CHIEF COMPLAINT: elevated INR

PRESENT ILLNESS: This is a 48 yo woman with HIV, Hepatitis, who was refered to
the ED by her PCP for increased INR of 15. History was obtained
from chart given pt unresponsiveness on arrival.

MEDICAL HISTORY: * HIV/AIDS
- dx [**2175**], CD4 nadir 69
- on multiple prior ARV regimens, h/o poor adherence
- OIs: oropharyngeal and esophageal candidiasis, pneumococcal
pna, [**Doctor First Name **]
* Recent Hepatitis thought [**2-7**] HAART, now off
* Recent ARF
* Hep C, undetectable VL [**5-/2191**]
* PE
* Anticardiolipin antibody ([**2186-4-28**])
* PPD+ s/p ethambutol x3mo [**2184**]
* Cocaine Induced Cardiomyopathy with LV thrombus, EF 20-25%
- dilated cardiomyopathy with chronic CHF
* CVA
* LLE arterial thrombus
* Lymphocytic pneumonitis
* Zoster
* Cholelithiasis
* Asthma
* Polysubstance abuse
* MI
* s/p hysterectomy
* Enterbacter pneumonia
* SIADH

MEDICATION ON ADMISSION: ABACAVIR-LAMIVUDINE 600 mg-300 mg tablet daily
DAPSONE 100 mg daily
FUROSEMIDE 20 mg Tablet daily
LISINOPRIL - 2.5 mg daily
LOPINAVIR-RITONAVIR [KALETRA] 400 mg-100 mg [**Hospital1 **]
METOPROLOL SUCCINATE 12.5 mg daily
PANTOPRAZOLE 20 mg daily
BACTRIM DS 800 mg-160 mg Tablet T/Th/Sat
WARFARIN 15 mg daily
ASPIRIN 81 mg Tablet daily
GUAIFENESIN daily

ALLERGIES: Zidovudine

PHYSICAL EXAM: Admission:
General: non responsive, intubated
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: Clear to auscultation bilaterally
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen:  distended, soft, non-tender, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: mother with DM

SOCIAL HISTORY: Homelessness - currently living with daughter and uncle. [**Name (NI) **]
been out of rehab for last 1 month. Admits to cocaine use prior
to admission, smokes [**1-7**] ppd, denies any EtoH or IV drug use.
Unspecified septicemia,Defibrination syndrome,Human immunodeficiency virus [HIV] disease,Acute and subacute necrosis of liver,Acute kidney failure, unspecified,Severe sepsis,Cardiac arrest,Cocaine abuse, continuous,Chronic hepatitis C without mention of hepatic coma
Septicemia NOS,Defibrination syndrome,Human immuno virus dis,Acute necrosis of liver,Acute kidney failure NOS,Severe sepsis,Cardiac arrest,Cocaine abuse-continuous,Chrnc hpt C wo hpat coma
Admission Date:  [**2191-8-29**]              Discharge Date:   [**2191-8-29**]

Date of Birth:  [**2143-7-12**]             Sex:   F

Service: MEDICINE

Allergies:
Zidovudine

Attending:[**First Name3 (LF) 5608**]
Chief Complaint:
elevated INR

Major Surgical or Invasive Procedure:
cental access

History of Present Illness:
This is a 48 yo woman with HIV, Hepatitis, who was refered to
the ED by her PCP for increased INR of 15. History was obtained
from chart given pt unresponsiveness on arrival.

She takes coumadin at home for hisotry of PE.  She recently
started using cocaine.

She came in to the ED in a lethargic state and then became
acutely delirious. She was intubated. Her BP decreased in the
80s and central access (femoral) as well as femoral a line were
placed. She given IVF and was started on levo and neo for blood
pressure control. In the ED VS were T 90, P 104, BP 67/32, 100%
on 400x?/FiO2 100%/PEEP 5. ECG sinus at 98, left axis deviation,
widened QRS with no ST elevations. Her INR was 20, PTT was in
the 100 range. No FFP was given in the ED. Also notable labs
were an elevated K, elevated transaminases and bilirubin as well
as  a lactate of 17. ABGS: 6.89 25 95.
.
On the floor, the patient was still hypotensive. Attempted right
IJ central line unsuccessful as only got pulsating arterial flow
despite ultrasound guidance showing large collapsible vessel.
Venous access attempted peripherally. BP remained in 80s despite
levophed, and soonafter with vasopressin, and neo. PEA arrested,
CPR for ~10 minutes until pulse returned. Repeated ABGs with pH
~6.9 to 7.07 following HCO3 boluses and HCO3 drip. Had 2nd PEA
arrest, CPR, stat echo showed severely depressed LV and no
pericardial effusion. Abdomen became increasingly distended
despite OG on suction. PIPs ~50.  Anesthesia and trauma surgery
were present to help with access but no accessible central
veins. EMS was also called to place IO catheter but within
minutes of placement in right LE, leg started to swell
confirming this was not in position. Dobutamine and epi drips
added. Decision was made after 60 minutes of code to not
escalate care. Daughter and mother were both called and at this
time are still on their way in. They were advised that the
patient is likely going to die. Cause of PEA arrest is still
unclear.


Past Medical History:
* HIV/AIDS
- dx [**2175**], CD4 nadir 69
- on multiple prior ARV regimens, h/o poor adherence
- OIs: oropharyngeal and esophageal candidiasis, pneumococcal
pna, [**Doctor First Name **]
* Recent Hepatitis thought [**2-7**] HAART, now off
* Recent ARF
* Hep C, undetectable VL [**5-/2191**]
* PE
* Anticardiolipin antibody ([**2186-4-28**])
* PPD+ s/p ethambutol x3mo [**2184**]
* Cocaine Induced Cardiomyopathy with LV thrombus, EF 20-25%
- dilated cardiomyopathy with chronic CHF
* CVA
* LLE arterial thrombus
* Lymphocytic pneumonitis
* Zoster
* Cholelithiasis
* Asthma
* Polysubstance abuse
* MI
* s/p hysterectomy
* Enterbacter pneumonia
* SIADH

Social History:
Homelessness - currently living with daughter and uncle. [**Name (NI) **]
been out of rehab for last 1 month. Admits to cocaine use prior
to admission, smokes [**1-7**] ppd, denies any EtoH or IV drug use.


Family History:
mother with DM

Physical Exam:
Admission:
General: non responsive, intubated
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: Clear to auscultation bilaterally
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen:  distended, soft, non-tender, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

Pertinent Results:
[**2191-8-29**] 09:07AM   TYPE-ART PO2-40* PCO2-62* PH-6.98* TOTAL
CO2-16* BASE XS--19
[**2191-8-29**] 09:07AM   LACTATE-11.9*
[**2191-8-29**] 08:29AM   TYPE-ART PO2-52* PCO2-47* PH-7.07* TOTAL
CO2-14* BASE XS--16
[**2191-8-29**] 08:29AM   LACTATE-12.3*
[**2191-8-29**] 08:20AM   GLUCOSE-304* NA+-140 K+-4.2 CL--108 TCO2-13*
[**2191-8-29**] 08:02AM   TYPE-ART PO2-85 PCO2-42 PH-6.89* TOTAL CO2-9*
BASE XS--26
[**2191-8-29**] 07:45AM   LD(LDH)-890* CK(CPK)-111
[**2191-8-29**] 07:45AM   CK-MB-9 cTropnT-0.06*
[**2191-8-29**] 07:45AM   CALCIUM-7.4* PHOSPHATE-10.2* MAGNESIUM-2.0
[**2191-8-29**] 07:45AM   HCT-40.8
[**2191-8-29**] 07:45AM   PT->150* PTT-76.7* INR(PT)-20.2*
[**2191-8-29**] 07:45AM   FDP-10-40*
[**2191-8-29**] 07:45AM   FIBRINOGE-201#
[**2191-8-29**] 06:33AM   TYPE-MIX RATES-/20 PO2-94 PCO2-34* PH-6.89*
TOTAL CO2-7* BASE XS--27 -ASSIST/CON INTUBATED-NOT INTUBA
[**2191-8-29**] 06:33AM   GLUCOSE-118* LACTATE-15.4* NA+-134* K+-5.9*
CL--110
[**2191-8-29**] 06:33AM   O2 SAT-90
[**2191-8-29**] 05:52AM   TYPE-[**Last Name (un) **] PO2-95 PCO2-25* PH-6.89* TOTAL
CO2-5* BASE XS--29
[**2191-8-29**] 05:50AM URINE  HOURS-RANDOM
[**2191-8-29**] 05:50AM URINE  HOURS-RANDOM
[**2191-8-29**] 05:50AM URINE  GR HOLD-HOLD
[**2191-8-29**] 05:50AM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2191-8-29**] 05:50AM URINE  BLOOD-LGE NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-4* PH-5.0 LEUK-SM
[**2191-8-29**] 05:50AM URINE  RBC-[**6-15**]* WBC-[**6-15**]* BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2191-8-29**] 05:50AM URINE  HYALINE-[**3-10**]*
[**2191-8-29**] 05:50AM URINE  CA OXAL-RARE
[**2191-8-29**] 05:44AM   LACTATE-17.4*
[**2191-8-29**] 05:30AM   PT-148.5* PTT-102.1* INR(PT)-20*
[**2191-8-29**] 04:31AM   LACTATE-16.4*
[**2191-8-29**] 04:20AM   GLUCOSE-115* UREA N-56* CREAT-3.3*#
SODIUM-135 POTASSIUM-5.7* CHLORIDE-99 TOTAL CO2-LESS THAN
[**2191-8-29**] 04:20AM   estGFR-Using this
[**2191-8-29**] 04:20AM   ALT(SGPT)-417* AST(SGOT)-619* CK(CPK)-128 ALK
PHOS-169* TOT BILI-2.7*
[**2191-8-29**] 04:20AM   LIPASE-105*
[**2191-8-29**] 04:20AM   CK-MB-9 cTropnT-0.05*
[**2191-8-29**] 04:20AM   CK-MB-9 cTropnT-0.05*

Brief Hospital Course:
The patient presented with hypotension and elevated PT/INR. On
initial presentation we attempted right IJ central line
unsuccessful as only got pulsating arterial flow despite
ultrasound guidance showing large collapsible vessel. Venous
access attempted peripherally. BP remained in 80s despite
levophed, and soonafter with vasopressin, and neo. PEA arrested,
CPR for ~10 minutes until pulse returned. Repeated ABGs with pH
~6.9 to 7.07 following HCO3 boluses and HCO3 drip. Had 2nd PEA
arrest, CPR, stat echo showed severely depressed LV and no
pericardial effusion. Abdomen became increasingly distended
despite OG on suction. PIPs ~50.  Anesthesia and trauma surgery
were present to help with access but no accessible central
veins. EMS was also called to place IO catheter but within
minutes of placement in right LE, leg started to swell
confirming this was not in position. Dobutamine and epi drips
added. Decision was made after 60 minutes of code to not
escalate care. Daughter and mother were both called and at this
time are still on their way in. They were advised that the
patient is likely going to die. Cause of PEA arrest is still
unclear. Possibilities include fulminant hepatic failure, DIC,
sepsis or cocaine induced cardiac arrest. Autopsy was accepted.



Medications on Admission:
ABACAVIR-LAMIVUDINE 600 mg-300 mg tablet daily
DAPSONE 100 mg daily
FUROSEMIDE 20 mg Tablet daily
LISINOPRIL - 2.5 mg daily
LOPINAVIR-RITONAVIR [KALETRA] 400 mg-100 mg [**Hospital1 **]
METOPROLOL SUCCINATE 12.5 mg daily
PANTOPRAZOLE 20 mg daily
BACTRIM DS 800 mg-160 mg Tablet T/Th/Sat
WARFARIN 15 mg daily
ASPIRIN 81 mg Tablet daily
GUAIFENESIN daily

Discharge Medications:
NA

Discharge Disposition:
Expired

Discharge Diagnosis:
Deceased

Discharge Condition:
Deceased

Discharge Instructions:
Deceased

Followup Instructions:
Deceased


Completed by:[**2191-9-8**]
{'Unspecified septicemia,Defibrination syndrome,Human immunodeficiency virus [HIV] disease,Acute and subacute necrosis of liver,Acute kidney failure, unspecified,Severe sepsis,Cardiac arrest,Cocaine abuse, continuous,Chronic hepatitis C without mention of hepatic coma'}


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: elevated INR

PRESENT ILLNESS: This is a 48 yo woman with HIV, Hepatitis, who was refered to
the ED by her PCP for increased INR of 15. History was obtained
from chart given pt unresponsiveness on arrival.

MEDICAL HISTORY: * HIV/AIDS
- dx [**2175**], CD4 nadir 69
- on multiple prior ARV regimens, h/o poor adherence
- OIs: oropharyngeal and esophageal candidiasis, pneumococcal
pna, [**Doctor First Name **]
* Recent Hepatitis thought [**2-7**] HAART, now off
* Recent ARF
* Hep C, undetectable VL [**5-/2191**]
* PE
* Anticardiolipin antibody ([**2186-4-28**])
* PPD+ s/p ethambutol x3mo [**2184**]
* Cocaine Induced Cardiomyopathy with LV thrombus, EF 20-25%
- dilated cardiomyopathy with chronic CHF
* CVA
* LLE arterial thrombus
* Lymphocytic pneumonitis
* Zoster
* Cholelithiasis
* Asthma
* Polysubstance abuse
* MI
* s/p hysterectomy
* Enterbacter pneumonia
* SIADH

MEDICATION ON ADMISSION: ABACAVIR-LAMIVUDINE 600 mg-300 mg tablet daily
DAPSONE 100 mg daily
FUROSEMIDE 20 mg Tablet daily
LISINOPRIL - 2.5 mg daily
LOPINAVIR-RITONAVIR [KALETRA] 400 mg-100 mg [**Hospital1 **]
METOPROLOL SUCCINATE 12.5 mg daily
PANTOPRAZOLE 20 mg daily
BACTRIM DS 800 mg-160 mg Tablet T/Th/Sat
WARFARIN 15 mg daily
ASPIRIN 81 mg Tablet daily
GUAIFENESIN daily

ALLERGIES: Zidovudine

PHYSICAL EXAM: Admission:
General: non responsive, intubated
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: Clear to auscultation bilaterally
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen:  distended, soft, non-tender, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: mother with DM

SOCIAL HISTORY: Homelessness - currently living with daughter and uncle. [**Name (NI) **]
been out of rehab for last 1 month. Admits to cocaine use prior
to admission, smokes [**1-7**] ppd, denies any EtoH or IV drug use. 

### Response:
{'Unspecified septicemia,Defibrination syndrome,Human immunodeficiency virus [HIV] disease,Acute and subacute necrosis of liver,Acute kidney failure, unspecified,Severe sepsis,Cardiac arrest,Cocaine abuse, continuous,Chronic hepatitis C without mention of hepatic coma'}
