CHIEF COMPLAINT: Fever

PRESENT ILLNESS: This is an 80 y/o Cantonese-speaking male with PMH significant
for ESRD on HD, DM II, atrial fibrillation, CAD, who presented
from hemodialysis on [**2183-11-18**] with a reported fever of 105.7. The
patient only complained of fatigue and weakness, starting
yesterday morning. At around 2pm [**2183-11-18**], he began feeling very
tired at HD and was having chills so EMS was called. Per EMS,
the patient was hypotensive during transport but upon arrival to
the [**Hospital1 18**] ED, was hypertensive to the 170's systolic.
.
In the ED, initial VS were T 102.3, BP 174/60, HR 102, RR 16,
SaO2 88%/RA. Due to the temperature, sepsis protocol was
initiated. R IJ was placed because he has poor access. CXR and
head CT were unremarkable. UA showed many bacteria but was
otherwise unremarkable. The patient reported symptoms of a
headache and neck stiffness during his ED course, however LP was
negative. Prior to the LP, he received Vancomycin 1 gm, CTX 2 gm
IV, Ampicillin 2gm IV. He also received 10 mg Dexamethasone and
a random cortisol level was sent which was normal (=8). His SBP
trended down from the 160's to 90's-100's while in the ED and he
received a total of 3 L IVF. His O2 requirement increased from 2
L NC -> 4 L NC and his SvO2 ranged from 91-97. His CVP was
documented from [**6-24**] (after approximately 2 L NS). He also
received 325 mg ASA and 2 mg IV morphine for his headache. He
was admitted to the MICU for further management. Of note, the
patient has had prior admissions for fever (101-102) in [**6-21**] and
[**7-22**] which after a thorough work-up, was attributed to gouty
flares and improved with a steroid taper. He recently saw his
rheumatologist 1 week ago, who increased his allopurinol from
200 to 300 mg daily due to acute flares through the prior dose
and increased the patient's steroid taper.
.
In the MICU, he was continued on vancomycin and ceftriaxone.
Ampicillin was discontinued given low likelihood of meningitis.
He remained hemodynamically stable and did not require fluids.
His steroid dose was increased to 32mg methylprednisolone daily,
per discussion with his outpatient rheumatologist Dr. [**Last Name (STitle) **].
During the afternoon of [**2183-11-19**], he became dyspneic and wheezy
with elevated JVP and mild increase in CHF on CXR. He was felt
to be volume overloaded [**1-17**] volume resuscitation and was sent to
HD for ultrafiltraion, 2.3 L was taken off. He was transferred
to the floor in stable condition and continued on the
antibiotics. His urine cx grew out likely >100,000 Enterococcus.

MEDICAL HISTORY: 1. CAD - reported as single vessel disease s/p catheterization
in [**5-20**] following ETT-MIBI demonstrating an inferolateral
perfusion defect.  Mid LCX was stented with a Drug Eluting Stent
with successful rescue of the OM1 with balloon angioplasty.
Also has history of catheterization more than 20 years ago.
2. Diabetes Mellitus Type II - for more than 30 years.  His
blood glucose levels are usually 97-100.  His most recent HbA1C
was 6.6 in [**2183-7-16**].  Has nephropathy and proteinuria, as
well as mild distal neuropathy.
3. Atrial fibrillation - paroxysmal atrial fibrillation
diagnosed in [**2170**]. On long-term anticoagulation.
4. Hypertension
5. History of GI bleed - History of gastric ulcers.  Presumed
lower GI bleed on [**1-20**].
6. Chronic renal insufficiency - Probable diabetic nephropathy.
Baseline creatinine 2.7.  Has seen been seeing Dr. [**Last Name (STitle) 1860**] for
possible initiation of peritoneal dialysis.
7. Sleep apnea
8. Musculoskeletal problems:
(a) Bilateral severe carpel tunnel
(b) Polyneuropathy of hands
(c) Right flexor tendon nodules/ contracture
(d) OA of DIPs, PIPs, and 1st CMC
(e) Gout - recent admission in [**2-18**] for gout flair.
(f) Pseudogout.
(g) osteopenia

MEDICATION ON ADMISSION: 1. Allopurinol 300 mg daily
2. ASA 81 mg daily
3. Atorvastatin 10 mg daily
4. Renal caps 1 tab daily
5. Coumadin 2.5 mg 2d/wk, 1.25mg 5d/wk
6. Folic acid 1 mg daily
7. Levemir insulin 16 units qhs
8. Novolog insulin sliding scale
9. Imdur 30 mg daily
10. Levothyroxine 75 mcg daily
11. Methylprednisolone 8 mg daily
12. Lopressor 25 mg [**Hospital1 **]
13. NTG SL prn
14. Protonix 40 mg daily
.

ALLERGIES: Lovastatin

PHYSICAL EXAM: VS: Tc 98.7, BP 91/44, HR 120-130, RR 19-20, SaO2 96%/4L NC
General: Elderly Asian male in NAD, lying comfortably in bed
HEENT: NC/AT, PERRL, EOMI. +dentures. MMM, OP clear
Neck: supple, +right IJ CVL in place
Chest: crackles and expiratory wheezes to the apices
CV: irregularly tachycardic, s1 s2 normal, [**1-21**] SM at the base
Abd: soft, NT/ND, NABS, no HSM
Ext: no c/c/e, several ecchymosis over the upper extremities;
left AV fistula with palpable thrill and bruit - no erythema,
tenderness or swelling
Neuro: Non-focal, moving all extremities.

FAMILY HISTORY: Both parents deceased.  Father had diabetes. He has 2 children
who are well and no siblings.

SOCIAL HISTORY: Mr. [**Known lastname **] is Cantonese speaking.  He lives with his wife.  [**Name (NI) **] has
a remote 20-year history of tobacco smoking.  He quit 20 years
ago.  No alcohol or illicit drug use.  Performs most ADLs at
baseline.
Personal history of peptic ulcer disease,Septicemia due to gram-negative organism, unspecified,Sepsis,Acute on chronic systolic heart failure,Atrial fibrillation,Other pulmonary insufficiency, not elsewhere classified,Urinary tract infection, site not specified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Polyneuropathy in diabetes,Unspecified sleep apnea,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Long-term (current) use of anticoagulants,Personal history of tobacco use
Prsnl hst peptic ulcr ds,Gram-neg septicemia NOS,Sepsis,Ac on chr syst hrt fail,Atrial fibrillation,Other pulmonary insuff,Urin tract infection NOS,DMII renl nt st uncntrld,Hyp kid NOS w cr kid V,End stage renal disease,Neuropathy in diabetes,Sleep apnea NOS,Crnry athrscl natve vssl,Status-post ptca,Long-term use anticoagul,History of tobacco use
Admission Date:  [**2183-11-18**]              Discharge Date:   [**2183-11-24**]

Date of Birth:  [**2103-1-26**]             Sex:   M

Service: MEDICINE

Allergies:
Lovastatin

Attending:[**First Name3 (LF) 545**]
Chief Complaint:
Fever


Major Surgical or Invasive Procedure:
None


History of Present Illness:
This is an 80 y/o Cantonese-speaking male with PMH significant
for ESRD on HD, DM II, atrial fibrillation, CAD, who presented
from hemodialysis on [**2183-11-18**] with a reported fever of 105.7. The
patient only complained of fatigue and weakness, starting
yesterday morning. At around 2pm [**2183-11-18**], he began feeling very
tired at HD and was having chills so EMS was called. Per EMS,
the patient was hypotensive during transport but upon arrival to
the [**Hospital1 18**] ED, was hypertensive to the 170's systolic.
.
In the ED, initial VS were T 102.3, BP 174/60, HR 102, RR 16,
SaO2 88%/RA. Due to the temperature, sepsis protocol was
initiated. R IJ was placed because he has poor access. CXR and
head CT were unremarkable. UA showed many bacteria but was
otherwise unremarkable. The patient reported symptoms of a
headache and neck stiffness during his ED course, however LP was
negative. Prior to the LP, he received Vancomycin 1 gm, CTX 2 gm
IV, Ampicillin 2gm IV. He also received 10 mg Dexamethasone and
a random cortisol level was sent which was normal (=8). His SBP
trended down from the 160's to 90's-100's while in the ED and he
received a total of 3 L IVF. His O2 requirement increased from 2
L NC -> 4 L NC and his SvO2 ranged from 91-97. His CVP was
documented from [**6-24**] (after approximately 2 L NS). He also
received 325 mg ASA and 2 mg IV morphine for his headache. He
was admitted to the MICU for further management. Of note, the
patient has had prior admissions for fever (101-102) in [**6-21**] and
[**7-22**] which after a thorough work-up, was attributed to gouty
flares and improved with a steroid taper. He recently saw his
rheumatologist 1 week ago, who increased his allopurinol from
200 to 300 mg daily due to acute flares through the prior dose
and increased the patient's steroid taper.
.
In the MICU, he was continued on vancomycin and ceftriaxone.
Ampicillin was discontinued given low likelihood of meningitis.
He remained hemodynamically stable and did not require fluids.
His steroid dose was increased to 32mg methylprednisolone daily,
per discussion with his outpatient rheumatologist Dr. [**Last Name (STitle) **].
During the afternoon of [**2183-11-19**], he became dyspneic and wheezy
with elevated JVP and mild increase in CHF on CXR. He was felt
to be volume overloaded [**1-17**] volume resuscitation and was sent to
HD for ultrafiltraion, 2.3 L was taken off. He was transferred
to the floor in stable condition and continued on the
antibiotics. His urine cx grew out likely >100,000 Enterococcus.

.
This morning on the floor at 6:30 am, the patient triggered for
a HR in the 160's and mild respiratory distress. He received 5
mg IV metoprolol and neb treatments with improvement in his HR
to the 110's and resolution of his respiratory distress. Around
7:30 am, he was noted to be tachypneic in the 40's, extremely
wheezy, tachycardic to the 160's (a fib with RVR), and
hypertensive to the 190's systolic. He was hypoxic and placed on
a NRB, with improvement of his SaO2 to the 90's. ABG on the NRB
was 7.33/51/73. He was felt to have gone into flash pulmonary
edema and he received a total of 200 mg IV lasix with 225 cc
UOP, 1.5 mg IV morphine, 10 mg IV hydral, 5 mg IV dilt, 10 mg IV
metoprolol, and 1" nitropaste. He was initiated on BiPAP on the
floor and ABG [**4-19**] was 7.44/38/305. He received 25 mg metoprolol
po x 1 upon arrival to the MICU for persistent tachycardia in
the 140's.


Past Medical History:
1. CAD - reported as single vessel disease s/p catheterization
in [**5-20**] following ETT-MIBI demonstrating an inferolateral
perfusion defect.  Mid LCX was stented with a Drug Eluting Stent
with successful rescue of the OM1 with balloon angioplasty.
Also has history of catheterization more than 20 years ago.
2. Diabetes Mellitus Type II - for more than 30 years.  His
blood glucose levels are usually 97-100.  His most recent HbA1C
was 6.6 in [**2183-7-16**].  Has nephropathy and proteinuria, as
well as mild distal neuropathy.
3. Atrial fibrillation - paroxysmal atrial fibrillation
diagnosed in [**2170**]. On long-term anticoagulation.
4. Hypertension
5. History of GI bleed - History of gastric ulcers.  Presumed
lower GI bleed on [**1-20**].
6. Chronic renal insufficiency - Probable diabetic nephropathy.
Baseline creatinine 2.7.  Has seen been seeing Dr. [**Last Name (STitle) 1860**] for
possible initiation of peritoneal dialysis.
7. Sleep apnea
8. Musculoskeletal problems:
(a) Bilateral severe carpel tunnel
(b) Polyneuropathy of hands
(c) Right flexor tendon nodules/ contracture
(d) OA of DIPs, PIPs, and 1st CMC
(e) Gout - recent admission in [**2-18**] for gout flair.
(f) Pseudogout.
(g) osteopenia


Social History:
Mr. [**Known lastname **] is Cantonese speaking.  He lives with his wife.  [**Name (NI) **] has
a remote 20-year history of tobacco smoking.  He quit 20 years
ago.  No alcohol or illicit drug use.  Performs most ADLs at
baseline.


Family History:
Both parents deceased.  Father had diabetes. He has 2 children
who are well and no siblings.

Physical Exam:
VS: Tc 98.7, BP 91/44, HR 120-130, RR 19-20, SaO2 96%/4L NC
General: Elderly Asian male in NAD, lying comfortably in bed
HEENT: NC/AT, PERRL, EOMI. +dentures. MMM, OP clear
Neck: supple, +right IJ CVL in place
Chest: crackles and expiratory wheezes to the apices
CV: irregularly tachycardic, s1 s2 normal, [**1-21**] SM at the base
Abd: soft, NT/ND, NABS, no HSM
Ext: no c/c/e, several ecchymosis over the upper extremities;
left AV fistula with palpable thrill and bruit - no erythema,
tenderness or swelling
Neuro: Non-focal, moving all extremities.

Pertinent Results:
IMAGING:
CXR [**2183-11-18**] - Heart size is at the upper limits of normal. Mild
interstitial prominence is noted, which may be related to mild
CHF. No pleural effusions are seen. Bowel gas pattern in the
upper abdomen is unremarkable.
.
CXR [**2183-11-19**] - CHF has mildly increased compared to yesterday.
There is mild blunting of the left costophrenic angle indicating
pleural fluid.
.
CXR [**2183-11-20**] - worsening pulmonary edema with haziness of the
right base
.
EKG [**2183-11-20**] - afib with RVR, no ischemic changes noted

Brief Hospital Course:
MR. [**Known lastname **] is an 80 y/o Cantonese-speaking male with PMH
significant for ESRD on HD, DM II, atrial fibrillation, CAD, who
presented from hemodialysis on [**2183-11-18**] with a reported fever of
105.7. The patient only complained of fatigue and weakness,
starting the morning prior to admission. At around 2pm [**2183-11-18**],
he began feeling very tired at HD and was having chills so EMS
was called. Per EMS, the patient was hypotensive during
transport but upon arrival to the [**Hospital1 18**] ED, was hypertensive to
the 170's systolic.
.
In the ED, initial VS were T 102.3, BP 174/60, HR 102, RR 16,
SaO2 88%/RA. Due to the temperature, sepsis protocol was
initiated. R IJ was placed because he has poor access. CXR and
head CT were unremarkable. UA showed many bacteria but was
otherwise unremarkable. The patient reported symptoms of a
headache and neck stiffness during his ED course, however LP was
negative. Prior to the LP, he received Vancomycin 1 gm, CTX 2 gm
IV, Ampicillin 2gm IV. He also received 10 mg Dexamethasone and
a random cortisol level was sent which was normal (=8). His SBP
trended down from the 160's to 90's-100's while in the ED and he
received a total of 3 L IVF. His O2 requirement increased from 2
L NC -> 4 L NC and his SvO2 ranged from 91-97. His CVP was
documented from [**6-24**] (after approximately 2 L NS). He also
received 325 mg ASA and 2 mg IV morphine for his headache. He
was admitted to the MICU for further management. Of note, the
patient has had prior admissions for fever (101-102) in [**6-21**] and
[**7-22**] which after a thorough work-up, was attributed to gouty
flares and improved with a steroid taper. He recently saw his
rheumatologist 1 week prior to admission, who increased his
allopurinol from 200 to 300 mg daily due to acute flares through
the prior dose and increased the patient's steroid taper.
.
In the MICU, he was continued on vancomycin and ceftriaxone.
Ampicillin was discontinued given low likelihood of meningitis.
He remained hemodynamically stable and did not require fluids.
His steroid dose was increased to 32mg methylprednisolone daily,
per discussion with his outpatient rheumatologist Dr. [**Last Name (STitle) **].
During the afternoon of [**2183-11-19**], he became dyspneic and wheezy
with elevated JVP and mild increase in CHF on CXR. He was felt
to be volume overloaded [**1-17**] volume resuscitation and was sent to
HD for ultrafiltraion, 2.3 L was taken off. He was transferred
to the floor in stable condition and continued on the
antibiotics. His urine cx grew out likely >100,000 Enterococcus,
sensitive to Ampicillin, so Vanco/CTX was discontinued and the
patient was treated with Augmentin.
.
On the floor, the patient triggered for a HR in the 160's and
mild respiratory distress. He received 5 mg IV metoprolol and
neb treatments with improvement in his HR to the 110's and
resolution of his respiratory distress. Later that morning, he
was noted to be tachypneic in the 40's, extremely wheezy,
tachycardic to the 160's (a fib with RVR), and hypertensive to
the 190's systolic. He was hypoxic and placed on a NRB, with
improvement of his SaO2 to the 90's. ABG on the NRB was
7.33/51/73. He was felt to have gone into flash pulmonary edema
and he received a total of 200 mg IV lasix with 225 cc UOP, 1.5
mg IV morphine, 10 mg IV hydral, 5 mg IV dilt, 10 mg IV
metoprolol, and 1" nitropaste. He was initiated on BiPAP on the
floor and ABG [**4-19**] was 7.44/38/305. He received 25 mg metoprolol
po x 1 upon arrival to the MICU for persistent tachycardia in
the 140's.  The patient again went to HD for ultrafiltration
with resolution of his respiratory symptoms.  He was slowly
weaned off O2 onto room air and on [**2183-11-22**] he was transferred
back to the floor. He remained stable on the floor with no signs
or symptoms of respiratory distress.

# Respiratory distress - Mr. [**Known lastname 108492**] respiratory distress was
likely due to flash pulmonary edema, in the setting of fluid
resusitation, afib with RVR, leading to the respiratory event.
He was treated as outlined above.
.
# Atrial fibrillation with RVR - Mr. [**Known lastname **] has a known history of
atrial firbrillation, for which he is on coumadin.  His atrial
fibrillation was likely exacerbated due to volume
overload/pulmonary edema. He was initially rate controlled with
IV dilt and IV metoprolol.  EKG without ischemic changes.  His
PO metoprolol dose was increased to 20mg [**Hospital1 **].  He takes coumadin
for anticoagulation.  His coumadin was held for 2 days due to a
supratherapeutic INR, likely secondary to antibiotic therapy. On
his day of discharge, Mr. [**Known lastname 108492**] heart rate was well-controlled
and he had been restarted on his home coumadin regimen.

#UTI - My. [**Known lastname **] was initially treated broadly due to concern for
urosepsis.  The urine culture grew out enterococcus, sensitive
to Ampicillin.  He was treated with Augmentin for 7 days total.
On his day of discharge, he had one additional day of Augmentin.
.
# Gout - Mr. [**Known lastname **] has history of gout and pseudogout.  He has
had two admissions this year with fever felt to be secondary to
gout flares.  He was started on methylprednisolone 32 mg to
treat a gout flare.  Per Rhematology, his steriods were tapered
quickly -> 24mg x 2days, 16mg x 2days, 12mg x 2days, 8mg.  8mg
Methylprednisolone is his home dose.  He continued allopurinol
300 mg daily.  He will follow up with Rhematology as scheduled.
.
# ESRD - Mr. [**Known lastname **] has ESRD secondary to diabetes.  He has on
hemodialysis Tuesday, Thursday, and Saturday. Renal followed the
patient throughout his hospitalization.  during this admission,
he was emergently hemodialyzed twice.
.
# Diabetes - Patient continued Lantus with Humalog sliding
scale.
.
# HTN - Mr. [**Known lastname **] continued metoprolol and imdur.

Mr. [**Known lastname **] was discharged home with VNA on hospital day #7 in
stable condition.  He will follow up on Tuesday, [**11-25**] for
hemodialysis as scheduled.


Medications on Admission:
1. Allopurinol 300 mg daily
2. ASA 81 mg daily
3. Atorvastatin 10 mg daily
4. Renal caps 1 tab daily
5. Coumadin 2.5 mg 2d/wk, 1.25mg 5d/wk
6. Folic acid 1 mg daily
7. Levemir insulin 16 units qhs
8. Novolog insulin sliding scale
9. Imdur 30 mg daily
10. Levothyroxine 75 mcg daily
11. Methylprednisolone 8 mg daily
12. Lopressor 25 mg [**Hospital1 **]
13. NTG SL prn
14. Protonix 40 mg daily
.


Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. Levothyroxine 50 mcg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
8. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily) for 1 days: please take AFTER
hemodialysis.
Disp:*1 Tablet(s)* Refills:*0*
9. Methylprednisolone 2 mg Tablet Sig: Six (6) Tablet PO DAILY
(Daily) for 2 days: Please take 12mg on [**2183-11-25**] and on
[**2183-11-26**].
Disp:*12 Tablet(s)* Refills:*0*
10. Methylprednisolone 8 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Start this medication on [**2183-11-27**]. .
11. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
12. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
13. Nitroglycerin  Sublingual
14. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO 2days/week:
Take 2.5mg 2days per week.
15. Coumadin 2.5 mg Tablet Sig: 0.5 Tablet PO 5days/week: Take
1.25mg 5days per week.
16. Levemir 100 unit/mL Solution Sig: Sixteen (16) units
Subcutaneous at bedtime.
17. Novolog 100 unit/mL Solution Subcutaneous


Discharge Disposition:
Home With Service

Facility:
Caregroup VNA

Discharge Diagnosis:
Primary:
Flash Pulmonary Edema
Urinary Tract Infection
Gout Flare

Secondary:
Diabetes
Atrial Fibrillation
End Stage Renal Disease
HTN
CAD
h/o GIB


Discharge Condition:
Stable


Discharge Instructions:
- You were treated for a urinary tract infection with Augmentin.
 You only need to take it for one more day. Take Augmentin after
hemodialysis tomorrow ([**2183-11-25**]).
- You were treated for a gout flare with steriods.  You are
currently on a steriod taper.  You will take Methylprednisolone
12mg tomorrow ([**2183-11-25**]) and then following day ([**2183-11-26**]).
Then starting on [**2183-11-27**], you should take Methylprednisolone
8mg (your home dose).
- You should continue to take your coumadin (blood thinner).
You should take 1.25mg 5 days per week and 2.5mg 2 days per
week.  This is the same regimen that you were on before.
- We increased your blood pressure medication, Lopressor to
37.5mg two times per day.
- You treated for pulmonary edema with lasix and hemodyalysis.
- Continue all your other medications as listed below.

Please call your doctor immediately for chest pain, difficulty
breathing, abdominal pain, fever>100.4, or any concerns.

Followup Instructions:
1. Please follow up with Renal [**2183-11-25**] for hemodialysis as
scheduled.
2. Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 233**] [**Last Name (NamePattern1) 5444**], [**2183-11-28**] at
9:30am, #[**Telephone/Fax (1) 250**].
3. Please follow up with Rhematology as needed. Your next
scheduled appointment is [**2184-3-18**] at 08:30a with Dr. [**Last Name (STitle) 16932**].
{'Personal history of peptic ulcer disease,Septicemia due to gram-negative organism, unspecified,Sepsis,Acute on chronic systolic heart failure,Atrial fibrillation,Other pulmonary insufficiency, not elsewhere classified,Urinary tract infection, site not specified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Polyneuropathy in diabetes,Unspecified sleep apnea,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Long-term (current) use of anticoagulants,Personal history of tobacco use'}


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

PRESENT ILLNESS: This is an 80 y/o Cantonese-speaking male with PMH significant
for ESRD on HD, DM II, atrial fibrillation, CAD, who presented
from hemodialysis on [**2183-11-18**] with a reported fever of 105.7. The
patient only complained of fatigue and weakness, starting
yesterday morning. At around 2pm [**2183-11-18**], he began feeling very
tired at HD and was having chills so EMS was called. Per EMS,
the patient was hypotensive during transport but upon arrival to
the [**Hospital1 18**] ED, was hypertensive to the 170's systolic.
.
In the ED, initial VS were T 102.3, BP 174/60, HR 102, RR 16,
SaO2 88%/RA. Due to the temperature, sepsis protocol was
initiated. R IJ was placed because he has poor access. CXR and
head CT were unremarkable. UA showed many bacteria but was
otherwise unremarkable. The patient reported symptoms of a
headache and neck stiffness during his ED course, however LP was
negative. Prior to the LP, he received Vancomycin 1 gm, CTX 2 gm
IV, Ampicillin 2gm IV. He also received 10 mg Dexamethasone and
a random cortisol level was sent which was normal (=8). His SBP
trended down from the 160's to 90's-100's while in the ED and he
received a total of 3 L IVF. His O2 requirement increased from 2
L NC -> 4 L NC and his SvO2 ranged from 91-97. His CVP was
documented from [**6-24**] (after approximately 2 L NS). He also
received 325 mg ASA and 2 mg IV morphine for his headache. He
was admitted to the MICU for further management. Of note, the
patient has had prior admissions for fever (101-102) in [**6-21**] and
[**7-22**] which after a thorough work-up, was attributed to gouty
flares and improved with a steroid taper. He recently saw his
rheumatologist 1 week ago, who increased his allopurinol from
200 to 300 mg daily due to acute flares through the prior dose
and increased the patient's steroid taper.
.
In the MICU, he was continued on vancomycin and ceftriaxone.
Ampicillin was discontinued given low likelihood of meningitis.
He remained hemodynamically stable and did not require fluids.
His steroid dose was increased to 32mg methylprednisolone daily,
per discussion with his outpatient rheumatologist Dr. [**Last Name (STitle) **].
During the afternoon of [**2183-11-19**], he became dyspneic and wheezy
with elevated JVP and mild increase in CHF on CXR. He was felt
to be volume overloaded [**1-17**] volume resuscitation and was sent to
HD for ultrafiltraion, 2.3 L was taken off. He was transferred
to the floor in stable condition and continued on the
antibiotics. His urine cx grew out likely >100,000 Enterococcus.

MEDICAL HISTORY: 1. CAD - reported as single vessel disease s/p catheterization
in [**5-20**] following ETT-MIBI demonstrating an inferolateral
perfusion defect.  Mid LCX was stented with a Drug Eluting Stent
with successful rescue of the OM1 with balloon angioplasty.
Also has history of catheterization more than 20 years ago.
2. Diabetes Mellitus Type II - for more than 30 years.  His
blood glucose levels are usually 97-100.  His most recent HbA1C
was 6.6 in [**2183-7-16**].  Has nephropathy and proteinuria, as
well as mild distal neuropathy.
3. Atrial fibrillation - paroxysmal atrial fibrillation
diagnosed in [**2170**]. On long-term anticoagulation.
4. Hypertension
5. History of GI bleed - History of gastric ulcers.  Presumed
lower GI bleed on [**1-20**].
6. Chronic renal insufficiency - Probable diabetic nephropathy.
Baseline creatinine 2.7.  Has seen been seeing Dr. [**Last Name (STitle) 1860**] for
possible initiation of peritoneal dialysis.
7. Sleep apnea
8. Musculoskeletal problems:
(a) Bilateral severe carpel tunnel
(b) Polyneuropathy of hands
(c) Right flexor tendon nodules/ contracture
(d) OA of DIPs, PIPs, and 1st CMC
(e) Gout - recent admission in [**2-18**] for gout flair.
(f) Pseudogout.
(g) osteopenia

MEDICATION ON ADMISSION: 1. Allopurinol 300 mg daily
2. ASA 81 mg daily
3. Atorvastatin 10 mg daily
4. Renal caps 1 tab daily
5. Coumadin 2.5 mg 2d/wk, 1.25mg 5d/wk
6. Folic acid 1 mg daily
7. Levemir insulin 16 units qhs
8. Novolog insulin sliding scale
9. Imdur 30 mg daily
10. Levothyroxine 75 mcg daily
11. Methylprednisolone 8 mg daily
12. Lopressor 25 mg [**Hospital1 **]
13. NTG SL prn
14. Protonix 40 mg daily
.

ALLERGIES: Lovastatin

PHYSICAL EXAM: VS: Tc 98.7, BP 91/44, HR 120-130, RR 19-20, SaO2 96%/4L NC
General: Elderly Asian male in NAD, lying comfortably in bed
HEENT: NC/AT, PERRL, EOMI. +dentures. MMM, OP clear
Neck: supple, +right IJ CVL in place
Chest: crackles and expiratory wheezes to the apices
CV: irregularly tachycardic, s1 s2 normal, [**1-21**] SM at the base
Abd: soft, NT/ND, NABS, no HSM
Ext: no c/c/e, several ecchymosis over the upper extremities;
left AV fistula with palpable thrill and bruit - no erythema,
tenderness or swelling
Neuro: Non-focal, moving all extremities.

FAMILY HISTORY: Both parents deceased.  Father had diabetes. He has 2 children
who are well and no siblings.

SOCIAL HISTORY: Mr. [**Known lastname **] is Cantonese speaking.  He lives with his wife.  [**Name (NI) **] has
a remote 20-year history of tobacco smoking.  He quit 20 years
ago.  No alcohol or illicit drug use.  Performs most ADLs at
baseline. 

### Response:
{'Personal history of peptic ulcer disease,Septicemia due to gram-negative organism, unspecified,Sepsis,Acute on chronic systolic heart failure,Atrial fibrillation,Other pulmonary insufficiency, not elsewhere classified,Urinary tract infection, site not specified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Polyneuropathy in diabetes,Unspecified sleep apnea,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Long-term (current) use of anticoagulants,Personal history of tobacco use'}
