CHIEF COMPLAINT: Fever, hypoxia

PRESENT ILLNESS: 46 yo M well known to our service with a history of morbid
obesity, OSA, COPD, chronic trach, DM presenting to the ED from
[**Hospital **] rehab with fever to 105 and hypoxia. He was on PS 12/5,
40% and desatted today to the 70s. He was transferred to the
[**Hospital1 18**] ED. He was found to have a temp of 105.4, sinus tach to
140-150s, SBP 100-120s. CXR was sig. for increased bilateral
pleural effusions and LUL infiltrate/edema. He was treated with
Vanco/Meropenem/Bactrim IV. Cultures were taken. Fi02 was
increased to 100% with PEEP 15 and improvement in his
oxygenation to upper 90s. He was bolused a total of 850 cc NS.
His fever was treated with tylenol/cooling blanket with
improvement. RLE US was negative for DVT.

MEDICAL HISTORY: 1) DM2 diagnosed [**2114**] with triopathy: Creatinine has been as low
as 0.8 in the last couple of years, however widely fluctuant, as
high as 2 in the recent past. 0.9 in [**1-7**].
2) COPD, on home O2. Multiple episodes of respiratory failure
requiring intubation in recent years. Most recently, was
admitted in [**12-6**] with a perforated transverse colon requiring
partial colectomy and transverse colostomy. This course c/b
anticipated respiratory failure and anticipatory tracheostomy,
pseudomonal and MRSA PNA. Also with acalculous cholecystitis
requiring cholecystostomy tube. Had G-tube placed.
3) OSA on CPAP
3) VRE
4) s/p tracheostomy, as above in [**1-7**]
5) HTN
6) CHF: During hospitalization in [**10-20**] it was thought that
failure contributed to his respiratory failure. Last echo was in
[**12-6**] at which time LVEF thought to be roughly normal, however
very poor study and RV not visualized. Not on lasix.
7) Anemia of chronic disease, multiple transfusions in the past

MEDICATION ON ADMISSION: Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Gabapentin 250 mg/5 mL Solution Sig: Three Hundred (300) mg
PO Q12H (every 12 hours).
5. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q4-6H (every 4 to 6 hours) as needed.
7. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML

ALLERGIES: Cephalosporins / Morphine / Fentanyl

PHYSICAL EXAM: PE: 101.5  125  106/36  96% AC 14x550, 15, 100%Fi02
GEN: A+O x 3, diaphoretic
HEENT: PERRL, EOMI, MMM
CV; Tachy, regular, no m/r/g
LUNGS: distant, no crackles/wheezes
ABD: soft, NTND +BS, +colostomy/ostomy, surgical scar
EXT: s/p BKA left, right with no edema, improved erythema
NEURO: moving all extremities

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Lives home alone with VNA. Denies etoh. Remote cigar smoking, no
cigarettes. No IVDU or marijuana. Has 1 brother, [**Name (NI) **].
Unspecified septicemia,Acute and chronic respiratory failure,Pneumonia, organism unspecified,Chronic airway obstruction, not elsewhere classified,Dependence on respirator, status,Infection and inflammatory reaction due to other vascular device, implant, and graft,Cellulitis and abscess of leg, except foot,Urinary tract infection, site not specified,Chronic diastolic heart failure,Acute kidney failure, unspecified,Chronic kidney disease, unspecified,Severe sepsis,Unspecified sleep apnea,Morbid obesity,Anemia of other chronic disease,Below knee amputation status,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled,Background diabetic retinopathy,Polyneuropathy in diabetes,Attention to tracheostomy
Septicemia NOS,Acute & chronc resp fail,Pneumonia, organism NOS,Chr airway obstruct NEC,Respirator depend status,React-oth vasc dev/graft,Cellulitis of leg,Urin tract infection NOS,Chr diastolic hrt fail,Acute kidney failure NOS,Chronic kidney dis NOS,Severe sepsis,Sleep apnea NOS,Morbid obesity,Anemia-other chronic dis,Status amput below knee,Nephritis NOS in oth dis,DMII ophth nt st uncntrl,Diabetic retinopathy NOS,Neuropathy in diabetes,Atten to tracheostomy
Admission Date:  [**2134-4-21**]              Discharge Date:   [**2134-4-26**]

Date of Birth:  [**2087-11-5**]             Sex:   M

Service: MEDICINE

Allergies:
Cephalosporins / Morphine / Fentanyl

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Fever, hypoxia

Major Surgical or Invasive Procedure:
none

History of Present Illness:
46 yo M well known to our service with a history of morbid
obesity, OSA, COPD, chronic trach, DM presenting to the ED from
[**Hospital **] rehab with fever to 105 and hypoxia. He was on PS 12/5,
40% and desatted today to the 70s. He was transferred to the
[**Hospital1 18**] ED. He was found to have a temp of 105.4, sinus tach to
140-150s, SBP 100-120s. CXR was sig. for increased bilateral
pleural effusions and LUL infiltrate/edema. He was treated with
Vanco/Meropenem/Bactrim IV. Cultures were taken. Fi02 was
increased to 100% with PEEP 15 and improvement in his
oxygenation to upper 90s. He was bolused a total of 850 cc NS.
His fever was treated with tylenol/cooling blanket with
improvement. RLE US was negative for DVT.


Past Medical History:
1) DM2 diagnosed [**2114**] with triopathy: Creatinine has been as low
as 0.8 in the last couple of years, however widely fluctuant, as
high as 2 in the recent past. 0.9 in [**1-7**].
2) COPD, on home O2. Multiple episodes of respiratory failure
requiring intubation in recent years. Most recently, was
admitted in [**12-6**] with a perforated transverse colon requiring
partial colectomy and transverse colostomy. This course c/b
anticipated respiratory failure and anticipatory tracheostomy,
pseudomonal and MRSA PNA. Also with acalculous cholecystitis
requiring cholecystostomy tube. Had G-tube placed.
3) OSA on CPAP
3) VRE
4) s/p tracheostomy, as above in [**1-7**]
5) HTN
6) CHF: During hospitalization in [**10-20**] it was thought that
failure contributed to his respiratory failure. Last echo was in
[**12-6**] at which time LVEF thought to be roughly normal, however
very poor study and RV not visualized. Not on lasix.
7) Anemia of chronic disease, multiple transfusions in the past

8) s/p BKA for chronic LE ulcer
9) TIA in [**2125**].
10) Difficult intubation; fiberoptic guidance in [**Month (only) 359**] of
[**2131**].
11) Urinary retention.
12) Osteoarthritis.
13) Depression.
14) C. Difficile in [**2129**].
15) Hypogonadism.
16) Morbid obesity
.
PAST SURGICAL HISTORY:
1. Bilateral carpal tunnel release in [**2123**].
2. Hydrocele repair in [**2126-4-3**].
3. Quadriceps tendon repair in [**2127**].
4. Status post partial resection of transverse colon, end
transverse colostomy, mucus fistula, jejunostomy tube and
percutaneous tracheostomy on [**2132-12-16**].


Social History:
Lives home alone with VNA. Denies etoh. Remote cigar smoking, no
cigarettes. No IVDU or marijuana. Has 1 brother, [**Name (NI) **].


Family History:
Non-contributory

Physical Exam:
PE: 101.5  125  106/36  96% AC 14x550, 15, 100%Fi02
GEN: A+O x 3, diaphoretic
HEENT: PERRL, EOMI, MMM
CV; Tachy, regular, no m/r/g
LUNGS: distant, no crackles/wheezes
ABD: soft, NTND +BS, +colostomy/ostomy, surgical scar
EXT: s/p BKA left, right with no edema, improved erythema
NEURO: moving all extremities

Pertinent Results:
Micro:
[**4-23**] - C DIFF: negative
[**4-23**] - Cath Tip Cx: negative
[**4-22**] - BLOOD CX x 2: pending
[**4-22**] - URINE CX: negative
[**4-21**] - blood cultures x 3 pending, fungal isolators pending, Ucx
pending; Sputum GRAM STAIN: >25 PMNs and <10 epi, GPC's;
CULTURE: GNRs x 2-> sparse oral pharyngeal flora
[**4-21**] - blood/fungal cultures pending
[**4-21**] - urine culture pending- U/A negative
[**4-12**] - urine 10-100,000 Acinetobacter sensitive to
tobra/bactrim/gent
[**4-11**] - sputum
                            ACINETOBACTER BAUMANNII
                             |          PSEUDOMONAS AERUGINOSA
                             |          |
CEFEPIME--------------    16 I       16 I
CEFTAZIDIME-----------  =>64 R     =>64 R
CIPROFLOXACIN---------   =>4 R      =>4 R
GENTAMICIN------------     2 S        2 S
IMIPENEM--------------     8 I        8 I
LEVOFLOXACIN----------     4 I
MEROPENEM-------------                8 I
PIPERACILLIN----------            =>128 R
PIPERACILLIN/TAZO-----               64 S
TOBRAMYCIN------------   <=1 S      <=1 S
TRIMETHOPRIM/SULFA----   <=1 S

[**2134-4-26**] 04:49AM BLOOD WBC-5.7 RBC-2.86* Hgb-8.6* Hct-24.8*
MCV-87 MCH-30.1 MCHC-34.8 RDW-16.5* Plt Ct-191
[**2134-4-24**] 03:15AM BLOOD WBC-4.5 RBC-2.27* Hgb-6.7* Hct-20.0*
MCV-88 MCH-29.5 MCHC-33.7 RDW-16.9* Plt Ct-190
[**2134-4-23**] 03:59AM BLOOD WBC-6.5 RBC-2.50* Hgb-8.0* Hct-22.2*
MCV-89 MCH-32.0 MCHC-36.1* RDW-17.0* Plt Ct-184
[**2134-4-21**] 05:53AM BLOOD WBC-13.6* RBC-2.78* Hgb-8.1* Hct-24.2*
MCV-87 MCH-29.1 MCHC-33.3 RDW-16.9* Plt Ct-242
[**2134-4-26**] 04:49AM BLOOD Neuts-62.9 Lymphs-22.3 Monos-4.3 Eos-9.9*
Baso-0.6
[**2134-4-25**] 04:30AM BLOOD Neuts-55.4 Lymphs-29.1 Monos-3.4
Eos-11.3* Baso-0.7
[**2134-4-21**] 05:53AM BLOOD Neuts-86.2* Bands-0 Lymphs-8.8* Monos-2.4
Eos-2.3 Baso-0.4
[**2134-4-26**] 04:49AM BLOOD PT-14.2* PTT-29.5 INR(PT)-1.3*
[**2134-4-24**] 03:15AM BLOOD PT-13.5* PTT-28.7 INR(PT)-1.2*
[**2134-4-22**] 02:45AM BLOOD PT-13.6* PTT-28.9 INR(PT)-1.2*
[**2134-4-21**] 05:53AM BLOOD PT-13.9* PTT-29.8 INR(PT)-1.2*
[**2134-4-21**] 12:40AM BLOOD Fibrino-588*# D-Dimer-2558*
[**2134-4-25**] 04:30AM BLOOD Glucose-124* UreaN-36* Creat-1.7* Na-140
K-3.7 Cl-101 HCO3-31 AnGap-12
[**2134-4-24**] 03:15AM BLOOD Glucose-182* UreaN-39* Creat-1.7* Na-139
K-3.5 Cl-100 HCO3-29 AnGap-14
[**2134-4-23**] 03:59AM BLOOD Glucose-211* UreaN-37* Creat-1.9* Na-136
K-4.2 Cl-98 HCO3-28 AnGap-14
[**2134-4-21**] 05:53AM BLOOD Glucose-217* UreaN-38* Creat-1.8* Na-135
K-6.2* Cl-100 HCO3-27 AnGap-14
[**2134-4-25**] 04:30AM BLOOD ALT-8 AST-10 LD(LDH)-181 AlkPhos-32*
TotBili-0.3
[**2134-4-22**] 10:48AM BLOOD LD(LDH)-182 TotBili-0.4
[**2134-4-21**] 05:53AM BLOOD proBNP-2283*
[**2134-4-26**] 04:49AM BLOOD Calcium-8.6 Phos-5.4* Mg-1.6
[**2134-4-25**] 04:30AM BLOOD Calcium-9.0 Phos-5.0* Mg-1.6
[**2134-4-22**] 10:48AM BLOOD calTIBC-239* VitB12-671 Folate-7.8
Hapto-176 Ferritn-645* TRF-184*
[**2134-4-22**] 10:48AM BLOOD TSH-2.1
[**2134-4-26**] 04:49AM BLOOD Tobra-PND
[**2134-4-25**] 08:07AM BLOOD Type-ART Temp-36.7 Rates-/22 Tidal V-365
PEEP-10 FiO2-40 pO2-83* pCO2-44 pH-7.45 calHCO3-32* Base XS-5
Intubat-INTUBATED
[**2134-4-24**] 02:26PM BLOOD Type-ART pO2-90 pCO2-48* pH-7.44
calHCO3-34* Base XS-6

Brief Hospital Course:
A/P: 46 yo M with MMP presenting with fever and hypoxia.
.
# Hypoxic respiratory failure: Now requiring high fi02 and PEEP
to oxygenate. CXR with increasing bilateral effusions and
infiltrates. Has had multiple resistant organisms grow from his
sputum including Acinetobacter, pseudomonas, citrobacter, MRSA.
Completed 2 courses for VAP at last admission. Possibility of PE
is also raised. Pt was on PPX heparin TID. LE us negative for
DVT. He underwent trach change on [**4-24**]. He was on
Vanco/Meropenem/Bactrim initially but this was changed to
vanco/iminipenem/tobramycin for double coverage for VAP. Her
respiratory culture only grew out oral pharyngeal flora. Her CXR
as of [**4-26**] showed stable bilateral pleural effusion and
opacities. There was initial consideration to tap the effusion
but his respiratory status remained stable. He was also
continued on lasix for diuresis of possible fluid overload to
his pleural effusion.  He was also continued his albuterol and
atrovent inhalers.
.
# Fever: Lactate 2.5. Sources include PNA, UTI, line infection,
clot. He was discharged on course of Vanco for RLE cellulitis
during prior admission. During this admission, his lactate
improved and central line was d/c after concern of line
infection. He has remained afebrile since [**4-23**] with temperature
in the 97-98F. His culture came back notably w/ actinobacter
10-100,000 colonies sensitive to tobramycin and intermediate to
iminipenem. He is finish out w/ total 8 days of
vanco/iminipenm/tobramycin for actinobacter UTI and possible
VAP.
.
# Renal insufficiency: His creatine also slowly improved during
this admission from 1.9 to 1.5. His medications including
antibioitics were adjusted renally and his urine output was
monitored closely. He was continued on lasix and repleted
electrolytes carefully.
.
# Anemia: It has remained stable around 22-24. His anemia is
consistent w/ anemia of chronic disease. His stools were guiaced
and continued to follow his hct daily. His ferritin 645 (not
consistent w/ iron defiency anemia), so his iron replacement was
stopped.
.
#hypertension: He was taken off his labetolol and captopril
given initiall concern of sepsis and respiratory failure. On the
day of discharge, he was to be restarted on low dose captopril
and uptitrated as tolerated.
.
# FEN: He was initially NPO for high PEEP requirements. He was
restarted on diabetic diet once he was stabilized and his PEEP
requirement on trach came down.
.
# PPX: He was continued on sc heparin TID (7500 units tid given
his weight), PPI, peridex
.
# Contact: Brother [**Name (NI) **]
.
# Code: Full

Medications on Admission:
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Gabapentin 250 mg/5 mL Solution Sig: Three Hundred (300) mg
PO Q12H (every 12 hours).
5. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q4-6H (every 4 to 6 hours) as needed.
7. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML

Mucous membrane  TID (3 times a day).
8. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: [**1-4**] Tablet,
Sublinguals Sublingual PRN (as needed) as needed for chest pain.


9. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
10. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
12. Fluticasone 110 mcg/Actuation Aerosol Sig: Eight (8) Puff
Inhalation [**Hospital1 **] (2 times a day).
13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 8-10 Puffs

Inhalation QID (4 times a day).
14. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig:
Thirty (30) ml PO DAILY (Daily).
15. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a

day) as needed.
16. Labetalol 300 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day): hold if sbp<100, pulse<55.
17. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
18. Clonazepam 1 mg Tablet Sig: Three (3) Tablet PO BID (2 times

a day).
19. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every

4 to 6 hours) as needed.
20. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
21. Captopril 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times

a day): hold if sbp<90.
22. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Ten
(10) ML Intravenous  DAILY (Daily) as needed.
23. Prochlorperazine Edisylate 5 mg/mL Solution Sig: Ten (10) mg

Injection Q6H (every 6 hours) as needed.
24. Lorazepam 2 mg/mL Syringe Sig: 1-2 mg Injection Q4H (every 4

hours) as needed.
25. Furosemide 10 mg/mL Solution Sig: Eighty (80) mg Injection
DAILY (Daily).
26. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous  Q 12H (Every 12 Hours) for 7 days.
27. Insulin Glargine 100 unit/mL Cartridge Sig: Sixty (60) units

Subcutaneous twice a day: see additional sliding scale order.
28. Humalog 100 unit/mL Cartridge Sig: as dir units Subcutaneous

four times a day: Sliding Scale
FS<60 give oj, [**Name8 (MD) 138**] md
FS61-120   mg/dL: 0 units
121-160   mg/dL: 2 units
161-200   mg/dL 4
201-240   mg/dL 6
241-280   mg/dL 8
281-320   mg/dL 10
321-360   mg/dL 12
361-400   mg/dL 14
>400 [**Name8 (MD) 138**] md.
29. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical  QID

(4 times a day).


Discharge Medications:
1. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q4-6H (every 4 to 6 hours) as needed.
2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 8-10 Puffs
Inhalation QID (4 times a day).
3. Fluticasone 110 mcg/Actuation Aerosol Sig: Eight (8) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. Albuterol 90 mcg/Actuation Aerosol Sig: 8-10 Puffs Inhalation
Q6H (every 6 hours).
5. Albuterol 90 mcg/Actuation Aerosol Sig: 8-10 Puffs Inhalation
Q4H (every 4 hours) as needed.
6. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane  TID (3 times a day).
7. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: 1.5 ml
Injection TID (3 times a day).
9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
10. Lidocaine HCl 2 % Gel Sig: One (1) Appl Urethral PRN (as
needed).
11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
12. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous  Q24H (every 24 hours).
13. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1)
Intravenous  Q8H (every 8 hours) as needed.
14. Metoclopramide 5 mg/mL Solution Sig: One (1)  Injection Q6H
(every 6 hours) as needed for nausea.
15. Furosemide 10 mg/mL Solution Sig: One (1)  Injection [**Hospital1 **] (2
times a day).
16. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1)  Injection
QMOWEFR (Monday -Wednesday-Friday).
17. Clonazepam 1 mg Tablet Sig: Three (3) Tablet PO QHS (once a
day (at bedtime)).
18. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
19. Insulin Glargine 100 unit/mL Solution Sig: Sixty Seven (67)
unit Subcutaneous twice a day: please also check glucose 4 times
per day.
FS<60 give oj, [**Name8 (MD) 138**] md
FS61-120 mg/dL: 0 units
121-160 mg/dL: 2 units
161-200 mg/dL 4
201-240 mg/dL 6
241-280 mg/dL 8
281-320 mg/dL 10
321-360 mg/dL 12
361-400 mg/dL 14
>400 [**Name8 (MD) 138**] md.
.
20. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous  Q 12H (Every 12 Hours) for 2 days.
21. Imipenem-Cilastatin 500 mg Recon Soln Sig: One (1) Recon
Soln Intravenous  Q6H (every 6 hours) for 4 days.
22. Tobramycin Sulfate 40 mg/mL Solution Sig: One (1)  Injection
Q48H (every 48 hours) for 6 days.
23. Prochlorperazine Edisylate 5 mg/mL Solution Sig: One (1)
Injection Q6H (every 6 hours) as needed.
24. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous  DAILY (Daily) as needed.
25. Aspirin EC 325 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
26. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.

27. Outpatient Lab Work
please check daily CBC, electrolytes, creatine, and coagulation

please check tobramycin trough at 11pm on [**4-27**] and should be
<2.0

please dose iminepem according to daily creatine clearance

please check vanco trough level tomorrow and trough should be
[**5-12**]
28. Captopril 25 mg Tablet Sig: One (1) Tablet PO three times a
day: please titrate up as indicated for BP<130/80. Pt's
captopril dose prior to admission was 75mg tid.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
actinobacter UTI
hypoxic respiratory failure
pneumonia
right lower extremity cellulitis
line infection
acute renal failure
chronic renal insuffiency
diastolic heart dysfunction
anemia of chronic disease
diabetes


Discharge Condition:
stable


Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:2L fluid restriction

Please call if recurrent fever, chills, chest pain, shortness of
breath, abdominal pain.

please take all of your medications as listed in discharge
summary

please call hospital for followup on micro results [**Telephone/Fax (1) 4645**]

please check for daily labs including electrolytes (ca/phos/mg),
CBC and coagulation.

please check tobramycin level at 11pm on [**4-27**] and keep trough
level <2

please check vancomycin trough level on [**4-27**], and keep trough
level [**5-12**]

please adjust iminipenem according to creatine clearance

please consider stopping phoslo once phosphate level normalizes

please uptitrate captopril (meds on admission) as BP stablizes;
held per low blood pressure; and then restart labetolol slowly

please remove PICC line once pt finishes antibiotic therapy

Followup Instructions:
please call for followup with your primary care physician [**Last Name (NamePattern4) **] [**1-4**]
weeks
{'Unspecified septicemia,Acute and chronic respiratory failure,Pneumonia, organism unspecified,Chronic airway obstruction, not elsewhere classified,Dependence on respirator, status,Infection and inflammatory reaction due to other vascular device, implant, and graft,Cellulitis and abscess of leg, except foot,Urinary tract infection, site not specified,Chronic diastolic heart failure,Acute kidney failure, unspecified,Chronic kidney disease, unspecified,Severe sepsis,Unspecified sleep apnea,Morbid obesity,Anemia of other chronic disease,Below knee amputation status,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled,Background diabetic retinopathy,Polyneuropathy in diabetes,Attention to tracheostomy'}


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: Fever, hypoxia

PRESENT ILLNESS: 46 yo M well known to our service with a history of morbid
obesity, OSA, COPD, chronic trach, DM presenting to the ED from
[**Hospital **] rehab with fever to 105 and hypoxia. He was on PS 12/5,
40% and desatted today to the 70s. He was transferred to the
[**Hospital1 18**] ED. He was found to have a temp of 105.4, sinus tach to
140-150s, SBP 100-120s. CXR was sig. for increased bilateral
pleural effusions and LUL infiltrate/edema. He was treated with
Vanco/Meropenem/Bactrim IV. Cultures were taken. Fi02 was
increased to 100% with PEEP 15 and improvement in his
oxygenation to upper 90s. He was bolused a total of 850 cc NS.
His fever was treated with tylenol/cooling blanket with
improvement. RLE US was negative for DVT.

MEDICAL HISTORY: 1) DM2 diagnosed [**2114**] with triopathy: Creatinine has been as low
as 0.8 in the last couple of years, however widely fluctuant, as
high as 2 in the recent past. 0.9 in [**1-7**].
2) COPD, on home O2. Multiple episodes of respiratory failure
requiring intubation in recent years. Most recently, was
admitted in [**12-6**] with a perforated transverse colon requiring
partial colectomy and transverse colostomy. This course c/b
anticipated respiratory failure and anticipatory tracheostomy,
pseudomonal and MRSA PNA. Also with acalculous cholecystitis
requiring cholecystostomy tube. Had G-tube placed.
3) OSA on CPAP
3) VRE
4) s/p tracheostomy, as above in [**1-7**]
5) HTN
6) CHF: During hospitalization in [**10-20**] it was thought that
failure contributed to his respiratory failure. Last echo was in
[**12-6**] at which time LVEF thought to be roughly normal, however
very poor study and RV not visualized. Not on lasix.
7) Anemia of chronic disease, multiple transfusions in the past

MEDICATION ON ADMISSION: Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Gabapentin 250 mg/5 mL Solution Sig: Three Hundred (300) mg
PO Q12H (every 12 hours).
5. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q4-6H (every 4 to 6 hours) as needed.
7. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML

ALLERGIES: Cephalosporins / Morphine / Fentanyl

PHYSICAL EXAM: PE: 101.5  125  106/36  96% AC 14x550, 15, 100%Fi02
GEN: A+O x 3, diaphoretic
HEENT: PERRL, EOMI, MMM
CV; Tachy, regular, no m/r/g
LUNGS: distant, no crackles/wheezes
ABD: soft, NTND +BS, +colostomy/ostomy, surgical scar
EXT: s/p BKA left, right with no edema, improved erythema
NEURO: moving all extremities

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Lives home alone with VNA. Denies etoh. Remote cigar smoking, no
cigarettes. No IVDU or marijuana. Has 1 brother, [**Name (NI) **]. 

### Response:
{'Unspecified septicemia,Acute and chronic respiratory failure,Pneumonia, organism unspecified,Chronic airway obstruction, not elsewhere classified,Dependence on respirator, status,Infection and inflammatory reaction due to other vascular device, implant, and graft,Cellulitis and abscess of leg, except foot,Urinary tract infection, site not specified,Chronic diastolic heart failure,Acute kidney failure, unspecified,Chronic kidney disease, unspecified,Severe sepsis,Unspecified sleep apnea,Morbid obesity,Anemia of other chronic disease,Below knee amputation status,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled,Background diabetic retinopathy,Polyneuropathy in diabetes,Attention to tracheostomy'}
