CHIEF COMPLAINT: 

PRESENT ILLNESS: This is a 77 year old female
with past medical history that includes recent C2 fracture
and resultant quadriparetic state, multiple infectious
complications over the last one half year that have included
Methicillin resistant Staphylococcus aureus pneumonia and
Methicillin resistant Staphylococcus aureus endocarditis as
well as a sacral decubitus ulcer complicated by
osteomyelitis, who presents from [**Hospital3 7**] with
respiratory failure following an aspiration of tube feeds.
The patient was apparently doing well at the [**Hospital3 5090**] until the morning of admission when she was turned
for a dressing change and was noted to become agonal, thick
fluid was later noted to be suctioned from her lungs.  The
patient was noted to desaturate and had a SAO2 of 68% and a
blood pressure of 80/palpable and a heart rate of 100 at
[**Hospital1 **]. She was given 100% nonrebreather where her SAO2 was
noted to increase to 98% and arterial blood gas was drawn at
[**Hospital1 **] and was noted to be 7.3/47/96.  The patient was
transferred to the [**Hospital1 69**] for
further evaluation and treatment.

MEDICAL HISTORY: 1.  Status post fall in [**10-4**], in which she suffered a C2
type II odontoid fracture and subdural hematoma.  She is
status post evacuation of hematoma/craniotomy which was done
at [**Hospital6 1129**].  Status post fall, she is
quadriparetic.  Her hospital course at [**Hospital6 1130**] was a complicated three month course that included
several infectious complications, Methicillin resistant
Staphylococcus aureus endocarditis, thrush, pneumonia, for
which she received eight weeks of Vancomycin and had last
positive blood culture on [**2148-1-11**], while at [**Hospital6 2121**], as well as several other infectious
complications.  The patient was transferred to [**Hospital3 6373**] on [**2147-12-31**], however, was readmitted to
[**Hospital6 1129**] on [**2148-2-2**], with worsening
renal failure in the setting of hypotension following a large
gastrointestinal bleed.  The patient has since become
hemodialysis dependent.  She, however, received a
percutaneous endoscopic gastrostomy and tracheostomy at
[**Hospital6 1129**] and the tracheostomy is now
decannulated.
2.  The patient also has a history of VRE urinary tract
infection.
3.  Stage IV sacral decubitus ulcer involving the sacrum and
coccyx that is complicated by osteomyelitis for which she has
received an extended course of antibiotics that included
Imipenem and later Meropenem, Linezolid and Amikacin.
4.  The patient also had a recent Methicillin resistant
Staphylococcus aureus PICC line infection. The PICC line was
removed shortly prior to this current admission.
5.  As noted, the patient had a gastrointestinal bleed in
[**2148-1-1**], at [**Hospital1 **].  We do not have records that
indicate the location of this gastrointestinal bleed although
the patient has apparently had no further bleed since that
time.
6.  Hypertension.
7.  Diabetes mellitus type 2.
8.  Hypothyroidism.
9.  Asthma.
10. Hyperlipidemia.
11. Anemia.
12. Hypercalcemia which is thought to be secondary to a
secondary hyperparathyroidism and the patient has recently
been started on Zemplar (that is, Paricalcitol) which she
receives with hemodialysis.
13. The patient also developed Clostridium difficile colitis
recently and was treated with p.o. Flagyl.
14. The patient has malnutrition and received tube feeds.
15. The patient also has neurologic impairment and thought to
have a waxing and [**Doctor Last Name 688**] encephalopathy for which she is
given Lactulose.
16. The patient also suffered a radial artery pseudoaneurysm
and is status post repair.
17. Depression.

MEDICATION ON ADMISSION: 

ALLERGIES: Iodine and iodine containing dyes, Mevacor,
Lipitor, Hydrochlorothiazide and Unasyn.

PHYSICAL EXAM: 

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: The patient is recently widowed, denies any
alcohol or tobacco use.  She lives at [**Hospital3 7**]
currently and was very active prior to her fall in [**2147-10-2**].
Unspecified septicemia,Acute respiratory failure,Acute kidney failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Unspecified protein-calorie malnutrition,Other convulsions,Severe sepsis,Unspecified osteomyelitis, other specified sites
Septicemia NOS,Acute respiratry failure,Acute kidney failure NOS,Hyp kid NOS w cr kid V,Protein-cal malnutr NOS,Convulsions NEC,Severe sepsis,Osteomyelit NOS-oth site
Admission Date:  [**2148-4-29**]       Discharge Date: [**2148-5-8**]

Date of Birth:   [**2071-2-22**]       Sex:  F

Service:  MEDICINE/ICU

This covers hospital course through [**2148-5-6**].

HISTORY OF PRESENT ILLNESS:  This is a 77 year old female
with past medical history that includes recent C2 fracture
and resultant quadriparetic state, multiple infectious
complications over the last one half year that have included
Methicillin resistant Staphylococcus aureus pneumonia and
Methicillin resistant Staphylococcus aureus endocarditis as
well as a sacral decubitus ulcer complicated by
osteomyelitis, who presents from [**Hospital3 7**] with
respiratory failure following an aspiration of tube feeds.
The patient was apparently doing well at the [**Hospital3 5090**] until the morning of admission when she was turned
for a dressing change and was noted to become agonal, thick
fluid was later noted to be suctioned from her lungs.  The
patient was noted to desaturate and had a SAO2 of 68% and a
blood pressure of 80/palpable and a heart rate of 100 at
[**Hospital1 **]. She was given 100% nonrebreather where her SAO2 was
noted to increase to 98% and arterial blood gas was drawn at
[**Hospital1 **] and was noted to be 7.3/47/96.  The patient was
transferred to the [**Hospital1 69**] for
further evaluation and treatment.

On Emergency Department admission to the [**Hospital1 346**], the patient was found to be
hypotensive and in further respiratory distress.  Out of
concern for her hypertension, the patient was initiated on
sepsis protocol and was intubated for respiratory failure in
the Emergency Department.  A left subclavian line was placed
and the patient received three liters of fluid in the
Emergency Department.  The patient was restarted on empiric
antibiotics given her known history of Methicillin resistant
Staphylococcus aureus and colonization with Acinetobacter.
In the Emergency Department, the patient was also noted to
become unresponsive and fingerstick glucose was 28.  The
patient was also noted to have a temperature of 101.8 and a
lactate of 2.2.  She was started on Levophed and admitted to
the Medical Intensive Care Unit for further evaluation.

PAST MEDICAL HISTORY:
1.  Status post fall in [**10-4**], in which she suffered a C2
type II odontoid fracture and subdural hematoma.  She is
status post evacuation of hematoma/craniotomy which was done
at [**Hospital6 1129**].  Status post fall, she is
quadriparetic.  Her hospital course at [**Hospital6 1130**] was a complicated three month course that included
several infectious complications, Methicillin resistant
Staphylococcus aureus endocarditis, thrush, pneumonia, for
which she received eight weeks of Vancomycin and had last
positive blood culture on [**2148-1-11**], while at [**Hospital6 2121**], as well as several other infectious
complications.  The patient was transferred to [**Hospital3 6373**] on [**2147-12-31**], however, was readmitted to
[**Hospital6 1129**] on [**2148-2-2**], with worsening
renal failure in the setting of hypotension following a large
gastrointestinal bleed.  The patient has since become
hemodialysis dependent.  She, however, received a
percutaneous endoscopic gastrostomy and tracheostomy at
[**Hospital6 1129**] and the tracheostomy is now
decannulated.
2.  The patient also has a history of VRE urinary tract
infection.
3.  Stage IV sacral decubitus ulcer involving the sacrum and
coccyx that is complicated by osteomyelitis for which she has
received an extended course of antibiotics that included
Imipenem and later Meropenem, Linezolid and Amikacin.
4.  The patient also had a recent Methicillin resistant
Staphylococcus aureus PICC line infection. The PICC line was
removed shortly prior to this current admission.
5.  As noted, the patient had a gastrointestinal bleed in
[**2148-1-1**], at [**Hospital1 **].  We do not have records that
indicate the location of this gastrointestinal bleed although
the patient has apparently had no further bleed since that
time.
6.  Hypertension.
7.  Diabetes mellitus type 2.
8.  Hypothyroidism.
9.  Asthma.
10. Hyperlipidemia.
11. Anemia.
12. Hypercalcemia which is thought to be secondary to a
secondary hyperparathyroidism and the patient has recently
been started on Zemplar (that is, Paricalcitol) which she
receives with hemodialysis.
13. The patient also developed Clostridium difficile colitis
recently and was treated with p.o. Flagyl.
14. The patient has malnutrition and received tube feeds.
15. The patient also has neurologic impairment and thought to
have a waxing and [**Doctor Last Name 688**] encephalopathy for which she is
given Lactulose.
16. The patient also suffered a radial artery pseudoaneurysm
and is status post repair.
17. Depression.

ALLERGIES:  Iodine and iodine containing dyes, Mevacor,
Lipitor, Hydrochlorothiazide and Unasyn.

MEDICATIONS ON TRANSFER FROM [**Hospital1 **]:
1.  Hydralazine 25 mg three times a day.
2.  Epogen 4000 Monday, Wednesday and Friday.
3.  Labetalol 300 mg three times a day.
4.  Sertraline 25 mg once daily.
5.  Norvasc 5 mg once daily.
6.  Levoxyl 112 mcg once daily.
7.  Heparin subcutaneously.
8.  Keppra 500 mg twice a day.
9.  NPH insulin 10 units twice a day.
10. Albuterol and Atrovent nebulizers q2hours p.r.n.
11. Albuterol and Atrovent nebulizers q4hours standing.
12. Bisacodyl 10 mg p.r.n.
13. Lactulose 20.
14. Fluconazole 100 mg twice a day. (apparently started after
workup for fever did not reveal source at [**Hospital1 **]).

SOCIAL HISTORY:  The patient is recently widowed, denies any
alcohol or tobacco use.  She lives at [**Hospital3 7**]
currently and was very active prior to her fall in [**2147-10-2**].

FAMILY HISTORY:  Noncontributory.

PHYSICAL EXAMINATION:  On admission, temperature was 98.4,
pulse 70, blood pressure 101/33.  The patient was intubated
and had a SAO2 of 100% on assist control ventilation with
tidal volume of 400, PEEP of 5, respiratory rate 18.  On
physical examination, the patient was intubated and sedated
and unresponsive.  Right pupil was pin point and left was 3.0
millimeters and reactive.  The patient was noted to have an
absence of cervical lymphadenopathy, had brisk carotid
upstrokes, had well healed site of former tracheostomy.  Her
heart had a regular rate and rhythm with no murmurs, rubs or
gallops.  Chest was rhonchorous anterolaterally.  The abdomen
was soft with gastrostomy tube in place, nontender,
nondistended, positive bowel sounds.  Extremities were warm,
no cyanosis and no edema.  The patient has a sacral decubitus
ulcer which is Stage IV and which has a purulent discharge.
The patient is sedated and was not moving extremities
spontaneously.  She did respond to pain.

LABORATORY DATA:  On admission, white blood cell count was
11.7, hematocrit 32.0, platelet count 370,000.  Sodium 132,
potassium 5.9, chloride 97, bicarbonate 23, blood urea
nitrogen 72, creatinine 4.0, glucose 89, ALT 13, AST 18,
amylase 51, lipase 18, alkaline phosphatase 434.  Troponin T
0.8 with CK of 20.  Calcium 11.4, magnesium 2.3, phosphorus
1.9.  Urinalysis (urine withdrawn by straight catheter, the
patient is anuric) shows greater than 50 red cells, greater
than 50 white cells.  Arterial blood gas reveals 7.24/59/55
that improved with intubation to 7.28/48/323.

Electrocardiogram shows normal sinus rhythm with left axis
deviation, no significant changes from prior
electrocardiogram of [**10-4**].

Chest film shows multilobar infiltrates involving the right
upper lobe, right middle lobe and left upper lobe with a left
subclavian central venous line that is properly positioned
and endocardial tube that is also properly positioned.  CT of
the head does not show any mass or hemorrhage.

Sputum reveals greater than 25 polymorphonuclear cells with
less than 10 epithelial cells and 1 positive gram positive
cocci in pairs.

HOSPITAL COURSE:
1.  Aspiration/respiratory failure - The patient as noted was
intubated on arrival to the Emergency Department for hypoxic
respiratory failure in the setting of tube feed aspiration.
The patient was maintained on a ventilator from admission in
the Emergency Department through the [**2148-5-4**], when she was
successfully extubated.  The patient was given meter dose
inhalers as well as empiric antibiotics for aspiration
pneumonia that included Linezolid and Meropenem given the
patient's known colonization with Methicillin resistant
Staphylococcus aureus and Acinetobacter.  Given the patient's
recent history of Clostridium difficile colitis on
antibiotics, the patient was also maintained on p.o. Flagyl.
Sputum culture revealed coagulase positive Staphylococcus
aureus that was pansensitive.  The patient's infiltrates were
noted to improve somewhat over the course of hospitalization
on chest film.  The possibility of replacement of the
patient's tracheostomy was discussed with the patient's
family given her risk for further aspiration.  However, the
[**Hospital 228**] health care proxy (her son) decided that he did not
want to pursue a tracheostomy for protection against further
aspiration as he felt that this would not merit the decrement
and quality of life for her and felt that the problem was
caused by a malpositioned percutaneous endoscopic gastrostomy
tube (see below).

2.  Sepsis - The patient was admitted with hypotension and
fever.  She was noted to have greater than 100,000
Acinetobacter in fluid withdrawn from her bladder on
admission (the patient is anuric).  It is felt that the
patient was likely not uroseptic from this source as all
blood cultures were negative during the hospitalization.
However, the patient's PICC line was removed on Emergency
Department admission and the catheter tip on [**2148-4-29**], did
reveal greater than 15 colonies of Methicillin resistant
Staphylococcus aureus.  In addition, it was felt that the
patient has ongoing osteomyelitis (see below).  The patient
was maintained on broad spectrum antibiotics that included
Meropenem and Linezolid and Flagyl and infectious disease
consultation was obtained.  The patient's hypotension
improved over the course of hospitalization and the patient
was weaned off pressors shortly after admission.  The patient
also had a significant bandemia on admission that disappeared
over the course of hospitalization.

3.  Osteomyelitis/sacral decubitus ulcer - The patient is
known to have a Stage IV sacral decubitus ulcer that is
colonized by Acinetobacter and Methicillin resistant
Staphylococcus aureus.  The Acinetobacter is resistant to
multiple antibiotics though is sensitive to Meropenem and the
patient had been treated with Meropenem up until several days
prior to this admission.  The patient was recently started on
Meropenem as above as well as Linezolid as above.  Wound
culture again revealed the Methicillin resistant
Staphylococcus aureus and Acinetobacter as well as VRE.
Plastic surgery was consulted for possible wound debridement
as well as consideration for placement of a VAC dressing on
the wound since it has been slow to heal. However, it was the
opinion of plastic surgery consultation that the location of
the wound was too close to the anus for a VAC dressing.  The
VAC dressing would likely become contaminated with fecal
material.  Furthermore, it was felt that no debridement was
indicated and the patient was continued on antibiotics as
above.  The patient was turned every two hours to promote
wound healing of this pressure sore.  The patient was
maintained on a Triadyne bed and the patient's wound dressing
was changed twice a day.

4.  Chronic renal insufficiency/hemodialysis - The patient
was maintained on hemodialysis.  The patient received Zemplar
with dialysis.  The patient remained anuric while in the
hospital.

5.  Diabetes mellitus - The patient was initially maintained
on insulin sliding drip and transitioned to a regular insulin
sliding scale.

6.  Asthma - The patient was maintained on Albuterol and
Atrovent inhalers while ventilated and later on Atrovent and
Albuterol nebulizers.

7.  Anemia - The patient had a hematocrit on admission of
32.2, though with hydration this decreased to 25.0.  The
patient was transfused a total of three units of blood with
hemodialysis over the course of the hospitalization.

8.  Hypertension - The patient's antihypertensive regimen was
held on admission in the setting of hypotension, however,
after several days of admission, the patient was weaned off
pressors and became hypertensive and her antihypertensive
regimen of Amlodipine, Hydralazine and Labetalol was
restarted.

9.  Seizure disorder - The patient was maintained on Keppra
for prophylaxis of seizures.

10. Hypercalcemia - As mentioned above, the patient has
secondary hyperparathyroidism and was maintained on Zemplar
with dialysis.  Her calcium remains elevated though it is
felt that it will take longer for the Zemplar to exert its
full effect.

11. Hypothyroidism - The patient was maintained on
Levothyroxine.

12. Depression - The patient was maintained on Zoloft.

13. Fluid, electrolytes and nutrition - The patient was
admitted with a gastrostomy tube that was apparently placed
at the [**Hospital6 1129**] over a prior admission
and that had apparently recently been changed and replaced
with a Foley catheter while at [**Hospital3 7**].  The
patient was taken to interventional radiology where it was
found that her gastrostomy tube was placed high in the
stomach (in the fundus) and was oriented cranially.  Initial
attempts to redirect the catheter caudally were unsuccessful.
The patient underwent further evaluation by interventional
radiology in which the Foley was removed and was converted to
a PEJ tube over a wire.  A 16.5French [**Location (un) 12056**]/Talzote/Coombs
gastrojejunostomy tube was placed over a wire such that there
are now two ports; a blue port is present in the jejunum and
a red port is present in the stomach and can be used for
suction.  The patient was restarted on tube feeds on [**2148-5-4**]
(her jejunostomy was placed on [**2148-5-3**]), and tube feeds were
increased subsequently on [**2148-5-5**].

14. Elevated alkaline phosphatase - As noted on a previous
admission in [**Month (only) 956**], the patient's alkaline phosphatase
increased over the course of hospitalization after TPN was
begun.  Her alkaline phosphatase increased from admission
value of 434 up to a maximum of 414 on [**2148-5-3**].  TPN was
discontinued and the patient's alkaline phosphatase was 1063
on [**2148-5-5**].  Her transaminases did not elevate significantly
over the course of hospitalization, nor did the bilirubin
(maximum bilirubin was 0.4 on admission).  The patient
underwent ultrasound examination of the right upper quadrant
which again revealed adenomyomatosis of the gallbladder wall
(which was seen on ultrasound in [**2147-5-2**]) and there was no
evidence of cholelithiasis or choledocholithiasis.

15. Prophylaxis - The patient was maintained on proton pump
inhibitor as well as subcutaneous Heparin and bowel regimen.

16. Mental Status - The patient was noted to have waxing and
[**Doctor Last Name 688**] mental status though at times was interactive with the
staff and with her family and could follow commands. At other
times, the patient was more somnolent and less interactive
with the staff.

CONDITION ON DISCHARGE: The patient is discharged in stable
condition.

DISCHARGE DIAGNOSES:
1.  Hypoxic respiratory failure.
2.  Aspiration pneumonia.
3.  Fever.
4.  Sepsis.
5.  Sacral Stage IV decubitus ulcer.
6.  Osteomyelitis (sacral/coccygeal).
7.  End stage renal disease, hemodialysis dependent.
8.  Hypertension.
9.  Encephalopathy.
10. Asthma.
11. Hypothyroidism.
12. Depression.
13. Anemia.
14. Hypercalcemia/secondary to hyperparathyroidism.

MEDICATIONS ON DISCHARGE:
1.  Levetiracetam 500 mg p.o. twice a day.
2.  Levothyroxine 112 once daily.
3.  Zinc Sulfate 220 mg once daily.
4.  Sertraline 25 mg once daily.
5.  Thiamine 100 mg p.o. once daily.
6.  Bisacodyl p.r.n. once daily.
7.  Ascorbic Acid 500 mg once daily.
8.  Linezolid 600 mg twice a day.
9.  Meropenem 500 mg once daily.
10. Flagyl 500 mg p.o. twice a day.
11. Acetaminophen 650 mg q4hours p.r.n.
12. Hydralazine 10 mg three times a day.
13. Labetalol 300 mg p.o. three times a day.
14. Amlodipine 5 mg p.o. once daily.
15. Lactulose q8hours p.r.n.
16. Albuterol and Atrovent nebulizers q4hours.
17. Albuterol and Atrovent nebulizers q2hours p.r.n.
18. Regular insulin sliding scale.
19. Nephrocaps.
20. Subcutaneous Heparin 5000 units twice a day.

CONDITION ON DISCHARGE:  The patient is discharged in stable
condition.




                            [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D.

Dictated By:[**Last Name (NamePattern1) 11363**]
MEDQUIST36

D:  [**2148-5-5**]  13:14
T:  [**2148-5-5**]  14:22
JOB#:  [**Job Number 12057**]

cc:[**Hospital1 12058**]

Admission Date:  [**2148-4-29**]       Discharge Date:  [**2148-5-8**]

Date of Birth:   [**2071-2-22**]       Sex:  F

Service:  PULMONARY

ADDENDUM - 1) PULMONARY ISSUE/ASPIRATION PNEUMONIA:  The
patient has maintained good O2 sats on face tent and her
respiratory status has been stable.  She still sounds
rhonchorous on exam anteriorly, and chest x-ray from [**2148-5-7**] appeared slightly worsened on the left side.  However,
repeat chest x-ray on [**5-8**] appeared slightly improved, and
indicates that the patient most likely has atelectasis and
possibly some mucous plugging as well.  The patient has been
stable with her oxygenation and her secretions have lessened
somewhat in their amount, and secretions are mostly whitish
in color.  Suctioning has been performed q 4 h, and the
patient will need to continue with the suctioning q 4 h, or
may need to increase frequency if patient sounds more
rhonchorous.  She will also need frequent chest PT,
especially on the left side, given her atelectasis and thick
secretions.  As mentioned in the previous discharge summary,
her G-tube was converted to a J-tube to prevent further
aspiration events, and she will be maintained on
broad-spectrum antibiotics for sacral decub osteomyelitis
that also empirically covers her aspiration pneumonia.

2) SEPSIS/ID:  The patient's leukocytosis continues to
improve.  Per ID recs, the patient will remain on
broad-spectrum antibiotics, meropenem and linezolid, for
sacral decub osteomyelitis for an indefinite period of time.
The patient has an ID follow-up appointment in 2 weeks
(Please see page 1), and further antibiotic coverage will
have to be decided at that time.  In the meantime, while
patient remains on meropenem and linezolid, she will also
remain on C. diff prophylaxis with Flagyl [**Hospital1 **] until these
antibiotics are discontinued.  The patient is having a PICC
line placed for an extended course of antibiotics (She
previously had a left subclavian which will be discontinued
prior to discharge.).

3) FEN:  The patient's sodium has improved on the day of
discharge, but this should continue to be monitored every few
days following discharge to insure that the patient has
adequate intake of free water.

4) END-STAGE RENAL DISEASE:  The patient is on a Tuesday,
Thursday, Saturday schedule for hemodialysis, and she should
continue this as an outpatient.  She should receive her dose
of meropenem as directed daily, but on days of hemodialysis
should receive the medication after hemodialysis.  The
patient has a right tunneled IJ catheter for hemodialysis.

5) CODE STATUS:  The patient is still full code, as has been
discussed with the family on numerous occasions with the MICU
team, as well as Dr. [**Last Name (STitle) 217**].  They state that their
mother would want this, and they are aware that she may need
to be reintubated in the future, despite her probable poor
outcome.

6) NEURO/PSYCH:  Per family, the patient is at her baseline
mental status.  It appears that the patient's behavior is
often volitional, but often speaks in full sentences to her
family.  Psych was consulted on this admission and do not
feel that there is a component of depression involved in her
neuro status and recommended discontinuation of the Zoloft.

DISCHARGE MEDICATIONS:  Same as on the previous discharge
summary, except Zoloft 25 mg po qd has been discontinued.

DISCHARGE STATUS:  To [**Hospital **] Rehab.  Please see page 1 for
follow-up appointment.




                            [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D.
[**MD Number(1) 3091**]

Dictated By:[**Name8 (MD) 10397**]
MEDQUIST36

D:  [**2148-5-8**]  13:52
T:  [**2148-5-8**]  14:00
JOB#:  [**Job Number 12059**]
{'Unspecified septicemia,Acute respiratory failure,Acute kidney failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Unspecified protein-calorie malnutrition,Other convulsions,Severe sepsis,Unspecified osteomyelitis, other specified sites'}


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: 

PRESENT ILLNESS: This is a 77 year old female
with past medical history that includes recent C2 fracture
and resultant quadriparetic state, multiple infectious
complications over the last one half year that have included
Methicillin resistant Staphylococcus aureus pneumonia and
Methicillin resistant Staphylococcus aureus endocarditis as
well as a sacral decubitus ulcer complicated by
osteomyelitis, who presents from [**Hospital3 7**] with
respiratory failure following an aspiration of tube feeds.
The patient was apparently doing well at the [**Hospital3 5090**] until the morning of admission when she was turned
for a dressing change and was noted to become agonal, thick
fluid was later noted to be suctioned from her lungs.  The
patient was noted to desaturate and had a SAO2 of 68% and a
blood pressure of 80/palpable and a heart rate of 100 at
[**Hospital1 **]. She was given 100% nonrebreather where her SAO2 was
noted to increase to 98% and arterial blood gas was drawn at
[**Hospital1 **] and was noted to be 7.3/47/96.  The patient was
transferred to the [**Hospital1 69**] for
further evaluation and treatment.

MEDICAL HISTORY: 1.  Status post fall in [**10-4**], in which she suffered a C2
type II odontoid fracture and subdural hematoma.  She is
status post evacuation of hematoma/craniotomy which was done
at [**Hospital6 1129**].  Status post fall, she is
quadriparetic.  Her hospital course at [**Hospital6 1130**] was a complicated three month course that included
several infectious complications, Methicillin resistant
Staphylococcus aureus endocarditis, thrush, pneumonia, for
which she received eight weeks of Vancomycin and had last
positive blood culture on [**2148-1-11**], while at [**Hospital6 2121**], as well as several other infectious
complications.  The patient was transferred to [**Hospital3 6373**] on [**2147-12-31**], however, was readmitted to
[**Hospital6 1129**] on [**2148-2-2**], with worsening
renal failure in the setting of hypotension following a large
gastrointestinal bleed.  The patient has since become
hemodialysis dependent.  She, however, received a
percutaneous endoscopic gastrostomy and tracheostomy at
[**Hospital6 1129**] and the tracheostomy is now
decannulated.
2.  The patient also has a history of VRE urinary tract
infection.
3.  Stage IV sacral decubitus ulcer involving the sacrum and
coccyx that is complicated by osteomyelitis for which she has
received an extended course of antibiotics that included
Imipenem and later Meropenem, Linezolid and Amikacin.
4.  The patient also had a recent Methicillin resistant
Staphylococcus aureus PICC line infection. The PICC line was
removed shortly prior to this current admission.
5.  As noted, the patient had a gastrointestinal bleed in
[**2148-1-1**], at [**Hospital1 **].  We do not have records that
indicate the location of this gastrointestinal bleed although
the patient has apparently had no further bleed since that
time.
6.  Hypertension.
7.  Diabetes mellitus type 2.
8.  Hypothyroidism.
9.  Asthma.
10. Hyperlipidemia.
11. Anemia.
12. Hypercalcemia which is thought to be secondary to a
secondary hyperparathyroidism and the patient has recently
been started on Zemplar (that is, Paricalcitol) which she
receives with hemodialysis.
13. The patient also developed Clostridium difficile colitis
recently and was treated with p.o. Flagyl.
14. The patient has malnutrition and received tube feeds.
15. The patient also has neurologic impairment and thought to
have a waxing and [**Doctor Last Name 688**] encephalopathy for which she is
given Lactulose.
16. The patient also suffered a radial artery pseudoaneurysm
and is status post repair.
17. Depression.

MEDICATION ON ADMISSION: 

ALLERGIES: Iodine and iodine containing dyes, Mevacor,
Lipitor, Hydrochlorothiazide and Unasyn.

PHYSICAL EXAM: 

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: The patient is recently widowed, denies any
alcohol or tobacco use.  She lives at [**Hospital3 7**]
currently and was very active prior to her fall in [**2147-10-2**]. 

### Response:
{'Unspecified septicemia,Acute respiratory failure,Acute kidney failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Unspecified protein-calorie malnutrition,Other convulsions,Severe sepsis,Unspecified osteomyelitis, other specified sites'}
