CHIEF COMPLAINT: altered mental status

PRESENT ILLNESS: Ms. [**Last Name (Titles) **]. [**Doctor Last Name **] is a 66 year-old woman with history of diastolic
CHF, Stage 1A NSCLC, COPD, presenting to the emergency room with
cough and dyspnea. Ms. [**Last Name (Titles) **]. [**Doctor Last Name **] has frequent dyspnea at
baseline, but over the past four days patient had noted
increased shortness of breath and ocugh. She was supposed to
have an endoscopy done last Thursday but it was cancelled
because she was complaining of cough and dyspnea and anesthesia
was not available for the procedure. She has been taking her
home dose of toresemide, but has noted decreasing urine output
over the past day. She has not been eating or drinking as much
at home as she typically does. Denies fevers or chills. This
morning her daughter noted that she had a low grade fever of 100
and seemed more confused. FS was 119 at that time. She was also
complaining of worsened dyspnea, so she called 911.
Of note patient was last hospitalized in either [**Month (only) 205**] or [**Month (only) 216**],
but has not been hospitalized in the last month. Her daughter,
who she lives with, has also been sick at home over the past
week and also has a bad cough.
In the ED, initial VS were: 99.6 68 126/59 28 100%
Non-Rebreather. On arrival exam was significant for b/l wheezing
and the patient was slightly confused. Labs were significant for
creatinine of 1.9 (baseline 0.6 - 1), troponin 0.05, BNP 3247
(last was 900 in [**2112-6-12**]), leukocytosis to 11.6. ABG was
7.3/56/69 - last ABG in [**11/2111**] was 7.44/38/66. CXR with low
lung volumes, known-stable RLL mass, and concern for right
mid-lung pneumonia. Patient required BiPAP while in the ED. In
the ED patient received albuterol and ipratripium nebs,
nitroglycerin 0.4 mg SL x1, methylprednisolone 125 mg IV x1,
azithromycin 500 mg IV x1, and ceftriaxone 1 gram IV x1.
On arrival to the MICU, patient is on BiPAP. She is lethargic,
but opens her eyes to her name. Patient nods that her breathing
feels better on the BiPAP. She denies any pain.

MEDICAL HISTORY: s/p Left Lower Lobectomy ([**10/2110**]) for mass - Pathology returned
as a 2.0 cm undifferentiated large cell carcinoma, pT1aN0Mx, neg
nodes clear margins, stage 1a. Currently followed by thoracic
surgery for spiculated RLL lesion, which has increased in size
and is concerning for malignancy.
- Diastolic CHF (also with mild MR, AS)
- A. Fib on coumadin
- Cirrhosis (likely [**1-14**] NASH vs. congestive hepatopathy)
- DMII c/w peripheral neuropathy
- pansenitive e.coli uti
- c. diff currently on fidaxomicin
- COPD
- Chronic venous insuffiency LE cellulitis
- depression
- anemia baseline hct 28.7
- HLD
- Gastritis
- Nephrolithiasis
- Psoriasis
- History of choleycystectomy
- Obesity
- Osteoporosis
- Hypercholesterolemia

MEDICATION ON ADMISSION: The Preadmission Medication list is accurate and complete.
1. Clobetasol Propionate 0.05% Ointment 1 Appl TP [**Hospital1 **]
apply to affected area
2. Duloxetine 20 mg PO DAILY
3. Enalapril Maleate 20 mg PO DAILY
4. fidaxomicin *NF* 200 mg Oral [**Hospital1 **]
planned through [**9-30**]
5. NPH 52 Units Breakfast
NPH 56 Units Bedtime
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Nadolol 20 mg PO BID
8. Mirtazapine 30 mg PO HS
9. Omeprazole 40 mg PO DAILY
10. Pregabalin 150 mg PO BID
11. Torsemide 80 mg PO DAILY
12. Warfarin 6.5 mg PO DAILY
13. Fluticasone-Salmeterol Diskus (250/50)  1 INH IH [**Hospital1 **]
14. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
15. Aspirin 81 mg PO DAILY

ALLERGIES: Amoxicillin / Glipizide / Ciprofloxacin / Bactrim / Soriatane /
Potassium Chloride / Bupropion / Calcium Channel Blocking
Agents-Benzothiazepines / atenolol

PHYSICAL EXAM: Admission Physical Exam
Vitals: T: 100.8 BP: 110/51 P: 71 R: 14 O2: 100% on BiPAP (30%
FiO2)
General: Lethargic, but arousable to voice, on BiPAP
HEENT: Sclera anicteric, PERRL, psoriasis on scalp
Neck: supple, unable to assess JVP 2/2 habitus
CV: Regular rate and rhythm, S1, S2, no murmurs appreciated
Lungs: Diffuse rhonchi anteriorly, no rales or wheezes.
Abdomen: obses, soft, non-tender, non-distended, bowel sounds
present
GU: foley catheter in place
Ext: erythema of lower extremity b/l likely consistent with
chronic venous stasis changes, 1+ pedal edema, 1+ DP pulses,
Neuro: Lethargic, arousable to voice, follows simple commands,
PERRLA, reflexes symmetric, asterixis

FAMILY HISTORY: +fh for diabetes, no FH for malignances

SOCIAL HISTORY: Lives with daughter. Retired file clerk in a law office. Current
smoker 1 to 1.5 ppd (60 pack year history). No alcohol or
illicits. Ambulates with a cane because walker doesn't fit well
in hallways.
Methicillin susceptible pneumonia due to Staphylococcus aureus,Acute on chronic diastolic heart failure,Acute respiratory failure,Acute kidney failure, unspecified,Intestinal infection due to Clostridium difficile,Acidosis,Shock, unspecified,Personal history of malignant neoplasm of bronchus and lung,Atrial fibrillation,Long-term (current) use of anticoagulants,Osteoporosis, unspecified,Obesity, unspecified,Other and unspecified hyperlipidemia,Depressive disorder, not elsewhere classified,Venous (peripheral) insufficiency, unspecified,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Tobacco use disorder,Thrombocytopenia, unspecified,Other psoriasis,Esophageal reflux,Cirrhosis of liver without mention of alcohol
Meth sus pneum d/t Staph,Ac on chr diast hrt fail,Acute respiratry failure,Acute kidney failure NOS,Int inf clstrdium dfcile,Acidosis,Shock NOS,Hx-bronchogenic malignan,Atrial fibrillation,Long-term use anticoagul,Osteoporosis NOS,Obesity NOS,Hyperlipidemia NEC/NOS,Depressive disorder NEC,Venous insufficiency NOS,DMII neuro nt st uncntrl,Neuropathy in diabetes,Tobacco use disorder,Thrombocytopenia NOS,Other psoriasis,Esophageal reflux,Cirrhosis of liver NOS
Admission Date:  [**2112-9-25**]              Discharge Date:   [**2112-10-4**]

Date of Birth:  [**2046-9-9**]             Sex:   F

Service: MEDICINE

Allergies:
Amoxicillin / Glipizide / Ciprofloxacin / Bactrim / Soriatane /
Potassium Chloride / Bupropion / Calcium Channel Blocking
Agents-Benzothiazepines / atenolol

Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
altered mental status

Major Surgical or Invasive Procedure:
Left IJ central catheter
Right arterial line

History of Present Illness:
Ms. [**Last Name (Titles) **]. [**Doctor Last Name **] is a 66 year-old woman with history of diastolic
CHF, Stage 1A NSCLC, COPD, presenting to the emergency room with
cough and dyspnea. Ms. [**Last Name (Titles) **]. [**Doctor Last Name **] has frequent dyspnea at
baseline, but over the past four days patient had noted
increased shortness of breath and ocugh. She was supposed to
have an endoscopy done last Thursday but it was cancelled
because she was complaining of cough and dyspnea and anesthesia
was not available for the procedure. She has been taking her
home dose of toresemide, but has noted decreasing urine output
over the past day. She has not been eating or drinking as much
at home as she typically does. Denies fevers or chills. This
morning her daughter noted that she had a low grade fever of 100
and seemed more confused. FS was 119 at that time. She was also
complaining of worsened dyspnea, so she called 911.
Of note patient was last hospitalized in either [**Month (only) 205**] or [**Month (only) 216**],
but has not been hospitalized in the last month. Her daughter,
who she lives with, has also been sick at home over the past
week and also has a bad cough.
In the ED, initial VS were: 99.6 68 126/59 28 100%
Non-Rebreather. On arrival exam was significant for b/l wheezing
and the patient was slightly confused. Labs were significant for
creatinine of 1.9 (baseline 0.6 - 1), troponin 0.05, BNP 3247
(last was 900 in [**2112-6-12**]), leukocytosis to 11.6. ABG was
7.3/56/69 - last ABG in [**11/2111**] was 7.44/38/66. CXR with low
lung volumes, known-stable RLL mass, and concern for right
mid-lung pneumonia. Patient required BiPAP while in the ED. In
the ED patient received albuterol and ipratripium nebs,
nitroglycerin 0.4 mg SL x1, methylprednisolone 125 mg IV x1,
azithromycin 500 mg IV x1, and ceftriaxone 1 gram IV x1.
On arrival to the MICU, patient is on BiPAP. She is lethargic,
but opens her eyes to her name. Patient nods that her breathing
feels better on the BiPAP. She denies any pain.


Past Medical History:
s/p Left Lower Lobectomy ([**10/2110**]) for mass - Pathology returned
as a 2.0 cm undifferentiated large cell carcinoma, pT1aN0Mx, neg
nodes clear margins, stage 1a. Currently followed by thoracic
surgery for spiculated RLL lesion, which has increased in size
and is concerning for malignancy.
- Diastolic CHF (also with mild MR, AS)
- A. Fib on coumadin
- Cirrhosis (likely [**1-14**] NASH vs. congestive hepatopathy)
- DMII c/w peripheral neuropathy
- pansenitive e.coli uti
- c. diff currently on fidaxomicin
- COPD
- Chronic venous insuffiency LE cellulitis
- depression
- anemia baseline hct 28.7
- HLD
- Gastritis
- Nephrolithiasis
- Psoriasis
- History of choleycystectomy
- Obesity
- Osteoporosis
- Hypercholesterolemia


Social History:
Lives with daughter. Retired file clerk in a law office. Current
smoker 1 to 1.5 ppd (60 pack year history). No alcohol or
illicits. Ambulates with a cane because walker doesn't fit well
in hallways.


Family History:
+fh for diabetes, no FH for malignances


Physical Exam:
Admission Physical Exam
Vitals: T: 100.8 BP: 110/51 P: 71 R: 14 O2: 100% on BiPAP (30%
FiO2)
General: Lethargic, but arousable to voice, on BiPAP
HEENT: Sclera anicteric, PERRL, psoriasis on scalp
Neck: supple, unable to assess JVP 2/2 habitus
CV: Regular rate and rhythm, S1, S2, no murmurs appreciated
Lungs: Diffuse rhonchi anteriorly, no rales or wheezes.
Abdomen: obses, soft, non-tender, non-distended, bowel sounds
present
GU: foley catheter in place
Ext: erythema of lower extremity b/l likely consistent with
chronic venous stasis changes, 1+ pedal edema, 1+ DP pulses,
Neuro: Lethargic, arousable to voice, follows simple commands,
PERRLA, reflexes symmetric, asterixis

Discharge Physical Exam
Vitals: wt 77.3kg 98.7, 138/70, 69, 19, 96%2L
General: NAD, sitting up in bed in NAD
HEENT: Sclera anicteric, PERRL, psoriasis on scalp,
subconjunctival hemorrhage obscuring white of the eye on the
left, not into the [**Doctor First Name 2281**] at all
Neck: supple, JVD 5cm above the clavicle
CV: RRR, III/VI SEM at the base and II/VI holosystolic murmur in
the mitral area
Lungs: Crackles [**12-16**] way up the bases bilaterally
Abdomen: obsese, soft, non-tender, non-distended, bowel sounds
present
GU: foley catheter in place draining clear yellow urine
Ext: erythema of lower extremity b/l likely consistent with
chronic venous stasis changes, 1+ LE edema up to knees, 1+ DP
pulses,
Neuro: AAOx3. no asterixis, tongue fasiculations


Pertinent Results:
Admission Labs:
[**2112-9-25**] 09:20AM BLOOD WBC-11.6* RBC-3.87* Hgb-9.4* Hct-30.8*
MCV-80* MCH-24.4* MCHC-30.6* RDW-17.4* Plt Ct-158
[**2112-9-25**] 09:20AM BLOOD Neuts-79.4* Lymphs-14.4* Monos-5.0
Eos-0.9 Baso-0.3
[**2112-9-25**] 09:20AM BLOOD PT-17.0* PTT-27.5 INR(PT)-1.6*
[**2112-9-25**] 09:20AM BLOOD Glucose-111* UreaN-51* Creat-1.9* Na-142
K-4.3 Cl-103 HCO3-27 AnGap-16
[**2112-9-25**] 09:20AM BLOOD ALT-22 AST-36 CK(CPK)-43 AlkPhos-133*
TotBili-0.5
[**2112-9-25**] 09:20AM BLOOD CK-MB-3 proBNP-3247*
[**2112-9-26**] 05:27AM BLOOD Calcium-8.3* Phos-5.6*# Mg-1.9
[**2112-9-25**] 05:10PM BLOOD Ammonia-25
[**2112-9-25**] 09:42AM BLOOD Type-[**Last Name (un) **] pO2-49* pCO2-61* pH-7.27*
calTCO2-29 Base XS-0 Comment-GREEN TOP
[**2112-9-25**] 09:42AM BLOOD Lactate-1.5

Discharge labs:
[**2112-10-4**] 06:55AM BLOOD WBC-10.8 RBC-4.07* Hgb-9.5* Hct-31.3*
MCV-77* MCH-23.4* MCHC-30.4* RDW-17.3* Plt Ct-88*
[**2112-10-4**] 06:55AM BLOOD PT-30.4* PTT-36.7* INR(PT)-2.8*
[**2112-10-4**] 06:55AM BLOOD Glucose-130* UreaN-15 Creat-0.7 Na-142
K-3.1* Cl-98 HCO3-42* AnGap-5*
[**2112-10-4**] 06:55AM BLOOD Calcium-9.3 Phos-2.7 Mg-1.9

Urine studies
[**2112-9-25**] 10:15AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011
[**2112-9-25**] 10:15AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2112-9-25**] 10:15AM URINE RBC-0 WBC-2 Bacteri-FEW Yeast-NONE Epi-0
TransE-<1
[**2112-9-25**] 10:15AM URINE CastHy-260*

Micro:
[**2112-9-25**] 7:03 pm SPUTUM      Source: Expectorated.

                            **FINAL REPORT [**2112-10-2**]**

   GRAM STAIN (Final [**2112-9-25**]):
      [**10-6**] PMNs and <10 epithelial cells/100X field.
      NO MICROORGANISMS SEEN.

   RESPIRATORY CULTURE (Final [**2112-9-30**]):
      RARE GROWTH Commensal Respiratory Flora.
      STAPH AUREUS COAG +.    RARE GROWTH.
         Staphylococcus species may develop resistance during
prolonged
         therapy with quinolones.   Therefore, isolates that are
initially
         susceptible may become resistant within three to four
days after
         initiation of therapy.  Testing of repeat isolates may
be
         warranted.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------     1 S
TETRACYCLINE----------   <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S

   LEGIONELLA CULTURE (Final [**2112-10-2**]):    NO LEGIONELLA
ISOLATED.

Blood cultures x 2 [**2112-9-25**]- NEGATIVE
Urine culture [**2112-9-25**]- NEGATIVE

Brief Hospital Course:
Ms. [**Last Name (Titles) **]. [**Doctor Last Name **] is a 66 yo female with h/o diastolic CHF, COPD,
Stage 1a NSCLC (and new concerning RLL lesion), presenting with
dyspnea, wheezing and altered mental status who was admitted
with RML pnuemonia who required intubation secondary to altered
mental status and worsening hypercarbia who was found to have an
MSSA pneumonia, and had CHF exacerbation requiring diuresis who
was improved respiratory and mental status at the time of
discharge to rehab.

#Right middle lobe MSS pneumonia- patient was admitted with
cough and new CXR finding of infiltrat in the right middle lobe.
She required intubation for hypercarbic respiratory failure and
altered mental status and was extubated after 24 hour with no
further respiratory decompensation.  Pt was started on
Ceftriaxone and azithromycin on admission and completed a 5 day
course of this. During this time her sputum culture grew out
MSSA and the patient was treatd with IV vancomycin from
[**Date range (1) 87529**] (the course was abridged by 1 day [**1-14**]
thrombocytopenia that there was concern was secondary to the
vancomycin.  She was treated with vancomycin even after
sensisitivies came back given her penicillin and fluroquinolone
allergy, and current Cdiff infection did not want to treat with
clindamycin.  After hte patient was called out of the ICU she
had no further fevers and a nonproductive cough and had no
episodes of respitaory distress. She continued to require oxygen
around 98% on 2L NC.

#CHF decompensation- on admission the patient had evidence fo
volume overload with an elevated BNP concerning for CHF
exacerbation, gvein her underlying pneumonia she was not
initially diuresed. After transfer to the floor she was diuresed
agressively and responded well to 80mg IV lasix 1-2x/day.  Her
weight at the time of discharge is 77.3kg.  She has some mild
edema in her lower extremitis on discharge and will likely still
require continued diuresis at home. She normally takes 80mg of
po torsemide as an outpatient. Given that she put out 3L to this
when given inpatient and developed a contraction alkalsois with
it was decided to decrease the dose of her torsemide to 40mg po
qday and her outpatient providers can assess if this should be
uptitrated once she resumes her regular home food.  She was
briefly off of her ACEI given acute renal failure and low blood
pressures and this was restarted at 1/2 of her home dose at the
time of discharge. She developed chronic hypokalemia in the
setting of diuresis and was started on standing potassium
supplements.
-discharge wt 77.3kg
-decreased po torsemide from 80mg to 40mg once a day
-decreased enalapril from 20mg to 10 mg once a day
-patient has follow-up with Dr. [**First Name (STitle) 437**]
[**Name (STitle) **] will need repeat CHEM 7 checked on [**10-6**] to assess for
electrolyte abnormalities and assess specifically for her bicarb
elevation (was 42 at the time of discharge)

# Altered mental status: Likely multifactorial - likely in
setting of hypercarbia/COPD vs, pneumonia/acute infection vs.
metabolic derangements from renal failure.  While the patient
has a history of cirrhosis she had no signs of encephalopathy on
exam and never had asterxis.  After transfer onto the floor she
continued to be altered and her antidepressives were held and
then restarted prior to her discharge.  She had a nonfocal exam
and had a negative head CT.  She was awake and A+Ox3 at the time
of discharge.

# Acute renal failure: Pt presented with elevated BUN/ Cr
(59/1.9). This was likely secondary to intravascular depletion
and she had many hyalnie casts on her admission UA which was
consistent with this.  This resolved to baseline and Cr was 0.7
on discharge.

#Thrombocytopenia- patient devloped thrombocytopenia during her
admission downt o 70 at the lowest and was increasing to 88 at
the time of discharge. On review of her medicaitons that she was
receiving inhouse she was getting vancomycin and it is likely
that the combination of vancomycin and her acute infection lead
to this.  She was NOT on heaprin during this admission as she is
on warfarin for afib.
-Patient will need platelet count checked in two weeks after
discharge to assure that it is improving or sooner if she has
petichiae or concerns for bleeding

#Afib on warfarin- patient was continued on her warfarin while
inhouse.  Per records she was taking 6.5mg of warfarin as an
outpatient, this was decreased to 4 and then when cymbalta was
restarted increased to supratherapeutic levels and it was held x
1 day and restarted on the day of discharge to 3mg.
-she will need her INR checked on [**10-6**] and warfarin dose
adjusted then.

# Recurrent c. diff: Patient has had difficult to treat c. diff
despite long taper of vancomycin and is now on fidaxomicin on
admission.  She was asymptomatic during her admission. She was
followed by ID as an outpatient. Given that she was on
antibiotics throughout the ocurse of her hospital stay her
fidaxomicin was continued.  She will need to complete a 10 day
course started on [**10-4**] as this was the planned course prior to
her admission
-will continue fidaxamicin until [**2112-10-13**]

# DM: During her admission her NPH was held and she was kept on
a sliding scale and her metformin was held. As she started to
take in more PO her blood sugars were remaining elevated. She
NPH wa restarted at a lower dose on [**10-3**] with improved control.
 Would recommend that the outpatient providers uptitrate as
needed and will be the ones to decide whether or not to restart
the metformin as an outpatient.
-stopped metformin
-lowered NPH dose 56U down to 25 U [**Hospital1 **]
-Patient was discharged with a sliding scale

# Psoriasis: Continued clobetasol 0.05% ointment.

# Depression: Patient originally had her antidepresents held
during her altered mental status and these were restarted prior
to her discharge. She continued to have very low energy,
decreased appetitte and felt depressed while here. She was seen
by social work while inpatient and they recommend that she
follow-up with social work in [**Company 191**]
-recommend f/u with the [**Company 191**] social worker.
-mirtazapine was decreased from 30mg to 7.5 during this
admission due to exessive sleepiness initially (could be
reuptitrated as an outpatient)

#GERD: Continued pantoprazole 40 mg po daily


Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clobetasol Propionate 0.05% Ointment 1 Appl TP [**Hospital1 **]
apply to affected area
2. Duloxetine 20 mg PO DAILY
3. Enalapril Maleate 20 mg PO DAILY
4. fidaxomicin *NF* 200 mg Oral [**Hospital1 **]
planned through [**9-30**]
5. NPH 52 Units Breakfast
NPH 56 Units Bedtime
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Nadolol 20 mg PO BID
8. Mirtazapine 30 mg PO HS
9. Omeprazole 40 mg PO DAILY
10. Pregabalin 150 mg PO BID
11. Torsemide 80 mg PO DAILY
12. Warfarin 6.5 mg PO DAILY
13. Fluticasone-Salmeterol Diskus (250/50)  1 INH IH [**Hospital1 **]
14. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
15. Aspirin 81 mg PO DAILY


Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Duloxetine 20 mg PO DAILY
3. Fluticasone-Salmeterol Diskus (250/50)  1 INH IH [**Hospital1 **]
4. NPH 25 Units Breakfast
NPH 25 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Mirtazapine 7.5 mg PO HS
6. Nadolol 20 mg PO BID
7. Omeprazole 40 mg PO DAILY
8. Potassium Chloride 40 mEq PO DAILY Duration: 1 Doses
Hold for K >5
9. Enalapril Maleate 10 mg PO DAILY
10. fidaxomicin *NF* 200 mg Oral [**Hospital1 **]
planned through [**2112-10-13**]
11. Torsemide 40 mg PO DAILY
12. Pregabalin 150 mg PO BID
13. Warfarin 3 mg PO DAILY
14. Clobetasol Propionate 0.05% Ointment 1 Appl TP [**Hospital1 **]
apply to affected area
15. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
16. Senna 1 TAB PO BID:PRN Constipation
17. Ipratropium Bromide Neb 1 NEB IH Q6H
18. Docusate Sodium 100 mg PO BID
19. Acetaminophen 650 mg PO Q6H:PRN pain
do not exceed 3g in 24 hour


Discharge Disposition:
Extended Care

Facility:
[**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) **] at [**Location (un) 1821**]

Discharge Diagnosis:
MSSA pneumonia
decompensated dCHF
Acute kidney injury
Thrombocytopenia


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).

Discharge Instructions:
Dear Ms. [**First Name8 (NamePattern2) **] [**Last Name (Titles) **],
It was a pleasure taking care of you while you were here at
[**Hospital1 18**].  You were admitted to the hospital when you were
confused. You were found to have a pneumonia and were in the ICU
where you were intubated for a day and then improved your
breathing status. You completed a course of antibiotics for your
pneumonia. You were also having worsening heart failure in the
setting of this and required more fluid removal with IV lasix to
help your breathing.
It will be important to monitor your weight daily after you
leave.


Followup Instructions:
You should have a follow-up appointment scheduled with your PCP
for when you get out of rehab.

Department: MEDICAL SPECIALTIES
When: TUESDAY [**2112-10-11**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9661**], MD [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: PFT
When: TUESDAY [**2112-10-11**] at 9:00 AM

Department: PULMONARY FUNCTION LAB
When: TUESDAY [**2112-10-11**] at 8:40 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Methicillin susceptible pneumonia due to Staphylococcus aureus,Acute on chronic diastolic heart failure,Acute respiratory failure,Acute kidney failure, unspecified,Intestinal infection due to Clostridium difficile,Acidosis,Shock, unspecified,Personal history of malignant neoplasm of bronchus and lung,Atrial fibrillation,Long-term (current) use of anticoagulants,Osteoporosis, unspecified,Obesity, unspecified,Other and unspecified hyperlipidemia,Depressive disorder, not elsewhere classified,Venous (peripheral) insufficiency, unspecified,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Tobacco use disorder,Thrombocytopenia, unspecified,Other psoriasis,Esophageal reflux,Cirrhosis of liver without mention of alcohol'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: altered mental status

PRESENT ILLNESS: Ms. [**Last Name (Titles) **]. [**Doctor Last Name **] is a 66 year-old woman with history of diastolic
CHF, Stage 1A NSCLC, COPD, presenting to the emergency room with
cough and dyspnea. Ms. [**Last Name (Titles) **]. [**Doctor Last Name **] has frequent dyspnea at
baseline, but over the past four days patient had noted
increased shortness of breath and ocugh. She was supposed to
have an endoscopy done last Thursday but it was cancelled
because she was complaining of cough and dyspnea and anesthesia
was not available for the procedure. She has been taking her
home dose of toresemide, but has noted decreasing urine output
over the past day. She has not been eating or drinking as much
at home as she typically does. Denies fevers or chills. This
morning her daughter noted that she had a low grade fever of 100
and seemed more confused. FS was 119 at that time. She was also
complaining of worsened dyspnea, so she called 911.
Of note patient was last hospitalized in either [**Month (only) 205**] or [**Month (only) 216**],
but has not been hospitalized in the last month. Her daughter,
who she lives with, has also been sick at home over the past
week and also has a bad cough.
In the ED, initial VS were: 99.6 68 126/59 28 100%
Non-Rebreather. On arrival exam was significant for b/l wheezing
and the patient was slightly confused. Labs were significant for
creatinine of 1.9 (baseline 0.6 - 1), troponin 0.05, BNP 3247
(last was 900 in [**2112-6-12**]), leukocytosis to 11.6. ABG was
7.3/56/69 - last ABG in [**11/2111**] was 7.44/38/66. CXR with low
lung volumes, known-stable RLL mass, and concern for right
mid-lung pneumonia. Patient required BiPAP while in the ED. In
the ED patient received albuterol and ipratripium nebs,
nitroglycerin 0.4 mg SL x1, methylprednisolone 125 mg IV x1,
azithromycin 500 mg IV x1, and ceftriaxone 1 gram IV x1.
On arrival to the MICU, patient is on BiPAP. She is lethargic,
but opens her eyes to her name. Patient nods that her breathing
feels better on the BiPAP. She denies any pain.

MEDICAL HISTORY: s/p Left Lower Lobectomy ([**10/2110**]) for mass - Pathology returned
as a 2.0 cm undifferentiated large cell carcinoma, pT1aN0Mx, neg
nodes clear margins, stage 1a. Currently followed by thoracic
surgery for spiculated RLL lesion, which has increased in size
and is concerning for malignancy.
- Diastolic CHF (also with mild MR, AS)
- A. Fib on coumadin
- Cirrhosis (likely [**1-14**] NASH vs. congestive hepatopathy)
- DMII c/w peripheral neuropathy
- pansenitive e.coli uti
- c. diff currently on fidaxomicin
- COPD
- Chronic venous insuffiency LE cellulitis
- depression
- anemia baseline hct 28.7
- HLD
- Gastritis
- Nephrolithiasis
- Psoriasis
- History of choleycystectomy
- Obesity
- Osteoporosis
- Hypercholesterolemia

MEDICATION ON ADMISSION: The Preadmission Medication list is accurate and complete.
1. Clobetasol Propionate 0.05% Ointment 1 Appl TP [**Hospital1 **]
apply to affected area
2. Duloxetine 20 mg PO DAILY
3. Enalapril Maleate 20 mg PO DAILY
4. fidaxomicin *NF* 200 mg Oral [**Hospital1 **]
planned through [**9-30**]
5. NPH 52 Units Breakfast
NPH 56 Units Bedtime
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Nadolol 20 mg PO BID
8. Mirtazapine 30 mg PO HS
9. Omeprazole 40 mg PO DAILY
10. Pregabalin 150 mg PO BID
11. Torsemide 80 mg PO DAILY
12. Warfarin 6.5 mg PO DAILY
13. Fluticasone-Salmeterol Diskus (250/50)  1 INH IH [**Hospital1 **]
14. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
15. Aspirin 81 mg PO DAILY

ALLERGIES: Amoxicillin / Glipizide / Ciprofloxacin / Bactrim / Soriatane /
Potassium Chloride / Bupropion / Calcium Channel Blocking
Agents-Benzothiazepines / atenolol

PHYSICAL EXAM: Admission Physical Exam
Vitals: T: 100.8 BP: 110/51 P: 71 R: 14 O2: 100% on BiPAP (30%
FiO2)
General: Lethargic, but arousable to voice, on BiPAP
HEENT: Sclera anicteric, PERRL, psoriasis on scalp
Neck: supple, unable to assess JVP 2/2 habitus
CV: Regular rate and rhythm, S1, S2, no murmurs appreciated
Lungs: Diffuse rhonchi anteriorly, no rales or wheezes.
Abdomen: obses, soft, non-tender, non-distended, bowel sounds
present
GU: foley catheter in place
Ext: erythema of lower extremity b/l likely consistent with
chronic venous stasis changes, 1+ pedal edema, 1+ DP pulses,
Neuro: Lethargic, arousable to voice, follows simple commands,
PERRLA, reflexes symmetric, asterixis

FAMILY HISTORY: +fh for diabetes, no FH for malignances

SOCIAL HISTORY: Lives with daughter. Retired file clerk in a law office. Current
smoker 1 to 1.5 ppd (60 pack year history). No alcohol or
illicits. Ambulates with a cane because walker doesn't fit well
in hallways. 

### Response:
{'Methicillin susceptible pneumonia due to Staphylococcus aureus,Acute on chronic diastolic heart failure,Acute respiratory failure,Acute kidney failure, unspecified,Intestinal infection due to Clostridium difficile,Acidosis,Shock, unspecified,Personal history of malignant neoplasm of bronchus and lung,Atrial fibrillation,Long-term (current) use of anticoagulants,Osteoporosis, unspecified,Obesity, unspecified,Other and unspecified hyperlipidemia,Depressive disorder, not elsewhere classified,Venous (peripheral) insufficiency, unspecified,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Tobacco use disorder,Thrombocytopenia, unspecified,Other psoriasis,Esophageal reflux,Cirrhosis of liver without mention of alcohol'}
