CHIEF COMPLAINT: Altered mental status

PRESENT ILLNESS: Patient with recent illness and admission to the [**Hospital1 18**] MICU for
pneumosepsis, discharged home on [**2168-7-12**] to rehab at [**Hospital 1263**]
Hospital on vanc/cefepime with vanc scheduled to complete on
[**7-21**]. The patient had initially been doing well at rehab, and
according to her daughter, coming to terms with her current
rehab arrangement and shortness of breath. She was unfortunately
diagnosed with c.diff colitis on [**2168-7-14**] in the setting of
increased stool output and was started on oral vancomycin.
.
2 days ago on [**7-19**] the patient was noted to have acute worsening
of her mentation following feeding, which was normally alert and
verbal to be found complaining of shortness of breath, despite
having normal oxygen saturations - she was found to have
hyperkalemia, hypocalcemia, and anemia - she was treated for all
three including transfusion of 2 units of PRBCs and subsequently
underwent suctioning with transient improvement in her mental
status. She had no interval increase in sputum production.
.
The next day, [**7-20**], the patient was noted to have similar
symptoms but even worsening mental status requiring from the
rehab area to the intensive care unit as she had a diminished
mental status and was being ventilated with a bag-valve mask.
She was placed back on a vent on assist control. She was found
to be somnolent on arrival with a tongue bite and the
differential included post-ictal state although no seizure
activity was noted, this was confirmed with an EEG which showed
slowing but no epileptiform activity. She reportedly had a
normal head CT, and a CT of the chest which revealed left lower
lobe collapse which has been frequently noted on previous
imaging studies. Additionally, she was noted to have [**Last Name (un) **] and a
significantly elevated vancomycin level - this was presumably
held, but not clearly noted in the chart, there was an
appreciable decline in the vancomycin trough between [**7-20**] to
[**7-21**] from 50 to 30.
.
She was seen and evaluated by neurology who recommended volume
expansion for possible dysautonomic crisis. She was also started
on an ativan drip at 0.5mg per hour which was discontinued
around 8am on [**7-21**]. This significantly improved her rigidity,
but then her mental status did not improve and her spasticity
returned gradually over several hours. Due to lack of clinical
improvement and family request, the patient was transferred back
to [**Hospital1 18**] MICU.
.
On arrival to the MICU, the patient was noted to be completely
unresponsive to verbal and painful stimuli, occassionally
grimacing to suction, but had no purposeful movements. She was
hemodynamically stable, but vital signs were notable for a
bradycardia in the low 50s, BP was elevated, but not markedly
so. Labs were drawn, a CXR was ordered, and a neurology consult
was ordered who initially recommended MRI/MRA of the head and
neck.
.
Review of systems:
Unable to obtain due to altered mental status of the patient;
the family denies any recent history of fever, chills, or
grossly bloody stools.

MEDICAL HISTORY: C5 [**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 39850**]
Chronic respiratory failure with trach
s/p C6 corpectomy and ACDF C7T1 c allograft and plate c/b CSF
leak
Stage II pressure ulcers
MRSA/Hflu Ventilator-associated Pneumonia
Left upper extremity Deep vein thrombosis (DVT)
Neurogenic bowel
Neurogenic bladder
h/o Hypertension (HTN)
h/o Myocardial Infarction in 03 s/p BMS to LCcx
Diabetes Mellitus (diet controlled)
hypercholesterolemia
s/p TAH-BSO [**2146**]
hypotension, on florinef/MICU and glycopyrrelate
previous pan-sensitive pseudomonal pneumonia

MEDICATION ON ADMISSION: (per [**2168-7-12**] Disharge Summary):
1. baclofen 10 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO q6am, q12pm.
2. baclofen 10 mg Tablet [**Month/Day/Year **]: Three (3) Tablet PO q8pm.
3. gabapentin 250 mg/5 mL Solution [**Month/Day/Year **]: Eight Hundred (800) mg
PO q 8am and 8pm.
4. gabapentin 250 mg/5 mL Solution [**Month/Day/Year **]: Four Hundred (400) mg PO

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
Vitals: T: 36.6 BP: 139/52 P: 48 R: 14 O2: 100%
General: Trached, unresponsive
HEENT: Sclera anicteric, dry oral mucosa, the patient is noted
to be biting down, there is a 4mm non-gaping laceration on the L
lateral tongue with a small amount of oozing, there is bloody
secretion suctioned from the oral cavity
Neck: supple, JVP not elevated, no LAD; a tracheostomy is in
place
CV: Bradycardic, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Rhonchi bilaterally, no wheezing, the patient is not
breathing over vent
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, PEG is present in the L abdomen
GU: Foley Present
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Unresponsive to verbal and painful stimuli, corneal
reflex present x1 on L, absent on R. She has intermittent
myoclonic jerks of the BUE, absent DTRs in all extremities, she
is in flexor contractions at the elbows, with rigidity. Her
lower extremities are flaccid. Intermittent grimace with
oropharyngeal suctioning.
.
DISCHARGE PHYSICAL EXAM:
Vitals: T 98.0, HR 79, BP 151/79, RR 30, SaO2 100% 10L 35% FiO2
trach mask
General: Awake, interactive, trach in place.
HEENT: PERRL, anicteric sclera, OP clear. Trach in place.
CV: S1S2 RRR no m/r/g's..
Lungs: CTA bilaterally w/o crackles / wheezing.
Ab: Positive BS's, NT/ND, No HSM.
Neuro: Alert and interactive. [**Hospital1 56633**] with minimal residual
UE motor function.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Drugs: none
Tobacco: prior (30-40 years) 1+ pack/day smoker
Alcohol: none
Other: used to work as [**Hospital1 112**] clerk
Toxic encephalopathy,Quadriplegia, C5-C7, incomplete,Acute kidney failure with lesion of tubular necrosis,Chronic respiratory failure,Neurogenic bowel,Hyperosmolality and/or hypernatremia,Other specified antibiotics causing adverse effects in therapeutic use,Hypocalcemia,Anemia, unspecified,Tracheostomy status,Neurogenic bladder NOS,Personal history of venous thrombosis and embolism,Other and unspecified hyperlipidemia,Other convulsions
Toxic encephalopathy,Quadrplg c5-c7, incomplt,Ac kidny fail, tubr necr,Chronic respiratory fail,Neurogenic bowel,Hyperosmolality,Adv eff antibiotics NEC,Hypocalcemia,Anemia NOS,Tracheostomy status,Neurogenic bladder NOS,Hx-ven thrombosis/embols,Hyperlipidemia NEC/NOS,Convulsions NEC
Admission Date:  [**2168-7-21**]              Discharge Date:   [**2168-7-29**]

Date of Birth:  [**2105-6-17**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Altered mental status

Major Surgical or Invasive Procedure:
Endotracheal intubation, mechanical ventilation

History of Present Illness:
Patient with recent illness and admission to the [**Hospital1 18**] MICU for
pneumosepsis, discharged home on [**2168-7-12**] to rehab at [**Hospital 1263**]
Hospital on vanc/cefepime with vanc scheduled to complete on
[**7-21**]. The patient had initially been doing well at rehab, and
according to her daughter, coming to terms with her current
rehab arrangement and shortness of breath. She was unfortunately
diagnosed with c.diff colitis on [**2168-7-14**] in the setting of
increased stool output and was started on oral vancomycin.
.
2 days ago on [**7-19**] the patient was noted to have acute worsening
of her mentation following feeding, which was normally alert and
verbal to be found complaining of shortness of breath, despite
having normal oxygen saturations - she was found to have
hyperkalemia, hypocalcemia, and anemia - she was treated for all
three including transfusion of 2 units of PRBCs and subsequently
underwent suctioning with transient improvement in her mental
status. She had no interval increase in sputum production.
.
The next day, [**7-20**], the patient was noted to have similar
symptoms but even worsening mental status requiring from the
rehab area to the intensive care unit as she had a diminished
mental status and was being ventilated with a bag-valve mask.
She was placed back on a vent on assist control. She was found
to be somnolent on arrival with a tongue bite and the
differential included post-ictal state although no seizure
activity was noted, this was confirmed with an EEG which showed
slowing but no epileptiform activity. She reportedly had a
normal head CT, and a CT of the chest which revealed left lower
lobe collapse which has been frequently noted on previous
imaging studies. Additionally, she was noted to have [**Last Name (un) **] and a
significantly elevated vancomycin level - this was presumably
held, but not clearly noted in the chart, there was an
appreciable decline in the vancomycin trough between [**7-20**] to
[**7-21**] from 50 to 30.
.
She was seen and evaluated by neurology who recommended volume
expansion for possible dysautonomic crisis. She was also started
on an ativan drip at 0.5mg per hour which was discontinued
around 8am on [**7-21**]. This significantly improved her rigidity,
but then her mental status did not improve and her spasticity
returned gradually over several hours. Due to lack of clinical
improvement and family request, the patient was transferred back
to [**Hospital1 18**] MICU.
.
On arrival to the MICU, the patient was noted to be completely
unresponsive to verbal and painful stimuli, occassionally
grimacing to suction, but had no purposeful movements. She was
hemodynamically stable, but vital signs were notable for a
bradycardia in the low 50s, BP was elevated, but not markedly
so. Labs were drawn, a CXR was ordered, and a neurology consult
was ordered who initially recommended MRI/MRA of the head and
neck.
.
Review of systems:
Unable to obtain due to altered mental status of the patient;
the family denies any recent history of fever, chills, or
grossly bloody stools.


Past Medical History:
C5 [**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 39850**]
Chronic respiratory failure with trach
s/p C6 corpectomy and ACDF C7T1 c allograft and plate c/b CSF
leak
Stage II pressure ulcers
MRSA/Hflu Ventilator-associated Pneumonia
Left upper extremity Deep vein thrombosis (DVT)
Neurogenic bowel
Neurogenic bladder
h/o Hypertension (HTN)
h/o Myocardial Infarction in 03 s/p BMS to LCcx
Diabetes Mellitus (diet controlled)
hypercholesterolemia
s/p TAH-BSO [**2146**]
hypotension, on florinef/MICU and glycopyrrelate
previous pan-sensitive pseudomonal pneumonia


Social History:
Drugs: none
Tobacco: prior (30-40 years) 1+ pack/day smoker
Alcohol: none
Other: used to work as [**Hospital1 112**] clerk


Family History:
Non-contributory

Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 36.6 BP: 139/52 P: 48 R: 14 O2: 100%
General: Trached, unresponsive
HEENT: Sclera anicteric, dry oral mucosa, the patient is noted
to be biting down, there is a 4mm non-gaping laceration on the L
lateral tongue with a small amount of oozing, there is bloody
secretion suctioned from the oral cavity
Neck: supple, JVP not elevated, no LAD; a tracheostomy is in
place
CV: Bradycardic, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Rhonchi bilaterally, no wheezing, the patient is not
breathing over vent
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, PEG is present in the L abdomen
GU: Foley Present
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Unresponsive to verbal and painful stimuli, corneal
reflex present x1 on L, absent on R. She has intermittent
myoclonic jerks of the BUE, absent DTRs in all extremities, she
is in flexor contractions at the elbows, with rigidity. Her
lower extremities are flaccid. Intermittent grimace with
oropharyngeal suctioning.
.
DISCHARGE PHYSICAL EXAM:
Vitals: T 98.0, HR 79, BP 151/79, RR 30, SaO2 100% 10L 35% FiO2
trach mask
General: Awake, interactive, trach in place.
HEENT: PERRL, anicteric sclera, OP clear. Trach in place.
CV: S1S2 RRR no m/r/g's..
Lungs: CTA bilaterally w/o crackles / wheezing.
Ab: Positive BS's, NT/ND, No HSM.
Neuro: Alert and interactive. [**Hospital1 56633**] with minimal residual
UE motor function.

Pertinent Results:
LABS ON ADMISSION:
WBC-10.2 RBC-3.44* Hgb-8.9* Hct-29.4* MCV-85 MCH-25.8*
MCHC-30.2* RDW-16.3* Plt Ct-195
Neuts-83.9* Lymphs-8.4* Monos-6.7 Eos-0.8 Baso-0.2
PT-34.6* PTT-42.4* INR(PT)-3.4*
Glucose-88 UreaN-31* Creat-2.3*# Na-136 K-4.5 Cl-103 HCO3-24
AnGap-14
Albumin-2.9* Calcium-8.5 Phos-5.7*# Mg-1.9 Iron-9*
ALT-21 AST-30 LD(LDH)-223 CK(CPK)-308* AlkPhos-78 TotBili-0.2
proBNP-1673*
Ammonia-19
TSH-0.36, Free T4-1.0
Cortsol-23.1* ([**2168-7-22**], 6:30 AM)
Vanco trough 37.1*
Lactate 1.3
ABG: Type-ART Rates-12/ Tidal V-400 PEEP-5 FiO2-30 pO2-105
pCO2-36 pH-7.43 calTCO2-25 Base XS-0 -ASSIST/CON
Intubat-INTUBATED
URINALYSIS: Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.004 Blood-TR
Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG
Urobiln-NEG pH-6.0 Leuks-LG
[**2168-7-21**] 08:56PM URINE RBC-4* WBC-15* Bacteri-FEW Yeast-NONE
Epi-0 TransE-<1 Mucous-RARE
URINE LYTES: Hours-RANDOM UreaN-161 Creat-20 Na-42 K-9 Cl-26
TotProt-11 Calcium-0.6 Phos-24.6 Mg-1.9 Prot/Cr-0.6*
URINE Osmolal-162
.
LABS ON DISCHARGE:
WBC-9.9 RBC-3.10* Hgb-8.2* Hct-26.8* MCV-86 MCH-26.3* MCHC-30.5*
RDW-16.2* Plt Ct-281
PT-13.7* INR(PT)-1.3*
Glucose-96 UreaN-37* Creat-1.5* Na-148* K-3.7 Cl-105 HCO3-33*
AnGap-14
Calcium-8.6 Phos-3.8 Mg-1.8
VBG: pO2-40* pCO2-52* pH-7.45 calTCO2-37* Base XS-9
.
MICROBIOLOGY:
-Sputum culture ([**2168-7-21**]):
GRAM STAIN (Final [**2168-7-21**]):
      >25 PMNs and <10 epithelial cells/100X field.
      2+   (1-5 per 1000X FIELD):   GRAM NEGATIVE ROD(S).

   RESPIRATORY CULTURE (Final [**2168-7-27**]):
      Commensal Respiratory Flora Absent.
      PSEUDOMONAS AERUGINOSA.    SPARSE GROWTH.
         Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
         [**Last Name (NamePattern1) 3060**].
      STAPH AUREUS COAG +.    SPARSE GROWTH.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations.

         Rifampin should not be used alone for therapy.
         This isolate is presumed to be resistant to clindamycin
based on
         the detection of inducible resistance .
      STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA.    SPARSE
GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             PSEUDOMONAS AERUGINOSA
                             |          STAPH AUREUS COAG +
                             |          |
STENOTROPHOMONAS (XANTHOMON
                             |          |          |
CEFEPIME--------------    32 R
CEFTAZIDIME-----------  =>64 R
CIPROFLOXACIN---------   =>4 R
CLINDAMYCIN-----------                  R
ERYTHROMYCIN----------              =>8 R
GENTAMICIN------------   <=1 S    <=0.5 S
LEVOFLOXACIN----------              =>8 R
MEROPENEM-------------     1 S
OXACILLIN-------------              =>4 R
PIPERACILLIN/TAZO-----       I
RIFAMPIN--------------            <=0.5 S
TETRACYCLINE----------              <=1 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----            <=0.5 S      <=1 S
VANCOMYCIN------------                1 S

-Blood culture ([**2168-7-21**]): NEGATIVE
-Blood culture ([**2168-7-22**]): NEGATIVE

CHEST X-RAY ([**2168-7-21**]): Substantial left lower lobe atelectasis
is chronic, and now there is more pronounced atelectasis at the
base of the left hemithorax, some of which could be in the upper
lobe.  Right lung is clear. The heart is top normal size,
chronically leftward shifted.  New left PIC line ends in the
right atrium and would need to be withdrawn 5.5 cm to place it
within the low SVC.

CHEST X-RAY ([**2168-7-22**]): Repositioned left PICC now terminates in
the upper SVC. The study is otherwise unchanged.

24-HOUR VIDEO EEG ([**2168-7-22**]): This is an abnormal continuous ICU
monitoring study because of one brief generalized electrographic
seizure at 04:23:38 as is described under Continuous EEG. This
electrographic seizure has no
clinical correlation on video. In addition, there are frequent
bisynchronus parasagittal periodic epileptic discharges in the
first few
hours of the recording. These discharges later become
generalized and
continue with a waxing and [**Doctor Last Name 688**] frequency through the rest of
the
recording. These findings are indicative of diffuse cortical
irritability with epileptogenicity. Furthermore, background
activity is
diffusely slow and discontinuous indicative of severe diffuse
cerebral
dysfunction of non-specific etiology.

MRI/MRA BRAIN AND NECK WITHOUT CONTRAST ([**2168-7-22**]):
1. No acute intracranial abnormality.
2. Mild fluid signal in bilateral mastoid air cells.
3. Very faint flow signal in the left vertebral artery may be
related to
hypoplastic artery or chronic occlusion.  Appearance is similar
to that seen on the previous MRI from [**2167-5-8**].

RENAL ULTRASOUND ([**2168-7-22**]): Normal-sized kidneys with increased
cortical echogenicity consistent with diffuse parenchymal renal
disease.  No evidence of obstruction.

EEG ([**2168-7-23**]): This is an abnormal continuous ICU monitoring
study because
of generalized periodic epileptic discharges in the first half
of the
recording indicative of diffuse cortical irritability with
potential
epileptogenicity. In the second half of the recording, epileptic

discharges appeared more in a discrete pattern and they resolve
after
14:30 indicative of attenuation of cortical irritability. In
addition,
in the first half of the recording background activity is
diffusely slow
and discontinuous with generalized triphasic waves. These
findings are
indicative of severe cerebral dysfunction as is seen the setting
of
hepatic or renal dysfunction where triphasic waves are more
common. In
the second half of the recording however, the triphasic waves
resolve
and a more continuous though slow background activity is
present. These
findings are suggestive of improvement in the degree of cerebral

dysfunction. No electrographic seizures are present. Compared to
the
prior day's recording, there is significant improvement in the
second
half of the study as is described above.

EEG ([**2168-7-24**]): This is  an abnormal continuous ICU monitoring
study because of moderate to severe generalized background
slowing indicative of
moderate diffuse cerebral dysfunction of non-specific etiology.
In
addition, in the first 20 minutes of the recording, there are
abundant
generalized epileptiform discharges indicative of diffuse
cortical
irritability with potential epileptogenicity. However, the
epileptiform
discharges nearly completely resolved after the initial portion
of the
recording. No electrographic seizures are present. Compared to
prior
day's recording, this study shows improvement with resolution of
the
epileptiform discharges through the recording as well as
appearance of a
more continuous and faster background activity.

CHEST X-RAY ([**2168-7-24**]): Compared to yesterday's study, there is
overall interval stability of mild acute-on-chronic congestive
heart failure, right lower lobe atelectasis, and opacification
of the lingula.  This may represent atelectasis, or given the
patient's clinical history, consolidation from pneumonia.  This
is stable from yesterday's study, but slightly increased since
[**7-22**].

EEG ([**2168-7-26**]): This is an abnormal continuous ICU monitoring
study due to
moderate diffuse background slowing with intermittent bursts of
further
generalized slowing suggestive of moderate generalized
encephalopathy of
non-specific etiology. No epileptiform discharges or
electrographic
seizures are present. Compared to the prior day's recording,
this study
shows improvement with no epileptiform discharges. However,
background
activity remains the same.

Brief Hospital Course:
63 year old woman with a history of C5/C6 [**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 39850**]
status post cervical decompression surgery 1 year ago, trach
collar dependent, admitted with encephalopathy and [**Last Name (un) **].
.
# ENCEPHALOPATHY/COMA: On admission from OSH, patient was
completely unresponsive, areflexic, noted to have facial grimace
and rigid, flexed upper extremities. Her GCS was E1V1M1. Her OSH
EEG reportedly showed no seizure activity. Labs showed normal
TSH, ammonia, cortisol. They were however notable for acute
renal failure (Cr 2.3, baseline Cr 0.3) and vancomycin toxicity
(vanc level 37.1). Neurology was consulted and recommended
MRI/MRA head which ruled out stroke. 24-hour video EEG showed
generalized periodic epileptiform discharges (GPEDs)
superimposed on encephalopathic slowing, but no explicit
seizures. She was started on Keppra which was uptitrated to
750mg PO BID. Based on her presentation with acute renal
failure, it was felt that she likely developed renal failure due
to vancomycin toxicity, which caused accumulation of
psychoactive meds including Baclofen, Tizanidine, Morphine,
Tramadol and Gabapentin resulting in toxic/metabolic
encephalopathy as well as some uremic encephalopathy. All of the
above meds were held. Over the next several days and with
uptitration of Keppra, her epileptiform activity resolved and
her encephalopathy gradually improved. On discharge, her mental
status had returned to baseline (AAOx3) and her rigidity had
improved somewhat despite holding all muscle relaxants. On
discharge she remained on Keppra but the Baclofen, Tizanidine,
Morphine and Tramadol were all stopped given that her renal
function was still not back to baseline. Per neurology recs, if
her renal function continues to improve then Baclofen can be
restarted at low dose if needed.
.
# Rigidity: The patient has rigid upper extremities, decorticate
posturing, spastic quadriparesis secondary to her C-spine
injury. This was previously managed with Baclofen and
Tizinidine, but even with both being held per above her rigidity
improved during hospitalization.
.
# Hypoxic respiratory Distress: At admission, the patient was
vent dependent (has trach), subjectively short of breath, but
without declining respiratory parameters.  She was afebrile with
no leukocytosis so the patient was not treated empirically for
pneumonia. Sputum cultures grew out MRSA, Pseudomonas and
Stenotrophomonas on [**7-21**]. Given her bronchiectasis, positive
cultures were found to be likely secondary to chronic
colonization. She was therefore treated with an 8-day course of
Meropenam to decrease her bacterial burden (last day [**2168-7-30**]).
Because consecutive chest Xrays showed complete LLL collapse
(result of prior episodes of Pseudomonas pneumonia and
consistent with prior CXRs) with potential worsening with
pulmonary edema, the patient was diuresed with 50 mg IV Lasix
daily. The patient was taken off the vent on [**7-27**], and did well
off the vent without respiratory distress until discharge.
.
#[**Last Name (un) **]: The patient's acute kidney injury was most likely
intrinsic, but could have some volume component, dramatic
increase from baseline (0.3-->2.3), foley in, not obstructive.
The patient had a renal ultrasound which showed diffuse
parenchymal disease.  Per renal consult, her renal failure could
have been caused by ATN or AIN.  The patient had had no exposure
to nephrotoxic drugs and had no documented episodes of
hypotension, but her prior treatment with vancomycin and
cefepime could have precipitated her ATN or AIN.  Urine eos x 3
were sent out, only 1 of which returned mildly positive. The
patient's vanc levels were monitored and continued to downtrend
from her vanc level at admission (51) to 24.5 on [**7-27**].  The
patient's Creatinine and urine ouput was monitored and the
patient also received 40 mg Lasix IV daily to help with her
volume overload.  The patient's lisinopril, tizanidine and
tramadol were held during her hospitalization to limit exposure
to potentially nephrotoxic medications.

#Hypernatremia: The patient was mildly hypernatremic on [**7-27**]
with a serum Na of 147.  This was most likely [**3-10**] insensible
losses with her ventilation, but could also represent the
recovery phase of her ATN. Her free water deficit was calculated
to be 2.3 L in the setting of volume overload. The patient's
free water flushes were increased and her serum Na monitored.
.
#HTN: The patient's lisinopril was held while she was in renal
failure, but she was treated with IV Hydralazine prn for SBPs >
160. She is reportedly normotensive at baseline on her home meds
prior to admission, likely partly due to her multiple neuropsych
meds (Baclofen, Tramadol, Tizanidine etc) blood-pressure
lowering effects. Since all of these meds are still being held,
she was discharged on Lisinopril 5mg daily (home med) as well as
hydralazine 50mg PO q6 hrs. As her neuropsych meds are added
back on, hydralazine should be downtitrated or stopped as
needed.
.
#Anemia: The patient had a Hct of 29.4 at admission.  She has a
hx of guiaic positive stools, anemia, requiring transfusion at
outside hospital. The patient's Hct was 25.9 on [**7-27**], but her
stool guaiac was negative.
.
#H/O C. diff colitis: Patient was admitted on PO and IV vanc,
with toxic serum vanc level as mentioned above. It is unclear at
what date the patient was diagnosed with C. diff, although per
verbal report from family this was diagnosed on [**2168-7-14**] at OSH.
Given her toxic vanc levels, IV vanc was held and levels were
trended throughout hospitalization: trended down to 24.5 on
[**7-27**]. Her PO vanc was continued in light of C diff history and
because being treated with broad spectrum abx (Meropenam), will
continue PO vanc for two weeks after Meropenam course is
completed (last day of PO vanc is [**2168-8-13**]).
.
#LUE DVT:  The patient was prevously on Coumadin for a DVT
diagnosed back in [**2167-5-8**]. Given the patient's quadriplegid
status, the patient's Coumadin was d/c'ed on [**7-27**] (because all
venous tone is lost after several months of [**Month/Year (2) 39850**], her
risk for DVT/PE is significantly lower). DVT prophylaxis was
with pneumoboots.
.
#FEN/GI: patient with PEG.  Tube feeds @ goal
#Prophylaxis: pneumoboots
#Access: PICC
#Communication: Daughter [**Name (NI) 27414**]
#[**Name2 (NI) 7092**]: DNR/OK to intubate (confirmed with daughter)

Medications on Admission:
(per [**2168-7-12**] Disharge Summary):
1. baclofen 10 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO q6am, q12pm.
2. baclofen 10 mg Tablet [**Month/Day/Year **]: Three (3) Tablet PO q8pm.
3. gabapentin 250 mg/5 mL Solution [**Month/Day/Year **]: Eight Hundred (800) mg
PO q 8am and 8pm.
4. gabapentin 250 mg/5 mL Solution [**Month/Day/Year **]: Four Hundred (400) mg PO

NOON (At Noon).
5. hydroxyzine HCl 10 mg/5 mL Syrup [**Month/Day/Year **]: Fifty (50) mg PO every

four (4) hours as needed for anxiety.
6. ipratropium bromide 0.02 % Solution [**Month/Day/Year **]: One (1) inhalation
Inhalation Q4H (every 4 hours) as needed for dyspnea/wheezing:
please give as duoneb with albuterol .
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day/Year **]: One (1) inhalation Inhalation Q4H (every 4
hours) as needed for dyspnea/wheezing: please give as duoneb
with ipratropium .
8. lisinopril 5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily).

9. morphine 10 mg/5 mL Solution [**Month/Day/Year **]: 10-20 mg PO Q6H (every 6
hours) as needed for pain.
10. nitroglycerin 0.4 mg Tablet, Sublingual [**Month/Day/Year **]: One (1) SL
Sublingual q5 minutes x 3 as needed for chest pain: call your
doctor if you take this medication.
11. omeprazole magnesium 10 mg Susp,Delayed Release for Recon
[**Month/Day/Year **]: Twenty (20) mg PO once a day.
12. simvastatin 20 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO at bedtime.

13. tizanidine 2 mg Tablet [**Month/Day/Year **]: 4-6 mg PO TID (3 times a day) as

needed for muscle spasm.
14. tramadol 50 mg Tablet [**Month/Day/Year **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
15. warfarin 2 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO q mon, fri.
16. warfarin 2 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO q sun, tues,
wed, thurs, sat.
17. acetaminophen 650 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO four
times a day as needed for pain.
18. aspirin 81 mg Tablet, Chewable [**Month/Day/Year **]: One (1) Tablet, Chewable

PO DAILY (Daily).
19. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet [**Month/Day/Year **]: One

(1) Tablet PO twice a day.
20. docusate sodium 60 mg/15 mL Syrup [**Month/Day/Year **]: Twenty Five (25) mL
PO twice a day: per G tube.
21. docusate sodium 283 mg Enema [**Month/Day/Year **]: One (1) enema Rectal once

a day as needed for constipation.
22. cefepime 2 gram Recon Soln [**Month/Day/Year **]: Two (2) grams Injection Q8H

(every 8 hours) for 5 days.
23. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid [**Month/Day/Year **]: Three
Hundred (300) mg PO once a day.
24. heparin, porcine (PF) 10 unit/mL Syringe [**Month/Day/Year **]: One (1) ML
Intravenous PRN (as needed) as needed for line flush: Flush with

10 mL Normal Saline followed by Heparin as above daily and PRN.

25. enoxaparin 80 mg/0.8 mL Syringe [**Month/Day/Year **]: Eighty (80) mg
Subcutaneous Q12H (every 12 hours): discontinue when INR > 2.0.

26. metoprolol tartrate 25 mg Tablet [**Month/Day/Year **]: 0.5 Tablet PO BID (2
times a day).
27. vancomycin 750 mg Recon Soln [**Month/Day/Year **]: Seven [**Age over 90 1230**]y (750)

mg Intravenous twice a day for 9 days: please check vanco trough

after 4th dose.


Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN SOB, wheezing
3. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN sob, wheezing
4. Aspirin 81 mg PO DAILY
5. Calcium Carbonate 1250 mg PO TID W/MEALS
6. Docusate Sodium (Liquid) 100 mg PO BID
7. esomeprazole magnesium *NF* 20 mg Oral daily
8. Ferrous Sulfate (Liquid) 300 mg PO DAILY
9. Metoprolol Tartrate 25 mg PO BID
Please hold for HR < 60, SBP < 100
10. Simvastatin 20 mg PO DAILY
11. Vitamin D 800 UNIT PO DAILY
12. Vancomycin Oral Liquid 125 mg PO Q6H Duration: 16 Days
Last day = [**2168-8-13**]
13. HydrALAzine 50 mg PO Q6H
pls hold for SBP<100
14. LeVETiracetam 750 mg PO BID
15. Meropenem 500 mg IV Q8H Duration: 3 Days
First day: [**7-23**]
Last day: [**7-30**]


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **] [**Hospital1 **]

Discharge Diagnosis:
Toxic/metabolic encephalopathy and acute renal failure

Discharge Condition:
Improved mental status: responsive and conversant

Discharge Instructions:
Dear Ms. [**Known lastname 105209**],

You were admitted for altered mental status. This most likely
occurred because you developed a kidney failure and as a result
your medications were not filtered. The build-up of these
medications caused metabolic encephalopathy (delirium) and
seizures.  The cause of your kidney function may have been from
an allergic reaction to one of the antibiotics you were taking
(vancomycin) at the level of your kidney.  You were admitted to
the intensive care, where kidney specialists (nephrologists),
brain specialists (neurologists) and our critical care team
cared for you. Most of your medications were stopped and as your
kidneys continued to improve so did your mental status.  We have
completely stopped some of the medications that you take
chronically.  These should be started in the future when your
kidneys are more stable.  You have tolerated being off these
medications well.

We wish you all the best.

The following changes were made to your medication list:
1. START hydralazine 50mg every 6 hours for hypertension
2. START keppra 750 mg twice a day
3. CONTINUE meropenem 500mg IV every 8 hours until [**2168-7-30**]
4. CONTINUE vancomycin oral 125mg every 6 hours until [**2168-8-13**]
5  INCREASE metoprolol tartrate to 25mg twice a day
6. STOP baclofen 20mg twice a day
7. STOP baclofen 30mg in the evening
8. STOP gabapentin 400mg daily
9. STOP hydroxyzine 25/12.5 mL [**Male First Name (un) **] every 4 hours as needed for
pain
10. STOP lisinopril 5mg daily
11. STOP morphine 10mg every 6 hours for pain
12. STOP nitroglycerin 0.4mg for pain
13. STOP tizanidine 4mg every 8 hours as needed for pain
14. STOP tramadol 50mh every 6 hours as needed for pain
15. STOP warfarin 8mg daily
16. STOP enoxaparin 80mg SC every 12 hours
17. STOP vancomycin IV 1g IV every 12 hours

Followup Instructions:
Department: WEST [**Hospital 2002**] CLINIC/NEPHROLOGY
When: MONDAY [**2168-8-8**] at 1:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST     Best Parking: [**Street Address(1) 592**] Garage

Department: NEUROLOGY
When: TUESDAY [**2168-8-16**] at 12:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**], M.D. [**Telephone/Fax (1) 541**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage


                             [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
{'Toxic encephalopathy,Quadriplegia, C5-C7, incomplete,Acute kidney failure with lesion of tubular necrosis,Chronic respiratory failure,Neurogenic bowel,Hyperosmolality and/or hypernatremia,Other specified antibiotics causing adverse effects in therapeutic use,Hypocalcemia,Anemia, unspecified,Tracheostomy status,Neurogenic bladder NOS,Personal history of venous thrombosis and embolism,Other and unspecified hyperlipidemia,Other convulsions'}


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: Altered mental status

PRESENT ILLNESS: Patient with recent illness and admission to the [**Hospital1 18**] MICU for
pneumosepsis, discharged home on [**2168-7-12**] to rehab at [**Hospital 1263**]
Hospital on vanc/cefepime with vanc scheduled to complete on
[**7-21**]. The patient had initially been doing well at rehab, and
according to her daughter, coming to terms with her current
rehab arrangement and shortness of breath. She was unfortunately
diagnosed with c.diff colitis on [**2168-7-14**] in the setting of
increased stool output and was started on oral vancomycin.
.
2 days ago on [**7-19**] the patient was noted to have acute worsening
of her mentation following feeding, which was normally alert and
verbal to be found complaining of shortness of breath, despite
having normal oxygen saturations - she was found to have
hyperkalemia, hypocalcemia, and anemia - she was treated for all
three including transfusion of 2 units of PRBCs and subsequently
underwent suctioning with transient improvement in her mental
status. She had no interval increase in sputum production.
.
The next day, [**7-20**], the patient was noted to have similar
symptoms but even worsening mental status requiring from the
rehab area to the intensive care unit as she had a diminished
mental status and was being ventilated with a bag-valve mask.
She was placed back on a vent on assist control. She was found
to be somnolent on arrival with a tongue bite and the
differential included post-ictal state although no seizure
activity was noted, this was confirmed with an EEG which showed
slowing but no epileptiform activity. She reportedly had a
normal head CT, and a CT of the chest which revealed left lower
lobe collapse which has been frequently noted on previous
imaging studies. Additionally, she was noted to have [**Last Name (un) **] and a
significantly elevated vancomycin level - this was presumably
held, but not clearly noted in the chart, there was an
appreciable decline in the vancomycin trough between [**7-20**] to
[**7-21**] from 50 to 30.
.
She was seen and evaluated by neurology who recommended volume
expansion for possible dysautonomic crisis. She was also started
on an ativan drip at 0.5mg per hour which was discontinued
around 8am on [**7-21**]. This significantly improved her rigidity,
but then her mental status did not improve and her spasticity
returned gradually over several hours. Due to lack of clinical
improvement and family request, the patient was transferred back
to [**Hospital1 18**] MICU.
.
On arrival to the MICU, the patient was noted to be completely
unresponsive to verbal and painful stimuli, occassionally
grimacing to suction, but had no purposeful movements. She was
hemodynamically stable, but vital signs were notable for a
bradycardia in the low 50s, BP was elevated, but not markedly
so. Labs were drawn, a CXR was ordered, and a neurology consult
was ordered who initially recommended MRI/MRA of the head and
neck.
.
Review of systems:
Unable to obtain due to altered mental status of the patient;
the family denies any recent history of fever, chills, or
grossly bloody stools.

MEDICAL HISTORY: C5 [**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 39850**]
Chronic respiratory failure with trach
s/p C6 corpectomy and ACDF C7T1 c allograft and plate c/b CSF
leak
Stage II pressure ulcers
MRSA/Hflu Ventilator-associated Pneumonia
Left upper extremity Deep vein thrombosis (DVT)
Neurogenic bowel
Neurogenic bladder
h/o Hypertension (HTN)
h/o Myocardial Infarction in 03 s/p BMS to LCcx
Diabetes Mellitus (diet controlled)
hypercholesterolemia
s/p TAH-BSO [**2146**]
hypotension, on florinef/MICU and glycopyrrelate
previous pan-sensitive pseudomonal pneumonia

MEDICATION ON ADMISSION: (per [**2168-7-12**] Disharge Summary):
1. baclofen 10 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO q6am, q12pm.
2. baclofen 10 mg Tablet [**Month/Day/Year **]: Three (3) Tablet PO q8pm.
3. gabapentin 250 mg/5 mL Solution [**Month/Day/Year **]: Eight Hundred (800) mg
PO q 8am and 8pm.
4. gabapentin 250 mg/5 mL Solution [**Month/Day/Year **]: Four Hundred (400) mg PO

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
Vitals: T: 36.6 BP: 139/52 P: 48 R: 14 O2: 100%
General: Trached, unresponsive
HEENT: Sclera anicteric, dry oral mucosa, the patient is noted
to be biting down, there is a 4mm non-gaping laceration on the L
lateral tongue with a small amount of oozing, there is bloody
secretion suctioned from the oral cavity
Neck: supple, JVP not elevated, no LAD; a tracheostomy is in
place
CV: Bradycardic, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Rhonchi bilaterally, no wheezing, the patient is not
breathing over vent
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, PEG is present in the L abdomen
GU: Foley Present
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Unresponsive to verbal and painful stimuli, corneal
reflex present x1 on L, absent on R. She has intermittent
myoclonic jerks of the BUE, absent DTRs in all extremities, she
is in flexor contractions at the elbows, with rigidity. Her
lower extremities are flaccid. Intermittent grimace with
oropharyngeal suctioning.
.
DISCHARGE PHYSICAL EXAM:
Vitals: T 98.0, HR 79, BP 151/79, RR 30, SaO2 100% 10L 35% FiO2
trach mask
General: Awake, interactive, trach in place.
HEENT: PERRL, anicteric sclera, OP clear. Trach in place.
CV: S1S2 RRR no m/r/g's..
Lungs: CTA bilaterally w/o crackles / wheezing.
Ab: Positive BS's, NT/ND, No HSM.
Neuro: Alert and interactive. [**Hospital1 56633**] with minimal residual
UE motor function.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Drugs: none
Tobacco: prior (30-40 years) 1+ pack/day smoker
Alcohol: none
Other: used to work as [**Hospital1 112**] clerk 

### Response:
{'Toxic encephalopathy,Quadriplegia, C5-C7, incomplete,Acute kidney failure with lesion of tubular necrosis,Chronic respiratory failure,Neurogenic bowel,Hyperosmolality and/or hypernatremia,Other specified antibiotics causing adverse effects in therapeutic use,Hypocalcemia,Anemia, unspecified,Tracheostomy status,Neurogenic bladder NOS,Personal history of venous thrombosis and embolism,Other and unspecified hyperlipidemia,Other convulsions'}
