CHIEF COMPLAINT: Lethargy

PRESENT ILLNESS: Mrs [**Known lastname 74676**] is a 64F discharged to rehab 2d prior for admission
after mechanical fall and bilateral wrist fx p/w lethargy, now
presenting with lethargy and respiratory distress.  Per
patient's husband, she had been doing well after recent
discharge, however he had visited her in rehab earlier today and
noted that she was more lethargic than usual.  Later on this
evening in rehab pt was noted to be more somnolent, without
increased SOB or difficulty breathing, and therefore EMS was
called.  On arrival to the nursing facility, EMS noted a L
facial droop.  According to her family, pt had no other
complaints leading up to this event.
.
In the ED, initial vitals were 78% on RA RR 20-30, HR 80-100,
BPs 150-180 systolic.  Pt was initially interacting with family
but became confused and unable to answer questions, was SOB with
hypoxia to the 70s on 3 L NC.  She was given oxycodone and nebs.
 Given her desaturations to the 70s with tachycardic
hypertension and hypercarbia, pt was intubated.  CXR showed
severe emphysema, head CT was negative.  Rectal exam was
performed given severe crit drop and was negative.  Pt was also
seen by neuro out of concern for stroke, however this was
thought to be unlikely.
..
ROS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.

MEDICAL HISTORY: COPD/severe emphysema on 3-5L home O2 and FEV1=13% predicted,
baseline sat 80-85%
HTN
anxiety

MEDICATION ON ADMISSION: Medications at home (per last DC summary [**2178-8-2**]):
acetaminophen 325 mg Q6H
docusate sodium 100 mg [**Hospital1 **]
Symbicort 160-4.5 mcg/Actuation [**2-1**] Inh [**Hospital1 **]
lisinopril 20 mg DAILY
clonazepam 0.5 mg [**Hospital1 **]:PRN
oxycodone 5 mg [**2-1**] tab Q3H:PRN
ipratropium bromide 17 mcg/Actuation HFA Aerosol 3 puffs TID
Keflex 500 mg Capsule QID for 10 days (day 1 was [**2178-8-5**])

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On Admission:
VS: Temp:98.6 BP: 124/49 HR:102 RR:20 O2sat 98%
GEN: intubated, sedated
HEENT: PERRL, EOMI, anicteric, MMM, ETT in place, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
CV: RR, S1 and S2 wnl, no m/r/g
RESP: CTA b/l, prolongued expiratory phase, no W/r/r
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: opens eyes to voice, follows commands

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: Independent with ambulation. H/o smoking [**2-1**] ppd for 25 years.
Denies alcohol or drugs.
Acute and chronic respiratory failure,Obstructive chronic bronchitis with (acute) exacerbation,Drug-induced delirium,Hyperosmolality and/or hypernatremia,Anemia, unspecified,Anxiety state, unspecified,Other alteration of consciousness,Unspecified essential hypertension,Aftercare for healing traumatic fracture of other bone,Other opiates and related narcotics causing adverse effects in therapeutic use,Other dependence on machines, supplemental oxygen
Acute & chronc resp fail,Obs chr bronc w(ac) exac,Drug-induced delirium,Hyperosmolality,Anemia NOS,Anxiety state NOS,Other alter consciousnes,Hypertension NOS,Aftrce traum fx bone NEC,Adv eff opiates,Depend-supplement oxygen
Admission Date:  [**2178-8-7**]              Discharge Date:   [**2178-8-15**]

Date of Birth:  [**2114-6-9**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Lethargy


Major Surgical or Invasive Procedure:
Intubation/ventilation twice


History of Present Illness:
Mrs [**Known lastname 74676**] is a 64F discharged to rehab 2d prior for admission
after mechanical fall and bilateral wrist fx p/w lethargy, now
presenting with lethargy and respiratory distress.  Per
patient's husband, she had been doing well after recent
discharge, however he had visited her in rehab earlier today and
noted that she was more lethargic than usual.  Later on this
evening in rehab pt was noted to be more somnolent, without
increased SOB or difficulty breathing, and therefore EMS was
called.  On arrival to the nursing facility, EMS noted a L
facial droop.  According to her family, pt had no other
complaints leading up to this event.
.
In the ED, initial vitals were 78% on RA RR 20-30, HR 80-100,
BPs 150-180 systolic.  Pt was initially interacting with family
but became confused and unable to answer questions, was SOB with
hypoxia to the 70s on 3 L NC.  She was given oxycodone and nebs.
 Given her desaturations to the 70s with tachycardic
hypertension and hypercarbia, pt was intubated.  CXR showed
severe emphysema, head CT was negative.  Rectal exam was
performed given severe crit drop and was negative.  Pt was also
seen by neuro out of concern for stroke, however this was
thought to be unlikely.
..
ROS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.


Past Medical History:
COPD/severe emphysema on 3-5L home O2 and FEV1=13% predicted,
baseline sat 80-85%
HTN
anxiety


Social History:
Independent with ambulation. H/o smoking [**2-1**] ppd for 25 years.
Denies alcohol or drugs.

Family History:
Non-contributory.

Physical Exam:
On Admission:
VS: Temp:98.6 BP: 124/49 HR:102 RR:20 O2sat 98%
GEN: intubated, sedated
HEENT: PERRL, EOMI, anicteric, MMM, ETT in place, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
CV: RR, S1 and S2 wnl, no m/r/g
RESP: CTA b/l, prolongued expiratory phase, no W/r/r
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: opens eyes to voice, follows commands

On discharge:
GEN: NAD, sitting up in bed, alert
HEENT: Right eye with surrounding ecchymoses, PERRL, EOMI, oral
mucosa moist
NECK: Supple, no JVD
PULM: Minimal air movement on exam without audible wheezing or
crackles
CARD: RR, nl S1, nl S2, no M/R/G
ABD: Soft, BS+, NT, ND
EXT: No cyanosis or edema
NEURO: Oriented to place, day of week, clinical situation, month
and year, not oriented to date (16th)


Pertinent Results:
ADMISSION LABS:
[**2178-8-7**] 09:05PM BLOOD WBC-8.4 RBC-2.92* Hgb-9.2* Hct-28.3*
MCV-97 MCH-31.6 MCHC-32.5 RDW-12.2 Plt Ct-382

[**2178-8-7**] 09:05PM BLOOD PT-11.8 PTT-19.1* INR(PT)-1.0

[**2178-8-7**] 09:05PM BLOOD Glucose-113* UreaN-18 Creat-0.5 Na-143
K-4.4 Cl-93* HCO3-44* AnGap-10

[**2178-8-7**] 09:05PM BLOOD ALT-13 AST-24 AlkPhos-45 TotBili-0.4

[**2178-8-7**] 09:05PM BLOOD Calcium-9.4 Phos-4.1 Mg-2.0

[**2178-8-8**] 05:14AM BLOOD calTIBC-226* VitB12-309 Folate-19.3
Ferritn-113 TRF-174*

[**2178-8-8**] 02:00AM BLOOD Rates-/25 pO2-56* pCO2-95* pH-7.31*
calTCO2-50*

[**2178-8-8**] 06:02PM BLOOD Lactate-0.7

DISCHARGE LABS:
[**2178-8-15**] 03:12AM BLOOD WBC-10.8 RBC-2.55* Hgb-8.0* Hct-25.3*
MCV-99* MCH-31.3 MCHC-31.6 RDW-13.4 Plt Ct-384
[**2178-8-15**] 03:12AM BLOOD Plt Ct-384
[**2178-8-15**] 03:12AM BLOOD Glucose-152* UreaN-18 Creat-0.4 Na-144
K-4.6 Cl-94* HCO3-45* AnGap-10
[**2178-8-15**] 03:12AM BLOOD Calcium-8.8 Phos-4.0 Mg-1.7

ANEMIA W/U:
[**2178-8-8**] 05:14AM BLOOD calTIBC-226* VitB12-309 Folate-19.3
Ferritn-113 TRF-174*

most recent VBG:
[**2178-8-14**] 04:51AM BLOOD Type-[**Last Name (un) **] Temp-37.2 pO2-47* pCO2-93*
pH-7.35 calTCO2-54* Base XS-20 Intubat-NOT INTUBA

MICRO:
[**2178-8-8**] 1:30 am URINE     Site: NOT SPECIFIED
                            **FINAL REPORT [**2178-8-9**]**
   URINE CULTURE (Final [**2178-8-9**]):    NO GROWTH.

[**2178-8-12**] 10:21 am SPUTUM      Source: Endotracheal.

   GRAM STAIN (Final [**2178-8-12**]):
      [**11-24**] PMNs and <10 epithelial cells/100X field.
      NO MICROORGANISMS SEEN.

   RESPIRATORY CULTURE (Final [**2178-8-14**]):
      SPARSE GROWTH Commensal Respiratory Flora.

   LEGIONELLA CULTURE (Preliminary):    NO LEGIONELLA ISOLATED.

   FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.

Blood cultures 7/13, [**8-13**]: pending

STUDIES:
CXR [**2178-8-7**]:
IMPRESSION: COPD. No acute cardiopulmonary process.

CXR [**2178-8-8**]:
The lungs are hyperinflated and the diaphragms are flattened,
consistent with COPD. There is probable mild cardiomegaly. There
is upper zone
redistribution, without other definite evidence of CHF. There is
slight
prominence of markings at both lung bases, new compared with
[**2178-8-7**]. These
could represent small pneumonic infiltrates or areas aspiration.
The
differential includes an atypical distribution of CHF, in the
setting of
considerable parenchymal scarring, but this is considered less
likely.

Focal density in the right lung apex appears to represent
overlap of vascular and osseous shadows. Attention to this area
on followup films is recommended.

CT HEAD W/O:
IMPRESSION: No acute intracranial process.

CXR [**2178-8-8**]:
ET tube is in standard position. The tip is 5.7 cm above the
carina. NG tube tip is out of view below the diaphragm.
Cardiomediastinal contours are normal. There is no pneumothorax
or pleural effusion. The lungs are
hyperinflated consistent with emphysema. Atelectases in the left
base are
minimal.

CTA CHEST [**2178-8-11**]:
IMPRESSION:
No CT evidence of central or segmental pulmonary emboli.
Panlobular emphysema.
Atelectatis in the right lower lobe, right middle lobe and
lingula.
Stable calcified right adrenal nodule which is likely a sequela
to previous adrenal hemorrhage.

CXR [**2178-8-14**]:
Cardiomediastinal contours are normal. The lungs are
hyperinflated consistent with emphysema. There are no lung
consolidations or evidence of pulmonary edema, pneumothorax or
pleural effusion.


Brief Hospital Course:
64 yo woman with history of COPD, presenting from rehab with AMS
and lethargy most likely secondary to opioid use, found to be in
respiratory distress with hypercarbia and hypoxia. Pt was
intubated and transferred to the MICU.

# Lethargy/AMS: Initial AMS most likely secondary to medication
effect. Patient presented with AMS and lethargy, however was
responsive and interactive.  O2 requirements and somnolence
worsened after a dose of oxycodone while in the ED. MS [**First Name (Titles) 1095**] [**Last Name (Titles) 41963**]d by hypercarbia/hypoxia.  Low concern for infectious
process initially given no fever, leukocytosis or localizing
symptoms prior on admission, nl UA. Cultures revealed no growth
to date including blood, sputum, urine, and stool. Her mental
status cleared as her hypercarbia improved.

# Hypoxia, hypercarbic respiratory distress: Likely due to
COPD/severe emphysema on 3-5L home O2 and FEV1=13% predicted.
Given recent surgery and sudden onset of sympoms, also
considered PE given hypoxia out of proportion to lung disease
and ruled out with CTA. No signs of PNA or COPD flare and the
inciting insult causing her respiratory failure was thought to
be oversedation in someone who is very sensitive given her very
poor lung function. Pt was extubated on HOD#1; however, pt again
had hypercarbia, and dyspnea requiring re-intubation. She was
started on IV steroids and Azithromycin for COPD exacerbation
for optimization. She was able to be weaned off the ventilator
on [**2178-8-12**] with transition directly to facemask and continued to
improve for the next two hospital days. She was discharged on a
prednisone taper. She will have continued BiPAP as needed at
LTAC. She will continue to follow with Dr. [**Last Name (STitle) 575**] and [**Hospital1 **] as an outpatient for lung transplant evaluation.

# L distal radius fx: s/p closure and reduction with improved
alignment on post-reduction plain films. Receiving antibiotics
to prevent infection and oxycodone and tylenol for pain prior to
admission. Completed Keflex 500 mg Capsule QID for 10 days (day
1 was [**2178-8-1**], last day [**2178-8-10**]), Tylenol for pain. Ortho was
consulted while an inpatient and repeated x-rays that were
unremarkable. Casts were changed on [**2178-8-14**]. She should follow
up in ortho clinic after discharge.

# HTN: Normotensive on admission, continued lisinopril 20 mg
daily, but increased to 30mg daily due to persistent
hypertension.

# Anxiety: Held clonazepam (prn medication) initially in the
MICU given presentation of lethargy as discussed above.
Post-extubation, she was given small doses of Ativan for
anxiety. Restarted on home Clonazepam prn on discharge, with
holding parameters for sedation, or low respiratory rate.

# Anemia: Mildly decreased from recent baseline. Pt had no
active bleeding and was guaiac negative. Iron studies c/w
possible ACD or mixed picture. Vitamin B12 level 309, could
consider workup with MMA vs. empiric treatment with Vitamin B12.
Could consider outpatient colonoscopy with her PCP, [**Name10 (NameIs) **] would be
challenging given sedation issues as above.

# Left facial droop: Concern for stroke initially; however,
evaluated by neuro who was not concerned for acute stroke. There
was no further focal neurologic findings during her MICU course.


TRANSITIONAL CARE:
1. CODE: FULL
2. CONTACT: HUSBAND
3. RISKS TO RE-HOSPITALIZATION: severe COPD, requiring
intubation
4. MEDICAL MANAGEMENT: steroid taper, start spiriva, continue
symbicort, pulmonary rehab at LTAC; try to avoid oversedation
with benzos or pain medications

Medications on Admission:
Medications at home (per last DC summary [**2178-8-2**]):
acetaminophen 325 mg Q6H
docusate sodium 100 mg [**Hospital1 **]
Symbicort 160-4.5 mcg/Actuation [**2-1**] Inh [**Hospital1 **]
lisinopril 20 mg DAILY
clonazepam 0.5 mg [**Hospital1 **]:PRN
oxycodone 5 mg [**2-1**] tab Q3H:PRN
ipratropium bromide 17 mcg/Actuation HFA Aerosol 3 puffs TID
Keflex 500 mg Capsule QID for 10 days (day 1 was [**2178-8-5**])


Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna Laxative 8.6 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for Constipation.
3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8 PRN  ()
as needed for pain.
5. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): Sliding scale.
6. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
7. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
8. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO twice a day.
9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for sob,
wheezing.
11. prednisone 5 mg Tablet Sig: 1-6 Tablets PO once a day: -40mg
by mouth daily x 4 days ([**Date range (1) 74677**])
-then 30mg by mouth daily x 4 days ([**Date range (1) 18858**])
-then 20mg by mouth daily x 4 days ([**Date range (1) 57841**])
-then 10mg by mouth x 4 days ([**Date range (1) 74678**])
-then 5mg by mouth x 4 days ([**Date range (1) 74679**])
.
12. dextrose 50% in water (D50W)     Syringe Sig: One (1)
Intravenous PRN (as needed) as needed for hypoglycemia protocol.

13. Sodium Chloride 0.9%  Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
14. lisinopril 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
16. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for anxiety: hold for sedation, RR<12.
17. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: [**2-1**]
puffs Inhalation twice a day.
18. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1)  Inhalation once a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 700**] TCU - [**Location (un) 701**]

Discharge Diagnosis:
1) Severe chronic obstructive pulmonary disease
2) Hypercarbic respiratory failure
3) Hypoxia
4) Bilateral wrist fractures
5) Anxiety
6) Delerium
7) Anemia
8) Hypertension


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


Discharge Instructions:
Dear Ms. [**Known lastname 74676**],

It was a pleasure taking care of you here at [**Hospital1 18**]. You were
admitted for respiratory failure, secondary to sedating pain
medications. You intubated twice, and extubated twice, and were
slow to recover your breathing function due to your severe lung
disease. As you know, continuing to quit smoking, frequent
inhaler use as prescribed, and pulmonary physical therapy are
the keys to your recovery. In the long term, you should continue
to follow with Dr. [**Last Name (STitle) 575**], and [**Hospital6 1708**]
for lung transplant evaluation.
You were also seen by the orthopedic doctors [**Name5 (PTitle) 1028**] [**Name5 (PTitle) **] were
here, and your casts were replaced.

We have made the following changes to your medications:
1) START taking prednisone taper starting with
-40mg by mouth daily x 4 days ([**Date range (1) 74677**])
-then 30mg by mouth daily x 4 days ([**Date range (1) 18858**])
-then 20mg by mouth daily x 4 days ([**Date range (1) 57841**])
-then 10mg by mouth x 4 days ([**Date range (1) 74678**])
-then 5mg by mouth x 4 days ([**Date range (1) 74679**])
-then stop
2) CONTINUE taking symbicort inhaler twice daily
3) START taking albuterol inhalers every 4 hours
4) START taking spiriva inhaler daily
5) START doing chest physical therapy daily
6) START Seroquel 12.5mg twice daily
7) INCREASE dose of Lisinopril to 30mg daily
8) START Insulin sliding scale as needed for hyperglycemia
9) START Calcium & Vitamin D for bone health

Followup Instructions:
Please follow up in ortho trauma clinic in [**8-9**] days with [**Doctor Last Name **]

[**Name8 (MD) **], NP. Please call [**Telephone/Fax (1) 1228**] to make an appointment.

Department: PULMONARY FUNCTION LAB
When: TUESDAY [**2178-10-13**] at 9:00 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: PFT
When: TUESDAY [**2178-10-13**] at 9:00 AM

Department: MEDICAL SPECIALTIES
When: TUESDAY [**2178-10-13**] at 9:30 AM
With: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage



Completed by:[**2178-8-15**]
{'Acute and chronic respiratory failure,Obstructive chronic bronchitis with (acute) exacerbation,Drug-induced delirium,Hyperosmolality and/or hypernatremia,Anemia, unspecified,Anxiety state, unspecified,Other alteration of consciousness,Unspecified essential hypertension,Aftercare for healing traumatic fracture of other bone,Other opiates and related narcotics causing adverse effects in therapeutic use,Other dependence on machines, supplemental oxygen'}


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: Lethargy

PRESENT ILLNESS: Mrs [**Known lastname 74676**] is a 64F discharged to rehab 2d prior for admission
after mechanical fall and bilateral wrist fx p/w lethargy, now
presenting with lethargy and respiratory distress.  Per
patient's husband, she had been doing well after recent
discharge, however he had visited her in rehab earlier today and
noted that she was more lethargic than usual.  Later on this
evening in rehab pt was noted to be more somnolent, without
increased SOB or difficulty breathing, and therefore EMS was
called.  On arrival to the nursing facility, EMS noted a L
facial droop.  According to her family, pt had no other
complaints leading up to this event.
.
In the ED, initial vitals were 78% on RA RR 20-30, HR 80-100,
BPs 150-180 systolic.  Pt was initially interacting with family
but became confused and unable to answer questions, was SOB with
hypoxia to the 70s on 3 L NC.  She was given oxycodone and nebs.
 Given her desaturations to the 70s with tachycardic
hypertension and hypercarbia, pt was intubated.  CXR showed
severe emphysema, head CT was negative.  Rectal exam was
performed given severe crit drop and was negative.  Pt was also
seen by neuro out of concern for stroke, however this was
thought to be unlikely.
..
ROS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.

MEDICAL HISTORY: COPD/severe emphysema on 3-5L home O2 and FEV1=13% predicted,
baseline sat 80-85%
HTN
anxiety

MEDICATION ON ADMISSION: Medications at home (per last DC summary [**2178-8-2**]):
acetaminophen 325 mg Q6H
docusate sodium 100 mg [**Hospital1 **]
Symbicort 160-4.5 mcg/Actuation [**2-1**] Inh [**Hospital1 **]
lisinopril 20 mg DAILY
clonazepam 0.5 mg [**Hospital1 **]:PRN
oxycodone 5 mg [**2-1**] tab Q3H:PRN
ipratropium bromide 17 mcg/Actuation HFA Aerosol 3 puffs TID
Keflex 500 mg Capsule QID for 10 days (day 1 was [**2178-8-5**])

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On Admission:
VS: Temp:98.6 BP: 124/49 HR:102 RR:20 O2sat 98%
GEN: intubated, sedated
HEENT: PERRL, EOMI, anicteric, MMM, ETT in place, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
CV: RR, S1 and S2 wnl, no m/r/g
RESP: CTA b/l, prolongued expiratory phase, no W/r/r
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: opens eyes to voice, follows commands

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: Independent with ambulation. H/o smoking [**2-1**] ppd for 25 years.
Denies alcohol or drugs. 

### Response:
{'Acute and chronic respiratory failure,Obstructive chronic bronchitis with (acute) exacerbation,Drug-induced delirium,Hyperosmolality and/or hypernatremia,Anemia, unspecified,Anxiety state, unspecified,Other alteration of consciousness,Unspecified essential hypertension,Aftercare for healing traumatic fracture of other bone,Other opiates and related narcotics causing adverse effects in therapeutic use,Other dependence on machines, supplemental oxygen'}
