CHIEF COMPLAINT: lethargy, N/V

PRESENT ILLNESS: 87 yo F with a history of hypertension and recent weight loss,
who was brought by EMS to the [**Hospital1 18**] ED after her sister called
having diarrhea with black stools, and some blood, and having
body aches; "not able to drink, too weak to speak."
.
Ms [**Known lastname 13060**] is an uncertain and likely quite unreliable historian,
but does affirm that she has been feeling poorly recently and
that she has had some nausea and vomiting. She denies any
shortness of breath or chest pain; she denies current abdominal
pain; she denies current fever or chills and does not remember
any febrile symptoms recently.
.
In the ED, her vitals were initially T 99, HR 87, BP 151/68, O2
sat 96% but within a half hour of arrival her T was 103, then
100.9 one hour after that. A CXR was significant for a patchy
opacity in the R middle and lower lobes; UA was negative; had
"brown stool, guiaic +++". She was given levaquin 750 mg IV X 1,
CTX 1 gm X 1, and flagyl 500 mg IV X 1.
.
.

MEDICAL HISTORY: 1. Hypertension
2. Guaiac positive stool - pt has been refusing colonoscopy
3. Weight loss- PCP concerned about an underlying malignancy but
pt did not desire extensive workup.
4. Numbness in feet- Concern for peripheral neuropathy.
5. S/P removal of melanoma- Pt is unclear regarding the date of

MEDICATION ON ADMISSION: ocuvite tab, 2 tablets PO BID
acetaminophen-codeine 300-30, 1 tab PO q4-6hrs PRN pain
amoxicillin 500 mg, 4 tabs PO before any dental procedure
hydrocortisone 2.5% rectal cream [**Hospital1 **]
norvasc 10 mg PO daily
toprol XL 50 mg PO daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: BP 168/62
HR 88
RR 27
O2 sat 98% 2L NC
Gen - Thin/cachectic elderly woman, staring up at ceiling
HEENT - Dry mucus membranes and tongue, no lesions of OP
Neck - No JVP appreciated
CV - RRR, low-pitched systolic murmur heard best at L sternal
border
Lungs - +egophony, diminished breath sounds in middle of R lung
field, crackles at bases bilaterally, R>L
Abd - Non-tender, non-distended, some masses ?stool
Ext - No edema, WWP
Neuro - Oriented to place but not time; tangential, vague,
confabulates some answers; pleasant
Skin - Multiple keratoses, most strikingly on lower legs
bilaterally

FAMILY HISTORY: NC

SOCIAL HISTORY: Pt is a retired middle school English teacher. She lives with
her sister [**Name (NI) **], and has a regular caretaker, [**Name (NI) **], who helps her
with ADLs including getting dressed. No ETOH, tobacco, or drugs.
Her PCP is [**Last Name (NamePattern4) **]. [**First Name (STitle) **]. Pt reaffirms with us today that she
wishes to be DNR/DNI, which is also reflected in past notes.
Septicemia due to escherichia coli [E. coli],Pneumonia, organism unspecified,Hypopotassemia,Blood in stool,Unspecified protein-calorie malnutrition,Sepsis,Unspecified essential hypertension,Other alteration of consciousness
E coli septicemia,Pneumonia, organism NOS,Hypopotassemia,Blood in stool,Protein-cal malnutr NOS,Sepsis,Hypertension NOS,Other alter consciousnes
Admission Date:  [**2176-3-10**]              Discharge Date:   [**2176-3-19**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
lethargy, N/V

Major Surgical or Invasive Procedure:
none


History of Present Illness:
87 yo F with a history of hypertension and recent weight loss,
who was brought by EMS to the [**Hospital1 18**] ED after her sister called
having diarrhea with black stools, and some blood, and having
body aches; "not able to drink, too weak to speak."
.
Ms [**Known lastname 13060**] is an uncertain and likely quite unreliable historian,
but does affirm that she has been feeling poorly recently and
that she has had some nausea and vomiting. She denies any
shortness of breath or chest pain; she denies current abdominal
pain; she denies current fever or chills and does not remember
any febrile symptoms recently.
.
In the ED, her vitals were initially T 99, HR 87, BP 151/68, O2
sat 96% but within a half hour of arrival her T was 103, then
100.9 one hour after that. A CXR was significant for a patchy
opacity in the R middle and lower lobes; UA was negative; had
"brown stool, guiaic +++". She was given levaquin 750 mg IV X 1,
CTX 1 gm X 1, and flagyl 500 mg IV X 1.
.
.


Past Medical History:
1. Hypertension
2. Guaiac positive stool - pt has been refusing colonoscopy
3. Weight loss- PCP concerned about an underlying malignancy but
pt did not desire extensive workup.
4. Numbness in feet- Concern for peripheral neuropathy.
5. S/P removal of melanoma- Pt is unclear regarding the date of

this removal.
6. S/P umbilical hernia repair
7. Arthritis
8. S/P multiple falls
9. Macular degeneration
.


Social History:
Pt is a retired middle school English teacher. She lives with
her sister [**Name (NI) **], and has a regular caretaker, [**Name (NI) **], who helps her
with ADLs including getting dressed. No ETOH, tobacco, or drugs.
Her PCP is [**Last Name (NamePattern4) **]. [**First Name (STitle) **]. Pt reaffirms with us today that she
wishes to be DNR/DNI, which is also reflected in past notes.


Family History:
NC

Physical Exam:
BP 168/62
HR 88
RR 27
O2 sat 98% 2L NC
Gen - Thin/cachectic elderly woman, staring up at ceiling
HEENT - Dry mucus membranes and tongue, no lesions of OP
Neck - No JVP appreciated
CV - RRR, low-pitched systolic murmur heard best at L sternal
border
Lungs - +egophony, diminished breath sounds in middle of R lung
field, crackles at bases bilaterally, R>L
Abd - Non-tender, non-distended, some masses ?stool
Ext - No edema, WWP
Neuro - Oriented to place but not time; tangential, vague,
confabulates some answers; pleasant
Skin - Multiple keratoses, most strikingly on lower legs
bilaterally


Pertinent Results:
[**2176-3-19**] 07:40AM BLOOD WBC-7.6 RBC-3.11* Hgb-10.3* Hct-29.6*
MCV-95 MCH-33.1* MCHC-34.8 RDW-13.2 Plt Ct-472*
[**2176-3-17**] 08:12AM BLOOD WBC-9.6 RBC-3.61* Hgb-12.1 Hct-34.6*
MCV-96 MCH-33.5* MCHC-34.9 RDW-13.0 Plt Ct-456*
[**2176-3-12**] 07:05AM BLOOD WBC-15.4* RBC-3.34* Hgb-11.5* Hct-35.0*
MCV-97 MCH-34.4* MCHC-35.5* RDW-13.5 Plt Ct-203
[**2176-3-10**] 01:30PM BLOOD WBC-13.5*# RBC-4.16* Hgb-14.8 Hct-42.1
MCV-94 MCH-35.7* MCHC-35.1* RDW-14.1 Plt Ct-245
[**2176-3-17**] 08:12AM BLOOD Neuts-80.3* Bands-0 Lymphs-14.1*
Monos-2.8 Eos-2.6 Baso-0.1
[**2176-3-19**] 07:40AM BLOOD Plt Ct-472*
[**2176-3-19**] 07:40AM BLOOD Glucose-105 UreaN-15 Creat-0.6 Na-140
K-4.2 Cl-101 HCO3-34* AnGap-9
[**2176-3-11**] 03:54AM BLOOD ALT-10 AST-20 LD(LDH)-272* AlkPhos-49
Amylase-54 TotBili-0.6
[**2176-3-11**] 03:54AM BLOOD Lipase-12
[**2176-3-19**] 07:40AM BLOOD Phos-3.2 Mg-2.0
[**2176-3-10**] 01:57PM BLOOD Lactate-2.7*
[**2176-3-11**] 11:37AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.013
[**2176-3-11**] 11:37AM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2176-3-11**] 11:37AM URINE RBC-2 WBC-4 Bacteri-FEW Yeast-NONE Epi-1
TransE-<1
[**2176-3-11**] 11:37AM URINE CastGr-3*

[**2176-3-10**] 1:30 pm BLOOD CULTURE

                            **FINAL REPORT [**2176-3-13**]**

   Blood Culture, Routine (Final [**2176-3-13**]):
      ESCHERICHIA COLI.    FINAL SENSITIVITIES.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ESCHERICHIA COLI
                             |
AMPICILLIN------------   <=2 S
AMPICILLIN/SULBACTAM--   <=2 S
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CEFUROXIME------------     4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN----------   <=4 S
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S

   Anaerobic Bottle Gram Stain (Final [**2176-3-11**]):
      REPORTED BY PHONE TO [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 25581**], R.N. ON [**2176-3-11**] AT 0400.

      GRAM NEGATIVE RODS.

VIDEO FLUOROSCOPIC SWALLOWING EVALUATION: In collaboration with
the speech and pathology department, an oropharyngeal swallowing
evaluation was performed. Barium of various consistencies was
administered orally to the patient under continuous video
fluoroscopy.

ORAL PHASE: There is moderate reduction in bolus formation,
bolus control, and anterior to posterior tongue movement.
Premature spillover was noted. Moderate residue remained in the
oral cavity following the swallow.

PHARYNGEAL PHASE: There is moderate delay of the pharyngeal
swallow. Palatal elevation and upper esophageal sphincter
relaxation were grossly within normal limits. There is mild
reduction in laryngeal elevation, laryngeal valve closure and
absence of the epiglottic deflection. Mild amount of residue
remained within the valleculae and piriform sinuses.

ASPIRATION/PENETRATION: There was no penetration or aspiration
seen on the examination.

IMPRESSION: Moderate oral and mild-to-moderate pharyngeal
dysphagia. No evidence of aspiration. For further details,
please refer to the speech and pathology report from the same
day.

AP CHEST RADIOGRAPH: Lungs demonstrate patchy opacity within the
right mid and lower lung zone. The heart, mediastinum, and hila
are within normal limits. No pneumothorax or pleural effusion is
detected. The aorta shows atherosclerotic calcification. A left
apical granuloma is stable.

IMPRESSION: Patchy opacity within the right mid and lower lung
zones consistent with pneumonia or aspiration.

Brief Hospital Course:
PNEUMONIA - treated with IV antibiotics and then with po
levofloxacin to finish a 14 days course. Swallow eval as above.
Aspiration precautions and pulmonary toilet/ O2 as needed
recommended.

E coli bacteremia - pansensitive and treated with levofloxacin.
Repeat blood cultures negative.

Delirium - likely from the above issues. Improved with Rx of
infections. Per sister close to baseline at discharge.

GUIAIC-POSITIVE STOOL: History of guiaic positive stool for
which patient has refused work-up, and guiaic positive stool
now, in setting of weight loss. Defer work up to PCP.

Hypertension: Initially meds held and restarted prior to
discharge (Toprol XL, amlodipine). Dose of toprol increased.

Malnutrition: nutrition followed pt for caloric count and
supplements were added. po intake was inconsistent likely due to
delirium. Should get [**2-13**] assistance with meals and nutrition
consult recommended at rehab to ensure patient has appropriate
po intake.

PT evaluated patient and recommended rehab.

CODE: DNR/DNI (confirmed with patient, noted in past notes)
Sister [**Name (NI) **] aware of transfer to rehab.

Medications on Admission:
ocuvite tab, 2 tablets PO BID
acetaminophen-codeine 300-30, 1 tab PO q4-6hrs PRN pain
amoxicillin 500 mg, 4 tabs PO before any dental procedure
hydrocortisone 2.5% rectal cream [**Hospital1 **]
norvasc 10 mg PO daily
toprol XL 50 mg PO daily

Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 7 days. Tablet(s)
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
5. Amoxicillin 500 mg Tablet Sig: Four (4) Tablet PO prior to
dental procedure.
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
7. Ocuvite  Oral
8. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO
every 6-8 hours as needed for pain.
9. Metoprolol XL (Toprol XL) 150 mg PO DAILY


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 599**] of [**Location (un) 55**]

Discharge Diagnosis:
multilobar pneumonia
E coli septicemia
delirium
hypertension, essential, benign
Malnutrition


Discharge Condition:
stable


Discharge Instructions:
You were admitted with multilobar PNA that required initial ICU
care. You were also found to have blood infection. Both will
require that you complete the prescribed course of antibiotics.
Physical theray has recommended rehab for further Physical
therapy as we discussed.


Followup Instructions:
You will need to follow up with Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 250**]
within 1 -2 weeks of discharge from rehab. The physicians at
rehab will care for your further medical needs.
{'Septicemia due to escherichia coli [E. coli],Pneumonia, organism unspecified,Hypopotassemia,Blood in stool,Unspecified protein-calorie malnutrition,Sepsis,Unspecified essential hypertension,Other alteration of consciousness'}


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, N/V

PRESENT ILLNESS: 87 yo F with a history of hypertension and recent weight loss,
who was brought by EMS to the [**Hospital1 18**] ED after her sister called
having diarrhea with black stools, and some blood, and having
body aches; "not able to drink, too weak to speak."
.
Ms [**Known lastname 13060**] is an uncertain and likely quite unreliable historian,
but does affirm that she has been feeling poorly recently and
that she has had some nausea and vomiting. She denies any
shortness of breath or chest pain; she denies current abdominal
pain; she denies current fever or chills and does not remember
any febrile symptoms recently.
.
In the ED, her vitals were initially T 99, HR 87, BP 151/68, O2
sat 96% but within a half hour of arrival her T was 103, then
100.9 one hour after that. A CXR was significant for a patchy
opacity in the R middle and lower lobes; UA was negative; had
"brown stool, guiaic +++". She was given levaquin 750 mg IV X 1,
CTX 1 gm X 1, and flagyl 500 mg IV X 1.
.
.

MEDICAL HISTORY: 1. Hypertension
2. Guaiac positive stool - pt has been refusing colonoscopy
3. Weight loss- PCP concerned about an underlying malignancy but
pt did not desire extensive workup.
4. Numbness in feet- Concern for peripheral neuropathy.
5. S/P removal of melanoma- Pt is unclear regarding the date of

MEDICATION ON ADMISSION: ocuvite tab, 2 tablets PO BID
acetaminophen-codeine 300-30, 1 tab PO q4-6hrs PRN pain
amoxicillin 500 mg, 4 tabs PO before any dental procedure
hydrocortisone 2.5% rectal cream [**Hospital1 **]
norvasc 10 mg PO daily
toprol XL 50 mg PO daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: BP 168/62
HR 88
RR 27
O2 sat 98% 2L NC
Gen - Thin/cachectic elderly woman, staring up at ceiling
HEENT - Dry mucus membranes and tongue, no lesions of OP
Neck - No JVP appreciated
CV - RRR, low-pitched systolic murmur heard best at L sternal
border
Lungs - +egophony, diminished breath sounds in middle of R lung
field, crackles at bases bilaterally, R>L
Abd - Non-tender, non-distended, some masses ?stool
Ext - No edema, WWP
Neuro - Oriented to place but not time; tangential, vague,
confabulates some answers; pleasant
Skin - Multiple keratoses, most strikingly on lower legs
bilaterally

FAMILY HISTORY: NC

SOCIAL HISTORY: Pt is a retired middle school English teacher. She lives with
her sister [**Name (NI) **], and has a regular caretaker, [**Name (NI) **], who helps her
with ADLs including getting dressed. No ETOH, tobacco, or drugs.
Her PCP is [**Last Name (NamePattern4) **]. [**First Name (STitle) **]. Pt reaffirms with us today that she
wishes to be DNR/DNI, which is also reflected in past notes. 

### Response:
{'Septicemia due to escherichia coli [E. coli],Pneumonia, organism unspecified,Hypopotassemia,Blood in stool,Unspecified protein-calorie malnutrition,Sepsis,Unspecified essential hypertension,Other alteration of consciousness'}
