CHIEF COMPLAINT: dyspnea

PRESENT ILLNESS: For a full admission note, please see MICU Green note. In brief,
this is a 53 year old woman with PMH significant for T1-T2
paraplegia s/p MVC, recurrent UTI/PNA, chronically on 2L of
oxygen at home, and anxiety who presented to hospital with
shortness of breath and fevers.
.
Caretaker noted her to be breathing faster than normal prior to
admission. She also reports recent dysphagia, concerning for
aspiration pneumonia. At home does intermittently straight-cath,
however she is unable to discern signs/sx of UTI. Per care
taker, she was seen by Dr [**Last Name (STitle) 665**] several weeks again found to
have +UA however no definite culture data so not treated.
.
In the ED she was found to have temp of 100.7 with O2 sat at 84%
on 2L (baseline in low 90s) and SBP in 90s. Her WBC count was
elevated and UA found to be positive. She got 2 L of fluid and
was transferred to the MICU. Of note, she had a PICC line on
admission.
.
While in the MICU, she started treatment for UTI with vanc and
[**Last Name (un) 2830**] given hx of [**Last Name (un) 40097**]. She had a CXR that could not exclude
pneumonia. She was also on levaquin for 3 days for legionella
coverage but this was stopped on [**11-11**] when found to be
negative. She has been getting chest PT and nebs and also
reports some cough. Sputum culture growing coagulase positive
staph and gram negative rods.
She had 1 positive blood cx for coag negative staph and PICC
line was pulled.
.
Prior to transfer to the floor her blood pressure was in low
100s, she was mentating well and had no active complaints.

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

MEDICATION ON ADMISSION: ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for
Nebulization - one vial inh 4-6 hours prn
BACLOFEN - 10 mg Tablet - 2 (Two) Tablet(s) by mouth in the
morning; 1 (One) tablet at 4 pm and 2 (Two) tablets at bedtime
CITALOPRAM - 20 mg Tablet - 2 Tablet(s) by mouth once a day
CLONAZEPAM [KLONOPIN] - 0.5 mg Tablet - 2 Tablet(s) by mouth (1
mg) three times a day
ESTRADIOL [ESTRACE] - 0.01 % Cream - apply to exterrnal gyn area
twice a week
IPRATROPIUM-ALBUTEROL [COMBIVENT] - 18 mcg-103 mcg (90
mcg)/Actuation Aerosol - 2 puffs three times a day
LEVOTHYROXINE - 112 mcg Tablet - 1 (One) Tablet(s) by mouth once
a day
LIDOCAINE - 5 % (700 mg/patch) Adhesive Patch, Medicated - apply
four patches to the affected areas once a day 12 hours off and
12
hours on - No Substitution
LIDOCAINE HCL - 5 % Ointment - Apply externally to affected area
once a day  as needed for burning
METHADONE - 5 mg Tablet - 1 Tablet(s) by mouth three times daily
for pain
METHENAMINE HIPPURATE - 1 gram Tablet - 1 Tablet(s) by mouth
twice a day take with Vitamin C 500
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - one
Capsule(s) by mouth twice a day
OXYBUTYNIN CHLORIDE - 5 mg Tablet - 2 Tablet(s) by mouth in the
AM, one in the afternoon, and 2 in the evening
OXYCODONE - 5 mg Tablet - 1 Tablet(s) by mouth three times a day
as needed for pain
PREGABALIN [LYRICA] - 100 mg Capsule - 1 Capsule(s) by mouth
three times a day
SIMVASTATIN - 10 mg Tablet - 1 Tablet(s) by mouth daily
SUCRALFATE -  (post d/c med) (On Hold from [**2148-8-27**] to
[**2148-9-3**] for while taking levaquin) - 1 gram Tablet - 1
Tablet(s) by mouth four times a day
TRAZODONE - 100 mg Tablet - 1 Tablet(s) by mouth at bedtime
.
Medications - OTC
CALCIUM CARBONATE [CALCIUM 500] -  (Prescribed by Other
Provider)
(On Hold from [**2148-8-27**] to [**2148-9-3**] for while taking
levaquin)
- 500 mg (1,250 mg) Tablet - 1 Tablet(s) by mouth twice daily pt
unsure if 500mg or 600mg
CATHETER [FOLEY CATHETER] - 14 Fr [**Year (4 digits) 12106**] - Use for urinary
control/self catheterizaion as needed Dx: Neurogenic bladder,
paraplegia  (1 month supply)
FACIAL-BODY WIPES [BABY WIPES] -   [**Name2 (NI) 12106**] - USE AS DIRECTED PRN
NEBULIZER -   Kit - for use in home qd. dx: pneumonia
NICOTINE -  (Prescribed by Other Provider) (Not Taking as
Prescribed) - 21 mg/24 hour Patch 24 hr - apply 1 patch daily as
directed
POLYETHYLENE GLYCOL 3350 [MIRALAX] -  (Not Taking as Prescribed:
not on medication list provided by patient [**2146-6-15**]) - 17 gram
(100 %) Powder in Packet - one pack by mouth once a day
SURGICAL LUBRICANT JELLY [SURGILUBE] -   Gel - as needed for
straight cath

ALLERGIES: Ativan

PHYSICAL EXAM: Physical Exam on Arrival to the MICU
VS: Tmax: 37.1 ??????C (98.7 ??????F)
Tcurrent: 36 ??????C (96.8 ??????F)
HR: 65 (62 - 80) bpm
BP: 83/47(55) {83/45(55) - 93/74(77)} mmHg
RR: 17 (12 - 23) insp/min
SpO2: 99%
General: Alert, oriented, agitated
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Mother passed away with lung disease.

SOCIAL HISTORY: Lives at home with husband and 2 adolescent children.
- Tobacco: 35-pack-years, quit several months ago, relapsed
recently.
- Alcohol: Denies.
- Illicits: Denies.
Paraplegia,Urinary tract infection, site not specified,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Chronic hepatitis C without mention of hepatic coma,Tracheostomy status,Dysphagia, oropharyngeal phase,Other respiratory abnormalities,Chronic airway obstruction, not elsewhere classified,Late effect of spinal cord injury,Late effects of motor vehicle accident,Unspecified disorder of esophagus,Unspecified disorder of metabolism,Atrophic gastritis, without mention of hemorrhage,Other chronic pain,Anemia of other chronic disease,Dysthymic disorder,Personal history of venous thrombosis and embolism,Methicillin resistant pneumonia due to Staphylococcus aureus,Alkalosis
Paraplegia NOS,Urin tract infection NOS,Klebsiella pneumoniae,Chrnc hpt C wo hpat coma,Tracheostomy status,Dysphagia, oropharyngeal,Respiratory abnorm NEC,Chr airway obstruct NEC,Late eff spinal cord inj,Late eff motor vehic acc,Esophageal disorder NOS,Metabolism disorder NOS,Atrph gastrtis w/o hmrhg,Chronic pain NEC,Anemia-other chronic dis,Dysthymic disorder,Hx-ven thrombosis/embols,Meth res pneu d/t Staph,Alkalosis
Admission Date:  [**2149-11-10**]              Discharge Date:   [**2149-11-17**]

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

Service: MEDICINE

Allergies:
Ativan

Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
dyspnea


Major Surgical or Invasive Procedure:
CENTRAL VENOUS LINE PLACEMENT


History of Present Illness:
For a full admission note, please see MICU Green note. In brief,
this is a 53 year old woman with PMH significant for T1-T2
paraplegia s/p MVC, recurrent UTI/PNA, chronically on 2L of
oxygen at home, and anxiety who presented to hospital with
shortness of breath and fevers.
.
Caretaker noted her to be breathing faster than normal prior to
admission. She also reports recent dysphagia, concerning for
aspiration pneumonia. At home does intermittently straight-cath,
however she is unable to discern signs/sx of UTI. Per care
taker, she was seen by Dr [**Last Name (STitle) 665**] several weeks again found to
have +UA however no definite culture data so not treated.
.
In the ED she was found to have temp of 100.7 with O2 sat at 84%
on 2L (baseline in low 90s) and SBP in 90s. Her WBC count was
elevated and UA found to be positive. She got 2 L of fluid and
was transferred to the MICU. Of note, she had a PICC line on
admission.
.
While in the MICU, she started treatment for UTI with vanc and
[**Last Name (un) 2830**] given hx of [**Last Name (un) 40097**]. She had a CXR that could not exclude
pneumonia. She was also on levaquin for 3 days for legionella
coverage but this was stopped on [**11-11**] when found to be
negative. She has been getting chest PT and nebs and also
reports some cough. Sputum culture growing coagulase positive
staph and gram negative rods.
She had 1 positive blood cx for coag negative staph and PICC
line was pulled.
.
Prior to transfer to the floor her blood pressure was in low
100s, she was mentating well and had no active complaints.


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


Social History:
Lives at home with husband and 2 adolescent children.
- Tobacco: 35-pack-years, quit several months ago, relapsed
recently.
- Alcohol: Denies.
- Illicits: Denies.


Family History:
Mother passed away with lung disease.


Physical Exam:
Physical Exam on Arrival to the MICU
VS: Tmax: 37.1 ??????C (98.7 ??????F)
Tcurrent: 36 ??????C (96.8 ??????F)
HR: 65 (62 - 80) bpm
BP: 83/47(55) {83/45(55) - 93/74(77)} mmHg
RR: 17 (12 - 23) insp/min
SpO2: 99%
General: Alert, oriented, agitated
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

Discharge exam
VS 96.9 117/72 79 20 97% 2L
General: Alert, oriented
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP difficult to assess, no LAD
Lungs:  few bibasilar crackles. good aeration
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, bowel sounds present, no rebound
tenderness or guarding
GU: + foley, no suprapubic tenderness
Ext: warm, well perfused, 1+ LE edema halfway up shins. 2+ DP
pulses


Pertinent Results:
[**2149-11-10**] 10:50AM BLOOD WBC-11.7*# RBC-3.51* Hgb-9.6* Hct-30.5*
MCV-87 MCH-27.2 MCHC-31.4 RDW-14.8 Plt Ct-192
[**2149-11-10**] 10:50AM BLOOD Neuts-92.8* Lymphs-5.0* Monos-1.3*
Eos-0.6 Baso-0.3
[**2149-11-10**] 10:50AM BLOOD Glucose-141* UreaN-9 Creat-0.4 Na-140
K-4.2 Cl-100 HCO3-32 AnGap-12
[**2149-11-11**] 03:35AM BLOOD Calcium-8.3* Phos-2.9 Mg-1.8
[**2149-11-10**] 11:02AM BLOOD Lactate-2.3*
[**2149-11-11**] 03:52AM BLOOD Type-[**Last Name (un) **] pO2-74* pCO2-75* pH-7.26*
calTCO2-35* Base XS-3 Comment-GREEN TOP
[**2149-11-11**] 03:52AM BLOOD Lactate-1.3
[**2149-11-11**] 07:51AM BLOOD Type-[**Last Name (un) **] pO2-47* pCO2-87* pH-7.24*
calTCO2-39* Base XS-6
[**2149-11-11**] 12:18PM BLOOD Type-[**Last Name (un) **] pO2-96 pCO2-73* pH-7.28*
calTCO2-36* Base XS-4 Comment-GREEN TOP
[**2149-11-11**] 07:51AM BLOOD Lactate-0.8
.
micro:
   **FINAL REPORT [**2149-11-12**]**

   URINE CULTURE (Final [**2149-11-12**]):
      KLEBSIELLA PNEUMONIAE.    >100,000 ORGANISMS/ML..
         Piperacillin/tazobactam sensitivity testing available
on request.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             KLEBSIELLA PNEUMONIAE
                             |
AMIKACIN--------------  =>64 R
AMPICILLIN/SULBACTAM--    16 I
CEFAZOLIN-------------  =>64 R
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------  =>64 R
CEFTRIAXONE-----------     8 R
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------  =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN--------   256 R
TOBRAMYCIN------------  =>16 R
TRIMETHOPRIM/SULFA----  =>16 R

                            **FINAL REPORT [**2149-11-13**]**

   GRAM STAIN (Final [**2149-11-10**]):
      >25 PMNs and <10 epithelial cells/100X field.
      4+   (>10 per 1000X FIELD):   MULTIPLE ORGANISMS
CONSISTENT WITH
                                    OROPHARYNGEAL FLORA.
      SMEAR REVIEWED; RESULTS CONFIRMED.

   RESPIRATORY CULTURE (Final [**2149-11-13**]):
      Commensal Respiratory Flora Absent.
      STAPH AUREUS COAG +.    MODERATE GROWTH.
         OF TWO COLONIAL MORPHOLOGIES.
         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.
      KLEBSIELLA PNEUMONIAE.    SPARSE GROWTH.
         Piperacillin/tazobactam sensitivity testing available
on request.
         Cefazolin interpretative criteria are based on a dosage
regimen of
         2g every 8h.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |          KLEBSIELLA PNEUMONIAE
                             |          |
AMIKACIN--------------             =>64 R
AMPICILLIN/SULBACTAM--                8 S
CEFAZOLIN-------------             =>64 R
CEFEPIME--------------              <=1 S
CEFTAZIDIME-----------             =>64 R
CEFTRIAXONE-----------                8 R
CIPROFLOXACIN---------              =>4 R
CLINDAMYCIN-----------   =>8 R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S     =>16 R
LEVOFLOXACIN----------   =>8 R
MEROPENEM-------------           <=0.25 S
OXACILLIN-------------   =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
TOBRAMYCIN------------             =>16 R
TRIMETHOPRIM/SULFA---- <=0.5 S        2 S
VANCOMYCIN------------     1 S

CXR [**2149-11-10**]
CHEST, AP AND LATERAL: Patient was unable to raise her arms for
the lateral view, on which bilateral humeral fixation plates and
screws obscure evaluation.  Left internal jugular catheter has
been removed. Right PICC again terminates in the mid SVC. There
is no pneumothorax.  The lungs are overinflated. Moderate
cardiomegaly persists, with vascular congestion and small
bilateral pleural effusions. Lower lobe opacities
persist, left greater than right.  There are old healed
bilateral rib fractures, with associated chest wall deformity.
IMPRESSION:
1. Chronic obstructive airways disease.
2. Congestive heart failure.
3. Bilateral lower lobe opacities may be secondary to #2, but
superimposed
pneumonia is not excluded.

ECHO
The left atrium is elongated. The right atrium is moderately
dilated. Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is mild
pulmonary artery systolic hypertension. There is a very small
pericardial effusion.
IMPRESSION: Suboptimal study. Normal global biventricular
systolic function. Mild pulmonary hypertension. Very small
pericardial effusion.
.
video swallow study
Penetration and aspiration with thin liquids. Chin tuck helps to

limit aspiration with thin liquids. Penetration with
nectar-thick liquids.  For details, please refer to speech and
swallow division note in OMR.
.
discharge labs
[**2149-11-17**] 05:50AM BLOOD WBC-4.9 RBC-3.12* Hgb-8.3* Hct-27.2*
MCV-87 MCH-26.5* MCHC-30.4* RDW-14.6 Plt Ct-216
[**2149-11-17**] 05:50AM BLOOD Glucose-81 UreaN-5* Creat-0.2* Na-145
K-4.0 Cl-102 HCO3-40* AnGap-7*
[**2149-11-17**] 05:50AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.0

Brief Hospital Course:
53F T1-T2 paraplegia s/p MVC, recurrent UTI/PNA, and anxiety who
is presented with SOB and fever initially admitted to the MICU
found to have UTI and pneumonia which improved with antibiotic
treatment.
.
# UTI - Urine cx showed multi-drug resistant klebsiella (only
sensitive to meropenem and cefepime). Patient started on
meropenem. PICC line placement was unsuccessful and tunneled
line was placed. Patient discharged with plans to complete total
10 day course of antibiotics.
.
# pneumonia - Patient presented with SOB, fever, and increased
O2 requirement. CXR showed R pleural effusion and could not
exclude pneumonia. Also given dysphagia concern for aspiration.
Pleural effusion thought to be parapneumonic vs [**3-5**] to heart
failure (CXR also showed enlarged heart). Echo was done and
showed normal EF.
Component of SOB/hypoxia also thought to be secondary to
hypoventilation from underlying paraplegia. Sputum cultures grew
MRSA and klebsiella. Patient was treated with vancomycin,
meropenum, levofloxacin, nebulizers and chest PT while in the
MICU. Levofloxacin was discontinued prior to transfer to the
floor after urine legionella was found to be negative.  Given
difficult access, a tunneled line was eventually placed after
failed PICC attempts. Patient clinically improved and oxygen
requirement returned to baseline 2L. Patient was discharged with
plans to complete total 10 day course of IV antibiotics.
.
# Hypotension. Patient initially presented with SBP in the 90s.
She was given 3L in the ED. BP remained stable in the MICU and
on the floor after fluid resuscitation.
.
# Dysphagia. - followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 572**] as outpatient. Symptoms
are thought to be related to dysphagia for solid foods, although
there is some question whether there may be over spill into the
larynx as well. Previous endoscopy demonstrated some mild
changes in the esophagus, but no obvious stricture; it is
possible in the interim she has developed a stricture as pt with
h/o tracheostomy. Also note of possible esophageal mass on [**9-11**]
CT, although very small in size.  S&S recommended regular diet
with thin liquid and video swallow study. Video swallow study
was completed which showed penetration and aspiration with thin
liquids. Chin tuck helped to limit aspiration with thin liquids.
Also showed penetration with nectar-thick liquids.
Recommendations included thin liquids and moist solids, pills
with puree, and aspiration precautions. Patient has plans to
follow up with outpatient gastroenterologist for further
evaluation and treatment.
.
# Depression/Anxiety - continued clonazepam, citalopram,
trazodone
.
# Hypothyroid - continued levothyroxine
.
# chronic pain - continued baclofen, lyrica, methadone,
lidocaine patches. Also was given oxycodone prn.
.
transitional issues
- complete antibiotics as prescribed
- tunneled line will need to be removed after completion of
treatment
- HCO3 will need to be rechecked as was slightly elevated upon
discharge
- patient was full code on this admission

Medications on Admission:
ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for
Nebulization - one vial inh 4-6 hours prn
BACLOFEN - 10 mg Tablet - 2 (Two) Tablet(s) by mouth in the
morning; 1 (One) tablet at 4 pm and 2 (Two) tablets at bedtime
CITALOPRAM - 20 mg Tablet - 2 Tablet(s) by mouth once a day
CLONAZEPAM [KLONOPIN] - 0.5 mg Tablet - 2 Tablet(s) by mouth (1
mg) three times a day
ESTRADIOL [ESTRACE] - 0.01 % Cream - apply to exterrnal gyn area
twice a week
IPRATROPIUM-ALBUTEROL [COMBIVENT] - 18 mcg-103 mcg (90
mcg)/Actuation Aerosol - 2 puffs three times a day
LEVOTHYROXINE - 112 mcg Tablet - 1 (One) Tablet(s) by mouth once
a day
LIDOCAINE - 5 % (700 mg/patch) Adhesive Patch, Medicated - apply
four patches to the affected areas once a day 12 hours off and
12
hours on - No Substitution
LIDOCAINE HCL - 5 % Ointment - Apply externally to affected area
once a day  as needed for burning
METHADONE - 5 mg Tablet - 1 Tablet(s) by mouth three times daily
for pain
METHENAMINE HIPPURATE - 1 gram Tablet - 1 Tablet(s) by mouth
twice a day take with Vitamin C 500
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - one
Capsule(s) by mouth twice a day
OXYBUTYNIN CHLORIDE - 5 mg Tablet - 2 Tablet(s) by mouth in the
AM, one in the afternoon, and 2 in the evening
OXYCODONE - 5 mg Tablet - 1 Tablet(s) by mouth three times a day
as needed for pain
PREGABALIN [LYRICA] - 100 mg Capsule - 1 Capsule(s) by mouth
three times a day
SIMVASTATIN - 10 mg Tablet - 1 Tablet(s) by mouth daily
SUCRALFATE -  (post d/c med) (On Hold from [**2148-8-27**] to
[**2148-9-3**] for while taking levaquin) - 1 gram Tablet - 1
Tablet(s) by mouth four times a day
TRAZODONE - 100 mg Tablet - 1 Tablet(s) by mouth at bedtime
.
Medications - OTC
CALCIUM CARBONATE [CALCIUM 500] -  (Prescribed by Other
Provider)
(On Hold from [**2148-8-27**] to [**2148-9-3**] for while taking
levaquin)
- 500 mg (1,250 mg) Tablet - 1 Tablet(s) by mouth twice daily pt
unsure if 500mg or 600mg
CATHETER [FOLEY CATHETER] - 14 Fr [**Year (4 digits) 12106**] - Use for urinary
control/self catheterizaion as needed Dx: Neurogenic bladder,
paraplegia  (1 month supply)
FACIAL-BODY WIPES [BABY WIPES] -   [**Name2 (NI) 12106**] - USE AS DIRECTED PRN
NEBULIZER -   Kit - for use in home qd. dx: pneumonia
NICOTINE -  (Prescribed by Other Provider) (Not Taking as
Prescribed) - 21 mg/24 hour Patch 24 hr - apply 1 patch daily as
directed
POLYETHYLENE GLYCOL 3350 [MIRALAX] -  (Not Taking as Prescribed:
not on medication list provided by patient [**2146-6-15**]) - 17 gram
(100 %) Powder in Packet - one pack by mouth once a day
SURGICAL LUBRICANT JELLY [SURGILUBE] -   Gel - as needed for
straight cath


Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day/Year **]: One (1) vial Inhalation Q6H (every 6 hours) as
needed for SOB.
2. baclofen 10 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO BID (2 times a
day).
3. citalopram 20 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO DAILY (Daily).

4. clonazepam 0.5 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO three times a
day.
5. vancomycin in D5W 1 gram/200 mL Piggyback [**Month/Day/Year **]: One (1) gram
Intravenous Q 12H (Every 12 Hours) for 5 days: continue until
[**2149-11-21**]. .
Disp:*10 gram* Refills:*0*
6. meropenem 1 gram Recon Soln [**Month/Day/Year **]: One (1) Recon Soln
Intravenous Q8H (every 8 hours) for 5 days: continue through
[**2149-11-21**].
Disp:*QS Recon Soln(s)* Refills:*0*
7. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Month/Day/Year **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply
four patches to the affected areas once a day 12 hours off and
12 hours on - No Substitution
.
8. levothyroxine 112 mcg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
9. Combivent 18-103 mcg/Actuation Aerosol Inhalation
10. methadone 5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO TID (3 times a
day).
11. oxycodone 5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO three times a
day as needed for pain.
12. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Month/Day/Year **]: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
13. pregabalin 100 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO TID (3
times a day).
14. simvastatin 10 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
15. trazodone 100 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO at bedtime.
16. Outpatient Lab Work
Please check CBC, Chem 7, Vancomycin trough level on [**2149-11-18**]
and fax results to Dr.[**Last Name (STitle) 665**] FAX#:[**Telephone/Fax (1) 78619**].
17. Outpatient Lab Work
Please check CBC, Chem 7, on [**2149-11-22**] and fax results to
Dr.[**Last Name (STitle) 665**] FAX#:[**Telephone/Fax (1) 78619**].
18. estradiol 0.01 % (0.1 mg/g) Cream [**Telephone/Fax (1) **]: as directed mg
Vaginal twice weekly: apply to external gyn area twice a week
.
19. lidocaine 5 % Cream [**Telephone/Fax (1) **]: as directed cream Topical once a
day as needed for pain: Apply externally to affected area
once a day as needed for burning
.
20. methenamine hippurate 1 gram Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO
twice a day: take with Vitamin C 500
.
21. oxybutynin chloride 5 mg Tablet [**Telephone/Fax (1) **]: as directed Tablet PO
as directed: 2 Tablet(s) by mouth in the
AM, one in the afternoon, and 2 in the evening
.


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 1474**] VNA

Discharge Diagnosis:
1)Pneumonia
2)Urinary Tract Infection


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


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

You were admitted to our hospital with a concern for a urinary
tract infection and pneumonia. We had trouble obtaining
intravenous access to administer antibiotics, and finally
established it. You will need to have the catheter in for
administration of intravenous antibiotics for a total of 5 more
days. After that you will need to have the catheter removed.
Please keep the catheter site dry and intact.

The following changes were made to your medication regimen:

START Vancomycin
START Meropenem


Followup Instructions:
Department: DIGESTIVE DISEASE CENTER
When: WEDNESDAY [**2149-11-19**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**]
Campus: EAST     Best Parking: Main Garage

Department: ENDO SUITES
When: WEDNESDAY [**2149-11-19**] at 1 PM

Department: [**Hospital3 249**]
When: WEDNESDAY [**2149-11-26**] at 9:00 AM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage



Completed by:[**2149-11-17**]
{"Paraplegia,Urinary tract infection, site not specified,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Chronic hepatitis C without mention of hepatic coma,Tracheostomy status,Dysphagia, oropharyngeal phase,Other respiratory abnormalities,Chronic airway obstruction, not elsewhere classified,Late effect of spinal cord injury,Late effects of motor vehicle accident,Unspecified disorder of esophagus,Unspecified disorder of metabolism,Atrophic gastritis, without mention of hemorrhage,Other chronic pain,Anemia of other chronic disease,Dysthymic disorder,Personal history of venous thrombosis and embolism,Methicillin resistant pneumonia due to Staphylococcus aureus,Alkalosis"}


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: dyspnea

PRESENT ILLNESS: For a full admission note, please see MICU Green note. In brief,
this is a 53 year old woman with PMH significant for T1-T2
paraplegia s/p MVC, recurrent UTI/PNA, chronically on 2L of
oxygen at home, and anxiety who presented to hospital with
shortness of breath and fevers.
.
Caretaker noted her to be breathing faster than normal prior to
admission. She also reports recent dysphagia, concerning for
aspiration pneumonia. At home does intermittently straight-cath,
however she is unable to discern signs/sx of UTI. Per care
taker, she was seen by Dr [**Last Name (STitle) 665**] several weeks again found to
have +UA however no definite culture data so not treated.
.
In the ED she was found to have temp of 100.7 with O2 sat at 84%
on 2L (baseline in low 90s) and SBP in 90s. Her WBC count was
elevated and UA found to be positive. She got 2 L of fluid and
was transferred to the MICU. Of note, she had a PICC line on
admission.
.
While in the MICU, she started treatment for UTI with vanc and
[**Last Name (un) 2830**] given hx of [**Last Name (un) 40097**]. She had a CXR that could not exclude
pneumonia. She was also on levaquin for 3 days for legionella
coverage but this was stopped on [**11-11**] when found to be
negative. She has been getting chest PT and nebs and also
reports some cough. Sputum culture growing coagulase positive
staph and gram negative rods.
She had 1 positive blood cx for coag negative staph and PICC
line was pulled.
.
Prior to transfer to the floor her blood pressure was in low
100s, she was mentating well and had no active complaints.

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

MEDICATION ON ADMISSION: ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for
Nebulization - one vial inh 4-6 hours prn
BACLOFEN - 10 mg Tablet - 2 (Two) Tablet(s) by mouth in the
morning; 1 (One) tablet at 4 pm and 2 (Two) tablets at bedtime
CITALOPRAM - 20 mg Tablet - 2 Tablet(s) by mouth once a day
CLONAZEPAM [KLONOPIN] - 0.5 mg Tablet - 2 Tablet(s) by mouth (1
mg) three times a day
ESTRADIOL [ESTRACE] - 0.01 % Cream - apply to exterrnal gyn area
twice a week
IPRATROPIUM-ALBUTEROL [COMBIVENT] - 18 mcg-103 mcg (90
mcg)/Actuation Aerosol - 2 puffs three times a day
LEVOTHYROXINE - 112 mcg Tablet - 1 (One) Tablet(s) by mouth once
a day
LIDOCAINE - 5 % (700 mg/patch) Adhesive Patch, Medicated - apply
four patches to the affected areas once a day 12 hours off and
12
hours on - No Substitution
LIDOCAINE HCL - 5 % Ointment - Apply externally to affected area
once a day  as needed for burning
METHADONE - 5 mg Tablet - 1 Tablet(s) by mouth three times daily
for pain
METHENAMINE HIPPURATE - 1 gram Tablet - 1 Tablet(s) by mouth
twice a day take with Vitamin C 500
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - one
Capsule(s) by mouth twice a day
OXYBUTYNIN CHLORIDE - 5 mg Tablet - 2 Tablet(s) by mouth in the
AM, one in the afternoon, and 2 in the evening
OXYCODONE - 5 mg Tablet - 1 Tablet(s) by mouth three times a day
as needed for pain
PREGABALIN [LYRICA] - 100 mg Capsule - 1 Capsule(s) by mouth
three times a day
SIMVASTATIN - 10 mg Tablet - 1 Tablet(s) by mouth daily
SUCRALFATE -  (post d/c med) (On Hold from [**2148-8-27**] to
[**2148-9-3**] for while taking levaquin) - 1 gram Tablet - 1
Tablet(s) by mouth four times a day
TRAZODONE - 100 mg Tablet - 1 Tablet(s) by mouth at bedtime
.
Medications - OTC
CALCIUM CARBONATE [CALCIUM 500] -  (Prescribed by Other
Provider)
(On Hold from [**2148-8-27**] to [**2148-9-3**] for while taking
levaquin)
- 500 mg (1,250 mg) Tablet - 1 Tablet(s) by mouth twice daily pt
unsure if 500mg or 600mg
CATHETER [FOLEY CATHETER] - 14 Fr [**Year (4 digits) 12106**] - Use for urinary
control/self catheterizaion as needed Dx: Neurogenic bladder,
paraplegia  (1 month supply)
FACIAL-BODY WIPES [BABY WIPES] -   [**Name2 (NI) 12106**] - USE AS DIRECTED PRN
NEBULIZER -   Kit - for use in home qd. dx: pneumonia
NICOTINE -  (Prescribed by Other Provider) (Not Taking as
Prescribed) - 21 mg/24 hour Patch 24 hr - apply 1 patch daily as
directed
POLYETHYLENE GLYCOL 3350 [MIRALAX] -  (Not Taking as Prescribed:
not on medication list provided by patient [**2146-6-15**]) - 17 gram
(100 %) Powder in Packet - one pack by mouth once a day
SURGICAL LUBRICANT JELLY [SURGILUBE] -   Gel - as needed for
straight cath

ALLERGIES: Ativan

PHYSICAL EXAM: Physical Exam on Arrival to the MICU
VS: Tmax: 37.1 ??????C (98.7 ??????F)
Tcurrent: 36 ??????C (96.8 ??????F)
HR: 65 (62 - 80) bpm
BP: 83/47(55) {83/45(55) - 93/74(77)} mmHg
RR: 17 (12 - 23) insp/min
SpO2: 99%
General: Alert, oriented, agitated
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Mother passed away with lung disease.

SOCIAL HISTORY: Lives at home with husband and 2 adolescent children.
- Tobacco: 35-pack-years, quit several months ago, relapsed
recently.
- Alcohol: Denies.
- Illicits: Denies. 

### Response:
{"Paraplegia,Urinary tract infection, site not specified,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Chronic hepatitis C without mention of hepatic coma,Tracheostomy status,Dysphagia, oropharyngeal phase,Other respiratory abnormalities,Chronic airway obstruction, not elsewhere classified,Late effect of spinal cord injury,Late effects of motor vehicle accident,Unspecified disorder of esophagus,Unspecified disorder of metabolism,Atrophic gastritis, without mention of hemorrhage,Other chronic pain,Anemia of other chronic disease,Dysthymic disorder,Personal history of venous thrombosis and embolism,Methicillin resistant pneumonia due to Staphylococcus aureus,Alkalosis"}
