CHIEF COMPLAINT: altered mental status

PRESENT ILLNESS: : 81yo previously active & ambulatory woman with DM2, HTN,
hypothyroid, ESRD on HD x 9 months (MWF, last done [**8-20**]).
Admitted to OSH on [**2162-8-12**] with MSSA line infection, line
removed, treated with nafcillin, defervesced on [**8-15**], never
septic. Subsequently developed severe neck/back pain.  MRI whole
spine negative for abscess, discitis, fracture, or
osteomyelitis, but patient continues to not be able to speak or
walk. Mental Status is distinctly decreased from beginning of
hospitalization per family. She denies chest pain, abdominal
pain, or difficulty breathing.    Remains alert &
hemodynamically stable. MRI brain showed 2 acute infarcts R & L
parietal areas. Family requesting transfer to [**Hospital1 18**] for further
evaluation.

MEDICAL HISTORY: 1. Type 2 DM (diet controlled)
2. ESRD on HD MWF
3. HTN
4. Hypothyroidism
5. Anemia
6. Depression
7. Breast Cancer s/p mastectomy [**2156**]

MEDICATION ON ADMISSION: Atenolol 75mg PO daily
Hectorol 2.5 micrograms
Hydralazine 25mg PO TID
Lisinopril 2.5mg daily
Rocaltrol 0.25 micrograms daily
synthroid 100mcg Qday
senna
protonix 40mg QD
nephrocaps
nafcillin 2gm IV Q6hr
morphine 1-2mg IV Q4hr

ALLERGIES: Feldene

PHYSICAL EXAM: Vitals- Tm 99.1 BP 118/50 HR 81 R 16 O2sat 95%2L FSBG 128
General- thin woman, moaning, skin icteric
HEENT- +scleral icterus, pinpoint pupils, full lateral gaze
Neck- tender to palpation posteriorly
Pulm- limited exam secondary to pain, clear anteriorly
CV- RRR, [**4-12**] holosystolic murmur
Abd- soft, non-tender, +bs
Extrem- no edema, dp pulses intact bilaterally
Neuro- A&OX1, follows some simple, one step commands, difficult
to understand speech, moves all extremities equally, babinski:R
upgoing.  [**4-11**] motor strength upper extremities, L>R

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: lives with her husband.  Up until this illness, was shopping,
cooking, driving. Daughters [**Name (NI) **] and [**Name2 (NI) 4457**] involved in care.
tob: none   etoh: none   other drugs: none
Infection and inflammatory reaction due to other vascular device, implant, and graft,Methicillin susceptible Staphylococcus aureus septicemia,Septic shock,Cerebral artery occlusion, unspecified with cerebral infarction,Acute kidney failure, unspecified,Acute respiratory failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Unspecified protein-calorie malnutrition,Severe sepsis,Profound impairment, both eyes, impairment level not further specified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified acquired hypothyroidism,Anemia in chronic kidney disease,Personal history of malignant neoplasm of breast,Infection with microorganisms resistant to penicillins,Encounter for palliative care
React-oth vasc dev/graft,Meth susc Staph aur sept,Septic shock,Crbl art ocl NOS w infrc,Acute kidney failure NOS,Acute respiratry failure,Hyp kid NOS w cr kid V,End stage renal disease,Protein-cal malnutr NOS,Severe sepsis,Both eyes blind-who def,DMII wo cmp nt st uncntr,Hypothyroidism NOS,Anemia in chr kidney dis,Hx of breast malignancy,Inf mcrg rstn pncllins,Encountr palliative care
Admission Date:  [**2162-8-22**]              Discharge Date:   [**2162-8-26**]

Date of Birth:  [**2081-3-18**]             Sex:   F

Service: MEDICINE

Allergies:
Feldene

Attending:[**First Name3 (LF) 297**]
Chief Complaint:
altered mental status

Major Surgical or Invasive Procedure:
none

History of Present Illness:
: 81yo previously active & ambulatory woman with DM2, HTN,
hypothyroid, ESRD on HD x 9 months (MWF, last done [**8-20**]).
Admitted to OSH on [**2162-8-12**] with MSSA line infection, line
removed, treated with nafcillin, defervesced on [**8-15**], never
septic. Subsequently developed severe neck/back pain.  MRI whole
spine negative for abscess, discitis, fracture, or
osteomyelitis, but patient continues to not be able to speak or
walk. Mental Status is distinctly decreased from beginning of
hospitalization per family. She denies chest pain, abdominal
pain, or difficulty breathing.    Remains alert &
hemodynamically stable. MRI brain showed 2 acute infarcts R & L
parietal areas. Family requesting transfer to [**Hospital1 18**] for further
evaluation.


Past Medical History:
1. Type 2 DM (diet controlled)
2. ESRD on HD MWF
3. HTN
4. Hypothyroidism
5. Anemia
6. Depression
7. Breast Cancer s/p mastectomy [**2156**]

Social History:
lives with her husband.  Up until this illness, was shopping,
cooking, driving. Daughters [**Name (NI) **] and [**Name2 (NI) 4457**] involved in care.
tob: none   etoh: none   other drugs: none


Family History:
non-contributory

Physical Exam:
Vitals- Tm 99.1 BP 118/50 HR 81 R 16 O2sat 95%2L FSBG 128
General- thin woman, moaning, skin icteric
HEENT- +scleral icterus, pinpoint pupils, full lateral gaze
Neck- tender to palpation posteriorly
Pulm- limited exam secondary to pain, clear anteriorly
CV- RRR, [**4-12**] holosystolic murmur
Abd- soft, non-tender, +bs
Extrem- no edema, dp pulses intact bilaterally
Neuro- A&OX1, follows some simple, one step commands, difficult
to understand speech, moves all extremities equally, babinski:R
upgoing.  [**4-11**] motor strength upper extremities, L>R


Pertinent Results:
MRI head: Acute infarct in high R and high L parietal areas
.MRI C-spine: bulges C5/C6, no impingement, no abcess.
.MRI T/L spine showed no osteomyelitis, mulitlevel
spondylolisthesis, disc bulging L5-S1, narrowing of canal.
EGD ([**2162-8-13**]): gastroenteritis
U/S LE ([**2162-8-20**]): bilat DVT
TTEcho ([**2162-8-20**]): EF 60%, no evidence of vegetations
.


Brief Hospital Course:
A/P: 81F with h/o ESRD on HD, hypertension, DM2, transferred
from OSH with mental status changes, line infection, and back
pain. Now with acute bilateral vision loss thought secondary to
b/l occipital strokes.
.
#. Septic shock:
On arrival to the ICU, patient hypotensive and tacchycardic
overnight (alternating with rapid rate with RBBB and LBBB).
Despite frequent fluid boluses patient and being on 2 pressors,
she was persistently hypotensive. The patient was started on
broad spectrum abx vanc/levo/ flagyll and naficillin. During her
ICU course, she continued to require pressors and her pressor
needs escalated to the point of requiring a 3rd pressor for
hypotension.

# Acute Vision Loss
- MRI showed new bilateral occipital strokes thought to be [**3-11**]
hypotension. Neurology was consulted, but in the setting of
patient's septic picture, neuro exam was deferred because of
ongoing shock.
.
# Mental Status Change: Neuro felt that AMS could be due to
vascular insults, infarcts and extensive small vessel disease;
other etiologies that could be contributing are infection or
other metabolic disturbances.
.
# Line infection: from central dialysis catheter, dxed and
removed at osh on [**2162-8-12**]. Blood cultures grew MSSA - hence
patient was placed on nafcillin. Blood cultures here from [**8-22**]
and [**8-24**] were pending on date of death.
.
# Abd Pain- with diarrhea, may be infectious.
-- cdif ordered
-- kub- no free air
.
# Back pain: severe from recent fall. An MRI C-spine showed
bulges at C5/C6, no impingement and no abcess. MRI T/L spine
showed no osteomyelitis, mulitlevel spondylolisthesis, disc
bulging L5-S1, narrowing of canal. No evidence of acute
fracture. PAtient placed on morphine for pain.
.
# ESRD on HD, mon/wed/fri schedule.
.
# Anemia, likely from CKD (36-->28-->27 since admission),
unclear why drop but has how been stable. iron studies
consistent with chronic disease. no signs of active bleeding.
Hcts stable through rest of stay.
.
# Hypertension: held antihypertensives because of recent
infarcts and need for pressor support. Neuro recommended BPs to
be in the 130s.
.
After an extensive discussion with the patien's family on [**8-26**]
(daughters and husband) the decision was made to make the
patient CMO.  Pulm fellow, residents, sw and nurse were all
present. Pressors were discontinued and later this evening,
patient expired. Family was at bedside. Autopsy was offered, but
declined by daughters.
.


Medications on Admission:
Atenolol 75mg PO daily
Hectorol 2.5 micrograms
Hydralazine 25mg PO TID
Lisinopril 2.5mg daily
Rocaltrol 0.25 micrograms daily
synthroid 100mcg Qday
senna
protonix 40mg QD
nephrocaps
nafcillin 2gm IV Q6hr
morphine 1-2mg IV Q4hr

Discharge Medications:
NA

Discharge Disposition:
Expired

Discharge Diagnosis:
Deceased

Discharge Condition:
Deceased

Discharge Instructions:
NA

Followup Instructions:
NA


Completed by:[**2162-8-26**]
{'Infection and inflammatory reaction due to other vascular device, implant, and graft,Methicillin susceptible Staphylococcus aureus septicemia,Septic shock,Cerebral artery occlusion, unspecified with cerebral infarction,Acute kidney failure, unspecified,Acute respiratory failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Unspecified protein-calorie malnutrition,Severe sepsis,Profound impairment, both eyes, impairment level not further specified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified acquired hypothyroidism,Anemia in chronic kidney disease,Personal history of malignant neoplasm of breast,Infection with microorganisms resistant to penicillins,Encounter for palliative care'}


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: : 81yo previously active & ambulatory woman with DM2, HTN,
hypothyroid, ESRD on HD x 9 months (MWF, last done [**8-20**]).
Admitted to OSH on [**2162-8-12**] with MSSA line infection, line
removed, treated with nafcillin, defervesced on [**8-15**], never
septic. Subsequently developed severe neck/back pain.  MRI whole
spine negative for abscess, discitis, fracture, or
osteomyelitis, but patient continues to not be able to speak or
walk. Mental Status is distinctly decreased from beginning of
hospitalization per family. She denies chest pain, abdominal
pain, or difficulty breathing.    Remains alert &
hemodynamically stable. MRI brain showed 2 acute infarcts R & L
parietal areas. Family requesting transfer to [**Hospital1 18**] for further
evaluation.

MEDICAL HISTORY: 1. Type 2 DM (diet controlled)
2. ESRD on HD MWF
3. HTN
4. Hypothyroidism
5. Anemia
6. Depression
7. Breast Cancer s/p mastectomy [**2156**]

MEDICATION ON ADMISSION: Atenolol 75mg PO daily
Hectorol 2.5 micrograms
Hydralazine 25mg PO TID
Lisinopril 2.5mg daily
Rocaltrol 0.25 micrograms daily
synthroid 100mcg Qday
senna
protonix 40mg QD
nephrocaps
nafcillin 2gm IV Q6hr
morphine 1-2mg IV Q4hr

ALLERGIES: Feldene

PHYSICAL EXAM: Vitals- Tm 99.1 BP 118/50 HR 81 R 16 O2sat 95%2L FSBG 128
General- thin woman, moaning, skin icteric
HEENT- +scleral icterus, pinpoint pupils, full lateral gaze
Neck- tender to palpation posteriorly
Pulm- limited exam secondary to pain, clear anteriorly
CV- RRR, [**4-12**] holosystolic murmur
Abd- soft, non-tender, +bs
Extrem- no edema, dp pulses intact bilaterally
Neuro- A&OX1, follows some simple, one step commands, difficult
to understand speech, moves all extremities equally, babinski:R
upgoing.  [**4-11**] motor strength upper extremities, L>R

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: lives with her husband.  Up until this illness, was shopping,
cooking, driving. Daughters [**Name (NI) **] and [**Name2 (NI) 4457**] involved in care.
tob: none   etoh: none   other drugs: none 

### Response:
{'Infection and inflammatory reaction due to other vascular device, implant, and graft,Methicillin susceptible Staphylococcus aureus septicemia,Septic shock,Cerebral artery occlusion, unspecified with cerebral infarction,Acute kidney failure, unspecified,Acute respiratory failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Unspecified protein-calorie malnutrition,Severe sepsis,Profound impairment, both eyes, impairment level not further specified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified acquired hypothyroidism,Anemia in chronic kidney disease,Personal history of malignant neoplasm of breast,Infection with microorganisms resistant to penicillins,Encounter for palliative care'}
