CHIEF COMPLAINT: altered mental status, hypotension

PRESENT ILLNESS: 68 y/o M with SLE who p/w 1d hx of dysuria, polyuria, chills,
mental status changes. Driving with wife and drove onto grass [**Street Address(1) 29525**]. States urine was "bright red" with increasing
urgency, called PCP and was told to go to hospital. En route,
had episodes of n/v, worsening mental status. Denies pain.

MEDICAL HISTORY: SLE- on plaquenil

MEDICATION ON ADMISSION: home meds: plaquenil 200mg/400mg alternating days

ALLERGIES: Sulfa (Sulfonamides)

PHYSICAL EXAM: On admission [**2113-2-15**]
vitals: T 101.3, BP 129/63, HR 115, RR 18, 96% RA
Gen: ashen appearing, cachectic, but NAD
HEENT: PERRLA/EOMI; MMM; OP Clear
PUlM: CTA b/l. no r/r/w
CV: Normal S1/S2. tachycardic. no m/r/g
ABD: BS present, soft, NT/ND
EXT: no edema, warm
Neuro: A&O x 3. downgoing toes b/l. 5/5 strength
skin: no rash/lesions
Neck: R neck hematoma, RIJ in place
*
On transfer from MICU [**2113-2-17**]
vitals:  97.9, BP 122/70, HR 47, RR 20 , 95% on RA
Gen- well appearing, sitting up in bed, communicating
appropriately
HEENT- PERRLA/EOMI. no scleral injection. OP w/ mild posterior
pharyngeal erythema.
Neck- supple. R IJ central line in place
PULM- CTA b/l. no r/r/w
CV- RRR. no m/r/g. normal s1/s2
ABD- soft, NT/ND. NABS
EXT- 2+ pedal edema b/l. No joint swelling or redness.
NEURO- A&O x 3. CN II-XII intact.
SKin- no diaphoresis, no rash

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: doesn't smoke, [**4-14**] glasses wine/night
Married, no children, retired writer
Disseminated candidiasis,Other septicemia due to gram-negative organisms,Systemic lupus erythematosus,Sepsis,Anemia, unspecified,Rheumatoid arthritis
Disseminated candidiasis,Gram-neg septicemia NEC,Syst lupus erythematosus,Sepsis,Anemia NOS,Rheumatoid arthritis
Admission Date:  [**2113-2-15**]              Discharge Date:   [**2113-2-19**]

Date of Birth:  [**2044-5-8**]             Sex:   M

Service: MEDICINE

Allergies:
Sulfa (Sulfonamides)

Attending:[**Doctor Last Name 10493**]
Chief Complaint:
altered mental status, hypotension

Major Surgical or Invasive Procedure:
R IJ central line

History of Present Illness:
68 y/o M with SLE who p/w 1d hx of dysuria, polyuria, chills,
mental status changes. Driving with wife and drove onto grass [**Street Address(1) 29525**]. States urine was "bright red" with increasing
urgency, called PCP and was told to go to hospital. En route,
had episodes of n/v, worsening mental status. Denies pain.

In ED, initially given ASA, lopressor, then MUST protocol
started. Got 4.5L IVFs, started on levophed/vasopressin.
Lactate=4.4; Given dose of levo/flagyl. T 101.3 HR 115 BP 129/63
RR 18 96% on RA. Dirty urine.

In MICU, weaned off pressors. Switched to GENT for empiric
coverage of GNR bacteremia. Started on Fluconazole emperically
for yeast in the blood. Hydrated with IVF and remained
hemodynamically stable.

Transferred to Medicine on [**2112-2-17**].

Past Medical History:
SLE- on plaquenil

Social History:
doesn't smoke, [**4-14**] glasses wine/night
Married, no children, retired writer

Family History:
non-contributory

Physical Exam:
On admission [**2113-2-15**]
vitals: T 101.3, BP 129/63, HR 115, RR 18, 96% RA
Gen: ashen appearing, cachectic, but NAD
HEENT: PERRLA/EOMI; MMM; OP Clear
PUlM: CTA b/l. no r/r/w
CV: Normal S1/S2. tachycardic. no m/r/g
ABD: BS present, soft, NT/ND
EXT: no edema, warm
Neuro: A&O x 3. downgoing toes b/l. 5/5 strength
skin: no rash/lesions
Neck: R neck hematoma, RIJ in place
*
On transfer from MICU [**2113-2-17**]
vitals:  97.9, BP 122/70, HR 47, RR 20 , 95% on RA
Gen- well appearing, sitting up in bed, communicating
appropriately
HEENT- PERRLA/EOMI. no scleral injection. OP w/ mild posterior
pharyngeal erythema.
Neck- supple. R IJ central line in place
PULM- CTA b/l. no r/r/w
CV- RRR. no m/r/g. normal s1/s2
ABD- soft, NT/ND. NABS
EXT- 2+ pedal edema b/l. No joint swelling or redness.
NEURO- A&O x 3. CN II-XII intact.
SKin- no diaphoresis, no rash

Pertinent Results:
Admission labs:
*
WBC-2.0* RBC-4.29* Hgb-13.5* Hct-39.7* MCV-93 MCH-31.4 MCHC-33.9
RDW-13.6 Plt Ct-151
Neuts-78* Bands-7* Lymphs-13* Monos-2
Gran Ct-1680*
Glucose-125* UreaN-20 Creat-0.9 Na-138 K-3.3 Cl-105 HCO3-23
AnGap-13
BLOOD ALT-15 AST-18 AlkPhos-42 Amylase-32 TotBili-0.3
Albumin-2.7* Calcium-6.8* Phos-0.8* Mg-1.3*
BLOOD Cortsol-36.6*
BLOOD Genta-0.8*
BLOOD Type-[**Last Name (un) **] pO2-35* pCO2-37 pH-7.40 calHCO3-24
BLOOD Lactate-4.4*
*
Micro:
Blood Cx [**2-14**]: Enterobacter (4/4 bottles) pansensitive, Yeast
Urine Cx [**2-15**]: Negative
Blood Cx [**2-17**]: no growth to date
Blood Cx [**2-18**]: no growth to date
*
Radiologic Studies:
CXR [**2113-2-15**]: negative for failure/infiltrate
CT abdomen [**2113-2-18**]: gallstones w/ gallbladder wall edema,
moderate bilateral pleural effusions, normal colon with no
evidence of diverticulosis/diverticulitis
*
Transthoracic ECHO [**2113-2-15**]:
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are mildly thickened. There is no aortic
valve stenosis. The mitral valve leaflets are mildly thickened.
Mild to moderate ([**2-12**]+) mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.



Brief Hospital Course:
Brief [**Hospital **] Hospital Course is outlined below:

1) Enterobacter bacteremia: The patient was initially admitted
to the ICU on the MUST protocol based on a lactate of 4.4. He
was mildly hypotensive and febrile to 101.4. He was aggressively
hydrated with IVF and empirically initiated on amp/gent. He was
briefly placed on levophed/vasopressin pressors but was able to
be weaned off by his second hospital day. Blood cultures from
admission grew enterobacter in [**5-15**] bottles, pan sensitive. In
addition cultures were positive for yeast, unspeciated upon
discharge. Fluconazole was added to his regimen and ampicillin
was discontinued. The source of his infection was unclear,
although urine source was suspected given dirty urine on
admission. Admission urinalysis showed >50 RBCs, >50 WBC's and
moderate leukocytes, although urine cultures were negative. The
patient was transferred to the medicine service on [**2-17**], hospital
day #3. ID was consulted and recommended a switch to levaquin
based on culture sensitivities. Flagyl was also added for
empiric GI coverage pending further evaluation. CT abdomen was
performed and demonstrated no evidence of abscess or bowel
pathology. There was mention of gallstones and gallbladder wall
thickening suspicious for cholecystitis. However the patient
remained afebrile with no abdominal pains and normal liver
function tests. Given his clinical stability with maintenance of
his blood pressure off IVF, tolerance of PO intake, and absence
of fever, he was discharged to home on [**2-19**]. He was discharged
home on PO levaquin and PO fluconazole for a 14 day course based
on ID recommendations. Flagyl was discontinued. He will
follow-up with his PCP [**Last Name (NamePattern4) **] [**2-12**] weeks.

2) Rheumatoid arthritis- previoiusly on plaquenil, so relatively
immunosuppressed. Granulocyte count on admission= 1680, so he
was not neutropenic. He was re-started on plaquenil after he was
clinically stable.

3) Anemia: secondary to SLE likely. Goal HCT>27. Hct remained
>30 through his hospital course. Initital decrease in hematocrit
was likely secondary to IVF hydration.

4) Edema: Noted peripheral edema following IVF hydration. He was
also noted to have bilateral pleural effusions by CT scan, also
likely secondary to aggressive fluid resuscitation. He was not
started on lasix since he was able to autodiurese well, with >2
liters off over the last 24 hours prior to discharge.

5) Mental status change: Initially delirious on admission,
likely secondary to his underlying infection. Once infection
cleared his mental status improved back to baseline. No further
evaluation was performed.


Medications on Admission:
home meds: plaquenil 200mg/400mg alternating days


Discharge Medications:
1. Hydroxychloroquine Sulfate 200 mg Tablet Sig: One (1) Tablet
PO EVERY OTHER DAY (Every Other Day).
2. Hydroxychloroquine Sulfate 200 mg Tablet Sig: Two (2) Tablet
PO EVERY OTHER DAY (Every Other Day): alternate days with 200mg
dose.
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
4. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnosis:
1. Enterobacter bacteremia (pan-sensitive)

Secondary Diagnosis:
1. SLE
2. Rheumatoid arthritis


Discharge Condition:
good. hemodynamically stable. afebrile.

Discharge Instructions:
Report fever, chills, lightheadedness, stomach pains or bleeding
to your PCP.

Please complete your antibiotic regimen as prescribed below.
Stay well-hydrated. Drink at least [**4-14**] 8oz glasses of water each
day.

Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 1007**] in [**2-12**] weeks at phone #
[**Telephone/Fax (1) 10492**].


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]
{'Disseminated candidiasis,Other septicemia due to gram-negative organisms,Systemic lupus erythematosus,Sepsis,Anemia, unspecified,Rheumatoid arthritis'}


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, hypotension

PRESENT ILLNESS: 68 y/o M with SLE who p/w 1d hx of dysuria, polyuria, chills,
mental status changes. Driving with wife and drove onto grass [**Street Address(1) 29525**]. States urine was "bright red" with increasing
urgency, called PCP and was told to go to hospital. En route,
had episodes of n/v, worsening mental status. Denies pain.

MEDICAL HISTORY: SLE- on plaquenil

MEDICATION ON ADMISSION: home meds: plaquenil 200mg/400mg alternating days

ALLERGIES: Sulfa (Sulfonamides)

PHYSICAL EXAM: On admission [**2113-2-15**]
vitals: T 101.3, BP 129/63, HR 115, RR 18, 96% RA
Gen: ashen appearing, cachectic, but NAD
HEENT: PERRLA/EOMI; MMM; OP Clear
PUlM: CTA b/l. no r/r/w
CV: Normal S1/S2. tachycardic. no m/r/g
ABD: BS present, soft, NT/ND
EXT: no edema, warm
Neuro: A&O x 3. downgoing toes b/l. 5/5 strength
skin: no rash/lesions
Neck: R neck hematoma, RIJ in place
*
On transfer from MICU [**2113-2-17**]
vitals:  97.9, BP 122/70, HR 47, RR 20 , 95% on RA
Gen- well appearing, sitting up in bed, communicating
appropriately
HEENT- PERRLA/EOMI. no scleral injection. OP w/ mild posterior
pharyngeal erythema.
Neck- supple. R IJ central line in place
PULM- CTA b/l. no r/r/w
CV- RRR. no m/r/g. normal s1/s2
ABD- soft, NT/ND. NABS
EXT- 2+ pedal edema b/l. No joint swelling or redness.
NEURO- A&O x 3. CN II-XII intact.
SKin- no diaphoresis, no rash

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: doesn't smoke, [**4-14**] glasses wine/night
Married, no children, retired writer 

### Response:
{'Disseminated candidiasis,Other septicemia due to gram-negative organisms,Systemic lupus erythematosus,Sepsis,Anemia, unspecified,Rheumatoid arthritis'}
