CHIEF COMPLAINT: Cough, fever & change in mental status; incidental finding of
maroon stool

PRESENT ILLNESS: 89 yo M with a history of prostate CA and Alzheimer's dementia
who presents after home nurses noted he appeared unwell,
incidentally noted to have maroon, guaiac positive stool. Of
note, the patient has had several recent admissions to [**Hospital1 18**] and
consultations with Gerontology since his wife suffered a recent
stroke.
.
The patient's daughter reports that he lives at home with 24
hour PCA. He was noted to have a non-productive cough for
approximately 1.5 weeks. He was prescribed cough suppresent but
his symptom persisted. On the day of admission he was noted to
appear shaky and generally unwell by his home nurses, including
shakiness and weakness. His PCP was called who referred him to
the ED.
.
In the ED, T 102.8 HR 105 BP 122/64 RR 26 O2Sat 97%2L NC. He was
felt to have 2 possible sources of infection including lung and
urine and received ceftriaxone 1g and Azithromycin 500mg as well
as acetaminophen 650mg. A foley catheter was placed. While
having a diaper change in the ED, the patient was incidentally
found to have maroon, grossly (and confirmed on testing) guaiac
positive stool. He was hemodynamically stable with baseline Hct.
The pateint was admitted to the [**Hospital Unit Name 153**] & transferred to 11R on
[**2153-9-27**].
.
ROS: Patient's daughter denies home fevers, chills, nightsweats,
headaches, blurry vision, chest pain, shortness of breath,
abdominal pain, nausea, vomiting, diarrhea, dysuria, lower
extremity edema or weight gain. The patient of note has a long
history of guaiac positive stool by the report of his daughter.
She does not know if his stool is normally maroon in color. At
baseline A&Ox2.
.

MEDICAL HISTORY: Alzheimer's dementia, has had wandering & aggitation
h/o Prostate Ca, s/p XRT ([**2149**]), followed by Urology ([**Name8 (MD) **],MD)
CKD, Stage 3 (baseline creatinine ~1.0)
GERD
Anxiety
Depression
Severe degenerative disease in the lumbar spine
Anemia
h/o Diverticulum
h/o Colonic polyps
Internal hemorrhoids

MEDICATION ON ADMISSION: Namenda (Memantine) 10 mg PO BID
Aricept (Donepezil) 10 mg PO QD
Risperidone 1mg PO QHS

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: ADMISSION PE:
============

FAMILY HISTORY: NC

SOCIAL HISTORY: Patient is a retired dentist. Lives at home with 24H PCA's. Son
[**Name (NI) **]. [**Name (NI) **] [**Known lastname 7078**], Chief, Division of Oral Medicine, Department
of Surgery, [**Company 2860**]), is primary contact & HCP: [**Telephone/Fax (3) 7079**]. Patient had been living with wife independently at
home until recently. Wife [**Doctor First Name **] - second marriage; patient's
first wife & mother of children died ~ 30 years ago) was
visiting her family in [**State 7080**] and had a stroke (? [**Month (only) **]
[**2153**]). Wife is currently living in [**State 7080**] and
participating in outpatient rehab. Patient has services through
JCFS.
.
Patient is dependent in all ADLs & IADLs.
Pneumonia due to Legionnaires' disease,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Hemorrhage of gastrointestinal tract, unspecified,Acute posthemorrhagic anemia,Dementia in conditions classified elsewhere with behavioral disturbance,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Thrombocytopenia, unspecified,Esophageal reflux,Chronic kidney disease, Stage III (moderate),Degeneration of lumbar or lumbosacral intervertebral disc,Alzheimer's disease,Personal history of malignant neoplasm of prostate
Legionnaires' disease,Acute kidney failure NOS,Urin tract infection NOS,Gastrointest hemorr NOS,Ac posthemorrhag anemia,Dementia w behavior dist,Enterococcus group d,Thrombocytopenia NOS,Esophageal reflux,Chr kidney dis stage III,Lumb/lumbosac disc degen,Alzheimer's disease,Hx-prostatic malignancy
Admission Date:  [**2153-9-26**]              Discharge Date:   [**2153-9-29**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2167**]
Chief Complaint:
Cough, fever & change in mental status; incidental finding of
maroon stool

Major Surgical or Invasive Procedure:
none

History of Present Illness:
89 yo M with a history of prostate CA and Alzheimer's dementia
who presents after home nurses noted he appeared unwell,
incidentally noted to have maroon, guaiac positive stool. Of
note, the patient has had several recent admissions to [**Hospital1 18**] and
consultations with Gerontology since his wife suffered a recent
stroke.
.
The patient's daughter reports that he lives at home with 24
hour PCA. He was noted to have a non-productive cough for
approximately 1.5 weeks. He was prescribed cough suppresent but
his symptom persisted. On the day of admission he was noted to
appear shaky and generally unwell by his home nurses, including
shakiness and weakness. His PCP was called who referred him to
the ED.
.
In the ED, T 102.8 HR 105 BP 122/64 RR 26 O2Sat 97%2L NC. He was
felt to have 2 possible sources of infection including lung and
urine and received ceftriaxone 1g and Azithromycin 500mg as well
as acetaminophen 650mg. A foley catheter was placed. While
having a diaper change in the ED, the patient was incidentally
found to have maroon, grossly (and confirmed on testing) guaiac
positive stool. He was hemodynamically stable with baseline Hct.
The pateint was admitted to the [**Hospital Unit Name 153**] & transferred to 11R on
[**2153-9-27**].
.
ROS: Patient's daughter denies home fevers, chills, nightsweats,
headaches, blurry vision, chest pain, shortness of breath,
abdominal pain, nausea, vomiting, diarrhea, dysuria, lower
extremity edema or weight gain. The patient of note has a long
history of guaiac positive stool by the report of his daughter.
She does not know if his stool is normally maroon in color. At
baseline A&Ox2.
.


Past Medical History:
Alzheimer's dementia, has had wandering & aggitation
h/o Prostate Ca, s/p XRT ([**2149**]), followed by Urology ([**Name8 (MD) **],MD)
CKD, Stage 3 (baseline creatinine ~1.0)
GERD
Anxiety
Depression
Severe degenerative disease in the lumbar spine
Anemia
h/o Diverticulum
h/o Colonic polyps
Internal hemorrhoids


Social History:
Patient is a retired dentist. Lives at home with 24H PCA's. Son
[**Name (NI) **]. [**Name (NI) **] [**Known lastname 7078**], Chief, Division of Oral Medicine, Department
of Surgery, [**Company 2860**]), is primary contact & HCP: [**Telephone/Fax (3) 7079**]. Patient had been living with wife independently at
home until recently. Wife [**Doctor First Name **] - second marriage; patient's
first wife & mother of children died ~ 30 years ago) was
visiting her family in [**State 7080**] and had a stroke (? [**Month (only) **]
[**2153**]). Wife is currently living in [**State 7080**] and
participating in outpatient rehab. Patient has services through
JCFS.
.
Patient is dependent in all ADLs & IADLs.


Family History:
NC

Physical Exam:
ADMISSION PE:
============

T 99.2F  76 103/47 23 92% 6L
Gen: Elderly gentleman. NAD.
HEENT: PERRL.
CV: RRR. Normal S1 and S2. No M/R/G.
Pulm: Upper airway congestion. Possible small amount of left
base rhonchi. Otherwise clear to auscultation.
Abd: Soft, nontender. No organomegaly.
Ext: No edema.
Neuro: A&Ox1. Moving all extremities.


Pertinent Results:
ADMISSION LABS:
==============
[**2153-9-26**] 05:36PM URINE  HOURS-RANDOM CREAT-186 SODIUM-39
POTASSIUM-82 CHLORIDE-46
[**2153-9-26**] 05:36PM URINE  OSMOLAL-699
[**2153-9-26**] 05:36PM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2153-9-26**] 02:49PM URINE  HOURS-RANDOM
[**2153-9-26**] 02:49PM URINE  COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.022
[**2153-9-26**] 02:49PM URINE  BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2153-9-26**] 02:49PM URINE  RBC-0-2 WBC->50 BACTERIA-FEW YEAST-NONE
EPI-0
[**2153-9-26**] 02:49PM URINE  EOS-POSITIVE

[**2153-9-26**] 03:05PM   PT-14.6* PTT-27.7 INR(PT)-1.3*
[**2153-9-26**] 03:02PM   LACTATE-2.7*
[**2153-9-26**] 02:49PM   GLUCOSE-153* UREA N-35* CREAT-1.3* SODIUM-142
POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-28 ANION GAP-12
[**2153-9-26**] 02:49PM   ALT(SGPT)-33 AST(SGOT)-21 LD(LDH)-195
CK(CPK)-72 ALK PHOS-72 AMYLASE-106* TOT BILI-0.5
[**2153-9-26**] 02:49PM   LIPASE-18
[**2153-9-26**] 02:49PM   CK-MB-NotDone
[**2153-9-26**] 02:49PM   CALCIUM-9.0 PHOSPHATE-1.8* MAGNESIUM-2.1
[**2153-9-26**] 02:49PM   ETHANOL-NEG bnzodzpn-NEG barbitrt-NEG
[**2153-9-26**] 02:49PM   WBC-9.7# RBC-3.99* HGB-10.9* HCT-33.3* MCV-83
MCH-27.2 MCHC-32.6 RDW-14.2
[**2153-9-26**] 02:49PM   NEUTS-89* BANDS-2 LYMPHS-5* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2153-9-26**] 02:49PM   HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2153-9-26**] 02:49PM   PLT SMR-NORMAL PLT COUNT-152
.
MICROBIOLOGY:
============
[**2153-9-27**] URINE (Catheter) - Legionella Urinary Antigen,
PRESUMPTIVE POSITIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.

IMAGING:
=======
[**2153-9-27**] CHEST (PORTABLE AP) - Feeding tube terminates in the
proximal stomach. Patchy bibasilar opacities, slightly improved
on the left. Although possibly related to atelectasis,
aspiration should also be considered.
.
SPEECH & SWALLOW:
================
RECOMMENDATIONS:
1. Safest recommendation continues to be NPO, however patient's
family understands and is willing to accept risks of aspiration
(patient not yet made CMO) and continue po intake, suggest small
sips of honey thick liquids and puree consistencies;
2. Pills crushed with small bites of puree at home;
3. Monitor hydration as patient at risk of dehydration on
thickened liquids.
.
DISCHARGE LABS:
==============
none


Brief Hospital Course:
# Cough, question of PNA per CXR, Urine legionella screen
positive, fever to 102 in ED & looked unwell to 24H PCA.
Currently patient afebrile & o2 sats stable on RA. Family
desires treatment of any infectious process. Continue
levofloxacin q48h renally dosed for total treatment of 14 days.
Afebrile on discharge.
.
# Urinary Tract Infection
U/A positive on admission, initially placed on Macrodantin, C&S
returned ENTEROCOCCUS SP >100,000 Organisms/ml, sensitive to
Ampicillin, Nitrofurantoin & Vancomycin; resistant to
TETRACYCLINE. Patient continued/placed on ampicillin and has
five days of treatment to complete after discharge.
.
#Dementia
Increase in behavioral symptoms since wife had recent stroke &
is no longer in home, despite 24H PCAs in house. Past recent
[**Hospital1 18**] admissions for wandering, aggitation: has had Psych & [**Last Name (un) **]
consultaions. Reportedly with poor orientation at baseline.
Oriented to self (name & DOB) during this admission. Goals for
patient, per disscussions with family & HCP, now palliation.
Family will pursue home Hospice services and continue 24H PCAs.
Family to discuss w/ primary care physician utility of
continuing medications such as namenda and aricept given current
status. Would also be reasonable to consider [**Doctor Last Name 360**] for
secretions, should they become copious and bothersome to
patient, such as scopolamine. Use as needed low dose risperidal
for agitation.

# Failed swallow study x's 2
The patient continues to present with overt aspiration and had
pulled out a pedi-NGT that had been placed. After discussion
with family & with HCP by Dr [**Last Name (STitle) **] via TC: no more NGT's, no
g-tubes to be placed and the patient will be offered food for
comfort, with the accepted risk of aspiration.
.
# Guaiac positive stool.
Hemodynamically stable, GI was consulted and per discussion with
the family, the patient would likely not want further work-up
for this issue. This has been discussed by their report in the
past with the patient's PCP. [**Name10 (NameIs) **] Hct 32.8 on [**2153-9-28**].
.
# Anemia
Baseline of 30-35. B12 474 (low normal) and folate 14.0 on
[**2153-7-19**]. Current drop in HCT thought due to GIB, but now
stablized. No further W/U at this time.
.
# Acute on chronic renal failure
Cr 1.3 on presentation up from baseline of 1.0, but came down to
0.9 with hydration. IVF were repleted.

# Code Status: DNR/DNI, treat infections with antibiotics, to
consult hospice at home.


Medications on Admission:
Namenda (Memantine) 10 mg PO BID
Aricept (Donepezil) 10 mg PO QD
Risperidone 1mg PO QHS


Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2)  PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Risperidone 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Donepezil 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO q48h for 6
doses.
Disp:*6 Tablet(s)* Refills:*0*
6. Memantine 10 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Ampicillin 250 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 5 days.
Disp:*15 Capsule(s)* Refills:*0*
8. Risperdal 0.25 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for agitation.
Disp:*30 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
ADMITTING DIAGNOSIS:
===================
Pneumonia, Legionella (Positive Serogroup 1 Antigen Urinary
Screen)
Urinary Tract Infection, Enterococcus Sp
Lower GI Bleed
.
SECONDARY DIAGNOSIS:
===================
Alzheimer's dementia, has had wandering & aggitation
CKD, Stage 3 (baseline creatinine ~1.0)
GERD
Anxiety
Depression
Severe degenerative disease in the lumbar spine
Anemia
h/o Prostate Ca, s/p XRT ([**2149**]), followed by Urology ([**Name8 (MD) **],MD)

h/o Diverticulum
h/o Colonic polyps
Internal hemorrhoids


Discharge Condition:
Stable

Discharge Instructions:
You were admitted to the hospital with a fever, cough and a
decline in your level of alertness. It was found that you had a
pneumonia and a urinay tract infection and have been started on
antibiotics.
.
Your family is going to arrange for additional professional help
to assist you in having the best quality of life.
.
Please take all of your medications as prescribed.
.
Contact your Primary Care Provider [**Name Initial (PRE) **]/or your other health
profesionals for any health-related concerns.


Followup Instructions:
Please notify your Primary Care Provider that you are back home.
.
Nutrition:
1. Safest recommendation continues to be nothing by mouth,
however as patient's family understands and is willing to accept
risks of aspiration, suggest small sips of honey thick liquids
and puree consistencies;
2. Pills crushed with small bites of puree at home;
3. Monitor hydration as patient at risk of dehydration on
thickened liquids.
.
Family will be contacting and arranging for home hospice
services upon discharge. Contact information will be provided by
Case Management.



Completed by:[**2153-9-29**]
{"Pneumonia due to Legionnaires' disease,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Hemorrhage of gastrointestinal tract, unspecified,Acute posthemorrhagic anemia,Dementia in conditions classified elsewhere with behavioral disturbance,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Thrombocytopenia, unspecified,Esophageal reflux,Chronic kidney disease, Stage III (moderate),Degeneration of lumbar or lumbosacral intervertebral disc,Alzheimer's disease,Personal history of malignant neoplasm of prostate"}


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: Cough, fever & change in mental status; incidental finding of
maroon stool

PRESENT ILLNESS: 89 yo M with a history of prostate CA and Alzheimer's dementia
who presents after home nurses noted he appeared unwell,
incidentally noted to have maroon, guaiac positive stool. Of
note, the patient has had several recent admissions to [**Hospital1 18**] and
consultations with Gerontology since his wife suffered a recent
stroke.
.
The patient's daughter reports that he lives at home with 24
hour PCA. He was noted to have a non-productive cough for
approximately 1.5 weeks. He was prescribed cough suppresent but
his symptom persisted. On the day of admission he was noted to
appear shaky and generally unwell by his home nurses, including
shakiness and weakness. His PCP was called who referred him to
the ED.
.
In the ED, T 102.8 HR 105 BP 122/64 RR 26 O2Sat 97%2L NC. He was
felt to have 2 possible sources of infection including lung and
urine and received ceftriaxone 1g and Azithromycin 500mg as well
as acetaminophen 650mg. A foley catheter was placed. While
having a diaper change in the ED, the patient was incidentally
found to have maroon, grossly (and confirmed on testing) guaiac
positive stool. He was hemodynamically stable with baseline Hct.
The pateint was admitted to the [**Hospital Unit Name 153**] & transferred to 11R on
[**2153-9-27**].
.
ROS: Patient's daughter denies home fevers, chills, nightsweats,
headaches, blurry vision, chest pain, shortness of breath,
abdominal pain, nausea, vomiting, diarrhea, dysuria, lower
extremity edema or weight gain. The patient of note has a long
history of guaiac positive stool by the report of his daughter.
She does not know if his stool is normally maroon in color. At
baseline A&Ox2.
.

MEDICAL HISTORY: Alzheimer's dementia, has had wandering & aggitation
h/o Prostate Ca, s/p XRT ([**2149**]), followed by Urology ([**Name8 (MD) **],MD)
CKD, Stage 3 (baseline creatinine ~1.0)
GERD
Anxiety
Depression
Severe degenerative disease in the lumbar spine
Anemia
h/o Diverticulum
h/o Colonic polyps
Internal hemorrhoids

MEDICATION ON ADMISSION: Namenda (Memantine) 10 mg PO BID
Aricept (Donepezil) 10 mg PO QD
Risperidone 1mg PO QHS

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: ADMISSION PE:
============

FAMILY HISTORY: NC

SOCIAL HISTORY: Patient is a retired dentist. Lives at home with 24H PCA's. Son
[**Name (NI) **]. [**Name (NI) **] [**Known lastname 7078**], Chief, Division of Oral Medicine, Department
of Surgery, [**Company 2860**]), is primary contact & HCP: [**Telephone/Fax (3) 7079**]. Patient had been living with wife independently at
home until recently. Wife [**Doctor First Name **] - second marriage; patient's
first wife & mother of children died ~ 30 years ago) was
visiting her family in [**State 7080**] and had a stroke (? [**Month (only) **]
[**2153**]). Wife is currently living in [**State 7080**] and
participating in outpatient rehab. Patient has services through
JCFS.
.
Patient is dependent in all ADLs & IADLs. 

### Response:
{"Pneumonia due to Legionnaires' disease,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Hemorrhage of gastrointestinal tract, unspecified,Acute posthemorrhagic anemia,Dementia in conditions classified elsewhere with behavioral disturbance,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Thrombocytopenia, unspecified,Esophageal reflux,Chronic kidney disease, Stage III (moderate),Degeneration of lumbar or lumbosacral intervertebral disc,Alzheimer's disease,Personal history of malignant neoplasm of prostate"}
