CHIEF COMPLAINT: Altered mental status

PRESENT ILLNESS: EAST HOSPITAL MEDICINE ATTENDING [**Hospital **] TRANSFER TO FLOOR ACCEPT
NOTE

MEDICAL HISTORY: - Orthostatic hypotension, BP range on average 90-150 systolic.

MEDICATION ON ADMISSION: -Potassium Chloride 10 mEq Oral Tablet Extended Release Take 1
tablet twice daily or as otherwise directed
-Midodrine 10 mg Oral Tablet take one tablet three times daily
or as otherwise prescribed
-Fludrocortisone (FLORINEF) 0.1 mg Oral Tablet take 1 tablet
daily until otherwise instructed
-Simvastatin 40 mg Oral Tablet 1 tablet every evening for
cholesterol
-CALCIUM ORAL
-MULTIVITAMIN ORAL

ALLERGIES: Macrobid

PHYSICAL EXAM: VS: 98.2 134/60 89 20 96%RA; 0/10 pain at rest; [**7-6**] left hip
pain with movement
GEN: No apparent distress, pleasant
HEENT: No trauma, pupils round and reactive to light and
accommodation, no LAD, oropharynx clear, no exudates
CV: Regular rate and rhythm, no murmurs/gallops/rubs
PULM: Clear to auscultation bilaterally, no
rales/crackles/rhonchi
GI: Soft, non-tender, non-distended; no guarding/rebound
EXT: No clubbing/cyanosis/edema; 2+ distal pulses; peripheral IV
present; pneumoboots in place
NEURO: Alert and oriented to person, place and situation; CN
II-XII intact, [**5-1**] motor function globally
DERM: Ecchymoses on left upper posterior thigh/butt

FAMILY HISTORY: Not relevent to presentation of altered mental status and UTI in
an 86 y/o F.

SOCIAL HISTORY: Lives by her self, has HHA but not 24 hrs, family attempts to
fill gaps in supervision. Has frequent falls primarily [**1-29**]
orthostatic hypotension sustaining injuries including SAH, hip
fx, facial fx. Was in rehab following fall from a stair for 6
weeks in Summer [**2165**].
Urinary tract infection, site not specified,Toxic encephalopathy,Acute respiratory failure,Delirium due to conditions classified elsewhere,Acute posthemorrhagic anemia,Other and unspecified Escherichia coli [E. coli],Contusion of hip,Disorders of phosphorus metabolism,Orthostatic hypotension,Other and unspecified hyperlipidemia,Osteoporosis, unspecified,History of fall,Fall from other slipping, tripping, or stumbling,Oliguria and anuria
Urin tract infection NOS,Toxic encephalopathy,Acute respiratry failure,Delirium d/t other cond,Ac posthemorrhag anemia,E.coli infection NEC/NOS,Contusion of hip,Dis phosphorus metabol,Orthostatic hypotension,Hyperlipidemia NEC/NOS,Osteoporosis NOS,Personal history of fall,Fall from slipping NEC,Oliguria & anuria
Admission Date:  [**2166-10-9**]              Discharge Date:   [**2166-10-14**]

Date of Birth:  [**2080-5-14**]             Sex:   F

Service: MEDICINE

Allergies:
Macrobid

Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Altered mental status

Major Surgical or Invasive Procedure:
Endotracheal intubation

History of Present Illness:
EAST HOSPITAL MEDICINE ATTENDING [**Hospital **] TRANSFER TO FLOOR ACCEPT
NOTE

The patient is an 86 yo F with h/o orthostatic hypotension and
recent SAH in [**6-/2166**] sustained following a mechanical fall who
presented to the ED this evening with acutely altered mental
status with incoherent speech.
For the past week, she has been having b/l "body" tremors
including UE and head. The episodes last about 10 mins and are
low amplitude. Her daughter describes an episode where she
begins to fall following the episode, but that she is speaking
during the event and is not confused either during or after the
episode. She also has been experiencing a [**Hospital1 **]-temporal headache
that began on Wednesday evening and was associated with
decreased appetite, nausea and vomiting. The daughter's report
that their mother described it as pressure like on both sides of
her head.

On the night prior to admission, she got up to use the bathroom
and reported sustained a mechanical fall on to her left hip (not
uncommon for her according to her daughter), following which she
was "normal" and went back to sleep. She woke up in the morning,
her home health associate noted that she "was not her self" and
took her to see her PCP. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 91538**] head CT (NCHCT) was done
and reportedly negative. She also had left hip films which
revealed fractures of the L superior and inferior pubic rami
(subacute vs old) with minor degenerative changes. Her BP was
recorded at 124/70. Of note, the patient sustained a hip
fracture over the summer.

Upon returning home, she slept from 2pm-5pm and upon wakening,
she was acutely altered and confused with incoherent speech and
was brought to the ED.

In the ED, inital vitals were, 191/127, 94, 22, 98% on RA. A
Code Stroke was called. She was electively intubated due to
agitation so that she could undergo her imaging studies. A NCHCT
preliminary showed no acute intracranial process. As per the
neuro consult note, a CTA of the head and neck showed normal
vasculature with no thrombi or dissections and a CT perfusion
study did not reveal any perfusion deficits. She was not given
tPA as she thought to be outside of the therapeutic window.
Neurology reported her neuro exam was non localizing and that
the etiology of her AMS was not entirely clear. They are
concerned for PRES or a hypertensive encephalopathy given her
dramatic swings in BP. Of note, during her ED course, she spiked
a fever to 102 F and was also found to have a UA c/w UTI and was
given ceftriaxone. She was then transfered to the ICU for
further management.

Vitals on transfer were, 103/79 98 RR 16 on vent, Vt 400, PEEP
5, FiO2 50%. She was hypertensive on arrival with a recorded SBP
of 190. She was not given antihypertensives, however following
sedation with propofol her SBP was in the 140s. She was switched
from propofol to fent/versed just prior to transfer. Of note,
she dropped her BP to 82/55 while being moved to the stretcher
and required a 500cc bolus. Her BP then improved to 106/66. In
the ICU, her UTI was treated with bactrim. She was subsequently
extubated and her mental status was found to be at baseline. In
the ICU, her UTI was treated with bactrim. She was transferred
to the medicine floor for further management.

On the medicine floor, she reports no problems. She endorses
left hip pain only when she is moving around. She denies
headache, chest pain, shortness of breath, diarrhea, fevers,
chills, nausea, vomitting.

Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies visual changes, headache, dizziness, sinus
tenderness, neck stiffness, rhinorrhea, congestion, sore throat
or dysphagia. Denies chest pain, palpitations, orthopnea,
dyspnea on exertion. Denies shortness of breath, cough or
wheezes. Denies nausea, vomiting, heartburn, diarrhea,
constipation, BRBPR, melena, or abdominal pain. No dysuria,
urinary frequency. Denies arthralgias or myalgias. Denies
rashes. No increasing lower extremity swelling. No
numbness/tingling or muscle weakness in extremities. No feelings
of depression or anxiety. All other review of systems negative.

Past Medical History:
- Orthostatic hypotension, BP range on average 90-150 systolic.

- SAH ([**6-/2166**]) following ?mechanical fall during which she also
sustained a orbital fracture
- Hyperlipidema
- Urinary incontinence
- Hip fracture, noted in [**Month (only) 205**]. Imaging studies not entirely
clear, but daughter reported it is on the L and was incorrectly
reported as R on CT.
- Chronic LE edema
- Chronic hearing Loss
- Osteoporosis

Social History:
Lives by her self, has HHA but not 24 hrs, family attempts to
fill gaps in supervision. Has frequent falls primarily [**1-29**]
orthostatic hypotension sustaining injuries including SAH, hip
fx, facial fx. Was in rehab following fall from a stair for 6
weeks in Summer [**2165**].

Family History:
Not relevent to presentation of altered mental status and UTI in
an 86 y/o F.

Physical Exam:
VS: 98.2 134/60 89 20 96%RA; 0/10 pain at rest; [**7-6**] left hip
pain with movement
GEN: No apparent distress, pleasant
HEENT: No trauma, pupils round and reactive to light and
accommodation, no LAD, oropharynx clear, no exudates
CV: Regular rate and rhythm, no murmurs/gallops/rubs
PULM: Clear to auscultation bilaterally, no
rales/crackles/rhonchi
GI: Soft, non-tender, non-distended; no guarding/rebound
EXT: No clubbing/cyanosis/edema; 2+ distal pulses; peripheral IV
present; pneumoboots in place
NEURO: Alert and oriented to person, place and situation; CN
II-XII intact, [**5-1**] motor function globally
DERM: Ecchymoses on left upper posterior thigh/butt

Pertinent Results:
[**2166-10-9**] 08:15PM BLOOD WBC-9.8 RBC-3.46* Hgb-11.3* Hct-32.9*
MCV-95 MCH-32.6* MCHC-34.3 RDW-13.3 Plt Ct-290
[**2166-10-9**] 08:15PM BLOOD PT-12.7 PTT-19.8* INR(PT)-1.1
[**2166-10-10**] 04:30AM BLOOD Glucose-148* UreaN-16 Creat-1.0 Na-136
K-4.2 Cl-102 HCO3-27 AnGap-11
[**2166-10-10**] 04:30AM BLOOD ALT-6 AST-24 LD(LDH)-153 CK(CPK)-136
AlkPhos-21* TotBili-0.5
[**2166-10-9**] 08:15PM BLOOD cTropnT-<0.01
[**2166-10-10**] 04:30AM BLOOD Albumin-3.4* Calcium-8.4 Phos-4.0 Mg-1.6
[**2166-10-10**] 04:30AM BLOOD TSH-2.4
[**2166-10-10**] 04:30AM BLOOD VitB12-565 Folate-GREATER TH
[**2166-10-11**] 04:27AM BLOOD Hapto-71

[**2166-10-14**] 07:05AM BLOOD Glucose-95 UreaN-10 Creat-0.7 Na-139
K-3.5 Cl-103 HCO3-26 AnGap-14
[**2166-10-14**] 07:05AM BLOOD WBC-8.2 RBC-2.88* Hgb-9.2* Hct-27.2*
MCV-95 MCH-32.0 MCHC-33.8 RDW-15.3 Plt Ct-277

URINALYSIS:
[**2166-10-9**] 10:30PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.046*
[**2166-10-9**] 10:30PM URINE Blood-SM  Nitrite-POS Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG
[**2166-10-9**] 10:30PM URINE RBC-66* WBC-83* Bacteri-MANY Yeast-NONE
Epi-0
[**2166-10-9**] 10:30PM URINE CastHy-2*

[**2166-10-9**] 10:30 pm URINE     Site: CATHETER
                            **FINAL REPORT [**2166-10-12**]**
   URINE CULTURE (Final [**2166-10-12**]):
      ESCHERICHIA COLI.    >100,000 ORGANISMS/ML..
_________________________________________________________
                             ESCHERICHIA COLI
                             |
AMPICILLIN------------  =>32 R
AMPICILLIN/SULBACTAM--    16 I
CEFAZOLIN-------------     8 R
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN--------  <=16 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S

IMAGING:
CTA Head ([**2166-10-9**])
IMPRESSION:
1. No evidence of infarction, or hemorrhage.
2. No evidence of stenosis, occlusion, or aneurysm .
3. Calcified plaque at the left distal common carotid artery
causing approximately 25% stenosis.

CXR ([**2166-10-9**])
IMPRESSION: Endotracheal tube in appropriate position. Trace
right pleural effusion.

MRI HEAD ([**2166-10-10**])
IMPRESSION: Limited study. With this limitation in mind, there
is no large territorial infarct seen on diffusion-weighted
imaging.

CT Chest/Abd/Pelvis ([**2166-10-11**])
IMPRESSION:
1. Massive left gluteal/posterior thigh hematoma measuring 12.9
x 7.7 x 19.8 cm. Active extravasation cannot be assessed given
the lack of intravenous contrast material.
2. Multiple old fractures involving the left scapula, left
posterior ribs,
and left pelvic bones, as described above.
3. Lingular pulmonary nodule measuring 2 mm requires no
additional followup if this patient is a non-smoker and has no
prior history of malignancy. Otherwise, followup with a chest CT
in one year is recommended.

Brief Hospital Course:
86 year-old woman with orthostatic hypotension and recent SAH in
[**6-/2166**] following a mechanical fall presented to the ED this
evening with acutely altered mental status with incoherent
speech.

#. Delirium from Metabolic Encephalopathy: The patient presented
with an acute alteration in her mental status which was
originally concerning for a neurologic origin. A Code Stroke was
called and her initial imaging (NCHCT, CTA head, and CT
perfusion imaging) did not reveal an acute neurologic cause.
Neurology was consulted and recommened an MRI of the head to
evaluate for other causes including PRES or hypertensive
encephalopathy, and while the study was limited by motion
artifact, it did not reveal any neurology abnormalities. Upon
arrival, the patient was found to have a UA consistent with a
UTI. She was originally treated with antibiotics as below, and
her mental status greatly improved and it seems most likely that
her AMS was a result of her infection. Upon transfer from the
ICU, the patient was reportedly almost back at her baseline
mental status which some residual confusion as per her daughter.
She was alert and oriented to name and place, and was not
oriented to year, but did know that it was [**Month (only) 359**]. On the floor
she is alert and oriented to name, place, and date, but does
still get confused sometimes.

#. Orthostatic hypotension:
Upon arrival to the ICU, the patients blood pressure was highly
elevated. Following her intubation, her BP began to drop and
fluctuated widely early in her admission.  Her home medications
for orthostatic hypotension were held and her sedation while
intubated was limited to minimize swings in BP. Following
extubation, her BP remained more stable and her home medications
were restarted. The day of transfer from the MICU, her BP ranged
from 123/55 to 166/77.
- Continue home midodrine and fludrocortisone

#. Urinary Tract Infection, E Coli: Patient's urinalysis was
found to be consistent with UTI. She was started on ceftriaxone
and her mental status improved as above. When cultures returned,
she was transitioned to Bactrim in the ICU. Due to a concern for
potential allergy to Bactrim per ICU and per Ucx sensitivities,
her Bactrim was changed to ciprofloxacin. 5 total days of
antibiotics were administered.

#. Anemia: Stable.  It was noted that the patients hematocrit
had decreased from admission (34.9 to 24.0). Hemolysis labs were
done and were unrevealing. A CT scan of the Chest/Abdomen/Pelvis
was done which revealed a large hematoma surronding her left hip
(consistent with the events surronding her fall prior to
admission). She was closely monitored for compartment syndrome.
She received a total of 4 units of PRBCs while in the ICU and
her hematocrit stablized.

#. Respiratory Status: Stable.  The patient was electively
intubated for airway protection in the setting of her acute
agitation and need for emergent head imaging. She was extubated
without event the following afternoon and was satting well on
room air prior to and after her transfer to the general medical
floor.

#. Hip Fractures: At the time of her fall prior to admission,
the patient also fell onto her L hip.  Plain films done at her
PCPs office revealed left sided fractures, which were known from
a prior fall. As above, the patient also underwent a CT scan
which revealed a large hematoma around her left hip.
- Pain control with acetaminophen and lidocaine patch.  Avoid
narcotic pain medications if possible as they may worsen her
confusion.

#. Hyperlipidemia: The patient statin was initially held when
she was intubated and restarted prior to her transfer to the
general medical floor. Continue home simvastatin.

#. Communication: Daughter: [**First Name8 (NamePattern2) **] [**Known lastname 16807**]: [**Telephone/Fax (1) 91539**]
#. CODE: Full code

Medications on Admission:
-Potassium Chloride 10 mEq Oral Tablet Extended Release Take 1
tablet twice daily or as otherwise directed
-Midodrine 10 mg Oral Tablet take one tablet three times daily
or as otherwise prescribed
-Fludrocortisone (FLORINEF) 0.1 mg Oral Tablet take 1 tablet
daily until otherwise instructed
-Simvastatin 40 mg Oral Tablet 1 tablet every evening for
cholesterol
-CALCIUM ORAL
-MULTIVITAMIN ORAL

Discharge Medications:
1. midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
2. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
4. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO twice a day.
5. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1)
Tablet PO twice a day.
6. multivitamin     Tablet Sig: One (1) Tablet PO once a day.
7. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for left lower back.
8. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every [**4-2**]
hours as needed for fever or pain.

Discharge Disposition:
Extended Care

Facility:
[**Location (un) 582**] at [**Location (un) 620**]

Discharge Diagnosis:
- Metabolic encephalopathy
- Urinary tract infection
- Anemia from acute blood loss
- Left upper thigh hematoma
- Orthostatic hypotension

Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - should not ambulate without
assistance from another person to supervise.

Discharge Instructions:
You presented with delirium likely caused by Urinary Tract
Infection. CT scan of the head did not reveal a stroke.  You
were also found to have a low blood count and were found to have
bleeding into your upper left thigh.  You received blood
transfusions.  Your confusion is improving, but you are not
quite at your baseline yet.  You will complete a course of
antibiotics for your urinary tract infection.  Your blood count
was stable after the blood transfusions.

Followup Instructions:
After you are discharged from rehab, you should make an
appointment for follow-up with your primary care physician:

Name: [**Last Name (LF) **],[**First Name3 (LF) **] J
Location: [**Location (un) 2274**]-[**Location **]
Address: 291 INDEPENDENCE DR, [**Location **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 28551**]
{'Urinary tract infection, site not specified,Toxic encephalopathy,Acute respiratory failure,Delirium due to conditions classified elsewhere,Acute posthemorrhagic anemia,Other and unspecified Escherichia coli [E. coli],Contusion of hip,Disorders of phosphorus metabolism,Orthostatic hypotension,Other and unspecified hyperlipidemia,Osteoporosis, unspecified,History of fall,Fall from other slipping, tripping, or stumbling,Oliguria and anuria'}


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: Altered mental status

PRESENT ILLNESS: EAST HOSPITAL MEDICINE ATTENDING [**Hospital **] TRANSFER TO FLOOR ACCEPT
NOTE

MEDICAL HISTORY: - Orthostatic hypotension, BP range on average 90-150 systolic.

MEDICATION ON ADMISSION: -Potassium Chloride 10 mEq Oral Tablet Extended Release Take 1
tablet twice daily or as otherwise directed
-Midodrine 10 mg Oral Tablet take one tablet three times daily
or as otherwise prescribed
-Fludrocortisone (FLORINEF) 0.1 mg Oral Tablet take 1 tablet
daily until otherwise instructed
-Simvastatin 40 mg Oral Tablet 1 tablet every evening for
cholesterol
-CALCIUM ORAL
-MULTIVITAMIN ORAL

ALLERGIES: Macrobid

PHYSICAL EXAM: VS: 98.2 134/60 89 20 96%RA; 0/10 pain at rest; [**7-6**] left hip
pain with movement
GEN: No apparent distress, pleasant
HEENT: No trauma, pupils round and reactive to light and
accommodation, no LAD, oropharynx clear, no exudates
CV: Regular rate and rhythm, no murmurs/gallops/rubs
PULM: Clear to auscultation bilaterally, no
rales/crackles/rhonchi
GI: Soft, non-tender, non-distended; no guarding/rebound
EXT: No clubbing/cyanosis/edema; 2+ distal pulses; peripheral IV
present; pneumoboots in place
NEURO: Alert and oriented to person, place and situation; CN
II-XII intact, [**5-1**] motor function globally
DERM: Ecchymoses on left upper posterior thigh/butt

FAMILY HISTORY: Not relevent to presentation of altered mental status and UTI in
an 86 y/o F.

SOCIAL HISTORY: Lives by her self, has HHA but not 24 hrs, family attempts to
fill gaps in supervision. Has frequent falls primarily [**1-29**]
orthostatic hypotension sustaining injuries including SAH, hip
fx, facial fx. Was in rehab following fall from a stair for 6
weeks in Summer [**2165**]. 

### Response:
{'Urinary tract infection, site not specified,Toxic encephalopathy,Acute respiratory failure,Delirium due to conditions classified elsewhere,Acute posthemorrhagic anemia,Other and unspecified Escherichia coli [E. coli],Contusion of hip,Disorders of phosphorus metabolism,Orthostatic hypotension,Other and unspecified hyperlipidemia,Osteoporosis, unspecified,History of fall,Fall from other slipping, tripping, or stumbling,Oliguria and anuria'}
