CHIEF COMPLAINT: Respiratory Distress

PRESENT ILLNESS: Ms. [**Known lastname **] is a 74yo F with history of COPD and recent
respiratory distress due to COPD exacerbation and pneumonia
requiring chest tube, VATS and eventual trach at [**Location (un) 620**] earlier
this month who presented to the ER from LTAC with respiratory
distress and vent dyssynchrony.
.
Patient was recently hospitalized at [**Hospital1 **] [**Location (un) 620**] from [**Date range (1) 80824**]
with complicated hospital course.  She presented with
respiratory distress and given concern for pneumothorax, she
underwent needle decompression.  Patient eventually underwent
VATS and trach with pleural fluid cultures from the VATS
revealing VRE, Proteus, coag-negative staph and [**Female First Name (un) 564**].
Initial sputum cultures revealed Pseudomonas.  Her hospital stay
was also complicated by sepsis requiring brief pressor support.
Her antibiotics were tailored to fluconazole, imipenem and
linezolid with plans for additional 10 day course (to end approx
[**5-25**]), and she was discharged to [**Hospital1 100**] LTAC on these through a
subclavian central line.
.
At the rehab, she was continued on these antibiotics.  Patient
developed vent discordance and was sent to [**Hospital1 18**] ER for further
evaluation.
.
In the ED, initial vs significant for hypotension with SBP<90.
She was started on levophed.  Patient was also given stress dose
steroids, home dose linezolid, 2L of NS and had CXR which showed
bilateral pleural effusions and bibasilar atelectasis.  CT of
her head was remarkable for encephalomalacia and CT torso showed
resolving pneumonia, stable AAA and large ventral hernia
containing bowel without signs of incarceration.  Surgery was
consulted but felt there was no acute surgical need.  Patient
was unable to have ABG drawn and VBG was significant for extreme
hypoxemia with gas 7.21/66/29/28.  She was admitted to the MICU
for further treatment.  Vitals on transfer were 77, 158/81 with
levo at 0.06, 94% AC 450x20, 5, 50% Fi02.
.
In the ICU, patient is intubated and not following commands or
responding to questions.
.
Review of systems: Unable to obtain

MEDICAL HISTORY: - MI
- DM
- recent respiratory distress s/p trach replacement earlier this
month, [**5-9**]
- COPD s/p ruptured diverticulum with prolonged resp failure and

MEDICATION ON ADMISSION: Medications: per rehab notes
Linezolid 600 mg IV bid
Imipenem 500 mg IV q. 6 hours
Fluconazole 400 mg PO daily
Albuterol 6puffs q4 MDI
Albuterol nebs q4
Amlodipine 10mg qdaily
Atenolol 50mg [**Hospital1 **]
Clonazepam 1mg [**Hospital1 **]
Senna daily
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 10711**]/mg hydro/simeth 30mL q6 NG PRN
Guaifenesin 300mg q4 NG PRN
Ativan 1mg q4 IV PRN
Morphine 2mg SL q4 PRN
Nitro 0.3mg SL PRN
Prochlorperazine 25mg PR PRN
Clotrimazole 1% cream [**Hospital1 **]
Eucerin [**Hospital1 **]
Flucinolone 0.025% ointment qHS
Acetaminophen 650mg q6 NG PRN
Miconazole [**Hospital1 **] topically and vaginally
Zinc oxide 40% [**Hospital1 **]

ALLERGIES: Penicillins / Levaquin in D5W

PHYSICAL EXAM: ADMISSION PHYSICAL:
Vitals: T:99.8rectal BP:154/99 P:64 R:26 O2: 96%
General: opens eyes to voice, will not follow commands
HEENT: mucous membranes dry, no LAD, PERRLA
Neck: JVP not elevated,
Lungs: harsh upper airway sound from trach with cough leak,
clear to auscultation bilaterally, no wheezes, rales, rhonchi
CV: Regular rate and rhythm, no murmurs, rubs, gallops
Abdomen: soft, non-tender, colectomy site non tender/non
erythematous, large right sided pannus with evidence of multiple
abdominal surgeries. bowel sounds present, no rebound tenderness
or guarding, no organomegaly
GU: foley in place, macerated area under right sided pannus that
is erythematous
Ext: slightly cool extremities, well perfused, 1+  pedal pulses,
no palpable radial or ulnar pulses. Bilateral clubbing in feet.
No cyanosis or edema
.
DISCHARGE PHYSICAL:
General: opens eyes to voice, follows commands
HEENT: mucous membranes dry, no LAD, PERRLA
Neck: JVP not elevated,
Lungs: no audible leak, no rhonchi, no rales, no wheezes
CV: Regular rate and rhythm, no murmurs, rubs, gallops
Abdomen: soft, non-tender, colectomy site non tender/non
erythematous, large right sided pannus with evidence of multiple
abdominal surgeries. bowel sounds present and visible
peristalsis, no rebound tenderness or guarding, no organomegaly

FAMILY HISTORY: Per records, Positive for CAD.

SOCIAL HISTORY: The patient is a nursing home resident, a former smoker.
Mechanical complication of tracheostomy,Chronic respiratory failure,Ventilator associated pneumonia,Chronic diastolic heart failure,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Other iatrogenic hypotension,Hypovolemia,Unspecified essential hypertension,Chronic airway obstruction, not elsewhere classified,Ventral, unspecified, hernia without mention of obstruction or gangrene,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Long-term (current) use of anticoagulants
Tracheostomy - mech comp,Chronic respiratory fail,Ventltr assoc pneumonia,Chr diastolic hrt fail,Abnrml coagultion prfile,Adv eff anticoagulants,Iatrogenc hypotnsion NEC,Hypovolemia,Hypertension NOS,Chr airway obstruct NEC,Ventral hernia NOS,Hx TIA/stroke w/o resid,Long-term use anticoagul
Admission Date:  [**2163-5-21**]              Discharge Date:   [**2163-5-25**]

Date of Birth:  [**2088-12-23**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Levaquin in D5W

Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Respiratory Distress

Major Surgical or Invasive Procedure:
Tracheostomy change with bronchoscopy and biopsy
.
PICC placement


History of Present Illness:
Ms. [**Known lastname **] is a 74yo F with history of COPD and recent
respiratory distress due to COPD exacerbation and pneumonia
requiring chest tube, VATS and eventual trach at [**Location (un) 620**] earlier
this month who presented to the ER from LTAC with respiratory
distress and vent dyssynchrony.
.
Patient was recently hospitalized at [**Hospital1 **] [**Location (un) 620**] from [**Date range (1) 80824**]
with complicated hospital course.  She presented with
respiratory distress and given concern for pneumothorax, she
underwent needle decompression.  Patient eventually underwent
VATS and trach with pleural fluid cultures from the VATS
revealing VRE, Proteus, coag-negative staph and [**Female First Name (un) 564**].
Initial sputum cultures revealed Pseudomonas.  Her hospital stay
was also complicated by sepsis requiring brief pressor support.
Her antibiotics were tailored to fluconazole, imipenem and
linezolid with plans for additional 10 day course (to end approx
[**5-25**]), and she was discharged to [**Hospital1 100**] LTAC on these through a
subclavian central line.
.
At the rehab, she was continued on these antibiotics.  Patient
developed vent discordance and was sent to [**Hospital1 18**] ER for further
evaluation.
.
In the ED, initial vs significant for hypotension with SBP<90.
She was started on levophed.  Patient was also given stress dose
steroids, home dose linezolid, 2L of NS and had CXR which showed
bilateral pleural effusions and bibasilar atelectasis.  CT of
her head was remarkable for encephalomalacia and CT torso showed
resolving pneumonia, stable AAA and large ventral hernia
containing bowel without signs of incarceration.  Surgery was
consulted but felt there was no acute surgical need.  Patient
was unable to have ABG drawn and VBG was significant for extreme
hypoxemia with gas 7.21/66/29/28.  She was admitted to the MICU
for further treatment.  Vitals on transfer were 77, 158/81 with
levo at 0.06, 94% AC 450x20, 5, 50% Fi02.
.
In the ICU, patient is intubated and not following commands or
responding to questions.
.
Review of systems: Unable to obtain


Past Medical History:
- MI
- DM
- recent respiratory distress s/p trach replacement earlier this
month, [**5-9**]
- COPD s/p ruptured diverticulum with prolonged resp failure and

trach in rehab for approximately 1 year and removed in [**11-5**]
- HTN
- CHF [**3-2**] diastolic dysfunction
- Prior CVA
- Depression and anxiety
- colostomy [**3-2**] to multiple hernia repair(?)
- h/o MRSA, C. Diff, pseudomonas, VRE


Social History:
The patient is a nursing home resident, a former smoker.


Family History:
Per records, Positive for CAD.


Physical Exam:
ADMISSION PHYSICAL:
Vitals: T:99.8rectal BP:154/99 P:64 R:26 O2: 96%
General: opens eyes to voice, will not follow commands
HEENT: mucous membranes dry, no LAD, PERRLA
Neck: JVP not elevated,
Lungs: harsh upper airway sound from trach with cough leak,
clear to auscultation bilaterally, no wheezes, rales, rhonchi
CV: Regular rate and rhythm, no murmurs, rubs, gallops
Abdomen: soft, non-tender, colectomy site non tender/non
erythematous, large right sided pannus with evidence of multiple
abdominal surgeries. bowel sounds present, no rebound tenderness
or guarding, no organomegaly
GU: foley in place, macerated area under right sided pannus that
is erythematous
Ext: slightly cool extremities, well perfused, 1+  pedal pulses,
no palpable radial or ulnar pulses. Bilateral clubbing in feet.
No cyanosis or edema
.
DISCHARGE PHYSICAL:
General: opens eyes to voice, follows commands
HEENT: mucous membranes dry, no LAD, PERRLA
Neck: JVP not elevated,
Lungs: no audible leak, no rhonchi, no rales, no wheezes
CV: Regular rate and rhythm, no murmurs, rubs, gallops
Abdomen: soft, non-tender, colectomy site non tender/non
erythematous, large right sided pannus with evidence of multiple
abdominal surgeries. bowel sounds present and visible
peristalsis, no rebound tenderness or guarding, no organomegaly

GU: foley in place, macerated area under right sided pannus that
is erythematous
Ext: slightly cool extremities, well perfused, 1+  pedal pulses,
no palpable radial or ulnar pulses. Bilateral clubbing in feet.
No cyanosis or edema


Pertinent Results:
ADMISSION LABS:
[**2163-5-20**] 08:00PM BLOOD WBC-12.3* RBC-4.32 Hgb-11.1* Hct-36.1
MCV-84 MCH-25.7* MCHC-30.7* RDW-19.7* Plt Ct-570*
[**2163-5-20**] 08:00PM BLOOD Neuts-85.7* Lymphs-9.7* Monos-3.4 Eos-0.7
Baso-0.5
[**2163-5-20**] 08:00PM BLOOD Plt Ct-570*
[**2163-5-20**] 08:00PM BLOOD Glucose-133* UreaN-23* Creat-0.5 Na-136
K-5.6* Cl-104 HCO3-24 AnGap-14
[**2163-5-20**] 08:00PM BLOOD ALT-18 AST-19 LD(LDH)-266* AlkPhos-153*
TotBili-0.2
[**2163-5-20**] 08:00PM BLOOD cTropnT-0.05*
[**2163-5-21**] 03:22AM BLOOD CK-MB-5 cTropnT-0.02*
[**2163-5-21**] 12:12PM BLOOD CK-MB-4 cTropnT-<0.01
[**2163-5-20**] 08:00PM BLOOD Albumin-3.7
[**2163-5-21**] 03:22AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.0
[**2163-5-20**] 09:17PM BLOOD Type-ART Tidal V-450 PEEP-5 FiO2-50
pO2-29* pCO2-66* pH-7.21* calTCO2-28 Base XS--4 -ASSIST/CON
Intubat-INTUBATED
.
DISCHARGE LABS:
[**2163-5-25**] 04:30AM BLOOD WBC-7.4 RBC-3.91* Hgb-10.1* Hct-31.8*
MCV-81* MCH-25.8* MCHC-31.8 RDW-19.7* Plt Ct-512*
[**2163-5-24**] 03:28AM BLOOD WBC-10.3 RBC-4.22 Hgb-10.7* Hct-34.5*
MCV-82 MCH-25.3* MCHC-30.9* RDW-20.3* Plt Ct-652*
[**2163-5-23**] 03:03AM BLOOD WBC-10.0# RBC-4.03* Hgb-10.4* Hct-32.5*
MCV-81* MCH-25.8* MCHC-32.0 RDW-19.9* Plt Ct-585*
[**2163-5-22**] 03:52PM BLOOD Hct-32.5*
[**2163-5-22**] 04:48AM BLOOD WBC-6.2 RBC-3.78* Hgb-9.7* Hct-30.8*
MCV-81* MCH-25.6* MCHC-31.4 RDW-20.4* Plt Ct-562*
[**2163-5-25**] 04:30AM BLOOD Plt Ct-512*
[**2163-5-25**] 04:30AM BLOOD PT-13.4 PTT-22.3 INR(PT)-1.1
[**2163-5-24**] 03:28AM BLOOD Plt Ct-652*
[**2163-5-24**] 03:28AM BLOOD PT-17.8* PTT-24.3 INR(PT)-1.6*
[**2163-5-23**] 03:03AM BLOOD Plt Ct-585*
[**2163-5-23**] 03:03AM BLOOD PT-40.0* PTT-31.7 INR(PT)-4.1*
[**2163-5-22**] 04:48AM BLOOD Plt Ct-562*
[**2163-5-25**] 04:30AM BLOOD Glucose-95 UreaN-8 Creat-0.3* Na-142
K-4.1 Cl-100 HCO3-32 AnGap-14
[**2163-5-24**] 03:28AM BLOOD Glucose-108* UreaN-12 Creat-0.3* Na-140
K-4.2 Cl-97 HCO3-32 AnGap-15
[**2163-5-23**] 02:36PM BLOOD Glucose-100 UreaN-14 Creat-0.4 Na-143
K-5.2* Cl-102 HCO3-31 AnGap-15
[**2163-5-23**] 03:03AM BLOOD Glucose-97 UreaN-13 Creat-0.3* Na-142
K-3.3 Cl-105 HCO3-29 AnGap-11
.
STUDIES:
CXR [**2163-5-20**]:
IMPRESSION: Tubes and lines positioned appropriately.
Cardiomegaly with
bilateral pleural effusions and bibasilar atelectasis.
.
CXR [**2163-5-22**]:
IMPRESSION: Limited study demonstrating no definite change.
.
CXR [**2163-5-24**]:
FINDINGS: The right PICC line extends to the mid-to-lower
portion of the SVC. Otherwise little change.
.
CT TORSO [**2163-5-20**]:
IMPRESSION:
1. Resolving bibasilar pneumonia, with trace residual pleural
effusions.
2. Large left ventral hernia, with simple ascites and mild
stranding of the fat and thickening of the omentum within the
hernia. Consider and element of fat necrosis in the right
clinical setting.
3. No evidence of bowel pathology.
4. Unchanged suprarenal aortic ectasia and infrarenal AAA.
.
IP study [**2163-5-24**]: read pending
.
MICRO:
  URINE CULTURE (Final [**2163-5-21**]):    NO GROWTH.
.
BCX [**2163-5-20**]: PENDING
.
[**2163-5-21**] 9:08 am SPUTUM     Site: ENDOTRACHEAL
      Source: Endotracheal.

                            **FINAL REPORT [**2163-5-25**]**

   GRAM STAIN (Final [**2163-5-21**]):
      >25 PMNs and <10 epithelial cells/100X field.
      4+   (>10 per 1000X FIELD):   GRAM NEGATIVE ROD(S).

   RESPIRATORY CULTURE (Final [**2163-5-25**]):
      Commensal Respiratory Flora Absent.
      PSEUDOMONAS AERUGINOSA.    MODERATE GROWTH.
         Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
         [**Last Name (NamePattern1) 3060**].
      KLEBSIELLA PNEUMONIAE.    SPARSE GROWTH.
         WARNING! This isolate is an extended-spectrum
beta-lactamase
         (ESBL) producer and should be considered resistant to
all
         penicillins, cephalosporins, and aztreonam. Consider
Infectious
         Disease consultation for serious infections caused by
         ESBL-producing species.
         Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
         [**Last Name (NamePattern1) 3060**].

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             PSEUDOMONAS AERUGINOSA
                             |          KLEBSIELLA PNEUMONIAE
                             |          |
AMPICILLIN/SULBACTAM--             =>32 R
CEFAZOLIN-------------             =>64 R
CEFEPIME--------------    32 R          R
CEFTAZIDIME-----------    32 R     =>64 R
CEFTRIAXONE-----------                  R
CIPROFLOXACIN---------   =>4 R      =>4 R
GENTAMICIN------------     8 I      <=1 S
MEROPENEM-------------  =>16 R   <=0.25 S
PIPERACILLIN/TAZO----- =>128 R       16 S
TOBRAMYCIN------------   <=1 S     =>16 R
TRIMETHOPRIM/SULFA----              <=1 S

BAL:
[**2163-5-24**] 3:30 pm BRONCHOALVEOLAR LAVAGE      RIGHT MIDDLE LOBE.

   GRAM STAIN (Final [**2163-5-24**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      NO MICROORGANISMS SEEN.

   RESPIRATORY CULTURE (Preliminary):    RESULTS PENDING.


Brief Hospital Course:
HOSPITAL COURSE:
Ms. [**Known lastname **] is a 74yo F with history of COPD and recent
respiratory distress requiring VATS and trach here with vent
dyssynchrony and respiratory distress. Pt was continued on broad
spectrum abx, and continued course with completed date on [**5-25**].
Pt had trach changed with IP on [**5-24**], without complications.
.
ACTIVE ISSUES:
.
# Respiratory failure: Patient has been vent dependent at the
rehab facility since trach replacement earlier this month in
setting of COPD exacerbation and pneumonia.  Her CT here shows
resolving pneumonia, and she has been treated with broad
spectrum antibiotics - linezolid, imipenem and fluconazole based
on her prior sensitivities from her pleural fluid. Once pt
admitted, did well on vent without dysynchrony. Respiratory
distress there attributed Bubona trach. She was continued on
MDIs on the ventilator. IP was consulted regarding change of her
trach. The patient had her trach changed on [**5-24**] in the OR to a
long (130mm) flexible trach. The patient afterwards did not have
any dyssynchrony. Otherwise was not having any respiratory
distress. Her lung sounds improved and her oxygen saturations
were consistent after the trach was replaced.
Of note, pt had sputum cultures here growing pseudomonas &
klebsiella. However, these were thought to be [**3-2**] colonization,
as pt remained afebrile without leukocytosis or secretions to
suggest pneumonia.
.
# Hypotension: Most likely [**3-2**] continued VAP, vs. auto-PEEP,
some sedation. Pt required brief levophed in the ED. She was
continued on broad spectrum abx with
Linezolid/Meropenem/Fluconazole per previous regiment with end
date [**2163-5-25**]. ACS was ruled-out with CE's. Auto-PEEP considered
as well, but did not appear to be auto-PEEPing on vent. C. diff
was sent as well, but was negative. BPs improved. After the
procedure on [**5-24**] the patient became hypotensive into the high
70s however quickly resolved with pressures in the 90s after a
500 cc bolus. The hypotension completely resolved 4 hours after
the procedure with blood pressures in the 120s. Pt has
hemodynamically stable at time of discharge.
Home atenolol 50mg [**Hospital1 **] and amlodipine 10mg daily were held
during this admission. These should be restarted as needed per
her physicians at the LTAC.
.
# Diastolic dysfunction: She has known diastolic dysfunction
with suggestion of cardiomegaly on CXR.  No signs of volume
overload on exam but she has received 2 liters of NS in the ER.
Maintained euvolemic volume status with gentle hydration for
hypotension as above. Appeared euvolemic at discharge.
.
# h/o hyperglycemia: She had history of glucose intolerance
while on steroids at [**Location (un) 620**].  While here, will have her on FSBS
QID with insulin sliding scale while on steroids. Her BG were
normal on discharge, and insulin was not continued on discharge.
This should be followed up further at rehab to assess insulin
needs.
.
INACTIVE ISSUES:
.
# h/o CVA: INR Supratherapeutic on admission, and Warfarin held.
The patient was not restarted on her warfarin given that the
reason was for her previous CVA and with no history of embolic
disease. She was started on an ASA 325mg daily.
.
# Large hernia: She has a large ventral hernia containing bowel
without signs of incarceration. The patient's PCP was notified
and will follow up with general surgery clinic for elective
repair.
.
TRANSITIONAL CARE:
1. CODE: FULL
2. FOLLOW-UP:
- with physicians at LTAC
3. Medical management:
- STOP Warfarin
- Completed Linezolid/Vanc/Fluconazole
- Complete one more day of Prednisone 5mg
- START Aspirin, Lansoprazole, Chlorhexidine oral care
- Increase dose of prn Ativan
- Held Amlodipine, Atenolol - should be restarted as needed at
LTAC

Medications on Admission:
Medications: per rehab notes
Linezolid 600 mg IV bid
Imipenem 500 mg IV q. 6 hours
Fluconazole 400 mg PO daily
Albuterol 6puffs q4 MDI
Albuterol nebs q4
Amlodipine 10mg qdaily
Atenolol 50mg [**Hospital1 **]
Clonazepam 1mg [**Hospital1 **]
Senna daily
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 10711**]/mg hydro/simeth 30mL q6 NG PRN
Guaifenesin 300mg q4 NG PRN
Ativan 1mg q4 IV PRN
Morphine 2mg SL q4 PRN
Nitro 0.3mg SL PRN
Prochlorperazine 25mg PR PRN
Clotrimazole 1% cream [**Hospital1 **]
Eucerin [**Hospital1 **]
Flucinolone 0.025% ointment qHS
Acetaminophen 650mg q6 NG PRN
Miconazole [**Hospital1 **] topically and vaginally
Zinc oxide 40% [**Hospital1 **]


Discharge Medications:
1. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
Six (6) Puff Inhalation Q4H (every 4 hours).
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
Six (6) Puff Inhalation Q4H (every 4 hours).
3. acetaminophen 650 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
4. clonazepam 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day.
5. lorazepam 2 mg/mL Syringe [**Hospital1 **]: Two (2) mg Injection Q4H
(every 4 hours) as needed for anxiety.
6. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. clotrimazole 1 % Cream [**Last Name (STitle) **]: One (1)  Topical twice a day.
8. nitroglycerin 0.3 mg Tablet, Sublingual [**Last Name (STitle) **]: One (1)
Sublingual ONCE as needed for chest pain.
9. prochlorperazine 25 mg Suppository [**Last Name (STitle) **]: One (1)  Rectal once
a day as needed for nausea.
10. Eucerin     Cream [**Last Name (STitle) **]: One (1)  Topical twice a day.
11. aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).

12. heparin, porcine (PF) 10 unit/mL Syringe [**Last Name (STitle) **]: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
13. senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day as
needed for constipation.
14. prednisone 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily)
for 1 days.
15. Maalox Advanced 200-200-20 mg/5 mL Suspension [**Last Name (STitle) **]: Thirty
(30) ml PO every six (6) hours as needed for heartburn.
16. chlorhexidine gluconate 0.12 % Mouthwash [**Last Name (STitle) **]: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day).
17. zinc oxide 40 % Ointment [**Hospital1 **]: One (1)  Topical twice a day.

18. miconazole     Powder [**Hospital1 **]: One (1)  Miscellaneous twice a
day.
19. morphine 2 mg/mL Syringe [**Hospital1 **]: Two (2) mg Injection every
four (4) hours as needed for chest pain, tachypnea.
20. docusate sodium 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a
day.
21. guaifenesin 200 mg/5 mL Liquid [**Hospital1 **]: Three Hundred (300) ml
PO every four (4) hours as needed for cough.
22. fluocinolone 0.025 % Cream [**Hospital1 **]: One (1)  Topical at bedtime.



Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
Primary Diagnosis
Trach leak
.
Secondary Diagnoses:
CAD
DM
COPD
HTN
dCHF
Prior CVA
Depression and anxiety
Colostomy [**3-2**] to multiple hernia repair(?)
h/o MRSA, C. Diff, pseudomona, VRE


Discharge Condition:
Activity Status: Bedbound.
Level of Consciousness: Lethargic but arousable.
Mental Status: Confused - always.


Discharge Instructions:
You were admitted to [**Hospital1 18**] for evaluation of respiratory
distress.  You were found to have an ill fitting tracheostomy.
You had this replaced on [**2163-5-24**].  Your symptoms improved.
.
MEDICATION CHANGES:
STOP Linezolid
STOP Meropenem
STOP Fluconazole
Continue prednisone 5mg for one more day
DO NOT RESTART Coumadin
START Aspirin 325mg daily
START Colace 100mg twice daily
START Lansoprazole 30mg by mouth daily
START Chlorhexidone oral rinse 15mL twice daily
Change the dose of Lorazepam from 1mg to 2-4mg IV every 4 hrs as
needed for anxiety
Discuss restarting Amlodipine and Atenolol with your doctors (we
held both of these here given low blood pressures)

Followup Instructions:
Please follow up with the rehab physicians.



Completed by:[**2163-5-25**]
{'Mechanical complication of tracheostomy,Chronic respiratory failure,Ventilator associated pneumonia,Chronic diastolic heart failure,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Other iatrogenic hypotension,Hypovolemia,Unspecified essential hypertension,Chronic airway obstruction, not elsewhere classified,Ventral, unspecified, hernia without mention of obstruction or gangrene,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Long-term (current) use of anticoagulants'}


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: Respiratory Distress

PRESENT ILLNESS: Ms. [**Known lastname **] is a 74yo F with history of COPD and recent
respiratory distress due to COPD exacerbation and pneumonia
requiring chest tube, VATS and eventual trach at [**Location (un) 620**] earlier
this month who presented to the ER from LTAC with respiratory
distress and vent dyssynchrony.
.
Patient was recently hospitalized at [**Hospital1 **] [**Location (un) 620**] from [**Date range (1) 80824**]
with complicated hospital course.  She presented with
respiratory distress and given concern for pneumothorax, she
underwent needle decompression.  Patient eventually underwent
VATS and trach with pleural fluid cultures from the VATS
revealing VRE, Proteus, coag-negative staph and [**Female First Name (un) 564**].
Initial sputum cultures revealed Pseudomonas.  Her hospital stay
was also complicated by sepsis requiring brief pressor support.
Her antibiotics were tailored to fluconazole, imipenem and
linezolid with plans for additional 10 day course (to end approx
[**5-25**]), and she was discharged to [**Hospital1 100**] LTAC on these through a
subclavian central line.
.
At the rehab, she was continued on these antibiotics.  Patient
developed vent discordance and was sent to [**Hospital1 18**] ER for further
evaluation.
.
In the ED, initial vs significant for hypotension with SBP<90.
She was started on levophed.  Patient was also given stress dose
steroids, home dose linezolid, 2L of NS and had CXR which showed
bilateral pleural effusions and bibasilar atelectasis.  CT of
her head was remarkable for encephalomalacia and CT torso showed
resolving pneumonia, stable AAA and large ventral hernia
containing bowel without signs of incarceration.  Surgery was
consulted but felt there was no acute surgical need.  Patient
was unable to have ABG drawn and VBG was significant for extreme
hypoxemia with gas 7.21/66/29/28.  She was admitted to the MICU
for further treatment.  Vitals on transfer were 77, 158/81 with
levo at 0.06, 94% AC 450x20, 5, 50% Fi02.
.
In the ICU, patient is intubated and not following commands or
responding to questions.
.
Review of systems: Unable to obtain

MEDICAL HISTORY: - MI
- DM
- recent respiratory distress s/p trach replacement earlier this
month, [**5-9**]
- COPD s/p ruptured diverticulum with prolonged resp failure and

MEDICATION ON ADMISSION: Medications: per rehab notes
Linezolid 600 mg IV bid
Imipenem 500 mg IV q. 6 hours
Fluconazole 400 mg PO daily
Albuterol 6puffs q4 MDI
Albuterol nebs q4
Amlodipine 10mg qdaily
Atenolol 50mg [**Hospital1 **]
Clonazepam 1mg [**Hospital1 **]
Senna daily
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 10711**]/mg hydro/simeth 30mL q6 NG PRN
Guaifenesin 300mg q4 NG PRN
Ativan 1mg q4 IV PRN
Morphine 2mg SL q4 PRN
Nitro 0.3mg SL PRN
Prochlorperazine 25mg PR PRN
Clotrimazole 1% cream [**Hospital1 **]
Eucerin [**Hospital1 **]
Flucinolone 0.025% ointment qHS
Acetaminophen 650mg q6 NG PRN
Miconazole [**Hospital1 **] topically and vaginally
Zinc oxide 40% [**Hospital1 **]

ALLERGIES: Penicillins / Levaquin in D5W

PHYSICAL EXAM: ADMISSION PHYSICAL:
Vitals: T:99.8rectal BP:154/99 P:64 R:26 O2: 96%
General: opens eyes to voice, will not follow commands
HEENT: mucous membranes dry, no LAD, PERRLA
Neck: JVP not elevated,
Lungs: harsh upper airway sound from trach with cough leak,
clear to auscultation bilaterally, no wheezes, rales, rhonchi
CV: Regular rate and rhythm, no murmurs, rubs, gallops
Abdomen: soft, non-tender, colectomy site non tender/non
erythematous, large right sided pannus with evidence of multiple
abdominal surgeries. bowel sounds present, no rebound tenderness
or guarding, no organomegaly
GU: foley in place, macerated area under right sided pannus that
is erythematous
Ext: slightly cool extremities, well perfused, 1+  pedal pulses,
no palpable radial or ulnar pulses. Bilateral clubbing in feet.
No cyanosis or edema
.
DISCHARGE PHYSICAL:
General: opens eyes to voice, follows commands
HEENT: mucous membranes dry, no LAD, PERRLA
Neck: JVP not elevated,
Lungs: no audible leak, no rhonchi, no rales, no wheezes
CV: Regular rate and rhythm, no murmurs, rubs, gallops
Abdomen: soft, non-tender, colectomy site non tender/non
erythematous, large right sided pannus with evidence of multiple
abdominal surgeries. bowel sounds present and visible
peristalsis, no rebound tenderness or guarding, no organomegaly

FAMILY HISTORY: Per records, Positive for CAD.

SOCIAL HISTORY: The patient is a nursing home resident, a former smoker. 

### Response:
{'Mechanical complication of tracheostomy,Chronic respiratory failure,Ventilator associated pneumonia,Chronic diastolic heart failure,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Other iatrogenic hypotension,Hypovolemia,Unspecified essential hypertension,Chronic airway obstruction, not elsewhere classified,Ventral, unspecified, hernia without mention of obstruction or gangrene,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Long-term (current) use of anticoagulants'}
