CHIEF COMPLAINT: altered mental status

PRESENT ILLNESS: This is a 76 year-old male with a history of sarcoid and recent
admission who presents with altered mental status.
.
In the ED, the patient had initial vitals of 100.1 with BP
137/100 HR 80s rr 100% RA. While in the ED the patient was
treated empirically for pneumonia with levofloxacin and
vancomycin. O2 sats ranged from 90-100% eventually being placed
on 100% NRB. He was given 0.5 mg ativan at 23:40. Due to hypoxia
to 74% and increased work of breathing the patient was intubated
at 1AM. He was sedated on propofol. The ED attempted to contact
the nursing home without success to address code status.
There is mention in the ED note that the patient may have taken
oxycodone prior to presentation.
.
Upon discussion with the family the patient has not been feeling
well for the last 1 week. He was not specific about his
discomfort, but has been increasing his pain medications. The
family is concerned that he has been increasing his intake of
oxycodone and has become more confused as a result. The reason
for his increased intake of oxycodone (i.e. the location of
increased pain) is unclear. The family reports that he took at
least 8 percocets in the last 36 hours. The do not recall any
localizing symptoms including no fever, chills, chest pain,
shortness of breath, diarrhea. The family was concerned about
his general health such that they took him to his PCP on
thursday and he saw his nurse practitioner [**First Name (Titles) **] [**Last Name (Titles) **]. Both
health care practitioners were not concerned for any acute
change in his health and are well known to the patient.
.
ROS: unable to be obtained as the patient is intubated and
sedated.

MEDICAL HISTORY: 1) Sarcoidosis
2) GERD
3) Paroxysmal atrial fibrillation
4) CVA with resulting memory difficulty
5) Hypertension
6) Anemia
7) Chronic Back Pain (post-herpetic neuralgia)on chronic
prednisone

MEDICATION ON ADMISSION: Discharge meds as of 11.24, family believes them to be correct
1. Percocet 2.5-325 mg up to 8/day per family
2. Lidocaine 5 %(700 mg/patch)
3. Pregabalin 75 mg Capsule Sig: Two (2) Capsule PO QAM (once a

ALLERGIES: Penicillins

PHYSICAL EXAM: Vitals: Afebrile, normotensive, satting well on room air, at
times requires 1-2L NC.
General Appearance: Thin
Eyes / Conjunctiva: constricted pupils approx , mildly reactive
Head, Ears, Nose, Throat: Normocephalic, Poor dentition
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal), No(t) Rub
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Resonant : ), (Breath Sounds: Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: Absent edema , Left: Absent edema
Skin: small faruncle on left leg, no surrounding erythema
Musculoskeletal:
Skin:  Warm
Neurologic: Sedated, Tone: Not assessed, down going plantar
reflexes, withdraws all extremities to pain

FAMILY HISTORY: NC, no family history of sarcoid

SOCIAL HISTORY: Retired physician, [**Name Initial (NameIs) **], 2 grandchildren. Son-in-law [**Name (NI) **]
very supportive. Divorced from wife, who recently died. Patient
has never smoked. Patient rarely consumes alcohol. Patient lives
alone at [**Hospital1 100**] Senior Life. His meals are provided for him, he
does go shopping on his own and is quite active. He ambulates
with a walker since fracturing his acetabulum recently.
Acute respiratory failure,Delirium due to conditions classified elsewhere,Herpes zoster with other nervous system complications,Foreign body in respiratory tree, unspecified,Pain in joint, pelvic region and thigh,Atrial fibrillation,Sarcoidosis,Lung involvement in other diseases classified elsewhere,Unspecified essential hypertension,Esophageal reflux,Lumbosacral spondylosis without myelopathy,Unspecified persistent mental disorders due to conditions classified elsewhere,Memory loss,Dysphagia, unspecified,Other late effects of cerebrovascular disease,Long-term (current) use of anticoagulants
Acute respiratry failure,Delirium d/t other cond,H zoster nerv syst NEC,FB respiratory tree NOS,Joint pain-pelvis,Atrial fibrillation,Sarcoidosis,Lung involv in oth dis,Hypertension NOS,Esophageal reflux,Lumbosacral spondylosis,Mental disor NOS oth dis,Memory loss,Dysphagia NOS,Late effect CV dis NEC,Long-term use anticoagul
Admission Date:  [**2157-1-1**]              Discharge Date:   [**2157-1-5**]

Date of Birth:  [**2080-1-23**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 348**]
Chief Complaint:
altered mental status

Major Surgical or Invasive Procedure:
Intubation


History of Present Illness:
This is a 76 year-old male with a history of sarcoid and recent
admission who presents with altered mental status.
.
In the ED, the patient had initial vitals of 100.1 with BP
137/100 HR 80s rr 100% RA. While in the ED the patient was
treated empirically for pneumonia with levofloxacin and
vancomycin. O2 sats ranged from 90-100% eventually being placed
on 100% NRB. He was given 0.5 mg ativan at 23:40. Due to hypoxia
to 74% and increased work of breathing the patient was intubated
at 1AM. He was sedated on propofol. The ED attempted to contact
the nursing home without success to address code status.
There is mention in the ED note that the patient may have taken
oxycodone prior to presentation.
.
Upon discussion with the family the patient has not been feeling
well for the last 1 week. He was not specific about his
discomfort, but has been increasing his pain medications. The
family is concerned that he has been increasing his intake of
oxycodone and has become more confused as a result. The reason
for his increased intake of oxycodone (i.e. the location of
increased pain) is unclear. The family reports that he took at
least 8 percocets in the last 36 hours. The do not recall any
localizing symptoms including no fever, chills, chest pain,
shortness of breath, diarrhea. The family was concerned about
his general health such that they took him to his PCP on
thursday and he saw his nurse practitioner [**First Name (Titles) **] [**Last Name (Titles) **]. Both
health care practitioners were not concerned for any acute
change in his health and are well known to the patient.
.
ROS: unable to be obtained as the patient is intubated and
sedated.


Past Medical History:
1) Sarcoidosis
2) GERD
3) Paroxysmal atrial fibrillation
4) CVA with resulting memory difficulty
5) Hypertension
6) Anemia
7) Chronic Back Pain (post-herpetic neuralgia)on chronic
prednisone


Social History:
Retired physician, [**Name Initial (NameIs) **], 2 grandchildren. Son-in-law [**Name (NI) **]
very supportive. Divorced from wife, who recently died. Patient
has never smoked. Patient rarely consumes alcohol. Patient lives
alone at [**Hospital1 100**] Senior Life. His meals are provided for him, he
does go shopping on his own and is quite active. He ambulates
with a walker since fracturing his acetabulum recently.


Family History:
NC, no family history of sarcoid

Physical Exam:
Vitals: Afebrile, normotensive, satting well on room air, at
times requires 1-2L NC.
General Appearance: Thin
Eyes / Conjunctiva: constricted pupils approx , mildly reactive
Head, Ears, Nose, Throat: Normocephalic, Poor dentition
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal), No(t) Rub
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Resonant : ), (Breath Sounds: Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: Absent edema , Left: Absent edema
Skin: small faruncle on left leg, no surrounding erythema
Musculoskeletal:
Skin:  Warm
Neurologic: Sedated, Tone: Not assessed, down going plantar
reflexes, withdraws all extremities to pain


Pertinent Results:
LABS ON ADMISSION:
.
HEMATOLOGY:
[**2156-12-31**] 07:30PM BLOOD WBC-10.7 RBC-4.69 Hgb-13.7* Hct-39.5*
MCV-84 MCH-29.3 MCHC-34.8 RDW-15.5 Plt Ct-233
[**2156-12-31**] 07:30PM BLOOD Neuts-87.8* Lymphs-5.9* Monos-5.2 Eos-0.8
Baso-0.4
[**2157-1-1**] 05:54AM BLOOD PT-35.2* PTT-36.2* INR(PT)-3.7*
.
CHEMISTRY:
[**2156-12-31**] 07:30PM BLOOD Glucose-107* UreaN-18 Creat-1.2 Na-141
K-4.1 Cl-99 HCO3-33* AnGap-13
[**2156-12-31**] 07:30PM BLOOD ALT-27 AST-32 CK(CPK)-222* AlkPhos-96
TotBili-1.1
[**2156-12-31**] 07:30PM BLOOD Lipase-33
[**2156-12-31**] 07:30PM BLOOD CK-MB-10 MB Indx-4.5 cTropnT-0.10*
[**2157-1-1**] 05:54AM BLOOD CK-MB-7 cTropnT-0.06*
[**2156-12-31**] 07:30PM BLOOD Calcium-9.2 Phos-2.2*# Mg-2.3
.
TOX:
[**2156-12-31**] 07:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
URINE:
[**2156-12-31**] 08:10PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-1 pH-7.0 Leuks-NEG
[**2156-12-31**] 08:10PM URINE RBC-0 WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-0
.
MICROBIO:
blood, urine, sputum - no growth to date
.
.
RADIOLOGY:
CT HEAD ([**12-31**])
FINDINGS: Exam is moderately limited by motion, although there
is no gross
intracranial abnormality. There is no evidence of shift of
normally midline structures, large hemorrhage or fracture. The
paranasal sinuses and mastoid air cells are grossly clear except
to note persistent mucosal retention cyst in the right anterior
ethmoid sinus.
IMPRESSION: Moderately limited exam without large intracranial
hemorrhage or fracture.
.
MRI HEAD (Prelim [**1-1**])
No evidence of acute ischemia or infarction. Moderate degree of
chronic small vessel ischemia again seen. No gross vascular
abnormalities. Major vessels patent and well perfused.
.
CTA CHEST ([**12-31**]) prelim
sl. limited by resp motion. no central/segmental PE
similar chronic lung changes related to sarcoidosis, possibly
worse at L
hilum.
small bilateral pleural effusions.

MRI L-SPINE:
IMPRESSION:

1. Multilevel spondylosis of the lumbar spine which is most
severe at level of L4-L5.
2. Grade 1 anterolisthesis of L4 over L5 is associated with mild
canal
narrowing and bilateral moderate neural foraminal narrowing.


Brief Hospital Course:
76 year-old male with a history of sarcoidosis and atrial
fibrillation who presents with 1 week of malaise and worsening
respiratory status.
.
# Altered mental status:  unclear etiology though increased pain
meds (fentanyl patch, percocet, pregabalin) seem at least partly
the cause.  It seems that the patient took 8 percocets in one
day when he normally takes 2.  Resolved after intubation.  Per
outpatient PCP patient is on a strict narcotics regemin and
usually keeps to this.
.
# Respiratory failure: brief period of hypoxemia followed by
persistent O2 requirement.  Patient was found to be aspirating.
It is thought that the altered mental status may have worsened
his aspiration events and caused him to become hypoxic.  After
extubation his persistent O2 requirement improved with regular
PT and chest PT.  Patient had difficulty understanding and
complying with the incentive spirometry.
.
# Hip pain: New pain seems to be refered from his L-spine.  He
has been seen by ortho as an outpatient.  A repeat MRI showed
L4-L5 disease.  The pain team was consulted and his pain
medications were adjusted.  Pain did not limit his movement with
PT.  A lidocaine patch was started, his fentanyl patch was
decreased and his home dose of percocer and pregabalin was
continued upon discharge.
.
# Sarcoidosis: Not currently treated (except for inhalers as
prednisone is not for sarcoid per pulmonologist).  Continued
inhalers.
.
# Atrial fibrillation: Currently rate controlled and
anticaogulated.  INR initially therapeutic and so was held.  He
was discharged on coumadin.
.
# History CVA: Head CT no acute hemorrhagic event.
.
# GERD: continued pantoprazole

Medications on Admission:
Discharge meds as of 11.24, family believes them to be correct
1. Percocet 2.5-325 mg up to 8/day per family
2. Lidocaine 5 %(700 mg/patch)
3. Pregabalin 75 mg Capsule Sig: Two (2) Capsule PO QAM (once a

day (in the morning)).
4. Pregabalin 75 mg Capsule Sig: Three (3) Capsule PO QPM (once

a day (in the evening)).
5. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q48H (every 48 hours).
6. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q48H (every 48 hours).
7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
8. Warfarin 5 mg
9. Docusate Sodium 100 mg
10. Senna 8.6 mg .
11. Omeprazole 20 mg Capsule, [**Hospital1 **]
12. Donepezil 5 mg Tablet Sig: One (1) Tablet PO qhs
13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID
14. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
15. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.

16. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:

One (1) Inhalation Inhalation [**Hospital1 **]
17. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol
18. Calcitrate-Vitamin D 315-200 mg-unit Tablet Sig: Two (2)


Discharge Medications:
1. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).

2. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed for wheezing.
4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day) as needed for wheezing.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).
8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
12. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-17**]
Drops Ophthalmic PRN (as needed).
13. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
14. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
15. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
16. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for pain: No more than 2 per day - preferably 1.5 .
17. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for Hip pain.
18. Pregabalin 75 mg Capsule Sig: Three (3) Capsule PO QPM (once
a day (in the evening)).
19. Pregabalin 75 mg Capsule Sig: Two (2) Capsule PO QAM (once a
day (in the morning)).


Discharge Disposition:
Extended Care

Facility:
[**Location (un) 582**] Of [**Location (un) 5176**]

Discharge Diagnosis:
Hypoxic respiratory failure
Aspiration


Discharge Condition:
Stable, At times requires 1L O2 via NC.


Discharge Instructions:
You were admitted to the hospital because of confusion.  In the
ED you had low oxygen level which required you to be intubated
and sent to the ICU.  You did well and the tube was removed the
next day and you were transfered to a medical floor.  On the
floor you required oxygen to keep your oxygen levels up.  This
improved with the chest PT and walking around with PT.  You were
evaluated by the speech and swallow team who recomended a
special diet for you to help you swallow safely.  We think that
you may have aspirated some food into your lungs which caused
your oxygen level to go low.  You will need to be very careful
when you eat.

Medication changes:
Fentanyl patch to 100
Lidocaine patch for back

Please continue the rest of your medications as presiously
directed.  You should not take more than 2 percocets per day per
your primary care doctor.

Please return to the hospital or call your doctor if you have
temperature greater than 101, shortness of breath, worsening
difficulty with swallowing, chest pain, abdominal pain,
diarrhea, or any other symptoms that you are concerned about.


Followup Instructions:
Please call Dr. [**Last Name (STitle) 5351**] at [**Telephone/Fax (1) 608**] after rehab to set up a
follow up appointment.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11642**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2157-3-1**] 1:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], MD Phone:[**Telephone/Fax (1) 5068**]
Date/Time:[**2157-5-19**] 2:00
{'Acute respiratory failure,Delirium due to conditions classified elsewhere,Herpes zoster with other nervous system complications,Foreign body in respiratory tree, unspecified,Pain in joint, pelvic region and thigh,Atrial fibrillation,Sarcoidosis,Lung involvement in other diseases classified elsewhere,Unspecified essential hypertension,Esophageal reflux,Lumbosacral spondylosis without myelopathy,Unspecified persistent mental disorders due to conditions classified elsewhere,Memory loss,Dysphagia, unspecified,Other late effects of cerebrovascular disease,Long-term (current) use of anticoagulants'}


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: This is a 76 year-old male with a history of sarcoid and recent
admission who presents with altered mental status.
.
In the ED, the patient had initial vitals of 100.1 with BP
137/100 HR 80s rr 100% RA. While in the ED the patient was
treated empirically for pneumonia with levofloxacin and
vancomycin. O2 sats ranged from 90-100% eventually being placed
on 100% NRB. He was given 0.5 mg ativan at 23:40. Due to hypoxia
to 74% and increased work of breathing the patient was intubated
at 1AM. He was sedated on propofol. The ED attempted to contact
the nursing home without success to address code status.
There is mention in the ED note that the patient may have taken
oxycodone prior to presentation.
.
Upon discussion with the family the patient has not been feeling
well for the last 1 week. He was not specific about his
discomfort, but has been increasing his pain medications. The
family is concerned that he has been increasing his intake of
oxycodone and has become more confused as a result. The reason
for his increased intake of oxycodone (i.e. the location of
increased pain) is unclear. The family reports that he took at
least 8 percocets in the last 36 hours. The do not recall any
localizing symptoms including no fever, chills, chest pain,
shortness of breath, diarrhea. The family was concerned about
his general health such that they took him to his PCP on
thursday and he saw his nurse practitioner [**First Name (Titles) **] [**Last Name (Titles) **]. Both
health care practitioners were not concerned for any acute
change in his health and are well known to the patient.
.
ROS: unable to be obtained as the patient is intubated and
sedated.

MEDICAL HISTORY: 1) Sarcoidosis
2) GERD
3) Paroxysmal atrial fibrillation
4) CVA with resulting memory difficulty
5) Hypertension
6) Anemia
7) Chronic Back Pain (post-herpetic neuralgia)on chronic
prednisone

MEDICATION ON ADMISSION: Discharge meds as of 11.24, family believes them to be correct
1. Percocet 2.5-325 mg up to 8/day per family
2. Lidocaine 5 %(700 mg/patch)
3. Pregabalin 75 mg Capsule Sig: Two (2) Capsule PO QAM (once a

ALLERGIES: Penicillins

PHYSICAL EXAM: Vitals: Afebrile, normotensive, satting well on room air, at
times requires 1-2L NC.
General Appearance: Thin
Eyes / Conjunctiva: constricted pupils approx , mildly reactive
Head, Ears, Nose, Throat: Normocephalic, Poor dentition
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal), No(t) Rub
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Resonant : ), (Breath Sounds: Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: Absent edema , Left: Absent edema
Skin: small faruncle on left leg, no surrounding erythema
Musculoskeletal:
Skin:  Warm
Neurologic: Sedated, Tone: Not assessed, down going plantar
reflexes, withdraws all extremities to pain

FAMILY HISTORY: NC, no family history of sarcoid

SOCIAL HISTORY: Retired physician, [**Name Initial (NameIs) **], 2 grandchildren. Son-in-law [**Name (NI) **]
very supportive. Divorced from wife, who recently died. Patient
has never smoked. Patient rarely consumes alcohol. Patient lives
alone at [**Hospital1 100**] Senior Life. His meals are provided for him, he
does go shopping on his own and is quite active. He ambulates
with a walker since fracturing his acetabulum recently. 

### Response:
{'Acute respiratory failure,Delirium due to conditions classified elsewhere,Herpes zoster with other nervous system complications,Foreign body in respiratory tree, unspecified,Pain in joint, pelvic region and thigh,Atrial fibrillation,Sarcoidosis,Lung involvement in other diseases classified elsewhere,Unspecified essential hypertension,Esophageal reflux,Lumbosacral spondylosis without myelopathy,Unspecified persistent mental disorders due to conditions classified elsewhere,Memory loss,Dysphagia, unspecified,Other late effects of cerebrovascular disease,Long-term (current) use of anticoagulants'}
