CHIEF COMPLAINT: Confusion

PRESENT ILLNESS: After her last dialysis on Wednesday, she complained of
inability to sleep
at night and became increasingly confused. Her daughter
states that she has tried ativan and trazadone in the past with
poor results. She states the pt has hallucinated but is easily
oriented . Pt's daughter [**Name (NI) **] called to clinic. [**Name (NI) **] states
that pt has gotten worse. She is more disoriented and
hallucinating more. Pt
has been drinking, eating, and going to the bathroom w/o
difficulty. She currently denies any headache, dizziness. She
has some baseline chronic neck stiffness. Denies shortness of
breath, chest pain, palpitation or abdominal pain. Denies any
diarrhea.

MEDICAL HISTORY: Diabetes type II, diet-controlled
end-stage renal disease on dialysis q. [**Name (NI) 766**], Wednesday, [**Name (NI) 2974**]

MEDICATION ON ADMISSION: 

ALLERGIES: A.C.E Inhibitors / Ativan / Ambien

PHYSICAL EXAM: VSS: Tc 97.5 BP 145-160/74-110 160/110 (metoprolol given early)
P 64-70 O2 97-98%RA FS [**Telephone/Fax (3) 98749**]-193-178-155-155
GEN: NAD, comfortable, well-appearing
HEENT: NC/AT, PERRL, MMM, OP clear with denture in place,
sclarae anicteric
Neck: Supple, no bruit, no JVD
CV: RRR, no m/r/g
Chest: decreased breath sound on bases
Abd: S, NT/ND +BS, no palp hepatosplenomegaly, no palp masses,
no bruits
Ext: WWW, no edema, dialysis shunt in place over left arm
Neuro: [**Telephone/Fax (3) **] and oriented to person, place, not time,
appropriate response, CN II-XII grossly intact, motor and
sensory grossly intact

FAMILY HISTORY: 

SOCIAL HISTORY: Widow, retired English professor, lives with
her son and daughter, denies any drinking, drugs, or tobacco.
Ambulates with a cane
Hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney disease stage V or end stage renal disease,Congestive heart failure, unspecified,Hypertensive encephalopathy,Acute respiratory failure,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Coronary atherosclerosis of native coronary artery,Anemia in chronic kidney disease,Personal history of venous thrombosis and embolism,Depressive disorder, not elsewhere classified
Mal hyp ht/kd stg V w hf,CHF NOS,Hypertens encephalopathy,Acute respiratry failure,DMII wo cmp nt st uncntr,Crnry athrscl natve vssl,Anemia in chr kidney dis,Hx-ven thrombosis/embols,Depressive disorder NEC
Admission Date:  [**2172-8-21**]              Discharge Date:   [**2172-9-1**]

Date of Birth:  [**2103-11-27**]             Sex:   F

Service: MED

Allergies:
A.C.E Inhibitors / Ativan / Ambien

Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Confusion

Major Surgical or Invasive Procedure:
lumbar puncture

History of Present Illness:
After her last dialysis on Wednesday, she complained of
inability to sleep
at night and became increasingly confused. Her daughter
states that she has tried ativan and trazadone in the past with
poor results. She states the pt has hallucinated but is easily
oriented . Pt's daughter [**Name (NI) **] called to clinic. [**Name (NI) **] states
that pt has gotten worse. She is more disoriented and
hallucinating more. Pt
has been drinking, eating, and going to the bathroom w/o
difficulty. She currently denies any headache, dizziness. She
has some baseline chronic neck stiffness. Denies shortness of
breath, chest pain, palpitation or abdominal pain. Denies any
diarrhea.

Denies any recent medications, infections.

COurse in ED:
Her initial SBP at 210 and increased to 240. Labetolol 10mg X2
had to be given. Later, labetolol drip was started. It was
stopped at the time of transfer to the floor. 100mg lopressor
was given to continue maintain SBP. Her SBP at transfer was SBP
180 P 80. She denies any discomfort.


Past Medical History:
Diabetes type II, diet-controlled
end-stage renal disease on dialysis q. [**Name (NI) 766**], Wednesday, [**Name (NI) 2974**]

CHF, EF of 40% in [**8-1**], CAD, 2-vessel disease, RCA, and LAD,
[**2171-6-5**], catheterization unchanged
Stress test from [**5-3**], with 8 minutes on [**Doctor Last Name 4001**] protocol
without chest discomfort(appears to be a new reversible defect
inferior wall perfusion defect.

catheterization from [**8-1**], EF of 40%, 2-vessel disease as
described above, LAD 50% occluded,RCA totally occluded,
unchanged from [**12/2158**].

history of DVT
history of CVA and TIA
increased homocystine
cervical spondyloarthropathy
status post C4 and C7 fusion
refractory hypertension requiring hemodialysis
macrocytic anemia


Social History:
Widow, retired English professor, lives with
her son and daughter, denies any drinking, drugs, or tobacco.
Ambulates with a cane

Physical Exam:
VSS: Tc 97.5 BP 145-160/74-110 160/110 (metoprolol given early)
P 64-70 O2 97-98%RA FS [**Telephone/Fax (3) 98749**]-193-178-155-155
GEN: NAD, comfortable, well-appearing
HEENT: NC/AT, PERRL, MMM, OP clear with denture in place,
sclarae anicteric
Neck: Supple, no bruit, no JVD
CV: RRR, no m/r/g
Chest: decreased breath sound on bases
Abd: S, NT/ND +BS, no palp hepatosplenomegaly, no palp masses,
no bruits
Ext: WWW, no edema, dialysis shunt in place over left arm
Neuro: [**Telephone/Fax (3) **] and oriented to person, place, not time,
appropriate response, CN II-XII grossly intact, motor and
sensory grossly intact


Pertinent Results:
[**2172-8-29**] 09:45AM BLOOD WBC-5.8 RBC-3.98* Hgb-12.5 Hct-37.4
MCV-94 MCH-31.4 MCHC-33.4 RDW-14.7 Plt Ct-259
[**2172-8-28**] 06:45AM BLOOD WBC-7.7 RBC-3.87* Hgb-11.9* Hct-35.9*
MCV-93 MCH-30.8 MCHC-33.2 RDW-14.8 Plt Ct-265
[**2172-8-29**] 09:45AM BLOOD PT-12.2 PTT-26.7 INR(PT)-1.0
[**2172-8-29**] 09:45AM BLOOD Plt Ct-259
[**2172-8-29**] 09:45AM BLOOD Glucose-222* UreaN-20 Creat-5.2*# Na-141
K-3.7 Cl-100 HCO3-28 AnGap-17
[**2172-8-29**] 09:45AM BLOOD Glucose-222* UreaN-20 Creat-5.2*# Na-141
K-3.7 Cl-100 HCO3-28 AnGap-17
[**2172-8-29**] 09:45AM BLOOD Calcium-11.5* Phos-3.9 Mg-1.8
[**2172-8-29**] 09:45AM BLOOD Metanephrines (Plasma)-PND
[**2172-8-21**] 08:49PM BLOOD VITAMIN D [**2-23**] DIHYDROXY-PND


Brief Hospital Course:
1.  Acute Respiratory Failure:  Pt was admitted with acute
hypoxic/hypercapnic respiratory failure and emergently
transferred to the MICU.  She was intubated and placed on AC
ventilation without problem.  [**Name (NI) **] follow up ABG's showed
adequate ventilation and oxygenation on the ventilator.  Her CXR
showed new bilateral pulmonary infiltrates that were consistent
with acute cardiogenic pulmonary edema [**3-2**] hypertensive
emergency (i.e. forward failure due to increased afterload).
Since then, the pt has done well from a resp standpoint and was
extubated [**8-23**]. Discharged wtihout respiratory complaints.

2.  Hypertension:  Pt was admitted to MICU with SBP>180 and
treated with labetolol drip for 5-8 minutes before her BP
dropped to SBP 60's.  She was sedated with propofol prior to
this and her precipitous drop in MAP was thought to be [**3-2**]
propofol and vasovagal reaction from intubation.  She did
require dopamine and levophed and fluids (2L) to maintain her
SBP > 70.  This episode of shock lasted one hour and then his
resolved.  At that point her pressors were stopped and she
returned to SBP's > 170 again.

Her blood pressure significantly improved after dialysis with
removal of fluid and optimization of anti-HTN meds labetaolol,
valsartan, and norvasc.  Per pt's PCP, [**Name10 (NameIs) **] is quite sensitive to
anti-hypertensives and is at risk for orthostatic hypotension.

HTN thought to be secondary to chronic volume overload and
significant vessel non-compliance. Plasma metanephrin was sent
off and pt ruled out for pheochromocytoma.

3.  Renal Failure:  Dialysis was attempted on pt [**8-22**] but failed
due to labile BP's.  Her systolics decreased to < 60's during
dialysis so it had to be stopped.  Dialysis will be attempted
today agian.Dialyzed off 3L on [**8-23**].7L on [**8-26**] and 1.6 L on
[**8-28**]

4. Hypercalcemia. Ca climbed to 12. This is in the light of PTH
trending down on admission to 134. SPEP sent to rule out
multiple myeloma. PTH-rp workup is to be done as outpt for
possible malignancy. Ca trending down to 11.5 following vitD
analog administration.

4.  Altered Mental Status:  Pt was admitted to the hospital for
altered mental status, per daughter, thought to be secondary to
hypertensive encephalopathy vs uremia vs. infection.
Experienced waxing and [**Doctor Last Name 688**] mental status in the MICU with ICU
psychosis.  Steadily improved to baseline MS with resolution of
HTN.

5.  Leukocytosis:  Pt developed an elevated WBC count after
being admitted to the MICU.  This was attributed to stress
response of being intubated.  Meningitis r/o by LP.
Leukocytosis resolved without antibiotics.

6. Anemia-secondary to ESRD. Fe studies, B12, folate studies
pending.

Full Code

Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).

2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
3. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO QD (once a day).
5. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
6. Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
7. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Amlodipine Besylate 2.5 mg Tablet Sig: Three (3) Tablet PO HS
(at bedtime).
Disp:*60 Tablet(s)* Refills:*2*
9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).

10. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 86**] VNA

Discharge Diagnosis:
Acute Pulmonary Edema [**3-2**] Malignant Hypertension
Hypertensive Emergency
Altered Mental Status
Leukocytosis

Discharge Condition:
Stable

Discharge Instructions:
Transfer to floor

Followup Instructions:
Please continue with your MWF HD sessions.  Appointment made for
this Wednesday, [**2172-9-2**] at [**Location (un) 4265**] [**Location (un) **].

Provider: [**First Name11 (Name Pattern1) 4283**] [**Last Name (NamePattern4) 4284**], M.D. Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2172-10-1**] 9:30


                             [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
{'Hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney disease stage V or end stage renal disease,Congestive heart failure, unspecified,Hypertensive encephalopathy,Acute respiratory failure,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Coronary atherosclerosis of native coronary artery,Anemia in chronic kidney disease,Personal history of venous thrombosis and embolism,Depressive disorder, not elsewhere classified'}


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: Confusion

PRESENT ILLNESS: After her last dialysis on Wednesday, she complained of
inability to sleep
at night and became increasingly confused. Her daughter
states that she has tried ativan and trazadone in the past with
poor results. She states the pt has hallucinated but is easily
oriented . Pt's daughter [**Name (NI) **] called to clinic. [**Name (NI) **] states
that pt has gotten worse. She is more disoriented and
hallucinating more. Pt
has been drinking, eating, and going to the bathroom w/o
difficulty. She currently denies any headache, dizziness. She
has some baseline chronic neck stiffness. Denies shortness of
breath, chest pain, palpitation or abdominal pain. Denies any
diarrhea.

MEDICAL HISTORY: Diabetes type II, diet-controlled
end-stage renal disease on dialysis q. [**Name (NI) 766**], Wednesday, [**Name (NI) 2974**]

MEDICATION ON ADMISSION: 

ALLERGIES: A.C.E Inhibitors / Ativan / Ambien

PHYSICAL EXAM: VSS: Tc 97.5 BP 145-160/74-110 160/110 (metoprolol given early)
P 64-70 O2 97-98%RA FS [**Telephone/Fax (3) 98749**]-193-178-155-155
GEN: NAD, comfortable, well-appearing
HEENT: NC/AT, PERRL, MMM, OP clear with denture in place,
sclarae anicteric
Neck: Supple, no bruit, no JVD
CV: RRR, no m/r/g
Chest: decreased breath sound on bases
Abd: S, NT/ND +BS, no palp hepatosplenomegaly, no palp masses,
no bruits
Ext: WWW, no edema, dialysis shunt in place over left arm
Neuro: [**Telephone/Fax (3) **] and oriented to person, place, not time,
appropriate response, CN II-XII grossly intact, motor and
sensory grossly intact

FAMILY HISTORY: 

SOCIAL HISTORY: Widow, retired English professor, lives with
her son and daughter, denies any drinking, drugs, or tobacco.
Ambulates with a cane 

### Response:
{'Hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney disease stage V or end stage renal disease,Congestive heart failure, unspecified,Hypertensive encephalopathy,Acute respiratory failure,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Coronary atherosclerosis of native coronary artery,Anemia in chronic kidney disease,Personal history of venous thrombosis and embolism,Depressive disorder, not elsewhere classified'}
