CHIEF COMPLAINT: altered mental status, dyspnea

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, LUE DVT on home O2
who presents with dyspnea, AMS. Of note, patient was discharged
2 days ago from hospitalization for AMS, dyspnea and
representing with same complaints.  Somnolent since discharge
per daughter, sleep 2 days prior to admission at home on 0.5L -
2LNC per daughter. [**Name (NI) **] prior to admission, daughter noted thumb
twitching and picking at site of port-a-cath. VNA visited for
line check. Reports new incontinence. Daughter worried because
patient ate 4 yogurts.
.
In ED, 7.13/108/97 on bipap.  EMS reported 60% pulse ox on
roomair. Patient has been taking cefepime. Vitals 97.7 73 152/67
rr 16 non-rebreather 15L 100%. edema. a*o *2. UA neg. HyperK+
6.9 (K+ 5 on d/c [**8-28**]). In ED, Ca gluc, D50, insulin, 1gm vanc.
CXR atelextasis vs infilatrate. Sent blood cultures. HR 77 BP
154/95 RR 14 on BiPAP 100% on bipap.
.
Upon arrival to MICU, somnolent with stable vitals on BiPAP.

MEDICAL HISTORY: -h/o hyperkalemia
-PICC assiated LUE DVT and hematoma [**5-8**]
-Multifactorial anemia ([**3-3**] CRI, chronic disease, MDS)
-MDS dx 3 yrs ago
-Crohn's disease
-CAD s/p NSTEMI '[**89**]
-Chronic diastolic CHF EF 60-70's
-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
-s/p CY 10 yrs ago
-s/p Lumpectomy 13 yrs ago

MEDICATION ON ADMISSION: MVI w/ minerals
Ciprofloxacin * 1 sat due to concern for somnulence
Cefepime 1 gram daily
Heparin line flush
NaCl line flush
Enoxaparin 60 mg daily
Triamcinolone Acetonide 0.025 % PRN: lower extremitites
Mesalamine 400 mg Tablet 3 tabs daily
Miconazole Nitrate 2 % Powder QID:PRN
Epoetin Alfa 40,000 units weekly
Folic Acid 1 mg daily
Furosemide 20 mg daily
Artificial Tears TI:PRN
Omeprazole 20 mg daily
Timolol Maleate 0.5 % one drop daily
Atovaquone 750 mg/5 mL Suspension Sig: Ten (10) MLs PO DAILY --
has not taken at home
Prednisone [**Date Range **] 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

ALLERGIES: Belladonna Alkaloids

PHYSICAL EXAM: Physical Exam on discharge:
Vitals Tm 98.0 HR 70-85 BP 130-133/50-63 RR 20 Sats 94-97% on
1.5L NC
General: NAD, cooperative, [**Name (NI) 595**]-speaking
[**Name (NI) 4459**]: NCAT, OP clear
Lungs: poor air movement throughout, CTA on limited exam
CV: RRR, nl S1, S2, systolic murmur heard best at LUSB. No
appreciable JVD.
Abd: S, NT/ND
Ext: WWP, 2+ pulses
Access: POC with benign skin changes, no appreciable erythema or
wamrth.  Mildly tender to palpation.

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.
Unspecified septicemia,Acute respiratory failure,Acidosis,Regional enteritis of unspecified site,Acute on chronic diastolic heart failure,Sepsis,Myelodysplastic syndrome, unspecified,Chronic kidney disease, unspecified,Anemia of other chronic disease,Esophageal reflux,Venous (peripheral) insufficiency, unspecified,Candidiasis of skin and nails,Old myocardial infarction,Coronary atherosclerosis of native coronary artery,Personal history of venous thrombosis and embolism,Personal history of malignant neoplasm of breast
Septicemia NOS,Acute respiratry failure,Acidosis,Regional enteritis NOS,Ac on chr diast hrt fail,Sepsis,Myelodysplastic synd NOS,Chronic kidney dis NOS,Anemia-other chronic dis,Esophageal reflux,Venous insufficiency NOS,Cutaneous candidiasis,Old myocardial infarct,Crnry athrscl natve vssl,Hx-ven thrombosis/embols,Hx of breast malignancy
Admission Date:  [**2194-8-31**]              Discharge Date:   [**2194-9-9**]

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

Service: MEDICINE

Allergies:
Belladonna Alkaloids

Attending:[**First Name3 (LF) 800**]
Chief Complaint:
altered mental status, dyspnea

Major Surgical or Invasive Procedure:
BIPAP
1U pRBC given


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, LUE DVT on home O2
who presents with dyspnea, AMS. Of note, patient was discharged
2 days ago from hospitalization for AMS, dyspnea and
representing with same complaints.  Somnolent since discharge
per daughter, sleep 2 days prior to admission at home on 0.5L -
2LNC per daughter. [**Name (NI) **] prior to admission, daughter noted thumb
twitching and picking at site of port-a-cath. VNA visited for
line check. Reports new incontinence. Daughter worried because
patient ate 4 yogurts.
.
In ED, 7.13/108/97 on bipap.  EMS reported 60% pulse ox on
roomair. Patient has been taking cefepime. Vitals 97.7 73 152/67
rr 16 non-rebreather 15L 100%. edema. a*o *2. UA neg. HyperK+
6.9 (K+ 5 on d/c [**8-28**]). In ED, Ca gluc, D50, insulin, 1gm vanc.
CXR atelextasis vs infilatrate. Sent blood cultures. HR 77 BP
154/95 RR 14 on BiPAP 100% on bipap.
.
Upon arrival to MICU, somnolent with stable vitals on BiPAP.

Past Medical History:
-h/o hyperkalemia
-PICC assiated LUE DVT and hematoma [**5-8**]
-Multifactorial anemia ([**3-3**] CRI, chronic disease, MDS)
-MDS dx 3 yrs ago
-Crohn's disease
-CAD s/p NSTEMI '[**89**]
-Chronic diastolic CHF EF 60-70's
-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
-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:
Physical Exam on discharge:
Vitals Tm 98.0 HR 70-85 BP 130-133/50-63 RR 20 Sats 94-97% on
1.5L NC
General: NAD, cooperative, [**Name (NI) 595**]-speaking
[**Name (NI) 4459**]: NCAT, OP clear
Lungs: poor air movement throughout, CTA on limited exam
CV: RRR, nl S1, S2, systolic murmur heard best at LUSB. No
appreciable JVD.
Abd: S, NT/ND
Ext: WWP, 2+ pulses
Access: POC with benign skin changes, no appreciable erythema or
wamrth.  Mildly tender to palpation.

Pertinent Results:
[**2194-8-31**] 01:40AM BLOOD WBC-7.2 RBC-3.01* Hgb-10.3* Hct-33.1*
MCV-110* MCH-34.1* MCHC-31.0 RDW-21.7* Plt Ct-156
[**2194-8-31**] 01:40AM BLOOD Neuts-85.0* Lymphs-11.0* Monos-3.6
Eos-0.2 Baso-0.2
[**2194-9-2**] 03:02AM BLOOD PT-10.5 PTT-25.6 INR(PT)-0.9
[**2194-8-31**] 01:40AM BLOOD Glucose-146* UreaN-43* Creat-2.1* Na-141
K-6.9* Cl-107 HCO3-26 AnGap-15
[**2194-8-31**] 05:19AM BLOOD Type-ART pO2-97 pCO2-108* pH-7.13*
calTCO2-38* Base XS-2
[**2194-9-3**] 05:23AM BLOOD WBC-4.4 RBC-2.73* Hgb-8.9* Hct-29.3*
MCV-107* MCH-32.5* MCHC-30.3* RDW-22.1* Plt Ct-140*
[**2194-9-2**] 03:02AM BLOOD Neuts-77.7* Lymphs-15.1* Monos-6.6
Eos-0.4 Baso-0.2
[**2194-9-3**] 05:23AM BLOOD Glucose-110* UreaN-41* Creat-1.9* Na-140
K-5.6* Cl-99 HCO3-37* AnGap-10
[**2194-9-3**] 05:49AM BLOOD Type-[**Last Name (un) **] pO2-30* pCO2-67* pH-7.38
calTCO2-41* Base XS-10
[**2194-9-5**] 04:11AM BLOOD WBC-7.7 RBC-3.25* Hgb-10.6* Hct-33.1*
MCV-102* MCH-32.5* MCHC-31.9 RDW-25.2* Plt Ct-208
[**2194-9-4**] 05:46AM BLOOD WBC-5.2 RBC-2.67* Hgb-9.1* Hct-28.2*
MCV-106* MCH-34.0* MCHC-32.1 RDW-22.3* Plt Ct-181
[**2194-9-3**] 05:23AM BLOOD WBC-4.4 RBC-2.73* Hgb-8.9* Hct-29.3*
MCV-107* MCH-32.5* MCHC-30.3* RDW-22.1* Plt Ct-140*
[**2194-9-5**] 08:25AM BLOOD HCO3-37*
[**2194-9-5**] 04:11AM BLOOD Glucose-91 UreaN-40* Creat-2.1* Na-143
K-4.6 Cl-99 HCO3-37* AnGap-12
[**2194-9-4**] 05:46AM BLOOD Glucose-88 UreaN-41* Creat-1.9* Na-140
K-4.9 Cl-99 HCO3-35* AnGap-11
[**2194-9-3**] 06:11PM BLOOD Glucose-137* UreaN-44* Creat-2.0* Na-138
K-5.3* Cl-97 HCO3-38* AnGap-8
[**2194-9-5**] 04:11AM BLOOD Calcium-8.5 Phos-3.8# Mg-2.4
[**2194-9-4**] 05:46AM BLOOD Calcium-8.1* Phos-2.2* Mg-2.3
[**2194-9-4**] 05:46AM BLOOD Vanco-27.0*
[**2194-9-5**] 10:39AM BLOOD Type-ART pO2-43* pCO2-84* pH-7.31*
calTCO2-44* Base XS-11
Cardiology Report ECG Study Date of [**2194-8-31**]  4:53:28 AM

Sinus rhythm with premature atrial contractions. Left atrial
abnormality.
Right bundle-branch block. Compared to the previous tracing of
[**2194-8-25**] there is no significant change.

CXR ([**8-31**])
IMPRESSION:
1. Retrocardiac opacity likely combination of atelectasis and
effusion. A
superimposed pneumonia in this region cannot be excluded.
2. CHF with interstitial edema, more prominent than prior study.


CXR ([**9-9**])
FINDINGS: There is essentially unchanged presentation of the
left pleural
effusion and of a left retrocardiac consolidation, most likely
consistent with atelectasis. The right lung is clear without
evidence of pneumothorax, consolidation or pleural effusion.
There is a right Port-A-Catheter in place with its tip ending at
the superior vena cava

IMPRESSION: Compared to [**2194-9-6**], there is unchanged left
retrocardiac consolidation, consistent with atelectasis and
there is unchanged left pleural effusion.

Brief Hospital Course:
82F with MDS, Crohn's with multiple GI bleeds, CAD s/p NSTEMI,
CKD, breast CA, with worsening respiratory status over past
several months of unclear etiology, admitted for altered mental
status and dyspnea within 3 days of discharge for same
presentation.

#. AMS. The patient presented with somnolence likely secondary
to hypercarbia. The patient had a PCO2 of 108 on admission with
a stable CXR and no WBC or fever. The patient was on cefepime
from her last hospitalization. The patient was pan-cultured
including blood and urine cultures. She was started on BiPAP
overnight. Patient CO2 improved per VBG. Blood cultures drawn
from the line were positive for coagulase negative gram
positive. The patient was discontinued from cefepime and started
on a two week course of vancomycin (Day 1 [**2194-9-1**]) for a
susptected line infection. The line was not removed due to poor
access. The patient's mental status returned to baseline after
antibiotics and a decrease in her VBG CO2. The following
surviellance cultures were negative. The patient was then
transferred to the medical floor from [**Date range (1) 62751**], at which time
she improved until [**9-5**] when she triggered after her daughter
decided to place the pt on BIPAP late in the morning but did not
connect the BIPAP to the machine. This caused acute hypoxia,
which was treated with nasal canula oxygen and BIPAP on the
floor. A CXR was unchanged from prior, and ABG (thought to be
venous stick) showed labs c/w hypercarbia probably secondary to
over oxygenation after the trigger event. There were no signs of
acute pulm edema or CHF. Due to receiving BIPAP on the floor,
she was transferred back to the ICU.
.
During her ICU course, her hypercarbia generally resolved on
nightly BIPAP and NC throughout the day at 2-4L.  With this came
an improvement in mental status to baseline per the patient's
daughter.  Giving 2.5 mg Zyprexa was found to be beneficial in
improving pt compliance with BIPAP at night.  On [**9-8**], the pt
was transferred back to the floor and remained stable on nightly
BIPAP and 1.5L NC during the day.
.
The patient was discharged with instructions to complete her
2-wk course of vancomycin (concluding [**2194-9-15**]), as well as
nightly BIPAP 13/5 and NC during the day as needed.
.
# Dyspnea. The patient was slightly dyspneic at baseline on
presentation. The daughter reported that the patient was wearing
continuous O2 at home with good oxygen sats. The CXR was
consistent with fluid overload. The patient was diuresed with
lasix. The diureses greatly improved the patient's symptoms. She
was sating in the low 90's on room air. She was placed on CPAP
at night (on the patient's home settings) and nasal canula
during the day. She was then transferred to the floor, where the
patient had an inpatient overnight sleep study. As described
above, she then triggered and was transferred back to the ICU.
.
As described above, the pt's hypercarbia resolved on nightly
BIPAP and NC during the day.
.
# Diastolic Heart Failure. The patient presented with fluid
overload, which likely contributed to her dyspnea. The CXR was
consistent with fluid overload. The patient had an elevated BNP
as well. The patient was diuresed with lasix and her home dose
of lopressor was started (although the patient was not taking
this medication). The lopressor was later stopped due to patient
and family refusal. On the floor, the patient was diuresed on
her home dose of 20 Lasix PO. She did not have any signs of
acute CHF.
.
# Hyperkalemia. The hyperkalemia was likely in the setting of
acidemia. The patient was given kayexelate in the emergency
department. An EKG was checked on presentation and is described
above.  Throughout the pt's hospitalization, the pt had episodes
of hyperkalemia noted on AM labs that responded well to po Lasix
and po Kayexalate.  As these repeated episodes are concerning,
the pt will have K+ checked twice weekly by her visiting nurses,
with the results forwarded to her PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3357**].  He will
interpret these results and provide guidance as to usage of
Kayexalate, for which the patient was given a prescription on
discharge.
.
# Crohn's Disease: The patient was continued on her home
mesalamin. She was also continued on her steroid [**Last Name (STitle) 15123**]. The
patient was guaiac positive during her stay, however, her
hematocrit remained stable and was not further assessed. The
patient also had 4 episodes of diarrhea.  On the floor, her
steroids were continued on a [**Last Name (STitle) 15123**] starting at 35 mg po qd.
This [**Last Name (STitle) 15123**] was not completed at the time of discharge, and the
patient was discharged with instructions to continue tapering
down to 20 mg po qd.
.
# CKD. The patient presented with a creatinine near baseline.
.
# Anemia. The patient presented with a hematocrit at her
baseline, which has been stable since her last admission. The
etiology is likely of chronic disease. We continued her epo and
folic acit. She got B12 on [**2194-8-25**]. She had a HCT of 28 on the
floor and she received 1U pRBC with repeat HCT 33.
.
# CAD. The patient has a history of an NSTEMI. She is not on ASA
due to a history of recent GI bleeds. The patient was restarted
on her low dose beta blocker, which was later discontinued due
to patient request.
.
# LUE DVT. The patient had an ultrasound on [**2194-8-25**] which
revealed a stable hematoma and upper extremity DVT. She was
continued on her home dose of lovenox.
.
# Chronic bilateral LE edema and venous stasis. The patient was
continued on her home trimacinolone cream.
.
# GERD. Continued on protonix
.
# Fungal groin rash. Continued on Miconazole powder.

Medications on Admission:
MVI w/ minerals
Ciprofloxacin * 1 sat due to concern for somnulence
Cefepime 1 gram daily
Heparin line flush
NaCl line flush
Enoxaparin 60 mg daily
Triamcinolone Acetonide 0.025 % PRN: lower extremitites
Mesalamine 400 mg Tablet 3 tabs daily
Miconazole Nitrate 2 % Powder QID:PRN
Epoetin Alfa 40,000 units weekly
Folic Acid 1 mg daily
Furosemide 20 mg daily
Artificial Tears TI:PRN
Omeprazole 20 mg daily
Timolol Maleate 0.5 % one drop daily
Atovaquone 750 mg/5 mL Suspension Sig: Ten (10) MLs PO DAILY --
has not taken at home
Prednisone [**Date Range **] 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.


Discharge Medications:
1. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1)  Subcutaneous
Q24H (every 24 hours).
2. Triamcinolone Acetonide 0.025 % Cream Sig: One (1) Appl
Topical DAILY (Daily) as needed for lower extremities.
3. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash.
5. Epoetin Alfa 20,000 unit/mL Solution Sig: One (1)  Injection
QMOWEFR (Monday -Wednesday-Friday).
6. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-31**]
Drops Ophthalmic [**Hospital1 **] (2 times a day) as needed for dry eye.
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
9. Atovaquone 750 mg/5 mL Suspension Sig: Two (2)  PO DAILY
(Daily).
Disp:*300 ml* Refills:*2*
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H
(every 4 hours) as needed for pain.
12. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily) as
needed for shortness of breath, leg swelling.
Disp:*15 Tablet(s)* Refills:*2*
13. Prednisone 10 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily):
Please [**Hospital1 15123**] to home dose of 20mg. Take 35mg for 1 day, then
30mg 2 days, 25mg 2 days, then 20 mg daily.
Disp:*60 Tablet(s)* Refills:*0*
14. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet, Chewable(s)* Refills:*0*
15. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
16. Vancomycin 500 mg Recon Soln Sig: 1.5 Recon Solns
Intravenous Q48H (every 48 hours) for 6 days.
Disp:*6 Recon Soln(s)* Refills:*0*
17. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Five (5) ML
Intravenous PRN (as needed) as needed for line flush: Indwelling
Port (e.g. Portacath), heparin dependent: Flush with 10 mL
Normal Saline followed by Heparin as above daily and PRN per
lumen.
Disp:*500 ML(s)* Refills:*1*
18. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Five
(5) ML Intravenous PRN (as needed) as needed for DE-ACCESSING
port: Indwelling Port (e.g. Portacath), heparin dependent: When
de-accessing port, instill Heparin as above per lumen.
Disp:*500 ML(s)* Refills:*1*
19. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)): Administer
before BiPap.
Disp:*15 Tablet, Rapid Dissolve(s)* Refills:*2*
20. Kayexalate     Powder Sig: Thirty (30) grams PO once a day
as needed for elevated potassium levels.
Disp:*300 grams* Refills:*2*
21. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
22. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation. Capsule(s)
23. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.


Discharge Disposition:
Home With Service

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

Discharge Diagnosis:
Primary:
acute mental status change secondary to sepsis/bacteremia and
respiratory distress
.
Secondary:
-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 1.8-2.0 for past month, prior 1.5-1.7
-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
-?Arrhythmia unspecified which daughter says is tx with
metoprolol

Discharge Condition:
afebrile, stable vitals, tolerating POs, AOx3, stable
respiratory status, saturations > 93% on nightly BIPAP 13/5 and
NC 1.5L/min during the day


Discharge Instructions:
You were admitted for changes to your mental status. You were
found to have some difficulty breathing as well as blood
infection for which you were treated with IV antibiotics. You
were also given blood for low hematocrit. Your body fluid
balance and electrolytes were also corrected. You were placed on
BIPAP which improved your breathing. You were also evaluated
with a sleep study to determine your optimum level of BIPAP. You
will be treated with IV vancomycin for 6 more days. Your
prednisone was also increased and you will be sent home with
35mg day, which you can then slowly [**Year (2 digits) 15123**] to your home dose of
20mg. You should continue taking 20mg daily of lasix.
.
Please take all medications as prescribed.
Use BiPap as ordered at night.
Please attend all appointments below.
Please do not hesitate to return to the hospital for any
concerning symptoms or changes in your mental status or
breathing.

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.

Followup Instructions:
PULMONARY FUNCTION [**Name8 (MD) **] Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2194-9-11**]
1:00


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]

Completed by:[**2194-9-10**]
{'Unspecified septicemia,Acute respiratory failure,Acidosis,Regional enteritis of unspecified site,Acute on chronic diastolic heart failure,Sepsis,Myelodysplastic syndrome, unspecified,Chronic kidney disease, unspecified,Anemia of other chronic disease,Esophageal reflux,Venous (peripheral) insufficiency, unspecified,Candidiasis of skin and nails,Old myocardial infarction,Coronary atherosclerosis of native coronary artery,Personal history of venous thrombosis and embolism,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: altered mental status, dyspnea

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, LUE DVT on home O2
who presents with dyspnea, AMS. Of note, patient was discharged
2 days ago from hospitalization for AMS, dyspnea and
representing with same complaints.  Somnolent since discharge
per daughter, sleep 2 days prior to admission at home on 0.5L -
2LNC per daughter. [**Name (NI) **] prior to admission, daughter noted thumb
twitching and picking at site of port-a-cath. VNA visited for
line check. Reports new incontinence. Daughter worried because
patient ate 4 yogurts.
.
In ED, 7.13/108/97 on bipap.  EMS reported 60% pulse ox on
roomair. Patient has been taking cefepime. Vitals 97.7 73 152/67
rr 16 non-rebreather 15L 100%. edema. a*o *2. UA neg. HyperK+
6.9 (K+ 5 on d/c [**8-28**]). In ED, Ca gluc, D50, insulin, 1gm vanc.
CXR atelextasis vs infilatrate. Sent blood cultures. HR 77 BP
154/95 RR 14 on BiPAP 100% on bipap.
.
Upon arrival to MICU, somnolent with stable vitals on BiPAP.

MEDICAL HISTORY: -h/o hyperkalemia
-PICC assiated LUE DVT and hematoma [**5-8**]
-Multifactorial anemia ([**3-3**] CRI, chronic disease, MDS)
-MDS dx 3 yrs ago
-Crohn's disease
-CAD s/p NSTEMI '[**89**]
-Chronic diastolic CHF EF 60-70's
-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
-s/p CY 10 yrs ago
-s/p Lumpectomy 13 yrs ago

MEDICATION ON ADMISSION: MVI w/ minerals
Ciprofloxacin * 1 sat due to concern for somnulence
Cefepime 1 gram daily
Heparin line flush
NaCl line flush
Enoxaparin 60 mg daily
Triamcinolone Acetonide 0.025 % PRN: lower extremitites
Mesalamine 400 mg Tablet 3 tabs daily
Miconazole Nitrate 2 % Powder QID:PRN
Epoetin Alfa 40,000 units weekly
Folic Acid 1 mg daily
Furosemide 20 mg daily
Artificial Tears TI:PRN
Omeprazole 20 mg daily
Timolol Maleate 0.5 % one drop daily
Atovaquone 750 mg/5 mL Suspension Sig: Ten (10) MLs PO DAILY --
has not taken at home
Prednisone [**Date Range **] 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

ALLERGIES: Belladonna Alkaloids

PHYSICAL EXAM: Physical Exam on discharge:
Vitals Tm 98.0 HR 70-85 BP 130-133/50-63 RR 20 Sats 94-97% on
1.5L NC
General: NAD, cooperative, [**Name (NI) 595**]-speaking
[**Name (NI) 4459**]: NCAT, OP clear
Lungs: poor air movement throughout, CTA on limited exam
CV: RRR, nl S1, S2, systolic murmur heard best at LUSB. No
appreciable JVD.
Abd: S, NT/ND
Ext: WWP, 2+ pulses
Access: POC with benign skin changes, no appreciable erythema or
wamrth.  Mildly tender to palpation.

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:
{'Unspecified septicemia,Acute respiratory failure,Acidosis,Regional enteritis of unspecified site,Acute on chronic diastolic heart failure,Sepsis,Myelodysplastic syndrome, unspecified,Chronic kidney disease, unspecified,Anemia of other chronic disease,Esophageal reflux,Venous (peripheral) insufficiency, unspecified,Candidiasis of skin and nails,Old myocardial infarction,Coronary atherosclerosis of native coronary artery,Personal history of venous thrombosis and embolism,Personal history of malignant neoplasm of breast'}
