CHIEF COMPLAINT: Shortness of breath, intermittent hypoxia.
.
Reason for MICU transfer: Shortness of breath, PE, tracheostomy,
likely bronchoscopy.

PRESENT ILLNESS: 62yoF with complicated medical history including DVT, CAD s/p
stent, spinal surgery complicated by [**First Name3 (LF) 39850**], tracheostomy
presenting for shortness of breath and transient hypoxia.
.
The patient has reportedly been undergoing chest PT by her
family at home for chronic secretions in the setting of her
tracheostomy.  She reports having increased secretions recently
but denies cough, fevers at home prior to presentation, recent
chest pain or shortness of breath prior to her current acute
symptoms.  The day of presentation, the patient reported
shortness of breath at rest and on exertion.  She was noted to
be hypoxic by her VNA, and was brought to the ED for further
evaluation.
.
Of note, the patient has a history of an upper extremity DVT and
was on Coumadin up until a few days ago (last [**Doctor First Name **]).  She was
also recently treated with Bactrim for a UTI.
.
In the ED, intial VS:  88 99/59 16 88% 3L
Her hypoxia on initial presentation subsequently recovered and
she was consistently in the low 90's on 3L NC through her
tracheostomy throughout the remainder of her ED course.  She
underwent CTA chest given her symptoms, hypoxia, and history of
DVT, which showed a R sided PE with LLL collapse.  She was
started on a Heparin gtt.  CTA chest also showed LLL collapse
with debris slightly worse than previously seen.  The patient
was started on Vanc 1gm x1/Cefepime to cover for HAP/HCAP.  Her
UA was positive in the setting of multiple UTI's in the past,
and she was started on Ceftriaxone 1gm.  Tmax in the ED was
101.8 per report but documented as 100.2 in the ED records.  Her
K was 5.7 without acute EKG changes and she was given Kayexalate
30mg po x1.  She was noted to have diarrhea x2 through the
course of her ED stay.  She was also noted to be hyponatremic
and received 1L NS.  She was given Morphine 4mg IV x1 for
chronic shoulder pain.
.
On transfer, VS were:  81, 18, 116/62, 97% on 3L
On arrival to the ICU, the patient reported continued dyspnea
but PO2 was stable on 3L NC through tracheostomy.  The patient
.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
.

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 Myocardia Infarction in 03 s/p BMS to LCcx
Diabetes Mellitus (diet controlled)
hypercholesterolemia
s/p TAH-BSO [**2146**]
hypotension, on florinef/MICU and glycopyrrelate

MEDICATION ON ADMISSION: aspirin 81 mg Tablet, Chewable [**Month/Day (2) **]: One (1) Tablet, Chewable PO
DAILY (Daily).
tizanidine 2 mg Tablet [**Month/Day (2) **]: Three (3) Tablet PO BID (2 times a
day).
diazepam 2 mg Tablet [**Month/Day (2) **]: 0.5 Tablet PO Q8H (every 8 hours) as
needed for anxiety.
docusate sodium 50 mg/5 mL Liquid [**Month/Day (2) **]: One (1) PO BID (2 times a
day).  bisacodyl 10 mg Suppository [**Month/Day (2) **]: One (1) Rectal once a
day.
magnesium hydroxide 400 mg/5 mL Suspension [**Month/Day (2) **]: Thirty (30) ml
PO once a day as needed for constipation.
lisinopril 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily).
simvastatin 10 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO DAILY (Daily).
lansoprazole 15 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
gabapentin 250 mg/5 mL Solution [**Last Name (STitle) **]: Eight Hundred (800) mg PO
twice a day.
gabapentin 250 mg/5 mL Solution [**Last Name (STitle) **]: Four Hundred (400) mg PO
1200 Daily.
acetaminophen 650 mg/20.3 mL Solution [**Last Name (STitle) **]: Six [**Age over 90 1230**]y
(650) mg PO every six (6) hours.
Combivent 18-103 mcg/Actuation Aerosol [**Age over 90 **]: One (1) Inhalation
every six (6) hours.
baclofen 10 mg Tablet [**Age over 90 **]: Two (2) Tablet PO BID (2 times a
day).
baclofen 10 mg Tablet [**Age over 90 **]: Three (3) Tablet PO DAILY (Daily).
capsaicin 0.075 % Cream [**Age over 90 **]: One (1) Topical every six (6)
hours.
Naproxen as needed for pain

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Physical Exam:
Vitals: T: BP: 116/62 P: 81 R: 18 O2: 97% on 3L
General: Alert, oriented, no acute distress
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, non-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: Hypertension

SOCIAL HISTORY: Occupation:
Drugs:
Tobacco: prior (30-40 years) 1+ pack/day smoker
Alcohol:
Other: used to work as [**Hospital1 112**] clerk
.
Other pulmonary embolism and infarction,Quadriplegia, unspecified,Pulmonary collapse,Urinary tract infection, site not specified,Neurogenic bowel,Hyposmolality and/or hyponatremia,Foreign body in larynx,Inhalation and ingestion of other object causing obstruction of respiratory tract or suffocation,Late effect of spinal cord injury,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Tracheostomy status,Pressure ulcer, buttock,Personal history of venous thrombosis and embolism,Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site,Neurogenic bladder NOS,Old myocardial infarction,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypotension, unspecified,Do not resuscitate status,Diarrhea,Pain in joint, shoulder region,Other chronic pain,Personal history of tobacco use,Anxiety state, unspecified
Pulm embol/infarct NEC,Quadriplegia, unspecifd,Pulmonary collapse,Urin tract infection NOS,Neurogenic bowel,Hyposmolality,Foreign body in larynx,Resp obstr-inhal obj NEC,Late eff spinal cord inj,Abn react-surg proc NEC,Tracheostomy status,Pressure ulcer, buttock,Hx-ven thrombosis/embols,Proteus infection NOS,Neurogenic bladder NOS,Old myocardial infarct,DMII wo cmp nt st uncntr,Hypotension NOS,Do not resusctate status,Diarrhea,Joint pain-shlder,Chronic pain NEC,History of tobacco use,Anxiety state NOS
Admission Date:  [**2167-10-7**]              Discharge Date:   [**2167-10-16**]

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

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2006**]
Chief Complaint:
Shortness of breath, intermittent hypoxia.
.
Reason for MICU transfer: Shortness of breath, PE, tracheostomy,
likely bronchoscopy.


Major Surgical or Invasive Procedure:
Flexible Bronchoscopy
Tracheostomy tube changeout


History of Present Illness:
62yoF with complicated medical history including DVT, CAD s/p
stent, spinal surgery complicated by [**First Name3 (LF) 39850**], tracheostomy
presenting for shortness of breath and transient hypoxia.
.
The patient has reportedly been undergoing chest PT by her
family at home for chronic secretions in the setting of her
tracheostomy.  She reports having increased secretions recently
but denies cough, fevers at home prior to presentation, recent
chest pain or shortness of breath prior to her current acute
symptoms.  The day of presentation, the patient reported
shortness of breath at rest and on exertion.  She was noted to
be hypoxic by her VNA, and was brought to the ED for further
evaluation.
.
Of note, the patient has a history of an upper extremity DVT and
was on Coumadin up until a few days ago (last [**Doctor First Name **]).  She was
also recently treated with Bactrim for a UTI.
.
In the ED, intial VS:  88 99/59 16 88% 3L
Her hypoxia on initial presentation subsequently recovered and
she was consistently in the low 90's on 3L NC through her
tracheostomy throughout the remainder of her ED course.  She
underwent CTA chest given her symptoms, hypoxia, and history of
DVT, which showed a R sided PE with LLL collapse.  She was
started on a Heparin gtt.  CTA chest also showed LLL collapse
with debris slightly worse than previously seen.  The patient
was started on Vanc 1gm x1/Cefepime to cover for HAP/HCAP.  Her
UA was positive in the setting of multiple UTI's in the past,
and she was started on Ceftriaxone 1gm.  Tmax in the ED was
101.8 per report but documented as 100.2 in the ED records.  Her
K was 5.7 without acute EKG changes and she was given Kayexalate
30mg po x1.  She was noted to have diarrhea x2 through the
course of her ED stay.  She was also noted to be hyponatremic
and received 1L NS.  She was given Morphine 4mg IV x1 for
chronic shoulder pain.
.
On transfer, VS were:  81, 18, 116/62, 97% on 3L
On arrival to the ICU, the patient reported continued dyspnea
but PO2 was stable on 3L NC through tracheostomy.  The patient
.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
.


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 Myocardia Infarction in 03 s/p BMS to LCcx
Diabetes Mellitus (diet controlled)
hypercholesterolemia
s/p TAH-BSO [**2146**]
hypotension, on florinef/MICU and glycopyrrelate

Social History:
Occupation:
Drugs:
Tobacco: prior (30-40 years) 1+ pack/day smoker
Alcohol:
Other: used to work as [**Hospital1 112**] clerk
.


Family History:
Hypertension

Physical Exam:
Admission Physical Exam:
Vitals: T: BP: 116/62 P: 81 R: 18 O2: 97% on 3L
General: Alert, oriented, no acute distress
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, non-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 Physical Exam:
Vitals- 99.2 132/62 70 18 100%RA
General: Quadripelegic woman in NAD, lying in bed
HEENT: PERRLA, EOMI, Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Limited exam. Coarse breath sounds.
CV: RRR, S1 and S2, no m/r/g
Abdomen: soft, NT/ND, BSx4
GU: Supra-pubic catheter
Ext: Multiple contractures, no edema
Neuro: Awake and alert, quadripelegic, CN II-XII intact


Pertinent Results:
On Admission:
[**2167-10-6**] 08:55PM BLOOD WBC-9.8# RBC-4.53# Hgb-12.1# Hct-37.3#
MCV-82# MCH-26.6*# MCHC-32.3 RDW-17.9* Plt Ct-286
[**2167-10-6**] 08:35PM BLOOD PT-12.0 PTT-24.4 INR(PT)-1.0
[**2167-10-6**] 08:55PM BLOOD Glucose-112* UreaN-33* Creat-0.5 Na-128*
K-5.7* Cl-96 HCO3-21* AnGap-17

On Discharge:
[**2167-10-16**] 08:00AM BLOOD WBC-8.0 RBC-4.04* Hgb-11.1* Hct-33.3*
MCV-82 MCH-27.5 MCHC-33.3 RDW-17.6* Plt Ct-196
[**2167-10-16**] 08:00AM BLOOD PT-20.7* PTT-34.3 INR(PT)-1.9*
[**2167-10-16**] 08:00AM BLOOD Glucose-112* UreaN-20 Creat-0.3* Na-139
K-4.1 Cl-102 HCO3-29 AnGap-12
Imaging:
CTA ([**10-6**]):  1. Acute pulmonary embolism involving the distal
right main and segmental branches supplying the right lower and
middle lobes. No evidence for heart strain. 2. Copious
secretions within the left main stem bronchus and left lower
lobe bronchus with progression of left lower lobe collapse since
the prior study. No pleural fluid.
.
CXR ([**10-6**]):  IMPRESSION: Limited study with retrocardiac opacity
suggesting segmental collapse of the left lower lobe.
.
EKG:  NSR, left axis, TWI diffusely throughout precordial leads,
sub-mm STE in V2, V3, Q waves in ?II, III.


Brief Hospital Course:
Ms. [**Known lastname 105209**] is a 62 year-old woman with [**Known lastname 39850**]
(complication of past surgery), DVT, CAD s/p stent, and
tracheostomy who presented [**2167-10-7**] with shortness of breath
and transient hypoxia.  She was found to have right main
pulmonary embolism and left lower lobe collapse.

#. Pulmonary Embolism:  The patient developed acutely worsening
SOB and presented to the ED here.  On arrival a CTA was done
which revealed a pulmonary embolism in the right pulmonary
artery. The patient had been taking coumadin until 6 days PTA
for an UE DVT.  She had a subtherapeutic INR on admission.
Heparin drip was started but she was then switched to enoxaparin
as a bridge to coumadin therapy, which was started at 5 mg dose
on [**2167-10-8**]. [Of note: enoxaparin has a black box warning from
the FDA for patients who have received procedures of the spinal
column.  This patient's spinal surgery is remote and no other
procedures are planned at this time.  The enoxaparin is only a
bridge to coumadin and should be discontinued upon therapeutic
INR].  In house the patient's INRs increased appropriatly and IS
1.9 on day of discharge with goal of [**3-12**]. The patient will
follow with the [**Hospital 191**] [**Hospital 2786**] clinic.  She is being
discharged on 5mg of warfarin daily.
.
#. LLL Collapse: In addition to the PE described above, initial
imaging also revealed left lower lung lobe collapse with debris.
 LLL collapse was believed to be [**3-11**] mucus plugging given
significant yellowish-white sputum suctioned on initial deep
tracheostomy suction in the ED.  Patient was given one dose of
vanc/cefepime in the ED for suspected PNA, but this treatment
was discontinued on the floor.  Therapeutic bronchoscopy was
performed on the floor confirming mucus plugging and the LLL was
transiently re-expanded however it collapsed again.  Also tried
positive pressure ventilation which too transiently expanded the
lung.  The patient was continued with intermittent
deep-suctioning and cough-assist throughout her hospital stay.
At time of discharge, the LLL is still collapsed although the
patient is reporting less secretions and denies any subjective
respiratory compromise.  Will go home with valve in place and
home oxygen.
.
# UTI (Pansensitive Pseudomonas): Patient has history of
recurrent UTI's, even following suprapubic catheter placement.
Here, positive UA and low grade documented fever 100.2 in the
ED. Started on ciprofloxacin (IV initially and then transitioned
to PO). Started on a 7 day course on [**2167-10-7**].  Suprapubic
catheter replaced on [**2167-10-10**]. The patient completed her course
and remained afebrile during her hospital stay.
.
#. [**Year (4 digits) **]: Spinal surgery c/b [**Year (4 digits) 39850**] in [**2167**] as
above.  Multiple contractures and pain.  The patient was
continued on her home pain regimen with the exception of NSAIDs
given interaction with lovenox.  Did have [**2-8**] nights with
burning pain on left lateral leg although this resolved without
itnervention.
.
#. HTN: Continued on home Lisinopril.
.
#. Anxiety: Continued on lorazepam as needed and zolpidem for
sleep.
.
#. GERD: Continued on PPI.
.
#. HL: Continued on simvastatin and ASA.




Medications on Admission:
aspirin 81 mg Tablet, Chewable [**Month/Day (2) **]: One (1) Tablet, Chewable PO
DAILY (Daily).
tizanidine 2 mg Tablet [**Month/Day (2) **]: Three (3) Tablet PO BID (2 times a
day).
diazepam 2 mg Tablet [**Month/Day (2) **]: 0.5 Tablet PO Q8H (every 8 hours) as
needed for anxiety.
docusate sodium 50 mg/5 mL Liquid [**Month/Day (2) **]: One (1) PO BID (2 times a
day).  bisacodyl 10 mg Suppository [**Month/Day (2) **]: One (1) Rectal once a
day.
magnesium hydroxide 400 mg/5 mL Suspension [**Month/Day (2) **]: Thirty (30) ml
PO once a day as needed for constipation.
lisinopril 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily).
simvastatin 10 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO DAILY (Daily).
lansoprazole 15 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
gabapentin 250 mg/5 mL Solution [**Last Name (STitle) **]: Eight Hundred (800) mg PO
twice a day.
gabapentin 250 mg/5 mL Solution [**Last Name (STitle) **]: Four Hundred (400) mg PO
1200 Daily.
acetaminophen 650 mg/20.3 mL Solution [**Last Name (STitle) **]: Six [**Age over 90 1230**]y
(650) mg PO every six (6) hours.
Combivent 18-103 mcg/Actuation Aerosol [**Age over 90 **]: One (1) Inhalation
every six (6) hours.
baclofen 10 mg Tablet [**Age over 90 **]: Two (2) Tablet PO BID (2 times a
day).
baclofen 10 mg Tablet [**Age over 90 **]: Three (3) Tablet PO DAILY (Daily).
capsaicin 0.075 % Cream [**Age over 90 **]: One (1) Topical every six (6)
hours.
Naproxen as needed for pain

Discharge Medications:
1. Lovenox 80 mg/0.8 mL Syringe [**Age over 90 **]: Seventy (70) mg
Subcutaneous twice a day for 4 days: Please administer 70mg
(waste first 0.1mL)
.
Disp:*8 Syringes* Refills:*0*
2. aspirin 81 mg Tablet, Chewable [**Age over 90 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
3. tizanidine 2 mg Tablet [**Age over 90 **]: Three (3) Tablet PO BID (2 times
a day).
4. diazepam 2 mg Tablet [**Age over 90 **]: 0.5 Tablet PO Q8H (every 8 hours)
as needed for anxiety.
5. docusate sodium 50 mg/5 mL Liquid [**Age over 90 **]: One (1)  PO BID (2
times a day).
6. bisacodyl 10 mg Suppository [**Age over 90 **]: One (1)  Rectal once a day.

7. magnesium hydroxide 400 mg/5 mL Suspension [**Age over 90 **]: Thirty (30)
ml PO once a day as needed for constipation.
8. lisinopril 5 mg Tablet [**Age over 90 **]: One (1) Tablet PO DAILY (Daily).

9. simvastatin 10 mg Tablet [**Age over 90 **]: Two (2) Tablet PO DAILY
(Daily).
10. Home Oxygen
Oxygen 40% by air compressor via trach. Diagnosis: Left Lower
Lobe lung collapse.
11. lansoprazole 15 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
12. gabapentin 250 mg/5 mL Solution [**Last Name (STitle) **]: Eight Hundred (800) mg
PO twice a day.
13. gabapentin 250 mg/5 mL Solution [**Last Name (STitle) **]: Four Hundred (400) mg
PO 1200 Daily.
14. acetaminophen 650 mg/20.3 mL Solution [**Last Name (STitle) **]: Six [**Age over 90 1230**]y
(650) mg PO every six (6) hours.
15. Combivent 18-103 mcg/Actuation Aerosol [**Age over 90 **]: One (1)
Inhalation every six (6) hours.
16. baclofen 10 mg Tablet [**Age over 90 **]: Two (2) Tablet PO BID (2 times a
day).
17. baclofen 10 mg Tablet [**Age over 90 **]: Three (3) Tablet PO DAILY
(Daily).
18. capsaicin 0.075 % Cream [**Age over 90 **]: One (1)  Topical every six (6)
hours.
19. Ultram 50 mg Tablet [**Age over 90 **]: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
20. warfarin 2.5 mg Tablet [**Age over 90 **]: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 2255**] [**Name (NI) 2256**]

Discharge Diagnosis:
Pulmonary Embolism
Urinary Tract Infection


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: [**Name (NI) 56633**]

Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 18**]!

You were admitted due to difficulty with breathing and were
found to have a pulmonary embolism (clot in the lung) and a
partial left lung collapse.  During your stay you were started
on anti-coagulation for the lung clot and were provided with
agressive respiratory therapy including deep suctioning and
cough-assist.  You are now ready to return home with VNA
services.

Please note the following changes to your medication regimen:
1) START Warfarin 5mg daily and follow-up with the [**Hospital 191**]
[**Hospital 2786**] clinic for changes in dosing.
2) CONTINUE Lovenox injections for 2 more days or until INR >2.0
3) STOP Naproxen while using the Lovenox injections
4) START home oxygen as needed for shortness of breath or
hypoxia

Please see below for follow-up instructions:

Followup Instructions:
Please follow up with the [**Hospital 2786**] clinic at [**Hospital **] as instructed.

Additionally, you have a primary care appointment with Dr. [**First Name (STitle) 3535**]
as below:
Department: [**Hospital3 249**]
When: THURSDAY [**2167-10-22**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage



Completed by:[**2167-10-18**]
{'Other pulmonary embolism and infarction,Quadriplegia, unspecified,Pulmonary collapse,Urinary tract infection, site not specified,Neurogenic bowel,Hyposmolality and/or hyponatremia,Foreign body in larynx,Inhalation and ingestion of other object causing obstruction of respiratory tract or suffocation,Late effect of spinal cord injury,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Tracheostomy status,Pressure ulcer, buttock,Personal history of venous thrombosis and embolism,Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site,Neurogenic bladder NOS,Old myocardial infarction,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypotension, unspecified,Do not resuscitate status,Diarrhea,Pain in joint, shoulder region,Other chronic pain,Personal history of tobacco use,Anxiety state, 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: Shortness of breath, intermittent hypoxia.
.
Reason for MICU transfer: Shortness of breath, PE, tracheostomy,
likely bronchoscopy.

PRESENT ILLNESS: 62yoF with complicated medical history including DVT, CAD s/p
stent, spinal surgery complicated by [**First Name3 (LF) 39850**], tracheostomy
presenting for shortness of breath and transient hypoxia.
.
The patient has reportedly been undergoing chest PT by her
family at home for chronic secretions in the setting of her
tracheostomy.  She reports having increased secretions recently
but denies cough, fevers at home prior to presentation, recent
chest pain or shortness of breath prior to her current acute
symptoms.  The day of presentation, the patient reported
shortness of breath at rest and on exertion.  She was noted to
be hypoxic by her VNA, and was brought to the ED for further
evaluation.
.
Of note, the patient has a history of an upper extremity DVT and
was on Coumadin up until a few days ago (last [**Doctor First Name **]).  She was
also recently treated with Bactrim for a UTI.
.
In the ED, intial VS:  88 99/59 16 88% 3L
Her hypoxia on initial presentation subsequently recovered and
she was consistently in the low 90's on 3L NC through her
tracheostomy throughout the remainder of her ED course.  She
underwent CTA chest given her symptoms, hypoxia, and history of
DVT, which showed a R sided PE with LLL collapse.  She was
started on a Heparin gtt.  CTA chest also showed LLL collapse
with debris slightly worse than previously seen.  The patient
was started on Vanc 1gm x1/Cefepime to cover for HAP/HCAP.  Her
UA was positive in the setting of multiple UTI's in the past,
and she was started on Ceftriaxone 1gm.  Tmax in the ED was
101.8 per report but documented as 100.2 in the ED records.  Her
K was 5.7 without acute EKG changes and she was given Kayexalate
30mg po x1.  She was noted to have diarrhea x2 through the
course of her ED stay.  She was also noted to be hyponatremic
and received 1L NS.  She was given Morphine 4mg IV x1 for
chronic shoulder pain.
.
On transfer, VS were:  81, 18, 116/62, 97% on 3L
On arrival to the ICU, the patient reported continued dyspnea
but PO2 was stable on 3L NC through tracheostomy.  The patient
.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
.

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 Myocardia Infarction in 03 s/p BMS to LCcx
Diabetes Mellitus (diet controlled)
hypercholesterolemia
s/p TAH-BSO [**2146**]
hypotension, on florinef/MICU and glycopyrrelate

MEDICATION ON ADMISSION: aspirin 81 mg Tablet, Chewable [**Month/Day (2) **]: One (1) Tablet, Chewable PO
DAILY (Daily).
tizanidine 2 mg Tablet [**Month/Day (2) **]: Three (3) Tablet PO BID (2 times a
day).
diazepam 2 mg Tablet [**Month/Day (2) **]: 0.5 Tablet PO Q8H (every 8 hours) as
needed for anxiety.
docusate sodium 50 mg/5 mL Liquid [**Month/Day (2) **]: One (1) PO BID (2 times a
day).  bisacodyl 10 mg Suppository [**Month/Day (2) **]: One (1) Rectal once a
day.
magnesium hydroxide 400 mg/5 mL Suspension [**Month/Day (2) **]: Thirty (30) ml
PO once a day as needed for constipation.
lisinopril 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily).
simvastatin 10 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO DAILY (Daily).
lansoprazole 15 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
gabapentin 250 mg/5 mL Solution [**Last Name (STitle) **]: Eight Hundred (800) mg PO
twice a day.
gabapentin 250 mg/5 mL Solution [**Last Name (STitle) **]: Four Hundred (400) mg PO
1200 Daily.
acetaminophen 650 mg/20.3 mL Solution [**Last Name (STitle) **]: Six [**Age over 90 1230**]y
(650) mg PO every six (6) hours.
Combivent 18-103 mcg/Actuation Aerosol [**Age over 90 **]: One (1) Inhalation
every six (6) hours.
baclofen 10 mg Tablet [**Age over 90 **]: Two (2) Tablet PO BID (2 times a
day).
baclofen 10 mg Tablet [**Age over 90 **]: Three (3) Tablet PO DAILY (Daily).
capsaicin 0.075 % Cream [**Age over 90 **]: One (1) Topical every six (6)
hours.
Naproxen as needed for pain

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Physical Exam:
Vitals: T: BP: 116/62 P: 81 R: 18 O2: 97% on 3L
General: Alert, oriented, no acute distress
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, non-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: Hypertension

SOCIAL HISTORY: Occupation:
Drugs:
Tobacco: prior (30-40 years) 1+ pack/day smoker
Alcohol:
Other: used to work as [**Hospital1 112**] clerk
. 

### Response:
{'Other pulmonary embolism and infarction,Quadriplegia, unspecified,Pulmonary collapse,Urinary tract infection, site not specified,Neurogenic bowel,Hyposmolality and/or hyponatremia,Foreign body in larynx,Inhalation and ingestion of other object causing obstruction of respiratory tract or suffocation,Late effect of spinal cord injury,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Tracheostomy status,Pressure ulcer, buttock,Personal history of venous thrombosis and embolism,Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site,Neurogenic bladder NOS,Old myocardial infarction,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypotension, unspecified,Do not resuscitate status,Diarrhea,Pain in joint, shoulder region,Other chronic pain,Personal history of tobacco use,Anxiety state, unspecified'}
