CHIEF COMPLAINT: Neck pain with left arm numbness

PRESENT ILLNESS: 66 year-old man with past medical history of GERD, tobacco use,
COPD, hypothyroidism, cauda equina syndrome, and cervical
spondylosis with stenosis, who was admitted 2.13 for C3-C6
diskectomy and fusion, found to have elevated troponin (peak
0.22) and new wall motion abnormality and 2+MR [**First Name (Titles) **] [**Last Name (Titles) 113**] checked
after episode of acute resp distress 2.17. Resp distress thought
to be aspiration and multifocal pneumonia. His daughter states
that all this was precipitated by him receiving a sleeping pill
the night that this aspiration event occured. He was intubated
for airway protection considering he had a significant amount of
neck swelling (post-cervical surgery). He successfully extubated
and transfered to the floor. He is now sat'ing in the mid 90s on
room air. He has a persistent productive cough. He has been
afebrile since coming to the floor and denies any chest pain.
Per his daughter [**Name (NI) **] he also has been more confused since his
ICU stay and has had difficulty sleeping over the last several
days. She also states that he has been more anxious lately as
well something that is not usual for him.
ROS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.

MEDICAL HISTORY: - COPD: mild-moderate; FEV1 66% predicted, FEV1/FVC 80%
predicted
- Cauda equina syndrome: dx [**8-8**], s/p L2-laminectomy in [**11-7**],
with baseline BLE paresis, neuropathic pain, and neurogenic
bladder/bowel
- Abdominal pain / Dyspepsia
- H. pylori gastritis, s/p treatment; ?hiatal hernia on CXR
today
- Hyperthyroidism [**1-8**] [**Doctor Last Name 933**] disease s/p radioi-active iodine
ablation [**10/2191**], now on replacement therapy
- Erectile dysfunction
- h/o Pneumonia, [**2186**]
- L hip sebaceous cyst
- chronic groin pain, on Ultram

MEDICATION ON ADMISSION: 1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
shortness of breath or wheezing.
2. doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).

ALLERGIES: Primidone / Bactrim

PHYSICAL EXAM: Admision Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
RUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; + [**Doctor Last Name 937**], hyperreflexic at
biceps, triceps and brachioradialis
LUE- strength and sensation decreased throughout; hyperreflexic;
+ [**Doctor Last Name 937**]
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles
.
DC Physical exam
VS: Tm/c 98.2 112/62 (112-132/62-91) 76 (76-80)
20 (16-20) 94%RA (94-96)
16-hr I/O: 940/925
Gen: frail, chronically ill appearing, lying in bed, comfortably
HEENT: EOMI, PERRL, MMM, OP clear, cervical collar in place,
slight conjuctival pallor
Neck: posterior and anterior surgical scars healing well, no
purulent discharge
CV: regular rate and rhythm, no MRG, normal S1/S2
Resp: harsh inspiratory sounds diffusely, decreased breath
sounds at left lung base
GI: soft NTND, no HSM, +BS
Ext: thin extremities, multiple ecchymosis present, no c/c/e
Neuro: Right sided weakness with dorsiflexion ([**3-12**]), otherwise
strength in UE/LE [**4-11**] bilaterally. Decreased sensation in right
leg from knee down through toes.

FAMILY HISTORY: Denies any major family illnesses. Father died age [**Age over 90 **], mother
died age [**Age over 90 **]. Sister w/breast cancer. No premature heart disease
or other cancers.

SOCIAL HISTORY: 60 pk-yr smoker, quit 5 yrs ago. Denies EtOH use, no IVDA. He is
divorced and lives alone in [**Location 4288**]. He went on disability
after the surgery for the cauda equina syndrome. Semi-retired,
previously worked in administration for construction company.
Cervical spondylosis with myelopathy,Pneumonitis due to inhalation of food or vomitus,Subendocardial infarction, initial episode of care,Pneumonia, organism unspecified,Acute respiratory failure following trauma and surgery,Acute systolic heart failure,Chronic or unspecified duodenal ulcer with hemorrhage, with obstruction,Cardiac complications, not elsewhere classified,Aneurysm of heart (wall),Cauda equina syndrome with neurogenic bladder,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Esophageal reflux,Chronic airway obstruction, not elsewhere classified,Other postablative hypothyroidism,Mononeuritis of lower limb, unspecified,Personal history of tobacco use
Cerv spondyl w myelopath,Food/vomit pneumonitis,Subendo infarct, initial,Pneumonia, organism NOS,Ac resp flr fol trma/srg,Ac systolic hrt failure,Chr duoden ulc hem-obstr,Surg compl-heart,Aneurysm of heart,Neurogenic bladder,Abn react-surg proc NEC,Esophageal reflux,Chr airway obstruct NEC,Postablat hypothyr NEC,Mononeuritis leg NOS,History of tobacco use
Admission Date:  [**2195-1-19**]              Discharge Date:   [**2195-2-2**]

Date of Birth:  [**2128-12-25**]             Sex:   M

Service: MEDICINE

Allergies:
Primidone / Bactrim

Attending:[**First Name3 (LF) 5606**]
Chief Complaint:
Neck pain with left arm numbness

Major Surgical or Invasive Procedure:
Anterior/posterior cervical fusion C3-6


History of Present Illness:
66 year-old man with past medical history of GERD, tobacco use,
COPD, hypothyroidism, cauda equina syndrome, and cervical
spondylosis with stenosis, who was admitted 2.13 for C3-C6
diskectomy and fusion, found to have elevated troponin (peak
0.22) and new wall motion abnormality and 2+MR [**First Name (Titles) **] [**Last Name (Titles) 113**] checked
after episode of acute resp distress 2.17. Resp distress thought
to be aspiration and multifocal pneumonia. His daughter states
that all this was precipitated by him receiving a sleeping pill
the night that this aspiration event occured. He was intubated
for airway protection considering he had a significant amount of
neck swelling (post-cervical surgery). He successfully extubated
and transfered to the floor. He is now sat'ing in the mid 90s on
room air. He has a persistent productive cough. He has been
afebrile since coming to the floor and denies any chest pain.
Per his daughter [**Name (NI) **] he also has been more confused since his
ICU stay and has had difficulty sleeping over the last several
days. She also states that he has been more anxious lately as
well something that is not usual for him.
ROS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.


Past Medical History:
- COPD: mild-moderate; FEV1 66% predicted, FEV1/FVC 80%
predicted
- Cauda equina syndrome: dx [**8-8**], s/p L2-laminectomy in [**11-7**],
with baseline BLE paresis, neuropathic pain, and neurogenic
bladder/bowel
- Abdominal pain / Dyspepsia
- H. pylori gastritis, s/p treatment; ?hiatal hernia on CXR
today
- Hyperthyroidism [**1-8**] [**Doctor Last Name 933**] disease s/p radioi-active iodine
ablation [**10/2191**], now on replacement therapy
- Erectile dysfunction
- h/o Pneumonia, [**2186**]
- L hip sebaceous cyst
- chronic groin pain, on Ultram

Social History:
60 pk-yr smoker, quit 5 yrs ago. Denies EtOH use, no IVDA. He is
divorced and lives alone in [**Location 4288**]. He went on disability
after the surgery for the cauda equina syndrome. Semi-retired,
previously worked in administration for construction company.


Family History:
Denies any major family illnesses. Father died age [**Age over 90 **], mother
died age [**Age over 90 **]. Sister w/breast cancer. No premature heart disease
or other cancers.

Physical Exam:
Admision Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
RUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; + [**Doctor Last Name 937**], hyperreflexic at
biceps, triceps and brachioradialis
LUE- strength and sensation decreased throughout; hyperreflexic;
+ [**Doctor Last Name 937**]
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles
.
DC Physical exam
VS: Tm/c 98.2 112/62 (112-132/62-91) 76 (76-80)
20 (16-20) 94%RA (94-96)
16-hr I/O: 940/925
Gen: frail, chronically ill appearing, lying in bed, comfortably
HEENT: EOMI, PERRL, MMM, OP clear, cervical collar in place,
slight conjuctival pallor
Neck: posterior and anterior surgical scars healing well, no
purulent discharge
CV: regular rate and rhythm, no MRG, normal S1/S2
Resp: harsh inspiratory sounds diffusely, decreased breath
sounds at left lung base
GI: soft NTND, no HSM, +BS
Ext: thin extremities, multiple ecchymosis present, no c/c/e
Neuro: Right sided weakness with dorsiflexion ([**3-12**]), otherwise
strength in UE/LE [**4-11**] bilaterally. Decreased sensation in right
leg from knee down through toes.

Pertinent Results:
ADMISSION LABS
==============
[**2195-1-22**] 05:10AM BLOOD WBC-8.2 RBC-4.28* Hgb-11.7* Hct-36.1*
MCV-84 MCH-27.3 MCHC-32.3 RDW-14.2 Plt Ct-162
[**2195-1-20**] 06:23AM BLOOD WBC-9.3# RBC-4.60 Hgb-12.6* Hct-39.7*
MCV-86 MCH-27.4 MCHC-31.7 RDW-14.3 Plt Ct-183
[**2195-1-20**] 06:23AM BLOOD Glucose-145* UreaN-13 Creat-0.6 Na-136
K-4.5 Cl-103 HCO3-25 AnGap-13
[**2195-1-27**] 11:00AM BLOOD WBC-5.5 RBC-3.90* Hgb-10.8* Hct-32.4*
MCV-83 MCH-27.7 MCHC-33.3 RDW-14.0 Plt Ct-253
[**2195-1-25**] 01:18AM BLOOD WBC-8.5 RBC-3.97* Hgb-11.0* Hct-32.6*
MCV-82 MCH-27.8 MCHC-33.9 RDW-14.3 Plt Ct-167
[**2195-1-27**] 11:00AM BLOOD Glucose-107* UreaN-15 Creat-0.4* Na-135
K-3.8 Cl-100 HCO3-26 AnGap-13
[**2195-1-26**] 01:21AM BLOOD Glucose-88 UreaN-14 Creat-0.4* Na-139
K-3.6 Cl-104 HCO3-23 AnGap-16
[**2195-1-24**] 04:52AM BLOOD Glucose-147* UreaN-10 Creat-0.5 Na-136
K-4.2 Cl-102 HCO3-25 AnGap-13
.
CARDIAC ENZYMES
===============
[**2195-1-25**] 01:18AM BLOOD CK-MB-18* cTropnT-0.13*
[**2195-1-24**] 09:05PM BLOOD CK-MB-20* MB Indx-3.1 cTropnT-0.16*
[**2195-1-24**] 04:00PM BLOOD CK-MB-13* MB Indx-3.2 cTropnT-0.21*
[**2195-1-24**] 04:52AM BLOOD CK-MB-10 MB Indx-2.4 cTropnT-0.22*
.
DISCHARGE LABS
==============
[**2195-2-2**] 02:49PM BLOOD WBC-5.9 RBC-3.66* Hgb-10.8* Hct-31.5*
MCV-86 MCH-29.3 MCHC-34.1 RDW-15.7* Plt Ct-307
[**2195-1-31**] 03:56AM BLOOD PT-14.0* PTT-27.5 INR(PT)-1.3*
[**2195-2-1**] 05:34AM BLOOD Glucose-85 UreaN-14 Creat-0.5 Na-136
K-3.4 Cl-104 HCO3-19* AnGap-16
.
IMAGING
=======
CXR [**2195-1-22**]: There remains marked elevation of the left
hemidiaphragm. New
increased opacity in the left retrocardiac region adjacent to an
increasingly elevated left hemidiaphragm could reflect
atelectasis or aspiration given the clinical suspicion for the
latter entity. A subcentimeter nodular opacity in the level of
the right third anterior rib is again demonstrated and
previously carried a recommendation for followup chest
radiographs. Linear opacities at right lung base are consistent
with atelectasis. Cardiomediastinal contours are unchanged.
IMPRESSION:
Left lower lobe atelectasis or aspiration.
Persistent nodular opacity right 3rd anterior rib level.
PA and lateral CXR are recommended for more complete evaluation
of these
findings when the patient's condition permits.
.
TTE [**2195-1-24**]: The left atrium is mildly dilated. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. There is an inferoposterobasal left ventricular
aneurysm. Overall left ventricular systolic function is low
normal (LVEF 50%) secondary to basal inferior and posterior wall
akinesis. Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. Moderate
[2+] tricuspid regurgitation is seen. There is borderline
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Impression: inferior posterior myocardial infarct of
indeterminate age; due to the technically suboptimal nature of
this study, the mitral and tricuspid regurgitation may have been
significantly underestimated by color-flow imaging
.
CXR [**2195-1-24**]: Interval appearance of diffuse airspace process,
most likely representing mild-to-moderate pulmonary edema, less
likely diffuse pneumonia. There is persistent elevation of the
left hemidiaphragm with adjacent more confluent airspace
opacity, which could reflect confluent pulmonary edema or an
area of atelectasis. There is some overlying motion artifact on
the study as well. Cardiac and mediastinal contours are
difficult to assess but likely unchanged. Portion of the spinal
fusion hardware is seen overlying the lower cervical spine. The
described right upper lobe nodular opacity is not well
appreciated on the current study due to the diffuse airspace
process.
.
CXR [**2195-1-24**]: Interval intubation with the tip of the
endotracheal tube 5.5 cm above the carina. Improved aeration of
both lungs, particularly on the left side. There is diffuse
airspace process in the right lung as well as more patchy focal
process at the left lung base. These findings could reflect
asymmetric pulmonary edema, although bilateral pneumonia should
also be considered. Overall, cardiac and mediastinal contours
are stable. Previously reported more focal nodular opacity in
the right upper lobe again is not well appreciated on the
current study due to the diffuse airspace process. Spinal fusion
hardware overlying the lower cervical spine is incompletely
visualized.
.
CTA CHEST WITH & WITHOUT CONTRAST [**2195-1-24**]: The pulmonary
arterial tree is well opacified and no filling defect to suggest
pulmonary embolism is seen. The aorta is normal in caliber and
configuration without evidence of acute aortic syndrome.
Within the lungs, there is bilateral basilar atelectasis with
consolidation. An area of additional consolidation is noted
within the posterior right upper lobe with areas of
peribronchial opacification, bronchial wall thickening and
ground-glass opacity. Patchy opacities are also seen in the
lingula. No significant pleural effusion is seen. No
pneumothorax.
The heart and great vessels are grossly unremarkable. There
appears to be
some distal impaction of bronchi possibly due to aspiration or
mucoid
impaction in the areas of atelectasis and consolidation. There
are coronary
artery calcifications.
The patient is intubated with endotracheal tube in standard
position. Limited views of the upper abdomen are grossly
unremarkable.
No concerning osseous lesion is seen.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Findings consistent with multifocal pneumonia.
.
CXR [**2195-1-25**]: In comparison with the study of [**1-24**], there is some
increased
patchy opacification at the left base. This suggests the
possibility of
aspiration or pneumonia superimposed upon atelectasis and
pleural effusion.
Indistinctness of the right hemidiaphragm could reflect small
effusion and
atelectasis as well. Patchy area in the right mid zone could
also represent a focus of consolidation. Engorgement of the
pulmonary vessels suggests some elevated pulmonary venous
pressure.
.
CXR [**2195-1-26**]: Endotracheal tube continues to lie 5.5 cm above the
carina. There is a persistent opacification and consolidation at
the left lung base which may represent an area of pneumonia,
although it is possible that this could also reflect worsening
lobar atelectasis in the setting of a layering effusion as the
pulmonary vasculature is now more ill defined consistent with
superimposed pulmonary edema. Cardiac and mediastinal contours
are stable. No pneumothorax is seen.
.
DIPYRAMIDOLE-MIBI [**2195-1-28**]:
Stress: INTERPRETATION: This 66 year old man with a history of
hypertension, hyperlipidemia, COPD, cervical disc disease with
recent operation complicated by peri-operative myocardial
infarction, new cardiomyopathy and heart failure was referred to
the lab to evaluate his new heart failure. The patient was
infused with 0.142mg/kg/min of dipyrimadole over 4 minutes. The
patient reported no chest, back, arm, or neck discomfort during
the study. There were no ST segment changes during the infusion.
The rhythm was sinus with rare VPBs. The hemodynamic response
to the infusion was appropriate. At 4 minutes into recover the
dipyrimadole was reversed with 125mg of aminophylline.
IMPRESSION: No symptoms or ST segment changes with pharmacologic
stress.
Nuclear report sent separately.
.
Nuclear Perfusion: INTERPRETATION: Left ventricular cavity size
is mildly enlarged, with a calculated end diastolic volume of
113ml.
Rest and stress perfusion images reveal a moderate fixed
perfusion defect in the base of the inferoseptal wall. No
reversible ischemic perfusion defect is identified.
Gated images reveal hypokinesis in the basal aspect of the
inferoseptal wall.
The calculated left ventricular ejection fraction is 46%.
Compared with the study of [**2188-1-24**], these findings are new.
IMPRESSION: 1. No reversible ischemic perfusion defect. 2.
Moderate fixed
perfusion defect in the base of the inferoseptal wall with
associated
hypokinesis.
.
VIDEO SWALLOW [**2195-1-28**]: An oral and pharyngeal swallowing
videofluoroscopy was performed in collaboration with the speech
pathology service. During the oral phase, there was mild
impairment of bolus formation. Epiglottic deflection was
incomplete. There was intermittent, trace penetration with thin
and nectar-thick liquids and no aspiration.
IMPRESSION: No aspiration. Trace penetration with liquids as
above. For
further details, please consult the speech pathology note in the
medical
record dated [**0-0-0**].

Brief Hospital Course:
Mr. [**Known lastname **] is a 66 yo M w/ for cauda equina syndrome s/p L2
laminectomy c/b persistent LE neuropathy, now s/p Cervical
laminectomy for cervical spondylosis with post surgical course
complicated by pneumonia, acute hypoxic event requiring TICU
admission, and melena concerning for GI bleed.
.
.
ACTIVE ISSUES:
#. C-spine Decompression/Fusion: The patient underwent C3-6
discectomy with posterior decompression and fusion on [**1-21**]. The
surgery was without complication and the patient was transferred
to the PACU in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
given per standard protocol. Initial postop pain was controlled
with a PCA. On HD#2 he returned to the operating room for a
scheduled C3-6 decompression and fusion as part of a staged
2-part procedure. Post-operatively he developed orophyrngeal
swelling which caused difficulty swallowing. He was made NPO and
speech and swallow was consulted. His diet was advanced slowly.
.
# Upper Gastrointestinal Bleed- Patient suddenly developed
melena with mixed bright red blood and hypotension. He was
emergently transfered to the MICU. An EGD was performed which
showed multiple duodenal ulcers one with clot present. He was
transfused 2 units unmatched pRBC and another unit of matched
pRBC. The ulcers were injected epinephrine and no further
bleeding resulted. He was started on PPI gtt initially then
transitioned to omeprazole 40mg [**Hospital1 **]. Serum H. pylori antigen was
positive however he has a history of h. pylori gastritis, the
antigen may remain positive after the infection has cleared.
.
#. Hypoxemic respiratory failure: The evening of [**1-23**] he became
hypoxic to the 70's on room air. A code blue was called for
respiratory distress, he was not pulseless and CPR was not
performed.  He was transfered to the T/SICU and intubated for
airway protection.  It was thought he developed an aspiration
pneumonia and he was started on vancomycin and cefepime.  Chest
x-ray showed multifocal pneumonia.
.
#. Health Care Acquired Pneumonia: We continued
Vancomycin/Cefepime for a total of a 10 day course for HCAP. He
remained afebrile and w/o a leukocytosis. He had one positive
sputum culture obtained while intubated grew GPCs in pairs and
clusters. the rest of his cultures have remained negative.
.
# Upper GI Bleed: On [**1-30**], patient was noted to have large
melenic stool concerning for upper GI bleed. Bleed was
accompanied by a Hct drop of 10 points over the course of 24
hours and blood pressures in the 90s (baseline pressure in the
120s). Patient was transferred to the MICU where he was
intubated for airway protection given his recent cervical spine
surgery and underwent emergent endoscopy. He was noted to have
five kissing stress ulcers in the duodenum, one of which had a
large adherent clot but none of which were actively bleeding.
They injected epi into the largest clot. Cause of stress ulcers
felt to be discontinuation of patient's home dose omeprazole
during this hospitalization and the stress of surgery,
infection, and hospitalization leading to increased acid
secretion. He was transfused 3 units of blood and started on a
PPI drip. Patient briefly required peripheral pressor support
with phenylephrine while intubated but was successfully
extubated and off pressors several hours post-endoscopy. He had
a few episodes of resolving melena but his hematocrit and blood
pressures remained stable requiring no further transfusions.
.
#. Left Ventricular Dysfunction: At the time of hypoxemic
respiratory failure, elevated cardiac biomarkers were noted
(peaking at troponin 0.2).  [**Month/Year (2) **] showed The patient has a newly
found LV aneurysm and new inferior and posterior wall motion
abnormalities as well as new MR [**First Name (Titles) **] [**Last Name (Titles) **] compared to his prior TTE
in [**2187**]. Most likely these new findings were related to an old
MI of indeterminant age. Cardiology recommened anticoagulation
for the LV aneurysm but considering his recent spine surgery
this was not initiated. Nuclear stress showed fixed defect
representing an old MI as well. Started pt on Metoprolol 12.5mg
[**Hospital1 **], ASA 325mg and Atorvastatin 80mg daily. Aspirin 81mg was
discontinued in the setting of acute gastrointestinal bleed, it
should be resumed [**2195-2-8**].
.
.
CHRONIC ISSUES:
#. Neuropathic pain- Pt was taking 800mg of Gabapentin q4 at
home for neuropathic pain resulting from prior cauda equina
syndrome. This medication was abruptly stopped after acute
respiratory failure. He started complaining of increasing
neuropathic pain. Gabapentin was restarted at 300mg TID which
can be up titrated as tolerated.
.
#Hypothyroidism- S/P radio ablation for [**Doctor Last Name **], we continued
levothyroxine 175mcg
.
#COPD- stable we continued the following medications at home
doses: Fluticasone, albuterol prn, tiotroprium
.
.
TRANSITIONAL ISSUES:
- Patient should be continued on a PPI indefinitely given his
history of gastritis and this current episode of serious upper
GI bleed due to stress ulceration
- Patient should have h. pylori stool antigen or breath test
performed following discharge. If positive, he should be treated
and h. pylori eradication confirmed.
- Further consideration into anticoagulation or cardiology
consultation for further management of his LV aneurysm will be
deferred to his PCP.

Medications on Admission:
1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
shortness of breath or wheezing.
2. doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).

3. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Neurontin 400mg TID

Discharge Medications:
1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
shortness of breath or wheezing.
2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).

5. docusate sodium 50 mg/5 mL Liquid Sig: Two (2) 50 mg/5 mL
Liquid
 PO BID (2 times a day).
6. tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
7. doxazosin 2 mg Tablet Sig: One (1) Tablet PO once a day.
8. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.

9. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
10. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
12. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One
(1) Tablet PO three times a day.
13. multivitamin     Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Location (un) 86**]

Discharge Diagnosis:
Cervical stenosis and spondylosis
Aspiration pneumonia
Demand Myocardial ischemia
Acute gastrointestinal bleed


Discharge Condition:
Good


Discharge Instructions:
Mr [**Known lastname **], it was a pleasure taking care of you in your stay at
[**Hospital1 18**]. As you know, you were admitted for cervical spine
surgery. Your hospitalization was complicated by respiratory
failure and pneumonia. You were intubated and treated with
antibiotics, when your breathing improved, we removed the
breathing tube. Your hospital course was complicated by an acute
gastrointestinal bleed, we placed a small camera into your
stomach and found two bleeding ulcers. We stabalized the
bleeding and transfused blood to replace the blood that you
lost.

START Atorvastatin
START Metoprolol
INCREASE Omeprazole
DECREASE Gabapentin
STOP Ibuprofen

Followup Instructions:
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.

Name: [**Last Name (LF) 363**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 **]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3573**]
Appointment: Monday [**2195-2-9**] 9:00am

Department: CARDIAC SERVICES
When: FRIDAY [**2195-2-27**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Cervical spondylosis with myelopathy,Pneumonitis due to inhalation of food or vomitus,Subendocardial infarction, initial episode of care,Pneumonia, organism unspecified,Acute respiratory failure following trauma and surgery,Acute systolic heart failure,Chronic or unspecified duodenal ulcer with hemorrhage, with obstruction,Cardiac complications, not elsewhere classified,Aneurysm of heart (wall),Cauda equina syndrome with neurogenic bladder,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Esophageal reflux,Chronic airway obstruction, not elsewhere classified,Other postablative hypothyroidism,Mononeuritis of lower limb, unspecified,Personal history of tobacco use'}


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: Neck pain with left arm numbness

PRESENT ILLNESS: 66 year-old man with past medical history of GERD, tobacco use,
COPD, hypothyroidism, cauda equina syndrome, and cervical
spondylosis with stenosis, who was admitted 2.13 for C3-C6
diskectomy and fusion, found to have elevated troponin (peak
0.22) and new wall motion abnormality and 2+MR [**First Name (Titles) **] [**Last Name (Titles) 113**] checked
after episode of acute resp distress 2.17. Resp distress thought
to be aspiration and multifocal pneumonia. His daughter states
that all this was precipitated by him receiving a sleeping pill
the night that this aspiration event occured. He was intubated
for airway protection considering he had a significant amount of
neck swelling (post-cervical surgery). He successfully extubated
and transfered to the floor. He is now sat'ing in the mid 90s on
room air. He has a persistent productive cough. He has been
afebrile since coming to the floor and denies any chest pain.
Per his daughter [**Name (NI) **] he also has been more confused since his
ICU stay and has had difficulty sleeping over the last several
days. She also states that he has been more anxious lately as
well something that is not usual for him.
ROS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.

MEDICAL HISTORY: - COPD: mild-moderate; FEV1 66% predicted, FEV1/FVC 80%
predicted
- Cauda equina syndrome: dx [**8-8**], s/p L2-laminectomy in [**11-7**],
with baseline BLE paresis, neuropathic pain, and neurogenic
bladder/bowel
- Abdominal pain / Dyspepsia
- H. pylori gastritis, s/p treatment; ?hiatal hernia on CXR
today
- Hyperthyroidism [**1-8**] [**Doctor Last Name 933**] disease s/p radioi-active iodine
ablation [**10/2191**], now on replacement therapy
- Erectile dysfunction
- h/o Pneumonia, [**2186**]
- L hip sebaceous cyst
- chronic groin pain, on Ultram

MEDICATION ON ADMISSION: 1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
shortness of breath or wheezing.
2. doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).

ALLERGIES: Primidone / Bactrim

PHYSICAL EXAM: Admision Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
RUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; + [**Doctor Last Name 937**], hyperreflexic at
biceps, triceps and brachioradialis
LUE- strength and sensation decreased throughout; hyperreflexic;
+ [**Doctor Last Name 937**]
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles
.
DC Physical exam
VS: Tm/c 98.2 112/62 (112-132/62-91) 76 (76-80)
20 (16-20) 94%RA (94-96)
16-hr I/O: 940/925
Gen: frail, chronically ill appearing, lying in bed, comfortably
HEENT: EOMI, PERRL, MMM, OP clear, cervical collar in place,
slight conjuctival pallor
Neck: posterior and anterior surgical scars healing well, no
purulent discharge
CV: regular rate and rhythm, no MRG, normal S1/S2
Resp: harsh inspiratory sounds diffusely, decreased breath
sounds at left lung base
GI: soft NTND, no HSM, +BS
Ext: thin extremities, multiple ecchymosis present, no c/c/e
Neuro: Right sided weakness with dorsiflexion ([**3-12**]), otherwise
strength in UE/LE [**4-11**] bilaterally. Decreased sensation in right
leg from knee down through toes.

FAMILY HISTORY: Denies any major family illnesses. Father died age [**Age over 90 **], mother
died age [**Age over 90 **]. Sister w/breast cancer. No premature heart disease
or other cancers.

SOCIAL HISTORY: 60 pk-yr smoker, quit 5 yrs ago. Denies EtOH use, no IVDA. He is
divorced and lives alone in [**Location 4288**]. He went on disability
after the surgery for the cauda equina syndrome. Semi-retired,
previously worked in administration for construction company. 

### Response:
{'Cervical spondylosis with myelopathy,Pneumonitis due to inhalation of food or vomitus,Subendocardial infarction, initial episode of care,Pneumonia, organism unspecified,Acute respiratory failure following trauma and surgery,Acute systolic heart failure,Chronic or unspecified duodenal ulcer with hemorrhage, with obstruction,Cardiac complications, not elsewhere classified,Aneurysm of heart (wall),Cauda equina syndrome with neurogenic bladder,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Esophageal reflux,Chronic airway obstruction, not elsewhere classified,Other postablative hypothyroidism,Mononeuritis of lower limb, unspecified,Personal history of tobacco use'}
