CHIEF COMPLAINT: Pancreatitis, AMS, respiratory failure

PRESENT ILLNESS: Ms. [**Known lastname **] is a 55 year-old female with a PMH of HTN, PVD,
seizure disorder, chronic pain on oxycodone, methadone, OSA who
presented to an OSH on [**2150-3-6**] after being found stuporous with
white foam and white poweder around her mouth at home. Her son,
whom she lives with, reviewed her [**Date Range 4085**] boxes and verified
that no medications were missing or overconsumed. EMS brought
her to the ED and en route she was given Narcan with some
effect. On presentation, she was found to be hypoxic to 74% on
RA with rhonchi and had a Glascow of 4. She was noted to have a
depressed mental status with an absent gag and some secretions
at the glottic opening. She was intubated for airway protection
(7.34/60/322). A CXR was performed and was negative for
pneumonia per report. Her labs were significant for a lipase of
3882 and WBC of 15 and serum and urine tox were significant for
positive TCA, methadone, and THC, but negative for tylenol,
phenobarbital, and alcohol. Creatinine and LFTs were normal with
a mildly elevated Alk phos. An EKG was also NSR. The
differential was thought to include seizure versus aspiration vs
overdose. She was transferred to [**Hospital1 18**] for further mgmnt and her
ventilator settings at the time were Vt 500, 90% PEEP 5 RR 18.
There was difficulty noted in weaning the FiO2. She was
intermittently sedated with ativan.
.
On arrival, her VS were T 102.6 P 110 100%ra BP 170/100. She was
intubated but awake and alert, following simple commands. A RSBI
was performed and was 150, with a RR of 25 and Vt of ~200. She
was also witnessed to aspirate.
.
Review of systems is otherwise unremarkable per report.

MEDICAL HISTORY: - pulmonary htn
- OSA - pt refuses CPAP.
- COPD - PFTs in [**6-20**] showed FEV1/FEV 87% predicted
- AS - s/p AVR with 21mm [**Company 1543**] Mosaic valve [**2149-4-1**] ([**Doctor Last Name **])
- hypertension
- high cholesterol
- Crohn's disease since age 19, no surgeries, treated with
prednisone off and on
- prednisone induced hyperglycemia
- gastritis/GERD, h/o GI bleed
- one seizures in the setting of emesis in [**12-20**], no AEDs
- basal cell skin cancer on nose
- inflammatory [**Last Name **] problem periodically
- pyoderma gangrenosum-on L calf and R ankle, tx with Prednisone
- osteopenia
- all teeth extracted secondary to prednisone
- right arm arterial bypass when she presented with right arm
pain and pulselessness

MEDICATION ON ADMISSION: Albuterol inhaler 1-2puffs QID prn
Atenolol 25mg daily
Atorvastatin 20mg daily
Budesonide 6mg daily
Cyclobenzaprine 10mg TID prn
Duloxetine 50mg [**Hospital1 **]
Folic acid 1mg daily
Abandronate 150mg monthly
Lisinopril 20mg daily
Methadone 5mg Q4H, 10mg QHS
Nicotine patch 21
Pantoprazole 40mg [**Hospital1 **]
Donnatal (phenobarbital/belladonna)
Pregabalin 225mg [**Hospital1 **]
Sucralfate 1g [**Hospital1 **]
Sulfasalazine 1g TID
Tiotropium 18mcg daily
Trazodone 100-200mg QHS prn
ASA 81mg daily
Calcium 500mg [**Hospital1 **]
Vitamin B12 100mcg daily
Ferrous sulfate 160mg daily
MVI
Seroquel 6.125-12.5mg [**Hospital1 **] prn

ALLERGIES: Penicillins / Darvocet-N 100 / Aspirin / Amitriptyline /
Wellbutrin

PHYSICAL EXAM: T 102.6 P 110 100%ra BP 170/100
PHYSICAL EXAM
GENERAL: intubated, agitated, awake, alert, responds to commands

FAMILY HISTORY: mother deceased age 62 of stroke, HTN, high chol, father
deceased age 56 of MI and also had low back pain, sisters x 4
one with diabetes and neuropathy, one brother deceased (in
army), and another alive with HTN, high chol, and prostate
cancer, one son healthy.

SOCIAL HISTORY: completed 12th grade, currently on disability but formerly
worked in an airplane factory, divorced, lives with son, active
[**Name2 (NI) 1818**] - 1-1.5 ppd x 32 years. No drinking or drug use (IVDA).
Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Methicillin susceptible pneumonia due to Staphylococcus aureus,Toxic encephalopathy,Mixed acid-base balance disorder,Acute kidney failure, unspecified,Regional enteritis of unspecified site,Cushing's syndrome,Acute pancreatitis,Other alteration of consciousness,Other and unspecified special symptoms or syndromes, not elsewhere classified,Other specified hypotension,Other antipsychotics, neuroleptics, and major tranquilizers causing adverse effects in therapeutic use,Dysphagia, unspecified,Other nonspecific abnormal serum enzyme levels,Hypercalcemia,Chronic pain syndrome,Lumbago,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Chronic airway obstruction, not elsewhere classified,Chronic pulmonary heart disease, unspecified,Epilepsy, unspecified, without mention of intractable epilepsy,Atherosclerosis of native arteries of the extremities with intermittent claudication,Other dependence on machines, supplemental oxygen,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Heart valve replaced by transplant,Long-term (current) use of steroids,Secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or unspecified,Adrenal cortical steroids causing adverse effects in therapeutic use,Dysthymic disorder,Tobacco use disorder,Nonspecific abnormal electrocardiogram [ECG] [EKG]
Acute respiratry failure,Food/vomit pneumonitis,Meth sus pneum d/t Staph,Toxic encephalopathy,Mixed acid-base bal dis,Acute kidney failure NOS,Regional enteritis NOS,Cushing's syndrome,Acute pancreatitis,Other alter consciousnes,Special symptom NEC/NOS,Hypotension NEC,Adv eff antipsychotc NEC,Dysphagia NOS,Abn serum enzy level NEC,Hypercalcemia,Chronic pain syndrome,Lumbago,Hypertension NOS,Hyperlipidemia NEC/NOS,Chr airway obstruct NEC,Chr pulmon heart dis NOS,Epilep NOS w/o intr epil,Ath ext ntv at w claudct,Depend-supplement oxygen,Hx TIA/stroke w/o resid,Heart valve transplant,Long-term use steroids,Sec DM wo cmp nt st uncn,Adv eff corticosteroids,Dysthymic disorder,Tobacco use disorder,Abnorm electrocardiogram
Admission Date:  [**2150-3-7**]              Discharge Date:   [**2150-3-13**]

Date of Birth:  [**2100-1-23**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Darvocet-N 100 / Aspirin / Amitriptyline /
Wellbutrin

Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Pancreatitis, AMS, respiratory failure

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Ms. [**Known lastname **] is a 55 year-old female with a PMH of HTN, PVD,
seizure disorder, chronic pain on oxycodone, methadone, OSA who
presented to an OSH on [**2150-3-6**] after being found stuporous with
white foam and white poweder around her mouth at home. Her son,
whom she lives with, reviewed her [**Date Range 4085**] boxes and verified
that no medications were missing or overconsumed. EMS brought
her to the ED and en route she was given Narcan with some
effect. On presentation, she was found to be hypoxic to 74% on
RA with rhonchi and had a Glascow of 4. She was noted to have a
depressed mental status with an absent gag and some secretions
at the glottic opening. She was intubated for airway protection
(7.34/60/322). A CXR was performed and was negative for
pneumonia per report. Her labs were significant for a lipase of
3882 and WBC of 15 and serum and urine tox were significant for
positive TCA, methadone, and THC, but negative for tylenol,
phenobarbital, and alcohol. Creatinine and LFTs were normal with
a mildly elevated Alk phos. An EKG was also NSR. The
differential was thought to include seizure versus aspiration vs
overdose. She was transferred to [**Hospital1 18**] for further mgmnt and her
ventilator settings at the time were Vt 500, 90% PEEP 5 RR 18.
There was difficulty noted in weaning the FiO2. She was
intermittently sedated with ativan.
.
On arrival, her VS were T 102.6 P 110 100%ra BP 170/100. She was
intubated but awake and alert, following simple commands. A RSBI
was performed and was 150, with a RR of 25 and Vt of ~200. She
was also witnessed to aspirate.
.
Review of systems is otherwise unremarkable per report.


Past Medical History:
- pulmonary htn
- OSA - pt refuses CPAP.
- COPD - PFTs in [**6-20**] showed FEV1/FEV 87% predicted
- AS - s/p AVR with 21mm [**Company 1543**] Mosaic valve [**2149-4-1**] ([**Doctor Last Name **])
- hypertension
- high cholesterol
- Crohn's disease since age 19, no surgeries, treated with
prednisone off and on
- prednisone induced hyperglycemia
- gastritis/GERD, h/o GI bleed
- one seizures in the setting of emesis in [**12-20**], no AEDs
- basal cell skin cancer on nose
- inflammatory [**Last Name **] problem periodically
- pyoderma gangrenosum-on L calf and R ankle, tx with Prednisone
- osteopenia
- all teeth extracted secondary to prednisone
- right arm arterial bypass when she presented with right arm
pain and pulselessness

Social History:
completed 12th grade, currently on disability but formerly
worked in an airplane factory, divorced, lives with son, active
[**Name2 (NI) 1818**] - 1-1.5 ppd x 32 years. No drinking or drug use (IVDA).


Family History:
mother deceased age 62 of stroke, HTN, high chol, father
deceased age 56 of MI and also had low back pain, sisters x 4
one with diabetes and neuropathy, one brother deceased (in
army), and another alive with HTN, high chol, and prostate
cancer, one son healthy.

Physical Exam:
T 102.6 P 110 100%ra BP 170/100
PHYSICAL EXAM
GENERAL: intubated, agitated, awake, alert, responds to commands

HEENT: Normocephalic, atraumatic, ETT. No conjunctival pallor.
No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. [**2-20**]
ejection murmur at RUSB. No JVD.
LUNGS: coarse B b/l.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: Follows commands. Moves all extremities. CN 2-12 grossly
intact.


Pertinent Results:
[**3-9**] echo: The left atrium is dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). There is no left ventricular
outflow obstruction at rest or with Valsalva. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. A bioprosthetic aortic valve
prosthesis is present. The transaortic gradient is higher than
expected for this type of prosthesis. No masses or vegetations
are seen on the aortic valve, but cannot be fully excluded due
to suboptimal image quality. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. No masses or vegetations are seen on the
mitral valve, but cannot be fully excluded due to suboptimal
image quality. Trivial mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Normal regional and global systolic function.
Bioprosthetic AVR with higher than expected gradients.
Endocarditis cannot be excluded on the basis of this study.
Moderate pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of [**2150-3-8**],
inferior hypokinesis is not seen on the current study. The apex
is well seen and contracts normally.
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
.
CXR [**3-9**]: Left moderately severe left lower lobe atelectasis has
progressed, mild interstitial edema is new accompanied by
increasing small bilateral pleural effusions and increase in top
normal heart size as well as congestion of the hilar and
mediastinal vessels. ET tube, right internal jugular line,
nasogastric tube in standard placements. No pneumothorax.
.
MRI head [**3-9**]:
1. No acute infarction.
2. Contour irregularity of the left middle cerebral artery, and
some of the branches of the right middle cerebral artery with
minimal decrease in caliber of the left middle cerebral artery
in the interval since the prior study, with mild narrowing.
Vasculitis related changes or other etiology cannot be excluded.
Interventional neuorradiology consult can be consdiered for
further management decision.
3. No flow-limiting stenosis or occlusion or aneurysm more than
3 mm within the resolution of MR angiogram.
.
CXR [**3-10**]: Lateral aspect of the right chest is excluded from the
examination. Mild pulmonary edema and small right pleural
effusion increased. Heart size top normal. Mediastinal venous
engorgement unchanged. Left lower lobe largely airless probably
due to atelectasis. ET tube, nasogastric tube and right internal
jugular line in standard placements. No pneumothorax.
.
CXR [**3-12**]
1. Improved CHF.
2. Multifocal patchy and linear opacities in mid and lower
lungs, many of
which may be due to atelectasis, but coexisting pneumonia should
be considered considering clinical suspicion for infection.
3. Right middle lobe atelectasis, for which followup radiographs
are
suggested to document resolution.
4. Small bilateral pleural effusions.
.
EEG [**3-9**] This is an abnormal portable EEG recording due to the
background activity which was at times slow and disorganized and
at
other times showed a burst suppression pattern. These
abnormalities are
suggestive of encephalopathy. The first one of moderate
encephalopathy
and the second one with a more severe encephalopathy. The fact
that the
patient's background was viable throughout the recording is
suggestive
of the possibility of a better prognosis of encephalopathy.
Metabolic
disturbances, medications, infection, and ischemia are among the
most
common causes of encephalopathy. There are no clear epileptiform

features seen in this recording. Of note is the tachycardia.


Brief Hospital Course:
55 year-old female with a PMH of HTN, PVD, seizure disorder,
chronic pain on oxycodone, methadone, OSA who presented with
after being found down with inability to be roused by her son.
.
#. Acutely altered mental status: intubated for airway
protection from MS changes, cause was unclear, possibilities
included toxic metabolic encephalopathy, delirium, [**Month/Year (2) 4085**]
effect (hx of seroquel, cyclobenzaprine, methadone, trazadone),
seizure, CVA, infection (pancreatitis, aspiration pna,
meningitis).  She was prescribed seroquel on [**3-6**], tox screen
positive for TCA (Duloxetine, cyclobenz, and seroquel can cause
false positives), opiate (methadone hx), THC, and phenobarbital
(in Donnatal), but negative for alcohol.  Also hypercapnia in
setting of COPD and aggravating factor also possible.  She had
no nuchal rigidity, photophobia, or focal neural deficits.
Her sedatives were initially held, she was pancultures and
treated for an aspiration pna, and her metabolic work-up was
negative.  Upon extubation, she continued to show an atypical
affect, but was alert and oriented x3, and tolerating the
reinitiation of her SSRI and percocet for pain.
.
The etiology of the episode was unclear, but thought possibly
due to polypharmacy after EEG was negative, and MRI was without
acute changes. Seroquel was discontinued as possible cause for
decompensation.  Given the episodes, she was advised not to
drive until cleared by the neurologists.
.
#. Acute Hypoxemic respiratory failure: thought liklely
respiratory acidosis with metabolic compensation at baseline
secondary to COPD.   CXR showed right base atelectasis and scant
infiltrates.  She was on stress dose steroids for airway and
relative hypotension, as she was on budesonide at baseline.  As
above, she was intubated for respiratory failure, then extubated
two days prior to transfer to floor, and demonstrated good
respiratory mechanics.  She was transferred to the floor with
stable oxygen saturations on low O2 requirement (3L NC).  Upon
transfer, she was transitioned back to her budesonide dosing.
She ultimately stabilized from a respiratory perspective,
although she had a cough, and finding on her CXR of possible
infiltrate.  She was discharged to complete a course of
levofloxacin.
.
#. Pneumonia: She presented with leukocytosis.  CXR ultimately
showed likely infiltrate.  She was pan cultured, as above, her
only positive cultures were GPC in her sputum.  She was
initially on vanco, levo, flagyl, then transitioned to
levofloxacin as monotherapy, with plan to complete 7d course on
[**3-14**].
.
# EKG changes/?Takasubo's cardiomyopathy: while intubated on
hospital day 2, pt was noted to have t wave inversions in 7 of
12 leads, predominantly in lateral leads, cardiac
enzymes/troponin was elevated at OSH, cks flat upon admit here.
Cardiology was consulted, bedside echo performed, with mild
hypokinesis, concern for takayasu's cardiomyopathy, started on
beta blockade, and mild diuresis while on ventilator.  A repeat
echocardiogram was performed, which showed improved systolic
dysfunction without apical ballooning, but her EKG continued to
show t wave inversions at discharge.  She has close follow up
with Dr. [**Last Name (STitle) 171**] for further evaluation.  On his review of her
echocardiograms, there was no apical ballooning seen.
.
# Acute renal failure:  She developed acute renal failure while
in the ICU, likely due to diuresis.  She was rehydrated, her
lisinopril was held, and her renal function was still elevated
at baseline.  Her urine eos were negative.  Her Cr was still
elevated at 1.2 at discharge, and her lisinopril was held until
she sees Dr. [**Last Name (STitle) **].
.
#. pancreatitis: Pt had elevated lipase secondary to possibly
gallstone pancreatitis (alk phos elevated at 190), alcohol
(though tox neg), or other less common etiologies such as
hypertriglycerides, pancreatic carcinoma, medications, viral
infections, abdominal trauma.  Enzymatic analysis of
pancreatitis resolved, pt denies abd pain on exam, and her diet
was advanced without issue.
.
#. Crohns Disease: pt followed by Dr. [**First Name (STitle) 572**]; diagnosis was
mainly symptom based with little objective evidence, on chronic
budesonide.  EGD and colonoscopy normal in 1/[**2150**].
.
# chronic pain: She has a history of chronic pain and has been
on methadone. Given concern for polypharmacy, the methadone was
discontinued on discharge, and she was discharged on dialudid.
.
#. HTN: Patient's lisinopril and atenolol were initially held
due to infection.
.
#. Obstructive sleep apnea: notes indicate pt use BiPap at home,
pt refused to wear bipap in the icu.
.
#. Depression/anxiety: her anxiolytics were initially held in
icu as per work-up of mental status changes, then restarted at
lower doses upon transfer to floor.  She was discharged on her
home doses, and Dr. [**Last Name (STitle) 18529**] will continue to work with her on
other anxiety management.  She may consider psychotherapy as an
outpatient, at a facility close to her home.
.
#. COPD: On baseline home O2 of 3L and has a long smoking
history. She did not require oxygen at discharge, with O2 sat of
95% with ambulation, and will only use O2 at night.  She was
also urged to stop smoking.
.
# Follow up:  Given the unclear etiology of the episode, she
will have close outpatient follow up with Dr. [**Last Name (STitle) **] ([**3-24**]), Dr.
[**Last Name (STitle) 171**] (first week of [**Month (only) 958**]), Dr. [**Last Name (STitle) 18529**] (psychiatry - 2 weeks)
and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 18530**]/[**Doctor Last Name **] of neurology.  Dr. [**Last Name (STitle) **], precepting
Dr. [**First Name (STitle) **], is aware of all events and will continue to coordinate
care for this complex patient.
.
EMERGENCY CONTACT: HCP is sister: [**Name (NI) **] [**Name (NI) 18531**] at
[**Telephone/Fax (5) 18532**] and secondary HCP is son [**Name (NI) 6644**] [**Name (NI) 18533**]
at same #.
.


Medications on Admission:
Albuterol inhaler 1-2puffs QID prn
Atenolol 25mg daily
Atorvastatin 20mg daily
Budesonide 6mg daily
Cyclobenzaprine 10mg TID prn
Duloxetine 50mg [**Hospital1 **]
Folic acid 1mg daily
Abandronate 150mg monthly
Lisinopril 20mg daily
Methadone 5mg Q4H, 10mg QHS
Nicotine patch 21
Pantoprazole 40mg [**Hospital1 **]
Donnatal (phenobarbital/belladonna)
Pregabalin 225mg [**Hospital1 **]
Sucralfate 1g [**Hospital1 **]
Sulfasalazine 1g TID
Tiotropium 18mcg daily
Trazodone 100-200mg QHS prn
ASA 81mg daily
Calcium 500mg [**Hospital1 **]
Vitamin B12 100mcg daily
Ferrous sulfate 160mg daily
MVI
Seroquel 6.125-12.5mg [**Hospital1 **] prn


Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Multivitamin,Tx-Minerals     Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Sulfasalazine 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
12. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Fifty
(50) mg PO BID (2 times a day).
13. Budesonide 3 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
14. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for muscle spasm.
15. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
16. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
17. Lyrica 75 mg Capsule Sig: Three (3) Capsule PO twice a day.

18. Boniva 150 mg Tablet Sig: One (1) Tablet PO once a month.
19. Dilaudid 4 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*45 Tablet(s)* Refills:*0*
20. Nocturnal O2, 3L
21. Levofloxacin 500 mg daily, for 3 more days


Discharge Disposition:
Home With Service

Facility:
VNA of Southeastern Mass.

Discharge Diagnosis:
Acute altered mental status
Acute respiratory failure
EKG changes
Chronic pain syndrome
Severe anxiety
Oxygen dependent COPD
Obstructive sleep apnea
Acute renal failure

Discharge Condition:
stable, tolerating diet, on home oxygen supplementation.

Discharge Instructions:
You were admitted after your son found you and could not awaken
you.  You were having trouble breathing, and needed to be
intubated.  You got agitated and were in the ICU for several
days.  Your MRI did not show an acute stroke, and your EEG did
not show an obvious seizure.  It is possible that the seroquel
caused this problem, or some combination of all of your
medications.
.
You should continue to talk to your doctors about your
[**Name5 (PTitle) 4085**] regimen, which is extremly complicated, and may be
causing problems.  DO NOT DRIVE UNTIL YOU SEE THE NEUROLOGISTS.
Do not change any of your medications without talking to your
doctors.
.
You need a repeat chest xray
.
Return to the ED if you have trouble breathing, get confused or
agitated again, develop high fevers or chills, or chest pain.
.
Changes to your medications:
Seroquel was discontinued.
Levofloxacin was added (for possible pneumonia).

Followup Instructions:
Provider: [**Name10 (NameIs) **],TEACHING [**Hospital **] CLINIC-CC2 (SB)
Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2150-3-17**] 11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9001**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2150-3-24**] 6:20
Provider: [**First Name8 (NamePattern2) 18534**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1387**]
Date/Time:[**2150-3-30**] 9:00
.
Repeat chest xray in [**3-18**] weeks.
Repeat basic metabolic panel with Dr. [**Last Name (STitle) **].
{"Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Methicillin susceptible pneumonia due to Staphylococcus aureus,Toxic encephalopathy,Mixed acid-base balance disorder,Acute kidney failure, unspecified,Regional enteritis of unspecified site,Cushing's syndrome,Acute pancreatitis,Other alteration of consciousness,Other and unspecified special symptoms or syndromes, not elsewhere classified,Other specified hypotension,Other antipsychotics, neuroleptics, and major tranquilizers causing adverse effects in therapeutic use,Dysphagia, unspecified,Other nonspecific abnormal serum enzyme levels,Hypercalcemia,Chronic pain syndrome,Lumbago,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Chronic airway obstruction, not elsewhere classified,Chronic pulmonary heart disease, unspecified,Epilepsy, unspecified, without mention of intractable epilepsy,Atherosclerosis of native arteries of the extremities with intermittent claudication,Other dependence on machines, supplemental oxygen,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Heart valve replaced by transplant,Long-term (current) use of steroids,Secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or unspecified,Adrenal cortical steroids causing adverse effects in therapeutic use,Dysthymic disorder,Tobacco use disorder,Nonspecific abnormal electrocardiogram [ECG] [EKG]"}


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: Pancreatitis, AMS, respiratory failure

PRESENT ILLNESS: Ms. [**Known lastname **] is a 55 year-old female with a PMH of HTN, PVD,
seizure disorder, chronic pain on oxycodone, methadone, OSA who
presented to an OSH on [**2150-3-6**] after being found stuporous with
white foam and white poweder around her mouth at home. Her son,
whom she lives with, reviewed her [**Date Range 4085**] boxes and verified
that no medications were missing or overconsumed. EMS brought
her to the ED and en route she was given Narcan with some
effect. On presentation, she was found to be hypoxic to 74% on
RA with rhonchi and had a Glascow of 4. She was noted to have a
depressed mental status with an absent gag and some secretions
at the glottic opening. She was intubated for airway protection
(7.34/60/322). A CXR was performed and was negative for
pneumonia per report. Her labs were significant for a lipase of
3882 and WBC of 15 and serum and urine tox were significant for
positive TCA, methadone, and THC, but negative for tylenol,
phenobarbital, and alcohol. Creatinine and LFTs were normal with
a mildly elevated Alk phos. An EKG was also NSR. The
differential was thought to include seizure versus aspiration vs
overdose. She was transferred to [**Hospital1 18**] for further mgmnt and her
ventilator settings at the time were Vt 500, 90% PEEP 5 RR 18.
There was difficulty noted in weaning the FiO2. She was
intermittently sedated with ativan.
.
On arrival, her VS were T 102.6 P 110 100%ra BP 170/100. She was
intubated but awake and alert, following simple commands. A RSBI
was performed and was 150, with a RR of 25 and Vt of ~200. She
was also witnessed to aspirate.
.
Review of systems is otherwise unremarkable per report.

MEDICAL HISTORY: - pulmonary htn
- OSA - pt refuses CPAP.
- COPD - PFTs in [**6-20**] showed FEV1/FEV 87% predicted
- AS - s/p AVR with 21mm [**Company 1543**] Mosaic valve [**2149-4-1**] ([**Doctor Last Name **])
- hypertension
- high cholesterol
- Crohn's disease since age 19, no surgeries, treated with
prednisone off and on
- prednisone induced hyperglycemia
- gastritis/GERD, h/o GI bleed
- one seizures in the setting of emesis in [**12-20**], no AEDs
- basal cell skin cancer on nose
- inflammatory [**Last Name **] problem periodically
- pyoderma gangrenosum-on L calf and R ankle, tx with Prednisone
- osteopenia
- all teeth extracted secondary to prednisone
- right arm arterial bypass when she presented with right arm
pain and pulselessness

MEDICATION ON ADMISSION: Albuterol inhaler 1-2puffs QID prn
Atenolol 25mg daily
Atorvastatin 20mg daily
Budesonide 6mg daily
Cyclobenzaprine 10mg TID prn
Duloxetine 50mg [**Hospital1 **]
Folic acid 1mg daily
Abandronate 150mg monthly
Lisinopril 20mg daily
Methadone 5mg Q4H, 10mg QHS
Nicotine patch 21
Pantoprazole 40mg [**Hospital1 **]
Donnatal (phenobarbital/belladonna)
Pregabalin 225mg [**Hospital1 **]
Sucralfate 1g [**Hospital1 **]
Sulfasalazine 1g TID
Tiotropium 18mcg daily
Trazodone 100-200mg QHS prn
ASA 81mg daily
Calcium 500mg [**Hospital1 **]
Vitamin B12 100mcg daily
Ferrous sulfate 160mg daily
MVI
Seroquel 6.125-12.5mg [**Hospital1 **] prn

ALLERGIES: Penicillins / Darvocet-N 100 / Aspirin / Amitriptyline /
Wellbutrin

PHYSICAL EXAM: T 102.6 P 110 100%ra BP 170/100
PHYSICAL EXAM
GENERAL: intubated, agitated, awake, alert, responds to commands

FAMILY HISTORY: mother deceased age 62 of stroke, HTN, high chol, father
deceased age 56 of MI and also had low back pain, sisters x 4
one with diabetes and neuropathy, one brother deceased (in
army), and another alive with HTN, high chol, and prostate
cancer, one son healthy.

SOCIAL HISTORY: completed 12th grade, currently on disability but formerly
worked in an airplane factory, divorced, lives with son, active
[**Name2 (NI) 1818**] - 1-1.5 ppd x 32 years. No drinking or drug use (IVDA). 

### Response:
{"Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Methicillin susceptible pneumonia due to Staphylococcus aureus,Toxic encephalopathy,Mixed acid-base balance disorder,Acute kidney failure, unspecified,Regional enteritis of unspecified site,Cushing's syndrome,Acute pancreatitis,Other alteration of consciousness,Other and unspecified special symptoms or syndromes, not elsewhere classified,Other specified hypotension,Other antipsychotics, neuroleptics, and major tranquilizers causing adverse effects in therapeutic use,Dysphagia, unspecified,Other nonspecific abnormal serum enzyme levels,Hypercalcemia,Chronic pain syndrome,Lumbago,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Chronic airway obstruction, not elsewhere classified,Chronic pulmonary heart disease, unspecified,Epilepsy, unspecified, without mention of intractable epilepsy,Atherosclerosis of native arteries of the extremities with intermittent claudication,Other dependence on machines, supplemental oxygen,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Heart valve replaced by transplant,Long-term (current) use of steroids,Secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or unspecified,Adrenal cortical steroids causing adverse effects in therapeutic use,Dysthymic disorder,Tobacco use disorder,Nonspecific abnormal electrocardiogram [ECG] [EKG]"}
