CHIEF COMPLAINT: AMS, shortness of breath

PRESENT ILLNESS: Ms. [**Known lastname 108328**] is an 82 year old female with MDS, Crohn's disease,
CAD s/p NSTEMI, CRI, h/o DVT with saddle embolus on weekly
lovenox due to h/o GIBs, h/o breast cancer, on home O2 who
presents with dyspnea, AMS. Of note, patient was discharged 6
days ago with left upper extremity DVT from PICC and subsequent
port placement.
.
In ED, patient presented solmnolent with marked tachypnea from
ambulance. ABG 7.21/80/76 given baseline pCO2 60 patient was
started on BiPAP. CXR with effusions, but unclear if any
consolidation. Mildly positive UA, minimal urine output. Patient
was started on Vanc/Zosyn and given methylpred 125mg
empirically. Patient with troponin at baseline. K noted to be
7.0: 60 gm kayexelate enema (with no significant bowel
movement), amp D50, 10 unit insulin iv, albuterol/ipratropium
nebs, and 1 gm calcium gluconate. EKG no peaked Ts, QRS 130
which is baseline and no other concerning ST/T changes. Patient
repeat K pending. Renal aware of K+ but given EKG felt no need
for urgent HD. Given recent left upper extremity DVT, patient
got 60 mg lovenox in ED as has not gotten today. Unable to get
PE CTA given renal failure. Minimal improvement on BiPAP in
terms of mental status. Current vitals: temp afebrile by rectal,
BP 140/40s, HR 50s, O2sat 97% on bipap 8/5, 2LNC.
.
Event prior to transfer: SBP 70s suddenly, and SBP improved 100s
off BiPAP, still sinus brady. Patient slightly more awake now
off BiPAP, getting 500 ml bolus. ABG just prior 7.27/68/74.
.
Upon arrival to MICU, patient somnulent off BiPAP. Patient
placed back on BiPAP and want unable to answer questions.
Daughter provided the following history. Daughter reports since
discharge from hospital patient has been weak, not interested in
eating, and intermittently very somnulent. Daughter reports her
mother is [**Name2 (NI) 18248**] and then not confused. [**Name2 (NI) 108329**] describes 2
episodes of confusion this week in the setting of document
hypoxia to 70s, that resolved upon increasing oxygen. Daughter
reports mother [**Name (NI) **] hot w/o fever by thermometer, and w/o chills.
Over the week the daughter has noted she issues with oxygenation
and has changed her O2 between 1.5 to 3LNC. Usually her mother
is only on O2 at night, but has been on it continuously since
just prior to last hospitalization. Daughter has been giving her
Bactrim and vitamins to help. She also gave her mother [**Doctor Last Name **]
yesterday, because she wanted her to retain water and was
concerned she was becoming dehydrated. Daughter reports
increased UOP earlier in the week followed by minimal urine
output today. Early on day of admission patient called out to
daughter and reports not seeing well and wanting to get out of
bed. Per daughter, these are symptoms of hypercarbia in her
mother. Daughter also report mother has had non-productive
cough, but without coughing after eating. Per daughter [**Name (NI) **] [**Name2 (NI) **]
check was K =5.3 from VNA labs.
.
Review of systems:  (+) Per HPI. Daughter reports ongoing groin
rash.

MEDICAL HISTORY: -Multifactorial anemia ([**3-3**] CRI, chronic disease, MDS)
-MDS dx 3 yrs ago
-Crohn's disease
-CAD s/p NSTEMI '[**89**]
-CRI w baseline Cr 1.5-1.8
-BL DVTs and saddle embolus in [**2190**] and [**2193**], previously on
warfarin, now off Lovenox as well for GIB
-Chronic BL LE edema
-Breast cancer s/p lumpectomy & XRT
-GERD
-Intracranial bleed and fx after pedestrian vs car 20 yrs ago
-Cataracts
-Venous stasis dermatitis
-Tinea pedis
-?Arrhythmia unspecified which daughter says is tx with
metoprolol
-dHF with EF 60-70%
-s/p CY 10 yrs ago
-s/p Lumpectomy 13 yrs ago

MEDICATION ON ADMISSION: Folic Acid 1 mg daily
Mesalamine 1200 mg TID
Bone Reenforcement (MVI/Ca/D/Mg/vitC)
Trimethoprim-Sulfamethoxazole 80-400 mg every other day -- took
daily for 10 days for UTI prior to last hospital presentation
and has been taking almost daily since discharge from last
hospitalization for subj fevers.
Ciprofloxacin 250 mg [**Hospital1 **], taken PRN for diarrhea, last taken [**3-4**]
wks ago
Epoetin Alfa 40,000 unit/mL weekly
Miconazole Nitrate 2 % Powder TID:PRN rash
Omeprazole EC 20 mg daily
Lasix 10mg daily:PRN leg swelling - got tues or wed this past wk
Cyanocobalamin 1,000 mcg/mL INJ monthly - due this week
Triamcinolone Acetonide 0.025 % Cream to affected area [**Hospital1 **]
Prednisone 20 mg daily
Lovenox 60 mg INJ daily - got Wed-Fri, missed Mon/Tues due to no
supply, missed Sat/Sun as not feeling well and daughter worried
about giving
Metoprolol Tartrate 12.5 mg prn SBP >130 (daughter checks at
home) last given saturday.

ALLERGIES: Belladonna Alkaloids

PHYSICAL EXAM: Initial MICU exam:
General Appearance: Thin
Eyes / Conjunctiva: No(t) Pupils dilated, No(t) Conjunctiva
pale, conjugate gaze
Head, Ears, Nose, Throat: Normocephalic, on BiPAP
Lymphatic: No(t) Cervical WNL
Cardiovascular: (S1: Normal), (S2: Distant), (Murmur: No(t)
Systolic)
Peripheral [**Name (NI) **]: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Diminished), (Left DP pulse:
Diminished)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : ), anterior, lateral
Abdominal: Soft, Non-tender, Bowel sounds present, Distended
Extremities: Right: 1+ edema, Left: 1+ edema, legs wrapped in
ACE bandages
Skin:  Warm, Rash: in groin erythematous.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: [**Year (4 digits) 595**] speaking only. Married; lives with her daughter [**Name (NI) 108329**],
[**Name2 (NI) 108330**] husband and 6 [**Name2 (NI) **] granddaughter. [**Name (NI) 108329**] is the caretaker
for both of her parents. Has daily visiting nurse at home.
Pneumonia, organism unspecified,Urinary tract infection, site not specified,Regional enteritis of unspecified site,Unspecified pleural effusion,Pulmonary collapse,Chronic systolic heart failure,Hyperpotassemia,Myelodysplastic syndrome, unspecified,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Chronic kidney disease, unspecified,Anemia in chronic kidney disease,Venous (peripheral) insufficiency, unspecified,Esophageal reflux,Candidiasis of skin and nails,Personal history of malignant neoplasm of breast
Pneumonia, organism NOS,Urin tract infection NOS,Regional enteritis NOS,Pleural effusion NOS,Pulmonary collapse,Chr systolic hrt failure,Hyperpotassemia,Myelodysplastic synd NOS,Crnry athrscl natve vssl,Old myocardial infarct,Chronic kidney dis NOS,Anemia in chr kidney dis,Venous insufficiency NOS,Esophageal reflux,Cutaneous candidiasis,Hx of breast malignancy
Admission Date:  [**2194-8-24**]              Discharge Date:   [**2194-8-28**]

Date of Birth:  [**2112-2-19**]             Sex:   F

Service: MEDICINE

Allergies:
Belladonna Alkaloids

Attending:[**First Name3 (LF) 905**]
Chief Complaint:
AMS, shortness of breath

Major Surgical or Invasive Procedure:
None

History of Present Illness:
Ms. [**Known lastname 108328**] is an 82 year old female with MDS, Crohn's disease,
CAD s/p NSTEMI, CRI, h/o DVT with saddle embolus on weekly
lovenox due to h/o GIBs, h/o breast cancer, on home O2 who
presents with dyspnea, AMS. Of note, patient was discharged 6
days ago with left upper extremity DVT from PICC and subsequent
port placement.
.
In ED, patient presented solmnolent with marked tachypnea from
ambulance. ABG 7.21/80/76 given baseline pCO2 60 patient was
started on BiPAP. CXR with effusions, but unclear if any
consolidation. Mildly positive UA, minimal urine output. Patient
was started on Vanc/Zosyn and given methylpred 125mg
empirically. Patient with troponin at baseline. K noted to be
7.0: 60 gm kayexelate enema (with no significant bowel
movement), amp D50, 10 unit insulin iv, albuterol/ipratropium
nebs, and 1 gm calcium gluconate. EKG no peaked Ts, QRS 130
which is baseline and no other concerning ST/T changes. Patient
repeat K pending. Renal aware of K+ but given EKG felt no need
for urgent HD. Given recent left upper extremity DVT, patient
got 60 mg lovenox in ED as has not gotten today. Unable to get
PE CTA given renal failure. Minimal improvement on BiPAP in
terms of mental status. Current vitals: temp afebrile by rectal,
BP 140/40s, HR 50s, O2sat 97% on bipap 8/5, 2LNC.
.
Event prior to transfer: SBP 70s suddenly, and SBP improved 100s
off BiPAP, still sinus brady. Patient slightly more awake now
off BiPAP, getting 500 ml bolus. ABG just prior 7.27/68/74.
.
Upon arrival to MICU, patient somnulent off BiPAP. Patient
placed back on BiPAP and want unable to answer questions.
Daughter provided the following history. Daughter reports since
discharge from hospital patient has been weak, not interested in
eating, and intermittently very somnulent. Daughter reports her
mother is [**Name2 (NI) 18248**] and then not confused. [**Name2 (NI) 108329**] describes 2
episodes of confusion this week in the setting of document
hypoxia to 70s, that resolved upon increasing oxygen. Daughter
reports mother [**Name (NI) **] hot w/o fever by thermometer, and w/o chills.
Over the week the daughter has noted she issues with oxygenation
and has changed her O2 between 1.5 to 3LNC. Usually her mother
is only on O2 at night, but has been on it continuously since
just prior to last hospitalization. Daughter has been giving her
Bactrim and vitamins to help. She also gave her mother [**Doctor Last Name **]
yesterday, because she wanted her to retain water and was
concerned she was becoming dehydrated. Daughter reports
increased UOP earlier in the week followed by minimal urine
output today. Early on day of admission patient called out to
daughter and reports not seeing well and wanting to get out of
bed. Per daughter, these are symptoms of hypercarbia in her
mother. Daughter also report mother has had non-productive
cough, but without coughing after eating. Per daughter [**Name (NI) **] [**Name2 (NI) **]
check was K =5.3 from VNA labs.
.
Review of systems:  (+) Per HPI. Daughter reports ongoing groin
rash.


Past Medical History:
-Multifactorial anemia ([**3-3**] CRI, chronic disease, MDS)
-MDS dx 3 yrs ago
-Crohn's disease
-CAD s/p NSTEMI '[**89**]
-CRI w baseline Cr 1.5-1.8
-BL DVTs and saddle embolus in [**2190**] and [**2193**], previously on
warfarin, now off Lovenox as well for GIB
-Chronic BL LE edema
-Breast cancer s/p lumpectomy & XRT
-GERD
-Intracranial bleed and fx after pedestrian vs car 20 yrs ago
-Cataracts
-Venous stasis dermatitis
-Tinea pedis
-?Arrhythmia unspecified which daughter says is tx with
metoprolol
-dHF with EF 60-70%
-s/p CY 10 yrs ago
-s/p Lumpectomy 13 yrs ago


Social History:
[**Year (4 digits) 595**] speaking only. Married; lives with her daughter [**Name (NI) 108329**],
[**Name2 (NI) 108330**] husband and 6 [**Name2 (NI) **] granddaughter. [**Name (NI) 108329**] is the caretaker
for both of her parents. Has daily visiting nurse at home.


Family History:
Non-contributory

Physical Exam:
Initial MICU exam:
General Appearance: Thin
Eyes / Conjunctiva: No(t) Pupils dilated, No(t) Conjunctiva
pale, conjugate gaze
Head, Ears, Nose, Throat: Normocephalic, on BiPAP
Lymphatic: No(t) Cervical WNL
Cardiovascular: (S1: Normal), (S2: Distant), (Murmur: No(t)
Systolic)
Peripheral [**Name (NI) **]: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Diminished), (Left DP pulse:
Diminished)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : ), anterior, lateral
Abdominal: Soft, Non-tender, Bowel sounds present, Distended
Extremities: Right: 1+ edema, Left: 1+ edema, legs wrapped in
ACE bandages
Skin:  Warm, Rash: in groin erythematous.

Initial floor exam:
Vitals: 99.2 72 140/58 22 93% 0.5LNC
Gen: pleasant elderly woman lying in bed, in NAD
[**Name (NI) 4459**]: NC/AT, EOMI, MMM, supple neck
CV: RRR, normal S1S2, no m/r/g
Lungs: CTA b/l, decreased breath sounds, no rales/wheezing
appreciated
Abd: soft, nt, nd, +bs, no masses
Ext: 2+ edema in all extremities, +distal pulses


Pertinent Results:
Labs on Admission: [**2194-8-24**]
WBC-5.9 RBC-2.41* Hgb-8.5* Hct-27.3* MCV-114* RDW-23.9* Plt
Ct-244
Neuts-51.8 Lymphs-36.6 Monos-8.3 Eos-2.6 Baso-0.8
PT-10.5 PTT-22.3 INR(PT)-0.9
Glucose-115* UreaN-31* Creat-1.9* Na-140 K-7.0* Cl-105 HCO3-34*
AnGap-8
Calcium-8.7 Phos-4.1 Mg-2.7*
ALT-7 AST-11 CK(CPK)-16* AlkPhos-103 TotBili-0.3
Lipase-61*
proBNP-4081*
.
.
Micro:
[**2194-8-24**] Blood cultures: pending
[**2194-8-24**] Urine culture: URINE CULTURE (Preliminary):
GRAM NEGATIVE ROD(S).    >100,000 ORGANISMS/ML..
.
Other Studies:
[**2194-8-24**] EKG: Possible wandering atrial pacemaker or irregular
sinus bradycardia with premature atrial contractions and first
degree A-V block. Right bundle-branch block. Non-specific ST-T
wave changes. Compared to tracing #1 no significant change.
[**2194-8-24**] CXR: 1. Moderate left and small right pleural effusions.

2. Left retrocardiac opacity, atelectasis and/or consolidation.
[**2194-8-24**] CT Head w/o: No acute intracranial pathology. Stable
encephalomalacic changes as described. However, MRI would be
more sensitive for [**Month/Day/Year 2742**] of acute infarct if clinical
concern warrants.
[**2194-8-25**] Echo: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global and regional
biventricular systolic function. Mild pulmonary artery systolic
hypertension. Mild mitral regurgitation. Compared with the prior
study (images reviewed) of [**2194-4-8**], the estimated pulmonary
artery systolic pressure is now lower. The right ventricular
cavity is also smaller/now normal.
[**2194-8-25**] Left arm U/S: 1. Deep vein thrombosis is identified in
one of the two brachial veins. Flow within the axillary vein
appears to be normal on today's exam. 2. Stable appearing
hematoma in the left upper arm.
[**2194-8-26**] CXR: The Port-A-Cath catheter tip is in superior SVC.
The left retrocardiac consolidation which is most likely a
combination of atelectasis and pleural effusion is unchanged.
Infectious superimposed process cannot be excluded.  There is
interval worsening of [**Month/Day/Year 1106**] engorgement with currently
[**Month/Day/Year 1106**] engorgement seen in the perihilar areas bilateral.
There is no pneumothorax.  The patient is after cholecystectomy




Brief Hospital Course:
This is an 82 year old female with MDS, Crohn's with multiple GI
bleeds, CAD s/p NSTEMI, CKD, h/o DVT/saddle embolus on daily
Lovenox, breast ca, on home O2 only at night secondary to
non-compliance with bipap, admitted for altered mental status
and dyspnea.
.
#. AMS.  The patient was admitted to the MICU with lethargy and
confusion which the daughter felt was due to hypercarbia.  Upon
arrival to MICU, the patient was somnolent off BiPAP and
improved after being placed back on BiPAP.  Ever since her last
admission, the daughter reports that the patient has been weak,
not interested in eating, and intermittently very somnolent. She
was found to have a questionable retrocardiac pneumonia on CXR
and a UTI.  Her AMS resolved after antibiotic coverage and her
ABG returned to her baseline on nasal cannula prior to leaving
the ICU.  She was treated empirically for HAP and UTI with
vanco, cefepime, and ciprofloxacin starting on [**8-24**] in the MICU.
 Her antibiotics were modified to cefepime only for a total of a
10 day course to be completed at home.  Blood cultures were
negative on discharge and urine culture was positive for
enterobacter sensitive to cefepime.
.
#. Dyspnea.  She is slightly dyspneic at baseline, but was
satting well on room air prior to discharge.  Her current chest
imaging does not have a clear infiltrate and just shows interval
worsening of [**Month/Year (2) 1106**] engorgement in bilateral perihilar areas
which may be secondary to fluid overload.  Cefepime alone would
also provide good lung coverage in case the patient has a
non-focal pneumonia.  She does have a history of PE, but no RV
strain was seen on ECHO on admission.  She will most likely need
some gentle diuresis with her home dose of Lasix 10mg.  She will
continue on her stress dose steroid [**Month/Year (2) 15123**] that was started in
MICU, and per the daughter's request will be tapered back slowly
by 5mg every 2 days down to her 20mg chronic dose after
discharge.
.
#. Hyperkalemia.  This seems to be a chronic issue.  Her Bactrim
was switched to atovaquone as Bactrim can sometimes contribute
to hyperkalemia.  Her potassium had remained stable without
intervention over the two days prior to discharge.
.
#. Anemia.  She was transfused 2 units [**8-26**] which appropriately
increased her hematocrit from 23.5 to 31.3.  Her hematocrit
remained stable thereafter.  Her stools were guaiac negative.
Her monthly B12 shot was administered [**2194-8-25**] and she was
continued on daily folic acid.
.
#. LUE DVT.  Last ultrasound was done on [**2194-8-25**] which revealed
a stable hematoma and upper extremity DVT.  She continued daily
Lovenox 60mg and her hematocrit was followed closely.
.
#. MDS.  She has transfusion dependent disease and she was
transfused to keep her hematocrit greater than 23.  Her PCP
prophylaxis was switched from Bactrim to Atovaquone.
.
#. Crohn's disease.  Her home mesalamine was continued and her
steroids were stress dosed.  She will be tapered back to her
20mg home dose slowly.
.
#. CAD s/p NSTEMI.  She is not on ASA secondary to her history
of multiple GI bleeds.  She was continued on her beta blocker.
.
#. Chronic b/l LE edema/venous stasis.  Her home trimacinolone
cream was continued PRN as well as intermittent Lasix 10mg PRN.
.
#. GERD.  She was maintained on daily pantoprazole 40mg during
the admission.
.
#. CKD - Her baseline creatinine is around 2 and was 1.9 on the
day of discharge.  She will be continued on weekly Epogen 40,000
units as an outpatient, but was given 10,000 units on a
Monday/Wednesday/Friday schedule as an inpatient.
.
#. Fungal groin rash. Miconazole QID was given during admission.

Medications on Admission:
Folic Acid 1 mg daily
Mesalamine 1200 mg TID
Bone Reenforcement (MVI/Ca/D/Mg/vitC)
Trimethoprim-Sulfamethoxazole 80-400 mg every other day -- took
daily for 10 days for UTI prior to last hospital presentation
and has been taking almost daily since discharge from last
hospitalization for subj fevers.
Ciprofloxacin 250 mg [**Hospital1 **], taken PRN for diarrhea, last taken [**3-4**]
wks ago
Epoetin Alfa 40,000 unit/mL weekly
Miconazole Nitrate 2 % Powder TID:PRN rash
Omeprazole EC 20 mg daily
Lasix 10mg daily:PRN leg swelling - got tues or wed this past wk
Cyanocobalamin 1,000 mcg/mL INJ monthly - due this week
Triamcinolone Acetonide 0.025 % Cream to affected area [**Hospital1 **]
Prednisone 20 mg daily
Lovenox 60 mg INJ daily - got Wed-Fri, missed Mon/Tues due to no
supply, missed Sat/Sun as not feeling well and daughter worried
about giving
Metoprolol Tartrate 12.5 mg prn SBP >130 (daughter checks at
home) last given saturday.


Discharge Medications:
1. Cefepime 1 gram Recon Soln Sig: One (1) gram Injection Q24H
(every 24 hours) for 6 doses.
Disp:*6 grams* Refills:*0*
2. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Five (5) ML
Intravenous PRN (as needed) as needed for line flush.
Disp:*30 ML(s)* Refills:*0*
3. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Five
(5) ML Intravenous PRN (as needed) as needed for DE-ACCESSING
port.
Disp:*30 ML(s)* Refills:*0*
4. Sodium Chloride 0.9 % 0.9 % Solution Sig: Ten (10) ML
Injection PRN (as needed) as needed for line flush.
Disp:*60 ML(s)* Refills:*0*
5. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) injection
Subcutaneous Q24H (every 24 hours).
6. Triamcinolone Acetonide 0.025 % Cream Sig: One (1) Appl
Topical DAILY (Daily) as needed for to lower extremities.
7. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for groin.
9. Epoetin Alfa 10,000 unit/mL Solution Sig: 40,000 units
Injection once a week.
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
11. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO once a day as
needed.
12. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for dry eyes.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Portacath care
Portacath supplies
16. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
17. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
18. Atovaquone 750 mg/5 mL Suspension Sig: Ten (10) MLs PO DAILY
(Daily).
Disp:*300 MLs* Refills:*2*
19. Prednisone 10 mg Tablet Sig: Take 55mg for 2 days, 50mg for
2 days, 45mg for 2 days, 40mg for 2 days, 35mg for 2 days, 30mg
for 2 days, 25mg for 2 days, then continue with 20mg daily
Tablet PO once a day.
Disp:*QS Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital6 1952**], [**Location (un) 86**]

Discharge Diagnosis:
Pneumonia
urinary tract infection
altered mental status

Secondary diagnoses:
-h/o hyperkalemia
-PICC associated left upper extremity DVT and hematoma [**5-8**]
-BL DVTs and saddle embolus in [**2190**] and [**2193**], previously on
warfarin, on weekly lovenox due to prior UGIB, recently [**8-18**]
increased to daily lovenox for upper extremity DVT.
-Multifactorial anemia ([**3-3**] CRI, chronic disease, MDS)
-MDS dx 3 yrs ago
-Crohn's disease
-CAD s/p NSTEMI '[**89**] AND chronic diastolic congestive heart
failure: EF 60-70%
-CRI w baseline Cr 1.4-1.7
-Chronic BL LE edema
-Breast cancer s/p lumpectomy & XRT
-GERD
-Intracranial bleed and fx after pedestrian vs car 20 yrs ago
-Cataracts
-Venous stasis dermatitis
-Tinea pedis


Discharge Condition:
Stable, afebrile


Discharge Instructions:
You were admitted to [**Hospital1 **] Hospital for
[**Hospital1 2742**] of altered mental status.  You were found to have a
pneumonia, urinary tract infection and a high potassium level.
Your potassium levels were treated and have remained stable.  At
first you were extremely somnolent and were cared for in the
intensive care unit where you were treated with broad spectrum
antibiotics to cover a pneumonia as well as a urinary tract
infection.  Your mental status improved with oxygen and
antibiotics.  For your congestive heart failure, please weigh
yourself every morning, call your primary care doctor if your
weight > 3 lbs.  You should continue to dose Lasix as needed to
take off any extra fluid.  Please adhere to a 2 gm sodium and
low potassium diet.

The following changes have been made to your medication regimen:
-You will take 6 more doses of Cefepime 1 gram IV daily
-You will [**Hospital1 15123**] your prednisone dose as directed by 5mg every 2
days back down to 20mg daily
-You will take atovaquone 1500mg daily
-You will stop taking Bactrim

Please keep all of your follow-up outpatient medical
appointments.

Please seek medical care for any concerning symptoms such as
confusion, fevers, chills, vomiting, increased shortness of
breath, chest pain, or bloos in your stool.

Followup Instructions:
Please follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3357**].


                             [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
{'Pneumonia, organism unspecified,Urinary tract infection, site not specified,Regional enteritis of unspecified site,Unspecified pleural effusion,Pulmonary collapse,Chronic systolic heart failure,Hyperpotassemia,Myelodysplastic syndrome, unspecified,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Chronic kidney disease, unspecified,Anemia in chronic kidney disease,Venous (peripheral) insufficiency, unspecified,Esophageal reflux,Candidiasis of skin and nails,Personal history of malignant neoplasm of breast'}


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: AMS, shortness of breath

PRESENT ILLNESS: Ms. [**Known lastname 108328**] is an 82 year old female with MDS, Crohn's disease,
CAD s/p NSTEMI, CRI, h/o DVT with saddle embolus on weekly
lovenox due to h/o GIBs, h/o breast cancer, on home O2 who
presents with dyspnea, AMS. Of note, patient was discharged 6
days ago with left upper extremity DVT from PICC and subsequent
port placement.
.
In ED, patient presented solmnolent with marked tachypnea from
ambulance. ABG 7.21/80/76 given baseline pCO2 60 patient was
started on BiPAP. CXR with effusions, but unclear if any
consolidation. Mildly positive UA, minimal urine output. Patient
was started on Vanc/Zosyn and given methylpred 125mg
empirically. Patient with troponin at baseline. K noted to be
7.0: 60 gm kayexelate enema (with no significant bowel
movement), amp D50, 10 unit insulin iv, albuterol/ipratropium
nebs, and 1 gm calcium gluconate. EKG no peaked Ts, QRS 130
which is baseline and no other concerning ST/T changes. Patient
repeat K pending. Renal aware of K+ but given EKG felt no need
for urgent HD. Given recent left upper extremity DVT, patient
got 60 mg lovenox in ED as has not gotten today. Unable to get
PE CTA given renal failure. Minimal improvement on BiPAP in
terms of mental status. Current vitals: temp afebrile by rectal,
BP 140/40s, HR 50s, O2sat 97% on bipap 8/5, 2LNC.
.
Event prior to transfer: SBP 70s suddenly, and SBP improved 100s
off BiPAP, still sinus brady. Patient slightly more awake now
off BiPAP, getting 500 ml bolus. ABG just prior 7.27/68/74.
.
Upon arrival to MICU, patient somnulent off BiPAP. Patient
placed back on BiPAP and want unable to answer questions.
Daughter provided the following history. Daughter reports since
discharge from hospital patient has been weak, not interested in
eating, and intermittently very somnulent. Daughter reports her
mother is [**Name2 (NI) 18248**] and then not confused. [**Name2 (NI) 108329**] describes 2
episodes of confusion this week in the setting of document
hypoxia to 70s, that resolved upon increasing oxygen. Daughter
reports mother [**Name (NI) **] hot w/o fever by thermometer, and w/o chills.
Over the week the daughter has noted she issues with oxygenation
and has changed her O2 between 1.5 to 3LNC. Usually her mother
is only on O2 at night, but has been on it continuously since
just prior to last hospitalization. Daughter has been giving her
Bactrim and vitamins to help. She also gave her mother [**Doctor Last Name **]
yesterday, because she wanted her to retain water and was
concerned she was becoming dehydrated. Daughter reports
increased UOP earlier in the week followed by minimal urine
output today. Early on day of admission patient called out to
daughter and reports not seeing well and wanting to get out of
bed. Per daughter, these are symptoms of hypercarbia in her
mother. Daughter also report mother has had non-productive
cough, but without coughing after eating. Per daughter [**Name (NI) **] [**Name2 (NI) **]
check was K =5.3 from VNA labs.
.
Review of systems:  (+) Per HPI. Daughter reports ongoing groin
rash.

MEDICAL HISTORY: -Multifactorial anemia ([**3-3**] CRI, chronic disease, MDS)
-MDS dx 3 yrs ago
-Crohn's disease
-CAD s/p NSTEMI '[**89**]
-CRI w baseline Cr 1.5-1.8
-BL DVTs and saddle embolus in [**2190**] and [**2193**], previously on
warfarin, now off Lovenox as well for GIB
-Chronic BL LE edema
-Breast cancer s/p lumpectomy & XRT
-GERD
-Intracranial bleed and fx after pedestrian vs car 20 yrs ago
-Cataracts
-Venous stasis dermatitis
-Tinea pedis
-?Arrhythmia unspecified which daughter says is tx with
metoprolol
-dHF with EF 60-70%
-s/p CY 10 yrs ago
-s/p Lumpectomy 13 yrs ago

MEDICATION ON ADMISSION: Folic Acid 1 mg daily
Mesalamine 1200 mg TID
Bone Reenforcement (MVI/Ca/D/Mg/vitC)
Trimethoprim-Sulfamethoxazole 80-400 mg every other day -- took
daily for 10 days for UTI prior to last hospital presentation
and has been taking almost daily since discharge from last
hospitalization for subj fevers.
Ciprofloxacin 250 mg [**Hospital1 **], taken PRN for diarrhea, last taken [**3-4**]
wks ago
Epoetin Alfa 40,000 unit/mL weekly
Miconazole Nitrate 2 % Powder TID:PRN rash
Omeprazole EC 20 mg daily
Lasix 10mg daily:PRN leg swelling - got tues or wed this past wk
Cyanocobalamin 1,000 mcg/mL INJ monthly - due this week
Triamcinolone Acetonide 0.025 % Cream to affected area [**Hospital1 **]
Prednisone 20 mg daily
Lovenox 60 mg INJ daily - got Wed-Fri, missed Mon/Tues due to no
supply, missed Sat/Sun as not feeling well and daughter worried
about giving
Metoprolol Tartrate 12.5 mg prn SBP >130 (daughter checks at
home) last given saturday.

ALLERGIES: Belladonna Alkaloids

PHYSICAL EXAM: Initial MICU exam:
General Appearance: Thin
Eyes / Conjunctiva: No(t) Pupils dilated, No(t) Conjunctiva
pale, conjugate gaze
Head, Ears, Nose, Throat: Normocephalic, on BiPAP
Lymphatic: No(t) Cervical WNL
Cardiovascular: (S1: Normal), (S2: Distant), (Murmur: No(t)
Systolic)
Peripheral [**Name (NI) **]: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Diminished), (Left DP pulse:
Diminished)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : ), anterior, lateral
Abdominal: Soft, Non-tender, Bowel sounds present, Distended
Extremities: Right: 1+ edema, Left: 1+ edema, legs wrapped in
ACE bandages
Skin:  Warm, Rash: in groin erythematous.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: [**Year (4 digits) 595**] speaking only. Married; lives with her daughter [**Name (NI) 108329**],
[**Name2 (NI) 108330**] husband and 6 [**Name2 (NI) **] granddaughter. [**Name (NI) 108329**] is the caretaker
for both of her parents. Has daily visiting nurse at home. 

### Response:
{'Pneumonia, organism unspecified,Urinary tract infection, site not specified,Regional enteritis of unspecified site,Unspecified pleural effusion,Pulmonary collapse,Chronic systolic heart failure,Hyperpotassemia,Myelodysplastic syndrome, unspecified,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Chronic kidney disease, unspecified,Anemia in chronic kidney disease,Venous (peripheral) insufficiency, unspecified,Esophageal reflux,Candidiasis of skin and nails,Personal history of malignant neoplasm of breast'}
