CHIEF COMPLAINT: Fever and tachypnea

PRESENT ILLNESS: 54 year old male with CAD, DM, CHF, and CKD was at his baseline
state of health until he fell from his chair car yesterday,
striking his right hip and head. According to the patient, who
is a poor historian, he denies loss of consciousness, but has
continued right hip pain. According to the staff at his rehab
facility, he refused to go to the hospital. Today, the patient
reports feeling "sick" and nauseous. He also reports having
chest pain while moving his wheelchair that lasted 5 minutes,
radiated down his left arm, but did not make him short of
breath, sweaty, or nauseous. According to the staff at his rehab
facility, he was febrile to 101.6, tachypnic and diaphoretic and
was convinced to go to the ED. FSBS 154. He denies shortness of
breath at any point in the last few days. He denies subjective
fever, chills, cough or sore throat.
In the ED, initial VS were: T 98.1 HR 58 BP 95/48 RR 20 100% 4L
Nasal Cannula. His temperature spiked at 100.4. He had good
rectal tone.

MEDICAL HISTORY: hypothyroidism
Insulin-dependent diabetes mellitus since [**2082**]
Peripheral neuropathy s/p R mid foot amputation
Retinopathy w/ hx detached R retina
Coronary artery disease, status post silent MI - EF >55%,
cardiac cath [**5-1**]: L circumflex [**Last Name (un) **] 40% stenosis, proximal RCA
30% stenosis
Peripheral vascular disease
Chronic left heel ulcer
Breast lipoma s/p removal
Hypertension
MRSA +

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from  rehab records.
1. Baclofen 10 mg PO TID
2. Oxycodone SR (OxyconTIN) 10 mg PO Q12H
hold for sedation or rr<10
3. Multivitamins W/minerals 1 TAB PO DAILY
4. Amlodipine 10 mg PO DAILY
5. Aspirin 325 mg PO DAILY
6. Metoclopramide 5 mg PO TID:PRN nausea
7. Levothyroxine Sodium 100 mcg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY
9. Docusate Sodium 100 mg PO TID
10. Bisacodyl 10 mg PO DAILY:PRN constipation
11. Quetiapine Fumarate 50 mg PO HS
12. Quetiapine Fumarate 25 mg PO BID:PRN agitation
13. Prochlorperazine 10 mg PO Q6H:PRN nausea
14. Acetaminophen 650 mg PO Q4H:PRN pain or fever
15. Clopidogrel 75 mg PO DAILY
16. Pantoprazole 40 mg PO Q24H
17. Atorvastatin 80 mg PO DAILY
18. Ferrous Sulfate 325 mg PO DAILY
19. Gabapentin 300 mg PO DAILY
20. Tamsulosin 0.4 mg PO HS
21. HydrOXYzine 50 mg PO Q8H:PRN itch
22. MetFORMIN (Glucophage) 500 mg PO DAILY
23. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
24. Glargine 48 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
25. Lactulose 15 mL PO DAILY
26. Senna 2 TAB PO BID
27. Furosemide 20 mg PO BID
28. Ipratropium Bromide Neb 1 NEB IH Q4H:PRN SOB
29. Metoprolol Succinate XL 50 mg PO DAILY
30. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
31. Fluocinolone Acetonide 0.01% Cream 1 Appl TP [**Hospital1 **]
32. Isosorbide Dinitrate 5 mg PO TID

ALLERGIES: Morphine / adhesive tape

PHYSICAL EXAM: #ADMISSION PHYSICAL EXAM:
General: Alert, oriented x3, no acute distress
HEENT: Scabs on scalp, sclera anicteric, MMM, oropharynx clear,
pupils equal round reactive
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Breath sounds diminished bilateral lower/middle lobes,
bilateral upper lobes clear, no crackles or wheezes appreciated,
dull to percussion throughout.
Abdomen: Soft, diffusely tender to palpation, distended,
hypoactive bowel sounds present, no organomegaly. Skin breakdown
under bilateral breasts, erythematous exanthems on abdomen.
GU: Foley in place
Ext: Warm, well perfused, 2+ radial pulses bilaterally, fingers
contracted, no clubbing, cyanosis or edema. Multiple sites of
skin breakdown on right lower leg, raised weeping lesions. Heel
ulcer right foot. Diminished leg hair.
Neuro: Asterixis present
.
#DISCHARGE PHYSICAL EXAM:
Vitals: T98.6, BP (143-156)/(76-79), HR 61-67, RR 18-20, O2 sat
97% RA.
General: Alert, oriented x3, no acute distress
HEENT: Scabs on scalp, sclera anicteric, MMM, oropharynx clear,
pupils equal round reactive
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Chest: Breath sounds diminished bilateral lower/middle lobes,
bilateral upper lobes clear, minimal scattered crackles, no
wheezes appreciated, dull to percussion throughout.
Abdomen: Soft, NT/ND, bowel sounds present, no organomegaly.
Skin breakdown under bilateral breasts, erythematous exanthems
on abdomen.
GU: Foley in place
Ext: Warm, 2+ radial pulses bilaterally, fingers contracted, no
clubbing, cyanosis or edema.
Lower extr:  2+ bilateral lower extremity edema.  Pulses not
palpable [**12-26**] edema.  s/p left BKA, RIGHT LEG IN CAST
(previously: 1.5cm ulcer with necrotic edges on sole of R foot.
Stasis dermatitis on RLE, dressings c/d/i).

FAMILY HISTORY: Father passed away from MI, but had DM. Mother also passed away
from MI.

SOCIAL HISTORY: Denies smoking, alcohol and tobacco use.  Used to work in a mail
Unspecified septicemia,Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Pathologic fracture of vertebrae,Ulcer of heel and midfoot,Cellulitis and abscess of leg, except foot,Severe sepsis,Venous (peripheral) insufficiency, unspecified,Coronary atherosclerosis of native coronary artery,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled,Polyneuropathy in diabetes,Atherosclerosis of native arteries of the extremities with ulceration,Background diabetic retinopathy,Unspecified acquired hypothyroidism,Hypoxemia,Pain in joint, pelvic region and thigh,Constipation, unspecified,Anemia, unspecified,Old myocardial infarction,Foot amputation status,Percutaneous transluminal coronary angioplasty status,Long-term (current) use of aspirin,Family history of ischemic heart disease,History of fall,Wheelchair dependence,Personal history of Methicillin resistant Staphylococcus aureus
Septicemia NOS,Ac on chr diast hrt fail,Acute kidney failure NOS,Path fx vertebrae,Ulcer of heel & midfoot,Cellulitis of leg,Severe sepsis,Venous insufficiency NOS,Crnry athrscl natve vssl,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,DMI neuro nt st uncntrld,Neuropathy in diabetes,Ath ext ntv art ulcrtion,Diabetic retinopathy NOS,Hypothyroidism NOS,Hypoxemia,Joint pain-pelvis,Constipation NOS,Anemia NOS,Old myocardial infarct,Status amput foot,Status-post ptca,Long-term use of aspirin,Fam hx-ischem heart dis,Personal history of fall,Wheelchair dependence,Hx Methicln resist Staph
Admission Date:  [**2121-8-7**]              Discharge Date:   [**2121-8-18**]

Date of Birth:  [**2067-6-19**]             Sex:   M

Service: MEDICINE

Allergies:
Morphine / adhesive tape

Attending:[**Last Name (un) 2888**]
Chief Complaint:
Fever and tachypnea

Major Surgical or Invasive Procedure:
NONE


History of Present Illness:
54 year old male with CAD, DM, CHF, and CKD was at his baseline
state of health until he fell from his chair car yesterday,
striking his right hip and head. According to the patient, who
is a poor historian, he denies loss of consciousness, but has
continued right hip pain. According to the staff at his rehab
facility, he refused to go to the hospital. Today, the patient
reports feeling "sick" and nauseous. He also reports having
chest pain while moving his wheelchair that lasted 5 minutes,
radiated down his left arm, but did not make him short of
breath, sweaty, or nauseous. According to the staff at his rehab
facility, he was febrile to 101.6, tachypnic and diaphoretic and
was convinced to go to the ED. FSBS 154. He denies shortness of
breath at any point in the last few days. He denies subjective
fever, chills, cough or sore throat.
In the ED, initial VS were: T 98.1 HR 58 BP 95/48 RR 20 100% 4L
Nasal Cannula. His temperature spiked at 100.4. He had good
rectal tone.

His labs were notable for WBC 9.5, H/H 10.2/30.1 (baseline
~[**9-23**]), Pro BNP 3622, Cr 2.6 (baseline ~1.6 [**2117**]), BUN 72, AG
12. Trop 0.14 (has been 0.1-0.2 in the past), UA 1 WBC, 0 Epi,
mod bact, cast 9. Blood and urine cultures sent. ABG 7.43/38/99
with lactate 1.7. He was given 1 L NS, vancomycin 1gm, cefepime
1gm, and lasix 40mg IV. The patient was placed on CPAP.

Non contrast CT head, CT C-spine, CT chest, and CT Abd/pelvis
were prelim reads as negative except for wedge fracture of L1
without retropulsion, likely subacute on chronic. Also right
sided small-bowel-containing inguinal hernia.

The patient arrived in the MICU on CPAP. After it was removed,
the patient reported feeling like his normal self. He denied any
shortness of breath, chest pain, or abdominal pain.


Past Medical History:
hypothyroidism
Insulin-dependent diabetes mellitus since [**2082**]
Peripheral neuropathy s/p R mid foot amputation
Retinopathy w/ hx detached R retina
Coronary artery disease, status post silent MI - EF >55%,
cardiac cath [**5-1**]: L circumflex [**Last Name (un) **] 40% stenosis, proximal RCA
30% stenosis
Peripheral vascular disease
Chronic left heel ulcer
Breast lipoma s/p removal
Hypertension
MRSA +

Social History:
Denies smoking, alcohol and tobacco use.  Used to work in a mail

room in [**Location (un) 86**] but could not after an accident. Now is living in

nursing home v. rehab.


Family History:
Father passed away from MI, but had DM. Mother also passed away
from MI.

Physical Exam:
#ADMISSION PHYSICAL EXAM:
General: Alert, oriented x3, no acute distress
HEENT: Scabs on scalp, sclera anicteric, MMM, oropharynx clear,
pupils equal round reactive
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Breath sounds diminished bilateral lower/middle lobes,
bilateral upper lobes clear, no crackles or wheezes appreciated,
dull to percussion throughout.
Abdomen: Soft, diffusely tender to palpation, distended,
hypoactive bowel sounds present, no organomegaly. Skin breakdown
under bilateral breasts, erythematous exanthems on abdomen.
GU: Foley in place
Ext: Warm, well perfused, 2+ radial pulses bilaterally, fingers
contracted, no clubbing, cyanosis or edema. Multiple sites of
skin breakdown on right lower leg, raised weeping lesions. Heel
ulcer right foot. Diminished leg hair.
Neuro: Asterixis present
.
#DISCHARGE PHYSICAL EXAM:
Vitals: T98.6, BP (143-156)/(76-79), HR 61-67, RR 18-20, O2 sat
97% RA.
General: Alert, oriented x3, no acute distress
HEENT: Scabs on scalp, sclera anicteric, MMM, oropharynx clear,
pupils equal round reactive
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Chest: Breath sounds diminished bilateral lower/middle lobes,
bilateral upper lobes clear, minimal scattered crackles, no
wheezes appreciated, dull to percussion throughout.
Abdomen: Soft, NT/ND, bowel sounds present, no organomegaly.
Skin breakdown under bilateral breasts, erythematous exanthems
on abdomen.
GU: Foley in place
Ext: Warm, 2+ radial pulses bilaterally, fingers contracted, no
clubbing, cyanosis or edema.
Lower extr:  2+ bilateral lower extremity edema.  Pulses not
palpable [**12-26**] edema.  s/p left BKA, RIGHT LEG IN CAST
(previously: 1.5cm ulcer with necrotic edges on sole of R foot.
Stasis dermatitis on RLE, dressings c/d/i).


Pertinent Results:
#ADMISSION LABS:
[**2121-8-6**] 11:28PM   PT-12.8* PTT-33.0 INR(PT)-1.2*
[**2121-8-6**] 11:28PM   PLT COUNT-249
[**2121-8-6**] 11:28PM   NEUTS-78.7* LYMPHS-15.1* MONOS-3.3 EOS-2.5
BASOS-0.3
[**2121-8-6**] 11:28PM   WBC-9.5# RBC-3.90* HGB-10.2* HCT-32.1* MCV-82
MCH-26.3* MCHC-31.9 RDW-15.0
[**2121-8-6**] 11:28PM   ALBUMIN-3.6 CALCIUM-8.0* PHOSPHATE-3.2#
MAGNESIUM-2.3
[**2121-8-6**] 11:28PM   CK-MB-2 proBNP-3622*
[**2121-8-6**] 11:28PM   cTropnT-0.14*
[**2121-8-6**] 11:28PM   LIPASE-9
[**2121-8-6**] 11:28PM   ALT(SGPT)-17 AST(SGOT)-26 CK(CPK)-120 ALK
PHOS-111 TOT BILI-0.3
[**2121-8-6**] 11:28PM   GLUCOSE-207* UREA N-72* CREAT-2.6* SODIUM-139
POTASSIUM-4.6 CHLORIDE-103 TOTAL CO2-25 ANION GAP-16
[**2121-8-6**] 11:37PM   LACTATE-1.7
[**2121-8-6**] 11:37PM   PO2-99 PCO2-38 PH-7.43 TOTAL CO2-26 BASE XS-0
COMMENTS-GREEN TOP
[**2121-8-7**] 12:04AM URINE  MUCOUS-RARE
[**2121-8-7**] 12:04AM URINE  HYALINE-9*
[**2121-8-7**] 12:04AM URINE  RBC-7* WBC-1 BACTERIA-MOD YEAST-NONE
EPI-0 TRANS EPI-<1
[**2121-8-7**] 12:04AM URINE  RBC-7* WBC-1 BACTERIA-MOD YEAST-NONE
EPI-0 TRANS EPI-<1
[**2121-8-7**] 12:04AM URINE  BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2121-8-7**] 12:04AM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2121-8-7**] 03:58AM   TYPE-[**Last Name (un) **] PO2-193* PCO2-39 PH-7.41 TOTAL
CO2-26 BASE XS-0 COMMENTS-GREEN TOP
[**2121-8-7**] 05:05AM   PLT COUNT-181
[**2121-8-7**] 05:05AM   WBC-8.4 RBC-3.85* HGB-10.5* HCT-31.4* MCV-81*
MCH-27.2 MCHC-33.5 RDW-15.1
[**2121-8-7**] 05:05AM   CK-MB-4 cTropnT-0.16*
[**2121-8-7**] 05:05AM   CK(CPK)-110
[**2121-8-7**] 05:05AM   GLUCOSE-191* UREA N-70* CREAT-2.3* SODIUM-140
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-28 ANION GAP-11
[**2121-8-7**] 11:19AM   %HbA1c-7.6* eAG-171*
[**2121-8-7**] 11:19AM   CK-MB-3 cTropnT-0.18*
[**2121-8-7**] 11:19AM   CK(CPK)-100
.
#PERTINENT LABS:
[**2121-8-17**] 05:35AM BLOOD WBC-11.2*# RBC-3.86* Hgb-10.5* Hct-31.5*
MCV-82 MCH-27.2 MCHC-33.2 RDW-15.8* Plt Ct-449*
[**2121-8-15**] 01:00PM BLOOD WBC-5.9 RBC-4.05* Hgb-10.9* Hct-33.2*
MCV-82 MCH-26.9* MCHC-32.8 RDW-15.5 Plt Ct-454*
[**2121-8-14**] 05:04AM BLOOD WBC-6.0 RBC-3.72* Hgb-10.0* Hct-30.7*
MCV-83 MCH-26.9* MCHC-32.6 RDW-15.3 Plt Ct-390
[**2121-8-13**] 09:15AM BLOOD WBC-6.1 RBC-3.87* Hgb-10.3* Hct-31.5*
MCV-81* MCH-26.7* MCHC-32.8 RDW-15.0 Plt Ct-338
[**2121-8-12**] 01:15PM BLOOD WBC-5.4 RBC-3.83* Hgb-10.3* Hct-31.6*
MCV-83 MCH-27.0 MCHC-32.7 RDW-14.8 Plt Ct-330
[**2121-8-12**] 05:26AM BLOOD WBC-5.0 RBC-3.64* Hgb-9.7* Hct-29.5*
MCV-81* MCH-26.7* MCHC-33.0 RDW-14.9 Plt Ct-289
[**2121-8-11**] 07:38AM BLOOD WBC-5.0 RBC-4.01* Hgb-10.9* Hct-32.8*
MCV-82 MCH-27.2 MCHC-33.3 RDW-14.7 Plt Ct-309
[**2121-8-10**] 05:37AM BLOOD WBC-3.7* RBC-3.35* Hgb-9.1* Hct-27.3*
MCV-82 MCH-27.2 MCHC-33.3 RDW-14.4 Plt Ct-211
[**2121-8-9**] 05:25AM BLOOD WBC-5.9 RBC-3.79* Hgb-10.1* Hct-30.7*
MCV-81* MCH-26.8* MCHC-33.0 RDW-14.7 Plt Ct-225
[**2121-8-8**] 04:27AM BLOOD WBC-5.8 RBC-3.66* Hgb-10.0* Hct-29.8*
MCV-82 MCH-27.3 MCHC-33.5 RDW-14.8 Plt Ct-209
[**2121-8-7**] 05:05AM BLOOD WBC-8.4 RBC-3.85* Hgb-10.5* Hct-31.4*
MCV-81* MCH-27.2 MCHC-33.5 RDW-15.1 Plt Ct-181
[**2121-8-11**] 07:38AM BLOOD Neuts-45* Bands-0 Lymphs-39 Monos-10
Eos-6* Baso-0 Atyps-0 Metas-0 Myelos-0
[**2121-8-9**] 05:25AM BLOOD Neuts-55.4 Lymphs-32.6 Monos-6.6 Eos-5.0*
Baso-0.4
[**2121-8-11**] 07:38AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Tear Dr[**Last Name (STitle) 833**]
[**2121-8-12**] 05:26AM BLOOD PT-11.1 PTT-34.3 INR(PT)-1.0
[**2121-8-10**] 05:37AM BLOOD PT-10.8 PTT-33.5 INR(PT)-1.0
[**2121-8-9**] 01:36PM BLOOD ESR-87*
[**2121-8-18**] 05:30AM BLOOD Glucose-211* UreaN-64* Creat-2.1* Na-137
K-4.2 Cl-98 HCO3-31 AnGap-12
[**2121-8-17**] 05:35AM BLOOD Glucose-58* UreaN-60* Creat-1.9* Na-140
K-3.9 Cl-101 HCO3-28 AnGap-15
[**2121-8-16**] 05:35AM BLOOD Glucose-91 UreaN-55* Creat-1.9* Na-143
K-4.3 Cl-103 HCO3-29 AnGap-15
[**2121-8-14**] 09:00PM BLOOD Glucose-121* UreaN-55* Creat-2.1* Na-140
K-5.0 Cl-101 HCO3-28 AnGap-16
[**2121-8-14**] 05:04AM BLOOD Glucose-76 UreaN-59* Creat-1.8* Na-144
K-4.2 Cl-105 HCO3-34* AnGap-9
[**2121-8-12**] 01:15PM BLOOD Glucose-367* UreaN-63* Creat-1.9* Na-142
K-4.6 Cl-104 HCO3-30 AnGap-13
[**2121-8-11**] 07:38AM BLOOD Glucose-159* UreaN-69* Creat-2.0* Na-143
K-4.7 Cl-105 HCO3-28 AnGap-15
[**2121-8-10**] 05:37AM BLOOD Glucose-244* UreaN-76* Creat-2.1* Na-136
K-4.3 Cl-101 HCO3-29 AnGap-10
[**2121-8-9**] 05:25AM BLOOD Glucose-113* UreaN-79* Creat-2.6* Na-139
K-4.5 Cl-103 HCO3-29 AnGap-12
[**2121-8-8**] 04:27AM BLOOD Glucose-206* UreaN-74* Creat-2.4* Na-138
K-4.4 Cl-103 HCO3-25 AnGap-14
[**2121-8-7**] 05:05AM BLOOD Glucose-191* UreaN-70* Creat-2.3* Na-140
K-4.0 Cl-105 HCO3-28 AnGap-11
[**2121-8-8**] 04:27AM BLOOD ALT-12 AST-20 LD(LDH)-305* AlkPhos-103
TotBili-0.5
[**2121-8-7**] 11:19AM BLOOD CK(CPK)-100
[**2121-8-7**] 08:15PM BLOOD CK-MB-3 cTropnT-0.13*
[**2121-8-7**] 11:19AM BLOOD CK-MB-3 cTropnT-0.18*
[**2121-8-7**] 05:05AM BLOOD CK-MB-4 cTropnT-0.16*
[**2121-8-18**] 05:30AM BLOOD Calcium-8.8 Phos-4.7* Mg-2.4
[**2121-8-16**] 05:35AM BLOOD Calcium-8.6 Phos-5.3* Mg-2.5
[**2121-8-14**] 09:00PM BLOOD Calcium-9.0 Phos-5.4* Mg-2.4
[**2121-8-13**] 09:15AM BLOOD Calcium-8.2* Phos-4.0 Mg-2.5
[**2121-8-12**] 05:26AM BLOOD Calcium-8.3* Phos-4.0 Mg-2.7*
[**2121-8-11**] 07:38AM BLOOD Calcium-8.3* Phos-4.1 Mg-2.8*
[**2121-8-10**] 05:37AM BLOOD Calcium-8.0* Phos-4.4 Mg-2.6
[**2121-8-9**] 05:25AM BLOOD Calcium-8.3* Phos-4.8* Mg-2.5
[**2121-8-8**] 04:27AM BLOOD Albumin-3.4* Calcium-7.8* Phos-3.9 Mg-2.5
[**2121-8-7**] 11:19AM BLOOD %HbA1c-7.6* eAG-171*
[**2121-8-7**] 03:58AM BLOOD Type-[**Last Name (un) **] pO2-193* pCO2-39 pH-7.41
calTCO2-26 Base XS-0 Comment-GREEN TOP
[**2121-8-12**] 06:28PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.008
[**2121-8-9**] 02:31PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.009
[**2121-8-7**] 12:04AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012
[**2121-8-12**] 06:28PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2121-8-9**] 02:31PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2121-8-7**] 12:04AM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2121-8-12**] 06:28PM URINE RBC-2 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
[**2121-8-9**] 02:31PM URINE RBC-53* WBC-2 Bacteri-FEW Yeast-NONE
Epi-<1
[**2121-8-7**] 12:04AM URINE RBC-7* WBC-1 Bacteri-MOD Yeast-NONE Epi-0
TransE-<1
[**2121-8-12**] 06:28PM URINE CastHy-15*
[**2121-8-9**] 02:31PM URINE CastHy-35*
[**2121-8-7**] 12:04AM URINE CastHy-9*
.
#MICROBIOLOGY:
[][**2121-8-6**] 11:29 pm BLOOD CULTURE      # 1.

                            **FINAL REPORT [**2121-8-12**]**

   Blood Culture, Routine (Final [**2121-8-12**]):    NO GROWTH.
.
[][**2121-8-6**] 11:29 pm BLOOD CULTURE      # 2.

                            **FINAL REPORT [**2121-8-12**]**

   Blood Culture, Routine (Final [**2121-8-12**]):    NO GROWTH
.
[][**2121-8-7**] 12:04 am URINE

                            **FINAL REPORT [**2121-8-8**]**

   URINE CULTURE (Final [**2121-8-8**]):    NO GROWTH.
.
[][**2121-8-8**] 4:20 pm BLOOD CULTURE

   Blood Culture, Routine (Preliminary):
      STAPHYLOCOCCUS, COAGULASE NEGATIVE.
         Isolated from only one set in the previous five days
SENSITIVITIES
         PERFORMED ON REQUEST..  WORK UP PER DR.[**Last Name (STitle) 16107**] #[**Numeric Identifier 16108**].

   Aerobic Bottle Gram Stain (Final [**2121-8-9**]):
      Reported to and read back by [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 16109**] @ 1815 ON [**8-9**] -
[**Numeric Identifier 16110**].
      GRAM POSITIVE COCCI.
      IN PAIRS AND CLUSTERS.

   Anaerobic Bottle Gram Stain (Final [**2121-8-9**]):
      GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
.
[][**2121-8-8**] 5:50 pm BLOOD CULTURE      #2.

                            **FINAL REPORT [**2121-8-14**]**

   Blood Culture, Routine (Final [**2121-8-14**]):    NO GROWTH.
.
[][**2121-8-9**] 2:31 pm URINE      Source: Catheter.

                            **FINAL REPORT [**2121-8-10**]**

   URINE CULTURE (Final [**2121-8-10**]):    NO GROWTH.
.
[][**2121-8-9**] 2:31 pm MRSA SCREEN      Source: Nasal swab.

                            **FINAL REPORT [**2121-8-11**]**

   MRSA SCREEN (Final [**2121-8-11**]):    No MRSA isolated.
.
[][**2121-8-10**] 1:00 pm BLOOD CULTURE

                            **FINAL REPORT [**2121-8-16**]**

   Blood Culture, Routine (Final [**2121-8-16**]):    NO GROWTH.

.
[][**2121-8-11**] 7:38 am BLOOD CULTURE      1 OF 2.

                            **FINAL REPORT [**2121-8-17**]**

   Blood Culture, Routine (Final [**2121-8-17**]):    NO GROWTH.
.
[][**2121-8-12**] 5:26 am BLOOD CULTURE

                            **FINAL REPORT [**2121-8-18**]**

   Blood Culture, Routine (Final [**2121-8-18**]):    NO GROWTH.
.
[][**2121-8-17**] 3:09 pm TISSUE     Site: SKIN

   GRAM STAIN (Final [**2121-8-17**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      NO MICROORGANISMS SEEN.

   TISSUE (Preliminary):
      Reported to and read back by DR. [**Last Name (STitle) **] [**2121-8-18**] 12:28PM.

      GRAM POSITIVE COCCUS(COCCI).    RARE GROWTH.

   ANAEROBIC CULTURE (Preliminary):

   ACID FAST SMEAR (Final [**2121-8-18**]):
      NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.

   ACID FAST CULTURE (Preliminary):

   FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.
.
#STUDIES:
[]ECG	Study Date of [**2121-8-6**]  11:26:16 PM
Sinus rhythm with P-R interval prolongation. Occasional
ventricular premature
contraction. Poor R wave progression across the precordium.
Cannot exclude
old anteroseptal myocardial infarction. Possible left anterior
fascicular
block. Compared to the previous tracing of [**2118-8-25**] ventricular
premature
contraction is now noted, axis is more leftward. Otherwise, no
significant
changes.
Read by:	DAS,SAUMYA
 	Intervals	Axes
Rate	PR	QRS	QT/QTc	P	QRS	T
71	272	112	400/419	34	-41	81
.
[]CHEST (PORTABLE AP)	Study Date of [**2121-8-6**] 11:30 PM
FINDINGS:
The lung volumes are low with secondary widening of the
cardiomediastinal
silhouette.  There is no pleural effusion, no pneumothorax.  No
lung
consolidation. Repeat study with deep inspiration is
recommended, since
assessment of edema is difficult with low lung volumes.
.
[]CT HEAD W/O CONTRAST	Study Date of [**2121-8-6**] 11:45 PM
FINDINGS:
CT OF THE HEAD:
There is no evidence of hemorrhage, edema, mass effect, or
infarction.  The
ventricles and sulci are normal in size and configuration.  The
[**Doctor Last Name 352**]-white
matter differentiation is well preserved. There is no calvarial
or skull base
fracture.  The paranasal sinuses and mastoid air cells are
clear. There is
bilateral vertebral artery and cavernous carotid artery
calcification.
IMPRESSION:  Mild arterial atherosclerotic calcification.
Otherwise normal
study.
.
[]TTE [**2121-8-7**]
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
low normal (LVEF 50-55%). Tissue Doppler imaging suggests a
normal left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic arch is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.

IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity size and wall thickness with preserved global left
ventricular systolic function. Mildly dilated ascending aorta
and aortic arch. No clinically significant valvular
regurgitation or stenosis. Mild pulmonary artery systolic
hypertension.

Compared with the prior study (images reviewed) of [**2118-8-23**], it
appears that the global left ventricular systolic function may
have diminished slightly vs the prior study, but the image
quality is markedly worse on the current study and thus a direct
comparison of all previously measured parameters cannot be made.

.
[]ECG	Study Date of [**2121-8-7**]  9:18:18 AM
Normal sinus rhythm with frequent premature atrial contractions.
A-V conduction delay with P-R interval equal to 0.25 seconds.
Left anterior
fascicular block. Non-specific ST-T wave abnormalities. Delayed
R wave
transition. Compared to the previous tracing of [**2121-8-6**] no
diagnostic change.
TRACING #1
Read by:	[**Last Name (LF) **],[**First Name8 (NamePattern2) 2206**] [**Doctor Last Name **]
 	Intervals	Axes
Rate	PR	QRS	QT/QTc	P	QRS	T
90	[**Telephone/Fax (3) 16111**]/414	69	-47	90
.
[] CT C-SPINE W/O CONTRAST	Study Date of [**2121-8-7**] 12:12 AM
FINDINGS:
CT OF THE SPINE:
The height of the vertebral bodies of the C-spine is preserved.
No
prevertebral soft tissue swelling.  There is no evidence of
fracture or
malalignment.  Secretions are seen in the hypopharynx at the
level of the
piriform sinuses.  There are no significant degenerative
changes.  The lung
apices are clear.   The thyroid gland is normal. CT has limited
resolution for
intraspinal soft tissue abnormalities. If there are new
neurological findings
after trauma, an MR may be helpful to identify abnormalities
such as disk
protrusions or hematoma.

IMPRESSION:  No evidence of fracture or malalignment.
Secretions in
hypopharynx at the level of the piriform sinuses.
.
[]CT ABD & PELVIS & CHEST W/O CONTRAST	Study Date of [**2121-8-7**]
1:02 AM
FINDINGS:
CT OF THE CHEST:
There is no pneumomediastinum, mediastinal hemorrhage,
pericardial or pleural
effusion. There are atherosclerotic calcifications of the
coronary arteries.
There is no mediastinal, hilar, or axillary lymphadenopathy.
The right middle
lobe bronchus is slightly narrowed.  There are bibasilar
atelectatic changes.
There are no suspicious pulmonary nodules. The pulmonary artery
is enlarged,
likely due to pulmonary hypertension with prominent vascular
hila.  There is
no evidence of pericholecystic fluid or wall thickening. There
are no focal
hepatic lesions, however, evaluation is limited without
intravenous contrast.
The pancreas is atrophic. The spleen and both kidneys are
normal.  There is no
retroperitoneal or mesenteric lymphadenopathy.  There are mild
atherosclerotic
calcifications at the [**Female First Name (un) 899**] and external iliac arteries.  The
stomach, and large
bowel are normal. Moderate amount of stool throughout colon.

CT OF THE PELVIS:
There is a right small bowel-containing inguinal hernia and a
left
fat-containing inguinal hernia.  No free fluid and no free air.
The prostate
gland, seminal vesicles, and urinary bladder are normal.  A
Foley catheter is
seen in the urinary bladder.  Diverticulosis, but no
diverticulitis.  There is
a severe, likely chronic compression fracture of the L1
vertebral body of
unknown chronicity without significant retropulsion and moderate
multilevel
facet degenerative changes.

IMPRESSION:
1. Almost complete wedge compression fracture of L1 without
retropulsion into
the spinal canal, more likely subacute or chronic.
2. Right nonobstructed small bowel containing inguinal hernia.
3. Bibasilar lung opacities, likely atelectasis.
4. Prominent pulmonary artery.
.
[]CHEST (PORTABLE AP)	Study Date of [**2121-8-7**] 7:18 AM
FINDINGS:  As compared to the previous radiograph, the lung
volumes remain
low.  Despite the low lung volumes, the findings are suggestive
of
mild-to-moderate pulmonary edema.  Newly occurred areas of
atelectasis at the
left lung base.
.
[]ECG	Study Date of [**2121-8-8**]  8:55:58 AM
Normal sinus rhythm with A-V conduction delay. Left anterior
fascicular block.
Delayed R wave transition. No diagnostic change from tracing #1.
TRACING #2
Read by:	[**Last Name (LF) **],[**First Name8 (NamePattern2) 2206**] [**Doctor Last Name **]
 	Intervals	Axes
Rate	PR	QRS	QT/QTc	P	QRS	T
83	[**Telephone/Fax (3) 16112**]/424	31	-40	85
.
[] FOOT 2 VIEWS RIGHT	Study Date of [**2121-8-9**] 3:45 PM
FINDINGS:  Prior exam dated [**2109-3-25**] demonstrates
transmetatarsal amputation
of all digits.  In the interval there has been increased
vascular
calcifications and increased osteopenia.  There is no periosteal
reaction to
suggest osteomyelitis but MR would be more sensitive.  There is
irregularity
of the distal tibia compatible with a fracture.  This is only
seen on the
lateral film.  This finding was called to Dr. [**Last Name (STitle) 11924**] at the
time of discovery
at 8 a.m. by Dr. [**Last Name (STitle) 410**] by phone.
.
[]CHEST (PA & LAT)	Study Date of [**2121-8-9**] 3:45 PM
FINDINGS:  Lung volumes continue to be low but are slightly
improved compared
to the study from two days prior.  There is improved aeration at
the bases and
decreased vascular plethora, however, there is still an element
of pulmonary
vascular redistribution and mild cardiomegaly.  Thus, mild fluid
overload is
likely.
.
[]ECG	Study Date of [**2121-8-16**]  1:42:54 AM
Baseline artifact. Sinus rhythm with marked P-R interval
prolongation and
intraventricular conduction delay. Left ventricular hypertrophy
with strain
type pattern. Left axis deviation with left anterior fascicular
block.
Delayed anterior R wave progression may be due to left
ventricular hypertrophy,
but prior anteroseptal myocardial infarction cannot be excluded.
Compared to
the previous tracing of [**2121-8-8**] the rate is slower. Downsloping
ST segment
depression has given way to ST segment flattening in lead I. T
wave inversions
are similar in lead aVL. ST segments are flatter in leads V3-V6
of uncertain
significance.
Read by:	[**Last Name (LF) **],[**First Name3 (LF) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name **]
 	Intervals	Axes
Rate	PR	QRS	QT/QTc	P	QRS	T
61	296	116	450/451	21	-45	95
.
[] CHEST (PA & LAT)	Study Date of [**2121-8-17**] 6:37 PM
IMPRESSION:  AP chest compared to [**2117-2-1**] through
[**2121-8-12**]:
Region of scarring in the right middle lobe has been present to
some degree
for several years.  There is also a region of chronic
atelectasis in the left
lower lobe.  Overall, there are no new focal findings to suggest
pneumonia.
Low lung volumes are probably due in part to vascular dilatation
in the lungs
and top normal heart dimensions.
.
[]KNEE (2 VIEWS) RIGHT	Study Date of [**2121-8-17**] 6:50 PM
FINDINGS:
No acute fracture or dislocation.  Cast material projects over
the proximal
right tibia and fibula.  Bone demineralization
Prominent atherosclerotic calcifications.  Lack of tangential or
standing
views renders evaluation of the joint spaces suboptimal.
IMPRESSION:
1.  No acute fracture or dislocation.
2.  Prominent atherosclerosis.
3.  Bone demineralization.
.
[]TIB/FIB (AP & LAT) RIGHT PORT	Study Date of [**2121-8-18**] 3:26 PM
FINDINGS:  In comparison with the study of [**8-17**], there is cast
about somewhat
obscuring what appears to be a complex fracture of the ankle
with involvement
of the distal tibial shaft as well as the medial malleolus.


Brief Hospital Course:
[]BRIEF CLINICAL COURSE:  54 year old male with CAD, CHF, and
PVD presents with fever and tachypnea, initial c/f sepsis and
sent to MICU, quickly stabilized and sent to floor for
optimization of CHF exacerbation and continuation of r/o ACS.
He continued to spike fevers without an identifiable source, ID
consulted, serial cultures negative and antibiotics held.
Patient defervesced over the 3 days prior to discharge and was
evaluated by derm for stasis dermatitis of RLE, and evaluated by
ortho for distal tib/fib fracture that was placed in a cast.
.
[]ACTIVE ISSUES:
.
# ACUTE ON CHRONIC DIASTOLIC CHF EXACERBATION: New oxygen
requirement previously requiring cpap. Initial admission CXR
consistent with pulmonary edema and crackles on exam. The
patient received 20mg Lasix IV on arrival to the floor and
another 40mg IV at 1300 on [**2121-8-8**], was started on 60mg IV lasix
[**Hospital1 **] on [**2121-8-9**].  The patient was started on daily 60mg torsemide
on [**2121-8-12**]; got extra dose of 60mg IV lasix afternoon of
[**2121-8-12**]. Transitioned to 60mg torsemide [**Hospital1 **] [**2121-8-14**] with daily
net negatives of ~2L.  Creatinine and electrolytes remained
stable throughout his inpatient diuresis and repeat CXR showed
interval improvement in lung fields, vascular congestion, and no
evidence of a pneumonia.  Clinically, the patient had no O2
requirement in the 48 hours leading up to discharge, denies SOB,
dyspnea or orthopnea.
.
# FEVER/SIRS LIKELY [**12-26**] DIABETIC FOOT ULCER: Meets SIRS criteria
for fever, tachycardia likely [**12-26**] diabetic foot ulcer. Possible
other sources included urine, cellulitis, or PNA. Received a
dose of vancomycin and cefepime in ED. Although the tachypnea
could be CHF exacerbation, the patient has risk factors for
health care associated pneumonia.  CXR suboptimal given
pulmonary edema and body habitus.  The patient was placed on
vancomycin, ciprofloxacin, metronidazole on [**2121-8-9**]: covering
for MRSA, gm-, pseudomonas, anaerobes given ulcer & high risk
for infection, diabetes, peripheral vascular disease.  This
regimen was stopped on [**2121-8-10**] given no clear etiology for
fevers.  The patient was afebrile X 24 hours and recultured on
[**2121-8-10**] and [**2121-8-11**] per ID recs and will restart Vanc and
cefepime if he spikes >101.  Wound care consulted, recs
implemented and podiatry was consulted, rec'd continuing current
regimen.  We ruled out chronic RLE osteomyelitis with foot and
leg plain films.  The patient had an elevated ESR 87. X-ray of
RLE, revealed tib-fib fracture, consulted ortho cast placed
[**2121-8-13**].  Derm consulted for large RLE wound with weeping,
little concern for infectious source given good wound care.
Repeat CXR, final read no e/o PNA.  F/u blood cultures, GPCs in
clusters from blood cultures, speciation of S. epi likely
contaminant since [**11-25**] bottle sets; ID consulted.  1st urine
culture negative, repeat UA/Ucx negative for growth.
.
#STASIS DERMATITIS: PAtient with chronic (since [**2119**]) large
right lower extremity lesion that encompasses the entire ventral
surface of the shin, with keloid formations, tense bullae and
areas of weeping serosanguinous discharge; little clinical
suspicion for infection given good wound care.  Derm consulted
and saw patient; diagnosis of stasis dermatitis. PAtient refused
biopsy on first attempt, then allowed biopsy which preliminarily
came back + for GPCs, with plans to follow up in derm clinic.

.
# CHEST PAIN: On the day of admission he reports having 5
minutes of chest pain with radiation down his left arm without
nausea, sweating or exacerbation with movement. The chest pain
had resolved on admission and his EKG did not have ischemic
changes. His troponin was elevated at 0.14 which is near
baseline for him. Troponins trended up to 0.18 but his CKMB was
normal at 2-4. He did not have any other episodes of chest pain.

.
#HYPERTENSION: Patient's BP meds stopped on arrival to the MICU
[**12-26**] hypotension and c/f septic picture.  SBPs > 170 on arrival
to the floor. Switched from metoprolol to coreg 12.5 on [**2121-8-13**].
 We continued the patient on amlodipine, hydralazine 40mg TID,
isosorbide dinitrate 20mg TID.
.
# BRADYCARDIA: On the morning of admission to the MICU he had an
episode of bradycardia to the 30-40s with nausea and
diaphoresis, but did not have an further episodes while in the
MICU. Unclear [**Name2 (NI) 16113**], very transient, but in the setting
of a troponinemia and known right coronary disease, concern for
possible SA node dysfunction secondary to NSTEMI. Also possible
is vasovagal episode.  troponins downtrending and known to be
baseline elevated in past [**12-26**] CKD. Once on the floor, the
patient's heart rate never dipped below the 70's and he had no
more episodes of symptomatic bradycardia.
.
#DISTAL TIBIA/FIBULA FRACTURE:  Likely [**12-26**] fall prior to
admission.  Patient did not complain of right lower extremity
pain out of proportion to his baseline pain with the stasis
dermatitis.  The patient received a foot x-ray out of concern
for osteomyelitis after podiatry saw patient and gave wound care
recs.  Foot x-ray negative for osteomyelitis but revealed
possible distal tib/fib fracture.  Repeat leg x-ray of right
lower extremity showed distal tib/fib fracture.  Orthopedics saw
patient and decided not to operate, and opted for short casting
instead.
.
# TACHYPNEA: On admission his CXR was c/w pulmonary edema
secondary to CHF but could not rule out pneumonia or a PE.
Because of his kidney failure he was unable to get a CTA to rule
out a PE. Because he was febrile in the ED he was given one dose
of vancomycin and cefepime to cover for health care associated
pneumonia but these antibiotics were discontinued in the MICU
because he did not have evidence of infection.  Repeat chest
X-ray revealed no evidence of pneumonia.  Patient had no
supplemental O2 requirement in the days leading up to discharge,
with normal respiratory rates, no increased work of breathing
and O2 sats >95% on room air.
.
# ACUTE ON CHRONIC CKD: Unclear history of CKD, Cr elevated on
admission to 2.6, up from recent baseline value 1.6.  I/O's
trended and at discharge the patient's creatinine was 1.8 and
the patient's urine output was WNL.
.
# L1 COMPRESSION FRACTURE: Possible acute exacerbation of
chronic injury. We continued his home pain regimen of oxycontin
and oxycodone.
.
# HIP PAIN: Secondary to fall.  CT-abdomen/pelvis revealed no
hip fracture or other pathology. Pain control as above.
.
[]TRANSITIONAL ISSUES:
-patient will f/u with orthopedics in 2 weeks with Dr. [**Last Name (STitle) **]
for eval of distal tib/fib fracture
-patient will f/u with dermatology as an outpatient; prelim
biopsy results showed GPCs on gram stain, final report pending.
-patient will f/u with [**Last Name (un) 387**] providers as an outpatient
-patient will f/u with Dr. [**Last Name (STitle) **] for cardiology med management
and optimization on [**8-26**].


Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from  rehab records.
1. Baclofen 10 mg PO TID
2. Oxycodone SR (OxyconTIN) 10 mg PO Q12H
hold for sedation or rr<10
3. Multivitamins W/minerals 1 TAB PO DAILY
4. Amlodipine 10 mg PO DAILY
5. Aspirin 325 mg PO DAILY
6. Metoclopramide 5 mg PO TID:PRN nausea
7. Levothyroxine Sodium 100 mcg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY
9. Docusate Sodium 100 mg PO TID
10. Bisacodyl 10 mg PO DAILY:PRN constipation
11. Quetiapine Fumarate 50 mg PO HS
12. Quetiapine Fumarate 25 mg PO BID:PRN agitation
13. Prochlorperazine 10 mg PO Q6H:PRN nausea
14. Acetaminophen 650 mg PO Q4H:PRN pain or fever
15. Clopidogrel 75 mg PO DAILY
16. Pantoprazole 40 mg PO Q24H
17. Atorvastatin 80 mg PO DAILY
18. Ferrous Sulfate 325 mg PO DAILY
19. Gabapentin 300 mg PO DAILY
20. Tamsulosin 0.4 mg PO HS
21. HydrOXYzine 50 mg PO Q8H:PRN itch
22. MetFORMIN (Glucophage) 500 mg PO DAILY
23. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
24. Glargine 48 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
25. Lactulose 15 mL PO DAILY
26. Senna 2 TAB PO BID
27. Furosemide 20 mg PO BID
28. Ipratropium Bromide Neb 1 NEB IH Q4H:PRN SOB
29. Metoprolol Succinate XL 50 mg PO DAILY
30. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
31. Fluocinolone Acetonide 0.01% Cream 1 Appl TP [**Hospital1 **]
32. Isosorbide Dinitrate 5 mg PO TID


Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
2. Amlodipine 10 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Baclofen 10 mg PO TID
5. Bisacodyl 10 mg PO DAILY:PRN constipation
6. Clopidogrel 75 mg PO DAILY
7. Docusate Sodium 100 mg PO TID
8. Ferrous Sulfate 325 mg PO DAILY
9. Gabapentin 300 mg PO DAILY
10. Ipratropium Bromide Neb 1 NEB IH Q4H:PRN SOB
11. Lactulose 15 mL PO DAILY
12. Levothyroxine Sodium 100 mcg PO DAILY
13. Metoclopramide 5 mg PO TID:PRN nausea
14. Multivitamins W/minerals 1 TAB PO DAILY
15. Oxycodone SR (OxyconTIN) 10 mg PO Q12H
hold for sedation or rr<10
16. Pantoprazole 40 mg PO Q24H
17. Polyethylene Glycol 17 g PO DAILY
18. Prochlorperazine 10 mg PO Q6H:PRN nausea
19. Quetiapine Fumarate 50 mg PO HS
20. Quetiapine Fumarate 25 mg PO BID:PRN agitation
21. Senna 2 TAB PO BID
22. Tamsulosin 0.4 mg PO HS
23. Acetaminophen 650 mg PO Q4H:PRN pain or fever
24. Fluocinolone Acetonide 0.01% Cream 1 Appl TP [**Hospital1 **]
25. HydrOXYzine 50 mg PO Q8H:PRN itch
26. MetFORMIN (Glucophage) 500 mg PO DAILY
27. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
hold for sedation or RR < 10
28. Isosorbide Dinitrate 20 mg PO TID
hold for sbp < 100
29. HydrALAzine 40 mg PO TID
hold for SBP < 100
30. Aspirin 81 mg PO DAILY
31. Glargine 50 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
32. Torsemide 60 mg PO DAILY
hold for SBP < 90
33. Carvedilol 12.5 mg PO BID
hold for SBP < 100 or HR < 60


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **] Nursing & Therapy Center - [**Hospital3 4414**] ([**Hospital3 4414**]
Rehabilitation and Nursing Center)

Discharge Diagnosis:
acute on chronic dCHF exacerbation


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
Dear Mr. [**Known lastname 16114**],

It was a pleasure taking care of you.

You were admitted to the [**Hospital1 69**]
for having low blood pressures and breathing rapidly.  There was
concern that you may  have had an infection and you were placed
on antibiotics and transferred to the intensive care unit.  You
quickly stabilized and were transferred to the cardiology unit
out of concern that you may have had some fluid overload.  We
gave you medicine to increase your urination to get some of that
fluid off.  You improved significantly and were stable enough to
go back to your extended care facility.  We wish you the best.

Followup Instructions:
Department: CARDIAC SERVICES
When: TUESDAY [**2121-8-26**] at 2:00 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 6738**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: ORTHOPEDICS
When: THURSDAY [**2121-8-28**] at 3:20 PM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: ORTHOPEDICS
When: THURSDAY [**2121-8-28**] at 3:40 PM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: DERMATOLOGY
When: WEDNESDAY [**2121-9-24**] at 10:00 AM
With: [**Doctor First Name **]-[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8476**], MD, PHD [**Telephone/Fax (1) 1971**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Unspecified septicemia,Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Pathologic fracture of vertebrae,Ulcer of heel and midfoot,Cellulitis and abscess of leg, except foot,Severe sepsis,Venous (peripheral) insufficiency, unspecified,Coronary atherosclerosis of native coronary artery,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled,Polyneuropathy in diabetes,Atherosclerosis of native arteries of the extremities with ulceration,Background diabetic retinopathy,Unspecified acquired hypothyroidism,Hypoxemia,Pain in joint, pelvic region and thigh,Constipation, unspecified,Anemia, unspecified,Old myocardial infarction,Foot amputation status,Percutaneous transluminal coronary angioplasty status,Long-term (current) use of aspirin,Family history of ischemic heart disease,History of fall,Wheelchair dependence,Personal history of Methicillin resistant Staphylococcus aureus'}


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 and tachypnea

PRESENT ILLNESS: 54 year old male with CAD, DM, CHF, and CKD was at his baseline
state of health until he fell from his chair car yesterday,
striking his right hip and head. According to the patient, who
is a poor historian, he denies loss of consciousness, but has
continued right hip pain. According to the staff at his rehab
facility, he refused to go to the hospital. Today, the patient
reports feeling "sick" and nauseous. He also reports having
chest pain while moving his wheelchair that lasted 5 minutes,
radiated down his left arm, but did not make him short of
breath, sweaty, or nauseous. According to the staff at his rehab
facility, he was febrile to 101.6, tachypnic and diaphoretic and
was convinced to go to the ED. FSBS 154. He denies shortness of
breath at any point in the last few days. He denies subjective
fever, chills, cough or sore throat.
In the ED, initial VS were: T 98.1 HR 58 BP 95/48 RR 20 100% 4L
Nasal Cannula. His temperature spiked at 100.4. He had good
rectal tone.

MEDICAL HISTORY: hypothyroidism
Insulin-dependent diabetes mellitus since [**2082**]
Peripheral neuropathy s/p R mid foot amputation
Retinopathy w/ hx detached R retina
Coronary artery disease, status post silent MI - EF >55%,
cardiac cath [**5-1**]: L circumflex [**Last Name (un) **] 40% stenosis, proximal RCA
30% stenosis
Peripheral vascular disease
Chronic left heel ulcer
Breast lipoma s/p removal
Hypertension
MRSA +

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from  rehab records.
1. Baclofen 10 mg PO TID
2. Oxycodone SR (OxyconTIN) 10 mg PO Q12H
hold for sedation or rr<10
3. Multivitamins W/minerals 1 TAB PO DAILY
4. Amlodipine 10 mg PO DAILY
5. Aspirin 325 mg PO DAILY
6. Metoclopramide 5 mg PO TID:PRN nausea
7. Levothyroxine Sodium 100 mcg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY
9. Docusate Sodium 100 mg PO TID
10. Bisacodyl 10 mg PO DAILY:PRN constipation
11. Quetiapine Fumarate 50 mg PO HS
12. Quetiapine Fumarate 25 mg PO BID:PRN agitation
13. Prochlorperazine 10 mg PO Q6H:PRN nausea
14. Acetaminophen 650 mg PO Q4H:PRN pain or fever
15. Clopidogrel 75 mg PO DAILY
16. Pantoprazole 40 mg PO Q24H
17. Atorvastatin 80 mg PO DAILY
18. Ferrous Sulfate 325 mg PO DAILY
19. Gabapentin 300 mg PO DAILY
20. Tamsulosin 0.4 mg PO HS
21. HydrOXYzine 50 mg PO Q8H:PRN itch
22. MetFORMIN (Glucophage) 500 mg PO DAILY
23. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
24. Glargine 48 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
25. Lactulose 15 mL PO DAILY
26. Senna 2 TAB PO BID
27. Furosemide 20 mg PO BID
28. Ipratropium Bromide Neb 1 NEB IH Q4H:PRN SOB
29. Metoprolol Succinate XL 50 mg PO DAILY
30. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
31. Fluocinolone Acetonide 0.01% Cream 1 Appl TP [**Hospital1 **]
32. Isosorbide Dinitrate 5 mg PO TID

ALLERGIES: Morphine / adhesive tape

PHYSICAL EXAM: #ADMISSION PHYSICAL EXAM:
General: Alert, oriented x3, no acute distress
HEENT: Scabs on scalp, sclera anicteric, MMM, oropharynx clear,
pupils equal round reactive
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Breath sounds diminished bilateral lower/middle lobes,
bilateral upper lobes clear, no crackles or wheezes appreciated,
dull to percussion throughout.
Abdomen: Soft, diffusely tender to palpation, distended,
hypoactive bowel sounds present, no organomegaly. Skin breakdown
under bilateral breasts, erythematous exanthems on abdomen.
GU: Foley in place
Ext: Warm, well perfused, 2+ radial pulses bilaterally, fingers
contracted, no clubbing, cyanosis or edema. Multiple sites of
skin breakdown on right lower leg, raised weeping lesions. Heel
ulcer right foot. Diminished leg hair.
Neuro: Asterixis present
.
#DISCHARGE PHYSICAL EXAM:
Vitals: T98.6, BP (143-156)/(76-79), HR 61-67, RR 18-20, O2 sat
97% RA.
General: Alert, oriented x3, no acute distress
HEENT: Scabs on scalp, sclera anicteric, MMM, oropharynx clear,
pupils equal round reactive
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Chest: Breath sounds diminished bilateral lower/middle lobes,
bilateral upper lobes clear, minimal scattered crackles, no
wheezes appreciated, dull to percussion throughout.
Abdomen: Soft, NT/ND, bowel sounds present, no organomegaly.
Skin breakdown under bilateral breasts, erythematous exanthems
on abdomen.
GU: Foley in place
Ext: Warm, 2+ radial pulses bilaterally, fingers contracted, no
clubbing, cyanosis or edema.
Lower extr:  2+ bilateral lower extremity edema.  Pulses not
palpable [**12-26**] edema.  s/p left BKA, RIGHT LEG IN CAST
(previously: 1.5cm ulcer with necrotic edges on sole of R foot.
Stasis dermatitis on RLE, dressings c/d/i).

FAMILY HISTORY: Father passed away from MI, but had DM. Mother also passed away
from MI.

SOCIAL HISTORY: Denies smoking, alcohol and tobacco use.  Used to work in a mail 

### Response:
{'Unspecified septicemia,Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Pathologic fracture of vertebrae,Ulcer of heel and midfoot,Cellulitis and abscess of leg, except foot,Severe sepsis,Venous (peripheral) insufficiency, unspecified,Coronary atherosclerosis of native coronary artery,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled,Polyneuropathy in diabetes,Atherosclerosis of native arteries of the extremities with ulceration,Background diabetic retinopathy,Unspecified acquired hypothyroidism,Hypoxemia,Pain in joint, pelvic region and thigh,Constipation, unspecified,Anemia, unspecified,Old myocardial infarction,Foot amputation status,Percutaneous transluminal coronary angioplasty status,Long-term (current) use of aspirin,Family history of ischemic heart disease,History of fall,Wheelchair dependence,Personal history of Methicillin resistant Staphylococcus aureus'}
