CHIEF COMPLAINT: SOB

PRESENT ILLNESS: 76 yo M transferred from [**Hospital3 417**] on [**5-10**] after cardiac
catheterization showed 3 vessel disease.

MEDICAL HISTORY: HTN
NIDDM
Hypercholesterolemia
R rotator cuff injury s/p surgical repair
R knee surgery
R CEA
h/o polyps, nonmalignant
COPD (last PFTs this year, but unk results)
Atrial Fibrillation (on warfarin)
CVA w/ residual facial weakness 1/05
R CEA [**1-16**]
PVD s/p R Fem-[**Doctor Last Name **] bypass
R knee surgery
Last colonoscopy ?5 yrs ago, (+) polyps
BPH

MEDICATION ON ADMISSION: coumadin 2.5', nephrocaps, terazosin 2', prilosec 20', lopressor
25", lantus 10', mirtazipine 7.5', zocor 40', dig 0.125 [**Last Name (LF) **], [**First Name3 (LF) **]
81', imdur 60', megace"

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission
HR 81 RR 18 BP 119/81
NAD, flat after cath. Sob with talking.
Skin 3 areas at right temple where skin ca excised, some
crusting and erythema at superior area; well healed TKR, right
LE medial vein harvest incision
Lungs CTAB
Heart Irreg Systolic murmur
Extrem cool, no edema
Slight right facial droop, MAE

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Lives with wife in [**Name (NI) **].
Tobacco: 2PPD X 52yrs, quit 10yrs ago.
Alcohol: 2drinks/day
Congestive heart failure, unspecified,End stage renal disease,Acute vascular insufficiency of intestine,Pneumonitis due to inhalation of food or vomitus,Pneumonia due to Pseudomonas,Acute and chronic cholecystitis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Acidosis,Urinary tract infection, site not specified,Intestinal infection due to Clostridium difficile,Disruption of external operation (surgical) wound,Coronary atherosclerosis of native coronary artery,Mitral valve disorders,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic airway obstruction, not elsewhere classified,Laparoscopic surgical procedure converted to open procedure,Thrombocytopenia, unspecified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
CHF NOS,End stage renal disease,Ac vasc insuff intestine,Food/vomit pneumonitis,Pseudomonal pneumonia,Acte & chr cholecystitis,Hyp kid NOS w cr kid V,Acidosis,Urin tract infection NOS,Int inf clstrdium dfcile,Disrup-external op wound,Crnry athrscl natve vssl,Mitral valve disorder,Atrial fibrillation,DMII wo cmp nt st uncntr,Chr airway obstruct NEC,Lap surg convert to open,Thrombocytopenia NOS,Abn react-procedure NEC
Admission Date:  [**2134-5-10**]              Discharge Date:   [**2134-6-11**]

Date of Birth:  [**2057-9-22**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
SOB

Major Surgical or Invasive Procedure:
[**5-12**] CABGx3 (LIMA->Ramus, SVG->LAD, SVG->RCA)/MVR(#27mm [**First Name8 (NamePattern2) **] [**First Name5 (NamePattern1) 923**]
[**Last Name (NamePattern1) 9041**] Valve)


History of Present Illness:
76 yo M transferred from [**Hospital3 417**] on [**5-10**] after cardiac
catheterization showed 3 vessel disease.

Past Medical History:
HTN
NIDDM
Hypercholesterolemia
R rotator cuff injury s/p surgical repair
R knee surgery
R CEA
h/o polyps, nonmalignant
COPD (last PFTs this year, but unk results)
Atrial Fibrillation (on warfarin)
CVA w/ residual facial weakness 1/05
R CEA [**1-16**]
PVD s/p R Fem-[**Doctor Last Name **] bypass
R knee surgery
Last colonoscopy ?5 yrs ago, (+) polyps
BPH

Social History:
Lives with wife in [**Name (NI) **].
Tobacco: 2PPD X 52yrs, quit 10yrs ago.
Alcohol: 2drinks/day


Family History:
Noncontributory

Physical Exam:
Admission
HR 81 RR 18 BP 119/81
NAD, flat after cath. Sob with talking.
Skin 3 areas at right temple where skin ca excised, some
crusting and erythema at superior area; well healed TKR, right
LE medial vein harvest incision
Lungs CTAB
Heart Irreg Systolic murmur
Extrem cool, no edema
Slight right facial droop, MAE

Discharge
VS T 98.4  HR 85 SR  BP 115/52  RR 24  O2sat 100% on 50% trach
collar
Gen NAD
Neuro Alert, interactive. Follows commands, moves all
extremities
Pulm course rhonchi
CV RRR, no murmur. sternum stable incision-CDI
Abdm soft, NT midline incision w/VAC-clean margins. Colostomy
stoma-clean-healthy. G-J tube site-CDI
Ext warm, no edema


Pertinent Results:
[**2134-5-10**] 03:50PM   GLUCOSE-161* UREA N-44* CREAT-2.9* SODIUM-139
POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-25 ANION GAP-17
[**2134-5-10**] 03:50PM   ALT(SGPT)-12 AST(SGOT)-15 ALK PHOS-124* TOT
BILI-0.6
[**2134-5-10**] 03:50PM   %HbA1c-6.5*
[**2134-5-10**] 03:50PM   WBC-6.8 RBC-4.44*# HGB-13.0*# HCT-39.6*#
MCV-89 MCH-29.3 MCHC-32.9 RDW-19.4*
[**2134-5-10**] 03:50PM   PLT COUNT-255
[**2134-5-10**] 03:50PM   PT-15.3* PTT-28.1 INR(PT)-1.4*
[**2134-5-10**] 01:32PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.026
[**2134-5-10**] 01:32PM URINE  BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-1 PH-7.0 LEUK-MOD
[**2134-5-10**] 01:32PM URINE  RBC-[**3-17**]* WBC->50 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2134-6-11**] 02:32AM BLOOD WBC-9.9 RBC-2.93* Hgb-8.9* Hct-30.2*
MCV-103* MCH-30.3 MCHC-29.4* RDW-20.1* Plt Ct-370
[**2134-6-11**] 02:32AM BLOOD Plt Ct-370
[**2134-6-11**] 02:32AM BLOOD PT-16.9* PTT-80.9* INR(PT)-1.5*
[**2134-6-11**] 02:32AM BLOOD Glucose-196* UreaN-55* Creat-2.6* Na-146*
K-3.8 Cl-113* HCO3-25 AnGap-12
[**2134-6-10**] 03:16AM BLOOD ALT-27 AST-37 LD(LDH)-299* AlkPhos-146*
Amylase-70 TotBili-0.9
[**2134-6-11**] 02:32AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.9

[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Last Name (LF) **], [**Known firstname **]       [**Hospital1 18**] [**Numeric Identifier 69045**]TTE (Focused
views) Done [**2134-5-20**] at 4:48:29 AM      FINAL
Referring Physician     [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 1112**] W.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**]  Status: Inpatient DOB: [**2057-9-22**]
Age (years): 76 M  Hgt (in): 66
BP (mm Hg): 106/52  Wgt (lb): 140
HR (bpm): 110  BSA (m2): 1.72 m2
Indication: Left ventricular function.
ICD-9 Codes: 427.31, 424.0
Test Information
Date/Time: [**2134-5-20**] at 04:48    Interpret MD: [**Name6 (MD) **] [**Name8 (MD) **], MD
Test Type: TTE (Focused views) Son[**Name (NI) 930**]: Cardiology Fellow
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Adequate
Tape #: 2008W000-0:00 Machine: Vivid [**7-18**]
Echocardiographic Measurements
Results  Measurements  Normal Range
Left Atrium - Long Axis Dimension:  *5.4 cm  <= 4.0 cm
Left Atrium - Four Chamber Length:  4.0 cm  <= 5.2 cm
Right Atrium - Four Chamber Length:  4.1 cm  <= 5.0 cm
Left Ventricle - Septal Wall Thickness:  *1.3 cm  0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness:  *1.2 cm  0.6 - 1.1 cm

Left Ventricle - Ejection Fraction:  35%  >= 55%
Tricuspid Valve - Peak Velocity:  1.4 m/sec
Findings
This study was compared to the prior study of [**2134-5-10**].
LEFT ATRIUM: Marked LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Moderate regional LV systolic dysfunction. False
LV tendon (normal variant). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size. Mild global RV free
wall hypokinesis. Paradoxic septal motion consistent with prior
cardiac surgery.
AORTA: Focal calcifications in aortic root.
AORTIC VALVE: ?# aortic valve leaflets. Mildly thickened aortic
valve leaflets. No AR.
MITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR).
Cannot assess MVR. No MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Significant PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Resting tachycardia (HR>100bpm). The rhythm
appears to be atrial fibrillation. Emergency study performed by
the cardiology fellow on call.
REGIONAL LEFT VENTRICULAR WALL MOTION:
Conclusions
The left atrium is markedly dilated. There is moderate regional
left ventricular systolic dysfunction with anteroseptal,
anterior and anterolateral wall hypokinesis. Right ventricular
chamber size is normal with mild global free wall hypokinesis.
The number of aortic valve leaflets cannot be determined. The
aortic valve leaflets are mildly thickened. No aortic
regurgitation is seen. A bioprosthetic mitral valve prosthesis
is present. The prosthesis cannot be adequately assessed. No
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. Significant pulmonic regurgitation
is seen. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2134-5-10**],
the focal wall motion abnormality now includes the anterolateral
wall and the mitral bioprothesis is new.

   RADIOLOGY  Final Report
CHEST (PORTABLE AP)  [**2134-6-10**] 10:44 AM
CHEST (PORTABLE AP)
Reason: assess for infiltrates
[**Hospital 93**] MEDICAL CONDITION:
76 year old man s/p avr/cabg explor lap
REASON FOR THIS EXAMINATION:
assess for infiltrates
HISTORY: Status post cardiac surgery.
FINDINGS: In comparison with study of [**6-7**], the pulmonary
vessels are somewhat less distinct, raising the possibility of
increasing pulmonary venous pressure. Blunting of the
costophrenic angles are again consistent with pleural fluid. The
hemidiaphragms again are not well seen, consistent with some
atelectatic changes at the bases. The central catheter and
tracheostomy tube remain in place.
IMPRESSION: Little change except possibly for some increasing
vascular congestion.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]

[**2134-6-8**] 9:14 am SPUTUM
                            **FINAL REPORT [**2134-6-10**]**
   GRAM STAIN (Final [**2134-6-8**]):
      >25 PMNs and <10 epithelial cells/100X field.
      3+  (5-10 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.
   RESPIRATORY CULTURE (Final [**2134-6-10**]):
      OROPHARYNGEAL FLORA ABSENT.
      STAPH AUREUS COAG +.    MODERATE GROWTH.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations
Rifampin
         should not be used alone for therapy.
      ESCHERICHIA COLI.    SPARSE GROWTH.  OF TWO COLONIAL
MORPHOLOGIES.

                      SENSITIVITIES: MIC expressed in MCG/Mg

________________________________________________________
                             STAPH AUREUS COAG +
                             |          ESCHERICHIA COLI
                             |          |
AMPICILLIN------------             =>32 R
AMPICILLIN/SULBACTAM--               16 I
CEFAZOLIN-------------              <=4 S
CEFEPIME--------------              <=1 S
CEFTAZIDIME-----------              <=1 S
CEFTRIAXONE-----------              <=1 S
CEFUROXIME------------                4 S
CIPROFLOXACIN---------              =>4 R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S     =>16 R
LEVOFLOXACIN----------   =>8 R
MEROPENEM-------------           <=0.25 S
OXACILLIN-------------   =>4 R
PENICILLIN G---------- =>0.5 R
PIPERACILLIN/TAZO-----              <=4 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
TOBRAMYCIN------------                4 S
TRIMETHOPRIM/SULFA---- <=0.5 S     =>16 R
VANCOMYCIN------------   <=1 S

OPERATIVE REPORT
[**Last Name (LF) **],[**First Name3 (LF) **] R.
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) **] R on FRI [**2134-5-21**] 6:59
AM
Name:  [**Last Name (LF) **], [**Known firstname **] M            Unit No:  [**Numeric Identifier **]
Service:                          Date:  [**2134-5-20**]
Date of Birth:  [**2057-9-22**]        Sex:  M
Surgeon:  [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD 2919
PROCEDURE PERFORMED:  Exploratory laparotomy, intended right
colectomy with takedown of hepatic and splenic flexure,
cholecystectomy and gastrojejunostomy tube.
PREOPERATIVE DIAGNOSIS:  Mesenteric ischemia.
POSTOPERATIVE DIAGNOSIS:  Mesenteric ischemia.
ASSISTANT:  [**Doctor Last Name **] [**Doctor Last Name **].
ANESTHESIA:  General endotracheal.
INTRAOPERATIVE FLUIDS:  4 units of FFP, 1 unit of packed
cells.
ESTIMATED BLOOD LOSS:  200.
OPERATIVE FINDINGS:  Upon opening the abdomen using a
diagnostic laparoscopy, we identified normal small bowel and
gangrenous changes of the cecum with near perforation. Based
upon this, we converted to an open laparotomy.
DESCRIPTION OF PROCEDURE:  The patient was brought to the
operating room and placed on the operating table in the
supine position. After general endotracheal anesthesia was
obtained, an infraumbilical incision was made. We dissected
down to the subcutaneous tissues into the peritoneal cavity
using [**Last Name (un) 24631**] technique. Pneumoperitoneum was obtained. The 10
mm scope was placed in the peritoneum. We inspected the liver
and gallbladder. The liver looked unremarkable but the small
bowel that we were able to visualize was unremarkable. The
cecum had gangrenous changes. Based upon this, we converted
to open.

A midline laparotomy incision was made. We dissected through
subcutaneous tissues and then lengthened the opening in the
fascia to the xiphoid process all the way down to the pubic
symphysis. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 24412**] retractor was placed on the patient's
bed. Retractors were placed in the right upper, right lower
and left medial aspect of the incision. We took down the
right colon by dividing the white line of Toldt with
electrocautery. We extended this all the way up to the
hepatic flexure and took down the hepatic flexure. In doing
this, we were easily able to identify gangrenous changes in
the gallbladder as well. We divided the terminal ileum with [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 3224**] stapler and then began taking down the mesentery. We
divided the mesenteric vessels with [**Doctor Last Name 1356**] clamps and tied off
the tissue with 2-0 silk tie. As we traversed the hepatic
flexure and identified the transverse colon, we identified
multiple patchy areas in the transverse colon as well as in
the splenic flexure. The sigmoid colon and distal descending
colon were unremarkable. We took down the splenic flexure and
then divided the colon at the mid descending colon location.
The colon was divided with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3224**] stapler. We took the
mesentery down with 2-0 silk ties and divided the tissue.

The middle colic vessels were suture ligated with a 3-0 silk
stitch. We then turned our attention to the gallbladder. The
gallbladder was taken down in a retrograde fashion. We
incised the peritoneum over the gallbladder and took it down
off the gallbladder in a retrograde fashion. We identified
the cystic artery and duct which were individually ligated
and divided. The gallbladder was then removed. A small
circular incision just below the umbilicus over the rectus
sheath was made. We took a core of subcutaneous tissues down
to the fascia, made a cruciate incision in the fascia and
then pulled the distal ileum through the opening to create an
ileostomy.

We irrigated the abdomen with crystalloid solution. Once we
had satisfactory control of all bleeding and hemostasis was
adequate, we then identified the stomach and placed two 2-0
silk pursestring sutures in the fundus of the stomach. A
small gastrotomy was made. A GJ tube was then advanced
through the anterior abdominal wall, positioned in the
stomach. The jejunal portion of the tube was then advanced
through the pylorus into the fourth portion of the duodenum.
The pursestring sutures were tied down. The tube was everted.
The stomach was then tacked up to the anterior abdominal wall
and once this was done, the balloon was inflated and the
sutures were tied down. The disk was then left at
approximately 4 cm on the anterior abdominal wall. The disk
was secured in place with a series of interrupted 3-0 nylons
and a 0 silk suture. The G-tube was left open. The J-tube was
clamped. The fascia was closed with running #1 looped PDS.
The skin was closed with staples. The ileostomy was matured
in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] fashion using interrupted 3-0 silk sutures. An
ostomy appliance was affixed.
The patient was returned to the cardiovascular intensive care
unit in critical but stable condition.
                        [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:  [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD

OPERATIVE REPORT
[**Last Name (LF) **],[**First Name3 (LF) **] S.
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) **] on [**Doctor First Name **] [**2134-6-3**] 8:08 AM
Name:  [**Last Name (LF) **], [**Known firstname **] M            Unit No:  [**Numeric Identifier **]
Service:                          Date:  [**2134-5-28**]
Date of Birth:  [**2057-9-22**]        Sex:  M
Surgeon:  [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 25514**]
PREOPERATIVE DIAGNOSIS:  Respiratory failure.
POSTOPERATIVE DIAGNOSIS:  Respiratory failure.
PROCEDURE:
1. A surgical tracheostomy (Portex #7).
2. Therapeutic bronchoscopy.
ASSISTANT:  [**First Name8 (NamePattern2) 5321**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
ANESTHESIA:  General.
ESTIMATED BLOOD LOSS:  Minimal.
OPERATIVE INDICATIONS:  The patient is a gentleman who
underwent a sternotomy by the cardiac service. He developed
respiratory failure postoperatively and the thoracic service
was consulted for placement of a tracheostomy.
OPERATIVE REPORT IN DETAIL:  The patient was brought to the
operating room, placed supine on the operating table. After
patient identification and time-out, we performed a
therapeutic bronchoscopy through the endotracheal tube. The
purpose of this was to clean the trachea of the secretions
prior to tracheostomy insertion. There were some thick
secretions from the central airways that were suctioned free.

We then gently hyperextended the neck and prepped and draped
the anterior neck and chest in the usual sterile fashion. We
made a 3-cm collar incision one fingerbreadth above the
sternal notch. The platysma muscle was divided. The strap
muscles were retracted laterally and the thyroid isthmus
divided. The cricoid cartilage was identified and elevated
with a hook.

We made a  transverse tracheotomy incision between the second
and third tracheal ring. The #7 Portex tracheostomy was
inserted without resistance into the tracheal lumen. There
was good return of CO2 and the patient's O2 saturation
remained above 90% during this portion of the procedure.
We then performed confirmatory bronchoscopy that identified
the appropriate position of the tracheostomy.
The tracheostomy was then sewn to the skin using 2-0 PDS. The
tracheostomy tape was also applied.
                        [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(2) 32450**]
Dictated By:  [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.


Brief Hospital Course:
He was admitted to cardiac surgery. He was seen by renal to
continue on dialysis. He was seen by dermatology and started on
bactroban for his facial lesion. He was started on bactrim for a
UTI.
On [**5-12**] he was taken to the operating room where he underwent a
CABG x 3 and Mitral valve replacement. He was extubated later
that same day. He was confused and was started on haldol. A
dobhoff tube was placed as he was high risk for aspiration  as
he could not manage his secretions. He remained in the ICU for
pulmonary toilet.
He was started on amiodarone and then digoxin and heparin and
seen by electrophysiology for atrial fibrillation. Bedside
swallow evaluation showed aspiration and he remained NPO.
Dobhoff tubes were placed but he continued to pull them out.
Sputum culture grew GNR/GPC and he was started on zosyn and
vanco. On [**5-19**] he was found to be in respiratory distress, as
well as bradycardic and hypotensive and he was reintubated.
Bronchoscopy after intubation showed large amounts of
secretions. He was started on dopamine. He was cardioverted
successfully for atrial fibrillation with hypotension. His
dopamine was dc'd, and he was started on levophed. He continued
to be acidotic and underwent abdominal CT scan which showed
ischemic bowel. He was taken to the operating room on [**5-20**] where
he underwent a Exploratory laparotomy, intended right colectomy
with takedown of hepatic and splenic flexure, cholecystectomy
and gastrojejunostomy tube.  He was started on TPN. He continued
on CVVH. HIT antibody and SRA sent for thrombocytopenia were
negative. His ostomy began functioning and He was started on
tube feeds through his GJ tube on [**5-26**]. He underwent tacheostomy
on [**5-28**]. He was started on fluconazole for yeast in urine and
sputum. Zosyn was changed to ceftazidime. He was positive for
cdiff and was started on flagyl and PO vanco. His ventilatory
support was slowly weaned. The superior aspect of his abdominal
wound opened and a VAC dressing was placed by the general
surgery team. He was weaned from his pressors and ventilator
over the next several days.  On POD 30/22/14 he was started on
Ceftriaxone and Vanco for VAP/tracheobronchitis.
He was ready for discharge to rehab on [**6-11**]

Medications on Admission:
coumadin 2.5', nephrocaps, terazosin 2', prilosec 20', lopressor
25", lantus 10', mirtazipine 7.5', zocor 40', dig 0.125 [**Last Name (LF) **], [**First Name3 (LF) **]
81', imdur 60', megace"

Discharge Medications:
1. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. Famotidine 20 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q24H (every 24 hours).
7. Warfarin 1 mg Tablet Sig: adjust dose to INR Tablet PO DAILY
(Daily) as needed for afib: Target INR 2-2.5
last dose 5/26-1mg.
8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl
Topical QID (4 times a day) as needed for nose.
11. Fluconazole 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 2 days.
12. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg
Intravenous HD PROTOCOL (HD Protochol) for 7 days.
13. Ceftriaxone 1 gram Recon Soln Sig: One (1) gm Intravenous
Q24H (every 24 hours) for 7 days.
14. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: as directed
below ML Intravenous PRN (as needed) as needed for line flush:
Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Mid-line, heparin dependent: Flush with 10 mL Normal Saline
followed by Heparin as above, daily and PRN per lumen.
Order was filled by pharmacy with a dosage form of Syringe and a
strength of 10 UNIT/ML .
15. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 10
days.
16. Lantus 100 unit/mL Solution Sig: Ten (10) units Subcutaneous
once a day.
17. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale  Injection Q AC&HS.
18. Maalox/Diphenhydramine/Lidocaine   Sig: Five (5) cc  every
six (6) hours as needed.
19. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-13**]
Drops Ophthalmic PRN (as needed).
20. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**6-20**]
Puffs Inhalation Q4H (every 4 hours) as needed for when on vent.



Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
CAD, MR now s/p CABG, MVR
perforated gall bladder, mesenteric ischemia s/p Exploratory
laparotomy, extended right colectomy with takedown of hepatic
and splenic flexure, cholecystectomy and gastrojejunostomy tube
post op respiratory failure s/p tracheostomy

PMH CRF on HD, PVD s/p fem [**Doctor Last Name **] and rt iliac stents, Afib, CVA w/
facial residual, DM, Subdural hematoma from fall, pulm HTN,
Retinal embolus, Carotid disease s/p rt CEA, HTN, lipids, bilat
cataracts, urosepsis, COPD, Chronic bronchitis, diverticulosis,
squamous cell CA, basal cell CA, colon polyp, gout


Discharge Condition:
Stable.


Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds in 10 weeks.
No driving until follow up with surgeon.

Followup Instructions:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20561**] [**2-14**] wks after discharge from rehab
[**Telephone/Fax (1) 26190**]
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] 2 wks after discharge from rehab [**Telephone/Fax (1) 170**]
Dr. [**First Name (STitle) **] [**Name (STitle) **] [**2-14**] wks after discharge from rehab
Pt has numerous actinic keratoses (precancerous lesions) which
will need to be treated as an outpatient. He agrees to follow up
with his new primary dermatologist as scheduled in [**Month (only) **].

Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]  (General Surgery Clinic) in [**2-14**] weeks.
Patient to call for all appointments



Completed by:[**2134-6-11**]
{'Congestive heart failure, unspecified,End stage renal disease,Acute vascular insufficiency of intestine,Pneumonitis due to inhalation of food or vomitus,Pneumonia due to Pseudomonas,Acute and chronic cholecystitis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Acidosis,Urinary tract infection, site not specified,Intestinal infection due to Clostridium difficile,Disruption of external operation (surgical) wound,Coronary atherosclerosis of native coronary artery,Mitral valve disorders,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic airway obstruction, not elsewhere classified,Laparoscopic surgical procedure converted to open procedure,Thrombocytopenia, unspecified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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: SOB

PRESENT ILLNESS: 76 yo M transferred from [**Hospital3 417**] on [**5-10**] after cardiac
catheterization showed 3 vessel disease.

MEDICAL HISTORY: HTN
NIDDM
Hypercholesterolemia
R rotator cuff injury s/p surgical repair
R knee surgery
R CEA
h/o polyps, nonmalignant
COPD (last PFTs this year, but unk results)
Atrial Fibrillation (on warfarin)
CVA w/ residual facial weakness 1/05
R CEA [**1-16**]
PVD s/p R Fem-[**Doctor Last Name **] bypass
R knee surgery
Last colonoscopy ?5 yrs ago, (+) polyps
BPH

MEDICATION ON ADMISSION: coumadin 2.5', nephrocaps, terazosin 2', prilosec 20', lopressor
25", lantus 10', mirtazipine 7.5', zocor 40', dig 0.125 [**Last Name (LF) **], [**First Name3 (LF) **]
81', imdur 60', megace"

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission
HR 81 RR 18 BP 119/81
NAD, flat after cath. Sob with talking.
Skin 3 areas at right temple where skin ca excised, some
crusting and erythema at superior area; well healed TKR, right
LE medial vein harvest incision
Lungs CTAB
Heart Irreg Systolic murmur
Extrem cool, no edema
Slight right facial droop, MAE

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Lives with wife in [**Name (NI) **].
Tobacco: 2PPD X 52yrs, quit 10yrs ago.
Alcohol: 2drinks/day 

### Response:
{'Congestive heart failure, unspecified,End stage renal disease,Acute vascular insufficiency of intestine,Pneumonitis due to inhalation of food or vomitus,Pneumonia due to Pseudomonas,Acute and chronic cholecystitis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Acidosis,Urinary tract infection, site not specified,Intestinal infection due to Clostridium difficile,Disruption of external operation (surgical) wound,Coronary atherosclerosis of native coronary artery,Mitral valve disorders,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic airway obstruction, not elsewhere classified,Laparoscopic surgical procedure converted to open procedure,Thrombocytopenia, unspecified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
