CHIEF COMPLAINT: Shortness of Breath, hypoxia

PRESENT ILLNESS: Pt is an 88 yo woman with PMHx sig. for DM2, dyslipidemia, and
recent admission for L comminuted, intertrochanteric left
femoral neck fracture, s/p open reduction internal fixation, and
L proximal comminuted and displaced fracture of the left humeral
neck fx treated with a sling ([**Date range (1) 96848**]) after fall was sent
from rehab with respiratory distress.  Patient was found to be
in respiratory distress this AM with wheezing, using accessory
muscles, poor air exachange, and tachypenia.  Her O2 sat was in
the high 80s, improved to 100% on NRB.  Other VS were 140/90,
120, 30, temp 98.5.  After a nebulizer treatment, her RR came
down to 24.  She also complained of diaphoresis.  She denied any
chest pain.
.
In the emergency department, initial vitals were:  98.5 110
140/90 34 98 on NRB.  She had a CXR that showed bilateral
pleural effusions, ?infiltrate.  Pt received levofloxacin 750
mg, vanc, and nebulizers.  UCx and BCx were obtained.  Pt is
currently feeling a little better, now satting 94% on 6L NC.
.
Currently, she feels uncomfortable, but cannot specify why.  She
denies any SOB and does not appear in respiratory distress while
lying supine.  She denies any cough, chest pain, nausea,
vomiting, abdominal pain, dysuria, and fever/chills.  She had
some rhinorrhea about 2 weeks ago.
.

MEDICAL HISTORY: - Type 2 Diabetes Mellitus
- Dyslipidemia
- Anxiety
- Osteoporosis
- HOH
- Diverticulosis
- Aortic Insufficiency, 1+
- Cystic lesion of pancreas felt to be benign
- Spinal Stenosis
- large HH into chest

MEDICATION ON ADMISSION: Enoxaparin 30 mg Subcutaneous QD for 4 weeks.
Ascorbic Acid 500 mg PO DAILY
B Complex Vitamins PO DAILY
Calcium Carbonate 500 mg PO DAILY
Cholecalciferol (Vitamin D3) 400 unit PO DAILY
Famotidine 20 mg PO BID
Docusate Sodium 100 mg PO BID
Senna 8.6 mg PO HS
Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain, fever.
Omega-3 Fatty Acids PO DAILY
Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation: hold for loose stool.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: GENERAL: Pleasant, well appearing female in NAD.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PER/EOMI. MM dry. OP clear.
Neck:  Supple, No LAD, No thyromegaly.  + JVD.
CARDIAC: Occasionally irregular rhythm, tachycardic, normal S1,
S2. Systolic murmur best at LLSB and apex.
LUNGS: Decreased breath sounds at the bases bilaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 1+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes, ecchymoses.  Stage II heel ulcers bilaterally.
Surgical incision over L hip c/d/i.
NEURO: A&Ox3. Appropriate.  CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout except proximal
LLE and LUE secondary to pain. Gait assessment deferred.
PSYCH: Listens and responds to questions appropriately, pleasant

FAMILY HISTORY: Mother with throat cancer.

SOCIAL HISTORY: Patient was born in Poland and grew up in [**Country 2784**].  Prior to her
fall, she lived alone in a private apartment and visited the
[**Location (un) **] Senior Center for all 3 meals.  She denies any
tobacco/etoh.
Diaphragmatic hernia with obstruction,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Unspecified pleural effusion,Urinary tract infection, site not specified,Intestinal infection due to Clostridium difficile,Hypoxemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Anemia, unspecified,Other and unspecified hyperlipidemia,Osteoporosis, unspecified,Spinal stenosis, lumbar region, without neurogenic claudication,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Pressure ulcer, lower back
Diaphragm hernia w obstr,Food/vomit pneumonitis,Acute respiratry failure,Pleural effusion NOS,Urin tract infection NOS,Int inf clstrdium dfcile,Hypoxemia,DMII wo cmp nt st uncntr,Anemia NOS,Hyperlipidemia NEC/NOS,Osteoporosis NOS,Spin sten,lumbr wo claud,Pseudomonas infect NOS,Pressure ulcer, low back
Admission Date:  [**2187-1-22**]              Discharge Date:   [**2187-2-16**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3531**]
Chief Complaint:
Shortness of Breath, hypoxia

Major Surgical or Invasive Procedure:
Laparoscopic gastric pulldown and PEG placement x2
PICC placement


History of Present Illness:
Pt is an 88 yo woman with PMHx sig. for DM2, dyslipidemia, and
recent admission for L comminuted, intertrochanteric left
femoral neck fracture, s/p open reduction internal fixation, and
L proximal comminuted and displaced fracture of the left humeral
neck fx treated with a sling ([**Date range (1) 96848**]) after fall was sent
from rehab with respiratory distress.  Patient was found to be
in respiratory distress this AM with wheezing, using accessory
muscles, poor air exachange, and tachypenia.  Her O2 sat was in
the high 80s, improved to 100% on NRB.  Other VS were 140/90,
120, 30, temp 98.5.  After a nebulizer treatment, her RR came
down to 24.  She also complained of diaphoresis.  She denied any
chest pain.
.
In the emergency department, initial vitals were:  98.5 110
140/90 34 98 on NRB.  She had a CXR that showed bilateral
pleural effusions, ?infiltrate.  Pt received levofloxacin 750
mg, vanc, and nebulizers.  UCx and BCx were obtained.  Pt is
currently feeling a little better, now satting 94% on 6L NC.
.
Currently, she feels uncomfortable, but cannot specify why.  She
denies any SOB and does not appear in respiratory distress while
lying supine.  She denies any cough, chest pain, nausea,
vomiting, abdominal pain, dysuria, and fever/chills.  She had
some rhinorrhea about 2 weeks ago.
.


Past Medical History:
- Type 2 Diabetes Mellitus
- Dyslipidemia
- Anxiety
- Osteoporosis
- HOH
- Diverticulosis
- Aortic Insufficiency, 1+
- Cystic lesion of pancreas felt to be benign
- Spinal Stenosis
- large HH into chest

Social History:
Patient was born in Poland and grew up in [**Country 2784**].  Prior to her
fall, she lived alone in a private apartment and visited the
[**Location (un) **] Senior Center for all 3 meals.  She denies any
tobacco/etoh.


Family History:
Mother with throat cancer.


Physical Exam:
GENERAL: Pleasant, well appearing female in NAD.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PER/EOMI. MM dry. OP clear.
Neck:  Supple, No LAD, No thyromegaly.  + JVD.
CARDIAC: Occasionally irregular rhythm, tachycardic, normal S1,
S2. Systolic murmur best at LLSB and apex.
LUNGS: Decreased breath sounds at the bases bilaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 1+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes, ecchymoses.  Stage II heel ulcers bilaterally.
Surgical incision over L hip c/d/i.
NEURO: A&Ox3. Appropriate.  CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout except proximal
LLE and LUE secondary to pain. Gait assessment deferred.
PSYCH: Listens and responds to questions appropriately, pleasant

.
on Dicharge
Vitals: 96.2  142/81  95  18  98%1L NC
Pain: L shoulder
Access: PIV
Gen: elderly frail female, tired appearing, intermittent
episodes with audible gurgling and accessory muscle use
HEENT: mm dry
Neck: prominent neck veins
CV: RRR, [**2-3**] SM USB
Back: severe scoliosis
Resp: [**Month (only) **] BS bases, +scattered crackles, no wheezing
Abd;  nontender, +BS
Ext; 1+ b/l LE edema, 1+ UE edema (new during this
hospitalization)
MS: L arm in sling
Neuro: A&OX3, grossly nonfocal, gait not assessed
Skin: scattered heel ulcers, L hip incision healing, sacral
stage II with dressing, L thigh bruising stable
psych: calm, pleasant
GU: foley back in place
.


Pertinent Results:
[**2187-1-22**] 11:45AM BLOOD WBC-9.7 RBC-4.04*# Hgb-11.8*# Hct-37.1
MCV-92 MCH-29.2 MCHC-31.9 RDW-15.9* Plt Ct-423#
[**2187-1-23**] 03:03AM BLOOD WBC-9.7 RBC-3.50* Hgb-10.7* Hct-32.2*
MCV-92 MCH-30.6 MCHC-33.2 RDW-15.3 Plt Ct-419
[**2187-1-24**] 07:50AM BLOOD WBC-9.9 RBC-3.34* Hgb-10.3* Hct-31.7*
MCV-95 MCH-30.9 MCHC-32.6 RDW-15.8* Plt Ct-425
[**2187-1-25**] 07:40AM BLOOD WBC-8.8 RBC-3.23* Hgb-10.1* Hct-30.6*
MCV-95 MCH-31.2 MCHC-32.9 RDW-15.5 Plt Ct-482*
[**2187-1-26**] 07:35AM BLOOD WBC-8.8 RBC-3.42* Hgb-10.6* Hct-32.8*
MCV-96 MCH-31.0 MCHC-32.4 RDW-15.6* Plt Ct-451*
[**2187-1-27**] 06:35AM BLOOD WBC-11.0 RBC-3.28* Hgb-10.5* Hct-31.8*
MCV-97 MCH-32.0 MCHC-33.0 RDW-15.7* Plt Ct-430
[**2187-1-28**] 07:42AM BLOOD WBC-12.2* RBC-3.60* Hgb-11.3* Hct-35.4*
MCV-98 MCH-31.3 MCHC-31.8 RDW-15.4 Plt Ct-534*
[**2187-1-29**] 07:17AM BLOOD WBC-13.0* RBC-3.21* Hgb-10.4* Hct-31.1*
MCV-97 MCH-32.4* MCHC-33.5 RDW-15.6* Plt Ct-476*
[**2187-1-30**] 08:00AM BLOOD WBC-12.4* RBC-3.40* Hgb-10.3* Hct-32.4*
MCV-95 MCH-30.4 MCHC-31.9 RDW-15.7* Plt Ct-476*
[**2187-1-31**] 06:55AM BLOOD WBC-10.3 RBC-3.30* Hgb-10.2* Hct-31.5*
MCV-96 MCH-30.9 MCHC-32.4 RDW-16.0* Plt Ct-455*
[**2187-2-1**] 04:05AM BLOOD WBC-12.3* RBC-3.23* Hgb-10.1* Hct-31.3*
MCV-97 MCH-31.3 MCHC-32.4 RDW-15.9* Plt Ct-405
[**2187-2-2**] 06:00AM BLOOD WBC-16.1* RBC-3.04* Hgb-9.6* Hct-29.0*
MCV-95 MCH-31.6 MCHC-33.1 RDW-16.2* Plt Ct-395
[**2187-2-3**] 05:39AM BLOOD WBC-21.6* RBC-2.55* Hgb-8.1* Hct-24.1*
MCV-95 MCH-31.7 MCHC-33.6 RDW-16.4* Plt Ct-339
[**2187-2-4**] 05:24AM BLOOD WBC-18.2* RBC-2.57* Hgb-8.1* Hct-25.1*
MCV-98 MCH-31.5 MCHC-32.3 RDW-16.2* Plt Ct-328
[**2187-2-5**] 05:23AM BLOOD WBC-13.7* RBC-2.65* Hgb-8.5* Hct-25.7*
MCV-97 MCH-32.0 MCHC-33.0 RDW-16.1* Plt Ct-326
[**2187-2-6**] 04:12AM BLOOD WBC-10.8 RBC-2.37* Hgb-7.6* Hct-23.0*
MCV-97 MCH-32.0 MCHC-33.0 RDW-16.1* Plt Ct-342
[**2187-2-7**] 05:08AM BLOOD WBC-7.8 RBC-2.81* Hgb-8.6* Hct-27.3*
MCV-97 MCH-30.6 MCHC-31.5 RDW-15.8* Plt Ct-391
[**2187-2-8**] 05:03AM BLOOD WBC-7.3 RBC-2.84* Hgb-8.9* Hct-27.6*
MCV-97 MCH-31.1 MCHC-32.0 RDW-15.9* Plt Ct-386
[**2187-2-9**] 05:45AM BLOOD WBC-7.8 RBC-2.68* Hgb-8.3* Hct-26.4*
MCV-99* MCH-31.2 MCHC-31.6 RDW-15.7* Plt Ct-364
[**2187-2-10**] 05:28AM BLOOD WBC-8.1 RBC-2.22* Hgb-7.0* Hct-21.9*
MCV-99* MCH-31.5 MCHC-32.0 RDW-16.0* Plt Ct-376
[**2187-2-10**] 05:33PM BLOOD Hct-30.8*#
[**2187-2-10**] 10:58PM BLOOD Hct-29.3*
[**2187-2-11**] 05:46AM BLOOD WBC-8.6 RBC-3.10*# Hgb-9.7*# Hct-29.8*
MCV-96 MCH-31.3 MCHC-32.6 RDW-16.9* Plt Ct-323
[**2187-2-12**] 06:00AM BLOOD WBC-8.6 RBC-3.25* Hgb-10.3* Hct-31.0*
MCV-95 MCH-31.8 MCHC-33.3 RDW-16.4* Plt Ct-368

[**2187-1-22**] 11:45AM BLOOD Glucose-202* UreaN-46* Creat-0.7 Na-137
K-4.4 Cl-101 HCO3-27 AnGap-13
[**2187-1-23**] 03:03AM BLOOD Glucose-165* UreaN-41* Creat-0.6 Na-135
K-4.0 Cl-98 HCO3-28 AnGap-13
[**2187-1-24**] 07:50AM BLOOD Glucose-95 UreaN-29* Creat-0.6 Na-138
K-3.5 Cl-101 HCO3-31 AnGap-10
[**2187-1-25**] 07:40AM BLOOD Glucose-186* UreaN-25* Creat-0.6 Na-138
K-3.8 Cl-103 HCO3-28 AnGap-11
[**2187-1-26**] 07:35AM BLOOD Glucose-140* UreaN-21* Creat-0.6 Na-138
K-4.4 Cl-103 HCO3-30 AnGap-9
[**2187-1-27**] 06:35AM BLOOD Glucose-113* UreaN-19 Creat-0.5 Na-136
K-5.2* Cl-101 HCO3-24 AnGap-16
[**2187-1-28**] 07:42AM BLOOD Glucose-143* UreaN-15 Creat-0.6 Na-139
K-4.6 Cl-101 HCO3-30 AnGap-13
[**2187-1-29**] 07:17AM BLOOD Glucose-157* UreaN-15 Creat-0.4 Na-136
K-4.2 Cl-97 HCO3-31 AnGap-12
[**2187-1-30**] 08:00AM BLOOD Glucose-160* UreaN-13 Creat-0.4 Na-137
K-3.9 Cl-98 HCO3-32 AnGap-11
[**2187-1-31**] 06:55AM BLOOD Glucose-147* UreaN-11 Creat-0.3* Na-137
K-3.8 Cl-98 HCO3-30 AnGap-13
[**2187-2-1**] 04:05AM BLOOD Glucose-132* UreaN-12 Creat-0.4 Na-138
K-3.5 Cl-98 HCO3-31 AnGap-13
[**2187-2-2**] 06:00AM BLOOD Glucose-163* UreaN-17 Creat-0.5 Na-138
K-3.6 Cl-99 HCO3-33* AnGap-10
[**2187-2-2**] 06:48PM BLOOD Glucose-725* UreaN-20 Creat-0.5 Na-132*
K-6.3* Cl-95* HCO3-30 AnGap-13
[**2187-2-2**] 09:35PM BLOOD Glucose-188* UreaN-21* Creat-0.5 Na-139
K-3.5 Cl-99 HCO3-33* AnGap-11
[**2187-2-3**] 05:39AM BLOOD Glucose-135* UreaN-23* Creat-0.4 Na-140
K-3.4 Cl-102 HCO3-32 AnGap-9
[**2187-2-3**] 05:33PM BLOOD Na-139 K-3.4 Cl-100
[**2187-2-4**] 05:24AM BLOOD Glucose-87 UreaN-29* Creat-0.3* Na-140
K-3.9 Cl-101 HCO3-33* AnGap-10
[**2187-2-5**] 05:23AM BLOOD Glucose-83 UreaN-32* Creat-0.5 Na-138
K-4.5 Cl-103 HCO3-32 AnGap-8
[**2187-2-6**] 04:12AM BLOOD Glucose-69* UreaN-33* Creat-0.4 Na-140
K-4.9 Cl-105 HCO3-31 AnGap-9
[**2187-2-7**] 05:08AM BLOOD Glucose-75 UreaN-37* Creat-0.4 Na-139
K-5.6* Cl-104 HCO3-29 AnGap-12
[**2187-2-8**] 05:03AM BLOOD Glucose-72 UreaN-37* Creat-0.4 Na-137
K-5.4* Cl-103 HCO3-29 AnGap-10
[**2187-2-9**] 05:45AM BLOOD Glucose-99 UreaN-36* Creat-0.4 Na-140
K-4.2 Cl-111* HCO3-25 AnGap-8
[**2187-2-10**] 05:28AM BLOOD Glucose-60* UreaN-44* Creat-0.5 Na-138
K-4.8 Cl-105 HCO3-31 AnGap-7*
[**2187-2-11**] 05:46AM BLOOD Glucose-121* UreaN-39* Creat-0.4 Na-139
K-4.6 Cl-105 HCO3-31 AnGap-8
[**2187-2-12**] 06:00AM BLOOD Glucose-160* UreaN-37* Creat-0.4 Na-138
K-4.8 Cl-103 HCO3-31 AnGap-9

as of [**2187-1-28**]
wbc 8->12s 83%N
HCT 31-32 stable (up today to 35 may be concentrated)
BUN/creat 16/0.6
trop 0.01->0.02->0.02
BNP 3661 no prior
albumin 2.8  LFTs wnl
lactate 1.6
urine legionella: neg
.
UA 0-2 wbc, +nitrite, many bacteria
UCx >100K pseudomonas with intermediate sensitivity to cipro,
[**Last Name (un) 36**] to ceftaz
.
Blood cx [**1-22**] X2 NTD
.
.
.
Imaging/results:
CXR [**1-22**]: large b/l pleural effusions not present on CXR [**1-14**]
.
CXR Pa/Lat [**1-24**] Large, right greater than left bilateral pleural
effusions associated with atelectasis and a very large hiatal
hernia are unchanged. The visualized upper lungs are well
aerated. Cardiac size cannot be evaluated.
.
CXR [**1-26**]: There is still evidence of a large hiatal hernia, and
the stomach is still distended with air-fluid levels unchanged
from prior. Large bilateral pleural effusions are unchanged. New
bilateral perihilar opacities are worrisome for aspiration.

.
CTA [**1-22**]
1. No evidence of pulmonary embolism or aortic dissection.
2. Large bilateral pleural effusions, which in conjunction with
large type III hiatal hernia resultants in collapse of the right
middle, right lower, and left lower lobe. The remaining aerated
lung displays no focal opacity to suggest underlying pneumonia.

3. Atherosclerotic disease involving the coronary tree and aorta
with minimal dilatation of the ascending aorta. Mass effect from
the posterior hiatal hernia displaces the heart anteriorly with
compression of the right atrium and right ventricle noted by the
sternum.
4. Thyroid goiter and probable benign simple right renal cyst
and hyperdense left renal cyst.
.
CT chest [**1-27**]-reviewed personally with radiologist
Large pleural effusions are present bilaterally, slightly larger
on
the right than the left. These effusions as well as a massive
hiatal hernia result in extensive atelectasis of the lower
lobes. Compression of [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] present. Undigested food in
stomach and now esophagus->high risk for aspiration. Aerated
parts of lungs w/o evidence of PNA or pulm edema but difficult
to exclude this underlying the areas of lung collapse.

CT [**2-10**] (C/A/P):
1. No definite evidence for active extravasation into the chest,
abdomen,
pelvis, or subcutaneous tissues.
2. Large bilateral pleural effusions.
3. Large right flank fluid collection which is incompletely
assessed but may represent a hematoma.
4. Interval decreased distention of large hiatal hernia. The
distal stomach is fixated with two PEG tubes. There is no
evidence for active extravasation into the abdomen.
5. Small volume of free intraperitoneal air likely related to
recent
post-operative status.
6. Nonobstructed small bowel loops within bilateral inguinal
hernias.
7. Hypodense right renal lesions, compatible with cysts.
8. Hypodense pancreatic head lesion, incompletely characterized,
may
represent cyst or dilated pancreatic duct side branch.
9. Multilevel lumbar body vertebral compression fractures, age
indeterminate. Status post ORIF of a left intertrochanteric
fracture with avulsion of the lesser trochanter. Osteopenia.

Echo [**1-16**] 70%EF, nl LA/RA

Echo [**1-23**]: 70%EF, extrinisic compression of LA by HH

Echo [**2-13**]: The left atrium is normal/small in size. The wall of
the left atrium appears to be compressed by an external
structure. Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>55%). Compared with
the prior study (images reviewed) of [**2187-1-29**], there may be
slightly less compression of the left atrium by an external
structure.


Brief Hospital Course:
Ms. [**Known lastname 96849**] is an 88-year old woman with h/o DM and recent L
humeral and L femur fracture s/p ORIF of her L femur ([**2187-1-16**]),
who was admitted from rehab for [**1-22**] for acute respiratory
distress and hypoxia. She was found to have bilateral pleural
effusions, as well as a large hiatal hernia which was
compressing her left atrium and likely contributing to her
pulmonary effusions. Over her hospital course, Ms. [**Known lastname 96849**] [**Last Name (Titles) 96850**]y developed aspiration PNA, pseudomonal UTI, and C.
difficile colitis. Each of these issues is addressed below.

##Hypoxia
The patient was admitted on [**1-22**] from her rehab facility with
increased RR and O2 saturations in the 80s. Her O2 requirement
on admission was 6L. CXR in the ED revealed bibasilar
infiltrates, and chest CT revealed bibasilar effusions and
collapse of the right middle, right lower, and left lower lung.
Her effusions were thought to be caused at least in part by
compression of her left atrium by her hiatal hernia, leading to
increased pressure in her pulmonary vasculature. Empiric
levofloxacin and vancomycin were started for pneumonia. No
evidence of pulmonary embolism was seen on CTA.

On [**1-23**], 2x 20 mg IV Lasix was given, leading to a diuresis of
1.5L and improvement in her hypoxia (O2 requirement from 6 to
3L). Vancomycin and levofloxacin were discontinued on [**1-23**]
because no clear evidence of PNA had been found. Between [**1-24**]
and [**2-1**], IV Lasix was used only intermittently because of
concern for her preload limitations caused by the hiatal hernia
compressing her left atrium (please see 'hiatal hernia' as
separate issue below).

On [**1-26**], CXR showed new perihilar opacities worrisome for
aspiration. IV flagyl was added to her ceftazidime (which she
was already taking for Pseudomonas UTI, discussed as separate
issue below) for empiric coverage of aspiration PNA. Her IV
flagyl and ceftazidime were continued for a 10 day course.

On [**2-2**], the patient's O2 requirement increased from 2L to 3L.
She received 2x 20 mg IV Lasix, to which she diuresed 1.3 L. On
[**2-3**], a thoracentesis was performed in her R pleural space, and
850 mL of straw-colored transudate was removed. Pleural fluid
analysis revealed a transudate, and cultures have not grown any
organisms to date. Diuresis with 1 or 2 20 mg doses of IV Lasix
per day was continued on [**3-18**] (TBB goal -500 cc), and by
[**2-8**], her oxygen requirement had been reduced to 0.5-1L.

On [**2-8**], the patient underwent endoscopic gastric pulldown with
double PEG placement (see management of hiatal hernia as
separate issue below), and her post-op O2 requirement was
initially 4L. Between [**2-8**] and [**2-12**], she was diuresed with 20 mg
doses of IV lasix to a TBB goal -500, and on [**2-12**], her O2
requirement was 0.5-1L.

On [**2-13**], the patient was transitioned from IV Lasix to 40 mg PO
Lasix [**Hospital1 **]. The patient's daily TBB was -250 to -500 L on this
dosage, and she was increased to 60 mg po Lasix [**Hospital1 **]. For rehab
planning, it is recommended that this dosage be weaned as
necessary (based on her O2 requirement, daily TBB, and clinical
volume status) so that she is not chronically using Lasix for
diuresis.

##Hiatal Hernia
Echocardiogram revealed a hiatal hernia compressing the L
atrium. Ejection fraction was 70%. On [**1-24**], NGT placement under
fluoroscopy was attempted but unsuccessful. IV IV Reglan was
begun on [**1-25**] in order to promote forward motility and gastric
emptying. The patient was made NPO with all non-essential PO
meds held, and on [**1-30**], a PICC line was placed for TPN. TPN was
started on [**2187-1-31**] and continued until [**2187-2-11**].

On [**2187-2-8**], the patient underwent laparoscopic gastric pulldown
and double PEG placement in order to anchor her stomach and
prevent reherniation/volvulus. On [**2187-2-9**], she was transitioned
to an oral diet of nectar thick liquids and pureed solids. On
[**2187-2-11**], she began getting tube feeds through one of her PEG
tubes (rate of 15 cc/hr to goal rate of 45 cc/hr). By [**2187-2-13**],
her tube feeds were at goal, and she was taking minimal PO's
(thick liquids, pureed solids, crushed pills).

Of note, her foley catheter was left in place because her
mobility was still quite limited at the time of discharge.
However, once she is able to progress in her rehabilitation and
move more easily, foley should be discontinued.

##Pseudomonal UTI
Patient was diagnosed with UTI on [**1-23**], and cultures grew
Pseudomonas sensitive to ceftazidime. A five day course of
ceftazidime was started on [**1-24**]. Ceftazidime was continued past
five days for concurrent empiric coverage of aspiration PNA (see
hypoxia section above).

##C. dificile colitis
On [**2-2**], the patient's WBC rose from 12.3 to 16.1, and on [**2-3**], it
rose further to 21.6. She was also having diarrhea ([**1-31**]
episodes/day) during this time. Stool specimen was newly
positive for C. difficile toxin on [**2-4**], and this was thought to
underlie her leukocytosis. PO liquid vancomycin was started on
[**2-4**]. On [**2-5**], her WBC was reduced to 13.7, and by [**2-6**], it had
decrased <10.

##Anemia
The patient had two episodes of HCT drops during her admission.
The first occurred on [**2-3**], when her HCT dropped from 29.0 to
24.1. CBC was immediately rechecked, and HCT rose back to 27.8
without intervention. This HCT drop was thought most likely due
to fluid shift, dilution from TPN, and/or lab error caused by
drawing the blood from her PICC line.

The pt's HCT stayed stable from [**2-4**] to [**2-9**], when it dropped
from 26.4 to 21.9 overnight. 1U of pRBCs were given, and her
post-transfusion HCT was 30.8 Because of her endoscopic surgery
on [**2-8**], there was concern for internal bleeding. CT scans were
taken of her abdomen, L thigh, and L humerus. There was no
active extravasation, but fluid collections representing seromas
vs. hematomas were seen in her R flank and L hip, likely caused
by her [**Month (only) 404**] fall and humeral/femoral fractures. In the
absence of obvious extravasation, the differential for her HCT
drop was fluid shift from her surgery or lab abnormalities
caused by her PICC line. Her large increase in HCT (21.9 to
30.8) with only 1U of pRBCs suggested that her HCT drop was not
caused by a true pathology.

##Rehabilitation from open reduction internal fixation of L
femur
The patient was followed by the orthopedic trauma team
throughout her stay, and per their recommendations,
weight-bearing as tolerated/passive range of motion exercises
were performed for her L femur and non-weight bearing/range of
motion as tolerated exercises for her L humerus. A four-week
course of Lovenox was continued for DVT prophylaxis. Lovenox was
continued because of her high risk of DVT (immobile, s/p
orthopedic and abdominal surgery, elderly). Tylenol 1g TID was
used for pain. IV Morphine 0.25 mg [**Hospital1 **] was started on [**2-4**] for
pain as well. Staples from her L thigh incision were removed on
[**2187-1-31**]. There was no evidence of hemarthrosis during her
admission.

Outpatient follow-up with Dr.[**Name8 (MD) 8091**] NP has been scheduled.

##Diabetes
The patient's home metformin was held, and she was treated with
insulin sliding scale, as well as supplemental insulin while
receiving her TPN from [**2187-1-31**] to [**2187-2-11**]. Once she transitioned
from TPN to tube feeds, she was being controlled only on her
insulin SS. She will be discharged on the sliding scale, while
holding her home meformin.

##Pressure ulcers
The patient had a sacral ulcer and scattered bilateral heel
ulcers on admission.  She received daily wound care with
elevation of both heels off the bed using boots. She was also
brought ouf of bed as tolerated in order to relieve pressure on
her ulcerated areas.

#Nutrition
The patient was on TPN from [**Date range (1) 66202**]. Thereafter, she was taking
limited PO diet (nectar thick liquids/pureed solids) and tube
feeds at a goal rate of 45 cc/hr.

##DVT Prophylaxis
Lovenox 40 mg sc daily was used for DVT prophylaxis.


Medications on Admission:
Enoxaparin 30 mg Subcutaneous QD for 4 weeks.
Ascorbic Acid 500 mg PO DAILY
B Complex Vitamins PO DAILY
Calcium Carbonate 500 mg PO DAILY
Cholecalciferol (Vitamin D3) 400 unit PO DAILY
Famotidine 20 mg PO BID
Docusate Sodium 100 mg PO BID
Senna 8.6 mg PO HS
Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain, fever.
Omega-3 Fatty Acids PO DAILY
Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation: hold for loose stool.


Discharge Medications:
1. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. B Complex Vitamins     Capsule Sig: One (1) Cap PO DAILY
(Daily).
5. Omega-3 Fatty Acids     Capsule Sig: One (1) Capsule PO BID
(2 times a day).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
9. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
11. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1)  Subcutaneous
DAILY (Daily).
12. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
13. Oxycodone 5 mg/5 mL Solution Sig: 2.5 mg PO BID (2 times a
day).
14. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): Day 1 of 14 day course was [**2187-2-4**]. Please continue
until [**2187-2-18**]. .
15. Famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day.

16. Insulin Lispro 100 unit/mL Solution Sig: Please follow
sliding scale  Subcutaneous ASDIR (AS DIRECTED): Please follow
insulin sliding scale.
17. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).


Discharge Disposition:
Home With Service

Facility:
[**Hospital3 2558**]

Discharge Diagnosis:
Large paraesophageal hernia causing left atrium compression s/p
gastric pulldown and PEG placement x2
Bilateral Pleural Effusions
Hypoxia
Clostridium difficile colitis
Pseudomonas aeruginosa UTI
Aspiration Pneumonia


Discharge Condition:
Stable on 0.5-1L oxygen.


Discharge Instructions:
You were admitted from your nursing home with shortness of
breath and low oxygen. You were found to have fluid around your
lungs which is new and was compressing your lungs. This is
secondary to your large hernia that was displacing your stomach
into your chest.

We treated your low oxygen by giving you a medication that helps
you urinate out excess body fluid. Your oxygen improved steadily
during your hospital stay. For your hernia, we initially stopped
feeding you by mouth and started you on IV nutrition. You then
underwent a surgery in which your stomach was pulled down closer
to its original position and anchored to your abdominal wall
using two tubes. Following surgery, your IV nutrition was
stopped, and you were fed both orally as well as through your
stomach tube.

In addition to your low oxygen level and your hernia, you also
developed infection of your lungs, urinary tract, and GI tract
(at different points during your admission). We treated each of
these infections with the appropriate antibiotics.

On admission, you were still recovering from your left arm and
left femur fracture. The orthopedics team followed you during
your admission, and we tried to get you out of bed as much as
possible in order to do weight-bearing exercises. You had some
pressure sores and were seen by wound care.

Please take all your medications as written. The following
changes were made to your medications:

NEW:
1) Albuterol/Ipratropium inhalors as needed for shortness of
breath (you do not need to have this at home if it does not help
you)
2) Vancomycin 125mg orally four times a day (q6 hours) until
[**2187-2-18**]
3) Subcutaneous insulin for your diabetes
4) Lasix 60 mg two times a day to prevent fluid in your lungs
5) Oxycodone 2.5 mg twice a day as needed for pain.
CHANGES:
Please continue enoxaparin 40mg sub-cutaneous once a day until
you talk to your orthopedist.
Calcium carbonate increased to 500mg three times a day
Vitamin D increased to 800 units daily
We stopped your metformin during your admission and controlled
your diabetes with insulin

Followup Instructions:
1) Primary care doctor: Dr. [**Last Name (STitle) 60967**] [**Telephone/Fax (1) 2573**], [**2187-2-19**], 2:45 pm,
[**Hospital1 **]

2) Hernia surgery: Dr. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD
Phone:[**Telephone/Fax (1) 2359**] Date/Time:[**2187-2-22**] 11:45

3) Orthopedics: Appointment with [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP.
[**2187-3-8**], 9:20 am, [**Location (un) 830**] [**Hospital Ward Name 23**] Bldg [**Location (un) **]
{'Diaphragmatic hernia with obstruction,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Unspecified pleural effusion,Urinary tract infection, site not specified,Intestinal infection due to Clostridium difficile,Hypoxemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Anemia, unspecified,Other and unspecified hyperlipidemia,Osteoporosis, unspecified,Spinal stenosis, lumbar region, without neurogenic claudication,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Pressure ulcer, lower back'}


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: Shortness of Breath, hypoxia

PRESENT ILLNESS: Pt is an 88 yo woman with PMHx sig. for DM2, dyslipidemia, and
recent admission for L comminuted, intertrochanteric left
femoral neck fracture, s/p open reduction internal fixation, and
L proximal comminuted and displaced fracture of the left humeral
neck fx treated with a sling ([**Date range (1) 96848**]) after fall was sent
from rehab with respiratory distress.  Patient was found to be
in respiratory distress this AM with wheezing, using accessory
muscles, poor air exachange, and tachypenia.  Her O2 sat was in
the high 80s, improved to 100% on NRB.  Other VS were 140/90,
120, 30, temp 98.5.  After a nebulizer treatment, her RR came
down to 24.  She also complained of diaphoresis.  She denied any
chest pain.
.
In the emergency department, initial vitals were:  98.5 110
140/90 34 98 on NRB.  She had a CXR that showed bilateral
pleural effusions, ?infiltrate.  Pt received levofloxacin 750
mg, vanc, and nebulizers.  UCx and BCx were obtained.  Pt is
currently feeling a little better, now satting 94% on 6L NC.
.
Currently, she feels uncomfortable, but cannot specify why.  She
denies any SOB and does not appear in respiratory distress while
lying supine.  She denies any cough, chest pain, nausea,
vomiting, abdominal pain, dysuria, and fever/chills.  She had
some rhinorrhea about 2 weeks ago.
.

MEDICAL HISTORY: - Type 2 Diabetes Mellitus
- Dyslipidemia
- Anxiety
- Osteoporosis
- HOH
- Diverticulosis
- Aortic Insufficiency, 1+
- Cystic lesion of pancreas felt to be benign
- Spinal Stenosis
- large HH into chest

MEDICATION ON ADMISSION: Enoxaparin 30 mg Subcutaneous QD for 4 weeks.
Ascorbic Acid 500 mg PO DAILY
B Complex Vitamins PO DAILY
Calcium Carbonate 500 mg PO DAILY
Cholecalciferol (Vitamin D3) 400 unit PO DAILY
Famotidine 20 mg PO BID
Docusate Sodium 100 mg PO BID
Senna 8.6 mg PO HS
Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain, fever.
Omega-3 Fatty Acids PO DAILY
Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation: hold for loose stool.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: GENERAL: Pleasant, well appearing female in NAD.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PER/EOMI. MM dry. OP clear.
Neck:  Supple, No LAD, No thyromegaly.  + JVD.
CARDIAC: Occasionally irregular rhythm, tachycardic, normal S1,
S2. Systolic murmur best at LLSB and apex.
LUNGS: Decreased breath sounds at the bases bilaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 1+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes, ecchymoses.  Stage II heel ulcers bilaterally.
Surgical incision over L hip c/d/i.
NEURO: A&Ox3. Appropriate.  CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout except proximal
LLE and LUE secondary to pain. Gait assessment deferred.
PSYCH: Listens and responds to questions appropriately, pleasant

FAMILY HISTORY: Mother with throat cancer.

SOCIAL HISTORY: Patient was born in Poland and grew up in [**Country 2784**].  Prior to her
fall, she lived alone in a private apartment and visited the
[**Location (un) **] Senior Center for all 3 meals.  She denies any
tobacco/etoh. 

### Response:
{'Diaphragmatic hernia with obstruction,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Unspecified pleural effusion,Urinary tract infection, site not specified,Intestinal infection due to Clostridium difficile,Hypoxemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Anemia, unspecified,Other and unspecified hyperlipidemia,Osteoporosis, unspecified,Spinal stenosis, lumbar region, without neurogenic claudication,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Pressure ulcer, lower back'}
