CHIEF COMPLAINT: frequent suctioning

PRESENT ILLNESS: 88 year old female with recent acute on chronic left SDH, recent
SAH s/p coiling of right PCA artery aneurysm, hydrocephalus with
VP shunt, acute respiratory failure secondary to large thoracic
mass (benign thyroid nodule) requiring trach, severe dysphagia
with PEG placement, ?GI bleed, DVT with IVC filter placement
transferred from OSH for anemia and admitted to MICU for
increasing respiratory secretions.
.
Patient had been at [**Hospital3 **] prior to transfer and per
report patient noted to have Hct 23.8 and concern for GI bleed
and was sent to OSH for blood transfusion. There VS: 100.4
114/66 80 94% RA. There was question of allergic rxn (?seizures)
to blood in the past so OHS transferred her to [**Hospital1 18**]. Prior to
transfer patient had CXR with concern for a RLL pneumonia. Given
750mg of levoquin.
.
In the ED, initial VS were 100 98 106/54 26 94%. 18g and 20g
were placed for access. Exam notable for rectal exam: no stool
in the vault, very trace guiac + effluent.  Pulmonary exam with
coarse breath sounds bilaterally, scattered rhonchi, pink
secretions from trache collar. Patient received PR tylenol for
temp of 100.8. Abx were not continued as suspicion for PNA low.
.
On arrival to the MICU, patient comfortable without complaint
with cough, SOB, CP.
.
Of note, anemnia/dark tarry stools has been chronic issue and
per previous DC summaries patient with recent EGD and C-scope
wnl. Previously, initial positive guaiac tests thought secondary
due to manipulation of her PEG tube,
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.

MEDICAL HISTORY: Subarachnoid hemorrhage s/p coiling of R PCA aneurysm
Hydrocephalus s/p VP shunt
Respiratory failure requiring trach placement
Thoracic mass: biopsied - benign thyroid nodule
Hyperthyroidism with goiter
Anemia - prior black stools with no source found from
EGD/c-scope
Deep vein thrombosis s/p IVC filter
Hypertension
Atrial fibrillation

MEDICATION ON ADMISSION: 1. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
2. levetiracetam 750 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO twice a
day.
3. lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO Q6H (every 6
hours) as needed for mouth movements.
4. docusate sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One Hundred (100) mg
PO BID (2 times a day).
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) neb Inhalation Q6H (every 6 hours) as

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Physical:
General: Alert, oriented, no acute distress, comfortable,
pleasant, breathing comfortably on trach mask
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Rhonchorus breath sounds bilaterally, no wheezes, rales
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: non-focal, moving all four extremities with sensation
intact

FAMILY HISTORY: CAD

SOCIAL HISTORY: Originally from [**Country 13622**] Republic, Spanish-speaking. Prior to
her prolonged hospitalization in [**Month (only) 1096**] she was living with
her
daughter and granddaughter and was very independent. Currently
she is at [**Hospital3 **]. She walks with a cane or walker at
baseline.
No history of tobacco or alcohol use.
Hemorrhage of gastrointestinal tract, unspecified,Acute posthemorrhagic anemia,Chronic respiratory failure,Obstructive hydrocephalus,Dysphagia, unspecified,Fever, unspecified,Goiter, unspecified,Thyrotoxicosis without mention of goiter or other cause, and without mention of thyrotoxic crisis or storm,Epilepsy, unspecified, without mention of intractable epilepsy,Atrial fibrillation,Unspecified essential hypertension,Presence of cerebrospinal fluid drainage device,Gastrostomy status,Tracheostomy status,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Long-term (current) use of anticoagulants,Heart valve replaced by transplant
Gastrointest hemorr NOS,Ac posthemorrhag anemia,Chronic respiratory fail,Obstructiv hydrocephalus,Dysphagia NOS,Fever NOS,Goiter NOS,Thyrotox NOS no crisis,Epilep NOS w/o intr epil,Atrial fibrillation,Hypertension NOS,Ventricular shunt status,Gastrostomy status,Tracheostomy status,Hx TIA/stroke w/o resid,Long-term use anticoagul,Heart valve transplant
Admission Date:  [**2181-2-17**]              Discharge Date:   [**2181-2-21**]


Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2291**]
Chief Complaint:
frequent suctioning


Major Surgical or Invasive Procedure:
None


History of Present Illness:
88 year old female with recent acute on chronic left SDH, recent
SAH s/p coiling of right PCA artery aneurysm, hydrocephalus with
VP shunt, acute respiratory failure secondary to large thoracic
mass (benign thyroid nodule) requiring trach, severe dysphagia
with PEG placement, ?GI bleed, DVT with IVC filter placement
transferred from OSH for anemia and admitted to MICU for
increasing respiratory secretions.
.
Patient had been at [**Hospital3 **] prior to transfer and per
report patient noted to have Hct 23.8 and concern for GI bleed
and was sent to OSH for blood transfusion. There VS: 100.4
114/66 80 94% RA. There was question of allergic rxn (?seizures)
to blood in the past so OHS transferred her to [**Hospital1 18**]. Prior to
transfer patient had CXR with concern for a RLL pneumonia. Given
750mg of levoquin.
.
In the ED, initial VS were 100 98 106/54 26 94%. 18g and 20g
were placed for access. Exam notable for rectal exam: no stool
in the vault, very trace guiac + effluent.  Pulmonary exam with
coarse breath sounds bilaterally, scattered rhonchi, pink
secretions from trache collar. Patient received PR tylenol for
temp of 100.8. Abx were not continued as suspicion for PNA low.
.
On arrival to the MICU, patient comfortable without complaint
with cough, SOB, CP.
.
Of note, anemnia/dark tarry stools has been chronic issue and
per previous DC summaries patient with recent EGD and C-scope
wnl. Previously, initial positive guaiac tests thought secondary
due to manipulation of her PEG tube,
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.


Past Medical History:
Subarachnoid hemorrhage s/p coiling of R PCA aneurysm
Hydrocephalus s/p VP shunt
Respiratory failure requiring trach placement
Thoracic mass: biopsied - benign thyroid nodule
Hyperthyroidism with goiter
Anemia - prior black stools with no source found from
EGD/c-scope
Deep vein thrombosis s/p IVC filter
Hypertension
Atrial fibrillation


Social History:
Originally from [**Country 13622**] Republic, Spanish-speaking. Prior to
her prolonged hospitalization in [**Month (only) 1096**] she was living with
her
daughter and granddaughter and was very independent. Currently
she is at [**Hospital3 **]. She walks with a cane or walker at
baseline.
No history of tobacco or alcohol use.


Family History:
CAD

Physical Exam:
Admission Physical:
General: Alert, oriented, no acute distress, comfortable,
pleasant, breathing comfortably on trach mask
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Rhonchorus breath sounds bilaterally, no wheezes, rales
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: non-focal, moving all four extremities with sensation
intact


Pertinent Results:
LABS:

Admission Labs:
[**2181-2-17**] 12:55AM BLOOD WBC-8.0# RBC-2.80* Hgb-8.7* Hct-25.4*
MCV-91 MCH-31.2 MCHC-34.5 RDW-16.2* Plt Ct-475*
[**2181-2-17**] 12:55AM BLOOD Neuts-77.2* Lymphs-11.9* Monos-5.8
Eos-4.6* Baso-0.4
[**2181-2-17**] 12:55AM BLOOD PT-12.4 PTT-30.5 INR(PT)-1.1
[**2181-2-17**] 12:55AM BLOOD Ret Aut-3.9*
[**2181-2-17**] 12:55AM BLOOD Glucose-119* UreaN-25* Creat-1.0 Na-139
K-4.6 Cl-102 HCO3-28 AnGap-14
[**2181-2-17**] 12:55AM BLOOD ALT-12 AST-15 LD(LDH)-147 AlkPhos-77
TotBili-0.3
[**2181-2-17**] 06:42AM BLOOD Calcium-9.2 Phos-4.0 Mg-1.8 Iron-15*
[**2181-2-17**] 12:55AM BLOOD Hapto-330*
[**2181-2-17**] 06:42AM BLOOD calTIBC-250* Ferritn-41 TRF-192*

Discharge Labs:

Thyroid function tests:
[**2181-2-19**] 06:40AM BLOOD T3-65* Free T4-1.5
[**2181-2-19**] 06:40AM BLOOD TSH-0.34

MICRO:
[**2181-2-17**] 	URINE CULTURE-FINAL negative 	
[**2181-2-17**] 	MRSA SCREEN-FINAL negative	
[**2181-2-17**] 	Blood Culture, Routine-PENDING 	EMERGENCY [**Hospital1 **]
[**2181-2-17**] 	Blood Culture, Routine-PENDING

STUDIES:
CXR [**2181-2-17**]:
IMPRESSION:
1. Grossly stable thyroid goiter causing widening of the right
paratracheal stripe.
2. Unchanged elevation of the right hemidiaphragm and bibasilar
atelectasis.
3. No evidence of pneumonia or acute pulmonary edema.


Brief Hospital Course:
88 year old female with recent acute on chronic left SDH, recent
SAH s/p coiling of right PCA artery aneurysm, hydrocephalus with
VP shunt, acute respiratory failure secondary to large thoracic
mass (benign thyroid nodule) requiring trach, severe dysphagia
with PEG placement, ?GI bleed transferred from OSH for anemia
and admitted to initially to the MICU for increasing respiratory
secretions.  She was stable for transfer to the medicine floor
within one day.

ACTIVE ISSUES BY PROBLEM:
# Respiratory secretions: On arrival to MICU, patient's
secretions were minimal and she had no signs of respiratory
distress. Initial concern for ?PNA vs tracheitis however patient
without leukocytosis or fevers (except initial temp of 100, no
recurrence). CXR without focal infiltrate.  Previous sputum
cultures have grown pseudomonas; however this likely represents
colonization rather than infection, so it was felt that repeat
sputum cultures would not be helpful in this clinical setting.
Antibiotics were not started.  Secretions appear to be coming
from both oropharyngeal and pulmonary sources, however they are
clear and she is able to expectorate them extremely well on her
own.  She was seen by the Interventional Pulmonary team, who had
no further recommendations or plans for interventions at this
time. Pt was continued on trach mask and required suctioning
every 6-8 hours.  Guaifenesin and saline nebs were initiated to
help break up the thickened sputum.  This regimen, along with
albuterol, should be continued at her rehab facility.

# Normocytic Anemia: Likely due to a very slow lower GI bleed.
Admission HCT 25.4, with baseline HCT ~28-30. Exam in ED guaiac
+ but without overt melena or BRBPR. Previous GI work-up with
unrevealing EGD (documented in [**11-27**] operative note) and
reportedly normal colonoscopy at [**Hospital3 **] in [**2176**]. PEG
lavage on arrival to the MICU guaiac negative. Previous vitamin
B12, folate wnl. Iron studies suggested iron deficiency anemia,
for which she was continued on her iron supplementation. She was
transfused one unit PRBC's for Hct 22 with appropriate response
to 25.  After transfer to the medicine floor, hct continued to
remain stable.  She did have more dark brown guaiac positive
stools.  It is likely that she has a very slow GI bleed that is
causing her anemia, more likely lower rather than upper GI given
the guaiac negative PEG lavage.  As this appears to be a chronic
issue that is relatively stable, it is recommended that she
continue to have her hemoglobin/hematocrit followed and could
have a repeat colonoscopy for further work up, however will
defer to her PCP or the rehab medical director for further
management.

# Dysphagia: Secondary to esophageal narrowing by large thyroid
mass and difficulty swallowing (noted to have likely aspirations
in the past). PEG tube in place. Initially held tube feeds in
the setting of possible GI bleed, however these were restarted
on hospital day 2 with no issues. Speech and swallow consult was
obtained, however they deferred further evaluation to her speech
therapist at [**Hospital3 **], as they have been working with her
for 3 months now on this issue.  She remained NPO and on tube
feeds for her stay in the hospital.

# Substernal goiter, hyperthyroidism: TFTs sent while inpatient,
which appear improved (however less reliable in acute illness):
TSH 0.34, freeT4 1.5, and T3 65.  ENT team was notified of her
admission and requested an appointment be made for her with Dr.
[**Last Name (STitle) 1837**] for evaluation for resection of thyroid mass.
This appointment will be on  ###, after which the ENT, IP,
neurology, and endocrine teams will need to decide on the best
future course of action.

CHRONIC INACTIVE ISSUES:
# DVT s/p filter placement: placed on heparin SC

# Seizure disorder: Continued keppra, with prn Ativan.

# Hyperthyroidism: Continued methimazole.

# History of Atrial Fibrillation. CHADS 2. Anticoagulated with
ASA.

TRANSITION OF CARE ISSUES:
- Resp secretions: will need suctioning at least every [**5-25**]
hours, continue with saline nebs, albuterol/ipratropium nebs,
and guaifenesin
- Goiter, Hyperthyroidism: appears to be in euthyroid state now,
may now be a surgical candidate.  Has ENT appt with Dr.
[**Last Name (STitle) 1837**] for surgical eval, after which ENT, IP, neurology,
and endocrine teams will decide on the best future course of
action for removal of thyroid mass
- Anemia: slow GI bleed most likely, should have
hemoglobin/hematocrit checked 2x/weekly.  Transfuse for hct <21,
hemodynamic instability, or symptoms.
- Dysphagia: should continue to work with speech/swallow
therapist at [**Hospital1 **] to determine when it may be safe to try PO
nutrition again.
- FULL CODE this admission

Medications on Admission:
1. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
2. levetiracetam 750 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO twice a
day.
3. lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO Q6H (every 6
hours) as needed for mouth movements.
4. docusate sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One Hundred (100) mg
PO BID (2 times a day).
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) neb Inhalation Q6H (every 6 hours) as

needed for shortness of breath, wheezing.
6. methimazole 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times

a day).
7. senna 8.8 mg/5 mL Syrup [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a

day) as needed for constipation .
8. acetaminophen 500 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO every six

(6) hours as needed for pain.
9. heparin (porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1) ml
Injection three times a day: for DVT prophylaxis.
10. aspirin 325 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: One (1)
Tablet, Delayed Release (E.C.) PO once a day: Please do not
start taking until [**2181-1-28**]. .
11. Ferrous Sulfate 300mg PO BID
12. Latanoprost 0.005% 1drop each eye qhs
13. Solumedrol IV 40mg q12hr  (never received at [**Hospital1 **], not
continued during this hospitalizations)

Discharge Medications:
1. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
2. lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO every six (6)
hours as needed for for mouth movements.
3. docusate sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One Hundred (100) mg
PO BID (2 times a day).
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) neb inhalation Inhalation Q6H (every 6
hours) as needed for sob, wheezing.
5. methimazole 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times
a day).
6. senna 8.8 mg/5 mL Syrup [**Last Name (STitle) **]: Five (5) ml PO twice a day as
needed for constipation.
7. acetaminophen 500 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO every six
(6) hours as needed for pain.
8. aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
9. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid [**Last Name (STitle) **]: Three
Hundred (300) mg PO BID (2 times a day).
10. latanoprost 0.005 % Drops [**Last Name (STitle) **]: One (1) Drop(s) each eye
Ophthalmic HS (at bedtime).
11. levetiracetam 100 mg/mL Solution [**Last Name (STitle) **]: 1500 (1500) mg PO BID
(2 times a day).
12. guaifenesin 100 mg/5 mL Syrup [**Last Name (STitle) **]: Ten (10) ML PO Q6H (every
6 hours).
13. sodium chloride 3 % Solution for Nebulization [**Last Name (STitle) **]: Fifteen
(15) ML(s) (1 nebulization) Inhalation Q6H (every 6 hours).
14. ipratropium bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) neb
Inhalation Q6H (every 6 hours) as needed for sob, wheezing .
15. heparin (porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
injection (5000 units) Injection three times a day: Can
discontinue if patient is able to ambulate 3x daily.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]

Discharge Diagnosis:
Primary diagnoses:
Chronic respiratory failure
Dysphagia
Anemia likely secondary to slow gastrointestinal bleed
Substernal goiter
Hyperthyroidism

Secondary diagnoses:
Deep vein thrombosis
Seizure disorder
Atrial fibrillation


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


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

You were admitted to the hospital for increased respiratory
secretions and low blood counts.  We did blood tests and xrays,
and we do not believe that you have have a lung infection.  The
increased secretion is partly due to the benign thyroid mass and
difficulty swallowing.  Your low blood counts are likely coming
from a very small and very slow bleed in your intestines.  You
got 1 unit of blood and your blood counts have been very stable.
 Your doctor may decided if you should have a colonoscopy as an
outpatient for further evaluation.

Changes made to your medications:
START guaifenesin 10 ml every 6 hours
START saline nebulizations every 6 hours
START ipratropium nebulizations every 6 hours as needed for
shortness of breath or wheezing

It was a pleasure to take care of you at [**Hospital1 **]!

Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] M
Location: GREATER [**Hospital1 **] FAMILY HEALTH CENTER
Address: [**Location (un) **], [**Hospital1 **],[**Numeric Identifier 66038**]
Phone: [**Telephone/Fax (1) 82128**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.


We are working on a follow up appointment in Otolaryngology with
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1837**] for your hospitalization. You must follow
up within 1 week of discharge. The office will contact you at
the facility with the appointment information. If you have not
heard within 2 business days please call the office at
[**Telephone/Fax (1) 41**].

Department: RADIOLOGY
When: THURSDAY [**2181-3-1**] at 2:00 PM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST     Best Parking: [**Street Address(1) 592**] Garage

Department: NEUROSURGERY
When: THURSDAY [**2181-3-1**] at 2:45 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7746**], MD [**Telephone/Fax (1) 3666**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: NEUROLOGY
When: WEDNESDAY [**2181-3-28**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD [**Telephone/Fax (1) 2574**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: INTERVENTIONAL PULMONARY
When: TUESDAY [**2181-4-3**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Doctor Last Name **]
Building: DE [**Hospital1 **] BUILDING ([**Hospital Ward Name **] COMPLEX), [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: ENDOCRINOLOGY
When: TUESDAY [**2181-4-3**] at 11:20 AM
With: [**First Name11 (Name Pattern1) 1409**] [**Last Name (NamePattern4) 91212**], MD [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name **] Garage
{'Hemorrhage of gastrointestinal tract, unspecified,Acute posthemorrhagic anemia,Chronic respiratory failure,Obstructive hydrocephalus,Dysphagia, unspecified,Fever, unspecified,Goiter, unspecified,Thyrotoxicosis without mention of goiter or other cause, and without mention of thyrotoxic crisis or storm,Epilepsy, unspecified, without mention of intractable epilepsy,Atrial fibrillation,Unspecified essential hypertension,Presence of cerebrospinal fluid drainage device,Gastrostomy status,Tracheostomy status,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Long-term (current) use of anticoagulants,Heart valve replaced by transplant'}


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: frequent suctioning

PRESENT ILLNESS: 88 year old female with recent acute on chronic left SDH, recent
SAH s/p coiling of right PCA artery aneurysm, hydrocephalus with
VP shunt, acute respiratory failure secondary to large thoracic
mass (benign thyroid nodule) requiring trach, severe dysphagia
with PEG placement, ?GI bleed, DVT with IVC filter placement
transferred from OSH for anemia and admitted to MICU for
increasing respiratory secretions.
.
Patient had been at [**Hospital3 **] prior to transfer and per
report patient noted to have Hct 23.8 and concern for GI bleed
and was sent to OSH for blood transfusion. There VS: 100.4
114/66 80 94% RA. There was question of allergic rxn (?seizures)
to blood in the past so OHS transferred her to [**Hospital1 18**]. Prior to
transfer patient had CXR with concern for a RLL pneumonia. Given
750mg of levoquin.
.
In the ED, initial VS were 100 98 106/54 26 94%. 18g and 20g
were placed for access. Exam notable for rectal exam: no stool
in the vault, very trace guiac + effluent.  Pulmonary exam with
coarse breath sounds bilaterally, scattered rhonchi, pink
secretions from trache collar. Patient received PR tylenol for
temp of 100.8. Abx were not continued as suspicion for PNA low.
.
On arrival to the MICU, patient comfortable without complaint
with cough, SOB, CP.
.
Of note, anemnia/dark tarry stools has been chronic issue and
per previous DC summaries patient with recent EGD and C-scope
wnl. Previously, initial positive guaiac tests thought secondary
due to manipulation of her PEG tube,
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.

MEDICAL HISTORY: Subarachnoid hemorrhage s/p coiling of R PCA aneurysm
Hydrocephalus s/p VP shunt
Respiratory failure requiring trach placement
Thoracic mass: biopsied - benign thyroid nodule
Hyperthyroidism with goiter
Anemia - prior black stools with no source found from
EGD/c-scope
Deep vein thrombosis s/p IVC filter
Hypertension
Atrial fibrillation

MEDICATION ON ADMISSION: 1. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
2. levetiracetam 750 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO twice a
day.
3. lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO Q6H (every 6
hours) as needed for mouth movements.
4. docusate sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One Hundred (100) mg
PO BID (2 times a day).
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) neb Inhalation Q6H (every 6 hours) as

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Physical:
General: Alert, oriented, no acute distress, comfortable,
pleasant, breathing comfortably on trach mask
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Rhonchorus breath sounds bilaterally, no wheezes, rales
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: non-focal, moving all four extremities with sensation
intact

FAMILY HISTORY: CAD

SOCIAL HISTORY: Originally from [**Country 13622**] Republic, Spanish-speaking. Prior to
her prolonged hospitalization in [**Month (only) 1096**] she was living with
her
daughter and granddaughter and was very independent. Currently
she is at [**Hospital3 **]. She walks with a cane or walker at
baseline.
No history of tobacco or alcohol use. 

### Response:
{'Hemorrhage of gastrointestinal tract, unspecified,Acute posthemorrhagic anemia,Chronic respiratory failure,Obstructive hydrocephalus,Dysphagia, unspecified,Fever, unspecified,Goiter, unspecified,Thyrotoxicosis without mention of goiter or other cause, and without mention of thyrotoxic crisis or storm,Epilepsy, unspecified, without mention of intractable epilepsy,Atrial fibrillation,Unspecified essential hypertension,Presence of cerebrospinal fluid drainage device,Gastrostomy status,Tracheostomy status,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Long-term (current) use of anticoagulants,Heart valve replaced by transplant'}
