CHIEF COMPLAINT: Altered mental status

PRESENT ILLNESS: 80 yo F with h/o MI in [**2-/2172**], RA on steroids (10mg daily) long
term, recurrent UTI's with urosepsis w/ resistant organisms (?
VRE and pseudomonas resistent to cipro), who had a recent
hospital admission on [**7-21**] for AMS, hypercarbia (Pc02:
100) requiring intubation and UTI for which she was treated for
with 14 day course of cefepime. She was discharge back to her
[**Hospital1 1501**] and was found to have AMS with O2sat 76% on RA. She was then
sent to the ED where her O2 sat was 94% on RA her ABG showed pH
7.40/ pCO2 56/pO2 56/ HCO3 36. Her vitals were T98, HR84,
BP105/51, RR18. Labs were notable for WBC of 13.8 with 90%
PMN's, BUN of 41, Cr of 2.3, glucose of 158, few bacteria in her
urine with small amounts of blood and luekocyte esterase, and 3
wbc's. She was then admitted to the floor for further eval. This
morning she was found to be very lethargic and and shaking.
Neurology was called for eval for ? stroke, she had Head CT that
showed no IC process. She had a repeat ABG that showed pH 7.28/
pCO2
75/pO2 114/ HCO3 37 not on oxygen. She was then sent to the
floor for acute respiratory acidosis and hypercarbia for bipap.
During her prior admission, pt refused to used bipap and had
decided to be DNR/DNI. However during her AMS today her daughter
who is her HCP decided to reverse her code DNI and okay to
resuscitate. So, she was transferred to the MICU for further
management.
She was placed on bipap on arrival to the MICU, she was having
periods of apnea, sating well in the upper 90s%. She then became
more alert. Unfortunately we were unable to obtain an ABG prior
to her being d/ced from BIPAP.
.
Of note, during her last admssion she also presented with AMS
which was at the time atributed to hypercarbia and infection.
Her hypercarbia was originally thought to be due to baseline
obstructive disease in setting of hypoventilation from
significant AMS from recieiving tramadol and quinolone and a
UTI. She also would desat in the evening and had observed
periods of apnea while sleeping, but she refused to use BIPAP.
We were also able to obtain records from [**Hospital3 2005**] and it
was reported that pt had PFTs which were consistent with
obstructive pattern which was attributed to scoliosis. However
there were no numbers reported. She had an ECHO on [**6-26**] that
showed pulm hypertension. So given her hx of RA and concern for
interstial [**Last Name **] problem, she had high resolution CT which showed
no evidence of interstitial lung disease and possible
tracheobronchomalacia, severity indeterminate.
.
Her MICU course is as follows: On [**7-8**] she was on BiPAP with
periods of apnea ([**Last Name (un) 6055**]-[**Doctor Last Name **]) ameliorated with increased
PEEP. Her code status was reversed to FULL. On [**7-9**] she continued
on BiPAP and completed her course of cefepime. Laboratories
appeared to indicate prerenal azotemia and she was run TBB even
with fluids as respiratory status allowed. While on BiPAP her BP
dropped at one point, ABG indicating hypercarbia and acidemia
during which she was minimally responsive. She responded to
fluid bolus and became alert again. On [**7-10**] she was kept TBB even
and Renal added sevelamer prn for phos > 6. She revisited code
status with her proxy (daughter) and became DNR/ok to intubate.
On [**7-11**] she was transferred to medicine sating 90s on RA and
requiring BiPAP for periods of napping due to persistent bouts
of hypercarbia.
.
On arrival to the floor, VS were 96.3  80-90  SBP 106-130 RR
15-20  96%RA.  Her mental status was clear, she was alert and
oriented and tolerating BiPAP well with no shortness of breath
or chest pain.

MEDICAL HISTORY: - ? Lung disease with "CO2 retention"- severe restrictive
disease
- ? Sleep Apnea
- CAD, sp CABG, s/p STEMI in [**2-/2172**] w/ 2 BMS to the RCA and RBL
- S/p DVT w/ lupus anticoag (was on coumadin but had GI bleed on
[**2-/2172**] in the setting of supra-therapeutic INR)
- L retinal vein occlusion
- Chronic anemia
- diastolic dysfunction w/ EF of 75%
- Bioprosthetic mitral valve seen on echo [**6-/2172**]
- Moderate TR
- Moderate pulmonary HTN
- frequent UTIs and urosepsis - [**Hospital3 **], h/o VRE
(pseudomonas)
- RA
- HL
- HTN
- hypothyroidism
- TKR

MEDICATION ON ADMISSION: heparin (porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day)
aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
qday
clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY
docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
senna 8.6 mg Tablet Sig: One (1) Tablet PO BID
gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID
cefepime 2 gram Recon Soln Sig: Two (2) Grams Injection Q12H
(every 12 hours) for 7 days (on 7.28/11)
pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
poqday
miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for yeast.
camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day)
multivitamin Tablet Sig: One (1) Tablet PO DAILY
lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily)
metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID

ALLERGIES: Penicillins / Sulfa (Sulfonamide Antibiotics) / Gold Salts

PHYSICAL EXAM: ADMISSION EXAM
VS: 98.2 | 122/44 | 102| 20| 95% RA
GENERAL:NAD, comfortable, appropriate.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no thyromegaly, no JVD, no carotid bruits.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: Coarse BS BL. good air movement, resp unlabored.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, some past pointing on cerebellar exam. [**2-8**]
strenth in lower extremities/upper extremities seemingly from
effort. Has base line tremor and jerking. 3+ UE/LE DTR's.

FAMILY HISTORY: NC

SOCIAL HISTORY: Daughter reports patient has lived at [**Hospital3 2558**] since
hospitalization in [**Month (only) 958**]. She does not have dementia or
cognitive impairment at baseline.
- Tobacco: past h/o heavy smoking
- Alcohol:  none
Acute and chronic respiratory failure,Acute kidney failure with lesion of tubular necrosis,Metabolic encephalopathy,Acute on chronic diastolic heart failure,Mixed acid-base balance disorder,Retinal vascular occlusion, unspecified,Urinary tract infection, site not specified,Chronic venous embolism and thrombosis of deep vessels of distal lower extremity,Facial weakness,Other musculoskeletal symptoms referable to limbs,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Other alteration of consciousness,Obstructive chronic bronchitis without exacerbation,Long-term (current) use of anticoagulants,Other and unspecified nonspecific immunological findings,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Obstructive sleep apnea (adult)(pediatric),Other diseases of trachea and bronchus,Other chronic pulmonary heart diseases,Unspecified acquired hypothyroidism,Rheumatoid arthritis,Postinflammatory pulmonary fibrosis,Kyphosis (acquired) (postural),Aortocoronary bypass status,Old myocardial infarction,Anemia of other chronic disease,Heart valve replaced by transplant,Personal history of tobacco use,Do not resuscitate status
Acute & chronc resp fail,Ac kidny fail, tubr necr,Metabolic encephalopathy,Ac on chr diast hrt fail,Mixed acid-base bal dis,Retinal vasc occlus NOS,Urin tract infection NOS,Ch DVT/embl dstl low ext,Facial weakness,Muscskel sympt limb NEC,Pseudomonas infect NOS,Other alter consciousnes,Obst chr bronc w/o exac,Long-term use anticoagul,Oth unspcf nspf imun fnd,Crnry athrscl natve vssl,Hypertension NOS,Obstructive sleep apnea,Trachea & bronch dis NEC,Chr pulmon heart dis NEC,Hypothyroidism NOS,Rheumatoid arthritis,Postinflam pulm fibrosis,Kyphosis NOS,Aortocoronary bypass,Old myocardial infarct,Anemia-other chronic dis,Heart valve transplant,History of tobacco use,Do not resusctate status
Admission Date:  [**2172-7-7**]              Discharge Date:   [**2172-7-15**]

Date of Birth:  [**2091-10-7**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Gold Salts

Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Altered mental status

Major Surgical or Invasive Procedure:
BiPAP


History of Present Illness:
80 yo F with h/o MI in [**2-/2172**], RA on steroids (10mg daily) long
term, recurrent UTI's with urosepsis w/ resistant organisms (?
VRE and pseudomonas resistent to cipro), who had a recent
hospital admission on [**7-21**] for AMS, hypercarbia (Pc02:
100) requiring intubation and UTI for which she was treated for
with 14 day course of cefepime. She was discharge back to her
[**Hospital1 1501**] and was found to have AMS with O2sat 76% on RA. She was then
sent to the ED where her O2 sat was 94% on RA her ABG showed pH
7.40/ pCO2 56/pO2 56/ HCO3 36. Her vitals were T98, HR84,
BP105/51, RR18. Labs were notable for WBC of 13.8 with 90%
PMN's, BUN of 41, Cr of 2.3, glucose of 158, few bacteria in her
urine with small amounts of blood and luekocyte esterase, and 3
wbc's. She was then admitted to the floor for further eval. This
morning she was found to be very lethargic and and shaking.
Neurology was called for eval for ? stroke, she had Head CT that
showed no IC process. She had a repeat ABG that showed pH 7.28/
pCO2
75/pO2 114/ HCO3 37 not on oxygen. She was then sent to the
floor for acute respiratory acidosis and hypercarbia for bipap.
During her prior admission, pt refused to used bipap and had
decided to be DNR/DNI. However during her AMS today her daughter
who is her HCP decided to reverse her code DNI and okay to
resuscitate. So, she was transferred to the MICU for further
management.
She was placed on bipap on arrival to the MICU, she was having
periods of apnea, sating well in the upper 90s%. She then became
more alert. Unfortunately we were unable to obtain an ABG prior
to her being d/ced from BIPAP.
.
Of note, during her last admssion she also presented with AMS
which was at the time atributed to hypercarbia and infection.
Her hypercarbia was originally thought to be due to baseline
obstructive disease in setting of hypoventilation from
significant AMS from recieiving tramadol and quinolone and a
UTI. She also would desat in the evening and had observed
periods of apnea while sleeping, but she refused to use BIPAP.
We were also able to obtain records from [**Hospital3 2005**] and it
was reported that pt had PFTs which were consistent with
obstructive pattern which was attributed to scoliosis. However
there were no numbers reported. She had an ECHO on [**6-26**] that
showed pulm hypertension. So given her hx of RA and concern for
interstial [**Last Name **] problem, she had high resolution CT which showed
no evidence of interstitial lung disease and possible
tracheobronchomalacia, severity indeterminate.
.
Her MICU course is as follows: On [**7-8**] she was on BiPAP with
periods of apnea ([**Last Name (un) 6055**]-[**Doctor Last Name **]) ameliorated with increased
PEEP. Her code status was reversed to FULL. On [**7-9**] she continued
on BiPAP and completed her course of cefepime. Laboratories
appeared to indicate prerenal azotemia and she was run TBB even
with fluids as respiratory status allowed. While on BiPAP her BP
dropped at one point, ABG indicating hypercarbia and acidemia
during which she was minimally responsive. She responded to
fluid bolus and became alert again. On [**7-10**] she was kept TBB even
and Renal added sevelamer prn for phos > 6. She revisited code
status with her proxy (daughter) and became DNR/ok to intubate.
On [**7-11**] she was transferred to medicine sating 90s on RA and
requiring BiPAP for periods of napping due to persistent bouts
of hypercarbia.
.
On arrival to the floor, VS were 96.3  80-90  SBP 106-130 RR
15-20  96%RA.  Her mental status was clear, she was alert and
oriented and tolerating BiPAP well with no shortness of breath
or chest pain.

Past Medical History:
- ? Lung disease with "CO2 retention"- severe restrictive
disease
- ? Sleep Apnea
- CAD, sp CABG, s/p STEMI in [**2-/2172**] w/ 2 BMS to the RCA and RBL
- S/p DVT w/ lupus anticoag (was on coumadin but had GI bleed on
[**2-/2172**] in the setting of supra-therapeutic INR)
- L retinal vein occlusion
- Chronic anemia
- diastolic dysfunction w/ EF of 75%
- Bioprosthetic mitral valve seen on echo [**6-/2172**]
- Moderate TR
- Moderate pulmonary HTN
- frequent UTIs and urosepsis - [**Hospital3 **], h/o VRE
(pseudomonas)
- RA
- HL
- HTN
- hypothyroidism
- TKR


Social History:
Daughter reports patient has lived at [**Hospital3 2558**] since
hospitalization in [**Month (only) 958**]. She does not have dementia or
cognitive impairment at baseline.
- Tobacco: past h/o heavy smoking
- Alcohol:  none


Family History:
NC

Physical Exam:
ADMISSION EXAM
VS: 98.2 | 122/44 | 102| 20| 95% RA
GENERAL:NAD, comfortable, appropriate.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no thyromegaly, no JVD, no carotid bruits.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: Coarse BS BL. good air movement, resp unlabored.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, some past pointing on cerebellar exam. [**2-8**]
strenth in lower extremities/upper extremities seemingly from
effort. Has base line tremor and jerking. 3+ UE/LE DTR's.

DISCHARGE EXAM:
VS:
GENERAL: awake, NAD
HEENT: NCAT, R eye EOMI, sclera anicteric
HEART: irreg rate, rhythm, nl S1, S2, III/VI systolic murmur at
LSB radiating to axilla
LUNGS:  bibasilar crackles
ABDOMEN: soft, NT, ND, + BS, no masses
EXTREMITIES: wwp, no edema
NEURO:  alert, CNII-XII grossly intact except for decreased
hearing in L ear to finger rub, [**2-8**] stregth in UE, LE,
cerebellar exam not performed.

Pertinent Results:
Admission Labs:
[**2172-7-7**] 04:45PM BLOOD WBC-13.8* RBC-4.06* Hgb-9.9* Hct-33.0*
MCV-81* MCH-24.4* MCHC-30.1* RDW-17.7* Plt Ct-168
[**2172-7-7**] 04:45PM BLOOD Neuts-90.2* Lymphs-7.0* Monos-2.0 Eos-0.4
Baso-0.4
[**2172-7-8**] 06:29AM BLOOD Glucose-85 UreaN-40* Creat-2.5* Na-142
K-3.9 Cl-101 HCO3-32 AnGap-13
[**2172-7-7**] 04:45PM BLOOD Glucose-158* UreaN-41* Creat-2.3*# Na-138
K-4.4 Cl-94* HCO3-31 AnGap-17
[**2172-7-7**] 04:45PM BLOOD ALT-22 AST-27 AlkPhos-74 TotBili-0.2
[**2172-7-7**] 04:45PM BLOOD TSH-2.6
[**2172-7-7**] 08:20PM BLOOD Type-ART pO2-56* pCO2-56* pH-7.40
calTCO2-36* Base XS-7
[**2172-7-8**] 09:59AM BLOOD Type-ART O2 Flow-2 pO2-114* pCO2-75*
pH-7.28* calTCO2-37* Base XS-5 Intubat-NOT INTUBA Comment-NASAL
[**Last Name (un) 154**]
[**2172-7-8**] 09:59AM BLOOD Lactate-0.5

Discharge Labs:
[**2172-7-15**] 07:30AM BLOOD WBC-8.7 RBC-3.17* Hgb-8.1* Hct-25.5*
MCV-81* MCH-25.5* MCHC-31.7 RDW-18.5* Plt Ct-209
[**2172-7-12**] 06:52AM BLOOD Neuts-69.9 Lymphs-23.1 Monos-4.8 Eos-1.6
Baso-0.5
[**2172-7-14**] 07:25AM BLOOD PT-12.2 PTT-30.1 INR(PT)-1.0
[**2172-7-15**] 07:30AM BLOOD Glucose-92 UreaN-55* Creat-3.1* Na-144
K-4.3 Cl-103 HCO3-31 AnGap-14
[**2172-7-14**] 07:25AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.9
[**2172-7-14**] 07:35AM BLOOD Type-[**Last Name (un) **] pO2-217* pCO2-47* pH-7.45
calTCO2-34* Base XS-8

Other:
[**2172-7-7**] 04:45PM BLOOD TSH-2.6
[**2172-7-12**] 06:52AM BLOOD Free T4-1.4

MICRO:
[**7-7**] BCx neg
8/2-3 UCx neg
[**7-8**] MRSA screen neg

IMAGING
[**2172-7-7**]:
INDICATION: COPD.

COMPARISON: [**2172-6-30**].

PA AND LATERAL VIEWS OF THE CHEST: Patient is status post median
sternotomy,
CABG, and mitral valve replacement. The heart size is unchanged.
The aorta
is slightly tortuous and diffusely calcified. There is evidence
of mild
pulmonary edema, which is similar when compared to the prior
study. Right
PICC tip terminates in the SVC. Small bilateral pleural
effusions are
unchanged. There is no pneumothorax. No acute osseous
abnormalities are
visualized. Epicardial leads are again demonstrated.

IMPRESSION: Mild pulmonary edema with small bilateral pleural
effusions, not
significantly changed when compared to the prior exam.

[**2172-7-8**]: Head CT without contrast
INDICATION: 80-year-old female with tremulousness, weakness and
hyperreflexia
for several days. Evaluate for evidence of parenchymal disease.

TECHNIQUE: Contiguous axial images were obtained through the
brain. No
contrast was administered. Multiple sections were degraded by
motion and
repeated with improved result.

COMPARISON: CTA of the head and neck from [**2172-6-25**].

FINDINGS: There is no evidence of hemorrhage, edema, mass
effect, or
territorial infarction. The ventricles and sulci are moderately
enlarged
consistent with age-related atrophy. There are scattered foci of
white matter hypodensity, including areas of the brainstem,
consistent with chronic small vessel ischemic disease. There is
an old lacunar infarct in the left caudate head and in the right
caudate body. There is calcification of the carotid siphons
bilaterally. The visualized portion of the paranasal sinuses,
mastoid air cells and middle ear cavities are clear. Osseous
structures are unremarkable.

IMPRESSION:
1. No acute intracranial process.
2. Prominence of the ventricles and sulci consistent with
age-related
atrophy.
3. Hypodensities in the periventricular and brainstem white
matter,
consistent with sequelae of chronic small vessel ischemic
disease. Old
lacunar infarcts in the left caudate head and right caudate
body.

[**2172-7-8**]:
CHEST RADIOGRAPH

INDICATION: New PE, evaluation for fluid overload.

COMPARISON: [**2172-7-7**].

FINDINGS: As compared to the previous radiograph, there is
improvement of
signs indicative of pulmonary edema. Trace of the signs,
however, is seen.  The atelectasis at the left lung base is
unchanged. The size of the cardiac silhouette is minimally
decreased. No interval appearance of pleural effusions. No hilar
or mediastinal abnormalities.

[**2172-7-9**]: ECG
Sinus tachycardia. Left atrial abnormality. Frequent atrial
ectopy and
periods of atrial bigeminy. Prior inferior myocardial infarction
with likely posterior component, as well, as recorded on [**2172-7-7**].
The rate has increased. There is frequent atrial ectopy and
slight inferior ST segment elevation persists. Otherwise, no
diagnostic interim change.
  Intervals Axes
Rate PR QRS QT/QTc P QRS T
116 126 76 324/422 14 -9 21

[**2172-7-9**]:
CHEST RADIOGRAPH

INDICATION: Hypoxia, evaluation for pleural effusion.

COMPARISON: [**2172-7-8**].

FINDINGS: As compared to the previous radiograph, the right PICC
line,
previously well positioned, has changed in position. The tip is
now
malpositioned in the internal jugular vein. Re-positioning is
required.

There is no evidence of complications, notably no pneumothorax.

Mild pulmonary edema, retrocardiac and left basal atelectasis.
The presence of small pleural effusions cannot be excluded.

Brief Hospital Course:
80 y/o Spanish-speaking female hx of COPD (hx of recent
intubation), RA on steroids, HTN, recent UTI, PICC line in place
for abx (cef), admitted for confusion and tremor.  Her course
was complicated by hypercarbic respiratory failure and acute
kidney injury.

# Hypercarbic respiratory failure: The pt had an unclear lung
disease on admission as no PFT reports were available; there was
some report of restrictive lung disease; however as discussed
she likely has a severe obstructive defect, in combination with
sleep-disordered breathing; there is also some component of
diastolic heart failure. Through MICU she was noted to have
apneic spells.
.
She stayed several nights in the MICU for titration of BiPAP
which will need to be a permanent intervention for her while she
sleeps. Through MICU, her last settings were BiPAP 8/5 which she
appeared to tolerate well. When somnolent, her ABG appears to be
more respiratorily acidotic with pH's in the 7.27-7.3 range;
after BiPAP her pH improves to the 7.36-7.39 range and her
mental status is completely clear. After transfer out of the
MICU, her pH's were improved to the 7.45 range and remained
stable. She continued to tolerate BiPAP well at night and for
occasional naps, and had no episodes of apneic spells.
.
Sleep/pulmonology was consulted to assist with titration of
BiPAP. Sleep decided to defer inpt sleep study to outpt setting
as lack of close monitoring would push her into hypercarbia. Pt
had PFT studies done to evaluate for restrictive lung
disease--official report is not available but pt will f/u with
Dr. [**Last Name (NamePattern1) 4512**]for both issues.
- Continue nebs
- Continue BIPAP on settings [**7-10**] at night and for naps

# Acute Renal Failure: Pt with rising Cr through admission.
Renal was consulted while in MICU and  felt she likely had ATN
due to prolonged hypovolemia. Her Cr peaked to 5.3 and began to
downtrend once out of the MICU. Electrolytes remained stable on
the floor. Cre on discharge was 3.1. Lasix was held for duration
of hospitalization out of MICU to maintain fluid balance.
- Trend Cre
- Track I+Os. Fluid balance goal: even to slightly positive.
- Replete electrolytes prn
- [**Month (only) 116**] need to restart Lasix once kidney function stabilizes.

# Left sided deficits: On admission to floor, pt with left sided
facial droop, tremor and dysmetria, left pupil not reactive and
blind. Per nursing home, pt has had blindness in left eye for
years and has had the facial droop/tremor/dysmetria for days.
Prior retinal vein occlusion has left her blind in her left eye
so her pupillary nonreactivity is not new. The Stroke team was
called and they felt this might be reactivation of symptoms from
prior stroke in setting of underlying metabolic process. Head CT
showed no new stroke.  Once out of the MICU, she had no signs of
L sided deficits.

# Tremulousness with hyperreflexia: Bilateral, and per the
daughter is an exacerbation of a chronically present condition.
Was felt to be a metabolic process (acute renal faliure),
possibly a side effect of Gabapentin (was stopped in MICU),
Cefepime (finished the course in MICU). CT head was negative.
These symptoms were not present once she was out of the MICU on
the floors. Once out of the MICU, these symptoms seemed to have
resolved.

# Bacterial UTI: Pt with recent UTI noted during last admission,
she completed her 14d course of Cefepime this admission. ID was
consulted given h/o frequent UTI's, urosepsis, and h/o resistant
organisms. They recommended Methenamine 1g PO bid for UTI
prophylaxis but this is contraindicated in renal failure, so
should be started when her renal fxn improves at rehab. Pt has
h/o urinary incontinence that has been managed with a Foley.
This is a difficult situation as a Foley catheter ideally should
not be used given her history of recurrent UTIs. She was
discharged with the Foley catheter can in place to avoid skin
breakdown from her urinary incontinence.
- continue Foley but would benefit from either intermittent
straight cath to relieve urine prior to incontinence or frequent
diaper changes to avoid skin breakdown from incontience.
- start Methenamine 1 g PO BID for UTI prophylaxis

# Metabolic Encephalopathy: On arrival to the floor, pt was
somnolent and had arterial blood gas which showed an acute on
chronic respiratory acidosis. Therefore, she was transferred to
MICU and placed on BiPAP. Of note, she had refused intubation,
resuscitations, and NIPPV during last admission; however her
daughter [**Name (NI) 15359**] was called and requested reversal of code
status and NIPPV. She did well with BiPAP and perked up back to
her baseline alert and conversant mental status.  After transfer
out of the MICU, she had no episodes of confusion. Her mental
status remained clear; she was alert and oriented to person,
place, and time.

# Chronic Diastolic CHF (EF75%): Continued ASA, plavix,
atorvastatin, beta blocker, and lasix at 40 mg daily. Not on
Ace-I, as was dc'd on last admission due to ARF. While pt was
transferred out of MICU, Lasix was held daily (per Renal) to
keep her fluid balance even.
- Continue ASA, plavix, atorvastatin, beta blocker

# Rheumatoid Arthritis: Continued home prednisone 10 mg daily.
Pt complained of hip, back, shoulder pain.  Oxycodone
contraindicated given concern for altered mental status.
- Continue prednisone
- Continue Tramadol prn pain

# CAD with Stents and hx of MI [**2-/2172**]: Continued ASA /
Clopidogrel / Atorvastatin / Metoprolol.

# Hypothyroidism: TSH wnl. Continued levothyroxine.

# Code status: She was DNR/DNI on arrival, but reversed on
arrival to MICU and through continuous discussion with her
daughter [**Name (NI) 15359**], it was finally decided to make her DNR but OK
to intubate

Daughter [**Name (NI) 15359**] [**Telephone/Fax (1) 100099**]


Medications on Admission:
heparin (porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day)
aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
qday
clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY
docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
senna 8.6 mg Tablet Sig: One (1) Tablet PO BID
gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID
cefepime 2 gram Recon Soln Sig: Two (2) Grams Injection Q12H
(every 12 hours) for 7 days (on 7.28/11)
pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
poqday
miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for yeast.
camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day)
multivitamin Tablet Sig: One (1) Tablet PO DAILY
lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily)
metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID


Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash.
11. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
13. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
14. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
15. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) inhalation Inhalation Q6H (every 6
hours).
16. ipratropium bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours).
17. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
18. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
19. BiPap
Patient requires BiPap for OSA during sleep.  Her settings are
[**7-10**].


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
Hypercarbic respiratory failure
Acute tubular necrosis as cause of acute kidney injury
Restrictive lung disease


Discharge Condition:
Condition: improved
Mental Status: alert and oriented
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


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

It was a pleasure taking care of you in the hospital.  You
presented with a change in mental status and breathing
difficulty during periods of sleep which improved with a
breathing machine called BiPap.  You should continue using this
every time you sleep.  You were also treated for a urinary tract
infection. You had some kidney failure that is improving.
Please follow-up with your doctors as below.

The following changes were made to your medications:
1. Started BiPap breathing machine with sleep
2. Started tramadol as needed for pain control
3. Stopped lasix due to your kidney failure
4. Completed/stopped cefepime for your prior UTI as you finished
the treatment course.
5. Started Advair, Ipratropium and Albuterol inhalers for your
lungs.
6. Stopped gabapentin given your kidney failure.

Please continue all of your other medications as previously
prescribed.

Followup Instructions:
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2172-8-6**] at 3:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) 611**], 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

Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2172-8-19**] at 3:00 PM
With: [**First Name8 (NamePattern2) 1955**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage
{'Acute and chronic respiratory failure,Acute kidney failure with lesion of tubular necrosis,Metabolic encephalopathy,Acute on chronic diastolic heart failure,Mixed acid-base balance disorder,Retinal vascular occlusion, unspecified,Urinary tract infection, site not specified,Chronic venous embolism and thrombosis of deep vessels of distal lower extremity,Facial weakness,Other musculoskeletal symptoms referable to limbs,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Other alteration of consciousness,Obstructive chronic bronchitis without exacerbation,Long-term (current) use of anticoagulants,Other and unspecified nonspecific immunological findings,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Obstructive sleep apnea (adult)(pediatric),Other diseases of trachea and bronchus,Other chronic pulmonary heart diseases,Unspecified acquired hypothyroidism,Rheumatoid arthritis,Postinflammatory pulmonary fibrosis,Kyphosis (acquired) (postural),Aortocoronary bypass status,Old myocardial infarction,Anemia of other chronic disease,Heart valve replaced by transplant,Personal history of tobacco use,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: Altered mental status

PRESENT ILLNESS: 80 yo F with h/o MI in [**2-/2172**], RA on steroids (10mg daily) long
term, recurrent UTI's with urosepsis w/ resistant organisms (?
VRE and pseudomonas resistent to cipro), who had a recent
hospital admission on [**7-21**] for AMS, hypercarbia (Pc02:
100) requiring intubation and UTI for which she was treated for
with 14 day course of cefepime. She was discharge back to her
[**Hospital1 1501**] and was found to have AMS with O2sat 76% on RA. She was then
sent to the ED where her O2 sat was 94% on RA her ABG showed pH
7.40/ pCO2 56/pO2 56/ HCO3 36. Her vitals were T98, HR84,
BP105/51, RR18. Labs were notable for WBC of 13.8 with 90%
PMN's, BUN of 41, Cr of 2.3, glucose of 158, few bacteria in her
urine with small amounts of blood and luekocyte esterase, and 3
wbc's. She was then admitted to the floor for further eval. This
morning she was found to be very lethargic and and shaking.
Neurology was called for eval for ? stroke, she had Head CT that
showed no IC process. She had a repeat ABG that showed pH 7.28/
pCO2
75/pO2 114/ HCO3 37 not on oxygen. She was then sent to the
floor for acute respiratory acidosis and hypercarbia for bipap.
During her prior admission, pt refused to used bipap and had
decided to be DNR/DNI. However during her AMS today her daughter
who is her HCP decided to reverse her code DNI and okay to
resuscitate. So, she was transferred to the MICU for further
management.
She was placed on bipap on arrival to the MICU, she was having
periods of apnea, sating well in the upper 90s%. She then became
more alert. Unfortunately we were unable to obtain an ABG prior
to her being d/ced from BIPAP.
.
Of note, during her last admssion she also presented with AMS
which was at the time atributed to hypercarbia and infection.
Her hypercarbia was originally thought to be due to baseline
obstructive disease in setting of hypoventilation from
significant AMS from recieiving tramadol and quinolone and a
UTI. She also would desat in the evening and had observed
periods of apnea while sleeping, but she refused to use BIPAP.
We were also able to obtain records from [**Hospital3 2005**] and it
was reported that pt had PFTs which were consistent with
obstructive pattern which was attributed to scoliosis. However
there were no numbers reported. She had an ECHO on [**6-26**] that
showed pulm hypertension. So given her hx of RA and concern for
interstial [**Last Name **] problem, she had high resolution CT which showed
no evidence of interstitial lung disease and possible
tracheobronchomalacia, severity indeterminate.
.
Her MICU course is as follows: On [**7-8**] she was on BiPAP with
periods of apnea ([**Last Name (un) 6055**]-[**Doctor Last Name **]) ameliorated with increased
PEEP. Her code status was reversed to FULL. On [**7-9**] she continued
on BiPAP and completed her course of cefepime. Laboratories
appeared to indicate prerenal azotemia and she was run TBB even
with fluids as respiratory status allowed. While on BiPAP her BP
dropped at one point, ABG indicating hypercarbia and acidemia
during which she was minimally responsive. She responded to
fluid bolus and became alert again. On [**7-10**] she was kept TBB even
and Renal added sevelamer prn for phos > 6. She revisited code
status with her proxy (daughter) and became DNR/ok to intubate.
On [**7-11**] she was transferred to medicine sating 90s on RA and
requiring BiPAP for periods of napping due to persistent bouts
of hypercarbia.
.
On arrival to the floor, VS were 96.3  80-90  SBP 106-130 RR
15-20  96%RA.  Her mental status was clear, she was alert and
oriented and tolerating BiPAP well with no shortness of breath
or chest pain.

MEDICAL HISTORY: - ? Lung disease with "CO2 retention"- severe restrictive
disease
- ? Sleep Apnea
- CAD, sp CABG, s/p STEMI in [**2-/2172**] w/ 2 BMS to the RCA and RBL
- S/p DVT w/ lupus anticoag (was on coumadin but had GI bleed on
[**2-/2172**] in the setting of supra-therapeutic INR)
- L retinal vein occlusion
- Chronic anemia
- diastolic dysfunction w/ EF of 75%
- Bioprosthetic mitral valve seen on echo [**6-/2172**]
- Moderate TR
- Moderate pulmonary HTN
- frequent UTIs and urosepsis - [**Hospital3 **], h/o VRE
(pseudomonas)
- RA
- HL
- HTN
- hypothyroidism
- TKR

MEDICATION ON ADMISSION: heparin (porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day)
aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
qday
clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY
docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
senna 8.6 mg Tablet Sig: One (1) Tablet PO BID
gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID
cefepime 2 gram Recon Soln Sig: Two (2) Grams Injection Q12H
(every 12 hours) for 7 days (on 7.28/11)
pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
poqday
miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for yeast.
camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day)
multivitamin Tablet Sig: One (1) Tablet PO DAILY
lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily)
metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID

ALLERGIES: Penicillins / Sulfa (Sulfonamide Antibiotics) / Gold Salts

PHYSICAL EXAM: ADMISSION EXAM
VS: 98.2 | 122/44 | 102| 20| 95% RA
GENERAL:NAD, comfortable, appropriate.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no thyromegaly, no JVD, no carotid bruits.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: Coarse BS BL. good air movement, resp unlabored.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, some past pointing on cerebellar exam. [**2-8**]
strenth in lower extremities/upper extremities seemingly from
effort. Has base line tremor and jerking. 3+ UE/LE DTR's.

FAMILY HISTORY: NC

SOCIAL HISTORY: Daughter reports patient has lived at [**Hospital3 2558**] since
hospitalization in [**Month (only) 958**]. She does not have dementia or
cognitive impairment at baseline.
- Tobacco: past h/o heavy smoking
- Alcohol:  none 

### Response:
{'Acute and chronic respiratory failure,Acute kidney failure with lesion of tubular necrosis,Metabolic encephalopathy,Acute on chronic diastolic heart failure,Mixed acid-base balance disorder,Retinal vascular occlusion, unspecified,Urinary tract infection, site not specified,Chronic venous embolism and thrombosis of deep vessels of distal lower extremity,Facial weakness,Other musculoskeletal symptoms referable to limbs,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Other alteration of consciousness,Obstructive chronic bronchitis without exacerbation,Long-term (current) use of anticoagulants,Other and unspecified nonspecific immunological findings,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Obstructive sleep apnea (adult)(pediatric),Other diseases of trachea and bronchus,Other chronic pulmonary heart diseases,Unspecified acquired hypothyroidism,Rheumatoid arthritis,Postinflammatory pulmonary fibrosis,Kyphosis (acquired) (postural),Aortocoronary bypass status,Old myocardial infarction,Anemia of other chronic disease,Heart valve replaced by transplant,Personal history of tobacco use,Do not resuscitate status'}
