CHIEF COMPLAINT: change in mental status

PRESENT ILLNESS: Mr. [**Known lastname 23203**] is a 78 year old male with h/o HTN, AAA, CVA and TIA,
found slumped over in a chair, unresponsive with ?new L facial
droop at his nursing home this a.m.  Of note, he was admitted 1
year ago in [**5-24**] with the exact same chief complaint,
additionally with slurred speech s/p reported fall and question
of incontinence.  A head CT at the time was negative for acute
stroke, MRI showed chronic microvascular disease, an old left
thalamic lacunar infarct, and MRA with some moderate stenosis in
the proximal to mid portion of his basilar artery.  His
neurologic deficits, thought to be a TIA, resolved, and he was
discharged on ASA 325 mg daily.

MEDICAL HISTORY: TIA, chronic microvascular disease.  See above.
HTN
AAA
vertebral compression fx s/p surgery
BPH
hx of removal of "skin tumor" on left face 40 years ago

MEDICATION ON ADMISSION: Aspirin 325mg QD
MVT QD
Atenolol 50mg QD
Hydrochlorothiazide 12.5mg QD
Vitamin D 400U QD
OYST-CAL-500 [**Hospital1 **]
Doxazosin 4mg QHS
FLomax 0.4mg QHS
Acetaminophen 325mg 2tbl Q4h prn for pain
Acetaminophen/ Diphenhydramin 1tabl QHS
Artificial tears

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 97.9, BP 147/71, HR 82, O2Sat 96, RR 19
GEN: NAD, intubated
HEENT: moist MM, Pupils 4mm, equal, reactive to light, JVP
difficult to evaluate [**12-23**] central line.
HEART: RR, normal rate, cresc-decresc murmur II/VI best heard
over RSB, no rubs or gallop.
LUNGS: anterior: mild, b/l crackles at the bases.
ABD: soft, nontender, nondistended, +BS
EXT: b/l symmetric, pitting 1+ edema, 2+DP
Skin: erythematous, indurated plaque with vesicles in T3
distribution over L side extending from sternum to mid-axillary
line. Also with petechial, nonblanching rash on dorsum of b/l
hands and feet.
NEURO: intubated, responsive to pain, turns his head to verbal
stimuli, normal muscle tone, 1+ reflexes b/l, no ankle reflexes
appreciated, plantars mute b/l.

FAMILY HISTORY: Unknown

SOCIAL HISTORY: Smoked in the past, quit 50 years ago, came from [**Doctor Last Name **] house.
Unspecified septicemia,Pneumonitis due to inhalation of food or vomitus,Methicillin susceptible pneumonia due to Staphylococcus aureus,Acute respiratory failure,Alkalosis,Severe sepsis,Unspecified essential hypertension,Abdominal aneurysm without mention of rupture
Septicemia NOS,Food/vomit pneumonitis,Meth sus pneum d/t Staph,Acute respiratry failure,Alkalosis,Severe sepsis,Hypertension NOS,Abdom aortic aneurysm
Admission Date:  [**2134-7-18**]              Discharge Date:   [**2134-7-24**]

Date of Birth:  [**2056-4-25**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 4052**]
Chief Complaint:
change in mental status

Major Surgical or Invasive Procedure:
intubation x 1 day in MICU
Right internal jugular central line placed in MICU
Left midline placed by interventional radiology on [**2134-7-22**] - pt t
obe discharged with this line.


History of Present Illness:
Mr. [**Known lastname 23203**] is a 78 year old male with h/o HTN, AAA, CVA and TIA,
found slumped over in a chair, unresponsive with ?new L facial
droop at his nursing home this a.m.  Of note, he was admitted 1
year ago in [**5-24**] with the exact same chief complaint,
additionally with slurred speech s/p reported fall and question
of incontinence.  A head CT at the time was negative for acute
stroke, MRI showed chronic microvascular disease, an old left
thalamic lacunar infarct, and MRA with some moderate stenosis in
the proximal to mid portion of his basilar artery.  His
neurologic deficits, thought to be a TIA, resolved, and he was
discharged on ASA 325 mg daily.

Report from the nursing home this morning is minimal.  He was
reportedly found slumped on his side in a chair in his room,
minimally responsive.  T 96, HR 60, BP 122/60.  Sent to [**Hospital1 18**]
ED.

Vitals on arrival to the ED were T 101, HR 111, BP 155/48, RR
28, 96% on 2L O2.  Given his fever, AMS, and a new petechial
rash that was noted, an LP was perfored: 3 WBC, 1 RBC, prot 47,
glucose 138.  He was pan cultured and started on
ceftriaxone/vancomycin.  UA negative.  Head CT negative for
acute process.  MRI head was negative for acute stroke, with
mild basilar artery stenosis and extensive white matter disease
seen on previous MRI that has progressed.  He was tachypneic,
with ABG 7.46/30/60, subsequently intubated.  Labs notable for
mild leukocytosis of 12.6, lactate 10; he had a central line
placed and was started on sepsis protocol, with lactate
decreasing to 8.6 then 2.8 with IVF.  CK 2184, increasing to
5000, though MBI wnl.  Trop 0.05.  Amylase was 512, lipase 53,
CT abdomen with consolidation/atelectasis at L lung base,
otherwise no intra-abdominal source for fever.

Past Medical History:
TIA, chronic microvascular disease.  See above.
HTN
AAA
vertebral compression fx s/p surgery
BPH
hx of removal of "skin tumor" on left face 40 years ago


Social History:
Smoked in the past, quit 50 years ago, came from [**Doctor Last Name **] house.

Family History:
Unknown

Physical Exam:
T 97.9, BP 147/71, HR 82, O2Sat 96, RR 19
GEN: NAD, intubated
HEENT: moist MM, Pupils 4mm, equal, reactive to light, JVP
difficult to evaluate [**12-23**] central line.
HEART: RR, normal rate, cresc-decresc murmur II/VI best heard
over RSB, no rubs or gallop.
LUNGS: anterior: mild, b/l crackles at the bases.
ABD: soft, nontender, nondistended, +BS
EXT: b/l symmetric, pitting 1+ edema, 2+DP
Skin: erythematous, indurated plaque with vesicles in T3
distribution over L side extending from sternum to mid-axillary
line. Also with petechial, nonblanching rash on dorsum of b/l
hands and feet.
NEURO: intubated, responsive to pain, turns his head to verbal
stimuli, normal muscle tone, 1+ reflexes b/l, no ankle reflexes
appreciated, plantars mute b/l.


Pertinent Results:
Admission labs:

Glucose-266* UreaN-25* Creat-1.5* Na-142 K-3.3 Cl-98 HCO3-20*

WBC-12.6* Hct-43.9 MCV-84 MCH-29.2 MCHC-34.8 RDW-14.0 Plt Ct-200
  - Neuts-90.1* Bands-0 Lymphs-6.4* Monos-3.0 Eos-0.2 Baso-0.3

PT-13.1 PTT-23.6 INR(PT)-1.1
[**2134-7-18**] CK(CPK)-5108*

[**2134-7-18**] Fibrino-295
[**2134-7-19**] FDP-10-40
[**2134-7-20**] Fibrino-531*#
[**2134-7-20**] FDP-10-40
Hapto-134
[**2134-7-18**] ANCA-NEGATIVE B
[**2134-7-18**] [**Doctor First Name **]-NEGATIVE
[**2134-7-18**] CRP-58.8*
[**2134-7-18**] C3-98 C4-21
ESR 10

[**2134-7-20**] ALT-32 AST-48* LD(LDH)-215 CK(CPK)-1624* AlkPhos-50
Amylase-198* TotBili-0.7
[**2134-7-18**] Lipase-53

[**2134-7-18**] CK-MB-19* MB Indx-0.9 cTropnT-0.05*
[**2134-7-18**] CK-MB-37* MB Indx-0.7 cTropnT-0.05*
[**2134-7-18**] CK-MB-31* MB Indx-0.7 cTropnT-0.03*

[**2134-7-19**] Albumin-3.1*

[**2134-7-18**] Type-ART pO2-60* pCO2-30* pH-7.46* calHCO3-22 Base XS-0
Intubat-NOT INTUBA
[**2134-7-18**] Type-ART PEEP-5 pO2-122* pCO2-39 pH-7.41 calHCO3-26
Base XS-0 Intubat-INTUBATED

[**2134-7-18**] Lactate-10.3*
[**2134-7-18**] Lactate-2.8*

CSF: WBC-3 RBC-1* Polys-7 Lymphs-62 Monos-0 Macroph-31,
TotProt-47* Glucose-138

CSF culture - no growth

sputum culture x 2 - MRSA isolated

[**Doctor Last Name 3945**] culture - Cdiff negative

IMAGING:
Admission CXR:
1. Left lower lobe atelectasis and probable pleural effusion.
Pneumonia in this region cannot be excluded.
2. Minor linear atelectasis at the right lung base.

CT HEAD: Study somewhat limited by motion and streak artifact.
No definite evidence of acute infarction. Chronic small vessel
infarction.

MRI/MRI HEAD:
1) No evidence of acute infarction or an infectious process.
2) Multiple small foci of likely chronic hemorrhage within the
basal ganglia, corona radiata, and brainstem; the etiology is
most likely secondary to chronic hypertensive hemorrhages. Less
likely differential considerations would include amyloid
angiopathy and occult arteriovenous malformations.
3) Multifocal elevated T2/FLAIR signal suggesting chronic
microvascular infarction.
4) Moderate stenosis of the proximal basilar artery. The
cerebral vessels are otherwise unremarkable.

CT ABDOMEN:
1) No definite source of fever/infection identified.
2) Bibasilar consolidation/atelectasis; correlate with clinical
picture for possible early pneumonia.
3) Atypical appearing fluid filled structure adjacent to the
bladder, which may represent a bladder diverticulum or
neobladder; correlate with urologic/surgical history.
4) Simple right kidney cyst.
5) Left lateral chest wall subcutaneous edema, which is likely
dependent.

EKG:  Sinus tachycardia, LAD, early R wave progression.  Not
significantly changed from prior.


Brief Hospital Course:
A/P:  78 year old male with h/o HTN, AAA, CVA and TIA, p/w
lethargy, L facial droop (?old), found to have mild
leukocytosis, fever, lactate of 10, ?PNA on CXR and CT.

1) Sepsis:  The patient was admitted to the [**Hospital Unit Name 153**] for code sepsis
based on elevated WBC count, elevated lactate, tachypneia.  It
was felt that the likely source was PNA.  His UA was negative,
CT abdomen negative for acute intra-abdominal process.  LP
showed 3 wbc, normal fluid studies, making meningitis unlikely.
C. Diff negative.  He was aggressively hydrated and lactate
dropped precipitously within the first 12 hours.  He was started
on broad spectrum antibiotics - ceftriaxone and vancomycin, as
well as azithromycin to cover atypical pneumonia which was later
discontinued given low clinical suspicion.  He remained afebrile
after the first day, with improvement in leukocytosis.  He
remained hemodynamically stable, and in fact became hypertensive
by his 2nd hospital day.  He was called out to the floors after
2 days in the ICU. On the floor the patient continued to
improve. He remained afebrile throughout and his sputum cultures
from the MICU grew MRSA. He was kept on IV vanco and ceftriaxone
and will be discharged with these medications to finish a 10 day
course.

It is unclear whether or not his PNA was the primary event, or
whether he had a viral syndrome with lethargy and resultant
aspiration pneumonia given the bilaterality of the pneumonia and
relative obtundation on admission.  He was kept on aspiration
precautions on the floor.  A swallow evaluation post-extubation
demonstrated good swallowing but difficulty handling his own
secretions. It was repeated on [**2134-7-23**] and the patient passed
swallow evaluation.

2) Hypoxic respiratory failure:  He was intubated in the ED
secondary to concern for impending airway compromise given his
altered level of consciousness and borderline ABG.  He was
maintained on AC for 1 day and extubated within 24 hours.
Pneumonia probably contributed to his initially mild A-a
gradient.  His initial mild respiratory alkalosis was likely
secondary to early sepsis.  He did well post-extubation. The
patient was kept on oxygen by nasal cannula while on the floor
and it was titrated down to room air with only occasional oxygen
prn.

3) Lethargy, facial droop:  Given his normal CT and head MRI, as
well as relatively normal LP (3 WBC borderline), these symptoms
were felt most consistent with reexpression of an old lesion in
the setting of distant infection - especially since he presented
with the exact same clinical findings on last admit 1 year ago.
Per Dr. [**Last Name (STitle) **], his facial droop was actually not new.  We
continued his daily ASA for stroke prophylaxis.

4) CK elevation:  This was felt likely secondary to prolonged
down time, with possible viral infection.  His MB index was
normal, therefore not likely cardiac.  His head MRI was negative
for stroke, making intracranial source unlikely.  His CK peaked
on the first night and declined with aggressive hydration.

5) Petechial rash:  His INR rose to 3.0 on admission, therefore
his rash was thought possibly secondary to DIC, though his
fibrinogen and FDP, haptoglobin, LDH were all normal.  Labs were
sent to rule out a vasculitis.  [**Doctor First Name **], ANCA, C3, C4 were all
normal.  CRP was markedly elevated, the significance of which is
uncertain in the setting of infection.  His petechiae slowly
resolved, and his coags normalized.

6) Erythematous rashe on chest: In the MICU this was felt most
consistent with Zoster given the distribution and small
vesicles.  He was placed on acyclovir.  His rash also extended
down his L arm, which is atypical for zoster, however. This was
discussed throughout his stay, as the rash on the chest did not
represent a full dermatomal band, not extending all the way
medially or laterally, and ending where the arm covered the
chest. The floor team suggested possible contact dermatitis,
although the rash did not resolve at all throughout his stay.
Notably the rash only extended up to the arm/armpit area of the
chest, and the pt also had a veyr erythematous area under the
tape holding his R arm IV.  It was decided to discontinue his
acyclovir as an outpatient given unlikely zoster presentation
and not improving. We will discharge him with hydrocortisone
cream [**Hospital1 **] applications to the chest rash.  Please follow this
rash as an outpt for progression/improvement.

7) Increased Amylase: His amylase elevation on admission
prompted a CT abdomen which did not demonstrate a source.  His
lipase was normal and his amylase trended down.

8) FEN:  He was kept NPO while intubated and before obtaining
clearance by speech and swallow. On [**7-23**] the patient was
restarted on ground consistency heart healthy diet with thin
liquids. Meds were given in applesauce.

9) Code: Full - discussed with HCP during this admission.

10) PPx: Placed on SQ heparin, Pantoprazole while intubated.

11) Access: In the MICU, pt had a R IJ, which was d/c-ed on
arrival to floor. He then had a midline placed on [**2134-7-22**] for
administration of IV antibiotics which will extend through
discharge. Please d/c the patient's midline access after abx
course finished.

12) s/p fall - on his first day on the floor, the pt stood to
use the bathroom, became dizzy and disoriented, and fell. He
reports hitting his head on the floor, neuro exam was unchanged,
it was not thought to be necessary to get a head CT given
unchanged neuro status.  Pt was placed on strict fall
precautions and PT evaluation was subsequently called.

12) pneumonia ppx - on the day of discharge the pt was given
pneumovax for pneumococcus prevention, as he is greater than 65
yo. His nursing home was called, who verified that according to
their records the pt had not received the vaccine, although they
could not verify longer than one year ago. Pt was unsure of his
status so vaccine was given.


Medications on Admission:
Aspirin 325mg QD
MVT QD
Atenolol 50mg QD
Hydrochlorothiazide 12.5mg QD
Vitamin D 400U QD
OYST-CAL-500 [**Hospital1 **]
Doxazosin 4mg QHS
FLomax 0.4mg QHS
Acetaminophen 325mg 2tbl Q4h prn for pain
Acetaminophen/ Diphenhydramin 1tabl QHS
Artificial tears


Discharge Medications:
1. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1)
ML Intravenous  DAILY (Daily) as needed: 10 ml NS followed by
1mL heparin flush in each lumen qDay and prn. Please inspect
site daily.
2. Ceftriaxone Sodium 1 g Piggyback Sig: One (1) gram
Intravenous  once a day for 5 days.
3. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous
q12 hours for 5 days.
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
5. Multivitamin     Tablet Sig: One (1) Tablet PO once a day.
6. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
7. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
once a day.
8. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO once a day.

9. Oyst-Cal-500 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
10. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO at bedtime.
11. Flomax 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO at bedtime.
12. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO q4h prn as needed
for pain.
13. Artificial Tears     Drops Sig: [**11-22**]  Ophthalmic  as needed
as needed.
14. Hydrocortisone 1 % Cream Sig: One (1) application Topical
twice a day for 1-2 weeks: please apply topically to rash on
chest twice a day for 1-2 weeks as needed.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 2670**] - [**Location (un) **]

Discharge Diagnosis:
MRSA pneumonia


Discharge Condition:
fair


Discharge Instructions:
Please give pt IV antibiotics as directed. Please d/c the
patient's midline access after IV antibiotics are finished.
Please use care when using pt's line to avoid infection.

Please check the patient's vancomycin trough level to be sure it
is below 15 (to preserve renal function). It was due to be
checked at 10pm on [**2134-7-23**]. Vanco dose can be lowered by your
physician on staff if necessary for high level.

Please call PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] to follow up with patient within
the next 1-2 weeks.

Patient may return to all of his previous medications.

Please note that pt received the pneumovax (pneumococcus
vaccine) on [**2132-7-22**].

If you have fever, chills, shortness of breath, or chest pain
please call Dr. [**Last Name (STitle) **] or go to the emergency room.

Followup Instructions:
Please call Dr. [**Last Name (STitle) **] to schedule a follow up appt within [**11-22**]
weeks.


                             [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 4055**]

Completed by:[**2134-7-24**]
{'Unspecified septicemia,Pneumonitis due to inhalation of food or vomitus,Methicillin susceptible pneumonia due to Staphylococcus aureus,Acute respiratory failure,Alkalosis,Severe sepsis,Unspecified essential hypertension,Abdominal aneurysm without mention of rupture'}


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: change in mental status

PRESENT ILLNESS: Mr. [**Known lastname 23203**] is a 78 year old male with h/o HTN, AAA, CVA and TIA,
found slumped over in a chair, unresponsive with ?new L facial
droop at his nursing home this a.m.  Of note, he was admitted 1
year ago in [**5-24**] with the exact same chief complaint,
additionally with slurred speech s/p reported fall and question
of incontinence.  A head CT at the time was negative for acute
stroke, MRI showed chronic microvascular disease, an old left
thalamic lacunar infarct, and MRA with some moderate stenosis in
the proximal to mid portion of his basilar artery.  His
neurologic deficits, thought to be a TIA, resolved, and he was
discharged on ASA 325 mg daily.

MEDICAL HISTORY: TIA, chronic microvascular disease.  See above.
HTN
AAA
vertebral compression fx s/p surgery
BPH
hx of removal of "skin tumor" on left face 40 years ago

MEDICATION ON ADMISSION: Aspirin 325mg QD
MVT QD
Atenolol 50mg QD
Hydrochlorothiazide 12.5mg QD
Vitamin D 400U QD
OYST-CAL-500 [**Hospital1 **]
Doxazosin 4mg QHS
FLomax 0.4mg QHS
Acetaminophen 325mg 2tbl Q4h prn for pain
Acetaminophen/ Diphenhydramin 1tabl QHS
Artificial tears

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 97.9, BP 147/71, HR 82, O2Sat 96, RR 19
GEN: NAD, intubated
HEENT: moist MM, Pupils 4mm, equal, reactive to light, JVP
difficult to evaluate [**12-23**] central line.
HEART: RR, normal rate, cresc-decresc murmur II/VI best heard
over RSB, no rubs or gallop.
LUNGS: anterior: mild, b/l crackles at the bases.
ABD: soft, nontender, nondistended, +BS
EXT: b/l symmetric, pitting 1+ edema, 2+DP
Skin: erythematous, indurated plaque with vesicles in T3
distribution over L side extending from sternum to mid-axillary
line. Also with petechial, nonblanching rash on dorsum of b/l
hands and feet.
NEURO: intubated, responsive to pain, turns his head to verbal
stimuli, normal muscle tone, 1+ reflexes b/l, no ankle reflexes
appreciated, plantars mute b/l.

FAMILY HISTORY: Unknown

SOCIAL HISTORY: Smoked in the past, quit 50 years ago, came from [**Doctor Last Name **] house. 

### Response:
{'Unspecified septicemia,Pneumonitis due to inhalation of food or vomitus,Methicillin susceptible pneumonia due to Staphylococcus aureus,Acute respiratory failure,Alkalosis,Severe sepsis,Unspecified essential hypertension,Abdominal aneurysm without mention of rupture'}
