CHIEF COMPLAINT: Confusion and lethargy

PRESENT ILLNESS: 77yo WF presents w confusion for 3-4 days. I communicated w the
pt via Italian interpreter over the phone. The interpreter did
not understand the pt very well. I talked to her daughter-in-law
[**First Name5 (NamePattern1) **] [**Name (NI) 107847**] [**Telephone/Fax (1) 107848**]) to obtain the hx. She has been
talking non-sensically for 3-4 days. She fell asleep several
times during the day. She did not use C pap machine consistently
at night for OSA.

MEDICAL HISTORY: HTN, CHF, CAD
Hyperlipidemia
Dm2
Afib on Coumadin
Gout
Sleep Apnea
COPD
LE venous stasis

MEDICATION ON ADMISSION: 1. KCl 20meq 2tabs daily
2. Isosorbide 30mg daily
3. Gabapentin 300mg [**Hospital1 **]
4. Furosemide 20mg 2tabs QAM, 1tab QHS
5. Allopurinol 300mg daily
6. Coumadin 2mg daily
7. Tramadol 50mg 1-2tabs Q6H prn
8. Lipitor 20mg daily
9. Glyburide 5mg [**Hospital1 **]

ALLERGIES: Lisinopril

PHYSICAL EXAM: 97.1, 84, 150/70, 20, 97% on 3L
GEN: Morbid obese, AAOx1 (to person), NAD
HEENT: Grossly intact, EOMI
NECK: Supple
HEART: Irregularly irregular w 3/6 SEM
LUNG: Decreased BS equally bilateral. CTAB
ABD: BS+, soft, NT/ND
EXT: Bilateral LE skin change [**12-26**] venous stasis
NEURO: Non focal, ME [**3-27**] UE, [**2-26**] LE. Could not eval DTR as pt
did not relax.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: denies smoking, etoh use
Lives w son and daughter in law
Uses wheelchair to ambulate
Acute respiratory failure,Paroxysmal ventricular tachycardia,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Hyperosmolality and/or hypernatremia,Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Chronic airway obstruction, not elsewhere classified,Gout, unspecified
Acute respiratry failure,Parox ventric tachycard,Pneumonia, organism NOS,Urin tract infection NOS,Hyperosmolality,Proteus infection NOS,DMII wo cmp uncntrld,Chr airway obstruct NEC,Gout NOS
Admission Date:  [**2184-8-16**]              Discharge Date:   [**2184-9-1**]

Date of Birth:  [**2107-1-31**]             Sex:   F

Service: MEDICINE

Allergies:
Lisinopril

Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Confusion and lethargy

Major Surgical or Invasive Procedure:
bipap and cpap ventilation


History of Present Illness:
77yo WF presents w confusion for 3-4 days. I communicated w the
pt via Italian interpreter over the phone. The interpreter did
not understand the pt very well. I talked to her daughter-in-law
[**First Name5 (NamePattern1) **] [**Name (NI) 107847**] [**Telephone/Fax (1) 107848**]) to obtain the hx. She has been
talking non-sensically for 3-4 days. She fell asleep several
times during the day. She did not use C pap machine consistently
at night for OSA.

The pt uses wheelchair to ambulate for several years [**12-26**] knee
pain. She has been eating and voiding well

Denies CP, SOB, HA, dizziness or any other Sx

Past Medical History:
HTN, CHF, CAD
Hyperlipidemia
Dm2
Afib on Coumadin
Gout
Sleep Apnea
COPD
LE venous stasis

Social History:
denies smoking, etoh use
Lives w son and daughter in law
Uses wheelchair to ambulate


Family History:
Noncontributory

Physical Exam:
97.1, 84, 150/70, 20, 97% on 3L
GEN: Morbid obese, AAOx1 (to person), NAD
HEENT: Grossly intact, EOMI
NECK: Supple
HEART: Irregularly irregular w 3/6 SEM
LUNG: Decreased BS equally bilateral. CTAB
ABD: BS+, soft, NT/ND
EXT: Bilateral LE skin change [**12-26**] venous stasis
NEURO: Non focal, ME [**3-27**] UE, [**2-26**] LE. Could not eval DTR as pt
did not relax.


Pertinent Results:
[**2184-8-15**] WBC-9.3 RBC-3.48* Hgb-10.5* Hct-32.8* MCV-94 MCH-30.1
MCHC-31.9 RDW-15.7* Plt Ct-363 Neuts-80.1* Lymphs-13.4*
Monos-4.9 Eos-1.4 Baso-0.2
[**2184-8-15**] PT-17.4* PTT-25.8 INR(PT)-1.6*
[**2184-8-15**]  Glucose-208* UreaN-11 Creat-0.9 Na-141 K-3.9 Cl-101
HCO3-33*  Calcium-8.6 Phos-2.8 Mg-2.2
[**2184-8-15**] BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
[**2184-8-15**] 07:40PM BLOOD Lactate-2.0

[**2184-8-15**] 11:10PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.019
Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG RBC-0-2 WBC-0
Bacteri-NONE Yeast-NONE Epi-0-2
[**2184-8-16**] 12:09AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG

[**2184-8-15**] 07:40PM BLOOD CK(CPK)-45  CK-MB-NotDone cTropnT-0.02*
[**2184-8-16**] 03:07AM BLOOD CK(CPK)-53  CK-MB-NotDone  cTropnT-0.02*
[**2184-8-16**] 07:15AM BLOOD CK(CPK)-39  CK-MB-2 cTropnT-<0.01
[**2184-8-16**] 03:40PM CK(CPK)-40 CK-MB-2
[**2184-8-17**] 10:33AM BLOOD CK(CPK)-25* CK-MB-3 cTropnT-<0.01

ABG DATA:
[**2184-8-15**] 10:25PM BLOOD Type-ART Rates-/20 O2 Flow-3 pO2-96
pCO2-60* pH-7.37 calTCO2-36* NOT intubated
[**2184-8-16**] 02:46PM BLOOD Type-ART pO2-43* pCO2-66* pH-7.35
calTCO2-38*
[**2184-8-17**] 01:26AM BLOOD Type-ART pO2-128* pCO2-68* pH-7.33*
calTCO2-37*
[**2184-8-17**] 07:50AM BLOOD Type-ART pO2-248* pCO2-65* pH-7.35
calTCO2-37*

[**2184-8-19**]  WBC-9.7 RBC-3.57* Hgb-10.8* Hct-34.1* MCV-95 MCH-30.2
MCHC-31.7 RDW-15.7* Plt Ct-330
[**2184-8-19**]  PT-18.9* PTT-26.6 INR(PT)-1.8*
[**2184-8-19**]  Glucose-106* UreaN-8 Creat-0.6 Na-144 K-3.9 Cl-101
HCO3-34*
[**2184-8-18**]  ALT-9 AST-12 LD(LDH)-217 AlkPhos-65 Amylase-22
TotBili-0.5
[**2184-8-18**] 03:40AM BLOOD Lipase-23

PCXR:  Apparent interval improvement in the degree of pulmonary
congestion.  Cardiomegaly is stable.

EKG: A fib w VR controlled, PVC, nl axis. No signi change since
[**6-29**].

[**2184-8-15**] CT head: There is no evidence of infarctin, hemorrhage,
mass effect, shift of normally midline structures or
hydrocephalus. There has been no change since the prior study.
The ventricles and sulci are prominent consistent with
age-related involutional change. No definite osseous
abnormalities are appreciated. There are no air-fluid levels
within the paranasal sinuses. The mastoid air cells are
bilaterally poorly pneumatized. The middle ear cavities are
clear. The soft tissues appear unremarkable.

[**2184-8-15**] CTA chest:
1.  No evidence of central or segmental pulmonary embolism.
2.  Stable cardiomegaly.
3.  Mild increase in the size of the small bilateral pleural
effusions with associated atelectasis compared to the [**2184-6-26**] study.
4.  Patchy areas of increased lucency within both lungs, may
relate to air
trapping.

[**2184-8-18**] CXR: Possible new right pleural effusion. Evaluation
with standard PA and lateral radiograph would be recommended for
precise evaluation of these findings. Pulmonary hypertension.

[**2184-8-14**] RUQ US: Cholelithiasis, without evidence of acute
cholecystitis.

[**2184-8-28**]:
A comparison is made with the prior chest x-rays of [**Month (only) 359**] the
6th. Tracheostomy tube is again seen. A nasogastric tube is
present. The position of the left PICC line remains unaltered.

The heart is enlarged. Bilateral pleural effusions are present
and there is generally increased pulmonary plethora even
allowing for the supine position and I suspect the presence of
failure. Pneumonia less likely.
.
[**2184-8-28**] CXR:INDICATION: PICC line placement.
Repeat AP view of the chest is obtained [**2184-8-28**] at 18:20 hours
for PICC line placement and shows that the PICC line is within
the right atrium. Dr. [**Last Name (STitle) **] discussed this with [**Doctor Last Name 7830**] and
advised a repeat film after repositioning.
.
LABS ON DISCHARGE:[**2184-9-1**] 05:49AM    10.5 3.32* 10.0* 30.4*
92 30.1 32.8 15.7* 387
Source: Line-picc line
  DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2184-8-31**] 04:56AM    80.8*   11.4* 4.4 3.2 0.2
Source: Line-PICC
  BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2184-9-1**] 05:49AM        387
Source: Line-picc line
[**2184-9-1**] 05:49AM    19.4* 28.7   1.9*
Source: Line-picc line
HEMOLYTIC WORKUP Ret Aut
[**2184-8-26**] 04:34AM    1.9
DIFF ADDED 9:51AM

Chemistry
  RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2184-9-1**] 05:49AM    176* 13 0.6 144 3.6 106 33* 9
TROUGH/VANCO
  ESTIMATED GFR (MDRD CALCULATION) estGFR
[**2184-8-29**] 12:31AM    Using this1
Source: Line-PICC
1 Using this patient's age, gender, and serum creatinine value
of 0.6,
Estimated GFR = >75 if non African-American (mL/min/1.73 m2)
Estimated GFR = >75 if African-American (mL/min/1.73 m2)
For comparison, mean GFR for age group 70+ is 75 (mL/min/1.73
m2)
GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure
  ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2184-8-30**] 04:30AM    4 9     49   0.6
Source: Line-PICC
OTHER ENZYMES & BILIRUBINS Lipase
[**2184-8-18**] 03:40AM    23
LFT ADDED [**8-18**] @ 12:16
  CPK ISOENZYMES CK-MB cTropnT proBNP
[**2184-8-26**] 04:34AM    4 <0.[**Telephone/Fax (1) 107849**]*2
CHEMS ADDED 9:53AM
1 <0.01
CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
2 REFERENCE VALUES VARY WITH AGE, SEX, AND RENAL FUNCTION;AT 35%
PREVALENCE, NTPROBNP VALUES; < 450 HAVE 99% NEG PRED VALUE;
>1000 HAVE 78% POS PRED VALUE;SEE ONLINE LAB MANUAL FOR MORE
DETAILED INFORMATION
  CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron

[**2184-9-1**] 05:49AM          8.6 2.3* 2.0
TROUGH/VANCO
  ANTIBIOTICS Vanco
[**2184-9-1**] 05:49AM    16.81
TROUGH/VANCO
1 UPDATED REFERENCE RANGE AS OF [**2183-7-23**] == REPRESENTS
THERAPEUTIC TROUGH
  CARDIAC/PULMONARY Digoxin
[**2184-8-17**] 03:00AM    1.2
TOXICOLOGY, SERUM AND OTHER DRUGS ASA Acetmnp Bnzodzp Barbitr
Tricycl
[**2184-8-15**] 07:40PM    NEG NEG NEG NEG NEG
LAB USE ONLY RedHold
[**2184-8-15**] 07:40PM    HOLD

Blood Gas
  BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2
pH calTCO2 Base XS Intubat Vent Comment
[**2184-8-30**] 08:25AM    ART             94 54* 7.39 34* 5
  WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Glucose Lactate Na K Cl
[**2184-8-30**] 08:25AM      1.0
HEMOGLOBLIN FRACTIONS ( COOXIMETRY) Hgb calcHCT
[**2184-8-20**] 10:45AM    11.3* 34



Brief Hospital Course:
77 y.o. Italian speaking female with PMHx of OSA, obesity,
atrial fibrillation, DM who was transferred to the MICU for
concern for hypercarbic respiratory failure.
.
1) Respiratory Failure: Tracheostomy [**8-27**], on BiPAP continuously
at pressure support of 15 and positive end expiratory pressure
of 5 with oxygen saturations greater than 95%.
.
Patient has COPD and OSA and is non-compliant with CPAP, likely
causing chronic CO2 retention. Patient's baseline seems to be
50s to mid 60s recently and she is compensated given elevated
bicarbonate values. In addition, to elevated PCO2 is the
patient's hypoxia on room air. Pulmonary embolism was ruled out
on CTA. Postulated that there was a possible contribution of
obesity-hyperventilation syndrome for explanation for hypoxia.
Initially. on BiPAP on admission to [**Hospital Unit Name 153**] with improved ABG.
Changed BiPAP to O2 via NC with repeat ABG showing adequate
oxygenation.  Transitions to CPAP with improvement in PCO2 and
PO2.  Primary problem is that patient becomes agitated at night
and does not keep CPAP mask on.  Haldol did not improve
patient's agitation.  Patient initially improved with Zyprexa,
but continue to experience trouble wearing CPAP.  Ativan was
tried, but proved to be over sedating. Patient with medication
given adequate trial of CPAP, and BiPAP, but still failed to
improve mental status and continued to resist wearing a mask.
.
Discussion with family, especially son who is healthcare power
of attorney and translator [**8-19**] if the patient is unable to
tolerate the mask and/or does not improve mental status she may
need tracheostomy.  Completed 3 days of nightly ventilation with
no clearing of delirium.  Patient continues to struggle against
mask.  Feel tracheostomy is indicated to provide more stable
airway.  Tracheostomy placed [**2184-8-27**], quickly weaned off of
midazolam. Patient stabilized on trazodone and zyprexa for
delirium.
.
Within 24 hours of placing tracheostomy, patient developed new
infiltrate on [**8-28**] CXR, increased sputum and fever to 100.8.
Patient treated empirically for hospital-acquired pneumonia.
Patient sputum rare MRSA growth. Will finish 10 -day course of
Vancomycin and Cefepime on [**9-6**].
.
Patient also diuresed as CXR while in hospital show bilateral
pleural effusions not seen on admission. during diuresis patient
has required electrolyte monitoring and repletion. Will continue
to diurese patient at rehabilitation facility.
.
Patient with tracheostomy at time of discharge doing well on
BiPAP continuously at pressure support of 15 and positive end
expiratory pressure of 5 with oxygen saturations greater than
95%. Tolerating trials on tracheostomy mask while sitting up.
-----At facility, continue antibiotics Vancomycin 1 gm q12h and
Cefepime 2gm q12h until [**9-6**]
-----After antibiotic course if finished, if not needed for
another purpose, pull PICC.
-----Continue to diurese patient until BUN and Cr bump. Then
transition patient to PO regimen. Patient initially admitted on
standing PO Lasix.
.
2) Mental Status Changes: Alert at time of discharge. Able to
follow simple commands.
.
On admission altered mental status initially attributed to
hypercarbia given recent transfer to the MICU for similar CO2 of
65 in early [**Month (only) 216**]. Hypercarbia treated as above with no to
minimal clearing of mental status.
.
Infectious work-up for altered mental status was initially
negative including blood and urine cultures. Patient recognizes
family, disoriented as to location, date, reason for
hospitalization with waxing and [**Doctor Last Name 688**] levels of alertness =
delirium. Patient was started on Ativan which was too sedating.
Patient was tried on Haldol with no effect. Patient was
stabilized on zyprexa and trazodone. This has improved patient's
sleep/wake cycles which had been initially disturbed and the
patient is more alert at time of discharge.
.
Patient mental status was complicated by low grade fevers.  The
work-up of these fevers revealed a pan-sensitive proteus urinary
tract infection which was treated for a seven day course.
Patient re-spiked fever with increased secretions and diagnosed
with a hospital acquired pneumonia [**8-28**].  Patient currently
being treated with Vancomycin and Cefepime.
----- Finish Vancomycin/Cefepime course for pneumonia (see
above)
----- Avoid benzodiazepines
----- Continue Zyprexa 5mg and Trazodone 25 mg QHS to assist
with sleep/wake cycles
----- Patient may have some component of underlying dementia.
.
3) Fever/Leukocytosis: Patient course complicated by low grade
fevers and leukocytosis.  These have been attributed to urinary
tract infection, and pneumonia. [**Month (only) 116**] also be a component of
atelectasis. At time of discharge patient afebrile greater than
48 hours, and leukocytosis resolving.
---- Complete antibiotic course as above.
.
4) Hypernatremia: Resolved. Occurred in the setting of diuresis.

----- Free water flushes 150ml q4hr.
----- Monitor daily electrolytes
.
5) Hypoxemia: Resolved. Patient became acutely hypoxic after
removal of BiPAP 10/4 am. Strongly suspect patient went into
flash pulmonary edema. O2 sats to 78% with HR in Afib to 160s at
times, rapidly improved with reinitiation of BiPAP.  No change
in patients CO2 by ABG. This episode of hypoxemia was managed by
reinitiating BiPAP, giving IV lopressor for keep HR <100 and
diuresis, 20 mg iv lasix, goal volume decrease 0.5L over 24
hours. ECG was unremarkable. BNP was at baseline
.
6) Atrial Fibrillation:
Rate-controlled and anticoagulated on Coumadin. Digoxin being
held given recent elevated level.  Will continue to hold Digoxin
for now as patient is rate controlled. Pt. can follow-up with
PCP for further [**Name9 (PRE) 23367**]. Coumadin held [**8-25**] and [**8-26**] and received
10 mg vitamin K in preparation for tracheostomy.  Patient
tolerated procedure well and was retarted on coumadin 2 mg daily
[**8-28**]. Held Coumadin for INR of 3 [**8-30**].
---- Metoprolol 50 mg TID for rate control.
---- Coumadin 2mg qhs
---- Monitor INR
.
7) Diabetes - Well controlled.
Has been well controlled since admit to the ICU with simple ISS
and home dosing of glyburide.  Additionally has some component
of diabetic neuropathy and was on gabapentin as an outpatient,
but held secondary to AMS. Glyburide held while patient NPO, but
restarted with patient tube feeds.
---- Continue glyburide
---- Restart gabapentin at rehabilitation facility and monitor
mental status
.
8) HTN: Controlled while in intensive care unit.  Uptitrated
betablocker for better heart rate control of atrial
fibrillation.
---- Metoprolol 50 mg TID
---- Restart Isosorbide Mononitrate 10 mg TID (on extended
release as outpatient, but this could not be delivered via
Dopoff).
.
9) Hyperlipidemia: No active issues.
- Statin
.
10) Gout: Does not report any joint pain at this time, no
evidence of acute flair.
- Allopurinol.
.
11) Abdominal pain - Resolved. Pt reported abdominal pain on
exam this AM.  Though clear language barrier, she was indicating
her entire abdomen.  Given h/o cholelithiasis without
cholecystitis, we rechecked her LFTs - all were wnl.
Additionally, spoke with husband via an interpretor who confirms
that pt still has AMS, but denies all abdominal pain at this
time.
----- Continue proton pump inhibitor
----- Ensure regular bowel movements
.
12) Ventricular tachycardia - No new episodes.  48 beat run of
Vtach around time of transfer to ICU.  Will discuss with outpt
cardiologist.  Could be resultant from fever or occult ischemia
despite no EKG changes.  Electrolytes wnl, negative tox screen.
Prior ECHO with evidence of structural heart disease.  CE wnl
[**2184-8-17**].
---- Monitor daily electrolytes and replete as needed.
.
13) Electrolytes -  Aggressively replete electrolytes in setting
of recent diuresis.
.
14) Nutrition - On tube feeds s/p tracheostomy.
---- Consult speech/swallow re: PO intake
.
15) PPx
- Coumadin
- Bowel regimen
- PPI
.
16) Access: PICC placed [**7-29**], also has PIV
.
17) Communication: Son - [**Name (NI) 107850**] ([**Telephone/Fax (1) 107851**] who is health
care power of attorney
.
18) Code status: FULL
.
19) Dispo: To acute rehabilitation.

Medications on Admission:
1. KCl 20meq 2tabs daily
2. Isosorbide 30mg daily
3. Gabapentin 300mg [**Hospital1 **]
4. Furosemide 20mg 2tabs QAM, 1tab QHS
5. Allopurinol 300mg daily
6. Coumadin 2mg daily
7. Tramadol 50mg 1-2tabs Q6H prn
8. Lipitor 20mg daily
9. Glyburide 5mg [**Hospital1 **]

Discharge Medications:
1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
2. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).

6. Erythromycin 5 mg/g Ointment Sig: One (1)  Ophthalmic [**Hospital1 **] (2
times a day).
7. Tramadol 50 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed for pain.
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for to skin folds .
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
 Inhalation Q6H (every 6 hours) as needed for shortness of
breath or wheezing.
11. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain: do not exceed 4 grams per
day.
12. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous Q 12H (Every 12 Hours) for 5 days: Final
day:[**9-6**]
Final dose:[**9-6**] pm.
Disp:*10 gram* Refills:*0*
13. Cefepime 2 gram Recon Soln Sig: Two (2) Recon Soln Injection
Q12H (every 12 hours) for 5 days: Final Day: [**9-6**]
Final Dose: [**9-6**] pm.
Disp:*20 Recon Soln(s)* Refills:*0*
14. Isosorbide Mononitrate 10 mg Tablet Sig: One (1) Tablet PO
three times a day.
Disp:*90 Tablet(s)* Refills:*2*
15. Lopressor 50 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
16. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO DAILY AT 1800 ().
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*2*
17. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
Disp:*30 Tablet(s)* Refills:*0*
18. Furosemide 40 mg/5 mL Solution Sig: 20-40 mg PO twice a day:
goal diuresis: until BUN/Cr bump. then transition to stable
regimen.
Disp:*150 mL* Refills:*2*
19. Speech/Swallow
Needs speech/swallow eval for potential to take PO


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
Primary Diagnosis:
Obstructive sleep apnea
Hypercarbia
Altered mental status
Diabetes mellitus
COPD
Urinary Tract Infection
Pneumonia
.
Secondary diagnoses:
Atrial fibrillation on coumadin


Discharge Condition:
stable, using BiPAP 15/5 with oxygen saturations >95%,
tolerating brief trach collar trials while sitting, alert, able
to follow simple commands


Discharge Instructions:

You were admitted with change in mental status and sleep apnea.
You were initially placed on bipap but transitioned quickly to
your CPAP machine. You did not tolerate your CPAP machine or an
additional trial on BiPAP and continued to have trouble with
your mental status.  You underwent a tracheostomy to help with
your breathing. Your breathing on the tracheostomy with the
BiPAP machine is much improved. You are ready to be discharged
for pulmonary rehabilitation and weaning from the BiPAP.  Your
mental status has improved. You will still need use either CPAP
or BiPAP every night to help with your breathing.
.
You were discovered to have an urinary tract infection and
pneumonia.  You were treated with antibiotics for these
infections and you have greatly improved. You will need to
complete your course of antibiotics.
.
Please call 911 or return to the hospital if you experience
chest pain, shortness of breath, fevers, confusion, weakness or
other concerning symptoms.

Followup Instructions:
You have the following scheduled appointments:
Provider: [**Name10 (NameIs) 1576**],[**First Name8 (NamePattern2) 2352**] [**Doctor Last Name 4694**] APG (SB)
Phone:[**Telephone/Fax (1) 1579**] Date/Time:[**2184-9-9**] 10:30
.
Please follow-up with your primary care physician within [**Name Initial (PRE) **] week
after discharge from rehab.
{'Acute respiratory failure,Paroxysmal ventricular tachycardia,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Hyperosmolality and/or hypernatremia,Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Chronic airway obstruction, not elsewhere classified,Gout, unspecified'}


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: Confusion and lethargy

PRESENT ILLNESS: 77yo WF presents w confusion for 3-4 days. I communicated w the
pt via Italian interpreter over the phone. The interpreter did
not understand the pt very well. I talked to her daughter-in-law
[**First Name5 (NamePattern1) **] [**Name (NI) 107847**] [**Telephone/Fax (1) 107848**]) to obtain the hx. She has been
talking non-sensically for 3-4 days. She fell asleep several
times during the day. She did not use C pap machine consistently
at night for OSA.

MEDICAL HISTORY: HTN, CHF, CAD
Hyperlipidemia
Dm2
Afib on Coumadin
Gout
Sleep Apnea
COPD
LE venous stasis

MEDICATION ON ADMISSION: 1. KCl 20meq 2tabs daily
2. Isosorbide 30mg daily
3. Gabapentin 300mg [**Hospital1 **]
4. Furosemide 20mg 2tabs QAM, 1tab QHS
5. Allopurinol 300mg daily
6. Coumadin 2mg daily
7. Tramadol 50mg 1-2tabs Q6H prn
8. Lipitor 20mg daily
9. Glyburide 5mg [**Hospital1 **]

ALLERGIES: Lisinopril

PHYSICAL EXAM: 97.1, 84, 150/70, 20, 97% on 3L
GEN: Morbid obese, AAOx1 (to person), NAD
HEENT: Grossly intact, EOMI
NECK: Supple
HEART: Irregularly irregular w 3/6 SEM
LUNG: Decreased BS equally bilateral. CTAB
ABD: BS+, soft, NT/ND
EXT: Bilateral LE skin change [**12-26**] venous stasis
NEURO: Non focal, ME [**3-27**] UE, [**2-26**] LE. Could not eval DTR as pt
did not relax.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: denies smoking, etoh use
Lives w son and daughter in law
Uses wheelchair to ambulate 

### Response:
{'Acute respiratory failure,Paroxysmal ventricular tachycardia,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Hyperosmolality and/or hypernatremia,Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Chronic airway obstruction, not elsewhere classified,Gout, unspecified'}
