CHIEF COMPLAINT: hypotension and lethargy

PRESENT ILLNESS: Mrs. [**Known lastname 9780**] is a [**Age over 90 **] yo f w/ hx dementia, presents from NH with
somnolence and hct 17, with reports of black, guaiac positive
stools. Per reports pt with hx of guaiac positive stools and hct
20 on [**2121-12-30**]. She did well otherwise until yesterday when
noted to be minimally responsive, with hct 17. Sent to ED, where
NGL was performed and was negative. No further BMs, but minimal
stool in diaper was brown. Pt w/o discernable abd pain. Per
nursing, straight cath of urine revealed purulent material. U/A
floridly positive. BPs low in the 70's to 80's, and pt started
on cipro for presumed urosepsis. She has also been given
levophed for BP support. Hct rose from 17 to 30 with 3 U PRBCs,
but decreased to a more appropriate 25.6 with additional IVFs.
No further stool output overnight.

MEDICAL HISTORY: Hypertension
Dementia with delusions (listed as [**Last Name (un) 309**] body dementia and
Alzheimer's dementia in different areas of her outside records)

MEDICATION ON ADMISSION: Atenolol 25 mg PO daily
Norvasc 5 mg PO daily
Colace 100 mg [**Hospital1 **] daily
Senna 2 tabs by mouth daily
Dulcolax 5 mg PO daily as needed
Prilosec 20 mg PO daily
Celexa 40 mg qHS
Risperdal 0.5 mg PO 8 am, 12 noon, and HS
Multivitamins

ALLERGIES: Depakote / Sulfa (Sulfonamide Antibiotics) / Penicillins /
Aspirin / Tetracycline

PHYSICAL EXAM: Afebrile, HR 86, BP 115/40 on levophed. RR 18, 100% RA
Pt awake but non-interactive (unclear baseline)
No oropharyngeal erythema or exudate.
RRR. II/VI SEM.
Lungs clear anteriorly with minimal effort.
+BS. NTND.
Rectal with brown, guaiac positive stool
No c/c, 1+ edema bilateraly.

FAMILY HISTORY: N/C

SOCIAL HISTORY: Lives at [**Hospital3 **]. Husband [**First Name8 (NamePattern2) 4580**] [**Name (NI) 9780**]) is HCP. Unable
to obtain EtOH or IVDU/illegal drug use history from patient.
Former smoker.
Unspecified septicemia,Septic shock,Urinary tract infection, site not specified,Acute kidney failure, unspecified,Hyperosmolality and/or hypernatremia,Hemorrhage of gastrointestinal tract, unspecified,Acute posthemorrhagic anemia,Severe sepsis,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Pressure ulcer, lower back,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance
Septicemia NOS,Septic shock,Urin tract infection NOS,Acute kidney failure NOS,Hyperosmolality,Gastrointest hemorr NOS,Ac posthemorrhag anemia,Severe sepsis,Chronic kidney dis NOS,Hy kid NOS w cr kid I-IV,Pressure ulcer, low back,Alzheimer's disease,Dementia w/o behav dist
Admission Date:  [**2122-1-5**]              Discharge Date:   [**2122-1-13**]


Service: MEDICINE

Allergies:
Depakote / Sulfa (Sulfonamide Antibiotics) / Penicillins /
Aspirin / Tetracycline

Attending:[**First Name3 (LF) 4654**]
Chief Complaint:
hypotension and lethargy

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Mrs. [**Known lastname 9780**] is a [**Age over 90 **] yo f w/ hx dementia, presents from NH with
somnolence and hct 17, with reports of black, guaiac positive
stools. Per reports pt with hx of guaiac positive stools and hct
20 on [**2121-12-30**]. She did well otherwise until yesterday when
noted to be minimally responsive, with hct 17. Sent to ED, where
NGL was performed and was negative. No further BMs, but minimal
stool in diaper was brown. Pt w/o discernable abd pain. Per
nursing, straight cath of urine revealed purulent material. U/A
floridly positive. BPs low in the 70's to 80's, and pt started
on cipro for presumed urosepsis. She has also been given
levophed for BP support. Hct rose from 17 to 30 with 3 U PRBCs,
but decreased to a more appropriate 25.6 with additional IVFs.
No further stool output overnight.

Past Medical History:
Hypertension
Dementia with delusions (listed as [**Last Name (un) 309**] body dementia and
Alzheimer's dementia in different areas of her outside records)


Per OMR, recent psychiatric history:
Psychiatric admission in [**Month (only) 359**] for increased agitation and
delusions--currently on citalopram, risperdal
Psychiatric Hospitalization at [**Doctor First Name 1191**] in [**2121-6-5**] for
increasingly aggressive/agitated behavior
Psychiatric Hospitalization at [**Hospital3 **] (?summer [**2121**])
for increasingly aggressive/agitated behavior (5 wks)


Social History:
Lives at [**Hospital3 **]. Husband [**First Name8 (NamePattern2) 4580**] [**Name (NI) 9780**]) is HCP. Unable
to obtain EtOH or IVDU/illegal drug use history from patient.
Former smoker.


Family History:
N/C

Physical Exam:
Afebrile, HR 86, BP 115/40 on levophed. RR 18, 100% RA
Pt awake but non-interactive (unclear baseline)
No oropharyngeal erythema or exudate.
RRR. II/VI SEM.
Lungs clear anteriorly with minimal effort.
+BS. NTND.
Rectal with brown, guaiac positive stool
No c/c, 1+ edema bilateraly.


Pertinent Results:
[**2122-1-5**] 03:30PM   WBC-11.1* RBC-2.01*# HGB-5.8*# HCT-17.8*#
MCV-89 MCH-29.0 MCHC-32.7 RDW-15.8*
[**2122-1-5**] 03:30PM   NEUTS-79.3* LYMPHS-17.4* MONOS-2.7 EOS-0.1
BASOS-0.4
[**2122-1-5**] 03:30PM   PLT COUNT-343
[**2122-1-5**] 03:30PM   PT-13.3 PTT-26.1 INR(PT)-1.1

[**2122-1-5**] 04:28PM URINE  BLOOD-SM NITRITE-POS PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-7.0
LEUK-MOD
[**2122-1-5**] 04:28PM URINE  RBC-2 WBC->50 BACTERIA-MANY YEAST-NONE
EPI-2
[**2122-1-5**] 04:28PM URINE  COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.014
[**2122-1-5**] 03:40PM   LACTATE-1.6

[**2122-1-5**] 03:30PM   GLUCOSE-113* UREA N-131* CREAT-3.6*#
SODIUM-145 POTASSIUM-5.5* CHLORIDE-111* TOTAL CO2-21* ANION
GAP-19
[**2122-1-5**] 11:27PM   POTASSIUM-5.0

Discharge Labs:

[**2122-1-13**] 06:05AM BLOOD WBC-7.6 RBC-3.09* Hgb-9.0* Hct-26.5*
MCV-86 MCH-29.2 MCHC-34.0 RDW-16.0* Plt Ct-190
[**2122-1-13**] 06:05AM BLOOD Plt Ct-190
[**2122-1-13**] 06:05AM BLOOD Glucose-103 UreaN-24* Creat-0.8 Na-140
K-4.5 Cl-107 HCO3-28 AnGap-10
[**2122-1-13**] 06:05AM BLOOD Calcium-7.7* Phos-3.0 Mg-1.7

CT Abdomen/Pelvis: 1. A right-sided 8 x 9 mm non-obstructive
stone in the area of the right UPJ. No hydronephrosis. No stones
on the left side.
2. Small-to-moderate bilateral pleural effusions with bibasilar
atelectasis. 3. Severe scoliosis with accompanying degenerative
changes of the thoracolumbar spine. 4. Fecalized loops of small
bowel, without evidence for bowel obstruction.

PICC Placement X ray: Right PICC in mid SVC.

CXR ([**1-5**]): Lungs are clear and unchanged without evidence of
pneumothorax, edema, or pleural effusions. A questionable small
peripheral granuloma is also unchanged within the right upper
lung field. Cardiomediastinal silhouette and hilar contours are
stable with atherosclerotic disease again noted. Degenerative
changes are noted within the spine and the left
acromioclavicular joint.


Brief Hospital Course:
1. HYPOTENSION SECONDARY TO URINARY TRACT INFECTION AND SEPSIS:
Presented with UTI, grew E coli and Proteus--required pressors
for several days in ICU.  Initially treated with ciprofloxacin,
but Proteus resistant. Changed to Ceftriaxone with plan to
complete a 10 day course. She has an unknown reaction to
penicillin (PCP, [**Name10 (NameIs) 1501**] and husband do now know reaction), but
tolerated the Ceftriaxone in the hospital.  PICC placement
[**2122-1-12**].  Had abdominal pain in the MICU, at CT scan
demonstrated a nonobstructing stone on the right.  This pain
self-resolved.

2. Acute blood loss anemia from GI Bleed: source unclear as
patient did not undergo endoscopy. At admission had HCT of 17.5,
and received 5 units pRBC. Had guaiac positive stool.  Her
profound anemia likely contributed to her hypotension/pressor
requirement.  Her HCT remained stable after these transfusions
and the decision was made not to pursue endoscopy at this point.
 Had guaiac positive stool still at discharge, but not grossly
bloody or tarry.

3. Dementia: history of agitated delirium, which did not
manifest on this hospitalization.  Continued on outpatient
risperidone and celexa.

4.  Acute renal failure on chronic renal insufficiency:
creatinine 3.6 at admission, related to hypotension.  Responded
to resuscitation and improved to baseline at discharge.

5. FEN: failed speech/swallow evaulation, required Dobhoff
placement.  Repeat S/S evaluation on [**2122-1-12**] was performed. The
patient had minimal participation and was unable to move the
food back through the oral cavity to start swallowing. PEG was
discussed with the husband, and after extensive discussion, was
declined. She should be able to eat if she wants to/shows
interest.  Previous s/s evaluation cleared her for soft
solid/think liquid with nutritional supplements ([**11-12**])--repeat
swallowing evaluation could be performed at the [**Hospital1 1501**], if the
medical team feels this in indicated. There was no evidence of
aspiration on this hospitalization, the patient was unable to
participate with the swallow evaluation.

6. Disposition: discharged to [**Hospital1 1501**] to complete 10 day course of
Ceftriaxone. DNR/DNI. Further goals of care to be discussed at
[**Hospital3 2558**].  Hospital course and plan discussed with her
primary caretakers at [**Hospital3 2558**] and her Husband.  [**Name (NI) **]
expressed a desire for her to be comfortable/not suffer. She was
taken off antihypertensives, but her BP was normal.
Nonessential medications were discontinued.  She had an NGT
until the day of discharge, and thus received all oral
medications.

Medications on Admission:
Atenolol 25 mg PO daily
Norvasc 5 mg PO daily
Colace 100 mg [**Hospital1 **] daily
Senna 2 tabs by mouth daily
Dulcolax 5 mg PO daily as needed
Prilosec 20 mg PO daily
Celexa 40 mg qHS
Risperdal 0.5 mg PO 8 am, 12 noon, and HS
Multivitamins


Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
4. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

5. Risperidone 0.5 mg Tablet, Rapid Dissolve Sig: One (1)
Tablet, Rapid Dissolve PO TID (3 times a day).
6. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback Sig:
One (1) gram Intravenous Q24H (every 24 hours): to complete a 10
day course, last dose [**2121-11-18**].
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 2558**] - [**Location (un) **]

Discharge Diagnosis:
Primary:
Septic shock due to UTI-E. coli and P. mirabilis
Acute blood loss anemia due to GI bleed
Acute renal failure on chronic renal insufficiency
Hypernatremia

Secondary:
Alzheimer Dementia
Hypertension


Discharge Condition:
Hemodynamically stable


Discharge Instructions:
You were admitted with a urinary tract infection and bleeding
from your GI tract.  You were admitted to the MICU for blood
pressure support and antibiotics.  You required blood
transfusions.

stool or blood per rectum, inability to tolerate medications,
chest pain, shortness of breath or any other concerning symptom.

Followup Instructions:
Please follow up with the practitioners at [**Hospital3 2558**]


                             [**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**]
{"Unspecified septicemia,Septic shock,Urinary tract infection, site not specified,Acute kidney failure, unspecified,Hyperosmolality and/or hypernatremia,Hemorrhage of gastrointestinal tract, unspecified,Acute posthemorrhagic anemia,Severe sepsis,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Pressure ulcer, lower back,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance"}


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: hypotension and lethargy

PRESENT ILLNESS: Mrs. [**Known lastname 9780**] is a [**Age over 90 **] yo f w/ hx dementia, presents from NH with
somnolence and hct 17, with reports of black, guaiac positive
stools. Per reports pt with hx of guaiac positive stools and hct
20 on [**2121-12-30**]. She did well otherwise until yesterday when
noted to be minimally responsive, with hct 17. Sent to ED, where
NGL was performed and was negative. No further BMs, but minimal
stool in diaper was brown. Pt w/o discernable abd pain. Per
nursing, straight cath of urine revealed purulent material. U/A
floridly positive. BPs low in the 70's to 80's, and pt started
on cipro for presumed urosepsis. She has also been given
levophed for BP support. Hct rose from 17 to 30 with 3 U PRBCs,
but decreased to a more appropriate 25.6 with additional IVFs.
No further stool output overnight.

MEDICAL HISTORY: Hypertension
Dementia with delusions (listed as [**Last Name (un) 309**] body dementia and
Alzheimer's dementia in different areas of her outside records)

MEDICATION ON ADMISSION: Atenolol 25 mg PO daily
Norvasc 5 mg PO daily
Colace 100 mg [**Hospital1 **] daily
Senna 2 tabs by mouth daily
Dulcolax 5 mg PO daily as needed
Prilosec 20 mg PO daily
Celexa 40 mg qHS
Risperdal 0.5 mg PO 8 am, 12 noon, and HS
Multivitamins

ALLERGIES: Depakote / Sulfa (Sulfonamide Antibiotics) / Penicillins /
Aspirin / Tetracycline

PHYSICAL EXAM: Afebrile, HR 86, BP 115/40 on levophed. RR 18, 100% RA
Pt awake but non-interactive (unclear baseline)
No oropharyngeal erythema or exudate.
RRR. II/VI SEM.
Lungs clear anteriorly with minimal effort.
+BS. NTND.
Rectal with brown, guaiac positive stool
No c/c, 1+ edema bilateraly.

FAMILY HISTORY: N/C

SOCIAL HISTORY: Lives at [**Hospital3 **]. Husband [**First Name8 (NamePattern2) 4580**] [**Name (NI) 9780**]) is HCP. Unable
to obtain EtOH or IVDU/illegal drug use history from patient.
Former smoker. 

### Response:
{"Unspecified septicemia,Septic shock,Urinary tract infection, site not specified,Acute kidney failure, unspecified,Hyperosmolality and/or hypernatremia,Hemorrhage of gastrointestinal tract, unspecified,Acute posthemorrhagic anemia,Severe sepsis,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Pressure ulcer, lower back,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance"}
