CHIEF COMPLAINT: Fever, Abdominal Wall Infection

PRESENT ILLNESS: 48F with chronic HBV, diarrhea and malnutrition of unclear
etiology s/p PEG placement on [**2168-1-6**], diabetes, admitted to [**Hospital **] on [**2168-1-20**], now transferred to [**Hospital1 18**] for multiple medical
issues and ?abscess at PEG site.

MEDICAL HISTORY: 1. Chronic hepatitis B virus infection
- current evaluation for liver transplant at [**Hospital1 18**]
- also with ?autoimmune cholangiopathy, treated with prednisone
in past and ?currently
2. End-stage renal disease
- Secondary to diabetes
- Being evaluated for renal transplant
3. Hypertension
4. Diabetes.
- complicated by neuropathy, nephropathy, retinopathy.
5. Chronic diarrhea/weight loss/malabsorption
- No known etiology
6. H/o stroke
- Residual L-sided weakness most pronounced in leg, hand
coordination/strength; uses walker to ambulate
7. s/p PEG placement [**2168-1-6**] by GI for malnutrition

MEDICATION ON ADMISSION: - Entecavir 1 mg once a week: Fridays AFTER hemodialysis.
- Oxycodone 5 mg: [**1-2**] every 4-6 hours as needed for pain *
- B Complex-Vitamin C-Folic Acid 1 mg DAILY *
- Folic Acid 1 mg DAILY *
- Lisinopril 20 mg DAILY *
- Megestrol 400 mg/10 mL: Ten mL Q12H as needed for poor PO
intake.
- Loperamide 2 mg Q4H as needed for diarrhea. *
- tincture of opium 10 gtts QID *
- Metoprolol Succinate 50 mg DAILY (or 25 mg daily) *
- Ursodiol 300 mg [**Hospital1 **]
- Multivitamin DAILY *
- Nexium 40 mg daily *
- Tenofovir 300 mg 1X/WEEK (FR)
- Prochlorperazine 10 mg once a day as needed for nausea. *
- Ferrous Sulfate 325 mg TID (or daily) *
- Ascorbic Acid 500 mg TID Please give with iron.
- Gabapentin 300 mg DAILY
- Prednisone 5 mg Tablet DAILY
- Insulin regular according to sliding scale
- Insulin Glargine Fifteen units Subcutaneous at bedtime. (or 30
[**Hospital1 **] per OSH notes) *
- ?Klor-Con 20 [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On admission:
General: Lethargic, falls asleep easily but very easily
arousable.  Speech slowed and quiet but appropriate.
[**Year (4 digits) 4459**]: No obvious facial droop.  PERRL 3.5->3, EOMI.  Sclera
mildly icteric, MMM, oropharynx clear.
Neck: supple, JVD not elevated, no LAD, good ROM.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi; slight decrease at right base.
CV: Regular rate and rhythm, normal S1 + S2, loud holosystolic
murmur heard throughout precordium.
Abdomen:  PEG site in LUQ.  Small amount of dried blood at exit
site but no purulent drainage noted.  Mostly clear bilious fluid
from PEG.  No surrounding erythema.  + Moderate TTP in L side of
abdomen with guarding, no clear rebound.  + TTP in R abdomen as
well but seems to be bothering her more in L side with R sided
palpation.  +tender with shaking bed.  Bowel sounds present.
Ext: warm, well perfused, [**2-3**]+ edema equal bilaterally.
Tunnelled R HD line looks benign.  Stage II decub on buttocks.
Neuro: Mental status as above.  CN II-XII intact.  Strength 5/5
in all RUE and RLE muscle groups.  4-/5 at L plantar and
dorsiflexors.  [**5-4**] intrinsic hand muscles. 4+/5 in elbow flexors
and extensors.

FAMILY HISTORY: Father died of complications from diabetes. Mother also
diabetic. Otherwise no known illness in family including no
known renal/liver disease.

SOCIAL HISTORY: Lives with her mother and daughter (15) and son (12). Not
married. Born in [**Country 2045**] but moved to the US in [**2144**]. Has been out
of work since her stroke and has both VNA and home health aide
to assist her at home with ADLs and meds.
Other postoperative infection,Peritoneal abscess,Necrotizing fasciitis,End stage renal disease,Disseminated candidiasis,Sepsis,Other severe protein-calorie malnutrition,Mechanical complication of gastrostomy,Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Bacteremia,Umbilical hernia without mention of obstruction or gangrene,Diabetes with renal manifestations, type II or unspecified type, uncontrolled,Renal dialysis status,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Anemia, unspecified,Other specified diseases of pancreas
Other postop infection,Peritoneal abscess,Necrotizing fasciitis,End stage renal disease,Disseminated candidiasis,Sepsis,Oth severe malnutrition,Gastrostomy comp - mech,Hpt B chrn wo cm wo dlta,Hyp kid NOS w cr kid V,Bacteremia,Umbilical hernia,DMII renal uncntrld,Renal dialysis status,Pseudomonas infect NOS,Anemia NOS,Pancreatic disease NEC
Admission Date:  [**2168-1-21**]              Discharge Date:   [**2168-3-17**]

Date of Birth:  [**2119-5-26**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
Fever, Abdominal Wall Infection

Major Surgical or Invasive Procedure:
[**2168-3-2**] PICC and Tunneled HD cath
[**2168-2-15**] I+D abdominal wound
[**2168-2-13**] I+D abdominal wall infection
[**2168-2-5**] I+D abdominal wall abscess
[**2168-1-28**] Ex-Lap, gastrostomy closure, umbo hernia, I&D abscess
[**2168-1-21**] Abdominal Wall Abscess Drainage, IR,


History of Present Illness:
48F with chronic HBV, diarrhea and malnutrition of unclear
etiology s/p PEG placement on [**2168-1-6**], diabetes, admitted to [**Hospital **] on [**2168-1-20**], now transferred to [**Hospital1 18**] for multiple medical
issues and ?abscess at PEG site.

Per notes, she presented to OSH yesterday with 3 days of
myalgias, arthralgias, and malaise.  She missed HD 2 days PTA
due to symptoms.  She had also been noting elevated sugars at
home, initially attributed to newly instituted tube feeds.  Also
noted abdominal pain and nausea to ED providers.  Labs at OSH
notable for WBC 31K, Hct 25 (from 29 last here) with guaiac
positive stools and PEG aspirate.  Initial glucose 752.  Anion
gap 18 with negative urine ketones.  Positive UA.  Antibiotics
given were vancomycin and timentin.  CT was eventually performed
which showed a large fluid collection in the left abdomen
adjacent to her PEG tube that tracks inferiorly.  Also was
written for (?received) 2 units prbcs.

She was recently admitted for malnutrition/failure to thrive
from [**12-29**] to [**1-8**].  A dobhoff tube was placed and tube feeds
initiated.  However, her insurance would not cover home dobhoff
services, and thus PEG tube was placed on [**2168-1-6**] by GI.
Entecavir was started that admission for chronic HBV infection.
She returned for outpatient liver followup [**1-15**] - labs at that
time notable for WBC 24.2, new hyperbilirubinemia at 4.3.

On the floor, patient lethargic and generally poor historian.
Does not remember exactly when symptoms started or details of
what brought her to the ED.  Denies recent fevers.  Does seem to
endorse left sided abdominal pain, nausea/vomiting, ongoing
diarrhea (4-5 times per day), headache, neck pain.  Ongoing
weight loss associated with her poor nutritional status.  She is
unsure how much insulin she is taking at home.

Review of systems:
(+) Per HPI
(-) Denies fever, chills, cough, shortness of breath, chest
pain, chest pressure, palpitations, or weakness. Denies
constipation, abdominal pain, or changes in bowel habits. Denies
dysuria, frequency, or urgency. Denies rashes or skin changes.

Past Medical History:
1. Chronic hepatitis B virus infection
- current evaluation for liver transplant at [**Hospital1 18**]
- also with ?autoimmune cholangiopathy, treated with prednisone
in past and ?currently
2. End-stage renal disease
- Secondary to diabetes
- Being evaluated for renal transplant
3. Hypertension
4. Diabetes.
- complicated by neuropathy, nephropathy, retinopathy.
5. Chronic diarrhea/weight loss/malabsorption
- No known etiology
6. H/o stroke
- Residual L-sided weakness most pronounced in leg, hand
coordination/strength; uses walker to ambulate
7. s/p PEG placement [**2168-1-6**] by GI for malnutrition

Social History:
Lives with her mother and daughter (15) and son (12). Not
married. Born in [**Country 2045**] but moved to the US in [**2144**]. Has been out
of work since her stroke and has both VNA and home health aide
to assist her at home with ADLs and meds.


Family History:
Father died of complications from diabetes. Mother also
diabetic. Otherwise no known illness in family including no
known renal/liver disease.

Physical Exam:
On admission:
General: Lethargic, falls asleep easily but very easily
arousable.  Speech slowed and quiet but appropriate.
[**Year (4 digits) 4459**]: No obvious facial droop.  PERRL 3.5->3, EOMI.  Sclera
mildly icteric, MMM, oropharynx clear.
Neck: supple, JVD not elevated, no LAD, good ROM.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi; slight decrease at right base.
CV: Regular rate and rhythm, normal S1 + S2, loud holosystolic
murmur heard throughout precordium.
Abdomen:  PEG site in LUQ.  Small amount of dried blood at exit
site but no purulent drainage noted.  Mostly clear bilious fluid
from PEG.  No surrounding erythema.  + Moderate TTP in L side of
abdomen with guarding, no clear rebound.  + TTP in R abdomen as
well but seems to be bothering her more in L side with R sided
palpation.  +tender with shaking bed.  Bowel sounds present.
Ext: warm, well perfused, [**2-3**]+ edema equal bilaterally.
Tunnelled R HD line looks benign.  Stage II decub on buttocks.
Neuro: Mental status as above.  CN II-XII intact.  Strength 5/5
in all RUE and RLE muscle groups.  4-/5 at L plantar and
dorsiflexors.  [**5-4**] intrinsic hand muscles. 4+/5 in elbow flexors
and extensors.

On discharge:
Tm=100.4, Tc=97.5, HR=70s-100s, BP=130s-160s/70s-100s, RR=18,
Pox=99% RA
Blood sugars: 80s-130s
8hr I/Os: 585cc TPN / 0
24hr I/Os: 720cc PO + 1952cc TPN / BMx1
GENERAL - NAD, depressed
[**Month/Day (1) 4459**] - PERRL, EOMI, sclerae icteric with subungual icterus
NECK - Supple, no JVD
LUNGS - Coarse BS bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, loud holosystolic murmur heard
throughout precordium, nl S1-S2
ABDOMEN - + BS, wound vac in place over recent I&D site.
Diffuse, but mild TTP
EXTREMITIES - WWP, [**1-2**]+ edema bilaterally with fluid
concentrated in feet/ankles, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - A&Ox3


Pertinent Results:
Labs on Admission:
[**2168-1-21**] 10:10AM   PT-14.2* PTT-28.3 INR(PT)-1.2*
[**2168-1-21**] 10:10AM   PLT COUNT-482*
[**2168-1-21**] 10:10AM   HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-OCCASIONAL
MACROCYT-OCCASIONAL MICROCYT-2+ POLYCHROM-NORMAL TARGET-2+
[**2168-1-21**] 10:10AM   NEUTS-86.5* LYMPHS-10.0* MONOS-2.8 EOS-0.3
BASOS-0.3
[**2168-1-21**] 10:10AM   WBC-26.7* RBC-4.11* HGB-9.4* HCT-30.8*
MCV-75* MCH-22.8*# MCHC-30.4*# RDW-19.3*
[**2168-1-21**] 10:10AM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2168-1-21**] 10:10AM   VANCO-16.1
[**2168-1-21**] 10:10AM   ACETONE-NEGATIVE
[**2168-1-21**] 10:10AM   ALBUMIN-2.2* CALCIUM-8.6 PHOSPHATE-4.1
MAGNESIUM-2.5
[**2168-1-21**] 10:10AM   LIPASE-18
[**2168-1-21**] 10:10AM   ALT(SGPT)-28 AST(SGOT)-73* LD(LDH)-226 ALK
PHOS-421* TOT BILI-5.5*
[**2168-1-21**] 10:10AM   estGFR-Using this
[**2168-1-21**] 10:10AM   GLUCOSE-373* UREA N-73* CREAT-4.3* SODIUM-134
POTASSIUM-5.1 CHLORIDE-90* TOTAL CO2-28 ANION GAP-21*

Labs on Discharge:
[**2168-3-16**]
WBC   RBC   Hgb  Hct   MCV MCH  MCHC  RDW   Plt Ct
19.3* 3.25* 8.9* 29.4* 91  27.5 30.4* 20.9* 604*

Neuts Bands Lymphs Monos Eos Baso
88.6* 0     7.5*   3.1   0.5 0.2

PT     PTT      INR(PT)
13.41  34.8     1.1

Glucose UreaN Creat Na   K    Cl  HCO3 AnGap
75      74*   3.0*  140  4.7  103 23   19

ALT AST LD(LDH) AlkPhos TotBili
36  96* 262*    552*    7.5*

Albumin Calcium Phos   Mg
2.5*    9.1     2.2*#  2.2

Microbiology:
STOOL STUDIES:
- CDiff: Negative x 10 (last negative [**2168-3-12**])
- Positive Stool AFB (non-TB/MAC AFB) [**2168-1-24**]: State Lab pending
final speciation
- MICROSPORIDIA STAIN (Final [**2168-1-26**]): NO MICROSPORIDIUM SEEN.
- CYCLOSPORA STAIN (Final [**2168-1-26**]): NO CYCLOSPORA SEEN.
- OVA + PARASITES ([**2168-1-24**], [**2168-1-26**], [**2-25**], [**2-26**]):  NO OVA AND
PARASITES SEEN.
- Cryptosporidium/Giardia (DFA) (Final [**2168-1-26**]): NO
CRYPTOSPORIDIUM OR GIARDIA SEEN.

Blood Cx:

- Blood culture [**2168-1-21**]: Positive for [**Female First Name (un) **] (TORULOPSIS)
GLABRATA

 Blood Culture, Routine (Final [**2168-2-28**]):
      ESCHERICHIA COLI.    FINAL SENSITIVITIES.
      PSEUDOMONAS AERUGINOSA.    FINAL SENSITIVITIES.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ESCHERICHIA COLI
                             |          PSEUDOMONAS AERUGINOSA
                             |          |
AMIKACIN--------------               16 S
AMPICILLIN------------     8 S
AMPICILLIN/SULBACTAM--     4 S
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S       16 I
CEFTAZIDIME-----------   <=1 S        8 S
CEFTRIAXONE-----------   <=1 S
CIPROFLOXACIN---------     2 I      =>4 R
GENTAMICIN------------   <=1 S     =>16 R
MEROPENEM-------------<=0.25 S        4 S
PIPERACILLIN/TAZO-----   <=4 S    =>128 R
TOBRAMYCIN------------   <=1 S     =>16 R
TRIMETHOPRIM/SULFA----   <=1 S

Blood Cultures Negative x26 (Last blood culture [**2168-3-10**] was
negative)

- Abscess culture [**2168-1-21**]: Mixed bacterial types
      GRAM STAIN (Final [**2168-1-21**]):
      4+   (>10 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      4+   (>10 per 1000X FIELD):   GRAM POSITIVE ROD(S).
      4+   (>10 per 1000X FIELD):   GRAM NEGATIVE ROD(S).
      3+  (5-10 per 1000X FIELD):   BUDDING YEAST.

WOUND CULTURE (Final [**2168-2-28**]):
      Mixed bacterial types (>= 3 colony morphologies) isolated.

      PSEUDOMONAS AERUGINOSA.    >15 colonies.
      ESCHERICHIA COLI.    >15 colonies.
      STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA.    <15
colonies.
                              SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
                             PSEUDOMONAS AERUGINOSA
                             |          ESCHERICHIA COLI
                             |          |
STENOTROPHOMONAS (XANTHOMON
                             |          |          |
AMIKACIN--------------     8 S
AMPICILLIN------------                8 S
AMPICILLIN/SULBACTAM--                4 S
CEFAZOLIN-------------              <=4 S
CEFEPIME--------------     8 S      <=1 S
CEFTAZIDIME-----------     8 S      <=1 S
CEFTRIAXONE-----------              <=1 S
CIPROFLOXACIN---------   =>4 R        1 S
GENTAMICIN------------  =>16 R      <=1 S
MEROPENEM-------------     4 S   <=0.25 S
PIPERACILLIN/TAZO----- =>128 R      <=4 S
TOBRAMYCIN------------  =>16 R      <=1 S
TRIMETHOPRIM/SULFA----              <=1 S    <=0.5 S

- HIV PCR: non-detected [**3-11**], [**3-10**]

HBV Viral Load (Final [**2168-3-11**]):
      HBV DNA detected, less than 40 IU/mL.
 HBV Viral Load (Final [**2168-1-27**]):
      192 IU/mL.

Sputum:
   ACID FAST SMEAR (Final [**2168-3-11**]):
      NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
   ACID FAST CULTURE (Preliminary):

Wound:
WOUND CULTURE (Final [**2168-2-14**]):
      ENTEROCOCCUS SP..    SPARSE GROWTH.
         SENSITIVITIES REQUESTED PER DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] #[**Numeric Identifier 17648**]
[**2168-2-8**].
      [**Female First Name (un) **] (TORULOPSIS) GLABRATA.    SPARSE GROWTH.
         IDENTIFICATION REQUESTED BY DR.[**Last Name (STitle) **].
         SENT TO [**State 15238**] FOR SENSITIVITIES TO
FLUCONOZOLE.
         Refer to sendout system for results.
      LACTOBACILLUS SPECIES.    SPARSE GROWTH.
                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ENTEROCOCCUS SP.
                             |
AMPICILLIN------------  =>32 R
LINEZOLID-------------     1 S
PENICILLIN G----------  =>64 R
VANCOMYCIN------------  =>32 R

Studies:

CT-guided drainage of abscess [**2168-1-21**]:
IMPRESSION: Technically successful aspiration and insertion of
drainage catheter into left anterior abdominal abscess.
Post-procedure orders were entered into provider order entry
system. Sample sent for microbiology studies.

CT Abdomen/pelvis with contrast [**2168-1-23**]:
IMPRESSION:
1. Large anterior abdominal air and fluid collection with
peripheral enhancement status post drainage catheter placement
is minimally decreased in AP diameter in the superior portion;
however, the inferior portion cannot be compared to prior study
as it was not included in the field of imaging. Catheter is in
appropriate position.
2. Small amount of heterogeneous and hyperdense material
adjacent to the inferior aspect of the liver may represent small
amount of blood clot. Please correlate with recent intervention
at this location.
3. Extensive anasarca and intra-abdominal and pelvic ascites.

G-TUBE CHECK [**2168-1-24**]:
FINDINGS: A percutaneous gastrostomy has been placed. Contrast
outlines the lumen of the stomach and rugal folds. No
extravasation of contrast outside the tube or the stomach is
identified. Also noted is a pigtail catheter entering from the
left side of the abdomen.

Transthoracic echocardiogram [**2168-1-25**]:
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is 0-5 mmHg. Left ventricular
wall thicknesses and cavity size are normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is mildly depressed (LVEF= 40-45 %). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are structurally normal. Mild (1+)
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
Ascites is present. IMPRESSION: Normal cavity size with mild
global left ventricular hypokinesis c/w diffuse process (toxin,
metabolic, etc.) Mild mitral regurgitation with normal valve
morphology. Aortic valve sclerosis. Ascites.

CT-guided evaluation of drain [**2168-1-26**]:
IMPRESSION:
1. Free communication of anterior abdominal wall abscess with
the stomach via the patient's G-tube tract.
2. The anterior abdominal wall is stable in appearance and
likely comprises a combination of gas from the stomach and
extensive phlegmon. The pre-existing pigtail catheter is in
appropriate location. Unsuccessful attempted placement of the
second inferior pigtail catheter as this area was not in fact a
fluid collection, but instead inflammatory phlegmonous tissue.

Temporary HD line placement, RIJ [**2168-1-26**]: Report pending

Nasointestinal tube placement [**2168-1-27**]:
IMPRESSION: Nasointestinal feeding tube positioned within the
stomach.  Unable to advance into a post-pyloric position.
Recommend followup KUB to assess for advancement via
peristalsis.

Preoperative CXR PA/lateral [**2168-1-27**]:
CHEST, FRONTAL AND LATERAL VIEWS: The lungs are clear. The right
hemidiaphragm is elevated. Heart size, mediastinal and hilar
contours are normal. There is no effusion, consolidation or
evidence of pulmonary edema. Right central venous catheter
terminates in the expected location of the superior vena cava.
Nasogastric tube terminates below the stomach, with the tip in
the left upper quadrant directed cephalad. The PEG balloon
projects over the stomach. IMPRESSION: No acute cardiopulmonary
abnormality

[**2168-2-4**] CT-abd/pelvis
IMPRESSION:
1. Status post debridement of left anterior abdominal air and
fluid
collection. Gas and fluid persists in the left abdominal wall
but has reduced
since prior study, with a small residual fluid-containeng
component at the
left inguinal region.
2. Persistent but lessened moderate ascites
3. Extensive third space fluid.
4. Progressed appearance of airspace opacification at bases
(right greater
than left), compatible with aspiration and/or infection.
5. Persistent extensive vascular calcifications.
6. Multifocal areas of colonic wall thickening compatible with
resolving
colitis.

[**2168-3-3**] CT-abd/pelvis
IMPRESSION:

1. No evidence of intra-abdominal or pelvic abscess.

2. Ascites and widespread peritoneal, pelvic and omental
nodularity, similar
to that seen previously. It is unclear if this is reactive or
neoplastic. If
indicated, peritoneal fluid cytology could be considered.

3. Cholelithiasis.

4. Dobbhoff tube terminating in the proximal stomach. The tube
could be
advanced by 5-10 cm.

5. Increasing bibasilar pulmonary consolidations.

6. Heterogeneous splenic attenuation. Given the atherosclerosis,
this may be
related to abnormal perfusion timing. Attention to this area is
recommended
on follow-up imaging.

7. Extensive atherosclerotic disease.

RUQ U/S [**3-9**]
IMPRESSION:
1. Diffuse echogenicity of the liver, most likely in keeping
with fatty
infiltration.
2. Small amount of ascites.
3. Severely thickened gallbladder wall, secondary to the
patient's
hypoalbuminemia.
4. No evidence of filling defects within the biliary tree.

[**3-9**] CXR PA/Lat
Right PICC tip is in the upper SVC. Right IJ hemodialysis
catheter is in
standard position. There are low lung volumes. Mild cardiomegaly
is stable.  Right lower lobe atelectasis is more conspicuous
from prior. There is no pneumothorax or pleural effusion.

[**3-10**] CT-chest
IMPRESSION:
1. No evidence of chronic or active tuberculosis.
2. No pnuemonia. No intrathoracic lymphadenopathy. Mild
bibasilar
atelectasis. Chronic RLL subsegmental atelectasis.
3. Persistent moderate-sized simple ascites.
4. Simple cholelithiasis.


Brief Hospital Course:
48F with h/o Hep B, DM, chronic diarrhea, malnutrition s/p
recent PEG placement, who presented with abdominal pain and
malaise, found to have an abdominal wall abscess, now s/p ex-lap
and extensive debridement.  Her hospital course has been
complicated by E.Coli, [**Female First Name (un) 564**], and Pseudomonas bacteremia and
increased diarrhea likely secondary to a mycobacterial GI
infection.

#. Abdominal Wall Abscess:
The patient initially presented with fatigue and was found to
have DKA at an OSH.  Given concern for abdominal fullness on
physical exam, she had a CT-abdomen, which showed evidence of an
abdominal abscess around the site of her PEG tube, which was
placed on [**2168-1-6**].  She was then transferred to [**Hospital1 18**] on [**2168-1-21**],
given the fact that her PEG tube was placed here.  This fluid
collection was drained by IR on [**1-21**] and demonstrated [**First Name5 (NamePattern1) 564**]
[**Last Name (NamePattern1) 17649**].  Blood cultures from admission also demonstrated
Candidemia.  On [**1-28**], the patient underwent an ex-lap for
debridement and limited gastric resection.  Her hospital course
has been complicated by extensive abdominal wall debridement
requiring I&D by surgery: [**2168-2-15**] I+D abdominal wound, [**2168-2-13**]
I+D abdominal wall infection, and [**2168-2-5**] I+D abdominal wall
abscess.  She has completed multiple courses of antibiotics
including Linezolid discontinued on [**3-3**] after a 24 day course,
Fluconazole discontinued on [**3-3**] after a 23 day course and
completed meropenem day [**10-9**] on [**3-10**] for Pseudomonas,
Enterococcus, E. Coli and [**Female First Name (un) **] infection.  The patient's
abdominal wound has a wound-vac placed by Plastic Surgery.  The
plan is to continue the wound-vac at rehab and will follow-up
with Dr. [**First Name (STitle) **] in outpatient clinic for closure options.
Additionally, she will continue TPN in hopes of improving her
nutritional status for appropriate wound healing for closure.
The patient should continue the wound-vac and follow-up with Dr.
[**First Name (STitle) **] in Plastic Surgery clinic in the next 1-2 weeks.  Dr.[**Last Name (STitle) 17650**]
office is aware of the patient and will call the rehab with a
follow-up appointment.
.
#. Diarrhea: The patient has a history of diarrhea, s/p
extensive outpatient workup.  She is currently being seen by
gastroenterology and has known pancreatic insufficiency on
Creon.  TTG IGA is negative for celiac disease, and she was
previously found to have low stool elastase and positive fecal
fat, concerning for malabsorption.  The patient had a
colonoscopy and biopsy from [**3-3**] with no diagnostic
abnormalities.  The patient's diarrhea improved after her TF
were discontinued on [**3-5**].  She was initiated on TPN for
nutrition with minimal po intake.  She has had multiple stool C.
diff and cultures that have returned negative.  However, stool
study from [**1-24**] came back positive for AFB [**3-8**] that was shown
not to be TB or MAC.  A CT chest with contrast was negative for
any signs of active or chronic Tb and respiratory isolation
precautions were discontinued per ID recommendations [**3-11**].  HIV
viral load has been negative as well.  The state lab is
attempting to speciate the type of mycobacterium via DNA probes
and may take up to 6 weeks.  The AFB in her stools could be a
cause of her chonic diarrhea, but treat is not being pursued
until final speciation has been made.  Additionally, her
diarrhea has improved with tincture of opium, loperamide and
Creon.  She has been having [**2-3**] BM per day, that is at her
baseline.  The AFB cultures from the state lab should be
followed-up.

# Chronic hep B infection/autoimmune cholangiopathy.  The
patient remains jaundiced on physical exam and her LFTs have
been fluctuating likely secondary to a combination of her
chronic liver diseases, blood transfusions, and TPN.  Her
alkaline phosphatase peaked at 1313 and her AST peaked at 104 on
[**3-8**].  Her total bilirubin peaked at 8.5 [**3-3**].  RUQ U/S read
indicates irregular contour and heterogeneity of the liver
suggestive of chronic liver disease with a small amount of
ascites.  Her albumin has been slowly increasing with TPN to 2.5
She is being continued on entecavir/tenofovir and HB viral
levels were 192 on [**1-25**], but were undetectable on [**3-10**].  She was
started on ursodiol 250mg TID on [**3-8**].  Her bilirubin began
trending up again [**3-10**].  Her prednisone was increased to 15mg
daily and her bilirubin began to decrease 7.5 at the time of
discharge.  The plan is to continue 15mg prednisone for 7 days
(started on [**3-14**]).  Then tapering to 10mg daily for 7 days
(initiate on [**3-21**]) and then again tapering to 5mg daily.  She
should continue 5mg prednisone daily, after her taper until she
follows-up with Liver Clinic.

# Bacteremia:  The patient was found to have [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 17649**] in
her blood on [**1-21**].  Her blood cultures also grew Pseudomonas and
E.Coli on [**2-24**].  The patient was closely followed by infectious
disease.  She has completed multiple courses of antibiotics
including Linezolid discontinued on [**3-3**] after a 24 day course,
Fluconazole discontinued on [**3-3**] after a 23 day course and
completed a 10 day course of Meropenem on [**3-10**].  Likely source
is her intra-abdominal infection.  She is hemodynamically stable
and afebrile.  The patient should have Ophtho follow-up in 2
weeks given her Candidemia or sooner if she develops vision
symptoms.  The patient's last positive blood cultures were from
[**2-24**] and have remained negative since (last negative culture
[**3-10**]).  The patient with persistent leukocytosis during her
hospitalization ranging between 15-20K.

# Hyperglycemia/DM. Per the patient's PCP she has uncontrolled
type II diabetes.  The patient was followed by [**Last Name (un) **] Diabetes
during her hospitalization.  Her current regimen is 8U lantus
qhs and Humolog SS.

# ESRD. The patient receives HD M/W/F at [**Hospital1 1474**] via R
tunnelled line.  She was maintained on her HD scheduled and
followed by the renal team.  Given the patient's bacteremia and
fungemia her previous tunnelled line was removed on [**1-24**].  Her
temp dialysis line was again removed [**2-24**] and grew pseudomonas,
E. Coli, and stenotrophomonas.  A new right IJ tunnelled HD line
was placed on [**2168-3-1**].  The patient's last HD session was on
[**3-16**].

# Anemia:  During her hospital course she has received a total
of 6U pRBC.  Her last transfusion was on [**3-7**] and her Hct has
remained stable (32-28).  Her anemia is likely secondary to
anemia of chronic disease/inflammation and chronic kidney
disease.  She has been receiving Procrit at HD sessions per
renal.

# Hypertension.  The patient has known hypertension.  Her
lisionpril and metoprolol were titrated during her
hospitalization.  She was discahrged on lisinopril 20mg daily
and metoprolol 25mg [**Hospital1 **].  Her BP medications should be held
until after dialysis per renal in order to minimize hypotension
in HD.

# FEN: See above regarding diarrhea.  The patient was started on
TPN on [**3-5**] and should continue TPN at rehab.  She has been
taking minimal po intake as well.


Medications on Admission:
- Entecavir 1 mg once a week: Fridays AFTER hemodialysis.
- Oxycodone 5 mg: [**1-2**] every 4-6 hours as needed for pain *
- B Complex-Vitamin C-Folic Acid 1 mg DAILY *
- Folic Acid 1 mg DAILY *
- Lisinopril 20 mg DAILY *
- Megestrol 400 mg/10 mL: Ten mL Q12H as needed for poor PO
intake.
- Loperamide 2 mg Q4H as needed for diarrhea. *
- tincture of opium 10 gtts QID *
- Metoprolol Succinate 50 mg DAILY (or 25 mg daily) *
- Ursodiol 300 mg [**Hospital1 **]
- Multivitamin DAILY *
- Nexium 40 mg daily *
- Tenofovir 300 mg 1X/WEEK (FR)
- Prochlorperazine 10 mg once a day as needed for nausea. *
- Ferrous Sulfate 325 mg TID (or daily) *
- Ascorbic Acid 500 mg TID Please give with iron.
- Gabapentin 300 mg DAILY
- Prednisone 5 mg Tablet DAILY
- Insulin regular according to sliding scale
- Insulin Glargine Fifteen units Subcutaneous at bedtime. (or 30
[**Hospital1 **] per OSH notes) *
- ?Klor-Con 20 [**Hospital1 **]

Discharge Medications:
1. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1) mg
Injection Q15MIN () as needed for hypoglycemia protocol. mg
2. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO 1X/WEEK (FR).
3. Entecavir 0.5 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK (FR).

4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
7. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal TID (3 times a day) as needed for rectal pain.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection [**Hospital1 **] (2 times a day).
9. Loperamide 2 mg Capsule Sig: One (1) Capsule PO Q1H (every
hour) as needed for diarrhea.
10. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Please hold prior to HD, can administer after HD, hold
for SBP<100
.
11. Opium Tincture 10 mg/mL Tincture Sig: Ten (10) Drop PO Q4H
(every 4 hours) as needed for diarrhea: Please administer to
patient 1-2 hours prior to taking PO .
12. Ursodiol 250 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
13. Lipase-Protease-Amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: Four (4) Cap PO TID W/MEALS (3 TIMES
A DAY WITH MEALS): Please give 1 capsule before, 2 capsule
during, and 1 capsule after meals and snacks.
.
14. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety, dizziness, nausea.
15. Mirtazapine 15 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet,
Rapid Dissolve PO HS (at bedtime).
16. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO QD () for 4
days: Last dose 3/22.
17. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QD () for 7
days: starting [**2168-3-22**].
18. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QD () as
needed for autoimmune cholangitis: Starting on [**3-30**].
19. Medium Chain Triglycerides 7.7 kcal/mL Oil Sig: Fifteen (15)
ML PO TID (3 times a day).
20. Dextrose 50% in Water (D50W)     Syringe Sig: 12.5 grams
Intravenous PRN (as needed) as needed for hypoglycemia protocol.

21. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed for nausea.
22. Sodium Chloride 0.9%  Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
23. Sodium Chloride 0.9%  Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
24. Hydromorphone (PF) 1 mg/mL Syringe Sig: 0.5 mg Injection Q6H
(every 6 hours) as needed for breakthrough pain.
25. Lantus 100 unit/mL Solution Sig: Eight (8) units
Subcutaneous at bedtime.
26. Insulin Lispro 100 unit/mL Solution Sig: as directed
Subcutaneous four times a day: refer to attached sliding scale.



Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
Intrabdominal abscess, Bacteremia, Fungemia, pancreatic
insufficiency, malnutrition
.
Secondary diagnoses:
-chronic hepatitis B infection
-autoimmune cholangiopathy
-ESRD on HD M/W/F
-HTN
-Diabetes
-h/o CVA
-chronic diarrhea


Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Out of Bed with assistance to chair or
wheelchair


Discharge Instructions:
You were admitted to [**Hospital1 **] Hospital for
evaluation of fatigue and were found to have diabetic
ketoacidosis as a result of an abdominal abscess/infection
around the site of your PEG tube.  The fluid inside the abscess
was drained and grew out several multi drug resistant bacteria
and yeast.  This bacteria also entered your blood stream and
required a long course of treatment with several powerful
antibiotics and antifungals.  You also needed additional
surgeries to clean out the infection and abscess which led to
your open abdominal wound requiring a wound vac.  You were also
having profuse diarrhea following food intake and were
malnourished.  Therefore TPN or IV nutrition was started along
with normal food intake.
.
Several changes were made to your home medication regimen which
will be passed along to your rehab facility.
.
Please follow-up with all of your outpatient medical
appointments listed below.

Followup Instructions:
Please follow-up at the following appointments listed below:
.
You will be contact[**Name (NI) **] by our plastic surgery office at [**Hospital1 18**] for
follow up regarding your wound and also regarding the VAC.
Please contact the office at [**Telephone/Fax (1) 4652**] to schedule a follow
up appointment with Dr. [**First Name (STitle) **] if you do not hear from them.

Ophthomology Appointment:
[**Hospital1 18**] Eye Clinic: [**Telephone/Fax (1) 253**]
[**3-27**] at 9:30am
[**Hospital Ward Name 23**] Floor 5
.
1. Provider: [**Name10 (NameIs) 1382**] [**Name11 (NameIs) 1383**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2168-3-25**] 8:40
{'Other postoperative infection,Peritoneal abscess,Necrotizing fasciitis,End stage renal disease,Disseminated candidiasis,Sepsis,Other severe protein-calorie malnutrition,Mechanical complication of gastrostomy,Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Bacteremia,Umbilical hernia without mention of obstruction or gangrene,Diabetes with renal manifestations, type II or unspecified type, uncontrolled,Renal dialysis status,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Anemia, unspecified,Other specified diseases of pancreas'}


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: Fever, Abdominal Wall Infection

PRESENT ILLNESS: 48F with chronic HBV, diarrhea and malnutrition of unclear
etiology s/p PEG placement on [**2168-1-6**], diabetes, admitted to [**Hospital **] on [**2168-1-20**], now transferred to [**Hospital1 18**] for multiple medical
issues and ?abscess at PEG site.

MEDICAL HISTORY: 1. Chronic hepatitis B virus infection
- current evaluation for liver transplant at [**Hospital1 18**]
- also with ?autoimmune cholangiopathy, treated with prednisone
in past and ?currently
2. End-stage renal disease
- Secondary to diabetes
- Being evaluated for renal transplant
3. Hypertension
4. Diabetes.
- complicated by neuropathy, nephropathy, retinopathy.
5. Chronic diarrhea/weight loss/malabsorption
- No known etiology
6. H/o stroke
- Residual L-sided weakness most pronounced in leg, hand
coordination/strength; uses walker to ambulate
7. s/p PEG placement [**2168-1-6**] by GI for malnutrition

MEDICATION ON ADMISSION: - Entecavir 1 mg once a week: Fridays AFTER hemodialysis.
- Oxycodone 5 mg: [**1-2**] every 4-6 hours as needed for pain *
- B Complex-Vitamin C-Folic Acid 1 mg DAILY *
- Folic Acid 1 mg DAILY *
- Lisinopril 20 mg DAILY *
- Megestrol 400 mg/10 mL: Ten mL Q12H as needed for poor PO
intake.
- Loperamide 2 mg Q4H as needed for diarrhea. *
- tincture of opium 10 gtts QID *
- Metoprolol Succinate 50 mg DAILY (or 25 mg daily) *
- Ursodiol 300 mg [**Hospital1 **]
- Multivitamin DAILY *
- Nexium 40 mg daily *
- Tenofovir 300 mg 1X/WEEK (FR)
- Prochlorperazine 10 mg once a day as needed for nausea. *
- Ferrous Sulfate 325 mg TID (or daily) *
- Ascorbic Acid 500 mg TID Please give with iron.
- Gabapentin 300 mg DAILY
- Prednisone 5 mg Tablet DAILY
- Insulin regular according to sliding scale
- Insulin Glargine Fifteen units Subcutaneous at bedtime. (or 30
[**Hospital1 **] per OSH notes) *
- ?Klor-Con 20 [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On admission:
General: Lethargic, falls asleep easily but very easily
arousable.  Speech slowed and quiet but appropriate.
[**Year (4 digits) 4459**]: No obvious facial droop.  PERRL 3.5->3, EOMI.  Sclera
mildly icteric, MMM, oropharynx clear.
Neck: supple, JVD not elevated, no LAD, good ROM.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi; slight decrease at right base.
CV: Regular rate and rhythm, normal S1 + S2, loud holosystolic
murmur heard throughout precordium.
Abdomen:  PEG site in LUQ.  Small amount of dried blood at exit
site but no purulent drainage noted.  Mostly clear bilious fluid
from PEG.  No surrounding erythema.  + Moderate TTP in L side of
abdomen with guarding, no clear rebound.  + TTP in R abdomen as
well but seems to be bothering her more in L side with R sided
palpation.  +tender with shaking bed.  Bowel sounds present.
Ext: warm, well perfused, [**2-3**]+ edema equal bilaterally.
Tunnelled R HD line looks benign.  Stage II decub on buttocks.
Neuro: Mental status as above.  CN II-XII intact.  Strength 5/5
in all RUE and RLE muscle groups.  4-/5 at L plantar and
dorsiflexors.  [**5-4**] intrinsic hand muscles. 4+/5 in elbow flexors
and extensors.

FAMILY HISTORY: Father died of complications from diabetes. Mother also
diabetic. Otherwise no known illness in family including no
known renal/liver disease.

SOCIAL HISTORY: Lives with her mother and daughter (15) and son (12). Not
married. Born in [**Country 2045**] but moved to the US in [**2144**]. Has been out
of work since her stroke and has both VNA and home health aide
to assist her at home with ADLs and meds. 

### Response:
{'Other postoperative infection,Peritoneal abscess,Necrotizing fasciitis,End stage renal disease,Disseminated candidiasis,Sepsis,Other severe protein-calorie malnutrition,Mechanical complication of gastrostomy,Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Bacteremia,Umbilical hernia without mention of obstruction or gangrene,Diabetes with renal manifestations, type II or unspecified type, uncontrolled,Renal dialysis status,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Anemia, unspecified,Other specified diseases of pancreas'}
