CHIEF COMPLAINT: Tracheostomy Tube Displacement

PRESENT ILLNESS: 67F w h/o schizoaffective d/o, DM, HTN, chronic respiratory
failure, tracheal stenosis now sp trach/peg presents from [**Hospital1 1501**]
after accidentally pulling out her trach this AM. Denied any SOB
or difficulty breathing, although endorsed some "noisy
breathing" while in the ED.  Patient currently protecting airway
and was speaking in full sentences in the ED.  Pt has a history
of subglottic stenosis since [**2103**] with multiple trach tube
changes and granulation tissue noted around the tube.  Of note
she has had several episodes of the trach being pulled out.

MEDICAL HISTORY: 1. Respiratory failure requiring intubation, followed by failure
to wean, requiring tracheostomy.
2. Post-intubation tracheal stenosis, requiring chronic
tracheostomy.
3. Subglottic stenosis causing nearly 90% occlusion of the
airway status post rigid bronchoscopy, tracheal dilatation and
redo percutaneous tracheostomy on [**2106-10-12**].
4. Type 2 diabetes mellitus, insulin dependent.
5. Chronic pain disorder.
6. Schizoaffective disorder.
7. Depression.
8. Hypertension.
9. Glaucoma.
10. Cataracts bilaterally.
.
PAST SURGICAL HISTORY:
1. Trach and PEG placement initially in [**2105-5-5**].
2. Rigid bronchoscopy, tracheal dilatation and redo percutaneous
tracheostomy on [**2106-10-12**].

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from  nursing home records.
1. NovoLIN R *NF* (insulin regular human) 12 units  Injection
daily
7:30 AM
2. NovoLIN R *NF* (insulin regular human) 12 units Injection
daily
12:30
3. NovoLIN R *NF* (insulin regular human) 8 units Injection
daily
dinner
4. Lantus *NF* (insulin glargine) 58 units Subcutaneous QPM
at 20:00
5. Lisinopril 30 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Amlodipine 10 mg PO DAILY
8. Furosemide 20 mg PO DAILY
9. Fluticasone Propionate NASAL 1 SPRY NU DAILY
10. Omeprazole 40 mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. Labetalol 200 mg PO BID
13. guaiFENesin *NF* 600 mg Oral [**Hospital1 **]
14. Docusate Sodium 100 mg PO BID
15. Clonazepam 0.5 mg PO BID
16. Benztropine Mesylate 0.5 mg PO BID
17. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg
base)/3 mL Inhalation QID
18. Senna 1 TAB PO HS
19. Ranitidine 300 mg PO HS
20. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
21. Atorvastatin 10 mg PO DAILY
22. Citalopram 20 mg PO DAILY
23. Risperidone 4 mg PO QAM
24. Bisacodyl 10 mg PR HS:PRN constipation
25. Milk of Magnesia 30 mL PO Q6H:PRN constipation
26. Acetaminophen 650 mg PO Q6H:PRN pain, fever
27. Benzonatate 200 mg PO Q8H:PRN cough
28. Clonazepam 0.5 mg PO QHS:PRN anxiety
20:00
29. Risperidone 5 mg PO HS

ALLERGIES: Penicillins / Keflex

PHYSICAL EXAM: General: intubated, sedated
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL
Neck: supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic
murmur
Lungs: clear to ausculation bilaterally when auscultated
anteriorly
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: not responding to verbal stimulation or sternal rub, not
responding to commands

FAMILY HISTORY: Father: died brain tumor
Mother: died from CHF

SOCIAL HISTORY: Prior to hospitalization for PNA in Summer [**2104**], the patient
lived alone in [**Location (un) 1294**]; she now lives at [**Hospital 44563**]
nursing home ([**Hospital1 **] system). She retired as a school teacher
(French and [**Doctor First Name 533**]). She smoked 2 ppd for 40 years.
Personal history of allergy to penicillin,Personal history of allergy to other antibiotic agent,Surgical operation with formation of external stoma causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in residential institution,Mechanical complication of tracheostomy,Acute and chronic respiratory failure following trauma and surgery,Schizoaffective disorder, chronic,Other abnormal granulation tissue,Chronic airway obstruction, not elsewhere classified,Dysthymic disorder,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Chronic pain syndrome,Esophageal reflux,Personal history of tobacco use,Hypopotassemia,Disorders of phosphorus metabolism,Anemia, unspecified,Leukocytosis, unspecified,Unspecified late effects of cerebrovascular disease
Hx-penicillin allergy,Hx-antibiot allergy NEC,Abn react-external stoma,Accid in resident instit,Tracheostomy - mech comp,Ac/chr rsp flr fol tr/sg,Schizoaffective dis-chr,Abnormal granulation NEC,Chr airway obstruct NEC,Dysthymic disorder,DMII wo cmp nt st uncntr,Long-term use of insulin,Hypertension NOS,Crnry athrscl natve vssl,Chronic pain syndrome,Esophageal reflux,History of tobacco use,Hypopotassemia,Dis phosphorus metabol,Anemia NOS,Leukocytosis NOS,Late effect CV dis NOS
Admission Date:  [**2107-6-21**]              Discharge Date:   [**2107-6-23**]

Date of Birth:  [**2039-8-31**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Keflex

Attending:[**First Name3 (LF) 594**]
Chief Complaint:
Tracheostomy Tube Displacement

Major Surgical or Invasive Procedure:
Percutaneous Tracheostomy by IP [**2107-6-22**]

History of Present Illness:
67F w h/o schizoaffective d/o, DM, HTN, chronic respiratory
failure, tracheal stenosis now sp trach/peg presents from [**Hospital1 1501**]
after accidentally pulling out her trach this AM. Denied any SOB
or difficulty breathing, although endorsed some "noisy
breathing" while in the ED.  Patient currently protecting airway
and was speaking in full sentences in the ED.  Pt has a history
of subglottic stenosis since [**2103**] with multiple trach tube
changes and granulation tissue noted around the tube.  Of note
she has had several episodes of the trach being pulled out.

In the ED initial VS were T97.9 HR60 BP144/92 RR20 SpO2 100% 2L,
noted to be speaking in full sentences and AOx3, and also had
stridor per report and transmitted upper airway noises on lung
exam.  IP consulted in ED and bedside replacement of trach was
attempted however there was tooo much bleeding.  She went to OR
for replacement of tube in her tract, but too much granulation
tissue was present to introduce the tube.  Attempts were made to
dilate the stoma and to place tracheostomy tube with guidance of
fiberoptic bronchoscopy but unable to place.  She was intubated
in the OR with ETT for airway protection with plans to return to
OR in AM for rigid bronchoscopy and percutaneous tracheostomy.

On arrival to MICU, patient is intubated and sedated, not
responding to stimulation or comands.   Of note Dr. [**Last Name (STitle) **] of IP
has been recommending tracheal resection and reconstruction in
the past but patient has refused.

Past Medical History:
1. Respiratory failure requiring intubation, followed by failure
to wean, requiring tracheostomy.
2. Post-intubation tracheal stenosis, requiring chronic
tracheostomy.
3. Subglottic stenosis causing nearly 90% occlusion of the
airway status post rigid bronchoscopy, tracheal dilatation and
redo percutaneous tracheostomy on [**2106-10-12**].
4. Type 2 diabetes mellitus, insulin dependent.
5. Chronic pain disorder.
6. Schizoaffective disorder.
7. Depression.
8. Hypertension.
9. Glaucoma.
10. Cataracts bilaterally.
.
PAST SURGICAL HISTORY:
1. Trach and PEG placement initially in [**2105-5-5**].
2. Rigid bronchoscopy, tracheal dilatation and redo percutaneous
tracheostomy on [**2106-10-12**].


Social History:
Prior to hospitalization for PNA in Summer [**2104**], the patient
lived alone in [**Location (un) 1294**]; she now lives at [**Hospital 44563**]
nursing home ([**Hospital1 **] system). She retired as a school teacher
(French and [**Doctor First Name 533**]). She smoked 2 ppd for 40 years.

HCP: (brother) [**Name (NI) 2174**] [**Name (NI) **] [**Telephone/Fax (1) 86961**]


Family History:
Father: died brain tumor
Mother: died from CHF

Physical Exam:
General: intubated, sedated
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL
Neck: supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic
murmur
Lungs: clear to ausculation bilaterally when auscultated
anteriorly
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: not responding to verbal stimulation or sternal rub, not
responding to commands

Pertinent Results:
[**2107-6-22**]: CXR
ET tube is in standard position, tip is 2.7 cm above the carina.
 NG tube tip is in the stomach.  There are low lung volumes.
There is mild cardiomegaly.  There is mild vascular congestion.
There are minimal atelectases in the right lower lobe.  If any,
there is a small right pleural effusion.  The study and the
report were reviewed by the staff radiologist.

[**2107-6-23**] 12:24AM BLOOD WBC-13.2* RBC-3.73* Hgb-10.9* Hct-33.5*
MCV-90 MCH-29.1 MCHC-32.4 RDW-15.1 Plt Ct-322
[**2107-6-22**] 05:14AM BLOOD WBC-11.0 RBC-4.23 Hgb-12.4 Hct-38.4
MCV-91 MCH-29.4 MCHC-32.3 RDW-14.7 Plt Ct-332
[**2107-6-21**] 06:14PM BLOOD WBC-8.7 RBC-4.16* Hgb-12.0 Hct-37.9
MCV-91 MCH-28.8 MCHC-31.7 RDW-14.8 Plt Ct-324
[**2107-6-21**] 06:14PM BLOOD Neuts-79.0* Lymphs-15.3* Monos-3.9
Eos-1.4 Baso-0.4
[**2107-6-23**] 12:24AM BLOOD PT-12.4 PTT-27.6 INR(PT)-1.1
[**2107-6-22**] 05:14AM BLOOD PT-12.9* PTT-29.8 INR(PT)-1.2*
[**2107-6-21**] 06:14PM BLOOD PT-11.6 PTT-31.3 INR(PT)-1.1
[**2107-6-23**] 12:24AM BLOOD Glucose-67* UreaN-19 Creat-1.0 Na-142
K-3.3 Cl-107 HCO3-23 AnGap-15
[**2107-6-22**] 05:14AM BLOOD Glucose-212* UreaN-15 Creat-0.7 Na-139
K-4.0 Cl-104 HCO3-23 AnGap-16
[**2107-6-21**] 06:14PM BLOOD Glucose-88 UreaN-15 Creat-0.8 Na-142
K-4.1 Cl-103 HCO3-27 AnGap-16
[**2107-6-23**] 12:24AM BLOOD ALT-10 AST-14 AlkPhos-64 TotBili-0.5
[**2107-6-23**] 12:24AM BLOOD Calcium-9.1 Phos-2.4*# Mg-2.0
[**2107-6-21**] 06:14PM BLOOD Calcium-9.5 Phos-3.9 Mg-2.1

Brief Hospital Course:
67 y.o. woman w/ a history of post-intubation tracheal stenosis,
s/p multiple IP procedures, who presented with dislodged
tracheostomy tube now POD1 s/p percutaneous tracheostomy tube
placement.

# Dislodged tracheostomy tube:
She has dislodged her tube several time in the past. IP has
previously recommended tracheal resection and reconstruction
with thoracic surgery for definitive management but patient has
refused.  The initial attempt at bedside trach placement failed
in the ED w/ too much bleeding. She was then taken to the OR,
but there was too much granulation tissue present to place the
tube. Attempts were made to dilate the stoma and place the
tracheostomy tube under the guidance of fiberoptic bronchoscopy
but it was unable to be placed. Thus, in the OR she was
intubated for airway protection in preparation for another
attempt w/ a rigid bronchoscopy the next day. She was admitted
to the MICU. The next day, she was brought to the OR and
interventional pulmonology was able to place the percutaneous
tracheostomy tube under rigid bronchoscopy. She remained on the
ventilator on POD0 of the procedure given that she did not
tolerate CPAP well. She also became agitated after the
procedure, requiring restraints, Zyprexa, and lorazepam.
However, the next morning, she was calm and cooperative and was
able to be taken off the ventilator and transitioned to 10L
high-flow O2 for her trach. She was evaluated by speech and
swallow, and their recommendations were regular diet but the
CUFF ON THE TRACH TUBE NEEDS TO BE DOWN WHILE EATING. Also, she
cannot tolerate the valve for speaking at this time, so she will
need reevaluation at a later time at the nursing home.

# Diabetes:
At home, she is on lantus 58 units HS and standing prandial
insulin (12-12-8U regular insulin w/ meals and ISS). However,
since she was made NPO she was given 30U lantus and started on
ISS. Following speech and swallow evaluation, she was
transitioned back to her home insulin regimen.

#Hypokalemia:
She developed hypokalemia (K 3.3) in the post-op setting. This
was repleted according to the standard replacement scale.

#Hypophosphatemia:
She developed hypophosphatemia (2.4) in the post-op setting.
This was repleted according to the standard replacement scale.

#Leukocytosis:
She developed leukocytosis to 13.2 on POD1. This was likely due
to the stress of having a procedure. It is c/w her leukocytosis
she developed in the past in the same setting. She was not
started on any antibiotics or other treatment for this.

#Anemia:
On POD1, her Hct dropped to 33.5 after being 38.4 the previous
day. There was minimal blood loss during the procedure, but
there was low concern for any active bleeds. She did receive
several L NS in between these readings, which may have
contributed to the decreased Hct, w/ her procedure causing an
acute rise in platelets and WBC, keeping all cell lines from
being down.

# CAD/Hypertension:
She was continued on home lisinopril, labetalol, amlodipine,
aspirin and atorvastatin until she was post-op, at which time
these medications were held since she did not have an NG/OG tube
in place in anticipation of a quick wean off the ventilator. She
was resumed on these medications once she was evaluated by
speech and swallow and permitted to receive orals. This also
occurred for her other meds below.

# Depression/Anxiety:
She was continued on home citalopram. She had clonazepam and
lorazepam held while sedated prior to procedure. She was given
lorazepam in the post-op setting.

# Schizoaffective:
She was continued on home risperidone and benztropine.

# GERD:
She was continued on home omeprazole and ranitidine.

Transitional issues:
-f/u with IP within next 8 days, will receive phone call on appt
date and time.
-Per [**6-23**] speech and swallow eval: Pt can start thin liquids and
regular consistency solids with the following precautions:
     a) tracheal cuff deflated for all PO intake
     b) single sips of liquids


Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from  nursing home records.
1. NovoLIN R *NF* (insulin regular human) 12 units  Injection
daily
7:30 AM
2. NovoLIN R *NF* (insulin regular human) 12 units Injection
daily
12:30
3. NovoLIN R *NF* (insulin regular human) 8 units Injection
daily
dinner
4. Lantus *NF* (insulin glargine) 58 units Subcutaneous QPM
at 20:00
5. Lisinopril 30 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Amlodipine 10 mg PO DAILY
8. Furosemide 20 mg PO DAILY
9. Fluticasone Propionate NASAL 1 SPRY NU DAILY
10. Omeprazole 40 mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. Labetalol 200 mg PO BID
13. guaiFENesin *NF* 600 mg Oral [**Hospital1 **]
14. Docusate Sodium 100 mg PO BID
15. Clonazepam 0.5 mg PO BID
16. Benztropine Mesylate 0.5 mg PO BID
17. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg
base)/3 mL Inhalation QID
18. Senna 1 TAB PO HS
19. Ranitidine 300 mg PO HS
20. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
21. Atorvastatin 10 mg PO DAILY
22. Citalopram 20 mg PO DAILY
23. Risperidone 4 mg PO QAM
24. Bisacodyl 10 mg PR HS:PRN constipation
25. Milk of Magnesia 30 mL PO Q6H:PRN constipation
26. Acetaminophen 650 mg PO Q6H:PRN pain, fever
27. Benzonatate 200 mg PO Q8H:PRN cough
28. Clonazepam 0.5 mg PO QHS:PRN anxiety
20:00
29. Risperidone 5 mg PO HS


Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain, fever
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 10 mg PO DAILY
5. Benztropine Mesylate 0.5 mg PO BID
6. Bisacodyl 10 mg PR HS:PRN constipation
7. Citalopram 20 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Fluticasone Propionate NASAL 1 SPRY NU DAILY
10. Furosemide 20 mg PO DAILY
11. Labetalol 200 mg PO BID
12. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
13. Lisinopril 30 mg PO DAILY
14. Milk of Magnesia 30 mL PO Q6H:PRN constipation
15. Multivitamins 1 TAB PO DAILY
16. Omeprazole 40 mg PO DAILY
17. Ranitidine 300 mg PO HS
18. Risperidone 4 mg PO QAM
19. Risperidone 5 mg PO HS
20. Senna 1 TAB PO HS
21. Lantus *NF* (insulin glargine) 58 units SUBCUTANEOUS QPM
at 20:00
22. NovoLIN R *NF* (insulin regular human) 12 units INJECTION
DAILY
7:30 AM
23. NovoLIN R *NF* (insulin regular human) 12 units INJECTION
DAILY
12:30
24. NovoLIN R *NF* (insulin regular human) 8 units INJECTION
DAILY
dinner
25. Clonazepam 0.5 mg PO QHS:PRN anxiety
20:00
26. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg
base)/3 mL Inhalation QID
27. guaiFENesin *NF* 600 mg Oral [**Hospital1 **]
28. Clonazepam 0.5 mg PO BID
29. Benzonatate 200 mg PO Q8H:PRN cough


Discharge Disposition:
Extended Care

Facility:
Kindrid in Malborough

Discharge Diagnosis:
Primary: Tracheal stenosis, chronic respiratory failure

Secondary: schizoaffective disorder, diabetes mellitus


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Dear Ms. [**Known lastname 174**],

You were seen in the hospital for your dislodged tracheostomy
tube, which was replaced by our interventional pulmonology team.

No changes were made to your medications. Please take your
medications as previously prescribed.


Followup Instructions:
Department: Pulmonary
When:The Pulmonary department is working on a follow up
appointment for you in [**3-13**] days after your hospital discharge.
You will be called with the appointment date and time. If you
have not heard from the office or have questions please call the
Pulmonary Department at ([**Telephone/Fax (1) 513**].

Per Speech and Swallow:
She was evaluated by speech and swallow, and their
recommendations were regular diet but the CUFF ON THE TRACH TUBE
NEEDS TO BE DOWN WHILE EATING. Also, she cannot tolerate the
valve for speaking at this time, so she will need reevaluation
at a later time at the nursing home.
{'Personal history of allergy to penicillin,Personal history of allergy to other antibiotic agent,Surgical operation with formation of external stoma causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in residential institution,Mechanical complication of tracheostomy,Acute and chronic respiratory failure following trauma and surgery,Schizoaffective disorder, chronic,Other abnormal granulation tissue,Chronic airway obstruction, not elsewhere classified,Dysthymic disorder,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Chronic pain syndrome,Esophageal reflux,Personal history of tobacco use,Hypopotassemia,Disorders of phosphorus metabolism,Anemia, unspecified,Leukocytosis, unspecified,Unspecified late effects of cerebrovascular disease'}


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: Tracheostomy Tube Displacement

PRESENT ILLNESS: 67F w h/o schizoaffective d/o, DM, HTN, chronic respiratory
failure, tracheal stenosis now sp trach/peg presents from [**Hospital1 1501**]
after accidentally pulling out her trach this AM. Denied any SOB
or difficulty breathing, although endorsed some "noisy
breathing" while in the ED.  Patient currently protecting airway
and was speaking in full sentences in the ED.  Pt has a history
of subglottic stenosis since [**2103**] with multiple trach tube
changes and granulation tissue noted around the tube.  Of note
she has had several episodes of the trach being pulled out.

MEDICAL HISTORY: 1. Respiratory failure requiring intubation, followed by failure
to wean, requiring tracheostomy.
2. Post-intubation tracheal stenosis, requiring chronic
tracheostomy.
3. Subglottic stenosis causing nearly 90% occlusion of the
airway status post rigid bronchoscopy, tracheal dilatation and
redo percutaneous tracheostomy on [**2106-10-12**].
4. Type 2 diabetes mellitus, insulin dependent.
5. Chronic pain disorder.
6. Schizoaffective disorder.
7. Depression.
8. Hypertension.
9. Glaucoma.
10. Cataracts bilaterally.
.
PAST SURGICAL HISTORY:
1. Trach and PEG placement initially in [**2105-5-5**].
2. Rigid bronchoscopy, tracheal dilatation and redo percutaneous
tracheostomy on [**2106-10-12**].

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from  nursing home records.
1. NovoLIN R *NF* (insulin regular human) 12 units  Injection
daily
7:30 AM
2. NovoLIN R *NF* (insulin regular human) 12 units Injection
daily
12:30
3. NovoLIN R *NF* (insulin regular human) 8 units Injection
daily
dinner
4. Lantus *NF* (insulin glargine) 58 units Subcutaneous QPM
at 20:00
5. Lisinopril 30 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Amlodipine 10 mg PO DAILY
8. Furosemide 20 mg PO DAILY
9. Fluticasone Propionate NASAL 1 SPRY NU DAILY
10. Omeprazole 40 mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. Labetalol 200 mg PO BID
13. guaiFENesin *NF* 600 mg Oral [**Hospital1 **]
14. Docusate Sodium 100 mg PO BID
15. Clonazepam 0.5 mg PO BID
16. Benztropine Mesylate 0.5 mg PO BID
17. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg
base)/3 mL Inhalation QID
18. Senna 1 TAB PO HS
19. Ranitidine 300 mg PO HS
20. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
21. Atorvastatin 10 mg PO DAILY
22. Citalopram 20 mg PO DAILY
23. Risperidone 4 mg PO QAM
24. Bisacodyl 10 mg PR HS:PRN constipation
25. Milk of Magnesia 30 mL PO Q6H:PRN constipation
26. Acetaminophen 650 mg PO Q6H:PRN pain, fever
27. Benzonatate 200 mg PO Q8H:PRN cough
28. Clonazepam 0.5 mg PO QHS:PRN anxiety
20:00
29. Risperidone 5 mg PO HS

ALLERGIES: Penicillins / Keflex

PHYSICAL EXAM: General: intubated, sedated
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL
Neck: supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic
murmur
Lungs: clear to ausculation bilaterally when auscultated
anteriorly
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: not responding to verbal stimulation or sternal rub, not
responding to commands

FAMILY HISTORY: Father: died brain tumor
Mother: died from CHF

SOCIAL HISTORY: Prior to hospitalization for PNA in Summer [**2104**], the patient
lived alone in [**Location (un) 1294**]; she now lives at [**Hospital 44563**]
nursing home ([**Hospital1 **] system). She retired as a school teacher
(French and [**Doctor First Name 533**]). She smoked 2 ppd for 40 years. 

### Response:
{'Personal history of allergy to penicillin,Personal history of allergy to other antibiotic agent,Surgical operation with formation of external stoma causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in residential institution,Mechanical complication of tracheostomy,Acute and chronic respiratory failure following trauma and surgery,Schizoaffective disorder, chronic,Other abnormal granulation tissue,Chronic airway obstruction, not elsewhere classified,Dysthymic disorder,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Chronic pain syndrome,Esophageal reflux,Personal history of tobacco use,Hypopotassemia,Disorders of phosphorus metabolism,Anemia, unspecified,Leukocytosis, unspecified,Unspecified late effects of cerebrovascular disease'}
