CHIEF COMPLAINT: Hypoxia and delirium

PRESENT ILLNESS: Mr. [**Known lastname 79199**] is a 35 M who was brought to the ED from his sober
house tremulous, somnolent, and with slurred speech. Per report,
he took ten 1 mg pills of Xanax at 4pm on the day prior to
admission and 2 1mg Xanax tablets again on the day of admission,
3 hours prior to presentation.

MEDICAL HISTORY: - Hepatitis C
- Chronic low back pain
- Polysubstance abuse
- Asthma
- Prior history of being stabbed in the chest requiring a
sternotomy and open repair with a synthetic patch. This surgery
was performed at [**Hospital1 2177**].

MEDICATION ON ADMISSION: suboxone 8mg twice daily
gabapentin 800mg four times daily
Motrin as needed for back pain

ALLERGIES: Penicillins / Sulfa (Sulfonamide Antibiotics)

PHYSICAL EXAM: INITIAL PHYSICAL EXAM ON ARRIVAL TO ICU:

FAMILY HISTORY: Not relevant to the current admission.

SOCIAL HISTORY: Smokes 1 pack per day. Denies heavy alcohol use. Admits to
marijuana and heroin use. Reports that he rarely uses cocaine.
Bacterial pneumonia, unspecified,Encephalopathy, unspecified,Cocaine dependence, continuous,Pneumonitis due to inhalation of food or vomitus,Chronic hepatitis C without mention of hepatic coma,Lumbago,Other chronic pain,Asthma, unspecified type, unspecified
Bacterial pneumonia NOS,Encephalopathy NOS,Cocaine depend-contin,Food/vomit pneumonitis,Chrnc hpt C wo hpat coma,Lumbago,Chronic pain NEC,Asthma NOS
Admission Date:  [**2134-4-15**]              Discharge Date:   [**2134-4-21**]

Date of Birth:  [**2099-2-27**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics)

Attending:[**First Name3 (LF) 2758**]
Chief Complaint:
Hypoxia and delirium

Major Surgical or Invasive Procedure:
Hip joint aspirate on [**2134-4-16**]
IR-guided lumbar puncture on [**2134-4-16**]

History of Present Illness:
Mr. [**Known lastname 79199**] is a 35 M who was brought to the ED from his sober
house tremulous, somnolent, and with slurred speech. Per report,
he took ten 1 mg pills of Xanax at 4pm on the day prior to
admission and 2 1mg Xanax tablets again on the day of admission,
3 hours prior to presentation.

In the ED, initial vs were: T 100.4 P 132 BP 165/118 R 26 O2 sat
92%. Initial chest X-ray showed bilateral patchy opacities
greater in the lower lung fields. Patient was given duonebs.
Labs were significant for a WBC of 13.0 with a bandemia of 7%.
Urine tox was positive for benzodiazepines, opiates, and
amphetamines. A right groin central venous catheter was placed.
Given fever and leukocytosis, patient was given Vancomycin and
levofloxacin. Urine and blood cultures were sent. In the ED, he
was also given 3L NS, with improvement of his heart rate. Prior
to transfer to the ICU, the patient spiked a temperature.

On arrival to the ICU, the patient's VS were T 100.8 HR 122 BP
138/61 RR 22 O2 Sat 96% on 2L. He was oriented x 3; however, he
was somnolent with slurred speech and unable to give a complete
history. He admitted to injecting cocaine and heroin prior to
admission. He also admitted to recently drinking beer. He gave
differing stories regarding his Xanax use. He admitted to some
slight shortness of breath and to cough. He also endorsed chest
tightness. He denied any nausea or recent vomiting. He also
endorsed a headache and some neck pain.

Of note, he does report a recent episode of falling on ice. He
endorses some left shoulder pain, knee pain, and right ankle
pain since this fall. It is unclear whether he hit his head in
this fall.

Past Medical History:
- Hepatitis C
- Chronic low back pain
- Polysubstance abuse
- Asthma
- Prior history of being stabbed in the chest requiring a
sternotomy and open repair with a synthetic patch. This surgery
was performed at [**Hospital1 2177**].

Social History:
Smokes 1 pack per day. Denies heavy alcohol use. Admits to
marijuana and heroin use. Reports that he rarely uses cocaine.


Family History:
Not relevant to the current admission.

Physical Exam:
INITIAL PHYSICAL EXAM ON ARRIVAL TO ICU:

Vitals: T: 100.8 BP: 138/61 P: 122 R: 22 O2: 96% on 2L
General: Somnolent, arousable to voice but quickly falls asleep,
oriented x 3
HEENT: Sclera anicteric, dry MM
Neck: supple, JVP not elevated
Lungs: Bilateral crackles, greater in the lower lung fields
CV: Tachycardic, regular 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: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, tenderness of left shoulder, right ankle


Pertinent Results:
ADMISSION LABORATORY STUDIES:
[**2134-4-15**] 12:00PM BLOOD WBC-13.0* RBC-4.99 Hgb-16.3 Hct-47.1
MCV-95 MCH-32.7* MCHC-34.6 RDW-13.0 Plt Ct-222
[**2134-4-15**] 12:00PM BLOOD Glucose-89 UreaN-11 Creat-0.9 Na-139
K-4.4 Cl-103 HCO3-29 AnGap-11
[**2134-4-15**] 12:00PM BLOOD ALT-91* AST-71* LD(LDH)-269* CK(CPK)-187
AlkPhos-88 TotBili-0.6
[**2134-4-15**] 12:17PM BLOOD Lactate-1.7
[**2134-4-15**] 12:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG

OTHER NOTABLE STUDIES:
[**2134-4-16**] 03:20AM BLOOD WBC-22.8*# RBC-4.72 Hgb-15.5 Hct-42.9
MCV-91 MCH-32.8* MCHC-36.0* RDW-12.6 Plt Ct-182
[**2134-4-17**] 03:46AM BLOOD HIV Ab-NEGATIVE
[**2134-4-17**] 03:46AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE
[**2134-4-17**] 03:46AM BLOOD HCV Ab-POSITIVE*

DISCHARGE LABORATORY STUDIES:
[**2134-4-20**] 06:40AM BLOOD WBC-14.7* RBC-4.89 Hgb-15.8 Hct-46.3
MCV-95 MCH-32.3* MCHC-34.1 RDW-12.5 Plt Ct-179
[**2134-4-20**] 06:40AM BLOOD Glucose-85 UreaN-14 Creat-0.9 Na-138
K-4.1 Cl-103 HCO3-27 AnGap-12
[**2134-4-19**] 12:55PM BLOOD ALT-57* AST-43* AlkPhos-54 TotBili-0.4

MICROBIOLOGY:
[**2134-4-15**]  Legionella Urinary Antigen - Negative
[**2134-4-15**]  SPUTUM Culture: SPARSE GROWTH Commensal Respiratory
Flora [**2134-4-15**]  MRSA SCREEN MRSA SCREEN - No MRSA isolated.
[**2134-4-15**]  BLOOD CULTURE - No Growth
[**2134-4-15**]  URINE CULTURE - GRAM POSITIVE RODS~[**2123**]/ML.
[**2134-4-15**]  BLOOD CULTURE - No Growth
[**2134-4-16**]  JOINT FLUID: GRAM STAIN-Negative. No PMNs. No Growth
on Culture.
[**2134-4-16**]  CSF FLUID: GRAM STAIN-Negative. No PMNs. No Growth
on Culture.
[**2134-4-16**]  CSF CRYPTOCOCCAL ANTIGEN - CRYPTOCOCCAL ANTIGEN NOT
DETECTED
[**2134-4-16**]  CSF FLUID: PCR negative for HSV.
[**2134-4-16**]  BLOOD CULTURE - No Growth
[**2134-4-16**]  Influenza Swab: DIRECT INFLUENZA A ANTIGEN TEST
Negative for Influenza A. DIRECT INFLUENZA B ANTIGEN TEST
Negative for Influenza B.
[**2134-4-17**]  SPUTUM Culture: RARE GROWTH of commensal respiratory
flora and SPARSE GROWTH of yeast with TWO COLONIAL MORPHOLOGIES.

RADIOLOGY:
[**2134-4-15**] Portable Chest X-Ray:
1. Underpenetrated exam, presumably from patient body habitus.
2. Low lung volumes with suggestion of patchy bilateral
mid-to-lower lung opacities, which may in part relate to low
lung volumes and technique, however, multifocal infection or
edema are also a consideration depending on clinical situation.
Followup recommended and if clinically feasible, PA and lateral
views for further and better evaluation. 3. Status post median
sternotomy. Mild enlargement of the cardiac silhouette.

[**2134-4-15**] CT Head:
No definite acute intracranial process is seen. If high clinical
concern for meningitis or acute ischemia, consider MRI if
patient is able to cooperate.

[**2134-4-16**] Left Hip Plain Film: No acute abnormality. If there is
concern for a joint effusion, recommend further evaluation with
MRI.

[**2134-4-16**] CT Left Lower Extremities without contrast: No acute
abnormalities. Specifically, no evidence of osteomyelitis, hip
joint
effusion, or necrotizing fasciitis.

[**2134-4-16**] CT of the Chest, Abdomen, and Pelvis: Suboptimal timing
of the IV bolus (no peripheral line available, femoral line was
hand injected by radiologist). 1. Multifocal ground-glass lung
opacities, worse on the left, concerning for multifocal
pneumonia in appropriate clinical setting. 2. Bibasilar
opacities, more confluent, could be bibasilar atelectasis;
however, cannot exclude aspiration. 3. Moderate cardiomegaly. 4.
Small amount of free fluid in the pelvis. 5. Left renal cyst
with probable dependent punctate stones in the interpolar region
of the left kidney. No hydronephrosis. 6. Possible fatty liver,
difficult to assess with certainty post-contrast.

[**2134-4-20**] TTE: The left atrium is normal in size. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF 65%). Tissue Doppler imaging suggests a
normal left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The aortic
arch is mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. No masses or vegetations are
seen on the aortic valve. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. No mass or vegetation is seen on the mitral
valve. The pulmonary artery systolic pressure could not be
determined. No vegetation/mass is seen on the pulmonic valve.
There is no pericardial effusion. If clinically indicated, a
transesophageal echocardiographic examination is recommended to
exclude vegetation. IMPRESSION: no vegetations seen


Brief Hospital Course:
Mr. [**Known lastname 79199**] is a 35 year-old male with a medical history notable
for polysubstance abuse and hepatitis C. He presented with
fevers, somnolence, and hypoxia in the setting of having taking
at least cocaine, heroin, and Xanax prior to admission. He was
initially admitted to the ICU and underwent a broad infectious
evaluation that included influenza swabs, a lumbar puncture,
aspiration of his left hip, and imaging of his heart, chest,
abdomen, pelvis, and left hip/lower extremity. The left hip and
leg were evaluated as he developed a rapidly progressive rash on
his left hip shortly after admission concerning for an infected
joint and/or necrotizing fascitis. This ultimately proved to be
non-infectious and resolved without further intervention.

He was initially treated with broad-spectrum antibiotics
including treatment for pneumonia, necrotizing fasciitis,
meningitis, and herpes encephalitis. Each treatment was slowly
discontinued as his above evaluation returned negative.

Ultimately, he likely had either an aspiration pneumonitis or
bacterial community-acquired pneumonia in the setting of
polysubstance abuse. He will complete a 7-day course of
levofloxacin/moxifloxacin for community-acquired pneumonia and
return to treatment for his polysubstance abuse. Management of
specific problems outlined below.

1. Aspiration pneumonitis and/or bacterial community-acquired
pneumonia
 - complete 7 days of antibiotics on [**2134-4-22**]. Received
levofloxacin as an inpatient and will complete moxifloxacin as
an outpatient.

2. Polysubstance abuse
 - will return to his sober house in [**Location (un) 669**]
 - he receives his Suboxone through New Horizons in [**Location (un) **]
and will be seeing them on the day of discharge at 11am
 - starting to see a new psychiatrist (name unknown) in [**Hospital1 392**],
MA

3. Chronic low back pain
 - He has a history of chronic opioid abuse. In an attempt to
avoid NSAIDs and Tylenol (to monitor fever curve) he initially
received small doses of morphine to control his back pain. He
was eventually restarted on his home gabapentin and the morphine
was discontinued prior to discharge.

There were no changes made to his medications and he will
follow-up with Dr. [**Last Name (STitle) 75650**] (an infectious disease doctor) as he
has no current PCP and his new psychiatrist. There were no tests
pending at discharge.


Medications on Admission:
suboxone 8mg twice daily
gabapentin 800mg four times daily
Motrin as needed for back pain


Discharge Medications:
1. gabapentin 400 mg Capsule Sig: Two (2) Capsule PO four times
a day.
2. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for back pain.
3. moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days: first dose on [**4-21**] and last dose 3/17.
Disp:*2 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
pneumonia
polysubstance abuse


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Lungs were clear to auscultation and oxygen saturations of 97%
on room air.

Discharge Instructions:
Dear Mr. [**Known lastname 79199**],

You were admitted with fever and confusion. We think this was
from drugs you took and a pneumonia. You are slowly improving on
antibiotics and you should continue to take them with your next
dose on [**4-21**] and your last dose on [**4-22**].

You should also continue your gabapentin for your back pain. You
have follow-up arranged with the New Horizons in [**Location (un) **] on
[**4-21**] to restart your Suboxone therapy. We made no other changes
to your medications.

You should also stop smoking. It is one of the most important
things you can do for your health.


Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) 1955**] J.
Address: [**Location (un) 79200**], [**Apartment Address(1) **], [**Location (un) **],[**Numeric Identifier 31449**]
Phone: [**Telephone/Fax (1) 79201**]
Appt: We have notified Dr. [**Last Name (STitle) 75650**] that you need a follow up
appt with in the next week from your hospital stay.  We have
instructed them to call you at home with an appt.  If you dont
hear from them by Thursday, please call them directly to book
one.
{'Bacterial pneumonia, unspecified,Encephalopathy, unspecified,Cocaine dependence, continuous,Pneumonitis due to inhalation of food or vomitus,Chronic hepatitis C without mention of hepatic coma,Lumbago,Other chronic pain,Asthma, unspecified type, unspecified'}


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: Hypoxia and delirium

PRESENT ILLNESS: Mr. [**Known lastname 79199**] is a 35 M who was brought to the ED from his sober
house tremulous, somnolent, and with slurred speech. Per report,
he took ten 1 mg pills of Xanax at 4pm on the day prior to
admission and 2 1mg Xanax tablets again on the day of admission,
3 hours prior to presentation.

MEDICAL HISTORY: - Hepatitis C
- Chronic low back pain
- Polysubstance abuse
- Asthma
- Prior history of being stabbed in the chest requiring a
sternotomy and open repair with a synthetic patch. This surgery
was performed at [**Hospital1 2177**].

MEDICATION ON ADMISSION: suboxone 8mg twice daily
gabapentin 800mg four times daily
Motrin as needed for back pain

ALLERGIES: Penicillins / Sulfa (Sulfonamide Antibiotics)

PHYSICAL EXAM: INITIAL PHYSICAL EXAM ON ARRIVAL TO ICU:

FAMILY HISTORY: Not relevant to the current admission.

SOCIAL HISTORY: Smokes 1 pack per day. Denies heavy alcohol use. Admits to
marijuana and heroin use. Reports that he rarely uses cocaine. 

### Response:
{'Bacterial pneumonia, unspecified,Encephalopathy, unspecified,Cocaine dependence, continuous,Pneumonitis due to inhalation of food or vomitus,Chronic hepatitis C without mention of hepatic coma,Lumbago,Other chronic pain,Asthma, unspecified type, unspecified'}
