CHIEF COMPLAINT: altered mental status

PRESENT ILLNESS: Ms. [**Known lastname 68459**] is a 50F with HCV cirrhosis, DM, and adrenal
insufficiency who presents with altered mental status. Of note,
she was just recently admitted [**Date range (1) 66383**] with the same
complaints, felt at that time to be due to hepatic
encephalopathy and she cleared on rifaximin and lactulose. Her
spironolactone was initially held in setting of hyponatremia to
125, but restarted at discharge. She was also restarted on
prophalactic bactrim at discharge for her history of LE
cellulitis.
.
Per discussion, mother thought she was still confused, weak,
unsteady on feet, and disoriented. She would fall asleep in the
middle of eating. Had a unwitnessed fall 4am on Sunday. Patient
was taking her rifaximin and lactulose, had two BMs yesterday.
She had a "rattling" cough. Was running low grade temps in the
99.8. Blood sugars were under good control 100's, as low as 78
good for her.
.
In the emergency department, vitals were T 99 P 97 BP 140/89 RR
16 O2 93% on RA. Fingerstick glucose was 98. Serum Na was 112,
down from 137 on [**4-27**], WBC 14k. CT head was negative. Abdominal
ultrasound showed a patent TIPS and NO ascites. Wrist films
showed ?periosteal reaction. Blood cultures were obtained, but
no antibiotics given Mental status wakes to sternal rub. 84
133/72 14 96% on 4L. access PIV 20guage. ER reports discussion
with liver fellow.

MEDICAL HISTORY: * HCV Cirrhosis, diagnosed [**2151**], nonresponder to interferon /
ribavirin, s/p TIPS [**11-9**] for ascites. Course has been
complicated by encephalopathy, thrombocytopenia, ascites, and
hydrothorax. Currently on [**Month/Year (2) **] list.
* Hyponatremia baseline 128-133
* Secondary adrenal insufficiency
* asthma
* DM
* GERD
* Anxiety
* h/o UTI's
* Hip fx and L4 compression Fx on [**2157-11-6**] s/p ORIF of hip fx.
Susequently she had coag neg Staph abscess w/ joint involvement

MEDICATION ON ADMISSION: Lasix 80mg daily
Spironolactone 100mg daily
Rifaximin 400mg TID
Prednisone 5mg daily
Bactrim DS 1tab [**Hospital1 **]
Insulin lantus 21 units at bedtime
Humalog sliding scale
Advair 250/50mg [**Hospital1 **]
Albuterol prn
Singulair 10mg daily
Venlafaxine 75mg [**Hospital1 **]
Oxycodone 5mg q8h prn
Oxycontin 10mg q12h
Neurontin 100mg [**Hospital1 **]
Nepro
Lidoderm patch
MVT
Folate 1mg daily
L-lysine 500mg [**Hospital1 **]
Triamcinolone cream
Senna prn

ALLERGIES: Shellfish / Flexeril / Tricyclic Compounds

PHYSICAL EXAM: Upon arrival to the MICU
Vitals 98.1 89 162/78 16 97% on RA
General Chronically ill appearing, twitching occasionally
HEENT PEARL, sclera anicteric, MMM
Neck No JVD, supple
Pulm Lungs with few rales R base persist after cough, no
wheezing
CV Regular S1 S2 systolic murmur at apex
Abd Soft nondistender mild RUQ tenderness to palpation
GU guiac negative in ER
Extrem Warm no edema palpable distal pulses
Neuro Opens eyes to voice but shuts them again soon after,
sleepy, does follow commands intermittently, verbalizing but
speech not coherent. Does not follow commands to track finger
but EOMI spontaneous movement. No facial weakness. Able to raise
upper extremities and feet off of bed. +clonus, not cooperative
with asterixis testing.
Derm Jaundiced with multiple spider angiomas
Lines/tubes/drains foley in place draining yellow urine

FAMILY HISTORY: F-COPD, alcohol cirrhosis
M-diabetes, HTN, HL
Daughter-congenital heart dz

SOCIAL HISTORY: Currently lives with her mother.
Smoking: 1ppd for years, quit ~[**2154**]. Currently sober, unclear
when last drank alcohol but maybe as recently as a year ago.
IVDU: h/o IV heroin use in the remote past
Chronic hepatitis C with hepatic coma,Pneumonitis due to inhalation of food or vomitus,Glucocorticoid deficiency,Paralytic ileus,Hyposmolality and/or hyponatremia,Cirrhosis of liver without mention of alcohol,Asthma, unspecified type, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Esophageal reflux,Anxiety state, unspecified,Pain in joint, forearm,Other chronic pain,Thrombocytopenia, unspecified,Hypercalcemia,Personal history of tobacco use
Chrnc hpt C w hepat Coma,Food/vomit pneumonitis,Glucocorticoid deficient,Paralytic ileus,Hyposmolality,Cirrhosis of liver NOS,Asthma NOS,DMII wo cmp nt st uncntr,Esophageal reflux,Anxiety state NOS,Joint pain-forearm,Chronic pain NEC,Thrombocytopenia NOS,Hypercalcemia,History of tobacco use
Admission Date:  [**2159-5-1**]              Discharge Date:   [**2159-5-5**]

Date of Birth:  [**2109-1-23**]             Sex:   F

Service: MEDICINE

Allergies:
Shellfish / Flexeril / Tricyclic Compounds

Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
altered mental status

Major Surgical or Invasive Procedure:
Nasogastric tube


History of Present Illness:
Ms. [**Known lastname 68459**] is a 50F with HCV cirrhosis, DM, and adrenal
insufficiency who presents with altered mental status. Of note,
she was just recently admitted [**Date range (1) 66383**] with the same
complaints, felt at that time to be due to hepatic
encephalopathy and she cleared on rifaximin and lactulose. Her
spironolactone was initially held in setting of hyponatremia to
125, but restarted at discharge. She was also restarted on
prophalactic bactrim at discharge for her history of LE
cellulitis.
.
Per discussion, mother thought she was still confused, weak,
unsteady on feet, and disoriented. She would fall asleep in the
middle of eating. Had a unwitnessed fall 4am on Sunday. Patient
was taking her rifaximin and lactulose, had two BMs yesterday.
She had a "rattling" cough. Was running low grade temps in the
99.8. Blood sugars were under good control 100's, as low as 78
good for her.
.
In the emergency department, vitals were T 99 P 97 BP 140/89 RR
16 O2 93% on RA. Fingerstick glucose was 98. Serum Na was 112,
down from 137 on [**4-27**], WBC 14k. CT head was negative. Abdominal
ultrasound showed a patent TIPS and NO ascites. Wrist films
showed ?periosteal reaction. Blood cultures were obtained, but
no antibiotics given Mental status wakes to sternal rub. 84
133/72 14 96% on 4L. access PIV 20guage. ER reports discussion
with liver fellow.

Past Medical History:
* HCV Cirrhosis, diagnosed [**2151**], nonresponder to interferon /
ribavirin, s/p TIPS [**11-9**] for ascites. Course has been
complicated by encephalopathy, thrombocytopenia, ascites, and
hydrothorax. Currently on [**Month/Year (2) **] list.
* Hyponatremia baseline 128-133
* Secondary adrenal insufficiency
* asthma
* DM
* GERD
* Anxiety
* h/o UTI's
* Hip fx and L4 compression Fx on [**2157-11-6**] s/p ORIF of hip fx.
Susequently she had coag neg Staph abscess w/ joint involvement

- washout [**6-/2158**]
- Vancomcyin 7/2~[**7-22**] --> Bactrim 1 tab TID
- E.coli, enterococcus, coag neg Staph
- hardware removal [**9-19**]
- vancomycin + meropenem, [**2158-9-6**]
* LE Cellulitis
* h/o UTIs
* ?prolactinoma suggestion of microadenoma [**5-13**] MRI
* hypercalcemia thought due to aggressive vitamind D repletion

Social History:
Currently lives with her mother.
Smoking: 1ppd for years, quit ~[**2154**]. Currently sober, unclear
when last drank alcohol but maybe as recently as a year ago.
IVDU: h/o IV heroin use in the remote past

Family History:
F-COPD, alcohol cirrhosis
M-diabetes, HTN, HL
Daughter-congenital heart dz


Physical Exam:
Upon arrival to the MICU
Vitals 98.1 89 162/78 16 97% on RA
General Chronically ill appearing, twitching occasionally
HEENT PEARL, sclera anicteric, MMM
Neck No JVD, supple
Pulm Lungs with few rales R base persist after cough, no
wheezing
CV Regular S1 S2 systolic murmur at apex
Abd Soft nondistender mild RUQ tenderness to palpation
GU guiac negative in ER
Extrem Warm no edema palpable distal pulses
Neuro Opens eyes to voice but shuts them again soon after,
sleepy, does follow commands intermittently, verbalizing but
speech not coherent. Does not follow commands to track finger
but EOMI spontaneous movement. No facial weakness. Able to raise
upper extremities and feet off of bed. +clonus, not cooperative
with asterixis testing.
Derm Jaundiced with multiple spider angiomas
Lines/tubes/drains foley in place draining yellow urine

Pertinent Results:
CBC 14>38<58 N 83 no bands E 0.3
Chem 112/5.5/94/18/26/0.9<77
Ca [**60**].4 Mag 1.0 Phos 2.3
ALT 47, AST 107, ALKP 160, Tbil 4.2, Alb 3.3
INR 1.5, PTT 37
lactate 1.3
UA mod bld tr ket, 0-2 rbc, 0 wbc
.
Micro:
[**5-1**] blood cx NGTD
.
ECG: SR @93, nl axis and intervals, peaked T's more prominent
[**4-26**]
.
STUDIES:
CT head
1. No acute intracranial pathology identified. If clinical
concern warrants however, would recommend repeat imaging of the
posterior fossa.
.
Abdominal ultrasound
no ascitic fluid. wall to wall flow seen in TIPS. stable
appearance to cirrhotic liver.
.
CXR no infiltrate L elevated hemidiaphragm, atelectasis, small
bowel appears dilated
.
Plain films R wrist periosteal reaction distal radius,
nonspecific finding but could be c/w subacute fracture
.
CXR:Unchanged position of the nasogastric tube. The pre-existing
right lower lobe opacity shows moderate decrease in extent.
Unchanged left basilar atelectasis. No newly occurred focal
parenchymal opacities. Unchanged bilateral healed rib fractures.
Unchanged size of the cardiac silhouette.


Brief Hospital Course:
This 50F with hepatitis C cirrhosis, DM, and secondary adrenal
insufficiency with recent hospitalization for hepatic
encephalopathy returns with altered mental status and is found
to be profoundly hyponatremic now called out from MICU.
.
#)Altered mental status: Improved throughout admission, likely
multi-factorial including, hyponatremia, hypercalcemia, hepatic
encephalopathy, and multiple sedating meds. No other signs of
decompenstation such as ascites to tap. No evidence of GIB.
Electrolytes improved with repletion. Tolerated PO now, blood
and urine cultures NGTD. Held neurontin but restated prior to
admisison. Cont rifaximin and lactulose. She was AAOX3 prior to
discharge.
.
#)Hyponatremia: 112 on admission, improved with NS. 130 upon
discharge. Likely [**1-8**] poor PO intake in setting of restarting
spironolactone at too high a dose. Restarted
lasix/spironolactone at half doses.
.
#)?Aspiration Pneumonia: patient had leukocytosis on admission,
improved without fever right lower lobe opacity seen on CXR.
Patient with new nonproductive cough. Treated with 5 day course
of levo/flagyl plus nebs for aspiration pneumonia. Blood, Urine,
NGTD. Legionella negative.
.
#)Cirrhosis: C/b encephalopathy, MELD 16 upon admission,
continued rifaximin and lactulose at increased dose, trended
LFTs, INR, restarted Bactrim ppx once levo/flagyl finishes.
.
#)Hypercalcemia: Improved.  Free ionized calcium normal this am.
Has been ongoing,(seen in endocrinology clinic and thought to be
[**1-8**] high doses of calcitriol). Patient was hypercalcemic at last
admit, with improvement with holding calcium supplements per DC
summary. PTH appropriately down at 13. Continued to hold
calcium/D, should be monitored by endocrine/PCP.
.
#)Ileus: [**Month (only) 116**] have had in setting of narcotics, poor PO intake
and electrolyte abnormalities. NGT placed but once she tolerated
PO with +BS and stool output, d/ced it.
.
#)Wrist pain: Question of wrist fracture on plain films that was
re-read as unlikely to be fracture. Pt with known osteoporosis.
Continued splint per [**Month (only) **]
.
#)Thrombocytopenia: [**1-8**] spenomegaly/sequestration, remained at
baseline in 40-60s, monitored
.
#)DM: Covered with insulin sliding scale, diabetic diet
.
#)Adrenal insufficiency: continued home prednisone in addition
to adding florinef for mineralicorticoids.
.
#)Asthma: Continued home inhalers
.
#)Chronic pain: continued home narcotics at a smaller dose
.
#)General Care: FEN: low sodium diet, follow and replete elytes,
Access 2PIV, PPX: PPI, boots, strict aspiration precautions,
Dispo: pending electrolyte repletion, Code: full, Comm with
mother [**Name (NI) 2048**] Phone: [**Telephone/Fax (1) 68660**]

Medications on Admission:
Lasix 80mg daily
Spironolactone 100mg daily
Rifaximin 400mg TID
Prednisone 5mg daily
Bactrim DS 1tab [**Hospital1 **]
Insulin lantus 21 units at bedtime
Humalog sliding scale
Advair 250/50mg [**Hospital1 **]
Albuterol prn
Singulair 10mg daily
Venlafaxine 75mg [**Hospital1 **]
Oxycodone 5mg q8h prn
Oxycontin 10mg q12h
Neurontin 100mg [**Hospital1 **]
Nepro
Lidoderm patch
MVT
Folate 1mg daily
L-lysine 500mg [**Hospital1 **]
Triamcinolone cream
Senna prn

Discharge Medications:
1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Insulin Glargine 100 unit/mL Cartridge Sig: Twenty One (21)
units Subcutaneous at bedtime.
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
5. Humalog 100 unit/mL Cartridge Sig: as directed per sliding
scale units Subcutaneous four times a day.
6. Triamcinolone Acetonide 0.1 % Paste Sig: One (1)  Dental
twice a day.
7. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. Venlafaxine 75 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
9. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

10. Oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q8H (every 8
hours) as needed for pain.
11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO twice a
day.
12. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**12-8**] IH Inhalation every six (6) hours.
13. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day): Please titrate to 4 bowel movements a day.
Disp:*3600 ML(s)* Refills:*2*
14. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
15. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a
day.
16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
17. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

18. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
19. L-Lysine 500 mg Capsule Sig: One (1) Capsule PO twice a day.

20. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1)  Topical once a day.


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 6136**] Home Care Services

Discharge Diagnosis:
Primary:
Hepatic Encephalopathy
Aspiration Pneumonia
Hyponatremia
Ileus
Hyperkalemia
Hypercalcemia
.
Secondary:
Cirrhosis due to Hepatitis C
Diabetes


Discharge Condition:
vitals signs stable, cleared by physical therapy


Discharge Instructions:
You were admitted because of confusion which we believe was
because of your encephalopathy and electroyltes abnormalities.
We treated you with fluids and replaced your electrolytes.  Your
bowels also slowed down but improved with hydration. We also
treated you for an aspiration pneumonia.
.
We STOPPED your tube feeds, oxycontin, and senna.
We STARTED florinef 0.1mg by mouth daily.
We decreased your sprionolactone to 50mg by mouth daily.
We decreased your lasix to 40mg by mouth daily.
We decreased your oxycodone to 2.5-5mg PO every 8 hours as
needed.
We increased your lactulose to 30mL by mouth 4 times a day.
.
Please follow up in the liver clinic on [**2159-5-23**] at 8:40am.
.
If you develop chest pain, shortness of breath, cough, fever,
chills, nausea, vomiting, diarrhea, abdominal pain, confusion,
falls, headaches, or dizziness please call your primary care
doctor or go to your local emergency room.

Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2159-9-6**] 10:00
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2159-9-6**] 9:40
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2159-5-23**] 8:40


                             [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]

Completed by:[**2159-5-6**]
{'Chronic hepatitis C with hepatic coma,Pneumonitis due to inhalation of food or vomitus,Glucocorticoid deficiency,Paralytic ileus,Hyposmolality and/or hyponatremia,Cirrhosis of liver without mention of alcohol,Asthma, unspecified type, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Esophageal reflux,Anxiety state, unspecified,Pain in joint, forearm,Other chronic pain,Thrombocytopenia, unspecified,Hypercalcemia,Personal history of tobacco use'}


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: altered mental status

PRESENT ILLNESS: Ms. [**Known lastname 68459**] is a 50F with HCV cirrhosis, DM, and adrenal
insufficiency who presents with altered mental status. Of note,
she was just recently admitted [**Date range (1) 66383**] with the same
complaints, felt at that time to be due to hepatic
encephalopathy and she cleared on rifaximin and lactulose. Her
spironolactone was initially held in setting of hyponatremia to
125, but restarted at discharge. She was also restarted on
prophalactic bactrim at discharge for her history of LE
cellulitis.
.
Per discussion, mother thought she was still confused, weak,
unsteady on feet, and disoriented. She would fall asleep in the
middle of eating. Had a unwitnessed fall 4am on Sunday. Patient
was taking her rifaximin and lactulose, had two BMs yesterday.
She had a "rattling" cough. Was running low grade temps in the
99.8. Blood sugars were under good control 100's, as low as 78
good for her.
.
In the emergency department, vitals were T 99 P 97 BP 140/89 RR
16 O2 93% on RA. Fingerstick glucose was 98. Serum Na was 112,
down from 137 on [**4-27**], WBC 14k. CT head was negative. Abdominal
ultrasound showed a patent TIPS and NO ascites. Wrist films
showed ?periosteal reaction. Blood cultures were obtained, but
no antibiotics given Mental status wakes to sternal rub. 84
133/72 14 96% on 4L. access PIV 20guage. ER reports discussion
with liver fellow.

MEDICAL HISTORY: * HCV Cirrhosis, diagnosed [**2151**], nonresponder to interferon /
ribavirin, s/p TIPS [**11-9**] for ascites. Course has been
complicated by encephalopathy, thrombocytopenia, ascites, and
hydrothorax. Currently on [**Month/Year (2) **] list.
* Hyponatremia baseline 128-133
* Secondary adrenal insufficiency
* asthma
* DM
* GERD
* Anxiety
* h/o UTI's
* Hip fx and L4 compression Fx on [**2157-11-6**] s/p ORIF of hip fx.
Susequently she had coag neg Staph abscess w/ joint involvement

MEDICATION ON ADMISSION: Lasix 80mg daily
Spironolactone 100mg daily
Rifaximin 400mg TID
Prednisone 5mg daily
Bactrim DS 1tab [**Hospital1 **]
Insulin lantus 21 units at bedtime
Humalog sliding scale
Advair 250/50mg [**Hospital1 **]
Albuterol prn
Singulair 10mg daily
Venlafaxine 75mg [**Hospital1 **]
Oxycodone 5mg q8h prn
Oxycontin 10mg q12h
Neurontin 100mg [**Hospital1 **]
Nepro
Lidoderm patch
MVT
Folate 1mg daily
L-lysine 500mg [**Hospital1 **]
Triamcinolone cream
Senna prn

ALLERGIES: Shellfish / Flexeril / Tricyclic Compounds

PHYSICAL EXAM: Upon arrival to the MICU
Vitals 98.1 89 162/78 16 97% on RA
General Chronically ill appearing, twitching occasionally
HEENT PEARL, sclera anicteric, MMM
Neck No JVD, supple
Pulm Lungs with few rales R base persist after cough, no
wheezing
CV Regular S1 S2 systolic murmur at apex
Abd Soft nondistender mild RUQ tenderness to palpation
GU guiac negative in ER
Extrem Warm no edema palpable distal pulses
Neuro Opens eyes to voice but shuts them again soon after,
sleepy, does follow commands intermittently, verbalizing but
speech not coherent. Does not follow commands to track finger
but EOMI spontaneous movement. No facial weakness. Able to raise
upper extremities and feet off of bed. +clonus, not cooperative
with asterixis testing.
Derm Jaundiced with multiple spider angiomas
Lines/tubes/drains foley in place draining yellow urine

FAMILY HISTORY: F-COPD, alcohol cirrhosis
M-diabetes, HTN, HL
Daughter-congenital heart dz

SOCIAL HISTORY: Currently lives with her mother.
Smoking: 1ppd for years, quit ~[**2154**]. Currently sober, unclear
when last drank alcohol but maybe as recently as a year ago.
IVDU: h/o IV heroin use in the remote past 

### Response:
{'Chronic hepatitis C with hepatic coma,Pneumonitis due to inhalation of food or vomitus,Glucocorticoid deficiency,Paralytic ileus,Hyposmolality and/or hyponatremia,Cirrhosis of liver without mention of alcohol,Asthma, unspecified type, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Esophageal reflux,Anxiety state, unspecified,Pain in joint, forearm,Other chronic pain,Thrombocytopenia, unspecified,Hypercalcemia,Personal history of tobacco use'}
