CHIEF COMPLAINT: Altered Mental Status

PRESENT ILLNESS: Ms. [**Known lastname **] is a 80 y/o Spanish-speaking female with h/o MI in
[**2-/2172**] (in setting of urosepsis), RA on steroids, HTN, recent
UTI on levaquin, ? lung disease, who presents with AMS at rehab.

MEDICAL HISTORY: - ? Lung disease with "CO2 retention"- severe restrictive
disease
- ? Sleep Apnea
- CAD, sp CABG, s/p STEMI in [**2-/2172**] w/ 2 BMS to the RCA and RBL
- S/p DVT w/ lupus anticoag (was on coumadin but had GI bleed on
[**2-/2172**] in the setting of supra-therapeutic INR)
- L retinal vein occlusion
- Chronic anemia
- diastolic dysfunction w/ EF of 75%
- Bioprosthetic mitral valve seen on echo [**6-/2172**]
- Moderate TR
- Moderate pulmonary HTN
- frequent UTIs and urosepsis - [**Hospital3 **], h/o VRE
(pseudomonas)
- RA
- HL
- HTN
- hypothyroidism
- TKR

MEDICATION ON ADMISSION: (per [**Hospital3 **] records)
- ASA 81
- Plavix
- Levaquin 500 mg x 5 days (started [**6-23**])
- Lasix 40mg [**Hospital1 **] (as of [**6-23**], was on 20mg at 2PM and 40mg at 6PM
prior to this)
- Lipitor 80 mg
- pantoprazole 40 mg
- Tramadol 50 mg TID PRN
- gabapentin 300 mg [**Hospital1 **]
- levothyroxine 25 mcg daily
- Toprol XL 100 mg daily
- Remeron 15 mg qhs
- KCL 20 meq daily
- prednisone 10 mg daily
- folic acid 1mg
- MVI
- lidoderm patch to right hip
- colace
.

ALLERGIES: Penicillins / Sulfa (Sulfonamide Antibiotics) / Gold Salts

PHYSICAL EXAM: Vitals: 96.8 79 113/72 12 91% on CPAP
General: minimally responsive to sternal rub only
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: cool, tready pulses, multiple ecchymoses
.

FAMILY HISTORY: NC

SOCIAL HISTORY: daughter reports patient has lived at [**Hospital3 2558**] since
hospitalization in [**Month (only) 958**]. She does not have dementia or
cognitive impairment at baseline.
- Tobacco: past h/o heavy smoking
- Alcohol:  none
Acute respiratory failure,Toxic encephalopathy,Acute on chronic diastolic heart failure,Acute kidney failure with lesion of tubular necrosis,Pneumonia, organism unspecified,Mixed acid-base balance disorder,Urinary tract infection, site not specified,Retinal vascular occlusion, unspecified,Nonspecific low blood pressure reading,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Altered mental status,Dysarthria,Coronary atherosclerosis of unspecified type of vessel, native or graft,Old myocardial infarction,Percutaneous transluminal coronary angioplasty status,Rheumatoid arthritis,Long-term (current) use of steroids,Obstructive sleep apnea (adult)(pediatric),Personal history of venous thrombosis and embolism,Anemia of other chronic disease,Heart valve replaced by transplant,Diseases of tricuspid valve,Other chronic pulmonary heart diseases,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Esophageal reflux
Acute respiratry failure,Toxic encephalopathy,Ac on chr diast hrt fail,Ac kidny fail, tubr necr,Pneumonia, organism NOS,Mixed acid-base bal dis,Urin tract infection NOS,Retinal vasc occlus NOS,Low blood press reading,Pseudomonas infect NOS,Altered mental status,Dysarthria,Cor ath unsp vsl ntv/gft,Old myocardial infarct,Status-post ptca,Rheumatoid arthritis,Long-term use steroids,Obstructive sleep apnea,Hx-ven thrombosis/embols,Anemia-other chronic dis,Heart valve transplant,Tricuspid valve disease,Chr pulmon heart dis NEC,Hyperlipidemia NEC/NOS,Hypertension NOS,Hypothyroidism NOS,Esophageal reflux
Admission Date:  [**2172-6-25**]              Discharge Date:   [**2172-7-2**]

Date of Birth:  [**2091-10-7**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Gold Salts

Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Altered Mental Status


Major Surgical or Invasive Procedure:
Intubation, central venous line placement

History of Present Illness:
Ms. [**Known lastname **] is a 80 y/o Spanish-speaking female with h/o MI in
[**2-/2172**] (in setting of urosepsis), RA on steroids, HTN, recent
UTI on levaquin, ? lung disease, who presents with AMS at rehab.

.
Per reports, patient was in USOH at 7am this morning when
patient was evaluated by [**Hospital1 1501**] staff. Per daughter, who last spoke
with patient at 10am, patient was alert and conversant however
noticed that her words were slurred. Was apparently also
nauseous. Later this PM, pt vomited and was noted to have
desatted. She then was noted to be lethargic and less
responsive.
.
Patient was then transferred to [**Hospital1 18**] ED for further evaluation.
On arrival to ED, patient's vitals were 101.2 92 133/50 19 100%
NRB. Code stroke was called and patient was evalauted by neuro
who left that AMS was [**1-8**] toxic/metabolic causes. NCHCT was
completed and was unremarkable.
.
Given level was consciousness, ABG was completed and showed
significant hypercarbia with pCO2 of 100. Patient was started
BiPAP however SBPs dropped to 73/49. CPAP was then tried and
SBPs remained in 120s and MS improved. Patient was also given 1
dose of CTX for UTI as well as 1000cc of fluid. Lactate was
noted be 1.0. Pt has positive UA and mild leukocytosis. Given
tenuous mental status, patient was admitted to MICU. Prior to
transfer, VS were afebrile HR 76 BP 105/41 RR 17 SpO2 92% on
Cpap (PEEP 5mmHg).
.
In MICU, pt was minimally responsive to sternal rub.
Review of systems:
(+) Per HPI: chest pain (per dtr)
.


Past Medical History:
- ? Lung disease with "CO2 retention"- severe restrictive
disease
- ? Sleep Apnea
- CAD, sp CABG, s/p STEMI in [**2-/2172**] w/ 2 BMS to the RCA and RBL
- S/p DVT w/ lupus anticoag (was on coumadin but had GI bleed on
[**2-/2172**] in the setting of supra-therapeutic INR)
- L retinal vein occlusion
- Chronic anemia
- diastolic dysfunction w/ EF of 75%
- Bioprosthetic mitral valve seen on echo [**6-/2172**]
- Moderate TR
- Moderate pulmonary HTN
- frequent UTIs and urosepsis - [**Hospital3 **], h/o VRE
(pseudomonas)
- RA
- HL
- HTN
- hypothyroidism
- TKR


Social History:
daughter reports patient has lived at [**Hospital3 2558**] since
hospitalization in [**Month (only) 958**]. She does not have dementia or
cognitive impairment at baseline.
- Tobacco: past h/o heavy smoking
- Alcohol:  none


Family History:
NC

Physical Exam:
Vitals: 96.8 79 113/72 12 91% on CPAP
General: minimally responsive to sternal rub only
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: cool, tready pulses, multiple ecchymoses
.


Pertinent Results:
ON ADMISSION:
- ABG (prior to NIPPV): 7.22/100/82/43
- Lactate: 1.0
- UA: 11 WBC, Mod Leuk, Few Bact
Outside Labs: from [**2172-6-24**] <-- [**2172-6-19**]
- WBC 12.8 <-- 15.8
- Neuts: 70.5%
- Lymphs: 19.6%
- Hct 40.2
- Plt 265
- Na 138
- K 3.9
- Cl 91
- Co2 34 <-- 35
- BUN 26
- Cr 1.1 <-- 1.0
- Glucose 136
- Ca 8.6
.
Discharge Labs:

[**2172-7-2**] 06:05AM BLOOD WBC-9.6 RBC-3.77* Hgb-9.5* Hct-30.8*
MCV-82 MCH-25.2* MCHC-30.9* RDW-17.0* Plt Ct-207
[**2172-7-2**] 06:05AM BLOOD Glucose-105* UreaN-23* Creat-1.1 Na-145
K-4.2 Cl-104 HCO3-37* AnGap-8
[**2172-7-2**] 06:05AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.1
[**2172-6-26**] 03:35AM BLOOD TSH-2.7
[**2172-7-1**] 05:47AM BLOOD Ferritn-69

Micro:
- [**2172-6-25**]: URINE CULTURE-PENDING

.
Images:
- CT HEAD: (prelim read) No acute intracranial hemorrhage or
mass effect. White matter hypodense areas- likely non-spf;
consider MR if not CI to exclude acute infarction.
- CTA Head and Neck: (prelim read) Atherosclerotic disease at
the common carotid bifurcations- pending review of reformations
to assess the extent of stenosis. Focal prominence at the
junction of the A1 and A2 on the right may relate to confluence;
however, to be reviewed on ref. to exclude a small incidental
aneurysm. ( se 3, im 246)
No obvious flow limiting stenosis, occlusion or obvious
aneurysm.
Final read pending all the 3D reformations.
- CXR: [**2172-6-25**]
Lung volumes are quite low, making it difficult to determine if
there really is pulmonary vascular congestion or just vascular
crowding and whether there is atelectasis or consolidation at
the base of the left lung. Heart size is top normal. No
pneumothorax.

- CXR: [**2172-6-30**] FINDINGS: As compared to the previous radiograph,
the patient has been extubated. The nasogastric tube has also
been removed. The right-sided subclavian vein catheter is in
unchanged position. Also unchanged are the external pacemaker
leads. Unchanged alignment of the sternal wires, unchanged
position of the valve replacement.

The pre-existing signs of mild-to-moderate pulmonary edema,
combined to a
retrocardiac and left basal atelectasis as well as to a left
pleural effusion are unchanged. A previously described right
pleural effusion is no longer visible. There is no evidence of
newly appeared focal parenchymal opacities

Echo showed "mild symmetric LVH with normal global and regional
biventricular systolic function. Mildly thickened mitral
bioprosthesis with normal function. Moderate tricuspid
regurgitation. Moderate pulmonary hypertension."
.
AS PER [**Hospital3 **] REC:
[**2172-4-3**] CT- pelvis: this was done for evaluation of hip
replacement.
- Showed extensive diverticulosis w/out diverticulitis. Urinary
bladder significantly distended. There is a small ventral hernia
in the region of the pelvis that contains small bowel loops and
extensive vascular calcification. No other comments on urinary
tract system.



Brief Hospital Course:
80 y/o F with history of recurrent UTIs, MI, RA on steroids who
presents with sudden onset altered mental status in setting of
fever and positive UA found to have hypercarbia (Pc02: 100)
requiring bipap and subsequent intubation.

#. Acute on Chronic Hypercapnia: Severe hypercarbia with pCO2 to
100. Felt to be secondary to baseline obstructive disease in
setting of hypoventilation from significant AMS from recieiving
tramadol and quinolone and a UTI. Pt initially failed NIPPV from
mental status standpoint and was intubated. Started
CTX/Azithromycin for CAP, however broadened to linezolid (VRE
history) and cefepime. Able to be weaned from ventilator, was
diursed with IV Lasix gtt. Weaned off the vent to room air. Had
episodes of hypotension that were fluid responsive in the MICU.
Urine culture grew [**Last Name (LF) 100098**], [**First Name3 (LF) **] patient was narrowed to
cefepime only. Her respiratory status improved greatly. Patient
will follow up with pulmonary clinic.

2. Altered Mental Status/Somnolence: CT head unremarkable, EKG
unremarkable, sedating meds were limited. Likely related to pain
medication, levofloxacin she received plus UTI. Improved with
treatment of UTI and holding these medications.

#. Hypotension: Transiently after receiving sedation. Normal
lactate, EKG. NICOM showed fluid responsiveness and was given
IVF's. Got subclavian CVL which was removed after PICC placed.

#. Urinary tract infection: Has h/o VRE in urine per daughter.
Recurrent UTI with prior urosepsis in [**12/2171**] requiring
intubation at [**Hospital6 **]. UCx grew out Pseudomonas
Cipro resistant (was treated with Levaquin as outpt before
admission), intermediate Gent, otherwise sensitive. Will be
treated with a 14 day course of Cefepime. She will also follow
up with ID in the outpatient for other possible management of
her resistant UTIs.

# CHF/CAD: s/p MI in 03/[**2171**]. EKGs unremarkable. Recent Echo
shows EF: 75%. Roughly equal to negative fluid balance during
entire length of stay. Now on 2 liters O2, saturating well.
Continued ASA, plavix, atorvastatin, beta blocker, and restarted
lasix at 40 mg daily and should be uptitrated back to home
regimen as patient is tolerating.

# ARF: Creatinine increased from 1 to 1.3 in setting of starting
captopril and diuresis. Patient was normotensive on floor and
captopril was being held, so this was stopped prior to
discharge. She was placed back on her regimen as above.

# Shakiness/Weakness: Patient complaining of shakiness. Normal
neuro exam. Appeared to be secondary to significant
deconditioning. She will be discharged back to rehab.

# Rheumatoid Arthritis: On chronic steroids. Given 50 mg stress
dose of Hydrocortisone initially. Continued prednisone 10mg

# Hypothyroidism: continued levothyroxine

# GERD: continued pantoprazole

# Communication: Patient and Family: daughter [**Name (NI) 15359**]:
[**Telephone/Fax (1) 100099**]

# Code: Was full, then pt stated she wanted to be DNR/DNI, not
receive NIPPV either.


Medications on Admission:
(per [**Hospital3 **] records)
- ASA 81
- Plavix
- Levaquin 500 mg x 5 days (started [**6-23**])
- Lasix 40mg [**Hospital1 **] (as of [**6-23**], was on 20mg at 2PM and 40mg at 6PM
prior to this)
- Lipitor 80 mg
- pantoprazole 40 mg
- Tramadol 50 mg TID PRN
- gabapentin 300 mg [**Hospital1 **]
- levothyroxine 25 mcg daily
- Toprol XL 100 mg daily
- Remeron 15 mg qhs
- KCL 20 meq daily
- prednisone 10 mg daily
- folic acid 1mg
- MVI
- lidoderm patch to right hip
- colace
.


Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day): Continue until patient is
ambulatory.
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
11. cefepime 2 gram Recon Soln Sig: Two (2) Grams Injection Q12H
(every 12 hours) for 7 days.
12. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for yeast infection.
14. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Hold for sbp < 100.
15. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for yeast.
16. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
17. multivitamin     Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain: 12 hours on and 12 hours off.
19. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 2558**] - [**Location (un) **]

Discharge Diagnosis:
Primary:
Hypercarbic respiratory failure
Pseudomonas UTI
Metabolic encephalopathy


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
You were admitted for altered mental status and found to have a
urinary tract infection. Your carbon dioxide in your blood was
very high, which can cause signficant sleepiness. You were
ultimately intubated to correct this problem. [**Name (NI) **] received
antibiotics for your infection and you improved.

You should continue all of your medications with the following
important changes:
1. Continue Cefepime 2 grams every 12 hours. Last day [**2172-7-9**]
2. Decrease lasix to 40 mg daily and should uptitrate by your
primary care doctor as needed
3. STOP Tramadol as this may have been why you were so sleepy
4. Decrease metoprolol to 37.5 mg twice per day

Followup Instructions:
Department: MEDICAL SPECIALTIES
When: MONDAY [**2172-7-13**] at 1:30 PM
With: DR. [**Last Name (STitle) 51373**]/DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
**Please arrive at 1:00pm for this appointment.

Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2172-8-19**] at 3:00 PM
With: [**First Name8 (NamePattern2) 1955**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

**Please call our registration department at [**Telephone/Fax (1) 10676**] to
update your demographic information before your appointments.


                             [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
{'Acute respiratory failure,Toxic encephalopathy,Acute on chronic diastolic heart failure,Acute kidney failure with lesion of tubular necrosis,Pneumonia, organism unspecified,Mixed acid-base balance disorder,Urinary tract infection, site not specified,Retinal vascular occlusion, unspecified,Nonspecific low blood pressure reading,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Altered mental status,Dysarthria,Coronary atherosclerosis of unspecified type of vessel, native or graft,Old myocardial infarction,Percutaneous transluminal coronary angioplasty status,Rheumatoid arthritis,Long-term (current) use of steroids,Obstructive sleep apnea (adult)(pediatric),Personal history of venous thrombosis and embolism,Anemia of other chronic disease,Heart valve replaced by transplant,Diseases of tricuspid valve,Other chronic pulmonary heart diseases,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Esophageal reflux'}


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: Ms. [**Known lastname **] is a 80 y/o Spanish-speaking female with h/o MI in
[**2-/2172**] (in setting of urosepsis), RA on steroids, HTN, recent
UTI on levaquin, ? lung disease, who presents with AMS at rehab.

MEDICAL HISTORY: - ? Lung disease with "CO2 retention"- severe restrictive
disease
- ? Sleep Apnea
- CAD, sp CABG, s/p STEMI in [**2-/2172**] w/ 2 BMS to the RCA and RBL
- S/p DVT w/ lupus anticoag (was on coumadin but had GI bleed on
[**2-/2172**] in the setting of supra-therapeutic INR)
- L retinal vein occlusion
- Chronic anemia
- diastolic dysfunction w/ EF of 75%
- Bioprosthetic mitral valve seen on echo [**6-/2172**]
- Moderate TR
- Moderate pulmonary HTN
- frequent UTIs and urosepsis - [**Hospital3 **], h/o VRE
(pseudomonas)
- RA
- HL
- HTN
- hypothyroidism
- TKR

MEDICATION ON ADMISSION: (per [**Hospital3 **] records)
- ASA 81
- Plavix
- Levaquin 500 mg x 5 days (started [**6-23**])
- Lasix 40mg [**Hospital1 **] (as of [**6-23**], was on 20mg at 2PM and 40mg at 6PM
prior to this)
- Lipitor 80 mg
- pantoprazole 40 mg
- Tramadol 50 mg TID PRN
- gabapentin 300 mg [**Hospital1 **]
- levothyroxine 25 mcg daily
- Toprol XL 100 mg daily
- Remeron 15 mg qhs
- KCL 20 meq daily
- prednisone 10 mg daily
- folic acid 1mg
- MVI
- lidoderm patch to right hip
- colace
.

ALLERGIES: Penicillins / Sulfa (Sulfonamide Antibiotics) / Gold Salts

PHYSICAL EXAM: Vitals: 96.8 79 113/72 12 91% on CPAP
General: minimally responsive to sternal rub only
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: cool, tready pulses, multiple ecchymoses
.

FAMILY HISTORY: NC

SOCIAL HISTORY: daughter reports patient has lived at [**Hospital3 2558**] since
hospitalization in [**Month (only) 958**]. She does not have dementia or
cognitive impairment at baseline.
- Tobacco: past h/o heavy smoking
- Alcohol:  none 

### Response:
{'Acute respiratory failure,Toxic encephalopathy,Acute on chronic diastolic heart failure,Acute kidney failure with lesion of tubular necrosis,Pneumonia, organism unspecified,Mixed acid-base balance disorder,Urinary tract infection, site not specified,Retinal vascular occlusion, unspecified,Nonspecific low blood pressure reading,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Altered mental status,Dysarthria,Coronary atherosclerosis of unspecified type of vessel, native or graft,Old myocardial infarction,Percutaneous transluminal coronary angioplasty status,Rheumatoid arthritis,Long-term (current) use of steroids,Obstructive sleep apnea (adult)(pediatric),Personal history of venous thrombosis and embolism,Anemia of other chronic disease,Heart valve replaced by transplant,Diseases of tricuspid valve,Other chronic pulmonary heart diseases,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Esophageal reflux'}
