CHIEF COMPLAINT: Alcohol withdrawal.

PRESENT ILLNESS: The patient is a 55-year-old
male with a history of panic attacks who came to the hospital
on [**2159-7-9**], for a preoperative arteriogram for a
scheduled left femoral popliteal bypass.  While in the far
lobby the patient began to feel anxious and short of breath
accompanied by chills and uncontrollable shaking.  The
patient denied chest pain, headache, nausea, vomiting or
abdominal pain.  The patient denied lightheadedness.  The
patient thought he was having a panic attack but did feel
that this was different than any prior panic attack that he
had had.  The patient was taken to the Emergency Department
where he was noted to be diaphoretic, tachypneic and
tachycardic with a heart rate of 105, a respiratory rate of
28 and a temperature of 101.5 degrees.  In addition, the
patient was extremely anxious.  The patient was given 2 mg IV
of Ativan.  Subsequently, the patient's blood pressure was
178/94 with a heart rate of 130, a respiratory rate of 32 and
an oxygen saturation of 92% on room air.  The patient's heart
rate increased to 150's and his respiratory rate increased to
36.  The patient became more agitated with slurred speech.
The patient received 10 mg of Valium and was given a
nonrebreather mask which he did not tolerate.  The patient
was thought to be in alcohol withdrawal versus PE versus
myocardial infarction.  The patient was taken for a CT
arteriogram of the chest to rule out pulmonary embolus which
showed no evidence of pulmonary embolus.  The CT did show
evidence of tracheomalacia.  At this time the patient's wife
admitted that the patient drinks one case of beer a day which
he stopped on Saturday.  The patient received a total of 14
mg of Ativan and 40 mg of Valium plus 5 mg of droperidol and
20 mg of labetalol in the Emergency Room.  The patient's
blood pressure rose of a value of 225/110.  The patient also
received four liters of normal saline with a urine output of
100 cc.  The patient was brought to the Medical Intensive
Care Unit where he continued to be tachypneic and tachycardic
and received 80 mg IV of Valium which had no effect.  He then
received 120 mg of Valium.  The patient continued to be
tachypneic and hypertensive with a systolic blood pressure of
150.  He was therefore put on noninvasive positive pressure
ventilation at a pressure support of 20 and a PEEP of 8.  The
patient's arterial blood gas on these settings was 7.39, 47
and 179.  The patient continued to be febrile with a
temperature of 102.6, a heart rate of 130, a blood pressure
of 180/106 and a respiratory rate of 36 to 40.  The patient
continued to require Valium 10 mg every 20 minutes in order
to maintain adequate anxiolytic effect.  It was decided to
intubate the patient in order to achieved adequate sedation.
The patient was sedated with dexmedetomidine per Anesthesia
recommendation and intubated in the Intensive Care Unit.

MEDICAL HISTORY: 1.  Bilateral carotid stenosis 100% on the left and 80% on
the right.
2.  Hypertension.
3.  Panic disorder.
4.  Left leg claudication.
5.  Tobacco use 60 pack year history, quit two years ago.

MEDICATION ON ADMISSION: 

ALLERGIES: Penicillin causes hives.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient is a sales representatives,
married with no children.
Alcohol withdrawal delirium,Atherosclerosis of native arteries of the extremities with gangrene,Acute appendicitis with peritoneal abscess,Congestive heart failure, unspecified,Acute kidney failure with lesion of tubular necrosis,Unspecified septicemia,Other disorders of muscle, ligament, and fascia,Other and unspecified alcohol dependence, unspecified
Delirium tremens,Ath ext ntv art gngrene,Abscess of appendix,CHF NOS,Ac kidny fail, tubr necr,Septicemia NOS,Muscle/ligament dis NEC,Alcoh dep NEC/NOS-unspec
Admission Date:  [**2159-7-9**]       Discharge Date:  [**2159-7-15**]

Date of Birth:   [**2104-2-11**]       Sex:  M

Service:  MICU

CHIEF COMPLAINT:  Alcohol withdrawal.

HISTORY OF PRESENT ILLNESS:  The patient is a 55-year-old
male with a history of panic attacks who came to the hospital
on [**2159-7-9**], for a preoperative arteriogram for a
scheduled left femoral popliteal bypass.  While in the far
lobby the patient began to feel anxious and short of breath
accompanied by chills and uncontrollable shaking.  The
patient denied chest pain, headache, nausea, vomiting or
abdominal pain.  The patient denied lightheadedness.  The
patient thought he was having a panic attack but did feel
that this was different than any prior panic attack that he
had had.  The patient was taken to the Emergency Department
where he was noted to be diaphoretic, tachypneic and
tachycardic with a heart rate of 105, a respiratory rate of
28 and a temperature of 101.5 degrees.  In addition, the
patient was extremely anxious.  The patient was given 2 mg IV
of Ativan.  Subsequently, the patient's blood pressure was
178/94 with a heart rate of 130, a respiratory rate of 32 and
an oxygen saturation of 92% on room air.  The patient's heart
rate increased to 150's and his respiratory rate increased to
36.  The patient became more agitated with slurred speech.
The patient received 10 mg of Valium and was given a
nonrebreather mask which he did not tolerate.  The patient
was thought to be in alcohol withdrawal versus PE versus
myocardial infarction.  The patient was taken for a CT
arteriogram of the chest to rule out pulmonary embolus which
showed no evidence of pulmonary embolus.  The CT did show
evidence of tracheomalacia.  At this time the patient's wife
admitted that the patient drinks one case of beer a day which
he stopped on Saturday.  The patient received a total of 14
mg of Ativan and 40 mg of Valium plus 5 mg of droperidol and
20 mg of labetalol in the Emergency Room.  The patient's
blood pressure rose of a value of 225/110.  The patient also
received four liters of normal saline with a urine output of
100 cc.  The patient was brought to the Medical Intensive
Care Unit where he continued to be tachypneic and tachycardic
and received 80 mg IV of Valium which had no effect.  He then
received 120 mg of Valium.  The patient continued to be
tachypneic and hypertensive with a systolic blood pressure of
150.  He was therefore put on noninvasive positive pressure
ventilation at a pressure support of 20 and a PEEP of 8.  The
patient's arterial blood gas on these settings was 7.39, 47
and 179.  The patient continued to be febrile with a
temperature of 102.6, a heart rate of 130, a blood pressure
of 180/106 and a respiratory rate of 36 to 40.  The patient
continued to require Valium 10 mg every 20 minutes in order
to maintain adequate anxiolytic effect.  It was decided to
intubate the patient in order to achieved adequate sedation.
The patient was sedated with dexmedetomidine per Anesthesia
recommendation and intubated in the Intensive Care Unit.

PAST MEDICAL HISTORY:
1.  Bilateral carotid stenosis 100% on the left and 80% on
the right.
2.  Hypertension.
3.  Panic disorder.
4.  Left leg claudication.
5.  Tobacco use 60 pack year history, quit two years ago.

MEDICATIONS AT HOME:
1.  Paxil.
2.  Atenolol 50 mg b.i.d.
3.  Xanax 0.25 mg p.r.n.
4.  Pletal.

ALLERGIES:  Penicillin causes hives.

SOCIAL HISTORY:  The patient is a sales representatives,
married with no children.

PHYSICAL EXAMINATION ON ADMISSION:  The patient's temperature
was 102.6 degrees, his heart rate was 130, blood pressure
184/106, respiratory rate 36 and oxygen saturation was 99% on
assist control ventilation.  In general, the patient was
obese, now sedated on Ativan and Valium, with an erythematous
face, very diaphoretic.  On head, eyes, ears, nose and
throat, the pupils equal, round and reactive to light and
accommodation.  Extraocular movements intact.  There were
moist mucus membranes.  The patient was noted to have a thick
neck.  The lung examination revealed clear lungs bilaterally.
The chest examination revealed tachycardia, regular rhythm
with no murmurs, rubs or gallops.  The abdominal examination
revealed a soft distended belly with positive bowel sounds.
The extremity examination revealed no clubbing, cyanosis or
edema.  Cool extremities bilaterally with a palpable dorsalis
pedis pulse on the right and a dopplerable dorsalis pedis
pulse on the left.

RADIOLOGY:  Chest x-ray revealed a rib fracture of the fourth
rib of indeterminate age and presence of consolidation or
effusion at the left base that could not be excluded.  Chest
CT angiogram showed no evidence of pulmonary embolus.  It was
positive for dependent atelectasis.  Negative for effusion.
It was also noted that the trachea and major bronchi
bilaterally demonstrated excessive collapsibility.  There was
no mediastinal adenopathy.  The heart was enlarged.  There
were multiple rib fractures and the liver was noted to have
fatty infiltrates.

LABORATORY ON ADMISSION:  Revealed white blood count of 8.6,
hematocrit 44.9, platelet count 305,000 with a differential
as follows:  87% neutrophils, 5% bands, 5% leukocytes, 1%
monocytes, 2% eosinophils.  The PT was 13.9, INR 1.3, PTT
24.2.  Sodium 135, potassium 4.4, chloride 93, bicarb 30, BUN
11, creatinine 1.0, glucose 157, anion gap 16.  Urinalysis
revealed pH 7.0, specific gravity of 1.010, negative nitrite,
negative leukocyte esterase, negative ketones, negative
glucose, no red blood cells and no white blood cells.
Arterial blood gas revealed a pH of 7.36, pCO2 of 46, paO2 of
74.  Blood cultures and urine cultures were taken at this
time.

HOSPITAL COURSE:
1.  Alcohol withdrawal:  The patient required very large
amounts of benzodiazepines on admission for withdrawal.  The
patient received 260 mg of Valium in his first six hours in
the Medical Intensive Care Unit and was, therefore, intubated
and sedated with an Ativan infusion dexmedetomidine.  On [**7-10**] the patient was put on a standing Valium in order to wean
the Ativan infusion.  Initially the patient did well,
however, he became very agitated on the 9th requiring 280 mg
of Valium in six hours and 420 mg of Valium in 12 hours plus
55 mg of Ativan.  At this time Pharmacy was consulted and it
was decided to discontinue the dexmedetomidine and start
propofol for proper sedation.  In addition, the Ativan drip
was changed to a Versed drip to avoid renal toxicity that is
associated with Ativan.  Toxicology consult was obtained
which recommended using phenobarbital as a long acting [**Doctor Last Name 360**]
with Valium as needed and propofol as needed while the
patient was still febrile.  The patient received 500 mg of
phenobarbital q. 8h. starting on [**7-12**] and continuing
until [**7-15**].  We were able to discontinue the Versed drip
on [**7-12**].  The patient was still requiring Valium 60 mg
IV q. 4h.  In addition, a labetalol drip was started on [**7-13**] as it was determined that the patient's labile blood
pressure was due partly to withdrawal symptoms and partly to
underlying hypertension.  Phenobarbital levels on [**7-14**]
were 19.7, below the toxic range.  On [**7-15**] the propofol
was able to be weaned and the patient remained on
phenobarbital and Valium.  It is anticipated that the patient
will not need additional doses of phenobarbital and will
self-taper the phenobarbital dose.

2.  The patient was persistently febrile since admission with
temperatures of 102.6 to 101.8.  On [**7-11**] culs from [**7-9**] and [**7-10**] came back positive for Gram negative rods
growing in the anaerobic bottle.  The patient was started on
ciprofloxacin and gentamicin on the 9th but, the patient
continues to remain febrile on this drug regimen, therefore
an abdominal ultrasound was obtained to rule out biliary
obstruction.  This study was nonconclusive so a HIDA scan was
ordered which showed no abnormalities of the gallbladder or
biliary tree.  A follow-up abdominal CT showed an inflamed
appendix with a fluid collection consistent with perforated
appendicitis.  A CT of the abdomen showed a fluid collection
in the right lower quadrant measuring 3 cm x 2.8 cm inferior
to the cecum in addition to a possible second fluid
collection of 1 cm adjacent to the terminal ileum, an 8 mm
tubular structure that could represent an inflamed appendix
was noted on reconstructed images.  This was thought to be
consistent with perforated appendicitis.  Surgery was
consulted and recommended antibiotic treatment with Flagyl,
gentamicin, levofloxacin and one dose of vancomycin which the
patient received on [**7-12**].  The patient was followed by
continued to spike fevers.  Therefore, an abdominal CT was
repeated on [**7-15**] in order to evaluate for possible
abscess around the appendix which could be drained
surgically.  In addition, sinus CT was obtained to rule out
other sources of fevers.  At this time the blood cultures
came back positive for Clostridium non perfringens, non
septicum in one bottle and bacterial species in the other
bottle.

3.  Respiratory:  Initially the patient was hypoxic with a CT
angiogram on admission which showed no evidence of pulmonary
embolus but did show severe tracheomalacia of unclear
etiology.  The patient was intubated for progressive hypoxia
for airway protection given his high benzodiazepine
requirement.  The patient was initially given Lasix for some
findings of EHF on chest x-ray.  The patient was switched to
pressure control ventilation on [**7-14**] as he was noted to
have some asynchronous breathing with the vent.  Thereafter,
the patient was ventilated and oxygenating air.  Thereafter,
the patient maintained good ventilation and oxygenation on
the ventilator.  It is anticipated that when the patient is
no longer febrile and no longer in alcohol withdrawal, he
will be fairly simple to extubate.

4.  Fluids, Electrolytes and Nutrition:  The patient was
started on tube feeds on [**7-12**] with thiamine, folate,
insulin, heparin and ranitidine in the tube feeds.  The
patient was kept NPO due to his appendicitis.

5.  Hypertension:  The patient continued to have labile blood
pressure during his MICU stay with blood pressures rising to
200/110 usually late at night and in the early morning.  The
patient was initially treated with Valium as it was thought
that the hypertension was secondary to withdrawal but then
the patient was switched over to a labetalol drip for blood
pressure control as it was thought that his hypertension was
more long-standing in origin.  On [**7-15**], the patient was
switched to a clonidine patch and labetalol was weaned.  The
patient had an echocardiogram on admission which was limited
due to the patient's size but showed a normal sized left
ventricle with normal systolic function.  The patient had had
a preoperative cardiac Persantine ETT and cardiac perfusion
scan.  These were also limited studies due to the patient not
achieving his goal heart rate.  In addition, the cardiac
perfusion scan showed an enlarged left ventricle with a
calcified left ventricular end diastolic volume of 285 mL
with a moderate defect of 8, inferior wall that was a fixed
defect, a calculated left ventricular ejection fraction of
49%.

6.  Renal:  The patient's creatinine remained stable
throughout his hospital stay.  He was given _________ before
any CT dye loads.  The patient's acid based abnormalities on
admission resolved quite quickly when he was started on
ventilatory support.

MEDICATIONS ON DISCHARGE TO FLOOR:
1.  Insulin sliding scale.
2.  Albuterol ipratropium nebulizers q. 2h.
3.  Metronidazole 500 mg IV q. 8h.
4.  Levofloxacin 500 mg IV q. 24h.




                            [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 4561**]

Dictated By:[**Last Name (NamePattern1) 5615**]
MEDQUIST36

D:  [**2159-7-15**]  16:49
T:  [**2159-7-15**]  16:01
JOB#:  [**Job Number 48861**]


Name:  [**Known lastname 9064**], [**Known firstname **] L.                       Unit No:  [**Numeric Identifier 9065**]

Admission Date:  [**2159-7-9**]     Discharge Date:  [**2159-7-15**]

Date of Birth:   [**2104-2-11**]     Sex:  M

Service:  MICU

DISCHARGE MEDICATIONS:
1.  Insulin sliding scale.
2.  Albuterol Ipratropium nebulizers q. two hours.
3.  Metronidazole 500 mg intravenously q. eight.
4.  Levofloxacin 500 mg intravenously q. 24.
5.  Valium 80 mg intravenously q. two hours p.r.n.
6.  Diazepam 60 mg intravenously q. four hours.
7.  Clonidine one patch transdermal q. week.
8.  Oxymetazoline one spray twice a day.
9.  Sodium chloride nasal, one to two sprays four times a
day.
10. Beclomethasone Nasal two twice a day.
11. Phenobarbital 500 mg intravenously q. eight.
12. Acetyl 15 600 mg p.o. twice a day times four doses.
13. Labetalol 3 mg per minute.
14. Gentamicin 520 mg intravenously q. 24 hours.

DISCHARGE STATUS:   The patient remained in the Medical
Intensive Care Unit.

The patient was in guarded condition.




                          [**First Name4 (NamePattern1) 963**] [**Last Name (NamePattern1) 964**], M.D.  [**MD Number(1) 965**]

Dictated By:[**Last Name (NamePattern1) 662**]

MEDQUIST36

D:  [**2159-7-15**]  16:53
T:  [**2159-7-15**]  17:28
JOB#:  [**Job Number 9066**]


Name:  [**Known lastname 9064**], [**Known firstname **] L.                       Unit No:  [**Numeric Identifier 9065**]

Admission Date:  [**2159-7-9**]     Discharge Date:  [**2159-7-31**]

Date of Birth:   [**2104-2-11**]     Sex:  M

Service:

ADDENDUM:   This is an Addendum to a previous Discharge
Summary.  I am dictating his hospital course in the Medical
Intensive Care Unit from the dates of [**7-16**] through [**7-28**].

HOSPITAL COURSE BY ISSUE/SYSTEM:

1.  FEVERS:  During his hospital course, Mr. [**Known lastname **] continued to
spike fevers ranging from 101 to 104.  He had numerous
workups that he received; including a fine-needle biopsy on
[**7-17**] which was intended to drain the pericecal abscess
that he had.  This pericecal abscess was sent for culture and
grew out Streptococcus milleri and [**Female First Name (un) **] albicans, and the
patient was continued on vancomycin and started on
fluconazole.

The patient had numerous further workups for these fevers;
including head computed tomographies which did show worsening
of sinus opacities.  However, Ear/Nose/Throat was consulted
and they did not feel the worsening sinusitis was
contributing to his fevers, and they said that no further
intervention was required at this time.

Numerous blood, urine, and bronchoalveolar lavage specimens
were sent for culture.  None of these specimens were
productive for any bacteria.

It was then felt that these fevers might be secondary to drug
fevers.  The patient was being treated with metronidazole,
fluconazole, vancomycin, and gentamicin.  These were
eventually switched clindamycin and aztreonam.  It was felt
that metronidazole may possibly have been the drug that was
contributing to his drug fever; he was receiving this
medication throughout his hospital course.

2.  ATRIAL FIBRILLATION:  On [**7-23**], the patient went from a
normal sinus rhythm into atrial fibrillation with rapid
ventricular response.  He was started on amiodarone as well
as a diltiazem drip.  He was also started on an esmolol drip
for rate control.  He was also started on a heparin drip for
atrial fibrillation.

I talked with Cardiology over the telephone, and they did not
recommend direct current cardioversion as the patient was
continuing to spike fevers and would likely revert back into
atrial fibrillation.

3.  LEFT LOWER LEG ISCHEMIA:  As per the initial History and
Physical, Mr. [**Known lastname **] originally presented to the hospital for a
workup of left lower leg claudication.

During his hospital course it was noted that he was having
elevated creatine kinases, and there was concern for severe
left lower leg ischemia possibly causing his fevers.

Vascular Surgery had been following the patient, and on [**7-24**] he was taken to the operating room for exploration of the
left lower extremity.  There was no evidence for fasciitis,
or necrosis, or compartment syndrome.  His creatine kinases
continued to decline throughout the rest of his hospital
course.

4.  ETHANOL WITHDRAWAL:  The patient's Valium dose was weaned
throughout the past weeks, and he was continued on a Fentanyl
drip for sedation.

5.  RESPIRATORY FAILURE:  The patient was continued on the
ventilator, and a tracheostomy was scheduled for [**2159-7-31**].

6.  INCREASED CREATININE:  On [**7-20**], a Renal consultation
was obtained as the patient started developing an increased
creatinine.  Per their evaluation, the patient had acute
tubular necrosis likely secondary to immunoglycoside
administration.  They recommended discontinuing all
nephrotoxic agents and continuing to follow his renal
function.





                          [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.  [**MD Number(2) 5452**]

Dictated By:[**Name8 (MD) 6500**]

MEDQUIST36

D:  [**2159-7-31**]  08:42
T:  [**2159-7-31**]  08:58
JOB#:  [**Job Number 9076**]


Name:  [**Known lastname 9064**], [**Known firstname **] L.                       Unit No:  [**Numeric Identifier 9065**]

Admission Date:  [**2159-7-9**]     Discharge Date:  [**2159-8-27**]

Date of Birth:   [**2104-2-11**]     Sex:  M

Service:  Medical Intensive Care Unit - Green Team

Addendum to discharge summary that documented events of
hospital course up until [**2159-7-31**].  This dictation is
the subsequent hospital course through [**2159-8-27**].

HOSPITAL COURSE:  This is a 55 year old male with a history
of severe peripheral vascular disease and known carotid
artery stenosis and occlusion on the left who presented to
[**Hospital6 2003**] on [**7-9**] for a left
lower extremity preoperative arteriogram for ongoing
claudication but the patient went into delirium tremens from
alcohol withdrawal and was brought to the Emergency
Department for evaluation.  The patient was managed in the
Medical Intensive Care Unit with large doses of
Benzodiazepines and a Phenobarbital course for marked
withdrawal symptoms.  During his hospital course he was found
to have tracheomalacia in addition to a perforated appendix.
The patient is now status post tracheostomy and percutaneous
endoscopic gastrostomy placement and status post an
antibiotic course for perforated appendix and drainage of the
pericecal abscess.  The patient is status post antibiotic
treatment for ongoing fevers related to line sepsis and
management of fevers due to likely drug fever.  The patient
is also status post a left below the knee amputation for
extensive left calf necrosis despite a revascularization by a
left common femoral artery endarterectomy and a left
superficial femoral artery thrombectomy.  The patient now has
a weak left arm from a right-sided posterior frontal stroke,
discovered by an magnetic resonance imaging scan done on
[**2159-8-23**].  Otherwise the patient is doing well with
adequate oxygen saturations on a tracheostomy mask and has
had no significant fevers in three days while on an
antibiotic course for a vent-associated pneumonia and
suspected line sepsis from an arterial line that was removed
five days ago.

1.  Vascular - The patient presented for preoperative
evaluation of his left lower extremity claudication through
an arteriogram, however, this evaluation was delayed
secondary to his delirium tremens.  During his hospital
course he was noted to have elevated creatinine kinase level,
possibly related to ischemia.  Therefore, the patient was
brought to the Operating Room for a fasciotomy on [**7-24**],
which showed no evidence of necrotic tissue or fasciitis.
His creatinine kinase level subsequently declined.  On [**7-30**], aortography and left lower extremity runoff showed a
distal superficial femoral artery occlusion and a near
occlusion of the common femoral artery on the left side.  On
[**8-1**], a left common femoral artery endarterectomy and left
superficial femoral artery thrombectomy was completed.  The
patient was noted to have a well perfused left foot following
the procedure.  On [**8-8**], the patient was brought back to
the Operating Room for debridement of necrotic tissue seen in
the left lower extremity.  However, during this procedure the
patient was noted to have extensive necrosis of his left calf
without viable tissue remaining.  Therefore on [**8-17**], the
patient was brought back to the Operating Room for a left
below the knee amputation for gangrenous tissue.  Currently
the site of his left below the knee amputation is healing
well and dressing changes are continuing every other day.
Other vascular issues were addressed during this hospital
stay including the patient's carotid stenosis which on [**8-14**] was evaluated by ultrasound, persistence of his left
internal carotid artery occlusion was noted and worsening of
his right internal carotid artery to greater than 80%
stenosis was noted.  The patient was continued on
anticoagulation for his vascular intervention with a Lovenox
regimen, likely to be changed to Coumadin in the future.

2.  Respiratory - The patient was maintained on a ventilator
for the majority of his hospital stay.  On [**7-31**] the
patient had bronchoscopy with removal through suctioning of
multiple copious secretions in all of his lower airways.  A
tracheostomy was placed at that time.  On [**8-23**], the
patient was weaned to a tracheostomy mask and has maintained
adequate oxygen saturations.  He was then fitted with a
Passy-Muir valve to allow him to communicate.  He continues
Albuterol and Atrovent nebulizers.

3.  Infectious disease - The patient is currently finishing a
course of Linezolid for suspected line sepsis from an
arterial line that was removed [**8-22**].  The culture from
this line grew coagulase negative Staphylococcus.  The
patient has a Vancomycin allergy and is therefore continued
on Linezolid.  Also the patient was noted to have a left
lower lobe pneumonia by chest x-ray and recent sputum culture
on [**8-24**] did grow Acinetobacter and Klebsiella and is
currently being treated with Levaquin for this pneumonia.
The patient is status post antibiotic course for his
perforated appendix that had a pericecal abscess drained.  He
will need to have his perforated appendix removed in the
future.  A subsequent computerized axial tomography scan of
his abdomen showed no recollection of an abscess at this
site.  Also the patient had a course of Linezolid and Flagyl
prior to his left below the knee amputation due to
Enterococcus growing on tissue cultures and suspected
anaerobe infection at the site of his left necrotic leg.

4.  Renal/genitourinary - The patient had no evidence of
urinary tract infection despite longterm Foley catheter in
place.  Also his creatinine has been maintained within normal
limits for the last month of his hospital stay.

5.  Neurology - The patient had an magnetic resonance imaging
scan/magnetic resonance angiography on [**8-23**] that
confirmed a cerebrovascular accident during his hospital
course.  Following debridement of his left lower leg, the
patient was noticed to have no movement of his left arm.  On
[**8-14**] a computerized axial tomography scan showed no
acute infarct but the subsequent magnetic resonance imaging
scan did confirm a right posterior frontal stroke.  Neurology
recommendations were followed and follow up arranged.  Also
physical therapy and occupational therapy were ordered to
work with the patient to address this issue and Intensive
Care Unit neuromyopathy which had also been confirmed by
electromyogram during his hospital stay.

6.  Cardiovascular - During his hospital course the patient
had atrial fibrillation that resolved spontaneously on [**8-5**] while on a Diltiazem and Esmolol drip.  The patient
subsequently had an episode of nonsustained ventricular
tachycardia approximately 40 beats long.  He continues on a
course of Amiodarone 400 mg p.o. b.i.d. until [**9-11**] and
will then need to be tapered.  His ongoing hypertension was
controlled with Metoprolol, Captopril and Hydralazine prn.
The patient will require cardiology follow up in the near
future to address these issues.

7.  Fluids, electrolytes and nutrition - After placement of a
percutaneous endoscopic gastrostomy tube on [**7-31**], the
patient had adequate nutrition through daily tube feedings.
The patient recently had a speech and swallow evaluation
which did allow for minimal oral intake and will likely be
advanced in the near future.  The patient had dramatic
diuresis throughout the final month of his hospital stay to
bring him closer to his presenting weight.

8.  Pain - The patient is noted to have left arm pain and is
continued on a Fentanyl patch to control this ongoing issue.

9.  Psychiatry - As the patient has a history of anxiety
disorder, alcohol abuse and panic attacks, he was started on
Olanzapine q.h.s. and as needed for psychosis and agitation.

10.  Hematology - The patient was noted to have a decreased
hematocrit during his hospital stay, often this was suspected
to be due to fluid shift, however, at one point he was
transfused with 2 units of packed red blood cells to bring
him back to acceptable hematocrit.

11.  Prophylaxis - The patient was continued on a proton pump
inhibitors and anticoagulation with heparin and then later
Lovenox.

12.  Code status - The patient was a full code throughout his
hospital stay.

13.  Access - On [**8-27**], the patient is scheduled to have
a PICC line placed for ongoing antibiotic and intravenous
therapy.

DISCHARGE STATUS/MEDICATIONS/FOLLOW UP PLANS:  To be
addressed in a subsequent discharge addendum.



                          [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 3662**]

Dictated By:[**Last Name (NamePattern1) 8843**]`
MEDQUIST36

D:  [**2159-8-26**]  18:16
T:  [**2159-8-26**]  18:38
JOB#:  [**Job Number 9095**]

cc:[**Last Name (NamePattern1) 9096**]

Name:  [**Known lastname 9064**], [**Known firstname **] L.                       Unit No:  [**Numeric Identifier 9065**]

Admission Date:  [**2159-7-9**]     Discharge Date:  [**2159-8-27**]

Date of Birth:   [**2104-2-11**]     Sex:  M

Service:

Please see previous dictation summaries and addendums for
hospital course from [**7-9**] through [**8-27**].





Dictated By:[**Last Name (NamePattern1) 9097**]

MEDQUIST36

D:  [**2159-8-28**]  13:25
T:  [**2159-8-28**]  13:29
JOB#:  [**Job Number 9098**]


Admission Date:  [**2159-7-9**]     Discharge Date:  [**2159-8-28**]

Date of Birth:   [**2104-2-11**]     Sex:  M

Service:  Medical Intensive Care Unit, Green Team

ADDENDUM:  This is an Addendum to a Discharge Summary
documenting hospital course through [**2159-8-27**].  This
Addendum will cover the hospitalization from [**8-27**]
through [**2159-8-28**].  Please see the previous Discharge
Summary for the full hospital course from [**Month (only) 205**] through [**8-27**].

HOSPITAL COURSE BY ISSUE/SYSTEM (CONTINUED):  The patient is
a 55-year-old gentleman with a past medical history
significant for severe peripheral vascular disease and
carotid artery stenosis and occlusion in the left carotid
artery who presented to [**Hospital1 69**]
on [**7-9**] for left lower extremity preoperative arteriogram
for ongoing claudication.

While in the Waiting Room for this procedure, the patient
went into alcohol withdrawal syndrome with delirium tremens
and was then taken to the Emergency Department.

The patient was subsequently admitted from the Emergency
Department to the Medical Intensive Care Unit.  His
subsequent hospital course is documented per previous
Discharge Summary.

1.  WITHDRAWAL SYNDROME ISSUES:  The patient continued to
spike fevers but continued to have negative blood cultures.
No other fossae of infection was found.  He had an ultrasound
of his left groin site which was negative for any localized
infection.

2.  RESPIRATORY ISSUES:  The patient's respiratory status
remained stable.  He remained on 35% FIO2 via his
tracheostomy site.

3.  CARDIOVASCULAR ISSUES:  The patient remained stable.  He
remained in a normal sinus rhythm and was continued on
metoprolol and amiodarone for his previous atrial
fibrillation.  His blood pressure was well controlled, and
his ACE inhibitor was decreased to avoid any hypotension.

4.  LEFT BELOW-KNEE AMPUTATION ISSUES:  His left below-knee
amputation site continued to heal well with dressing changes
every other day.  His last dressing change was on [**8-27**].

5.  NEUROLOGIC ISSUES:  Neurology continued to follow the
patient.  He was started on Lipitor, Plavix, and aspirin
given his recent cerebrovascular accident.

Given his acute medical issues, a repeat carotid Doppler
imaging was not done while in the hospital.  The patient was
to receive carotid Doppler studies as an outpatient within
one week and he was then to follow up with Neurology in one
month for further evaluation and possible plans for surgical
treatment of his carotid artery stenosis.

6.  FLUIDS/ELECTROLYTES/NUTRITION ISSUES:  The patient
continued to be followed by Nutrition.  He had a follow-up
Speech and Swallow study which showed no overt aspiration;
although a modified barium swallow was unable to be obtained
due to the patient not fitting in the scanner.

It was recommended that his diet continued to be advanced.
The patient was started on thin liquids and on ground solids
which he tolerated well.

7.  PROPHYLAXIS ISSUES:  He was continued on proton pump
inhibitors and Lovenox anticoagulation prophylaxis.

8.  CODE STATUS:  The patient remained a full code throughout
his hospitalization.

CONDITION AT DISCHARGE:  Condition on discharge was stable.

DISCHARGE DIAGNOSES:
 1.  Delirium tremens/alcohol withdrawal.
 2.  Distal superficial femoral artery occlusion.
 3.  Near occlusion left common femoral artery.
 4.  Left lower extremity gangrene.
 5.  Respiratory failure.
 6.  Bacteremia.
 7.  Tracheomalacia.
 8.  Perforated appendix.
 9.  Peripheral vascular disease.
10.  Carotid artery stenosis.
11.  Right posterior frontal cerebrovascular accident.
12.  Arterial line sepsis.
13.  Ventilator-associated pneumonia.
14.  Atrial fibrillation.
15.  Hypertension.

PROCEDURE PERFORMED:
 1.  Fasciotomy of the left leg.
 2.  Aortogram, left lower extremity runoff.
 3.  Left below-knee amputation.
 4.  Tracheostomy.
 5.  Percutaneous gastrostomy placement.
 6.  Drainage of pericecal abscess.
 7.  Left common femoral endarterectomy.
 8.  Left superficial femoral artery thrombectomy.
 9.  Magnetic resonance imaging of the head.
10.  Computed tomography scan of the abdomen.
11.  Speech and Swallow evaluation.
12.  Ultrasound of the left groin.
13.  Multiple chest x-rays.

MEDICATIONS ON DISCHARGE:
 1.  Captopril 6.25 mg by mouth three times per day.
 2.  Lasix 80 mg by mouth once per day.
 3.  Olanzapine 2.5 mg by mouth q.a.m.
 4.  Lovenox 100 mg subcutaneously q.12h.
 5.  Levaquin 500 mg by mouth q.24h. (times two days).
 6.  Fentanyl patch 25 mcg transdermally q.72h.
 7.  Multivitamin 5 mL by mouth once per day (via feeding
tube).
 8.  Olanzapine 5 mg by mouth q.h.s.
 9.  Metoprolol 100 mg by mouth three times per day.
10.  Amiodarone 400 mg by mouth twice per day.
11.  Zinc sulfate 220 mg by mouth every day.
12.  Linezolid 600 mg by mouth q.12h. (times 2.5 days).
13.  Senna two tablets by mouth twice per day as needed.
14.  Bisacodyl 10 mg per rectum once per day as needed.
15.  Ibuprofen 400 mg by mouth q.8h. as needed.
16.  Albuterol/ipratropium inhaler 6 to 8 puffs inhaled q.4h.
17.  Tylenol 325 mg to 650 mg by mouth q.4-6h. as needed.
18.  Lansoprazole 30 mg by mouth once per day.
19.  Colace 200 mg by mouth three times per day.
20.  Miconazole powder 2% twice per day as needed.
21.  Nystatin oral suspension twice per day as needed.
22.  Lipitor 10 mg by mouth once per day.
23.  Aspirin 81 mg by mouth once per day.
24.  Plavix 75 mg by mouth once per day.

ALLERGIES:  VANCOMYCIN.

DISCHARGE INSTRUCTIONS ON DISCHARGE:
1.  Dressing changes to left below-knee amputation site every
other day (last changed on [**8-27**]).
2.  Down-size tracheostomy to size 6.
3.  Carotid Doppler study within one week.
4.  Follow Promote with fiber full-strength diet at 95 cc per
hour via percutaneous endoscopic gastrostomy tube.
5.  Advance diet to thin liquids and ground solids as
tolerated.
6.  Followup as scheduled.
7.  The patient was to call his primary care physician or go
to the Emergency Department for chest pain, difficulty
breathing, abdominal pain, nausea, vomiting, fevers, chills,
or other concerning symptoms.

DISCHARGE FOLLOWUP ON DISCHARGE:
1.  The patient was to follow up with Neurology (Dr. [**Last Name (STitle) 48962**]
on [**10-2**] at 1 p.m. (telephone number [**Telephone/Fax (1) 1694**]);
please call this number to give insurance information.
2.  The patient was to follow up with Vascular Surgery; the
patient to call telephone number [**Telephone/Fax (1) 3121**] to schedule an
appointment in two to four weeks.
3.  The patient was to follow up with Cardiology (Dr.
[**First Name (STitle) **] [**Name (STitle) 1911**]) on [**9-6**] at 4:15 p.m.
(telephone number [**Telephone/Fax (1) 2207**]); the patient to call to
confirm appointment.
4.  The patient was to follow up with primary care physician
as soon as possible.  The patient was to call for an
appointment.

DISCHARGE DISPOSITION:   The patient was discharged to
[**Hospital3 **].

CONDITION AT DISCHARGE:  Condition on discharge was stable.





                          [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D.  [**MD Number(1) 6223**]

Dictated By:[**Last Name (NamePattern1) 5212**]

MEDQUIST36

D:  [**2159-8-28**]  13:45
T:  [**2159-8-28**]  14:01
JOB#:  [**Job Number 48963**]
{'Alcohol withdrawal delirium,Atherosclerosis of native arteries of the extremities with gangrene,Acute appendicitis with peritoneal abscess,Congestive heart failure, unspecified,Acute kidney failure with lesion of tubular necrosis,Unspecified septicemia,Other disorders of muscle, ligament, and fascia,Other and unspecified alcohol dependence, 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: Alcohol withdrawal.

PRESENT ILLNESS: The patient is a 55-year-old
male with a history of panic attacks who came to the hospital
on [**2159-7-9**], for a preoperative arteriogram for a
scheduled left femoral popliteal bypass.  While in the far
lobby the patient began to feel anxious and short of breath
accompanied by chills and uncontrollable shaking.  The
patient denied chest pain, headache, nausea, vomiting or
abdominal pain.  The patient denied lightheadedness.  The
patient thought he was having a panic attack but did feel
that this was different than any prior panic attack that he
had had.  The patient was taken to the Emergency Department
where he was noted to be diaphoretic, tachypneic and
tachycardic with a heart rate of 105, a respiratory rate of
28 and a temperature of 101.5 degrees.  In addition, the
patient was extremely anxious.  The patient was given 2 mg IV
of Ativan.  Subsequently, the patient's blood pressure was
178/94 with a heart rate of 130, a respiratory rate of 32 and
an oxygen saturation of 92% on room air.  The patient's heart
rate increased to 150's and his respiratory rate increased to
36.  The patient became more agitated with slurred speech.
The patient received 10 mg of Valium and was given a
nonrebreather mask which he did not tolerate.  The patient
was thought to be in alcohol withdrawal versus PE versus
myocardial infarction.  The patient was taken for a CT
arteriogram of the chest to rule out pulmonary embolus which
showed no evidence of pulmonary embolus.  The CT did show
evidence of tracheomalacia.  At this time the patient's wife
admitted that the patient drinks one case of beer a day which
he stopped on Saturday.  The patient received a total of 14
mg of Ativan and 40 mg of Valium plus 5 mg of droperidol and
20 mg of labetalol in the Emergency Room.  The patient's
blood pressure rose of a value of 225/110.  The patient also
received four liters of normal saline with a urine output of
100 cc.  The patient was brought to the Medical Intensive
Care Unit where he continued to be tachypneic and tachycardic
and received 80 mg IV of Valium which had no effect.  He then
received 120 mg of Valium.  The patient continued to be
tachypneic and hypertensive with a systolic blood pressure of
150.  He was therefore put on noninvasive positive pressure
ventilation at a pressure support of 20 and a PEEP of 8.  The
patient's arterial blood gas on these settings was 7.39, 47
and 179.  The patient continued to be febrile with a
temperature of 102.6, a heart rate of 130, a blood pressure
of 180/106 and a respiratory rate of 36 to 40.  The patient
continued to require Valium 10 mg every 20 minutes in order
to maintain adequate anxiolytic effect.  It was decided to
intubate the patient in order to achieved adequate sedation.
The patient was sedated with dexmedetomidine per Anesthesia
recommendation and intubated in the Intensive Care Unit.

MEDICAL HISTORY: 1.  Bilateral carotid stenosis 100% on the left and 80% on
the right.
2.  Hypertension.
3.  Panic disorder.
4.  Left leg claudication.
5.  Tobacco use 60 pack year history, quit two years ago.

MEDICATION ON ADMISSION: 

ALLERGIES: Penicillin causes hives.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient is a sales representatives,
married with no children. 

### Response:
{'Alcohol withdrawal delirium,Atherosclerosis of native arteries of the extremities with gangrene,Acute appendicitis with peritoneal abscess,Congestive heart failure, unspecified,Acute kidney failure with lesion of tubular necrosis,Unspecified septicemia,Other disorders of muscle, ligament, and fascia,Other and unspecified alcohol dependence, unspecified'}
