32* PCO2-40 PH-7.36 TOTAL CO2-24
BASE XS--3
[**2169-10-13**] 12:00AM   LACTATE-1.5
[**2169-10-13**] 12:00AM   O2 SAT-53
[**2169-10-13**] 12:00AM   freeCa-1.07*
[**2169-10-12**] 11:18PM   GLUCOSE-119* UREA N-71* CREAT-1.7* SODIUM-136
POTASSIUM-4.8 CHLORIDE-102 TOTAL CO2-23 ANION GAP-16
[**2169-10-12**] 11:18PM   ALT(SGPT)-366* AST(SGOT)-482* CK(CPK)-540*
ALK PHOS-105 TOT BILI-0.8
[**2169-10-12**] 11:18PM   CK-MB-8 cTropnT-0.14*
[**2169-10-12**] 11:18PM   CALCIUM-8.0* PHOSPHATE-6.6* MAGNESIUM-2.2
[**2169-10-12**] 11:18PM   TSH-2.5
[**2169-10-12**] 11:18PM   WBC-7.3 RBC-4.14* HGB-13.4 HCT-40.2 MCV-97
MCH-32.2* MCHC-33.2 RDW-16.1*
[**2169-10-12**] 11:18PM   PLT COUNT-60*
[**2169-10-12**] 11:18PM   PT-13.9* PTT-37.2* INR(PT)-1.2*
[**2169-10-12**] 09:25PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2169-10-12**] 09:25PM URINE  BLOOD-LG NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2169-10-12**] 09:25PM URINE  RBC-[**6-15**]* WBC-0-2 BACTERIA-RARE
YEAST-NONE EPI-0-2
[**2169-10-12**] 05:05PM   COMMENTS-GREEN TOP
[**2169-10-12**] 05:05PM   LACTATE-1.4
[**2169-10-12**] 05:00PM   GLUCOSE-88 UREA N-66* CREAT-1.7* SODIUM-131*
POTASSIUM-5.2* CHLORIDE-101 TOTAL CO2-19* ANION GAP-16
[**2169-10-12**] 05:00PM   estGFR-Using this
[**2169-10-12**] 05:00PM   cTropnT-0.15* proBNP-[**Numeric Identifier **]*
[**2169-10-12**] 05:00PM   CALCIUM-8.1* PHOSPHATE-5.4*# MAGNESIUM-2.1
[**2169-10-12**] 05:00PM   WBC-5.8 RBC-4.01* HGB-12.8 HCT-38.1 MCV-95
MCH-31.9 MCHC-33.6 RDW-16.8*
[**2169-10-12**] 05:00PM   NEUTS-95* BANDS-3 LYMPHS-0 MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-2* MYELOS-0 NUC RBCS-5*
[**2169-10-12**] 05:00PM   HYPOCHROM-NORMAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-NORMAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
[**2169-10-12**] 05:00PM   PLT SMR-VERY LOW PLT COUNT-55*#

Labs prior to expiration:

[**2169-10-19**] 06:36AM BLOOD WBC-18.9* RBC-2.89* Hgb-9.3* Hct-27.3*
MCV-95 MCH-32.3* MCHC-34.1 RDW-17.0* Plt Ct-44*
[**2169-10-19**] 06:36AM BLOOD Neuts-93.9* Bands-0 Lymphs-4.3*
Monos-1.5* Eos-0 Baso-0.3
[**2169-10-19**] 06:36AM BLOOD PT-21.6* PTT-40.6* INR(PT)-2.0*
[**2169-10-19**] 06:36AM BLOOD Glucose-112* UreaN-114* Creat-4.3*
Na-131* K-5.1 Cl-102 HCO3-16* AnGap-18
[**2169-10-19**] 06:36AM BLOOD ALT-89* AST-127* LD(LDH)-1585*
AlkPhos-113* TotBili-0.9
[**2169-10-19**] 06:36AM BLOOD Calcium-6.8* Phos-6.2* Mg-2.0
[**2169-10-18**] 02:25PM BLOOD freeCa-1.01*
[**2169-10-18**] 02:45PM BLOOD O2 Sat-67
[**2169-10-18**] 02:25PM BLOOD Lactate-1.0

Imaging:
CT spine [**10-12**]: No evidence of fracture or fluid collection of
the cervical spine.

Echo [**10-13**]:  IMPRESSION: amyloid heart

CT head [**10-13**]:  no acute process

BAL cytology [**10-14**]: NEGATIVE FOR MALIGNANT CELLS. Macrophages,
some hemosiderin-laden, lymphocytes and neutrophils

CT head [**10-17**]: IMPRESSIONS: Newly apparent loss of [**Doctor Last Name 352**]-white
matter differentiation along the posterior right MCA vascular
distribution raises concern for interval infarction, not
previously seen on [**2169-10-13**]. No acute intracranial hemorrhage or
shift of normally midline structures. MRI recommended for more
sensitive evaluation of infarction if patient's cardiac
pacemaker is MRI-compatible.

CT chest [**10-17**]:

IMPRESSION:
Extensive bilateral dependent consolidations, accompanying
pleural effusions and ground-glass-like opacities in the left
dependent lung regions. The findings suggest a combination of
pulmonary edema and infection.   Extensive lymph node
calcifications, splenic calcifications and hepatic
calcifications. Several nonspecific mainly subpleural pulmonary
nodular lesions. The monitoring and support devices in correct
position. The study and the report were reviewed by the staff
radiologist.

Renal US [**10-18**]:
IMPRESSION:
1. Diffuse increased echogenicity of the renal cortices,
compatible with
chronic medical renal disease.
2. Abnormal Doppler evaluation of the kidneys bilaterally, with
elevated RIs
and decreased diastolic flow.
3. Echogenic foci with posterior shadowing seen in the right
kidney at the
corticomedullary junction. While the appearance suggests
nephrocalcinosis,
the unilaterality is atypical, and these may rather represent
non-obstructing
stones. However, of note, on prior CT of the lumbar spine dated
[**2169-10-12**], scattered dense foci were seen as well on the left, not
seen by
ultrasound.
4. Simple right renal cysts.


Micro:

-Blood cultures negative
-blood fungal cx negative
-HSV culture negative
-urine cx's negative
-stool cx's negative

BAL [**10-17**]:
 GRAM STAIN (Final [**2169-10-17**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      1+    (<1 per 1000X FIELD):   BUDDING YEAST.

   RESPIRATORY CULTURE (Final [**2169-10-19**]):
      Commensal Respiratory Flora Absent.
      YEAST.    10,000-100,000 ORGANISMS/ML..
         OF TWO COLONIAL MORPHOLOGIES.

   POTASSIUM HYDROXIDE PREPARATION (Final [**2169-10-18**]):
      This is a low yield procedure based on our in-house
studies.
      if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
      Aspergillosis or Mucormycosis is strongly suspected,
contact the
      Microbiology Laboratory (7-2306).
      TEST REQUESTED BY DR. [**Last Name (STitle) 54548**] #[**Numeric Identifier 54549**] [**2169-10-18**].
      BUDDING YEAST WITH PSEUDOHYPHAE.

   Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
      [**2169-10-18**]):    NEGATIVE for Pneumocystis jirovecii
(carinii)..

   FUNGAL CULTURE (Final [**2169-10-30**]):
      YEAST.    OF TWO COLONIAL MORPHOLOGIES

BAL [**10-14**]:

   GRAM STAIN (Final [**2169-10-14**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.

   RESPIRATORY CULTURE (Final [**2169-10-16**]):    NO GROWTH, <1000
CFU/ml.

   LEGIONELLA CULTURE (Final [**2169-10-21**]):    NO LEGIONELLA
ISOLATED.

   Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
      [**2169-10-15**]):    NEGATIVE for Pneumocystis jirovecii
(carinii)..

   FUNGAL CULTURE (Final [**2169-10-30**]):    NO FUNGUS ISOLATED.

   ACID FAST SMEAR (Final [**2169-10-16**]):
      NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
      NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.

   ACID FAST CULTURE (Preliminary):    NO MYCOBACTERIA ISOLATED.


   VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):
      No Virus isolated so far.

   VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Final [**2169-10-23**]):
      No Herpes simplex (HSV) virus isolated.

   VARICELLA-ZOSTER CULTURE (Preliminary):    No Virus isolated
so far.

-Cryptococcal antigen: neg
-Groin swab VZV positive


Brief Hospital Course:
67 yo F h/o amyloidosis, including cardiac involvement s/p
pacemaker with mixed septic and cardiogenic shock and
respiratory failure [**2-7**] to pneumonia of unclear etiology. pt
eventually expired [**2-7**] multiorgan failure in setting of
septic/cardiogenic shock.

Issues throughout ICU stay included:

*Shock. Likely secondary to a septic process combined with an
exacerbation of chronic HF. Treated w/ dopamine, levophed and
fluids. ID favored VZV pneumonia as the most likely source and
also considered PCP likely possibly [**Name Initial (PRE) **]/ a bacterial
superinfection.

*Respiratory failure. Likely secondary to a pneumonia of unknown
etiology, perhaps a VZV pneumonia. Developed large area of
consolidation in RLL>LLL visible on CT and RLL bleeding observed
on BAL.
.
*Renal failure: ATN [**2-7**] shock and worsening renal function from
day to day with urine output declining to 10-15cc/hr. Renal U/S
showed evidence of chronic amyloid kidney and doppler showed
decreased diastolic flow.
.
*Possible stroke on CT head in the right posterior MCA
territory.
.
*Decreased perfusion to feet secondary to cardiogenic failure
and the requirement for levophed to maintain her blood pressure.
This was treated by warming her feet and prefering dopamine over
levophed as a pressor to reduce vasoconstriction and increase
cardiac output.
.
*Tachycardia. Underlying atrial tachycardia likely with A sensed
V paced pacermaker settings. Intermittent tachy into the 110s.
Possibly exacerbated by her dopamine requirement. Tachycardia
tolerated for HR < 130 as long as BP not affected in order to
maintain foot perfusion.
.
*Thrombocytopenia. Likely [**2-7**] sepsis. HIT assay negative. DIC
work up negative. Transfused plts to maintain platlet count >
50.
.
*Transaminitis. Likely [**2-7**] shock liver.  Trended down during
admission.
.
*VZV rash over left anterior thigh. Treated with acyclovir and
improved.
.
*Leg weakness and fecal incontinence. Patient seen by ortho
spine and neurology and both services agreed that there were no
focal signs of cauda equine. The patient endorsed a mechanical
fall a week prior to admission as source of leg pain and
weakness. Hip films negative for fracture.
.
*At a family meeting, the patient's multiple organ failure and
poor prognosis was discussed with her husband and three
children. They agreed that the patient would not want her life
to be prolonged without a significant hope of a return to her
previous quality of life. The patient was made DNR/DNI and no
escalation of care and then made CMO when her family was ready.
She expired at 13:10 on [**2169-10-19**].

Medications on Admission:
AMIODARONE -  (Prescribed by Other Provider) - 200 mg Tablet - 2
Tablet(s) by mouth once a day for 7 days then 1 tablet daily
ATORVASTATIN [LIPITOR] -  (Prescribed by Other Provider) - 20 mg
Tablet - 2 Tablet(s) by mouth once a day
CITALOPRAM -  (Prescribed by Other Provider) - 10 mg Tablet - 1
(One) Tablet(s) by mouth once a day
DEXAMETHASONE - 4 mg Tablet - 10 Tablet(s) by mouth once per day
for 4 days or as directed
FUROSEMIDE -  (Prescribed by Other Provider) - 40 mg Tablet - 1
(One) Tablet(s) by mouth twice a day
POTASSIUM CHLORIDE -  (Prescribed by Other Provider) - 20 mEq
Tab
Sust.Rel. Particle/Crystal - 2 Tab(s) by mouth once a day
RANITIDINE HCL -  (Prescribed by Other Provider) - 150 mg Tablet
- 1 Tablet(s) by mouth twice a day

Discharge Medications:
pt expired

Discharge Disposition:
Expired

Discharge Diagnosis:
Septic and Cardiogenic shock secondary to pneumonia.

Discharge Condition:
expired

Discharge Instructions:
expired

Followup Instructions:
expired
{'Unspecified septicemia,Acute respiratory failure,Septic shock,Acute on chronic combined systolic and diastolic heart failure,Acute kidney failure with lesion of tubular necrosis,Varicella (hemorrhagic) pneumonitis,Other amyloidosis,Nutritional and metabolic cardiomyopathy,Peripheral stem cells replaced by transplant,Hyposmolality and/or hyponatremia,Severe sepsis,Thrombocytopenia, unspecified,Cardiac pacemaker in situ,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere'}


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/Cardiogenic Shock

PRESENT ILLNESS: 67 yo F with h/o CHF and amyloidosis receiving chemotherapy at
[**Hospital1 18**] presents with altered mental status and increasing LBP x 5
days with some new bowel/bladder incontinence and LE weakness.
.
Mrs. [**Known lastname **] started her first cycle of Velcade / Decadron
chemotherapy regimen 1 month ago and last dose was 10 days ago.
Over the last 5 days she experienced worsening back pain and
lower extremity weakness. She has become confused with an
altered mental status according to her husband and developed new
bowel and bladder incontinence 1 day prior to presentation.
.
The patient presented to [**Location (un) **] in a hypotensive state with
ARDS/pul edema on CXR. Initially, pneumonia vs CHF was
considered. The pt was given lasix, IVF, ceftazidime and
levaquin. Because of patients acute change in mental status, the
pt was given a full dose ASA and sent for head CT which was
negative. A U/A positive for blood. The pt was deemed to have
[**3-10**] BLE weakness and after decadron 10mg IV she was transferred
to [**Hospital1 **] for possible cauda equina vs. sepsis. The patient was
incontinent of stool en route.
.
In the ED, initial vs were: 99 76 85/41 18 100% on NRB.
Initially the patient was confused but A&Ox3 and complained only
of fatigue and aching in low back. Neuro exam revealed
weak-normal rectal tone and LE weakness, but normal reflexes and
sensation. CXR in ED was consistent with CHF. BNP was [**Numeric Identifier **]
(previously [**Numeric Identifier 890**] in [**2164**]). EKG V-paced but does not ST criteria
for STEMI. Troponin was 0.15 here (trop at [**Location (un) **] higher, but
they may be using a different assay). Because of concern for a
possible epidural abscess, the pt was sent for CT of full (C, T
and L) spine that showed no obvious fluid collections. The
patient cannot be sent for MRI because she has a pacemaker. She
started on vancomycin and received a 500cc NS bolus, had a right
IJ line place and was started on levophed. SBP rose to 110s with
an SpO2 98% on 4L NC with RR 20. She was transferred to [**Hospital Unit Name 153**] for
hemodynamic instability and concern for sepsis vs. cardiogenic
shock. On transfer, her vitals were 95.3F 61 102/59 19 95% on 5L
O2 by NC.
.
On the floor, pt is alert, but disoriented on 0.06mcg/kg/min
levophed with a warming blanket for hypothermia.

MEDICAL HISTORY: 1) Primary amyloidosis diagnosed in [**2163**]. Renal biopsy
showed a lambda light chain deposition and she had light chains
in her urine.  At that time, she has had marked lower extremity
edema and recurrent infections.  She ultimately had her stem
cells mobilized with Cytoxan and underwent autologous stem cell
transplant with melphalan as her conditioning regimen.
Transplant was complicated by GI bleed and ICU admission;
however, she was ultimately discharged and has been doing quite
well since transplant.
2) Pacemaker for symptomatic sinus block early [**2169-5-6**]
3) CHF
4) HTN
5) High cholesterol
6) Left wrist fracture
7) History of premature ventricular complexes
8) History of duodenal ulcer
9) Multiple bilateral breast cysts: Biopsies negative for
cancer.
10) tendon repair right leg in [**2139**]'s

MEDICATION ON ADMISSION: AMIODARONE -  (Prescribed by Other Provider) - 200 mg Tablet - 2
Tablet(s) by mouth once a day for 7 days then 1 tablet daily
ATORVASTATIN [LIPITOR] -  (Prescribed by Other Provider) - 20 mg
Tablet - 2 Tablet(s) by mouth once a day
CITALOPRAM -  (Prescribed by Other Provider) - 10 mg Tablet - 1
(One) Tablet(s) by mouth once a day
DEXAMETHASONE - 4 mg Tablet - 10 Tablet(s) by mouth once per day
for 4 days or as directed
FUROSEMIDE -  (Prescribed by Other Provider) - 40 mg Tablet - 1
(One) Tablet(s) by mouth twice a day
POTASSIUM CHLORIDE -  (Prescribed by Other Provider) - 20 mEq
Tab
Sust.Rel. Particle/Crystal - 2 Tab(s) by mouth once a day
RANITIDINE HCL -  (Prescribed by Other Provider) - 150 mg Tablet
- 1 Tablet(s) by mouth twice a day

ALLERGIES: Sulfa (Sulfonamide Antibiotics)

PHYSICAL EXAM: General: Appears ill, aware she is at [**Hospital1 18**], but disoriented to
time.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP 3cm above sternal angle, no LAD
Lungs: + upper airway transmitted sounds on expiration, a few
wheezes, inspiratory crackles.
CV: regular rate and rhythm, faint S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley draining clear fluid.
Ext: warm, well perfused, 2+ pulses, 1+ pedal edema bilat up to
knees.
Neuro: PERLA, good strength of facial muscles, normal tongue
movements, palate rises. strength 5/5 in ankles and elbows for
extension and flexion. strength 3/5 for hip flexion bilat. DTR
Patellar 3+ right, 1+ left. achilles 1+ bilat. biceps 3+ bilat.
-ve babinski bilat. good sensation and equal bilat in feet.
Skin: brownish discoloration above ankles bilaterally, macular
non blanching rash with confluent areas over inguinal/pubic
area.

FAMILY HISTORY: Unable to obtain secondary to confusion

SOCIAL HISTORY: She has been married for 47 years. She has three children and
five grandchildren who live locally.
- Tobacco: one to two cigarettes a day. 

### Response:
{'Unspecified septicemia,Acute respiratory failure,Septic shock,Acute on chronic combined systolic and diastolic heart failure,Acute kidney failure with lesion of tubular necrosis,Varicella (hemorrhagic) pneumonitis,Other amyloidosis,Nutritional and metabolic cardiomyopathy,Peripheral stem cells replaced by transplant,Hyposmolality and/or hyponatremia,Severe sepsis,Thrombocytopenia, unspecified,Cardiac pacemaker in situ,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere'}
