CHIEF COMPLAINT: progressive DOE x 3 days

PRESENT ILLNESS: 87 yoM with h/o AFib not on coumadin and SCC on the face s/p
resection, who presents with three days of progressive DOE. He
reports pink-tinged frothy sputum as well as chills, anorexia
and rhinorrhea, though he denies fever, Ha,
arhtralgias/myalgias, chest pain, emesis and diarrhea. He says
he "may have gained weight recently," though was at the doctor
on [**2203-12-22**] and seemed to be doing well. He denies weight loss
over the last several months. He also told the ED he had
increased urinary output.
.
In the ED, VS were T 100.3, BP 139/70, HR 124 in AFib, RR 16,
96% on NRB (85% RA, 95% 4LNC) on presentation. He was given ASA
325 mg, ibuprofen 400 mg Po, and levofloxacin 740 mg IV,
ceftriaxone 1 g IV, and vanco 1g IV for CAP. In the ED, BP was
initially in the 120's on admission but then dropped to 84/43;
it improved to the 110-120's with a IVF bolus. He got a total of
~2L betwen IVF and antibiotics. Blood cultures were sent. ABG
was not done. There was concern for an element of CHF with a BNP
> [**Numeric Identifier 3652**], though he was not diuresed in the ED because of the
concern for infection.
.
On arrival to the ICU, T 96.0, HR 92, BP 122/49, 92-96% NRB.
Initially there was concern for volume overload and he was given
lasix 20 mg IV. He also had some hemoptysis.

MEDICAL HISTORY: DM2
Paroxysmal Atrial Fibrillation on anticoagulation
CRI- baseline Cr 1.5 - 2.0
HTN
Gout
COPD
OA
h/o GIB ([**2198**]; found to have gastritis, ulcerations, no active
bleeding, and angioectasia in colon)
h/o hip fx s/p ORIF/IM nail R hip, L hip [**2201**]
[**Name (NI) 3674**] unclear etiology, previously treated with regular
transfusions, now on procrit, baseline 30
h/o pericardial effusion in setting of AF with RVR, CHF, pleural
effusions ([**2198**])
s/p TURP for prostate enlargement and urinary retention
h/o sigmoid colon ca s/p sigmoid colectomy [**2192**]
right cheek SCC s/p skin graft
Diastolic CHF

MEDICATION ON ADMISSION: Buproprion 75 mg [**Hospital1 **]
Combivent 2 puffs [**Hospital1 **]
Diltiazem 240 mg QD
Epo 10,000 SC QWeek
Ferroud sulfate 325 mg QD
Fluticasone [**Hospital1 **]
Lasix 40 mg QD
Lisinopril 10 mg QD
Montelukast 10 mg QD
MVI
Pantoprazole 40 mg QD
Rosiglitazone 2 mg Qd

ALLERGIES: Percocet / Tylenol

PHYSICAL EXAM: VS on arrival to the ICU: T 96.0, HR 92, BP 122/49, 92-96% NRB
General: elderly, comfortable but appears somewhat SOB, NAD,
speaking in full sentences
HEENT: poor dentition, OP clear, tacky MM
Lungs: end exp wheezes on right throughout; high pitched sounds,
rhonchi, crackles throughout on left; some use of SCM for
breathing
Cardio: heart sounds difficult to hear over O2 and breath
sounds; difficult to assess JVD with surgical scars and SCM use

FAMILY HISTORY: NC

SOCIAL HISTORY: Patient denies tobacco or illicit drugs. He reports occasional
alcohol consumption. [**Name (NI) **] (HCP) report recent falls. House
with stairs between kitchen and bedroom. Speaks multiple
languages.
Pneumonia, organism unspecified,Acute respiratory failure,Empyema without mention of fistula,Acute kidney failure, unspecified,Acute on chronic combined systolic and diastolic heart failure,Intestinal infection due to Clostridium difficile,Delirium due to conditions classified elsewhere,Hyperosmolality and/or hypernatremia,Blood in stool,Surgical or other procedure not carried out because of patient's decision,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic kidney disease, unspecified,Personal history of other malignant neoplasm of skin,History of fall,Gout, unspecified,Other acquired deformity of other parts of limb,Constipation, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified
Pneumonia, organism NOS,Acute respiratry failure,Empyema w/o fistula,Acute kidney failure NOS,Ac/chr syst/dia hrt fail,Int inf clstrdium dfcile,Delirium d/t other cond,Hyperosmolality,Blood in stool,No proc/patient decision,Atrial fibrillation,DMII wo cmp nt st uncntr,Chronic kidney dis NOS,Hx-skin malignancy NEC,Personal history of fall,Gout NOS,Oth acq limb deformity,Constipation NOS,Hy kid NOS w cr kid I-IV
Admission Date:  [**2203-12-25**]              Discharge Date:   [**2204-1-16**]


Service: MEDICINE

Allergies:
Percocet / Tylenol

Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
progressive DOE x 3 days

Major Surgical or Invasive Procedure:
PICC line placement
CPAP

History of Present Illness:
87 yoM with h/o AFib not on coumadin and SCC on the face s/p
resection, who presents with three days of progressive DOE. He
reports pink-tinged frothy sputum as well as chills, anorexia
and rhinorrhea, though he denies fever, Ha,
arhtralgias/myalgias, chest pain, emesis and diarrhea. He says
he "may have gained weight recently," though was at the doctor
on [**2203-12-22**] and seemed to be doing well. He denies weight loss
over the last several months. He also told the ED he had
increased urinary output.
.
In the ED, VS were T 100.3, BP 139/70, HR 124 in AFib, RR 16,
96% on NRB (85% RA, 95% 4LNC) on presentation. He was given ASA
325 mg, ibuprofen 400 mg Po, and levofloxacin 740 mg IV,
ceftriaxone 1 g IV, and vanco 1g IV for CAP. In the ED, BP was
initially in the 120's on admission but then dropped to 84/43;
it improved to the 110-120's with a IVF bolus. He got a total of
~2L betwen IVF and antibiotics. Blood cultures were sent. ABG
was not done. There was concern for an element of CHF with a BNP
> [**Numeric Identifier 3652**], though he was not diuresed in the ED because of the
concern for infection.
.
On arrival to the ICU, T 96.0, HR 92, BP 122/49, 92-96% NRB.
Initially there was concern for volume overload and he was given
lasix 20 mg IV. He also had some hemoptysis.


Past Medical History:
DM2
Paroxysmal Atrial Fibrillation on anticoagulation
CRI- baseline Cr 1.5 - 2.0
HTN
Gout
COPD
OA
h/o GIB ([**2198**]; found to have gastritis, ulcerations, no active
bleeding, and angioectasia in colon)
h/o hip fx s/p ORIF/IM nail R hip, L hip [**2201**]
[**Name (NI) 3674**] unclear etiology, previously treated with regular
transfusions, now on procrit, baseline 30
h/o pericardial effusion in setting of AF with RVR, CHF, pleural
effusions ([**2198**])
s/p TURP for prostate enlargement and urinary retention
h/o sigmoid colon ca s/p sigmoid colectomy [**2192**]
right cheek SCC s/p skin graft
Diastolic CHF

Social History:
Patient denies tobacco or illicit drugs. He reports occasional
alcohol consumption. [**Name (NI) **] (HCP) report recent falls. House
with stairs between kitchen and bedroom. Speaks multiple
languages.

Family History:
NC

Physical Exam:
VS on arrival to the ICU: T 96.0, HR 92, BP 122/49, 92-96% NRB
General: elderly, comfortable but appears somewhat SOB, NAD,
speaking in full sentences
HEENT: poor dentition, OP clear, tacky MM
Lungs: end exp wheezes on right throughout; high pitched sounds,
rhonchi, crackles throughout on left; some use of SCM for
breathing
Cardio: heart sounds difficult to hear over O2 and breath
sounds; difficult to assess JVD with surgical scars and SCM use

Abd: somewhat distended and obese, but soft, no fluid wave
appreciated, NT
Ext: chronic woody changes of b/l LE to mid-shin, [**1-21**]+ [**Location (un) **] b/l
symmetric
Skin: multiple SK's and AK's; large area of skin
graft/post-surgery on left fronto-parietal foreheaad/head
MS: left leg slightly shorter and externally rotated
Neuro: AA, Ox3, speaking in full sentences, conversant,
appropriate, resting tremor in L>R


Pertinent Results:
Admission CXR (12/6/9):
SINGLE UPRIGHT FRONTAL CHEST RADIOGRAPH: There is near-complete
opacification
of the left hemithorax, with some residual aeration noted in the
upper lung.
Air-bronchogram is the mid lung suggests a component of
air-space
consolidation with probable increased effusion. The right
hemithorax is
normally aerated. There is no pneumothorax. No large pleural
effusion is
noted on the right. The cardiomediastinal silhouette is
incompletely assessed
secondary to the left hemithorax opacification. There is
unchanged
calcification in the aortic knob.
IMPRESSION: Interval near-complete opacification of the left
hemithorax,
compatible with a large left-sided pleural effusion and likely
consolidation.
.
12/7/9 echo:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is
moderate global left ventricular hypokinesis (LVEF = 35 %). The
right ventricular cavity is moderately dilated with mild global
free wall hypokinesis. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is a
trivial/physiologic pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2199-10-11**], biventricular systolic function is now
seen.
CLINICAL IMPLICATIONS:
The left ventricular ejection fraction is <40%, a threshold for
which the patient may benefit from an ACEI or [**Last Name (un) **]
.
12/7/9 CT chest:
1)Diffuse dense left lung consolidation and collapse with
extensive airway
occlusion, likely due to infectious pneumonia and coexisting
atelectasis from retained secretions. Correlation with
bronchoscopy may be helpful to clear secretions and to exclude a
fixed endoluminal lesion. No definite hilar mass but assessment
limited by absence of IV contrast.
2)Focal consolidation in the right upper lobe also likely due to
infection but attention to this area on follow up imaging
recommended to ensure resolution.
3)Coronary artery, aortic valve and mitral annulus
calcification.
4)Gallstones
.
[**1-1**] CXR:
There is slight improvement of the left lung consolidation
although
significant amount of consolidation is still involving most of
the left lung with some minimal sparing of the lateral portion
of the left lower lobe. The right upper lobe is entirely
consolidated but the right lower lung appears to be relatively
clear. There is potentially present left pleural effusion.
There is no pneumothorax. Multiple abnormalities might be
further evaluated by chest CT if clinically warranted.
.
[**1-5**] CXR:
Cardiomediastinal contours are unchanged with cardiac size top
normal.
Multifocal consolidations have continuously improved. Still they
are greater on the right upper lobe and left lower lobe. If any,
there is a small left pleural effusion. There is no
pneumothorax.
.
[**1-11**] CXR:
Left PICC tip is in the proximal SVC. Cardiomediastinal contours
are obscured by the lung abnormalities. Multifocal
consolidations are unchanged as does a left pleural effusion.
There are lower lung volumes . There is no evident
pneumothorax.
.
[**1-16**] CXR:
HISTORY: Pneumonia, to evaluate for change.

FINDINGS: In comparison with the study of [**1-14**], the patient has
taken a
somewhat better inspiration. The degree of left perihilar
opacification,
retrocardiac opacification, and perihilar opacification on the
right is
similar. There may be some increase in the right upper lobe
opacification
when compared to the prior study.

PICC line position is unchanged.

[**12-25**] negative blood cultures
12/7 negative urine legionella
.
[**1-1**]:
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
.
Labs on day of discharge;
WBC RBC Hgb Hct MCV Plt Ct
7.5 2.6 6.6 24.5 99 140*
.
Glucose UreaN Creat Na  K    Cl HCO3 AnGap
172*    60*    1.1  143 4.6 109* 32  7*


Brief Hospital Course:
Mr. [**Known lastname 1968**] is an 87yoM, with a PMH significant for AFib not on
coumadin and SCC on the face s/p resection, who presented to the
MICU with complete white out of left lung.
.
#. UNILATERAL PLEURAL EFFUSION: This was thought to be due to a
pneumonia given the unilateral nature of the effusion;
parapneumonic effusion as most likely diagnosis. Given smoking
history and degree to which whole lung is affected,
post-obstructive PNA (due to malignancy) was considered as a
possibility too. Less likely CHF b/c of left-sided unilateral
nature, although the pt appeared to have element of volume
overload with peripheral edema and response to lasix. It seems
of relatively short onset, given that the patient had a normal
PEat PCP's office four days prior to admission, per the pt.
Blood and sputum cultures and urine legionella were negative. CT
and CXR's showed the significant effusion. The patient refused
VATS/surgery/thoracentesis, so no clear etiology was discovered.
He was treated broadly with antibiotics (empirically), and there
was progressive (albeit slow) improvement in patient's
oxygenation (>90% on 2L NC at discharge), his physical exam, and
his chest x-rays. He was treated empirically with
vancomycin/cefepime/azithromycin for hospital-acquired pneumonia
broad coverage.
.
On multiple occasions, patient had SOB, increased RR and work of
breathing, SpO2 decreased - on those occasions, lasix was tried,
in case CHF was a component, in addition to morphine, haldol
(sparingly, for anxiety/confusion), and nebs. We found that
talking/anxiety was big contibutor to [**Last Name (LF) **], [**First Name3 (LF) **] tried to control
that with reassurance. Patient was placed on CPAP on a few of
these separate occasions, and tolerated it well, and was able to
come back off of the CPAP without repercussion. Goal SpO2 in low
90s which is finally acheived with 2L NC and off CPAP for
several days prior to dishcarge.
.
Chemical pneumonitis is likely a component of the dypnea, as the
pt's neighbor later reported that he had found no less than 2
dozen RAID bombs on the patient's bedroom floor, which the
patient had been setting off due to "bugs on the floor" (likely
visual hallucinations). The pt completed 5 days of
methylprednisolone course.
.
#. COPD/ASTHMA: As patient will now be long-term NPO any
non-inhaled meds had to be d/c'd and he was sent out on
fluticasone INH and PRN nebs.
.
#. AFIB:  The pt went into Afib went into RVR after his PO meds
(including metoprolol) were held. Ultimately, scheduled IV
metoprolol was begun with good rate control. He required
diltiazem drip at two different time points during his
hospitalization. One of those times, his heart rate went into
the bradycardic range. On other occasions, he would just become
bradycardic without an obvious trigger, but tolerated it without
symptoms.  He was in sinus rhythm at discharge.
.
Given fall risk/history and questionable history of GI bleed,
patient was not anticoagulated. He was originally on aspirin
325mg daily, but in the setting of melena (see below), that was
stopped. This should be restarted [**1-17**].
.
#Melena - Patient had one large melanotic stool without CHT drop
or decompensation during his hospitaliation, thoguht to be due
to c. diff infection.  We held aspirin which should be restarted
as below. His PPI was also increased to [**Hospital1 **], and should be
restarted at QD on the [**1-17**].
.
# Agitation/Disorientaion:  Patient quite classically sundowns,
but responds well to redirection and zydis tab if necessary. He
had apparently been having nightly visual hallucinations at home
prior to this admission.
.
#. DIABETES:  Held home PO meds, used SSI. Not an active issue.
.
# C.DIFFICILE INFECTION: C. diff positive, started on Flagyl
morning of [**2204-1-2**], should continue until [**2204-1-23**].
.
#.CONTACT: with the patient, has friends/[**Name2 (NI) 9259**] who are [**Name (NI) 18133**]
([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 111706**]). They were updated
frequently.
.
#. CODE: DNR, DNI. Palliative care was consulted, suggested
morphine for discomfort/anxiety, and consider zydis as needed
also (used very rarely during admission).
.
# Access: PICC (double-lumen).
.
# Nutrition: Started TPN through PICC. We watched electrolytes
closely, due to concern for refeeding syndrome given patient was
not eating for many days prior. Difficulty swallowing, concern
for aspiration. PO pills converted to IV form and non-essentials
d/c'd.


Medications on Admission:
Buproprion 75 mg [**Hospital1 **]
Combivent 2 puffs [**Hospital1 **]
Diltiazem 240 mg QD
Epo 10,000 SC QWeek
Ferroud sulfate 325 mg QD
Fluticasone [**Hospital1 **]
Lasix 40 mg QD
Lisinopril 10 mg QD
Montelukast 10 mg QD
MVI
Pantoprazole 40 mg QD
Rosiglitazone 2 mg Qd


Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation. Tablet, Delayed Release (E.C.)(s)
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. Insulin Lispro 100 unit/mL Solution Sig: see attached sliding
scale unit Subcutaneous ASDIR (AS DIRECTED): See attached
sliding scale.
5. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours).
6. Albuterol Sulfate 2.5 mg/0.5 mL Solution for Nebulization
Sig: One (1)  Inhalation every six (6) hours.
7. Morphine 2 mg/mL Syringe Sig: One (1)  Injection Q6H (every 6
hours) as needed for pain,.
8. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1)  Intravenous Q8H (every 8 hours): D 1 = [**1-2**], DC on
[**2204-1-23**] for 14 day course after planned completion of cefepime.
Changed to IV as pt could not swallow pill [**1-4**].
9. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
10. Metoprolol Tartrate 5 mg/5 mL Solution Sig: 7.5 mg
Intravenous Q6H (every 6 hours).
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) treatment Inhalation Q6H (every 6
hours) as needed for wheezing/sob.
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatment
Inhalation Q6H (every 6 hours) as needed for wheezing/sob.
13. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet,
Rapid Dissolve PO BID (2 times a day) as needed for Agitation.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **]

Discharge Diagnosis:
Primary: 1) pneumonia, 2) respiratory distress, 3) C. dificile
colitis, 4) atrial fibrillation

Secondary: 1) congestive heart failure, 2) Type 2 diabetes, 3)
chronic renal insuffiency, 4) squamous cell cancer, 5) iron
deficiency anemia


Discharge Condition:
Mental status: Confused - majority of time, especially when
hypoxic. Difficult to understand speech [**2-21**] hoarseness, face
mask.
Generally Alert and interactive.
Out of Bed with assistance to chair or wheelchair


Discharge Instructions:
You were seen in the ED for difficulty breathing. You had a very
large pneumonia and required a large amount of respiratory
support in the MICU at [**Hospital3 **] Medical Center for several
weeks in the ICU to maintain your oxygenation levels.  Overtime,
you improved with IV antbiotics and IV steroids.  While you were
hospitalized, you developed an antibiotic-associated infection
of the colon called Clostridium Dificile, which you will need to
take antibiotics for 2 weeks after the treatment for your
pneumonia is completed.

During your stay in the ICU, you became quite confused.  We
think this is due to your pneumonia, decreased oxygen levels in
your blood, and being in an unfamiliar location.  You can take a
medication called zydis which disolves on your tongue when you
get very confused or agiatated.

Your heart was evaluated while you were hospitalized and you do
have congestive heart failure; because of your CHF, pleae weigh
yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3
lbs.  You were diuresed with IV lasix periodically during your
hospitalization.

Additionally, your infection triggerred your heart to go into a
rapid, abnormal rhythm, atrial fibrillation, during your
hospitalization--this was treated with Metoprolol IV.

New Medications:
Antibiotics:
MetRONIDAZOLE (FLagyl) 500 mg IV Q8H (discontinue on [**2204-1-23**] for
14 day course, can be changed to PO when patient is eating)
Vancomycin 500 mg IV Q 24H Start: [**2204-1-1**], discontinue on
[**2204-1-15**] for 14 day course.
Heart medications:
Metoprolol Tartrate 7.5 mg IV Q6H (Hold for HR<60 SBP<90,
patient can be started on Metop 25mg PO TID when taking PO
again)
Zydis 2.5mg fast melt can be uptitrated to a max of 5mg [**Hospital1 **] for
agitation
Heparin 5000 Units subcutaneous TID for anticoagulation
Combivent nebulizer treatments

Changed Pantoprazole 40 mg PO Qday to Pantoprazole IV 40mg [**Hospital1 **]
(can be changed to PO when pt taking POs).

Holding these medications in acute setting:
Rosiglitazone 2 mg Qday
Buproprion 75 mg [**Hospital1 **]
Lasix 40mg PO Qday
Ferrous sulfate 325 mg PO QDay

Discontinued:
Diltiazem 240 mg PO QDay


Followup Instructions:
Please follow up with your Primary Care Physician [**Name Initial (PRE) **] [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 7476**] in [**1-21**] weeks. You will need to call for an appointment.
Phone: [**Telephone/Fax (1) 7477**]
.
Please see your cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
Date & Time: Tuesday, [**1-31**] at 12:40pm
Location: [**Location (un) **], [**Hospital Ward Name 23**] Bldg [**Location (un) **], [**Location (un) 86**], MA

Phone:  [**Telephone/Fax (1) 62**]


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
{"Pneumonia, organism unspecified,Acute respiratory failure,Empyema without mention of fistula,Acute kidney failure, unspecified,Acute on chronic combined systolic and diastolic heart failure,Intestinal infection due to Clostridium difficile,Delirium due to conditions classified elsewhere,Hyperosmolality and/or hypernatremia,Blood in stool,Surgical or other procedure not carried out because of patient's decision,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic kidney disease, unspecified,Personal history of other malignant neoplasm of skin,History of fall,Gout, unspecified,Other acquired deformity of other parts of limb,Constipation, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or 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: progressive DOE x 3 days

PRESENT ILLNESS: 87 yoM with h/o AFib not on coumadin and SCC on the face s/p
resection, who presents with three days of progressive DOE. He
reports pink-tinged frothy sputum as well as chills, anorexia
and rhinorrhea, though he denies fever, Ha,
arhtralgias/myalgias, chest pain, emesis and diarrhea. He says
he "may have gained weight recently," though was at the doctor
on [**2203-12-22**] and seemed to be doing well. He denies weight loss
over the last several months. He also told the ED he had
increased urinary output.
.
In the ED, VS were T 100.3, BP 139/70, HR 124 in AFib, RR 16,
96% on NRB (85% RA, 95% 4LNC) on presentation. He was given ASA
325 mg, ibuprofen 400 mg Po, and levofloxacin 740 mg IV,
ceftriaxone 1 g IV, and vanco 1g IV for CAP. In the ED, BP was
initially in the 120's on admission but then dropped to 84/43;
it improved to the 110-120's with a IVF bolus. He got a total of
~2L betwen IVF and antibiotics. Blood cultures were sent. ABG
was not done. There was concern for an element of CHF with a BNP
> [**Numeric Identifier 3652**], though he was not diuresed in the ED because of the
concern for infection.
.
On arrival to the ICU, T 96.0, HR 92, BP 122/49, 92-96% NRB.
Initially there was concern for volume overload and he was given
lasix 20 mg IV. He also had some hemoptysis.

MEDICAL HISTORY: DM2
Paroxysmal Atrial Fibrillation on anticoagulation
CRI- baseline Cr 1.5 - 2.0
HTN
Gout
COPD
OA
h/o GIB ([**2198**]; found to have gastritis, ulcerations, no active
bleeding, and angioectasia in colon)
h/o hip fx s/p ORIF/IM nail R hip, L hip [**2201**]
[**Name (NI) 3674**] unclear etiology, previously treated with regular
transfusions, now on procrit, baseline 30
h/o pericardial effusion in setting of AF with RVR, CHF, pleural
effusions ([**2198**])
s/p TURP for prostate enlargement and urinary retention
h/o sigmoid colon ca s/p sigmoid colectomy [**2192**]
right cheek SCC s/p skin graft
Diastolic CHF

MEDICATION ON ADMISSION: Buproprion 75 mg [**Hospital1 **]
Combivent 2 puffs [**Hospital1 **]
Diltiazem 240 mg QD
Epo 10,000 SC QWeek
Ferroud sulfate 325 mg QD
Fluticasone [**Hospital1 **]
Lasix 40 mg QD
Lisinopril 10 mg QD
Montelukast 10 mg QD
MVI
Pantoprazole 40 mg QD
Rosiglitazone 2 mg Qd

ALLERGIES: Percocet / Tylenol

PHYSICAL EXAM: VS on arrival to the ICU: T 96.0, HR 92, BP 122/49, 92-96% NRB
General: elderly, comfortable but appears somewhat SOB, NAD,
speaking in full sentences
HEENT: poor dentition, OP clear, tacky MM
Lungs: end exp wheezes on right throughout; high pitched sounds,
rhonchi, crackles throughout on left; some use of SCM for
breathing
Cardio: heart sounds difficult to hear over O2 and breath
sounds; difficult to assess JVD with surgical scars and SCM use

FAMILY HISTORY: NC

SOCIAL HISTORY: Patient denies tobacco or illicit drugs. He reports occasional
alcohol consumption. [**Name (NI) **] (HCP) report recent falls. House
with stairs between kitchen and bedroom. Speaks multiple
languages. 

### Response:
{"Pneumonia, organism unspecified,Acute respiratory failure,Empyema without mention of fistula,Acute kidney failure, unspecified,Acute on chronic combined systolic and diastolic heart failure,Intestinal infection due to Clostridium difficile,Delirium due to conditions classified elsewhere,Hyperosmolality and/or hypernatremia,Blood in stool,Surgical or other procedure not carried out because of patient's decision,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic kidney disease, unspecified,Personal history of other malignant neoplasm of skin,History of fall,Gout, unspecified,Other acquired deformity of other parts of limb,Constipation, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified"}
