CHIEF COMPLAINT: Diaphoresis, SOB, and hypoxia

PRESENT ILLNESS: 79 year-old female with advanced dementia, PE with IVC filter
placement ([**2116**]) and subsequent large bilateral LE DVT at
rehabilitation facility for CONS endocarditis and right ankle
osteomyelitis on daptomycin admitted with acute diaphoresis,
SOB, and hypoxia concerning for PE.  Prior to transfer from
[**Hospital3 2558**], temperature 99.5, given Tylenol.  Baseline
oxygen saturation 93% RA.
.
Per discussion with son, as recently as [**Name (NI) 766**] patient was
conversing (limited conversation at baseline).  He noticed a
decline over the week - increased pain in her right leg,
increased crying.  When he saw her the night preceding
admission, she was "just not with it."  He also noticed she was
breathing fast.
.
[**Name (NI) **] son believes decline in her health began around
[**2119-12-23**].  She was admitted to [**Hospital3 **] for lethargy, and
was found to have serum sodium 182.  She was hydrated and
improved dramatically.  A PEG tube was placed.
.
She was admitted [**1-12**] to [**2120-1-17**] with CONS
bacteremia/endocarditis, Klebsiella UTI, and severe
constipation.  CONS bacteremia with suspected source right
lateral malleolus stage III ulcer/osteomyelitis; TTE with MV
vegetation and worsened MR; initially on vancomycin, then due to
reaction switched to daptomycin.  Surgical intervention for MR
was not pursued at discretion of patient's son/HCP.
.
She was subsequently admitted [**1-19**] to [**2120-1-21**] with bilateral
lower extremity DVT extending to previously placed IVC filter.
Anticoagulation was initiated but not continued due to
risk>benefit longterm.  Per discussions with son, patient was
made DNR/DNI with plan to transition to palliative care as an
outpatient.
.
A new PEG placed was last week, [**2120-2-2**].
.
In the ED, 98.6 110 157/94 34 95%.  Triggered for tachypnea, 34.
 Tmax to 101.  Physical examination notable for nonverbal,
decreased breath sounds left base, benign abdominal examination.
 Laboratory data significant for creatinine 0.4, CBC within
normal limits, troponin 0.08, lactate 1.3, and UA benign.  EKG
with sinus tachycardia, isolated TWI III, and without ischemic
changes.  CTA chest discussed with family; wished to proceed
with imaging despite prior notes indicating patient is not
candidate for anticoagulation.  CTA chest with no PE or acute
aortic syndrome and pneumatosis of hepatic flexure of colon.
Subsequent CT abdomen/pelvis with contrast with pneumatosis of
cecum (positioned up by the liver) and ileum - no free air or
mesenteric/portal venous gas.  Discussed with son; wished to
proceed with surgical consultation prior to making a decision
regarding surgical intervention.  Surgery was consulted for
pneumatosis - suspected etiology of pneumatosis benign and
related to recent PEG placement given benign abdominal
examination, normal lactate, and absence of leukocytosis;
recommended NPO, IVF, repeat lactate, enemas for continued
constipation with surgery continuing to follow.  Received
cipro/Flagyl, Tylenol.  On transfer to MICU, 69, 101/51, 19, 99%
6L NC.
.
On the floor, patient is unable to participate in conversation.
Says hello on reevaluation, but history otherwise limited.

MEDICAL HISTORY: Hypernatremia,
History of dehydation
Dementia
Aspiration pnumonia,
Bipolar disorder.
hip fracture with contraction fracture
history of PE x 2 during the surgery
Osteomyelitis and ferquent UTI

MEDICATION ON ADMISSION: Daptomycin 500mg Q24 hours until [**2120-2-28**]  x
Glucerna 1.2 60ml/hour
Remeron 30mg PO daily  x
Bactrim DS [**Hospital1 **]  - d/c'ed
Memantine 5mg PO BID  x
Vitamin C 250mg PO daily  x
Olanzapine 5mg PO daily  x
Vitamin D 50,000 units monthly  x
Donepezil 10mg PO QHS  x
Senna 8.6mg PO BID  x
Tylenol 650mg PO Q6hrs PRN  x
Docusate 50mg/5ml 10ml [**Hospital1 **]  x
ASA 81mg PO daily  x
Famotidine 20mg PO BID  x
Protein powder [**Hospital1 **]
?Roxanol 5mg Q6 hours
Levofloxacin 500mg daily "indefinitely"  x
Ativan 0.25mg PH QHS PRN insomnia
Miralax 17 gram PO daily PRN  x
Lactulose 30ml [**Hospital1 **] PRN  x
Hyoscyamine 0.125mg SL QID PRN secretions  x

ALLERGIES: Penicillins

PHYSICAL EXAM: Admission Physical Exam:
VS: Temp 98.8, HR 68, BP 126/49, RR 30, SpO2 100% 5L NC
General: Sleeping; opens eyes to painful stimulation, now with
verbal stimulation
HEENT: Sclera anicteric, MMM
Neck: Supple; prominent venous pulsation
Lungs: Right lung CTA; severe kyphoscoliosis limits auscultation
of left lung; no appreciable wheezes, rales, rhonchi
CV: RRR; normal S1/S2; III/VI early systolic murmur best heard
at LLSB
Abdomen: PEG in place without surrounding erythema; hypoactive
bowel sounds; soft, non-tender, not distended
Ext: In waffleboots; warm, well-perfused, 2+ pulses; right ankle
dressed; DP, radial pulses 2+ and symmetric
Neuro: Limited examination; awakes to sternal rub, does not
participate in physical examination

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Currently at rehab facility. Well-supported by son/HCP.
Pulmonary collapse,Acute and subacute bacterial endocarditis,Ulcer of ankle,Bacteremia,Unspecified osteomyelitis, pelvic region and thigh,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Other specified disorders of intestine,Other constipation,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Bipolar disorder, unspecified,Gastrostomy status,Personal history of venous thrombosis and embolism,Do not resuscitate status
Pulmonary collapse,Ac/subac bact endocard,Ulcer of ankle,Bacteremia,Osteomyelitis NOS-pelvis,Other staphylococcus,Intestinal disorders NEC,Constipation NEC,Alzheimer's disease,Dementia w/o behav dist,Bipolar disorder NOS,Gastrostomy status,Hx-ven thrombosis/embols,Do not resusctate status
Admission Date:  [**2120-2-9**]              Discharge Date:   [**2120-2-13**]

Date of Birth:  [**2040-4-5**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 4588**]
Chief Complaint:
Diaphoresis, SOB, and hypoxia

Major Surgical or Invasive Procedure:
None


History of Present Illness:
79 year-old female with advanced dementia, PE with IVC filter
placement ([**2116**]) and subsequent large bilateral LE DVT at
rehabilitation facility for CONS endocarditis and right ankle
osteomyelitis on daptomycin admitted with acute diaphoresis,
SOB, and hypoxia concerning for PE.  Prior to transfer from
[**Hospital3 2558**], temperature 99.5, given Tylenol.  Baseline
oxygen saturation 93% RA.
.
Per discussion with son, as recently as [**Name (NI) 766**] patient was
conversing (limited conversation at baseline).  He noticed a
decline over the week - increased pain in her right leg,
increased crying.  When he saw her the night preceding
admission, she was "just not with it."  He also noticed she was
breathing fast.
.
[**Name (NI) **] son believes decline in her health began around
[**2119-12-23**].  She was admitted to [**Hospital3 **] for lethargy, and
was found to have serum sodium 182.  She was hydrated and
improved dramatically.  A PEG tube was placed.
.
She was admitted [**1-12**] to [**2120-1-17**] with CONS
bacteremia/endocarditis, Klebsiella UTI, and severe
constipation.  CONS bacteremia with suspected source right
lateral malleolus stage III ulcer/osteomyelitis; TTE with MV
vegetation and worsened MR; initially on vancomycin, then due to
reaction switched to daptomycin.  Surgical intervention for MR
was not pursued at discretion of patient's son/HCP.
.
She was subsequently admitted [**1-19**] to [**2120-1-21**] with bilateral
lower extremity DVT extending to previously placed IVC filter.
Anticoagulation was initiated but not continued due to
risk>benefit longterm.  Per discussions with son, patient was
made DNR/DNI with plan to transition to palliative care as an
outpatient.
.
A new PEG placed was last week, [**2120-2-2**].
.
In the ED, 98.6 110 157/94 34 95%.  Triggered for tachypnea, 34.
 Tmax to 101.  Physical examination notable for nonverbal,
decreased breath sounds left base, benign abdominal examination.
 Laboratory data significant for creatinine 0.4, CBC within
normal limits, troponin 0.08, lactate 1.3, and UA benign.  EKG
with sinus tachycardia, isolated TWI III, and without ischemic
changes.  CTA chest discussed with family; wished to proceed
with imaging despite prior notes indicating patient is not
candidate for anticoagulation.  CTA chest with no PE or acute
aortic syndrome and pneumatosis of hepatic flexure of colon.
Subsequent CT abdomen/pelvis with contrast with pneumatosis of
cecum (positioned up by the liver) and ileum - no free air or
mesenteric/portal venous gas.  Discussed with son; wished to
proceed with surgical consultation prior to making a decision
regarding surgical intervention.  Surgery was consulted for
pneumatosis - suspected etiology of pneumatosis benign and
related to recent PEG placement given benign abdominal
examination, normal lactate, and absence of leukocytosis;
recommended NPO, IVF, repeat lactate, enemas for continued
constipation with surgery continuing to follow.  Received
cipro/Flagyl, Tylenol.  On transfer to MICU, 69, 101/51, 19, 99%
6L NC.
.
On the floor, patient is unable to participate in conversation.
Says hello on reevaluation, but history otherwise limited.


Past Medical History:
Hypernatremia,
History of dehydation
Dementia
Aspiration pnumonia,
Bipolar disorder.
hip fracture with contraction fracture
history of PE x 2 during the surgery
Osteomyelitis and ferquent UTI


Social History:
Currently at rehab facility. Well-supported by son/HCP.

Family History:
Noncontributory

Physical Exam:
Admission Physical Exam:
VS: Temp 98.8, HR 68, BP 126/49, RR 30, SpO2 100% 5L NC
General: Sleeping; opens eyes to painful stimulation, now with
verbal stimulation
HEENT: Sclera anicteric, MMM
Neck: Supple; prominent venous pulsation
Lungs: Right lung CTA; severe kyphoscoliosis limits auscultation
of left lung; no appreciable wheezes, rales, rhonchi
CV: RRR; normal S1/S2; III/VI early systolic murmur best heard
at LLSB
Abdomen: PEG in place without surrounding erythema; hypoactive
bowel sounds; soft, non-tender, not distended
Ext: In waffleboots; warm, well-perfused, 2+ pulses; right ankle
dressed; DP, radial pulses 2+ and symmetric
Neuro: Limited examination; awakes to sternal rub, does not
participate in physical examination

Discharge Exam:
VS: Temp 97.8 BP 135/55 HR 79 RR 26 SpO2 94% RA
Lungs: bibasilar crackles
Abdomen: soft non tender non distended
Neuro: lethargic but awakes to name (when speaking loudly). Not
oriented.


Pertinent Results:
Admission Labs:
[**2120-2-9**] 03:26PM BLOOD WBC-7.7# RBC-4.05* Hgb-11.9* Hct-38.3#
MCV-95 MCH-29.3 MCHC-31.0 RDW-15.5 Plt Ct-245
[**2120-2-9**] 03:26PM BLOOD Neuts-67.4 Lymphs-25.5 Monos-4.3 Eos-2.4
Baso-0.4
[**2120-2-9**] 03:26PM BLOOD Glucose-153* UreaN-31* Creat-0.4 Na-143
K-4.2 Cl-105 HCO3-26 AnGap-16
[**2120-2-9**] 03:28PM BLOOD Lactate-1.3

Discharge Labs:
[**2120-2-11**] 05:21AM BLOOD WBC-4.6 RBC-3.31* Hgb-9.8* Hct-30.7*
MCV-93 MCH-29.6 MCHC-31.9 RDW-15.3 Plt Ct-220
[**2120-2-10**] 04:22AM BLOOD PT-14.1* PTT-24.9 INR(PT)-1.2*
[**2120-2-11**] 05:21AM BLOOD Glucose-109* UreaN-18 Creat-0.3* Na-141
K-3.4 Cl-108 HCO3-29 AnGap-7*
[**2120-2-10**] 04:22AM BLOOD ALT-11 AST-22 CK(CPK)-35 AlkPhos-37
TotBili-0.4
[**2120-2-11**] 05:21AM BLOOD Calcium-8.9 Phos-2.8 Mg-2.0

Other Notable Labs:
[**2120-2-11**] 05:21AM BLOOD ESR-25*
[**2120-2-10**] 04:22AM BLOOD CRP-21.1*
[**2120-2-9**] 03:26PM BLOOD cTropnT-0.08*
[**2120-2-10**] 04:22AM BLOOD CK-MB-4 cTropnT-0.11*
[**2120-2-11**] 05:21AM BLOOD cTropnT-0.08*

[**2120-2-9**] 3:26 pm BLOOD CULTURE

   Blood Culture, Routine (Preliminary):
      STAPHYLOCOCCUS, COAGULASE NEGATIVE.
      GRAM POSITIVE RODS.
         CONSISTENT WITH CORYNEBACTERIUM OR

         PROPIONIBACTERIUM SPECIES.

   Aerobic Bottle Gram Stain (Final [**2120-2-10**]):
      GRAM POSITIVE COCCI.
      IN PAIRS AND CLUSTERS.

   Anaerobic Bottle Gram Stain (Final [**2120-2-11**]):
      GRAM POSITIVE COCCI IN PAIRS.
      GRAM POSITIVE ROD(S) CONSISTENT WITH CORYNEBACTERIUM OR

                          PROPIONIBACTERIUM SPECIES.

CHEST (PORTABLE AP)	Study Date of [**2120-2-9**] 3:23 PM
SEMI-UPRIGHT AP VIEW OF THE CHEST: The study is markedly limited
due to
patient positioning and respiratory motion. Allowing for these
limitations,
again noted is moderate cardiomegaly with pronounced mitral
annular
calcifications. The aorta is tortuous. Evaluation of the lungs
is severely
limited. No gross large area of focal consolidation is seen. No
sizable
pleural effusion is present. Assessment for pneumothorax is
suboptimal.
IMPRESSION: Markedly limited exam. No gross interval change from
prior, but
consider followup radiographs when the patient's condition
improves.
.
CTA CHEST W&W/O C&RECONS, NON-CORONARY	Study Date of [**2120-2-9**]
4:59 PM
FINDINGS: The patient is markedly kyphotic, somewhat limiting
assessment of
the cervicothoracic junction. Within that limitation, no
axillary, hilar, or mediastinal lymphadenopathy is seen. The
aorta is of a normal caliber along its course with calcified
atherosclerotic disease in the arch, but no evidence of
intramural hematoma or aortic dissection. Patient respiratory
motion through the right lung makes evaluation of segmental and
subsegmental pulmonary arterial branches suboptimal. There is no
evidence of a more central pulmonary embolism on the right nor a
pulmonary embolism on the left to the subsegmental lvel.
Bibasilar atelectasis is noted, more pronounced in the left base
than the right. The right lung parenchyma is obscured by motion
artifact. There is no pleural or pericardial effusion. Calcified
atherosclerotic disease is seen in the coronary arteries. The
cecum is located adjacent/above the liver and demonstrates
pneumatosis, not fully evaluated. There is no free air detected
below the diaphragm.
BONES: There is an unchanged appearance to a compression
deformity of a lower thoracic vertebral body. There is
thoracolumbar scoliosis and marked
kyphosis. A bone island is seen in the right pedicle of a mid
thoracic
vertebra (400B:25). There are no aggressive-appearing lytic or
sclerotic
lesions.
IMPRESSION:
1. Suboptimal evaluation of right segmental and subsegmental
pulmonary
arterial branches due to patient respiratory motion. No evidence
of more
central pulmonary embolism on the right. No evidence of
pulmonary embolism on the left side to the subsegmental level.
No acute aortic syndrome.
2. Colonic pneumatosis in the right upper quadrant, not fully
evaluated.
3. Marked kyphosis.
.
CT ABD & PELVIS WITH CONTRAST	Study Date of [**2120-2-9**] 9:10 PM
ABDOMEN: The visualized portion of the lower chest is better
characterized on chest CTA performed shorterly earlier this same
date, [**2120-2-9**].
Imaging is suboptimal secondary to streak artifact from
patient's arms
included within this study. Given this, the liver shows no focal
lesion or
intrahepatic biliary dilatation. Subtle dense material in the
gallbladder may represent small stones or sludge. The spleen is
normal in size and
appearance. The pancreas is atrophic. The adrenal glands are
normal
appearing bilaterally. The kidneys enhance with and excrete
contrast
symmetrically. A percutaneous GJ tube is in place. The small and
large intestines show no evidence of obstruction. Pneumatosis is
seen in multiple loops of ileum in the right abdomen (2; 46)
extending to the midline. Additionally, pneumatosis is seen in
the cecum of the colon which is positioned up near the liver
(2;14). No free air is seen nor is there mesenteric or portal
venous gas. Calcified atherosclerotic disease is seen throughout
the abdominal aorta. Additionally, an IVC filter is seen just
below the confluence of the renal veins. There is no free fluid
or lymphadenopathy.
PELVIS: Streak artifact from right femoral neck fracture
fixation hardware
limits assessment of the pelvis mildly. Given this, the urinary
bladder is
noted to be decompressed around a Foley balloon. The uterus is
atrophic. A
large stool ball is seen within the distended rectum measuring
approximately 9.5 cm in diameter. Additionally, a 3-cm hypodense
structure is seen in the left adnexa. A similar-appearing 1.8 cm
hypodense structure is seen in the right adnexa.
BONES: There still appears an L2 compression deformity as well
as the T12
compression deformity. An intramedullary rod and interlocking
screw are seen in the right proximal femur. There are no
aggressive-appearing lytic or sclerotic lesions.
IMPRESSION:
1. Pneumatosis involving the ileum and cecum without evidence of
free air or portal/mesenteric venous air. Correlation with labs,
clinical history, and physical exam is recommended. Benign
etiologies of pneumatosis are also
diagnostic considerations.
2. Percutaneous GJ tube and IVC filter in place.
3. Large stool ball within distended rectum, may be impacted.
4. Bilateral adnexal hypodense structures; suggest further
evaluation with
nonurgent ultrasound if clinically appropriate and not recently
obtained.
5. Cholelithiasis without cholecystitis.
6. Stable T12 and L2 compression deformities.

Brief Hospital Course:
79 year-old female with advanced dementia, PE with IVC filter
placement ([**2116**]) and subsequent large bilateral LE DVT at
rehabilitation facility for Coag negative Staph aureus
endocarditis and right ankle osteomyelitis on daptomycin who was
admitted with fevers and tachypnea.
.
ACTIVE ISSUES
# Goals of Care: On admission, it was noted that patient's
quality of life was very poor. She was initially DNR but okay to
intubate however after discussion with patient's HCP [**Name (NI) **], [**Name (NI) **]
[**Name (NI) 109310**]), she was made DNR/DNI. He expressed interest in talking
with in-house palliative care who spoke to HCP and made referral
to [**Hospital 2188**] [**Location (un) 86**] Office ([**Telephone/Fax (1) 97440**]). The Palliative
[**Name6 (MD) **] Program NP was contact[**Name (NI) **] and will call son about enrolling
patient in hospice care. *** Would recommend faciliating this
discussion with son. ***
.
#. Tachypnea/Hypoxia: Patient was admitted with new hypoxia with
concern for PE. CTA chest ruled out PE. It did not appear that
the patient fluid overloaded. Ultimately atelectasis was deemed
the cause of her hypoxia. Given her fevers, pneumonia was also
consideration however CXR although a limited study did not
reveal a focal consolidation. Of note patient becomes tachypneic
when constipated. On discharge, she satting well on room air
without any difficulty.
.
# Fever: Patient also presented with fever to 101. While
admitted however did not have any further fevers. This was
thought to be [**1-24**] atelectasis v. transient fever from ongoing
endocarditis. Given that patient remained afebrile for the
remainder of hospitalization, no further work-up was necessary.
.
# Positive blood culture/Endocarditis: On set of blood cultures
were positive for coagulase negative staph aureus. ID was
consulted who felt that given negative subsequent blood
cultures, this blood culture was likely a contaminant. At
discharge, blood cultures from [**2-10**] and [**2-11**] were negative to
date. Patient was continued on daptomycin as per prior
recommendations. Her last day of daptomycin will be [**2120-2-28**].
She will continue to require weekly OPAT labs including CBC,
Chem-7, ESR, CRP, and LFTs.
.
#.  Ileal/colonic pneumatosis: CTA chest on admission revealed
pneumatosis of cecum and ileum. Dedicated CTA of abdomen/pelvis
were completed comfirming diagnosis. Surgery was consulted who
felt that this should be managed non-operative given benign exam
and lack of leukocytosis or lactic acidosis. This was thought to
be [**1-24**] recent PEG tube placement versus severe constipation (see
below). Patient made NPO initially and was slowly started back
on tube feeds to goal rate.
.
# Constipation: On admission, patient was noted to be severely
constipation requiring a very aggressive bowel regimen and
manual disempaction. It was thought that this may have
contributed significantly to recent decompensation. Tachypnea
was also thought to be [**1-24**] constipation. After disempaction,
patient's mental status improved and she was thought to be
closer to her baseline. She should remain on an aggressive bowel
regimen with goal BM every other day.
.
# Right Ankle Ulcer: Wound care was continued while in hospital.
The following are recommendations for dressing:
- cleanse skin/ulcer and pat dry
- apply aloe vesta moisturizer to intact dry skin
- For ANKLE : cover wound with aquacel/ag rope - moisten
slightly with NS, followed by dry gauze
- For HEEL : cover with Adaptic then dry gauze and ABD pad and
wrap with Kerlix
- Please change daily
.
# L adnexal hypodense structure: On CTA of abdomen, a hypodense
structure was noted on the left adnexa. Radiology recommended a
nonemergent pelvic ultrasound. Given recent goals of care
discussion, this was not pursued as an in patient and should be
done as an outpatient if congruent with goals of care.
.
#. Dementia: Inactive issue. Patient was continued on home meds.
Patient was at baseline mental status on discharge.
.
TRANSITIONAL ISSUES:
1) Code Status: DNR/DNI confirmed. *** PLEASE NOTE: this
represents a change in code status from admission. Hospice care
referral was also made for patient after discussion with HCP.
2) Pending: On discharge, final reads for blood cultures from
[**2-10**] and [**2-11**] are outstanding. Please call [**Telephone/Fax (1) 4645**] to
follow up with results. Final reads are usually processed [**4-26**]
days after blood cultures are drawn.
3) Transition of care: Patient will be transferred back to
[**Hospital3 **] for remaining portion of daptomycin.

Medications on Admission:
Daptomycin 500mg Q24 hours until [**2120-2-28**]  x
Glucerna 1.2 60ml/hour
Remeron 30mg PO daily  x
Bactrim DS [**Hospital1 **]  - d/c'ed
Memantine 5mg PO BID  x
Vitamin C 250mg PO daily  x
Olanzapine 5mg PO daily  x
Vitamin D 50,000 units monthly  x
Donepezil 10mg PO QHS  x
Senna 8.6mg PO BID  x
Tylenol 650mg PO Q6hrs PRN  x
Docusate 50mg/5ml 10ml [**Hospital1 **]  x
ASA 81mg PO daily  x
Famotidine 20mg PO BID  x
Protein powder [**Hospital1 **]
?Roxanol 5mg Q6 hours
Levofloxacin 500mg daily "indefinitely"  x
Ativan 0.25mg PH QHS PRN insomnia
Miralax 17 gram PO daily PRN  x
Lactulose 30ml [**Hospital1 **] PRN  x
Hyoscyamine 0.125mg SL QID PRN secretions  x

Discharge Medications:
1. daptomycin 500 mg Recon Soln [**Hospital1 **]: One (1) Recon Soln
Intravenous Q24H (every 24 hours): Last dose on [**2120-2-28**].
2. mirtazapine 30 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO once a day.
3. memantine 5 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO BID (2 times a
day).
4. Vitamin C 250 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO once a day.
5. olanzapine 5 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily).

6. Vitamin D 50,000 unit Capsule [**Year (4 digits) **]: One (1) Capsule PO once a
month.
7. donepezil 10 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO once a day.
8. senna 8.6 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO BID (2 times a
day).
9. docusate sodium 50 mg/5 mL Liquid [**Year (4 digits) **]: Ten (10) ML PO BID (2
times a day).
10. acetaminophen 650 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO every six
(6) hours as needed for pain.
11. aspirin 81 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO once a day.
12. famotidine 20 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO Q12H (every
12 hours).
13. levofloxacin 500 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO Q24H
(every 24 hours).
14. polyethylene glycol 3350 17 gram/dose Powder [**Year (4 digits) **]: One (1)
PO DAILY (Daily) as needed for Constipation.
15. lactulose 10 gram/15 mL Solution [**Year (4 digits) **]: Thirty (30) mL PO
twice a day as needed for constipation.
16. hyoscyamine sulfate 0.125 mg Tablet, Sublingual [**Year (4 digits) **]: One (1)
 Sublingual four times a day as needed for secretions.
17. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 2558**] - [**Location (un) **]

Discharge Diagnosis:
Endocarditis
Dementia
Chronic hip infection


Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.


Discharge Instructions:
You were admitted because you were having fevers and shortness
of breath. We obtained a CT scan that ruled out a clot in your
lungs. We found that there was air in the wall of your colon.
This could be due to the feeding tube that was placed. You were
also found to be severely constipated requiring lots of stool
softeners to help move your bowels.
.
Your fevers may have been from your old infection. You were
continued on your antibiotics and you did not have any further
fevers
.
While you were in the hospital, we discussed your code status
with your son and decided to change it to do not resuscitate and
do not intubate. Our palliative care team spoke with your son to
discuss hospice care.
.
No changes were made to your medications. Please be sure to
change them as directed.

Followup Instructions:
Please be sure to keep the following appointment.
Department: INFECTIOUS DISEASE
When: THURSDAY [**2120-2-22**] at 10:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10000**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage



Completed by:[**2120-2-13**]
{"Pulmonary collapse,Acute and subacute bacterial endocarditis,Ulcer of ankle,Bacteremia,Unspecified osteomyelitis, pelvic region and thigh,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Other specified disorders of intestine,Other constipation,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Bipolar disorder, unspecified,Gastrostomy status,Personal history of venous thrombosis and embolism,Do not resuscitate 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: Diaphoresis, SOB, and hypoxia

PRESENT ILLNESS: 79 year-old female with advanced dementia, PE with IVC filter
placement ([**2116**]) and subsequent large bilateral LE DVT at
rehabilitation facility for CONS endocarditis and right ankle
osteomyelitis on daptomycin admitted with acute diaphoresis,
SOB, and hypoxia concerning for PE.  Prior to transfer from
[**Hospital3 2558**], temperature 99.5, given Tylenol.  Baseline
oxygen saturation 93% RA.
.
Per discussion with son, as recently as [**Name (NI) 766**] patient was
conversing (limited conversation at baseline).  He noticed a
decline over the week - increased pain in her right leg,
increased crying.  When he saw her the night preceding
admission, she was "just not with it."  He also noticed she was
breathing fast.
.
[**Name (NI) **] son believes decline in her health began around
[**2119-12-23**].  She was admitted to [**Hospital3 **] for lethargy, and
was found to have serum sodium 182.  She was hydrated and
improved dramatically.  A PEG tube was placed.
.
She was admitted [**1-12**] to [**2120-1-17**] with CONS
bacteremia/endocarditis, Klebsiella UTI, and severe
constipation.  CONS bacteremia with suspected source right
lateral malleolus stage III ulcer/osteomyelitis; TTE with MV
vegetation and worsened MR; initially on vancomycin, then due to
reaction switched to daptomycin.  Surgical intervention for MR
was not pursued at discretion of patient's son/HCP.
.
She was subsequently admitted [**1-19**] to [**2120-1-21**] with bilateral
lower extremity DVT extending to previously placed IVC filter.
Anticoagulation was initiated but not continued due to
risk>benefit longterm.  Per discussions with son, patient was
made DNR/DNI with plan to transition to palliative care as an
outpatient.
.
A new PEG placed was last week, [**2120-2-2**].
.
In the ED, 98.6 110 157/94 34 95%.  Triggered for tachypnea, 34.
 Tmax to 101.  Physical examination notable for nonverbal,
decreased breath sounds left base, benign abdominal examination.
 Laboratory data significant for creatinine 0.4, CBC within
normal limits, troponin 0.08, lactate 1.3, and UA benign.  EKG
with sinus tachycardia, isolated TWI III, and without ischemic
changes.  CTA chest discussed with family; wished to proceed
with imaging despite prior notes indicating patient is not
candidate for anticoagulation.  CTA chest with no PE or acute
aortic syndrome and pneumatosis of hepatic flexure of colon.
Subsequent CT abdomen/pelvis with contrast with pneumatosis of
cecum (positioned up by the liver) and ileum - no free air or
mesenteric/portal venous gas.  Discussed with son; wished to
proceed with surgical consultation prior to making a decision
regarding surgical intervention.  Surgery was consulted for
pneumatosis - suspected etiology of pneumatosis benign and
related to recent PEG placement given benign abdominal
examination, normal lactate, and absence of leukocytosis;
recommended NPO, IVF, repeat lactate, enemas for continued
constipation with surgery continuing to follow.  Received
cipro/Flagyl, Tylenol.  On transfer to MICU, 69, 101/51, 19, 99%
6L NC.
.
On the floor, patient is unable to participate in conversation.
Says hello on reevaluation, but history otherwise limited.

MEDICAL HISTORY: Hypernatremia,
History of dehydation
Dementia
Aspiration pnumonia,
Bipolar disorder.
hip fracture with contraction fracture
history of PE x 2 during the surgery
Osteomyelitis and ferquent UTI

MEDICATION ON ADMISSION: Daptomycin 500mg Q24 hours until [**2120-2-28**]  x
Glucerna 1.2 60ml/hour
Remeron 30mg PO daily  x
Bactrim DS [**Hospital1 **]  - d/c'ed
Memantine 5mg PO BID  x
Vitamin C 250mg PO daily  x
Olanzapine 5mg PO daily  x
Vitamin D 50,000 units monthly  x
Donepezil 10mg PO QHS  x
Senna 8.6mg PO BID  x
Tylenol 650mg PO Q6hrs PRN  x
Docusate 50mg/5ml 10ml [**Hospital1 **]  x
ASA 81mg PO daily  x
Famotidine 20mg PO BID  x
Protein powder [**Hospital1 **]
?Roxanol 5mg Q6 hours
Levofloxacin 500mg daily "indefinitely"  x
Ativan 0.25mg PH QHS PRN insomnia
Miralax 17 gram PO daily PRN  x
Lactulose 30ml [**Hospital1 **] PRN  x
Hyoscyamine 0.125mg SL QID PRN secretions  x

ALLERGIES: Penicillins

PHYSICAL EXAM: Admission Physical Exam:
VS: Temp 98.8, HR 68, BP 126/49, RR 30, SpO2 100% 5L NC
General: Sleeping; opens eyes to painful stimulation, now with
verbal stimulation
HEENT: Sclera anicteric, MMM
Neck: Supple; prominent venous pulsation
Lungs: Right lung CTA; severe kyphoscoliosis limits auscultation
of left lung; no appreciable wheezes, rales, rhonchi
CV: RRR; normal S1/S2; III/VI early systolic murmur best heard
at LLSB
Abdomen: PEG in place without surrounding erythema; hypoactive
bowel sounds; soft, non-tender, not distended
Ext: In waffleboots; warm, well-perfused, 2+ pulses; right ankle
dressed; DP, radial pulses 2+ and symmetric
Neuro: Limited examination; awakes to sternal rub, does not
participate in physical examination

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Currently at rehab facility. Well-supported by son/HCP. 

### Response:
{"Pulmonary collapse,Acute and subacute bacterial endocarditis,Ulcer of ankle,Bacteremia,Unspecified osteomyelitis, pelvic region and thigh,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Other specified disorders of intestine,Other constipation,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Bipolar disorder, unspecified,Gastrostomy status,Personal history of venous thrombosis and embolism,Do not resuscitate status"}
