CHIEF COMPLAINT: altered mental status

PRESENT ILLNESS: Pt is a 66 yo man with pmhx MCA stroke [**7-7**] and [**12-7**],
hyperlipidemia, HTN, DM who presents from [**Hospital 38**] rehab with
altered mental status for the last three days. His wife reported
that he was barely responsive on the day of admission and he was
sent to the ED. Of note, he has also been having very loose
stools for the last three days and was c dif positive on tuesday
and started on flagyl. He spiked fever on monday and had low
grade temps at rehab since then. He was on IVF at rehab per his
wife.

MEDICAL HISTORY: R M1 segment MCA stroke [**7-/2111**] with residual left facial droop,
left hand weakness/stiffness, mild dysarthria
hyperlipidemia
hypertension
diabetes, diagnosed [**8-/2111**], initially diet controlled w/ FS
100s,
last A1C 6.8, started on metformin
h/o tobacco use, quit after stroke [**7-/2111**]
s/p tonsillectomy

MEDICATION ON ADMISSION: senna
zocor 80 mg qd
coumadin
dulcolax daily
zofran 4 mg prn
oxycodone 5 mg q4 prn
sorbitol 30 cc qd
cardizem 30 mg q6
colace 100 mg [**Hospital1 **]
pepcid 20 mg [**Hospital1 **]
neurontin 300 mg tid
sliding scale insulin
lisinopril 5 mg qd
combivent q4 prn
tylenol prn
asa 325 mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 97 HR 127 Bp 102/51, RR 27, SaO2 92% on 100% NRB
Genl: tacchypneic, not responsive to questions or sternal rub,
withdrew to painful stimuli
HEENT: NCAT, Pupils 2 mm and slugishly reactive, MM dry
Neck: supple, no bruits
CV: irreg and tacchy, nl S1, S2, difficult to appreciate murmur
over loud chest sounds
Chest: anterior exam was diffusely rhoncherous
Abd: soft, NTND, BS+
Ext: warm and dry

FAMILY HISTORY: mother died age 66, had HTN, stroke; father died age 87

SOCIAL HISTORY: tob 2.5ppd x 50yrs, h/o heavy EtOH use, "in recovery" 21yrs,
no drug use, married
Unspecified septicemia,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Intestinal infection due to Clostridium difficile,Acute kidney failure, unspecified,Severe sepsis,Respiratory arrest,Other convulsions,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Atrial fibrillation,Other late effects of cerebrovascular disease, facial weakness,Encounter for palliative care,Personal history of tobacco use
Septicemia NOS,Pneumonia, organism NOS,Urin tract infection NOS,Int inf clstrdium dfcile,Acute kidney failure NOS,Severe sepsis,Respiratory arrest,Convulsions NEC,Hyperlipidemia NEC/NOS,Hypertension NOS,DMII wo cmp nt st uncntr,Atrial fibrillation,Facial weakness,Encountr palliative care,History of tobacco use
Admission Date:  [**2111-12-31**]              Discharge Date:   [**2112-1-3**]

Date of Birth:  [**2045-6-26**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
altered mental status

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Pt is a 66 yo man with pmhx MCA stroke [**7-7**] and [**12-7**],
hyperlipidemia, HTN, DM who presents from [**Hospital 38**] rehab with
altered mental status for the last three days. His wife reported
that he was barely responsive on the day of admission and he was
sent to the ED. Of note, he has also been having very loose
stools for the last three days and was c dif positive on tuesday
and started on flagyl. He spiked fever on monday and had low
grade temps at rehab since then. He was on IVF at rehab per his
wife.



Past Medical History:
R M1 segment MCA stroke [**7-/2111**] with residual left facial droop,
left hand weakness/stiffness, mild dysarthria
hyperlipidemia
hypertension
diabetes, diagnosed [**8-/2111**], initially diet controlled w/ FS
100s,
last A1C 6.8, started on metformin
h/o tobacco use, quit after stroke [**7-/2111**]
s/p tonsillectomy


Social History:
tob 2.5ppd x 50yrs, h/o heavy EtOH use, "in recovery" 21yrs,
no drug use, married


Family History:
mother died age 66, had HTN, stroke; father died age 87


Physical Exam:
VS: T 97 HR 127 Bp 102/51, RR 27, SaO2 92% on 100% NRB
Genl: tacchypneic, not responsive to questions or sternal rub,
withdrew to painful stimuli
HEENT: NCAT, Pupils 2 mm and slugishly reactive, MM dry
Neck: supple, no bruits
CV: irreg and tacchy, nl S1, S2, difficult to appreciate murmur
over loud chest sounds
Chest: anterior exam was diffusely rhoncherous
Abd: soft, NTND, BS+
Ext: warm and dry

Pertinent Results:
ADMISSION LABS

[**2111-12-31**] 08:10PM BLOOD WBC-5.5 RBC-4.19* Hgb-12.7* Hct-37.9*
MCV-91 MCH-30.4 MCHC-33.6 RDW-14.1 Plt Ct-192
[**2111-12-31**] 08:10PM BLOOD Neuts-79* Bands-5 Lymphs-5* Monos-6 Eos-0
Baso-0 Atyps-5* Metas-0 Myelos-0
[**2111-12-31**] 08:10PM BLOOD Plt Ct-192
[**2112-1-1**] 12:17AM BLOOD Fibrino-649*
[**2112-1-2**] 04:17AM BLOOD Fibrino-806*# D-Dimer-1592*
[**2112-1-1**] 12:17AM BLOOD Ret Aut-0.6*
[**2111-12-31**] 08:10PM BLOOD Glucose-144* UreaN-93* Creat-3.6*#
Na-149* K-3.9 Cl-109* HCO3-25 AnGap-19
[**2112-1-1**] 12:17AM BLOOD ALT-46* AST-105* LD(LDH)-318* AlkPhos-41
TotBili-0.2
[**2111-12-31**] 08:10PM BLOOD Calcium-8.4 Phos-4.0 Mg-2.4
[**2112-1-1**] 12:17AM BLOOD Hapto-305*
[**2112-1-1**] 12:17AM BLOOD TSH-0.36
[**2112-1-1**] 06:23AM BLOOD Phenyto-4.8*
[**2112-1-2**] 04:17AM BLOOD Phenyto-8.4*
[**2111-12-31**] 11:39PM BLOOD Type-ART Temp-36.1 pO2-52* pCO2-48*
pH-7.25* calTCO2-22 Base XS--6
.
LACTATES:
[**2111-12-31**] 08:18PM BLOOD Lactate-2.6*
[**2111-12-31**] 11:39PM BLOOD Lactate-1.3
[**2112-1-1**] 06:55AM BLOOD Lactate-1.2
[**2112-1-2**] 03:03PM BLOOD Lactate-2.3*
.
IMAGING
----------------
[**12-31**] head CT
Evolution of right MCA territory infarction with cortical
laminar necrosis.
.

[**1-1**] chest X ray
Airspace process of both lower lungs consistent with aspiration
or pneumonia.
.
[**1-2**]/ EEG
evidence of encephalomalacia, no epileptiform focus (prelim
read)


Brief Hospital Course:
Mr. [**Known lastname 23203**] is a 66 yo man with pmhx HTN, DM2, hyperlipidemia, R
MCA CVA who presented with altered mental status, fever, c diff,
seizure and was found to have pna and uti.
.
In the ED, initial vs were: T 98.4 HR 103 BP 120/60 R 26 O2 sat
90 % on RA. He was given 1 g vanco, 1 g ceftriaxone, 500 mg IV
flagyl, 975 mg rectal tylenol, 3 liters IVF for presumed UTI and
pna. He had a seizure in ED characterized by tonic clonic
movements witnessed and he was given 2 mg ativan. CT head done
in ED showed evolution of R MCA infarction. While in the ED, he
went into afib with rvr to the 140s which was new for the
patient. He was bolused with fluids but not given beta blockers
because of borderline low blood pressure. Patient was also noted
to be hypoxic to 80s on room air and cxr showed b/l infiltrates.
He was put on NRB and sats went up to mid 90s. Patient's family
confirmed DNR/DNI and did not want central line placed either.
.
On admission to the ICU, patient was tachy to 120-140s, SBP low
100s, afebrile, RR 20-30s and satting 88-90% on 100% NRB.
.
#. MS [**Name13 (STitle) 52034**] had multiple reasons for ms changes. Most
likely reason is infection given fever, newly diagnosed pna and
uti and recently diagnosed c diff infection. Patient had normal
ms after his cva and was alert and oriented x 3 before the past
few days when he began to spike fevers. He is somnolent now
after seizure in ED follwed by ativan and morphine. His stoke
may also be contributing although head CT showed evolution of
cva not a new stroke or bleeding into the stroke already
present.  He was initially treated with vanc, zosyn and flagyl
He was given a dilantin load and then continued on q 8 hour
dilantin at 100 mg.  EEG was done although seizure occured in
setting of fever of 104 which is likely culprit although he does
have known stroke focus.  He was not communicative, but did move
right side, respond to painful stimuli and eye flutter to voice.
 Neurology consulted but not following. MS changes likely
multifactorial, infection (PNA, UTI, Cdiff), stroke, hypoxia, w/
some residual deficits from old stroke. His mental status did
not recover after 2 days and after conversation with his wife,
his status was changed to [**Name (NI) 3225**].

#. Hypoxia- Patient had a large Aa gradient. This is likely due
to pna. He is unlikely to have PE given supratherapeutic INR of
6.1 and his cxr shows b/l infiltrates c/w pna. This could be
aspiration pna given ms changes and recent stroke. Pt may also
have a component of fluid overload from IVF given in ED.
He was treated with vanc and zosyn for broad coverage of nursing
home/hosp acquired pna and aspiration. Non-invasive ventilation
was started but he became uncomfortable, NC was used, then
discontinued after he became [**Name (NI) 3225**].
.
#. Hypotension- Fever, bandemia, consolidations on cxr, dirty
ua, recent c dif dx point towards sepsis as likely cause.
Patient also in afib with rvr which is contributing. Attempted
to slow hr down with 5 mg IV lopressor and pressure dropped to
70s systolic. He was given IVF to keep MAP > 65.  No central
access or a-line was placed as per his wife.
.
# cdif- He was continued on IV flagyl as he could not take po
due to mental status changes.
.
#. UTI- UA positive for leuks, bacteria and nitrites.  He was
treated with vanc and zosyn as he was covered for PNA was well.
Antibiotics were discontinued when the patients status was
changed to [**Name (NI) 3225**]
.
#. PNA- Patient could have nursing home associated pna and he
has recently been hospitalized. He had bands on diff,
consolidation on cxr and fever. Treated initially with
vanc/zosyn, then discontinued.

.
#. ARF- likely pre-renal given low bp and afib with rvr, sepsis.
Bolused w/ IVF and renally dosed meds. Held lisinopril.
.
#. Stroke- Patient has known MCA infarct and on CT head here he
has evolution of infarct but no new stroke or bleed.
Dilantin loaded and maitenance doses given, INR was
supratherapeutic, held coumadin
continued asa pr.
.
#. Seizure- patient had seizure in ED likely related to high
grade fever or known cva. Given ativan in ED. Dilantin as above
and eeg with results as reported.
.
#. hyperlipidemia- held statin as npo
.
#. HTN-held anti-hypertensives as pt was hypotensive
.
#. Afib- patient already supratherapeutic on coumadin, rate
under better control after 5 mg IV lopressor
.
#. DM- RISS, finger sticks qachs
.
#. FEN- IVF bolus to keep MAP > 65, replete lytes prn, npo
.
#. PPx- IV protonix, no need for subq heparin as last INR was 6
.
#. Access: 2 PIV, family does not want central access
.
#. Communication: with wife: [**Name (NI) 2048**] [**Name (NI) 23203**], p# is (c)
[**Telephone/Fax (1) 52033**], (h) [**Telephone/Fax (1) 52032**]
.
#. Code: DNR/DNI confirmed with wife
.
#. Dispo: ICU level of care for now
.
#.
MICU INTERN PROGRESS NOTE UPDATED [**2112-1-2**]

A/P: Pt is a 66 yo man with pmhx HTN, DM2, hyperlipidemia, R MCA
CVA [**12-7**] and [**7-7**] who presents from rehab w/ 1 week of diarrhea,
cdiff confirmed at rehab, did not improve on IV flagyl at rehab,
presenting with Acute MS changes, seizure, Afib w/ RVR, found to
have PNA, UTI, hypoxia with supratherapeutic INR.
.
#. MS changes-  Unlikely Non-convulsive status epilepticus, but
needs to be ruled out still.
- EEG today to rule out epileptic focus and NCSE
- Cont infection rx as below.
- Monitor for clinica sz activity if worsens give ativan,
otherwise avoid ativan.
- If aggitated use haldol rather than ativan.
.
#. Hypoxia- Patient has large Aa gradient. This is likely due to
pna. He is unlikely to have PE given supratherapeutic INR of 6.1
and his cxr shows b/l infiltrates c/w pna. Possible Asp PNA
given stroke hx.
-Cont Rx with Vanc and zosyn for PNA covergage given
NH/rehab/hosp exposure.
-discuss non-invasive vent w/ family.
-DNI
.
#FEVER to 101.1 [**1-2**]
-cont ABX
-po liquid tylenol
-pan culture
.
#. [**Name (NI) **] Resolved, Pt had SIRS like picture on admission.

-Leukocytosis and bandemia
-IVF to keep MAP > 65, UOp >25cc/hr
-no central access or a-line per wife
- IF respiratory status declines, could consider brief
peripheral pressors to avoid fluid overload.
.
# cdif- Send repeat Cdiff eia.
-Pt spiked through IV flagyl at rehab,
-added PO Vanc starting [**1-2**]
.
#. UTI- UA positive for leuks, bacteria and nitrites.
-[**12-31**] Ucx grew GNR
-F/u sensi.
-Cont Zosyn, narrow coverage as sensitivities return.
.
#. PNA- Patient could have nursing home associated pna and he
has recently been hospitalized. Has bands on diff, consolidation
on cxr and fever.
-treat w/ vanc and zosyn
-check sputum cx
-urine legionella ag pending
.
#. [**Name (NI) 10271**] Pt has ATN like picture. FENA of 3.6% on [**1-1**].
-Cr improving from 3.2 to 2.5
-cont to follow urine lytes.
-dose meds renally
-hold lisinopril.
.
#. Stroke- Patient has known MCA [**12-7**] and [**7-7**] infarct and on CT
head here he has evolution of infarct but no new stroke or
bleed.
-dilantin load and maitenance doses
-check level in am
-INR supratherapeutic, will hold coumadin
-cont asa pr
.
#. Seizure- patient had seizure in ED likely related to high
grade fever
-cont dilantin 100mg TID, check daily levels
-eeg today r/o NCSE
-ativan for breaking any clinical seizures.
.
#. hyperlipidemia- hold statin as npo
.
#. HTN-hold anti-hypertensives as pt is hypotensive at this time
.
#. Afib w/ RVR. Difficult to control likely related to
infection. Did not respond to lopressor.
-Better response to dilt,
-cont Dilt drip
.
#. Hypernatremia:
-continue D5W and free water boluses.
.
#. Coagulopathy: INR 7.5, PTT 78 not on heparin,
-5mg Vitamin K SQ
-cont to monitor
.
#. DM- RISS, finger sticks qachs
.
#. FEN- IVF bolus to keep MAP > 65, replete lytes prn, Place
dopoff, nutrition consult.
.
#. PPx- IV protonix, no need for subq heparin as last INR was 6
.
#. Access: 2 PIV, family does not want central access
.
#. Communication: with wife: [**Name (NI) 2048**] [**Name (NI) 23203**], p# is (c)
[**Telephone/Fax (1) 52033**], (h) [**Telephone/Fax (1) 52032**]
.
#. Code: DNR/DNI confirmed with wife
.
#. Dispo: ICU level of care for now
.


Medications on Admission:
senna
zocor 80 mg qd
coumadin
dulcolax daily
zofran 4 mg prn
oxycodone 5 mg q4 prn
sorbitol 30 cc qd
cardizem 30 mg q6
colace 100 mg [**Hospital1 **]
pepcid 20 mg [**Hospital1 **]
neurontin 300 mg tid
sliding scale insulin
lisinopril 5 mg qd
combivent q4 prn
tylenol prn
asa 325 mg daily

Discharge Medications:
pt expired

Discharge Disposition:
Expired

Discharge Diagnosis:
pt expired

Discharge Condition:
pt expired

Discharge Instructions:
non-applicable

Followup Instructions:
non-applicable

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

Completed by:[**2112-5-12**]
{'Unspecified septicemia,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Intestinal infection due to Clostridium difficile,Acute kidney failure, unspecified,Severe sepsis,Respiratory arrest,Other convulsions,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Atrial fibrillation,Other late effects of cerebrovascular disease, facial weakness,Encounter for palliative care,Personal history of tobacco use'}


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

PRESENT ILLNESS: Pt is a 66 yo man with pmhx MCA stroke [**7-7**] and [**12-7**],
hyperlipidemia, HTN, DM who presents from [**Hospital 38**] rehab with
altered mental status for the last three days. His wife reported
that he was barely responsive on the day of admission and he was
sent to the ED. Of note, he has also been having very loose
stools for the last three days and was c dif positive on tuesday
and started on flagyl. He spiked fever on monday and had low
grade temps at rehab since then. He was on IVF at rehab per his
wife.

MEDICAL HISTORY: R M1 segment MCA stroke [**7-/2111**] with residual left facial droop,
left hand weakness/stiffness, mild dysarthria
hyperlipidemia
hypertension
diabetes, diagnosed [**8-/2111**], initially diet controlled w/ FS
100s,
last A1C 6.8, started on metformin
h/o tobacco use, quit after stroke [**7-/2111**]
s/p tonsillectomy

MEDICATION ON ADMISSION: senna
zocor 80 mg qd
coumadin
dulcolax daily
zofran 4 mg prn
oxycodone 5 mg q4 prn
sorbitol 30 cc qd
cardizem 30 mg q6
colace 100 mg [**Hospital1 **]
pepcid 20 mg [**Hospital1 **]
neurontin 300 mg tid
sliding scale insulin
lisinopril 5 mg qd
combivent q4 prn
tylenol prn
asa 325 mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 97 HR 127 Bp 102/51, RR 27, SaO2 92% on 100% NRB
Genl: tacchypneic, not responsive to questions or sternal rub,
withdrew to painful stimuli
HEENT: NCAT, Pupils 2 mm and slugishly reactive, MM dry
Neck: supple, no bruits
CV: irreg and tacchy, nl S1, S2, difficult to appreciate murmur
over loud chest sounds
Chest: anterior exam was diffusely rhoncherous
Abd: soft, NTND, BS+
Ext: warm and dry

FAMILY HISTORY: mother died age 66, had HTN, stroke; father died age 87

SOCIAL HISTORY: tob 2.5ppd x 50yrs, h/o heavy EtOH use, "in recovery" 21yrs,
no drug use, married 

### Response:
{'Unspecified septicemia,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Intestinal infection due to Clostridium difficile,Acute kidney failure, unspecified,Severe sepsis,Respiratory arrest,Other convulsions,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Atrial fibrillation,Other late effects of cerebrovascular disease, facial weakness,Encounter for palliative care,Personal history of tobacco use'}
