CHIEF COMPLAINT: Drop in Hematocrit, hypoxia

PRESENT ILLNESS: 54 yo with anemia, COPD, h/o cirrhosis, PVD s/p recent AKA,
recent admit for MSSA bacteremia and necrotizing LUL pneumonia
now on course of CTX comes in from rehab for ?anemia vs
increasing oxygen requirement. Pt reported to be desatting to
75-85% on RA (96% on 2L) and also to have Hct of 25, which was
described as low; however, she was discharged from the hospital
recently with a hct of 24.
.
Seeing the patient this morning [**1-/2120**] she looked extremely
dyspneic, tachypneic w/ RR 40s, confused able to answer some
questions, but mostly answering inappropriately. Denies recent
fevers. Admits to increased thirst, shortness of breath in past
24 hours. Pt was discharged from [**Hospital1 18**] on [**1-25**] w/ MSSA PNA went
to rehab on CTX for antibiotics. She was triggered for increased
resp rate, ABG showed 7.32/32/78/17 on 4L oxygen
.
Of note: Her recent pulmonary history showed persistent hypoxia,
she had a VATS procedure and biopsy that showed respiratory
bronchiolitis with underlying interstitial lung disease
(RB-ILD). After AKA, she represented with a LUL necrotizing PNA
that is currently being treated with Ceftriaxone. Her hospital
course was also complicated by MSSA bacteremia, which was also
sensitive to Ceftriaxone . She was also anemic, with Hct of 24
on discharge, with a set transfusion threshold of 21. On
anticoagulation for recurrent thromboses of unknown etiology.

MEDICAL HISTORY: 1. s/p AKA [**11-10**] (right)
2. s/p VATS and hypoxemia, biopsy c/w Respiratory
Bronchiolitis-interstitial lung disease (RB-ILD) -- now on
intermittent supplemental oxygen
3. PVD - s/p rt. ileo-fem bpg [**12-10**] complicated by
lymphocele s/p drainage [**2198-1-11**],rt. ililac/femoral thrombectomy
[**4-10**],rt. ileo-fem graft thrombectomy with bovine
patchangioplasty [**2196**],rt. ileofem bpg with PTFE [**2195**],
4. chronic pancreatitis s/p Puestow,J-tube,ccy1998,Expl lap [**2189**]

MEDICATION ON ADMISSION: Ranitidine 150mg PO BID
Zofran PRN
Advair [**Hospital1 **]
Atorvastatin 20 mg PO DAILY
Lisinopril 5mg daily
Metoprolol 25mg TID
ISS
Duloxetine 60mg daily
Tiotropium Bromide 18 mcg daily inhalation
ZnSO4 220mg daily
Amitriptyline 50 mg PO HS
Benzocaine 20 % Paste TID:PRN
Dextromethorphan-Guaifenesin 10-100 mg/5 mL, Syrup Sig: 5-10ml
PO Q6H PRN
NPH 8 units qam and 5 units qpm
Hexavitamin Tablet daily
Folic Acid 1 mg daily
Thiamine HCl 100 mg PO once a day.
Albuterol PRN
Fexofenadine 60mg PO BID
Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule PO TID
W/MEALS
Gabapentin 400mg PO Q8H
Medium Chain Triglycerides Oil 15ml TID
Aspirin 325 mg daily
Colace 100mg TID
Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H PRN
Morphine 45 mg Sustained Release PO Q12H
Warfarin 3mg daily, Saturday/Sunday 2mg
Ceftriaxone-Dextrose 1g Q24H (every 24 hours) for 18 days until
[**2199-2-12**]

ALLERGIES: Penicillins

PHYSICAL EXAM: VS: 98.6, 135/66, HR: 90s-100s, 24, 86% on RA -> 93% on 4L
General - Somnolent, but arousable. Not always answering
questions appropriately.
HEENT - [**Last Name (un) **], MMM, no icteric sclera
Neck - non elevated JVP
CV - +s1+s2 Tachycardic Hyperdynamic. (thin chest wall)
Chest -
LUL - coarse. LLL - crackles. RLL with some crackles.
Abdomen - mildly tender to deep palpation along RLQ, mildly
distended, no dullness to percussin. Surgical scars, + BS. No
rebound. No guarding.
Ext - Left LE with 1+ edema, warm well perfused. R AKA with
dressing, non tense, tender to palpation, no erythema above
bandaged site. Palpable R,L fem pulse

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Recently discharged from [**Hospital3 **] to home. Married and
lives at home generally with her husband, no children.
Previously worked as a counselor in drug and alcohol programs.
She quit smoking approximately [**12/2198**] with an over 80-pack year
history of smoking. She quit drinking alcohol 23 years ago. She
has no known exposure to tuberculosis. She was cleaning her
husband's
clothes during the time that he was working with asbestos for a
three-month period. She has one dog at home and reports no
allergies to animals. Years ago she had a parrot, a dove, and
two parakeets.
.
Patient was transferred to [**Hospital1 18**] from NH East point
[**Telephone/Fax (1) 63761**]. She otherwise lives at home generally with her
husband, no children.
.
Abscess of lung,Acute respiratory failure,Bacteremia,Influenza with pneumonia,Acute kidney failure, unspecified,Obstructive chronic bronchitis with (acute) exacerbation,Other specified hypersensitivity angiitis,Chronic systolic heart failure,Pressure ulcer, buttock,Chronic pancreatitis,Other and unspecified infection due to central venous catheter,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Anemia, unspecified,Cirrhosis of liver without mention of alcohol,Phlebitis and thrombophlebitis of upper extremities, unspecified,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants
Abscess of lung,Acute respiratry failure,Bacteremia,Influenza with pneumonia,Acute kidney failure NOS,Obs chr bronc w(ac) exac,Hypersensit angiitis NEC,Chr systolic hrt failure,Pressure ulcer, buttock,Chronic pancreatitis,Oth/uns inf-cen ven cath,Mth sus Stph aur els/NOS,DMII wo cmp uncntrld,Anemia NOS,Cirrhosis of liver NOS,Phlbts vn NOS up extrm,Hx-ven thrombosis/embols,Long-term use anticoagul
Admission Date:  [**2199-1-31**]              Discharge Date:   [**2199-2-15**]

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

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Drop in Hematocrit, hypoxia

Major Surgical or Invasive Procedure:
Intubation

History of Present Illness:
54 yo with anemia, COPD, h/o cirrhosis, PVD s/p recent AKA,
recent admit for MSSA bacteremia and necrotizing LUL pneumonia
now on course of CTX comes in from rehab for ?anemia vs
increasing oxygen requirement. Pt reported to be desatting to
75-85% on RA (96% on 2L) and also to have Hct of 25, which was
described as low; however, she was discharged from the hospital
recently with a hct of 24.
.
Seeing the patient this morning [**1-/2120**] she looked extremely
dyspneic, tachypneic w/ RR 40s, confused able to answer some
questions, but mostly answering inappropriately. Denies recent
fevers. Admits to increased thirst, shortness of breath in past
24 hours. Pt was discharged from [**Hospital1 18**] on [**1-25**] w/ MSSA PNA went
to rehab on CTX for antibiotics. She was triggered for increased
resp rate, ABG showed 7.32/32/78/17 on 4L oxygen
.
Of note: Her recent pulmonary history showed persistent hypoxia,
she had a VATS procedure and biopsy that showed respiratory
bronchiolitis with underlying interstitial lung disease
(RB-ILD). After AKA, she represented with a LUL necrotizing PNA
that is currently being treated with Ceftriaxone. Her hospital
course was also complicated by MSSA bacteremia, which was also
sensitive to Ceftriaxone . She was also anemic, with Hct of 24
on discharge, with a set transfusion threshold of 21. On
anticoagulation for recurrent thromboses of unknown etiology.

Past Medical History:
1. s/p AKA [**11-10**] (right)
2. s/p VATS and hypoxemia, biopsy c/w Respiratory
Bronchiolitis-interstitial lung disease (RB-ILD) -- now on
intermittent supplemental oxygen
3. PVD - s/p rt. ileo-fem bpg [**12-10**] complicated by
lymphocele s/p drainage [**2198-1-11**],rt. ililac/femoral thrombectomy
[**4-10**],rt. ileo-fem graft thrombectomy with bovine
patchangioplasty [**2196**],rt. ileofem bpg with PTFE [**2195**],
4. chronic pancreatitis s/p Puestow,J-tube,ccy1998,Expl lap [**2189**]

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

Social History:
Recently discharged from [**Hospital3 **] to home. Married and
lives at home generally with her husband, no children.
Previously worked as a counselor in drug and alcohol programs.
She quit smoking approximately [**12/2198**] with an over 80-pack year
history of smoking. She quit drinking alcohol 23 years ago. She
has no known exposure to tuberculosis. She was cleaning her
husband's
clothes during the time that he was working with asbestos for a
three-month period. She has one dog at home and reports no
allergies to animals. Years ago she had a parrot, a dove, and
two parakeets.
.
Patient was transferred to [**Hospital1 18**] from NH East point
[**Telephone/Fax (1) 63761**]. She otherwise lives at home generally with her
husband, no children.
.


Family History:
Noncontributory

Physical Exam:
VS: 98.6, 135/66, HR: 90s-100s, 24, 86% on RA -> 93% on 4L
General - Somnolent, but arousable. Not always answering
questions appropriately.
HEENT - [**Last Name (un) **], MMM, no icteric sclera
Neck - non elevated JVP
CV - +s1+s2 Tachycardic Hyperdynamic. (thin chest wall)
Chest -
LUL - coarse. LLL - crackles. RLL with some crackles.
Abdomen - mildly tender to deep palpation along RLQ, mildly
distended, no dullness to percussin. Surgical scars, + BS. No
rebound. No guarding.
Ext - Left LE with 1+ edema, warm well perfused. R AKA with
dressing, non tense, tender to palpation, no erythema above
bandaged site. Palpable R,L fem pulse

Pertinent Results:
ADMISSION LABS:
[**2199-1-31**] 04:00PM BLOOD WBC-7.8 Hgb-6.8* Hct-22.0* Plt Ct-690*
[**2199-2-1**] 03:32AM BLOOD WBC-8.7 RBC-2.75* Hgb-8.1* Hct-26.5*
MCV-96 MCH-29.5 MCHC-30.6* RDW-15.7* Plt Ct-643*
[**2199-1-31**] 04:00PM BLOOD Neuts-82.7* Bands-0 Lymphs-12.6*
Monos-3.5 Eos-1.0 Baso-0.2
[**2199-2-2**] 06:00AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
[**2199-1-31**] 04:00PM BLOOD Glucose-65* UreaN-35* Creat-1.1 Na-140
K-5.6* Cl-114* HCO3-20* AnGap-12
[**2199-1-31**] 07:40PM BLOOD ALT-15 AST-19 LD(LDH)-316* CK(CPK)-87
AlkPhos-282* TotBili-0.1
[**2199-1-31**] 07:40PM BLOOD Albumin-2.0*
[**2199-2-1**] 03:32AM BLOOD Calcium-7.4* Phos-6.4* Mg-2.4
[**2199-2-1**] 09:40AM BLOOD Hapto-315*
[**2199-2-3**] 02:45AM BLOOD Acetone-NEGATIVE
[**2199-1-31**] 06:27PM BLOOD Type-ART pO2-92 pCO2-47* pH-7.27*
calTCO2-23 Base XS--5
[**2199-1-31**] 06:27PM BLOOD Lactate-0.7 K-5.7*
[**2199-2-6**] 02:18AM BLOOD freeCa-1.11*
ROMI:
.
[**2199-2-1**] 09:40AM BLOOD CK-MB-3 cTropnT-0.04* proBNP-[**Numeric Identifier 63762**]*
[**2199-1-31**] 07:40PM BLOOD CK-MB-NotDone cTropnT-0.04*
LFTS:

[**2199-1-31**] 07:40PM BLOOD ALT-15 AST-19 LD(LDH)-316* CK(CPK)-87
AlkPhos-282* TotBili-0.1
[**2199-2-1**] 03:32AM BLOOD ALT-14 AST-16 LD(LDH)-329* AlkPhos-290*
TotBili-0.1
[**2199-2-9**] 02:42AM BLOOD ALT-10 AST-12 LD(LDH)-288* AlkPhos-171*
TotBili-0.0
[**2199-2-14**] 06:04AM BLOOD ALT-7 AST-45* AlkPhos-386* TotBili-0.1

IN-111 WHITE BLOOD CELL STUDY  [**2199-2-12**]
.
IMPRESSION: 1) Left upper lung pneumonia.
2) No evidence of vascular graft/stent infection, and no other
site
of infection.
3) Rectal tube balloon may be overinflated.
CHEST (PORTABLE AP)  [**2199-2-12**] 4:20 AM
.
CHEST AP: Cardiac, mediastinal and hilar contours are unchanged.
Endotracheal and nasogastric tubes have been removed.
Right-sided PICC tip is in the SVC. The left pulmonary opacities
are not significantly changed from prior exam. There continues
to be right lower lobe atelectasis. There are moderate bilateral
pleural effusions which accounting for differences in technique
are not significantly changed. Re-distribution of effusion along
the left lateral chest is likely positional in nature.
.
IMPRESSION: Accounting for differences in technique, the
bilateral pulmonary opacities and moderate pleural effusions are
not significantly changed.
TEE [**2-6**]
A TEE was performed in the location listed above. I certify I
was present in compliance with HCFA regulations. The patient was
monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**] throughout the procedure. The
patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**] throughout the
procedure. The patient was sedated for the TEE. Medications and
dosages are listed above (see Test Information section). No TEE
related complications.
Conclusions
LV systolic function appears depressed. There are simple
atheroma in the aortic arch. There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. No masses or
vegetations are seen on the aortic valve. There are filamentous
strands on the aortic leaflets consistent with Lambl's
excresences (normal variant). No aortic regurgitation is seen.
The mitral valve leaflets are structurally normal. No mass or
vegetation is seen on the mitral valve. Mild to moderate ([**12-5**]+)
mitral regurgitation is seen.
.
IMPRESSION: No 2D echocardiographic evidence of endocarditis or
abscess. Mild to moderate mitral regurgitation. Depressed LV
function.
TTE [**2199-2-4**]
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is 0-5 mmHg. Left ventricular
wall thicknesses and cavity size are normal. Regional left
ventricular wall motion is normal. Systolic function of apical
segments is relatively preserved. Overall left ventricular
systolic function is low normal (LVEF 50-55%). Right ventricular
chamber size and free wall motion are normal. No patent ductus
arteriosus is seen. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is an anterior space which
most likely represents a fat pad.
.
Compared with the prior study (images reviewed) of [**2198-12-13**],
trace aortic regurgitation and low normal left venticular
systolic function are seen on the current study (c/w diffuse
process - toxin, metabolic, etc.). A PDA is not seen on review
of the prior study nor on the current study.

Brief Hospital Course:
54 yo F with multiple medical problems including COPD, EtOH
cirrhosis, pancreatitis, PVD s/p AKA in [**11-10**] who initially
presented with MSSA bacteremia and pneumonia, started improving
on antibiotics then returned [**1-31**] with worsening oxygen
requirement in the setting fo superimposed influenza B. She was
being treated with broad antibiotics including cefazolin and
clindamycin (vancomycin has been discontinued). The patient
required intubation on [**2-6**], extubated [**2-11**], now on 4L oxygen
requirement with o2 at 98%/4L. The Influenza B infection was
treated with 5 day course of Oseltamivir [**Date range (1) 56769**]. MI was ruled
out due to no ECG changes, no ST changes, no TWI, and Trops at
0.04.
.
In addition, given her MSSA bacteremia and worsened respiratory
status, patient was investigated for possibility of
endocarditis, TTE and TEE were negative although she did have
[**Last Name (un) 1003**] lesions and [**Doctor Last Name **] spots identified. Pt also had a thigh
CT to investigate possibility of R thigh graft infection, which
was negative. A WBC scan showed a left upper lung pneumonia that
we know about, and no evidence of vascular graft/stent
infection, and no other site of infection
.
# Hypoxemia: Patient has persistent hypoxemia, most likely from
necrotizing pneumonia, s/p Influenza B infection, also
combination of CHF, COPD, persistent bilateral pleural effusion.
 She was placed on Ceftriaxone for her necrotizing PNA. A CT
Chest questioned new infiltrates vs. worsening of ILD or PNA,
and oxygen requirement increased to 4L. Patient also appeared
fluid overloaded. Patient responded well to diuresis. Pt had to
be transfered to the medical ICU for intubation, for hypoxic
respiratory failure. She was intubated [**2-6**]-extubated [**2-11**].
She responded well to duonebs, chest PT, and incentive
spirometry.
.
# Necrotizing pneumonia: CXR on [**2199-1-31**] showed dense left upper
lobe consolidation  consistent with known prior necrotizing
pneumonia, loculated left pleural effusions due to the likely
superimposed viral infection, and a left basilar atelectasis. A
DFA tests was positive for influenza B virus. She received
ceftriaxone, vancomycin clindamycin and cefazolin while in the
hospital. Pt completed a 10 days course of clindamycin for any
anaerobic causes of her PNA while in the hospital. She was
started on cefapime [**2-2**]-d/c [**2-8**]. She was then placed on
cefazolin 2gm q8h, for a 4week course. Pt transferred to rehab
with picc, scheduled to finish her cefazolin on [**3-4**]. Pt is to
get follow up CT in less than a month as listed in d/c
instructions. She is to have CBC, LFTs and to have this
information faxed to Dr. [**Last Name (STitle) 7443**]. Pt should also redceive Chest
PT, incentive spirometry and Guafenison.
.
#Supratherapteutic INR: Patient was bridged from heparin back to
coumadin for her history of venous and arterial clots, prior R
illeo-fem graft clot. At discharge INR was 6.0. Indication to
hold coumadin for 2 days. Check INR on [**2-16**], titrate up.

#COPD: Patient continued to respond to duonebs standing at q6
hours albuterol, q6h ipratropium, and Q2 PRN Nebs. During
hospital stay patient received one time dose of 125mg
methyprednisolone. Pulmonary consultants were unconvinced that
she had a copd exacerbation.
.
#RB-ILD: Disease monitored in house. Pulmonary consultants did
not believe to be having worsening of this condition.
.
# Coccyx skin infection: Skin checks was ordered to prevent bed
sores. Nursing skin/wound care was consulted for a minor coccyx
skin infection and patient was placed in a buffy bed to prevent
further wound care.
.
#Phlebitis/cellulitis: On admission prior Picc site was
erythematous as was lower L leg. Concern for cellulitis. Picc
tip no growth. Pt received IV vanco in house for treatment.
Resolved at d/c.
.
# Influenza B infection: DFA-B positive, may have been
insighting trigger to resp failure. Pt treated with 5 day course
of oseltamivir.
.
# Ruled out for endocarditis: Negative TTE/TEE. Despite [**Doctor Last Name **]
spots and jainway lesions.
.
# Aortic Atheroma: [**Month (only) 116**] be cause of [**Last Name (un) 1003**] lesions and [**Doctor Last Name **]
spots. Needs to be monitored by PCP.
.
# Hypertension: A regimen was created during MICU course. At
discharge patient was normotensive on metoprolol 75mg q8h, and
lisinopril 20mg daily.
.
# Anemia: No active bleeding. Pt received PRN transfusions two
units overall while in hospital. Discharge HCT was 24.5. All
guaic stools negative.
.
# Pancreatitis: Chronic, thought to be [**1-5**] alcohol use in past,
continues pancrease supplementation with diet. Not active
admission.
.
# Cirrhosis: continue lactulose, titrate to 3 BMs daily, to
prevent encephalopathy. Continue thiamine, folate, vitamins with
PRN lasix.
.
#Phantom Limb pain:
Discharge regimen Gabapentin 600mg TID, Amitriptyline 50mg,
Lidocaine patch, Morphine SR 50mg Q12h, 2-4mg morphine IV
q4-6h:prn.
.
# DM: Patient has finger sticks and sliding scale insulin. We
titrated NPH as needed, pt had NPH standing doses at 7 units for
breakfast and dinner.
.
# Hx of venous and arterial thrombi: Patient was on heparin gtt
during her stay with an INR goal [**1-6**], and she was therapeutic
[**Date range (1) 63763**].  She began to become supertherapeutic after she was
restarted on Coumadin 3mg qhs and Coumadin/Heparin was
discontinued
.
# Left hand dermatitis: Dr.[**Last Name (STitle) 63764**] was consulted from
Dermatology on [**2-2**] and confirmed [**Last Name (un) 1003**] lesions, splinter
hemorrhages, positive endocarditis stigmata.  A biopsy was done
and sutures were placed, specimen was demonstrated a negative
gram stain/culture, fungal cx, anaerobic culture.
.
# Cholystasis: alk phos of 280 should be followed up with PCP.
.
# Depression: Continued Duloxetine
.
# Hypernatremia: Na of 151, responded to D5W. At discharge 146.
.
# FEN: Low Na/DM diet.
.
# Access: PICC
.
# Communication: Husband [**Name (NI) **] [**Name (NI) 7168**] [**Telephone/Fax (1) 63765**].
.
# Code: Full code as discussed w/ Pt and HCP [**Name (NI) **]
.
# Dispo: Acute Rehab, pending clinical improvement. Patient will
be followed by Primary Care physician and with Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7443**]
from Infectious Disease.


Medications on Admission:
Ranitidine 150mg PO BID
Zofran PRN
Advair [**Hospital1 **]
Atorvastatin 20 mg PO DAILY
Lisinopril 5mg daily
Metoprolol 25mg TID
ISS
Duloxetine 60mg daily
Tiotropium Bromide 18 mcg daily inhalation
ZnSO4 220mg daily
Amitriptyline 50 mg PO HS
Benzocaine 20 % Paste TID:PRN
Dextromethorphan-Guaifenesin 10-100 mg/5 mL, Syrup Sig: 5-10ml
PO Q6H PRN
NPH 8 units qam and 5 units qpm
Hexavitamin Tablet daily
Folic Acid 1 mg daily
Thiamine HCl 100 mg PO once a day.
Albuterol PRN
Fexofenadine 60mg PO BID
Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule PO TID
W/MEALS
Gabapentin 400mg PO Q8H
Medium Chain Triglycerides Oil 15ml TID
Aspirin 325 mg daily
Colace 100mg TID
Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H PRN
Morphine 45 mg Sustained Release PO Q12H
Warfarin 3mg daily, Saturday/Sunday 2mg
Ceftriaxone-Dextrose 1g Q24H (every 24 hours) for 18 days until
[**2199-2-12**]

Discharge Medications:
1. Morphine 2 mg/mL Syringe Sig: One (1)  Injection Q4-6H () as
needed for pain: hold for sedation or RR below 12.
2. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed.
5. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1)  Inhalation Q6H (every 6 hours) as needed.
6. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO Q8H
(every 8 hours).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours).
9. Morphine 50 mg Capsule, Sust. Release Pellets Sig: One (1)
Capsule, Sust. Release Pellets PO Q12H (every 12 hours).
10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
11. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).
12. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: One (1)
Subcutaneous twice a day: Patient has been receiving 7 units NPH
at breakfast and 7 units NPH at dinner.
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
14. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Amitriptyline 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
16. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO QAM (once a day (in the
morning)).
17. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
19. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
20. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: [**4-13**]
MLs PO Q6H (every 6 hours) as needed.
21. Hexavitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).
22. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
23. Medium Chain Triglycerides     Oil Sig: Fifteen (15) ML PO
TID (3 times a day).
24. Cefazolin in D5W 2 gram/100 mL Solution Sig: One (1)
Intravenous every eight (8) hours for 19 days: 2grams cefazolin
q 8H. Start date of therapy [**2-8**] end date [**3-4**]. Replacing
Cefepime [**Date range (1) 23163**].
.
25. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q2H (every 2 hours) as needed for wheezing.
26. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q4H (every 4 hours).
27. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
28. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
29. Outpatient Lab Work
CBC, Chem7, Liver function tests, weekly basis and send the
results by fax to Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7443**] at [**Telephone/Fax (1) 1419**].
30. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Capsule, Delayed
Release(E.C.) PO three times a day: TID w/ meals.


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
Primary:
#. Hypoxemia
#. Hypoxic Respiratory Failure
#. Necrotizing Pneumonia
#. MSSA Bacteremia
#. COPD
Secondary:
#. Phlebitis/cellulitis Left arm
#. Tacyhycardia
#. Anemia
#. Congestive heart failure
#. Left hand dermatitis
#. Altered Mental Status
#. Acute renal faliure
#. Cholecystasis
#. Hyperkalemia
#. Diabetes II
#. Thrombocytosis- likely reactive
#. GERD
#. Hx of small bowel obstruction
#. Hx of DVT/PE, SMV thrombosis
#. Hx of Cervical Ca multiple d/cs
#. Hx of Cdiff colitis
#. Esophagitis w/ stricture
#. AKA [**11-10**] (right)
#. VATS in [**12-11**]
#. Respiratory Bronchiolitis-interstitial lung disease
#. PVD - s/p rt. ileo-fem bpg [**12-10**] complicated by lymphocele s/p
drainage [**2198-1-11**],rt. ililac/femoral thrombectomy [**4-10**],rt.
ileo-fem graft thrombectomy with bovine patchangioplasty
[**2196**],rt. ileofem bpg with PTFE [**2195**].
#. Chronic pancreatitis s/p Puestow,J-tube.
#. Hx of ETOH cirrhosis/chronic pancreatitis
#. Hx of L breast cyst s/p excision


Discharge Condition:
Stable. HCT 24/5 at d/c.
Needs home oxygen
Saturating 93-94% on 2.5L n/c oxygen.


Discharge Instructions:
You were admitted for question of worsening anemia, severe
dyspnea, tachypnea, and tachycardia. You were found to have a
worsening of respiratory status. You had to be intubated to help
support your breathing. You improved with antibiotics, diuretics
and nebulizer treatments.  You received several types of
echocardiograms which failed to show any type of infection on
any of your valves. You also received a WBC scan which did not
show any other area of infection outside the area of your lung.
You had a CT study of your leg which showed no abnormalities
with your graft.
.
We modified your pain medication while you have been in the
hospital.
.
Please continue to take your antibiotic Cefazolin until
[**2199-3-4**].
.
Please take all of your medications as below.
.
Please have your acute rehabilitation center at [**Hospital1 **] check
your complete blood count, White Blood Cell Differential, Liver
function tests, and BUN/Creatinine on a weekly basis and send
the results by fax to Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7443**] at [**Telephone/Fax (1) 1419**]. He will be
monitoring your laboratory values during your recovery
.
Please return to the emergency department or call your primary
care provider if you experience mental status changes,
difficulty breathing, fevers greater than 101.5 degrees F,
somnolence, worsening pain, or any other symptoms that concern
you.


Followup Instructions:
Please attend the following medical appointments:
1) Provider [**Last Name (NamePattern4) **]. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 5302**] Phone:[**Telephone/Fax (1) 1144**]
Date/Time:[**2199-3-1**] 9:40AM
.
2) Provider CAT SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2199-2-27**]
1:45PM [**Hospital Ward Name 23**] Building [**Location (un) 861**]
.
3) Provider PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2199-3-27**] 4:10PM
.
4) Provider [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2199-3-11**] 10:00AM. [**Hospital **] Medical Office Building Suite
GB.
{'Abscess of lung,Acute respiratory failure,Bacteremia,Influenza with pneumonia,Acute kidney failure, unspecified,Obstructive chronic bronchitis with (acute) exacerbation,Other specified hypersensitivity angiitis,Chronic systolic heart failure,Pressure ulcer, buttock,Chronic pancreatitis,Other and unspecified infection due to central venous catheter,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Anemia, unspecified,Cirrhosis of liver without mention of alcohol,Phlebitis and thrombophlebitis of upper extremities, unspecified,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants'}


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: Drop in Hematocrit, hypoxia

PRESENT ILLNESS: 54 yo with anemia, COPD, h/o cirrhosis, PVD s/p recent AKA,
recent admit for MSSA bacteremia and necrotizing LUL pneumonia
now on course of CTX comes in from rehab for ?anemia vs
increasing oxygen requirement. Pt reported to be desatting to
75-85% on RA (96% on 2L) and also to have Hct of 25, which was
described as low; however, she was discharged from the hospital
recently with a hct of 24.
.
Seeing the patient this morning [**1-/2120**] she looked extremely
dyspneic, tachypneic w/ RR 40s, confused able to answer some
questions, but mostly answering inappropriately. Denies recent
fevers. Admits to increased thirst, shortness of breath in past
24 hours. Pt was discharged from [**Hospital1 18**] on [**1-25**] w/ MSSA PNA went
to rehab on CTX for antibiotics. She was triggered for increased
resp rate, ABG showed 7.32/32/78/17 on 4L oxygen
.
Of note: Her recent pulmonary history showed persistent hypoxia,
she had a VATS procedure and biopsy that showed respiratory
bronchiolitis with underlying interstitial lung disease
(RB-ILD). After AKA, she represented with a LUL necrotizing PNA
that is currently being treated with Ceftriaxone. Her hospital
course was also complicated by MSSA bacteremia, which was also
sensitive to Ceftriaxone . She was also anemic, with Hct of 24
on discharge, with a set transfusion threshold of 21. On
anticoagulation for recurrent thromboses of unknown etiology.

MEDICAL HISTORY: 1. s/p AKA [**11-10**] (right)
2. s/p VATS and hypoxemia, biopsy c/w Respiratory
Bronchiolitis-interstitial lung disease (RB-ILD) -- now on
intermittent supplemental oxygen
3. PVD - s/p rt. ileo-fem bpg [**12-10**] complicated by
lymphocele s/p drainage [**2198-1-11**],rt. ililac/femoral thrombectomy
[**4-10**],rt. ileo-fem graft thrombectomy with bovine
patchangioplasty [**2196**],rt. ileofem bpg with PTFE [**2195**],
4. chronic pancreatitis s/p Puestow,J-tube,ccy1998,Expl lap [**2189**]

MEDICATION ON ADMISSION: Ranitidine 150mg PO BID
Zofran PRN
Advair [**Hospital1 **]
Atorvastatin 20 mg PO DAILY
Lisinopril 5mg daily
Metoprolol 25mg TID
ISS
Duloxetine 60mg daily
Tiotropium Bromide 18 mcg daily inhalation
ZnSO4 220mg daily
Amitriptyline 50 mg PO HS
Benzocaine 20 % Paste TID:PRN
Dextromethorphan-Guaifenesin 10-100 mg/5 mL, Syrup Sig: 5-10ml
PO Q6H PRN
NPH 8 units qam and 5 units qpm
Hexavitamin Tablet daily
Folic Acid 1 mg daily
Thiamine HCl 100 mg PO once a day.
Albuterol PRN
Fexofenadine 60mg PO BID
Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule PO TID
W/MEALS
Gabapentin 400mg PO Q8H
Medium Chain Triglycerides Oil 15ml TID
Aspirin 325 mg daily
Colace 100mg TID
Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H PRN
Morphine 45 mg Sustained Release PO Q12H
Warfarin 3mg daily, Saturday/Sunday 2mg
Ceftriaxone-Dextrose 1g Q24H (every 24 hours) for 18 days until
[**2199-2-12**]

ALLERGIES: Penicillins

PHYSICAL EXAM: VS: 98.6, 135/66, HR: 90s-100s, 24, 86% on RA -> 93% on 4L
General - Somnolent, but arousable. Not always answering
questions appropriately.
HEENT - [**Last Name (un) **], MMM, no icteric sclera
Neck - non elevated JVP
CV - +s1+s2 Tachycardic Hyperdynamic. (thin chest wall)
Chest -
LUL - coarse. LLL - crackles. RLL with some crackles.
Abdomen - mildly tender to deep palpation along RLQ, mildly
distended, no dullness to percussin. Surgical scars, + BS. No
rebound. No guarding.
Ext - Left LE with 1+ edema, warm well perfused. R AKA with
dressing, non tense, tender to palpation, no erythema above
bandaged site. Palpable R,L fem pulse

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Recently discharged from [**Hospital3 **] to home. Married and
lives at home generally with her husband, no children.
Previously worked as a counselor in drug and alcohol programs.
She quit smoking approximately [**12/2198**] with an over 80-pack year
history of smoking. She quit drinking alcohol 23 years ago. She
has no known exposure to tuberculosis. She was cleaning her
husband's
clothes during the time that he was working with asbestos for a
three-month period. She has one dog at home and reports no
allergies to animals. Years ago she had a parrot, a dove, and
two parakeets.
.
Patient was transferred to [**Hospital1 18**] from NH East point
[**Telephone/Fax (1) 63761**]. She otherwise lives at home generally with her
husband, no children.
. 

### Response:
{'Abscess of lung,Acute respiratory failure,Bacteremia,Influenza with pneumonia,Acute kidney failure, unspecified,Obstructive chronic bronchitis with (acute) exacerbation,Other specified hypersensitivity angiitis,Chronic systolic heart failure,Pressure ulcer, buttock,Chronic pancreatitis,Other and unspecified infection due to central venous catheter,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Anemia, unspecified,Cirrhosis of liver without mention of alcohol,Phlebitis and thrombophlebitis of upper extremities, unspecified,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants'}
