CHIEF COMPLAINT: Pneumonia

PRESENT ILLNESS: The patient is a 53 year old male with history of gastric bypass
and multiple other abdominal surgeries [**2-11**] nesidioblastosis
including pancreatectomy, splenectomy, gastrectomy and
thoracotomy, chronic TPN with indwelling PICC lines, cachexia,
multiple admissions to the intensive care units for PICC line
sepsis, and a recent fall from bed complicated by rib fractures
and hemothorax, which required chest tube drainage and
VATS/decortication for reaccumulation/loculation returns again
with fall from bed.
.
The patient reports an unwitnessed fall from bed on the day PTA,
and remained on the floor for approximately 20 hours. Notes that
when he woke up he had vomited, and he is concerned he may have
aspirated. He reports onset of 10 out of 10 sharp, pleuritic,
left-sided chest pain subsequent to the fall. Patient noted that
he did strike the left side of his face, left shoulder and elbow
with subsequent pain and decreased range of motion, left hip,
left knee, and left ankle. Patient remains able to ambulate but
is in excruciating pain. Thr patient's ROS is positive for
shortness of breath at rest, cough, nausea. He denies V/D,
seizure activity, neck pain, focal numbness or tingling,
dysuria, no abdominal pain, palpitations, lower back pain, GI
incontinence, or GU retention. He reports that the chest pain is
similar to the pain that the patient has had previously in the
setting of a hemopneumothorax from a fall with multiple rib
fractures.

MEDICAL HISTORY: 1. Roux-en-Y gastric bypass surgery with bile duct injury
complicated by stricture
2. S/P revision with total gastrectomy and
choledochojejunostomy.
3. S/P distal pancreatectomy, splenectomy, and ventral hernia
repair
4. Surgery for islet cell hyperplasia of the pancreas
5. MSSA endocarditis
6. recurrent line sepsis
7. circumferential abdominoplasty
8. hypoglycemia thought to be from nesidioblastosis
9. Osteomalacia [**2-11**] vitamin D deficiency
10. Vitamin B12 deficiency
11. Testosterone deficiency
12. Anemia of chronic disease
13. uvulectomy and tonsillectomy
14. lumbar spinal fusion at L4-L5
15. bilateral shoulder surgeries
16. right ankle fusion
17. hx of TB - treated with 4 drug therapy for 9 mo
18. ?eye infection - seen at MEEI and currently being treated
(needs clarification)
19. basilar migraines

MEDICATION ON ADMISSION: 1. amphetamine-dextroamphetamine 20 mg Capsule, Ext Release 24
hr Sig: One (1) Capsule, Ext Release 24 hr PO BID (2 times a
day).
2. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
3. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: One
(1) injection Injection once a month.
4. diazepam 2 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
5. dronabinol 10 mg Capsule Sig: One (1) Capsule PO BID (2 times

ALLERGIES: adhesive bandage / Benzoin / Mastisol Stertip / Compazine /
gabapentin / Neurontin

PHYSICAL EXAM: Discharge PE:
Vitals: 97.4 115/80 61 18 95%RA
General: Thin man in NAD
HEENT: MMM
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: good air movement, clear b/l
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: grossly intact, has some dyskinesia noted previously.

FAMILY HISTORY: Significant for CAD in his father and a sister w/ SLE

SOCIAL HISTORY: Denies IVDU, alcohol, or tobacco history. Worked as a CEO for
multiple companies until [**2152**]. Has an 17 yr old daughter and is
divorced.
Unspecified septicemia,Septic shock,Pneumonitis due to inhalation of food or vomitus,Acute kidney failure, unspecified,Intestinal infection due to Clostridium difficile,Anemia of other chronic disease,Contusion of multiple sites, not elsewhere classified,Severe sepsis,Abrasion or friction burn of face, neck, and scalp except eye, without mention of infection,Painful respiration,Accidental fall from bed,Lack of coordination,Essential thrombocythemia,Osteomalacia, unspecified,Other B-complex deficiencies,Bipolar disorder, unspecified,Attention deficit disorder with hyperactivity,Migraine with aura, without mention of intractable migraine without mention of status migrainosus,Anxiety state, unspecified,Unspecified endocrine disorder,Arthrodesis status,Bariatric surgery status
Septicemia NOS,Septic shock,Food/vomit pneumonitis,Acute kidney failure NOS,Int inf clstrdium dfcile,Anemia-other chronic dis,Multiple contusions NEC,Severe sepsis,Abrasion head,Painful respiration,Fall from bed,Lack of coordination,Essntial thrombocythemia,Osteomalacia NOS,B-complex defic NEC,Bipolar disorder NOS,Attn deficit w hyperact,Mgrn w aura wo ntrc mgrn,Anxiety state NOS,Endocrine disorder NOS,Arthrodesis status,Bariatric surgery status
Admission Date:  [**2161-11-9**]              Discharge Date:   [**2161-11-13**]

Date of Birth:  [**2108-1-21**]             Sex:   M

Service: MEDICINE

Allergies:
adhesive bandage / Benzoin / Mastisol Stertip / Compazine /
gabapentin / Neurontin

Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Pneumonia

Major Surgical or Invasive Procedure:
None


History of Present Illness:
The patient is a 53 year old male with history of gastric bypass
and multiple other abdominal surgeries [**2-11**] nesidioblastosis
including pancreatectomy, splenectomy, gastrectomy and
thoracotomy, chronic TPN with indwelling PICC lines, cachexia,
multiple admissions to the intensive care units for PICC line
sepsis, and a recent fall from bed complicated by rib fractures
and hemothorax, which required chest tube drainage and
VATS/decortication for reaccumulation/loculation returns again
with fall from bed.
.
The patient reports an unwitnessed fall from bed on the day PTA,
and remained on the floor for approximately 20 hours. Notes that
when he woke up he had vomited, and he is concerned he may have
aspirated. He reports onset of 10 out of 10 sharp, pleuritic,
left-sided chest pain subsequent to the fall. Patient noted that
he did strike the left side of his face, left shoulder and elbow
with subsequent pain and decreased range of motion, left hip,
left knee, and left ankle. Patient remains able to ambulate but
is in excruciating pain. Thr patient's ROS is positive for
shortness of breath at rest, cough, nausea. He denies V/D,
seizure activity, neck pain, focal numbness or tingling,
dysuria, no abdominal pain, palpitations, lower back pain, GI
incontinence, or GU retention. He reports that the chest pain is
similar to the pain that the patient has had previously in the
setting of a hemopneumothorax from a fall with multiple rib
fractures.

In the ED, initial VS: 98 96 105/63 16 96%. Exam was significant
for  superficial abrasion to nasal bridge with no septal
hematoma, pain with active and passive ROM over L
shoulder/elbow/hip/knee/ankle and normal neuro exam. Labs were
significant for WBC 42.2 (13% bands), CK 672, Cr 1.7 (baseline
1.0), initial lactate 7.3. FAST exam showed no e/o of PTX. L
shoulder/elbow/hip films and CT sinus showed no evidence of
fracture. CT Head showed no IC process. CXR showed likely large
LUL and moderate RUL opacity. Despite 2L IVF bolus in the ED,
MAPs remained 55-60, with SBP in 80s. There was attempted
placement of L subclavian, though they were unable to thread
wire. A RIJ was placed. The patient was started on levophed.
Repeat lactate was 2.9, ScV02: 64, CVP ranging [**8-19**] after total
5L NS. He made 100 cc urine/hour in the ED. He was given
vancomycin/zosyn X 1.
.
On arrival to the MICU,
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.


Past Medical History:
1. Roux-en-Y gastric bypass surgery with bile duct injury
complicated by stricture
2. S/P revision with total gastrectomy and
choledochojejunostomy.
3. S/P distal pancreatectomy, splenectomy, and ventral hernia
repair
4. Surgery for islet cell hyperplasia of the pancreas
5. MSSA endocarditis
6. recurrent line sepsis
7. circumferential abdominoplasty
8. hypoglycemia thought to be from nesidioblastosis
9. Osteomalacia [**2-11**] vitamin D deficiency
10. Vitamin B12 deficiency
11. Testosterone deficiency
12. Anemia of chronic disease
13. uvulectomy and tonsillectomy
14. lumbar spinal fusion at L4-L5
15. bilateral shoulder surgeries
16. right ankle fusion
17. hx of TB - treated with 4 drug therapy for 9 mo
18. ?eye infection - seen at MEEI and currently being treated
(needs clarification)
19. basilar migraines


Social History:
Denies IVDU, alcohol, or tobacco history. Worked as a CEO for
multiple companies until [**2152**]. Has an 17 yr old daughter and is
divorced.


Family History:
Significant for CAD in his father and a sister w/ SLE


Physical Exam:
Discharge PE:
Vitals: 97.4 115/80 61 18 95%RA
General: Thin man in NAD
HEENT: MMM
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: good air movement, clear b/l
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: grossly intact, has some dyskinesia noted previously.

Pertinent Results:
Admission labs:
[**2161-11-8**] 10:15PM BLOOD WBC-42.2*# RBC-3.58* Hgb-10.1* Hct-34.0*
MCV-95 MCH-28.3 MCHC-29.7* RDW-15.9* Plt Ct-628*
[**2161-11-8**] 10:15PM BLOOD Neuts-82* Bands-13* Lymphs-1* Monos-3
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2161-11-8**] 10:15PM BLOOD PT-14.2* PTT-31.2 INR(PT)-1.2*
[**2161-11-8**] 10:15PM BLOOD Glucose-247* UreaN-29* Creat-1.7* Na-134
K-5.2* Cl-101 HCO3-18* AnGap-20
[**2161-11-8**] 10:15PM BLOOD ALT-23 AST-34 CK(CPK)-672* AlkPhos-109
TotBili-0.4
[**2161-11-8**] 10:15PM BLOOD Calcium-8.7 Phos-4.0 Mg-1.6
[**2161-11-8**] 10:23PM BLOOD Lactate-7.3*
.
Immunoglobulins:
[**2161-11-12**] 06:10AM BLOOD IgG-1176 IgA-143 IgM-68
.
MICRO:
Blood cx [**2161-11-8**]: negative at time of discharge
[**11-10**]: C Diff positive by toxin (stool)
.
IMAGING:
TWO VIEWS OF THE CHEST [**2161-11-8**]:

The lungs are low in volume and show a new or substantially
worsening
heterogenous right upper lobe opacification and progression of
similart left upper lobe abnormality. Mediastinal fullness in
the right lower paratracheal region and bilateral hilar
enlargement have progressed since [**10-4**]. No pleural effusion or
pneumothorax is present.

IMPRESSION: Progressive bilateral pneumonia and concurrent
cardiac decompensation.

CT CHEST, [**2161-11-9**].

COMPARISON: Chest CTA study of [**2161-9-30**] and chest CT
of [**2161-9-29**]. Comparison is also made to chest
radiographs dating between [**2161-5-17**] and [**2161-11-9**].

TECHNIQUE: Volumetric, multidetector CT of the chest was
performed without
intravenous or oral contrast. Images are presented for display
in the axial plane at 5-mm and 1.25-mm collimation. A series of
multiplanar reformation images were also submitted for review.

FINDINGS: Since the prior chest CT of [**2161-9-30**], a left
hemothorax with loculated pneumothorax component has improved,
with resolution of blood contents and air contents. A residual
small, dependent left pleural effusion remains, with simple
fluid-attenuation characteristics. A small right pleural
effusion is also present and has slightly increased in size
since the prior study. Within the lungs, preexisting areas of
atelectasis in the left lower lobe adjacent to the pleural
effusion have improved, but extensive peribronchovascular
consolidation, more centrally in the left lower lobe is new.
Central consolidation in the left upper lobe and lingula has
progressed, and centrally distributed perihilar consolidation in
the right upper lobe is
mostly new. Basilar-predominant smoothly thickened interlobular
septa have
increased since the prior study. Scattered peribronchiolar
opacities in
superior segment right lower lobe are slightly improved compared
to the prior exam, and an area of opacity in the right middle
lobe on the prior exam has resolved. Although, the airways are
patent, note is made of mild narrowing and irregularity of the
lingular bronchus which in retrospect was present on the prior
study as well. The degree of narrowing, however, appears
improved compared to the earlier study of [**2161-9-29**].

Numerous subcentimeter mediastinal lymph nodes are largely
unchanged. There is likely bilateral hilar lymphadenopathy
present, difficult to measure in the absence of intravenous
contrast. Heart size is normal, and diffuse coronary artery
calcifications are present.

Exam was not specifically tailored to evaluate the
subdiaphragmatic region, but note is made of postoperative
changes in the upper abdomen and a persistent 4.2-cm diameter
fluid-density structure adjacent to the mid pole portion of the
left kidney, roughly similar in appearance to prior abdominal CT
scan, but incompletely imaged on this chest CT exam.

Healing lower left rib fractures are present at the
costovertebral junctions and possibly also at the L1 vertebral
body level. The thoracic fractures are at the T7 through T12
levels.

IMPRESSION:
1. Multifocal consolidations in both lungs, concerning for
multifocal
pneumonia. Coexisting pulmonary edema is likely, particularly in
the setting of smooth interlobular septal thickening with
basilar predominance.

2. Irregular narrowing of lingular bronchus, raising the
possibility of
intrinsic stenosis or extrinsic compression. Followup CT scan in
4 weeks
after completion of antibiotic therapy may be helpful to
document resolution of the pneumonia and to revaluate the
lingular bronchus. If interval chest radiographs fail to
demonstrate clearance of the consolidation, bronchoscopy may be
considered.

3. Improved left pleural effusion with residual small, simple
effusion
remaining. Slight increase in small right pleural effusion.
.
CXR:
[**11-12**]:
Marked improvement of pulmonary infiltrates during the last two
days examination interval. Remaining changes resemble those that
existed
previously when patient was treated for trauma and hemothorax.
The rather
extensive parenchymal infiltrates were identified on chest
examinations of
[**2161-11-8**], [**2161-11-9**], and [**2161-11-10**] and also documented on
chest CT of
[**2161-11-9**]. It is possible that this episode of extensive
infiltrates may
have been caused by aspiration, which however must have been
very massive
.
Discharge labs:

[**2161-11-13**] 05:55AM BLOOD WBC-13.5* RBC-3.70* Hgb-10.1* Hct-32.8*
MCV-89 MCH-27.2 MCHC-30.7* RDW-15.5 Plt Ct-715*
[**2161-11-11**] 07:00AM BLOOD PT-13.6* PTT-31.6 INR(PT)-1.2*
[**2161-11-12**] 06:10AM BLOOD Glucose-95 UreaN-8 Creat-1.0 Na-140 K-4.7
Cl-104 HCO3-28 AnGap-13
[**2161-11-11**] 07:00AM BLOOD Calcium-8.9 Phos-4.8*# Mg-1.9
[**2161-11-10**] 04:04AM BLOOD Lactate-1.7

Brief Hospital Course:
Summary:  53M history of gastric bypass and multiple other
abdominal surgeries, multiple admissions to the ICU for PICC
line sepsis, and a recent fall from bed complicated by rib
fractures and hemothorax admitted after a fall and subsequent
sepsis.
.
#. Sepsis: The patient was admitted with sepsis requiring IV
antibiotics and 12 hours of pressors in the ICU.  He was
stabilized and transferred to the floor.  He improved markedly,
with stable vitals and no O2 requirement by the time he was
transferred, approximately 24 hours after admission.  It was
felt that the most likely source was pneumonia seen on CT.  A
repeat CXR several days after admission showed marked
improvement in infiltrates seen initially.  After an infectious
disease consult, it was decided to narrow antibiotics to 7d of
levofloxacin, and he was discharged after remaining afebrile for
24 hours on PO levo and flagyl.  The flagyl was added after
stool was positive for C. Diff, though the patient was not
having loose stool or signs of megacolon.
.
# Thrombocytosis:  His plt count trended up this admission.
Previous admissions had documented plt levels of nearly 1.5
million.  On this admission, plts were below 800, and it was
felt that this was reactive thrombocytosis (similar to previous
admissions).
.
The remainder of his multiple medical conditions remained stable
during this admission, and his outpatient regimen was continued.

.
==
Transitional issues:
.
# Antibiotics: Will complete 7d course of levofloxacin, and 14
day course of flagyl for pna and c diff colitis respectively.
.
# Serum immunoglobulins were checked, and were within normal
limits.
.
# F/u CT: A CT scan done this admission suggested a follow-up
scan in ~1 month to assess for interval change.  However, a
repeat CXR done several days later showed marked resolution in
the infiltrates, so it may be that this repeat scan is
unnecessary.
.
#) Vitamin D:  The patient is currently taking Calcium
citrate-vitamin D3 as well as ergocalciferol.  He noted this was
his outpatient regimen, so it was continued on discharge,
however may need follow-up as to whether it is necessary.
.
# Psychosocial issues:  The patient has had a marked decline in
nutrition and weight over the past year.  It is very possible
that underlying his extensive medical disease is an eating
disorder.  This merits exploration, and it may be beneficial on
potential future admissions to have a nutrition consult and
strict calorie counts immediately upon admission, to monitor for
the presence of an eating disorder.

Medications on Admission:
1. amphetamine-dextroamphetamine 20 mg Capsule, Ext Release 24
hr Sig: One (1) Capsule, Ext Release 24 hr PO BID (2 times a
day).
2. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
3. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: One
(1) injection Injection once a month.
4. diazepam 2 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
5. dronabinol 10 mg Capsule Sig: One (1) Capsule PO BID (2 times

a day).
6. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO EVERY OTHER DAY (Every Other Day).
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed
Release(E.C.) PO three times a day.
9. lithium carbonate 450 mg Tablet Extended Release Sig: One (1)

Tablet Extended Release PO QHS (once a day (at bedtime)).
10. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,

Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
11. oxybutynin chloride 10 mg Tablet Extended Rel 24 hr Sig:
Three (3) Tablet Extended Rel 24 hr PO once a day.
12. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for headache.
13. venlafaxine 150 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO twice a day.
14. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO at bedtime.

15. zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
16. zonisamide 100 mg Capsule Sig: Three (3) Capsule PO at
bedtime.
17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
18. omega-3 fatty acids     Capsule Sig: One (1) Capsule PO BID
(2 times a day).
19. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable

PO once a day.
20. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for Constipation.
21. thiamine HCl 250 mg Tablet Sig: One (1) Tablet PO once a
day.
22. calcium citrate-vitamin D3 315-250 mg-unit Tablet Sig: Three

(3) Tablet PO twice a day.
23. Centrum Silver     Tablet Sig: Two (2) Tablet PO once a day.

24. vitamin E 400 unit Tablet Sig: One (1) Tablet PO once a day.

25. Pro-Stat 101 15-101 gram-kcal/30 mL Liquid Sig: Thirty (30)
mL PO Three Times a Day with Meals.
Disp:*QS 1 month supply* Refills:*2*
26. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) for 1
months.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
27. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours

as needed for pain for 1 weeks: Do not drink alcohol or operate
heavy machinery while on this medication. .
Disp:*QS 1 week supply* Refills:*0*


Discharge Medications:
1. amphetamine-dextroamphetamine 20 mg Capsule, Ext Release 24
hr Sig: One (1) Capsule, Ext Release 24 hr PO BID (2 times a
day).
2. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day.

3. Vitamin B-12 1,000 mcg/mL Solution Sig: One (1)  Injection
once a month.
4. dronabinol 10 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
5. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO every other day.
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
7. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed
Release(E.C.) PO three times a day.
8. lithium carbonate 450 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO QHS (once a day (at bedtime)).
9. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
10. oxybutynin chloride 5 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
11. tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for headache.
12. venlafaxine 150 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
13. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
14. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. omega-3 fatty acids     Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
18. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
19. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. calcium citrate-vitamin D3 315-250 mg-unit Tablet Sig: Three
(3) Tablet PO twice a day.
21. Centrum Silver     Tablet Sig: Two (2) Tablet PO once a day.

22. Pro-Stat 101 15-101 gram-kcal/30 mL Liquid Sig: Thirty (30)
ml PO three times a day: With meals.
23. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
24. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 13 days.
Disp:*qs Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
primary healthcare specialties

Discharge Diagnosis:
Pneumonia
Clostridium Difficile Infection


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
Mr. [**Known lastname 39278**],

It was a pleasure seeing you again.  You were admitted for an
infection, that required IV antibiotics in the ICU.  You rapidly
improved, and were transferred to the floor.  It is likely you
had a pneumonia, and a c diff infection (a bacteria in the
bowels, that usually happens when people are treated with
multiple antibiotics).  This is a relatively common infection in
hospitalized patients, and it should improve quickly with the
antibiotic flagyl.
.
After speaking with your primary care doctor and the infectious
disease experts, it was decided that oral antibiotics are the
best choice.  You should finish a 7 day total course of
levofloxacin, and a 14 day total course of flagyl.  We have not
changed any of your other medications.

Followup Instructions:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2161-11-18**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage



Completed by:[**2161-11-13**]
{'Unspecified septicemia,Septic shock,Pneumonitis due to inhalation of food or vomitus,Acute kidney failure, unspecified,Intestinal infection due to Clostridium difficile,Anemia of other chronic disease,Contusion of multiple sites, not elsewhere classified,Severe sepsis,Abrasion or friction burn of face, neck, and scalp except eye, without mention of infection,Painful respiration,Accidental fall from bed,Lack of coordination,Essential thrombocythemia,Osteomalacia, unspecified,Other B-complex deficiencies,Bipolar disorder, unspecified,Attention deficit disorder with hyperactivity,Migraine with aura, without mention of intractable migraine without mention of status migrainosus,Anxiety state, unspecified,Unspecified endocrine disorder,Arthrodesis status,Bariatric surgery status'}


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: Pneumonia

PRESENT ILLNESS: The patient is a 53 year old male with history of gastric bypass
and multiple other abdominal surgeries [**2-11**] nesidioblastosis
including pancreatectomy, splenectomy, gastrectomy and
thoracotomy, chronic TPN with indwelling PICC lines, cachexia,
multiple admissions to the intensive care units for PICC line
sepsis, and a recent fall from bed complicated by rib fractures
and hemothorax, which required chest tube drainage and
VATS/decortication for reaccumulation/loculation returns again
with fall from bed.
.
The patient reports an unwitnessed fall from bed on the day PTA,
and remained on the floor for approximately 20 hours. Notes that
when he woke up he had vomited, and he is concerned he may have
aspirated. He reports onset of 10 out of 10 sharp, pleuritic,
left-sided chest pain subsequent to the fall. Patient noted that
he did strike the left side of his face, left shoulder and elbow
with subsequent pain and decreased range of motion, left hip,
left knee, and left ankle. Patient remains able to ambulate but
is in excruciating pain. Thr patient's ROS is positive for
shortness of breath at rest, cough, nausea. He denies V/D,
seizure activity, neck pain, focal numbness or tingling,
dysuria, no abdominal pain, palpitations, lower back pain, GI
incontinence, or GU retention. He reports that the chest pain is
similar to the pain that the patient has had previously in the
setting of a hemopneumothorax from a fall with multiple rib
fractures.

MEDICAL HISTORY: 1. Roux-en-Y gastric bypass surgery with bile duct injury
complicated by stricture
2. S/P revision with total gastrectomy and
choledochojejunostomy.
3. S/P distal pancreatectomy, splenectomy, and ventral hernia
repair
4. Surgery for islet cell hyperplasia of the pancreas
5. MSSA endocarditis
6. recurrent line sepsis
7. circumferential abdominoplasty
8. hypoglycemia thought to be from nesidioblastosis
9. Osteomalacia [**2-11**] vitamin D deficiency
10. Vitamin B12 deficiency
11. Testosterone deficiency
12. Anemia of chronic disease
13. uvulectomy and tonsillectomy
14. lumbar spinal fusion at L4-L5
15. bilateral shoulder surgeries
16. right ankle fusion
17. hx of TB - treated with 4 drug therapy for 9 mo
18. ?eye infection - seen at MEEI and currently being treated
(needs clarification)
19. basilar migraines

MEDICATION ON ADMISSION: 1. amphetamine-dextroamphetamine 20 mg Capsule, Ext Release 24
hr Sig: One (1) Capsule, Ext Release 24 hr PO BID (2 times a
day).
2. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
3. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: One
(1) injection Injection once a month.
4. diazepam 2 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
5. dronabinol 10 mg Capsule Sig: One (1) Capsule PO BID (2 times

ALLERGIES: adhesive bandage / Benzoin / Mastisol Stertip / Compazine /
gabapentin / Neurontin

PHYSICAL EXAM: Discharge PE:
Vitals: 97.4 115/80 61 18 95%RA
General: Thin man in NAD
HEENT: MMM
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: good air movement, clear b/l
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: grossly intact, has some dyskinesia noted previously.

FAMILY HISTORY: Significant for CAD in his father and a sister w/ SLE

SOCIAL HISTORY: Denies IVDU, alcohol, or tobacco history. Worked as a CEO for
multiple companies until [**2152**]. Has an 17 yr old daughter and is
divorced. 

### Response:
{'Unspecified septicemia,Septic shock,Pneumonitis due to inhalation of food or vomitus,Acute kidney failure, unspecified,Intestinal infection due to Clostridium difficile,Anemia of other chronic disease,Contusion of multiple sites, not elsewhere classified,Severe sepsis,Abrasion or friction burn of face, neck, and scalp except eye, without mention of infection,Painful respiration,Accidental fall from bed,Lack of coordination,Essential thrombocythemia,Osteomalacia, unspecified,Other B-complex deficiencies,Bipolar disorder, unspecified,Attention deficit disorder with hyperactivity,Migraine with aura, without mention of intractable migraine without mention of status migrainosus,Anxiety state, unspecified,Unspecified endocrine disorder,Arthrodesis status,Bariatric surgery status'}
