CHIEF COMPLAINT: cough, shortness of breath

PRESENT ILLNESS: 54yoF with hx of DM, PVD, COPD presents with fever and
productive cough over 5 days.  Patient reports that she has had
increasing blood-tinged sputum production with association cough
over previous 3-5 days, cannot identify a specific time which it
started.  She denies any sick contacts.  Denies diarrhea,
nausea, or vomiting.  She did receive her flu shot this year,
but did not receive pneumovax.   Also complains of left sides
pleuritic chest pain, below nipple, began 5 days prior to
arrival, somewhat associated with breathing.

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: 1. Insulin NPH 16units qam, 7 units qpm
2. Ondansetron 4 mg prn
3. Fluticasone-Salmeterol 250-50 mcg/Dose [**Hospital1 **]
4. Simvastatin 20mg qd
5. Lorazepam 0.5 mg prn
6. Lisinopril 5 mg qd
7. Metoprolol 25mg tid
8. Duloxetine 60mg qd
9. Morphine 30 mg extended release - [**Hospital1 **]
10. Tiotropium Bromide 18 mcg qd
11. Albuterol 90 mcg prn
12. Fexofenadine 60 mg [**Hospital1 **]
13. Hexavitamin qd
14. Folic Acid 1 mg qd
15. Thiamine HCl 100 mg qd
16. Amylase-Lipase-Protease 20,000-4,500- 25,000 tid w/meals
17. Gabapentin 400 mg tid
18. Ranitidine HCl 150 mg [**Hospital1 **]
19. Medium Chain Triglycerides 15cc tid
20. Aspirin 325 mg qd
21. Zinc Sulfate 220 mg qd
22. Warfarin 3mg Tablet qd (but PCP notes state 6mg daily)
23. Docusate Sodium 100 mg [**Hospital1 **]
24. Prochlorperazine Maleate 10 mg prn
25. Amitriptyline 50 mg qhs
26. Lidocaine 5 %(700 mg/patch)patch to chest and leg prn
27. Oxycodone 5 mg q4 prn
28. dalteparin 5k

ALLERGIES: Penicillins

PHYSICAL EXAM: T 99 BP 107/78 HR 118 RR 20  97% 3L
Gen - NAD, A/Ox3, lying in bed, conversant, cooperative.
HEENT - no conjunctival pallor, no scleral icterus appreciated,
dry mucous membranes
NECK - no JVD appreciated
CV - tachy, no murmurs appreciated.
LUNGS - expiratory rhonchi heard throughout in all fields, more
in upper fields.  coarse inspiratory sounds in upper, medial
fields.  Increased area of crackles in left upper lobe, no
egophony.
ABD - NABS, soft, non-tender, non-distended.  No organomegaly
appreciated.  Significant scarring on abdomen from pancreatic
surgeries and feeding tubes.
EXT - no lower extremity edema.  1+ palpable pulse on L.  R
above knee amputation scar intact without ecchymoses or skin
breakdown.
SKIN: No rashes/lesions, ecchymoses.
NEURO - A&Ox3, seems apropriate. CN 2-12 grossly intact, did not
do fundoscopy.  Preserved sensation throughout.  MSK 4+/5 bil
UEs.
Psyche - listens and responds to questions appropriately

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.
Methicillin susceptible pneumonia due to Staphylococcus aureus,Methicillin susceptible Staphylococcus aureus septicemia,Other pulmonary insufficiency, not elsewhere classified,Diabetes with ketoacidosis, type II or unspecified type, uncontrolled,Chronic pancreatitis,Ulcer of calf,Primary hypercoagulable state,Long-term (current) use of insulin,Postinflammatory pulmonary fibrosis,Alcoholic cirrhosis of liver,Esophageal reflux,Chronic obstructive asthma, unspecified,Above knee amputation status,Atherosclerosis of native arteries of the extremities with ulceration,Dehydration,Personal history of malignant neoplasm of cervix uteri
Meth sus pneum d/t Staph,Meth susc Staph aur sept,Other pulmonary insuff,DMII ketoacd uncontrold,Chronic pancreatitis,Ulcer of calf,Prim hypercoagulable st,Long-term use of insulin,Postinflam pulm fibrosis,Alcohol cirrhosis liver,Esophageal reflux,Chronic obst asthma NOS,Status amput above knee,Ath ext ntv art ulcrtion,Dehydration,Hx-cervical malignancy
Admission Date:  [**2199-1-15**]              Discharge Date:   [**2199-1-25**]

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

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 348**]
Chief Complaint:
cough, shortness of breath

Major Surgical or Invasive Procedure:
none

History of Present Illness:
54yoF with hx of DM, PVD, COPD presents with fever and
productive cough over 5 days.  Patient reports that she has had
increasing blood-tinged sputum production with association cough
over previous 3-5 days, cannot identify a specific time which it
started.  She denies any sick contacts.  Denies diarrhea,
nausea, or vomiting.  She did receive her flu shot this year,
but did not receive pneumovax.   Also complains of left sides
pleuritic chest pain, below nipple, began 5 days prior to
arrival, somewhat associated with breathing.

   [**Name (NI) **] husband had been noticing elevated glucoses at home
and had been communicating with PCP over phone about elevated
levels over previous days.  Patient had labs drawn the morning
before arrival in ED, which showed a glucose of 400 and an anion
gap.

   Of note, patient recently admitted in [**Month (only) 404**] for an above
knee, right leg amputation due to an infected ulcer, discharged
to [**Hospital3 **], and most recently living at home.  She was
readmitted to [**Hospital1 18**] in late [**Month (only) 404**] for two days for R-sided
chest pain, ?thought [**1-5**] to VATs procedure, started on lidoderm
patch.  Per report, it appears patient has had difficulty caring
for herself.

   In [**Hospital1 18**] ED, t99, hr 120, sbp 90s, 95%3L nc, ill-appearing
female with difficulty clearing secretions.  CXR showed LUL
pneumonia and labs showed a normal anion gap.  Three peripheral
IVs were placed and patient given a dose of levaquin, ctx, and
flagyl for community acquired vs. aspiration pneumonia.  Given
vancomycin for unsure reason.  She transiently dropped her
pressures to the 80s, which responded with fluids, receiving 4L
NS while in ED.

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.

Family History:
noncontributory

Physical Exam:
T 99 BP 107/78 HR 118 RR 20  97% 3L
Gen - NAD, A/Ox3, lying in bed, conversant, cooperative.
HEENT - no conjunctival pallor, no scleral icterus appreciated,
dry mucous membranes
NECK - no JVD appreciated
CV - tachy, no murmurs appreciated.
LUNGS - expiratory rhonchi heard throughout in all fields, more
in upper fields.  coarse inspiratory sounds in upper, medial
fields.  Increased area of crackles in left upper lobe, no
egophony.
ABD - NABS, soft, non-tender, non-distended.  No organomegaly
appreciated.  Significant scarring on abdomen from pancreatic
surgeries and feeding tubes.
EXT - no lower extremity edema.  1+ palpable pulse on L.  R
above knee amputation scar intact without ecchymoses or skin
breakdown.
SKIN: No rashes/lesions, ecchymoses.
NEURO - A&Ox3, seems apropriate. CN 2-12 grossly intact, did not
do fundoscopy.  Preserved sensation throughout.  MSK 4+/5 bil
UEs.
Psyche - listens and responds to questions appropriately


Pertinent Results:
[**2199-1-15**] 01:50AM BLOOD WBC-8.9 RBC-3.63* Hgb-11.5*# Hct-35.3*
MCV-97 MCH-31.6 MCHC-32.6 RDW-15.4 Plt Ct-322
[**2199-1-15**] 03:25AM BLOOD WBC-9.5 RBC-3.17* Hgb-9.9* Hct-29.7*
MCV-94 MCH-31.2 MCHC-33.3 RDW-15.1 Plt Ct-325
[**2199-1-21**] 06:03AM BLOOD WBC-15.3* RBC-2.65* Hgb-7.9* Hct-25.9*
MCV-98 MCH-29.8 MCHC-30.6* RDW-15.2 Plt Ct-447*
[**2199-1-22**] 11:53AM BLOOD WBC-14.3* RBC-2.65* Hgb-7.8* Hct-25.5*
MCV-96 MCH-29.5 MCHC-30.7* RDW-15.0 Plt Ct-507*
[**2199-1-15**] 01:50AM BLOOD Neuts-58 Bands-28* Lymphs-6* Monos-4
Eos-0 Baso-0 Atyps-3* Metas-1* Myelos-0
[**2199-1-22**] 11:53AM BLOOD Neuts-83.9* Lymphs-12.2* Monos-3.0
Eos-0.6 Baso-0.2
[**2199-1-22**] 11:53AM BLOOD PT-17.5* PTT-28.6 INR(PT)-1.6*
[**2199-1-21**] 07:24AM BLOOD Glucose-170* UreaN-22* Creat-0.8 Na-139
K-4.4 Cl-107 HCO3-24 AnGap-12
[**2199-1-15**] 03:25AM BLOOD cTropnT-0.03*
[**2199-1-15**] 03:25AM BLOOD CK(CPK)-77

DISCHARGE LABS [**1-25**]:
WBC 13.6, HCT 24, PLT 605
INR 2.9, PTT 41.6
NA 142, K 4.2, CL 111, BICARB 24, BUN 21, CR 0.6, GLUCOSE 52

[**2199-1-15**] 3:30 am BLOOD CULTURE     Site: ARM      X2.

                            **FINAL REPORT [**2199-1-21**]**

   Blood Culture, Routine (Final [**2199-1-21**]):
      STAPH AUREUS COAG +.    FINAL SENSITIVITIES.
         Staphylococcus species may develop resistance during
prolonged
         therapy with quinolones.   Therefore, isolates that are
initially
         susceptible may become resistant within three to four
days after
         initiation of therapy.  Testing of repeat isolates may
be
         warranted.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------  0.25 S
OXACILLIN-------------   0.5 S
PENICILLIN------------ =>0.5 R
TRIMETHOPRIM/SULFA---- <=0.5 S

   Anaerobic Bottle Gram Stain (Final [**2199-1-16**]):
      REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] AT 0025 ON [**2199-1-16**].
      GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
[**2199-1-23**] 8:46 am SPUTUM      Source: Expectorated.

   GRAM STAIN (Final [**2199-1-23**]):
      >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 POSITIVE ROD(S).
      1+    (<1 per 1000X FIELD):   YEAST(S).

   RESPIRATORY CULTURE (Preliminary):
      SPARSE GROWTH OROPHARYNGEAL FLORA.
      STAPH AUREUS COAG +.    SPARSE GROWTH.

PANOREX FILMS [**1-21**]:
HISTORY:  Dental pain.
FINDINGS:  No previous images.  Panorex image shows extensive
metallic dental work in the remaining teeth.  No convincing
evidence of osteomyelitis.

CHEST CT WITH CONTRAST: [**2199-1-16**]
TECHNIQUE:  COPD, interstitial lung disease, left upper lobe
pneumonia and
evidence of loculated pleural effusion concerning for empyema.

TECHNIQUE:  MDCT was used to obtain contiguous axial images
through the chest after uneventful administration of 70 mL of
Optiray IV contrast.  Multiplanar reformats were obtained.  This
study was compared with [**2198-4-27**], [**11-22**]. [**2197**],
[**2198-11-28**], [**2198-12-2**], and [**2198-12-24**] chest
CT scans.

FINDINGS:  The left upper lobe consolidation is worse since the
[**2198-12-24**] study, with central gas and low density that
likely represents a
necrotizing component (series 4, image 21).  The left lower lobe
consolidation is probably similar to the previous study.

The right lower lobe consolidation has improved, and the right
upper lobe
consolidation has also improved.  There are sutures along the
right lateral chest wall, with a tiny amount of extrapleural air
(series 4, image 41).

The loculated right pleural effusion is smaller than previous,
and is now
small. The left pleural effusion is larger than the last
examination, and
loculated; there is no definite evidence for empyema, though
this cannot be excluded at this time.  Diffuse smooth
intralobular septal thickening is seen, primarily at the lung
apices and bases, and can represent superimposed edema on the
patient's known emphysema, however, there may be a component of
underlying non-emphysematous interstitial lung disease.

Lymphadenopathy in the mediastinum has slightly increased,
particularly in the left prevascular aorticopulmonary window,
now up to a thickness of
approximately 13 mm, previously only 11 mm.  A subcarinal lymph
node
conglomerate is similar to the previous study.  There is no
pericardial
effusion.  No coronary vascular calcifications are seen.  There
is no axillary lymphadenopathy.

This study is not targeted to the abdomen, however, imaged
portion of the
liver, adrenals, spleen, kidneys, and stomach are normal.

No suspicious sclerotic or lytic lesions.

Multiplanar reformats were essential in delineating the findings
above,
particularly of the left upper lobe findings.

IMPRESSION:
1.  Increase in consolidation of the left upper lobe with
development of
central low density, suggesting necrotizing pneumonia with early
abscess
formation.
2.  Overall improved right lobe consolidations.  Probably
similar left lobe consolidations.
3.  Loculated moderately sized left pleural effusion; no
definite evidence of empyema at this time.
4.  Decrease in right pleural effusion.
5.  Mediastinal lymphadenopathy is likely reactive.
6.  Smooth intralobular septal thickening may indicate patient's
known
interstitial lung disease with possible component of
superimposed hydrostatic edema.

CXR [**1-15**]:
AP SEMI-UPRIGHT CHEST:  Since the previous study, there has been
development of a large area of consolidation in the left mid and
upper lung.  Pleural effusions have improved.  Pulmonary
interstitial prominence remains stable.  Cardiac and mediastinal
contours are unchanged.

Lateral view demonstrates the consolidation to be anteriorly
situated, thus probably within the left upper lobe.  The bones
are diffusely demineralized.

IMPRESSION:  Interval development of large left upper lobe
consolidation
consistent with pneumonia.  Followup imaging after treatment is
recommended to ensure resolution.

[**1-18**] PICC LINE PLACEMENT:
Uncomplicated ultrasound and fluoroscopically guided 5-French
PICC
line placement via the right brachial venous approach. Final
internal length is 38 cm, with the tip positioned in SVC. The
line is ready to use.


Brief Hospital Course:
PNEUMONIA- smoking hx with copd, and on previous admission had
persistent hypoxemia with resultant VATS procedure and biopsy
that showed respiratory bronchiolitis with underlying
interstitial lung disease (RB-ILD), here with a superimposed LUL
pneumonia.  A chest CT revealed an extensive LUL pneumonia also
with a necrotizing component.  Her blood cultures grew MSSA.
She was started on Ceftriaxone IV, plan to continue this for 4
weeks given fem-[**Doctor Last Name **] bypass graft could be considered hardware,
she was afebrile and repeat blood cultures were negative making
infected hardware less likely.  Patient's symptoms of cough had
improved and stabilized upon discharge and she denied any
shortness of breath.  Last day of antibiotics [**2-12**].  She was
continued on her home inhalers.  She has PCP and pulmonary
follow up as an outpatient.

ANEMIA: anemia of chornic disease, patient has needed blood
tranfusions in the past, no dramatic drop in hematocrit and no
source of bleeding.  Baseline hct in mid to low 20s.  Plan to
transfuse for hct < 21, patient has no active end organ
ischemia.  Discharge hct: 24.0. Patient should have hct
rechecked on Monday [**1-28**] and if < 21 would have patient
transfused 1 unit PRBC (if unable at rehab would sent patient to
ER for transfusion for anemia of chronic disease).

IDDM - patient had not been taking NPH as prescribed since
recent discharge from [**Hospital1 **] last week.  She had a blood
glucose of 400 upon admission.  She was discharged on NPH 10
units qam and 4 units qpm in addition to a sliding scale.  She
should follow up with [**Last Name (un) **] diabetes center.

HYPERCOAGULABILITY: history of multiple venous and arterial
thrombi in the past without a definitive etiology, has seen
hematology, Dr. [**Last Name (STitle) **], in the past and a w/u was negative but
patient on anticoagulation at that time.  They had determined at
that time that she remain on anticoagulation for the long term.
On lovenox bridging to a therapeutic INR on coumadin, goal INR
[**1-6**].  INR 2.9 upon discharge, on 3mg daily, changed to 2mg on
Sat / Sun and 3mg daily on Mon-Fri.

PAIN CONTROL: phantom limb pain, pain well controlled on regimen
of tylenol, MS contin and MSIR, cymbalta and neurontin.

DEPRESSION: clinically depressed with a history of suicidal
ideation, no attempts, denies suicidal ideation now.  good
support from her husband, feels stable, no mania or psychotic
features.  On cymbalta.  Phone number for psychiatry appointment
provided to patient upon discharge for outpatient psychiatry
follow up.

CHRONIC PANCRETITIS: s/p Puestow procedure which anastamosed her
pancreastic duct to her small bowel, she is on enzymatic
replacement therapy and is stable with this regimen.  No active
inpatient issues.

Medications on Admission:
1. Insulin NPH 16units qam, 7 units qpm
2. Ondansetron 4 mg prn
3. Fluticasone-Salmeterol 250-50 mcg/Dose [**Hospital1 **]
4. Simvastatin 20mg qd
5. Lorazepam 0.5 mg prn
6. Lisinopril 5 mg qd
7. Metoprolol 25mg tid
8. Duloxetine 60mg qd
9. Morphine 30 mg extended release - [**Hospital1 **]
10. Tiotropium Bromide 18 mcg qd
11. Albuterol 90 mcg prn
12. Fexofenadine 60 mg [**Hospital1 **]
13. Hexavitamin qd
14. Folic Acid 1 mg qd
15. Thiamine HCl 100 mg qd
16. Amylase-Lipase-Protease 20,000-4,500- 25,000 tid w/meals
17. Gabapentin 400 mg tid
18. Ranitidine HCl 150 mg [**Hospital1 **]
19. Medium Chain Triglycerides 15cc tid
20. Aspirin 325 mg qd
21. Zinc Sulfate 220 mg qd
22. Warfarin 3mg Tablet qd (but PCP notes state 6mg daily)
23. Docusate Sodium 100 mg [**Hospital1 **]
24. Prochlorperazine Maleate 10 mg prn
25. Amitriptyline 50 mg qhs
26. Lidocaine 5 %(700 mg/patch)patch to chest and leg prn
27. Oxycodone 5 mg q4 prn
28. dalteparin 5k


Discharge Medications:
1. hospital bed
One hospital bed
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: as
directed  Subcutaneous as directed: please take 10 units of NPH
in the a.m. and 7 units of NPH in the p.m.
4. Insulin Regular Human 100 unit/mL Solution Sig: as directed
Injection as directed: sliding scale insulin for breakfast,
lunch, dinner, and bedtime.
5. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO three times a day as needed for nausea.
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Three
(3) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
12. Morphine 15 mg Tablet Sustained Release Sig: Three (3)
Tablet Sustained Release PO Q12H (every 12 hours).
13. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
14. Albuterol 90 mcg/Actuation Aerosol Sig: One (1)  Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
15. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
16. Hexavitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).
17. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

18. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a
day.
19. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
20. Gabapentin 100 mg Capsule Sig: Four (4) Capsule PO Q8H
(every 8 hours).
21. Medium Chain Triglycerides     Oil Sig: Fifteen (15) ML PO
TID (3 times a day).
22. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

23. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
24. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY16 (Once
Daily at 16): please take 3mg daily on Monday through Friday and
2mg daily on Saturday and Sunday, please have your INR checked
on Monday [**1-28**].
25. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2)  PO BID (2
times a day).
26. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
27. Benzocaine 20 % Paste Sig: One (1) Appl Mucous membrane TID
(3 times a day) as needed.
28. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback Sig:
One (1)  Intravenous Q24H (every 24 hours) for 18 days: until
[**2199-2-12**].
29. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: [**4-13**]
MLs PO Q6H (every 6 hours) as needed.


Discharge Disposition:
Extended Care

Facility:
[**Last Name (LF) **], [**First Name3 (LF) **]

Discharge Diagnosis:
Primary Diagnosis:
Pneumonia

Secondary diagnosis:
Hypercoagulability
s/p R AKA


Discharge Condition:
stable, sating well on room air


Discharge Instructions:
You were admitted with pneumonia and treated with antibiotics,
you should continue IV antibiotics for a 4 week total course.
Start date [**1-15**], last day [**2199-2-12**].

Please call your doctor or return to the emergency room if you
have a worsening cough, shortness of breath, fevers or other
symptoms that concern you.

Followup Instructions:
You have the following appointment with a new primary care
physician: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 1439**] [**Last Name (NamePattern1) **] on Tuesday [**2-19**] at 2:30 p.m.
(phone [**Telephone/Fax (1) 250**])

You have the following appointment with your pulmonologist: Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4507**], Wednesday [**2-6**] at 3:30 [**Initials (NamePattern5) **] [**Last Name (NamePattern5) 23**] [**Location (un) 436**].

In addition please follow up with the [**Last Name (un) **] Diabetes Center for
your diabetes: [**3-11**] at 4:00 p.m. Dr. [**Last Name (STitle) 4379**], [**Last Name (un) **],
[**Location (un) **]. ([**Telephone/Fax (1) 4847**]

Also, you have the following appointment with psychiatry: ([**Telephone/Fax (1) 33215**]

You have the following appointments:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2199-3-20**] 3:15
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2199-3-27**] 4:10
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2199-3-27**] 4:30

Also, you can call the [**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**] Management center at the [**Hospital1 **]
to help with your pain. ([**Telephone/Fax (1) 19088**]
{'Methicillin susceptible pneumonia due to Staphylococcus aureus,Methicillin susceptible Staphylococcus aureus septicemia,Other pulmonary insufficiency, not elsewhere classified,Diabetes with ketoacidosis, type II or unspecified type, uncontrolled,Chronic pancreatitis,Ulcer of calf,Primary hypercoagulable state,Long-term (current) use of insulin,Postinflammatory pulmonary fibrosis,Alcoholic cirrhosis of liver,Esophageal reflux,Chronic obstructive asthma, unspecified,Above knee amputation status,Atherosclerosis of native arteries of the extremities with ulceration,Dehydration,Personal history of malignant neoplasm of cervix uteri'}


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: 54yoF with hx of DM, PVD, COPD presents with fever and
productive cough over 5 days.  Patient reports that she has had
increasing blood-tinged sputum production with association cough
over previous 3-5 days, cannot identify a specific time which it
started.  She denies any sick contacts.  Denies diarrhea,
nausea, or vomiting.  She did receive her flu shot this year,
but did not receive pneumovax.   Also complains of left sides
pleuritic chest pain, below nipple, began 5 days prior to
arrival, somewhat associated with breathing.

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: 1. Insulin NPH 16units qam, 7 units qpm
2. Ondansetron 4 mg prn
3. Fluticasone-Salmeterol 250-50 mcg/Dose [**Hospital1 **]
4. Simvastatin 20mg qd
5. Lorazepam 0.5 mg prn
6. Lisinopril 5 mg qd
7. Metoprolol 25mg tid
8. Duloxetine 60mg qd
9. Morphine 30 mg extended release - [**Hospital1 **]
10. Tiotropium Bromide 18 mcg qd
11. Albuterol 90 mcg prn
12. Fexofenadine 60 mg [**Hospital1 **]
13. Hexavitamin qd
14. Folic Acid 1 mg qd
15. Thiamine HCl 100 mg qd
16. Amylase-Lipase-Protease 20,000-4,500- 25,000 tid w/meals
17. Gabapentin 400 mg tid
18. Ranitidine HCl 150 mg [**Hospital1 **]
19. Medium Chain Triglycerides 15cc tid
20. Aspirin 325 mg qd
21. Zinc Sulfate 220 mg qd
22. Warfarin 3mg Tablet qd (but PCP notes state 6mg daily)
23. Docusate Sodium 100 mg [**Hospital1 **]
24. Prochlorperazine Maleate 10 mg prn
25. Amitriptyline 50 mg qhs
26. Lidocaine 5 %(700 mg/patch)patch to chest and leg prn
27. Oxycodone 5 mg q4 prn
28. dalteparin 5k

ALLERGIES: Penicillins

PHYSICAL EXAM: T 99 BP 107/78 HR 118 RR 20  97% 3L
Gen - NAD, A/Ox3, lying in bed, conversant, cooperative.
HEENT - no conjunctival pallor, no scleral icterus appreciated,
dry mucous membranes
NECK - no JVD appreciated
CV - tachy, no murmurs appreciated.
LUNGS - expiratory rhonchi heard throughout in all fields, more
in upper fields.  coarse inspiratory sounds in upper, medial
fields.  Increased area of crackles in left upper lobe, no
egophony.
ABD - NABS, soft, non-tender, non-distended.  No organomegaly
appreciated.  Significant scarring on abdomen from pancreatic
surgeries and feeding tubes.
EXT - no lower extremity edema.  1+ palpable pulse on L.  R
above knee amputation scar intact without ecchymoses or skin
breakdown.
SKIN: No rashes/lesions, ecchymoses.
NEURO - A&Ox3, seems apropriate. CN 2-12 grossly intact, did not
do fundoscopy.  Preserved sensation throughout.  MSK 4+/5 bil
UEs.
Psyche - listens and responds to questions appropriately

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. 

### Response:
{'Methicillin susceptible pneumonia due to Staphylococcus aureus,Methicillin susceptible Staphylococcus aureus septicemia,Other pulmonary insufficiency, not elsewhere classified,Diabetes with ketoacidosis, type II or unspecified type, uncontrolled,Chronic pancreatitis,Ulcer of calf,Primary hypercoagulable state,Long-term (current) use of insulin,Postinflammatory pulmonary fibrosis,Alcoholic cirrhosis of liver,Esophageal reflux,Chronic obstructive asthma, unspecified,Above knee amputation status,Atherosclerosis of native arteries of the extremities with ulceration,Dehydration,Personal history of malignant neoplasm of cervix uteri'}
