CHIEF COMPLAINT: 

PRESENT ILLNESS: This is a 68 year old gentleman
with a history of Parkinson's disease and a recent prolonged
complicated admission, status post motor vehicle accident
where he was hit by a car as a pedestrian who returned with
fever, shortness of breath and hypotension from
rehabilitation.  He was admitted on [**2140-1-15**] to
[**2140-3-12**] after being struck by a car.  In that
admission he had a complicated course including a right
fibular fracture and right acetabular fracture and multiple
left rib fractures and left perisplenic hematoma and left
common femoral vein deep vein thrombosis and had a inferior
vena cava filter placed on [**2140-1-6**].  He also had
evidence of right lower extremity skin necrosis in the thigh
and cellulitis which was debrided and had a skin graft from
his thigh.  Also during that hospitalization, he had an
exploratory laparotomy which showed left retroperitoneal,
perinephric hematoma, also complicated by pancreatitis status
post endoscopic retrograde cholangiopancreatography and
sphincterotomy and Methicillin-resistant Staphylococcus
aureus pneumonia which was treated with Vancomycin.  He was
discharged on [**1-10**] to [**Hospital1 **].  He was there two to
three days prior to representation at [**Hospital6 649**].  He developed fevers, tachypnea and shortness
of breath at that rehabilitation and was sent back in for
further evaluation.  On admission he had evidence of a right
lower lobe pneumonia.  He was started on Flagyl for concern
for aspiration pneumonia.  He was given a dose of Azotreanam
at the rehabilitation and was started on Vancomycin given his
history of Methicillin-resistant Staphylococcus aureus.

MEDICAL HISTORY: Past medical history includes 1.
Parkinson's disease since [**2121**]; 2.  Hypertension; 3.  Status
post motor vehicle accident trauma, being hit as a
pedestrian; 4.  Prostate cancer, status post prostatectomy.

MEDICATION ON ADMISSION: Sinemet, Senna, Atrovent,
Albuterol, Seroquel, Ultram, Entacapone with the Sinemet,
cream Glycerine, Lactulose, Colace, multivitamin, Tylenol,
Fragmin, Prevacid, Flagyl started on [**3-20**], Azotreanam
started on [**3-21**] and then Vancomycin given one dose on
[**3-21**].

ALLERGIES: Zosyn and Levaquin.

PHYSICAL EXAM: 

FAMILY HISTORY: Negative for coronary artery disease,
diabetes and coronary artery disease or cancers.

SOCIAL HISTORY: Negative tobacco or alcohol.  He was an
engineer on a ship with positive asbestosis exposure,
currently at rehabilitation.  He has a wife and daughter in
the nearby town.
Unspecified septicemia,Severe sepsis,Pneumonia, organism unspecified,Intestinal infection due to Clostridium difficile,Urinary tract infection, site not specified,Pulmonary collapse
Septicemia NOS,Severe sepsis,Pneumonia, organism NOS,Int inf clstrdium dfcile,Urin tract infection NOS,Pulmonary collapse
Admission Date:  [**2140-3-21**]       Discharge Date:  [**2140-4-2**]

Date of Birth:   [**2071-10-30**]       Sex:  M

Service:

HISTORY OF PRESENT ILLNESS:  This is a 68 year old gentleman
with a history of Parkinson's disease and a recent prolonged
complicated admission, status post motor vehicle accident
where he was hit by a car as a pedestrian who returned with
fever, shortness of breath and hypotension from
rehabilitation.  He was admitted on [**2140-1-15**] to
[**2140-3-12**] after being struck by a car.  In that
admission he had a complicated course including a right
fibular fracture and right acetabular fracture and multiple
left rib fractures and left perisplenic hematoma and left
common femoral vein deep vein thrombosis and had a inferior
vena cava filter placed on [**2140-1-6**].  He also had
evidence of right lower extremity skin necrosis in the thigh
and cellulitis which was debrided and had a skin graft from
his thigh.  Also during that hospitalization, he had an
exploratory laparotomy which showed left retroperitoneal,
perinephric hematoma, also complicated by pancreatitis status
post endoscopic retrograde cholangiopancreatography and
sphincterotomy and Methicillin-resistant Staphylococcus
aureus pneumonia which was treated with Vancomycin.  He was
discharged on [**1-10**] to [**Hospital1 **].  He was there two to
three days prior to representation at [**Hospital6 649**].  He developed fevers, tachypnea and shortness
of breath at that rehabilitation and was sent back in for
further evaluation.  On admission he had evidence of a right
lower lobe pneumonia.  He was started on Flagyl for concern
for aspiration pneumonia.  He was given a dose of Azotreanam
at the rehabilitation and was started on Vancomycin given his
history of Methicillin-resistant Staphylococcus aureus.

Review of systems was positive for fevers, shortness of
breath, cough which was nonproductive with a rare yellowish
sputum.  He had dark brown diarrhea, positive back pain since
his accident.  No abdominal pain.  He was taking p.o., no
coughing after eating.  No nausea, vomiting or dysuria.  In
the Emergency Room, he was noted to have temperature to 101.5
with systolic blood pressure of 84, respiratory rate between
30 to 40 and 87% saturations on room air.  He was given 3
liters of normal saline.  His blood pressure came up to
133/86.  A central line was placed in his right internal
jugular vein.  He was given Ceftriaxone and admitted to the
Medicine Intensive Care Unit.

PAST MEDICAL HISTORY:  Past medical history includes 1.
Parkinson's disease since [**2121**]; 2.  Hypertension; 3.  Status
post motor vehicle accident trauma, being hit as a
pedestrian; 4.  Prostate cancer, status post prostatectomy.

ALLERGIES:  Zosyn and Levaquin.

MEDICATIONS ON ADMISSION:  Sinemet, Senna, Atrovent,
Albuterol, Seroquel, Ultram, Entacapone with the Sinemet,
cream Glycerine, Lactulose, Colace, multivitamin, Tylenol,
Fragmin, Prevacid, Flagyl started on [**3-20**], Azotreanam
started on [**3-21**] and then Vancomycin given one dose on
[**3-21**].

SOCIAL HISTORY:  Negative tobacco or alcohol.  He was an
engineer on a ship with positive asbestosis exposure,
currently at rehabilitation.  He has a wife and daughter in
the nearby town.

FAMILY HISTORY:  Negative for coronary artery disease,
diabetes and coronary artery disease or cancers.

PHYSICAL EXAMINATION ON ADMISSION:  Notable for temperature
101.5, blood pressure 181/76, heart rate 109, respiratory
rate 30, saturations 95% on 3 liters of nasal cannula.  In
general, he was an elderly Russian-speaking only male,
tachypneic.  Head, eyes, ears, nose and throat, flat neck
veins, pupils equal, round and reactive to light, anicteric
sclera, moist mucous membranes, left subclavian triple lumen
with some secondary erythema but no tenderness, warmth or
fluctuance.  Chest with bronchial breath sounds and rhonchi
of the left base with right bibasilar rales.  Heart was
tachycardiac with heart sounds obscured by rapid breath
sounds.  Abdomen was soft with a healed midline scar,
nontender.  Extremities, trace to 1+ patchy edema in
bilateral lower extremities.  Well granulation tissue over
graft on his right lower extremity.  Back, left Stage 1
decubitus ulcer over his left buttocks, no surrounding
cellulitis.  Rectal, guaiac negative.  Neurological, cogwheel
rigidity, alert and oriented.

LABORATORY DATA:  Laboratory data on admission revealed white
count 17.5, hematocrit 28.6, platelets 292.  Sodium 140,
potassium 4.1, chloride 104, bicarbonate 27, BUN 26,
creatinine 0.9, glucose 99, lactate 2.1, INR 1.4.  Urinalysis
was hazy with a specific gravity of 1.029, 30 protein, 15
ketones, trace leukocyte esterase, large blood, 11 to 20 of
red blood cells, treated by white blood cells, moderate
bacteria. Cultures were pending on admission.  An
echocardiogram in [**2140-1-4**] with normal ejection
fraction, no wall motion abnormality, no valvular disease.
Chest x-ray with left lower lobe opacity.

HOSPITAL COURSE:  This is a 68 year old gentleman with
Parkinson's disease, status post recent long complicated
hospital course, status post a motor vehicle accident who
presented with fevers, shortness of breath and hypotension.

1.  Sepsis - The patient's likely sources were considered to
be pneumonia, urinary tract infection and diarrhea, given his
history of Clostridium difficile colitis.  Also a source
could have been decubitus ulcer.  The patient was admitted to
the Intensive Care Unit and started on broad spectrum
antibiotics, including Vancomycin, Ceftriaxone for pneumonia,
and Flagyl to cover for Clostridium difficile.  The patient's
previous left subclavian central line was pulled and sent for
cultures.  He had a new right internal jugular central line
placed.  He continued to have aggressive intravascular
repletion with intravenous fluids to which he responded,
presumably initially hypovolemic secondary to diarrhea,
fevers, tachypnea.  Chest x-ray confirmed left lower lobe
collapse, consolidation which has increased in prominence
since the previous study.  He does have a known elevated
right hemidiaphragm and this was stable from the previous
chest x-ray.  However, the patient was treated as a
nosocomial pneumonia with his recent hospitalization.  As he
was coming from the nursing home, the patient was treated
broadly with goal to complete a 14 day course of Vancomycin
and Ceftriaxone of which he started on [**3-21**], and which
will be completed on [**4-4**].  Blood cultures drawn on the
day of admission and follow up cultures remained negative.
The patient's stool was positive for Clostridium difficile
and sputum was positive for Methicillin-resistant
Staphylococcus aureus and the patient is to complete the two
week courses of both, and both will be completed on [**4-4**].
His leukocytosis from an admission of 17,000 did trend down
during the course of his stay with antibiotics.  His
hypotension through the course of the Medicine Intensive Care
Unit stay and on the floor was fluid-responsive and remains
stable.  Eventually he was restarted on his outpatient
hypertensive regimen.

2.  Respiratory distress - The patient was noted to have some
episodes of respiratory distress in the Medicine Intensive
Care Unit, he was treated with BiPAP as he was hypercapnic
and this did help improve his ventilatory status.  He
tolerated BiPAP well.  He was eventually weaned just to BiPAP
nightly.  He continued to retain carbon dioxide with a rise
in bicarbonate throughout the course of his stay and this was
considered likely secondary to a persistent carbon dioxide
retention.  His respiratory distress and hypercapnia were
attributed to his pneumonia.  Eventually also evidence of
right lower lobe pneumonia and right lower lobe collapse
likely was more susceptible secondary to his elevated right
hemidiaphragm which was chronic and more susceptible to
atelectasis in light of his hypotension and mental status
issues.  His respiratory status remained stable on the floor.
He was continued on oxygen by nasal cannula at a rate of 3
liters.  He tolerated this well with stable saturations
around 96%.  He was continued on nebulizers q. [**5-10**] with good
results and continued to produce good cough efforts, although
still gaining back strength.  He was continued on BiPAP at
settings of 10 and 5 with three to four liters of bleeding
over night with good result.  This is to be continued at
rehabilitation.  His chest x-ray confirmed small right
pleural effusion which was stable in size and improving
through the course of his stay as was the respiratory status.
No plans were made to tap as it was considered increasing
risk for thoracentesis than to just continue treatment. Again
the patient has completed a two week course of Ceftriaxone
and Vancomycin for nosocomial acquired pneumonia at the
nursing home and his course will be completed on [**4-4**].
The patient had a mid line placed in his right forearm to
complete the rest of his antibiotics at rehabilitation.

3.  Clostridium difficile colitis - The patient again had
stool samples which were positive for Clostridium difficile
and the patient was again restarted on Flagyl to complete a
two week course which he will complete on [**4-4**].  Otherwise
his diarrhea improved throughout the course of his stay with
treatment and this was stable at the time of discharge.

4.  Wound care - The patient does have a Stage 1 to 2 Grade
sacral decubitus ulcer, continue wound care at rehabilitation
as had been appropriate.  Continue to ambulate and improve
the patient's nutritional status to help wound healings.

5.  Parkinson's disease - He was stable from his Parkinson's
issues on his home medications of Sinemet and Entacapone.
Continue his home brands in five times a day dosing of
Entacapone and Parkinson's was stable here.

6.  Altered mental status - Noted in Medicine Intensive Care
Unit to have some change in mental status.  This was
attributed to multiple factors including overuse of
intravenous Morphine.  Once this was cut back his mental
status and agitation improved.  Also the patient was started
on b.i.d. dosing of Seroquel which he tolerated well with
improvement in his mental status.  He was also started on prn
doses of Zyprexa which he did not require as he remained
stable.  For a short time he was on a 1:1 sitter which was
discontinued as the patient was stable and was not agitated
further.  For altered mental status, the patient was
restarted on smaller doses of Percocet for pain control and
he tolerated this well without altered mental status.  He
continued to improve and was back to baseline per family.  He
did recognize them alert and oriented, even per interpreter,
except did note that the patient continued to have some
strange dreams which have been chronic issues with him and
his Parkinson's disease per family and are unchanged from his
baseline.  So, his altered mental status was likely delirium
from infectious causes and over-narcotics.  Concern was also
related to hypercarbia, however, this was stable, his pCO2
and his mental status improved.

6.  Acid base - The patient initially with respiratory
acidosis which improved with BiPAP, however, secondary to
prolonged respiratory acidosis, compensated with a metabolic
alkalosis, the patient was alkalinizing his urine
appropriately and his metabolic alkalosis was attributed in
part to post hypercarbic respiratory acidosis and post
hypercarbic metabolic alkalosis in response to his
hypercarbic state.  Also, compounding that was a contraction
alkalosis and he remained stable in terms of his acid base
status and we will continue to follow his bicarbonates in his
chemistries.  However, his blood gases remained stable with
pCO2 ranging from 50s and with some respiratory distress up
to 70s, however, persistently in the 50s.  This may be his
new baseline.  His bicarbonate was stable at 38 at the time
of discharge.

7.  Atrial fibrillation - He did have new onset atrial
fibrillation while in the Intensive Care Unit.  He was
cardioverted and loaded on Amiodarone and remained stable in
sinus throughout the rest of his stay.

8.  Left thigh pain - Originally, known fractures of the
right acetabulum and right femur and has had extensive
necrosis of his right thigh, status post debridement and
status post skin graft placement in [**Last Name (LF) 404**], [**First Name3 (LF) **] the surgical
team.  However, per patient this intermittent cramping type
pain has been with him over the past month and he describes
it as an intermittent cramping type pain.  The patient was
started back on Percocets with good relief.  He was also
started back on anti-inflammatories like Ultram and also
started on Quinine to help with leg cramps and for concern of
possible neuropathic pain was started on low doses of
Neurontin which can be titrated up at rehabilitation.

9.  Nutrition - The patient passed a video speech and swallow
evaluation with no evidence of aspiration and originally had
been on nectar-thickened liquids after having been on tube
feeds in the Medicine Intensive Care Unit.  However, as he
showed no signs of aspiration, he was started on regular
consistency diet with thin liquids which he tolerated well,
however, just required assistance in terms of feeding.  The
patient admitted he had very little appetite but when
encouraged to eat and drink Boost supplemental drinks, he
would, knowing that the alternative to poor p.o. intake was a
possible feeding tube.  He agreed with continuing to try and
family agreed trying to encourage p.o. intake as they wanted
to avoid placing an nasogastric tube or possible gastrostomy
tube if his nutritional intake does not increase.  The
patient's electrolytes were followed closely and were
repleted as needed.

10. Right lower extremity deep vein thrombosis - The patient
had a right lower extremity deep vein thrombosis after his
fracture, and had an inferior vena cava filter placed at the
time in [**2140-1-4**].  He was continued on his Lovenox here
and started on Coumadin to be titrated up with goal INR
between 2 and 3.  His Lovenox should be discontinued once he
reached his goal INR.

11. Hypertension - Although throughout much of his stay, he
was slightly hypotensive, by the time of discharge he was
started back on his home regimen of Metoprolol but to
continue at low doses.

DISCHARGE DIAGNOSIS:
1.  Sepsis.
2.  Pneumonia.
3.  Pleural effusion.
4.  Urinary tract infection.
5.  Clostridium difficile colitis.
6.  Parkinson's disease.
7.  Status post deep vein thrombosis.
8.  Delirium.
9.  Atrial fibrillation.
10. Failure to thrive.

DISCHARGE MEDICATIONS:
1.  Entacapone 200 mg p.o. five times a day.
2.  Multivitamin one p.o. q. day.
3.  Acetaminophen 325 mg one to two p.o. q. 4-6 hours.
4.  Albuterol nebulizers one neb q. 2 hours prn.
5.  Albuterol nebulizers, one neb inhaled q. 4 hours.
6.  Atrovent nebulizers, one neb q. 6 hours.
7.  Carbidopa/Levodopa 25-250 mg p.o. five times a day.
8.  Zyprexa rapid release 5 mg tablet, one p.o. q. day prn
agitation.
9.  Metoprolol 25 mg p.o. b.i.d., hold for systolic blood
pressures less than 110.
10. Pantoprazole 40 mg p.o. q. day
11. Seroquel 50 mg p.o. b.i.d.
12. Lovenox 80 mg p.o. subcutaneously q. 12 until INR is
greater than 10.
13. Warfarin 5 mg tablets, p.o. q.h.s. to be titrated to goal
INR between 2 to 3.
14. Ultram 50 mg p.o. q.i.d.
15. Quinine 260 mg p.o. b.i.d.
16. Guaifenesin 10 ml p.o. q. 6 hours.
17. Percocet 5/325 mg one p.o. q. 4 hours prn pain.
18. Colace 100 mg p.o. b.i.d.
19. Senna 1 tablet p.o. b.i.d.
20. Flagyl 500 mg p.o. t.i.d. to be completed [**4-4**].
21. Vancomycin 1 gm q. 12 hours to be completed [**4-4**].
22. Ceftriaxone 1 gm q. 24 hours to be completed [**4-4**].
23. Neurontin 100 mg p.o. q. 8 hours to be titrated up as
tolerated.

DISCHARGE FOLLOW UP/INSTRUCTIONS:  The patient is to follow
up with his primary care physician in seven to ten days after
discharge from rehabilitation.  The patient is to follow up
with the Trauma Clinic as was previously recommended.  The
patient is to follow up with the Plastic Surgery Team as was
previously recommended.  The patient is to continue with
aggressive pulmonary toilet and suctioning, supplemental
oxygen, BiPAP at night with settings of 10 and 5, to be
continued with aggressive physical therapy in rehabilitation.
The patient is to continue to be encouraged to take p.o.
intake to improve nutritional status.

DISPO: Prior to transfer to rehab, the patient was scheduled for
monitoring and continued hospital level treatment over the
weekend to assess for stability.  He became acutely dyspneic with
worsening respiratory acidosis and hypoxemic, and was transferred
to the ICU.  Please see a subsequent d/c addendum for further
details.

[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5613**], M.D. 12- AHU

Dictated By:[**Name8 (MD) 264**]
MEDQUIST36

D:  [**2140-4-1**]  14:32
T:  [**2140-4-1**]  16:11
JOB#:  [**Job Number 53741**]


Name:  [**Known lastname 9966**], [**Known firstname 4794**]               Unit No:  [**Numeric Identifier 9967**]

Admission Date:  [**2140-3-21**]       Discharge Date:  [**2140-4-21**]

Date of Birth:   [**2071-10-30**]       Sex:  M

Service:

This is an addendum to his prior dictation summary up until
[**4-2**] and will comprise his MICU course from [**4-3**] until [**4-20**].

In summary, this is a 68-year-old gentleman with a history of
Parkinson's disease and hypertension with recent prolonged
hospitalization at [**Hospital1 536**]
status post motor vehicle accident as pedestrian struck by a
motor vehicle, who was transferred to the ICU following an
extended hospital course from [**3-21**] to [**3-/2065**] for progressive
hypercarbic and hypoxic respiratory failure.  Please see
complete dictation summary as stated above for details of
hospitalization prior to this dictation summary.

However, in brief, the patient was transferred to the ICU on
the evening of Sunday, [**4-3**] with progressive
hypercarbic and hypoxic respiratory failure.  He was being
treated on the floor intermittently receiving BiPAP when he
was noted to have oxygen desaturations in the 80s and became
increasingly agitated.  There was some mild improvement with
suctioning and diuresis, however, he became increasingly
delirious with tachypnea, altered mental status, and
hypotension.

An ABG was performed on the 28th showing a gas on 100% face
mask of 7.31, 84, and 60.  Prior gas which was 7.32, 81, and
53.  Consequently, the patient was semiurgently intubated and
transferred to the ICU for continued medical care with
multiple medical problems.

1. Respiratory failure:  Patient has had a long history of
respiratory failure stemming from complications related to
his motor vehicle accident in [**2140-1-4**], and was
originally admitted for progressive hypercarbic respiratory
failure.  Patient's respiratory failure was multifactorial
comprising of poor respiratory mechanics secondary to chest
wall trauma, diaphragmatic weakness, bibasilar
consolidations, question of obstructive-sleep apnea,
infection with possible pneumonia nosocomial versus
aspiration pneumonia with progressive increasing of his pCO2
over two-week period of this recent hospitalization.

Prior to admission to the ICU, patient was attempted to be
treated with BiPAP, however, repeatedly failed, and did not
tolerate the procedure.  In the ICU, he remained intubated
and demonstrated progressive improvement in his respiratory
status from [**3-/2065**] until the time of discharge.

On presentation there was a question of aspiration pneumonia
or nosocomial pneumonia, which was treated with a 10-day
course of antibiotics.  He was progressively weaned from the
ventilator with trials of pressure support and spontaneous
breathing trials improving his strength and stamina along
with aggressive chest and physical therapy.  For part of his
course, his extubation was limited by increased secretion,
where he would tolerate spontaneous breathing trials with
subsequent secretion development and then require return to
pressure support ventilation.

Finally, it was determined that tracheostomy tube placement
would be the best indication for ..........  However, after
consult with the IP service followed by ENT, it was noticed
the patient had a low-lying trachea, and that placement of a
tracheostomy tube would not be possible without resection of
manubrium.

Consequently, the plan was to give him a trial of extubation
on Saturday, [**4-16**], however, the patient self extubated
on the night of Friday, [**4-15**].  He was followed closely
with repeat blood gases showing pH of approximately 7.4, pCO2
in the middle to high 40s with adequate oxygenation.  Initial
attempts were made to use BiPAP at night using 10 and 5 and
then 12 and 8 settings, however, the patient did not tolerate
this procedure.  The intention of the BiPAP was to provide
respiratory support at night to rest him in order to
facilitate his continued extubation.

However, at day four of extubation, the patient continued to
do remarkably well and has not required BiPAP at night.
Consequently, his discharge plan includes the following:  To
continue to follow him for evidence of respiratory failure,
though he appears stable at this time.  He is generally
improved in is strength and ability to tolerate spontaneous
breathing trials prior to extubation.  He no longer has
evidence of pneumonia or infection, and his chest x-rays on
left lung have repeatedly improved, though he still has
evidence of an elevated right hemidiaphragm.

Consequently, he will not need BiPAP at night and the patient
has not tolerated it, and he will need continued chest
physical therapy for treatment.

2. Pneumonia:  It was felt based on the patient's chest x-ray
and his clinical presentation that he may have had either an
aspiration or nosocomial-acquired pneumonia.  During his stay
in the ICU, culture data was repeatedly negative.  He was
treated with a 10-day course of vancomycin, ceftaz, and
clindamycin.  Currently he remains afebrile without
leukocytosis.  He did have a recent sputum sample from the
[**4-13**] showing MRSA and cephalosporin-resistant
Klebsiella.  However, it was thought that these were
colonizers and not actual agents of infection, and he was not
restarted on any antibiotics.  However, it would be prudent
to consider reculture and starting antibiotics if he were to
clinically deteriorate.

3. Clostridium difficile colitis:  The patient had a history
of Clostridium difficile colitis.  He completed a two-week
course of Flagyl without further events.

4. Change in mental status:  Patient has had repeated
episodes of well-documented change in mental status.  During
his ICU stay here, he was initially treated with Seroquel 50
b.i.d. with prn Haldol, Ativan, and narcotics additionally,
he received Flexeril three days prior to discharge with
associated delta MS.

Consequently, having spoken with neurologist, it was
suggested that we discontinue Haldol as this can have
delirious effects on Parkinson's disease and can contribute
to confusion.  Additionally, Flexeril, benzodiazepines, and
narcotics were discontinued, and should be minimized on his
discharge.  He will be discharged on Seroquel 50 b.i.d. and
would suggest prn Zyprexa if needed for acute management of
agitation.

5. Bright red blood per rectum:  During his stay in the ICU,
he had one episode of bright red blood per rectum after
passage of a hard-formed stool.  Subsequent stools were
guaiac negative.  He did not have any additional episodes.
It was thought he possibly had a hemorrhoid versus fissure,
and he has responded well to stool softeners without
additional events.

6. Eosinophilia:  The patient continues to have eosinophilia
counts approximately 8-10%.  This was felt to be related to
antibiotic use.  There are no obvious signs of parasitic or
other infection.  This should be continued to be followed,
but it is felt likely related to medication effect.

7. Pain control:  The patient intermittently complains of
cramping leg pain.  Was treated with narcotics.  However,
narcotics were felt to have a delirious effect on mental
status, and he now is well controlled on Morphine with NSAIDs
prn as needed for pain.

8. Hypertension:  Patient has reported hypertension at
baseline.  He was well controlled in-house with Lopressor 50
t.i.d.

9. DVT:  Patient has a known history of DVT with IVC filter
placement.  He continued on Lovenox 80 mg subq b.i.d. for
therapeutic prophylaxis.  If it is desired, he can consider
transition to Coumadin in the outpatient setting.

10. Atrial fibrillation:  The patient had an episode of
atrial fibrillation prior to his transfer to the ICU.  He
remained in normal sinus rhythm throughout his stay.  He will
continue on Lopressor 50 t.i.d. for hypertension and for rate
control.

11. FEN:  The patient had a PEG tube placed on [**4-12**], which
was intended to coincide with placement of a tracheostomy
tube.  However, tracheostomy tube failed as stated above.
Patient is now tolerating p.o., though minimal, he has
repeatedly passed swallow evaluations, and as patient's
strength and mental status improves, would suggesting
discontinuing the PEG tube encouraging full p.o. diet.

12. Parkinson's disease:  Patient has a history of
Parkinson's disease that he is treated with Sinemet on 5x a
day dosing 250 mg tablets, he receives dosing at 7 a.m., 10
a.m., 1 p.m., 4 p.m., 7 p.m.  Additionally he receives
entacapone 200 mg tablet 5x a day with his Sinemet.  Patient
will need to be continued to followed by his outpatient
neurologist and should have a scheduled appointment in the
near future.

13. Deconditioning:  Patient is extremely deconditioned
following his extensive hospitalization from [**1-15**],
on [**3-12**] was subsequently discharged and readmission
to [**Hospital1 8**] on [**3-21**].  He will need aggressive Physical Therapy.
He suffered multiple fractures of his lower extremities, had
skin grafting on his left following a severe cause of
cellulitis.  Please continue Physical Therapy as indicated
for assistance with ambulation and activities of daily
living.

DISCHARGE CONDITION:  Patient was stable on discharge.  He is
breathing comfortably on 4 liters nasal cannula, which is
required for appropriate oxygenation.  He is tolerating p.o.
intake with nutritional supplementation via PEG tube.  His
mental status has improved over the last 24-48 hours by
minimizing his medications.

DISCHARGE STATUS:  Patient is to be discharged to [**Hospital6 2696**] for an extended period of time.

DISCHARGE DIAGNOSES:
1. Sepsis, multifactorial.
2. Hypercarbic respiratory failure.
3. Hypoxic respiratory failure.
4. Pneumonia.
5. Clostridium difficile colitis.
6. Delirium, change in mental status.
7. Complications of Parkinson's disease.
8. Pain:  Status post motor vehicle accident.
9. Bright red blood per rectum/gastrointestinal bleed.
10. Eosinophilia.
11. Deep venous thrombosis.
12. Complications of Parkinson's disease.
13. Failure to thrive.

DISCHARGE MEDICATIONS:
1. Seroquel 50 mg p.o. b.i.d.
2. Metoprolol 50 mg p.o. t.i.d.
3. Senna one tablet p.o. b.i.d. prn constipation.
4. Colace 100 mg p.o. b.i.d, hold for loose stool.
5. Dermagen ointment one applicator TP b.i.d. prn.
6. Albuterol 1-2 puffs inhalation q.4. q.i.d.
7. Ipratropium bromide MDI two puffs inhalation q.i.d.
8. Tylenol liquid 650 mg p.o. q.4-6h. prn fever and pain.
9. Lansoprazole 30 mg q.d. via PEG.
10. Ascorbic acid 500 mg p.o. b.i.d.
11. Enoxaparin 80 mg subq q.12.
12. Sinemet 25/250 5x a day at 7 a.m., 10 a.m., 1 p.m., 4
p.m., and 7 p.m.
13. Multivitamin one cap p.o. q.d.
14. Entacapone 200 mg tablets 5x a day 7 a.m., 10 a.m., 1
p.m., 4 p.m., and 7 p.m.
15. Ibuprofen prn pain.
16. Zyprexa prn anxiety/agitation.

DISCHARGE INSTRUCTIONS:
1. The patient is to be discharged to [**Hospital6 9892**].
2. The patient should follow up with his primary neurologist
for continued management of his Parkinson's disease.
3. Patient should contact his primary care doctor within one
week to set a follow-up appointment and discuss his
complicated course at [**Hospital3 **] and continued medical care.
4. Patient should continue to be followed by Orthopedics for
management of his multiple lower extremity fracture sites.



                            [**First Name4 (NamePattern1) 963**] [**Last Name (NamePattern1) 964**], M.D.  [**MD Number(1) 965**]

Dictated By:[**Last Name (NamePattern1) 4517**]
MEDQUIST36

D:  [**2140-4-20**]  13:50
T:  [**2140-4-20**]  13:58
JOB#:  [**Job Number 9979**]

 (cclist)
{'Unspecified septicemia,Severe sepsis,Pneumonia, organism unspecified,Intestinal infection due to Clostridium difficile,Urinary tract infection, site not specified,Pulmonary collapse'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: 

PRESENT ILLNESS: This is a 68 year old gentleman
with a history of Parkinson's disease and a recent prolonged
complicated admission, status post motor vehicle accident
where he was hit by a car as a pedestrian who returned with
fever, shortness of breath and hypotension from
rehabilitation.  He was admitted on [**2140-1-15**] to
[**2140-3-12**] after being struck by a car.  In that
admission he had a complicated course including a right
fibular fracture and right acetabular fracture and multiple
left rib fractures and left perisplenic hematoma and left
common femoral vein deep vein thrombosis and had a inferior
vena cava filter placed on [**2140-1-6**].  He also had
evidence of right lower extremity skin necrosis in the thigh
and cellulitis which was debrided and had a skin graft from
his thigh.  Also during that hospitalization, he had an
exploratory laparotomy which showed left retroperitoneal,
perinephric hematoma, also complicated by pancreatitis status
post endoscopic retrograde cholangiopancreatography and
sphincterotomy and Methicillin-resistant Staphylococcus
aureus pneumonia which was treated with Vancomycin.  He was
discharged on [**1-10**] to [**Hospital1 **].  He was there two to
three days prior to representation at [**Hospital6 649**].  He developed fevers, tachypnea and shortness
of breath at that rehabilitation and was sent back in for
further evaluation.  On admission he had evidence of a right
lower lobe pneumonia.  He was started on Flagyl for concern
for aspiration pneumonia.  He was given a dose of Azotreanam
at the rehabilitation and was started on Vancomycin given his
history of Methicillin-resistant Staphylococcus aureus.

MEDICAL HISTORY: Past medical history includes 1.
Parkinson's disease since [**2121**]; 2.  Hypertension; 3.  Status
post motor vehicle accident trauma, being hit as a
pedestrian; 4.  Prostate cancer, status post prostatectomy.

MEDICATION ON ADMISSION: Sinemet, Senna, Atrovent,
Albuterol, Seroquel, Ultram, Entacapone with the Sinemet,
cream Glycerine, Lactulose, Colace, multivitamin, Tylenol,
Fragmin, Prevacid, Flagyl started on [**3-20**], Azotreanam
started on [**3-21**] and then Vancomycin given one dose on
[**3-21**].

ALLERGIES: Zosyn and Levaquin.

PHYSICAL EXAM: 

FAMILY HISTORY: Negative for coronary artery disease,
diabetes and coronary artery disease or cancers.

SOCIAL HISTORY: Negative tobacco or alcohol.  He was an
engineer on a ship with positive asbestosis exposure,
currently at rehabilitation.  He has a wife and daughter in
the nearby town. 

### Response:
{'Unspecified septicemia,Severe sepsis,Pneumonia, organism unspecified,Intestinal infection due to Clostridium difficile,Urinary tract infection, site not specified,Pulmonary collapse'}
