CHIEF COMPLAINT: Altered mental status, hypoxia

PRESENT ILLNESS: 73 yo female with hx of recent admission for R hip
fracture/pinning with period of hypoxia during the previous
admission, now presents from rehab with unresponsiveness,
refusal to take meds, hypoxia. In the ED, her triage vitals were
T96F, HR 106, BP 124/91, RR 14, Sat 90%. CTA showed bilateral
pulmonary emboli. Vascular surgery was consulted via the ED, and
considering pt developed PE despite outpt prophylaxis doses of
Lovenox, an IVC filter was placed, and the patient was started
on heparin drip. She was admitted to Medicine for ongoing
management. On evaluation on the floor, she is a poor historian
and reports that she is in the hospital because she was not
treated well at rehab. She does recall (with prompting) being
told that there are clots in her lungs and that she had a
procedure before coming to the floor. Multiple attempts to
contact her daughter were made, but her phone was busy.
.
ROS: She reports mild difficulty breathing and pain at the site
of her recent surgery (right hip), as well as lower extremity
swelling. She denies fevers, chills, night sweats, visual
changes, sore throat, chest pain, abdominal pain, nausea,
vomiting, diarrhea, cough, urinary frequency, dysuria, and
constipation.

MEDICAL HISTORY: Seizure disorder (developed [**1-13**] DKA in [**2095**])
breast CA s/p mastectomy with prosthetic reconstruction ([**2107**])
IDDM
RA
HTN
glaucoma
bilat TKRs
.
Of note, neuropsych evaluation in [**2125**] commented that "her
marked attentional impairments raises concerns around her
safety, medication compliance, and other areas of functional
vulnerability."

MEDICATION ON ADMISSION: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission:
VITALS: T97.0F, BP 138/87, HR 85, RR 22, Sat 100%5L face mask
GEN: Alert and oriented x 2
HEENT: EOMI, perrl, MMM.
Neck:  No LAD. JVP WNL.
RESP:  CTA B. No wheezes, rales, or rhonchi
CV:  RRR. Pronounced S2. No mrg.
ABD:  +BS. Soft, NT/ND.
Back: Stage 2 coccyx ulcer, currently dressed.
Ext:  Pitting edema in LLE, trace edema in RLE. Extremities cool
but pulses palpable. Right hip with staples, mildly tender to
palpation.
Neuro:  CN 2-12 grossly intact. Oriented to self and place, not
time. Easily distracted with waxing/[**Doctor Last Name 688**] attention.

FAMILY HISTORY: Family History: mother died at 47 in surgery (possibly during a
hysterectomy). No information was available to her regarding her
birth father. She has several step siblings. Her daughter is
healthy.

SOCIAL HISTORY: Social History: Lived alone prior to recent hospitalization.
Ambulatory at baseline (with cane).
- Tobacco: none
- Alcohol: none
- Illicits: none
Other pulmonary embolism and infarction,Acute on chronic diastolic heart failure,Pneumonia, organism unspecified,Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Urinary tract infection, site not specified,Acute posthemorrhagic anemia,Subendocardial infarction, subsequent episode of care,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Pressure ulcer, lower back,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Epilepsy, unspecified, without mention of intractable epilepsy,Duodenitis, without mention of hemorrhage,Rheumatoid arthritis,Unspecified essential hypertension,Internal hemorrhoids without mention of complication,Gastric diverticulum,Unspecified glaucoma,Leiomyoma of uterus, unspecified,Other orthopedic aftercare,Knee joint replacement,Personal history of malignant neoplasm of breast,Long-term (current) use of insulin,Other postprocedural status
Pulm embol/infarct NEC,Ac on chr diast hrt fail,Pneumonia, organism NOS,Chr duoden ulcer w hem,Urin tract infection NOS,Ac posthemorrhag anemia,Subendo infarct, subseq,Enterococcus group d,Pressure ulcer, low back,DMII wo cmp uncntrld,Epilep NOS w/o intr epil,Duodenitis w/o hmrhg,Rheumatoid arthritis,Hypertension NOS,Int hemorrhoid w/o compl,Gastric diverticulum,Glaucoma NOS,Uterine leiomyoma NOS,Orthopedic aftercare NEC,Joint replaced knee,Hx of breast malignancy,Long-term use of insulin,Post-proc states NEC
Admission Date:  [**2128-2-23**]              Discharge Date:   [**2128-3-10**]

Date of Birth:  [**2054-3-20**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3043**]
Chief Complaint:
Altered mental status, hypoxia

Major Surgical or Invasive Procedure:
IVC filter placement; no plans for filter removal, per Vascular
Surgery attending.

EGD/Colonscopy


History of Present Illness:
73 yo female with hx of recent admission for R hip
fracture/pinning with period of hypoxia during the previous
admission, now presents from rehab with unresponsiveness,
refusal to take meds, hypoxia. In the ED, her triage vitals were
T96F, HR 106, BP 124/91, RR 14, Sat 90%. CTA showed bilateral
pulmonary emboli. Vascular surgery was consulted via the ED, and
considering pt developed PE despite outpt prophylaxis doses of
Lovenox, an IVC filter was placed, and the patient was started
on heparin drip. She was admitted to Medicine for ongoing
management. On evaluation on the floor, she is a poor historian
and reports that she is in the hospital because she was not
treated well at rehab. She does recall (with prompting) being
told that there are clots in her lungs and that she had a
procedure before coming to the floor. Multiple attempts to
contact her daughter were made, but her phone was busy.
.
ROS: She reports mild difficulty breathing and pain at the site
of her recent surgery (right hip), as well as lower extremity
swelling. She denies fevers, chills, night sweats, visual
changes, sore throat, chest pain, abdominal pain, nausea,
vomiting, diarrhea, cough, urinary frequency, dysuria, and
constipation.

Past Medical History:
Seizure disorder (developed [**1-13**] DKA in [**2095**])
breast CA s/p mastectomy with prosthetic reconstruction ([**2107**])
IDDM
RA
HTN
glaucoma
bilat TKRs
.
Of note, neuropsych evaluation in [**2125**] commented that "her
marked attentional impairments raises concerns around her
safety, medication compliance, and other areas of functional
vulnerability."


Social History:
Social History: Lived alone prior to recent hospitalization.
Ambulatory at baseline (with cane).
- Tobacco: none
- Alcohol: none
- Illicits: none

Family History:
Family History: mother died at 47 in surgery (possibly during a
hysterectomy). No information was available to her regarding her
birth father. She has several step siblings. Her daughter is
healthy.

Physical Exam:
Admission:
VITALS: T97.0F, BP 138/87, HR 85, RR 22, Sat 100%5L face mask
GEN: Alert and oriented x 2
HEENT: EOMI, perrl, MMM.
Neck:  No LAD. JVP WNL.
RESP:  CTA B. No wheezes, rales, or rhonchi
CV:  RRR. Pronounced S2. No mrg.
ABD:  +BS. Soft, NT/ND.
Back: Stage 2 coccyx ulcer, currently dressed.
Ext:  Pitting edema in LLE, trace edema in RLE. Extremities cool
but pulses palpable. Right hip with staples, mildly tender to
palpation.
Neuro:  CN 2-12 grossly intact. Oriented to self and place, not
time. Easily distracted with waxing/[**Doctor Last Name 688**] attention.

Discharge exam:
VITALS: 96.9F, BP 174/72, HR 72, RR 18, Sat 95%RA
Lungs: Bilateral rales at bases
Heart: Regular rate and rhythm
Abdomen: Benign
Extremities: 1+ pitting edema bilaterally
Neuro:  CN 2-12 intact. Oriented to self and place, not time.
Able to hold coherent conversation, but has mild
cognitive/memory deficits

Pertinent Results:
CTA CHEST W&W/O C&RECONS IMPRESSION:
1. Bilateral lobar and segmental PE, without evidence of right
heart strain.
2. Pulmonary edema with evolving infarcts. Close imaging
followup is
recommended.

CT HEAD W/O CONTRAST IMPRESSION: No acute changes.

BILAT LOWER EXT VEINS IMPRESSION: Clot within the left posterior
tibial vein. Otherwise, normal study.

CT ABDOMEN W/O CONTRAST: HISTORY: Known bilateral PEs with
16-point hematocrit drop after initiating heparin. Evaluate for
bleeding.
IMPRESSION: 1. No evidence of retroperitoneal bleeding.
2. Small bilateral pleural effusions and ground-glass opacity
with septal
thickening, unchanged.
3. Subcentimeter liver hypodensities, too small to characterize.

4. Gastric diverticulum.
5. Bilateral renal hypodensities, some of which are too small to

characterize, others of which may represent simple cysts.
6. Left adrenal gland thickening.
7. IVC filter placement.
8. Fibroid uterus.

9. Slight asymmetrical enlargement of the right anterior thigh
musculature
with vague hyperdensity which may suggest small amount of
intramuscular
bleeding.
10. Diffuse anasarca.


[**2128-2-23**] 11:48AM BLOOD WBC-19.2*# RBC-4.14* Hgb-13.0 Hct-38.9
MCV-94 MCH-31.5 MCHC-33.5 RDW-17.7* Plt Ct-389#
[**2128-2-24**] 05:40AM BLOOD WBC-18.6* RBC-3.00*# Hgb-9.6*# Hct-28.9*#
MCV-96 MCH-32.0 MCHC-33.2 RDW-17.3* Plt Ct-293
[**2128-2-24**] 10:37AM BLOOD WBC-19.1* RBC-2.41* Hgb-7.6* Hct-22.8*
MCV-95 MCH-31.8 MCHC-33.6 RDW-17.1* Plt Ct-287
[**2128-2-29**] 06:20AM BLOOD WBC-17.4* RBC-3.77* Hgb-10.9* Hct-33.2*
MCV-88 MCH-28.9 MCHC-32.8 RDW-18.2* Plt Ct-184
[**2128-2-25**] 02:30AM BLOOD Fibrino-356
[**2128-2-24**] 08:53PM BLOOD ESR-9 QG6PD-17.5*
[**2128-2-24**] 10:37AM BLOOD Ret Aut-5.1*
[**2128-2-25**] 02:30AM BLOOD Ret Aut-3.5*
[**2128-2-23**] 11:48AM BLOOD Glucose-176* UreaN-18 Creat-0.9 Na-137
K-4.3 Cl-98 HCO3-30 AnGap-13
[**2128-2-29**] 06:20AM BLOOD Glucose-64* UreaN-26* Creat-1.0 Na-139
K-3.8 Cl-104 HCO3-29 AnGap-10
[**2128-2-24**] 05:40AM BLOOD ALT-17 AST-25 LD(LDH)-491* AlkPhos-142*
TotBili-0.3
[**2128-2-29**] 06:20AM BLOOD LD(LDH)-380*
[**2128-2-24**] 05:40AM BLOOD Hapto-<5*
[**2128-2-25**] 02:30AM BLOOD Hapto-<5*
[**2128-2-26**] 01:43PM BLOOD Hapto-26*
[**2128-2-27**] 05:35AM BLOOD Hapto-49
[**2128-2-28**] 08:15AM BLOOD Hapto-69
[**2128-2-29**] 06:20AM BLOOD Hapto-72

Micro:
                              SENSITIVITIES: MIC expressed in
MCG/ML
                             ENTEROBACTER AEROGENES
                             |          ENTEROCOCCUS SP.
                             |          |
AMPICILLIN------------              <=2 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN--------    64 I     <=16 S
PIPERACILLIN/TAZO-----   <=4 S
TETRACYCLINE----------             =>16 R
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S
VANCOMYCIN------------                2 S

CT Pelvis [**2128-3-2**]: IMPRESSION: 1. No findings to explain
hematocrit decrease. 2. Diffuse anasarca.

Chest PA/Lat [**2128-3-9**]: The current study demonstrates the left
PICC line tip being located at the junction of the left
brachiocephalic vein and SVC. Cardiomediastinal silhouette is
relatively stable. Widespread parenchymal opacities are present
but improved since the prior study. Subpleural interstitial
changes are noted and are most likely consistent with chronic
interstitial changes rather than acute infection, and as was
mentioned, improved compared to the prior images.  No focal
consolidations to suggest new infection are currently
demonstrated, but given the two-week interval compared to the
prior imaging, cannot be entirely excluded. No increase in
pleural effusion is demonstrated. No substantial evidence for
failure is seen.

Hip X-ray [**2128-3-8**]: IMPRESSION: Fixation of right femoral
subcapital fracture with unchanged alignment.


Brief Hospital Course:
73yF with history of rheumatoid arthritis, breast cancer, recent
right hip fracture s/p ORIF and presumed NSTEMI during
hospitalization, presented with altered mental status and
hypoxia from rehab, found to have bilateral pulmonary embolism,
possible pneumonia, and a UTI. Hospitalization was complicated
by recurrent drops in her hematocrit, initially thought to be
[**1-13**] to hemolysis, but was subsequently noted to have an upper GI
bleed [**1-13**] to a large duodenal ulcer.

An IVC filter was placed via Vascular Surgery consult from the
ED, she was started on heparin gtt and antibiotics (Vanc, CTX,
levo), and she was admitted to the Hospitalist service for
ongoing care.  Following admission, she was found to have a very
rapid HCT drop of unclear source (16 points within 11 hours).
Her heparin was reversed with IV protamine, a STAT CT Abd/Pelvis
was obtained, and she was transferred to the ICU for ongoing
care.

CT scans were without evidence of any significant bleed.
Hemolysis labs were sent, with very low haptoglobin, elevated
LDH.  Vanc and Ceftriaxone were discontinued for concern of
possibly inducing hemolysis (although remains extremely unlikely
this was the source).  Pt's heparin gtt was resumed and she was
subsequently transferred to floor for ongoing care after further
H/H monitoring.

She was transfused a total of 5 units of PRBC during this
hospitalization.

Hematology was consulted, however it remained unclear why she
had her sudden HCT drop, but there was likely a contribution of
pulmonary infarct and infection driving anemia, based upon
findings of toxic granulations on smear. While the haptoglobin
was very low which would argue in favor of hemolysis, the bili
level remained stable, which would argue against.  Coombs
negative. G6PD negative.

Her H/H and haptoglobin levels were followed, which continued to
improve and stabilize.  Once her HCT was reasonably stable, but
she was noted to have a slight decline in her hematocrit in the
setting of dark guaiac positive stools. Thus, heparin and
coumadin were discontinued, a PPI was initiated, and GI was
consulted. The patient underwent EGD and colonscopy several days
after initiation of a PPI that revealed a large duodenal ulcer
that was likely the source of bleeding. The ulcer was shallow,
without a visible vessel, and was thought the  be low risk for
bleeding. Her heparin was restarted. H pylori serology was sent
and was ultimately negative.

#) Acute on chronic diastolic CHF: The patient was noted to be
markedly volume overloaded and anasarcic; furosemide was
increased to 20mg IV BID, which should be continued until
diffuse edema resolves.

#) Leukocytosis/UTI. Pt had a leukocytosis during the admission
due to UTI and pulmonary infarcts. It was thought that pt may
possibly have a pneumonia, but this was thought to be less
likely.  Her urine grew Enterobacter and Enterococcus.  She
completed a 5 day course of Levofloxacin 750 mg. Her repeat
urine culture was negative.  WBC improved by the time of
discharge.

#) Stage II coccyx ulcer. Wound care was consulted and wound
care should be continued: Mepilex and DuoDerm wound gel, along
with pressure redistribution guidelines.

#) Diabetes mellitus uncontrolled with complications. Held oral
hypoglycemics while in the hospital and covered with insulin
sliding scale and diabetic diet.

#) Seizure disorder. Continued carbamazepine.

#) Rheumatoid arthritis. Methotrexate was discontinued last
admission secondary to pancytopenia. She has follow up with her
rheumatologist.

#) Hypertension. Continued metoprolol (home medication,
increased dose to 25mg [**Hospital1 **]), lisinopril changed to
hydralazine/isosorbide inhouse given mild acute renal failure.
Lisinopril (home dose 5mg daily) can be restarted as blood
pressure tolerates.

#) Code Status. DNR/DNI, confirmed with patient during this
hospitalization.

Medications on Admission:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2

times a day).
3. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
4. Enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) mg
Subcutaneous DAILY (Daily) for 25 days: LAST DAY OF THERAPY IS
[**2128-3-14**].
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
6. Vitamin D 400 unit Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
7. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
8. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4

hours) as needed for pain.
12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
13. Metformin 500 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
14. Percocet 2.5-325 mg Tablet Sig: One (1) Tablet PO every [**5-18**]
hours as needed for pain: HOLD for any CNS or respiratory
depression (RR <12). Can be given prior to physical therapy
sessions.


Discharge Medications:
1. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
2. Heparin (Porcine) in D5W 10,000 unit/100 mL Parenteral
Solution Sig: 1150 (1150) units/hour Intravenous Continuous:
According to attached sliding scale. Heparin gtt at 1150
units/hr and stable.
3. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One (1)
Tablet PO three times a day.
7. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
8. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
10. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
14. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
15. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
16. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

17. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO every six (6) hours
as needed for pain.
18. Furosemide 10 mg/mL Solution Sig: Two (2) injection
Injection twice a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
# Bilateral pulmonary embolism
# Pulmonary infarcts
# Anemia, multifactorial
# Urinary tract infection
# Upper GI bleed
# Duodenal ulcer

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

Discharge Instructions:


Followup Instructions:
Department: [**Hospital3 249**]
When: MONDAY [**2128-3-22**] at 1:50 PM
With: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
Follow up for hospitalization. Will be reconnected with Primary
Care Physican for the end [**Month (only) 547**].

Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2128-3-24**] at 7:40 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2128-3-24**] at 8:00 AM
With: DR [**Last Name (STitle) **] & DR [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: RHEUMATOLOGY
When: TUESDAY [**2128-3-30**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 14465**], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Unit Name **] [**Location (un) 861**]
Campus: WEST     Best Parking: [**Doctor First Name **]. GARAGE

Department: [**Hospital3 249**]
When: THURSDAY [**2128-4-8**] at 12:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3031**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: ORTHOPEDICS
When: TUESDAY [**2128-5-4**] at 9:40 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: ORTHOPEDICS
When: TUESDAY [**2128-5-4**] at 10:00 AM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Other pulmonary embolism and infarction,Acute on chronic diastolic heart failure,Pneumonia, organism unspecified,Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Urinary tract infection, site not specified,Acute posthemorrhagic anemia,Subendocardial infarction, subsequent episode of care,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Pressure ulcer, lower back,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Epilepsy, unspecified, without mention of intractable epilepsy,Duodenitis, without mention of hemorrhage,Rheumatoid arthritis,Unspecified essential hypertension,Internal hemorrhoids without mention of complication,Gastric diverticulum,Unspecified glaucoma,Leiomyoma of uterus, unspecified,Other orthopedic aftercare,Knee joint replacement,Personal history of malignant neoplasm of breast,Long-term (current) use of insulin,Other postprocedural status'}


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



### Clinical text :
CHIEF COMPLAINT: Altered mental status, hypoxia

PRESENT ILLNESS: 73 yo female with hx of recent admission for R hip
fracture/pinning with period of hypoxia during the previous
admission, now presents from rehab with unresponsiveness,
refusal to take meds, hypoxia. In the ED, her triage vitals were
T96F, HR 106, BP 124/91, RR 14, Sat 90%. CTA showed bilateral
pulmonary emboli. Vascular surgery was consulted via the ED, and
considering pt developed PE despite outpt prophylaxis doses of
Lovenox, an IVC filter was placed, and the patient was started
on heparin drip. She was admitted to Medicine for ongoing
management. On evaluation on the floor, she is a poor historian
and reports that she is in the hospital because she was not
treated well at rehab. She does recall (with prompting) being
told that there are clots in her lungs and that she had a
procedure before coming to the floor. Multiple attempts to
contact her daughter were made, but her phone was busy.
.
ROS: She reports mild difficulty breathing and pain at the site
of her recent surgery (right hip), as well as lower extremity
swelling. She denies fevers, chills, night sweats, visual
changes, sore throat, chest pain, abdominal pain, nausea,
vomiting, diarrhea, cough, urinary frequency, dysuria, and
constipation.

MEDICAL HISTORY: Seizure disorder (developed [**1-13**] DKA in [**2095**])
breast CA s/p mastectomy with prosthetic reconstruction ([**2107**])
IDDM
RA
HTN
glaucoma
bilat TKRs
.
Of note, neuropsych evaluation in [**2125**] commented that "her
marked attentional impairments raises concerns around her
safety, medication compliance, and other areas of functional
vulnerability."

MEDICATION ON ADMISSION: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission:
VITALS: T97.0F, BP 138/87, HR 85, RR 22, Sat 100%5L face mask
GEN: Alert and oriented x 2
HEENT: EOMI, perrl, MMM.
Neck:  No LAD. JVP WNL.
RESP:  CTA B. No wheezes, rales, or rhonchi
CV:  RRR. Pronounced S2. No mrg.
ABD:  +BS. Soft, NT/ND.
Back: Stage 2 coccyx ulcer, currently dressed.
Ext:  Pitting edema in LLE, trace edema in RLE. Extremities cool
but pulses palpable. Right hip with staples, mildly tender to
palpation.
Neuro:  CN 2-12 grossly intact. Oriented to self and place, not
time. Easily distracted with waxing/[**Doctor Last Name 688**] attention.

FAMILY HISTORY: Family History: mother died at 47 in surgery (possibly during a
hysterectomy). No information was available to her regarding her
birth father. She has several step siblings. Her daughter is
healthy.

SOCIAL HISTORY: Social History: Lived alone prior to recent hospitalization.
Ambulatory at baseline (with cane).
- Tobacco: none
- Alcohol: none
- Illicits: none 

### Response:
{'Other pulmonary embolism and infarction,Acute on chronic diastolic heart failure,Pneumonia, organism unspecified,Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Urinary tract infection, site not specified,Acute posthemorrhagic anemia,Subendocardial infarction, subsequent episode of care,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Pressure ulcer, lower back,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Epilepsy, unspecified, without mention of intractable epilepsy,Duodenitis, without mention of hemorrhage,Rheumatoid arthritis,Unspecified essential hypertension,Internal hemorrhoids without mention of complication,Gastric diverticulum,Unspecified glaucoma,Leiomyoma of uterus, unspecified,Other orthopedic aftercare,Knee joint replacement,Personal history of malignant neoplasm of breast,Long-term (current) use of insulin,Other postprocedural status'}
