CHIEF COMPLAINT: altered mental status
hypotension

PRESENT ILLNESS: 74 YO M who was recently weaned from vent dependency brought in
from [**Hospital 100**] Rehab for altered mental status s/p recent
hospitalization for left fronto-parietal ICH c/b resp failure
requiring trach. The patient was in his usual state of health
this evening at dinner but shortly thereafter he became altered.
EMS was called and found BP 80s/40s, 93% 4L, FS 140, ABG done
with pCO2 50, left IO placed for access and transferred here for
further evaluation.
.
Of note, he was recently admitted to [**Hospital1 18**] with AMS secondary to
fronto-parietal ICH.  His course was complicated by respiratory
failure requiring intubation and eventual tracheostomy.  He
required PEG tube placement for extended feeding.  He underwent
treatment for VAP with vanco/cefepime/[**Hospital1 9847**], then a course of
vanco/zosyn for a urinary tract infection that grew a relatively
[**Name2 (NI) **]-sensitive proteus and enterococcus.  He had been rehabbing
at [**Hospital 100**] Rehab when he was noted to have altered mental status
today.  Of note, he developed a pruritic rash over his arms and
back two days ago, treated with topical steroids, antifungals,
and antihistamines.
.
In the ED, initial vs were: T98 P68 BP110/62 --> 80s --> 130s
--> 90s 79% 3L --> 95% on 4L. Exam was notable for R>L abd
tenderness to palpation and maculopapular rash on his torso.
Labs were notable for K 5.5, mild leukocytosis and UTI. CT
head/chest(CTA)/abd revealed soft tissue lesion. Vanc, zosyn and
1L NS were given. 2 PIVs were placed.
.
Upon arrival to the ICU, the patient reports no pain or adverse
symptoms.  Denies shortness of breath

MEDICAL HISTORY: - CHF (EF unknown)
- SBO
- gallstones
- HTN
- HLD
- GERD
- emphysema - on 3.5 L suppl O2 at baseline

MEDICATION ON ADMISSION: -amlodipine 10mg daily
-atenolol 100 qd
-cetirizine 10mg (started [**4-23**])
-erythromycin eye oitnement
-keppra 1000mg [**Hospital1 **] (started [**3-22**])
-methylphenidate 2.5mg [**Hospital1 **]
-nystatin S&S
-omeprazole 40mg daily
-zocor 40mg daiyl
-flomax 0.4 qhs
-albuterol/ipratroprium nebs PRN
-senna 8.6mg [**Hospital1 **]
-clobetasol topical [**Hospital1 **]
-nystatin topical prn
-zinc oxide topical

ALLERGIES: Flagyl

PHYSICAL EXAM: Physical Exam:
Vitals: T:98.2 BP: 127/52 P: 72 R: 19 O2: 95% 2LNC
General: Alert, answering questions appropriately, though thinks
he is still at rehab. Unclear on date, oriented to self.
HEENT: Sclera anicteric, mouth is dry, some desquamative lesions
on roof of mouth.
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, 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  in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: confluent, erythematous maculopapular rash over the
thoracic back, extensor arms and thighs.  Desquamation over
arms.

FAMILY HISTORY: - negative for known neurological conditions

SOCIAL HISTORY: - lives with fiance
- retired police officer
Urinary tract infection, site not specified,Diverticulitis of small intestine (without mention of hemorrhage),Chronic diastolic heart failure,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms,Other alteration of consciousness,Other specified hypotension,Neoplasms of unspecified nature, other specified sites,Unspecified late effects of cerebrovascular disease,Other specified disorders of skin,Unspecified drug or medicinal substance causing adverse effects in therapeutic use,Attention to tracheostomy,Other emphysema,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Unspecified essential hypertension,Esophageal reflux
Urin tract infection NOS,Dvrtcli sml int w/o hmrg,Chr diastolic hrt fail,Oth gram negatv bacteria,Other alter consciousnes,Hypotension NEC,Neoplasm other sites NOS,Late effect CV dis NOS,Skin disorders NEC,Adv eff medicinal NOS,Atten to tracheostomy,Emphysema NEC,Cholelithiasis NOS,Hypertension NOS,Esophageal reflux
Admission Date:  [**2173-4-25**]              Discharge Date:   [**2173-4-26**]

Date of Birth:  [**2098-12-21**]             Sex:   M

Service: MEDICINE

Allergies:
Flagyl

Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
altered mental status
hypotension

Major Surgical or Invasive Procedure:
none

History of Present Illness:
74 YO M who was recently weaned from vent dependency brought in
from [**Hospital 100**] Rehab for altered mental status s/p recent
hospitalization for left fronto-parietal ICH c/b resp failure
requiring trach. The patient was in his usual state of health
this evening at dinner but shortly thereafter he became altered.
EMS was called and found BP 80s/40s, 93% 4L, FS 140, ABG done
with pCO2 50, left IO placed for access and transferred here for
further evaluation.
.
Of note, he was recently admitted to [**Hospital1 18**] with AMS secondary to
fronto-parietal ICH.  His course was complicated by respiratory
failure requiring intubation and eventual tracheostomy.  He
required PEG tube placement for extended feeding.  He underwent
treatment for VAP with vanco/cefepime/[**Hospital1 9847**], then a course of
vanco/zosyn for a urinary tract infection that grew a relatively
[**Name2 (NI) **]-sensitive proteus and enterococcus.  He had been rehabbing
at [**Hospital 100**] Rehab when he was noted to have altered mental status
today.  Of note, he developed a pruritic rash over his arms and
back two days ago, treated with topical steroids, antifungals,
and antihistamines.
.
In the ED, initial vs were: T98 P68 BP110/62 --> 80s --> 130s
--> 90s 79% 3L --> 95% on 4L. Exam was notable for R>L abd
tenderness to palpation and maculopapular rash on his torso.
Labs were notable for K 5.5, mild leukocytosis and UTI. CT
head/chest(CTA)/abd revealed soft tissue lesion. Vanc, zosyn and
1L NS were given. 2 PIVs were placed.
.
Upon arrival to the ICU, the patient reports no pain or adverse
symptoms.  Denies shortness of breath


Past Medical History:
- CHF (EF unknown)
- SBO
- gallstones
- HTN
- HLD
- GERD
- emphysema - on 3.5 L suppl O2 at baseline


Social History:
- lives with fiance
- retired police officer


Family History:
- negative for known neurological conditions


Physical Exam:
Physical Exam:
Vitals: T:98.2 BP: 127/52 P: 72 R: 19 O2: 95% 2LNC
General: Alert, answering questions appropriately, though thinks
he is still at rehab. Unclear on date, oriented to self.
HEENT: Sclera anicteric, mouth is dry, some desquamative lesions
on roof of mouth.
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, 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  in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: confluent, erythematous maculopapular rash over the
thoracic back, extensor arms and thighs.  Desquamation over
arms.

Changes at discharge:
gen: A+0x3
skin: improving rash


Pertinent Results:
[**2173-4-25**] 05:17AM   ALBUMIN-3.2* CALCIUM-8.8 PHOSPHATE-4.9*#
MAGNESIUM-2.4 IRON-42*
[**2173-4-25**] 05:17AM   GLUCOSE-95 UREA N-40* CREAT-1.3* SODIUM-137
POTASSIUM-4.7 CHLORIDE-99 TOTAL CO2-31 ANION GAP-12
[**2173-4-25**] 05:17AM   WBC-15.9* RBC-3.18* HGB-10.1* HCT-30.2*
MCV-95 MCH-31.9 MCHC-33.6 RDW-17.5*
[**2173-4-24**] 10:25PM   CK-MB-2 cTropnT-<0.01
[**2173-4-24**] 10:25PM   WBC-14.3* RBC-3.41* HGB-10.8* HCT-32.6*
MCV-96 MCH-31.5 MCHC-33.0 RDW-17.4*
[**2173-4-24**] 10:32PM   LACTATE-1.9

Brief Hospital Course:
 Mr. [**Known lastname 90430**] is a 74yoM with recent hospitalization for
fronto-parietal ICH c/b respiratory failure requiring
tracheostomy, who presents from rehab with AMS in the setting of
leukocytosis, hypotension, and UA evidence of UTI.
.
# ALTERED MENTAL STATUS:  He presented altered from acute rehab
without clear catalyst.  Toxic/metabolic source from UTI appears
most likely.  In setting of recent ICH, CT head was pursued and
revealed no structural abnormality or bleed.  Electrolytes are
otherwise within normal limits.  No seizure activity noted.  ACS
possible given risk factors, though troponins negative.
Hypercarbia likewise possible, but his pCO2 seems to be better
than reference levels at the time of his last discharge.
Antihistamines provided in treatment of his rash can also
contribute to his AMS. Urine tox screen was negative. AMS likely
due to urosepsis.
.
# HYPOTENSION:  Patient presented with BP 80/40s from rehab,
also of unclear etiology though it was fluid-responsive in the
ED to 2LNS to sbb>100.  Urosepsis is possible given his
concerning UA and leukocytosis- no other infectious sources seen
in the lung, however abdominal CT makes note of a soft tissue
density c/w neoplasm versus diverticulitis.  PE and dissection
ruled out with CTA due to hypoxia and hypotension.  Started on
ciprofloxacin which will need to continue for total 14 days.
Holding atenolol until BP normalizes.
.
# URINARY TRACT INFECTION:  UA revealing likely UTI.  Had recent
UTI in his last hospitalization growing a relatively
[**Name2 (NI) **]-sensitive proteus and enterococcus.  Will narrow his
antibiotic spectrum to ciprofloxacin based on his previous
sensitivities. Blood and urine cultures need to be followed.
.
# RASH:  Blanching, confluent maculopapular rash over the back
and extensor surfaces of the upper arms and legs.  Appears
consistent with drug rash, though he has no peripheral
eosinophilia, and he was not recently challenged with new drugs.
A viral exanthem is also possible.  Fungal/candidal infection
appears unlikely. Rash is improving and should be followed by
PCP. [**Name10 (NameIs) **] mucosal involvment.
.
# ABDOMINAL SOFT TISSUE DENSITY: Seen on CT abdomen, of unclear
etiology: neoplasm versus possible small bowel diverticulitis.
Will need repeat CT in three weeks

# RECENT INTRACRANIAL HEMORRHAGE:  He recently underwent
hemorrhagic stroke possibly from converted ischemic stroke
versus amyloid process.  His neurologic exam is considerably
improved compared to his discharge exam.  No further bleed seen
on admission CT Head.  Continue keppra for seizure prophylaxis.
.
# CHRONIC OBSTRUCTIVE PULMONARY DISEASE:  CTA makes note of
stable emphysema. He has a substantial baseline 02 requirement
of 3.5LNC, so he is likewise at his respiratory baseline.
Exacerbation appears unlikely.  Continue albuterol and
ipratropium nebs as needed
.
# DIASTOLIC DYSFUNCTION: he carries a diagnosis of CHF,  though
EF shown to be preserved at 50-55% per previous hospitalization.
Appears dry on exam
.
# HYPERTENSION: holding amlodipine and atenolol in the setting
of hypotension.
.

Pt admitted [**4-25**] with hypotension and responsive to 2L NS with
SBP in low 100's. NCHCT showed no acute process (final read.) CT
torso concering for possible malignancy. He will require
interval CT in three weeks. Read posted below.
-CT Torso final read: 1. No acute process of the chest.
2. Soft tissue lesion in the mesentery of the right mid abdomen
with
surrounding inflammation of the mesenteric fat is new compared
to [**2173-3-5**]. Differential diagnosis is broad and
includes carcinoid, or less likely atypical Meckel
diverticulitis, sclerosing mesenteritis, or or other neoplasms
(metastases, soft tissue sarcoma or lymphoma).
He was started on [**Year (4 digits) 9847**] for his likely urinary source and will
continue this regime pending cultures. Attempted to load with
phenytoin but pt did not tolerate [**2-24**] caustic infusion and
hypotension. Per Neuro and Pharmacy, Keppra unlikely to cause
drug rash that was present upon presentation, and given Dilantin
intolerance, started Keppra back. He was alos Guaiac negative.
Hypotension likely result of urosepsis and caused altered mental
status. At dischare pt with SBP>100 and at normal mentation.
Unclear source of rash, but it is resolving. Given h/o ICH there
was concern for an acute intracranial process, but neg CT.
  Pt now at baseline mental status and wbc 10.5 from 15.9.


Medications on Admission:
-amlodipine 10mg daily
-atenolol 100 qd
-cetirizine 10mg (started [**4-23**])
-erythromycin eye oitnement
-keppra 1000mg [**Hospital1 **] (started [**3-22**])
-methylphenidate 2.5mg [**Hospital1 **]
-nystatin S&S
-omeprazole 40mg daily
-zocor 40mg daiyl
-flomax 0.4 qhs
-albuterol/ipratroprium nebs PRN
-senna 8.6mg [**Hospital1 **]
-clobetasol topical [**Hospital1 **]
-nystatin topical prn
-zinc oxide topical


Discharge Medications:
-amlodipine 10mg daily
-atenolol 100 qd
-cetirizine 10mg (started [**4-23**])
-erythromycin eye oitnement
-keppra 1000mg [**Hospital1 **] (started [**3-22**])
-methylphenidate 2.5mg [**Hospital1 **]
-nystatin S&S
-omeprazole 40mg daily
-zocor 40mg daiyl
-flomax 0.4 qhs
-albuterol/ipratroprium nebs PRN
-senna 8.6mg [**Hospital1 **]
-clobetasol topical [**Hospital1 **]
-nystatin topical prn
-zinc oxide topical
-[**Hospital1 9847**] 500mg PO q12 x 13 days

Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
urinary tract infection with likely urosepsis

Discharge Condition:
stable at baseline mental status

Discharge Instructions:
You were admitted to the intensive care unit and found to to
have a urinary tract infection. There are blood cultures still
pending that your doctor will need to follow up the results off.
We believe that the infection in your urine spread to your blood
stream causing your low blood pressure and altered mental
status. If your blood pressure is found to be low at your long
term care facility. Please take the [**Hospital6 9847**] 500mg every 12 hours
for the next 13 days to treat your urinary tract infection.
  On your CT scan there was a mass noted in the abdomen. You
will need a follow up CT in three weeks to further evaluate.
This could represent an infection or a possible cancer.

Followup Instructions:
Please be seen by your doctor in two day for a repeat evaluation
of your urine. You will need your blood pressure monitored until
then at your long term care facility.

                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]

Completed by:[**2173-4-26**]
{'Urinary tract infection, site not specified,Diverticulitis of small intestine (without mention of hemorrhage),Chronic diastolic heart failure,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms,Other alteration of consciousness,Other specified hypotension,Neoplasms of unspecified nature, other specified sites,Unspecified late effects of cerebrovascular disease,Other specified disorders of skin,Unspecified drug or medicinal substance causing adverse effects in therapeutic use,Attention to tracheostomy,Other emphysema,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Unspecified essential hypertension,Esophageal reflux'}


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
hypotension

PRESENT ILLNESS: 74 YO M who was recently weaned from vent dependency brought in
from [**Hospital 100**] Rehab for altered mental status s/p recent
hospitalization for left fronto-parietal ICH c/b resp failure
requiring trach. The patient was in his usual state of health
this evening at dinner but shortly thereafter he became altered.
EMS was called and found BP 80s/40s, 93% 4L, FS 140, ABG done
with pCO2 50, left IO placed for access and transferred here for
further evaluation.
.
Of note, he was recently admitted to [**Hospital1 18**] with AMS secondary to
fronto-parietal ICH.  His course was complicated by respiratory
failure requiring intubation and eventual tracheostomy.  He
required PEG tube placement for extended feeding.  He underwent
treatment for VAP with vanco/cefepime/[**Hospital1 9847**], then a course of
vanco/zosyn for a urinary tract infection that grew a relatively
[**Name2 (NI) **]-sensitive proteus and enterococcus.  He had been rehabbing
at [**Hospital 100**] Rehab when he was noted to have altered mental status
today.  Of note, he developed a pruritic rash over his arms and
back two days ago, treated with topical steroids, antifungals,
and antihistamines.
.
In the ED, initial vs were: T98 P68 BP110/62 --> 80s --> 130s
--> 90s 79% 3L --> 95% on 4L. Exam was notable for R>L abd
tenderness to palpation and maculopapular rash on his torso.
Labs were notable for K 5.5, mild leukocytosis and UTI. CT
head/chest(CTA)/abd revealed soft tissue lesion. Vanc, zosyn and
1L NS were given. 2 PIVs were placed.
.
Upon arrival to the ICU, the patient reports no pain or adverse
symptoms.  Denies shortness of breath

MEDICAL HISTORY: - CHF (EF unknown)
- SBO
- gallstones
- HTN
- HLD
- GERD
- emphysema - on 3.5 L suppl O2 at baseline

MEDICATION ON ADMISSION: -amlodipine 10mg daily
-atenolol 100 qd
-cetirizine 10mg (started [**4-23**])
-erythromycin eye oitnement
-keppra 1000mg [**Hospital1 **] (started [**3-22**])
-methylphenidate 2.5mg [**Hospital1 **]
-nystatin S&S
-omeprazole 40mg daily
-zocor 40mg daiyl
-flomax 0.4 qhs
-albuterol/ipratroprium nebs PRN
-senna 8.6mg [**Hospital1 **]
-clobetasol topical [**Hospital1 **]
-nystatin topical prn
-zinc oxide topical

ALLERGIES: Flagyl

PHYSICAL EXAM: Physical Exam:
Vitals: T:98.2 BP: 127/52 P: 72 R: 19 O2: 95% 2LNC
General: Alert, answering questions appropriately, though thinks
he is still at rehab. Unclear on date, oriented to self.
HEENT: Sclera anicteric, mouth is dry, some desquamative lesions
on roof of mouth.
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, 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  in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: confluent, erythematous maculopapular rash over the
thoracic back, extensor arms and thighs.  Desquamation over
arms.

FAMILY HISTORY: - negative for known neurological conditions

SOCIAL HISTORY: - lives with fiance
- retired police officer 

### Response:
{'Urinary tract infection, site not specified,Diverticulitis of small intestine (without mention of hemorrhage),Chronic diastolic heart failure,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms,Other alteration of consciousness,Other specified hypotension,Neoplasms of unspecified nature, other specified sites,Unspecified late effects of cerebrovascular disease,Other specified disorders of skin,Unspecified drug or medicinal substance causing adverse effects in therapeutic use,Attention to tracheostomy,Other emphysema,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Unspecified essential hypertension,Esophageal reflux'}
