CHIEF COMPLAINT: respiratory distress, hypoxia, tachycardia, fever, chills

PRESENT ILLNESS: Pt. is a 87 y/o with a history of Dementia, thrombocytosis on
hydroxyurea, TIA, seizure, and gout, who presented to [**Hospital1 18**] ED
from NH with hypoxia of 84% RA --> 97% 15L after being noted by
nursing staff to be gurgling as well as nasal congestion and
drainage early in the morning. Pt was given combivent nebs at
the NH and at the time was noted to be afebrile with temp of
98F, P 100, RR 20, BP 136/68. Later in the afternoon, the
patient was noted to have some difficulty breathing, and at that
time was found to be 84% on RA.
.
On arrival to ER pt was found to have TMax 102.2, Tachy to
120's, SBP 130's, and initially 100% on non-rebreather.  Pt was
able to be weaned down to a 50% FM (98%), and HR improved to
100's after 1L IV fluids. CXR: showed a possible LLL pna, and a
chest CTA was negative for PE, but did show a L sided
consolidation.  Pt recieved Levaquin, Cefepime, Vanco while in
the ED and arrived to the MICU satting 96% on 5L NC.
.
Of note, the patient had been recieving Penicillin VK 250mg po
QID since [**7-6**] following a recent dental procedure.

MEDICAL HISTORY: 1.) Dementia
2.) Essential thrombocytosis
3.) Gout
4.) Anemia
5.) TIA
6.) Seizure, previously on Trileptal now d/c'd

MEDICATION ON ADMISSION: Triamcinolone 0.1% cream topically prn itching
Tylenol 500mg po BID, ATC
Allopurinol 100mg po daily
ASA 325mg po daily
CaCarbonate 500 mg po tid
Docusate 100 mg po BId
Lasix 20 mg po daily on M, W, F
Hydrea 500 mg po every other day
Nasacort nasal spray to nostrils daily
Artificial tears, 3 drops to eyes daily
Multivitamin daily
Protonix 40 mg po daily
Simvasatatin 40 mg po daily
Vitamin D 800U po daily
Fleets, Dulcolax, MOM PRN constipation
Penicillin VK  250 mg 4x/day s/p dental procedure

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Tmax: 37.6 ??????C (99.6 ??????F)
Tcurrent: 37.6 ??????C (99.6 ??????F)
HR: 111 (111 - 116) bpm
BP: 156/85(104) {149/58(81) - 156/85(104)} mmHg
RR: 21 (16 - 21) insp/min
SpO2: 97%
Heart rhythm: ST (Sinus Tachycardia)
Height: 51 Inch

FAMILY HISTORY: Reviewed past records and found to be non-contributory

SOCIAL HISTORY: Occupation: Retired urologist at [**Hospital6 **] Hosp
Drugs: Unknown
Tobacco: Unknown
Alcohol: Unknown
Other: NH resident from [**Hospital1 599**] of [**Location (un) 55**]
Pneumonitis due to inhalation of food or vomitus,Pulmonary collapse,Candidiasis of other urogenital sites,Unspecified pleural effusion,Pneumonia, organism unspecified,Urinary incontinence, unspecified,Gout, unspecified,Other disorders of calcium metabolism,Chondrocalcinosis, due to pyrophosphate crystals, upper arm,Other persistent mental disorders due to conditions classified elsewhere,Essential thrombocythemia,Hypoxemia
Food/vomit pneumonitis,Pulmonary collapse,Candidias urogenital NEC,Pleural effusion NOS,Pneumonia, organism NOS,Urinary incontinence NOS,Gout NOS,Dis calcium metablsm NEC,Pyrophosph cryst-up/arm,Mental disor NEC oth dis,Essntial thrombocythemia,Hypoxemia
Admission Date:  [**2197-7-16**]              Discharge Date:   [**2197-8-2**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2610**]
Chief Complaint:
respiratory distress, hypoxia, tachycardia, fever, chills

Major Surgical or Invasive Procedure:
Nasogastric Tube
Left elbow joint aspiration

History of Present Illness:
Pt. is a 87 y/o with a history of Dementia, thrombocytosis on
hydroxyurea, TIA, seizure, and gout, who presented to [**Hospital1 18**] ED
from NH with hypoxia of 84% RA --> 97% 15L after being noted by
nursing staff to be gurgling as well as nasal congestion and
drainage early in the morning. Pt was given combivent nebs at
the NH and at the time was noted to be afebrile with temp of
98F, P 100, RR 20, BP 136/68. Later in the afternoon, the
patient was noted to have some difficulty breathing, and at that
time was found to be 84% on RA.
.
On arrival to ER pt was found to have TMax 102.2, Tachy to
120's, SBP 130's, and initially 100% on non-rebreather.  Pt was
able to be weaned down to a 50% FM (98%), and HR improved to
100's after 1L IV fluids. CXR: showed a possible LLL pna, and a
chest CTA was negative for PE, but did show a L sided
consolidation.  Pt recieved Levaquin, Cefepime, Vanco while in
the ED and arrived to the MICU satting 96% on 5L NC.
.
Of note, the patient had been recieving Penicillin VK 250mg po
QID since [**7-6**] following a recent dental procedure.

Past Medical History:
1.) Dementia
2.) Essential thrombocytosis
3.) Gout
4.) Anemia
5.) TIA
6.) Seizure, previously on Trileptal now d/c'd

Social History:
Occupation: Retired urologist at [**Hospital6 **] Hosp
Drugs: Unknown
Tobacco: Unknown
Alcohol: Unknown
Other: NH resident from [**Hospital1 599**] of [**Location (un) 55**]


Family History:
Reviewed past records and found to be non-contributory

Physical Exam:
Tmax: 37.6 ??????C (99.6 ??????F)
Tcurrent: 37.6 ??????C (99.6 ??????F)
HR: 111 (111 - 116) bpm
BP: 156/85(104) {149/58(81) - 156/85(104)} mmHg
RR: 21 (16 - 21) insp/min
SpO2: 97%
Heart rhythm: ST (Sinus Tachycardia)
Height: 51 Inch

General Appearance: No acute distress, Thin
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, Poor dentition
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal), No murmurs, gallops,
or rubs
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Percussion: No(t)
Resonant : ), (Breath Sounds: No(t) Clear : , Rhonchorous:
bilateral rhonchi throughout all lung fields with no wheezing),
Significant upper airway secretions and gurgling
Abdominal: Soft, Non-tender, Bowel sounds present, reducible
ventral hernia
Extremities: Right: 1+, Left: 1+
Musculoskeletal: Muscle wasting, Thin lower extremeties with
decreased bulk
Skin:  Warm
Neurologic: Follows simple commands, Responds to: Verbal
stimuli, Oriented (to): self, Movement: Purposeful, Tone: Not
assessed, Somnolent but easily arousable, able to follow simple
commands and answer questions


Pertinent Results:
[**2197-7-16**] [**Year (4 digits) 5283**] Ultrasound
<br>
IMPRESSION:
Unremarkable right upper quadrant ultrasound. Please note,
failure to image the gallbladder may be due to prior
cholecystectomy or due to collapsed state. No intrahepatic
ductal dilatation.
<br>
[**2197-7-16**] CTA CHEST WITH AND WITHOUT CONTRAST
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Left lower lobe consolidation consistent with pneumonia.
3. Calcification of the coronary arteries and aorta.
4. 4 mm pulmonary nodule in the right upper lobe. Based on risk
factors, [**5-18**] month follow up is recommended.
<br>
[**2197-7-17**] CT HEAD W/O CONTRAST
CONCLUSIONS:
1. Age-related diffuse cerebral atrophy and ventricular
enlargement, stable since [**2196-7-6**].
2. Bilateral lacunar infarcts in the basal ganglia and small
vessel ischemic disease.
3. Periodontoid pannus in keeping with possible rheumatoid
arthritis or pseudogout. Clinical correlation is recommended.
4. Overall, if clinical concern is high for acute ischemic
disease, an MRI evaluation of the brain would be helpful.
<br>
[**2197-7-17**] CXR
IMPRESSION:
Left retrocardiac alveolar opacity associated with left small
pleural effusion is new, consistent with pneumonia or
aspiration. Less marked right basal alveolar opacity increased,
could be due to atelectasis, multifocal aspiration or pneumonia.
There is no right pleural effusion. There is no vascular
congestion. Tortuosity and calcifications of the aorta are
unchanged.
<br>
[**2197-7-25**] CXR
FINDINGS: The enteric tube reaches the stomach. The
cardiomediastinal contours are stable. There is no evidence of
central lymphadenopathy. Bibasilar consolidations have improved.
There are small bilateral pleural effusions. Pulmonary
vascularity is normal. There is no pneumothorax. IMPRESSION:
Interval improvement in left lower and right lower lobe
consolidations. No radiographic findings to suggest interval
aspiration.
<br>
[**2197-7-29**] CT CHEST
IMPRESSION:
1. Persistent consolidation and atelectasis involving the
majority of the left lower lobe. The patency of the left lower
lobe bronchus is in question, and a small obstructing mass
cannot be excluded. Correlation with bronchoscopy is
recommended.
2. New small region of consolidation in the right lower lobe.
This may be due to aspiration or atelectasis.
3. Mild right lower lobe bronchiectasis.
4. Stable small right upper lobe nodule.
5. A few borderline mediastinal lymph nodes.
6. Small calcified granuloma in the spleen.
7. Bilateral non-obstructing nephrolithiasis.
8. Bilateral glenohumeral degenerative changes.
9. Central venous catheter tip in the superior vena cava.
10. Small fat containing anterior abdominal wall hernia.
<br>
[**2197-7-29**] BILAT UPPER EXTREMITY VENOUS ULTRASOUND
IMPRESSION: Thrombosis involving the left cephalic and basilic
veins. No
evidence of deep vein thrombosis of the right or left upper
extremity.
<br>
[**2197-8-1**] CXR (PA and LAT)
FINDINGS: As compared to the previous examination, the
right-sided PICC line is in unchanged position. The retrocardiac
opacity shows subtotal resolution, in the left basal lung. Very
subtle remnant peribronchial opacitie are seen. There is no
evidence of newly appeared parenchymal opacities, and no
evidence of pleural effusion. The size of the cardiac silhouette
is at the upper range of normal, there is no evidence of
overhydration.
<br>
MICROBIOLOGY
[**2197-8-1**]  STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
(NEGATIVE)
[**2197-7-28**]  STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
(NEGATIVE)
[**2197-7-26**]  URINE URINE CULTURE-FINAL {> 10^5 [**Year (4 digits) **]}
[**2197-7-26**]  BLOOD CULTURE Blood Culture, Routine-FINAL (NO
GROWTH)
[**2197-7-26**]  BLOOD CULTURE Blood Culture, Routine-FINAL (NO
GROWTH)
[**2197-7-25**]  JOINT FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL
(NO GROWTH)
[**2197-7-23**]  STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
(NEGATIVE)
[**2197-7-21**]  URINE URINE CULTURE-FINAL {> 10^5 [**Year (4 digits) **]}
[**2197-7-18**]  SPUTUM GRAM STAIN-FINAL (TWO MORPHOLOGIES OF GNRs);
RESPIRATORY CULTURE-FINAL (NO GROWTH)
[**2197-7-18**]  BLOOD CULTURE Blood Culture, Routine-FINAL (NO
GROWTH)
[**2197-7-18**]  BLOOD CULTURE Blood Culture, Routine-FINAL (NO
GROWTH)
[**2197-7-18**]  URINE URINE CULTURE-FINAL (NO GROWTH)
[**2197-7-17**]  URINE URINE CULTURE-FINAL (NO GROWTH)
[**2197-7-17**]  URINE Legionella Urinary Antigen -FINAL (NEGATIVE)
[**2197-7-16**]  SPUTUM GRAM STAIN-FINAL (NO MICROORGANISMS);
RESPIRATORY CULTURE-FINAL (NO GROWTH)
[**2197-7-16**]  BLOOD CULTURE Blood Culture, Routine-FINAL (NO
GROWTH)
[**2197-7-16**]  BLOOD CULTURE Blood Culture, Routine-FINAL (NO
GROWTH)


Brief Hospital Course:
87 y/o M with a history of dementia, thrombocytosis previously
on hydroxyurea, TIA, seizure, and gout who presented from his
nursing home in respiratory distres with acute hypoxia,
tachycardia, fevers, and leukocytosis.
<br>
PNEUMONIA:
Likely related to a respiratory infection in the setting of
possible aspiration event given copious upper airway secretions
and notable cough, fever, and leukocytosis. CTA with L lower
lobe consolidation correlates with CXR at presentation. Patient
never experienced hypotension related to pneumonia. Initial
sputum gram staining showed two morphologies of gram negative
rods; however, there were never postive sputum cultures or blood
cultures. Patient was transiently on levofloxacin due to concern
for Legionella; however, a negative urine legionella antigen
prompted the discontinuation of levofloxacin on [**2197-7-18**]. The
pneumonia was treated with a full 14 day course of cefepime
starting on [**2197-7-17**]. Metronidazole and Vancomycin were also
part of the patient's antibiotic regimen; however, the cefepime
was the only antibiotic used for the full 14 days of treatment.
All IV antibiotics were stopped on [**2197-7-29**]. The patient's
initial copius and thick secretions improved day by day
throughout the patient's hospitalization. He required less and
less suctioning and was able to mount a good cough in response
to chest physiotherapy. He should continue to receive chest PT
at his long term care facility.
<br>
HYPOXIA:
Pt initially 84% on RA at [**Hospital1 1501**] and weaned from 100% NRB to 50% FM
to 3L NC with O2 sats in mid 90's. He remained on supplemental
oxygen for several days after transfer from the MICU; however,
with suctioning, and good chest PT, the patient was liberated
from supplemental oxygen and had acceptable O2 sats (> 92%) for
greater than a week prior to discharge.
<br>
GOUT / PSEUDOGOUT:
The patient presented to the hosptial with allopurinol listed as
a home medication; however, this was discontinued in the MICU
due to concerns that it would exacerbate patient's constipation.
The medication was restarted upon transfer to the floor team.
After being on the medical floor for two days, that patient was
noted to grimace when arms were passively moved. There was
bilateral swelling, warmth, and erythema of the elbow joints
noted on exam. This was thought to be a gout flare in response
to illness and re-initiation of allopurinol therapy. Allopurinol
was again discontinued and remained discontinued for the rest of
the hospitalization. Patient received two days of colchicine at
a low dose and had no notable response to this medication.
Rheumatology was consulted and they aspirated fluid from the
left elbow on [**2197-7-25**]. The joint aspirate had ~[**Numeric Identifier 7206**] WBCs and
many positively birefringent rhomboid crytals. This was thought
to be consistent with a CPPD pseudogout inflammatory arthritis.
As the patient's peripheral WBC count was rising at this time,
this was postulated as a contributor. The patient received
naproxen 250 mg twice a day for 7 days. At end of naproxen
course on [**2197-8-1**], the patient had full passive and active ROM
of both elbows without any pain.
<br>
TACHYCARDIA:
On presentation, pt initially tachy to 120's, which improved
somewhat with 1L NS. On exam, mucous membranes dry and clinical
patient appears somewhat volume down. CTA negative for PE, and
tachycardia could be related to fevers, leukocytosis and
underlying infection. EKG consistent with sinus tachycardia in
the MICU. Added low dose metroprolol [**2197-7-18**] (12.5mg PO TID) and
continued that dose through the hospitalization. The patient's
tachycardia eventually improved as his overall presentation
improved with decreasing WBC count, treatment of pneumonia,
treatment of pseudogout, and treatment of fungal UTI.
<br>
DEMENTIA / ALTERED MENTAL STATUS:
Pt with known dementia; however, his sister reported that at
baseline he was quite conversant and would frequently read
medical journals and the [**Location (un) 86**] Globe. He often clipped
newspaper articles to send to his sister in [**Name (NI) 7080**]. At
presentation he was oriented to person only, but was able to
answer simple questions and follow commands. B12, folic acid,
and TSH were all measured upon admission and found to be within
normal limites. A head CT on [**2197-7-17**] showed multiple lacunar
infarcts and diffuse cerebral atrophy. The patient became
agitated and confused while in the MICU and this was controlled
with Zyprexa initially. Upon transfer to the floor the patient
was extremely somnolent. Zyprexa was discontinued and the
patient gradually became more awake and aware. At time of
discharge he was oriented to himself, the name of the hospital,
the date, and his reason for admission.
<br>
DIARRHEA / C DIFF TESTING:
Patient developed soft liquid stools shortly after the
initiation of colchicine and continued to have soft stools up to
the day of discharge. He also struggled with fecal incontinence
and although this was most likely a function of the patient
being unable to use the bathroom without help. A rectal exam was
performed on [**7-28**] to check for evidence of fecal impaction and
the exam bore out that the patient had adequate rectal tone and
there was only liquid stool in the rectal vault. He was ruled
out for c. diff by three negative fecal c. diff toxin studies on
[**9-19**], and [**8-1**]. He was on oral vancomycin for 4 days for
empiric treatment of c. diff in setting of persistent
leukocytosis; however, this medication was discontinued on day
of discharge. Upon discharge, the patient's stool consistency
was still loose; however, he was requesting a toilet to
examining physicians, so he seemed capable of sensing his bowel
movement in his rectal vault and was capable of holding it in.
This issue should be followed and bowel regimen should be
adjusted as needed by outpatient physicians.
<br>
URINARY INCONTINENCE / UTI:
Patient was incontinent of urine during the hospitalization and
has an unknown baseline of urinary continence. This, like fecal
incontinence was thought to be a function of the patient's
inability to request help appropriately so that he could use a
urinal in bed. He deconditioned state left him unable to urinate
on his own. He did have a urine dipstick positive for WBCs as
well as a urine culture positive for greater than 10^5 colonies
of [**Last Name (LF) 23087**], [**First Name3 (LF) **] he was treated with a three-day course of
fluconazole prior to discharge. His urinary incontinence should
be followed to see if it resolves following discharge.
<br>
ELEVATED LFTs:
Elevated transaminases, alk phos and LDH on admission of unclear
etiology given normal [**Name (NI) 5283**] u/s with no evidence of cholecystitis.
Could possibly be related to underlying infection, fever, and
SIRS syndrome. AST > ALT, though patient with no known history
of heaty EtOH use. D2 of admission ALT>AST. This condition
resolved shortly after departure from the MICU and was not
further worked-up while the patient was on the floor.
<br>
THROMBOCYTOSIS:
Platelet count 310 on admission, consistent with previous
platelet counts. Known history essential thrombocytosis;
however, platelets were as high as 962 on [**2197-7-29**] presumably
due to systemic inflammatory status in setting of ongoing CPPD
psuedogout flare. At discharge the platelet count was and had
been trending down for three days. This level should be checked
a week after discharge to make sure that it doesn't begin to
rise again.
<br>
NUTRITION:
In the MICU, the patient initially failed two speech and swallow
evaluations in the setting of altered mental status and poor
respiratory function. He was NPO with tube feeds through NG tube
as sole nutrition upon transfer from the MICU. As his mental
status improved, he was initiated on a liquid diet and tolerated
that and was quickly advanced to a regular diet which he handled
with ease aside from needing assistance to feed himself due to
decreased arm strength from muscular deconditioning.
<br>
PPX:
While in hospital, the patient received SQ Heparin, Pneumoboots,
and a Bowel regimen
<br>
CODE STATUS:
FULL CODE (This was confirmed when [**Hospital 228**] health care proxy
(HCP) [**Name (NI) 28622**] [**Name (NI) 65305**] visited him from [**State 7080**]
<br>
COMMUNICATION:
Sister: [**Name (NI) 28622**] [**Name (NI) 65305**] [**Telephone/Fax (1) 74320**] is [**Hospital 228**] health care proxy
and came to visit the patient and was involved in discussion of
his care as well as his code status.


Medications on Admission:
Triamcinolone 0.1% cream topically prn itching
Tylenol 500mg po BID, ATC
Allopurinol 100mg po daily
ASA 325mg po daily
CaCarbonate 500 mg po tid
Docusate 100 mg po BId
Lasix 20 mg po daily on M, W, F
Hydrea 500 mg po every other day
Nasacort nasal spray to nostrils daily
Artificial tears, 3 drops to eyes daily
Multivitamin daily
Protonix 40 mg po daily
Simvasatatin 40 mg po daily
Vitamin D 800U po daily
Fleets, Dulcolax, MOM PRN constipation
Penicillin VK  250 mg 4x/day s/p dental procedure


Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Calcium Carbonate 1,250 mg/5 mL(500 mg) Suspension Sig: One
(1)  PO TID (3 times a day).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Therapeutic Multivitamin     Liquid Sig: One (1) Tablet PO
DAILY (Daily).
5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-7**]
Drops Ophthalmic DAILY (Daily).
6. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
9. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily).
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Outpatient Lab Work
please check hematocrit on [**2197-8-7**] and forward result to facility
physician.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 599**] of [**Location (un) 55**]

Discharge Diagnosis:
Pneumonia
Calcium Pryophosphate Deposition Disease
Altered Mental Status
Urinary Tract Infection
Dementia
Essential Thrombocytosis
hypertension
hypercholesterolemia


Discharge Condition:
stable, pneumonia resolving


Discharge Instructions:
Dear Dr. [**Known lastname 74321**],
You were admitted to the hospital to treat a pneumonia.  You
were given supplemental oxygen and treated with antibiotics.
Your pneumonia appears improved on a repeat CXR.
You were evaluated and noted to be at risk for aspiration and
were fed through a nasogastric tube.  The nasogastric tube was
eventually taken out and you were fed a regular diet.
You developed Calcium Pyrophosphate Deposition (CPPD) Disease
while in the hospital.  You were treated with an
anti-inflammatory and antibiotics, and your disease appears
improved.
You developed a urinary tract infection and were treated with an
anti-fungal.  You were tested for C. diff and it was negative.
.
Please make sure you take all of the medications we have listed.
.
we have made changes to your medications, we have stopped lasix
and allopurinol.
.
.
Please discuss with your PCP regarding starting Colchicine 0.6mg
PO BID for maintenance of CPPD remission.
.
Please keep the appointment listed below with your pulmonologist
to follow up on your pneumonia.
.
Please come back to the Emergency Room if you have fever,
chills, joint pain, shortness of breath, markedly altered mental
status, or chest pain.


Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Last Name (STitle) **]/DR [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2197-8-28**] 3:00



Completed by:[**2197-8-3**]
{'Pneumonitis due to inhalation of food or vomitus,Pulmonary collapse,Candidiasis of other urogenital sites,Unspecified pleural effusion,Pneumonia, organism unspecified,Urinary incontinence, unspecified,Gout, unspecified,Other disorders of calcium metabolism,Chondrocalcinosis, due to pyrophosphate crystals, upper arm,Other persistent mental disorders due to conditions classified elsewhere,Essential thrombocythemia,Hypoxemia'}


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: respiratory distress, hypoxia, tachycardia, fever, chills

PRESENT ILLNESS: Pt. is a 87 y/o with a history of Dementia, thrombocytosis on
hydroxyurea, TIA, seizure, and gout, who presented to [**Hospital1 18**] ED
from NH with hypoxia of 84% RA --> 97% 15L after being noted by
nursing staff to be gurgling as well as nasal congestion and
drainage early in the morning. Pt was given combivent nebs at
the NH and at the time was noted to be afebrile with temp of
98F, P 100, RR 20, BP 136/68. Later in the afternoon, the
patient was noted to have some difficulty breathing, and at that
time was found to be 84% on RA.
.
On arrival to ER pt was found to have TMax 102.2, Tachy to
120's, SBP 130's, and initially 100% on non-rebreather.  Pt was
able to be weaned down to a 50% FM (98%), and HR improved to
100's after 1L IV fluids. CXR: showed a possible LLL pna, and a
chest CTA was negative for PE, but did show a L sided
consolidation.  Pt recieved Levaquin, Cefepime, Vanco while in
the ED and arrived to the MICU satting 96% on 5L NC.
.
Of note, the patient had been recieving Penicillin VK 250mg po
QID since [**7-6**] following a recent dental procedure.

MEDICAL HISTORY: 1.) Dementia
2.) Essential thrombocytosis
3.) Gout
4.) Anemia
5.) TIA
6.) Seizure, previously on Trileptal now d/c'd

MEDICATION ON ADMISSION: Triamcinolone 0.1% cream topically prn itching
Tylenol 500mg po BID, ATC
Allopurinol 100mg po daily
ASA 325mg po daily
CaCarbonate 500 mg po tid
Docusate 100 mg po BId
Lasix 20 mg po daily on M, W, F
Hydrea 500 mg po every other day
Nasacort nasal spray to nostrils daily
Artificial tears, 3 drops to eyes daily
Multivitamin daily
Protonix 40 mg po daily
Simvasatatin 40 mg po daily
Vitamin D 800U po daily
Fleets, Dulcolax, MOM PRN constipation
Penicillin VK  250 mg 4x/day s/p dental procedure

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Tmax: 37.6 ??????C (99.6 ??????F)
Tcurrent: 37.6 ??????C (99.6 ??????F)
HR: 111 (111 - 116) bpm
BP: 156/85(104) {149/58(81) - 156/85(104)} mmHg
RR: 21 (16 - 21) insp/min
SpO2: 97%
Heart rhythm: ST (Sinus Tachycardia)
Height: 51 Inch

FAMILY HISTORY: Reviewed past records and found to be non-contributory

SOCIAL HISTORY: Occupation: Retired urologist at [**Hospital6 **] Hosp
Drugs: Unknown
Tobacco: Unknown
Alcohol: Unknown
Other: NH resident from [**Hospital1 599**] of [**Location (un) 55**] 

### Response:
{'Pneumonitis due to inhalation of food or vomitus,Pulmonary collapse,Candidiasis of other urogenital sites,Unspecified pleural effusion,Pneumonia, organism unspecified,Urinary incontinence, unspecified,Gout, unspecified,Other disorders of calcium metabolism,Chondrocalcinosis, due to pyrophosphate crystals, upper arm,Other persistent mental disorders due to conditions classified elsewhere,Essential thrombocythemia,Hypoxemia'}
