CHIEF COMPLAINT: - Neurological deficits described as "spinning" while at acute
rehab.
- Originally had right innominate artery aneurysm which was
repaired with left carotid to aortic innominate artery bypass
[**2125-5-22**], c/b respiratory failure and PEA arrest.

PRESENT ILLNESS: 65F c complex medical history, s/p repair of aortic innominate
aneurysm (please see list of operative procedures), who returned
to [**Hospital1 18**] from acute rehab with neurological symptoms and found
to have numerous problems both related and unrelated to previous
operative procedures.

MEDICAL HISTORY: -- DM2
-- chronic foot ulcers/PVD
-- HTN
-- OA
-- obesity
-- asthma
-- leg pain/neuropathy
-- depression
-- anemia
-- h/o MRSA bacteremia [**11-18**], also septic arthritis treated at
[**Hospital3 **]
.
Right thalamic hemorrhage resulting in a gait disorder and
incontinence of urine, followed by Dr. [**Last Name (STitle) **].
Old CVAs.
Neuropathy, peripheral.
Anxiety and panic disorder.
Status post total abdominal hysterectomy.
Hypercholesterolemia.

MEDICATION ON ADMISSION: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

ALLERGIES: Penicillins / Linezolid

PHYSICAL EXAM: On admission:
NAD, alert
RRR, no murmurs
Decreased BS left hemithorax
Abd: obese, soft, ? NT, ? ND, unable to auscultate bowel sounds
Rect: guiac negative, no masses
Ext: warm and well perfused, + peripheral edema
Pulse: DP/PT dopplerable bilaterally

FAMILY HISTORY: Brother died of an MI in his 30's, she denies diabetes mellitus
in the family. Cancer in parents (mother died in 40s, father in
80s), at least two siblings, but unsure what kind.

SOCIAL HISTORY: The patient lives with her daughter [**Name (NI) 2048**] and her three kids
since being d/c'ed from a nursing home last [**Month (only) 205**]. Has seven
children, many grandchildren. Smokes [**1-16**] to 1 pack per day.
Cerebral artery occlusion, unspecified with cerebral infarction,Other postoperative infection,Unspecified septicemia,Severe sepsis,Acute respiratory failure,Acute pancreatitis,Other retroperitoneal abscess,Unspecified pleural effusion,Empyema without mention of fistula,Calculus of gallbladder with other cholecystitis, without mention of obstruction,Chronic airway obstruction, not elsewhere classified,Urinary tract infection, site not specified,Acute kidney failure, unspecified,Thrombocytopenia, unspecified,Other noninfectious disorders of lymphatic channels,Anemia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension
Crbl art ocl NOS w infrc,Other postop infection,Septicemia NOS,Severe sepsis,Acute respiratry failure,Acute pancreatitis,Retroperiton abscess NEC,Pleural effusion NOS,Empyema w/o fistula,Cholelith w cholecys NEC,Chr airway obstruct NEC,Urin tract infection NOS,Acute kidney failure NOS,Thrombocytopenia NOS,Noninfect lymph dis NEC,Anemia NOS,DMII wo cmp nt st uncntr,Hypertension NOS
Admission Date:  [**2125-7-13**]              Discharge Date:   [**2125-9-28**]

Date of Birth:  [**2060-7-29**]             Sex:   F

Service: SURGERY

Allergies:
Penicillins / Linezolid

Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
- Neurological deficits described as "spinning" while at acute
rehab.
- Originally had right innominate artery aneurysm which was
repaired with left carotid to aortic innominate artery bypass
[**2125-5-22**], c/b respiratory failure and PEA arrest.

Major Surgical or Invasive Procedure:
On this hospital stay:
1. Right VATS and thoracic duct ligation [**2125-7-20**]
2. Thoracic duct embolization and talc pleurodesis [**2125-7-27**]
3. Tracheostomy and percutaneous endoscopic gastrostomy [**2125-8-8**]
4. Exploratory laparotomy, pancreatic necrosectomy, gastrostomy
tube [**2125-8-22**]
5. Exploratory laparotomy, abdominal wash out [**2125-8-23**]
6. Exploratory lap, takedown gastrostomy, debride necrotic
pancreas and multiple retroperitoneal abscesses [**2125-8-25**]
7. Abdominal closure and vac dressing application [**2125-8-26**]
8. Left thoracotomy and decortication, flexible bronchoscopy
[**2125-9-19**]

On previous hospital stays:
9. Aorto innominate and left carotid bypass [**2125-5-22**]
10. Left carotid to left subclavian bypass using 8 mm PTFE and
thoracic aortic stent graft placement [**2125-5-23**]

History of Present Illness:
65F c complex medical history, s/p repair of aortic innominate
aneurysm (please see list of operative procedures), who returned
to [**Hospital1 18**] from acute rehab with neurological symptoms and found
to have numerous problems both related and unrelated to previous
operative procedures.

Past Medical History:
-- DM2
-- chronic foot ulcers/PVD
-- HTN
-- OA
-- obesity
-- asthma
-- leg pain/neuropathy
-- depression
-- anemia
-- h/o MRSA bacteremia [**11-18**], also septic arthritis treated at
[**Hospital3 **]
.
Right thalamic hemorrhage resulting in a gait disorder and
incontinence of urine, followed by Dr. [**Last Name (STitle) **].
Old CVAs.
Neuropathy, peripheral.
Anxiety and panic disorder.
Status post total abdominal hysterectomy.
Hypercholesterolemia.


Social History:
The patient lives with her daughter [**Name (NI) 2048**] and her three kids
since being d/c'ed from a nursing home last [**Month (only) 205**]. Has seven
children, many grandchildren. Smokes [**1-16**] to 1 pack per day.

Family History:
Brother died of an MI in his 30's, she denies diabetes mellitus
in the family. Cancer in parents (mother died in 40s, father in
80s), at least two siblings, but unsure what kind.


Physical Exam:
On admission:
NAD, alert
RRR, no murmurs
Decreased BS left hemithorax
Abd: obese, soft, ? NT, ? ND, unable to auscultate bowel sounds
Rect: guiac negative, no masses
Ext: warm and well perfused, + peripheral edema
Pulse: DP/PT dopplerable bilaterally

Pertinent Results:
[**2125-9-24**] 03:14PM BLOOD WBC-10.6 RBC-2.52* Hgb-7.8* Hct-23.0*
MCV-91 MCH-31.1 MCHC-34.1 RDW-16.0* Plt Ct-68*
[**2125-9-24**] 03:14PM BLOOD Plt Ct-68*
[**2125-9-24**] 03:14PM BLOOD Glucose-117* UreaN-37* Creat-1.1 Na-137
K-3.3 Cl-106 HCO3-24 AnGap-10
[**2125-9-24**] 03:14PM BLOOD ALT-13 AST-27 LD(LDH)-588* AlkPhos-119*
Amylase-52 TotBili-0.2
[**2125-9-24**] 03:14PM BLOOD Lipase-34
[**2125-9-24**] 03:14PM BLOOD Albumin-1.4* Calcium-6.6* Phos-3.8 Mg-1.7
UricAcd-7.1* Iron-57
[**2125-9-24**] 03:14PM BLOOD calTIBC-68* Ferritn-GREATER TH TRF-52*
[**2125-9-24**] 03:14PM BLOOD TSH-16*

[**2125-9-18**] 12:15PM PLEURAL Triglyc-242

Microbiology:
Time Taken Not Noted     Log-In Date/Time: [**2125-9-20**] 1:02 am
      PLEURAL FLUID

                            **FINAL REPORT [**2125-9-25**]**

   GRAM STAIN (Final [**2125-9-20**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.

   FLUID CULTURE (Final [**2125-9-24**]):
      ENTEROBACTER CLOACAE.    SPARSE GROWTH.
         This organism may develop resistance to third
generation
         cephalosporins during prolonged therapy. Therefore,
isolates that
         are initially susceptible may become resistant within
three to
         four days after initiation of therapy.  For serious
infections,
         repeat culture and sensitivity testing may therefore be
warranted
         if third generation cephalosporins were used.
         Trimethoprim/Sulfa sensitivity testing available on
request.
      PROTEUS SPECIES.    RARE GROWTH.
      STAPH AUREUS COAG +.    SPARSE GROWTH.
         SENSITIVITIES PERFORMED ON CULTURE # 236-6444J [**2125-9-19**].
      ENTEROCOCCUS SP..
         Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
         ORGANISMS.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ENTEROBACTER CLOACAE
                             |          ENTEROCOCCUS SP.
                             |          |
AMPICILLIN------------             =>32 R
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------  =>64 R
CEFTRIAXONE-----------  =>64 R
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------   <=1 S
IMIPENEM--------------   <=1 S
LINEZOLID-------------                2 S
MEROPENEM-------------<=0.25 S
PENICILLIN------------             =>64 R
PIPERACILLIN----------    32 I
TOBRAMYCIN------------   <=1 S
VANCOMYCIN------------             =>32 R

   ANAEROBIC CULTURE (Final [**2125-9-24**]):    NO ANAEROBES ISOLATED.


[**2125-9-19**] 5:14 pm URINE      Source: Catheter.

                            **FINAL REPORT [**2125-9-22**]**

   URINE CULTURE (Final [**2125-9-22**]):
      PROTEUS MIRABILIS.    >100,000 ORGANISMS/ML..
      ENTEROBACTER CLOACAE.    10,000-100,000 ORGANISMS/ML..
         This organism may develop resistance to third
generation
         cephalosporins during prolonged therapy. Therefore,
isolates that
         are initially susceptible may become resistant within
three to
         four days after initiation of therapy.  For serious
infections,
         repeat culture and sensitivity testing may therefore be
warranted
         if third generation cephalosporins were used.
         Trimethoprim/Sulfa sensitivity testing confirmed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             PROTEUS MIRABILIS
                             |          ENTEROBACTER CLOACAE
                             |          |
AMPICILLIN------------   <=2 S
AMPICILLIN/SULBACTAM--   <=2 S
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S      <=1 S
CEFTAZIDIME-----------   <=1 S     =>64 R
CEFTRIAXONE-----------   <=1 S     =>64 R
CEFUROXIME------------   <=1 S
CIPROFLOXACIN---------     2 I      =>4 R
GENTAMICIN------------   <=1 S      <=1 S
IMIPENEM--------------              <=1 S
MEROPENEM-------------<=0.25 S   <=0.25 S
NITROFURANTOIN--------              128 R
PIPERACILLIN----------   <=4 S       32 I
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------   <=1 S      <=1 S
TRIMETHOPRIM/SULFA----   <=1 S      <=1 S

[**2125-9-19**] 11:52 am BLOOD CULTURE
      Source: Line-tunneled cath - no peripheral access.

                            **FINAL REPORT [**2125-9-22**]**

   AEROBIC BOTTLE (Final [**2125-9-22**]):
      STAPH AUREUS COAG +.    FINAL SENSITIVITIES.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations
Rifampin
         should not be used alone for therapy.
         Trimethoprim/Sulfa sensitivity testing performed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------   =>8 R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
TRIMETHOPRIM/SULFA----       S
VANCOMYCIN------------   <=1 S

   ANAEROBIC BOTTLE (Final [**2125-9-22**]):
      REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] AT 0755 ON [**2125-9-20**].
      STAPH AUREUS COAG +.    SENSITIVITIES PERFORMED FROM
AEROBIC BOTTLE.

[**2125-9-19**] 10:47 am SPUTUM      Source: Endotracheal.

                            **FINAL REPORT [**2125-9-23**]**

   GRAM STAIN (Final [**2125-9-19**]):
      >25 PMNs and <10 epithelial cells/100X field.
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.
      1+    (<1 per 1000X FIELD):   GRAM NEGATIVE ROD(S).

   RESPIRATORY CULTURE (Final [**2125-9-23**]):
      Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
      workup will be performed appropriate to the isolates
recovered from
      this site.
      UNABLE TO DEFINITIVELY DETERMINE THE PRESENCE OR ABSENCE
OF
      OROPHARYNGEAL FLORA.
      UNABLE TO R/O PATHOGENS DUE TO OVERGROWTH OF SWARMING
PROTEUS SPP..
      PROTEUS SPECIES.    MODERATE GROWTH.
      STAPH AUREUS COAG +.    MODERATE GROWTH.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations.

         Rifampin should not be used alone for therapy.
         Trimethoprim/Sulfa sensitivity testing performed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
      GRAM NEGATIVE ROD(S).    SPARSE GROWTH.
         OF TWO COLONIAL MORPHOLOGIES.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------   =>8 R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
TRIMETHOPRIM/SULFA----       S
VANCOMYCIN------------   <=1 S

[**2125-9-13**] 5:08 pm VARICELLA-ZOSTER CULTURE     Site: BACK
      2 M4 REC'D, ALSO R/O HSV.

                            **FINAL REPORT [**2125-9-27**]**

   VARICELLA-ZOSTER CULTURE (Final [**2125-9-27**]):
      HERPES SIMPLEX VIRUS TYPE 2.
         CONFIRMED BY MONOCLONAL FLUORESCENT ANTIBODY..

[**2125-8-25**] 2:00 pm TISSUE      PANCREAS.

                            **FINAL REPORT [**2125-9-5**]**

   GRAM STAIN (Final [**2125-8-25**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      3+  (5-10 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS, CHAINS, AND
CLUSTERS.

   TISSUE (Final [**2125-9-5**]):
      REPORTED BY PHONE TO [**First Name5 (NamePattern1) 640**] [**Last Name (NamePattern1) 94708**] [**2125-8-27**] CC7C.
      THIS IS A CORRECTED REPORT ([**2125-8-31**]).
      REPORTED BY PHONE TO DR. [**Last Name (STitle) **] ([**Numeric Identifier 94709**]) [**2125-8-31**].
      ENTEROCOCCUS SP..    MODERATE GROWTH.
         ADDITIONAL SENSITIVTY TESTING PER DR [**First Name (STitle) **].
         Tigecycline 1.0 MCG/ML (NON-SUCEPTIBLE).
         Tigecycline IS NOT APPROVED FOR TESTING WITH [**Doctor Last Name **]
RESISTANT
         ENTEROCOCCI.  SYNERCID SENSITIVE BY [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
         REPORTED BY PHONE TO DR [**Last Name (STitle) **] [**2125-8-30**]  AT 10:45AM.
                                   .  PREVIOUSLY REPORTED AS.
         SENSITIVE TO Tigecycline ([**2125-8-30**]).
         Daptomycin.         16 MCG/ML (PERFORMED AT [**Hospital1 4534**]
LABORATORIES).
      STAPHYLOCOCCUS, COAGULASE NEGATIVE.    RARE GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ENTEROCOCCUS SP.
                             |
AMPICILLIN------------  =>32 R
LINEZOLID-------------     2 S
PENICILLIN------------  =>64 R
VANCOMYCIN------------  =>32 R

   ANAEROBIC CULTURE (Final [**2125-8-29**]):    NO ANAEROBES ISOLATED.


[**2125-8-30**] 7:39 pm STOOL     CONSISTENCY: SOFT      Source: Stool.


                            **FINAL REPORT [**2125-8-31**]**

   CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2125-8-31**]):
      FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
           (Reference Range-Negative).


Brief Hospital Course:
Neuro: Ms. [**Known lastname 1661**] is a woman with a history of right thalamic
hemorrhage and left genu/internal capsular lacunar infarcts who
is admitted for vascular surgeries
and treatment of sepsis on whom we were re-consulted for
disconjugate gaze in the setting of sedating medications for
intubation. Her neuro exam is notable for decreased mental
status (following commands only intermittently) although she is
arousable by voice and a disconjugate gaze that returns to
conjugate midline when she is aroused. Certainly, it is
reassuring that her gaze corrects itself when she is aroused.
She also has all her other brainstem reflexes intact and when
aroused
she is able to occasionally follow commands. Most likely, the
intermittent disconjugate gaze (occurring only when she is
unconscious) is the result of an encephalopathy. Certainly, she
has many metabolic reasons to be encephalopathic, as she has
bacteremia and pneumonia. However, given her history of
intracranial hemorrhage and her maintenance on a Heparin gtt
(for a history of clotting), we would recommend a low threshold
for re-imaging her head. Although our suspicion for recurrent
intracranial hemorrhage is low, it cannot be fully excluded and
she does have risks and a history. CT head [**2125-8-29**]: 1. Stable
appearance of the brain. 2.  New air-fluid levels in the
sphenoid sinus. The appearance may reflect
recent intubation but could be seen in sinusitis, in the
appropriate clinical
setting.

CV: Ms. [**Known lastname 1661**] was intermittently on vasopressors throughout
her long hospital course, most often for BP support in the
setting of sepsis.  No evidence of myocardial infarction.  Most
recent echo [**2125-7-26**] showed: The left atrium is elongated. Left
ventricular wall thicknesses are normal.  The left ventricular
cavity size is normal. Overall left ventricular systolic
function is mildly depressed with inferior/inferolateral
akinesis (LVEF= 50%). Right ventricular chamber size and free
wall motion are normal. The aortic root is mildly dilated at the
sinus level. There are three aortic valve leaflets. The aortic
valve is not well seen. There is no aortic valve stenosis. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
She has been otherwise stable from a cardiovascular standpoint.
No apparent difficulty with her vascular repair.  Pt also has
very difficult vascular access with significant thrombosis of
upper neck veins, currently with a left IJ CVL which has been
placed and repositioned multiple times in interventional
radiology.  The CVL presently infuses but does not aspirate.

Pulmonary: Ms. [**Known lastname 1661**] experienced chylothorax treated with
multiple operative procedures (please see operative report
list).  At present, drainage from the left hemithorax greatly
reduced.  Two chest tubes were removed on date of discharge with
one remaining draining to gravity.

GI: Ms. [**Known lastname 1661**] experience near total pancreatic necrosis of
unknown etiology treated with pancreatic debridement and
necrosectomy and abdominal drainage (please see operative report
list).  At present, most recent CT abd/pelvis [**2125-9-20**] showed:
There is evidence of peripancreatic fat stranding and a small
peripancreatic fluid collection measuring 2.9 x 1.2 cm.  General
surgery consultation deemed that this fluid collection was
remarkable but not necessitating intervention.  Pt was
maintained on tube feeds at a stable rate and frequency.

Heme: Ms. [**Known lastname 1661**] has experienced anemia and thrombocytopenia
which has necessitated intermittent transfusion of packed RBC
and platelets.

ID: Ms. [**Known lastname 1661**] has numerous positive cultures from various
sites (please see pertinent lab results for more detail) that
have been treated with antibiotics intermittenly per the ID
consultation service.  These infections have manifested with
hypothermia and hypotension, sometimes requiring vasopressor
support.  Pt is currently on Synercid, Meropenem, and
Caspofungin.  Antibiotics x 7 days post-discharge with the
knowledge that the pt is likley heavily colonized with multiple
resistant organisms and may deteriorate without antibiotic
support.


Medications on Admission:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q6H (every 6 hours).
4. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
INH Inhalation Q6H (every 6 hours).
5. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig: One

(1) INH Inhalation [**Hospital1 **] (2 times a day).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): Hold for SBP < 100 or HR < 60.
10. Daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours) for 4 weeks: from [**6-15**] /
may DC [**7-29**] Follow labs as on Pg 1.
11. Insulin
Sliding Scale
Fingerstick Q6H
Insulin SC Sliding Scale
Regular
Glucose Insulin Dose
0-60      mg/dL 1 amp D50
61-120    mg/dL 0   Units
121-140   mg/dL 2   Units
141-160   mg/dL 4   Units
161-180   mg/dL 6   Units
181-200   mg/dL 8   Units
201-220   mg/dL 10   Units
221-240   mg/dL 12   Units
241-260   mg/dL 14   Units
261-280   mg/dL 16   Units
281-300   mg/dL 18   Units
> 300   mg/dL Notify M.D.
12. Enoxaparin 120 mg/0.8 mL Syringe Sig: One (1)  Subcutaneous
Q12H (every 12 hours) for 7 days: DC when INR is greater then 2/

Keep INR [**2-17**].
13. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime: INR
goal is [**2-17**].

Discharge Medications:
1. MED Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN  [**9-19**] @ 2257

2. MED Aquaphor Ointment 1 Appl TP TID:PRN  [**9-19**] @ 2257
3. MED Sarna Lotion 1 Appl TP TID:PRN  [**9-19**] @ 2257
4. MED Miconazole Powder 2% 1 Appl TP TID:PRN  [**9-19**] @ 2257
5. MED Dextrose 50% 25 gm IV PRN Glu<55  [**9-19**] @ 2257
6. MED Levothyroxine Sodium 25 mcg PO/NG DAILY  [**9-19**] @ 2257
7. MED Heparin 5000 UNIT SC TID  [**9-19**] @ 2257
8. MED Quinupristin-Dalfopristin 650 mg IV Q8H  [**9-19**] @ 2257
9. MED Insulin SC  (per Insulin Flowsheet)
      Sliding Scale 09/05 @ 2257
10. MED Meropenem 1000 mg IV Q8H  [**9-19**] @ 2257
11. MED HYDROmorphone (Dilaudid) 1 mg IV Q4H:PRN pain  [**9-19**] @
2257
12. MED Metoclopramide 5 mg PO/IV QID:PRN  [**9-20**] @ 0846
13. MED Ranitidine (Liquid) 150 mg PO DAILY  [**9-20**] @ 0900
14. MED Albuterol [**4-20**] PUFF IH Q4H  [**9-20**] @ 2148
15. MED Ipratropium Bromide MDI [**4-20**] PUFF IH Q4H  [**9-20**] @ 2148
16. MED Caspofungin 50 mg IV Q24H  [**9-22**] @ 0937

Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
1. Peripheral vascular disease
2. Chylothorax
3. Pancreatic necrosis
4. Sepsis
5. Upper vein thrombosis
6. Diabetes mellitus
7. Hypertension
8. COPD
9. Right thalamic hemorrhage
10. Innominate artery aneurysm

Discharge Condition:
Stable

Discharge Instructions:
1. D/C antibiotics 7 days post discharge.
2. Vac dressing change Q4days.
3. Trach mask as tolerated.

Followup Instructions:
1. Follow up with Dr. [**Last Name (STitle) **] regarding removal of chest
tube.
{'Cerebral artery occlusion, unspecified with cerebral infarction,Other postoperative infection,Unspecified septicemia,Severe sepsis,Acute respiratory failure,Acute pancreatitis,Other retroperitoneal abscess,Unspecified pleural effusion,Empyema without mention of fistula,Calculus of gallbladder with other cholecystitis, without mention of obstruction,Chronic airway obstruction, not elsewhere classified,Urinary tract infection, site not specified,Acute kidney failure, unspecified,Thrombocytopenia, unspecified,Other noninfectious disorders of lymphatic channels,Anemia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension'}


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: - Neurological deficits described as "spinning" while at acute
rehab.
- Originally had right innominate artery aneurysm which was
repaired with left carotid to aortic innominate artery bypass
[**2125-5-22**], c/b respiratory failure and PEA arrest.

PRESENT ILLNESS: 65F c complex medical history, s/p repair of aortic innominate
aneurysm (please see list of operative procedures), who returned
to [**Hospital1 18**] from acute rehab with neurological symptoms and found
to have numerous problems both related and unrelated to previous
operative procedures.

MEDICAL HISTORY: -- DM2
-- chronic foot ulcers/PVD
-- HTN
-- OA
-- obesity
-- asthma
-- leg pain/neuropathy
-- depression
-- anemia
-- h/o MRSA bacteremia [**11-18**], also septic arthritis treated at
[**Hospital3 **]
.
Right thalamic hemorrhage resulting in a gait disorder and
incontinence of urine, followed by Dr. [**Last Name (STitle) **].
Old CVAs.
Neuropathy, peripheral.
Anxiety and panic disorder.
Status post total abdominal hysterectomy.
Hypercholesterolemia.

MEDICATION ON ADMISSION: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

ALLERGIES: Penicillins / Linezolid

PHYSICAL EXAM: On admission:
NAD, alert
RRR, no murmurs
Decreased BS left hemithorax
Abd: obese, soft, ? NT, ? ND, unable to auscultate bowel sounds
Rect: guiac negative, no masses
Ext: warm and well perfused, + peripheral edema
Pulse: DP/PT dopplerable bilaterally

FAMILY HISTORY: Brother died of an MI in his 30's, she denies diabetes mellitus
in the family. Cancer in parents (mother died in 40s, father in
80s), at least two siblings, but unsure what kind.

SOCIAL HISTORY: The patient lives with her daughter [**Name (NI) 2048**] and her three kids
since being d/c'ed from a nursing home last [**Month (only) 205**]. Has seven
children, many grandchildren. Smokes [**1-16**] to 1 pack per day. 

### Response:
{'Cerebral artery occlusion, unspecified with cerebral infarction,Other postoperative infection,Unspecified septicemia,Severe sepsis,Acute respiratory failure,Acute pancreatitis,Other retroperitoneal abscess,Unspecified pleural effusion,Empyema without mention of fistula,Calculus of gallbladder with other cholecystitis, without mention of obstruction,Chronic airway obstruction, not elsewhere classified,Urinary tract infection, site not specified,Acute kidney failure, unspecified,Thrombocytopenia, unspecified,Other noninfectious disorders of lymphatic channels,Anemia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension'}
