CHIEF COMPLAINT: confusion, headache

PRESENT ILLNESS: [**Known firstname **] [**Known lastname **] is a 53 year-old woman who was brought into the ED by
her husband after she was confused and not making sense this
morning at home. She has a notable history of paraplegia
secondary to motor-vehicle accident in [**2142**] with T1/2 cord
injury. She was recently hospitalized from [**4-14**] - [**4-16**] after
she developed yellow productive sputum with a likely right lower
lobe consolidation. She was treated w/ Vancomycin, cefepime and
azithromycin for a healthcare associated pneumonia (HCAP) and
discharged on [**4-16**]. She was also found to have a multidrug
resistant klebsiella UTI and was started on Vanc/Zosyn for a 14
day course.

MEDICAL HISTORY: # T1 to T2 paraplegia status post a motor vehicle accident.
# Recurrent pneumonia (followed by pulm - Last [**2149-4-9**])
- Per pulm, recurrent pneumonia likely from pulmonary toilet
issues secondary to neuromuscular disease with improvement with
consistent and aggressive bronchopulmonary therapy.
- Prior sputum cultures + for MRSA, pan-sensitive Klebsiella,
and Pseudomonas.
# Recurrent UTIs in the setting of urinary retention requiring
straight catheterization
# COPD
# hepatitis C
# anxiety
# DVT in [**2142**] -IVC filter placed in [**2142**]
# Pulmonary nodules
# Hypothyroidism
# Chronic pain
# Chronic gastritis
# Anemia of chronic disease
# S/p PEA arrest during hospitalization in [**2147-10-3**]

MEDICATION ON ADMISSION: albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Name (NI) **]: One (1)  Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
baclofen 10 mg Tablet [**Name (NI) **]: Two (2) Tablet PO BID (2 times a
day).
baclofen 10 mg Tablet [**Name (NI) **]: One (1) Tablet PO Once Daily at 4
PM.
calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
[**Name (NI) **]: Two (2) Tablet, Chewable PO twice a day.
citalopram 40 mg Tablet [**Name (NI) **]: One (1) Tablet PO once a day.
6. ipratropium bromide 0.02 % Solution [**Name (NI) **]: One (1)  Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
7. levothyroxine 112 mcg Tablet [**Name (NI) **]: One (1) Tablet PO DAILY
(Daily).
8. clonazepam 1 mg Tablet [**Name (NI) **]: One (1) Tablet PO three times a
day as needed for anxiety.
9. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Name (NI) **]:
Three (3) Adhesive Patches, Medicated Topical DAILY (Daily).
10. methadone 5 mg Tablet [**Name (NI) **]: One (1) Tablet PO TID (3 times a
day).
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Name (NI) **]: One (1)

ALLERGIES: Ativan

PHYSICAL EXAM: afebrile; 116-190s/70s-110s P 90s R 30s SpO2 95% facemask
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.

FAMILY HISTORY: Mom - lung cancer
Dad - healthy

SOCIAL HISTORY: Lives at home with husband and 2 adolescent children.
- Tobacco: 35-pack-years, has tried to quit but smokes
intermittently.
- Alcohol: Denies.
- Illicits: Denies.
Other encephalopathy,Acute respiratory failure,Chronic airway obstruction, not elsewhere classified,Other convulsions,Other dependence on machines, supplemental oxygen,Urinary tract infection, site not specified,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Paraplegia,Anxiety state, unspecified,Personal history of venous thrombosis and embolism,Unspecified acquired hypothyroidism,Other chronic pain,Anemia, unspecified,Tobacco use disorder,Unspecified essential hypertension,Atrophic gastritis, without mention of hemorrhage,Other iatrogenic hypotension,Other and unspecified agents primarily affecting the cardiovascular system causing adverse effects in therapeutic use
Encephalopathy NEC,Acute respiratry failure,Chr airway obstruct NEC,Convulsions NEC,Depend-supplement oxygen,Urin tract infection NOS,Klebsiella pneumoniae,Paraplegia NOS,Anxiety state NOS,Hx-ven thrombosis/embols,Hypothyroidism NOS,Chronic pain NEC,Anemia NOS,Tobacco use disorder,Hypertension NOS,Atrph gastrtis w/o hmrhg,Iatrogenc hypotnsion NEC,Adv eff cardiovasc NEC
Admission Date:  [**2150-4-20**]              Discharge Date:   [**2150-4-27**]

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

Service: NEUROLOGY

Allergies:
Ativan

Attending:[**First Name3 (LF) 5831**]
Chief Complaint:
confusion, headache

Major Surgical or Invasive Procedure:
none


History of Present Illness:
[**Known firstname **] [**Known lastname **] is a 53 year-old woman who was brought into the ED by
her husband after she was confused and not making sense this
morning at home. She has a notable history of paraplegia
secondary to motor-vehicle accident in [**2142**] with T1/2 cord
injury. She was recently hospitalized from [**4-14**] - [**4-16**] after
she developed yellow productive sputum with a likely right lower
lobe consolidation. She was treated w/ Vancomycin, cefepime and
azithromycin for a healthcare associated pneumonia (HCAP) and
discharged on [**4-16**]. She was also found to have a multidrug
resistant klebsiella UTI and was started on Vanc/Zosyn for a 14
day course.

Her husband and primary caregiver at home felt that the evening
prior to admission she was at her baseline which they describe
as
communicative, pleasant and with mobility in her upper
extremities. On [**4-20**] she awoke stating that she had a bad
headache (further description unobtainable) and she was no
longer
making sense. She continued to repeat phrases and was not
following commands. She was brought into the ED. During her time
in the ED she was noted to have a seizure for around 1 minute
which consisted of deviation of the head to the right with eyes
to the right. She also had tonic contraction of both arms. This
resolved spontaneously and was then given 2 mg of Versed (hx of
adverse reaction to Ativan). Her caregiver reports that she had
one seizure in the past, around 1 year ago in the setting of
multiple medication discontinuation (including - baclofen).

She also has a history of PRES in the setting of a MICU
admission
in [**2147-12-3**] in which systolic blood pressures were greater than
160s. She had binocular vision loss during the episode and MRI
with occipital lobe FLAIR hyperintensities.

She is unable to provide any additional history. Her husband
states that at home her blood pressure typically run in the
90s-110s systolic.


Past Medical History:
# T1 to T2 paraplegia status post a motor vehicle accident.
# Recurrent pneumonia (followed by pulm - Last [**2149-4-9**])
- Per pulm, recurrent pneumonia likely from pulmonary toilet
issues secondary to neuromuscular disease with improvement with
consistent and aggressive bronchopulmonary therapy.
- Prior sputum cultures + for MRSA, pan-sensitive Klebsiella,
and Pseudomonas.
# Recurrent UTIs in the setting of urinary retention requiring
straight catheterization
# COPD
# hepatitis C
# anxiety
# DVT in [**2142**] -IVC filter placed in [**2142**]
# Pulmonary nodules
# Hypothyroidism
# Chronic pain
# Chronic gastritis
# Anemia of chronic disease
# S/p PEA arrest during hospitalization in [**2147-10-3**]


Social History:
Lives at home with husband and 2 adolescent children.
- Tobacco: 35-pack-years, has tried to quit but smokes
intermittently.
- Alcohol: Denies.
- Illicits: Denies.


Family History:
Mom - lung cancer
Dad - healthy

Physical Exam:
afebrile; 116-190s/70s-110s P 90s R 30s SpO2 95% facemask
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.

Neurologic:
-Mental Status: continuously repeating phrases "yes, ok, yes,
ok". Not following simple appendicular or midline commands.

-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 5 to 2mm and sluggish.  blinks to threat b/l.
Funduscopic exam revealed no papilledema, exudates, or
hemorrhages.
III, IV, VI: eyes midline and will track to the left, not moving
past midline to the right
V: reacts to stimuli on both sides of face
[**Year (4 digits) **]: No facial droop, facial musculature symmetric.
VIII: reacts to auditory stimuli b/l
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: unable to test
XII: unable to test

-Motor: diminished bulk in LE, flaccid tone in LE.
No adventitious movements, such as tremor, noted. Has b/l
movements of arms that are purposeful and symmetric, some
resistance b/l at the triceps. No movement of legs (chronic)

-Sensory: reacting to stimuli on UE b/l

-DTRs:
  [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L  2  2    2    0   0
R  2  2    2    0   0
Plantar response was muted bilaterally.

-Coordination: unable to test

-Gait: unable to test given paraplegia

.
Exam on discharge:
.
Unchanged except for the following Mental status exam: Alert,
oriented X3, language normal, attention: able to recite months
of year backwards, short-term memory: [**4-5**] words @ 5minutes,
slight perseveration,

Pertinent Results:
Labs on admission:

[**2150-4-20**] 09:45AM   PT-12.5 PTT-29.9 INR(PT)-1.2*
[**2150-4-20**] 09:45AM   PLT COUNT-218#
[**2150-4-20**] 09:45AM   NEUTS-79.0* LYMPHS-14.4* MONOS-2.9 EOS-3.1
BASOS-0.6
[**2150-4-20**] 09:45AM   WBC-9.1 RBC-3.84* HGB-10.0* HCT-33.7*# MCV-88
MCH-26.0* MCHC-29.7* RDW-16.4*
[**2150-4-20**] 09:45AM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2150-4-20**] 09:45AM   ALBUMIN-3.8 CALCIUM-9.2 PHOSPHATE-3.8#
MAGNESIUM-2.3
[**2150-4-20**] 09:45AM   LIPASE-16
[**2150-4-20**] 09:45AM   ALT(SGPT)-30 AST(SGOT)-22 ALK PHOS-78 TOT
BILI-0.2
[**2150-4-20**] 09:45AM   GLUCOSE-119* UREA N-9 CREAT-0.5 SODIUM-146*
POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-40* ANION GAP-11
[**2150-4-20**] 09:51AM   LACTATE-1.0
[**2150-4-20**] 10:17AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2150-4-20**] 10:17AM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2150-4-20**] 10:17AM URINE  UHOLD-HOLD
[**2150-4-20**] 10:17AM URINE  HOURS-RANDOM
[**2150-4-20**] 12:16PM CEREBROSPINAL FLUID (CSF)  WBC-3 RBC-1100*
POLYS-45 LYMPHS-45 MONOS-10
[**2150-4-20**] 12:16PM CEREBROSPINAL FLUID (CSF)  WBC-9 RBC-3*
POLYS-43 LYMPHS-45 MONOS-12
[**2150-4-20**] 12:16PM CEREBROSPINAL FLUID (CSF)  PROTEIN-79*
GLUCOSE-71
[**2150-4-20**] 12:35PM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2150-4-20**] 12:35PM URINE  HOURS-RANDOM

Imaging studies:
.
[**2150-4-20**]
CT_HEAD
IMPRESSION: Significant motion artifact limits evaluation. White
matter
hypodensity in the left parietal lobe may represent sequela of
prior event of PRES.
.
NOTE ADDED AT ATTENDING REVIEW: Although the left frontal
hypodensity might be a sequelum of prior PRES, the MR
examination of [**2147-12-29**] did not demonstrate abnormality in
this location. Further, there is loss of grey white contrast,
but no atrophy, as might be expected if this were an old lesion.
These findings raise concern of acute-subacute infarction, or
perhaps swelling after a seizure. MR is recommended for further
evaluation. This revised interpretation was noticed at 5:25 pm,
and discussed by telephone, by Dr. [**Last Name (STitle) **], with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 22924**]
of the Emergency Department at 5:30pm.

[**2150-4-19**]
EEG
IMPRESSION: This is an abnormal portable EEG due to the presence
of
frequent left temporal and left hemisphere sharp and slow wave
discharges occurring for a few seconds at a time at 1 Hz
indicative of
an epileptogenic focus in this region. However, the study was
severely
limited by abundant and frequent movement artifact during the
majority
of the study, and the rightsided electrodes were most severely
affected. The background was otherwise slow and disorganized
reaching
up to a maximum of [**6-7**] Hz posteriorly indicative of a moderate
to
severe encephalopathy. Given the above findings, we suggest 24
bedside
EEG monitoring for further diagnosis.

[**2150-4-24**]
CT-HEAD
IMPRESSION: Hypodensities in bilateral occipital, left temporal,
and left
frontal lobes are not significantly changed since the prior
exam, and may
represent PRES or post-seizure changes. MRI is recommended for
further
evaluation.


Brief Hospital Course:
Ms. [**Known lastname **] is 53 yo woman with T1-T2 level paraplegia since [**2142**],
with previous history of episode of PRES, was in [**Hospital1 **] with
pneumonia and UTI last week, home for 4 days when she developed
headache and confusion.  She came in to ER, was hypertensive to
SBP of 170's-180's and DBP in 110-120 range, had a focal seizure
and severe encephalopathy.

On [**2150-4-20**] she was admitted to the ICU and her hypertension was
treated with nicardipine IV. She was loaded with [**Date Range 13401**] for
possible seizures. She was given Acyclovir empirically for
possibility of HSV encephalitis and underwent a lumbar puncture.
She was treated empirically for MDR UTI and possible PNA with
Vancomycin/Cepefime/Flagyl.

She underwent NCHCT which showed hypodensities consistent with
PRES with possibility of acute-subacute infarct.

Given her overall improvement, she was transfered to the floor
on [**2150-4-22**].

She remained afebrile and her BP was well controlled. Her CSF
did not show HSV and Acyclovir was discontinued. Her other ABx
were also stopped.

On [**2150-4-22**], she had an extended routine EEG which did not show
electrographic seizures or clear spikes. Her [**Date Range 13401**] was
continued for seizure prophylaxis as she did not have any other
episodes concerning for seizure.

To evaluate the hypodensity seen on previous scan, she was
ordered for MRI brain but refused. She was then ordered for a
repeat NCHCT which showed stable changes consistent with PRES.

She will be discharge home to resume her typical pre-admission
home services.

Transitional issues:
.
1. PRES: this is the second episode since [**2147**]. Given her
paraplegia, she is at risk for dysautonomia and hypertensive
crises which have required inpatient hospitalizations for BP
control. Her BP is somewhat labile and attempts to start low
dose BP control meds (lisinopril) have led to significant
hypotension. Going forward, she might benefit from BP cuff with
PRN BP control at home. She should continue her typical home
care to limit pain, constipation or other triggers of
hypertension.
.
2. Pulmonary function: she has chronic recurrent PNA and
followed by Pulmonary service. She has PFTs tomorrow and ongoing
home chest-PT which she will continue on discharge.
.
3. Sleep apnea: during this hospitalization, she had several
episodes of desaturations (80s) at night despite being on 2LNC.
It is [possible that her likely sleep apnea is contributing to
HTN. We will recommend a sleep study as outpatient.
.
4. Seizures: these were likely provoked by PRES. For the moment,
she will remain on [**Name (NI) 13401**] prophylactically until neurology
follow-up.



Medications on Admission:
albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Name (NI) **]: One (1)  Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
baclofen 10 mg Tablet [**Name (NI) **]: Two (2) Tablet PO BID (2 times a
day).
baclofen 10 mg Tablet [**Name (NI) **]: One (1) Tablet PO Once Daily at 4
PM.
calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
[**Name (NI) **]: Two (2) Tablet, Chewable PO twice a day.
citalopram 40 mg Tablet [**Name (NI) **]: One (1) Tablet PO once a day.
6. ipratropium bromide 0.02 % Solution [**Name (NI) **]: One (1)  Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
7. levothyroxine 112 mcg Tablet [**Name (NI) **]: One (1) Tablet PO DAILY
(Daily).
8. clonazepam 1 mg Tablet [**Name (NI) **]: One (1) Tablet PO three times a
day as needed for anxiety.
9. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Name (NI) **]:
Three (3) Adhesive Patches, Medicated Topical DAILY (Daily).
10. methadone 5 mg Tablet [**Name (NI) **]: One (1) Tablet PO TID (3 times a
day).
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Name (NI) **]: One (1)

Capsule, Delayed Release(E.C.) PO BID (2 times a day).
12. oxybutynin chloride 5 mg Tablet [**Name (NI) **]: One (1) Tablet PO Once
Daily at 4 PM.
13. oxybutynin chloride 5 mg Tablet [**Name (NI) **]: Two (2) Tablet PO BID
(2 times a day).
14. polyethylene glycol 3350 17 gram Powder in Packet [**Name (NI) **]: One
(1) Powder in Packet PO DAILY (Daily).
15. pregabalin 100 mg Capsule [**Name (NI) **]: One (1) Capsule PO TID (3
times a day).
16. simvastatin 10 mg Tablet [**Name (NI) **]: One (1) Tablet PO once a day.


17. sucralfate 1 gram Tablet [**Name (NI) **]: One (1) Tablet PO TID (3 times

a day).
18. oxycodone 5 mg Tablet [**Name (NI) **]: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
19. trazodone 100 mg Tablet [**Name (NI) **]: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
20. azithromycin 250 mg Tablet [**Name (NI) **]: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
21. prednisone 10 mg Tablet [**Name (NI) **]: Two (2) Tablet PO once a day:
Friday, then 1 tablet daily Saturday/Sunday.
Disp:*4 Tablet(s)* Refills:*0*
22. vancomycin 500 mg Recon Soln [**Name (NI) **]: 1250 (1250) mg Intravenous

Q 12H (Every 12 Hours) for 23 doses.
Disp:*23 inj* Refills:*0*
23. piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback
[**Name (NI) **]: One (1)  Intravenous Q8H (every 8 hours) for 32 doses.
Disp:*32 inj* Refills:*0*


Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Name (NI) **]: One (1)  Inhalation Q6H (every 6 hours) as
needed for dyspnea.
2. baclofen 10 mg Tablet [**Name (NI) **]: Two (2) Tablet PO BID (2 times a
day).
3. baclofen 10 mg Tablet [**Name (NI) **]: One (1) Tablet PO Q 24H (Every 24
Hours).
4. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
[**Name (NI) **]: Two (2) Tablet, Chewable PO twice a day.
5. citalopram 20 mg Tablet [**Name (NI) **]: Two (2) Tablet PO DAILY (Daily).

6. ipratropium bromide 0.02 % Solution [**Name (NI) **]: One (1)  Inhalation
Q6H (every 6 hours) as needed for dyspnea.
7. levothyroxine 112 mcg Tablet [**Name (NI) **]: One (1) Tablet PO DAILY
(Daily).
8. clonazepam 1 mg Tablet [**Name (NI) **]: One (1) Tablet PO TID (3 times a
day).
9. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Name (NI) **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
10. methadone 5 mg Tablet [**Name (NI) **]: One (1) Tablet PO TID (3 times a
day).
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Name (NI) **]: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
12. oxybutynin chloride 5 mg Tablet [**Name (NI) **]: Two (2) Tablet PO BID
(2 times a day).
13. oxybutynin chloride 5 mg Tablet [**Name (NI) **]: One (1) Tablet PO Q24H
(every 24 hours).
14. polyethylene glycol 3350 17 gram Powder in Packet [**Name (NI) **]: One
(1) Powder in Packet PO DAILY (Daily).
15. pregabalin 25 mg Capsule [**Name (NI) **]: Four (4) Capsule PO TID (3
times a day).
16. simvastatin 10 mg Tablet [**Name (NI) **]: One (1) Tablet PO DAILY
(Daily).
17. sucralfate 1 gram Tablet [**Name (NI) **]: One (1) Tablet PO three times
a day.
18. oxycodone 5 mg Tablet [**Name (NI) **]: One (1) Tablet PO Q8H (every 8
hours) as needed for Pain.
19. trazodone 50 mg Tablet [**Name (NI) **]: Two (2) Tablet PO HS (at
bedtime) as needed for anxiety.
20. acetaminophen 650 mg/20.3 mL Solution [**Name (NI) **]: One (1)  PO Q6H
(every 6 hours) as needed for headache.
21. levetiracetam 500 mg Tablet [**Name (NI) **]: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*3*


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 **] VNA

Discharge Diagnosis:
Encephalopathy
PRES syndrome
seizure


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


Discharge Instructions:
You were admitted to the hospital for confusion and headaches
and were found to have very high blood pressure. You also may
have had a seizure.

You confusion was thought to be the result of either high blood
pressure or the result of an infection. Both your high blood
pressure and possible infection were treated and you improved.
The antibiotics were stopped. An anti-seizure medication was
started.

You were closely monitored over the next several days and your
condition improved every day.

You should follow up with the neurologist once you leave the
hospital.

You should follow up with the Pulmonary doctor once you leave
the hospital given the concern for sleep apnea. You may benefit
from a sleep study to ensure that your oxygen level does not
decrease at night. You should continue respiratory therapeutic
maneuvers every day.

During your hospitalization, you were noted to have several high
blood pressure readings. You should discuss starting a
medication to help treat this.

Please note the following medication changes

START
- [**Hospital1 13401**] (to help prevent seizures, this medication might be
stopped by your neurologist in the future)

STOP:
-

Please continue taking all your other medication as prescribed
by your physicians.

Followup Instructions:
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2150-4-30**] at 1:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: PFT
When: THURSDAY [**2150-4-30**] at 1:30 PM

Department: MEDICAL SPECIALTIES
When: THURSDAY [**2150-4-30**] at 1:30 PM
With: DRS. [**Name5 (PTitle) 4013**] & [**Doctor Last Name **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: Neurology
When: [**2150-5-13**]  02:30p
With: [**Doctor Last Name 43**],[**Doctor Last Name **]
Where: SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] NEUROLOGY UNIT CC8
{"Other encephalopathy,Acute respiratory failure,Chronic airway obstruction, not elsewhere classified,Other convulsions,Other dependence on machines, supplemental oxygen,Urinary tract infection, site not specified,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Paraplegia,Anxiety state, unspecified,Personal history of venous thrombosis and embolism,Unspecified acquired hypothyroidism,Other chronic pain,Anemia, unspecified,Tobacco use disorder,Unspecified essential hypertension,Atrophic gastritis, without mention of hemorrhage,Other iatrogenic hypotension,Other and unspecified agents primarily affecting the cardiovascular system causing adverse effects in therapeutic use"}


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: confusion, headache

PRESENT ILLNESS: [**Known firstname **] [**Known lastname **] is a 53 year-old woman who was brought into the ED by
her husband after she was confused and not making sense this
morning at home. She has a notable history of paraplegia
secondary to motor-vehicle accident in [**2142**] with T1/2 cord
injury. She was recently hospitalized from [**4-14**] - [**4-16**] after
she developed yellow productive sputum with a likely right lower
lobe consolidation. She was treated w/ Vancomycin, cefepime and
azithromycin for a healthcare associated pneumonia (HCAP) and
discharged on [**4-16**]. She was also found to have a multidrug
resistant klebsiella UTI and was started on Vanc/Zosyn for a 14
day course.

MEDICAL HISTORY: # T1 to T2 paraplegia status post a motor vehicle accident.
# Recurrent pneumonia (followed by pulm - Last [**2149-4-9**])
- Per pulm, recurrent pneumonia likely from pulmonary toilet
issues secondary to neuromuscular disease with improvement with
consistent and aggressive bronchopulmonary therapy.
- Prior sputum cultures + for MRSA, pan-sensitive Klebsiella,
and Pseudomonas.
# Recurrent UTIs in the setting of urinary retention requiring
straight catheterization
# COPD
# hepatitis C
# anxiety
# DVT in [**2142**] -IVC filter placed in [**2142**]
# Pulmonary nodules
# Hypothyroidism
# Chronic pain
# Chronic gastritis
# Anemia of chronic disease
# S/p PEA arrest during hospitalization in [**2147-10-3**]

MEDICATION ON ADMISSION: albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Name (NI) **]: One (1)  Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
baclofen 10 mg Tablet [**Name (NI) **]: Two (2) Tablet PO BID (2 times a
day).
baclofen 10 mg Tablet [**Name (NI) **]: One (1) Tablet PO Once Daily at 4
PM.
calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
[**Name (NI) **]: Two (2) Tablet, Chewable PO twice a day.
citalopram 40 mg Tablet [**Name (NI) **]: One (1) Tablet PO once a day.
6. ipratropium bromide 0.02 % Solution [**Name (NI) **]: One (1)  Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
7. levothyroxine 112 mcg Tablet [**Name (NI) **]: One (1) Tablet PO DAILY
(Daily).
8. clonazepam 1 mg Tablet [**Name (NI) **]: One (1) Tablet PO three times a
day as needed for anxiety.
9. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Name (NI) **]:
Three (3) Adhesive Patches, Medicated Topical DAILY (Daily).
10. methadone 5 mg Tablet [**Name (NI) **]: One (1) Tablet PO TID (3 times a
day).
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Name (NI) **]: One (1)

ALLERGIES: Ativan

PHYSICAL EXAM: afebrile; 116-190s/70s-110s P 90s R 30s SpO2 95% facemask
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.

FAMILY HISTORY: Mom - lung cancer
Dad - healthy

SOCIAL HISTORY: Lives at home with husband and 2 adolescent children.
- Tobacco: 35-pack-years, has tried to quit but smokes
intermittently.
- Alcohol: Denies.
- Illicits: Denies. 

### Response:
{"Other encephalopathy,Acute respiratory failure,Chronic airway obstruction, not elsewhere classified,Other convulsions,Other dependence on machines, supplemental oxygen,Urinary tract infection, site not specified,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Paraplegia,Anxiety state, unspecified,Personal history of venous thrombosis and embolism,Unspecified acquired hypothyroidism,Other chronic pain,Anemia, unspecified,Tobacco use disorder,Unspecified essential hypertension,Atrophic gastritis, without mention of hemorrhage,Other iatrogenic hypotension,Other and unspecified agents primarily affecting the cardiovascular system causing adverse effects in therapeutic use"}
