CHIEF COMPLAINT: Fever and Diaphoresis

PRESENT ILLNESS: Mr. [**Known lastname 7716**] is a 42 year old gentleman with a history of
pilocytic astrocytoma (at age 2), multiple CVAs, and a medullary
cavernoma with persistent right hemiparesis, epilepsy, and
aspiration who presents with with diaphoresis and fevers to
100.2 at home. He states that he has increased frequency of
cough after being given a G tube 3 weeks prior due to recurrant
aspiration pneumonia and difficulty swallowing, but that the
cough has not worsened in the past few days.  He feels otherwise
well with no sensation of fevers/chills or increased sweating,
but was brought into the ED due to concern from his group home
caretaker.

MEDICAL HISTORY: Medullary cavernoma in [**4-13**] at site of radiation
Epilepsy (absence, complex partial, and generalized seizures)
Cerebellar pilocytic astrocytoma resection at age two s/p
brainstem radiation
Presumed radiation-induced vasculopathy with multiple strokes
Strokes:  Left internal capsule/thalamus [**2167**], left posterior
cerebellum, left cerebellar peduncle [**10/2169**], TIA with facial
droop, followed by Dr. [**Last Name (STitle) 1693**]
Presumed XRT-induced bilateral hearing loss
Hypertension
Hyperparathyroidism
Bilateral Kidney Stones (thought to be due to parathyroidism,
not
Topamax use)
Hypercalcemia
Osteopenia

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver[**Name (NI) 581**].
1. Amiloride HCl 5 mg PO QAM
2. Cinacalcet 30 mg PO BID
3. Citalopram 40 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Levothyroxine Sodium 88 mcg PO DAILY
6. Oxcarbazepine 1500 mg PO BID
7. PredniSONE 17.5 mg PO DAILY
8. Simvastatin 80 mg PO DAILY
9. Topiramate (Topamax) 200 mg PO BID
10. Vitamin D 1000 UNIT PO DAILY
11. Vitamin E 400 UNIT PO DAILY
12. Ranitidine (Liquid) 150 mg PO BID
13. Aspirin 81 mg PO DAILY
14. Miconazole Powder 2% 1 Appl TP TID:PRN diaper rash
15. Docusate Sodium (Liquid) 100 mg PO BID
per peg tube
16. lactobacillus rhamnosus GG *NF* 10 billion cell Oral daily
17. Fibersource HN *NF* (nutritional supplement - fiber)    Oral
daily
Tubefeeding: Fibersource HN Full strength;
Starting rate: 100 ml/hr; Do not advance rate Goal rate: 100
ml/hr
Cycle?: Yes, when at goal Cycle start: 1900 Cycle end: 1100
Residual Check: q4h Hold feeding for residual >= : 250
Flush w/ 30 ml water q8h

ALLERGIES: hydrochlorothiazide

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM
VS - 98.3 HR 104  BP 123/74  RR 20  96% on 3 LNC
GENERAL:  Well-appearing man, not acutely distressed. Speaking
comfortably in full sentences
HEENT:  Mucous membranes semi-dry. No cervical lymphadenopathy.
Soft palate elevates symetrically
HEART:  Heart sounds distant, RRR, normal S1 S2
LUNGS:  Clear to auscultation but limited by poor air movement
due to poor respiratory effort. No evidence of respiratory
distress or accessory muscle requirement.
ABDOMEN:  Soft and nontender except at the insertion of the
G-tube.  He does have a G-tube in position with scabing. No
erythema or exudates. Mildly distended (likely secondary to
constipation). + bowel sounds in all 4 quadrants
EXTREMITIES:  He does not have any edema of his lower
extremities, + distal pulses, warm and well perfused.
NEURO: EOMI, pupils are equal and reactive. No facial weakness.
There is right hemiplegia.

FAMILY HISTORY: There is no family history of seizures. His sister died of
multiple myeloma.

SOCIAL HISTORY: He lives in a group home, and during the week goes to sports
program, gateway arts, and massage. He uses a wheelchair to get
around since his strokes, but does walk with assistance at his
sports class. He denies cigarette or EtOH use.
Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Malnutrition of mild degree,Precipitous drop in hematocrit,Foreign body in other specified parts bronchus and lung,Epilepsy, unspecified, without mention of intractable epilepsy,Gastrostomy status,Methicillin resistant pneumonia due to Staphylococcus aureus,Personal history of malignant neoplasm of brain,Personal history of irradiation, presenting hazards to health,Unspecified essential hypertension,Disorder of bone and cartilage, unspecified,Hyperparathyroidism, unspecified,Obstructive sleep apnea (adult)(pediatric),Unspecified acquired hypothyroidism,Depressive disorder, not elsewhere classified,Dysphagia, unspecified,Body Mass Index between 19-24, adult,Inhalation and ingestion of other object causing obstruction of respiratory tract or suffocation
Food/vomit pneumonitis,Acute respiratry failure,Late ef-hemplga side NOS,Malnutrition mild degree,Drop, hematocrit, precip,FB trach/bronch/lung NEC,Epilep NOS w/o intr epil,Gastrostomy status,Meth res pneu d/t Staph,Hx of brain malignancy,Hx of irradiation,Hypertension NOS,Bone & cartilage dis NOS,Hyperparathyroidism NOS,Obstructive sleep apnea,Hypothyroidism NOS,Depressive disorder NEC,Dysphagia NOS,BMI between 19-24,adult,Resp obstr-inhal obj NEC
Admission Date:  [**2175-10-1**]              Discharge Date:   [**2175-10-14**]

Date of Birth:  [**2132-12-29**]             Sex:   M

Service: MEDICINE

Allergies:
hydrochlorothiazide

Attending:[**First Name3 (LF) 594**]
Chief Complaint:
Fever and Diaphoresis

Major Surgical or Invasive Procedure:
[**2175-10-3**] Endotracheal intubation
[**2175-10-5**] Tracheostomy
[**2175-10-11**] J tube placement
[**2175-10-12**] Bronchoscopy


History of Present Illness:
Mr. [**Known lastname 7716**] is a 42 year old gentleman with a history of
pilocytic astrocytoma (at age 2), multiple CVAs, and a medullary
cavernoma with persistent right hemiparesis, epilepsy, and
aspiration who presents with with diaphoresis and fevers to
100.2 at home. He states that he has increased frequency of
cough after being given a G tube 3 weeks prior due to recurrant
aspiration pneumonia and difficulty swallowing, but that the
cough has not worsened in the past few days.  He feels otherwise
well with no sensation of fevers/chills or increased sweating,
but was brought into the ED due to concern from his group home
caretaker.

Regarding his feedings, he gets them from 8pm to 5pm every day.
They have been unable to increase the rate due to gastric
residuals with feeding.  The patient notes regurgitation 2-3x a
day with a sensation of food coming up into his chest and
sometimes into the back of his throat and into his mouth.  He
cannot be for certain whether the coughing is associated with
his feedings.  Pt is without any complaints including chest
pain, shortness of breath, dizziness, abdominal pain, nausea,
vomiting, dysuria, or new swelling. He reports being constipated
without a normal BMs for the past 4-5 days.  He has + flatulence
and minimal burping.  He was given an enema yesterday with
minimal stool output.

Past Medical History:
Medullary cavernoma in [**4-13**] at site of radiation
Epilepsy (absence, complex partial, and generalized seizures)
Cerebellar pilocytic astrocytoma resection at age two s/p
brainstem radiation
Presumed radiation-induced vasculopathy with multiple strokes
Strokes:  Left internal capsule/thalamus [**2167**], left posterior
cerebellum, left cerebellar peduncle [**10/2169**], TIA with facial
droop, followed by Dr. [**Last Name (STitle) 1693**]
Presumed XRT-induced bilateral hearing loss
Hypertension
Hyperparathyroidism
Bilateral Kidney Stones (thought to be due to parathyroidism,
not
Topamax use)
Hypercalcemia
Osteopenia

Social History:
He lives in a group home, and during the week goes to sports
program, gateway arts, and massage. He uses a wheelchair to get
around since his strokes, but does walk with assistance at his
sports class. He denies cigarette or EtOH use.

Family History:
There is no family history of seizures. His sister died of
multiple myeloma.

Physical Exam:
ADMISSION PHYSICAL EXAM
VS - 98.3 HR 104  BP 123/74  RR 20  96% on 3 LNC
GENERAL:  Well-appearing man, not acutely distressed. Speaking
comfortably in full sentences
HEENT:  Mucous membranes semi-dry. No cervical lymphadenopathy.
Soft palate elevates symetrically
HEART:  Heart sounds distant, RRR, normal S1 S2
LUNGS:  Clear to auscultation but limited by poor air movement
due to poor respiratory effort. No evidence of respiratory
distress or accessory muscle requirement.
ABDOMEN:  Soft and nontender except at the insertion of the
G-tube.  He does have a G-tube in position with scabing. No
erythema or exudates. Mildly distended (likely secondary to
constipation). + bowel sounds in all 4 quadrants
EXTREMITIES:  He does not have any edema of his lower
extremities, + distal pulses, warm and well perfused.
NEURO: EOMI, pupils are equal and reactive. No facial weakness.
There is right hemiplegia.

DISCHARGE PHYSICAL EXAM
PHYSICAL EXAM:
VS - Tmax 98  Tcurr 98  BP 112/80  HR 81 RR 18 100% pm 35%FM
GENERAL - NAD, comfortable, appropriate
HEENT - Sclerae anicteric, MMM
LUNGS - Mild coarse breath sounds throughout, good air movement,
resp unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - Soft and nontender.  G-tube in place with no erythema
or exudates. Non-distended. + bowel sounds in all 4 quadrants
EXTREMITIES - He does not have any edema of his lower
extremities, + distal pulses, warm and well perfused.
Pneumoboots in place.
NEURO - awake, A&Ox3, Right hemiplegia

Pertinent Results:
ADMISSION LABS:
[**2175-10-1**] 01:30PM BLOOD WBC-20.8*# RBC-4.46* Hgb-14.3 Hct-41.6
MCV-93 MCH-32.0 MCHC-34.3 RDW-12.9 Plt Ct-238
[**2175-10-1**] 01:30PM BLOOD Neuts-89.1* Lymphs-4.6* Monos-5.9 Eos-0.2
Baso-0.2
[**2175-10-1**] 01:30PM BLOOD Plt Ct-238
[**2175-10-1**] 01:30PM BLOOD Glucose-111* UreaN-32* Creat-1.2 Na-143
K-4.2 Cl-107 HCO3-25 AnGap-15
[**2175-10-3**] 08:45PM BLOOD ALT-102* AST-99* CK(CPK)-274 AlkPhos-131*
TotBili-0.8
[**2175-10-3**] 08:45PM BLOOD CK-MB-2 cTropnT-<0.01
[**2175-10-1**] 01:30PM BLOOD Calcium-9.8 Phos-2.7# Mg-1.9
[**2175-10-1**] 01:30PM BLOOD D-Dimer-792*
[**2175-10-3**] 03:10PM BLOOD Type-ART Temp-37.5 pO2-55* pCO2-31*
pH-7.40 calTCO2-20* Base XS--3 Intubat-NOT INTUBA Comment-SIMPLE
FAC

IMAGING:
[**10-1**] CTA CHEST W&W/O C&RECONS, NON-CORONARY and CT ABD & PELVIS
WITH CO
1. Right middle, right lower, and left lower lobe consolidations
compatible with pneumonia.
2. No pulmonary embolism.
3. No acute intra-abdominal process.
4. Bladder trigone thickening may represent focal inflammation,
less likely malignancy.

[**10-1**] CHEST XRAY
FINDINGS:  There is opacification of the right lower lobe seen
both on frontal and lateral radiographs.  In addition, the right
heart border is obscured, worsened from [**2175-9-9**].  There is no
pleural effusion or pneumothorax.  The heart size is normal.
The left lung is clear.
IMPRESSION:  Right middle and lower lobe pneumonia, possibly due
to recurrent aspiration.

[**10-4**] PORTAL AP CHEST XRAY
IMPRESSION:  AP chest compared to [**9-2**] through [**10-3**]:
Tip of the endotracheal tube is no less than 7 cm from the
carina.  It could
be safely advanced 2 cm for more secured seating. Nasogastric
tube passes into the stomach and out of view.  Bibasilar
pneumonia has not changed appreciably overnight.  There is no
pneumothorax or pleural effusion.  Cardiomediastinal and hilar
silhouettes are normal.

[**10-5**] ECG:
Sinus rhythm. Right bundle-branch block. Non-specific
repolarization
abnormalities. Compared to the previous tracing of [**2175-10-3**] the
quality of the tracing has improved somewhat. Otherwise,
findings are similar.

DISCHARGE LABS:
[**2175-10-14**] 03:22AM BLOOD WBC-12.8* RBC-3.68* Hgb-11.6* Hct-34.0*
MCV-92 MCH-31.5 MCHC-34.1 RDW-14.1 Plt Ct-357
[**2175-10-14**] 03:22AM BLOOD Plt Ct-357
[**2175-10-14**] 03:22AM BLOOD Glucose-100 UreaN-15 Creat-1.1 Na-137
K-3.7 Cl-104 HCO3-21* AnGap-16
[**2175-10-14**] 03:22AM BLOOD Calcium-9.1 Phos-3.0 Mg-2.0

Brief Hospital Course:
Mr. [**Known lastname 7716**] is a 42 year old gentleman with a history of
pilocytic astrocytoma (at age 2), multiple CVAs, and a medullary
cavernoma hemorrhage with persistent right hemiparesis,
epilepsy, and aspiration who presents with low grade fever,
found to have likely aspiration pneumonia on CXR and chest CT.
He deteriorated with hypoxia and was intubated and then recieved
a tracheostomy.

#MRSA Pneumonia: The patient has a history of aspiration
pneumonia given swallow dysfunction related to prior
neurological disease.  On the night of [**2175-10-3**], he desaturated
to the high 70s.  Given his concerning respiratory status which
is unlikely to improve since it is due to neurologic dysfunction
of pharyngeal muscles, he was transferred to MICU, intubated and
a tracheostomy was performed [**10-5**]. CT scan suggestive of
consolidations consistent with pneumonia. We initiated tube
feeds on the night of [**2175-10-5**] which he seemed to tolerate
without obvious regurgitation.  However, there was continued
concern over oral secretions and his tracheostomy cuff was left
inflated.  Speech/swallow felt it would be best to avoid placing
a speaking valve until his respiratory condition resolved in the
short term. He completed an 8 day course of Vancomycin for HCAP.
Elevated WBC has resolved on discharge and he has remained
afebrile for several days.

#RLL Collapse: On [**2175-10-12**] Pt began exhibiting worsening O2
saturations down to the high 70s on 35%TM. Attempted aggressive
respiratory suction with minimal removal of mucus. Chest XRay
done on the bedside showed right middle and lower lobe collapse
most likely attributable to a mucus plug.  He was transferred to
the MICU for bronchoscopy which successfully removed mucus plug
and reinflated his RLL. Post brochoscopy CXR showed reinflation
of RLL. Following the procedure his O2 requirement improved and
is respiratory status returned to baseline. He did require
aggressive mucus suctioning to prevent further plugging.

#Tube Feeds: We initially stopped tube feeds due to concern of
regurgitation on admission along with aspiration of oral
secretions.  We contact[**Name (NI) **] and consulted both speech/swallow and
nutrition for appropriate recommendations to optimize his G tube
feeding.  Per their recommendations, we continued with 16 hrs
cycled feeds with Fibersource HN Oral liquid 100 ml/hr g tube
and Ranitidine 15 mg/ml syrup 150 mg by mouth twice a day. Per
speech/swallow we initiated mouth rinses every 4 hours to
prophylactically prevent oral secretion aspiration pneumonia.
IR was able to successfully convert his G tube to a GJ tube
without complications on [**2175-10-11**].

#Obstructive sleep apnea: Suspected by PCP and from prior
inpatient stays he had reports of snoring and nighttime
desaturations.  After his trach was placed, these resolved and
he was more alert during the daytime.

#Transaminitis: Bilirubin not elevated, but AST/ALT above
baseline. Felt most likely due to drug effect, especially from
the pip-tazo.  Trended down after pip-tazo was stopped.  Patient
remained asymptomatic thoughout.

CHRONIC ISSUES:
#Hx Stroke / Cavernoma Hemorrhage / Seizure Disorder: Stable
neurologic exam during admission.  Had been in [**Hospital3 **]
for PT and speech/[**Hospital3 22701**].  Continued prednisone 17.5 mg
daily with plan to taper by 2.5 mg weekly for cerebral edema.
Per PCP, [**Name10 (NameIs) **] had a clinical decline when this was tapered too
quickly in the past.  Also, for risk modification of further
strokes, continued Simvastatin 80 mg daily, cilostazol 100 mg
[**Hospital1 **], Aspirin 81 mg daily.  For headaches and neurologic
function, continued topiramate 200 mg [**Hospital1 **], and trileptal 1500 mg
[**Hospital1 **].

#Hx right bundle branch block (RBBB): Unclear cause. Patient
remains asymptomatic from a cardiac perspective.

#Hypothyroidism: Stable.  Continued levothyroxine 88 mcg daily.

#Hypertension: Stable.  Continued Amiloride 5 mg daily.

#Hyperparathyroidism: Stable.  Continued Cinacalcet 30 mg [**Hospital1 **].

#Depression: Stable.  Continued citalopram 40 mg daily.

#Maintanence: Patient received flu shot at last discharge visit
1 week ago. Recieved pneumococcal vaccine this admission.

TRANSITIONAL ISSUES:
#Please taper prednisone dose by 2.5mg per week. Can stop
Bactrim once dose is below 10mg per week.

#Consideration for down-sizing of his trach so that he can have
a speaking valve and consider eating per goals of care of the
patient

#Pt needs suctioning in order to prevent mucus plugging.  Mucus
plugging is frequent but usual responds to respiratory therapy
maneuvers.  Consider increasing nebulized saline frequency.

#Pt is DNR but can be intubated

#Please see discharge paperwork for patient's outpatient follow
up appointments

Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver[**Name (NI) 581**].
1. Amiloride HCl 5 mg PO QAM
2. Cinacalcet 30 mg PO BID
3. Citalopram 40 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Levothyroxine Sodium 88 mcg PO DAILY
6. Oxcarbazepine 1500 mg PO BID
7. PredniSONE 17.5 mg PO DAILY
8. Simvastatin 80 mg PO DAILY
9. Topiramate (Topamax) 200 mg PO BID
10. Vitamin D 1000 UNIT PO DAILY
11. Vitamin E 400 UNIT PO DAILY
12. Ranitidine (Liquid) 150 mg PO BID
13. Aspirin 81 mg PO DAILY
14. Miconazole Powder 2% 1 Appl TP TID:PRN diaper rash
15. Docusate Sodium (Liquid) 100 mg PO BID
per peg tube
16. lactobacillus rhamnosus GG *NF* 10 billion cell Oral daily
17. Fibersource HN *NF* (nutritional supplement - fiber)    Oral
daily
Tubefeeding: Fibersource HN Full strength;
Starting rate: 100 ml/hr; Do not advance rate Goal rate: 100
ml/hr
Cycle?: Yes, when at goal Cycle start: 1900 Cycle end: 1100
Residual Check: q4h Hold feeding for residual >= : 250
Flush w/ 30 ml water q8h

18. cilostazol *NF* 100 mg Oral [**Hospital1 **]
19. Polyethylene Glycol 17 g PO DAILY:PRN constipation


Discharge Medications:
1. Amiloride HCl 5 mg PO QAM
2. Aspirin 81 mg PO DAILY
3. cilostazol *NF* 100 mg Oral [**Hospital1 **]
4. Cinacalcet 30 mg PO BID
5. Citalopram 40 mg PO DAILY
6. Docusate Sodium (Liquid) 100 mg PO BID
per peg tube. Hold for loose stools
7. FoLIC Acid 1 mg PO DAILY
8. Levothyroxine Sodium 88 mcg PO DAILY
9. Miconazole Powder 2% 1 Appl TP TID:PRN diaper rash
10. Oxcarbazepine 1500 mg PO BID
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. PredniSONE 15 mg PO DAILY
Please decrease this dose by 2.5mg per week
13. Simvastatin 80 mg PO DAILY
14. Topiramate (Topamax) 200 mg PO BID
15. Vitamin D 1000 UNIT PO DAILY
16. Vitamin E 400 UNIT PO DAILY
17. lactobacillus rhamnosus GG *NF* 10 billion cell Oral daily
18. Fibersource HN *NF* (nutritional supplement - fiber) 0
ORAL DAILY
Tubefeeding: Fibersource HN Full strength;
Starting rate: 100 ml/hr; Do not advance rate Goal rate: 100
ml/hr
Cycle?: Yes, when at goal Cycle start: 1900 Cycle end: 1100
Residual Check: q4h Hold feeding for residual >= : 250
Flush w/ 30 ml water q8h

19. Ranitidine (Liquid) 150 mg PO BID
20. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN sob/ wheeze
21. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob/ wheeze
22. Sulfameth/Trimethoprim SS 1 TAB PO DAILY prophylaxis
Can stop taking after prednisone dose is below 10mg daily
23. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
24. Acetaminophen 650 mg PO Q8H:PRN pain
25. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL [**Hospital1 **]
26. Medication
Nebulized saline [**Hospital1 **]


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Hospital - [**Hospital1 8**]

Discharge Diagnosis:
PRIMARY DIAGNOSIS
Chronic aspiration pneumonia due to stroke
Mucus plugging


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


Discharge Instructions:
Dear Mr. [**Known lastname 7716**],

It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
for difficulty breathing and found to have pneumonia most likely
from aspirating food. You required intubation with a breathing
tube to assist breathing and a tracheostomy was placed to help
prevent further complications. You were treated with
antiobiotics for you pneumonia and it improved.

While you were recovering, you became short of breath due to a
mucuc plug which caused collapse of your lung. We re-inflated
your lung and your breathing returned to [**Location 213**].

We have made no changes in your medications. Please decrease you
dose of predisone by 2.5 mg per week after leaving the hospital.

Followup Instructions:
Department: [**Hospital3 249**]
When: TUESDAY [**2175-10-24**] at 2:10 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: MEDICAL SPECIALTIES
When: THURSDAY [**2175-10-26**] at 1 PM
With: DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3172**] [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: NEUROLOGY
When: MONDAY [**2175-11-27**] at 3:30 PM
With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 1694**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Malnutrition of mild degree,Precipitous drop in hematocrit,Foreign body in other specified parts bronchus and lung,Epilepsy, unspecified, without mention of intractable epilepsy,Gastrostomy status,Methicillin resistant pneumonia due to Staphylococcus aureus,Personal history of malignant neoplasm of brain,Personal history of irradiation, presenting hazards to health,Unspecified essential hypertension,Disorder of bone and cartilage, unspecified,Hyperparathyroidism, unspecified,Obstructive sleep apnea (adult)(pediatric),Unspecified acquired hypothyroidism,Depressive disorder, not elsewhere classified,Dysphagia, unspecified,Body Mass Index between 19-24, adult,Inhalation and ingestion of other object causing obstruction of respiratory tract or suffocation'}


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: Fever and Diaphoresis

PRESENT ILLNESS: Mr. [**Known lastname 7716**] is a 42 year old gentleman with a history of
pilocytic astrocytoma (at age 2), multiple CVAs, and a medullary
cavernoma with persistent right hemiparesis, epilepsy, and
aspiration who presents with with diaphoresis and fevers to
100.2 at home. He states that he has increased frequency of
cough after being given a G tube 3 weeks prior due to recurrant
aspiration pneumonia and difficulty swallowing, but that the
cough has not worsened in the past few days.  He feels otherwise
well with no sensation of fevers/chills or increased sweating,
but was brought into the ED due to concern from his group home
caretaker.

MEDICAL HISTORY: Medullary cavernoma in [**4-13**] at site of radiation
Epilepsy (absence, complex partial, and generalized seizures)
Cerebellar pilocytic astrocytoma resection at age two s/p
brainstem radiation
Presumed radiation-induced vasculopathy with multiple strokes
Strokes:  Left internal capsule/thalamus [**2167**], left posterior
cerebellum, left cerebellar peduncle [**10/2169**], TIA with facial
droop, followed by Dr. [**Last Name (STitle) 1693**]
Presumed XRT-induced bilateral hearing loss
Hypertension
Hyperparathyroidism
Bilateral Kidney Stones (thought to be due to parathyroidism,
not
Topamax use)
Hypercalcemia
Osteopenia

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver[**Name (NI) 581**].
1. Amiloride HCl 5 mg PO QAM
2. Cinacalcet 30 mg PO BID
3. Citalopram 40 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Levothyroxine Sodium 88 mcg PO DAILY
6. Oxcarbazepine 1500 mg PO BID
7. PredniSONE 17.5 mg PO DAILY
8. Simvastatin 80 mg PO DAILY
9. Topiramate (Topamax) 200 mg PO BID
10. Vitamin D 1000 UNIT PO DAILY
11. Vitamin E 400 UNIT PO DAILY
12. Ranitidine (Liquid) 150 mg PO BID
13. Aspirin 81 mg PO DAILY
14. Miconazole Powder 2% 1 Appl TP TID:PRN diaper rash
15. Docusate Sodium (Liquid) 100 mg PO BID
per peg tube
16. lactobacillus rhamnosus GG *NF* 10 billion cell Oral daily
17. Fibersource HN *NF* (nutritional supplement - fiber)    Oral
daily
Tubefeeding: Fibersource HN Full strength;
Starting rate: 100 ml/hr; Do not advance rate Goal rate: 100
ml/hr
Cycle?: Yes, when at goal Cycle start: 1900 Cycle end: 1100
Residual Check: q4h Hold feeding for residual >= : 250
Flush w/ 30 ml water q8h

ALLERGIES: hydrochlorothiazide

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM
VS - 98.3 HR 104  BP 123/74  RR 20  96% on 3 LNC
GENERAL:  Well-appearing man, not acutely distressed. Speaking
comfortably in full sentences
HEENT:  Mucous membranes semi-dry. No cervical lymphadenopathy.
Soft palate elevates symetrically
HEART:  Heart sounds distant, RRR, normal S1 S2
LUNGS:  Clear to auscultation but limited by poor air movement
due to poor respiratory effort. No evidence of respiratory
distress or accessory muscle requirement.
ABDOMEN:  Soft and nontender except at the insertion of the
G-tube.  He does have a G-tube in position with scabing. No
erythema or exudates. Mildly distended (likely secondary to
constipation). + bowel sounds in all 4 quadrants
EXTREMITIES:  He does not have any edema of his lower
extremities, + distal pulses, warm and well perfused.
NEURO: EOMI, pupils are equal and reactive. No facial weakness.
There is right hemiplegia.

FAMILY HISTORY: There is no family history of seizures. His sister died of
multiple myeloma.

SOCIAL HISTORY: He lives in a group home, and during the week goes to sports
program, gateway arts, and massage. He uses a wheelchair to get
around since his strokes, but does walk with assistance at his
sports class. He denies cigarette or EtOH use. 

### Response:
{'Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Malnutrition of mild degree,Precipitous drop in hematocrit,Foreign body in other specified parts bronchus and lung,Epilepsy, unspecified, without mention of intractable epilepsy,Gastrostomy status,Methicillin resistant pneumonia due to Staphylococcus aureus,Personal history of malignant neoplasm of brain,Personal history of irradiation, presenting hazards to health,Unspecified essential hypertension,Disorder of bone and cartilage, unspecified,Hyperparathyroidism, unspecified,Obstructive sleep apnea (adult)(pediatric),Unspecified acquired hypothyroidism,Depressive disorder, not elsewhere classified,Dysphagia, unspecified,Body Mass Index between 19-24, adult,Inhalation and ingestion of other object causing obstruction of respiratory tract or suffocation'}
