CHIEF COMPLAINT: Hypoxia and AMS

PRESENT ILLNESS: Pt was recently discharged from [**Hospital1 18**] on [**2147-1-6**] following
hospitalization for falls and SOB. Falls were thought to be due
to a mechanical nature. SOB was attributed to Acute CHF
exacerbation. Also noted to have intermittent delirium in
addition to baseline dementia (A&Ox2, occassionally x 3).
Medications actively avoided were Trazodone (worsened
sedation/confusion), hydralazine (potential for delirium) and
Lisinopril (5mg caused hypotension). Discharged to rehab center
for further recovery. He was then transferred by ambulance ot
[**Hospital3 **] on [**2147-1-21**] with concern for cyanotic toes and
fingers. EMS evaluation with 85% on unknown O2. At that time he
denied F/Ch, SOB, N, CP per OSH ED records. Initial ABG
7.33/66/314 on NRB. He was given Lasix 40mg IV, Nitropaste 1"
and Moxifloxicin 400 mg IV. Treated for CHF with Lasix.
Neurology was contact[**Name (NI) **] and thought it unlikely (per OSH
records) that the patient had an acute CVA. OSH labs Na 143, K
4.6, Cl 103, CO2 35, BUN 31, Cr 1.23, Ca 9.7, Mg 2.1, TSH 2.71,
B1 541, Folate > 24, INR 3.19, Hct 32.1, WBC 8.6, Plt 136, BNP
202. OSH telemetry/EKG with V-pacing vs Afib. CTA with near
complete occulsion of the left internal carotid artery which may
be on the basis of a dissection (noted on prior study). NC CT
head with atrophy without acute finding. CXR [**1-21**] likely
consistent with congestive heart failure. Patient was then
placed on BiPAP for further respiratory support, though what
prompted need for increased ventilatory support is unclear. VS
on transfer 97.9, 79, 16, 177/77, weight 220 lbs. Patient with
DNR/DNI order upon arrival.
.
On arrival to the MICU, patient is with BiPAP but able to follow
simple commands. He is not in notable distress. Oriented to
hospital. Cannot provide further details as to history.
.
FLOOR ADMISSION NOTE
HPI:
See MICU admission note for full details.
Briefly, 89yoM who was admitted to [**Hospital3 **] from rehab
[**2147-1-21**] with hypoxia and AMS. Per EMS eval, was hypoxic to 85%
on unknown O2.
At OSH, ABG on NRB showed 7.33/66/314. Got Lasix, Nitro, and
Moxiflox at OSH, treated for CHF. Neuro evaluated and felt acute
CVA unlikely, and CT-A head and neck negative for CVA, but
stable occlusion of L-ICA. EKG showing AFib vs V-pacing. CXR
[**1-21**] showed volume overload without obvious infiltrate. Put on
BiPAP there.
.
Family wanted transfer here, so pt came on Monday, vitals on
transfer 97.9 79 16 177/77 weight 220 lbs. Labs/imaging through
MICU stay significant for: normal WBC count, Hct 32.2 but within
baseline from previous dc, plts 130 lower than previous dc, INR
3.0 on Coumadin, Cr 1.2 below baseline, Trop 0.06 x2 (but with
CRI) and CK/MB negative. UA negative for infxn but with blood.
UCx pending. CXR showing mild pulm edema and mediastinal
engorgement c/w cardiac decompensation and small R pleural
effusion.
.
In the MICU, was easily weaned off BiPAP. Diuresed with 80mg IV
lasix once yesterday, once this AM with approx 675 cc's negative
through MICU stay. EP was consulted for interrogation of pt's
pacer but not performed yet. Echo was ordered but has not been
performed yet. Pt received 1 dose of Levaquin/Cefepime/Vanc
prophylactically as pt not noted to be febrile or have WBC count
here or at OSH, no localizing symptoms noted on OSH ROS (unable
to obtain in MICU). ABx was were stopped [**2147-1-24**] and Cx's from
OSH negative to date. Ortho spine was consulted due to pt's
chronic C2 fracture, and pt noted to be in soft collar with
recent dc summary notes indicating necessity of hard collar.
Mental status noted to be slightly confused.
.
Of note, during recent admission [**2147-1-6**] for falls and SOB
(falls felt to be mechanical and SOB attributed to CHF
exacerbation), pt noted to have intermittent delirium on top of
baseline dementia. Medications avoided were Trazadone
(sedation/confusion), Hydralazine (delirium), and Lisinopril
(hypotension).
.
On evaluation in the MICU, pt is somnolent, rousable to voice,
but sleeps if not stimulated. No specific complaints.
.
Review of systems:
(+) Per HPI, otherwise able to obtain further. Per MICU note,
OSH ROS was without localizing symptoms.

MEDICAL HISTORY: 1. Coronary artery disease status post PTCA [**2128**]
2. Hypertension
3. Hypercholesterolemia
4. Atrial fibrillation. Should not be anticoagulated due to
falls, but anticoagulated without complications for L vertebral
artery dissection [**12/2146**], stopped [**1-/2147**]
5. Pacemaker [**2141-11-25**]
6. Obstructive sleep apnea, on BIPAP at night --> poorly
tolerated/not compliant with Bipap
7. Left upper extremity cellulitis [**2141-11-25**]
8. Right knee replacement 6-7 years ago
9. Bilateral cataract surgery
[**46**]. Status post tonsillectomy
11. C2 dens fracture [**1-27**], managed with [**Location (un) 2848**]-J collar, no
surgery --> Per Dr. [**Last Name (STitle) 363**] in ortho, pt does NOT need to be in
any type of collar.
12. Mechanical falls
13. Congestive Heart Failure EF 40% per [**2141**] echo --> subsequent
2 echos though past several years with difficult to obtain
windows, so unable to assess EF well
14. Left vertebral artery dissection --> managed with 1 month of
Coumadin [**Month (only) **]-[**2147-1-23**], then stopped and should be on daily ASA
325 per Neuro
15. [**Last Name (un) **] on CRI (baseline creatinine 1.5 from [**1-4**])
16. Mild dementia --> and frequent waxing/[**Doctor Last Name 688**] delirium during
[**1-/2147**] admission
17. Gout
18. Idiopathic pulmonary fibrosis --> has chronic crackles in
bilateral bases to mid lung fields

MEDICATION ON ADMISSION: .
[**Hospital3 **] Meds (Per OMR / OSH records, patient cannot
confirm)
Nitroglycerin ointment
Albuterol Neb Q4H
Ipratroprium Q4H
Omeprazole 20 mg po daily
Allopurinol 100mg po daily
Loratidine 10 mg po daily
Folic acie 1 mg po daily
Atorvastatin 80 mg po daily
Metoprolol XL 100mg po daily
Bumex 1 mgy IV daily
Nitroglycerin 0.4mg PRN chest pain
Tylenol 650 mg po Q4H PRN headache
Ativan 0.5 mg IV Q2-3H PRN agitation
.
Medications at Rehab (per OSH ED documentation)
Docusate 100mg
Atorvastatin 80 mg
Isosorbide 30 mg
Metoprolol 25 mg
MVI 1 capsule
Fluticasone 50mcg disk
Zyrtex 10 mg tab
Folic acid 1mg daily
Allopurinol 100mg daily
ASA 81 mg daily
Furosemide 80 mg daily
Trazodone 50 mg tablet
Warfarin - 6 mg MWFSun, 7 mg [**Name (NI) 17888**]
MOM PRN
Acetaminophen PRN
Bisacodyl PRN
Nasal saline
Senna
Nystatin to abdominal folds and groin every shift
Dimehitcone cream to butoocks
Fleet Enema PRN
.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Initial PE on Admit to MICU:
Vitals: 96.9, 78, 141/68, 19 and 100% BiPAP 40% 5/10
General: [**Name (NI) **], unclear level of orientation, mildly distressed

FAMILY HISTORY: (per OMR):
Father - died from lung cancer.
1 Brother, 5 sisters
2 sons and 2 daughters
[**Name (NI) **] family history of stroke or other neurologic disease.

SOCIAL HISTORY: EtOH: Never
Drugs: none
Tobacco: Never
Lives (per prior records): lives with his wife and son in
[**Name (NI) 1474**] in a 2 story home (bedrooms and bathroom on the [**Location (un) 17879**]); ambulates with walker at home
Occupation: retired truck driver
[**2147-1-23**]: being discharged to rehab facility
Acute on chronic combined systolic and diastolic heart failure,Dissection of vertebral artery,Alkalosis,Delirium due to conditions classified elsewhere,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Other alteration of consciousness,Other persistent mental disorders due to conditions classified elsewhere,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Postinflammatory pulmonary fibrosis,Obstructive sleep apnea (adult)(pediatric),Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Gout, unspecified,Percutaneous transluminal coronary angioplasty status,Other orthopedic aftercare,Cardiac pacemaker in situ,Personal history of malignant neoplasm of bronchus and lung
Ac/chr syst/dia hrt fail,Dissect vertebral artery,Alkalosis,Delirium d/t other cond,Ocl crtd art wo infrct,Other alter consciousnes,Mental disor NEC oth dis,Chronic kidney dis NOS,Hy kid NOS w cr kid I-IV,Postinflam pulm fibrosis,Obstructive sleep apnea,Atrial fibrillation,Crnry athrscl natve vssl,Gout NOS,Status-post ptca,Orthopedic aftercare NEC,Status cardiac pacemaker,Hx-bronchogenic malignan
Admission Date:  [**2147-1-23**]              Discharge Date:   [**2147-1-31**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Hypoxia and AMS

Major Surgical or Invasive Procedure:
None


History of Present Illness:
Pt was recently discharged from [**Hospital1 18**] on [**2147-1-6**] following
hospitalization for falls and SOB. Falls were thought to be due
to a mechanical nature. SOB was attributed to Acute CHF
exacerbation. Also noted to have intermittent delirium in
addition to baseline dementia (A&Ox2, occassionally x 3).
Medications actively avoided were Trazodone (worsened
sedation/confusion), hydralazine (potential for delirium) and
Lisinopril (5mg caused hypotension). Discharged to rehab center
for further recovery. He was then transferred by ambulance ot
[**Hospital3 **] on [**2147-1-21**] with concern for cyanotic toes and
fingers. EMS evaluation with 85% on unknown O2. At that time he
denied F/Ch, SOB, N, CP per OSH ED records. Initial ABG
7.33/66/314 on NRB. He was given Lasix 40mg IV, Nitropaste 1"
and Moxifloxicin 400 mg IV. Treated for CHF with Lasix.
Neurology was contact[**Name (NI) **] and thought it unlikely (per OSH
records) that the patient had an acute CVA. OSH labs Na 143, K
4.6, Cl 103, CO2 35, BUN 31, Cr 1.23, Ca 9.7, Mg 2.1, TSH 2.71,
B1 541, Folate > 24, INR 3.19, Hct 32.1, WBC 8.6, Plt 136, BNP
202. OSH telemetry/EKG with V-pacing vs Afib. CTA with near
complete occulsion of the left internal carotid artery which may
be on the basis of a dissection (noted on prior study). NC CT
head with atrophy without acute finding. CXR [**1-21**] likely
consistent with congestive heart failure. Patient was then
placed on BiPAP for further respiratory support, though what
prompted need for increased ventilatory support is unclear. VS
on transfer 97.9, 79, 16, 177/77, weight 220 lbs. Patient with
DNR/DNI order upon arrival.
.
On arrival to the MICU, patient is with BiPAP but able to follow
simple commands. He is not in notable distress. Oriented to
hospital. Cannot provide further details as to history.
.
FLOOR ADMISSION NOTE
HPI:
See MICU admission note for full details.
Briefly, 89yoM who was admitted to [**Hospital3 **] from rehab
[**2147-1-21**] with hypoxia and AMS. Per EMS eval, was hypoxic to 85%
on unknown O2.
At OSH, ABG on NRB showed 7.33/66/314. Got Lasix, Nitro, and
Moxiflox at OSH, treated for CHF. Neuro evaluated and felt acute
CVA unlikely, and CT-A head and neck negative for CVA, but
stable occlusion of L-ICA. EKG showing AFib vs V-pacing. CXR
[**1-21**] showed volume overload without obvious infiltrate. Put on
BiPAP there.
.
Family wanted transfer here, so pt came on Monday, vitals on
transfer 97.9 79 16 177/77 weight 220 lbs. Labs/imaging through
MICU stay significant for: normal WBC count, Hct 32.2 but within
baseline from previous dc, plts 130 lower than previous dc, INR
3.0 on Coumadin, Cr 1.2 below baseline, Trop 0.06 x2 (but with
CRI) and CK/MB negative. UA negative for infxn but with blood.
UCx pending. CXR showing mild pulm edema and mediastinal
engorgement c/w cardiac decompensation and small R pleural
effusion.
.
In the MICU, was easily weaned off BiPAP. Diuresed with 80mg IV
lasix once yesterday, once this AM with approx 675 cc's negative
through MICU stay. EP was consulted for interrogation of pt's
pacer but not performed yet. Echo was ordered but has not been
performed yet. Pt received 1 dose of Levaquin/Cefepime/Vanc
prophylactically as pt not noted to be febrile or have WBC count
here or at OSH, no localizing symptoms noted on OSH ROS (unable
to obtain in MICU). ABx was were stopped [**2147-1-24**] and Cx's from
OSH negative to date. Ortho spine was consulted due to pt's
chronic C2 fracture, and pt noted to be in soft collar with
recent dc summary notes indicating necessity of hard collar.
Mental status noted to be slightly confused.
.
Of note, during recent admission [**2147-1-6**] for falls and SOB
(falls felt to be mechanical and SOB attributed to CHF
exacerbation), pt noted to have intermittent delirium on top of
baseline dementia. Medications avoided were Trazadone
(sedation/confusion), Hydralazine (delirium), and Lisinopril
(hypotension).
.
On evaluation in the MICU, pt is somnolent, rousable to voice,
but sleeps if not stimulated. No specific complaints.
.
Review of systems:
(+) Per HPI, otherwise able to obtain further. Per MICU note,
OSH ROS was without localizing symptoms.


Past Medical History:
1. Coronary artery disease status post PTCA [**2128**]
2. Hypertension
3. Hypercholesterolemia
4. Atrial fibrillation. Should not be anticoagulated due to
falls, but anticoagulated without complications for L vertebral
artery dissection [**12/2146**], stopped [**1-/2147**]
5. Pacemaker [**2141-11-25**]
6. Obstructive sleep apnea, on BIPAP at night --> poorly
tolerated/not compliant with Bipap
7. Left upper extremity cellulitis [**2141-11-25**]
8. Right knee replacement 6-7 years ago
9. Bilateral cataract surgery
[**46**]. Status post tonsillectomy
11. C2 dens fracture [**1-27**], managed with [**Location (un) 2848**]-J collar, no
surgery --> Per Dr. [**Last Name (STitle) 363**] in ortho, pt does NOT need to be in
any type of collar.
12. Mechanical falls
13. Congestive Heart Failure EF 40% per [**2141**] echo --> subsequent
2 echos though past several years with difficult to obtain
windows, so unable to assess EF well
14. Left vertebral artery dissection --> managed with 1 month of
Coumadin [**Month (only) **]-[**2147-1-23**], then stopped and should be on daily ASA
325 per Neuro
15. [**Last Name (un) **] on CRI (baseline creatinine 1.5 from [**1-4**])
16. Mild dementia --> and frequent waxing/[**Doctor Last Name 688**] delirium during
[**1-/2147**] admission
17. Gout
18. Idiopathic pulmonary fibrosis --> has chronic crackles in
bilateral bases to mid lung fields


Social History:
EtOH: Never
Drugs: none
Tobacco: Never
Lives (per prior records): lives with his wife and son in
[**Name (NI) 1474**] in a 2 story home (bedrooms and bathroom on the [**Location (un) 17879**]); ambulates with walker at home
Occupation: retired truck driver
[**2147-1-23**]: being discharged to rehab facility


Family History:
(per OMR):
Father - died from lung cancer.
1 Brother, 5 sisters
2 sons and 2 daughters
[**Name (NI) **] family history of stroke or other neurologic disease.

Physical Exam:
Initial PE on Admit to MICU:
Vitals: 96.9, 78, 141/68, 19 and 100% BiPAP 40% 5/10
General: [**Name (NI) **], unclear level of orientation, mildly distressed

HEENT: Sclera anicteric, MM mildly dry, oropharynx clear
Neck: supple, JVP difficult to assess with BiPAP, no LAD
Lungs: Difficult to hear over ventilator, symmetric, no wheezes,
? diffuse ronchi
CV: Seemingly regular, normal S1 + S2, diffcult to ausculate
murmurs
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: Foley in place with mildly pink urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

PE ON FLOOR ADMISSION

98.1 97.6 65 (Vpaced) 122/58 23 100% RA
Somnolent appearing, elderly man sitting at bedside chair.
Awakens to voice but goes back to sleep if not constantly
stimulated.
Able to name days of weeks forwards and backwards. [**Name (NI) **] to
[**Hospital1 18**], not to year or day.
Mouth dry appearing and pt taking big sips of water at bedside
table.
Neck obese but no apparent JVD noted.
Bilateral crackles up to about mid lung field, poor air
movement.
Difficult to auscultate heart sounds, but best heard at upper L
sternal border with early systolic murmur also noted. Regular
rhythm. Radial pulses appreciated.
Abd obese, non tender, not distended.
BLE's in pneumoboots, skin is indented from the boots making
assessment of pitting edema difficult, but not severely
edematous
Foley in place.
CN2-12 grossly intact, no dysarthria or facial droop noted, but
pt noted to be inattentive and sleepy appearing. Spontanously
moving all 4 extremities. Not compliant with rest of exam.

SIGNIFICANT PE FINDINGS ON DISCHARGE:
Awake, [**Hospital1 3584**], conversant but often closes his eyes while he
talks. He waxed and waned during admission and was seen to be
very somnolent often, but medically stable.
Able to do days of the week forward and backward consistently,
and sometimes able to do months of the year forward only.
Upper airway wheezes heard while he talks but lungs without
wheezes. Pan inspiratory crackles at the bases up to mid lung
field, difficult to ascertain whether due to volume overload vs
Dx of IPF
S1 S2 clear, regular, but difficult to auscultate, with systolic
murmur
Trace to 1+ pitting edema to mid shin


Pertinent Results:
ADMISSION LABS:
.
[**2147-1-23**] 11:40PM BLOOD WBC-8.9 RBC-3.17* Hgb-10.4* Hct-32.2*
MCV-101* MCH-32.9* MCHC-32.4 RDW-16.2* Plt Ct-130*
[**2147-1-23**] 11:40PM BLOOD PT-30.3* PTT-33.9 INR(PT)-3.0*
[**2147-1-23**] 11:40PM BLOOD Glucose-79 UreaN-29* Creat-1.2 Na-149*
K-4.2 Cl-106 HCO3-34* AnGap-13
[**2147-1-23**] 11:40PM BLOOD CK(CPK)-91
[**2147-1-23**] 11:40PM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2147-1-23**] 11:40PM BLOOD Calcium-9.7 Phos-2.9 Mg-2.3
[**2147-1-23**] 11:45PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.021
[**2147-1-23**] 11:45PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2147-1-23**] 11:45PM URINE RBC-[**10-14**]* WBC-0-2 Bacteri-NONE
Yeast-NONE Epi-0
[**2147-1-26**] 08:01PM URINE Hours-RANDOM Cl-LESS THAN
.
DISCHARGE LABS:
.
[**2147-1-31**] 07:25AM BLOOD WBC-7.4 RBC-2.95* Hgb-9.1* Hct-28.7*
MCV-97 MCH-30.8 MCHC-31.7 RDW-16.7* Plt Ct-161
[**2147-1-30**] 07:25AM BLOOD WBC-7.1 RBC-3.02* Hgb-9.5* Hct-29.4*
MCV-97 MCH-31.3 MCHC-32.2 RDW-16.8* Plt Ct-146*
[**2147-1-31**] 07:25AM BLOOD PT-27.0* PTT-29.1 INR(PT)-2.6*
[**2147-1-30**] 07:25AM BLOOD PT-23.9* PTT-29.5 INR(PT)-2.3*
[**2147-1-31**] 07:25AM BLOOD Glucose-89 UreaN-37* Creat-1.3* Na-143
K-4.4 Cl-100 HCO3-38* AnGap-9
[**2147-1-30**] 07:25AM BLOOD Glucose-94 UreaN-40* Creat-1.3* Na-140
K-4.2 Cl-99 HCO3-37* AnGap-8
[**2147-1-31**] 07:25AM BLOOD Calcium-9.2 Phos-2.5* Mg-2.1
[**2147-1-28**] 07:30AM BLOOD Calcium-9.5 Phos-2.2* Mg-2.2
[**2147-1-28**] 07:30AM BLOOD VitB12-989* Folate-GREATER TH
.
CARDIAC ENZYMES:
[**2147-1-23**] 11:40PM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2147-1-23**] 11:40PM BLOOD CK(CPK)-91
[**2147-1-24**] 10:38AM BLOOD CK-MB-5 cTropnT-0.06*
[**2147-1-24**] 10:38AM BLOOD CK(CPK)-113
.
STUDIES:
ECG: [**2147-1-23**]
Ventricular paced rhythm with ventricular premature beats.
Atrial mechanism is uncertain. Since the previous tracing of
[**2146-12-29**] there is no significant change.

CXR: [**2147-1-24**]
Mild pulmonary edema and mediastinal vascular engorgement
indicate cardiac
decompensation, even though the borderline cardiomegaly is
unchanged. Small right pleural effusion is newly apparent.
Transvenous right ventricular pacer lead in standard placements.
No pneumothorax.

TTE: [**2147-1-25**]
The left atrium is moderately dilated. There is severe symmetric
left ventricular hypertrophy. The left ventricular cavity is
unusually small. Left ventricular systolic function appears
grossly preserved but views are suboptimal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. There is abnormal septal motion/position
consistent with right ventricular pressure/volume overload. The
ascending aorta is mildly dilated. The aortic valve leaflets are
moderately thickened with fair leaflet motion. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. The tricuspid valve leaflets are mildly thickened.
Moderate [2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.

CXR: [**2147-1-26**]
In comparison with the study of [**1-24**], there is continued
enlargement
of the cardiac silhouette with pulmonary vascular congestion,
essentially
unchanged from the previous study. Single-lead pacemaker device
remains in
place with the tip in the region of the apex of the right
ventricle.

MICRO:
[**1-23**] UCx: Negative
[**1-24**] Sputum Cx: Contaminant


Brief Hospital Course:
89 yo M with CAD, CHF, Atrial Fibrillation, dementia with recent
hospitalization for falls and SOB, admitted to OSH from rehab
with hypoxia to [**Hospital3 2737**], where he was treated for CHF
exacerbation and transferred here for further management.  He
was temporarily admitted to the MICU where he received BiPAP,
then transferred to the floor.
.
#. Hypoxia/Tachypnea: He was initially on Bipap which was weaned
on HD#1. The etiology of his respiratory symptoms was believed
to be acute excacerbation of chronic systolic/diastolic heart
failure, given his clinical and radiologic findings. His
cultures and cardiac enzymes were negative. He was subsequently
maintained on albuterol and ipratropium and diuresed with Lasix.
His diuresis was slowed down as he developed worsening metabolic
alkalosis, with peak HCO3 of 40. His diuresis was restarted as
his HCO3 trended down and he was tolerating 80 mg daily Lasix by
discharge, and should continue this dose, with close monitoring
of his HCO3, volume status, daily weights, ins and outs.
.
Given his diagnosis of OSA and his audible upper expiratory
wheezes (without associated lung wheezes) would also encourage
Bipap at night or during daytime naps, however pt seen to be
very resistant to keeping it on.
.
By discharge, HCO3 was 38, pt was 96% on RA, not tachypneic,
ambulating to bathroom without difficulty. It should be noted
that pt seen to occasionally desaturate to mid 80's on room air,
however if told to breathe deeply his sats quickly returned up
to mid to high 90's, and if put on 1-2L by nasal cannula he
would stay in the high 90's to 100%. It would be reasonable to
keep him on low level O2 as needed. On physical exam, he has
crackles in his lungs bilaterally up to about the mid lung
field, however this is difficult to differentiate volume
overload vs his carried diagnosis of interstitial pulmonary
fibrosis. His lower extremities have trace to minimal edema to
below mid shin.
.
# Delirium: Most recent admission patient occasionally oriented
to place, never oriented to day or year. Upon arrival patient
knew he was in [**Hospital **] hospital. We attempted to minimize
wake-ups and avoid sedating medications (Trazodone has been
particularly difficult for him in the past & appears was on this
medication at rehab). We pulled the Foley catheter and kept him
off telemetry. At the time of discharge, the patient was aware
of the current season and was able to recite days of the week
backwards and forwards, occasionally state the months forward,
but not backward.
.
# L vertebral artery dissection: Noted during previous
admission, and was seen on CT to be due to a lateral
displacement of his vertebrae in the setting of the chronic C2
fracture. He was felt to be a high risk for Coumadin
anticoagulation; however since (during past admission) he was
going to rehab where he could be closely monitored, the plan as
discussed with his family, was to anticoagulate with Coumadin
for one month, after which he would be transitioned to full dose
Aspirin. This transition was done while pt was admitted and he
should continue on full dose Aspirin, NOT on Coumadin. His INR
was therapeutic on discharge at 2.6. Other than these changes,
was not an active issue this admission.
.
# Chronic C2 fracture: After last admission, pt was seen by Dr.
[**Last Name (STitle) 363**] in orthopedics and had a plain film which showed no
interval change of his known C2 fracture. The pt was admitted
from OSH in a soft collar, however Dr. [**Last Name (STitle) 363**] saw the pt this
admission and he stated that the pt does NOT need to wear any
collar for this. Appt was made for pt to f/u with Dr. [**Last Name (STitle) 363**].
His soft collar was taken off through the admission without
complication.
.
# Coronary artery disease/Chest pain: Stated to have CP on
arrival. EKG with some Twave inversions in lateral leads V4-V6,
which were intermittently seen in prior EKGs and difficult to
follow clearly given intermittent V-pacing. Upon repeat
questioning, he denied chest pain.  Cardiac enzymes were
negative x2. He was continued on his ASA, atorvastatin,
metoprolol, and imdur. He had no further chest pain through
admission.
.
Of note the pt is not currently on an ACEi, as he was noted
during a previous admission to have a drop in his systolic blood
pressures on Lisinopril. This medication was not restarted
during this admission, but should be considered if his blood
pressure can tolerate it.
.
# CKD: Baseline Cr approximately 1.5. Previously more elevated
in the setting of Lisinopril. Most recently 1.23 at OSH.  Labs
were monitored and nephrotoxic drugs were avoided. His
creatinine was stable at 1.3 for several days leading up to his
discharge.
.
# AFib: Patient with intermittent AFib and also V-paced. Pacer
interrogated on last admission.  Pacer was interrogated as
tachycardia may have initiated this CHF exacerbation, and was
felt to be working appropriately. Pt was continued on beta
blockade, diuresis as above, and Coumadin was stopped as above
and pt will continue on full dose ASA.
.
# HTN: Stable on arrival,  BP meds were maintained, except for
furosemide (as above).
.
# Gout: Stable, was continued on allopurinol.
.
.
# Code: DNR/DNI (per HCP / OSH transport documentation)

Medications on Admission:
.
[**Hospital3 **] Meds (Per OMR / OSH records, patient cannot
confirm)
Nitroglycerin ointment
Albuterol Neb Q4H
Ipratroprium Q4H
Omeprazole 20 mg po daily
Allopurinol 100mg po daily
Loratidine 10 mg po daily
Folic acie 1 mg po daily
Atorvastatin 80 mg po daily
Metoprolol XL 100mg po daily
Bumex 1 mgy IV daily
Nitroglycerin 0.4mg PRN chest pain
Tylenol 650 mg po Q4H PRN headache
Ativan 0.5 mg IV Q2-3H PRN agitation
.
Medications at Rehab (per OSH ED documentation)
Docusate 100mg
Atorvastatin 80 mg
Isosorbide 30 mg
Metoprolol 25 mg
MVI 1 capsule
Fluticasone 50mcg disk
Zyrtex 10 mg tab
Folic acid 1mg daily
Allopurinol 100mg daily
ASA 81 mg daily
Furosemide 80 mg daily
Trazodone 50 mg tablet
Warfarin - 6 mg MWFSun, 7 mg [**Name (NI) 17888**]
MOM PRN
Acetaminophen PRN
Bisacodyl PRN
Nasal saline
Senna
Nystatin to abdominal folds and groin every shift
Dimehitcone cream to butoocks
Fleet Enema PRN
.


Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**2-28**]
hours as needed for headache, pain or fever > 101: Do not exceed
4 grams/day.
7. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
12. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
14. Nystatin 100,000 unit/g Cream Sig: One (1)  Topical as
needed: To abdominal folds and groin as needed.
15. Dimethicone     Cream Sig: One (1)  Topical as needed : To
buttocks as needed.
16. Outpatient Lab Work

Please monitor pt's chemistries (Bicarbonate and renal function)
as pt was seen to have contraction alkalosis with the Lasix
diuresis. If is bicarbonate is rising, would consider decreasing
his Lasix diuresis. Please also monitor renal function, his
baseline Cr is around 1.3.
17. Outpatient Physical Therapy
The pt is lethargic and has low motivation through the day, but
stable from a medical standpoint. Therefore, he would benefit
from being made to get out of bed to chair, or ambulate, a
couple times per day.


Discharge Disposition:
Extended Care

Facility:
Life Care CTR of [**Location (un) 5165**]

Discharge Diagnosis:
Primary: Acute on chronic systolic and diastolic heart failure
.
Secondary: Atrial fibrillation
Coronary artery disease
Chronic C2 dens fracture
Chronic renal insufficiency
Delirium and Dementia
Gout

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

Discharge Instructions:
Mr. [**Known lastname 17881**],
You were admitted to the hospital for shortness of breath and
low oxygen levels that were believed to be due to an
exacerbation of your chronic congestive heart failure. You were
temporarily admitted to the intensive care unit, so that you
could receive supplemental oxygen through a positive-pressure
mask. You were given medications to help removed excess fluid
from your body, and your symptoms subsequently improved. Our
orthopedic surgeons believed that you do not need to wear the
collar for your cervical vertebral fracture. Your pacemaker was
interrogated and found to be working appropriately. Through your
course here, you were seen to have delirium on top of chronic
dementia.

We made the following changes to your medication regimen:
- STOP WARFARIN (Coumadin), as your reason for taking this
medication originally called for one month of warfarin therapy.
This month will be complete later this week.
- DECREASE your FUROSEMIDE (Lasix) dose, to 40 mg tabs, one tab
by mouth twice daily
- INCREASE Aspirin from 80 mg daily to 325 mg daily
- STOP Zyrtec, for allergies. You can restart this if you need
it.
- STOP Trazadone. You should avoid sedating medications.

You should weigh yourself every morning, and call your primary
care physician if your weight goes up more than 3 lbs.

Followup Instructions:
Primary Care Physician: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17887**], MD
Date/Time: Wednesday [**2-8**] @ 4:00 PM
Phone: [**Telephone/Fax (1) 6699**]
Please call Dr.[**Name (NI) 17889**] office to reschedule this
appointment, if necessary

You also have the following appointment:
MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**]
Specialty: Orthopedics
Date/ Time: Wednesday, [**3-15**], 4pm
Location: [**Hospital Ward Name 23**] building, [**Location (un) 17890**]
Phone number: [**Telephone/Fax (1) 3573**]



Completed by:[**2147-1-31**]
{'Acute on chronic combined systolic and diastolic heart failure,Dissection of vertebral artery,Alkalosis,Delirium due to conditions classified elsewhere,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Other alteration of consciousness,Other persistent mental disorders due to conditions classified elsewhere,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Postinflammatory pulmonary fibrosis,Obstructive sleep apnea (adult)(pediatric),Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Gout, unspecified,Percutaneous transluminal coronary angioplasty status,Other orthopedic aftercare,Cardiac pacemaker in situ,Personal history of malignant neoplasm of bronchus and lung'}


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 and AMS

PRESENT ILLNESS: Pt was recently discharged from [**Hospital1 18**] on [**2147-1-6**] following
hospitalization for falls and SOB. Falls were thought to be due
to a mechanical nature. SOB was attributed to Acute CHF
exacerbation. Also noted to have intermittent delirium in
addition to baseline dementia (A&Ox2, occassionally x 3).
Medications actively avoided were Trazodone (worsened
sedation/confusion), hydralazine (potential for delirium) and
Lisinopril (5mg caused hypotension). Discharged to rehab center
for further recovery. He was then transferred by ambulance ot
[**Hospital3 **] on [**2147-1-21**] with concern for cyanotic toes and
fingers. EMS evaluation with 85% on unknown O2. At that time he
denied F/Ch, SOB, N, CP per OSH ED records. Initial ABG
7.33/66/314 on NRB. He was given Lasix 40mg IV, Nitropaste 1"
and Moxifloxicin 400 mg IV. Treated for CHF with Lasix.
Neurology was contact[**Name (NI) **] and thought it unlikely (per OSH
records) that the patient had an acute CVA. OSH labs Na 143, K
4.6, Cl 103, CO2 35, BUN 31, Cr 1.23, Ca 9.7, Mg 2.1, TSH 2.71,
B1 541, Folate > 24, INR 3.19, Hct 32.1, WBC 8.6, Plt 136, BNP
202. OSH telemetry/EKG with V-pacing vs Afib. CTA with near
complete occulsion of the left internal carotid artery which may
be on the basis of a dissection (noted on prior study). NC CT
head with atrophy without acute finding. CXR [**1-21**] likely
consistent with congestive heart failure. Patient was then
placed on BiPAP for further respiratory support, though what
prompted need for increased ventilatory support is unclear. VS
on transfer 97.9, 79, 16, 177/77, weight 220 lbs. Patient with
DNR/DNI order upon arrival.
.
On arrival to the MICU, patient is with BiPAP but able to follow
simple commands. He is not in notable distress. Oriented to
hospital. Cannot provide further details as to history.
.
FLOOR ADMISSION NOTE
HPI:
See MICU admission note for full details.
Briefly, 89yoM who was admitted to [**Hospital3 **] from rehab
[**2147-1-21**] with hypoxia and AMS. Per EMS eval, was hypoxic to 85%
on unknown O2.
At OSH, ABG on NRB showed 7.33/66/314. Got Lasix, Nitro, and
Moxiflox at OSH, treated for CHF. Neuro evaluated and felt acute
CVA unlikely, and CT-A head and neck negative for CVA, but
stable occlusion of L-ICA. EKG showing AFib vs V-pacing. CXR
[**1-21**] showed volume overload without obvious infiltrate. Put on
BiPAP there.
.
Family wanted transfer here, so pt came on Monday, vitals on
transfer 97.9 79 16 177/77 weight 220 lbs. Labs/imaging through
MICU stay significant for: normal WBC count, Hct 32.2 but within
baseline from previous dc, plts 130 lower than previous dc, INR
3.0 on Coumadin, Cr 1.2 below baseline, Trop 0.06 x2 (but with
CRI) and CK/MB negative. UA negative for infxn but with blood.
UCx pending. CXR showing mild pulm edema and mediastinal
engorgement c/w cardiac decompensation and small R pleural
effusion.
.
In the MICU, was easily weaned off BiPAP. Diuresed with 80mg IV
lasix once yesterday, once this AM with approx 675 cc's negative
through MICU stay. EP was consulted for interrogation of pt's
pacer but not performed yet. Echo was ordered but has not been
performed yet. Pt received 1 dose of Levaquin/Cefepime/Vanc
prophylactically as pt not noted to be febrile or have WBC count
here or at OSH, no localizing symptoms noted on OSH ROS (unable
to obtain in MICU). ABx was were stopped [**2147-1-24**] and Cx's from
OSH negative to date. Ortho spine was consulted due to pt's
chronic C2 fracture, and pt noted to be in soft collar with
recent dc summary notes indicating necessity of hard collar.
Mental status noted to be slightly confused.
.
Of note, during recent admission [**2147-1-6**] for falls and SOB
(falls felt to be mechanical and SOB attributed to CHF
exacerbation), pt noted to have intermittent delirium on top of
baseline dementia. Medications avoided were Trazadone
(sedation/confusion), Hydralazine (delirium), and Lisinopril
(hypotension).
.
On evaluation in the MICU, pt is somnolent, rousable to voice,
but sleeps if not stimulated. No specific complaints.
.
Review of systems:
(+) Per HPI, otherwise able to obtain further. Per MICU note,
OSH ROS was without localizing symptoms.

MEDICAL HISTORY: 1. Coronary artery disease status post PTCA [**2128**]
2. Hypertension
3. Hypercholesterolemia
4. Atrial fibrillation. Should not be anticoagulated due to
falls, but anticoagulated without complications for L vertebral
artery dissection [**12/2146**], stopped [**1-/2147**]
5. Pacemaker [**2141-11-25**]
6. Obstructive sleep apnea, on BIPAP at night --> poorly
tolerated/not compliant with Bipap
7. Left upper extremity cellulitis [**2141-11-25**]
8. Right knee replacement 6-7 years ago
9. Bilateral cataract surgery
[**46**]. Status post tonsillectomy
11. C2 dens fracture [**1-27**], managed with [**Location (un) 2848**]-J collar, no
surgery --> Per Dr. [**Last Name (STitle) 363**] in ortho, pt does NOT need to be in
any type of collar.
12. Mechanical falls
13. Congestive Heart Failure EF 40% per [**2141**] echo --> subsequent
2 echos though past several years with difficult to obtain
windows, so unable to assess EF well
14. Left vertebral artery dissection --> managed with 1 month of
Coumadin [**Month (only) **]-[**2147-1-23**], then stopped and should be on daily ASA
325 per Neuro
15. [**Last Name (un) **] on CRI (baseline creatinine 1.5 from [**1-4**])
16. Mild dementia --> and frequent waxing/[**Doctor Last Name 688**] delirium during
[**1-/2147**] admission
17. Gout
18. Idiopathic pulmonary fibrosis --> has chronic crackles in
bilateral bases to mid lung fields

MEDICATION ON ADMISSION: .
[**Hospital3 **] Meds (Per OMR / OSH records, patient cannot
confirm)
Nitroglycerin ointment
Albuterol Neb Q4H
Ipratroprium Q4H
Omeprazole 20 mg po daily
Allopurinol 100mg po daily
Loratidine 10 mg po daily
Folic acie 1 mg po daily
Atorvastatin 80 mg po daily
Metoprolol XL 100mg po daily
Bumex 1 mgy IV daily
Nitroglycerin 0.4mg PRN chest pain
Tylenol 650 mg po Q4H PRN headache
Ativan 0.5 mg IV Q2-3H PRN agitation
.
Medications at Rehab (per OSH ED documentation)
Docusate 100mg
Atorvastatin 80 mg
Isosorbide 30 mg
Metoprolol 25 mg
MVI 1 capsule
Fluticasone 50mcg disk
Zyrtex 10 mg tab
Folic acid 1mg daily
Allopurinol 100mg daily
ASA 81 mg daily
Furosemide 80 mg daily
Trazodone 50 mg tablet
Warfarin - 6 mg MWFSun, 7 mg [**Name (NI) 17888**]
MOM PRN
Acetaminophen PRN
Bisacodyl PRN
Nasal saline
Senna
Nystatin to abdominal folds and groin every shift
Dimehitcone cream to butoocks
Fleet Enema PRN
.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Initial PE on Admit to MICU:
Vitals: 96.9, 78, 141/68, 19 and 100% BiPAP 40% 5/10
General: [**Name (NI) **], unclear level of orientation, mildly distressed

FAMILY HISTORY: (per OMR):
Father - died from lung cancer.
1 Brother, 5 sisters
2 sons and 2 daughters
[**Name (NI) **] family history of stroke or other neurologic disease.

SOCIAL HISTORY: EtOH: Never
Drugs: none
Tobacco: Never
Lives (per prior records): lives with his wife and son in
[**Name (NI) 1474**] in a 2 story home (bedrooms and bathroom on the [**Location (un) 17879**]); ambulates with walker at home
Occupation: retired truck driver
[**2147-1-23**]: being discharged to rehab facility 

### Response:
{'Acute on chronic combined systolic and diastolic heart failure,Dissection of vertebral artery,Alkalosis,Delirium due to conditions classified elsewhere,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Other alteration of consciousness,Other persistent mental disorders due to conditions classified elsewhere,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Postinflammatory pulmonary fibrosis,Obstructive sleep apnea (adult)(pediatric),Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Gout, unspecified,Percutaneous transluminal coronary angioplasty status,Other orthopedic aftercare,Cardiac pacemaker in situ,Personal history of malignant neoplasm of bronchus and lung'}
