CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is an 82 year old
male with a past medical history of coronary artery disease
status post coronary artery bypass graft in [**2085**],
hypertension and diabetes mellitus type 2, found in [**Hospital1 6687**]
Bay on [**2103-8-25**], unresponsive, floating in the water
supine, motionless.  The patient was spotted by lifeguards
who pulled him from the water and initiated CPR.  An AED
Device was attached; the patient was noted to be in
ventricular fibrillation and underwent defibrillation times
two.  The patient was presumed to have ventricular
fibrillation arrest and was shocked into third degree AV
block with slow ventricular escape beats.  He was placed on
external transcutaneous pacing.  He remained hypotensive,
unresponsive, hypothermic, with a core body temperature of
94.0 F.

MEDICAL HISTORY: 1.  Coronary artery disease status post coronary artery
bypass graft in [**2085**].
2.  Hypertension.
3.  Diabetes mellitus type 2.
4.  Status post hip replacement.
5.  Status post total knee replacement.

MEDICATION ON ADMISSION: 

ALLERGIES: The patient with no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: On initial arrival, the patient was [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) **] without any identification; however, on hospital day
number two, his wife was located and notified.  She travelled
to [**Hospital1 69**] from the patient's
home in Tenafly, [**State 760**].  The patient and his wife have
been married for quite some years.  He has two grown
children.  The patient's wife serves as his durable Power of
Attorney and Health Care Proxy.
Ventricular fibrillation,Hyperosmolality and/or hypernatremia,Anoxic brain damage,Streptococcal septicemia,Acute kidney failure with lesion of tubular necrosis,Drowning and nonfatal submersion,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled
Ventricular fibrillation,Hyperosmolality,Anoxic brain damage,Streptococcal septicemia,Ac kidny fail, tubr necr,Drowning/nonfatal submer,DMII wo cmp nt st uncntr
Admission Date:  [**2103-8-25**]       Discharge Date:  [**2103-9-3**]


Service:  CCU

HISTORY OF PRESENT ILLNESS:   The patient is an 82 year old
male with a past medical history of coronary artery disease
status post coronary artery bypass graft in [**2085**],
hypertension and diabetes mellitus type 2, found in [**Hospital1 6687**]
Bay on [**2103-8-25**], unresponsive, floating in the water
supine, motionless.  The patient was spotted by lifeguards
who pulled him from the water and initiated CPR.  An AED
Device was attached; the patient was noted to be in
ventricular fibrillation and underwent defibrillation times
two.  The patient was presumed to have ventricular
fibrillation arrest and was shocked into third degree AV
block with slow ventricular escape beats.  He was placed on
external transcutaneous pacing.  He remained hypotensive,
unresponsive, hypothermic, with a core body temperature of
94.0 F.

He was taken to [**Hospital3 22439**] where he was intubated and
received epinephrine times five and one dose of atropine.
Due to an episode of hypotension, he transiently required
dopamine.  Dopamine was weaned down as the patient's blood
pressure stabilized with external pacing.

While at [**Hospital3 22439**], he required another
defibrillation.  He was started on a lidocaine drip and
received a right subclavian central venous line.  He was then
transferred on [**2103-8-25**] to [**Hospital1 188**] via [**Location (un) **].  On arrival, temperature was noted to
be 92.0 F.; pulse 70; blood pressure 146/69; respiratory rate
16 on assisted control ventilation with total volume of 700,
100% FIO2 with PEEP of 5.

PAST MEDICAL HISTORY:
1.  Coronary artery disease status post coronary artery
bypass graft in [**2085**].
2.  Hypertension.
3.  Diabetes mellitus type 2.
4.  Status post hip replacement.
5.  Status post total knee replacement.

ALLERGIES:   The patient with no known drug allergies.

MEDICATIONS PRIOR TO ADMISSION: Initially the patient's
medications were unknown, however, after contacting his wife,
we were able to obtain the following medication list.
1.  Novolin N 17 to 20 units q. a.m.
2.  Novolin N 17 to 20 units q. p.m.
3.  Novalog 8 units q. 6 p.m.
4.  Trimethyl glycine 750 mg q. day.
5.  Fish Oil 250 mg q. day.
6.  Magnesium 64 mg q. day.
7.  B12 vitamin, 100 mg q. day.
8.  Coenzyme Q 20 mg p.o. q. day.
9.  Vitamin B6 200 mg q. day.
10. Aspirin 325 mg q. day.
11. Isosorbide 120 mg p.o. q. day.
12. Folic acid 5 mg p.o. twice a day.
13. Zestril 20 mg p.o. q. day.
14. Niacin [**2100**] mg p.o. q. day.
15. Metoprolol 25 mg p.o. q. day.

SOCIAL HISTORY:   On initial arrival, the patient was [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) **] without any identification; however, on hospital day
number two, his wife was located and notified.  She travelled
to [**Hospital1 69**] from the patient's
home in Tenafly, [**State 760**].  The patient and his wife have
been married for quite some years.  He has two grown
children.  The patient's wife serves as his durable Power of
Attorney and Health Care Proxy.

PHYSICAL EXAMINATION:   Upon admission, temperature 98.2 F.;
pulse 70; blood pressure 146/69; [**Location (un) 2611**] Coma Scale 3, on
assist control ventilation with total volume 700, respiratory
rate 16, 100% FIO2, PEEP of 5.  General appearance:
Obtunded, nonresponsive.  HEENT:  Normocephalic, atraumatic.
Pupils nonreactive.  No evidence of facial trauma.  Neck:
C-collar neck stabilizer in place.  Lungs:  Decreased
bibasilar breath sounds.  Bronchial breath sounds anteriorly
with coarse crackles throughout.  Cardiovascular is regular
rate and rhythm.  Externally paced to a rate of 70 beats per
minute. Well healed sternotomy scar present.  Abdomen:  Soft,
nontender, nondistended.  Rectal examination was guaiac
negative, no rectal tone noted.  Back:  No spine step off.
No evidence of spinal trauma.  Extremities cool, one plus
dorsalis pedis, posterior tibialis pulses. Neurological:
[**Location (un) 2611**] Coma Scale 3, paralyzed.

LABORATORY:  Labs available from [**Hospital3 22439**] prior to
transfer demonstrated complete blood cell count with white
blood cell count of 9.5, hematocrit 37.1, platelet count 141.
Serum chemistry demonstrated a sodium of 146, potassium 5.1,
chloride 116, bicarbonate 18, BUN 45, creatinine 1.9, glucose
131, calcium 9.5.

Coagulation profile showed PT 13.8, PTT 41.7, INR 1.26.
Liver function tests showed a total bilirubin of 1.0, albumin
4.2, total protein 7.2, alkaline phosphatase 189, ALT 130,
AST 164, LDH 1330.

Cardiac enzymes showed a CK of 452, MB 49, MB index 11%,
troponin 0.28.

Arterial blood gases on arrival to [**Hospital3 22439**] showed
pH of 6.96, Carbon dioxide 47, O2 88.

Repeat laboratory studies done at [**Hospital1 190**] after transfer showed white blood cell count
19.8, hematocrit 33.1, platelet count 103.  Serum chemistry
at [**Hospital1 69**] was sodium of 143,
potassium 5.1, chloride 114, bicarbonate 16, BUN 50,
creatinine 1.8, glucose 162.

Coagulation profile showed PT 15.4, PTT 37.5, INR 1.6,
fibrinogen 242.

Urinalysis showed specific gravity of 1.015, large blood, 30
protein, greater than 50 red blood cells, zero to two white
blood cells, few bacteria.

Urine toxicology screen was negative.  Serum toxicology
screen was negative.

Chest x-ray on [**2103-8-25**], demonstrated cardiomegaly with
moderate pulmonary edema.

CT scan of the head without contrast on [**2103-8-25**], showed no
intracranial hemorrhage or mass effect.  Fluid within the
sinuses likely related to the patient's recent prolonged
submersion in water.  Recommendation is if neurological
symptoms persist, a follow-up CT scan or MRI may be performed
within 12 to 24 hours.

CT scan of the cervical spine without contrast; CT scan
reconstruction demonstrated extensive degenerative changes
throughout the cervical spine.  There was fusion of C5, C6
and C7.  There is disc space narrowing at C7 and T1.  There
is reversal of the normal cervical spine curvature in the
region of fusion centered on C6.  There are areas of spinal
canal stenosis, most prominent at the C6 to C7 level, where
there is new bone formation from the fusion.  There is no
prevertebral soft tissue swelling.  Additionally seen is
fusion of multiple spinous processes and ossification of the
nuchal ligament.  The patient is intubated.  There is
consolidation dependently within the lung apices.  No
asymmetric soft tissue densities are seen within the neck.
There is calcification of the carotid arteries.  The patient
also has an nasogastric tube.

Echocardiogram on [**2103-8-26**], was a limited study.  The left
atrium was normal in size.  The left ventricular cavity size
was normal.  Overall left ventricular systolic function is
severely depressed with left ventricular ejection fraction
estimated at 15 to 20%.  Akinesis of the basal and mid
inferior, and inferolateral walls.  Hypokinesis of the
remainder of the ventricle.  Regional wall motion assessment
is limited; however, the basal and mid to lateral walls
appear relatively better preserved.  Left ventricular chamber
size was normal.  There is abnormal septal motion.  The
aortic valve leaflets are mildly thickened.  No aortic
regurgitation is seen.  The mitral valve leaflets are mildly
thickened.  No mitral regurgitation is seen.  There is no
pericardial effusion.  There is linear echogenic structure in
the right ventricle consistent with a pacemaker wire /
catheter.

Echocardiogram on [**2103-8-27**] with left ventricular ejection
fraction of 20 to 25%.  The left atrium is mildly dilated.
Left ventricular wall thicknesses are normal.  The left
ventricular cavity is moderately dilated.  There is severe
global left ventricular hypokinesis with a relative
preservation of the base of the lateral and septal walls.
Overall left ventricular systolic function is severely
depressed.  Right ventricular chamber size is normal.  Right
ventricular systolic function is normal.  The aortic root is
mildly dilated.  The aortic valve leaflets (three) appear
structurally normal with good leaflet excursion.  The aortic
valve leaflets are moderately thickened.  No aortic
regurgitation is seen.  Mitral valve leaflets are mildly
thickened.  There is no pericardial effusion.

Compared with the findings of the prior report of [**2103-8-26**],
no significant change was noted.

EEG on [**2103-8-26**], with impression that this was an abnormal
EEG due to the monotonous theta range diffuse slowing seen
throughout the record.  Infrequent bursts of suppression were
also observed.  In addition, the amplitudes of the wave form
were increased frontally as compared to posteriorly which is
a poor prognostic factor.  The fact that there was little
response to verbal or physical stimulation is also indicative
of a poor prognosis.  This record is consistent with severe
encephalopathy.  The record is not consistent with brain
death.

In order to further prognosticate, it may be helpful to
repeat the EEG.

MRI of the cervical spine on [**2103-8-30**], showed there is bony
fusion of C5, C6, and 7.  A normal vertebral body height and
signal intensity are preserved.  The spinal canal is patent
throughout and the spinal cord is of normal signal.  The
cranial cervical junction is within normal limits.  There is
no increased signal on the STIR images to indicate an acute
soft tissue injury.   At the C3, C4 levels, there are
posterior spondylotic ridges resulting in moderate bilateral
neural foraminal narrowing.  At C5-6, there is a right
paracentral disc osteophyte complex resulting in mild
impression upon the ventral subarachnoid, with no significant
neural foraminal or spinal stenosis.  At the C6-7 level,
there is a left posterior spondylotic ridge resulting in mild
left neural foraminal narrowing.  No other significant
abnormalities are identified.

Impression was that there was no evidence of increased ST IR
signals to indicate acute bony or ligamentous injury.

MRI of the head without contrast on [**2103-8-30**], showed that
several of the sequences are limited due to excessive motion
artifact.  Allowing for this limitation, the brain appears
morphologically normal.  There is no mass affect of shift of
the normally midline structures.  The ventricles and sulci
are prominent but symmetric, compatible with involutional
change. There are few discrete foci of T2 flare
hyperintensity within the subcortical white matter,
compatible with chronic microvascular ischemia.  There is no
increased susceptibility artifact to indicate the presence of
blood products.  In addition, there is no restricted
diffusion to indicate an ischemic event.  Normal vascular
flow voids are preserved.  Visualized soft tissues are
notable for fluid within the mastoid air cells bilaterally,
likely resulting from the patient's recent drowning event.

Impression was that there were no acute intracranial
abnormalities identified.

BRIEF SUMMARY OF HOSPITAL COURSE:   The patient was admitted
to the Coronary Care Unit status post presumed ventricular
fibrillation with arrest.

1.  CARDIOVASCULAR:  On arrival, the patient demonstrated a
slow ventricular escape rhythm.  A temporary ventricular
pacing wire was placed in his right subclavian central venous
line.  Overnight from [**2103-8-25**] until [**2103-8-26**], he was
ventricularly paced at a rate of 80 beats per minute.  The
following morning of [**2103-8-26**], the pacer rate was decreased
to 60 beats per minute as the patient was noted to have his
own intrinsic rhythm in the 70s.  The patient was able to
maintain his own intrinsic rhythm without need for pacing.

The pacer wire was discontinued on [**2103-8-27**].  After
discontinuation of the pacer, the patient was able to
maintain his own normal sinus rhythm.  He had only occasional
episodes of ventricular ectopy on Telemetry monitoring.
Telemetry was discontinued on [**2103-8-31**].

As it was unclear on admission if a primary cardiac event was
the etiology of the patient's near drowning, his cardiac
enzymes were cycled.  He had a peak creatinine kinase of
1618, peak troponin T of 1.57.  Please note, however, these
values were obviously drawn after the patient received
multiple defibrillations.

As the patient did not exhibit any evidence of ischemic
changes on serial electrocardiograms or ectopy on Telemetry
monitoring, it was felt that a primary cardiac event was
unlikely to be the etiology of his downing.

An echocardiogram was obtained to evaluate the patient's
overall cardiac function.  Echocardiogram on [**2103-8-26**],
showed left ventricular ejection fraction of 20 to 25% with
severe global hypokinesis.

That evening, the patient had an episode of hypotension
requiring transient dopamine and NeoFed pressor support.  It
was questionable whether his hypotension was due to
distributive sepsis versus cardiogenic shock.  Therefore, a
Swan-Ganz catheter was placed on [**2103-8-27**] for better
hemodynamic monitoring and assessment.

Initially, values from the Swan Ganz catheter showed values
consistent with early sepsis, with cardiac output of 6.7,
systemic vascular resistance of 8 to 96; however, over the
next two days, the patient's cardiac function normalized.

Prior to discontinuation of the Swan on [**2103-8-30**], the
patient's cardiac output was noted to be 4.8, cardiac index
2.42, with systemic vascular resistance of 1417.

Throughout the remainder of his hospital course, the patient
maintained hemodynamic stability without pressor support.

As the patient has a history of coronary artery disease, he
was initiated on his outpatient medications of aspirin,
Zestril and Metoprolol.  Particularly, the Zestril and
Metoprolol were utilized for better blood pressure control.
The patient tolerated this regimen well and, as above, was
hemodynamically stable at the time of discharge.

2.  NEUROLOGICAL:  On arrival, the patient was obtunded with
[**Location (un) 2611**] Coma Scale score of three.  He was felt to have
global hypoxic brain injury in the setting of presumed
ventricular fibrillatory arrest, with an unknown period of
hypoxia.

Initially, the patient was without corneal reflexes; pupils
were nonreactive and he was unresponsive to verbal or noxious
stimuli.  He did not demonstrate any spontaneous movements or
pain induced movements.

On initial Neurological consultation, hyperventilation over
and above ventilatory settings was the only sign of central
nervous system function.  An EEG was done to assess the
patient's level of cortical function.  The EEG demonstrated
severe encephalopathy.

On [**2103-8-26**], the patient was noted to open his eyes
spontaneously and grimace to pain.  On [**2103-8-27**], he
demonstrated withdrawal movements with sternal rub and other
noxious stimuli.  He also had a positive gag reflex at this
time.

In order to assess for diffuse ischemic injury, an MRI of the
head was done without contrast on [**2103-8-31**].  It was felt
that having this information would help with prognostication
in terms of the patient's long term neurological prognosis as
well as provide the family with additional information that
could be used in making further health care decisions on the
patient's behalf. An MRI demonstrated no acute intracranial
abnormality.

The family decided to pursue further care of the patient at a
facility closer to their home in [**State 760**]; namely the
patient will be transferred to [**Hospital **] [**Hospital 25757**] Medical
Center for further neurological evaluation and treatment.

At the time of discharge on [**2103-9-3**], the patient was noted
to open eyes spontaneously.  His eyes did not track stimuli.
He did demonstrate spontaneous movements, particularly of his
upper extremities; however, it was unclear whether these
movements were simply reflex or were purposeful in response
to stimuli.  He did withdrawn his extremities to pain.  He
did have a positive gag reflex.  He demonstrated facial
movement and grimacing to pain.  He was not able to follow
simple commands.

3.  PULMONARY:  The patient arrived to [**Hospital1 190**] intubated and sedated.  He was placed on
Midazolam and Fentanyl intravenous drips as he was
dramatically over breathing his ventilatory settings.

Chest x-ray showed a questionable adult respiratory distress
syndrome like picture.  Therefore, initially, ventilation
settings were optimized with low PEEP, low volume and high
rate settings.  Staff experienced difficulty sedating the
patient as blood pressure would drop dramatically with
Propofol.  With withdrawal of paralytic agents, the patient
became increasing tachypneic, desynchronous and difficult to
ventilate.  Therefore, a Pulmonary consultation was obtained
in order to assist with appropriate ventilation settings.

The Pulmonary staff recommended low tidal volumes, EG500 to
600 cc, with tolerance of increased rate as needed by the
patient to compensate for his underlying metabolic acidosis.
It was felt that this acidosis was likely secondary to his
prolonged arrest and hypoxia.

The patient tolerated these ventilation settings and
continued to breath over the ventilator.  On [**2103-8-28**], he
underwent a trial of pressor support and tolerated this well.
He was ultimately extubated on [**2103-8-28**] and started on four
liters of nasal cannula O2.  He was able to maintain oxygen
saturation levels in the high 90s on the four liters nasal
cannula O2.

Therefore, over the course of the next several days, he was
weaned off of oxygen altogether and at the time of discharge
had oxygen saturation levels ranging from 95 to 99% on room
air.

4.  INFECTIOUS DISEASE:  Overnight on hospital day number
one, the patient spiked a temperature to 101.2 F.
Additionally, a repeat white blood cell count showed white
blood cell count level dropped to 1.0 from 10.8.  We were
concerned regarding possible aspiration of seawater versus
gastric contents during the patient's drowning event.
Therefore, he was started on Vancomycin one gram intravenous
q. 24 hours and Zosyn 2.25 grams q. six hours for presumed
sepsis.  Please note that these were renally dosed
medications.

Blood cultures were drawn from his arterial line after his
temperature spike and eventually grew out four out of four
cultures with positive alpha Streptococci, vancomycin
sensitive.  After this culture resolved, Zosyn was
discontinued on [**2103-8-29**].

Surveillance cultures drawn on [**2103-8-28**], demonstrated no
growth.  It was unclear whether the patient actually had
alpha Streptococcus bacteremia or if blood cultures drawn on
[**2103-8-26**] were contaminated; however, the decision was made
to continue a total Vancomycin course of two weeks.

At the time of discharge on [**2103-9-3**], the patient will be
on Vancomycin day number nine.

The patient also had questionable evidence of pulmonary
infiltrates on his original chest x-ray examination;
therefore a sputum sample was sent.  The sputum grew out four
plus Gram positive cocci on Gram stain; however, final
culture demonstrated only moderate growth of flora consistent
with oropharyngeal bacteria.

5.  RENAL:  Upon admission, the patient's BUN and creatinine
were elevated; this was felt to be secondary to hypoxemia and
poor renal blood flow during his drowning event, leading to
acute tubular necrosis; therefore, he was aggressively
rehydrated with intravenous fluids.  Additionally, all of his
medications were renally dosed in order to decrease any
further renal insult.

The aggressive hydration led to a progressive decline in his
BUN and creatinine values.  At the time of discharge, his BUN
and creatinine were stable at BUN 37, creatinine 1.0.

6.  HYPOTHERMIA:  On arrival to [**Hospital1 188**], the patient's core body temperature was 92.0 F.
After arrival in the Coronary Care Unit, he was rewarmed
slowly back to normal core temperature with rewarming
blankets and warm intravenous fluids.

7.  QUESTIONABLE CERVICAL / SPINAL CORD INJURY:  A
ligamentous injury to the patient's cervical spine could not
be ruled out.  According to Trauma Surgery consultation, MRI
needed to be done within 48 hours of the patient's initial
injury; however this was not able to be obtained because the
patient had a pacer wire in place.

The MRI was done on [**2103-8-30**], after the 48 hour window.
This demonstrated no evidence of ligamentous injury.  In
order to fully clear the patient's cervical spine, Trauma
Surgery consultation team recommended flexion and extension
cervical spine films; however, the patient was unable to
follow command for this purpose.  Therefore, they recommended
maintaining cervical spine immobilization with cervical
collar for the next four weeks, or until such time as the
patient can undergo flexion and extension x-rays.

8.  ENDOCRINE:  For the patient's history of diabetes
mellitus type 2, he was initially monitored with four times a
day fingerstick blood glucose testing.  Blood glucose levels
in the Coronary Care Unit were initially 80s to 150s.  The
patient was covered with Regular insulin sliding scale.  On
[**2103-8-31**], the patient's outpatient NPH was added to his
medication regimen.

The patient was then transferred to the Floor on [**2103-8-31**],
at which point it seemed that his blood glucose levels became
very elevated with sugars on the floor ranging between 250 to
400.  Therefore, his NPH dosing was increased to 35 units q.
a.m. and 30 units q. p.m.  With these elevated blood glucose
levels, the patient was also noted to have a relative
increase in his urine output.  Therefore, a repeat urinalysis
was obtained on [**2103-9-2**] that demonstrated small blood,
trace protein, 100 glucose; negative for ketones, bilirubin,
leukocyte esterase or nitrite.

After initiation of tube feedings, the patient's sodium level
progressively elevated.  It peaked at a level of 149.  At
this point, it was felt that the patient was likely suffering
from a total body water deficit; therefore, free water
boluses of 250 cc of free water q. six hours were initiated.
As this produced on a modest decrease in his sodium level,
free water boluses were increased to 250 cc q. four hours.

On the day prior to discharge, his sodium level was 140.  As
we were concerned about the possibility of diabetes insipidus
in light of his history of neurological injury status post
hypoxia, urine studies were sent which demonstrated urine
osmolality of 780, urine creatinine 63, urine sodium 151,
urine chloride 101.  These values seemed to refute the
diagnosis of diabetes insipidus.  Therefore, we postulated
that the patient's polyuria was likely secondary to
glycosuria.

Now that his sodium level was normalized at 140, the decision
was made to just continue with free water boluses q. six
hours for relative maintenance of his sodium level.

9.  FLUIDS, ELECTROLYTES AND NUTRITION:  Nutritional
consultation was obtained early on in the [**Hospital 228**] hospital
course.  The patient was started on tube feedings with ProMod
with fiber at a rate of 70 cc per hour with frequent residual
checks.  This was initially given via an OG tube secondary to
concern for sinusitis status post the patient's drowning
event as the head CT scan noted fluid in the patient's
maxillary spaces.

On [**2103-8-31**], the OG tube was switched to a Dobbhoff tube
for patient's comfort.  Throughout his course, the patient
was maintained on aspiration precautions.

As noted above, the patient was noted to have a free water
deficit and therefore was given 250 cc boluses of free water
q. six hours initially, increased to q. four hours after his
sodium level failed to decline initially.

At the time of discharge, he had reached his nutritional goal
for his tube feedings on ProMod with fiber at a rate of 70 cc
per hour with residual checks q. four hours, free water
boluses of 250 cc H2O q. four hours.

10.  ACTIVITY:  The patient underwent a Physical Therapy
consultation on [**2103-8-31**].  Assessment was that the patient
had impaired balance, functional mobility, motor function,
cognition, endurance.  Impression was that he would require
extensive rehabilitation upon discharge; however, it was felt
that his rehabilitation potential was good given his high
baseline and good support system in place, namely his
prognosis will depend mainly on his neurological recovery.

Additionally, a Speech and Swallow evaluation was obtained,
also on [**2103-8-31**].  The impression was that the patient was
demonstrating overt signs and symptoms of aspiration with
thin liquids as well as puree consistency.  The patient
likely had increasing pharyngeal residue over multiple
boluses, placing him at high risk for aspiration.  While he
did demonstrate appropriate responses to p.o. attempts, he
was not felt to be ready at this time for p.o. initiation or
for a video swallow study.  Therefore, recommendation is that
the patient remain n.p.o. at this time.  Nasogastric tube
feedings were continued for nutrition and hydration.  Oral
care attempts were to be continued as possible avoiding
biting behavior.  The patient was to have a follow-up
reassessment of his swallow function within one week, likely
with a video swallow study if deemed appropriate.

11.  CODE STATUS:  Discussion with the patient's durable
power of attorney and wife, [**Name (NI) 31250**] [**Name (NI) 52293**], and the
patient's son on [**2103-8-31**], took place regarding the
patient's code status.  The patient's wife and son clearly
and explicitly expressed their desire that the patient be
made "Do Not Resuscitate", "Do Not Intubate".

CONDITION ON DISCHARGE:   Guarded.

DISCHARGE STATUS:   The patient is being discharged
transferred to [**Hospital **] [**Hospital 25757**] Hospital in [**State 531**].
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] will take over primary responsibility for
the patient's care.

DISCHARGE DIAGNOSES:
1.  Status post drowning with anoxic brain injury.
2.  Coronary artery disease status post coronary artery
bypass graft.
3.  Diabetes mellitus type 2.
4.  Hypertension.
5.  Hypernatremia.
6.  Acute renal failure.

DISCHARGE MEDICATIONS:
1.  NPH insulin 35 units q. a.m. and 30 units q. p.m.
2.  Regular insulin sliding scale.
3.  Colace liquid 100 mg p.o. twice a day.
4.  Metoprolol 25 mg p.o. twice a day.
5.  Lisinopril 20 mg p.o. q. day.
6.  Aspirin 325 mg p.o. q. day.
7.  Pantoprazole 40 mg p.o. q. 24 hours.
8.  Acetaminophen 650 mg p.r. q. six hours p.r.n. fever.
9.  Vancomycin 1 gram intravenously q. 24 hours; please note
that on [**2103-9-3**], will be day number nine.

DISCHARGE INSTRUCTIONS:
1.  The patient is being transferred to [**Hospital **] [**Hospital 25757**]
Medical Center in [**State 531**].  There, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] will
assume responsibility for his care.
2.  The patient is being transferred for further neurological
evaluation and neurological care.  Additionally, his family
wanted the patient transferred to a location closer to their
home in [**State 760**].
3.  The patient will be transferred on [**2103-9-3**].
Transportation will occur via air ambulance.
4.  The patient's wife, Mrs. [**First Name4 (NamePattern1) 31250**] [**Known lastname 52293**] will continue to
serve as the patient's power of attorney and health care
proxy.



                            [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D.  [**MD Number(1) 23649**]

Dictated By:[**Last Name (NamePattern1) 41068**]
MEDQUIST36

D:  [**2103-9-2**]  15:23
T:  [**2103-9-2**]  15:52
JOB#:  [**Job Number 52294**]

cc:[**Last Name (NamePattern4) 52295**]
{'Ventricular fibrillation,Hyperosmolality and/or hypernatremia,Anoxic brain damage,Streptococcal septicemia,Acute kidney failure with lesion of tubular necrosis,Drowning and nonfatal submersion,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}


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: 

PRESENT ILLNESS: The patient is an 82 year old
male with a past medical history of coronary artery disease
status post coronary artery bypass graft in [**2085**],
hypertension and diabetes mellitus type 2, found in [**Hospital1 6687**]
Bay on [**2103-8-25**], unresponsive, floating in the water
supine, motionless.  The patient was spotted by lifeguards
who pulled him from the water and initiated CPR.  An AED
Device was attached; the patient was noted to be in
ventricular fibrillation and underwent defibrillation times
two.  The patient was presumed to have ventricular
fibrillation arrest and was shocked into third degree AV
block with slow ventricular escape beats.  He was placed on
external transcutaneous pacing.  He remained hypotensive,
unresponsive, hypothermic, with a core body temperature of
94.0 F.

MEDICAL HISTORY: 1.  Coronary artery disease status post coronary artery
bypass graft in [**2085**].
2.  Hypertension.
3.  Diabetes mellitus type 2.
4.  Status post hip replacement.
5.  Status post total knee replacement.

MEDICATION ON ADMISSION: 

ALLERGIES: The patient with no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: On initial arrival, the patient was [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) **] without any identification; however, on hospital day
number two, his wife was located and notified.  She travelled
to [**Hospital1 69**] from the patient's
home in Tenafly, [**State 760**].  The patient and his wife have
been married for quite some years.  He has two grown
children.  The patient's wife serves as his durable Power of
Attorney and Health Care Proxy. 

### Response:
{'Ventricular fibrillation,Hyperosmolality and/or hypernatremia,Anoxic brain damage,Streptococcal septicemia,Acute kidney failure with lesion of tubular necrosis,Drowning and nonfatal submersion,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}
