CHIEF COMPLAINT: Tachypnea

PRESENT ILLNESS: 79 y/o female with advanced dementia recently discharged from
[**Hospital3 **] s/p admission for PNA and PEG placement. At the
[**Hospital 228**] nursing home she was noted to have repspiratory rate
elevation that did not improve with morphine.  Vitals at the NH
noted to be 123/68, 93, 33, 99.6, 91-92% on RA.
.
In the ED intial vital signs were 98.5, 145/89, 57, 34, 100% A.
She was noted to have abdominal pain and distension.  A CT of
the abdomen was performed for concern of SBO and the patient was
evaluated by surgery.  She had dilated loops of bowel, but the
overall exam and imaging was felt to be most consistent with
constipation.  Disimpaction was recommended.
.
A UA with positive WBC, bacteria.  Patient was given
levofloxacin, clindamycin, and vancomycin for coverage of both
PNA and UTI.  The emergency room spoke to the son who reversed
her DNR/DNI with the thought of possible intubation if she has a
short-term process.  The patient was admitted to the ICU for
further evaluation.
.
Review of systems:  Patient unable to provide.

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: Robitussin
Ativan for insomnia
Tylenol for pain/Tempterature
Miralax
Colace
Tramadol
Roxanol
[**Last Name (un) 39705**]
Namenda 5 [**Hospital1 **]
Vitamin C 250
Zyprexa 6mg
Aricept 10 Daily
Senna
ASA 9am daily
ASA
Remeron

ALLERGIES: Penicillins

PHYSICAL EXAM: On Admission:
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
On Discharge:
Vitals: Tm/c: 97.9/97.5, BP: 132/62 (110-132/52-62), HR: 87
(82-87), RR: 22, O2: 97%RA
GA: Pt lying in bed, verbally responsive
HEENT:  MMM. no LAD. neck supple.
Cards: No RVH. [**2-25**] holosystolic murmur heard best at the right
upper sternal, loud S1, soft S2.
Pulm: fine crackles at the bases bilaterally
Abd: soft, NT, +BS. no g/rt.
Extremities: 1+ radial pulses bilaterally, lower extremity
pulses difficult to palpate secondary to edema.  Lower extremity
edema bilaterally, with soft fluffy skin around patella
bilaterally, PICC line on the left.
Skin: pt has bilateral heel blisters.  The blister on the left
is intact and the one on the right is popped and skin peeling.
The patient also has a stage 2 right lateral malleolus ulcer
with clean borders.  A well healing scar at the inferior border
and otherwise pink granulation tissue
Neuro/Psych: Answers questions appropriately

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Lives in [**Hospital 745**] [**Hospital **] Nursing home.
Acute and subacute bacterial endocarditis,Pressure ulcer, stage III,Bacteremia,Unspecified osteomyelitis, ankle and foot,Urinary tract infection, site not specified,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other specified bacteria,Fecal impaction,Other constipation,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Bipolar disorder, unspecified,Anxiety state, unspecified,Gastrostomy status,Personal history of venous thrombosis and embolism,Do not resuscitate status
Ac/subac bact endocard,Pressure ulcer,stage III,Bacteremia,Osteomyelitis NOS-ankle,Urin tract infection NOS,Oth specf bacteria,Fecal impaction,Constipation NEC,Hypertension NOS,Hyperlipidemia NEC/NOS,Alzheimer's disease,Dementia w/o behav dist,Bipolar disorder NOS,Anxiety state NOS,Gastrostomy status,Hx-ven thrombosis/embols,Do not resusctate status
Admission Date:  [**2120-1-12**]              Discharge Date:   [**2120-1-17**]

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

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 2610**]
Chief Complaint:
Tachypnea


Major Surgical or Invasive Procedure:
none

History of Present Illness:
79 y/o female with advanced dementia recently discharged from
[**Hospital3 **] s/p admission for PNA and PEG placement. At the
[**Hospital 228**] nursing home she was noted to have repspiratory rate
elevation that did not improve with morphine.  Vitals at the NH
noted to be 123/68, 93, 33, 99.6, 91-92% on RA.
.
In the ED intial vital signs were 98.5, 145/89, 57, 34, 100% A.
She was noted to have abdominal pain and distension.  A CT of
the abdomen was performed for concern of SBO and the patient was
evaluated by surgery.  She had dilated loops of bowel, but the
overall exam and imaging was felt to be most consistent with
constipation.  Disimpaction was recommended.
.
A UA with positive WBC, bacteria.  Patient was given
levofloxacin, clindamycin, and vancomycin for coverage of both
PNA and UTI.  The emergency room spoke to the son who reversed
her DNR/DNI with the thought of possible intubation if she has a
short-term process.  The patient was admitted to the ICU for
further evaluation.
.
Review of systems:  Patient unable to provide.


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:
Lives in [**Hospital 745**] [**Hospital **] Nursing home.

Son [**Name (NI) **].


Family History:
Noncontributory

Physical Exam:
On Admission:
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
On Discharge:
Vitals: Tm/c: 97.9/97.5, BP: 132/62 (110-132/52-62), HR: 87
(82-87), RR: 22, O2: 97%RA
GA: Pt lying in bed, verbally responsive
HEENT:  MMM. no LAD. neck supple.
Cards: No RVH. [**2-25**] holosystolic murmur heard best at the right
upper sternal, loud S1, soft S2.
Pulm: fine crackles at the bases bilaterally
Abd: soft, NT, +BS. no g/rt.
Extremities: 1+ radial pulses bilaterally, lower extremity
pulses difficult to palpate secondary to edema.  Lower extremity
edema bilaterally, with soft fluffy skin around patella
bilaterally, PICC line on the left.
Skin: pt has bilateral heel blisters.  The blister on the left
is intact and the one on the right is popped and skin peeling.
The patient also has a stage 2 right lateral malleolus ulcer
with clean borders.  A well healing scar at the inferior border
and otherwise pink granulation tissue
Neuro/Psych: Answers questions appropriately


Pertinent Results:
[**2120-1-12**] 02:45PM BLOOD WBC-8.6# RBC-3.57* Hgb-10.6* Hct-32.7*
MCV-92 MCH-29.7 MCHC-32.4 RDW-15.8* Plt Ct-211
[**2120-1-14**] 07:05AM BLOOD WBC-4.4# RBC-3.39* Hgb-9.8* Hct-31.2*
MCV-92 MCH-28.9 MCHC-31.3 RDW-15.9* Plt Ct-203
[**2120-1-17**] 05:25AM BLOOD WBC-6.3 RBC-3.26* Hgb-9.4* Hct-29.4*
MCV-90 MCH-28.8 MCHC-32.0 RDW-15.6* Plt Ct-276
[**2120-1-12**] 02:45PM BLOOD PT-13.8* PTT-22.5 INR(PT)-1.2*
[**2120-1-13**] 04:01AM BLOOD PT-16.5* PTT-23.2 INR(PT)-1.5*
[**2120-1-12**] 02:45PM BLOOD Glucose-147* UreaN-21* Creat-0.3* Na-138
K-4.5 Cl-102 HCO3-30 AnGap-11
[**2120-1-17**] 05:25AM BLOOD Glucose-126* UreaN-12 Creat-0.4 Na-137
K-4.4 Cl-104 HCO3-28 AnGap-9
[**2120-1-12**] 02:45PM BLOOD Calcium-8.8 Phos-3.8 Mg-2.0
[**2120-1-15**] 04:50AM BLOOD Calcium-8.6 Phos-2.4* Mg-2.2
[**2120-1-17**] 05:25AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.0
.
CT [**2119-1-12**]:
Extensive venous thrombus extending inferiorly from the IVC
filter to involve at least the common femoral veins with the
left extending further, off of imaged field.
.
Cecum in abnormal location in the right upper quadrant though
non-dilated measuring up to 5.0cm with no wall thickening.
Contrast from prior procedure seen distal to this point.
Top-normal measured loops of small bowel measuring just up to
3.0cm with focal areas of narrowing though no transition. Air is
still in colon, ?Ileus versus early partial obstruction.  Rectal
wall thickening with fecal impaction, ?stercoral colitis. Focal
fluid in the left pelvis.
.
[**2120-1-15**]
[**Month/Day/Year **]
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. [Intrinsic left ventricular systolic function is
likely more depressed given the severity of valvular
regurgitation.] The estimated cardiac index is normal
(>=2.5L/min/m2). The aortic valve leaflets are mildly thickened
(?#). No discrete vegetation is seen (cannot exclude). There is
no aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is mild
bileaflet leaflet mitral valve prolapse. A small 5-6cm mobile
echodensity is seenon the left atrial side of the valve (clip
[**Clip Number (Radiology) **]), near the coaptation point of the leaflets, c/w a vegetation.
An eccentric, anterior and posteriorly directely jets of severe
(4+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.

Compared with the prior study (images reviewed) of [**2117-6-21**],
the mobile mitral leaflet echodensity is new and c/w a
vegetation. The severity of mitral regurgitation is markedly
increased as well.
.
[**2120-1-15**] MRI Ankle
FINDINGS: Evaluation of the bone marrow demonstrates edema in
the distal 5 cm
of the fibula, and cortical irregularity at the lateral aspect
of the distal
lateral malleolus. With an overlying soft tissue ulcer, these
findings are
consistent with osteomyelitis. There is no discrete fluid
collection.

There is no bone marrow edema elsewhere. There is trace fluid in
the
calcaneocuboid and talonavicular joints. The tibiotalar joint is
intact. The
sinus tarsi contains fat. The Achilles tendon is intact, however
there is
significant subcutaneous fluid posterior to it. Marked edema is
seen at the
dorsal aspect of the foot.

There is mild edema at the plantar fascia, which is suboptimally
evaluated in
absence of sagittal views, as well as mild edema in the plantar
foot muscles.

The deltoid and spring ligaments are grossly intact. The
anterior
tibiofibular, posterior tibiofibular, calcaneofibular, and
posterior
talofibular ligaments are intact. The anterior talofibular
ligament is torn.


There is mild tenosynovitis of the peroneus longus and brevis
tendons, but the
intrinsic signal intensity of the tendons is normal. Posterior
tibialis
tendon, flexor hallucis longus tendon, and flexor digitorum
longus tendon are
intact. The extensor tendons are intact.

IMPRESSION:
1. Deep soft tissue ulcer, extending to the lateral aspect of
the lateral
malleolus, associated with cortical irregularity and bone marrow
edema in the distal fibula, most consistent with osteomyelitis.
No abscess.
2. Marked circumferential ankle edema, most pronounced in the
dorsal aspect of the foot.
3. Edema in the plantar foot muscles,nonspecific myositis, the
differential diagnosis is broad and includes infectious or
inflammatory or neurogenic etiologies.
4. Mild peroneal tenosynovitis.
5. Tear of the anterior talofibular ligament, likely chronic.
.
[**2120-1-17**] CXR PICC placement
FINDINGS: A left PICC catheter has been reinserted and is now
positioned more centrally with the tip in the mid-to-upper SVC.
Lung volumes remain with left basilar atelectasis. No
pneumothorax is present. An IVC filter and catheter projecting
over the upper abdomen are unchanged.

IMPRESSION: Left PICC tip in the mid-to-upper SVC. No
complications.



Brief Hospital Course:
79 y/o female with tachypnea, tachycardia, abdominal pain and
distentsion.
.
# Tachypnea: The patient came in with rapid breathing but
overnight her RR improved to the mid-20's.  Her oxygen
saturation was maintained, and there was no evidence of PNA on
CT.  Given this clinical picture tachypnea was thought to be a
response to pain from her distended abdomen or from restrictive
physiology due to abdominal distension.  Abdominal distention
was treated as below, with improvement in respiratory symptoms.
She remained slightly tachypneic and it was found that she was
bacteremic. Her tachypnea could be secondary to infection as
well as pain in addition to her underlying fecal impaction.  Her
respiratory status should be followed, but she is breathing
comfortably at the time of discharge.
.
# Abdominal Distension/Pain: CT with evidence of significant
constipation, likely in context of morphine use. There is no
evidence of abdominal pathology requiring surgical intervention
per ACS.  The patient cleared out rectally following fleet and
soap suds enema but still has considerable amount of stool
throughout her colon.
Started on lactulose/miralax from above.  The patient began
moving her bowels well and, in fact started having very loose
stools.  We pulled back on her bowel regiment and made most of
her medications PRN with the instructions to give them if she
does not have a bowel movement in 2 days.
.
# Urinary Tract Infection: Patient with history of E Coli,
Enterococcus, and Morganella all sensitive to ciprofloxacin.
Started on cipro/vanc.  Culture sent.  The patient was growing
klebsiella from her urine and she was started on cipro as she
had UTI's all sensitive to cipro on the past.  This UTI was
resistent to cipro and she was switched to Bactrim.  She will
complete a 7 day course of Bactrim for her UTI.
.
# Bacteremia:  Blood cultures from the ICU grew GPC and was
empirically started on vancomycin.  Ultimately it speciated as
coag negative staph and she patient was switch from vancomycin
to daptomycin because of a reaction to vancomycin that she has
had in the past.  She was clinically improving on daptomycin and
serial cultures were all negative.  Suspicion for source was the
right hip which had been infected in the past and her right
ankle that had a lateral malleolus stage III ulcer.  [**Month/Day/Year **] showed
a 3-5mm vegetation on the mitral valve and worsening MR [**First Name (Titles) **] [**Last Name (Titles) **]
compared to [**2116**].  She also had an MRI of the right ankle as
suspicion for osteomyelitis was high with an overlying stage III
ulcer in the region.  Initial [**Location (un) 1131**] of the MRI was highly
suspicious for osteomyelitis, likely the source for her
bacteremia.  A PICC line was placed and she will be continued on
daptomycin for 6 weeks.  Weekly CBC with Differential, BMP, Ca,
Mg, Phos, CK, LFTs will be faxed to [**Telephone/Fax (1) 457**]. [**First Name8 (NamePattern2) 47034**] [**Last Name (NamePattern1) **]
will follow the results and follow up with the patient in [**Hospital **]
clinic.
.
# Goals of care: After goals of care discussion with the son it
was decided not to be more agressive with washout of the right
hip to assess if the fluid collection was infectious.  He also
decided not to consult surgery regarding valve replacement.  Ms
[**Known lastname 109139**] will be continued on IV Abx and follow up in outpatient
clinic as described above.
.
# Dementia: Continued on Namenda, Aricept, Remeron, with zyprexa
PRN for agitation.


Medications on Admission:
Robitussin
Ativan for insomnia
Tylenol for pain/Tempterature
Miralax
Colace
Tramadol
Roxanol
[**Last Name (un) 39705**]
Namenda 5 [**Hospital1 **]
Vitamin C 250
Zyprexa 6mg
Aricept 10 Daily
Senna
ASA 9am daily
ASA
Remeron

Discharge Medications:
1. Fibersource HN     Liquid [**Hospital1 **]: full strength PO continuous:
Tubefeeding: Fibersource HN Full strength;
Starting rate: 50 ml/hr; Do not advance rate
Residual Check: q4h Hold feeding for residual >= : 200 ml
give 150cc bolus water every 8 hours.
2. acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H (every
6 hours).
3. Robitussin Cough & Cold 2-15 mg/5 mL Liquid [**Hospital1 **]: Two (2)  PO
every six (6) hours as needed for cough.
4. Ativan 0.5 mg Tablet [**Hospital1 **]: 0.5 Tablet PO QHS as needed for
insomnia.
5. acetaminophen 650 mg Tablet [**Hospital1 **]: One (1) Tablet PO every six
(6) hours as needed for pain, temp>101.
6. Miralax 17 gram Powder in Packet [**Hospital1 **]: One (1)  PO once a day
as needed for constipation: please give if no BM in greater than
48hrs.
7. docusate sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1)  PO BID (2
times a day).
8. sulfamethoxazole-trimethoprim 800-160 mg Tablet [**Hospital1 **]: One (1)
Tablet PO BID (2 times a day) for 4 days.
9. daptomycin 500 mg Recon Soln [**Hospital1 **]: 0.8 Recon Soln Intravenous
Q24H (every 24 hours) for 6 weeks.
10. tramadol 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO every eight (8)
hours as needed for pain.
11. roxanol  [**Hospital1 **]: Five (5) mg  every four (4) hours as needed
for shortness of breath or wheezing.
12. memantine 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
13. Vitamin C 250 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day.

14. olanzapine 5 mg Tablet, Rapid Dissolve [**Hospital1 **]: One (1) Tablet,
Rapid Dissolve PO DAILY (Daily).
15. Vitamin D 50,000 unit Capsule [**Hospital1 **]: One (1) Capsule PO once a
month.
16. donepezil 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS (at
bedtime).
17. senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
18. aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
19. Remeron 30 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
20. lactulose 10 gram/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO BID (2
times a day) as needed for constipation: if no bowel movement
for three days.
21. polyethylene glycol 3350 17 gram/dose Powder [**Hospital1 **]: One (1)
PO DAILY (Daily) as needed for constipation.
22. hyoscyamine sulfate 0.125 mg Tablet, Sublingual [**Hospital1 **]: One (1)
Tablet, Sublingual Sublingual QID (4 times a day) as needed for
increased secretions.
23. miconazole nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical QID
(4 times a day) as needed for rash.
24. famotidine 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H (every
12 hours).
25. Outpatient Lab Work
weekly CBC with Differential, BMP, Ca, Mg, Phos, CK, LFTs.
Please fax these results to [**Telephone/Fax (1) 457**].

Fax results att: [**First Name8 (NamePattern2) 47034**] [**Last Name (NamePattern1) **].


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
Primary Diagnosis:
Endocarditis
Osteomyelitis
Bacteremia
UTI
Fecal impaction
.
Secondary Diagnosis:
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


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.


Discharge Instructions:
You are being discharged from [**Hospital1 1170**].  It was a pleasure taking care of you.  You were
admitted to the hosptial and found to have a lot of stool in
your rectum.  You were admitted to the ICU for fast breathing
and once they were able to move your bowels, your breathing
decreased.  However, your blood was found to have an infection
that was thought to be coming from your right ankle ulcer and
infection of the underlying bone.  You also were found to have a
urinary tract infection with a different antibiotic.  An
ultrasound of the heart also showed that you have an infection
on your heart valve.  You were started on the appropriate
anitbiotics and your cognitive state greatly improved.  At this
time, we will treat you with long term IV antibiotics to treat
the blood infection and the infection on the heart valve.
.
The following medication was started:
Daptomycin 400 mg IV every 24hours for
Bactrim DS 1 tab Daily for 5 days
.
Please take you other medications as prescribed.

Followup Instructions:
You will follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], [**Telephone/Fax (1) 719**],
while you are at your nursing home.  You will also be followed
by the nurses, NP and physicians there.

Department: INFECTIOUS DISEASE
When: MONDAY [**2120-1-29**] at 10:10 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

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
{"Acute and subacute bacterial endocarditis,Pressure ulcer, stage III,Bacteremia,Unspecified osteomyelitis, ankle and foot,Urinary tract infection, site not specified,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other specified bacteria,Fecal impaction,Other constipation,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Bipolar disorder, unspecified,Anxiety state, 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: Tachypnea

PRESENT ILLNESS: 79 y/o female with advanced dementia recently discharged from
[**Hospital3 **] s/p admission for PNA and PEG placement. At the
[**Hospital 228**] nursing home she was noted to have repspiratory rate
elevation that did not improve with morphine.  Vitals at the NH
noted to be 123/68, 93, 33, 99.6, 91-92% on RA.
.
In the ED intial vital signs were 98.5, 145/89, 57, 34, 100% A.
She was noted to have abdominal pain and distension.  A CT of
the abdomen was performed for concern of SBO and the patient was
evaluated by surgery.  She had dilated loops of bowel, but the
overall exam and imaging was felt to be most consistent with
constipation.  Disimpaction was recommended.
.
A UA with positive WBC, bacteria.  Patient was given
levofloxacin, clindamycin, and vancomycin for coverage of both
PNA and UTI.  The emergency room spoke to the son who reversed
her DNR/DNI with the thought of possible intubation if she has a
short-term process.  The patient was admitted to the ICU for
further evaluation.
.
Review of systems:  Patient unable to provide.

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: Robitussin
Ativan for insomnia
Tylenol for pain/Tempterature
Miralax
Colace
Tramadol
Roxanol
[**Last Name (un) 39705**]
Namenda 5 [**Hospital1 **]
Vitamin C 250
Zyprexa 6mg
Aricept 10 Daily
Senna
ASA 9am daily
ASA
Remeron

ALLERGIES: Penicillins

PHYSICAL EXAM: On Admission:
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
On Discharge:
Vitals: Tm/c: 97.9/97.5, BP: 132/62 (110-132/52-62), HR: 87
(82-87), RR: 22, O2: 97%RA
GA: Pt lying in bed, verbally responsive
HEENT:  MMM. no LAD. neck supple.
Cards: No RVH. [**2-25**] holosystolic murmur heard best at the right
upper sternal, loud S1, soft S2.
Pulm: fine crackles at the bases bilaterally
Abd: soft, NT, +BS. no g/rt.
Extremities: 1+ radial pulses bilaterally, lower extremity
pulses difficult to palpate secondary to edema.  Lower extremity
edema bilaterally, with soft fluffy skin around patella
bilaterally, PICC line on the left.
Skin: pt has bilateral heel blisters.  The blister on the left
is intact and the one on the right is popped and skin peeling.
The patient also has a stage 2 right lateral malleolus ulcer
with clean borders.  A well healing scar at the inferior border
and otherwise pink granulation tissue
Neuro/Psych: Answers questions appropriately

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Lives in [**Hospital 745**] [**Hospital **] Nursing home. 

### Response:
{"Acute and subacute bacterial endocarditis,Pressure ulcer, stage III,Bacteremia,Unspecified osteomyelitis, ankle and foot,Urinary tract infection, site not specified,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other specified bacteria,Fecal impaction,Other constipation,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Bipolar disorder, unspecified,Anxiety state, unspecified,Gastrostomy status,Personal history of venous thrombosis and embolism,Do not resuscitate status"}
