CHIEF COMPLAINT: altered mental status

PRESENT ILLNESS: 52 y.o female with pmhx of COPD on home 2L NC, recurrent
pneumonia, paraplegia, and recent admission for hypercarbic resp
failure,MDR pneumonia,Proteus UTI discharged last week
presenting with altered mental status. She has been noted by her
caretaker to be more confused at home. In the ED she was alert
and oriented X 3,with no complanits.In the ED she trigerred for
a oxygen  saturation of 82% RA with insp crackles and some
wheezing, afebrile. She was diagnosed with recurrent RLL
pnemonumona, and given Meropenem and Vancomycin. Her SBP briefly
was  72 and with 500cc NS increased to SBP 100. Prior to
transfer her vitals were: T-99 HR 99,107/60, RR 20 86% 6L with
BIPAP being started.

MEDICAL HISTORY: # T1 to T2 paraplegia status post a motor vehicle accident.
# Recurrent pneumonia
- 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
# 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: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
2. Baclofen 20 mg PO QAM, QPM
3. Baclofen 10 mg PO 4PM
4. Citalopram 40 mg PO DAILY
5. Clonazepam 1 mg PO TID:PRN anxiety
6. Lidocaine 5% Patch 1 PTCH TD DAILY
feet and shoulder blade
7. Omeprazole 20 mg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY
9. Simvastatin 10 mg PO DAILY
10. traZODONE 100 mg PO HS:PRN anxiety
11. Clonazepam 2 mg PO QHS
12. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN dyspnea
13. Oxybutynin 10 mg PO QAM, QHS
14. Oxybutynin 5 mg PO 4PM
15. Sucralfate 1 gm PO TID
16. Levothyroxine Sodium 112 mcg PO DAILY
17. Gabapentin 600 mg PO TID

ALLERGIES: Ativan

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
Vitals: T:99.1 BP:93/62 P:94 R:16 18 O2:95% BIPAP
General: Alert, oriented, not retracting, has BIPAP mask on,
mouthing words and nodding yes/no to questions appropiately.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: insp/ exp. wheezes difussely,insp rales in RLL, some exp
ronchi diffusley.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no current foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred,

FAMILY HISTORY: Mom - lung cancer
Dad - healthy

SOCIAL HISTORY: Lives at home with husband
- [**Name (NI) 1139**]: 35-pack-years, currently abusing tobacco
- Alcohol: Denies.
- Illicits: Denies.
Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Pneumonia due to Hemophilus influenzae [H. influenzae],Paraplegia,Foreign body in larynx,Hypotension, unspecified,Chronic airway obstruction, not elsewhere classified,Chronic hepatitis C without mention of hepatic coma,Opioid abuse, unspecified,Neurogenic bladder NOS,Mononeuritis of unspecified site,Foreign body accidentally entering other orifice,Other chronic pain,Anemia, unspecified,Dysthymic disorder,Leukocytosis, unspecified,Unspecified acquired hypothyroidism,Atrophic gastritis, without mention of hemorrhage,Constipation, unspecified,Pure hypercholesterolemia,Solitary pulmonary nodule,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Long-term (current) use of anticoagulants,Family history of malignant neoplasm of trachea, bronchus, and lung
Acute respiratry failure,Food/vomit pneumonitis,H.influenzae pneumonia,Paraplegia NOS,Foreign body in larynx,Hypotension NOS,Chr airway obstruct NEC,Chrnc hpt C wo hpat coma,Opioid abuse-unspec,Neurogenic bladder NOS,Mononeuritis NOS,FB entering oth orifice,Chronic pain NEC,Anemia NOS,Dysthymic disorder,Leukocytosis NOS,Hypothyroidism NOS,Atrph gastrtis w/o hmrhg,Constipation NOS,Pure hypercholesterolem,Solitary pulmonry nodule,Hx TIA/stroke w/o resid,Long-term use anticoagul,Fm hx-trach/bronchog mal
Admission Date:  [**2150-8-25**]              Discharge Date:   [**2150-9-3**]

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

Service: MEDICINE

Allergies:
Ativan

Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
altered mental status


Major Surgical or Invasive Procedure:
None


History of Present Illness:
52 y.o female with pmhx of COPD on home 2L NC, recurrent
pneumonia, paraplegia, and recent admission for hypercarbic resp
failure,MDR pneumonia,Proteus UTI discharged last week
presenting with altered mental status. She has been noted by her
caretaker to be more confused at home. In the ED she was alert
and oriented X 3,with no complanits.In the ED she trigerred for
a oxygen  saturation of 82% RA with insp crackles and some
wheezing, afebrile. She was diagnosed with recurrent RLL
pnemonumona, and given Meropenem and Vancomycin. Her SBP briefly
was  72 and with 500cc NS increased to SBP 100. Prior to
transfer her vitals were: T-99 HR 99,107/60, RR 20 86% 6L with
BIPAP being started.

In the ED initial vitals were: 99 100 140/122 24 92%. She was
given Meropenem and Vancomycin.

On arrival to the MICU, the patient is on BIBAP and able to
answer some questions. She knows its [**2150-8-2**], oriented to
[**Hospital1 18**] denies chest pain, abdominal pain,diarrhea,
fevers/chills,dizziness, dysuria at home. Denies headaches,
syncope and vision changes at home. She does endorse tan sputum
production and cough for the past few weeks.


Past Medical History:
# T1 to T2 paraplegia status post a motor vehicle accident.
# Recurrent pneumonia
- 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
# 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
- [**Name (NI) 1139**]: 35-pack-years, currently abusing tobacco
- Alcohol: Denies.
- Illicits: Denies.


Family History:
Mom - lung cancer
Dad - healthy

Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T:99.1 BP:93/62 P:94 R:16 18 O2:95% BIPAP
General: Alert, oriented, not retracting, has BIPAP mask on,
mouthing words and nodding yes/no to questions appropiately.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: insp/ exp. wheezes difussely,insp rales in RLL, some exp
ronchi diffusley.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no current foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred,

DISCHARGE PHYSICAL EXAM:
VS - T97.8 HR 73 BP 100/60 RR 20 O2Sat 97% 2L NC
GENERAL - awake, NAD
LUNGS - No increased work of breathing, no wheezes or crackles
HEART -  RRR, S1-S2 clear, no MRG
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
GU - Foley in place
NEURO - A&Ox3, CN 2-12 grossly intact

Pertinent Results:
ADMISSION LABS:
[**2150-8-25**] 02:45PM BLOOD WBC-13.4*# RBC-3.26* Hgb-8.9* Hct-28.7*
MCV-88 MCH-27.2 MCHC-30.9* RDW-16.0* Plt Ct-282
[**2150-8-25**] 02:45PM BLOOD Neuts-90.9* Lymphs-4.7* Monos-3.3 Eos-0.9
Baso-0.2
[**2150-8-25**] 02:45PM BLOOD PT-13.7* PTT-29.7 INR(PT)-1.3*
[**2150-8-25**] 02:45PM BLOOD Glucose-135* UreaN-18 Creat-0.4 Na-141
K-4.2 Cl-102 HCO3-33* AnGap-10
[**2150-8-25**] 02:45PM BLOOD Calcium-8.8 Phos-3.3 Mg-2.2
[**2150-8-25**] 02:45PM BLOOD proBNP-927*

[**2150-8-25**] 05:29PM BLOOD Type-ART pO2-76* pCO2-76* pH-7.25*
calTCO2-35* Base XS-2
[**2150-8-25**] 03:06PM BLOOD Lactate-1.4
[**2150-8-25**] 05:40PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2150-8-25**] 02:45PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG

RELEVANT LABS:
[**2150-8-26**] 07:37AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-POS

[**2150-9-2**] 06:05AM BLOOD WBC-7.0 RBC-3.43* Hgb-8.9* Hct-29.3*
MCV-85 MCH-25.9* MCHC-30.4* RDW-16.3* Plt Ct-274
[**2150-9-2**] 06:05AM BLOOD Glucose-96 UreaN-6 Creat-0.2* Na-143
K-3.6 Cl-101 HCO3-38* AnGap-8
[**2150-9-2**] 06:05AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.0
[**2150-9-2**] 08:10PM BLOOD Type-ART pO2-86 pCO2-58* pH-7.44
calTCO2-41* Base XS-12

PERTINENT MICRO: 	  		  	
[**2150-8-27**] 	 	BLOOD CULTURE 	-PENDING NGTD AT DISCHARGE
[**2150-8-25**] 	 	URINE 	Legionella Urinary Antigen -FINAL NEG	
[**2150-8-25**] 	 	URINE CULTURE-FINAL NEG	
[**2150-8-25**] 	 	BLOOD CULTURE 	-PENDING NGTD AT DISCHARGE
[**2150-8-25**] 2:45 pm BLOOD CULTURE

   Blood Culture, Routine (Preliminary):
      STAPHYLOCOCCUS, COAGULASE NEGATIVE.
         Isolated from only one set in the previous five days.
         SENSITIVITIES PERFORMED ON REQUEST..

   Aerobic Bottle Gram Stain (Final [**2150-8-27**]):
      Reported to and read back by DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] ON [**2150-8-27**] AT
0645.
      GRAM POSITIVE COCCI IN CLUSTERS.
	
[**2150-8-25**] 4:45 pm SPUTUM      Source: Expectorated.

                            **FINAL REPORT [**2150-8-28**]**

   GRAM STAIN (Final [**2150-8-25**]):
      >25 PMNs and <10 epithelial cells/100X field.
      4+   (>10 per 1000X FIELD):   GRAM NEGATIVE ROD(S).

   RESPIRATORY CULTURE (Final [**2150-8-28**]):
      RARE GROWTH Commensal Respiratory Flora.
      HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE.    HEAVY
GROWTH.
         Beta-lactamse negative: presumptively sensitive to
ampicillin.
         Confirmation should be requested in cases of treatment
failure in
         life-threatening infections..
      STAPH AUREUS COAG +.    SPARSE GROWTH.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations.

         Rifampin should not be used alone for therapy.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------   =>8 R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------     1 S

Blood Culture, Routine (Final [**2150-9-2**]):    NO GROWTH.

Legionella Urinary Antigen  (Final [**2150-8-26**]):
      NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.

PERTINENT IMAGING:
pCXR [**2150-8-25**]
 COMPARISONS:  Multiple prior chest radiographs, most recently
of [**2150-8-17**].

FINDINGS:  Single frontal portable view of the chest was
obtained.  The heart is enlarged and its right border is
silhouetted by right lung base
consolidation, which is increased since [**2150-8-17**] and
compatible with
pneumonia, pleural effusion, or a combination of both.  The left
lung is
clear.  No pneumothorax is identified.  A right central catheter
terminates in the low SVC.  Left humeral hardware is similar to
prior and right humeral hardware is incompletely imaged.

IMPRESSION:  Right lung base parenchymal opacity, increased
since prior,
compatible with pneumonia in the correct clinical setting.
Probable
superimposed right pleural effusion.
	

Brief Hospital Course:
53 y.o woman with pmhx of COPD on home 2L NC, recurrent
pneumonias and UTIs, T1-T2 paraplegia , and recent admission for
hypercarbic resp failure, MDR pneumonia, Proteus UTI discharged
one week prior who presented with altered mental status and
hypoxia, found to have new RLL Haemophilus influenzae and MRSA
pneumonia.

# Pneumonia: RLL pneumonia with MRSA and heavy Haemophilus
influenzae on sputum cultures. Patient was initially started
empirically on vancomycin, cefepime, meropenem, and was able to
be narrowed to vancomycin and meropenem only following
speciation of sputum cultures. Pneumonia was most likely cause
of hypotension, leukocytosis, hypoxia on admission. Patient has
history of recurrent pneumonias and most recently completed
eight-day Vancomycin and Meropenem course for HCAP on [**2150-8-18**].
 Given frequent AMS and RLL pna, high suspicion for aspiration.
She was treated for a total of 10 days with Vancomycin and
Meropenem. She was counseled on the contribution of underlying
substance dependence/polypharmacy leading to readmissions for
AMS and aspiration pneumonia.

# Positive blood cultures: One of four blood cultures positive
for coagulase negative staph, most likely contaminate. Patient
with indwelling CVC which did not appear infected, pneumonia was
treated as above. Repeat blood cultures showed no growth.

#Hypotension- Most likely [**3-5**] medications or infection. Fluid
responsive in the ED, lactate normal, patient did not require
pressors in the MICU. SBP at baseline fluctuates between 100-150
according to past records. Infection treated as above, weaned to
half doses of sedating medications.  No signs of cardiogenic
cause or adrenal cause. BPs were stable to elevated during her
stay on the medicine floor.

#Altered mental status- Patient presented with decreased
responsiveness and likely aspiration pneumonia similar to prior
hospitalizations, and was found to have Utox positive for
methadone, which patient admitted to taking without prescription
"from a friend" at unknown dose, for her chronic leg pain, as
narcotics agreement was termintated with PCP. [**Name10 (NameIs) **] spoke at length
with patient about this. Psychiatry consult was offered but
patient declined. Patient was not treated with narcan this
admission, but was known to have be responsive to narcan during
the previous admission. Opioid abuse and polypharmacy are the
most likely culprits for her recurrent admissions with AMS and
pneumonias most likely caused by aspiration, AMS compounded by
infection and poor pulmonary toilet. Sedating medication doses
were decreased by half.

CHRONIC ISSUES:
# COPD: on 2L O2 NC at baseline; resumed tobacco use last month.

-Continued home albuterol, ipratroprium, supplemental O2

# Chronic Pain: Foot and shoulder pain related to prior MVA and
likely neuropathy. Narcotics contract terminated by PCP as
documented in OMR. Utox positive for methadone (not prescribed)
this admission as discussed above.
-Lidocaine patches, baclofen, continued
-Gabapentin, pregabalin intially held for AMS, pregabalin
restarted, gabapentin restarted at half home dose when mental
status improved.
-Follow up at pain clinic as outpatient

# Urinary Retention: Patient usually self-catheterizes at home
but prefers to use foley when hospitalized. Foley was placed on
admission and removed before discharge. Oxybutin held initially
for AMS but restarted when mental status improved.

# Anxiety/Depression: Continued on citalopram, sedating
medications were held on admission for AMS, and were restarted
at half home dose when mental status improved, including
clonazepam, trazadone. Patient declined psychiatry consult but
opened up to SW during this admission about home stressors,
including her relationship with caregivers and husband.

# Hypothyroidism:  Continued levothyroxine

# Hypercholesterolemia: Continued simvastatin

# Hep C: Stable, no current treatment, no LFT abnormalities this
admission.

# GERD: Continued omeprazole

Transitional issues for this patient include:
- Continued investigation into options of treatment of methadone
abuse and dependence


Medications on Admission:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
2. Baclofen 20 mg PO QAM, QPM
3. Baclofen 10 mg PO 4PM
4. Citalopram 40 mg PO DAILY
5. Clonazepam 1 mg PO TID:PRN anxiety
6. Lidocaine 5% Patch 1 PTCH TD DAILY
feet and shoulder blade
7. Omeprazole 20 mg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY
9. Simvastatin 10 mg PO DAILY
10. traZODONE 100 mg PO HS:PRN anxiety
11. Clonazepam 2 mg PO QHS
12. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN dyspnea
13. Oxybutynin 10 mg PO QAM, QHS
14. Oxybutynin 5 mg PO 4PM
15. Sucralfate 1 gm PO TID
16. Levothyroxine Sodium 112 mcg PO DAILY
17. Gabapentin 600 mg PO TID


Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
2. Baclofen 20 mg PO QAM, QPM
3. Baclofen 10 mg PO 4PM
4. Citalopram 40 mg PO DAILY
5. Levothyroxine Sodium 112 mcg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Oxybutynin 10 mg PO QAM, QHS
8. Oxybutynin 5 mg PO 4PM
9. Polyethylene Glycol 17 g PO DAILY
10. Simvastatin 10 mg PO DAILY
11. Lidocaine 5% Patch 1 PTCH TD DAILY
feet and shoulder blade
12. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN dyspnea
13. Sucralfate 1 gm PO TID
14. Pregabalin 100 mg PO TID
15. Clonazepam 1 mg PO QHS
16. Clonazepam 0.5 mg PO TID:PRN anxiety
hold for sedation or RR<10
17. Gabapentin 300 mg PO Q8H
18. traZODONE 50 mg PO HS:PRN insomnia


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 1474**] VNA

Discharge Diagnosis:
Primary diagnosis: pneumonia (Haemophilus influenzae,
Methicillin Resistant Staph aureus)

Secondary diagnosis:
opioid dependence
chronic obstructive pulmonary disease
T1/T2 paraplegia with neurogenic bladder


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


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

It was a pleasure taking part in your care during your
hospitalization at [**Hospital1 18**]. You were admitted with confusion,
difficulty breathing, and low blood pressure and were found to
have a pneumonia. You were briefly admitted to the intensive
care unit for your symptoms, but did not require intubation. You
improved with IV antibiotics and were able to be discharged.

Please be aware that taking medications that are not prescribed
to you can be dangerous to your health and is likely
contributing to your recurrent hospitalizations. It is very
important that you follow up with the pain clinic to treat your
pain in a safe manner. Also please follow up with your PCP at
the appointment below.

Please note that the following changes have been made to your
medications:
1. Your dose of gabapentin was decreased to 300 mg PO Q8HRS
2. Please only take 1 mg of clonazepam by mouth at bedtime
and/or 0.5 mg by mouth up to 3 times per day as needed for
anxiety

Followup Instructions:
Department: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**]
When: THURSDAY [**2150-9-10**] at 1:10 PM
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
NOTE:   This appointment is with a hospital-based doctor as part
of your transition from the hospital back to your primary care
provider

Department: PAIN MANAGEMENT CENTER
When: TUESDAY [**2150-9-15**] at 8:40 AM
With: [**Name6 (MD) 10720**] [**Last Name (NamePattern4) 10721**], MD [**Telephone/Fax (1) 1652**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS     Best Parking: Parking on Site

Department: [**Hospital3 249**]
When: TUESDAY [**2150-9-22**] at 10:40 AM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**], M.D. [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage



Completed by:[**2150-9-6**]
{'Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Pneumonia due to Hemophilus influenzae [H. influenzae],Paraplegia,Foreign body in larynx,Hypotension, unspecified,Chronic airway obstruction, not elsewhere classified,Chronic hepatitis C without mention of hepatic coma,Opioid abuse, unspecified,Neurogenic bladder NOS,Mononeuritis of unspecified site,Foreign body accidentally entering other orifice,Other chronic pain,Anemia, unspecified,Dysthymic disorder,Leukocytosis, unspecified,Unspecified acquired hypothyroidism,Atrophic gastritis, without mention of hemorrhage,Constipation, unspecified,Pure hypercholesterolemia,Solitary pulmonary nodule,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Long-term (current) use of anticoagulants,Family history of malignant neoplasm of trachea, bronchus, and lung'}


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

PRESENT ILLNESS: 52 y.o female with pmhx of COPD on home 2L NC, recurrent
pneumonia, paraplegia, and recent admission for hypercarbic resp
failure,MDR pneumonia,Proteus UTI discharged last week
presenting with altered mental status. She has been noted by her
caretaker to be more confused at home. In the ED she was alert
and oriented X 3,with no complanits.In the ED she trigerred for
a oxygen  saturation of 82% RA with insp crackles and some
wheezing, afebrile. She was diagnosed with recurrent RLL
pnemonumona, and given Meropenem and Vancomycin. Her SBP briefly
was  72 and with 500cc NS increased to SBP 100. Prior to
transfer her vitals were: T-99 HR 99,107/60, RR 20 86% 6L with
BIPAP being started.

MEDICAL HISTORY: # T1 to T2 paraplegia status post a motor vehicle accident.
# Recurrent pneumonia
- 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
# 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: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
2. Baclofen 20 mg PO QAM, QPM
3. Baclofen 10 mg PO 4PM
4. Citalopram 40 mg PO DAILY
5. Clonazepam 1 mg PO TID:PRN anxiety
6. Lidocaine 5% Patch 1 PTCH TD DAILY
feet and shoulder blade
7. Omeprazole 20 mg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY
9. Simvastatin 10 mg PO DAILY
10. traZODONE 100 mg PO HS:PRN anxiety
11. Clonazepam 2 mg PO QHS
12. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN dyspnea
13. Oxybutynin 10 mg PO QAM, QHS
14. Oxybutynin 5 mg PO 4PM
15. Sucralfate 1 gm PO TID
16. Levothyroxine Sodium 112 mcg PO DAILY
17. Gabapentin 600 mg PO TID

ALLERGIES: Ativan

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
Vitals: T:99.1 BP:93/62 P:94 R:16 18 O2:95% BIPAP
General: Alert, oriented, not retracting, has BIPAP mask on,
mouthing words and nodding yes/no to questions appropiately.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: insp/ exp. wheezes difussely,insp rales in RLL, some exp
ronchi diffusley.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no current foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred,

FAMILY HISTORY: Mom - lung cancer
Dad - healthy

SOCIAL HISTORY: Lives at home with husband
- [**Name (NI) 1139**]: 35-pack-years, currently abusing tobacco
- Alcohol: Denies.
- Illicits: Denies. 

### Response:
{'Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Pneumonia due to Hemophilus influenzae [H. influenzae],Paraplegia,Foreign body in larynx,Hypotension, unspecified,Chronic airway obstruction, not elsewhere classified,Chronic hepatitis C without mention of hepatic coma,Opioid abuse, unspecified,Neurogenic bladder NOS,Mononeuritis of unspecified site,Foreign body accidentally entering other orifice,Other chronic pain,Anemia, unspecified,Dysthymic disorder,Leukocytosis, unspecified,Unspecified acquired hypothyroidism,Atrophic gastritis, without mention of hemorrhage,Constipation, unspecified,Pure hypercholesterolemia,Solitary pulmonary nodule,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Long-term (current) use of anticoagulants,Family history of malignant neoplasm of trachea, bronchus, and lung'}
