CHIEF COMPLAINT: rigors, fever

PRESENT ILLNESS: Ms. [**Known lastname **] is an 80 y/o F with a h/o E. coli urosepsis, dementia
and HTN, who developed rigors while getting an EGD this morning
for abdominal pain and f/u of known ulcer. Her fever was noted
to be 103, and she was sent to the ED. She denied CP, N/V, HA;
she initially had some abd pain after the provcedure but that
has now resolved. She received demerol, fentanyl and versed
during the EGD.
.
In the ED, VS were T 103.4 PO, HR 100, BP 134/66, RR 18, satting
97% 2LNC. Lactate was noted to be 5.8; she then received 3L NS
for presumed sepsis, and her lactate improved to 1.9. She was
tachycardic to 87-100 but was never hypotensive (SBP 110 - 160
in the ED). CXR was negative for PNA, and abd CT was negative
for perforation. UA was positive for LE and 21-50 WBC's. She was
given levo, flagyl, ampicillin and Tylenol.
.
Of note, the patient has been c/o right sided HA with ESR 100
and WBC ~ 15 on [**6-11**], concerning for temporal arteritis. Her PCP
scheduled her to have a biopsy on [**6-14**], and she is supposed to
be taking prednisone 40 mg PO QD. She also had a UCx from [**6-8**],
presumably ordered by her OB, which showed E. coli. It is
uncertain whether she was put on any abx for this culture
(according to her son, she was not). The patient is a poor
historian due to her dementia.

MEDICAL HISTORY: Dementia
Stroke
Seizure d/o
CAD
HTN
Hyperlipidemia
Small sliding hiatal hernia-- per EGD on [**6-12**]
Urosepsis-- admitted in [**6-4**]; was on Zosyn and then cipro for tx

MEDICATION ON ADMISSION: Aspirin 81 mg
Prednisone 40 mg-- started [**6-11**]
Lotrel 5/40 QD (amlodipine/benzapril)
HCTZ 12.5 mg QD
Simvastatin 40 mg QD
Paroxetine 10 mg QD
Toprol XL 25 mg QHS
donezapil

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: General Appearance: Thin
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Resonant : ), (Breath Sounds: Diminished: )
Abdominal: Soft
Extremities: Right: Trace, Left: Trace
Skin:  Not assessed
Neurologic: Attentive, Responds to: Not assessed, Movement: Not
assessed, Tone: Not assessed

FAMILY HISTORY: NC

SOCIAL HISTORY: Retired, lives with her husband and son. [**Name (NI) **] smoking, EtoH,
ilicits.
Bacteremia,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Hyperosmolality and/or hypernatremia,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction,Unspecified essential hypertension,Other persistent mental disorders due to conditions classified elsewhere,Epilepsy, unspecified, without mention of intractable epilepsy,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia
Bacteremia,Acute kidney failure NOS,Urin tract infection NOS,Hyperosmolality,Gstr/ddnts NOS w/o hmrhg,Stomach ulcer NOS,Hypertension NOS,Mental disor NEC oth dis,Epilep NOS w/o intr epil,Crnry athrscl natve vssl,Hyperlipidemia NEC/NOS
Admission Date:  [**2142-6-12**]              Discharge Date:   [**2142-6-16**]

Date of Birth:  [**2062-6-11**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 4654**]
Chief Complaint:
rigors, fever

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Ms. [**Known lastname **] is an 80 y/o F with a h/o E. coli urosepsis, dementia
and HTN, who developed rigors while getting an EGD this morning
for abdominal pain and f/u of known ulcer. Her fever was noted
to be 103, and she was sent to the ED. She denied CP, N/V, HA;
she initially had some abd pain after the provcedure but that
has now resolved. She received demerol, fentanyl and versed
during the EGD.
.
In the ED, VS were T 103.4 PO, HR 100, BP 134/66, RR 18, satting
97% 2LNC. Lactate was noted to be 5.8; she then received 3L NS
for presumed sepsis, and her lactate improved to 1.9. She was
tachycardic to 87-100 but was never hypotensive (SBP 110 - 160
in the ED). CXR was negative for PNA, and abd CT was negative
for perforation. UA was positive for LE and 21-50 WBC's. She was
given levo, flagyl, ampicillin and Tylenol.
.
Of note, the patient has been c/o right sided HA with ESR 100
and WBC ~ 15 on [**6-11**], concerning for temporal arteritis. Her PCP
scheduled her to have a biopsy on [**6-14**], and she is supposed to
be taking prednisone 40 mg PO QD. She also had a UCx from [**6-8**],
presumably ordered by her OB, which showed E. coli. It is
uncertain whether she was put on any abx for this culture
(according to her son, she was not). The patient is a poor
historian due to her dementia.


Past Medical History:
Dementia
Stroke
Seizure d/o
CAD
HTN
Hyperlipidemia
Small sliding hiatal hernia-- per EGD on [**6-12**]
Urosepsis-- admitted in [**6-4**]; was on Zosyn and then cipro for tx

s/p TAHBSO
h/o vaginal prolapse and vaginal pessary
h/o R central retinal vein occlusion


Social History:
Retired, lives with her husband and son. [**Name (NI) **] smoking, EtoH,
ilicits.

Family History:
NC

Physical Exam:
General Appearance: Thin
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Resonant : ), (Breath Sounds: Diminished: )
Abdominal: Soft
Extremities: Right: Trace, Left: Trace
Skin:  Not assessed
Neurologic: Attentive, Responds to: Not assessed, Movement: Not
assessed, Tone: Not assessed


Pertinent Results:
[**2142-6-12**] CT ABD/PELV: 1. No evidence of perforation,
intra-abdominal fluid collection or contrast extravasation.
2. Multiple prominent mediastinal and axillary lymph nodes
measuring up to 6 mm in short axis not meeting CT criteria for
pathologic enlargement.
3. Bilateral diffuse thickening of the adrenals without
associated discrete masses, could represent adrenal hyperplasia.
Clinical correlation is recommended.
.
[**2142-6-12**] Endoscopy:
Impression: Small hiatal hernia (biopsy)
Friability and erythema in the antrum compatible with gastritis
(biopsy)
Ulcer in the antrum (biopsy)
Granularity, friability, erythema and congestion in the duodenal
bulb compatible with duodenitis (biopsy)
Diverticulum in the post bulbar
Otherwise normal EGD to third part of the duodenum
Recommendations: follow-up biopsy results
Pantoprozole 40 mgm twice daily for one month, then once daily
Repeat EGD in 2 months.Stop aspirin
.
[**2142-6-11**] 04:40PM   WBC-15.8*# RBC-4.15* HGB-12.9 HCT-37.5 MCV-91
MCH-31.1 MCHC-34.4 RDW-12.7
[**2142-6-11**] 04:40PM   PLT COUNT-329
[**2142-6-11**] 04:40PM   SED RATE-108*
[**2142-6-11**] 04:40PM   TSH-1.4
[**2142-6-11**] 04:40PM   ALT(SGPT)-15 AST(SGOT)-19 ALK PHOS-106
[**2142-6-11**] 04:40PM   ALBUMIN-4.1 CALCIUM-9.9 CHOLEST-160
[**2142-6-11**] 04:40PM   HDL CHOL-52 CHOL/HDL-3.1
[**2142-6-11**] 04:40PM   UREA N-48* CREAT-2.2* SODIUM-142
POTASSIUM-3.0* CHLORIDE-98 TOTAL CO2-27 ANION GAP-20
[**2142-6-12**] 03:41PM   LACTATE-5.8*
[**2142-6-12**] 03:30PM   GLUCOSE-194* UREA N-64* CREAT-2.7*
SODIUM-147* POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-23 ANION
GAP-25*

Brief Hospital Course:
1. Urosepsis/E. Coli Bacteremia: Reason for admission, quickly
responded to IVF with SBP not lower than 100, was
hemodynamically stable through out time once arrived on floor.
E.coli isolated from urine culture [**2142-6-8**], pan-sensitive (with
exception of ampicillin), blood cultures from this admission
([**6-12**]) positive with 4/4 bottles for E. Coli with same profile.
SBP never dropped below 100 and was fluid-responsive. She did
not require central venous access or pressors. She was treated
with IVF and ceftriaxone initially. Initial lactate of 5.8 was
recheked and was 1.9. She also had CT abdomen/pelvis on
admission which did not show any alternate source of infection.
Pt remained afebrile for 48h, antibiotic were changed to po
Cipro, and monitored for another 24h to assure defervence (pt
remained stable/afebrile/[**Month/Year (2) 6060**]). Plan for 14 day treatment course
for E. Coli bacteremia.  Discussed case with PCP, [**Name10 (NameIs) 6217**] is
already following the patient as an outpt with care again
coordinated by PCP.  [**Name10 (NameIs) **] will have PCP f/u next tuesday [**2142-6-19**],
(also pt's Gastroenterologist).
<br>
2. PUD/gastritis: noted on EGD [**2142-6-12**], which was done to
investigate her recent symptoms of abdominal pain. Does have a
h/o ulcer disease. Biopsies taken at time of EGD are still
pending at time of d/c. Pt cont to be tx with PPI [**Hospital1 **], and
instructed by PCP/GI to hold ASA.
<br>
3.  Right temporal headache: Concerning for temporal arteritis
per pt's PCP with elevated ESR - pt was started on prednison
prior to admission.  Given pt presented with bacteremia, d/w PCP
impression of initial presentation as pt [**Name (NI) 6060**] when evaluated on
floor (pt was continued on prednisone while in unit), PCP noted
more chronic HA and lower suspicion - decision to d/c prednisone
then once on floor - pt remained [**Name (NI) 6060**] rest of admission without
HA/visual changes.  Pt will f/u with PCP this tuesday and be
re-evaluted for need for future bx.
<br>
4. Acute on Chronic RF/Hypernatremia: Unclear baseline, more
likely around 1.4-1.6, but Cr improved with volume repletion,
c/w pre-renal physiology in the setting of sepsis. Was never
profoundly hypotensive to create an ATN-type picture. Pt at time
of d/c had stable Cr for >48h and lytes were stable at time of
d/c.  Na initially elevated, also responded to IVF - resolved
hypovolemic hypernatremia.
<br>
5. Hypertension: Antihypertensives were held on admission due to
mild hypotension. BP began to rise- pt re-started on home meds
with exception of ace-i given ARF - BP mildly elevated at time
of d/c at 149/90.  Renal fx stable as above, pt instructed to
re-start all home meds including ace-i as taken prior.  HR
mostly in 60s at time of d/c, PCP to [**Name Initial (PRE) **]/u and add back metoprolol
if indicated.
<br>
6. CAD: Aspirin was discontinued based on EGD findings.  Pt
remained CP free.  BB as above.
<br>
7. Seizure d/o - Cont. keppra
<br>
8. HLP - continued statin.
<br>
9. Dementia - baseline - AA0x3 while on floor, continued
donepezal.  PT evaluated pt prior to d/c, deamed safe for home
ambulation.

Medications on Admission:
Aspirin 81 mg
Prednisone 40 mg-- started [**6-11**]
Lotrel 5/40 QD (amlodipine/benzapril)
HCTZ 12.5 mg QD
Simvastatin 40 mg QD
Paroxetine 10 mg QD
Toprol XL 25 mg QHS
donezapil


Discharge Medications:
1. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) as
needed for gastric ulcer tx.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
8. Lotrel 5-40 mg Capsule Sig: One (1) Capsule PO once a day.


Discharge Disposition:
Home

Discharge Diagnosis:
Primary: E. Coli Bacteremia/Urosepsis/UTI

Secondary:
h/o vaginal prolapse with pessary
Gastric Ulcer
Headaches
Acute on Chronic Renal Failure
Hypernatremia
Hypertension
Depression
CAD


Discharge Condition:
stable


Discharge Instructions:
Please take your anti-biotics for the completion of its course
(another 10days).  F/U with your PCP as below.  Please call your
PCP or return to ED if you start re-developing fevers, abdominal
pain in the next few days.  Please resume your home medications
as listed - note to STOP your aspirin as your have an ulcer, and
holding your metoprolol till seen by your PCP this tuesday (your
HR is fine).  Also do not take your recently prescribed
prednisone until you re-address this medication with your PCP.

Followup Instructions:
1.  Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 172**] (PCP/GI) on [**2142-6-19**].  Please call him at
[**Telephone/Fax (1) 133**] to confirm the time of your appointment.

Provider: [**Name10 (NameIs) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 11793**], MD Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2142-8-8**] 2:00


                             [**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**]

Completed by:[**2142-6-16**]
{'Bacteremia,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Hyperosmolality and/or hypernatremia,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction,Unspecified essential hypertension,Other persistent mental disorders due to conditions classified elsewhere,Epilepsy, unspecified, without mention of intractable epilepsy,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia'}


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: rigors, fever

PRESENT ILLNESS: Ms. [**Known lastname **] is an 80 y/o F with a h/o E. coli urosepsis, dementia
and HTN, who developed rigors while getting an EGD this morning
for abdominal pain and f/u of known ulcer. Her fever was noted
to be 103, and she was sent to the ED. She denied CP, N/V, HA;
she initially had some abd pain after the provcedure but that
has now resolved. She received demerol, fentanyl and versed
during the EGD.
.
In the ED, VS were T 103.4 PO, HR 100, BP 134/66, RR 18, satting
97% 2LNC. Lactate was noted to be 5.8; she then received 3L NS
for presumed sepsis, and her lactate improved to 1.9. She was
tachycardic to 87-100 but was never hypotensive (SBP 110 - 160
in the ED). CXR was negative for PNA, and abd CT was negative
for perforation. UA was positive for LE and 21-50 WBC's. She was
given levo, flagyl, ampicillin and Tylenol.
.
Of note, the patient has been c/o right sided HA with ESR 100
and WBC ~ 15 on [**6-11**], concerning for temporal arteritis. Her PCP
scheduled her to have a biopsy on [**6-14**], and she is supposed to
be taking prednisone 40 mg PO QD. She also had a UCx from [**6-8**],
presumably ordered by her OB, which showed E. coli. It is
uncertain whether she was put on any abx for this culture
(according to her son, she was not). The patient is a poor
historian due to her dementia.

MEDICAL HISTORY: Dementia
Stroke
Seizure d/o
CAD
HTN
Hyperlipidemia
Small sliding hiatal hernia-- per EGD on [**6-12**]
Urosepsis-- admitted in [**6-4**]; was on Zosyn and then cipro for tx

MEDICATION ON ADMISSION: Aspirin 81 mg
Prednisone 40 mg-- started [**6-11**]
Lotrel 5/40 QD (amlodipine/benzapril)
HCTZ 12.5 mg QD
Simvastatin 40 mg QD
Paroxetine 10 mg QD
Toprol XL 25 mg QHS
donezapil

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: General Appearance: Thin
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Resonant : ), (Breath Sounds: Diminished: )
Abdominal: Soft
Extremities: Right: Trace, Left: Trace
Skin:  Not assessed
Neurologic: Attentive, Responds to: Not assessed, Movement: Not
assessed, Tone: Not assessed

FAMILY HISTORY: NC

SOCIAL HISTORY: Retired, lives with her husband and son. [**Name (NI) **] smoking, EtoH,
ilicits. 

### Response:
{'Bacteremia,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Hyperosmolality and/or hypernatremia,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction,Unspecified essential hypertension,Other persistent mental disorders due to conditions classified elsewhere,Epilepsy, unspecified, without mention of intractable epilepsy,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia'}
