CHIEF COMPLAINT: Failure to thrive at rehab

PRESENT ILLNESS: 80 y/o female with a progressive upper cervical myelopathy who
is s/p cervical spine surgery [**2190-10-13**], trach/peg placement
[**2190-11-2**], who presented from [**Hospital6 23973**] ([**Location (un) 1110**]) with
failure to thrive. Per daughter, she has had no progression at
rehab. She has been immobile. Her daughter wanted her
re-evaluated and transferred to another rehab facility. The
patient is unable to give any history as she is non verbal from
this presumed mass. In ED, T101.6, P 106,BP 108/49, RR 16, 96%
on trach mask 35% O2. Over the course of the evening she had
sveral episodes of desats to the 80's requiring frequent
suctioning productive of mucous plugs. During one suctioning of
a large mucous plug she became hypotensive with an SBP in the
70's. She was started on normal saline and dopamine and her SBP
increased to 80'-100s. In the ED she was given a total of 5 L of
NS, vancomycin 1 gram, ceftriaxone 2 grams (given before LP
sent), tylenol, ativan.

MEDICAL HISTORY: 1. s/p C-spine operation (as above) for subluxation with pannus
around odontoid
2. Tracheostomy [**2190-11-2**]
3. PEG placement [**2190-11-1**]
4. HIT, diagnosed [**10-14**]
5. IVC filter placement [**2190-10-28**]
6. Bipolar d/o, on lithium
7. c-section x3

MEDICATION ON ADMISSION: Metoprolol 50 mg daily
Hydralazine 10 mg Q 6 hours
Levaquin 500 mg daily
Colace
Bisacodyl
Prevacid 30 mg daily
Estrogen 0.3
Lithium carbonate 300 mg daily
Ativan 0.5 mg Q 4-6 hours PRN
Tylenol PRN
Isosource

ALLERGIES: Penicillins / Demerol / Heparin Agents

PHYSICAL EXAM: T: 98.4  BP: 120/60  P: 75  R: 20  O2 sat 98% on 40% trach mask
Gen: elderly female in cervical collar, tracks with eyes,
following some commands, answers yes/no questions, mouthing
words
HEENT: Trach in place, PERRL, anicteric, MMM
CV: RRR, nl S1, S2, II/VI SEM at LSB.
Lungs: coarse breath sounds throughout but less rhonchorous than
on admission
Abd: +PEG, site drsg c/d/i, NT, +BS, approx 5 cm ventral hernia
easily reducible
Ext: no edema
Neuro: RUE dense paresis, otherwise moves BLE and LUE slightly
against gravity, nonresponsive to questions, withdraws to pain.
increased tone in RUE.

FAMILY HISTORY: Parents with CAD

SOCIAL HISTORY: Came from rehab, married, husband is also sick at times per
daughters, has 2 daughters and 1 son, children very involved.
Unspecified septicemia,Pneumonitis due to inhalation of food or vomitus,Sepsis,Tracheostomy status,Gastrostomy status,Bipolar I disorder, most recent episode (or current) unspecified,Cervical spondylosis with myelopathy
Septicemia NOS,Food/vomit pneumonitis,Sepsis,Tracheostomy status,Gastrostomy status,Bipolor I current NOS,Cerv spondyl w myelopath
Name:  [**Known lastname 4088**],[**Known firstname 4089**]                   Unit No:   [**Numeric Identifier 4090**]

Admission Date:  [**2190-11-17**]              Discharge Date:   [**2190-11-22**]

Date of Birth:  [**2110-8-17**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Demerol / Heparin Agents

Attending:[**First Name3 (LF) 4091**]
Addendum:
-of note, pt had hx of guaiac pos stool while in ICU, but was
negative when repeated on the floor.  Hematocrit was stable
throughout stay on floor.

Discharge Disposition:
Extended Care

Facility:
[**Hospital1 49**] - [**Location (un) 50**]

                             [**First Name8 (NamePattern2) 1558**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 2301**]

Completed by:[**2190-11-22**]

Admission Date:  [**2190-11-17**]              Discharge Date:   [**2190-11-22**]


Service: MEDICINE

Allergies:
Penicillins / Demerol / Heparin Agents

Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Failure to thrive at rehab

Major Surgical or Invasive Procedure:
None


History of Present Illness:
80 y/o female with a progressive upper cervical myelopathy who
is s/p cervical spine surgery [**2190-10-13**], trach/peg placement
[**2190-11-2**], who presented from [**Hospital6 23973**] ([**Location (un) 1110**]) with
failure to thrive. Per daughter, she has had no progression at
rehab. She has been immobile. Her daughter wanted her
re-evaluated and transferred to another rehab facility. The
patient is unable to give any history as she is non verbal from
this presumed mass. In ED, T101.6, P 106,BP 108/49, RR 16, 96%
on trach mask 35% O2. Over the course of the evening she had
sveral episodes of desats to the 80's requiring frequent
suctioning productive of mucous plugs. During one suctioning of
a large mucous plug she became hypotensive with an SBP in the
70's. She was started on normal saline and dopamine and her SBP
increased to 80'-100s. In the ED she was given a total of 5 L of
NS, vancomycin 1 gram, ceftriaxone 2 grams (given before LP
sent), tylenol, ativan.

She was admitted to the MICU with hypotension, fevers, change in
mental status and concern for sepsis. She was placed on the MUST
protocol.  She received IVF per the protocol to maintain a CVP
greater than 8.  She was placed on vancomycin, levaquin, and
flagyl.  Her LP did not indicate infection.  She only required
dopamine for a few hours, and was weaned off.  On [**2190-11-18**] she
was transferred to the floor as she was hemodynamically stable.

Her neurological history is as follows:  She originally
presented in [**2186**] with cervical spondylosis, which was treated
symptomatically for 3 years.  In [**2190-1-10**], she presented to
[**Hospital 7817**] Clinic c/o tingling in her hands.  At that time
she declined MRI [**1-11**] claustrophobia and was managed
symptomatically with physical therapy.  In [**2190-5-11**], she
returned to their clinic with a significant deterioration.  She
was quadriparetic and had developed urinary incontinence.  MRI
revealed C1-2 subluxation with a large degenerative pannus (as
is seen in rheumatoid arthritis) around the odontoid process,
compressing the cervical medullary junction, as well as C3-C4
stenosis.
She underwent neurosurgery on [**2190-10-13**], where she had a transoral
resection of the odontoid/pannus as well as a posterior
occipital cervical decompression.  This was complicated by a
prolonged intubation and failure to wean.  She was extubated on
[**10-19**] but required reintubation on [**10-27**].  At that point she had
a trach and a peg placed.  Per the d/c summary, post-op the pt
was able to open her eyes, grip with her hands, move all
extremities spontaneous (although decreased in the RUE as she
was preop) but could not follow commands.  She was discharged to
rehab at this point.

Past Medical History:
1. s/p C-spine operation (as above) for subluxation with pannus
around odontoid
2. Tracheostomy [**2190-11-2**]
3. PEG placement [**2190-11-1**]
4. HIT, diagnosed [**10-14**]
5. IVC filter placement [**2190-10-28**]
6. Bipolar d/o, on lithium
7. c-section x3

Social History:
Came from rehab, married, husband is also sick at times per
daughters, has 2 daughters and 1 son, children very involved.

Communication:  Husband/daughter at ([**Telephone/Fax (1) 23974**]
Son at ([**Telephone/Fax (1) 23975**]

Family History:
Parents with CAD

Physical Exam:
T: 98.4  BP: 120/60  P: 75  R: 20  O2 sat 98% on 40% trach mask
Gen: elderly female in cervical collar, tracks with eyes,
following some commands, answers yes/no questions, mouthing
words
HEENT: Trach in place, PERRL, anicteric, MMM
CV: RRR, nl S1, S2, II/VI SEM at LSB.
Lungs: coarse breath sounds throughout but less rhonchorous than
on admission
Abd: +PEG, site drsg c/d/i, NT, +BS, approx 5 cm ventral hernia
easily reducible
Ext: no edema
Neuro: RUE dense paresis, otherwise moves BLE and LUE slightly
against gravity, nonresponsive to questions, withdraws to pain.
increased tone in RUE.

Pertinent Results:
[**2190-11-16**] 07:40PM BLOOD WBC-12.7* RBC-3.08* Hgb-9.7* Hct-29.1*
MCV-95 MCH-31.4 MCHC-33.3 RDW-14.3 Plt Ct-291
[**2190-11-17**] 08:00PM BLOOD Hct-24.3*
[**2190-11-18**] 06:09AM BLOOD WBC-9.4 RBC-3.20* Hgb-9.9* Hct-29.8*
MCV-93 MCH-30.9 MCHC-33.1 RDW-15.7* Plt Ct-295
[**2190-11-16**] 07:40PM BLOOD Neuts-85.4* Lymphs-10.9* Monos-3.1
Eos-0.4 Baso-0.3

[**2190-11-18**] 06:09AM BLOOD PT-12.9 PTT-23.6 INR(PT)-1.1

[**2190-11-18**] 06:09AM BLOOD Glucose-88 UreaN-13 Creat-0.4 Na-145
K-3.7 Cl-113* HCO3-24 AnGap-12
[**2190-11-17**] 10:30AM BLOOD ALT-36 AST-22 LD(LDH)-232 AlkPhos-107
TotBili-0.4
[**2190-11-18**] 06:09AM BLOOD Calcium-8.4 Phos-2.8 Mg-2.3
[**2190-11-17**] 10:30AM BLOOD Albumin-2.3* Calcium-7.8* Phos-2.8 Mg-1.9
[**2190-11-17**] 10:30AM BLOOD VitB12-599
[**2190-11-17**] 10:30AM BLOOD TSH-4.8*
[**2190-11-17**] 08:00PM BLOOD Free T4-1.0
[**2190-11-17**] 10:30AM BLOOD Cortsol-21.9*
[**2190-11-18**] 06:09AM BLOOD Vanco-21.4*
[**2190-11-16**] 07:46PM BLOOD Lactate-1.2
[**2190-11-17**] 10:31AM BLOOD Lactate-0.6

D/c labs:
[**2190-11-22**] 10:32AM BLOOD WBC-10.2 RBC-3.33* Hgb-10.7* Hct-31.1*
MCV-94 MCH-32.1* MCHC-34.2 RDW-15.8* Plt Ct-382
[**2190-11-22**] 10:32AM BLOOD Glucose-128* UreaN-18 Creat-0.4 Na-145
K-3.5 Cl-113* HCO3-28 AnGap-8
[**2190-11-22**] 10:32AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.2

LP results:
Tube 1: (CSF) WBC-49 RBC-[**Numeric Identifier 16351**]* Polys-98 Lymphs-1 Monos-1
Tube 4: (CSF) WBC-0 RBC-68* Polys-64 Lymphs-36 Monos-0
(CSF) TotProt-36 Glucose-62
Gram stain neg for polys or bacteria

UA lg blood, neg nit/leuk, [**10-30**] RBCs, 3-5 WBCs, few bact, urine
cx no growth (final)
Sputum cx with 4+ oropharyngeal flora

EKG [**11-17**]: Sinus rhythm, Nonspecific inferolateral T wave
flattening

CXR [**11-17**]: Bibasilar patchy and linear opacities with slight
worsening at left lung base. This may be due to atelectasis or
aspiration. Infectious pneumonia in left lower lobe is not
excluded.


Brief Hospital Course:
1. Hypotension:  This had resolved by the time she arrived on
the floor, and at that point she actually became hypertensive.
Her antihypertensives were restarted.  Her original hypotension
was felt to be secondary to sepsis given her fever and
infiltrate on CXR.  Her cortisol was normal and so it was not
likely due to adrenal insufficiency.

2. Fever:  This was likely due to an aspiration pneumonia.  Her
urine, CSF, and blood cultures all remained negative.  She was
originally treated with vanc/levo/flagyl, but the vanc was
discontinued on HD3 as she appeared to have an aspiration
pneumonia.  She will be treated with Levaquin and Flagyl for a
total 14 day course, last day [**2190-11-30**].

3. Altered mental status:  Her AMS resolved while in the ICU.
Her TSH was mildly elevated (not a helpful test in the acutely
ill) with a normal T4.  Her LFTs, B12, and LP were wnl.  Her
lithium was continued and her Ativan was restarted on a lower
dose, prn basis.  Neurosurgery followed her while she was an
inpatient and did not feel she had any acute issues related to
her recent surgery.

4. FEN: On HD3, she appeared to develop abdominal pain, with
abdominal tenderness on exam which was not present 2 minutes
later while the patient was asleep.  She was having bowel
movements and had normoactive bowel sounds.  Her ventral hernia
was nontender and easily reducible.  Because of this, her tube
feeds were held.  They were restarted later and she tolerated
this well.  She was placed on aspiration precautions.  On HD3,
respiratory therapy gave her a pessy-muir valve, which she
tolerated for only a few minutes at a time.

5. RUE edema:  Initially on exam she had some RUE edema, which
was concerning as she had a R subclavian central line in place.
An u/s was done, which ruled out DVT.

6. Guaiac pos stool:  She was guaiac pos. in the ICU.  Her Hct
actually increased from 29 to 31 when she reached the floor.  It
was felt this may be due to her PEG tube, and her hematocrit
remained stable.

7. Ppx: She was on lansoprazole, pneumoboots (no heparin as has
HIT)/IVC filter while an inpatient.

Medications on Admission:
Metoprolol 50 mg daily
Hydralazine 10 mg Q 6 hours
Levaquin 500 mg daily
Colace
Bisacodyl
Prevacid 30 mg daily
Estrogen 0.3
Lithium carbonate 300 mg daily
Ativan 0.5 mg Q 4-6 hours PRN
Tylenol PRN
Isosource

Medications on transfer:
Metoprolol 12.5 mg [**Hospital1 **]
Metronidazole 500 mg GT tid
Levofloxacin 250 mg GT daily
Lithium 300 mg daily
Vancomycin 1 g IV daily
Lansoprazole 30 mg daily
Bisacodyl
Colace

Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain, fever.
4. Lithium Carbonate 300 mg Capsule Sig: One (1) Capsule PO QD
().
5. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 9 days: Last dose [**2190-11-30**].
Disp:*9 Tablet(s)* Refills:*0*
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 9 days: Last dose [**2190-11-30**].
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Hold for SBP<100 or pulse <60.
8. Conjugated Estrogens 0.3 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Hydralazine HCl 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours): Hold for SBP <100.
10. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) ml PO BID
(2 times a day).
11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed.


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
Aspiration Pneumonia


Discharge Condition:
Stable

Discharge Instructions:
Please call your PCP or return to the ED if you experience
fevers, lightheadedness, chest pain, shortness of breath,
increased secretions from your trach, greenish secretions from
your trach, abdominal pain, nausea, vomiting, diarrhea, or
swelling in your legs.

Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12005**] Where: LM [**Hospital Unit Name 12006**] Phone:[**Telephone/Fax (1) 3666**] Date/Time:[**2190-12-7**] 10:00

Please f/u with your PCP [**Last Name (NamePattern4) **] 1 week.


                             [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
{'Unspecified septicemia,Pneumonitis due to inhalation of food or vomitus,Sepsis,Tracheostomy status,Gastrostomy status,Bipolar I disorder, most recent episode (or current) unspecified,Cervical spondylosis with myelopathy'}


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: Failure to thrive at rehab

PRESENT ILLNESS: 80 y/o female with a progressive upper cervical myelopathy who
is s/p cervical spine surgery [**2190-10-13**], trach/peg placement
[**2190-11-2**], who presented from [**Hospital6 23973**] ([**Location (un) 1110**]) with
failure to thrive. Per daughter, she has had no progression at
rehab. She has been immobile. Her daughter wanted her
re-evaluated and transferred to another rehab facility. The
patient is unable to give any history as she is non verbal from
this presumed mass. In ED, T101.6, P 106,BP 108/49, RR 16, 96%
on trach mask 35% O2. Over the course of the evening she had
sveral episodes of desats to the 80's requiring frequent
suctioning productive of mucous plugs. During one suctioning of
a large mucous plug she became hypotensive with an SBP in the
70's. She was started on normal saline and dopamine and her SBP
increased to 80'-100s. In the ED she was given a total of 5 L of
NS, vancomycin 1 gram, ceftriaxone 2 grams (given before LP
sent), tylenol, ativan.

MEDICAL HISTORY: 1. s/p C-spine operation (as above) for subluxation with pannus
around odontoid
2. Tracheostomy [**2190-11-2**]
3. PEG placement [**2190-11-1**]
4. HIT, diagnosed [**10-14**]
5. IVC filter placement [**2190-10-28**]
6. Bipolar d/o, on lithium
7. c-section x3

MEDICATION ON ADMISSION: Metoprolol 50 mg daily
Hydralazine 10 mg Q 6 hours
Levaquin 500 mg daily
Colace
Bisacodyl
Prevacid 30 mg daily
Estrogen 0.3
Lithium carbonate 300 mg daily
Ativan 0.5 mg Q 4-6 hours PRN
Tylenol PRN
Isosource

ALLERGIES: Penicillins / Demerol / Heparin Agents

PHYSICAL EXAM: T: 98.4  BP: 120/60  P: 75  R: 20  O2 sat 98% on 40% trach mask
Gen: elderly female in cervical collar, tracks with eyes,
following some commands, answers yes/no questions, mouthing
words
HEENT: Trach in place, PERRL, anicteric, MMM
CV: RRR, nl S1, S2, II/VI SEM at LSB.
Lungs: coarse breath sounds throughout but less rhonchorous than
on admission
Abd: +PEG, site drsg c/d/i, NT, +BS, approx 5 cm ventral hernia
easily reducible
Ext: no edema
Neuro: RUE dense paresis, otherwise moves BLE and LUE slightly
against gravity, nonresponsive to questions, withdraws to pain.
increased tone in RUE.

FAMILY HISTORY: Parents with CAD

SOCIAL HISTORY: Came from rehab, married, husband is also sick at times per
daughters, has 2 daughters and 1 son, children very involved. 

### Response:
{'Unspecified septicemia,Pneumonitis due to inhalation of food or vomitus,Sepsis,Tracheostomy status,Gastrostomy status,Bipolar I disorder, most recent episode (or current) unspecified,Cervical spondylosis with myelopathy'}
