CHIEF COMPLAINT: babesiosis

PRESENT ILLNESS: Mrs. [**Known lastname **] is a formerly healthy 73 F with a PMHx of dormant SLE
who presented to [**Hospital6 2561**] [**2156-8-30**] with few days'
history of fatigue, profound sleepiness, slurred speech and
fever. She lives in [**Hospital1 6687**], and gives a history of working
outside at home in the yard and being too busy to check herself
for ticks about a week ago, although she is uncertain of the
time. On [**8-30**] she was driving through [**State 350**] to a wedding
in upstate [**State 531**] when a concerned motorist who had been
following her felt that she had been driving erratically and
called police. She was then adviced to take a taxi to her
friend's house. She was noted to have slurred speech and "not
herself".
She was then brought to [**Hospital3 **] and was found to have
temperature of 102.6. Initial lab show WBC 6.8 Hct 29.1,
pletelet 76, nml PT and PTT. Patient received ASA and CTX in the
ED. She was intially thought to have lupus flare, and remained
intermittently somnolent and confused. ESR 83 and CRP350. Blood
smear on [**2156-8-31**] show >50% babesia. Patient received 2 doses of
azithromycin and was then started on clindamycin and quinine on
[**2156-9-1**]. Head CT showed subcortical disease bifrontally and MRI
head was negative.
She had a spurious Hct drop from 29.1 to 15.1, now 28.9 post 2u
PRBC transfusion. Platelets dropped from 76 to 40s with normal
coags and Cr 1.3 improving to 0.8. She was also found to have
rising LFTs and high LDH. She was transferred to [**Hospital1 18**] [**Hospital Unit Name 153**] [**9-1**]
in anticipation of possible exchange transfusion given her
parasite burden.
.
ROS: denies sick contacts. Otherwise, she denies chest pain,
shortness of breath, cough, abdominal pain, nausea/vomiting,
urinary complaints, heache, dizziness. She does have diarrhea
but claims that it is chronic.

MEDICAL HISTORY: systemic lupus not on immunosuppresion, no flare for >10 years
pernicious anemia
celiac sprue w/ chronic loose stool
hypertension
appendectomy
[**7-6**] ORIF of olecranon fracture(by Dr. [**Last Name (STitle) 284**]
abnormal LFTs from ?liver disease:liver bx in 97, us in
[**2154**]-neg.
mild aortic stenosis, recently diagnosed by echo [**6-5**], EF 75%
osteopenia

MEDICATION ON ADMISSION: MEDICATION at home
ALENDRONATE 70MG
ATENOLOL 25 MG QD
FLONASE
HYDROCHLOROTHIAZIDE 25 mg
LIDEX 0.05 %--apply to affected area twice a day
METROGEL 0.75%--Aplly twice a day to face for rash
OPTICROM 4%--1-2 drops each eye twice a day
PRILOSEC 20 mg
UNIVASC 15 mg [**Hospital1 **]
VITAMIN B-12 1000MCG QD
.
MEDICATION ON TRANSFER:
folic acid 1mg po QD
MVI
azithromycin 250 QD(d1=[**2156-9-1**], started w/500mg load, d/c's [**9-1**])

ALLERGIES: Penicillins

PHYSICAL EXAM: PHYSICAL EXAMINATION:
T100.3 P77 BP93/37 R28 97% on RA
Gen- lethargic, conversant initially but fall asleep later on in
exam
HEENT- anicteric, PERRLA, EOMI, dry mucous membrane, neck
supple, no cervical LAD
CV- rrr, 2/6 SEM in aortic area
RESP- CTAB
ABDOMEN- soft, nontender, nondistended, nml bowel sounds
EXT- no edema, strong pedal pulses bilaterally
SKIN- no rashes
NEURO- A+O to self, CNII-XII intact, move all 4 symmetrically

FAMILY HISTORY: deferred

SOCIAL HISTORY: Widowed, 2 children, lives in [**Hospital1 6687**].Former [**Male First Name (un) **] of [**Location (un) 11269**]
School, retired [**2144**]. Occasional alcohol use up to [**3-5**] drinks
daily.
Babesiosis,Hyposmolality and/or hyponatremia,Aortic valve disorders,Systemic lupus erythematosus,Other non-autoimmune hemolytic anemias,Thrombocytopenia, unspecified,Congestive heart failure, unspecified,Celiac disease,Disorder of bone and cartilage, unspecified,Unspecified essential hypertension
Babesiosis,Hyposmolality,Aortic valve disorder,Syst lupus erythematosus,Oth nonauto hem anemia,Thrombocytopenia NOS,CHF NOS,Celiac disease,Bone & cartilage dis NOS,Hypertension NOS
Admission Date:  [**2156-9-1**]              Discharge Date:   [**2156-9-7**]

Date of Birth:  [**2082-9-2**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 5755**]
Chief Complaint:
babesiosis

Major Surgical or Invasive Procedure:
none


History of Present Illness:
Mrs. [**Known lastname **] is a formerly healthy 73 F with a PMHx of dormant SLE
who presented to [**Hospital6 2561**] [**2156-8-30**] with few days'
history of fatigue, profound sleepiness, slurred speech and
fever. She lives in [**Hospital1 6687**], and gives a history of working
outside at home in the yard and being too busy to check herself
for ticks about a week ago, although she is uncertain of the
time. On [**8-30**] she was driving through [**State 350**] to a wedding
in upstate [**State 531**] when a concerned motorist who had been
following her felt that she had been driving erratically and
called police. She was then adviced to take a taxi to her
friend's house. She was noted to have slurred speech and "not
herself".
She was then brought to [**Hospital3 **] and was found to have
temperature of 102.6. Initial lab show WBC 6.8 Hct 29.1,
pletelet 76, nml PT and PTT. Patient received ASA and CTX in the
ED. She was intially thought to have lupus flare, and remained
intermittently somnolent and confused. ESR 83 and CRP350. Blood
smear on [**2156-8-31**] show >50% babesia. Patient received 2 doses of
azithromycin and was then started on clindamycin and quinine on
[**2156-9-1**]. Head CT showed subcortical disease bifrontally and MRI
head was negative.
She had a spurious Hct drop from 29.1 to 15.1, now 28.9 post 2u
PRBC transfusion. Platelets dropped from 76 to 40s with normal
coags and Cr 1.3 improving to 0.8. She was also found to have
rising LFTs and high LDH. She was transferred to [**Hospital1 18**] [**Hospital Unit Name 153**] [**9-1**]
in anticipation of possible exchange transfusion given her
parasite burden.
.
ROS: denies sick contacts. Otherwise, she denies chest pain,
shortness of breath, cough, abdominal pain, nausea/vomiting,
urinary complaints, heache, dizziness. She does have diarrhea
but claims that it is chronic.


Past Medical History:
systemic lupus not on immunosuppresion, no flare for >10 years
pernicious anemia
celiac sprue w/ chronic loose stool
hypertension
appendectomy
[**7-6**] ORIF of olecranon fracture(by Dr. [**Last Name (STitle) 284**]
abnormal LFTs from ?liver disease:liver bx in 97, us in
[**2154**]-neg.
mild aortic stenosis, recently diagnosed by echo [**6-5**], EF 75%
osteopenia

Social History:
Widowed, 2 children, lives in [**Hospital1 6687**].Former [**Male First Name (un) **] of [**Location (un) 11269**]
School, retired [**2144**]. Occasional alcohol use up to [**3-5**] drinks
daily.

Family History:
deferred

Physical Exam:
PHYSICAL EXAMINATION:
T100.3 P77 BP93/37 R28 97% on RA
Gen- lethargic, conversant initially but fall asleep later on in
exam
HEENT- anicteric, PERRLA, EOMI, dry mucous membrane, neck
supple, no cervical LAD
CV- rrr, 2/6 SEM in aortic area
RESP- CTAB
ABDOMEN- soft, nontender, nondistended, nml bowel sounds
EXT- no edema, strong pedal pulses bilaterally
SKIN- no rashes
NEURO- A+O to self, CNII-XII intact, move all 4 symmetrically


Pertinent Results:
[**2156-9-1**] 02:49PM   GLUCOSE-122* UREA N-25* CREAT-0.6 SODIUM-131*
POTASSIUM-3.9 TOTAL CO2-24
[**2156-9-1**] 02:49PM   ALT(SGPT)-37 AST(SGOT)-108* LD(LDH)-1100*
CK(CPK)-183* ALK PHOS-163* TOT BILI-1.9*
[**2156-9-1**] 02:49PM   CK-MB-3 cTropnT-<0.01
[**2156-9-1**] 02:49PM   ALBUMIN-2.4* CALCIUM-7.3* PHOSPHATE-1.5*
MAGNESIUM-2.2
[**2156-9-1**] 02:49PM   WBC-5.0 RBC-3.19* HGB-10.1* HCT-28.5*# MCV-90
MCH-31.6 MCHC-35.3* RDW-16.4*
[**2156-9-1**] 02:49PM   NEUTS-68 BANDS-12* LYMPHS-12* MONOS-3 EOS-0
BASOS-0 ATYPS-5* METAS-0 MYELOS-0
[**2156-9-1**] 02:49PM   PLT SMR-VERY LOW PLT COUNT-57*# LPLT-1+
[**2156-9-1**] 02:49PM   PT-12.2 PTT-27.7 INR(PT)-1.0
[**2156-9-1**] 02:49PM   FIBRINOGE-796*
[**2156-9-1**] 02:49PM   PARST SMR-POSITIV
[**2156-9-1**] 02:49PM   RET AUT-1.6
.
c diff negative [**9-6**], [**9-5**], [**9-4**], [**9-1**]
[**Last Name (un) **] cx [**9-1**]: negative
bld cx [**9-1**]: negative
Lyme serology: pending (Quest)
Ehrlichia: pending
.
EKG: NSR nl axis no ST/TW changes
.
CXR [**9-1**]:  Mediastinal widening is new in the interval and
may be due to lymphadenopathy.  Low lung volumes are present.
Heart is normal size.  Pulmonary vascularity is normal.  Lungs
are clear
.
CT CHEST WITHOUT AND WITH IV CONTRAST: There are no
pathologically enlarged lymph nodes within the mediastinum,
hila, or axilla. There are small bilateral pleural effusions
with associated dependent atelectasis. There are no focal
nodular opacities or areas of consolidation. There is no
evidence of pneumothorax.
Limited views of the upper abdomen demonstrate no obvious
abnormalities within the upper abdominal organs.
CTA CHEST: There is no evidence of filling defects within the
pulmonary arterial vasculature. No evidence of pulmonary
embolism. No evidence of aortic dissection or aneurysmal
dilatation. There are a few calcifications seen within the
aortic arch and descending aorta.
BONES: No suspicious lytic or sclerotic bony lesions.

IMPRESSION:
1. No evidence of pulmonary embolism, aortic dissection, or
mediastinal lymphadenopathy.
2. No evidence of pneumonia.


Brief Hospital Course:
# Babesiosis: Patient was admitted to the [**Hospital Unit Name 153**] for initial
admission for possible exchange transfusion given her extreme
parasite burden, however this was not necessary.  She was
monitored in the ICU and required intermittent boluses overnight
on hospital day #1 for sbp 80s.  ID was consulted and suggested
coverage with quinine and clindamycin, in addition to
doxycycline for possible concurrent Lyme or Ehrlichia.  Repeat
parasite smears trended down to 0.2% from > 50% at OSH, however,
patient's platelets continued to drop and she complained of
hearing loss concerning for possible cinchonism due to quinine.
She was thus switched to azithromycin and atovaqoune (through
[**9-13**]) and continued on the doxycycline (through [**9-21**]).
.
# Hemolytic anemia: Likely due to babesiosis.  Ferritin was >
[**2150**].  Folate and B12 were within normal limits.  Patient's
baseline hct was 38.5 in [**Month (only) 205**].  She was admitted to the OSH with
a hematocrit of 20.  She received a total of 4 U PRBC over the
course of her admission and her hematocrit on the day of
discharge was 32.5.  She was guiac negative during her hospital
stay.
.
# Thrombocytopenia:  Likely due to babesiosis.  Fibrinogen was
normal.  Platelets on day of discharge were up to 116.
.
# CHF: Developed in setting of IVF resuscitation.  On transfer
to the floor, patient was requiring 2 L supplemental O2 but this
resolved with autodiuresis.  CTA on transfer to the floor given
abnormal CXR in the ICU showed only mild CHF.
.
# Hyponatremia:  Likely was due to hypovolemia.  Returned to
[**Location 213**] with IVFs.
.
# Transaminitis:  Patient has baseline elevated AST, likely due
to alcohol use.  Ultrasound from '[**54**] normal.  Hepatitis
serologies were repeated this admission and were negative for
hep A and C antibody and showed borderline immune status to
hepatitis B without evidence of past infection.
.
# Diarrhea:  Patient had diarrhea during her hospital admission
which she stated was typical of her celiac sprue.  She normally
manages her symptoms with imodium.  C diff was negative x 4 and
patient was restarted on her imodium with good control of her
symptoms.
.
# Lupus: Asymptomatic without medications
.
# Hypertension:  BP meds initially held in the setting of
hypotension on admission.  Her blood pressure stabilized and her
BB and ACEI were restarted.  She will follow-up with her primary
care doctor as an outpatient to consider restarting her
diuretic.
.
# Osteopenia:  Patient was continued on calcium and fosamax and
started on vitamin D.
.
# Celiac sprue: Continued on B12.  Started on folate and vitamin
D supplementation.  Imodium prn.  Gluten-free diet.
.
# Recent ORIF for olecranon fx: Patient was scheduled for
follow-up with Dr. [**First Name (STitle) 4304**] [**Name (STitle) 284**].
.
# Dispo: PT was consulted and felt patient was safe for
discharge to home

Medications on Admission:
MEDICATION at home
ALENDRONATE 70MG
ATENOLOL 25 MG QD
FLONASE
HYDROCHLOROTHIAZIDE 25 mg
LIDEX 0.05 %--apply to affected area twice a day
METROGEL 0.75%--Aplly twice a day to face for rash
OPTICROM 4%--1-2 drops each eye twice a day
PRILOSEC 20 mg
UNIVASC 15 mg [**Hospital1 **]
VITAMIN B-12 1000MCG QD
.
MEDICATION ON TRANSFER:
folic acid 1mg po QD
MVI
azithromycin 250 QD(d1=[**2156-9-1**], started w/500mg load, d/c's [**9-1**])

atovaqoune 750mg [**Hospital1 **](d1=[**2156-9-1**]); d/c [**9-1**]
clindamycin 1200mg IV Q12(d1= [**9-1**])
quinine 520mg Q8H(d1= [**9-1**])
ativan prn
thiamine injection QD
protonix
ECASA 325


Discharge Medications:
1. Outpatient Lab Work
CBC w/ diff, sodium, glucose, BUN, creat, ALT, AST, alk phos, t
bili to be drawn at your follow-up with Dr. [**Last Name (STitle) **] on [**9-16**], [**2156**]
2. Atovaquone 750 mg/5 mL Suspension Sig: Seven [**Age over 90 1230**]y
(750) mg PO BID (2 times a day) for 7 days.
Disp:*[**Numeric Identifier **] mg* Refills:*0*
3. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours) for 7 days.
Disp:*14 Capsule(s)* Refills:*0*
4. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 15 days.
Disp:*30 Capsule(s)* Refills:*0*
5. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every
Monday).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO TID (3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Calcium Carbonate 500 mg Tablet Sig: One (1) Tablet PO three
times a day.
9. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Loperamide 2 mg Capsule Sig: [**2-2**] Capsules PO QID (4 times a
day) as needed for diarrhea: Start with 2 tablets following your
first loose stool, followed by additional 1 tablet as needed,
max 6 tablets perday.
13. Univasc 15 mg Tablet Sig: One (1) Tablet PO twice a day.


Discharge Disposition:
Home

Discharge Diagnosis:
primary: babesiosis
secondary: hemolytic anemia, thrombocytopenia, celiac sprue,
hypertension, osteopenia, transaminitis


Discharge Condition:
good - afebrile, cbc stable, afebrile


Discharge Instructions:
Please call your primary care doctor or go to the emergency room
if you experience temperature > 101, confusion/sleepiness,
abdominal pain or cramping, vomiting, or other concerning
symptoms.

Medication changes:
1. Please be sure to take your calcium 2 hours after your
antibiotics, as the 2 medications interact.
2. Please do not restart your hydrochlorothiazide until you see
Dr. [**Last Name (STitle) **]
3. Please start taking vitamin D and folate, as prescribed.
4. Please take the antibiotics, as prescribed, until they are
gone.

Followup Instructions:
Dr. [**Last Name (STitle) 13336**] office will be in contact with you regarding an
appointment to be scheduled for [**9-16**] to have your blood
counts and electrolytes rechecked.  If you do not hear from his
office by Friday, please call to determine your appointment
time.  Phone: [**Telephone/Fax (1) 250**]

Please follow-up with Dr. [**Last Name (STitle) 284**] on [**9-16**] at 9:00 AM.
[**Street Address(2) 1126**], [**Location (un) **], MA. Phone: ([**Telephone/Fax (1) 109381**]
{'Babesiosis,Hyposmolality and/or hyponatremia,Aortic valve disorders,Systemic lupus erythematosus,Other non-autoimmune hemolytic anemias,Thrombocytopenia, unspecified,Congestive heart failure, unspecified,Celiac disease,Disorder of bone and cartilage, unspecified,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: babesiosis

PRESENT ILLNESS: Mrs. [**Known lastname **] is a formerly healthy 73 F with a PMHx of dormant SLE
who presented to [**Hospital6 2561**] [**2156-8-30**] with few days'
history of fatigue, profound sleepiness, slurred speech and
fever. She lives in [**Hospital1 6687**], and gives a history of working
outside at home in the yard and being too busy to check herself
for ticks about a week ago, although she is uncertain of the
time. On [**8-30**] she was driving through [**State 350**] to a wedding
in upstate [**State 531**] when a concerned motorist who had been
following her felt that she had been driving erratically and
called police. She was then adviced to take a taxi to her
friend's house. She was noted to have slurred speech and "not
herself".
She was then brought to [**Hospital3 **] and was found to have
temperature of 102.6. Initial lab show WBC 6.8 Hct 29.1,
pletelet 76, nml PT and PTT. Patient received ASA and CTX in the
ED. She was intially thought to have lupus flare, and remained
intermittently somnolent and confused. ESR 83 and CRP350. Blood
smear on [**2156-8-31**] show >50% babesia. Patient received 2 doses of
azithromycin and was then started on clindamycin and quinine on
[**2156-9-1**]. Head CT showed subcortical disease bifrontally and MRI
head was negative.
She had a spurious Hct drop from 29.1 to 15.1, now 28.9 post 2u
PRBC transfusion. Platelets dropped from 76 to 40s with normal
coags and Cr 1.3 improving to 0.8. She was also found to have
rising LFTs and high LDH. She was transferred to [**Hospital1 18**] [**Hospital Unit Name 153**] [**9-1**]
in anticipation of possible exchange transfusion given her
parasite burden.
.
ROS: denies sick contacts. Otherwise, she denies chest pain,
shortness of breath, cough, abdominal pain, nausea/vomiting,
urinary complaints, heache, dizziness. She does have diarrhea
but claims that it is chronic.

MEDICAL HISTORY: systemic lupus not on immunosuppresion, no flare for >10 years
pernicious anemia
celiac sprue w/ chronic loose stool
hypertension
appendectomy
[**7-6**] ORIF of olecranon fracture(by Dr. [**Last Name (STitle) 284**]
abnormal LFTs from ?liver disease:liver bx in 97, us in
[**2154**]-neg.
mild aortic stenosis, recently diagnosed by echo [**6-5**], EF 75%
osteopenia

MEDICATION ON ADMISSION: MEDICATION at home
ALENDRONATE 70MG
ATENOLOL 25 MG QD
FLONASE
HYDROCHLOROTHIAZIDE 25 mg
LIDEX 0.05 %--apply to affected area twice a day
METROGEL 0.75%--Aplly twice a day to face for rash
OPTICROM 4%--1-2 drops each eye twice a day
PRILOSEC 20 mg
UNIVASC 15 mg [**Hospital1 **]
VITAMIN B-12 1000MCG QD
.
MEDICATION ON TRANSFER:
folic acid 1mg po QD
MVI
azithromycin 250 QD(d1=[**2156-9-1**], started w/500mg load, d/c's [**9-1**])

ALLERGIES: Penicillins

PHYSICAL EXAM: PHYSICAL EXAMINATION:
T100.3 P77 BP93/37 R28 97% on RA
Gen- lethargic, conversant initially but fall asleep later on in
exam
HEENT- anicteric, PERRLA, EOMI, dry mucous membrane, neck
supple, no cervical LAD
CV- rrr, 2/6 SEM in aortic area
RESP- CTAB
ABDOMEN- soft, nontender, nondistended, nml bowel sounds
EXT- no edema, strong pedal pulses bilaterally
SKIN- no rashes
NEURO- A+O to self, CNII-XII intact, move all 4 symmetrically

FAMILY HISTORY: deferred

SOCIAL HISTORY: Widowed, 2 children, lives in [**Hospital1 6687**].Former [**Male First Name (un) **] of [**Location (un) 11269**]
School, retired [**2144**]. Occasional alcohol use up to [**3-5**] drinks
daily. 

### Response:
{'Babesiosis,Hyposmolality and/or hyponatremia,Aortic valve disorders,Systemic lupus erythematosus,Other non-autoimmune hemolytic anemias,Thrombocytopenia, unspecified,Congestive heart failure, unspecified,Celiac disease,Disorder of bone and cartilage, unspecified,Unspecified essential hypertension'}
