CHIEF COMPLAINT: fever, respiratory distress

PRESENT ILLNESS: This is an 87 year old male with a past medical history of
stroke with persistent R near-hemiplegia and averbal s/p PEG
placement, DM2, CKD (baseline Cr 1.6-2) who presented from his
nursing home today for evaluation of fevers and acute on chronic
renal failure. He is at [**Hospital 100**] Rehab since [**Month (only) 404**], in the MACU,
stable on a trach mask, with his course punctuated by c diff
colitis and a return for fevers. This past weekend, he initially
started spiking fevers with increasing diarrhea. He was started
empirically on PO vanco (given his + c diff in the past). His
respiratory status then acutely decompensated requiring return
to mechanical ventilation.
Sputum collected returned positive for ESBL Klebsiella for which
he initially received Imipenem which was then switched to Zosyn
based on culture data. He also was noted to have anasarca with
worsening urine output and his creatinine was above his
baseline. He was given D5W with bicarb to which he did not
respond. Today he spiked through Zosyn, so he was sent to the ED
for further work up.
.
In the ED, his vital signs were stable with HR in the 80's and
BP in the 120's. He was febrile to 101.7, and was satting 93% on
A/C 500x 14 FiO2 0.4 and peep 5. He was found to be anasarcic on
exam and his CXR was notable for a persistent LLL effusion and
pulmonary edema.
He received vanco and cefepime and about 1L of IVF. He also
underwent a bedside echocardiogram which was negative for
pericardial effusion or ascites. A UA was grossly positive. Also
of note, he was in and out of afib on tele in the 80's.
.
He is admitted to the MICU for further work up and evaluation

MEDICAL HISTORY: - Diabetes mellitus
- Chronic kidney disease, Cr 1.6-2
- Hypertension
- dyslipidemia
- Aortic insufficiency
- Thoracic aortic aneurysm
- Osteoarthritis.
- First degree A-V delay
- GERD
- BPH
- Nephrolithiasis
- Cataracts
- Ventral hernia
- History of malaria
- Baseline chronic anemia
- s/p PEG tube placement [**10/2154**]

MEDICATION ON ADMISSION: Folic Acid 1 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily).
Atorvastatin 80 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY
Cholecalciferol (Vitamin D3) 400 unit Tablet [**Date Range **]: One (1)
Tablet PO once a day.
Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Metoclopramide 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID PRN
HIGH RESIDUALS ().
Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Last Name (STitle) **]:
One (1) Inhalation Q4H (every 4 hours).
Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation
Q4H (every 4 hours).
Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection three times a day.
Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Clopidogrel 75 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily).
Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual [**Last Name (STitle) **]: One (1)
Tablet, Sublingual Sublingual QID (4 times a day).
Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day).
Amlodipine 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
Gabapentin 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO Q12H
(every 12 hours).
Quetiapine 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime).
Modafinil 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times
a day).
Lantus 100 unit/mL Solution [**Last Name (STitle) **]: Forty Six (46) units
Subcutaneous at bedtime.
Sevelamer HCl 800 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2
times a day).
Insulin Sliding Scale

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 98.8 75 143/49 23 100%ra A/C 500 x 14 FiO2 0.5 peep 8
pulsus = 9
GEN: NAD, responds to voice, can shake head yes/no to simple
questions
HEENT: AT, NC, EOMI, glaucomatous changes in left eye, no
conjuctival injection, anicteric, OP clear, MM dry. Neck supple,
no LAD, no carotid bruits. JVP @ 6cm @ 30 degrees.
CV: RRR, nl s1, s2, soft [**12-8**] SM at base, distant heart sounds
PULM: trached. scattered rhonchi with decreased breath sounds at
the bases
ABD: mild-moderate distention, grimacing with palpation
diffusely. No shifting dullness. +BS. G tube c/d/i.
EXT: warm, dry, +1 distal pulses BL, 1+ pitting edema diffusely

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: No smoking, occasional alcohol, no drug use.
Acute respiratory failure,Pneumonia due to Pseudomonas,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Other and unspecified complications of medical care, not elsewhere classified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Anemia, unspecified,Atrial fibrillation,Tracheostomy status
Acute respiratry failure,Pseudomonal pneumonia,Acute kidney failure NOS,Hyposmolality,Late ef-hemplga side NOS,Complic med care NEC/NOS,DMII renl nt st uncntrld,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Anemia NOS,Atrial fibrillation,Tracheostomy status
Admission Date:  [**2155-5-6**]              Discharge Date:   [**2155-5-12**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
fever, respiratory distress

Major Surgical or Invasive Procedure:
none


History of Present Illness:
This is an 87 year old male with a past medical history of
stroke with persistent R near-hemiplegia and averbal s/p PEG
placement, DM2, CKD (baseline Cr 1.6-2) who presented from his
nursing home today for evaluation of fevers and acute on chronic
renal failure. He is at [**Hospital 100**] Rehab since [**Month (only) 404**], in the MACU,
stable on a trach mask, with his course punctuated by c diff
colitis and a return for fevers. This past weekend, he initially
started spiking fevers with increasing diarrhea. He was started
empirically on PO vanco (given his + c diff in the past). His
respiratory status then acutely decompensated requiring return
to mechanical ventilation.
Sputum collected returned positive for ESBL Klebsiella for which
he initially received Imipenem which was then switched to Zosyn
based on culture data. He also was noted to have anasarca with
worsening urine output and his creatinine was above his
baseline. He was given D5W with bicarb to which he did not
respond. Today he spiked through Zosyn, so he was sent to the ED
for further work up.
.
In the ED, his vital signs were stable with HR in the 80's and
BP in the 120's. He was febrile to 101.7, and was satting 93% on
A/C 500x 14 FiO2 0.4 and peep 5. He was found to be anasarcic on
exam and his CXR was notable for a persistent LLL effusion and
pulmonary edema.
He received vanco and cefepime and about 1L of IVF. He also
underwent a bedside echocardiogram which was negative for
pericardial effusion or ascites. A UA was grossly positive. Also
of note, he was in and out of afib on tele in the 80's.
.
He is admitted to the MICU for further work up and evaluation


Past Medical History:
- Diabetes mellitus
- Chronic kidney disease, Cr 1.6-2
- Hypertension
- dyslipidemia
- Aortic insufficiency
- Thoracic aortic aneurysm
- Osteoarthritis.
- First degree A-V delay
- GERD
- BPH
- Nephrolithiasis
- Cataracts
- Ventral hernia
- History of malaria
- Baseline chronic anemia
- s/p PEG tube placement [**10/2154**]

Social History:
No smoking, occasional alcohol, no drug use.


Family History:
non-contributory

Physical Exam:
VS: 98.8 75 143/49 23 100%ra A/C 500 x 14 FiO2 0.5 peep 8
pulsus = 9
GEN: NAD, responds to voice, can shake head yes/no to simple
questions
HEENT: AT, NC, EOMI, glaucomatous changes in left eye, no
conjuctival injection, anicteric, OP clear, MM dry. Neck supple,
no LAD, no carotid bruits. JVP @ 6cm @ 30 degrees.
CV: RRR, nl s1, s2, soft [**12-8**] SM at base, distant heart sounds
PULM: trached. scattered rhonchi with decreased breath sounds at
the bases
ABD: mild-moderate distention, grimacing with palpation
diffusely. No shifting dullness. +BS. G tube c/d/i.
EXT: warm, dry, +1 distal pulses BL, 1+ pitting edema diffusely

NEURO: residual right hemiplegia, averbal but will shake head
yes/no appropriately
SKIN: warm/dry. Diffuse trace to 1+ edema, including face. No
rash.


Pertinent Results:
[**2155-5-6**] 07:55PM   WBC-9.9# RBC-2.95* HGB-9.1* HCT-26.7* MCV-90
MCH-30.7 MCHC-33.9 RDW-14.2
[**2155-5-6**] 07:55PM   PLT COUNT-290
[**2155-5-6**] 07:55PM   NEUTS-69.8 LYMPHS-22.1 MONOS-4.5 EOS-3.2
BASOS-0.4
[**2155-5-6**] 07:55PM   GLUCOSE-384* UREA N-104* CREAT-2.7*#
SODIUM-129* POTASSIUM-4.7 CHLORIDE-96 TOTAL CO2-19* ANION GAP-19
[**2155-5-6**] 07:55PM   CK-MB-NotDone proBNP-3469*
[**2155-5-6**] 07:55PM   ALBUMIN-2.9*
[**2155-5-6**] 07:55PM   CORTISOL-25.9*

pre-hosp:
Sputum Culture: ESBL Klebsiella pneumonia

Hosp:
Afib with LAFB @ 71bpm. Scattered P waves noted on the EKG
however. Second ekg with NSR @ 98

CXR ([**2155-5-6**]) -
1. Persistent left lower lobe collapse/consolidation.
2. Mild CHF.

CT torso ([**2155-5-6**]) -
1. High position of the endotracheal tube just at the thoracic
inlet. The tube should be advanced for more optimal placement.
2. Moderate-sized bilateral low-attenuation pleural effusions
with associated bibasilar atelectasis.
3. Moderate low attenuation pericardial effusion and coronary
artery calcifications.
4. Diffuse anasarca within the regional soft tissues with
scattered ascites consistent with volume overload.
5. Multiple bilateral renal hypodensities, the largest
compatible with cysts and others too small to characterize.

TTE ([**2155-5-7**])-
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Regional left ventricular wall motion is probably
normal. Overall left ventricular systolic function is probably
normal (LVEF 50-60%). There is no ventricular septal defect.
Right ventricular chamber size is normal. with mild global free
wall hypokinesis. There is abnormal septal motion/position. The
aortic root is moderately dilated at the sinus level. The
ascending aorta is moderately dilated. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Mild to moderate ([**12-4**]+) aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is at least mild pulmonary artery systolic hypertension. There
is a small pericardial effusion. The effusion is echo dense,
consistent with blood, inflammation or other cellular elements.
There are no echocardiographic signs of tamponade.


Brief Hospital Course:
In brief, the patient is an 87 yo male with history of CVA s/p
trach/peg in LTAC unit admitted with increasing respiratory
distress, fevers, diarrhea and acute on chronic renal failure.
.
1) Respiratory Distress: patient was trached after difficult
attempts to wean post CVA. He has been treated in the last
several months for HAP, most recently finishing a course of
antibiotics on [**2155-4-11**] for pansensitive pseudomonas and proteus
from sputum on last admission. He has a persistent left sided
effusion and evidence of pulmonary edema on plain chest imaging
on presentation. His pre-hospital sputum cultures revealed and
ESBL Klebsiella species consistent with a ventilator associated
pneumonia and he was continued on appropriate antibiotics.
While being volume resusitated from his sepsis his respiratory
status was challenged by the fluid load.  Investigations for
other infectious causes such as UTI or c. diff associated
colitis were negative. As his sepsis improved, he was able to
tolerate gradual diuresis which allowed him to return to
pressure support ventilation.
.
2) Acute on Chronic Renal Failure: The patient presented in
acute on chronic renal failure which seemed to be in a low flow
state, although acute worsenining of renal function could be
medication induced, secondary to ATN or prerenal azotemia. The
most likely cause was thought to be pre-renal due to the septic
physiology then worsened by volume overload.  He was gradually
diuresed as above and discharged on his hospital dose of 120 mg
IV Lasix daily. This can be gradually tapered down as his
respiratory status and peripheral edema improves. His creatinine
and electrolytes should be monitored as his diuresis continues.
.
3) Hyponatremia/metabolic acidosis: The patient presented as
hypovolemic hyponatremic and mild metabolic acidosis associated
with renal failure.  He was volume repleted as above and his
metabolic derangements improved.
.
4) Hypertension: The patient has a history of hypertension. His
blood pressure medications were held during his stay and resumed
prior to discharge.
.
5) Atrial fibrillation: The patient presented in paroxysmal
atrial fibrillation.  This was a new finding for the patient
according to our records. His rate was well controlled during
the hospital stay.  The decision to anti-coagulate the patient
with coumadin was deferred to the patient's primary care
providers and LTAC physicians.
.
6) Diabetes mellitus type 2: Elevated blood glucose on arrival
likely indicative of intravascular volume depletion. insulin
sliding scale for now with insulin gtt if uncontrolled. Monitor
fingersticks.
.
# Hyperlipidemia: Statin was continued.
.
# S/p CVA: Plavix was continued.
.
# Chronic Anemia: at baseline.


Medications on Admission:
Folic Acid 1 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily).
Atorvastatin 80 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY
Cholecalciferol (Vitamin D3) 400 unit Tablet [**Date Range **]: One (1)
Tablet PO once a day.
Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Metoclopramide 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID PRN
HIGH RESIDUALS ().
Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Last Name (STitle) **]:
One (1) Inhalation Q4H (every 4 hours).
Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation
Q4H (every 4 hours).
Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection three times a day.
Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Clopidogrel 75 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily).
Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual [**Last Name (STitle) **]: One (1)
Tablet, Sublingual Sublingual QID (4 times a day).
Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day).
Amlodipine 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
Gabapentin 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO Q12H
(every 12 hours).
Quetiapine 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime).
Modafinil 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times
a day).
Lantus 100 unit/mL Solution [**Last Name (STitle) **]: Forty Six (46) units
Subcutaneous at bedtime.
Sevelamer HCl 800 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2
times a day).
Insulin Sliding Scale


Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection TID (3 times a day).
2. Folic Acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).

3. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: 1-2 Puffs Inhalation
Q4H (every 4 hours).
4. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2)
Puff Inhalation Q4H (every 4 hours).
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily).
6. Atorvastatin 40 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily).
7. Clopidogrel 75 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
8. Sevelamer HCl 800 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily).
10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
11. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H
(every 6 hours) as needed.
12. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day).
13. Lactulose 10 gram/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO TID (3
times a day).
14. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal
HS (at bedtime) as needed.
15. Meropenem 500 mg Recon Soln [**Last Name (STitle) **]: One (1) Recon Soln
Intravenous Q8H (every 8 hours) for 7 days: Last day is [**2155-5-20**].
.
16. Furosemide 10 mg/mL Solution [**Month/Day/Year **]: One [**Age over 90 **]y (120)
mg Injection once a day: Can titrate down as peripheral
edema/respiratory status improves. .
17. Insulin
Continue Insulin regimen per sliding scale.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
Primary:
Ventilator associated pneumonia
Pre-renal azotemia

Secondary:
Stroke
Hypertension
Diabetes mellitus type 2 with complication of nephropathy


Discharge Condition:
stable vital signs. tolerating pressure support ventilation.
tolerating tube feeds at goal.


Discharge Instructions:
You were admitted with pneumonia and kidney dysfunction. You
received antibiotics for your pneumonia, which you will continue
for a total of 14 days. Your kidney function recovered gradually
as your infection improved and your blood pressure normalized.
You are now being discharged to [**Hospital3 **] Center
where your medical care will be continued.

Take the medications as prescribed.

If there are new or concerning symptoms such as shortness of
breath, fever, chest or abdominal pain; please seek medical
attention.

Followup Instructions:
per rehab facility
{'Acute respiratory failure,Pneumonia due to Pseudomonas,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Other and unspecified complications of medical care, not elsewhere classified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Anemia, unspecified,Atrial fibrillation,Tracheostomy 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: fever, respiratory distress

PRESENT ILLNESS: This is an 87 year old male with a past medical history of
stroke with persistent R near-hemiplegia and averbal s/p PEG
placement, DM2, CKD (baseline Cr 1.6-2) who presented from his
nursing home today for evaluation of fevers and acute on chronic
renal failure. He is at [**Hospital 100**] Rehab since [**Month (only) 404**], in the MACU,
stable on a trach mask, with his course punctuated by c diff
colitis and a return for fevers. This past weekend, he initially
started spiking fevers with increasing diarrhea. He was started
empirically on PO vanco (given his + c diff in the past). His
respiratory status then acutely decompensated requiring return
to mechanical ventilation.
Sputum collected returned positive for ESBL Klebsiella for which
he initially received Imipenem which was then switched to Zosyn
based on culture data. He also was noted to have anasarca with
worsening urine output and his creatinine was above his
baseline. He was given D5W with bicarb to which he did not
respond. Today he spiked through Zosyn, so he was sent to the ED
for further work up.
.
In the ED, his vital signs were stable with HR in the 80's and
BP in the 120's. He was febrile to 101.7, and was satting 93% on
A/C 500x 14 FiO2 0.4 and peep 5. He was found to be anasarcic on
exam and his CXR was notable for a persistent LLL effusion and
pulmonary edema.
He received vanco and cefepime and about 1L of IVF. He also
underwent a bedside echocardiogram which was negative for
pericardial effusion or ascites. A UA was grossly positive. Also
of note, he was in and out of afib on tele in the 80's.
.
He is admitted to the MICU for further work up and evaluation

MEDICAL HISTORY: - Diabetes mellitus
- Chronic kidney disease, Cr 1.6-2
- Hypertension
- dyslipidemia
- Aortic insufficiency
- Thoracic aortic aneurysm
- Osteoarthritis.
- First degree A-V delay
- GERD
- BPH
- Nephrolithiasis
- Cataracts
- Ventral hernia
- History of malaria
- Baseline chronic anemia
- s/p PEG tube placement [**10/2154**]

MEDICATION ON ADMISSION: Folic Acid 1 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily).
Atorvastatin 80 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY
Cholecalciferol (Vitamin D3) 400 unit Tablet [**Date Range **]: One (1)
Tablet PO once a day.
Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Metoclopramide 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID PRN
HIGH RESIDUALS ().
Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Last Name (STitle) **]:
One (1) Inhalation Q4H (every 4 hours).
Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation
Q4H (every 4 hours).
Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection three times a day.
Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Clopidogrel 75 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily).
Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual [**Last Name (STitle) **]: One (1)
Tablet, Sublingual Sublingual QID (4 times a day).
Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day).
Amlodipine 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
Gabapentin 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO Q12H
(every 12 hours).
Quetiapine 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime).
Modafinil 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times
a day).
Lantus 100 unit/mL Solution [**Last Name (STitle) **]: Forty Six (46) units
Subcutaneous at bedtime.
Sevelamer HCl 800 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2
times a day).
Insulin Sliding Scale

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 98.8 75 143/49 23 100%ra A/C 500 x 14 FiO2 0.5 peep 8
pulsus = 9
GEN: NAD, responds to voice, can shake head yes/no to simple
questions
HEENT: AT, NC, EOMI, glaucomatous changes in left eye, no
conjuctival injection, anicteric, OP clear, MM dry. Neck supple,
no LAD, no carotid bruits. JVP @ 6cm @ 30 degrees.
CV: RRR, nl s1, s2, soft [**12-8**] SM at base, distant heart sounds
PULM: trached. scattered rhonchi with decreased breath sounds at
the bases
ABD: mild-moderate distention, grimacing with palpation
diffusely. No shifting dullness. +BS. G tube c/d/i.
EXT: warm, dry, +1 distal pulses BL, 1+ pitting edema diffusely

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: No smoking, occasional alcohol, no drug use. 

### Response:
{'Acute respiratory failure,Pneumonia due to Pseudomonas,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Other and unspecified complications of medical care, not elsewhere classified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Anemia, unspecified,Atrial fibrillation,Tracheostomy status'}
