CHIEF COMPLAINT: Altered mental status, hypotension, hypoxia.

PRESENT ILLNESS: Mrs. [**Known lastname 4636**] is a 72 y/o woman with PMH notable for paraplegia
[**1-5**] anterior spinal artery infarct, indwelling suprapubic
catheter with frequent UTIs admitted with altered mental status
and hypoxia.  Per nursing facility notes, the patient was noted
to be unresponsive to voice commands but responsive to tactile
stimuli.  Vitals at the time were BP 100/50, HR 100, RR 20, O2
80% on RA which increased to 97% on 6 L NC.  Reportedly, she is
alert & oriented X 3 at her baseline.  Of note, she is currently
on nitrofurantoin 100 mg PO BID for a UTI (? culture result)
which she started on [**2137-10-29**] for a planned 10 day course.  She
apparently also complained of nausea and may have vomited so
lactulose was held today.
.
On arrival to the ED, initial vitals were T 102.1, HR 100, BP
132/56, RR 24, 97% on 15 L via nasal cannula.  Blood pressure
trended down to 80s systolic.  She was originally on peripheral
dopamine for BP improvement but as this was not effective, it
was changed to peripheral levophed with subsequent improvement
in blood pressures to 120s systolic.  Blood and urine cultures
were sent.  She was treated with PR tylenol, levofloxacin 750 mg
IV X 1, vancomycin 1 g IV X 1, and 1 g ceftriaxone X 1.  She
received a total of 6 L NS in the ED.
.
On arrival to the MICU, the patient denies any pain.  She is
alert and speaking a few words at a time though they are
difficult to interpret.  She specifically denies any shortness
of breath or any abdominal pain.

MEDICAL HISTORY: Past Medical History: (from OMR)
- Paraplegia [**1-5**] Anterior Spinal Infarct ([**2128**])
- Thoracic Aneurysm Repair ([**2128**])
- COPD (? on home O2). With history of LLL Collapse/PNA s/p
mucous plug removal via bronchoscopy.
- HTN
- Hyperlipidemia
- GERD
- Suprapubic Catheter Placement / UTIs on Ppx Bactrim
- Fecal Incontinence
- Depression
- Atraumatic comminuted L intertrochanteric femur fracture
- Chronic sacral decubitus ulcers with past bilateral ischial
tuberosity osteomyelitis

MEDICATION ON ADMISSION: * alendronate 70 mg weekly on Thursday
* protonix 40 mg daily
* zincate 220 mg daily
* MVI daily
* vitamin D 800 U daily
* ASA 81 mg daily
* buspar 10 mg [**Hospital1 **]
* baclofen 40 mg TID
* lactulose 30 mL daily
* heparin 5000 U sc tid
* bisacodyl 10 mg daily
* nortriptyline 50 mg qhs
* combivent 1 puff q6h prn
* tylenol 650 mg po prn
* ensure tid with meals
* milk of mag 30 mL daily prn
* bisacodyl 10 mg pr daily prn
* fleet's enema prn
* macrobid 100 mg [**Hospital1 **] X 10 days (last day [**11-7**])
* advair 250/50 [**Hospital1 **]
* vitamin c 500 mg [**Hospital1 **]
* senna [**Hospital1 **]
* colace 100 mg [**Hospital1 **]
* gabapentin 900 mg q8h
* oxybutynin 5 mg tid
* calcium carbonate 1000 mg tid

ALLERGIES: Adhesive Tape

PHYSICAL EXAM: VS T 101.3, HR 84, BP 153/42, RR 23, O2 97% on 4L NC
Gen: obese elderly woman lying in bed, eyes open, no acute
distress
HEENT: PERRL, EOMI, OP clear, MMM
Neck: no JVD, no lymphadenopathy, no meningismus
CV: RRR, no appreciable murmur
Chest: grossly clear with occasional expiratory wheezing
Abd: obese, distended but soft, normoactive bowel sounds, no
tenderness to palpation; suprapubic catheter in place with
dressing; + erythematous yeast infection inferior to both
breasts and in groin around to back
Ext: upper extremities with > tone than lower extremities,
bilateral lower ext in multipodus boots, no peripheral edema
Back: sacral ulcer which probes to bone, some thick tan
discharge in wound but tissue appears beefy red; bilateral
ischial ulcers 2 cm in size
Neuro: face symmetric, CN II-XII grossly intact, bilateral hand
grip [**3-9**], shoulder shrug symmetric bilaterally, does not move
either leg, DTRs not elicited at bilateral biceps, patellae;
speaking short sentences & seems to appropriately answer yes/no
questions; denies any pain; toes mute bilaterally; upper
extremities stiff.

FAMILY HISTORY: Son has DM.

SOCIAL HISTORY: The patient admits 2-3ppd x 40+ years, but has smoked
intermittently for the past five years. The patient denies
alcohol or illicit drug use. Her son, [**Name (NI) **], is listed as her
HCP ([**Telephone/Fax (1) 4635**]); however, he tells me that she "has made it
clear she wants nothing to do with him" and he defers to his
other brother [**Name (NI) 1704**], [**Telephone/Fax (1) 4655**].
Methicillin resistant Staphylococcus aureus septicemia,Toxic encephalopathy,Acute osteomyelitis, other specified sites,Paraplegia,Septic shock,Pressure ulcer, stage IV,Infection and inflammatory reaction due to indwelling urinary catheter,Urinary tract infection, site not specified,Severe sepsis,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Esophageal reflux,Chronic airway obstruction, not elsewhere classified,Other disorders of muscle, ligament, and fascia,Osteoporosis, unspecified,Dermatomycosis, unspecified
MRSA septicemia,Toxic encephalopathy,Ac osteomyelitis NEC,Paraplegia NOS,Septic shock,Pressure ulcer, stage IV,React-indwell urin cath,Urin tract infection NOS,Severe sepsis,Hypertension NOS,Hyperlipidemia NEC/NOS,Esophageal reflux,Chr airway obstruct NEC,Muscle/ligament dis NEC,Osteoporosis NOS,Dermatomycosis NOS
Admission Date:  [**2137-11-6**]              Discharge Date:   [**2137-11-20**]

Date of Birth:  [**2065-8-18**]             Sex:   F

Service: MEDICINE

Allergies:
Adhesive Tape

Attending:[**First Name3 (LF) 4654**]
Chief Complaint:
Altered mental status, hypotension, hypoxia.


Major Surgical or Invasive Procedure:
CT-guided drainage of left gluteal abscess ([**2137-11-15**]).


History of Present Illness:
Mrs. [**Known lastname 4636**] is a 72 y/o woman with PMH notable for paraplegia
[**1-5**] anterior spinal artery infarct, indwelling suprapubic
catheter with frequent UTIs admitted with altered mental status
and hypoxia.  Per nursing facility notes, the patient was noted
to be unresponsive to voice commands but responsive to tactile
stimuli.  Vitals at the time were BP 100/50, HR 100, RR 20, O2
80% on RA which increased to 97% on 6 L NC.  Reportedly, she is
alert & oriented X 3 at her baseline.  Of note, she is currently
on nitrofurantoin 100 mg PO BID for a UTI (? culture result)
which she started on [**2137-10-29**] for a planned 10 day course.  She
apparently also complained of nausea and may have vomited so
lactulose was held today.
.
On arrival to the ED, initial vitals were T 102.1, HR 100, BP
132/56, RR 24, 97% on 15 L via nasal cannula.  Blood pressure
trended down to 80s systolic.  She was originally on peripheral
dopamine for BP improvement but as this was not effective, it
was changed to peripheral levophed with subsequent improvement
in blood pressures to 120s systolic.  Blood and urine cultures
were sent.  She was treated with PR tylenol, levofloxacin 750 mg
IV X 1, vancomycin 1 g IV X 1, and 1 g ceftriaxone X 1.  She
received a total of 6 L NS in the ED.
.
On arrival to the MICU, the patient denies any pain.  She is
alert and speaking a few words at a time though they are
difficult to interpret.  She specifically denies any shortness
of breath or any abdominal pain.

Past Medical History:
Past Medical History: (from OMR)
- Paraplegia [**1-5**] Anterior Spinal Infarct ([**2128**])
- Thoracic Aneurysm Repair ([**2128**])
- COPD (? on home O2). With history of LLL Collapse/PNA s/p
mucous plug removal via bronchoscopy.
- HTN
- Hyperlipidemia
- GERD
- Suprapubic Catheter Placement / UTIs on Ppx Bactrim
- Fecal Incontinence
- Depression
- Atraumatic comminuted L intertrochanteric femur fracture
- Chronic sacral decubitus ulcers with past bilateral ischial
tuberosity osteomyelitis

Social History:
The patient admits 2-3ppd x 40+ years, but has smoked
intermittently for the past five years. The patient denies
alcohol or illicit drug use. Her son, [**Name (NI) **], is listed as her
HCP ([**Telephone/Fax (1) 4635**]); however, he tells me that she "has made it
clear she wants nothing to do with him" and he defers to his
other brother [**Name (NI) 1704**], [**Telephone/Fax (1) 4655**].


Family History:
Son has DM.

Physical Exam:
VS T 101.3, HR 84, BP 153/42, RR 23, O2 97% on 4L NC
Gen: obese elderly woman lying in bed, eyes open, no acute
distress
HEENT: PERRL, EOMI, OP clear, MMM
Neck: no JVD, no lymphadenopathy, no meningismus
CV: RRR, no appreciable murmur
Chest: grossly clear with occasional expiratory wheezing
Abd: obese, distended but soft, normoactive bowel sounds, no
tenderness to palpation; suprapubic catheter in place with
dressing; + erythematous yeast infection inferior to both
breasts and in groin around to back
Ext: upper extremities with > tone than lower extremities,
bilateral lower ext in multipodus boots, no peripheral edema
Back: sacral ulcer which probes to bone, some thick tan
discharge in wound but tissue appears beefy red; bilateral
ischial ulcers 2 cm in size
Neuro: face symmetric, CN II-XII grossly intact, bilateral hand
grip [**3-9**], shoulder shrug symmetric bilaterally, does not move
either leg, DTRs not elicited at bilateral biceps, patellae;
speaking short sentences & seems to appropriately answer yes/no
questions; denies any pain; toes mute bilaterally; upper
extremities stiff.

Pertinent Results:
Labs at admission
[**2137-11-6**] 11:00AM BLOOD WBC-16.7*# RBC-4.56 Hgb-12.1 Hct-36.8
MCV-81* MCH-26.6* MCHC-32.9 RDW-17.6* Plt Ct-416
[**2137-11-6**] 11:00AM BLOOD Neuts-88.5* Lymphs-7.6* Monos-3.1 Eos-0.3
Baso-0.4
[**2137-11-6**] 07:37PM BLOOD PT-17.8* PTT-25.6 INR(PT)-1.6*
[**2137-11-6**] 11:00AM BLOOD Glucose-141* UreaN-9 Creat-0.5 Na-145
K-2.8* Cl-104 HCO3-29 AnGap-15
[**2137-11-6**] 07:37PM BLOOD Albumin-2.4* Calcium-6.6* Phos-1.4*#
Mg-1.7
.
Culture data
.
[**2137-11-15**]      ABSCESS GRAM STAIN-FINAL; WOUND CULTURE-FINAL
{STAPH AUREUS COAG +}; ANAEROBIC CULTURE-PRELIMINARY INPATIENT
[**2137-11-15**]      BLOOD CULTURE   negative
[**2137-11-14**]      BLOOD CULTURE   negative
[**2137-11-13**]      BLOOD CULTURE   negative
[**2137-11-13**]      BLOOD CULTURE   negative
[**2137-11-12**]      BLOOD CULTURE   negative
[**2137-11-12**]      BLOOD CULTURE   negative
[**2137-11-11**]      BLOOD CULTURE   negative
[**2137-11-11**]      BLOOD CULTURE   negative
[**2137-11-10**] 	BLOOD CULTURE 	MRSA
[**2137-11-10**] 	BLOOD CULTURE 	negative
[**2137-11-9**] 	BLOOD CULTURE 	negative
[**2137-11-9**] 	BLOOD CULTURE 	negative
[**2137-11-8**] 	BLOOD CULTURE 	MRSA
[**2137-11-8**] 	URINE CULTURE   YEAST
[**2137-11-8**] 	BLOOD CULTURE 	negative
[**2137-11-7**] 	BLOOD CULTURE 	negative
[**2137-11-7**] 	BLOOD CULTURE 	negative
[**2137-11-7**] 	BLOOD CULTURE 	negative
[**2137-11-6**] 	URINE CULTURE   YEAST
[**2137-11-6**] 	BLOOD CULTURE 	MRSA
.
Studies
.
Chest x-ray ([**2137-11-6**])
There is bilateral atelectasis. There is no evidence of focal
consolidation that would be indicative of pneumonia.  There is
no evidence of congestive heart failure. The mediastinal and
cardiac contours are stable. There is again evidence of
post-surgical changes. There is no pleural effusion and no
evidence of pneumothorax. The visualized osseous structures are
stable.
IMPRESSION: No evidence of pneumonia.
.
Transthoracic echocardiogram ([**2137-11-9**])
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and global systolic function (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The pulmonary artery systolic pressure could not be determined.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Compared with the prior study (images reviewed) of [**2136-9-12**],
the findings are similar.
.
CT head without contrast ([**2137-11-9**])
1. No evidence of acute intracranial abnormalities.
2. Fluid in the right maxillary sinus, which may indicate acute
sinusitis.
.
MR pelvis ([**2137-11-10**])
IMPRESSION:
1. Large sacral/coccygeal decubitus ulcer extending up to the
inferior
sacrum. Abnormal signal involves both sides of the inferior
sacrum, likely
from a combination of osteomyelitis. Te possibility of a
superimposed
nondisplaced left sacral alar insufficiency fracture cannot be
excluded.
2. 2.6- cm rim-enhancing high T2 structure in the left gluteal
soft tissues lateral to and apparently communicating with the
ulcer tract -- ? abcess collection vs packing material in recess
of ulcer. Please see comment above.
3. Stable appearance of the ulcer tracts extending up to the
ischial
tuberosities bilaterally with abnormal signal and enhancement
about the
posterior aspect of the ischial tuberosities, consistent with
osteomyelitis.
4. Old left intertrochanteric fracture only partially imaged on
today's
study.
5. Prominent sacral Tarlov's cysts.
6. Suprapubic catheter seen approaching the bladder; it is
difficult on the images performed today to determine if the
balloon and tip are in fact within the bladder lumen. Clinical
correlation is therefore requested -- is this tube draining
urine?.
7. Distended large bowel most consistent with ileus.
.
MR brain ([**2137-11-10**])
1. Unchanged bilateral white matter foci of hyperintensities on
T2-weighted and FLAIR images may correspond to chronic
microvascular ischemia.
2. No evidence of acute infarction, masses, or other lesions.
3. Limited MRA evaluation of the brain due to a significant
image degradation from motion artifact demonstrates no
identifiable stenosis, occlusion, aneurysm in the visualized
vessels. The MCAs and the left vertebral artery are poorly
visualized.
.
EEG ([**2137-11-12**])
IMPRESSION: This is a normal routine EEG in the waking and
drowsy
states. There is no evidence of focal slowing or epileptiform
discharges.
.
CT-guided drainage of left gluteal abscess ([**2137-11-15**])
1. Successful CT-guided aspiration of approximately 1 cc of
bloody pus from the left parasacral/left gluteal collection.
2. Sclerosis of both ischial tuberosities, highly suggestive of
osteomyelitis.
3. Persistent left intertrochanteric fracture.
.
Chest x-ray PA and lateral ([**2137-11-16**])
There are multiple healed rib fractures from prior thoracotomy
on the left, with residual osseous deformity. Right PICC
terminates in the superior vena cava. There is bibasilar
atelectasis.
IMPRESSION: No appreciable change from the prior study.

Brief Hospital Course:
A 72 year-old woman with past medical history notable for
paraplegia secondary to spinal artery infarct, COPD, and
indwelling suprapubic catheter admitted with mental status
change, fever, and leukocytosis.
.
1. Septic shock.
She presented with low blood pressure, elevated white count,
fever, and mental status change.  She was bolused with 6L normal
saline in the ED and started on dopamine.  When she arrived to
the ICU levophed was running peripherally with systolic blood
pressures in the 130s. This was quickly weaned off and her
systolic BP stablized in the 90-110s.
   Overnight, she was started on vancomycin and cefepime for
empiric coverage of sepsis from UTI versus other source, such as
large stage IV sacral decubitus ulcer.  A blood culture from
this first hospital day later grew out methicillin resistent
staph aureus.  A urine culture grew out [**Female First Name (un) **] but no
significant bacteria.  Thus the vancomycin was continued and
cefepime discontinued on hospital day 3.  Her suprapubic
catheter was changed in the ICU.
   Infectious disease was consulted for treatment
recommendations.  They agreed that sacral decubitus ulcer was
the likely source for bacteremia and recommended MR [**First Name (Titles) **] [**Last Name (Titles) 4656**]
for sacral osteomyelitis as well as TTE to [**Last Name (Titles) 4656**] for valvular
vegetations.  Blood cultures were followed serially.  The
echocardiogram, as above, was negative for endocarditis.  Three
subsequent blood cultures grew out MRSA; the last was on [**11-10**].
Vancomycin was continued.  Surveillance cultures were followed
through [**11-14**] and all returned negative.  Once therapeutic on
vancomycin, she defervesced and her white count returned to
[**Location 213**].
   She will need to complete a six-week course of vancomycin
(last day will be [**12-24**]) for treatment of osteomyelitis.
A right PICC line has been placed for this purpose.
.
2. Altered mental status.
On admission, she was minimally interactive, somnolent, and
disoriented.  Overnight in the ICU, her mental status improved
such that she was talking and interactive, with improved speech,
following commands and oriented x3 by the first hospital day.
This is how she appeared when she was transferred to the
medicine floor. It was believed at the time that her altered
mental status was due to fever and infection.
   However, when she did not make significant improvement over
the first weekend, neurology was consulted.  Per their note, the
altered mental status was likely secondary to toxic/metabolic
encephalopathy in the context of infection.  However, they
recommended MR [**First Name (Titles) **] [**Last Name (Titles) 4656**] for stroke and consideration of
lumbar puncture.  MR brain showed no acute abnormalities.  Her
mental status continued to improved during the week, although
she still has periods of waxing and [**Doctor Last Name 688**] alertness.  Her
oxygen sats have been fine on RA, CXR was negative for
infiltrate, and MR as above was negative.
.
3. Urinary tract infection / leakage around suprapubic catheter.
Her first urine culture grew out >100,000 colonies of [**Female First Name (un) **].
She had been started on fluconazole in the unit and her
suprapubic catheter changed.  However, given that she was not
symptomatic, infectious disease offered that she did not need to
continue the fluconazole.
   She was noted to have leakage around her suprapubic catheter.
 [**Female First Name (un) 159**] was called and instructed us to restart her oxybutynin
which had been stopped for concern of mental status change.  She
has follow-up planned in [**Female First Name (un) **] clinic as outlined in discharge
instructions.
.
4. Sacral decubitus ulcer and ischial ulcers.
She presented with a stage IV sacral decubitus ulcer and two
stage III ulcers over the ischial tuberosities.  Plastics,
consulted in the ED, recommended wet-to-dry dressing changes
three times daily, with frequent turning and kinair bed.
Patient was started on zinc/vitamin c/mvi and nutritional
supplements to ensure adequate wound healing.
   As above, MR sacral spine was ordered to [**Female First Name (un) 4656**] for
osteomyelitis.  This showed a small fluid collection in the left
gluteal soft tissue concerning for abscess.  Interventional
radiology drained this abscess percutaneously under CT-guidance.
 One cc of bloody pustular fluid was drained that later grew out
MRSA.  She will continue IV vancomycin as above for a total six
week course.  Dressing changes should continue as outlined in
the discharge orders.
.
5. Hypoxia.
Initially she required oxygen in the ED and overnight in the
ICU.  Chest x-ray showed volume overload but no infiltrate.
With treatment of her infection her oxygen requirements
gradually improved.  We continued her home COPD regimen of
inhaled steroids and bronchodilators, and her oxygen saturation
steadily improved.
.
6. Fungal infections.
We treated superficial fungal infections under the breast and in
the groin with miconazole powder.
.
7. Paraplegia s/p spinal artery infarct.
We continued her outpatient baclofen.
.
8. Abdominal distension/nausea.
This improved overnight in the ICU and was no longer a problem
at time of transfer to the floors.  LFTs were within normal
limits.
.
9. Osteoporosis.
We continued her outpatient calcium, vitamin D, and fosamax.
.
Her diet was progressed to normal diet with ensure supplements.
She was kept on subcutaneous heparin for venous thrombosis
prophylaxis.  Her code status is DNR/DNI.

Medications on Admission:
* alendronate 70 mg weekly on Thursday
* protonix 40 mg daily
* zincate 220 mg daily
* MVI daily
* vitamin D 800 U daily
* ASA 81 mg daily
* buspar 10 mg [**Hospital1 **]
* baclofen 40 mg TID
* lactulose 30 mL daily
* heparin 5000 U sc tid
* bisacodyl 10 mg daily
* nortriptyline 50 mg qhs
* combivent 1 puff q6h prn
* tylenol 650 mg po prn
* ensure tid with meals
* milk of mag 30 mL daily prn
* bisacodyl 10 mg pr daily prn
* fleet's enema prn
* macrobid 100 mg [**Hospital1 **] X 10 days (last day [**11-7**])
* advair 250/50 [**Hospital1 **]
* vitamin c 500 mg [**Hospital1 **]
* senna [**Hospital1 **]
* colace 100 mg [**Hospital1 **]
* gabapentin 900 mg q8h
* oxybutynin 5 mg tid
* calcium carbonate 1000 mg tid


Discharge Medications:
1. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
Take one pill every Thursday.
2. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours) for 7 weeks: Continue through
[**2137-12-25**].
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for yeast.
4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Baclofen 10 mg Tablet Sig: Four (4) Tablet PO TID (3 times a
day).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
10. Buspirone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY
(Daily) as needed for constipation.
13. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
14. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO Q8H
(every 8 hours).
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
17. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
18. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
19. Nortriptyline 25 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
20. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
21. Heparin, Porcine (PF) 5,000 unit/0.5 mL Syringe Sig: One (1)
 Injection three times a day.
22. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO once a
day.
23. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1)
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 4657**] - [**Location 1268**]

Discharge Diagnosis:
Primary Diagnosis
Sepsis secondary to osteomyelitis
.
Secondary Diagnoses
Chronic sacral and ischial decubitus ulcers
Paraplegia secondary to anterior spinal artery infarct
Hypertension
Hyperlipidemia
Gastroesophageal reflux disease
Chronic obstructive pulmonary disease
Fecal incontinence


Discharge Condition:
Vital signs stable.  Afebrile.


Discharge Instructions:
You were hospitalized for treatment of sepsis.  We believe the
source of the infection was the ulcer over your lower back.
Cultures we took of the blood grew out bacteria that likely
originated from this ulcer.  You were treated with intravenous
antibiotics for the infection.  Please continue to take the
antibiotics for a period of 6 weeks.  Because the antibiotics
were started on [**11-6**], the last dose should happen on
[**12-24**].
.
Your follow-up appointments are listed below.
.
Please call your doctor or return to the emergency room if you
have fever, change in mental status, or any other symptoms that
are concerning to you.

Followup Instructions:
1. Follow-up with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] [**Last Name (STitle) **] clinic [**11-25**], [**Hospital Ward Name 23**] [**Location (un) **] at 3PM: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD Phone: [**Telephone/Fax (1) 921**]
Date/Time:[**2137-11-25**] 3:00
.
2. Follow-up in infectious disease clinic with Dr. [**First Name (STitle) **]: [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2137-12-20**] 10:30
.
3. Follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1266**], as
needed: [**Telephone/Fax (1) 608**].


                             [**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**]

Completed by:[**2137-11-20**]
{'Methicillin resistant Staphylococcus aureus septicemia,Toxic encephalopathy,Acute osteomyelitis, other specified sites,Paraplegia,Septic shock,Pressure ulcer, stage IV,Infection and inflammatory reaction due to indwelling urinary catheter,Urinary tract infection, site not specified,Severe sepsis,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Esophageal reflux,Chronic airway obstruction, not elsewhere classified,Other disorders of muscle, ligament, and fascia,Osteoporosis, unspecified,Dermatomycosis, unspecified'}


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, hypotension, hypoxia.

PRESENT ILLNESS: Mrs. [**Known lastname 4636**] is a 72 y/o woman with PMH notable for paraplegia
[**1-5**] anterior spinal artery infarct, indwelling suprapubic
catheter with frequent UTIs admitted with altered mental status
and hypoxia.  Per nursing facility notes, the patient was noted
to be unresponsive to voice commands but responsive to tactile
stimuli.  Vitals at the time were BP 100/50, HR 100, RR 20, O2
80% on RA which increased to 97% on 6 L NC.  Reportedly, she is
alert & oriented X 3 at her baseline.  Of note, she is currently
on nitrofurantoin 100 mg PO BID for a UTI (? culture result)
which she started on [**2137-10-29**] for a planned 10 day course.  She
apparently also complained of nausea and may have vomited so
lactulose was held today.
.
On arrival to the ED, initial vitals were T 102.1, HR 100, BP
132/56, RR 24, 97% on 15 L via nasal cannula.  Blood pressure
trended down to 80s systolic.  She was originally on peripheral
dopamine for BP improvement but as this was not effective, it
was changed to peripheral levophed with subsequent improvement
in blood pressures to 120s systolic.  Blood and urine cultures
were sent.  She was treated with PR tylenol, levofloxacin 750 mg
IV X 1, vancomycin 1 g IV X 1, and 1 g ceftriaxone X 1.  She
received a total of 6 L NS in the ED.
.
On arrival to the MICU, the patient denies any pain.  She is
alert and speaking a few words at a time though they are
difficult to interpret.  She specifically denies any shortness
of breath or any abdominal pain.

MEDICAL HISTORY: Past Medical History: (from OMR)
- Paraplegia [**1-5**] Anterior Spinal Infarct ([**2128**])
- Thoracic Aneurysm Repair ([**2128**])
- COPD (? on home O2). With history of LLL Collapse/PNA s/p
mucous plug removal via bronchoscopy.
- HTN
- Hyperlipidemia
- GERD
- Suprapubic Catheter Placement / UTIs on Ppx Bactrim
- Fecal Incontinence
- Depression
- Atraumatic comminuted L intertrochanteric femur fracture
- Chronic sacral decubitus ulcers with past bilateral ischial
tuberosity osteomyelitis

MEDICATION ON ADMISSION: * alendronate 70 mg weekly on Thursday
* protonix 40 mg daily
* zincate 220 mg daily
* MVI daily
* vitamin D 800 U daily
* ASA 81 mg daily
* buspar 10 mg [**Hospital1 **]
* baclofen 40 mg TID
* lactulose 30 mL daily
* heparin 5000 U sc tid
* bisacodyl 10 mg daily
* nortriptyline 50 mg qhs
* combivent 1 puff q6h prn
* tylenol 650 mg po prn
* ensure tid with meals
* milk of mag 30 mL daily prn
* bisacodyl 10 mg pr daily prn
* fleet's enema prn
* macrobid 100 mg [**Hospital1 **] X 10 days (last day [**11-7**])
* advair 250/50 [**Hospital1 **]
* vitamin c 500 mg [**Hospital1 **]
* senna [**Hospital1 **]
* colace 100 mg [**Hospital1 **]
* gabapentin 900 mg q8h
* oxybutynin 5 mg tid
* calcium carbonate 1000 mg tid

ALLERGIES: Adhesive Tape

PHYSICAL EXAM: VS T 101.3, HR 84, BP 153/42, RR 23, O2 97% on 4L NC
Gen: obese elderly woman lying in bed, eyes open, no acute
distress
HEENT: PERRL, EOMI, OP clear, MMM
Neck: no JVD, no lymphadenopathy, no meningismus
CV: RRR, no appreciable murmur
Chest: grossly clear with occasional expiratory wheezing
Abd: obese, distended but soft, normoactive bowel sounds, no
tenderness to palpation; suprapubic catheter in place with
dressing; + erythematous yeast infection inferior to both
breasts and in groin around to back
Ext: upper extremities with > tone than lower extremities,
bilateral lower ext in multipodus boots, no peripheral edema
Back: sacral ulcer which probes to bone, some thick tan
discharge in wound but tissue appears beefy red; bilateral
ischial ulcers 2 cm in size
Neuro: face symmetric, CN II-XII grossly intact, bilateral hand
grip [**3-9**], shoulder shrug symmetric bilaterally, does not move
either leg, DTRs not elicited at bilateral biceps, patellae;
speaking short sentences & seems to appropriately answer yes/no
questions; denies any pain; toes mute bilaterally; upper
extremities stiff.

FAMILY HISTORY: Son has DM.

SOCIAL HISTORY: The patient admits 2-3ppd x 40+ years, but has smoked
intermittently for the past five years. The patient denies
alcohol or illicit drug use. Her son, [**Name (NI) **], is listed as her
HCP ([**Telephone/Fax (1) 4635**]); however, he tells me that she "has made it
clear she wants nothing to do with him" and he defers to his
other brother [**Name (NI) 1704**], [**Telephone/Fax (1) 4655**]. 

### Response:
{'Methicillin resistant Staphylococcus aureus septicemia,Toxic encephalopathy,Acute osteomyelitis, other specified sites,Paraplegia,Septic shock,Pressure ulcer, stage IV,Infection and inflammatory reaction due to indwelling urinary catheter,Urinary tract infection, site not specified,Severe sepsis,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Esophageal reflux,Chronic airway obstruction, not elsewhere classified,Other disorders of muscle, ligament, and fascia,Osteoporosis, unspecified,Dermatomycosis, unspecified'}
