CHIEF COMPLAINT: 

PRESENT ILLNESS: Mr. [**Known lastname 20400**] is a 48 year old male
who was transferred from [**Hospital3 1443**] Hospital with the
diagnosis of pulmonary embolism.  He presented to [**Hospital3 1442**] with a two day complaint of severe right sided sharp
24 hour period.  CT angiogram had been done to evaluate his
symptoms revealing a right pulmonary artery embolus.  He was
started on a heparin drip and transferred to [**Hospital1 346**] for further evaluation and care.

MEDICAL HISTORY: 1.  Hypertension.

MEDICATION ON ADMISSION: 

ALLERGIES: Penicillin.

PHYSICAL EXAM: 

FAMILY HISTORY: Noncontributory except for there is no
history of clotting disorder.

SOCIAL HISTORY: He is married with children.  He has no
significant alcohol or cigarette history.  He is a truck
driver.
Other pulmonary embolism and infarction,Unspecified pleural effusion,Accidental puncture or laceration during a procedure, not elsewhere classified,Acute kidney failure, unspecified,Other shock without mention of trauma,Cardiac arrest,Empyema without mention of fistula
Pulm embol/infarct NEC,Pleural effusion NOS,Accidental op laceration,Acute kidney failure NOS,Shock w/o trauma NEC,Cardiac arrest,Empyema w/o fistula
Admission Date:  [**2124-10-23**]       Discharge Date:  [**2124-11-16**]

Date of Birth:   [**2076-10-13**]       Sex:  M


HISTORY OF PRESENT ILLNESS:  Mr. [**Known lastname 20400**] is a 48 year old male
who was transferred from [**Hospital3 1443**] Hospital with the
diagnosis of pulmonary embolism.  He presented to [**Hospital3 1442**] with a two day complaint of severe right sided sharp
24 hour period.  CT angiogram had been done to evaluate his
symptoms revealing a right pulmonary artery embolus.  He was
started on a heparin drip and transferred to [**Hospital1 346**] for further evaluation and care.

Of note, the patient had reported that he has experienced
exactly the same symptoms approximately two weeks prior to
and received a ten day course of antibiotics and no other
further work-up or evaluation, however, his symptoms did
spontaneously resolve.

His pulmonary embolus risk factors include long sitting as a
truck driver; no family history of deep venous thrombosis or
pulmonary embolism.  No hypercoagulable syndrome.  No prior
history of clot.  He is not a tobacco user and he has no
history of malignancy.

PAST MEDICAL HISTORY:
1.  Hypertension.

ALLERGIES:   Penicillin.

MEDICATIONS ON TRANSFER:
1.  Atenolol.
2.  Heparin drip.

SOCIAL HISTORY:  He is married with children.  He has no
significant alcohol or cigarette history.  He is a truck
driver.

FAMILY HISTORY:  Noncontributory except for there is no
history of clotting disorder.

PHYSICAL EXAMINATION:  On admission is notable for vital
signs of temperature 102.0 F.; pulse rate of 126; blood
pressure 134/85; respiratory rate was 30 with a saturation of
96% on six liter face mask.  In general, he is alert and
oriented times three.  He was in a significant amount of
pain.  HEENT was notable for pupils being equal, reactive and
round to light and accommodation.  Extraocular movements are
intact.  Oropharynx was clear.  Mucous membranes were moist.
He was having some pursed lip breathing.  Lungs:  He had left
base crackles, otherwise right was markedly decreased.  He
was clear at the apices.  On heart examination, tachycardia,
regular, no murmurs, rubs or gallops.  He did have a
prominent S1.  Abdomen is soft, nontender, nondistended.  No
hepatosplenomegaly.  Lower extremities had two plus bilateral
dorsalis pedis and posterior tibial pulses.  He had no
cyanosis, clubbing or edema.  There was no calf tenderness.
[**Last Name (un) 5813**] sign was negative.

LABORATORY:  On admission, white blood cell count 12.1,
hematocrit 42.4, platelet count 149, BUN and creatinine were
12 and 1.0.  His PTT on transfer was 48.9, CK of 121.  His
calcium, magnesium, phosphorus and remainder of his
electrolyte profile were within normal limits.

Outside hospital just showed chest x-ray significant for a
right pleural effusion.

CT angiogram was consistent with a right pulmonary embolus.

HOSPITAL COURSE:  Hemodynamically he was stable.  There was
no indication for clot lysis on transfer.  He was on heparin
and he was started on Coumadin 5 mg q. day.  He was started
on a hypercoagulable work-up at the outside hospital and this
was continued.  Over the next 24 hours, the patient was on
Telemetry and being watched appropriately.

He had a cardiogram on admission which just showed sinus
tachycardia at 107 beats per minute.  His PR interval was
approximately 0.173 milliseconds with a QRS of 89
milliseconds.  His QT interval was 283 milliseconds.  A QTC
value of 377 milliseconds was additionally noted.  He had a
slight right shifted axis at minus 23.  Normal P waves.  He
had a delayed R wave progression in V4, V5.  He had no
pathologic Q's.  He had a narrow complex QRS otherwise.  No
evidence of left ventricular hypertrophy; there was no
evidence of heart strain.  He had normal ST-T segments and he
did have T wave flattening in III and AVF.

This was repeated, however, at the time of admission at the
[**Hospital1 69**].  At that time, he had
an abnormal R wave progression upright in V3 transitioning at
V5.  There were no Q waves.  His axis had shifted to plus 60
degrees.  He still had a narrow complex QRS and was in sinus
tachycardia at 144.  There was evidence of right heart strain
with an S in I, a Q in III, and a T wave inversion in III as
well.

Of note on admission, the patient also was describing
hemoptysis and pleuritic chest pain, tachycardia and
respiratory distress and with a right strain pattern on EKG,
all suggested a pulmonary embolism and consistent with the CT
angiogram findings after being admitted to the Medical
Intensive Care Unit.

The patient remained febrile at 101.6 F., to 102.0 F. range.
He was still tachypneic in the 30s, saturating approximately
94% on 10 liter face mask.  He required extensive dosing of
morphine to control his pain.  He continued on a heparin
infusion which was therapeutic with PTT values in the 55 to
60 range.  A central access was required for invasive
hemodynamic monitoring.  On hospital day number two, the CVP
was measured to be 13 with right ventricular pressures 36/5,
PA pressure of 36/20, a wedge of 16.

Serially, the patient was supported.  He underwent
thoracentesis to investigate his effusion.  This was
completed on [**2124-10-25**].  An opening pressure of 7 cm of
water was noted.  The patient became pale and hypotensive at
the end of the procedure at which time the thoracentesis was
aborted.  The patient was placed in Trendelenburg position
and resuscitated with fluids.  Approximately two liters of
gross blood was removed at the time of the right sided
thoracentesis. Thoracic surgery was consulted and a right chest
tube was placed without any significant drainage.  Despite
agressive resuscitation, he continued with hemodynamic
instability and was taken to the OR for urgent exploration to
manage the hemorrhage and drain a potential empyema.  During
positioning he suffered an asystolic arrest and CPR
immediately initiated.  Silmultaneously, he underwent a emergent
left resuscitative thoracotomy and right thoracotomy (clam-shell
incision) and an abdominal exploration.  After internal cardiac
message, futher resuscitation and epinephrine/atropine he
recovered his own rhythym. Operative findings included a right
empyema and fresh blood arround the liver, but no ongoing
bleeding. His right lung was decorticated and chest and abdomen
closed with a silo because of edema. The next day he was taken
back to the OR and his chest and abdomen closed.
     He slowly came off pressures and the vent was weened down.
However, he was very slow to wakeup.  Because of concern over
possible hypoxic brain injury during his code neurology was
consulted.  It was felt that he likely suffered some degree of
hypoxic brain injury and that improve. However, a Brain MRI did
not show this.  Due to his persistent ventilatory needs, he
underwent a tracheostomy and PEG placement on [**2124-11-10**].  He
subsequently developed a line sepsis.  He then deveoped a severe
allergic reaction to a ceflosporin used to treat this, including
an allergic nephritis with renal insufficiency. After recovering
from this he weaned off the ventilator
and was discharged to rehab.  He was interactive with family, but
not back to baseline. At the time of discharge he was
postoperative day number 22,
20 and 7, from the three previously mentioned procedures.  He
was off of Fluconazole, still on Vancomycin, still taking
Ciprofloxacin.  His temperature maximum was 100.2 F.; his
blood pressure was ranging 100 to 130 systolic with a
diastolic pressure of 60, heart rate of 110, respiratory rate
of 15.  He was saturating at 95% on tracheostomy mask 50%.
His gas on that was significant for a pH of 7.45, pACO2 of
36, pAO2 of 81, base excess of minus two, saturating at 96%,
otherwise looking comfortable.

His hematocrit at this time was 37.2; he had a BUN and
creatinine of 20 and 0.8.  He still had a left PICC which is
day number three, a left radial arterial line which was day
seven, a PEG, a tracheostomy and continued to make some
improvements neurologically.  He was just being supported to
start with Physical Therapy and Occupational Therapy.

He was placed back on his Atenolol 100 mg q. day to combat
blood pressure and cardiac issues.  He was on Ciprofloxacin,
day 9 of 14, continued on subcutaneous heparin and Protonix
for prophylaxis.  Given this disposition, on overall plan,
the patient looked stable and appropriate for discharge.  He
was on the following.

DISCHARGE MEDICATIONS:
1.  Impact at 90 cc per hour.
2.  Atenolol 100 mg p.o. q. day.
3.  Sliding scale insulin as needed.
4.  Subcutaneous heparin 5000 units three times a day.
5.  Reglan 10 mg intravenously q. six.
6.  Colace 100 mg p.o. twice a day.
7.  Vancomycin, day 21 of 21, completed on [**2124-11-16**].
8.  Ciprofloxacin, day number 9 of 14, to be continued until
[**2124-11-21**].
9.  Albuterol and Atrovent inhalers as needed.
10. Actigall 300 mg p.o. twice a day for some biliary stasis
issues.
11. Being offered p.r.n. Tylenol.

At this time, he was deemed appropriate and stable for
discharge to a vented rehabilitation.  He will be on his
tracheostomy collar and continue to get aggressive pulmonary
toilet.  He will continue Ciprofloxacin, as stated, for the
Pseudomonal organism that had grown out from either
tracheobronchitis or pneumonia.  He has already completed his
Vancomycin therapy for the Strep milleri as well as for his
Methicillin resistant Staphylococcus aureus in his sputum;
note that the Strep milleri was from his thoracic wound.

DISCHARGE INSTRUCTIONS:
1.  Wound care for this patient can be just a dry dressing
applied to the wound twice a day.

2.  He will continue on aggressive Physical Therapy, out of
bed, ambulating.

3.  Pulmonary toilet including coughing and deep breathing,
incentive spirometry, tracheostomy collar and suctioning as
indicated.  If he were to become tachypneic or to tire, he
should go back on a ventilator and be supported accordingly
with the rehabilitation physicians titrating the settings for
appropriate arterial blood gases.

4.  The patient should follow-up with Dr. [**Last Name (STitle) 952**] in one to
two weeks from time of discharge.


                            [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D.  [**MD Number(1) 3352**]

Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36

D:  [**2124-11-16**]  13:57
T:  [**2124-11-16**]  14:21
JOB#:  [**Job Number 44894**]\

cc:[**Last Name (NamePattern4) 44895**]

Admission Date:  [**2124-10-23**]       Discharge Date:  [**2124-11-16**]

Date of Birth:   [**2076-10-13**]       Sex:  M

Service:

HISTORY OF THE PRESENT ILLNESS:  Mr. [**Known lastname 20400**] is a 48-year-old
male with a past medical history significant for
hypertension, who was transferred by LifeFlight from [**Hospital3 1442**] Hospital with the diagnosis of PE.  The patient
stated on Saturday evening, he developed sharp pleuritic
right-sided chest pain.  He had taken Vicodin at home, which
he utilized for sleep.  He woke up on Sunday morning with
ongoing chest pain.  He went to an outside hospital, [**Hospital3 1442**] Hospital where CT angiogram revealed right pulmonary
artery embolus.  The patient was started on heparin.  The
patient was transferred to the [**Hospital1 188**] for further evaluation.  Of note, the patient reports
exactly the same type of symptoms two weeks prior to
admission.  He had gone to an outside hospital at that time.
He was given antibiotics for ten days.  The symptoms had
subsequently spontaneously resolved.  The PE risk factors
were significant for long sitting as a truck driver.  He had
no family history of hypercoagulable syndrome.  There is no
family history of pulmonary embolus/DVT.  The patient is not
a smoker.  There is no history of malignancy.

PAST MEDICAL HISTORY:  Hypertension.

ALLERGIES:  The patient is allergic to PENICILLIN.

MEDICATIONS ON TRANSFER:
1.  Atenolol.
2.  Heparin.

SOCIAL HISTORY:  The patient is married with children.  He is
a truck driver.  There is no alcohol or cigarette history.
The patient was given




                            [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D.  [**MD Number(1) 3352**]

Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36

D:  [**2124-11-16**]  13:22
T:  [**2124-11-16**]  13:29
JOB#:  [**Job Number 17540**]


Name:  [**Known lastname 8238**], [**Known firstname 126**]                     Unit No:  [**Numeric Identifier 8239**]

Admission Date:  [**2124-10-23**]     Discharge Date:  [**2124-11-24**]

Date of Birth:   [**2076-10-13**]     Sex:  M

Service:

ADDENDUM:

At last dictation, the [**Hospital 1325**] hospital course had been
updated until [**2124-11-16**].  On the date of [**2124-11-16**], the
patient was overall doing clinically well.  He was deemed
appropriate and stable for discharge, although there was some
concern from the family.  They wished that he could stay in
the hospital for an additional 36 to 48 hours for closure
monitoring.  Additionally the rehab facility that had
originally been chosen by case management and the family was
not "close enough" nor did it offer all the amenities that
the patient had hoped for, therefore a compromise was made
and the patient was to stay in-house for an additional 36 to
48 hours.

Over the next two days he was actually transferred to the
floor where he had ultimately developed severe tachypnea with
respiratory rate in the 45 to 60 range.  It was felt that the
patient required pressure support ventilation.  It was
originally planned that the patient would go to a vent rehab
regardless of his pulmonary status knowing that he would
ultimately require intermittent vent support before he was
ultimately weaned, therefore he was transferred back to an
ICU setting after being on the floor for approximately 30
hours where he got aggressive pulmonary toileting.  He was
placed on pressure support with values in the 20s.  This
ultimately decreased his overall agitation and also brought
his respiratory rate down into the 20 range.

On [**2124-11-19**], the patient was postoperative days #25, #23,
and #9.  He was finishing up his course of Ciprofloxacin
which was to end on [**2124-11-21**].  He was already transferred
to the ICU unit, was getting adequate pulmonary suctioning
and was getting pressure support ventilation.  He had been
weaned back to the value of 15 pressure support.  His peaked
remained at a value of 5 with 40% FIO2 and setting 100% with
a respiratory rate of 21.

On [**2124-11-20**], the patient was noted to have sputum with 1+
gram negative rods from [**2124-11-19**] of which had been sent for
a temperature spike of 101.6 F.  The patient was not
empirically started as his white count had been normal and
his secretions were minimal.  He continued with aggressive
pulmonary suctioning and care.  A chest x-ray had been
obtained which showed overall improvement of his prior films.
By [**2124-11-23**], the patient had already being working with
Occupational Therapy as well as Speech and Swallow and
Nutrition Service.  All of these services provided input
regarding his follow up.

Nutrition stated the patient should continue on a tube feed
regimen of ProMod  with fiber at a rate of 8 cc per hour
which would provide him with a 1,920 kilocalories, 120 grams
of protein per day which would meet his assessed nutritional
needs.  Additionally, they recommended to his basic metabolic
panel as needed to keep his electrolytes within normal
parameters and also to follow his weight one to two times per
week to ensure he was staying in a relative embolic status.

Occupational therapy recommended the patient be seen one to
three times per week and do recommended rehab with goals for
him able to sit up in his chair adequately, utilize bilateral
flexural hand splints two hours on and two hours off and just
to continue his overall OT interaction to enhance his OT
covering.

Physical Therapy stated the patient was still getting
shortness of breath and requiring a significant amount of
assistance, but was able to stand pivot.  Patient's speech
and language pathology noted he had adequate voice.  He was
able to do self suctioning for oral secretions with a
Yankauer.  He continued to work with his relative aphagia and
dysarthria which appeared to be improving.  Based on all of
the dispositioning and rehabing issues, it was deemed that
the patient was now again appropriate for discharge to a
vented rehab facility.

DISCHARGE MEDICATIONS:  To include the following and this is
the corrected list.
1.  Atenolol 100 mg p.o. b.i.d.
2.  Heparin 5000 units subcutaneous t.i.d.
3.  Reglan 10 mg per PEG tube q.i.d.
4.  Nystatin Swish and Swallow 5 cc p.o. q.i.d. p.r.n.
5.  Actigall 300 mg p.o. b.i.d. per PEG.
6.  Colace 100 mg per PEG b.i.d.
7.  Albuterol and Atrovent nebs MDI q. four around the clock.
8.  Tylenol 650 mg per PEG q. four to six p.r.n.
9.  Ambien 5 to 10 mg per PEG q.h.s p.r.n.
10. Protonix 40 mg per PEG q. day.
11. Lorazepam 1 mg q. four p.r.n. agitation.
12. Miconazole powder 2% solution one
application topically as needed.
13. Lacrilube ointment one application o.u. p.r.n.

Treatments and frequencies will include:
1.  Checking a metabolic panel every three to five days to
ensure adequate electrolyte repletion while given his tube
feeding status.
2.  Get chest PT q. six around the clock.
3.  Continue with Speech and Swallow evaluation at rehab.
Continue with PT/OT as outlined above.
4.  Will get aggressive pulmonary toileting and suctioning
and continue to encourage the patient to induce his own
pulmonary hygiene.
5.  Encourage him to undergo incentive spirometry, coughing
and deep breathing.  Diet will include ProMod with fiber at
80 cc per hour and swabs to his mouth.

His follow up appointment should be to see Dr. [**Last Name (STitle) 384**] in
approximately one to two weeks from the time of discharge and
the Rehab facility can call to arrange an appointment to be
followed up accordingly.




                          [**First Name11 (Name Pattern1) 904**] [**Last Name (NamePattern4) 1369**], M.D.  [**MD Number(1) 1370**]

Dictated By:[**Last Name (NamePattern4) 935**]

MEDQUIST36

D:  [**2124-11-23**]  10:22
T:  [**2124-11-23**]  11:05
JOB#:  [**Job Number 8240**]


Admission Date:  [**2124-10-23**]       Discharge Date: [**2124-12-19**]

Date of Birth:                    Sex:  M

Service:

ADDENDUM:  The patient was scheduled for discharge on [**2124-11-24**]; however, he spiked a temperature.  He grew out
coagulase-negative Staphylococcus from presumed line sepsis
from his peripherally inserted central catheter line.  The
peripherally inserted central catheter line was discontinued.
The patient was started on vancomycin.  He became hypotensive
due to sepsis and was started on Levophed.

Around this time it was noted that his alkaline phosphatase
and bilirubins began to rise.  On [**11-24**], and ultrasound
was done which showed distended common bile duct with sludge.
He was started on Levaquin and Flagyl to cover possible
cholangitis or other intra-abdominal infections.

A CT of the abdomen was done on [**11-24**].  It showed slight
thickening of the cecum, not associated with fat stranding.
The above finding could be secondary to not fully distended
cecum versus chronic colitis.  There was no evidence of
perforation or abscess.

On [**11-28**], the patient had a HIDA scan performed which
showed no visualization of the gallbladder, consistent with
acute cholecystitis.

A right upper quadrant ultrasound done on [**11-29**] showed
gallbladder mildly distended with sludge, thickened wall,
pericholecystic fluid.  No stones seen in the common bile
duct.  A percutaneous cholecystostomy tube was placed on
[**11-29**] with drainage of bile.  The fluid was sent for
staining.  No organisms were found.  A cholangiogram was
performed and showed normal cystic duct, intrahepatic and
extrahepatic biliary tree with flow of contrast to the
duodenum.  No ductal stones or strictures were visualized.
The bile fluid was sent for culture and did not show any
growth.

After the procedure, his alkaline phosphatase and total
bilirubin began to trend down.  They continued to trend down
over several days; however, his alkaline phosphatase (which
had been 1500) plateaued around 1000.

A repeat right upper quadrant ultrasound was done on [**12-4**] which showed no biliary ductal dilatation, no fluid
collection, and cholecystostomy tube in the appropriate
place.

The patient also was noted to have a rash around this time.
Dermatology was consulted.  It was noted that the patient's
rash corresponded to an increase in eosinophilia.
Dermatology felt that the rash was secondary to drug
interaction.  The patient was noted to have had
cephalosporins during the course of the admission.  These
were discontinued.  The rash and the eosinophilia improved
after the patient was taken off cephalosporins; mainly
ceftazidime and cefepime.

The patient remained hypotensive secondary to presumed
sepsis.  Around this time, the patient was noted to have a
rise in his creatinine.  Renal Service was consulted who felt
the acute renal failure was secondary to hypoperfusion rather
than acute tubular necrosis or acute interstitial nephritis.
It was recommended that the patient's blood pressure be kept
above 110.  Once this was accomplished with increasing
pressors, the patient's creatinine began to trend down, and
by the time of discharge, the patient's creatinine had been
at baseline for at least one week.

The patient continued to spike despite his antibiotic
therapy.  A CT of the torso was done on [**12-2**] to look
for possible intra-abdominal abscess.  It showed interval
development of multiple wedge-shaped and irregular low
attenuation fossae within the spleen; suggestive of septic
emboli.

A transesophageal echocardiogram was performed on [**11-24**]
that showed no evidence of endocarditis.  No signs of atrial
septal defect or patent foramen ovale.

The patient had a CT done of his head to look for signs of
septic emboli to the brain.  The head CT showed a small
subacute cerebellar cortical infarct; concerning for possible
emboli.  A magnetic resonance imaging was done on [**12-7**]
and showed no significant findings.  Did not see the infarct
found on the head CT.  There were no signs of abnormal
intracranial enhancement to suggest an infectious process,
and there was no evidence of infarction.

The patient was noted to have sinus and mastoid congestion
which were noted to be present earlier in the course of his
admission.

The patient became defervescent around the end of [**Month (only) 359**].
However, at this time it was also noted that his white blood
cell count started trending down from 6 down to 3.5 down to
2.4.  With concern for anemia and possible neutropenia,
Hematology was consulted.  It was noted that his platelets
remained stable.  Hematology felt that the most likely
etiology was a drug reaction; however, infectious etiologies
were also high on the list.  Vasculitis and infiltrations
were less likely; however, these were worked up.  The patient
initially had Haldol, ursodiol, and hydralazine discontinued
without effect.

In terms of infectious workup, cytomegalovirus, [**Doctor Last Name 3271**]-[**Doctor Last Name **]
virus, and parvovirus were all sent and turned out negative.
Additionally, Legionella, ehrlichiosis, and Bartonella were
also sent off.  Infiltrative processes were evaluated
initially by SPEP which was negative; later by bone marrow
biopsy which showed no evidence of malignant process and
decreased myeloid and erythroid cells; consistent with bone
marrow suppression secondary to drug reaction or infectious
process.  Vasculitis was less likely after ANCA came back
negative.  The patient was started on G-CSF.  His vancomycin
was discontinued after a 16-day course.  At that time, he was
also started on doxycycline to cover possible ehrlichiosis
mycoplasma, and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9880**] spotted fever.

The patient started spiking fevers again as aztreonam was
started in the setting of continued Pseudomonas growth in his
sputum; concern that his colonization was Pseudomonas might
present a problem in the status of his neutropenia.
Levofloxacin was also continued.  The patient was started on
G-CSF around this time.  His absolute neutrophil count fell
to as low as 70 before starting to recover.  It was felt at
this time that the most likely cause of his neutropenia was
the vancomycin.  Flagyl was also discontinued around this
time; however, it was less likely, and his titers for
mycoplasma ehrlichiosis and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9880**] spotted fever all
came up negative; so it was felt that infectious was not a
likely cause of his neutropenia.  Doxycycline was
discontinued after seven days.  The dual coverage for the
Pseudomonas were continued for seven days, and then aztreonam
and levofloxacin were discontinued.

The patient had a repeat CT scan to evaluate for progression
of his splenic infarct to see if there were any interval
changes.  The abdominal CT performed on [**2124-12-13**]
showed no change in splenic emboli, and no new infarcts.  It
also noted interval decrease in his ascites.  At this point,
it is believed that the patient does not have any ongoing
endovascular process.

The patient continued to be ventilator dependent with
withdrawal of the tracheostomy which was placed on [**2124-11-10**].  This was secondary to deconditioning, secretions, and
anxiety, and volume overload.  As his blood urea nitrogen and
creatinine had fallen with the resolution of his acute renal
failure, it was felt that the patient could be started on
diuretics to remove fluid.  The patient was up 30 liters.
The patient was diuresed over 10 liters in the ensuring week
and a half with his weight actually falling to below where it
was on admission.  At this point, the patient had no signs of
edema.  It was felt that it was reasonable to start weaning
him from the ventilator.  The patient was given a short trial
on a tracheostomy mask and was found to tolerate it.  He
continued to be given trials on tracheostomy mask; going
several hours during the day and then being rested on the
ventilator overnight.  Eventually, the patient tolerated a
tracheostomy mask 24 hours without requiring ventilatory
support.  The patient still required frequent suctioning;
however, near the end of his course, he was showing signs of
adequate clearance through cough.  The patient will likely
still need pulmonary rehabilitation in the near future before
discontinuing his tracheostomy.

In the setting of his unknown splenic infarcts, a
hypercoagulable workup was performed.  The patient was found
to have positive anticardiolipin IgM.  In the setting of this
and his persistent tachycardia, a LENI was performed on
[**2124-12-14**] and revealed a thrombus in the right greater
saphenous vein extending to the origin of the common femoral.
Radiology was consulted and felt that there was risk for
emboli, so he will be treated as having a deep venous
thrombosis.  He was started on a heparin drip and started on
Coumadin.  The patient was to be discharged on Coumadin and
switched over to Lovenox for discharge.  The patient will
require INR checks.  Lovenox can be discontinued once his INR
is therapeutic (between 2.5 and 3).  Anticoagulation should
continue for three months.

During the course of his admission, the patient was noted to
have anxiety attacks.  It was unclear what the cause of these
attacks were.  To evaluate for ischemia, electrocardiograms
were done but they showed no change.  Also, cardiac enzymes
were sent but the cardiac enzymes remained negative.  It was
felt that these attacks represented somewhat as panic
attacks.  He was started on low-dose Klonopin and Ativan as
needed with improvement in his anxiety attacks.

The patient was communicative and able to walk to some extent
on [**11-23**], around the time that he was planned to go to
rehabilitation.  From that point on, when he became septic,
the patient's mental status declined.  As his infection
improved, the patient was noted to have monoclonic jerking of
his arms.  This continued while he still had the fevers.
Eventually, the monoclonic jerking decreased.  Neurology was
consulted and believed his decreased mental status to be
related to encephalopathy from sepsis.  The magnetic
resonance imaging was done and showed no abnormalities.  No
evidence of infarcts.  The patient's mental status improved,
and the patient became more interactive.  He still was unable
to speak but was beginning to mouth words near the time of
discharge.  The patient responded to commands.  He still has
significant discoordination; much of which is secondary to
deconditioning.  However, the patient likely has some degree
of hypoxic brain injury from his original cardiac arrest
during surgery.

During the course of his admission, the patient was severely
hypertensive and tachycardic.  This was felt to be related to
fever, but agitation was also a component.  The patient was
started originally on hydralazine for blood pressure control.
He was later switched to an ACE inhibitor (captopril).  He
was also started on Lopressor.  The Lopressor was increased
to 75 mg t.i.d.  His captopril was 25 mg t.i.d.  At some
point, the patient can be switched over to once a day dosing;
but at the time of discharge he will be maintained on these
doses.

The patient received nutrition through his percutaneous
endoscopic gastrostomy tube.  While he had acute renal
failure, he was switched to Napril.  When this resolved, he
was switched to Resporal full strength.  Near the end of his
hospital course, the patient was started on cycling.  He was
advanced to 110 cc per hour for 12 hours at night.

The patient had a right subclavian in for much of his
hospital course (for 15 days).  This was discontinued prior
to discharge.  A peripheral line was placed.  The patient was
to have a peripherally inserted central catheter line placed
prior to discharge for the frequent need for blood draws and
possible antibiotics at a later time.  The patient currently
is not on antibiotics; however, he did have a low-grade
temperature.  The patient continues to have Pseudomonas
growing in his sputum.  It was unclear whether this was a
colonization or an infection.  The patient will be followed
by Infectious Disease.  If the patient continues to spike a
temperature, he should be started on antibiotics to cover the
Pseudomonas.

CONDITION AT DISCHARGE:  Condition on discharge was stable.

DISCHARGE STATUS:  Discharge status was to a pulmonary
rehabilitation facility.

MEDICATIONS ON DISCHARGE:
 1.  Warfarin 10 mg p.o. q.h.s. (to be adjusted depending on
INR).
 2.  Klonopin 0.25 mg p.o. t.i.d.
 3.  Lopressor 75 mg p.o. t.i.d.
 4.  Captopril 25 mg p.o. t.i.d.
 5.  Ativan 0.5 mg q.4-6h. as needed.
 6.  Lansoprazole 30 mg per nasogastric tube q.d.
 7.  Lactulose 30 mL p.o. q.8h. p.r.n.
 8.  Bisacodyl 10 mg p.o. q.d. as needed.
 9.  Atrovent 2 puffs inhaled q.d.
10.  Albuterol 1 to 2 puffs inhaled q.4h. as needed.
11.  Colace 100 mg p.o. b.i.d.
12.  Resporal full strength via tube feeds.

DISCHARGE FOLLOWUP:   The patient was to follow up with Dr.
[**Last Name (STitle) **] and through the Infectious Disease Clinic.

DISCHARGE DATE:  Projected date of discharge is [**2124-12-20**].



                         DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-367



Dictated By:[**Name8 (MD) 9508**]
MEDQUIST36

D:  [**2124-12-19**]  17:05
T:  [**2124-12-19**]  17:22
JOB#:  [**Job Number 44896**]


Name:  [**Known lastname 8238**], [**Known firstname 126**]                     Unit No:  [**Numeric Identifier 8239**]

Admission Date:  [**2124-10-23**]     Discharge Date:  [**2124-12-28**]

Date of Birth:   [**2076-10-13**]     Sex:  M

Service:  MICU

DISCHARGE MEDICATION:
1.  Amoxapine sodium 90 mg subq q 12 hours.
2.  Docusate sodium 100 mg po b.i.d.
3.  Albuterol one to two puffs IH q 4 p.r.n.
4.  Captopril 25 mg po t.i.d.
5.  Clonazepam 1 mg po t.i.d.,
6.  Lansoprazole 30 mg nasogastric q.d.
7.  Lorazepam .5 mg intravenous q 6 p.r.n.
8.  Acetaminophen 325 to 650 mg po q 4 to 6 p.r.n.
9.  Lactulose 30 ml po q 8 p.r.n.
10. Milk of Magnesia 30 ml po q 6 h p.r.n.
11. Zolpidem tartrate 5 mg po q.h.s. p.r.n.
12. Ipratropium bromide two puffs IH q 4 to 6 hours p.r.n.
13. Atenolol 75 mg po q day.
14. Warfarin 5 mg po q day; will need INR checks.

Please review previous discharge summary dictated for
complete hospital course.

ACTIVE ISSUES [**12-24**] to [**12-28**]:  Neurological:  Over the last
few days of admission the patient's neurologic status
improved.  The patient is able to mouth and speak several
words, able to follow multistep commands.  With Physical
Therapy able to bear weight and perform at least six
footsteps.

Hematology:  The patient's Coumadin was held beginning on
[**12-26**] for possible PICC line placement, however, given lack
of necessity for intravenous antibiotics PICC line placement
was deferred.  Coumadin will be initiated on [**12-27**] (Coumadin
of 10 mg).  We recommended monitoring of INR over the next
week until therapeutic.  The Lovenox may be discontinued.
Please initiate Warfarin 5 mg po q.h.s.

Tachycardia:  The patient has a history of tachycardia.  We
note that the tachycardia improved slightly over the last
several days of admission to an a.m. heart rate of
approximately 100.  We increased beta blocker Atenolol 75 mg
po q day.

Infectious disease:  Patient received a nine day course of
Tobramycin, Linezolid and Imipenem for Pseudomonas aureus
sputum/tracheal bronchitis.  The patient remained afebrile
for six days prior to discharge.  We recommend monitoring the
patient off of antibiotics.  Of note the patient has a
history of recurrent pleural effusions.

Respiratory:  The patient's respiratory status improved over
the last several days of admission.  On discharge the
patient's O2 saturation is 98% on room air with tracheostomy.

Cholecystostomy:  Of note the patient's cholecystostomy must
be removed on [**1-13**].

Prophylaxis:  On Pepcid, Lovenox, Coumadin re-initiated on
[**12-27**].

DISPOSITION:  The patient is to be discharged to [**Hospital1 **]
Acute Rehab.  A family meeting was held on [**12-17**] to
discuss complete plans.  Family agreed with plan.

DISCHARGE DIAGNOSES:
1.  Pneumonia.
2.  Empyema.
3.  Thoracotomy.
4.  Asystole in Operating Room.
5.  Infection, strep milleri, C. albicans, MRSA, Pseudomonas,
coag negative staph, septic ascending cholangitis.
6.  Respiratory failure.
7.  Anoxic brain injury.
8.  Splenic infarction.
9.  Neutropenia, history of drug rash.
10. Fever.
11. Persistent pleural effusion.
12. Thoracentesis for liver.
13. Greater saphenous vein thrombosis.
14. Cholecystostomy tube.

DISCHARGE CONDITION:  Fair.

TREATMENT AND FREQUENCIES:
1.  Checking metabolic panel over three to five days to
ensure adequate electrolyte repletion when given tube
feeding.
2.  Get chest physical therapy q six around the clock.
3.  Continuous speech and swallowing evaluation at rehab.
Continue with PT/OT.
4.  Aggressive pulmonary toilet and suctioning, continue
encouraging the patient to induce his own pulmonary hygiene.
5.  Encourage to undergo incentive spirometry, coughing and
deep breathing, include Risperdal cycled q 12 hours (please
see nursing notes for complete nursing care and
instructions).

FOLLOW UP:
1.  We recommend Mr. [**Known lastname **] make follow up appointments with
Dr. [**Last Name (STitle) 384**] within one month.
2.  We recommend Mr. [**Known lastname **] make follow up plans with Dr.
[**Last Name (STitle) **] in one month.  Mr. [**Known lastname 8241**] cholecystostomy
must be removed on [**1-13**].


                          [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) 304**], M.D.  [**MD Number(1) 594**]

Dictated By:[**Last Name (NamePattern1) 3021**]

MEDQUIST36

D:  [**2124-12-28**]  10:45
T:  [**2125-1-3**]  11:18
JOB#:  [**Job Number 8242**]
{'Other pulmonary embolism and infarction,Unspecified pleural effusion,Accidental puncture or laceration during a procedure, not elsewhere classified,Acute kidney failure, unspecified,Other shock without mention of trauma,Cardiac arrest,Empyema without mention of fistula'}


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: Mr. [**Known lastname 20400**] is a 48 year old male
who was transferred from [**Hospital3 1443**] Hospital with the
diagnosis of pulmonary embolism.  He presented to [**Hospital3 1442**] with a two day complaint of severe right sided sharp
24 hour period.  CT angiogram had been done to evaluate his
symptoms revealing a right pulmonary artery embolus.  He was
started on a heparin drip and transferred to [**Hospital1 346**] for further evaluation and care.

MEDICAL HISTORY: 1.  Hypertension.

MEDICATION ON ADMISSION: 

ALLERGIES: Penicillin.

PHYSICAL EXAM: 

FAMILY HISTORY: Noncontributory except for there is no
history of clotting disorder.

SOCIAL HISTORY: He is married with children.  He has no
significant alcohol or cigarette history.  He is a truck
driver. 

### Response:
{'Other pulmonary embolism and infarction,Unspecified pleural effusion,Accidental puncture or laceration during a procedure, not elsewhere classified,Acute kidney failure, unspecified,Other shock without mention of trauma,Cardiac arrest,Empyema without mention of fistula'}
