CHIEF COMPLAINT: falls, bacteremia

PRESENT ILLNESS: This is a 78 year old male with type II diabetes, severe
peripheral [**First Name3 (LF) 1106**] disease, coronary artery disease s/p CABG
and atrial fibrillation on coumadin who presents to the
emergency room after two falls at home. The first fall occurred
on [**2174-11-3**] at home when he fell in his kitchen. He hit is right
shoulder and presented to the emergency room where he had a
right clavicle xray which showed no fracture of dislocation and
was discharged home with pain medications. The patient has very
limited mobility at baseline and uses a wheelchair. He requires
the use of his arms to help get out of bed and into his
wheelchair and also for balance. He has had significant pain his
his right arm since his fall and this has made getting around
his house increasingly difficult. On [**2174-11-4**] he was trying to
take a shower and had a plastic bag on his right foot to protect
his foot ulcers. He tried to get out of the shower and he
slipped on the plastic bag and fell on his right hip. Because
his arm was hurt as well he was unable to get himself back to a
seated position and lay on the ground for an hour before a
friend found him and called 911. EMS came to his home but he did
not want to come back to the hospital so they placed him in his
bed. He reports that they placed him facing in the wrong
position and he was unable to get out of bed or reach his pills
so he has not been taking his pills now for 48 hours. He was so
disabled that he ultimately called EMS again so that he could be
brought to the emergency room.
.
In the ED, initial vs were: T: 99 P: 108 BP: 131/81 R: 16 O2 sat
99% on RA. He had a CXR which showed mild [**Date Range 1106**] prominence
but no focal infiltrates. He had an xray of his right hip which
was negative for fracture and a non-contrast head CT which
showed no evidence of hemorrhage. Patient was given one liter of
normal saline, zofran 4 mg IV x 1 and vancomycin 1000 mg IV x 1
out of concern for possible right shoulder cellulitis. He is
admitted to the floor for further management.
.
On the floor he continues to have significant right shoulder
pain. He has mild right hip pain but is able to move his right
leg. He denies fevers, chills, lightheadedness, dizziness, chest
pain or shortness of breath. He did have nausea earlier in the
day but this has resolved. He denies abdominal pain,
constipation, diarrhea, melena, hematochezia, dysuria or
hematuria. He has minimal sensation in his feet bilaterally but
denies foot pain. All other review of systems is negative in
detail.

MEDICAL HISTORY: 1. CAD (s/p CABG, [**1-14**])
2. CHF (EF 17% on pMIBI from [**3-17**])
3. DM (diet controlled, HgA1c 6.2 on no agents)
4. PVD
s/p R AK popliteal to post tibial artery bypass in [**3-14**],
percutaneous intervention [**3-16**]
s/p PTSG L [**7-14**]
s/p plasty & stent of R SFA, plasty of PT [**2173-2-16**]
5. Afib/flutter on chronic anticoagulation
6. htxn
7. hyperlipidemia

MEDICATION ON ADMISSION: Brimonidine 0.15 % 1 drop in right eye Q8H
Citalopram 20 mg daily
Ergocalciferol 50,000 units weekly
Famotidine 20 mg daily
Furosemide 40 mg 1-2 tablets daily
Lisinopril 5 mg daily
Metoprolol Tartrate 25 mg [**Hospital1 **]
Nitroglycerin 0.4 mg SL PRN
Oxycodone-Acetaminophen 5 mg-325 mg 1-2 tabs PRN
Simvastatin 20 mg daily
Warfarin 7.5 mg daily
Aspirin 81 mg daily
Bisacodyl 5 mg 1-2 tablets [**Hospital1 **]:PRN
Cyanocobalamin 1,000 mcg daily
Colace TID:PRN

ALLERGIES: Penicillins / Morphine / Codeine / Cefazolin

PHYSICAL EXAM: On admission:
Vitals: T: 100.0 BP: 154/96 P: 103 R: 20 O2: 99% on RA FS: 99
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Scarce inspiratory crackles at the bases, no wheezes, or
ronchi
CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops, well healed CABG scar
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: Warm, severe peripheral [**Year (4 digits) 1106**] disease, multiple toe
amputations, small ulcer near nailbed on right second toe with
dried blood, 2 x 2 cm healing ulcer on medial plantar right
foot, dopplerable distal pulses bilaterally, decreased sensation
in lower extremities throughout. Right shoulder with mild
erythema and pain over palpation of the right clavical. Although
he has 5/5 strength in the right upper extremity he is severely
limited by pain, particularly with arm flexion. The right hip
has pain over palpation near the right trochanteric bursa. There
is no gross bruising. No significant pain with flexion or
extension of the right leg.
.
On discharge: VSS, lungs clear, RRR, full movement in legs to
anti-gravity.  SC pain, errythema resolved.  Foley in place.
Exam otherwise unchanged

FAMILY HISTORY: He has one brother with diabetes and one sister with stomach
cancer. His mother had diabetes. His father died at age 79 of
unclear reasons. He has four daughters and one son who are
healthy.

SOCIAL HISTORY: He lives by himself and does all of his own activities of daily
living. He quit smoking in [**5-/2174**] but has a heavy smoking
history. He uses a walker and a wheelchair to assist with
ambulation. He does not currently drink alcohol or use illicit
drugs.
Methicillin susceptible Staphylococcus aureus septicemia,Intraspinal abscess,Acute on chronic systolic heart failure,Pneumonitis due to inhalation of food or vomitus,Ventricular fibrillation,Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction,Acute kidney failure, unspecified,Acute myocardial infarction of anterolateral wall, initial episode of care,Pyogenic arthritis, shoulder region,Acute osteomyelitis, other specified sites,Ulcer of heel and midfoot,Rhabdomyolysis,Hyperosmolality and/or hypernatremia,Acute posthemorrhagic anemia,Paralytic ileus,Malignant neoplasm of pleura, unspecified,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Severe sepsis,Fall from other slipping, tripping, or stumbling,Atherosclerosis of native arteries of the extremities with ulceration,Long-term (current) use of anticoagulants,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Aortocoronary bypass status,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Depressive disorder, not elsewhere classified,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Other and unspecified general anesthetics causing adverse effects in therapeutic use,Osteoarthrosis, localized, not specified whether primary or secondary, shoulder region,Retention of urine, unspecified,Asbestosis
Meth susc Staph aur sept,Intraspinal abscess,Ac on chr syst hrt fail,Food/vomit pneumonitis,Ventricular fibrillation,Chr stomach ulc w hem,Acute kidney failure NOS,AMI anterolateral, init,Pyogen arthritis-shlder,Ac osteomyelitis NEC,Ulcer of heel & midfoot,Rhabdomyolysis,Hyperosmolality,Ac posthemorrhag anemia,Paralytic ileus,Malig neopl pleura NOS,Mth sus Stph aur els/NOS,Severe sepsis,Fall from slipping NEC,Ath ext ntv art ulcrtion,Long-term use anticoagul,DMII wo cmp nt st uncntr,Aortocoronary bypass,Hypertension NOS,Hyperlipidemia NEC/NOS,Depressive disorder NEC,Abnrml coagultion prfile,Adv eff anticoagulants,Adv eff gen anes NEC/NOS,Loc osteoarth NOS-shlder,Retention urine NOS,Asbestosis
Admission Date:  [**2174-11-6**]              Discharge Date:   [**2174-12-9**]

Date of Birth:  [**2096-8-27**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Morphine / Codeine / Cefazolin

Attending:[**First Name3 (LF) 759**]
Chief Complaint:
falls, bacteremia

Major Surgical or Invasive Procedure:
Esophagastroduodenoscopy
Cardioversion
Intubation
IR guided drainage of abcess
PICC placement


History of Present Illness:
This is a 78 year old male with type II diabetes, severe
peripheral [**First Name3 (LF) 1106**] disease, coronary artery disease s/p CABG
and atrial fibrillation on coumadin who presents to the
emergency room after two falls at home. The first fall occurred
on [**2174-11-3**] at home when he fell in his kitchen. He hit is right
shoulder and presented to the emergency room where he had a
right clavicle xray which showed no fracture of dislocation and
was discharged home with pain medications. The patient has very
limited mobility at baseline and uses a wheelchair. He requires
the use of his arms to help get out of bed and into his
wheelchair and also for balance. He has had significant pain his
his right arm since his fall and this has made getting around
his house increasingly difficult. On [**2174-11-4**] he was trying to
take a shower and had a plastic bag on his right foot to protect
his foot ulcers. He tried to get out of the shower and he
slipped on the plastic bag and fell on his right hip. Because
his arm was hurt as well he was unable to get himself back to a
seated position and lay on the ground for an hour before a
friend found him and called 911. EMS came to his home but he did
not want to come back to the hospital so they placed him in his
bed. He reports that they placed him facing in the wrong
position and he was unable to get out of bed or reach his pills
so he has not been taking his pills now for 48 hours. He was so
disabled that he ultimately called EMS again so that he could be
brought to the emergency room.
.
In the ED, initial vs were: T: 99 P: 108 BP: 131/81 R: 16 O2 sat
99% on RA. He had a CXR which showed mild [**Date Range 1106**] prominence
but no focal infiltrates. He had an xray of his right hip which
was negative for fracture and a non-contrast head CT which
showed no evidence of hemorrhage. Patient was given one liter of
normal saline, zofran 4 mg IV x 1 and vancomycin 1000 mg IV x 1
out of concern for possible right shoulder cellulitis. He is
admitted to the floor for further management.
.
On the floor he continues to have significant right shoulder
pain. He has mild right hip pain but is able to move his right
leg. He denies fevers, chills, lightheadedness, dizziness, chest
pain or shortness of breath. He did have nausea earlier in the
day but this has resolved. He denies abdominal pain,
constipation, diarrhea, melena, hematochezia, dysuria or
hematuria. He has minimal sensation in his feet bilaterally but
denies foot pain. All other review of systems is negative in
detail.


Past Medical History:
1. CAD (s/p CABG, [**1-14**])
2. CHF (EF 17% on pMIBI from [**3-17**])
3. DM (diet controlled, HgA1c 6.2 on no agents)
4. PVD
s/p R AK popliteal to post tibial artery bypass in [**3-14**],
percutaneous intervention [**3-16**]
s/p PTSG L [**7-14**]
s/p plasty & stent of R SFA, plasty of PT [**2173-2-16**]
5. Afib/flutter on chronic anticoagulation
6. htxn
7. hyperlipidemia

Social History:
He lives by himself and does all of his own activities of daily
living. He quit smoking in [**5-/2174**] but has a heavy smoking
history. He uses a walker and a wheelchair to assist with
ambulation. He does not currently drink alcohol or use illicit
drugs.


Family History:
He has one brother with diabetes and one sister with stomach
cancer. His mother had diabetes. His father died at age 79 of
unclear reasons. He has four daughters and one son who are
healthy.

Physical Exam:
On admission:
Vitals: T: 100.0 BP: 154/96 P: 103 R: 20 O2: 99% on RA FS: 99
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Scarce inspiratory crackles at the bases, no wheezes, or
ronchi
CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops, well healed CABG scar
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: Warm, severe peripheral [**Year (4 digits) 1106**] disease, multiple toe
amputations, small ulcer near nailbed on right second toe with
dried blood, 2 x 2 cm healing ulcer on medial plantar right
foot, dopplerable distal pulses bilaterally, decreased sensation
in lower extremities throughout. Right shoulder with mild
erythema and pain over palpation of the right clavical. Although
he has 5/5 strength in the right upper extremity he is severely
limited by pain, particularly with arm flexion. The right hip
has pain over palpation near the right trochanteric bursa. There
is no gross bruising. No significant pain with flexion or
extension of the right leg.
.
On discharge: VSS, lungs clear, RRR, full movement in legs to
anti-gravity.  SC pain, errythema resolved.  Foley in place.
Exam otherwise unchanged


Pertinent Results:
LABS
On Admission
.
[**2174-11-5**] 10:43PM BLOOD WBC-12.8* RBC-4.79 Hgb-12.9* Hct-38.4*
MCV-80*# MCH-27.0 MCHC-33.7 RDW-15.8* Plt Ct-219
[**2174-11-5**] 10:43PM BLOOD Neuts-90.2* Lymphs-5.9* Monos-3.7 Eos-0
Baso-0.1
[**2174-11-5**] 10:43PM BLOOD PT-24.0* PTT-33.6 INR(PT)-2.3*
[**2174-11-5**] 10:43PM BLOOD Glucose-84 UreaN-50* Creat-1.4* Na-134
K-4.0 Cl-100 HCO3-21* AnGap-17
[**2174-11-5**] 10:43PM BLOOD ALT-26 AST-56* CK(CPK)-786* AlkPhos-117
TotBili-0.4
[**2174-11-5**] 10:43PM BLOOD cTropnT-0.04*
[**2174-11-6**] 08:10AM BLOOD CK-MB-9 cTropnT-0.04*
[**2174-11-6**] 05:05PM BLOOD CK-MB-9 cTropnT-0.04*
[**2174-11-6**] 08:10AM BLOOD Calcium-8.3* Phos-3.2 Mg-2.1.
On discharge:
.
[**2174-12-5**] 05:27AM BLOOD WBC-6.8 RBC-3.34* Hgb-9.3* Hct-28.0*
MCV-84 MCH-27.8 MCHC-33.2 RDW-17.8* Plt Ct-171
[**2174-12-5**] 05:27AM BLOOD Glucose-91 UreaN-11 Creat-0.8 Na-136
K-3.9 Cl-98 HCO3-35* AnGap-7*
[**2174-12-5**] 05:27AM BLOOD Calcium-7.9* Phos-3.6 Mg-1.9
.
Other relevant labs:
.
[**2174-11-13**] 05:16AM Hct-22.1
.
[**2174-11-29**] 04:34AM BLOOD ESR-44*
[**2174-11-14**] 05:26AM BLOOD ESR-30*
[**2174-11-10**] 05:59AM BLOOD ESR-72*
[**2174-11-10**] 05:59AM BLOOD calTIBC-190 Ferritn-252 TRF-146*
[**2174-11-29**] 04:34AM BLOOD CRP-9.3*
[**2174-11-14**] 05:26AM BLOOD CRP-67.3*
[**2174-11-10**] 05:59AM BLOOD CRP-215.1*
.
MICROBIOLOGY
.
[**11-6**]
STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   0.5 S
OXACILLIN-------------   0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
.
[**11-6**]
WOUND CULTURE (Final [**2174-11-9**]):
      STAPH AUREUS COAG +.    MODERATE GROWTH OF TWO COLONIAL
MORPHOLOGIES.
         Staphylococcus species may develop resistance during
prolonged
         therapy with quinolones.   Therefore, isolates that are
initially
         susceptible may become resistant within three to four
days after
         initiation of therapy.  Testing of repeat isolates may
be
         warranted.
      CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).    MODERATE
GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------  0.25 S
OXACILLIN-------------   0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
.
[**11-7**] JOINT FLUID
STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------  0.25 S
OXACILLIN-------------     1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
.
[**10-14**]
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2174-11-16**]):
      EQUIVOCAL BY EIA.
.
IMAGING
[**11-5**]
HIP XR
IMPRESSION: No fracture or dislocation with degenerative changes
at the hips bilaterally and extensive atherosclerotic disease
with right femoral stents.
.
CXR
Progression of mild pulmonary edema and redemonstration of large

cardiomegaly.
.
[**11-6**]
CT HEAD
1. No acute intracranial hemorrhage or acute fracture
2. Mild paranasal sinus disease.
.
CT UPPER EXT
1. Low attenuation collection about the right sternoclavicular
joint, which is superiorly and anteriorly subluxed with
surrounding soft tissue and muscular edema. Amorphous
calcifications in both sternoclavicular joints. While infection
must be excluded, these findings may be secondary to trauma in
the setting of pre-existing CPPD arthropathy.
2. Circumferential thickening of the right pleura in the setting
of prior
asbestos exposure. If there is no recent outside chest CT, this
should be
further evaluated with a dedicated chest CT.
.
FOOT XRAY
1) New shallow concavity at the base of the fifth metatarsal.
However, no
aggressive features identified. Please see comment.
.
[**11-8**]
ECHO
Mild spontaneous echo contrast is seen in the body of the left
atrium. No thrombus is seen in the left atrial appendage. There
is mild regional left ventricular systolic dysfunction with
inferior and inferolateral hypokinesis (EF 40-45%). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are moderately thickened with focal calcification
of the right coronary cusp. No masses or vegetations are seen on
the aortic valve. The mitral valve leaflets are structurally
normal. No mass or vegetation is seen on the mitral valve.
Trivial mitral regurgitation is seen. No masses or vegetations
are seen on the pulmonic valve, but cannot be fully excluded due
to suboptimal image quality. There is no pericardial effusion.
IMPRESSION: No definitive evidence of valvular vegetation. Focal
thickening of the right aortic cusp that appears unchanged from
prior study [**2174-3-14**].
.
[**11-9**]
CXR
As compared to the previous examination from [**2174-11-5**], a

PICC line has been inserted over the right upper extremity. The
tip of the
line projects over the right atrium, the line should be
retracted by 3 to 4 cm. There is no evidence of pneumothorax or
other complication. Otherwise, the radiographic appearance is
unchanged.
.
[**11-10**]
MRI SPINE
Though the evaluation for spine infection is quite limited in
the
absence of gadolinium and further, by the significant motion
degradation of image quality,
1. Findings are quite concerning for a septic right L4-5 facet
joint with
right paraspinal abscess and possible developing discitis. It is
possible
that there is a small epidural fluid collection at L4-5, as
detailed above, though this is not conclusive.
2. Severe multilevel spinal canal narrowing and cauda equina
compression.
3. Moderately severe multilevel bilateral foraminal narrowing.
.
XR PELVIS
1. Moderate to severe lumbar spine and SI joint degenerative
changes.
2. Diffuse calcified atherosclerotic disease with left femoral
[**Month/Year (2) 1106**]
stents; otherwise no radiopaque foreign bodies.
.
L-SPINE
1. Moderate to severe lumbar spine and SI joint degenerative
changes.
2. Diffuse calcified atherosclerotic disease with left femoral
[**Month/Year (2) 1106**]
stents; otherwise no radiopaque foreign bodies.
.
[**11-11**]
KUB
Small bowel loops and large bowel loops are distended. The small
bowel loops measure up to 5.5 cm. This is consistent with ileus.
Moderate-to-severe degenerative changes are in the lumbar spine.

.
[**11-17**]
CXR
Cardiomegaly persists. Low lung
volumes limit assessment. Left basilar and retrocardiac
opacification is
consistent with atelectasis although a pneumonitis from
aspiration or
infection can certainly be superimposed. Peribrochial cuffing,
cephalization, and a small left pleural effusion suggest
continue volume overload/congestion. No pneumothorax. Bilateral
calcified pleural plaques. Median sternotomy wires are again
seen.
.
[**11-18**]
VIDEO SWALLOW
Normal video oropharyngeal swallow exam without evidence of
penetration or aspiration.
.
MRI SPINE
There is continued suspicion for question of septic arthritis of

the right facet joint at L4-5 level with a small epidural and
paraspinal fluid collection. Examination is limited by motion.
Gadolinium-enhanced repeat study possibly under anesthesia is
recommended to get better evaluation of the abnormality.
Multilevel degenerative changes are again noted. Findings were
discussed with Dr. [**First Name (STitle) **] [**Name (STitle) **] at the time of interpretation of
this study on [**2174-11-19**] at 12:30 p.m.
.
[**11-21**]
ECHO
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is top
normal/borderline dilated. There is mild to moderate regional
left ventricular systolic dysfunction with severe hypokinesis of
the basal half of the inferior and anterolateral walls. The
remaining segments are mildly hypokinetic. Overal LVEF is
moderately reduced (LVEF 35-40 %). No masses or thrombi are seen
in the left ventricle (but apical images are suboptimal image
quality). Right ventricular chamber size and free wall motion
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 mildly thickened. Mild (1+)
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is an anterior space
which most likely represents a fat pad.
Compared with the prior study (images reviewed) of [**2174-3-14**], the
regional left ventricular systolic dysfuntion is more extensive
c/w interim ischemia.
.
MRI L-SPINE
1. Suspicious finding on the recent non-enhanced examinations is
demonstrated
to represent a 2.5 cm (CC) relatively thick rim-enhancing fluid
collection,
centered at the L5 level, dorsal to and significantly
compressing the thecal
sac. In this clinical context, this very likely represents an
epidural
abscess. There may be a right ventral epidural component, as
well.
2. At least two small rim-enhancing fluid collections the right
paraspinal
muscles, likely representing small focal abscesses, which may
relate to septic
arthritis of the right L4-L5 facet joint; however, this process
is not
definitely demonstrated on the present examination.
3. Pathologic T2-hyperintensity within the L3-4 through L5-S1
discs, without
definitive discal enhancement or endplate destruction; this may
be
degenerative in nature.
4. No other site of organized collection identified within the
lumbar spine.
5. Extensive multilevel, multifactorial degenerative changes
with severe
spinal canal stenosis at the L2-3 through L4-5 levels.
.
PORT LINE PLACEMENT
As compared to the previous radiograph, the patient has been
intubated. The tip of the tube projects 5 cm above the carina.
New central
venous access line over the left subclavian vein. The tip of the
line
projects over the superior SVC. Unchanged sternal wires,
unchanged moderate cardiomegaly with mild overhydration. No
evidence of pneumothorax.
.
CXR
.
In comparison with the study of earlier in this date, there has
been placement of a nasogastric tube, that extends well into the
stomach.
Poor definition of the hemidiaphragms raises the possibility of
developing
pleural effusion and basilar atelectasis bilaterally.
.
[**11-22**]
CXR
In comparison with the study of [**11-21**], the monitoring and support

devices remain in place. Enlargement of the cardiac silhouette
persists with
evidence of [**Date Range 1106**] congestion. Poor definition of the
hemidiaphragms is
consistent with bibasilar atelectasis and effusion.
.
[**11-23**]
 In comparison with the study of [**11-22**], the monitoring and
support
devices remain in place. Substantial enlargement of the cardiac
silhouette
persists with some evidence of [**Date Range 1106**] congestion. The
hemidiaphragms are
somewhat more sharply seen on this study. Persistent low lung
volumes.
.
CT HEAD
1. No evidence of acute hemorrhage or acute [**Date Range 1106**] territorial
infarction.
.
[**11-24**]
CXR
As compared to the previous radiograph, the patient has been
extubated and the nasogastric tube has been removed. The lung
volumes have
minimally decreased. There is unchanged moderate cardiomegaly,
the
radiographic signs suggesting overhydration have slightly
increased. Also, a potentially pre-existing right pleural
effusion is better visible than on the previous image.
Otherwise, no relevant change.
.
[**11-27**]
The cardiomegaly is moderate, unchanged. The sternotomy wires
are unchanged.  The patient is in mild pulmonary edema, that is
also unchanged since the prior study, accompanied by bilateral
pleural effusions, moderate. There are no new focal
consolidations, but bilateral basal retrocardiac atelectasis is
unchanged. There is no evidence of pneumothorax.
.
KUB
There is a significantly dilated air filled stomach. There are
multiple air filled and dilated small bowel loops (luminal
diameter up to 3.5 cm) and large bowel loops (luminal diameter
up to 6.5 cm). There is no evidence of air fluid levels or free
air.
.
[**11-28**]
CXR
In comparison with the study of [**11-27**], there has been a
substantial
increase in bilateral pulmonary opacifications in this patient
with
enlargement of the cardiac silhouette and evidence of midline
sternal wires.
The radiographic findings could reflect severe pulmonary edema,
widespread
pneumonia, or even ARDS.
.
[**11-29**] ABD
Ileus has resolved. There is no bowel obstruction.
.
CXR
Marked improvement of previously existing pulmonary edema. No
pneumothorax.
.
[**11-30**]
CT SPINE
Severe multilevel disc degenerative changes throughout the
lumbar
spine as described in detail above. The previously identified
epidural
collection at L5 level is not visualized in this examination,
correlation with MRI is recommended, since CT is not able to
provide the same anatomical detail in the thecal sac.
PATHOLOGY
[**11-17**]
GASTRIC BIOPSY:
Antral and fundic mucosa, no diagnostic abnormalities
recognized.
No bacillary forms consistent with H. pylori identified on
[**Doctor Last Name 6311**] stain.
.
EEG
[**11-22**]
This telemetry captured no pushbutton activations. Routine
sampling showed a mild to moderately slow and disorganized
background
consisting of mixed theta frequencies. Occasionally, this
occurred in a
burst suppression type pattern. This is suggestive of a moderate
to
severe encephalopathy which may be secondary to medications. No
focal
or lateralized abnormalities were noted and no epileptiform
features
were seen.
.
[**11-23**]
This telemetry captured no pushbutton activations. Routine
sampling showed a mild to moderately slow and disorganized
background
with occasional periods of burst suppression. This is consistent
with a
moderate to severe encephalopathy and may have been related to
medications. No focal abnormalities were noted and no
epileptiform
features were seen.


Brief Hospital Course:
Mr [**Known lastname 29275**] is a 78 yo gentleman who initally presented for a
fall, however was found to be bacteremic with a seeded SC joint
infection.  His hospital course was initially complicated by an
UGI bleed leading to ICU admission, then later complicated by
vfib arrest in MRI scanner while undergoing imaging for back
pain concerning for epidural abcess, leading to CCU admission.
He underwent cooling protocol and was discharged from the CCU in
stable condition.  He was found to have an epidural abcess,
however given his high surgical risk, we proceeded with medical
management.  He continued to improve on the floor with no
further complications.
.
#) Bacteremia: Pt presented with fever and elevated WBC and was
found to have MSSA in his blood.  He was started on cefazolin
(pt with PCN allergy) per ID recs.  His cultures cleared after
the first positive set and his SC joint infection improved
clinically.  The source of his bacteremia was unclear, however
the most likely source was his lower extremity ulcers vs
possible indolent [**Known lastname **] infection from prior [**Known lastname 1106**] surgery.
He was seen by podiatry and [**Known lastname 1106**] who were not concerned for
osteomyelitis or active infection of the foot.  There were no
valvular vegetations on TEE, therefore little concern for
endocarditis.  He did have evidence of infection of his
sternoclavicular joint and an aspiration was positive for MSSA,
and this was thought to be resulting from his bacteremia rather
than a primary infection in the context of a fall.  CT
[**Doctor First Name **]/ortho were consulted but felt that he was not a good
surgical candidate for debridment of the joint given his hx of
CABG.  He will complete an 8 week course of Cefazolin 2g IV q8
(day1=[**2174-11-8**]) and should follow-up with ID on discharage and
should also obtain weekly safety labs (CBC/diff, BUN, Cr, LFTs,
ESR, CRP) while on antibiotics (next set of labs due [**12-10**]).
.
# s/p cardiac arrest: During MRI scan for assessment of back
pain patient went into cardiac arrest.  Unclear whether he was
in ventricular tachycardia/fibrillation vs. PEA.  He was
intubated and coded for 40 minutes, intermittently regaining
pulses during the code.  NSR was finally achieved after
amiodarone and defibrillation.  However, the patient remained
hypotensive and was started on pressors, sedation, and Arctic
Sun cooling protocol in the CCU.  EEG and head CT were
unremarkable.  TTE was initially concerning for new wall motion
abnormalities suggesting an ischemic etiology, but EKG showed no
evidence of ACS and CE remained flat.  It is therefore thought
that the patient may have had PEA [**2-14**] anesthesia for MRI scan.
After completion of the cooling protocol, the patient was
successfully weaned off the ventilator and extubated without
difficulty.  He regained consciousness and appered to be back to
his neurologic baseline.  He stayed in NSR with only a few
episodes of afib with aberrancy while on tele on the floor.  The
patient will need to follow up with EP on discharge for further
assessment and evaluation.
.
#) Epidural Abcess: Pt reported back pain with point tenderness
and neurosurgery was consulted out of concern for epidural
abcess.  MRI was performed and was concerning for epidural
abscess as well as R paraspinal muscle abcesses by MRI, however
the study was inadequate.  Pt underwent MRI under anesthesia in
attempt to obtain a better study, however arrested in MRI
scanner.  Given these circumstances, it was decided that further
intervention, including imaging or surgery requiring anesthesia,
would be deferred.  IR guided drainage of the fluid collection
was attempted but minimal fluid was obtained and no organisms
were isolated in the aspirate.  He was treated with IV abx and
monitored for neurological change.  Given his baseline disabiliy
and ongoing issues with incontinence, we monitored for decrease
in lower extremity strength (anti-gravity at baseline) and
saddle parasthesia, and pt remained clinically stable.  His pain
also improved and on discharge was controlled with tylenol.
Neurosurgery plans for f/u with MRI lumbar spine after
completion of abx course, for which pt will be hospitalized
given his inability to tolerate MRI without sedation and high
risk for complications with anesthesia.  Would also recommend
monitoring neurologic status while at rehab, contacting
neurosurgery urgently if change in neuro exam.
.
# chronic atrial fibrillation: His coumadin was initially held
on admission due to supratherapeutic INR and then [**2-14**] GI bleed.
After defibrillation, the patient was noted to be in normal
sinus rhythm.  He remained in sinus rhythm throughout his time
in the intensive care unit and medical floor.  It was felt that
although anticoagulation is often still used up to four weeks
s/p conversion to NSR from AF, in the setting of his recent GI
bleed, anticoagulation should be held.  He will be discharged on
aspirin, consider restarting coumadin after colonoscopy.
.
#) Coffee-ground emesis: The patient had increasing emesis
throughout his admission, first occurring subsequent to meals.
On [**11-12**] he had 4-5 episodes of vomiting and then developed
coffee ground emesis requiring MICU transfer.  He remained
hemodynamically stable, but required 7 units of blood over a 24
hour period to maintain a Hct>25.  EGD showed a single, clean
base, 2.5cm x3cm non-bleeding ulcer with blood clot in the
antrum. The clot was flushed away, epi injected at ulcer edge,
cauterized area covered with blood.  His hematocrit subsequently
stabilized and he had no further coffee ground emesis at the
time of his transfer back to the floor, however his Hct was seen
to slowly drift downwards and he received another unit of blood
before discharge to the floor.  He was treated for h pylori
infection with flagyl, clarithromycin and IV PPI given equivicol
H pylori ab screening test.  Plan was for colonoscopy as well
but this was deferred [**2-14**] cardiac arrest. In the cardiac ICU,
Clarithromycin was switched to tetracycline as it was felt that
the medication was prolonging the patient's QTc.  He had no
further episodes of hematemasis while on the floor and crit
remained stable.  EGD and colonoscopy were deferred in the
hospital given his instability, however he is scheduled for
EG/colonoscopy on discharge and will also be discharged on a
PPI.
.
#) Hypertension: Pt had periods of normal BP but tended to have
higher BPs in the AM.  His Metoprolol and lisinopril were
titrated to BP control prior to discharge, pressures in
120s-130s on discharge however may need further titration as an
outpatient for optimal control.  He was also re-started on lasix
prior to discharge given his hx of volume overload as an
inpatient, however at a decreased dose given that he had poor PO
intake and increased bicarb while in the hospital.
.
#) Acute Renal Failure: Elevated creatinine on admission.
Pre-renal and thought to be due to dehydration in the context of
poor mobility/poor access to fluids.  He was re-hydrated and his
kidney function improved and remained normal throughout the
admission.  Lasix and lisinopril were initially held, but
restarted due to hypertension and volume overload.
.
#) Ileus: pt with abd distension and decreased BMs on return
from the cardiac intensive care unit.  KUB showed no acute
obstruction.   Pt improved with uptitration of his bowel
regimen, which will be continued on discharge.
.
#) s/p falls: The patient had two mechanical falls in the
setting of living alone and having little sensation and poor
mobility in his lower extremities. His sore right shoulder
likely also contributed to his second fall, also may have been
disoriented [**2-14**] bacteremia.  There was evidence of chronic
degenerative changes but no acute process.  He was seen by PT/OT
as an inpatient.  He will be discharged to outpatient rehab and
will require PT/OT/social work f/u.
.
#) Type 2 diabetes: Diet controlled, last HbA1c was 5.7%. Has
had minimal insulin requirements as an inpatient, however QID
blood glucose was initially continued due to poor nutrition and
hypoglycemia.  Fingersticks were dc'd 2 days prior to discharge
as sugars normalized with increasing PO intake.
.
#) Peripheral [**Month/Day (2) **] Disease: s/p multiple surgeries,
currently with ulcer on medial plantar right foot followed by
podiatry and [**Month/Day (2) 1106**]. Foot xray not concerning for aggresive
osteo at this time.  He was treated with wound care per podiatry
recs and continued on aspirin for his PVD.
.
#) Chronic Systolic Heart Failure: Pt had some evidence of
volume overload on CXR and by exam throughout the admission.  He
was treated with IV/PO lasix and metoprolol.  PO lasix dose
decreased on discharge given pts poor PO intake and increased
bicarb, however may need to be up-titrated as an outpatient.
Additionally, when adequate dose for BP/HR control is achieved,
would consider switching to Toprol XL for cardioprotection in
the context of sCHF.
.
#) Nutrition: Pt with poor PO intake therefore NG tube was
placed when the patient returned from the cardiac intensive care
unit.  Placement required IR guidance given his hx of prior nose
surgeries.  He pulled the tube before reaching goal tube feeds
and it was not replaced given that his PO intake was increasing.
 He was cleared for ground solids and small pills with
applesauce by speech and swallow, who also stated that he could
be advanced to solid diet as tolerated.
.
#) Urinary retention: Pt failed last voiding trial prior to
discharge, therefore foley was re-placed and pt discharged to
rehab with foley in place.  He was continued on tamsulosin on
DC.  Would recommend voiding trial in rehab.
.
#) ? Mesothelioma: Pleural thickening (in the setting of prior
asbestos exposure) noted on [**2174-11-6**] Chest CT, concerning for
mesothelioma. Bilateral calcified pleural plaques consistent
with possible asbestosis on CXR [**2174-11-17**].  Pt is scheduled to f/u
with thoracic surgery on discharge.
.
#) Hyperlipidemia: His home statin was continued
.
#) Anemia: Initially concerning for iron deficiency therfore was
started on ferrous gluconate.  Worsened with GI bleed but
improved after transfusions and stabilized.  Iron
supplementation was held on discharge given his history of
consitipation.
.
#) Depression:  Home celexa was continued.

Medications on Admission:
Brimonidine 0.15 % 1 drop in right eye Q8H
Citalopram 20 mg daily
Ergocalciferol 50,000 units weekly
Famotidine 20 mg daily
Furosemide 40 mg 1-2 tablets daily
Lisinopril 5 mg daily
Metoprolol Tartrate 25 mg [**Hospital1 **]
Nitroglycerin 0.4 mg SL PRN
Oxycodone-Acetaminophen 5 mg-325 mg 1-2 tabs PRN
Simvastatin 20 mg daily
Warfarin 7.5 mg daily
Aspirin 81 mg daily
Bisacodyl 5 mg 1-2 tablets [**Hospital1 **]:PRN
Cyanocobalamin 1,000 mcg daily
Colace TID:PRN


Discharge Medications:
1. Brimonidine 0.15 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic Q8H
(every 8 hours).
2. Citalopram 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).

3. Ergocalciferol (Vitamin D2) 50,000 unit Capsule [**Hospital1 **]: One (1)
Capsule PO once a week.
4. Furosemide 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).

5. Lisinopril 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).

6. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: Three (3) Tablet PO TID
(3 times a day).
7. Nitroglycerin 0.4 mg Tablet, Sublingual [**Hospital1 **]: One (1)
Sublingual once as needed for chest pain.
8. Simvastatin 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO QHS (once a
day (at bedtime)).
9. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
10. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Hospital1 **]: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
11. Bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
12. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. Ondansetron HCl (PF) 4 mg/2 mL Solution [**Hospital1 **]: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
14. Cyanocobalamin 1,000 mcg Tablet [**Hospital1 **]: One (1) Tablet PO once
a day.
15. Simethicone 80 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet,
Chewable PO four times a day as needed for gas.
16. Cefazolin 10 gram Recon Soln [**Hospital1 **]: One (1) Recon Soln
Injection Q8H (every 8 hours): Please continue for 8 week course
(day 1=[**2174-11-8**]).
17. Docusate Sodium 100 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO BID (2
times a day) as needed for constipation.
18. Outpatient Lab Work
Please obtain weekly CBC/diff, BUN, Cr, LFTs, ESR, CRP, please
send to infectious disease clinic, attn: [**Doctor First Name 1423**] [**Doctor Last Name **]
([**Telephone/Fax (1) 1419**]).  First set should be drawn on [**12-10**].
19. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
20. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain: Not to exceed 4 g/day.


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
Primary:
- Bacteremia
- Sternal/spinal MSSA osteomyelitis
- Antral ulcer with bleeding
- Acute blood loss anemia
- Acute renal failure
- Cardiac arrest

Secondary:
- Right pleural thickening NOS
- CAD s/p CABG (LIMA-LAD, SVG-PDA, and SVG-OM)
- Chronic systolic heart failure (40%)
- Atrial fibrillation
- Small secundum ASD/PFO
- Left retinal artery occlusion
- Peripheral [**Hospital1 1106**] disease
- s/p bilateral hallux amputations
- Chronic right foot ulceration
- Hypertension
- Anemia of chronic disease
- Diabetes mellitus type II


Discharge Condition:
stable but frail


Discharge Instructions:
You were admitted for falls and you were found to have bacteria
in your blood, therefore you were treated with intravenous
antibiotics.  While in the hospital, you developed an upper
gastrointestinal bleed and were seen by gastroenterology who
examined your stomach with a camera and found ulcers.  These
were cauterized and injected to prevent any further bleeding.
Additionally, while in the hospital, you had back pain and were
found to have an abcess in your spine.  While getting imaging of
this abcess, your heart went into an abnormal rhythm and you
were transferred to the cardiac intensive care unit.  In the
intensive care unit, you were stabilized and eventually returned
to the medicine floor, where we decided to delay further imaging
or surgery of your spine given the high risk of intervention.
Therefore, we continued to manage your condition with IV
antibiotics.  You remained stable however had decreased oral
intake and urinary retention, therefore you were seen by
nutrition and had a foley catheter placed.
.
Please take your medications as prescribed and follow-up with
your physicians as outlined below.  The following changes have
been made to your medications:
-you will need to take IV cefazolin (day 1=[**2174-11-8**] for a total
of 6 weeks
-please take pantoprazole 40 mg by mouth every day
.
Please return to the hospital if you have fevers, chills,
shortness of breath, chest pain, increasing weakness in your
legs, or any other symptoms that are concerning to you.


Followup Instructions:
Please follow up with infectious disease regarding your
bacteremia:
.
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] BLOOD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2174-12-12**]
11:00
.
You will need safety labs including CBC/diff, BUN, Cr, LFTs,
ESR, CRP on [**12-10**], and every week thereafter while on abx.
.
Please follow up with gastroenterology in regards to your GI
bleed:
.
Dr. [**First Name8 (NamePattern2) 1586**] [**Name (STitle) 2161**]
Specialty: Gastroenterology
Date and time: Wednesday, [**12-28**] at 11:00am
Location: [**Location (un) **], [**Hospital Ward Name 1950**] Bldg [**Location (un) **], [**Location (un) 86**], MA
Phone number: [**Telephone/Fax (1) 463**]
.
Please follow up with cardiology in regards to your cardiac
arrest:
.
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Date and time: Friday, [**12-30**] at 10:20am
Location: [**Location (un) **], [**Hospital Ward Name 23**] Bldg [**Location (un) **], [**Location (un) 86**], MA
Phone number: [**Telephone/Fax (1) 62**]
.
Also, please follow up with thoracic surgery in regards to the
pleural thickening that was found on your CT:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**0-0-**]
Date/Time:[**2174-12-22**] 10:00
.
Please keep the following previously scheduled appointment:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2174-12-28**] 8:40
.
You will also need to be readmitted to the hospital in 6 weeks
for follow-up imaging of your spine given your epidural abces.
{'Methicillin susceptible Staphylococcus aureus septicemia,Intraspinal abscess,Acute on chronic systolic heart failure,Pneumonitis due to inhalation of food or vomitus,Ventricular fibrillation,Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction,Acute kidney failure, unspecified,Acute myocardial infarction of anterolateral wall, initial episode of care,Pyogenic arthritis, shoulder region,Acute osteomyelitis, other specified sites,Ulcer of heel and midfoot,Rhabdomyolysis,Hyperosmolality and/or hypernatremia,Acute posthemorrhagic anemia,Paralytic ileus,Malignant neoplasm of pleura, unspecified,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Severe sepsis,Fall from other slipping, tripping, or stumbling,Atherosclerosis of native arteries of the extremities with ulceration,Long-term (current) use of anticoagulants,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Aortocoronary bypass status,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Depressive disorder, not elsewhere classified,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Other and unspecified general anesthetics causing adverse effects in therapeutic use,Osteoarthrosis, localized, not specified whether primary or secondary, shoulder region,Retention of urine, unspecified,Asbestosis'}


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: falls, bacteremia

PRESENT ILLNESS: This is a 78 year old male with type II diabetes, severe
peripheral [**First Name3 (LF) 1106**] disease, coronary artery disease s/p CABG
and atrial fibrillation on coumadin who presents to the
emergency room after two falls at home. The first fall occurred
on [**2174-11-3**] at home when he fell in his kitchen. He hit is right
shoulder and presented to the emergency room where he had a
right clavicle xray which showed no fracture of dislocation and
was discharged home with pain medications. The patient has very
limited mobility at baseline and uses a wheelchair. He requires
the use of his arms to help get out of bed and into his
wheelchair and also for balance. He has had significant pain his
his right arm since his fall and this has made getting around
his house increasingly difficult. On [**2174-11-4**] he was trying to
take a shower and had a plastic bag on his right foot to protect
his foot ulcers. He tried to get out of the shower and he
slipped on the plastic bag and fell on his right hip. Because
his arm was hurt as well he was unable to get himself back to a
seated position and lay on the ground for an hour before a
friend found him and called 911. EMS came to his home but he did
not want to come back to the hospital so they placed him in his
bed. He reports that they placed him facing in the wrong
position and he was unable to get out of bed or reach his pills
so he has not been taking his pills now for 48 hours. He was so
disabled that he ultimately called EMS again so that he could be
brought to the emergency room.
.
In the ED, initial vs were: T: 99 P: 108 BP: 131/81 R: 16 O2 sat
99% on RA. He had a CXR which showed mild [**Date Range 1106**] prominence
but no focal infiltrates. He had an xray of his right hip which
was negative for fracture and a non-contrast head CT which
showed no evidence of hemorrhage. Patient was given one liter of
normal saline, zofran 4 mg IV x 1 and vancomycin 1000 mg IV x 1
out of concern for possible right shoulder cellulitis. He is
admitted to the floor for further management.
.
On the floor he continues to have significant right shoulder
pain. He has mild right hip pain but is able to move his right
leg. He denies fevers, chills, lightheadedness, dizziness, chest
pain or shortness of breath. He did have nausea earlier in the
day but this has resolved. He denies abdominal pain,
constipation, diarrhea, melena, hematochezia, dysuria or
hematuria. He has minimal sensation in his feet bilaterally but
denies foot pain. All other review of systems is negative in
detail.

MEDICAL HISTORY: 1. CAD (s/p CABG, [**1-14**])
2. CHF (EF 17% on pMIBI from [**3-17**])
3. DM (diet controlled, HgA1c 6.2 on no agents)
4. PVD
s/p R AK popliteal to post tibial artery bypass in [**3-14**],
percutaneous intervention [**3-16**]
s/p PTSG L [**7-14**]
s/p plasty & stent of R SFA, plasty of PT [**2173-2-16**]
5. Afib/flutter on chronic anticoagulation
6. htxn
7. hyperlipidemia

MEDICATION ON ADMISSION: Brimonidine 0.15 % 1 drop in right eye Q8H
Citalopram 20 mg daily
Ergocalciferol 50,000 units weekly
Famotidine 20 mg daily
Furosemide 40 mg 1-2 tablets daily
Lisinopril 5 mg daily
Metoprolol Tartrate 25 mg [**Hospital1 **]
Nitroglycerin 0.4 mg SL PRN
Oxycodone-Acetaminophen 5 mg-325 mg 1-2 tabs PRN
Simvastatin 20 mg daily
Warfarin 7.5 mg daily
Aspirin 81 mg daily
Bisacodyl 5 mg 1-2 tablets [**Hospital1 **]:PRN
Cyanocobalamin 1,000 mcg daily
Colace TID:PRN

ALLERGIES: Penicillins / Morphine / Codeine / Cefazolin

PHYSICAL EXAM: On admission:
Vitals: T: 100.0 BP: 154/96 P: 103 R: 20 O2: 99% on RA FS: 99
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Scarce inspiratory crackles at the bases, no wheezes, or
ronchi
CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops, well healed CABG scar
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: Warm, severe peripheral [**Year (4 digits) 1106**] disease, multiple toe
amputations, small ulcer near nailbed on right second toe with
dried blood, 2 x 2 cm healing ulcer on medial plantar right
foot, dopplerable distal pulses bilaterally, decreased sensation
in lower extremities throughout. Right shoulder with mild
erythema and pain over palpation of the right clavical. Although
he has 5/5 strength in the right upper extremity he is severely
limited by pain, particularly with arm flexion. The right hip
has pain over palpation near the right trochanteric bursa. There
is no gross bruising. No significant pain with flexion or
extension of the right leg.
.
On discharge: VSS, lungs clear, RRR, full movement in legs to
anti-gravity.  SC pain, errythema resolved.  Foley in place.
Exam otherwise unchanged

FAMILY HISTORY: He has one brother with diabetes and one sister with stomach
cancer. His mother had diabetes. His father died at age 79 of
unclear reasons. He has four daughters and one son who are
healthy.

SOCIAL HISTORY: He lives by himself and does all of his own activities of daily
living. He quit smoking in [**5-/2174**] but has a heavy smoking
history. He uses a walker and a wheelchair to assist with
ambulation. He does not currently drink alcohol or use illicit
drugs. 

### Response:
{'Methicillin susceptible Staphylococcus aureus septicemia,Intraspinal abscess,Acute on chronic systolic heart failure,Pneumonitis due to inhalation of food or vomitus,Ventricular fibrillation,Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction,Acute kidney failure, unspecified,Acute myocardial infarction of anterolateral wall, initial episode of care,Pyogenic arthritis, shoulder region,Acute osteomyelitis, other specified sites,Ulcer of heel and midfoot,Rhabdomyolysis,Hyperosmolality and/or hypernatremia,Acute posthemorrhagic anemia,Paralytic ileus,Malignant neoplasm of pleura, unspecified,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Severe sepsis,Fall from other slipping, tripping, or stumbling,Atherosclerosis of native arteries of the extremities with ulceration,Long-term (current) use of anticoagulants,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Aortocoronary bypass status,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Depressive disorder, not elsewhere classified,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Other and unspecified general anesthetics causing adverse effects in therapeutic use,Osteoarthrosis, localized, not specified whether primary or secondary, shoulder region,Retention of urine, unspecified,Asbestosis'}
