CHIEF COMPLAINT: Transferred for hypoxia and bronchoscopy

PRESENT ILLNESS: 68 y/o male with a history of angioimmunoblastic T cell Lymphoma
s/p 6 cycles of CHOP chemotherapy diagnosed in [**2144-9-23**] on [**6-9**] with increasing hypoxia
(90% on RA), orthopnea, decreasing appetite, increasing weakness
and increasing abdominal girth.  He was thought to be in
decompensated CHF with pulmonary edema and ascites and underwent
aggressive diuresis with no improvement in his symptoms. On
admission he was started on azithromycin and ceftriaxone for
community acquired pneumonia.  Per report he was not febrile
thru out his hospital stay. He was evaluated by infectious
disease given his lack of improvment who recommended vancomycin
for MRSA infection, bactrim for PCP pna, cefepime for GN
coverage, and gatifloxacin for atypical pna.  HIs WBC trended
downward however his oxygen requirment continued to increase.

MEDICAL HISTORY: 1. Angioimmunoblastic T cell lymphoma s/p 6 cycles of chop
diagnosed in late [**2144-9-23**] due to symptoms of night sweats,
weight loss and bulky adenopathy in the neck.
2 COPD with FEV1/FVC 124% predicted, FEV1 42%, FVC 34%, TLC 76 %
predicted
3 atrial fibrillation
4. coronary artery disease
5. diabetes mellitus
6. CRI
7. Nephrolithiasis
8. CHF  (EF variable reported 35-60%)

MEDICATION ON ADMISSION: allopurinol 100 qd
dilt 120 [**Hospital1 **]
colace
lasix 40 [**Hospital1 **]
gatafloxacin 200 qd
insulin 70/30 ss
solumedrol 60 q6 hours
metoprolol 50 tid
bactrim 18 ml IV q 6 hours
        18 IV q 12 hours
albuterol/atrovent prn
morphine prn
.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE: 96.8 // 111 /62, 95% on 100% NRB FM, HR 111 (afib)
gen- alert, agitated. chronically ill appearing male
heent- EOMI. sclera non-icteric.
neck- JVP at 7cm at 45 degrees. neg HJR
pulm- diffuse ronchi b/l L >R. no wheezes
cv- irreg irreg. variable s1. no murmurs
abd- distended, not tense; no pain- except mild pain at L-sided
paracentesis site (no erythema or pus at this area). + fluid
wave.
no caput. no spider angiomas. no HSM.
ext- trace b/l LE edema to ankles.
neuro- able to respond to yes/no questions, and follow simple
commands, but speech is mostly incoherent; pt is mildly
agitated, pulling at lines. currently in soft UE restraints.
*primary language is portugese, but able to communicate in
english at baseline- per son's report

FAMILY HISTORY: mother died of trauma, father died of old age

SOCIAL HISTORY: retired and lives with his wife.  previously smoked 1 ppd, no
etoh or ivda.  Originally from [**Country 6257**]
Unspecified septicemia,Acute and chronic respiratory failure,Acute kidney failure with lesion of tubular necrosis,Mycosis fungoides, lymph nodes of multiple sites,Defibrination syndrome,Atrial fibrillation,Septic shock,Methicillin susceptible pneumonia due to Staphylococcus aureus,Other tracheostomy complications,Congestive heart failure, unspecified,Chronic airway obstruction, not elsewhere classified,Mitral valve disorders,Severe sepsis,Infection with microorganisms resistant to penicillins,Other chronic pulmonary heart diseases,Dermatitis due to drugs and medicines taken internally,Cephalosporin group causing adverse effects in therapeutic use,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin
Septicemia NOS,Acute & chronc resp fail,Ac kidny fail, tubr necr,Mycosis fungoides mult,Defibrination syndrome,Atrial fibrillation,Septic shock,Meth sus pneum d/t Staph,Tracheostomy comp NEC,CHF NOS,Chr airway obstruct NEC,Mitral valve disorder,Severe sepsis,Inf mcrg rstn pncllins,Chr pulmon heart dis NEC,Drug dermatitis NOS,Adv eff cephalosporin,DMII wo cmp nt st uncntr,Long-term use of insulin
Admission Date:  [**2145-6-17**]              Discharge Date:   [**2145-7-29**]

Date of Birth:  [**2077-5-8**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 338**]
Chief Complaint:
Transferred for hypoxia and bronchoscopy

Major Surgical or Invasive Procedure:
intubation
pulmonary artery catheter placement

History of Present Illness:
68 y/o male with a history of angioimmunoblastic T cell Lymphoma
s/p 6 cycles of CHOP chemotherapy diagnosed in [**2144-9-23**] on [**6-9**] with increasing hypoxia
(90% on RA), orthopnea, decreasing appetite, increasing weakness
and increasing abdominal girth.  He was thought to be in
decompensated CHF with pulmonary edema and ascites and underwent
aggressive diuresis with no improvement in his symptoms. On
admission he was started on azithromycin and ceftriaxone for
community acquired pneumonia.  Per report he was not febrile
thru out his hospital stay. He was evaluated by infectious
disease given his lack of improvment who recommended vancomycin
for MRSA infection, bactrim for PCP pna, cefepime for GN
coverage, and gatifloxacin for atypical pna.  HIs WBC trended
downward however his oxygen requirment continued to increase.

He underwent CT chest/abdomen/pelvis which demonstrated
extensive hilar, mediastinal, retroperitoneal, iliac and
inguinal adenopathy. A 2.5 cm left perihilar mass and and 8 mm
nodule in  left lung near the descending aorta.  Right sided
pleural effusion.  Small bilateral renal calculi with no
obstructive changes. He underwent CT neck which revealed stable
LN dz in neck, and LN enlargement in mediastinum

He underwent echo with normal EF and was evaluated by cardiology
who felt his symptoms were consistent with CHF.

His hospital course was complicated by the development of acute
renal failure with a Cr of 4.6 and agitation requiring haldol.
And supratherapeutic INR.

Worsening of his rapid afib with RVR to the 140s for which he
was started on diltiazem.  There were also rate related ST
depressions reported.

He underwent diagnostic paracentesis which revealed atypical
cells on cytology and WBC 14,030,  RBC 38,000, with 41%
Neutropil concerning for SBP.

He was transferred to [**Hospital1 18**] for bronch.

Past Medical History:
1. Angioimmunoblastic T cell lymphoma s/p 6 cycles of chop
diagnosed in late [**2144-9-23**] due to symptoms of night sweats,
weight loss and bulky adenopathy in the neck.
2 COPD with FEV1/FVC 124% predicted, FEV1 42%, FVC 34%, TLC 76 %
predicted
3 atrial fibrillation
4. coronary artery disease
5. diabetes mellitus
6. CRI
7. Nephrolithiasis
8. CHF  (EF variable reported 35-60%)


Social History:
retired and lives with his wife.  previously smoked 1 ppd, no
etoh or ivda.  Originally from [**Country 6257**]

Family History:
mother died of trauma, father died of old age

Physical Exam:
PE: 96.8 // 111 /62, 95% on 100% NRB FM, HR 111 (afib)
gen- alert, agitated. chronically ill appearing male
heent- EOMI. sclera non-icteric.
neck- JVP at 7cm at 45 degrees. neg HJR
pulm- diffuse ronchi b/l L >R. no wheezes
cv- irreg irreg. variable s1. no murmurs
abd- distended, not tense; no pain- except mild pain at L-sided
paracentesis site (no erythema or pus at this area). + fluid
wave.
no caput. no spider angiomas. no HSM.
ext- trace b/l LE edema to ankles.
neuro- able to respond to yes/no questions, and follow simple
commands, but speech is mostly incoherent; pt is mildly
agitated, pulling at lines. currently in soft UE restraints.
*primary language is portugese, but able to communicate in
english at baseline- per son's report


Pertinent Results:
LAB Trends at OSH:
-----------------
WBC:  17.2 <-- 18.2 <-- 24.8 <-- 23.2 <--22 <--19.5 <--18.2
<--19.1
.
Cr: 4.6 <-- 4.8 <-- 4.2 <-- 2.3<--1.5 <-- 1.4 <-- 1.3
.
Micro data: cdiff negative, blood cx ngtd, UA wnl
.
EKG:  atrial fibrillation at 100
.
Admission Labs:
---------------
FIBRINOGE-101*
PT-15.0* PTT-27.0 INR(PT)-1.5
PLT COUNT-153
WBC-16.7* RBC-3.17* HGB-10.4* HCT-29.7* MCV-94
DIGOXIN-1.1
VANCO-14.4*
CORTISOL-100.8*
TSH-8.8*
calTIBC-270 HAPTOGLOB-94 FERRITIN-326 TRF-208
ALBUMIN-3.6 CALCIUM-7.3* PHOSPHATE-6.4* MAGNESIUM-2.2 URIC
ACID-17.2*
IRON-78
LIPASE-33
ALT(SGPT)-10 AST(SGOT)-17 LD(LDH)-548* ALK PHOS-134* AMYLASE-54
TOT BILI-0.4
GLUCOSE-317* UREA N-95* CREAT-4.0* SODIUM-130* POTASSIUM-4.1
CHLORIDE-93* TOTAL CO2-22 ANION GAP-19
freeCa-1.04*
LACTATE-2.3*
.
Radiologic Studies:
------------------
CXR [**6-17**]: There are diffuse bilateral opacities and this is a
cardiomegaly, consistent with CHF. However, a multifocal
pneumonia cannot be excluded.
.
Micro Data:
-----------
[**2145-6-18**] BAL-

GRAM STAIN (Final [**2145-6-18**]):
1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR LEUKOCYTES.
3+  (5-10 per 1000X FIELD):   BUDDING YEAST WITH PSEUDOHYPHAE.

RESPIRATORY CULTURE (Final [**2145-6-20**]):
~1000/ML OROPHARYNGEAL FLORA.
YEAST.    10,000-100,000 ORGANISMS/ML..
STAPH AUREUS COAG +.    ~5000/ML.

LEGIONELLA CULTURE (Preliminary):    NO LEGIONELLA ISOLATED.

IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII (Final
[**2145-6-18**]):
PNEUMOCYSTIS CARINII NOT SEEN.

ACID FAST SMEAR (Preliminary): NO AFB SEEN ON DIRECT SMEAR.





Brief Hospital Course:
68 y/o male with progressive pulmonary decline unresponsive to
diuresis and broad spectrum antibiotics and new onset of ascites
concerning for rapidly progressive metastatic lymphoma and new
acute renal failure. Intubated emergently for refractory
hypoxemia on [**6-17**] w/prolonged ICU stay c/b vent-assoc MRSA PNA,
periods of rapid Afib, drug rash, and diffuculty weaning off
ventilator.
.
# Hypoxemic Respiratory Failure/SIRS: Emergently intubated on
admission to the ICU for refractory hypoxemia. The cause of his
respiratory failure was unclear. However, infectious etiology
was felt to be high given his immunosuppressed state from his
T-cell lymphoma. He was covered broadly with ceftriaxone,
azithromycin, bactrim, vancomycin, and voriconazole. Was on
Vanco/CTX/Azithro/Vori x 14 days([**Date range (1) 62192**]), on Zosyn for
increased fever and secretions, 7 day course ([**7-1**]- [**7-8**]).
Bronchoscopy/BAL was performed and was negative for AFB, PCP or
bacterial microorganisms. Induced sputum was also negative. He
was continued empirically on antibiotics given his clinical
decline with sepsis physiology. Tumor burden with lymphangitic
spread was also considered as a potential etiology of his
respiratory distress, but was felt less likely given the stable
appearance of his tumor on imaging studies. CTA was negative for
PE as a potential source. He had a tracheotomy tube placed on
[**7-14**] and was slowly weaned off the ventilator.  Weaning was
complicated by large amount of bleeding from tracheostomy while
on heparin and by large amounts of secretions leading to mucous
plugging.  Heparin was d/ced [**2-24**] to bleeding from tracheostomy.
Course was further complicated by MRSA tracheobronchitis treated
with Vancomycin ([**7-20**]-expected [**7-29**] to complete 10 day course).
He improved greatly with decreased secretions with Vancomycin.
Recent speech consult for passey muir valve, patient was able to
tolerate for short periods of time (approximately 30 seconds [**2-24**]
secretions) - currently able to tolerate longer periods of time.
 Currently patient with O2 sats @ 100% on 60% face mask.
Current respiratory treatments include Vancomycin 1gm q12hr (day
[**9-1**]), Albuterol q 6hr. It is hoped that in the next week or so
he will have the trach removed and return to breathing from his
oral airway.
.
# Hypotension: Hypotension felt to be septic in etiology given
its distributive nature. SVR was found to be low, in 500's, by
pulmonary artery cath, with normal cardiac output. He was
treated with broad-spectrum antibiotics as outlined above. In
addition he was started on pressors with neosynephrine. However,
he remained persistently hypotensive, with decreasing SVR's.
Therefore vasopressin was added to his regimen. Subsequently his
MAP's increased >60 with steady UOP >30 cc/hr. He was also noted
to have initial evidence of low-grade DIC with increasing
PT/PTT, and decreasing fibrinogen and platelets. Therefore he
was started on activated protein C. His fibrinogen levels
subsequently improved with stable coags and platelets. He did
not require cryoprecipitate or FFP transfusions. In addition he
had no noted bleeding complications w/ APC. Currently he is
normotensive with BP 130's-150's/50's-80's without use of
pressors - given improvement of hypotension with antibiotic
treatment, likely etiology was sepsis.
.
# Ascites: Cytology from outside hospital consistent with
lymphoma and SBP. Started on ceftriaxone for sbp. Repeat
ultrasound showed loculated abdominal ascites, not felt to be
ammenable to paracentesis. Therefore he was monitored
clinically, without further intervention.  Repeat ultrasound
[**7-13**] showed small amount of ascites.  Unable to place PEG given
ascites.  He is currently with slightly distended, non-firm,
non-tender abdomen, on Ciprofloxacin 400mg 1x/wk for SBP
prophylaxis.
.
# Mental Status:  Patient with episodes of delirium since
admission to ICU - most commonly in morning then becomes more
lucid later in day.  Possibly [**2-24**] to lack of sleep, infection,
medications, or combination.  Haldol initially tried, but d/ced
[**2-24**] to increased QTc. Zyprexa and Versed were also tried but
were found to be ineffective in treating his delirium.  Ativan
2mg was effective in assisting the patient to sleep, and patient
has not had delirium since this time.  He is currently awake and
alert, oriented to being in [**Location (un) 86**], but remains slightly
confused when asked if he knows what type of building he is in.
He is portugeuse speaking, and therefore interviewed with help
of an interpreter.
.
# Lymphoma: initially presented with hypocalcemia,
hyperphosphatemia and acute renal failure, concern for suspected
tumor lysis.  Treated with IVF, allopurinol and close monitoring
of electrolytes. He was felt to be too sick for chemotherapy
during his stay.  Pt??????s outpt onc will follow him once
discharged.  Cont acyclovir for prophylaxis.
.
# Acute renal failure -?????? Initially, pt had elevation of BUN, Cr,
which resolved with fluid resuscitation.  Cr stabilized at 0.8
.
# Afib -- Loaded with Digoxin, and continued on 0.125 mg daily.
Initially on heparin, but discontinued because of large amount
of bleeding from trach site.  Restarted with TPN (5000units).
Good rate control with 0.125mg Digoxin QD, Metoprolol 7.5mg
q4hr. Attempted anticoagulation with heparin drip and coumadin.
However, had extensive bloody secretions and anticoagulation was
subsequently stopped.  Plan for Coumadin once start PO. As pt
was not able to take po medications, metoprolol was d/c'd prior
to discharge to rehab. Once he is able to take po's this
medication may be restarted should he have rapid ventricular
rates.
.
# Pulmonary Hypertension -- an echo on [**7-2**] showed severe
pulmonary HTN associated with 2+ mitral regurgitation.  It was
unclear whether this could be due to the MR [**First Name (Titles) **] [**Last Name (Titles) **] pulmonary
emboli.  He was initially started on heparin, but this was
discontinued given large amounts of bleeding from the trach
site.  Furthermore, MR was felt to be more likely the cause of
the pulmonary hypertension.
.
# FEN ?????? Pt had post-pyloric feeding tube inserted twice, both of
which he pulled out while in episodes of confusion/delirium.  He
failed a bedside swallowing study, and we were unable to place a
PEG [**2-24**] ascites.  As a result, he was started on TPN for
nutrition. It is expected that pt will only require the trach
mask for approx one more week, at which time the trach will be
removed and hopefully he will be able to eat again.
.
# Rash and eosinophilia ?????? rash started after starting multiple
antibiotics, biopsy performed, felt to be drug rash associated
with antibiotics most likely ceftriaxone, improved on steroids.
.
# CAD ?????? Pt was treated with beta-blocker and ASA.  Hydralazine
for afterload reduction was initiated at low doses but d/c'd
before discharge since pt could not take po medications and IV
hydral could not be dosed at rehab. Pt should be started on an
ACE-I once he can tolerate po's again.
.
# Anemia ?????? stable hct
- pt previously with bleeding from trach when on heparin, now
stopped.  No evidence of bleeding. (Anticoag was primarily for
afib)
-Continue to monitor hct.

# DM1 - ISS, Humalin (dose calculated out and based on carbs in
tube feeds) and glargine (calculated based on basal metabolic
rate). Currently pt is receiving insulin in TPN. Once this is
stopped and he is able to eat he should be restarted on glargine
approximately 18 units.
.
# [**Female First Name (un) 564**] in urine - Changed foley, but repeat culture has
yeast.
-No antifungal treatment for now.  Latest UA with occ yeast and
0 WBCs
.
# ppx - heparin stopped because of bloody secretions - restarted
in TPN.
.
# Access ?????? pt pulled out TLC and A-line.  Currently has PIV and
PICC for access.
.
# full code
.
Communication:  [**Telephone/Fax (1) 62193**] wife/son [**Telephone/Fax (1) 62194**]
PCP [**Name9 (PRE) 62195**], ONC [**Name9 (PRE) 17881**] ([**Hospital 42317**] Medical)


Medications on Admission:
allopurinol 100 qd
dilt 120 [**Hospital1 **]
colace
lasix 40 [**Hospital1 **]
gatafloxacin 200 qd
insulin 70/30 ss
solumedrol 60 q6 hours
metoprolol 50 tid
bactrim 18 ml IV q 6 hours
        18 IV q 12 hours
albuterol/atrovent prn
morphine prn
.

Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
2. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
5. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
6. Senna 8.8 mg/5 mL Syrup Sig: One (1)  PO BID (2 times a day).

7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-24**]
Puffs Inhalation Q6H (every 6 hours).
8. Aspirin 300 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
9. Digoxin 250 mcg/mL Solution Sig: One (1) 0.125mg Injection
DAILY (Daily).
10. Diphenhydramine HCl 50 mg/mL Solution Sig: One (1)
Injection Q6H (every 6 hours) as needed.
11. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) 1g
Intravenous  Q 12H (Every 12 Hours) for 10 days: (total 10 days
- through [**7-29**]).
12. Ciprofloxacin in D5W 400 mg/200 mL Piggyback Sig: One (1)
400mg Intravenous  1X/WEEK (SA): (Please give on Saturdays).
13. Pantoprazole Sodium 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous  Q24H (every 24 hours).
14. Lorazepam 2 mg/mL Syringe Sig: One (1) 2mg Injection HS (at
bedtime) as needed.
15. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl
Topical  QID (4 times a day) as needed for neck sore.
16. Insulin Regular Human 100 unit/mL Solution Sig: As directed
units Injection qachs: For FSBS 0-159, 0 units
For FSBS 160-199, 2 units
For FSBS 200-239, 4 units
For FSBS 240-279, 6 units
For FSBS 280-319, 8 units
For FSBS 320-359, 10 units
For FSBS 360-399, 12 units
For FSBS >400, notify M.D.


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] REHAB

Discharge Diagnosis:
1.) Community Aquired Pneumonia/Sepsis requiring long intubation
2.) Tracheobronchitis
3.) SBP
4.) s/p ARF with Cr increase to 4.6, resolved with fluid
rescusitation
5.) AFib - currently well controlled with Digoxin, Metoprolol
6.) Angioimmunoblastic T cell lymphoma s/p 6x cycles CHOP (dx in
[**9-26**])
7.) Ascites - [**2-24**] lymphoma.
8.) DM1
9.) CAD
10.) Anemia
11.) COPD


Discharge Condition:
Patient in fair/good condition on discharge.  Main issues
include tracheostomy, on trach mask to achieve good ventilation,
TPN for nutrition, ascites [**2-24**] lymphoma.

Discharge Instructions:
1.)  Come to hospital if fever >100.4, increased respiratory
distress, any other concerns.


Followup Instructions:
1.) Follow up with Oncologist Dr. [**Last Name (STitle) 17881**] @ [**Hospital 42317**] Medical
center
2.) Follow up with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 62195**]





Name:  [**Known lastname 11186**],[**Known firstname **] H             Unit No:   [**Numeric Identifier 11187**]

Admission Date:  [**2145-6-17**]              Discharge Date:   [**2145-7-29**]

Date of Birth:  [**2077-5-8**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 10790**]
Addendum:
Please check digoxin level in 3 days, target level 0.9-1.5.
Please relay level to nursing home MD on call to adjust digoxin
level as necessary and recheck digoxin accordingly.

Discharge Disposition:
Extended Care

Facility:
[**Hospital **] REHAB

                             [**Doctor First Name 3354**] [**First Name8 (NamePattern2) **] [**Name8 (MD) 3353**] MD [**MD Number(2) 10791**]

Completed by:[**2145-7-29**]
{'Unspecified septicemia,Acute and chronic respiratory failure,Acute kidney failure with lesion of tubular necrosis,Mycosis fungoides, lymph nodes of multiple sites,Defibrination syndrome,Atrial fibrillation,Septic shock,Methicillin susceptible pneumonia due to Staphylococcus aureus,Other tracheostomy complications,Congestive heart failure, unspecified,Chronic airway obstruction, not elsewhere classified,Mitral valve disorders,Severe sepsis,Infection with microorganisms resistant to penicillins,Other chronic pulmonary heart diseases,Dermatitis due to drugs and medicines taken internally,Cephalosporin group causing adverse effects in therapeutic use,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin'}


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: Transferred for hypoxia and bronchoscopy

PRESENT ILLNESS: 68 y/o male with a history of angioimmunoblastic T cell Lymphoma
s/p 6 cycles of CHOP chemotherapy diagnosed in [**2144-9-23**] on [**6-9**] with increasing hypoxia
(90% on RA), orthopnea, decreasing appetite, increasing weakness
and increasing abdominal girth.  He was thought to be in
decompensated CHF with pulmonary edema and ascites and underwent
aggressive diuresis with no improvement in his symptoms. On
admission he was started on azithromycin and ceftriaxone for
community acquired pneumonia.  Per report he was not febrile
thru out his hospital stay. He was evaluated by infectious
disease given his lack of improvment who recommended vancomycin
for MRSA infection, bactrim for PCP pna, cefepime for GN
coverage, and gatifloxacin for atypical pna.  HIs WBC trended
downward however his oxygen requirment continued to increase.

MEDICAL HISTORY: 1. Angioimmunoblastic T cell lymphoma s/p 6 cycles of chop
diagnosed in late [**2144-9-23**] due to symptoms of night sweats,
weight loss and bulky adenopathy in the neck.
2 COPD with FEV1/FVC 124% predicted, FEV1 42%, FVC 34%, TLC 76 %
predicted
3 atrial fibrillation
4. coronary artery disease
5. diabetes mellitus
6. CRI
7. Nephrolithiasis
8. CHF  (EF variable reported 35-60%)

MEDICATION ON ADMISSION: allopurinol 100 qd
dilt 120 [**Hospital1 **]
colace
lasix 40 [**Hospital1 **]
gatafloxacin 200 qd
insulin 70/30 ss
solumedrol 60 q6 hours
metoprolol 50 tid
bactrim 18 ml IV q 6 hours
        18 IV q 12 hours
albuterol/atrovent prn
morphine prn
.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE: 96.8 // 111 /62, 95% on 100% NRB FM, HR 111 (afib)
gen- alert, agitated. chronically ill appearing male
heent- EOMI. sclera non-icteric.
neck- JVP at 7cm at 45 degrees. neg HJR
pulm- diffuse ronchi b/l L >R. no wheezes
cv- irreg irreg. variable s1. no murmurs
abd- distended, not tense; no pain- except mild pain at L-sided
paracentesis site (no erythema or pus at this area). + fluid
wave.
no caput. no spider angiomas. no HSM.
ext- trace b/l LE edema to ankles.
neuro- able to respond to yes/no questions, and follow simple
commands, but speech is mostly incoherent; pt is mildly
agitated, pulling at lines. currently in soft UE restraints.
*primary language is portugese, but able to communicate in
english at baseline- per son's report

FAMILY HISTORY: mother died of trauma, father died of old age

SOCIAL HISTORY: retired and lives with his wife.  previously smoked 1 ppd, no
etoh or ivda.  Originally from [**Country 6257**] 

### Response:
{'Unspecified septicemia,Acute and chronic respiratory failure,Acute kidney failure with lesion of tubular necrosis,Mycosis fungoides, lymph nodes of multiple sites,Defibrination syndrome,Atrial fibrillation,Septic shock,Methicillin susceptible pneumonia due to Staphylococcus aureus,Other tracheostomy complications,Congestive heart failure, unspecified,Chronic airway obstruction, not elsewhere classified,Mitral valve disorders,Severe sepsis,Infection with microorganisms resistant to penicillins,Other chronic pulmonary heart diseases,Dermatitis due to drugs and medicines taken internally,Cephalosporin group causing adverse effects in therapeutic use,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin'}
