CHIEF COMPLAINT: Bloody sputum for 5 days, post-bronchoscopy respiratory distress

PRESENT ILLNESS: Mr. [**Known lastname 108855**] is a very pleasant 84 y/o male with a h/o colon
cancer s/p resection and radiation, CAD s/p stents, systolic CHF
with EF 40-45%, dilated cardiomyopathy, afib, h/o cardiac arrest
and complete heart block now with pacer/AICD, and history of GI
bleed secondary to duodenal telangiectasia who is here from
rehab following evaluation of blood in his respiratory
secretions.
.
Mr. [**Known lastname 108855**] had a lengthy, complex, and recent admission to
the TICU which is summarized in brief. He had a fall on [**2163-6-23**],
leading to multiple rib fractures. He had L 1-10th rib frx, R
5-7th rib frx, L hemothorax decompressed by pigtail catheter,
and a L distal clavicle fracture. He was given a tracheostomy
and PEG tube after failed extubation and reintubation.
.
In rehab, the patient was noted to have blood tinged secretions
via his trach. A bronschoscopy was performed and reportedly saw
bleeding inside of his trachea with poor visualization. He was
transfused 2 unit pRBC and was transferred to [**Hospital1 18**]. Here, the
patient reports no resp distress. His wife stated that the pt
has been stable with no change in his respiration.
.
He underwent a bronchoscopy with our [**Hospital1 18**] group on [**7-13**], which
did not find an etiology of the bleed. Only suction trauma was
seen. Of note, he was receiving intermittent lasix and IVF for
hypernatremia prior to bronchoscopy. Post-procedure, he was
noted to be mildly tachypnic with RR 30s and was satting 88% on
15L NC. As such, he was transferred to the medical ICU for
closer monitoring. Of note, he is typically on 50% FIO2 with his
trach mask.

MEDICAL HISTORY: rectal cancer s/p removal and radiation ijn [**2157**]
CAD s/p stents
Complete heart block (now with pacer)
afib
h/o cardiac arrest (now with AICD)
systolic CHF (EF 40-45%)
fall with multiple rib fractures ([**2163-6-23**])
GI bleed

MEDICATION ON ADMISSION: acetaminophen 975mg PO Q8H
carvedilol 3.125mg PO BID
Citalopram 20mg PO daily
docusate 100mg PO BID
ferrous sulfate 300mg PO daily
fluconazole 100mg PO Q12H
folic acid 1 mg po daily
lasix 40mg PO daily
gabapentin 300mg PO Q12H
heparin 5000U SC Q12H
lisinopril 2.5mg PO daily
MVI daily
omeprazole 20mg PO daily
protein supplement daily
albuterol inhaler 4 puffs Q2H prn wheezing
simethicone 80mg PO Q8Hprn
oxycodone 5-10mg po q4h prn

ALLERGIES: Penicillins / Erythromycin Base / Streptomycin / Citric Acid /
Atenolol / Torsemide / Heparin Agents

PHYSICAL EXAM: VS: T 101, BP:111/49, HR: 70, RR:19, O2:95% on 50% FiO2
General: NAD, resting comfortably and sleeping, arousable with
mild stimuli from sleep, no labored breathing
HEENT: NC, AT, no blood at trach opening or in oropharynx, MMM
Neck: no JVD, no LAD
Lungs: rhonchi throughout, diminished sounds at the bases
Heart: RRR, no M/R/G
Abdomen: soft, nontender, nondistended, normoactive bowel
sounds, PEG and ostomy in place, ostomy has brown stool
Skin: dry, hyperpigmentation of distal LE bilaterally; LUE seems
to be more swollen than RUE
Ext: bilateral lower extremities wrapped in dressing
NEURO: Coherent but sluggish, has episodic confusion. Can
verbalize some words through mask. CN II-XII intact, no motor or
sensory deficits on screening exam.
At discharge: same as above except
Gen: Arousable to verbal stimuli
HEENT: clear/tan secretions at trach site
Ext: LUE with swelling

FAMILY HISTORY: Father died in 80s from MI. Mother died in 80s from PE. No
family history of colon, breast, uterine, or ovarian cancer. No
family history of seizures.

SOCIAL HISTORY: Mr. [**Known lastname 108855**] lives in [**Location 745**] with his wife. They are currently
in the process of moving to an apartment. Per wife, Mr.
[**Known lastname 108855**] has been feeling stress/depressed about moving out of
their 42 year home. They have 2 children. He is a retired
computer science professor. [**First Name (Titles) **] [**Last Name (Titles) 22381**] smoked 5 cigars a day
for 30 years and quit in [**2150**] after his CVA. He drinks once or
twice a week. His wife says that even just a little alcohol
'affects him quite a bit' in changing his mood and makes 'him
sick'
Attention to tracheostomy,Acute on chronic systolic heart failure,Methicillin susceptible pneumonia due to Staphylococcus aureus,Acute and chronic respiratory failure,Other primary cardiomyopathies,Acute posthemorrhagic anemia,Hyperosmolality and/or hypernatremia,Candidiasis of mouth,Heparin-induced thrombocytopenia (HIT),Atrial fibrillation,Long-term (current) use of anticoagulants,Personal history of malignant neoplasm of large intestine,Personal history of irradiation, presenting hazards to health,Automatic implantable cardiac defibrillator in situ,Percutaneous transluminal coronary angioplasty status,Personal history of sudden cardiac arrest,History of fall,Personal history of traumatic fracture
Atten to tracheostomy,Ac on chr syst hrt fail,Meth sus pneum d/t Staph,Acute & chronc resp fail,Prim cardiomyopathy NEC,Ac posthemorrhag anemia,Hyperosmolality,Thrush,Heparin-indu thrombocyto,Atrial fibrillation,Long-term use anticoagul,Hx of colonic malignancy,Hx of irradiation,Status autm crd dfbrltr,Status-post ptca,Hx sudden cardiac arrest,Personal history of fall,Hx traumatic fracture
Admission Date:  [**2163-7-12**]              Discharge Date:   [**2163-7-20**]

Date of Birth:  [**2079-1-17**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Erythromycin Base / Streptomycin / Citric Acid /
Atenolol / Torsemide / Heparin Agents

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Bloody sputum for 5 days, post-bronchoscopy respiratory distress

Major Surgical or Invasive Procedure:
[**7-13**]: Bronchoscopy - only suction trauma visualized, no source
of bleeding found.


History of Present Illness:
Mr. [**Known lastname 108855**] is a very pleasant 84 y/o male with a h/o colon
cancer s/p resection and radiation, CAD s/p stents, systolic CHF
with EF 40-45%, dilated cardiomyopathy, afib, h/o cardiac arrest
and complete heart block now with pacer/AICD, and history of GI
bleed secondary to duodenal telangiectasia who is here from
rehab following evaluation of blood in his respiratory
secretions.
.
Mr. [**Known lastname 108855**] had a lengthy, complex, and recent admission to
the TICU which is summarized in brief. He had a fall on [**2163-6-23**],
leading to multiple rib fractures. He had L 1-10th rib frx, R
5-7th rib frx, L hemothorax decompressed by pigtail catheter,
and a L distal clavicle fracture. He was given a tracheostomy
and PEG tube after failed extubation and reintubation.
.
In rehab, the patient was noted to have blood tinged secretions
via his trach. A bronschoscopy was performed and reportedly saw
bleeding inside of his trachea with poor visualization. He was
transfused 2 unit pRBC and was transferred to [**Hospital1 18**]. Here, the
patient reports no resp distress. His wife stated that the pt
has been stable with no change in his respiration.
.
He underwent a bronchoscopy with our [**Hospital1 18**] group on [**7-13**], which
did not find an etiology of the bleed. Only suction trauma was
seen. Of note, he was receiving intermittent lasix and IVF for
hypernatremia prior to bronchoscopy. Post-procedure, he was
noted to be mildly tachypnic with RR 30s and was satting 88% on
15L NC. As such, he was transferred to the medical ICU for
closer monitoring. Of note, he is typically on 50% FIO2 with his
trach mask.


Past Medical History:
rectal cancer s/p removal and radiation ijn [**2157**]
CAD s/p stents
Complete heart block (now with pacer)
afib
h/o cardiac arrest (now with AICD)
systolic CHF (EF 40-45%)
fall with multiple rib fractures ([**2163-6-23**])
GI bleed

Social History:
Mr. [**Known lastname 108855**] lives in [**Location 745**] with his wife. They are currently
in the process of moving to an apartment. Per wife, Mr.
[**Known lastname 108855**] has been feeling stress/depressed about moving out of
their 42 year home. They have 2 children. He is a retired
computer science professor. [**First Name (Titles) **] [**Last Name (Titles) 22381**] smoked 5 cigars a day
for 30 years and quit in [**2150**] after his CVA. He drinks once or
twice a week. His wife says that even just a little alcohol
'affects him quite a bit' in changing his mood and makes 'him
sick'

Family History:
Father died in 80s from MI. Mother died in 80s from PE. No
family history of colon, breast, uterine, or ovarian cancer. No
family history of seizures.

Physical Exam:
VS: T 101, BP:111/49, HR: 70, RR:19, O2:95% on 50% FiO2
General: NAD, resting comfortably and sleeping, arousable with
mild stimuli from sleep, no labored breathing
HEENT: NC, AT, no blood at trach opening or in oropharynx, MMM
Neck: no JVD, no LAD
Lungs: rhonchi throughout, diminished sounds at the bases
Heart: RRR, no M/R/G
Abdomen: soft, nontender, nondistended, normoactive bowel
sounds, PEG and ostomy in place, ostomy has brown stool
Skin: dry, hyperpigmentation of distal LE bilaterally; LUE seems
to be more swollen than RUE
Ext: bilateral lower extremities wrapped in dressing
NEURO: Coherent but sluggish, has episodic confusion. Can
verbalize some words through mask. CN II-XII intact, no motor or
sensory deficits on screening exam.
At discharge: same as above except
Gen: Arousable to verbal stimuli
HEENT: clear/tan secretions at trach site
Ext: LUE with swelling

Pertinent Results:
[**2163-7-12**] 02:15PM BLOOD WBC-10.4 RBC-3.05* Hgb-9.1* Hct-28.8*
MCV-95 MCH-29.9 MCHC-31.6 RDW-19.7* Plt Ct-273
[**2163-7-19**] 03:00AM BLOOD WBC-3.8* RBC-2.68* Hgb-8.0* Hct-25.5*
MCV-95 MCH-29.7 MCHC-31.2 RDW-17.1* Plt Ct-111*
[**2163-7-12**] 02:15PM BLOOD Neuts-80.6* Bands-0 Lymphs-8.4* Monos-9.6
Eos-0.6 Baso-0.6
[**2163-7-12**] 02:15PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+
Macrocy-2+ Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL
Burr-OCCASIONAL Stipple-OCCASIONAL
[**2163-7-12**] 02:15PM BLOOD PT-14.1* PTT-30.5 INR(PT)-1.2*
[**2163-7-15**] 05:37AM BLOOD PT-15.0* PTT-29.6 INR(PT)-1.3*
[**2163-7-12**] 02:15PM BLOOD Glucose-138* UreaN-63* Creat-1.1 Na-150*
K-4.8 Cl-108 HCO3-33* AnGap-14
[**2163-7-19**] 03:00AM BLOOD Glucose-130* UreaN-36* Creat-0.9 Na-141
K-5.1 Cl-105 HCO3-32 AnGap-9
[**2163-7-12**] 02:15PM BLOOD ALT-43* AST-38 AlkPhos-151* TotBili-1.0
[**2163-7-12**] 02:15PM BLOOD Lipase-523*
[**2163-7-12**] 02:15PM BLOOD proBNP-7598*
[**2163-7-19**] 03:00AM BLOOD Calcium-8.2* Phos-2.8 Mg-2.4
[**2163-7-13**] 04:36PM BLOOD Type-ART Rates-/32 FiO2-100 pO2-60*
pCO2-48* pH-7.47* calTCO2-36* Base XS-9 Intubat-NOT INTUBA
Comment-TRACH MASK
[**2163-7-12**] 02:22PM BLOOD Lactate-1.1
.
Microbiology:
[**7-13**] Blood Cx: No growth
[**7-13**] Urine Cx: No growth
[**7-13**] Sputum Cx: Staph aureus coag +, sensitive to levofloxacin
[**7-13**] MRSA nasal screen: negative
.
Imaging:
[**7-16**] LUE doppler: No evidence of deep venous thrombosis in the
left upper extremity.
[**7-19**] CXR: Slightly rotated positioning. A tracheostomy tube is in
place. A left-sided dual-lead pacemaker is in place, with lead
tips over right atrium and right ventricle.  There is moderately
severe cardiomegaly, with left lower lobe collapse and/or
consolidation. There is upper zone redistribution and diffuse
vascular blurring, suggestive of mild CHF. There is focal patchy
opacity in the left mid zone, which could reflect atelectasis or
a pneumonic infiltrate. There is a small left and possible
minimal right effusion. Minimal atelectasis right base. The hila
are enlarged.


Brief Hospital Course:
Mr. [**Known lastname 108855**] is a 84 y/o male with colon cancer s/p resection
and radiation, CAD s/p stents, systolic CHF with EF 40-45%,
dilated cardiomyopathy, afib, h/o cardiac arrest and complete
heart block now with pacer/AICD, and history of GI bleed
secondary to duodenal telangiectasia who is here from rehab for
hemoptysis. Of note, he had lengthy TICU hospitalization for L
1-10th rib fractures, R 5-7th rib fractures, a L hemothorax, a L
dist clavicle fracture, and he is s/p trach and peg.
.
# Hemoptysis: Mr. [**Known lastname 108855**] was noted to have blood tinged
secretions via his trach. An OSH bronschoscopy was performed and
reportedly saw bleeding inside the trachea with poor
visualization. He was transfused 2 units of pRBC and transferred
to [**Hospital1 18**]. Here, he reported no resp distress. He is status post
bronchoscopy with our pulmonary team on [**7-13**], which did not find
an etiology of the bleed. Only suction trauma was seen, and this
may be the primary etiology of his bloody tracheal secretions.
While the cause of his hemoptysis remains uncertain, his
hematocrits have remained stable and there are no signs of
continuing hemoptysis or active bleeding. Chemical DVT ppx was
held at time of discharge after he was HIT positive and given
risk of bleeding with suction trauma.
.
# Respiratory distress: His respiratory distress has
currentlyimproved. Post bronchoscopy, he was noted to be mildly
tachypnic with RR 30s and was 88% on 15L NC. A CXR showed
worsening pulmonary edema, and he received lasix with
improvement in PACU. He was transferred to the MICU for closer
monitoring. Of note, he was receiving intermittent lasix and an
IVF bolus prior to bronchoscopy. He is typically on 50% FIO2
with his trach mask. He was weaned from the ventilator, and was
continued on albuterol MDIs. He was also treated with vancomycin
and cefepime for HCAP, until his sputum Cx grew coag-positive
staph sensitive to levofloxacin. He was started on an 8-day
course of levofloxacin 750mg qday, of which the last dose will
be on [**7-21**]. Lasix 40mg PO daily was restarted on day of
discharge. This should be titrated as needed.
-We recommend keeping the patient on the ventilator (MMV)
overnight to decrease his work of breathing.
.
# Fever: The patient p/w low grade fever/temperature post
bronchoscopy. His fever curve was trended, and cultures were
sent. His urine and blood cultures showed no growth, while his
sputum culture grew coag-positive staph as mentioned above. He
was continued on levofloxacin.
.
# Anemia: His anemia was stable after 2u pRBC prior to transfer,
and his hematocrits remained stable. There was no further need
for transfusion.
.
# Asymetric swelling of LUE: His LUE was cooler than the RUE and
more swollen than the right, but still had good pulses. Although
his wife stated that his LUE has always been swollen, a doppler
of the LUE was obtained which showed no evidence of DVT. The
swelling appears to have reduced, although it still remains more
swollen than the RUE.
.
# Acute on chronic systolic CHF (40-45%): The initial physical
exam showed leg edema and his chest x-ray suggest mild CHF. He
was given 20mg of lasix in the PACU, and further diuresis was
not undertaken in the ICU. He was started on Lasix 40mg PO daily
(Previous home dose) on day of discharge. This should continue
to be monitored. He was given free water flushes through his G
tube for hypernatremia, which resolved during his stay.
.
# Low platelet count: His platelets fell from 273 on admission
to 107 prior to discharge. This drop was consistent with
heparin-induced thrombocytopenia, for which his heparin was
discontinued. This was confirmed as his heparin antibody from
[**2163-7-19**] was positive. His PLT count on [**7-19**] is 111. He was put on
pneumoboots for DVT prophylaxis given risk of bleeding with
suction.
-He should not be given heparin.
.
# Hypernatremia: As above, he was given free water flushes for
correction of his hypernatremia, which appears to have resolved.
Free water flushes were continued at time of discharge.
.
# Oral candidiasis: PO fluconazole was stopped prior to
discharge.
.
Only evidence of bleed is suection trauma in L maintstem
bronchus, needs to come back in 6 week from [**2163-7-13**] for rpt
bronch

Medications on Admission:
acetaminophen 975mg PO Q8H
carvedilol 3.125mg PO BID
Citalopram 20mg PO daily
docusate 100mg PO BID
ferrous sulfate 300mg PO daily
fluconazole 100mg PO Q12H
folic acid 1 mg po daily
lasix 40mg PO daily
gabapentin 300mg PO Q12H
heparin 5000U SC Q12H
lisinopril 2.5mg PO daily
MVI daily
omeprazole 20mg PO daily
protein supplement daily
albuterol inhaler 4 puffs Q2H prn wheezing
simethicone 80mg PO Q8Hprn
oxycodone 5-10mg po q4h prn


Discharge Medications:
1. acetaminophen 650 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO every
eight (8) hours as needed for pain.
2. acetaminophen 325 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO every
eight (8) hours as needed for pain.
3. carvedilol 3.125 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2
times a day).
4. citalopram 20 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day.
5. docusate sodium 50 mg/5 mL Liquid [**Month/Day/Year **]: Ten (10) milliliters
PO BID (2 times a day).
6. ferrous sulfate 325 mg (65 mg iron) Tablet [**Month/Day/Year **]: One (1)
Tablet PO once a day.
7. folic acid 1 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day.
8. Lasix 40 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day.
9. gabapentin 300 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO Q12H (every
12 hours).
10. lisinopril 2.5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day.

11. multivitamin     Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day.
12. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Month/Day/Year **]: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. protein supplement     Packet [**Month/Day/Year **]: One (1)  PO once a day.
14. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Month/Day/Year **]:
Four (4) Puff Inhalation q2hr as needed for SOB.
15. simethicone 80 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO every eight
(8) hours.
16. oxycodone 5 mg/5 mL Solution [**Month/Day/Year **]: [**1-16**]  PO Q4H (every 4
hours) as needed for tracheal pain.
17. levofloxacin 750 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY
(Daily) for 2 days: Pt needs one dose on [**7-20**] and one dose on [**7-21**]
(in order to complete 8day course, day 1 was [**7-14**]).


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
Respiratory distress, now improved.
Tracheostomy requiring ventilation
Pneumonia


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
You initially came from your rehab after receiving a
bronchoscopy to evaluate your bloody sputum that you had had for
5 days. You received another bronchoscopy on [**7-13**], which did not
show any obvious source of bleeding. Afterwards, you had a fast
breathing rate and low oxygen saturation, so you were monitored
in the ICU. You received antibiotics for suspected pneumonia and
were on a ventilator machine at night. Your breathing and
overall status has improved, and you can be discharged to your
rehab in order to begin regaining your strength.

You were found to have an antibody against heparin products and
should avoid getting any further heparin products.

The following changes were made to your medications:
New: Levofloxacin 750mg daily, for 2 more days (dose on [**7-20**] and
[**7-21**])
Discontinued: Fluconazole, Heparin

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.

Followup Instructions:
Please keep the following appointments that you have with your
doctors:

Department: DERMATOLOGY AND LASER
When: THURSDAY [**2163-7-28**] at 2:45 PM
With: [**Name6 (MD) 13953**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3965**]
Building: [**Location (un) 3966**] ([**Location (un) 55**], MA) [**Location (un) **]
Campus: OFF CAMPUS     Best Parking: Free Parking on Site
.
Department: CARDIAC SERVICES
When: MONDAY [**2163-8-8**] at 12:00 PM
With:  [**Year (4 digits) 3941**] CALL TRANSMISSIONS [**Telephone/Fax (1) 59**]
Building: None None
Campus: AT HOME SERVICE     Best Parking: None
.
Department: CARDIAC SERVICES
When: MONDAY [**2163-8-22**] at 1:30 PM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
.

                             [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
{'Attention to tracheostomy,Acute on chronic systolic heart failure,Methicillin susceptible pneumonia due to Staphylococcus aureus,Acute and chronic respiratory failure,Other primary cardiomyopathies,Acute posthemorrhagic anemia,Hyperosmolality and/or hypernatremia,Candidiasis of mouth,Heparin-induced thrombocytopenia (HIT),Atrial fibrillation,Long-term (current) use of anticoagulants,Personal history of malignant neoplasm of large intestine,Personal history of irradiation, presenting hazards to health,Automatic implantable cardiac defibrillator in situ,Percutaneous transluminal coronary angioplasty status,Personal history of sudden cardiac arrest,History of fall,Personal history of traumatic fracture'}


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: Bloody sputum for 5 days, post-bronchoscopy respiratory distress

PRESENT ILLNESS: Mr. [**Known lastname 108855**] is a very pleasant 84 y/o male with a h/o colon
cancer s/p resection and radiation, CAD s/p stents, systolic CHF
with EF 40-45%, dilated cardiomyopathy, afib, h/o cardiac arrest
and complete heart block now with pacer/AICD, and history of GI
bleed secondary to duodenal telangiectasia who is here from
rehab following evaluation of blood in his respiratory
secretions.
.
Mr. [**Known lastname 108855**] had a lengthy, complex, and recent admission to
the TICU which is summarized in brief. He had a fall on [**2163-6-23**],
leading to multiple rib fractures. He had L 1-10th rib frx, R
5-7th rib frx, L hemothorax decompressed by pigtail catheter,
and a L distal clavicle fracture. He was given a tracheostomy
and PEG tube after failed extubation and reintubation.
.
In rehab, the patient was noted to have blood tinged secretions
via his trach. A bronschoscopy was performed and reportedly saw
bleeding inside of his trachea with poor visualization. He was
transfused 2 unit pRBC and was transferred to [**Hospital1 18**]. Here, the
patient reports no resp distress. His wife stated that the pt
has been stable with no change in his respiration.
.
He underwent a bronchoscopy with our [**Hospital1 18**] group on [**7-13**], which
did not find an etiology of the bleed. Only suction trauma was
seen. Of note, he was receiving intermittent lasix and IVF for
hypernatremia prior to bronchoscopy. Post-procedure, he was
noted to be mildly tachypnic with RR 30s and was satting 88% on
15L NC. As such, he was transferred to the medical ICU for
closer monitoring. Of note, he is typically on 50% FIO2 with his
trach mask.

MEDICAL HISTORY: rectal cancer s/p removal and radiation ijn [**2157**]
CAD s/p stents
Complete heart block (now with pacer)
afib
h/o cardiac arrest (now with AICD)
systolic CHF (EF 40-45%)
fall with multiple rib fractures ([**2163-6-23**])
GI bleed

MEDICATION ON ADMISSION: acetaminophen 975mg PO Q8H
carvedilol 3.125mg PO BID
Citalopram 20mg PO daily
docusate 100mg PO BID
ferrous sulfate 300mg PO daily
fluconazole 100mg PO Q12H
folic acid 1 mg po daily
lasix 40mg PO daily
gabapentin 300mg PO Q12H
heparin 5000U SC Q12H
lisinopril 2.5mg PO daily
MVI daily
omeprazole 20mg PO daily
protein supplement daily
albuterol inhaler 4 puffs Q2H prn wheezing
simethicone 80mg PO Q8Hprn
oxycodone 5-10mg po q4h prn

ALLERGIES: Penicillins / Erythromycin Base / Streptomycin / Citric Acid /
Atenolol / Torsemide / Heparin Agents

PHYSICAL EXAM: VS: T 101, BP:111/49, HR: 70, RR:19, O2:95% on 50% FiO2
General: NAD, resting comfortably and sleeping, arousable with
mild stimuli from sleep, no labored breathing
HEENT: NC, AT, no blood at trach opening or in oropharynx, MMM
Neck: no JVD, no LAD
Lungs: rhonchi throughout, diminished sounds at the bases
Heart: RRR, no M/R/G
Abdomen: soft, nontender, nondistended, normoactive bowel
sounds, PEG and ostomy in place, ostomy has brown stool
Skin: dry, hyperpigmentation of distal LE bilaterally; LUE seems
to be more swollen than RUE
Ext: bilateral lower extremities wrapped in dressing
NEURO: Coherent but sluggish, has episodic confusion. Can
verbalize some words through mask. CN II-XII intact, no motor or
sensory deficits on screening exam.
At discharge: same as above except
Gen: Arousable to verbal stimuli
HEENT: clear/tan secretions at trach site
Ext: LUE with swelling

FAMILY HISTORY: Father died in 80s from MI. Mother died in 80s from PE. No
family history of colon, breast, uterine, or ovarian cancer. No
family history of seizures.

SOCIAL HISTORY: Mr. [**Known lastname 108855**] lives in [**Location 745**] with his wife. They are currently
in the process of moving to an apartment. Per wife, Mr.
[**Known lastname 108855**] has been feeling stress/depressed about moving out of
their 42 year home. They have 2 children. He is a retired
computer science professor. [**First Name (Titles) **] [**Last Name (Titles) 22381**] smoked 5 cigars a day
for 30 years and quit in [**2150**] after his CVA. He drinks once or
twice a week. His wife says that even just a little alcohol
'affects him quite a bit' in changing his mood and makes 'him
sick' 

### Response:
{'Attention to tracheostomy,Acute on chronic systolic heart failure,Methicillin susceptible pneumonia due to Staphylococcus aureus,Acute and chronic respiratory failure,Other primary cardiomyopathies,Acute posthemorrhagic anemia,Hyperosmolality and/or hypernatremia,Candidiasis of mouth,Heparin-induced thrombocytopenia (HIT),Atrial fibrillation,Long-term (current) use of anticoagulants,Personal history of malignant neoplasm of large intestine,Personal history of irradiation, presenting hazards to health,Automatic implantable cardiac defibrillator in situ,Percutaneous transluminal coronary angioplasty status,Personal history of sudden cardiac arrest,History of fall,Personal history of traumatic fracture'}
