CHIEF COMPLAINT: lethargy, respiratory depression

PRESENT ILLNESS: HPI: 49 y/o F with PMHx of paraplegia s/p MVA ([**2142**]), recurrent
UTIs, recent admission for PNA who was started on methadone for
chronic pain in [**8-9**], presented with lethargy and difficulty
breathing. Patient is accompanied by her husband and her friend,
[**Name (NI) **], who helps care for her. They report patient was found
very somnolent and was difficult to arouse, and reportedly
presents this way when she has a urinary track infection. Family
noted drowsiness starting the day prior to admission, and poor
po intake. On the am of admission, caretakers noted desaturation
to 89-90% on 2L o2 NC., which prompted them to bring her into
the ED.
ROS: Pt reports a low grade cough that has persisted from last
admission for PNA, that has been improving, some urinary
frequency (requiring additional catheterizations in addition to
Q4H) from 3 days PTA. Denies any shortness of breath, nausea,
vomiting, diarrhea, fevers or chills. Last bowel movement on
Friday night.
Regarding medications, patient is given her medications by
either her husband or friend. She has not run out of any of her
medications and does not recall taking any additional doses of
anything.
In the ED,  VS were 98 60 110/69 16 100% on nonrebreather. UA
was mildly positive with 6-10WBC, few bacteria, neg leuk est,
neg nitrates. Pt was given empiric 1g Vanco X1, Zosyn 4.5 g X1,
and Levo 750 mg X1 for ?LLL opacity on CXR. Official read of CXR
showed bibasilar ateletasis, no definitive evidence of PNA.
Primary care giver reported increased narcotic regimen including
Methadone. Pt was given Narcan 0.1mg and had significant
improvement in mental status, awake and responding
appropriately.  Pt required two addl doses of Narcan 0.1mg in ED
with rapid recovery of respiratory rate and transferred to the
ICU for closer monitoring. On transfer, VS were 95.9 66 110/76,
16 95% on 2L NC.

MEDICAL HISTORY: 1. Recurrent UTIs (q 2-3 months): last episode of ESBL
Klebsiella [**3-5**] to atonic bladder, intermittent catheterization
done by PCA or husband. Finished course of Bactrim on [**8-27**].
2. T1-T2 paraplegia following MVC [**1-5**]   s/p trach, s/p ORIF of

MEDICATION ON ADMISSION: Sucralfate 1 gram QID
Ipratropium-Albuterol q6hr prn
Lidocaine patch
Oxycodone 5 mg Tablet [**2-2**] q4hrs prn (approx [**6-7**]/day)
Gabapentin 400 mg QID
Loratadine 10mg daily
Levothyroxine 50 mcg
Baclofen 10 mg Tablet [**Hospital1 **]
Baclofen 5mg daily
Oxybutynin Chloride 5 mg Tablet TID
Trazodone 200mg qhs
Clonazepam 1 mg QID prn (often takes 3 tabs before bed)
Methadone 10 mg Tablet TID
Nicotine 21 mg/24 hr
Omeprazole 20 mg [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 95.9 BP: 119/76  HR: 66 RR: 12 O2Sat: 97% 2L NC
GEN: Well-appearing, somnolent but arousable
HEENT: EOMI, PERRL with 3mm pupils bilaterally, sclera
anicteric, no epistaxis or rhinorrhea, MMM, OP Clear
NECK: healed tracheotomy scar. No JVD, carotid pulses brisk, no
bruits, no cervical lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: (+) Crackles at the LLB
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. Spelled world
backwards correctly, deferred on serial 7s. [**2-3**] items on 3 item
recall. [**Doctor First Name **] intact. no Asterixis. 5/5 strength in UEs
bilaterally. Babinski could not be elicited b/l. 1+
brachioradialis DTR b/l. sensation to touch intact up to level
of nipples.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.

FAMILY HISTORY: mother- lung CA

SOCIAL HISTORY: Lives at home with her husband.
PCA is best friend, [**Name (NI) **]. Occasional EtOH, 35 pack-year tobacco
on a nicotine patch; last cigarette 3 weeks ago; no drugs.
Poisoning by methadone,Chronic airway obstruction, not elsewhere classified,Chronic hepatitis C without mention of hepatic coma,Neurogenic bladder NOS,Metabolic encephalopathy,Paraplegia,Late effect of spinal cord injury,Late effects of motor vehicle accident,Accidental poisoning by methadone,Anemia of other chronic disease,Unspecified acquired hypothyroidism,Other chronic pain,Insomnia, unspecified,Atrophic gastritis, without mention of hemorrhage,Dysthymic disorder,Unspecified menopausal and postmenopausal disorder,Tobacco use disorder,Tracheostomy status,Personal history of venous thrombosis and embolism,Other postprocedural status
Poisoning-methadone,Chr airway obstruct NEC,Chrnc hpt C wo hpat coma,Neurogenic bladder NOS,Metabolic encephalopathy,Paraplegia NOS,Late eff spinal cord inj,Late eff motor vehic acc,Acc poison-methadone,Anemia-other chronic dis,Hypothyroidism NOS,Chronic pain NEC,Insomnia NOS,Atrph gastrtis w/o hmrhg,Dysthymic disorder,Menopausal disorder NOS,Tobacco use disorder,Tracheostomy status,Hx-ven thrombosis/embols,Post-proc states NEC
Admission Date:  [**2146-9-19**]              Discharge Date:   [**2146-9-22**]

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

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 4654**]
Chief Complaint:
lethargy, respiratory depression

Major Surgical or Invasive Procedure:
none

History of Present Illness:
HPI: 49 y/o F with PMHx of paraplegia s/p MVA ([**2142**]), recurrent
UTIs, recent admission for PNA who was started on methadone for
chronic pain in [**8-9**], presented with lethargy and difficulty
breathing. Patient is accompanied by her husband and her friend,
[**Name (NI) **], who helps care for her. They report patient was found
very somnolent and was difficult to arouse, and reportedly
presents this way when she has a urinary track infection. Family
noted drowsiness starting the day prior to admission, and poor
po intake. On the am of admission, caretakers noted desaturation
to 89-90% on 2L o2 NC., which prompted them to bring her into
the ED.
ROS: Pt reports a low grade cough that has persisted from last
admission for PNA, that has been improving, some urinary
frequency (requiring additional catheterizations in addition to
Q4H) from 3 days PTA. Denies any shortness of breath, nausea,
vomiting, diarrhea, fevers or chills. Last bowel movement on
Friday night.
Regarding medications, patient is given her medications by
either her husband or friend. She has not run out of any of her
medications and does not recall taking any additional doses of
anything.
In the ED,  VS were 98 60 110/69 16 100% on nonrebreather. UA
was mildly positive with 6-10WBC, few bacteria, neg leuk est,
neg nitrates. Pt was given empiric 1g Vanco X1, Zosyn 4.5 g X1,
and Levo 750 mg X1 for ?LLL opacity on CXR. Official read of CXR
showed bibasilar ateletasis, no definitive evidence of PNA.
Primary care giver reported increased narcotic regimen including
Methadone. Pt was given Narcan 0.1mg and had significant
improvement in mental status, awake and responding
appropriately.  Pt required two addl doses of Narcan 0.1mg in ED
with rapid recovery of respiratory rate and transferred to the
ICU for closer monitoring. On transfer, VS were 95.9 66 110/76,
16 95% on 2L NC.

Of note,  last admission to [**Hospital1 18**] was [**2146-8-29**], where pt was
diagnosed with RUL-RML PNA and UTI and completed a 5 day course
of levofloxacin and bactrim respectively, and was started on
methadone in addition to longstanding gabapentin, oxycodone,
oxybutinin, and baclofen.

Past Medical History:
1. Recurrent UTIs (q 2-3 months): last episode of ESBL
Klebsiella [**3-5**] to atonic bladder, intermittent catheterization
done by PCA or husband. Finished course of Bactrim on [**8-27**].
2. T1-T2 paraplegia following MVC [**1-5**]   s/p trach, s/p ORIF of

R proximal humerus, s/p titanium steel plates in arms
3. HCV with apparent clearing of viremia as of [**5-10**]
4. Pneumonia (including MRSA in [**10-7**], last episode [**8-29**],
finished 5 day course of levofloxacin
5. Anxiety
6. DVT in [**2142**] -IVC filter placed in [**2142**]
7. Pulmonary nodules
8. Hypothyroidism
9. Chronic pain
10. Peri-menopausal; LMP [**9-8**]

Social History:
Lives at home with her husband.
PCA is best friend, [**Name (NI) **]. Occasional EtOH, 35 pack-year tobacco
on a nicotine patch; last cigarette 3 weeks ago; no drugs.

Family History:
mother- lung CA

Physical Exam:
Vitals: T: 95.9 BP: 119/76  HR: 66 RR: 12 O2Sat: 97% 2L NC
GEN: Well-appearing, somnolent but arousable
HEENT: EOMI, PERRL with 3mm pupils bilaterally, sclera
anicteric, no epistaxis or rhinorrhea, MMM, OP Clear
NECK: healed tracheotomy scar. No JVD, carotid pulses brisk, no
bruits, no cervical lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: (+) Crackles at the LLB
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. Spelled world
backwards correctly, deferred on serial 7s. [**2-3**] items on 3 item
recall. [**Doctor First Name **] intact. no Asterixis. 5/5 strength in UEs
bilaterally. Babinski could not be elicited b/l. 1+
brachioradialis DTR b/l. sensation to touch intact up to level
of nipples.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.


Pertinent Results:
[**2146-9-19**]:
WBC 6.1  Hgb 11.4 Hct 34.5 Plt 208
N:69.0 L:24.6 M:4.0 E:1.9 Bas:0.6
.
PT: 14.5  PTT: 31.2  INR: 1.3
.
136  97  8   BS 93   AGap=12
------------
5.9  33  0.3  Grossly hemolyzed
.
ECG: NSR

CXR [**2146-9-19**]: No definite evidence of pneumonia. Plate-like
atelectasis at both lung bases.
.
UA:SpecGr 1.004 pH 7.0 Leuk-Sm RBC 0 WBC [**7-12**] Bact-Few
Yeast-None Epi 0-2
.
Urine Cultures Sent


Brief Hospital Course:
Assessment: This is a 49 yo F/ T1-2 paraplegia, with chronic
pain, neurogenic bladder w/ hx of recurrent UTI, hx of DVT/PE
s/p IVC filter placement not being anticoagulated now p/w
altered mental status/lethargy and difficulty breathing in
setting of change in narcotic regimen 4 weeks ago.
.

# Mental status change with respiratory depression: [**3-5**] toxic
metabolic encephalopathy [**3-5**] narcotics and benzo polypharmacy,
infection (sources include urinary given hx of UTIs and self-
catherization, PNA given cough and recent PNA), and CXR shows
persistent LLL opacity, and undertreated hypothyroidism.
- f/u blood cx
- f/u Urine Culture
- hold benzos
- empiric zosyn  given prior last klebsiella UTI sensitivities,
until speciated
- titrate up levoxyl

# Paraplegia s/p MVA: complicated by atonic bladder requiring
self-catherization, DVT/PE s/p IVC filter, chronic pain
syndrome, post SCI anxiety/depression
- pain service consulted for simplification of regimen
- oxybutinin for urinary retention
- straight cath TID
- hold benzos

# Pain control -pain service recommended
1. Restart Baclofen home dose 10mg po bid and 5mg po mid day.
2. Lidocaine patch to affected area
3. Continue Neurontin 800mg QID
4. Hold Lyrica as it has similar action as neurontin.
5. Hold methadone and continue Oxycodone 5-10mg po Q4H PRN. Will
see how much she needs over the next 24h.
6. Continue NSAIDS and can give Toradol IV PRN if no
contraindication.
7. [**Month (only) 116**] restart all other home meds which are non-narcotic.


# obstructive lung disease: Last CT chest showed ground glass
opacities [**3-5**] PNA, emphysematous changes c/w COPD, and may have
component of restrictive lung dz [**3-5**] chest wall weakness related
to paraplegia.
No hx of pfts, yet on home inhaler and intermittant 2L home O2
since [**8-9**].
- continue Ipratropium-Albuterol
- incentive spirometry
- NC
- neb prn
- f/u with pulmonary as outpt for pfts
- check ABG if in respiratory distress
.
# HCV: chronic with undetectable viral load as of [**10-9**], with
baseline LFts ALT 15 ALT 17 Alk phos 66 tBil 0.2. LFts wnl.
stable.
.
# Anemia: normocytic anemia with baseline Hct 30-36; [**3-5**] ACD.
- f/u CBC qam
.
# gastritis: hx of antral erosions, on Omeprazole at home, no
GIB in past
- continue PPI
- on Sucralfate 1 g PO QID
.
# insomnia: hold ambien
.
# smoking cessation: nicotine patch.
-consider wellbutrin given hx of depression.
.
# Hypothyroid: continue Levothyroxine 50mcg daily, untreated.
- titrate up levoxyl
.

# Comm: [**First Name4 (NamePattern1) **] [**Name (NI) **], Husband, c [**Telephone/Fax (1) 104915**] / h [**Telephone/Fax (1) 104916**]

Medications on Admission:
Sucralfate 1 gram QID
Ipratropium-Albuterol q6hr prn
Lidocaine patch
Oxycodone 5 mg Tablet [**2-2**] q4hrs prn (approx [**6-7**]/day)
Gabapentin 400 mg QID
Loratadine 10mg daily
Levothyroxine 50 mcg
Baclofen 10 mg Tablet [**Hospital1 **]
Baclofen 5mg daily
Oxybutynin Chloride 5 mg Tablet TID
Trazodone 200mg qhs
Clonazepam 1 mg QID prn (often takes 3 tabs before bed)
Methadone 10 mg Tablet TID
Nicotine 21 mg/24 hr
Omeprazole 20 mg [**Hospital1 **]

Discharge Medications:
Baclofen 10mg po bid and 5mg po mid day.
Lidocaine patch to affected area
Neurontin 800mg QID
Oxycodone 5-10mg po Q4H PRN

Sucralfate 1 gram QID
Ipratropium-Albuterol q6hr prn
Loratadine 10mg daily
Levothyroxine 50 mcg
Trazodone 200mg qhs
Clonazepam 1 mg QID prn (often takes 3 tabs before bed)
Nicotine 21 mg/24 hr
Omeprazole 20 mg [**Hospital1 **]


Discharge Disposition:
Home with Service

Discharge Diagnosis:
Primary diagnosis: Altered mental status secondary to sedating
medications

Secondary diagnosis
#. Recurrent UTIs (q 2-3 months): last episode of ESBL
#. Klebsiella [**3-5**] to atonic bladder
#. T1-T2 paraplegia following MVC [**1-5**]   s/p trach, s/p ORIF of

R proximal humerus, s/p titanium steel plates in arms
#. HCV with apparent clearing of viremia as of [**5-10**]
#. Pneumonia (including MRSA in [**10-7**], last episode [**8-29**])
#. Anxiety
#. DVT in [**2142**] -IVC filter placed in [**2142**]
#. Pulmonary nodules
#. Hypothyroidism
#. Chronic pain




Discharge Condition:
stable

Discharge Instructions:
You were admitted with changed mental status and decreased
breathing due to oversedation from your pain medications.
Please confirm appropriate doses of your pain medications with
your primary doctor and your pain doctor.  Please do not
administer pain medications when respiratory rate is less than
10 breaths/minute.  Please do not drive or operate machinery
after having taken narcotic pain medications.

Please follow up with your primary care doctor to follow up on
blood culture and urine culture results to ensure that you do
not have an infection.

Followup Instructions:
Please follow up with your primary care provider as soon as
possible regarding correct dosage of your pain medications, and
to follow up on your blood and urine cultures.

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

Completed by:[**2146-9-21**]

Name:  [**Known lastname 104**],[**Known firstname 153**]                      Unit No:   [**Numeric Identifier 17053**]

Admission Date:  [**2146-9-19**]              Discharge Date:   [**2146-9-22**]

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

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1152**]
Addendum:
Please note this as the attending d/c summary, and disregard
prior d/c on record for this addmission.

Chief Complaint:
lethargy, difficulty breathing

Major Surgical or Invasive Procedure:
none

History of Present Illness:
HPI: 49 y/o F with PMHx of paraplegia s/p MVA ([**2142**]), recurrent
UTIs, recent admission for PNA who was started on methadone for
chronic pain in [**8-9**], presented with lethargy and difficulty
breathing. Family noted drowsiness starting the day prior to
admission, and poor po intake. On the am of admission,
caretakers noted desaturation to 89-90% on 2L o2 NC., which
prompted them to bring her into the ED.
Pt on a very complicated home pain regimen, with methadone 10mg
po TID started 8-10 weeks ago. Pain at rest at home 0/10, today
[**10-12**].
.
ROS: Pt reports a low grade cough that has persisted from last
admission for PNA, that has been improving, some urinary
frequency (requiring additional catheterizations in addition to
Q4H) from 3 days PTA. Denies any shortness of breath, nausea,
vomiting, diarrhea, fevers or chills. Last bowel movement on
Friday night.
Regarding medications, patient is given her medications by
either her husband or friend. She has not run out of any of her
medications and does not recall taking any additional doses of
anything.
.
In the ED, VS were 98 60 110/69 16 100% on nonrebreather. UA was
mildly positive with 6-10WBC, few bacteria, neg leuk est, neg
nitrates. Pt was given empiric 1g Vanco X1, Zosyn 4.5 g X1, and
Levo 750 mg X1 for ?LLL opacity on CXR. Official read of CXR
showed bibasilar ateletasis, no definitive evidence of PNA.
Primary care giver reported increased narcotic regimen including
Methadone. Pt was given Narcan 0.1mg and had significant
improvement in mental status, awake and responding
appropriately. Pt required two addl doses of Narcan 0.1mg in
EDPt was given Narcan with rapid recovery of respiratory rate
and transferred to the ICU for closer monitoring.


Past Medical History:
1. Recurrent UTIs (q 2-3 months): last episode of ESBL
Klebsiella [**3-5**] to atonic bladder, intermittent catheterization
done by PCA or husband. Finished course of Bactrim on [**8-27**].
2. T1-T2 paraplegia following MVC [**1-5**]   s/p trach, s/p ORIF of

R proximal humerus, s/p titanium steel plates in arms
3. HCV with apparent clearing of viremia as of [**5-10**]
4. Pneumonia (including MRSA in [**10-7**], last episode [**8-29**],
finished 5 day course of levofloxacin
5. Anxiety
6. DVT in [**2142**] -IVC filter placed in [**2142**]
7. Pulmonary nodules
8. Hypothyroidism
9. Chronic pain
10. Peri-menopausal; LMP [**9-8**]

Social History:
Lives at home with her husband.
PCA is best friend, [**Name (NI) 1679**]. Occasional EtOH, 35 pack-year tobacco
on a nicotine patch; last cigarette 3 weeks ago; no drugs.


Family History:
mother- lung CA

Physical Exam:
Physical Exam:
Vitals: T: 95.9 BP: 119/76  HR: 66 RR: 12 O2Sat: 97% 2L NC
GEN: Well-appearing, somnolent but arousable
HEENT: EOMI, PERRL with 3mm pupils bilaterally, sclera
anicteric, no epistaxis or rhinorrhea, MMM, OP Clear
NECK: healed tracheotomy scar. No JVD, carotid pulses brisk, no
bruits, no cervical lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: (+) Crackles at the LLB
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. Spelled world

backwards correctly, deferred on serial 7s. [**2-3**] items on 3 item
recall. [**Doctor First Name **] intact. no Asterixis. 5/5 strength in UEs
bilaterally. Babinski could not be elicited b/l. 1+
brachioradialis DTR b/l. sensation to touch intact up to level
of nipples.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.

Pertinent Results:
Pertinent Results:
[**2146-9-19**]:
WBC 6.1  Hgb 11.4 Hct 34.5 Plt 208
N:69.0 L:24.6 M:4.0 E:1.9 Bas:0.6
.
PT: 14.5  PTT: 31.2  INR: 1.3
.
136  97  8   BS 93   AGap=12
------------
5.9  33  0.3  Grossly hemolyzed
.
ECG: NSR

CXR [**2146-9-19**]: No definite evidence of pneumonia. Plate-like
atelectasis at both lung bases.
.
UA:SpecGr 1.004 pH 7.0 Leuk-Sm RBC 0 WBC [**7-12**] Bact-Few
Yeast-None Epi 0-2
.
Urine Cultures NEG

Brief Hospital Course:
49 yo F/ T1-2 paraplegia, with chronic pain, neurogenic bladder
w/ hx of recurrent UTI, hx of DVT/PE s/p IVC filter placement
not being anticoagulated now p/w
altered mental status/lethargy and difficulty breathing in
setting of change in narcotic regimen 4 weeks ago.  Pt initally
tx for suspected UTI with vanc/zosyn given past h/o sx
presentation, but of note pt did respond in ER rapidly to
narcan, pt subsequently observed in ICU.
<br>

# Acute Metabolic Encephalopathy with initial resp depression:
[**3-5**] narcotics and benzo polypharmacy, infection (sources include
urinary given hx of UTIs and self-
catherization, PNA given cough and recent PNA), and CXR shows
persistent LLL opacity were considered and treated as above
initially, and undertreated hypothyroidism though less likely to
be contributing to this acute presentation.  Pt did well first
day in ICU after narcan, stable for floor tx on [**9-20**] - abx d/c
at the point with urine cx being neg at that time (cx neg).  The
chronic pain management team was consulted, recommended
initially continuing all home meds, but holding methadone.  Pt's
pain increased day prior to d/c, with recs to re-start at lower
dose (5mg tid).  Pt appropriately apprehensive to re-start, but
after d/w pt and consult team -felt more comfortable and close
f/u arranged for [**2146-9-27**] with pain clinic at [**Hospital1 10986**].  Instructions
given to pt as below.  Noted pt has 24h care provider to help
with monitoring.
<br>

# Paraplegia s/p MVA: complicated by atonic bladder requiring
self-catherization, DVT/PE s/p IVC filter, chronic pain
syndrome, post SCI anxiety/depression
- pain service consulted for simplification of regimen as above
- oxybutinin for urinary retention (continued)
- straight cath TID
<br>

# Pain control -pain service recommendions as above.
1. Restart Baclofen home dose 10mg po bid and 5mg po mid day.
2. Lidocaine patch to affected area
3. Continue Neurontin dose
4. Held Lyrica as it has similar action as neurontin.
5. Initially held methadone and continued Oxycodone 5-10mg po
Q4H PRN. Restarted at 1/2 dose as above.
6. Continue NSAIDS
***7. Basically at the end, all home meds were re-started with
methadone dose cut in [**2-2**].
<br>

# obstructive lung disease: Last CT chest showed ground glass
opacities [**3-5**] PNA, emphysematous changes c/w COPD, and may have
component of restrictive lung dz [**3-5**] chest wall weakness related
to paraplegia. No hx of pfts, yet on home inhaler and
intermittant 2L home O2 since [**8-9**].  Defer to PCP for [**Name Initial (PRE) **]/u PFT
evaluation, cont home meds for now, after narcan resp sx
improved and controlled.
<br>

# HCV: chronic with undetectable viral load as of [**10-9**], with
baseline LFts ALT 15 ALT 17 Alk phos 66 tBil 0.2. LFts wnl.
stable.
<br>
.
# Anemia: normocytic anemia with baseline Hct 30-36; [**3-5**] ACD -
this was confirmed with Fe Studies in-house.  H/H remained
stable.
<br>
.
# gastritis: hx of antral erosions, on Omeprazole at home, no
GIB in past
- continue PPI
- on Sucralfate 1 g PO QID
<br>
.
# insomnia: held ambien in-house.
<br>
.
# smoking cessation: nicotine patch.
-consider wellbutrin given hx of depression, will defer to PCP
with recent medication changes and acute presention.
<br>
.
# Hypothyroidism: Free T4 mildly low (0.8) and TSH - 17,
increased home dose to 75mcg.  PCP to [**Name Initial (PRE) **]/u in 4-6wks.
<br>

# Comm: [**First Name4 (NamePattern1) **] [**Name (NI) **], Husband, c [**Telephone/Fax (1) 17054**] / h [**Telephone/Fax (1) 17055**]


Medications on Admission:
Sucralfate 1 gram QID
Ipratropium-Albuterol q6hr prn
Lidocaine patch
Oxycodone 5 mg Tablet [**2-2**] q4hrs prn (approx [**6-7**]/day)
Gabapentin 400 mg QID
Loratadine 10mg daily
Levothyroxine 50 mcg
Baclofen 10 mg Tablet [**Hospital1 **]
Baclofen 5mg daily
Oxybutynin Chloride 5 mg Tablet TID
Trazodone 200mg qhs
Clonazepam 1 mg QID prn (often takes 3 tabs before bed)
Methadone 10 mg Tablet TID
Nicotine 21 mg/24 hr
Omeprazole 20 mg [**Hospital1 **]


Discharge Medications:
1. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**2-2**]
Puffs Inhalation Q6H (every 6 hours).
2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QD ().
3. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
5. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for breal\kthrough pain: (approx [**5-7**]/day) .
Disp:*42 Tablet(s)* Refills:*0*
10. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
11. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
12. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO QID (4
times a day).
13. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day) as needed for constipation.
14. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO once a day as
needed for anxiety.
15. Methadone 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*45 Tablet(s)* Refills:*0*
16. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
17. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for anxiety.
18. Polyethylene Glycol 3350 100 % Powder Sig: One (1)  PO DAILY
(Daily) as needed for constipation.


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagosis: Acute metabolic encephalopathy [**3-5**] to
narocotic overdose

Secondary:
COPD - though you need further evaluation by your PCP
Hypothyroidism [**Name Initial (PRE) **] those was changed
Anemia of Chronic Disease
Chronic Gastritis


Discharge Condition:
stable


Discharge Instructions:
Your diagnosis is as below.  Please take the medication as
prescribed, do note that the methadone can accumulate over [**4-5**]
days.  If you start feeling any changes in your mental status at
that time, just hold off further doses of methadone - and
contact your pain M.D. or your PCP at that time.

Followup Instructions:
Pain clinic appt is at the [**Hospital1 **], booked for Tuesday [**2146-9-27**]
2:45pm. [**Location 17056**]in [**Location (un) **], [**Apartment Address(1) 17057**]. Call
[**Telephone/Fax (1) 15774**] if you need it with Dr. [**Last Name (STitle) 17058**], but would insist at
this time for this close f/u for close monitoring of your pain
medications.

Please call your PCP office for possible earlier appointment,
though appt as scheduled would be appropriate if care is
established soon at your pain clinic.  (Your PCP can [**Name Initial (PRE) **]/u with
your thyroid medication.)

Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17059**], [**MD Number(3) 6697**]:[**Telephone/Fax (1) 23**]
Date/Time:[**2146-10-14**] 11:20
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 14819**]
Date/Time:[**2146-10-26**] 1:30


                             [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 1155**]

Completed by:[**2146-9-22**]

Name:  [**Known lastname 104**],[**Known firstname 153**]                      Unit No:   [**Numeric Identifier 17053**]

Admission Date:  [**2146-9-19**]              Discharge Date:   [**2146-9-22**]

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

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1152**]
Addendum:
Please also note for main issue with acute mental status
changed, CT Head with and without contrast done to evaluate for
possible underlying pathology contributing to acute presentation
- study noted negative.  (Initially attempted MRI Head as
looking for ischemia - however pt did not tolerate and refused
to try with sedation).

Discharge Disposition:
Home

                             [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 1155**]

Completed by:[**2146-9-22**]
{'Poisoning by methadone,Chronic airway obstruction, not elsewhere classified,Chronic hepatitis C without mention of hepatic coma,Neurogenic bladder NOS,Metabolic encephalopathy,Paraplegia,Late effect of spinal cord injury,Late effects of motor vehicle accident,Accidental poisoning by methadone,Anemia of other chronic disease,Unspecified acquired hypothyroidism,Other chronic pain,Insomnia, unspecified,Atrophic gastritis, without mention of hemorrhage,Dysthymic disorder,Unspecified menopausal and postmenopausal disorder,Tobacco use disorder,Tracheostomy status,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: lethargy, respiratory depression

PRESENT ILLNESS: HPI: 49 y/o F with PMHx of paraplegia s/p MVA ([**2142**]), recurrent
UTIs, recent admission for PNA who was started on methadone for
chronic pain in [**8-9**], presented with lethargy and difficulty
breathing. Patient is accompanied by her husband and her friend,
[**Name (NI) **], who helps care for her. They report patient was found
very somnolent and was difficult to arouse, and reportedly
presents this way when she has a urinary track infection. Family
noted drowsiness starting the day prior to admission, and poor
po intake. On the am of admission, caretakers noted desaturation
to 89-90% on 2L o2 NC., which prompted them to bring her into
the ED.
ROS: Pt reports a low grade cough that has persisted from last
admission for PNA, that has been improving, some urinary
frequency (requiring additional catheterizations in addition to
Q4H) from 3 days PTA. Denies any shortness of breath, nausea,
vomiting, diarrhea, fevers or chills. Last bowel movement on
Friday night.
Regarding medications, patient is given her medications by
either her husband or friend. She has not run out of any of her
medications and does not recall taking any additional doses of
anything.
In the ED,  VS were 98 60 110/69 16 100% on nonrebreather. UA
was mildly positive with 6-10WBC, few bacteria, neg leuk est,
neg nitrates. Pt was given empiric 1g Vanco X1, Zosyn 4.5 g X1,
and Levo 750 mg X1 for ?LLL opacity on CXR. Official read of CXR
showed bibasilar ateletasis, no definitive evidence of PNA.
Primary care giver reported increased narcotic regimen including
Methadone. Pt was given Narcan 0.1mg and had significant
improvement in mental status, awake and responding
appropriately.  Pt required two addl doses of Narcan 0.1mg in ED
with rapid recovery of respiratory rate and transferred to the
ICU for closer monitoring. On transfer, VS were 95.9 66 110/76,
16 95% on 2L NC.

MEDICAL HISTORY: 1. Recurrent UTIs (q 2-3 months): last episode of ESBL
Klebsiella [**3-5**] to atonic bladder, intermittent catheterization
done by PCA or husband. Finished course of Bactrim on [**8-27**].
2. T1-T2 paraplegia following MVC [**1-5**]   s/p trach, s/p ORIF of

MEDICATION ON ADMISSION: Sucralfate 1 gram QID
Ipratropium-Albuterol q6hr prn
Lidocaine patch
Oxycodone 5 mg Tablet [**2-2**] q4hrs prn (approx [**6-7**]/day)
Gabapentin 400 mg QID
Loratadine 10mg daily
Levothyroxine 50 mcg
Baclofen 10 mg Tablet [**Hospital1 **]
Baclofen 5mg daily
Oxybutynin Chloride 5 mg Tablet TID
Trazodone 200mg qhs
Clonazepam 1 mg QID prn (often takes 3 tabs before bed)
Methadone 10 mg Tablet TID
Nicotine 21 mg/24 hr
Omeprazole 20 mg [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 95.9 BP: 119/76  HR: 66 RR: 12 O2Sat: 97% 2L NC
GEN: Well-appearing, somnolent but arousable
HEENT: EOMI, PERRL with 3mm pupils bilaterally, sclera
anicteric, no epistaxis or rhinorrhea, MMM, OP Clear
NECK: healed tracheotomy scar. No JVD, carotid pulses brisk, no
bruits, no cervical lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: (+) Crackles at the LLB
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. Spelled world
backwards correctly, deferred on serial 7s. [**2-3**] items on 3 item
recall. [**Doctor First Name **] intact. no Asterixis. 5/5 strength in UEs
bilaterally. Babinski could not be elicited b/l. 1+
brachioradialis DTR b/l. sensation to touch intact up to level
of nipples.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.

FAMILY HISTORY: mother- lung CA

SOCIAL HISTORY: Lives at home with her husband.
PCA is best friend, [**Name (NI) **]. Occasional EtOH, 35 pack-year tobacco
on a nicotine patch; last cigarette 3 weeks ago; no drugs. 

### Response:
{'Poisoning by methadone,Chronic airway obstruction, not elsewhere classified,Chronic hepatitis C without mention of hepatic coma,Neurogenic bladder NOS,Metabolic encephalopathy,Paraplegia,Late effect of spinal cord injury,Late effects of motor vehicle accident,Accidental poisoning by methadone,Anemia of other chronic disease,Unspecified acquired hypothyroidism,Other chronic pain,Insomnia, unspecified,Atrophic gastritis, without mention of hemorrhage,Dysthymic disorder,Unspecified menopausal and postmenopausal disorder,Tobacco use disorder,Tracheostomy status,Personal history of venous thrombosis and embolism,Other postprocedural status'}
