CHIEF COMPLAINT: Hypoxia

PRESENT ILLNESS: 67 yo M with a history of aspiration PNA, COPD, CHF, A fib on
coumadin, CAD s/p CABG, who presented to OSH on [**11-27**]
complaining of shortness of breath.
.
Per OSH records, the patients wife had diagnosed [**Name (NI) 30475**] recently.
The patient completed a 10 day course of tamiflu. 48 hours after
stopping tamiflu, he developed shortness of breath, along with
fevers, rigors, and green colored sputum.
.
He presented to the ED on [**11-27**] at noon, at which time he was
hypertensive with SBP in 200s. EKG notable for 1mm ST
depressions in lateral leads. The patient was given nitro paste,
and started on a nitro gtt. He received 1 dose of Ceftriaxone,
Azithro, and Levofloxacin for community acquired pneumonia seen
on CXR. He was transferred to OSH ICU.
.
In the ICU the patient received 1L NS, 1u PRBCs, and Combivent.
Shortly after finishing the transfusion he got acutely short of
breath, requiring BiPap. The patient was hypertensive again,
requiring increased dose of nitro gtt. He got lasix 20mg IV x1,
40mg IV x1, but only put out 15cc of urine to this. He desatted
to the high 70s, and was intubated for hypoxemia.
.
After intubation he had transient desats to the 80s, likely
secondary to improper sedation. He was started on a propofol gtt
and a versed gtt. Thereafter he was hypotensive and tachycardic,
and started on a Dopamine gtt, and Levophed gtt. A R subclavian
was placed after a 2nd attempt. CVP was 15 at that time.
.
WBC 10.6, HCT was initially 27.3, Cr initially 1.1, went up to
1.7.
The patient received one dose of Vancomycin, Flagyl, and
Tamiflu. He also got 120mg IV solumedrol.
.
Most recent set of vitals at time of sign out was Afebrile, HR
99, Systolic BP 100, 95% on FiO2 80%, Tv 6cc/kg, RR 16.

MEDICAL HISTORY: h/o aspiration pneumonia
COPD
Afib on coumadin
CAD s/p CABG in [**2099-4-4**]
CHF with normal EF
HTN
HL
PUD
Anemia
Dysphagia
PVD
s/p R CEA
s/p CCY

MEDICATION ON ADMISSION: Protonix 40mg po daily
Reglan 10mg po qid
Albuterol PRN
Benicar with HCTZ 40-12.5mg daily
Wellbutrin SR 150mg [**Hospital1 **]
Digoxin 0.125mg po daily
Metoprolol 25mg po bid
Coumadin 5mg po daily
Prozac 40mg, 80mg po qod
Simvastatin 40mg po daily
ASA 81mg po daily

ALLERGIES: Sulfa (Sulfonamide Antibiotics)

PHYSICAL EXAM: Admission
Vitals - T: 97.5 BP: 108/69 HR: 90 RR: 22 02 sat: 98%
GENERAL: Intubated, sedated
HEENT: NCAT. PERRL. No LAD.
CARDIAC: Irregularly irregular. No murmurs.
LUNG: Diffuse rhonchi bilaterally L>R.
ABDOMEN: Soft, NT, ND. No masses. No rebound or guarding.
EXT: WWP. No LE edema.
NEURO: Sedated
DERM: Chronic venous stasis.

FAMILY HISTORY: Unknown

SOCIAL HISTORY: Unknown
Streptococcal septicemia,Acute respiratory failure,Septic shock,Pneumonitis due to inhalation of food or vomitus,End stage renal disease,Acute kidney failure, unspecified,Influenza with pneumonia,Subendocardial infarction, initial episode of care,Encephalopathy, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Ventilator associated pneumonia,Atrial flutter,Diastolic heart failure, unspecified,Acidosis,Paralytic ileus,Severe sepsis,Chronic airway obstruction, not elsewhere classified,Renal dialysis status,Peripheral vascular disease, unspecified,Dysphagia, unspecified,Other and unspecified hyperlipidemia,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Long-term (current) use of anticoagulants,Thrombocytopenia, unspecified,Constipation, unspecified,Depressive disorder, not elsewhere classified,Other extrapyramidal diseases and abnormal movement disorders,Other drugs and medicinal substances causing adverse effects in therapeutic use
Streptococcal septicemia,Acute respiratry failure,Septic shock,Food/vomit pneumonitis,End stage renal disease,Acute kidney failure NOS,Influenza with pneumonia,Subendo infarct, initial,Encephalopathy NOS,Hyp kid NOS w cr kid V,Ventltr assoc pneumonia,Atrial flutter,Diastolc hrt failure NOS,Acidosis,Paralytic ileus,Severe sepsis,Chr airway obstruct NEC,Renal dialysis status,Periph vascular dis NOS,Dysphagia NOS,Hyperlipidemia NEC/NOS,Cor ath unsp vsl ntv/gft,Aortocoronary bypass,Long-term use anticoagul,Thrombocytopenia NOS,Constipation NOS,Depressive disorder NEC,Extrapyramidal dis NEC,Adv eff medicinal NEC
Admission Date:  [**2102-11-28**]              Discharge Date:   [**2103-1-2**]

Date of Birth:  [**2035-10-16**]             Sex:   M

Service: MEDICINE

Allergies:
Sulfa (Sulfonamide Antibiotics)

Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Hypoxia

Major Surgical or Invasive Procedure:
CVVH line placement
Central line placement
Tracheostomy placement
HD line placement
Lumbar puncture

History of Present Illness:
67 yo M with a history of aspiration PNA, COPD, CHF, A fib on
coumadin, CAD s/p CABG, who presented to OSH on [**11-27**]
complaining of shortness of breath.
.
Per OSH records, the patients wife had diagnosed [**Name (NI) 30475**] recently.
The patient completed a 10 day course of tamiflu. 48 hours after
stopping tamiflu, he developed shortness of breath, along with
fevers, rigors, and green colored sputum.
.
He presented to the ED on [**11-27**] at noon, at which time he was
hypertensive with SBP in 200s. EKG notable for 1mm ST
depressions in lateral leads. The patient was given nitro paste,
and started on a nitro gtt. He received 1 dose of Ceftriaxone,
Azithro, and Levofloxacin for community acquired pneumonia seen
on CXR. He was transferred to OSH ICU.
.
In the ICU the patient received 1L NS, 1u PRBCs, and Combivent.
Shortly after finishing the transfusion he got acutely short of
breath, requiring BiPap. The patient was hypertensive again,
requiring increased dose of nitro gtt. He got lasix 20mg IV x1,
40mg IV x1, but only put out 15cc of urine to this. He desatted
to the high 70s, and was intubated for hypoxemia.
.
After intubation he had transient desats to the 80s, likely
secondary to improper sedation. He was started on a propofol gtt
and a versed gtt. Thereafter he was hypotensive and tachycardic,
and started on a Dopamine gtt, and Levophed gtt. A R subclavian
was placed after a 2nd attempt. CVP was 15 at that time.
.
WBC 10.6, HCT was initially 27.3, Cr initially 1.1, went up to
1.7.
The patient received one dose of Vancomycin, Flagyl, and
Tamiflu. He also got 120mg IV solumedrol.
.
Most recent set of vitals at time of sign out was Afebrile, HR
99, Systolic BP 100, 95% on FiO2 80%, Tv 6cc/kg, RR 16.


Past Medical History:
h/o aspiration pneumonia
COPD
Afib on coumadin
CAD s/p CABG in [**2099-4-4**]
CHF with normal EF
HTN
HL
PUD
Anemia
Dysphagia
PVD
s/p R CEA
s/p CCY


Social History:
Unknown

Family History:
Unknown

Physical Exam:
Admission
Vitals - T: 97.5 BP: 108/69 HR: 90 RR: 22 02 sat: 98%
GENERAL: Intubated, sedated
HEENT: NCAT. PERRL. No LAD.
CARDIAC: Irregularly irregular. No murmurs.
LUNG: Diffuse rhonchi bilaterally L>R.
ABDOMEN: Soft, NT, ND. No masses. No rebound or guarding.
EXT: WWP. No LE edema.
NEURO: Sedated
DERM: Chronic venous stasis.


Pertinent Results:
=========
Labs
=========
Admission labs
135  101  34     AGap=21
=============< 160
4.3  17  2.1
estGFR: 32/38 (click for details)
CK: 672  MB: 33  MBI: 4.9  Trop-T: 0.55
 91
        8.7
 15.3  >   <   254
        27.5

Source: [**Name (NI) 83907**]
PT: 15.7  PTT: 32.3  INR: 1.4

Discharge labs
WBC 10.4  RBC 2.58 Hgb 7.5 Hct 23.1 MCV 90 Plt 331
INR 1.2 PTT 76.9
Glucose 120 UreaN 40 Creat 3 Na 137 K 3.9 Cl 97 HCO3 30

=========
Radiology
=========

[**2102-11-28**] Echo
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). The right
ventricular cavity is moderately dilated with severe global free
wall hypokinesis. There is abnormal systolic septal
motion/position consistent with right ventricular pressure
overload. The aortic valve leaflets (3) are mildly thickened.
There is no valvular aortic stenosis. The increased transaortic
velocity is likely related to high cardiac output. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Dilated right ventricle with severe RV systolic
dysfunction. Mild symmetric left ventricular hypertrophy with
normal global and regional biventricular systolic function. Mild
mitral regurgitation. Moderate pulmonary hypertension.
.
[**2102-12-19**] Echo
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 60-70%). Right ventricular chamber size and free wall
motion are normal. The aortic root is moderately dilated at the
sinus level. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The tricuspid valve leaflets are mildly thickened. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
No definite vegetations seen.
.
[**2102-11-28**] EKG Atrial fibrillation with rapid ventricular
response. Incomplete right bundle-branch block. Inferior and
lateral ST segment depression. No previous tracing available for
comparison.
.
[**2102-12-15**] CT chest abdomen pelvis
. Abnormally located short segment of jejunum demonstrating a
prominent
bowel wall. This finding can be asociated with internal hernia.
However, no secondary signs of obstruction or adjacent
mesenteric stranding are
identified. Clinical correlation is recommended.
2. Multifocal airspace opacities, which are somewhat more
confluent in the
right upper lobe, in addition to small bilateral pleural
effusions, right
greater than left. These findings are most consistent with
pulmonary edema.  However, superinfection, particularly in the
right upper lobe cannot entirely be excluded.

EEG [**12-20**]
This is an abnormal routine EEG secondary to persistent
generalized triphasic waves. During brief portions of the study
where
triphasics are not present, the background was diffusely slow
and
disorganized suggesting a moderate to severe encephalopathy.
There were
no epileptiform features on this study.

Renal U/s [**12-22**]
IMPRESSION: No hydronephrosis. Relatively echogenic renal
parenchyma, may be due to medical renal disease.

=============
Micro
=============
Blood 12/7
                            **FINAL REPORT [**2102-12-17**]**

   Blood Culture, Routine (Final [**2102-12-17**]):
      ENTEROCOCCUS FAECIUM.    FINAL SENSITIVITIES.
         HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
         gentamicin. Screen predicts possible synergy with
selected
         penicillins or vancomycin. Consult ID for details.
         HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to
1000mcg/ml of
         streptomycin.  Screen predicts possible synergy with
selected
         penicillins or vancomycin.  Consult ID for details..
                                   .
         SENSITIVE TO Daptomycin AT 1.5 MCG/ML  Sensitivity
testing
         performed by Etest.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ENTEROCOCCUS FAECIUM
                             |
AMPICILLIN------------  =>32 R
DAPTOMYCIN------------       S
LINEZOLID-------------     2 S
PENICILLIN G----------  =>64 R
VANCOMYCIN------------  =>32 R

Sputum [**12-21**]
                            **FINAL REPORT [**2102-12-27**]**

   GRAM STAIN (Final [**2102-12-21**]):
      >25 PMNs and <10 epithelial cells/100X field.
      2+   (1-5 per 1000X FIELD):   GRAM NEGATIVE ROD(S).
      1+    (<1 per 1000X FIELD):   BUDDING YEAST WITH
PSEUDOHYPHAE.

   RESPIRATORY CULTURE (Final [**2102-12-27**]):
      Commensal Respiratory Flora Absent.
      DR.[**Last Name (STitle) **],[**First Name3 (LF) **] PAGER [**Numeric Identifier 83908**] REQUESTED IDENTIFICATION AND
      SENSITIVITIES ON GRAM NEGATIVE RODS..
      STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA.    MODERATE
GROWTH.
         SENSITIVITIES REQUESTED PER DR.[**First Name (STitle) 815**] #[**Numeric Identifier **] [**2102-12-25**].
         ADDITIONAL sensitivity testing performed by Microscan.
         SENSITIVE TO CHLORAMPHENICOL (<=8 MCG/ML).
         SENSITIVE TO TIMENTIN (<=8 MCG/ML).
         Intermediate Levofloxacin (<=2 MCG/ML).
      YEAST.    SPARSE GROWTH.
      PSEUDOMONAS AERUGINOSA.    SPARSE GROWTH.
         OF TWO COLONIAL MORPHOLOGIES.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STENOTROPHOMONAS (XANTHOMONAS)
MALTOPHILIA
                             |          PSEUDOMONAS AERUGINOSA
                             |          |
AMIKACIN--------------                8 S
CEFEPIME--------------                8 S
CEFTAZIDIME-----------    16 I        2 S
CIPROFLOXACIN---------              =>4 R
GENTAMICIN------------             =>16 R
LEVOFLOXACIN----------       S
MEROPENEM-------------                4 S
PIPERACILLIN/TAZO-----                8 S
TOBRAMYCIN------------             =>16 R
TRIMETHOPRIM/SULFA----   <=1 S

Urine Culture [**12-23**]
[**2102-12-23**] 1:12 pm URINE      Source: Catheter.

                            **FINAL REPORT [**2102-12-24**]**

   URINE CULTURE (Final [**2102-12-24**]):
      YEAST.    >100,000 ORGANISMS/ML


Brief Hospital Course:
67 yo M with a history of aspiration PNA, COPD, CHF, A fib on
coumadin, CAD s/p CABG, who presented to OSH on [**11-27**]
complaining of shortness of breath. His wife had recently had
the flu and he was prophylaxed. His symptoms started 48 hours
after stopping prophylaxis. He was intubated in the ED for
hypoxia and admitted to the ICU. He was empirically treated with
oseltamivir for 10 days though his DFA and BAL respiratory viral
screen were negative. He was also noted to have some cardiac
ischemia thought secondary to demand, cardiology was consulted
and they felt that he would likely benefit from cardiac
catheterization after he is stabilized to define his anatomy. He
was treated medically for his cardiac ischemia. On admission he
was in shock which was initially thought to be cardiac secondary
to pulmonary hypertension and he was tried on inhaled nitric
oxide but did not improve his vigileo cardiac output. He was
started on amiodarone for AFib w/ RVR and hypotension, his blood
pressure improved with transition into regular atrial flutter
with a slower rate. He was maintained on a heparin drip and
started on coumadin on [**1-1**], and heparin was discontinued on
[**1-2**]. He was treated for septic shock from influenza with
pressors and then a ventilator associated pneumonia. He
developed acute on chronic renal failure and was initiated on
CVVH through a temporary line. He defervesced and slowly
improved from a ventilatory standpoint, and he was also weaned
from pressors after needing a small dose for >1 week. A
tracheostomy was performed as pt. did not appear to be able to
wean from the vent in the short term. He again began spiking
fevers and blood cultures grew out VRE 1/4 bottles so his
central lines were changed and his HD line was changed as well.
He was started on linezolid and continued to spike fevers. He
was also noted to be rigid on exam and so his buproprion and
prozac were discontinued for fear of serotonin syndrome. His
linezolid was changed to daptomycin out of concern for linezolid
contributing to serotonin syndrome. His rigidity and fevers
slowly improved. He was continued on dapto/meropenem for a total
of a 14/16 day course respectively, both finishing on [**12-26**].
.
However, his fevers continued after discontinuation of the above
antibiotics. Further sputum cultures revealed stenotrophomonas,
that was intermediately sensitive to ceftazidime but sensitive
to Bactrim. He was noted to have a sulfa drug allergy which his
wife thought was a rash but had never seen as it occured before
they were married. Per infectious disease, even the combination
of ceftazidime and levofloxacin would be inferior to Bactrim so
he was given one test dose of 1 DS tab of Bactrim. After 24
hours of observation, he exhibited no rash so he was started on
treatment dose for planned 14 day course, started on [**12-27**]. His
fevers began to completely resolve. Lines were removed during
fever workup.
.
After resolution of his fevers a tunnelled dialysis line was
placed as he showed no signs of renal recovery and would likely
be dialysis dependent. He was able to tolerate long periods of
trach mask at the time of discharge but was still not completely
independent from the vent.

Medications on Admission:
Protonix 40mg po daily
Reglan 10mg po qid
Albuterol PRN
Benicar with HCTZ 40-12.5mg daily
Wellbutrin SR 150mg [**Hospital1 **]
Digoxin 0.125mg po daily
Metoprolol 25mg po bid
Coumadin 5mg po daily
Prozac 40mg, 80mg po qod
Simvastatin 40mg po daily
ASA 81mg po daily


Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for erythema.
3. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
4. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
6. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day) as needed for constipation.
7. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Bisacodyl 10 mg Suppository Sig: Ten (10) Suppository Rectal
DAILY (Daily) as needed for constipation.
10. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) g PO DAILY (Daily) as needed for constipation.
11. Ammonium Lactate 12 % Lotion Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
13. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig:
Four (4) Puff Inhalation [**Hospital1 **] (2 times a day).
14. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Six
(6) Puff Inhalation Q4H (every 4 hours) as needed for wheezing.

15. Nystatin-Triamcinolone 100,000-0.1 unit/g-% Cream Sig: One
(1) Appl Topical [**Hospital1 **] (2 times a day) as needed for rash.
16. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
17. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
18. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
19. Oxycodone 5 mg/5 mL Solution Sig: Five (5) mg PO Q6H (every
6 hours) as needed for back pain.
20. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
21. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain,
flash.
22. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: 2.5
Tablets PO DAILY (Daily) for 8 days.
23. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
24. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM.
25. Lorazepam 0.5-1 mg IV Q8H:PRN anxiety
26. Ondansetron 4 mg IV Q8H:PRN n/v
27. Epogen  Injection
28. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **]

Discharge Diagnosis:
Enterococcal Sepsis
End stage renal failure on dialysis
Ventilator associated pneumonia
Atrial fibrillation


Discharge Condition:
Stable, afebrile


Discharge Instructions:
You were admitted to the hospital with low blood pressure from a
serious infection. You were treated for multiple infections in
the blood and lungs with various antibiotics. While in the
hospital you were started on dialysis because your kidneys were
severely damaged because of your infection. You were also
started on a blood thinning medication called coumadin because
of an irregular heart beat that you developed called atrial
fibrillation.

Followup Instructions:
Please follow up with your primary care physician after you
leave your long term acute care facility
{'Streptococcal septicemia,Acute respiratory failure,Septic shock,Pneumonitis due to inhalation of food or vomitus,End stage renal disease,Acute kidney failure, unspecified,Influenza with pneumonia,Subendocardial infarction, initial episode of care,Encephalopathy, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Ventilator associated pneumonia,Atrial flutter,Diastolic heart failure, unspecified,Acidosis,Paralytic ileus,Severe sepsis,Chronic airway obstruction, not elsewhere classified,Renal dialysis status,Peripheral vascular disease, unspecified,Dysphagia, unspecified,Other and unspecified hyperlipidemia,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Long-term (current) use of anticoagulants,Thrombocytopenia, unspecified,Constipation, unspecified,Depressive disorder, not elsewhere classified,Other extrapyramidal diseases and abnormal movement disorders,Other drugs and medicinal substances causing adverse effects in therapeutic use'}


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: Hypoxia

PRESENT ILLNESS: 67 yo M with a history of aspiration PNA, COPD, CHF, A fib on
coumadin, CAD s/p CABG, who presented to OSH on [**11-27**]
complaining of shortness of breath.
.
Per OSH records, the patients wife had diagnosed [**Name (NI) 30475**] recently.
The patient completed a 10 day course of tamiflu. 48 hours after
stopping tamiflu, he developed shortness of breath, along with
fevers, rigors, and green colored sputum.
.
He presented to the ED on [**11-27**] at noon, at which time he was
hypertensive with SBP in 200s. EKG notable for 1mm ST
depressions in lateral leads. The patient was given nitro paste,
and started on a nitro gtt. He received 1 dose of Ceftriaxone,
Azithro, and Levofloxacin for community acquired pneumonia seen
on CXR. He was transferred to OSH ICU.
.
In the ICU the patient received 1L NS, 1u PRBCs, and Combivent.
Shortly after finishing the transfusion he got acutely short of
breath, requiring BiPap. The patient was hypertensive again,
requiring increased dose of nitro gtt. He got lasix 20mg IV x1,
40mg IV x1, but only put out 15cc of urine to this. He desatted
to the high 70s, and was intubated for hypoxemia.
.
After intubation he had transient desats to the 80s, likely
secondary to improper sedation. He was started on a propofol gtt
and a versed gtt. Thereafter he was hypotensive and tachycardic,
and started on a Dopamine gtt, and Levophed gtt. A R subclavian
was placed after a 2nd attempt. CVP was 15 at that time.
.
WBC 10.6, HCT was initially 27.3, Cr initially 1.1, went up to
1.7.
The patient received one dose of Vancomycin, Flagyl, and
Tamiflu. He also got 120mg IV solumedrol.
.
Most recent set of vitals at time of sign out was Afebrile, HR
99, Systolic BP 100, 95% on FiO2 80%, Tv 6cc/kg, RR 16.

MEDICAL HISTORY: h/o aspiration pneumonia
COPD
Afib on coumadin
CAD s/p CABG in [**2099-4-4**]
CHF with normal EF
HTN
HL
PUD
Anemia
Dysphagia
PVD
s/p R CEA
s/p CCY

MEDICATION ON ADMISSION: Protonix 40mg po daily
Reglan 10mg po qid
Albuterol PRN
Benicar with HCTZ 40-12.5mg daily
Wellbutrin SR 150mg [**Hospital1 **]
Digoxin 0.125mg po daily
Metoprolol 25mg po bid
Coumadin 5mg po daily
Prozac 40mg, 80mg po qod
Simvastatin 40mg po daily
ASA 81mg po daily

ALLERGIES: Sulfa (Sulfonamide Antibiotics)

PHYSICAL EXAM: Admission
Vitals - T: 97.5 BP: 108/69 HR: 90 RR: 22 02 sat: 98%
GENERAL: Intubated, sedated
HEENT: NCAT. PERRL. No LAD.
CARDIAC: Irregularly irregular. No murmurs.
LUNG: Diffuse rhonchi bilaterally L>R.
ABDOMEN: Soft, NT, ND. No masses. No rebound or guarding.
EXT: WWP. No LE edema.
NEURO: Sedated
DERM: Chronic venous stasis.

FAMILY HISTORY: Unknown

SOCIAL HISTORY: Unknown 

### Response:
{'Streptococcal septicemia,Acute respiratory failure,Septic shock,Pneumonitis due to inhalation of food or vomitus,End stage renal disease,Acute kidney failure, unspecified,Influenza with pneumonia,Subendocardial infarction, initial episode of care,Encephalopathy, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Ventilator associated pneumonia,Atrial flutter,Diastolic heart failure, unspecified,Acidosis,Paralytic ileus,Severe sepsis,Chronic airway obstruction, not elsewhere classified,Renal dialysis status,Peripheral vascular disease, unspecified,Dysphagia, unspecified,Other and unspecified hyperlipidemia,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Long-term (current) use of anticoagulants,Thrombocytopenia, unspecified,Constipation, unspecified,Depressive disorder, not elsewhere classified,Other extrapyramidal diseases and abnormal movement disorders,Other drugs and medicinal substances causing adverse effects in therapeutic use'}
