CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 55-year-old
woman with the past medical history of schizoaffective
disease, atypical Parkinsonism, most likely secondary to
antipsychotic medications, hypothyroidism, lung nodule,
chronic obstructive pulmonary disease, torticollis and
urinary retention.  She presented to the ED from her [**Hospital3 12272**], where she was reported to be confused and short of
breath.  In the ED, she was 80% on room air, nonrebreather.
Saturations were 92%.  The ABG was 7.28, 59, 80, 29.  She had
a temperature of 101.4.  The blood pressure was 96/50, pulse
81, respiratory rate 24.  She was intubated for hypercarbic
respiratory failure on the 12th.  She went to the emergency
department.  She had Gram-negative rods greater than 100,000
in her urine. however, it was greater than two-colony
morphologies, possibly representing contamination.

MEDICAL HISTORY: 1.  Atypical Parkinsonism.  I spoke to the patient's outside
neurologist, Dr. [**Last Name (STitle) 98503**] at [**Hospital1 2025**], who said that the
patient had atypical features of Parkinsonism, most likely
secondary to neuroleptic medications, that the patient had
received for treatment of her schizoaffective disease.  The
patient has right torticollis and contractures.
Dr.  [**Last Name (STitle) 98503**] reported that the patient had been tried
on a number of antiParkinsonism medicines with no resolution
of her Parkinsonism or torticollis.  She had been tried on
Botox injections with no success.  He suggested Ativan and/or
Benadryl for relief of her discomfort and muscular pain, but
suggesting that due to the longstanding nature of the
torticollis for approximately three years, that the vertebra
most likely have been permanently damaged by the torticollis.
2.  Chronic obstructive pulmonary disease.
3.  Emphysema.
4.  Hypothyroidism.
5.  Osteoporosis.
6.  Failure to thrive.
7.  Urinary retention status post suprapubic catheter.

MEDICATION ON ADMISSION: 1.  Depakote 250 mg PO q.a.m.; 500 mg PO q.p.m.
2.  Tylenol #3 q.i.d.p.r.n.
3.  Klonopin 0.5 mg q.a.m.
4.  Effexor sustained release 37.5 mg q.a.m.
5.  Levoxyl 50 mg q.a.m.
6.  Zanaflex 2 mg t.i.d.
7.  Prilosec 20 mg b.i.d.
8.  Atrovent MDI, albuterol MDI.

ALLERGIES: The patient has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Not obtainable.  Her sister is [**Name (NI) 4134**]
[**Name (NI) 35914**].  Phone #:  [**Telephone/Fax (1) 98504**].  The PCP is [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
[**Telephone/Fax (1) 64118**].

SOCIAL HISTORY: The patient came from [**Hospital3 **]
[**Hospital3 **].  Her sister, [**Name (NI) 4134**] [**Name (NI) 35914**], was spoken to on many
occasions.  Phone #:  [**Telephone/Fax (1) 98504**].  PCP:  [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D.
Phone #:  [**Telephone/Fax (1) 64118**] at [**Hospital1 2025**].
Urinary tract infection, site not specified,Acute respiratory failure,Methicillin susceptible pneumonia due to Staphylococcus aureus,Schizoaffective disorder, unspecified,Torticollis, unspecified,Mixed acid-base balance disorder,Other emphysema,Secondary parkinsonism,Other antipsychotics, neuroleptics, and major tranquilizers causing adverse effects in therapeutic use
Urin tract infection NOS,Acute respiratry failure,Meth sus pneum d/t Staph,Schizoaffective dis NOS,Torticollis NOS,Mixed acid-base bal dis,Emphysema NEC,Secondary parkinsonism,Adv eff antipsychotc NEC
Admission Date:  [**2175-6-27**]       Discharge Date:  [**2175-7-7**]

Date of Birth:   [**2120-1-16**]       Sex:  F

Service:

HISTORY OF THE PRESENT ILLNESS:  The patient is a 55-year-old
woman with the past medical history of schizoaffective
disease, atypical Parkinsonism, most likely secondary to
antipsychotic medications, hypothyroidism, lung nodule,
chronic obstructive pulmonary disease, torticollis and
urinary retention.  She presented to the ED from her [**Hospital3 12272**], where she was reported to be confused and short of
breath.  In the ED, she was 80% on room air, nonrebreather.
Saturations were 92%.  The ABG was 7.28, 59, 80, 29.  She had
a temperature of 101.4.  The blood pressure was 96/50, pulse
81, respiratory rate 24.  She was intubated for hypercarbic
respiratory failure on the 12th.  She went to the emergency
department.  She had Gram-negative rods greater than 100,000
in her urine. however, it was greater than two-colony
morphologies, possibly representing contamination.

The patient was extubated on the [**10-27**] with good
result.  She had a sputum culture, which showed
Staphylococcus aureus Methicillin sensitive and sensitive to
Levaquin in her sputum.  The patient was treated initially
with Ampicillin and Levaquin in the Intensive Care Unit.  She
had two episodes of low blood pressure in 60s that responded
to IV fluids.  She was also given Hydrocort empirically.  The
Cortisol level was checked and it was 33.  She presented
initially with the anion gap of 20, normal on the second day
of hospital stay.

The patient has had multiple admission to [**Hospital6 2121**], [**9-/2174**], [**2175-1-13**], for failure to
thrive, multiple urinary tract infections.  The patient had a
suprapubic catheter placed and had another urinary tract
infection two weeks ago.  The patient has improved physically
in the unit.  But, according to the family members, the
patient had decreased level of functioning in that she had
been prior to admission.

PAST MEDICAL HISTORY:
1.  Atypical Parkinsonism.  I spoke to the patient's outside
neurologist, Dr. [**Last Name (STitle) 98503**] at [**Hospital1 2025**], who said that the
patient had atypical features of Parkinsonism, most likely
secondary to neuroleptic medications, that the patient had
received for treatment of her schizoaffective disease.  The
patient has right torticollis and contractures.
Dr.  [**Last Name (STitle) 98503**] reported that the patient had been tried
on a number of antiParkinsonism medicines with no resolution
of her Parkinsonism or torticollis.  She had been tried on
Botox injections with no success.  He suggested Ativan and/or
Benadryl for relief of her discomfort and muscular pain, but
suggesting that due to the longstanding nature of the
torticollis for approximately three years, that the vertebra
most likely have been permanently damaged by the torticollis.
2.  Chronic obstructive pulmonary disease.
3.  Emphysema.
4.  Hypothyroidism.
5.  Osteoporosis.
6.  Failure to thrive.
7.  Urinary retention status post suprapubic catheter.

The patient is to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], primary care
physician at [**Name9 (PRE) 2025**].  Dr. [**Last Name (STitle) **] had said that the patient had
neurogenic-like bladder and that she was unable to straight
catheterize herself due to her movement disorder and the
decision was between a Foley catheter and a suprapubic
catheter and the suprapubic catheter would be more
comfortable for the patient and less of an infection risk.

MEDICATIONS PRIOR TO ADMISSION:
1.  Effexor 32.5 mg q.a.m.
2.  Klonopin 0.5 mg q.h.s.
3.  Depakote 250/500.
4.  Levoxyl 50 q.a.m.
5.  Prilosec 20 b.i.d.
6.  Tylenol #3 q.d. for pain.
7.  Zanaflex 2 mg q.3h.
8.  Atrovent MDI.
9.  Albuterol MDI.

SOCIAL HISTORY:  The patient came from [**Hospital3 **]
[**Hospital3 **].  Her sister, [**Name (NI) 4134**] [**Name (NI) 35914**], was spoken to on many
occasions.  Phone #:  [**Telephone/Fax (1) 98504**].  PCP:  [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D.
Phone #:  [**Telephone/Fax (1) 64118**] at [**Hospital1 2025**].

PHYSICAL EXAMINATION:  Examination at the time of transfer to
the floor revealed the following:  Blood pressure 100/60,
pulse 78, oxygen saturation 98% on two liters.  GENERAL:  The
patient was lying in bed, curled with contractions.  HEENT:
The patient had right torticollis using neck accessory
muscles to assist breathing.  The patient initially had a
left subclavian line that was pulled two days after being on
the floor.  The patient had lung examination clear to
auscultation, bilaterally regular rate and rhythm, no
murmurs, rubs, or gallops.  The patient did have some
scattered wheezing, positive bowel sounds, soft, suprapubic
catheter site was clean, dry, and intact on transfer to the
floor.  EXTREMITIES:  Mild 1+ edema to the ankles.
Peripheral pulses intact.  NEUROLOGICAL:  The patient was
awake, alert, and in depressed mood.  The patient had
shuffling gait, when observed with the walker.  The patient
had cogwheel rigidity and right torticollis.

LABORATORY DATA:  Labs on admission revealed the following:
White blood cell count 17.8, hemoglobin 12.6, hematocrit
37.2, 249,000 platelet count, INR 1.6, lactate 1.3.  Sodium
144, potassium 4.1, chloride 101, bicarbonate 23, BUN 9,
creatinine 0.6, calcium 9.3, magnesium 1.6, phosphorus 3.1,
urinalysis cloudy, 11 to 20 red blood cells, 6 to 7 white
blood cells.  Serum toxicology was negative.  The patient had
a head CAT scan on admission, which showed no acute
intracranial pathology.  The patient had a chest x-ray on
[**6-27**], showing no pneumonia, no CHF, increased
interstitial markings, right middle and lower lobes.  As
mentioned before, the patient had Gram-negative rod in the
urine, greater than 100,000 colony-forming units, however,
two different specimen types.  The patient had coagulase
positive, Staphylococcus aureus in sputum, sensitive to
Levaquin and oxacillin.  Blood cultures:  No growth from
final.  The patient also had rare amount of Aspergillus
fumitagus on sputum culture, had rare growth.  The gram stain
from that culture showed greater than 25 PMNs, 4+
Gram-positive cocci in pairs and clusters, which were the
Staphylococcus aureus and 2+ Gram-negative rods.  The patient
had elevated CKs to 475 and 585 with negative troponins and
negative MBs both times.

The patient had a CT scan on the [**7-2**] to evaluate
the possibility of Aspergillosis.  This examination showed no
evidence of Aspergillosis or AVPA.  There was a 1 cm left
apical nodule, nonspecific apical and right middle lobe
scarring.  It was suggested that these studies be followed up
with a CAT scan in two to three months as a new process
cannot be excluded at the present time.  The patient had
bilateral pleural effusions, atelectasis, and mild emphysema.

The patient is a 55-year-old woman with the past medical
history of atypical Parkinsonism, schizoaffective disease,
extrapyramidal side effects, torticollis, multiple UTIs,
failure to thrive, suprapubic catheter placed. Chronic
obstructive pulmonary disease, who presented to the ED with
acute respiratory distress.  The patient was found to have
gram-negative rod UTI and Staphylococcus positive sputum.
The patient was extubated and now is on the floor doing well.

HOSPITAL COURSE:  (by system)

#1.  The patient had both the Staphylococcus aureus and
urinary bacteria be covered by Levaquin.  The patient was on
Levaquin 500 mg PO q.d, beginning on [**6-28**].  The
patient will finish a two-week course on [**7-12**].  The
patient is doing well, afebrile.  White blood cell count has
decreased to 10.5 on the [**7-7**].  The Aspergillosis
was most likely a colonizing organism, discovered on routine
sputum examination and has no pathological significance.

#2.  PSYCHIATRY:  The patient is being followed by the
Department of Psychiatry.  The patient was started on Effexor
75 mg q.d.  They suggested adding 1.25 Zyprexa q.h.s. for
sleep and history of psychosis in the past.  The patient is
also on Depakote 250 mg PO q.a.m. and 500 mg PO q.a.m.;
Klonopin 0.5 mg PO b.i.d.; Zyprexa 1.25 mg q.h.s. will be
stopped on the 23rd, for fear they may be discontinued even
at such a low dose contributing to the patient's torticollis
that she has been experiencing.

#3.  NEUROLOGICAL:  Parkinson torticollis rigidity.  The
patient is on Zanaflex 2 mg t.i.d.  The patient also was
started on Benadryl 25 mg t.i.d. and Ativan 0.5 mg to 1 mg
p.r.n.q.4h. for torticollis muscle rigidity.  The patient had
reported some improvement on this regimen.

#4.  ENDOCRINE:  The patient is on Levoxyl 50 mcg PO q.d. for
hypothyroidism.  TSH was checked; it was 0.19.  Free T4 was
1.2.

#5.  GENITOURINARY:  The patient has suprapubic catheter
placed at an outside institution.  During her stay here a
[**Hospital1 69**] the catheter became
dislodged and the nursing staff reports that the patient
pulled out the catheter.  The patient denies this.  The
Department of Urology was contact[**Name (NI) **] and the catheter is to be
replaced on the afternoon of the [**7-7**].

#6.  PROPHYLAXIS:  The patient was on Protonix 40 mg PO q.d.,
Tylenol, heparin subcutaneously 5000 q. 12.  The Department
of Physical Therapy is working with the patient.  The patient
is on aspiration precautions, solids are to be chopped.
Medications should be given with applesauce.  The patient has
a swallowing study on the [**6-30**], which was not
positive for aspiration, however, it did show that the
patient had quick transition from oropharynx to esophagus and
the recommendations were to chop her solids and to give her
medications in applesauce and to have the patient eat all
liquids and solids in an upright position.

CURRENT PLAN PER DISPOSITION:  The patient is being evaluated
for [**Hospital 4820**] rehabilitation skilled nursing facility.  This
option was discussed with the patient and the patient's
sister.  The patient initially had fears of being locked away
and complained that she did not want to go to a nursing home.
After conversations and explaining to the patient the nature
of skilled care she had received there, including physical
therapy and qualified nursing care, the patient agreed to a
long-term skill nursing facility with the hope that she would
be able to increase her function level to return to [**Hospital3 12272**].  The patient is also being screened by her prior
[**Hospital3 **] institution.

This covers the hospital course up to [**2175-7-7**].  The
rest of the charts should be dictated by the following
physician:  [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].




                            [**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D.
[**MD Number(1) 7855**]

Dictated By:[**Last Name (NamePattern1) 1659**]
MEDQUIST36

D:  [**2175-7-7**]  14:28
T:  [**2175-7-7**]  14:52
JOB#:  [**Job Number 98505**]


Name:  [**Known lastname **], [**Known firstname 540**]                         Unit No:  [**Numeric Identifier 15725**]

Admission Date:  [**2175-6-26**]     Discharge Date:  [**2175-7-14**]

Date of Birth:   [**2120-1-16**]     Sex:  F

Service:

1.  Endocrine.  Closentropin simulation test was performed
which showed no evidence of adrenal insufficiency.  60 minute
level was 30.  T3 9.1, T4 9.8, if blood pressures continue to
be low consider starting Florinef 0.1 mg p.o. q day.
Levothyroxine was increased to 75 mcg p.o. q day and a repeat
TSH should be checked in six weeks.

2.  Neurology.   The patient was seen by Neurology again on
[**2175-7-13**] who recommended beginning Mirapex 0.125 mg p.o. three
times a day.  Attempt was made to contact the patient's
primary neurologist, Dr. [**Last Name (STitle) **], he was out of town and the
team felt he would defer to Dr. [**Last Name (STitle) **] on that medication
change.  His first available appointment is [**2175-7-27**] at 4 PM
at [**Hospital3 11272**] [**Hospital3 **] but his secretary will call when he
is back from vacation to squeeze her in for an earlier
appointment.

3.  Psychiatry.  The patient was seen by Psychiatry on
[**2175-7-13**] who recommended increasing Effexor dose.

DISCHARGE MEDICATIONS:
1.  Magnesium oxide 800 mg p.o. q day.
2.  Protonix 40 mg p.o. q day.
3.  Combivent MDI with spacer two puffs b.i.d.
4.  Heparin 5000 units subcutaneously b.i.d.
5.  Depakote 250 mg p.o. q AM and 500 mg p.o. q PM.
6.  Klonopin 0.5 mg p.o. b.i.d.
7.  Effexor 100 mg p.o. q day.
8.  Levoxyl 75 mcg p.o. q day.
9.  Zanaflex 1 mg p.o. three times a day.
10. Atrovent and Albuterol nebs q 4 to 6 hours p.r.n.
11. Percocet one to two tabs p.o. q 4 to 6 hours p.r.n.
12. Milk of Magnesia 50 cc's p.o. q 4 hours p.r.n.
13. Tylenol 325 to 650 mg p.o. q 4 to 6 hours p.r.n.
14. Maalox 30 cc's p.o. q 6 hours p.r.n. nausea.
15. Nicotine patch 7 mg topical q day.

DISCHARGE DIAGNOSIS:
1.  Pneumonia.
2.  Urosepsis.

CONDITION ON DISCHARGE:  Stable.

DISCHARGE:  To [**Hospital 15726**].

FOLLOW-UP:  [**Hospital 3194**] of [**Doctor Last Name **] is going to organize psychiatrist
see patient.  Neurology, Dr. [**Last Name (STitle) 15727**] will call with
earlier appointment . Urology was called and on vacation
until next week therefore, I, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**First Name3 (LF) **] call to
schedule appointment and will contact [**Name (NI) 3194**] of [**Name (NI) **] with the
appointment.  The urology number is [**Telephone/Fax (1) 15728**].






                          [**Name6 (MD) **] [**Last Name (NamePattern4) 424**], M.D.  [**MD Number(1) 425**]

Dictated By:[**Last Name (NamePattern4) 15729**]

MEDQUIST36

D:  [**2175-7-14**]  16:20
T:  [**2175-7-20**]  07:50
JOB#:  [**Job Number **]


Admission Date:  [**2175-6-27**]       Discharge Date:  [**2175-7-14**]

Date of Birth:   [**2120-1-16**]       Sex:  F

Service:  MEDICINE, [**Company 191**].

HISTORY OF THE PRESENT ILLNESS:  The patient is a 55-year-old
female from [**Hospital3 11148**] [**Hospital3 **] who presents with
shortness of breath.  She has extended medical history and
she has been in the rehabilitation facility for failure to
thrive.  Subsequently, she was discharged to [**Hospital3 **]
facility.  While at assisted-living facility she had an
episode of shortness of breath and breathing difficulties.
She was brought to the emergency [**Hospital1 **] for evaluation.  While
in the emergency department she had an oxygen saturations of
80% on room air and then 97% on 100% nonrebreather.  Of note:
On the ambulance call-in sheet, the patient was also "not
herself," as reported by the assisted-living facility.  There
was a question of mental status change.  ABG showed pH of
7.28, pCO2 of 59, and pO2 80.  She was intubated for
respiratory depression.

PAST MEDICAL HISTORY:
1.  Schizoaffective disease.
2.  Chronic obstructive pulmonary disease and emphysema.
3.  Hypothyroidism.
4.  Urinary retention for which she received suprapubic
catheterization.
5.  Psychosis.
6.  Parkinson's disease secondary to neuroleptics.
7.  Stable lung nodules.
8.  Osteoporosis.
9.  Torticollis.

ALLERGIES:  The patient has no known drug allergies.

MEDICATIONS ON ADMISSION:
1.  Depakote 250 mg PO q.a.m.; 500 mg PO q.p.m.
2.  Tylenol #3 q.i.d.p.r.n.
3.  Klonopin 0.5 mg q.a.m.
4.  Effexor sustained release 37.5 mg q.a.m.
5.  Levoxyl 50 mg q.a.m.
6.  Zanaflex 2 mg t.i.d.
7.  Prilosec 20 mg b.i.d.
8.  Atrovent MDI, albuterol MDI.

SOCIAL HISTORY:  The patient is a smoker of 30 pack years.

FAMILY HISTORY:  Not obtainable.  Her sister is [**Name (NI) 4134**]
[**Name (NI) 35914**].  Phone #:  [**Telephone/Fax (1) 98504**].  The PCP is [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
[**Telephone/Fax (1) 64118**].

PHYSICAL EXAMINATION:  Examination revealed the following:
Vital signs:  101.4, heart rate 87, blood pressure 110/47,
MAP 68, respiratory rate 14, FIO2 100%.  Ventilation at tidal
volume of 500 and respiratory rate of 14.  FIO2 of 100%.
GENERAL:  She is a thin, elderly-appearing woman, curved in
bed.  HEENT:  Torticollis to the right.  Normocephalic,
atraumatic, pupils equal and reactive to light.  Light
lateral deviation of the right eye, does not follow finger,
intubated.  NECK:  No jugulovenous distention.  CHEST:  Bowel
sounds left greater than right.  Inspiratory rhonchi, right
greater than left.  CARDIOVASCULAR:  S1 and S2, normal,
regular rate and rhythm.  ABDOMEN  Soft, positive bowel
sounds, nondistended, nontender.  Suprapubic catheter site
clean.  EXTREMITIES:  No edema, 1+ peripheral pulses.
NEUROLOGICAL:  Blinks to command, minimally responsive,
spontaneously.  Bilateral fine hand tremor.

LABORATORY DATA:  Laboratory data revealed the following:
White blood count 17.3, hematocrit 37.2, platelet count
249,000, 85% polys, 13% lymphs, 2% monocytes.  PT 15.4, INR
1.6, PTT 29.9.  The Chem 7 revealed sodium 144, potassium
4.1, chloride 105, bicarbonate 23, BUN 9, creatinine 0.6,
glucose 119, calcium 9.3, magnesium 1.6, phosphorus 5.1.  The
serum toxicology was negative.  Urinalysis showed positive
nitrites, moderate leukocyte esterase, many bacteria, 6 to 10
white blood cells, 11 to 20 red blood cells.  The gas, when
intubated was 7.3 pH, pCO2 52, with a pO2 of 448.  The blood
cultures times two and urine cultures, taken at that time,
revealed the following:  Chest x-ray in the ED:  The
endotracheal tube 6.5 cm above the carina, no pneumonia,
increased right hemidiaphragm and emphysema and the head CT
was negative.  The EKG showed normal sinus tachycardia 104
with axis of about 90% with the baseline, no ST and T-wave
changes.

HOSPITAL COURSE:  In the ED, on [**6-27**], the patient's
blood pressure continued to trend downward despite IV fluid
hydration and boluses.  Systolic blood pressure was 65/38.
Discussion with the family revealed that the patient did not
want resuscitation and the sister [**Name (NI) **] did not want any
invasive procedures performed including central lines and the
IJ subclavian and femoral.  She also did not chest
compression or electrical shock should there be a cardiac
event.  After extensive discussion again with the family, it
was decided to make her do not resuscitate and focus on
comfort.

On [**2175-6-27**], secondary to the hypotension, Hydrocort was
started and no central access or pressors were begun due to
the family wishes.  The labs at that time showed a white
blood cell count of 18.1, hematocrit 29.5.  The patient was
febrile with an increased white blood count and started on
Ampicillin and Levofloxacin for positive urinalysis until
sensitivities came back.  On [**6-28**] the urine showed
Gram-negative rods.  Blood culture showed no growth.  The
patient was extubated on [**6-28**].  On that same day she
was afebrile.  White cell count was still elevated to 17.5.
Urine culture on [**2175-6-26**] showed a Gram-negative rods of two
morphologies with greater than 100,000 organisms, however, it
showed contamination with mixed skin and genital flora and
the clinical significance was uncertain.

Blood culture from [**2175-6-26**] was negative.  Blood culture
times two from [**2175-6-26**] was negative.  On [**2175-6-27**] the
sputum grew out moderate growth of Staphylococcus aureus
coagulase positive, Methicillin-sensitive and rate growth of
Aspergillus fumigatus.

The patient was originally started on Vancomycin for the
Staphylococcus aureus pneumonia until sensitivities came
back.  She was also continued on Levaquin.  It was felt that
the urosepsis lead to hypotension and that the Staphylococcus
was secondary to intubation.  The patient was transferred to
the floor to the [**Company 191**] team.

The patient was seen by the Psychiatric Department on
[**2175-6-29**], who made some suggestions about her management.
On [**2175-6-29**], the Staphylococcus aureus was sensitive to
Oxacillin so the Vancomycin was discontinued and she was
started on Oxicillin one gram q.8h.

She had a swallowing study on the 14th because of the concern
about a swallowing risk.  She was continued on Depakote,
Effexor, and Klonopin.  She did not require Haldol as she was
not agitated.

Although the patient had aspergillus in her sputum she did
not immunocompromise, no neutropenia, no known cavity disease
in the lung.  However, chest CT was ordered to further
assess.  CT of the abdomen done on [**2175-7-2**] showed 1 cm left
apical nodule and nonspecific left apical and right middle
lobe scarring.  There was no evidence of ABPA or an
aspergilloma.  The absence of neutropenia, these findings are
unlikely to represent invasive aspergillosis. Recommend
follow up in two to three months as a neoplastic process
cannot be excluded.  Bilateral pleural effusions and
atelectasis.  Mild emphysema.

Infectious Disease was consulted and felt that the positive
aspergillus in the sputum is likely colonizer in the setting
of pre-existing lung disease and emphysema, so there is no
need to start treatment yet for Aspergillosis now.
Infectious Disease also recommended a total of 10 to 14 day
course of Levaquin.  On a note by Infectious Disease date
[**7-5**], they state that due to the patient and the
family's wishes, the patient is not to have any further
diagnostic procedures and will not pursue investigation of
left apical nodule any further.

The Department of Neurology was contact[**Name (NI) **] on [**7-5**],
regarding placement of the suprapubic catheter.  However,
they eventually declined to see the patient as she is to get
services at [**Hospital3 **] and they stress that she
return there to continue with the Foley for now.  The
patient's neurologist at the [**Hospital3 **],
Dr.  [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 98503**], [**Telephone/Fax (1) 98506**] called regarding the
patient's movement disorder and torticollis.  Neurology
suggested Benadryl 25 t.i.d. for torticollis.  The patient
reported failing Botox injections.

On [**2175-7-10**] the urine cultures were growing yeast.  This is
after a 14-day course of Levaquin.  The patient was
complaining of burning in her urine and so she was started on
Mycelex cream times three days.  The patient was also having
some episode of hypotension noticeably the systolic blood
pressure came down to the 70s overnight.  She was treated
with fluid boluses, which did not lead to much improvement.
Repeat blood cultures were sent, including fungal cultures,
which show no growth to date.  She had a cardiac
echocardiogram on [**2175-7-12**], which showed an ejection
fraction of greater than 60% and no valvular abnormalities.
On the 28th, she complained of shortness of breath and chest
pain on inspiration.  She had a PT angiogram done, which
showed no evidence of PE, moderate-to-severe emphysema, line
opacities consistent with scarring and they commented again
on the right upper lobe nodule.  The patient, on the 29th,
was no longer complaining of shortness of breath.  The blood
pressure was taken with the pediatric cuff and it was still
low in the 80s.  The TSH returned.  The cortisol was 9.4,
taken at 8:40 in the morning.  Therefore, it was decided that
it was pertinent to do a Cortrosyn stimulation test in the
morning.  T3 and T4 were checked.




                            [**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D.  [**MD Number(1) 3475**]

Dictated By:[**Last Name (NamePattern1) 2918**]
MEDQUIST36

D:  [**2175-7-13**]  13:45
T:  [**2175-7-13**]  14:13
JOB#:  [**Job Number 98507**]


Name:  [**Known lastname **], [**Known firstname 540**]                         Unit No:  [**Numeric Identifier 15725**]

Admission Date:  [**2175-6-26**]     Discharge Date:  [**2175-7-14**]

Date of Birth:   [**2120-1-16**]     Sex:  F

Service:

ADDENDUM:

The patient is to follow-up with urologist on [**9-21**], at
11:30 a.m. at the [**Hospital6 2241**].  The phone
number there is [**Telephone/Fax (1) 15741**].  This is for a suprapubic
catheter placement and the patient needs a referral from her
managed care for this patient with Dr. [**Last Name (STitle) **].






                          [**Name6 (MD) **] [**Last Name (NamePattern4) 424**], M.D.  [**MD Number(1) 425**]

Dictated By:[**Last Name (NamePattern1) 1464**]

MEDQUIST36

D:  [**2175-7-26**]  14:10
T:  [**2175-7-26**]  14:33
JOB#:  [**Job Number 15742**]
{'Urinary tract infection, site not specified,Acute respiratory failure,Methicillin susceptible pneumonia due to Staphylococcus aureus,Schizoaffective disorder, unspecified,Torticollis, unspecified,Mixed acid-base balance disorder,Other emphysema,Secondary parkinsonism,Other antipsychotics, neuroleptics, and major tranquilizers 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: 

PRESENT ILLNESS: The patient is a 55-year-old
woman with the past medical history of schizoaffective
disease, atypical Parkinsonism, most likely secondary to
antipsychotic medications, hypothyroidism, lung nodule,
chronic obstructive pulmonary disease, torticollis and
urinary retention.  She presented to the ED from her [**Hospital3 12272**], where she was reported to be confused and short of
breath.  In the ED, she was 80% on room air, nonrebreather.
Saturations were 92%.  The ABG was 7.28, 59, 80, 29.  She had
a temperature of 101.4.  The blood pressure was 96/50, pulse
81, respiratory rate 24.  She was intubated for hypercarbic
respiratory failure on the 12th.  She went to the emergency
department.  She had Gram-negative rods greater than 100,000
in her urine. however, it was greater than two-colony
morphologies, possibly representing contamination.

MEDICAL HISTORY: 1.  Atypical Parkinsonism.  I spoke to the patient's outside
neurologist, Dr. [**Last Name (STitle) 98503**] at [**Hospital1 2025**], who said that the
patient had atypical features of Parkinsonism, most likely
secondary to neuroleptic medications, that the patient had
received for treatment of her schizoaffective disease.  The
patient has right torticollis and contractures.
Dr.  [**Last Name (STitle) 98503**] reported that the patient had been tried
on a number of antiParkinsonism medicines with no resolution
of her Parkinsonism or torticollis.  She had been tried on
Botox injections with no success.  He suggested Ativan and/or
Benadryl for relief of her discomfort and muscular pain, but
suggesting that due to the longstanding nature of the
torticollis for approximately three years, that the vertebra
most likely have been permanently damaged by the torticollis.
2.  Chronic obstructive pulmonary disease.
3.  Emphysema.
4.  Hypothyroidism.
5.  Osteoporosis.
6.  Failure to thrive.
7.  Urinary retention status post suprapubic catheter.

MEDICATION ON ADMISSION: 1.  Depakote 250 mg PO q.a.m.; 500 mg PO q.p.m.
2.  Tylenol #3 q.i.d.p.r.n.
3.  Klonopin 0.5 mg q.a.m.
4.  Effexor sustained release 37.5 mg q.a.m.
5.  Levoxyl 50 mg q.a.m.
6.  Zanaflex 2 mg t.i.d.
7.  Prilosec 20 mg b.i.d.
8.  Atrovent MDI, albuterol MDI.

ALLERGIES: The patient has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Not obtainable.  Her sister is [**Name (NI) 4134**]
[**Name (NI) 35914**].  Phone #:  [**Telephone/Fax (1) 98504**].  The PCP is [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
[**Telephone/Fax (1) 64118**].

SOCIAL HISTORY: The patient came from [**Hospital3 **]
[**Hospital3 **].  Her sister, [**Name (NI) 4134**] [**Name (NI) 35914**], was spoken to on many
occasions.  Phone #:  [**Telephone/Fax (1) 98504**].  PCP:  [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D.
Phone #:  [**Telephone/Fax (1) 64118**] at [**Hospital1 2025**]. 

### Response:
{'Urinary tract infection, site not specified,Acute respiratory failure,Methicillin susceptible pneumonia due to Staphylococcus aureus,Schizoaffective disorder, unspecified,Torticollis, unspecified,Mixed acid-base balance disorder,Other emphysema,Secondary parkinsonism,Other antipsychotics, neuroleptics, and major tranquilizers causing adverse effects in therapeutic use'}
