CHIEF COMPLAINT: Cough, shortness of breath

PRESENT ILLNESS: Patient is an 84 year old male with past medical history of
Parkinson's disease, CHF, CAD, and DM, who presents with 1 week
history of productive cough, 4 days of nausea and vomiting, and
1 day of diarrhea.  He states that he has been feeling 'sick'
for the past week, with the above constellation of symtpoms.  He
has not had a fever or chills.  He started with some loose
stools, then developed a cough productive of white sputum.  The
cough has persisted.  He then developed some nasusea and
vomiting.
.
He has also felt a bit more SOB this past week.  He relates that
he does not do much walking at baseline, but gets SOB with going
up 5 stairs.  He has felt some SOB at rest this past week.  He
has not had any chest pain.  His LE swelling has been much
better recently.
.
He has continued to take all of his medications this week,
including his oral hypoglycemics, warfarin, and lasix.
.

MEDICAL HISTORY: 1. CAD, cath 5 years ago at NEBH (cardiologist [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **])
2. CHF, TTE [**3-5**] w/depressed EF
3. Hypertension, per daughter pt's bp usually 90s-100s on meds
4. Severe Lumbar Spinal stenosis, mild cervical stenosis
5. Sleep apnea, on 2L home O2 at night
6. Afib, s/p DCCV which failed, now rate controlled
7. Arthritis
8. Gout
9. COPD? No PFTs
10. NIDDM
11. E-coli-Sepsis (admission [**2122-12-23**] - [**2123-1-1**])
12. BPH? (Flomax)
13. Parkinson's disease ? ?sinemet

MEDICATION ON ADMISSION: Wellbutrin 100mg ER by mouth every morning
Celebrex 200 mg qd
Coumadin 2.5 mg alternating with 5 mg
Protonix 40 mg,
Lasix 160 mg,
potassium 20 mEq,
Crestor 5 mg,
carbidopa 25 mg/100 mg one three times a day,
Flomax 0.4 mg,
glipizide 5 mg two a day,
colchicine 0.6 mg every other day,
Niaspan 500 mg,
trazodone 100 mg at bedtime,
[**Doctor First Name **] 180 mg,
sotalol 80 mg two times a day,
doxepin 100 mg at bedtime for skin itch,
lidocaine patches on the knees.
metolazone MWF
.
MEDICATIONS ON TRANSFER
Acetaminophen 650 mg PO q6h
Aspirin 81 mg PO
Bupropion 100 mg PO qAM
Carbidopa-levodopa 25-100 1 tab po TID
Docusate 100 mg PO BID:PRN
Fexofenadine 60 mg PO BID
Insulin scale
Ipratropium bromide Neb, 1 neb IH q6h
Levofloxacin 750 mg PO q48h
Lidocaine 5% patch 1 ptch TD daily
Niaspan 500 mg oral daily
Ondansetron 4-8 mg IV q8H: nausea
Pantoprazole 40 mg PO q24h
Potassium prn per lytes
Rosuvastatin calcium 5 mg PO daily
Senna 1 tab PO BID:PRN
Sotalol 40 mg PO BID
Tamsulosin 0.4 mg PO HS
Xopenex 0.63 mg/3 mL inhalation q6-8h prn wheezing/SOB
Trazodone 100 mg PO HS:PRN

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE on admission:
Physical Exam: 98.0  90/50  75  18  95% 2L
General: Elderly male with masked facies, speaking full
sentences, NAD
HEENT: MMdry, anicteric, EOMI, no sinus tenderness
Neck: Supple, JVP 6cm, no LAD
Cardiac: Irreg irreg, no m/r/g
Chest: Bilateral diffuse wheeze, no rales, no consolidation
Abdomen: obese, soft, nt, nd, pos bs on left, quiet on right
Extr: no c/c/e
Skin: multiple excoriations, scar from prior BCC removal on back
Neuro: AAO x 3, masked facies, cn intact, pill rolling  tremor,
minor cogwheel rigidity on right
Psych: Flat affect, appropriate
Msk: FROM at both knees, right slightly warmer than left
.
On transfer from MICU to medicine floor:
Baseline Physical Exam (on transfer to medicine floor from
MICU):
t 98.8
bp 96/56
hr 80
rr 20 by vitals sheet; 28 by my exam slightly later
o2 sat: 98% RA
.
General: Elderly man with visibly faster-than-usual respiratory
rate but without evident discomfort
HEENT: PERRL, EOMI; anicteric
Neck: JVD not appreciated on my exam (8 cm by prior MICU attg
note)
Cardiac: Mostly regular rate with occasional "extra
beats"/irregular beats; no murmurs or rubs appreciated
Chest: Expiratory wheezing heard throughout, good air movement
throughout, no rales appreciated
Abdomen: BS+, NT, ND
Extr: 1+ edema
Skin: ecchymoses on arms, IV sites, hands; several scabs on face

FAMILY HISTORY: Notable for CAD, HTN, and stroke.

SOCIAL HISTORY: Patient uses a cane for assistance at baseline. He lives with
his daughter [**Name (NI) 13118**]. Formerly worked at Sears. Widowed. No tobacco
or EtOH use.
Acute kidney failure, unspecified,Acidosis,Urinary tract infection, site not specified,Other and unspecified coagulation defects,Chronic diastolic heart failure,Unspecified viral infection,Gout, unspecified,Coronary atherosclerosis of native coronary artery,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic airway obstruction, not elsewhere classified,Intestinal infection due to other organism, not elsewhere classified,Acute bronchitis,Paralysis agitans,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified
Acute kidney failure NOS,Acidosis,Urin tract infection NOS,Coagulat defect NEC/NOS,Chr diastolic hrt fail,Viral infection NOS,Gout NOS,Crnry athrscl natve vssl,Atrial fibrillation,DMII wo cmp nt st uncntr,Chr airway obstruct NEC,Viral enteritis NOS,Acute bronchitis,Paralysis agitans,BPH w/o urinary obs/LUTS,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS
Admission Date:  [**2124-12-11**]              Discharge Date:   [**2124-12-20**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Cough, shortness of breath

Major Surgical or Invasive Procedure:
None


History of Present Illness:
Patient is an 84 year old male with past medical history of
Parkinson's disease, CHF, CAD, and DM, who presents with 1 week
history of productive cough, 4 days of nausea and vomiting, and
1 day of diarrhea.  He states that he has been feeling 'sick'
for the past week, with the above constellation of symtpoms.  He
has not had a fever or chills.  He started with some loose
stools, then developed a cough productive of white sputum.  The
cough has persisted.  He then developed some nasusea and
vomiting.
.
He has also felt a bit more SOB this past week.  He relates that
he does not do much walking at baseline, but gets SOB with going
up 5 stairs.  He has felt some SOB at rest this past week.  He
has not had any chest pain.  His LE swelling has been much
better recently.
.
He has continued to take all of his medications this week,
including his oral hypoglycemics, warfarin, and lasix.
.

ED Course:
Patient's vitals were noted to be: 97.3  75  86/56  16  96%ra.
He was given 750 mg of levofloxacin, potassium, Vancomycin 1
gram, and 10 mg of Vitamin K.  He had a CXR which was not read
as a pneumonia.

.
ROS: Denies sick contacts or recent hospitalizations.  He denies
dysuria, abdominal pain, HA, ST, chest pain, hematochezia,
melena, myaligias.  He endorses knee pain bilaterally,
rhinorrhea.
.


Past Medical History:
1. CAD, cath 5 years ago at NEBH (cardiologist [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **])
2. CHF, TTE [**3-5**] w/depressed EF
3. Hypertension, per daughter pt's bp usually 90s-100s on meds
4. Severe Lumbar Spinal stenosis, mild cervical stenosis
5. Sleep apnea, on 2L home O2 at night
6. Afib, s/p DCCV which failed, now rate controlled
7. Arthritis
8. Gout
9. COPD? No PFTs
10. NIDDM
11. E-coli-Sepsis (admission [**2122-12-23**] - [**2123-1-1**])
12. BPH? (Flomax)
13. Parkinson's disease ? ?sinemet


Social History:
Patient uses a cane for assistance at baseline. He lives with
his daughter [**Name (NI) 13118**]. Formerly worked at Sears. Widowed. No tobacco
or EtOH use.

Family History:
Notable for CAD, HTN, and stroke.

Physical Exam:
PE on admission:
Physical Exam: 98.0  90/50  75  18  95% 2L
General: Elderly male with masked facies, speaking full
sentences, NAD
HEENT: MMdry, anicteric, EOMI, no sinus tenderness
Neck: Supple, JVP 6cm, no LAD
Cardiac: Irreg irreg, no m/r/g
Chest: Bilateral diffuse wheeze, no rales, no consolidation
Abdomen: obese, soft, nt, nd, pos bs on left, quiet on right
Extr: no c/c/e
Skin: multiple excoriations, scar from prior BCC removal on back
Neuro: AAO x 3, masked facies, cn intact, pill rolling  tremor,
minor cogwheel rigidity on right
Psych: Flat affect, appropriate
Msk: FROM at both knees, right slightly warmer than left
.
On transfer from MICU to medicine floor:
Baseline Physical Exam (on transfer to medicine floor from
MICU):
t 98.8
bp 96/56
hr 80
rr 20 by vitals sheet; 28 by my exam slightly later
o2 sat: 98% RA
.
General: Elderly man with visibly faster-than-usual respiratory
rate but without evident discomfort
HEENT: PERRL, EOMI; anicteric
Neck: JVD not appreciated on my exam (8 cm by prior MICU attg
note)
Cardiac: Mostly regular rate with occasional "extra
beats"/irregular beats; no murmurs or rubs appreciated
Chest: Expiratory wheezing heard throughout, good air movement
throughout, no rales appreciated
Abdomen: BS+, NT, ND
Extr: 1+ edema
Skin: ecchymoses on arms, IV sites, hands; several scabs on face

Neuro: strength 4+ and symmetrical at: grip, pedal
dorsi/plantarflexion, biceps/triceps, shoulder shrug. CN: as
above EOMI and PERRL, tongue to midline, palate elevates, no
facial asymmetry, no slurring of speech, shoulder shrug intact.
Alert and oriented to place, town, date, day, year, self.
Psych: appropriate range of affect
Msk: slightly swollen R knee with bandaid and betadyne stains
c/w recent tap; tender inferior and medial to patella.
.


Pertinent Results:
[**2124-12-11**] 08:57PM   WBC-13.8* RBC-4.30* HGB-13.8*# HCT-40.4
MCV-94 MCH-32.2* MCHC-34.2 RDW-14.4
[**2124-12-11**] 08:57PM   NEUTS-83.9* LYMPHS-8.3* MONOS-7.0 EOS-0.6
BASOS-0.1
[**2124-12-11**] 08:57PM   PLT COUNT-232
[**2124-12-11**] 08:57PM   PT-64.5* PTT-55.3* INR(PT)-8.1*
.
[**2124-12-11**] 08:53PM   LACTATE-2.0
.
[**2124-12-11**] 08:57PM   GLUCOSE-87 UREA N-94* CREAT-3.9*# SODIUM-133
POTASSIUM-3.1* CHLORIDE-87* TOTAL CO2-25 ANION GAP-24*
.
[**2124-12-11**] 08:57PM   CK(CPK)-173
[**2124-12-11**] 08:57PM   CK-MB-4 cTropnT-0.05*
.
[**2124-12-11**] 11:42PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2124-12-11**] 11:42PM URINE  BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2124-12-11**] 11:42PM URINE  RBC-[**7-9**]* WBC-0-2 BACTERIA-FEW
YEAST-NONE EPI-0-2

Brief Hospital Course:
Patient is an 84 year old male with past medical history
significant for CAD, CHF, DM, and atrial fibrillation who
presents from home with one week of productive cough, decreased
PO intake, diarrhea, and N/V.
.
# Cough/N/V:
As the hospital course continued, we felt it most likely that he
had a viral syndrome that led to nausea, vomiting, decreased PO
intake, and cough. His productive cough with a leukocytosis was
initially concerning for pneumonia; however, his chest x-rays
were unrevealing. His vomiting by his history was actually
ambiguous and may have represented violently coughing up large
quantities of white sputum, according to his daughter's history.
.
Given the possibility of pneumonia, he was started on
levofloxacin for community acquired pneumonia, which was
discontinued on the equivalent of day [**7-6**] of the course
(uncertainty based on changing renal function at the time of
discontinuation). Vancomycin was started as well for this, but
was discontinued given that patient lives at home and has not
had a lot of exposure to the healthcare system.  Vancomycin was
re-introduced for concern for septic joint (see below). Cultures
were unrevealing, influenza DFA was negative, legionella ag was
negative, and follow-up chest x-rays were unrevealing.
.
When on the medicine floor he continued to be afebrile. His
white count rose while on the medicine floor; given that his
respiratory status remained stable, this was judged unlikely to
be secondary to the respiratory infection, and ultimately, more
likely to be the result of a florid gout flare.
.
# Atrial fibrillation: In the MICU he was continued on sotalol,
dosed 40 mg [**Hospital1 **] in light of ARF; he is on 80 mg [**Hospital1 **] at baseline.
As his renal function improved he had an episode of afib with
RVR to the 150s, with hypotension (70s over palp), for which he
was triggered, given IV metoprolol and IV fluids; this
eventually resolved, and he was then continued on 80 mg sotalol
[**Hospital1 **] thereafter, and had no further episodes of RVR.
.
His anticoagulation was held, first because of supratherapeutic
INR, and then because of concern for hemorrhagic joint. He was
started on enoxaparin (Lovenox) on [**2124-12-17**]. He was then started
on warfarin on [**2124-12-18**].
.
# Hypotension: Appears to be at baseline at this time, mainly in
90s-100s, and his baseline SBP is 80's to 90's per OMR records.
He responded well to the fluids given during first day of
admission.  His lactate was 2.0 at admission, and he remains not
tachycardic.  Ultimately we felt that it was more likely that
his hypotension was due to low baseline BP and severe
dehydration in setting of poor PO intake and diarrhea/vomiting.
He had one other episode of hypotension, which was clearly
secondary to afib with RVR, described above.
.
# Knee swelling, likely gout: Patient has right knee that
appeared bruised on admission, with possible joint effusion
appreciated. Rheumatology was consulted, given history of gout
as well as history of septic joint in setting of gout infection.
Joint aspiration of the R knee revealed hemarthrosis with joint
fluid Hct of 42, which was confirmed by MRI. Joint aspiration of
the L knee revealed a high white count ([**Numeric Identifier 24869**]). Both taps showed
gout crystals. Because of our initial concern for septic joint
we treated first with Ancef, and then when his white cell count
continued to rise and his joints appeared to be more inflamed,
we switched to vancomycin with concern for MRSA. However, he
remained afebrile and joint cultures were negative, as were
joint fluid gram stains; we thus discontinued antibiotics for
the joint. We consulted the [**Numeric Identifier 1083**] diseases service which
recommended this discontinuation of antibiotics followed by
close observation.
.
We treated pain with colchicine, celebrex, lidocaine patches,
tylenol, ultram, and ultimately steroids to reduce inflammation.
We avoided opioids because his family had given us the history
of delirium with mild opiates (likely codeine), and we judged
him to be at significant risk for delirium as well as for falls
should he become delirious.
.
At this point we believe that the hemarthrosis in the R joint
would be best dealt with by physical therapy that kept the joint
flexible, and would expect that this hemarthrosis will gradually
dissolve and be reabsorbed, particularly in the context of
anticoagulation therapy; we see no indication of rebleeding. We
had been holding colchicine in the setting of ARF but restarted
it. He also got celebrex as an anti-inflammatory.
.
# Diarrhea: He has had several days of diarrhea, with no recent
exposure ot antibiotics or health care institutions.  This could
be part of a viral syndrome. With a climbing white count we were
concerned for C. diff and had him on flagyl for several days;
however, C. diff toxin assays were negative twice and he was
taken off precautions and we did not continue flagyl. He had
formed stool starting several days before discharge. His
cultures were all negative.
.
# Acute renal failure: His creatinine was 3.9 at admission. With
hydration and holding his lasix, his creatinine declined to 1.5
before rising slightly again before discharge once a small dose
of lasix (40 mg daily compared to his 160 mg daily home dose)
was restarted. This was held once more. His urine lytes and
clinical picture was consistent with a mainly pre-renal picture,
worse on admission secondary to poor PO and diarrhea. Urine
output improved substantially. He will need to have his lasix
dose titrated back up as his gout flare and renal function
improve again, as he has consistently had lower extremity edema
that has responded well to lasix in the past.
.
# Coronary artery disease: Per records, he had a cath at NEBH
with Dr. [**Last Name (STitle) **] that showed non-obstructive coronary disease. We
restarted ASA 81 daily, as he does take this as an outpatient.
We continued his statin.
.
# Chronic diastolic congestive heart failure: He appears to be
well compensated at this point, with no clinical evidence of
failure. We monitored i/o, had him on a low Na diet, and checked
several chest x-rays during the course of his admission to look
for signs of worsening failure. We held lasix as above but he
did not have clinical indications of heart failure with us.
.
# Diabetes: Patient is on glipizide at home. Given poor PO
intake and his renal failure, his PO [**Doctor Last Name 360**] was held in the MICU,
replaced by insulin sliding scale; and given changing
circumstances of high white blood count, changing intake, and
changing renal function, we continued his insulin scale while on
the medicine floor.
.
# Parkinson's disease: We continued home medications of
carbidopa. He did not have significant manifestations of
parkinsonism while on the medicine floor, though as above he
apparently did have manifestations on arrival to the hospital.
.
# Coagulopathy: He received some vitamin K in the ED. Coumadin
was held. His INR drifted down over the admission; as above,
enoxaparin (Lovenox) was started on [**12-17**] and warfarin was
restarted on [**12-18**].
.
# AG acidosis: Resolved. Was felt to be likely due to acute
renal failure.  Also, he was hypochloremic from vomiting.  He
had no ketones in his urine.  His lactate remained within normal
limits.
.
# COPD: He had wheezes on exam fairly frequently which improved
with nebulizers and beta-agonist inhalers (levalbuterol to
minimize cardiac effect). Per Dr. [**Last Name (STitle) **], he has had no clear
diagnosis of COPD or history of wheezing. He had PFT's at NEBH
in [**2120**] which showed a restrictive pattern with a mildly
decreased TLC and diffusion capacity.  He is not on an inhaler
at home, but his daughters report this is partly because when he
has been prescribed them he has been unable or unwilling to
learn how to use them properly. His overall wheezing improved
over the admission. Given that he did not have signs of
progression of heart failure the wheezing was more likely
secondary to bronchitic infection, likely viral. The wheezing
seemed to benefit from steroids, which were started for gout.
.
# BPH: He had been on Flomax at home. We held this for concern
for labile blood pressure as described above. This could be
restarted.
.
# FEN: Cardiac [**Doctor First Name **] diet.
.
# PPx: Anticoagulated (high INR), PPI
.
# Code status: Full, discussed with patient
.
# Communication: Daughter [**Name (NI) 13118**] [**Telephone/Fax (1) 40195**]
.
# Dispo: To rehabilitation to build ability to walk
independently.
.

Medications on Admission:
Wellbutrin 100mg ER by mouth every morning
Celebrex 200 mg qd
Coumadin 2.5 mg alternating with 5 mg
Protonix 40 mg,
Lasix 160 mg,
potassium 20 mEq,
Crestor 5 mg,
carbidopa 25 mg/100 mg one three times a day,
Flomax 0.4 mg,
glipizide 5 mg two a day,
colchicine 0.6 mg every other day,
Niaspan 500 mg,
trazodone 100 mg at bedtime,
[**Doctor First Name **] 180 mg,
sotalol 80 mg two times a day,
doxepin 100 mg at bedtime for skin itch,
lidocaine patches on the knees.
metolazone MWF
.
MEDICATIONS ON TRANSFER
Acetaminophen 650 mg PO q6h
Aspirin 81 mg PO
Bupropion 100 mg PO qAM
Carbidopa-levodopa 25-100 1 tab po TID
Docusate 100 mg PO BID:PRN
Fexofenadine 60 mg PO BID
Insulin scale
Ipratropium bromide Neb, 1 neb IH q6h
Levofloxacin 750 mg PO q48h
Lidocaine 5% patch 1 ptch TD daily
Niaspan 500 mg oral daily
Ondansetron 4-8 mg IV q8H: nausea
Pantoprazole 40 mg PO q24h
Potassium prn per lytes
Rosuvastatin calcium 5 mg PO daily
Senna 1 tab PO BID:PRN
Sotalol 40 mg PO BID
Tamsulosin 0.4 mg PO HS
Xopenex 0.63 mg/3 mL inhalation q6-8h prn wheezing/SOB
Trazodone 100 mg PO HS:PRN


Discharge Medications:
1. Prednisone 20 mg Tablet Sig: One (1) Tablet PO daily () for 2
doses: start [**12-22**], after 25 mg dose on [**12-21**].
2. Prednisone 10 mg Tablet Sig: 1.5 Tablets PO daily () for 2
doses: after 20 mg doses.
3. Prednisone 10 mg Tablet Sig: One (1) Tablet PO daily () for 2
doses: after 15 mg doses.
4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO daily () for 2
doses: after 10 mg doses.
5. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for knee pain.
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q24H (every 24 hours)
as needed for knee pain.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
10. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
11. Bupropion 100 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QAM (once a day (in the morning)).
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
14. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours).
15. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO daily ().
17. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
18. Levalbuterol HCl 0.63 mg/3 mL Solution Sig: One (1)
inhalation Inhalation q6-8h prn () as needed for wheezing/SOB.
19. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
20. Celecoxib 200 mg Capsule Sig: One (1) Capsule PO daily ().
21. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours): do not give more than 4 grams per day.
22. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
23. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).

24. Guaifenesin 100 mg/5 mL Syrup Sig: [**2-1**] 5 mL doses PO four
times a day as needed for cough.
25. Warfarin 2.5 mg Tablet Sig: 1-2 Tablets PO once a day: 1
tablet (2.5 mg) MWF; 2 tablets (5 mg) SaSuTuTh.
26. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
injection Injection ASDIR (AS DIRECTED): SCALE: Breakfast, lunch
and dinner scale:
Glucose 0-75 mg/dL: 4 oz. juice. 76-149: none. 150-199: 3 units.
200-249: 5 units. 250-299: 7 units. 300-349: 9 units. 350-400:
11 units. >400: notify MD.
.
BEDTIME SCALE:
Glucose 0-75 mg/dL: 4 oz. juice. 76-149: none. 150-199: 2 units.
200-249: 4 units. 250-299: 6 units. 300-349: 8 units. 350-399:
10 units. >400: notify MD.
PLEASE NOTE: THIS SCALE WILL LIKELY REQUIRE ADJUSTMENT OVER THE
NEXT FEW DAYS BECAUSE PATIENT IS ON RAPID PREDNISONE TAPER.
.
27. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
28. Prednisone 10 mg Tablet Sig: 2.5 Tablets PO 1x on [**2124-12-21**]
for 1 days: starting on [**12-22**], use doses listed elsewhere on
this list, continue taper accordingly. (each dose for 2 days,
decreasing 5 mg, 2 more days at lower, decreasing 5 mg again,
and so on.).


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 2732**] & Retirement Home - [**Location (un) 55**]

Discharge Diagnosis:
Primary Diagnosis:
Diarrhea
Gout
Atrial Fibrillation with Rapid Ventricular Rate
Leukocytosis
.
Secondary Diagnosis:
Coronary Artery Disease
Chronic Diastolic Heart Failure
Diabetes Mellitus


Discharge Condition:
Good
Patient stable, with no fevers


Discharge Instructions:
You were admitted to the hospital with diarrhea and a cough.
This was most likely due to a viral infection, although we gave
you antibiotics to treat a possible bacterial infection in your
lungs, which you have finished. You also developed swelling of
your knees, which is likely due to gout. We started steroid
therapy for gout, which will be "tapered"--that is, its dose
will be reduced every two days. Your rehabilitation facility
will have instructions about how to continue this therapy.
.
Please take all of your medications as prescribed. We held your
lasix and reduced its dose on discharge because of concern about
your kidneys. As your health improves, it's likely that you'll
need to go back to your home dose of 160 mg daily.
.
Your allopurinol was stopped because of concern about your
kidneys. This will also likely need to be restarted later as
your health improves. Finally, your 81 mg of aspirin was held
because of the prednisone you are taking; it should be restarted
once you are finished with the prednisone.
.
Work with the rehabilitation facility staff, particularly the
physical therapists, to try to improve your mobility and your
overall health. Once you are discharged, please call your doctor
or return to the ER if you have chest pain, feelings that your
heart is racing fast, diarrhea, abdominal pain, fevers, chills,
shortness of breath, increasing pain in your knees, or other
concerning symptoms.
.
Go to a follow-up appointment with Dr [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] at the [**Hospital1 **] Wednesday [**1-10**], 3 pm.
.
Go to the rheumatology follow-up appointment with Dr [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **], Tuesday [**1-9**], 2 pm. [**Last Name (NamePattern1) 439**], [**Hospital1 18**].

Followup Instructions:
Go to a follow-up appointment with Dr [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] at the [**Hospital1 **] Wednesday [**1-10**], 3 pm.
[**Telephone/Fax (1) 7960**].
.
Go to the rheumatology follow-up appointment with Dr [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **], Tuesday [**1-9**], 2 pm. [**Last Name (NamePattern1) 439**], [**Hospital1 18**].
[**Telephone/Fax (1) 2226**].
.
Lasix dose is 160 mg at home; we have held it until today
because of concern re renal function; his renal function has
improved and we are dosing it at 40 mg daily to start. This will
likely need to be increased but renal function should be
followed.
.
His blood sugar levels have been in flux due to prednisone. His
scale was recently increased slightly, and the scale for
discharge represents a slight further increase. Because the
prednisone is on a fairly rapid taper downward, the appropriate
approach to blood sugar control is likely to change over the
next 2 weeks, and this will need to be followed.
.
We have thus far avoided opiates for pain control because of
concern about hospital delirium, which his family reports he has
had in the past.
.
Please feel free to contact [**Name (NI) **] [**Last Name (NamePattern1) 4427**], MD, via the [**Hospital1 18**]
operator at [**Telephone/Fax (1) 2756**] if you have further questions about the
inpatient course for this complicated and treasured patient; Dr.
[**Last Name (STitle) 4427**] is the medical intern who followed Mr [**Known lastname **] for this
admission.
{'Acute kidney failure, unspecified,Acidosis,Urinary tract infection, site not specified,Other and unspecified coagulation defects,Chronic diastolic heart failure,Unspecified viral infection,Gout, unspecified,Coronary atherosclerosis of native coronary artery,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic airway obstruction, not elsewhere classified,Intestinal infection due to other organism, not elsewhere classified,Acute bronchitis,Paralysis agitans,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified'}


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: Cough, shortness of breath

PRESENT ILLNESS: Patient is an 84 year old male with past medical history of
Parkinson's disease, CHF, CAD, and DM, who presents with 1 week
history of productive cough, 4 days of nausea and vomiting, and
1 day of diarrhea.  He states that he has been feeling 'sick'
for the past week, with the above constellation of symtpoms.  He
has not had a fever or chills.  He started with some loose
stools, then developed a cough productive of white sputum.  The
cough has persisted.  He then developed some nasusea and
vomiting.
.
He has also felt a bit more SOB this past week.  He relates that
he does not do much walking at baseline, but gets SOB with going
up 5 stairs.  He has felt some SOB at rest this past week.  He
has not had any chest pain.  His LE swelling has been much
better recently.
.
He has continued to take all of his medications this week,
including his oral hypoglycemics, warfarin, and lasix.
.

MEDICAL HISTORY: 1. CAD, cath 5 years ago at NEBH (cardiologist [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **])
2. CHF, TTE [**3-5**] w/depressed EF
3. Hypertension, per daughter pt's bp usually 90s-100s on meds
4. Severe Lumbar Spinal stenosis, mild cervical stenosis
5. Sleep apnea, on 2L home O2 at night
6. Afib, s/p DCCV which failed, now rate controlled
7. Arthritis
8. Gout
9. COPD? No PFTs
10. NIDDM
11. E-coli-Sepsis (admission [**2122-12-23**] - [**2123-1-1**])
12. BPH? (Flomax)
13. Parkinson's disease ? ?sinemet

MEDICATION ON ADMISSION: Wellbutrin 100mg ER by mouth every morning
Celebrex 200 mg qd
Coumadin 2.5 mg alternating with 5 mg
Protonix 40 mg,
Lasix 160 mg,
potassium 20 mEq,
Crestor 5 mg,
carbidopa 25 mg/100 mg one three times a day,
Flomax 0.4 mg,
glipizide 5 mg two a day,
colchicine 0.6 mg every other day,
Niaspan 500 mg,
trazodone 100 mg at bedtime,
[**Doctor First Name **] 180 mg,
sotalol 80 mg two times a day,
doxepin 100 mg at bedtime for skin itch,
lidocaine patches on the knees.
metolazone MWF
.
MEDICATIONS ON TRANSFER
Acetaminophen 650 mg PO q6h
Aspirin 81 mg PO
Bupropion 100 mg PO qAM
Carbidopa-levodopa 25-100 1 tab po TID
Docusate 100 mg PO BID:PRN
Fexofenadine 60 mg PO BID
Insulin scale
Ipratropium bromide Neb, 1 neb IH q6h
Levofloxacin 750 mg PO q48h
Lidocaine 5% patch 1 ptch TD daily
Niaspan 500 mg oral daily
Ondansetron 4-8 mg IV q8H: nausea
Pantoprazole 40 mg PO q24h
Potassium prn per lytes
Rosuvastatin calcium 5 mg PO daily
Senna 1 tab PO BID:PRN
Sotalol 40 mg PO BID
Tamsulosin 0.4 mg PO HS
Xopenex 0.63 mg/3 mL inhalation q6-8h prn wheezing/SOB
Trazodone 100 mg PO HS:PRN

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE on admission:
Physical Exam: 98.0  90/50  75  18  95% 2L
General: Elderly male with masked facies, speaking full
sentences, NAD
HEENT: MMdry, anicteric, EOMI, no sinus tenderness
Neck: Supple, JVP 6cm, no LAD
Cardiac: Irreg irreg, no m/r/g
Chest: Bilateral diffuse wheeze, no rales, no consolidation
Abdomen: obese, soft, nt, nd, pos bs on left, quiet on right
Extr: no c/c/e
Skin: multiple excoriations, scar from prior BCC removal on back
Neuro: AAO x 3, masked facies, cn intact, pill rolling  tremor,
minor cogwheel rigidity on right
Psych: Flat affect, appropriate
Msk: FROM at both knees, right slightly warmer than left
.
On transfer from MICU to medicine floor:
Baseline Physical Exam (on transfer to medicine floor from
MICU):
t 98.8
bp 96/56
hr 80
rr 20 by vitals sheet; 28 by my exam slightly later
o2 sat: 98% RA
.
General: Elderly man with visibly faster-than-usual respiratory
rate but without evident discomfort
HEENT: PERRL, EOMI; anicteric
Neck: JVD not appreciated on my exam (8 cm by prior MICU attg
note)
Cardiac: Mostly regular rate with occasional "extra
beats"/irregular beats; no murmurs or rubs appreciated
Chest: Expiratory wheezing heard throughout, good air movement
throughout, no rales appreciated
Abdomen: BS+, NT, ND
Extr: 1+ edema
Skin: ecchymoses on arms, IV sites, hands; several scabs on face

FAMILY HISTORY: Notable for CAD, HTN, and stroke.

SOCIAL HISTORY: Patient uses a cane for assistance at baseline. He lives with
his daughter [**Name (NI) 13118**]. Formerly worked at Sears. Widowed. No tobacco
or EtOH use. 

### Response:
{'Acute kidney failure, unspecified,Acidosis,Urinary tract infection, site not specified,Other and unspecified coagulation defects,Chronic diastolic heart failure,Unspecified viral infection,Gout, unspecified,Coronary atherosclerosis of native coronary artery,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic airway obstruction, not elsewhere classified,Intestinal infection due to other organism, not elsewhere classified,Acute bronchitis,Paralysis agitans,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified'}
