CHIEF COMPLAINT: confusion

PRESENT ILLNESS: 77yo woman with vent dependency, hx of COPD, sleep apnea here
with increasing confusion at NH. She takes insulin and
reportedly oral hypogylcemics in the NH. FS found to be 16 so
given 2 amps of D50. Also received 2 amps narcan. Minimal
response although BS up to 146. Reportedly still not at
baseline. Notably recent labs include INR 7.2 on [**10-8**] and
guaiac neg on [**10-11**], HCT 28 on [**10-11**].
.
Spoke with family: they report that she has been increasingly
confused and has almost daily episodes of "deep sleep." She had
her dobhoff removed 2 wks ago and has been taking very poor PO
intake. Yesterday though she was reportedly more interactive and
tolerating better PO intake.
.
pt has been on clinda and levaquin for PNA until yesterday then
[**Last Name (un) 2830**] started for "growth in sputum." She also has been treated
with PO vanco for c diff.
.
In the ED: VS: HR 88 BP 120/75 O2 100%. Exam responds to verbal
stimuli. OB negative, Head CT neg for hemorrhage or shift. CXR
showed stable pleural effusion R>L. Labs showed WBC 13 w 89%
polys, U/A largely negative, ARF (baseline Cr 0.6), HCT 23 (down
from 30s). Glucose initially 54. She was given 2 amps D50 and a
D5 gtt. Gluc fluctuated between 49 to 201. She also received
octreotide to try to reverse sulfonyurea. Her Afib was poorly
rate controlled and increased to HR 120s. Received IV dilt 10x1
and PO dilt 30 x1. BP dropped slightly to 100/50s from 130s/60s
and she received total of 1000 NS and 500 cc D5 gtt. Also
ordered for 2u pRBCs for HCT of 23.
.
Currently, she appears comfortable but does not verbalize.

MEDICAL HISTORY: OSA - failed CPAP at nights [**12-26**] agitation, trach placed [**8-27**]
COPD: PFTs [**2180**] with FEV1/FVC: 131, nl TLC
CHF: mild symmetric LVH, mild MR
CAD: documented but no studies on record
hyperchol
DM2
Gout
Afib on coumadin

MEDICATION ON ADMISSION: allopurinol 300mg daily
vit c 500mg [**Hospital1 **]
atorvastatin 20mg daily
calcium carbonate 1250mg [**Hospital1 **]
colace [**Hospital1 **]
advair [**Hospital1 **]
lasix 60mg [**Hospital1 **]
neurontin 300mg qhs
RISS
isosorbide dinitrate 10mg TID
meropenem 500mg x1 on [**10-13**]
linezolid 600mg [**Hospital1 **] ([**Date range (1) 107890**])
lopressor 50mg TID
MVI
zyprexa 2.5mg [**Hospital1 **]
potassium prn
risperdal 0.5mg [**Hospital1 **]
senna qhs
tiotropium daily
PO vanco 125 QID ([**10-8**]-planned until [**10-18**])
warfarin 2.5mg qhs
tylenol prn
albuterol prn
asa 81mg daily
bisacodyl prn
lactulose prn
magnesium prn
ntg prn
trazodone 25mg qhs
.
Allergies:
NKDA

ALLERGIES: Lisinopril

PHYSICAL EXAM: VS: 100.2 HR 117 BP 104/66 100% on FiO2 50%, R21
Vent: PS 10/5 FiO2 50%
GEN: obese, trach, nonverbal. NAD
HEENT: MMM, JVP flat, PERRLA,
CARDS: irreg, tachy 2/6 systolic murmur
LUNGS: coarse bilat with crackles R>L
ABD: obese, BS+ NT ND soft no rebound
EXT: edema. legs equal sized
NEURO: follows commands: smiles, shrugs shoulders, squeezes
hands bilat. CN: perrla, eomi, face symmetric. [**3-27**] distal upper
strength.
ACCESS: double lumen picc

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Lives at rehab. Denies tobb, etoh.
Son [**Name (NI) 107850**] is HCP [**Telephone/Fax (1) **]
Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Unspecified pleural effusion,Intestinal infection due to Clostridium difficile,Chronic diastolic heart failure,Obstructive chronic bronchitis with (acute) exacerbation,Chronic respiratory failure,Acute kidney failure, unspecified,Atrial fibrillation,Long-term (current) use of anticoagulants,Tracheostomy status,Gout, unspecified,Pure hypercholesterolemia,Obstructive sleep apnea (adult)(pediatric),Anemia, unspecified
DMII oth nt st uncntrld,Pleural effusion NOS,Int inf clstrdium dfcile,Chr diastolic hrt fail,Obs chr bronc w(ac) exac,Chronic respiratory fail,Acute kidney failure NOS,Atrial fibrillation,Long-term use anticoagul,Tracheostomy status,Gout NOS,Pure hypercholesterolem,Obstructive sleep apnea,Anemia NOS
Admission Date:  [**2184-10-14**]              Discharge Date:   [**2184-10-19**]

Date of Birth:  [**2107-1-31**]             Sex:   F

Service: MEDICINE

Allergies:
Lisinopril

Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
confusion

Major Surgical or Invasive Procedure:
mechanical ventilation via trach

History of Present Illness:
77yo woman with vent dependency, hx of COPD, sleep apnea here
with increasing confusion at NH. She takes insulin and
reportedly oral hypogylcemics in the NH. FS found to be 16 so
given 2 amps of D50. Also received 2 amps narcan. Minimal
response although BS up to 146. Reportedly still not at
baseline. Notably recent labs include INR 7.2 on [**10-8**] and
guaiac neg on [**10-11**], HCT 28 on [**10-11**].
.
Spoke with family: they report that she has been increasingly
confused and has almost daily episodes of "deep sleep." She had
her dobhoff removed 2 wks ago and has been taking very poor PO
intake. Yesterday though she was reportedly more interactive and
tolerating better PO intake.
.
pt has been on clinda and levaquin for PNA until yesterday then
[**Last Name (un) 2830**] started for "growth in sputum." She also has been treated
with PO vanco for c diff.
.
In the ED: VS: HR 88 BP 120/75 O2 100%. Exam responds to verbal
stimuli. OB negative, Head CT neg for hemorrhage or shift. CXR
showed stable pleural effusion R>L. Labs showed WBC 13 w 89%
polys, U/A largely negative, ARF (baseline Cr 0.6), HCT 23 (down
from 30s). Glucose initially 54. She was given 2 amps D50 and a
D5 gtt. Gluc fluctuated between 49 to 201. She also received
octreotide to try to reverse sulfonyurea. Her Afib was poorly
rate controlled and increased to HR 120s. Received IV dilt 10x1
and PO dilt 30 x1. BP dropped slightly to 100/50s from 130s/60s
and she received total of 1000 NS and 500 cc D5 gtt. Also
ordered for 2u pRBCs for HCT of 23.
.
Currently, she appears comfortable but does not verbalize.


Past Medical History:
OSA - failed CPAP at nights [**12-26**] agitation, trach placed [**8-27**]
COPD: PFTs [**2180**] with FEV1/FVC: 131, nl TLC
CHF: mild symmetric LVH, mild MR
CAD: documented but no studies on record
hyperchol
DM2
Gout
Afib on coumadin


Social History:
Lives at rehab. Denies tobb, etoh.
Son [**Name (NI) 107850**] is HCP [**Telephone/Fax (1) **]


Family History:
Noncontributory

Physical Exam:
VS: 100.2 HR 117 BP 104/66 100% on FiO2 50%, R21
Vent: PS 10/5 FiO2 50%
GEN: obese, trach, nonverbal. NAD
HEENT: MMM, JVP flat, PERRLA,
CARDS: irreg, tachy 2/6 systolic murmur
LUNGS: coarse bilat with crackles R>L
ABD: obese, BS+ NT ND soft no rebound
EXT: edema. legs equal sized
NEURO: follows commands: smiles, shrugs shoulders, squeezes
hands bilat. CN: perrla, eomi, face symmetric. [**3-27**] distal upper
strength.
ACCESS: double lumen picc


Pertinent Results:
EKG: afib rate of 87. nl ais, nl intervals. TW flattening V2,
otherwise no change.
.
Labs:
144 109 22
-------------< 34
3.4 25 1.4
CK: 19 -> 14
Trop-T: 0.03
Ca: 8.1
Mg: 1.9
P: 4.1
ALT: 15
AST: 18
AP: 64 Tbili: 0.4 Alb: 2.6
[**Doctor First Name **]: 19
Lip: 12
.
WBC: 12.7, 90% polys, no bands
Hct 22.4, MCV 86
Plt 241
.
PT: 16.5 PTT: 30.5 INR: 1.5
.
Hct: 22.4 -> 23.8 -> 21.9
.
TRENDS:
HCT: 22.4 - 21.9 - 24 - 26 - 26
WBC: 12.7 - 14.1 - 6.7
INR: 1.5 - 1.4
Creatinine: 1.4 - 1.0
Na 144 - 147
CK 19 - 14
Trop 0.03 - 0.04
.
Fe 113, TIBC 174, Ferritin 404
B12 628, Folate 12
Hapto 383
.
Blood gases:
[**2184-10-14**] ABG: pO2-150* pCO2-50* pH-7.31* calTCO2-26
[**2184-10-16**] ABG: pO2-67* pCO2-63* pH-7.21* calTCO2-27
[**2184-10-16**] ABG: pO2-104 pCO2-53* pH-7.27* calTCO2-25
[**2184-10-17**] VBG: pO2-40* pCO2-49* pH-7.33* calTCO2-27
[**2184-10-17**] VBG: pO2-43* pCO2-55* pH-7.30* calTCO2-28
.
[**2184-10-15**] 12:32AM BLOOD Lactate-1.3
[**2184-10-16**] 06:51AM BLOOD Lactate-1.2
.
Images:
CXR: my read: bilat effusions R>L, cardiomegaly, largely stable
from previous.
.
NON-CONTRAST HEAD CT: No hemorrhage, hydrocephalus, or shift of
normally midline structures. The [**Doctor Last Name 352**]-white matter
differentiation is preserved. No major vascular territorial
infarct is apparent. No osseous abnormality is detected. The
visualized paranasal sinuses and mastoid air cells which are
poorly pneumatized are normally aerated.
IMPRESSION: No hemorrhage.
.
[**10-16**]: RUQ u/s:
1. Cholelithiasis without evidence of acute cholecystitis.
2. Small right pleural effusion.
3. Minimal-moderate amount of abdominal ascites.
.
[**10-16**] CT Chest:
1. Multifocal bilateral pneumonia.
2. Large right pleural effusion and small left pleural effusion
in the setting of cardiomegaly consistent with moderate CHF.
3. Possible acute cholecystitis. Recommend ultrasound for futher
evaluation
.
[**10-16**] CT Head: No acute intracranial process.
.


Brief Hospital Course:
77yo Italian speaking woman with hx of OSA, obesity, afib, DM
here for worsening confusion, poor PO intake, and hypoglycemia.
Hospital course by problem:
.
# Confusion:
Ddx included hypoglycemia, sedating medications, infection,
central neuro process, malnutrition., hypercarbia.  Initially,
mental status improved with minimal intervention.  Her blood
glucose was monitored closely and infectious w/u as below.  Then
on [**10-16**], she developed increased somnulence.  Repeat head CT
negative.  ABG showed slight increase hypercarbia.  Repeat blood
cx NGTD.  We optimized her ventilation by placing her on SIMV on
[**10-16**] and her ms improved by [**10-17**] back to baseline.  We then
gradually restarted her antipsychotic medications.
.
# Resp failure:
Hx of OSA and COPD now with trach. She is reportedly on 15/5
BiPAP at night but has been recently on it all day at rehab.  In
the MICU, she was on trach collar on [**10-15**] but placed on SIMV on
[**10-16**] as above.  She then tolerated trach collar for >8h on
[**10-17**] but returned to SIMV at night.  She had mild hypercarbia
but we did not clearly believe this was cause of her delirium.
We continued her inhalers and oral care.  By [**2184-10-18**], she was
tolerating the trach mask well, when awake.  She was maintained
on SIMV when asleep at night. She was gently diuresed with PO
Lasix, and will continue this at rehab.
.
# ID:
Elevated WBC on admission and has recently been treated for many
infections.  Recent cx data from [**Hospital1 **] include sputum w
stenotrophonomas, acinetobacter, and pseudomonas.  She was
discharged from [**Hospital1 **] on [**9-1**] with cefepime and vanco to complete
course of PNA rx.  She then was on levaquin and clinda for PNA
but switched to [**Last Name (un) 2830**] on [**10-13**].  Also has hx of C. diff and MRSA
PNA.  She was also on PO vanco for  c diff.  On presentation, we
initially covered her broadly with cefepime, vanco, and PO
vanco.  Given stable resp status, we stopped antibiotics within
24h, except we continued CDiff treatment with PO flagyl. Blood
cultures remained negative.
- We did attempt thoracentesis of right sided pleural effusion
to help guage therapy.  This was unsuccessful and we were unable
to get fluid.
- A sputum culture grew Acinetobacter and Pseudomonas, with
sensitivities similar to what had been obtained at rehab.  She
had no clear infiltrate on chest CT, but given her initial
respiratory failure, we empirically began a 7-day course of
meropenem (for the Pseudomonas) and tobramycin (for the
Acinetobacter) for presumed tracheobronchitis.  Her respiratory
status immproved with these antibiotics, and she will complete a
7-day course.
****She will need trough and peak tobramycin levels drawn at
rehab to monitor for both therapeutic and toxic levels.****
- We continued PO flagyl for her C. Diff colitis; she will
continue this until 14 days after completion of all other
antibiotics.
- Lactate remained low.
.
# Anemia:
Baseline Hct 30-34, but was down to 21 on presentation. OB neg
stool but she has not been on PPI.  NGL negative.  Required 2u
PRBCs in the Emergency Dept to maintain hct >22.  Her hematocrit
remained stable in the mid-/high-20s, and no further
transfusions were needed.  Iron studies not c/w iron def anemia.
 retic count quite low suggestive of marrow suppression.
Hemolysis labs negative.
.
# Hypotension:
Baseline appears to be 130s SBP. Fluctuating here ranging from
SBP 100s to 130s on presentation.  We held her lasix and
antihypertensives and her BP stabilized within 24h.  Lasix was
resumed one day prior to discharge, with SBPs remaining in the
100s.
.
# CHF:
Right sided failure vs periph edema on exam. Previous echo here
not with profoundly depressed EF but does have some diastolic
dysfunction.  Diuretics held until [**10-17**] given BP as above.
Then she had good response to lasix.  We continued to hold her
Isordil in order to allow for diuresis with her Lasix.
.
# Cardiac; ischemia:
No new EKG changes.  Cardiac enzymes were not indicative of
active myocardial ischemia. Statin wsa continued. Isordil was
discontinued, as above.
.
# Atrial fibrillation:
We initially held her coumadin in the setting of her low
hematocrit, but this was resumed on [**10-18**].  Her goal INR is
2.0-3.0, and this will need to be monitored daily at rehab until
she is therapeutic. He metoprolol was uptitrated since she was
having bursts of atrial fibrillation with RVR.
.
# ARF: likely prerenal and intravascularly dry. Improved with
gentle hydration.
.
# DM2: as above.
No oral agents. Given low-dose sliding scale. Continued
neurontin for neuropathic pain
.
# Hyperlipidemia:
No active issues. Statin was continued.
.
# Gout:
Does not report any joint pain at this time, no evidence of
acute flair. Allopurinol continued.
.
# Nutrition:
Prior to admission, she had had no tube feeds for 2wks. Speech
and swallow eval suggested ground, thickened diet, but she was
not taking adequate POs.  An NG tube was placed so that tube
feeds and medications could be administered.  She will continue
the tube feeds at rehab until she is able to sustain her
nutrition by mouth.
.
# PPx: bowel regimen, PPI, SQ Heparin
.
# Access: PICC line
.
# Communication: Son - [**Name (NI) 107850**] ([**Name2 (NI) **]) [**Telephone/Fax (1) 107848**] who is health
care proxy/power of attorney
.
# Code status: FULL, discussed at length on admission w son
.
# Dispo: She is being discharged to [**Hospital **] rehab for
continuation of her above antibiotics, continued respiratory
support for her chronic obstructive sleep apnea, and for
continued nutritional and physical support, as above.

Medications on Admission:
allopurinol 300mg daily
vit c 500mg [**Hospital1 **]
atorvastatin 20mg daily
calcium carbonate 1250mg [**Hospital1 **]
colace [**Hospital1 **]
advair [**Hospital1 **]
lasix 60mg [**Hospital1 **]
neurontin 300mg qhs
RISS
isosorbide dinitrate 10mg TID
meropenem 500mg x1 on [**10-13**]
linezolid 600mg [**Hospital1 **] ([**Date range (1) 107890**])
lopressor 50mg TID
MVI
zyprexa 2.5mg [**Hospital1 **]
potassium prn
risperdal 0.5mg [**Hospital1 **]
senna qhs
tiotropium daily
PO vanco 125 QID ([**10-8**]-planned until [**10-18**])
warfarin 2.5mg qhs
tylenol prn
albuterol prn
asa 81mg daily
bisacodyl prn
lactulose prn
magnesium prn
ntg prn
trazodone 25mg qhs
.
Allergies:
NKDA


Discharge Medications:
1. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.

2. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Atorvastatin 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Insulin Regular Human 100 unit/mL Solution Sig: as directed
units Injection ASDIR (AS DIRECTED): per sliding scale.
5. Meropenem 1 gram Recon Soln Sig: Five Hundred (500) mg
Intravenous Q8H (every 8 hours) for 6 days.
6. Pantoprazole 40 mg Recon Soln Sig: Forty (40) mg Intravenous
Q12H (every 12 hours).
7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
9. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 20 days.
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
13. Hexavitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
15. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
16. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q6H (every 6 hours) as needed.
17. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4)
Puff Inhalation QID (4 times a day).
18. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
19. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
20. Risperidone 0.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
21. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN.  Inspect site every shift.
22. Calcium Carbonate 250 mg Tablet, Chewable Sig: Five (5)
Tablet, Chewable PO twice a day.
23. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) inhalation Inhalation once a day.
24. Outpatient Lab Work
Please check daily INR until patient is therapeutic on Coumadin
(goal INR [**12-27**]).
25. Outpatient Lab Work
Please draw peak and trough level for tobramycin and adjust dose
apprpriately.
26. Tobramycin Sulfate 40 mg/mL Solution Sig: One Hundred (100)
mg Injection Q8H (every 8 hours) for 6 days.


Discharge Disposition:
Extended Care

Discharge Diagnosis:
Primary diagnoses:
hypoglycemia
delirium
respiratory failure
anasarca

Secondary diagnoses:
obstructive sleep apnea, status-post tracheostomy
chronic obstructive pulmonary disease
chronic diastolic congestive heart failure
atrial fibrillation
anemia
hyperlipidemia


Discharge Condition:
Stable


Discharge Instructions:
You were admitted to the hospital with confusion and low blood
sugars.  Your confusion resolved with repletion of your blood
sugar, and your blood sugars have remained normal.  We have
started you on a course of IV antibiotics for treatment of
suspected tracheobronchitis; you will complete a 7-day course.
You received a blood transfusion to treat your anemia, and your
blood counts have remained stable.  You have been receiving
nutrition through a nasogastric tube. As you continue to
recover, your rehab facility can attempt to give you nutrition
by mouth.

It is very important that you continue to use the ventilator
when you're asleep at night.  You can use the trach collar
during the day.  As you regain your strength, the nasogastric
tube can eventually be removed as you are able to take food and
pills by mouth.

Followup Instructions:
You should call the office of your Primary Care Physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) **], at [**Telephone/Fax (1) 1579**] to schedule follow up within the
next 2 weeks.





Name:  [**Known lastname 17629**],[**Known firstname 17630**]                Unit No:   [**Numeric Identifier 17631**]

Admission Date:  [**2184-10-14**]              Discharge Date:   [**2184-10-19**]

Date of Birth:  [**2107-1-31**]             Sex:   F

Service: MEDICINE

Allergies:
Lisinopril

Attending:[**First Name3 (LF) 2969**]
Addendum:
Sputum culture data added to discharge summary.

Pertinent Results:
[**2184-10-15**] 1:16 am SPUTUM     Site: EXPECTORATED
      Source: Expectorated.

   GRAM STAIN (Final [**2184-10-15**]):
      [**9-16**] PMNs and <10 epithelial cells/100X field.
      2+   (1-5 per 1000X FIELD):   GRAM NEGATIVE ROD(S).

   RESPIRATORY CULTURE (Preliminary):
      OROPHARYNGEAL FLORA ABSENT.
      ACINETOBACTER BAUMANNII.    MODERATE GROWTH.
         "Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
         used, since therapeutic efficacy relies on intrinsic
activity of
         the sulbactam component".
      PSEUDOMONAS AERUGINOSA.    MODERATE GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ACINETOBACTER BAUMANNII
                             |          PSEUDOMONAS AERUGINOSA
                             |          |
AMPICILLIN/SULBACTAM--    16 I
CEFEPIME--------------  =>64 R        8 S
CEFTAZIDIME-----------  =>64 R        4 S
CIPROFLOXACIN---------   =>4 R      =>4 R
GENTAMICIN------------     4 S     =>16 R
IMIPENEM--------------  =>16 R      <=1 S
MEROPENEM-------------                1 S
PIPERACILLIN----------               32 S
PIPERACILLIN/TAZO-----               16 S
TOBRAMYCIN------------   <=1 S     =>16 R
TRIMETHOPRIM/SULFA----  =>16 R


Discharge Disposition:
Extended Care

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2970**] MD [**MD Number(2) 2971**]

Completed by:[**2184-10-19**]
{'Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Unspecified pleural effusion,Intestinal infection due to Clostridium difficile,Chronic diastolic heart failure,Obstructive chronic bronchitis with (acute) exacerbation,Chronic respiratory failure,Acute kidney failure, unspecified,Atrial fibrillation,Long-term (current) use of anticoagulants,Tracheostomy status,Gout, unspecified,Pure hypercholesterolemia,Obstructive sleep apnea (adult)(pediatric),Anemia, unspecified'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: confusion

PRESENT ILLNESS: 77yo woman with vent dependency, hx of COPD, sleep apnea here
with increasing confusion at NH. She takes insulin and
reportedly oral hypogylcemics in the NH. FS found to be 16 so
given 2 amps of D50. Also received 2 amps narcan. Minimal
response although BS up to 146. Reportedly still not at
baseline. Notably recent labs include INR 7.2 on [**10-8**] and
guaiac neg on [**10-11**], HCT 28 on [**10-11**].
.
Spoke with family: they report that she has been increasingly
confused and has almost daily episodes of "deep sleep." She had
her dobhoff removed 2 wks ago and has been taking very poor PO
intake. Yesterday though she was reportedly more interactive and
tolerating better PO intake.
.
pt has been on clinda and levaquin for PNA until yesterday then
[**Last Name (un) 2830**] started for "growth in sputum." She also has been treated
with PO vanco for c diff.
.
In the ED: VS: HR 88 BP 120/75 O2 100%. Exam responds to verbal
stimuli. OB negative, Head CT neg for hemorrhage or shift. CXR
showed stable pleural effusion R>L. Labs showed WBC 13 w 89%
polys, U/A largely negative, ARF (baseline Cr 0.6), HCT 23 (down
from 30s). Glucose initially 54. She was given 2 amps D50 and a
D5 gtt. Gluc fluctuated between 49 to 201. She also received
octreotide to try to reverse sulfonyurea. Her Afib was poorly
rate controlled and increased to HR 120s. Received IV dilt 10x1
and PO dilt 30 x1. BP dropped slightly to 100/50s from 130s/60s
and she received total of 1000 NS and 500 cc D5 gtt. Also
ordered for 2u pRBCs for HCT of 23.
.
Currently, she appears comfortable but does not verbalize.

MEDICAL HISTORY: OSA - failed CPAP at nights [**12-26**] agitation, trach placed [**8-27**]
COPD: PFTs [**2180**] with FEV1/FVC: 131, nl TLC
CHF: mild symmetric LVH, mild MR
CAD: documented but no studies on record
hyperchol
DM2
Gout
Afib on coumadin

MEDICATION ON ADMISSION: allopurinol 300mg daily
vit c 500mg [**Hospital1 **]
atorvastatin 20mg daily
calcium carbonate 1250mg [**Hospital1 **]
colace [**Hospital1 **]
advair [**Hospital1 **]
lasix 60mg [**Hospital1 **]
neurontin 300mg qhs
RISS
isosorbide dinitrate 10mg TID
meropenem 500mg x1 on [**10-13**]
linezolid 600mg [**Hospital1 **] ([**Date range (1) 107890**])
lopressor 50mg TID
MVI
zyprexa 2.5mg [**Hospital1 **]
potassium prn
risperdal 0.5mg [**Hospital1 **]
senna qhs
tiotropium daily
PO vanco 125 QID ([**10-8**]-planned until [**10-18**])
warfarin 2.5mg qhs
tylenol prn
albuterol prn
asa 81mg daily
bisacodyl prn
lactulose prn
magnesium prn
ntg prn
trazodone 25mg qhs
.
Allergies:
NKDA

ALLERGIES: Lisinopril

PHYSICAL EXAM: VS: 100.2 HR 117 BP 104/66 100% on FiO2 50%, R21
Vent: PS 10/5 FiO2 50%
GEN: obese, trach, nonverbal. NAD
HEENT: MMM, JVP flat, PERRLA,
CARDS: irreg, tachy 2/6 systolic murmur
LUNGS: coarse bilat with crackles R>L
ABD: obese, BS+ NT ND soft no rebound
EXT: edema. legs equal sized
NEURO: follows commands: smiles, shrugs shoulders, squeezes
hands bilat. CN: perrla, eomi, face symmetric. [**3-27**] distal upper
strength.
ACCESS: double lumen picc

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Lives at rehab. Denies tobb, etoh.
Son [**Name (NI) 107850**] is HCP [**Telephone/Fax (1) **] 

### Response:
{'Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Unspecified pleural effusion,Intestinal infection due to Clostridium difficile,Chronic diastolic heart failure,Obstructive chronic bronchitis with (acute) exacerbation,Chronic respiratory failure,Acute kidney failure, unspecified,Atrial fibrillation,Long-term (current) use of anticoagulants,Tracheostomy status,Gout, unspecified,Pure hypercholesterolemia,Obstructive sleep apnea (adult)(pediatric),Anemia, unspecified'}
