CHIEF COMPLAINT: Coffee-ground emesis

PRESENT ILLNESS: 83F with history of dementia, chronic LE cellulitis, recent DVT
and esophagitis/gastritis initially admitted to MICU with
coffee-ground emesis and subsequently found to have urosepsis
now transferred to floor.  Pt's history dates back to admission
in [**8-15**] for altered mental status where pt was found to have
hypercalcemia and hypernatremia and was diagnosed with
aspiration pneumonia and a UTI during that hospitalization. She
was also found to have a LLE DVT and was anticoagulated with
heparin. While supratherapeutic on heparin, she had am episode
of coffee-ground emesis which resolved with a stable hematocrit.
Pt had been discharged at that time with plans for outpatient
EGD.  Pt had been doing well until day PTA [**11-21**] when at nursing
home (NH), pt developed a temp of 104.8 and three episodes of
coffee-ground emesis. There was a question of an aspiration
event and the patient's oxygen saturation was noted to drop. In
the ED, the patient's temperature was 103.2 with heart rate 102.
Oxygen saturation was 89% on RA and she was placed on a NRB
mask. She refused an NG lavage, but while in the ED vomited
~100cc of brown/black liquid. She was given 3200cc of NS and
subsequently noted to have audible wheezing with respiratory
distress and was started on IV NTG, which was titrated up with
improvement in respiratory status. She was given Vancomycin,
levofloxacin, and metronidazole for presumed aspiration
pneumonia. Over the course of her stay in the ED, her SBP
progressively dropped to 70s-80s despite 3 L IVF and stopping
nitro gtt and pt was then started on peripheral levophed (family
refused central line).  Pt was then admitted to MICU for further
monitoring.
.
In MICU, blood cultures drawn [**11-21**] grew out GPC in clusters and
GNR, +UTI on U/A (urine culture still pending).  Pt was
initially placed on Vanc/Levo/Flagyl, changed to Vanc/Zosyn/Levo
[**11-22**].  Pressors weaned off last night but pt also developed IV
infiltration secondary to peripheral levophed, given
phentolamine overnight.  BP has been stable with systolics
90s-100s.  Respiratory status improved as well and NRB weaned
down to 4 L NC with O2 sats 96%.  Pt remains NPO for concern of
aspiration risk.  Now transferred to medicine floor for further
management.

MEDICAL HISTORY: PMH:
1. Dementia.
2. Anxiety.
3. Depression.
4. Hypertension.
5. Colon cancer, status post resection in [**2193-11-10**].
6. History of cellulitis of the left lower extremity and right
lower extremity.
7. Gait disturbance.
8. Grade III Esophagitis
9. Gastritis
10. Hiatal hernia
11. Hypercalcemia [**2-12**] Primary Hyperparathyroidism
12. Hypernatremia, two previous admissions with AMS
13. LLE DVT [**8-15**] s/p IVC filter placement [**2200-8-13**]
14. Coffee-ground emesis [**8-15**] while supratherapeutic PTT

MEDICATION ON ADMISSION: MEDS as outpatient:
Combivent Nebs q6h prn
Fluoxetine 20mg daily
Ferrous sulfate 330mg daily
Acetaminophen 650mg q4h prn
Lactulose 20g [**Hospital1 **]
Alendronate 70mg weekly
Ascorbic acid 500mg daily
Esomeprazole 40mg daily
Magnesium Oxide 400mg [**Hospital1 **]
Sorbitol 30mL daily
Vit D3-Cholecalciferol 400U daily
.
Meds on transfer:
1. Tylenol prn
2. Alb/Ipratropium IH q6hr prn
3. Levofloxacin 250 mg IV daily #3
4. Zyprexa [**Hospital1 **] prn
5. Protonix 40 IV BID
6. Phentolamine x 1 last night
7. Zosyn 2.25 gm IV q6 day #2
8. Vancomycin 1 gm IV q48hr #2
.
Allergies: NKDA

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T 98  BP 106/53 (92-106/48-53) P58-71 R20 Sat 95%4L NC,
wt = 79 kg
Gen: elderly woman, pleasant, breathing comfortably, follows
commands, oriented x 1 (maiden name, knows she's in hospital,
does not know year), asking repeatedly to be kissed
HEENT: pupils 3mm and reactive bilaterally, dry mucous
membranes, OP clear
Neck: no JVD, no LAD
Lung: coarse breath sounds bilaterally anteriorly, no wheezes
Cor: RRR, nml S1S2
Abd: obese, soft NTND, NABS
Rectal: guaiac positive (per ED initially in admisison), dark
brown soft stool
Ext: 2+ pitting edema bilateral lower extremities with chronic
venous status changes; LUE with samll 4x4 cm area of purplish
discoloration on forearm at previous PIV site which per nursing
is significantly improved

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: The patient is a widowed [**Hospital3 **] resident. The
patient used to sell shoes. The patient denied any tobacco or
alcohol use. Son has [**Name2 (NI) **] syndrome. Daughter [**Name (NI) **] used to take
care of her.
Methicillin susceptible Staphylococcus aureus septicemia,Severe sepsis,Septic shock,Urinary tract infection, site not specified,Hematemesis,Pneumonitis due to inhalation of food or vomitus,Acute kidney failure, unspecified,Acute posthemorrhagic anemia,Cellulitis and abscess of leg, except foot,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic kidney disease, unspecified,Hyperosmolality and/or hypernatremia,Infection with microorganisms resistant to penicillins,Personal history of venous thrombosis and embolism,Hyperparathyroidism, unspecified,Other persistent mental disorders due to conditions classified elsewhere
Meth susc Staph aur sept,Severe sepsis,Septic shock,Urin tract infection NOS,Hematemesis,Food/vomit pneumonitis,Acute kidney failure NOS,Ac posthemorrhag anemia,Cellulitis of leg,Hyp kid NOS w cr kid V,Chronic kidney dis NOS,Hyperosmolality,Inf mcrg rstn pncllins,Hx-ven thrombosis/embols,Hyperparathyroidism NOS,Mental disor NEC oth dis
Admission Date:  [**2200-11-22**]              Discharge Date:   [**2200-11-26**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 13386**]
Chief Complaint:
Coffee-ground emesis

Major Surgical or Invasive Procedure:
None

History of Present Illness:
83F with history of dementia, chronic LE cellulitis, recent DVT
and esophagitis/gastritis initially admitted to MICU with
coffee-ground emesis and subsequently found to have urosepsis
now transferred to floor.  Pt's history dates back to admission
in [**8-15**] for altered mental status where pt was found to have
hypercalcemia and hypernatremia and was diagnosed with
aspiration pneumonia and a UTI during that hospitalization. She
was also found to have a LLE DVT and was anticoagulated with
heparin. While supratherapeutic on heparin, she had am episode
of coffee-ground emesis which resolved with a stable hematocrit.
Pt had been discharged at that time with plans for outpatient
EGD.  Pt had been doing well until day PTA [**11-21**] when at nursing
home (NH), pt developed a temp of 104.8 and three episodes of
coffee-ground emesis. There was a question of an aspiration
event and the patient's oxygen saturation was noted to drop. In
the ED, the patient's temperature was 103.2 with heart rate 102.
Oxygen saturation was 89% on RA and she was placed on a NRB
mask. She refused an NG lavage, but while in the ED vomited
~100cc of brown/black liquid. She was given 3200cc of NS and
subsequently noted to have audible wheezing with respiratory
distress and was started on IV NTG, which was titrated up with
improvement in respiratory status. She was given Vancomycin,
levofloxacin, and metronidazole for presumed aspiration
pneumonia. Over the course of her stay in the ED, her SBP
progressively dropped to 70s-80s despite 3 L IVF and stopping
nitro gtt and pt was then started on peripheral levophed (family
refused central line).  Pt was then admitted to MICU for further
monitoring.
.
In MICU, blood cultures drawn [**11-21**] grew out GPC in clusters and
GNR, +UTI on U/A (urine culture still pending).  Pt was
initially placed on Vanc/Levo/Flagyl, changed to Vanc/Zosyn/Levo
[**11-22**].  Pressors weaned off last night but pt also developed IV
infiltration secondary to peripheral levophed, given
phentolamine overnight.  BP has been stable with systolics
90s-100s.  Respiratory status improved as well and NRB weaned
down to 4 L NC with O2 sats 96%.  Pt remains NPO for concern of
aspiration risk.  Now transferred to medicine floor for further
management.

Past Medical History:
PMH:
1. Dementia.
2. Anxiety.
3. Depression.
4. Hypertension.
5. Colon cancer, status post resection in [**2193-11-10**].
6. History of cellulitis of the left lower extremity and right
lower extremity.
7. Gait disturbance.
8. Grade III Esophagitis
9. Gastritis
10. Hiatal hernia
11. Hypercalcemia [**2-12**] Primary Hyperparathyroidism
12. Hypernatremia, two previous admissions with AMS
13. LLE DVT [**8-15**] s/p IVC filter placement [**2200-8-13**]
14. Coffee-ground emesis [**8-15**] while supratherapeutic PTT

Social History:
The patient is a widowed [**Hospital3 **] resident. The
patient used to sell shoes. The patient denied any tobacco or
alcohol use. Son has [**Name2 (NI) **] syndrome. Daughter [**Name (NI) **] used to take
care of her.


Family History:
Noncontributory.


Physical Exam:
Vitals: T 98  BP 106/53 (92-106/48-53) P58-71 R20 Sat 95%4L NC,
wt = 79 kg
Gen: elderly woman, pleasant, breathing comfortably, follows
commands, oriented x 1 (maiden name, knows she's in hospital,
does not know year), asking repeatedly to be kissed
HEENT: pupils 3mm and reactive bilaterally, dry mucous
membranes, OP clear
Neck: no JVD, no LAD
Lung: coarse breath sounds bilaterally anteriorly, no wheezes
Cor: RRR, nml S1S2
Abd: obese, soft NTND, NABS
Rectal: guaiac positive (per ED initially in admisison), dark
brown soft stool
Ext: 2+ pitting edema bilateral lower extremities with chronic
venous status changes; LUE with samll 4x4 cm area of purplish
discoloration on forearm at previous PIV site which per nursing
is significantly improved


Pertinent Results:
[**2200-11-22**] 06:34PM   HCT-32.4*
[**2200-11-22**] 11:34AM   HCT-32.0*
[**2200-11-22**] 05:55AM URINE  COLOR-LtAmb APPEAR-Cloudy SP [**Last Name (un) 155**]-1.020
[**2200-11-22**] 05:55AM URINE  BLOOD-LGE NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2200-11-22**] 05:55AM URINE  RBC-212* WBC->1000* BACTERIA-MANY
YEAST-NONE EPI-<1
[**2200-11-22**] 05:55AM URINE  WBCCLUMP-MANY MUCOUS-FEW
[**2200-11-22**] 05:24AM   TYPE-ART TEMP-37.9 PO2-153* PCO2-33* PH-7.37
TOTAL CO2-20* BASE XS--4 INTUBATED-NOT INTUBA
COMMENTS-NON-REBREA
[**2200-11-22**] 05:24AM   LACTATE-6.3*
[**2200-11-22**] 05:24AM   O2 SAT-99
[**2200-11-22**] 05:05AM   GLUCOSE-94 UREA N-30* CREAT-1.3* SODIUM-146*
POTASSIUM-4.2 CHLORIDE-114* TOTAL CO2-17* ANION GAP-19
[**2200-11-22**] 05:05AM   CALCIUM-9.8 PHOSPHATE-2.4* MAGNESIUM-1.8
[**2200-11-22**] 05:05AM   WBC-9.3 RBC-3.78* HGB-10.1* HCT-31.7* MCV-84
MCH-26.7* MCHC-31.9 RDW-19.8*
[**2200-11-22**] 05:05AM   PLT COUNT-217
[**2200-11-22**] 01:00AM URINE  COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.024
[**2200-11-22**] 01:00AM URINE  BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2200-11-22**] 01:00AM URINE  RBC-[**3-15**]* WBC-21-50* BACTERIA-MANY
YEAST-NONE EPI-[**6-20**]
[**2200-11-22**] 01:00AM URINE  CA OXAL-MOD
[**2200-11-21**] 11:00PM   GLUCOSE-126* UREA N-30* CREAT-1.2*
SODIUM-146* POTASSIUM-3.8 CHLORIDE-111* TOTAL CO2-25 ANION
GAP-14
[**2200-11-21**] 11:00PM   ALT(SGPT)-45* AST(SGOT)-51* ALK PHOS-151*
AMYLASE-42 TOT BILI-0.4
[**2200-11-21**] 11:00PM   MAGNESIUM-2.2
[**2200-11-21**] 11:00PM   WBC-16.8*# RBC-4.52 HGB-11.7*# HCT-36.2
MCV-80* MCH-26.0* MCHC-32.5 RDW-18.9*
[**2200-11-21**] 11:00PM   NEUTS-87* BANDS-6* LYMPHS-1* MONOS-6 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2200-11-21**] 11:00PM   HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL
[**2200-11-21**] 11:00PM   PLT SMR-NORMAL PLT COUNT-273#
[**2200-11-21**] 11:00PM   PT-13.5* PTT-27.1 INR(PT)-1.2
[**2200-11-21**] 11:00PM   D-DIMER-2320*
[**2200-11-21**] 10:26PM   LACTATE-2.8*

Brief Hospital Course:
83F with history of dementia, chronic LE cellulitis, recent DVT
and esophagitis/gastritis admitted with coffee-ground emesis and
UTI.
.
1. Hypotension:
Likely etiology was septic shock from UTI vs possible aspiration
PNA va aspiration pneumonitis.  Blood cultures now positive for
Staph aureus (MRSA) and Proteus mirabilis sensitive. Source is
likely the UTI with the Urine cultures from [**2200-11-20**] being
positive for gram positive bacteria >100,000 and Proteus species
10,000-100,000. BP now improved after IV hydration and
antibiotics, pressors were weaned off and the pt was maintaining
adequate BP. The Staph aureus (MRSA) was sensitive to Vancomycin
and the Proteus species was sensitive to Ceftriaxone. The pt was
treated with the these antibiotics and will be given a total of
4 week course (Vancomycin) and 2 week course of Ceftriaxone. An
ECHO done to rule out endocarditis showed: LV hypertrophy with
LEVF 55%, while the technique was sub-optimal, no evidence of
endocarditis was noted, 1+ aortic regurgitation and 1+ mitral
regurgitation.
Surveillance blood cultures should be continued in the rehab
q4-5 days to ensure clearance of the bacteremia. At the time of
discharge the pt was afebrile and the hypotension had resolved.

.
2. Gastrointestinal bleed:
Likely related to previously documented gastritis and/or
esophagitis vs peptic ulcer disease, arterio-venous
malformation. The pt has not had an EGD since [**2197**]. Pt did not
tolerate NG lavage in ED and per daughter ([**Name (NI) **]), does not want
endoscopy. The pt was kept NPO until she was evaluated by speech
and swallow. She was noted to be safe to tolerate supervised
intake of soft PO pureed solids. Her hematocrit was followed [**Hospital1 **]
until it stabilized. A GI consult was not obtained per request
from the patient's daughter ([**Name (NI) **], the health care proxy)
because she did not did not want any GI intervention per
attending, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The attending, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], discussed the therapeutic options with the patient's
son-in-law (the daughter [[**Doctor First Name **]] could not be contact[**Name (NI) **] despite
multiple attempts) and together they decided that the current
infections (bacteremia and UTI) would be treated in the [**Hospital 100**]
rehab but no attempt should be made to further workup the GI
bleeding.
.
3. Fever:
As above, likely source is UTI, sepsis and possible aspiration
pneumonia (bibasilar opacities on CXR) Blood cultures were
positive for Proteus mirabilis and Staph aureus; urine cultures
positive for Proteus mirabilis and Staph. aureus. The patient
was treated with appropriate antibiotics and remained afebrile.
.
4. Acute on chronic renal failure:
Baseline creatinine 0.8-1.2. Initial acute renal failure likely
secondary to prerenal failure from hypovolemia secondary to GI
bleed and/or sepsis. The patient's creatinine was closely
followed and was 0.7 at the time of discharge.
.
5. Respiratory distress:
Unclear etiology, ?CHF vs aspiration event in the setting of
fluid resuscitation in ED and decreased mental status. Oxygen
saturations were weaned off NRB to 2L. CXR revealed bibasilar
opacities which may relate to aspiration or atelectasis. The
patient was continued on Ceftriaxone and Vancomycin and remained
afebrile.
.
6. IV infiltrate of levophed:
The patient was treated with peripheral Levophed (IV
Norepinephrine) for pressor support in the MICU (the family
refused a central line). The drip had to be due to subdermal
infiltration of Levophed. The pt did not develop any signs of
skin necrosis secondary to Levophed infiltration.
.
7. Mental Status:
Pt was noted to be responsive, though confused. She has baseline
dementia and likely had delirium in the setting of fever and
hypotension. [**Hospital **] medical conditions were treated and her
mental status was closely followed. A head CT to assess bleed or
mass was negative. Her electrolyte derangements were corrected
daily (hypercalcemia and hypernatriemia). The patient's family
established that the current mental status was her baseline.
.
8. Hypercalcemia:
Likely secondary to primary hyperparathyroidism, has been on
bisphosphonate as outpatient. Ca had been initially normal on
admission, it trended upward and then resolved. The pt was
treated with IV fluids (D5W) to improve her free water deficit.
.
9. LFT elevation:
Improved from previous measurements.
.
10. FEN:
Electrolytes were repleted as needed.
.
11. Prophylaxis:
Pneumoboots.
Proton pump inhibitor PO BID.
.
10. Code Status: DNR/DNI
.
11. Access: PICC line
.
12. Communication: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (daughter, HCP):
[**Telephone/Fax (1) 96104**](home), [**Telephone/Fax (1) 96105**] (cell). [**Name (NI) **] [**Name (NI) **]
(son-in-law): [**Telephone/Fax (1) 96106**]. Has confirmed DNR/DNI; will avoid
central venous line and pressors if possible, but can place if
reversible condition. Confirmed DNR/DNI.
.
12. Dispo: to [**Hospital 100**] rehab


Medications on Admission:
MEDS as outpatient:
Combivent Nebs q6h prn
Fluoxetine 20mg daily
Ferrous sulfate 330mg daily
Acetaminophen 650mg q4h prn
Lactulose 20g [**Hospital1 **]
Alendronate 70mg weekly
Ascorbic acid 500mg daily
Esomeprazole 40mg daily
Magnesium Oxide 400mg [**Hospital1 **]
Sorbitol 30mL daily
Vit D3-Cholecalciferol 400U daily
.
Meds on transfer:
1. Tylenol prn
2. Alb/Ipratropium IH q6hr prn
3. Levofloxacin 250 mg IV daily #3
4. Zyprexa [**Hospital1 **] prn
5. Protonix 40 IV BID
6. Phentolamine x 1 last night
7. Zosyn 2.25 gm IV q6 day #2
8. Vancomycin 1 gm IV q48hr #2
.
Allergies: NKDA

Discharge Medications:
1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-12**]
Puffs Inhalation Q6H (every 6 hours) as needed.
Disp:*30 * Refills:*0*
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Pantoprazole 40 mg IV Q24H
4. Ceftriaxone 1 g Piggyback Sig: One (1) gram Intravenous  once
a day for 12 days.
Disp:*12 grams* Refills:*0*
5. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram
Intravenous  once a day for 28 days: 4 week course for MRSA
positive urosepsis.
Disp:*28 grams* Refills:*0*
6. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN.  Inspect site every shift.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - 4 South

Discharge Diagnosis:
Urosepsis
Upper GI bleed


Discharge Condition:
Stable

Discharge Instructions:
Please report to the nearest Emergency Department if you have
vomiting (that resembles coffee-grounds), black ot tarry stool,
shortness of breath, chest pain or fever.

Followup Instructions:
Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14959**] at the [**Hospital 100**] rehab for
evaluation of your urine and blood infection. The [**Hospital 100**] Rehab
has been made aware that you will be discharge today and that
you will be followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14959**].



Completed by:[**2200-11-26**]
{'Methicillin susceptible Staphylococcus aureus septicemia,Severe sepsis,Septic shock,Urinary tract infection, site not specified,Hematemesis,Pneumonitis due to inhalation of food or vomitus,Acute kidney failure, unspecified,Acute posthemorrhagic anemia,Cellulitis and abscess of leg, except foot,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic kidney disease, unspecified,Hyperosmolality and/or hypernatremia,Infection with microorganisms resistant to penicillins,Personal history of venous thrombosis and embolism,Hyperparathyroidism, unspecified,Other persistent mental disorders due to conditions classified elsewhere'}


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: Coffee-ground emesis

PRESENT ILLNESS: 83F with history of dementia, chronic LE cellulitis, recent DVT
and esophagitis/gastritis initially admitted to MICU with
coffee-ground emesis and subsequently found to have urosepsis
now transferred to floor.  Pt's history dates back to admission
in [**8-15**] for altered mental status where pt was found to have
hypercalcemia and hypernatremia and was diagnosed with
aspiration pneumonia and a UTI during that hospitalization. She
was also found to have a LLE DVT and was anticoagulated with
heparin. While supratherapeutic on heparin, she had am episode
of coffee-ground emesis which resolved with a stable hematocrit.
Pt had been discharged at that time with plans for outpatient
EGD.  Pt had been doing well until day PTA [**11-21**] when at nursing
home (NH), pt developed a temp of 104.8 and three episodes of
coffee-ground emesis. There was a question of an aspiration
event and the patient's oxygen saturation was noted to drop. In
the ED, the patient's temperature was 103.2 with heart rate 102.
Oxygen saturation was 89% on RA and she was placed on a NRB
mask. She refused an NG lavage, but while in the ED vomited
~100cc of brown/black liquid. She was given 3200cc of NS and
subsequently noted to have audible wheezing with respiratory
distress and was started on IV NTG, which was titrated up with
improvement in respiratory status. She was given Vancomycin,
levofloxacin, and metronidazole for presumed aspiration
pneumonia. Over the course of her stay in the ED, her SBP
progressively dropped to 70s-80s despite 3 L IVF and stopping
nitro gtt and pt was then started on peripheral levophed (family
refused central line).  Pt was then admitted to MICU for further
monitoring.
.
In MICU, blood cultures drawn [**11-21**] grew out GPC in clusters and
GNR, +UTI on U/A (urine culture still pending).  Pt was
initially placed on Vanc/Levo/Flagyl, changed to Vanc/Zosyn/Levo
[**11-22**].  Pressors weaned off last night but pt also developed IV
infiltration secondary to peripheral levophed, given
phentolamine overnight.  BP has been stable with systolics
90s-100s.  Respiratory status improved as well and NRB weaned
down to 4 L NC with O2 sats 96%.  Pt remains NPO for concern of
aspiration risk.  Now transferred to medicine floor for further
management.

MEDICAL HISTORY: PMH:
1. Dementia.
2. Anxiety.
3. Depression.
4. Hypertension.
5. Colon cancer, status post resection in [**2193-11-10**].
6. History of cellulitis of the left lower extremity and right
lower extremity.
7. Gait disturbance.
8. Grade III Esophagitis
9. Gastritis
10. Hiatal hernia
11. Hypercalcemia [**2-12**] Primary Hyperparathyroidism
12. Hypernatremia, two previous admissions with AMS
13. LLE DVT [**8-15**] s/p IVC filter placement [**2200-8-13**]
14. Coffee-ground emesis [**8-15**] while supratherapeutic PTT

MEDICATION ON ADMISSION: MEDS as outpatient:
Combivent Nebs q6h prn
Fluoxetine 20mg daily
Ferrous sulfate 330mg daily
Acetaminophen 650mg q4h prn
Lactulose 20g [**Hospital1 **]
Alendronate 70mg weekly
Ascorbic acid 500mg daily
Esomeprazole 40mg daily
Magnesium Oxide 400mg [**Hospital1 **]
Sorbitol 30mL daily
Vit D3-Cholecalciferol 400U daily
.
Meds on transfer:
1. Tylenol prn
2. Alb/Ipratropium IH q6hr prn
3. Levofloxacin 250 mg IV daily #3
4. Zyprexa [**Hospital1 **] prn
5. Protonix 40 IV BID
6. Phentolamine x 1 last night
7. Zosyn 2.25 gm IV q6 day #2
8. Vancomycin 1 gm IV q48hr #2
.
Allergies: NKDA

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T 98  BP 106/53 (92-106/48-53) P58-71 R20 Sat 95%4L NC,
wt = 79 kg
Gen: elderly woman, pleasant, breathing comfortably, follows
commands, oriented x 1 (maiden name, knows she's in hospital,
does not know year), asking repeatedly to be kissed
HEENT: pupils 3mm and reactive bilaterally, dry mucous
membranes, OP clear
Neck: no JVD, no LAD
Lung: coarse breath sounds bilaterally anteriorly, no wheezes
Cor: RRR, nml S1S2
Abd: obese, soft NTND, NABS
Rectal: guaiac positive (per ED initially in admisison), dark
brown soft stool
Ext: 2+ pitting edema bilateral lower extremities with chronic
venous status changes; LUE with samll 4x4 cm area of purplish
discoloration on forearm at previous PIV site which per nursing
is significantly improved

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: The patient is a widowed [**Hospital3 **] resident. The
patient used to sell shoes. The patient denied any tobacco or
alcohol use. Son has [**Name2 (NI) **] syndrome. Daughter [**Name (NI) **] used to take
care of her. 

### Response:
{'Methicillin susceptible Staphylococcus aureus septicemia,Severe sepsis,Septic shock,Urinary tract infection, site not specified,Hematemesis,Pneumonitis due to inhalation of food or vomitus,Acute kidney failure, unspecified,Acute posthemorrhagic anemia,Cellulitis and abscess of leg, except foot,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic kidney disease, unspecified,Hyperosmolality and/or hypernatremia,Infection with microorganisms resistant to penicillins,Personal history of venous thrombosis and embolism,Hyperparathyroidism, unspecified,Other persistent mental disorders due to conditions classified elsewhere'}
