CHIEF COMPLAINT: 

PRESENT ILLNESS: This is an 81 year old female
with past medical history of CAD, CHF with an EF of 15% to
20%, dementia and bipolar disorder, who presents from home
with a change in mental status.  Patient was discharged from
[**Hospital1 69**] several weeks prior to
admission for treatment of pneumonia and urinary tract
infection.  Patient initially went to rehab and then home one
week prior to admission.  Over the past two days prior to
admission patient's daughter noted that patient had been less
responsive.  There were no other specific complaints.  No
complaints of cough or shortness of breath.  Patient was
brought to the emergency department for evaluation.  In the
emergency department patient had initial chest x-ray which
showed suspicion of a left lower lobe infiltrate.  She also
was seen to have a urinary tract infection and was given
Levaquin.  After 18 hours in the emergency department,
patient developed decreased blood pressure of 60/40.  She was
given IV fluids, had a line placed and was started on
Neo-Synephrine with stabilization.  Currently patient says
she feels bad, but is unable to give any further history.  As
per the daughter, patient has only mild dementia at baseline.
She has lost a lot of strength recently from recent
admissions.

MEDICAL HISTORY: The patient has coronary artery
disease, status post MI in [**2188-8-1**], status post
angioplasty and stent to the RCA.  Patient is also status
post v-fib arrest, status post AICD placement in [**2191-5-2**].
Patient has ischemic cardiomyopathy and CHF with an EF of 15%
to 20%.  Insulin dependent diabetes mellitus.  Mild dementia.
Bipolar disease.

MEDICATION ON ADMISSION: Senna, Colace, insulin, Lasix,
multivitamins, zinc, lisinopril, Depakote, Lopressor.

ALLERGIES: Penicillin, sulfa, Coumadin, Integrilin.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient lives with her daughter and is
currently full code.
Unspecified septicemia,Urinary tract infection, site not specified,Congestive heart failure, unspecified,Other specified forms of chronic ischemic heart disease,Other persistent mental disorders due to conditions classified elsewhere,Bipolar I disorder, most recent episode (or current) unspecified,Automatic implantable cardiac defibrillator in situ
Septicemia NOS,Urin tract infection NOS,CHF NOS,Chr ischemic hrt dis NEC,Mental disor NEC oth dis,Bipolor I current NOS,Status autm crd dfbrltr
Admission Date:  [**2194-2-6**]       Discharge Date:  [**2194-2-11**]


Service:  [**Hospital1 212**]

HISTORY OF PRESENT ILLNESS:  This is an 81 year old female
with past medical history of CAD, CHF with an EF of 15% to
20%, dementia and bipolar disorder, who presents from home
with a change in mental status.  Patient was discharged from
[**Hospital1 69**] several weeks prior to
admission for treatment of pneumonia and urinary tract
infection.  Patient initially went to rehab and then home one
week prior to admission.  Over the past two days prior to
admission patient's daughter noted that patient had been less
responsive.  There were no other specific complaints.  No
complaints of cough or shortness of breath.  Patient was
brought to the emergency department for evaluation.  In the
emergency department patient had initial chest x-ray which
showed suspicion of a left lower lobe infiltrate.  She also
was seen to have a urinary tract infection and was given
Levaquin.  After 18 hours in the emergency department,
patient developed decreased blood pressure of 60/40.  She was
given IV fluids, had a line placed and was started on
Neo-Synephrine with stabilization.  Currently patient says
she feels bad, but is unable to give any further history.  As
per the daughter, patient has only mild dementia at baseline.
She has lost a lot of strength recently from recent
admissions.

PAST MEDICAL HISTORY:  The patient has coronary artery
disease, status post MI in [**2188-8-1**], status post
angioplasty and stent to the RCA.  Patient is also status
post v-fib arrest, status post AICD placement in [**2191-5-2**].
Patient has ischemic cardiomyopathy and CHF with an EF of 15%
to 20%.  Insulin dependent diabetes mellitus.  Mild dementia.
Bipolar disease.

ALLERGIES:  Penicillin, sulfa, Coumadin, Integrilin.

MEDICATIONS ON ADMISSION:  Senna, Colace, insulin, Lasix,
multivitamins, zinc, lisinopril, Depakote, Lopressor.

SOCIAL HISTORY:  The patient lives with her daughter and is
currently full code.

PHYSICAL EXAMINATION:  On admission, in general, an elderly
female in no acute distress.  Vital signs afebrile, heart
rate in the 60s, blood pressure 112/74 which was up from
60/40, 96% on 2 liters.  HEENT moist mucous membranes, but
dry.  Cardiovascular regular rate and rhythm, S1, S2.  Chest
decreased breath sounds at the bases, no rales.  Abdomen
normoactive bowel sounds, soft, nondistended, nontender.
Extremities 1+ edema bilaterally.  Neuro awake, alert,
responds intermittently with short answers.

LABORATORY DATA:  On admission white count 5.0, hematocrit
37.2, platelets 195.  Sodium 139, potassium 4.2, chloride 98,
bicarb 31, BUN 46, creatinine 1.1, glucose 116.  Calcium 9.2,
mag 1.9, phos 3.6.  TSH 3.4.  Valproic acid level 12.1.  UA
moderate leukocyte esterase, 11 to 20 WBCs.  Chest x-ray left
lower lobe infiltrate.

ASSESSMENT:  This is an 81 year old female with mild
dementia, CHF with EF of 15% to 20%, recent admission for UTI
who now presents with change in mental status, UTI and left
lower lobe infiltrate on chest x-ray in the absence of
symptoms.  Patient developed hypotension after a prolonged
emergency department stay.

HOSPITAL COURSE:
1.  Hypotension.  The patient was initially started on dopa
to help increase her blood pressure, but became tachycardiac.
Was then changed to Neo-Synephrine and eventually weaned off
as blood pressure tolerated.  Hypotension was thought to be
secondary to sepsis, given her positive urinary tract
infection.  It was unclear whether any component of
hypotension was secondary to pacer malfunction.  Patient had
pacer interrogated by electrophysiology with an increase in
her lower rate from 60 to 70.  Patient also had decrease in
random cortisol and she was started on prednisone 60 mg.

2.  Infectious disease.  The patient had positive urinary
tract infection on admission with 11 to 20 WBCs and many
bacteria.  Urine culture was positive for greater than
100,000 colonies of alpha Streptococcus.  She was afebrile
and did not have an elevated white count.  She was started on
ceftriaxone 1 gm q.24 hours.  Blood cultures have been no
growth to date.  She was originally thought to have a left
lower lobe infiltrate on chest x-ray, however, there was
decreased suspicion for this after her admission.

3.  Cardiovascular.  The patient was ruled out for MI.  She
had no new issues despite her significant cardiac history.

4.  Hematology.  The patient had one unit transfusion to
maintain hematocrit greater than 30, given her history of
CAD.

5.  Endocrine.  The patient had decreased random cortisol.
She was started on both prednisone and Florinef.  These drugs
will be tapered appropriately.

When the patient was transferred to the floor, she was
without complaints.  Of note, she is intermittently nonverbal
and is not a very good historian.  After transfer to the
floor, patient was continued to be monitored with no further
intervention.  She remained afebrile with no elevation in
white count.  She was continued on IV ceftriaxone.  While she
did not need to remain on this IV medication, given that she
would intermittently refuse her medications, we decided to
keep her on this.  Also given Streptococcus in her urine,
which was a rather mild bug, it was unclear that she needed
full strong coverage.  However, in the setting of her likely
urosepsis, it was felt we would continue treatment with
antibiotics for this.

The patient had no other issues regarding cardiovascular
status.  She was continued on aspirin, beta blocker and ACE
inhibitor.  It was noted that she was not on a statin, given
that she had an LDL of 80 and HDL of 90.  Her finger sticks
were continually monitored.  These were intermittently high,
sometimes above 200.  She was covered with regular insulin
sliding scale and continued on NPH.  She was continued on
prednisone for her adrenal insufficiency.  The start date was
[**2-8**].  She will continue on 60 mg for seven days and
then she will be on a taper.  She was also on Florinef in
conjunction with the diagnosis of adrenal insufficiency.
Patient was placed on vitamin D and calcium carbonate for
osteoporosis prevention, given her high dose steroids and her
age.  Patient has a history of bipolar and dementia.  Status
of dementia is mild.  This is not clear as patient often does
not remember when medical staff will come in and out and
often does not speak, so it was unclear how to evaluate her
mental status.  She was continued on risperidone, Lexapro and
valproic acid.

Finally, patient's hematocrit remained stable and above 30.
She did not need any more transfusions when she was
transferred to the floor.  There were no further
interventions.  Patient's discharge status is stable.  She
was elevated by physical therapy who agreed she would need
rehab, given her decreased mental status.  Patient needed
assistance with ambulation.  She was urinating and having
bowel movements and tolerating p.o.  Only issue on discharge
was that patient was slightly dry and we continued to give
her IV fluids and encouraged her to drink more fluids.

DISCHARGE DIAGNOSES:
1.  Urinary tract infection.
2.  Urosepsis.
3.  Coronary artery disease.
4.  CHF with EF of 15% to 20%.
5.  Insulin dependent diabetes.
6.  Dementia.
7.  Bipolar disease.

DISCHARGE STATUS:  The patient will be discharged to subacute
rehab.

DISCHARGE MEDICATIONS:
1.  Senna.
2.  Colace
3.  Regular insulin sliding scale
4.  NPH 8 units q.a.m.
5.  Lexapro 10 mg p.o. q.day.
6.  Multivitamins.
7.  Aspirin 325 mg p.o. q.day
8.  Risperidone 0.5 mg p.o. b.i.d.
9.  Subcu heparin.
10. Lisinopril 2.5 mg p.o. q.day.
11. Metoprolol 12.5 mg p.o. b.i.d.
12. Valproic acid 700 mg p.o. t.i.d.
13. Pantoprazole 40 mg p.o. q.day.
14. Calcium carbonate 500 mg p.o. b.i.d.
15. Vitamin D 400 units p.o. q.day
16. Florinef 0.05 mg p.o. q.day.  This will be continued for
as long as she is on a prednisone taper which will end as per
her prescription.
17. Prednisone 60 mg p.o. q.day until [**2194-2-15**], at
which point she will begin a taper that will last for 10
days.

In terms of antibiotics, patient has a sensitivity to
Levaquin, but she tolerates [**Last Name (LF) **], [**First Name3 (LF) **] she will be discharged
on [**First Name3 (LF) **] and will be treated for a total of 14 days.  In the
hospital patient received treatment from [**2-6**] through
[**2-11**], so she will receive nine more doses of this.





                            [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D.  [**MD Number(1) 1212**]

Dictated By:[**Doctor Last Name 6204**]
MEDQUIST36

D:  [**2194-2-11**]  08:45
T:  [**2194-2-11**]  08:50
JOB#:  [**Job Number 101037**]
{'Unspecified septicemia,Urinary tract infection, site not specified,Congestive heart failure, unspecified,Other specified forms of chronic ischemic heart disease,Other persistent mental disorders due to conditions classified elsewhere,Bipolar I disorder, most recent episode (or current) unspecified,Automatic implantable cardiac defibrillator in situ'}


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: 

PRESENT ILLNESS: This is an 81 year old female
with past medical history of CAD, CHF with an EF of 15% to
20%, dementia and bipolar disorder, who presents from home
with a change in mental status.  Patient was discharged from
[**Hospital1 69**] several weeks prior to
admission for treatment of pneumonia and urinary tract
infection.  Patient initially went to rehab and then home one
week prior to admission.  Over the past two days prior to
admission patient's daughter noted that patient had been less
responsive.  There were no other specific complaints.  No
complaints of cough or shortness of breath.  Patient was
brought to the emergency department for evaluation.  In the
emergency department patient had initial chest x-ray which
showed suspicion of a left lower lobe infiltrate.  She also
was seen to have a urinary tract infection and was given
Levaquin.  After 18 hours in the emergency department,
patient developed decreased blood pressure of 60/40.  She was
given IV fluids, had a line placed and was started on
Neo-Synephrine with stabilization.  Currently patient says
she feels bad, but is unable to give any further history.  As
per the daughter, patient has only mild dementia at baseline.
She has lost a lot of strength recently from recent
admissions.

MEDICAL HISTORY: The patient has coronary artery
disease, status post MI in [**2188-8-1**], status post
angioplasty and stent to the RCA.  Patient is also status
post v-fib arrest, status post AICD placement in [**2191-5-2**].
Patient has ischemic cardiomyopathy and CHF with an EF of 15%
to 20%.  Insulin dependent diabetes mellitus.  Mild dementia.
Bipolar disease.

MEDICATION ON ADMISSION: Senna, Colace, insulin, Lasix,
multivitamins, zinc, lisinopril, Depakote, Lopressor.

ALLERGIES: Penicillin, sulfa, Coumadin, Integrilin.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient lives with her daughter and is
currently full code. 

### Response:
{'Unspecified septicemia,Urinary tract infection, site not specified,Congestive heart failure, unspecified,Other specified forms of chronic ischemic heart disease,Other persistent mental disorders due to conditions classified elsewhere,Bipolar I disorder, most recent episode (or current) unspecified,Automatic implantable cardiac defibrillator in situ'}
