CHIEF COMPLAINT: Fever, altered mental status

PRESENT ILLNESS: HPI: Patient unable to give good history on his own; hx per
daughter.
Daughter found pt. when she returned home in evening [**8-20**] lying
on the ground, awake; lying there approx. 4 hrs per pt report.
Pt states he had "passed out" and couldn't rise.  Positive
mental status changes at the time and was not able to answer his
daughter's questions appropriately. He had not been incontinent
of stool or urine. She called her mother and the ambulance and
the patient was then brought in to the ED.
.
The daughter says the patient had not been feeling well the
previous day. He was complaining of not feeling well, but could
not specify symptoms. Prior to admission, complained of
intermittent nausea and insomnia.
.
At baseline, the patient has L sided weakness, both UE and LE,
from a previous stroke. He also has speech difficulties from his
most recent strokes in [**12-24**]. He understands some English.  He is
able to ambulate around their house with a cane.
.
ED: L IJ catheter placed. Concern for ischemia (EKG ? ST change
in V6 -> cards felt LVH not acute MI, received ASA and lopressor
IV), meningitis (LP done) or other infection (given tylenol,
vanc, ceftriaxone, acyclovir, and gentamicin). He was
transferred to [**Hospital Ward Name 121**] 3 and begun on dialysis for a Ca of 12.
.
On floor, pt. underwent HD; renal eval - AVF site warm and
swollen, not tender.  [**8-21**] evening, pt had episode hypotension -
txf to unit for evaluation - pt tx'd for bacteremia, pt bp
stabilized, tx'd with genta/vanco.
.
ROS: daughter denies any fevers, URI sx, diarrhea, chest pain or
SOB; thinks that the patient did have some vomiting yesterday
(day PTA).
.

MEDICAL HISTORY: 1. Coronary artery disease s/p MI in [**12/2164**], status post 2
stents to the LAD. Cath in [**1-/2165**] revealed re-stenosis of both
stents. He is status post 3-vessel CABG on [**2165-2-20**] with LIMA to

MEDICATION ON ADMISSION: Metoprolol 100 mg [**Hospital1 **]
Clonidine 0.1mg [**Hospital1 **] po
Enalapril 2.5 mg qd
Norvasc 5mg qd
Renagel 1 po tid (vs ca acetate? -- has both)
Ranitidine 150 mg po bid
ASA 325g po qd
Nephrocaps 1 po qd
Cinacalcet ? dose qd
Lipitor 10mg po qd

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE: Tm 99.1, Tc 96.9, HR 90-103, BP 111-142/49-62, RR 18-22, O2
sat 100% NC 2l, 90% ra; CVP 3-5, I: 1400 in, O: none
Gen: elderly man appears sleepy, speaks slowly
HEENT:  PERRL, OP clear, dry MM, neck veins flat
CV:  RRR, + [**2-22**] early systolic murmur
Lungs:  b/l basilar crackles, no wheezes
Abd:   soft, NT, ND
Ext:   L arm - fistula, no tenderness.  No erythema noted, no
drainage

FAMILY HISTORY: Mother with hypertension
No history of no strokes, seizures, or heart disease

SOCIAL HISTORY: The patient lives at home with his wife & daughter in a [**Location (un) 6332**] apartment with an elevator.
Infection and inflammatory reaction due to other vascular device, implant, and graft,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic airway obstruction, not elsewhere classified,Unspecified septicemia,Septic shock,Atrial fibrillation,Severe sepsis,Thrombocytopenia, unspecified,Anemia in chronic kidney disease,Pure hypercholesterolemia,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Gout, unspecified,Aortocoronary bypass status,Hypercalcemia
React-oth vasc dev/graft,Hyp kid NOS w cr kid V,Chr airway obstruct NEC,Septicemia NOS,Septic shock,Atrial fibrillation,Severe sepsis,Thrombocytopenia NOS,Anemia in chr kidney dis,Pure hypercholesterolem,Late ef-hemplga side NOS,Gout NOS,Aortocoronary bypass,Hypercalcemia
Admission Date:  [**2167-8-21**]              Discharge Date:   [**2167-9-1**]

Date of Birth:  [**2100-11-15**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 465**]
Chief Complaint:
Fever, altered mental status

Major Surgical or Invasive Procedure:
Lumbar Puncture
Transesophageal Echocardiagram


History of Present Illness:
HPI: Patient unable to give good history on his own; hx per
daughter.
Daughter found pt. when she returned home in evening [**8-20**] lying
on the ground, awake; lying there approx. 4 hrs per pt report.
Pt states he had "passed out" and couldn't rise.  Positive
mental status changes at the time and was not able to answer his
daughter's questions appropriately. He had not been incontinent
of stool or urine. She called her mother and the ambulance and
the patient was then brought in to the ED.
.
The daughter says the patient had not been feeling well the
previous day. He was complaining of not feeling well, but could
not specify symptoms. Prior to admission, complained of
intermittent nausea and insomnia.
.
At baseline, the patient has L sided weakness, both UE and LE,
from a previous stroke. He also has speech difficulties from his
most recent strokes in [**12-24**]. He understands some English.  He is
able to ambulate around their house with a cane.
.
ED: L IJ catheter placed. Concern for ischemia (EKG ? ST change
in V6 -> cards felt LVH not acute MI, received ASA and lopressor
IV), meningitis (LP done) or other infection (given tylenol,
vanc, ceftriaxone, acyclovir, and gentamicin). He was
transferred to [**Hospital Ward Name 121**] 3 and begun on dialysis for a Ca of 12.
.
On floor, pt. underwent HD; renal eval - AVF site warm and
swollen, not tender.  [**8-21**] evening, pt had episode hypotension -
txf to unit for evaluation - pt tx'd for bacteremia, pt bp
stabilized, tx'd with genta/vanco.
.
ROS: daughter denies any fevers, URI sx, diarrhea, chest pain or
SOB; thinks that the patient did have some vomiting yesterday
(day PTA).
.


Past Medical History:
1. Coronary artery disease s/p MI in [**12/2164**], status post 2
stents to the LAD. Cath in [**1-/2165**] revealed re-stenosis of both
stents. He is status post 3-vessel CABG on [**2165-2-20**] with LIMA to

LAD, saphenous vein to RCA, saphenous vein to OM.
2. ESRD on HD since [**2161**](MWF), felt secondary to HTN
3. Status post CVA in [**2149**] with residual left-sided hemiparesis
4. Hypertension
5. UGIB after cardiac cath on [**12/2164**]
6. Gout
7. Pancreatitis
8. Diverticulosis
9. History of multiple E coli bacteremias
10. Anemia of chronic disease (10.9Hgb [**11-22**])
11. Hypercholesteremia
12. COPD
13. Afib/Aflutter, not on anticoagulation secondary to history
of GI bleed.
14. [**12-24**] TEE: LVEF >55%, small ASD, complex (>4mm non-mobile)
atheroma in the descending thoracic aorta, ([**12-21**]+) AR, tr MR.
15. H/O Hepatitis B

Social History:
The patient lives at home with his wife & daughter in a [**Location (un) 6332**] apartment with an elevator.


Family History:
Mother with hypertension
No history of no strokes, seizures, or heart disease

Physical Exam:
PE: Tm 99.1, Tc 96.9, HR 90-103, BP 111-142/49-62, RR 18-22, O2
sat 100% NC 2l, 90% ra; CVP 3-5, I: 1400 in, O: none
Gen: elderly man appears sleepy, speaks slowly
HEENT:  PERRL, OP clear, dry MM, neck veins flat
CV:  RRR, + [**2-22**] early systolic murmur
Lungs:  b/l basilar crackles, no wheezes
Abd:   soft, NT, ND
Ext:   L arm - fistula, no tenderness.  No erythema noted, no
drainage


Pertinent Results:
MICRO:
[**2167-8-21**] bctx - G+ cocci pairs/clusters ([**3-23**])
[**2167-8-20**]: CSF cx pending, gram stain neg for PMNs/microorg
.
RADS:
[**2167-8-20**]: CXR - No consolidation.  L costophrenic angle blunting
c/w effusion/chronic thickening.  Evidence of CABG/stents
.
[**2167-8-20**]: CT head - No hemorrhage, no mass effect, no
hydrocephalus, chronic L parietal infarct
.
[**2167-8-21**]: ECHO - no vegetations

[**2167-8-21**] 11:15PM   CORTISOL-53.7*
[**2167-8-21**] 10:34PM   CORTISOL-36.0*
[**2167-8-21**] 10:02PM   TYPE-MIX TEMP-37.3 COMMENTS-MEDIAL POR
[**2167-8-21**] 10:02PM   LACTATE-2.7*
[**2167-8-21**] 10:02PM   O2 SAT-90
[**2167-8-21**] 09:59PM   GLUCOSE-144* UREA N-31* CREAT-4.9* SODIUM-142
POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-29 ANION GAP-14
[**2167-8-21**] 09:59PM   CALCIUM-11.9* PHOSPHATE-3.9 MAGNESIUM-2.0
[**2167-8-21**] 09:59PM   WBC-11.7* RBC-3.87* HGB-11.3* HCT-33.9*
MCV-88 MCH-29.2 MCHC-33.2 RDW-18.8*
[**2167-8-21**] 09:59PM   NEUTS-78* BANDS-14* LYMPHS-7* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2167-8-21**] 09:59PM   HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL
[**2167-8-21**] 09:59PM   PLT SMR-VERY LOW PLT COUNT-64*
[**2167-8-21**] 09:59PM   PT-14.0* PTT-33.2 INR(PT)-1.3
[**2167-8-21**] 06:39PM   LACTATE-4.9*
[**2167-8-21**] 06:22PM   GLUCOSE-175* UREA N-27* CREAT-4.8*#
SODIUM-144 POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-29 ANION GAP-20
[**2167-8-21**] 06:22PM   CK(CPK)-68
[**2167-8-21**] 06:22PM   CK-MB-NotDone cTropnT-0.19*
[**2167-8-21**] 06:22PM   ALBUMIN-4.1 CALCIUM-12.3* PHOSPHATE-4.3
MAGNESIUM-2.0
[**2167-8-21**] 07:15AM   GLUCOSE-131* UREA N-58* CREAT-8.7* SODIUM-139
POTASSIUM-3.1* CHLORIDE-92* TOTAL CO2-31 ANION GAP-19
[**2167-8-21**] 07:15AM   CK(CPK)-65
[**2167-8-21**] 07:15AM   cTropnT-0.20*
[**2167-8-21**] 07:15AM   CK-MB-NotDone
[**2167-8-21**] 02:30AM CEREBROSPINAL FLUID (CSF)  WBC-8 RBC-497*
POLYS-30 LYMPHS-14 MONOS-26 MACROPHAG-30

Brief Hospital Course:
A/P:
1. Bacteremia - Given hypotension, pt. in septic shock.
Etiology of bacteremia includes possible AV fistula infxn vs.
endocarditis.  Pt has hx MSSA bacteremia c possible cardiac
emboli involvement (d/c summ [**2-21**]) - at this time, no clinical
signs of endocarditis, all ECHOs neg for vegetations.  LP
results look like viral meningitis (WBC persist to 4th tube,
high protein, neg gram stain). Could be UTI but patient is
virtually anuric. He was sent to the MICU for a brief period
because of hypotension likely secondary to septic shock, adrenal
insufficiency was considered but cosyntropin stimulatory test
was normal.  He also became normotensive with hydration, and did
not require pressors.  His chest xrays show left sided pleural
effusions but no indications of pneumonia.  He Received
gentamicin and vancomycin while the blood cultures were pending
to cover for endocarditis, the vancomycin was changed to
oxacillin when cultures grew MSSA.  A TTE did no show
vegetations and no indications of endocarditis, a followup TEE
also indicated no evidence of endocarditis, thus he was treated
for bacteremia with a five day course of gentamicin and a ten
day course of oxacillin.  He remained afebrile for at least the
last week of his hospital course, with no evidence of infection.

.
2. ESRD - Secondary to hypertenson on hemodialysis. During his
hospital course HD was unable to access HD, a LUE ultrasound
showed patent brachial artery and vein, but very narrowed flow
in AVF, a fistulagram was ordered to followed up. His AVF was
ballooned during the fistulagram and was functioning.  His
electrolytes remained unchanged during the delay in his
hemodialysis, although he developed a slight decline of mental
status from his baseline, which was attributed to uremia, as the
patient was two days past his scheduled dialysis.  He was never
clinically fluid overloaded on exam.  He received HD and his
mental status dramatically improved.  He continued on sensipar
60 mg po qd dinner and his medications were renally dose meds
.
3. Mental status changes were likely due to uremia.  He received
a lumbar puncture which did not show indications of infection,
his viral cultures were negative.  His bacteremia may have
caused presentation of his prior strokes.  Hypercalcemia may
have also contributed to his mental status changes.  During his
hospital course he waxed/waned in mental status, with
correlation to his dialysis status.  He was noted to have
improvements after hemodialysis.
.
4. PAF-He was maintained on ASA and rate controlled with a beta
blocker, but kept off coumadin secondary to a history of
hematochezia.
.
4. Elevated troponin/?EKG changes:  He had EKG changes and
elevated troponins on admission, which trended down. Cardiology
was consulted and felt the EKG changes are due to LVH, not acute
MI. He was ruled out for a myocardial infarction, and the
elevated troponin was likely due leak combined with chronic
renal insufficiency.  His enzymes were trended and were negative
for MI.
.
5. Hypercalcemia: This was attributed to ESRD and he was
continued on sensipar and hemodialysis during his hospital
course
.
6. HTN: Well controlled currently. Monitored BP and continued on
metoprolol.
.
7. Anemia: Etiology unknown, but likely due to ESRD. Will trend
Hct over time to make sure anemia is not new finding.  He
hematocrit remained at a baseline anemia. It slowly trended down
his hospital course, with no indications of active bleeding. His
epogen received during dialysis was increased and he his
hematocrit was followed.
.
8. Mental status changes/? syncope: Unclear story. Has prior
strokes, so infection could cause reactivation of old deficits.
His MS improved with dialysis at the change was attributed to
likely uremia.  He did receive a lumbar puncture during his
hospital course which did not indicate infection, and HSV
cultures were negative.
.
9. PPX - heparin SC, pantoprazole, bowel regimen
.
10. Dispo - The patient agreed to physical therapy, but declined
rehabilitation although recommended, in lieu of going home.
.
12. Code - presumed FULL
.


Medications on Admission:
Metoprolol 100 mg [**Hospital1 **]
Clonidine 0.1mg [**Hospital1 **] po
Enalapril 2.5 mg qd
Norvasc 5mg qd
Renagel 1 po tid (vs ca acetate? -- has both)
Ranitidine 150 mg po bid
ASA 325g po qd
Nephrocaps 1 po qd
Cinacalcet ? dose qd
Lipitor 10mg po qd

Discharge Medications:
1. 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*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
4. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO QD ().
Disp:*60 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 86**] VNA

Discharge Diagnosis:
Sepsis
MSSA bacteremia

Discharge Condition:
Afebrile, Good

Discharge Instructions:
You had an infection,sepsis, in your bloodstream and were
treated with antibiotics.

Please take your medications as instructed

You are scheduled to follow up with your Nurse Practioner on
[**2167-9-14**] at 9:40am.

If you experience, fever, chills, shortness of breath, chest
pain, please call your PCP, [**Name10 (NameIs) **] go to the Emergency Room.

Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] within one week.


Followup Instructions:
Provider [**First Name8 (NamePattern2) 1238**] [**Last Name (NamePattern1) 1239**] [**Name8 (MD) **], [**MD Number(3) 3670**]: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2167-9-14**] 9:40

Provider: [**First Name4 (NamePattern1) 247**] [**Last Name (NamePattern1) 248**], MD Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2167-9-29**] 10:40

Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6925**],MD Where: [**First Name8 (NamePattern2) **] [**Hospital Ward Name **] BUILDING
([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX) ENDOSCOPY SUITE Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2167-10-15**] 9:30
Provider: [**First Name8 (NamePattern2) 1238**] [**Last Name (NamePattern1) 1239**] [**Name8 (MD) **], [**MD Number(3) 3670**]: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2167-9-14**] 9:40
Provider: [**First Name8 (NamePattern2) 1238**] [**Last Name (NamePattern1) 1239**] [**Name8 (MD) **], [**MD Number(3) 3670**]: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2167-9-14**] 9:40


                             [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
{'Infection and inflammatory reaction due to other vascular device, implant, and graft,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic airway obstruction, not elsewhere classified,Unspecified septicemia,Septic shock,Atrial fibrillation,Severe sepsis,Thrombocytopenia, unspecified,Anemia in chronic kidney disease,Pure hypercholesterolemia,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Gout, unspecified,Aortocoronary bypass status,Hypercalcemia'}


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, altered mental status

PRESENT ILLNESS: HPI: Patient unable to give good history on his own; hx per
daughter.
Daughter found pt. when she returned home in evening [**8-20**] lying
on the ground, awake; lying there approx. 4 hrs per pt report.
Pt states he had "passed out" and couldn't rise.  Positive
mental status changes at the time and was not able to answer his
daughter's questions appropriately. He had not been incontinent
of stool or urine. She called her mother and the ambulance and
the patient was then brought in to the ED.
.
The daughter says the patient had not been feeling well the
previous day. He was complaining of not feeling well, but could
not specify symptoms. Prior to admission, complained of
intermittent nausea and insomnia.
.
At baseline, the patient has L sided weakness, both UE and LE,
from a previous stroke. He also has speech difficulties from his
most recent strokes in [**12-24**]. He understands some English.  He is
able to ambulate around their house with a cane.
.
ED: L IJ catheter placed. Concern for ischemia (EKG ? ST change
in V6 -> cards felt LVH not acute MI, received ASA and lopressor
IV), meningitis (LP done) or other infection (given tylenol,
vanc, ceftriaxone, acyclovir, and gentamicin). He was
transferred to [**Hospital Ward Name 121**] 3 and begun on dialysis for a Ca of 12.
.
On floor, pt. underwent HD; renal eval - AVF site warm and
swollen, not tender.  [**8-21**] evening, pt had episode hypotension -
txf to unit for evaluation - pt tx'd for bacteremia, pt bp
stabilized, tx'd with genta/vanco.
.
ROS: daughter denies any fevers, URI sx, diarrhea, chest pain or
SOB; thinks that the patient did have some vomiting yesterday
(day PTA).
.

MEDICAL HISTORY: 1. Coronary artery disease s/p MI in [**12/2164**], status post 2
stents to the LAD. Cath in [**1-/2165**] revealed re-stenosis of both
stents. He is status post 3-vessel CABG on [**2165-2-20**] with LIMA to

MEDICATION ON ADMISSION: Metoprolol 100 mg [**Hospital1 **]
Clonidine 0.1mg [**Hospital1 **] po
Enalapril 2.5 mg qd
Norvasc 5mg qd
Renagel 1 po tid (vs ca acetate? -- has both)
Ranitidine 150 mg po bid
ASA 325g po qd
Nephrocaps 1 po qd
Cinacalcet ? dose qd
Lipitor 10mg po qd

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE: Tm 99.1, Tc 96.9, HR 90-103, BP 111-142/49-62, RR 18-22, O2
sat 100% NC 2l, 90% ra; CVP 3-5, I: 1400 in, O: none
Gen: elderly man appears sleepy, speaks slowly
HEENT:  PERRL, OP clear, dry MM, neck veins flat
CV:  RRR, + [**2-22**] early systolic murmur
Lungs:  b/l basilar crackles, no wheezes
Abd:   soft, NT, ND
Ext:   L arm - fistula, no tenderness.  No erythema noted, no
drainage

FAMILY HISTORY: Mother with hypertension
No history of no strokes, seizures, or heart disease

SOCIAL HISTORY: The patient lives at home with his wife & daughter in a [**Location (un) 6332**] apartment with an elevator. 

### Response:
{'Infection and inflammatory reaction due to other vascular device, implant, and graft,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic airway obstruction, not elsewhere classified,Unspecified septicemia,Septic shock,Atrial fibrillation,Severe sepsis,Thrombocytopenia, unspecified,Anemia in chronic kidney disease,Pure hypercholesterolemia,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Gout, unspecified,Aortocoronary bypass status,Hypercalcemia'}
