CHIEF COMPLAINT: Fevers, leukocytosis

PRESENT ILLNESS: Patient is a 43 year old gentleman recently discharged from
[**Hospital1 18**] after a prolonged hospital stay ([**Date range (1) 73853**]) who experienced
an reported episode of asystolic arrest in setting of fevers and
worsening pulmonary function. He was revived at the extended
care facility and was brought to [**Hospital1 18**] for further care. For
details of previous hospitalization please see dictated
discharge summary and multiple operative reports.

MEDICAL HISTORY: Polytrauma requiring multiple operative interventions
Anoxic brain injury
Placement of IVC filter, percutaneous gastrostomy, tracheostomy

MEDICATION ON ADMISSION: . Famotidine 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H (every 12
hours).
2. Artificial Tear with Lanolin 0.1-0.1 % Ointment [**Hospital1 **]: One (1)
Appl Ophthalmic PRN (as needed).
3. Levetiracetam 100 mg/mL Solution [**Hospital1 **]: [**2-13**] PO QHS (once a day
(at bedtime)).
4. Levetiracetam 100 mg/mL Solution [**Month/Day (2) **]: [**2-13**] PO QAM (once a day
(in the morning)).
5. Acetaminophen 160 mg/5 mL Solution [**Month/Day (2) **]: [**2-13**] PO Q6H (every 6
hours) as needed.
6. Ibuprofen 100 mg/5 mL Suspension [**Month/Day (2) **]: [**2-13**] PO Q8H (every 8
hours) as needed.
7. Enoxaparin 30 mg/0.3 mL Syringe [**Month/Day (2) **]: [**2-13**] Subcutaneous Q12H
(every 12 hours).
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Day (2) **]: Two (2)
Tablet, Delayed Release (E.C.) PO HS (at bedtime) as needed.
9. Phenobarbital 100 mg Tablet [**Month/Day (2) **]: Three (3) Tablet PO TID (3
times a day).
10. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (2) **]: [**2-13**] PO BID (2 times
a day).
11. Senna 8.6 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO BID (2 times a day)
as needed.
12. Topiramate 100 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO 5X/DAY (5
Times a Day).
13. Therapeutic Multivitamin Liquid [**Month/Day (2) **]: Five (5) ML PO
DAILY (Daily).
14. Folic Acid 1 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily).

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: HEENT: PERRLA, eyes opening spontneously
Resp: Tracheostomy, course breath sounds bilaterally. Trach
site without drainage or erythema
CV: RRR, strong pedal pulses
AB: soft, mildly distended, + BS. PEG tube w/o drainage or
erythema
GU: foley in place
Ext: cast on RUE, multipodus boots on bilateral LE, bilat LE
wrapped with gauze dressing; PIC on Left arm, c/d/i
Skin: pressure sore on coccyx - stage 3-4, covered wtih tegaderm
Neuro: no gag response, + corneal response, No motor seizure
activity

FAMILY HISTORY: no pertinent history

SOCIAL HISTORY: Firefighter
Pneumonia, organism unspecified,Pulmonary collapse,Anoxic brain damage,Pressure ulcer, lower back,Leukocytosis, unspecified,Acute sinusitis, unspecified,Other specified cardiac dysrhythmias,Tracheostomy status,Gastrostomy status
Pneumonia, organism NOS,Pulmonary collapse,Anoxic brain damage,Pressure ulcer, low back,Leukocytosis NOS,Acute sinusitis NOS,Cardiac dysrhythmias NEC,Tracheostomy status,Gastrostomy status
Admission Date:  [**2148-9-21**]              Discharge Date:   [**2148-9-26**]

Date of Birth:  [**2104-12-17**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Fevers, leukocytosis

Major Surgical or Invasive Procedure:
Central line placement
PICC placement


History of Present Illness:
Patient is a 43 year old gentleman recently discharged from
[**Hospital1 18**] after a prolonged hospital stay ([**Date range (1) 73853**]) who experienced
an reported episode of asystolic arrest in setting of fevers and
worsening pulmonary function. He was revived at the extended
care facility and was brought to [**Hospital1 18**] for further care. For
details of previous hospitalization please see dictated
discharge summary and multiple operative reports.

Past Medical History:
Polytrauma requiring multiple operative interventions
Anoxic brain injury
Placement of IVC filter, percutaneous gastrostomy, tracheostomy

Social History:
Firefighter


Family History:
no pertinent history

Physical Exam:
HEENT: PERRLA, eyes opening spontneously
Resp: Tracheostomy, course breath sounds bilaterally. Trach
site without drainage or erythema
CV: RRR, strong pedal pulses
AB: soft, mildly distended, + BS. PEG tube w/o drainage or
erythema
GU: foley in place
Ext: cast on RUE, multipodus boots on bilateral LE, bilat LE
wrapped with gauze dressing; PIC on Left arm, c/d/i
Skin: pressure sore on coccyx - stage 3-4, covered wtih tegaderm
Neuro: no gag response, + corneal response, No motor seizure
activity


Pertinent Results:
[**2148-9-24**] 02:12AM BLOOD WBC-13.8* RBC-2.65* Hgb-8.4* Hct-26.2*
MCV-99* MCH-31.9 MCHC-32.2 RDW-17.3* Plt Ct-539*
[**2148-9-23**] 01:20AM BLOOD WBC-15.7* RBC-2.75* Hgb-8.7* Hct-26.8*
MCV-97 MCH-31.5 MCHC-32.3 RDW-17.5* Plt Ct-579*
[**2148-9-22**] 02:11AM BLOOD WBC-23.1* RBC-2.81* Hgb-8.9* Hct-26.8*
MCV-95 MCH-31.7 MCHC-33.2 RDW-17.8* Plt Ct-540*
[**2148-9-21**] 03:25AM BLOOD WBC-24.3*# RBC-2.90* Hgb-9.3*# Hct-27.7*
MCV-95 MCH-32.0 MCHC-33.5 RDW-17.8* Plt Ct-495*
[**2148-9-22**] 02:11AM BLOOD Neuts-78.3* Lymphs-10.6* Monos-10.5
Eos-0.3 Baso-0.3
[**2148-9-21**] 03:25AM BLOOD Neuts-75* Bands-2 Lymphs-10* Monos-9
Eos-0 Baso-0 Atyps-1* Metas-3* Myelos-0
[**2148-9-24**] 02:12AM BLOOD Plt Ct-539*
[**2148-9-24**] 02:12AM BLOOD PT-13.2* PTT-25.7 INR(PT)-1.1
[**2148-9-23**] 01:20AM BLOOD Plt Ct-579*
[**2148-9-24**] 02:12AM BLOOD Glucose-139* UreaN-16 Creat-0.3* Na-147*
K-4.1 Cl-112* HCO3-31 AnGap-8
[**2148-9-23**] 01:20AM BLOOD Glucose-167* UreaN-15 Creat-0.3* Na-144
K-3.4 Cl-109* HCO3-28 AnGap-10
[**2148-9-21**] 10:25AM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2148-9-21**] 03:25AM BLOOD cTropnT-0.13*
[**2148-9-24**] 02:12AM BLOOD Albumin-1.6* Calcium-7.7* Phos-3.2 Mg-2.2
[**2148-9-23**] 01:20AM BLOOD Calcium-7.6* Phos-2.5* Mg-1.9
[**2148-9-22**] 09:19PM BLOOD Genta-0.7*
[**2148-9-24**] 02:12AM BLOOD Phenoba-91.2* Phenyto-11.7
[**2148-9-21**] 10:25AM BLOOD Valproa-8*
[**2148-9-21**] 10:22PM BLOOD Type-ART pO2-216* pCO2-36 pH-7.49*
calTCO2-28 Base

[**2148-9-22**] 12:13 am CATHETER TIP-IV

   WOUND CULTURE (Preliminary):    No significant growth
[**2148-9-21**] 4:46 pm SPUTUM     Site: ENDOTRACHEAL
      Source: Endotracheal.

   GRAM STAIN (Final [**2148-9-21**]):
      >25 PMNs and <10 epithelial cells/100X field.
      NO MICROORGANISMS SEEN.

   RESPIRATORY CULTURE (Final [**2148-9-23**]):
      RARE GROWTH OROPHARYNGEAL FLORA.
      Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
      workup will be performed appropriate to the isolates
recovered from
      this site.
      GRAM NEGATIVE ROD #1.    SPARSE GROWTH.
      GRAM NEGATIVE ROD #2.    RARE GROWTH.

   LEGIONELLA CULTURE (Preliminary):    NO LEGIONELLA ISOLATED.

   FUNGAL CULTURE (Preliminary):
      YEAST.

[**2148-9-21**] 4:43 pm ASPIRATE     Site: SINUS      Source: Sinus.

   GRAM STAIN (Final [**2148-9-21**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      1+    (<1 per 1000X FIELD):   GRAM NEGATIVE ROD(S).

   RESPIRATORY CULTURE (Final [**2148-9-23**]):
      SPARSE GROWTH OROPHARYNGEAL FLORA.
      GRAM NEGATIVE ROD(S).    RARE GROWTH.

   ANAEROBIC CULTURE (Preliminary):    RESULTS PENDING.

   POTASSIUM HYDROXIDE PREPARATION (Final [**2148-9-21**]):
      Test cancelled by laboratory.
      PATIENT CREDITED.
      if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
      Aspergillosis or Mucormycosis is strongly suspected,
contact the
      Microbiology Laboratory (7-2306).

   FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.

   VIRAL CULTURE (Preliminary):    No Virus isolated so far.
[**2148-9-21**] 2:05 am BLOOD CULTURE

   AEROBIC BOTTLE (Preliminary):
      REPORTED BY PHONE TO [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 73854**], R.N. ON [**2148-9-23**] AT
0520.
      GRAM POSITIVE COCCUS(COCCI).    IN PAIRS AND CLUSTERS.
         BEING ISOLATED FURTHER IDENTIFICATION TO FOLLOW.

RADIOLOGY   Preliminary Report

CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST  [**2148-9-21**] 1:28 PM

CT SINUS/MANDIBLE/MAXILLOFACIA

Reason: sinusitis? per trauma surgery

[**Hospital 93**] MEDICAL CONDITION:
1 mo + s/p traumatic arrest with fever, no clear source. trached
febrile, clear chest ct
REASON FOR THIS EXAMINATION:
sinusitis? per trauma surgery
CONTRAINDICATIONS for IV CONTRAST: None.

CT OF THE SINUS

Patient with a history of status post trauma one month ago with
fever, no clear source, evaluate for sinusitis.

COMPARISON: None.

TECHNIQUE: Multiple contiguous 2.5-mm axial CT images of the
sinuses were obtained. Subsequently, coronal reformations were
performed.

FINDINGS: There is near complete opacification of the bilateral
ethmoid air cells and sphenoid sinuses, with small gas
collections within them. There is moderate air-fluid level with
mucosal thickening in the right maxillary sinus and moderate
mucosal thickening in the left maxillary sinus. A small amount
of air-fluid level is seen in the frontal sinus. Nasal passages
demonstrate air- fluid levels, with soft tissue thickening.
There is thinning of the medial maxillary walls bilaterally.

The orbits are grossly unremarkable. The other visualized soft
tissues are grossly within normal limits. The visualized brain
parenchyma is grossly unremarkable. Streak artifacts from dental
hardware limit evaluation of this region. The bony structures
are intact.

IMPRESSION: Near complete opacification of the ethmoid air cells
and sphenoid sinuses. Moderate air-fluid level with mucosal
thickening of the right maxillary sinus and moderate mucosal
thickening of the left maxillary sinus. These findings most
likely represent infection on chronic changes.

The results were discussed with Dr. [**Last Name (STitle) 73855**], resident.

RADIOLOGY  Final Report

CHEST PORT. LINE PLACEMENT  [**2148-9-21**] 10:24 PM

CHEST PORT. LINE PLACEMENT

Reason: confirm line placement, r/o PTX

[**Hospital 93**] MEDICAL CONDITION:
29 year old man with mutliiple TRAUMA, now s/p PEA arrest today
and now with fever , s/p new R subclavian line
REASON FOR THIS EXAMINATION:
confirm line placement, r/o PTX
AP CHEST, 10:53 P.M.

HISTORY: Multiple trauma. Fever. Confirm line placement.

IMPRESSION: AP chest compared to [**9-16**] through 11.

Bibasilar consolidation has improved dramatically since [**9-21**], suggesting this may have been an atypical pulmonary edema or
atelectasis rather than pneumonia. Continued followup for
regions of bibasilar consolidation is nevertheless still
recommended. Heart size is normal. There is no appreciable
pleural effusion or indication of pneumothorax. Left PIC and
right subclavian lines end in the low SVC. Fracture of the mid
right clavicle has been present without much change since at
least [**8-23**]. Heart size is normal. Tip of the tracheostomy
tube may touch the left wall of the trachea. Clinical evaluation
is recommended.

Cardiology Report ECHO Study Date of [**2148-9-21**]



PATIENT/TEST INFORMATION:
Indication: Left ventricular function. S/p arrest.
Height: (in) 70
Weight (lb): 140
BSA (m2): 1.80 m2
BP (mm Hg): 128/47
HR (bpm): 99
Status: Inpatient
Date/Time: [**2148-9-21**] at 10:02
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007W040-0:17
Test Location: [**Location **]
Technical Quality: Adequate




REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]

MEASUREMENTS:
Left Atrium - Long Axis Dimension: 2.8 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 4.0 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 3.7 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm)

Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.7 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 50% (nl >=55%)
Aorta - Valve Level: 3.0 cm (nl <= 3.6 cm)
Aortic Valve - Peak Velocity: 1.5 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.9 m/sec
Mitral Valve - A Wave: 0.6 m/sec
Mitral Valve - E/A Ratio: 1.50
Mitral Valve - E Wave Deceleration Time: 200 msec

INTERPRETATION:

Findings:

LEFT ATRIUM: Normal LA size.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. The patient is
mechanically
ventilated. Cannot assess RA pressure.

LEFT VENTRICLE: Normal LV wall thickness and cavity size. Low
normal LVEF.
Transmitral Doppler E>A and TDI E/e' <8 suggesting normal
diastolic function,
and normal LV filling pressure (PCWP<12mmHg). No resting LVOT
gradient.

RIGHT VENTRICLE: Normal RV chamber size and free wall motion.

AORTIC VALVE: Normal aortic valve leaflets. No AS. No AR.

MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No
MVP.

TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
Indeterminate PA systolic pressure.

PERICARDIUM: No pericardial effusion.

GENERAL COMMENTS: Right pleural effusion.

Conclusions:
The left atrium is normal in size. Left ventricular wall
thicknesses and
cavity size are normal. There is possible focal basal inferior
hypokinesis.
The remaining segments contract well LVEF 50%). Transmitral and
tissue Doppler
imaging suggests normal diastolic function, and a normal left
ventricular
filling pressure (PCWP<12mmHg). Right ventricular chamber size
and free wall
motion are 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. There is no mitral valve prolapse.
The pulmonary
artery systolic pressure could not be determined. There is no
pericardial
effusion.

IMPRESSION: Possible mild regional left ventricular systolic
dysfunction with
low normal global systolic function. Right pleural effusion.

CLINICAL IMPLICATIONS:
Based on [**2148**] AHA endocarditis prophylaxis recommendations, the
echo findings
indicate prophylaxis is NOT recommended. Clinical decisions
regarding the need
for prophylaxis should be based on clinical and
echocardiographic data.

Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD on [**2148-9-21**]
13:30.
[**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**First Name3 (LF) **] J.





Brief Hospital Course:
Patient was admitted to [**Hospital1 18**] from extended care facility for
cardiac dysrhythmia, fevers. (see HPI).  On admission patient
was found to be in normal sinus tachycardia with a leukocytosis
of 24.3.  EKG was unremarkable. Chest CXR showed a right basilar
consolidation and bibasilar atelectasis.
Problem list:
Neuro:  severe neurologic dysfunction. No active issues this
admission. Patient remained without seizure activity and was
continued on anti-epileptic medications as per neurology service
recommendations.

Cardiac:  By report, patient experienced a brief episode of
asystole.  EKG, cardiac enzymes and ECHO were unremarkable.
Patient remained in normal sinus tachycardia with heart rates in
low 100's. This has been unchanged.

Pulmonary: Patient treated for a pneumonia (see ID) section.

GI: continuing tube feeds via gastrostomy tube. No changes or
issues this admission.

Heme: IVC filter in place. Continuing Lovenox for DVT
prophylaxis.

ID: Patient with fevers to 102 and leukocytosis. Blood cultures
were drawn and eventually grew 1 of 4 bottles with gram positive
cocci (being speciated). His PICC line was removed and a new
central line was placed. TIP cultures have been negative to
date.  Sputum cultures show Gram negative rods.  CT scan of
sinuses were also obtained and showed opacification consistent
with sinusitis. ENT service was consulted and sinus aspirate was
obtained, with cultures also showing Gram negative rods.  During
this hospitalization, patient was continued on Vancomycin and
Zosyn and Gentamycin was added for double Gram negative rod
coverage.  Over the next several days patient's leukocytosis
began to normalize and his fever curve improved. However, he
continued to have low grade temps with no other source of
infection.

A new PICC line was placed for IV access.

He is being discharged to an extended care facility.

Medications on Admission:
. Famotidine 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H (every 12
hours).
2. Artificial Tear with Lanolin 0.1-0.1 % Ointment [**Hospital1 **]: One (1)
Appl Ophthalmic PRN (as needed).
3. Levetiracetam 100 mg/mL Solution [**Hospital1 **]: [**2-13**] PO QHS (once a day
(at bedtime)).
4. Levetiracetam 100 mg/mL Solution [**Month/Day (2) **]: [**2-13**] PO QAM (once a day
(in the morning)).
5. Acetaminophen 160 mg/5 mL Solution [**Month/Day (2) **]: [**2-13**] PO Q6H (every 6
hours) as needed.
6. Ibuprofen 100 mg/5 mL Suspension [**Month/Day (2) **]: [**2-13**] PO Q8H (every 8
hours) as needed.
7. Enoxaparin 30 mg/0.3 mL Syringe [**Month/Day (2) **]: [**2-13**] Subcutaneous Q12H
(every 12 hours).
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Day (2) **]: Two (2)
Tablet, Delayed Release (E.C.) PO HS (at bedtime) as needed.
9. Phenobarbital 100 mg Tablet [**Month/Day (2) **]: Three (3) Tablet PO TID (3
times a day).
10. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (2) **]: [**2-13**] PO BID (2 times
a day).
11. Senna 8.6 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO BID (2 times a day)
as needed.
12. Topiramate 100 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO 5X/DAY (5
Times a Day).
13. Therapeutic Multivitamin Liquid [**Month/Day (2) **]: Five (5) ML PO
DAILY (Daily).
14. Folic Acid 1 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily).


15. Ferrous Sulfate 300 mg/5 mL Liquid [**Month/Day (2) **]: [**2-13**] PO DAILY
(Daily).
16. Metoprolol Tartrate 50 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO TID
(3 times a day).
17. Phenytoin 100 mg/4 mL Suspension [**Month/Day (2) **]: [**2-13**] PO Q6H (every 6
hours).
18. Insulin Regular Human 100 unit/mL Solution [**Month/Day (2) **]: [**2-13**]
Injection per ISS as needed.
19. Valproate Sodium 250 mg/5 mL Syrup [**Month/Day (2) **]: [**2-13**] PO Q3H (every 3
hours).
20. Papain-Urea 830,000-10 unit/g-% Ointment [**Month/Day (2) **]: [**2-13**] Appls
Topical DAILY (Daily).
21. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Month/Day (2) **]: [**2-13**]
MLs Intravenous DAILY (Daily) as needed.
22. Vancomycin in Dextrose 1 g/200 mL Piggyback [**Month/Day (2) **]: [**2-13**]
Intravenous Q 12H (Every 12 Hours).
23. Ciprofloxacin 400 mg/40 mL Solution [**Month/Day (2) **]: [**2-13**] Intravenous
Q12H (every 12 hours).
24. Cefepime 2 g Recon Soln [**Month/Day (2) **]: [**2-13**] Recon Solns Injection Q12H
(every 12 hours).


Discharge Medications:
Please adjust free water flushes in TUBE FEEDS to normalize
hypernatremia.

1. Enoxaparin 30 mg/0.3 mL Syringe [**Month/Day (2) **]: One (1)  Subcutaneous
Q12H (every 12 hours).
2. Acetaminophen 325 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO Q6H (every
6 hours) as needed.
3. Ibuprofen 100 mg/5 mL Suspension [**Month/Day (2) **]: One (1)  PO Q8H (every
8 hours) as needed.
4. Levetiracetam 100 mg/mL Solution [**Month/Day (2) **]: 15 ML  PO QAM (once a
day (in the morning)): 1500 mg down G tube every morning.
5. Levetiracetam 100 mg/mL Solution [**Month/Day (2) **]: 20 mL  PO HS (at
bedtime): [**2141**] mg down G tube every HS.
6. Senna 8.6 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO BID (2 times a
day) as needed.
7. Folic Acid 1 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily).

8. Polyvinyl Alcohol 1.4 % Drops [**Year (4 digits) **]: 1-2 Drops Ophthalmic PRN
(as needed).
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Year (4 digits) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
10. Topiramate 100 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO 5X/DAY (5
Times a Day).
11. Ferrous Sulfate 300 mg/5 mL Liquid [**Year (4 digits) **]: One (1)  PO DAILY
(Daily).
12. Papain-Urea 830,000-10 unit/g-% Ointment [**Year (4 digits) **]: One (1) Appl
Topical DAILY (Daily): To affected areas.
13. Insulin Regular Human 100 unit/mL Solution [**Year (4 digits) **]: One (1)
Injection ASDIR (AS DIRECTED): SEE SCALE.
14. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
15. Phenobarbital 100 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO TID (3
times a day).
16. Potassium Chloride 10 mEq Capsule, Sustained Release [**Last Name (STitle) **]:
One (1) Capsule, Sustained Release PO PRN (as needed).
17. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO TID (3
times a day): Hold for sbp < 100, HR < 60.
18. Phenytoin 100 mg/4 mL Suspension [**Last Name (STitle) **]: One (1)  PO Q6H (every
6 hours).
19. Therapeutic Multivitamin     Liquid [**Last Name (STitle) **]: Five (5) ML PO
DAILY (Daily).
20. Gentamicin 40 mg/mL Solution [**Last Name (STitle) **]: One (1)  Injection Q24H
(every 24 hours) for 12 days: 500 mg IV .
21. Piperacillin-Tazobactam 4.5 g Recon Soln [**Last Name (STitle) **]: One (1) Recon
Soln Intravenous Q8H (every 8 hours) for 12 days: 4.5 grams Q 8
Hours. Recon Soln(s)
22. Calcium Gluconate 100 mg/mL (10%) Solution [**Last Name (STitle) **]: One (1)
Intravenous ASDIR (AS DIRECTED).
23. Potassium Chloride 40 mEq/100 mL Piggyback [**Last Name (STitle) **]: One (1)
Intravenous PRN: maintain K+ over 4.0.
24. Magnesium Sulfate 4 % Solution [**Last Name (STitle) **]: One (1)  Injection PRN
(as needed): maintain mag >2.0.
25. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Last Name (STitle) **]: One
(1) ML Intravenous DAILY (Daily) as needed.
26. Colace 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO twice a day.
27. Insulin sliding scale
Insulin SC  (per Insulin Flowsheet)
      Sliding Scale

Fingerstick q 6 hrsInsulin SC Sliding Scale
  Breakfast Lunch Dinner Bedtime
Regular Regular Regular Regular
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-50   mg/dL 4 oz. Juice 4 oz. Juice 4 oz. Juice 4 oz. Juice
51-150   mg/dL 0   Units 0   Units 0   Units 0   Units
151-200   mg/dL 2   Units 2   Units 2   Units 2   Units
201-250   mg/dL 4   Units 4   Units 4   Units 4   Units
251-300   mg/dL 6   Units 6   Units 6   Units 6   Units
301-350   mg/dL 8   Units 8   Units 8   Units 8   Units
351-400   mg/dL 10   Units 10   Units 10   Units 10   Units
  Instructons for NPO Patients: 1 amp D50 for glucose 0-50mg/dL


28. Outpatient Lab Work
twice weekly electrolytes (or as per extended care facility
protocol). Replete electrolytes. Chem 10.
29. Tube feed order
Tubefeeding: Nutren Pulmonary Full strength; Additives:
Beneprotein, 40 gm/day
Starting rate: 65 ml/hr; Do not advance rate Goal rate: 65 ml/hr
Residual Check: q4h Hold feeding for residual >= : 100 ml
Flush w/ 200 ml water q6h

Please adjust free water flushes to normalize hypernatremia.

30. Phenytoin 100 mg/4 mL Suspension [**Last Name (STitle) **]: One (1)  PO Q6H (every
6 hours).
31. Vancomycin in Dextrose 1 g/200 mL Piggyback [**Last Name (STitle) **]: One (1)
Intravenous Q 8H (Every 8 Hours) for 12 days: 1000 mg q 8 hours.

32. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] Northeast - [**Location (un) 38**]

Discharge Diagnosis:
s/p recent multiple trauma injuries (see below) now admitted
with pneumonia and likely sinusitis resulting in fevers and
leukocytosis.
Other injuries include:
1)closed head injury
2)bilateral tibia/fibia fracture
3)Right upper extremity degloving-closed by plastics and VAC
drain placed
4)Bilateral Lower Extemity fasciotomy
5)Right Clavicle fracture
6)Left lower extremity arterial injury
7)Proximal Humerus fracture


Discharge Condition:
Stable to extended care facility


Discharge Instructions:
Continue mechanical ventilation: assist control (volume
targeted(Tidal volume 600 cc rr 14, PEEP 5 FIO2 40% ween to
PSV as tolerated

Continue Tube-feeds: Nutren pulmonary full strength with
Beneprotein 40 gm/day at rate of 65 mL/hr. Check residual q4hr,
and hold feeding for residual >100 mL. Flush with 200 mL water
q6hr, and follow sodium

Continue wet to dry dressings on bilateral LE, changed [**Hospital1 **]

On coccyx continue accuzyme, and tegaderm dressing

Continue standard trach and peg care, as well as decubitus
prevention. Keep on air mattress.


Followup Instructions:
1. Please follow with Dr. [**Last Name (STitle) 519**] in trauma surgery. Please call
to make an appointment: ([**Telephone/Fax (1) 5323**].
2. Please follow-up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 3407**] in
vascular surgery for your leg wounds. Please call to make an
appointment: ([**Telephone/Fax (1) 18181**].
3. Please follow-up with Dr. [**Last Name (STitle) 2719**] in orthopaedic surgery for
your leg fractures. Please call to make an appointment: ([**Telephone/Fax (1) 15940**]
4. Please follow-up with Dr. [**First Name (STitle) **] in plastic surgery for your
right arm. Please call to make an appointment:([**Telephone/Fax (1) 23796**]
5. Please follow-up with neurology service. Please call to make
an appointment [**Telephone/Fax (1) 44**].



Completed by:[**2148-10-1**]
{'Pneumonia, organism unspecified,Pulmonary collapse,Anoxic brain damage,Pressure ulcer, lower back,Leukocytosis, unspecified,Acute sinusitis, unspecified,Other specified cardiac dysrhythmias,Tracheostomy status,Gastrostomy 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: Fevers, leukocytosis

PRESENT ILLNESS: Patient is a 43 year old gentleman recently discharged from
[**Hospital1 18**] after a prolonged hospital stay ([**Date range (1) 73853**]) who experienced
an reported episode of asystolic arrest in setting of fevers and
worsening pulmonary function. He was revived at the extended
care facility and was brought to [**Hospital1 18**] for further care. For
details of previous hospitalization please see dictated
discharge summary and multiple operative reports.

MEDICAL HISTORY: Polytrauma requiring multiple operative interventions
Anoxic brain injury
Placement of IVC filter, percutaneous gastrostomy, tracheostomy

MEDICATION ON ADMISSION: . Famotidine 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H (every 12
hours).
2. Artificial Tear with Lanolin 0.1-0.1 % Ointment [**Hospital1 **]: One (1)
Appl Ophthalmic PRN (as needed).
3. Levetiracetam 100 mg/mL Solution [**Hospital1 **]: [**2-13**] PO QHS (once a day
(at bedtime)).
4. Levetiracetam 100 mg/mL Solution [**Month/Day (2) **]: [**2-13**] PO QAM (once a day
(in the morning)).
5. Acetaminophen 160 mg/5 mL Solution [**Month/Day (2) **]: [**2-13**] PO Q6H (every 6
hours) as needed.
6. Ibuprofen 100 mg/5 mL Suspension [**Month/Day (2) **]: [**2-13**] PO Q8H (every 8
hours) as needed.
7. Enoxaparin 30 mg/0.3 mL Syringe [**Month/Day (2) **]: [**2-13**] Subcutaneous Q12H
(every 12 hours).
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Day (2) **]: Two (2)
Tablet, Delayed Release (E.C.) PO HS (at bedtime) as needed.
9. Phenobarbital 100 mg Tablet [**Month/Day (2) **]: Three (3) Tablet PO TID (3
times a day).
10. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (2) **]: [**2-13**] PO BID (2 times
a day).
11. Senna 8.6 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO BID (2 times a day)
as needed.
12. Topiramate 100 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO 5X/DAY (5
Times a Day).
13. Therapeutic Multivitamin Liquid [**Month/Day (2) **]: Five (5) ML PO
DAILY (Daily).
14. Folic Acid 1 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily).

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: HEENT: PERRLA, eyes opening spontneously
Resp: Tracheostomy, course breath sounds bilaterally. Trach
site without drainage or erythema
CV: RRR, strong pedal pulses
AB: soft, mildly distended, + BS. PEG tube w/o drainage or
erythema
GU: foley in place
Ext: cast on RUE, multipodus boots on bilateral LE, bilat LE
wrapped with gauze dressing; PIC on Left arm, c/d/i
Skin: pressure sore on coccyx - stage 3-4, covered wtih tegaderm
Neuro: no gag response, + corneal response, No motor seizure
activity

FAMILY HISTORY: no pertinent history

SOCIAL HISTORY: Firefighter 

### Response:
{'Pneumonia, organism unspecified,Pulmonary collapse,Anoxic brain damage,Pressure ulcer, lower back,Leukocytosis, unspecified,Acute sinusitis, unspecified,Other specified cardiac dysrhythmias,Tracheostomy status,Gastrostomy status'}
