CHIEF COMPLAINT: Dyspnea/Hypoxemia

PRESENT ILLNESS: Ms. [**Known lastname **] is a 52F with T1-T2 paraplegia s/p MVC, recurent
UTI/PNA, and anxiety admitted with hypoxemia. She presented to
[**Company 191**] waiting room for an appt with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] [**9-8**], and her
routine O2 sat was 80%; BP 98/60 HR 105.  At the time pt states
she was not sob, no CP, and she was placed on 2L oxygen. At [**Company 191**]
her O2 sat on 2L=95%, BP 118/67, HR=85 T=97.2.  She typically
uses 2l oxygen at night but does not usually need it during the
day.  Patient endorses a more "junky" cough since the week prior
to admission, and now coughing up yellowish sputum but feeling
well otherwise.  CXR at [**Company 191**] was limited secondary to poor
penetration showing left upper lung opacification improved with
no new focal areas and persistent LLL opacity likely
representing atelectasis/effusion but cannot exclude pneumonia.
In clinic, her pOx was 93-94 on 2 L NC, with drops to 84 %
without oxygen.  She was sent to ED for hypoxia.
.
In the ED, she became hypotensive to SBP 70s, and a central line
was placed.  Levophed was started.  Patient was given
CeftriaXONE 1g for UTI, vancomycin, azithro for pneumonia, and
oxycodone for pain.  She was given 1500 cc NS.  VS upon transfer
to the MICU were T97.6 P 98 BP 88/55 --> 140/85 RR 22 O2 94%3L.

MEDICAL HISTORY: #T1 to T2 paraplegia status post a motor vehicle accident.
#Recurrent pneumonia (followed by pulm - Last [**2149-4-9**])
- Per pulm, recurrent pneumonia likely from pulmonary toilet
issues secondary to neuromuscular disease with improvement with
consistent and aggressive bronchopulmonary therapy.
- Prior sputum cultures + for MRSA, pan-sensitive Klebsiella,
and Pseudomonas.
#Recurrent UTIs in the setting of urinary retention requiring
straight catheterization
#COPD
#Hx Pres syndrome
#hepatitis C
#anxiety
#DVT in [**2142**] -IVC filter placed in [**2142**]
#Pulmonary nodules
#Hypothyroidism
#Chronic pain
#Chronic gastritis
#Anemia of chronic disease
#S/p PEA arrest during hospitalization in [**2147-10-3**]

MEDICATION ON ADMISSION: (from recent d/c summary)
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea/hypoxia
2. Albuterol-Ipratropium [**2-2**] PUFF IH TID
3. Baclofen 10 mg PO/NG HS
4. Baclofen 10 mg PO/NG NOON
5. Baclofen 20 mg PO/NG BREAKFAST
6. Citalopram Hydrobromide 40 mg PO/NG DAILY
7. Clonazepam 1 mg PO/NG [**Hospital1 **]
8. Docusate Sodium 100 mg PO BID
9. Levothyroxine Sodium 75 mcg PO/NG DAILY
10. Lidocaine 5% Patch 1 PTCH TD DAILY
11. Methadone 5 mg PO/NG TID
12. Oxybutynin 5 mg PO NOON
13. Oxybutynin 10 mg PO BREAKFAST
14. Oxybutynin 10 mg PO HS
15. Polyethylene Glycol 17 g PO/NG DAILY
16. Pregabalin 150 mg PO/NG TID
17. Sucralfate 1 gm PO/NG QID
18. traZODONE 100 mg PO/NG HS
19. OxycoDONE (Immediate Release) 5 mg PO TID pain

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission:
Vital Signs:  T 99.4 BP 137/69  HR 88  RR  13 O2 97% 3L NC CVP
10
Gen:  Alert, oriented, sitting calmly in bed;  patient with
weak, wet prolonged productive cough
HEENT:  Mucous membranes dry, no lymphadenopathy or JVD
Card:  Normal S1, S2, no murmurs, rubs or gallops
Resp: poor inspiratory effort;  mild scattered rhonchi
bilaterally
Abd: obese, soft non-tender, non-distended
Ext: 1+ pitting edema to low calf; no calf tenderness
Skin: no rashes
Neuro: CN II - XII grossly intact; UE strength grossly [**6-5**];  LE
strength 0/5;  feet slightly inverted but no evidence of lower
extremity contracture/rigidity
.
Discharge: Unchanged from above except for the following:
Vital Signs:  T96.1  BP 116/70  HR 75  RR 20  O2 97% 2.5L NC
GENERAL - NAD
NECK - supple, no thyromegaly, no JVD, no carotid bruits, CVL in
Left IJ clean and intact
LUNGS - talking in full sentences, small rhonchi on R side but
none on L, moderate air movement, resp unlabored, no accessory
muscle use.
NEURO - awake, A&Ox3.

FAMILY HISTORY: Mother passed away with lung disease.

SOCIAL HISTORY: Lives at home with husband and 2 adolescent children.
- Tobacco: 35-pack-years, quit several months ago, relapsed
recently.
- Alcohol: Denies.
- Illicits: Denies.
Unspecified septicemia,Septic shock,Acute and chronic respiratory failure,Acidosis,Late effect of spinal cord injury,Chronic airway obstruction, not elsewhere classified,Chronic hepatitis C without mention of hepatic coma,Methicillin resistant pneumonia due to Staphylococcus aureus,Urinary tract infection, site not specified,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Paraplegia,Severe sepsis,Late effects of motor vehicle accident,Lumbago,Pain in joint, shoulder region,Anemia of other chronic disease,Unspecified acquired hypothyroidism,Atrophic gastritis, without mention of hemorrhage,Other chronic pain,Dysthymic disorder,Other alteration of consciousness,Tobacco use disorder,Personal history of venous thrombosis and embolism,Other postprocedural status
Septicemia NOS,Septic shock,Acute & chronc resp fail,Acidosis,Late eff spinal cord inj,Chr airway obstruct NEC,Chrnc hpt C wo hpat coma,Meth res pneu d/t Staph,Urin tract infection NOS,Klebsiella pneumoniae,Paraplegia NOS,Severe sepsis,Late eff motor vehic acc,Lumbago,Joint pain-shlder,Anemia-other chronic dis,Hypothyroidism NOS,Atrph gastrtis w/o hmrhg,Chronic pain NEC,Dysthymic disorder,Other alter consciousnes,Tobacco use disorder,Hx-ven thrombosis/embols,Post-proc states NEC
Admission Date:  [**2149-9-8**]              Discharge Date:   [**2149-9-15**]

Date of Birth:  [**2096-10-22**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
Dyspnea/Hypoxemia


Major Surgical or Invasive Procedure:
-Left internal jugular central venous line, placed [**2149-9-8**]
-Right PICC line, placed [**2149-9-12**]


History of Present Illness:
Ms. [**Known lastname **] is a 52F with T1-T2 paraplegia s/p MVC, recurent
UTI/PNA, and anxiety admitted with hypoxemia. She presented to
[**Company 191**] waiting room for an appt with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] [**9-8**], and her
routine O2 sat was 80%; BP 98/60 HR 105.  At the time pt states
she was not sob, no CP, and she was placed on 2L oxygen. At [**Company 191**]
her O2 sat on 2L=95%, BP 118/67, HR=85 T=97.2.  She typically
uses 2l oxygen at night but does not usually need it during the
day.  Patient endorses a more "junky" cough since the week prior
to admission, and now coughing up yellowish sputum but feeling
well otherwise.  CXR at [**Company 191**] was limited secondary to poor
penetration showing left upper lung opacification improved with
no new focal areas and persistent LLL opacity likely
representing atelectasis/effusion but cannot exclude pneumonia.
In clinic, her pOx was 93-94 on 2 L NC, with drops to 84 %
without oxygen.  She was sent to ED for hypoxia.
.
In the ED, she became hypotensive to SBP 70s, and a central line
was placed.  Levophed was started.  Patient was given
CeftriaXONE 1g for UTI, vancomycin, azithro for pneumonia, and
oxycodone for pain.  She was given 1500 cc NS.  VS upon transfer
to the MICU were T97.6 P 98 BP 88/55 --> 140/85 RR 22 O2 94%3L.

Past Medical History:
#T1 to T2 paraplegia status post a motor vehicle accident.
#Recurrent pneumonia (followed by pulm - Last [**2149-4-9**])
- Per pulm, recurrent pneumonia likely from pulmonary toilet
issues secondary to neuromuscular disease with improvement with
consistent and aggressive bronchopulmonary therapy.
- Prior sputum cultures + for MRSA, pan-sensitive Klebsiella,
and Pseudomonas.
#Recurrent UTIs in the setting of urinary retention requiring
straight catheterization
#COPD
#Hx Pres syndrome
#hepatitis C
#anxiety
#DVT in [**2142**] -IVC filter placed in [**2142**]
#Pulmonary nodules
#Hypothyroidism
#Chronic pain
#Chronic gastritis
#Anemia of chronic disease
#S/p PEA arrest during hospitalization in [**2147-10-3**]

Social History:
Lives at home with husband and 2 adolescent children.
- Tobacco: 35-pack-years, quit several months ago, relapsed
recently.
- Alcohol: Denies.
- Illicits: Denies.

Family History:
Mother passed away with lung disease.

Physical Exam:
Admission:
Vital Signs:  T 99.4 BP 137/69  HR 88  RR  13 O2 97% 3L NC CVP
10
Gen:  Alert, oriented, sitting calmly in bed;  patient with
weak, wet prolonged productive cough
HEENT:  Mucous membranes dry, no lymphadenopathy or JVD
Card:  Normal S1, S2, no murmurs, rubs or gallops
Resp: poor inspiratory effort;  mild scattered rhonchi
bilaterally
Abd: obese, soft non-tender, non-distended
Ext: 1+ pitting edema to low calf; no calf tenderness
Skin: no rashes
Neuro: CN II - XII grossly intact; UE strength grossly [**6-5**];  LE
strength 0/5;  feet slightly inverted but no evidence of lower
extremity contracture/rigidity
.
Discharge: Unchanged from above except for the following:
Vital Signs:  T96.1  BP 116/70  HR 75  RR 20  O2 97% 2.5L NC
GENERAL - NAD
NECK - supple, no thyromegaly, no JVD, no carotid bruits, CVL in
Left IJ clean and intact
LUNGS - talking in full sentences, small rhonchi on R side but
none on L, moderate air movement, resp unlabored, no accessory
muscle use.
NEURO - awake, A&Ox3.


Pertinent Results:
ADMISSION LABS:
[**2149-9-8**] 04:31PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
[**2149-9-8**] 04:31PM URINE  RBC-3* WBC-36* BACTERIA-MOD YEAST-NONE
EPI-0
[**2149-9-8**] 04:31PM URINE  HOURS-RANDOM CREAT-60 SODIUM-39
POTASSIUM-64 CHLORIDE-62 albumin-2.5 alb/CREA-41.7*
[**2149-9-8**] 08:20PM   WBC-8.3 RBC-3.04* HGB-9.2* HCT-26.6* MCV-88
MCH-30.2 MCHC-34.4 RDW-16.6*
[**2149-9-8**] 08:20PM   NEUTS-77.1* LYMPHS-16.3* MONOS-4.5 EOS-1.4
BASOS-0.7
[**2149-9-8**] 08:20PM   PLT COUNT-177
[**2149-9-8**] 08:20PM   CALCIUM-8.2* PHOSPHATE-3.5 MAGNESIUM-1.9
[**2149-9-8**] 08:20PM   GLUCOSE-110* UREA N-7 CREAT-0.3* SODIUM-143
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-32 ANION GAP-12
[**2149-9-8**] 08:27PM   LACTATE-1.4
.
DISCHARGE LABS:
[**2149-9-14**] 06:05AM BLOOD WBC-5.4 RBC-2.93* Hgb-8.5* Hct-26.1*
MCV-89 MCH-28.9 MCHC-32.5 RDW-16.1* Plt Ct-175
[**2149-9-14**] 06:05AM BLOOD Plt Ct-175
[**2149-9-15**] 11:30AM BLOOD Glucose-112* UreaN-2* Creat-0.3* Na-145
K-4.3 Cl-102 HCO3-38* AnGap-9
[**2149-9-15**] 11:30AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.9
[**2149-9-9**] 04:21AM BLOOD TSH-0.64
[**2149-9-10**] 01:50PM BLOOD Type-ART pO2-100 pCO2-72* pH-7.33*
calTCO2-40* Base XS-8
[**2149-9-12**] 02:23PM BLOOD Type-ART pO2-81* pCO2-70* pH-7.40
calTCO2-45* Base XS-14
[**2149-9-13**] 10:44AM BLOOD Type-ART FiO2-94 O2 Flow-2.5 pO2-109*
pCO2-76* pH-7.37 calTCO2-46* Base XS-14 AADO2-487 REQ O2-82
[**2149-9-13**] 10:44AM BLOOD Lactate-1.2
.
MICROBIOLOGY:
-[**9-8**] URINE CULTURE (Final [**2149-9-12**]): KLEBSIELLA PNEUMONIAE.
>100,000 ORGANISMS/ML. Sensitive only to meropenem and pip/tazo.
-[**9-8**] Blood Cx No Growth
-[**9-11**] RESPIRATORY CULTURE (Preliminary): SPARSE GROWTH Commensal
Respiratory Flora. STAPH AUREUS COAG +. SPARSE GROWTH.
.
IMAGING:
.
- [**9-8**] Admission CXR:FINDINGS:  This is a limited examination
secondary to poor penetration. Within these limitations, left
upper lobe opacification is improved with no new focal areas of
opacification. There are no large effusions or pneumothorax. The
cardiomediastinal and hilar contours are normal. The patient is
status post bilateral humeral fixation. IMPRESSION: Extremely
limited examination. Improvement in left upper lobe
Opacification with no evidence of worsening effusion.
- EKG: ST @ 100bpm, NA/NI, no acute ST-Twave changes, no change
from prior.
-[**9-12**] CTA CHEST W&W/O C&RECONS: 1. No evidence of pulmonary
embolism. 2. Atelectatic changes at both lung bases, with some
hypoenhancements
suggesting some degree of superimposed infection as well. In the
presence of tracheal secretions, aspiration is a consideration.
3. Unchanged appearance of the right paravertebral soft tissue
mass adjacent to the azygoesophageal recess and posterior to the
left atrium. 4. Right hilar lymphadenopathy has decreased since
the prior examination. 5. Left-sided internal jugular vein
catheter tip is in the region of the left
brachiocephalic vein.


Brief Hospital Course:
Ms. [**Known lastname **] is a 51-yo woman with T1-T2 paraplegia, COPD, multiple
recent admissions for pneumonia, who was admitted to the MICU
with hypoxia and altered mental status found on vital signs at
[**Hospital 3782**] clinic. After being on pressors for about 24hrs, she
stabilized and was transferred to the regular medicine floor on
[**9-11**].
.
ACTIVE ISSUES:
.
#. Hypoxia: The patient was found to be significantly hypoxic in
the ED.  Her exam, CXR, leukocytosis, and increased sputum
initially suggested pneumonia and she was started on
broad-spectrum antibiotics.  She was treated with vancomycin
given coag + staph on prelim sputum Cx, ciprofloxacin for
empiric pseudomonal coverage, and meropenem for UTI (see below).
She was given nebulisers, and her O2 sats remained in the high
80's on 2-3L NC. Her oxygen requirements stabilized over the
course of her MICU stay and she was transferred to the regular
medicine floor on [**9-11**] with vitals Temp 98.8F, BP 92/56, HR 80,
R 24, O2-sat 98% 4L.
.
On the medicine floor, the pt was feeling better and did not c/o
SOB. She occasionally desatted to the 80's when feeling anxious
and tearful, but otherwise remained in the 90's on 2L NC. She
was initially continued on vancomycin, meropenem, and
ciprofloxacin. Given persisting hypoxia since admission, CTA
chest [**9-12**] was ordered which showed no evidence of pulonary
embolism, and a left lower lobe consolidation and small
effusion, likely representing PNA (less likely atelectasis). She
had several ABG's showing normal pH but pCO2 in the 70's; the pt
also had high bicarb which is likely robust compensation for
chronic respiratory acidosis. On [**9-15**], pt was stable with
further resolving SOB and improved lung sounds on exam, satting
98% on 2.5L NC.
.
#. Sepsis: The patient was hypotensive in the ED, even relative
to her home [**Name (NI) **] which are already low.  The initial concern was
for sepsis versus hypovolemia.  She was fluid responsive but did
require levophed, which was weaned after about 24 hours in the
MICU, after which her SBP remained in the 90's (her normal
baseline). On the medical floor, pt remained hemodynamically
stable.
.
#. Altered mental status: She had repeated episodes of
somnolence and difficulty being aroused.  However, these appear
to be a chronic issue and precede the current episode of hypoxia
and hypotension.  The cause is unclear, but her numerous
medications for pain and anxiety may be contributing to her
underlying hypercarbia and infection.  By the time of discharge,
the pt's mental status was AAOx3 and mentating well without
confusion.
.
#. UTI: The patient has a history of recurrent UTIs in the
setting of straight cathing.  Past cultures have grown [**Name (NI) 40097**]
organisms, including Klebsiella sensitive only to meropenem.
Her urine culture on this admission grew the same, and so she
was treated with meropenem. She was transitioned to ertapenem
for outpatient antibiotic administration.
.
#. PNA: The patient may have had some component of hypercarbia
in setting of COPD and sedating medications at home.  She was
continued on her home albuterol and ipratropium. Her sputum
prelim grew out coag + staph. She was treated with vancomycin as
above.
.
INACTIVE ISSUES:
.
#. Depression: Reportedly increased from baseline despite home
celexa. Patient was previously amenable to seeing a psychologist
as an outpatient.
.
#. T1-T2 paraplegia with chronic pain: The patient had
maintained on multiple medications at home including baclofen,
clonazepam, lidocaine patch, methadone, oxybutynin, pregabalin,
trazodone, oxycodone.  Several of these medications were
temporarily discontinued in the hospital given concern for
sedation (oxycodone, clonazepam, trazodone).
.
#. Hypothyroidism - TSH was 0.64. The patient was continued on
her home levothyroxine.
.
TRANSITIONS OF CARE:
-A PICC line was placed on [**9-12**] to replace her left IJ CVL.
-[**9-12**] CTA: Stable appearance of the soft tissue mass in the
azygoesophageal recess
since [**2148-2-24**].


Medications on Admission:
(from recent d/c summary)
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea/hypoxia
2. Albuterol-Ipratropium [**2-2**] PUFF IH TID
3. Baclofen 10 mg PO/NG HS
4. Baclofen 10 mg PO/NG NOON
5. Baclofen 20 mg PO/NG BREAKFAST
6. Citalopram Hydrobromide 40 mg PO/NG DAILY
7. Clonazepam 1 mg PO/NG [**Hospital1 **]
8. Docusate Sodium 100 mg PO BID
9. Levothyroxine Sodium 75 mcg PO/NG DAILY
10. Lidocaine 5% Patch 1 PTCH TD DAILY
11. Methadone 5 mg PO/NG TID
12. Oxybutynin 5 mg PO NOON
13. Oxybutynin 10 mg PO BREAKFAST
14. Oxybutynin 10 mg PO HS
15. Polyethylene Glycol 17 g PO/NG DAILY
16. Pregabalin 150 mg PO/NG TID
17. Sucralfate 1 gm PO/NG QID
18. traZODONE 100 mg PO/NG HS
19. OxycoDONE (Immediate Release) 5 mg PO TID pain


Discharge Medications:
1. ertapenem 1 gram Recon Soln [**Hospital1 **]: One (1) gram Intravenous
once a day for 7 days.
Disp:*7 grams* Refills:*0*
2. vancomycin 1,000 mg Recon Soln [**Hospital1 **]: One (1) gram Intravenous
every twelve (12) hours for 3 days.
Disp:*6 grams* Refills:*0*
3. baclofen 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO QAM (once a day
(in the morning)).
4. baclofen 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q DAY AT 1600
().
5. baclofen 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO QHS (once a day
(at bedtime)).
6. citalopram 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).

7. clonazepam 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO three times a
day: Hold for sedation or RR<12.
8. estradiol 0.01 % (0.1 mg/g) Cream [**Hospital1 **]: One (1)  Vaginal twice
a week: Apply to external gyn area twice a week  .
9. Combivent 18-103 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) puffs
Inhalation three times a day.
10. levothyroxine 112 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
11. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
Four (4) patch Topical once a day: Apply four patches to the
affected areas once a day 12 hours off and 12
hours on - No Substitution.
12. methadone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a
day).
13. methenamine hippurate 1 gram Tablet [**Hospital1 **]: One (1) Tablet PO
twice a day: take with Vitamin C 500.
14. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
15. oxybutynin chloride 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO once
a day: Take in AM.
16. oxybutynin chloride 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO once
a day: Take in afternoon.
17. oxybutynin chloride 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO once
a day: Take in evening.
18. oxycodone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO three times a
day as needed for pain for 60 doses.
Disp:*60 Tablet(s)* Refills:*0*
19. pregabalin 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO TID (3
times a day).
20. simvastatin 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
21. sucralfate 1 gram Tablet [**Hospital1 **]: One (1) Tablet PO four times a
day.
22. trazodone 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO at bedtime as
needed for insomnia.
23. Calcium 500 500 mg calcium (1,250 mg) Tablet [**Hospital1 **]: One (1)
Tablet PO once a day.
24. Surgilube     Gel [**Hospital1 **]: One (1)  Topical PRN as needed for
straight cath.
25. heparin (porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) mL
Injection TID (3 times a day).
26. ciprofloxacin 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
27. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1)  Inhalation Q4H (every 4 hours) as
needed for wheezing.


Discharge Disposition:
Home With Service

Facility:
Critical Care Systems

Discharge Diagnosis:
Primary diagnoses:
Sepsis secondary to urinary tract infection
Hypoxemia

Secondary diagnoses:
#T1 to T2 paraplegia status post a motor vehicle accident.
#Recurrent pneumonia with prior sputum cultures + for MRSA,
pan-sensitive Klebsiella, and Pseudomonas.
#Recurrent UTIs in the setting of urinary retention requiring
straight catheterization
#COPD
#Hx PRES syndrome
#hepatitis C
#anxiety
#DVT in [**2142**] -IVC filter placed in [**2142**]
#Chronic pain
#Anemia of chronic disease
#S/p PEA arrest during hospitalization in [**2147-10-3**]


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
Dear Ms. [**Known lastname **],

It was a pleasure providing care for you here at the [**Hospital3 **]
Hospital. You were admitted because you were found to have a low
oxygen saturation at your urologist's office on [**9-8**]. You were
taken to the emergency room, where because of low blood
pressure, you were given a central venous line. You were treated
in the intensive care unit, where you were given antibiotics,
fluids, and breathing treatments.

As your blood pressure and oxygen saturation improved, you were
transferred to the regular medical floor. Your antibiotics were
adjusted and you received further breathing treatments. Your
condition has steadily improved, and you can be discharged to
home with services.

The following changes were made to your medications:
NEW:
1. Ertapenem:  One (1) gram Intravenous once a day for 7 days.
2. Vancomycin:  One (1) gram Intravenous every twelve (12) hours
for 5 days.
3. Methenamine hippurate - 1 gram Tablet: 1 Tablet by mouth
twice a day, take with Vitamin C 500 (started on [**2149-9-8**] by your
urologist)
4. Ciprofloxacin: One (1) 500mg tablet by mouth every twelve
(12) hours for 3 days.

CHANGED:
-none

STOPPED:
- None

Please keep your follow-up appointments as scheduled below.


Followup Instructions:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2149-9-24**] at 8:10 AM
With: Dr. [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 1520**]
Address: [**Location (un) 830**] [**Location (un) 86**], [**Numeric Identifier 718**]
Location: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] South [**Hospital **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
This appointment is with a hospital-based doctor as part of your
transition from the hospital back to your primary care provider.
[**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor
in follow up.

Department: [**Hospital3 249**]
When: WEDNESDAY [**2149-10-8**] at 11:10 AM
With: [**First Name8 (NamePattern2) 1409**] [**Last Name (NamePattern1) **], NP [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: GASTROENTEROLOGY
When: [**Hospital Ward Name **] [**2149-11-3**] at 1:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4465**], MD [**Telephone/Fax (1) 463**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: [**Hospital3 249**]
When: TUESDAY [**2150-3-10**] at 11:00 AM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage



Completed by:[**2149-9-16**]
{"Unspecified septicemia,Septic shock,Acute and chronic respiratory failure,Acidosis,Late effect of spinal cord injury,Chronic airway obstruction, not elsewhere classified,Chronic hepatitis C without mention of hepatic coma,Methicillin resistant pneumonia due to Staphylococcus aureus,Urinary tract infection, site not specified,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Paraplegia,Severe sepsis,Late effects of motor vehicle accident,Lumbago,Pain in joint, shoulder region,Anemia of other chronic disease,Unspecified acquired hypothyroidism,Atrophic gastritis, without mention of hemorrhage,Other chronic pain,Dysthymic disorder,Other alteration of consciousness,Tobacco use disorder,Personal history of venous thrombosis and embolism,Other postprocedural status"}


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: Dyspnea/Hypoxemia

PRESENT ILLNESS: Ms. [**Known lastname **] is a 52F with T1-T2 paraplegia s/p MVC, recurent
UTI/PNA, and anxiety admitted with hypoxemia. She presented to
[**Company 191**] waiting room for an appt with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] [**9-8**], and her
routine O2 sat was 80%; BP 98/60 HR 105.  At the time pt states
she was not sob, no CP, and she was placed on 2L oxygen. At [**Company 191**]
her O2 sat on 2L=95%, BP 118/67, HR=85 T=97.2.  She typically
uses 2l oxygen at night but does not usually need it during the
day.  Patient endorses a more "junky" cough since the week prior
to admission, and now coughing up yellowish sputum but feeling
well otherwise.  CXR at [**Company 191**] was limited secondary to poor
penetration showing left upper lung opacification improved with
no new focal areas and persistent LLL opacity likely
representing atelectasis/effusion but cannot exclude pneumonia.
In clinic, her pOx was 93-94 on 2 L NC, with drops to 84 %
without oxygen.  She was sent to ED for hypoxia.
.
In the ED, she became hypotensive to SBP 70s, and a central line
was placed.  Levophed was started.  Patient was given
CeftriaXONE 1g for UTI, vancomycin, azithro for pneumonia, and
oxycodone for pain.  She was given 1500 cc NS.  VS upon transfer
to the MICU were T97.6 P 98 BP 88/55 --> 140/85 RR 22 O2 94%3L.

MEDICAL HISTORY: #T1 to T2 paraplegia status post a motor vehicle accident.
#Recurrent pneumonia (followed by pulm - Last [**2149-4-9**])
- Per pulm, recurrent pneumonia likely from pulmonary toilet
issues secondary to neuromuscular disease with improvement with
consistent and aggressive bronchopulmonary therapy.
- Prior sputum cultures + for MRSA, pan-sensitive Klebsiella,
and Pseudomonas.
#Recurrent UTIs in the setting of urinary retention requiring
straight catheterization
#COPD
#Hx Pres syndrome
#hepatitis C
#anxiety
#DVT in [**2142**] -IVC filter placed in [**2142**]
#Pulmonary nodules
#Hypothyroidism
#Chronic pain
#Chronic gastritis
#Anemia of chronic disease
#S/p PEA arrest during hospitalization in [**2147-10-3**]

MEDICATION ON ADMISSION: (from recent d/c summary)
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea/hypoxia
2. Albuterol-Ipratropium [**2-2**] PUFF IH TID
3. Baclofen 10 mg PO/NG HS
4. Baclofen 10 mg PO/NG NOON
5. Baclofen 20 mg PO/NG BREAKFAST
6. Citalopram Hydrobromide 40 mg PO/NG DAILY
7. Clonazepam 1 mg PO/NG [**Hospital1 **]
8. Docusate Sodium 100 mg PO BID
9. Levothyroxine Sodium 75 mcg PO/NG DAILY
10. Lidocaine 5% Patch 1 PTCH TD DAILY
11. Methadone 5 mg PO/NG TID
12. Oxybutynin 5 mg PO NOON
13. Oxybutynin 10 mg PO BREAKFAST
14. Oxybutynin 10 mg PO HS
15. Polyethylene Glycol 17 g PO/NG DAILY
16. Pregabalin 150 mg PO/NG TID
17. Sucralfate 1 gm PO/NG QID
18. traZODONE 100 mg PO/NG HS
19. OxycoDONE (Immediate Release) 5 mg PO TID pain

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission:
Vital Signs:  T 99.4 BP 137/69  HR 88  RR  13 O2 97% 3L NC CVP
10
Gen:  Alert, oriented, sitting calmly in bed;  patient with
weak, wet prolonged productive cough
HEENT:  Mucous membranes dry, no lymphadenopathy or JVD
Card:  Normal S1, S2, no murmurs, rubs or gallops
Resp: poor inspiratory effort;  mild scattered rhonchi
bilaterally
Abd: obese, soft non-tender, non-distended
Ext: 1+ pitting edema to low calf; no calf tenderness
Skin: no rashes
Neuro: CN II - XII grossly intact; UE strength grossly [**6-5**];  LE
strength 0/5;  feet slightly inverted but no evidence of lower
extremity contracture/rigidity
.
Discharge: Unchanged from above except for the following:
Vital Signs:  T96.1  BP 116/70  HR 75  RR 20  O2 97% 2.5L NC
GENERAL - NAD
NECK - supple, no thyromegaly, no JVD, no carotid bruits, CVL in
Left IJ clean and intact
LUNGS - talking in full sentences, small rhonchi on R side but
none on L, moderate air movement, resp unlabored, no accessory
muscle use.
NEURO - awake, A&Ox3.

FAMILY HISTORY: Mother passed away with lung disease.

SOCIAL HISTORY: Lives at home with husband and 2 adolescent children.
- Tobacco: 35-pack-years, quit several months ago, relapsed
recently.
- Alcohol: Denies.
- Illicits: Denies. 

### Response:
{"Unspecified septicemia,Septic shock,Acute and chronic respiratory failure,Acidosis,Late effect of spinal cord injury,Chronic airway obstruction, not elsewhere classified,Chronic hepatitis C without mention of hepatic coma,Methicillin resistant pneumonia due to Staphylococcus aureus,Urinary tract infection, site not specified,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Paraplegia,Severe sepsis,Late effects of motor vehicle accident,Lumbago,Pain in joint, shoulder region,Anemia of other chronic disease,Unspecified acquired hypothyroidism,Atrophic gastritis, without mention of hemorrhage,Other chronic pain,Dysthymic disorder,Other alteration of consciousness,Tobacco use disorder,Personal history of venous thrombosis and embolism,Other postprocedural status"}
