CHIEF COMPLAINT: Chief Complaint: Abd pain and fever
Reason for MICU transfer: A. fib with

PRESENT ILLNESS: Ms. [**Known lastname 10680**] is a 76 y/o F with a h/o frontal dementia,
hypothyroidism, and hypertension who was admitted from [**Location (un) 8220**] (lives there as long term care) on [**2153-6-3**] with abdominal
pain and fever. CT of her abdomen/pelvis in the ER were notable
for an SBO and a LLL PNA, she was admitted to ACS for
conservative management of a SBO. Her abdominal pain improved,
she had a BM and ACS said her SBO resolved, they then
transferred her to CC6 on [**2153-6-5**] for management of her pna and
and delirium. She is currently on vanc/cefepime/flagyl for abx
coverage. She is afebrile, only oriented to herself, she is
pulling out her IV's, etc. Her O2 requirement and CXR was
worseing during her [**Hospital1 **] course. On [**2153-6-6**] she triggered at
8:55 for difficulty breathing and HR to 140s in a fib with BPs
of 170s to 90s. Pt noted at that time to be positive 4Ls with
UOP of about 20/Hr of fluid and requiring 2L NC for 88%. 20mg of
IV lasix was given and 5mg of metoprolol iv which she diuressed.
Throughout the day she had occasional a fib with SBPs in the
160-170s and triggered an additional two times. She was given
20+20+40 IV lasix, 5+5 of metoprolol and 25 of PO metoprolol
Q8Hr. Then she continued to be in A. fib with RVR to the
150-160s and was transferred to the MICU.

MEDICAL HISTORY: - Dementia, Hypertension, Hypothryroid, Latent syphilis,
depression, Osteoarthritis
- Bilateral knee replacement in [**2140**]

MEDICATION ON ADMISSION: 1. Alendronate Sodium 70 mg PO Frequency is Unknown
2. Amlodipine 5 mg PO DAILY
3. Citalopram 20 mg PO DAILY
4. Clobetasol Propionate 0.05% Ointment 1 Appl TP PRN [**Hospital1 **] rash
stop when rash resolves
5. Mupirocin Nasal Ointment 2% 1 Appl NU [**Hospital1 **] PRN open wounsd
Duration: 5 Days
6. Nystatin Powder *NF* 1 application topical daily prn rash
7. Omeprazole 20 mg PO DAILY
8. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
9. traZODONE 50 mg PO DAILY
10. Triamcinolone Acetonide 0.1% Cream 1 Appl TP [**Hospital1 **]:PRN itch
11. Aspirin 81 mg PO DAILY
12. Calcium Carbonate 1500 mg PO BID
13. Guaifenesin [**4-19**] mL PO QID
1 table spoon of 100mg/5mL 4times a day
14. Multivitamins 1 TAB PO DAILY
15. Senna 2 TAB PO HS

ALLERGIES: Ace Inhibitors

PHYSICAL EXAM: ADMISSION EXAM PER ACS:
Vitals:  98.6   99    137/69    16    96%RA
GEN: sleeping but intermittently responsive, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear on right, mildly coarse BS on left
ABD: Soft, +distension, mildly tender L abd, no rebound or
guarding, normoactive bowel sounds, no palpable masses
Ext: No LE edema, LE warm and well perfused

FAMILY HISTORY: Two brothers and two sisters, one of which died of old age.  The
living siblings have dementia, hypertension, diabetes mellitus
and a stroke.  Five children, one with asthma, three with
hypertension.

SOCIAL HISTORY: The patient quit smoking 30 years ago, does not drink alcohol.
No recreational drugs, no transfusions.  Stopped working more
than ten years ago.
Unspecified intestinal obstruction,Pneumonia, organism unspecified,Other encephalopathy,Cerebral embolism with cerebral infarction,Pneumonitis due to inhalation of food or vomitus,Acute edema of lung, unspecified,Dementia in conditions classified elsewhere with behavioral disturbance,Delirium due to conditions classified elsewhere,Localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures, without mention of intractable epilepsy,Hyperosmolality and/or hypernatremia,Other frontotemporal dementia,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Atrial fibrillation,Altered mental status,Latent syphilis, unspecified,Depressive disorder, not elsewhere classified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Knee joint replacement,Personal history of tobacco use,Spasm of conjugate gaze,Essential and other specified forms of tremor,Rash and other nonspecific skin eruption,Dysphagia, oropharyngeal phase
Intestinal obstruct NOS,Pneumonia, organism NOS,Encephalopathy NEC,Crbl emblsm w infrct,Food/vomit pneumonitis,Acute lung edema NOS,Dementia w behavior dist,Delirium d/t other cond,Part epil w/o intr epil,Hyperosmolality,Frontotemp dementia NEC,Hypertension NOS,Hypothyroidism NOS,Atrial fibrillation,Altered mental status,Latent syphilis NOS,Depressive disorder NEC,Osteoarthros NOS-unspec,Joint replaced knee,History of tobacco use,Spasm of conjugate gaze,Tremor NEC,Nonspecif skin erupt NEC,Dysphagia, oropharyngeal
Admission Date:  [**2153-6-3**]              Discharge Date:   [**2153-6-22**]

Date of Birth:  [**2076-7-11**]             Sex:   F

Service: NEUROLOGY

Allergies:
Ace Inhibitors

Attending:[**First Name3 (LF) 7575**]
Chief Complaint:
Chief Complaint: Abd pain and fever
Reason for MICU transfer: A. fib with


Major Surgical or Invasive Procedure:
PEG tube placement [**2153-6-19**]


History of Present Illness:
Ms. [**Known lastname 10680**] is a 76 y/o F with a h/o frontal dementia,
hypothyroidism, and hypertension who was admitted from [**Location (un) 8220**] (lives there as long term care) on [**2153-6-3**] with abdominal
pain and fever. CT of her abdomen/pelvis in the ER were notable
for an SBO and a LLL PNA, she was admitted to ACS for
conservative management of a SBO. Her abdominal pain improved,
she had a BM and ACS said her SBO resolved, they then
transferred her to CC6 on [**2153-6-5**] for management of her pna and
and delirium. She is currently on vanc/cefepime/flagyl for abx
coverage. She is afebrile, only oriented to herself, she is
pulling out her IV's, etc. Her O2 requirement and CXR was
worseing during her [**Hospital1 **] course. On [**2153-6-6**] she triggered at
8:55 for difficulty breathing and HR to 140s in a fib with BPs
of 170s to 90s. Pt noted at that time to be positive 4Ls with
UOP of about 20/Hr of fluid and requiring 2L NC for 88%. 20mg of
IV lasix was given and 5mg of metoprolol iv which she diuressed.
Throughout the day she had occasional a fib with SBPs in the
160-170s and triggered an additional two times. She was given
20+20+40 IV lasix, 5+5 of metoprolol and 25 of PO metoprolol
Q8Hr. Then she continued to be in A. fib with RVR to the
150-160s and was transferred to the MICU.

Past Medical History:
- Dementia, Hypertension, Hypothryroid, Latent syphilis,
depression, Osteoarthritis
- Bilateral knee replacement in [**2140**]


Social History:
The patient quit smoking 30 years ago, does not drink alcohol.
No recreational drugs, no transfusions.  Stopped working more
than ten years ago.

Family History:
Two brothers and two sisters, one of which died of old age.  The
living siblings have dementia, hypertension, diabetes mellitus
and a stroke.  Five children, one with asthma, three with
hypertension.


Physical Exam:
ADMISSION EXAM PER ACS:
Vitals:  98.6   99    137/69    16    96%RA
GEN: sleeping but intermittently responsive, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear on right, mildly coarse BS on left
ABD: Soft, +distension, mildly tender L abd, no rebound or
guarding, normoactive bowel sounds, no palpable masses
Ext: No LE edema, LE warm and well perfused

TRANSFER EXAM:
GEN: eyes closed, NG tube in place, arms restrained, NAD
HEENT: sclera anicteric, no nuchal rigidity
CV: RRR, no m/r/g
PULM: CTA anteriorly
EXT: no edema

NEURO:
MSE: Eyes open with light sternal rub, grimaces, and makes sound
but not discernable words. Does not follow commands or answer
what her name is. Fixes on examiner intermittently when eyes
open and awake, but then closes eyes and has roving eye
movements apparent under closed lids. When eyes are forced open
she does resist, with positive Bells phenomenon. No clear
neglect, as she
attends to her daughter on either side.
CN: PERRL 4 to 2mm, no hippus. EOMI. R lower facial droop.
MOTOR: paratonia more on the left side. Bilateral hand tremor
while at rest, R>L that is not suppressible.
LUE spontaneous antigravity and purposeful (tries to grab my
hand while pinching her).
RUE not moving as much as left and not as purposeful, withdraws
very briskly and antigravity to pinch.
LLE is externally rotated and paratonic. Both LEs withdraw
briskly to Babinski testing.
Sensation intact to pinch throughout.
DTR: 2+ UEs, 0 patellars (s/p TKR), no clonus, L toe upgoing at
baseline with positive Babinski response, R toe equivocal.

DISCHARGE EXAM:
GENERAL EXAM: mildly tenderness to palpation on abdominal exam,
otherwise comfortable, NAD.

NEURO:
MSE: opens eyes briefly to voice, and the keeps it closed for
the rest of the exam. does not follow commands.
CN: PERRL 4->2mm bilaterally, right nasolabial flattening
MOTOR: paratonia on L side, also increased tone on right side.
LUE spontaneous antigravity and purposeful movements. RUE
withdraws with antigravity strength in elbow, some spontaneous
movements but less than left side. Both [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 43829**] to noxious
stimuli.
Reflexes: hyperreflexic in RUE, positive babinski bilaterally.

Pertinent Results:
Admission Lab:
[**2153-6-2**] 11:45PM   GLUCOSE-180* UREA N-26* CREAT-1.7* SODIUM-137
POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-23 ANION GAP-19
[**2153-6-2**] 11:45PM   WBC-20.4*# RBC-3.88* HGB-10.3* HCT-32.6*
MCV-84 MCH-26.7* MCHC-31.7 RDW-14.8
[**2153-6-2**] 11:45PM   NEUTS-95.7* LYMPHS-2.4* MONOS-1.4* EOS-0.5
BASOS-0
[**2153-6-2**] 11:45PM   PLT COUNT-236
[**2153-6-2**] 11:45PM   ALT(SGPT)-17 AST(SGOT)-37 ALK PHOS-66 TOT
BILI-0.7
[**2153-6-2**] 11:45PM   LIPASE-11
[**2153-6-2**] 11:45PM   ALBUMIN-3.8

EKG: A fib, rate 94, rr [**Age over 90 **]m pr 130, qrs 106, qtc 459, nl axis

DISCHARGE LABS:
[**2153-6-22**] 04:30AM BLOOD WBC-7.7 RBC-3.18* Hgb-8.3* Hct-27.6*
MCV-87 MCH-26.2* MCHC-30.2* RDW-17.6* Plt Ct-421
[**2153-6-22**] 04:30AM BLOOD Glucose-129* UreaN-11 Creat-0.6 Na-137
K-3.7 Cl-100 HCO3-31 AnGap-10
[**2153-6-22**] 04:30AM BLOOD Calcium-8.9 Phos-4.1 Mg-1.7

COAGS:
[**2153-6-22**] 04:30AM BLOOD PT-14.7* PTT-31.2 INR(PT)-1.4*
[**2153-6-21**] 07:10PM BLOOD PT-15.9* PTT-30.6 INR(PT)-1.5*
[**2153-6-21**] 01:35PM BLOOD PT-15.3* PTT-66.4* INR(PT)-1.4*
[**2153-6-21**] 04:35AM BLOOD PT-14.0* PTT-49.6* INR(PT)-1.3*
[**2153-6-20**] 07:35PM BLOOD PT-13.5* PTT-71.9* INR(PT)-1.3*

MICROBIOLOGY:
[**2153-6-13**] STOOL C. difficile DNA amplification assay NEGATIVE
[**2153-6-12**] BLOOD CULTURE NEGATIVE
[**2153-6-12**] BLOOD CULTURE NEGATIVE
[**2153-6-11**] URINE CULTURE- YEAST 10-100K
[**2153-6-7**] MRSA SCREEN NEGATIVE
[**2153-6-4**] URINE CULTURE- YEAST 10-100K
[**2153-6-3**] BLOOD CULTURE NEGATIVE
[**2153-6-3**] BLOOD CULTURE NEGATIVE
[**2153-6-3**] BLOOD CULTURE NEGATIVE
[**2153-6-2**] BLOOD CULTURE NEGATIVE

IMAGING:
[**2153-6-3**] CT ABD/PELVIS:
IMPRESSION:
1.  Findings consistent with small-bowel obstruction with a
transition point in the left lower quadrant of the abdomen.
2.  Left lower lobe pneumonia.
3.  Extensive lumbar spine degenerative changes with compression
of L1
vertebral body, acuity unknown.
4.  Healing right-sided rib fractures.

[**2153-6-8**] ECHO:
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF 65%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. There is a
minimally increased gradient consistent with minimal aortic
valve stenosis. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.

[**2153-6-8**] HEAD CT:
1.  No evidence of acute vascular territorial infarction.  In
the setting of high clinical suspicion for acute ischemia, MRI
with diffusion sequences can be considered for further
assessment.

[**2153-6-15**] HEAD CT:
1.  Low-attenuating region within the left corona radiata
extending into the left caudate head and possibly the left
putamen appears better evolved than [**2153-6-8**] and is concerning
for subacute infarction.
2.  Lacunes in the left striatocapsular region are unchanged
since the prior examination.
3.  Left maxillary sinus disease.

[**2153-6-8**] MRI HEAD:
IMPRESSION:
1.  Extensive relatively acute infarction involving the left
deep [**Doctor Last Name 352**] matter structures, including the caudate and lentiform
nuclei, likely accounting for the acute presentation.
2.  Numerous additional more punctate infarcts scattered
throughout both cerebral hemispheres, including in the posterior
circulation territory.  The overall appearance is suggestive of
"embolic shower" from a central source, with which should be
correlated with clinical information.
3.  No evidence of hemorrhage.
4.  No space-occupying lesion or pathologic enhancement.
5.  Disproportionate medial temporal atrophy, compared to the
degree of global volume loss, raising the possibility of
underlying Alzheimer disease, which should also be correlated
with clinical information.

[**2153-6-12**] EEG:
This is an abnormal continuous video EEG monitoring study
because of abundant generalized and multifocal epileptiform
discharges, seen in the
left central temporal region, right frontal temporal region, or
isolated to either the left central or right central regions. At
times, these discharges occurred in a periodic fashion at 1-1.5
Hz, but there was no clinical change noted on video during these
bursts. These findings indicate generalized and multifocal
epileptogenic cortex but the discharges did not evolve into
electrographic seizures. There was a single pushbutton
activation for limb shaking, but the EEG demonstrated no
evidence of electrographic seizures and this could not be
visualized on video. Otherwise, the background was slow and
disorganized indicative of a diffuse encephalopathy with further
slowing noted at times over the left hemisphere indicative of
focal hemispheric dysfunction. Compared to the previous day's
recording, there was no significant change.

[**2153-6-18**] CXR:
The NG tube is in good position in the distal stomach.
Stability of the surelevation of the right hemidiaphragm with
small pleural effusion. Stable left lower lobe atelectasis.
Stability of the proeminence of the
vessels that could be compatible with light volume overload.
Mediastinal and cardiac contours normal.

[**2153-6-22**] abdominal XRAY:
Nonspecific bowel gas pattern with no evidence of bowel
obstruction.

Brief Hospital Course:
TRANSITIONAL ISSUE:
[ ] Monitor INR and adjust coumadin dosing as needed
[ ] Post stroke rehab
====================

Mrs. [**Known lastname 10680**] is a 76 y/o F with PMH of dementia, hypothyroidism,
and hypertension who was admitted from [**Location (un) 169**] (lives
there as long term care) with abdominal pain and fever. She was
found to have an SBO and LLL infiltrate concerning for pneumonia
on CT of her abdomen/pelvis in the ER so she was initially
admitted to ACS. She was conservatively managed with improvement
in her abdominal pain. As her SBO resolved, she was transferred
to medicine service for management of her pneumonia and
delirium. She developed afib with RVR and hypertension and was
transferred to MICU for diltiazem gtt for her rate control and
was converted back to sinus rhythm. In MICU, she was noted to
have persistent left gaze and somnolence, so neurology was
consulted. Her CT did not show an acute process but her MRI did
show L sided acute infarcts, which was thought to be from
thromboembolic source associated with her paroxysmal afib and
conversion to sinus. Her TTE did not show an atrial thrombus.
She was started on anticoagulation with heparin gtt and bridged
to coumadin. She was called out to the neurology floor and was
monitored. Keppra was initially started given concern for
seizures, but as her long term EEG monitoring only epileptiform
discharges and no electrographic seizures, it was discontinued.
Unfortunately, her neurologic status did not improve much after
her stroke and as she was unable to pass speech/swallow
evaluation, PEG tube was placed. Coumadin was restarted after
PEG tube placement.

# NEURO: Patient with baseline dementia and living at dementia
unit, but during this hospitalization developed small embolic
infarcts L>R, likely from paroxysmal atrial fibrillation.
Embolic infarcts were found when patient developed persistent
left gaze and R sided weakness, CT head did not show an acute
stroke but her MRI did show multiple small embolic infarcts,
L>R. She was started on heparin gtt and bridged to coumadin.
Patient had residual right sided spastic hemiparesis, no speech
output and could not follow commands. Given these neurologic
deficits, she failed speech and swallow evaluation multiple
times. Given the poor mental status and leukocytosis during this
hospitalization, lumbar puncture was considered and her
anticoagulation was reversed and patient started on heparin gtt
for LP. Both the attempt on the floor and IR guided LP were
unsuccessful, and as leukocytosis resolved without any
antibiotics, no further attempt at LP were made. While she was
on heparin gtt, PEG tube was placed and patient was restarted on
coumadin. As she had been in sinus rhythm since transfer from
the ICU with heparin gtt on board, heparin was discontinued and
only coumadin was continued. Patient will require INR follow up
and [**Hospital 89367**] rehabilitation in hopes of improving her
functional status.

AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
() Yes - (x) No
 -> patient developed stroke more than 2 days into the
hospitalization, but heparin started within 2 days of diagnosis
of new stroke.
4. LDL documented? (x) Yes (LDL = 75) - () No
5. Intensive statin therapy administered? Not applicable, LDL =
75 (for LDL > 100) () Yes - (x) No (if LDL >100, Reason Not
Given: )
6. Smoking cessation counseling given? () Yes - (x) No (Reason
(x) non-smoker - (x) unable to participate)
7. Stroke education given? () Yes (to family) - () No
8. Assessment for rehabilitation? (x) Yes - () No
9. Discharged on statin therapy? () Yes - (x) No (LDL <100)
10. Discharged on antithrombotic therapy? (x) Yes (Type: ()
Antiplatelet - (x) Anticoagulation) - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No - () N/A

# CV: Patient developed atrial fibrillation with RVR on the
medicine service and was transferred to MICU for diltiazem gtt.
Her heart rhythm converted to sinus after diltiazem gtt was
started and remained in sinus. Her blood pressure initially
remained elevated but came down. Patient appeared volume
overloaded so she was diuresed with IV and then PO furosemide.
Her anticoagulation was managed as above.

# Pulm: Prior to transfer to the ICU, patient became hypoxic,
requiring supplemental O2. Thought to be due to acute pulmonary
congestion from volume overload. Respiratory status improved
with diuresis and she remained 93-96% on RA.

# ID: Patient with ? of LLL pneumonia on abdomen/pelvis CT on
admission. However, patient did not have leukocytosis or fevers
at that time. She was empirically treated with vanc/cefepime and
flagyl for healthcare associated pneumonia with possible
component of aspiration pneumonia. However, the antibiotics were
stopped as her respiratory status improved with diuresis. Later
during the hospitalization, patient did develop leukocytosis to
22, and another infectious work up was done with UA/UCx (yeast),
CXR (largely unchanged, still with bilateral pleural fluids and
atelectasis), c diff toxin and blood cultures, which were
otherwise negative. Patient's zoster was treated with 5 day
course of PO acyclovir. LP was also attempted without success
both by the floor team and also by IR. As patient's leukocytosis
resolved on its own without antibiotics and remained normal, no
further infectious work up was undertaken.

# GI: After her PEG placement, patient would wince with
abdominal exam, but otherwise comfortable. No peritoneal signs
and soft abdomen. This was thought to be due to recent procedure
and patient was given tylenol with improvement.

# Endo: Continued on levothyroxine for hypothyroidism.
# FEN: Patient unable to pass speech and swallow test after her
stroke, and underwent PEG placement on [**2153-6-19**]. Tube feed
started through PEG with residuals ranging from 30-100 cc, but
now tube feed at goal without issues.

# Contact: daughter [**Name (NI) 89368**] is HCP, cell [**Telephone/Fax (1) 89369**]
# [**Name2 (NI) 7092**] status: DNR/DNI, confirmed with daughter

Medications on Admission:
1. Alendronate Sodium 70 mg PO Frequency is Unknown
2. Amlodipine 5 mg PO DAILY
3. Citalopram 20 mg PO DAILY
4. Clobetasol Propionate 0.05% Ointment 1 Appl TP PRN [**Hospital1 **] rash
stop when rash resolves
5. Mupirocin Nasal Ointment 2% 1 Appl NU [**Hospital1 **] PRN open wounsd
Duration: 5 Days
6. Nystatin Powder *NF* 1 application topical daily prn rash
7. Omeprazole 20 mg PO DAILY
8. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
9. traZODONE 50 mg PO DAILY
10. Triamcinolone Acetonide 0.1% Cream 1 Appl TP [**Hospital1 **]:PRN itch
11. Aspirin 81 mg PO DAILY
12. Calcium Carbonate 1500 mg PO BID
13. Guaifenesin [**4-19**] mL PO QID
1 table spoon of 100mg/5mL 4times a day
14. Multivitamins 1 TAB PO DAILY
15. Senna 2 TAB PO HS


Discharge Medications:
1. Amlodipine 10 mg PO DAILY
Hold if SBP < 100 and HR <60
2. Citalopram 20 mg PO DAILY
3. Senna 1 TAB PO BID:PRN constipation
4. Bisacodyl 10 mg PO DAILY:PRN constipation
5. Docusate Sodium (Liquid) 100 mg PO BID:PRN constipation
6. Levothyroxine Sodium 12.5 mcg PO DAILY
7. Metoprolol Tartrate 25 mg PO BID
hold for SBP <100, HR<50
8. Alendronate Sodium 70 mg PO QMON
9. Calcium Carbonate 1500 mg PO BID
10. Acetaminophen 650 mg PO Q6H:PRN pain/fever
11. Ipratropium Bromide Neb 1 NEB IH Q6H
12. Aspirin 81 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Omeprazole 20 mg PO DAILY
15. Miconazole Powder 2% 1 Appl TP [**Hospital1 **]:PRN groin
16. Furosemide 40 mg PO DAILY
hold if SBP <100
17. Warfarin 5 mg PO DAILY16

Discharge Disposition:
Extended Care

Facility:
[**Hospital **] LivingCenter - [**Location (un) 1411**]

Discharge Diagnosis:
Primary Diagnosis: embolic stroke, paroxysmal atrial
fibrillation, dementia, hypertension, hypothyroidism
Secondary Diagnosis: latent syphilis, osteoarthritis


Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
Dear Mrs. [**Known lastname 10680**],
It was a pleasure to take care of you at [**Hospital1 827**]. You were admitted to the hospital because of
abdominal pain and fevers and were found to have a small bowel
obstruction. Your obstruction was managed medically and
improved. However, you developed a rapid irregular heart rhythm
(atrial fibrillation with rapid ventricular rhythm) and had to
be transferred to the intensive care unit. Your heart rate
returned to [**Location 213**] with medications. While in the ICU, you were
noted to have deviated eyes and brain imaging showed new
strokes. Because we thought your stroke was from the irregular
heart rhythm, you were started on blood thinner called heparin
and transitioned to coumadin.

Because of your strokes, you could not swallow without risk of
getting food or liquid into your lungs. Given this finding,
discussion was had with your daughter and feeding tube was
placed in your stomach.

Followup Instructions:
Please call your primary care physician's office at [**Telephone/Fax (1) 14405**]
after discharge from rehabilitation facility to make a follow up
appointment.

NEUROLOGY
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name **]
Phone:[**Telephone/Fax (1) 3506**]
Date/Time:[**2153-9-26**] 4:00
[**Hospital Ward Name 23**] [**Location (un) **]
{'Unspecified intestinal obstruction,Pneumonia, organism unspecified,Other encephalopathy,Cerebral embolism with cerebral infarction,Pneumonitis due to inhalation of food or vomitus,Acute edema of lung, unspecified,Dementia in conditions classified elsewhere with behavioral disturbance,Delirium due to conditions classified elsewhere,Localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures, without mention of intractable epilepsy,Hyperosmolality and/or hypernatremia,Other frontotemporal dementia,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Atrial fibrillation,Altered mental status,Latent syphilis, unspecified,Depressive disorder, not elsewhere classified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Knee joint replacement,Personal history of tobacco use,Spasm of conjugate gaze,Essential and other specified forms of tremor,Rash and other nonspecific skin eruption,Dysphagia, oropharyngeal phase'}


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: Chief Complaint: Abd pain and fever
Reason for MICU transfer: A. fib with

PRESENT ILLNESS: Ms. [**Known lastname 10680**] is a 76 y/o F with a h/o frontal dementia,
hypothyroidism, and hypertension who was admitted from [**Location (un) 8220**] (lives there as long term care) on [**2153-6-3**] with abdominal
pain and fever. CT of her abdomen/pelvis in the ER were notable
for an SBO and a LLL PNA, she was admitted to ACS for
conservative management of a SBO. Her abdominal pain improved,
she had a BM and ACS said her SBO resolved, they then
transferred her to CC6 on [**2153-6-5**] for management of her pna and
and delirium. She is currently on vanc/cefepime/flagyl for abx
coverage. She is afebrile, only oriented to herself, she is
pulling out her IV's, etc. Her O2 requirement and CXR was
worseing during her [**Hospital1 **] course. On [**2153-6-6**] she triggered at
8:55 for difficulty breathing and HR to 140s in a fib with BPs
of 170s to 90s. Pt noted at that time to be positive 4Ls with
UOP of about 20/Hr of fluid and requiring 2L NC for 88%. 20mg of
IV lasix was given and 5mg of metoprolol iv which she diuressed.
Throughout the day she had occasional a fib with SBPs in the
160-170s and triggered an additional two times. She was given
20+20+40 IV lasix, 5+5 of metoprolol and 25 of PO metoprolol
Q8Hr. Then she continued to be in A. fib with RVR to the
150-160s and was transferred to the MICU.

MEDICAL HISTORY: - Dementia, Hypertension, Hypothryroid, Latent syphilis,
depression, Osteoarthritis
- Bilateral knee replacement in [**2140**]

MEDICATION ON ADMISSION: 1. Alendronate Sodium 70 mg PO Frequency is Unknown
2. Amlodipine 5 mg PO DAILY
3. Citalopram 20 mg PO DAILY
4. Clobetasol Propionate 0.05% Ointment 1 Appl TP PRN [**Hospital1 **] rash
stop when rash resolves
5. Mupirocin Nasal Ointment 2% 1 Appl NU [**Hospital1 **] PRN open wounsd
Duration: 5 Days
6. Nystatin Powder *NF* 1 application topical daily prn rash
7. Omeprazole 20 mg PO DAILY
8. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
9. traZODONE 50 mg PO DAILY
10. Triamcinolone Acetonide 0.1% Cream 1 Appl TP [**Hospital1 **]:PRN itch
11. Aspirin 81 mg PO DAILY
12. Calcium Carbonate 1500 mg PO BID
13. Guaifenesin [**4-19**] mL PO QID
1 table spoon of 100mg/5mL 4times a day
14. Multivitamins 1 TAB PO DAILY
15. Senna 2 TAB PO HS

ALLERGIES: Ace Inhibitors

PHYSICAL EXAM: ADMISSION EXAM PER ACS:
Vitals:  98.6   99    137/69    16    96%RA
GEN: sleeping but intermittently responsive, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear on right, mildly coarse BS on left
ABD: Soft, +distension, mildly tender L abd, no rebound or
guarding, normoactive bowel sounds, no palpable masses
Ext: No LE edema, LE warm and well perfused

FAMILY HISTORY: Two brothers and two sisters, one of which died of old age.  The
living siblings have dementia, hypertension, diabetes mellitus
and a stroke.  Five children, one with asthma, three with
hypertension.

SOCIAL HISTORY: The patient quit smoking 30 years ago, does not drink alcohol.
No recreational drugs, no transfusions.  Stopped working more
than ten years ago. 

### Response:
{'Unspecified intestinal obstruction,Pneumonia, organism unspecified,Other encephalopathy,Cerebral embolism with cerebral infarction,Pneumonitis due to inhalation of food or vomitus,Acute edema of lung, unspecified,Dementia in conditions classified elsewhere with behavioral disturbance,Delirium due to conditions classified elsewhere,Localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures, without mention of intractable epilepsy,Hyperosmolality and/or hypernatremia,Other frontotemporal dementia,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Atrial fibrillation,Altered mental status,Latent syphilis, unspecified,Depressive disorder, not elsewhere classified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Knee joint replacement,Personal history of tobacco use,Spasm of conjugate gaze,Essential and other specified forms of tremor,Rash and other nonspecific skin eruption,Dysphagia, oropharyngeal phase'}
