CHIEF COMPLAINT: Altered mental status, hypoxia

PRESENT ILLNESS: Ms. [**Known lastname **] is an 89 yo female with PMH of Alzheimer's disease,
depression, hypernatremia, paroxysmal afib who presents from her
NH.  Her son was called by the nursing home reporting a fever to
101 and O2 sat 84-86%.  She was then sent to the ED.
.
In the ED, she was noted to have altered mental status.  She was
nonverbal but responded to pain.  Exam was reported as otherwise
unremarkable other than rhonchi.  She was noted to be hypoxic to
89%.  Her CXR was ok.  Her ABG at that time was 7.37/58/178.
Subsequent ABG showed worsening hypercarbia at 66, so she was
intubated.  She was transiently hypotensive after intubation.
This improved with fluid.  Her HCT was in the 50s and her serum
sodium was 170.  She received 2L NS in the ED with 2 more
hanging upon transport to the ICU.  She was noted to have pyuria
and was givne vanc and zosyn.  Lactate in the ED was 1.4.  VS in
the ED: T 103.6 rectal  115/60  HR 52   RR 16  98% on 100%FiO2,
Peep 5 Tv 400.

MEDICAL HISTORY: Alzheimer's
Depression
Hypernatremia
Paroxymal Afib
h/o Urinary tract infections
Cholelithiasis
h/o Influenza A/b

MEDICATION ON ADMISSION: bisocodyl supp 10mg daily prn
albuterol q 6 prn
ipratropium q 6 prn
tylenol 500 q 6 prn
guiatuss q 6 prn
tylenol suppos 650mg q 6 prn
lactulose 15ml po daily
vit E 800 po daily
caltrate 600 + D [**Hospital1 **]
aricept 10mg po daily
colace 100 qday
zyprexa 5mg qday
namenda 10mg [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission PE:
vitals: 97.3  89/49  99% on 100% FiO2
gen: resting, ill appearing
heent: ncat, mmd, pupils 2mm
neck: no elevated JVD
pulm: ctab, no w/r/r
cv: brady, 2/6 SEM, no r/g
abd: s/nt/nd/nabs
extr: no c/c/e, pulses thready
neuro: intubated, sedated. does not respond to voice.
withdrawals from pain.

FAMILY HISTORY: N/A

SOCIAL HISTORY: Permanent resident of [**Hospital3 **] Manor. Chinese speaking only,
Son and daughter active in her life and visit daily.
Unspecified septicemia,Acute respiratory failure,Hyperosmolality and/or hypernatremia,Toxic encephalopathy,Acute kidney failure, unspecified,Pneumonia due to other gram-negative bacteria,Urinary tract infection, site not specified,Ventilator associated pneumonia,Severe sepsis,Atrial fibrillation,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site,Pressure ulcer, lower back,Other second degree atrioventricular block
Septicemia NOS,Acute respiratry failure,Hyperosmolality,Toxic encephalopathy,Acute kidney failure NOS,Pneumo oth grm-neg bact,Urin tract infection NOS,Ventltr assoc pneumonia,Severe sepsis,Atrial fibrillation,Alzheimer's disease,Dementia w/o behav dist,Proteus infection NOS,Pressure ulcer, low back,Av block-2nd degree NEC
Admission Date:  [**2197-11-9**]              Discharge Date:   [**2197-11-26**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Altered mental status, hypoxia

Major Surgical or Invasive Procedure:
Intubation x 2, central line insertion, tracheostomy [**11-23**], PEG
placement [**11-23**]

History of Present Illness:
Ms. [**Known lastname **] is an 89 yo female with PMH of Alzheimer's disease,
depression, hypernatremia, paroxysmal afib who presents from her
NH.  Her son was called by the nursing home reporting a fever to
101 and O2 sat 84-86%.  She was then sent to the ED.
.
In the ED, she was noted to have altered mental status.  She was
nonverbal but responded to pain.  Exam was reported as otherwise
unremarkable other than rhonchi.  She was noted to be hypoxic to
89%.  Her CXR was ok.  Her ABG at that time was 7.37/58/178.
Subsequent ABG showed worsening hypercarbia at 66, so she was
intubated.  She was transiently hypotensive after intubation.
This improved with fluid.  Her HCT was in the 50s and her serum
sodium was 170.  She received 2L NS in the ED with 2 more
hanging upon transport to the ICU.  She was noted to have pyuria
and was givne vanc and zosyn.  Lactate in the ED was 1.4.  VS in
the ED: T 103.6 rectal  115/60  HR 52   RR 16  98% on 100%FiO2,
Peep 5 Tv 400.


Past Medical History:
Alzheimer's
Depression
Hypernatremia
Paroxymal Afib
h/o Urinary tract infections
Cholelithiasis
h/o Influenza A/b


Social History:
Permanent resident of [**Hospital3 **] Manor. Chinese speaking only,
Son and daughter active in her life and visit daily.

Family History:
N/A

Physical Exam:
Admission PE:
vitals: 97.3  89/49  99% on 100% FiO2
gen: resting, ill appearing
heent: ncat, mmd, pupils 2mm
neck: no elevated JVD
pulm: ctab, no w/r/r
cv: brady, 2/6 SEM, no r/g
abd: s/nt/nd/nabs
extr: no c/c/e, pulses thready
neuro: intubated, sedated. does not respond to voice.
withdrawals from pain.


Pertinent Results:
[**2197-11-9**] 10:30AM BLOOD WBC-9.1 RBC-5.03# Hgb-16.7*# Hct-52.6*#
MCV-105*# MCH-33.3* MCHC-31.8 RDW-15.3 Plt Ct-242
[**2197-11-9**] 10:30AM BLOOD Neuts-85.3* Bands-0 Lymphs-8.3* Monos-5.8
Eos-0.1 Baso-0.6
[**2197-11-9**] 03:00PM BLOOD PT-17.4* PTT-39.3* INR(PT)-1.6*
[**2197-11-9**] 10:21AM BLOOD Type-ART pO2-178* pCO2-58* pH-7.37
calTCO2-35* Base XS-6 Intubat-NOT INTUBA
[**2197-11-9**] 10:21AM BLOOD Lactate-2.0
[**2197-11-9**] 10:30AM BLOOD ESR-31*
[**2197-11-9**] 10:30AM BLOOD Glucose-128* UreaN-82* Creat-2.7* Na-170*
K-4.6 Cl-128* HCO3-33* AnGap-14
[**2197-11-9**] 10:30AM BLOOD ALT-30 AST-26 CK(CPK)-257* AlkPhos-55
Amylase-53 TotBili-1.3
[**2197-11-9**] 10:30AM BLOOD CK-MB-3 cTropnT-0.05*
[**2197-11-9**] 10:30AM BLOOD Albumin-3.6 Calcium-9.4 Phos-4.1# Mg-3.7*
.
[**2197-11-12**] 10:10AM BLOOD FDP-0-10
[**2197-11-12**] 10:10AM BLOOD Fibrino-397 Thrombn-14.3*
.
[**2197-11-22**] 05:09PM BLOOD Type-ART Temp-37.2 Rates-18/0 Tidal V-380
PEEP-5 FiO2-40 pO2-128* pCO2-38 pH-7.45 calTCO2-27 Base XS-3
-ASSIST/CON
[**2197-11-22**] 05:09PM BLOOD Lactate-1.4
.
[**2197-11-23**] 03:16AM BLOOD Cortsol-20.1*
.
[**2197-11-24**] 03:26AM BLOOD WBC-7.8 RBC-2.55* Hgb-8.5* Hct-25.3*
MCV-99* MCH-33.4* MCHC-33.7 RDW-16.1* Plt Ct-354
[**2197-11-24**] 03:26AM BLOOD PT-13.7* PTT-35.3* INR(PT)-1.2*
[**2197-11-24**] 03:26AM BLOOD Glucose-99 UreaN-13 Creat-1.0 Na-139
K-4.3 Cl-104 HCO3-28 AnGap-11
[**2197-11-24**] 03:26AM BLOOD Calcium-8.2* Phos-3.6# Mg-2.2
.
Radiographic studies:
.
CXR [**11-12**]: Interstitial edema increased. Left retrocardiac
atelectasis also worsened. Small bilateral pleural effusions,
more marked on the left are unchanged. Calcifications of the
aortic arch and old right rib fractures are stable. Heart size
remains normal. Hilar contours are unchanged.
.
CXR [**11-20**]: FINDINGS: Endotracheal tube, right internal jugular
central venous catheter and nasogastric tube appear unchanged.
There has been an interval worsening of the bilateral perihilar
opacities and probable slight increase in the layering bilateral
large pleural effusions. This could reflect developing pulmonary
edema although multifocal infection cannot be entirely excluded.

.
ECHO [**11-22**]: The left atrium is normal in size. Left ventricular
wall thickness, cavity size, and global systolic function are
normal (LVEF>55%). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). The right
ventricular cavity is mildly dilated with normal free wall
contractility. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion. IMPRESSION: Normal
biventricular cavity sizes with preserved global and regional
biventricular systolic function. Pulmonary artery systolic
hypertension. Mild mitral regurgitation.
.
Micro Data:
[**11-9**]: UCx w/proteus, sputum w/MRSA
[**11-18**]: sputum w/stenotrophomonas
BCx [**11-12**] negative
BCx [**11-18**], [**11-19**], [**11-20**], [**11-21**] pending
R IJ tip [**11-22**] culture negative
UCx x2 [**11-19**] negative
3x CDiff negative ([**11-12**], [**11-13**], [**11-14**])


Brief Hospital Course:
A/P: 89 yo with PMH of Alzheimer's dementia, hypernatremia, UTI
presents with AMS, sepsis physiology, UTI, and impressive
hypernatremia
.
#1 Sepsis: Initially presenting with fever, hypotension,
hypoxia.  Source was likely urine given pyuria, though may have
pneumonia as well given MRSA in sputum.  UCx grew out pan
sensitive proteus mirabilis, initial sputum grew MRSA.  BCx from
[**11-9**], [**11-12**] negative. BCx from [**11-18**], [**11-19**], [**11-20**], [**11-21**] all
pending.  Patient had short additional time in MICU when
required pressors for approx 48 hours.  Started on empiric zosyn
and gent for VAP. UCx during this time were negative and sputum
grew out Stenotrophomonas sensitive to Bactrim. IV Bactrim
started and zosyn/gent d/c.   Although blood pressure is low at
baseline, patient always makes urine.  Stool tests for C. diff
negative x 3 & flagyl stopped [**11-15**].
- completed 15d of vanco, was treated for 14d total for UTI
starting w/cipro/unasyn and switching to gent/zosyn (to double
cover for VAP)
- IV Bactrim 250mg Q8h for 14 days, starting [**11-24**] and finishing
on [**12-8**].
.
#2 Respiratory failure: Hypoxia and hypercarbia with spontaneous
breathing trials.  [**Month (only) 116**] now be volume overloaded due to fluid
resuscitation.  PNAs and deconditioning likely also contribute.
Patient failed SBTs due to RSBIs >130 and increasing acidosis.
Unclear why patient unable to be weaned off vent. Patient with
slightly hyperinflated [**Known lastname **]s and CO2 retention without acidosis
on admission. No Hx of COPD given but may be undiagnosed thus
far.  NIF poor at 16 with large amount of dead space ventilation
(70% on PSV).  Difficulty of weaning from the vent likely a mix
of decreased respiratory muscle strength combined with
underlying intrinsic [**Known lastname **] disease.
- Continue on Pressure support as tolerated and wean as
tolerated.
.
#3 Hypernatremia: likely from extreme dehydration.  Now
resolved.
Patient is currently getting free water boluses 100ml every 6
hours with tube feeds.  Continue to monitor sodium and adjust as
necessary.
.
#4 AMS: likely [**2-4**] toxic/metabolic, though other etiologies
could include stroke, and underlying dementia. Patient
increasingly alert as she is treated
.
#5 Hypotension: Resolved currently.  Dopamine drip weaned off.
ECHO relatively unremarkable given patient??????s age and does not
explain hypotension or bradycardia.  unclear etiology.  Lactate
and mixed venous do not suggest infection.  Pt did not respond
to fluid boluses and CVPs do not point to hypovolemia.  Repeat
ECHO w/normal biventricular cavity sizes with preserved global
and regional biventricular systolic function. Pulmonary artery
systolic hypertension. Mild mitral regurgitation. [**Month (only) 116**] also be
unable to mount HR response with conduction disorder.  EP
consulted twice and do not want to intervene given her hx of
sepsis.  Adrenal insufficiency also a possibility but AM
cortisol was normal.
.
Fluid balance should be maintained.  She has been both very
hypervolemic and exterienced flash pulmonary edema during her
stay, and fluid balance has been difficult.  Any PRN IVF should
be given with caution and extubation was probably in part
limited [**2-4**] to pulm edema.  Her sodium and other electrolytes
should be monitored every other day until stable and PO intake
of fluids encouraged.
.
Would reassess fluid status daily and give small doses of Lasix
as tolerated by blood pressure.  The patient has been
hypotensive with Lasix in the past, therefore small doses should
be given.
.
#6 Bradycardia, HR consistently in 50's but asymptomatic: Not
new ?????? old records show ekg w/nsr at 65 w/1st degree AV block 3
years ago. Initially EP commented that her rhythm could be a
variation of normal or tied to her underlying illness and
recommended treating her sepsis and re-evaluating once she has
recovered or becomes unstable.
.
#7 Paroxysmal afib: not on anticoagulation on admission for
unclear reason (fall risk?) The reason for this should be
followed up with her PCP.  [**Name10 (NameIs) **] was not investigated during this
stay.
.
#8 Alzheimer's: cont home meds of Namenda and Aricept.
.
#9 Anemia: hemoconcentrated upon admission, HCT trended to mid
to upper 20s during here stay.  Further workup should be
initiated by her PCP.  [**Name10 (NameIs) 357**] monitor her HCT every other day
until stable.
.
# PPx: H2 blocker, sc heparin, bowel regimen
.
# FEN: Tolerated TF at goal.
.
# Code: full code.  Discussed with patient??????s son [**Name (NI) **] who
wants ??????everything done?????? including reintubation if patient fails
extubation.

Medications on Admission:
bisocodyl supp 10mg daily prn
albuterol q 6 prn
ipratropium q 6 prn
tylenol 500 q 6 prn
guiatuss q 6 prn
tylenol suppos 650mg q 6 prn
lactulose 15ml po daily
vit E 800 po daily
caltrate 600 + D [**Hospital1 **]
aricept 10mg po daily
colace 100 qday
zyprexa 5mg qday
namenda 10mg [**Hospital1 **]


Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
5. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation q4hrs prn as needed.
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
10. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

11. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
12. Trimethoprim-Sulfamethoxazole 80-400 mg/5 mL Solution Sig:
Two [**Age over 90 1230**]y (250) mg Intravenous q8hrs for 13 days:
through [**2197-12-7**].
13. Vitamin E 800 unit Capsule Sig: One (1) Capsule PO once a
day.
14. Caltrate-600 Plus Vitamin D3 600-400 mg-unit Tablet Sig: One
(1) Tablet PO twice a day.
15. Lactulose 10 gram/15 mL Solution Sig: Fifteen (15) mL PO
once a day.
16. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1)
Puff Inhalation PRN (as needed) as needed for shortness of
breath or wheezing.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **] [**Location (un) 86**]

Discharge Diagnosis:
Primary:
proteus mirabilis urosepsis
bradycardia
stenotrophomonas pneumonia
.
Secondary:
Alzheimer's
Depression
Hypernatremia
Paroxymal Afib
h/o Urinary tract infections
Cholelithiasis
h/o Influenza A/b


Discharge Condition:
good, afebrile


Discharge Instructions:
Ms. [**Known lastname **] was seen at [**Hospital1 18**] for urosepsis for which she finished
a course of vanc, gent, zosyn.  She required pressors
intermittently for hypotension.  She was also extremely
hypernatremic.  She also was bradycardic with a mid-grade block.
 She is receiving bactrim for stenotrophomonas pna.  She will
need bactrim until [**2197-12-7**].  She will need ongoing nebulizers,
sc heparin, and bowel regimen per medication orders.  Please see
discharge [**Last Name (un) 17576**] for full details.
.
Vital signs should be monitored daily.  Fluid balance should be
maintained.  She has been both very hypervolemic and exterienced
flash pulmonary edema during her stay, and fluid balance has
been difficult.
.
She has not been anticoagulated for her PAF in the past.  The
reason for this should be followed up with her PCP as below.
This was not investigated during this stay.
.
She will need every other day electrolytes and CBC checked until
stable.  Other discharge orders per medication sheet and page 1
referral.
.
She should return to the ED if she develops altered mental
status, fever, hypotension, bradycardia.

Followup Instructions:
she should follow-up with her Primary Care Provider, [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 10145**], in the next 1-2 weeks.  His office number is
[**Telephone/Fax (1) 10573**].
{"Unspecified septicemia,Acute respiratory failure,Hyperosmolality and/or hypernatremia,Toxic encephalopathy,Acute kidney failure, unspecified,Pneumonia due to other gram-negative bacteria,Urinary tract infection, site not specified,Ventilator associated pneumonia,Severe sepsis,Atrial fibrillation,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site,Pressure ulcer, lower back,Other second degree atrioventricular block"}


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, hypoxia

PRESENT ILLNESS: Ms. [**Known lastname **] is an 89 yo female with PMH of Alzheimer's disease,
depression, hypernatremia, paroxysmal afib who presents from her
NH.  Her son was called by the nursing home reporting a fever to
101 and O2 sat 84-86%.  She was then sent to the ED.
.
In the ED, she was noted to have altered mental status.  She was
nonverbal but responded to pain.  Exam was reported as otherwise
unremarkable other than rhonchi.  She was noted to be hypoxic to
89%.  Her CXR was ok.  Her ABG at that time was 7.37/58/178.
Subsequent ABG showed worsening hypercarbia at 66, so she was
intubated.  She was transiently hypotensive after intubation.
This improved with fluid.  Her HCT was in the 50s and her serum
sodium was 170.  She received 2L NS in the ED with 2 more
hanging upon transport to the ICU.  She was noted to have pyuria
and was givne vanc and zosyn.  Lactate in the ED was 1.4.  VS in
the ED: T 103.6 rectal  115/60  HR 52   RR 16  98% on 100%FiO2,
Peep 5 Tv 400.

MEDICAL HISTORY: Alzheimer's
Depression
Hypernatremia
Paroxymal Afib
h/o Urinary tract infections
Cholelithiasis
h/o Influenza A/b

MEDICATION ON ADMISSION: bisocodyl supp 10mg daily prn
albuterol q 6 prn
ipratropium q 6 prn
tylenol 500 q 6 prn
guiatuss q 6 prn
tylenol suppos 650mg q 6 prn
lactulose 15ml po daily
vit E 800 po daily
caltrate 600 + D [**Hospital1 **]
aricept 10mg po daily
colace 100 qday
zyprexa 5mg qday
namenda 10mg [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission PE:
vitals: 97.3  89/49  99% on 100% FiO2
gen: resting, ill appearing
heent: ncat, mmd, pupils 2mm
neck: no elevated JVD
pulm: ctab, no w/r/r
cv: brady, 2/6 SEM, no r/g
abd: s/nt/nd/nabs
extr: no c/c/e, pulses thready
neuro: intubated, sedated. does not respond to voice.
withdrawals from pain.

FAMILY HISTORY: N/A

SOCIAL HISTORY: Permanent resident of [**Hospital3 **] Manor. Chinese speaking only,
Son and daughter active in her life and visit daily. 

### Response:
{"Unspecified septicemia,Acute respiratory failure,Hyperosmolality and/or hypernatremia,Toxic encephalopathy,Acute kidney failure, unspecified,Pneumonia due to other gram-negative bacteria,Urinary tract infection, site not specified,Ventilator associated pneumonia,Severe sepsis,Atrial fibrillation,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site,Pressure ulcer, lower back,Other second degree atrioventricular block"}
