CHIEF COMPLAINT: Lethargy

PRESENT ILLNESS: Ms. [**Known lastname **] is a 65 year old female with history of multiple
sclerosis, dementia, neurogenic bladder with indwelling foley,
right staghorn calculus, left obstructing UVJ stone with
nephrostomy tube presented from [**Hospital1 1501**] with worsening lethargy and
no output from nephrostomy tube for the two days prior to
admission. The patient was also reported to have been satting at
77% on NBR when EMS arrived. The patient has been admitted three
times in the past year with urosepsis.

MEDICAL HISTORY: Multiple Sclerosis - about 14yrs, followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Location (un) 2274**]
 - wheelchair at baseline, lives in nursing home
 - has no use of her lower extremities, sometimes spastic
movements
 - bladder chronically contracted
UTI with ESBL E.coli--sensitive to zosyn, [**Last Name (un) 2830**], gent in past
[**Last Name (un) 8304**] Depression
Anxiety
PVD s/p lower extremity bypass
COPD
Osteoporosis
Hx of +PPD
bilateral femur supracondylar fractures [**2113**]
hx of Urosepsis - hospitalized about once/yr, per husband
Neurogenic bladder - indwelling foley x [**4-27**] [**Last Name (LF) 1686**], [**First Name3 (LF) **] husband
Recurrent C. Diff
Hx of Sacral Decub
LE spasticity
Hx of jaw pain -- ?TMJ, improved on [**First Name3 (LF) **]

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from  [**Hospital1 1501**] documentation.
1. Sertraline 100 mg PO DAILY
2. Baclofen 10 mg PO BID
3. carBAMazepine *NF* 300 mg Oral [**Hospital1 **]
4. Cyclobenzaprine 10 mg PO BID
5. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
6. Ipratropium Bromide Neb 1 NEB IH Q6H
7. methenamine hippurate *NF* 1 gram Oral [**Hospital1 **]
8. Simvastatin 20 mg PO DAILY
9. Acetaminophen 1000 mg PO Q8H:PRN pain
10. Bisacodyl 10 mg PR DAILY:PRN constipation
11. cranberry ext-C-L. sporogenes *NF* [**Medical Record Number 18595**] mg-mg-million
Oral daily
12. Docusate Sodium 100 mg PO BID
13. Senna 1 TAB PO BID:PRN constipation

ALLERGIES: Zosyn / ceftriaxone / tuberculin ppd skin test

PHYSICAL EXAM: Physical Exam on Admission:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
Physical Exam on Discharge
VS: RR16-18
Gen: Debilitated female in no acute distress
HEENT: EOMI with horizontal nystagmus, MMM
CV: RRR, no m/g/r
Resp: anterolateral exam limited, CTAB, no w/r/r
GU: Foley, nephrostomy in place, clear yellow urine
Neuro: unable to assess due to pt dementia/decompensation
MSK: unable to assess due to pt dementia/decompensation

FAMILY HISTORY: No family members with Multiple Sclerosis.

SOCIAL HISTORY: Lives in nursing home for last 4 [**First Name3 (LF) 1686**].  Husband is HCP, lives
with one of their daughters.  [**Name (NI) **] daughter married and lives
in the area.  Nonambulatory and in wheelchair at baseline,
dependent for transfers and some of ADLs.  Has no use of lower
extremities at baseline.  On pureed thickened liquids at rehab.
Infection and inflammatory reaction due to indwelling urinary catheter,Unspecified septicemia,Septic shock,Pressure ulcer, stage III,Severe sepsis,Urinary tract infection, site not specified,Other and unspecified Escherichia coli [E. coli],Calculus of kidney,Multiple sclerosis,Neurogenic bladder NOS,Dementia, unspecified, without behavioral disturbance,Chronic airway obstruction, not elsewhere classified,Anxiety state, unspecified,Osteoporosis, unspecified,Depressive disorder, not elsewhere classified,Other artificial opening of urinary tract status,Personal history of traumatic fracture,Other dependence on machines, supplemental oxygen,Personal history of tobacco use,Do not resuscitate status,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Urinary catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
React-indwell urin cath,Septicemia NOS,Septic shock,Pressure ulcer,stage III,Severe sepsis,Urin tract infection NOS,E.coli infection NEC/NOS,Calculus of kidney,Multiple sclerosis,Neurogenic bladder NOS,Demen NOS w/o behv dstrb,Chr airway obstruct NEC,Anxiety state NOS,Osteoporosis NOS,Depressive disorder NEC,Urinostomy status NEC,Hx traumatic fracture,Depend-supplement oxygen,History of tobacco use,Do not resusctate status,Abn react-artif implant,Abn react-urinary cath
Admission Date:  [**2119-7-13**]              Discharge Date:   [**2119-7-18**]

Date of Birth:  [**2053-11-10**]             Sex:   F

Service: MEDICINE

Allergies:
Zosyn / ceftriaxone / tuberculin ppd skin test

Attending:[**First Name3 (LF) 16115**]
Chief Complaint:
Lethargy

Major Surgical or Invasive Procedure:
None


History of Present Illness:
Ms. [**Known lastname **] is a 65 year old female with history of multiple
sclerosis, dementia, neurogenic bladder with indwelling foley,
right staghorn calculus, left obstructing UVJ stone with
nephrostomy tube presented from [**Hospital1 1501**] with worsening lethargy and
no output from nephrostomy tube for the two days prior to
admission. The patient was also reported to have been satting at
77% on NBR when EMS arrived. The patient has been admitted three
times in the past year with urosepsis.

In the ER, the patient was febrile to 102.8 and tachycardic. She
had a leukocytosis to 16.4. Her foley catheter was exchanged and
foul-smelling urine emerged. She had numerous excoriations
within and around her vagina and decubitus ulcers on her sacrum.
The nephrostomy tube was encrusted, and when cleaned, purulent
discharge emerged. She also had erythema and fluctuance with
expressible pus around the nephrostomy site. The patient was
given vancomycin, aztreonam, and flagyl. She was transferred to
the MICU with a systolic pressure of 85 on peripheral low-dose
levophed.

Past Medical History:
Multiple Sclerosis - about 14yrs, followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Location (un) 2274**]
 - wheelchair at baseline, lives in nursing home
 - has no use of her lower extremities, sometimes spastic
movements
 - bladder chronically contracted
UTI with ESBL E.coli--sensitive to zosyn, [**Last Name (un) 2830**], gent in past
[**Last Name (un) 8304**] Depression
Anxiety
PVD s/p lower extremity bypass
COPD
Osteoporosis
Hx of +PPD
bilateral femur supracondylar fractures [**2113**]
hx of Urosepsis - hospitalized about once/yr, per husband
Neurogenic bladder - indwelling foley x [**4-27**] [**Last Name (LF) 1686**], [**First Name3 (LF) **] husband
Recurrent C. Diff
Hx of Sacral Decub
LE spasticity
Hx of jaw pain -- ?TMJ, improved on [**First Name3 (LF) **]


Social History:
Lives in nursing home for last 4 [**First Name3 (LF) 1686**].  Husband is HCP, lives
with one of their daughters.  [**Name (NI) **] daughter married and lives
in the area.  Nonambulatory and in wheelchair at baseline,
dependent for transfers and some of ADLs.  Has no use of lower
extremities at baseline.  On pureed thickened liquids at rehab.

-Tobacco: started at age 20, quit about 15yrs ago
-ETOH: social, occasional, per husband
-[**Name (NI) 3264**]: none


Family History:
No family members with Multiple Sclerosis.


Physical Exam:
Physical Exam on Admission:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
Physical Exam on Discharge
VS: RR16-18
Gen: Debilitated female in no acute distress
HEENT: EOMI with horizontal nystagmus, MMM
CV: RRR, no m/g/r
Resp: anterolateral exam limited, CTAB, no w/r/r
GU: Foley, nephrostomy in place, clear yellow urine
Neuro: unable to assess due to pt dementia/decompensation
MSK: unable to assess due to pt dementia/decompensation

Pertinent Results:
Abdominal XR ([**7-13**]): The left percutaneous nephrostomy tube is
in similar position
compared with prior imaging.  If the patient continues to have
symptoms and clinical concern exists for malposition of tube, a
dedicated antegrade nephrostomy tube study would be recommended.

.
LABS ON ADMISSION
[**2119-7-13**] 09:35AM BLOOD WBC-16.4*# RBC-4.08* Hgb-11.5* Hct-37.5
MCV-92 MCH-28.2 MCHC-30.6* RDW-16.1* Plt Ct-533*#
[**2119-7-13**] 09:35AM BLOOD Neuts-87.6* Lymphs-7.8* Monos-4.2 Eos-0.2
Baso-0.2
[**2119-7-13**] 09:35AM BLOOD PT-31.0* PTT-43.6* INR(PT)-3.0*
[**2119-7-13**] 09:35AM BLOOD Glucose-93 UreaN-17 Creat-0.8 Na-144
K-3.9 Cl-108 HCO3-25 AnGap-15
[**2119-7-13**] 09:35AM BLOOD cTropnT-<0.01
[**2119-7-13**] 09:35AM BLOOD CK-MB-2
[**2119-7-13**] 09:35AM BLOOD Albumin-2.3* Calcium-8.0* Phos-3.4 Mg-2.1
[**2119-7-13**] 10:14AM BLOOD Lactate-2.3*
.
LABS ON DISCHARGE
lab draws were discontinued due to patient and husband's wishes
for comfort measures only.

Brief Hospital Course:
The patient is a 65 year old female with history of MS,
dementia, neurogenic bladder with indwelling foley, b/l calculi
s/p left nephrostomy presenting with fatige and found to have
urosepsis.
.
ACUTE ISSUES
#Urosepsis:
The patient has long history of urinary tract infections with
MDR organisms including ESBL e. coli and pseudomonas due to her
abnormal anatomy. She has been considered for lithotripsy of
left UVJ stone in past but thought to be high risk due to
cardiac co-morbidities. The patient also has a staghorn calculus
in the right kidney. She presented febrile to 102.8 and with
systolic pressure in the 80s. Patient was found to have
foul-smelling urine from foley and purulent material emanating
from nephrostomy tube in the ER. She was started on low-dose
peripheral levophed and transferred to the MICU. She was started
on meropenem for likely ESBL E. coli and vancomycin. A Dobhoff
tube was inserted and the patient was started on tube feeds. A
goals of care discussion was had with the patient's husband, and
it was decided that the patient would seek comfort measures only
(see below). The patient was transferred to the floor for
continued management despite low pressures. On the floor she
remained clinically stable without the need for pressure
support. Her antibiotics were discontinued upon discharge.
.
#Goals of care:
The goals of care were discussed with the patient and husband in
both the ICU and the general medicine floor. After a long
discussion, it was decided that the patient would be continued
on IV antibiotics and tube feeds while inpatient. On the floor,
the patient removed her Dobhoff tube, and it was decided with
the husband not to reinitiate it. The patient's husband wished
to keep patient comfort at the forefront, but wanted to continue
interventions until the patient either declined or discontinued
them herself. Palliative care was consulted and it was planned
that the patient would return to her longterm care facility for
hospice services. IV antibiotics were discontinued, as they
would require PICC placement, which would not have been
consistent with pt and husband's goals of care. She was
discharged without antibiotics.
.
[**Month/Day/Year **] ISSUES
#Multiple sclerosis:
Long history of MS (14 years), quite debilitated, now
experiencing dementia. The patient's home baclofen and
cyclobenzaprine were continued while inpatient.
.
#COPD:
The patient had a history of COPD with nknown baseline status.
It was reported that the patient uses home O2 at unknown rate.
She was continued on her ipratropium and fluticasone at home
doses and she was given O2 by nasal canula as needed.
.
#Depression:
Patient has [**Month/Day/Year **] depression and has been on SSRI at home.
This was continued while inpatient.
.
TRANSITIONAL ISSUES
- Hospice care to be initiated once patient at [**Location (un) 583**] [**Hospital1 1501**]

Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from  [**Hospital1 1501**] documentation.
1. Sertraline 100 mg PO DAILY
2. Baclofen 10 mg PO BID
3. carBAMazepine *NF* 300 mg Oral [**Hospital1 **]
4. Cyclobenzaprine 10 mg PO BID
5. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
6. Ipratropium Bromide Neb 1 NEB IH Q6H
7. methenamine hippurate *NF* 1 gram Oral [**Hospital1 **]
8. Simvastatin 20 mg PO DAILY
9. Acetaminophen 1000 mg PO Q8H:PRN pain
10. Bisacodyl 10 mg PR DAILY:PRN constipation
11. cranberry ext-C-L. sporogenes *NF* [**Medical Record Number 18595**] mg-mg-million
Oral daily
12. Docusate Sodium 100 mg PO BID
13. Senna 1 TAB PO BID:PRN constipation


Discharge Medications:
1. Morphine Sulfate (Concentrated Oral Soln) 5-15 mg PO Q2H:PRN
pain
2. OLANZapine (Disintegrating Tablet) 2.5-5 mg PO DAILY:PRN
agitation
3. Acetaminophen 1000 mg PO Q8H:PRN pain
4. carBAMazepine *NF* 300 mg Oral [**Hospital1 **]
5. cranberry ext-C-L. sporogenes *NF* [**Medical Record Number 18595**] mg-mg-million
Oral daily
6. methenamine hippurate *NF* 1 gram Oral [**Hospital1 **]
7. Sertraline 100 mg PO DAILY
8. Senna 1 TAB PO BID:PRN constipation
9. Bisacodyl 10 mg PR DAILY:PRN constipation
10. Baclofen 10 mg PO BID
11. Cyclobenzaprine 10 mg PO BID
12. Docusate Sodium 100 mg PO BID
13. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
14. Ipratropium Bromide Neb 1 NEB IH Q6H


Discharge Disposition:
Extended Care

Facility:
[**Location (un) 583**] House Rehab & Nursing Center

Discharge Diagnosis:
Primary diagnoses:
Urosepsis
L UVJ calculus causing obstruction s/p nephrostomy
Neurogenic bladder s/p indwelling foley catheter

Secondary diagnoses:
Multiple sclerosis
Advancing dementia


Discharge Condition:
Mental status: responds to questions, limited speech
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.


Discharge Instructions:
Ms. [**Known lastname **],

You were admitted with infections in your urinary tract that
causes your blood pressure to be low. You were given antibiotics
and feedings by tube while you were here. You, your husband, and
the medical team discussed your goals of care. It was decided
that we would make you as comfortable as possible before
discharging you back to [**Location (un) 583**] House.

You are being discharged to a nursing facility. Please follow-up
with the physician there or your PCP.


Completed by:[**2119-7-19**]
{'Infection and inflammatory reaction due to indwelling urinary catheter,Unspecified septicemia,Septic shock,Pressure ulcer, stage III,Severe sepsis,Urinary tract infection, site not specified,Other and unspecified Escherichia coli [E. coli],Calculus of kidney,Multiple sclerosis,Neurogenic bladder NOS,Dementia, unspecified, without behavioral disturbance,Chronic airway obstruction, not elsewhere classified,Anxiety state, unspecified,Osteoporosis, unspecified,Depressive disorder, not elsewhere classified,Other artificial opening of urinary tract status,Personal history of traumatic fracture,Other dependence on machines, supplemental oxygen,Personal history of tobacco use,Do not resuscitate status,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Urinary catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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: Ms. [**Known lastname **] is a 65 year old female with history of multiple
sclerosis, dementia, neurogenic bladder with indwelling foley,
right staghorn calculus, left obstructing UVJ stone with
nephrostomy tube presented from [**Hospital1 1501**] with worsening lethargy and
no output from nephrostomy tube for the two days prior to
admission. The patient was also reported to have been satting at
77% on NBR when EMS arrived. The patient has been admitted three
times in the past year with urosepsis.

MEDICAL HISTORY: Multiple Sclerosis - about 14yrs, followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Location (un) 2274**]
 - wheelchair at baseline, lives in nursing home
 - has no use of her lower extremities, sometimes spastic
movements
 - bladder chronically contracted
UTI with ESBL E.coli--sensitive to zosyn, [**Last Name (un) 2830**], gent in past
[**Last Name (un) 8304**] Depression
Anxiety
PVD s/p lower extremity bypass
COPD
Osteoporosis
Hx of +PPD
bilateral femur supracondylar fractures [**2113**]
hx of Urosepsis - hospitalized about once/yr, per husband
Neurogenic bladder - indwelling foley x [**4-27**] [**Last Name (LF) 1686**], [**First Name3 (LF) **] husband
Recurrent C. Diff
Hx of Sacral Decub
LE spasticity
Hx of jaw pain -- ?TMJ, improved on [**First Name3 (LF) **]

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from  [**Hospital1 1501**] documentation.
1. Sertraline 100 mg PO DAILY
2. Baclofen 10 mg PO BID
3. carBAMazepine *NF* 300 mg Oral [**Hospital1 **]
4. Cyclobenzaprine 10 mg PO BID
5. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
6. Ipratropium Bromide Neb 1 NEB IH Q6H
7. methenamine hippurate *NF* 1 gram Oral [**Hospital1 **]
8. Simvastatin 20 mg PO DAILY
9. Acetaminophen 1000 mg PO Q8H:PRN pain
10. Bisacodyl 10 mg PR DAILY:PRN constipation
11. cranberry ext-C-L. sporogenes *NF* [**Medical Record Number 18595**] mg-mg-million
Oral daily
12. Docusate Sodium 100 mg PO BID
13. Senna 1 TAB PO BID:PRN constipation

ALLERGIES: Zosyn / ceftriaxone / tuberculin ppd skin test

PHYSICAL EXAM: Physical Exam on Admission:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
Physical Exam on Discharge
VS: RR16-18
Gen: Debilitated female in no acute distress
HEENT: EOMI with horizontal nystagmus, MMM
CV: RRR, no m/g/r
Resp: anterolateral exam limited, CTAB, no w/r/r
GU: Foley, nephrostomy in place, clear yellow urine
Neuro: unable to assess due to pt dementia/decompensation
MSK: unable to assess due to pt dementia/decompensation

FAMILY HISTORY: No family members with Multiple Sclerosis.

SOCIAL HISTORY: Lives in nursing home for last 4 [**First Name3 (LF) 1686**].  Husband is HCP, lives
with one of their daughters.  [**Name (NI) **] daughter married and lives
in the area.  Nonambulatory and in wheelchair at baseline,
dependent for transfers and some of ADLs.  Has no use of lower
extremities at baseline.  On pureed thickened liquids at rehab. 

### Response:
{'Infection and inflammatory reaction due to indwelling urinary catheter,Unspecified septicemia,Septic shock,Pressure ulcer, stage III,Severe sepsis,Urinary tract infection, site not specified,Other and unspecified Escherichia coli [E. coli],Calculus of kidney,Multiple sclerosis,Neurogenic bladder NOS,Dementia, unspecified, without behavioral disturbance,Chronic airway obstruction, not elsewhere classified,Anxiety state, unspecified,Osteoporosis, unspecified,Depressive disorder, not elsewhere classified,Other artificial opening of urinary tract status,Personal history of traumatic fracture,Other dependence on machines, supplemental oxygen,Personal history of tobacco use,Do not resuscitate status,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Urinary catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
