CHIEF COMPLAINT: Mental status change, abdominal pain

PRESENT ILLNESS: Ms. [**Known lastname 4636**] is a 71 yo wheel-chair bound woman with
paraplegia, hypertension, and question of COPD who was admitted
on [**9-11**] with altered mental status.   Per the patient, she had
been experiencing constipation for 5-6 days prior to admission.
She did have a small BM on the morning of admission. On the day
of admission, the patient reported feeling sweaty and dizzy, and
dropped a cup of tea onto her lap.  Her neighbor who was
visiting noticed she was weak and dysarthric, and called
lifeline who then brought the patient to the ED.
.
In the ED, her initial vitals were temp 99.5, bp 113/44, HR 96,
RR 16, SaO2 96% on NRB.  Her bp decreased to 81/38 in the ED and
she became unable to respond to commands, so she was given 4 L
NS.  Her bp slightly improved to 91/45.  She also had a large
loose BM in ED.  A right IJ was placed.  UA was nitrite positive
with moderate bacteria.  CXR was concerning for left lower lobe
pneumonia.  The patient was thought to have sepsis [**1-6**] to PNA
vs. UTI, and she was given Vancomycin 1 mg IV x1, Levaquin 750
mg IV x1, and Tylenol PR 1 gm x1 and transferred to the MICU.
.
In the MICU the patient was started on Levophed for pressure
support.  WBC 19.6 with a left shift, Lactate 3.4 -> 2.2.  She
was initially drowsy and lethargic.  She then complained of
being constipated, despite having repeated episodes of loose
stool since arrival to the MICU.  She complained of low back
pain & LLQ. No CP/SOB or cough. Other ROS negative.  The
patient's family reports that she often develops similar MS
changes when she has an infection.
.
Currently, the patient reports a 2 day history of servere
([**9-12**]) constant burning lower midline abdominal pain that
radiates down to her rectum.  She says this is similar pain to
what she experienced when she was admitted [**12-11**].  No back pain
though she is unsure if she would sense back pain. She also
notes severe diarrhea and loose stools since admission.  She
reports a cough occasionally productive of light brown mucous.
Denies HA, fevers/chills.

MEDICAL HISTORY: 1. Hypertension
2. Hyperlipidemia
3. Paraplegia (From Anterior Spinal Infarct sustained during a
thoracic aneurysm repair)
4. Suprapubic Catheter in place, recurrent UTIs ? on Ppx Bactrim

MEDICATION ON ADMISSION: MEDICATIONS (confirmed w/ [**Location (un) 1226**] pharmacy [**Telephone/Fax (1) 4642**]):
1. Baclofen 40 mg TID
2. Gabapentin 900 mg PO TID (3 times a day).
3. Nortriptyline 50 mg qhs
4. Lactulose 1 tablespoon [**Hospital1 **]
5. Bupropion SR 100 mg [**Hospital1 **]
6. Furosemide alternating 40 mg and 80 mg every other day.
7. Advair 250/50 one puff [**Hospital1 **]
8. Duonebs one amp QID prn
9. Nystatin powder
.
ALLERGIES: NKDA

ALLERGIES: Adhesive Tape

PHYSICAL EXAM: Vitals: temp 97.7, bp 130/70, HR 80, RR 20, SaO2 96% on 2L
Gen: Obese female in no distress. Alert and oriented to person,
place, and time.
HEENT: Slera anicteric. NCAT. EOMI. MMM. No pharyngeal erythema.
No nuchal rigidity.
CV: Regular rate.  Nl S1, S2, No murmur, rub, gallop.
Pulm: CTA anteriorly and laterally. No wheezes/rhonchi.
Abd: Positive bowel sounds.  Soft and obese abdomen. Tender
diffusely, but especially in periumbilical area.  Has decreased
senstaion of lateral abdominal wall.  No guarding, positive
rebound in the midline.  Tympanitic to percussion.  No masses.
Suprapubic catheter in place and the surrounding area is not
erythematous.  Rectal tube in place.
Ext: Trace lower extremity edema, stockings on.
Neuro: Sensory level on abdomen at approx T6.  Full [**4-7**] UE
strength, 0/0 LE strength.  PERRL. CN II-XII intact.

FAMILY HISTORY: Son: DM.

SOCIAL HISTORY: The patient lives alone in [**Hospital3 4634**]. Wheelchair bound.
She has a health aid for assistance in the morning and evening,
for help with dressing and bathing.  Her son usually prepares
her food.  Has son, [**Name (NI) **], & dtr in-law, [**Name (NI) 1439**], are her HCPs.
They see pt ~wkly. The patient has a 2-3ppd x 40+ years, but has
smoked +/- (3 cigarettes/day) for the past 5 yrs. No EtOH or
illicit drug use.
Pneumonia, organism unspecified,Anomalies of cerebrovascular system,Urinary tract infection, site not specified,Unspecified vascular insufficiency of intestine,Paraplegia,Chronic airway obstruction, not elsewhere classified,Other specified hypotension,Benign neoplasm of colon,Other and unspecified hyperlipidemia,Other constipation,Depressive disorder, not elsewhere classified,Esophageal reflux,Unspecified essential hypertension,Leukocytosis, unspecified,Other artificial opening of urinary tract status,Other dependence on machines, supplemental oxygen,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits
Pneumonia, organism NOS,Cerebrovascular anomaly,Urin tract infection NOS,Vasc insuff intest NOS,Paraplegia NOS,Chr airway obstruct NEC,Hypotension NEC,Benign neoplasm lg bowel,Hyperlipidemia NEC/NOS,Constipation NEC,Depressive disorder NEC,Esophageal reflux,Hypertension NOS,Leukocytosis NOS,Urinostomy status NEC,Depend-supplement oxygen,Hx TIA/stroke w/o resid
Admission Date:  [**2136-9-11**]              Discharge Date:   [**2136-9-15**]

Date of Birth:  [**2065-8-18**]             Sex:   F

Service: MEDICINE

Allergies:
Adhesive Tape

Attending:[**First Name3 (LF) 4052**]
Chief Complaint:
Mental status change, abdominal pain

Major Surgical or Invasive Procedure:
Flexible Sigmoidoscopy
Right IJ intravenous catheter placement


History of Present Illness:
Ms. [**Known lastname 4636**] is a 71 yo wheel-chair bound woman with
paraplegia, hypertension, and question of COPD who was admitted
on [**9-11**] with altered mental status.   Per the patient, she had
been experiencing constipation for 5-6 days prior to admission.
She did have a small BM on the morning of admission. On the day
of admission, the patient reported feeling sweaty and dizzy, and
dropped a cup of tea onto her lap.  Her neighbor who was
visiting noticed she was weak and dysarthric, and called
lifeline who then brought the patient to the ED.
.
In the ED, her initial vitals were temp 99.5, bp 113/44, HR 96,
RR 16, SaO2 96% on NRB.  Her bp decreased to 81/38 in the ED and
she became unable to respond to commands, so she was given 4 L
NS.  Her bp slightly improved to 91/45.  She also had a large
loose BM in ED.  A right IJ was placed.  UA was nitrite positive
with moderate bacteria.  CXR was concerning for left lower lobe
pneumonia.  The patient was thought to have sepsis [**1-6**] to PNA
vs. UTI, and she was given Vancomycin 1 mg IV x1, Levaquin 750
mg IV x1, and Tylenol PR 1 gm x1 and transferred to the MICU.
.
In the MICU the patient was started on Levophed for pressure
support.  WBC 19.6 with a left shift, Lactate 3.4 -> 2.2.  She
was initially drowsy and lethargic.  She then complained of
being constipated, despite having repeated episodes of loose
stool since arrival to the MICU.  She complained of low back
pain & LLQ. No CP/SOB or cough. Other ROS negative.  The
patient's family reports that she often develops similar MS
changes when she has an infection.
.
Currently, the patient reports a 2 day history of servere
([**9-12**]) constant burning lower midline abdominal pain that
radiates down to her rectum.  She says this is similar pain to
what she experienced when she was admitted [**12-11**].  No back pain
though she is unsure if she would sense back pain. She also
notes severe diarrhea and loose stools since admission.  She
reports a cough occasionally productive of light brown mucous.
Denies HA, fevers/chills.


Past Medical History:
1. Hypertension
2. Hyperlipidemia
3. Paraplegia (From Anterior Spinal Infarct sustained during a
thoracic aneurysm repair)
4. Suprapubic Catheter in place, recurrent UTIs ? on Ppx Bactrim

5. Fecal Incontinence
6. ? COPD: Per PCP note, patient is CO2 retainer. PFTs on [**3-/2129**]
showed FVC 3.59 (104% pred) and FEV1 2.66 (105% pred). On 2L
home O2 at night.
7. s/p Thoracic Aneurysm Repair ([**2128**])
8. LLL Collapse/PNA s/p mucous plug removal via bronchoscopy
9. GERD
10. Depression

Social History:
The patient lives alone in [**Hospital3 4634**]. Wheelchair bound.
She has a health aid for assistance in the morning and evening,
for help with dressing and bathing.  Her son usually prepares
her food.  Has son, [**Name (NI) **], & dtr in-law, [**Name (NI) 1439**], are her HCPs.
They see pt ~wkly. The patient has a 2-3ppd x 40+ years, but has
smoked +/- (3 cigarettes/day) for the past 5 yrs. No EtOH or
illicit drug use.

Family History:
Son: DM.

Physical Exam:
Vitals: temp 97.7, bp 130/70, HR 80, RR 20, SaO2 96% on 2L
Gen: Obese female in no distress. Alert and oriented to person,
place, and time.
HEENT: Slera anicteric. NCAT. EOMI. MMM. No pharyngeal erythema.
No nuchal rigidity.
CV: Regular rate.  Nl S1, S2, No murmur, rub, gallop.
Pulm: CTA anteriorly and laterally. No wheezes/rhonchi.
Abd: Positive bowel sounds.  Soft and obese abdomen. Tender
diffusely, but especially in periumbilical area.  Has decreased
senstaion of lateral abdominal wall.  No guarding, positive
rebound in the midline.  Tympanitic to percussion.  No masses.
Suprapubic catheter in place and the surrounding area is not
erythematous.  Rectal tube in place.
Ext: Trace lower extremity edema, stockings on.
Neuro: Sensory level on abdomen at approx T6.  Full [**4-7**] UE
strength, 0/0 LE strength.  PERRL. CN II-XII intact.

Pertinent Results:
LABS:
[**2136-9-11**] 08:25PM BLOOD WBC-19.6*# RBC-5.60* Hgb-17.1* Hct-50.5*
MCV-90 MCH-30.4 MCHC-33.7 RDW-16.0* Plt Ct-322
[**2136-9-15**] 06:45AM BLOOD WBC-8.5 RBC-4.06* Hgb-12.3 Hct-36.5
MCV-90 MCH-30.4 MCHC-33.8 RDW-15.7* Plt Ct-198
[**2136-9-11**] 08:25PM BLOOD Neuts-87.7* Lymphs-9.1* Monos-2.4 Eos-0.4
Baso-0.3
[**2136-9-12**] 05:47AM BLOOD PT-12.4 PTT-23.8 INR(PT)-1.1
[**2136-9-11**] 08:25PM BLOOD Glucose-270* UreaN-16 Creat-0.7 Na-136
K-4.5 Cl-94* HCO3-27 AnGap-20
[**2136-9-15**] 06:45AM BLOOD Glucose-150* UreaN-2* Creat-0.4 Na-144
K-3.0* Cl-108 HCO3-25 AnGap-14
[**2136-9-12**] 02:12AM BLOOD ALT-45* AST-53* LD(LDH)-203 CK(CPK)-50
AlkPhos-134* Amylase-63 TotBili-0.4
[**2136-9-12**] 12:46PM BLOOD CK(CPK)-55
[**2136-9-12**] 07:40PM BLOOD CK(CPK)-42
[**2136-9-13**] 07:15AM BLOOD CK(CPK)-37
[**2136-9-14**] 07:15AM BLOOD ALT-36 AST-30 LD(LDH)-200 AlkPhos-101
Amylase-29 TotBili-0.2
[**2136-9-12**] 02:12AM BLOOD Lipase-18
[**2136-9-14**] 07:15AM BLOOD Lipase-21
[**2136-9-12**] 02:12AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2136-9-12**] 12:46PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2136-9-12**] 07:40PM BLOOD CK-MB-NotDone cTropnT-0.01
[**2136-9-13**] 07:15AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2136-9-12**] 02:12AM BLOOD Albumin-3.5 Calcium-7.6* Phos-3.2 Mg-2.5
[**2136-9-14**] 07:15AM BLOOD Albumin-3.0* Cholest-160
[**2136-9-14**] 07:15AM BLOOD Triglyc-182* HDL-36 CHOL/HD-4.4
LDLcalc-88 LDLmeas-98
[**2136-9-13**] 01:02PM BLOOD %HbA1c-5.9
[**2136-9-12**] 03:30AM BLOOD Type-ART Temp-35.6 O2 Flow-4 pO2-92
pCO2-45 pH-7.32* calTCO2-24 Base XS--3 Intubat-NOT INTUBA
[**2136-9-11**] 08:33PM BLOOD Lactate-3.4*
[**2136-9-11**] 11:02PM BLOOD Lactate-2.2*
[**2136-9-13**] 10:59AM BLOOD Lactate-1.0
[**2136-9-11**] 09:25PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.021
[**2136-9-11**] 09:25PM URINE Blood-NEG Nitrite-POS Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-NEG pH-5.0 Leuks-TR
[**2136-9-11**] 09:25PM URINE RBC-0-2 WBC-[**2-6**] Bacteri-MOD Yeast-NONE
Epi-0-2 TransE-0-2
[**2136-9-11**] 09:25PM URINE CastHy-[**5-13**]*
[**2136-9-13**] 08:23PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006
[**2136-9-13**] 08:23PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
.
MICRO:
Blood Cx ([**9-11**]): No growth x4
.
Urine Cx ([**9-11**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES),
CONSISTENT WITH FECAL CONTAMINATION.
.
Stool Cx ([**9-12**]):
   FECAL CULTURE (Final [**2136-9-14**]):    NO SALMONELLA OR SHIGELLA
FOUND.

   CAMPYLOBACTER CULTURE (Final [**2136-9-14**]):    NO CAMPYLOBACTER
FOUND.

   OVA + PARASITES (Final [**2136-9-13**]):
      NO OVA AND PARASITES SEEN.
      This test does not reliably detect Cryptosporidium,
Cyclospora or
      Microsporidium. While most cases of Giardia are detected
by routine
      O+P, the Giardia antigen test may enhance detection when
organisms
      are rare.

   FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2136-9-13**]):
      NO E.COLI 0157:H7 FOUND.

   CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2136-9-13**]):
      FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.

   OVA + PARASITES (Final [**2136-9-13**]):
      NO OVA AND PARASITES SEEN.
.
Urine Cx ([**9-12**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
.
Stool Cx ([**9-13**]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
.
Urine Cx ([**9-13**]): YEAST.    ~1000/ML.
.
IMAGING:
CXR Portable ([**9-11**]): IMPRESSION: Findings concerning for left
lower lobe pneumonia.
.
CXR Portable ([**9-11**]): FINDINGS: There has been interval placement
of a right IJ intravenous catheter with its tip projecting over
the expected location of the lower SVC. The upper vascular
redistribution as well as interstitial edema is more prominent
in the supine view. Again seen is an area of increased opacity
projecting over the left mid lung. There is no supine evidence
of pneumothorax.
IMPRESSION:
1. No pneumothorax.
2. Findings concerning for left lower lobe pneumonia.
3. Pulmonary vascular redistribution and interstitial edema.
.
ECG ([**9-12**]): Sinus rhythm at a rate of 62 with prolonged P-R
interval to 224. Left axis deviation. Poor R wave progression.
Consider anterior myocardial infarction, age undetermined. Since
prior tracing of [**2135-12-12**] left atrial abnormality is not seen on
the current tracing.
.
CT Head ([**9-12**]): There is no acute intracranial hemorrhage.
There is no mass, edema or shift of normally midline structures.
Extensive periventricular white matter hypodensities are present
again. There is an area of new and more conspicuous and
extensive hypodensity in the left frontal lobe, extending to the
cortex and subcortical white matter.
Surrounding soft tissues and osseous structures are
unremarkable.
Imaged mastoid air cells are well aerated. There is mucosal
thickening in the maxillary sinuses, bilaterally, as well as
ethmoid and sphenoid sinuses.
IMPRESSION:
1. No acute intracranial hemorrhage.
2. New and more conspicuous area of left frontal hypodensity,
which may represent acute infarction. Evaluation with MR [**First Name (Titles) 151**] [**Last Name (Titles) 4639**]n-weighted sequence is recommended.
.
TTE ([**9-12**]): The left atrium is normal in size. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and systolic function (LVEF=60-65%). Right ventricular chamber
size and free wall motion are normal. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Normal biventricular systolic function. Mild
pulmonary artery systolic hypertension.
.
CT Abdomen/Pelvis ([**9-12**]):
Left basilar atelectasis is again noted.
Diffuse fatty infiltration of the liver is incidentally seen.
Adrenal glands, pancreas, and spleen appear grossly
unremarkable. Numerous gallstones are identified. Simple right
renal cyst is seen. Also, several small hypoattenuating foci are
seen within the kidneys bilaterally, which are too small to
characterize but likely represent simple cysts.
Evaluation of the bowel reveals mural thickening involving the
sigmoid colon as well as a portion of the rectum. Surrounding
fat stranding is noted consistent with inflammation. This is a
nonspecific imaging finding. Differential considerations do
include inflammatory and infectious etiologies as well as
ischemia. In retrospect on the prior exam dated [**2134-9-12**], there
is suggestion of distal sigmoid and rectal wall thickening to
suggest chronicity _____ recurrence of this disease process.
Pelvic structures are grossly unremarkable. A rectal tube and
Foley catheter are noted.
No lytic or blastic bony lesions are identified. Multiple
Tarlov's cysts are again seen within the region of the sacrum.
IMPRESSION:
1. Sigmoid and rectal thickening as detailed above. This is a
nonspecific finding and may represent an infectious or
inflammatory etiologies as well as ischemia. Of note, this
similar though less diffuse findings were identified on a prior
CT scan dated [**2134-9-12**].
.
MR [**Name13 (STitle) 430**]/MRA Brain ([**9-13**]): IMPRESSION:
1. No acute infarct.
2. FLAIR hyperintense foci consistent with chronic microvascular
infarcts in the white matter of both cerebral hemispheres.
3. Maxillary sinus disease.

Brief Hospital Course:
# Abdominal pain/Diarrhea: The patient reported constipation for
the 5-6 days prior to admission. In the MICU, she complained of
being constipated, despite having repeated episodes of loose
stool since arrival to the MICU. She was empirically started on
Flagyl. Once she was on the medicine floor, she reported a 2 day
history of servere ([**9-12**]) constant burning lower midline
abdominal pain that radiated down to her rectum. She also
complained of severe diarrhea and loose stools since admission.
CT abdomen/pelvis showed sigmoid and rectal thickening which is
a nonspecific finding and may represent infectious or
inflammatory etiologies as well as ischemia. Serial exams showed
a soft abdomen. Stools were guaiac positive. Stools were
negative for C. difficile x2 and O&P x2. Of note, her admission
in [**12-11**] noted "that the patient developed burning rectal pain
during course of admission" which was felt to be secondary to
referred neuropathic pain. GI was consulted as there was concern
for ischemic colitis given the patient's recent hypotension and
lactate of 3.4 on admission. She went for flexible sigmoidoscopy
on [**9-14**] which showed erythema and edema in the mid-sigmoid
colon and distal sigmoid colon compatible with colitis, and a
polyp in the mid-descending colon which was not removed since
the patient was on heparin SQ. These findings were compatible
with a resolving colitis including ischemic or infectious
etiologies. The patient was scheduled for a screening
colonoscopy on [**11-6**] at which point the very small polyp, and any
others can be removed. She was discharged on Flagyl PO.
.
# Hypotension: On admission, the patient's blood pressure was
113/44, then decreased to 81/38 in the ED. She became unable to
respond to commands and was given 4 L NS with only slight
improvement to 91/45. A right IJ was placed, and the patient was
transferred to the MICU with concern for pneumonia or UTI
sepsis. She received Levophed, but it remains unclear if the
patient was truly hypotensive. The MICU team reported that
non-invasive BPs were 20 points below the arterial values. TTE
showed mild symmetric LVH, LVEF 60-65%, and mild pulmonary
artery systolic hypertension. Cardiac enzymes were negative x4.
Her Lasix was held upon discharge until the patient follows up
with Dr. [**Last Name (STitle) 1266**] as an outpatient.
.
# Mental status change: On the day of admission, the patient
reported feeling sweaty and dizzy, and dropped a cup of tea onto
her lap. Her neighbor who was visiting noticed she was weak and
dysarthric, and called lifeline who then brought the patient to
the ED. She continued to have waxing and [**Doctor Last Name 688**] mental status,
which was likely due to delirium in the setting of acute
illness. Head CT showed no acute intracranial hemorrhage but did
show a new and more conspicuous area of left frontal
hypodensity, which may represent acute infarction. Neurology was
consulted, and they did not believe that the head CT findings
were consistent with her presentation with bilateral upper
extremity weakness. MRI head/MRA brain showed no acute infarct,
and FLAIR hyperintense foci were consistent with chronic
microvascular infarcts in the white matter of both cerebral
hemispheres. HgA1c was 5.9%. She was started on ASA 81 mg daily.
.
# Pneumonia: On admission to the ED, the patient was afebrile,
but SaO2 was 96% on NRB and she had a WBC of 19.6 with 88%
neutrophils. Lactate was 3.4. CXR was concerning for left lower
lobe pneumonia. She became hypotensive in the ED, and there was
concern she had a pneumonia or UTI sepsis, so she was started on
Vancomycin and Ceftriaxone and transferred to the MICU (she also
got Levofloxacin in the ED). Blood cultures were negative, and
urine legionella antigen was negative. On day 3 of admission,
the Vancomycin was discontinued, and Azithromycin was started.
She was discharged on Levofloxacin daily to complete a 10 day
course.
.
# UTI: The patient has a suprapubic catheter, and is likely
chronically colonized. UA showed positive nitrite, trace
leukocytosis, [**2-6**] WBC, and moderate bacteria. Urine culture
showed fecal contamination, and the patient has a history of
fecal incontinence. She was initially started on Ceftriaxone
which was changed to Levofloxacin.
.
# GERD: She was started on Protonix 40 mg daily.
.
# Hyperlipidemia: Lipid panel during this admission showed Chol
160, TG 182, HDL 36, and LDL 88. She is not on any medications
for hyperlipidemia.
.
# Paraplegia: The patient is paraplegic from an Anterior Spinal
Infarct sustained during a thoracic aneurysm repair. She was
continued on Gabepentin 900 mg tid and Baclofen 40 mg tid.
.
# COPD: She is on 2 L home O2 at night. She was continued on
Advair and Duonebs.
.
# Depression: She was continued on Nortriptyline 50 mg qhs and
Bupropion SR 100 mg [**Hospital1 **].
.
# Code status: DNR/DNI - confirmed with [**Name (NI) 1439**] [**Name (NI) 4640**] (pt's
dtr-in-law & HCP)
.
# Contact: [**Name (NI) 2759**] [**Name (NI) **] [**Name (NI) 4636**] (son) & [**Name (NI) 1439**] [**Name (NI) 4640**]
(daughter-in-law) [**Telephone/Fax (1) 4635**]/ c [**Telephone/Fax (1) 4641**]

Medications on Admission:
MEDICATIONS (confirmed w/ [**Location (un) 1226**] pharmacy [**Telephone/Fax (1) 4642**]):
1. Baclofen 40 mg TID
2. Gabapentin 900 mg PO TID (3 times a day).
3. Nortriptyline 50 mg qhs
4. Lactulose 1 tablespoon [**Hospital1 **]
5. Bupropion SR 100 mg [**Hospital1 **]
6. Furosemide alternating 40 mg and 80 mg every other day.
7. Advair 250/50 one puff [**Hospital1 **]
8. Duonebs one amp QID prn
9. Nystatin powder
.
ALLERGIES: NKDA

Discharge Medications:
1. Baclofen 10 mg Tablet Sig: Four (4) Tablet PO TID (3 times a
day).
2. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
3. Nortriptyline 25 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
4. Bupropion 100 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Nystatin 100,000 unit/g Powder Topical
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) as
needed for GERD.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
9. DuoNeb 2.5-0.5 mg/3 mL Solution Sig: One (1) amp Inhalation
four times a day as needed for shortness of breath or wheezing.

10. medication
Nystatin powder
11. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
12. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
13. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Home With Service

Facility:
VNA carenetwork

Discharge Diagnosis:
PRIMARY
1. Abdominal Pain, Diarrhea
2. Chronic Microvascular Brain Infarcts
3. Hypotension
SECONDARY
1. Hypertension
2. Hyperlipidemia
3. Paraplegia (From Anterior Spinal Infarct sustained during a
thoracic aneurysm repair)
4. Suprapubic Catheter
5. Fecal Incontinence
6. COPD on 2L Home O2 at night
7. s/p Thoracic Aneurysm Repair ([**2128**])
8. GERD
9. Depression


Discharge Condition:
afebrile, tolerating oral diet, abdominal pain improved


Discharge Instructions:
You came to the hospital with confusion.  You experienced low
blood pressure and required a stay in the intensive care unit.
You then underwent a CAT scan of your abdomen and a flex sig of
your intestines.  It showed that you had some colitis.  Please
have a repeat colonoscopy in several months/years as an
outpatient.
.
1. Take all medications as prescribed
2. Make all follow-up appointments
3. If you develop fevers >101.5, chills, nausea, vomiting,
severe abdominal pain, weakness, or any other concerning
symptoms, contact your provider or report to the Emergency
Department
4.  Please continue your levoflox and flagyl for another 5 days.
5.  Please hold your lasix until you meet with Dr. [**Last Name (STitle) 1266**] to
discuss.
6.  We started you on aspirin daily
7.  We started you on protonix daily.

Followup Instructions:
Please follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1266**] [**Telephone/Fax (1) 608**] in [**12-6**]
weeks.


                             [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 4055**]
{'Pneumonia, organism unspecified,Anomalies of cerebrovascular system,Urinary tract infection, site not specified,Unspecified vascular insufficiency of intestine,Paraplegia,Chronic airway obstruction, not elsewhere classified,Other specified hypotension,Benign neoplasm of colon,Other and unspecified hyperlipidemia,Other constipation,Depressive disorder, not elsewhere classified,Esophageal reflux,Unspecified essential hypertension,Leukocytosis, unspecified,Other artificial opening of urinary tract status,Other dependence on machines, supplemental oxygen,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits'}


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: Mental status change, abdominal pain

PRESENT ILLNESS: Ms. [**Known lastname 4636**] is a 71 yo wheel-chair bound woman with
paraplegia, hypertension, and question of COPD who was admitted
on [**9-11**] with altered mental status.   Per the patient, she had
been experiencing constipation for 5-6 days prior to admission.
She did have a small BM on the morning of admission. On the day
of admission, the patient reported feeling sweaty and dizzy, and
dropped a cup of tea onto her lap.  Her neighbor who was
visiting noticed she was weak and dysarthric, and called
lifeline who then brought the patient to the ED.
.
In the ED, her initial vitals were temp 99.5, bp 113/44, HR 96,
RR 16, SaO2 96% on NRB.  Her bp decreased to 81/38 in the ED and
she became unable to respond to commands, so she was given 4 L
NS.  Her bp slightly improved to 91/45.  She also had a large
loose BM in ED.  A right IJ was placed.  UA was nitrite positive
with moderate bacteria.  CXR was concerning for left lower lobe
pneumonia.  The patient was thought to have sepsis [**1-6**] to PNA
vs. UTI, and she was given Vancomycin 1 mg IV x1, Levaquin 750
mg IV x1, and Tylenol PR 1 gm x1 and transferred to the MICU.
.
In the MICU the patient was started on Levophed for pressure
support.  WBC 19.6 with a left shift, Lactate 3.4 -> 2.2.  She
was initially drowsy and lethargic.  She then complained of
being constipated, despite having repeated episodes of loose
stool since arrival to the MICU.  She complained of low back
pain & LLQ. No CP/SOB or cough. Other ROS negative.  The
patient's family reports that she often develops similar MS
changes when she has an infection.
.
Currently, the patient reports a 2 day history of servere
([**9-12**]) constant burning lower midline abdominal pain that
radiates down to her rectum.  She says this is similar pain to
what she experienced when she was admitted [**12-11**].  No back pain
though she is unsure if she would sense back pain. She also
notes severe diarrhea and loose stools since admission.  She
reports a cough occasionally productive of light brown mucous.
Denies HA, fevers/chills.

MEDICAL HISTORY: 1. Hypertension
2. Hyperlipidemia
3. Paraplegia (From Anterior Spinal Infarct sustained during a
thoracic aneurysm repair)
4. Suprapubic Catheter in place, recurrent UTIs ? on Ppx Bactrim

MEDICATION ON ADMISSION: MEDICATIONS (confirmed w/ [**Location (un) 1226**] pharmacy [**Telephone/Fax (1) 4642**]):
1. Baclofen 40 mg TID
2. Gabapentin 900 mg PO TID (3 times a day).
3. Nortriptyline 50 mg qhs
4. Lactulose 1 tablespoon [**Hospital1 **]
5. Bupropion SR 100 mg [**Hospital1 **]
6. Furosemide alternating 40 mg and 80 mg every other day.
7. Advair 250/50 one puff [**Hospital1 **]
8. Duonebs one amp QID prn
9. Nystatin powder
.
ALLERGIES: NKDA

ALLERGIES: Adhesive Tape

PHYSICAL EXAM: Vitals: temp 97.7, bp 130/70, HR 80, RR 20, SaO2 96% on 2L
Gen: Obese female in no distress. Alert and oriented to person,
place, and time.
HEENT: Slera anicteric. NCAT. EOMI. MMM. No pharyngeal erythema.
No nuchal rigidity.
CV: Regular rate.  Nl S1, S2, No murmur, rub, gallop.
Pulm: CTA anteriorly and laterally. No wheezes/rhonchi.
Abd: Positive bowel sounds.  Soft and obese abdomen. Tender
diffusely, but especially in periumbilical area.  Has decreased
senstaion of lateral abdominal wall.  No guarding, positive
rebound in the midline.  Tympanitic to percussion.  No masses.
Suprapubic catheter in place and the surrounding area is not
erythematous.  Rectal tube in place.
Ext: Trace lower extremity edema, stockings on.
Neuro: Sensory level on abdomen at approx T6.  Full [**4-7**] UE
strength, 0/0 LE strength.  PERRL. CN II-XII intact.

FAMILY HISTORY: Son: DM.

SOCIAL HISTORY: The patient lives alone in [**Hospital3 4634**]. Wheelchair bound.
She has a health aid for assistance in the morning and evening,
for help with dressing and bathing.  Her son usually prepares
her food.  Has son, [**Name (NI) **], & dtr in-law, [**Name (NI) 1439**], are her HCPs.
They see pt ~wkly. The patient has a 2-3ppd x 40+ years, but has
smoked +/- (3 cigarettes/day) for the past 5 yrs. No EtOH or
illicit drug use. 

### Response:
{'Pneumonia, organism unspecified,Anomalies of cerebrovascular system,Urinary tract infection, site not specified,Unspecified vascular insufficiency of intestine,Paraplegia,Chronic airway obstruction, not elsewhere classified,Other specified hypotension,Benign neoplasm of colon,Other and unspecified hyperlipidemia,Other constipation,Depressive disorder, not elsewhere classified,Esophageal reflux,Unspecified essential hypertension,Leukocytosis, unspecified,Other artificial opening of urinary tract status,Other dependence on machines, supplemental oxygen,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits'}
