CHIEF COMPLAINT: Fever

PRESENT ILLNESS: 73F with paraplegia, recurrent UTI, chronic sacral decubs,
presenting with fever and altered mental status. She was seen by
her NP yesterday with fever to 102 and positive UA. Her sacral
decub was noted to be improved since last exam. Cipro started
for UTI. Also seen by her visiting nurse today and son reported
that overnight she was confused, talking about getting up to
walk (though paraplegic) and ?visual hallucinations. Per son,
this is similar to when she has had UTIs in the past. She does
admit to sore throat and cough for a few days. Cough
nonproductive though feels she has something to cough up. No
shortness of breath or chest pain. No GI symptoms. No known
sick/flu contacts. [**Name (NI) **] recalls incident in which she told
her son she was going to get up and walk, and thought she was
dreaming. Pt DNR/[**Name6 (MD) 835**] [**Name8 (MD) **] NP.

MEDICAL HISTORY: - Paraplegia [**1-6**] Anterior Spinal Infarct ([**2128**]) - patient
reports no sensation or motor function below T8.
- Thoracic Aneurysm Repair ([**2128**])
- COPD (no PFTs in system; has been on home O2 in past though
none recently)
- HTN
- Hyperlipidemia
- GERD
- Suprapubic Catheter Placement / UTIs on Ppx Bactrim
- Fecal Incontinence
- Depression
- Atraumatic comminuted L intertrochanteric femur fracture
- Chronic sacral decubitus ulcers with past bilateral ischial
tuberosity osteomyelitis
- History of MRSA bacteremia [**11/2137**] thought to be due to sacral
decub abscess and osteomyelitis

MEDICATION ON ADMISSION: Advair 250/50 [**Hospital1 **]
ASA 81 mg daily
Alendronate 70 mg daily
Baclofen 10 mg TID
Bactrim DS [**Hospital1 **]
Colace 100 mg [**Hospital1 **]
gabapentin 900 mg TID
miralax 17grams daily
senna [**Hospital1 **]
nortriptyline 50 mg HS
tizanidine 2 mg TID
wellbutrin 100 mg [**Hospital1 **]

ALLERGIES: Adhesive Tape

PHYSICAL EXAM: General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, PERRL 4->2, MM slightly dry, posterior
oropharynx very difficult to fully visualize.
Neck: supple, JVD to 4 cm ASA, no LAD
Lungs: Few expiratory rhonchi, L>R. No crackles.
CV: Distant heart sounds. Regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Abdomen: appears grossly distended, though unchanged per
patient. Soft, non-tender, bowel sounds present, no rebound
tenderness or guarding, no organomegaly. Suprapubic catheter
site appears benign.
Back: stage IV sacral decub, appears to be down to bone, approx
4x4cm. No drainage or significant surrounding erythema, appears
to have good granulation tissue.
Ext: Slightly cool hands otherwise warm and well perfused, no
clubbing, cyanosis. Trace UE and LE edema, equal bilaterally.
Small pressure ulcers on bilateral heels.
Neuro: Alert and appropriate. CN II-XII intact, UE strength and
sensation preserved. LE sensation and movement absent. No
sensation from abdomen inferiorly.

FAMILY HISTORY: Son has DM

SOCIAL HISTORY: Lives with son (recently returned home from rehab in late
[**Month (only) 359**]) and has VNA. Smoked 2-3ppd x 40+ years, denies smoking
in last few years. No alcohol or illicit drug use.
Unspecified septicemia,Pressure ulcer, stage IV,Septic shock,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Paraplegia,Severe sepsis,Other dependence on machines, supplemental oxygen,Late effect of complications of surgical and medical care,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Flatulence, eructation, and gas pain,Other disorders of muscle, ligament, and fascia,Esophageal reflux,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Depressive disorder, not elsewhere classified
Septicemia NOS,Pressure ulcer, stage IV,Septic shock,Pneumonia, organism NOS,Urin tract infection NOS,Paraplegia NOS,Severe sepsis,Depend-supplement oxygen,Late eff surg/med compl,Abn react-anastom/graft,Flatul/eructat/gas pain,Muscle/ligament dis NEC,Esophageal reflux,Hypertension NOS,Hyperlipidemia NEC/NOS,Depressive disorder NEC
Admission Date:  [**2138-10-15**]              Discharge Date:   [**2138-10-23**]

Date of Birth:  [**2065-8-18**]             Sex:   F

Service: MEDICINE

Allergies:
Adhesive Tape

Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Fever

Major Surgical or Invasive Procedure:
None

History of Present Illness:
73F with paraplegia, recurrent UTI, chronic sacral decubs,
presenting with fever and altered mental status. She was seen by
her NP yesterday with fever to 102 and positive UA. Her sacral
decub was noted to be improved since last exam. Cipro started
for UTI. Also seen by her visiting nurse today and son reported
that overnight she was confused, talking about getting up to
walk (though paraplegic) and ?visual hallucinations. Per son,
this is similar to when she has had UTIs in the past. She does
admit to sore throat and cough for a few days. Cough
nonproductive though feels she has something to cough up. No
shortness of breath or chest pain. No GI symptoms. No known
sick/flu contacts. [**Name (NI) **] recalls incident in which she told
her son she was going to get up and walk, and thought she was
dreaming. Pt DNR/[**Name6 (MD) 835**] [**Name8 (MD) **] NP.

In the ED, initial vs were: T98.4 77 115/60 18 92% on RA.
Initially tried on 2 L O2 but O2 sats drifted to upper 80s, thus
increased to 4L. Initially normotensive with subsequent BP down
again to upper 80s despite 3 L NS. CXR with ?RLL process but
officially read as no acute process. UA positive. Received vanco
and levofloxacin. Debating MICU vs. floor admission but
ultimately admitted to MICU given borderline BPs and O2 sats.

Review of systems:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied cough, shortness of breath. Denied chest pain or
tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. Denied arthralgias or myalgias.


Past Medical History:
- Paraplegia [**1-6**] Anterior Spinal Infarct ([**2128**]) - patient
reports no sensation or motor function below T8.
- Thoracic Aneurysm Repair ([**2128**])
- COPD (no PFTs in system; has been on home O2 in past though
none recently)
- HTN
- Hyperlipidemia
- GERD
- Suprapubic Catheter Placement / UTIs on Ppx Bactrim
- Fecal Incontinence
- Depression
- Atraumatic comminuted L intertrochanteric femur fracture
- Chronic sacral decubitus ulcers with past bilateral ischial
tuberosity osteomyelitis
- History of MRSA bacteremia [**11/2137**] thought to be due to sacral
decub abscess and osteomyelitis

Social History:

Lives with son (recently returned home from rehab in late
[**Month (only) 359**]) and has VNA. Smoked 2-3ppd x 40+ years, denies smoking
in last few years. No alcohol or illicit drug use.


Family History:
Son has DM

Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, PERRL 4->2, MM slightly dry, posterior
oropharynx very difficult to fully visualize.
Neck: supple, JVD to 4 cm ASA, no LAD
Lungs: Few expiratory rhonchi, L>R. No crackles.
CV: Distant heart sounds. Regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Abdomen: appears grossly distended, though unchanged per
patient. Soft, non-tender, bowel sounds present, no rebound
tenderness or guarding, no organomegaly. Suprapubic catheter
site appears benign.
Back: stage IV sacral decub, appears to be down to bone, approx
4x4cm. No drainage or significant surrounding erythema, appears
to have good granulation tissue.
Ext: Slightly cool hands otherwise warm and well perfused, no
clubbing, cyanosis. Trace UE and LE edema, equal bilaterally.
Small pressure ulcers on bilateral heels.
Neuro: Alert and appropriate. CN II-XII intact, UE strength and
sensation preserved. LE sensation and movement absent. No
sensation from abdomen inferiorly.


Pertinent Results:
WBC 6.6
Hct 33.4 MCV 87
Plts 306

Na 140  K 3.3  Cl 107  HCO3 25  BUN 7  Cr 0.4  Gluc 144
Ca 7.4  Mg 2.1  Phos 2.5
ALT 39
AST 34
MB 2
Trop 0.02
BNP 556

Lact 2.3
UCx negative
BCx negative x2

CXR [**2138-10-15**]: The patient is rotated for the examination. The
lungs are clear without consolidation or edema. Again seen is
massive dilation and ectasia of the thoracic aorta with a
particular contour abnormality noted along the course of the
descending thoracic aorta. The cardiac silhouette size is within
normal limits. No definite effusion or pneumothorax is seen.
Chronic bony deformity consistent likely with prior left
thoracotomy is stable. Numerous surgical clips are noted over
the mediastinum. IMPRESSION: No acute pulmonary process.
Markedly dilated and ectatic aorta similar to prior studies but
accentuated by rotation. There is a focal outpouching along the
course of the descending thoracic aorta which may be
superimposition of pulmonary vessels or true contour abnormality
suggesting true or false aneurysm formation.
Addendum: In retrospect, in comparison to multiple prior
radiographs, the contour of the descending thoracic aorta is
stable and is unlikely to represent an acute process.
Additionally, there is subtle silhouetting of the right
hemidiaphragm which may correspond to increased opacity noted on
the lateral view. Atelectasis or an early infiltrate involving
the right lower lobe cannot be entirely excluded.
.
EKG: NSR at 74, normal intervals, borderline LAD, poor RWP, no
ST/T changes, overall minimally changed from prior.
.
[**2138-10-19**] KUB: FINDINGS: Comparison is made to the prior CT scan
and radiographs from [**2138-4-11**].
Similar to the prior studies, there was again seen marked
distention of
several small bowel loops. There is also stool and air is seen
throughout the colon.
No free intraperitoneal air is seen on the decubitus
radiographs. CT scan
will be helpful for further evaluation of the area of
obstruction. There is again noted a fracture deformity involving
the left proximal femur at the intertrochanteric region which is
unchanged since [**2137-10-5**].


Brief Hospital Course:
73F with paraplegia, COPD, recurrent UTI, presenting with UTI,
confusion, mild hypoxia and relative hypotension.

# Hypotension. Pt was mildly low BP's with baseline 100-110's.
Pt responded to IV fluids. Cardaic enzymes were neg. Likely [**1-6**]
to UTI/urosepsis. Pt was given [**Last Name (un) 104**] stim test which responded
appropriately.

# Hypoxia. Pt was on home oxygen in past for COPD, though not
currently. No evidence of PNA. Pt's O2 requirement was weaned,
and pt was also given nebs.

# Fever. Pt has fever to 101 at NP's office but was afebrile
during hospital stay. Likely [**1-6**] to UTI. Sacral decub appears
well. Ortho consulted regarding possibility of osteo, however
rec biopsy at a time when pt is off all antibiotics for at least
5 days. Pt was initially started on Vanc/Zosyn/Cipro for
complicated UTI, then eventually [**Last Name (un) 4662**] down to PO Cefpodoxime
for a total of 14 day course (last dose on [**10-28**]). Blood cx were
neg and flu swab was neg. First urine cx had fecal contamination
but subsequent one was neg.

# UTI. Has had a number of FQ and 2nd-3rd genereation
cephalosporin resistent organisms in the past. Also had history
of enterococcus in the past. On Bactrim prophylaxis at home. Pt
was thus initially started on Vanc/Zosyn/Cipro given
hypotension, then transitioned to PO Cefpodoxime for a total of
14d course (last day [**10-28**]). Pt improved clinically and remained
afebrile.

# Suprapubic catheter. Changed q month and needs to be changed.

# Sacral decub. Stage IV, did not appear overtly infected. Was
followed by wound care during hospital stay.

# Abdominal distension. Patient's abdomen is chronically
distended, but soft, no signs of an acute abdomen.  KUB on [**10-19**]
showed marked distention of
several small bowel loops, but similar to the prior studies.
also, no free intraperitoneal air was seen. Patient reports this
distension is no change from baseline. Pt did not have BMs for
several days. Bowel regimen was then escalated, with pt having
soft BMs by the day of discharge. If there is again a concern
regarding distension, a repeat KUB can be performed to reassess.
.
# Paraplegia. Was stable, pt was continued home meds
(tizanidine, baclofen, gabapentin, nortriptyline).
.
Pt was on a regular diet, on SC heparin for DVT ppx. Pt was
DNR/DNI and contact was son [**Male First Name (un) 1704**] [**Telephone/Fax (1) 4655**]. It was
originally though that perhps the pt could be discharged home
with services, however [**Name6 (MD) **] visiting RN emailed with concern
regarding that option- felt the pt needed to be in [**Hospital1 1501**] at least
for some time until she imrpoves further clinically.


Medications on Admission:
Advair 250/50 [**Hospital1 **]
ASA 81 mg daily
Alendronate 70 mg daily
Baclofen 10 mg TID
Bactrim DS [**Hospital1 **]
Colace 100 mg [**Hospital1 **]
gabapentin 900 mg TID
miralax 17grams daily
senna [**Hospital1 **]
nortriptyline 50 mg HS
tizanidine 2 mg TID
wellbutrin 100 mg [**Hospital1 **]


Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
4. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO Q8H
(every 8 hours).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Nortriptyline 25 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
7. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
8. Bupropion HCl 100 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
10. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
11. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a day.

12. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours): last dose on [**2138-10-28**] for total of 14d course of abx.

13. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
14. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours).
15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours).
16. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q2H
(every 2 hours) as needed for constipation.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 4657**] - [**Location 1268**]

Discharge Diagnosis:
UTI


Discharge Condition:
good, satting 96% on 2L


Discharge Instructions:
You were admitted to [**Hospital1 18**] because of fever altered mental
status. You were found to have low BPs and were in the ICU,
where you recovered with IV fluids.  You were found to have a
urinary infection, for which you were started on antibiotics.
You were also given an aggressive bowel regimen to help you pass
your bowels. Your belly was distended, however soft, nontender
and stable. You continued to improve clinically and you were
then discharged to a skilled nursing facility where you can
continue to improve under close care.

Please make the following changes to your medications:
1. START Ipratropium Bromide 0.02 % Solution One Inhalation
every 6 hours
2. START Albuterol Sulfate  0.083 % Solution One Inhalation
every 6 hours
3. START Lactulose 10 gram/15 mL Syrup 30 ML PO every 2 hours as
needed for constipation
4. START Bisacodyl 10 mg PO DAILY as needed for constipation
5. START Cefpodoxime 200 mg PO every 12 hours: last dose on
[**2138-10-28**] for a total of 14d course of abx

Please seek immediate medical attention if you start
experiencing confusion, fevers, acute abdominal pain or any
other concerning symptoms.

Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in Orthopedics on [**11-13**] at 10:30
AM at the [**Hospital Ward Name 23**] Bldg, [**Location (un) **]. Ph # ([**Telephone/Fax (1) 2007**]. A biopsy
to rule out bone infection may be needed, but the biopsy can be
performed only after all all antibiotics have been discontinued
for more than 5 days, which should be the case at this date.

A follow-up appointment with your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 4320**] [**Last Name (NamePattern1) 4321**] at [**Hospital1 **]
[**Location (un) 538**] will be made for you at the time of discharge from
the skilled nursing facility.


                             [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

Completed by:[**2138-10-23**]
{'Unspecified septicemia,Pressure ulcer, stage IV,Septic shock,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Paraplegia,Severe sepsis,Other dependence on machines, supplemental oxygen,Late effect of complications of surgical and medical care,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Flatulence, eructation, and gas pain,Other disorders of muscle, ligament, and fascia,Esophageal reflux,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Depressive disorder, not elsewhere classified'}


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: Fever

PRESENT ILLNESS: 73F with paraplegia, recurrent UTI, chronic sacral decubs,
presenting with fever and altered mental status. She was seen by
her NP yesterday with fever to 102 and positive UA. Her sacral
decub was noted to be improved since last exam. Cipro started
for UTI. Also seen by her visiting nurse today and son reported
that overnight she was confused, talking about getting up to
walk (though paraplegic) and ?visual hallucinations. Per son,
this is similar to when she has had UTIs in the past. She does
admit to sore throat and cough for a few days. Cough
nonproductive though feels she has something to cough up. No
shortness of breath or chest pain. No GI symptoms. No known
sick/flu contacts. [**Name (NI) **] recalls incident in which she told
her son she was going to get up and walk, and thought she was
dreaming. Pt DNR/[**Name6 (MD) 835**] [**Name8 (MD) **] NP.

MEDICAL HISTORY: - Paraplegia [**1-6**] Anterior Spinal Infarct ([**2128**]) - patient
reports no sensation or motor function below T8.
- Thoracic Aneurysm Repair ([**2128**])
- COPD (no PFTs in system; has been on home O2 in past though
none recently)
- HTN
- Hyperlipidemia
- GERD
- Suprapubic Catheter Placement / UTIs on Ppx Bactrim
- Fecal Incontinence
- Depression
- Atraumatic comminuted L intertrochanteric femur fracture
- Chronic sacral decubitus ulcers with past bilateral ischial
tuberosity osteomyelitis
- History of MRSA bacteremia [**11/2137**] thought to be due to sacral
decub abscess and osteomyelitis

MEDICATION ON ADMISSION: Advair 250/50 [**Hospital1 **]
ASA 81 mg daily
Alendronate 70 mg daily
Baclofen 10 mg TID
Bactrim DS [**Hospital1 **]
Colace 100 mg [**Hospital1 **]
gabapentin 900 mg TID
miralax 17grams daily
senna [**Hospital1 **]
nortriptyline 50 mg HS
tizanidine 2 mg TID
wellbutrin 100 mg [**Hospital1 **]

ALLERGIES: Adhesive Tape

PHYSICAL EXAM: General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, PERRL 4->2, MM slightly dry, posterior
oropharynx very difficult to fully visualize.
Neck: supple, JVD to 4 cm ASA, no LAD
Lungs: Few expiratory rhonchi, L>R. No crackles.
CV: Distant heart sounds. Regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Abdomen: appears grossly distended, though unchanged per
patient. Soft, non-tender, bowel sounds present, no rebound
tenderness or guarding, no organomegaly. Suprapubic catheter
site appears benign.
Back: stage IV sacral decub, appears to be down to bone, approx
4x4cm. No drainage or significant surrounding erythema, appears
to have good granulation tissue.
Ext: Slightly cool hands otherwise warm and well perfused, no
clubbing, cyanosis. Trace UE and LE edema, equal bilaterally.
Small pressure ulcers on bilateral heels.
Neuro: Alert and appropriate. CN II-XII intact, UE strength and
sensation preserved. LE sensation and movement absent. No
sensation from abdomen inferiorly.

FAMILY HISTORY: Son has DM

SOCIAL HISTORY: Lives with son (recently returned home from rehab in late
[**Month (only) 359**]) and has VNA. Smoked 2-3ppd x 40+ years, denies smoking
in last few years. No alcohol or illicit drug use. 

### Response:
{'Unspecified septicemia,Pressure ulcer, stage IV,Septic shock,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Paraplegia,Severe sepsis,Other dependence on machines, supplemental oxygen,Late effect of complications of surgical and medical care,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Flatulence, eructation, and gas pain,Other disorders of muscle, ligament, and fascia,Esophageal reflux,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Depressive disorder, not elsewhere classified'}
