CHIEF COMPLAINT: outside hospital transfer with hypotension adn hypothermia

PRESENT ILLNESS: This is a 89 year-old female with a history of [**Last Name (un) 309**] Body
dementia, CAD, HTN who presents with 3 days of progressive
altered mental status. At baseline, the patient is alert and
oriented x 3 and was in her usual state of health until 2 days
prior to admission. At that time her daughters noted that she
was not eating. The following day, she was not talking and was
less interactive than usual, answering questions with only "yes"
or "no". On the morning of admission, she was found unresponsive
and moaning and so EMS was called. On arrival EMS found her to
be hypothermic in the 80s (apartment was normal temperature) and
not responsive.
.
In the ED, initial vitals were T 85, BP 136/80, HR 52, RR 16, O2
sat 93% on 2L. On exam, she was moaning but not interactive.
Moving all extremities and was noted to have a cough. CXR was
concerning for LLL pna. UA positive. She was noted to be in ARF
with Cr 1.2 from baseline 0.6. At 11:50pm became hypotensive to
70s (HR 70s), however her BP quickly improved to 100s-90s with
IVF. Received vanco, ceftriaxone, and azithromycin. Hypothermia
was treated with a warming blanket and warmed IVF. Head CT neg.
EKG showed old LBBB however trop mildly elevated at 0.04 and so
she was given PR ASA. Abdominal CT with IV contrast revealed
diverticulosis (without diverticulitis), chronic LLL
atelectasis, no mesenteric ischemia, no abscess. She was
admitted to the [**Hospital Unit Name 153**] for further management.

MEDICAL HISTORY: -HTN
-GI Bleed--[**2158**], in setting of NSAID use as well as H.Pylori
infection, which was treated. That hospitalization included ICU
admission with multiple PRBC transfusions, several EGDs with
clipping and electrocaudery of bleeding lesion, intubation and
tx for PNA, and IMI that was likely in the setting of anemia.
-CAD--had an elevation in trop in setting of GIB as above (Echo
in [**10-31**] showed preserved EF (55%) with basal inferolateral
hypokinesis and septal apex hypokinesis, and [**11-30**]+ MR)
-CVA--[**10-31**] with L hemiparesis (distal right middle cerebral
artery
lenticulostriate artery infarction)
-Dementia--probable [**Last Name (un) 309**] Body

MEDICATION ON ADMISSION: Aricept 5mg PO BID
ASA 325mg PO daily
Calcium 500 + D one tab PO daily
Detrol LA 2mg PO qHS
Seroquel 37.5mg PO daily prn agitation

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 93.2 BP: 128/105 HR: 86 RR: 22 O2Sat: 96% on 2L
GEN: somnolent elderly female, unarousable, withdraws to painful
stimuli
HEENT: pupils pinpoint and minimally reactive, sclera anicteric,
no epistaxis or rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: HS muffled by heavy breathing, RRR, no M/G/R, normal S1 S2,
weak distal pulses
PULM: Lungs CTAB anteriorly however exam limited by patient's
mental status
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: L arm contracted. No LE edema.
RECTAL: guaiac negative per ED
NEURO: unresponsive, withdraws to painful stimuli, moves RUE and
bilateral [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 35718**]. Plantar reflex downgoing. ?
bilateral ankle clonus
SKIN: Scattered ecchymoses on extremities.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: One of her daughters is a nurse. She does not smoke and rarely
drinks alcohol. Prior history of [**1-1**] glasses of ETOH/day. She
likes drinking coffee, at least three cups a day.
Unspecified septicemia,Septic shock,Acute kidney failure, unspecified,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Severe sepsis,Dementia with lewy bodies,Dementia in conditions classified elsewhere without behavioral disturbance,Unspecified essential hypertension,Diverticulosis of colon (without mention of hemorrhage)
Septicemia NOS,Septic shock,Acute kidney failure NOS,Pneumonia, organism NOS,Urin tract infection NOS,Late ef-hemplga side NOS,Severe sepsis,Dementia w Lewy bodies,Dementia w/o behav dist,Hypertension NOS,Dvrtclo colon w/o hmrhg
Admission Date:  [**2164-11-19**]              Discharge Date:   [**2164-11-25**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
outside hospital transfer with hypotension adn hypothermia

Major Surgical or Invasive Procedure:
none

History of Present Illness:
This is a 89 year-old female with a history of [**Last Name (un) 309**] Body
dementia, CAD, HTN who presents with 3 days of progressive
altered mental status. At baseline, the patient is alert and
oriented x 3 and was in her usual state of health until 2 days
prior to admission. At that time her daughters noted that she
was not eating. The following day, she was not talking and was
less interactive than usual, answering questions with only "yes"
or "no". On the morning of admission, she was found unresponsive
and moaning and so EMS was called. On arrival EMS found her to
be hypothermic in the 80s (apartment was normal temperature) and
not responsive.
.
In the ED, initial vitals were T 85, BP 136/80, HR 52, RR 16, O2
sat 93% on 2L. On exam, she was moaning but not interactive.
Moving all extremities and was noted to have a cough. CXR was
concerning for LLL pna. UA positive. She was noted to be in ARF
with Cr 1.2 from baseline 0.6. At 11:50pm became hypotensive to
70s (HR 70s), however her BP quickly improved to 100s-90s with
IVF. Received vanco, ceftriaxone, and azithromycin. Hypothermia
was treated with a warming blanket and warmed IVF. Head CT neg.
EKG showed old LBBB however trop mildly elevated at 0.04 and so
she was given PR ASA. Abdominal CT with IV contrast revealed
diverticulosis (without diverticulitis), chronic LLL
atelectasis, no mesenteric ischemia, no abscess. She was
admitted to the [**Hospital Unit Name 153**] for further management.


Past Medical History:
-HTN
-GI Bleed--[**2158**], in setting of NSAID use as well as H.Pylori
infection, which was treated. That hospitalization included ICU
admission with multiple PRBC transfusions, several EGDs with
clipping and electrocaudery of bleeding lesion, intubation and
tx for PNA, and IMI that was likely in the setting of anemia.
-CAD--had an elevation in trop in setting of GIB as above (Echo
in [**10-31**] showed preserved EF (55%) with basal inferolateral
hypokinesis and septal apex hypokinesis, and [**11-30**]+ MR)
-CVA--[**10-31**] with L hemiparesis (distal right middle cerebral
artery
lenticulostriate artery infarction)
-Dementia--probable [**Last Name (un) 309**] Body

Social History:
One of her daughters is a nurse. She does not smoke and rarely
drinks alcohol. Prior history of [**1-1**] glasses of ETOH/day. She
likes drinking coffee, at least three cups a day.


Family History:
Non-contributory

Physical Exam:
Vitals: T: 93.2 BP: 128/105 HR: 86 RR: 22 O2Sat: 96% on 2L
GEN: somnolent elderly female, unarousable, withdraws to painful
stimuli
HEENT: pupils pinpoint and minimally reactive, sclera anicteric,
no epistaxis or rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: HS muffled by heavy breathing, RRR, no M/G/R, normal S1 S2,
weak distal pulses
PULM: Lungs CTAB anteriorly however exam limited by patient's
mental status
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: L arm contracted. No LE edema.
RECTAL: guaiac negative per ED
NEURO: unresponsive, withdraws to painful stimuli, moves RUE and
bilateral [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 35718**]. Plantar reflex downgoing. ?
bilateral ankle clonus
SKIN: Scattered ecchymoses on extremities.


Pertinent Results:
[**2164-11-20**] 03:30AM BLOOD WBC-9.7 RBC-3.76* Hgb-11.2*# Hct-33.3*
MCV-89 MCH-29.9 MCHC-33.8 RDW-16.4* Plt Ct-106*
[**2164-11-19**] 08:00PM BLOOD WBC-9.1 RBC-4.67# Hgb-14.4# Hct-42.1#
MCV-90 MCH-31.0 MCHC-34.3 RDW-16.5* Plt Ct-133*
[**2164-11-19**] 08:00PM BLOOD Neuts-91.7* Lymphs-5.5* Monos-1.7*
Eos-0.9 Baso-0.1
[**2164-11-19**] 08:00PM BLOOD PT-14.5* PTT-37.1* INR(PT)-1.3*
[**2164-11-19**] 08:00PM BLOOD Glucose-84 UreaN-30* Creat-1.2* Na-146*
K-4.8 Cl-108 HCO3-29 AnGap-14
[**2164-11-20**] 03:30AM BLOOD Glucose-64* UreaN-28* Creat-1.1 Na-144
K-4.6 Cl-115* HCO3-19* AnGap-15
[**2164-11-19**] 08:00PM BLOOD ALT-24 AST-27 CK(CPK)-61 AlkPhos-137*
Amylase-149* TotBili-0.5
[**2164-11-20**] 03:46AM BLOOD CK-MB-12* MB Indx-23.5* cTropnT-0.03*
[**2164-11-20**] 03:30AM BLOOD Calcium-7.4* Phos-3.1 Mg-1.9
[**2164-11-20**] 03:46AM BLOOD TSH-3.4
[**2164-11-20**] 03:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2164-11-20**] 06:26AM BLOOD Type-ART pO2-44* pCO2-44 pH-7.28*
calTCO2-22 Base XS--5
[**2164-11-19**] 08:05PM BLOOD Lactate-1.2
[**2164-11-19**] 10:30PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-1 pH-5.0 Leuks-SM
[**2164-11-19**] 10:30PM URINE RBC-0-2 WBC-[**10-18**]* Bacteri-MANY
Yeast-NONE Epi-0-2
[**2164-11-19**] 10:30PM URINE CastHy-[**5-8**]*
CT Abdomen/Pelvis:
IMPRESSION:

1. No evidence of mesenteric ischemia or acute abdominal
process.

2. Atherosclerotic disease of the aorta and its branches, with
bilateral
renal artery stenoses, and lesser stenoses of the celiac and
SMA.

3. Replaced right hepatic artery.

4 . Severe diverticulosis, without evidence of diverticulitis.

5. Right adnexal cyst, for which an outpatient ultrasound is
recommended.

The study and the report were reviewed by the staff radiologist.

INDICATION: 89-year-old with altered mental status.

COMPARISON: [**2162-9-11**].

NON-CONTRAST HEAD CT: There is no acute intracranial hemorrhage,
edema, or
major vascular territorial infarct. Extensive encephalomalacia
related to a
prior right MCA territory infarct is unchanged. There is
associated ex vacuo
dilatation of the right lateral ventricle. The ventricles and
sulci are
prominent, consistent with age-related involutional changes. The
basal
cisterns are preserved. There is no calvarial or soft tissue
abnormality. The
visualized paranasal sinuses and mastoid air cells are normally
pneumatized
and aerated. The lenses have been replaced.

IMPRESSION: No acute intracranial process including no evidence
of
hemorrhage.



Brief Hospital Course:
On arrival to the [**Hospital Unit Name 153**], the patient was hemodynamically stable.
However, within 2 hours, her BP dropped to the 60s systolic with
MAPs in the 40-50s. She was bolused 2L IVF and started on
peripheral dopamine. The patient was known to be DNR/DNI and the
family did not want a central line, however, they wanted the
rest of the family to be able to come in so we used the dopamine
for several hours with the goal of stopping it when the family
arrived. In the morning, we had a family meeting and it was
decided to make the patient CMO.  Her dopamine was d/c'd and she
was given morphine for pain control.  She remained stable
throughout the day and was transferred to the floor. On the
floor she was continued on morphine with no vital signs or labs
checked. She remained on the Morphine drip for several days. Her
daughters refused hospice at home or transfer to hospice house
because of the costs. A SNIF has refused to take her for end of
life care because she was on morphine drip. She finally expired
on [**2165-11-25**] at 3:00 PM.

Medications on Admission:
Aricept 5mg PO BID
ASA 325mg PO daily
Calcium 500 + D one tab PO daily
Detrol LA 2mg PO qHS
Seroquel 37.5mg PO daily prn agitation


Discharge Medications:
none

Discharge Disposition:
Extended Care

Discharge Diagnosis:
Sepsis


Discharge Condition:
expired
{'Unspecified septicemia,Septic shock,Acute kidney failure, unspecified,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Severe sepsis,Dementia with lewy bodies,Dementia in conditions classified elsewhere without behavioral disturbance,Unspecified essential hypertension,Diverticulosis of colon (without mention of hemorrhage)'}


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: outside hospital transfer with hypotension adn hypothermia

PRESENT ILLNESS: This is a 89 year-old female with a history of [**Last Name (un) 309**] Body
dementia, CAD, HTN who presents with 3 days of progressive
altered mental status. At baseline, the patient is alert and
oriented x 3 and was in her usual state of health until 2 days
prior to admission. At that time her daughters noted that she
was not eating. The following day, she was not talking and was
less interactive than usual, answering questions with only "yes"
or "no". On the morning of admission, she was found unresponsive
and moaning and so EMS was called. On arrival EMS found her to
be hypothermic in the 80s (apartment was normal temperature) and
not responsive.
.
In the ED, initial vitals were T 85, BP 136/80, HR 52, RR 16, O2
sat 93% on 2L. On exam, she was moaning but not interactive.
Moving all extremities and was noted to have a cough. CXR was
concerning for LLL pna. UA positive. She was noted to be in ARF
with Cr 1.2 from baseline 0.6. At 11:50pm became hypotensive to
70s (HR 70s), however her BP quickly improved to 100s-90s with
IVF. Received vanco, ceftriaxone, and azithromycin. Hypothermia
was treated with a warming blanket and warmed IVF. Head CT neg.
EKG showed old LBBB however trop mildly elevated at 0.04 and so
she was given PR ASA. Abdominal CT with IV contrast revealed
diverticulosis (without diverticulitis), chronic LLL
atelectasis, no mesenteric ischemia, no abscess. She was
admitted to the [**Hospital Unit Name 153**] for further management.

MEDICAL HISTORY: -HTN
-GI Bleed--[**2158**], in setting of NSAID use as well as H.Pylori
infection, which was treated. That hospitalization included ICU
admission with multiple PRBC transfusions, several EGDs with
clipping and electrocaudery of bleeding lesion, intubation and
tx for PNA, and IMI that was likely in the setting of anemia.
-CAD--had an elevation in trop in setting of GIB as above (Echo
in [**10-31**] showed preserved EF (55%) with basal inferolateral
hypokinesis and septal apex hypokinesis, and [**11-30**]+ MR)
-CVA--[**10-31**] with L hemiparesis (distal right middle cerebral
artery
lenticulostriate artery infarction)
-Dementia--probable [**Last Name (un) 309**] Body

MEDICATION ON ADMISSION: Aricept 5mg PO BID
ASA 325mg PO daily
Calcium 500 + D one tab PO daily
Detrol LA 2mg PO qHS
Seroquel 37.5mg PO daily prn agitation

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 93.2 BP: 128/105 HR: 86 RR: 22 O2Sat: 96% on 2L
GEN: somnolent elderly female, unarousable, withdraws to painful
stimuli
HEENT: pupils pinpoint and minimally reactive, sclera anicteric,
no epistaxis or rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: HS muffled by heavy breathing, RRR, no M/G/R, normal S1 S2,
weak distal pulses
PULM: Lungs CTAB anteriorly however exam limited by patient's
mental status
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: L arm contracted. No LE edema.
RECTAL: guaiac negative per ED
NEURO: unresponsive, withdraws to painful stimuli, moves RUE and
bilateral [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 35718**]. Plantar reflex downgoing. ?
bilateral ankle clonus
SKIN: Scattered ecchymoses on extremities.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: One of her daughters is a nurse. She does not smoke and rarely
drinks alcohol. Prior history of [**1-1**] glasses of ETOH/day. She
likes drinking coffee, at least three cups a day. 

### Response:
{'Unspecified septicemia,Septic shock,Acute kidney failure, unspecified,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Severe sepsis,Dementia with lewy bodies,Dementia in conditions classified elsewhere without behavioral disturbance,Unspecified essential hypertension,Diverticulosis of colon (without mention of hemorrhage)'}
