CHIEF COMPLAINT: Fever

PRESENT ILLNESS: 53yoM with indwelling R arm picc x 2 weeks and very complicated
surgical and medical history including gastric bypass and
multiple other abdominal surgeries, chronic TPN with indwelling
PICC lines, cachexia, and multiple admissions to the intensive
care units for PICC line sepsis, who presents with fever of 102
and tachycardia as well as a feeling of malaise, which he
associates with episodes of line sepsis.

MEDICAL HISTORY: 1. Roux-en-Y gastric bypass surgery with bile duct injury
complicated by stricture
2. S/P revision with total gastrectomy and
choledochojejunostomy.
3. S/P distal pancreatectomy, splenectomy, and ventral hernia
repair
4. Surgery for islet cell hyperplasia of the pancreas
5. MSSA endocarditis
6. recurrent line sepsis
7. circumferential abdominoplasty
8. hypoglycemia thought to be from nesidioblastosis
9. Osteomalacia [**2-11**] vitamin D deficiency
10. Vitamin B12 deficiency
11. Testosterone deficiency
12. Anemia of chronic disease
13. uvulectomy and tonsillectomy
14. lumbar spinal fusion at L4-L5
15. bilateral shoulder surgeries
16. right ankle fusion
17. hx of TB - treated with 4 drug therapy for 9 mo
18. ?eye infection - seen at MEEI and currently being treated
(needs clarification)
19. basilar migraines

MEDICATION ON ADMISSION: AMPHETAMINE-DEXTROAMPHETAMINE - 10 mg Capsule, Ext Release 24 hr
- 2 Capsule(s) by mouth twice a day
CIPROFLOXACIN - 500 mg Tablet - 1 Tablet(s) by mouth twice a day
CLONAZEPAM - 1 mg Tablet - 1 Tablet(s) by mouth twice a day as
needed for anxiety
CYANOCOBALAMIN (VITAMIN B-12) - 1,000 mcg/mL Solution - 1 ml IM
once a month
DIAZEPAM - 5 mg Tablet - 1 Tablet(s) by mouth three times a day
prn
DICLOFENAC SODIUM - 50 mg Tablet, Delayed Release (E.C.) - 2
Tablet(s) by mouth twice a day as needed for pain
DRONABINOL [MARINOL] - 10 mg Capsule - 1 Capsule(s) by mouth
twice a day start with once a day for 1 week, then increase if
no
ill effect
ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit Capsule - 1 Capsule(s)
by mouth every other day
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth once a day
FOOD SUPPLEMENT, LACTOSE-FREE BOOST -   - Liguid (vanilla,
strawberry, chocolate) 3 cans per day dx: anemia, Vitamin B12
deficiency, osteoporosis, depression, basilar migraines, tardive
dyskinesia, chronic pain
LEVOMEFOLATE CALCIUM [DEPLIN] - 15 mg Tablet - 1 Tablet(s) by
mouth am
LIPASE-PROTEASE-AMYLASE [CREON] - 24,000 unit-[**Unit Number **],000
unit-[**Unit Number **],000
unit Capsule, Delayed Release(E.C.) - 3 Capsule(s) by mouth
three
times a day
LIPASE-PROTEASE-AMYLASE [CREON] - 12,000 unit-[**Unit Number **],000 unit-[**Unit Number **],000
unit Capsule, Delayed Release(E.C.) - 2 Capsule(s) by mouth
three
times a day
LITHIUM CARBONATE - 450 mg Tablet Extended Release - one
Tablet(s) by mouth daily
MIRTAZAPINE - 15 mg Tablet - 2 Tablet(s) by mouth at bedtime
ONDANSETRON [ZOFRAN ODT] - 8 mg Tablet, Rapid Dissolve - 1
Tablet(s) by mouth three times a day as needed for nausea
OXYBUTYNIN CHLORIDE - 10 mg Tablet Extended Rel 24 hr - 3
Tablet(s) by mouth once a day
OXYCODONE - 5 mg Capsule - 1 Capsule(s) by mouth every eight (8)
hours as needed for pain
PHYSICAL THERAPY -   - please evaluate and treat for general
deconditioning, L hip pain, ankle fracture
RAMELTEON [ROZEREM] - 8 mg Tablet - 3 Tablet(s) by mouth at
bedtime
SYRINGES -   - for b12 shots for b12 shot every day
TETRABENAZINE [XENAZINE] -  (Prescribed by Other Provider) (Not
Taking as Prescribed) - 12.5 mg Tablet - 1 Tablet(s) by mouth
twice a day
TRAMADOL - 50 mg Tablet - 1 Tablet(s) by mouth prn headache
VENLAFAXINE [EFFEXOR XR] - 150 mg Capsule, Ext Release 24 hr - 2
Capsule(s) by mouth in AM
ZOLPIDEM - 10 mg Tablet - 1 Tablet(s) by mouth at bed time as
needed for sleep
ZONISAMIDE - 100 mg Capsule - 3 Capsule(s) by mouth at bedtime
ASPIRIN [ADULT LOW DOSE ASPIRIN] -  (OTC) - 81 mg Tablet,
Delayed
Release (E.C.) - 1 (One) Tablet(s) by mouth once a day
CALCIUM CITRATE-VITAMIN D3 - 315 mg-250 unit Tablet - 3
Tablet(s)
by mouth twice a day
DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth twice a
day
FISH OIL-DHA-EPA [FISH OIL] - 1,200 mg-144 mg Capsule - 4
Capsule(s) by mouth twice a day
FOOD SUPPLEMENT, LACTOSE-FREE [BOOST] -   Liquid - 1 by mouth
[**Hospital1 **]
MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] -  2 Tablet(s) by
mouth once a day
PSEUDOEPHEDRINE-GUAIFENESIN [MUCINEX D] -  Dosage uncertain
SENNOSIDES - 8.6 mg Tablet - 1 Tablet(s) by mouth once a day
THIAMINE HCL -  (Prescribed by Other Provider) - 50 mg Tablet -
1
Tablet(s) by mouth daily
THIAMINE HCL - 100 mg Tablet - 1 Tablet(s) by mouth once a day
THIAMINE HCL - 250 mg Tablet - 1 Tablet(s) by mouth once a day
VITAMIN E -  (OTC) - Dosage uncertain

ALLERGIES: adhesive bandage / Benzoin / Mastisol Stertip / Compazine /
gabapentin / Neurontin

PHYSICAL EXAM: Admission Labs:
Vitals: T: 100.9 BP: 120s/80s P: 110-120s R: 18 O2: 98-99%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
CV: tachycardic with normal rhythm, normal S1 + S2, I/VI
systolic murmur heard best @LLSB, no rubs or gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: extensive surgical scarring, soft, non-tender,
non-distended, bowel sounds present, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Significant for CAD in his father and a sister w/ SLE

SOCIAL HISTORY: Denies IVDU, alcohol, or tobacco history. Worked as a CEO for
multiple companies until [**2152**]. Has an 17 yr old daughter and is
divorced.
Other and unspecified infection due to central venous catheter,Sepsis,Septicemia due to escherichia coli [E. coli],Traumatic hemothorax without mention of open wound into thorax,Metabolic encephalopathy,Cachexia,Iatrogenic pneumothorax,Drug-induced delirium,Urinary tract infection, site not specified,Acute posthemorrhagic anemia,Closed fracture of two ribs,Eosinophilia,Malnutrition of moderate degree,Migraine with aura, without mention of intractable migraine without mention of status migrainosus,Essential thrombocythemia,Body Mass Index between 19-24, adult,Anxiety state, unspecified,Bipolar disorder, unspecified,Iron deficiency anemia, unspecified,Hypoglycemia, unspecified,Hyperpotassemia,Nausea with vomiting,Osteomalacia, unspecified,Other B-complex deficiencies,Unspecified endocrine disorder,Attention deficit disorder with hyperactivity,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Sulfonamides causing adverse effects in therapeutic use,Other opiates and related narcotics causing adverse effects in therapeutic use,Accidental fall from bed,Bariatric surgery status
Oth/uns inf-cen ven cath,Sepsis,E coli septicemia,Traum hemothorax-closed,Metabolic encephalopathy,Cachexia,Iatrogenic pneumothorax,Drug-induced delirium,Urin tract infection NOS,Ac posthemorrhag anemia,Fracture two ribs-closed,Eosinophilia,Malnutrition mod degree,Mgrn w aura wo ntrc mgrn,Essntial thrombocythemia,BMI between 19-24,adult,Anxiety state NOS,Bipolar disorder NOS,Iron defic anemia NOS,Hypoglycemia NOS,Hyperpotassemia,Nausea with vomiting,Osteomalacia NOS,B-complex defic NEC,Endocrine disorder NOS,Attn deficit w hyperact,Abn react-procedure NEC,Adv eff sulfonamides,Adv eff opiates,Fall from bed,Bariatric surgery status
Admission Date:  [**2161-9-17**]              Discharge Date:   [**2161-10-9**]

Date of Birth:  [**2108-1-21**]             Sex:   M

Service: MEDICINE

Allergies:
adhesive bandage / Benzoin / Mastisol Stertip / Compazine /
gabapentin / Neurontin

Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Fever

Major Surgical or Invasive Procedure:
[**9-23**]: Placement of right-sided PICC line by IV nurses
[**9-24**]: Bedside placement of chest tube by Interventional
Pulmonology
[**9-26**]: Removal of chest tube by Thoracic Surgery
[**10-1**]: VATS/decortication by Thoracic Surgery
[**10-3**]: Removal of chest tubes by Thoracic Surgery, Removal of
PICC line


History of Present Illness:
53yoM with indwelling R arm picc x 2 weeks and very complicated
surgical and medical history including gastric bypass and
multiple other abdominal surgeries, chronic TPN with indwelling
PICC lines, cachexia, and multiple admissions to the intensive
care units for PICC line sepsis, who presents with fever of 102
and tachycardia as well as a feeling of malaise, which he
associates with episodes of line sepsis.

In the ED, initial VS were:  100.1 120 129/81 20 97% 2L.
Patient given 1L NS bolus with no resolution of tachycardia.
Patient also c/o anxiety and given 1mg PO ativan with little
effect.  Motrin 600 mg and Morphine 4mg IV resolved patient's
headache.  WBC 18.9 w/ 88.5% neutrophils.  Patient covered for
unknown source of SIRS with vanc/zosyn/gent.  2 peripheral BCx
sent and 1 BCx of of PICC sent.  UCx sent, but clean U/A.  CXR
wnl.  Transfered to the ICU for tachycardia and SIRS with
possible sepsis.

Past Medical History:
1. Roux-en-Y gastric bypass surgery with bile duct injury
complicated by stricture
2. S/P revision with total gastrectomy and
choledochojejunostomy.
3. S/P distal pancreatectomy, splenectomy, and ventral hernia
repair
4. Surgery for islet cell hyperplasia of the pancreas
5. MSSA endocarditis
6. recurrent line sepsis
7. circumferential abdominoplasty
8. hypoglycemia thought to be from nesidioblastosis
9. Osteomalacia [**2-11**] vitamin D deficiency
10. Vitamin B12 deficiency
11. Testosterone deficiency
12. Anemia of chronic disease
13. uvulectomy and tonsillectomy
14. lumbar spinal fusion at L4-L5
15. bilateral shoulder surgeries
16. right ankle fusion
17. hx of TB - treated with 4 drug therapy for 9 mo
18. ?eye infection - seen at MEEI and currently being treated
(needs clarification)
19. basilar migraines


Social History:
Denies IVDU, alcohol, or tobacco history. Worked as a CEO for
multiple companies until [**2152**]. Has an 17 yr old daughter and is
divorced.


Family History:
Significant for CAD in his father and a sister w/ SLE


Physical Exam:
Admission Labs:
Vitals: T: 100.9 BP: 120s/80s P: 110-120s R: 18 O2: 98-99%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
CV: tachycardic with normal rhythm, normal S1 + S2, I/VI
systolic murmur heard best @LLSB, no rubs or gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: extensive surgical scarring, soft, non-tender,
non-distended, bowel sounds present, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

Pertinent Results:
Admission Labs:
[**2161-9-17**] 09:15PM   WBC-18.9* RBC-3.76* HGB-11.9* HCT-35.6*
MCV-95 MCH-31.6 MCHC-33.4 RDW-16.3*
[**2161-9-17**] 09:15PM   NEUTS-88.5* LYMPHS-7.9* MONOS-1.1* EOS-2.2
BASOS-0.3
[**2161-9-17**] 09:15PM   PLT COUNT-437
[**2161-9-17**] 09:15PM   GLUCOSE-85 UREA N-16 CREAT-0.8 SODIUM-136
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-24 ANION GAP-14
[**2161-9-17**] 09:24PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2161-9-17**] 09:24PM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2161-9-17**] 09:26PM   LACTATE-1.9

Studies:

[**2161-9-17**] CXR: Low lung volumes; however, no focal acute pulmonary
process
identified.

CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2161-9-30**]
12:44 PM
IMPRESSION:

1. Slight interval increase in fluid component of large left
hemopneumothorax.
No source of active extravasation identified.

2. Left upper lobe consolidation could represent infection.
Recommend CT
follow up after resolution of acute symptoms.

3. Scattered ground-glass opacity in the right lung compatible
with infection.


Brief Hospital Course:
53 year old male with multiple GI surgeries including Roux-en-Y
gastric bypass surgery with bile duct injury, total gastrectomy,
distal pancreatectomy, and splenectomy, was initially admitted
with malaise and fevers, found to have PICC line sepsis; during
this admission, patient had a fall from bed with subsequent rib
fractures and hemothorax, which required chest tube drainage and
VATS/decortication for reaccumulation/loculation.  This
hospitalization was also complicated by anemia, UTI, delirium
and thrombocytosis.
.
Active Issues:
# PICC line sepsis: The patient met SIRS criteria on admission
with fevers to 102, WBC 19 and tachycardia, along with a
confirmed site of infection in his PICC line.  He was initially
admitted to the MICU, but transferred to the floor after he was
determined to be hemodynamically stable.  The patient's right
PICC line was removed.  Blood cultures from the PICC line grew
E. coli, Enterococcus and Stenotrophomonas.  A new left-sided
PICC was placed on [**9-23**] for prolonged delivery of IV
antibiotics, and it was removed after antibiotics finished on
[**10-3**]. The patient was treated with meropenem, vancomycin and
levofloxacin.  TTE showed no valvular vegetations.  Serial blood
cultures were subsequently negative.
.
# Hemothorax: The patient fell out of bed on [**9-24**] and sustained
9th and 10th rib fractures, complicated by a hemothorax.  The
Interventional Pulmonology team inserted a chest tube for
drainage on [**9-24**], and it was subsequently removed by the
Thoracic Surgery team on [**10-3**].  Chest tube placement and removal
was complicated by a minimal pneumothorax. After removal of the
tube, the patient continued to have intermittent fevers and
periods of hypotension that were responsive to IV fluid boluses.
 On follow-up imaging of the chest, he was noted to have
reaccumulation of his effusion with loculations, unable to be
drained by IP.  He was taken to the OR on [**10-1**] for a
VATS/decortication by Thoracic Surgery.  There was minimal blood
loss during the surgery.  The patient felt that his breathing
and pain was much improved following the surgery
.
# Nutrition/cachexia: Ongoing problem for this patient secondary
to his prior gastrectomy.  During this admission, the patient
tolerated PO diet well along with nutritional supplements.
However, out of concern for his malnutrition, per his outpatient
providers, the patient was further supplemented with TPN for ten
days, while he had an indwelling PICC for antibiotic therapy.
TPN was discontinued when his PICC was removed on [**10-3**].  He was
followed by the Surgical Nutrition team and they recommended
high protein content supplements and patient followup as an
outpatient to ensure he maintains his weight and nutritional
status. There was extensive discussion among his outpatient care
providers, and the decision was made not to place another PICC
line for TPN. He is also not a candidate for J-tube placement.
.
# Anemia: Over the course of this admission, the patient
experienced slowly downtrending hematocrit from continued bleed
into his left pleural space.  He required three units of PRBCs
over the course of his stay.  Hematocrit sunsequently stabilized
in the mid-20s.
.
# UTI: Patient was noted to have a UA positive for 111 WBC,
without any growth on culture, along with increased frequency of
urination.  He was treated empirically for a UTI with seven days
of levofloxacin.
.
# Delirium: The patient was at times tangiential in thought
processes and sleepy.  This was attributed to acute medical
issues and pain medications.  He tended to be more delirious in
response to IV Dilaudid.  Lithium level was WNL; he was not
hypoglycemic during episodes of delirium.  After treatment of
bacteremia completed and the patient underwent
VATS/decortication, his mental status improved and subsequently
remained stable.
.
# Thrombocytosis: Thrombocytosis to peak of ~ 1.5 million was
thought to be an acute reaction in response to his infection and
hemothorax. Hematology was consulted and recommended no
interventions at this time. JAK2 sent off for possible
myeloproliferative disorder,  as he has also had chronic
leukocytosis and anemia. Results are pending.
.
Chronic issues:
# Anxiety/BPD/ADHD: Documented history of these problems.  The
patient was extremely anxious during this admission, likely
secondary to multiple medical problems.  [**Name (NI) **] was continued on his
home medications, including amphetamine-dextroamphetamine,
clonazepam, diazepam, dronabinol, lithium carbonate,
mirtazapine, oxycodone, Ramelteon, tramadol, venlafaxine,
zolpidem and zonisamide.
.
.
Transitional issues:
1.) Code: Full (but does not want to be intubated if it means he
will never be able to come off the vent), confirmed with patient
and his HCP (sister)
2.) Emergency contact: sister [**Name (NI) **] (HCP) [**Telephone/Fax (1) 39334**]; [**Name (NI) **]
[**Name (NI) 39335**] (girlfriend) [**Telephone/Fax (1) 39336**]'
3) JAK2 and ristoceiting cofactor sendout pending. Please
followup

Medications on Admission:
AMPHETAMINE-DEXTROAMPHETAMINE - 10 mg Capsule, Ext Release 24 hr
- 2 Capsule(s) by mouth twice a day
CIPROFLOXACIN - 500 mg Tablet - 1 Tablet(s) by mouth twice a day
CLONAZEPAM - 1 mg Tablet - 1 Tablet(s) by mouth twice a day as
needed for anxiety
CYANOCOBALAMIN (VITAMIN B-12) - 1,000 mcg/mL Solution - 1 ml IM
once a month
DIAZEPAM - 5 mg Tablet - 1 Tablet(s) by mouth three times a day
prn
DICLOFENAC SODIUM - 50 mg Tablet, Delayed Release (E.C.) - 2
Tablet(s) by mouth twice a day as needed for pain
DRONABINOL [MARINOL] - 10 mg Capsule - 1 Capsule(s) by mouth
twice a day start with once a day for 1 week, then increase if
no
ill effect
ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit Capsule - 1 Capsule(s)
by mouth every other day
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth once a day
FOOD SUPPLEMENT, LACTOSE-FREE BOOST -   - Liguid (vanilla,
strawberry, chocolate) 3 cans per day dx: anemia, Vitamin B12
deficiency, osteoporosis, depression, basilar migraines, tardive
dyskinesia, chronic pain
LEVOMEFOLATE CALCIUM [DEPLIN] - 15 mg Tablet - 1 Tablet(s) by
mouth am
LIPASE-PROTEASE-AMYLASE [CREON] - 24,000 unit-[**Unit Number **],000
unit-[**Unit Number **],000
unit Capsule, Delayed Release(E.C.) - 3 Capsule(s) by mouth
three
times a day
LIPASE-PROTEASE-AMYLASE [CREON] - 12,000 unit-[**Unit Number **],000 unit-[**Unit Number **],000
unit Capsule, Delayed Release(E.C.) - 2 Capsule(s) by mouth
three
times a day
LITHIUM CARBONATE - 450 mg Tablet Extended Release - one
Tablet(s) by mouth daily
MIRTAZAPINE - 15 mg Tablet - 2 Tablet(s) by mouth at bedtime
ONDANSETRON [ZOFRAN ODT] - 8 mg Tablet, Rapid Dissolve - 1
Tablet(s) by mouth three times a day as needed for nausea
OXYBUTYNIN CHLORIDE - 10 mg Tablet Extended Rel 24 hr - 3
Tablet(s) by mouth once a day
OXYCODONE - 5 mg Capsule - 1 Capsule(s) by mouth every eight (8)
hours as needed for pain
PHYSICAL THERAPY -   - please evaluate and treat for general
deconditioning, L hip pain, ankle fracture
RAMELTEON [ROZEREM] - 8 mg Tablet - 3 Tablet(s) by mouth at
bedtime
SYRINGES -   - for b12 shots for b12 shot every day
TETRABENAZINE [XENAZINE] -  (Prescribed by Other Provider) (Not
Taking as Prescribed) - 12.5 mg Tablet - 1 Tablet(s) by mouth
twice a day
TRAMADOL - 50 mg Tablet - 1 Tablet(s) by mouth prn headache
VENLAFAXINE [EFFEXOR XR] - 150 mg Capsule, Ext Release 24 hr - 2
Capsule(s) by mouth in AM
ZOLPIDEM - 10 mg Tablet - 1 Tablet(s) by mouth at bed time as
needed for sleep
ZONISAMIDE - 100 mg Capsule - 3 Capsule(s) by mouth at bedtime
ASPIRIN [ADULT LOW DOSE ASPIRIN] -  (OTC) - 81 mg Tablet,
Delayed
Release (E.C.) - 1 (One) Tablet(s) by mouth once a day
CALCIUM CITRATE-VITAMIN D3 - 315 mg-250 unit Tablet - 3
Tablet(s)
by mouth twice a day
DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth twice a
day
FISH OIL-DHA-EPA [FISH OIL] - 1,200 mg-144 mg Capsule - 4
Capsule(s) by mouth twice a day
FOOD SUPPLEMENT, LACTOSE-FREE [BOOST] -   Liquid - 1 by mouth
[**Hospital1 **]
MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] -  2 Tablet(s) by
mouth once a day
PSEUDOEPHEDRINE-GUAIFENESIN [MUCINEX D] -  Dosage uncertain
SENNOSIDES - 8.6 mg Tablet - 1 Tablet(s) by mouth once a day
THIAMINE HCL -  (Prescribed by Other Provider) - 50 mg Tablet -
1
Tablet(s) by mouth daily
THIAMINE HCL - 100 mg Tablet - 1 Tablet(s) by mouth once a day
THIAMINE HCL - 250 mg Tablet - 1 Tablet(s) by mouth once a day
VITAMIN E -  (OTC) - Dosage uncertain

Discharge Medications:
1. amphetamine-dextroamphetamine 20 mg Capsule, Ext Release 24
hr Sig: One (1) Capsule, Ext Release 24 hr PO BID (2 times a
day).
2. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
3. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: One
(1) injection Injection once a month.
4. diazepam 2 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
5. dronabinol 10 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
6. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO EVERY OTHER DAY (Every Other Day).
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed
Release(E.C.) PO three times a day.
9. lithium carbonate 450 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO QHS (once a day (at bedtime)).
10. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
11. oxybutynin chloride 10 mg Tablet Extended Rel 24 hr Sig:
Three (3) Tablet Extended Rel 24 hr PO once a day.
12. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for headache.
13. venlafaxine 150 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO twice a day.
14. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO at bedtime.

15. zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
16. zonisamide 100 mg Capsule Sig: Three (3) Capsule PO at
bedtime.
17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
18. omega-3 fatty acids     Capsule Sig: One (1) Capsule PO BID
(2 times a day).
19. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
20. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for Constipation.
21. thiamine HCl 250 mg Tablet Sig: One (1) Tablet PO once a
day.
22. calcium citrate-vitamin D3 315-250 mg-unit Tablet Sig: Three
(3) Tablet PO twice a day.
23. Centrum Silver     Tablet Sig: Two (2) Tablet PO once a day.

24. vitamin E 400 unit Tablet Sig: One (1) Tablet PO once a day.

25. Pro-Stat 101 15-101 gram-kcal/30 mL Liquid Sig: Thirty (30)
mL PO Three Times a Day with Meals.
Disp:*QS 1 month supply* Refills:*2*
26. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) for 1
months.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
27. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain for 1 weeks: Do not drink alcohol or operate
heavy machinery while on this medication. .
Disp:*QS 1 week supply* Refills:*0*
28. Outpatient Lab Work
Please check a CBC and Chem 7 on [**2161-10-12**] and [**2161-10-19**]. Please
fax the results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3535**] @ [**Telephone/Fax (1) 3382**]. His office
phone number is [**Telephone/Fax (1) 250**]. Please also fax the results to Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. His office phone number is [**Telephone/Fax (1) 22**].


Discharge Disposition:
Home With Service

Facility:
Primary Home Care Specialty

Discharge Diagnosis:
Primary diagnosis:
PICC line sepsis
moderate malnutrition
.
Secondary diagnoses:
Hemothorax
Left 9th and 10th rib fractures
Loculated pleural effusion
reactive thrombocytosis
depression/ anxiety


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
Dear Mr. [**Known lastname 39278**],
.
It was a pleasure to participate in your care here at [**Hospital1 1535**].  You were admitted with a fever
and overall malaise, and were found to have bacteria in your
bloodstream from your indwelling peripherally inserted central
catheter (PICC) line.  You were found to have three bacteria
growing in your blood: Escherischia coli, Entercoccus and
Stenotrophomonoas.  You were treated with intravenous fluids and
antibiotics (vancomycin, meropenem and levofloxacin).  Your
urine was also positive for an infection, which was covered by
these medications as well.  A new peripherally-inserted central
catheter line was placed for treatment with these antibiotics
and for delivery of total parenteral nutrition.  This was
removed on Saturday [**10-3**].
.
Additionally, on Thursday [**9-24**], you fell out of bed and
sustained fractures of your left 9th and 10th ribs.  These
fractures caused blood to accumulate in the space surrounding
your left lung.  The Interventional Pulmonology team drained
this blood with a chest tube, but it reaccumulated and developed
fibrotic pockets, which required surgical treatment.  On
Thursday [**10-1**], you had a video-assisted thoracic surgery to
clear out the space around your left lung.  You did very well
during the surgery with minimal blood loss.  Afterwards, your
breathing and pain improved.
.
Please note, the following changes have been made to your
medications:
.
START taking the following medications:
1. START taking ProSTAT 30 cc by mouth three times a day with
meals. This is a protein supplement that was recommedned by Dr.
[**Last Name (STitle) **]. The supplement will be delivered to your home on
[**2161-10-12**].
2. START using a Lidocaine patch as needed for rib pain. Apply
one patch daily for twelve hours and then remove. Please allow
for 12 hours between patches.
.
STOP taking the following medications:
- STOP taking Aspirin 81 mg by mouth daily until you follow up
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
.
CHANGE THE DOSE of the following medications:
1. Clonazepam was reduced from 1 mg by mouth twice a day as
needed for anxiety to 0.5 mg by mouth twice a day as needed for
anxiety.
2. Diazepam was reduced from 5 mg by mouth three times a day as
needed for anxiety to 2 mg three times a day as needed for
anxiety.
3. Mirtazapine was reduced from 60 mg by mouth at bedtime to 30
mg by mouth at bedtime.
4. Sennosides (Senna) was increased from 8.6 mg by mouth daily
for constipation to 8.6 mg by mouth twice daily for
constipation. You do not need to take this medication if you are
having loose stools.
5. Tetrabenazine (Xenazine) was not placed on your medication
list. Please clarify the dose and administration of this
medication with your primary care physician or prescribing
provider.
6. Your dose of Oxycodone has temporarily been increased from 5
mg by mouth every eight hours as needed for pain to 5 mg by
mouth every six hours as needed for pain. You have been given a
prescription for a week's worth of pain medications. If you feel
that you will need more, please discuss this with Dr. [**First Name (STitle) 3535**]. If
you feel that your pain has improved, you may return to your
original home regimen. Please do not drink alcohol or operate
heavy machinery while on this medication.
.
Of note, many of the medication changes were made as there was
concern that your mental status was intermittently affected by
many of the sedating medications that you were taking.

Followup Instructions:
Please keep all follow-up appointments as below:
.
It is recommended you follow up with [**First Name5 (NamePattern1) 553**] [**Last Name (NamePattern1) 39337**] in
Nutrition Services at ([**Telephone/Fax (1) 7026**].  Please call them once you
are home to make an appt within 1 week of discharge.
.
Department: [**Hospital3 249**]
When: WEDNESDAY [**2161-10-14**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
**Please contact your insurance and change your Dr [**Last Name (STitle) **] [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 3535**]. Failing to do so could result in you receiving [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] and
your referral for Hematology/Oncology will not be able to be
processed**
.
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2161-10-20**] at 1:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage


                             [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

Completed by:[**2161-10-12**]
{'Other and unspecified infection due to central venous catheter,Sepsis,Septicemia due to escherichia coli [E. coli],Traumatic hemothorax without mention of open wound into thorax,Metabolic encephalopathy,Cachexia,Iatrogenic pneumothorax,Drug-induced delirium,Urinary tract infection, site not specified,Acute posthemorrhagic anemia,Closed fracture of two ribs,Eosinophilia,Malnutrition of moderate degree,Migraine with aura, without mention of intractable migraine without mention of status migrainosus,Essential thrombocythemia,Body Mass Index between 19-24, adult,Anxiety state, unspecified,Bipolar disorder, unspecified,Iron deficiency anemia, unspecified,Hypoglycemia, unspecified,Hyperpotassemia,Nausea with vomiting,Osteomalacia, unspecified,Other B-complex deficiencies,Unspecified endocrine disorder,Attention deficit disorder with hyperactivity,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Sulfonamides causing adverse effects in therapeutic use,Other opiates and related narcotics causing adverse effects in therapeutic use,Accidental fall from bed,Bariatric surgery status'}


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: 53yoM with indwelling R arm picc x 2 weeks and very complicated
surgical and medical history including gastric bypass and
multiple other abdominal surgeries, chronic TPN with indwelling
PICC lines, cachexia, and multiple admissions to the intensive
care units for PICC line sepsis, who presents with fever of 102
and tachycardia as well as a feeling of malaise, which he
associates with episodes of line sepsis.

MEDICAL HISTORY: 1. Roux-en-Y gastric bypass surgery with bile duct injury
complicated by stricture
2. S/P revision with total gastrectomy and
choledochojejunostomy.
3. S/P distal pancreatectomy, splenectomy, and ventral hernia
repair
4. Surgery for islet cell hyperplasia of the pancreas
5. MSSA endocarditis
6. recurrent line sepsis
7. circumferential abdominoplasty
8. hypoglycemia thought to be from nesidioblastosis
9. Osteomalacia [**2-11**] vitamin D deficiency
10. Vitamin B12 deficiency
11. Testosterone deficiency
12. Anemia of chronic disease
13. uvulectomy and tonsillectomy
14. lumbar spinal fusion at L4-L5
15. bilateral shoulder surgeries
16. right ankle fusion
17. hx of TB - treated with 4 drug therapy for 9 mo
18. ?eye infection - seen at MEEI and currently being treated
(needs clarification)
19. basilar migraines

MEDICATION ON ADMISSION: AMPHETAMINE-DEXTROAMPHETAMINE - 10 mg Capsule, Ext Release 24 hr
- 2 Capsule(s) by mouth twice a day
CIPROFLOXACIN - 500 mg Tablet - 1 Tablet(s) by mouth twice a day
CLONAZEPAM - 1 mg Tablet - 1 Tablet(s) by mouth twice a day as
needed for anxiety
CYANOCOBALAMIN (VITAMIN B-12) - 1,000 mcg/mL Solution - 1 ml IM
once a month
DIAZEPAM - 5 mg Tablet - 1 Tablet(s) by mouth three times a day
prn
DICLOFENAC SODIUM - 50 mg Tablet, Delayed Release (E.C.) - 2
Tablet(s) by mouth twice a day as needed for pain
DRONABINOL [MARINOL] - 10 mg Capsule - 1 Capsule(s) by mouth
twice a day start with once a day for 1 week, then increase if
no
ill effect
ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit Capsule - 1 Capsule(s)
by mouth every other day
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth once a day
FOOD SUPPLEMENT, LACTOSE-FREE BOOST -   - Liguid (vanilla,
strawberry, chocolate) 3 cans per day dx: anemia, Vitamin B12
deficiency, osteoporosis, depression, basilar migraines, tardive
dyskinesia, chronic pain
LEVOMEFOLATE CALCIUM [DEPLIN] - 15 mg Tablet - 1 Tablet(s) by
mouth am
LIPASE-PROTEASE-AMYLASE [CREON] - 24,000 unit-[**Unit Number **],000
unit-[**Unit Number **],000
unit Capsule, Delayed Release(E.C.) - 3 Capsule(s) by mouth
three
times a day
LIPASE-PROTEASE-AMYLASE [CREON] - 12,000 unit-[**Unit Number **],000 unit-[**Unit Number **],000
unit Capsule, Delayed Release(E.C.) - 2 Capsule(s) by mouth
three
times a day
LITHIUM CARBONATE - 450 mg Tablet Extended Release - one
Tablet(s) by mouth daily
MIRTAZAPINE - 15 mg Tablet - 2 Tablet(s) by mouth at bedtime
ONDANSETRON [ZOFRAN ODT] - 8 mg Tablet, Rapid Dissolve - 1
Tablet(s) by mouth three times a day as needed for nausea
OXYBUTYNIN CHLORIDE - 10 mg Tablet Extended Rel 24 hr - 3
Tablet(s) by mouth once a day
OXYCODONE - 5 mg Capsule - 1 Capsule(s) by mouth every eight (8)
hours as needed for pain
PHYSICAL THERAPY -   - please evaluate and treat for general
deconditioning, L hip pain, ankle fracture
RAMELTEON [ROZEREM] - 8 mg Tablet - 3 Tablet(s) by mouth at
bedtime
SYRINGES -   - for b12 shots for b12 shot every day
TETRABENAZINE [XENAZINE] -  (Prescribed by Other Provider) (Not
Taking as Prescribed) - 12.5 mg Tablet - 1 Tablet(s) by mouth
twice a day
TRAMADOL - 50 mg Tablet - 1 Tablet(s) by mouth prn headache
VENLAFAXINE [EFFEXOR XR] - 150 mg Capsule, Ext Release 24 hr - 2
Capsule(s) by mouth in AM
ZOLPIDEM - 10 mg Tablet - 1 Tablet(s) by mouth at bed time as
needed for sleep
ZONISAMIDE - 100 mg Capsule - 3 Capsule(s) by mouth at bedtime
ASPIRIN [ADULT LOW DOSE ASPIRIN] -  (OTC) - 81 mg Tablet,
Delayed
Release (E.C.) - 1 (One) Tablet(s) by mouth once a day
CALCIUM CITRATE-VITAMIN D3 - 315 mg-250 unit Tablet - 3
Tablet(s)
by mouth twice a day
DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth twice a
day
FISH OIL-DHA-EPA [FISH OIL] - 1,200 mg-144 mg Capsule - 4
Capsule(s) by mouth twice a day
FOOD SUPPLEMENT, LACTOSE-FREE [BOOST] -   Liquid - 1 by mouth
[**Hospital1 **]
MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] -  2 Tablet(s) by
mouth once a day
PSEUDOEPHEDRINE-GUAIFENESIN [MUCINEX D] -  Dosage uncertain
SENNOSIDES - 8.6 mg Tablet - 1 Tablet(s) by mouth once a day
THIAMINE HCL -  (Prescribed by Other Provider) - 50 mg Tablet -
1
Tablet(s) by mouth daily
THIAMINE HCL - 100 mg Tablet - 1 Tablet(s) by mouth once a day
THIAMINE HCL - 250 mg Tablet - 1 Tablet(s) by mouth once a day
VITAMIN E -  (OTC) - Dosage uncertain

ALLERGIES: adhesive bandage / Benzoin / Mastisol Stertip / Compazine /
gabapentin / Neurontin

PHYSICAL EXAM: Admission Labs:
Vitals: T: 100.9 BP: 120s/80s P: 110-120s R: 18 O2: 98-99%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
CV: tachycardic with normal rhythm, normal S1 + S2, I/VI
systolic murmur heard best @LLSB, no rubs or gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: extensive surgical scarring, soft, non-tender,
non-distended, bowel sounds present, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Significant for CAD in his father and a sister w/ SLE

SOCIAL HISTORY: Denies IVDU, alcohol, or tobacco history. Worked as a CEO for
multiple companies until [**2152**]. Has an 17 yr old daughter and is
divorced. 

### Response:
{'Other and unspecified infection due to central venous catheter,Sepsis,Septicemia due to escherichia coli [E. coli],Traumatic hemothorax without mention of open wound into thorax,Metabolic encephalopathy,Cachexia,Iatrogenic pneumothorax,Drug-induced delirium,Urinary tract infection, site not specified,Acute posthemorrhagic anemia,Closed fracture of two ribs,Eosinophilia,Malnutrition of moderate degree,Migraine with aura, without mention of intractable migraine without mention of status migrainosus,Essential thrombocythemia,Body Mass Index between 19-24, adult,Anxiety state, unspecified,Bipolar disorder, unspecified,Iron deficiency anemia, unspecified,Hypoglycemia, unspecified,Hyperpotassemia,Nausea with vomiting,Osteomalacia, unspecified,Other B-complex deficiencies,Unspecified endocrine disorder,Attention deficit disorder with hyperactivity,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Sulfonamides causing adverse effects in therapeutic use,Other opiates and related narcotics causing adverse effects in therapeutic use,Accidental fall from bed,Bariatric surgery status'}
