CHIEF COMPLAINT: bladder perforation

PRESENT ILLNESS: Mr. [**Known lastname **] is an 84y/o male NH resident transferred from [**Hospital1 **]
[**Location (un) **] with extraperitoneal bladder perforation.  Pt presented
to [**Hospital1 **] [**Location (un) 620**] earlier today with incrasing confusion, SOB and
hematuria s/p foley change last night at his nursing home. At [**Hospital1 **]
[**Location (un) **], a three-way foley was put in and bladder irrigation was
done.  A CT Abdomen showed extraperitoneal bladder rupture and
an anterior fluid collection.  He was given 500 mg IV Flagyl and
Levaquin 500 mg IV.  He was also given 10U regular insulin bc he
was found to have a glucose of 1021.  Also, found to have
Lactate of 7.1 and Na of 126.  Pt was also given total of 2.5L
NS in boluses. Pt was then transferred to [**Hospital1 18**].
.
In the ED, VS: T 98.6 BP 96/60 HR 92 RR 20 O2Sat 97% on 2L NC.
There, pt was tachypnic to 35.  RIJ line was placed. q1h
fingersticks and q2h chem 7 were done and an insulin gtt at 8
units per hours was started.  He received a total of 3L NS IV,
SBP remained in 90s.  He had 1.5L of UOP in ED. No antibiotics
were given in the ED here.  Surgery and Urology were c/s.
Urology rec foley catheter to drainage, clamp CBI port, do not
irrigate bladder, when stablized, CT cystogram and possible IR
drainage of extraperitoneal fluid collection after CT cystogram.
.
On the floor, pt was tachypnic 28-30, complained of no pain. Pt
was awake, oriented x1, unable to communicate effectively.
.
Review of sytems: unable to elicit

MEDICAL HISTORY: HTN
DM2
Atrial fibrillation
hematuria
Seizure disorder
Urinary incontinence, chronic indwelling foley catheter
Recurrent UTI's
Mental retardation - reportedly confused at baseline but is able
to express his needs
Dementia
Osteoporsis
Hx of abdominal pain/chronic appendicitis (?)
Hx Aspiration PNA (Diet: Mech soft, nectar thick, asp
precautions)
Ex lap for lysis of adhesion

MEDICATION ON ADMISSION: Synthroid 25mcg Daily
Mebaral 32mg TID
Dilantin 100mg TID
Glypizide 5mg [**Hospital1 **]
Lisinopril 40mg Daily
Norvasc 10mg Daily
HCTZ 25mg Daily
Toprol XL 150mg Daily
Isordil 10mg TID
Prilosec 20mg Daily
ASA 325 daily
Colace 200mg daily
Sennakot 2 tabs [**Hospital1 **]
Lactulose 15ml [**Hospital1 **]
Tums TID
Vit D [**Numeric Identifier 1871**] q month on the 18th
MVI

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 97.2 BP: 98/44 P:90 R:30 O2: 91-93% on 3L NC
General: drowsy, arousable, oriented x1
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB anteriorly
CV: RRR, no murmurs, rubs, gallops
Abdomen: soft, non-tender, distended, bowel sounds present, no
rebound tenderness or guarding, no dullness to percussion
GU: foley in plce draining red-tinged urine
Ext: warm, well perfused, 1+ BLE edema, onychomycosis bilat

FAMILY HISTORY: NC

SOCIAL HISTORY: Resides in nursing home/Manor Care.  Baseline needs assist with
some ADL's, feed/toilets himself, walks with walker.
Septicemia due to escherichia coli [E. coli],Acute kidney failure, unspecified,Septic shock,Pneumonia, organism unspecified,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Diabetes with hyperosmolarity, type II or unspecified type, uncontrolled,Other forms of epilepsy and recurrent seizures, without mention of intractable epilepsy,Urinary tract infection, site not specified,Paralytic ileus,Other complications due to genitourinary device, implant, and graft,Hydronephrosis,Hyposmolality and/or hyponatremia,Inguinal hernia, with obstruction, without mention of gangrene, unilateral or unspecified (not specified as recurrent),Cystitis, unspecified,Severe sepsis,Accidental cut, puncture, perforation or hemorrhage during other specified medical care,Accidents occurring in residential institution,Urinary catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Unspecified intellectual disabilities,Osteoporosis, unspecified,Urinary incontinence, unspecified,Other appendicitis,Atrial fibrillation,Diverticulosis of colon (without mention of hemorrhage),Hypoxemia,Benign essential hypertension,Anemia, unspecified
E coli septicemia,Acute kidney failure NOS,Septic shock,Pneumonia, organism NOS,Food/vomit pneumonitis,Acute respiratry failure,DMII hprosmlr uncontrold,Epilep NEC w/o intr epil,Urin tract infection NOS,Paralytic ileus,Comp-genitourin dev/grft,Hydronephrosis,Hyposmolality,Unilat ing hernia w obst,Cystitis NOS,Severe sepsis,Acc cut in med care NEC,Accid in resident instit,Abn react-urinary cath,Intellect disability NOS,Osteoporosis NOS,Urinary incontinence NOS,Other appendicitis,Atrial fibrillation,Dvrtclo colon w/o hmrhg,Hypoxemia,Benign hypertension,Anemia NOS
Admission Date:  [**2160-7-26**]              Discharge Date:   [**2160-8-19**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
bladder perforation

Major Surgical or Invasive Procedure:
None

History of Present Illness:
Mr. [**Known lastname **] is an 84y/o male NH resident transferred from [**Hospital1 **]
[**Location (un) **] with extraperitoneal bladder perforation.  Pt presented
to [**Hospital1 **] [**Location (un) 620**] earlier today with incrasing confusion, SOB and
hematuria s/p foley change last night at his nursing home. At [**Hospital1 **]
[**Location (un) **], a three-way foley was put in and bladder irrigation was
done.  A CT Abdomen showed extraperitoneal bladder rupture and
an anterior fluid collection.  He was given 500 mg IV Flagyl and
Levaquin 500 mg IV.  He was also given 10U regular insulin bc he
was found to have a glucose of 1021.  Also, found to have
Lactate of 7.1 and Na of 126.  Pt was also given total of 2.5L
NS in boluses. Pt was then transferred to [**Hospital1 18**].
.
In the ED, VS: T 98.6 BP 96/60 HR 92 RR 20 O2Sat 97% on 2L NC.
There, pt was tachypnic to 35.  RIJ line was placed. q1h
fingersticks and q2h chem 7 were done and an insulin gtt at 8
units per hours was started.  He received a total of 3L NS IV,
SBP remained in 90s.  He had 1.5L of UOP in ED. No antibiotics
were given in the ED here.  Surgery and Urology were c/s.
Urology rec foley catheter to drainage, clamp CBI port, do not
irrigate bladder, when stablized, CT cystogram and possible IR
drainage of extraperitoneal fluid collection after CT cystogram.
.
On the floor, pt was tachypnic 28-30, complained of no pain. Pt
was awake, oriented x1, unable to communicate effectively.
.
Review of sytems: unable to elicit


Past Medical History:
HTN
DM2
Atrial fibrillation
hematuria
Seizure disorder
Urinary incontinence, chronic indwelling foley catheter
Recurrent UTI's
Mental retardation - reportedly confused at baseline but is able
to express his needs
Dementia
Osteoporsis
Hx of abdominal pain/chronic appendicitis (?)
Hx Aspiration PNA (Diet: Mech soft, nectar thick, asp
precautions)
Ex lap for lysis of adhesion


Social History:
Resides in nursing home/Manor Care.  Baseline needs assist with
some ADL's, feed/toilets himself, walks with walker.


Family History:
NC

Physical Exam:
Vitals: T: 97.2 BP: 98/44 P:90 R:30 O2: 91-93% on 3L NC
General: drowsy, arousable, oriented x1
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB anteriorly
CV: RRR, no murmurs, rubs, gallops
Abdomen: soft, non-tender, distended, bowel sounds present, no
rebound tenderness or guarding, no dullness to percussion
GU: foley in plce draining red-tinged urine
Ext: warm, well perfused, 1+ BLE edema, onychomycosis bilat


Pertinent Results:
STUDIES::
FINDINGS: As compared to the previous examination, the patient
position has considerably changed. There is very likely a
decrease of the extent of the pre-existing left pleural
effusion. Otherwise, the lung parenchyma appears unchanged.
Unchanged moderate cardiomegaly. No newly occurred focal
parenchymal opacity suggesting pneumonia.
.
.
[**2160-7-31**] CXR:
IMPRESSION: AP chest compared to [**2160-7-31**]:
The mandible obscures much of the upper lungs. The unencumbered
portion of the right lung is clear. There is probably
atelectasis at the base of the left. Heart is not grossly
enlarged.
.
.
[**2160-7-31**] CXR
[**2160-7-31**] AXR:
Final Addendum
ADDENDUM:
Upon further review of the CT from [**2160-7-27**], the prominent
gas-filled structure that extends transversely across the upper
abdomen corresponds to an extremely dilated stomach with
significant fluid contents. NG tube placement is recommended.
The remainder of the small and large bowel are not well
visualized, but appear nondilated.  These results were discussed
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2160-8-2**] at 10:20 a.m.

DR. [**First Name (STitle) 10307**] HO
DR. [**First Name (STitle) 8085**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8086**]
Approved: SAT [**2160-8-2**] 12:35 PM
Final Report
HISTORY: 84-year-old male with distended abdomen with
coffee-ground emesis.

ABDOMEN, THREE VIEWS: Evaluation is limited by extensive
overlying soft
tissue. The bowel gas pattern is not significantly changed from
CT on
[**2160-7-27**]. There is a dilated loop of transverse colon measuring 13
cm,
associated with an air-fluid level on lateral views. However,
gas is present in the rectum and in multiple nondilated bowel
loops throughout the abdomen. There is a small amount of
retained stool in the right colon.  There is a small left
pleural effusion. There is bibasilar atelectasis.
IMPRESSION: Chronic ileus, stable since prior CT.
.
.
.
[**2160-7-27**] CT CYSTOGRAM:
[**Known lastname **],[**Known firstname **] [**Medical Record Number 84971**] M  84  [**2075-10-21**]
Radiology Report CT CYSTOGRAM (PEL) W/O CONTRAST Study Date of
[**2160-7-27**] 12:04 PM

Provisional Findings Impression: CXWc SUN [**2160-7-27**] 1:30 PM
Urinary bladder demonstrates thickened trabeculae and numerous
diverticuli, which explains the irregular contour and air-filled
foci on yesterday's non- constrast scan. No extravasation of
contrast or fluid collection; no evidence of perforation.
Surrounding inflammatory changes are c/w cystitis. Dilated,
fluid-filled appendix with mild inflammatory changes stable
since yesterday, and c/w report of chronic appendicitis on prior
studies from [**Hospital1 2025**]. Enlarged, fluid-filled stomach, with fluid in
the distal esophagus increases risk for aspiration.
Final Report
INDICATION: 84-year-old man with report of ruptured bladder.

COMPARISON: Non-contrast CT of the abdomen and pelvis obtained
at [**Hospital 2538**] on [**2160-7-26**].

TECHNIQUE: MDCT-acquired axial images were obtained through the
pelvis before and after instillation of 150 cc of diluted
water-soluble contrast into the urinary bladder. Post-cystogram
images were also obtained through the abdomen. Multiplanar
reformatted images were generated.

CT ABDOMEN WITHOUT IV CONTRAST: At the lung bases, there is mild
dependent atelectasis bilaterally but no consolidation or
pleural effusion. The heart is enlarged with coronary artery
calcifications. There is no pericardial effusion.

In the abdomen, the absence of intravenous contrast limits
evaluation of solid organs. However, the liver, gallbladder,
spleen and duodenum are
unremarkable. The pancreas demonstrates fatty replacement. The
stomach is
distended with fluid, and the distal esophagus is mildly
patulous and also contains fluid, placing the patient at
increased risk for aspiration. Adrenal glands are prominent
bilaterally, without definite nodule or mass. Kidneys
demonstrate no calculus, hydronephrosis or hydroureter. On the
left, there is a moderate extrarenal pelvis. The abdominal aorta
demonstrates atherosclerotic calcifications but is normal in
caliber. Small lymph nodes in the retroperitoneum and mesentery
do not meet size criteria for abnormality. There is no free air
or free fluid in the abdomen. Small amount of stranding in the
retroperitoneum extends from duodenum toward right lower
quadrant about the appendix, but appears somewhat decreased from
the CT at [**Location (un) 620**] of the previous day.

CT PELVIS WITHOUT IV CONTRAST: Diluted, water-soluble contrast
was instilled into the patient's urinary bladder via an
indwelling Foley catheter. This demonstrates a markedly
trabeculated bladder with numerous bladder diverticuli,
explaining the lobulated, irregular contour noted on
non-contrast scan. There is no evidence of contrast
extravasation. Multiple bubbles of air are trapped within
individual diverticulae consistent with presence of Foley
catheter. There is continued thickening of the bladder wall and
stranding about the bladder although slightly improved from
prior. The prostate is enlarged measuring 5.1 x 6.3 x 5.6 cm.
There is no fluid collection in the pelvis.
Appendix is again noted to be dilated and fluid filled with
adjacent
stranding although the degree of periappendiceal stranding is
less marked
than that surrounding the bladder (400b:36).
The rectum is distended with fecal material. The remainder of
the colon
demonstrates a moderate amount of stool. Otherwise, loops of
large and small bowel are unremarkable. The prostate gland is
enlarged. There is no pelvic or inguinal lymphadenopathy by size
criteria.

OSSEOUS STRUCTURES: Bones are diffusely demineralized. There is
pronounced convex leftward curvature of the thoracolumbar spine,
with multilevel degenerative changes. However, no fracture is
identified. No worrisome bony lesions are seen. Soft tissues are
unremarkable.

IMPRESSIONS:
1. Instillation of contrast into the urinary bladder
demonstrates diffusely thickened trabeculae and numerous
diverticuli. Surrounding inflammatory changes are consistent
with cystitis and mildly improved. There is no evidence of
bladder perforation.
2. The appendix remains dilated and fluid filled, with mild
surrounding
inflammatory changes, by report, unchanged from prior studies
obtained at [**Hospital3 2576**] [**Hospital3 **] (although images are not
available for review). If changes are not acute, this is
consistent with chronic appendicitis.
3. Stomach distended with fluid, with fluid in the distal
esophagus,
increasing the risk of aspiration.
4. Rectum distended with fecal material.
5. Atherosclerotic calcification.
6. Enlarged prostate (likely leading to bladder trabeculation
and
diverticulae described above).
.
.
[**2160-7-26**] CT ABDOMEN/PELVIS [**Hospital1 18**]-[**Location (un) **]:
     CLINICAL HISTORY:  Abdominal distension.

     COMPARISON: None.

     TECHNIQUE:  Axial MDCT images were obtained from the lung
bases to the
     pubic symphysis without intravenous or oral contrast.
Coronal and
     sagittal reformatted images are provided.

     CONTRAST: None.

     CT ABDOMEN WITHOUT INTRAVENOUS CONTRAST:

     Imaged portion of the lung bases show bibasilar linear
atelectasis and
     appear otherwise unremarkable.  Coronary artery
calcifications are
     present within the imaged portion of the heart and
pericardium.
     Allowing for noncontrast technique, the liver, spleen,
pancreas,
     gallbladder and bilateral adrenal glands appear
unremarkable.  There
     is mild left sided hydronephrosis and extrarenal pelvis,
with dilation
     of the left proximal ureter. No calcified stones are
identified.  On
     the right, there is an extrarenal pelvis without
hydronephrosis.  Mild
     dilation of the proximal right ureter is present.
Abdominal aorta
     shows mural calcification consistent with atheromatous
disease.
     Stranding is present within the retroperitoneum extending
from the
     second portion of the duodenum inferiorly, along the
anterior
     pararenal space on the right, to the location of the
appendix, which
     is abnormally dilated and fluid filled, and measures up to
13 mm in
     diameter (2:72).  Small bowel loops are nondilated.  There
is a
     moderate amount of stool in the colon.  There is no free
     intraperitoneal air.

     CT PELVIS WITHOUT INTRAVENOUS CONTRAST:

     A Foley catheter is in place within the bladder.  There is
marked
     stranding surrounding the bladder.  Several foci of gas are
seen
     immediately adjacent to the bladder.  Evaluation is limited
due to the
     lack of intravenous contrast, although considerations might
include
     small foci of air located outside the bladder, or presence
of air in
     multiple bladder diverticula related to recent Foley
catheterization.
     A moderate amount of stool is present in the rectum.  There
is no
     inflammatory change about the sigmoid colon.  Bilateral fat
containing

[**Numeric Identifier 84972**] CT/CT ABD& PEL W/O & REFORMATS



     inguinal hernias are present, larger on the left with some
adjacent
     soft tissue density of uncertain significance that could
relate to
     prior surgery if appropriate history exists.

     BONE WINDOWS:

     There is degenerative change of the lumbar spine.  No
suspicious lytic
     or sclerotic osseous lesions are identified.

     IMPRESSION:

     1. MARKED STRANDING SURROUNDING AN ABNORMAL-APPEARING
BLADDER, WITH
     MULTIPLE FOCI OF GAS WHICH COULD REPRESENT EXTRAVESICAL
AIR, SUCH AS
     DUE TO INFECTION, OR ALTERNATIVELY, AIR WITHIN MULTIPLE
BLADDER
     DIVERTICULA (AIR IN THIS CASE DUE TO THE PRESENCE OF THE
FOLEY
     CATHETER).

     2. ABNORMALLY DILATED AND FLUID FILLED APPENDIX WITH
SURROUNDING
     INFLAMMATORY CHANGE.  THE FINDINGS ARE COMPATIBLE WITH
APPENDICITIS
     ALTHOUGH IT IS NOTED THAT THE DEGREE OF INFLAMMATORY CHANGE
IS
     SLIGHTLY LESS MARKED THAN ABOUT THE URINARY BLADDER.

     Please note that at the time of discussion of these
findings with the
     referring clinician a history of questionable chronic
appendicitis was
     provided with reported prior imaging at [**State 84973**] although this is unavailable for review.

     3. MODERATE FECAL LOADING.

     4. BILATERAL EXTRARENAL PELVES AND SUGGESTION OF LEFT SIDED
     HYDRONEPHROSIS WITH DILATION OF BILATERAL PROXIMAL URETERS,
OF
     UNCERTAIN SIGNIFICANCE.  NO RENAL STONES IDENTIFIED.

     Results were discussed with the referring provided at the
time of
     image acquisition on [**2160-7-26**], and also by Dr. [**First Name (STitle) **] on [**2160-7-27**]
at
     approximately 10:00 a.m. (Discussed with Dr. [**Last Name (STitle) **].



                    ** REPORT SIGNATURE ON FILE [**2160-7-28**] **
                    Reported By: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD
.
.
MICROBIOLOGY:
[**2160-7-26**] BLOOD CULTURE (4/4 bottles):
                           **FINAL REPORT [**2160-8-1**]**

   Blood Culture, Routine (Final [**2160-8-1**]):
      ESCHERICHIA COLI.    FINAL SENSITIVITIES.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ESCHERICHIA COLI
                             |
AMPICILLIN------------     4 S
AMPICILLIN/SULBACTAM--     4 S
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CEFUROXIME------------     4 S
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN----------   <=4 S
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S

   Anaerobic Bottle Gram Stain (Final [**2160-7-27**]):
      GRAM NEGATIVE ROD(S).

.
[**2160-7-26**] URINE CULTURE
                            **FINAL REPORT [**2160-7-30**]**

   URINE CULTURE (Final [**2160-7-30**]):
      ESCHERICHIA COLI.    >100,000 ORGANISMS/ML..
         PRESUMPTIVE IDENTIFICATION.
      YEAST.    10,000-100,000 ORGANISMS/ML..

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ESCHERICHIA COLI
                             |
AMPICILLIN------------     8 S
AMPICILLIN/SULBACTAM--     4 S
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CEFUROXIME------------     4 S
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN--------  <=16 S
PIPERACILLIN----------   <=4 S
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S
.
.
[**2160-7-28**] BLOOD CULTURES - PENDING.
[**2160-7-31**] BLOOD CULTURES - PENDING.
[**2160-7-31**] URINE CULTURES - YEAST.
.
.
.
LABS:
[**2160-7-26**] 08:45PM BLOOD WBC-24.1* RBC-4.18* Hgb-12.9* Hct-39.6*
MCV-95 MCH-30.9 MCHC-32.6 RDW-13.7 Plt Ct-282
[**2160-7-27**] 03:28AM BLOOD WBC-20.4* RBC-3.75* Hgb-11.7* Hct-34.4*
MCV-92 MCH-31.3 MCHC-34.1 RDW-13.1 Plt Ct-269
[**2160-7-28**] 03:50AM BLOOD WBC-17.1* RBC-3.52* Hgb-11.1* Hct-32.0*
MCV-91 MCH-31.5 MCHC-34.6 RDW-13.1 Plt Ct-202
[**2160-7-29**] 05:58AM BLOOD WBC-12.4* RBC-3.68* Hgb-11.3* Hct-34.7*
MCV-95 MCH-30.6 MCHC-32.4 RDW-13.4 Plt Ct-210
[**2160-7-30**] 04:41AM BLOOD WBC-12.8* RBC-4.36* Hgb-13.4* Hct-40.3
MCV-93 MCH-30.8 MCHC-33.2 RDW-13.6 Plt Ct-275
[**2160-7-30**] 11:17PM BLOOD WBC-20.2*# RBC-4.32* Hgb-13.5* Hct-39.2*
MCV-91 MCH-31.3 MCHC-34.5 RDW-13.1 Plt Ct-274
[**2160-7-31**] 07:00AM BLOOD WBC-16.9* RBC-4.05* Hgb-12.4* Hct-38.0*
MCV-94 MCH-30.6 MCHC-32.6 RDW-13.5 Plt Ct-252
[**2160-7-31**] 01:10PM BLOOD WBC-14.7* RBC-4.13* Hgb-12.9* Hct-37.9*
MCV-92 MCH-31.1 MCHC-34.0 RDW-13.2 Plt Ct-266
[**2160-7-31**] 06:04PM BLOOD WBC-19.0* RBC-4.30* Hgb-13.2* Hct-39.8*
MCV-93 MCH-30.8 MCHC-33.3 RDW-13.7 Plt Ct-302
[**2160-8-1**] 06:40AM BLOOD WBC-20.1* RBC-4.10* Hgb-12.6* Hct-37.9*
MCV-93 MCH-30.8 MCHC-33.2 RDW-13.5 Plt Ct-282
[**2160-8-2**] 07:00AM BLOOD WBC-22.7* RBC-3.83* Hgb-11.9* Hct-35.5*
MCV-93 MCH-31.1 MCHC-33.6 RDW-13.8 Plt Ct-307
[**2160-7-26**] 08:45PM BLOOD Glucose-746* UreaN-46* Creat-2.9* Na-132*
K-4.8 Cl-95* HCO3-24 AnGap-18
[**2160-7-27**] 03:28AM BLOOD Glucose-202* UreaN-51* Creat-2.8* Na-140
K-3.6 Cl-102 HCO3-26 AnGap-16
[**2160-7-28**] 01:20PM BLOOD Glucose-212* UreaN-58* Creat-2.2* Na-140
K-3.8 Cl-107 HCO3-25 AnGap-12
[**2160-7-30**] 04:41AM BLOOD Glucose-200* UreaN-35* Creat-1.3* Na-147*
K-3.1* Cl-103 HCO3-33* AnGap-14
[**2160-7-31**] 07:00AM BLOOD Glucose-481* UreaN-35* Creat-1.4* Na-143
K-4.2 Cl-103 HCO3-31 AnGap-13
[**2160-7-31**] 06:04PM BLOOD Glucose-277* UreaN-35* Creat-1.5* Na-149*
K-3.9 Cl-108 HCO3-29 AnGap-16
[**2160-8-1**] 01:15PM BLOOD Glucose-262* UreaN-39* Creat-1.5* Na-149*
K-3.3 Cl-105 HCO3-32 AnGap-15
[**2160-8-1**] 06:15PM BLOOD Glucose-295* UreaN-40* Creat-1.5* Na-147*
K-3.2* Cl-102 HCO3-33* AnGap-15
[**2160-8-2**] 07:00AM BLOOD Glucose-170* UreaN-36* Creat-1.5* Na-149*
K-3.4 Cl-102 HCO3-33* AnGap-17
[**2160-7-26**] 11:00PM BLOOD ALT-15 AST-12 LD(LDH)-168 CK(CPK)-98
AlkPhos-106 TotBili-0.4
[**2160-7-27**] 03:28AM BLOOD CK(CPK)-440*
[**2160-7-28**] 03:50AM BLOOD CK(CPK)-407*
[**2160-7-29**] 05:58AM BLOOD CK(CPK)-147
[**2160-7-30**] 11:17PM BLOOD CK(CPK)-74
[**2160-7-31**] 07:00AM BLOOD ALT-26 AST-23 AlkPhos-88 TotBili-0.2
[**2160-8-1**] 06:40AM BLOOD ALT-24 AST-30 AlkPhos-86 TotBili-0.2
[**2160-7-26**] 08:45PM BLOOD CK-MB-5 cTropnT-0.03*
[**2160-7-27**] 03:28AM BLOOD CK-MB-8 cTropnT-0.05*
[**2160-7-29**] 05:58AM BLOOD CK-MB-3 cTropnT-0.02*
[**2160-7-30**] 11:17PM BLOOD CK-MB-2 cTropnT-0.02*
[**2160-7-28**] 01:20PM BLOOD calTIBC-133* Ferritn-434* TRF-102*
[**2160-7-28**] 03:50AM BLOOD Phenoba-7.2* Phenyto-2.2*
[**2160-7-27**] 03:33AM BLOOD Type-ART pO2-71* pCO2-34* pH-7.46*
calTCO2-25 Base XS-0
[**2160-7-27**] 03:46AM BLOOD Type-CENTRAL VE Temp-37.7 pO2-29*
pCO2-47* pH-7.38 calTCO2-29 Base XS-0
[**2160-8-1**] 01:34PM BLOOD Type-[**Last Name (un) **] pO2-189* pCO2-48* pH-7.48*
calTCO2-37* Base XS-11 Comment-GREEN TOP
[**2160-8-2**] 08:03AM BLOOD Type-[**Last Name (un) **] pO2-168* pCO2-46* pH-7.50*
calTCO2-37* Base XS-11 Comment-PERIPHERAL
[**2160-7-26**] 08:48PM BLOOD Glucose-GREATER TH Lactate-4.1*
[**2160-7-29**] 06:29AM BLOOD Lactate-1.5
[**2160-8-1**] 01:34PM BLOOD Lactate-2.2*
[**2160-8-2**] 08:03AM BLOOD Lactate-3.0*

Brief Hospital Course:
Mr. [**Known lastname **] is an 84 year old nursing home resident with dementia,
mental retardation, DM2, chronic indwelling foley transferred
from [**Hospital1 **] [**Location (un) **] with urosepsis, anterior extraperitoneal bladder
perforation and hyperosmolar hyperglycemic state.
.
# Anterior extraperitoneal bladder perforation: CT cystogram
showed no evidence of bladder perforation but per urology
patient likely had micro-perforations.  Patient was comanaged by
urology and [**Hospital Unit Name 153**] team.  Per urology the most likely mechanism
for this bladder perforation would be increased bladder pressure
from CBI.  As it is extraperitoneal perforation, management is
non-operative with decompression.  The 3 way foley was left in
place but 3rd port was capped and not used. Patient had no UOP
on HD2 despite IVF boluses, and he was visibly uncomfortable.
After urology re-positioned the Foley catheter, 1300cc urine
drained from the catheter, and patient felt much better.  His
foley catheter continued to drain urine appropriately, and on
[**7-29**], per urology, plan is for patient to be discharged back to
rehab with foley management as per routine for patients with
chronic foley in place, and urology follow-up as needed.

# abdominal distension/ileus - pt presented with an enlarged
abdomen, which per family, has been chronic, though was notable
larger during this admission.  CT ABD done at [**Hospital1 18**]-[**Location (un) 620**]
revealed chronic appendicititis, moderate fecal loading, and
suggestion of left hydronephrosis, along with the bladder
findings above.  Repeat abdominal xray showed some dilation of
bowel loops, but upon initial interpretation with radiology was
felt to be unchanged from CT ABD.  He was treated with
aggressive bowel regimen, and disimpaction x2 on [**7-31**] and [**8-1**]
with some improvement in his abdominal distension, however upon
further discussion [**7-31**] with radiology, concern was raised for
distension of the stomach, and NGT placement was recommended for
decompression.  However, CT scan [**8-5**] showed decreased colon
size and no sign of obstruction.  At this time his abdominal
distension/ileus appears to have resolved.
.
#Acute renal failure: Creatinine 2.9-3.0 on admission, with
baseline creatinine on [**7-22**] of 1 by report, current exacerbation
likely [**12-24**] dehydration, urosepsis. Patient was volume resuscited
in the ICU, and his creatinine trended down to 2.2. Lisinopril
was held in the setting of ARF. He received intermittent IV
lasix given his tachypnea, and hypoxia with good urine output
(>2L) over the course of his initial course on the medical
service ([**Date range (1) 14790**]), and his creatinine was 1.5 on [**8-1**].  Of
note, CT ABD at [**Hospital1 18**]-N did reveal suggestion of left
hydronephrosis, which was felt to be treated with bladder
decompression above, but should be followed if his creatinine
fails to improve. He is being re-started on his home dose of
Lisinopril at discharge.
.
# Urinary Tract Infection/Septic Shock:  Initial presentation to
the ICU was consistent with septic shock.  He was treated with
IV fluid resuscitation, and did not require pressors. Urine and
blood culture revealed GNR.  Initial labs revealed leukocytosis
(20s) and 13% bandemia, this likely was the cause of initial
confusion at Nursing facility. Patient was initially on empiric
antibiotic therapy with  vancomycin/cefepime/cipro, which was
changed to cefepime once specifiation of GNR was found in blood
culture.  CVP was followed with goal of [**9-1**]. IVF boluses were
given for transient hypotension.
.
Upon transfer to the medical floor, he was switched to
cefpodoxime based on blood and urine cultures demonstrating
sensitivity to ceftriaxone, however, he subsequently developed
recurrence of fever and leukocytosis, and was switched to IV
ceftriaxone on [**2160-7-30**].   He continued to have fevers (101-102),
and on [**2160-7-31**] ID consult was obtained, with recommendation to
switch to IV bactrim given improved urinary penetration, and
fluconazole given persistent funguria. Fluconazole was
discontinued on [**2160-8-19**], renal/bladder ultrasound was negative
for a fungus ball, and, per infectious disease, repeat urine
cultures with yeast would not need to be treated.
.
# Hypoxia/tachypnea/hospital acquired PNA.  Upon arrival to the
medcal floor pt required 2-3L of supplemental oxygen.  This was
felt initially likely [**12-24**] volume overload in the setting of
renal failure and fluid resuscitation in the ICU given his
urosepsis.  Oxygenation did improve initially with iv lasix,
however he continued to maintain his oxygen requirement, with
baseline tachypnea in the 30s.  This was felt likely
multifactorial, with contribution from mild volume overload,
ongoing aspiration events given his confused mental status, and
most prominently, increasing intra-abdominal pressure from
significantly distended abdomen.
.
He was evaluated by speech and swallow service, and placed on a
ground diet with thickened liquids, with strict supervision at
meals.  He was diuresed as below.  his abdominal distension was
treated with aggressive bowel regimen, and disimpaction, with
soome improvement in his abdominal distension.

His was course then complicated by the development of
hospital-acquired PNA possible aspiration requiring intubation
and treatment with vanc/cefepime x 7 days.  His respiratory
status was quite tenuous and ultimately he was extubated with a
plan to focus on comfort measures.  He was briefly on a morphine
gtt but his respiratory status stabilized to the point where he
could be weaned to oxygen by NC and transferred to the floor.
Aspiration remains a concern as below. He is now stable on 2L
NC.

#Aspiration: Pt has a prior history of aspiration.  On initial
evaluation on the floor he was cleared for a ground diet, but
then he required ICU stay for sepsis, UTI, respiratory failure.
Post-extubation his swallow eval showed overt signs of
aspiration and he has remained NPO until a repeat evaluation on
[**2160-8-18**], at which time he was cleared for pureed solids and
nectar thick liquids. He was noted to do best with applesauce,
with some persistent difficulty with mashed potatoes. Please see
detailed nursing instructions regarding how best to feed the
patient.

#Hyperglycemia / Type II Diabetes: most likely [**12-24**] hyperosmolar
hyperglycemic state, unlikely to be diabetic ketoacidosis.  He
had normal bicarb on chem 7. Urine ketones were negative. Home
glyburide was held. Patient was initially on insulin gtt, which
was transitioned to subcutaneous insulin after glucose was
better controlled.
.
Upon arrival to the medical floor, his sugars remained elevated,
though his gap remained closed, and his insulin regimen was
aggressively uptitrated. As his infection is treated, his
regimen will need to be downtitrated appropriately.
.
# Elevated lactate: likely [**12-24**] dehydration from hyperglycemia as
well as bladder perforation and urosepsis. Lactate trended down
with volume resuscitation, and treatment of urosepsis.
.
# Hypernatremia/Hyponatremia: Initial hyponatremia felt [**12-24**]
hyperglycemia, corrected for glucose his sodium is normal at
142.  After arrival to the medical floor, his sodium trended
upward in the setting of delerium and poor oral intake.  He was
diuresed as below, and given D5W boluses prn. Sodium now
normalized.
.
# Hypertension, benign: initial hypotension was [**12-24**] dehydration
from HHS and urosepsis. Patient was given IVF boluses, and his
home antihypertensives (norvasc, lisinopril, isordil, toprol)
were held.  As his blood pressure normalized, metoprolol,
norvasc, isordil were restarted.  During ICU stay his BP meds
had to be converted to IV meds, which were converted back to PO
medications on [**2160-8-18**]. He is scheduled to receive his first
doses of Toprol 100mg Daily, Lisinopril 40mg Daily, and Norvasc
10mg Daily on [**2160-8-19**]. Given his recent sepsis, his HCTZ and
Isordil continued to be held, and should be re-started as needed
for additional blood pressure control.
.
# h/o seizure disorder: Home dose dilantin was continued.
Patient was on Mebaral 32mg TID at home. Phenobarbital was
continued here, and Mebaral should be re-started upon discharge.

.
#Hypothyroid: Home dose synthroid was initially converted to an
IV dose while patient was NPO, and was converted back to his
home PO dose upon discharge.

# osteoporosis: Home dose calcium and vitamin D were temporarily
on hold due to aspiration, and should be re-started at
discharge.
.
# Prophylaxis: Patient was put on pneumoboots, he was put on SQ
heparin later after it was determined that no IR drainage was
not indicated. Home dose PPI was continued.
.
Code:  DNR/DNI, do not re-hospitalize
Contact person: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 84974**] [**0-0-**] (friend),
sister-in-law [**Name (NI) 4100**] [**Name (NI) **] [**Telephone/Fax (1) 84975**]

Patient is being transitioned to Hospice level care, with no
escalation of care if respiratory status declines. Would treat
simple, reversible processes should they arise, such as
bacterial UTI's, elevated blood pressure, or elevated blood
sugar.


Medications on Admission:
Synthroid 25mcg Daily
Mebaral 32mg TID
Dilantin 100mg TID
Glypizide 5mg [**Hospital1 **]
Lisinopril 40mg Daily
Norvasc 10mg Daily
HCTZ 25mg Daily
Toprol XL 150mg Daily
Isordil 10mg TID
Prilosec 20mg Daily
ASA 325 daily
Colace 200mg daily
Sennakot 2 tabs [**Hospital1 **]
Lactulose 15ml [**Hospital1 **]
Tums TID
Vit D [**Numeric Identifier 1871**] q month on the 18th
MVI


Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup [**Numeric Identifier **]: Thirty (30) ML PO TID (3
times a day).
2. Aspirin 325 mg Tablet [**Numeric Identifier **]: One (1) Tablet PO DAILY (Daily).
3. Polyethylene Glycol 3350 17 gram/dose Powder [**Numeric Identifier **]: [**11-23**]  PO
DAILY (Daily) as needed for constipation.
4. Acetaminophen 325 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day (2) **]: One (1) nebullizer Inhalation Q6H (every 6
hours) as needed for shortness of breath or wheezing.
6. Ipratropium Bromide 0.02 % Solution [**Month/Day (2) **]: One (1) nebullizer
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
[**Month/Day (2) **]: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily):
Hold for SBP<100, HR<60.
8. Phenytoin Sodium Extended 100 mg Capsule [**Month/Day (2) **]: One (1) Capsule
PO TID (3 times a day).
9. Lisinopril 20 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO DAILY (Daily):
Hold for SBP<100.
10. Levothyroxine 25 mcg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY
(Daily).
11. Glipizide 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a
day).
12. Amlodipine 5 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO DAILY (Daily).

13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
14. Mebaral 32mg PO TID


Discharge Disposition:
Extended Care

Facility:
[**Location (un) 1036**] - [**Location (un) 620**]

Discharge Diagnosis:
Sepsis of a urinary source
Hospital acquired pneumonia
Bladder perforation
Aspiration


Discharge Condition:
Stable


Discharge Instructions:
Patient to be transitioned to Hospice level care. Continue all
home medications; do not re-hospitalize, DNR/DNI. Please obtain
Hospice consult for further evaluation.

Followup Instructions:
Hospice Care
{'Septicemia due to escherichia coli [E. coli],Acute kidney failure, unspecified,Septic shock,Pneumonia, organism unspecified,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Diabetes with hyperosmolarity, type II or unspecified type, uncontrolled,Other forms of epilepsy and recurrent seizures, without mention of intractable epilepsy,Urinary tract infection, site not specified,Paralytic ileus,Other complications due to genitourinary device, implant, and graft,Hydronephrosis,Hyposmolality and/or hyponatremia,Inguinal hernia, with obstruction, without mention of gangrene, unilateral or unspecified (not specified as recurrent),Cystitis, unspecified,Severe sepsis,Accidental cut, puncture, perforation or hemorrhage during other specified medical care,Accidents occurring in residential institution,Urinary catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Unspecified intellectual disabilities,Osteoporosis, unspecified,Urinary incontinence, unspecified,Other appendicitis,Atrial fibrillation,Diverticulosis of colon (without mention of hemorrhage),Hypoxemia,Benign essential hypertension,Anemia, unspecified'}


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: bladder perforation

PRESENT ILLNESS: Mr. [**Known lastname **] is an 84y/o male NH resident transferred from [**Hospital1 **]
[**Location (un) **] with extraperitoneal bladder perforation.  Pt presented
to [**Hospital1 **] [**Location (un) 620**] earlier today with incrasing confusion, SOB and
hematuria s/p foley change last night at his nursing home. At [**Hospital1 **]
[**Location (un) **], a three-way foley was put in and bladder irrigation was
done.  A CT Abdomen showed extraperitoneal bladder rupture and
an anterior fluid collection.  He was given 500 mg IV Flagyl and
Levaquin 500 mg IV.  He was also given 10U regular insulin bc he
was found to have a glucose of 1021.  Also, found to have
Lactate of 7.1 and Na of 126.  Pt was also given total of 2.5L
NS in boluses. Pt was then transferred to [**Hospital1 18**].
.
In the ED, VS: T 98.6 BP 96/60 HR 92 RR 20 O2Sat 97% on 2L NC.
There, pt was tachypnic to 35.  RIJ line was placed. q1h
fingersticks and q2h chem 7 were done and an insulin gtt at 8
units per hours was started.  He received a total of 3L NS IV,
SBP remained in 90s.  He had 1.5L of UOP in ED. No antibiotics
were given in the ED here.  Surgery and Urology were c/s.
Urology rec foley catheter to drainage, clamp CBI port, do not
irrigate bladder, when stablized, CT cystogram and possible IR
drainage of extraperitoneal fluid collection after CT cystogram.
.
On the floor, pt was tachypnic 28-30, complained of no pain. Pt
was awake, oriented x1, unable to communicate effectively.
.
Review of sytems: unable to elicit

MEDICAL HISTORY: HTN
DM2
Atrial fibrillation
hematuria
Seizure disorder
Urinary incontinence, chronic indwelling foley catheter
Recurrent UTI's
Mental retardation - reportedly confused at baseline but is able
to express his needs
Dementia
Osteoporsis
Hx of abdominal pain/chronic appendicitis (?)
Hx Aspiration PNA (Diet: Mech soft, nectar thick, asp
precautions)
Ex lap for lysis of adhesion

MEDICATION ON ADMISSION: Synthroid 25mcg Daily
Mebaral 32mg TID
Dilantin 100mg TID
Glypizide 5mg [**Hospital1 **]
Lisinopril 40mg Daily
Norvasc 10mg Daily
HCTZ 25mg Daily
Toprol XL 150mg Daily
Isordil 10mg TID
Prilosec 20mg Daily
ASA 325 daily
Colace 200mg daily
Sennakot 2 tabs [**Hospital1 **]
Lactulose 15ml [**Hospital1 **]
Tums TID
Vit D [**Numeric Identifier 1871**] q month on the 18th
MVI

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 97.2 BP: 98/44 P:90 R:30 O2: 91-93% on 3L NC
General: drowsy, arousable, oriented x1
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB anteriorly
CV: RRR, no murmurs, rubs, gallops
Abdomen: soft, non-tender, distended, bowel sounds present, no
rebound tenderness or guarding, no dullness to percussion
GU: foley in plce draining red-tinged urine
Ext: warm, well perfused, 1+ BLE edema, onychomycosis bilat

FAMILY HISTORY: NC

SOCIAL HISTORY: Resides in nursing home/Manor Care.  Baseline needs assist with
some ADL's, feed/toilets himself, walks with walker. 

### Response:
{'Septicemia due to escherichia coli [E. coli],Acute kidney failure, unspecified,Septic shock,Pneumonia, organism unspecified,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Diabetes with hyperosmolarity, type II or unspecified type, uncontrolled,Other forms of epilepsy and recurrent seizures, without mention of intractable epilepsy,Urinary tract infection, site not specified,Paralytic ileus,Other complications due to genitourinary device, implant, and graft,Hydronephrosis,Hyposmolality and/or hyponatremia,Inguinal hernia, with obstruction, without mention of gangrene, unilateral or unspecified (not specified as recurrent),Cystitis, unspecified,Severe sepsis,Accidental cut, puncture, perforation or hemorrhage during other specified medical care,Accidents occurring in residential institution,Urinary catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Unspecified intellectual disabilities,Osteoporosis, unspecified,Urinary incontinence, unspecified,Other appendicitis,Atrial fibrillation,Diverticulosis of colon (without mention of hemorrhage),Hypoxemia,Benign essential hypertension,Anemia, unspecified'}
