CHIEF COMPLAINT: Hypercarbic Respiratory Failure

PRESENT ILLNESS: Ms. [**Known lastname **] is a 53 y.o. woman with PMH of T1-T2 paraplegia,
frequent admissions for PNA and UTI, and COPD (on 1.5-2L NC at
home), who presented with acute mental status changes and
changes in her breathing status. She had dinner with her friend
and one of her primary caregivers, [**Name (NI) **]. She was having some
trouble eating - her friend notes chronic trouble eating/food
sticking in her throat. 45 minutes after eating, the friend went
back to her room where she found her vomiting and not feeling
well. She put her friend in bed and gave her 1.5 mg of
clonazepam. 30 minutes later she found her to be lethargic with
O2sat 83-84% on 2L NC (usually 90-92%).  Given this, her friend
drove her to the [**Hospital1 18**] [**Name (NI) **] from [**Location (un) 1475**] while keeping her on
8L NC.

MEDICAL HISTORY: # T1 to T2 paraplegia status post a motor vehicle accident.
# Recurrent pneumonia (followed by pulm - Last [**2149-4-9**])
- Per pulm, recurrent pneumonia likely from pulmonary toilet
issues secondary to neuromuscular disease with improvement with
consistent and aggressive bronchopulmonary therapy.
- Prior sputum cultures + for MRSA, pan-sensitive Klebsiella,
and Pseudomonas.
# Recurrent UTIs in the setting of urinary retention requiring
straight catheterization
# COPD
# hepatitis C
# anxiety
# DVT in [**2142**] -IVC filter placed in [**2142**]
# Pulmonary nodules
# Hypothyroidism
# Chronic pain
# Chronic gastritis
# Anemia of chronic disease
# S/p PEA arrest during hospitalization in [**2147-10-3**]

MEDICATION ON ADMISSION: 1. albuterol NEB Q6hr PRN dyspnea
2. baclofen 20 mg Qam, 10 mg 4PM, 20 mg Qpm
3. citalopram 40 mg PO DAILY
4. ipratropium Q6hr PRN dyspnea
5. levothyroxine 112 mcg PO DAILY
6. clonazepam 1 mg PO TID PRN (takes 2 mg QHS)
7. lidocaine patch - feet and shoulder blade
8. omeprazole 20 mg [**Hospital1 **]
9. oxybutynin chloride 10 mg Qam, 5 mg 4pm, 10mg QHS
10.Polyethylene Glycol 17g QD
11.gabapentin 600 mg TID
12.simvastatin 10 mg PO DAILY
13.sucralfate 1 gram TID
14.trazodone 100 mg QHS PRN anxiety.

ALLERGIES: Ativan

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
Vitals:  T 96.8, HR 89, BP 141/106, RR 13, 100% on ventilator
General: somnolent but arousable
HEENT: Sclera anicteric, oropharynx clear, EOMI, PERRL,  MMM
Neck: JVP not appreciated
CV: RRR, soft S1/S2, no murmurs, rubs, gallops
Lungs: diffuse rhonchi and adventitial sounds
Abdomen: soft, non-tender, obese, BS+
GU: Foley in place
Ext: cool but perfused, trace/1+ pulses in LE b/l, trace/1+ LE
edema to ankles
Neuro: arousable and oriented to self; detailed exam deferred

FAMILY HISTORY: Mom - lung cancer
Dad - healthy

SOCIAL HISTORY: Lives at home with husband and 2 adolescent children.
- Tobacco: 35-pack-years, has tried to quit but smokes
intermittently - started again 2 weeks ago.
- Alcohol: Denies.
- Illicits: Denies.
Other septicemia due to gram-negative organisms,Acute respiratory failure,Septic shock,Pneumonitis due to inhalation of food or vomitus,Paraplegia,Late effect of spinal cord injury,Delirium due to conditions classified elsewhere,Urinary tract infection, site not specified,Late effects of motor vehicle accident,Personal history, urinary (tract) infection,Tobacco use disorder,Opioid type dependence, unspecified,Unspecified viral hepatitis C without hepatic coma,Unspecified acquired hypothyroidism,Personal history of venous thrombosis and embolism,Infection with drug-resistant microorganisms, unspecified, with multiple drug resistance,Chronic airway obstruction, not elsewhere classified,Constipation, unspecified,Retention of urine, unspecified,Anemia of other chronic disease,Severe sepsis,Chronic pain due to trauma,Carrier or suspected carrier of other specified bacterial diseases
Gram-neg septicemia NEC,Acute respiratry failure,Septic shock,Food/vomit pneumonitis,Paraplegia NOS,Late eff spinal cord inj,Delirium d/t other cond,Urin tract infection NOS,Late eff motor vehic acc,Personal history UTI,Tobacco use disorder,Opioid dependence-unspec,Hpt C w/o hepat coma NOS,Hypothyroidism NOS,Hx-ven thrombosis/embols,Infc mcrg drgrst mult,Chr airway obstruct NEC,Constipation NOS,Retention urine NOS,Anemia-other chronic dis,Severe sepsis,Chronc pain d/t trauma,Bacteria dis carrier NEC
Admission Date:  [**2150-8-11**]              Discharge Date:   [**2150-8-20**]

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

Service: MEDICINE

Allergies:
Ativan

Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Hypercarbic Respiratory Failure

Major Surgical or Invasive Procedure:
Endotracheal intubation
Arterial line


History of Present Illness:
Ms. [**Known lastname **] is a 53 y.o. woman with PMH of T1-T2 paraplegia,
frequent admissions for PNA and UTI, and COPD (on 1.5-2L NC at
home), who presented with acute mental status changes and
changes in her breathing status. She had dinner with her friend
and one of her primary caregivers, [**Name (NI) **]. She was having some
trouble eating - her friend notes chronic trouble eating/food
sticking in her throat. 45 minutes after eating, the friend went
back to her room where she found her vomiting and not feeling
well. She put her friend in bed and gave her 1.5 mg of
clonazepam. 30 minutes later she found her to be lethargic with
O2sat 83-84% on 2L NC (usually 90-92%).  Given this, her friend
drove her to the [**Hospital1 18**] [**Name (NI) **] from [**Location (un) 1475**] while keeping her on
8L NC.

Her friend noted that she got poorer Chest PT over the weekend
and resumed smoking over the last two weeks. She denied noticing
any increase in cough, SOB, dysuria, incontinence, or cloudy
urine over the past few days.

She recently was given a narcotic agreement w/ her PCP [**Last Name (NamePattern4) **].
[**Last Name (STitle) 665**] who noted that he would not be prescribing her narcotics
anymore since he felt her burning lower extremity pain was
neuropathic in nature, not c/w her pain from her vehicle
accident, and would be better treated w/ gabapentin rather than
narcotics.

Upon arrival in the ED, initial VS were: T 34.6, HR 110, BP
128/102 or 156/108, RR 8, O2sat to 80s. She had blue lips and
was breathing at RR 8. She was given Narcan and became
arousable. However, 40 minutes later she became somnolent,
de-satted to the 80s, and was unresponsive to a 2nd dose of
Narcan.

She was intubated, which was reportedly difficult. Aspirate was
suctioned out. She was given a dose of levaquin. A U/A was
significant for negative nitrites, large leuks, negative blood,
negative glucose, negative ketones, 2 RBCs, 152 WBCs, few
bacteria, and 1 epi.  Utox was positive for benzos and
methadone, but she did get benzos with intubation. On an ABG
following her intubation, pH 7.28/pCO2 60/pO2 370/HCO3 29.

On arrival to the MICU, VS: T 96.8, HR 89, BP 141/106, RR 13,
100% on ventilator. She was started on vanc/[**Last Name (un) 2830**] and given a 1L
NS bolus given that her BP fell to SBP 80s.

Past Medical History:
# T1 to T2 paraplegia status post a motor vehicle accident.
# Recurrent pneumonia (followed by pulm - Last [**2149-4-9**])
- Per pulm, recurrent pneumonia likely from pulmonary toilet
issues secondary to neuromuscular disease with improvement with
consistent and aggressive bronchopulmonary therapy.
- Prior sputum cultures + for MRSA, pan-sensitive Klebsiella,
and Pseudomonas.
# Recurrent UTIs in the setting of urinary retention requiring
straight catheterization
# COPD
# hepatitis C
# anxiety
# DVT in [**2142**] -IVC filter placed in [**2142**]
# Pulmonary nodules
# Hypothyroidism
# Chronic pain
# Chronic gastritis
# Anemia of chronic disease
# S/p PEA arrest during hospitalization in [**2147-10-3**]


Social History:
Lives at home with husband and 2 adolescent children.
- Tobacco: 35-pack-years, has tried to quit but smokes
intermittently - started again 2 weeks ago.
- Alcohol: Denies.
- Illicits: Denies.


Family History:
Mom - lung cancer
Dad - healthy

Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals:  T 96.8, HR 89, BP 141/106, RR 13, 100% on ventilator
General: somnolent but arousable
HEENT: Sclera anicteric, oropharynx clear, EOMI, PERRL,  MMM
Neck: JVP not appreciated
CV: RRR, soft S1/S2, no murmurs, rubs, gallops
Lungs: diffuse rhonchi and adventitial sounds
Abdomen: soft, non-tender, obese, BS+
GU: Foley in place
Ext: cool but perfused, trace/1+ pulses in LE b/l, trace/1+ LE
edema to ankles
Neuro: arousable and oriented to self; detailed exam deferred

DISCHARGE PHYSICAL EXAM:
Vitals: T 98.7F, BP 137/77, HR 83, RR 20, 96%3L NC
General: A&OX3, NAD
HEENT: Sclera anicteric, oropharynx clear, EOMI, PERRL,  MMM
Neck: JVP not appreciated
CV: RRR, soft S1/S2, no murmurs, rubs, gallops
Lungs: diffuse rhonchi over R lung fields
Abdomen: soft, non-tender, obese, BS+
Ext: cool but well perfused, trace/1+ pulses in BLE with trace
edema to ankles in BLE
Neuro: A&Ox3, CNII-XII grossly intact, 5/5 strength in BUE, 0/5
strength in BLE


Pertinent Results:
ADMISSION LABS:
[**2150-8-11**] 12:01AM BLOOD WBC-7.9 RBC-3.98* Hgb-10.8* Hct-34.5*
MCV-87 MCH-27.0 MCHC-31.2 RDW-16.1* Plt Ct-145*
[**2150-8-11**] 12:01AM BLOOD PT-11.7 PTT-37.5* INR(PT)-1.1
[**2150-8-11**] 12:01AM BLOOD Fibrino-401*
[**2150-8-12**] 05:51AM BLOOD Glucose-94 UreaN-8 Creat-0.3* Na-142
K-3.0* Cl-112* HCO3-21* AnGap-12
[**2150-8-11**] 12:01AM BLOOD Lipase-23
[**2150-8-12**] 05:51AM BLOOD Calcium-7.9* Phos-1.6* Mg-1.6
[**2150-8-11**] 12:01AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2150-8-11**] 01:53AM BLOOD Type-ART Temp-34.6 Rates-14/ Tidal V-450
PEEP-5 FiO2-100 pO2-370* pCO2-60* pH-7.28* calTCO2-29 Base XS-0
AADO2-284 REQ O2-54 -ASSIST/CON Intubat-INTUBATED
[**2150-8-11**] 12:02AM BLOOD Glucose-126* Lactate-0.6 Na-142 K-4.1
Cl-99 calHCO3-35*

DISCHARGE LABS:
[**2150-8-20**] 05:25AM BLOOD WBC-6.2 RBC-3.35* Hgb-8.8* Hct-28.8*
MCV-86 MCH-26.4* MCHC-30.7* RDW-16.3* Plt Ct-282
[**2150-8-20**] 05:25AM BLOOD Glucose-83 UreaN-7 Creat-0.4 Na-148*
K-4.0 Cl-106 HCO3-33* AnGap-13
[**2150-8-20**] 05:25AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.2

PERTINENT MICRO:
[**2150-8-18**] BLOOD CULTURE Blood Culture, Routine-PENDING, no
growth at discharge
[**2150-8-15**] BLOOD CULTURE Blood Culture, Routine-PENDING, no
growth at discharge
[**2150-8-11**] BLOOD CULTURE Blood Culture, Routine-FINAL NEG
[**2150-8-11**] BLOOD CULTURE Blood Culture, Routine-FINAL NEG

[**2150-8-15**] URINE URINE CULTURE-FINAL {YEAST}
[**2150-8-14**] URINE Legionella Urinary Antigen -FINAL NEG
[**2150-8-13**] URINE Legionella Urinary Antigen -FINAL NEG
[**2150-8-11**] URINE URINE CULTURE-FINAL {PROTEUS MIRABILIS}

[**2150-8-13**] 10:45 am SPUTUM      Source: Endotracheal.
   GRAM STAIN (Final [**2150-8-13**]):
      >25 PMNs and <10 epithelial cells/100X field.
      1+    (<1 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.
   RESPIRATORY CULTURE (Final [**2150-8-16**]):
      Commensal Respiratory Flora Absent.
      YEAST.    SPARSE GROWTH.
      STAPH AUREUS COAG +.    SPARSE GROWTH OF TWO COLONIAL
MORPHOLOGIES.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations.

         Rifampin should not be used alone for therapy.

                              SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------   =>8 R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------     1 S

   LEGIONELLA CULTURE (Preliminary):    NO LEGIONELLA ISOLATED.
   FUNGAL CULTURE (Preliminary):
      YEAST.    OF TWO COLONIAL MORPHOLOGIES.
   ACID FAST SMEAR (Final [**2150-8-14**]):
      NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
   ACID FAST CULTURE (Preliminary):    NO MYCOBACTERIA ISOLATED.


PERTINENT IMAGING:
pCXR [**2150-8-11**]
FRONTAL CHEST RADIOGRAPH:
The patient is slightly rotated.  A right-sided central line
terminates at the low SVC.  The heart is mildly enlarged.  The
central pulmonary vessels are engorged, and mild pulmonary edema
is present.  This is not significantly changed since the [**2150-6-18**] examination.  There is a new right base opacity concerning
for consolidation.  There is no pneumothorax or large pleural
effusion.  Old right-sided rib fractures are present.
IMPRESSION:
1.  New right basilar opacity may represent a consolidation.
2.  Unchanged mild cariomegaly, pulmonary vascular congestion,
and
interstitial edema.

Brief Hospital Course:
53 y.o. woman with history of T1/T2 paraplegia s/p MVA, frequent
PNA/UTIs who presented with unresponsiveness and apnea requiring
mechanical ventilation and was found to have a RLL pneumonia and
proteus UTI, complicated by altered mental status associated
with sedating medications as well as septic shock requiring
pressors in the MICU.

#) RLL pneumonia:
Per witness, patient reportedly vomited and then became
lethargic/unresponsive after being administered 1.5 mg
clonazepam, with desaturation to 80s on baseline 2L NC. CXR on
admission with RLL opacity highly suspicious for aspiration
pneumonia or pre-existing pneumonia. Patient requiried
intubation and mechanical ventilation in the MICU this admission
due to persistent unresponiveness and hypoxia on admission after
transient response to narcan. If pneumonia were pre-existing,
most likely culprit would be strep pneumo, but if aspiration
pneumonia then respiratory distress likely [**3-5**] pneumonitis, with
polymicrobial infection possibly prevented with 8 day course of
Vancomycin/Meropenem, recieved four days of ciprofloxacin.
Respiratory status improved and patient was extubated after
seven days. Sputum cultures grew staph aureus, possibly
reflective of infection vs. colonization.
-Blood cultures from [**8-15**] and [**2150-8-18**] pending at time of
discharge

#) Proteus mirabilis UTI:
On [**2150-7-30**] she had cloudy urine and increased incontinence for
which she was given a 7-day course of Bactrim for what was found
to be a Klebsiella UTI. She reportedly completed her Bactrim on
Friday [**2150-8-7**].  Patient self-catheterizes at home and has had
recurrent multidrug-resistant UTIs. UA on admission showed large
leuks, neg nitrites and she was started on meropenem for empric
[**Year (4 digits) 40097**] coverage, though [**Year (4 digits) **] eventually grew >100k CFU of
meropenem-sensitive proteus mirabilis

#) Hypotension:
She was normotensive in the ED but became hypotensive to SBPs in
the 80s while in the MICU soon after admission. This was thought
to be from sedation. However, given that she dropped to the 70s
systolic and did not respond to fluids, she required pressors
the first day of admission to maintain SBPs in the 90s. Notably,
she lives in the SBPs 90s-100s per outpatient BP reads over the
past few years.  She developed a fever to 102.1F and also was
found to have a Proteus UTI (>100K) on [**Last Name (LF) 21574**], [**First Name3 (LF) **] she had a
possible urosepsis picture. Her hypotension resolved as she
clinically improved from her UTI and was able to be extubated.
She was occasionally hyPERtensive on the regular medical floor
to SBP 160s-170s but asymptomatic, likely due to anxiety, as
improved with decreased anxiety.

#) AMS:
Per witness, patient became lethargic/unresponsive after dinner
after an episode of vomiting following administration of PO
clonazepam. AMS likely due to over-sedation with medications
given timing of medication administration, Utox positive for
methadone, as well as bradypnea and transient response to narcan
on presentation. Urosepsis and hypotension may have also played
a role in AMS.
-Careful monitoring of polypharamcy with multiple sedating
medications
-Adherence to narcotics agreement and appointment at pain clinic


CHRONIC ISSUES:
# COPD/ Chronic Hypercarbia: On 2L O2 at home. Was on 3L NC at
time of discharge likely secondary to recent pneumonia. Home
albuterol and ipratroprium were continued.
-Continue to week to baseline O2 requirment
-Encourage smoking cessation (restarted 2wk prior to admission)

#)Chronic Pain: Foot and shoulder pain related to prior MVA and
likely neuropathy. Narcotics contract terminated as documented
in OMR because of negative Utox while be prescribed narcotics.
Currently on lidocaine patches, baclofen, gabapentin,
pregabalin.
-Rescheduled pain clinic appointment (missed during admission)

#)Urinary Retention: Patient usually self-catheterizes at home
but foley catheter used during admission extending past period
needed for UOP monitoring because of patient request.

# Anemia of chronic disease:
Her baseline Hct~28. Hct 34.5 on admission, 28.8 at time of
discharge.

# Constipation: Continued on home polyethylene glycol

# Anxiety/Depression: Continued on citalopram, clonazepam and
trazodone restarted when mental status improved.

# Hypothyroidism:  Continued levothyroxine

# Hypercholesterolemia: Continued simvastatin

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

# GERD: Continued omeprazole

Transitional issues for this patient:
-Pain management
-Sterile straight cath teaching for patient given recurrent UTIs
-Consider outpatient speech and swallow evaluation given
suspicion for recurrent aspiration pneumonias

Medications on Admission:
1. albuterol NEB Q6hr PRN dyspnea
2. baclofen 20 mg Qam, 10 mg 4PM, 20 mg Qpm
3. citalopram 40 mg PO DAILY
4. ipratropium Q6hr PRN dyspnea
5. levothyroxine 112 mcg PO DAILY
6. clonazepam 1 mg PO TID PRN (takes 2 mg QHS)
7. lidocaine patch - feet and shoulder blade
8. omeprazole 20 mg [**Hospital1 **]
9. oxybutynin chloride 10 mg Qam, 5 mg 4pm, 10mg QHS
10.Polyethylene Glycol 17g QD
11.gabapentin 600 mg TID
12.simvastatin 10 mg PO DAILY
13.sucralfate 1 gram TID
14.trazodone 100 mg QHS PRN anxiety.

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


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 1474**] VNA

Discharge Diagnosis:
Primary:
-RLL aspiration pneumonia with hypoxic respiratory failure

Secondary:
-proteus urinary tract infection
-chronic obstructive pulmonary disease
-chronic pain syndrome


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


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

It was a pleasure participating in your care during your
hospitalization at [**Hospital1 18**]. You were admitted for increased oxygen
requirement and decreased responsiveness, and a breathing tube
was placed for a machine to help you breathe. A chest xray
showed a pneumonia in your right lung and a urine study showed a
urinary tract infection.  You received antibiotics (vancomycin
and meropenem) for eight days during your stay in the intensive
care unit and your breathing improved and the breathing tube was
removed. You were stable for the regular medical floor and were
able to be discharged from there.

Followup Instructions:
Department: [**Hospital3 249**]
When: TUESDAY [**2150-9-1**] at 12:00 PM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**], M.D. [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: PAIN MANAGEMENT CENTER
When: WEDNESDAY [**2150-9-2**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], [**First Name3 (LF) **] [**Telephone/Fax (1) 1652**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS     Best Parking: Parking on Site
*** Unfortunately there were no later appointments available.
The next reported opening was not until [**9-29**].  If you are
unable to make this appointment, we recommend that you speak
with the office directly. ***

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


                             [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

Completed by:[**2150-8-20**]
{'Other septicemia due to gram-negative organisms,Acute respiratory failure,Septic shock,Pneumonitis due to inhalation of food or vomitus,Paraplegia,Late effect of spinal cord injury,Delirium due to conditions classified elsewhere,Urinary tract infection, site not specified,Late effects of motor vehicle accident,Personal history, urinary (tract) infection,Tobacco use disorder,Opioid type dependence, unspecified,Unspecified viral hepatitis C without hepatic coma,Unspecified acquired hypothyroidism,Personal history of venous thrombosis and embolism,Infection with drug-resistant microorganisms, unspecified, with multiple drug resistance,Chronic airway obstruction, not elsewhere classified,Constipation, unspecified,Retention of urine, unspecified,Anemia of other chronic disease,Severe sepsis,Chronic pain due to trauma,Carrier or suspected carrier of other specified bacterial diseases'}


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: Hypercarbic Respiratory Failure

PRESENT ILLNESS: Ms. [**Known lastname **] is a 53 y.o. woman with PMH of T1-T2 paraplegia,
frequent admissions for PNA and UTI, and COPD (on 1.5-2L NC at
home), who presented with acute mental status changes and
changes in her breathing status. She had dinner with her friend
and one of her primary caregivers, [**Name (NI) **]. She was having some
trouble eating - her friend notes chronic trouble eating/food
sticking in her throat. 45 minutes after eating, the friend went
back to her room where she found her vomiting and not feeling
well. She put her friend in bed and gave her 1.5 mg of
clonazepam. 30 minutes later she found her to be lethargic with
O2sat 83-84% on 2L NC (usually 90-92%).  Given this, her friend
drove her to the [**Hospital1 18**] [**Name (NI) **] from [**Location (un) 1475**] while keeping her on
8L NC.

MEDICAL HISTORY: # T1 to T2 paraplegia status post a motor vehicle accident.
# Recurrent pneumonia (followed by pulm - Last [**2149-4-9**])
- Per pulm, recurrent pneumonia likely from pulmonary toilet
issues secondary to neuromuscular disease with improvement with
consistent and aggressive bronchopulmonary therapy.
- Prior sputum cultures + for MRSA, pan-sensitive Klebsiella,
and Pseudomonas.
# Recurrent UTIs in the setting of urinary retention requiring
straight catheterization
# COPD
# hepatitis C
# anxiety
# DVT in [**2142**] -IVC filter placed in [**2142**]
# Pulmonary nodules
# Hypothyroidism
# Chronic pain
# Chronic gastritis
# Anemia of chronic disease
# S/p PEA arrest during hospitalization in [**2147-10-3**]

MEDICATION ON ADMISSION: 1. albuterol NEB Q6hr PRN dyspnea
2. baclofen 20 mg Qam, 10 mg 4PM, 20 mg Qpm
3. citalopram 40 mg PO DAILY
4. ipratropium Q6hr PRN dyspnea
5. levothyroxine 112 mcg PO DAILY
6. clonazepam 1 mg PO TID PRN (takes 2 mg QHS)
7. lidocaine patch - feet and shoulder blade
8. omeprazole 20 mg [**Hospital1 **]
9. oxybutynin chloride 10 mg Qam, 5 mg 4pm, 10mg QHS
10.Polyethylene Glycol 17g QD
11.gabapentin 600 mg TID
12.simvastatin 10 mg PO DAILY
13.sucralfate 1 gram TID
14.trazodone 100 mg QHS PRN anxiety.

ALLERGIES: Ativan

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
Vitals:  T 96.8, HR 89, BP 141/106, RR 13, 100% on ventilator
General: somnolent but arousable
HEENT: Sclera anicteric, oropharynx clear, EOMI, PERRL,  MMM
Neck: JVP not appreciated
CV: RRR, soft S1/S2, no murmurs, rubs, gallops
Lungs: diffuse rhonchi and adventitial sounds
Abdomen: soft, non-tender, obese, BS+
GU: Foley in place
Ext: cool but perfused, trace/1+ pulses in LE b/l, trace/1+ LE
edema to ankles
Neuro: arousable and oriented to self; detailed exam deferred

FAMILY HISTORY: Mom - lung cancer
Dad - healthy

SOCIAL HISTORY: Lives at home with husband and 2 adolescent children.
- Tobacco: 35-pack-years, has tried to quit but smokes
intermittently - started again 2 weeks ago.
- Alcohol: Denies.
- Illicits: Denies. 

### Response:
{'Other septicemia due to gram-negative organisms,Acute respiratory failure,Septic shock,Pneumonitis due to inhalation of food or vomitus,Paraplegia,Late effect of spinal cord injury,Delirium due to conditions classified elsewhere,Urinary tract infection, site not specified,Late effects of motor vehicle accident,Personal history, urinary (tract) infection,Tobacco use disorder,Opioid type dependence, unspecified,Unspecified viral hepatitis C without hepatic coma,Unspecified acquired hypothyroidism,Personal history of venous thrombosis and embolism,Infection with drug-resistant microorganisms, unspecified, with multiple drug resistance,Chronic airway obstruction, not elsewhere classified,Constipation, unspecified,Retention of urine, unspecified,Anemia of other chronic disease,Severe sepsis,Chronic pain due to trauma,Carrier or suspected carrier of other specified bacterial diseases'}
