CHIEF COMPLAINT: nausea, vomiting

PRESENT ILLNESS: Mr. [**Known lastname 10137**] is an 83 year old male with Alzheimer's Dementia,
DMII, HTN who presented from [**Hospital3 400**] with sudden onset
of shaking, nausea and vomiting. According to his son, he was
feeling well until the morning of admission when he returned
from a walk and was noted to be pale, diaphoretic and shaky. He
was thought to be hypoglycemic (received metformin 850mg in am)
and was given some OJ which he soon vomited non-bloody stomach
contents. Vitals at the time were stable (T97.5, HR60, BP120/56,
RR14). FS 228. He was thought to be "not himself", more confused
than at baseline and less interactive than usual.  Patient and
family denied cough, SOB, diarrhea, chest pain, palpitations,
headache, nightsweats, recent weightloss, recent travel, sick
contacts. [**Name (NI) **] was transferred to the ED for further work up. In
ED patient was pan cultured with +UA and was diagnosed with
urosepsis.  He was given vanc and ceftaz and admitted to the
[**Hospital Unit Name 153**] for further care.

MEDICAL HISTORY: DM II
HTN
Pancrease deficiency
Prior history of alcohol abuse (detox in [**2111**])
Alzheimers dz
? TIA in [**12-29**] with anomia and dysarthria t

MEDICATION ON ADMISSION: Aricept 10mg po qhs
Avandia 4mg po BID
Glimepiride 2mg po daily
metformin850 po BID
metoprolol po 12.5 BID
namenda 10mg po BID
pangestyme MT16 3 tabs TID

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On admission:
Vitals: T 98 HR 110 BP 134/54 R 19 Sa02 97% on 4L NC
Gen: Elderly male in NAD. Awake, alert, talkative, following
commands though occasionally has to have questions repeated.
HEENT:MM moist. Sclera clear and anicteric. OP clear. Poor
dentition, no pain on palpation of the teeth.
Skin: no rashes, excoriations or breaks in skin.
Neck: No [**Doctor First Name **]. no JVD
CV: tachy, regular, heart sounds distant. Nl S1 and S2, no
murmurs/gallops/rubs.
Lung: CTA bilaterally, except for few crackles in LLL, no
wheezes, or rhonchi
Ext:No cyanosis/edema, feet cold but quick capillary refill. 1+
radial and DP pulses b/l.
Neuro: Awake, alert, talkative. Oriented x 0. Occasionally slurs
speech. CN II-XII intact. Reflexes 2+ b/l. Babinsky equivocal.

FAMILY HISTORY: No strokes/CAD

SOCIAL HISTORY: Social History: Lives at [**Location 10138**], specialized [**Hospital **] for Alzheimer's Dementia. Able to walk unassisted. Wife
(health proxy) is currently traveling (visiting family in
Europe).
past president of [**University/College 5130**] [**Location (un) **]
no etoh
approx 80 pack year hx of tobacco use, stopped 10 years ago
Septicemia due to gram-negative organism, unspecified,Acute kidney failure, unspecified,Pyelonephritis, unspecified,Intestinal infection due to Clostridium difficile,Unspecified protein-calorie malnutrition,Phlebitis and thrombophlebitis of upper extremities, unspecified,Chronic kidney disease, unspecified,Subendocardial infarction, initial episode of care,Hyperpotassemia,Severe sepsis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Alzheimer's disease,Dementia in conditions classified elsewhere with behavioral disturbance,Personal history of other diseases of circulatory system,Other specified diseases of pancreas,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Anemia, unspecified
Gram-neg septicemia NOS,Acute kidney failure NOS,Pyelonephritis NOS,Int inf clstrdium dfcile,Protein-cal malnutr NOS,Phlbts vn NOS up extrm,Chronic kidney dis NOS,Subendo infarct, initial,Hyperpotassemia,Severe sepsis,DMII wo cmp nt st uncntr,Alzheimer's disease,Dementia w behavior dist,Hx-circulatory dis NEC,Pancreatic disease NEC,Hy kid NOS w cr kid I-IV,Anemia NOS
Name:  [**Known lastname 1406**],[**Known firstname **] G                 Unit No:   [**Numeric Identifier 1407**]

Admission Date:  [**2129-7-12**]              Discharge Date:   [**2129-7-31**]

Date of Birth:  [**2046-3-21**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1408**]
Addendum:
Pt has an occlusive left cephalic vein thrombus.  This does not
extend into deep veins.  Repeat u/s to ensure no progression in
[**12-25**] weeks.  In regards to the right arm, swelling was noted on
[**2129-7-30**] in the right upper arm.  This resolved spontaneously.  A
RUE U/S showed no thrombus.

Discharge Disposition:
Extended Care

Facility:
[**Hospital6 609**] for the Aged - [**Location (un) 1409**]

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1410**] MD [**MD Number(2) 1411**]

Completed by:[**2129-7-31**]

Admission Date:  [**2129-7-12**]              Discharge Date:   [**2129-7-31**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 358**]
Chief Complaint:
nausea, vomiting

Major Surgical or Invasive Procedure:
none


History of Present Illness:
Mr. [**Known lastname 10137**] is an 83 year old male with Alzheimer's Dementia,
DMII, HTN who presented from [**Hospital3 400**] with sudden onset
of shaking, nausea and vomiting. According to his son, he was
feeling well until the morning of admission when he returned
from a walk and was noted to be pale, diaphoretic and shaky. He
was thought to be hypoglycemic (received metformin 850mg in am)
and was given some OJ which he soon vomited non-bloody stomach
contents. Vitals at the time were stable (T97.5, HR60, BP120/56,
RR14). FS 228. He was thought to be "not himself", more confused
than at baseline and less interactive than usual.  Patient and
family denied cough, SOB, diarrhea, chest pain, palpitations,
headache, nightsweats, recent weightloss, recent travel, sick
contacts. [**Name (NI) **] was transferred to the ED for further work up. In
ED patient was pan cultured with +UA and was diagnosed with
urosepsis.  He was given vanc and ceftaz and admitted to the
[**Hospital Unit Name 153**] for further care.


Past Medical History:
DM II
HTN
Pancrease deficiency
Prior history of alcohol abuse (detox in [**2111**])
Alzheimers dz
? TIA in [**12-29**] with anomia and dysarthria t

Social History:
Social History: Lives at [**Location 10138**], specialized [**Hospital **] for Alzheimer's Dementia. Able to walk unassisted. Wife
(health proxy) is currently traveling (visiting family in
Europe).
past president of [**University/College 5130**] [**Location (un) **]
no etoh
approx 80 pack year hx of tobacco use, stopped 10 years ago

Family History:
No strokes/CAD

Physical Exam:
On admission:
Vitals: T 98 HR 110 BP 134/54 R 19 Sa02 97% on 4L NC
Gen: Elderly male in NAD. Awake, alert, talkative, following
commands though occasionally has to have questions repeated.
HEENT:MM moist. Sclera clear and anicteric. OP clear. Poor
dentition, no pain on palpation of the teeth.
Skin: no rashes, excoriations or breaks in skin.
Neck: No [**Doctor First Name **]. no JVD
CV: tachy, regular, heart sounds distant. Nl S1 and S2, no
murmurs/gallops/rubs.
Lung: CTA bilaterally, except for few crackles in LLL, no
wheezes, or rhonchi
Ext:No cyanosis/edema, feet cold but quick capillary refill. 1+
radial and DP pulses b/l.
Neuro: Awake, alert, talkative. Oriented x 0. Occasionally slurs
speech. CN II-XII intact. Reflexes 2+ b/l. Babinsky equivocal.


Pertinent Results:
RUE U/S [**2129-7-30**]: No definite evidence of right upper extremity
deep venous thrombosis. No fluid collection. If clinical
suspicion for DVT persist, the examination could be repeated.

LUE U/S [**2129-7-29**]: Persistent occlusive thrombus within the left
cephalic vein without evidence of extension into the deep veins.

Renal U/S [**2129-7-24**]: The exam is slightly limited due to
difficulties with patient positioning and inability to
breath-hold. The left kidney measures approximately 9.5 cm.
There is no hydronephrosis seen. The hypodense area of the left
upper pole seen on CT is not well delineated by ultrasound,
though a hypoechoic area with a slightly bulging contour is seen
in the upper pole, which likely corresponds to the CT findings.
No large fluid collection is seen.

CT abd [**2129-7-23**]: 1. 3.6 x 3.3 cm low-attenuation lesion with an
enlarged left kidney which cannot be further characterized.
Given presence of perinephric stranding, nephronia should be
considered. Differentials include underlying lesion or cyst. An
ultrasound can be performed for further evaluation.
2. Punctate nonobstructing left renal calculi. Possible left
distal ureteral calculi.
3. 1.5 x 1.2 cm soft tissue attenuation lesion arising off the
body of the pancreas. MRI can be performed for further
evaluation.
4. Bilateral small pleural effusions with associated
atelectasis.
5. Coronary artery calcifications.

ECHO [**2129-7-13**]: The left atrium is normal in size. The estimated
right atrial pressure is [**3-31**]  mmHg. Left ventricular wall
thicknesses and cavity size are normal. There is  mild regional
left ventricular systolic dysfunction with mild hypokinesis of
the inferior and inferolateral walls. Right ventricular chamber
size and free  wall motion are normal.The aortic root is
moderately dilated at the sinus  level. The ascending aorta is
mildly dilated. There are three aortic valve  leaflets. An
aortic valve vegetation/mass cannot be excluded. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. A mass  or vegetation on the mitral valve cannot be
excluded. No mitral regurgitation  is seen. There is a small
pericardial effusion, with echo dense material,  consistent with
blood, inflammation or other cellular elements.  If clinically
suggested, the absence of a vegetation by 2D echocardiography
does not exclude endocarditis, a transesophageal
echocardiographic examination is recommended.  Compared with the
prior study (images reviewed) of [**2129-1-6**], the focal
hypokinesis seems to be more prominent and the left ventricular
function is  slightly worse.


Brief Hospital Course:
1. urosepsis/pyelonephritis -- Mr. [**Known lastname 10137**] was initially admitted
to the [**Hospital Unit Name 153**] and treated broad spectrum IV antibiotics, then
changed to IV ciprofloxacin after blood cultures and urine
culture showed pan sensitive Klebsiella.  He improved and was
transferred to the [**Location **] service.  He was changed to
oral antibiotics after several stable days, and unfortuanately
significantly declined, with presistant fevers.  An extensive
workup for additional source of infection found little, except
that he had profuse diarrhea.  He improved after being
transitioned back to intravenous antibiotics.  He was also found
to have c diff colitis and was started on vancomycin orally.
Infectious disease was consulted and followed throughout his
course.  Further limited imaging was performed, as his renal
function excluded the use of IV contrast, but his left kidney
showed signs of infection without obvious abscess formation.
There was no apparent fluid collection to drain per radiology
and urology.  His infection was felt to be related to severe
pyelonephritis, likely from the original Klebsiella organism, as
no other cultures were positive.  Antibiotic coverage was
narrowed again, but remained IV.  Plan is for 3 weeks total of
ceftriaxone.  Day one was [**2129-7-23**], he will complete ceftriaxone
on [**2129-8-12**].

2.stress related cardiac ischemia -- Troponins were elevated on
admission, nadir of 0.64, probably related to the stress of
septic shock.  No invasive therapy was performed, and this
desire was discussed and verified by the family, and he was
treated medically with aspirin and a beta blocker.  Echo showed
mild hypokinesis which is slightly worse than prior echo.

3. acute renal failure -- multifactorial, related to sepsis,
pyelonephritis and possibly ATN.  Improved slowly prior to
discharge, but not entirely back to baseline. In the last day of
hospitalization pt had a creatinine of 1.7.  The worst
creatinine while in hospital was 2.3.  His baseline in 1.3.

4. C. difficile colitis -- patient is receiving vancomycin
orally at advice of infectious disease team.  This should be
continued until one week after ceftriaxone is finished, that is
to be continued until [**2129-8-19**].

5.  Malnutrition -- Patient initially with poor caloric intake.
He responded well to encouragement, and will benefit from close
nursing attention at meal times to encourage increased intake.
Would benefit from Ensure or other supplement.

6. Diabetes -- Isolated FSBG on day of discharge 300.  Responded
to regular insulin.  Previously well controlled on 5 units of
lantus qd.

Medications on Admission:
Aricept 10mg po qhs
Avandia 4mg po BID
Glimepiride 2mg po daily
metformin850 po BID
metoprolol po 12.5 BID
namenda 10mg po BID
pangestyme MT16 3 tabs TID


Discharge Medications:
1. Ceftriaxone-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One
(1) gram Intravenous Q24H (every 24 hours) for 12 days: last
dose [**2129-8-12**].
2. Outpatient Lab Work
q3day CBC, complete metabolic panel while on antibiotics
3. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for alzheimer's.
4. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for dementia.
5. Amylase-Lipase-Protease 48,000-16,000- 48,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID (3 times a day).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 19 days: last dose [**2129-8-19**].
10. Insulin Glargine 100 unit/mL Solution Sig: Five (5)
Subcutaneous at bedtime.
11. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QDAY ().
13. Regular insulin sliding scale per [**Hospital3 **]
Center protocol.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]

Discharge Diagnosis:
urosepsis/pyelonephritis
acute renal failure
NSTEMI


Discharge Condition:
afebrile, stable vitals signs, PICC line right upper extremity


Discharge Instructions:
You were hospitalized with a severe kidney infection.  This is
slowly improving and you are now well enough to transfer to
[**Hospital 100**] Rehab.  Please call your physician or return to the
hospital with any concerns or questions, particularly fever
greater than 101, redness or oozing around the PICC site,
decreased urination, inability to eat or drink, decline in
mental status, shortness of breath, abdominal or chest pain.

Followup Instructions:
1. ultrasound left kidney after discontinuation of antibiotics
2. ultrasound doppler left upper exptremity to assure no
extention of the cephalic vein thrombus after [**2129-8-12**]
3. [**Hospital 100**] Rehab physician to follow
4. Follow up with Dr. [**Last Name (STitle) 2903**], your primary physician, [**Name10 (NameIs) 10139**] you
have discharged from [**Hospital 100**] Rehab.  Call [**Telephone/Fax (1) 2205**] for an
appointment.
5. Remove PICC line after finsihing antibiotics in two weeks.



Completed by:[**2129-7-31**]
{"Septicemia due to gram-negative organism, unspecified,Acute kidney failure, unspecified,Pyelonephritis, unspecified,Intestinal infection due to Clostridium difficile,Unspecified protein-calorie malnutrition,Phlebitis and thrombophlebitis of upper extremities, unspecified,Chronic kidney disease, unspecified,Subendocardial infarction, initial episode of care,Hyperpotassemia,Severe sepsis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Alzheimer's disease,Dementia in conditions classified elsewhere with behavioral disturbance,Personal history of other diseases of circulatory system,Other specified diseases of pancreas,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Anemia, unspecified"}


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: nausea, vomiting

PRESENT ILLNESS: Mr. [**Known lastname 10137**] is an 83 year old male with Alzheimer's Dementia,
DMII, HTN who presented from [**Hospital3 400**] with sudden onset
of shaking, nausea and vomiting. According to his son, he was
feeling well until the morning of admission when he returned
from a walk and was noted to be pale, diaphoretic and shaky. He
was thought to be hypoglycemic (received metformin 850mg in am)
and was given some OJ which he soon vomited non-bloody stomach
contents. Vitals at the time were stable (T97.5, HR60, BP120/56,
RR14). FS 228. He was thought to be "not himself", more confused
than at baseline and less interactive than usual.  Patient and
family denied cough, SOB, diarrhea, chest pain, palpitations,
headache, nightsweats, recent weightloss, recent travel, sick
contacts. [**Name (NI) **] was transferred to the ED for further work up. In
ED patient was pan cultured with +UA and was diagnosed with
urosepsis.  He was given vanc and ceftaz and admitted to the
[**Hospital Unit Name 153**] for further care.

MEDICAL HISTORY: DM II
HTN
Pancrease deficiency
Prior history of alcohol abuse (detox in [**2111**])
Alzheimers dz
? TIA in [**12-29**] with anomia and dysarthria t

MEDICATION ON ADMISSION: Aricept 10mg po qhs
Avandia 4mg po BID
Glimepiride 2mg po daily
metformin850 po BID
metoprolol po 12.5 BID
namenda 10mg po BID
pangestyme MT16 3 tabs TID

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On admission:
Vitals: T 98 HR 110 BP 134/54 R 19 Sa02 97% on 4L NC
Gen: Elderly male in NAD. Awake, alert, talkative, following
commands though occasionally has to have questions repeated.
HEENT:MM moist. Sclera clear and anicteric. OP clear. Poor
dentition, no pain on palpation of the teeth.
Skin: no rashes, excoriations or breaks in skin.
Neck: No [**Doctor First Name **]. no JVD
CV: tachy, regular, heart sounds distant. Nl S1 and S2, no
murmurs/gallops/rubs.
Lung: CTA bilaterally, except for few crackles in LLL, no
wheezes, or rhonchi
Ext:No cyanosis/edema, feet cold but quick capillary refill. 1+
radial and DP pulses b/l.
Neuro: Awake, alert, talkative. Oriented x 0. Occasionally slurs
speech. CN II-XII intact. Reflexes 2+ b/l. Babinsky equivocal.

FAMILY HISTORY: No strokes/CAD

SOCIAL HISTORY: Social History: Lives at [**Location 10138**], specialized [**Hospital **] for Alzheimer's Dementia. Able to walk unassisted. Wife
(health proxy) is currently traveling (visiting family in
Europe).
past president of [**University/College 5130**] [**Location (un) **]
no etoh
approx 80 pack year hx of tobacco use, stopped 10 years ago 

### Response:
{"Septicemia due to gram-negative organism, unspecified,Acute kidney failure, unspecified,Pyelonephritis, unspecified,Intestinal infection due to Clostridium difficile,Unspecified protein-calorie malnutrition,Phlebitis and thrombophlebitis of upper extremities, unspecified,Chronic kidney disease, unspecified,Subendocardial infarction, initial episode of care,Hyperpotassemia,Severe sepsis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Alzheimer's disease,Dementia in conditions classified elsewhere with behavioral disturbance,Personal history of other diseases of circulatory system,Other specified diseases of pancreas,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Anemia, unspecified"}
