CHIEF COMPLAINT: Neck pain/Confusion

PRESENT ILLNESS: Mr. [**Known lastname 82412**] is a 77 year old man with a history of atrial
fibrillation on coumadin, hypertension, diabetes transferred on
[**5-18**] from [**Hospital 82413**] hospital for evaluation of confusion and neck
stiffness. According to the patient's daughter, the patient was
in his usual state of health until [**5-2**]. At that time, he
complained on bilateral neck pain and a sore throat. His
daughter took him to [**Hospital3 5365**] where a CT of the c-spine
was performed. He was felt to have torticollis and was
discharged with flexeril and percocet. On [**5-4**], the patient was
found in his home "out of it". He was still complaining of neck
pain, but was having visual hallucinations of things/people in
his house. His daughter called his PCP at which point they
attributed his symptoms to the medication changes and
percocet/flexeril was discontinued. Over the weekend, his mental
status continued to wax and wane. He appeared extremely fatigued
and was sleeping more. On [**5-8**], the patient was taken to his PCP
for evaluation and at that point he was referred to Carnitas for
work-up. He was found to be in atrial fibrillation with rapid
ventricular response w/HR of 160; it is unclear what medications
were changed at this time. The patient was apparently evaluated
over the course of a week without much in the way of cognitive
improvement. He was seen by neurology and this was felt to be
med effect. He was discharged to rehab on [**5-14**]. On [**5-16**] his
mental status apparently acutely declined again and he was noted
to be diaphoretic. He was then brought back to Carnitas.

MEDICAL HISTORY: Polycythemia [**Doctor First Name **]
Gout
Hypertension
Afib
Polio with upper extremity weakness (Right)
Diabetes (on metformin)

MEDICATION ON ADMISSION: Tylenol PRN
Colchicine 0.6mg QOD
Cardizem 240mg QD
Nexium 40mg QD
Metformin 500 QD *holding*
Coumadin 5mg QD *holding*
Valium 5mg po BID PRN anxiety
Enalapril 20mg PO QD
Clindamycin 300mg [**Hospital1 **] day [**3-13**]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T= 95.8 BP= 158/72 RR=20 O2= 94% on RA
GENERAL: Pleasant, uncomfortable appearly elderly man.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. Pupils constricted and minimally reactive.
EOMI. MMM. OP clear. Neck non-tender, painful to passive
rotation of the head, No LAD, no masses appreciated.
CARDIAC: irregular rhythm, normal rate. Normal S1, S2. No
murmurs appreciated.
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: Trace edema, no calf pain, 2+ dorsalis pedis/
posterior tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 3-/5 R deltoid, [**4-8**] R biceps/triceps, no
biceps reflex on right. 2+ reflexes, otherwise. Toes equivical.
PSYCH: Listens and responds to questions appropriately, pleasant

FAMILY HISTORY: No history of dementia or neurological disorders.

SOCIAL HISTORY: Independent at baseline; involved with his Church and civil war
groups. Widowed. Former smoker (quit at 30 yo, 15 pack-per-year
history), occasional etoh use. Denies drug use.
Intraspinal abscess,Encephalopathy, unspecified,Acute osteomyelitis, other specified sites,Bacteremia,Unspecified disease of spinal cord,Unspecified protein-calorie malnutrition,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other anaerobes,Atrial fibrillation,Long-term (current) use of anticoagulants,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Late effects of acute poliomyelitis,Polycythemia vera,Pressure ulcer, lower back,Urinary incontinence, unspecified,Gout, unspecified,Dysphagia, unspecified
Intraspinal abscess,Encephalopathy NOS,Ac osteomyelitis NEC,Bacteremia,Spinal cord disease NOS,Protein-cal malnutr NOS,Other anaerobes,Atrial fibrillation,Long-term use anticoagul,Hypertension NOS,DMII wo cmp nt st uncntr,Late effect acute polio,Polycythemia vera,Pressure ulcer, low back,Urinary incontinence NOS,Gout NOS,Dysphagia NOS
Admission Date:  [**2108-5-18**]              Discharge Date:   [**2108-5-31**]

Date of Birth:  [**2030-7-15**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 678**]
Chief Complaint:
Neck pain/Confusion

Major Surgical or Invasive Procedure:
1. C1-C2 posterior spinal decompression, transpedicular.
2. Deep biopsy and deep cultures of epidural abscess.


History of Present Illness:
Mr. [**Known lastname 82412**] is a 77 year old man with a history of atrial
fibrillation on coumadin, hypertension, diabetes transferred on
[**5-18**] from [**Hospital 82413**] hospital for evaluation of confusion and neck
stiffness. According to the patient's daughter, the patient was
in his usual state of health until [**5-2**]. At that time, he
complained on bilateral neck pain and a sore throat. His
daughter took him to [**Hospital3 5365**] where a CT of the c-spine
was performed. He was felt to have torticollis and was
discharged with flexeril and percocet. On [**5-4**], the patient was
found in his home "out of it". He was still complaining of neck
pain, but was having visual hallucinations of things/people in
his house. His daughter called his PCP at which point they
attributed his symptoms to the medication changes and
percocet/flexeril was discontinued. Over the weekend, his mental
status continued to wax and wane. He appeared extremely fatigued
and was sleeping more. On [**5-8**], the patient was taken to his PCP
for evaluation and at that point he was referred to Carnitas for
work-up. He was found to be in atrial fibrillation with rapid
ventricular response w/HR of 160; it is unclear what medications
were changed at this time. The patient was apparently evaluated
over the course of a week without much in the way of cognitive
improvement. He was seen by neurology and this was felt to be
med effect. He was discharged to rehab on [**5-14**]. On [**5-16**] his
mental status apparently acutely declined again and he was noted
to be diaphoretic. He was then brought back to Carnitas.

During this admission at Carnitas, he was noted to have low
grade fevers and a elevated wbc (12.6). [**Month/Year (2) **] cultures grew gram
positive bacteria - veilonella in [**2-8**] bottles ([**2-6**] anaerobic
[**Month/Day (2) **] cx). He was started on clindamycin for an intended 10 day
course. Echo (TTE) was performed and was negative for
vegitation. Due to persistent neck pain, the patient had a Head
CT that showed enlarged ventricles but nothing acute. MRI showed
hyperintense T2 signal in the left paraspinal muscles; no
evidence of abcess or osteomyelitis. INR was 6.1 on admission
and coumadin was held.

The patient was transferred to [**Hospital1 18**] on [**5-18**] for further work-up
at the request of the patient's PCP.

On arrival, the patient continues to have a sore throat and next
pain. Continues to have bad sore throat and headache radiating
from his neck. He reports occasional double vision but no
photophobia; he reports visual hallucinations (seeing people,
animals) but denies auditory or gustatory or other sensory
hallucinations. He has not noticed any rashes; denues weakness
beyond his baseline residual polio weakness. He has never had
any symptoms like this before. He is unaware of any sick
contacts. [**Name (NI) **] reports his last travel was in the fall when he
took a several week singles cruise in [**Country 149**]. He has had
unprotected sexual encounters. No known animal exposures. He
denies any dysuria but has some hesitency and urge. He denies
recent GI illness. Remaining review of systems is otherwise
negative.


Past Medical History:
Polycythemia [**Doctor First Name **]
Gout
Hypertension
Afib
Polio with upper extremity weakness (Right)
Diabetes (on metformin)


Social History:
Independent at baseline; involved with his Church and civil war
groups. Widowed. Former smoker (quit at 30 yo, 15 pack-per-year
history), occasional etoh use. Denies drug use.

Family History:
No history of dementia or neurological disorders.

Physical Exam:
T= 95.8 BP= 158/72 RR=20 O2= 94% on RA
GENERAL: Pleasant, uncomfortable appearly elderly man.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. Pupils constricted and minimally reactive.
EOMI. MMM. OP clear. Neck non-tender, painful to passive
rotation of the head, No LAD, no masses appreciated.
CARDIAC: irregular rhythm, normal rate. Normal S1, S2. No
murmurs appreciated.
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: Trace edema, no calf pain, 2+ dorsalis pedis/
posterior tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 3-/5 R deltoid, [**4-8**] R biceps/triceps, no
biceps reflex on right. 2+ reflexes, otherwise. Toes equivical.
PSYCH: Listens and responds to questions appropriately, pleasant


EXAM ON DISCHARGE: Afebriles, VSS. Cardiac [**Last Name (un) **], no murmur. Clear
lungs. Abd with [**Last Name (un) 282**] in place c/d/i. Sacral Stage II Pressure
Ulcer. Neuro exam at baseline as on admission.

Pertinent Results:
CBC:
[**2108-5-18**] WBC-21.6* RBC-5.31 Hgb-16.3 Hct-46.4 Plt Ct-463*
[**2108-5-19**] WBC-13.1* RBC-5.42 Hgb-16.4 Hct-48.1 Plt Ct-416
[**2108-5-20**] WBC-10.2  RBC-5.01 Hgb-15.3 Hct-45.3 Plt Ct-390
[**2108-5-21**] WBC-8.0   RBC-4.79 Hgb-14.9 Hct-41.8 Plt Ct-398
[**2108-5-22**] WBC-7.7   RBC-5.06 Hgb-15.6 Hct-44.6 Plt Ct-433
[**2108-5-23**] WBC-7.9   RBC-5.16 Hgb-16.0 Hct-46.2 Plt Ct-374
[**2108-5-24**] WBC-10.2  RBC-4.80 Hgb-14.7 Hct-42.1 Plt Ct-384
[**2108-5-24**] WBC-12.2* RBC-4.15* Hgb-12.8* Hct-36.1* Plt Ct-272
[**2108-5-25**] WBC-11.1* RBC-4.09* Hgb-12.4* Hct-35.5* Plt Ct-289
[**2108-5-26**] WBC-12.2* RBC-3.98* Hgb-12.2* Hct-35.1* Plt Ct-278
[**2108-5-27**] WBC-13.2* RBC-3.96* Hgb-12.2* Hct-34.3* Plt Ct-309
[**2108-5-29**] WBC-9.5   RBC-4.08* Hgb-12.5* Hct-35.3* Plt Ct-292
[**2108-5-30**] WBC-9.4   RBC-4.14* Hgb-12.7* Hct-36.3* Plt Ct-309
[**2108-5-31**] WBC-10.4  RBC-4.22* Hgb-12.8* Hct-37.2* Plt Ct-302

DIFFERENTIAL:
[**2108-5-19**] Neuts-85.6* Lymphs-10.2* Monos-3.0 Eos-0.7 Baso-0.6
[**2108-5-22**] Neuts-80.2* Lymphs-13.4* Monos-4.3 Eos-1.4 Baso-0.7
[**2108-5-23**] Neuts-74.2* Lymphs-18.2  Monos-4.9 Eos-2.3 Baso-0.4

CHEMISTRY:
[**2108-5-18**] Glucose-242* UreaN-13 Creat-0.7 Na-131* K-3.9 Cl-96
HCO3-27
[**2108-5-19**] Glucose-190* UreaN-13 Creat-0.7 Na-135 K-4.1 Cl-98
HCO3-25
[**2108-5-20**] Glucose-161* UreaN-12 Creat-0.7 Na-137 K-3.6 Cl-101
HCO3-28
[**2108-5-21**] Glucose-180* UreaN-8 Creat-0.6 Na-136 K-3.4 Cl-99
HCO3-27
[**2108-5-22**] Glucose-121* UreaN-10 Creat-0.7 Na-138 K-4.3 Cl-99
HCO3-27
[**2108-5-23**] Glucose-135* UreaN-10 Creat-0.7 Na-136 K-4.2 Cl-97
HCO3-30
[**2108-5-24**] Glucose-200* UreaN-8 Creat-0.7 Na-133 K-3.6 Cl-94*
HCO3-29
[**2108-5-24**] Glucose-196* UreaN-7 Creat-0.6 Na-132* K-3.5 Cl-95*
HCO3-24
[**2108-5-25**] Glucose-190* UreaN-6 Creat-0.6 Na-133 K-3.5 Cl-98
HCO3-27
[**2108-5-25**] Glucose-205* UreaN-6 Creat-0.6 Na-132* K-3.7 Cl-96
HCO3-26
[**2108-5-26**] Glucose-181* UreaN-6 Creat-0.5 Na-132* K-3.9 Cl-99
HCO3-24
[**2108-5-27**] Glucose-143* UreaN-6 Creat-0.5 Na-134 K-3.8 Cl-100
HCO3-25
[**2108-5-29**] Glucose-169* UreaN-12 Creat-0.4* Na-138 K-3.1* Cl-99
HCO3-29
[**2108-5-30**] Glucose-162* UreaN-12 Creat-0.5 Na-137 K-3.5 Cl-99
HCO3-28 [**2108-5-31**] Glucose-171* UreaN-13 Creat-0.5 Na-139 K-3.4
Cl-100 HCO3-29

CALCIUM, MAGNESIUM, PHOSPHATE
[**2108-5-18**] Calcium-9.0 Phos-2.6* Mg-1.5*
[**2108-5-19**] Calcium-9.0 Phos-2.7 Mg-2.6
[**2108-5-20**] Calcium-8.6 Phos-2.9 Mg-1.7
[**2108-5-21**] Calcium-8.8 Phos-3.4 Mg-1.6
[**2108-5-22**] Calcium-9.3 Phos-3.4 Mg-1.9
[**2108-5-24**] Calcium-9.2 Phos-3.1 Mg-1.2*
[**2108-5-25**] Mg-1.8
[**2108-5-25**] Calcium-8.5 Phos-3.0 Mg-1.6
[**2108-5-26**] Calcium-8.4 Phos-2.4* Mg-1.5*
[**2108-5-27**] Calcium-8.4 Phos-2.6* Mg-1.8
[**2108-5-29**] Calcium-8.3* Phos-2.9 Mg-1.7
[**2108-5-31**] Calcium-9.1 Phos-3.6 Mg-1.7

INR:
[**2108-5-19**] INR(PT)-1.3*
[**2108-5-20**] INR(PT)-1.3*
[**2108-5-22**] INR(PT)-1.4*
[**2108-5-23**] INR(PT)-1.6*
[**2108-5-24**] INR(PT)-1.6*
[**2108-5-24**] INR(PT)-1.5*
[**2108-5-24**] INR(PT)-1.5*
[**2108-5-25**] INR(PT)-1.5*
[**2108-5-26**] INR(PT)-1.4*
[**2108-5-29**] INR(PT)-1.2*
[**2108-5-31**] INR(PT)-1.3*

ESR: [**2108-5-20**] ESR-35*

CRP: [**2108-5-20**] CRP-105.2*

LFTs:
[**2108-5-19**] ALT-46* AST-34 LD(LDH)-271* AlkPhos-133* TotBili-2.0*
[**2108-5-20**] ALT-36 AST-27 LD(LDH)-203 AlkPhos-110 TotBili-2.0*
DirBili-0.8* IndBili-1.2
[**2108-5-27**] ALT-17 AST-15 AlkPhos-79 TotBili-1.4

ALBUMIN: [**2108-5-24**] Albumin-3.2*

B12,FOLATE: [**2108-5-20**] VitB12-1021* Folate-8.5

HIV SEROLOGY: [**2108-5-19**] HIV Ab-NEGATIVE
RPR: [**2108-5-19**] NON-REACTIVE
Chlamydia trachomatis, Urine [**2108-5-19**]: Negative for Chlamydia
trachomatis by PCR.

MICROBIOLOGY:
-[**Month/Day/Year **] cx [**5-9**] - [**2-6**] anaerobic sets positive [**5-11**] for Veillonella
-[**Month/Day (4) **] cx [**5-19**], [**5-20**], [**5-22**], [**5-23**], [**5-29**] - no growth to date
-[**Month/Year (2) **] cx ([**5-24**]): VEILLONELLA ISOLATE FROM [**Hospital **] HOSPITAL, TO
BE SENT TO [**Hospital1 4534**] FOR SENSITIVITIES.
-Urine cx (final [**5-22**]) - KLEBSIELLA PNEUMONIAE. 10,000-100,000
ORGANISMS/ML.. PSEUDOMONAS AERUGINOSA. 10,000-100,000
ORGANISMS/ML..
-Urine cx (final [**5-23**]) - <10,000 organisms
-Urine cx (final [**5-29**]) -  YEAST.    10,000-100,000 ORGANISMS/ML
-CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2108-5-30**]): Feces
negative for C.difficile toxin A & B by EIA
- Deep Cervical Culture
GRAM STAIN (Final [**2108-5-24**]):
1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR LEUKOCYTES.
NO MICROORGANISMS SEEN.

WOUND CULTURE (Final [**2108-5-27**]):    NO GROWTH.
ANAEROBIC CULTURE (Final [**2108-5-30**]):    NO GROWTH.
ACID FAST SMEAR (Final [**2108-5-25**]):
      NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary):  NO FUNGUS ISOLATED.

IMAGING:
MRI C-Spine W/ and W/O Contrast ([**5-20**]):
1. Fluid collection posterior to the vertebral body at C2 level
and involving the craniocervical junction and odontoid process
as described in detail above with significant pattern of
enhancement and soft tissue swelling, impinging and producing
the thecal sac without [**Known firstname **] evidence of signal abnormality with
the cervical spinal cord.
2. Epidural abscess at the level of the vertebral body of C2 is
a
consideration with associated abnormality in the odontoid
process, the possibility of osteomyelitis versus infiltration at
this level is a consideration.

MRI SOFT TISSUE NECK, W/O & W/CONTRAST ([**5-20**])
1. Abnormal pattern enhancement and epidural fluid collection
posterior to the vertebral body at C2 level, impinging the
thecal sac and the spinal cord as described previously on the
MRI of the cervical spine, likely consistent with an abscess.
2. Soft tissue edema is identified anteriorly and posteriorly at
the level of T2 level, please refer to the dedicated MRI of the
cervical spine for details.
3. Heterogeneous pattern of enhancement is noted in the base of
the odontoid process on the right, raising the possibility of
infiltration or osteomyelitis, correlation with CT of the
cervical spine is recommended for further assessment.

MR HEAD W/ CONTRAST ([**5-20**])
1. The previously noted fluid collection and abnormal
enhancement at the craniocervical junction is not clearly
identified, please refer to the dedicated MRI of the cervical
spine and neck for details.
2. Possible abnormal enhancement noted in the right internal
auditory canal, raising the possibility of an intracanalicular
vestibular schwannoma, correlation with a dedicated MRI of the
posterior fossa with contrast is recommended if clinically
warranted.
3. Multiple foci of T2 and FLAIR hyperintensity distributed in
the subcortical white matter, likely consistent with chronic
microvascular ischemic changes. Mild patchy mucosal thickening
noted in the mastoid air cells bilaterally.

MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST ([**5-20**])
1. Multilevel disc degenerative changes as described in detail
above, more significant from L2/L3 through L5/S1 levels.

CT C-SPINE W/CONTRAST ([**5-20**])
1. Lytic lesion within the dens and C2 vertebral body, with
partial
destruction of the anterior and posterior cortices. In the
presence of the adjacent epidural abscess, this lesion is highly
suggestive of osteomyelitis. Otherwise, its appearance would
also be compatible with a metastasis. No other bone lesions
seen.
2. Multilevel degenerative changes. Please see preceding MRI
report for further detail.
3. 4 mm thyroid nodule. Ultrasound may be considered.
4. Carotid atherosclerosis. If indicated, the degree of stenosis
in the cervical left internal carotid artery may be better
assessed by ultrasound.

MR [**Name13 (STitle) **] W/O Contrast ([**5-22**])
1. Unchanged epidural abscess posterior to C2. Unchanged
odontoid process
osteomyelitis. Unchanged inflammatory changes in the
atlantoaxial joint and the left posterior paravertebral soft
tissues.
2. Unchanged compression of the spinal cord by the epidural
abscess at C2,
without evidence of cord signal abnormalities.

Video Oropharyngeal Swallow ([**5-23**]): Aspiration all liquids.

Transthoracic Echo ([**5-23**]): No valvular vegetations seen. LVEF >
55%.

CT Spine W/O Contrast ([**5-24**]):
1. Increased size of lytic lucency in the C2 odontoid process
with increased posterior cortical destruction. Despite the
increased lytic lucency which is concerning for osteomyelitis,
there is normal anatomic alignment of the odontoid process
without fracture or dislocation.
2. Persistent epidural collection posterior to C2, less apparent
on this non- contrast-enhanced study, but there is persistent
indentation and compression of the thecal sac.
3. Stable multilevel degenerative changes throughout the
cervical spine.

MR [**Name13 (STitle) **] W& W/O CONTRAST ([**5-26**]):
Slight interval decrease in size of epidural abscess at C2 with
decreased mass effect on the cord. Stable abnormal signal at C2
extending to the C1-C2 articulations bilaterally and within the
prevertebral and posterior paraspinal soft tissues. No definite
cord hyperintensity is seen.
Post op changes with a fluid collection along the lamina/spinous
process from C2-C4 which may represent a seroma but superimposed
infection cannot  be excluded.

Video Oropharyngeal Swallow ([**5-30**]): Improvement but onoing
severe dyphagia with aspiration of thin liquids. Aspiration
linked to bolus size. Clears for sips of nectar thick liquids
with observation.

Brief Hospital Course:
1. Neck Pain/Stiffness: Patient had persistent neck pain and
stiffness on transfer to the [**Hospital1 18**] on [**2108-5-18**], with no new focal
neurological deficits (patient has baseline right upper
extremity weakness from a prior polio infection).  Patient had a
CT and MRI scan of the cervical spine on [**2108-5-20**] that showed an
epidural abscess at the level of the C2 vertebral body with
probable osteomyelitis involving the odontoid process.  There
was impingement of the thecal sac without signal abnormality of
the spinal cord.  Patient was continued on his IV Clindamycin
(Day 1 [**2108-5-16**]) and was started on IV Ceftriaxone on [**2108-5-20**].
Orthopedic spine was consulted and recommended conservative
management with continuing IV antibiotics given that surgery
would carry a significant morbidity (an anterior approach with
posterior fusion).  Patient's family was informed of the
difficulties of surgery and agreed with the plan for
conservative management for the time being.  Patient was
transferred to the MICU on [**2108-5-20**] for close observation and
neuro checks every 2 hours.  ENT was consulted on [**5-21**] and felt
the abscess was most likely from hematogenous seeding, with no
clear fistula tract or upper airway gross lesion. He was
transferred back to the medicine team on [**5-22**] in stable
condition ([**5-8**] motor strength throughout except baseline
weakness in RUE from polio) and afebrile.  He had a repeat MRI
of the cervical spine to evaluate for any progression of the
epidural abscess.  The MRI showed unchanged epidural abscess
posterior to C2, unchanged osteomyelitis of odontoid process,
and unchanged spinal cord compression from prior study.
Orthopedic spine decided to schedule surgery for [**5-25**] given no
resolution of abscess after conservative management.

On [**2108-5-24**], patient was noted to be significantly weaker in his
lower extremities bilaterally (4/5 strength at 7:30 AM,
progressed to 2+/5 strength at 9:00 AM), and incontinent of
urine.  Neurology confirmed findings on exam, and orthopedic
spine was emergently paged.  Orthopedic spine evaluated patient
and determined patient needed urgent surgery.  Patient had stat
CT C-spine, which showed increased cortical destruction of the
posterior and anterior aspect of the dens, with no displacement
or fracture.  Patient was typed and screened for [**Date Range **], given 2
units FFP, maintained NPO except for BP meds.  The patient's
daughter was [**Name2 (NI) 82414**] ([**Name (NI) **]) and was at the patient's bedside
for assistance with consent for [**Last Name (LF) **], [**First Name3 (LF) 282**], and surgical
procedure. Patient did recover to [**4-8**] LE strength after patient
repositioned head within cervical collar and rested hands on top
of head. Patient was taken to the OR on [**5-24**] for emergent
decompressive surgery. Pus was drained from the C2 site, but no
hardware was placed due to risk of infection.  Patient also had
a PICC line and [**Month/Year (2) 282**] placed at the time of surgery.  Patient was
transferred to the PACU, and due to difficulty extubating the
patient, he was then transferred to the SICU on [**5-25**].  His SICU
course was complicated by post-operative delirium, which
improved over the next few days.  Patient was extubated on [**5-26**],
and transferred back to the medicine team on [**5-28**].  His strength
in his lower extremities returned to 5-/5, and his pain was
well-controlled with the hard collar in place and oxycodone.  On
[**5-30**], infectious disease recommended discontinuing clindamycin
and ceftriaxone, and transitioning to ceftriaxone and flagyl
given the patient developed diarrhea on [**5-30**].
-- Patient will continue antibiotics to complete a 6 week
course, last day [**2108-7-6**].
-- Weekly CBC, BUN/Creatinine, LFTs, ESR, and CRP, and fax
results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 438**] (Fax: [**Telephone/Fax (1) 432**]). Then follow-up
with Dr. [**Last Name (STitle) 438**].
-- Follow-up with Dr. [**Last Name (STitle) 1352**] of Orthopedic Surgery.

2. Bacteremia/Leukocytosis: Patient was afebrile on transfer to
the [**Hospital1 18**], with a leukocytosis of 21k.  Infectious disease was
consulted and recommended continuing the IV Clindamycin (started
on [**5-16**] in [**Hospital 1263**] hospital) for anaerobic coverage, given the
positive [**Hospital **] cultures for Veilonella from the [**Hospital 1263**] hospital.
 Patient's leukocytosis resolved on [**5-20**] (WBC 10k) after 4 days
of clindamycin.  Ceftriaxone was started on [**5-20**] to for
polymicrobial coverage.  Given history of unprotected
intercourse, RPR and chlamydia tests were sent and were
negative.  Serial [**Month/Year (2) **] cultures ([**5-19**], [**5-20**], [**5-22**], [**5-23**], [**5-29**])
all showed no growth to date.  Urine culture from [**5-19**] had less
than 100k organisms (Pseudomonas, klebsiella), repeat urine
culture obtained [**5-23**] showed less than 10k organisms.  Patient
had a transthoracic echo on [**5-23**] that showed no valvular
vegetations.  [**Hospital 1263**] hospital was contact[**Name (NI) **] regarding
sensitivies of the organism, but the microbiology laboratory
reported that sensivities are not performed on anaerobic
organisms.  On request, [**Hospital 1263**] hospital transferred the [**Hospital **]
sample on [**5-24**] to [**Hospital1 18**], and the sample was sent out to [**Hospital1 **] for
sensitivity testing.  Sensitivity results were pending at the
time of discharge.  Patient was afebrile throughout hospital
course. Antibiotics are as above
--  Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 438**] is the ID specialist caring for this
patient. Her office number is ([**Telephone/Fax (1) 4170**] and she will
follow-up the [**Hospital1 **] Lab data.

3. Dysphagia - Patient was noted to have difficulty swallowing
on transfer to medicine service on [**5-22**].  Speech and swallow was
consulted and recommended keeping the patient NPO pending the
results of the video swallow.  Patient tolerated crush meds
well.  On [**5-23**], the video swallow was obtained and showed severe
oropharyngeal dysphagia with aspiration of thin and nectar thick
liquids.  Speech and swallow recommended keeping patient NPO
with no PO meds.  The etiology of his dysphagia was most likely
due to his epidural abscess with underlying osteomyelitis, with
further impairment from his hard collar.  Radiology re-evaluated
his MRI of the brain and did not see any other findings that
could explain his dysphagia.  Surgery was consulted for [**Month/Year (2) 282**]
placement, given patient's failed swallow test and expected
prolonged course (requiring hard collar for [**6-11**] wks) following
orthopedic spine surgery.  Surgery consented the patient with
patient's daughter at bedside, and performed the [**Month/Day (3) 282**] placement
during the emergent orthopedic spine surgery on [**5-24**]. Nutriton
was consulted and initated tube feeds with no complications.
Speech and swallow evaluated the patient after surgery on [**5-29**].
Repeat video swallow showed improved swallowing function from
previous video swallow on [**5-23**], but with continued risk of
aspiration.  Speech and swallow recommended continuing G-tube
feeds as primary source of nutrition, with supervised pleasure
feeds of small amounts of nectar thick liquids per sitting.
-- Continue G-tube feeds as primary means of nutrition,
hydration, and medications.
-- Initiate supervised pleasure feeds of small amounts of nectar
thick liquids per sitting.
-- Aspiration Precautions:
   A. Patient should be seated fully upright.
   B. Then, gently lean forward with upper body and look down
      as able.
   C. Effortful swallow and [**3-7**] repeat swallows for each sip.
   D. Remain upright following pleasure feeds.
   E. Yankauer suction pharynx to help remove valleculae
      residue.
-- Repeat instrumental evaluation at rehab prior to upgrading
diet and once patient has cervical collar removed to further
assess swallow function and effectiveness of treatment
techniques.
-- Q4 oral care.
-- Ongoing assessment of tube feeding requirements and
electrolytes needs by nutrition. Please check Potassium and
Magnesium twice - three times weekly and replete as needed

4. Atrial fibrillation - Patient's atrial fibrillation was well
rate-controlled on the day of transfer to [**Hospital1 18**].  His home
medications of digoxin and diltiazem were continued.  Orthopedic
spine recommended holding any anti-coagulation or
antithrombotics pending decision on need for surgical
intervention.  Patient was noted to be tachycardic with a heart
rate in the low 100s on [**5-22**].  His digoxin was discontinued and
patient was started on lopressor, which improved his heart rate
control.  Patient's INR increased from 1.3 on [**5-18**] to 1.6 on
[**5-24**], most likely due to nutritional deficiency.  He received 2
mg Vitamin K on [**5-23**] and 2 units FFP prior to his surgery.
Post-operatively the patient was reinitiated on his
anticoagulation on [**5-28**] at reduced dose of 3 mg (home dose 5mg).
The patient's heart rate continued in the 90s-110s, and thus his
diltiazem was increased to 90 mg QID for improved control.
Patient's heart rate remained borderline tachycardic, and
increased with exertion, and thus his lopressor was uptitrated
to 50 mg PO TID.  Patient has HR in 90s and will defer any
rhythm management until patient if fully anti-coagulated.
-- Ongoing monitoring of INR and dose adjustment of coumadin,
goal INR 2.0-2.3

5. Hypertension - Patient was hypertensive with systolics in the
160s on day of transfer to [**Hospital1 18**].  His home dose of enalapril
was increased to 40 mg Qdaily, with improvement in his [**Hospital1 **]
pressure recordings.  Patient was noted to be hypertensive again
on [**5-23**] with systolic in the 160s, and his lopressor was
up-titrated.  Patient tolerated his oral [**Month/Year (2) **] pressure
medications crushed, and his [**Month/Year (2) **] presure was stable in the
160s. Post operatively the patient's [**Month/Year (2) **] pressure improved to
systolics in the 120-130s.

6. Urinary incontinence - Patient first reported urinary
incontinence on [**5-24**], which coincided with his weakness in the
lower extremities and thus was concerning for spinal cord
compression.  Patient underwent emergent decompressive surgery
later on [**5-24**].  Following surgery, patient had a foley catheter
that was discontinued on [**5-28**].  Patient reported a return of his
urinary incontinence on [**5-29**].  Patient was initially managed
with scheduled urinations every 4 hours, which did not improve
his incontinence.  Due to risk of skin breakdown and continued
incontinence, a foley was placed on [**5-30**].
-- Plan for foley removal q3 days with scheduled voids, if this
does not work either condom catheter or re-insertion of foley.
-- If issue persists patient should see urology for further
evaluation. ([**Telephone/Fax (1) 772**] will connect to [**Hospital1 18**] for urology
appointment.

6. Diabetes - Metformin was held and an insulin sliding scale
was started.  Patient's [**Hospital1 **] glucose levels were
well-controlled prior to surgery. Following surgery and
initiation of tube feeds, patient's [**Hospital1 **] glucose levels rose
into the 200s.  Patient was started on 2 units lantus in
addition to his insulin sliding scale, with significantly
improved glucose control.
-- Continue lantus 2units and HISS with adjustment to dosing as
indicated. If patient is able to transition to oral feedings,
may transition back to metformin.

7. Diarrhea - Overnight on [**5-30**], patient had several loose bowel
movements and was incontinent.  The acute onset of diarrhea in a
patient on Clindamycin and Ceftriaxone was concerning for
C.difficile infection.  A stool sample was sent for C.diff
toxin.  After the sample was sent, patient was started
empirically on flagyl.  The C.difficile toxin test came back
negative later on [**5-30**]. ID determined that patient would be best
served on ceftriaxone, flagyl to complete antibiotic course for
veillonella. Additionally, patient's colchicine was stopped.
Patient is likely at increased risk for loose stools due to tube
feeds.
-- Ongoing monitoring of stool frequency, reinitiation of bowel
regimen if indicated

8. Gout/Knee pain - Home dose of colchine was continued until
patient went to OR [**5-24**].  Colchine was restarted [**5-29**]. After
patient developed diarrhea on [**5-29**], the colchicine was
discontinued given possible contribution to loose bowel
movements.  On [**5-31**], patient developed new onset of left knee
pain.  On exam, the knee joint was warm without palpable
effusion, with pain on active and passive ROM.  Given his
history of bacteremia, there was a concern for septic arthritis
and thus knee arthrocentesis was attempted.  There was no
drainable fluid on arthrocentesis after 3 attempts.  The lack of
effusion was more convincing that patient's knee pain was most
likely a recurrence of his gout, especially given patient was
recently taken off his Colchicine.  Colchicine was held given
the ongoing diarrhea, and pain was managed with Ibuprofen 600 mg
Q8H.
-- Ongoing assessment of patient's response to therapy.

9. Post-Operative Confusion: Patient intermittently needs
re-orientation to specific day of week, but improving over last
2 days. Likely resolving post-op delirium.
-- Continue reorientation
-- OOB, PT

10. Anxiety: Stopped diazepam to minimize altering medications.
Patient has been doing well.
-- monitor for anxiety

11. Skin: Provided skin care with special attention to buttocks
(stage II pressure ulcer at coccyx).

12. ? Right vestibular schwannoma - Asymptomatic, noted on MRI
of the brain.
-- Patient will need dedicated MRI of the posterior fossa with
contrast for further evaluation to be discussed with his primary
care physician [**Last Name (NamePattern4) **]. [**First Name (STitle) 216**]

13. Pain Control: Ibuprofen standing and oxycodone liquid prn

The patient was FULL CODE during this hospitalization.

Medications on Admission:
Tylenol PRN
Colchicine 0.6mg QOD
Cardizem 240mg QD
Nexium 40mg QD
Metformin 500 QD *holding*
Coumadin 5mg QD *holding*
Valium 5mg po BID PRN anxiety
Enalapril 20mg PO QD
Clindamycin 300mg [**Hospital1 **] day [**3-13**]


Discharge Medications:
1. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO QHS (once a day
(at bedtime)): goal INR 2.0-2.3, crushed via [**Month/Year (2) 282**].
2. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day): hold sbp < 100, hr <50, crushed via [**Month/Year (2) 282**].
3. Enalapril Maleate 20 mg Tablet Sig: Two (2) Tablet PO once a
day: crushed via [**Month/Year (2) 282**].
4. Insulin Glargine 100 unit/mL Solution Sig: Two (2) units
Subcutaneous at bedtime.
5. Insulin Lispro 100 unit/mL Solution Sig: as directed units
Subcutaneous QACHS: BG 151-200 take 1 units
BG 201-250 3 take units
BG 251-300 5 take units
BG 301-350 7 take units
BG 351-400 9 take units
getting food/tube feeds.
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day): stop once INR > 2.0 for
48 hours.
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): hold sbp <100 or HR <50, crushed via [**Month/Year (2) 282**].
8. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Five (5) ML
Intravenous PRN (as needed) as needed for line flush: to be used
with saline flushes.
9. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: Five (5)
ML Intravenous Q8H (every 8 hours) as needed for line flush.
10. PICC LINE
PICC Line Care and Dressing Changes per Protocol
11. Oxycodone 5 mg/5 mL Solution Sig: Five (5) mg PO every [**6-11**]
hours as needed for pain: through [**Month/Day (3) 282**].
12. Hard Cervical Collar
To be worn at all times until cleared by orthopedics, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 1352**] ([**Telephone/Fax (1) 3736**]). Anticipated discontinuation of collar is
[**2108-7-20**].
13. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for pain: pain in left knee.
14. Flagyl 500 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours for 6 weeks: last dose am Friday, [**7-6**].
15. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig:
Two (2) grams Intravenous Q24H (every 24 hours) for 6 weeks:
last dose am Friday, [**7-6**].
16. Potassium Chloride 10 mEq/100 mL Piggyback Sig: One (1)
Intravenous once a day: Please check potassium levels twice a
week.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 700**] - [**Location (un) 701**]

Discharge Diagnosis:
C2 osteomyelitis
C2 abscess
Veillonella bacteremia
Atrial Fibrillation
Hypertension
Diarrhea
Gout

Discharge Condition:
Stable, afebrile, deficits 3-/5 at right deltoid, [**4-8**] right
biceps and triceps from prior polio, otherwise no focal
neurological deficit.


Discharge Instructions:
You were admitted to the hospital for an infection in the bone
of your neck and an abscess by your spine. You were started on
antibiotics, but your infection did not improve. You were taken
to the operating room for surgical drainage of your infection
and stabilization of your neck to relieve compression on your
spinal cord. You had a [**Month/Day (1) 282**] (feeding tube) placed to assist with
eating while you recover.  Your strength in your legs improved
after having surgery.  You worked with physical therapy and were
able to move from your bed to your chair.  The orthopedic spine
specialists would recommend that you continue physical therapy
and walk as much as you can tolerate. You had what appeared to
be a gout flare and were started on ibuprofen for your left
knee.

Please take all your medications as prescribed. Please keep all
your doctor appointments.

If you develop, chest pain, slurred speech, loss of vision, loss
of ability to move a limb, increased weakness, fever, or any
other concerning symptom please return to the Hospital.

Followup Instructions:
Please follow-up with your orthopedic spine specialist, Dr.
[**First Name8 (NamePattern2) **]  [**Last Name (NamePattern1) 1352**] ([**Telephone/Fax (1) 3736**]) on [**2108-6-7**] at 11:00 AM. Location:
[**Hospital Ward Name 23**] Clinical Center, [**Hospital Ward Name 516**] [**Hospital1 18**] [**Location (un) **].

Before your follow-up appointment with Dr. [**Last Name (STitle) 1352**], please go to
the Orthopedic X-ray department on the [**Location (un) 1773**] of the
[**Hospital Ward Name 23**] Clinical Center ([**Telephone/Fax (1) 1228**]).  Your appointment is on
[**2108-6-7**] at 10:40 AM.

You will see Dr. [**First Name (STitle) 216**] to discuss your health. Dr. [**First Name (STitle) 216**] will
set up this appointment for you and be in contact with you. Dr.
[**First Name (STitle) 216**] can be reached at [**Telephone/Fax (1) 250**]. When you see him you
should talk about the thyroid nodule (4 mm in size) that was
noted on an MRI.  The radiologists recommend that you have an
ultrasound of your neck done to further evaluate the nodule. The
MRI also noted a possible schwannoma of your ear and you can
discuss an MRI of the posterior fossa, if needed.

Please follow-up with your infectious disease specialist, Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 438**] ([**Telephone/Fax (1) 457**]), on Date/Time:[**2108-6-25**] 10:30AM.
Location: [**Hospital Unit Name **] Basement, [**Hospital Ward Name 517**] [**Hospital1 18**].


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 684**]
{'Intraspinal abscess,Encephalopathy, unspecified,Acute osteomyelitis, other specified sites,Bacteremia,Unspecified disease of spinal cord,Unspecified protein-calorie malnutrition,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other anaerobes,Atrial fibrillation,Long-term (current) use of anticoagulants,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Late effects of acute poliomyelitis,Polycythemia vera,Pressure ulcer, lower back,Urinary incontinence, unspecified,Gout, unspecified,Dysphagia, 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: Neck pain/Confusion

PRESENT ILLNESS: Mr. [**Known lastname 82412**] is a 77 year old man with a history of atrial
fibrillation on coumadin, hypertension, diabetes transferred on
[**5-18**] from [**Hospital 82413**] hospital for evaluation of confusion and neck
stiffness. According to the patient's daughter, the patient was
in his usual state of health until [**5-2**]. At that time, he
complained on bilateral neck pain and a sore throat. His
daughter took him to [**Hospital3 5365**] where a CT of the c-spine
was performed. He was felt to have torticollis and was
discharged with flexeril and percocet. On [**5-4**], the patient was
found in his home "out of it". He was still complaining of neck
pain, but was having visual hallucinations of things/people in
his house. His daughter called his PCP at which point they
attributed his symptoms to the medication changes and
percocet/flexeril was discontinued. Over the weekend, his mental
status continued to wax and wane. He appeared extremely fatigued
and was sleeping more. On [**5-8**], the patient was taken to his PCP
for evaluation and at that point he was referred to Carnitas for
work-up. He was found to be in atrial fibrillation with rapid
ventricular response w/HR of 160; it is unclear what medications
were changed at this time. The patient was apparently evaluated
over the course of a week without much in the way of cognitive
improvement. He was seen by neurology and this was felt to be
med effect. He was discharged to rehab on [**5-14**]. On [**5-16**] his
mental status apparently acutely declined again and he was noted
to be diaphoretic. He was then brought back to Carnitas.

MEDICAL HISTORY: Polycythemia [**Doctor First Name **]
Gout
Hypertension
Afib
Polio with upper extremity weakness (Right)
Diabetes (on metformin)

MEDICATION ON ADMISSION: Tylenol PRN
Colchicine 0.6mg QOD
Cardizem 240mg QD
Nexium 40mg QD
Metformin 500 QD *holding*
Coumadin 5mg QD *holding*
Valium 5mg po BID PRN anxiety
Enalapril 20mg PO QD
Clindamycin 300mg [**Hospital1 **] day [**3-13**]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T= 95.8 BP= 158/72 RR=20 O2= 94% on RA
GENERAL: Pleasant, uncomfortable appearly elderly man.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. Pupils constricted and minimally reactive.
EOMI. MMM. OP clear. Neck non-tender, painful to passive
rotation of the head, No LAD, no masses appreciated.
CARDIAC: irregular rhythm, normal rate. Normal S1, S2. No
murmurs appreciated.
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: Trace edema, no calf pain, 2+ dorsalis pedis/
posterior tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 3-/5 R deltoid, [**4-8**] R biceps/triceps, no
biceps reflex on right. 2+ reflexes, otherwise. Toes equivical.
PSYCH: Listens and responds to questions appropriately, pleasant

FAMILY HISTORY: No history of dementia or neurological disorders.

SOCIAL HISTORY: Independent at baseline; involved with his Church and civil war
groups. Widowed. Former smoker (quit at 30 yo, 15 pack-per-year
history), occasional etoh use. Denies drug use. 

### Response:
{'Intraspinal abscess,Encephalopathy, unspecified,Acute osteomyelitis, other specified sites,Bacteremia,Unspecified disease of spinal cord,Unspecified protein-calorie malnutrition,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other anaerobes,Atrial fibrillation,Long-term (current) use of anticoagulants,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Late effects of acute poliomyelitis,Polycythemia vera,Pressure ulcer, lower back,Urinary incontinence, unspecified,Gout, unspecified,Dysphagia, unspecified'}
