CHIEF COMPLAINT: altered mental status

PRESENT ILLNESS: 53 yo W w/ DM1 (brittle on insulin pump), s/p LURT [**2106**]
(Baseline Cr 1.4-1.7), CAD (s/p multiple PCIs), [**Year (4 digits) 19874**] (EF 45%),
HTN/HL who initially presented to [**Hospital3 **] with a left
proximal humerus fracture now transfered to [**Hospital1 18**] for
respiratory distress, septic shock, and renal failure.

MEDICAL HISTORY: - DM1 ([**2076**]), brittle, c/b nephropathy and retinopathy on
insulin pump (last A1C at [**Last Name (un) **] in [**2110**] of 9.6%)
- s/p LURT in [**2106**], c/b humoral rejection followed by multiple
plasmapheresis, recent Cr baseline (1.4-1.7)
- CAD, s/p "silent" inferior MI '[**07**], s/p LAD and LCX DES '[**07**].
- [**Last Name (LF) 19874**], [**First Name3 (LF) **] 40-50%.
- Hypertension
- HL
- Obesity
- s/p vitreous hemorrhage OD
- L leg swelling [**3-16**] lymphocele in the pelvis
- Charcot-foot deformity on Left
- hx of RP bleed
- IBS
- Hypothyroidism

MEDICATION ON ADMISSION: Medications on OSH Transfer:
Acyclovir 750 mg IV Q12H ([**7-6**])
CefePIME 2 g IV Q12H ([**7-7**])
Vancomycin 1500 mg IV Q 24H ([**7-9**])
Vancomycin Oral Liquid 125 mg PO/NG Q6H ([**7-7**])
PredniSONE 4 mg PO/NG DAILY
Sirolimus 1 mg PO DAILY
Senna 1 TAB PO BID:PRN Constipation
Docusate Sodium (Liquid) 100 mg PO BID
Heparin 5000 UNIT SC TID
Aspirin 81 mg PO/NG DAILY Start: In am
Atorvastatin 80 mg PO/NG DAILY Start: In am
Levothyroxine Sodium 50 mcg PO/NG DAILY
Acetaminophen 650 mg PO/NG Q6H:PRN pain/fever
Insulin 100 Units/100 ml NS @ [**3-28**] UNIT/HR IV DRIP
Acetaminophen IV 1000 mg IV Q6H:PRN fever
Ondansetron 4 mg IV Q8H:PRN nausea
Promethazine 12.5 mg IV Q6H:PRN nausea/vomitting
LeVETiracetam 750 mg IV Q12H
Metoprolol Tartrate 37.5 mg PO/NG TID
Furosemide 40 mg PO/NG DAILY
Sulfameth/Trimethoprim SS 1 TAB PO/NG DAILY
Quetiapine Fumarate 25 mg PO/NG [**Hospital1 **]: PRN agitation
Valsartan 80 mg PO/NG DAILY
Ipratropium Bromide Neb 1 NEB IH Q6H
Albuterol 0.083% Neb Soln 1 NEB IH Q6H
Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN wheezing/sob
Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB/wheezing

ALLERGIES: Morphine / Norvasc

PHYSICAL EXAM: Admission exam:
General: Intubated and sedated, responsive to voice, comfortable
on vent, seems to become drowsy after a few minutes and closes
eyes
HEENT: Sclera anicteric, PERRL, ET tube in place
Neck: supple, no LAD, R IJ in place without surrounding erythema
or induration
CV: Regular rate and rhythm, normal S1 + S2, no m/r/g
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, distended [**3-16**] to habitus, faint BS
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, charcot
deformity on left with 2+ edema below ankle on left, trace edema
on right
Neuro: nods yes/no to simple questions, moves hands/feet on
command, pupils equal and reactive, comfortable, drowsy and
drifts off after a few seconds

FAMILY HISTORY: [**Name (NI) 12237**] DM
[**Name (NI) 12238**] [**Name (NI) 1932**] died at age 50's
No h/o of kidney disease

SOCIAL HISTORY: Lives in [**Location 7661**] w/ husband who is her kidney donor. Has two
adult children who are healthy. Retired from medical records.
Tobacco - denies
EtOH - denies
Drug use - denies.
Pneumonitis due to inhalation of food or vomitus,Unspecified septicemia,Septic shock,Toxic encephalopathy,Subendocardial infarction, initial episode of care,Acute respiratory failure,Severe sepsis,Chronic systolic heart failure,Acute kidney failure, unspecified,Intestinal infection due to Clostridium difficile,Complications of transplanted kidney,Tabes dorsalis,Closed fracture of unspecified part of humerus,Pneumonia, organism unspecified,Long-term (current) use of insulin,Insulin pump status,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Background diabetic retinopathy,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Unspecified acquired hypothyroidism,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Anemia in chronic kidney disease,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Depressive disorder, not elsewhere classified,Anxiety state, unspecified,Arthropathy associated with neurological disorders,Fall from other slipping, tripping, or stumbling,Diabetes with ophthalmic manifestations, type I [juvenile type], uncontrolled
Food/vomit pneumonitis,Septicemia NOS,Septic shock,Toxic encephalopathy,Subendo infarct, initial,Acute respiratry failure,Severe sepsis,Chr systolic hrt failure,Acute kidney failure NOS,Int inf clstrdium dfcile,Compl kidney transplant,Tabes dorsalis,Fx humerus NOS-closed,Pneumonia, organism NOS,Long-term use of insulin,Insulin pump status,Crnry athrscl natve vssl,Hyperlipidemia NEC/NOS,Diabetic retinopathy NOS,Nephritis NOS in oth dis,Hypothyroidism NOS,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Anemia in chr kidney dis,Abn react-org transplant,Depressive disorder NEC,Anxiety state NOS,Arthropathy w nerve dis,Fall from slipping NEC,DMI ophth uncntrld
Admission Date:  [**2113-7-4**]              Discharge Date:   [**2113-7-20**]

Date of Birth:  [**2060-1-14**]             Sex:   F

Service: MEDICINE

Allergies:
Morphine / Norvasc

Attending:[**First Name3 (LF) 3624**]
Chief Complaint:
altered mental status

Major Surgical or Invasive Procedure:
Inutbation
PICC placement
Lumbar Puncture


History of Present Illness:
53 yo W w/ DM1 (brittle on insulin pump), s/p LURT [**2106**]
(Baseline Cr 1.4-1.7), CAD (s/p multiple PCIs), [**Year (4 digits) 19874**] (EF 45%),
HTN/HL who initially presented to [**Hospital3 **] with a left
proximal humerus fracture now transfered to [**Hospital1 18**] for
respiratory distress, septic shock, and renal failure.

Patient initially went to [**Hospital3 **] on [**2113-7-3**] after
trippering over a chair, falling, and sustaining a left proximal
humerus fracture without dislocation. Orthopedics saw and
advised conservative management and she was given dilaudid for
pain as well as a muscle relaxant (unknown type). At 5am on
[**2113-7-4**], patient noted to be lethargic with sats to 70s as well
as febrile to 103.1. She was given 1 dose of Narcan with little
change. Put on 100% NRB and trasfered to CCU where she was given
Ceftazidime and Vancomycin. ABG at time showed pO2 of 60%. Some
question if EKG changes inferiorly (reported as elevations).
Cardiology saw and thought not a cardiac cause. ECHO showed EF
40%. Cards thought she was developing ARDS. ID consulted and
recommended switching Ceftazidime to Zosyn for Asp PNA. Cr was
2.1 on admission and rose to 2.9 on [**7-4**]. Continued to be
hypotensive despite fluids (unsure how much) and was started on
phenylephrine gtt. Insulin pump (home med) was discontinued and
ISS started. [**Last Name (un) **] and bactrim were held. Pts [**Hospital1 18**] renal
transplant attending ([**Doctor Last Name **]) was contact[**Name (NI) **] and patient was
transfered to [**Hospital1 18**] for further care.

Immediately prior to transfer patient was intubated due to
concerns Re transfer saftey with pt still on NRB and concerns by
[**Hospital3 **] that she was developing ARDS. Pressures dropped
significantly after intubation with Rocuronium and Propofol and
had to go up on Phenylephrine. Patient was stable on ride over
and EMTs were able to go down on her pressor requirement. She
did well on the vent with relatively minimal sedation and
remained responsive to voice on ride over.

On arrival to the MICU, patient intubated and sedated, just got
propofol bolus. However, able to respond to voice and follow
simple commands. Reporting no pain. Seems to understand what I
am saying.

Review of systems: Unable to obtain as intubaed


Past Medical History:
- DM1 ([**2076**]), brittle, c/b nephropathy and retinopathy on
insulin pump (last A1C at [**Last Name (un) **] in [**2110**] of 9.6%)
- s/p LURT in [**2106**], c/b humoral rejection followed by multiple
plasmapheresis, recent Cr baseline (1.4-1.7)
- CAD, s/p "silent" inferior MI '[**07**], s/p LAD and LCX DES '[**07**].
- [**Last Name (LF) 19874**], [**First Name3 (LF) **] 40-50%.
- Hypertension
- HL
- Obesity
- s/p vitreous hemorrhage OD
- L leg swelling [**3-16**] lymphocele in the pelvis
- Charcot-foot deformity on Left
- hx of RP bleed
- IBS
- Hypothyroidism


Social History:
Lives in [**Location 7661**] w/ husband who is her kidney donor. Has two
adult children who are healthy. Retired from medical records.
Tobacco - denies
EtOH - denies
Drug use - denies.


Family History:
[**Name (NI) 12237**] DM
[**Name (NI) 12238**] [**Name (NI) 1932**] died at age 50's
No h/o of kidney disease

Physical Exam:
Admission exam:
General: Intubated and sedated, responsive to voice, comfortable
on vent, seems to become drowsy after a few minutes and closes
eyes
HEENT: Sclera anicteric, PERRL, ET tube in place
Neck: supple, no LAD, R IJ in place without surrounding erythema
or induration
CV: Regular rate and rhythm, normal S1 + S2, no m/r/g
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, distended [**3-16**] to habitus, faint BS
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, charcot
deformity on left with 2+ edema below ankle on left, trace edema
on right
Neuro: nods yes/no to simple questions, moves hands/feet on
command, pupils equal and reactive, comfortable, drowsy and
drifts off after a few seconds

Discharge exam:
General: AOx3, anxious but appropriate
HEENT: anicteric, dry MM
CV: RRR, no m/r/g
Lungs: CTAB, no w/r/r
Abd: soft, not tender, +BS
Ext: warm, 2+ pulses, charcot deformity on left with 1+ edema
below ankle on left, trace edema on right; left arm with limited
mobility due to pain
Neuro: grossly intact

Pertinent Results:
Admission labs:
[**2113-7-4**] 07:19PM BLOOD WBC-17.2*# RBC-3.45* Hgb-8.6* Hct-28.4*
MCV-82 MCH-24.9* MCHC-30.3* RDW-17.6* Plt Ct-276
[**2113-7-4**] 07:19PM BLOOD Neuts-66 Bands-25* Lymphs-5* Monos-1*
Eos-1 Baso-0 Atyps-0 Metas-2* Myelos-0
[**2113-7-4**] 07:19PM BLOOD PT-11.6 PTT-27.5 INR(PT)-1.1
[**2113-7-4**] 07:19PM BLOOD Glucose-292* UreaN-57* Creat-3.1*#
Na-129* K-5.1 Cl-93* HCO3-21* AnGap-20
[**2113-7-4**] 07:19PM BLOOD ALT-60* AST-129* LD(LDH)-343*
CK(CPK)-1812* AlkPhos-117* TotBili-0.9
[**2113-7-4**] 07:19PM BLOOD Albumin-3.7 Calcium-7.9* Phos-5.7*#
Mg-2.0

Other pertinent labs:
[**2113-7-4**] 07:19PM BLOOD CK-MB-32* MB Indx-1.8 cTropnT-1.34*
[**2113-7-5**] 03:27AM BLOOD CK-MB-24* MB Indx-1.4 cTropnT-1.15*
[**2113-7-6**] 04:00AM BLOOD cTropnT-0.91*
[**2113-7-12**] 03:20AM BLOOD Hapto-553*
[**2113-7-5**] 03:27AM BLOOD %HbA1c-7.1* eAG-157*
[**2113-7-6**] 04:00AM BLOOD TSH-0.75
[**2113-7-5**] 03:27AM BLOOD Cortsol-23.8*
[**2113-7-8**] 07:14AM BLOOD IgG-524* IgM-13*

Discharge labs:
[**2113-7-20**] 05:30AM BLOOD WBC-10.3 RBC-3.06* Hgb-7.9* Hct-25.7*
MCV-84 MCH-25.8* MCHC-30.7* RDW-17.8* Plt Ct-701*
[**2113-7-20**] 05:30AM BLOOD Glucose-148* UreaN-22* Creat-1.1 Na-137
K-4.6 Cl-107 HCO3-20* AnGap-15
[**2113-7-20**] 05:30AM BLOOD Calcium-8.6 Phos-3.6 Mg-1.7
[**2113-7-19**] 05:20AM BLOOD calTIBC-189* Ferritn-750* TRF-145*
[**2113-7-20**] 05:30AM BLOOD rapmycn-4.9*

IMAGING
[**2113-7-4**] CXR:
Mild-to-moderate cardiomegaly is stable.  ET tube tip is low,
1.5 cm above the carina, can be withdraw couple of centimeters
for more standard position.  NG tube tip is in the stomach, but
the side hole is at the EG junction and should be advanced for
more standard position.  Right IJ catheter tip is at the
cavoatrial junction.  Left perihilar and lower lobe opacities
are worrisome for aspiration given the clinical concern.  There
is mild vascular congestion. There is no pneumothorax.  If any,
there is a small left pleural effusion.

[**2113-7-5**] Head CT:
FINDINGS:  There are no comparison studies on record.  There is
no significant abnormality of the extracalvarial soft tissues,
and no underlying skull fracture is seen.  There is no intra- or
extra-axial hemorrhage, the midline structures are in the
midline and the ventricles and cisterns are normal in size and
configuration, with slight asymmetric prominence of all
components of the right lateral ventricle, likely
congenital/developmental.  There is mucosal thickening involving
scattered anterior ethmoidal air cells, bilaterally, which
appears more marked since the sinus CT of [**2113-2-14**].  The
remaining visualized paranasal sinuses, as well as the mastoid
air cells and middle ear cavities are clear.
IMPRESSION:  No evidence of acute intracranial injury, and no
skull fracture.

[**2113-7-6**] Humerus XRay:
IMPRESSION:
Proximal left humerus comminuted fracture involving surgical
neck with mild subluxation posteriorly of distal fracture
fragment approximately two cortical widths with fracture line
extension also extending towards greater tuberosity.
Glenohumeral articulation is maintained.

[**2113-7-6**] Abdominal x-ray:
IMPRESSION:  Air within small and large bowel is nonspecific.
No evidence of obstruction.

[**2113-7-6**] EEG:
IMPRESSION: This is an abnormal continuous ICU monitoring study
because
of significantly abnormal background rhythms. At the beginning
of the
record, extremely frequent high voltage triphasic-appearing
waves admixed with a few more paroxysmal epileptiform discharges
were noted. Between the bursts, there was evidence of a severe
encephalopathy with suppression of electrical activity. Later in
the record, at that time noted above, there appeared to be a
marked improvement in terms of the paroxysmal behavior in the
record and an overall improvement in the background rhythms. No
significant asymmetry or sustained seizure activity was
identified.

[**2113-7-7**] EEG:
IMPRESSION: This is an abnormal continuous ICU monitoring study
because
of the diffuse encephalopathic features noted above which
include background slowing in the slow theta bandwidth and
superimposed paroxysmal high voltage sharp slow waves. These
latter discharges were predominantly bilateral and synchronous
but also showed right hemisphere predominance and periods of
multifocality. There were, however, no sustained seizures
recorded.

[**2113-7-8**] EEG:
IMPRESSION: This was a poor electrographic recording session.
Throughout the session, the recording from the right hemisphere
electrodes were non-functional. Late in the recording, the left
hemisphere electrodes also became disconnected. Prior to the
left hemisphere electrodes becoming non-functional, the EEG
showed improvement in the diffuse encephalopathic features from
the previous day and fewer paroxysmal bursts. No sustained
seizure discharges in the left hemisphere were identified.

[**2113-7-11**] MRI Head:
IMPRESSION:  No significant abnormalities on MRI of the brain
with and without gadolinium with somewhat limited
post-gadolinium images by motion.  Fluid in both bilateral
mastoid air cells.

Microbiology:
-[**2113-7-6**] 10:20 pm STOOL     CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2113-7-7**]**
C. difficile DNA amplification assay (Final [**2113-7-7**]):
CLOSTRIDIUM DIFFICILE.
-Blood Cultures ([**7-9**]): no growth
-CSF Studies:
Cyptococcal antigen - not detected
CMV DNA, QL PCR - NOT DETECTED
VARICELLA ZOSTER VIRUS (VZV) - Not Detected
Adenovirus DNA, Qn PCR - No DNA Detected
Herpes Simplex Virus PCR - Negative
BORRELIA BURGDORFERI ANTIBODY INDEX FOR CNS INFECTION: negative
CSF EBV-PCR: negative
CSF TOXOPLASMA GONDII BY PCR: negative
-DFA negative

Brief Hospital Course:
53 yo W w/ DM1, s/p LURT [**2106**] (on sirolimus/pred), CAD (s/p
multiple PCIs), [**Year (4 digits) 19874**] (EF 45%) who presented to [**Hospital3 **] with a fall and L humerus fracture now transfered to
[**Hospital1 18**] for management of [**Last Name (un) **], respiratory distress, and shock.
Patient had complicated MICU course where she was treated for
altered mental status, pneumonia, and c. diff. She stabilized
and was sent to rehab from the floor.

# Altered mental status:  On arrival from outside hospital,
patient had altered mental status.  She was intermittently
confused, agitated, and somnolent with definite waxing and
[**Doctor Last Name 688**] components.  In the setting of fevers and confusion,
there was concern for encephalitis or meningitis.  Patient had
an LP which was significant for elevated opening pressure of 37
and elevated RBCs - WBC was 5 (lymph predominant).  She was
empirically treated for bacterial and viral meningitis until
cultures negative and patient improved. HSV PCR from CSF
negative. Numerous other viral tests from CSF were sent and were
negative at time of discharge. Also, some concern for possible
seizures so neuro consulted and EEG done. EEG initially was
concerning for seizure-like activity so Keppra started. However,
repeat EEG's without seizures and ultimately thought that
seizures were highly unlikely so keppra was down-titrated and
discontinued. A significant portion if not all of AMS may have
been due to delirium and toxic-metabolic encephalopathy in
patient with two significant infections and admitted to the ICU
for a prolonged period. Mental status improved slowly over 10
days of ICU stay suggesting toxic-metabolic delerium as the
reason for the alteration. At discharge, patient is alert and
oriented x 3 and back to her baseline mental status.

# Respiratory Failure/Pneumonia: Was transfered to [**Hospital1 18**]
intubated after respiratory distress at an OSH which may have
been triggered by aspiration event. Chest imaging showed
prominent bilateral pneumonia. She was covered with broad
spectrum coverage for HCAP. Was extubated shortly after arrival
at [**Hospital1 18**] ICU, but had significant oxygen requirement for the
next few days. Had another questionable aspiration even a day or
two after arrival so was given very limited PO intake for first
few days. Pneumonia ultimately improved and antibotics stopped
after roughly 10 total days of HCAP coverage. She was discharged
on lasix 60mg daily and she was on room air.

# Severe Cdiff colitis: A couple days into hospitalization,
developed diarrhea and worsening WBC. Stool sent for Cdiff toxin
which was positive. Rectal tube placed and patient started on PO
Vancomycin 500mg Q6hrs. Couple days later also started on IV
metronidazole for both this and pneumonia. Never developed acute
abdomen or significant ileus although did require an NGT for a
few days due to vomiting. Plan to complete 14 days of PO
Vanco/PO metronidazole after last day of other antibiotics. Last
day of Cdiff treatment antibiotics should be [**2113-7-26**]. She was
also started on cholestyramine to help reduce the amount of
diarrhea she was having and this can be discontinued at the
patient's discretion in a few days.

# Acute on CKD: s/p LURT in [**2106**], c/b humoral rejection followed
by multiple plasmapheresis, recent Cr baseline (1.4-1.7) on
Sirolimus and prednisone. Cr up at presentation and presumed
that [**Last Name (un) **] was due to septic shock. Cr improved initially with
fluids and patient continued on home prednisone 4mg daily with
reduction of Sirolimus to 0.5mg daily. Renal consult service
followed and helped manage Sirolimus dosing, and she should
continue this dose of 0.5mg daily until she follows-up in
clinic. Valsartan held initially due to infection and [**Last Name (un) **] but
was restarted at discharge. Continued on Bactrim prophylaxis.
She requires a once weekly RAPAMYCIN level, CBC, Chem7, calcium,
phosphate, AST, ALT, UA, urine protein/creatinine ratio checked
every Tuesday and results faxed to [**Telephone/Fax (1) 697**].

# Anemia: Suspect secondary to renal failure and mild GI losses
secondary to C.diff (trace guaiac positive) +/- some bone marrow
stunning in setting of severe infection.  No evidence of
hemolysis or iron deficiency.  HCT responded to 2units HCT 20
->27 and stabilized. Patient receives Epo as an outpatient and
should continue this on discharge.

# DM1: Has history of brittle diabetes on home insulin pump
(although somewhat unclear how much [**Name (NI) 39150**] she takes). Was placed
on an insulin gtt while in the ICU and [**Last Name (un) **] consulted to help
with management. Day before ICU callout was transitioned to
lantus with humalog sliding scale. She was discharged on lantus
[**Hospital1 **] with sliding scale insulin and should not resume her insulin
pump until following up with her outpatient DM provider.

# Left Humeral Fracture: Had gone to OSH initially with fall and
found to have a proximal left humerus fracture. Ortho saw here
and recommended conservative management with a sling. Due to
mental status tried to limit narcotics (and some history that
she is very sensative to narcotics), so given tylenol, lidocaine
patch.  Patient will have to call orthopedic clinic to schedule
follow-up in four weeks and she was discharged with a cuff and
collar sling.

# Depression/Anxiety:  High dose citalopram at home as well as
busprione and clonazepam at home. Citalopram was decreased to
20mg in setting of multiple other meds and buspirone and
clonazepam were initially held given AMS.  The buspirone and
clonazepam were restarted at home dose, and citalopram was
reduced to 40mg at discharge.

# CAD/NSTEMI: Had elevated cardiac markers at OSH thought to be
demand ischemia in setting of septic shock. Cards saw here and
said no need for heparin gtt. Continued on ASA, statin,
metoprolol. Cardiac markers trended down.

# [**Hospital1 19874**] (EF 40-50%): Baseline mild decreased EF. Clincally stable
without evidence of exacerbation. Once infectious issues
stabilized, restarted lasix with PRN doses in the ICU, and
discharged on lasix 60mg PO daily.

# Charcot-foot deformity on Left:  Associated left sided LE
swelling.

# HYPERTENSION: Initially BP meds held in setting of infection.
Ultimately restarted all home meds.

# HLD: continued home atorvastatin

# Hypothyroidism: continued home levothyroxine

# FEN: Was NPO initially, then received tube feeds for a few
days, ultimately advanced to diabetic diet
# Code: Full
# Disposition: She is very deconditioned and needs significant
rehab.
.
TRANSITIONAL ISSUES
1. Please check RAPAMYCIN level, CBC, Chem7, calcium, phosphate,
AST, ALT, UA, urine protein/creatinine ratio every Tuesday and
results faxed to [**Telephone/Fax (1) 697**]
2. She needs to call her Diabetes provider and schedule an
appointment to discuss restarting her insulin pump once she is
on a stable diet
3. Rapamycin dose changed during this hospitalization, will have
weekly level checked and follow up with renal regarding dose
titration.
4.  Can discontinue cholestyramine in a few days once diarrhea
improves
5.  Consider up-titrating patient's citalopram dose from 40mg
back to baseline dose of 60mg for her anxiety/depression

Medications on Admission:
Medications on OSH Transfer:
Acyclovir 750 mg IV Q12H ([**7-6**])
CefePIME 2 g IV Q12H ([**7-7**])
Vancomycin 1500 mg IV Q 24H ([**7-9**])
Vancomycin Oral Liquid 125 mg PO/NG Q6H ([**7-7**])
PredniSONE 4 mg PO/NG DAILY
Sirolimus 1 mg PO DAILY
Senna 1 TAB PO BID:PRN Constipation
Docusate Sodium (Liquid) 100 mg PO BID
Heparin 5000 UNIT SC TID
Aspirin 81 mg PO/NG DAILY Start: In am
Atorvastatin 80 mg PO/NG DAILY Start: In am
Levothyroxine Sodium 50 mcg PO/NG DAILY
Acetaminophen 650 mg PO/NG Q6H:PRN pain/fever
Insulin 100 Units/100 ml NS @ [**3-28**] UNIT/HR IV DRIP
Acetaminophen IV 1000 mg IV Q6H:PRN fever
Ondansetron 4 mg IV Q8H:PRN nausea
Promethazine 12.5 mg IV Q6H:PRN nausea/vomitting
LeVETiracetam 750 mg IV Q12H
Metoprolol Tartrate 37.5 mg PO/NG TID
Furosemide 40 mg PO/NG DAILY
Sulfameth/Trimethoprim SS 1 TAB PO/NG DAILY
Quetiapine Fumarate 25 mg PO/NG [**Hospital1 **]: PRN agitation
Valsartan 80 mg PO/NG DAILY
Ipratropium Bromide Neb 1 NEB IH Q6H
Albuterol 0.083% Neb Soln 1 NEB IH Q6H
Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN wheezing/sob
Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB/wheezing


Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. BusPIRone 5 mg PO TID
4. Calcium Carbonate 500 mg PO TID
5. Clonazepam 0.5 mg PO BID:PRN anxiety
6. Fluticasone Propionate NASAL 1 SPRY NU [**Hospital1 **]
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Omeprazole 40 mg PO DAILY
9. PredniSONE 4 mg PO DAILY
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
11. Sirolimus 0.5 mg PO DAILY Start: In am
Daily dose to be administered at 6am
12. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN wheezing/sob
13. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB/wheezing
14. Lidocaine 5% Patch 1 PTCH TD DAILY
apply to left arm in area of fracture
15. Metoprolol Succinate XL 100 mg PO DAILY
16. Glargine 40 Units Breakfast
Glargine 18 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
17. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
18. Vancomycin Oral Liquid 125 mg PO Q6H
19. Citalopram 40 mg PO DAILY
20. Fish Oil (Omega 3) 1000 mg PO BID
21. Multivitamins 1 TAB PO DAILY
22. Nystatin Cream 1 Appl TP [**Hospital1 **]
23. Vitamin D 800 UNIT PO DAILY
24. Valsartan 80 mg PO BID
25. Cepacol (Menthol) 1 LOZ PO PRN sore throat
26. Cholestyramine 4 gm PO TID
please space out 3-4 hours from vanco
27. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
28. traZODONE 25 mg PO HS:PRN insomnia
29. Furosemide 60 mg PO DAILY
hold for sbp <100

30. Epoetin Alfa 10,000 UNIT SC QMOWEFR Start: HS
31. Outpatient Lab Work
- Have Rapamycin level, CBC, Chem7, calcium, phosphate, AST,
ALT, UA, urine protein/creatinine ratio checked every Tuesday
and results faxed to [**Telephone/Fax (1) 697**]


Discharge Disposition:
Extended Care

Facility:
[**Location (un) **] House Nursing Home - [**Location 9583**]

Discharge Diagnosis:
Pneumonia
Altered mental status


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. [**Known lastname 39143**],
  You were admitted to [**Hospital1 18**] after you developed a serious
infection in your lungs requiring intubation, blood pressure
support, and close monitoring in the intensive care unit. Your
lung infection resolved with antibiotic treatment.

You became very confused while in the ICU but this was not
thought to be due to an infection in your spinal cord as a
spinal tap was performed which was negative. There was some
concern that you were having seizures so you were briefly
started on seizure medications but the neurologists feel you do
not actually require this medication so this was discontinued.

You also developed a diarrheal infection in your colon called
clostridium difficile for which you will continue to require
antibiotics once you leave.

Followup Instructions:
1. Dr. [**First Name (STitle) **] [**Name (STitle) **]
   Renal transplant medicine
   WHERE: [**Hospital Unit Name **], [**Location (un) **] TRANSPLANT MEDICINE (NHB)
   WHERE: [**Hospital1 69**], [**Hospital Ward Name 517**]
   WHEN: Thursday, [**8-3**] at 8:20AM

2. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
   Orthopedics
   WHERE: [**Hospital Ward Name 23**] building, [**Location (un) **]
   WHERE: [**Hospital1 69**], [**Hospital Ward Name **]
   WHEN: Tuesday, [**8-15**] at 8:30AM

3.  Please call your diabetes doctor [**First Name (Titles) **] [**Hospital3 **] to arrange
for a follow-up appointment in the next few weeks to discuss
when it is safe for you to restart your insulin pump.


                             [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]
{'Pneumonitis due to inhalation of food or vomitus,Unspecified septicemia,Septic shock,Toxic encephalopathy,Subendocardial infarction, initial episode of care,Acute respiratory failure,Severe sepsis,Chronic systolic heart failure,Acute kidney failure, unspecified,Intestinal infection due to Clostridium difficile,Complications of transplanted kidney,Tabes dorsalis,Closed fracture of unspecified part of humerus,Pneumonia, organism unspecified,Long-term (current) use of insulin,Insulin pump status,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Background diabetic retinopathy,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Unspecified acquired hypothyroidism,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Anemia in chronic kidney disease,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Depressive disorder, not elsewhere classified,Anxiety state, unspecified,Arthropathy associated with neurological disorders,Fall from other slipping, tripping, or stumbling,Diabetes with ophthalmic manifestations, type I [juvenile type], uncontrolled'}


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: 53 yo W w/ DM1 (brittle on insulin pump), s/p LURT [**2106**]
(Baseline Cr 1.4-1.7), CAD (s/p multiple PCIs), [**Year (4 digits) 19874**] (EF 45%),
HTN/HL who initially presented to [**Hospital3 **] with a left
proximal humerus fracture now transfered to [**Hospital1 18**] for
respiratory distress, septic shock, and renal failure.

MEDICAL HISTORY: - DM1 ([**2076**]), brittle, c/b nephropathy and retinopathy on
insulin pump (last A1C at [**Last Name (un) **] in [**2110**] of 9.6%)
- s/p LURT in [**2106**], c/b humoral rejection followed by multiple
plasmapheresis, recent Cr baseline (1.4-1.7)
- CAD, s/p "silent" inferior MI '[**07**], s/p LAD and LCX DES '[**07**].
- [**Last Name (LF) 19874**], [**First Name3 (LF) **] 40-50%.
- Hypertension
- HL
- Obesity
- s/p vitreous hemorrhage OD
- L leg swelling [**3-16**] lymphocele in the pelvis
- Charcot-foot deformity on Left
- hx of RP bleed
- IBS
- Hypothyroidism

MEDICATION ON ADMISSION: Medications on OSH Transfer:
Acyclovir 750 mg IV Q12H ([**7-6**])
CefePIME 2 g IV Q12H ([**7-7**])
Vancomycin 1500 mg IV Q 24H ([**7-9**])
Vancomycin Oral Liquid 125 mg PO/NG Q6H ([**7-7**])
PredniSONE 4 mg PO/NG DAILY
Sirolimus 1 mg PO DAILY
Senna 1 TAB PO BID:PRN Constipation
Docusate Sodium (Liquid) 100 mg PO BID
Heparin 5000 UNIT SC TID
Aspirin 81 mg PO/NG DAILY Start: In am
Atorvastatin 80 mg PO/NG DAILY Start: In am
Levothyroxine Sodium 50 mcg PO/NG DAILY
Acetaminophen 650 mg PO/NG Q6H:PRN pain/fever
Insulin 100 Units/100 ml NS @ [**3-28**] UNIT/HR IV DRIP
Acetaminophen IV 1000 mg IV Q6H:PRN fever
Ondansetron 4 mg IV Q8H:PRN nausea
Promethazine 12.5 mg IV Q6H:PRN nausea/vomitting
LeVETiracetam 750 mg IV Q12H
Metoprolol Tartrate 37.5 mg PO/NG TID
Furosemide 40 mg PO/NG DAILY
Sulfameth/Trimethoprim SS 1 TAB PO/NG DAILY
Quetiapine Fumarate 25 mg PO/NG [**Hospital1 **]: PRN agitation
Valsartan 80 mg PO/NG DAILY
Ipratropium Bromide Neb 1 NEB IH Q6H
Albuterol 0.083% Neb Soln 1 NEB IH Q6H
Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN wheezing/sob
Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB/wheezing

ALLERGIES: Morphine / Norvasc

PHYSICAL EXAM: Admission exam:
General: Intubated and sedated, responsive to voice, comfortable
on vent, seems to become drowsy after a few minutes and closes
eyes
HEENT: Sclera anicteric, PERRL, ET tube in place
Neck: supple, no LAD, R IJ in place without surrounding erythema
or induration
CV: Regular rate and rhythm, normal S1 + S2, no m/r/g
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, distended [**3-16**] to habitus, faint BS
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, charcot
deformity on left with 2+ edema below ankle on left, trace edema
on right
Neuro: nods yes/no to simple questions, moves hands/feet on
command, pupils equal and reactive, comfortable, drowsy and
drifts off after a few seconds

FAMILY HISTORY: [**Name (NI) 12237**] DM
[**Name (NI) 12238**] [**Name (NI) 1932**] died at age 50's
No h/o of kidney disease

SOCIAL HISTORY: Lives in [**Location 7661**] w/ husband who is her kidney donor. Has two
adult children who are healthy. Retired from medical records.
Tobacco - denies
EtOH - denies
Drug use - denies. 

### Response:
{'Pneumonitis due to inhalation of food or vomitus,Unspecified septicemia,Septic shock,Toxic encephalopathy,Subendocardial infarction, initial episode of care,Acute respiratory failure,Severe sepsis,Chronic systolic heart failure,Acute kidney failure, unspecified,Intestinal infection due to Clostridium difficile,Complications of transplanted kidney,Tabes dorsalis,Closed fracture of unspecified part of humerus,Pneumonia, organism unspecified,Long-term (current) use of insulin,Insulin pump status,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Background diabetic retinopathy,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Unspecified acquired hypothyroidism,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Anemia in chronic kidney disease,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Depressive disorder, not elsewhere classified,Anxiety state, unspecified,Arthropathy associated with neurological disorders,Fall from other slipping, tripping, or stumbling,Diabetes with ophthalmic manifestations, type I [juvenile type], uncontrolled'}
