CHIEF COMPLAINT: Hypernatremia, Fever

PRESENT ILLNESS: [**Age over 90 **]yo f w/hx dementia, breast ca, recent sacral zoster with
superimposed infection sent in from NH for hypernatremia, decr
PO intake. Pt has been evaluated at NH over past few weeks for
zoster on buttocks, superinfection on antibiotics (recently
discontinued [**10-27**]). Over past weekend, noted to have incr
twitching mvmts of head, shoulders, arm while awake (not during
sleep). Pt following simple commands, answers simple quetions.
Denies pain. Pt at baseline mental status (answered "no" to "are
you in pain", "Jonny" to "who is your brother".) Wt decr 17lbs,
resistive to being fed. Today, O2 sat 85% RA, 96% 2L NC. Labs
checked and transferred pt into hospital for IVF hydration given
Na 168, BUN 102.
-
In [**Name (NI) **], pt agitated with T101.4 (rectal), HR 92, BP 76/45, RR 25,
O2 sat 98% NRB. Given 1L NS with SBP increase to 110's. Cefepime
and clinda given empirically to cover for ?aspiration PNA,
urosepsis. Started on 1/2NS at 150cc/hr for Na 165. EKG
w/changes concerning for ischemia, CK 446, trop 0.16. Discussed
with PCP to confirm DNR/DNI, no aggressive intervention (e.g.
cardiac catheterization). Txf'd to [**Hospital Unit Name 153**] given nursing needs.

MEDICAL HISTORY: Stage III sacral decub
Dementia with cerebellar dysfxn: felt due to ETOH abuse
Recurrent UTI, hx VRE UTI (recent cx's neg)
Incontinence
B12 deficiency
PVD
Chronically elevated r hemidiaphragm (PPD neg, RLL PNA [**2106**])
RBBB in 3/00 (resolved [**2-8**])
Hx ETOH abuse
Pancytopenia (?MDS)
Hx breast ca Stage 2 T2N1M0, receptor positive, dx'd [**2095**] s/p
resection L, tamoxifen, family declined f/u mammogram [**2106**]
Osteoarthritis
Hypothyroidism

MEDICATION ON ADMISSION: B12 1mg daily
Zinc 220 daily
Vit C 500 [**Hospital1 **]
Ensure 240ml qid
MVI daily
Levothyroxine 150 daily
Acetaminophen 650bid
Amox 500 [**Hospital1 **] x7days ended [**10-15**]
augmentin 875 [**Hospital1 **] x10days, d/c'd [**10-27**]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T97.5, HR 90, BP 102/33, RR 24, O2 sat 97% RA
Elderly female with intermittent agitation (able to be
assuaged), moving all extremities, sometimes responds yes to
questions but not following commands
MM dry, edentulous, intermittent cough
CTA, suction minimal white sputum
RR
Abd soft, NT/ND, +BS
No edema, warm
Back with numerous stage 2 ulcerations, no vesicles. Sacrum with
stage 3: 1cm probing ulceration, no purulent discharge
Rectum with non-inflamed hemorrhoid, guiac neg brown soft stool

FAMILY HISTORY: N/C

SOCIAL HISTORY: [**Hospital3 4414**] NH resident. HCP Sister [**Name (NI) 553**] [**Name (NI) **] [**Telephone/Fax (1) 59681**].
PCP [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4702**] [**Telephone/Fax (2) 59682**]Former ETOH.
Acute kidney failure, unspecified,Hyperosmolality and/or hypernatremia,Unspecified protein-calorie malnutrition,Thrombocytopenia, unspecified,Pressure ulcer, lower back,Alcohol-induced persisting dementia,Unspecified acquired hypothyroidism,Peripheral vascular disease, unspecified,Personal history of malignant neoplasm of breast,Other vitamin B12 deficiency anemia
Acute kidney failure NOS,Hyperosmolality,Protein-cal malnutr NOS,Thrombocytopenia NOS,Pressure ulcer, low back,Alcohol persist dementia,Hypothyroidism NOS,Periph vascular dis NOS,Hx of breast malignancy,B12 defic anemia NEC
Admission Date:  [**2112-11-1**]              Discharge Date:   [**2112-11-6**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Hypernatremia, Fever

Major Surgical or Invasive Procedure:
none
monitored in ICU for 2 nights


History of Present Illness:
[**Age over 90 **]yo f w/hx dementia, breast ca, recent sacral zoster with
superimposed infection sent in from NH for hypernatremia, decr
PO intake. Pt has been evaluated at NH over past few weeks for
zoster on buttocks, superinfection on antibiotics (recently
discontinued [**10-27**]). Over past weekend, noted to have incr
twitching mvmts of head, shoulders, arm while awake (not during
sleep). Pt following simple commands, answers simple quetions.
Denies pain. Pt at baseline mental status (answered "no" to "are
you in pain", "Jonny" to "who is your brother".) Wt decr 17lbs,
resistive to being fed. Today, O2 sat 85% RA, 96% 2L NC. Labs
checked and transferred pt into hospital for IVF hydration given
Na 168, BUN 102.
-
In [**Name (NI) **], pt agitated with T101.4 (rectal), HR 92, BP 76/45, RR 25,
O2 sat 98% NRB. Given 1L NS with SBP increase to 110's. Cefepime
and clinda given empirically to cover for ?aspiration PNA,
urosepsis. Started on 1/2NS at 150cc/hr for Na 165. EKG
w/changes concerning for ischemia, CK 446, trop 0.16. Discussed
with PCP to confirm DNR/DNI, no aggressive intervention (e.g.
cardiac catheterization). Txf'd to [**Hospital Unit Name 153**] given nursing needs.

Past Medical History:
Stage III sacral decub
Dementia with cerebellar dysfxn: felt due to ETOH abuse
Recurrent UTI, hx VRE UTI (recent cx's neg)
Incontinence
B12 deficiency
PVD
Chronically elevated r hemidiaphragm (PPD neg, RLL PNA [**2106**])
RBBB in 3/00 (resolved [**2-8**])
Hx ETOH abuse
Pancytopenia (?MDS)
Hx breast ca Stage 2 T2N1M0, receptor positive, dx'd [**2095**] s/p
resection L, tamoxifen, family declined f/u mammogram [**2106**]
Osteoarthritis
Hypothyroidism

Social History:
[**Hospital3 4414**] NH resident. HCP Sister [**Name (NI) 553**] [**Name (NI) **] [**Telephone/Fax (1) 59681**].
PCP [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4702**] [**Telephone/Fax (2) 59682**]Former ETOH.

Family History:
N/C

Physical Exam:
T97.5, HR 90, BP 102/33, RR 24, O2 sat 97% RA
Elderly female with intermittent agitation (able to be
assuaged), moving all extremities, sometimes responds yes to
questions but not following commands
MM dry, edentulous, intermittent cough
CTA, suction minimal white sputum
RR
Abd soft, NT/ND, +BS
No edema, warm
Back with numerous stage 2 ulcerations, no vesicles. Sacrum with
stage 3: 1cm probing ulceration, no purulent discharge
Rectum with non-inflamed hemorrhoid, guiac neg brown soft stool


Pertinent Results:
Labs at NH ([**2112-11-1**]):
WBC 11.9, Hct 45.7, Plt 236; 75N, 15L, 7M, 1.6E
Na 168, K4.7, Cl 128, CO2 17, BUN 102, Cr 2.8, Gluc 119, Ca 9.5,
TP 7.5, Alb 3.9
tbili 1.6, Alk Phos 180, ALT 54, AST 57
-
Labs at [**Hospital1 18**]:
[**2112-11-1**] 06:20PM   WBC-7.4 RBC-4.76 HGB-15.0 HCT-45.3 MCV-95
MCH-31.6 MCHC-33.1 RDW-13.5
[**2112-11-1**] 06:20PM   NEUTS-75.7* BANDS-0 LYMPHS-16.7* MONOS-5.7
EOS-1.4 BASOS-0.6
[**2112-11-1**] 06:20PM   PLT SMR-NORMAL PLT COUNT-268
[**2112-11-1**] 06:20PM   GLUCOSE-123* UREA N-115* CREAT-3.6*
SODIUM-165* POTASSIUM-8.1* CHLORIDE-129* TOTAL CO2-21* ANION
GAP-23*
[**2112-11-1**] 07:49PM   K+-4.8
[**2112-11-1**] 06:36PM   LACTATE-3.1*
[**2112-11-1**] 06:20PM   CK(CPK)-446*
[**2112-11-1**] 06:20PM   CK-MB-3 cTropnT-0.16*
-
[**2112-11-1**] 06:30PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-1 PH-6.5 LEUK-NEG
[**2112-11-1**] 06:30PM URINE  RBC-2 WBC-5 BACTERIA-FEW YEAST-NONE
EPI-0
-
At discharge:
Sodium decreased to 143, creatinine 1.0

[**11-5**]:
WBC      RBC      Hgb      Hct      MCV      MCH     MCHC
RDW     PLT
5.1     2.91*    8.8*     26.9*     92      30.4     32.9
14.3     123

CXR: There are low lung volumes. The pulmonary vascularity is
within normal limits given technique. There is a rounded opacity
at the left costophrenic angle. There is elevation of the right
hemidiaphragm. No focal consolidations are seen.
-
EKG: NSR at 93, nl axis, nl intervals, <1mm ST depressions in
[**1-12**],f (no old for comparison); rpt EKG later shows ?TWI III and
F c/w earlier

Brief Hospital Course:
A/P: [**Age over 90 **]F w/dementia, breast CA, hypothyroidism, recent Abx for
superimposed infection of sacral decub from zoster p/w
progressive weight loss, decr POs, fever, hypovolemia with ARF,
hypernatremia. Stabilized in [**Hospital Unit Name 153**] x 2 days then transferred to
floor on [**11-3**].

# Fever: unclear source. Thought possible aspiration PNA given
MS change & lung exam at admission. Other possible source wound
infection. U/A WNL. LFTs elevated, but abdomen benign. UCx, Bld
Cx NGTD. Rec'd cefepime & clinda in ED. abx d/c'd- nothing on
cxr, afebrile since admission.

# Hypernatremia: Hypovolemic hypernatremia. Given 10 liters IVF
in [**Hospital Unit Name 153**].
[**Hospital **] medical free water deficit was 2.05 L
-given d5w

# Renal: Unclear baseline Cr. Creat improved w/IVF. Prerenal.

# Hypovolemia/Hypotension: Improved w/IVF. Rec'd total 10L fluid
in [**Hospital Unit Name 153**].

# Hypoxia: resolved. No obvious infiltrate on CXR. L rounded
opacity at diaphragm of unclear etiology- can follow up as
outpt. Pt with cough but not productive sputum.

# Ischemia: dDx demand vs. ACS. EKG at admiss w/<1mm ST depres
in inf leads (no old for comparison); repeat EKG w/?TWI III and
F c/w earlier. No aggressive management or intervention per
discussion with pt's PCP.
[**Name Initial (NameIs) **] Managed on ASA. HR & BP well-controlled.

# Anemia: B12 deficiency. Hct & Plt at admission were likely
very concentrated. Hct & plt stable & no S/Sx active bleed.

# Sacral decub: Does not probe to bone. Cover with duoderm given
high risk for fecal contamination. No active vesicles.

# Dementia: Mental status back to baseline pleasant.  Was
agitated on admission. Acute worsening was likely
toxic-metabolic.

# Hypothyroid: Cont levothyroxine

# FEN: Speech and swallow rec thickened POs which pt is
tolerating well. Needs help w/feeding at NH.

# Prophylaxis: Pneumoboots. soft wrist restraints needed when pt
was agitated.

# Code/Communication: DNR/DNI, HCP Sister [**Name (NI) 553**] [**Last Name (NamePattern1) **], PCP
[**First Name4 (NamePattern1) **] [**Name (NI) 4702**]


Medications on Admission:
B12 1mg daily
Zinc 220 daily
Vit C 500 [**Hospital1 **]
Ensure 240ml qid
MVI daily
Levothyroxine 150 daily
Acetaminophen 650bid
Amox 500 [**Hospital1 **] x7days ended [**10-15**]
augmentin 875 [**Hospital1 **] x10days, d/c'd [**10-27**]


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 20847**] Home - [**Location (un) 86**]

Discharge Diagnosis:
mental status change
dehydration
hypernatremia
anemia


Discharge Condition:
stable, tolerating thickened POs, not ambulating independently
but unchanged from baseline.Needs assistance with feeding

Discharge Instructions:
contact MD if you develop fever/chills, shortness of breath, or
other concerning symptoms

Followup Instructions:
follow-up with primary care physician [**Name Initial (PRE) 176**] 1-2 months



Completed by:[**2112-11-6**]
{'Acute kidney failure, unspecified,Hyperosmolality and/or hypernatremia,Unspecified protein-calorie malnutrition,Thrombocytopenia, unspecified,Pressure ulcer, lower back,Alcohol-induced persisting dementia,Unspecified acquired hypothyroidism,Peripheral vascular disease, unspecified,Personal history of malignant neoplasm of breast,Other vitamin B12 deficiency anemia'}


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: Hypernatremia, Fever

PRESENT ILLNESS: [**Age over 90 **]yo f w/hx dementia, breast ca, recent sacral zoster with
superimposed infection sent in from NH for hypernatremia, decr
PO intake. Pt has been evaluated at NH over past few weeks for
zoster on buttocks, superinfection on antibiotics (recently
discontinued [**10-27**]). Over past weekend, noted to have incr
twitching mvmts of head, shoulders, arm while awake (not during
sleep). Pt following simple commands, answers simple quetions.
Denies pain. Pt at baseline mental status (answered "no" to "are
you in pain", "Jonny" to "who is your brother".) Wt decr 17lbs,
resistive to being fed. Today, O2 sat 85% RA, 96% 2L NC. Labs
checked and transferred pt into hospital for IVF hydration given
Na 168, BUN 102.
-
In [**Name (NI) **], pt agitated with T101.4 (rectal), HR 92, BP 76/45, RR 25,
O2 sat 98% NRB. Given 1L NS with SBP increase to 110's. Cefepime
and clinda given empirically to cover for ?aspiration PNA,
urosepsis. Started on 1/2NS at 150cc/hr for Na 165. EKG
w/changes concerning for ischemia, CK 446, trop 0.16. Discussed
with PCP to confirm DNR/DNI, no aggressive intervention (e.g.
cardiac catheterization). Txf'd to [**Hospital Unit Name 153**] given nursing needs.

MEDICAL HISTORY: Stage III sacral decub
Dementia with cerebellar dysfxn: felt due to ETOH abuse
Recurrent UTI, hx VRE UTI (recent cx's neg)
Incontinence
B12 deficiency
PVD
Chronically elevated r hemidiaphragm (PPD neg, RLL PNA [**2106**])
RBBB in 3/00 (resolved [**2-8**])
Hx ETOH abuse
Pancytopenia (?MDS)
Hx breast ca Stage 2 T2N1M0, receptor positive, dx'd [**2095**] s/p
resection L, tamoxifen, family declined f/u mammogram [**2106**]
Osteoarthritis
Hypothyroidism

MEDICATION ON ADMISSION: B12 1mg daily
Zinc 220 daily
Vit C 500 [**Hospital1 **]
Ensure 240ml qid
MVI daily
Levothyroxine 150 daily
Acetaminophen 650bid
Amox 500 [**Hospital1 **] x7days ended [**10-15**]
augmentin 875 [**Hospital1 **] x10days, d/c'd [**10-27**]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T97.5, HR 90, BP 102/33, RR 24, O2 sat 97% RA
Elderly female with intermittent agitation (able to be
assuaged), moving all extremities, sometimes responds yes to
questions but not following commands
MM dry, edentulous, intermittent cough
CTA, suction minimal white sputum
RR
Abd soft, NT/ND, +BS
No edema, warm
Back with numerous stage 2 ulcerations, no vesicles. Sacrum with
stage 3: 1cm probing ulceration, no purulent discharge
Rectum with non-inflamed hemorrhoid, guiac neg brown soft stool

FAMILY HISTORY: N/C

SOCIAL HISTORY: [**Hospital3 4414**] NH resident. HCP Sister [**Name (NI) 553**] [**Name (NI) **] [**Telephone/Fax (1) 59681**].
PCP [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4702**] [**Telephone/Fax (2) 59682**]Former ETOH. 

### Response:
{'Acute kidney failure, unspecified,Hyperosmolality and/or hypernatremia,Unspecified protein-calorie malnutrition,Thrombocytopenia, unspecified,Pressure ulcer, lower back,Alcohol-induced persisting dementia,Unspecified acquired hypothyroidism,Peripheral vascular disease, unspecified,Personal history of malignant neoplasm of breast,Other vitamin B12 deficiency anemia'}
