CHIEF COMPLAINT: hypoxia

PRESENT ILLNESS: The pt is a 51-yo woman with T1-T2 paraplegia, COPD, and
multiple recent admissions for pneumonia, who comes in from home
with hypoxia, somnolence, and cough productive of green sputum.
The pt and husband confirm that she had been feeling very well
until the morning of admission. On the morning of admission, the
husband found her to be more difficult to arouse. He checked her
oxygen saturation and found her to be 92-93% on 2L NC, but over
the next few hours continued to be somnolent and with
progressively worsening hypoxia to the low 80s on 2L NC and
still less than 90% on 4L NC, so she was brought in to the ED.
Her husband also reports that she has had increased cough today,
with green liquid/watery secretions, and feeling cold, but notes
that she was warm to touch. He found her temperature to be 99F.
She denies any chest pain, palpitations, shortness of breath, or
wheeze.
.
On arrival to the ED, VS - Temp 101.8F, BP 144/102, HR 110, R
24, SaO2 81%. She was placed on NRB with improvement to 100%.
CXR showed worsening RLL process, and ECG was unremarkable.
Right IJ CVL was placed due to difficulty gaining access, and
blood Cx were sent. She received 1L NS IVF, Zosyn 4.5g IV, and
Vancomycin 1g IV. She is admitted to the MICU for further care
given her hypoxia requiring NRB. Lactate was 1.5 and all other
labs were pending at time of transfer.
.
Of note, the pt was admitted for pneumonia from [**2148-6-11**] -
[**2148-6-15**] with RLL consolidations, treated with Vancomycin and
Cefepime, with a brief admission to the MICU for hypotension and
fever that improved without intubation or pressors, transferred
to the floor and ultimately discharged on a 7-day course of
antibiotics. She was again admitted to [**Hospital1 18**] from [**2148-7-19**] -
[**2148-7-21**] with fever and hypoxia, which was thought to be related
to a possible exacerbation of viral bronchitis with atelectasis.
She was discharged with acappella for chest PT to aid in lung
expansion and decrease oxygen dependence. She was feeling
significantly improved on discharge and was doing very well at
home until the day of admission.
.
ROS: As per HPI. Otherwise, she denies any headache, dizziness,
lightheadedness, chest pain, shortness of breath, abdominal
pain, nausea, vomiting, diarrhea, dysuria, arthralgias, or
myalgias.
.

MEDICAL HISTORY: 1. T1-T2 paraplegia following MVC [**1-4**]
2. Recurrent UTIs: [**Month/Year (2) 40097**] klebsiella
3. HCV, viral load suppressed
4. H/o recurrent PNAs: MRSA, pan-sensitive Kleb
5. Anxiety
6. DVT in [**2142**] -IVC filter placed in [**2142**]
7. Pulmonary nodules
8. Hypothyroidism
9. Chronic pain
10. Chronic gastritis
11. H/o obstructive lung disease
12. Anemia of chronic disease
13. S/p PEA arrest during last hospitalization in [**2147-10-3**]

MEDICATION ON ADMISSION: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea/hypoxia
2. Albuterol-Ipratropium [**2-3**] PUFF IH TID
3. Baclofen 10 mg PO/NG HS
4. Baclofen 10 mg PO/NG NOON
5. Baclofen 20 mg PO/NG BREAKFAST
6. Citalopram Hydrobromide 40 mg PO/NG DAILY
7. Clonazepam 1 mg PO/NG [**Hospital1 **]
8. Docusate Sodium 100 mg PO BID
9. Levothyroxine Sodium 75 mcg PO/NG DAILY
10. Lidocaine 5% Patch 1 PTCH TD DAILY
11. Methadone 5 mg PO/NG TID
12. Oxybutynin 5 mg PO NOON
13. Oxybutynin 10 mg PO BREAKFAST
14. Oxybutynin 10 mg PO HS
15. Polyethylene Glycol 17 g PO/NG DAILY
16. Pregabalin 150 mg PO/NG TID
17. Sucralfate 1 gm PO/NG QID
18. traZODONE 100 mg PO/NG HS
19. OxycoDONE (Immediate Release)  5 mg PO TID pain

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: Temp 99.8F, BP 103/49, HR 101, R 21, SaO2 93% NRB
Gen: ill appearing. On 4L NC. Mild respiratory distress
HEENT: pale conjunctiva. Dry mm. poor dentition. no cervical
LAD. neck supple. R IJ in place.
CV: Difficult to auscultate [**3-5**] to coarse BS. RRR. No MRG
appreciated. NL S1,S2
Pulm: Course breath sounds, rhonchorous throughout bilaterally
R>L. Exp wheezes present. Wet craclkes in LLF's B'L.
Abd: Protuberant. NBS. NT. No HSM appreciated.
GU: Foley. Chronic [**3-5**] T1/T2 paraplegia.
Ext: 2+ pitting edema B/L up to the knee
Neuro: Oriented to person, place, and time. Pt. appears midly
lethargic. CN II-XII grossliy intact. SNo sensation to touch
below L2 dermatome BL. Can twist abdomen and move arms. 5+
strength in UE B/L.
Skin: clammy, pale. 3x3 macule on R. Foremarm.

FAMILY HISTORY: No history of lung disease.

SOCIAL HISTORY: - Lives at home with her husband and 2 adolescent children
- Tobacco: 35 pack years, quit smoking several months ago, but
relapsed recently (last cigarette was week of presentation).
- etOH: Denies
- Illicits: Denies
Methicillin resistant pneumonia due to Staphylococcus aureus,Methicillin resistant Staphylococcus aureus septicemia,Sepsis,Acute on chronic diastolic heart failure,Chronic respiratory failure,Urinary tract infection, site not specified,Chronic hepatitis C without mention of hepatic coma,Paraplegia,Chronic airway obstruction, not elsewhere classified,Anemia of other chronic disease,Unspecified acquired hypothyroidism,Other chronic pain,Depressive disorder, not elsewhere classified,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Personal history of venous thrombosis and embolism,Other postprocedural status
Meth res pneu d/t Staph,MRSA septicemia,Sepsis,Ac on chr diast hrt fail,Chronic respiratory fail,Urin tract infection NOS,Chrnc hpt C wo hpat coma,Paraplegia NOS,Chr airway obstruct NEC,Anemia-other chronic dis,Hypothyroidism NOS,Chronic pain NEC,Depressive disorder NEC,Gstr/ddnts NOS w/o hmrhg,Hx-ven thrombosis/embols,Post-proc states NEC
Admission Date:  [**2148-7-27**]              Discharge Date:   [**2148-8-6**]

Date of Birth:  [**2096-10-22**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
hypoxia


Major Surgical or Invasive Procedure:
Peripherally Inserted Central Catheter
Central Line Placement (R IJ)


History of Present Illness:
The pt is a 51-yo woman with T1-T2 paraplegia, COPD, and
multiple recent admissions for pneumonia, who comes in from home
with hypoxia, somnolence, and cough productive of green sputum.
The pt and husband confirm that she had been feeling very well
until the morning of admission. On the morning of admission, the
husband found her to be more difficult to arouse. He checked her
oxygen saturation and found her to be 92-93% on 2L NC, but over
the next few hours continued to be somnolent and with
progressively worsening hypoxia to the low 80s on 2L NC and
still less than 90% on 4L NC, so she was brought in to the ED.
Her husband also reports that she has had increased cough today,
with green liquid/watery secretions, and feeling cold, but notes
that she was warm to touch. He found her temperature to be 99F.
She denies any chest pain, palpitations, shortness of breath, or
wheeze.
.
On arrival to the ED, VS - Temp 101.8F, BP 144/102, HR 110, R
24, SaO2 81%. She was placed on NRB with improvement to 100%.
CXR showed worsening RLL process, and ECG was unremarkable.
Right IJ CVL was placed due to difficulty gaining access, and
blood Cx were sent. She received 1L NS IVF, Zosyn 4.5g IV, and
Vancomycin 1g IV. She is admitted to the MICU for further care
given her hypoxia requiring NRB. Lactate was 1.5 and all other
labs were pending at time of transfer.
.
Of note, the pt was admitted for pneumonia from [**2148-6-11**] -
[**2148-6-15**] with RLL consolidations, treated with Vancomycin and
Cefepime, with a brief admission to the MICU for hypotension and
fever that improved without intubation or pressors, transferred
to the floor and ultimately discharged on a 7-day course of
antibiotics. She was again admitted to [**Hospital1 18**] from [**2148-7-19**] -
[**2148-7-21**] with fever and hypoxia, which was thought to be related
to a possible exacerbation of viral bronchitis with atelectasis.
She was discharged with acappella for chest PT to aid in lung
expansion and decrease oxygen dependence. She was feeling
significantly improved on discharge and was doing very well at
home until the day of admission.
.
ROS: As per HPI. Otherwise, she denies any headache, dizziness,
lightheadedness, chest pain, shortness of breath, abdominal
pain, nausea, vomiting, diarrhea, dysuria, arthralgias, or
myalgias.
.


Past Medical History:
1. T1-T2 paraplegia following MVC [**1-4**]
2. Recurrent UTIs: [**Month/Year (2) 40097**] klebsiella
3. HCV, viral load suppressed
4. H/o recurrent PNAs: MRSA, pan-sensitive Kleb
5. Anxiety
6. DVT in [**2142**] -IVC filter placed in [**2142**]
7. Pulmonary nodules
8. Hypothyroidism
9. Chronic pain
10. Chronic gastritis
11. H/o obstructive lung disease
12. Anemia of chronic disease
13. S/p PEA arrest during last hospitalization in [**2147-10-3**]

Social History:
- Lives at home with her husband and 2 adolescent children
- Tobacco: 35 pack years, quit smoking several months ago, but
relapsed recently (last cigarette was week of presentation).
- etOH: Denies
- Illicits: Denies


Family History:
No history of lung disease.

Physical Exam:
VS: Temp 99.8F, BP 103/49, HR 101, R 21, SaO2 93% NRB
Gen: ill appearing. On 4L NC. Mild respiratory distress
HEENT: pale conjunctiva. Dry mm. poor dentition. no cervical
LAD. neck supple. R IJ in place.
CV: Difficult to auscultate [**3-5**] to coarse BS. RRR. No MRG
appreciated. NL S1,S2
Pulm: Course breath sounds, rhonchorous throughout bilaterally
R>L. Exp wheezes present. Wet craclkes in LLF's B'L.
Abd: Protuberant. NBS. NT. No HSM appreciated.
GU: Foley. Chronic [**3-5**] T1/T2 paraplegia.
Ext: 2+ pitting edema B/L up to the knee
Neuro: Oriented to person, place, and time. Pt. appears midly
lethargic. CN II-XII grossliy intact. SNo sensation to touch
below L2 dermatome BL. Can twist abdomen and move arms. 5+
strength in UE B/L.
Skin: clammy, pale. 3x3 macule on R. Foremarm.


Pertinent Results:
[**2148-7-27**] 05:05PM URINE Blood-NEG Nitrite-POS Protein-25
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
.
[**2148-7-29**]
.
WBC 10.4 (93.3% PMNs), Hgb 9.8, Hct 30.4, Plt 210
Na 139, K 3.6, Cl 100, HCO3 32, BUN 13, Cr 0.3, Gluc 124
Lactate 1.5
UA: clear yellow, pH 6.5, SG 1.024, trace leuks, positive
nitrite, 25 protein, trace ketone; negative blood / glucose /
bilirubin / urobilinogen; 0-2 RBCs, 11-20 WBCs, many bacteria,
no yeast, 0-2 epithelial cells, 0-2 transitional epithelial
cells, 0-2 fine granular casts, occasional WBC clumps
.
[**2148-8-1**] 08:55PM BLOOD Type-ART pO2-64* pCO2-69* pH-7.40
calTCO2-44* Base XS-13
.
[**2148-8-2**] 05:41AM BLOOD calTIBC-190* Hapto-332* Ferritn-265*
TRF-146*
.
[**2148-8-6**]
BLOOD WBC-6.4 RBC-3.58* Hgb-9.5* Hct-30.7* MCV-86 MCH-26.6*
MCHC-31.1 RDW-15.4 Plt Ct-327
Glucose-89 UreaN-4* Creat-0.3* Na-146* K-3.7 Cl-100 HCO3-42*
AnGap-8
.
.
.
.
MICROBIOLOGY
.
URINE CULTURES  **FINAL REPORT [**2148-7-30**]**
.
   URINE CULTURE (Final [**2148-7-30**]):
      KLEBSIELLA PNEUMONIAE.    10,000-100,000 ORGANISMS/ML..
         WARNING! This isolate is an extended-spectrum
beta-lactamase
         ([**Month/Day/Year 40097**]) producer and should be considered resistant to
all
         penicillins, cephalosporins, and aztreonam. Consider
Infectious
         Disease consultation for serious infections caused by
         [**Month/Day/Year 40097**]-producing species.
                              SENSITIVITIES: MIC expressed in
MCG/ML

________________________________________________________
                             KLEBSIELLA PNEUMONIAE
                             |
AMIKACIN--------------  =>64 R
AMPICILLIN/SULBACTAM--    16 I
CEFAZOLIN-------------  =>64 R
CEFEPIME--------------       R
CEFTAZIDIME-----------  =>64 R
CEFTRIAXONE-----------       R
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------  =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN--------   256 R
PIPERACILLIN/TAZO-----     8 S
TOBRAMYCIN------------  =>16 R
TRIMETHOPRIM/SULFA----     2 S

SPUTUM CULTURES     **FINAL REPORT [**2148-7-31**]**
.
   GRAM STAIN (Final [**2148-7-28**]):
      >25 PMNs and <10 epithelial cells/100X field.
      3+  (5-10 per 1000X FIELD):   MULTIPLE ORGANISMS
CONSISTENT WITH
                                    OROPHARYNGEAL FLORA.
      2+   (1-5 per 1000X FIELD):   BUDDING YEAST WITH
PSEUDOHYPHAE.

   RESPIRATORY CULTURE (Final [**2148-7-31**]):
      SPARSE GROWTH Commensal Respiratory Flora.
      Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
      workup will be performed appropriate to the isolates
recovered from
      this site.
      BETA STREPTOCOCCI, NOT GROUP A.    MODERATE GROWTH.
      STAPH AUREUS COAG +.    SPARSE GROWTH.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations
Rifampin
         should not be used alone for therapy.
      YEAST.    SPARSE GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------   =>8 R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------     1 S




Brief Hospital Course:
51-yo woman with T1-T2 paraplegia, COPD, multiple recent
admissions for pneumonia, now admitted with hypoxia and fever,
altered mental status.
.
#. Hypotension: The patient was admitted with relative
hypotension compared to home blood pressures. A right IJ CVL was
placed in the ED and the patient's pressures did not respond
sufficiently to aggressive fluid resuscitation. On admission to
the MICU unit, a Levophed drip was started, more NS was
administered and her MAP and CVP responded.  On [**7-28**]/[**Numeric Identifier **], the
patient was weaned off levophed.  She remained relatively
normotensive throughout the remainder of her MICU stay, and was
eventually transferred to the general medical floors on [**2148-8-5**].
The pt. had one episode of severe hypotension to 60mmHg SBP
accompanied by altered mental status several days after being
transferred to the general medical floor.  This occurred after
delivering 20 mg of Lasix the day prior for severe shortness of
breath secondary to pulmonary edema. Additionally, the pt's O2
sats dropped to the mid 80's and ABG's were performed which
showed CO2 retention.  The pt. was stabilized with fluid boluses
and O2 nonrebreather.  At this time, her medication list was
re-evaluated as it contained multiple centrally acting sedating
medications (medication addendum listed below).  The pt. was
normotensive for the remainder of her stay.
.
#. Hypoxia: Pt was admitted with significant hypoxia.  Right
lower lung exam and CXR findings concerning for pneumonia.
Fever, leukocytosis with neutrophilic predominance, and
increased sputum production supportive as well of a pneumonia.
Sputum notably pink and mucoid in appearance.  Per recent chest
CT, the patient also had some atelectasis and mucoid impaction
which likely contributed to her presenting hypoxia.  Broad
spectrum antibiotics, vancomycin and zosyn, were initiated to
treat hospital acquired pneumona.  On [**2148-7-28**], after
persistent hypotension despite treatment, ciprofloxacin was
briefly initiated to provide double coverage for pseudomonas.
Ciprofloxacin was discontinued on the same day after infectious
disease consult advised low probablity of success with cipro
after zosyn resistance identified. On [**2148-7-29**], Zosyn was
discontinued as cultures were vancomycin sensitive.  Chest
physical therapy was performed throughout her stay and the
patient required oxygen supplementation (4 liter nasal canula)at
the time of transfer from the MICU. The patient was given 10mg
IV lasix on [**7-30**] and [**2148-7-31**] to diurese the patient after CXR
demonstrated evidence of fluid overload.  On transfer to the
floor, the pt. had oxygen saturations persistently in the low
90's.  Sputum cultures were MRSA positive, and the pt. was
continued on Vancomycin.  She had an episode of severe
respiratory distress several days after transferring to the
general medical floors.  The pt. had crackles on exam, and she
was given 20 mg of Lasix to relieve her pulmonary edema.
Additionally, she was put on O2 NRB, then weaned to 4-5 L NC.
The following day, the pt's blood pressure dropped and she
experienced aother episode of hypoxia (as outlined above).  She
was bolused fluids, put on NRB, and weaned to 4L NC.  At this
time, her medication list was also reevaluated (as above) as her
MS/pulmonary performance was waxing and [**Doctor Last Name 688**] since her return
from the MICU.  After her medication adjustments, the pt's O2
demands slowly improved until discharge where she was doing well
breathing room air.
.
#. Altered mental status:  Patient initially presented with
altered mental status thought to be likely toxic-metabolic given
infection, hypoxia and hypotension.  An ABG taken on [**7-27**]/201
showed CO2 of 56 suggesting carbon dioxide retention and mental
status changes secondary to hypercarbia.  However, review of
records demonstrated chronic hypercarbia with pCO2s in 50s-60s.
Altered mental status largely resolved throughout her stay in
the MICU. On the general medical floors, the pt. had several
issues with waxing/[**Doctor Last Name 688**] mental status thought to be a
combination of poor ventilation/over sedation with centrally
acting medications.  Adjustments were made to her medication
list, and the pt's mental status improved to a consistently
interactive state.  Changes in medications are outlined below:
.
Addendum: Pt has been waxing and [**Doctor Last Name 688**] with her mental status,
and has been fluctuating in her ability to maintian oxygen
saturations in the 90-92 range, dipping as far as 80%. Her
medications were reviewed, and with the help of the on-call
pharmacist, several changes have been made. Her attending Dr.
[**Last Name (STitle) 665**] is aware and agrees with the medication changes.
.
PREVIOUS MEDICATION DOSE..........NEW MEDICATION DOSE
Oxybutynin- 10 mg TID ........... DISCONTINUED
Pregabalin- 150 mg TID........... Titrated down- New dose 100 mg
TID
Methadone- 5 mg TID .........changed to 5mg [**Hospital1 **]-- back to TID
[**2148-8-6**]
Baclofen-20mg,10mg,10mg.............10 mg TID
.
#. UTI: Patient admitted with a urinalysis concerning for a UTI.
The patient has a history of [**Month/Day/Year 40097**] urinary tract infections.
Meropenem was initially withheld as colonization of her urinary
tract was presumed and prior [**Month/Day/Year 40097**] infections were Zosyn
sensitive.  While no urinary cultures were positive, Meropenem
treatment was initiated on [**2148-7-31**] as the patient's mental
status had some-what worsened despite treatment for pneumonia.
The pt. was continued on Meropenem throught the duration of her
hospitalization, and was discharged on Ertapenem to finish her
treatment cycle.
.
#. COPD: Past medical records demonstrate that the patient may
have some component of hypercarbia in setting of COPD, with
pCO2s in the 50s-60s.  Sedating medications were held as
tolerated during the day and the patient was continued on home
albuterol and ipratropium. She was counselled on smoking
cessation and reports that she has stopped several months prior.
 During her stay on the general medical floors, the pt had
several issues with chronic CO2 retention and exaing/[**Doctor Last Name 688**]
mental status as outlined above.  Upon discharge, the importance
of not smoking  was emphasized to the pt.
.
#. Depression: Reportedly increased from baseline despite home
Celexa. Patient previously amenable to seeing a psychologist as
an outpatient.  She was continued on her Celexa and social work
was consulted and has been following the patient. The patient
was continued on her home Klonapin dose for anxiety and
Trazadone was added on [**2148-7-31**] as a sleep aid.  The pt. was
continued on these medications during the rest of her hospital
stay.
.
#. T1-T2 paraplegia with chronic pain: Patient maintained on
multiple medications at home including baclofen, lidocaine
patch, methadone, oxybutynin, pregabalin, trazodone, oxycodone.
Due to waxing/[**Doctor Last Name 688**] mental status, several of her medications
were changed (see above addnedum).
.
#. Hypothyroidism - the patient was contined on home
levothyroxine.


Medications on Admission:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea/hypoxia
2. Albuterol-Ipratropium [**2-3**] PUFF IH TID
3. Baclofen 10 mg PO/NG HS
4. Baclofen 10 mg PO/NG NOON
5. Baclofen 20 mg PO/NG BREAKFAST
6. Citalopram Hydrobromide 40 mg PO/NG DAILY
7. Clonazepam 1 mg PO/NG [**Hospital1 **]
8. Docusate Sodium 100 mg PO BID
9. Levothyroxine Sodium 75 mcg PO/NG DAILY
10. Lidocaine 5% Patch 1 PTCH TD DAILY
11. Methadone 5 mg PO/NG TID
12. Oxybutynin 5 mg PO NOON
13. Oxybutynin 10 mg PO BREAKFAST
14. Oxybutynin 10 mg PO HS
15. Polyethylene Glycol 17 g PO/NG DAILY
16. Pregabalin 150 mg PO/NG TID
17. Sucralfate 1 gm PO/NG QID
18. traZODONE 100 mg PO/NG HS
19. OxycoDONE (Immediate Release)  5 mg PO TID pain


Discharge Medications:
1. Vancomycin 1,000 mg Recon Soln [**Hospital1 **]: One (1) gram Intravenous
every twelve (12) hours for 3 days.
Disp:*QS * Refills:*0*
2. Ertapenem 1 gram Recon Soln [**Hospital1 **]: One (1) gram Intravenous
once a day for 3 days.
Disp:*QS * Refills:*0*
3. Methadone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a
day).
4. Pregabalin 75 mg Capsule [**Hospital1 **]: One (1) Capsule PO TID (3 times
a day).
5. Citalopram 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).

6. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
7. Levothyroxine 75 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
9. Polyethylene Glycol 3350 17 gram/dose Powder [**Hospital1 **]: One (1)  PO
DAILY (Daily).
10. Sucralfate 1 gram Tablet [**Hospital1 **]: One (1) Tablet PO QID (4 times
a day).
11. Baclofen 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO NOON (At Noon).

12. Baclofen 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at
bedtime).
13. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
14. Famotidine 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H (every
12 hours).
15. Bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
16. Clonazepam 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for anxiety / sleep.
17. Trazodone 50 mg Tablet [**Hospital1 **]: 0.5 Tablet PO HS (at bedtime) as
needed for sleep.
18. Baclofen 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO BREAKFAST
(Breakfast).
19. Oxycodone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
20. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
Two (2)  Inhalation every 4-6 hours as needed for SOB.
21. Combivent 18-103 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puffs
Inhalation TID PRN as needed for shortness of breath or
wheezing.


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 1474**] VNA

Discharge Diagnosis:
Primary:
Pneumonia  (organism: Methicillin Resistant Staph Aureus)
Urinary Tract Infection - (organism: Extended spectrum
betalactamase resistant Klebsiella)
Sepsis (organisms per above)
.
Secondary Diagnosis
Chronic obstructive pulmonary disease
Paraplegia (lower extremity)
Chronic Pain
Hypothyroidism
Anxiety


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
You were hospitalized with a severe Pneumonia and Urinary Tract
Infection.  You developed a condition known as sepsis, and
required intensive care in the medical intensive care unit for
several days.  Once you were stable in the intensive care unit,
you were sent to the general medical floors to receive continued
care as you regained your strength and your infections resolved.
 You were treated with very strong antibiotics, which you will
continue to take outside the hosptial.  These drugs are called
VANCOMYCIN and ERTAPENEM.
   While you were on the general medical floors, you had issues
with your breathing, requiring increased oxygen to breath.  In
agreement with your primary care doctor, we changed several of
your medications that were causing you to be overly sedated,
preventing you from breathing well.  After the change in
medications was made, your clinical status continued to improve.
 You had installation of a peripherally inserted central
catheter (PICC LINE) to allow you to receive antibiotics IV
outside the hospital.
.
SEVERAL OF YOUR HOME MEDICATIONS HAVE BEEN CHANGED!
.
PREVIOUS MEDICATION DOSE..........NEW MEDICATION DOSE
Oxybutynin- 10 mg 3x day...........  DISCONTINUED
Pregabalin- 150 mg 3x day......... Titrated down- New dose 75mg
3x day
Methadone- 5 mg TID .........changed to 5mg [**Hospital1 **]-- back to TID
[**2148-8-6**]
Baclofen-20mg,10mg,10mg.............10 mg TID
.
You will continue to take antibiotics outside the hospital:
VANCOMCYIN:
ERTAPENEM:

Followup Instructions:
Department: [**Hospital3 249**]
When: TUESDAY [**2148-8-13**] at 10:00 AM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: [**Hospital3 249**]
When: TUESDAY [**2148-8-20**] at 12:20 PM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2148-8-29**] at 12:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Methicillin resistant pneumonia due to Staphylococcus aureus,Methicillin resistant Staphylococcus aureus septicemia,Sepsis,Acute on chronic diastolic heart failure,Chronic respiratory failure,Urinary tract infection, site not specified,Chronic hepatitis C without mention of hepatic coma,Paraplegia,Chronic airway obstruction, not elsewhere classified,Anemia of other chronic disease,Unspecified acquired hypothyroidism,Other chronic pain,Depressive disorder, not elsewhere classified,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Personal history of venous thrombosis and embolism,Other postprocedural 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: hypoxia

PRESENT ILLNESS: The pt is a 51-yo woman with T1-T2 paraplegia, COPD, and
multiple recent admissions for pneumonia, who comes in from home
with hypoxia, somnolence, and cough productive of green sputum.
The pt and husband confirm that she had been feeling very well
until the morning of admission. On the morning of admission, the
husband found her to be more difficult to arouse. He checked her
oxygen saturation and found her to be 92-93% on 2L NC, but over
the next few hours continued to be somnolent and with
progressively worsening hypoxia to the low 80s on 2L NC and
still less than 90% on 4L NC, so she was brought in to the ED.
Her husband also reports that she has had increased cough today,
with green liquid/watery secretions, and feeling cold, but notes
that she was warm to touch. He found her temperature to be 99F.
She denies any chest pain, palpitations, shortness of breath, or
wheeze.
.
On arrival to the ED, VS - Temp 101.8F, BP 144/102, HR 110, R
24, SaO2 81%. She was placed on NRB with improvement to 100%.
CXR showed worsening RLL process, and ECG was unremarkable.
Right IJ CVL was placed due to difficulty gaining access, and
blood Cx were sent. She received 1L NS IVF, Zosyn 4.5g IV, and
Vancomycin 1g IV. She is admitted to the MICU for further care
given her hypoxia requiring NRB. Lactate was 1.5 and all other
labs were pending at time of transfer.
.
Of note, the pt was admitted for pneumonia from [**2148-6-11**] -
[**2148-6-15**] with RLL consolidations, treated with Vancomycin and
Cefepime, with a brief admission to the MICU for hypotension and
fever that improved without intubation or pressors, transferred
to the floor and ultimately discharged on a 7-day course of
antibiotics. She was again admitted to [**Hospital1 18**] from [**2148-7-19**] -
[**2148-7-21**] with fever and hypoxia, which was thought to be related
to a possible exacerbation of viral bronchitis with atelectasis.
She was discharged with acappella for chest PT to aid in lung
expansion and decrease oxygen dependence. She was feeling
significantly improved on discharge and was doing very well at
home until the day of admission.
.
ROS: As per HPI. Otherwise, she denies any headache, dizziness,
lightheadedness, chest pain, shortness of breath, abdominal
pain, nausea, vomiting, diarrhea, dysuria, arthralgias, or
myalgias.
.

MEDICAL HISTORY: 1. T1-T2 paraplegia following MVC [**1-4**]
2. Recurrent UTIs: [**Month/Year (2) 40097**] klebsiella
3. HCV, viral load suppressed
4. H/o recurrent PNAs: MRSA, pan-sensitive Kleb
5. Anxiety
6. DVT in [**2142**] -IVC filter placed in [**2142**]
7. Pulmonary nodules
8. Hypothyroidism
9. Chronic pain
10. Chronic gastritis
11. H/o obstructive lung disease
12. Anemia of chronic disease
13. S/p PEA arrest during last hospitalization in [**2147-10-3**]

MEDICATION ON ADMISSION: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea/hypoxia
2. Albuterol-Ipratropium [**2-3**] PUFF IH TID
3. Baclofen 10 mg PO/NG HS
4. Baclofen 10 mg PO/NG NOON
5. Baclofen 20 mg PO/NG BREAKFAST
6. Citalopram Hydrobromide 40 mg PO/NG DAILY
7. Clonazepam 1 mg PO/NG [**Hospital1 **]
8. Docusate Sodium 100 mg PO BID
9. Levothyroxine Sodium 75 mcg PO/NG DAILY
10. Lidocaine 5% Patch 1 PTCH TD DAILY
11. Methadone 5 mg PO/NG TID
12. Oxybutynin 5 mg PO NOON
13. Oxybutynin 10 mg PO BREAKFAST
14. Oxybutynin 10 mg PO HS
15. Polyethylene Glycol 17 g PO/NG DAILY
16. Pregabalin 150 mg PO/NG TID
17. Sucralfate 1 gm PO/NG QID
18. traZODONE 100 mg PO/NG HS
19. OxycoDONE (Immediate Release)  5 mg PO TID pain

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: Temp 99.8F, BP 103/49, HR 101, R 21, SaO2 93% NRB
Gen: ill appearing. On 4L NC. Mild respiratory distress
HEENT: pale conjunctiva. Dry mm. poor dentition. no cervical
LAD. neck supple. R IJ in place.
CV: Difficult to auscultate [**3-5**] to coarse BS. RRR. No MRG
appreciated. NL S1,S2
Pulm: Course breath sounds, rhonchorous throughout bilaterally
R>L. Exp wheezes present. Wet craclkes in LLF's B'L.
Abd: Protuberant. NBS. NT. No HSM appreciated.
GU: Foley. Chronic [**3-5**] T1/T2 paraplegia.
Ext: 2+ pitting edema B/L up to the knee
Neuro: Oriented to person, place, and time. Pt. appears midly
lethargic. CN II-XII grossliy intact. SNo sensation to touch
below L2 dermatome BL. Can twist abdomen and move arms. 5+
strength in UE B/L.
Skin: clammy, pale. 3x3 macule on R. Foremarm.

FAMILY HISTORY: No history of lung disease.

SOCIAL HISTORY: - Lives at home with her husband and 2 adolescent children
- Tobacco: 35 pack years, quit smoking several months ago, but
relapsed recently (last cigarette was week of presentation).
- etOH: Denies
- Illicits: Denies 

### Response:
{'Methicillin resistant pneumonia due to Staphylococcus aureus,Methicillin resistant Staphylococcus aureus septicemia,Sepsis,Acute on chronic diastolic heart failure,Chronic respiratory failure,Urinary tract infection, site not specified,Chronic hepatitis C without mention of hepatic coma,Paraplegia,Chronic airway obstruction, not elsewhere classified,Anemia of other chronic disease,Unspecified acquired hypothyroidism,Other chronic pain,Depressive disorder, not elsewhere classified,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Personal history of venous thrombosis and embolism,Other postprocedural status'}
