CHIEF COMPLAINT: somnolence, hypoxic resp failure

PRESENT ILLNESS: 46 y/o M w/ h/o morbid obesity, COPD, chronic trach dependence,
DMII, PVD, s/p L BKA, h/o Klebsiella/Proteus UTI, PNA, MRSA,
VRE, who presents with increasing somnolence and hypoxic
respiratory failure
.
Presented to [**Location (un) 620**] ER in respiratory distress, hypoxic to 40's
at home. T to 101.Trach noted to have copius secretions, which
were aggressively suctioned, given o2, nebs, antibiotics
(zosyn/vanco). Improved respiratory status, but still somnolent
and also noted to be hyperkalemic at 6.4. No EKG changes. Given
Insulin/D50, calcium IV. Kayexalate ordered (but not given PTA).
Also had positive troponin of 0.05 (nL <0.01). Acidotic at 7.16
w/ CO2 of 65. Therefore placed on VENT for transport to [**Hospital1 18**].
U/A at OSH pos for WBC >100, Bacteria, neg nitr, Lge leuk's. Hct
31.7, WBC 15.6, Plt 358, 84.5%N. Creat 2.6.
.
Also as patient was leaving, patient care technician who cares
for patient at home says he may have fallen the night PTA.
.
In ED here. Vitals on arrival T99.8, BP 119/51, RR 16, 99% on
Vent. Vanco infusing. BP's subsequently dropped to 80's syst->
then 69/34. Recieved 2L NS IVF PTA and given 1 more L NS in ED.
Started on dopa gtt at 5mcg/kg/min, titrated up to 10
mcg/kg/min. BP initially up to 100's systolic, then back down to
80's. Changed to levophed gtt. ASA 325mg given. Trach tube
changed to Portex 6.0, cuffed to Vent 600/100/16/5. BP
subsequently up to 150's systolic.
.
Vanco given at 1700. Zosyn 4.5 gm prior to arrival at 1415.
Also given 10 U Insulin, 1 amp D50, 1 gm Ca Gluconate.  R
Femoral line placed under U/S guidance. EKG w/ NSR. Nl axis. TWI
V1, 1mm ST elev 2.
.
Recent admission [**1-8**] for presumed urosepsis.
.

MEDICAL HISTORY: 1) DM2 diagnosed [**2114**] with triopathy: Creatinine has been as low
as 0.8 in the last couple of years, however widely fluctuant, as
high as 2 in the recent past. 0.9 in [**1-7**].
2) COPD, on home O2. Multiple episodes of respiratory failure
requiring intubation in recent years. Most recently, was
admitted in [**12-6**] with a perforated transverse colon requiring
partial colectomy and transverse colostomy. This course c/b
anticipated respiratory failure and anticipatory tracheostomy,
pseudomonal and MRSA PNA. Also with acalculous cholecystitis
requiring cholecystostomy tube. Had G-tube placed.
3) OSA on CPAP
3) VRE
4) s/p tracheostomy, as above in [**1-7**]
5) HTN
6) CHF: During hospitalization in [**10-20**] it was thought that
failure contributed to his respiratory failure. Last echo was in
[**12-6**] at which time LVEF thought to be roughly normal, however
very poor study and RV not visualized. Not on lasix.
7) Anemia of chronic disease, multiple transfusions in the past

MEDICATION ON ADMISSION: Paxil 40mg 9am, 5pm
Trazadone 100mg qhs prn
MOM 30cc prn
Vicodin q 4 prn
APAP 650mg q4 prn
Klonopin 0.5mg [**Hospital1 **] prn
FS QID: SS humalog
Lopressor 75mg 9 am , 9pm
Flonase 2 spray [**Hospital1 **] prn
senna 2 tabs [**Hospital1 **] prn
neurontin 600mg 6am, 2pm, 10pm
pulmocort 1 puff by mouth 9am,9pm
Heparin SQ TID
Reglan 10mg QID
Albuterol/Atrovent by mouth QID
Lantus 44 units SC qam, qhs
Humalog SS

ALLERGIES: Cephalosporins / Morphine / Fentanyl

PHYSICAL EXAM: Physical Exam- T 99.8, BP 107/38, HR 75, RR 24, 100%
AC 24 x 600. 100FiO2. 10 PEEP
Gen- sleepy but arousable to voice
HEENT- Pupils equal and reactive 3->2 b/l. OP Clear
Neck- trach in place, no purulent secretions
PUlm- Ant w/ coars b/s b/l. no focal ronchi or rales
CV- distant heart sounds, RRR. no m/r/g
ABD- b/l osteomies intact w/o erythema. midline erythematous
scar tissue w/o ulceration.
Ext- 2+ pedal edema on R. R dist LE cellulitis w/o ulceration. L
BKA w/o cellulitic change. stump clean
BAck- no sacral decub. small area of erythema on R upper
buttocks dressed w/ guaze
Neuro-able to grip hands b/l= equal strength. wiggles R toes.
sticks out tongue. opens eyes to voice.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Lives home alone with VNA. Denies etoh. Remote cigar smoking, no
cigarettes. No IVDU or marijuana. Has 1 brother, [**Name (NI) **].
Unspecified septicemia,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Methicillin susceptible pneumonia due to Staphylococcus aureus,Urinary tract infection, site not specified,Mechanical complication of tracheostomy,Hyperpotassemia,Hypoxemia,Acute kidney failure, unspecified,Diastolic heart failure, unspecified,Cellulitis and abscess of leg, except foot,Chronic airway obstruction, not elsewhere classified,Dependence on respirator, status,Severe sepsis,Morbid obesity,Atherosclerosis of native arteries of the extremities, unspecified,Obstructive sleep apnea (adult)(pediatric),Unspecified essential hypertension,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Gastroparesis,Anemia of other chronic disease,Anxiety state, unspecified,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Pulmonary congestion and hypostasis,Other and unspecified complications of medical care, not elsewhere classified,Other testicular hypofunction,Pain in joint, shoulder region,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Infection with microorganisms resistant to penicillins,Infection with microorganisms without mention of resistance to multiple drugs,Colostomy status,Long-term (current) use of insulin,Personal history of other diseases of circulatory system,Below knee amputation status
Septicemia NOS,Acute respiratry failure,Food/vomit pneumonitis,Meth sus pneum d/t Staph,Urin tract infection NOS,Tracheostomy - mech comp,Hyperpotassemia,Hypoxemia,Acute kidney failure NOS,Diastolc hrt failure NOS,Cellulitis of leg,Chr airway obstruct NEC,Respirator depend status,Severe sepsis,Morbid obesity,Athscl extrm ntv art NOS,Obstructive sleep apnea,Hypertension NOS,DMII neuro nt st uncntrl,Gastroparesis,Anemia-other chronic dis,Anxiety state NOS,Klebsiella pneumoniae,Pulm congest/hypostasis,Complic med care NEC/NOS,Testicular hypofunc NEC,Joint pain-shlder,Osteoarthros NOS-unspec,Inf mcrg rstn pncllins,Inf mcr rst ot drg nt ml,Colostomy status,Long-term use of insulin,Hx-circulatory dis NEC,Status amput below knee
Admission Date:  [**2134-3-21**]              Discharge Date:   [**2134-4-15**]

Date of Birth:  [**2087-11-5**]             Sex:   M

Service: MEDICINE

Allergies:
Cephalosporins / Morphine / Fentanyl

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
somnolence, hypoxic resp failure

Major Surgical or Invasive Procedure:
R femoral line, now d/c'd
right Midline [**3-27**] by IR

History of Present Illness:
46 y/o M w/ h/o morbid obesity, COPD, chronic trach dependence,
DMII, PVD, s/p L BKA, h/o Klebsiella/Proteus UTI, PNA, MRSA,
VRE, who presents with increasing somnolence and hypoxic
respiratory failure
.
Presented to [**Location (un) 620**] ER in respiratory distress, hypoxic to 40's
at home. T to 101.Trach noted to have copius secretions, which
were aggressively suctioned, given o2, nebs, antibiotics
(zosyn/vanco). Improved respiratory status, but still somnolent
and also noted to be hyperkalemic at 6.4. No EKG changes. Given
Insulin/D50, calcium IV. Kayexalate ordered (but not given PTA).
Also had positive troponin of 0.05 (nL <0.01). Acidotic at 7.16
w/ CO2 of 65. Therefore placed on VENT for transport to [**Hospital1 18**].
U/A at OSH pos for WBC >100, Bacteria, neg nitr, Lge leuk's. Hct
31.7, WBC 15.6, Plt 358, 84.5%N. Creat 2.6.
.
Also as patient was leaving, patient care technician who cares
for patient at home says he may have fallen the night PTA.
.
In ED here. Vitals on arrival T99.8, BP 119/51, RR 16, 99% on
Vent. Vanco infusing. BP's subsequently dropped to 80's syst->
then 69/34. Recieved 2L NS IVF PTA and given 1 more L NS in ED.
Started on dopa gtt at 5mcg/kg/min, titrated up to 10
mcg/kg/min. BP initially up to 100's systolic, then back down to
80's. Changed to levophed gtt. ASA 325mg given. Trach tube
changed to Portex 6.0, cuffed to Vent 600/100/16/5. BP
subsequently up to 150's systolic.
.
Vanco given at 1700. Zosyn 4.5 gm prior to arrival at 1415.
Also given 10 U Insulin, 1 amp D50, 1 gm Ca Gluconate.  R
Femoral line placed under U/S guidance. EKG w/ NSR. Nl axis. TWI
V1, 1mm ST elev 2.
.
Recent admission [**1-8**] for presumed urosepsis.
.


Past Medical History:
1) DM2 diagnosed [**2114**] with triopathy: Creatinine has been as low
as 0.8 in the last couple of years, however widely fluctuant, as
high as 2 in the recent past. 0.9 in [**1-7**].
2) COPD, on home O2. Multiple episodes of respiratory failure
requiring intubation in recent years. Most recently, was
admitted in [**12-6**] with a perforated transverse colon requiring
partial colectomy and transverse colostomy. This course c/b
anticipated respiratory failure and anticipatory tracheostomy,
pseudomonal and MRSA PNA. Also with acalculous cholecystitis
requiring cholecystostomy tube. Had G-tube placed.
3) OSA on CPAP
3) VRE
4) s/p tracheostomy, as above in [**1-7**]
5) HTN
6) CHF: During hospitalization in [**10-20**] it was thought that
failure contributed to his respiratory failure. Last echo was in
[**12-6**] at which time LVEF thought to be roughly normal, however
very poor study and RV not visualized. Not on lasix.
7) Anemia of chronic disease, multiple transfusions in the past

8) s/p BKA for chronic LE ulcer
9) TIA in [**2125**].
10) Difficult intubation; fiberoptic guidance in [**Month (only) 359**] of
[**2131**].
11) Urinary retention.
12) Osteoarthritis.
13) Depression.
14) C. Difficile in [**2129**].
15) Hypogonadism.
16) Morbid obesity
.
PAST SURGICAL HISTORY:
1. Bilateral carpal tunnel release in [**2123**].
2. Hydrocele repair in [**2126-4-3**].
3. Quadriceps tendon repair in [**2127**].
4. Status post partial resection of transverse colon, end
transverse colostomy, mucus fistula, jejunostomy tube and
percutaneous tracheostomy on [**2132-12-16**].


Social History:
Lives home alone with VNA. Denies etoh. Remote cigar smoking, no
cigarettes. No IVDU or marijuana. Has 1 brother, [**Name (NI) **].


Family History:
Non-contributory

Physical Exam:
Physical Exam- T 99.8, BP 107/38, HR 75, RR 24, 100%
AC 24 x 600. 100FiO2. 10 PEEP
Gen- sleepy but arousable to voice
HEENT- Pupils equal and reactive 3->2 b/l. OP Clear
Neck- trach in place, no purulent secretions
PUlm- Ant w/ coars b/s b/l. no focal ronchi or rales
CV- distant heart sounds, RRR. no m/r/g
ABD- b/l osteomies intact w/o erythema. midline erythematous
scar tissue w/o ulceration.
Ext- 2+ pedal edema on R. R dist LE cellulitis w/o ulceration. L
BKA w/o cellulitic change. stump clean
BAck- no sacral decub. small area of erythema on R upper
buttocks dressed w/ guaze
Neuro-able to grip hands b/l= equal strength. wiggles R toes.
sticks out tongue. opens eyes to voice.

Pertinent Results:
Radiology:
========
CXR [**4-12**]: Tracheostomy tube, nasogastric tube, and right PICC
line remain in place, with a right PICC line continues to
terminate in the right subclavian vein. Cardiac silhouette
remains enlarged, and there is persistent increased pulmonary
vascularity as well as perihilar haziness and bilateral moderate
pleural effusions. Overall, there has not been a significant
change in degree of CHF.
.
LENI RLE [**4-12**]- IMPRESSION: Technically difficult exam, but no
evidence for DVT
.
TTE [**4-5**]: Suboptimal technical quality.
There is mild symmetric left ventricular hypertrophy with normal
cavity size  and systolic function (LVEF>55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Right ventricular chamber size is normal. The
aortic valve leaflets appear structurally normal with good
leaflet excursion. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation.

PICC [**2134-3-25**]- IMPRESSION:
1. The tip of the right-sided PICC line in the distal portion of
the right subclavian vein.
2. Moderate congestive heart failure with cardiomegaly and small
bilateral pleural effusion. Bibasilar patchy atelectasis
.
LENI B/L LE's- IMPRESSION: No evidence for DVT.
.
Micro Data:
==========
[**2134-3-26**] 7:04 am SPUTUM      Source: Expectorated.

                            **FINAL REPORT [**2134-3-30**]**

   GRAM STAIN (Final [**2134-3-26**]):
      >25 PMNs and <10 epithelial cells/100X field.
      NO MICROORGANISMS SEEN.

   RESPIRATORY CULTURE (Final [**2134-3-30**]):
      SPARSE GROWTH OROPHARYNGEAL FLORA.
      CITROBACTER KOSERI.    SPARSE GROWTH.  WORK-UP REQUEST PER
DR .
         This organism may develop resistance to third
generation
         cephalosporins during prolonged therapy. Therefore,
isolates that
         are initially susceptible may become resistant within
three to
         four days after initiation of therapy.  For serious
infections,
         repeat culture and sensitivity testing may therefore be
warranted
         if third generation cephalosporins were used.
      PSEUDOMONAS AERUGINOSA.    SPARSE GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             CITROBACTER KOSERI
                             |          PSEUDOMONAS AERUGINOSA
                             |          |
CEFEPIME--------------   <=1 S        8 S
CEFTAZIDIME-----------     4 S       32 R
CEFTRIAXONE-----------    16 I
CIPROFLOXACIN---------   =>4 R      =>4 R
GENTAMICIN------------   <=1 S        2 S
IMIPENEM--------------   <=1 S     =>16 R
LEVOFLOXACIN----------   =>8 R
MEROPENEM-------------<=0.25 S        8 I
PIPERACILLIN---------- =>128 R       64 S
PIPERACILLIN/TAZO-----    64 I       64 S
TOBRAMYCIN------------   <=1 S      <=1 S
TRIMETHOPRIM/SULFA----  =>16 R

.
[**2134-3-22**] 1:52 am SPUTUM      Source: Endotracheal.

                            **FINAL REPORT [**2134-3-26**]**

   GRAM STAIN (Final [**2134-3-22**]):
      >25 PMNs and <10 epithelial cells/100X field.
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE ROD(S).

   RESPIRATORY CULTURE (Final [**2134-3-26**]):
      SPARSE GROWTH OROPHARYNGEAL FLORA.
      STAPH AUREUS COAG +.    MODERATE GROWTH.
         OF TWO COLONIAL MORPHOLOGIES.
      PSEUDOMONAS AERUGINOSA.    RARE GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |          PSEUDOMONAS AERUGINOSA
                             |          |
CEFEPIME--------------               16 I
CEFTAZIDIME-----------             =>64 R
CIPROFLOXACIN---------              =>4 R
CLINDAMYCIN-----------   =>8 R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S        2 S
IMIPENEM--------------                8 I
LEVOFLOXACIN----------   =>8 R
MEROPENEM-------------                8 I
OXACILLIN-------------   =>4 R
PENICILLIN------------ =>0.5 R
PIPERACILLIN----------            =>128 R
PIPERACILLIN/TAZO-----               64 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------     2 S
TOBRAMYCIN------------              <=1 S
VANCOMYCIN------------   <=1 S

.
[**2134-3-22**] 1:52 am URINE

                            **FINAL REPORT [**2134-3-24**]**

   URINE CULTURE (Final [**2134-3-24**]):
      KLEBSIELLA PNEUMONIAE.    >100,000 ORGANISMS/ML..
      2ND ISOLATE.    <10,000 organisms/ml.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             KLEBSIELLA PNEUMONIAE
                             |
AMPICILLIN/SULBACTAM--     4 S
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CEFUROXIME------------     4 S
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------   <=1 S
IMIPENEM--------------   <=1 S
LEVOFLOXACIN----------   =>8 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN--------   256 R
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S
.
.
Sputum [**4-5**]:
GRAM STAIN (Final [**2134-4-11**]):
      >25 PMNs and <10 epithelial cells/100X field.
      4+   (>10 per 1000X FIELD):   GRAM NEGATIVE ROD(S).
      4+   (>10 per 1000X FIELD):   GRAM NEGATIVE DIPLOCOCCI.
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE COCCI IN
PAIRS.
      SMEAR REVIEWED; RESULTS CONFIRMED.

   RESPIRATORY CULTURE (Final [**2134-4-14**]):
      OROPHARYNGEAL FLORA ABSENT.
      ACINETOBACTER BAUMANNII.    HEAVY GROWTH.
      PSEUDOMONAS AERUGINOSA.    HEAVY GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ACINETOBACTER BAUMANNII
                             |          PSEUDOMONAS AERUGINOSA
                             |          |
CEFEPIME--------------    16 I       16 I
CEFTAZIDIME-----------  =>64 R     =>64 R
CIPROFLOXACIN---------   =>4 R      =>4 R
GENTAMICIN------------     2 S        2 S
IMIPENEM--------------     8 I        8 I
LEVOFLOXACIN----------     4 I
MEROPENEM-------------                8 I
PIPERACILLIN----------            =>128 R
PIPERACILLIN/TAZO-----               64 S
TOBRAMYCIN------------   <=1 S      <=1 S
TRIMETHOPRIM/SULFA----   <=1 S

Brief Hospital Course:
46 y/o M w/ h/o morbid obesity, chronic trach dependence
secondary to OSA, DMII, PVD, s/p L BKA, h/o Klebsiella/Proteus
UTI, MRSA/VRE pneumonias, who initially presented with
increasing somnolence and hypoxic respiratory failure. This was
felt to be secondary to MRSA pneumonia which was treated with a
course of vancomycin and Klebsiella UTI which was treated with
Zosyn. He responded well to antibiotic therapy and was weaned
off ventilatory support. However, he subsequently re-developed
hypoxic respiratory failure. The cause of this second episode
was felt to be multi-factorial from aspiration pneumonia,
pulmonary edema, de-recruitment of alveoli given body habitus
and developement of a new right pleural effusion. He was treated
with an 8 day course of meropenem for ventilator associated
pneumonia and he was diuresed to improve his pulmonary edema.
Recruitment maneuvers, including intermittent APRV ventilation,
were used to bridge him through hypoxic episodes. In addition,
intervential pulmonary re-positioned his trach on [**4-2**] after it
was found to be obstructed against the posterior wall of his
trachea.
.
A brief hospital course by problem is also outlined below:
.
1. Hypoxic Respiratory Failure: Initially admitted for hypoxic
respiratory failure with evidence of pneumonia on CXR with
associated fever and leukocytosis. Sputum culture revealed
evidence of MRSA in addition to Pseudomonas (S to Zosyn), and he
was treated with a 10 day course of Vanco/Zosyn with good
resolution of hypoxia. He was weaned off ventilatory support and
was doing well on trach collar whe he developed a subsequent
episode of hypoxia, with oxygen saturation transiently in the
60's, improved with bag-mask ventilation and placement back on
the ventilator. This second episode was thought to be
multifactorial. He had evidence of aspiration
pneumonitis/pneumonia clinically and radiographically and he was
initially continued on vancomycin and zosyn as above. After
completion of this course of antibiotics he continued to
demonstrate hypoxia. Therefore repeat sputum culture was
performed which also demonstrated citrobacter organism that was
resistant to zosyn, but sensitive to meropenem. Given his
worsening clinical condition he was additionall treated with a
course of meropenem antibiotics. Secondly, he had evidence of
pulmonary edema on CXR which was felt to be contributing to his
respiratory distress. Therefore he was diuresed initially with a
lasix drip and then daily boluses IV. He diuresed well, over 1L
negative per day. Over this hospital course he had also
inadvertantly pulled out his trach and it was replaced
emergently with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] #6. He did well with this new trach,
however did have one episode of acute obstruction on [**4-2**] where
it was found to be lodged against the posterior wall of the
trachea, causing near 80% obstruction of air flow. This was
re-positioned by interventional pulmonary with subsequent
resolution of flow. Lastly, he also developed an increasing R
pleural effusion, suspected secondary to CHF. A right sided
thorocentesis was performed with drainage of 1500cc. The fluid
was c/w a parapneumonic effusion.  Of importance, he also had
lower extremity non-invasive ultrasounds to r/o DVT, which were
negative, helping to argue against pulmonary embolism. However
due to size he was not able to undergo CT angiogram and V/Q scan
was felt to be sub-optimal as well, especially while on the
ventilator. It was felt that the other on-going issues, as
described above, were more likely the cause of his acute hypoxic
episodes and therefore he was not anti-coagulated with heparin.
His most recent CXRs have been c/w pulmonary edema and bilateral
pleural effusions. He has diuresed well with Lasix 80mg IV QD
making him negative >1L per day. His oxygenation has improved
with weaning of his vent settings. On discharge he was on PS
[**12-10**], FiO2 of 50%. This should continue to be weaned as he
becomes more euvolemic with diuresis.
.
It is also important to note that his hypoxic episodes were
often concurrent with a large component of anxiety. In fact his
anxiety was difficult to treat throughout his hospital course.
While it was not likely completely causative of his hypoxia, it
certainly exacerbated this acute episodes. He was placed on
standing clonazepam, which he took as outpatient. In addition,
he was given prn doses of zyprexa and evening trazadone.
.
2. Somnolence: He initially presented very somnolent, minimally
responsive to sternal rub and not able to follow commands. This
was felt to be a mixed picture from hypercarbia, infection
(pneumonia, UTI) and hypoxia. ABG w/ CO2 at 65. He had
improvement of his mental status after correcting his
hypercarbia/hypoxia and treating underlying infectious
processes. Upon improvement of his mental status he was found to
have no focal neurologic deficits. Although he had intermittent
episodes of lethargy in the setting of oversedation
(particularly after morphine), he was largely awake and alert
for the remainder of his hospital course.
.
3. Hyperkalemia: Initially hyperkalemic, with potassium of 7.
Likely exacerbated by acidemia and acute renal failure. This was
treated aggressively with D50, Insulin, Calcium, Kayexalate, and
bicarbonate. In addition, the hypercarbic component was
corrected through controlled ventilation. EKG demonstrated no
peaked T's or interval widening throughout and he had no
dysrythmia on telemetry monitoring. Potassium subsequently
normalized and was not an issue the remainder of his hospital
course
.
4. ARF: 2.6 on admission, which was up from 0.9 1 year prior.
BUN also elevated, with pre-renal physiology (FeNa =0.3%, BUN:Cr
ratio >20). No evidence of ATN by urine sediment. He was
initially treated aggressively with IV fluid repletion.
Nephrotoxic agents were held and medications were renally dosed.
Creatinine subsequently improved to 1.0-1.1. He had a second
episode of ARF to 2.0 during his hospital course which
subsequently improved to 1.4 on discharge with diuresis
.
5. Troponin Leak: Max troponin 0.09 (upper limit <0.10) with
flat CK/MB. He also had non-specific ST changes by EKG without
any acute ischemic changes. He was continued on ASA, STATIN,
B-Blocker. Heparin was held as he never had evidence of acute
coronary syndrome.
.
6. Hypotension/SIRS: Early sepsis (distributive) vs hypovolemic
hypotension on admission. SIRS criteria including tachypnea,
leukocytosis of 16,000. Lactate was 2.4 on admission and
systolic blood pressure improved after 3 liter NS IVF. He was
transiently placed on low dose pressors with levophed to
maintain MAP >65, with lactate rising to a peak of 4.8. Pressors
were weaned off after adequate IVF repletion and lacate
normalized. Suspected sourse of infection included pneumonia and
UTI. Importantly, blood cultures remained negative throughout.
His blood pressure remained wnl during the rest of his hospital
stay. His labetolol and captopril were added back to his
antihypertensive regimen.
.
7. Anemia of Chronic Disease: Baseline hematocirt appears to be
around 29, which is where he was at on admission. There was a
spurious level of 12 on admission, however repeat checks did not
corroborate this level. He had no signs of active bleeding and
hematocrit remained stable, although fluctuated from 22-26,
seeming to correlate with volume status. Iron studies were
checked and were felt to be consistent with anemia of chronic
disease. He was started on iron on this hospital stay. He was
placed on EPO for 1 week until his creatinine improved and then
it was d/c'd. He was guiac negative.
.
8. DM2: Initially placed on insulin drip for tight glycemic
control. He was subsequently re-started on glargine with sliding
scale insulin for breakthrough control. On admission he was on
44 units [**Hospital1 **]. This was adjusted based on blood glucose levels as
needed [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations. Hi insulin was titrated up to
Glargine 60 u [**Hospital1 **] with SSI QID
.
9. Hypertension: Systolic blood pressures were noted as high as
200's-220's. Often in the setting of anxiety, however it was
also suspected that he also had a component of difficult to
control essential hypertension. His blood pressure medications
were titrated up, with BP's subsequently controlled in
100's-110's. Initially he was on metoprolol, but his was changed
to standing labetolol with good effect. His BP was controlled on
Labetolol and Captopril
.
10. Emesis: Transient nausea, vomiting for 1 day, thought to be
secondary to gastroparesis, exacerbated from recent
hyperglycemia. He was placed on IV reglan w/ improved nausea.
Erythromycin also used transiently, then stopped because of new
rash. Reglan was then titrated off as pt was not having any
residuals from his TF.
.
11. Nutrtion: During most of his hospital course, pt received TF
from an NGT. His prior PEG had been d/c'd before admission as pt
was tolerating pos. Nutrition was consulted and he had a video
swallow test on PS [**12-10**], 50% with no signs of aspiration on
direct visualization. He can tolerate a full diet.
.
12. ID: Pt has grown multiple resistant organisms from his
sputum including MRSA, Pseudomonas, Citrobacter and
Acinetobacter. He was treated with a course of Vanco/Zosyn and
then Meropenem for a VAP. On discharge, he had scant sputum, was
afebrile and showed no signs of focal infiltrates on CXR. He
also has grown resistant Klebsiella from his urine which was
treated. He recently had a negative UA with a Ucx growing G-rods
thought to be a colonizer as he was afebrile without an elevated
WBC. His foley was changed on [**4-14**]. On [**4-13**], vancomycin was
started for a 7 day course for a RLE cellulitis. A vancomycin
trough should be checked [**4-14**] before his evening dose and dose
adjusted accordingly. His cellulitis looked improved on d/c.
.
13. Code status: Full code
.
14. Contact and HCP: brother [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 28633**]
.
15. PPX: heparin sc TID, PPI, bowel regimen, HOB elevated > 30,
peridex oral care
.
16. Access: Midline placed by IR on [**3-27**]

Medications on Admission:
Paxil 40mg 9am, 5pm
Trazadone 100mg qhs prn
MOM 30cc prn
Vicodin q 4 prn
APAP 650mg q4 prn
Klonopin 0.5mg [**Hospital1 **] prn
FS QID: SS humalog
Lopressor 75mg 9 am , 9pm
Flonase 2 spray [**Hospital1 **] prn
senna 2 tabs [**Hospital1 **] prn
neurontin 600mg 6am, 2pm, 10pm
pulmocort 1 puff by mouth 9am,9pm
Heparin SQ TID
Reglan 10mg QID
Albuterol/Atrovent by mouth QID
Lantus 44 units SC qam, qhs
Humalog SS

Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Gabapentin 250 mg/5 mL Solution Sig: Three Hundred (300) mg
PO Q12H (every 12 hours).
5. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q4-6H (every 4 to 6 hours) as needed.
7. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane  TID (3 times a day).
8. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: [**1-4**] Tablet,
Sublinguals Sublingual PRN (as needed) as needed for chest pain.

9. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
10. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
12. Fluticasone 110 mcg/Actuation Aerosol Sig: Eight (8) Puff
Inhalation [**Hospital1 **] (2 times a day).
13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 8-10 Puffs
Inhalation QID (4 times a day).
14. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig:
Thirty (30) ml PO DAILY (Daily).
15. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed.
16. Labetalol 300 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day): hold if sbp<100, pulse<55.
17. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
18. Clonazepam 1 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
19. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
20. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
21. Captopril 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day): hold if sbp<90.
22. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Ten
(10) ML Intravenous  DAILY (Daily) as needed.
23. Prochlorperazine Edisylate 5 mg/mL Solution Sig: Ten (10) mg
Injection Q6H (every 6 hours) as needed.
24. Lorazepam 2 mg/mL Syringe Sig: 1-2 mg Injection Q4H (every 4
hours) as needed.
25. Furosemide 10 mg/mL Solution Sig: Eighty (80) mg Injection
DAILY (Daily).
26. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous  Q 12H (Every 12 Hours) for 7 days.
27. Insulin Glargine 100 unit/mL Cartridge Sig: Sixty (60) units
Subcutaneous twice a day: see additional sliding scale order.
28. Humalog 100 unit/mL Cartridge Sig: as dir units Subcutaneous
four times a day: Sliding Scale
FS<60 give oj, [**Name8 (MD) 138**] md
FS61-120   mg/dL: 0 units
121-160   mg/dL: 2 units
161-200   mg/dL 4
201-240   mg/dL 6
241-280   mg/dL 8
281-320   mg/dL 10
321-360   mg/dL 12
361-400   mg/dL 14
>400 [**Name8 (MD) 138**] md.
29. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical  QID
(4 times a day).


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
Pneumonia
Obstructive Sleep Apnea
Diabetes type 2
COPD
Urinary tract infection
Anemia
Acute renal failure
Peripheral vascular disease
diastolic chf


Discharge Condition:
stable


Discharge Instructions:
Please check vanco level before next dose ([**4-14**])
Please check electrolytes qod and replete lytes as needed
check hematocrit two times a week and more often if falling from
in hospital value to HCT 22.8. Transfuse if <21

Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 22882**] within 2 weeks [**Telephone/Fax (1) 28634**]



Completed by:[**2134-4-14**]
{"Unspecified septicemia,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Methicillin susceptible pneumonia due to Staphylococcus aureus,Urinary tract infection, site not specified,Mechanical complication of tracheostomy,Hyperpotassemia,Hypoxemia,Acute kidney failure, unspecified,Diastolic heart failure, unspecified,Cellulitis and abscess of leg, except foot,Chronic airway obstruction, not elsewhere classified,Dependence on respirator, status,Severe sepsis,Morbid obesity,Atherosclerosis of native arteries of the extremities, unspecified,Obstructive sleep apnea (adult)(pediatric),Unspecified essential hypertension,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Gastroparesis,Anemia of other chronic disease,Anxiety state, unspecified,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Pulmonary congestion and hypostasis,Other and unspecified complications of medical care, not elsewhere classified,Other testicular hypofunction,Pain in joint, shoulder region,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Infection with microorganisms resistant to penicillins,Infection with microorganisms without mention of resistance to multiple drugs,Colostomy status,Long-term (current) use of insulin,Personal history of other diseases of circulatory system,Below knee amputation status"}


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: somnolence, hypoxic resp failure

PRESENT ILLNESS: 46 y/o M w/ h/o morbid obesity, COPD, chronic trach dependence,
DMII, PVD, s/p L BKA, h/o Klebsiella/Proteus UTI, PNA, MRSA,
VRE, who presents with increasing somnolence and hypoxic
respiratory failure
.
Presented to [**Location (un) 620**] ER in respiratory distress, hypoxic to 40's
at home. T to 101.Trach noted to have copius secretions, which
were aggressively suctioned, given o2, nebs, antibiotics
(zosyn/vanco). Improved respiratory status, but still somnolent
and also noted to be hyperkalemic at 6.4. No EKG changes. Given
Insulin/D50, calcium IV. Kayexalate ordered (but not given PTA).
Also had positive troponin of 0.05 (nL <0.01). Acidotic at 7.16
w/ CO2 of 65. Therefore placed on VENT for transport to [**Hospital1 18**].
U/A at OSH pos for WBC >100, Bacteria, neg nitr, Lge leuk's. Hct
31.7, WBC 15.6, Plt 358, 84.5%N. Creat 2.6.
.
Also as patient was leaving, patient care technician who cares
for patient at home says he may have fallen the night PTA.
.
In ED here. Vitals on arrival T99.8, BP 119/51, RR 16, 99% on
Vent. Vanco infusing. BP's subsequently dropped to 80's syst->
then 69/34. Recieved 2L NS IVF PTA and given 1 more L NS in ED.
Started on dopa gtt at 5mcg/kg/min, titrated up to 10
mcg/kg/min. BP initially up to 100's systolic, then back down to
80's. Changed to levophed gtt. ASA 325mg given. Trach tube
changed to Portex 6.0, cuffed to Vent 600/100/16/5. BP
subsequently up to 150's systolic.
.
Vanco given at 1700. Zosyn 4.5 gm prior to arrival at 1415.
Also given 10 U Insulin, 1 amp D50, 1 gm Ca Gluconate.  R
Femoral line placed under U/S guidance. EKG w/ NSR. Nl axis. TWI
V1, 1mm ST elev 2.
.
Recent admission [**1-8**] for presumed urosepsis.
.

MEDICAL HISTORY: 1) DM2 diagnosed [**2114**] with triopathy: Creatinine has been as low
as 0.8 in the last couple of years, however widely fluctuant, as
high as 2 in the recent past. 0.9 in [**1-7**].
2) COPD, on home O2. Multiple episodes of respiratory failure
requiring intubation in recent years. Most recently, was
admitted in [**12-6**] with a perforated transverse colon requiring
partial colectomy and transverse colostomy. This course c/b
anticipated respiratory failure and anticipatory tracheostomy,
pseudomonal and MRSA PNA. Also with acalculous cholecystitis
requiring cholecystostomy tube. Had G-tube placed.
3) OSA on CPAP
3) VRE
4) s/p tracheostomy, as above in [**1-7**]
5) HTN
6) CHF: During hospitalization in [**10-20**] it was thought that
failure contributed to his respiratory failure. Last echo was in
[**12-6**] at which time LVEF thought to be roughly normal, however
very poor study and RV not visualized. Not on lasix.
7) Anemia of chronic disease, multiple transfusions in the past

MEDICATION ON ADMISSION: Paxil 40mg 9am, 5pm
Trazadone 100mg qhs prn
MOM 30cc prn
Vicodin q 4 prn
APAP 650mg q4 prn
Klonopin 0.5mg [**Hospital1 **] prn
FS QID: SS humalog
Lopressor 75mg 9 am , 9pm
Flonase 2 spray [**Hospital1 **] prn
senna 2 tabs [**Hospital1 **] prn
neurontin 600mg 6am, 2pm, 10pm
pulmocort 1 puff by mouth 9am,9pm
Heparin SQ TID
Reglan 10mg QID
Albuterol/Atrovent by mouth QID
Lantus 44 units SC qam, qhs
Humalog SS

ALLERGIES: Cephalosporins / Morphine / Fentanyl

PHYSICAL EXAM: Physical Exam- T 99.8, BP 107/38, HR 75, RR 24, 100%
AC 24 x 600. 100FiO2. 10 PEEP
Gen- sleepy but arousable to voice
HEENT- Pupils equal and reactive 3->2 b/l. OP Clear
Neck- trach in place, no purulent secretions
PUlm- Ant w/ coars b/s b/l. no focal ronchi or rales
CV- distant heart sounds, RRR. no m/r/g
ABD- b/l osteomies intact w/o erythema. midline erythematous
scar tissue w/o ulceration.
Ext- 2+ pedal edema on R. R dist LE cellulitis w/o ulceration. L
BKA w/o cellulitic change. stump clean
BAck- no sacral decub. small area of erythema on R upper
buttocks dressed w/ guaze
Neuro-able to grip hands b/l= equal strength. wiggles R toes.
sticks out tongue. opens eyes to voice.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Lives home alone with VNA. Denies etoh. Remote cigar smoking, no
cigarettes. No IVDU or marijuana. Has 1 brother, [**Name (NI) **]. 

### Response:
{"Unspecified septicemia,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Methicillin susceptible pneumonia due to Staphylococcus aureus,Urinary tract infection, site not specified,Mechanical complication of tracheostomy,Hyperpotassemia,Hypoxemia,Acute kidney failure, unspecified,Diastolic heart failure, unspecified,Cellulitis and abscess of leg, except foot,Chronic airway obstruction, not elsewhere classified,Dependence on respirator, status,Severe sepsis,Morbid obesity,Atherosclerosis of native arteries of the extremities, unspecified,Obstructive sleep apnea (adult)(pediatric),Unspecified essential hypertension,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Gastroparesis,Anemia of other chronic disease,Anxiety state, unspecified,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Pulmonary congestion and hypostasis,Other and unspecified complications of medical care, not elsewhere classified,Other testicular hypofunction,Pain in joint, shoulder region,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Infection with microorganisms resistant to penicillins,Infection with microorganisms without mention of resistance to multiple drugs,Colostomy status,Long-term (current) use of insulin,Personal history of other diseases of circulatory system,Below knee amputation status"}
