CHIEF COMPLAINT: recurrent pneumonia

PRESENT ILLNESS: Briefly, this is a 65 year-old F with COPD who has been admitted
to an OSH 3 times in the past 2 months for a RLL pneumonia/
consolidation. She initially presented 2 months ago with RLL
PNA, and returned one month ago with RLL and lingular PNA. She
underwent bronchoscopy on [**7-2**] at which time BAL cultures were
negative and cytology from the washings was negative. A CT of
the chest was reportedly without malignancy. She most recently
returned to [**Hospital3 **] Hospital 8 days after discharge ([**7-12**]) with
increasing cough, sputum production, and left sided rib pain
which started two days
prior to presentation. A CT again showed mass-like consolidation
in the lingula with interval increase in size since the previous
film, RLL atelectasis and dense consolidation which is
unchanged, stable
mediastinal adenopathy, and an acute left 7th rib fracture. A
PPD placed at [**Hospital3 **] was negative according to their records.
She was started on zosyn on [**7-12**]; after sputum cx grew out MRSA
she was started on vancomycin on [**7-15**]. She was transferred to
[**Hospital1 18**] on [**7-18**] for further work-up and management of her
recurrent pneumonias. She had a repeat bronchoscopy on [**7-22**],
cytology from which revealed BAC.
While her current exacerbation was considered to be due to
infection, the pt was felt to have poor underlying lung function
from involvement of her tumor and therefore was started on
tarceva.
.
In the MICU the patient had waxing and [**Doctor Last Name 688**] respiratory status
and required a NRB. SHe was never intubated. Currently she is on
70% face mask. She continued to be treated for hospital acquired
pna with vanc/levo/flagyl. While the bronchoal lavage cx was
negative but a sputum cx grew MRSA. The pt was also found to
have new ARF with a creatinine of 1.5, which was thought to be
prerenal and resolved with IVF. Her chest pain was felt to be
due to a rib fracture and was treated with dilaudid.
.
The pt is now transfered for further management of her BAC. She
is currently on 6L NC with intermittent episodes of SOB and a
dry cough and denies CP, nausea, vomiting

MEDICAL HISTORY: Hypertension
MRSA pneumonia in [**2138**]
GERD
Dyslipidemia
Depression
Anxiety

MEDICATION ON ADMISSION: Medications at home:
Buspirone 10 Qid
Diovan 160 mg qd
FemHRT 1/.005 qd
[**Doctor First Name **] D 1 tab
Protonix 60 mg qd
Celexa 60 mg qd
Seroqul 200 mg qhs
potassium chloride 10 to 20 meq qd
trazonde 50 to 100 mg PO qhs prn
Albuterol prn
.
Medications on transfer:
PredniSONE 60 mg PO DAILY
Erlotinib (Tarceva) *NF* 150 mg PO DAILY Start
Morphine SR (MS Contin) 60 mg PO Q12H
Clonazepam 0.25 mg PO BID
Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN
Ipratropium Bromide Neb 1 NEB IH Q6H:PRN
Acetaminophen 650 mg PO Q6H:PRN
Lidocaine 5% Patch 2 PTCH TD QD
Guaifenesin [**6-13**] ml PO Q4H
Vancomycin 1000 mg IV Q 12H
HYDROmorphone (Dilaudid) 0.12 mg IVPCA Lockout Interval: 6
minutes Basal Rate: 0 mg(s)/hour 1-hr Max Limit: 1.2 mg(s)
MetRONIDAZOLE (FLagyl) 500 mg PO TID
Levofloxacin 250 mg PO Q24H [**7-23**] @ 0937 View
Fexofenadine 60 mg PO DAILY [**7-23**] @ 0409 View
Lorazepam 0.5 mg PO/IV Q4-6H:PRN anxiety
Aspirin 81 mg PO DAILY
Senna 1 TAB PO BID:PRN
Quetiapine Fumarate 200 mg PO QHS
Docusate Sodium 100 mg PO BID
Heparin 5000 UNIT SC TID
traZODONE HCl 50 mg PO HS:PRN [**7-23**] @ 0409 View
Amlodipine 10 mg PO DAILY
Citalopram Hydrobromide 60 mg PO DAILY
Pantoprazole 40 mg PO Q12H
Femhrt [**2-9**] *NF* 5-1 mcg-mg Oral QD
BusPIRone 10 mg PO QID

ALLERGIES: Antihistamines

PHYSICAL EXAM: Vitals: t 96.6 bp 122/62 P 93 RR 20 97 70% mask
Gen: mildly tachypneic when moving around, NAD
HEENT: MMM, op clear, perrl
Neck: no LAD, no thyromegaly, no JVD
Pulm: decreased breath sounds at the bases
Heart: RRR, no m/r/g
Abdomen: soft, NT/ND
Extr: no cyanosis , no edma, no clubing
Neuro: AxO3, cranial nerves grossly intact

FAMILY HISTORY: Mother (former smoker) is [**Age over 90 **] years old and carries a diagnosis
of "asthma". Mother had breast cancer. Father had liver disease.
Not family history of lung disease.

SOCIAL HISTORY: Patient lives a alone in [**Hospital3 **]. She had previous worked in
retail. She quit smoking in [**Month (only) 547**] and now uses nicorette gum.
She had smoked approximately 0.5 packs a day for 45 years. She
drink alcohol only socially. She reports no use of recreational
drugs.
Malignant neoplasm of other parts of bronchus or lung,Methicillin susceptible pneumonia due to Staphylococcus aureus,Acute kidney failure, unspecified,Obstructive chronic bronchitis with (acute) exacerbation,Acute and chronic respiratory failure,Closed fracture of four ribs,Candidiasis of other urogenital sites,Infection with microorganisms resistant to penicillins,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Anxiety state, unspecified,Depressive disorder, not elsewhere classified,Personal history of tobacco use,Fracture, cause unspecified,Anemia of other chronic disease,Other and unspecified coagulation defects,Stress incontinence, female,Diarrhea
Mal neo bronch/lung NEC,Meth sus pneum d/t Staph,Acute kidney failure NOS,Obs chr bronc w(ac) exac,Acute & chronc resp fail,Fracture four ribs-close,Candidias urogenital NEC,Inf mcrg rstn pncllins,Hypertension NOS,Hyperlipidemia NEC/NOS,Anxiety state NOS,Depressive disorder NEC,History of tobacco use,Fracture, cause NOS,Anemia-other chronic dis,Coagulat defect NEC/NOS,Fem stress incontinence,Diarrhea
Name:  [**Known lastname 10499**],[**Known firstname 1365**] A               Unit No:   [**Numeric Identifier 10500**]

Admission Date:  [**2148-7-17**]              Discharge Date:   [**2148-8-8**]

Date of Birth:  [**2082-9-12**]             Sex:   F

Service: MEDICINE

Allergies:
Antihistamines

Attending:[**First Name3 (LF) 10501**]
Addendum:
Please forward a copy of this discharge summary to Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **], [**Location (un) 10502**], MA [**Telephone/Fax (1) 10503**]

Discharge Disposition:
Extended Care

Facility:
[**Hospital1 170**] Senior Healthcare - [**Location (un) 10504**]

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10505**] MD, [**MD Number(3) 10506**]

Completed by:[**2148-8-8**]

Admission Date:  [**2148-7-17**]              Discharge Date:   [**2148-8-8**]

Date of Birth:  [**2082-9-12**]             Sex:   F

Service: MEDICINE

Allergies:
Antihistamines

Attending:[**First Name3 (LF) 16983**]
Chief Complaint:
recurrent pneumonia

Major Surgical or Invasive Procedure:
PICC, left arm


History of Present Illness:
Briefly, this is a 65 year-old F with COPD who has been admitted
to an OSH 3 times in the past 2 months for a RLL pneumonia/
consolidation. She initially presented 2 months ago with RLL
PNA, and returned one month ago with RLL and lingular PNA. She
underwent bronchoscopy on [**7-2**] at which time BAL cultures were
negative and cytology from the washings was negative. A CT of
the chest was reportedly without malignancy. She most recently
returned to [**Hospital3 **] Hospital 8 days after discharge ([**7-12**]) with
increasing cough, sputum production, and left sided rib pain
which started two days
prior to presentation. A CT again showed mass-like consolidation
in the lingula with interval increase in size since the previous
film, RLL atelectasis and dense consolidation which is
unchanged, stable
mediastinal adenopathy, and an acute left 7th rib fracture. A
PPD placed at [**Hospital3 **] was negative according to their records.
She was started on zosyn on [**7-12**]; after sputum cx grew out MRSA
she was started on vancomycin on [**7-15**]. She was transferred to
[**Hospital1 18**] on [**7-18**] for further work-up and management of her
recurrent pneumonias. She had a repeat bronchoscopy on [**7-22**],
cytology from which revealed BAC.
While her current exacerbation was considered to be due to
infection, the pt was felt to have poor underlying lung function
from involvement of her tumor and therefore was started on
tarceva.
.
In the MICU the patient had waxing and [**Doctor Last Name 688**] respiratory status
and required a NRB. SHe was never intubated. Currently she is on
70% face mask. She continued to be treated for hospital acquired
pna with vanc/levo/flagyl. While the bronchoal lavage cx was
negative but a sputum cx grew MRSA. The pt was also found to
have new ARF with a creatinine of 1.5, which was thought to be
prerenal and resolved with IVF. Her chest pain was felt to be
due to a rib fracture and was treated with dilaudid.
.
The pt is now transfered for further management of her BAC. She
is currently on 6L NC with intermittent episodes of SOB and a
dry cough and denies CP, nausea, vomiting


Past Medical History:
Hypertension
MRSA pneumonia in [**2138**]
GERD
Dyslipidemia
Depression
Anxiety


Social History:
Patient lives a alone in [**Hospital3 **]. She had previous worked in
retail. She quit smoking in [**Month (only) 547**] and now uses nicorette gum.
She had smoked approximately 0.5 packs a day for 45 years. She
drink alcohol only socially. She reports no use of recreational
drugs.

Family History:
Mother (former smoker) is [**Age over 90 **] years old and carries a diagnosis
of "asthma". Mother had breast cancer. Father had liver disease.
Not family history of lung disease.

Physical Exam:
Vitals: t 96.6 bp 122/62 P 93 RR 20 97 70% mask
Gen: mildly tachypneic when moving around, NAD
HEENT: MMM, op clear, perrl
Neck: no LAD, no thyromegaly, no JVD
Pulm: decreased breath sounds at the bases
Heart: RRR, no m/r/g
Abdomen: soft, NT/ND
Extr: no cyanosis , no edma, no clubing
Neuro: AxO3, cranial nerves grossly intact


Pertinent Results:
[**2148-8-8**] 12:00AM BLOOD WBC-13.8* RBC-2.97* Hgb-9.7* Hct-28.8*
MCV-97 MCH-32.8* MCHC-33.8 RDW-12.7 Plt Ct-422
[**2148-8-8**] 12:00AM BLOOD Plt Ct-422
[**2148-8-8**] 12:00AM BLOOD Glucose-126* UreaN-19 Creat-1.2* Na-138
K-4.2 Cl-97 HCO3-27 AnGap-18
[**2148-8-8**] 12:00AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.2
[**2148-8-4**] 01:30AM BLOOD Hapto-312*
[**2148-8-2**] 12:00AM BLOOD calTIBC-203* Ferritn-408* TRF-156*
[**2148-8-1**] 12:27AM BLOOD VitB12-590 Folate-10.5
[**2148-8-6**] 07:10PM BLOOD Vanco-5.2*
[**2148-7-23**] 12:19AM BLOOD Type-ART pO2-84* pCO2-44 pH-7.35
calTCO2-25 Base XS--1
[**Date range (1) 56011**] C. Diff Assay: Negative x3
.
   GRAM STAIN (Final [**2148-8-6**]):
      [**11-28**] PMNs and <10 epithelial cells/100X field.
      NO MICROORGANISMS SEEN.

   RESPIRATORY CULTURE (Preliminary):
      SPARSE GROWTH OROPHARYNGEAL FLORA.
      STAPH AUREUS COAG +.    SPARSE GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |

Bronchial lavage:[**7-23**]

  Suspicious for non-small cell carcinoma.

  Scattered single cells and loose clusters of cells with high
  nuclear cytoplasmic and nuclear membrane irregularity,
  nucleoli and chromatin clearing.

  These findings are suspiciuos for non-small cell carcinoma,
  possibly bronchioloalveolar type
.
Chest CT w/ contrast [**8-6**]:
IMPRESSION:
1. Improving right lower lobe consolidation and lymphadenopathy.

2. Improving left basilar atelectasis.

3. Stable suspicious mass in the lingula. A nearby area of
well-marginated ground-glass opacity may be inflammatory or also
raises suspicion for malignancy. The opacities are unchanged.

4. New mixed patchy ground glass and consolidative opacity in
the superior segment of the left lower lobe, which could be
infectious, inflammatory or due to aspiration.

5. No evidence of bony metastases, but several rib fractures,
which are unchanged in retrospect.

6. Pneumobilia, which could be seen in prior sphincterotomy.

7. Suspicious renal lesion not imaged.
.
Brain MRI:IMPRESSION: Mild-to-moderate brain atrophy. No
evidence of acute infarct or abnormal enhancement. No evidence
of mass effect or hydrocephalus.
.
Bone Scan: IMPRESSION: 1. Two adjacent areas of focal increased
tracer uptake in the left
lateral 7th and 8th ribs consistent with fractures. 2.
Nonspecific increased
tracer uptake within the right 6th posterior and 7th lateral
ribs. Given the
findings in the contralateral ribs, this tracer uptake may also
be due to a
trauma; however, correlation with cross-sectional imaging (CT
scan) could be
used for further evaluation if clinically indicated.
.
CT Abdomen/pelvis: [**7-26**]
IMPRESSION:
1. Complete consolidation of the right lower lobe, which may be
filled with fluid (perhaps related to recent lavage),
hemorrhage, or tumor. This appearance is rather extensive for
BAC, however, it is possible. No focal masses are identified
within the consolidated lobe.
2. Spiculated mass within the lingula with associated left hilar
lymphadenopathy is highly concerning for malignancy.
3. Vague airspace opacities at the left posterior lung base and
medial aspect of the right middle lobe may represent infection
or less likely tumor.
4. 1.3 cm soft tissue lesion within the right kidney which may
represent a hemorrhagic cyst, or renal cell carcinoma. Recommend
further evaluation with MRI.
5. Three hypoattenuating lesions within the liver are likely
cysts, however, attention should be paid to these on future
exams to ensure stability.
6. Diverticulosis without diverticulitis.
7. Moderate centrilobular emphysema.
.
TBBX:

Atypical mucinous glands, highly suspicious for
bronchiolo-alveolar carcinoma, mucinous type.


Brief Hospital Course:
63F with recurrent pneumonias, htn was transfered on [**7-17**] from
an OSH after 3 hospitalizations for RLL pneumonia in the last 2
months. The next hospitalization found RLL and Lingular PNA. A
BAL on [**7-2**] was negative for bacteria or atypical/malignant
cytology. On the most recent admission, Ms. [**Known lastname 56012**] was found
to have sputum positive for MRSA. The patient was at home for 8
days with 2.5 L continous oxygen requirement with dyspnea on
excertion. On [**7-12**] the patient returned to the hospital with
excruciating laft sided rib pain that developed over 3 days that
was though to be secondary to severe coughing. Admission CT was
postive for RLL a persistent RLL consildation, left lingular
process, and 7th rib fracture. Ms. [**Known lastname 56012**] was treated with
Zosyn starting [**7-12**] and vancomycin on [**7-15**] following a sputum
positive for MRSA on [**7-15**]. was found to have have a positive
MRSA result cultured from sputum. She underwent bronch at OSH
which revealed no evidence of tumor. She was transferred to
[**Hospital1 18**] for further management.
    At [**Hospital1 18**], she underwent work-up for the hypoxia which
involved pulmonary consult which recommended repeat bronch. The
patient underwent bronch with biopsies on [**7-22**]. Bronch was
remarkable for abundant secretions.
.
Negative PPD at OSH
.
Studies from OSH:
[**7-12**] CXR PA/lat [**Last Name (un) **] improvemtn of RLL consolidation, resolving
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 56013**] in LLL
.
Left rib films [**7-12**] on fracture
.
CTA chest [**7-12**] no PE, unchaged RLL atelectasis with dense
consliation interal increase in mass like lingular consliation
stable , medistial adeopathy, acute left 7th [**Last Name (un) **] fracture.
.
A/P:
63F with recurrent pneumonias, htn p/w hypoxia s/p bronch
.
# Acute hypoxia;
Patient experienced multiple episodes of acute hypoxia most
concerning for mucous plugging given the abundant secretions on
bronch.  No evidence of CHF. Patient never intubated throughout
ICU stay, was able to be maintained on NRB and then titrated as
secretions improved to Face Mask and 6L NC.  Two febrile
episodes with rising white count and worsening respiratory
status treated empirically for post-obstructive PNA with course
of vanco and zosyn.  Patient to complete a ten day course of IV
Vancomycin and Zosyn (total of 7 days post-dsicharge).
.
# Bronchoalveolar Carcinoma, mucinous type:
Persistent RLL cosolidation and cough over months despite
treatment, BAL demonstrated bronchorrhea from bronchoavelolar
cancer, mucinous type on pathology.  CT chest also demonstrated
spiculated mass in the lingula.  Patient started on 60mg
prednisone and Tarceva daily with improvement in brochorrhea.
Nebs given standing.  Patient to continue with Tarceva until she
is evaluated by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 20889**] ([**Telephone/Fax (1) 56014**]) as outpatient
for further management of BAC.  She also will continue with a
Prednisone taper over 30 days for bronchorrhea.  Chest CT prior
to discharge showed resolving areas of consolidation suggesting
improved control of mucinous secretions.
.
# Pain: Left Rib Fracture c/o pathologic fx
-Contolled on MsContin and prn oxycodone
.
# ARF:
Cr 1.5 on admission, was 0.9 on [**7-18**]. Prerenal state.
Stabilized with IVF at 1.0-1.2.
.
# Anxiety Depression:
- Continued buspar, celexa, seroquel, trazadone
- prn ativan for an acute anxiety attack
.
# HTN:
-continued norvasc, diovan


Medications on Admission:
Medications at home:
Buspirone 10 Qid
Diovan 160 mg qd
FemHRT 1/.005 qd
[**Doctor First Name **] D 1 tab
Protonix 60 mg qd
Celexa 60 mg qd
Seroqul 200 mg qhs
potassium chloride 10 to 20 meq qd
trazonde 50 to 100 mg PO qhs prn
Albuterol prn
.
Medications on transfer:
PredniSONE 60 mg PO DAILY
Erlotinib (Tarceva) *NF* 150 mg PO DAILY Start
Morphine SR (MS Contin) 60 mg PO Q12H
Clonazepam 0.25 mg PO BID
Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN
Ipratropium Bromide Neb 1 NEB IH Q6H:PRN
Acetaminophen 650 mg PO Q6H:PRN
Lidocaine 5% Patch 2 PTCH TD QD
Guaifenesin [**6-13**] ml PO Q4H
Vancomycin 1000 mg IV Q 12H
HYDROmorphone (Dilaudid) 0.12 mg IVPCA Lockout Interval: 6
minutes Basal Rate: 0 mg(s)/hour 1-hr Max Limit: 1.2 mg(s)
MetRONIDAZOLE (FLagyl) 500 mg PO TID
Levofloxacin 250 mg PO Q24H [**7-23**] @ 0937 View
Fexofenadine 60 mg PO DAILY [**7-23**] @ 0409 View
Lorazepam 0.5 mg PO/IV Q4-6H:PRN anxiety
Aspirin 81 mg PO DAILY
Senna 1 TAB PO BID:PRN
Quetiapine Fumarate 200 mg PO QHS
Docusate Sodium 100 mg PO BID
Heparin 5000 UNIT SC TID
traZODONE HCl 50 mg PO HS:PRN [**7-23**] @ 0409 View
Amlodipine 10 mg PO DAILY
Citalopram Hydrobromide 60 mg PO DAILY
Pantoprazole 40 mg PO Q12H
Femhrt [**2-9**] *NF* 5-1 mcg-mg Oral QD
BusPIRone 10 mg PO QID


Discharge Medications:
1. Buspirone 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
3. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
6. Quetiapine 100 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for anxiety.
10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QD ().
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed.
12. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Erlotinib 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 30 days.
14. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed.
16. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours).
17. Benzonatate 100 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
18. Morphine 100 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
19. Guaifenesin 100 mg/5 mL Syrup Sig: Fifteen (15) ML PO Q4H
(every 4 hours) as needed.
20. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
inhalation Inhalation Q6H (every 6 hours).
21. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
22. Sodium Chloride 0.9%  Flush 10 ml IV DAILY:PRN
For PASV Picc flush before and after each use Inspect site daily

23. Heparin Flush (10 units/ml) 2 ml IV PRN
24. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q6H (every 6 hours) for 7 days.
25. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) g
Intravenous Q 12H (Every 12 Hours) for 7 days.
26. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 30 days: Please take 6 pills x5 days, 5 pills x5 days, 4
pills x5 days, 3 pills x5 days, 2 pills x5 days, 1 pills x5
days. Tablet(s)
27. Prednisone 10 mg Tablet Sig: Six (6) Tablet PO once a day
for 30 days: Please take 6 pills x 5 days then taper to 5 pills
x5days, 4 pills x5 days, 3 pills x5 days, 2 pills x5days, 1 pill
x5 days.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **] Senior Healthcare - [**Location (un) 23638**]

Discharge Diagnosis:
Bronchoalveloar Carcinoma
Post-Obstructive Pneumonia in MRSA carrier
Chemotherapy-induced diarrhea
Acute Renal Failure
Normocytic Anemia of Chronic Disease
Vitamin K deficiency Coagulopathy
Stress Urinary Incontinence
Anxiety
Depression
Benign Hypertension
Vaginal Candidiasis


Discharge Condition:
Stable, requiring 6L of NC to maintain oxygen saturation.


Discharge Instructions:
You have been treated for Bronchoalveolar carcinoma and
associated bronchorrhea and post-obstructive pneumonia.  Please
complete a 7 day course of IV Vancomycin and Zosyn for empiric
treatment of MRSA post-obstructive pneumonia.  Please continue a
one month taper of your prednisone.  You are to follow-up once
discharged from the rehab facility with an oncologist, Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 20889**] [**Telephone/Fax (1) 56014**] in [**Location (un) 15566**], MA.  In the interim, please
continue with Tarceva for the next month until otherwise
instructed by Dr [**Last Name (STitle) 20889**].

Followup Instructions:
Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 20889**] [**Telephone/Fax (1) 56014**] in [**Location (un) 15566**],
MA for further management of your lung cancer.  Rahbilitation
facility is to call to schedule an appointment prior to
discharge home.


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16984**] MD, [**MD Number(3) 16985**]
{'Malignant neoplasm of other parts of bronchus or lung,Methicillin susceptible pneumonia due to Staphylococcus aureus,Acute kidney failure, unspecified,Obstructive chronic bronchitis with (acute) exacerbation,Acute and chronic respiratory failure,Closed fracture of four ribs,Candidiasis of other urogenital sites,Infection with microorganisms resistant to penicillins,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Anxiety state, unspecified,Depressive disorder, not elsewhere classified,Personal history of tobacco use,Fracture, cause unspecified,Anemia of other chronic disease,Other and unspecified coagulation defects,Stress incontinence, female,Diarrhea'}


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: recurrent pneumonia

PRESENT ILLNESS: Briefly, this is a 65 year-old F with COPD who has been admitted
to an OSH 3 times in the past 2 months for a RLL pneumonia/
consolidation. She initially presented 2 months ago with RLL
PNA, and returned one month ago with RLL and lingular PNA. She
underwent bronchoscopy on [**7-2**] at which time BAL cultures were
negative and cytology from the washings was negative. A CT of
the chest was reportedly without malignancy. She most recently
returned to [**Hospital3 **] Hospital 8 days after discharge ([**7-12**]) with
increasing cough, sputum production, and left sided rib pain
which started two days
prior to presentation. A CT again showed mass-like consolidation
in the lingula with interval increase in size since the previous
film, RLL atelectasis and dense consolidation which is
unchanged, stable
mediastinal adenopathy, and an acute left 7th rib fracture. A
PPD placed at [**Hospital3 **] was negative according to their records.
She was started on zosyn on [**7-12**]; after sputum cx grew out MRSA
she was started on vancomycin on [**7-15**]. She was transferred to
[**Hospital1 18**] on [**7-18**] for further work-up and management of her
recurrent pneumonias. She had a repeat bronchoscopy on [**7-22**],
cytology from which revealed BAC.
While her current exacerbation was considered to be due to
infection, the pt was felt to have poor underlying lung function
from involvement of her tumor and therefore was started on
tarceva.
.
In the MICU the patient had waxing and [**Doctor Last Name 688**] respiratory status
and required a NRB. SHe was never intubated. Currently she is on
70% face mask. She continued to be treated for hospital acquired
pna with vanc/levo/flagyl. While the bronchoal lavage cx was
negative but a sputum cx grew MRSA. The pt was also found to
have new ARF with a creatinine of 1.5, which was thought to be
prerenal and resolved with IVF. Her chest pain was felt to be
due to a rib fracture and was treated with dilaudid.
.
The pt is now transfered for further management of her BAC. She
is currently on 6L NC with intermittent episodes of SOB and a
dry cough and denies CP, nausea, vomiting

MEDICAL HISTORY: Hypertension
MRSA pneumonia in [**2138**]
GERD
Dyslipidemia
Depression
Anxiety

MEDICATION ON ADMISSION: Medications at home:
Buspirone 10 Qid
Diovan 160 mg qd
FemHRT 1/.005 qd
[**Doctor First Name **] D 1 tab
Protonix 60 mg qd
Celexa 60 mg qd
Seroqul 200 mg qhs
potassium chloride 10 to 20 meq qd
trazonde 50 to 100 mg PO qhs prn
Albuterol prn
.
Medications on transfer:
PredniSONE 60 mg PO DAILY
Erlotinib (Tarceva) *NF* 150 mg PO DAILY Start
Morphine SR (MS Contin) 60 mg PO Q12H
Clonazepam 0.25 mg PO BID
Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN
Ipratropium Bromide Neb 1 NEB IH Q6H:PRN
Acetaminophen 650 mg PO Q6H:PRN
Lidocaine 5% Patch 2 PTCH TD QD
Guaifenesin [**6-13**] ml PO Q4H
Vancomycin 1000 mg IV Q 12H
HYDROmorphone (Dilaudid) 0.12 mg IVPCA Lockout Interval: 6
minutes Basal Rate: 0 mg(s)/hour 1-hr Max Limit: 1.2 mg(s)
MetRONIDAZOLE (FLagyl) 500 mg PO TID
Levofloxacin 250 mg PO Q24H [**7-23**] @ 0937 View
Fexofenadine 60 mg PO DAILY [**7-23**] @ 0409 View
Lorazepam 0.5 mg PO/IV Q4-6H:PRN anxiety
Aspirin 81 mg PO DAILY
Senna 1 TAB PO BID:PRN
Quetiapine Fumarate 200 mg PO QHS
Docusate Sodium 100 mg PO BID
Heparin 5000 UNIT SC TID
traZODONE HCl 50 mg PO HS:PRN [**7-23**] @ 0409 View
Amlodipine 10 mg PO DAILY
Citalopram Hydrobromide 60 mg PO DAILY
Pantoprazole 40 mg PO Q12H
Femhrt [**2-9**] *NF* 5-1 mcg-mg Oral QD
BusPIRone 10 mg PO QID

ALLERGIES: Antihistamines

PHYSICAL EXAM: Vitals: t 96.6 bp 122/62 P 93 RR 20 97 70% mask
Gen: mildly tachypneic when moving around, NAD
HEENT: MMM, op clear, perrl
Neck: no LAD, no thyromegaly, no JVD
Pulm: decreased breath sounds at the bases
Heart: RRR, no m/r/g
Abdomen: soft, NT/ND
Extr: no cyanosis , no edma, no clubing
Neuro: AxO3, cranial nerves grossly intact

FAMILY HISTORY: Mother (former smoker) is [**Age over 90 **] years old and carries a diagnosis
of "asthma". Mother had breast cancer. Father had liver disease.
Not family history of lung disease.

SOCIAL HISTORY: Patient lives a alone in [**Hospital3 **]. She had previous worked in
retail. She quit smoking in [**Month (only) 547**] and now uses nicorette gum.
She had smoked approximately 0.5 packs a day for 45 years. She
drink alcohol only socially. She reports no use of recreational
drugs. 

### Response:
{'Malignant neoplasm of other parts of bronchus or lung,Methicillin susceptible pneumonia due to Staphylococcus aureus,Acute kidney failure, unspecified,Obstructive chronic bronchitis with (acute) exacerbation,Acute and chronic respiratory failure,Closed fracture of four ribs,Candidiasis of other urogenital sites,Infection with microorganisms resistant to penicillins,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Anxiety state, unspecified,Depressive disorder, not elsewhere classified,Personal history of tobacco use,Fracture, cause unspecified,Anemia of other chronic disease,Other and unspecified coagulation defects,Stress incontinence, female,Diarrhea'}
