CHIEF COMPLAINT: respiratory distress

PRESENT ILLNESS: [**Age over 90 **] yo M with HTN, PVD s/p fem-[**Doctor Last Name **] bypass, recurrent DVT on
Coumadin, Mobitz II s/p pacemaker, presenting with 1 day of
shortness of breath, cough and fever. Per the patient's care
assistant, he had some chest congestion yesterday, but was
otherwise well. Today, he had fatigue, malaise, fever, and
progressive shortness of breath, leading him to present the ED.
Of note, his Coumadin was held yesterday in preparation for a
dental procedure. He has had left lower extremity edema for the
past 3 weeks. He sometimes coughs after eating.
.
In the ED, initial vital signs were 99.4 90 142/69 34 90% 15L
Non-Rebreather. Lung exam was relatively clear per [**Name (NI) **] report.
EKG showed a venticularly-paced rhythm. Labs notable for WBC
24.9, INR 1.5, creatinine 1.4, lactate 2.8. U/A showed trace
leukocytes, trace blood, few bacteria. CXR showed no
consolidation. ABG 7.44/40/45 on bipap. He was treated with
levofloxacin, with a plan to also treat with vanc and cefepime,
although these were not given in the ED. He was started on bipap
with improvement in his respiratory status. Daughter is HCP
daughter [**Name (NI) **] [**Telephone/Fax (1) 39171**]. Son with [**Name2 (NI) 39172**]. Patient is full
code. Patient confused. Has 18-gauge for access. Vitals on
admission 128/104, 93, 20, 100% BIPAP FiO2 60%, [**6-6**].
.
On arrival to the ICU, the patient was on Bipap and was not able
to convey a history. Review of systems was unobtainable.
.
At baseline, the patient lives in an [**Hospital3 **] with
24-hour care. He receives assistance with eating, and with
transportation to bathroom. He is sometimes incontinent of urine
but not stool.

MEDICAL HISTORY: 1.  Hypertension.
2.  high grade AV block s/p PPM
3.  DVT, on Coumadin.
4.  Hyperlipidemia.
5.  Spinal stenosis.
6.  Osteoporosis.
7.  Several bowel obstructions.
8.  Scoliosis.
9.  Benign prostatic hypertrophy, followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 365**].
10.  Gallstones seen on CAT scan of abdomen.
11.  Renal cell carcinoma.  A mass was seen on his left kidney
on
a CT scan in [**2138**].
12.  Skin cancers. (BCC on nose and ear [**1-/2142**])
13.  Gastritis.
14.  Constipation.
15.  Hearing loss.
16.  Inguinal hernia.
17.  Urinary incontinence.
18.  Left hip fracture [**1-/2143**]
19.  Right heel ulcer [**3-/2143**]
.
Past Surgical History:
1.  TURP [**2118**].
2.  Appendectomy [**2067**].
3.  Arterial graft to left lower extremity [**2088**].
4.  Skin cancers removed from left cheek [**2138**].
5.  Status post pacemaker implant [**2140**].
6.  ORIF left hip 12/[**2142**].
7.  fem/[**Doctor Last Name **] bypass

MEDICATION ON ADMISSION: lisinopril 2.5 mg daily
Nystatin creme
tamsulosin 0.4 mg QHS
warfarin
vitamin D 1000 units daily
colace 100 mg daily
senna 8.6 mg QHS

ALLERGIES: Penicillins

PHYSICAL EXAM: Admission Physical Exam:
Vitals: 128/104, 93, 20, 100% BIPAP FiO2 60%, [**6-6**].
General: On Bipap. Unable to participate in conversation. No
acute distress.
HEENT: Sclera anicteric.
Neck: JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU: foley in place
Ext: warm, well perfused, 1+ LLE edema with warm blanching
erythema tracking to the level of the buttocks
.
Discharge Physical Exam:
96.3, 148/68, 56, 20, 98ra
Breathing comfortably, NAD, speech is difficult to understand at
baseline
HEENT: Sclera anicteric.
Neck: JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU: no foley
EXT: warm, venous stasis changes bilaterally, assymetric pitting
edema (L), 1+ DP/PT pulses bilaterally. Erythema has receded
significantly compare to admission and is now centered around a
healing ulceration on the left anterior leg. No fluctuance or
tenderness.

FAMILY HISTORY: Mother died of stroke age 75.  Father had bowel infarction age
57.

SOCIAL HISTORY: The patient is widowed.  He had been living in [**State 792**]in
the summer and [**State 108**] in the winter, but now is residing in the
[**Location (un) 86**] area [**Street Address(1) 19131**].  He went to college for two years
and was an executive during his lifetime. His son and daughter
are involved in his care.
Unspecified septicemia,Acute respiratory failure,Cellulitis and abscess of leg, except foot,Acute kidney failure, unspecified,Chronic venous embolism and thrombosis of unspecified deep vessels of lower extremity,Unspecified essential hypertension,Long-term (current) use of anticoagulants,Cardiac pacemaker in situ,Other and unspecified hyperlipidemia,Osteoporosis, unspecified,Anemia, unspecified,Do not resuscitate status,Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS),Hypovolemia,Severe sepsis,Constipation, unspecified
Septicemia NOS,Acute respiratry failure,Cellulitis of leg,Acute kidney failure NOS,Ch DVT/embl low ext NOS,Hypertension NOS,Long-term use anticoagul,Status cardiac pacemaker,Hyperlipidemia NEC/NOS,Osteoporosis NOS,Anemia NOS,Do not resusctate status,BPH w urinary obs/LUTS,Hypovolemia,Severe sepsis,Constipation NOS
Admission Date:  [**2144-3-23**]              Discharge Date:   [**2144-3-28**]


Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 1185**]
Chief Complaint:
respiratory distress

Major Surgical or Invasive Procedure:
none

History of Present Illness:
[**Age over 90 **] yo M with HTN, PVD s/p fem-[**Doctor Last Name **] bypass, recurrent DVT on
Coumadin, Mobitz II s/p pacemaker, presenting with 1 day of
shortness of breath, cough and fever. Per the patient's care
assistant, he had some chest congestion yesterday, but was
otherwise well. Today, he had fatigue, malaise, fever, and
progressive shortness of breath, leading him to present the ED.
Of note, his Coumadin was held yesterday in preparation for a
dental procedure. He has had left lower extremity edema for the
past 3 weeks. He sometimes coughs after eating.
.
In the ED, initial vital signs were 99.4 90 142/69 34 90% 15L
Non-Rebreather. Lung exam was relatively clear per [**Name (NI) **] report.
EKG showed a venticularly-paced rhythm. Labs notable for WBC
24.9, INR 1.5, creatinine 1.4, lactate 2.8. U/A showed trace
leukocytes, trace blood, few bacteria. CXR showed no
consolidation. ABG 7.44/40/45 on bipap. He was treated with
levofloxacin, with a plan to also treat with vanc and cefepime,
although these were not given in the ED. He was started on bipap
with improvement in his respiratory status. Daughter is HCP
daughter [**Name (NI) **] [**Telephone/Fax (1) 39171**]. Son with [**Name2 (NI) 39172**]. Patient is full
code. Patient confused. Has 18-gauge for access. Vitals on
admission 128/104, 93, 20, 100% BIPAP FiO2 60%, [**6-6**].
.
On arrival to the ICU, the patient was on Bipap and was not able
to convey a history. Review of systems was unobtainable.
.
At baseline, the patient lives in an [**Hospital3 **] with
24-hour care. He receives assistance with eating, and with
transportation to bathroom. He is sometimes incontinent of urine
but not stool.


Past Medical History:
1.  Hypertension.
2.  high grade AV block s/p PPM
3.  DVT, on Coumadin.
4.  Hyperlipidemia.
5.  Spinal stenosis.
6.  Osteoporosis.
7.  Several bowel obstructions.
8.  Scoliosis.
9.  Benign prostatic hypertrophy, followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 365**].
10.  Gallstones seen on CAT scan of abdomen.
11.  Renal cell carcinoma.  A mass was seen on his left kidney
on
a CT scan in [**2138**].
12.  Skin cancers. (BCC on nose and ear [**1-/2142**])
13.  Gastritis.
14.  Constipation.
15.  Hearing loss.
16.  Inguinal hernia.
17.  Urinary incontinence.
18.  Left hip fracture [**1-/2143**]
19.  Right heel ulcer [**3-/2143**]
.
Past Surgical History:
1.  TURP [**2118**].
2.  Appendectomy [**2067**].
3.  Arterial graft to left lower extremity [**2088**].
4.  Skin cancers removed from left cheek [**2138**].
5.  Status post pacemaker implant [**2140**].
6.  ORIF left hip 12/[**2142**].
7.  fem/[**Doctor Last Name **] bypass

Social History:
The patient is widowed.  He had been living in [**State 792**]in
the summer and [**State 108**] in the winter, but now is residing in the
[**Location (un) 86**] area [**Street Address(1) 19131**].  He went to college for two years
and was an executive during his lifetime. His son and daughter
are involved in his care.


Family History:
Mother died of stroke age 75.  Father had bowel infarction age
57.


Physical Exam:
Admission Physical Exam:
Vitals: 128/104, 93, 20, 100% BIPAP FiO2 60%, [**6-6**].
General: On Bipap. Unable to participate in conversation. No
acute distress.
HEENT: Sclera anicteric.
Neck: JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU: foley in place
Ext: warm, well perfused, 1+ LLE edema with warm blanching
erythema tracking to the level of the buttocks
.
Discharge Physical Exam:
96.3, 148/68, 56, 20, 98ra
Breathing comfortably, NAD, speech is difficult to understand at
baseline
HEENT: Sclera anicteric.
Neck: JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU: no foley
EXT: warm, venous stasis changes bilaterally, assymetric pitting
edema (L), 1+ DP/PT pulses bilaterally. Erythema has receded
significantly compare to admission and is now centered around a
healing ulceration on the left anterior leg. No fluctuance or
tenderness.

Pertinent Results:
Admission Labs:
[**2144-3-23**] 01:20PM BLOOD WBC-24.9*# RBC-4.75 Hgb-14.8 Hct-41.8
MCV-88 MCH-31.2 MCHC-35.5* RDW-13.3 Plt Ct-301
[**2144-3-23**] 01:20PM BLOOD Neuts-80* Bands-5 Lymphs-14* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2144-3-23**] 01:20PM BLOOD PT-16.0* PTT-33.7 INR(PT)-1.5*
[**2144-3-23**] 01:20PM BLOOD Glucose-109* UreaN-27* Creat-1.4* Na-140
K-4.4 Cl-100 HCO3-24 AnGap-20
[**2144-3-23**] 02:39PM BLOOD Type-ART pO2-45* pCO2-40 pH-7.44
calTCO2-28 Base XS-2 Intubat-NOT INTUBA
[**2144-3-23**] 01:35PM BLOOD Lactate-2.8*
[**2144-3-24**] 01:55AM BLOOD WBC-14.8* RBC-3.74* Hgb-10.9*# Hct-32.5*
MCV-87 MCH-29.2 MCHC-33.7 RDW-13.6 Plt Ct-204
[**2144-3-24**] 01:55AM BLOOD PT-22.0* PTT-150* INR(PT)-2.1*
[**2144-3-24**] 01:55AM BLOOD Glucose-116* UreaN-27* Creat-1.2 Na-137
K-3.7 Cl-107 HCO3-21* AnGap-13

Urine:
[**2144-3-23**] 02:19PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017
[**2144-3-23**] 02:19PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2144-3-23**] 02:19PM URINE RBC-2 WBC-4 Bacteri-FEW Yeast-NONE Epi-0

Blood Cultures x2 ([**3-23**], [**3-24**]): NGTD

Urine Culture ([**3-23**]): NGTD

   DIRECT INFLUENZA A ANTIGEN TEST (Final [**2144-3-24**]):
      Negative for Influenza A.

   DIRECT INFLUENZA B ANTIGEN TEST (Final [**2144-3-24**]):
      Negative for Influenza B.

STUDIES:
CXR ([**3-23**]):
IMPRESSION:
Low lung volumes, without acute cardiopulmonary process.
.
LENI ([**3-23**]):
IMPRESSION:
1. Limited study, without left lower extremity DVT above the
knee.
2. Bilateral reactive inguinal nodes.
.
[**2144-3-25**] 07:45AM BLOOD WBC-9.9 RBC-3.80* Hgb-11.5* Hct-33.1*
MCV-87 MCH-30.3 MCHC-34.8 RDW-13.5 Plt Ct-217
[**2144-3-26**] 07:05AM BLOOD WBC-6.9 RBC-3.79* Hgb-11.5* Hct-32.9*
MCV-87 MCH-30.4 MCHC-35.0 RDW-13.4 Plt Ct-232
[**2144-3-27**] 07:29AM BLOOD WBC-6.2 RBC-3.55* Hgb-10.6* Hct-30.9*
MCV-87 MCH-29.7 MCHC-34.2 RDW-13.2 Plt Ct-260
[**2144-3-28**] 06:12AM BLOOD WBC-7.1 RBC-3.87* Hgb-11.6* Hct-32.9*
MCV-85 MCH-29.9 MCHC-35.2* RDW-13.2 Plt Ct-282
[**2144-3-27**] 07:29AM BLOOD PT-15.2* PTT-57.3* INR(PT)-1.4*
[**2144-3-27**] 04:00PM BLOOD PT-15.5* PTT-81.2* INR(PT)-1.5*
[**2144-3-27**] 09:36PM BLOOD PT-15.8* PTT-80.1* INR(PT)-1.5*
[**2144-3-28**] 06:12AM BLOOD PT-15.9* PTT-78.9* INR(PT)-1.5*
[**2144-3-26**] 07:05AM BLOOD Glucose-96 UreaN-15 Creat-1.1 Na-141
K-3.9 Cl-108 HCO3-29 AnGap-8
[**2144-3-27**] 07:29AM BLOOD Glucose-91 UreaN-15 Creat-1.0 Na-141
K-4.0 Cl-107 HCO3-29 AnGap-9
[**2144-3-28**] 06:12AM BLOOD Glucose-93 UreaN-14 Creat-1.0 Na-141
K-4.2 Cl-107 HCO3-29 AnGap-9
.
URINE CULTURE PENDING AT THE TIME OF DISCHARGE.

Brief Hospital Course:
.
Mr. [**Known lastname 9449**] is a [**Age over 90 **] yo M with HTN, PVD s/p fem-[**Doctor Last Name **] bypass,
recurrent DVTs on indefinite Coumadin, Mobitz II s/p pacemaker.
He presented with acute respiratory failure, high fevers, and
severe LLE cellulitis. He initially required BIPAP and 100% O2
via non-rebreather. His improvement was unusually rapid with
empiric coverage for HCAP, cellulitis, and PE. He was
transferred out of the MICU on room air less than 24 hours after
admission.
.
# Acute Respiratory Failure: His decompensation and recovery
from a respiratory point of view were both remarkably rapid. CXR
was unremarkable, but he was initially covered empirically for
HCAP with cefepime and vancomycin. He has a history of recurrent
aspiration and is on a modified diet, but we would have expected
some evidence of plugging/collapse or pneumonitis if this
picture was  the consequence of an aspiration event.  He was
also empirically treated for PE on admission given his history
of recurrent DVTs and recent pausing of coumadin for an elective
procedure.  Cefepime was discontinued after transfer out of the
MICU and he was continued on vancomycin (for cellulitis) and
heparin drip.  The speed of his recovery argues against
pneumonia or PE. In less than 24 hours, he progressed from
requiring a non-rebreather to being on room air.  It is
conceivable that the increased metabolic demand (high fevers)
associated with his severe cellulitis was the cause of his acute
respiratory failure.
.
# LLL Cellulitis: Likely responsible for his acute
decompensation as above. LENIs were negative for persistent DVT.
He received vancomycin throughout this admission and was
transitioned to oral keflex/doxyclycine for 7 more days at the
time of discharge.  Given that he presented in extremis because
of cellulitis, an argument for a full course of vancomycin could
be made, but the patient's family reported that he has a history
of pulling out catheters and lines.  His infection will be
monitored by VNA and at his PCP's office (in four days).
Although he has a listed allergy to penicillins (rash), his
daughter [**Name (NI) **], his HCP, states that he has tolerated keflex
previously.
.
# h/o DVT: On coumadin chronically as an outpatient.
Subtherapeutic on admission and started on a heparin drip for
empiric coverage of PE.  His family declined CTA as he has a
history of agitation associated with CTs. Because of his history
of DVT recurrence and possiblity of PE, he was discharged on a
lovenox bridge (1.5mg/kg daily) and 5mg coumadin daily. INR on
the day of discharge is 1.5.  Arrangements were made for close
surveillance of his INR given the concomittant use of
anitbiotics (particularly doxycycline): he will have his INR
check on [**3-30**] by VNA and on [**3-/2061**] at his PCP's office.
.
# Anemia: He had a Hct drop after fluid resuscitation in the
MICU. He is guiaic negative and his Hct is trending up. It
should be re-checked when he follows-up in his PCPs office next
week.
.
# Nutrition: Coughing while trying to eat with nurse. He was
seen by speech and swallow. The patient declined a video swallow
and his diet was down-graded to ground solids with thickened
liquids.  He should be supervised for all meals.
.
# Hypertension: His lisinopril was held on admission because of
hypotension and renal failure. It was not re-started as he
remained normotensive without it.
# BPH: Tamsulosin was continued.
.
He is DNR, but he and his family are comfortable with
intubation.
.

Medications on Admission:
lisinopril 2.5 mg daily
Nystatin creme
tamsulosin 0.4 mg QHS
warfarin
vitamin D 1000 units daily
colace 100 mg daily
senna 8.6 mg QHS


Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
4. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
5. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
6. enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg Subcutaneous
Q 24H (Every 24 Hours).
Disp:*4 syringes* Refills:*0*
7. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 7 days.
Disp:*21 Capsule(s)* Refills:*0*
8. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 7 days.
Disp:*14 Capsule(s)* Refills:*0*
9. Outpatient Lab Work
Please check INR on Monday [**3-30**] and fax to the office of Dr.
[**Last Name (STitle) **]  at fax ([**Telephone/Fax (1) 39173**], tel ([**Telephone/Fax (1) 6846**].


Discharge Disposition:
Extended Care

Facility:
[**Street Address(1) 19127**] at [**First Name4 (NamePattern1) 3340**] [**Last Name (NamePattern1) 19128**] - [**Location (un) 583**]

Discharge Diagnosis:
Acute Respiratory Failure
Cellulitis
Chronic LE DVTs
Hypertension
BPH w/ urinary obstruction


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
Dear Mr. [**Known lastname 9449**],

You were brought to the hospital with acute respiratory failure
which required ICU-level support.  You improved very quickly
with the initiation of antibiotics and supplemental oxygen was
weaned over 2 days.  A CXR did not demonstrate pneumonia.  The
cause of your initial decompensation remains somewhat unclear:
it is possible that you had a pulmonary embolism as you had
paused coumadin, but this seems unlikely given the speed at
which you recovered.  More likely, this was all due to the
severe infection (cellulitis) in your leg and high fevers.

You received antibiotics while you were in the hospital and will
need to continue oral antibiotics for one week following
discharge: you have received prescriptions for keflex and
doxycycline.

You will be prescribed lovenox injections until your INR is
therapeutic. You will have your INR checked on Monday by the VNA
and faxed to your PCPs office. You will receive instructions
from the VNA and your PCPs office regarding the duration of
lovenox.

You should hold lisinopril as we have not given it to you in the
hospital and your blood pressure has been within a reasonable
range.

Followup Instructions:
WE HAVE SCHEDULED AN APPOINTMENT WITH YOUR PCP FOR YOU.
Department: GERONTOLOGY
When: WEDNESDAY [**2144-4-1**] at 12:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RNC [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

PREVIOUSLY SCHEDULE APPOINTMENT
Department: PODIATRY
When: THURSDAY [**2144-4-2**] at 1:40 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST     Best Parking: [**Street Address(1) 592**] Garage


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**]

Completed by:[**2144-3-29**]
{'Unspecified septicemia,Acute respiratory failure,Cellulitis and abscess of leg, except foot,Acute kidney failure, unspecified,Chronic venous embolism and thrombosis of unspecified deep vessels of lower extremity,Unspecified essential hypertension,Long-term (current) use of anticoagulants,Cardiac pacemaker in situ,Other and unspecified hyperlipidemia,Osteoporosis, unspecified,Anemia, unspecified,Do not resuscitate status,Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS),Hypovolemia,Severe sepsis,Constipation, unspecified'}


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: [**Age over 90 **] yo M with HTN, PVD s/p fem-[**Doctor Last Name **] bypass, recurrent DVT on
Coumadin, Mobitz II s/p pacemaker, presenting with 1 day of
shortness of breath, cough and fever. Per the patient's care
assistant, he had some chest congestion yesterday, but was
otherwise well. Today, he had fatigue, malaise, fever, and
progressive shortness of breath, leading him to present the ED.
Of note, his Coumadin was held yesterday in preparation for a
dental procedure. He has had left lower extremity edema for the
past 3 weeks. He sometimes coughs after eating.
.
In the ED, initial vital signs were 99.4 90 142/69 34 90% 15L
Non-Rebreather. Lung exam was relatively clear per [**Name (NI) **] report.
EKG showed a venticularly-paced rhythm. Labs notable for WBC
24.9, INR 1.5, creatinine 1.4, lactate 2.8. U/A showed trace
leukocytes, trace blood, few bacteria. CXR showed no
consolidation. ABG 7.44/40/45 on bipap. He was treated with
levofloxacin, with a plan to also treat with vanc and cefepime,
although these were not given in the ED. He was started on bipap
with improvement in his respiratory status. Daughter is HCP
daughter [**Name (NI) **] [**Telephone/Fax (1) 39171**]. Son with [**Name2 (NI) 39172**]. Patient is full
code. Patient confused. Has 18-gauge for access. Vitals on
admission 128/104, 93, 20, 100% BIPAP FiO2 60%, [**6-6**].
.
On arrival to the ICU, the patient was on Bipap and was not able
to convey a history. Review of systems was unobtainable.
.
At baseline, the patient lives in an [**Hospital3 **] with
24-hour care. He receives assistance with eating, and with
transportation to bathroom. He is sometimes incontinent of urine
but not stool.

MEDICAL HISTORY: 1.  Hypertension.
2.  high grade AV block s/p PPM
3.  DVT, on Coumadin.
4.  Hyperlipidemia.
5.  Spinal stenosis.
6.  Osteoporosis.
7.  Several bowel obstructions.
8.  Scoliosis.
9.  Benign prostatic hypertrophy, followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 365**].
10.  Gallstones seen on CAT scan of abdomen.
11.  Renal cell carcinoma.  A mass was seen on his left kidney
on
a CT scan in [**2138**].
12.  Skin cancers. (BCC on nose and ear [**1-/2142**])
13.  Gastritis.
14.  Constipation.
15.  Hearing loss.
16.  Inguinal hernia.
17.  Urinary incontinence.
18.  Left hip fracture [**1-/2143**]
19.  Right heel ulcer [**3-/2143**]
.
Past Surgical History:
1.  TURP [**2118**].
2.  Appendectomy [**2067**].
3.  Arterial graft to left lower extremity [**2088**].
4.  Skin cancers removed from left cheek [**2138**].
5.  Status post pacemaker implant [**2140**].
6.  ORIF left hip 12/[**2142**].
7.  fem/[**Doctor Last Name **] bypass

MEDICATION ON ADMISSION: lisinopril 2.5 mg daily
Nystatin creme
tamsulosin 0.4 mg QHS
warfarin
vitamin D 1000 units daily
colace 100 mg daily
senna 8.6 mg QHS

ALLERGIES: Penicillins

PHYSICAL EXAM: Admission Physical Exam:
Vitals: 128/104, 93, 20, 100% BIPAP FiO2 60%, [**6-6**].
General: On Bipap. Unable to participate in conversation. No
acute distress.
HEENT: Sclera anicteric.
Neck: JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU: foley in place
Ext: warm, well perfused, 1+ LLE edema with warm blanching
erythema tracking to the level of the buttocks
.
Discharge Physical Exam:
96.3, 148/68, 56, 20, 98ra
Breathing comfortably, NAD, speech is difficult to understand at
baseline
HEENT: Sclera anicteric.
Neck: JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU: no foley
EXT: warm, venous stasis changes bilaterally, assymetric pitting
edema (L), 1+ DP/PT pulses bilaterally. Erythema has receded
significantly compare to admission and is now centered around a
healing ulceration on the left anterior leg. No fluctuance or
tenderness.

FAMILY HISTORY: Mother died of stroke age 75.  Father had bowel infarction age
57.

SOCIAL HISTORY: The patient is widowed.  He had been living in [**State 792**]in
the summer and [**State 108**] in the winter, but now is residing in the
[**Location (un) 86**] area [**Street Address(1) 19131**].  He went to college for two years
and was an executive during his lifetime. His son and daughter
are involved in his care. 

### Response:
{'Unspecified septicemia,Acute respiratory failure,Cellulitis and abscess of leg, except foot,Acute kidney failure, unspecified,Chronic venous embolism and thrombosis of unspecified deep vessels of lower extremity,Unspecified essential hypertension,Long-term (current) use of anticoagulants,Cardiac pacemaker in situ,Other and unspecified hyperlipidemia,Osteoporosis, unspecified,Anemia, unspecified,Do not resuscitate status,Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS),Hypovolemia,Severe sepsis,Constipation, unspecified'}
