CHIEF COMPLAINT: altered mental status

PRESENT ILLNESS: Pt is a 66 y/o M with PMH significant for ESRD on HD,
compensated liver cirrhosis c/b esophageal varices, poorly
controlled D2M s/p bilateral BTK amputations, AV fistula
infections (VRE and MRSA) and recently diagnosed pancreatic head
mass likely pancreatic adenocarcinoma from EGD brushings was
admitted to the transplant surgery service [**2191-5-28**] ago for
altered mental status which has persisted over his hospital stay
despite abx (IV zosyn) for GNR found in blood (at [**Hospital 100**] Rehab
facility), lactulose.

MEDICAL HISTORY: ESRD from diabetic nephropathy on HD since [**5-/2183**]
Diabetes mellitus type II for over 20 years on insulin
HTN
Hepatitis C genotype 4
Hep B core Ab positive (negative viral load in [**2185**])
Cirrhosis - [**1-26**] HCV, portal hypertensive gastropathy
Ischemic colitis with GIB ([**2180**]), occ BRBPR; known small bowel
AVMs
Small bowel AVMs
Grade I esophageal varices
Chronic anemia
H/o right AV fistula infection
Gastric Antral Vascular Ectasia
S/p penectomy for necrosis [**1-26**] arterial insufficiency
S/p bilat BKA ([**2179**], [**2183**])
H/o IV drug use (heroin), on methadone since [**2159**]
H/o ESBL Klebsiella wound infections
H/o MRSA, VRE and Clostridium difficile
H/o L hand and finger MRSA osteomyelitides
H/o TB (age 15, Rx with PAS/INH x 2 yrs)
H/o line infections w/MSSA, E. fecalis, Pseudomonas and C.
glabrata

MEDICATION ON ADMISSION: (per OMR) amylase/lipase/protease 2caps PO TID with meals,
calcium acetate 667mg PO BID, diphenoxylate-atropine 2.5/0.025mg
PO q4h, doxepin 10mg PO qHS, famotidine 20mg PO qHS, folic acid
1mg PO daily, gabapentin 300mg PO daily, lantus 10Units SC qHS,
Humalog 2Units qAM and ISS with meals and at bedtime, methadone
600mg PO BID (per OMR, not verified!), nadolol 20mg PO daily,
opium tincture 6mg PO QID prn diarrhea, Renagel 1600mg PO TID
with meals, vit B12 500mcg PO daily, loperamide 4mg PO QID prn
diarrhea, iron 325mg PO daily

ALLERGIES: Cephalosporins / Metoclopramide / Infed / Heparin Agents

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
Vitals: Tm:98.7, Tc:96.7, HR:60-70, BP:150/81(110-160/40-80),
RR:18, O2 Sat: 96%RA
GEN: Sick appearing cachetic gentleman lying in bed with feeding
tube in right nostril, no teeth, hypophonic, no acute distress.
Alert, oriented to self but not place (in church) and time
([**Month (only) 404**])
HEENT: Normocephalic, sclera icterus, oropharynx clear, MMM
NECK: No thyromegaly, no lymphadenopathy
CV: Regular rate, normal rhythm, no
murmurs/gallops/regurgitation
PULM: Clear to auscultation bilaterally, mild crackles in the
bases, no wheezing/ronchi, non-labored breathing.
ABD: Soft, decreased bowel sounds, tender to palpation in all
four quadrants, no rebound/guarding
EXT: Bilateral below the need amputation, cool but pulses
palpable in all four extremities. Has 4 fingers on the left.
Nails are dark and clubbed.
SKIN: Difficult to evalaute for spider angioma or palmar
erythema.
NEURO: Alert, interactive, oriented to self but not time or
place. Limited due to inability to follow commands fully.

FAMILY HISTORY: Several siblings with diabetes.

SOCIAL HISTORY: Born in [**Location (un) 86**] and most recently lived in [**Hospital 100**] Rehab. He has
several brothers/sisters and four children. Worked with
computers. Has history of [**12-26**] ppd smoking for 10 years. Long
time history of IV drug (heroine use) and has been on methadone
since [**2159**]. Denies EtoH and other illicits currently.
Acute cholecystitis,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Renal dialysis status,Cirrhosis of liver without mention of alcohol,Chronic hepatitis C without mention of hepatic coma,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Below knee amputation status
Acute cholecystitis,End stage renal disease,Hyp kid NOS w cr kid V,Renal dialysis status,Cirrhosis of liver NOS,Chrnc hpt C wo hpat coma,DMII wo cmp nt st uncntr,Long-term use of insulin,Status amput below knee
Admission Date:  [**2191-5-28**]              Discharge Date:   [**2191-6-6**]

Date of Birth:  [**2125-5-16**]             Sex:   M

Service: MEDICINE

Allergies:
Cephalosporins / Metoclopramide / Infed / Heparin Agents

Attending:[**First Name3 (LF) 25504**]
Chief Complaint:
altered mental status

Major Surgical or Invasive Procedure:
[**2191-5-28**]: ultrasound-guided percutaneous cholecystostomy
[**2191-6-2**]: IR guided PICC placement


History of Present Illness:
Pt is a 66 y/o M with PMH significant for ESRD on HD,
compensated liver cirrhosis c/b esophageal varices, poorly
controlled D2M s/p bilateral BTK amputations, AV fistula
infections (VRE and MRSA) and recently diagnosed pancreatic head
mass likely pancreatic adenocarcinoma from EGD brushings was
admitted to the transplant surgery service [**2191-5-28**] ago for
altered mental status which has persisted over his hospital stay
despite abx (IV zosyn) for GNR found in blood (at [**Hospital 100**] Rehab
facility), lactulose.

He was sent to ED from [**Hospital 100**] Rehab where he resides with
altered mental status.  Reports from rehab indicate the patient
had a fever and altered mental status first on [**5-25**] and at that
time was started on empiric vanc/zosyn without a source of
infection.  Blood cultures sent that day have since yielded GNRs
in [**12-28**] bottles.  Reportedly the patient's mental status improved
and he did not have further fevers over the next two days.
Consequently he was sent to [**Hospital1 18**] ED for further evaluation
since his mental status declined again.

On arrival to [**Hospital1 18**] he continued to be somnolent; blood
pressures were marginal with SBP high 80s / low 90s.  Notably
the patient last received HD yesterday via his right IJ tunneled
catheter without complications. In the ED he was arousable to
voice but quickly returned to somnolence, he was unable to
answer history questions but denied pain.
.
Since his admission to the transplant service, he has been found
to have a perforated gallbladder on CT abd s/p IR guided
percutaneous chole since he is not a surgical candidate for
cholecystectomy. His CT was also neg for ascitis for tap. Head
CT has been neg for intra-cranial process or bleed. Blood
cultures here have been neg to date. Also, he has persistently
failed speech and swallow evaluations and is NPO for aspiration
risk. He is on tube feeds via Dobhoff.
.
Patient reports an increased sense that he is dying slowly
because his medical condition is deteriorating. He admits to
diffuse non-localized or radiating abdominal pain and chills.
Denies nausea/vomiting, chest pain/SOB. Had diarrhea
(appropriately from the lactulose), no pain/burning with
urination.


Past Medical History:
ESRD from diabetic nephropathy on HD since [**5-/2183**]
Diabetes mellitus type II for over 20 years on insulin
HTN
Hepatitis C genotype 4
Hep B core Ab positive (negative viral load in [**2185**])
Cirrhosis - [**1-26**] HCV, portal hypertensive gastropathy
Ischemic colitis with GIB ([**2180**]), occ BRBPR; known small bowel
AVMs
Small bowel AVMs
Grade I esophageal varices
Chronic anemia
H/o right AV fistula infection
Gastric Antral Vascular Ectasia
S/p penectomy for necrosis [**1-26**] arterial insufficiency
S/p bilat BKA ([**2179**], [**2183**])
H/o IV drug use (heroin), on methadone since [**2159**]
H/o ESBL Klebsiella wound infections
H/o MRSA, VRE and Clostridium difficile
H/o L hand and finger MRSA osteomyelitides
H/o TB (age 15, Rx with PAS/INH x 2 yrs)
H/o line infections w/MSSA, E. fecalis, Pseudomonas and C.
glabrata


Social History:
Born in [**Location (un) 86**] and most recently lived in [**Hospital 100**] Rehab. He has
several brothers/sisters and four children. Worked with
computers. Has history of [**12-26**] ppd smoking for 10 years. Long
time history of IV drug (heroine use) and has been on methadone
since [**2159**]. Denies EtoH and other illicits currently.


Family History:
Several siblings with diabetes.

Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: Tm:98.7, Tc:96.7, HR:60-70, BP:150/81(110-160/40-80),
RR:18, O2 Sat: 96%RA
GEN: Sick appearing cachetic gentleman lying in bed with feeding
tube in right nostril, no teeth, hypophonic, no acute distress.
Alert, oriented to self but not place (in church) and time
([**Month (only) 404**])
HEENT: Normocephalic, sclera icterus, oropharynx clear, MMM
NECK: No thyromegaly, no lymphadenopathy
CV: Regular rate, normal rhythm, no
murmurs/gallops/regurgitation
PULM: Clear to auscultation bilaterally, mild crackles in the
bases, no wheezing/ronchi, non-labored breathing.
ABD: Soft, decreased bowel sounds, tender to palpation in all
four quadrants, no rebound/guarding
EXT: Bilateral below the need amputation, cool but pulses
palpable in all four extremities. Has 4 fingers on the left.
Nails are dark and clubbed.
SKIN: Difficult to evalaute for spider angioma or palmar
erythema.
NEURO: Alert, interactive, oriented to self but not time or
place. Limited due to inability to follow commands fully.

DISCHARGE PHYSICAL EXAM:
Vitals: Tm:97.7, Tc:93.8, HR:60-70, BP:127/33(110-150/40-80),
RR:18, O2 Sat: 96%RA
GEN: Sick appearing cachetic gentleman lying curled in bed with
feeding tube in right nostril, no teeth, hypophonic, no acute
distress. Opens his eyes with mention of his name but does not
follow commands. Teary.
HEENT: Normocephalic, sclera icterus, oropharynx clear, MMM
NECK: No thyromegaly, no lymphadenopathy
CV: Regular rate, normal rhythm, no
murmurs/gallops/regurgitation
PULM: Clear to auscultation bilaterally, mild crackles in the
bases, no wheezing/ronchi, non-labored breathing.
ABD: Soft, decreased bowel sounds, tender to palpation in all
four quadrants, no rebound/guarding
EXT: Bilateral below the need amputation, cool and non-palpable
pulses in upper extremities. Has 4 fingers on the left. Nails
are dark and clubbed.
SKIN: Difficult to evalaute for spider angioma or palmar
erythema.
NEURO: Opens eyes with mention of name but does not follow
commands.


Pertinent Results:
[**2191-5-28**] 06:21AM BLOOD WBC-13.6*# RBC-3.30* Hgb-10.1* Hct-31.8*
MCV-97 MCH-30.5 MCHC-31.6 RDW-18.0* Plt Ct-162#
[**2191-5-30**] 05:12AM BLOOD WBC-10.3 RBC-2.95* Hgb-8.9* Hct-28.5*
MCV-97 MCH-30.3 MCHC-31.4 RDW-17.4* Plt Ct-146*
[**2191-6-1**] 05:21AM BLOOD WBC-6.4 RBC-3.09* Hgb-9.5* Hct-30.2*
MCV-98 MCH-30.7 MCHC-31.5 RDW-17.2* Plt Ct-136*
[**2191-6-3**] 05:10AM BLOOD WBC-6.7 RBC-3.05* Hgb-9.4* Hct-29.7*
MCV-97 MCH-30.7 MCHC-31.5 RDW-17.5* Plt Ct-163
[**2191-6-4**] 05:45AM BLOOD WBC-7.8 RBC-3.08* Hgb-9.7* Hct-30.0*
MCV-97 MCH-31.4 MCHC-32.2 RDW-17.8* Plt Ct-178
[**2191-6-5**] 06:00AM BLOOD WBC-9.0 RBC-3.47* Hgb-10.7* Hct-33.8*
MCV-97 MCH-30.7 MCHC-31.6 RDW-17.9* Plt Ct-212
[**2191-5-28**] 06:21AM BLOOD Neuts-88.7* Lymphs-8.1* Monos-2.7 Eos-0.2
Baso-0.2
[**2191-5-28**] 06:21AM BLOOD Plt Ct-162#
[**2191-5-30**] 05:12AM BLOOD Plt Ct-146*
[**2191-6-1**] 05:21AM BLOOD Plt Ct-136*
[**2191-6-4**] 05:45AM BLOOD Plt Ct-178
[**2191-6-5**] 06:00AM BLOOD Plt Ct-212
[**2191-5-28**] 06:21AM BLOOD Glucose-192* UreaN-28* Creat-3.1*# Na-140
K-3.4 Cl-100 HCO3-29 AnGap-14
[**2191-5-30**] 05:12AM BLOOD Glucose-70 UreaN-56* Creat-4.6*# Na-139
K-3.8 Cl-103 HCO3-25 AnGap-15
[**2191-6-1**] 05:21AM BLOOD Glucose-167* UreaN-40* Creat-4.2*# Na-138
K-4.1 Cl-102 HCO3-23 AnGap-17
[**2191-6-3**] 05:10AM BLOOD Glucose-81 UreaN-29* Creat-3.8* Na-135
K-4.0 Cl-96 HCO3-26 AnGap-17
[**2191-6-3**] 11:00AM BLOOD UreaN-6
[**2191-6-4**] 05:45AM BLOOD Glucose-106* UreaN-17 Creat-2.8* Na-135
K-4.8 Cl-95* HCO3-23 AnGap-22*
[**2191-6-5**] 06:00AM BLOOD Glucose-259* UreaN-30* Creat-4.2*# Na-133
K-5.7* Cl-93* HCO3-23 AnGap-23*
[**2191-6-5**] 02:43PM BLOOD Glucose-307* UreaN-33* Creat-4.8* Na-132*
K-8.1* Cl-92* HCO3-25 AnGap-23*
[**2191-5-28**] 06:21AM BLOOD ALT-19 AST-31 CK(CPK)-78 AlkPhos-119
Amylase-15 TotBili-3.9*
[**2191-5-29**] 01:28AM BLOOD ALT-19 AST-26 LD(LDH)-125 AlkPhos-93
TotBili-1.7*
[**2191-5-28**] 06:21AM BLOOD cTropnT-0.08*
[**2191-5-29**] 01:28AM BLOOD Calcium-9.7 Phos-2.5* Mg-2.1
[**2191-6-3**] 05:10AM BLOOD Calcium-8.6 Phos-5.0* Mg-2.2
[**2191-6-5**] 06:00AM BLOOD Calcium-9.0 Phos-4.3 Mg-2.8*
[**2191-6-5**] 05:21PM BLOOD Calcium-10.1 Phos-4.3 Mg-2.8*

Brief Hospital Course:
The patient is a 66M with cirrhosis and ESRD as well as
pancreatic neoplasm admitted to the surgery service with
perforated cholecystitis as seen on abd CT scan. Broad spectrum
antibiotic coverage (vanc/cefepime/flagyl)was started. He
underwent IR perc cholecystostomy tube placement (8 French
[**Last Name (un) 2823**] catheter) on [**5-28**]. Blood cultures from [**5-28**] isolated staph
coag negative. Bile gram stain were positive for gram negative
rods. Vancomycin was stopped. A 2 week course of flagyl and
cefepime was recommended. Given poor IV access, a right femoral
triple lumen central line was placed. This was removed on [**6-2**]
after a LUE picc was placed. A 28 cm single lumen PICC was
placed via left brachial approach with tip in left subclavian
vein (not SVC). Nephrology followed him and dialyzed him via the
right tunnelled dialysis line on M-W-F schedule. His mental
status wax and waned. On [**6-2**], he was more lethargic and
confused. A lactulose enema was given with slight improvement of
mental status. Speech and swallow evaluation was unable to be
done as patient was confused at that time and could not
participate in evaluation. He was more confused with aphasia
with left arm weakness prompted a non-contrast head CT that
demonstrated no acute process. There was concern that the
Cefepime could be responsible for mental status changes as
Cefepime can cause neuro toxicity as well as Flagyl. Cefepime
was switched to Zosyn on [**6-3**] and Flagyl was d/c'd. His mental
status continued to deteriorate.  He passed away on [**6-6**] after a
rapid decline and a change in goals of care to focus on comfort.


Medications on Admission:
(per OMR) amylase/lipase/protease 2caps PO TID with meals,
calcium acetate 667mg PO BID, diphenoxylate-atropine 2.5/0.025mg
PO q4h, doxepin 10mg PO qHS, famotidine 20mg PO qHS, folic acid
1mg PO daily, gabapentin 300mg PO daily, lantus 10Units SC qHS,
Humalog 2Units qAM and ISS with meals and at bedtime, methadone
600mg PO BID (per OMR, not verified!), nadolol 20mg PO daily,
opium tincture 6mg PO QID prn diarrhea, Renagel 1600mg PO TID
with meals, vit B12 500mcg PO daily, loperamide 4mg PO QID prn
diarrhea, iron 325mg PO daily

ALLERG: Cephalosporins (itching), Metoclopramide, Infed


Discharge Medications:
paient expired

Discharge Disposition:
Expired

Discharge Diagnosis:
patient expired

Discharge Condition:
patient expired

Discharge Instructions:
patient expired

Followup Instructions:
patient expired

                             [**First Name8 (NamePattern2) 819**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 25507**]
{'Acute cholecystitis,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Renal dialysis status,Cirrhosis of liver without mention of alcohol,Chronic hepatitis C without mention of hepatic coma,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Below knee amputation status'}


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: Pt is a 66 y/o M with PMH significant for ESRD on HD,
compensated liver cirrhosis c/b esophageal varices, poorly
controlled D2M s/p bilateral BTK amputations, AV fistula
infections (VRE and MRSA) and recently diagnosed pancreatic head
mass likely pancreatic adenocarcinoma from EGD brushings was
admitted to the transplant surgery service [**2191-5-28**] ago for
altered mental status which has persisted over his hospital stay
despite abx (IV zosyn) for GNR found in blood (at [**Hospital 100**] Rehab
facility), lactulose.

MEDICAL HISTORY: ESRD from diabetic nephropathy on HD since [**5-/2183**]
Diabetes mellitus type II for over 20 years on insulin
HTN
Hepatitis C genotype 4
Hep B core Ab positive (negative viral load in [**2185**])
Cirrhosis - [**1-26**] HCV, portal hypertensive gastropathy
Ischemic colitis with GIB ([**2180**]), occ BRBPR; known small bowel
AVMs
Small bowel AVMs
Grade I esophageal varices
Chronic anemia
H/o right AV fistula infection
Gastric Antral Vascular Ectasia
S/p penectomy for necrosis [**1-26**] arterial insufficiency
S/p bilat BKA ([**2179**], [**2183**])
H/o IV drug use (heroin), on methadone since [**2159**]
H/o ESBL Klebsiella wound infections
H/o MRSA, VRE and Clostridium difficile
H/o L hand and finger MRSA osteomyelitides
H/o TB (age 15, Rx with PAS/INH x 2 yrs)
H/o line infections w/MSSA, E. fecalis, Pseudomonas and C.
glabrata

MEDICATION ON ADMISSION: (per OMR) amylase/lipase/protease 2caps PO TID with meals,
calcium acetate 667mg PO BID, diphenoxylate-atropine 2.5/0.025mg
PO q4h, doxepin 10mg PO qHS, famotidine 20mg PO qHS, folic acid
1mg PO daily, gabapentin 300mg PO daily, lantus 10Units SC qHS,
Humalog 2Units qAM and ISS with meals and at bedtime, methadone
600mg PO BID (per OMR, not verified!), nadolol 20mg PO daily,
opium tincture 6mg PO QID prn diarrhea, Renagel 1600mg PO TID
with meals, vit B12 500mcg PO daily, loperamide 4mg PO QID prn
diarrhea, iron 325mg PO daily

ALLERGIES: Cephalosporins / Metoclopramide / Infed / Heparin Agents

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
Vitals: Tm:98.7, Tc:96.7, HR:60-70, BP:150/81(110-160/40-80),
RR:18, O2 Sat: 96%RA
GEN: Sick appearing cachetic gentleman lying in bed with feeding
tube in right nostril, no teeth, hypophonic, no acute distress.
Alert, oriented to self but not place (in church) and time
([**Month (only) 404**])
HEENT: Normocephalic, sclera icterus, oropharynx clear, MMM
NECK: No thyromegaly, no lymphadenopathy
CV: Regular rate, normal rhythm, no
murmurs/gallops/regurgitation
PULM: Clear to auscultation bilaterally, mild crackles in the
bases, no wheezing/ronchi, non-labored breathing.
ABD: Soft, decreased bowel sounds, tender to palpation in all
four quadrants, no rebound/guarding
EXT: Bilateral below the need amputation, cool but pulses
palpable in all four extremities. Has 4 fingers on the left.
Nails are dark and clubbed.
SKIN: Difficult to evalaute for spider angioma or palmar
erythema.
NEURO: Alert, interactive, oriented to self but not time or
place. Limited due to inability to follow commands fully.

FAMILY HISTORY: Several siblings with diabetes.

SOCIAL HISTORY: Born in [**Location (un) 86**] and most recently lived in [**Hospital 100**] Rehab. He has
several brothers/sisters and four children. Worked with
computers. Has history of [**12-26**] ppd smoking for 10 years. Long
time history of IV drug (heroine use) and has been on methadone
since [**2159**]. Denies EtoH and other illicits currently. 

### Response:
{'Acute cholecystitis,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Renal dialysis status,Cirrhosis of liver without mention of alcohol,Chronic hepatitis C without mention of hepatic coma,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Below knee amputation status'}
