CHIEF COMPLAINT: sepsis

PRESENT ILLNESS: this is a 74yo F w/ metatstatic sarcamatoid kidney cancer to L1,
T9, pelvic bone, liver, lung, skull currently undergoing
chemotherapy, Addison's on prednisone and recent hospitalization
for hypotension and fever, now admitted for fever to 102 in last
24hrs. 2 days prior to admission, she reports that she felt well
and had been afebrile but then progressively became more
confused w/ increased tenderness near her port site. She denies
any cough, SOB, CP, N/V, diarrhea, HA or sick contacts. [**Name (NI) **]
called ambulance yesterday when he noticed change in pt's MS.
.
Since admission, she was found to have elevated lactate levels,
and port site noted to have purulent drainage. This was removed,
and empiric abx were started - given cefepime, vanc, and flagyl.
Fem line was placed as pt has difficult access. Pt's blood cx
has grown out GPCPC, and she was continued on vancomycin. She
defervesced quickly, and has remained afebrile for 24hrs. She
has remained hemodynamically stable, and she is being
transferred to the floor for further management.

MEDICAL HISTORY: 1. Addison disease diagnosed at 37 years of age.
2. Hypercholesterolemia, on Lipitor in the past. The patient
recently stopped the Lipitor, which resulted in improved kidney

MEDICATION ON ADMISSION: atenolol 25 mg daily
valsartan 160 mg daily
isosorbide mononitrate 30 mg daily
lisinopril 40 mg daily
prednisone 10 mg twice daily
docusate 100 mg twice daily
senna 1 tablet twice daily
potassium and sodium phosphate 2 packets daily
ranitidine 150 mg daily
magnesium hydroxide 30 mL every 6 hours as needed
albuterol 2-4 puffs every 6 hours as needed
simethicone as needed
aspirin 325 mg daily

ALLERGIES: Penicillins / Caffeine / Quinine / Ampicillin

PHYSICAL EXAM: VS: Temp: 99.7 BP: 93 /44 HR:75 RR: 16 100% 4l ncO2sat-->91%
room air
.
general: ill-appearing, pleasant, uncomfortable secondary to
pain
HEENT: PERLLA, EOMI, anicteric, posterior skull with multiple
raised areas, no sinus tenderness, MMdry , op without lesions,
no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
lungs: crackles bilaterally
chest: kyphosis, tenderness at former port-a-cath site--site is
erythematous, warm and tender
heart: RR, S1 and S2 wnl, no murmurs, rubs or gallops
appreciated
abdomen: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
extremities: no cyanosis, clubbing or edema
skin/nails: chest skin as above--otherwise no rashes or lesions.

FAMILY HISTORY: One brother died at a young age probably secondary to Addison
disease. One brother has prostate cancer. One daughter has
melanoma. Her father had [**Name2 (NI) 499**] cancer. Two brothers have
coronary artery disease. There is no history of
osteoporosis in her family.

SOCIAL HISTORY: The patient used to smoke a pack and a half since [**17**] years of
age until 65 years of age. She does not drink alcohol. She is a
widow. She has 6 children and 18 grandchildren. She currently
lives with her son and his family. She used to work as a
waitress and then she had an office job.
Infection and inflammatory reaction due to other vascular device, implant, and graft,Other staphylococcal septicemia,Severe sepsis,Acute kidney failure, unspecified,Secondary malignant neoplasm of lung,Secondary malignant neoplasm of bone and bone marrow,Mitral valve disorders,Chronic airway obstruction, not elsewhere classified,Chronic kidney disease, unspecified,Cellulitis and abscess of trunk,Thrombocytopenia, unspecified,Malignant neoplasm of kidney, except pelvis,Long-term (current) use of steroids,Coronary atherosclerosis of native coronary artery,Osteoporosis, unspecified,Pure hypercholesterolemia,Anemia, unspecified,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use
React-oth vasc dev/graft,Staphylcocc septicem NEC,Severe sepsis,Acute kidney failure NOS,Secondary malig neo lung,Secondary malig neo bone,Mitral valve disorder,Chr airway obstruct NEC,Chronic kidney dis NOS,Cellulitis of trunk,Thrombocytopenia NOS,Malig neopl kidney,Long-term use steroids,Crnry athrscl natve vssl,Osteoporosis NOS,Pure hypercholesterolem,Anemia NOS,Adv eff antineoplastic
Admission Date:  [**2108-4-30**]              Discharge Date:   [**2108-5-8**]

Date of Birth:  [**2033-9-26**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Caffeine / Quinine / Ampicillin

Attending:[**First Name3 (LF) 18369**]
Chief Complaint:
sepsis

Major Surgical or Invasive Procedure:
femoral line placement
PICC line placed by IR
port removal by general surgery

History of Present Illness:
this is a 74yo F w/ metatstatic sarcamatoid kidney cancer to L1,
T9, pelvic bone, liver, lung, skull currently undergoing
chemotherapy, Addison's on prednisone and recent hospitalization
for hypotension and fever, now admitted for fever to 102 in last
24hrs. 2 days prior to admission, she reports that she felt well
and had been afebrile but then progressively became more
confused w/ increased tenderness near her port site. She denies
any cough, SOB, CP, N/V, diarrhea, HA or sick contacts. [**Name (NI) **]
called ambulance yesterday when he noticed change in pt's MS.
.
Since admission, she was found to have elevated lactate levels,
and port site noted to have purulent drainage. This was removed,
and empiric abx were started - given cefepime, vanc, and flagyl.
Fem line was placed as pt has difficult access. Pt's blood cx
has grown out GPCPC, and she was continued on vancomycin. She
defervesced quickly, and has remained afebrile for 24hrs. She
has remained hemodynamically stable, and she is being
transferred to the floor for further management.

Past Medical History:
1. Addison disease diagnosed at 37 years of age.
2. Hypercholesterolemia, on Lipitor in the past. The patient
recently stopped the Lipitor, which resulted in improved kidney

function, which allowed her to enter the chemotherapy trial.
3. Hypotension.
4. Chronic renal insufficiency.
5. COPD.
6. Peripheral vascular disease with bilateral carotid stenoses
status post TIA. In [**8-/2103**], the patient had left upper
extremity weakness and slurred speech with complete resolution
in
less than 24 hours.
7. Coronary artery disease (1 vessel). The first cardiac cath
in [**8-/2103**] showed total occlusion of right coronary artery. PCI

failed at that time. However, there were significant
left-to-right collaterals. Second cardiac cath in [**12/2107**] showed

no progression of her coronary artery disease. 60% diag, 40%lad

8. Preserved EF in past--echo [**2103**]-50%, cath showed normal index
in [**2107**] and RVG [**2108-3-28**] recently with ef of 72%
9. Osteoporosis, on Fosamax for 2 years and then on Forteo for 2

months, which she stopped at the end of [**Month (only) 359**]. Status post
undisplaced pathological fracture of her right pelvis, both
inferior and superior rami in 09/[**2107**].
10. Metastatic sarcomatoid kidney cancer.
11. Right ear deafness.
12. RAD


Social History:
The patient used to smoke a pack and a half since [**17**] years of
age until 65 years of age. She does not drink alcohol. She is a
widow. She has 6 children and 18 grandchildren. She currently
lives with her son and his family. She used to work as a
waitress and then she had an office job.


Family History:
One brother died at a young age probably secondary to Addison
disease. One brother has prostate cancer. One daughter has
melanoma. Her father had [**Name2 (NI) 499**] cancer. Two brothers have
coronary artery disease. There is no history of
osteoporosis in her family.


Physical Exam:
VS: Temp: 99.7 BP: 93 /44 HR:75 RR: 16 100% 4l ncO2sat-->91%
room air
.
general: ill-appearing, pleasant, uncomfortable secondary to
pain
HEENT: PERLLA, EOMI, anicteric, posterior skull with multiple
raised areas, no sinus tenderness, MMdry , op without lesions,
no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
lungs: crackles bilaterally
chest: kyphosis, tenderness at former port-a-cath site--site is
erythematous, warm and tender
heart: RR, S1 and S2 wnl, no murmurs, rubs or gallops
appreciated
abdomen: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
extremities: no cyanosis, clubbing or edema
skin/nails: chest skin as above--otherwise no rashes or lesions.

neuro: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated.


Pertinent Results:
*** CULTURE DATA  ***
[**2108-5-7**]: blood cx X 2 pending
[**2108-5-6**]: blood cx X 4 pending
[**2108-5-6**]: Cdiff pending
[**2108-5-6**]: Urine cx pending
[**2108-5-6**]: Cdiff negative
[**2108-5-3**]: blood cx pending X 2
[**2108-5-1**]: blood cx X 2 pending
[**2108-5-1**]: blood cx X 4 negative
[**2108-4-30**]: blood cx X 2 negative
[**2108-4-30**]: cath tip coag pos S.aureus, ox sensitive
[**2108-4-30**]: abscess: 2+ PMN, 3+ GPC in prs and clusters.  Ox
sensitive coag pos S. aureus
[**2108-4-30**]: Stool Cdiff negative
[**2108-4-30**]: urine cx no growth
[**2108-4-30**]: blood cx: S. aureus, ox sensitive.
.
EKG: NSR at 75, nl axis, nl intervals, no st changes.
.
Radiologic: CXR:
INDICATION: Addison's disease and metastatic sarcomatoid kidney
cancer, now with fever.

COMPARISON: Four previous chest radiographs including [**4-10**], [**2108**] and
[**2108-4-16**].
FINDINGS: There is a new right central line, the tip overlying
the distal SVC. No pneumothorax is seen. The heart size and
mediastinal contours are stable. There are bilateral linear
interstitial markings consistent with CHF on a background of
emphysema. Left upper lung mass is partially obscured by the
scapular shadow, but persists. Cholecystectomy clips and left
upper abdominal curvilinear calcifications are better seen on
today's exam.
IMPRESSION: CHF on a background of emphysema.
.
ECHO [**2108-5-4**]: EF 60-65%, 1+ MR, mod pulm artery HTN, no valvular
vegetations.


Brief Hospital Course:
Assessment and Plan: 74 year-old woman with metastatic
sarcamatoid kidney cancer, Addison's disease, admitted with
fever and hypotension likely from port infection. Port removed
by general surgery on admission - blood cx from admission
growing MSSA, with last positive blood culture [**2108-4-30**].  Port
cath tip growing MSSA.
.
# GPC/MSSA sepsis: Port is likely source of infxn given
purulence when it was examined in ED; was improving initially
after starting on vancomycin. Transitioned to PO prednisone from
stress-dose steroids on admission. MSSA organism initially
treated with vancomycin, now transitioned to IV Cefazolin 2g
q12h per Infectious Disease consultant recommendation (increased
from 1g IV). TTE to eval for vegetation in setting of gram
positive sepsis was negative; TEE was performed also confirming
no endocarditis.  The pt will continue IV cefazolin 2g IV q12h
until seen by ID ([**2108-6-6**]) by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].  She is to have
weekly CBC with diff, LFTs drawn and faxed to Dr. [**First Name (STitle) **] (see
prescription for outpt lab work).  She is to continue prednisone
5mg po bid until seen by her oncologist (see follow up appt).
She remains afebrile, with port site without erythema,
induration or drainage.  The site is non-painful and appears to
be healing well.  Her stress dose steroids were tapered to po
prednisone, and she will continue with 5mg po bid on discharge.
.
# Elevated WBC ct, persistent during admission: No clear source.
 Last positive blood culture was [**2108-4-30**].  UA negative with neg
Urine cx.  Stool is Cdiff negative X 2.  TEE was negative for
valvular lesions.  Pt continues to be afebrile.  VSS. A RUQ
ultrasound was ordered to assess for RUE DVT, and was negative.
Blood cultures were checked qd and her last positive blood cx
was [**2108-4-30**].  She will continue IV Cefazolin until seen by
Infectious Disease as an outpt.
.
# Hypotension, resolved: At baseline, BP fluctuates given hx of
Addison's. However, considered other etiologies for hypotension
- sepsis, adrenal insufficiency (s/p IV steroids tapered to po
prednisone), cardiogenic given cad history (unlikely),
hypovolemia/bleeding - hematocrit drop likely secondary to
fluids. BP increased during her admission so pt restarted on
outpt BP regimen (ACEI, BB, [**Last Name (un) **]). At discharge, her blood
pressure was within the normal range on her antihypertensive
regimen (atenolol, lisinopril and valsartan).  Her IV Cefazolin
should be continued.  We continued her steroids, tapered down to
5mg po bid, and she will see her PCP or endocrinologist as an
outpatient, where further steroid taper can be addressed.
.
# COPD: Uses oxygen intermittently at home. She is stable at 99%
on RA.  She continued albuterol prn, cont steroids.
.
# Addison's: Was receiving hydrocort in ICU; transitioned to PO
steroids. Appears stable w/ prednisone 5mg [**Hospital1 **]. She just
transferred endocrine care to [**Hospital1 18**] and will f/u with them as
needed.  We continued to taper her prednisone dose while she was
admitted.  She will be discharged on 5mg po bid.  She should f/u
with her PCP or endocrinologist for further tapering.
.
# Acute on chronic renal failure: Baseline Cr near 1.5; may have
had failure from prerenal etiology. Now improving w/ IVF and
renally dosing meds. restarted ACEI as she is hypertensive and
renal fxn back to baseline. At discharge, her Cr was better than
her baseline creatinine.
.
# Anemia/ thrombocytopenia: likely secondary to chronic disease,
renal disease, chemotherapy. Will need to monitor plts closely
as she is trending down - send HIT ab in this situation
- tx pRBC for goal Hct >24 and plts >10
.
# CAD: has hx 1 vessel dx w/ no interventions
- continue aspirin, beta blocker, ACEI
.
# PVD/TIA-- continue aspirin
.
# PPX: heparin sc, protonix with steroids, ISS
.
# Pain: both at port-a-cath site and due to bone mets; on
tylenol #3 at home, pain is now well controlled with Tylenol
III's.
.
# IV access: double lumen PICC and PIV
.
# DNR/DNI
.
# Communication: daughter [**Telephone/Fax (1) 34406**] [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) 34407**]
.

Medications on Admission:
atenolol 25 mg daily
valsartan 160 mg daily
isosorbide mononitrate 30 mg daily
lisinopril 40 mg daily
prednisone 10 mg twice daily
docusate 100 mg twice daily
senna 1 tablet twice daily
potassium and sodium phosphate 2 packets daily
ranitidine 150 mg daily
magnesium hydroxide 30 mL every 6 hours as needed
albuterol 2-4 puffs every 6 hours as needed
simethicone as needed
aspirin 325 mg daily


Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Valsartan 80 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Cefazolin 2 gm IV Q12H
7. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8
hours) as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
8. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
Disp:*1 MDI* Refills:*2*
9. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO
Q4H (every 4 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
Disp:*60 Tablet(s)* Refills:*0*
11. Heparin Flush CVL  (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN.  Inspect site every shift
12. Outpatient Lab Work
Please check weekly CBC with differential, BUN, Cr, ALT, AST,
alk phos, and total bilirubin and fax results to Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] in Infectious Disease clinic at : [**Telephone/Fax (1) 1419**].


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 511**] Home therapy

Discharge Diagnosis:
1. MSSA bacteremia
2. Addison's disease
3. Acute on chronic renal failure
4. Anemia
5. Thrombocytopenia
6. Coronary Artery disease
7. Peripheral vascular disease
8. history of Transient Ischemic Attack


Discharge Condition:
Stable, good


Discharge Instructions:
Please take all of your medications and keep all of your
appointments.

If you get worsening pain around the site of the line, or
increased drainage, or if you have fevers, chills, or other
concerning symptoms, please call your primary care doctor or go
to the emergency room.

Followup Instructions:
1.  Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2108-5-14**] 1:00
2.  Provider: [**Name10 (NameIs) **],HEM/ONC HEMATOLOGY/ONCOLOGY-CC9
Date/Time:[**2108-5-14**] 1:00
3.  Provider: [**Name10 (NameIs) **] FELT, RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2108-5-14**] 1:30
4.  Provider: [**First Name8 (NamePattern2) 1037**] [**Last Name (NamePattern1) **], MD INFECTIOUS DISEASE CLINIC.  Your
appointment has been set for: [**2108-6-6**] at 10:30am.  Please
call [**Telephone/Fax (1) 457**] if you have questions.



Completed by:[**2108-5-8**]
{'Infection and inflammatory reaction due to other vascular device, implant, and graft,Other staphylococcal septicemia,Severe sepsis,Acute kidney failure, unspecified,Secondary malignant neoplasm of lung,Secondary malignant neoplasm of bone and bone marrow,Mitral valve disorders,Chronic airway obstruction, not elsewhere classified,Chronic kidney disease, unspecified,Cellulitis and abscess of trunk,Thrombocytopenia, unspecified,Malignant neoplasm of kidney, except pelvis,Long-term (current) use of steroids,Coronary atherosclerosis of native coronary artery,Osteoporosis, unspecified,Pure hypercholesterolemia,Anemia, unspecified,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use'}


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: sepsis

PRESENT ILLNESS: this is a 74yo F w/ metatstatic sarcamatoid kidney cancer to L1,
T9, pelvic bone, liver, lung, skull currently undergoing
chemotherapy, Addison's on prednisone and recent hospitalization
for hypotension and fever, now admitted for fever to 102 in last
24hrs. 2 days prior to admission, she reports that she felt well
and had been afebrile but then progressively became more
confused w/ increased tenderness near her port site. She denies
any cough, SOB, CP, N/V, diarrhea, HA or sick contacts. [**Name (NI) **]
called ambulance yesterday when he noticed change in pt's MS.
.
Since admission, she was found to have elevated lactate levels,
and port site noted to have purulent drainage. This was removed,
and empiric abx were started - given cefepime, vanc, and flagyl.
Fem line was placed as pt has difficult access. Pt's blood cx
has grown out GPCPC, and she was continued on vancomycin. She
defervesced quickly, and has remained afebrile for 24hrs. She
has remained hemodynamically stable, and she is being
transferred to the floor for further management.

MEDICAL HISTORY: 1. Addison disease diagnosed at 37 years of age.
2. Hypercholesterolemia, on Lipitor in the past. The patient
recently stopped the Lipitor, which resulted in improved kidney

MEDICATION ON ADMISSION: atenolol 25 mg daily
valsartan 160 mg daily
isosorbide mononitrate 30 mg daily
lisinopril 40 mg daily
prednisone 10 mg twice daily
docusate 100 mg twice daily
senna 1 tablet twice daily
potassium and sodium phosphate 2 packets daily
ranitidine 150 mg daily
magnesium hydroxide 30 mL every 6 hours as needed
albuterol 2-4 puffs every 6 hours as needed
simethicone as needed
aspirin 325 mg daily

ALLERGIES: Penicillins / Caffeine / Quinine / Ampicillin

PHYSICAL EXAM: VS: Temp: 99.7 BP: 93 /44 HR:75 RR: 16 100% 4l ncO2sat-->91%
room air
.
general: ill-appearing, pleasant, uncomfortable secondary to
pain
HEENT: PERLLA, EOMI, anicteric, posterior skull with multiple
raised areas, no sinus tenderness, MMdry , op without lesions,
no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
lungs: crackles bilaterally
chest: kyphosis, tenderness at former port-a-cath site--site is
erythematous, warm and tender
heart: RR, S1 and S2 wnl, no murmurs, rubs or gallops
appreciated
abdomen: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
extremities: no cyanosis, clubbing or edema
skin/nails: chest skin as above--otherwise no rashes or lesions.

FAMILY HISTORY: One brother died at a young age probably secondary to Addison
disease. One brother has prostate cancer. One daughter has
melanoma. Her father had [**Name2 (NI) 499**] cancer. Two brothers have
coronary artery disease. There is no history of
osteoporosis in her family.

SOCIAL HISTORY: The patient used to smoke a pack and a half since [**17**] years of
age until 65 years of age. She does not drink alcohol. She is a
widow. She has 6 children and 18 grandchildren. She currently
lives with her son and his family. She used to work as a
waitress and then she had an office job. 

### Response:
{'Infection and inflammatory reaction due to other vascular device, implant, and graft,Other staphylococcal septicemia,Severe sepsis,Acute kidney failure, unspecified,Secondary malignant neoplasm of lung,Secondary malignant neoplasm of bone and bone marrow,Mitral valve disorders,Chronic airway obstruction, not elsewhere classified,Chronic kidney disease, unspecified,Cellulitis and abscess of trunk,Thrombocytopenia, unspecified,Malignant neoplasm of kidney, except pelvis,Long-term (current) use of steroids,Coronary atherosclerosis of native coronary artery,Osteoporosis, unspecified,Pure hypercholesterolemia,Anemia, unspecified,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use'}
