CHIEF COMPLAINT: AMS

PRESENT ILLNESS: Mr [**Known lastname 12067**] is a 46 yo man w/ HIV, HCV, polysubstance abuse found
with changes in MS, with fecal incontinence/explosive diarrhea.
All HPI at that time obtained from EMS report, as patient
intubated quickly after arrival for airway protection. Per EMS
report, pt w/ BP 62/P, admitted to using IV heroin, initially
reticent to come to ED for evaluation. After arrival in ED,
agitated with increasing secretions and intubated for airway
protection. Now Mr. [**Name13 (STitle) 429**] is alert and orientated x 3,
conversant. He cannot recall much of the circumstance
surrounding last evening, reports developing moderate and then
explosive diarrhea yesterday afternoon. Again endorses using
heroin yesterday. Denies any other systemic symtems including
fever, chills, SOB, urinary changes. States he had a recent
viral load and CD4 check though nothing is recorded in this
system.

MEDICAL HISTORY: - HIV, last CD4 292, VL >100K in [**5-7**], OI: PCP, [**Name Initial (NameIs) 11395**]. Followed
br Dr. [**Last Name (STitle) **].
- Hepatitis C. grade [**12-4**] liver fibrosis.
- Alcohol abuse. h/o withdrawl seizures, shakes
- ETOH pancreatitis
- HIV nephropathy
- Polysubstance abuse.
- History of Tylenol overdose.
- Peripheral neuropathy and neurogenic bladder.
- CAD s/p stent LCx
- UGI bleed, no EGD done

MEDICATION ON ADMISSION: As stated by patient on transfer:
1. Kaletra [**Hospital1 **]
2. Truvada qAM
3. Klonopin 1 mg TID
4. Lipitor 20 mg qday
5. ASA 325 mg q day
6. Atenolol 100 mg qday
7. Lisinopril 5 mg qday
9. Neurontin 1800 mg qday
As taken from past records from [**2173**], not included above:
1. Indinavir Sulfate 400 mg [**Hospital1 **]
2. Tenofovir Disoproxil Fumarate 300 mg qd
3. Ritonavir 100 mg [**Hospital1 **]
4. Lamivudine 150 mg [**Hospital1 **]

ALLERGIES: Penicillins / Sulfonamides / Tetracyclines

PHYSICAL EXAM: Exam on transfer to the medicine floor, [**2175-5-31**]
.
PE T 98.9 BP 111/67 HR 95 NSR R 14, 99% RA
Gen: pleasant, talkative, NAD
HEENT: MMM, PERRLA, EOMI, sclerae anicter, conjuntiva normal
apprearing.
Neck: Without LAD or noted JVD, R IJ triple lumen in place
Lungs: Diffuse coarse crackle B, no wheeze. Coughing up grey
sputum.
CV: RRR s m/r/g, nl s1/s2
Abd: S/NT/ND. + BS. liver edge 1 cm below costal margin. RLQ
scar from prior app'y noted.
extrm: no edema, pulses 2+ BLE.
skin: no rashes, no erythema
neuro: AOx3, CN 2-12 intact, MAE, neurologic function grossly
intact, MS now appropriate

FAMILY HISTORY: N/C

SOCIAL HISTORY: Patient has a history of heavy alcohol and heroin abuse. Denies
drinking now, used heroin yesterday. Is current smoker. Lives
independently in affiliation with an HIV case management group,
on disability.  Formerly in methadone clinic, "walked off"
shortly prior to admission.
Systemic inflammatory response syndrome due to noninfectious process without acute organ dysfunction,Other shock without mention of trauma,Human immunodeficiency virus [HIV] disease,Unspecified viral hepatitis C without hepatic coma,Opioid type dependence, unspecified,Alcohol abuse, unspecified,Acute kidney failure with lesion of tubular necrosis,Person awaiting admission to adequate facility elsewhere,Other alteration of consciousness,Diarrhea
SIRS-noninf w/o ac or ds,Shock w/o trauma NEC,Human immuno virus dis,Hpt C w/o hepat coma NOS,Opioid dependence-unspec,Alcohol abuse-unspec,Ac kidny fail, tubr necr,Wait adm to oth facility,Other alter consciousnes,Diarrhea
Admission Date:  [**2175-5-28**]              Discharge Date:   [**2175-6-6**]

Date of Birth:  [**2129-3-5**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Sulfonamides / Tetracyclines

Attending:[**First Name3 (LF) 562**]
Chief Complaint:
AMS

Major Surgical or Invasive Procedure:
Lumbar puncture performed on [**2175-6-1**] without complication.


History of Present Illness:
Mr [**Known lastname 12067**] is a 46 yo man w/ HIV, HCV, polysubstance abuse found
with changes in MS, with fecal incontinence/explosive diarrhea.
All HPI at that time obtained from EMS report, as patient
intubated quickly after arrival for airway protection. Per EMS
report, pt w/ BP 62/P, admitted to using IV heroin, initially
reticent to come to ED for evaluation. After arrival in ED,
agitated with increasing secretions and intubated for airway
protection. Now Mr. [**Name13 (STitle) 429**] is alert and orientated x 3,
conversant. He cannot recall much of the circumstance
surrounding last evening, reports developing moderate and then
explosive diarrhea yesterday afternoon. Again endorses using
heroin yesterday. Denies any other systemic symtems including
fever, chills, SOB, urinary changes. States he had a recent
viral load and CD4 check though nothing is recorded in this
system.

Past Medical History:
- HIV, last CD4 292, VL >100K in [**5-7**], OI: PCP, [**Name Initial (NameIs) 11395**]. Followed
br Dr. [**Last Name (STitle) **].
- Hepatitis C. grade [**12-4**] liver fibrosis.
- Alcohol abuse. h/o withdrawl seizures, shakes
- ETOH pancreatitis
- HIV nephropathy
- Polysubstance abuse.
- History of Tylenol overdose.
- Peripheral neuropathy and neurogenic bladder.
- CAD s/p stent LCx
- UGI bleed, no EGD done


Social History:
Patient has a history of heavy alcohol and heroin abuse. Denies
drinking now, used heroin yesterday. Is current smoker. Lives
independently in affiliation with an HIV case management group,
on disability.  Formerly in methadone clinic, "walked off"
shortly prior to admission.

Family History:
N/C

Physical Exam:
Exam on transfer to the medicine floor, [**2175-5-31**]
.
PE T 98.9 BP 111/67 HR 95 NSR R 14, 99% RA
Gen: pleasant, talkative, NAD
HEENT: MMM, PERRLA, EOMI, sclerae anicter, conjuntiva normal
apprearing.
Neck: Without LAD or noted JVD, R IJ triple lumen in place
Lungs: Diffuse coarse crackle B, no wheeze. Coughing up grey
sputum.
CV: RRR s m/r/g, nl s1/s2
Abd: S/NT/ND. + BS. liver edge 1 cm below costal margin. RLQ
scar from prior app'y noted.
extrm: no edema, pulses 2+ BLE.
skin: no rashes, no erythema
neuro: AOx3, CN 2-12 intact, MAE, neurologic function grossly
intact, MS now appropriate


Pertinent Results:
[**2175-5-28**] 07:40PM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-POS
[**2175-5-28**] 07:40PM URINE  COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2175-5-28**] 07:40PM URINE  BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-6.5 LEUK-NEG
[**2175-5-28**] 07:40PM URINE  RBC-[**2-4**]* WBC-[**2-4**] BACTERIA-MOD YEAST-NONE
EPI-[**2-4**] TRANS EPI-[**5-12**]
[**2175-5-28**] 07:40PM URINE  GRANULAR-0-2
[**2175-5-28**] 07:05PM   ALT(SGPT)-27 AST(SGOT)-29 CK(CPK)-298* ALK
PHOS-130* AMYLASE-71 TOT BILI-0.6
[**2175-5-28**] 07:05PM   CK-MB-7 cTropnT-0.06*
[**2175-5-28**] 07:05PM   CALCIUM-9.3 PHOSPHATE-7.5*# MAGNESIUM-1.9
[**2175-5-28**] 07:05PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-POS

Brief Hospital Course:
Patient was admitted intially to the MICU and then transferred
to the floor the next day.
.
1. Hypotension: Though not thought to be sepsic shock, pt was
pan-cultured and also checked for adrenal insufficiency by
CoSyntropin stim test (which was negative). Ingestion of ativan,
heroin, TCA and extreme GI loss postulated to contribute to
hypotension, which was responsive to fluids. Lactate was WNL. R
internal jugular triple lumen and foley were placed, and patient
was intubated for airway protection.  Once transferred out of
the MICU, BPs were appropriate. Eventually pt was restarted on
anti-hypertensives, and was discharged on lisinopril 20 mg
daily.
.
2. Fevers: Mr [**Name13 (STitle) 429**] was afebrile on admission to the MICU as
well as on transfer to the medicine floor. He developed
intermittent spiking fevers. CXR was initally read as unchanged
from the prior studies, and all Bcx and UCx demonstrated NG on
day of discharge.  LP was also negative for infectious process.
Fevers had resolved prior to discharge, and were attributed to
questionable post-intubation pulmonary process.
.
3. Altered Mental Status: Pt brought to emergency department
with severely AMS, presumed at that time to partially secondary
to drug use and hypotension.  Mr. [**Name13 (STitle) 429**] was promptly intubated
and sent to MICU for mangament of hypotension. After extubation,
patient was A and O x 3 on transfer to the medicine floor. While
on the floor, patient became quite confused and engaged in
bizzare behaviors such as putting sputum on cereal thinking it
was milk.  He also was intermittently lethargic and very
difficult to arouse. In the setting of intermittent fevers, an
LP was performed which was negative. To r/o any IC pathology or
mass, an MRI of the head was obtained and also negative.
Eventually, in conjuction with attending and pt's case manager,
team determined that AMS was most likely secondary to in-house
methadone dose, 120 mg daily.  Patient's methadone dose with
reduced to 60 mg daily, with a dramatic improvement in patient's
functional capacity and MS. Methadone was titrated up to avoid
withdrawal and preserve MS. [**First Name8 (NamePattern2) **] [**Last Name (Titles) 429**] was discharged on 100 mg
methdone daily, and kept in house for several days longer than
medically necessary until the next intake appointment at a
methadone clinic could be arranged.  He was scheduled to resume
methadone dosing and counseling at Bay Cove on [**2175-6-7**].
.
4. Acute Renal Failure: On admission to the MICU, pt also had
marked ARF with Cr to 7 from 1. He received aggressive hydration
and creatinine fell to 4.3 after 24 hours. FENa (calculated) =
1.3%, c/w renal etiology presumed to be ATN [**1-4**] hypovolemia.
Patient continued to receive agressive IVF and on discharge,
creatinine was back at baseline level of 1.1.  Lisinopril
reintiated as stated.
.
5. Diarrhea: Stool was sent for cultures to r/o infectious
etiolgy of diarrhea, especially in the setting of intermittent
fevers. Stool cultures for O & P, campylobacter, vibrio,
yersinia, e. coli, cyclospora, cryptosporidium, giarida and c.
difficle were all negative. Diarrhea resolved spontaneously
while in house.
.
6. HIV: Patient's HIV was under poor control and pt demonstrated
questionable reliability in regards to medication compliance.
For this reason, HAART was held during this hospitalization.
.
7. Hep C stable during hospitalization.


Medications on Admission:
As stated by patient on transfer:
1. Kaletra [**Hospital1 **]
2. Truvada qAM
3. Klonopin 1 mg TID
4. Lipitor 20 mg qday
5. ASA 325 mg q day
6. Atenolol 100 mg qday
7. Lisinopril 5 mg qday
9. Neurontin 1800 mg qday
As taken from past records from [**2173**], not included above:
1. Indinavir Sulfate 400 mg [**Hospital1 **]
2. Tenofovir Disoproxil Fumarate 300 mg qd
3. Ritonavir 100 mg [**Hospital1 **]
4. Lamivudine 150 mg [**Hospital1 **]


Discharge Medications:
1. Amitriptyline 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
2. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Atenolol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
5. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
6. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72HR(s)* Refills:*2*
7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*20 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnones:
1. Hypotension
2. Altered Mental Status
3. Diarrhea
4. ARF
5. Fever
.
Secondary Diagnoses:
1. HTN
2. Hepatitis C
3. HIV
4. h/o substance abuse


Discharge Condition:
Good, patient feeling well with clear mental status.

Discharge Instructions:
To patient: You have been accepted at the Bay Cove [**Hospital 27559**]
clinic for an appointment tomorrow, [**2175-6-7**]. You will need
to follow up with them thereafter according to their explicit
instructions.  Follow up with Dr [**Last Name (STitle) **] with the next two
weeks. You should return to the clinic or to the emergency
department with acute changes in your health, including fever
(>101F), chills, shortness of breath, confusion, or excess
sleepiness.

Followup Instructions:
With Dr. [**Last Name (STitle) **] in [**6-15**] days ([**Telephone/Fax (1) 2393**]), as well as with
[**Doctor Last Name 8214**] at Bay Cove ([**Telephone/Fax (1) 27560**]).
{'Systemic inflammatory response syndrome due to noninfectious process without acute organ dysfunction,Other shock without mention of trauma,Human immunodeficiency virus [HIV] disease,Unspecified viral hepatitis C without hepatic coma,Opioid type dependence, unspecified,Alcohol abuse, unspecified,Acute kidney failure with lesion of tubular necrosis,Person awaiting admission to adequate facility elsewhere,Other alteration of consciousness,Diarrhea'}


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: AMS

PRESENT ILLNESS: Mr [**Known lastname 12067**] is a 46 yo man w/ HIV, HCV, polysubstance abuse found
with changes in MS, with fecal incontinence/explosive diarrhea.
All HPI at that time obtained from EMS report, as patient
intubated quickly after arrival for airway protection. Per EMS
report, pt w/ BP 62/P, admitted to using IV heroin, initially
reticent to come to ED for evaluation. After arrival in ED,
agitated with increasing secretions and intubated for airway
protection. Now Mr. [**Name13 (STitle) 429**] is alert and orientated x 3,
conversant. He cannot recall much of the circumstance
surrounding last evening, reports developing moderate and then
explosive diarrhea yesterday afternoon. Again endorses using
heroin yesterday. Denies any other systemic symtems including
fever, chills, SOB, urinary changes. States he had a recent
viral load and CD4 check though nothing is recorded in this
system.

MEDICAL HISTORY: - HIV, last CD4 292, VL >100K in [**5-7**], OI: PCP, [**Name Initial (NameIs) 11395**]. Followed
br Dr. [**Last Name (STitle) **].
- Hepatitis C. grade [**12-4**] liver fibrosis.
- Alcohol abuse. h/o withdrawl seizures, shakes
- ETOH pancreatitis
- HIV nephropathy
- Polysubstance abuse.
- History of Tylenol overdose.
- Peripheral neuropathy and neurogenic bladder.
- CAD s/p stent LCx
- UGI bleed, no EGD done

MEDICATION ON ADMISSION: As stated by patient on transfer:
1. Kaletra [**Hospital1 **]
2. Truvada qAM
3. Klonopin 1 mg TID
4. Lipitor 20 mg qday
5. ASA 325 mg q day
6. Atenolol 100 mg qday
7. Lisinopril 5 mg qday
9. Neurontin 1800 mg qday
As taken from past records from [**2173**], not included above:
1. Indinavir Sulfate 400 mg [**Hospital1 **]
2. Tenofovir Disoproxil Fumarate 300 mg qd
3. Ritonavir 100 mg [**Hospital1 **]
4. Lamivudine 150 mg [**Hospital1 **]

ALLERGIES: Penicillins / Sulfonamides / Tetracyclines

PHYSICAL EXAM: Exam on transfer to the medicine floor, [**2175-5-31**]
.
PE T 98.9 BP 111/67 HR 95 NSR R 14, 99% RA
Gen: pleasant, talkative, NAD
HEENT: MMM, PERRLA, EOMI, sclerae anicter, conjuntiva normal
apprearing.
Neck: Without LAD or noted JVD, R IJ triple lumen in place
Lungs: Diffuse coarse crackle B, no wheeze. Coughing up grey
sputum.
CV: RRR s m/r/g, nl s1/s2
Abd: S/NT/ND. + BS. liver edge 1 cm below costal margin. RLQ
scar from prior app'y noted.
extrm: no edema, pulses 2+ BLE.
skin: no rashes, no erythema
neuro: AOx3, CN 2-12 intact, MAE, neurologic function grossly
intact, MS now appropriate

FAMILY HISTORY: N/C

SOCIAL HISTORY: Patient has a history of heavy alcohol and heroin abuse. Denies
drinking now, used heroin yesterday. Is current smoker. Lives
independently in affiliation with an HIV case management group,
on disability.  Formerly in methadone clinic, "walked off"
shortly prior to admission. 

### Response:
{'Systemic inflammatory response syndrome due to noninfectious process without acute organ dysfunction,Other shock without mention of trauma,Human immunodeficiency virus [HIV] disease,Unspecified viral hepatitis C without hepatic coma,Opioid type dependence, unspecified,Alcohol abuse, unspecified,Acute kidney failure with lesion of tubular necrosis,Person awaiting admission to adequate facility elsewhere,Other alteration of consciousness,Diarrhea'}
