CHIEF COMPLAINT: aspiration PNA, copious secretions

PRESENT ILLNESS: 65 M with HepC/EtOH cirrhosis, HCC s/p orthotopic liver
transplant [**2157**], DM2, CAD, tracheostomy [**1-9**] prolonged intubation
s/p transplant, prior episode heart block c no pacemaker, [**Hospital **]
transferred from OSH for ongoing management of aspiration
pneumonia, ARF/CRI, and ongoing suctioning requirement.
.
Per OSH d/c summary, pt admitted to OSH [**8-12**] after being found in
his nursing home "unresponsive." At OSH ED he was briefly
intubated via trach, found to have a signficant amount of mucus
plugging which was recovered with trach suctioning, after which
pt rapidly improved. He was hemodynamically stable, sats 88-90%
(unclear on what), and improved with suctioning and nebs to
96-99%3L NC. He was called out to the medical floor.
.
On [**8-17**] pt noted to have increased secretions, increased RR
requiring frequent suction, ?aspiration. Sputum cx, BCx, UA
negative. creatinine 1.9, pt noted to have fever 100.2, RR 24,
sats 98%5L NC. CXR with ?infiltrate, started on levaquin/flagyl
x 7d course. S&S revealed worsening swallow, NGT placed. Pt seen
by renal for elevated BUN/Creatinine (up to 2.0), report of
elevated K (6.5), and treated with IVF x 1L and 1U PRBC, d/c'd
lasix, as was felt to be pre-renal etiology.
.
Of note, at OSH, also noted to have R elbow pain and found to
have joint effusion over R elbow. Evaluated by ortho and found
to hvae non-displaced right radial head fracture, R arm placed
in a sling. Effusion not drained. Treated symptomatically with
vicodin/oxycodone.
.
Decision was made to transfer pt to [**Hospital1 18**] hepatorenal service
given his h/o liver transplant here. Prior to transfer, pt
decline PEG tube placement for feeding.

MEDICAL HISTORY: 1. Liver transplant for Hepatitis C/EtOH cirrhosis &
hepatocellular carcinoma, on tacrolimus, mycophenolate,
prednisone, bactrim followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**].
2. Tracheostomy: x2, [**8-11**] for chronic vent dependency,
subglottic stenosis, tracheomalacia. Known to the IP service;
tracheal dilation [**12-13**]. VATS [**2-10**] c organizing pneumonia [**1-9**]
Rapamune.
3. DM2
4. OSA / Pickwickian syndrome
5. COPD
6. Diastolic dysfunction
7. CKD
8. Bipolar d/o
9. HTN
10. H/o VRE, MRSA, C. diff, and resistant Pseudomonas infections
11. Hiatal hernia
12. Pulmonary hypertension
13. Hx of heart block - unable to have PM placed [**1-9**] infection,
heart block resolved, avoiding nodal blockers

MEDICATION ON ADMISSION: MEDICATIONS ON TRANSFER:
insulin sliding scale
glucerna TF
heparin SC tid
norvasc 5mg po qdaily
clonazepam 0.5mg po qdaily
levofloxcin 500mg po qdaily
flagyl 500mg daily
procrit 8000 units QMWF
prevacid 30mg po qam
nortriptyline 75mg po qdaily
colace 100mg po bid
senna [**Hospital1 **]
zyprexa 15mg po qpm
trazodone 25mg po qpm
clonazepam 1mg po daily (?in addition to qhs)
prograft 1mg po qam, 2mg po qpm
cellcept 500mg po bid
mvi
vitamin b 1000mcg daily
vitamin d 400 IU daily
zinc sulfate 220 mg po qdaily
mucomyst [**Hospital1 **] (unclear duration of treatment)
dulcolax prn
mom prn
[**Name2 (NI) 48520**] carbonate 500mg qid
oxycodone 5mg po q6hr prn
scoplamine patches

ALLERGIES: Penicillins / Nsaids / Rapamune

PHYSICAL EXAM: VS: 100.1 96 161/71 18 100% on 35% TM.
GEN: NAD, tracheostomy tube in place, minimal drainage.
HEENT: PERRLA, EOMI, sclera anicteric, OP clear, MM dry, no LAD,
no carotid bruits. No JVD.
CV: regular, nl s1, s2, no r/g. soft 2/6 SEM at LSB
?nonradiating
PULM: CTA anteriorly, no r/r/w.
ABD: scaphoid, soft, NT, ND, + BS, no HSM.
EXT: warm, 2+ dp/radial pulses BL. no LE edema.
NEURO: alert & oriented x 3, CN II-XII grossly intact.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Quit tobacco 8 years ago. Quit alcohol 17 years prior to
admission. Denies any recreational drugs.
Pneumonitis due to inhalation of food or vomitus,Chronic hepatitis C without mention of hepatic coma,Alcoholic cirrhosis of liver,Acute kidney failure, unspecified,Chronic kidney disease, unspecified,Liver replaced by transplant,Chronic airway obstruction, not elsewhere classified,Chronic diastolic heart failure,Pneumonia, organism unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Cardiac pacemaker in situ,Anemia, unspecified,Coronary atherosclerosis of native coronary artery,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Tracheostomy status,Effusion of joint, upper arm,Closed fracture of head of radius,Unspecified accident
Food/vomit pneumonitis,Chrnc hpt C wo hpat coma,Alcohol cirrhosis liver,Acute kidney failure NOS,Chronic kidney dis NOS,Liver transplant status,Chr airway obstruct NEC,Chr diastolic hrt fail,Pneumonia, organism NOS,Hy kid NOS w cr kid I-IV,Status cardiac pacemaker,Anemia NOS,Crnry athrscl natve vssl,DMII wo cmp nt st uncntr,Tracheostomy status,Joint effusion-up/arm,Fx radius head-closed,Accident NOS
Name:  [**Known lastname 8954**],[**Known firstname 2381**]                   Unit No:   [**Numeric Identifier 8955**]

Admission Date:  [**2161-8-23**]              Discharge Date:   [**2161-9-2**]

Date of Birth:  [**2096-4-23**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Nsaids / Rapamune

Attending:[**First Name3 (LF) 8956**]
Addendum:
Please check tacrolimus troughs every other day over the next
week to adjust levels.  Please also check potassium levels
daily.  His values should be faxed over to Dr [**Last Name (STitle) 8957**] office for
adjustment of his tacrolimus doses.

He had a speech and swallow on the day of discharge and was
found to be at a large risk of aspiration risk.  The patient has
continually refused PEG placement and continues to want to eat;
but we recommend strict NPO at this time.  PEG placement will
need to be re-addressed with the patient.


Discharge Disposition:
Extended Care

Facility:
[**Location (un) 5155**] - [**Location (un) **]

                             [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 8958**] MD [**MD Number(1) 8825**]

Completed by:[**2161-9-2**]

Admission Date:  [**2161-8-23**]              Discharge Date:   [**2161-9-2**]

Date of Birth:  [**2096-4-23**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Nsaids / Rapamune

Attending:[**First Name3 (LF) 330**]
Chief Complaint:
aspiration PNA, copious secretions

Major Surgical or Invasive Procedure:
none


History of Present Illness:
65 M with HepC/EtOH cirrhosis, HCC s/p orthotopic liver
transplant [**2157**], DM2, CAD, tracheostomy [**1-9**] prolonged intubation
s/p transplant, prior episode heart block c no pacemaker, [**Hospital **]
transferred from OSH for ongoing management of aspiration
pneumonia, ARF/CRI, and ongoing suctioning requirement.
.
Per OSH d/c summary, pt admitted to OSH [**8-12**] after being found in
his nursing home "unresponsive." At OSH ED he was briefly
intubated via trach, found to have a signficant amount of mucus
plugging which was recovered with trach suctioning, after which
pt rapidly improved. He was hemodynamically stable, sats 88-90%
(unclear on what), and improved with suctioning and nebs to
96-99%3L NC. He was called out to the medical floor.
.
On [**8-17**] pt noted to have increased secretions, increased RR
requiring frequent suction, ?aspiration. Sputum cx, BCx, UA
negative. creatinine 1.9, pt noted to have fever 100.2, RR 24,
sats 98%5L NC. CXR with ?infiltrate, started on levaquin/flagyl
x 7d course. S&S revealed worsening swallow, NGT placed. Pt seen
by renal for elevated BUN/Creatinine (up to 2.0), report of
elevated K (6.5), and treated with IVF x 1L and 1U PRBC, d/c'd
lasix, as was felt to be pre-renal etiology.
.
Of note, at OSH, also noted to have R elbow pain and found to
have joint effusion over R elbow. Evaluated by ortho and found
to hvae non-displaced right radial head fracture, R arm placed
in a sling. Effusion not drained. Treated symptomatically with
vicodin/oxycodone.
.
Decision was made to transfer pt to [**Hospital1 18**] hepatorenal service
given his h/o liver transplant here. Prior to transfer, pt
decline PEG tube placement for feeding.

Past Medical History:
1. Liver transplant for Hepatitis C/EtOH cirrhosis &
hepatocellular carcinoma, on tacrolimus, mycophenolate,
prednisone, bactrim followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**].
2. Tracheostomy: x2, [**8-11**] for chronic vent dependency,
subglottic stenosis, tracheomalacia. Known to the IP service;
tracheal dilation [**12-13**]. VATS [**2-10**] c organizing pneumonia [**1-9**]
Rapamune.
3. DM2
4. OSA / Pickwickian syndrome
5. COPD
6. Diastolic dysfunction
7. CKD
8. Bipolar d/o
9. HTN
10. H/o VRE, MRSA, C. diff, and resistant Pseudomonas infections
11. Hiatal hernia
12. Pulmonary hypertension
13. Hx of heart block - unable to have PM placed [**1-9**] infection,
heart block resolved, avoiding nodal blockers

Social History:
Quit tobacco 8 years ago. Quit alcohol 17 years prior to
admission. Denies any recreational drugs.


Family History:
Non-contributory

Physical Exam:
VS: 100.1 96 161/71 18 100% on 35% TM.
GEN: NAD, tracheostomy tube in place, minimal drainage.
HEENT: PERRLA, EOMI, sclera anicteric, OP clear, MM dry, no LAD,
no carotid bruits. No JVD.
CV: regular, nl s1, s2, no r/g. soft 2/6 SEM at LSB
?nonradiating
PULM: CTA anteriorly, no r/r/w.
ABD: scaphoid, soft, NT, ND, + BS, no HSM.
EXT: warm, 2+ dp/radial pulses BL. no LE edema.
NEURO: alert & oriented x 3, CN II-XII grossly intact.

Pertinent Results:
[**2161-8-23**] k=5.4, creat 1.5, bun 17, na 140.
[**2161-8-17**] BCx ngtd.
[**2161-8-17**] BCx ngtd.
[**2161-8-18**] Sputum - gs - gpc in clusters, rare gn bacilli, gp
bacilli.
[**8-15**] BUN/cre 25/2.0
[**2161-8-15**] hct 30.5
[**2161-8-15**] wbc 11.2
[**2161-8-12**] BCx - ngtd.
.
.
STUDIES:
[**2161-8-23**] CXR: no acute pulmonary process.
.
[**2161-8-18**] R ELBOW XRAY: joint effusion about elbow, suggestive of
ocult radial head fracture, although no definitive fracture line
is seen.
.
[**2161-8-17**] CXR (OSH): ngt in place.
.
Labs:
[**2161-8-27**] 03:44AM BLOOD WBC-6.5 RBC-3.39* Hgb-9.7* Hct-29.7*
MCV-87 MCH-28.4 MCHC-32.5 RDW-16.0* Plt Ct-174
[**2161-8-26**] 06:40AM BLOOD Neuts-83.6* Lymphs-9.8* Monos-4.0 Eos-2.5
Baso-0.1
[**2161-8-27**] 03:44AM BLOOD Plt Ct-174
[**2161-8-27**] 03:44AM BLOOD PT-12.3 PTT-32.2 INR(PT)-1.1
[**2161-8-27**] 03:44AM BLOOD Glucose-123* UreaN-21* Creat-1.4* Na-141
K-4.8 Cl-102 HCO3-37* AnGap-7*
[**2161-8-26**] 06:40AM BLOOD ALT-11 AST-15 LD(LDH)-124 AlkPhos-132*
TotBili-0.3
[**2161-8-27**] 03:44AM BLOOD Calcium-8.3* Phos-3.0 Mg-1.7
[**2161-8-27**] 03:44AM BLOOD Vanco-43.2*
[**2161-8-27**] 03:44AM BLOOD FK506-5.9
[**2161-8-24**] 07:39AM BLOOD Type-ART pO2-112* pCO2-66* pH-7.34*
calTCO2-37* Base XS-7

Brief Hospital Course:
65 M c Hep C/EtOH cirrhosis complicated by HCC s/p liver
transplant complicated by prolonged ventilation now tracheostomy
dependent, transferred from OSH after being found unresponsive
[**1-9**] mucus plugging, hospital course complicatd by PNA and [**Hospital **]
transferred to [**Hospital1 18**] with ongoing suctioning requirement.
.
# respiratory distress - pt with h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] induced BOOP,
initially transferred to OSH [**1-9**] being found unresponsive,
however apparently due to mucus plugging, and resolved quickly
after suction.  pt was briefly intubated at OSH via
tracheostomy, but quickly weaned. However pt then developed PNA
(?aspiration event), and is now s/p 7d course of levo/flagyl,
with slightly improving secretions.
.
CXR on admission to [**Hospital1 18**] demonstrated no obvious infiltrate.
ABG obtained showed increasing CO2 (66, and worsening
respiratory acidosis).  Given ongoing secretions and worsening
acidosis and patient's history of multiple drug resistent
organisms in sputum, decision made to start pt on 10d course of
meropenem and vancomycin for ongoing PNA vs tracheobronchitis
(day 1 [**8-24**]).  Pt's suctioning requirements gradually decreased
on meropenem and vancomycin, to q8h, and he was treated with
aggressive pulmonary toilet. On [**2161-9-1**], patient was noted to
have aspirated a significant portion of his lunchtime meal;
although he maintained his O2 sats. Video speech and swallow was
performed on [**2161-9-2**] and the results are still pending. The
results of the video speech and swallow and nutrition
recommendations will be faxed when ready.
.
# cirrhosis - pt with h/o hepC/etoh cirrhosis, s/p liver
transplant, on prograf, and cellcept, h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] induced BOOP.
LFTs wnl at OSH,  AP midly elevated here 140. on [**8-14**] AST/ALT
18/18, tbil 0.7.  tacro levels obtained here were initially low
(2.1), and prograf level was increased from 1 QAM and 2QPM to
2mg po BID.  However due to again rising prograf levels, the
dose was decreased again to 1.5mg PO bid. Pt was discussed with
the liver service, and felt stable for discharge.   He will need
to have daily prograf levels drawn, with levels faxed to his
hepatologist (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**], ([**Telephone/Fax (1) 1582**], fax=([**Telephone/Fax (1) 48518**]), so that these can be adjusted (pt has a history of
mild rejection).
.
# ARF/CRI - baseline creatinine unclear (was 1.6-1.7 per OSH
consult report). cre= 2.2 at time of admission to OSH, trended
down to 1.9, then up to 2.0, felt [**1-9**] dehydration, and pt's home
lasix regimen d/c'd, in favor of rehydration with 125 ml/hr
D5NS.  At time of admission, pt's creatinine 1.5, where it
remained during hospitalization, this was felt to represent his
baseline.
.
.
# elbow effusion - right radial head fracture of R UE,
nondisplaced, seen by orthopedics at OSH who recommended a
sling, no other intervention.  Repeat films here showed no
fracture, and pt denied elbow pain.
.
.
# anemia - baseline hct ~27-30 over past 6 months, though normal
in [**12-14**].  guaiac negative stools, this admission.  likely with
component of ACD.  His HCT remained stable during this
admission.
.
.
# Leukocytosis - initially presented with WBC 11.8, felt likely
[**1-9**] resolving PNA, though ongoing pulmonary secretions.  BCx,
UCx unremarkable.  Pt was treated for ongoing PNA as above with
meropenem/vancomycin based on previous sensitivities.  WBC count
resolved to 6.5 at time of discharge.
.
.
# cardiac - no known h/o cad, though h/o ?heart block.
## ischemia: no complaints of cp.
.
## rhythm: h/o ? intermittent heart block when placed on
beta-blockade in past, remained in NSR on telemetry this
admission.
.
## pump: euvolemic on exam, no need for lasix presently, had
been discontinued at OSH.
.
## htn: pt hypertensive throughout this admission, his dose of
norvasc was increased from 5mg po qdaily to 10mg po qdaily, and
hydralazine was added.  Plan was to avoid beta blockade and CCB
given h/o "heart block."  Given recent renal failure, plan was
to avoid ACE/[**Last Name (un) **], though these would be reasonable agents in
future once creatinine is stable at baseline.  He continued to
have elevated blood pressure and clonidine 0.1mg [**Hospital1 **] was added.
.
.
#DM: pt switched from RISS to HISS, his blood sugars were well
controlled (100-150s).
.
# psych - pt on nortryptiline, trazadone, clonazepam qhs at
home, which were continued here.
.
.
#FEN: pt was initially fed via NGT.  Per discharge summary, he
refused PEG at OSH after failing a speech and swallow
evaluation.  He was seen by speech and swallow service here and
felt safe to advance to regular diet, with thin liquids, with
aspiration precautions.   He was advanced to this diet and
tolerated well initially. On [**2161-9-1**], patient was noted to have
aspirated and a video speech and swallow was performed on
[**2161-9-2**]. The results of this study are pending and will be
faxed, along with nutrition recommendations.
.
#COMM: with patient and his niece [**Name (NI) **]: [**Telephone/Fax (3) 48519**]

Medications on Admission:
MEDICATIONS ON TRANSFER:
insulin sliding scale
glucerna TF
heparin SC tid
norvasc 5mg po qdaily
clonazepam 0.5mg po qdaily
levofloxcin 500mg po qdaily
flagyl 500mg daily
procrit 8000 units QMWF
prevacid 30mg po qam
nortriptyline 75mg po qdaily
colace 100mg po bid
senna [**Hospital1 **]
zyprexa 15mg po qpm
trazodone 25mg po qpm
clonazepam 1mg po daily (?in addition to qhs)
prograft 1mg po qam, 2mg po qpm
cellcept 500mg po bid
mvi
vitamin b 1000mcg daily
vitamin d 400 IU daily
zinc sulfate 220 mg po qdaily
mucomyst [**Hospital1 **] (unclear duration of treatment)
dulcolax prn
mom prn
[**Name2 (NI) 48520**] carbonate 500mg qid
oxycodone 5mg po q6hr prn
scoplamine patches

Discharge Medications:

1. Heparin (Porcine) 5,000 unit/mL Solution [**Name2 (NI) **]: One (1) inj
Injection TID (3 times a day).
2. Epoetin Alfa 4,000 unit/mL Solution [**Name2 (NI) **]: One (1) inj
Injection QMOWEFR (Monday -Wednesday-Friday).
3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
4. Nortriptyline 25 mg Capsule [**Last Name (STitle) **]: Three (3) Capsule PO DAILY
(Daily).
5. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) tab PO BID (2
times a day).
6. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed.
7. Olanzapine 7.5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO HS (at
bedtime) as needed.
8. Trazodone 50 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO HS (at bedtime) as
needed.
9. Mycophenolate Mofetil 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO
BID (2 times a day).
10. Hexavitamin     Tablet [**Last Name (STitle) **]: One (1) Cap PO DAILY (Daily).
11. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily).
12. Zinc Sulfate 220 (50) mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO
DAILY (Daily).
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
14. Calcium Carbonate 500 mg Tablet, Chewable [**Last Name (STitle) **]: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
15. Oxycodone 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6
hours) as needed.
16. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Last Name (STitle) **]: One (1)
neb Inhalation Q6H (every 6 hours) as needed.
17. Clonazepam 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QAM (once a
day (in the morning)).
18. Amlodipine 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily).

19. Clonidine 0.1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times
a day).
20. Vancomycin in Dextrose 1 g/200 mL Piggyback [**Last Name (STitle) **]: One (1)
Intravenous Q 12H (Every 12 Hours) for 7 days.
21. Meropenem 500 mg Recon Soln [**Last Name (STitle) **]: One (1) Recon Soln
Intravenous Q8H (every 8 hours) for 7 days.
22. Hydralazine 25 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO Q6H (every
6 hours).
23. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
24. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2)
Puff Inhalation QID PRN ().
25. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) neb
Inhalation Q6H (every 6 hours).
26. Artificial Tear with Lanolin 0.1-0.1 % Ointment [**Last Name (STitle) **]: One (1)
Appl Ophthalmic PRN (as needed).
27. Simethicone 80 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet,
Chewable PO QID (4 times a day).
28. Humalog 100 unit/mL Solution [**Last Name (STitle) **]: One (1)  Subcutaneous four
times a day: Please administer humalog sliding scale at
breakfast, lunch, dinner, and bedtime:
BS 0-60, administer 1 amp D50; FS 61-160, administer 0 units; FS
161-200, administer 2 units; FS 201-240, administer 3 units; FS
241-280, administer 4 units; FS 281-320, administer 5 units; FS
321-360, administer 6 units; FS 361-400, administer 7 units. .
29. Tacrolimus 0.5 mg Capsule [**Last Name (STitle) **]: Three (3) Capsule PO Q12H
(every 12 hours): 1.5mg PO bid. Please fax daily tacrolimus
levels to office of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] for further titration of
prograf dosage. .
30. Insulin Glargine 100 unit/mL Cartridge [**Last Name (NamePattern1) **]: Five (5) units
Subcutaneous at bedtime: Please administer 5 units lantus qhs
and then an additional sliding scale as needed. .


Discharge Disposition:
Extended Care

Facility:
[**Location (un) 29393**] - [**Location (un) 2251**]

Discharge Diagnosis:
primary:
pneumonia
.
secondary:
cirrhosis s/p liver transplant
acute renal failure
hypertension


Discharge Condition:
stable.


Discharge Instructions:
You were admitted with a pneumonia/tracheobronchitis and
increased secretions.  You were started on antibiotics to treat
this and suctionng requirement improved.


Followup Instructions:

please continue to have daily prograf levels drawn, and faxed to
your hepatologist (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**], ([**Telephone/Fax (1) 1582**], fax=([**Telephone/Fax (1) 48518**]), so that the dose can be adjusted accordingly (pt has
a history of mild rejection).

Continue antibiotics for pneumonia/bronchitis to complete a
course of 10.  Day 1 of [**Last Name (un) **]/Vanco on [**8-24**].

You also have the following appointments at [**Hospital1 771**]:
- Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2161-9-9**] 9:20
- Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2161-9-9**]
8:20
{'Pneumonitis due to inhalation of food or vomitus,Chronic hepatitis C without mention of hepatic coma,Alcoholic cirrhosis of liver,Acute kidney failure, unspecified,Chronic kidney disease, unspecified,Liver replaced by transplant,Chronic airway obstruction, not elsewhere classified,Chronic diastolic heart failure,Pneumonia, organism unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Cardiac pacemaker in situ,Anemia, unspecified,Coronary atherosclerosis of native coronary artery,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Tracheostomy status,Effusion of joint, upper arm,Closed fracture of head of radius,Unspecified accident'}


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: aspiration PNA, copious secretions

PRESENT ILLNESS: 65 M with HepC/EtOH cirrhosis, HCC s/p orthotopic liver
transplant [**2157**], DM2, CAD, tracheostomy [**1-9**] prolonged intubation
s/p transplant, prior episode heart block c no pacemaker, [**Hospital **]
transferred from OSH for ongoing management of aspiration
pneumonia, ARF/CRI, and ongoing suctioning requirement.
.
Per OSH d/c summary, pt admitted to OSH [**8-12**] after being found in
his nursing home "unresponsive." At OSH ED he was briefly
intubated via trach, found to have a signficant amount of mucus
plugging which was recovered with trach suctioning, after which
pt rapidly improved. He was hemodynamically stable, sats 88-90%
(unclear on what), and improved with suctioning and nebs to
96-99%3L NC. He was called out to the medical floor.
.
On [**8-17**] pt noted to have increased secretions, increased RR
requiring frequent suction, ?aspiration. Sputum cx, BCx, UA
negative. creatinine 1.9, pt noted to have fever 100.2, RR 24,
sats 98%5L NC. CXR with ?infiltrate, started on levaquin/flagyl
x 7d course. S&S revealed worsening swallow, NGT placed. Pt seen
by renal for elevated BUN/Creatinine (up to 2.0), report of
elevated K (6.5), and treated with IVF x 1L and 1U PRBC, d/c'd
lasix, as was felt to be pre-renal etiology.
.
Of note, at OSH, also noted to have R elbow pain and found to
have joint effusion over R elbow. Evaluated by ortho and found
to hvae non-displaced right radial head fracture, R arm placed
in a sling. Effusion not drained. Treated symptomatically with
vicodin/oxycodone.
.
Decision was made to transfer pt to [**Hospital1 18**] hepatorenal service
given his h/o liver transplant here. Prior to transfer, pt
decline PEG tube placement for feeding.

MEDICAL HISTORY: 1. Liver transplant for Hepatitis C/EtOH cirrhosis &
hepatocellular carcinoma, on tacrolimus, mycophenolate,
prednisone, bactrim followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**].
2. Tracheostomy: x2, [**8-11**] for chronic vent dependency,
subglottic stenosis, tracheomalacia. Known to the IP service;
tracheal dilation [**12-13**]. VATS [**2-10**] c organizing pneumonia [**1-9**]
Rapamune.
3. DM2
4. OSA / Pickwickian syndrome
5. COPD
6. Diastolic dysfunction
7. CKD
8. Bipolar d/o
9. HTN
10. H/o VRE, MRSA, C. diff, and resistant Pseudomonas infections
11. Hiatal hernia
12. Pulmonary hypertension
13. Hx of heart block - unable to have PM placed [**1-9**] infection,
heart block resolved, avoiding nodal blockers

MEDICATION ON ADMISSION: MEDICATIONS ON TRANSFER:
insulin sliding scale
glucerna TF
heparin SC tid
norvasc 5mg po qdaily
clonazepam 0.5mg po qdaily
levofloxcin 500mg po qdaily
flagyl 500mg daily
procrit 8000 units QMWF
prevacid 30mg po qam
nortriptyline 75mg po qdaily
colace 100mg po bid
senna [**Hospital1 **]
zyprexa 15mg po qpm
trazodone 25mg po qpm
clonazepam 1mg po daily (?in addition to qhs)
prograft 1mg po qam, 2mg po qpm
cellcept 500mg po bid
mvi
vitamin b 1000mcg daily
vitamin d 400 IU daily
zinc sulfate 220 mg po qdaily
mucomyst [**Hospital1 **] (unclear duration of treatment)
dulcolax prn
mom prn
[**Name2 (NI) 48520**] carbonate 500mg qid
oxycodone 5mg po q6hr prn
scoplamine patches

ALLERGIES: Penicillins / Nsaids / Rapamune

PHYSICAL EXAM: VS: 100.1 96 161/71 18 100% on 35% TM.
GEN: NAD, tracheostomy tube in place, minimal drainage.
HEENT: PERRLA, EOMI, sclera anicteric, OP clear, MM dry, no LAD,
no carotid bruits. No JVD.
CV: regular, nl s1, s2, no r/g. soft 2/6 SEM at LSB
?nonradiating
PULM: CTA anteriorly, no r/r/w.
ABD: scaphoid, soft, NT, ND, + BS, no HSM.
EXT: warm, 2+ dp/radial pulses BL. no LE edema.
NEURO: alert & oriented x 3, CN II-XII grossly intact.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Quit tobacco 8 years ago. Quit alcohol 17 years prior to
admission. Denies any recreational drugs. 

### Response:
{'Pneumonitis due to inhalation of food or vomitus,Chronic hepatitis C without mention of hepatic coma,Alcoholic cirrhosis of liver,Acute kidney failure, unspecified,Chronic kidney disease, unspecified,Liver replaced by transplant,Chronic airway obstruction, not elsewhere classified,Chronic diastolic heart failure,Pneumonia, organism unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Cardiac pacemaker in situ,Anemia, unspecified,Coronary atherosclerosis of native coronary artery,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Tracheostomy status,Effusion of joint, upper arm,Closed fracture of head of radius,Unspecified accident'}
