CHIEF COMPLAINT: Hypoxia

PRESENT ILLNESS: 54 year old female with h/o COPD, CHF (EF 50%), PVD s/p grafting
and R AKA, ILD, DM, and recent Staph pneumonia requiring
transient intubation who presents from rehab to OSH, then sent
here with respiratory distress.
.
Of note, patient was recently hospitalized [**Date range (1) 63766**] with Staph
aureus pneumonia with associated MSSA bacteremia. Discharged
[**1-25**] to complete a 4 week course of ceftriaxone to continue
through [**2-12**]. Returned [**1-31**] and was started on vancomycin,
ceftriaxone and clindamycin on [**1-31**]. Changed to
Vancomycin/Clinda/Cefepime as well as oseltamivir for flu B on
[**2-2**] when decompensated. She was intubated from [**2-6**] to [**2-11**] for
respiratory distress. Cefepime and clinda were continued for 8
days and transitioned to cefazolin [**2-10**]. Pt had extensive workup
for other sources which was unrevealing. She had a negative TEE,
CTA of the right stump and no evidence of increased uptake on
WBC scan. She was discharged to rehab with PICC and completed
Cefazolin course through 3/31 per last ID note.
.
On [**3-13**], she developed tremor, myoclonus and lethargy at rehab.
Amitryptilin was held. CXR with consolidation. Pt was started on
IV Vanc, Cefepime and Flagyl.
.
On [**3-17**], she developed increased respiratory distress and her O2
sats were dropping to 80s. She received 40 IV Lasix, 2mg IV
morphine and was sent to OSH ED on NRB. At [**Hospital 8**] Hospital
[**Last Name (LF) **], [**First Name3 (LF) **] ABG was 7.39/53/49 (?on NRB). A CXR showed supposedly
signs of CHF. BNP was elevated >5000 and was sent to [**Hospital1 18**] ED.
.
In the ED, her VS were T32 (rectally), 84, 160/90, RR in 40s, O2
sats in low 90s on NRB. Exam notable for crackles 3/4th way up
b/l. Her temp came up to 35.1 on warming blanket. Given her
respiratory distress, she was intubated with Etom and Succ. Her
VS post-intubation were stable. It was felt that she also has a
COPD flare and received 125 IV solumedrol and combivent nebs. In
addition she was empirically covered with Vanc 1gm IV, Cefepime
1gm IV and Flagyl 500 IV(unclear if Cefepime and Flagyl given)
b/o hypothermia and slight WBC elevation. A R IJ was placed. CXR
showed CVL and ETT in good position. Pt was admitted to ICU for
further care.
.
On arrival to the ICU, pt was intubated, sedated on AC.

MEDICAL HISTORY: 1. s/p AKA [**11-10**] (right)
2. s/p VATS and hypoxemia, biopsy c/w Respiratory
Bronchiolitis-interstitial lung disease (RB-ILD) -- now on
intermittent supplemental oxygen
3. PVD - 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
patchangioplasty [**2196**],rt. ileofem bpg with PTFE [**2195**],
4. chronic pancreatitis s/p Puestow,J-tube,ccy1998,Expl lap [**2189**]

MEDICATION ON ADMISSION: Cefepime 1 gm IV daily
Vanco 0.75 gm daily
Flagyl 250 IV q8h
Viokase 1 tab tid
Lipitor 20 daily
Dulcolax 10mg supp daily
Atrovent nebs q2h prn
Nicotine lozenge prn
Medium chain TG oil tid
Thiamine 100 dialy
Coumadin ?1 dose daily
Colace 100 [**Hospital1 **]
HISS
NPH 4U [**Hospital1 **]
Atrovent nebs q6h
Lactulose 20 gm tid
Lansoprazole 30 daily
Lidocaine patch daily
Lopressor 75 tid
MVI
.
Per last DC summary, pt was also in recent past on:
Lisinopril 20 mg qd
Tiotropium Bromide 18 mcg qd
Fexofenadine 60 mg [**Hospital1 **]
Gabapentin 400 mg tid
Aspirin 325 mg qd
Amitriptyline 50 mg qhs
Oxycodone 5 mg q4 prn

ALLERGIES: Penicillins

PHYSICAL EXAM: T 95.8 BP 152/74 HR 84 RR 17 100% on AC 480x16, FiO2 0.4, PEEP 5

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: per last DC summary - 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.
Pneumonia, organism unspecified,Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Intestinal infection due to Clostridium difficile,Acute respiratory failure,Hyperosmolality and/or hypernatremia,Unspecified pleural effusion,Ulcer of other part of lower limb,Other candidiasis of other specified sites,Chronic pancreatitis,Anemia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Postinflammatory pulmonary fibrosis,Alcoholic cirrhosis of liver,Other and unspecified alcohol dependence, continuous,Anxiety state, unspecified,Esophageal reflux,Hypoxemia,Above knee amputation status,Chronic obstructive asthma, unspecified,Personal history of malignant neoplasm of cervix uteri,Atherosclerosis of native arteries of the extremities with ulceration,Long-term (current) use of anticoagulants,Abnormal coagulation profile
Pneumonia, organism NOS,Ac on chr diast hrt fail,Acute kidney failure NOS,Int inf clstrdium dfcile,Acute respiratry failure,Hyperosmolality,Pleural effusion NOS,Ulcer oth part low limb,Candidiasis site NEC,Chronic pancreatitis,Anemia NOS,DMII wo cmp nt st uncntr,Postinflam pulm fibrosis,Alcohol cirrhosis liver,Alcoh dep NEC/NOS-contin,Anxiety state NOS,Esophageal reflux,Hypoxemia,Status amput above knee,Chronic obst asthma NOS,Hx-cervical malignancy,Ath ext ntv art ulcrtion,Long-term use anticoagul,Abnrml coagultion prfile
Admission Date:  [**2199-3-18**]              Discharge Date:   [**2199-4-2**]

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

Service: CARDIOTHORACIC

Allergies:
Penicillins

Attending:[**First Name3 (LF) 492**]
Chief Complaint:
Hypoxia

Major Surgical or Invasive Procedure:
tracheostomy
G-tube
intubation with mechanical ventilation
Right IJ and central line placed and pulled


History of Present Illness:
54 year old female with h/o COPD, CHF (EF 50%), PVD s/p grafting
and R AKA, ILD, DM, and recent Staph pneumonia requiring
transient intubation who presents from rehab to OSH, then sent
here with respiratory distress.
.
Of note, patient was recently hospitalized [**Date range (1) 63766**] with Staph
aureus pneumonia with associated MSSA bacteremia. Discharged
[**1-25**] to complete a 4 week course of ceftriaxone to continue
through [**2-12**]. Returned [**1-31**] and was started on vancomycin,
ceftriaxone and clindamycin on [**1-31**]. Changed to
Vancomycin/Clinda/Cefepime as well as oseltamivir for flu B on
[**2-2**] when decompensated. She was intubated from [**2-6**] to [**2-11**] for
respiratory distress. Cefepime and clinda were continued for 8
days and transitioned to cefazolin [**2-10**]. Pt had extensive workup
for other sources which was unrevealing. She had a negative TEE,
CTA of the right stump and no evidence of increased uptake on
WBC scan. She was discharged to rehab with PICC and completed
Cefazolin course through 3/31 per last ID note.
.
On [**3-13**], she developed tremor, myoclonus and lethargy at rehab.
Amitryptilin was held. CXR with consolidation. Pt was started on
IV Vanc, Cefepime and Flagyl.
.
On [**3-17**], she developed increased respiratory distress and her O2
sats were dropping to 80s. She received 40 IV Lasix, 2mg IV
morphine and was sent to OSH ED on NRB. At [**Hospital 8**] Hospital
[**Last Name (LF) **], [**First Name3 (LF) **] ABG was 7.39/53/49 (?on NRB). A CXR showed supposedly
signs of CHF. BNP was elevated >5000 and was sent to [**Hospital1 18**] ED.
.
In the ED, her VS were T32 (rectally), 84, 160/90, RR in 40s, O2
sats in low 90s on NRB. Exam notable for crackles 3/4th way up
b/l. Her temp came up to 35.1 on warming blanket. Given her
respiratory distress, she was intubated with Etom and Succ. Her
VS post-intubation were stable. It was felt that she also has a
COPD flare and received 125 IV solumedrol and combivent nebs. In
addition she was empirically covered with Vanc 1gm IV, Cefepime
1gm IV and Flagyl 500 IV(unclear if Cefepime and Flagyl given)
b/o hypothermia and slight WBC elevation. A R IJ was placed. CXR
showed CVL and ETT in good position. Pt was admitted to ICU for
further care.
.
On arrival to the ICU, pt was intubated, sedated on AC.


Past Medical History:
1. s/p AKA [**11-10**] (right)
2. s/p VATS and hypoxemia, biopsy c/w Respiratory
Bronchiolitis-interstitial lung disease (RB-ILD) -- now on
intermittent supplemental oxygen
3. PVD - 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
patchangioplasty [**2196**],rt. ileofem bpg with PTFE [**2195**],
4. chronic pancreatitis s/p Puestow,J-tube,ccy1998,Expl lap [**2189**]

5. ETOH cirrhosis/chronic pancreatitis
6. L breast cyst s/p excision
7. GERD, pud
8. esophagitis with stricture
9. small bowel obstruction
10. PV,SMV thrombosis; h/o DVT/PE
11. asthma/copd on inhalers
12. cervical ca s/p multiple d/c's
13. DM2 insulin dependent
14. entero-colonic fistula
15. cholecystectomy
[**06**]. cdiff colitis
17. acute renal failure

Social History:
per last DC summary - 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:
T 95.8 BP 152/74 HR 84 RR 17 100% on AC 480x16, FiO2 0.4, PEEP 5

Gen - intubated, sedated.
HEENT - PERRL, ETT in place
NECK - supple, R IJ in place
CV - RR, nl S1, S2, no murmurs appreciated.
LUNGS - Dry crackles b/l anteriorly, no wheezes, diffuse
rhonchi.
ABD - NABS, soft, non-tender, non-distended. Significant
scarring on abdomen from pancreatic surgeries and feeding tubes.

EXT - no lower extremity edema. 1+ palpable pulse on L. R above
knee amputation scar intact without ecchymoses or skin
breakdown.
SKIN: No rashes/lesions, ecchymoses.
NEURO - sedated, only opening eyes to command


Pertinent Results:
151  112  42
============ 319
5.1  28  1.1
.
CK: 105  MB: 7   Trop: 0.03
Lactate 0.9
Ca: 8.8 Mg: 2.1 P: 4.2
proBNP: >[**Numeric Identifier **]
.
WBC 11.3  Hb 10.6  Hct 33.2  Plt 380
 N:90.3 Band:0 L:6.0 M:2.5 E:0.9 Bas:0.2
.
PT: 20.4  PTT: 34.1  INR: 1.9
.
.
STUDIES:
EKG: SR at 67, normal axis, nonspecific ST changes
.
CXR in ED (prelim): AP view of the chest in semi-upright
position. There is an NG tube with the tip within the stomach.
Right-sided PICC with tip at the level of the mid SVC. Since
prior exam, there has been worsening the right-sided pleural
effusion and pulmonary edema. Persistent wedge-shaped opacity in
the left mid lung zone.
IMPRESSION: Worsening right-sided pleural effusion and pulmonary
edema.
.
Previous studies:
CT chest w/o contrast [**2199-3-6**]:
1. Left upper lobe consolidation is minimally decreased compared
to [**2199-2-2**] and smaller than [**2199-1-16**]. While the
cavitation favors a necrotizing infectious etiology, the slow
change in appearance raises the possibility of organizing
pneumonia.
2. Improvement in pulmonary edema and anasarca.
3. Increase in size of moderate right pleural effusion and
decrease in small left pleural effusion.
4. Slight increase in mediastinal adenopathy.
.
CHEST AP [**2-12**]: Cardiac, mediastinal and hilar contours are
unchanged. Endotracheal and nasogastric tubes have been removed.
Right-sided PICC tip is in the SVC. The left pulmonary opacities
are not significantly changed from prior exam. There continues
to be right lower lobe atelectasis. There are moderate bilateral
pleural effusions which accounting for differences in technique
are not significantly changed. Re-distribution of effusion along
the left lateral chest is likely positional in nature.
IMPRESSION: Accounting for differences in technique, the
bilateral pulmonary opacities and moderate pleural effusions are
not significantly changed.
.
TEE [**2199-2-6**]:
No 2D echocardiographic evidence of endocarditis or abscess.
Mild to moderate mitral regurgitation. Depressed LV function.
.
TTE [**2199-2-4**]:
Compared with the prior study (images reviewed) of [**2198-12-13**],
trace aortic regurgitation and low normal left venticular
systolic function are seen on the current study (c/w diffuse
process - toxin, metabolic, etc.). A PDA is not seen on review
of the prior study nor on the current study.


Brief Hospital Course:
Summary: Ms. [**Known lastname 7168**] is a 54 year old female with h/o
interstitial lung disease (COP), COPD, diastolic CHF (EF 50%),
PVD s/p grafting and R AKA, DM, and recent Staph pneumonia
requiring transient intubation who presented from rehab to an
OSH, then sent here with respiratory distress. She was initially
intubated, started on empiric antibiotics for possible PNA,
although cultures returned negative and these were stopped. She
was also felt to have an acute on chronic diastolic CHF
exacerbation, responding well to having her transudative pleural
effusion tapped and gentle diuresis as needed.  She was found to
have C diff colitis and is being treated with flagyl. She was
given tracheostomy and G-tube on [**3-28**].
.
# Respiratory failure: Most likely multifactorial with known
COPD, RB-ILD, CHF exacerbation, recent necrotizing staph aureus
pneumonia with MSSA bacteremia. Given all cultures have remained
negative, this is unlikely to be infection and antibiotics were
stopped and BAL on [**3-23**] with no WBC. Given rapid response to
thoracentesis, unlikely to be purely her underlying lung disease
and steroids were discontiued after a few days. She responded
well to high volume thoracentesis (1.2L), with ability to wean
on vent settings after this.  Thoracentesis consistent with
transudate - likely due to CHF.  Her rate was well controlled
iwht metoprolol. Goal ins/outs were to remain even and the
patient received lasix 40mg IV on a prn basis, although she
began autodiuresing well with net negative 500cc for the last
three days of her stay with out medications.  Notably, her BNP
on admission was greater than 70,000.  She was extubated on [**3-22**]
and re-intubated for persistent respiratory distress.  Pt self
extubated [**3-23**], but reintubated early morning [**3-24**] due to
respiratory distress.  The patient did well on pressure support
of [**4-8**]. On [**3-28**] she had tracheostomy and G-tube. Since then she
has been maintained on 50% trach collar with PSV 5/5 available
on a prn basis only.
.
# C dificile colitis: The patient was found to have C dificile
colitis and was started on Flagyl PO 500mg po tid for planned 14
day course.  Day 1 was [**3-22**] and the patient should continue this
medication until [**2199-4-4**].
.
# H/o arterial and venous thrombi s/p thrombectomy: The patient
was maintained on a heparin drip with goal of PTT 60-70 (this
was tightened after she had some bloody OGT contents at higher
PTT levels).  Her coumadin dose on admission was 3mg po qday,
and she was restarted on coumadin 5mg on [**3-29**] after trach/PEG.
Her INR jumped in one day from 1.4 to 2.0, so this was decreased
to 3mg po qday on [**3-30**].  She was continued on heparin drip until
her INR was therapeutic at goal of [**1-6**].  Her INR should be
monitored frequently to alter her coumadin dose as needed for
INR [**1-6**] (current dose 4mg po qday). Interactions with flagyl
discontinuation should be considered.
.
# Altered Mental Status: The patient was initially altered at
her rehab, likely due to hypoxia and hypercarbia with rapid
shallow breathing (she demonstrated this repeatedly early on in
her stay whenever her ventilator settings were changed to PSV.
This breathing pattern resolved after large volume
thoracentesis.) Off sedation the patient has been alert and
interactive.  She does become quite anxious/agitated, especially
at night, and especially while lying in bed as she prefers to
sit in a chair.  She is also quite disoriented in the early
morning and immediately after waking.  When she initially wakes
up, she complains of total body pain and seems quite distressed.
 Once she is awake, by mid-morning, she is again alert and able
to give a true report of her status.  She was treated with
olanzapine 10mg qhs and 5mg qam.  She also recieved ativan 0.5mg
q6h prn anxiety.  Generally speaking she is more agitated at
night, and by day sits up in chair without problem.
.
# Acute on chronic diastolic CHF: EF of 50% on last echo. As
above, the patient had likely diastolic CHF exacerbation on
admission with crackles, veyr elevated BNP and CXR with edema.
She improved with prn IV lasix (last needed several days prior
to discharge), and had a transudative effusion that was tapped
for 1200cc. We continued her metoprolol and captopril for
diastolic CHF and continued home ASA 325. Home Lasix was
restarted eventually and uptitrated to 80 mg PO daily, to be
titrated as needed.
.
# h/o COPD: The patient's COPD was stable during her stay. We
continued the patient's nebulizers and inhaled steroids while
in-house. These should be continued as an outpatient as well.
.
# Anemia: Hct was stable between 23-26. She had bloody gastric
content from OGT on [**3-19**] and guaiac + stool, but no frank blood.
 In preparation of her trach/Gtube placement she was given
1uPRBC [**3-26**].
.
# Diabetes Mellitus Type II: The patient was admitted on ISS and
NPH 4 [**Hospital1 **]. Due to her initial pulse steroids, hte patient had
very elevated FS to the 300s and was maintained on an insulin
drip for better glucose control.  She was eventually restarted
on NPH at 6 units qam and 6 units qpm and insulin slide scale
and should continue this dosing on discharge; to be adjusted as
needed per FS.
.
# Peripheral Vascular Disease: Ms. [**Known lastname 7168**] is s/p Right AKA [**11-10**]
for non-healing leg ulcer. Her skin remained intact throughout
her stay.
.
# EtOH cirrhosis: Ammonia and LFTs were normal. Although it is
unclear when the patient last had alcohol, she has been between
hospitals and rehab for the past four months. She was treated
with MVI, folate, thiamine.
.
# h/o pancreatic insufficiency: s/p chronic pancreatitis. While
the patient is on tube feeds or eating she should be maintained
on viokase TID.
.
# h/o GERD: we continued her on a PPI throughout her stay.
.
# FEN: The patient was not deemed ready for a swallow study at
the time of discharge. She remains NPO with meds crushed through
G-tube. tube feeds were intitiaed through her Gtube on [**3-29**] in
the afternoon, 24 hours after it was placed.  She was initially
admitted with hypernatreia requiring free water boluses, but
this resolved and they were stopped.
.
# Prophylaxis: Ms. [**Known lastname 7168**] was maintained on PPI and heparin drip
throughout her stay.
.
# Access: Ms. [**Known lastname 7168**] had a Right IJ central venous catheter
placed in ED on [**3-18**], and removed on [**3-27**] in preparation for
tracheostomy.  She has a Right PICC which was placed in early
[**2-9**] at [**Hospital1 18**]. This is still present and used as access. This
does not appear to be infected. however given the high infection
risk, this should be pulled as soon as her heparin drip is
discontinued.
.
# CODE - full code per her husband and health care Proxy, [**First Name8 (NamePattern2) **]
[**Name (NI) 7168**]. Phone number [**Telephone/Fax (1) 63765**]
.
# Disposition: The patient is stable for discharge to an acute
rehab facility where her trach can be managed (PSV prn, in
future evaluate for Passy-Muir valve), her heparin drip can be
continued as a bridge to coumadin anticoagulation with goal INR
[**1-6**], and she can continue Flagyl for her c difficile colitis.
Her leg should be monitored for possible cellulitis, but as of
discharge patient has no white count, no fevers, no tenderness.
Antibiotics should be started in conjuction with Flagyl as
patient is high risk for antibiotic-associated C diff infection.

Medications on Admission:
Cefepime 1 gm IV daily
Vanco 0.75 gm daily
Flagyl 250 IV q8h
Viokase 1 tab tid
Lipitor 20 daily
Dulcolax 10mg supp daily
Atrovent nebs q2h prn
Nicotine lozenge prn
Medium chain TG oil tid
Thiamine 100 dialy
Coumadin ?1 dose daily
Colace 100 [**Hospital1 **]
HISS
NPH 4U [**Hospital1 **]
Atrovent nebs q6h
Lactulose 20 gm tid
Lansoprazole 30 daily
Lidocaine patch daily
Lopressor 75 tid
MVI
.
Per last DC summary, pt was also in recent past on:
Lisinopril 20 mg qd
Tiotropium Bromide 18 mcg qd
Fexofenadine 60 mg [**Hospital1 **]
Gabapentin 400 mg tid
Aspirin 325 mg qd
Amitriptyline 50 mg qhs
Oxycodone 5 mg q4 prn


Discharge Medications:
1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
2. Hexavitamin     Tablet [**Hospital1 **]: One (1) Cap PO DAILY (Daily).
3. Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).

4. Captopril 12.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times
a day).
5. Amylase-Lipase-Protease 30,000-8,000- 30,000 unit Tablet [**Hospital1 **]:
One (1) Tablet PO TID (3 times a day): TID while having tube
feeds or eating.
6. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID
(3 times a day).
7. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
8. Olanzapine 5 mg Tablet, Rapid Dissolve [**Hospital1 **]: Two (2) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)).
9. Olanzapine 5 mg Tablet, Rapid Dissolve [**Hospital1 **]: One (1) Tablet,
Rapid Dissolve PO QAM (once a day (in the morning)).
10. Lorazepam 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID prn as
needed for anxiety.
11. Thiamine HCl 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
12. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol [**Hospital1 **]:
One (1) Puff Inhalation [**Hospital1 **] (2 times a day).
13. Fentanyl 50 mcg/hr Patch 72 hr [**Hospital1 **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
14. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
15. Metronidazole 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3
times a day) for 6 days: Last day is [**2199-4-4**].
16. Warfarin 3 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY16 (Once
Daily at 16): please titrate does to goal INR [**1-6**].
17. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Month/Day (3) **]: One
Hundred (100) units Intravenous DAILY (Daily) as needed: flush
each lumen of PICC with 10mL NS followed by 100 units heparin
(1mL) qday and prn.
18. Morphine 15 mg Tablet [**Month/Day (3) **]: 1-2 Tablets PO q4hrs prn as
needed for pain.
19. Sodium Chloride 0.65 % Aerosol, Spray [**Month/Day (3) **]: [**12-5**] Sprays Nasal
QID (4 times a day) as needed for dry nose.
20. heparin IV drip
Please titrate as needed for goal PTT 60-70. Please stop heparin
IV drip when pt's INR is greater than 2. (bridge to
anticoagulation with coumadin only)
21. insulin
Please give insulin NPH 5units qam and 5 units qPM.
Please check FS q6 hours and treat with regular insulin by slide
scale (starting dose 2 units if FS 151-200, increase by 2 units
for every increase of FS by 50)
22. Albuterol Sulfate 1.25 mg/3 mL Solution for Nebulization
[**Month/Day (2) **]: One (1) nebulization Inhalation every six (6) hours as
needed for shortness of breath or wheezing.
23. Ipratropium Bromide 0.02 % Solution [**Month/Day (2) **]: One (1)
nebulization Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
Interstitial lung disease
congestive heart failure
c dificile colitis
anxiety
EtOH cirrhosis
Peripheral vascular disease s/p AKA
anemia
COPD
pancreatic insufficiency
GERD


Discharge Condition:
blood pressure stable, O2 sat high 90s on 50% trach collar,
sitting up in chair, interactive


Discharge Instructions:
Patient had Trach/G-tube placed on [**3-28**]. G-tube ok to use as of
2pm on [**3-29**]. Patient was able to tolerate an oral diet of nectar
thick liquids and ground solids.  Will likely need nutrition
consult for calorie counts and for supplemental tube feedings.

Patient has known arterial/venous thrombi. We restarted her
coumadin on [**3-29**] at 5mg po qday and adjusted as needed. Her
prior dose was 3mg po qday. Coumadin dose should be adjusted for
goal INR [**1-6**] after discharge.

The patient is currently on 50% trach cuff. We anticipate that
she will need to return to PSV 5/5  as needed, potentially
overnight or intermittently throughout the day. Patient is
tolerating Passy-Muir valve.

The patient has C difficile colitis and is taking flagyl per
Gtube. She should continue this until [**4-4**] for a total of 14
days.

The patient has a R sided PICC that was placed in [**2-9**] on her
last admission at [**Hospital1 18**]. Please pull this PICC as soon as not
needed anymore in order to prevent infection.

Patient needs to have her L leg monitored for possible
cellulitis - it is slightly erythematous on day of discharge.
No white count, no fevers, no tenderness.  Given her tendency to
have anti-biotic associated C diff infections, please be sure
she has cellulitis before starting antibiotics and consider
concurrent flagyl.

Patient has waxing and [**Doctor Last Name 688**] mental status.  In the mornings
immediately upon wakening she is often disoriented and complains
of total body pain.  By mid-morning her mental status has
cleared and she is able to give a true self-assessment.

Followup Instructions:
Please evaluate oxygen needs by trach. Currently on 50% trach
collar, anticipate may need PSV 5/5 prn.

Please call Dr. [**Last Name (STitle) 7443**] for a follow up appointment in infectious
disease in 2 weeks. [**Telephone/Fax (1) 457**]

Please call your primary care physician for [**Name Initial (PRE) **] follow up
appointment in the next 2 weeks.


                             [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
{'Pneumonia, organism unspecified,Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Intestinal infection due to Clostridium difficile,Acute respiratory failure,Hyperosmolality and/or hypernatremia,Unspecified pleural effusion,Ulcer of other part of lower limb,Other candidiasis of other specified sites,Chronic pancreatitis,Anemia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Postinflammatory pulmonary fibrosis,Alcoholic cirrhosis of liver,Other and unspecified alcohol dependence, continuous,Anxiety state, unspecified,Esophageal reflux,Hypoxemia,Above knee amputation status,Chronic obstructive asthma, unspecified,Personal history of malignant neoplasm of cervix uteri,Atherosclerosis of native arteries of the extremities with ulceration,Long-term (current) use of anticoagulants,Abnormal coagulation profile'}


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: Hypoxia

PRESENT ILLNESS: 54 year old female with h/o COPD, CHF (EF 50%), PVD s/p grafting
and R AKA, ILD, DM, and recent Staph pneumonia requiring
transient intubation who presents from rehab to OSH, then sent
here with respiratory distress.
.
Of note, patient was recently hospitalized [**Date range (1) 63766**] with Staph
aureus pneumonia with associated MSSA bacteremia. Discharged
[**1-25**] to complete a 4 week course of ceftriaxone to continue
through [**2-12**]. Returned [**1-31**] and was started on vancomycin,
ceftriaxone and clindamycin on [**1-31**]. Changed to
Vancomycin/Clinda/Cefepime as well as oseltamivir for flu B on
[**2-2**] when decompensated. She was intubated from [**2-6**] to [**2-11**] for
respiratory distress. Cefepime and clinda were continued for 8
days and transitioned to cefazolin [**2-10**]. Pt had extensive workup
for other sources which was unrevealing. She had a negative TEE,
CTA of the right stump and no evidence of increased uptake on
WBC scan. She was discharged to rehab with PICC and completed
Cefazolin course through 3/31 per last ID note.
.
On [**3-13**], she developed tremor, myoclonus and lethargy at rehab.
Amitryptilin was held. CXR with consolidation. Pt was started on
IV Vanc, Cefepime and Flagyl.
.
On [**3-17**], she developed increased respiratory distress and her O2
sats were dropping to 80s. She received 40 IV Lasix, 2mg IV
morphine and was sent to OSH ED on NRB. At [**Hospital 8**] Hospital
[**Last Name (LF) **], [**First Name3 (LF) **] ABG was 7.39/53/49 (?on NRB). A CXR showed supposedly
signs of CHF. BNP was elevated >5000 and was sent to [**Hospital1 18**] ED.
.
In the ED, her VS were T32 (rectally), 84, 160/90, RR in 40s, O2
sats in low 90s on NRB. Exam notable for crackles 3/4th way up
b/l. Her temp came up to 35.1 on warming blanket. Given her
respiratory distress, she was intubated with Etom and Succ. Her
VS post-intubation were stable. It was felt that she also has a
COPD flare and received 125 IV solumedrol and combivent nebs. In
addition she was empirically covered with Vanc 1gm IV, Cefepime
1gm IV and Flagyl 500 IV(unclear if Cefepime and Flagyl given)
b/o hypothermia and slight WBC elevation. A R IJ was placed. CXR
showed CVL and ETT in good position. Pt was admitted to ICU for
further care.
.
On arrival to the ICU, pt was intubated, sedated on AC.

MEDICAL HISTORY: 1. s/p AKA [**11-10**] (right)
2. s/p VATS and hypoxemia, biopsy c/w Respiratory
Bronchiolitis-interstitial lung disease (RB-ILD) -- now on
intermittent supplemental oxygen
3. PVD - 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
patchangioplasty [**2196**],rt. ileofem bpg with PTFE [**2195**],
4. chronic pancreatitis s/p Puestow,J-tube,ccy1998,Expl lap [**2189**]

MEDICATION ON ADMISSION: Cefepime 1 gm IV daily
Vanco 0.75 gm daily
Flagyl 250 IV q8h
Viokase 1 tab tid
Lipitor 20 daily
Dulcolax 10mg supp daily
Atrovent nebs q2h prn
Nicotine lozenge prn
Medium chain TG oil tid
Thiamine 100 dialy
Coumadin ?1 dose daily
Colace 100 [**Hospital1 **]
HISS
NPH 4U [**Hospital1 **]
Atrovent nebs q6h
Lactulose 20 gm tid
Lansoprazole 30 daily
Lidocaine patch daily
Lopressor 75 tid
MVI
.
Per last DC summary, pt was also in recent past on:
Lisinopril 20 mg qd
Tiotropium Bromide 18 mcg qd
Fexofenadine 60 mg [**Hospital1 **]
Gabapentin 400 mg tid
Aspirin 325 mg qd
Amitriptyline 50 mg qhs
Oxycodone 5 mg q4 prn

ALLERGIES: Penicillins

PHYSICAL EXAM: T 95.8 BP 152/74 HR 84 RR 17 100% on AC 480x16, FiO2 0.4, PEEP 5

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: per last DC summary - 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:
{'Pneumonia, organism unspecified,Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Intestinal infection due to Clostridium difficile,Acute respiratory failure,Hyperosmolality and/or hypernatremia,Unspecified pleural effusion,Ulcer of other part of lower limb,Other candidiasis of other specified sites,Chronic pancreatitis,Anemia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Postinflammatory pulmonary fibrosis,Alcoholic cirrhosis of liver,Other and unspecified alcohol dependence, continuous,Anxiety state, unspecified,Esophageal reflux,Hypoxemia,Above knee amputation status,Chronic obstructive asthma, unspecified,Personal history of malignant neoplasm of cervix uteri,Atherosclerosis of native arteries of the extremities with ulceration,Long-term (current) use of anticoagulants,Abnormal coagulation profile'}
