CHIEF COMPLAINT: 

PRESENT ILLNESS: Mr. [**Known lastname 42915**] is a 73 year old male
with a past medical history significant for obstructive sleep
apnea requiring CPAP, rheumatoid arthritis, gastroesophageal
reflux disease, status post cerebrovascular accident of the
left temporal lobe, frequent and recurrent urinary tract
infections, complicated by urinary retention.  The patient
initially presented to [**Hospital3 3583**] on [**2162-12-11**]
with pyuria, rigors, fevers to 106 and mental status changes
as well as bilateral flank pain, urinalysis with 25-30 white
cells but culture negative.  Blood culture during admission
grew 202 bottles positive for Providencia Alcalifaciens
sensitive to Imipenem and Levofloxacin.  The [**Hospital 228**]
hospital stay at the outside hospital was complicated by the
following, 1.  Renal failure secondary to acute tubular
necrosis resulting in the potassiums of 6, anuria, worsening
acidosis requiring hemodialysis; 2.  Distributive shock
secondary to gram negative sepsis requiring Dopamine drip,
antibiotic coverage with Levaquin, Gentamicin and Imipenem;
3.  Cholestasis, ischemic pancreatitis, mesenteric ischemia,
obstructive jaundice; 4.  DIC with a platelet count of
20,000; 5.  Subendocardial ischemia with a peak troponin of
1.47; 6.  Toxic metabolic encephalopathy that has since
resolved; 7.  Respiratory failure, the patient was initially
intubated for airway protection after failing CPAP due to his
mental status changes.  The patient self-extubated on
[**12-17**].

MEDICAL HISTORY: 1.  Obstructive sleep apnea on CPAP;
2.  Gastroesophageal reflux disease; 3.  Rheumatoid arthritis
on immune modulator therapy; 4.  Cerebrovascular accident
with a left temporal lobe stroke in [**2156**], possibly a
cavernous hemangioma; 5.  Urinary tract infections frequent
and recurrent; 6.  Ejection fraction within normal limits, 2+
tricuspid regurgitation, 1+ mitral regurgitation,
echocardiogram [**2160-11-21**]; 7.  Urinary retention
secondary to benign prostatic hypertrophy.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient is married, lives with his wife,
occasional [**Name2 (NI) 46951**] alcohol, quit smoking 15 years ago.
Acute respiratory failure,Other septicemia due to gram-negative organisms,Pyelonephritis, unspecified,Pneumonitis due to inhalation of food or vomitus,Acute kidney failure with lesion of tubular necrosis,Retention of urine, unspecified,Intracerebral hemorrhage,Subendocardial infarction, initial episode of care,Hyperosmolality and/or hypernatremia
Acute respiratry failure,Gram-neg septicemia NEC,Pyelonephritis NOS,Food/vomit pneumonitis,Ac kidny fail, tubr necr,Retention urine NOS,Intracerebral hemorrhage,Subendo infarct, initial,Hyperosmolality
Admission Date:  [**2162-12-21**]       Discharge Date: [**2163-1-6**]

Date of Birth:   [**2089-7-4**]       Sex:  M

Service:  [**Location (un) **]-Medicine

HISTORY OF PRESENT ILLNESS:  Mr. [**Known lastname 42915**] is a 73 year old male
with a past medical history significant for obstructive sleep
apnea requiring CPAP, rheumatoid arthritis, gastroesophageal
reflux disease, status post cerebrovascular accident of the
left temporal lobe, frequent and recurrent urinary tract
infections, complicated by urinary retention.  The patient
initially presented to [**Hospital3 3583**] on [**2162-12-11**]
with pyuria, rigors, fevers to 106 and mental status changes
as well as bilateral flank pain, urinalysis with 25-30 white
cells but culture negative.  Blood culture during admission
grew 202 bottles positive for Providencia Alcalifaciens
sensitive to Imipenem and Levofloxacin.  The [**Hospital 228**]
hospital stay at the outside hospital was complicated by the
following, 1.  Renal failure secondary to acute tubular
necrosis resulting in the potassiums of 6, anuria, worsening
acidosis requiring hemodialysis; 2.  Distributive shock
secondary to gram negative sepsis requiring Dopamine drip,
antibiotic coverage with Levaquin, Gentamicin and Imipenem;
3.  Cholestasis, ischemic pancreatitis, mesenteric ischemia,
obstructive jaundice; 4.  DIC with a platelet count of
20,000; 5.  Subendocardial ischemia with a peak troponin of
1.47; 6.  Toxic metabolic encephalopathy that has since
resolved; 7.  Respiratory failure, the patient was initially
intubated for airway protection after failing CPAP due to his
mental status changes.  The patient self-extubated on
[**12-17**].

The patient was then transferred on [**12-21**], to [**Hospital6 1760**] to the MICU as the patient's
family wished him to come to this hospital.

PAST MEDICAL HISTORY:  1.  Obstructive sleep apnea on CPAP;
2.  Gastroesophageal reflux disease; 3.  Rheumatoid arthritis
on immune modulator therapy; 4.  Cerebrovascular accident
with a left temporal lobe stroke in [**2156**], possibly a
cavernous hemangioma; 5.  Urinary tract infections frequent
and recurrent; 6.  Ejection fraction within normal limits, 2+
tricuspid regurgitation, 1+ mitral regurgitation,
echocardiogram [**2160-11-21**]; 7.  Urinary retention
secondary to benign prostatic hypertrophy.

ALLERGIES:  No known drug allergies.

MEDICATIONS ON TRANSFER:  1.  Regular insulin sliding scale;
2.  Protonix 40 intravenously; 3.  Permax 250 intravenously
q. 12; 4.  Nystatin powder topical q. 12; 5.  Atrovent q. 4
hours; 6.  Albuterol q. 4 hours; 7.  Imipenem 250 q. 12
hours; 8.  Tylenol prn; 9.  Versed 2 to 4 mg q. 2 hours prn;
10. Morphine Sulfate 2 mg q. 4 hours prn; 11. Milk of
magnesia prn; 12. Haldol 1 to 2.5 q. 4 hours prn; 13.
Levofloxacin 250 mg q.d.; 14. Fentanyl prn.

SOCIAL HISTORY:  The patient is married, lives with his wife,
occasional [**Name2 (NI) 46951**] alcohol, quit smoking 15 years ago.

PHYSICAL EXAMINATION:  On examination the patient had a
temperature maximum of 99.5 which is also his temperature
currently, heartrate 79, blood pressure 154/49, respiratory
rate 18 and he was 94% on vent settings of SIMV 700 by 12, 5
positive end-expiratory pressure, 5 pressure support.  In
general, pleasant, awake and alert in no apparent distress,
intubated.  Head, eyes, ears, nose and throat, mucous
membranes moist, endotracheal tube in place.  Surgical pupil
right.  Cardiovascular regular rate and rhythm, normal S1 and
S2, no murmurs, rubs or gallops.  Lungs clear to auscultation
bilaterally.  Slightly decreased breathsounds at bases.
Abdomen, obese, soft, nontender, decreased bowel sounds.  No
suprapubic tenderness.  Foley catheter in place.
Extremities, warm, good distal pulses, no edema.

LABORATORY DATA:  Laboratory data on admission revealed
hematocrit of 30.1, white count 11.8, platelets 274, INR 1.3,
PT 27.3.  Chemistries, sodium 146, potassium 4.3, chloride
108, bicarbonate 25, BUN 89, creatinine 5.7, glucose 95,
calcium 8.5, magnesium 2.5 and phosphorus 6.1.

Chest x-ray showed mild congestive heart failure, possible
right lower lobe infiltrate.  Electrocardiogram, normal sinus
rhythm with a rate of 80, normal axis, normal intervals, T
wave inversions in the inferior and lateral leads, isolated
Qs in L, slight ST depression in V4.

ASSESSMENT:  This is a 73 year old white male with a history
of obstructive sleep apnea requiring CPAP, history of
rheumatoid arthritis on Enbrel, admitted to [**Hospital3 3583**]
on [**12-11**] with likely pyelonephritis and gram negative
sepsis causing multi-organ dysfunction including renal
failure secondary to acute tubular necrosis requiring
hemodialysis, DIC subendocardial ischemia, toxic metabolic
encephalopathy and hypercarbic respiratory failure,
transferred from the outside hospital for further management
at the family's request.

HOSPITAL COURSE:  1.  Infectious disease - The patient was
admitted with a resolving pyelonephritis and gram negative
sepsis as well as a possible right lower lobe pneumonia.  The
patient was continued on Levaquin 250 q.d. and Imipenem 250
q. 12 hours for four days after admission for a total of 14
days of antibiotics.  Per renal recommendations, the
Levofloxacin was changed to 250 mg q. 48 hours.  Imipenem was
discontinued on [**12-23**], Levaquin was discontinued on
[**2162-12-26**].  The patient remained afebrile with a normal
to slightly elevated white blood count.  The patient's Foley
catheter was changed on [**12-27**] and a repeat urinalysis was
read as no evidence of infection.  Urine cultures were
negative times two as of [**2162-12-31**].  The [**Hospital 228**]
hospital course was then complicated when on [**2163-1-1**], the patient was ready to be transferred to
rehabilitation.  He was noted to have decreased responses at
4 AM.  His arterial blood gases was 7.26, 54 and 71, showing
a hypercarbic respiratory acidosis.  The patient had
increasing oxygen requirement over the following hours and
was unresponsive to medications.  At 7 AM he was found to be
unresponsive and a code was called.  The patient was
intubated but became hypotensive after intubation requiring
transient pressure support with Dopamine.  MICU evaluation
suggested that the patient suffered a respiratory arrest
likely secondary to aspiration pneumonia.  A neurologic event
was considered as the cause of this, however, the patient had
a head computerized tomography scan with no significant
changes.  Sputum cultures in the MICU grew out
Methicillin-resistant Staphylococcus aureus and the patient
was started on Vancomycin that was dosed renally by prn
Vancomycin levels.  Abdominal computerized tomography scan
showed no other obvious infections source.  The patient was
successfully extubated on day #3 in the MICU.  His
computerized tomography scan on [**2163-1-1**] showed
bilateral pneumonia with no effusions, essentially normal
abdomen.  The patient's bilateral aspiration pneumonia
responded well to Vancomycin.  He was transferred to the
floor, back to the [**Hospital **] Medical Service on [**2163-1-4**] and was to continue on Vancomycin for a total of a 12
day course.  On transfer to the floor the patient denied any
specific complaints.  He denied shortness of breath and
stated that he was ready to leave the hospital.

2.  Gastrointestinal - The patient had speech and swallow
study during his admission that he failed.  Therefore a
percutaneous endoscopic gastrostomy was placed by
Interventional Radiology while the patient was in the MICU.
The percutaneous endoscopic gastrostomy was placed [**2163-1-3**].  The percutaneous endoscopic gastrostomy was used
for tube feeds on [**2163-1-4**] without complications.
The patient was also noted to have elevated transaminases
during his admission.  It was felt that this was likely
secondary to his hypotensive episode after the respiratory
failure on the floor.

3.  Renal - The patient, as stated above, had acute tubular
necrosis secondary to his gram negative sepsis and
hypotension.  The patient required transient hemodialysis but
by [**1-4**] his creatinine was back to baseline levels at
2.2.  He required no further hemodialysis and continued to
have good urine output.

4.  Genitourinary - The patient was followed by Urology while
he was in-house for his urinary retention.  They recommended
Flomax and that the patient have indwelling Foley catheter to
prevent further episodes of retention and urosepsis.  The
catheter was kept in place.  The patient was continued on
Flomax with no difficulty.

5.  Neurological - The patient's sepsis as stated above was
complicated by encephalopathy.  The patient also had a left
temporal hemorrhage which was noted on magnetic resonance
imaging scan and computerized tomography scan.  The patient
was consulted by Neurosurgery who recommended blood pressure
control and normalizing the INR.  The patient received
Vitamin K for this purpose.  There was some concern that this
hemorrhage might reflect malignancy/brain metastases,
therefore the patient had pan computerized tomography scan
which all ruled out malignancy.

6.  Pulmonary - The patient was extubated on day #3 of
initial MICU course, transferred to the floor and then, as
stated above under Infectious Disease, the patient had a
recurrent episode of respiratory failure secondary to
aspiration pneumonia.  The patient was again extubated day #3
of this MICU course, transferred to the floor with normal
respiratory function on [**2163-1-4**].  For his
obstructive sleep apnea the patient utilized his CPAP.  He
was continued on Albuterol, Atrovent nebulizers and
Vancomycin.

7.  Cardiology - The patient had suffered a non-Q wave
myocardial infarction at the outside hospital.  As a
consequence he was medically managed for his cardiac disease,
treated with Aspirin and with blood pressure control.
Lopressor was held as the patient was bradycardiac on his
medication.  For blood pressure control the patient was on
Amlodipine 5 mg q.d. and the patient was also on Lasix 40 mg
q.d.

DISPOSITION:  The patient was ready for transfer to a
rehabilitation facility on [**2163-1-6**]

MEDICATIONS ON DISCHARGE:
1.  Vancomycin 1 gm q. 24 hours to be continued until [**2163-1-13**]
2.  Combivent 1 to 2 puffs inhaled q. 6 hours
3.  Miconazole powder 2% one application topically b.i.d.
4.  Nystatin ointment one application q.i.d.
5.  Insulin sliding scale
6.  Tamsulosin .4 mg h.s.
7.  Lansoprazole 30 mg per percutaneous endoscopic
gastrostomy q.d.
8.  Salmeterol 2 puffs inhaled q.d.
9.  Albuterol nebulizers 1 to 2 nebulizers q. 6 hours prn
10. Ipratropium Bromide nebulizer, 1 to 2 nebulizers inhaled
q. 6 hours prn
11. Lorazepam .5 to 1 mg intravenously q. 4 hours prn
12. Amlodipine 5 mg p.o. q.d.
13. Aspirin entered coated 325 mg p.o. q.d.
14. Heparin 5000 units SV q. 12 hours
15. Lasix 40 mg p.o. q.d.



                            [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 2506**]

Dictated By:[**Last Name (NamePattern1) 5851**]
MEDQUIST36

D:  [**2163-1-6**]  08:14
T:  [**2163-1-6**]  08:23
JOB#:  [**Job Number 46952**]


[**Numeric Identifier 46950**]

Admission Date:  [**2162-12-21**]       Discharge Date:  [**2163-1-6**]

Date of Birth:   [**2089-7-4**]       Sex:  M

Service:  [**Location (un) **]-Medicine

HISTORY OF PRESENT ILLNESS:  Mr. [**Known lastname 42915**] is a 73 year old male
with a past medical history significant for obstructive sleep
apnea requiring CPAP, rheumatoid arthritis, gastroesophageal
reflux disease, status post cerebrovascular accident of the
left temporal lobe, frequent and recurrent urinary tract
infections, complicated by urinary retention.  The patient
initially presented to [**Hospital3 3583**] on [**2162-12-11**]
with pyuria, rigors, fevers to 106 and mental status changes
as well as bilateral flank pain, urinalysis with 25-30 white
cells but culture negative.  Blood culture during admission
grew 202 bottles positive for Providencia Alcalifaciens
sensitive to Imipenem and Levofloxacin.  The [**Hospital 228**]
hospital stay at the outside hospital was complicated by the
following, 1.  Renal failure secondary to acute tubular
necrosis resulting in the potassiums of 6, anuria, worsening
acidosis requiring hemodialysis; 2.  Distributive shock
secondary to gram negative sepsis requiring Dopamine drip,
antibiotic coverage with Levaquin, Gentamicin and Imipenem;
3.  Cholestasis, ischemic pancreatitis, mesenteric ischemia,
obstructive jaundice; 4.  DIC with a platelet count of
20,000; 5.  Subendocardial ischemia with a peak troponin of
1.47; 6.  Toxic metabolic encephalopathy that has since
resolved; 7.  Respiratory failure, the patient was initially
intubated for airway protection after failing CPAP due to his
mental status changes.  The patient self-extubated on
[**12-17**].

The patient was then transferred on [**12-21**], to [**Hospital6 1760**] to the MICU as the patient's
family wished him to come to this hospital.

PAST MEDICAL HISTORY:  1.  Obstructive sleep apnea on CPAP;
2.  Gastroesophageal reflux disease; 3.  Rheumatoid arthritis
on immune modulator therapy; 4.  Cerebrovascular accident
with a left temporal lobe stroke in [**2156**], possibly a
cavernous hemangioma; 5.  Urinary tract infections frequent
and recurrent; 6.  Ejection fraction within normal limits, 2+
tricuspid regurgitation, 1+ mitral regurgitation,
echocardiogram [**2160-11-21**]; 7.  Urinary retention
secondary to benign prostatic hypertrophy.

ALLERGIES:  No known drug allergies.

MEDICATIONS ON TRANSFER:  1.  Regular insulin sliding scale;
2.  Protonix 40 intravenously; 3.  Permax 250 intravenously
q. 12; 4.  Nystatin powder topical q. 12; 5.  Atrovent q. 4
hours; 6.  Albuterol q. 4 hours; 7.  Imipenem 250 q. 12
hours; 8.  Tylenol prn; 9.  Versed 2 to 4 mg q. 2 hours prn;
10. Morphine Sulfate 2 mg q. 4 hours prn; 11. Milk of
magnesia prn; 12. Haldol 1 to 2.5 q. 4 hours prn; 13.
Levofloxacin 250 mg q.d.; 14. Fentanyl prn.

SOCIAL HISTORY:  The patient is married, lives with his wife,
occasional [**Name2 (NI) 46951**] alcohol, quit smoking 15 years ago.

PHYSICAL EXAMINATION:  On examination the patient had a
temperature maximum of 99.5 which is also his temperature
currently, heartrate 79, blood pressure 154/49, respiratory
rate 18 and he was 94% on vent settings of SIMV 700 by 12, 5
positive end-expiratory pressure, 5 pressure support.  In
general, pleasant, awake and alert in no apparent distress,
intubated.  Head, eyes, ears, nose and throat, mucous
membranes moist, endotracheal tube in place.  Surgical pupil
right.  Cardiovascular regular rate and rhythm, normal S1 and
S2, no murmurs, rubs or gallops.  Lungs clear to auscultation
bilaterally.  Slightly decreased breathsounds at bases.
Abdomen, obese, soft, nontender, decreased bowel sounds.  No
suprapubic tenderness.  Foley catheter in place.
Extremities, warm, good distal pulses, no edema.

LABORATORY DATA:  Laboratory data on admission revealed
hematocrit of 30.1, white count 11.8, platelets 274, INR 1.3,
PT 27.3.  Chemistries, sodium 146, potassium 4.3, chloride
108, bicarbonate 25, BUN 89, creatinine 5.7, glucose 95,
calcium 8.5, magnesium 2.5 and phosphorus 6.1.

Chest x-ray showed mild congestive heart failure, possible
right lower lobe infiltrate.  Electrocardiogram, normal sinus
rhythm with a rate of 80, normal axis, normal intervals, T
wave inversions in the inferior and lateral leads, isolated
Qs in L, slight ST depression in V4.

ASSESSMENT:  This is a 73 year old white male with a history
of obstructive sleep apnea requiring CPAP, history of
rheumatoid arthritis on Enbrel, admitted to [**Hospital3 3583**]
on [**12-11**] with likely pyelonephritis and gram negative
sepsis causing multi-organ dysfunction including renal
failure secondary to acute tubular necrosis requiring
hemodialysis, DIC subendocardial ischemia, toxic metabolic
encephalopathy and hypercarbic respiratory failure,
transferred from the outside hospital for further management
at the family's request.

HOSPITAL COURSE:  1.  Infectious disease - The patient was
admitted with a resolving pyelonephritis and gram negative
sepsis as well as a possible right lower lobe pneumonia.  The
patient was continued on Levaquin 250 q.d. and Imipenem 250
q. 12 hours for four days after admission for a total of 14
days of antibiotics.  Per renal recommendations, the
Levofloxacin was changed to 250 mg q. 48 hours.  Imipenem was
discontinued on [**12-23**], Levaquin was discontinued on
[**2162-12-26**].  The patient remained afebrile with a normal
to slightly elevated white blood count.  The patient's Foley
catheter was changed on [**12-27**] and a repeat urinalysis was
read as no evidence of infection.  Urine cultures were
negative times two as of [**2162-12-31**].  The [**Hospital 228**]
hospital course was then complicated when on [**2163-1-1**], the patient was ready to be transferred to
rehabilitation.  He was noted to have decreased responses at
4 AM.  His arterial blood gases was 7.26, 54 and 71, showing
a hypercarbic respiratory acidosis.  The patient had
increasing oxygen requirement over the following hours and
was unresponsive to medications.  At 7 AM he was found to be
unresponsive and a code was called.  The patient was
intubated but became hypotensive after intubation requiring
transient pressure support with Dopamine.  MICU evaluation
suggested that the patient suffered a respiratory arrest
likely secondary to aspiration pneumonia.  A neurologic event
was considered as the cause of this, however, the patient had
a head computerized tomography scan with no significant
changes.  Sputum cultures in the MICU grew out
Methicillin-resistant Staphylococcus aureus and the patient
was started on Vancomycin that was dosed renally by prn
Vancomycin levels.  Abdominal computerized tomography scan
showed no other obvious infections source.  The patient was
successfully extubated on day #3 in the MICU.  His
computerized tomography scan on [**2163-1-1**] showed
bilateral pneumonia with no effusions, essentially normal
abdomen.  The patient's bilateral aspiration pneumonia
responded well to Vancomycin.  He was transferred to the
floor, back to the [**Hospital **] Medical Service on [**2163-1-4**] and was to continue on Vancomycin for a total of a 12
day course.  On transfer to the floor the patient denied any
specific complaints.  He denied shortness of breath and
stated that he was ready to leave the hospital.

2.  Gastrointestinal - The patient had speech and swallow
study during his admission that he failed.  Therefore a
percutaneous endoscopic gastrostomy was placed by
Interventional Radiology while the patient was in the MICU.
The percutaneous endoscopic gastrostomy was placed [**2163-1-3**].  The percutaneous endoscopic gastrostomy was used
for tube feeds on [**2163-1-4**] without complications.
The patient was also noted to have elevated transaminases
during his admission.  It was felt that this was likely
secondary to his hypotensive episode after the respiratory
failure on the floor.

3.  Renal - The patient, as stated above, had acute tubular
necrosis secondary to his gram negative sepsis and
hypotension.  The patient required transient hemodialysis but
by [**1-4**] his creatinine was back to baseline levels at
2.2.  He required no further hemodialysis and continued to
have good urine output.

4.  Genitourinary - The patient was followed by Urology while
he was in-house for his urinary retention.  They recommended
Flomax and that the patient have indwelling Foley catheter to
prevent further episodes of retention and urosepsis.  The
catheter was kept in place.  The patient was continued on
Flomax with no difficulty.

5.  Neurological - The patient's sepsis as stated above was
complicated by encephalopathy.  The patient also had a left
temporal hemorrhage which was noted on magnetic resonance
imaging scan and computerized tomography scan.  The patient
was consulted by Neurosurgery who recommended blood pressure
control and normalizing the INR.  The patient received
Vitamin K for this purpose.  There was some concern that this
hemorrhage might reflect malignancy/brain metastases,
therefore the patient had pan computerized tomography scan
which all ruled out malignancy.

6.  Pulmonary - The patient was extubated on day #3 of
initial MICU course, transferred to the floor and then, as
stated above under Infectious Disease, the patient had a
recurrent episode of respiratory failure secondary to
aspiration pneumonia.  The patient was again extubated day #3
of this MICU course, transferred to the floor with normal
respiratory function on [**2163-1-4**].  For his
obstructive sleep apnea the patient utilized his CPAP.  He
was continued on Albuterol, Atrovent nebulizers and
Vancomycin.

7.  Cardiology - The patient had suffered a non-Q wave
myocardial infarction at the outside hospital.  As a
consequence he was medically managed for his cardiac disease,
treated with Aspirin and with blood pressure control.
Lopressor was held as the patient was bradycardiac on his
medication.  For blood pressure control the patient was on
Amlodipine 5 mg q.d. and the patient was also on Lasix 40 mg
q.d.

DISPOSITION:  The patient was ready for transfer to a
rehabilitation facility on [**2163-1-6**]

MEDICATIONS ON DISCHARGE:
1.  Vancomycin 1 gm q. 24 hours to be continued until [**2163-1-13**]
2.  Combivent 1 to 2 puffs inhaled q. 6 hours
3.  Miconazole powder 2% one application topically b.i.d.
4.  Nystatin ointment one application q.i.d.
5.  Insulin sliding scale
6.  Tamsulosin .4 mg h.s.
7.  Lansoprazole 30 mg per percutaneous endoscopic
gastrostomy q.d.
8.  Salmeterol 2 puffs inhaled q.d.
9.  Albuterol nebulizers 1 to 2 nebulizers q. 6 hours prn
10. Ipratropium Bromide nebulizer, 1 to 2 nebulizers inhaled
q. 6 hours prn
11. Lorazepam .5 to 1 mg intravenously q. 4 hours prn
12. Amlodipine 5 mg p.o. q.d.
13. Aspirin entered coated 325 mg p.o. q.d.
14. Heparin 5000 units SV q. 12 hours
15. Lasix 40 mg p.o. q.d.



                            [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 2506**]

Dictated By:[**Last Name (NamePattern1) 5851**]
MEDQUIST36

D:  [**2163-1-6**]  08:14
T:  [**2163-1-6**]  08:23
JOB#:  [**Job Number 46952**]
{'Acute respiratory failure,Other septicemia due to gram-negative organisms,Pyelonephritis, unspecified,Pneumonitis due to inhalation of food or vomitus,Acute kidney failure with lesion of tubular necrosis,Retention of urine, unspecified,Intracerebral hemorrhage,Subendocardial infarction, initial episode of care,Hyperosmolality and/or hypernatremia'}


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: 

PRESENT ILLNESS: Mr. [**Known lastname 42915**] is a 73 year old male
with a past medical history significant for obstructive sleep
apnea requiring CPAP, rheumatoid arthritis, gastroesophageal
reflux disease, status post cerebrovascular accident of the
left temporal lobe, frequent and recurrent urinary tract
infections, complicated by urinary retention.  The patient
initially presented to [**Hospital3 3583**] on [**2162-12-11**]
with pyuria, rigors, fevers to 106 and mental status changes
as well as bilateral flank pain, urinalysis with 25-30 white
cells but culture negative.  Blood culture during admission
grew 202 bottles positive for Providencia Alcalifaciens
sensitive to Imipenem and Levofloxacin.  The [**Hospital 228**]
hospital stay at the outside hospital was complicated by the
following, 1.  Renal failure secondary to acute tubular
necrosis resulting in the potassiums of 6, anuria, worsening
acidosis requiring hemodialysis; 2.  Distributive shock
secondary to gram negative sepsis requiring Dopamine drip,
antibiotic coverage with Levaquin, Gentamicin and Imipenem;
3.  Cholestasis, ischemic pancreatitis, mesenteric ischemia,
obstructive jaundice; 4.  DIC with a platelet count of
20,000; 5.  Subendocardial ischemia with a peak troponin of
1.47; 6.  Toxic metabolic encephalopathy that has since
resolved; 7.  Respiratory failure, the patient was initially
intubated for airway protection after failing CPAP due to his
mental status changes.  The patient self-extubated on
[**12-17**].

MEDICAL HISTORY: 1.  Obstructive sleep apnea on CPAP;
2.  Gastroesophageal reflux disease; 3.  Rheumatoid arthritis
on immune modulator therapy; 4.  Cerebrovascular accident
with a left temporal lobe stroke in [**2156**], possibly a
cavernous hemangioma; 5.  Urinary tract infections frequent
and recurrent; 6.  Ejection fraction within normal limits, 2+
tricuspid regurgitation, 1+ mitral regurgitation,
echocardiogram [**2160-11-21**]; 7.  Urinary retention
secondary to benign prostatic hypertrophy.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient is married, lives with his wife,
occasional [**Name2 (NI) 46951**] alcohol, quit smoking 15 years ago. 

### Response:
{'Acute respiratory failure,Other septicemia due to gram-negative organisms,Pyelonephritis, unspecified,Pneumonitis due to inhalation of food or vomitus,Acute kidney failure with lesion of tubular necrosis,Retention of urine, unspecified,Intracerebral hemorrhage,Subendocardial infarction, initial episode of care,Hyperosmolality and/or hypernatremia'}
