CHIEF COMPLAINT: Lethargy

PRESENT ILLNESS: 50 yo F h/o paraplegia, recurrent UTIs with ESBL klebsiella
presents with lethargy. Recently admitted here with urosepsis.
Hospitalized 1 week prior at [**Hospital3 **] with PNA and UTI,
completed course levaquin last Tuesday, remained on 3.5L home O2
(no prior need for home O2).

MEDICAL HISTORY: T1-T2 paraplegia due to MVA ([**2142**]) s/p trach, s/p ORIF of R
proximal humerus, s/p titanium steel plates in arms
Recurrent UTIs (q 2-3 months) [**3-5**] to atonic bladder with Proteus
and ESBL Klebsiella
Intermittent urinary catheterizations (Q4H) done by PCA or
husband
Depression
HCV with apparent clearing of viremia as of [**5-10**]
h/o pneumonia (including MRSA in [**10-7**])
Anxiety
h/o DVT ([**2142**]) s/p IVC filter
h/o pulmonary nodules
Hypothyroidism
Chronic pain
Anemia of Chronic Disease
Chronic Gastritis
?obstructive lung disease - Possible COPD, also may have
component of restrictive lung dz [**3-5**] chest wall weakness related
to paraplegia. No prior PFTs, yet on home inhaler and
intermittant 2L home O2 since [**8-9**], but until [**11-9**]
hospitalization not requiring home O2

MEDICATION ON ADMISSION: Baclofen 20mg qam, 10mg lunch, 20mg qhs
Citalopram 20mg daily
Klonopin 1mg qid prn, 2mg qhs prn
Gabapentin 800mg qid
Combivent inh 2 puffs tid
Levothyroxine 75mcg daily
Methadone 10mg tid
Nicotine 21mg patch q24h
Omeprazole 20mg [**Hospital1 **]
Oxybutynin 10mg qam, 5mg lunch, 10mg qhs
Oxycodone 5mg q4-6h prn
Lyrica 150mg tid
Sucralfate 1gm qid
Trazodone 200mg qhs
Calcium 500mg [**Hospital1 **]
Laratadine 10mg daily
Miralax 17gm daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 95.2 BP: 93/60  HR: 64 RR: 11 O2Sat: 99% on 3L
GEN: Chronically ill-appearing, NAD, speaks slowly, appropriate,
A&Ox3 but occasionally closes eyes, breathing comfortably
without accessory muscle use
HEENT: EOMI, PERRL, sclera anicteric, MM dry, OP Clear
NECK: No JVD, right CVL, carotid pulses brisk, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Bibasilar crackles (R>L), no wheeze or rhonchi
ABD: Soft, NT, ND, +BS, no masses
EXT: Nonpitting bilateral edema, no cyanosis, no palpable cords

FAMILY HISTORY: Mother (lung CA)

SOCIAL HISTORY: Lives at home with her husband. PCA is best friend, [**Name (NI) **].
Occasional EtOH, 35 pack-year tobacco on a nicotine patch; no
drugs.
Streptococcal septicemia,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Other candidiasis of other specified sites,Chronic airway obstruction, not elsewhere classified,Chronic hepatitis C without mention of hepatic coma,Atony of bladder,Paraplegia,Sepsis,Dehydration,Late effect of spinal cord injury,Late effects of motor vehicle accident,Esophageal reflux,Other diseases of lung, not elsewhere classified,Other chronic pain,Unspecified menopausal and postmenopausal disorder,Anemia of other chronic disease,Dysthymic disorder,Other postprocedural status,Personal history of venous thrombosis and embolism
Streptococcal septicemia,Pneumonia, organism NOS,Urin tract infection NOS,Candidiasis site NEC,Chr airway obstruct NEC,Chrnc hpt C wo hpat coma,Atony of bladder,Paraplegia NOS,Sepsis,Dehydration,Late eff spinal cord inj,Late eff motor vehic acc,Esophageal reflux,Other lung disease NEC,Chronic pain NEC,Menopausal disorder NOS,Anemia-other chronic dis,Dysthymic disorder,Post-proc states NEC,Hx-ven thrombosis/embols
Admission Date:  [**2146-11-27**]              Discharge Date:   [**2146-12-11**]

Date of Birth:  [**2096-10-22**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
Lethargy

Major Surgical or Invasive Procedure:
None

History of Present Illness:
50 yo F h/o paraplegia, recurrent UTIs with ESBL klebsiella
presents with lethargy. Recently admitted here with urosepsis.
Hospitalized 1 week prior at [**Hospital3 **] with PNA and UTI,
completed course levaquin last Tuesday, remained on 3.5L home O2
(no prior need for home O2).

At home, noted worsening lethargy x2 days, perhaps some
suprapubic abdominal pain, and T 100.9; similar to prior admits
for urosepsis. No real fevers or chills otherwise. Denies cough,
SOB, chest pain. She is also on an extensive home pain regimen,
including methadone 10mg PO TID.

In the ED, vitals: 99.0, 67, SBP 70s, 100% 2L NC. Exam nonfocal
except sleepy but arousable and Ox3, neuro exam unchanged from
baseline. Labs notable for WBC 9.7 without bands, lactate 1.2,
Na 132, BNP 1588. U/A positive. CXR with ?mild edema vs. RLL
infiltrate. Blood and urine Cx sent. Right IJ CVL placed. SBP
improved to high 80s and CVP 10 after 3L NS. CVP 10. Given
vanco/zosyn for presumed early urosepsis. Admit ICU.

ROS: The patient denies any fevers, chills, nausea, vomiting,
diarrhea, constipation, melena, hematochezia, chest pain,
orthopnea, PND, dysuria, lightheadedness, vision changes,
headache, rash or skin changes.

Past Medical History:
T1-T2 paraplegia due to MVA ([**2142**]) s/p trach, s/p ORIF of R
proximal humerus, s/p titanium steel plates in arms
Recurrent UTIs (q 2-3 months) [**3-5**] to atonic bladder with Proteus
and ESBL Klebsiella
Intermittent urinary catheterizations (Q4H) done by PCA or
husband
Depression
HCV with apparent clearing of viremia as of [**5-10**]
h/o pneumonia (including MRSA in [**10-7**])
Anxiety
h/o DVT ([**2142**]) s/p IVC filter
h/o pulmonary nodules
Hypothyroidism
Chronic pain
Anemia of Chronic Disease
Chronic Gastritis
?obstructive lung disease - Possible COPD, also may have
component of restrictive lung dz [**3-5**] chest wall weakness related
to paraplegia. No prior PFTs, yet on home inhaler and
intermittant 2L home O2 since [**8-9**], but until [**11-9**]
hospitalization not requiring home O2

Social History:
Lives at home with her husband. PCA is best friend, [**Name (NI) **].
Occasional EtOH, 35 pack-year tobacco on a nicotine patch; no
drugs.


Family History:
Mother (lung CA)

Physical Exam:
Vitals: T: 95.2 BP: 93/60  HR: 64 RR: 11 O2Sat: 99% on 3L
GEN: Chronically ill-appearing, NAD, speaks slowly, appropriate,
A&Ox3 but occasionally closes eyes, breathing comfortably
without accessory muscle use
HEENT: EOMI, PERRL, sclera anicteric, MM dry, OP Clear
NECK: No JVD, right CVL, carotid pulses brisk, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Bibasilar crackles (R>L), no wheeze or rhonchi
ABD: Soft, NT, ND, +BS, no masses
EXT: Nonpitting bilateral edema, no cyanosis, no palpable cords

NEURO: CN II ?????? XII grossly intact. Moves all upper extremities
with 5/5 strength, no motor tone lowers.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.


Pertinent Results:
Labs on discharge:
[**2146-12-10**] 01:45PM BLOOD WBC-5.8 RBC-3.88* Hgb-11.3* Hct-33.4*
MCV-86 MCH-29.1 MCHC-33.7 RDW-14.5 Plt Ct-285
[**2146-12-4**] 12:57AM BLOOD Neuts-74.9* Lymphs-16.2* Monos-7.2
Eos-1.2 Baso-0.5
[**2146-12-10**] 01:45PM BLOOD Plt Ct-285
[**2146-12-10**] 01:45PM BLOOD Glucose-95 UreaN-3* Creat-0.3* Na-140
K-4.3 Cl-97 HCO3-36* AnGap-11
[**2146-12-5**] 05:25AM BLOOD ALT-7 AST-9 LD(LDH)-118 AlkPhos-63
TotBili-0.2
[**2146-12-10**] 01:45PM BLOOD Calcium-9.4 Phos-4.7* Mg-2.2
[**2146-11-29**] 05:45AM BLOOD calTIBC-161* Ferritn-522* TRF-124*
.
Imaging:
Renal US:
FINDINGS: The right kidney measures 13.1 cm and the left kidney
measures 14.5 cm. There is no hydronephrosis, renal masses or
stones. There is probably a left-sided duplicated system, as
discussed on the previous reports. Limited views of the bladder
are unremarkable.
IMPRESSION: No hydronephrosis.

CXR:
IMPRESSION: AP chest compared to [**11-30**] and [**12-3**]: Bibasilar consolidation has grown progressively worse since
[**11-30**] and [**12-3**], concerning for pneumonia. Vascular
congestion and severe
cardiomegaly indicate cardiac decompensation, with probable new
edema in the mid lung zones. Right jugular line ends at the
superior cavoatrial junction. No pneumothorax.


Brief Hospital Course:
50F h/o paraplegia, recurrent UTIs with ESBL klebsiella presents
with likely urosepsis.

# Hypotension: Met SIRS criteria with likely source urine, and
has history of resistant ESBL Klebsiella and Proteus, sensitive
to Zosyn and carbapenems. Also with h/o MRSA. Pulmonary source
also possible although less likely.  There was no evidence of a
new infection to date. Her blood pressures were a little lower
than they usually are, likely due to decreased food intake.  She
was discharged with instruction to continue to stay hydrated and
increase salt in her diet in order to keep your blood pressures
in her usual range.  Discharged on prior Amoxicillin dosing.

# Altered mental status: Likely toxic-metabolic due to combo of
infection and pain medications.  Improved without change in
medications or clear infection.

# Chronic pain: Followed by pain clinic at the [**Hospital1 756**] (Dr.
[**Last Name (STitle) **].  Initially held sedating medication but then restarted
prior to discharge as mental status improved.

# Paraplegia s/p MVA: Complicated by atonic bladder requiring
self-catherization, DVT/PE s/p IVC filter, chronic pain
syndrome, post SCI anxiety/depression.  Continued oxybutinin for
urinary retention.

# Hepatitis C: Chronic with undetectable viral load as of [**10-9**].
No acute issues.

# Anemia: Anemia of chronic disease, normocytic; currently at
baseline Hct 30-36.

# Hypothyroidism: Continued outpatient levothyroxine.


Medications on Admission:
Baclofen 20mg qam, 10mg lunch, 20mg qhs
Citalopram 20mg daily
Klonopin 1mg qid prn, 2mg qhs prn
Gabapentin 800mg qid
Combivent inh 2 puffs tid
Levothyroxine 75mcg daily
Methadone 10mg tid
Nicotine 21mg patch q24h
Omeprazole 20mg [**Hospital1 **]
Oxybutynin 10mg qam, 5mg lunch, 10mg qhs
Oxycodone 5mg q4-6h prn
Lyrica 150mg tid
Sucralfate 1gm qid
Trazodone 200mg qhs
Calcium 500mg [**Hospital1 **]
Laratadine 10mg daily
Miralax 17gm daily

Discharge Medications:
1. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO QID (4
times a day).
2. Methadone 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
6. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. Oxybutynin Chloride 5 mg Tablet Sig: 1-2 Tablets PO three
times a day: Please take 2 tabs in the morning; 1 tab at lunch;
2 tabs at nighttime.
9. Miralax 17 gram (100 %) Powder in Packet Sig: One (1)  PO
once a day.
10. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation three times a day.
11. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for anxiety.
12. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
13. Calcium 500 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO
twice a day.
14. Lyrica 150 mg Capsule Sig: One (1) Capsule PO three times a
day.
15. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
16. Amoxicillin 500 mg Capsule Sig: One (1) Capsule PO every
eight (8) hours for 11 days: Please take for two weeks total.
Disp:*34 Capsule(s)* Refills:*0*
17. Miconazole Nitrate 2 % Cream Sig: One (1) thin layer to rash
Topical twice a day.
Disp:*30 grams* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnosis:
1. Sepsis secondary to urinary tract infection
2. Anxiety
3. Restrictive Lung disease
4. Neurogenic Bladder

Secondary Diagnosis:
1. Paraplegia
2. Chronic Pain
3. Anemia


Discharge Condition:
patient is afebrile, with SBPs in the 110s-120s; normal
mentation, feeling well


Discharge Instructions:
You were admitted to the hospital with low blood pressure and
fever, likely related to your urinary tract infection.  You were
in the ICU overnight and given several liters of IV fluids and
IV antibiotics.  You were then transfered to the medicine floor
where you did well until your antibiotics were changed.  You
developed another fever and some moderately low blood pressure
and were brought back to the ICU.  Again, you did well.  We then
completed your course of IV antibiotics and started you on oral
antibiotics.  The bacteria that we grew from your urine culture
showed that it would be killed by this oral antibiotic.  You
were doing well and your blood pressure and temperature stayed
normal.

During your hospitalization, you also developed a rash from
yeast in your groin.  We took out your foley and returned to
your home regimen of straight catheterizations.

You also had some mild pain in your throat one day that was
likely related to anxiety.  It went away with a dose of ativan.
An EKG was normal and it was very unlikely that your heart was
the cause of this pain.

You also started requiring some oxygen through your nasal
canula.  You have oxygen at home for comfort.  Your oxygen
levels are normal on room air and you should not be worried
about not wearing oxygen, but if it makes you more comfortable,
it is ok to use.  In the future you may need further testing of
your lungs, but for now your respiratory status is stable.

When you go home, make sure to complete your course of
antibiotics at home.  Also continue using the cream for yeast
infection in your groin.  We also stopped the baclofen because
of your low blood pressures.  If you are able to tolerate your
pain without it, we would not recommend restarting it at this
time.  We did not change any of your other medicines.

Please follow up with Dr. [**Last Name (STitle) 665**] within one to two weeks for
followup.

Please return to the hospital for any confusion, weakness, low
blood pressures, difficulties breathing, fevers, chills, chest
pain, worsening abdominal pain or any other concerns.

Followup Instructions:
Please call Dr.[**Name (NI) 666**] office on Monday morning to make an
appointment for follow up.  You should be seen within one to two
weeks.  The phone number to the [**Hospital 191**] clinic is [**Telephone/Fax (1) 250**].
{'Streptococcal septicemia,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Other candidiasis of other specified sites,Chronic airway obstruction, not elsewhere classified,Chronic hepatitis C without mention of hepatic coma,Atony of bladder,Paraplegia,Sepsis,Dehydration,Late effect of spinal cord injury,Late effects of motor vehicle accident,Esophageal reflux,Other diseases of lung, not elsewhere classified,Other chronic pain,Unspecified menopausal and postmenopausal disorder,Anemia of other chronic disease,Dysthymic disorder,Other postprocedural status,Personal history of venous thrombosis and embolism'}


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: Lethargy

PRESENT ILLNESS: 50 yo F h/o paraplegia, recurrent UTIs with ESBL klebsiella
presents with lethargy. Recently admitted here with urosepsis.
Hospitalized 1 week prior at [**Hospital3 **] with PNA and UTI,
completed course levaquin last Tuesday, remained on 3.5L home O2
(no prior need for home O2).

MEDICAL HISTORY: T1-T2 paraplegia due to MVA ([**2142**]) s/p trach, s/p ORIF of R
proximal humerus, s/p titanium steel plates in arms
Recurrent UTIs (q 2-3 months) [**3-5**] to atonic bladder with Proteus
and ESBL Klebsiella
Intermittent urinary catheterizations (Q4H) done by PCA or
husband
Depression
HCV with apparent clearing of viremia as of [**5-10**]
h/o pneumonia (including MRSA in [**10-7**])
Anxiety
h/o DVT ([**2142**]) s/p IVC filter
h/o pulmonary nodules
Hypothyroidism
Chronic pain
Anemia of Chronic Disease
Chronic Gastritis
?obstructive lung disease - Possible COPD, also may have
component of restrictive lung dz [**3-5**] chest wall weakness related
to paraplegia. No prior PFTs, yet on home inhaler and
intermittant 2L home O2 since [**8-9**], but until [**11-9**]
hospitalization not requiring home O2

MEDICATION ON ADMISSION: Baclofen 20mg qam, 10mg lunch, 20mg qhs
Citalopram 20mg daily
Klonopin 1mg qid prn, 2mg qhs prn
Gabapentin 800mg qid
Combivent inh 2 puffs tid
Levothyroxine 75mcg daily
Methadone 10mg tid
Nicotine 21mg patch q24h
Omeprazole 20mg [**Hospital1 **]
Oxybutynin 10mg qam, 5mg lunch, 10mg qhs
Oxycodone 5mg q4-6h prn
Lyrica 150mg tid
Sucralfate 1gm qid
Trazodone 200mg qhs
Calcium 500mg [**Hospital1 **]
Laratadine 10mg daily
Miralax 17gm daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 95.2 BP: 93/60  HR: 64 RR: 11 O2Sat: 99% on 3L
GEN: Chronically ill-appearing, NAD, speaks slowly, appropriate,
A&Ox3 but occasionally closes eyes, breathing comfortably
without accessory muscle use
HEENT: EOMI, PERRL, sclera anicteric, MM dry, OP Clear
NECK: No JVD, right CVL, carotid pulses brisk, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Bibasilar crackles (R>L), no wheeze or rhonchi
ABD: Soft, NT, ND, +BS, no masses
EXT: Nonpitting bilateral edema, no cyanosis, no palpable cords

FAMILY HISTORY: Mother (lung CA)

SOCIAL HISTORY: Lives at home with her husband. PCA is best friend, [**Name (NI) **].
Occasional EtOH, 35 pack-year tobacco on a nicotine patch; no
drugs. 

### Response:
{'Streptococcal septicemia,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Other candidiasis of other specified sites,Chronic airway obstruction, not elsewhere classified,Chronic hepatitis C without mention of hepatic coma,Atony of bladder,Paraplegia,Sepsis,Dehydration,Late effect of spinal cord injury,Late effects of motor vehicle accident,Esophageal reflux,Other diseases of lung, not elsewhere classified,Other chronic pain,Unspecified menopausal and postmenopausal disorder,Anemia of other chronic disease,Dysthymic disorder,Other postprocedural status,Personal history of venous thrombosis and embolism'}
