CHIEF COMPLAINT: CC:[**CC Contact Info **]
Major Surgical or Invasive Procedure:
s/p washout septic knee washout in OR
s/p PICC placement
s/p GJ placement, IR guided

PRESENT ILLNESS: .
HPI: Patient is an 84 year old male who presented from NH with
hypotension. Per records as patient is poor historian d/t
dementia.  Per the patients family, he was in his USOH until [**3-31**]
days ago at [**Hospital1 **] when he was noted to be disoriented/confused.
He improved for a day but then became worse last night.  Last
night he was found to be hypotensive x 2 at the nursing home and
was tranferred to [**Hospital1 18**] for further evaluation.   He denies
cough, URI symptoms, abdominal pain, SOB, or chest pain.  +
urinary frequency without dysuria.  No sick contacts.  [**Name (NI) **] has
chronic diarrhea which has not worsened.
.
Until [**Month (only) **], the patient had been living at home with his
wife.  At that time he began falling (8-10x during [**Month (only) 321**]).
He was admitted to [**Hospital3 2568**] on [**12-13**] - 21st for workup of
these falls.  Per report from the patients son, the patient was
found to have elevated cardiac enzymes and a stress/echo that
showed an old MI.  The CE's were attributed to ARF (thought to
be prerenal).  He was transferred to [**Hospital1 **] on [**12-18**] and has
been there since.  Of note, while at [**Hospital3 2568**] the patient was
accidently given klonipin instead of clonidine and per family
report his mental status deteriorated at that time and has not
returned to baseline ( baseline MS - someone checked on 1x per
day, son lays out pills, but lived alone with wife).
.
In the ED, the patient was found to have a temp of 100.2, HR 73,
BP 88/41, RR20, O2 sats NRB.  lactate was 2.2/WBC 11.4.  A code
sepsis was called and a right subclavian was placed.  He
recieved a total of 4 L IVF with response of BP to the 120's.
He was treated with a dose of ceftriaxone and vancomycin.
Received 1 unit PRBC.  Urology was called because of difficulty
placing a foley and they were able to place a foley.  A UA was
grossly positive.  A CT abdomen was preformed which showed a AAA
as well as + perichol. fluid and GB wall enhancement.  Surgery
was consulted and an RUQ U/S was performed which did not show
evidence of cholcystitis.  Per surgery, no active surgical
issues.  He was admitted the ICU with a diagnosis of sepsis.
.

MEDICAL HISTORY: .
# Right total hip replacement in [**7-/2136**]
# Duodenal ulcer in [**2134**], status post laparotomy
# Cataract surgery in [**2130**]
# tonsils and adenoids in the [**2066**]
# CRI, unclear baseline
# knee surgery
# silent MI
# pacer placed at [**Hospital1 **] [**2140-6-28**]
.

MEDICATION ON ADMISSION: MEDS:
simvastatin 20mg QD
felodipine 5mg QD
atenolol 50mg QD
fosinopril 40mg QD
zoloft 50mg QD
omeprazole 20mg QD
calium 500mg [**Hospital1 **]
aricept 10mg QD
loperamide prn
no asa
[**1-29**] ibuprofen prn
.
ALL: NKDA

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: .
PE:  T 97.9, BP 97/51, HR 68, O2 98% on
GEN: awake, nad
HEENT: poor dentition, dry mmm
Cardiac: s1 s2 no m/r/g
Lungs: cta x 2
Abd: distended, soft, neg [**Doctor Last Name **] sign
Ext: right knee with punctate wound draining wound with
surrounding erythema, no c/c/e
Neuro: AOx1
GU: blood at tip of penis, foley inserted
.

FAMILY HISTORY: .
FH:  non-contributory
.

SOCIAL HISTORY: .
SH:  smokes cigars, no cig, quit etoh 10 yrs ago (abuse 10 yrs
ago)
.
Methicillin susceptible Staphylococcus aureus septicemia,Acute respiratory failure,Pyogenic arthritis, lower leg,Atrial fibrillation,Pneumonitis due to inhalation of food or vomitus,Septic shock,Acute kidney failure with lesion of tubular necrosis,Chronic kidney disease, unspecified,Ulcer of other part of lower limb,Cellulitis and abscess of leg, except foot,Severe sepsis,Hip joint replacement,Cardiac pacemaker in situ,Delirium due to conditions classified elsewhere,Other specified disorders of joint, lower leg,Polycystic kidney, unspecified type,Anemia of other chronic disease,Unspecified derangement of joint, pelvic region and thigh,Intestinal bypass or anastomosis status
Meth susc Staph aur sept,Acute respiratry failure,Pyogen arthritis-l/leg,Atrial fibrillation,Food/vomit pneumonitis,Septic shock,Ac kidny fail, tubr necr,Chronic kidney dis NOS,Ulcer oth part low limb,Cellulitis of leg,Severe sepsis,Joint replaced hip,Status cardiac pacemaker,Delirium d/t other cond,Joint dis NEC-l/leg,Polycystic kidney NOS,Anemia-other chronic dis,Jt derangment NOS-pelvis,Intestinal bypass status
Admission Date:  [**2143-1-28**]              Discharge Date:   [**2143-2-8**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1974**]
Chief Complaint:
CC:[**CC Contact Info **]
Major Surgical or Invasive Procedure:
s/p washout septic knee washout in OR
s/p PICC placement
s/p GJ placement, IR guided

History of Present Illness:
.
HPI: Patient is an 84 year old male who presented from NH with
hypotension. Per records as patient is poor historian d/t
dementia.  Per the patients family, he was in his USOH until [**3-31**]
days ago at [**Hospital1 **] when he was noted to be disoriented/confused.
He improved for a day but then became worse last night.  Last
night he was found to be hypotensive x 2 at the nursing home and
was tranferred to [**Hospital1 18**] for further evaluation.   He denies
cough, URI symptoms, abdominal pain, SOB, or chest pain.  +
urinary frequency without dysuria.  No sick contacts.  [**Name (NI) **] has
chronic diarrhea which has not worsened.
.
Until [**Month (only) **], the patient had been living at home with his
wife.  At that time he began falling (8-10x during [**Month (only) 321**]).
He was admitted to [**Hospital3 2568**] on [**12-13**] - 21st for workup of
these falls.  Per report from the patients son, the patient was
found to have elevated cardiac enzymes and a stress/echo that
showed an old MI.  The CE's were attributed to ARF (thought to
be prerenal).  He was transferred to [**Hospital1 **] on [**12-18**] and has
been there since.  Of note, while at [**Hospital3 2568**] the patient was
accidently given klonipin instead of clonidine and per family
report his mental status deteriorated at that time and has not
returned to baseline ( baseline MS - someone checked on 1x per
day, son lays out pills, but lived alone with wife).
.
In the ED, the patient was found to have a temp of 100.2, HR 73,
BP 88/41, RR20, O2 sats NRB.  lactate was 2.2/WBC 11.4.  A code
sepsis was called and a right subclavian was placed.  He
recieved a total of 4 L IVF with response of BP to the 120's.
He was treated with a dose of ceftriaxone and vancomycin.
Received 1 unit PRBC.  Urology was called because of difficulty
placing a foley and they were able to place a foley.  A UA was
grossly positive.  A CT abdomen was preformed which showed a AAA
as well as + perichol. fluid and GB wall enhancement.  Surgery
was consulted and an RUQ U/S was performed which did not show
evidence of cholcystitis.  Per surgery, no active surgical
issues.  He was admitted the ICU with a diagnosis of sepsis.
.



Past Medical History:
.
# Right total hip replacement in [**7-/2136**]
# Duodenal ulcer in [**2134**], status post laparotomy
# Cataract surgery in [**2130**]
# tonsils and adenoids in the [**2066**]
# CRI, unclear baseline
# knee surgery
# silent MI
# pacer placed at [**Hospital1 **] [**2140-6-28**]
.


Social History:
.
SH:  smokes cigars, no cig, quit etoh 10 yrs ago (abuse 10 yrs
ago)
.


Family History:
.
FH:  non-contributory
.


Physical Exam:
.
PE:  T 97.9, BP 97/51, HR 68, O2 98% on
GEN: awake, nad
HEENT: poor dentition, dry mmm
Cardiac: s1 s2 no m/r/g
Lungs: cta x 2
Abd: distended, soft, neg [**Doctor Last Name **] sign
Ext: right knee with punctate wound draining wound with
surrounding erythema, no c/c/e
Neuro: AOx1
GU: blood at tip of penis, foley inserted
.


Pertinent Results:
Studies:
CT abd/pelvis:
1.  Dilatation of the ascending aorta to 4.5 cm.
2.  A 2-mm right middle lobe pulmonary nodule, which can be
followed if clinically indicated in one year.
3.  Abdominal aortic aneurysm measuring 3.7 cm extending to the
common iliac arteries.
4.  Polycystic kidney disease.  Hyperdense lesions within both
kidneys likely represent hemorrhagic cysts, although these
cannot be fully evaluated on this examination.
5.  Pericholecystic fluid and mild gallbladder wall enhancement.
 If there is clinical concern for cholecystitis, gallbladder
ultrasound can be performed.
.
CT Head - No hemmorhage or mass effect
.
CXR - A left side pacemaker is seen with leads in appropriate
position. There is mild cardiomegaly. The aorta is tortuous and

dilated. The lungs are clear without focal consolidation,
effusion, or pneumothorax. The left costophrenic angle is
incompletely evaluated. The osseous structures are unremarkable.

.


Brief Hospital Course:
.
Assessment/Plan: 84 yo M with h/o CAD s/p pacer placement
transferred from MICU after sepsis and hypotension found to have
MSSA bacteremia [**3-1**] left knee infection s/p washout in OR.
.
# Sepsis/Infected Knee Joint - The patient was admitted to the
MICU with hypotension and sepsis without elevated WBC or fevers.
 He was initially started on Vanc/Gent for broad coverage until
a source could be isolated.  Blood cultures on admission grew
coag positive Staph aureus (MSSA) in [**5-1**] bottles.  He was found
to have a draining knee abscess with fistula tract to the skin
which was thought to be the source of his sepsis.  He went to
the OR with orthopedics who performed a knee washout.  Cultures
from the knee were found to be coag positive Staph aureus
(MSSA).  The patient was put on a 6 week course of Nafcillin.
He was found to have an appropriate response to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim
test.  An intra-op TEE demonstrated no significant valvular
regurgitation, but a possible small echodensity at tip of
anterior mitral leaflet.  Additionally, hip films from site of
prior total hip replacement were unremarkable making infected
hardware less likely.  Surveillance cultures were monitored and
showed no evidence of further MSSA bacteremia.  An ID consult
was obtained and they recommended reviewing the TEE with
cardiology to ensure there was no evidence of vegetations.  The
patient has a pacemaker with wires but it did not appear that
these were seeded given that his bacteremia cleared quickly and
his surveillance cultures were negative.  During his hospital
course, he was found to have some serosanguinous drainage from
his knee wound and he was followed closely by ortho.  The
drainage tapered off and there was no need for further washouts.

.
# Atrial fibrillation: Patient found to be intermittently in
atrial fibrillation during his MICU course.  Patient was not
previously anticoagulated per OSH records as well as from
history from son and daughter, but OSH records indicate history
of atrial fibrillation.  Was on heparin gtt in the MICU for
a-fib.  He was seen by cardiology during his MICU course who
recommended long term anticoagulation.  After receiving 2 doses
of Coumadin, the patient's INR climbed rapidly to 11.4 likely
due to his very poor nutritional status.  The patient required
two units of FFP to reverse this INR.  He was restarted on
Coumadin at a much lower dose, 1mg PO QOD.  His INR..   He was
maintained on low dose beta blocker for rate control.
.
# Agitation/Mental status: The patient has dementia at baseline
and per his family, this has been worsening over the last year.
The patient was intermittently agitated initially from his acute
sepsis and bacteremia, as well as from sundowning in setting of
acute illness.  He was given PRN Haldol for agitation and a 1:1
sitter as necessary.  His Aricept for dementia was held initally
given his aspiration with plans to restart after obtaining a GJ
tube.
.
# Gallbladder wall thickening - RUQ u/s without evidence of
cholecystitis. Per surgery, there was no need for acute surgical
intervention.  The patient had no evidence of ductal dilation
and only mildly elevated AST and alk phos but normal bili.
There was no current concern for an obstructive pattern.
.
# ARF -  Patient's creatinine was 3.2 upon admission which
improved to 1.5 upon IVF volume resuscitation.  Prior creatinine
1.0 in 11/[**2142**]. An FEurea was 58%. Renal U/S demonstrating
polycystic kidneys, but no frank hydronephrosis.  His
medications were renally dosed.  His ACEI was held upon
admission.  His polycystic kidneys can be further evaluated as
an outpatient.
.
# Aspiration: The patient was evaluated by speech and swallow
while in the MICU and was found to be aspirating.  An NGT was
attempted in the MICU but was unsuccessful.  The patient was
sent to fluoro for NGT placement but fluoro was also
unsuccessful in placing the NGT.  An IR guided GJ tube was also
attempted but was unsuccessful given the patient's unusual
anatomy after bowel resection for duodenal ulcer in the past.
Surgery placed a J-tube in the OR and the procedure was well
tolerated.  Tube feeds were initiated as per a nutrition
consult.  After approximately 14 hours of tube feeds, the
patient was found to have bilious emesis with respiratory
distress concerning for aspiration.  The patient was found to be
85% on RA with ABG showing pH 7.3, CO2 33, O2 37, and HCO3 17.
His O2 sat improved with 50% face mask.  A chest xray obtained
revealed a new left upper lobe consolidation concerning for
aspiration.  Additionally on CXR, free air was seen in the
peritoneum but given the patient's J-tube placement, the free
air was thought to be consistent with recent surgical procedure.
 The patient showed no signs of an acute abdomen.  Flagyl was
added to the patient's regimen for concern of aspiration.
.
# Polycystic kidneys: Not known to be on patient's problem list
prior to this hospitalization but patient is usually followed at
VA.  He had an elevated Cr to 3.4 upon admission but currently
1.6 after IVF hydration and resolution of sepsis.  Baseline
creatinine unclear.  [**Name2 (NI) **] will need to have this followed as an
outpatient.
.
# CAD s/p pacer placement: Not clear why patient has pacemaker
but thought to be from SSS (placed at [**Hospital1 2025**] in [**2140**]).  The patient
was found to have mildly elevated troponin (.12) in setting of
flat CKs.  His troponin trended down.  His elevated troponin was
thought to be related to his ARF but could also be consistent
with demand ischemia in the setting of sepsis.  He ruled out for
MI by three sets of cardiac enzymes.  As an outpatient, he was
on simvastatin, felodipine, atenolol, and fosinopril as an
outpatient.  These were held initially in the setting of
aspiration but were restarted after his J-tube was placed.
.
# Anemia: His anemia was found to be consistent with anemia of
chronic disease.  He got 1 unit PRBCs for drifting Hct in MICU
on [**2142-1-30**].  His hematocrit remained stable after receiving 1
unit PRBCs.
.
# AAA: 4.5 cm, No concern for rupture or leakage on CT without
contrast.  There is no prior imaging of the patient's AAA at
[**Hospital1 18**].  This will continued to be followed by his outpatient
doctor.
.
# Hypercholesterolemia: Continue Simvastatin when PEG placed
.
# FENL IVF as above.  Not tolerating PO intake [**3-1**] aspiration.
NG tube could not be placed by fluoro.  GJ tube was obtained for
tube feeds and meds.
.
# PPX - SQ Heparin
.
# Access - PICC line for 6 weeks of Nafcillin for septic knee
.
# Code - Full
.
# Dispo - On the morning of [**2143-2-8**], the patient was seen to
have large volume bilious green emesis after tube feeds were
started overnight with desaturation to 85% on 3L NC (which
improved with non-rebreather).  There was concern for
aspiration.  A chest xray was obtained which revealed a new LUL
consolidation concerning for aspiration.  Free air in the
peritoneum was also seen on CXR but this was consistent with
recent PEG tube placement.  Additionally, a KUB showed no
evidence of SBO.  Later in the day, the patient was found to
desaturate to the 70s on 50% face mask.  An ABG was obtained
which showed: pH 7.14, pO2 52, pCO2 44, bicarb 16, lactate 4.4.
Given the patient's respiratory distress and ABG, he was
transferred to the MICU.  He was intubated with repeat ABG
showing pH 7.08, pO2 62, pCO2 56, bicarb 18, lactate 6.0.  A
repeat CXR showed worsening bilateral opacities.  The family was
contact[**Name (NI) **] and given a decision was made to make the patient CMO.
 He passed away shortly after.
.


Medications on Admission:
MEDS:
simvastatin 20mg QD
felodipine 5mg QD
atenolol 50mg QD
fosinopril 40mg QD
zoloft 50mg QD
omeprazole 20mg QD
calium 500mg [**Hospital1 **]
aricept 10mg QD
loperamide prn
no asa
[**1-29**] ibuprofen prn
.
ALL: NKDA

Discharge Disposition:
Expired

Discharge Diagnosis:
Primary:
Respiratory failure from aspiration pneumonia
Septic shock
MSSA bacteremia from knee abscess
Open G-tube placement
.
Secondary:
s/p total hip replacement
h/o duodenal ulcer
Atrial fibrillation
CAD
ARF on CRI
Dementia

.


Discharge Condition:
Expired


Discharge Instructions:
Not applicable

Followup Instructions:
Not applicable



Completed by:[**2143-2-12**]
{'Methicillin susceptible Staphylococcus aureus septicemia,Acute respiratory failure,Pyogenic arthritis, lower leg,Atrial fibrillation,Pneumonitis due to inhalation of food or vomitus,Septic shock,Acute kidney failure with lesion of tubular necrosis,Chronic kidney disease, unspecified,Ulcer of other part of lower limb,Cellulitis and abscess of leg, except foot,Severe sepsis,Hip joint replacement,Cardiac pacemaker in situ,Delirium due to conditions classified elsewhere,Other specified disorders of joint, lower leg,Polycystic kidney, unspecified type,Anemia of other chronic disease,Unspecified derangement of joint, pelvic region and thigh,Intestinal bypass or anastomosis status'}


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: CC:[**CC Contact Info **]
Major Surgical or Invasive Procedure:
s/p washout septic knee washout in OR
s/p PICC placement
s/p GJ placement, IR guided

PRESENT ILLNESS: .
HPI: Patient is an 84 year old male who presented from NH with
hypotension. Per records as patient is poor historian d/t
dementia.  Per the patients family, he was in his USOH until [**3-31**]
days ago at [**Hospital1 **] when he was noted to be disoriented/confused.
He improved for a day but then became worse last night.  Last
night he was found to be hypotensive x 2 at the nursing home and
was tranferred to [**Hospital1 18**] for further evaluation.   He denies
cough, URI symptoms, abdominal pain, SOB, or chest pain.  +
urinary frequency without dysuria.  No sick contacts.  [**Name (NI) **] has
chronic diarrhea which has not worsened.
.
Until [**Month (only) **], the patient had been living at home with his
wife.  At that time he began falling (8-10x during [**Month (only) 321**]).
He was admitted to [**Hospital3 2568**] on [**12-13**] - 21st for workup of
these falls.  Per report from the patients son, the patient was
found to have elevated cardiac enzymes and a stress/echo that
showed an old MI.  The CE's were attributed to ARF (thought to
be prerenal).  He was transferred to [**Hospital1 **] on [**12-18**] and has
been there since.  Of note, while at [**Hospital3 2568**] the patient was
accidently given klonipin instead of clonidine and per family
report his mental status deteriorated at that time and has not
returned to baseline ( baseline MS - someone checked on 1x per
day, son lays out pills, but lived alone with wife).
.
In the ED, the patient was found to have a temp of 100.2, HR 73,
BP 88/41, RR20, O2 sats NRB.  lactate was 2.2/WBC 11.4.  A code
sepsis was called and a right subclavian was placed.  He
recieved a total of 4 L IVF with response of BP to the 120's.
He was treated with a dose of ceftriaxone and vancomycin.
Received 1 unit PRBC.  Urology was called because of difficulty
placing a foley and they were able to place a foley.  A UA was
grossly positive.  A CT abdomen was preformed which showed a AAA
as well as + perichol. fluid and GB wall enhancement.  Surgery
was consulted and an RUQ U/S was performed which did not show
evidence of cholcystitis.  Per surgery, no active surgical
issues.  He was admitted the ICU with a diagnosis of sepsis.
.

MEDICAL HISTORY: .
# Right total hip replacement in [**7-/2136**]
# Duodenal ulcer in [**2134**], status post laparotomy
# Cataract surgery in [**2130**]
# tonsils and adenoids in the [**2066**]
# CRI, unclear baseline
# knee surgery
# silent MI
# pacer placed at [**Hospital1 **] [**2140-6-28**]
.

MEDICATION ON ADMISSION: MEDS:
simvastatin 20mg QD
felodipine 5mg QD
atenolol 50mg QD
fosinopril 40mg QD
zoloft 50mg QD
omeprazole 20mg QD
calium 500mg [**Hospital1 **]
aricept 10mg QD
loperamide prn
no asa
[**1-29**] ibuprofen prn
.
ALL: NKDA

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: .
PE:  T 97.9, BP 97/51, HR 68, O2 98% on
GEN: awake, nad
HEENT: poor dentition, dry mmm
Cardiac: s1 s2 no m/r/g
Lungs: cta x 2
Abd: distended, soft, neg [**Doctor Last Name **] sign
Ext: right knee with punctate wound draining wound with
surrounding erythema, no c/c/e
Neuro: AOx1
GU: blood at tip of penis, foley inserted
.

FAMILY HISTORY: .
FH:  non-contributory
.

SOCIAL HISTORY: .
SH:  smokes cigars, no cig, quit etoh 10 yrs ago (abuse 10 yrs
ago)
. 

### Response:
{'Methicillin susceptible Staphylococcus aureus septicemia,Acute respiratory failure,Pyogenic arthritis, lower leg,Atrial fibrillation,Pneumonitis due to inhalation of food or vomitus,Septic shock,Acute kidney failure with lesion of tubular necrosis,Chronic kidney disease, unspecified,Ulcer of other part of lower limb,Cellulitis and abscess of leg, except foot,Severe sepsis,Hip joint replacement,Cardiac pacemaker in situ,Delirium due to conditions classified elsewhere,Other specified disorders of joint, lower leg,Polycystic kidney, unspecified type,Anemia of other chronic disease,Unspecified derangement of joint, pelvic region and thigh,Intestinal bypass or anastomosis status'}
