CHIEF COMPLAINT: Respiratory distress

PRESENT ILLNESS: Ms. [**Known lastname 20948**] is a 62F with a PMH s/f COPD (home O2 2-3L) on
chronic prednisone, DM, CAD, s/p MI, VF s/p ICD, Chronic
diastolic heart failure, with a recent hospitalization at [**Hospital 79221**] hospital in Main ([**2196-6-9**]) for CHF exacerbation and
unstable angina.
Her hospitalzation was complicated by respiratory failure,
pseudomonas tracheal-bronchitis, severe c. diff colitis and
subsequent toxic megacolon leading to abdominal compartment
syndrome. Patient underwent tracheotomy / PEG tube placement
after prolonged hospitalization and failure to wean off
mechianical ventilator.
Patient was recently discharged to a rehab facility where on
arrival she was noted to be in respiratory distress with an ABG
of 7.24/59/80.  She was sent to the [**Hospital1 2177**] ED where a repeat ABG
was 7.38/23/73. She was empirically started on Vancomycin /
Levaquin and sent back to rehab. On the morning of admission,
patient desaturated to the 80s, requiring FiO2 of 100% and an
increase in her PEEP to 10, and was sent to the [**Hospital1 18**] ED as the
[**Hospital1 2177**] ICU was on diversion.
In the emergency department her initial vital signs were 96.9,
SBP's 70-90, HR= 108-120.  A right femoral line (patient has a
left subclavian clot, and a right PICC placed in [**Month (only) 596**]) and
arterial line were placed, and the patient was started on
levophed (was volume overloaded on CXR).
Current ventilator settings are tidal volume of 550, PEEP of 10,
and an FiO2 of 100%, where she is satting 100% with an ABG of pH
7.31 pCO2
50 pO2 109 HCO3 26 .
She was given albuterol and atrovent nebulizers for COPD.  CXR
revealed volume overload vs. PNA, so the patient was given 40mg
of IV lasix, and vancomycin/zosyn for presumed VAP.  Urine and
blood cultures were obtained. She was sent for a CTA prior to
coming to the MICU, but heparin was not started as her
tracheostomy site is bleeding.

MEDICAL HISTORY: 1)COPD (baseline 3L NC at home)
2)CAD
-- s/p MI
-- s/p BMS to mid RCA ([**2189-10-5**])
3)Diastolic heart failure, EF 45-50% with basal and mid inferior
hypokinesis, impaired diastolic function (E to A reversal)
-- Stress test [**2192-8-6**] with fixed inferolateral wall defect
and global hypokinesis.
4)V Fib (out of hospital arrest)
-- s/p ICD placement ([**2193-2-5**])
-- [**Company 1543**] GEM III DR [**Last Name (STitle) **] #7275
5)C diff colitis / Toxic megacolon / Abdominal compartment
syndrome
-- S/P Exploratory lap [**2196-6-22**]
6)Subclavian DVT: coumadin held from bleeding complications
7)Morbid obesity
8)RUL pulmonary nodules
9)Respiratory failure ([**2196-6-30**])
10)VRE from wound (Enterococcus Faecalis)
11)Diabetes Mellitus
12)h/o Breast Cancer

MEDICATION ON ADMISSION: Amikacin 1300mg Q36H (last day [**8-4**])
Ascorbic acid 500mg PO daily
Diltiazem 30mg PO daily
Doripenem 500mg Q8H
NPH 40u QAM, 25u QPM
Atrovent 6 puffs Q4H
Isosorbide 60mg PO Q12
Prevacid 30mg PO daily
Lopressor 50mg PO BID
Prednisone 5mg PO daily
Vitamin A [**Numeric Identifier 389**] units daily
Zinc sulfate 220mg PO daily
Ambien 5mg PO QHS PRN
Combivent
ASA 325mg PO daily
Lovenox 40mg SQ daily
Paxil 20mg PO daily

ALLERGIES: Cephalosporins / Quinolones / Clonidine / Atenolol / Lipitor /
Digoxin

PHYSICAL EXAM: T = 100.3  BP = 98/68 HR = 119 RR= 22 O2= 99%
GENERAL: Intubated, very pleasant elderly woman, comfortable.
HEENT: Normocephalic, atraumatic.  No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. Tracheotomy site clean/dry,
no blood visible.
CARDIAC: Regular rhythm, tachycardic. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: Diffuse rhonchi and mildly decreased breath sounds.
ABDOMEN: NABS. Soft, midline wound with mild erythema, dressing
clean / dry/ intact. PEG site also c/d/i.
EXTREMITIES: 3+ pitting edema of lower extremities. 2+ dorsalis
pedis/ posterior tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: Appropriate. CN 2-12 grossly intact.

FAMILY HISTORY: NC

SOCIAL HISTORY: Married, Currently in a rehab facility in [**Location (un) 86**] (no vent
facilities near her home in [**State 1727**]). Daughter very involved.
Unspecified septicemia,Acute respiratory failure,Septic shock,Embolism and thrombosis of other specified artery,Pneumonitis due to inhalation of food or vomitus,Acute on chronic diastolic heart failure,Pressure ulcer, heel,Glucocorticoid deficiency,Paroxysmal ventricular tachycardia,Intermediate coronary syndrome,Paralytic ileus,Hyperosmolality and/or hypernatremia,Severe sepsis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic airway obstruction, not elsewhere classified,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Automatic implantable cardiac defibrillator in situ,Morbid obesity,Personal history of malignant neoplasm of breast,Other convulsions,Other dependence on machines, supplemental oxygen,Tracheostomy status,Gastrostomy status,Anemia, unspecified
Septicemia NOS,Acute respiratry failure,Septic shock,Arterial embolism NEC,Food/vomit pneumonitis,Ac on chr diast hrt fail,Pressure ulcer, heel,Glucocorticoid deficient,Parox ventric tachycard,Intermed coronary synd,Paralytic ileus,Hyperosmolality,Severe sepsis,DMII wo cmp nt st uncntr,Chr airway obstruct NEC,Crnry athrscl natve vssl,Old myocardial infarct,Status autm crd dfbrltr,Morbid obesity,Hx of breast malignancy,Convulsions NEC,Depend-supplement oxygen,Tracheostomy status,Gastrostomy status,Anemia NOS
Admission Date:  [**2196-8-4**]              Discharge Date:   [**2196-8-15**]

Date of Birth:  [**2134-6-29**]             Sex:   F

Service: MEDICINE

Allergies:
Cephalosporins / Quinolones / Clonidine / Atenolol / Lipitor /
Digoxin

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Respiratory distress

Major Surgical or Invasive Procedure:
Right Femoral CVL
Right Internal Jugular CVL
Right axillary arterial line
Left radial arterial line
Right PICC line

History of Present Illness:
Ms. [**Known lastname 20948**] is a 62F with a PMH s/f COPD (home O2 2-3L) on
chronic prednisone, DM, CAD, s/p MI, VF s/p ICD, Chronic
diastolic heart failure, with a recent hospitalization at [**Hospital 79221**] hospital in Main ([**2196-6-9**]) for CHF exacerbation and
unstable angina.
Her hospitalzation was complicated by respiratory failure,
pseudomonas tracheal-bronchitis, severe c. diff colitis and
subsequent toxic megacolon leading to abdominal compartment
syndrome. Patient underwent tracheotomy / PEG tube placement
after prolonged hospitalization and failure to wean off
mechianical ventilator.
Patient was recently discharged to a rehab facility where on
arrival she was noted to be in respiratory distress with an ABG
of 7.24/59/80.  She was sent to the [**Hospital1 2177**] ED where a repeat ABG
was 7.38/23/73. She was empirically started on Vancomycin /
Levaquin and sent back to rehab. On the morning of admission,
patient desaturated to the 80s, requiring FiO2 of 100% and an
increase in her PEEP to 10, and was sent to the [**Hospital1 18**] ED as the
[**Hospital1 2177**] ICU was on diversion.
In the emergency department her initial vital signs were 96.9,
SBP's 70-90, HR= 108-120.  A right femoral line (patient has a
left subclavian clot, and a right PICC placed in [**Month (only) 596**]) and
arterial line were placed, and the patient was started on
levophed (was volume overloaded on CXR).
Current ventilator settings are tidal volume of 550, PEEP of 10,
and an FiO2 of 100%, where she is satting 100% with an ABG of pH
7.31 pCO2
50 pO2 109 HCO3 26 .
She was given albuterol and atrovent nebulizers for COPD.  CXR
revealed volume overload vs. PNA, so the patient was given 40mg
of IV lasix, and vancomycin/zosyn for presumed VAP.  Urine and
blood cultures were obtained. She was sent for a CTA prior to
coming to the MICU, but heparin was not started as her
tracheostomy site is bleeding.

Past Medical History:
1)COPD (baseline 3L NC at home)
2)CAD
-- s/p MI
-- s/p BMS to mid RCA ([**2189-10-5**])
3)Diastolic heart failure, EF 45-50% with basal and mid inferior
hypokinesis, impaired diastolic function (E to A reversal)
-- Stress test [**2192-8-6**] with fixed inferolateral wall defect
and global hypokinesis.
4)V Fib (out of hospital arrest)
-- s/p ICD placement ([**2193-2-5**])
-- [**Company 1543**] GEM III DR [**Last Name (STitle) **] #7275
5)C diff colitis / Toxic megacolon / Abdominal compartment
syndrome
-- S/P Exploratory lap [**2196-6-22**]
6)Subclavian DVT: coumadin held from bleeding complications
7)Morbid obesity
8)RUL pulmonary nodules
9)Respiratory failure ([**2196-6-30**])
10)VRE from wound (Enterococcus Faecalis)
11)Diabetes Mellitus
12)h/o Breast Cancer

Social History:
Married, Currently in a rehab facility in [**Location (un) 86**] (no vent
facilities near her home in [**State 1727**]). Daughter very involved.

Family History:
NC

Physical Exam:
T = 100.3  BP = 98/68 HR = 119 RR= 22 O2= 99%
GENERAL: Intubated, very pleasant elderly woman, comfortable.
HEENT: Normocephalic, atraumatic.  No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. Tracheotomy site clean/dry,
no blood visible.
CARDIAC: Regular rhythm, tachycardic. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: Diffuse rhonchi and mildly decreased breath sounds.
ABDOMEN: NABS. Soft, midline wound with mild erythema, dressing
clean / dry/ intact. PEG site also c/d/i.
EXTREMITIES: 3+ pitting edema of lower extremities. 2+ dorsalis
pedis/ posterior tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: Appropriate. CN 2-12 grossly intact.

Pertinent Results:
==================
  ADMISSION LABS
==================

[**2196-8-4**] 07:45AM BLOOD WBC-15.0* RBC-3.28* Hgb-9.9* Hct-32.1*
MCV-98 MCH-30.2 MCHC-30.8* RDW-18.6* Plt Ct-409
[**2196-8-4**] 07:45AM BLOOD Neuts-89.3* Lymphs-5.5* Monos-4.7 Eos-0.4
Baso-0.1
[**2196-8-4**] 07:45AM BLOOD Glucose-180* UreaN-52* Creat-0.8 Na-144
K-4.2 Cl-108 HCO3-25 AnGap-15
[**2196-8-4**] 07:45AM BLOOD ALT-24 AST-28 CK(CPK)-29 AlkPhos-308*
TotBili-0.9
[**2196-8-4**] 07:45AM BLOOD CK-MB-NotDone cTropnT-0.13* proBNP-[**Numeric Identifier 63314**]*
[**2196-8-4**] 07:45AM BLOOD Albumin-4.1 Calcium-10.3* Phos-5.9*
Mg-2.5
[**2196-8-9**] 09:46AM BLOOD Phenyto-16.4
[**2196-8-4**] 09:53AM BLOOD Type-ART pO2-109* pCO2-50* pH-7.31*
calTCO2-26 Base XS--1 Comment-RADIAL LEF
[**2196-8-4**] 07:48AM BLOOD Lactate-1.5

=============
  RADIOLOGY
=============

CHEST X-RAY ([**2196-8-4**])
SINGLE AP SEMI-UPRIGHT RADIOGRAPH OF THE CHEST: There is diffuse
bilateral
pulmonary edema, right more than left with associated small
right pleural
effusion and probable left pleural effusion. There is mild
cardiomegaly.
Aortic calcifications are evident. There is no pneumothorax.

Right chest wall AICD device with right ventricular lead in
standard location and another shorter lead with distal anchoring
device projecting over the right lung apex. There is a third
lead, which is not definitely visualized, and best visualized up
to the upper portion of right atrium. The PICC line is
terminating within the proximal right subclavian. Tracheostomy
tube is noted. Visualized osseous and soft tissue structures are
otherwise unremarkable.

IMPRESSION:
1. Severe bilateral pulmonary edema, right more than left, with
associated
small pleural effusions.
2. AICD device with right ventricular lead in standard location
and second
lead not seen in its entirety is best visualized up to the upper
atrium. Third redundant lead is seen to project over the right
lung apex.
3. Right PICC line terminating in the proximal subclavian

-------------------
CTA CHEST ([**2196-8-4**])
-------------------
The pulmonary arteries are well opacified with no filling defect
suspicious for pulmonary embolism. The aorta shows mild
atherosclerotic calcification, but the size is within normal
limit, and there is no evidence of aneurysmal dilatation or
dissection.
The heart size is moderately enlarged. There is no pericardial
effusion.
Bilateral left more than right moderate pleural effusions are
seen.
Diffuse airspace disease with ground-glass opacities, septal
thickening, and areas of consolidation are seen in both lung
fields.
In the mediastinum, there are multiple enlarged lymph nodes;
11.2-mm right
paratracheal lymph node, 7-mm left prevascular lymph node,
8.8-mm left
paratracheal lymph node, and 1-cm right lower paratracheal lymph
node.
A tracheostomy tube terminates in the midthoracic portion of the
trachea. A right-sided dual-leaded pacemaker is seen with the
right atrial lead projects beyond the boundaries of the right
atrium and terminates in the IVC.
The evaluation of the abdomen shows diffuse atherosclerotic
calcification of The aorta, celiac artery, SMA, renal arteries,
and iliacs. The patient is status post aorto-[**Hospital1 **]-iliac bypass.
The weak contrast material within the circulation system of the
abdomen and pelvis cannot exclude or confirm the presence of
underlying DVT involving the iliac veins.
There is no evidence of contrast excretion from both kidneys.
The liver, spleen are unremarkable. The pancreas is unremarkable
as well.
A small stone is seen in the Gallbladder. One of the cruses of
the right
adrenal gland has a speckle of calcification without soft tissue
masses.
A hypodense lesion likely a cyst is seen arising from the
inferior pole of the right kidney.
The small and large bowels demonstrate normal caliber with no
evidence of wall thickening, pneumatosis, or adjacent
inflammation.
Trace amount of free fluid is seen in the right upper quadrant
and left upper quadrant and in the pelvis in close proximity to
an atrophic uterus.
a Foley catheter is seen in the bladder which does not contain
any opacified contrast material.

Extensive fatty stranding of the subcutaneous fatty structures
of the anterior abdominal and pelvic wall as well as the flanks
and the lateral margins of the chest wall.

IMPRESSION:
1. Negative examination for pulmonary embolism or aortic
dissection.
2. Diffuse airspace disease which could represent pulmonary
edema either from a cardiogenic cause or non-cardiogenic cause
like renal failure. Other possibiltis would include pneuomonia
or hemmorage.

------------------
  ECHO
-----------
Very limited image quality (patient on ventilator). The left
atrium is dilated. The right atrium is moderately dilated. There
is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. There is moderate global left
ventricular hypokinesis (LVEF = 30-40 %). The right ventricular
free wall is hypertrophied. Right ventricular chamber size is
normal. with depressed free wall contractility. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate ([**1-13**]+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. The
supporting structures of the tricuspid valve are
thickened/fibrotic. There is no pericardial effusion. There is
an anterior space which most likely represents a fat pad.

----------
 KUB [**2196-8-14**]
----------
Two radiographs of the chest and abdomen are submitted. The
bilateral apices are excluded. Assessment of the pulmonary
parenchyma is markedly limited by technique and respiratory
motion. The cardiomediastinal contours are similar to that seen
on [**2196-8-13**]. No pneumoperitoneum is evident. There are multiple
air-filled distended loops of small and large bowel. Air is
present within the stomach. Air and stool are identified within
the descending colon. Surgical staples project over the mid
abdomen as does a radiopaque catheter.  Single-lead cardiac
pacemaker is again noted. The aorta is calcified and tortuous.

IMPRESSION:
Nonspecific bowel gas pattern. Close clinical followup is
recommended.

-----------------
Labs [**2196-8-14**]
-----------------
14.6* \______/ 111
      / 32.1*\

141 | 108 | 21  /
---------------     114
4.2 | 25  | 0.7 \

PT: 17.7  PTT: 28.0  INR: 1.6


Brief Hospital Course:
Ms. [**Known lastname **] is a 62yo female with severe COPD, CAD, and long
hospital course c/b VAP with hypoxemic respiratory failure s/p
tracheostomy, toxic megacolon from C. diff and abdominal
compartment syndrome, presented on [**8-4**] with hypotension and
respiratory distress. Patient however continued to decompensate
and family requested transition to comfort measures only after
she acutely worsened. Patient expired shortly therafter. Details
are listed by problem below:

1)Hypotension: Patient initially presented with hypotension
requiring pressors. The differential included sepsis, adrenal
insufficiency, and cardiogenic shock. Possible sources of
infection included ventilator associated pneumonia although she
was completing course with amikacin and doripenem. Patient
required short course of pressors on admission with prompt wean.
There was no evidence of adrenal insufficiency and although an
organism was not isolated, patient was empirically treated for
VAP with meropenem and amikacin. PICC line placed at OSH was
removed and sent for culture. Patient however continued to have
transient episodes of hypotension without known etiology or
organism isolation. Patient was agressively cultured and placed
back on broad spectrum antibiotics and placed on pressors after
an aspiration event, but patient continued to have refractory
hypotensive episodes.

After prolonged hospitalization and lack of improvement (for
full list see below) family meeting was arranged, where decision
to transition to comfort measures only was made. The patient
expired shortly thereafter, with her family at the bedside.

#. Digitalis toxicity: Due to tachycardia in setting of
hypotension, patient was loaded with digoxin. After completion
of load however, high degree of ectopy was noted and patient
exhibited signs of digitalis toxicity with an accelerated
junctional escape rhythm. Digitalis level of 4 was noted and
patient experienced seizures. Although it is not clear that the
latter were caused by digitalis, given the ECG changes patient
was given digibind, with good resolution back to baseline sinus
rhythm. Due to narrow therapeutic window in spite of appropiate
dosing, would avoid using digoxin in the future.

#. Possible Cardiogenic shock: Although it was not clear that
patient was in cardiogenic shock, strong cardiac history,
hypotension at presentation and gross volume overload were
concerning for this.
Echocardiogram was obtained and revealed globally depressed
systolic function and diastolic failure. Cardiac enzymes were
obtained and although mild elevation in troponins were noted, CK
remained normal. Troponin leak likely secondary to rapid hear
rate and demand ischemia.
.
#. Possible Adrenal insufficiency: Given critical illness,
patient was pulsed with stress dose steroids, however this was
not continued after it AI was ruled out.
.
#. Respiratory distress: As above, likely a combination of
diastolic heart failure and pneumonia, with possible cardiogenic
shock. Patient treated broadly for possible ventilator
associated pneumonia, however respiratory status worsened after
witnessed vomiting and aspiration of tube feeds (given via PEG
tube). Patient was transitioned over to full assist control and
remained unable to return to CPAP.
.
#. COPD: No evidence of acute exacerbation, although continued
on steroids.
.
# Subclavian DVT: Unclear etiology, likely iatrogenic from line
placement at OSH. Due to Upper extremity location, low risk of
propagation/ pulmonary embolization and recent peri-trach
bleeding, No anticoagulation was given.
.
Seizure activity: Patient was noted to have twitching of the
right upper and lower extremities. She was immediately loaded
with Fosphenytoin and then started on Dilantin 100mg IV TID. CT
head was unrevealing. Neurology was immediately consulted. The
etiology was unclear but was thought to be secondary to digoxin
toxicity. As a result, he was given Digibind to try and reverse
the toxic effects. She also underwent an EEG which was
consistent with moderate to severe global encephalopathy.
She was continued on Dilantin and was started on Keppra.

Atrial fibrillation: Rate controlled at first with Digoxin,
until toxicity noted. Rate controlled with beta blocker
thereafter.
.
#. SVC ICD lead: Per cardiology report, this appears to have
been a placement issue and not a dislodgement issue.


Medications on Admission:
Amikacin 1300mg Q36H (last day [**8-4**])
Ascorbic acid 500mg PO daily
Diltiazem 30mg PO daily
Doripenem 500mg Q8H
NPH 40u QAM, 25u QPM
Atrovent 6 puffs Q4H
Isosorbide 60mg PO Q12
Prevacid 30mg PO daily
Lopressor 50mg PO BID
Prednisone 5mg PO daily
Vitamin A [**Numeric Identifier 389**] units daily
Zinc sulfate 220mg PO daily
Ambien 5mg PO QHS PRN
Combivent
ASA 325mg PO daily
Lovenox 40mg SQ daily
Paxil 20mg PO daily

Discharge Medications:
Patient expired

Discharge Disposition:
Expired

Discharge Diagnosis:
Patient expired

Discharge Condition:
Patient expired

Discharge Instructions:
Patient expired

Followup Instructions:
Patient expired
{'Unspecified septicemia,Acute respiratory failure,Septic shock,Embolism and thrombosis of other specified artery,Pneumonitis due to inhalation of food or vomitus,Acute on chronic diastolic heart failure,Pressure ulcer, heel,Glucocorticoid deficiency,Paroxysmal ventricular tachycardia,Intermediate coronary syndrome,Paralytic ileus,Hyperosmolality and/or hypernatremia,Severe sepsis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic airway obstruction, not elsewhere classified,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Automatic implantable cardiac defibrillator in situ,Morbid obesity,Personal history of malignant neoplasm of breast,Other convulsions,Other dependence on machines, supplemental oxygen,Tracheostomy status,Gastrostomy status,Anemia, unspecified'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: Respiratory distress

PRESENT ILLNESS: Ms. [**Known lastname 20948**] is a 62F with a PMH s/f COPD (home O2 2-3L) on
chronic prednisone, DM, CAD, s/p MI, VF s/p ICD, Chronic
diastolic heart failure, with a recent hospitalization at [**Hospital 79221**] hospital in Main ([**2196-6-9**]) for CHF exacerbation and
unstable angina.
Her hospitalzation was complicated by respiratory failure,
pseudomonas tracheal-bronchitis, severe c. diff colitis and
subsequent toxic megacolon leading to abdominal compartment
syndrome. Patient underwent tracheotomy / PEG tube placement
after prolonged hospitalization and failure to wean off
mechianical ventilator.
Patient was recently discharged to a rehab facility where on
arrival she was noted to be in respiratory distress with an ABG
of 7.24/59/80.  She was sent to the [**Hospital1 2177**] ED where a repeat ABG
was 7.38/23/73. She was empirically started on Vancomycin /
Levaquin and sent back to rehab. On the morning of admission,
patient desaturated to the 80s, requiring FiO2 of 100% and an
increase in her PEEP to 10, and was sent to the [**Hospital1 18**] ED as the
[**Hospital1 2177**] ICU was on diversion.
In the emergency department her initial vital signs were 96.9,
SBP's 70-90, HR= 108-120.  A right femoral line (patient has a
left subclavian clot, and a right PICC placed in [**Month (only) 596**]) and
arterial line were placed, and the patient was started on
levophed (was volume overloaded on CXR).
Current ventilator settings are tidal volume of 550, PEEP of 10,
and an FiO2 of 100%, where she is satting 100% with an ABG of pH
7.31 pCO2
50 pO2 109 HCO3 26 .
She was given albuterol and atrovent nebulizers for COPD.  CXR
revealed volume overload vs. PNA, so the patient was given 40mg
of IV lasix, and vancomycin/zosyn for presumed VAP.  Urine and
blood cultures were obtained. She was sent for a CTA prior to
coming to the MICU, but heparin was not started as her
tracheostomy site is bleeding.

MEDICAL HISTORY: 1)COPD (baseline 3L NC at home)
2)CAD
-- s/p MI
-- s/p BMS to mid RCA ([**2189-10-5**])
3)Diastolic heart failure, EF 45-50% with basal and mid inferior
hypokinesis, impaired diastolic function (E to A reversal)
-- Stress test [**2192-8-6**] with fixed inferolateral wall defect
and global hypokinesis.
4)V Fib (out of hospital arrest)
-- s/p ICD placement ([**2193-2-5**])
-- [**Company 1543**] GEM III DR [**Last Name (STitle) **] #7275
5)C diff colitis / Toxic megacolon / Abdominal compartment
syndrome
-- S/P Exploratory lap [**2196-6-22**]
6)Subclavian DVT: coumadin held from bleeding complications
7)Morbid obesity
8)RUL pulmonary nodules
9)Respiratory failure ([**2196-6-30**])
10)VRE from wound (Enterococcus Faecalis)
11)Diabetes Mellitus
12)h/o Breast Cancer

MEDICATION ON ADMISSION: Amikacin 1300mg Q36H (last day [**8-4**])
Ascorbic acid 500mg PO daily
Diltiazem 30mg PO daily
Doripenem 500mg Q8H
NPH 40u QAM, 25u QPM
Atrovent 6 puffs Q4H
Isosorbide 60mg PO Q12
Prevacid 30mg PO daily
Lopressor 50mg PO BID
Prednisone 5mg PO daily
Vitamin A [**Numeric Identifier 389**] units daily
Zinc sulfate 220mg PO daily
Ambien 5mg PO QHS PRN
Combivent
ASA 325mg PO daily
Lovenox 40mg SQ daily
Paxil 20mg PO daily

ALLERGIES: Cephalosporins / Quinolones / Clonidine / Atenolol / Lipitor /
Digoxin

PHYSICAL EXAM: T = 100.3  BP = 98/68 HR = 119 RR= 22 O2= 99%
GENERAL: Intubated, very pleasant elderly woman, comfortable.
HEENT: Normocephalic, atraumatic.  No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. Tracheotomy site clean/dry,
no blood visible.
CARDIAC: Regular rhythm, tachycardic. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: Diffuse rhonchi and mildly decreased breath sounds.
ABDOMEN: NABS. Soft, midline wound with mild erythema, dressing
clean / dry/ intact. PEG site also c/d/i.
EXTREMITIES: 3+ pitting edema of lower extremities. 2+ dorsalis
pedis/ posterior tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: Appropriate. CN 2-12 grossly intact.

FAMILY HISTORY: NC

SOCIAL HISTORY: Married, Currently in a rehab facility in [**Location (un) 86**] (no vent
facilities near her home in [**State 1727**]). Daughter very involved. 

### Response:
{'Unspecified septicemia,Acute respiratory failure,Septic shock,Embolism and thrombosis of other specified artery,Pneumonitis due to inhalation of food or vomitus,Acute on chronic diastolic heart failure,Pressure ulcer, heel,Glucocorticoid deficiency,Paroxysmal ventricular tachycardia,Intermediate coronary syndrome,Paralytic ileus,Hyperosmolality and/or hypernatremia,Severe sepsis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic airway obstruction, not elsewhere classified,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Automatic implantable cardiac defibrillator in situ,Morbid obesity,Personal history of malignant neoplasm of breast,Other convulsions,Other dependence on machines, supplemental oxygen,Tracheostomy status,Gastrostomy status,Anemia, unspecified'}
