CHIEF COMPLAINT: fever, abdominal pain

PRESENT ILLNESS: HPI: 81 year old male, CP, A fib hx,L DVT in femoral vein,
started to develop GIB, , s/p IVC filter RA on MTX and
prednisone, recently admitted for worsening hip pain and
inability to walk, and recent CT of abd/hip that revealed
diverticular abscess [**3-4**] to perforated diverticulum and s/p
drainage and drain removed on [**9-28**]. CT scan noted abscess well
drained. He was d/c back to rehab Vanc/Levo/Flagyl. levaquin 500
qd x 3, ticarcillin 3.1 gm IV
He is was noted to have spiking over past 24-48 hrs
(101.8-103.8) with highest 103. 8 at 10pm on [**9-28**]. CXR -> LLL
infiltrate . He was examed by HO at 9pm on [**9-28**] He did not have
any complaints to HO at rehab. He denies any abd pain, SOB or
SOB, no diarrhea. No cough or sputum. He was given vanco X 1. On
exam, CV: tachy, abd: no pain on deep palp, no rebound, Resp:
scattered rales, Ext: + pain w/ flexor of L hip
He c/o [**9-9**] CP this AM at 9am. He was given asa, sub lingual
nitro, BP 100/60, P 132-> 5 mins post 162/88 P 192 A fib and 2nd
sublingual nitro given-> 10 mins post, BP 172/88 P 192, 2nd
nitro sl given-> 9am 5 mg lopressor, HR down to 130s.CP
disspiated at 945am. BP normalized in 100/60 at 10am. He was
admitted to [**Hospital1 18**]  where sepsis protocal was initiated in the ED
after CT abd showed marked increase in the size of the LLQ
abscess associated with ileopsoas muscle and extending into the
thigh. Bilateral residual pulmonary emboli were also noted

MEDICAL HISTORY: 1) Perforated diverticulum with pelvic abscess
[**Hospital1 18**] admission, his CT pelvis which revealed a large left
pelvic abscess (7.3 x 11.1 x 14.4 cm), felt likely secondary to
perforated diverticulum. He underwent CT-guided drainage of his
abscess on [**9-3**] in IR, and was started on emipiric abx with
Levo/Flagyl. Vanco added following an episode of hypotension
responsive to IVF, D/C'd [**9-7**]. He was also started on Heparin
on [**9-3**] with initial bolus for PE, and Coumadin started on
[**9-4**].
On [**2178-9-7**], Mr. [**Known lastname 50388**] had an episode of BRBPR, initially with
BM described as 3 "coinsized clots", then 2 further episodes
with clots without stools. Hct drop 34 last night-->27 this AM,
transfused an additional unit of PRBCs. Hemodynamically stable
overnight, but this AM BP drop to 84/60, with spontaneous
recovery. PTT intermittently supratherapeutic (101, 108, 143) in
past days, INR 2.5 this AM. Still on heparin, last Coumadin on
[**9-6**]. Last C-scope in [**2172**] with diverticulosis. Only prior
history of occasional blood on toilet paper after straining.

MEDICATION ON ADMISSION: Insulin SS
Linezolid 600 mg IV Q12H
Aspirin 325 mg PO DAILY
Atorvastatin 20 mg PO DAILY
Meropenem 1000 mg IV Q8H
Metoprolol 12.5 mg PO QID
Caspofungin 50 mg IV Q24H
Ezetimibe 10 mg PO DAILY
Pantoprazole 40 mg PO Q24H
Folic Acid 1 mg PO DAILY
Furosemide 20 mg IV
Prednisone 5 mg PO DAILY
Heparin 5000 UNIT SC TID

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T98.9 BP110-138/60-90  HR84-90  RR20-22  o2sat: 94-98%RA
Is/Os 1750/4200cc over 24 hrs   FS99-247
HEENT: O/P clear. Anicteric sclera.
Neck: Supple.
CV: Regular, occasional irreg beats.  Nml s1,s2.  No s3 or
murmur
Resp: CTAB with occasional crackles at the bases.
Abd: Soft. NTND.  +BS.  No TTP over LLQ.  No HSM.  No rebound or
gurading.  No erythema or TTP over JP drain site.
Ext: [**2-1**]+ edema to mid-shins bilat.
GU: no CVA tenderness
Neuro: AAOx3, moves all extremities

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: No etoh, no tob, was at [**Hospital **] rehab since d/c from [**9-25**],
previously lived w/ wife ( who is unofficial HCP)
Unspecified septicemia,Septic shock,Atrial fibrillation,Acute kidney failure with lesion of tubular necrosis,Other disorders of muscle, ligament, and fascia,Other candidiasis of other specified sites,Other pulmonary embolism and infarction,Congestive heart failure, unspecified,Abscess of intestine,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Diverticulitis of colon (without mention of hemorrhage),Dermatophytosis of nail,Other chest pain,Severe sepsis,Rheumatoid arthritis,Long-term (current) use of steroids
Septicemia NOS,Septic shock,Atrial fibrillation,Ac kidny fail, tubr necr,Muscle/ligament dis NEC,Candidiasis site NEC,Pulm embol/infarct NEC,CHF NOS,Intestinal abscess,Ac DVT/emb prox low ext,Dvrtcli colon w/o hmrhg,Dermatophytosis of nail,Chest pain NEC,Severe sepsis,Rheumatoid arthritis,Long-term use steroids
Admission Date:  [**2178-9-29**]              Discharge Date:   [**2178-10-11**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**Last Name (NamePattern1) 1572**]
Chief Complaint:
fever, abdominal pain

Major Surgical or Invasive Procedure:
JP drain placement


History of Present Illness:
HPI: 81 year old male, CP, A fib hx,L DVT in femoral vein,
started to develop GIB, , s/p IVC filter RA on MTX and
prednisone, recently admitted for worsening hip pain and
inability to walk, and recent CT of abd/hip that revealed
diverticular abscess [**3-4**] to perforated diverticulum and s/p
drainage and drain removed on [**9-28**]. CT scan noted abscess well
drained. He was d/c back to rehab Vanc/Levo/Flagyl. levaquin 500
qd x 3, ticarcillin 3.1 gm IV
He is was noted to have spiking over past 24-48 hrs
(101.8-103.8) with highest 103. 8 at 10pm on [**9-28**]. CXR -> LLL
infiltrate . He was examed by HO at 9pm on [**9-28**] He did not have
any complaints to HO at rehab. He denies any abd pain, SOB or
SOB, no diarrhea. No cough or sputum. He was given vanco X 1. On
exam, CV: tachy, abd: no pain on deep palp, no rebound, Resp:
scattered rales, Ext: + pain w/ flexor of L hip
He c/o [**9-9**] CP this AM at 9am. He was given asa, sub lingual
nitro, BP 100/60, P 132-> 5 mins post 162/88 P 192 A fib and 2nd
sublingual nitro given-> 10 mins post, BP 172/88 P 192, 2nd
nitro sl given-> 9am 5 mg lopressor, HR down to 130s.CP
disspiated at 945am. BP normalized in 100/60 at 10am. He was
admitted to [**Hospital1 18**]  where sepsis protocal was initiated in the ED
after CT abd showed marked increase in the size of the LLQ
abscess associated with ileopsoas muscle and extending into the
thigh. Bilateral residual pulmonary emboli were also noted

Pt had fevers/sepsis on admission which was from diverticular
abscess but also concern for about PICC line infection.  PICC
line was d/c on [**9-29**] - no growth from tip.  Blood culture from
[**9-29**] grew [**Female First Name (un) **] parapsilosis ([**2-3**]). Blood cultures are
negative to date subsequent. A drain was placed by IR on [**10-1**] by
CT guidance.  Colorectal surgery has been following.  Abscess
culture from [**10-1**] grew entrococcus (vanc/amp/levo/pcn resistant)
and yeast (likely c. albicans). Pt covered linezolid (hx VRE),
meropenem (for GNR and anaerobes) and caspofungin (fungemia) .
Infectious disease team has been following.  Right IJ line was
d/c and tip showed no growth. Pt has been afebrile for past 48
hours.  His WBC count has improved from 14K to 6k since
admission.
Pt blood pressure runs in SBP 90-100.  HR is controlled with QID
metoprolol.  Today the MICU team is attempting gentle diuresis
for volume overload

Past Medical History:
1) Perforated diverticulum with pelvic abscess
[**Hospital1 18**] admission, his CT pelvis which revealed a large left
pelvic abscess (7.3 x 11.1 x 14.4 cm), felt likely secondary to
perforated diverticulum. He underwent CT-guided drainage of his
abscess on [**9-3**] in IR, and was started on emipiric abx with
Levo/Flagyl. Vanco added following an episode of hypotension
responsive to IVF, D/C'd [**9-7**]. He was also started on Heparin
on [**9-3**] with initial bolus for PE, and Coumadin started on
[**9-4**].
On [**2178-9-7**], Mr. [**Known lastname 50388**] had an episode of BRBPR, initially with
BM described as 3 "coinsized clots", then 2 further episodes
with clots without stools. Hct drop 34 last night-->27 this AM,
transfused an additional unit of PRBCs. Hemodynamically stable
overnight, but this AM BP drop to 84/60, with spontaneous
recovery. PTT intermittently supratherapeutic (101, 108, 143) in
past days, INR 2.5 this AM. Still on heparin, last Coumadin on
[**9-6**]. Last C-scope in [**2172**] with diverticulosis. Only prior
history of occasional blood on toilet paper after straining.

2) CAD since [**2138**], s/p IMI in [**2145**]. Stress thallium in [**2163**] with
redistributing posterolateral and inferior defect.
3) Hypertension
4) Hyperlipidemia
5) Rheumatoid arthritis, recently diagnosed, on Prednisone 5 mg
PO BID and Methotrexate 10 mg Qwk
6) Diverticulosis, last colonoscopy in [**2172**]
7)VRE but unclear sources
8)RLL PE ([**2178-9-28**]), bilat DVT
9) GI bleed on last admission, coumadin and hep held -> filter
placed by IR  s/p IVC filter (removable)

Social History:
No etoh, no tob, was at [**Hospital **] rehab since d/c from [**9-25**],
previously lived w/ wife ( who is unofficial HCP)

Family History:
Noncontributory

Physical Exam:
VS: T98.9 BP110-138/60-90  HR84-90  RR20-22  o2sat: 94-98%RA
Is/Os 1750/4200cc over 24 hrs   FS99-247
HEENT: O/P clear. Anicteric sclera.
Neck: Supple.
CV: Regular, occasional irreg beats.  Nml s1,s2.  No s3 or
murmur
Resp: CTAB with occasional crackles at the bases.
Abd: Soft. NTND.  +BS.  No TTP over LLQ.  No HSM.  No rebound or
gurading.  No erythema or TTP over JP drain site.
Ext: [**2-1**]+ edema to mid-shins bilat.
GU: no CVA tenderness
Neuro: AAOx3, moves all extremities

Pertinent Results:
[**2178-10-9**] 05:40AM BLOOD WBC-8.8 RBC-3.59* Hgb-10.7* Hct-32.2*
MCV-90 MCH-29.8 MCHC-33.2 RDW-16.7* Plt Ct-210
[**2178-10-9**] 05:40AM BLOOD Plt Ct-210
[**2178-10-9**] 05:40AM BLOOD Glucose-78 UreaN-22* Creat-1.0 Na-139
K-3.8 Cl-102 HCO3-27 AnGap-14
[**2178-10-8**] 05:35AM BLOOD ALT-30 AST-27 LD(LDH)-173 AlkPhos-66
TotBili-0.2
[**2178-10-9**] 05:40AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.5*

[**2178-9-21**] 1:30 pm ABSCESS      Source: LLQ drain.

                            **FINAL REPORT [**2178-9-27**]**

   GRAM STAIN (Final [**2178-9-21**]):
      4+   (>10 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      2+   (1-5 per 1000X FIELD):   GRAM NEGATIVE ROD(S).

   FLUID CULTURE (Final [**2178-9-25**]):
      Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
      workup is performed appropriate to the isolates recovered
from the
      site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
      aureus and beta streptococcus).
      CITROBACTER FREUNDII COMPLEX.    MODERATE GROWTH.
         Trimethoprim/Sulfa sensitivity available on request.
      ENTEROCOCCUS SP..    SPARSE GROWTH.
      YEAST.    SPARSE GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             CITROBACTER FREUNDII COMPLEX
                             |          ENTEROCOCCUS SP.
                             |          |
AMPICILLIN------------             =>32 R
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CHLORAMPHENICOL-------                8 S
GENTAMICIN------------     4 S
IMIPENEM--------------   <=1 S
LEVOFLOXACIN----------   0.5 S      =>8 R
MEROPENEM-------------<=0.25 S
PENICILLIN------------             =>64 R
PIPERACILLIN----------   <=4 S
PIPERACILLIN/TAZO-----     8 S
TOBRAMYCIN------------     4 S
VANCOMYCIN------------             =>32 R

   ANAEROBIC CULTURE (Final [**2178-9-27**]):
      BACTEROIDES FRAGILIS GROUP.    SPARSE GROWTH.
         BETA LACTAMASE POSITIVE.

                            **FINAL REPORT [**2178-10-5**]**

   AEROBIC BOTTLE (Final [**2178-10-3**]):
      REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Doctor Last Name 17975**] ON [**2178-10-1**] @ 10:10AM.
      [**Female First Name (un) **] PARAPSILOSIS.

   ANAEROBIC BOTTLE (Final [**2178-10-5**]):    NO GROWTH.


Brief Hospital Course:
A/P: 81 year old, CAD, HTN, recent admission w/ diverticular
abscess, s/p drainage, hosp course c/b PE/DVT and GIB likely [**3-4**]
anticoagulation, d/c to [**Hospital1 **] for rehab, re-presented with hx
of 24-48 hx of fever and CP, with a 5 day stay in the MICU s/p
IVF, [**Last Name (un) **]/Caspo/Linezolid, pRBC, never required pressors or
intubation.
*
1.  Fever
Patient with recurrant LLQ intraabdominal abscess as seen on abd
CT, s/p drainage.  Cx's have grown VRE, C.parapsilosis,
Citrobacter, Bacteroides at various times of drainage.
-Pt afebrile, without leukocytosis, appears resolving today.
Continues to have minor pus drainage from JP drain, <50cc/day.
Cont to flush drain with 10cc twice daily, and monitor for
patency.
-ID following, appreciate recs
-Cont Levaquin 500mg po qD, Flagyl 500mg po q8, Diflucan 400 mg
po qD, Linezolid 600 PO qD.
- Will check repeat CT abd in 2 weeks to look for resolution of
abscess.
-Surgery following, who believes that surgical intervention is
not required at the present time.  Pt to continue to have drain
in place, to follow up with Dr. [**Last Name (STitle) **] in 2 weeks to
reevaluate surgical candidacy.
-PICC line pulled on [**9-29**]
-R IJ pulled on [**10-1**] -> tip sent for cx, (-) on cx.
-Pt with hx of onchomycosis predating diverticular abscess,
candidemia.  No need for ECHO, r/o endocarditis at this time.
Cont diflucan.
*
2. CP - now resolved.
-unclear etiology, resolved since admission
-No new PE per reread of CTA
-admission EKG notable for a fib but resolved to sinus on
admission s/p fluid boluses
-3 sets of CKs flat, trop peaked 0.44 on [**9-30**]
-monitor clinically for now
*
3. A fib - now resolved
-initial a fib likely in setting of sepsis but resolved to sinus
on admission
-no anticoag per hx of GIB, IVC filter in place.
-returned to a fib on [**9-30**], lopressor IV given x 3 this AM
-continue on lopressor 25mg [**Hospital1 **]
*
4. CAD
-Cont ASA, Lopressor increased to 25mg [**Hospital1 **] (originally held with
GIB, sepsis)
-d/c'ed Zetia, Atorvastatin due to risk of LFT abnormalities.
Restart under direction of Dr. [**Last Name (STitle) **], PCP.
*
5. CHF
Patient currently volume overloaded, with 2+ pitting edema, but
improving on Lasix and increased mobilization with PT.
-Cont Lasix 20mg PO qD, putting out good UOP to this dose
-Goal -1L per day.
*
5. PE/DVT
- No new PE on reread of CTA on [**9-29**]; residual PE remains from
before, femoral DVTs bilaterally remain.  Pt not a candidate for
coumadin d/t GI bleed hx.
-IVC filter in place.  Cont to hold anticoagulation.
*
6. Anemia
-baseline 31-32, currently at baseline.
-goal hct>27
-daily hct, transfuse as needed.
*
7. ARF - now resolved
-initially 1.3 up from 0.9-1.0 but resolved to baseline 0.9 s/p
fluid boluses
-likely [**3-4**] to shock/ATN, now resolved.
*
8. Adenopathy on abd CT
- f/u abd CT as outpt
*
9. RA
Pt complaining of worsening R shoulder and R elbow pain.
Patient in past had RA mostly in bilat knee, but has had
shoulder pain in past.  Patient has been off MTX x4 weeks, and
at a lower dose of prednisone due to infection/sepsis.
-Consulted rheum , will cont pred at dose of 5mg po qd today -
pt more comfortable.  If continues to have escalating pain, will
consider increasing to [**Hospital1 **], although in lieu of systemic
infection, will not increase steroid dose unless absolutely
necessary.  No joints appear septic at this time - will continue
to closely monitor.
-Hold off MTX for now due to infection risk.  No NSAIDs due to
GI bleed.
-Cont pain medicine as tolerated.
*
10. FEN:
-continue cardiac/low residue diet
*
11. PPX: IVC filter, hep sc, holding coumadin d/t GIB hx. C.dif
(-) x2.
*
12. Hyperglycemia
No hx of DM.  In light of infection, will attempt to control
sugars while currently infected.
- Cont NPH 4mg SQ qAM with breakfast, and Insulin SS with
regular insulin throughout day to prevent high sugars leading to
worsening infection.
*
13. Code: full
*
14. Drain: JP drain in place.  Please flush with 10cc NS [**Hospital1 **] -
tid and ensure that are removing amount flushed to ensure
patency.  Drain was noted to be out of place on [**10-9**], and patient
was taken down to CT to have his drain re-placed in the abscess.

*
15.  DISPO:  Pt is being discharged to Rehab today.  Pt
continues to have drain in place, which will remain in place for
a minimum of 2 weeks, until has a repeat CT scan of abdomen in 2
weeks to evaluate for resolution of his abscess.  Continue pt on
4 ABx regimen (Linezolid, Levaquin, Flagyl, Diflucan PO) for a
minimum of 2 weeks, and do not stop unless instructed by ID
fellow, Dr. [**Last Name (STitle) 4334**].  Pt is tolerating PO diet, and ambulating
with assistance of walker.  Please continue to improve his
functional status with rehab, along with proper drain
maintainence.  Please refer to the numbers below for his
continued follow up.
*
*
Consults
PCP [**Name Initial (PRE) **] [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]  ([**Telephone/Fax (1) 16148**]
ID- Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4334**] ([**Telephone/Fax (1) 457**]
Gen Surgery - Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 1483**]

Medications on Admission:
Insulin SS
Linezolid 600 mg IV Q12H
Aspirin 325 mg PO DAILY
Atorvastatin 20 mg PO DAILY
Meropenem 1000 mg IV Q8H
Metoprolol 12.5 mg PO QID
Caspofungin 50 mg IV Q24H
Ezetimibe 10 mg PO DAILY
Pantoprazole 40 mg PO Q24H
Folic Acid 1 mg PO DAILY
Furosemide 20 mg IV
Prednisone 5 mg PO DAILY
Heparin 5000 UNIT SC TID

Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.

6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical  TID
(3 times a day) as needed.
9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).

10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
13. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
14. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
15. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000
(5000) Unit Injection TID (3 times a day).
[**Telephone/Fax (1) **]:*[**Numeric Identifier 31034**] Unit* Refills:*2*
18. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: Scale
as below Insulin Scale Subcutaneous four times a day: FS 150-200
Give 2 Units
FS 200-250 Give 4 Units
FS 250-300 Give 6 units
FS 300-350 Give 8 Units
FS 350-400 Give 10 Units
FS >400 Call physician.
[**Name Initial (NameIs) **]:*300 Insulin Scale* Refills:*2*
19. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Four (4)
Units Subcutaneous qBreakfast.
[**Name Initial (NameIs) **]:*10 mL* Refills:*2*


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
1. Diverticular Abscess
2. Hypertension
3. Coronary Artery Disease.


Discharge Condition:
Stable to be discharged to rehab.


Discharge Instructions:
1. Please continue all medications as prescribed. Please
continue all antibiotics until your next ID appointment. Please
schedule a follow up appointment with Dr. [**Last Name (STitle) **] in 2 weeks
after discharge.  Please call ([**Telephone/Fax (1) 1483**] to schedule that
appointment.
.
2. Please have abdominal CT scan on [**2178-10-15**].
.
3. The JP drain should remain in place until follow up with ID
(Dr. [**Last Name (STitle) 4334**], and Dr. [**Last Name (STitle) **].

Followup Instructions:
CT Scan of abdomen.  Where: [**Hospital Ward Name 452**] 3 ([**Hospital Ward Name 516**]).   When:
[**2178-10-15**] at 8:45 am.  You must not eat or drink anything after
4am on [**2178-10-15**].
.
Provider: [**Name10 (NameIs) 12082**] CARE ID Where: LM [**Hospital Unit Name 4337**]
DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2178-10-22**] 2:00
.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 4337**]
DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2178-11-5**] 11:30
.
Provider: [**Name10 (NameIs) **] WEST,ROOM FOUR GI ROOMS Where: GI ROOMS
Date/Time:[**2178-10-28**] 10:00
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],MD Where: [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **] COMPLEX)
Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2178-10-28**] 10:00
.
{'Unspecified septicemia,Septic shock,Atrial fibrillation,Acute kidney failure with lesion of tubular necrosis,Other disorders of muscle, ligament, and fascia,Other candidiasis of other specified sites,Other pulmonary embolism and infarction,Congestive heart failure, unspecified,Abscess of intestine,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Diverticulitis of colon (without mention of hemorrhage),Dermatophytosis of nail,Other chest pain,Severe sepsis,Rheumatoid arthritis,Long-term (current) use of steroids'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: fever, abdominal pain

PRESENT ILLNESS: HPI: 81 year old male, CP, A fib hx,L DVT in femoral vein,
started to develop GIB, , s/p IVC filter RA on MTX and
prednisone, recently admitted for worsening hip pain and
inability to walk, and recent CT of abd/hip that revealed
diverticular abscess [**3-4**] to perforated diverticulum and s/p
drainage and drain removed on [**9-28**]. CT scan noted abscess well
drained. He was d/c back to rehab Vanc/Levo/Flagyl. levaquin 500
qd x 3, ticarcillin 3.1 gm IV
He is was noted to have spiking over past 24-48 hrs
(101.8-103.8) with highest 103. 8 at 10pm on [**9-28**]. CXR -> LLL
infiltrate . He was examed by HO at 9pm on [**9-28**] He did not have
any complaints to HO at rehab. He denies any abd pain, SOB or
SOB, no diarrhea. No cough or sputum. He was given vanco X 1. On
exam, CV: tachy, abd: no pain on deep palp, no rebound, Resp:
scattered rales, Ext: + pain w/ flexor of L hip
He c/o [**9-9**] CP this AM at 9am. He was given asa, sub lingual
nitro, BP 100/60, P 132-> 5 mins post 162/88 P 192 A fib and 2nd
sublingual nitro given-> 10 mins post, BP 172/88 P 192, 2nd
nitro sl given-> 9am 5 mg lopressor, HR down to 130s.CP
disspiated at 945am. BP normalized in 100/60 at 10am. He was
admitted to [**Hospital1 18**]  where sepsis protocal was initiated in the ED
after CT abd showed marked increase in the size of the LLQ
abscess associated with ileopsoas muscle and extending into the
thigh. Bilateral residual pulmonary emboli were also noted

MEDICAL HISTORY: 1) Perforated diverticulum with pelvic abscess
[**Hospital1 18**] admission, his CT pelvis which revealed a large left
pelvic abscess (7.3 x 11.1 x 14.4 cm), felt likely secondary to
perforated diverticulum. He underwent CT-guided drainage of his
abscess on [**9-3**] in IR, and was started on emipiric abx with
Levo/Flagyl. Vanco added following an episode of hypotension
responsive to IVF, D/C'd [**9-7**]. He was also started on Heparin
on [**9-3**] with initial bolus for PE, and Coumadin started on
[**9-4**].
On [**2178-9-7**], Mr. [**Known lastname 50388**] had an episode of BRBPR, initially with
BM described as 3 "coinsized clots", then 2 further episodes
with clots without stools. Hct drop 34 last night-->27 this AM,
transfused an additional unit of PRBCs. Hemodynamically stable
overnight, but this AM BP drop to 84/60, with spontaneous
recovery. PTT intermittently supratherapeutic (101, 108, 143) in
past days, INR 2.5 this AM. Still on heparin, last Coumadin on
[**9-6**]. Last C-scope in [**2172**] with diverticulosis. Only prior
history of occasional blood on toilet paper after straining.

MEDICATION ON ADMISSION: Insulin SS
Linezolid 600 mg IV Q12H
Aspirin 325 mg PO DAILY
Atorvastatin 20 mg PO DAILY
Meropenem 1000 mg IV Q8H
Metoprolol 12.5 mg PO QID
Caspofungin 50 mg IV Q24H
Ezetimibe 10 mg PO DAILY
Pantoprazole 40 mg PO Q24H
Folic Acid 1 mg PO DAILY
Furosemide 20 mg IV
Prednisone 5 mg PO DAILY
Heparin 5000 UNIT SC TID

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T98.9 BP110-138/60-90  HR84-90  RR20-22  o2sat: 94-98%RA
Is/Os 1750/4200cc over 24 hrs   FS99-247
HEENT: O/P clear. Anicteric sclera.
Neck: Supple.
CV: Regular, occasional irreg beats.  Nml s1,s2.  No s3 or
murmur
Resp: CTAB with occasional crackles at the bases.
Abd: Soft. NTND.  +BS.  No TTP over LLQ.  No HSM.  No rebound or
gurading.  No erythema or TTP over JP drain site.
Ext: [**2-1**]+ edema to mid-shins bilat.
GU: no CVA tenderness
Neuro: AAOx3, moves all extremities

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: No etoh, no tob, was at [**Hospital **] rehab since d/c from [**9-25**],
previously lived w/ wife ( who is unofficial HCP) 

### Response:
{'Unspecified septicemia,Septic shock,Atrial fibrillation,Acute kidney failure with lesion of tubular necrosis,Other disorders of muscle, ligament, and fascia,Other candidiasis of other specified sites,Other pulmonary embolism and infarction,Congestive heart failure, unspecified,Abscess of intestine,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Diverticulitis of colon (without mention of hemorrhage),Dermatophytosis of nail,Other chest pain,Severe sepsis,Rheumatoid arthritis,Long-term (current) use of steroids'}
