CHIEF COMPLAINT: "altered mental status."

PRESENT ILLNESS: This is a 73 yo WF with a PMHx of breast cancer originally
diagnosed in [**2160**] with recurrence 6 months ago, s/p recent
bilateral mastectomy c/b infection and removal of expanders, now
with pseudomonas osteomyelitis who now p/f home with subacute
changes in MS and increased problems ambulating.
.
The patient was discharged for the plastic surgery service about
2 months ago for surgical treatment for complications related to
her bilateral mastetomy.  She was re-admitted several weeks ago
for a delayed closure of her wounds.  Her most recent tissues
culture from her chest grew pan-sensitive pseudomonas.  She is
on vancomycin and cefipme therpay, end date is [**2190-9-29**].  The
patient had been at home for the last several weeks and the
family notes a slow decline in mental functioning.  They report
she is slower to answer questions and has a poor attention span.
 They thinks her metal function started to decline noticably as
she was diagnosed with her second breast cancer in 2/[**2190**].  They
did note that she has some level of forgetfulness at baseline.
The day of admission, the patietn had decreased ability to
ambulate with a walked like she had been able to previously, so
they presented to the hospital.  They denied falls and the
patietn denies dysequilibrium or vertigo.  The patient has had
problems taking in po [**3-17**] to increased nausea and vomiting of
clear liquid.  The patient family notes she is on many
medications and that her pain medications and reglan may have
been changed recently.  Per the ED notes, reglan was added
recently.
.
In the ED they got a HCT which was negative for acute processes
and a CXR that was negative except for her picc was in her RIJ.
The patients labs were signifcant for acidosis with a bicarb of
14, a normal lactate and a creatinine of 1.8.  There the patient
was AAOX2.

MEDICAL HISTORY: PMH:
1) Left breast cancer [**2160**]
-carcinoma of the left breast diagnosed in [**2160**]
-At that time, she was treated with breast conserving surgery
including an axillary dissection, chemotherapy, and adjuvant
radiation therapy.
-She has had no further problems with her breast until [**2-/2190**]
when Ms. [**Known lastname **] [**Last Name (Titles) 1834**] a wire localized right breast
biopsy for a mammographic abnormality, which demonstrated
microcalcifications associated with benign breast lobules.  An
initial core biopsy had demonstrated calcifications associated
with a sclerosed fibroadenoma and lobular carcinoma in situ
-new left breast ca, the pathology of which was the same as her
initial breast ca over 20 yrs ago
-there was 1 positive sebtinel node, Her-2 neg
-In [**Month (only) 956**] she [**Month (only) 1834**] a bilateral mastectomy
with expanders placed
-her post op course was complicated by a significant cellulitis
of both surgical sights, requiring surgical intervention and
removal of expanders
2) L squamous cell carcinoma
3) Hypertension
4) Hyperlipidemia
5) Hypothyroidism
6) Arthritis
7) Diverticulitis s/p sigmoidectomy

MEDICATION ON ADMISSION: 1. triamterene-hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily)-will hold
2. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) grams PO DAILY (Daily).
4. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

ALLERGIES: Erythromycin Base / Codeine / Bactrim DS / IV Dye, Iodine
Containing / Levofloxacin / Lipitor / Shellfish / Sulfa
(Sulfonamide Antibiotics)

PHYSICAL EXAM: Admission Physical Exam:
.
VS 98.6, 138/62, 67, 16, 97 RA
General: patient is easily arousable, AAOX3-knows she is in the
hospital, knows the month, unsure of the year, throughts are
somewhat tangential and sometiems does not answer questions
appropirately
HEENT: CN 2-12 grossly intact, mmm, no lad
Endo: no obvious thyroid masses
CV: 3/6 systolic murmur
Lungs: CTAB no wrr
Abdomen: positive bs, obese but not TTP, liver and spleen not
palpable, no rebound
Extremities:
UE:5/5 strength, pulses 2+ and equal, sensation grossly intact
LE:4+/5 strength, pulses 2+ and equal, sensation grossly intact,
2+ pitting ble edema
Neuro:
-strength equal, slightly decreased per above
-reflexes 1+ and equal
-sensation grossly intact
-unable to participate in cerebellar exam
-mental status per above, able to answer some simple questions
but is tangential

FAMILY HISTORY: negative for breast and ovarian cancer.

SOCIAL HISTORY: Cigarettes-denied, EtOH rare social.
Other postoperative infection,Nutritional marasmus,Acute kidney failure with lesion of tubular necrosis,Acute glomerulonephritis with other specified pathological lesion in kidney,Unspecified osteomyelitis, other specified sites,Acidosis,Delirium due to conditions classified elsewhere,Pulmonary congestion and hypostasis,Other pulmonary insufficiency, not elsewhere classified,Mechanical complication due to other implant and internal device, not elsewhere classified,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Unspecified essential hypertension,Nausea with vomiting,Adult failure to thrive,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Pressure ulcer, lower back,Anemia of other chronic disease,Arthropathy, unspecified, site unspecified,Anxiety state, unspecified,Personal history of malignant neoplasm of breast,Personal history of irradiation, presenting hazards to health,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Other specified antibiotics causing adverse effects in therapeutic use,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Other postop infection,Nutritional marasmus,Ac kidny fail, tubr necr,Acute nephritis NEC,Osteomyelit NOS-oth site,Acidosis,Delirium d/t other cond,Pulm congest/hypostasis,Other pulmonary insuff,Malfunc oth device/graft,Pseudomonas infect NOS,Hypertension NOS,Nausea with vomiting,Failure to thrive-adult,Hyperlipidemia NEC/NOS,Hypothyroidism NOS,Pressure ulcer, low back,Anemia-other chronic dis,Arthropathy NOS-unspec,Anxiety state NOS,Hx of breast malignancy,Hx of irradiation,Abn react-surg proc NEC,Adv eff antibiotics NEC,Abn react-procedure NEC
Admission Date:  [**2190-9-2**]              Discharge Date:   [**2190-9-20**]

Date of Birth:  [**2117-7-15**]             Sex:   F

Service: MEDICINE

Allergies:
Erythromycin Base / Codeine / Bactrim DS / IV Dye, Iodine
Containing / Levofloxacin / Lipitor / Shellfish / Sulfa
(Sulfonamide Antibiotics)

Attending:[**First Name3 (LF) 5141**]
Chief Complaint:
"altered mental status."

Major Surgical or Invasive Procedure:
PICC placement

History of Present Illness:
This is a 73 yo WF with a PMHx of breast cancer originally
diagnosed in [**2160**] with recurrence 6 months ago, s/p recent
bilateral mastectomy c/b infection and removal of expanders, now
with pseudomonas osteomyelitis who now p/f home with subacute
changes in MS and increased problems ambulating.
.
The patient was discharged for the plastic surgery service about
2 months ago for surgical treatment for complications related to
her bilateral mastetomy.  She was re-admitted several weeks ago
for a delayed closure of her wounds.  Her most recent tissues
culture from her chest grew pan-sensitive pseudomonas.  She is
on vancomycin and cefipme therpay, end date is [**2190-9-29**].  The
patient had been at home for the last several weeks and the
family notes a slow decline in mental functioning.  They report
she is slower to answer questions and has a poor attention span.
 They thinks her metal function started to decline noticably as
she was diagnosed with her second breast cancer in 2/[**2190**].  They
did note that she has some level of forgetfulness at baseline.
The day of admission, the patietn had decreased ability to
ambulate with a walked like she had been able to previously, so
they presented to the hospital.  They denied falls and the
patietn denies dysequilibrium or vertigo.  The patient has had
problems taking in po [**3-17**] to increased nausea and vomiting of
clear liquid.  The patient family notes she is on many
medications and that her pain medications and reglan may have
been changed recently.  Per the ED notes, reglan was added
recently.
.
In the ED they got a HCT which was negative for acute processes
and a CXR that was negative except for her picc was in her RIJ.
The patients labs were signifcant for acidosis with a bicarb of
14, a normal lactate and a creatinine of 1.8.  There the patient
was AAOX2.

When the patient arrived to the floor she had no complaints.
She denied pain, cp, sob, f/c.  The plastic surgery team
evalauted the patietn and probed her wound and got pus like
drainage from the patient right chest.  She had minimal pain
during the procedure.

Past Medical History:
PMH:
1) Left breast cancer [**2160**]
-carcinoma of the left breast diagnosed in [**2160**]
-At that time, she was treated with breast conserving surgery
including an axillary dissection, chemotherapy, and adjuvant
radiation therapy.
-She has had no further problems with her breast until [**2-/2190**]
when Ms. [**Known lastname **] [**Last Name (Titles) 1834**] a wire localized right breast
biopsy for a mammographic abnormality, which demonstrated
microcalcifications associated with benign breast lobules.  An
initial core biopsy had demonstrated calcifications associated
with a sclerosed fibroadenoma and lobular carcinoma in situ
-new left breast ca, the pathology of which was the same as her
initial breast ca over 20 yrs ago
-there was 1 positive sebtinel node, Her-2 neg
-In [**Month (only) 956**] she [**Month (only) 1834**] a bilateral mastectomy
with expanders placed
-her post op course was complicated by a significant cellulitis
of both surgical sights, requiring surgical intervention and
removal of expanders
2) L squamous cell carcinoma
3) Hypertension
4) Hyperlipidemia
5) Hypothyroidism
6) Arthritis
7) Diverticulitis s/p sigmoidectomy

Past Surgical History:
1) [**2190-4-15**] Bilateral breast debridement
2) [**2190-3-30**] Bilateral total simple mastectomies
3) [**2183**] Sigmoidectomy for diverticulitis
4) [**2180-7-11**]  arthroscopy with major synovectomy and thermal
chondroplasty of right knee
5) [**2180-1-25**] operative arthroscopy with partial medial
meniscectomy and debridement
6) [**2179-8-18**] Wire localized right breast biopsy
7) [**2178-4-13**] Excision of cyst on buttocks
8) [**2175-9-15**] Removal of distal radius pin
9) [**2175-7-24**] Closed reduction of the right distal radius
fracture,
external fixator application of right wrist, percutaneous K-wire
placement of right distal radius
10) [**2165**] Left breast lumpectomy and chemoradiation
11) [**2153**] C-section
12) [**2135**] Appendectomy
13) [**2123**] Tonsillectomy


Social History:
Cigarettes-denied, EtOH rare social.


Family History:
negative for breast and ovarian cancer.


Physical Exam:
Admission Physical Exam:
.
VS 98.6, 138/62, 67, 16, 97 RA
General: patient is easily arousable, AAOX3-knows she is in the
hospital, knows the month, unsure of the year, throughts are
somewhat tangential and sometiems does not answer questions
appropirately
HEENT: CN 2-12 grossly intact, mmm, no lad
Endo: no obvious thyroid masses
CV: 3/6 systolic murmur
Lungs: CTAB no wrr
Abdomen: positive bs, obese but not TTP, liver and spleen not
palpable, no rebound
Extremities:
UE:5/5 strength, pulses 2+ and equal, sensation grossly intact
LE:4+/5 strength, pulses 2+ and equal, sensation grossly intact,
2+ pitting ble edema
Neuro:
-strength equal, slightly decreased per above
-reflexes 1+ and equal
-sensation grossly intact
-unable to participate in cerebellar exam
-mental status per above, able to answer some simple questions
but is tangential

ICU Admission Exam:
Vitals: T 98.9, BP 168/61, HR 92, RR 27, SpO2 97% on 8L
Ventimask
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Chest wall: Dressing in place, non-tender, bilateral mastectomy
sutures clean.
Lungs: Increased work of breathing, tachypnea. Bibasilar
crackles. Wheezing audible without stethoscope, upper airway.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: Warm, well perfused. Distal pulses 2+.  Lower extremity
edema 1+ bilaterally at ankles.
DERM: Sacral decub ulcer, healing incision on right mid-back.
.
Discharge Physical Exam:
.
VS 97.8, 132/78, 72, 18, 97 RA
General: AOx3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Chest wall: Dressing in place, non-tender, bilateral mastectomy
sutures clean.
Lungs: Increased work of breathing, tachypnea. Bibasilar
crackles. Wheezing audible without stethoscope, upper airway.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: Warm, well perfused. Distal pulses 2+.  Lower extremity
edema 1+ bilaterally at ankles.
Neuro: non-focal
.



Pertinent Results:
Admission Labs:
.
[**2190-9-2**] 12:15PM URINE  HOURS-RANDOM
[**2190-9-2**] 12:15PM URINE  GR HOLD-HOLD
[**2190-9-2**] 12:15PM URINE  COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.008
[**2190-9-2**] 12:15PM URINE  BLOOD-SM  NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-SM

[**2190-9-2**] 12:15PM URINE  RBC-1 WBC-21* BACTERIA-FEW YEAST-NONE
EPI-<1
[**2190-9-2**] 12:15PM URINE  AMORPH-FEW
[**2190-9-2**] 12:15PM URINE  MUCOUS-RARE
[**2190-9-2**] 10:12AM   LACTATE-1.0 K+-4.1
[**2190-9-2**] 10:05AM   GLUCOSE-84 UREA N-34* CREAT-1.8* SODIUM-133
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-14* ANION GAP-19
[**2190-9-2**] 10:05AM   estGFR-Using this
[**2190-9-2**] 10:05AM   ALT(SGPT)-3 AST(SGOT)-12 LD(LDH)-226 ALK
PHOS-93 TOT BILI-0.2
[**2190-9-2**] 10:05AM   LIPASE-10
[**2190-9-2**] 10:05AM   CALCIUM-9.6 PHOSPHATE-3.3 MAGNESIUM-1.4*
[**2190-9-2**] 10:05AM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2190-9-2**] 10:05AM   WBC-8.4 RBC-3.54* HGB-10.4* HCT-33.2* MCV-94
MCH-29.4 MCHC-31.3 RDW-16.2*
[**2190-9-2**] 10:05AM   NEUTS-83.3* LYMPHS-6.3* MONOS-3.7 EOS-5.7*
BASOS-1.0
[**2190-9-2**] 10:05AM   PLT COUNT-353
.
Pertinent Labs:
.
[**2190-9-3**] 07:05AM BLOOD freeCa-1.25
[**2190-9-3**] 11:17AM BLOOD Type-ART pO2-273* pCO2-26* pH-7.28*
calTCO2-13* Base XS--12
[**2190-9-14**] 03:47AM BLOOD Type-ART pO2-43* pCO2-38 pH-7.51*
calTCO2-31* Base XS-6
[**2190-9-2**] 10:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2190-9-18**] 05:47AM BLOOD CRP-31.1*
[**2190-9-5**] 06:00AM BLOOD T4-3.4*
[**2190-9-4**] 05:45AM BLOOD TSH-8.0*
[**2190-9-3**] 06:00AM BLOOD Ammonia-34
[**2190-9-7**] 06:00AM BLOOD Triglyc-151*
[**2190-9-3**] 06:00AM BLOOD VitB12-272 Folate-5.3
.
Discharge Labs:
.
[**2190-9-20**] 06:00AM BLOOD WBC-6.5 RBC-3.23* Hgb-9.8* Hct-28.7*
MCV-89 MCH-30.2 MCHC-34.0 RDW-15.2 Plt Ct-375
[**2190-9-20**] 06:00AM BLOOD Plt Ct-375
[**2190-9-20**] 02:00PM BLOOD Glucose-121* UreaN-49* Creat-1.3* Na-135
K-5.3* Cl-99 HCO3-26 AnGap-15
[**2190-9-20**] 02:00PM BLOOD Calcium-10.1 Phos-4.2 Mg-2.2
.
MICRO/PATH:
.
Blood culture [**9-2**]: No growth
Abscess Culture [**9-2**]: Pseudomonas Aeruginosa pan-sensitive
Blood culture x 2 [**9-4**]: No growth
Urine Culture [**9-4**]: Yeast 10k-100k orgs/ml
Stool Cdiff [**9-6**]: Negative
Stool Cdiff [**9-7**]: Negative
MRSA Screen [**9-8**]: Negative
Urine Culture [**9-10**]: No growth
Urine Culture [**9-14**]: No growth
Urine Legionella Antigen [**9-14**]: Negative
Stool Cdiff [**9-14**]: Negative
.
IMAGING:
.
Chest Portable [**9-14**]
IMPRESSION:
1.Mild interval progression of pulmonary edema
2.New left upper lung opacity which could potentially represent
a focus of
consolidation or may be from the summation shadows of the ribs
and scapula. Lateral radiograph is suggested for further
evaluation.
3. Unchanged bilateral minimal pleural effusions
.
CXR PA/LAT [**9-2**]
IMPRESSION:
1. Right PICC terminates in the right neck - likely within the
internal
jugular vein and should be repositioned.
2. Mild congestive heart failure. No pneumonia.
.
CT Head [**9-2**]
1. No acute intracranial hemorrhage. Note that MRI is more
sensitive for
detection of metastases and mass lesions.
2. Bifrontal prominence of CSF space could reflect bifrontal
atrophy, chronic small subdural hematomas, or CSF hygromas.
.
MR [**Name13 (STitle) 430**] [**9-4**]
1. No acute intracranial abnormality; specifically, there is no
evidence of an acute ischemic event.
2. No secondary finding to specifically suggest intracranial
metastatic
disease on this non-enhanced examination.
3. Relatively marked symmetric prominence of the bifrontal
extra-axial CSF
spaces, most likely representing severe bifrontal cortical
atrophy.
.
CT Chest [**9-3**]
1. Extensive irregularity and sclerosis of the sternum since the
prior study, concerning for progression of osteomyelitis with
soft tissue stranding anterior to the sternum.
2. No focal fluid collections or tracking soft tissue air with
soft tissue
inflammatory changes in the left greater than right chest wall
possibly
reflecting associated soft tissue infection.
3. Right greater than left pleural effusions.
4. Right middle lobe nodules similar in size, although perhaps
slightly
[**Hospital1 2824**] than on the prior study, can be followed in three to six
months with a followup chest CTA.
5. Mild pulmonary edema with small bilateral effusions.
6. Lucent lesion in the left glenoid could reflect degenerative
subchondral cystic change. However, metastasis cannot be fully
excluded.
.
CXR [**9-7**]
Pulmonary edema, if present, is mild. There is substantial
opacification of the right lower lung, probably collapsed. On
the left, there may be a moderate pleural effusion and basal
consolidation is not excluded. Heart is mildly-to-moderately
enlarged, and there is mild mediastinal venous engorgement.
Right PICC line ends in the upper right atrium.
.
CXR [**9-9**]
Mild left lower lobe atelectasis or pneumonia. Vascular
congestion has improved.
.
ECHO [**9-3**]
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears grossly normal with
trivial mitral regurgitation. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal study. No valvular
pathology or pathologic flow identified.
.
RENAL US [**9-3**]
No hydroureteronephrosis or renal stone.
.
LUB [**9-3**]
Unremarkable abdominal x-ray. No evidence of free air.
.

Brief Hospital Course:
This is a 73 yo WF with a PMHx of breast cancer with new primary
diagnosed [**2-/2190**] s/p bialteral mastecomy c/b sternal and rib
osteomyelitis who was on IV abx at home who now p/w altered
mental status and decreased ability to abulate with a walker and
persistent n/v, found to have 3/6 systolic murmur, ARF (Cr 1.8),
metabolic acidosis (bicarb 14), and only able to answer simple
questions with tangential thoughts.
.
Active Diagnoses:
.
#Altered mental status: The etiology of Mrs.[**Known lastname 69032**] altered
mental status was likely multifactorial but predominately a
result of delirium given her serious medical illnesses. We
tested for reversible causes of AMS including B12 and folate
levels which were wnl's, CT head which was negative for
intracranial processes, UA and urine cultures which were
negative for UTI, and reduced her doses of CNS-depressing
medications including her fentanyl patch, gabapentin, and
benadryl. We continued to treat her underlying skin/wound
infection of IV vanc and cefepime and her mental status
gradually improved until she became alert, oriented, conversant,
and demanding for discharge home.
.
#Pseudomonas osteomyelitis of chest: She remained afebrile
during the admission but had immunosuppression from
chemotherapy, metastatic disease, and malnutrition. She was
treated with IV vanc and cefepime and was followed closely by
plastics for evlauation of her wounds and removal of her wound
drains. Her urine and blood cultures remained negative
throughout admission but her wound abscess grew pan-sensitive
pseudomonas. Her TTE was negative for vegetations as well. Stool
Cdiff antigen test was negative x 2. Her infection was monitored
with weekly CRP/ESR levels which remained severely elevated.
During her admission she was switched to daptomycin and
meropenem per ID recs. She was followed closely by ID and
continued on IV antibiotics on discharge with follow-up
established in the [**Hospital **] clinic for final antibiotic course
determination to be made as an outpatient. Per the plastics
team, she will need further severe surgical debridement if she
is able to become healthy enough to tolerate such an operation
in the future.
.
#[**Last Name (un) **]: Pt with [**Last Name (un) **] that was assessed to be pre-renal or as a
result of interstitial nephritis from her IV cefepime. She had
an elevated BUN/Cr ratio and trace urine Eos. Her ACEI and home
diuretics were held and she was given good amounts of continuous
IV fluids and her Cr level fell towards baseline down to 1.3
from 2.3 earlier in her hospital course.
.
#Metabolic Acidosis, Anion Gap +: She had a widened anion gap
metabolic acidosis early in her hospital course but with a
normal lactate level thought to be related to her smoldering
pseudomonas osteomyelitis. We continued treatment of her
underlying infection and this resolved.
.
#Malnutrition: This patient was found to have low-low normal
albumin levels with a pre-albumin wnl's. She however, had
significant nausea and occasional vomiting and had difficulty
tolerating food by mouth. She was treated with TPN for much of
her admission yet as her mental status improved her nausea began
to fade and she was able to tolerate a better diet. She was
discharged home without TPN as it was determined that her risk
of developing further infection given her widespread pseudomonal
osteomyelitis was quite high and her appetite and PO intake was
rapidly improving.
.
ICU Course:
Mrs. [**Known lastname **], a 73 year old lady with Pseumonal osteomyelitis and
soft tissue infection s/p breast resections, was transferred to
the East ICU on [**9-8**] after developing respiratory distress on
the floor with a concern for anaphylaxis.  Her ICU course was
also complicated by hypertension, acute kidney injury, altered
mental status and anemia.
.
# Respiratory Distress: Floor team was concerned that the
patient had developed anaphylaxis to meropenem, as she had
recently begun that antibiotic for treatment of her Pseudomonal
osteomyelitis and soft tissue infection.  On arrival to the ICU
however, her history, exam, labs (elevated BNP [**Numeric Identifier **]) and chest
x-ray (vascular congestion) seemed most consistent with
pulmonary edema in the setting of uncontrolled hypertension.
For her suspected allergic reaction, her meropenem was
discontinued, and she was treated with ranitidine and
albuterol/iprotropium nebulizers.  For her pulmonary edema, she
was diuresed with furosemide IV.  She responded with good UOP
and improved exam.  Her blood pressure was also controlled.
Prior to transitioning back to the floor, the patient was
challenged with meropenem and carefully monitored for signs of
anaphylaxis. She tolerated the meropenem challenge, and was
continued on meropenem along with daptomycin for treatment of
her sternal osteomyelitis. Patient acutely developed anxiety,
but [**3-17**] AMS patient was unable to explain symptoms. CE cycled
and negative; EKG without acute ST/T wave changes. CXR done at
the time consistent with pulmonary edema. She was diuresed and
given 10mg IV hydralazine and her symptoms seemed to improve.
.
# Pseudomonal Wound Infection:  Infectious Disease and Plastic
Surgery continued to follow the patient in the ICU.  She was
continued on vancomycin and cefepime for treatment of her wound
infection, until she passed the meropenem challenge.  Wound care
and dry dressings were done per the advice of the Plastic
Surgery team. On discharge from the ICU, the patient's
antibiotic regimen was meropenem and daptomycin.
.
# Hypertension:  The patient's blood pressures remained elevated
in the ICU; however, some elevation was attributed to the fact
that there was significant external pressure on her leg blood
pressure cuff.  This pressure was likely falsely elevating her
readings. Home lisinopril was held [**3-17**] elevated sCr. She was
treated with amlodipine 10mg qDay and hydralazine 10mg TID, as
well as IV furosemide for diuresis.  We tolerated leg blood
pressures of SBP 150-170, so that her kidneys would remain
well-perfused.
.
# [**Last Name (un) **]: Elevated creatinine persisted while in the ICU.  Renal
team continued to follow and believed that her urine sediment
was consistent with ATN.  Volume status, urine output, and
electrolytes were monitored, and her medications were
renally-dosed.
.
# Altered Mental Status: The patient reportedly had subacute
mental status changes at home with confusion and impaired gait
which prompted her presentation.  Several deliriogenic meds,
including Fentanyl patch, were stopped on admission to the
hospital or shortly after.  In the ICU, she continued to have
waxing and [**Doctor Last Name 688**] confusion and impaired attention consistent
with delirium. She seemed to have a better mental status with
her family present in the room. Her Ativan was changed from qHS
to [**Hospital1 **], and other delirogenic medications were avoided.
.
# Anemia: The patient's Hct was low, but stable at her recent
baseline prior to hospitalization.  Her CBC was trended and
stools Guaiac'd to monitor.
Transitional/Follow-up Issues:
-F/u w/ primary breast surgeon: will need more surgery to remove
osteomyelitis of sternum but not until she is more stable, ~6
weeks. Follow-up was set up with the ID team to tailor and
determine her final antibiotic course as an outpatient.

Medications on Admission:
1. triamterene-hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily)-will hold
2. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) grams PO DAILY (Daily).
4. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).


5. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every

6 hours).
7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for burning pain, anterior right chest.
Disp:*63 Capsule(s)* Refills:*1*
8. fentanyl 100 mcg/hr Patch 72 hr Sig: One (1)  Transdermal
Q72H (every 72 hours) as needed for cancer pain.
Disp:*10 patches* Refills:*1*
9. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) patch Transdermal

every seventy-two (72) hours as needed for cancer pain.
Disp:*10 patches* Refills:*1*
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day).
11. vancomycin in D5W 1 gram/200 mL Piggyback Sig: 1000 (1000)
mgs Intravenous Q 24H (Every 24 Hours): Last dose to be given on

[**2190-9-29**].
Disp:*7 IV bags* Refills:*6*
12. ferrous sulfate 300  mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
13. cefepime 2 gram Recon Soln Sig: Two (2) gms Injection Q8H
(every 8 hours): Last dose to be given on [**2190-9-29**].
Disp:*21 IV bags* Refills:*6*


Discharge Medications:
1. meropenem 1 gram Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours) for 15 days.
Disp:*30 Recon Soln(s)* Refills:*0*
2. daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q48H (every 48 hours) for 15 days.
Disp:*8 Recon Soln* Refills:*0*
3. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. ferrous sulfate 300  mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*1 Tablet(s)* Refills:*0*
6. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)  PO
DAILY (Daily) as needed for constipation.
Disp:*1 * Refills:*0*
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO three
times a day.
Disp:*30 Capsule(s)* Refills:*0*
8. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
10. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day) as needed for nausea.
Disp:*120 Tablet(s)* Refills:*0*
11. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
Disp:*14 Tablet, Rapid Dissolve(s)* Refills:*0*
12. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety: hold for sedation.
Disp:*7 Tablet(s)* Refills:*0*
13. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain.
Disp:*24 Tablet(s)* Refills:*0*
14. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
15. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*0*
16. hydralazine 10 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours.
Disp:*240 Tablet(s)* Refills:*0*
17. Outpatient Lab Work
Please obtain blood and check CBC and Chem 10 (including
magnesium, calcium, and phosphate)


Discharge Disposition:
Home With Service

Facility:
Critical Care Systems

Discharge Diagnosis:
Pseudomonal osteomyelitis
pulmonary edema
hypertension
acute kidney injury
delirium
anemia

Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


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

It was a pleasure caring for you. You were admitted with altered
mental status and were found to have an infection in the site of
your prior mastectomies, and kidney damage. We are treating your
infection with antibiotics and your kidney function is
improving.
.
We made the following changes to your medications:
-START Meropenem 1g IV every 12 hours
-START Daptomycin 400mg IV every 48 hours
-START Hydralazine 10mg, 2 tablets, by mouth every 6 hours
-START Amlodipine 10mg by mouth daily
-START Hydrochlorothiazide 25mg by mouth daily
-START Omeprazole 20mg by mouth daily
-START Metoclopramide 10mg by mouth four times daily as needed
for nausea
-START Zofran 8mg by mouth every eight hours as needed for
nausea
-START Compazine 10mg by mouth every six hours as needed for
nausea
-START Ativan 0.5mg by mouth every four hours as needed for
anxiety
-START Dilaudid 2mg by mouth every four hours as needed for pain
-STOP Triamterene
-STOP Lisinopril
-STOP Gabapentin
-STOP Fentanyl patches
-STOP Cefepime
-STOP Vancomycin

Please make sure to eat as much as you can by mouth to keep up
your nutritional status. Also, please make sure to follow up
with your primary care doctor sometime this week for repeated
lab work and follow-up. You will have to discuss with him the
possibility of returning to your original blood pressure
medications once your kidney function improves. Please also
continue your IV antibitoics until your appointment with Dr.
[**Last Name (STitle) **] on [**10-5**]. We wish you a speedy recovery.

Followup Instructions:
Department: INFECTIOUS DISEASE
When: TUESDAY [**2190-10-5**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4593**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST
Best Parking: [**Hospital Ward Name **] Garage

Name:[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 97917**],MD
[**Last Name (Titles) 90499**]: Primary CAre
Location: PERSONAL MDS, LLC
Address: [**Location (un) **] [**Apartment Address(1) 97918**], [**Location (un) **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 95663**]
When: [**Last Name (LF) 766**], [**9-27**] at 10:30am



Completed by:[**2190-10-12**]
{'Other postoperative infection,Nutritional marasmus,Acute kidney failure with lesion of tubular necrosis,Acute glomerulonephritis with other specified pathological lesion in kidney,Unspecified osteomyelitis, other specified sites,Acidosis,Delirium due to conditions classified elsewhere,Pulmonary congestion and hypostasis,Other pulmonary insufficiency, not elsewhere classified,Mechanical complication due to other implant and internal device, not elsewhere classified,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Unspecified essential hypertension,Nausea with vomiting,Adult failure to thrive,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Pressure ulcer, lower back,Anemia of other chronic disease,Arthropathy, unspecified, site unspecified,Anxiety state, unspecified,Personal history of malignant neoplasm of breast,Personal history of irradiation, presenting hazards to health,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Other specified antibiotics causing adverse effects in therapeutic use,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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: This is a 73 yo WF with a PMHx of breast cancer originally
diagnosed in [**2160**] with recurrence 6 months ago, s/p recent
bilateral mastectomy c/b infection and removal of expanders, now
with pseudomonas osteomyelitis who now p/f home with subacute
changes in MS and increased problems ambulating.
.
The patient was discharged for the plastic surgery service about
2 months ago for surgical treatment for complications related to
her bilateral mastetomy.  She was re-admitted several weeks ago
for a delayed closure of her wounds.  Her most recent tissues
culture from her chest grew pan-sensitive pseudomonas.  She is
on vancomycin and cefipme therpay, end date is [**2190-9-29**].  The
patient had been at home for the last several weeks and the
family notes a slow decline in mental functioning.  They report
she is slower to answer questions and has a poor attention span.
 They thinks her metal function started to decline noticably as
she was diagnosed with her second breast cancer in 2/[**2190**].  They
did note that she has some level of forgetfulness at baseline.
The day of admission, the patietn had decreased ability to
ambulate with a walked like she had been able to previously, so
they presented to the hospital.  They denied falls and the
patietn denies dysequilibrium or vertigo.  The patient has had
problems taking in po [**3-17**] to increased nausea and vomiting of
clear liquid.  The patient family notes she is on many
medications and that her pain medications and reglan may have
been changed recently.  Per the ED notes, reglan was added
recently.
.
In the ED they got a HCT which was negative for acute processes
and a CXR that was negative except for her picc was in her RIJ.
The patients labs were signifcant for acidosis with a bicarb of
14, a normal lactate and a creatinine of 1.8.  There the patient
was AAOX2.

MEDICAL HISTORY: PMH:
1) Left breast cancer [**2160**]
-carcinoma of the left breast diagnosed in [**2160**]
-At that time, she was treated with breast conserving surgery
including an axillary dissection, chemotherapy, and adjuvant
radiation therapy.
-She has had no further problems with her breast until [**2-/2190**]
when Ms. [**Known lastname **] [**Last Name (Titles) 1834**] a wire localized right breast
biopsy for a mammographic abnormality, which demonstrated
microcalcifications associated with benign breast lobules.  An
initial core biopsy had demonstrated calcifications associated
with a sclerosed fibroadenoma and lobular carcinoma in situ
-new left breast ca, the pathology of which was the same as her
initial breast ca over 20 yrs ago
-there was 1 positive sebtinel node, Her-2 neg
-In [**Month (only) 956**] she [**Month (only) 1834**] a bilateral mastectomy
with expanders placed
-her post op course was complicated by a significant cellulitis
of both surgical sights, requiring surgical intervention and
removal of expanders
2) L squamous cell carcinoma
3) Hypertension
4) Hyperlipidemia
5) Hypothyroidism
6) Arthritis
7) Diverticulitis s/p sigmoidectomy

MEDICATION ON ADMISSION: 1. triamterene-hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily)-will hold
2. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) grams PO DAILY (Daily).
4. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

ALLERGIES: Erythromycin Base / Codeine / Bactrim DS / IV Dye, Iodine
Containing / Levofloxacin / Lipitor / Shellfish / Sulfa
(Sulfonamide Antibiotics)

PHYSICAL EXAM: Admission Physical Exam:
.
VS 98.6, 138/62, 67, 16, 97 RA
General: patient is easily arousable, AAOX3-knows she is in the
hospital, knows the month, unsure of the year, throughts are
somewhat tangential and sometiems does not answer questions
appropirately
HEENT: CN 2-12 grossly intact, mmm, no lad
Endo: no obvious thyroid masses
CV: 3/6 systolic murmur
Lungs: CTAB no wrr
Abdomen: positive bs, obese but not TTP, liver and spleen not
palpable, no rebound
Extremities:
UE:5/5 strength, pulses 2+ and equal, sensation grossly intact
LE:4+/5 strength, pulses 2+ and equal, sensation grossly intact,
2+ pitting ble edema
Neuro:
-strength equal, slightly decreased per above
-reflexes 1+ and equal
-sensation grossly intact
-unable to participate in cerebellar exam
-mental status per above, able to answer some simple questions
but is tangential

FAMILY HISTORY: negative for breast and ovarian cancer.

SOCIAL HISTORY: Cigarettes-denied, EtOH rare social. 

### Response:
{'Other postoperative infection,Nutritional marasmus,Acute kidney failure with lesion of tubular necrosis,Acute glomerulonephritis with other specified pathological lesion in kidney,Unspecified osteomyelitis, other specified sites,Acidosis,Delirium due to conditions classified elsewhere,Pulmonary congestion and hypostasis,Other pulmonary insufficiency, not elsewhere classified,Mechanical complication due to other implant and internal device, not elsewhere classified,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Unspecified essential hypertension,Nausea with vomiting,Adult failure to thrive,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Pressure ulcer, lower back,Anemia of other chronic disease,Arthropathy, unspecified, site unspecified,Anxiety state, unspecified,Personal history of malignant neoplasm of breast,Personal history of irradiation, presenting hazards to health,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Other specified antibiotics causing adverse effects in therapeutic use,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
