CHIEF COMPLAINT: Altered mental status, fever, hypotension

PRESENT ILLNESS: The patient is a [**Age over 90 **] year old resident of [**Hospital 100**] Rehab who
presents with altered mental status. She was recently started on
a course of cipro (D1 [**5-21**]). Today had addominal pain and
chills. Was noted to be hypotensive to 94/62. She had urinary
retention and a Foley was placed.
.
In the ED, initial vs were: 98.3 69 113/66 18 96% RA. Labs were
notable for leukocytosis with bandemia, thrombocytopenia, acute
renal failure and lactate of 3.8. She was given vanc and cipro.
She was given only 500cc of NS for IVF due to hyponatremia.
.
On arrival her family states that on tuesday ([**5-21**]) she had
severe flank pain and on wednesday ([**5-22**]) had pain that reminded
her of menstrual cramping. Last night she became acutely
confused but denied pain. At baseline, she has short term memory
loss but is oriented x3 and very active. Her mental status
represented an acute change and she was also lethargic. Other
notable recent past medical history is a tooth infection treated
with a course of antibiotics 3 weeks ago. She was suppossed to
have the tooth removed but this did not occur. She had
resolution of her symptoms.
.
Currently she denies pain, chest pain, dyspnea, abdominal pain.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.

MEDICAL HISTORY: NIDDM
HTN
high chol
dementia
cataracts
melanoma (completely excised)
s/p hysterctomy

MEDICATION ON ADMISSION: acetaminophen 650 q4h prn
ASA 81 daily
Kcl 10 meq daily
simvastatin 20 daily
atenolol 25 mg [**Hospital1 **]
hydrochlorothiazide 25 mg daily
Metformin 1000mg [**Hospital1 **]
calcium carbonate 1300 daily
ciprofloxacin 250mg [**Hospital1 **] (received 2 doses, first dose 5/26 am)
D5 [**12-29**] normal saline @ 75 cc/hr x 13 hours, 20 min

ALLERGIES: Sulfa (Sulfonamide Antibiotics) / Suprax / Paxil / Penicillins

PHYSICAL EXAM: Admission Exam:
General Appearance: Thin
Eyes / Conjunctiva: PERRL, ecchymoses on tongue
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : bilat bases, No(t) Wheezes : )
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing
Skin:  Warm, No(t) Rash: , No(t) Jaundice, many many SKs
Neurologic: Follows simple commands, Responds to: Verbal
stimuli, Movement: Not assessed, Tone: Not assessed, CNs intact

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: - Tobacco:  none
- Alcohol:  h/o very occaisional
- Illicits:  none
Septicemia due to escherichia coli [E. coli],Urinary tract infection, site not specified,Acute kidney failure, unspecified,Hydronephrosis,Hyposmolality and/or hyponatremia,Delirium due to conditions classified elsewhere,Pulmonary collapse,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other persistent mental disorders due to conditions classified elsewhere,Thrombocytopenia, unspecified,Iron deficiency anemia, unspecified,Unspecified essential hypertension,Other seborrheic keratosis,Severe sepsis
E coli septicemia,Urin tract infection NOS,Acute kidney failure NOS,Hydronephrosis,Hyposmolality,Delirium d/t other cond,Pulmonary collapse,DMII wo cmp nt st uncntr,Mental disor NEC oth dis,Thrombocytopenia NOS,Iron defic anemia NOS,Hypertension NOS,Other sborheic keratosis,Severe sepsis
Admission Date:  [**2194-5-23**]              Discharge Date:   [**2194-5-29**]


Service: MEDICINE

Allergies:
Sulfa (Sulfonamide Antibiotics) / Suprax / Paxil / Penicillins

Attending:[**First Name3 (LF) 2610**]
Chief Complaint:
Altered mental status, fever, hypotension

Major Surgical or Invasive Procedure:
Percutaneous nephrostomy tube placement [**2194-5-25**]

History of Present Illness:
The patient is a [**Age over 90 **] year old resident of [**Hospital 100**] Rehab who
presents with altered mental status. She was recently started on
a course of cipro (D1 [**5-21**]). Today had addominal pain and
chills. Was noted to be hypotensive to 94/62. She had urinary
retention and a Foley was placed.
.
In the ED, initial vs were: 98.3 69 113/66 18 96% RA. Labs were
notable for leukocytosis with bandemia, thrombocytopenia, acute
renal failure and lactate of 3.8. She was given vanc and cipro.
She was given only 500cc of NS for IVF due to hyponatremia.
.
On arrival her family states that on tuesday ([**5-21**]) she had
severe flank pain and on wednesday ([**5-22**]) had pain that reminded
her of menstrual cramping. Last night she became acutely
confused but denied pain. At baseline, she has short term memory
loss but is oriented x3 and very active. Her mental status
represented an acute change and she was also lethargic. Other
notable recent past medical history is a tooth infection treated
with a course of antibiotics 3 weeks ago. She was suppossed to
have the tooth removed but this did not occur. She had
resolution of her symptoms.
.
Currently she denies pain, chest pain, dyspnea, abdominal pain.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.


Past Medical History:
NIDDM
HTN
high chol
dementia
cataracts
melanoma (completely excised)
s/p hysterctomy

Social History:
- Tobacco:  none
- Alcohol:  h/o very occaisional
- Illicits:  none

Family History:
noncontributory

Physical Exam:
Admission Exam:
General Appearance: Thin
Eyes / Conjunctiva: PERRL, ecchymoses on tongue
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : bilat bases, No(t) Wheezes : )
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing
Skin:  Warm, No(t) Rash: , No(t) Jaundice, many many SKs
Neurologic: Follows simple commands, Responds to: Verbal
stimuli, Movement: Not assessed, Tone: Not assessed, CNs intact

Discharge Exam:
Vitals: T:96.9 BP:160/70 (140-180/70-81) P:64 (64-80) R:18 O2:
94% RA
I/O: --/600+500nephro; 1130/1050++BM
General: sleeping but easily rousable, oriented to self and
date, year, no acute distress, speaking in full sentences
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, did not appreciate
bibasilar crackles at this time, no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley draining clear yellow urine; l PCN draining
serosanguinous fluid. No CVAT.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Multiple sebborrheic keratoses and nevi
Neuro: CN 2-12 intact. Tangential, spelling words frequently.
Perseverates and repeats important life dates.


Pertinent Results:
[**2194-5-23**] 12:00PM BLOOD WBC-20.6*# RBC-3.55* Hgb-10.7* Hct-30.1*
MCV-85 MCH-30.0 MCHC-35.5* RDW-13.2 Plt Ct-54*#
[**2194-5-23**] 12:00PM BLOOD Neuts-88* Bands-6* Lymphs-3* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2194-5-23**] 12:00PM BLOOD PT-14.6* PTT-29.0 INR(PT)-1.3*
[**2194-5-23**] 12:00PM BLOOD Fibrino-918*
[**2194-5-23**] 12:00PM BLOOD Ret Aut-PND
[**2194-5-23**] 12:00PM BLOOD Glucose-224* UreaN-50* Creat-2.0* Na-120*
K-4.9 Cl-86* HCO3-20* AnGap-19
[**2194-5-23**] 12:00PM BLOOD ALT-19 AST-55* LD(LDH)-257* AlkPhos-66
TotBili-0.9
[**2194-5-23**] 12:00PM BLOOD Albumin-3.5 Calcium-8.2* Phos-2.9 Mg-1.6
[**2194-5-23**] 12:00PM BLOOD Hapto-PND
[**2194-5-23**] 12:00PM BLOOD Osmolal-PND
[**2194-5-23**] 12:00PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.014
[**2194-5-23**] 12:00PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
[**2194-5-23**] 12:00PM URINE RBC-7* WBC-54* Bacteri-FEW Yeast-NONE
Epi-0
[**2194-5-23**] 12:00PM URINE CastHy-4*
[**2194-5-23**] 12:00PM URINE Mucous-RARE
[**2194-5-23**] 03:33PM URINE Hours-RANDOM Creat-87 Na-21 K-89 Cl-20
[**2194-5-23**] 03:33PM URINE Osmolal-449

[**2194-5-23**] 11:55 am BLOOD CULTURE

                            **FINAL REPORT [**2194-5-26**]**

   Blood Culture, Routine (Final [**2194-5-26**]):
      ESCHERICHIA COLI.    FINAL SENSITIVITIES.
         Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
         [**Last Name (NamePattern1) 3060**].

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ESCHERICHIA COLI
                             |
AMPICILLIN------------ =>256 R
AMPICILLIN/SULBACTAM--     4 S
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CIPROFLOXACIN---------   0.5 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S
   Aerobic Bottle Gram Stain (Final [**2194-5-24**]):
      Reported to and read back by DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 18708**] ON [**2194-5-24**] AT
0630.
      GRAM NEGATIVE ROD(S).
   Anaerobic Bottle Gram Stain (Final [**2194-5-24**]):    GRAM
NEGATIVE ROD(S).

Other Blood and urine cultures pending.

IMAGING:
CHEST (PORTABLE AP) Study Date of [**2194-5-24**] 6:13 AM
FRONTAL CHEST RADIOGRAPH: There is increased perihilar
indistinctness and
diffuse ground-glass opacity with small bilateral pleural
effusion and cardiac enlargement in keeping with congestive
heart failure. Retrocardiac opacity has increased and may
reflect atelectasis. Again seen is mild prominence in the region
of the ascending aorta. Attention to this area should be paid on
followup chest radiographs. There is no pneumothorax.
.
CHEST (PORTABLE AP) Study Date of [**2194-5-24**] 5:07 PM
FRONTAL CHEST RADIOGRAPH: There has been mild improvement in the
degree of
pulmonary edema. Cardiomediastinal silhouette is stable. There
is unchanged retrocardiac opacity as well as a moderate-sized
left-sided pleural effusion. There is a linear lucency at the
right lung apex. This may represent [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] line, however, a
pneumothorax is not excluded. Recommend repeat chest radiograph.

IMPRESSION:
1. Improving pulmonary edema.
2. Left-sided pleural effusion and retrocardiac opacity.
3. Lucency at the right lung apex may represent [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] line from
an overlying skin fold. Recommend repeat chest radiographs.

.
CT ABD & PELVIS W/O CONTRAST Study Date of [**2194-5-24**] 4:10 AM
FINDINGS:
CT ABDOMEN: Lung bases demonstrate small bilateral pleural
effusions with
adjacent compressive atelectasis. The coronary arteries are
calcified.
Evaluation is limited without IV contrast. The non-contrast
appearance of the spleen, adrenal glands, liver, and stomach are
within normal limits. A
calcified gallstone is noted within the gallbladder. There is
diffuse fatty atrophy of the pancreas, making it hard to fully
visualize. There is diffuse calcified atherosclerotic disease of
the intra-abdominal arterial vasculature. There is a small
amount of ascites.
The non-contrast appearance of the right kidney is within normal
limits. There is mild-to-moderate hydronephrosis of the left
kidney with mild surrounding fat stranding with hydroureter seen
down to the level of the mid ureter. However, the ureter is not
definitively seen beyond this point. A candidate distal left
ureter may be seen with calcification versus multiple small
obstructing stones in the distal left ureter (300b:30 and
2:64-71).
CT PELVIS: There is a large amount of stool within the rectum.
The bladder
is decompressed with a Foley catheter. The uterus is absent.
There is small amount of free fluid within the pelvis.
Intrapelvic loops of bowel are within normal limits. There is no
inguinal or pelvic lymphadenopathy.
BONE WINDOWS: There is grade 1 anterolisthesis of L4 on L5,
likely due to
degenerative changes.
IMPRESSION:
1. Limited evaluation given lack of IV contrast.
Mild-to-moderate
hydronephrosis of the left kidney with mild surrounding fat
stranding with
hydroureter. The distal left ureter is not definitely seen, but
may contain calcification of the ureter versus multiple small
obstructing stones. Alternatively, this could represent a small
calcified branch artery off the internal iliac artery.
2. Small amount of ascites.
3. Small bilateral pleural effusions.
4. Cholelithiasis.

RENAL U.S. PORT Study Date of [**2194-5-24**] 12:13 AM
FINDINGS: The right kidney measures 12.3 cm. It is normal in
appearance
without hydronephrosis, stones or mass. There is a trace amount
of fluid
surrounding the lower pole of the right kidney, however. The
left kidney measures 10.1 cm and demonstrates moderate
hydronephrosis. There are no renal stones or masses. The
proximal ureter is dilated; however, an obstructing cause is not
seen as overlying bowel gas limits evaluation. The bladder is
decompressed with a Foley catheter and not well seen.
IMPRESSION:
1. Moderate hydronephrosis of the left kidney. The obstructing
cause is not identified on this study.
2. Normal appearance of right kidney. Trace amount of fluid
surrounding the lower pole of the right kidney.
3. Bilateral pleural effusions.

CT HEAD W/O CONTRAST Study Date of [**2194-5-23**] 12:34 PM
FINDINGS: There is no evidence of any intra-axial or extra-axial
hemorrhage.  There is good [**Doctor Last Name 352**]-white matter differentiation.
There is disproportionate atrophy seen in the frontal lobes
bilaterally. There is no evidence of large mass cerebral edema
or shift of midline structures. There is some periventricular
white matter hypodensities suggestive of small vessel ischemic
disease. There is no evidence of any underlying fracture. Mucus
retention cysts are seen within the sphenoid sinuses. Minimal
mucosal thickening of the ethmoid air cells is noted. Mastoid
air cells are well pneumatized.
IMPRESSION:
1. No evacute intracranial process.
2. Mucosal retention cysts in the sphenoid sinuses


Brief Hospital Course:
[**Age over 90 **] yo F p/w sepsis likely [**1-29**] UTI, hyponatremia, [**Last Name (un) **] and
delirium.

# Urosepsis: U/A positive for pan-sensitive E coli with blood
cultures growing GNRs. Patient met SIRS criteria. Previously had
flank pain concerning for pyelonephritis though U/S and CT not
suggestive of active infection or any current obstruction. Given
L mild hydronephrosis she may have previously passed a stone.
Patient with persistent hypotension and elevated WBC after two
days of antibiotics and it was felt infectious source not likely
well controlled.  On [**2194-5-25**], IR placed percutaneous nephrostomy
tube.  Patient was continued on ceftriaxone and then switched to
PO cipro given senstitivities showed E coli was pan sensitive.
Plan was to complete a 14 day course of abx (Day 1 =[**5-25**]; Day 14
= [**2194-6-7**]). Pt improved and was able to go to floor. Pt
continued to recover and remain stable with improved mental
status and VS. Pt was discharged back to [**Hospital 100**] Rehab with
planned follow-up with urology and IR (IR placed nephrostomy
tube).
.
# Altered mental status: Per family, patient with dementia at
baseline, but was more altered on admission. Differential
diagnosis included delirium in setting of urosepsis, cipro med
effect and hyponatremia. Patient's mental status improved with
treatment of urosepsis and treatment of hyponatremia. On floor
she was very alert and pleasant, telling jokes and interacting
with staff appropriately. Delerium had cleared and pt had
returned to baseline.
.
# Hyponatremia: Likely hypovolemic hyponatremia, may be
component of SIADH in setting of sepsis though low urine Na.
Sodium acutely dropped from 128 to 120, now improved to 132 in
the ICU after patient received volume with NS.
.
# Acute renal failure: Likely [**1-29**] to sepsis vs hypovolemia
(pre-renal). Concern for obstructive component. Improved with
fluid and decompression of obstruction.
.
# Thrombocytopenia: No TTP per heme-onc. [**Month (only) 116**] be [**1-29**] sepsis vs
med effect. DIC work-up unrevealing.  Likely secondary to
sepsis.
.
# Anemia: as above, no evidence of TTP. [**Month (only) 116**] be due to anemia of
chronic inflammation vs renal failure. Hct at recent baseline.
.
# DM2: Held metformin while in house, ISS.
.
# HLD: Continued statin, held aspirin.

.
Planned follow-up with urology and IR:
Pt will be seen by urology on [**6-11**] for follow-up and
determination if additional intervention is required.
Per IR, regarding care of percutaneous nephrostomy tube: Check
site daily for signs of infection. If soiled or erythematous,
change dressing and monitor. As wound heals, dressing changes
can be transitioned to once per week or unless the dressing
becomes soiled HOWEVER site should be monitored daily for signs
of infection. dressing should be changed once per week or unless
the dressing becomes soiled. Pt will also need to have a routine
exchange of the tube every 3 months unless urology chooses to
intervene (this has been scheduled for [**2194-8-29**]). If a problem
occurs with the tube or urology requests an earlier tube
exchange or change, please call the interventional radiology
clinic services number [**Telephone/Fax (1) 8243**] to make the necessary
arrangements. As above, pt will be seen by urology on [**6-11**]
by urology for follow-up to ensure improvement and to determine
if additional interventions are required.
[]f/up remaining blood and urine cultures
[]f/up nephrostomy tube and resolution of infection; question
remains if further intervention will be needed to remove
obsturction


Medications on Admission:
acetaminophen 650 q4h prn
ASA 81 daily
Kcl 10 meq daily
simvastatin 20 daily
atenolol 25 mg [**Hospital1 **]
hydrochlorothiazide 25 mg daily
Metformin 1000mg [**Hospital1 **]
calcium carbonate 1300 daily
ciprofloxacin 250mg [**Hospital1 **] (received 2 doses, first dose 5/26 am)
D5 [**12-29**] normal saline @ 75 cc/hr x 13 hours, 20 min

Discharge Medications:
1. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO once a day.
4. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. atenolol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
6. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
7. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.

8. calcium carbonate 500 mg calcium (1,250 mg) Tablet, Chewable
Sig: Two (2) Tablet, Chewable PO once a day.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 9 days: To complete a total of 14 days of
abx. Day 1 = [**5-25**]
Day 14 = [**6-7**].
Disp:*9 Tablet(s)* Refills:*0*
12. Percutaneous Nephrostomy Tube
Nephrostomy site should be checked daily for signs of infection.
If soiled or erythematous, change dressing and monitor. As wound
heals, dressing changes can be transitioned to once per week or
if the dressing becomes soiled HOWEVER site should be monitored
daily for signs of infection. Tube will also need to have a
routine exchange of the tube every 3 months unless urology
chooses to intervene. An appointment has been made for [**2194-8-29**].
However, if a problem occurs with the tube or urology requests
an earlier tube exchange or change, please call the
interventional radiology clinic services number [**Telephone/Fax (1) 8243**] to
make the necessary arrangements.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - LTC

Discharge Diagnosis:
Primary:
-altered mental status, fever, hypotension due to E coli sepsis
secondary to UTI and nephrolithiasis
-acute renal failure due to obstruction and acute infectious
process

Secondary:
hypoxia
thrombocytopenia
anemia
hypertension

Discharge Condition:
Mental Status: Clear and coherent but with baseline mild
dementia

Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).

Discharge Instructions:
You came to the hospital because you were experiencing altered
mental status, fever, decreased blood pressure and were found to
have and bacterial infection of your urinary track as well as a
blockage of your left kidney because of stones. You were
admitted to the internsive care unit where you recieved
antibiotics, fluids and a tube was placed to help to decompress
your left kidney and drain the urine. Your symptoms improved and
you were able to be moved from the intensive care unit to the
regular floor. You continued to make improvements and it was
felt you could be discharge back to [**Hospital 100**] Rehab to complete
your recovery there. You will have close follow-up with your
regular doctor as well as urology and interventional radiology
(the doctors who placed the tube to help drain your kidney).
.
The following changes were made to your medications:
- Please START taking cipro to complete your 14 day course of
antibiotics (day 1 =[**5-25**]).
- Please continue to take all of your other home medications as
prescribed.

Percutaneous nephrostomy tube: Your site should be checked daily
for signs of infection. If soiled or erythematous, change
dressing and monitor. As wound heals, dressing changes can be
transitioned to once per week or unless the dressing becomes
soiled HOWEVER site should be monitored daily for signs of
infection. You will also need to have a routine exchange of the
tube every 3 months unless urology chooses to intervene. An
appointment has been made for you already. However, if a problem
occurs with the tube or urology requests an earlier tube
exchange or change, please call the interventional radiology
clinic services number [**Telephone/Fax (1) 8243**] to make the necessary
arrangements. You will also be seen by urology on [**6-11**] for
follow-up to ensure improvement and to determine if additional
interventions are required.

Please be sure to keep all follow-up appointments with your
primary care doctor, urologist and other health care providers.
.
It was a pleasure taking care of you and we wish you a speedy
recovery.


Followup Instructions:
Please be sure to keep all follow-up appointments with your
primary care doctor, urologist and other health care providers.

Department: SURGICAL SPECIALTIES
When: WEDNESDAY [**2194-6-11**] at 10:00 AM
With: UROLOGY UNIT [**Telephone/Fax (1) 164**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: RADIOLOGY CARE UNIT
When: FRIDAY [**2194-8-29**] at 7:00 AM [**Telephone/Fax (1) 446**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST     Best Parking: [**Street Address(1) 592**] Garage
**Nothing to eat or drink after midnight the night before**

Department: RADIOLOGY
When: FRIDAY [**2194-8-29**] at 8:30 AM [**Telephone/Fax (1) 8243**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST     Best Parking: [**Street Address(1) 592**] Garage



Completed by:[**2194-6-1**]
{'Septicemia due to escherichia coli [E. coli],Urinary tract infection, site not specified,Acute kidney failure, unspecified,Hydronephrosis,Hyposmolality and/or hyponatremia,Delirium due to conditions classified elsewhere,Pulmonary collapse,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other persistent mental disorders due to conditions classified elsewhere,Thrombocytopenia, unspecified,Iron deficiency anemia, unspecified,Unspecified essential hypertension,Other seborrheic keratosis,Severe sepsis'}


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, fever, hypotension

PRESENT ILLNESS: The patient is a [**Age over 90 **] year old resident of [**Hospital 100**] Rehab who
presents with altered mental status. She was recently started on
a course of cipro (D1 [**5-21**]). Today had addominal pain and
chills. Was noted to be hypotensive to 94/62. She had urinary
retention and a Foley was placed.
.
In the ED, initial vs were: 98.3 69 113/66 18 96% RA. Labs were
notable for leukocytosis with bandemia, thrombocytopenia, acute
renal failure and lactate of 3.8. She was given vanc and cipro.
She was given only 500cc of NS for IVF due to hyponatremia.
.
On arrival her family states that on tuesday ([**5-21**]) she had
severe flank pain and on wednesday ([**5-22**]) had pain that reminded
her of menstrual cramping. Last night she became acutely
confused but denied pain. At baseline, she has short term memory
loss but is oriented x3 and very active. Her mental status
represented an acute change and she was also lethargic. Other
notable recent past medical history is a tooth infection treated
with a course of antibiotics 3 weeks ago. She was suppossed to
have the tooth removed but this did not occur. She had
resolution of her symptoms.
.
Currently she denies pain, chest pain, dyspnea, abdominal pain.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.

MEDICAL HISTORY: NIDDM
HTN
high chol
dementia
cataracts
melanoma (completely excised)
s/p hysterctomy

MEDICATION ON ADMISSION: acetaminophen 650 q4h prn
ASA 81 daily
Kcl 10 meq daily
simvastatin 20 daily
atenolol 25 mg [**Hospital1 **]
hydrochlorothiazide 25 mg daily
Metformin 1000mg [**Hospital1 **]
calcium carbonate 1300 daily
ciprofloxacin 250mg [**Hospital1 **] (received 2 doses, first dose 5/26 am)
D5 [**12-29**] normal saline @ 75 cc/hr x 13 hours, 20 min

ALLERGIES: Sulfa (Sulfonamide Antibiotics) / Suprax / Paxil / Penicillins

PHYSICAL EXAM: Admission Exam:
General Appearance: Thin
Eyes / Conjunctiva: PERRL, ecchymoses on tongue
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : bilat bases, No(t) Wheezes : )
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing
Skin:  Warm, No(t) Rash: , No(t) Jaundice, many many SKs
Neurologic: Follows simple commands, Responds to: Verbal
stimuli, Movement: Not assessed, Tone: Not assessed, CNs intact

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: - Tobacco:  none
- Alcohol:  h/o very occaisional
- Illicits:  none 

### Response:
{'Septicemia due to escherichia coli [E. coli],Urinary tract infection, site not specified,Acute kidney failure, unspecified,Hydronephrosis,Hyposmolality and/or hyponatremia,Delirium due to conditions classified elsewhere,Pulmonary collapse,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other persistent mental disorders due to conditions classified elsewhere,Thrombocytopenia, unspecified,Iron deficiency anemia, unspecified,Unspecified essential hypertension,Other seborrheic keratosis,Severe sepsis'}
