CHIEF COMPLAINT: Fatigue

PRESENT ILLNESS: 75 year old male with a history of a cerebral vascular accident,
chronic back pain and sarcoidosis who was found down by his son
[**2155-1-3**] in his living room. The patient does not recall how he
fell. He states he does not recall what parts of his body hit
the floor.  He recalls trying to pull himself up and being
unable.  He remembers hearing acceptance speeches from the NH
primary. When he woke up he found he was soiled with feces. He
does believe he lost consciousness. He denies any prior similar
episodes. Brought in by family because of continued generalized
weakness. He states that since wednesday afternoon he has had a
dry productive cough and had trouble "getting a deep breath". Of
note of the day he fell, he went to his pain doctor after the
fall and was told it may have been vasovagal.
.
In ED, 95.8, 81, 121/63, 18 96%RA. His spine was noted to be
diffusely tender. Imaging of CT cervical spine indicative of
C3-C4 ligamentous injury, and C7 ? acute fracture for which
patient has been placed in a c-collar. Patient noted to have a
mildly elevated BUN, and anemia. He was admitted for further
work-up of this event.
.
Review of Systems: + constipation, +cough, +shortness of breath,
+dysphagia, +weight loss (40 lbs, 8 months), +chronic lower back
pain. Patient denies fevers, chills, nausea, vomiting, headache,
vision changes.

MEDICAL HISTORY: Sarcoid, on chronic prednisone
GERD, on omeprazole
Dyspagea, on limited diet, but refuses any of the thickened
liquids
CVA, 1 yr ago, residual left foot drop, memory difficulty
Hypertension
Anemia
Chronic Back Pain, on fentanyl patch

MEDICATION ON ADMISSION: Metoprolol 25 mg PO BID
Aspirin 325 mg PO DAILY
Miralax *NF* 17 gram (100 %)HS
Benefiber Clear 3 gram/3.5 [**12-17**] tbsp by mouth at bedtime mixed
with water
Donepezil 5 mg PO HS
OxycoDONE (Immediate Release)  10 mg PO Q4H:PRN pain
Docusate Sodium 100 mg PO BID
Pantoprazole 40 mg PO Q24H
Fentanyl Patch 50 mcg/hr TP Q72H Start: SAT [**12-27**] AM
Potassium Chloride 10 mEq PO BID Duration: 24 Hours
Fluticasone-Salmeterol (100/50) 1 INH IH [**Hospital1 **]
Gabapentin 300 mg PO 1-4 tablets DAILY: patient has been taking
more than once a day
Hydrochlorothiazide 12.5 mg PO EVERY OTHER DAY: patient has been
taking daily
Simvastatin 20 mg PO DAILY
Losartan Potassium 50 mg PO DAILY
Thiamine 100 mg PO DAILY
Methylprednisolone 4 mg PO 1-3 tablets DAILY : patient had been
varying dose and taking more than prescribed

ALLERGIES: Penicillins

PHYSICAL EXAM: Gen Alert and Oriented *3
Skin: rash, left macular-papular irregular areas (6)of
hyperpigmentation roughly oval with center darkening
HEENT: PERRL, EOMI, CN II-XII intact, no nystagmus
CV: RRR, nl S1, S2, no m/r/g
Pulm: CTA b/l, no w/r/r
Back: kyphotic, tender diffusely in t-spine. No l spine
tenderness.
Abd: s/nt/nd +bs no hepatosplenomegaly
Ext: no c/c/e, 2+ DP
Neurological: UE biceps [**4-19**], triceps [**4-19**], deltoids 5-/5, LE:
hamstrings [**4-19**], hip flexors [**4-19**], knee flexors 5-/5, knee
extensors 5-/5, plantarflexion [**4-19**], dorsiflexion L [**3-20**] R [**4-19**].
DTRs 1+, no clonus. able to stand and balance. Rectal tone good
per ED.

FAMILY HISTORY: NC, no family history of sarcoid

SOCIAL HISTORY: retired physician, [**Name Initial (NameIs) **], 2 grandchildren. Son-in-law [**Name (NI) **]
very supportive. Divorced from wife, who recently died. Patient
does not/has never smoked. Patient rarely consumes alcohol.
Patient lives alone at [**Hospital1 100**] Senior Life. His meals are
provided for him, he does go shopping on his own and is quite
active. He ambulates without a cane.
C5-C7 level with unspecified spinal cord injury,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Pressure ulcer, buttock,Syncope and collapse,Unspecified fall,Sarcoidosis,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Unspecified essential hypertension,Anemia, unspecified
C5-c7 spin cord inj NOS,Acute respiratry failure,Food/vomit pneumonitis,Pressure ulcer, buttock,Syncope and collapse,Fall NOS,Sarcoidosis,DMII wo cmp uncntrld,Hypertension NOS,Anemia NOS
Admission Date:  [**2155-12-25**]              Discharge Date:   [**2156-1-9**]

Date of Birth:  [**2080-1-23**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 4052**]
Chief Complaint:
Fatigue

Major Surgical or Invasive Procedure:
Intubation


History of Present Illness:
75 year old male with a history of a cerebral vascular accident,
chronic back pain and sarcoidosis who was found down by his son
[**2155-1-3**] in his living room. The patient does not recall how he
fell. He states he does not recall what parts of his body hit
the floor.  He recalls trying to pull himself up and being
unable.  He remembers hearing acceptance speeches from the NH
primary. When he woke up he found he was soiled with feces. He
does believe he lost consciousness. He denies any prior similar
episodes. Brought in by family because of continued generalized
weakness. He states that since wednesday afternoon he has had a
dry productive cough and had trouble "getting a deep breath". Of
note of the day he fell, he went to his pain doctor after the
fall and was told it may have been vasovagal.
.
In ED, 95.8, 81, 121/63, 18 96%RA. His spine was noted to be
diffusely tender. Imaging of CT cervical spine indicative of
C3-C4 ligamentous injury, and C7 ? acute fracture for which
patient has been placed in a c-collar. Patient noted to have a
mildly elevated BUN, and anemia. He was admitted for further
work-up of this event.
.
Review of Systems: + constipation, +cough, +shortness of breath,
+dysphagia, +weight loss (40 lbs, 8 months), +chronic lower back
pain. Patient denies fevers, chills, nausea, vomiting, headache,
vision changes.

Past Medical History:
Sarcoid, on chronic prednisone
GERD, on omeprazole
Dyspagea, on limited diet, but refuses any of the thickened
liquids
CVA, 1 yr ago, residual left foot drop, memory difficulty
Hypertension
Anemia
Chronic Back Pain, on fentanyl patch

Social History:
retired physician, [**Name Initial (NameIs) **], 2 grandchildren. Son-in-law [**Name (NI) **]
very supportive. Divorced from wife, who recently died. Patient
does not/has never smoked. Patient rarely consumes alcohol.
Patient lives alone at [**Hospital1 100**] Senior Life. His meals are
provided for him, he does go shopping on his own and is quite
active. He ambulates without a cane.

Family History:
NC, no family history of sarcoid

Physical Exam:
Gen Alert and Oriented *3
Skin: rash, left macular-papular irregular areas (6)of
hyperpigmentation roughly oval with center darkening
HEENT: PERRL, EOMI, CN II-XII intact, no nystagmus
CV: RRR, nl S1, S2, no m/r/g
Pulm: CTA b/l, no w/r/r
Back: kyphotic, tender diffusely in t-spine. No l spine
tenderness.
Abd: s/nt/nd +bs no hepatosplenomegaly
Ext: no c/c/e, 2+ DP
Neurological: UE biceps [**4-19**], triceps [**4-19**], deltoids 5-/5, LE:
hamstrings [**4-19**], hip flexors [**4-19**], knee flexors 5-/5, knee
extensors 5-/5, plantarflexion [**4-19**], dorsiflexion L [**3-20**] R [**4-19**].
DTRs 1+, no clonus. able to stand and balance. Rectal tone good
per ED.

Pertinent Results:
STUDIES
MRI C SPINE:  1.  Ligamentous injury adjacent to an old C7
spinous process fracture.  2.  Tiny abnormality of the ligament
anterior to C3-4, without findings suggestive of acute
disruption.  3.  Degenerative disease of the cervical spine as
detailed above.  Diffuse idiopathic skeletal hyperostosis
(DISH).
.
CT L SPINE:1.  No evidence of acute fracture of the lumbar
spine.
2.  Multilevel degenerative changes, most severe at L4-5 and
L5-S1, with central canal encroachment by a disc osteophyte
complex at L4-5.
.
CT T SPINE 1.  No evidence of fracture within the thoracic spine
with preservation of vertebral body height throughout. 2.
Findings compatible with diffuse idiopathic skeletal
hyperostosis (DISH).
3.  Right adrenal myelolipoma.
.
CT C SPINE:1.  Widening of the anterior disc space at C3-4 which
may be chronic; however, ligamentous injury cannot be excluded.
Recommend MRI for further evaluation. 2.  Irregularity and
disruption of the spinous process at C7 which could represent an
acute fracture.  An underlying lytic lesion cannot be excluded.
3.  Diffuse idiopathic skeletal hyperostosis (DISH) and
multilevel degenerative changes. 4.  Right upper lobe pneumonia.

.
CXR:  Focal, increased parenchymal opacities involving the right
upper
lobe which may represent aspiration and/or pneumonia.
.
CT HEAD: No evidence of intracranial hemorrhage or edema.
.
BILATERAL HIPS: 1.  Degenerative changes of both hips which are
mild, as well as moderate degenerative changes of the lumbar
spine. 2.  No signs for acute bony injury.
.
CTA CHEST [**2156-1-5**]
.
TECHNIQUE: Axial volumetric images have been obtained through
the chest, abdomen and pelvis. IV contrast was administered
according to the PE protocol.

COMPARISON: There is a [**2155-12-28**] chest CT for comparison.

FINDINGS: The main pulmonary artery is enlarged measuring 4
cm.This is highly suggestive of pulmonary hypertension. The
segmental and subsegmental arteries appear to be prominent,
which is unchanged compared to previous. Again noted are the
airspace changes within the right upper lobe as well as within
the left lower lobe, which appear unchanged, compared to
previous.There is a soft tissue density associated with
atelectasis around the right hilum which is unchanged compared
to previous. Right basal atlectasis is also present. There are
bilateral pleural effusions. The airway is patent with no
evidence of significant lymphadenopathy.

ABDOMINAL AND PELVIC CT: There are no suspicious hepatic
lesions. The spleen appears unremarkable. There is evidence of
cholelithiasis and the CBD is prominent measuring 1.5 cm. No
evidence of intrahepatic biliary duct dilatation. The pancreas
appears unremarkable. Within the right adrenal gland, there is a
rounded hypodense fatty lesion measuring 3.5 x 4 cm, most likely
in keeping with adrenal myelolipoma. The left adrenal appears
unremarkable. There is a left upper pole renal cyst. Otherwise,
the bilateral kidneys appear unremarkable with no evidence of
hydronephrosis.

The small and large bowel appear unremarkable with no evidence
of dilatation or wall thickening. There is no evidence of
pneumatosis, free air or free fluid. There is no significant
retroperitoneal lymphadenopathy. The abdominal aorta is
atherosclerotic. The bladder appears unremarkable with evidence
of Foley catheter in place.

There are multilevel degenerative changes within the lumbosacral
spine. There are no suspicious bony lesions.

IMPRESSION:
1. No evidence for pulmonary embolism. Evidence for pulmonary
arterial hypertension with prominent peripheral pulmonary
vessels, especially on the left, which is unchanged from
previous.

2. No significant change in the airspace disease within the
bilateral lungs with persistent soft tissue density within the
right hilum, which is concerning for an underlying mass lesion
obscured by the airspace disease or resulting in obstructive
airway changes and thus followup is recommended.

3. Cholelithiasis.

4. Left adrenal myelolipoma. Findings were discussed with Dr.
[**Last Name (STitle) **] from team medicine on the same day.

.
ON ADMIT:
[**2155-12-25**] 11:30AM BLOOD WBC-6.4 RBC-3.79* Hgb-11.8* Hct-34.7*
MCV-91 MCH-31.2 MCHC-34.1 RDW-13.2 Plt Ct-304
[**2155-12-25**] 11:30AM BLOOD Neuts-88.0* Bands-0 Lymphs-6.9* Monos-4.4
Eos-0.4 Baso-0.4
[**2155-12-25**] 11:30AM BLOOD PT-13.1 PTT-26.8 INR(PT)-1.1
[**2155-12-25**] 11:30AM BLOOD Glucose-99 UreaN-27* Creat-1.2 Na-140
K-4.4 Cl-100 HCO3-30 AnGap-14
[**2155-12-26**] 07:05AM BLOOD Calcium-8.9 Phos-3.5 Mg-2.1 Iron-12*
[**2155-12-26**] 07:05AM BLOOD calTIBC-182* VitB12-304 Folate-8.0
Ferritn-1122* TRF-140*
.
AT DISCHARGE
.
  COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2156-1-9**] 06:45AM    12.0* 3.52* 11.3* 32.5* 92 32.1* 34.8
13.7 354
  DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2156-1-5**] 08:28AM    86.2* 0 10.3* 2.9 0.5 0.1
Source: Line-picc
  RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr
[**2156-1-5**] 08:28AM    NORMAL 1+ NORMAL NORMAL NORMAL 1+
Source: Line-picc
  BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2156-1-9**] 06:45AM          354
[**2156-1-9**] 06:45AM    13.11 30.2     1.1
1 NOTE NEW REFERENCE RANGE AS OF [**2155-10-29**] 12:00A
  MISCELLANEOUS HEMATOLOGY ESR
[**2156-1-7**] 12:40PM    55*
[**2156-1-7**] 05:46AM    22*
ESR ADDED 12:20PM


Brief Hospital Course:
75 year old male with past medical history significant for
sarcoid on chronic low dose predisone was brought by son to [**Name (NI) **]
for generalized weakness following a syncopal episode with loss
of consciousness. The patient's syncope was felt to be in the
setting of the patient self regulating his pain medications
including starting neurotin. He woke up surrounded by feces.
.
1) Syncope: It is unclear if the patient lost bowel or bladder
function during the event or if it was a result of his prolonged
immobility. He has a history of chronic back pain and
degenerative disk disease. CT imaging done in emergency
department revealed no evidence of acute event. His neurological
examination was benign.  No disturbances in electrolytes noted.
The patient was monitored on telemetry and was noted to have 18
beats of atrial tachycardia which spontaneously resolved. The
patient was restarted on his hydrochlorothiazide every other
day, then transitioned to daily. He had no syncopal or seizure
episodes in house. He did become quite delirious with visual
hallucinations a few days into his admission. He refused to be
examined. thought doctors [**First Name (Titles) **] [**Last Name (Titles) 75467**], and said he would not do
anything until the government issued a report. A psychiatry
consultation was obtained. He was felt by the psy team not to be
psychotic, but delirious in the setting of prolonged hospital
stay, and narcotics. RPR and B12 were ordered to complete the
labs, results pending at time of discharge. However, within 48
hours he returned to baseline, where he is conversant with some
logic but has obvious obsessions, reiterations, a monotone
speech, flat affect and lack of eye contact and insight. He is
otherwise very cooperative, with his thought content focused on
his pain control and his ability to handle thin liquids. His
cultures remained negative. However, he had findings of PNA for
which he is on a 14 day course of aztreonam and vancomycin, 3
days left.
.
2) Fall: When the patient syncopized, he fell to the floor.
Apparently he remained on the floor for a significant period of
time. He was treated for mildly elevated BUN with fluids.
Multiple imaging modalities were used to evaluate him status
post fall and he was noted to have a C 7 ligamentous injury by
MRI and several old cervical spinal fractures. Ortho was
consulted, with the recommendation to wear a cervical collar for
one month.
.
3) Pulmonary Infiltrate: In the MICU the patient had persistent
hypercarbic hypoxia. By chest x-ray the patient had a question
of a RUL PNA. The patient had a nonproductive cough. He is a
known aspiration risk and this may represent an aspiration event
and pneumonitis, although infection could not be excluded. The
patient cough likely also occured after he spent likely >7 hours
on the floor and he could have aspirated while unconscious.  He
was noted to have a mild left shift in his white blood cell
count with no leukocytosis. Patient was also noted to have no
fever. On the morning after admission, the patient was noted to
have development of diffuse rhonchi with a need for 2 liters of
nasal cannula oxygen to keep oxygenation at >95%. Patient at
this time was presumed to have pneumonia. He was given the
pneumovax vaccine and continued on Levofloxacin/Flagyl for
therapy, then switched to aztreonam and vancomycin as stated
above. Subsequently, his oxygen requirements increased to 5 L
while on antibiotics with lung exam significant for rhonchi. A
sarcoid flare was suspected and his dose of prednisone was
increased to 40 mg daily. Within two days of this regimen, with
chest PT and nebulizers, he was able to completely wean off
oxygen, satting in the high 90s on room air. He also benefitted
from gentle diuresis although edema was felt to be a small
contributor to his hypoxia.
.
4) Chronic Back Pain: Patient was restarted on his home pain
medication per his primary care physician, [**Name10 (NameIs) **] [**Last Name (STitle) 1266**].
Overnight post admission, he developed acute pain. This was felt
to be due to his recent fall and due to the fact that he was
liberally self medicating at home. The patient threatened to
leave against medical advice. After a detailed discussion with
the patient and his daughter, the patient made clear his
preference for improved pain control, even if this means he will
be very sleepy. After consultation with the pain service the
patient was started on PCA morphine pain control. He was
eventually transitioned to a fentanyl patch, initially 50
micrograms with percocet for breakthrough. At discharge, he is
on a fentanyl patch 100 micrograms with which his patient seems
to be well controlled, on no other narcotics.
.
5) Sarcoid: As stated above, his sarcoid was felt to be
contributing to his hypercarbic hypoxia, as his oxygenation
improved dramatically on increased steroids. It is unclear if he
has a component of neurosarcoid which is affecting his mental
status. He is reiterative at baseline, with obsessive thoughts
and tangential.
.
6)Cerebral Vascular Accident: Thombotic event. Patient notes
residual left foot drop. Unclear if dysphagia result of CVA but
patient has noted difficulty since CVA. He was kept on ASA.
.
7) Dysphagia: The patient had significant dyspagia which has
been evaluated by ENT and revealed aspiration, perhaps a
residual deficit from stroke. In the setting of this dysphagia
he has lost weight. Speech and swallow evaluations were
challenging for the patient, who insisted to be placed on thin
liquids. He initially did not collaborate with speech and
swallow evaluations, but was placed on thickened liquids, nectar
diet with crushed pills. On the day of discharged, he agreed to
a speech and swallow evaluation given that his sensorium was
clearer. The recommendations are to keep him on thick liquids,
nectar  pureed foods, and crush his pills.
.
8) DISH: disease of spine/bones which results in osteophytes.
This may be causing esophageal compression/tortuousness seen by
EGD. This might be contributing to his dysphagia and his pain.
.
FULL CODE
.
FEN: he was kept on special diet as above, repleted lytes as
needed
.
CONTACT: [**Name (NI) **] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 27772**] -- his daught and son-in-law,
live in [**Name (NI) 5176**], recently moved Mr. [**Known lastname **] to be nearer to
family. Cell #s [**Telephone/Fax (1) 75468**] or [**Telephone/Fax (1) 75469**]


Medications on Admission:
Metoprolol 25 mg PO BID
Aspirin 325 mg PO DAILY
Miralax *NF* 17 gram (100 %)HS
Benefiber Clear 3 gram/3.5 [**12-17**] tbsp by mouth at bedtime mixed
with water
Donepezil 5 mg PO HS
OxycoDONE (Immediate Release)  10 mg PO Q4H:PRN pain
Docusate Sodium 100 mg PO BID
Pantoprazole 40 mg PO Q24H
Fentanyl Patch 50 mcg/hr TP Q72H Start: SAT [**12-27**] AM
Potassium Chloride 10 mEq PO BID Duration: 24 Hours
Fluticasone-Salmeterol (100/50) 1 INH IH [**Hospital1 **]
Gabapentin 300 mg PO 1-4 tablets DAILY: patient has been taking
more than once a day
Hydrochlorothiazide 12.5 mg PO EVERY OTHER DAY: patient has been
taking daily
Simvastatin 20 mg PO DAILY
Losartan Potassium 50 mg PO DAILY
Thiamine 100 mg PO DAILY
Methylprednisolone 4 mg PO 1-3 tablets DAILY : patient had been
varying dose and taking more than prescribed

Discharge Medications:
1. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Psyllium     Packet Sig: [**12-17**] Packets PO TID (3 times a day)
as needed for constipation.
5. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day) as needed for constipation.
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual ASDIR (AS DIRECTED).
9. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
10. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation Q4H (every 4 hours) as needed for
shortness of breath or wheezing.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
13. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
15. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
16. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) inhalation Inhalation [**Hospital1 **] (2 times a day).
17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO every twenty-four(24)
hours.
18. 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.
19. Aztreonam 1 gram Recon Soln Sig: Two (2) grams Injection Q8H
(every 8 hours) for 3 days.
20. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous Q 12H (Every 12 Hours) for 3 days.
21. Sliding scale insulin as needed while on steroids


Discharge Disposition:
Extended Care

Facility:
[**Hospital 100**] Rehab

Discharge Diagnosis:
Hypercarbic respiratory failure
Syncope
Chest pain
Aspiration Pneumonia
Sarcoidosis
C7 ligamentous injury
Dysphagia


Discharge Condition:
Breathing well on room air


Discharge Instructions:
Admitted with syncope and cervical ligament injury, developed
respiratory failure and pneumonia. Had to be intubated in the
MICU. The pneumonia was treated with antibiotics (still needs
two more days) and the sarcoidosis with prednisone. You need to
discuss when to stop the prednisone with your doctors. There was
also some fluid in your lungs which we treated with lasix.
.
Your speech and swallow evaluation has concluded that you need
to continue on the thick liquids, as you run the risk of a
pneumonia otherwise. You can be reevaluated again. Please
discuss with Dr [**Last Name (STitle) 1266**].
.
Take the medications in the list below and return to the ED if
you experience any concerning symptoms.

Followup Instructions:
CT chest [**2-9**] at 10:45 ([**Hospital Ward Name 23**] building)
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 5376**] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2156-1-12**]
8:30
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2156-1-19**] 10:40
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2156-1-19**] 11:00
With Dr [**Last Name (STitle) 1266**] within 2-3 weeks. PLease call [**Telephone/Fax (1) 10688**]
Orthopedics: [**1-30**] at 2: 25 pm. [**Hospital Ward Name 23**] building [**Location (un) **]


                             [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 4055**]
{'C5-C7 level with unspecified spinal cord injury,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Pressure ulcer, buttock,Syncope and collapse,Unspecified fall,Sarcoidosis,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Unspecified essential hypertension,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: Fatigue

PRESENT ILLNESS: 75 year old male with a history of a cerebral vascular accident,
chronic back pain and sarcoidosis who was found down by his son
[**2155-1-3**] in his living room. The patient does not recall how he
fell. He states he does not recall what parts of his body hit
the floor.  He recalls trying to pull himself up and being
unable.  He remembers hearing acceptance speeches from the NH
primary. When he woke up he found he was soiled with feces. He
does believe he lost consciousness. He denies any prior similar
episodes. Brought in by family because of continued generalized
weakness. He states that since wednesday afternoon he has had a
dry productive cough and had trouble "getting a deep breath". Of
note of the day he fell, he went to his pain doctor after the
fall and was told it may have been vasovagal.
.
In ED, 95.8, 81, 121/63, 18 96%RA. His spine was noted to be
diffusely tender. Imaging of CT cervical spine indicative of
C3-C4 ligamentous injury, and C7 ? acute fracture for which
patient has been placed in a c-collar. Patient noted to have a
mildly elevated BUN, and anemia. He was admitted for further
work-up of this event.
.
Review of Systems: + constipation, +cough, +shortness of breath,
+dysphagia, +weight loss (40 lbs, 8 months), +chronic lower back
pain. Patient denies fevers, chills, nausea, vomiting, headache,
vision changes.

MEDICAL HISTORY: Sarcoid, on chronic prednisone
GERD, on omeprazole
Dyspagea, on limited diet, but refuses any of the thickened
liquids
CVA, 1 yr ago, residual left foot drop, memory difficulty
Hypertension
Anemia
Chronic Back Pain, on fentanyl patch

MEDICATION ON ADMISSION: Metoprolol 25 mg PO BID
Aspirin 325 mg PO DAILY
Miralax *NF* 17 gram (100 %)HS
Benefiber Clear 3 gram/3.5 [**12-17**] tbsp by mouth at bedtime mixed
with water
Donepezil 5 mg PO HS
OxycoDONE (Immediate Release)  10 mg PO Q4H:PRN pain
Docusate Sodium 100 mg PO BID
Pantoprazole 40 mg PO Q24H
Fentanyl Patch 50 mcg/hr TP Q72H Start: SAT [**12-27**] AM
Potassium Chloride 10 mEq PO BID Duration: 24 Hours
Fluticasone-Salmeterol (100/50) 1 INH IH [**Hospital1 **]
Gabapentin 300 mg PO 1-4 tablets DAILY: patient has been taking
more than once a day
Hydrochlorothiazide 12.5 mg PO EVERY OTHER DAY: patient has been
taking daily
Simvastatin 20 mg PO DAILY
Losartan Potassium 50 mg PO DAILY
Thiamine 100 mg PO DAILY
Methylprednisolone 4 mg PO 1-3 tablets DAILY : patient had been
varying dose and taking more than prescribed

ALLERGIES: Penicillins

PHYSICAL EXAM: Gen Alert and Oriented *3
Skin: rash, left macular-papular irregular areas (6)of
hyperpigmentation roughly oval with center darkening
HEENT: PERRL, EOMI, CN II-XII intact, no nystagmus
CV: RRR, nl S1, S2, no m/r/g
Pulm: CTA b/l, no w/r/r
Back: kyphotic, tender diffusely in t-spine. No l spine
tenderness.
Abd: s/nt/nd +bs no hepatosplenomegaly
Ext: no c/c/e, 2+ DP
Neurological: UE biceps [**4-19**], triceps [**4-19**], deltoids 5-/5, LE:
hamstrings [**4-19**], hip flexors [**4-19**], knee flexors 5-/5, knee
extensors 5-/5, plantarflexion [**4-19**], dorsiflexion L [**3-20**] R [**4-19**].
DTRs 1+, no clonus. able to stand and balance. Rectal tone good
per ED.

FAMILY HISTORY: NC, no family history of sarcoid

SOCIAL HISTORY: retired physician, [**Name Initial (NameIs) **], 2 grandchildren. Son-in-law [**Name (NI) **]
very supportive. Divorced from wife, who recently died. Patient
does not/has never smoked. Patient rarely consumes alcohol.
Patient lives alone at [**Hospital1 100**] Senior Life. His meals are
provided for him, he does go shopping on his own and is quite
active. He ambulates without a cane. 

### Response:
{'C5-C7 level with unspecified spinal cord injury,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Pressure ulcer, buttock,Syncope and collapse,Unspecified fall,Sarcoidosis,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Unspecified essential hypertension,Anemia, unspecified'}
