CHIEF COMPLAINT: 

PRESENT ILLNESS: This is an 83 year old female
who was recently admitted for bright red blood per rectum
noted to have a rectal ulcer on sigmoidoscopy.  She was
discharged to [**Hospital **] Rehabilitation and readmitted with
fever to 102.0 F., hypotension with systolic blood pressures
in the 80s.  She was initially started on Vancomycin,
Levofloxacin and Flagyl.  The patient was noted to be
lethargic and less responsive.  A urine culture at [**Hospital1 **]
grew Levofloxacin resistant enterococcus.

MEDICAL HISTORY: 1.  Schizo-affective disorder for over fifty years.
2.  Bipolar disorder.
3.  Hypernatremia secondary to diabetes insipidus from
lithium.
4.  Delirium.
5.  Malnutrition status post feeding tube placement.
6.  Recurrent urinary tract infections; possible urinary
retention.
7.  Osteoarthritis.
8.  Hypercalcemia.
9.  Hyperparathyroidism.

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Infection and inflammatory reaction due to other vascular device, implant, and graft,Other staphylococcal septicemia,Urinary tract infection, site not specified,Hemorrhage of rectum and anus,Hyperosmolality and/or hypernatremia,Diabetes insipidus,Schizoaffective disorder, unspecified,Retention of urine, unspecified
React-oth vasc dev/graft,Staphylcocc septicem NEC,Urin tract infection NOS,Rectal & anal hemorrhage,Hyperosmolality,Diabetes insipidus,Schizoaffective dis NOS,Retention urine NOS
Admission Date:  [**2148-4-12**]       Discharge Date:  [**2148-4-18**]


Service:  ICU-MEDICI

The projected date of discharge is [**2148-4-19**].


HISTORY OF PRESENT ILLNESS:  This is an 83 year old female
who was recently admitted for bright red blood per rectum
noted to have a rectal ulcer on sigmoidoscopy.  She was
discharged to [**Hospital **] Rehabilitation and readmitted with
fever to 102.0 F., hypotension with systolic blood pressures
in the 80s.  She was initially started on Vancomycin,
Levofloxacin and Flagyl.  The patient was noted to be
lethargic and less responsive.  A urine culture at [**Hospital1 **]
grew Levofloxacin resistant enterococcus.

In the Emergency Department, the patient was found to have a
decreased hematocrit to 23.3.  Gastrointestinal was consulted
and a PEG tube lavage was done which was negative.  The
patient initially had a response with increased blood
pressure with intravenous fluids, however, given that it was
a transient increase in blood pressure, she was transferred
to the Intensive Care Unit for closer observation.  She was
admitted under the MUST protocol.  Again, in the Emergency
Department, the patient was noted to have a positive
urinalysis.

PAST MEDICAL HISTORY:
1.  Schizo-affective disorder for over fifty years.
2.  Bipolar disorder.
3.  Hypernatremia secondary to diabetes insipidus from
lithium.
4.  Delirium.
5.  Malnutrition status post feeding tube placement.
6.  Recurrent urinary tract infections; possible urinary
retention.
7.  Osteoarthritis.
8.  Hypercalcemia.
9.  Hyperparathyroidism.

MEDICATIONS ON TRANSFER:
1.  Lactulose 20 three times a day.
2.  Fluoxetine 20 q. day.
3.  Risperdal 0.5 q. h.s.
4.  Docusate 30 twice a day.
5.  Senna 5 ml twice a day.
6.  Mineral oil q.o.d.; titrate to bowel movement q.o.d.
7.  Milk of Magnesia, 5 mg q.o.d. p.r.n.; titrate to bowel
movement q.o.d.
8.  Divalproex 125 twice a day.
9.  Amiloride one tablet q. day.
10. Protonix 40 q. day.
11. Multivitamin q. day.
12. Lisinopril 20 p.o. q. day.
13. Bactrim one double strength twice a day, day number six.
14. Tylenol q. four to six hours p.r.n.

PHYSICAL EXAMINATION:  Vital signs on admission her
temperature was 98.1 F.; blood pressure 97/40; heart rate
101; respiratory rate 20; oxygen saturation 100% on two
liters nasal cannula.  Her weight was 61.3 kilograms.  In
general, she was lying comfortably in no apparent distress.
HEENT:  She was nonicteric.  Mucous membranes were slightly
dry.  She had no jugular venous distention on examination.
Chest is clear to auscultation anteriorly and laterally.  Her
abdomen was soft with active bowel sounds and G-tube in
place, nondistended, nontender.  On Neurologic examination,
the patient was nonverbal and not following commands.
Cardiovascular is regular rate and rhythm with no murmurs,
rubs or gallops.  Extremities were without cyanosis, clubbing
or edema.

LABORATORY DATA:  White blood cell count of 11.5; hematocrit
23.3, it was noted to be 34.2 on [**4-7**]; INR of 1.3.  Sodium
148, potassium 4.7, chloride 117, bicarbonate 26, BUN 45,
creatinine 1.0, glucose 107, lactate of 1.6.  Differential is
74% polys, 70% lymphocytes, 4.2 monocytes, 1.1 eos, 0.3
basophils.

Urinalysis was notable for a moderate leukocyte esterase,
greater than 50 white blood cells and a few bacteria, zero to
two red blood cells.

Per [**Hospital1 **] report, the patient had Group D enterococcus
Levofloxacin resistant and had two sets of blood cultures
which were negative with no growth to date.

BRIEF HOSPITAL COURSE:  This is an 83 year old female with a
recent bleeding from rectal ulcer, presents again with
hypotension and fevers consistent with sepsis.
1.  SEPSIS:  This patient was admitted under the sepsis
protocol to the Intensive Care Unit for close monitoring.
She had a right internal jugular line placed for close
monitoring.  The patient tolerated the procedure well.  Her
urinalysis was consistent with an active urinary tract
infection.  In addition, the patient's blood cultures grew
out coagulase negative Staphylococcus.  Her urine cultures
grew out enterococcus.  Her PICC line which had been
bilateral at the time of admission grew out coagulase
negative Staphylococcus as well with the same resistance
patterns as the blood cultures.

Given the laboratory data, it is likely that the patient had
line associated sepsis.  Given that the coagulase negative
Staphylococcus was sensitive to Vancomycin, the patient was
continued on Vancomycin which she will need to continue for a
full six week course.  Initially, she had been on Vancomycin,
ceftriaxone, however, the ceftriaxone was discontinued after
the sensitivities to antibiotics were back.

The patient had left PICC line placed on [**2148-4-18**], to
permit continued intravenous access for the full six week
course of intravenous Vancomycin.

2.  HEMATOCRIT DROP:  The patient had a recent bright red
blood per rectum during her last hospital stay and was found
to have a significant rectal ulcer which was felt to be the
cause of bleeding.  Examination per GI felt that this was
secondary to her severe constipation; however, on this
admission, her hematocrit had dropped significantly.
However, there was no note of rectal bleeding evolving.  This
was confirmed with the [**Hospital1 **] staff.

The patient was transfused two units of packed red blood
cells and her hematocrit remained stable throughout her
hospital stay.  It did drop slightly after having an
colonoscopy and endoscopy to further evaluate her GI tract.
Her hematocrit was 28.6 on [**2148-4-18**].  There is placed for a
repeat hematocrit check on the evening of [**2148-4-18**], and
again prior to discharge on [**2148-4-19**].  If there is no
change in her hematocrit and she has significant evidence of
blood loss, the patient will not be discharged on [**2148-4-19**].

Her endoscopy was normal.  The patient's colonoscopy revealed
a healing rectal ulcer as well as a small sigmoid polyp which
was biopsied.  In addition, there are grade 1 internal
hemorrhoids noted.  There were no other masses or obvious
sources of bleeding documented during the colonoscopy.

3.  HYPERNATREMIA:  The patient continued to have significant
hypernatremia during her hospital stay.  It was felt that
this was likely secondary to diabetes insipidus from long
term lithium treatment.  The patient was continued on free
water boluses through her PEG tube which were titrated to
serum sodium between 144 and 148.  Currently, the patient is
receiving free water 300 cc q. four hours via her PEG tube.

4.  RIGHT UPPER EXTREMITY DEEP VENOUS THROMBOSIS:  The
patient had a PICC associated deep venous thrombosis in the
right upper extremity noted on her last hospital stay.  Given
that the line was still functional, the decision was made to
discharge the patient with that line in place so as not to
disturb the blood clot.  However, given that the patient
became septic and that deep venous thrombosis was likely
associated with an infection, her right PICC had been pulled
in the Emergency Department.

A repeat ultrasound of the right upper extremity deep venous
thrombosis showed that it was a non occlusive clot.  Given
the recent drop in hematocrit the decision was made not to
anti-coagulate the patient.  There was some concern that her
risk of having life threatening GI bleeding was more
significant than having embolization from the right upper
extremity deep venous thrombosis.

5.  RECURRENT URINARY TRACT INFECTIONS:  The patient was
recently treated for a Citrobacter urinary tract infection,
however, on this admission she was noted to have
enterococcus.  It was thought to be associated with the Foley
catheter.  An attempt will be made to remove the Foley
catheter prior to discharge; however, the patient is indeed
suffering from significant urinary retention and this is
documented.  She should have an outpatient urology follow-up.
She will likely need to have the Foley catheter replaced
prior to discharge if she is not able to void once it has
been removed.

6.  BIPOLAR DISORDER / SCHIZO-AFFECTIVE DISORDER:  The
patient's affect was significantly improved from her last
hospital stay.  She was speaking in full sentences and is
responsive to questions.  She was continued on her
fluoxetine, valproate and Risperdal for her outpatient
regimen.

CODE STATUS:   The patient is "DO NOT RESUSCITATE" and "DO
NOT INTUBATE".  Her son, Dr. [**First Name4 (NamePattern1) 892**] [**Known lastname 3532**], is a cardiologist
and her health care proxy.  [**Name (NI) **] can be reached at
[**Telephone/Fax (1) 54701**].

DISCHARGE DIAGNOSES:
1.  Urinary tract infection with enterococcus.
2.  Line associated sepsis with coagulase negative
Staphylococcus.
3.  Diabetes insipidus.
4.  Right upper extremity deep venous thrombosis.
5.  Bipolar / schizo-affective disorder.

CONDITION AT DISCHARGE:   Stable.  The patient is taking good
p.o.  She had been re-evaluated by Swallow study and was
advanced from her previous thickened liquid diet to thin
liquids with pureed solids.

DISCHARGE STATUS:  To extended care facility, [**Hospital **]
[**Hospital **] Hospital.

ADDENDUM!!!*****!!!!!
the patient was not discharged because of low grade tempertures.
Please see addendum for details


[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D.  [**MD Number(1) 3475**]

Dictated By:[**Name8 (MD) 3482**]
MEDQUIST36

D:  [**2148-4-18**]  14:45
T:  [**2148-4-18**]  13:42
JOB#:  [**Job Number 54702**]


Name:  [**Known lastname 10212**], [**Known firstname 1911**]                       Unit No:  [**Numeric Identifier 10213**]

Admission Date:  [**2148-4-12**]     Discharge Date:

Date of Birth:   [**2065-2-11**]     Sex:  F

Service: Medicine

ADDENDUM:  This is an Addendum to the previous Discharge
Summary dated [**2148-4-18**].

The patient was not discharged on [**2148-4-19**] given the
patient had a low-grade temperature of 100.6 the night prior
to expected discharge.  The patient was kept for observation
given there was some concern that the patient may spike a
fever as she had been having temperatures only up to 97 prior
to this elevated temperature.  The patient had repeat blood
cultures done, as well as a repeat urinalysis, and repeat
urine cultures.  Repeat blood cultures have not grown out any
bacteria to date.  In addition, the urine culture was no
growth on [**2148-4-19**].

The patient had a repeat chest x-ray which did show small
bilateral pleural effusions with some blunting at the
costophrenic angles.  There was a new left subclavian line in
place.  There was no evidence of focal pneumonia, or evidence
of congestive heart failure, or evidence of pneumothorax.

On [**2148-4-21**] the patient spiked a temperature to 101.2.
She was complaining of some abdominal pain which was diffuse,
more prominent in the left lower quadrant.  In addition, she
had some new diarrhea.  Given the patient has been on
antibiotics for some time, the patient had stool culture sent
for Clostridium difficile which were pending at the time of
this dictation.  On [**2148-4-21**] the patient was empirically
begun on Flagyl three times per day to cover for a possible
Clostridium difficile colitis.

Other possibilities for her abdominal pain and fever would be
ischemic colitis, diverticulitis, or mesenteric ischemia.
The team felt that we should initially treat for Clostridium
difficile colitis given the clinical picture; however, if the
patient does not improve or clinically worsens, we would
image her abdomen with an abdominal computed tomography scan
to evaluate for other causes.

NOTE:  Please Discharge Summary Addendum for the final
hospital course.





                     DR.[**Last Name (STitle) 1035**],[**First Name3 (LF) 1034**] 12-AAD

Dictated By:[**Name8 (MD) 1314**]

MEDQUIST36

D:  [**2148-4-21**]  11:47
T:  [**2148-4-21**]  12:31
JOB#:  [**Job Number 10214**]


Name:  [**Known lastname 10212**], [**Known firstname 1911**]                       Unit No:  [**Numeric Identifier 10213**]

Admission Date:  [**2148-4-12**]     Discharge Date:  [**2148-4-26**]

Date of Birth:   [**2065-2-11**]     Sex:  F

Service: Medicine

HOSPITAL COURSE:
1.  Infectious disease:  On [**2148-4-26**] the patient spiked a
temperature to 101.2.  Blood cultures and urine cultures were
obtained for several days and all were negative.  Initially
the patient was complaining of some diarrhea so she was
started empirically on Flagyl, however, two stool samples for
C-difficile toxin were negative.  Therefore the Flagyl was
discontinued.  The patient continued to remain afebrile while
off of the Flagyl.  She was continued on the Vancomycin due
to line infection with evidence of right upper extremity deep
venous thrombosis.  There was no evidence of pneumonia on
chest x-ray and the patient had no cough.  Cough and CT of
the abdomen was obtained in order to ensure that there was no
fluid collection or evidence of colitis and this was negative
for fluid collection or colitis, however, it did show a large
dermoid in the pelvis, which was not a new finding according
to the patient's family.  All blood cultures and urine
cultures remained negative during the patient's stay.

2.  Gastrointestinal bleed:  The patient had presented with
bright red blood per rectum on her prior admission.
Endoscopy was negative and colonoscopy showed only a rectal
ulcer thought to be due to chronic constipation.  The
patient's hematocrit had initially remained stable and then
had decreased to 27.  The patient did receive another unit of
blood during her hospital stay.  Hemolysis laboratories were
sent and showed no evidence of hemolysis.  Iron studies and
B-12 were sent, which were within normal limits.  The patient
remained guaiac negative and her hematocrit was stable on the
day of discharge.

3.  Hypernatremia:  Due to nephrogenic diabetes insipidus,
the patient's sodium was maintained between 143 and 147 with
free water boluses.  On the day prior to discharge the
patient's sodium was 155, therefore her free water boluses
were increased.  Would recommend increasing free water
boluses in order to maintain a sodium between 135 and 145.

4.  Coagulation:  The patient had a right upper extremity
deep venous thrombosis.  Her arm initially was edematous,
however, edema was decreasing at the time of discharge.
Initially the patient was not anticoagulated due to concerns
for gastrointestinal bleed, however, the CT scan showed
incidental bilateral common femoral deep venous thrombosis,
which were not occlusive, therefore due to the increased risk
of thromboembolism from a femoral deep venous thrombosis the
patient was started on Lovenox on the day prior to discharge
in addition to Coumadin.  Goal INR would be 2 to 3 and the
Lovenox should be discontinued when INR is 2 and the Coumadin
titrated to a goal INR of 2 to 3.  The patient did not show
any signs of gastrointestinal bleeding on the
anticoagulation, although this is clearly a risk and should
be followed.

5.  Bipolar disorder:  The patient was continued on her
current medical regimen.

6.  Fluids, electrolytes and nutrition:  The patient was
continued on tube feeds with free water boluses and
occasionally required potassium repletion.

7.  Hypertension:  The patient continued to be hypertensive
on the maximum dose of Lisinopril 40 daily, therefore she was
started on Metoprolol 12.5 b.i.d.  This should be increased
as tolerated.

8.  Access:  The patient has a left PICC line, which was
placed on [**2148-4-21**].

9.  Urinary retention:  The patient has a urinary catheter
due to concerns of urinary retention.  They should be changed
periodically to prevent urinary tract infection.

10.  Prophylaxis:  While the patient is not ambulatory she
should be maintained on subcutaneous heparin.

11.  Code status:  The patient is DNR/DNI.

12.  Disposition:  The patient will be discharged to [**Hospital6 2696**] as her electrolytes and hematocrit are
stable and she has been afebrile for several days with no
signs of infection.

DISCHARGE STATUS:  To [**Hospital6 908**].

DISCHARGE CONDITION:  Stable with no fevers, stable
hematocrit and stable sodium.

DISCHARGE DIAGNOSES:
1.  Coagulase negative staphylococcal line associated sepsis.
2.  Enterococcal upper respiratory infection.
3.  Schizo-affective disorder.
4.  Bipolar disorder.
5.  Diabetes insipidus.
6.  Right upper extremity deep venous thrombosis.
7.  Bright red blood per rectum due to rectal fissure.
8.  Bilateral common femoral deep venous thrombosis, dermoid.

DISCHARGE MEDICATIONS:
1.  Colace 100 mg one po b.i.d.
2.  Fluoxetine 20 mg one po q.d.
3.  Risperidone 0.2 mg one po q.a.m.
4.  Risperidone 0.5 mg one po q.h.s.
5.  Valproic acid 250 mg po b.i.d.
6.  Acetaminophen 325 mg one to two po q 4 to 6 prn.
7.  Magnesium oxide 400 mg one po b.i.d.
8.  Senna one po b.i.d.
9.  Lactulose 30 milliliters po q 8 hours as needed for
constipation.  Please titrate for every other day bowel
movement.
10.  Vancomycin 1 gram intravenously daily for 27 days.
11.  Regular insulin sliding scale.
12.  Heparin 5000 units one injection twice a day until the
patient is ambulating.
13.  Sodium chloride flush.
14.  Prevacid 300 mg one po daily.
15.  Mineral oil one to two tablespoons po at bedtime as
needed for constipation.  Titrate to one bowel movement every
other day.
16.  Lisinopril 40 mg po q.d.
17.  Metoprolol 12.5 mg po b.i.d.
18.  Warfarin 5 mg po q.h.s.  Please titrate for goal INR 2
to 3.
19.  Lovenox 60 mg one b.i.d. for six days.  Can discontinue
once INR is 2.0.

MAJOR SURGICAL OR INVASIVE PROCEDURES:  Left PICC [**Doctor Last Name **] was
placed on [**2148-4-21**].

FOLLOW UP:  The patient is to follow up with her [**Hospital1 **]
physician on arrival.  She will also need psychiatric follow
up at [**Hospital1 **].  She may need a urologic consult if she is
noted to have recurrent urinary retention.  Per GI the
patient will need a small bowel follow through arranged as an
outpatient.






                          [**Name6 (MD) 1034**] [**Name8 (MD) 1035**], M.D.  [**MD Number(1) 1036**]

Dictated By:[**Last Name (NamePattern1) 662**]

MEDQUIST36

D:  [**2148-4-26**]  09:42
T:  [**2148-4-26**]  09:42
JOB#:  [**Job Number 10215**]

cc:[**Hospital6 10216**]
{'Infection and inflammatory reaction due to other vascular device, implant, and graft,Other staphylococcal septicemia,Urinary tract infection, site not specified,Hemorrhage of rectum and anus,Hyperosmolality and/or hypernatremia,Diabetes insipidus,Schizoaffective disorder, unspecified,Retention of urine, 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: 

PRESENT ILLNESS: This is an 83 year old female
who was recently admitted for bright red blood per rectum
noted to have a rectal ulcer on sigmoidoscopy.  She was
discharged to [**Hospital **] Rehabilitation and readmitted with
fever to 102.0 F., hypotension with systolic blood pressures
in the 80s.  She was initially started on Vancomycin,
Levofloxacin and Flagyl.  The patient was noted to be
lethargic and less responsive.  A urine culture at [**Hospital1 **]
grew Levofloxacin resistant enterococcus.

MEDICAL HISTORY: 1.  Schizo-affective disorder for over fifty years.
2.  Bipolar disorder.
3.  Hypernatremia secondary to diabetes insipidus from
lithium.
4.  Delirium.
5.  Malnutrition status post feeding tube placement.
6.  Recurrent urinary tract infections; possible urinary
retention.
7.  Osteoarthritis.
8.  Hypercalcemia.
9.  Hyperparathyroidism.

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Infection and inflammatory reaction due to other vascular device, implant, and graft,Other staphylococcal septicemia,Urinary tract infection, site not specified,Hemorrhage of rectum and anus,Hyperosmolality and/or hypernatremia,Diabetes insipidus,Schizoaffective disorder, unspecified,Retention of urine, unspecified'}
