CHIEF COMPLAINT: Dyspnea, fevers, mental status change

PRESENT ILLNESS: Ms. [**Known lastname **] is an 82 year old female with past medical history of
DM2, CAD who is admitted from [**Hospital **] Healthcare Center after
change in mental status. At baseline the patient is conversant
however today she was found to be less responsive than usual.
There was also note of some respiratory distress. She was
brought to [**Hospital1 18**] from the nursing home for further monitoring.
.
In the ED, the patient's vital signs were T 98.8, Tmax 102.2, BP
100/65, HR 118, RR 34, O2 sat 98% on NRB. On physical exam the
patient was unresponsive and did not withdraw to painful
stimuli. [**Hospital1 **] were notable for elevated WBC count 17.5, lactate
4.3, Na 164. CXR showed low lung volumes, with patchy airspace
process at the left lung base, which may be pneumonic
infiltrate. UA was positive for infection. She was given
Levofloxacin 750mg x1 and Ceftriaxone 1g x1, tylenol 500mg x1. A
head CT was done to work up the altered mental status. BP was
noted to be systolic 80s in the ED and she was given 3L NS. BP
responded to systolic 110s. She was also initially hypoxic to
84%, improved to 96% on NRB however remained tachypneic. She was
started on noninvasive ventilation and oxygen saturation
remained 95-99%. She is being admitted to the [**Hospital Unit Name 153**] for further
monitoring and treatment.

MEDICAL HISTORY: Diabetes Mellitus
Hypertension
Bipolar
Schizophrenia
Anemia
L1-L4 compression fracture
R hip revision
Osteoporosis
DVT in bilateral lower extremities
Tardive dyskinesia
.

MEDICATION ON ADMISSION: Lasix 20mg daily
Ascorbic acid 500mg daily
Glipizide 2.5mg daily
Fosamax 70mg weekly
Remeron 7.5mg daily
Lipitor 10mg daily
Valproic acid 250mg daily
Risperdal 0.5mg daily
Vicodin 5-500mg PRN

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 97.6, BP 108/49, HR 120, RR 16, 94 O2 sat .
GEN: Ill appearing elderly female in distress, rigoring.
Tachypneic.
HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection,
anicteric, OP clear, MMM, Neck supple, no LAD, no carotid bruits

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Lives at a nursing home. Unable to obtain remainder of social
history.
Unspecified septicemia,Pneumonitis due to inhalation of food or vomitus,Urinary tract infection, site not specified,Hyperosmolality and/or hypernatremia,Acute kidney failure, unspecified,Pressure ulcer, lower back,Pathologic fracture of vertebrae,Sepsis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified schizophrenia, unspecified,Personal history of venous thrombosis and embolism,Unspecified acquired hypothyroidism,Anemia, unspecified,Unspecified essential hypertension,Colostomy status,Long-term (current) use of insulin,Right bundle branch block and left posterior fascicular block
Septicemia NOS,Food/vomit pneumonitis,Urin tract infection NOS,Hyperosmolality,Acute kidney failure NOS,Pressure ulcer, low back,Path fx vertebrae,Sepsis,DMII wo cmp nt st uncntr,Schizophrenia NOS-unspec,Hx-ven thrombosis/embols,Hypothyroidism NOS,Anemia NOS,Hypertension NOS,Colostomy status,Long-term use of insulin,Rt bbb/lft post fasc blk
Admission Date:  [**2138-5-12**]              Discharge Date:   [**2138-5-16**]

Date of Birth:  [**2055-8-15**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Dyspnea, fevers, mental status change

Major Surgical or Invasive Procedure:
Speech and swallow eval

History of Present Illness:
Ms. [**Known lastname **] is an 82 year old female with past medical history of
DM2, CAD who is admitted from [**Hospital **] Healthcare Center after
change in mental status. At baseline the patient is conversant
however today she was found to be less responsive than usual.
There was also note of some respiratory distress. She was
brought to [**Hospital1 18**] from the nursing home for further monitoring.
.
In the ED, the patient's vital signs were T 98.8, Tmax 102.2, BP
100/65, HR 118, RR 34, O2 sat 98% on NRB. On physical exam the
patient was unresponsive and did not withdraw to painful
stimuli. [**Hospital1 **] were notable for elevated WBC count 17.5, lactate
4.3, Na 164. CXR showed low lung volumes, with patchy airspace
process at the left lung base, which may be pneumonic
infiltrate. UA was positive for infection. She was given
Levofloxacin 750mg x1 and Ceftriaxone 1g x1, tylenol 500mg x1. A
head CT was done to work up the altered mental status. BP was
noted to be systolic 80s in the ED and she was given 3L NS. BP
responded to systolic 110s. She was also initially hypoxic to
84%, improved to 96% on NRB however remained tachypneic. She was
started on noninvasive ventilation and oxygen saturation
remained 95-99%. She is being admitted to the [**Hospital Unit Name 153**] for further
monitoring and treatment.


Past Medical History:
Diabetes Mellitus
Hypertension
Bipolar
Schizophrenia
Anemia
L1-L4 compression fracture
R hip revision
Osteoporosis
DVT in bilateral lower extremities
Tardive dyskinesia
.


Social History:
Lives at a nursing home. Unable to obtain remainder of social
history.

Family History:
non-contributory

Physical Exam:
VS: T 97.6, BP 108/49, HR 120, RR 16, 94 O2 sat .
GEN: Ill appearing elderly female in distress, rigoring.
Tachypneic.
HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection,
anicteric, OP clear, MMM, Neck supple, no LAD, no carotid bruits

CV: RRR, nl s1, s2, no m/r/g
PULM: CTAB, no w/r/r with good air movement throughout
ABD: Soft, NT, ND, + BS, no HSM
EXT: warm, dry, +2 distal pulses BL, no femoral bruits
NEURO: alert & oriented, CN II-XII grossly intact, 5/5 strength
throughout. No sensory deficits to light touch appreciated. No
asterixis


Pertinent Results:
ADMISSION [**Hospital Unit Name **]:
===============

[**2138-5-12**] 10:28PM   TYPE-ART PO2-112* PCO2-35 PH-7.45 TOTAL
CO2-25 BASE XS-0
[**2138-5-12**] 10:28PM   LACTATE-4.3*
[**2138-5-12**] 07:29PM URINE  BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2138-5-12**] 07:29PM URINE  RBC-[**10-23**]* WBC->50 BACTERIA-MANY
YEAST-NONE EPI-[**2-5**]
[**2138-5-12**] 06:50PM   GLUCOSE-239* UREA N-34* CREAT-1.1 SODIUM-164*
POTASSIUM-3.9 CHLORIDE-124* TOTAL CO2-28 ANION GAP-16
[**2138-5-12**] 06:50PM   CK(CPK)-129
[**2138-5-12**] 06:50PM   cTropnT-0.07*
[**2138-5-12**] 06:50PM   CK-MB-2
[**2138-5-12**] 06:50PM   WBC-17.5* RBC-4.68 HGB-13.2 HCT-43.0 MCV-92
MCH-28.1 MCHC-30.6* RDW-15.2
[**2138-5-12**] 06:50PM   NEUTS-74.4* LYMPHS-22.7 MONOS-2.3 EOS-0.4
BASOS-0.3
[**2138-5-12**] 06:50PM   PT-13.7* PTT-23.4 INR(PT)-1.2*
[**2138-5-12**] 06:50PM   PLT COUNT-266

MICRO:
=====
[**2138-5-13**] 10:31 pm URINE      Source: Catheter.
URINE CULTURE (Final [**2138-5-15**]):    NO GROWTH.
[**2138-5-14**] 5:26 am BLOOD CULTURE      Source: Venipuncture.
Blood Culture, Routine (Pending):

DISCHARGE [**Month/Day/Year **]:
==============
[**2138-5-16**] 06:30AM BLOOD WBC-10.2 RBC-3.46* Hgb-9.7* Hct-31.3*
MCV-91 MCH-28.1 MCHC-31.0 RDW-15.0 Plt Ct-265
[**2138-5-16**] 06:30AM BLOOD Glucose-110* UreaN-4* Creat-0.4 Na-147*
K-4.1 Cl-108 HCO3-29 AnGap-14
[**2138-5-13**] 05:09AM BLOOD ALT-39 AST-35 LD(LDH)-242 CK(CPK)-144*
AlkPhos-46 TotBili-0.4
[**2138-5-16**] 06:30AM BLOOD Calcium-7.8* Phos-2.8 Mg-2.1
[**2138-5-16**] 06:30AM BLOOD Valproa-30*

IMAGING:
========
Non-contrast head CT.

IMPRESSION:
1. Severe global atrophy with prominent sulci and dilated
ventricles.
2. No acute intracranial process.

CHEST (PORTABLE AP)

IMPRESSION: Low lung volumes, with patchy airspace process at
the left lung base, which may be pneumonic.

EKG
Sinus tachycardia
Atrial premature complex
Incomplete right bundle branch block
Left anterior fascicular block
No previous tracing available for comparison

Intervals Axes
Rate PR QRS QT/QTc P QRS T
121 136 112 344/450 73 -86 43

CHEST (PA & LAT)
IMPRESSION:

1. Aspiration and/or pneumonia at the lung bases.
2. Diffuse calcified atherosclerosis of the thoracic aorta.
3. Compression deformity of a mid thoracic vertebral body, age
indeterminate.


Brief Hospital Course:
82 year old female with history of DM, CAD who presented to the
ED with altered mental status admitted with AMS found to have
UTI, LLL PNA.

# Hypotension/fever: Patient presented with altered mental
status, hypotension, elevated WBC count concerning for presepsis
picture. Source was concerning for urine vs lung or both. She
was briefly hypotensive in the ED, BP improved with fluids.
She was covered broadly with Vanc/Cefepime as she is from
nursing home and may have resistant bacteria. She received
volume resuscitation with IV boluses. Her urine culture final
report was no growth but it was taken after start of IV abx, she
was transitioned to po levaquin for a total 7 day course.
- On discharge she is afebrile and BP is 136/86, hr 95 95% ra

# hypoxia: she received CPAP for tachypnea with improvement.

# Hypernatremia: Na 164 on admission. Differential is insensible
losses, GI losses, hypothalamic lesion, central/nephrogenic DI
vs intrinsic renal disease. CT head showed no acute intracranial
process. Free water deficit was figured at 5.1L with plan to
give half over first 24hrs, then second half over second 24
hours. Her Na continued to trend down and was 146 on discharge.
- She needs to increase her PO free water intake
- If she is on hospice, discuss with guardian whether [**Name2 (NI) **]
should continue to be drawn.
- Her lasix was held in the setting of dehyration. Monitor for
need to restart.

# delirium: she required prn haldol upon admission but on day of
discharge was much calmer, oriented to self, able to repeat a
few words and followed some commands. She was engaging in
conversation. Her remeron was stopped in the setting of her
delirium as all unnecessary medications were stopped in an
effort to clear her sensorium. Her PM valproic acid was
decreased to help with MS.
- d/c foley ASAP as wound care allows
- monitor mental status with decrease of valproic acid.

# LLL Pneumonia: Patient hypoxic on arrival to the ED. Her xray
revealed LLL pna and was treated with levaquin. She was also
seen by speech and swallow as there was concern for aspiration.
- Complete course of levaquin

# Swallowing eval: seen by speech pathologist. Did not exhibit
signs of overt aspiration. She did pocket her foods.
- Supervision with meals is suggested to ensure that she takes
small sips.
- recommendation is pureed diet with nectar thick liquids via
sip cup, aternating between bites and sips.
- clear her mouth prior to reclining in bed
- ensure pudding between meals
.
# Acute Renal Failure: her creatine was 1.1 on admission from a
baseline of 0.5. On discharge it is 0.4.

# Diabetes mellitus: Oral agents were held and she was placed on
an insulin sliding scale. Her blood sugars were well controlled.
Consider whether she needs oral agents.

# Schizophrenia: continued on risperdal and valproic acid (at
reduced dose).

# Wound Care: she was seen by our wound care team as well as
plastic surgery who felt ulcer was not infected. See wound care
recommendations. She was placed on ATC tylenol for pain control.

# hypothyroidism: her TSH was elevated at 5.38. No medications
were started. This should be reaccessed when she is out of her
acute illness.
.
# PPx: she received sc heparin for dvt prophylaxis, may
discontinue per primary team. Also was on bowel regimen.

#CODE: DNR/DNI per guardian. She does not have capacity to make
decisions. Spoke with hospice nurse who felt that a discussion
should be had with the guardian around possible do not
hospitalize orders. Due to her hospice status her fosomax was
not continued. Consider also stopping her atorvastatin.


Medications on Admission:
Lasix 20mg daily
Ascorbic acid 500mg daily
Glipizide 2.5mg daily
Fosamax 70mg weekly
Remeron 7.5mg daily
Lipitor 10mg daily
Valproic acid 250mg daily
Risperdal 0.5mg daily
Vicodin 5-500mg PRN


Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale  Injection ASDIR (AS DIRECTED).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. Valproate Sodium 250 mg/5 mL Syrup Sig: One (1)  PO QAM (once
a day (in the morning)).
9. Valproate Sodium 250 mg/5 mL Syrup Sig: One (1)  PO QPM (once
a day (in the evening)).
10. Papain-Urea 830,000-10 unit/g-% Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
11. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours) for 7 days: First dose was [**5-14**], last dose
should be [**5-21**].
12. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Powder in
Packet Sig: One (1) Powder in Packet PO TID (3 times a day) for
2 days.
13. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO four
times a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Healthcare-[**Location (un) 86**]

Discharge Diagnosis:
Sepsis
Aspiration pneumonia
Urinary Tract Infection
Hypernatremia
Delirium
Acute Renal Failure
Sacral decubitis stage III
Diabetes Mellitus
Schizophrenia
h/o DVT bilateral lower extremeties


Discharge Condition:
Fair


Discharge Instructions:
You were admitted with mental status change, low blood pressure
and low oxygen count. You had a fever and a presumed infection
in your lung and were treated with antibiotics and intravenous
fluids. You also had a high level of sodium in your blood and
this can be helped by drinking more water.


Followup Instructions:
1. Patient should resume hospice services and consider a DO NOT
HOSPITALIZE order to go with her DNR.

2. Encourage increased PO water intake



Completed by:[**2138-5-16**]
{'Unspecified septicemia,Pneumonitis due to inhalation of food or vomitus,Urinary tract infection, site not specified,Hyperosmolality and/or hypernatremia,Acute kidney failure, unspecified,Pressure ulcer, lower back,Pathologic fracture of vertebrae,Sepsis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified schizophrenia, unspecified,Personal history of venous thrombosis and embolism,Unspecified acquired hypothyroidism,Anemia, unspecified,Unspecified essential hypertension,Colostomy status,Long-term (current) use of insulin,Right bundle branch block and left posterior fascicular block'}


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: Dyspnea, fevers, mental status change

PRESENT ILLNESS: Ms. [**Known lastname **] is an 82 year old female with past medical history of
DM2, CAD who is admitted from [**Hospital **] Healthcare Center after
change in mental status. At baseline the patient is conversant
however today she was found to be less responsive than usual.
There was also note of some respiratory distress. She was
brought to [**Hospital1 18**] from the nursing home for further monitoring.
.
In the ED, the patient's vital signs were T 98.8, Tmax 102.2, BP
100/65, HR 118, RR 34, O2 sat 98% on NRB. On physical exam the
patient was unresponsive and did not withdraw to painful
stimuli. [**Hospital1 **] were notable for elevated WBC count 17.5, lactate
4.3, Na 164. CXR showed low lung volumes, with patchy airspace
process at the left lung base, which may be pneumonic
infiltrate. UA was positive for infection. She was given
Levofloxacin 750mg x1 and Ceftriaxone 1g x1, tylenol 500mg x1. A
head CT was done to work up the altered mental status. BP was
noted to be systolic 80s in the ED and she was given 3L NS. BP
responded to systolic 110s. She was also initially hypoxic to
84%, improved to 96% on NRB however remained tachypneic. She was
started on noninvasive ventilation and oxygen saturation
remained 95-99%. She is being admitted to the [**Hospital Unit Name 153**] for further
monitoring and treatment.

MEDICAL HISTORY: Diabetes Mellitus
Hypertension
Bipolar
Schizophrenia
Anemia
L1-L4 compression fracture
R hip revision
Osteoporosis
DVT in bilateral lower extremities
Tardive dyskinesia
.

MEDICATION ON ADMISSION: Lasix 20mg daily
Ascorbic acid 500mg daily
Glipizide 2.5mg daily
Fosamax 70mg weekly
Remeron 7.5mg daily
Lipitor 10mg daily
Valproic acid 250mg daily
Risperdal 0.5mg daily
Vicodin 5-500mg PRN

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 97.6, BP 108/49, HR 120, RR 16, 94 O2 sat .
GEN: Ill appearing elderly female in distress, rigoring.
Tachypneic.
HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection,
anicteric, OP clear, MMM, Neck supple, no LAD, no carotid bruits

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Lives at a nursing home. Unable to obtain remainder of social
history. 

### Response:
{'Unspecified septicemia,Pneumonitis due to inhalation of food or vomitus,Urinary tract infection, site not specified,Hyperosmolality and/or hypernatremia,Acute kidney failure, unspecified,Pressure ulcer, lower back,Pathologic fracture of vertebrae,Sepsis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified schizophrenia, unspecified,Personal history of venous thrombosis and embolism,Unspecified acquired hypothyroidism,Anemia, unspecified,Unspecified essential hypertension,Colostomy status,Long-term (current) use of insulin,Right bundle branch block and left posterior fascicular block'}
