CHIEF COMPLAINT: lethargy

PRESENT ILLNESS: 82 M with h/o IPF (on chronic steroids), PVD, h/o VT (on
dofetilide), and P.D. who had chronic constipation and taking 1
Tbsp of milk of magnesia QHS for 2 weeks.  He was noted to have
increasing somnulence from his baseline (interactive, able to
feed himself) and [**2169-1-2**] he was more lethargic with
unintelligible speech and visual hallucinations.  Per daughter
he was seeing cats and dogs.  Pt saw PCP the day prior to labs
drawn and found to have Mg 7.3.  He was instructed to go to OSH
where he was found to have Cr 2.2 (baseline 0.8).  He was given
3 amps CaGluc, IVF.  Transfered to [**Hospital1 18**] where he had Mg 6.3 and
Cr 1.6 --> taken to MICU for furhter monitoring.

MEDICAL HISTORY: 1. pulm fibrosis (on chronic steroids)
2. h/o VT (on dofetilide)
3. Shy-[**Last Name (un) **]/Parkinson's
4. venous stasis ulcers
5. PVD
6. GERD
7. s/p b/l knee replacement
8. s/p laminectomy
9. s/p R 1st toe amputation for gangrene

MEDICATION ON ADMISSION: prednisone 2.5 mg QD
combivent q6
triamterine-hctz 37.5/25 PO Qday
colace 100 mg PO Qday
Oxybutinin 5 mg PO BID
promipetol 0.125 PO BID
senna
percocet
sinemet 25-100 1.5 tabs QD
seroquel 25 mg PO QHS
Zocor 20 mg PO Qday
metoprolol 25 mg PO BID
omeprazole 10 mg PO Qday
Midodrine 10 mg PO TID

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 98.9 130/79 62 19 100% (RA)
Gen: lethargic, responds to name, follows commands, not oriented
to time/place
HEENT: dry mm
neck: no jvd, supple, no LAD
CV: s1, s2, no murmurs
Pulm: cta b/l
Abd: sft, nt, nd,
ext: s/p 1st toe amputation - well healing

FAMILY HISTORY: NC

SOCIAL HISTORY: lives at home with wife, who is HCP.  Former [**Name2 (NI) 1818**], quit.
Acute kidney failure, unspecified,Acute respiratory failure,Urinary tract infection, site not specified,Pneumonitis due to inhalation of food or vomitus,Toxic encephalopathy,Postinflammatory pulmonary fibrosis,Disorders of magnesium metabolism,Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site,Other specified cardiac dysrhythmias,Paralysis agitans,Esophageal reflux,Other toe(s) amputation status
Acute kidney failure NOS,Acute respiratry failure,Urin tract infection NOS,Food/vomit pneumonitis,Toxic encephalopathy,Postinflam pulm fibrosis,Dis magnesium metabolism,Proteus infection NOS,Cardiac dysrhythmias NEC,Paralysis agitans,Esophageal reflux,Status amput othr toe(s)
Admission Date:  [**2169-1-3**]              Discharge Date:   [**2169-1-31**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 898**]
Chief Complaint:
lethargy

Major Surgical or Invasive Procedure:
intubation; central line placement

History of Present Illness:
82 M with h/o IPF (on chronic steroids), PVD, h/o VT (on
dofetilide), and P.D. who had chronic constipation and taking 1
Tbsp of milk of magnesia QHS for 2 weeks.  He was noted to have
increasing somnulence from his baseline (interactive, able to
feed himself) and [**2169-1-2**] he was more lethargic with
unintelligible speech and visual hallucinations.  Per daughter
he was seeing cats and dogs.  Pt saw PCP the day prior to labs
drawn and found to have Mg 7.3.  He was instructed to go to OSH
where he was found to have Cr 2.2 (baseline 0.8).  He was given
3 amps CaGluc, IVF.  Transfered to [**Hospital1 18**] where he had Mg 6.3 and
Cr 1.6 --> taken to MICU for furhter monitoring.


Past Medical History:
1. pulm fibrosis (on chronic steroids)
2. h/o VT (on dofetilide)
3. Shy-[**Last Name (un) **]/Parkinson's
4. venous stasis ulcers
5. PVD
6. GERD
7. s/p b/l knee replacement
8. s/p laminectomy
9. s/p R 1st toe amputation for gangrene

Social History:
lives at home with wife, who is HCP.  Former [**Name2 (NI) 1818**], quit.

Family History:
NC

Physical Exam:
T 98.9 130/79 62 19 100% (RA)
Gen: lethargic, responds to name, follows commands, not oriented
to time/place
HEENT: dry mm
neck: no jvd, supple, no LAD
CV: s1, s2, no murmurs
Pulm: cta b/l
Abd: sft, nt, nd,
ext: s/p 1st toe amputation - well healing

Pertinent Results:
cxr: no infiltrate; no effulsion; +cardiomegaly
EKG: bigeminy; 1st degree AV block
*
[**2169-1-2**] 11:55PM   CALCIUM-9.3 PHOSPHATE-6.0*# MAGNESIUM-6.5*
[**2169-1-2**] 11:55PM   GLUCOSE-126* UREA N-67* CREAT-1.6* SODIUM-140
POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-31* ANION GAP-14
*

[**2169-1-3**] 10:24PM   CREAT-1.1
[**2169-1-3**] 10:24PM   CK(CPK)-29*
[**2169-1-3**] 10:24PM   CK-MB-NotDone cTropnT-0.04*
[**2169-1-3**] 10:24PM   CALCIUM-8.2* PHOSPHATE-5.4* MAGNESIUM-3.7*
[**2169-1-3**] 05:55PM   GLUCOSE-101 UREA N-51* CREAT-1.2 SODIUM-141
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-28 ANION GAP-11
[**2169-1-3**] 05:55PM   CALCIUM-8.6 PHOSPHATE-5.8* MAGNESIUM-3.9*
[**2169-1-3**] 02:32PM   GLUCOSE-124* UREA N-50* CREAT-1.1 SODIUM-141
POTASSIUM-3.3 CHLORIDE-105 TOTAL CO2-28 ANION GAP-11
[**2169-1-3**] 02:32PM   CK(CPK)-28*
[**2169-1-3**] 02:32PM   CK-MB-NotDone cTropnT-0.03*
[**2169-1-3**] 02:32PM   CALCIUM-7.7* PHOSPHATE-5.4* MAGNESIUM-3.8*
[**2169-1-3**] 02:32PM   HCT-36.0*
[**2169-1-3**] 01:04PM   TYPE-ART TEMP-36.5 RATES-/13 TIDAL VOL-500
PEEP-5 O2-50 PO2-193* PCO2-44 PH-7.42 TOTAL CO2-30 BASE XS-4
INTUBATED-INTUBATED VENT-SPONTANEOU
[**2169-1-3**] 01:04PM   LACTATE-1.4
[**2169-1-3**] 01:04PM   freeCa-1.01*
[**2169-1-3**] 05:25AM   GLUCOSE-230* UREA N-61* CREAT-1.3* SODIUM-138
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-28 ANION GAP-12
[**2169-1-3**] 05:25AM   CK(CPK)-27*
[**2169-1-3**] 05:25AM   CK-MB-3 cTropnT-0.03*
[**2169-1-3**] 05:25AM   CALCIUM-8.1* PHOSPHATE-6.4* MAGNESIUM-4.8*
[**2169-1-3**] 05:25AM   WBC-6.6 RBC-3.88* HGB-12.4* HCT-35.2* MCV-91
MCH-31.9 MCHC-35.2* RDW-14.5
[**2169-1-3**] 05:25AM   PLT COUNT-192
[**2169-1-3**] 05:05AM   TYPE-ART TEMP-37.2 RATES-12/ TIDAL VOL-650
PEEP-5 O2-100 PO2-455* PCO2-50* PH-7.42 TOTAL CO2-34* BASE XS-7
AADO2-217 REQ O2-44 -ASSIST/CON INTUBATED-INTUBATED
[**2169-1-3**] 05:05AM   LACTATE-1.6 NA+-135 K+-4.0
[**2169-1-3**] 04:39AM   LACTATE-0.3* NA+-146 K+-0.7*
[**2169-1-3**] 04:39AM   freeCa-0.37*
[**2169-1-3**] 12:47AM   LACTATE-3.3*
[**2169-1-3**] 12:20AM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2169-1-3**] 12:20AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2169-1-3**] 12:20AM URINE  RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2169-1-2**] 11:55PM   GLUCOSE-126* UREA N-67* CREAT-1.6* SODIUM-140
POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-31* ANION GAP-14
[**2169-1-2**] 11:55PM   CALCIUM-9.3 PHOSPHATE-6.0*# MAGNESIUM-6.5*
[**2169-1-2**] 11:55PM   ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2169-1-2**] 11:55PM   WBC-9.4 RBC-4.66 HGB-14.2 HCT-42.9 MCV-92
MCH-30.4 MCHC-33.0 RDW-14.6
[**2169-1-2**] 11:55PM   NEUTS-82* BANDS-8* LYMPHS-6* MONOS-3 EOS-0
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2169-1-2**] 11:55PM   PLT COUNT-206
[**2169-1-2**] 11:55PM   PT-13.8* PTT-31.8 INR(PT)-1.2

Brief Hospital Course:
hypermagnesemia - With regards to his hypermagnesemia, it
appears likely that he experienced dangerously elevated levels
of magnesium, with a maximum of 6.5 on admission.  The renal
service was consulted, and HD was considered, though his
electrolytes normalized shortly after admission, and his Cr
returned to baseline with rehydration.  It is felt that the
etiology of his hypermagnesemia was primarily secondary to
excessive Milk of Magnesia intake prior to admission and ARF (he
had been on oxycontin/oxycodone following toe amputation, and
was using laxative to counteract his constipation).

Hypotension - shortly after hospital admission, Mr. [**Known lastname 21781**]
became hypotensive in setting of hypermagnesemia and lasix
diuresis, and was briefly admitted to the MICU.  His MICU course
was notable for placement of a R subclavian line, volume
resuscitation with IV saline, and briefly requiring pressors,
with subsequent rapid resolution of his hypotension.

Hypoxia - MICU course also notable for an apneic episode,
lasting 50 seconds, with O2 desaturation from 100% RA to 90% RA,
and requiring emergent intubation.  He was successfully
extubated the following day.  It is felt that his hypoxia was
likely secondary to hypermagnesemia.  His electrolytes
normalized and he was transfered to the medical floor.

ARF - His Cr 1.6 on admission, and improved back to his baseline
of .5 -.9 with IV hydration.  Cr remained stable for remainder
of hospital course

arrhythmia - Mr. [**Known lastname 21781**] has been maintained on dofetilide,
given his history of ventriculra tachycardia (VT).  He was noted
to have frequent ectopy while on telemetry and on daily ECGs,
and given his h/o VT, an EP consult was obtained for further
titration of his medication regimen.  His dofetilide was
discontinued given his ARF, and out of concern for possible
future episodes of renal insufficiency (as it is not clear what
precipitated his ARF on admission).  After an appropriate time,
he was initiated on quinidine, and maintained on a dose of 324
mg SR twice daily.  His QT interval was monitored with daily
ECGs for the first several weeks, and remained stable.  He has
continued to have frequent ectopy, with frequent episodes of
short runs of supraventricular tachycardia.  He was monitored on
telemetry for 9 days, notable only for frequent ectopy and short
runs of SVT.  Prior to discharge, he was given [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts
monitor, for further evalution and titration of his quinidine
dosing, and he will follow-up with Dr. [**Last Name (STitle) 3321**], his
cardiologist.

UTI - Mr. [**Known lastname 21781**] was noted to have a proteus UTI, with a
multiply-drug resistant isolate.  He was initially treated for 3
days with levofloxacin, though switched to ceftriaxone when the
sensitivities returned (fluoroquinolone resistant isolate), with
resolution of his leukocytosis.

diarrhea - noted to have episodes of diarrhea worrisome for C
difficile colitis.  Though the toxin assay was negative, given
his significant leukocytosis and abx exposure, he was treated
with an empiric course of metronidazole via his NG-tube.

Altered mental status - On the medical floor, Mr [**Known lastname 21781**]
continued to be deleirius for much of the hospitalization.  A
neurology consult was obtained, and felt that his delerium and
lethargy were likely attributable to toxic/metabolic effects of
his acute illness, that may persist for weeks after
stabilization/resolution of his acute issues.  Multiple
medication changes were made to remove or reduce non-essential
medications.  EEG demonstrated encephalopathy (toxic-metabolic
pattern), with no evidence of epileptiform activity, and brain
MRI did not reveal any evidence of an acute intracranial
process.

Nutrition - Mr. [**Known lastname 21781**] required NG tube placement for
medications and for nutrition, given his altered sensorium,
which caused him to fail his first three speech and swallow
evaluations.  An NG tube was placed on two occasions via IR (he
pulled the first out), and he was maintained on tube feeds for
much of the hospitalization.  A fourth Speech and Swallow
evaluation, including videoswallow study, was obtained, and it
was determined that Mr. [**Known lastname 21781**] could in fact resume PO intake
with pureed solids and thin liquids, with Boost supplementation
with all meals, and with strict aspiration precautions.  His NG
tube was removed.  A calorie count was instated for several
days, and although Mr. [**Known lastname 21781**] only achieved approximately [**12-11**]
of his calorie target and [**12-12**] of his protein target, his family
was quite encouraged by his progress and on multiple occasions
clearly stated that they would not want to have a PEG tube
placed for enteral nutrition.  He also had not met his fluid
goals, and required saline rehydration several days prior to
discharge.

Parkinson's - maintained on carbidopa/levodopa, though Mirapex
was discontinued in an effort to simplify his medical regimen,
given his ongoing delerium.

pulmonary fibrosis - maintained on 5mg/day of prednisone for
much of the hospitalizaiton, though dose decreased to 2.5mg/day
several days prior to discharge as above (regimen
simplification).

Gout - Mr. [**Known lastname 21781**], in the setting of dehydration, was noted
to have an erythematous second MCP of the Right hand several
days prior to discharge, tender to palpation.  Given his h/o
gout, it is likely that this represented a gouty arthritis, and
was self-limited.  I have discussed with his family members that
when his delerium clears, it may be appropriate to restart him
on allopurinol, which he should discuss with his PCP.

s/p toe amputation - vascular surgery was consulted to follow
the patient, and twice daily dressing changes were carreid out,
with evidence of granulation tissue and overall good wound
healing.  He is to have once daily dry dressing changes
following discharge.

tinea - axillary rash with likely fungal involvement, and
miconazole was applied.


Medications on Admission:
prednisone 2.5 mg QD
combivent q6
triamterine-hctz 37.5/25 PO Qday
colace 100 mg PO Qday
Oxybutinin 5 mg PO BID
promipetol 0.125 PO BID
senna
percocet
sinemet 25-100 1.5 tabs QD
seroquel 25 mg PO QHS
Zocor 20 mg PO Qday
metoprolol 25 mg PO BID
omeprazole 10 mg PO Qday
Midodrine 10 mg PO TID

Discharge Medications:
1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
5000U Injection TID (3 times a day): until ambulatory.
2. Albuterol Sulfate 0.083 % Solution Sig: One (1)  Inhalation
Q4H (every 4 hours) as needed.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Quinidine Gluconate 324 mg Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO Q12H (every 12 hours).
5. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1)  PO TID (3
times a day).
6. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO QD
().
7. Carbidopa-Levodopa 25-100 mg Tablet Sig: 1.5 Tablets PO QD
().
8. Carbidopa-Levodopa 25-100 mg Tablet Sig: Two (2) Tablet PO Q
9AM ().
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical  TID
(3 times a day) as needed for rash in axilla.
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed.
12. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Multivitamin     Capsule Sig: One (1) Cap PO DAILY (Daily).



Discharge Disposition:
Extended Care

Facility:
Highgate Manor

Discharge Diagnosis:
hypermagnesemia
acute renal failure
hypotension
hypoxia/respiratory failure
s/p gangrene, right great toe amputation
delerium
Parkinson's disease
history of ventricular tachycardia
ectopy
Urinary tract infection (Proteus)
Gout
pulmonary fibrosis
GERD

Discharge Condition:
stable, though with ongoing delerium

Discharge Instructions:
Continue to take your medications as directed.
Your feet, and in particular the amputation site, should be
examined daily for signs of infection.  Contact your physician
or return to the emergency room if you notice any redness,
swelling or other concerning signs of infection, or if you
experience fevers or chills.
Contact your physician or return to the emergency department if
you experience any chest pain, shortness of breath, or other
symptoms that are concerning to you.

Followup Instructions:
Mr. [**Known lastname 21781**] should be maintained on strict aspiration
precautions, with pureed solids/thin liquids and Boost
supplementation until mental status (delreium) improves, at
which time repeat Speech and Swallow evaluation should be
carried out, and if he passes, diet can be advanced.

You have been given a 'King of Hearts' monitor, and should
follow up with the heart monitor laboratory at [**Hospital1 771**] ([**Telephone/Fax (1) 3104**]) and with Dr. [**Last Name (STitle) **]
to discuss the results, as well as possible changes in your
Quinidine dosing.

Follow-up with Dr. [**Last Name (STitle) 23155**]. Please phone his office to
schedule your appointment within the next 1-2 weeks
([**Telephone/Fax (1) 3121**]).

Follow-up with your primary care physician and with your
neurologist. Please call to schedule your appointments within
the next 1-2 weeks.

You have the following appointments:

Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Where: [**Hospital6 29**]
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2169-2-17**]
9:55

Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 611**]/DR. [**Last Name (STitle) **] Where: [**Hospital6 29**] MEDICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2169-2-17**] 10:10
{'Acute kidney failure, unspecified,Acute respiratory failure,Urinary tract infection, site not specified,Pneumonitis due to inhalation of food or vomitus,Toxic encephalopathy,Postinflammatory pulmonary fibrosis,Disorders of magnesium metabolism,Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site,Other specified cardiac dysrhythmias,Paralysis agitans,Esophageal reflux,Other toe(s) amputation status'}


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: lethargy

PRESENT ILLNESS: 82 M with h/o IPF (on chronic steroids), PVD, h/o VT (on
dofetilide), and P.D. who had chronic constipation and taking 1
Tbsp of milk of magnesia QHS for 2 weeks.  He was noted to have
increasing somnulence from his baseline (interactive, able to
feed himself) and [**2169-1-2**] he was more lethargic with
unintelligible speech and visual hallucinations.  Per daughter
he was seeing cats and dogs.  Pt saw PCP the day prior to labs
drawn and found to have Mg 7.3.  He was instructed to go to OSH
where he was found to have Cr 2.2 (baseline 0.8).  He was given
3 amps CaGluc, IVF.  Transfered to [**Hospital1 18**] where he had Mg 6.3 and
Cr 1.6 --> taken to MICU for furhter monitoring.

MEDICAL HISTORY: 1. pulm fibrosis (on chronic steroids)
2. h/o VT (on dofetilide)
3. Shy-[**Last Name (un) **]/Parkinson's
4. venous stasis ulcers
5. PVD
6. GERD
7. s/p b/l knee replacement
8. s/p laminectomy
9. s/p R 1st toe amputation for gangrene

MEDICATION ON ADMISSION: prednisone 2.5 mg QD
combivent q6
triamterine-hctz 37.5/25 PO Qday
colace 100 mg PO Qday
Oxybutinin 5 mg PO BID
promipetol 0.125 PO BID
senna
percocet
sinemet 25-100 1.5 tabs QD
seroquel 25 mg PO QHS
Zocor 20 mg PO Qday
metoprolol 25 mg PO BID
omeprazole 10 mg PO Qday
Midodrine 10 mg PO TID

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 98.9 130/79 62 19 100% (RA)
Gen: lethargic, responds to name, follows commands, not oriented
to time/place
HEENT: dry mm
neck: no jvd, supple, no LAD
CV: s1, s2, no murmurs
Pulm: cta b/l
Abd: sft, nt, nd,
ext: s/p 1st toe amputation - well healing

FAMILY HISTORY: NC

SOCIAL HISTORY: lives at home with wife, who is HCP.  Former [**Name2 (NI) 1818**], quit. 

### Response:
{'Acute kidney failure, unspecified,Acute respiratory failure,Urinary tract infection, site not specified,Pneumonitis due to inhalation of food or vomitus,Toxic encephalopathy,Postinflammatory pulmonary fibrosis,Disorders of magnesium metabolism,Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site,Other specified cardiac dysrhythmias,Paralysis agitans,Esophageal reflux,Other toe(s) amputation status'}
