CHIEF COMPLAINT: Hypotension, hypoxia

PRESENT ILLNESS: 75M with h/o ESRD on HD, chronic trach/vent [**1-17**] PNA [**12-23**], T2DM,
recent PEG removal, presenting from NH after being found with
decreased responsiveness and found to have hypotension and
hypoxia at NH. Baseline BP is 90-100 systolic. Physician called
to bedside 3:30am for periodic leg muscle twitching, due to his
h/o seizures. He was noted to be A&Ox3 and asymptomatic, with T
99.1F, satting 94% on 40% TM, RR 18, BP 98/60, FS 193. Over the
next 2-3 hours, he became intermittently restless and lethargic
but per EMS records, patient became less responsive, with repeat
BP of 60/40, which improved to 80/40 with a 250mL bolus. HR was
116-120 in AF with RVR, RR 22, SaO2 94-7% on 100% TM. Patient
does have known stage 2-4 sacral decubs, and known fistulous
track from removal of PEG recently removed due to leak. NH staff
have been attempting to give him pills PO with purees, no
reports of aspiration per family.
.
In the ED, initial VS were T 99.4F, BP: 69/26, HR: 115, RR: 26,
SaO2: 91% on 40% TM. He was given 2L NS, whereupon IVF were
stopped due to a CXR consistent with volume overload. Reportedly
due for HD today. BP improved to 90/40, and levophed was started
through a preexisting midline catheter, raising BP to 128/68 at
Levophed at 0.05. He was found to have a leukocytosis to 30.1
with 92% PMN, lactate 1.6. Chem 7 and LFTs near baseline. As
mentioned, CXR demonstrated moderate pulmonary edema with
bilateral effusions, can't exclude underlying PNA. An abd/pelvis
CT was done to r/o abdominal wall abscess due to recent leaking
PEG. The CT showed no fluid collections, cholelithiasis with
mild GB wall edema, and likely retroperitoneal adenopathy. A RUQ
U/S was done which again showed cholelithiasis with no evidence
of cholecystitis. Cultures were drawn from midline, and he was
started on vanc/Levofloxacin, and Flagyl.
.
MICU course: Hypotension and hypoxia found to be due to Serratia
sepsis. The source of the sepsis was felt to be his HD catheter,
aspiration PNA, sacral decubs/ LE ulcers or infection along the
fistulous track from recent PEG. Patient initially resusitated
on IVFs, but given development of pulmonary edema he was changes
to pressor support with levophed. He was weaned off pressors
after being given albumin.  He was weaned off the ventilator and
onto his trach collar after drainage of a right pleural
effusion. He remains on vancomycin and ciprofloxacin (initially
had been on vanc, meropenem and tobramycin). He was transferred
to the floor for further management.

MEDICAL HISTORY: # DM2
# CRI (baseline 2.5)- recently started on HD
# CHF
# Trached and vent dependent [**1-17**] PNA in [**12-23**]
# PNA [**4-23**] with BAL growing stenotrophomonas (Bactrim sensitive)
and acenitobacter ([**Last Name (un) 36**] to Unasyn, Gent and Tobra, resistant to
FQ, ceftaz, cefepime)
# ESBL Klebsiella UTI [**3-24**]
# Morbid obesity
# Afib on Coumadin
# Hypercholesterolemia
# Known coccyx ulcers

MEDICATION ON ADMISSION: Home Meds:
1. Metoprolol 25mg PO TID
2. Simvastatin 10mg PO DAILY
3. Insulin Glargine 18 units once a day.
4. Insulin Regular SSI (5U for FS 151-200, 6U 201-300, 7U if
above 300)
5. Citalopram 20mg PO DAILY
6. Clonazepam 0.5mg PO TID prn anxiety.
7. Trazodone 50mg PO HS as needed.
8. Albuterol MDI 6-8 Puffs Inhalation Q4H as needed
9. Ipratropium inh Q4H as needed
10. Oxycodone-Acetaminophen 5-325 mg/5 mL: 5-10 MLs PO Q6H as
needed
11. Acetaminophen 325mg PO Q6H as needed.
12. Docusate Sodium 50 mg/5 mL PO BID as needed.
13. Miconazole 2% Powder TID as needed.
14. Heparin 5,000 unit/mL SC TID
15. Warfarin 3mg PO daily at 4 PM
16. Lansoprazole 30mg PO daily
17. Epo [**Numeric Identifier 961**] units T, Th, Sat
.
Medications on Transfer:
Acetaminophen 650 mg PR Q6H:PRN fever
Heparin IV per Weight-Based Dosing Guidelines
Order date: [**6-4**] @ 1203
Albuterol MDI [**1-19**] PUFF IH Q4H wheezing
Insulin SC  (per Insulin Flowsheet)Sliding Scale & Fixed Dose
Calcium Gluconate 2 gm / 100 ml D5W IV PRN ionized Ca<0.9
Ipratropium Bromide MDI [**1-19**] PUFF IH QID
Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL [**Hospital1 **]
Senna 1 TAB PO BID:PRN
Docusate Sodium 100 mg PO BID
Vancomycin 1000 mg IV HD PROTOCOL day 1 [**6-2**]
Ciprofloxacin 400 mg IV Q24H day 1 = [**6-1**]
Famotidine 20 mg IV Q24H

ALLERGIES: Penicillins / Sulfa (Sulfonamides)

PHYSICAL EXAM: T: 98.6F BP: 107/50, HR: 95, RR: 18, SaO2: 98% on 40% Fio2
General: Obese Caucasian gentleman, lying in bed.
HEENT: PERRL, sclerae anicteric, oropharynx clear
Neck: Supple, JVP difficult to estimate, no LAD
CV: [**Last Name (un) 3526**] [**Last Name (un) 3526**], no m/r/g
Chest: CTA b/l, min bibasilar crackles
Abd: Soft, nontender on deep palpation in all quadrants, ND, PEG
site non erythematous draining yellow fluid. +BS.
Extr: Multiple ulcers on shins bilaterally, no evidence of
superinfection. Necrotic and ulcerated right heel. No [**Name6 (MD) **] edema,
NP DP pulses.
Skin: Two large stage 3 sacral decubs. Ulcer on R appears with
clean base, draining yellow fluid. Ulcer on left with necrotic
appearing base, small rim of surrounding erythema.
Neuro: A&Ox3, MAEW, DTRs 2+ and symmetric. No elicitable
myoclonus.

FAMILY HISTORY: N/C

SOCIAL HISTORY: Used to live with wife, who is HCP. Now at [**Hospital1 **].
Infection and inflammatory reaction due to other vascular device, implant, and graft,Septicemia due to serratia,Severe sepsis,Septic shock,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Pneumonitis due to inhalation of food or vomitus,Fistula of intestine, excluding rectum and anus,Pressure ulcer, heel,Acute and chronic respiratory failure,Chronic systolic heart failure,Other chronic pulmonary heart diseases,Attention to tracheostomy,Atrial fibrillation,Unspecified disorder of plasma protein metabolism,Carrier or suspected carrier of other specified bacterial diseases,Diabetes with other specified manifestations, type II or unspecified type, uncontrolled,Morbid obesity
React-oth vasc dev/graft,Serratia septicemia,Severe sepsis,Septic shock,End stage renal disease,Hyp kid NOS w cr kid V,Food/vomit pneumonitis,Intestinal fistula,Pressure ulcer, heel,Acute & chronc resp fail,Chr systolic hrt failure,Chr pulmon heart dis NEC,Atten to tracheostomy,Atrial fibrillation,Dis plas protein met NOS,Bacteria dis carrier NEC,DMII oth uncntrld,Morbid obesity
Admission Date:  [**2150-5-30**]              Discharge Date:   [**2150-7-9**]

Date of Birth:  [**2075-1-1**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Sulfa (Sulfonamides)

Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Hypotension, hypoxia

Major Surgical or Invasive Procedure:
Thoracentesis [**2150-6-3**]
CT Guided Retroperitoneal Biopsy [**2150-6-12**]


History of Present Illness:
75M with h/o ESRD on HD, chronic trach/vent [**1-17**] PNA [**12-23**], T2DM,
recent PEG removal, presenting from NH after being found with
decreased responsiveness and found to have hypotension and
hypoxia at NH. Baseline BP is 90-100 systolic. Physician called
to bedside 3:30am for periodic leg muscle twitching, due to his
h/o seizures. He was noted to be A&Ox3 and asymptomatic, with T
99.1F, satting 94% on 40% TM, RR 18, BP 98/60, FS 193. Over the
next 2-3 hours, he became intermittently restless and lethargic
but per EMS records, patient became less responsive, with repeat
BP of 60/40, which improved to 80/40 with a 250mL bolus. HR was
116-120 in AF with RVR, RR 22, SaO2 94-7% on 100% TM. Patient
does have known stage 2-4 sacral decubs, and known fistulous
track from removal of PEG recently removed due to leak. NH staff
have been attempting to give him pills PO with purees, no
reports of aspiration per family.
.
In the ED, initial VS were T 99.4F, BP: 69/26, HR: 115, RR: 26,
SaO2: 91% on 40% TM. He was given 2L NS, whereupon IVF were
stopped due to a CXR consistent with volume overload. Reportedly
due for HD today. BP improved to 90/40, and levophed was started
through a preexisting midline catheter, raising BP to 128/68 at
Levophed at 0.05. He was found to have a leukocytosis to 30.1
with 92% PMN, lactate 1.6. Chem 7 and LFTs near baseline. As
mentioned, CXR demonstrated moderate pulmonary edema with
bilateral effusions, can't exclude underlying PNA. An abd/pelvis
CT was done to r/o abdominal wall abscess due to recent leaking
PEG. The CT showed no fluid collections, cholelithiasis with
mild GB wall edema, and likely retroperitoneal adenopathy. A RUQ
U/S was done which again showed cholelithiasis with no evidence
of cholecystitis. Cultures were drawn from midline, and he was
started on vanc/Levofloxacin, and Flagyl.
.
MICU course: Hypotension and hypoxia found to be due to Serratia
sepsis. The source of the sepsis was felt to be his HD catheter,
aspiration PNA, sacral decubs/ LE ulcers or infection along the
fistulous track from recent PEG. Patient initially resusitated
on IVFs, but given development of pulmonary edema he was changes
to pressor support with levophed. He was weaned off pressors
after being given albumin.  He was weaned off the ventilator and
onto his trach collar after drainage of a right pleural
effusion. He remains on vancomycin and ciprofloxacin (initially
had been on vanc, meropenem and tobramycin). He was transferred
to the floor for further management.

Past Medical History:
# DM2
# CRI (baseline 2.5)- recently started on HD
# CHF
# Trached and vent dependent [**1-17**] PNA in [**12-23**]
# PNA [**4-23**] with BAL growing stenotrophomonas (Bactrim sensitive)
and acenitobacter ([**Last Name (un) 36**] to Unasyn, Gent and Tobra, resistant to
FQ, ceftaz, cefepime)
# ESBL Klebsiella UTI [**3-24**]
# Morbid obesity
# Afib on Coumadin
# Hypercholesterolemia
# Known coccyx ulcers

Social History:
Used to live with wife, who is HCP. Now at [**Hospital1 **].


Family History:
N/C

Physical Exam:
T: 98.6F BP: 107/50, HR: 95, RR: 18, SaO2: 98% on 40% Fio2
General: Obese Caucasian gentleman, lying in bed.
HEENT: PERRL, sclerae anicteric, oropharynx clear
Neck: Supple, JVP difficult to estimate, no LAD
CV: [**Last Name (un) 3526**] [**Last Name (un) 3526**], no m/r/g
Chest: CTA b/l, min bibasilar crackles
Abd: Soft, nontender on deep palpation in all quadrants, ND, PEG
site non erythematous draining yellow fluid. +BS.
Extr: Multiple ulcers on shins bilaterally, no evidence of
superinfection. Necrotic and ulcerated right heel. No [**Name6 (MD) **] edema,
NP DP pulses.
Skin: Two large stage 3 sacral decubs. Ulcer on R appears with
clean base, draining yellow fluid. Ulcer on left with necrotic
appearing base, small rim of surrounding erythema.
Neuro: A&Ox3, MAEW, DTRs 2+ and symmetric. No elicitable
myoclonus.

Pertinent Results:
IMAGING:
abdominal CT scan
CT OF THE ABDOMEN WITH IV CONTRAST: Within the visualized lung
bases, there are moderate-sized bilateral pleural effusions,
with associated atelectasis of the adjacent lung. The heart is
enlarged, without evidence of a pericardial effusion.

The liver, spleen, and adrenal glands are unremarkable. There
are several
gallstones present within the gallbladder, with mild distention
of the
gallbladder. There is no evidence of gallbladder wall thickening
or
pericholecystic fluid. Pancreas is atrophic, without a focal
lesion. Both
kidneys are also mildly atrophic, with multiple rounded
hypodense lesions
within the left kidney too small to characterize. Extensive
atherosclerotic calcifications of the abdominal aorta and the
major branches are seen.

There is a defect within the anterior abdominal wall, with a
fistulous
connection with the anterior portion of the stomach, which is
compatible with given history of recent gastrostomy tube that
was subsequently removed. Stomach and small bowel are normal.
There are several scattered diverticula throughout the colon,
without evidence of diverticulitis. There is no free air or free
fluid. Abnormal retroperitoneal soft tissue is seen,
particularly in a para-aortic location, likely reflects
retroperitoneal adenopathy. The craniocaudad dimension of this
lesion is approx. 10 cm.
CT OF THE PELVIS WITH IV CONTRAST: Urinary bladder is normal.
There are
prostatic calcifications. Apparent mild wall thickening of the
rectum likely is related to underdistension. There is no pelvic
free fluid or adenopathy.

OSSEOUS STRUCTURES: Multilevel degenerative changes are present
throughout
the thoracolumbar spine, with loss of disc height, endplate
sclerosis, and
marginal osteophytes. No suspicious lesions are identified.

STUDY: AP chest, [**2150-6-27**].
HISTORY: Patient with thick secretions and possible mucus plug.
FINDINGS: Comparison is made to previous study from [**2150-6-11**].
The tracheostomy, right-sided central venous catheter are
unchanged in
position. There is again seen a large left retrocardiac opacity
and bilateral pleural effusions, which are stable.

FOOT 2 VIEWS RIGHT  ([**2150-7-6**])
INDICATION: Evaluate for osteomyelitis or extension of right
heel ulcer past eschar.
IMPRESSION:
Soft tissue swelling and right heel ulcer without definite
evidence of
underlying osteomyelitis. Small enthesophyte at the insertion of
the Achilles tendon on the calcaneus. Increased sensitivity for
detection of osteomyelitis could be achieved with MR.

BIOPSY RESULTS:

##. SPECIMEN SUBMITTED: FNA for immunophenotyping

Procedure date     Tissue received     Report Date    Diagnosed
by
[**2150-6-11**] [**2150-6-12**] [**2150-6-16**] DR. [**Last Name (STitle) **]. MARIAPPAN/ttl
Previous biopsies:    [**-7/2463**]  RETROPERITONEAL LN...1 JAR.
  [**Numeric Identifier 77793**]  R. ILIAC CREST BONE MARROW BX...1 JAR.

FLOW CYTOMETRY REPORT

FLOW CYTOMETRY IMMUNOPHENOTYPING

The following tests (antibodies) were performed: HLA-DR, FMC-7,
Kappa, Lambda, and CD antigens 2, 3, 5, 7, 10, 19, 20, 23, 45.



RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield.  B cells are scant in number (less
than 5% of total analyzed events) precluding evaluation of
clonality.  T cells comprise approximately 83% of lymphoid gated
events and express mature lineage antigens (CD 2, 3, 5, 7).

INTERPRETATION

Non-specific T cell dominant lymphoid profile; Clonality could
not be assessed in this case due to paucity of B cells in this
sample.  Unequivocal diagnostic immunophenotypic features of
involvement by non-Hodgkin B-cell lymphoma are not seen in
specimen.  Correlation with clinical findings and morphology
(see S08-[**Numeric Identifier 77794**]) is recommended.  In addition, cytospin reveals
that the specimen is hemodiluted.  Flow cytometry
immunophenotyping may not detect all lymphomas due to
topography, sampling or artifacts of sample preparation.



Note: This test was performed using analyte specific reagents
(ASRs).  These ASRs have not been cleared or approved by the US
Food and Drug Administration (FDA).  However, the FDA has
determined that such clearance or approval is not necessary.
This test was developed and its performance characteristics
determined by the Flow Cytometry Laboratory at [**Hospital1 771**], which is licensed by CLIA to perform
high complexity tests.  This test was used for clinical
purposes; it should not be regarded as for research.

##.  SPECIMEN SUBMITTED: RETROPERITONEAL LN...1 JAR.

Procedure date     Tissue received     Report Date    Diagnosed
by
[**2150-6-11**] [**2150-6-11**] [**2150-6-16**] DR. [**Last Name (STitle) **]. MARIAPPAN/axg
Previous biopsies:    [**Numeric Identifier 77793**]  R. ILIAC CREST BONE MARROW
BX...1 JAR.


DIAGNOSIS:
Lymph node, retroperitoneal, needle core biopsy:

Fragments of lymphoid tissue with quiescent appearing germinal
centers, see note.

No definitive morphologic or immunophenotypic evidence of plasma
cell myeloma

Note:  Sections show multiple cores of 'nodal' tissue
infiltrated by small lymphocytes.  A capsule is noticed in one
edge but definitive lymph nodal sinuses are deficient.  This
'lymph node' contains a population of small mature lymphocytes
organized in nodules separated by fibrocollagenous bundles.  By
immunohistochemistry, the lymphocytic infiltrate is a mixture of
 CD20 (localized to presumable germinal centers) positive
B-cells; CD3 and CD5 highlights T cells mostly in
interfollicular areas (CD3+ and CD5+).  Bcl-2 mirrors CD3 stain
and also highlights several primary follicles.  CD21 stains the
dendritic cell meshwork of these primary follicles.  The
proliferation index, measured by MIB-1 staining shows low level
(~10%) of labeling. CD10 stain is weakly positive within the
germinal centers.  CD138 stains small clusters of plasma cells
that are polyclonal, demonstrated by equal staining of kappa and
lambda staining, albeit with a heavy background staining.

         Overall, there is no morphologic or immunophenotypic
evidence of the patient's known plasma cell dyscrasia in this
biopsy. However, given the size of the biopsy specimen we are
unable to rule out a separate lymphoproliferative process. If
suspicion for lymphoma exists (persistent lymphadenopathy, FDG
avidity etc.,), we recommend an open biopsy.

LAB RESULTS:
------------
Please see Attached

CULTURES:
----------
Blood Culture, Routine (Final [**2150-7-7**]):    NO GROWTH.
Blood Culture, Routine (Final [**2150-7-6**]):    NO GROWTH.
Blood Culture, Routine (Final [**2150-7-6**]):    NO GROWTH.
Blood Culture, Routine (Final [**2150-6-28**]):    NO GROWTH.
Blood Culture, Routine (Final [**2150-6-6**]):    NO GROWTH.
Blood Culture, Routine ([**2150-5-30**]): SERRATIA MARCESCENS.

_________________________________________________________
                             SERRATIA MARCESCENS
                             |
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
IMIPENEM--------------   <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN----------   <=4 S
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S
URINE CULTURES
[**2150-6-6**] 2:25 pm URINE      Source: Catheter.
                            **FINAL REPORT [**2150-6-7**]**
   URINE CULTURE (Final [**2150-6-7**]):
      YEAST.    >100,000 ORGANISMS/ML..

PLEURAL FLUID CULTURE
[**2150-6-3**] 6:42 pm PLEURAL FLUID
                            **FINAL REPORT [**2150-6-9**]**

   GRAM STAIN (Final [**2150-6-3**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      NO MICROORGANISMS SEEN.

   FLUID CULTURE (Final [**2150-6-6**]):    NO GROWTH.

   ANAEROBIC CULTURE (Final [**2150-6-9**]):    NO GROWTH.

SPUTUM CULTURE
[**2150-6-27**] 6:21 am SPUTUM      Source: Expectorated.
                            **FINAL REPORT [**2150-7-2**]**
   GRAM STAIN (Final [**2150-6-27**]):
      >25 PMNs and <10 epithelial cells/100X field.
      2+   (1-5 per 1000X FIELD):   GRAM NEGATIVE ROD(S).

   RESPIRATORY CULTURE (Final [**2150-7-2**]):
      OROPHARYNGEAL FLORA ABSENT.
      Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
      workup will be performed appropriate to the isolates
recovered from
      this site.
      SERRATIA MARCESCENS.    MODERATE GROWTH.
         This organism may develop resistance to third
generation
         cephalosporins during prolonged therapy. Therefore,
isolates that
         are initially susceptible may become resistant within
three to
         four days after initiation of therapy.  For serious
infections,
         repeat culture and sensitivity testing may therefore be
warranted
         if third generation cephalosporins were used.
      PSEUDOMONAS AERUGINOSA.    MODERATE GROWTH.
      PSEUDOMONAS AERUGINOSA.    MODERATE GROWTH.
      GRAM NEGATIVE ROD(S).    OF TWO COLONIAL MORPHOLOGIES.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             SERRATIA MARCESCENS
                             |          PSEUDOMONAS AERUGINOSA
                             |          |          PSEUDOMONAS
AERUGINOSA
                             |          |          |
AMIKACIN--------------     8 S
CEFEPIME--------------   <=1 S        2 S      <=1 S
CEFTAZIDIME-----------    16 I        2 S      <=1 S
CEFTRIAXONE-----------     8 S
CIPROFLOXACIN---------   0.5 S        2 I      =>4 R
GENTAMICIN------------  =>16 R      <=1 S      <=1 S
IMIPENEM--------------   <=1 S
MEROPENEM-------------<=0.25 S   <=0.25 S   <=0.25 S
PIPERACILLIN----------    32 I      <=4 S      <=4 S
PIPERACILLIN/TAZO-----   <=4 S      <=4 S      <=4 S
TOBRAMYCIN------------  =>16 R      <=1 S      <=1 S
TRIMETHOPRIM/SULFA----  =>16 R





Brief Hospital Course:
75 y/o with chronic trach, HD-dependent ESRD, sacral/LE ulcers
admitted to the ICU for serratia sepsis most likely [**1-17**] dialysis
line infection s/p antibiotic regimen and stable.

#Sepsis: Patient determined to have serratia sepsis by [**3-20**]
positive blood cultures on [**5-30**]. This was felt to be secondary
to hemodialysis line infection. HD line was removed and he
completed a 21 day course of IV Ciprofloxacin. Since completion
of antibiotics on [**2150-6-22**] pt has had several negative blood
cultures, remained afebrile, vital signs stable and WBC has
normalized.

#ESRD:Patient has been receiving HD during this hospitalization
MWF. His HD line was removed due to infection and replaced on
[**6-8**].

#Retroperitoneal Mass: Abdominal CT on [**5-30**] showed abnormal
retroperitoneal soft tissue measuring up to 10 cm suspicous for
lymphoma. CT guided biopsy performed on [**6-11**]. Pt tolerated
procedure well. Needle Core biopsy and tissue FNA showed
germinal centers that were likely due to his infectious state at
the time. He should be seen in hematology/oncology clinic for a
follow up appointment to see if he needs re-imaging to reassess
his lymph nodes.

#Respiratory failure: Mr. [**Known lastname 77792**] has a history of
hypercarbic/hypoxic respiratory failure and is s/p trachostomy
earlier in [**2149**].  Early in this hospital course he required
postive pressure mechanical ventilation.  His last day of
ventilator support was [**6-4**] and he was maintained on 40% FiO2
trach collar humidified oxygen. On [**2150-6-26**] pt was noted to have
difficulty with his Passy-Muir valve. ENT team was consulted and
a directed visualization showed granulation tissue above the
site of his trachea. Mr. [**Known lastname 77792**] has been scheduled to see Dr.
[**Last Name (STitle) 1837**] on [**2150-7-31**] for possible surgical intervention to
remove the granulating tissue. Please keep pt off the Passy-Muir
valve until Dr. [**Last Name (STitle) 1837**] sees him and clears him.

#Atrial Fibrillation: he has been rate controlled on metoprolol
12.5mg po bid. He will be discharged on Warfarin 1mg. Please
monitor pt's [**Last Name (STitle) 263**] every Monday, Wednesday Friday and discuss with
MD to keep anticoagulation goal of an [**Last Name (STitle) 263**] [**1-18**].

#Type II DM: Patient has been on sliding scale insulin and
Lantus.

#Sacral and leg ulcers [presented with on admission]: Please
follow the wound care guidelines as included with the discharge
paperwork. Mr. [**Known lastname 77795**] right heel has an eschar that was
followed by vascular surgery and podiatry. A foot x-ray showed
no osteomyelitis, he will be seen by Dr. [**First Name (STitle) 3209**] as an outpatient
on [**2150-7-27**] at 1350. Please continue to use the Papain-Urea
Ointment 1 Appl once a day to his right heel.

# Nutrition: Mr. [**Known lastname 77792**] has been on a low sodium / Heart healthy,
Renal Protein: 60 gm; Potassium: 2 gm; Sodium: 2 gm; Phosphorus:
1 gm, Diabetic/Consistent Carbohydrate; Thin liquids. Please sit
him upright when he heats with the cuff deflated when he is
eating. Please do not use passy-muir valve until he is seen and
cleared by Dr. [**Last Name (STitle) 1837**] (ENT) on his appointment on [**7-31**]
at 2:30pm

# Plasma cell dyscrasia: on last admission Mr. [**Known lastname 77792**] was found
to have IgA kappa on serum electrophoresis with an imbalance in
the free kappa:lambda light chain ratio. BM biopsy showed 5-10%
plasma cells.  During his work up the hematology team felt he
likely had MGUS and ordered a retroperitoneal biopsy of a mass
that was noted on his abd CT scan. His FNA was non-diagnostic
and a needle core biopsy showed fragments of lymphoid tissue
with quiescent appearing germinal centers. He will be seen as an
outpatient by Dr. [**Last Name (STitle) 410**] (Hematology/Oncology) on [**7-14**] at 1:30pm
in [**Hospital Ward Name 23**] Bldg [**Location (un) 436**].


Medications on Admission:
Home Meds:
1. Metoprolol 25mg PO TID
2. Simvastatin 10mg PO DAILY
3. Insulin Glargine 18 units once a day.
4. Insulin Regular SSI (5U for FS 151-200, 6U 201-300, 7U if
above 300)
5. Citalopram 20mg PO DAILY
6. Clonazepam 0.5mg PO TID prn anxiety.
7. Trazodone 50mg PO HS as needed.
8. Albuterol MDI 6-8 Puffs Inhalation Q4H as needed
9. Ipratropium inh Q4H as needed
10. Oxycodone-Acetaminophen 5-325 mg/5 mL: 5-10 MLs PO Q6H as
needed
11. Acetaminophen 325mg PO Q6H as needed.
12. Docusate Sodium 50 mg/5 mL PO BID as needed.
13. Miconazole 2% Powder TID as needed.
14. Heparin 5,000 unit/mL SC TID
15. Warfarin 3mg PO daily at 4 PM
16. Lansoprazole 30mg PO daily
17. Epo [**Numeric Identifier 961**] units T, Th, Sat
.
Medications on Transfer:
Acetaminophen 650 mg PR Q6H:PRN fever
Heparin IV per Weight-Based Dosing Guidelines
Order date: [**6-4**] @ 1203
Albuterol MDI [**1-19**] PUFF IH Q4H wheezing
Insulin SC  (per Insulin Flowsheet)Sliding Scale & Fixed Dose
Calcium Gluconate 2 gm / 100 ml D5W IV PRN ionized Ca<0.9
Ipratropium Bromide MDI [**1-19**] PUFF IH QID
Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL [**Hospital1 **]
Senna 1 TAB PO BID:PRN
Docusate Sodium 100 mg PO BID
Vancomycin 1000 mg IV HD PROTOCOL day 1 [**6-2**]
Ciprofloxacin 400 mg IV Q24H day 1 = [**6-1**]
Famotidine 20 mg IV Q24H

Discharge Medications:
1. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection PRN (as needed) as needed for line flush.
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
5. Papain-Urea 830,000-10 unit/g-% Ointment Sig: One (1) Appl
Topical DAILY (Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q4H (every 4 hours) as
needed for wheezing.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours).
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. Insulin Glargine 100 unit/mL Cartridge Sig: Ten (10) units
Subcutaneous at bedtime.
11. Insulin Lispro 100 unit/mL Cartridge Sig: One (1) unit
Subcutaneous qAC + qHS: Per Sliding scale.
12. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.

13. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day:
Monitor [**Month/Year (2) 263**] level every Mon, Wed, Fri and obtain dosing
recommendations from MD [**First Name (Titles) **] [**Last Name (Titles) 263**] goal of [**1-18**].
14. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for fever or pain.
15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) for 6 doses.
16. Papain-Urea 830,000-10 unit/g-% Ointment Sig: One (1) Appl
Topical DAILY (Daily).


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **] Northeast [**Hospital1 **]

Discharge Diagnosis:
Primary: sepsis
Secondary: pleural effusion, end stage renal disease, diabetes
mellitus, retroperitoneal mass, anemia


Discharge Condition:
stable, afebrile


Discharge Instructions:
You presented from your care facility after being found with
decreased responsiveness and low blood pressure. You were
intially treated in the ICU for sepsis and then transferred to
the floor when you became stable. We have been treating you with
antibiotics and you have improved. While here you have continued
to receive dialysis. You have also had a procedure to remove
fluid from your lung. Your respiratory status has been stable
and we feel the pleural effusion is stable. Before you left the
hospital you were afebrile and you had finished all of your
antibiotics.

On Abd CT we determined that you had a mass in your abdomen. You
had a CT guided biopsy. The pathology results showed that it is
most likely that your mass was due to your infection. Please see
Dr. [**Last Name (STitle) 410**] (Heme/Onc doctor) for a follow up appointment.

The podiatry service also saw you about your right heel ulcer.
They want you to continue with the accuzyme dressing and they
will see you in Dr.[**Name (NI) 14868**] clinic for a follow up appointment.

In the hospital you had trouble with your Passy-Muir valve (the
valve that helps you speak). The Ears, Nose, Throat doctors took
a [**Name5 (PTitle) **] at your mouth and noticed some healing tissue above your
tracheostomy site that was causing the problem with your valve.
Please do not use your valve until you have seen the ENT doctors
on [**7-31**].

The following changes were made to your home medications: Your
home metoprolol dose was reduced. Your home citalopram,
clonazepam, trazodone and percocet were discontinued. Your home
warfarin dose was significantly reduced. You should be
adminstered warfarin with a goal [**Name5 (PTitle) 263**] of [**1-18**]. Please have your
blood [**Date Range 263**] level checked on Monday, Wednesday and Friday and
obtain dosage recommendations from a physician regarding
warfarin dosing. When your [**Date Range 263**] stabilizes you can reduce [**Date Range 263**]
checks to once weekly.

If you feel severe shortness of breath, chest pain or experience
fevers or chills please come to the emergency room for
evaluation.

Followup Instructions:
F/U with the following:

Dr. [**Last Name (STitle) 410**] (Hematology/Oncology) on [**7-14**] at 1:30pm in [**Hospital Ward Name 23**]
Bldg [**Location (un) 436**]

[**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM ([**Telephone/Fax (1) **]) on [**7-27**] at 1:50pm

Dr. [**Last Name (STitle) 1837**] (ENT) ([**Telephone/Fax (1) **]) on [**7-31**] at 2:30pm
{'Infection and inflammatory reaction due to other vascular device, implant, and graft,Septicemia due to serratia,Severe sepsis,Septic shock,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Pneumonitis due to inhalation of food or vomitus,Fistula of intestine, excluding rectum and anus,Pressure ulcer, heel,Acute and chronic respiratory failure,Chronic systolic heart failure,Other chronic pulmonary heart diseases,Attention to tracheostomy,Atrial fibrillation,Unspecified disorder of plasma protein metabolism,Carrier or suspected carrier of other specified bacterial diseases,Diabetes with other specified manifestations, type II or unspecified type, uncontrolled,Morbid obesity'}


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: Hypotension, hypoxia

PRESENT ILLNESS: 75M with h/o ESRD on HD, chronic trach/vent [**1-17**] PNA [**12-23**], T2DM,
recent PEG removal, presenting from NH after being found with
decreased responsiveness and found to have hypotension and
hypoxia at NH. Baseline BP is 90-100 systolic. Physician called
to bedside 3:30am for periodic leg muscle twitching, due to his
h/o seizures. He was noted to be A&Ox3 and asymptomatic, with T
99.1F, satting 94% on 40% TM, RR 18, BP 98/60, FS 193. Over the
next 2-3 hours, he became intermittently restless and lethargic
but per EMS records, patient became less responsive, with repeat
BP of 60/40, which improved to 80/40 with a 250mL bolus. HR was
116-120 in AF with RVR, RR 22, SaO2 94-7% on 100% TM. Patient
does have known stage 2-4 sacral decubs, and known fistulous
track from removal of PEG recently removed due to leak. NH staff
have been attempting to give him pills PO with purees, no
reports of aspiration per family.
.
In the ED, initial VS were T 99.4F, BP: 69/26, HR: 115, RR: 26,
SaO2: 91% on 40% TM. He was given 2L NS, whereupon IVF were
stopped due to a CXR consistent with volume overload. Reportedly
due for HD today. BP improved to 90/40, and levophed was started
through a preexisting midline catheter, raising BP to 128/68 at
Levophed at 0.05. He was found to have a leukocytosis to 30.1
with 92% PMN, lactate 1.6. Chem 7 and LFTs near baseline. As
mentioned, CXR demonstrated moderate pulmonary edema with
bilateral effusions, can't exclude underlying PNA. An abd/pelvis
CT was done to r/o abdominal wall abscess due to recent leaking
PEG. The CT showed no fluid collections, cholelithiasis with
mild GB wall edema, and likely retroperitoneal adenopathy. A RUQ
U/S was done which again showed cholelithiasis with no evidence
of cholecystitis. Cultures were drawn from midline, and he was
started on vanc/Levofloxacin, and Flagyl.
.
MICU course: Hypotension and hypoxia found to be due to Serratia
sepsis. The source of the sepsis was felt to be his HD catheter,
aspiration PNA, sacral decubs/ LE ulcers or infection along the
fistulous track from recent PEG. Patient initially resusitated
on IVFs, but given development of pulmonary edema he was changes
to pressor support with levophed. He was weaned off pressors
after being given albumin.  He was weaned off the ventilator and
onto his trach collar after drainage of a right pleural
effusion. He remains on vancomycin and ciprofloxacin (initially
had been on vanc, meropenem and tobramycin). He was transferred
to the floor for further management.

MEDICAL HISTORY: # DM2
# CRI (baseline 2.5)- recently started on HD
# CHF
# Trached and vent dependent [**1-17**] PNA in [**12-23**]
# PNA [**4-23**] with BAL growing stenotrophomonas (Bactrim sensitive)
and acenitobacter ([**Last Name (un) 36**] to Unasyn, Gent and Tobra, resistant to
FQ, ceftaz, cefepime)
# ESBL Klebsiella UTI [**3-24**]
# Morbid obesity
# Afib on Coumadin
# Hypercholesterolemia
# Known coccyx ulcers

MEDICATION ON ADMISSION: Home Meds:
1. Metoprolol 25mg PO TID
2. Simvastatin 10mg PO DAILY
3. Insulin Glargine 18 units once a day.
4. Insulin Regular SSI (5U for FS 151-200, 6U 201-300, 7U if
above 300)
5. Citalopram 20mg PO DAILY
6. Clonazepam 0.5mg PO TID prn anxiety.
7. Trazodone 50mg PO HS as needed.
8. Albuterol MDI 6-8 Puffs Inhalation Q4H as needed
9. Ipratropium inh Q4H as needed
10. Oxycodone-Acetaminophen 5-325 mg/5 mL: 5-10 MLs PO Q6H as
needed
11. Acetaminophen 325mg PO Q6H as needed.
12. Docusate Sodium 50 mg/5 mL PO BID as needed.
13. Miconazole 2% Powder TID as needed.
14. Heparin 5,000 unit/mL SC TID
15. Warfarin 3mg PO daily at 4 PM
16. Lansoprazole 30mg PO daily
17. Epo [**Numeric Identifier 961**] units T, Th, Sat
.
Medications on Transfer:
Acetaminophen 650 mg PR Q6H:PRN fever
Heparin IV per Weight-Based Dosing Guidelines
Order date: [**6-4**] @ 1203
Albuterol MDI [**1-19**] PUFF IH Q4H wheezing
Insulin SC  (per Insulin Flowsheet)Sliding Scale & Fixed Dose
Calcium Gluconate 2 gm / 100 ml D5W IV PRN ionized Ca<0.9
Ipratropium Bromide MDI [**1-19**] PUFF IH QID
Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL [**Hospital1 **]
Senna 1 TAB PO BID:PRN
Docusate Sodium 100 mg PO BID
Vancomycin 1000 mg IV HD PROTOCOL day 1 [**6-2**]
Ciprofloxacin 400 mg IV Q24H day 1 = [**6-1**]
Famotidine 20 mg IV Q24H

ALLERGIES: Penicillins / Sulfa (Sulfonamides)

PHYSICAL EXAM: T: 98.6F BP: 107/50, HR: 95, RR: 18, SaO2: 98% on 40% Fio2
General: Obese Caucasian gentleman, lying in bed.
HEENT: PERRL, sclerae anicteric, oropharynx clear
Neck: Supple, JVP difficult to estimate, no LAD
CV: [**Last Name (un) 3526**] [**Last Name (un) 3526**], no m/r/g
Chest: CTA b/l, min bibasilar crackles
Abd: Soft, nontender on deep palpation in all quadrants, ND, PEG
site non erythematous draining yellow fluid. +BS.
Extr: Multiple ulcers on shins bilaterally, no evidence of
superinfection. Necrotic and ulcerated right heel. No [**Name6 (MD) **] edema,
NP DP pulses.
Skin: Two large stage 3 sacral decubs. Ulcer on R appears with
clean base, draining yellow fluid. Ulcer on left with necrotic
appearing base, small rim of surrounding erythema.
Neuro: A&Ox3, MAEW, DTRs 2+ and symmetric. No elicitable
myoclonus.

FAMILY HISTORY: N/C

SOCIAL HISTORY: Used to live with wife, who is HCP. Now at [**Hospital1 **]. 

### Response:
{'Infection and inflammatory reaction due to other vascular device, implant, and graft,Septicemia due to serratia,Severe sepsis,Septic shock,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Pneumonitis due to inhalation of food or vomitus,Fistula of intestine, excluding rectum and anus,Pressure ulcer, heel,Acute and chronic respiratory failure,Chronic systolic heart failure,Other chronic pulmonary heart diseases,Attention to tracheostomy,Atrial fibrillation,Unspecified disorder of plasma protein metabolism,Carrier or suspected carrier of other specified bacterial diseases,Diabetes with other specified manifestations, type II or unspecified type, uncontrolled,Morbid obesity'}
