CHIEF COMPLAINT: Respiratory Failure Requiring Intubation

PRESENT ILLNESS: 54-year-old woman with a history of ILD, COPD, diastolic CHF
(EF 50% in [**2-/2199**]), DM2, PVD s/p R AKA, chronic pancreatitis,
alcoholic cirrhosis who was transferred from OSH with pneumonia
and was intubated enroute because of desaturation and agitation.

MEDICAL HISTORY: * Diastolic CHF: EF 50% in [**2-/2199**]
* COPD: on nebs and inhaled steroids; s/p temp trach in [**3-/2199**]
after intubation for respiratory failure
* DM2: insulin-dependent
* respiratory bronchiolitis-ILD: on VATS biopsy, now on
intermittent supplemental oxygen
* PVD: s/p R AKA [**11/2198**], s/p rt. ileo-fem bpg [**12-10**] complicated
by
lymphocele s/p drainage [**2198-1-11**],rt. ililac/femoral thrombectomy
[**4-10**],rt. ileo-fem graft thrombectomy with bovine patch
angioplasty [**2196**],rt. ileofem bpg with PTFE [**2195**],
* chronic pancreatitis s/p Puestow,J-tube,ccy1998,Expl lap [**2189**]

MEDICATION ON ADMISSION: warfarin 6 mg qday
senna prn
vitamin D
lactulose 30 mL qday
artificial tears both eyes tid
floranex [**Hospital1 **]
viokase tid
humibid 600 mg [**Hospital1 **]
Advair 250/50 1 inh [**Hospital1 **]
tums 500 mg [**Hospital1 **]
phoslo 667 mg tid
spiriva 18 mcg 1 inh qday
omeprazole 40 mg qday
alb nebs [**Hospital1 **] and prn
lidoderm to AKA site qday
pepto-bismol prn
morphine 45 mg PO q6h prn
MoM prn
dulcolax prn
mucomyst via nebs prn
acetaminophen prn
fleet enema prn
glargine 15 u qhs
mirtazapine 22.76 mg qhs
trazodone 150 qam
bumex 20 mg qday
aldactone 12.5 mg qday

ALLERGIES: Penicillins

PHYSICAL EXAM: On admission:
Tmax: 37.3 ??????C (99.1 ??????F)
Tcurrent: 37.3 ??????C (99.1 ??????F)
HR: 96 (94 - 96) bpm
BP: 122/58(73) {122/58(73) - 144/63(78)} mmHg
RR: 21 (15 - 21) insp/min
SpO2: 96%
Heart rhythm: SR (Sinus Rhythm)
GEN: Middle-aged woman, intubated, withdrawing to painful
stimuli
HEENT: PERRL, sclera anicteric, ET tube in place, MM dry,
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2, JVP flat
PULM: coarse BS bilaterally
ABD: Soft, ND, +BS, no HSM, no masses
EXT: R AKA, L leg with chronic statis changes, weak PD pulse
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Currently at rehab. Married and lives at home generally with her
husband, no children. Previously worked as a counselor in drug
and alcohol programs. She quit smoking approximately [**12/2198**] with
an over 80-pack year history of smoking. She quit drinking
alcohol 23 years ago. She has no known exposure to tuberculosis.
She was cleaning her husband's clothes during the time that he
was working with asbestos for a three-month period.
Methicillin resistant pneumonia due to Staphylococcus aureus,Acute respiratory failure,Chronic obstructive asthma with (acute) exacerbation,Chronic pancreatitis,Intestinal infection due to Clostridium difficile,Other primary cardiomyopathies,Acute kidney failure, unspecified,Acute on chronic diastolic heart failure,Alcoholic cirrhosis of liver,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Esophageal reflux,Personal history of malignant neoplasm of cervix uteri,Contact with or exposure to tuberculosis,Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus,Mitral valve disorders,Postinflammatory pulmonary fibrosis,Anemia, unspecified,Atherosclerosis of native arteries of the extremities, unspecified,Other and unspecified alcohol dependence, continuous
Meth res pneu d/t Staph,Acute respiratry failure,Ch obst asth w (ac) exac,Chronic pancreatitis,Int inf clstrdium dfcile,Prim cardiomyopathy NEC,Acute kidney failure NOS,Ac on chr diast hrt fail,Alcohol cirrhosis liver,DMII wo cmp nt st uncntr,Esophageal reflux,Hx-cervical malignancy,Tuberculosis contact,Meth resis Staph carrier,Mitral valve disorder,Postinflam pulm fibrosis,Anemia NOS,Athscl extrm ntv art NOS,Alcoh dep NEC/NOS-contin
Admission Date:  [**2199-10-6**]              Discharge Date:   [**2199-10-14**]

Date of Birth:  [**2144-10-24**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 8487**]
Chief Complaint:
Respiratory Failure Requiring Intubation

Major Surgical or Invasive Procedure:
Intubation- enroute to hospital [**2199-10-6**]
Self extubation and re-intubation [**2199-10-8**]
Extubation [**2199-10-12**]
PICC line placement [**2199-10-9**]
s/p Thoracentesis [**2199-10-11**]


History of Present Illness:
 54-year-old woman with a history of ILD, COPD, diastolic CHF
(EF 50% in [**2-/2199**]), DM2, PVD s/p R AKA, chronic pancreatitis,
alcoholic cirrhosis who was transferred from OSH with pneumonia
and was intubated enroute because of desaturation and agitation.

.
For the past few days the patient has experienced subjective
fevers, chills, chest tightness, and orthopnea. She presented to
[**Hospital3 **] today, was diagnosed with pneumonia and CHF
exacerbation (BNP > 35,000). She was started on moxifloxacin and
given furosemide 40 mg IV x 1 for presumed CHF exacerbation as
well as IV steroids. Reportedly her respiratory status improved
after the furosemide. There was some mentioning of her being
started on a heparin gtt for presumed PE in the [**Location (un) **] chart
but there was no documentation of her arriving to [**Hospital1 **] on heparin
gtt. She was deemed too sick for [**Location (un) **] and was transferred to
[**Hospital 18**] medical floor. During the ambulance ride, she desated to
80% on NRB, became agitated, and was intubated.
.
On arrival to [**Hospital1 18**] ED, T 99.1, HR 98, BP 128/66, RR 16,
intubated. ABG was 7.41/50/105. Exam revealed bibasilar
crackles. CXR was c/w RLL pna and also ?pulmonary edema. She
received vanco, levo. Was admitted to [**Hospital Unit Name 153**] for further
management.
.
ROS: not obtained as patient was intubated


Past Medical History:
* Diastolic CHF: EF 50% in [**2-/2199**]
* COPD: on nebs and inhaled steroids; s/p temp trach in [**3-/2199**]
after intubation for respiratory failure
* DM2: insulin-dependent
* respiratory bronchiolitis-ILD: on VATS biopsy, now on
intermittent supplemental oxygen
* PVD: s/p R AKA [**11/2198**], s/p rt. ileo-fem bpg [**12-10**] complicated
by
lymphocele s/p drainage [**2198-1-11**],rt. ililac/femoral thrombectomy
[**4-10**],rt. ileo-fem graft thrombectomy with bovine patch
angioplasty [**2196**],rt. ileofem bpg with PTFE [**2195**],
* chronic pancreatitis s/p Puestow,J-tube,ccy1998,Expl lap [**2189**]

* EtOH cirrhosis
* L breast cyst s/p excision
* GERD
* PUD
* esophagitis with stricture
* small bowel obstruction
* PV,SMV thrombosis; h/o DVT/PE
* cervical ca s/p multiple d/c's
* entero-colonic fistula
* s/p cholecystectomy


Social History:
Currently at rehab. Married and lives at home generally with her
husband, no children. Previously worked as a counselor in drug
and alcohol programs. She quit smoking approximately [**12/2198**] with
an over 80-pack year history of smoking. She quit drinking
alcohol 23 years ago. She has no known exposure to tuberculosis.
She was cleaning her husband's clothes during the time that he
was working with asbestos for a three-month period.

Family History:
Noncontributory

Physical Exam:
On admission:
Tmax: 37.3 ??????C (99.1 ??????F)
Tcurrent: 37.3 ??????C (99.1 ??????F)
HR: 96 (94 - 96) bpm
BP: 122/58(73) {122/58(73) - 144/63(78)} mmHg
RR: 21 (15 - 21) insp/min
SpO2: 96%
Heart rhythm: SR (Sinus Rhythm)
GEN: Middle-aged woman, intubated, withdrawing to painful
stimuli
HEENT: PERRL, sclera anicteric, ET tube in place, MM dry,
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2, JVP flat
PULM: coarse BS bilaterally
ABD: Soft, ND, +BS, no HSM, no masses
EXT: R AKA, L leg with chronic statis changes, weak PD pulse
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.



Pertinent Results:
Admission Labs:
[**2199-10-6**] 08:20PM URINE  RBC-21-50* WBC-[**2-6**] BACTERIA-RARE
YEAST-NONE EPI-0-2
[**2199-10-6**] 08:20PM URINE  BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-100 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2199-10-6**] 08:20PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2199-10-6**] 08:20PM   FIBRINOGE-487* D-DIMER-1641*
[**2199-10-6**] 08:20PM   PLT COUNT-303
[**2199-10-6**] 08:20PM   PT-22.9* PTT-36.3* INR(PT)-2.2*
[**2199-10-6**] 08:20PM   WBC-6.3 RBC-2.50* HGB-7.6* HCT-24.4* MCV-97
MCH-30.5 MCHC-31.3 RDW-17.5*
[**2199-10-6**] 08:20PM URINE  bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2199-10-6**] 08:20PM   ASA-4 ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2199-10-6**] 08:20PM   cTropnT-0.03*
[**2199-10-6**] 08:20PM   cTropnT-0.03*
[**2199-10-6**] 08:20PM   UREA N-61* CREAT-1.4*
[**2199-10-6**] 08:36PM   GLUCOSE-261* LACTATE-1.0
[**2199-10-6**] 08:36PM   TYPE-ART PO2-105 PCO2-50* PH-7.41 TOTAL
CO2-33* BASE XS-5
[**2199-10-6**] 08:42PM   GLUCOSE-265* LACTATE-1.1 NA+-144 K+-4.8
CL--97* TCO2-30
.
Pertinent Micro:
RESPIRATORY CULTURE (Final [**2199-10-10**]):
      SPARSE GROWTH OROPHARYNGEAL FLORA.
      STAPH AUREUS COAG +.    SPARSE GROWTH.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations.

         Rifampin should not be used alone for therapy.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_____________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------   =>8 R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
PENICILLIN G---------- =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------     2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------   <=1 S
.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2199-10-13**]):
      REPORTED BY PHONE TO [**First Name5 (NamePattern1) 1037**] [**Last Name (NamePattern1) 63910**] [**2199-10-13**] @1:40 PM.
      CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
           (Reference Range-Negative).
.
CXR: [**2199-10-13**]:
HISTORY: Thoracentesis.
One portable view. Comparison with [**2199-10-11**]. Diffuse bilateral
interstitial
infiltrates and a small right pleural effusion persist.
Loculated pleural
fluid or pleural thickening is again noted on the left.
Mediastinal structures are unchanged. The patient has been
extubated. A PICC line remains in place.
IMPRESSION: No significant change post extubation.
.
Discharge labs:

[**2199-10-14**] 05:00AM BLOOD WBC-9.5 RBC-2.72* Hgb-8.3* Hct-25.7*
MCV-95 MCH-30.6 MCHC-32.3 RDW-17.2* Plt Ct-212
[**2199-10-13**] 04:47AM BLOOD Neuts-90.2* Lymphs-4.9* Monos-3.3 Eos-1.6
Baso-0.1
[**2199-10-14**] 05:00AM BLOOD PT-19.7* PTT-55.1* INR(PT)-1.8*
[**2199-10-14**] 05:00AM BLOOD Glucose-266* UreaN-36* Creat-1.0 Na-140
K-4.2 Cl-106 HCO3-28 AnGap-10
[**2199-10-13**] 10:42PM BLOOD CK(CPK)-54
[**2199-10-11**] 05:05AM BLOOD ALT-17 AST-17 LD(LDH)-299* AlkPhos-263*
TotBili-0.2
[**2199-10-13**] 10:42PM BLOOD CK-MB-6 cTropnT-0.02*
[**2199-10-9**] 04:00AM BLOOD proBNP-[**Numeric Identifier 63911**]*
[**2199-10-14**] 05:00AM BLOOD Calcium-6.8* Phos-3.2 Mg-2.4
[**2199-10-7**] 06:40AM BLOOD calTIBC-260 Ferritn-885* TRF-200
[**2199-10-7**] 06:40AM BLOOD Triglyc-78 HDL-48 CHOL/HD-2.3 LDLcalc-45
[**2199-10-14**] 05:00AM BLOOD Vanco-28.9*

Brief Hospital Course:
Ms. [**Known lastname 7168**] is a 54 yo WF w PMHx of MSSA pna/bacteremia earlier
in [**2198**], ILD, COPD, diastolic CHF who presents with hypoxic
respiratory failure and is found to have MRSA pna and new
cardiomyopathy.

1. Hypotension/hypothermia:  noted on arrival from ICU to floor
on [**2199-10-13**]. Pt asymptomatic and had recently recieved both
Metoprolol and Lisinopril in quick succession. Pt was bolused 1L
and SBP quickly went from 80's to 120's.  BP remains stable at
130's/50's at discharge.

2. MRSA Pna - Has hx of MSSA pna earlier in [**2198**] which required
multiple hospitalizations and intubations. Now presented with
MRSA pna requiring intubation from [**10-6**] to [**10-12**]. Pt initially
started on broad spectrum abx with Vanc (day 1= [**10-6**]) but then
narrowed following MRSA in sputum. Pt to finish full 14 day
course Vanco [**10-20**]. Vancomycin was dosed intermittently [**1-5**]
fluctuation renal function causing fluctuating vanco levels.
Vanco is currently being dosed 1000mg for daily vanco level <20
(this is approx QOD). Last dose was [**2199-10-13**]. PICC in place. Pt
will follow up with pulmonary on [**10-30**].

3. New cardiomyopathy - [**Month/Year (2) **] in [**2-9**] showed EF of 50-55% w
mild-mod MR. [**Name14 (STitle) **] this admission shows EF of 30%, mod-severe MR
and TR. Pt was ruled out for MI w serial CEs on admission. Has
no diagnosed CAD but has high risk factors for CAD (Peripheral
arterial disease and DM). Continue with ASA, metoprolol and
lisinopril. Unclear why pt was not on statin at admission but
given PAD lipitor was added [**10-13**]. AST/ALT [**2199-10-11**] was wnl. Pt
was diuresed PRN with 100mg Lasix IV. She is not requiring
standing lasix at discharge.

4. Hx of COPD/ILD - On home oxygen at 3Liters NC at baseline. At
discharge, on 3L NC. Pt given solumedrol 125mg IV Q6 initially
in ICU for COPD exacerbation, which was quickly tapered.  At
discharge, pt to recieve 20mg Predx 4 days then 10mg for 4 days
then to finsih. Continued Advair, spiriva, albuterol.

5. T2DM - On lantus 14 units QHS and Humalog SS.

6. ARF - Cr 1.4 on admission, improved w fluids down to 0.8.
IVFS stopped given CHF. At discharge, Cr 1.0 likely [**1-5**]
diuresis.

7. Hx of multiple venous and arterial clots on chronic
anticoagulation - In ICU, pt was put on heparin gtt which was
stopped prior to discharge on [**10-14**]. Coumadin was restarted
[**10-13**]. INR should be checked daily at rehab until therapeutic.

8. Cdiff colitis - [**10-12**] stool Cdiff +, started on flagyl [**10-13**],
will need a 14 day course and re-eval.

9. Anemia - Hct 25 on discharge and stable. Iron panel
consistent with anemia of chronic disease. Of note, pt has had
an outpt EGD and Colonoscopy at [**Hospital1 **] end of [**Month (only) **] which only
showed gastritis and benign polyps.

10. Hx of chronic pancreatitis - Continued viokase.

11. Abnormal CT scan finding - spiculated nodule noted on [**10-10**]
chest CT in LLL. Repeat CT in 6 weeks is recommended. PCP
[**Name Initial (PRE) **]/fax sent but husband tells me that the old PCP has
retired. Appt is set up at [**Hospital1 18**] in [**Location (un) **] for [**10-23**]. Pt will
start with new PCP in [**Hospital1 18**] on [**2200-1-3**].

12. Hx of ETOH cirrhosis - LFTS nl here. Ascites noted on CT
chest 11/6likely [**1-5**] hx of ETOH cirrhosis but pt not having abd
pain, afebrile  for several days prior to discharge.

13. Hx of gastritis/gerd - recent EGD w/o ulcers, only
gastritis. Continued PPI.

Medications on Admission:
warfarin 6 mg qday
senna prn
vitamin D
lactulose 30 mL qday
artificial tears both eyes tid
floranex [**Hospital1 **]
viokase tid
humibid 600 mg [**Hospital1 **]
Advair 250/50 1 inh [**Hospital1 **]
tums 500 mg [**Hospital1 **]
phoslo 667 mg tid
spiriva 18 mcg 1 inh qday
omeprazole 40 mg qday
alb nebs [**Hospital1 **] and prn
lidoderm to AKA site qday
pepto-bismol prn
morphine 45 mg PO q6h prn
MoM prn
dulcolax prn
mucomyst via nebs prn
acetaminophen prn
fleet enema prn
glargine 15 u qhs
mirtazapine 22.76 mg qhs
trazodone 150 qam
bumex 20 mg qday
aldactone 12.5 mg qday

Discharge Medications:
1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
[**12-5**] Caps Inhalation DAILY (Daily).
2. Amylase-Lipase-Protease 30,000-8,000- 30,000 unit Tablet Sig:
One (1) Tablet PO TID (3 times a day).
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QDAY ().
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
DAILY (Daily) as needed.
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) 10 ml PO BID
(2 times a day): Hold for diarrhea.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
11. Vancomycin 1000 mg IV DAILY:PRN vanco level <20
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed.
14. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
15. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): 1 tab daily for 4 days then half tab daily for 4 days
then stop. .
17. Morphine 10 mg/5 mL Solution Sig: Five (5) ml PO Q6H (every
6 hours) as needed.
18. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
19. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
20. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours): 14 day course to finish [**2199-10-27**].
21. Insulin Glargine 100 unit/mL Solution Sig: Fourteen (14)
units Subcutaneous once a day.
22. Humalog 100 unit/mL Solution Sig: One (1) sliding scale
Subcutaneous three times a day: see attached sliding scale.
23. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
inh Inhalation twice a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 4860**] - [**Location (un) 4310**]

Discharge Diagnosis:
Primary Diagnosis:
PNA
Secondary Diagnoses:
C Diff colitis
ILD
COPD
PVD s/p right AKA
CHF
DM type 2
Chronic Pancreatitis
GERD


Discharge Condition:
Stable on home O2 requirement of 3L NC


Discharge Instructions:
You were admitted after you had difficulty breathing. You were
intubated on  your way here on [**2199-10-6**] because of this. Here,
you briefly pulled out your intubation tube on [**10-8**] after which
it was quickly replaced. On the 7th, you had fluid removed from
your lung space which seemed to help you breathe better. On the
8th, you were extubated and have been doing well ever since on
3L oxygen by nasal canulla. On the 9th, you were transferred to
the floor briefly but then brought back to the ICU with low
blood pressure. You have been stable here since that time. We
think the underlying causes of your difficulty breathing include
your congestive heart failure, COPD and interstitial lung
disease as well as a MRSA pneumonia and fluid accumulation in
your lung space.
.
You are being discharged on the attached medications. Please
take all your medications as directed.
.
Please keep all your follow up appointments as below.
.
If you have worstening shortness of breath, chest pain, fever,
cough, pain with urination, vomitting or any other concerning
symptoms, please call your doctor or return to the emergency
room.

Followup Instructions:
Please follow up with Pulmonary Medicine with Dr. [**Last Name (STitle) 4507**] on Wed
[**10-30**] at 9:40am. This is located in the [**Hospital Ward Name 23**] Building, [**Location (un) **] in the Medical Specialty Office. If you need to
reschedule, please call([**Telephone/Fax (1) 63912**].
.
Please follow up at your current primary care office, Dr.
[**Last Name (STitle) **], at [**Hospital1 18**] in [**Location (un) **] on [**10-23**] at 12:00 noon. If you
need to reschedule, please call [**Telephone/Fax (1) 9556**].

You will meet your new primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], at
[**Hospital3 **] in the [**Location (un) 448**] of the [**Hospital Ward Name 23**] building
at [**Hospital1 18**] on [**1-2**] at 9:40 am. If you cannot for any reason make
this appointment, you must call [**Telephone/Fax (1) 1247**] to reschedule.



Completed by:[**2199-10-14**]
{'Methicillin resistant pneumonia due to Staphylococcus aureus,Acute respiratory failure,Chronic obstructive asthma with (acute) exacerbation,Chronic pancreatitis,Intestinal infection due to Clostridium difficile,Other primary cardiomyopathies,Acute kidney failure, unspecified,Acute on chronic diastolic heart failure,Alcoholic cirrhosis of liver,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Esophageal reflux,Personal history of malignant neoplasm of cervix uteri,Contact with or exposure to tuberculosis,Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus,Mitral valve disorders,Postinflammatory pulmonary fibrosis,Anemia, unspecified,Atherosclerosis of native arteries of the extremities, unspecified,Other and unspecified alcohol dependence, continuous'}


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: Respiratory Failure Requiring Intubation

PRESENT ILLNESS: 54-year-old woman with a history of ILD, COPD, diastolic CHF
(EF 50% in [**2-/2199**]), DM2, PVD s/p R AKA, chronic pancreatitis,
alcoholic cirrhosis who was transferred from OSH with pneumonia
and was intubated enroute because of desaturation and agitation.

MEDICAL HISTORY: * Diastolic CHF: EF 50% in [**2-/2199**]
* COPD: on nebs and inhaled steroids; s/p temp trach in [**3-/2199**]
after intubation for respiratory failure
* DM2: insulin-dependent
* respiratory bronchiolitis-ILD: on VATS biopsy, now on
intermittent supplemental oxygen
* PVD: s/p R AKA [**11/2198**], s/p rt. ileo-fem bpg [**12-10**] complicated
by
lymphocele s/p drainage [**2198-1-11**],rt. ililac/femoral thrombectomy
[**4-10**],rt. ileo-fem graft thrombectomy with bovine patch
angioplasty [**2196**],rt. ileofem bpg with PTFE [**2195**],
* chronic pancreatitis s/p Puestow,J-tube,ccy1998,Expl lap [**2189**]

MEDICATION ON ADMISSION: warfarin 6 mg qday
senna prn
vitamin D
lactulose 30 mL qday
artificial tears both eyes tid
floranex [**Hospital1 **]
viokase tid
humibid 600 mg [**Hospital1 **]
Advair 250/50 1 inh [**Hospital1 **]
tums 500 mg [**Hospital1 **]
phoslo 667 mg tid
spiriva 18 mcg 1 inh qday
omeprazole 40 mg qday
alb nebs [**Hospital1 **] and prn
lidoderm to AKA site qday
pepto-bismol prn
morphine 45 mg PO q6h prn
MoM prn
dulcolax prn
mucomyst via nebs prn
acetaminophen prn
fleet enema prn
glargine 15 u qhs
mirtazapine 22.76 mg qhs
trazodone 150 qam
bumex 20 mg qday
aldactone 12.5 mg qday

ALLERGIES: Penicillins

PHYSICAL EXAM: On admission:
Tmax: 37.3 ??????C (99.1 ??????F)
Tcurrent: 37.3 ??????C (99.1 ??????F)
HR: 96 (94 - 96) bpm
BP: 122/58(73) {122/58(73) - 144/63(78)} mmHg
RR: 21 (15 - 21) insp/min
SpO2: 96%
Heart rhythm: SR (Sinus Rhythm)
GEN: Middle-aged woman, intubated, withdrawing to painful
stimuli
HEENT: PERRL, sclera anicteric, ET tube in place, MM dry,
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2, JVP flat
PULM: coarse BS bilaterally
ABD: Soft, ND, +BS, no HSM, no masses
EXT: R AKA, L leg with chronic statis changes, weak PD pulse
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Currently at rehab. Married and lives at home generally with her
husband, no children. Previously worked as a counselor in drug
and alcohol programs. She quit smoking approximately [**12/2198**] with
an over 80-pack year history of smoking. She quit drinking
alcohol 23 years ago. She has no known exposure to tuberculosis.
She was cleaning her husband's clothes during the time that he
was working with asbestos for a three-month period. 

### Response:
{'Methicillin resistant pneumonia due to Staphylococcus aureus,Acute respiratory failure,Chronic obstructive asthma with (acute) exacerbation,Chronic pancreatitis,Intestinal infection due to Clostridium difficile,Other primary cardiomyopathies,Acute kidney failure, unspecified,Acute on chronic diastolic heart failure,Alcoholic cirrhosis of liver,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Esophageal reflux,Personal history of malignant neoplasm of cervix uteri,Contact with or exposure to tuberculosis,Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus,Mitral valve disorders,Postinflammatory pulmonary fibrosis,Anemia, unspecified,Atherosclerosis of native arteries of the extremities, unspecified,Other and unspecified alcohol dependence, continuous'}
