CHIEF COMPLAINT: increased lethargy

PRESENT ILLNESS: 74yo F with HTN, DM, CVA, CRI and hx of frequent falls s/p ORIF
[**11-30**] who presents from [**Hospital3 2558**] unresponsive and O2 sat
of 80%. She was last admitted from [**Date range (1) **] with acute on
chronic renal failure and new CHF with new systolic and
diastolic dysfunction and was started on diuretics.
.
On discussion with staff at the [**Hospital3 2558**], the pt. was in
her USOH until this AM when she was noted to be more lethargic
than usual and demonstrated oxygen saturation of 62% on 3L NC.
She wears 3L O2 at baseline. She has been afebrile. No cough.
Baseline, can answer questions and is on oxygen per nursing. Per
[**Hospital3 **] RN, her lasix dose was decreased on [**3-14**] from 120
mg po qd to 80 mg po qd.
.
Per ED signout, she presented there initially hypoxic and with a
right gaze preference, not initially moving her LUE, and a
decreased gag reflex. She was intubated for airway protection
secondary to her decreased gag and she had a head CT that showed
no acute hemorrhage but an equivocal new hypodense focus in
right parietal white matter. Urine tox screen was negative and
labs showed worsening renal failure from 3.9-->4.6. She was
given vancomycin/levofloxacin/clindamycin for a questionable
PNA? She was also given narcan and lidocaine for unclear
reasons.
.
She was transferred to the [**Hospital Unit Name 153**] for further evaluation. Here,
she was intubated and sedated. No further history could be
obtained.
.

MEDICAL HISTORY: 1. Hypertension.
2. Diabetes mellitus.
3. Paranoid schizophrenia.
4. History of frequent falls.
5. Hypercholesterolemia.
6. Iron deficiency anemia.
7. Status post cerebrovascular accident in [**2149**].
8. History of granulomatous hepatitis in [**2139**].
9. Chronic renal insufficiency with a baseline creatinine of
1.2-1.6 but since surgery in [**Month (only) **] has been between [**1-15**].
10. OA
11. Hx of amyloid angiopathy
12. L. ORIF [**11-15**]
13. Paranoid schizophrenia

MEDICATION ON ADMISSION: 1. Hydralazine 75 mg po q6h
2. Ferrous Sulfate 325 mg po qd
3. Pantoprazole 40 mg po qd
4. Isosorbide Mononitrate SR 90 mg po qd
5. Lovenox 30 mg SC q24 h
6. B Complex-Vitamin C-Folic Acid 1 mg PO DAILY
7. Citalopram 10 mg po qd
8. Olanzapine 2.5 mg po qhs
9. Atorvastatin 10 mg po qd
10. Miconazole Nitrate 2 % Powder PRN
11. Metoprolol Tartrate 100 mg PO bid
12. Diltiazem SR 120 mg po qd
13. Epo Alfa 4000 units qM/W/F
14. Lasix 120 mg po qd-> 80 mg po qd
15. Metolazone 5 mg po bid

ALLERGIES: Penicillins / Aspirin / Cephalosporins

PHYSICAL EXAM: 97.1, 150/72, 89, 17, 100% on AC 450/16/5/100%
GEN- lying in bed intubated and sedated
HEENT- R. pupil larger than left, both reactive to light
NECK- supple
CV- RR, no M
CHEST- bibasilar rales anteriorly
ABD- soft, NT/ND, +BS
EXT- + 2 pitting edema bilaterally to upper thighs
NEURO- upgoing toes bilaterally, R>L patellar reflexes, could
not assess CN exam, not withdrawing to pain stimuli while on
propofol

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: No ETOH or IVDA. No smoking.
Acute respiratory failure,Acute on chronic combined systolic and diastolic heart failure,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Chronic kidney disease, unspecified,Paranoid type schizophrenia, chronic,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension
Acute respiratry failure,Ac/chr syst/dia hrt fail,Acute kidney failure NOS,Urin tract infection NOS,Chronic kidney dis NOS,Paranoid schizo-chronic,DMII wo cmp nt st uncntr,Hypertension NOS
Admission Date:  [**2157-3-20**]              Discharge Date:   [**2157-3-25**]

Date of Birth:  [**2082-2-26**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Aspirin / Cephalosporins

Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
increased lethargy

Major Surgical or Invasive Procedure:
Intubation, central line placement, arterial line placement


History of Present Illness:
74yo F with HTN, DM, CVA, CRI and hx of frequent falls s/p ORIF
[**11-30**] who presents from [**Hospital3 2558**] unresponsive and O2 sat
of 80%. She was last admitted from [**Date range (1) **] with acute on
chronic renal failure and new CHF with new systolic and
diastolic dysfunction and was started on diuretics.
.
On discussion with staff at the [**Hospital3 2558**], the pt. was in
her USOH until this AM when she was noted to be more lethargic
than usual and demonstrated oxygen saturation of 62% on 3L NC.
She wears 3L O2 at baseline. She has been afebrile. No cough.
Baseline, can answer questions and is on oxygen per nursing. Per
[**Hospital3 **] RN, her lasix dose was decreased on [**3-14**] from 120
mg po qd to 80 mg po qd.
.
Per ED signout, she presented there initially hypoxic and with a
right gaze preference, not initially moving her LUE, and a
decreased gag reflex. She was intubated for airway protection
secondary to her decreased gag and she had a head CT that showed
no acute hemorrhage but an equivocal new hypodense focus in
right parietal white matter. Urine tox screen was negative and
labs showed worsening renal failure from 3.9-->4.6. She was
given vancomycin/levofloxacin/clindamycin for a questionable
PNA? She was also given narcan and lidocaine for unclear
reasons.
.
She was transferred to the [**Hospital Unit Name 153**] for further evaluation. Here,
she was intubated and sedated. No further history could be
obtained.
.


Past Medical History:
1. Hypertension.
2. Diabetes mellitus.
3. Paranoid schizophrenia.
4. History of frequent falls.
5. Hypercholesterolemia.
6. Iron deficiency anemia.
7. Status post cerebrovascular accident in [**2149**].
8. History of granulomatous hepatitis in [**2139**].
9. Chronic renal insufficiency with a baseline creatinine of
1.2-1.6 but since surgery in [**Month (only) **] has been between [**1-15**].
10. OA
11. Hx of amyloid angiopathy
12. L. ORIF [**11-15**]
13. Paranoid schizophrenia


Social History:
No ETOH or IVDA. No smoking.

Family History:
noncontributory

Physical Exam:
97.1, 150/72, 89, 17, 100% on AC 450/16/5/100%
GEN- lying in bed intubated and sedated
HEENT- R. pupil larger than left, both reactive to light
NECK- supple
CV- RR, no M
CHEST- bibasilar rales anteriorly
ABD- soft, NT/ND, +BS
EXT- + 2 pitting edema bilaterally to upper thighs
NEURO- upgoing toes bilaterally, R>L patellar reflexes, could
not assess CN exam, not withdrawing to pain stimuli while on
propofol

Pertinent Results:
PRIOR ECHO: [**2157-2-1**]- EF 40-45%, symmetric LVH, Resting regional
wall motion abnormalities include mid to distal anteroseptal and
apical akinesis/hypokinesis. 1+ MR.
.
HEAD CT-
No acute hemorrhage or shift of normally midline structures.
Equivocal new hypodense focus in right parietal white matter.
MRI with diffusion weighted images is more sensitive in
evaluation of acute ischemia/infarct and for vascular detail.
.
CXR #1 - R. mainstem bronchus intubation, cardiomegaly,
pulmonary congestion, diffuse opacity of left lung, NG tube in
stomach
.
CXR #2 - CHF. Cannot clearly see an infiltrate on this CXR.


Brief Hospital Course:
A/P: 75 yo F with HTN, DM, CVA, CRI who presents from her NH
with hypoxia and unresponsive and intubated in the ED for airway
protection.
.
1. Hypoxia- Most likely etiology of this hypoxia is CHF
exacerbation given the CXR and BNP >70,000. Also considered in
the differential was a pneumonia and she was covered with
vanco/levaquin.  However, she remained afebrile and with flat
wbc count so these were eventually discontinued.  She received
diuretics that initially included a lasix gtt.  Howerver, she
failed to diurese well to this and it was expanded to include
diuril.  She responded with moderate diuresis to this regimen.
A family meeting was held with the sister [**1-13**] her recent decline
in functional capacity and the decision was made to extubate the
patient and change her code status to DNR/DNI.  She tolerated
the extubation w/out event and was maintained on a high flow
mask with SpO2 in the 90s.  Her CHF regimen was maximized with
hydralazine and imdur although an ACE-I was avoided [**1-13**] her ARF.

.
2. AMS:  The patient was unresponsive with decreased gag reflex
and left UE paralysis initially.  Neurology evaluated the
patient and a CT scan showed a new hypodensity.  Neurology felt
that this could be responsible for her AMS but that it was
likely not an acute event and had happened in the recent past.
After extubation, her mental status continued to be depressed
despite adequate treatment of her CHF and infectious processes.

.
3. Acute on chronic renal failure - This was attributed to both
her UTI and her increased lasix dose.  Her FeUrea >30 which did
not suggest a prerenal etiology.  She was treated for her
proteus UTI with ceftriaxone and continued to be diuresed as
above.  Her creatinine initially trended towards normal but rose
again just prior to discharge likely due to more aggressive
diuresis in the setting of her active CHF.
.
4. UTI - Treated with with ciprofloxacin initially but this was
changed to CTX once culture sensitivities became available.
.
4. HTN - Her BP was treated w/ hydral/imdur as above.
.
5. DM - She was followed with finger sticks and covered with an
ISS.
.
6. Code status - As mentioned previously, the patient was
initially full code and was intubated for respiratory
protection.  Discussion with her sister (and HCP) led to her
being extubated and her code status being changed to DNR/DNI.
At the time of discharge, the current plan of care was to make
her comfortable and continue to treat her underlying CHF/UTI
with oral meds if the patient was able to take them.  The HCP
wished to avoid any procedures that would cause her pain such as
central line placement, NGT placement, or the initiation of
pressors.

Medications on Admission:
1. Hydralazine 75 mg po q6h
2. Ferrous Sulfate 325 mg po qd
3. Pantoprazole 40 mg po qd
4. Isosorbide Mononitrate SR 90 mg po qd
5. Lovenox 30 mg SC q24 h
6. B Complex-Vitamin C-Folic Acid 1 mg PO DAILY
7. Citalopram 10 mg po qd
8. Olanzapine 2.5 mg po qhs
9. Atorvastatin 10 mg po qd
10. Miconazole Nitrate 2 % Powder PRN
11. Metoprolol Tartrate 100 mg PO bid
12. Diltiazem SR 120 mg po qd
13. Epo Alfa 4000 units qM/W/F
14. Lasix 120 mg po qd-> 80 mg po qd
15. Metolazone 5 mg po bid

Discharge Medications:
1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
2. Citalopram 20 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY (Daily).
3. Olanzapine 2.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime).
4. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical  TID
(3 times a day) as needed.
5. Benztropine 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
6. Docusate Sodium 150 mg/15 mL Liquid [**Last Name (STitle) **]: One Hundred (100) mg
PO BID (2 times a day).
7. Hydralazine 25 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO Q6H (every
6 hours).
8. Isosorbide Dinitrate 10 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO
TID (3 times a day).
9. Calcium Acetate 667 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
10. Ferrous Sulfate 325 (65) mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO
once a day.
11. Lasix 80 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO twice a day.
12. Rocephin in Dextrose (Iso-osm) 1 g/50 mL Piggyback [**Last Name (STitle) **]: One
(1) g Intravenous  Q24H (every 24 hours) for 7 days.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 2558**] - [**Location (un) **]

Discharge Diagnosis:
Urinary tract infection
Acute on chronic renal failure
sub-acute CVA


Discharge Condition:
Stable, bedbound and not taking POs


Discharge Instructions:
please take your medications as directed by the facility

Followup Instructions:
Please arrange to see your PCP [**Name Initial (PRE) 176**] 2weeks of discharge


                             [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

Completed by:[**2157-3-25**]
{'Acute respiratory failure,Acute on chronic combined systolic and diastolic heart failure,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Chronic kidney disease, unspecified,Paranoid type schizophrenia, chronic,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension'}


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: increased lethargy

PRESENT ILLNESS: 74yo F with HTN, DM, CVA, CRI and hx of frequent falls s/p ORIF
[**11-30**] who presents from [**Hospital3 2558**] unresponsive and O2 sat
of 80%. She was last admitted from [**Date range (1) **] with acute on
chronic renal failure and new CHF with new systolic and
diastolic dysfunction and was started on diuretics.
.
On discussion with staff at the [**Hospital3 2558**], the pt. was in
her USOH until this AM when she was noted to be more lethargic
than usual and demonstrated oxygen saturation of 62% on 3L NC.
She wears 3L O2 at baseline. She has been afebrile. No cough.
Baseline, can answer questions and is on oxygen per nursing. Per
[**Hospital3 **] RN, her lasix dose was decreased on [**3-14**] from 120
mg po qd to 80 mg po qd.
.
Per ED signout, she presented there initially hypoxic and with a
right gaze preference, not initially moving her LUE, and a
decreased gag reflex. She was intubated for airway protection
secondary to her decreased gag and she had a head CT that showed
no acute hemorrhage but an equivocal new hypodense focus in
right parietal white matter. Urine tox screen was negative and
labs showed worsening renal failure from 3.9-->4.6. She was
given vancomycin/levofloxacin/clindamycin for a questionable
PNA? She was also given narcan and lidocaine for unclear
reasons.
.
She was transferred to the [**Hospital Unit Name 153**] for further evaluation. Here,
she was intubated and sedated. No further history could be
obtained.
.

MEDICAL HISTORY: 1. Hypertension.
2. Diabetes mellitus.
3. Paranoid schizophrenia.
4. History of frequent falls.
5. Hypercholesterolemia.
6. Iron deficiency anemia.
7. Status post cerebrovascular accident in [**2149**].
8. History of granulomatous hepatitis in [**2139**].
9. Chronic renal insufficiency with a baseline creatinine of
1.2-1.6 but since surgery in [**Month (only) **] has been between [**1-15**].
10. OA
11. Hx of amyloid angiopathy
12. L. ORIF [**11-15**]
13. Paranoid schizophrenia

MEDICATION ON ADMISSION: 1. Hydralazine 75 mg po q6h
2. Ferrous Sulfate 325 mg po qd
3. Pantoprazole 40 mg po qd
4. Isosorbide Mononitrate SR 90 mg po qd
5. Lovenox 30 mg SC q24 h
6. B Complex-Vitamin C-Folic Acid 1 mg PO DAILY
7. Citalopram 10 mg po qd
8. Olanzapine 2.5 mg po qhs
9. Atorvastatin 10 mg po qd
10. Miconazole Nitrate 2 % Powder PRN
11. Metoprolol Tartrate 100 mg PO bid
12. Diltiazem SR 120 mg po qd
13. Epo Alfa 4000 units qM/W/F
14. Lasix 120 mg po qd-> 80 mg po qd
15. Metolazone 5 mg po bid

ALLERGIES: Penicillins / Aspirin / Cephalosporins

PHYSICAL EXAM: 97.1, 150/72, 89, 17, 100% on AC 450/16/5/100%
GEN- lying in bed intubated and sedated
HEENT- R. pupil larger than left, both reactive to light
NECK- supple
CV- RR, no M
CHEST- bibasilar rales anteriorly
ABD- soft, NT/ND, +BS
EXT- + 2 pitting edema bilaterally to upper thighs
NEURO- upgoing toes bilaterally, R>L patellar reflexes, could
not assess CN exam, not withdrawing to pain stimuli while on
propofol

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: No ETOH or IVDA. No smoking. 

### Response:
{'Acute respiratory failure,Acute on chronic combined systolic and diastolic heart failure,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Chronic kidney disease, unspecified,Paranoid type schizophrenia, chronic,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension'}
