CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is an 86-year-old
woman with congestive heart failure (with an ejection
fraction of 20% to 25%), chronic atrial fibrillation,
non-insulin-dependent diabetes mellitus, severe peripheral
vascular disease (with several right lower extremity bypass
surgeries) who was recently admitted to the Vascular Service
at the [**Hospital1 69**] for worsening
right lower extremity ischemia that was treated
conservatively with antibiotics (Zosyn), dressing changes,
and pain management.

MEDICAL HISTORY: 1.  Congestive heart failure.
2.  Atrial fibrillation.
3.  Non-insulin-dependent diabetes mellitus (with
neuropathy).
4.  Mitral valve regurgitation.
5.  Peripheral vascular disease; status post right lower
extremity bypass times four with the latest in [**2139-11-17**], followed by Dr. [**Last Name (STitle) **].
6.  History of hypercalcemia.
7.  Hypercholesterolemia.
8.  Echocardiogram in [**2140-1-15**] showed left atrial
dilatation with moderate left ventricular hypertrophy, an
ejection fraction of 20% to 25%, with global hypokinesis, 2+
mitral regurgitation, 2+ tricuspid regurgitation, 1+ aortic
regurgitation, and moderate pulmonary hypertension.

MEDICATION ON ADMISSION: 1.  Lasix 40 mg p.o. t.i.d.
 2.  Lisinopril 2.5 mg p.o. q.d.
 3.  Protonix 40 mg p.o. q.d.
 4.  Pravastatin 20 mg p.o. q.d.
 5.  Aspirin 81 mg p.o. q.d.
 6.  Coumadin 1 mg p.o. q.d. (at rehabilitation).  At home,
the patient was on Coumadin 3 mg on odd days alternating with
2 mg on even days.
 7.  Darvocet N-100 one tablet p.o. q.4-6h. as needed.
 8.  Bacitracin ointment to ulcer area.
 9.  Metoprolol 25 mg p.o. t.i.d.
10.  Ativan 0.5 mg p.o. q.4-6h. as needed.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Unspecified septicemia,Pneumonia, organism unspecified,Rheumatic heart failure (congestive),Mitral valve insufficiency and aortic valve insufficiency,Diseases of tricuspid valve,Unspecified pleural effusion,Atherosclerosis of native arteries of the extremities with gangrene,Acute kidney failure, unspecified,Atrial fibrillation
Septicemia NOS,Pneumonia, organism NOS,Rheumatic heart failure,Mitral/aortic val insuff,Tricuspid valve disease,Pleural effusion NOS,Ath ext ntv art gngrene,Acute kidney failure NOS,Atrial fibrillation
Admission Date:  [**2140-11-18**]     Discharge Date: [**2140-11-27**]


Service:  Medicine

NOTE:  This is an incomplete Discharge Summary.  Please see
additional Discharge Summary dictations for completion of the
[**Hospital 228**] hospital course, discharge diagnoses, and discharge
medications.

HISTORY OF PRESENT ILLNESS:  The patient is an 86-year-old
woman with congestive heart failure (with an ejection
fraction of 20% to 25%), chronic atrial fibrillation,
non-insulin-dependent diabetes mellitus, severe peripheral
vascular disease (with several right lower extremity bypass
surgeries) who was recently admitted to the Vascular Service
at the [**Hospital1 69**] for worsening
right lower extremity ischemia that was treated
conservatively with antibiotics (Zosyn), dressing changes,
and pain management.

Cardiology Service followed the patient and adjusted
medications for volume overload and blood pressure
management.  The patient was discharged to rehabilitation on
[**11-2**] with an amputation scheduled for [**11-20**] at
[**Hospital1 69**].

At the rehabilitation facility ([**Location (un) **]), on the day of
admission, the patient complained of shortness of breath with
an oxygen saturation of 75% on room air which increased to
90% with 2 liters nasal cannula.  There was also a question
of low blood pressures, and the patient was transferred to
the [**Hospital 26200**] Hospital where oxygen saturations were
noted to be 79% on room air, which improved to 93% with 2
liters; however, the respiratory rate was 34.  The patient's
blood pressure was noted to be 134/72, but then dropped to
70/palpable, and the patient was noted to hypothermic with a
temperature of 95.4.

A chest x-ray performed at the outside facility showed
questionable right upper lobe consolidation and congestive
heart failure.  The patient received Lasix 40 mg
intravenously times one and was started on intravenous
levofloxacin 500 mg p.o. q.d. with plans to initiate Flagyl
as well.

The patient was then transferred to the [**Hospital1 190**] Emergency Room with continued shortness of
breath and an oxygen saturation of 86% to 100% on 4 liters
which improved to 98%.  The patient was noted to be in atrial
fibrillation with a heart rate into the 110s and 120s and a
blood pressure of 100/60 which dropped to 84/56.

At approximately 1:30 in the morning, the patient was started
on Levophed 2 mcg/min with an increase in blood pressure to
99/65.  The patient's temperature was 96.6.  Therefore, the
patient was started on a bear hugger.  In the Emergency
Department, the patient became more alert with an elevation
of her blood pressure as the patient was able to speak in
full sentences as opposed to one-word answers, and a noted
right eyelid drop had resolved at this time.  Blood cultures
were drawn after the initiation of antibiotics.  The
patient's heart rate was noted to become elevated into the
150s in the Emergency Department; and, therefore, intravenous
Cardizem 5 mg was given times two with a decrease in heart
rate to the 120s to 130s.

REVIEW OF SYSTEMS:  The patient complained of thirst and
discomfort with swallowing.  She denied any chest pain,
palpitations, shortness of breath, abdominal pain, nausea,
vomiting, diarrhea, and dysuria.  She did have right leg
pain.

PAST MEDICAL HISTORY:
1.  Congestive heart failure.
2.  Atrial fibrillation.
3.  Non-insulin-dependent diabetes mellitus (with
neuropathy).
4.  Mitral valve regurgitation.
5.  Peripheral vascular disease; status post right lower
extremity bypass times four with the latest in [**2139-11-17**], followed by Dr. [**Last Name (STitle) **].
6.  History of hypercalcemia.
7.  Hypercholesterolemia.
8.  Echocardiogram in [**2140-1-15**] showed left atrial
dilatation with moderate left ventricular hypertrophy, an
ejection fraction of 20% to 25%, with global hypokinesis, 2+
mitral regurgitation, 2+ tricuspid regurgitation, 1+ aortic
regurgitation, and moderate pulmonary hypertension.

PAST SURGICAL HISTORY:
1.  Right femoral-popliteal bypass times five.
2.  Right common femoral artery to anterior tibialis with
vein angioplasty and jump graft in [**2138-7-18**].
3.  Balloon angioplasty and proximal anastomosis in [**2139-7-18**].

MEDICATIONS ON ADMISSION:
 1.  Lasix 40 mg p.o. t.i.d.
 2.  Lisinopril 2.5 mg p.o. q.d.
 3.  Protonix 40 mg p.o. q.d.
 4.  Pravastatin 20 mg p.o. q.d.
 5.  Aspirin 81 mg p.o. q.d.
 6.  Coumadin 1 mg p.o. q.d. (at rehabilitation).  At home,
the patient was on Coumadin 3 mg on odd days alternating with
2 mg on even days.
 7.  Darvocet N-100 one tablet p.o. q.4-6h. as needed.
 8.  Bacitracin ointment to ulcer area.
 9.  Metoprolol 25 mg p.o. t.i.d.
10.  Ativan 0.5 mg p.o. q.4-6h. as needed.

ALLERGIES:  No known drug allergies.

PHYSICAL EXAMINATION ON PRESENTATION:  In general, the
patient was alert and awake but disoriented somewhat; with
the date being [**3141-10-16**] being [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) 2748**].  Temperature was 96.6 rectally,
heart rate was 122 (in atrial fibrillation), blood pressure
was 122/76 (which decreased to 84/56), oxygen saturation was
94% on 4 liters.  Head, eyes, ears, nose, and throat
examination revealed pupils were equal, round and reactive to
light.  Extraocular movements were intact.  Normocephalic and
atraumatic.  The oropharynx with petechiae on posterior
oropharynx and some exudate on the tongue and buccal mucosa.
The neck was supple with right internal jugular in place.
Cardiovascular examination revealed irregularly irregular and
tachycardic.  The chest revealed decreased breath sounds at
the right base with crackles halfway up bilaterally.  The
abdomen revealed normal active bowel sounds.  Soft,
nontender, and nondistended.  Extremity examination revealed
necrotic right toes with dressing in place and pneumatic
boots on.  Lower extremity edema of 1+ up to the knees
bilaterally and dry gangrene over the right foot and lower
extremity.

PERTINENT LABORATORY VALUES ON PRESENTATION:  Laboratories
revealed white blood cell count was 10 (with a differential
of 89 polys, 3 bands, 6 lymphocytes, and 2 monocytes),
hematocrit was 43.6, and platelets were 138.  Prothrombin
time was 15.5, INR was 1.6, and partial thromboplastin time
was 34.8.  Sodium was 140, potassium was 4.4, chloride was
102, bicarbonate was 25, blood urea nitrogen was 65,
creatinine was 1.3, and blood glucose was 100.  Calcium was
9.5, magnesium was 2, and phosphate was 5.1.  Urinalysis
revealed 0 to 2 red blood cells, 0 white blood cells, no
bacteria or yeast.  Urine culture was pending.

RADIOLOGY/IMAGING:  A chest x-ray revealed right effusion
with mild congestive heart failure, middle right upper lobe
consolidation with questionable left retrocardiac
consolidation.

Electrocardiogram revealed atrial fibrillation with a rate of
118, left axis deviation, with a left bundle-branch block, ST
elevations of 1 mm in leads V2, ST depressions of 1 mm in V5
through V6 (which were slightly more pronounced than prior
electrocardiograms).

HOSPITAL COURSE BY ISSUE/SYSTEM:

1.  CARDIOVASCULAR SYSTEM:  The patient's initial hypotension
was thought to be secondary to sepsis with an element of
congestive heart failure and atrial fibrillation with a rapid
ventricular response.

The patient was started on Levophed initially and was
admitted to the Medical Intensive Care Unit.  The patient was
weaned off the Levophed quickly on [**2140-11-19**].  The
patient was also started on broad spectrum antibiotics given
the possible diagnosis of sepsis secondary to pneumonia and a
right gangrenous leg.  The patient's hypotension improved to
a systolic blood pressure of 100s to 120s.

Once the patient was transferred out of the Intensive Care
Unit (on [**2140-11-19**]), it was unclear what the patient's
intravascular volume status was given evidence of rales on
pulmonary examination and elevated jugular venous pressure;
however, a fractional secretion of sodium was found to be
less than 1%, and the patient was complaining of thirst.
Initially, the patient was given normal saline fluid boluses
to help increase her urine output; which, by hospital day
five, had decreased less than 15 cc per hour.  However, there
was minimal responsiveness to these normal saline intravenous
fluid boluses.

The decision was made to determine intracardiac filling
pressures by placing a Swan-Ganz catheter on [**2140-11-23**].
Unfortunately, the catheter was unable to wedge; and,
therefore, pulmonary capillary wedge pressures were unable to
be obtained.  The catheter readings did show a cardiac index
of 0.8 to 1.1, and a central venous pressure of 12 to 16, and
elevated pulmonary artery pressures of 50/20, and a systemic
vascular resistance of 2424 to 3677.

As a result, the patient's afterload reduction was maximized
with captopril.  A trial of diuresis was given with Lasix
with a good response in urine output.  However, on [**11-27**], diuresis had to be held since the patient's systolic
blood pressure became borderline hypotensive at 96.

In terms of the patient's atrial fibrillation, the patient
did experience episodes of rapid ventricular response into
the 140s and 150s.  The patient initially was loaded with
digoxin; however, upon further discussion with the patient's
cardiologist (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]), it was noted that the
patient often times become bradycardic on digoxin and
diltiazem.  As a result, the patient was started on Lopressor
25 mg p.o. b.i.d. to help control the patient's heart rate.

2.  INFECTIOUS DISEASE:  The patient was noted to have a
multilobar pneumonia on chest x-ray as well as a right
gangrenous leg.  The patient was started on broad spectrum
antibiotics with vancomycin, cefepime, and Flagyl.  The
patient was then changed from cefepime to ceftriaxone once
the patient was transferred from the Medical Intensive Care
Unit to the Vascular Intensive Care Unit.

The patient's blood cultures were negative to date.  The
patient remained afebrile, and her white blood cell count
remained stable.

3.  PULMONARY SYSTEM:  The patient was noted to have a right
large pleural effusion on chest x-ray which was stable from a
prior chest x-ray in [**2140-10-16**].

The patient, as well as the patient's family, expressed that
no invasive diagnostic procedures be performed.  Therefore, a
thoracentesis was not done for diagnostic purposes in the
patient.

A chest computed tomography was done which revealed a large
right pleural effusion, and moderate left pleural effusion,
with a small pericardial effusion, and less than 3-mm nodules
in the lung parenchyma.  There was evidence of likely
hydrostatic edema, but lymphangitic carcinomatosis could not
be excluded.  However, since thoracentesis could not be
pursued in this patient, there was no reason to pursue a
further workup of malignancy.

The patient's oxygenation did remain stable on 3 liters to 4
liters at 97%.

4.  PERIPHERAL VASCULAR DISEASE:  The patient was noted to
have a right dry gangrenous leg and foot.  The patient was
followed by the Vascular Service, and it was determined that
given the patient's ill condition amputation would likely not
benefit the patient at this point.

The right amputation of the lower leg was cancelled for now,
and Dr. [**Last Name (STitle) **] will continue to follow the patient to
determine if it should be rescheduled.

5.  ENDOCRINE SYSTEM:  The patient was continued on a regular
insulin sliding-scale, and her fingersticks were checked on a
q.i.d. basis.  She remained in good glycemic control.

6.  RIGHT UPPER EXTREMITY SWELLING:  The patient was noted to
have asymmetric right upper extremity swelling on [**2140-11-27**].  A right upper extremity ultrasound was performed in
order to rule out a diagnosis of deep venous thrombosis; the
results of which were pending at the time of this dictation.

7.  CODE STATUS:  The patient was made do not resuscitate/do
not intubate after a full discussion with the patient and the
patient's family.  It appeared that the patient and the
patient's family did not wish to proceed with any invasive
measures; and for now the Medicine Service will offer
supportive care and all measures for comfort.


NOTE:  This is an incomplete Discharge Summary.  Please see
Discharge Summary Addendums for completion of the [**Hospital 228**]
hospital course, discharge diagnoses, and discharge
medications.





                          [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4465**], M.D.  [**MD Number(1) 6243**]

Dictated By:[**Last Name (NamePattern1) 1336**]

MEDQUIST36

D:  [**2140-11-27**]  16:02
T:  [**2140-11-30**]  08:24
JOB#:  [**Job Number 30735**]


Admission Date:  [**2140-11-18**]     Discharge Date: [**2140-11-30**]


Service:  Medicine

NOTE:  This is an incomplete Discharge Summary.  Please see
additional Discharge Summary dictations for completion of the
[**Hospital 228**] hospital course, discharge diagnoses, and discharge
medications.

HISTORY OF PRESENT ILLNESS:  The patient is an 86-year-old
woman with congestive heart failure (with an ejection
fraction of 20% to 25%), chronic atrial fibrillation,
non-insulin-dependent diabetes mellitus, severe peripheral
vascular disease (with several right lower extremity bypass
surgeries) who was recently admitted to the Vascular Service
at the [**Hospital1 69**] for worsening
right lower extremity ischemia that was treated
conservatively with antibiotics (Zosyn), dressing changes,
and pain management.

Cardiology Service followed the patient and adjusted
medications for volume overload and blood pressure
management.  The patient was discharged to rehabilitation on
[**11-2**] with an amputation scheduled for [**11-20**] at
[**Hospital1 69**].

At the rehabilitation facility ([**Location (un) **]), on the day of
admission, the patient complained of shortness of breath with
an oxygen saturation of 75% on room air which increased to
90% with 2 liters nasal cannula.  There was also a question
of low blood pressures, and the patient was transferred to
the [**Hospital 26200**] Hospital where oxygen saturations were
noted to be 79% on room air, which improved to 93% with 2
liters; however, the respiratory rate was 34.  The patient's
blood pressure was noted to be 134/72, but then dropped to
70/palpable, and the patient was noted to hypothermic with a
temperature of 95.4.

A chest x-ray performed at the outside facility showed
questionable right upper lobe consolidation and congestive
heart failure.  The patient received Lasix 40 mg
intravenously times one and was started on intravenous
levofloxacin 500 mg p.o. q.d. with plans to initiate Flagyl
as well.

The patient was then transferred to the [**Hospital1 190**] Emergency Room with continued shortness of
breath and an oxygen saturation of 86% to 100% on 4 liters
which improved to 98%.  The patient was noted to be in atrial
fibrillation with a heart rate into the 110s and 120s and a
blood pressure of 100/60 which dropped to 84/56.

At approximately 1:30 in the morning, the patient was started
on Levophed 2 mcg/min with an increase in blood pressure to
99/65.  The patient's temperature was 96.6.  Therefore, the
patient was started on a bear hugger.  In the Emergency
Department, the patient became more alert with an elevation
of her blood pressure as the patient was able to speak in
full sentences as opposed to one-word answers, and a noted
right eyelid drop had resolved at this time.  Blood cultures
were drawn after the initiation of antibiotics.  The
patient's heart rate was noted to become elevated into the
150s in the Emergency Department; and, therefore, intravenous
Cardizem 5 mg was given times two with a decrease in heart
rate to the 120s to 130s.

REVIEW OF SYSTEMS:  The patient complained of thirst and
discomfort with swallowing.  She denied any chest pain,
palpitations, shortness of breath, abdominal pain, nausea,
vomiting, diarrhea, and dysuria.  She did have right leg
pain.

PAST MEDICAL HISTORY:
1.  Congestive heart failure.
2.  Atrial fibrillation.
3.  Non-insulin-dependent diabetes mellitus (with
neuropathy).
4.  Mitral valve regurgitation.
5.  Peripheral vascular disease; status post right lower
extremity bypass times four with the latest in [**2139-11-17**], followed by Dr. [**Last Name (STitle) **].
6.  History of hypercalcemia.
7.  Hypercholesterolemia.
8.  Echocardiogram in [**2140-1-15**] showed left atrial
dilatation with moderate left ventricular hypertrophy, an
ejection fraction of 20% to 25%, with global hypokinesis, 2+
mitral regurgitation, 2+ tricuspid regurgitation, 1+ aortic
regurgitation, and moderate pulmonary hypertension.

PAST SURGICAL HISTORY:
1.  Right femoral-popliteal bypass times five.
2.  Right common femoral artery to anterior tibialis with
vein angioplasty and jump graft in [**2138-7-18**].
3.  Balloon angioplasty and proximal anastomosis in [**2139-7-18**].

MEDICATIONS ON ADMISSION:
 1.  Lasix 40 mg p.o. t.i.d.
 2.  Lisinopril 2.5 mg p.o. q.d.
 3.  Protonix 40 mg p.o. q.d.
 4.  Pravastatin 20 mg p.o. q.d.
 5.  Aspirin 81 mg p.o. q.d.
 6.  Coumadin 1 mg p.o. q.d. (at rehabilitation).  At home,
the patient was on Coumadin 3 mg on odd days alternating with
2 mg on even days.
 7.  Darvocet N-100 one tablet p.o. q.4-6h. as needed.
 8.  Bacitracin ointment to ulcer area.
 9.  Metoprolol 25 mg p.o. t.i.d.
10.  Ativan 0.5 mg p.o. q.4-6h. as needed.

ALLERGIES:  No known drug allergies.

PHYSICAL EXAMINATION ON PRESENTATION:  In general, the
patient was alert and awake but disoriented somewhat; with
the date being [**3141-10-16**] being [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) 2748**].  Temperature was 96.6 rectally,
heart rate was 122 (in atrial fibrillation), blood pressure
was 122/76 (which decreased to 84/56), oxygen saturation was
94% on 4 liters.  Head, eyes, ears, nose, and throat
examination revealed pupils were equal, round and reactive to
light.  Extraocular movements were intact.  Normocephalic and
atraumatic.  The oropharynx with petechiae on posterior
oropharynx and some exudate on the tongue and buccal mucosa.
The neck was supple with right internal jugular in place.
Cardiovascular examination revealed irregularly irregular and
tachycardic.  The chest revealed decreased breath sounds at
the right base with crackles halfway up bilaterally.  The
abdomen revealed normal active bowel sounds.  Soft,
nontender, and nondistended.  Extremity examination revealed
necrotic right toes with dressing in place and pneumatic
boots on.  Lower extremity edema of 1+ up to the knees
bilaterally and dry gangrene over the right foot and lower
extremity.

PERTINENT LABORATORY VALUES ON PRESENTATION:  Laboratories
revealed white blood cell count was 10 (with a differential
of 89 polys, 3 bands, 6 lymphocytes, and 2 monocytes),
hematocrit was 43.6, and platelets were 138.  Prothrombin
time was 15.5, INR was 1.6, and partial thromboplastin time
was 34.8.  Sodium was 140, potassium was 4.4, chloride was
102, bicarbonate was 25, blood urea nitrogen was 65,
creatinine was 1.3, and blood glucose was 100.  Calcium was
9.5, magnesium was 2, and phosphate was 5.1.  Urinalysis
revealed 0 to 2 red blood cells, 0 white blood cells, no
bacteria or yeast.  Urine culture was pending.

RADIOLOGY/IMAGING:  A chest x-ray revealed right effusion
with mild congestive heart failure, middle right upper lobe
consolidation with questionable left retrocardiac
consolidation.

Electrocardiogram revealed atrial fibrillation with a rate of
118, left axis deviation, with a left bundle-branch block, ST
elevations of 1 mm in leads V2, ST depressions of 1 mm in V5
through V6 (which were slightly more pronounced than prior
electrocardiograms).

HOSPITAL COURSE BY ISSUE/SYSTEM:

1.  CARDIOVASCULAR SYSTEM:  The patient's initial hypotension
was thought to be secondary to sepsis with an element of
congestive heart failure and atrial fibrillation with a rapid
ventricular response.

The patient was started on Levophed initially and was
admitted to the Medical Intensive Care Unit.  The patient was
weaned off the Levophed quickly on [**2140-11-19**].  The
patient was also started on broad spectrum antibiotics given
the possible diagnosis of sepsis secondary to pneumonia and a
right gangrenous leg.  The patient's hypotension improved to
a systolic blood pressure of 100s to 120s.

Once the patient was transferred out of the Intensive Care
Unit (on [**2140-11-19**]), it was unclear what the patient's
intravascular volume status was given evidence of rales on
pulmonary examination and elevated jugular venous pressure;
however, a fractional secretion of sodium was found to be
less than 1%, and the patient was complaining of thirst.
Initially, the patient was given normal saline fluid boluses
to help increase her urine output; which, by hospital day
five, had decreased less than 15 cc per hour.  However, there
was minimal responsiveness to these normal saline intravenous
fluid boluses.

The decision was made to determine intracardiac filling
pressures by placing a Swan-Ganz catheter on [**2140-11-23**].
Unfortunately, the catheter was unable to wedge; and,
therefore, pulmonary capillary wedge pressures were unable to
be obtained.  The catheter readings did show a cardiac index
of 0.8 to 1.1, and a central venous pressure of 12 to 16, and
elevated pulmonary artery pressures of 50/20, and a systemic
vascular resistance of 2424 to 3677.

As a result, the patient's afterload reduction was maximized
with captopril.  A trial of diuresis was given with Lasix
with a good response in urine output.  However, on [**11-27**], diuresis had to be held since the patient's systolic
blood pressure became borderline hypotensive at 96.

In terms of the patient's atrial fibrillation, the patient
did experience episodes of rapid ventricular response into
the 140s and 150s.  The patient initially was loaded with
digoxin; however, upon further discussion with the patient's
cardiologist (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]), it was noted that the
patient often times become bradycardic on digoxin and
diltiazem.  As a result, the patient was started on Lopressor
25 mg p.o. b.i.d. to help control the patient's heart rate.

2.  INFECTIOUS DISEASE:  The patient was noted to have a
multilobar pneumonia on chest x-ray as well as a right
gangrenous leg.  The patient was started on broad spectrum
antibiotics with vancomycin, cefepime, and Flagyl.  The
patient was then changed from cefepime to ceftriaxone once
the patient was transferred from the Medical Intensive Care
Unit to the Vascular Intensive Care Unit.

The patient's blood cultures were negative to date.  The
patient remained afebrile, and her white blood cell count
remained stable.

3.  PULMONARY SYSTEM:  The patient was noted to have a right
large pleural effusion on chest x-ray which was stable from a
prior chest x-ray in [**2140-10-16**].

The patient, as well as the patient's family, expressed that
no invasive diagnostic procedures be performed.  Therefore, a
thoracentesis was not done for diagnostic purposes in the
patient.

A chest computed tomography was done which revealed a large
right pleural effusion, and moderate left pleural effusion,
with a small pericardial effusion, and less than 3-mm nodules
in the lung parenchyma.  There was evidence of likely
hydrostatic edema, but lymphangitic carcinomatosis could not
be excluded.  However, since thoracentesis could not be
pursued in this patient, there was no reason to pursue a
further workup of malignancy.

The patient's oxygenation did remain stable on 3 liters to 4
liters at 97%.

4.  PERIPHERAL VASCULAR DISEASE:  The patient was noted to
have a right dry gangrenous leg and foot.  The patient was
followed by the Vascular Service, and it was determined that
given the patient's ill condition amputation would likely not
benefit the patient at this point.

The right amputation of the lower leg was cancelled for now,
and Dr. [**Last Name (STitle) **] will continue to follow the patient to
determine if it should be rescheduled.

5.  ENDOCRINE SYSTEM:  The patient was continued on a regular
insulin sliding-scale, and her fingersticks were checked on a
q.i.d. basis.  She remained in good glycemic control.

6.  RIGHT UPPER EXTREMITY SWELLING:  The patient was noted to
have asymmetric right upper extremity swelling on [**2140-11-27**].  A right upper extremity ultrasound was performed in
order to rule out a diagnosis of deep venous thrombosis; the
results of which were pending at the time of this dictation.

7.  CODE STATUS:  The patient was made do not resuscitate/do
not intubate after a full discussion with the patient and the
patient's family.  It appeared that the patient and the
patient's family did not wish to proceed with any invasive
measures; and for now the Medicine Service will offer
supportive care and all measures for comfort.


NOTE:  This is an incomplete Discharge Summary.  Please see
Discharge Summary Addendums for completion of the [**Hospital 228**]
hospital course, discharge diagnoses, and discharge
medications.





                          [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4465**], M.D.  [**MD Number(1) 6243**]

Dictated By:[**Last Name (NamePattern1) 1336**]

MEDQUIST36

D:  [**2140-11-27**]  16:02
T:  [**2140-11-30**]  08:24
JOB#:  [**Job Number 30735**]


Name:  [**Known lastname 2703**], [**Known firstname 1911**]                         Unit No:  [**Numeric Identifier 5363**]

Admission Date:  [**2140-11-18**]       Discharge Date:  [**2140-12-3**]

Date of Birth:   [**2054-1-1**]       Sex:  F


HISTORY OF PRESENT ILLNESS:   This is a STAT dictation
addendum to prior Discharge Summary from [**2140-11-30**].

HOSPITAL COURSE BY SYSTEMS:
occasional episodes of hypertension with continued
decompensated heart failure with increased rales on pulmonary
examination, peripheral edema, decreased urine output and
continued supplemental oxygen requirement.  The patient's
Captopril dose was increased to 75 mg p.o. three times a day
to maximize after load reduction.  The patient remained
normotensive on a low dose beta blocker and elevated dose of
patient received one dose of p.o. Lasix for symptomatic
shortness of breath with subsequent transient hypotension.
The Lasix was discontinued and reserved for a p.r.n. basis.

The patient remained with decompensated heart failure with
continued oxygen requirement (though stable), tachypnea and
rales [**1-17**] of the way up bilaterally on pulmonary examination.
The patient also remained oliguric likely due to decreased
effective circulation secondary to heart failure.  Despite the
patient's biventricular failure with relative decompensation, the
patient remained stable without requiring continued diuresis.

The patient continued in atrial fibrillation, rate
controlled, with a low dose beta blocker.  The patient's
Coumadin was held initially secondary to the potential
surgical intervention.  With the decision to defer surgery
indefinitely, the Coumadin was then held secondary to the
patient's request to minimize interventions including blood
draws.  The patient continued on subcutaneous heparin without
evidence of thromboembolic events.

The patient, with known peripheral vascular disease and
likely coronary artery disease, was continued on a statin and
aspirin for the duration of the hospitalization.

2.  INFECTIOUS DISEASE:  The patient completed a ten day
course of empiric antibiotics for a multi-lobar pneumonia.
At the completion of the antibiotic course, the patient
remained afebrile with no further evidence of infection.

3.  VASCULAR:  The Surgical Team continued to follow the
patient throughout the hospital course.  Because the patient
was deemed a particularly high risk surgical candidate, the
Surgery Service deferred right lower extremity amputation
indefinitely.  The patient continued with daily dry dressing
changes with wound care and splinting.  There was no evidence
of infection and the patient's pain was adequately controlled
with Darvocet.

4.  PULMONARY:  The patient has known chronic bilateral
pleural effusions, right greater than left, with
decompensated heart failure.  The patient remained
persistently tachypneic and short of breath with stable
oxygen requirement, however, continued to defer therapeutic
thoracentesis.

5.  ENDOCRINE:  The patient continued on a sliding scale
insulin for diabetes mellitus management.  The patient's
insulin requirement was minimal to none, and the patient's
fingerstick glucose monitoring was changed to twice a day.

6.  RENAL:  The patient remained oliguric with persistent
urine output less than 50 cc. per hour for greater than one
week.  No labs were drawn during this time to document the
progression of the renal failure.  The patient's progressive
renal failure is likely secondary to both decreased effective
and actual intervascular volume.  The patient continued on an
ACE inhibitor despite the worsening renal function for needed
afterload reduction.  The patient's urinary output did not
improve with a trial of fluid boluses to positively effect the
intravascular volume, nor did it respond to attempts to diurese
with Lasix.

7.  FLUIDS, ELECTROLYTES AND NUTRITION:  The patient
continued with poor appetite and minimal oral intake.  No
labs were drawn during the last week of hospitalization to
evaluate electrolyte status.

Without the recommended option for surgery, discussions
regarding the [**Hospital 1325**] medical management were ongoing with
both patient and family.  The patient requested to minimize
aggressive interventions, however, opted to continue current
therapy.  The Palliative Care Service was consulted in order
to facilitate discussion with the patient and family
regarding end of life care.

At the time of dictation, the patient continues on the
current medication regimen with the addition of several
medications for symptomatic management.

CONDITION ON DISCHARGE:   Fair.

DISCHARGE DIAGNOSES:
1.  Multi-lobar pneumonia with sepsis.
2.  Severe peripheral vascular disease with dry right lower
extremity gangrene, status post multiple femoral-popliteal
bypass grafts.
3.  Insulin dependent diabetes mellitus.
4.  [**Hospital1 **]-ventricular failure, decompensated congestive heart
failure.
5.  Atrial fibrillation with rapid ventricular rate.
6.  Peripheral neuropathy.
7.  Mitral regurgitation.
8.  Oliguric renal failure.

DISCHARGE MEDICATIONS:
1.  Captopril 50 mg p.o. three times a day (hold for systolic
blood pressure less than 100).
2.  Lopressor 25 mg p.o. twice a day (hold for systolic blood
pressure less than 100, heart rate less than 55).
3.  Darvocet N100, one pill p.o. q. six hours p.r.n. pain.
4.  Pravastatin 20 mg p.o. q. day.
5.  Aspirin 81 mg p.o. q. day.
6.  Sliding scale insulin (Regular insulin).
7.  Heparin 5000 units subcutaneously q. 12 hours.
8.  Lansoprazole 30 mg p.o. q. day.
9.  Scopolamine patch one transdermal q. 72 hours p.r.n.
secretions.
10. Ativan 0.5 mg p.o. (sublingual) q. two hours p.r.n.
agitation/shortness of breath.
11. Percocet Elixir 2.5 to 20 ml p.o. q. three hours p.r.n.
pain / shortness of breath.

DISCHARGE INSTRUCTIONS:
1.  The patient is to be discharged to prior nursing facility
for continued management and discussion of goals of care.



                            [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2701**], M.D.  [**MD Number(1) 2702**]

Dictated By:[**Name8 (MD) 5365**]
MEDQUIST36

D:  [**2140-12-4**]  21:54
T:  [**2140-12-5**]  00:19
JOB#:  [**Job Number 5366**]
{'Unspecified septicemia,Pneumonia, organism unspecified,Rheumatic heart failure (congestive),Mitral valve insufficiency and aortic valve insufficiency,Diseases of tricuspid valve,Unspecified pleural effusion,Atherosclerosis of native arteries of the extremities with gangrene,Acute kidney failure, unspecified,Atrial fibrillation'}


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: The patient is an 86-year-old
woman with congestive heart failure (with an ejection
fraction of 20% to 25%), chronic atrial fibrillation,
non-insulin-dependent diabetes mellitus, severe peripheral
vascular disease (with several right lower extremity bypass
surgeries) who was recently admitted to the Vascular Service
at the [**Hospital1 69**] for worsening
right lower extremity ischemia that was treated
conservatively with antibiotics (Zosyn), dressing changes,
and pain management.

MEDICAL HISTORY: 1.  Congestive heart failure.
2.  Atrial fibrillation.
3.  Non-insulin-dependent diabetes mellitus (with
neuropathy).
4.  Mitral valve regurgitation.
5.  Peripheral vascular disease; status post right lower
extremity bypass times four with the latest in [**2139-11-17**], followed by Dr. [**Last Name (STitle) **].
6.  History of hypercalcemia.
7.  Hypercholesterolemia.
8.  Echocardiogram in [**2140-1-15**] showed left atrial
dilatation with moderate left ventricular hypertrophy, an
ejection fraction of 20% to 25%, with global hypokinesis, 2+
mitral regurgitation, 2+ tricuspid regurgitation, 1+ aortic
regurgitation, and moderate pulmonary hypertension.

MEDICATION ON ADMISSION: 1.  Lasix 40 mg p.o. t.i.d.
 2.  Lisinopril 2.5 mg p.o. q.d.
 3.  Protonix 40 mg p.o. q.d.
 4.  Pravastatin 20 mg p.o. q.d.
 5.  Aspirin 81 mg p.o. q.d.
 6.  Coumadin 1 mg p.o. q.d. (at rehabilitation).  At home,
the patient was on Coumadin 3 mg on odd days alternating with
2 mg on even days.
 7.  Darvocet N-100 one tablet p.o. q.4-6h. as needed.
 8.  Bacitracin ointment to ulcer area.
 9.  Metoprolol 25 mg p.o. t.i.d.
10.  Ativan 0.5 mg p.o. q.4-6h. as needed.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Unspecified septicemia,Pneumonia, organism unspecified,Rheumatic heart failure (congestive),Mitral valve insufficiency and aortic valve insufficiency,Diseases of tricuspid valve,Unspecified pleural effusion,Atherosclerosis of native arteries of the extremities with gangrene,Acute kidney failure, unspecified,Atrial fibrillation'}
