CHIEF COMPLAINT: Leukocytosis, fever, hypotension, and tachycardia.

PRESENT ILLNESS: 71 year old male known to the surgical service, initially
presented after undergoing ERCP [**10-16**] for an ampullary polyp and
subsequently developed necrotizing pancreatitis as well as
cholecystitis, cholangitis, and ARDS.  He underwent perc chole
tube placement, Trach, and J-tube.  He was transfered to the
[**Hospital1 18**] for further care.  Ultimately he recovered, and his perc
chole was changed over to an internal-external drain.  He also
developed SMV and splenic vein thrombosis leading to
anticoagulation.  He was discharged to rehab.  He now presents
from an OSH.  He had a fever at home to 103 and was seen at OSH
where he had a leukocytosis, fever, and was hypotensive and
tachycardiac.  He was transfered here for further management. He
currently has no complaints.  No abdominal pain, no N/V/D.  Says
he has been tolerating a regular diet.  His I/E drain has been
capped since he left the hospital.

MEDICAL HISTORY: PMHx: HTN, Type II DM, nephrolithiasis, ampullary polyp, and
depression.
.
PSHx: Open tracheostomy, J-tube placement, chole tube placement

MEDICATION ON ADMISSION: 11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours)
12. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily)
13. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1)  Inhalation every six (6) hours as needed for shortness
of breath or wheezing
14. Lactobacillus Acidophilus Tablet Sig: One (1) Tablet PO
once a day
15. Labetalol 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day)
16. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On Admission:
VS: Tm 103 (at OSH) Tc 97.5  HR 113 (now 100) BP 87/55 (now
110/40) RR 18 O2sats 97%RA
.
Gen: NAD, AAOx3
HEENT: Anicteric
CV: tachycardiac
Pulm: CTA b/l
Abd: soft, NT, ND. Jtube capped, I/E drain RUQ capped
(semi-purulent material upon aspiration)
Ext: no edema or cyanosis, palp pulses.
.
At Discharge:
AVSS/afebrile.
GEN: Well in NAD.
HEENT: Sclerae anicteric. O-P clear.
NECK: Supple. Anterior tracheostomy site now decannulated with
DSD cover.
LUNGS: CTA(B)
COR: RRR
ABD: PTC drain capped; insertion site patent. Prior J-tube (now
discontinued) clean, slowly healing over with DSD cover. BSX4.
Soft/NT/ND.
EXTREM: No c/c/e
NEURO: Deconditioned, otherwise non-focal.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Married. Former smoker. Occasional social alcohol; no alcohol x
8months.
Cholangitis,Attention to tracheostomy,Hypotension, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Personal history of venous thrombosis and embolism,Hematuria, unspecified,Long-term (current) use of anticoagulants,Depressive disorder, not elsewhere classified,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site
Cholangitis,Atten to tracheostomy,Hypotension NOS,DMII wo cmp nt st uncntr,Hypertension NOS,Hx-ven thrombosis/embols,Hematuria NOS,Long-term use anticoagul,Depressive disorder NEC,MRSA elsewhere/NOS
Admission Date:  [**2138-2-14**]              Discharge Date:   [**2138-2-20**]

Date of Birth:  [**2066-9-11**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Leukocytosis, fever, hypotension, and tachycardia.

Major Surgical or Invasive Procedure:
[**2138-2-17**]: Flexible bronchoscopy for purpose of decannulation and
trache (tracheostomy removal)
.
[**2138-2-18**]: Cholangiogram and replacement of internal-external
biliary drain.
.
[**2138-2-19**]: Removal of jejunostomy tube.


History of Present Illness:
71 year old male known to the surgical service, initially
presented after undergoing ERCP [**10-16**] for an ampullary polyp and
subsequently developed necrotizing pancreatitis as well as
cholecystitis, cholangitis, and ARDS.  He underwent perc chole
tube placement, Trach, and J-tube.  He was transfered to the
[**Hospital1 18**] for further care.  Ultimately he recovered, and his perc
chole was changed over to an internal-external drain.  He also
developed SMV and splenic vein thrombosis leading to
anticoagulation.  He was discharged to rehab.  He now presents
from an OSH.  He had a fever at home to 103 and was seen at OSH
where he had a leukocytosis, fever, and was hypotensive and
tachycardiac.  He was transfered here for further management. He
currently has no complaints.  No abdominal pain, no N/V/D.  Says
he has been tolerating a regular diet.  His I/E drain has been
capped since he left the hospital.

Past Medical History:
PMHx: HTN, Type II DM, nephrolithiasis, ampullary polyp, and
depression.
.
PSHx: Open tracheostomy, J-tube placement, chole tube placement

Social History:
Married. Former smoker. Occasional social alcohol; no alcohol x
8months.


Family History:
Non-contributory

Physical Exam:
On Admission:
VS: Tm 103 (at OSH) Tc 97.5  HR 113 (now 100) BP 87/55 (now
110/40) RR 18 O2sats 97%RA
.
Gen: NAD, AAOx3
HEENT: Anicteric
CV: tachycardiac
Pulm: CTA b/l
Abd: soft, NT, ND. Jtube capped, I/E drain RUQ capped
(semi-purulent material upon aspiration)
Ext: no edema or cyanosis, palp pulses.
.
At Discharge:
AVSS/afebrile.
GEN: Well in NAD.
HEENT: Sclerae anicteric. O-P clear.
NECK: Supple. Anterior tracheostomy site now decannulated with
DSD cover.
LUNGS: CTA(B)
COR: RRR
ABD: PTC drain capped; insertion site patent. Prior J-tube (now
discontinued) clean, slowly healing over with DSD cover. BSX4.
Soft/NT/ND.
EXTREM: No c/c/e
NEURO: Deconditioned, otherwise non-focal.


Pertinent Results:
On Admission:

[**2138-2-14**] 03:23PM   GLUCOSE-120* UREA N-14 CREAT-0.6 SODIUM-139
POTASSIUM-3.7 CHLORIDE-111* TOTAL CO2-22 ANION GAP-10
[**2138-2-14**] 03:23PM   CALCIUM-8.1* PHOSPHATE-2.6* MAGNESIUM-1.8
[**2138-2-14**] 03:23PM   WBC-20.1* RBC-3.08* HGB-9.3* HCT-28.9* MCV-94
MCH-30.2 MCHC-32.2 RDW-16.3*
[**2138-2-14**] 03:23PM   PLT COUNT-344
[**2138-2-14**] 03:23PM   PT-29.1* PTT-40.1* INR(PT)-2.9*
[**2138-2-14**] 08:32AM   LACTATE-1.3
[**2138-2-14**] 07:53AM   GLUCOSE-135* UREA N-17 CREAT-0.7 SODIUM-137
POTASSIUM-3.7 CHLORIDE-108 TOTAL CO2-21* ANION GAP-12
[**2138-2-14**] 07:53AM   ALT(SGPT)-34 AST(SGOT)-35 ALK PHOS-767* TOT
BILI-0.6
[**2138-2-14**] 07:53AM   CALCIUM-7.7* PHOSPHATE-3.1 MAGNESIUM-1.7
[**2138-2-14**] 07:53AM   WBC-28.7* RBC-3.27* HGB-9.8* HCT-30.6* MCV-93
MCH-30.0 MCHC-32.1 RDW-16.0*
[**2138-2-14**] 07:53AM   PLT COUNT-398
[**2138-2-14**] 04:51AM   COMMENTS-GREEN TOP
[**2138-2-14**] 03:14AM   LACTATE-1.8
[**2138-2-14**] 03:14AM   HGB-10.4* calcHCT-31 O2 SAT-77
[**2138-2-14**] 12:20AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2138-2-14**] 12:20AM URINE  RBC-[**4-11**]* WBC-[**4-11**] BACTERIA-MOD YEAST-NONE
EPI-0
[**2138-2-14**] 12:20AM URINE  HYALINE-[**7-17**]*
[**2138-2-14**] 12:08AM   LACTATE-3.3*
[**2138-2-13**] 11:55PM   PT-33.9* PTT-38.7* INR(PT)-3.5*
[**2138-2-13**] 11:55PM   PLT SMR-HIGH PLT COUNT-472*
[**2138-2-13**] 11:55PM   NEUTS-91* BANDS-4 LYMPHS-2* MONOS-2 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2138-2-13**] 11:55PM   HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2138-2-13**] 11:55PM   WBC-35.8*# RBC-3.38* HGB-10.2* HCT-32.3*
MCV-96 MCH-30.1 MCHC-31.5 RDW-16.0*
[**2138-2-13**] 11:55PM   LIPASE-53
.
IMAGING:
[**2138-2-14**] ABD/PELVIC CT W/CONTRAST:
1. Necrotizing pancreatitis with minimal residual pancreatic
tissue, similar to the prior study.
2. Peripancreatic collections have decreased in size. There are
no new collections. Stable position to an internal-external
drain. The presence of air in these collections suggests
communication between the CBD, containing the stent, and the
pseudocyts.
3. Mild intrahepatic biliary ductal dilation, improved.
4. Slight increased simple fluid within the pelvis, without
drainable fluid collections.
5. Stable small left effusion with atelectasis.
6. Stable hyperdense left renal cyst.
.
[**2138-2-14**] AP CXR:
Probable atelectasis and small effusion at the left base,
decreased since the previous examination. No acute findings.
.
[**2138-2-13**] ECG:
Sinus tachycardia. There is a late transition which is probably
normal.  No previous tracing available for comparison.
   Intervals Axes:
Rate PR QRS QT/QTc P QRS T
114 164 70 348/442 68 34 35
.
[**2138-2-14**] ECG:
Artifact is present. Sinus tachycardia. Normal tracing. Compared
to the previous tracing late transition is no longer present.
  Intervals Axes:
Rate PR QRS QT/QTc P QRS T
107 164 78 352/434 62 0 28
.
MICROBIOLOGY:
[**2138-2-14**] 2:25 am BILE

   GRAM STAIN (Final [**2138-2-14**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      4+   (>10 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS, CHAINS, AND
CLUSTERS.
      4+   (>10 per 1000X FIELD):   GRAM POSITIVE ROD(S).
      2+   (1-5 per 1000X FIELD):   GRAM NEGATIVE ROD(S).

   FLUID CULTURE (Preliminary):
      Due to mixed bacterial types (>=3) an abbreviated workup
is
      performed; P.aeruginosa, S.aureus and beta strep. are
reported if
      present. Susceptibility will be performed on P.aeruginosa
and
      S.aureus if sparse growth or greater..
      DR. [**Last Name (STitle) **] #[**Numeric Identifier 84349**] REQUESTED FURTHER WORK-UP [**2138-2-18**].
      ENTEROCOCCUS SP..    HEAVY GROWTH.
      STAPH AUREUS COAG +.    SPARSE GROWTH OF TWO COLONIAL
MORPHOLOGIES.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations.

         Rifampin should not be used alone for therapy.
      GRAM NEGATIVE ROD(S).    SPARSE GROWTH.
      ENTEROCOCCUS SP..    MODERATE GROWTH.  SECOND MORPHOLOGY.
      [**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION.    RARE
GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S

   ANAEROBIC CULTURE (Final [**2138-2-18**]):
      CLOSTRIDIUM PERFRINGENS.    SPARSE GROWTH.
.
[**2138-2-14**] 8:30 am MRSA SCREEN (Source: Nasal swab): POSITIVE FOR
METHICILLIN RESISTANT STAPH AUREUS.
.
[**2138-2-13**] Blood Cx: No growth - FINAL.
[**2138-2-14**] Blood Cx: No growth - FINAL.
.
[**2138-2-14**] CLOSTRIDIUM DIFFICILE TOXIN A & B TEST: Negative.
[**2138-2-15**] CLOSTRIDIUM DIFFICILE TOXIN A & B TEST: Negative.

Brief Hospital Course:
The patient was transferredd from an Outside Hospital (OSH) and
admitted to the General Surgical Service on [**2138-2-14**] for
evaluation of fever, leukocytosis, hypotension, and confusion.
Initially, he was admited to the SICU and made NPO except
medications, started on IV fluids and empiric IV Vancomycin and
Zosyn, a foley catheter was placed, and he was placed on
continuous bland aerosol mask 35 % trach collar. The PTC drain,
which had been capped, was opened to gravity drainage. The
longstanding J-Tube remained clamped. The patient was
hemodynamically stable.
.
The patient was started on a regular diet on [**2138-2-15**], which he
tolerated. He was transferred to the inpatient floor later on
[**2138-2-15**] continued on IV antibiotics, home medications, a
Passy-Muir valve was replaced, the PTC remained to gravity
drainage, and the J-Tube clamped. He no longer required IV
fluids. The foley was in place. Bile culture wa returned with
MRSA.
.
On [**2138-2-17**], the patient underwent cholangiogram, during which
the external-internal biliary drain was replaced. Also, on
[**2138-2-17**], the patient underwent flexible bronchoscopy for purpose
of decannulation and tracheostomy removal by Thoracic Surgery,
which went well (see Operative Note). Peri-procedurally, the
patient received IV pain medications, but only required
acetaminophen otherwise during the admission for discomfort.
.
Over the next two days after the above procedures, the patient's
foley catheter was discontinued and the J-Tube was removed, as
it had not been used in over one month. The patient subsequently
voided without problem. The PTC was capped on [**2138-2-19**], which the
patient tolerated without fever, abdominal pain, nausea,
vomiting, or appetite changes overnight. IV Vancomycin and Zosyn
were discontinued, and changed to Bactrim and Ciprofloxacin. He
was discharged on a two week course of both. Home Coumadin
dosing was also restarted on [**2138-2-19**]. INR [**2138-2-20**] AM was 1.3.
INR goal 2.5 with therapeutic range of [**3-12**]. Patient's PCP
[**Name (NI) 653**] and has kindly agreed to manage Coumadin once
discharged.
.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirrometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. Labwork was routinely followed;
electrolytes were repleted when indicated. Once recovered, he
was returned to the floor with previous orders re-initiated.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs.  The patient was tolerating a regular
diet, ambulating, voiding without assistance, and was not
experiencing any pain.  He was discharged home with VNA
services. The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.

Medications on Admission:
11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours)
12. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily)
13. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1)  Inhalation every six (6) hours as needed for shortness
of breath or wheezing
14. Lactobacillus Acidophilus Tablet Sig: One (1) Tablet PO
once a day
15. Labetalol 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day)
16. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation

Q6H (every 6 hours) as needed for SOB
17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours)
18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
19. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily)
21. Multivitamins Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day
22. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO Every
Monday
24. Seroquel 25 mg Tablet Sig: One (1) Tablet PO every 4-6 hours

as needed for Agitation
25. Humalog 100 unit/mL Solution Sig: One (1) From 4-11 Units
Subcutaneous four times a day: As directed per sliding scale
26. Oyster Shell Calcium 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO twice a day

Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Labetalol 200 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety/agitation .
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
6. Zoloft 50 mg Tablet Sig: One (1) Tablet PO once a day.
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
9. Lactobacillus Acidophilus 500 million cell Tablet Sig: One
(1) Tablet PO once a day.
10. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week.
11. Oyster Shell Calcium 500 500 mg (1,250 mg) Tablet Sig: One
(1) Tablet PO twice a day.
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
13. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
[**Name (NI) **]:*60 Capsule(s)* Refills:*0*
14. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 14 days.
[**Name (NI) **]:*28 Tablet(s)* Refills:*0*
15. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 14 days.
[**Name (NI) **]:*28 Tablet(s)* Refills:*0*
16. Coumadin 1 mg Tablet Sig: One (1) Tablet PO QTuesday,
Thursday, Saturday AND 2 tablets orally Q Monday, Wednesday,
Friday, and Sunday.: Please take same time in the evening.
17. Lantus 100 unit/mL Solution Sig: Fifteen (15) units
Subcutaneous at bedtime.


Discharge Disposition:
Home With Service

Facility:
Diversified VNA and hospice

Discharge Diagnosis:
1. Tracheostomy for previous chronic respiratory failure post
adult respiratory distress syndrome.
2. Necrotizing pancreatitis
3. MRSA
4. SMV and splenic vein thrombosis on Coumadin prophylaxis
5. Cholangitis


Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent


Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication.  Also, please take
any new medications as prescribed.

Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.  Avoid lifting
weights greater than [**6-16**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.

Avoid driving or operating heavy machinery while taking pain
medications.

Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
.
General Drain Care:

*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever). [**Name6 (MD) **] your MD if you
expereimnce these symptoms, or if you experience fever,
abdominal pain, nausea, vomiting, abdominal distension, or
prurlent drainage.
*Wash the area gently with warm, soapy water or 1/2 strength
hydrogen peroxide followed by saline rinse, pat dry, and place a
drain sponge. Change daily and as needed.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
.
Coumadin (Warfarin):

What is this medicine used for?
This medicine is used to thin the blood so that clots will not
form.

How does it work?
Warfarin changes the body's clotting system. It thins the blood
to prevent clots from forming.

What you should contact your healthcare provider [**Name Initial (PRE) **]:
Signs of a life-threatening reaction. These include wheezing;
chest tightness; fever; itching; bad cough; blue skin color;
fits; or swelling of face, lips, tongue, or throat, severe
dizziness or passing out, falls or accidents, especially if you
hit your head. Talk with healthcare provider even if you feel
fine, significant change in thinking clearly and logically,
severe headache, severe back pain, severe belly pain, black,
tarry, or bloody stools, blood in the urine, nosebleeds,
coughing up blood, vomiting blood, unusual bruising or bleeding,
severe menstrual bleedin, or rash.

Call your doctor if you are unable to eat for several days, for
whatever reason. Also call if you have stomach problems,
vomiting, or diarrhea that lasts more than 1 day. These problems
could affect your Coumadin??????/warfarin dosage.

Coumadin (Warfarin) and diet:
Certain foods and beverages can impair the effect of warfarin.
For this reason, it's important to pay attention to what you eat
while taking this medication.

Until recently, doctors advised [**Name5 (PTitle) **] taking warfarin to avoid
foods high in vitamin K. This is because large amounts of
vitamin K can counteract the benefits of warfarin. However,
recent research shows that rather than eliminating vitamin K
from your diet, it is more important to be consistent in your
dietary vitamin K intake.

These foods contain vitamin K:
Fruits and vegetables, such as: Kiwi, Blueberries, Broccoli,
Cabbage, [**Location (un) 2831**] sprouts, Green onions, Asparagus, Cauliflower,
Peas, Lettuce, Spinach, Turnip, collard, and mustard greens,
Parsley, Kale, Endive. Meats, such as: Beef liver, Pork liver.
Other: Mayonnaise, Margarine, Canola oil, Soybean oil, Vitamins,
Soybeans and Cashews.

Limit alcohol. Alcohol can affect your Coumadin??????/warfarin dosage
but it does not mean you must avoid all alcohol. Serious
problems can occur with alcohol and Coumadin??????/warfarin when you
drink more than 2 drinks a day or when you change your usual
pattern. Binge drinking is not good for you. Be careful on
special occasions or holidays, and drink only what you usually
would on any regular day of the week.

Monitoring:
The doctor decides how much Coumadin??????/warfarin you need by
testing your blood. The test measures how fast your blood is
clotting and lets the doctor know if your dosage should change.
If your blood test is too high, you might be at risk for
bleeding problems. If it is too low, you might be at risk for
forming clots. Your doctor has decided on a range on the blood
test that is right for you. The blood test used for monitoring
is called an INR.

Use of Other medications:
When Coumadin??????/warfarin is taken with other medicines it can
change the way other medicines work. Other medicines can also
change the way Coumadin??????/warfarin works. It is very important to
talk with your doctor about all of the other medicines that you
are taking, including over-the-counter medicines, antibiotics,
vitamins, or herbal products.

Followup Instructions:
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2835**] Date/Time:[**2138-3-10**]
8:30. Location: Shapiro3, [**Hospital Ward Name 516**].
.
Provider: [**Name10 (NameIs) 17853**] CLINIC INTERVENTIONAL PULMONARY (SB)
Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2138-3-18**] 10:30
.
Please call ([**Telephone/Fax (1) 83543**] to arrange a follow-up appointment
with Dr. [**Last Name (STitle) 2479**] (PCP) in [**3-12**] weeks.



Completed by:[**2138-2-20**]
{'Cholangitis,Attention to tracheostomy,Hypotension, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Personal history of venous thrombosis and embolism,Hematuria, unspecified,Long-term (current) use of anticoagulants,Depressive disorder, not elsewhere classified,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site'}


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: Leukocytosis, fever, hypotension, and tachycardia.

PRESENT ILLNESS: 71 year old male known to the surgical service, initially
presented after undergoing ERCP [**10-16**] for an ampullary polyp and
subsequently developed necrotizing pancreatitis as well as
cholecystitis, cholangitis, and ARDS.  He underwent perc chole
tube placement, Trach, and J-tube.  He was transfered to the
[**Hospital1 18**] for further care.  Ultimately he recovered, and his perc
chole was changed over to an internal-external drain.  He also
developed SMV and splenic vein thrombosis leading to
anticoagulation.  He was discharged to rehab.  He now presents
from an OSH.  He had a fever at home to 103 and was seen at OSH
where he had a leukocytosis, fever, and was hypotensive and
tachycardiac.  He was transfered here for further management. He
currently has no complaints.  No abdominal pain, no N/V/D.  Says
he has been tolerating a regular diet.  His I/E drain has been
capped since he left the hospital.

MEDICAL HISTORY: PMHx: HTN, Type II DM, nephrolithiasis, ampullary polyp, and
depression.
.
PSHx: Open tracheostomy, J-tube placement, chole tube placement

MEDICATION ON ADMISSION: 11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours)
12. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily)
13. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1)  Inhalation every six (6) hours as needed for shortness
of breath or wheezing
14. Lactobacillus Acidophilus Tablet Sig: One (1) Tablet PO
once a day
15. Labetalol 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day)
16. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On Admission:
VS: Tm 103 (at OSH) Tc 97.5  HR 113 (now 100) BP 87/55 (now
110/40) RR 18 O2sats 97%RA
.
Gen: NAD, AAOx3
HEENT: Anicteric
CV: tachycardiac
Pulm: CTA b/l
Abd: soft, NT, ND. Jtube capped, I/E drain RUQ capped
(semi-purulent material upon aspiration)
Ext: no edema or cyanosis, palp pulses.
.
At Discharge:
AVSS/afebrile.
GEN: Well in NAD.
HEENT: Sclerae anicteric. O-P clear.
NECK: Supple. Anterior tracheostomy site now decannulated with
DSD cover.
LUNGS: CTA(B)
COR: RRR
ABD: PTC drain capped; insertion site patent. Prior J-tube (now
discontinued) clean, slowly healing over with DSD cover. BSX4.
Soft/NT/ND.
EXTREM: No c/c/e
NEURO: Deconditioned, otherwise non-focal.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Married. Former smoker. Occasional social alcohol; no alcohol x
8months. 

### Response:
{'Cholangitis,Attention to tracheostomy,Hypotension, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Personal history of venous thrombosis and embolism,Hematuria, unspecified,Long-term (current) use of anticoagulants,Depressive disorder, not elsewhere classified,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site'}
