CHIEF COMPLAINT: hypotension, altered mental status, apnea

PRESENT ILLNESS: Ms. [**Known lastname **] is a 64 year old female w/MS (bedbound), DM, COPD [**Hospital 4045**]
transferred from rehab facility w/acute onset AMS.  Reportedly
hypoxic to high 80s.  The history is obtained from her son who
is at bedside.
.
Of note, she has frequent UTIs and was hospitalized in [**Month (only) 116**] for
urosepsis (E.coli sensitive to Zosyn, Meropenem, Gent).
.
In the ED, she very rapidly deteriorated, began vomiting and her
BPs rose to 200s systolic initially in the ED.  She underwent a
CT head - no bleed.  She became not responsive to voice or
sternal rub, then became apneic.  There was ?seizure, no known
seizure disorder --> given 2mg ativan.  Due to ongoing hypoxia,
she was given ketamine to take a look at the cords -->
laryngospasm --> intubation.   Intubated with ketamine,
lidocaine and fentanyl for airway protection; fent and midaz for
sedation.  During the intubation, she actively vomited and
aspirated gastric contents.  She was given gentamicin and
admitted to the MICU.

MEDICAL HISTORY: Multiple Sclerosis -- about 14yrs, followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Location (un) 2274**]
 - wheelchair at baseline, lives in nursing home
 - has no use of her lower extremities, sometimes spastic
movements, bladder chronically contracted
UTI with ESBL E.coli--sensitive to zosyn, [**Last Name (un) 2830**], gent
Chronic Depression
Anxiety
PVD s/p lower extremity bypass
COPD
Osteoporosis
Hx of +PPD
bilateral femur supracondylar fractures [**2113**]
hx of Urosepsis - hospitalized about once/yr, per husband
Neurogenic bladder - indwelling foley x [**4-26**] [**Last Name (LF) 1686**], [**First Name3 (LF) **] husband
Recurrent C. Diff
Hx of Sacral [**First Name3 (LF) **]
LE spasticity
Hx of jaw pain -- ?TMJ, improved on Tegretol

MEDICATION ON ADMISSION: (According to nursing home records with the patient)
methenamine hippurate 1gm [**Hospital1 **]
simvastatin 20 mg QHS
carbamazepine 300mg XR [**Hospital1 **]
carbamazepine 100 mg daily at noon
cyclobenzaprine 10 mg [**Hospital1 **]
baclofen 5 mg [**Hospital1 **]
Copaxone 20 mg Subcutaneous once a day
Os-Cal 500 + D  Oral
alendronate 70 mg weekly
citalopram 40 mg daily
donepezil 10 mg HS
trazodone 25 mg hs
cranberry  Oral
Norvasc 5 mg daily
aspirin 81 mg
albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution qam prn
ipratropium bromide 0.02 % Solution qam prn
acetaminophen 650 mg q6 prn
vitamin E  Oral
senna 8.6 mg
potassium chloride 20 mEq daily
Fleet Enema 19-7 gram/118 mL M/W/F
docusate sodium 50 mg/5 mL Liquid [**Hospital1 **]
Flovent HFA 110 mcg/Actuation Aerosol 2puffs [**Hospital1 **]

ALLERGIES: Zosyn / ceftriaxone

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
Vitals: T: 100.3 BP: 111/70 P: 91 R: 22 O2:  100% (vented)
General: intubated, sedated, not responsive to voice or sternal
rub
HEENT: Sclera anicteric, MMM, pinpoint pupils
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, ronchi
Abdomen: mildly tense, non-tender, non-distended, bowel sounds
present, no organomegaly
GU: chronic foley
Ext: cool, pale, 1+ pulses, no clubbing, cyanosis or edema
Neuro: non-focal
.
DISCHARGE PHYSICAL EXAM:
Vitals: T: 99 BP: 150/80 P: 88 R: 22 O2:  96% 4LNC
Neck: no JVD not elevated
CV: RRR normal s1/s2 no mrg
Lungs: CTABL
Abdomen: NT/ND
GU: chronic foley
Ext: no c/c/e

FAMILY HISTORY: No family members with Multiple Sclerosis.

SOCIAL HISTORY: Lives in nursing home for last 4 [**First Name3 (LF) 1686**].  Husband is HCP, lives
with one of their daughters.  [**Name (NI) **] daughter married and lives
in the area.  Wheelchair at baseline, dependent for transfers
and some of ADLs.  Has no use of lower extremities at baseline.
Tobacco: started at age 20, quit about 15yrs ago
ETOH: social, occasional, per husband
[**Name (NI) 3264**]: none
Septicemia due to escherichia coli [E. coli],Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Obstructive chronic bronchitis with (acute) exacerbation,Hydronephrosis,Urinary tract infection, site not specified,Acute kidney failure, unspecified,Other pneumothorax,Severe sepsis,Multiple sclerosis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Laryngeal spasm,Neurogenic bladder NOS,Calculus of kidney,Coronary atherosclerosis of native coronary artery,Dysphagia, unspecified,Other and unspecified hyperlipidemia,Depressive disorder, not elsewhere classified,Anxiety state, unspecified,Osteoporosis, unspecified,Wheelchair dependence
E coli septicemia,Food/vomit pneumonitis,Acute respiratry failure,Obs chr bronc w(ac) exac,Hydronephrosis,Urin tract infection NOS,Acute kidney failure NOS,Other pneumothorax,Severe sepsis,Multiple sclerosis,DMII wo cmp nt st uncntr,Laryngeal spasm,Neurogenic bladder NOS,Calculus of kidney,Crnry athrscl natve vssl,Dysphagia NOS,Hyperlipidemia NEC/NOS,Depressive disorder NEC,Anxiety state NOS,Osteoporosis NOS,Wheelchair dependence
Admission Date:  [**2118-10-19**]              Discharge Date:   [**2118-10-29**]

Date of Birth:  [**2053-11-10**]             Sex:   F

Service: MEDICINE

Allergies:
Zosyn / ceftriaxone

Attending:[**First Name3 (LF) 602**]
Chief Complaint:
hypotension, altered mental status, apnea

Major Surgical or Invasive Procedure:
[**2118-10-20**] central venous catheter placed
[**2118-10-20**] arterial line placed
[**2118-10-21**] left percutaneous nephrostomy tube placed

History of Present Illness:
Ms. [**Known lastname **] is a 64 year old female w/MS (bedbound), DM, COPD [**Hospital 4045**]
transferred from rehab facility w/acute onset AMS.  Reportedly
hypoxic to high 80s.  The history is obtained from her son who
is at bedside.
.
Of note, she has frequent UTIs and was hospitalized in [**Month (only) 116**] for
urosepsis (E.coli sensitive to Zosyn, Meropenem, Gent).
.
In the ED, she very rapidly deteriorated, began vomiting and her
BPs rose to 200s systolic initially in the ED.  She underwent a
CT head - no bleed.  She became not responsive to voice or
sternal rub, then became apneic.  There was ?seizure, no known
seizure disorder --> given 2mg ativan.  Due to ongoing hypoxia,
she was given ketamine to take a look at the cords -->
laryngospasm --> intubation.   Intubated with ketamine,
lidocaine and fentanyl for airway protection; fent and midaz for
sedation.  During the intubation, she actively vomited and
aspirated gastric contents.  She was given gentamicin and
admitted to the MICU.

Son reports that this all happened over a matter of 1 hour this
afternoon.  She has needed to be intubated in the past for
urosepsis.  Additionally, she had minimal UOP and was given 3L
NS.  However, she was never hypotensive, 102/78 at lowest
(usually 110s-120s).  Febrile to 103 rectally.  ABG: pH 7.25
pCO2 55 pO2 87 HCO3 25 BaseXS -3 (done after intubation, before
adjustment of vent setting).
.
On transfer: 103 rectal, 102/68, 94, 97% on AC 400/18/5/100%.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.


Past Medical History:
Multiple Sclerosis -- about 14yrs, followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Location (un) 2274**]
 - wheelchair at baseline, lives in nursing home
 - has no use of her lower extremities, sometimes spastic
movements, bladder chronically contracted
UTI with ESBL E.coli--sensitive to zosyn, [**Last Name (un) 2830**], gent
Chronic Depression
Anxiety
PVD s/p lower extremity bypass
COPD
Osteoporosis
Hx of +PPD
bilateral femur supracondylar fractures [**2113**]
hx of Urosepsis - hospitalized about once/yr, per husband
Neurogenic bladder - indwelling foley x [**4-26**] [**Last Name (LF) 1686**], [**First Name3 (LF) **] husband
Recurrent C. Diff
Hx of Sacral [**First Name3 (LF) **]
LE spasticity
Hx of jaw pain -- ?TMJ, improved on Tegretol


Social History:
Lives in nursing home for last 4 [**First Name3 (LF) 1686**].  Husband is HCP, lives
with one of their daughters.  [**Name (NI) **] daughter married and lives
in the area.  Wheelchair at baseline, dependent for transfers
and some of ADLs.  Has no use of lower extremities at baseline.
Tobacco: started at age 20, quit about 15yrs ago
ETOH: social, occasional, per husband
[**Name (NI) 3264**]: none


Family History:
No family members with Multiple Sclerosis.

Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 100.3 BP: 111/70 P: 91 R: 22 O2:  100% (vented)
General: intubated, sedated, not responsive to voice or sternal
rub
HEENT: Sclera anicteric, MMM, pinpoint pupils
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, ronchi
Abdomen: mildly tense, non-tender, non-distended, bowel sounds
present, no organomegaly
GU: chronic foley
Ext: cool, pale, 1+ pulses, no clubbing, cyanosis or edema
Neuro: non-focal
.
DISCHARGE PHYSICAL EXAM:
Vitals: T: 99 BP: 150/80 P: 88 R: 22 O2:  96% 4LNC
Neck: no JVD not elevated
CV: RRR normal s1/s2 no mrg
Lungs: CTABL
Abdomen: NT/ND
GU: chronic foley
Ext: no c/c/e


Pertinent Results:
ADMISSION LABS:
[**2118-10-19**] 02:40PM BLOOD WBC-11.6*# RBC-4.83# Hgb-14.8# Hct-44.9#
MCV-93 MCH-30.6 MCHC-32.9 RDW-13.9 Plt Ct-229
[**2118-10-19**] 02:40PM BLOOD Neuts-93.3* Lymphs-5.1* Monos-0.9*
Eos-0.4 Baso-0.2
[**2118-10-19**] 02:40PM BLOOD PT-10.7 PTT-29.3 INR(PT)-1.0
[**2118-10-19**] 02:40PM BLOOD Glucose-167* UreaN-27* Creat-1.2* Na-140
K-4.5 Cl-100 HCO3-27 AnGap-18
[**2118-10-19**] 02:40PM BLOOD ALT-61* AST-84* AlkPhos-176* TotBili-0.7
[**2118-10-19**] 02:40PM BLOOD Lipase-17
[**2118-10-19**] 02:40PM BLOOD cTropnT-<0.01
[**2118-10-19**] 02:40PM BLOOD Albumin-4.0 Calcium-9.9 Phos-3.9# Mg-2.1
[**2118-10-19**] 02:40PM BLOOD Carbamz-9.3
[**2118-10-19**] 03:29PM BLOOD Type-ART FiO2-100 O2 Flow-100 pO2-87
pCO2-55* pH-7.25* calTCO2-25 Base XS--3 AADO2-566 REQ O2-94
-ASSIST/CON Intubat-INTUBATED
[**2118-10-19**] 02:55PM BLOOD Glucose-159* Lactate-3.7* Na-143 K-4.3
Cl-102
[**2118-10-20**] 05:15AM BLOOD freeCa-0.98*
.
DISCHARGE LABS:
[**2118-10-29**] 05:09AM BLOOD WBC-6.0 RBC-3.48* Hgb-10.4* Hct-32.2*
MCV-93 MCH-30.0 MCHC-32.4 RDW-14.4 Plt Ct-321
[**2118-10-29**] 05:09AM BLOOD Glucose-98 UreaN-8 Creat-0.6 Na-140
K-3.1* Cl-102 HCO3-31 AnGap-10
[**2118-10-29**] 05:09AM BLOOD Calcium-8.9 Phos-3.0 Mg-2.0
.
IMAGING:
[**10-19**] CT HEAD: FINDINGS: No hemorrhage, evidence of acute major
vascular territorial infarction, edema, or shift of normally
midline structures is present.  Extensive confluent
periventricular and subcortical white matter hypodensities are
consistent with small vessel ischemic changes. The ventricles
and sulci are enlarged consistent with cortical atrophy, likely
secondary to patient's known multiple sclerosis. Basal cisterns
are patent. Air-fluid levels in the maxillary and sphenoid
sinuses are consistent with sinusitis. Mastoid air cells are
well pneumatized.
IMPRESSION: No acute intracranial process
.
[**10-20**] CT CHEST/ABD/PELVIS: CHEST: There is a consolidation in
the right lower lobe, consistent with patient's history of
aspiration pneumonia. There are bilateral trace effusions. There
is a possible tiny right pneumothorax, which is incompletely
imaged. There are no pulmonary nodules or masses. The base of
the heart is normal in size. There is calcifications of the
coronary arteries. There is no pericardial effusion.
ABDOMEN: The liver is normal shape and contour. There are no
discrete
hepatic masses. There is no intra- or extra-hepatic biliary duct
dilation.  The portal veins are patent. There is no gallbladder.
The spleen and pancreas are unremarkable. The bilateral adrenal
glands are normal.
In the right kidney, there is a large renal staghorn calculus
without
hydronephrosis or hydroureter. In the left kidney, there is a 16
mm calculus within the left proximal ureter. There is associated
mild-to-moderate hydronephrosis, likely secondary to ureteral
obstruction. Three smaller non-obstructing left renal calculi
are present. They measure 10 mm, 6 mm and 5 mm. The kidneys
enhance heterogeneously. On the right, it appears to be more due
to artifact. On the left, the heterogeneous enhancement appears
somewhat more geographical, is concerning for pyelonephritis.
There is no excretion of the contrast into either ureter on the
right or the left. The right ureter, although nor opacified, is
normal in course and caliber. The left ureter has peripheral rim
enhancement, suggesting underlying infection.  There is a Foley
in place in a collapsed bladder. There are no stones seen within
the bladder.
The stomach is unremarkable. The duodenum and jejunum are normal
in course
and caliber. There is no mesenteric stranding. There is a large
amount of
fecal material within the rectum. The sigmoid and descending
colon are
relatively collapsed. There is some fat stranding in the left
retroperitoneum, which is likely due to the kidney and ureter,
rather than the colon. There are multiple diverticula, but no
definite evidence of
diverticulitis. There is no abdominal, mesenteric, pelvic or
inguinal
lymphadenopathy. The abdominal vasculature is normal in course
and caliber, other than a calcified splenic artery aneurysm,
which is stable since [**11**]/[**2117**].
OSSEOUS STRUCTURES: There are no concerning lytic or sclerotic
lesions. The right hip appears malrotated with the acetabular
notch approximating the anterior acetabulum. There are no
fractures.
IMPRESSION:
1. 16-mm calculus within the left proximal ureter with moderate
hydronephrosis. Heterogenous enhancement of the kidney and rim
enhancement of the ureter suggest infection.
2. Three nonobstructing left renal calculi.
3. Right renal staghorn calculus without hydronephrosis or
hydroureter.
4. Right lower lobe consolidation.
5. Possible tiny right pneumothorax, which is incompletely
imaged.
6. Calcified splenic artery aneurysm.
.
MICRO:
[**10-19**] BLOOD CULTURE POSITIVE FOR GNR
[**10-20**] BLOOD CULTURE POSITIVE FOR GPR PRESUMPTIVE CORYNEBACTERIUM

.


Brief Hospital Course:
Mrs. [**Known lastname **] is a 64 year old female with history of recurrent
urinary tract infections, including extended-spectrum
beta-lactamase producing organisms, multiple sclerosis with
spastic bladder, and nephrolithiasis admitted for urinary tract
infection, E. coli septicemia, and sepsis.

#Sepsis/E. coli bacteremia/urinary tract
infection/nephrolithiasis/hydronephrosis:
Patient was admitted with sepsis and was admitted to the
intensive care unit. She required vasopressor support and was
noted to have an obstructing left renal stone. Urology was
consulted and Infectious Disease was consulted and a
percutaneous nephrostomy tube was placed to facilitate urinary
drainage. The patient improved with antibiotics and was
transferred to the floor to complete a 14 day course of IV
Meropenem with Ertapenem to be used to complete course following
discharge. Although it was noted that without removal or the
left renal stone the patient would be at risk for recurrent
infections, the patient was felt to be at too high risk for
surgical nephrolithotomy or extra-corporeal shock wave
lithotripsy. Therefore, the patient was discharged with
percutaneous nephrostomy tube to be changed every 3 months and
the patient will follow up in [**Hospital 159**] clinic.

#Respiratory failure/Chronic obstructive pulmonary
disease/Multiple sclerosis:
Patient developed hypercarbic respiratory failure in the setting
of her infection and required intubation. She was treated with
bronchodilators and steroids and had improvement in her
symptoms. She was extubated but had a persistent oxygen
requirement felt to be due to a combination of respiratory
muscle weakness in the setting of multiple sclerosis and
infection. There was also intermittent aspiration that improved
when diet was changed to a dysphagia diet. Patient completed her
steroid course in the hospital and was discharged to rehab on 4L
supplemental oxygen which had been a stable requirement for >48
hours prior to discharge.

#Dysphagia: Ms. [**Known lastname **] was seen by speech and swallow following a
witnessed aspiration on [**2118-10-26**]. She was approved for nectar
thick liquids and pureed solids.

#Encephalopathy: This was felt to be due to sepsis. Head CT was
negative for bleeding and mental status improved slowly over
hospital course.

#Acute kidney injury ([**Last Name (un) **])/Acute Renal Failure: Baseline
creatinine was 0.6 and upon admission was elevated. She was
treated with IV fluids and antibiotics as above.  By the time of
discharge, her Cr had improved to baseline.

#Hypertension: When she was NPO her home amlodpine and diltiazem
were held.  This resulted in her systolic blood pressures
increasing to 170s-180s with tachycardia.  She had worsening
respiratory distress with elevated blood pressures.  Thus, she
was controlled with an esmolol drip in the ICU with improvement
in her oxygen saturations.  When she was able to take oral
medications again, her home diltiazem and amlodipine were
restarted also with good control of blood pressure and heart
rate.
.
CHRONIC ISSUES BY PROBLEM:
#Hyperlipidemia (HLD): Continued statin
.
#Multiple sclerosis (MS): Continued her home copaxone and after
extubation she was restarted on her muscle relaxants
.
# Depression: Citalopram was initially held then restarted
.
# Hypertension: Amlodipine was held and then restarted.
.
TRANSITIONAL ISSUES:
# Nephrostomy tube: per urology consult this will remain in
place until outpatient followup with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] Urologist. [**Month (only) 116**]
need nephrostomy tube indefinitely.


Medications on Admission:
(According to nursing home records with the patient)
methenamine hippurate 1gm [**Hospital1 **]
simvastatin 20 mg QHS
carbamazepine 300mg XR [**Hospital1 **]
carbamazepine 100 mg daily at noon
cyclobenzaprine 10 mg [**Hospital1 **]
baclofen 5 mg [**Hospital1 **]
Copaxone 20 mg Subcutaneous once a day
Os-Cal 500 + D  Oral
alendronate 70 mg weekly
citalopram 40 mg daily
donepezil 10 mg HS
trazodone 25 mg hs
cranberry  Oral
Norvasc 5 mg daily
aspirin 81 mg
albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution qam prn
ipratropium bromide 0.02 % Solution qam prn
acetaminophen 650 mg q6 prn
vitamin E  Oral
senna 8.6 mg
potassium chloride 20 mEq daily
Fleet Enema 19-7 gram/118 mL M/W/F
docusate sodium 50 mg/5 mL Liquid [**Hospital1 **]
Flovent HFA 110 mcg/Actuation Aerosol 2puffs [**Hospital1 **]


Discharge Medications:
1. methenamine hippurate 1 gram Tablet Sig: One (1) Tablet PO
twice a day.
2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. carbamazepine 100 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO Q 24H (Every 24 Hours).
4. carbamazepine 100 mg Tablet, Chewable Sig: Three (3) Tablet,
Chewable PO BID (2 times a day).
5. baclofen 10 mg Tablet Sig: One (1) Tablet PO twice a day.
6. glatiramer 20 mg Kit Sig: Twenty (20) mg Subcutaneous Daily
().
7. Os-Cal 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One (1)
Tablet PO once a day.
8. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.

9. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

10. donepezil 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
11. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
12. cranberry 250 mg Tablet Sig: One (1) Tablet PO once a day.
13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) 2.5mg nebulization Inhalation Q4H
(every 4 hours).
15. ipratropium bromide 0.02 % Solution Sig: One (1)
nebulization Inhalation Q6H (every 6 hours).
16. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
17. vitamin E 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
18. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
19. potassium chloride 20 mEq Packet Sig: One (1)  PO once a
day.
20. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1)  Rectal q
M/W/F.
21. docusate sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).
22. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
23. Sodium Chloride 0.9%  Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
24. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
25. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
26. meropenem 500 mg Recon Soln Sig: One (1)  Intravenous every
eight (8) hours for 5 days.


Discharge Disposition:
Extended Care

Facility:
[**Location (un) 583**] House Rehab & Nursing Center

Discharge Diagnosis:
PRIMARY DIAGNOSIS
Septicemia/bloodstream infection secondary to urinary tract
infection
urinary tract infection.

SECONDARY DIAGNOSIS
multiple sclerosis


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
Dear Mrs. [**Known lastname **],
.
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
to the hospital because you had an infection in your bloodstream
which caused your blood pressure to drop and you stopped
breathing.  You were treated with antibiotics and medications to
keep your blood pressure up.  Also we put you on a ventilator to
breath for you.
.
The following changes were made to your medications:
Continue Meropenem
.
It is very important that you keep all of the follow-up
appointments listed below.
Start Meropenem IV for 5 more days for your urinary tract
infection
Stop norvasc due to normal blood pressure

Followup Instructions:
Department: SURGICAL SPECIALTIES
When: MONDAY [**2118-11-28**] at 2:00 PM
With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 164**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Septicemia due to escherichia coli [E. coli],Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Obstructive chronic bronchitis with (acute) exacerbation,Hydronephrosis,Urinary tract infection, site not specified,Acute kidney failure, unspecified,Other pneumothorax,Severe sepsis,Multiple sclerosis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Laryngeal spasm,Neurogenic bladder NOS,Calculus of kidney,Coronary atherosclerosis of native coronary artery,Dysphagia, unspecified,Other and unspecified hyperlipidemia,Depressive disorder, not elsewhere classified,Anxiety state, unspecified,Osteoporosis, unspecified,Wheelchair dependence'}


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: hypotension, altered mental status, apnea

PRESENT ILLNESS: Ms. [**Known lastname **] is a 64 year old female w/MS (bedbound), DM, COPD [**Hospital 4045**]
transferred from rehab facility w/acute onset AMS.  Reportedly
hypoxic to high 80s.  The history is obtained from her son who
is at bedside.
.
Of note, she has frequent UTIs and was hospitalized in [**Month (only) 116**] for
urosepsis (E.coli sensitive to Zosyn, Meropenem, Gent).
.
In the ED, she very rapidly deteriorated, began vomiting and her
BPs rose to 200s systolic initially in the ED.  She underwent a
CT head - no bleed.  She became not responsive to voice or
sternal rub, then became apneic.  There was ?seizure, no known
seizure disorder --> given 2mg ativan.  Due to ongoing hypoxia,
she was given ketamine to take a look at the cords -->
laryngospasm --> intubation.   Intubated with ketamine,
lidocaine and fentanyl for airway protection; fent and midaz for
sedation.  During the intubation, she actively vomited and
aspirated gastric contents.  She was given gentamicin and
admitted to the MICU.

MEDICAL HISTORY: Multiple Sclerosis -- about 14yrs, followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Location (un) 2274**]
 - wheelchair at baseline, lives in nursing home
 - has no use of her lower extremities, sometimes spastic
movements, bladder chronically contracted
UTI with ESBL E.coli--sensitive to zosyn, [**Last Name (un) 2830**], gent
Chronic Depression
Anxiety
PVD s/p lower extremity bypass
COPD
Osteoporosis
Hx of +PPD
bilateral femur supracondylar fractures [**2113**]
hx of Urosepsis - hospitalized about once/yr, per husband
Neurogenic bladder - indwelling foley x [**4-26**] [**Last Name (LF) 1686**], [**First Name3 (LF) **] husband
Recurrent C. Diff
Hx of Sacral [**First Name3 (LF) **]
LE spasticity
Hx of jaw pain -- ?TMJ, improved on Tegretol

MEDICATION ON ADMISSION: (According to nursing home records with the patient)
methenamine hippurate 1gm [**Hospital1 **]
simvastatin 20 mg QHS
carbamazepine 300mg XR [**Hospital1 **]
carbamazepine 100 mg daily at noon
cyclobenzaprine 10 mg [**Hospital1 **]
baclofen 5 mg [**Hospital1 **]
Copaxone 20 mg Subcutaneous once a day
Os-Cal 500 + D  Oral
alendronate 70 mg weekly
citalopram 40 mg daily
donepezil 10 mg HS
trazodone 25 mg hs
cranberry  Oral
Norvasc 5 mg daily
aspirin 81 mg
albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution qam prn
ipratropium bromide 0.02 % Solution qam prn
acetaminophen 650 mg q6 prn
vitamin E  Oral
senna 8.6 mg
potassium chloride 20 mEq daily
Fleet Enema 19-7 gram/118 mL M/W/F
docusate sodium 50 mg/5 mL Liquid [**Hospital1 **]
Flovent HFA 110 mcg/Actuation Aerosol 2puffs [**Hospital1 **]

ALLERGIES: Zosyn / ceftriaxone

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
Vitals: T: 100.3 BP: 111/70 P: 91 R: 22 O2:  100% (vented)
General: intubated, sedated, not responsive to voice or sternal
rub
HEENT: Sclera anicteric, MMM, pinpoint pupils
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, ronchi
Abdomen: mildly tense, non-tender, non-distended, bowel sounds
present, no organomegaly
GU: chronic foley
Ext: cool, pale, 1+ pulses, no clubbing, cyanosis or edema
Neuro: non-focal
.
DISCHARGE PHYSICAL EXAM:
Vitals: T: 99 BP: 150/80 P: 88 R: 22 O2:  96% 4LNC
Neck: no JVD not elevated
CV: RRR normal s1/s2 no mrg
Lungs: CTABL
Abdomen: NT/ND
GU: chronic foley
Ext: no c/c/e

FAMILY HISTORY: No family members with Multiple Sclerosis.

SOCIAL HISTORY: Lives in nursing home for last 4 [**First Name3 (LF) 1686**].  Husband is HCP, lives
with one of their daughters.  [**Name (NI) **] daughter married and lives
in the area.  Wheelchair at baseline, dependent for transfers
and some of ADLs.  Has no use of lower extremities at baseline.
Tobacco: started at age 20, quit about 15yrs ago
ETOH: social, occasional, per husband
[**Name (NI) 3264**]: none 

### Response:
{'Septicemia due to escherichia coli [E. coli],Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Obstructive chronic bronchitis with (acute) exacerbation,Hydronephrosis,Urinary tract infection, site not specified,Acute kidney failure, unspecified,Other pneumothorax,Severe sepsis,Multiple sclerosis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Laryngeal spasm,Neurogenic bladder NOS,Calculus of kidney,Coronary atherosclerosis of native coronary artery,Dysphagia, unspecified,Other and unspecified hyperlipidemia,Depressive disorder, not elsewhere classified,Anxiety state, unspecified,Osteoporosis, unspecified,Wheelchair dependence'}
