CHIEF COMPLAINT: mental status changes

PRESENT ILLNESS: Mr. [**Known lastname 104743**] is an 81 year old man with a history of PAF, PVD,
hypertension and MSSA endocarditis who presents from home with
mental status changes.  He was accompanied by his daughter who
stated that she had noticed the patient was increasingly
confused, and had subjective fevers.  He had a fall last night
without hitting head or loss of conciousness.  He also has been
having increased dyspnea on exertion that has progressed over
several weeks.  The patient has also had worsening lower
extremity edema.  Today, his legs have become warm, red and
tender.  He also has difficulty walking due to the pain.

MEDICAL HISTORY: Paroxysmal atrial fibrillation
Peripheral vascular disease
Hypertension
MSSA mitral valve endocarditis
Septic left knee joint prosthesis, status post surgical removal
of left knee hardware
History of Clostridium difficile gastritis
History of an elevated PSA with reported negative biopsies.

MEDICATION ON ADMISSION: 1.Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2.Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO QD (once a day).
3.Lisinopril 20 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
4.Furosemide 40 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
5.Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
6.Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
7.Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO QD
(once a day).
8.Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO QD (once a day).
9.Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 100.1 HR 89 BP 114/71 RR 20 Sat 94%RA
Gen: Elderly man in bed in no apparent distress.
HEENT: NCAT, mmm, PERRL.
CV: irregular, III/VI HSM radiating to axilla.
Pulm: CATB/l with bibasilar scant crackles, no rhonchi
Abd: +ecchymosis
Ext: +TTP below knees, bilateral swelling, weeping.
Neuro: A/A Ox3, president [**Last Name (un) 2450**], location, date, day.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: [**Last Name (un) **] any tobacco, alcohol, and IVDA
Currently lives at rehab facility, but prior to that was living
w/ daughter
[**Name (NI) **] was able to do [**Name (NI) 5669**], drive car prior to left knee
replacement
Acute diastolic heart failure,Cellulitis and abscess of leg, except foot,Pneumonitis due to inhalation of food or vomitus,Atrial fibrillation,Acute kidney failure with lesion of tubular necrosis,Other pulmonary insufficiency, not elsewhere classified,Retention of urine, unspecified,Toxic encephalopathy,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Hyperosmolality and/or hypernatremia,Ulcer of calf,Unspecified septicemia,Severe sepsis,Abnormal coagulation profile,Unspecified disease of pericardium,Hypotension, unspecified
Ac diastolic hrt failure,Cellulitis of leg,Food/vomit pneumonitis,Atrial fibrillation,Ac kidny fail, tubr necr,Other pulmonary insuff,Retention urine NOS,Toxic encephalopathy,Hyp kid NOS w cr kid V,Hyperosmolality,Ulcer of calf,Septicemia NOS,Severe sepsis,Abnrml coagultion prfile,Pericardial disease NOS,Hypotension NOS
Admission Date:  [**2128-11-14**]              Discharge Date:   [**2128-12-4**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 898**]
Chief Complaint:
mental status changes

Major Surgical or Invasive Procedure:
central line placement


History of Present Illness:
Mr. [**Known lastname 104743**] is an 81 year old man with a history of PAF, PVD,
hypertension and MSSA endocarditis who presents from home with
mental status changes.  He was accompanied by his daughter who
stated that she had noticed the patient was increasingly
confused, and had subjective fevers.  He had a fall last night
without hitting head or loss of conciousness.  He also has been
having increased dyspnea on exertion that has progressed over
several weeks.  The patient has also had worsening lower
extremity edema.  Today, his legs have become warm, red and
tender.  He also has difficulty walking due to the pain.

He was diagnosed with MSSA endocarditis in [**3-5**] and he
finished a 6 week course of iv abx in mid [**Month (only) 958**]. He later had
MSSA grow out from his knee and had hardware there removed.  He
has no knee pain currently.

In the ED he was started on IV oxacillin.

Past Medical History:
Paroxysmal atrial fibrillation
Peripheral vascular disease
Hypertension
MSSA mitral valve endocarditis
Septic left knee joint prosthesis, status post surgical removal
of left knee hardware
History of Clostridium difficile gastritis
History of an elevated PSA with reported negative biopsies.


Social History:
[**Last Name (un) **] any tobacco, alcohol, and IVDA
Currently lives at rehab facility, but prior to that was living
w/ daughter
[**Name (NI) **] was able to do [**Name (NI) 5669**], drive car prior to left knee
replacement


Family History:
Non-contributory

Physical Exam:
VS: T 100.1 HR 89 BP 114/71 RR 20 Sat 94%RA
Gen: Elderly man in bed in no apparent distress.
HEENT: NCAT, mmm, PERRL.
CV: irregular, III/VI HSM radiating to axilla.
Pulm: CATB/l with bibasilar scant crackles, no rhonchi
Abd: +ecchymosis
Ext: +TTP below knees, bilateral swelling, weeping.
Neuro: A/A Ox3, president [**Last Name (un) 2450**], location, date, day.

Pertinent Results:
[**2128-11-14**] 02:45AM   GLUCOSE-127* UREA N-52* CREAT-2.2* SODIUM-140
POTASSIUM-3.6 CHLORIDE-96 TOTAL CO2-30 ANION GAP-18
[**2128-11-14**] 02:45AM   CALCIUM-9.5 PHOSPHATE-2.6* MAGNESIUM-1.8

[**2128-11-14**] 02:45AM   WBC-21.2*# RBC-4.50*# HGB-12.5* HCT-38.5*
MCV-86 MCH-27.8 MCHC-32.5 RDW-14.7
[**2128-11-14**] 02:45AM   PLT COUNT-263

[**2128-11-14**] 02:45AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-0.2 PH-5.0 LEUK-NEG
[**2128-11-14**] 02:45AM URINE  HYALINE-[**7-9**]*

[**2128-11-14**] 02:45AM   PT-28.0* PTT-45.5* INR(PT)-5.8

[**2128-11-14**] 02:45AM   cTropnT-0.04*
[**2128-11-14**] 02:45AM   CK(CPK)-55
[**2128-11-14**] 03:23AM   LACTATE-3.4*

CXR: Interval development of small bilateral pleural effusions
and mild left lower lobe atelectasis. Cardiomegaly without
evidence for heart failure.

NCHCT: Stable appearance of the brain without evidence of
intracranial hemorrhage or mass effect

LENIS: No evidence of deep venous thrombosis in either lower
extremity.

ECG: Atrial fibrillation with rapid ventricular response
Loss of R waves in leads V1 and V2 consider old anteroseptal
infarct
Inferior/lateral ST-T changes may be due to myocardial ischemia
Repolarization changes may be partly due to rate/rhythm
No change from previous

ECHO: ([**11-16**]) The left atrium is mildly dilated. No atrial
septal defect is seen by 2D or color Doppler. There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF 60-70%). Right ventricular chamber size
and free wall motion are normal. The aortic root is moderately
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild to moderate ([**2-1**]+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is borderline pulmonary artery systolic hypertension. There is a
moderate sized pericardial effusion subtending primarily the
inferior and posterior walls. The effusion appears
circumferential. There are no echocardiographic signs of
tamponade. No right atrial or right ventricular diastolic
collapse is seen.

Video Swallow: Mild-to-moderate oropharyngeal dysphagia and
weakened oral phase, resulting in premature spillover and silent
aspiration of thin liquids.

ECHO ([**11-24**]):
1. Left ventricular wall thickness, cavity size, and systolic
function are  normal (LVEF>55%). Regional left ventricular wall
motion is normal.
2. The aortic valve leaflets are moderately thickened. Mild to
moderate ([**2-1**]+) aortic regurgitation is seen.
3. The mitral valve leaflets are mildly thickened.
4. There is moderate pulmonary artery systolic hypertension.
5. There is a moderate sized, circumferential, pericardial
effusion with
fibrin deposits on the surface of the heart. There are no
echocardiographic signs of tamponade.
6. Compared with the findings of the prior report of [**2128-11-22**],
the pericardial effusion may be smaller.


Brief Hospital Course:
1) Pneumonia: Patient was initially admitted due to cellulitis
and delirium.  On hospital day # 3 patient became more agitated
and was noted to be hypoxic.  A new left lower lobe pneumonia
was found on CXR.  Given his poor mental status, aspiration was
presumed.  He was transferred to the ICU due to hypoxia,
hypotension , and atrial fibrillation with rapid ventricular
response.  His pneumonia was treated with Levofloxacin and
Metronidazole and subsquently Vancomycin as well (sputum grew
MSSA).  He required significant amount of supplemental oxygen,
however mechanical ventilation was avoided (he is DNR/DNI in any
case).  His mental status improved with treatment and his oxygen
was weaned.  He had a speech and swallow evalutaion which showed
a significant risk for further aspiration and so he was
maintained on thickened liquids, and pureed solids with
aspiration precautions at meal times.  He will require a repeat
evaluation as his mental status returns to normal.

2) Cellultitis: Given history of MSSA endocarditis, he was
initially started on Oxacillin for bilateral lower extemity
cellulitis.  His chronic lower extremity edema was felt to be
the risk factor for developing this infection.  His antibiotic
was changed to Vancomycin when he clinical course worsened.  An
attempt to change back to Oxacillin resulted in a worsening of
the cellulitis so he was changed to Vancomycin to complete a 14
day course.  He also had local wound care and his cellulitis
resolved nicely.

3) Atrial fibrillation: He has a history of PAF was was in
atrial fibrillation throughout his hospital course.  His rate
was difficult to control and was complicated by episodes of
hypotension.  He was tried on a sotalol drip and a diltiazem
drip, but these medications had to be stopped due to low blood
pressure.  Eventually he was loaded on digoxin with good effect.
 Metoprolol was started and titrated up and a heart rate of
80-90 bpm was achieved.  He may need further titration of his
lopressor dose for rate control.  He will need to have digoxin
levels checked if his renal function worsens in the future.  He
was maintained on coumadin and was supratherapeutic at time of
discharge.  He will need his coumadin restarted once his INR
drops to below 2.5.

4) Delirium: The patient was intermittently delirious throughout
his hospital stay.  It was felt to be due to his infections.
His mental status improved as his clinical status improved.  Low
dose Seroquel at bedtime and prn was utilized.  Wean off
psychotropic meds as mental status improves.

5) CHF: Patient likely has diastolic dysfunction worsened by
atrial fibrillation and tachycardia.  His echocardiogram
revealed a normal EF.  After his fluid resuscitation in the ICU,
he required aggressive diuresis with IV lasix.  He was then
transitioned to his home PO regimen of Lasix 40mg daily.  His
beta blocker was titrated up as above.  He would benefit from an
ACE-I being restarted as an outpatient.

6) Pericardial Effusion: A moderate effusion was seen by Echo.
Serial Echocardiograms were followed and the effusion remained
unchanged of slightly improved.  The etiology was not clear,
although fluid overload was possible.  As the patient and family
did not wish for aggressive diagnostic measures and the
patient's clinical course was positive, no further diagnostic
studies were performed.  Patient should have a follow-up Echo to
evaluate this as an outpatient.

7) Hypernatremia: Due to free water deficit from poor PO intake.
 Treated with D5W for 2-3 liters.  Sodium improved as mental
status improved and PO intake increased.  Will need periodic
(2x/week) sodium checks at rehab and needs encouragement to have
good free water intake.

8) Acute on Chronic Renal Failure: Baseline creatinine is about
1.2-1.6.  Early in hospital course creatinine ranged from
2.2-2.4.  By the time of discharge, creatinine was stable near
baseline at 1.6.

9) Urinary retention: Still with foley in.  Needs foley to be
removed and have voiding trial at Rehab.  It still retaining,
needs urology follow-up.

10) Code Status: DNR/DNI

Medications on Admission:
1.Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2.Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO QD (once a day).
3.Lisinopril 20 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
4.Furosemide 40 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
5.Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
6.Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
7.Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO QD
(once a day).
8.Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO QD (once a day).
9.Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).


Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
2. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Ascorbic Acid 90 mg/mL Drops Sig: Five Hundred (500) mg PO
DAILY (Daily).
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical  PRN
(as needed).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QHS (once a day
(at bedtime)).
8. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO BID PRN ().
9. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours).
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Start when INR < 2.5.  Titrate to goal INR 2.0-3.0.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]

Discharge Diagnosis:
Aspiration Pneumonia
Diastolic Congestive Heart Failure
Atrial Fibrillation
Delirium
Cellulitis
Pericardial Effusion
Hypernatremia
Acute Renal Failure
Chronic Renal Failure
Urinary Retention


Discharge Condition:
good, mental status improved, oxygenation improved


Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet

Notify your doctor if you experience chest pain, shortness of
breath, palpitations, or other concerning symptoms.

Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 28190**] [**Name (STitle) 16528**] in 1 week.  Please call to
schedule appt. ([**Telephone/Fax (1) 104744**]

Repeat echocardiogram in [**3-4**] weeks

Repeat speech and swallow evaluation in [**2-1**] weeks
{'Acute diastolic heart failure,Cellulitis and abscess of leg, except foot,Pneumonitis due to inhalation of food or vomitus,Atrial fibrillation,Acute kidney failure with lesion of tubular necrosis,Other pulmonary insufficiency, not elsewhere classified,Retention of urine, unspecified,Toxic encephalopathy,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Hyperosmolality and/or hypernatremia,Ulcer of calf,Unspecified septicemia,Severe sepsis,Abnormal coagulation profile,Unspecified disease of pericardium,Hypotension, unspecified'}


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: mental status changes

PRESENT ILLNESS: Mr. [**Known lastname 104743**] is an 81 year old man with a history of PAF, PVD,
hypertension and MSSA endocarditis who presents from home with
mental status changes.  He was accompanied by his daughter who
stated that she had noticed the patient was increasingly
confused, and had subjective fevers.  He had a fall last night
without hitting head or loss of conciousness.  He also has been
having increased dyspnea on exertion that has progressed over
several weeks.  The patient has also had worsening lower
extremity edema.  Today, his legs have become warm, red and
tender.  He also has difficulty walking due to the pain.

MEDICAL HISTORY: Paroxysmal atrial fibrillation
Peripheral vascular disease
Hypertension
MSSA mitral valve endocarditis
Septic left knee joint prosthesis, status post surgical removal
of left knee hardware
History of Clostridium difficile gastritis
History of an elevated PSA with reported negative biopsies.

MEDICATION ON ADMISSION: 1.Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2.Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO QD (once a day).
3.Lisinopril 20 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
4.Furosemide 40 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
5.Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
6.Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
7.Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO QD
(once a day).
8.Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO QD (once a day).
9.Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 100.1 HR 89 BP 114/71 RR 20 Sat 94%RA
Gen: Elderly man in bed in no apparent distress.
HEENT: NCAT, mmm, PERRL.
CV: irregular, III/VI HSM radiating to axilla.
Pulm: CATB/l with bibasilar scant crackles, no rhonchi
Abd: +ecchymosis
Ext: +TTP below knees, bilateral swelling, weeping.
Neuro: A/A Ox3, president [**Last Name (un) 2450**], location, date, day.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: [**Last Name (un) **] any tobacco, alcohol, and IVDA
Currently lives at rehab facility, but prior to that was living
w/ daughter
[**Name (NI) **] was able to do [**Name (NI) 5669**], drive car prior to left knee
replacement 

### Response:
{'Acute diastolic heart failure,Cellulitis and abscess of leg, except foot,Pneumonitis due to inhalation of food or vomitus,Atrial fibrillation,Acute kidney failure with lesion of tubular necrosis,Other pulmonary insufficiency, not elsewhere classified,Retention of urine, unspecified,Toxic encephalopathy,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Hyperosmolality and/or hypernatremia,Ulcer of calf,Unspecified septicemia,Severe sepsis,Abnormal coagulation profile,Unspecified disease of pericardium,Hypotension, unspecified'}
