CHIEF COMPLAINT: OSH transfer for ? pulomonary stent

PRESENT ILLNESS: 83F h/o HTN, CHF, and recent afib s/p PM implantation who was
transferred to [**Hospital3 17921**] Center on [**2113-5-31**] with 1 week of
lightheadeness and episodes of syncope. Creatinine was 1.0, BUN
22.
.
CXR and BNP were consistent with CHF, and TTE showed valve area
of 0.75cm2, moderate MR, and EF 55%. LHC on [**5-31**] revealed RCA
lesion of 60%. The decision was made to pursue aortic valve
replacement on [**6-6**] with a tissue valve, and ascending aorta
endarterectomy. She was extubated on [**6-7**].
.
Her post-operative course was complicated by worsening pulmoanry
function, cough, ?RUL PNA on CXR, and rising WBC to 17K, with
concern of retained secretions, and poor cough. On [**6-9**], she
underwent bronchoscopy to evaluate for concern for retained
secretions, at which time thick secretions, which showed
purulent secretions, for which broad spectrum abx were started,
and pt was started on BiPaP.
.
She was also noted to have bilateral pleural fluid collections,
ultimately resulting in left thoracentesis [**6-8**] (250cc
serosang), left [**Female First Name (un) 576**] on [**6-12**], right side 20 french chest tube on
[**6-13**], right side anteriolateral thoracentesis [**6-14**] (100cc serous
fluid), left thoracentesis on [**6-5**], and [**6-25**] (250cc serous).
.
She continued to do poorly from a respiratory standpoint, and CT
on [**6-26**] was concerning for right side hemothorax, prompting
right thoracotomy and VATs with decortication of the right lung,
evacuation of right hemothorax, and repair of the right lung
with a xenograft.
.
On [**6-29**], repeat bronchoscopy was performed which revealed marked
thickening and narrowing of the right main and intermediate
bronchus, with concern of a mass compressing the right maintstem
bronchus. Per d/c summary, the endobronchaial papearance
suggested the possibility of neoplasm, and material was
aspirated, but biopsy was deferred [**2-13**] INR 1.8.
.
The patient was also seen by general surgery on [**6-18**] for
?abdominal pain in the setting of kayexalate induced stooling
for hyperkalemia, however she denied abdominal pain upon repeat
questioning, and no further intervention was performed. She was
seen by nephrology pre-operatively with plan to hold lasix, ACE,
and potassium. By report, she is alert, and interactive, though
had been increasingly tachypneic, agitated on BiPaP was was
therefore intubated prior to transfer.
.
She is transferred to [**Hospital1 18**] for consideration of stenting of the
right minstem and intermediate bronchus with possible
transbronchial biopsy.
.
At the time of her transfer, UOP over past 24 hours was 1065 cc,
chest tube drainiage was 390 cc.

MEDICAL HISTORY: - Severe aortic stenosis (0.75 cm2) s/p AVR (#19 carpenter)
- CHF felt [**2-13**] AS
- CAD - 60%RCA disease pre-valve surgery.
- H/o afib s/p pacemaker implantation
- CRI (baseline 1.0 on [**5-31**])
- HTN
- Osteoporosis
- Dementia
- Cataract surgery

MEDICATION ON ADMISSION: Medications at Home:
- Actonel qmonthly
- Aspirin 81mg po qdaily
- Amiodarone 200mg po qdaily
- KCl daily
- Lasix 80mg po qam, 40mg po qpm
- MVI
- Protonix 40mg po qdaily
- Toprol 200mg po
- Coumadin 2.5mg po
- Lisinopril 20mg po
- Zocor 40mg po
.
.
Medications on Transfer:
- Albuterol/Atrovent Duoneb INH Q6H
- Pulmozyme 2.5mg IH [**Hospital1 **]
- Epogen 20,000U SC x 1 ([**6-30**] 6PM)
- Lasix 20mg iv x 1 ([**2113-7-1**] 12AM)
- Imipenem-Cilastin 500mg IV Q8HR
- Methylprednisolone 60mg IV Q8H (start [**2113-7-1**])
- Methylprednisolone 20mg IV BID (start [**2113-7-3**])
- Metoprolol 50mg po bid
- Pantoprazole 40mg iv qdaily
- Vitamin c 500mg po qdaily
- Aspirin 81mg po qdaily
- Colace 100mg po bid
- Ferrous sulfate 325mg po qdaily
- Lisinopril 2.5mg po qdaily
- Simvastain 20mg po qdaily
- Tylenol prn
- Bisacodyl prn
- Nicardipine gtt (started [**6-30**] 9AM)
- Phenylephrine gtt (started [**6-27**] 11AM) -> not receiving on
arrival
- TPN gtt @ 65ml/hr
- SSI
- Ativan 0.25mg po qhs prn insomnia
- Ativan 1mg po q6hr prn agitation

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: 97.1 71 135/50 18 98% on AC 650x10 100% PEEP 7
General: intubated, sedated.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
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, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: NC.

SOCIAL HISTORY: She lives in [**Hospital3 83025**]. She denies
tobacco, notes occassional ETOH, denies IVDU.
Acute respiratory failure,Acute on chronic systolic heart failure,Obstructive chronic bronchitis with (acute) exacerbation,Bacteremia,Unspecified pleural effusion,Hyperosmolality and/or hypernatremia,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Atrial fibrillation,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Anemia, unspecified,Edema,Dysphagia, unspecified,Secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or unspecified,Osteoporosis, unspecified,Other persistent mental disorders due to conditions classified elsewhere,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Heart valve replaced by transplant,Percutaneous transluminal coronary angioplasty status,Cardiac pacemaker in situ,Adrenal cortical steroids causing adverse effects in therapeutic use
Acute respiratry failure,Ac on chr syst hrt fail,Obs chr bronc w(ac) exac,Bacteremia,Pleural effusion NOS,Hyperosmolality,Chronic kidney dis NOS,Hy kid NOS w cr kid I-IV,Atrial fibrillation,Other staphylococcus,Anemia NOS,Edema,Dysphagia NOS,Sec DM wo cmp nt st uncn,Osteoporosis NOS,Mental disor NEC oth dis,Crnry athrscl natve vssl,Old myocardial infarct,Heart valve transplant,Status-post ptca,Status cardiac pacemaker,Adv eff corticosteroids
Admission Date:  [**2113-7-1**]              Discharge Date:   [**2113-7-8**]

Date of Birth:  [**2030-1-12**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 783**]
Chief Complaint:
OSH transfer for ? pulomonary stent

Major Surgical or Invasive Procedure:
Rigid and flex bronchoscopy, with biopsy
s/p 2 right sided chest tubes


History of Present Illness:
83F h/o HTN, CHF, and recent afib s/p PM implantation who was
transferred to [**Hospital3 17921**] Center on [**2113-5-31**] with 1 week of
lightheadeness and episodes of syncope. Creatinine was 1.0, BUN
22.
.
CXR and BNP were consistent with CHF, and TTE showed valve area
of 0.75cm2, moderate MR, and EF 55%. LHC on [**5-31**] revealed RCA
lesion of 60%. The decision was made to pursue aortic valve
replacement on [**6-6**] with a tissue valve, and ascending aorta
endarterectomy. She was extubated on [**6-7**].
.
Her post-operative course was complicated by worsening pulmoanry
function, cough, ?RUL PNA on CXR, and rising WBC to 17K, with
concern of retained secretions, and poor cough. On [**6-9**], she
underwent bronchoscopy to evaluate for concern for retained
secretions, at which time thick secretions, which showed
purulent secretions, for which broad spectrum abx were started,
and pt was started on BiPaP.
.
She was also noted to have bilateral pleural fluid collections,
ultimately resulting in left thoracentesis [**6-8**] (250cc
serosang), left [**Female First Name (un) 576**] on [**6-12**], right side 20 french chest tube on
[**6-13**], right side anteriolateral thoracentesis [**6-14**] (100cc serous
fluid), left thoracentesis on [**6-5**], and [**6-25**] (250cc serous).
.
She continued to do poorly from a respiratory standpoint, and CT
on [**6-26**] was concerning for right side hemothorax, prompting
right thoracotomy and VATs with decortication of the right lung,
evacuation of right hemothorax, and repair of the right lung
with a xenograft.
.
On [**6-29**], repeat bronchoscopy was performed which revealed marked
thickening and narrowing of the right main and intermediate
bronchus, with concern of a mass compressing the right maintstem
bronchus. Per d/c summary, the endobronchaial papearance
suggested the possibility of neoplasm, and material was
aspirated, but biopsy was deferred [**2-13**] INR 1.8.
.
The patient was also seen by general surgery on [**6-18**] for
?abdominal pain in the setting of kayexalate induced stooling
for hyperkalemia, however she denied abdominal pain upon repeat
questioning, and no further intervention was performed. She was
seen by nephrology pre-operatively with plan to hold lasix, ACE,
and potassium. By report, she is alert, and interactive, though
had been increasingly tachypneic, agitated on BiPaP was was
therefore intubated prior to transfer.
.
She is transferred to [**Hospital1 18**] for consideration of stenting of the
right minstem and intermediate bronchus with possible
transbronchial biopsy.
.
At the time of her transfer, UOP over past 24 hours was 1065 cc,
chest tube drainiage was 390 cc.

Past Medical History:
- Severe aortic stenosis (0.75 cm2) s/p AVR (#19 carpenter)
- CHF felt [**2-13**] AS
- CAD - 60%RCA disease pre-valve surgery.
- H/o afib s/p pacemaker implantation
- CRI (baseline 1.0 on [**5-31**])
- HTN
- Osteoporosis
- Dementia
- Cataract surgery

Social History:
She lives in [**Hospital3 83025**]. She denies
tobacco, notes occassional ETOH, denies IVDU.


Family History:
NC.

Physical Exam:
Vitals: 97.1 71 135/50 18 98% on AC 650x10 100% PEEP 7
General: intubated, sedated.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
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, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

Pertinent Results:
OSH LABS:
[**2113-6-30**] CRE 0.8, ALT 25, AST 27, INR 1.5, PT 15.4. by d/c
summary, HCT 32.6.
[**2113-6-19**] BCx (line) - staphyloccocus
[**2113-6-19**] UCx - ngtd.
[**2113-6-26**] MRSA swab - negative.
[**2113-6-26**] R pleural clot - gram stain - rare polys, no organism.
[**2113-6-29**] BAL washings - grams tstain - moderate polys.
[**2113-6-8**] catheter tip - no growth.
.
On Admission:
[**2113-7-1**] 03:10PM BLOOD WBC-12.2* RBC-3.06* Hgb-8.6* Hct-26.6*
MCV-87 MCH-28.2 MCHC-32.4 RDW-16.6* Plt Ct-282
[**2113-7-1**] 03:10PM BLOOD Neuts-94.8* Lymphs-2.3* Monos-2.6 Eos-0.1
Baso-0.1
[**2113-7-1**] 03:10PM BLOOD PT-14.7* PTT-24.6 INR(PT)-1.3*
[**2113-7-1**] 03:10PM BLOOD Glucose-157* UreaN-43* Creat-0.8 Na-146*
K-3.6 Cl-109* HCO3-28 AnGap-13
[**2113-7-1**] 03:10PM BLOOD Calcium-8.2* Phos-1.4* Mg-2.1
[**2113-7-1**] 03:10PM BLOOD ALT-15 AST-17 LD(LDH)-370* AlkPhos-101
TotBili-0.7 Albumin-2.5*
[**2113-7-1**] 03:34PM BLOOD Lactate-1.7
[**2113-7-1**] 03:10PM BLOOD CK(CPK)-23* CK-MB-4 cTropnT-0.18*
.
[**2113-7-1**] Blood Culture, Routine (Preliminary):
      GRAM POSITIVE COCCUS(COCCI).    IN PAIRS AND CLUSTERS.

   Anaerobic Bottle Gram Stain (Final [**2113-7-3**]):
      REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20488**] @ 0800AM, [**2113-7-3**].
      GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
.
STUDIES:

[**2113-7-1**] CXR
FINDINGS: In comparison with the study of [**7-2**], the tip of the
endotracheal tube has been pulled back so that it now lies
approximately 3.3 cm above the carina. Nasogastric tube has been
repositioned so that the side hole is well below the
esophagogastric junction. Small right pneumothorax persists with
chest tube in place.
Otherwise, little change in the appearance of the heart and
lungs.
.
[**2113-7-1**] Chest CT
IMPRESSION:
1. Bilateral pleural effusions. The right-sided pleural fluid is
loculated
in the major fissure and also has a component that is higher
attenuation in the dependent aspect, which may represent
hemorrhage or complex fluid.
Recommend correlation with chest tube output.
2. Small 1.2-cm right hilar node. No obstructing bronchus mass,
which was
the clinical concern.
3. Heterogeneous nodular thyroid gland. Recommend non-emergent
thyroid
ultrasound.
4. Complex left renal cystic lesion. Renal ultrasound is
recommended for
additional evaluation.
.
[**7-3**] Rigid and Flex Bronch: No significant central airway
obstruction, narrowing or collapse. Successful transbronchial
needle aspiration of station 11R. Balloon dilatation of right
middle lobe orifice.
.
[**7-3**] U/S LUE: no DVT
.
[**7-3**] ECHO: no obvious vegetation, but can get TEE if suspicion
is high
serial CXRs: unchanged extensive opacification in the right lung
and left lower lobe
.
serial CXRs (last one [**2113-7-7**]): extensive opacities in left
lower lobe and right lung with no interval changes

MICRO:
[**7-1**]: 1 bottle gram pos, coag negative cocci, likely Staph epi
from OSH
[**2028-7-1**]: no growth to date
.
DISCHARGE LABS ([**2113-7-8**]):
.
WBC-16.6* RBC-3.91* Hgb-11.0* Hct-35.0* MCV-90 MCH-28.2
MCHC-31.5 RDW-16.3* Plt Ct-436
([**2113-7-7**]) Neuts-94.8* Lymphs-2.3* Monos-2.8 Eos-0.1 Baso-0.1
Glucose-112* UreaN-24* Creat-0.8 Na-142 K-3.8 Cl-102 HCO3-33*
AnGap-11
Calcium-8.5 Phos-2.4* Mg-2.1

Brief Hospital Course:
83F s/p AVR, with post-op course complicated by respiratory
failure [**2-13**] pulmonary secretions, recurrent bilateral pleural
effusions requiring thoracentesis, and concern for mass
compressing right mainstem bronchus.  Mass not seen on CT or
Bronch, and biopsy showed normal tissue (cartilage, fibrin).
Respiratory failure likely secondary to secretions, CHF, pleural
effusions.
.
# Respiratory Failure - This was likely multifactorial,
attributed to chronic post-op complications with significant
secretions that she is having difficulty clearing, fluid
overload due to acute on chronic systolic CHF, COPD
exacerbation. She continues to have expiratory wheezing/rhonchi
on exam. She had small PTX at R apex with chest tubes in place
that improved, and the chest tubes were subsequently removed by
Thoracic Surgery ([**7-5**], [**7-6**]). Her CXRs have remained stable
after removal of the chest tubes, and her breathing remains the
same. Radiologist noted sternal dehiscence, which Thoracic
Surgery recommended could be followed as outpatient or if
patient experiences symptoms. Pt was placed on steroid taper as
her COPD exacerbation was improving. She will be discharged on
PO prednisone 40mg daily 40mg daily [**Date range (1) 83026**], 20mg daily
[**Date range (1) 83027**], 10mg daily [**Date range (1) 39988**], d/c [**7-30**]. Daily lung exams
remain similar - patient has mild respiratory distress and uses
accessory muscles, with rhonchorous breath sounds and bibasilar
crackles. We have weaned her oxygen requirement down to 2L (95%
O2 sat). Respiratory rate 16. Recommend to continue aggressive
chest PT, nebulizers, mucomyst, and suction for thick secretions
in lung. Continue diuresis as below.
.
# CHF ?????? Pt is s/p AVR (tissue valve). She responded well to IV
Lasix 40mg [**Hospital1 **], reaching her goal of net negative 1L/day.
Lisinopril was uptitrated in the Metoprolol was increased to 100
mg po TID to control her BP, which reached SBPmax 180. Recommend
strict I/Os with goal of net negative 500-1000ml/day, daily
weights, titrate Lasix dose as needed. Discharge Cr 0.8.
.
# HTN - Patient had elevated BP during her stay, up to SBP 180s.
Uptitrated Metoprolol to 100mg TID and Lisinopril to 40mg daily.
Current BP in 150s/60s. Continue to moniter as she is being
diuresed and titrate as necessary.
.
# Bacteremia - Single OSH blood culture dated [**6-19**] from "line"
reported +staph epi sensitive to vanc/tetracycline on [**6-25**]. [**7-1**]
bcx growing GPC in pairs/chains. No stigmata of endocarditis at
this time. TTE neg for veg on [**2113-7-3**]. Blood cultures from
[**2028-7-1**] have no growth to date. Leukocytosis (11.7-16.6) likely
secondary to steroid use, as there are no bands. WBC currently
16.6 with no bands. Recommend close follow up of WBC, f/u
temperature closely (patient has not had fever throughout
hospital course on the floor): keep low threshold for fever
work-up/rule out pneumonia: chest x-ray, blood cultures,
antibiotics. Patient is being treated for the initial positive
blood cultures with vancomycin for a 2 weeks course, ending on
[**2113-7-17**].
.
# H/o AFib ?????? Patient is currently rate controlled in normal
sinus rythym on metoprolol. Patient was not taking her home dose
of amiodarone 200mg PO daily when she was transferred to this
hospital, but was restarted on [**2113-7-3**]. [**Country **] score was
calculated to [**2-14**], so anticoagulation was restarted at her home
dose of Coumadin 2.5mg PO daily. INR subtherapeutic for several
days, so Coumadin was increased to 5mg PO daily. Discharge INR
is 1.4. Please continue Coumadin 5mg daily until INR>2, then
decrease back to initial dose of 2.5mg daily.
.
# DIFFICULTY SWALLOWING - Patient is tolerating diet
recommendations (thin liquid and pureed food, crushed pills
mixed with puree, 1:1 supervision while eating, chin tuck,
staying upright after meals) well. Consider Barium swallow study
in the future - postponed for now due to limited mobility of
patient. Please place patient on aspiration precautions.
.
# Anemia - Patient's baseline HCT is unknown, but per family,
patient has a h/o "bleeding from GI system" which was evaluated
by GI ~2y ago, with no clear source. Hct remained stable,
currently Hct 33.8.
.
# Hypernatremia - Likely due to volume depletion during
intubation. Na level improved with D5W, and patient is now
allowed to take free water. Sodium is 142 today. Recommend to
continue to monitor sodium, as it may rise as the patient
continues to be diuresed.

# CRI - By report, but currently creatinine is 0.8. Cr has been
within normal limits throughout hospital stay. Please follow
electrolytes with further diuresis.

# DM - Pt has no h/o DM as per family, but was started on SSI at
OSH, likely secondary to steroid use. FS range between 107-264.
Recommend to continue sliding scale insulin and wean as steroids
are tapered.

# UPPER EXTREMITY EDEMA - Pt has upper extremity edema,
left>right. DVT was ruled out with left upper extremity Doppler.
Edema is improving with diuresis.

Medications on Admission:
Medications at Home:
- Actonel qmonthly
- Aspirin 81mg po qdaily
- Amiodarone 200mg po qdaily
- KCl daily
- Lasix 80mg po qam, 40mg po qpm
- MVI
- Protonix 40mg po qdaily
- Toprol 200mg po
- Coumadin 2.5mg po
- Lisinopril 20mg po
- Zocor 40mg po
.
.
Medications on Transfer:
- Albuterol/Atrovent Duoneb INH Q6H
- Pulmozyme 2.5mg IH [**Hospital1 **]
- Epogen 20,000U SC x 1 ([**6-30**] 6PM)
- Lasix 20mg iv x 1 ([**2113-7-1**] 12AM)
- Imipenem-Cilastin 500mg IV Q8HR
- Methylprednisolone 60mg IV Q8H (start [**2113-7-1**])
- Methylprednisolone 20mg IV BID (start [**2113-7-3**])
- Metoprolol 50mg po bid
- Pantoprazole 40mg iv qdaily
- Vitamin c 500mg po qdaily
- Aspirin 81mg po qdaily
- Colace 100mg po bid
- Ferrous sulfate 325mg po qdaily
- Lisinopril 2.5mg po qdaily
- Simvastain 20mg po qdaily
- Tylenol prn
- Bisacodyl prn
- Nicardipine gtt (started [**6-30**] 9AM)
- Phenylephrine gtt (started [**6-27**] 11AM) -> not receiving on
arrival
- TPN gtt @ 65ml/hr
- SSI
- Ativan 0.25mg po qhs prn insomnia
- Ativan 1mg po q6hr prn agitation

Discharge Medications:
1. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Three (3) ML
Miscellaneous Q 8H (Every 8 Hours).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) NEB Inhalation Q 8H (Every 8 Hours).
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) NEB Inhalation Q6H (every 6 hours) as
needed for wheezing.
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day) as needed for constipation.
9. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
10. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid Sig: One (1)
dose PO DAILY (Daily).
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) dose
Injection TID (3 times a day).
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) NEB
Inhalation Q6H (every 6 hours).
13. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
15. Zocor 40 mg Tablet Sig: One (1) Tablet PO once a day.
16. Warfarin 2.5 mg Tablet Sig: 1-2 Tablets PO once a day: take
5mg/day until INR>2, then decrease to 2.5mg/day.
17. Furosemide 10 mg/mL Solution Sig: Four (4) ml Injection [**Hospital1 **]
(2 times a day).
18. Prednisone 10 mg Tablet Sig: Four (4) Tablet PO once a day
for 3 weeks: Steroid taper:
week 1 ([**Date range (1) 83026**]): 40mg/day
week 2 ([**Date range (1) 83027**]): 20mg/day
week 3 ([**Date range (1) 39988**]): 10mg/day
week 4: d/c .
19. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q 12H (Every 12 Hours) for 10 days: for 2 week
course, end date: [**7-17**].
20. Actonel 150 mg Tablet Sig: One (1) Tablet PO once a month.
21. Insulin Lispro 100 unit/mL Solution Sig: as directed by
insulin sliding scale units Subcutaneous ASDIR (AS DIRECTED).
22. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15)
ML Mucous membrane Q 12H (Every 12 Hours).
23. Outpatient Lab Work
Please recheck INR, CBC with DIFF, CHEM7 with diuresis on [**7-9**],
and afterwards as needed to follow INR, leukocytosis, and lytes.
24. Heparin Flush 10 unit/mL Kit Sig: Two (2) ml Intravenous
every eight (8) hours.
25. Saline Flush 0.9 % Syringe Sig: Ten (10) ml Injection every
6-8 hours.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 1293**] - [**Location (un) **]

Discharge Diagnosis:
Primary diagnosis:
respiratory failure
pleural effusions

Secondary diagnoses:
acute on chronic systolic congestive heart failure
hypertension
bacterial infection: Staph epidermidis bacteremia
atrial fibrillation
s/p 2 chest tubes
anemia
s/p aortic valve replacement


Discharge Condition:
Improved, stable


Discharge Instructions:
You were treated at the hospital for respiratory failure due to
a combination of recent chest surgery, fluid backup from your
heart failure, and thick secretions in your lungs. While you
were here, you underwent a bronchoscopy to take a look inside
your lungs and to take a biopsy of a small lymph node. They did
not see a mass, as it was previously thought you might have from
previous studies at the outside hospital. The biopsy that they
took showed normal tissue - cartilage, blood, and fibrin. Two
chest tubes that were draining fluid from your lungs were
removed, and your chest xrays have remained stable. Your
breathing has continued to improve with the current medications,
chest physical therapy, and suction.

You were also evaluated for your swallowing ability while you
were here. Be sure to continue the following recommendations:
1. 1:1 supervision while eating/drinking
2. you can have thin liquids and pureed food
3. crush pills and mix with puree
4. use chin tuck and stay upright after meals

You have received a PICC line (semi-permanent IV line), so you
have IV access for your antibiotics.

The following changes were made to your medications:
- You were started on Vancomycin, which is an antibiotic that
you will receive through your PICC line until [**7-17**].
- You were given steroids (methylprednisolone) to help with your
breathing. You will be discharged on Prednisone 40mg daily for 1
week and tapered down as tolerated.
- Your dose of Warfarin was increased to 5mg daily until your
INR>2. Then it can be decreased back to your normal done of
2.5mg daily.
- Your dose of Lasix was changed to 40mg IV twice a day
- Your dose of Toprol was changed to Metoprolol 100mg three
times a day and Lisinopril to 40mg daily to control your blood
pressure
- You were started on a sliding scale of Insulin to control your
high blood sugars, likely secondary to the steroid use.

If you have difficulty breathing/worsening shortness of breath,
chest pain, fevers, chills, or any other concerning symptoms,
please call your physician or return to the hospital.

It was a pleasure meeting you and taking part in your care.

Followup Instructions:
- strict I/Os with goal of net negative 500-1000ml/day, daily
weights, titrate Lasix dose as needed
- f/u temperature closely (patient has not had fever throughout
hospital course on the floor): keep low threshold for fever
work-up/rule out pneumonia: chest x-ray, blood cultures,
antibiotics
- INR checks: when INR>2, decrease Warfarin dose from 5mg to
2.5mg daily
- aggressive chest PT, nebulizers, mucomyst, and suction for
thick secretions in lung
- oral predinose taper: 40mg daily [**Date range (1) 83026**], 20mg daily
[**Date range (1) 83027**], 10mg daily [**Date range (1) 39988**], d/c [**7-30**]
- IV vancomycin until [**7-17**]

Please follow-up with your primary care physician and your
cardiology, Dr. [**Last Name (STitle) 13310**] ([**Telephone/Fax (1) **]), within 1-2 weeks of
discharge.

Please follow-up any chest discomfort.


                             [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
{'Acute respiratory failure,Acute on chronic systolic heart failure,Obstructive chronic bronchitis with (acute) exacerbation,Bacteremia,Unspecified pleural effusion,Hyperosmolality and/or hypernatremia,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Atrial fibrillation,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Anemia, unspecified,Edema,Dysphagia, unspecified,Secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or unspecified,Osteoporosis, unspecified,Other persistent mental disorders due to conditions classified elsewhere,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Heart valve replaced by transplant,Percutaneous transluminal coronary angioplasty status,Cardiac pacemaker in situ,Adrenal cortical steroids causing adverse effects in therapeutic use'}


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: OSH transfer for ? pulomonary stent

PRESENT ILLNESS: 83F h/o HTN, CHF, and recent afib s/p PM implantation who was
transferred to [**Hospital3 17921**] Center on [**2113-5-31**] with 1 week of
lightheadeness and episodes of syncope. Creatinine was 1.0, BUN
22.
.
CXR and BNP were consistent with CHF, and TTE showed valve area
of 0.75cm2, moderate MR, and EF 55%. LHC on [**5-31**] revealed RCA
lesion of 60%. The decision was made to pursue aortic valve
replacement on [**6-6**] with a tissue valve, and ascending aorta
endarterectomy. She was extubated on [**6-7**].
.
Her post-operative course was complicated by worsening pulmoanry
function, cough, ?RUL PNA on CXR, and rising WBC to 17K, with
concern of retained secretions, and poor cough. On [**6-9**], she
underwent bronchoscopy to evaluate for concern for retained
secretions, at which time thick secretions, which showed
purulent secretions, for which broad spectrum abx were started,
and pt was started on BiPaP.
.
She was also noted to have bilateral pleural fluid collections,
ultimately resulting in left thoracentesis [**6-8**] (250cc
serosang), left [**Female First Name (un) 576**] on [**6-12**], right side 20 french chest tube on
[**6-13**], right side anteriolateral thoracentesis [**6-14**] (100cc serous
fluid), left thoracentesis on [**6-5**], and [**6-25**] (250cc serous).
.
She continued to do poorly from a respiratory standpoint, and CT
on [**6-26**] was concerning for right side hemothorax, prompting
right thoracotomy and VATs with decortication of the right lung,
evacuation of right hemothorax, and repair of the right lung
with a xenograft.
.
On [**6-29**], repeat bronchoscopy was performed which revealed marked
thickening and narrowing of the right main and intermediate
bronchus, with concern of a mass compressing the right maintstem
bronchus. Per d/c summary, the endobronchaial papearance
suggested the possibility of neoplasm, and material was
aspirated, but biopsy was deferred [**2-13**] INR 1.8.
.
The patient was also seen by general surgery on [**6-18**] for
?abdominal pain in the setting of kayexalate induced stooling
for hyperkalemia, however she denied abdominal pain upon repeat
questioning, and no further intervention was performed. She was
seen by nephrology pre-operatively with plan to hold lasix, ACE,
and potassium. By report, she is alert, and interactive, though
had been increasingly tachypneic, agitated on BiPaP was was
therefore intubated prior to transfer.
.
She is transferred to [**Hospital1 18**] for consideration of stenting of the
right minstem and intermediate bronchus with possible
transbronchial biopsy.
.
At the time of her transfer, UOP over past 24 hours was 1065 cc,
chest tube drainiage was 390 cc.

MEDICAL HISTORY: - Severe aortic stenosis (0.75 cm2) s/p AVR (#19 carpenter)
- CHF felt [**2-13**] AS
- CAD - 60%RCA disease pre-valve surgery.
- H/o afib s/p pacemaker implantation
- CRI (baseline 1.0 on [**5-31**])
- HTN
- Osteoporosis
- Dementia
- Cataract surgery

MEDICATION ON ADMISSION: Medications at Home:
- Actonel qmonthly
- Aspirin 81mg po qdaily
- Amiodarone 200mg po qdaily
- KCl daily
- Lasix 80mg po qam, 40mg po qpm
- MVI
- Protonix 40mg po qdaily
- Toprol 200mg po
- Coumadin 2.5mg po
- Lisinopril 20mg po
- Zocor 40mg po
.
.
Medications on Transfer:
- Albuterol/Atrovent Duoneb INH Q6H
- Pulmozyme 2.5mg IH [**Hospital1 **]
- Epogen 20,000U SC x 1 ([**6-30**] 6PM)
- Lasix 20mg iv x 1 ([**2113-7-1**] 12AM)
- Imipenem-Cilastin 500mg IV Q8HR
- Methylprednisolone 60mg IV Q8H (start [**2113-7-1**])
- Methylprednisolone 20mg IV BID (start [**2113-7-3**])
- Metoprolol 50mg po bid
- Pantoprazole 40mg iv qdaily
- Vitamin c 500mg po qdaily
- Aspirin 81mg po qdaily
- Colace 100mg po bid
- Ferrous sulfate 325mg po qdaily
- Lisinopril 2.5mg po qdaily
- Simvastain 20mg po qdaily
- Tylenol prn
- Bisacodyl prn
- Nicardipine gtt (started [**6-30**] 9AM)
- Phenylephrine gtt (started [**6-27**] 11AM) -> not receiving on
arrival
- TPN gtt @ 65ml/hr
- SSI
- Ativan 0.25mg po qhs prn insomnia
- Ativan 1mg po q6hr prn agitation

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: 97.1 71 135/50 18 98% on AC 650x10 100% PEEP 7
General: intubated, sedated.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
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, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: NC.

SOCIAL HISTORY: She lives in [**Hospital3 83025**]. She denies
tobacco, notes occassional ETOH, denies IVDU. 

### Response:
{'Acute respiratory failure,Acute on chronic systolic heart failure,Obstructive chronic bronchitis with (acute) exacerbation,Bacteremia,Unspecified pleural effusion,Hyperosmolality and/or hypernatremia,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Atrial fibrillation,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Anemia, unspecified,Edema,Dysphagia, unspecified,Secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or unspecified,Osteoporosis, unspecified,Other persistent mental disorders due to conditions classified elsewhere,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Heart valve replaced by transplant,Percutaneous transluminal coronary angioplasty status,Cardiac pacemaker in situ,Adrenal cortical steroids causing adverse effects in therapeutic use'}
