CHIEF COMPLAINT: Fevers at dialysis

PRESENT ILLNESS: 63 y/o female with h/o Diabetes Mellitus Type II, End Stage
Renal Disease on dialysis, HTN, unknown pulmonary condition on
3L 02 by nasal canula at home, presents from the [**Location (un) **]
Dialysis with fevers occuring during dialysis.  [**Name (NI) **]
husband reports that she has been mildly lethargic for the past
week and has been having fevers following dialysis.  Husband
reports patient was slightly confused on the day prior to
admission.  Patient repots that she was feeling "fine" prior to
hospitilization.  She went to dialysis on the morning of
admission as per her usual routine and developed a temperature
during the procedure.  She was given IV Vancomycin at dialysis
and was transferred to the ED for evaluation of infection
concerns.  During ambulance transfer, patient vomited and there
was a question that she may have aspirated gastric contents.
Patient recalls being placed in the ambulance but does not
recall anything from that moment until after she arrived in the
MICU.
.
Patient had previously had a right tunneled hemodialysis
catheter which was placed in [**9-2**].  Six months prior to
admission patient had a fistula for hemodialysis created  in the
right arm.  This fistula was seeded with bovine material.
Tunneled catheter was left in place because patient reported
signficiant pain with blood draws.
.
[**Hospital1 18**] ED Course: VS- T 100.5; HR 98; BP 161/64; RR 22; O2 100%
RA.  ED notes indicate that the patient had labored breathing
upon arrival with tachypnea.  Given the clinical apperance of
the patient, she was intubated to protect her airway.  A Left IJ
central line was placed for access.  Patient was given
Vancomycin/Ceftriaxone, Metronidazole, and Levaquin.  She was
admitted to the MICU.
.
ROS:
General: Patient notes that she has felt tired for approximately
three weeks.  She denies feeling feverous and notes that her
husband takes her temperature regularly.  She denies any chills.
 Patient reports that she has had good appetite and has not had
any recent dietary changes.  She denies any changes in her sleep
pattern.
Skin: Patient reports that she regularly has ulcers on her legs.
 Patient's daughter reported away from the presence of her
mother that she regularly witnesses her mother picking at the
scabs on her arms with a tweezers.  Patient reports that her
legs are always red and swollen.
HEENT:  Patient denies any vision changes.  She does not
remember when her last eye exam was conducted.  Patient denies
headaches or changes in her hearing.  She denies allergies or
nasal drainage.
Cardiac: S/p 5 Vessel CABG in [**2179**].  Patient reports that she
was dancing with her son in-law at her sister's birthday party
in [**2179**].  She said that she felt short of breath and needed to
sit down.  She then went to her PCP who recommended cardiology
f/u which resulted in cardiac catherization.  Patient any other
episodes of chest pain or pressure.
Resp: Patient reports that she has been evaluated for sleep
problems but nothing was found on these studies.  She says that
she cannot use CPAP machine.  She is on 3L O2 by nasal canula at
all times at home.  She reports that she sleeps in bed with only
one pillow at night.  She denies any PND.
GI: Patient denies any diarrhea, constipation or recent changes
in the stool.  She notes that she feels her abdomen is slight
distended.
GU: Patient reports that she has been on hemodialysis since
[**2184**].  She says that she produces very little urine and denies
pain or burning with urination.
ENDO: Patient reports that she is hypothyroid and is medically
managed.
EXT: Patient reports that she has sores on her feet that are
very slow to heal.  She reports that she fell and broke her hip
requiring surgical correction.
NEURO: Patient reports that she does not feel her feet or her
hands. She notes that she does not feel pain from the ulcers.
She is unsteady on her feet and gets tired when she tries to use
her arms to push herself up from a chair.  Most recently she has
been primarily using her wheelchair in the home.

MEDICAL HISTORY: 1. DM2 since her 40s, dialysis since [**2-3**]
2. ESRD [**2-1**] DMII, on MWF HD, followed by Dr. [**First Name (STitle) 805**].  RIJ
tunneled cath placed on [**2185-12-13**] for peritoneal dialysis.
Fistula created in [**1-6**] but RIJ tunneled cath left in place for
access.
3. h/o MRSA cellulitis of bilateral LE
4. HTN
5. Hyperlipidemia
6. Hypothyroidism
7. PD cath placement on [**2185-12-13**] with RIJ tunneled cath
8. CAD s/p CABG [**2179**], NSTEMI in [**9-2**] during admission; echo [**3-4**]

MEDICATION ON ADMISSION: AMBIEN 10 mg--1 tablet(s) by mouth at bedtime
AMOXICILLIN 500 mg--4 capsule(s) by mouth 1 hr before dental
work
ASPIRIN 81 mg--1 tablet(s) by mouth once a day
B COMPLEX --1 capsule(s) by mouth daily
COZAAR 50 mg--1 tablet(s) by mouth 4 times a week
DAYPRO 600MG--2 by mouth every day with food
DIGOXIN 125 mcg--[**1-1**] alternating with 1 tab tablet(s) by mouth
q4days 2 tabs po initially, then [**1-1**] alternating with 1 tab
every 4 days.
Humalog Pen 100 unit/mL (75-25)--use as directed twice a day as

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS- T: 97.1 BP: 131/67 P: 85 RR: 22 O2 Sat: 95% on 3L
Fingerstick: 103 Weight: 94.0 kg
GEN: Patient is ill-appearing woman who appears much older than
her stated age of 63.  She appears very pale and has thinning of
her hair.  She was being fed dinner by her husband.  She is in
no acute distress on 3L O2 by nasal canula.
SKIN- Scabs were noted on the extremeties.
HEENT: NC, AT.  MMM, No oral sores noted.  PERRLA.  Midline
nasal septa.  Opthalmoscopic exam revealed red reflux, no
diabetic changes noted (no cotton wool spots or hemorrages).
LIJ in place with slight ooze.
HEART: RRR. Systolic ejection murmur was heard best at the LUSB,
grade II/VI. No gallops or rubs noted.
LUNGS: Diffuse crackles were noted over both lung fields.
ABD: Bowel sounds were noted in all four quadrants.  Abdomen was
distended with no tenderness.  Right-sided abdominal hernia
noted which was easily reducable.
EXT: An ulcer was noted on the left malleolus which measures
approx. 1.5 x 0.8 cm.  There is undermining from [**5-8**] oclock,
0.5 cm.  The wound bed is 100% nonviable tissue and the bone is
palpable in the center of the wound bed.  The wound edges are
macerated and defined.  The periwound tissue is macerated and
erythemic, slight edema.  There is no induration, fluctuance or
crepitus.  R ankle is significant for displaced calcaneus bone.
+1 Ankle edema was noted on the right ankle.  Patient has had an
amputation of the right fifth toe.  Erythema is noted on both
shins extending from the ankle until 2 in below the knee. +1
DT/PT pulses. Palpable thrill over left arm AV fistula.
NEURO: PERRLA. CN II - XII intact.  Decreased vibration and
temperature sensation in stocking glove distribution.

FAMILY HISTORY: Father - Deceased with MI at 60
Sister - Breast cancer diagnosed at age 56.
Mother - 60s, CAD; diagnosed with breast cancer in her 30s.
Son with DM

SOCIAL HISTORY: The patient lives with her husband who is her primary caregiver.
 She denies past or present tobacco use.  She denies alcohol or
IV drug use.  Patient previously worked as a secretary.  She
endorses carbohydrate counting to control her diabetes and eats
a renal and cardiac friendly diet.
Other staphylococcal septicemia,Cellulitis and abscess of leg, except foot,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Congestive heart failure, unspecified,End stage renal disease,Ulcer of ankle,Infection and inflammatory reaction due to other vascular device, implant, and graft,Anemia in chronic kidney disease,Restless legs syndrome (RLS),Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Unspecified acquired hypothyroidism,Osteoporosis, unspecified,Other and unspecified hyperlipidemia,Old myocardial infarction,Other dependence on machines, supplemental oxygen,Aortocoronary bypass status
Staphylcocc septicem NEC,Cellulitis of leg,Hyp kid NOS w cr kid V,CHF NOS,End stage renal disease,Ulcer of ankle,React-oth vasc dev/graft,Anemia in chr kidney dis,Restless legs syndrome,DMII renl nt st uncntrld,Hypothyroidism NOS,Osteoporosis NOS,Hyperlipidemia NEC/NOS,Old myocardial infarct,Depend-supplement oxygen,Aortocoronary bypass
Admission Date:  [**2188-7-30**]              Discharge Date:   [**2188-8-5**]

Date of Birth:  [**2125-3-28**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Fevers at dialysis

Major Surgical or Invasive Procedure:
Removal of tunneled dialysis catheter
Intubation.
Central Line Placement.


History of Present Illness:
63 y/o female with h/o Diabetes Mellitus Type II, End Stage
Renal Disease on dialysis, HTN, unknown pulmonary condition on
3L 02 by nasal canula at home, presents from the [**Location (un) **]
Dialysis with fevers occuring during dialysis.  [**Name (NI) **]
husband reports that she has been mildly lethargic for the past
week and has been having fevers following dialysis.  Husband
reports patient was slightly confused on the day prior to
admission.  Patient repots that she was feeling "fine" prior to
hospitilization.  She went to dialysis on the morning of
admission as per her usual routine and developed a temperature
during the procedure.  She was given IV Vancomycin at dialysis
and was transferred to the ED for evaluation of infection
concerns.  During ambulance transfer, patient vomited and there
was a question that she may have aspirated gastric contents.
Patient recalls being placed in the ambulance but does not
recall anything from that moment until after she arrived in the
MICU.
.
Patient had previously had a right tunneled hemodialysis
catheter which was placed in [**9-2**].  Six months prior to
admission patient had a fistula for hemodialysis created  in the
right arm.  This fistula was seeded with bovine material.
Tunneled catheter was left in place because patient reported
signficiant pain with blood draws.
.
[**Hospital1 18**] ED Course: VS- T 100.5; HR 98; BP 161/64; RR 22; O2 100%
RA.  ED notes indicate that the patient had labored breathing
upon arrival with tachypnea.  Given the clinical apperance of
the patient, she was intubated to protect her airway.  A Left IJ
central line was placed for access.  Patient was given
Vancomycin/Ceftriaxone, Metronidazole, and Levaquin.  She was
admitted to the MICU.
.
ROS:
General: Patient notes that she has felt tired for approximately
three weeks.  She denies feeling feverous and notes that her
husband takes her temperature regularly.  She denies any chills.
 Patient reports that she has had good appetite and has not had
any recent dietary changes.  She denies any changes in her sleep
pattern.
Skin: Patient reports that she regularly has ulcers on her legs.
 Patient's daughter reported away from the presence of her
mother that she regularly witnesses her mother picking at the
scabs on her arms with a tweezers.  Patient reports that her
legs are always red and swollen.
HEENT:  Patient denies any vision changes.  She does not
remember when her last eye exam was conducted.  Patient denies
headaches or changes in her hearing.  She denies allergies or
nasal drainage.
Cardiac: S/p 5 Vessel CABG in [**2179**].  Patient reports that she
was dancing with her son in-law at her sister's birthday party
in [**2179**].  She said that she felt short of breath and needed to
sit down.  She then went to her PCP who recommended cardiology
f/u which resulted in cardiac catherization.  Patient any other
episodes of chest pain or pressure.
Resp: Patient reports that she has been evaluated for sleep
problems but nothing was found on these studies.  She says that
she cannot use CPAP machine.  She is on 3L O2 by nasal canula at
all times at home.  She reports that she sleeps in bed with only
one pillow at night.  She denies any PND.
GI: Patient denies any diarrhea, constipation or recent changes
in the stool.  She notes that she feels her abdomen is slight
distended.
GU: Patient reports that she has been on hemodialysis since
[**2184**].  She says that she produces very little urine and denies
pain or burning with urination.
ENDO: Patient reports that she is hypothyroid and is medically
managed.
EXT: Patient reports that she has sores on her feet that are
very slow to heal.  She reports that she fell and broke her hip
requiring surgical correction.
NEURO: Patient reports that she does not feel her feet or her
hands. She notes that she does not feel pain from the ulcers.
She is unsteady on her feet and gets tired when she tries to use
her arms to push herself up from a chair.  Most recently she has
been primarily using her wheelchair in the home.

Past Medical History:
1. DM2 since her 40s, dialysis since [**2-3**]
2. ESRD [**2-1**] DMII, on MWF HD, followed by Dr. [**First Name (STitle) 805**].  RIJ
tunneled cath placed on [**2185-12-13**] for peritoneal dialysis.
Fistula created in [**1-6**] but RIJ tunneled cath left in place for
access.
3. h/o MRSA cellulitis of bilateral LE
4. HTN
5. Hyperlipidemia
6. Hypothyroidism
7. PD cath placement on [**2185-12-13**] with RIJ tunneled cath
8. CAD s/p CABG [**2179**], NSTEMI in [**9-2**] during admission; echo [**3-4**]

with EF 35-40%
9. Anemia
10. Osteoporosis
11. Depression
12. h/o right hip fx s/o ORIF
13. On Home 3L O2, PFTs [**2186**] with restrictive pattern, pulmonary
HTN
14. R Charcot Foot
15. Restless Leg Syndrome

Social History:
The patient lives with her husband who is her primary caregiver.
 She denies past or present tobacco use.  She denies alcohol or
IV drug use.  Patient previously worked as a secretary.  She
endorses carbohydrate counting to control her diabetes and eats
a renal and cardiac friendly diet.

Family History:
Father - Deceased with MI at 60
Sister - Breast cancer diagnosed at age 56.
Mother - 60s, CAD; diagnosed with breast cancer in her 30s.
Son with DM

Physical Exam:
VS- T: 97.1 BP: 131/67 P: 85 RR: 22 O2 Sat: 95% on 3L
Fingerstick: 103 Weight: 94.0 kg
GEN: Patient is ill-appearing woman who appears much older than
her stated age of 63.  She appears very pale and has thinning of
her hair.  She was being fed dinner by her husband.  She is in
no acute distress on 3L O2 by nasal canula.
SKIN- Scabs were noted on the extremeties.
HEENT: NC, AT.  MMM, No oral sores noted.  PERRLA.  Midline
nasal septa.  Opthalmoscopic exam revealed red reflux, no
diabetic changes noted (no cotton wool spots or hemorrages).
LIJ in place with slight ooze.
HEART: RRR. Systolic ejection murmur was heard best at the LUSB,
grade II/VI. No gallops or rubs noted.
LUNGS: Diffuse crackles were noted over both lung fields.
ABD: Bowel sounds were noted in all four quadrants.  Abdomen was
distended with no tenderness.  Right-sided abdominal hernia
noted which was easily reducable.
EXT: An ulcer was noted on the left malleolus which measures
approx. 1.5 x 0.8 cm.  There is undermining from [**5-8**] oclock,
0.5 cm.  The wound bed is 100% nonviable tissue and the bone is
palpable in the center of the wound bed.  The wound edges are
macerated and defined.  The periwound tissue is macerated and
erythemic, slight edema.  There is no induration, fluctuance or
crepitus.  R ankle is significant for displaced calcaneus bone.
+1 Ankle edema was noted on the right ankle.  Patient has had an
amputation of the right fifth toe.  Erythema is noted on both
shins extending from the ankle until 2 in below the knee. +1
DT/PT pulses. Palpable thrill over left arm AV fistula.
NEURO: PERRLA. CN II - XII intact.  Decreased vibration and
temperature sensation in stocking glove distribution.


Pertinent Results:
Admission Labs:
[**2188-7-30**] 07:21PM   WBC-13.7* RBC-3.09* HGB-9.4* HCT-31.6*
MCV-102*# MCH-30.5 MCHC-29.9* RDW-21.5*
[**2188-7-30**] 07:21PM   NEUTS-91.9* BANDS-0 LYMPHS-5.1* MONOS-1.9*
EOS-1.0 BASOS-0.2
[**2188-7-30**] 07:21PM   HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-OCCASIONAL
MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL
[**2188-7-30**] 07:21PM   PLT SMR-NORMAL PLT COUNT-324
[**2188-7-30**] 07:21PM   PT-15.0* PTT-28.6 INR(PT)-1.3*
[**2188-7-30**] 07:21PM   GLUCOSE-142* UREA N-21* CREAT-3.1* SODIUM-138
POTASSIUM-3.9 CHLORIDE-94* TOTAL CO2-31 ANION GAP-17
[**2188-7-30**] 07:21PM   ALT(SGPT)-17 AST(SGOT)-20 ALK PHOS-237*
AMYLASE-36 TOT BILI-0.6
[**2188-7-30**] 07:29PM   LACTATE-2.7*
[**2188-7-30**] 09:02PM   TYPE-ART TEMP-38.1 PO2-237* PCO2-51* PH-7.45
TOTAL CO2-37* BASE XS-10
.
Discharge Labs:
[**2188-8-5**] 05:25AM BLOOD WBC-7.2 RBC-2.78* Hgb-8.6* Hct-29.2*
MCV-105* MCH-30.8 MCHC-29.3* RDW-21.9* Plt Ct-312
[**2188-8-4**] 06:07AM BLOOD Neuts-81.0* Lymphs-10.6* Monos-4.2
Eos-3.9 Baso-0.3
[**2188-8-5**] 05:25AM BLOOD Glucose-82 UreaN-24* Creat-4.1*# Na-139
K-4.5 Cl-99 HCO3-30 AnGap-15
.
Imaging:
CXR An endotracheal tube and nasogastric tube are in unchanged
positions. A Portable chest radiograph is obtained. A right IJ
central line is again noted with its tip in the approximate
location of the caval atrial junction. Midline sternotomy wires
are again noted. The ET tube tip is seen approximately 2 cm
above the carina. The OG tube tip descends below the diaphragm,
with its tip excluded from view. Low lung volumes limits
evaluation. Small amount of linear atelectasis is seen in the
left mid and lower lung. No large effusions are present. There
is no pneumothorax. Stable mild cardiomegaly is again noted.
There is no evidence of CHF. Mediastinal and hilar configuration
is grossly unremarkable. The visualized osseous structures are
intact.
IMPRESSION:
1. Lines and tubes in good position.
2. Stable cardiomegaly, with linear atelectasis involving the
left mid-to- lower lung.
.
Transthoracic Echo: IMPRESSION: No vegetations or abscess seen,
but the study is technically suboptimal for full assessment of
valvular structure. Moderate biventricular systolic dysfunction.
Moderate mitral regurgitation. Moderate to severe tricuspid
regurgitation. Moderate pulmonary hypertension.
.
Compared with the prior study (images reviewed) of [**2187-3-29**],
severity of
tricuspid regurgitation may have slightly increased. Severity of
pulmonary hypertension has decreased. The other findings are
similar.
.
Transesophageal Echo:
IMPRESSION: Aneurysmal interatrial septum with small secundum
ASD/right-to-left flow. Moderate mitral regurgitation. Moderate
tricuspid
regurgitation. Complex atheroma in the aortic arch. Rigth
ventricular cavity
enlargement with free wall hypokinesis. No discrete valvular
vegetations
identified.
.
Left Ankle X-ray:
There are no findings to suggest osteomyelitis such as bony
destruction or
soft tissue defects.  However, of note there is significant
demineralization of the osseous structures, which decreases the
sensitivity for detection of such findings.  Small plantar and
posterior calcaneal spurs are also seen.  Marked vascular
calcifications are present.

Brief Hospital Course:
[**Hospital1 18**] ED Course: VS- T 100.5; HR 98; BP 161/64; RR 22; O2 100%
RA.  ED notes indicate that the patient had labored breathing
upon arrival with tachypnea.  Given the clinical apperance of
the patient, she was intubated to protect her airway.  A Left IJ
central line was placed for access.  Patient was given
Vancomycin/Ceftriaxone, Metronidazole, and Levaquin.  She was
admitted to the MICU.
.
MICU Course: VS- T 101.3; BP 116/37; HR 70; RR 18-20; O2 100% AC
FIO2 0.5 TV 500 RR 18 PEEP 5.  Removal of tunneled hemodialysis
catheter was performed by Radiology on [**2188-7-31**]. Patient extubated
with out event. Patient was treated in MICU given indwelling
line and leukocytosis with left shift with vancomycin dosed per
level and ceftriaxone 1g IV q24h for gram negative coverage.
.
FLOOR Course:
.
Mrs. [**Known lastname 5395**] was admitted to the floor from the MICU in stable
condition.  During the course of her stay, she had [**6-6**] blood
cultures taken on [**2188-7-30**] positive for coagulase negative
staphlococcus.  There was no growth in [**4-2**] blood cultures taken
on [**2188-8-1**] and [**2188-8-2**].  Patient's indwelling catheter tip was
negative for growth.  Wound in the patient's foot was positive
for Coagulase positive Staph Aureus.  MRSA swab of the nares was
negative; patient has past history significant for MRSA positive
bilateral lower extremity cellulitis.  Stool culture was
negative for for C. Difficile.  CBC was significant for
leukocytosis with left shift throught the duration of stay.  TTE
and TEE were negative for valvular involvement. Patient denied
any pain or burning with urination though she notes that she
does not produce much urine.  Patient had a potential witnessed
aspiration event in the ambulance, CXR did not show any evidence
of consolidation, cough, or chest pain throughout the duration
of her stay.  Patient was dosed Vancomycin IV with her dialysis.
 Trough goals were 15-20 mg.
.
Patient had 2 episodes of shortness of breath which were
temporally linked to episodes of hypoglycemia.  Patient denied
cough productive of sputum, chest pain, or recurrent shortness
of breath following hypoglycemic events.  Mild diffuse crackles
were noted on physical exam; CXR was clean.  Previous PFTs from
[**2186**] note a restrictive lung process.  Patient was increased to
4L oxygen by nasal canula.  02 sats were stable at 97% on 4L at
the time of discharge.
.
Patient was seen by podiatry and wound care for an open wound of
her left malleolus.  X-ray of the foot showed no findings of
osteomyelitis such as bony deformation of soft tissues.  Patient
was noted to have significant demineralization of the bone which
decreases the efficacy of x-ray for osteoperosis diagnosis.
Wound swab grew coagulase positive Staphlococcus Aureus.
Patient has palpable pulses in both feet.  Wet to dry dressings
were applied to foot by wound care.  Vancomycin was dosed with
dialysis.
.
Patient is hemodialysis dependant secondary to ESRD.  She
received dialysis on MWF as well as an additional day of
dialysis on Tu ([**2188-8-5**]) for concern of volume overload.
Continued Sevelmar Hydrochloride, Nephrocaps, Calcium Acetate
dosing at dialysis.  Vancomycin was dosed at dialysis.
.
Patient has long standing Diabetes Mellitus.  She had 2 episodes
of hypoglycemia (BS - 40s) occuring in the early morning
(04:00).  Patient was given juice and 1 amp D50 which she
responded with blood glucose to 200.  Her Lantus dose was
decreased to 30 mg daily; her sliding scale insulin was
decreased at bedtime.  Blood sugars remained stable on this
regimen.
.
Patient was maintained on Clopidogrel 75 mg daily, Asprin 81 mg
daily, and Metoprolol 50 mg [**Hospital1 **] for her CAD and hypertension.
Hypothyroidism was maintained on Levothyroxine Sodium 50 mcg
daily.  Depression was treated with home Sertraline 100 mg
daily.  Patient received Carbidopa-Levodopa (25-100) 2 tablets
at bedtime for known restless leg syndrome.
.
Left central IJ line was removed prior to discharge by medicine
team.


Medications on Admission:
AMBIEN 10 mg--1 tablet(s) by mouth at bedtime
AMOXICILLIN 500 mg--4 capsule(s) by mouth 1 hr before dental
work
ASPIRIN 81 mg--1 tablet(s) by mouth once a day
B COMPLEX --1 capsule(s) by mouth daily
COZAAR 50 mg--1 tablet(s) by mouth 4 times a week
DAYPRO 600MG--2 by mouth every day with food
DIGOXIN 125 mcg--[**1-1**] alternating with 1 tab tablet(s) by mouth
q4days 2 tabs po initially, then [**1-1**] alternating with 1 tab
every 4 days.
Humalog Pen 100 unit/mL (75-25)--use as directed twice a day as

needed for high sugars
KLONOPIN 1 mg--1 tablet(s) by mouth 0 1 po qhs and 2 po before
hd
LANTUS 100 unit/mL--30-50 unit once a day as directed
LIPITOR 10 mg--1 tablet(s) by mouth at bedtime
MIRAPEX 0.125 mg--[**1-1**] tablet(s) by mouth at 6pm and again at
bedtime
NEPHROCAPS 1 mg--1 capsule(s) by mouth once a day
NORVASC 5 mg--1 tablet(s) by mouth once a day
PHOSLO 667 mg--2 capsule(s) by mouth as directed
PLAVIX 75 mg--1 tablet(s) by mouth q am
RENAGEL 800 mg--1 tablet(s) by mouth as directed
SYNTHROID 50 mcg--1 tablet(s) by mouth once a day
TOPROL XL 100 mg--1 tablet(s) by mouth at bedtime
ZOLOFT 100 mg--1 tablet(s) by mouth q am


Discharge Medications:
1. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

5. Sevelamer 800 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
6. Vancomycin in Dextrose 1 g/250 mL Solution Sig: Three (3)
grams Intravenous with HD for 36 days: please treat for a total
of 6 weeks starting [**2188-7-31**] and ending [**2188-9-11**].
7. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
9. B Complex     Capsule Sig: One (1) Capsule PO once a day.
10. Daypro 600 mg Tablet Sig: Two (2) Tablet PO once a day: with
food.
11. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO at bedtime.
12. Lipitor 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
13. Norvasc 5 mg Tablet Sig: One (1) Tablet PO once a day.
14. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.

15. Mirapex 0.125 mg Tablet Sig: [**1-1**] Tablet PO once at 6pm then
at bedtime.
16. Digoxin 125 mcg Tablet Sig: [**1-1**] alternating with 1 Tablet PO
every 4 days 2 tabs po initially, then [**1-1**] alternating with 1
tab every 4 days.
17. Klonopin 1 mg Tablet Sig: One (1) Tablet PO at bedtime: and
2 tablets before hemodialysis
.
18. Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig: use as
directed  Subcutaneous twice a day as needed for for high
sugars.
19. Lantus 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous once a day: at lunchtime.
Disp:*1 10 mL* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital3 **] VNA

Discharge Diagnosis:
Primary Diagnosis:
- Coagulase Negative Staphlococcus Bactermia

Secondary Diagnosis:
- Diabetes Mellitus Type II
- End Stage Renal Disease
- Open Wound on Left Malleolus
- Restrictive Pulmonary Process
- Restless Leg Syndrome
- Hypertension
- Hypercholesterolemia
- Coronary Artery Disease
- Hypothyroidism
- Anemia
- Osteoperosis
- Depression


Discharge Condition:
Stable.


Discharge Instructions:
You were admitted to the hospitals for fevers which were noted
at your dialysis center.  While in the hospital you received an
antibiotic, Vancomycin, at your inpatient dialysis appointments.
 You will continue to receive this antibiotic at dialysis for
six weeks because you had bacteria in your blood and in your
foot that are being treated with this antibiotic.  You are no
longer showing any clinical signs of infection.
.
In the emergency room your physician was concerned about your
ability to breath and you were intubated.  You were taken off
the ventilator one day after admission.  You have been short of
breath a few times since admission and your oxygen settings have
been increased to 4L.  Please continue to use 4L of oxygen at
home.

Please follow the attached medication list.  Your home
medications are all being continued except for Cozaar.  Please
have the staff at hemodialysis check your blood pressure and if
it is high speak with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5781**] about adding your
Cozaar. You will also be receiving a new medication, Vancomycin,
with hemodialysis.
.
If you experience any fevers, chills, nausea, vomiting,
shortness of breath, increasing fatigue, or any other concern,
please call your primary doctor.  If you cannot reach your
primary doctor or still have concerns, please return to the
Emergency Room or call 911.

Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2188-8-21**] 12:20
Provider: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2188-8-28**] 2:50
Provider: [**Name10 (NameIs) 6821**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2188-8-28**]
10:15
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2188-9-2**]
2:00
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 1401**], M.D. Phone:[**Telephone/Fax (1) 2386**]
Date/Time:[**2188-9-2**] 3:00
{'Other staphylococcal septicemia,Cellulitis and abscess of leg, except foot,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Congestive heart failure, unspecified,End stage renal disease,Ulcer of ankle,Infection and inflammatory reaction due to other vascular device, implant, and graft,Anemia in chronic kidney disease,Restless legs syndrome (RLS),Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Unspecified acquired hypothyroidism,Osteoporosis, unspecified,Other and unspecified hyperlipidemia,Old myocardial infarction,Other dependence on machines, supplemental oxygen,Aortocoronary bypass 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: Fevers at dialysis

PRESENT ILLNESS: 63 y/o female with h/o Diabetes Mellitus Type II, End Stage
Renal Disease on dialysis, HTN, unknown pulmonary condition on
3L 02 by nasal canula at home, presents from the [**Location (un) **]
Dialysis with fevers occuring during dialysis.  [**Name (NI) **]
husband reports that she has been mildly lethargic for the past
week and has been having fevers following dialysis.  Husband
reports patient was slightly confused on the day prior to
admission.  Patient repots that she was feeling "fine" prior to
hospitilization.  She went to dialysis on the morning of
admission as per her usual routine and developed a temperature
during the procedure.  She was given IV Vancomycin at dialysis
and was transferred to the ED for evaluation of infection
concerns.  During ambulance transfer, patient vomited and there
was a question that she may have aspirated gastric contents.
Patient recalls being placed in the ambulance but does not
recall anything from that moment until after she arrived in the
MICU.
.
Patient had previously had a right tunneled hemodialysis
catheter which was placed in [**9-2**].  Six months prior to
admission patient had a fistula for hemodialysis created  in the
right arm.  This fistula was seeded with bovine material.
Tunneled catheter was left in place because patient reported
signficiant pain with blood draws.
.
[**Hospital1 18**] ED Course: VS- T 100.5; HR 98; BP 161/64; RR 22; O2 100%
RA.  ED notes indicate that the patient had labored breathing
upon arrival with tachypnea.  Given the clinical apperance of
the patient, she was intubated to protect her airway.  A Left IJ
central line was placed for access.  Patient was given
Vancomycin/Ceftriaxone, Metronidazole, and Levaquin.  She was
admitted to the MICU.
.
ROS:
General: Patient notes that she has felt tired for approximately
three weeks.  She denies feeling feverous and notes that her
husband takes her temperature regularly.  She denies any chills.
 Patient reports that she has had good appetite and has not had
any recent dietary changes.  She denies any changes in her sleep
pattern.
Skin: Patient reports that she regularly has ulcers on her legs.
 Patient's daughter reported away from the presence of her
mother that she regularly witnesses her mother picking at the
scabs on her arms with a tweezers.  Patient reports that her
legs are always red and swollen.
HEENT:  Patient denies any vision changes.  She does not
remember when her last eye exam was conducted.  Patient denies
headaches or changes in her hearing.  She denies allergies or
nasal drainage.
Cardiac: S/p 5 Vessel CABG in [**2179**].  Patient reports that she
was dancing with her son in-law at her sister's birthday party
in [**2179**].  She said that she felt short of breath and needed to
sit down.  She then went to her PCP who recommended cardiology
f/u which resulted in cardiac catherization.  Patient any other
episodes of chest pain or pressure.
Resp: Patient reports that she has been evaluated for sleep
problems but nothing was found on these studies.  She says that
she cannot use CPAP machine.  She is on 3L O2 by nasal canula at
all times at home.  She reports that she sleeps in bed with only
one pillow at night.  She denies any PND.
GI: Patient denies any diarrhea, constipation or recent changes
in the stool.  She notes that she feels her abdomen is slight
distended.
GU: Patient reports that she has been on hemodialysis since
[**2184**].  She says that she produces very little urine and denies
pain or burning with urination.
ENDO: Patient reports that she is hypothyroid and is medically
managed.
EXT: Patient reports that she has sores on her feet that are
very slow to heal.  She reports that she fell and broke her hip
requiring surgical correction.
NEURO: Patient reports that she does not feel her feet or her
hands. She notes that she does not feel pain from the ulcers.
She is unsteady on her feet and gets tired when she tries to use
her arms to push herself up from a chair.  Most recently she has
been primarily using her wheelchair in the home.

MEDICAL HISTORY: 1. DM2 since her 40s, dialysis since [**2-3**]
2. ESRD [**2-1**] DMII, on MWF HD, followed by Dr. [**First Name (STitle) 805**].  RIJ
tunneled cath placed on [**2185-12-13**] for peritoneal dialysis.
Fistula created in [**1-6**] but RIJ tunneled cath left in place for
access.
3. h/o MRSA cellulitis of bilateral LE
4. HTN
5. Hyperlipidemia
6. Hypothyroidism
7. PD cath placement on [**2185-12-13**] with RIJ tunneled cath
8. CAD s/p CABG [**2179**], NSTEMI in [**9-2**] during admission; echo [**3-4**]

MEDICATION ON ADMISSION: AMBIEN 10 mg--1 tablet(s) by mouth at bedtime
AMOXICILLIN 500 mg--4 capsule(s) by mouth 1 hr before dental
work
ASPIRIN 81 mg--1 tablet(s) by mouth once a day
B COMPLEX --1 capsule(s) by mouth daily
COZAAR 50 mg--1 tablet(s) by mouth 4 times a week
DAYPRO 600MG--2 by mouth every day with food
DIGOXIN 125 mcg--[**1-1**] alternating with 1 tab tablet(s) by mouth
q4days 2 tabs po initially, then [**1-1**] alternating with 1 tab
every 4 days.
Humalog Pen 100 unit/mL (75-25)--use as directed twice a day as

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS- T: 97.1 BP: 131/67 P: 85 RR: 22 O2 Sat: 95% on 3L
Fingerstick: 103 Weight: 94.0 kg
GEN: Patient is ill-appearing woman who appears much older than
her stated age of 63.  She appears very pale and has thinning of
her hair.  She was being fed dinner by her husband.  She is in
no acute distress on 3L O2 by nasal canula.
SKIN- Scabs were noted on the extremeties.
HEENT: NC, AT.  MMM, No oral sores noted.  PERRLA.  Midline
nasal septa.  Opthalmoscopic exam revealed red reflux, no
diabetic changes noted (no cotton wool spots or hemorrages).
LIJ in place with slight ooze.
HEART: RRR. Systolic ejection murmur was heard best at the LUSB,
grade II/VI. No gallops or rubs noted.
LUNGS: Diffuse crackles were noted over both lung fields.
ABD: Bowel sounds were noted in all four quadrants.  Abdomen was
distended with no tenderness.  Right-sided abdominal hernia
noted which was easily reducable.
EXT: An ulcer was noted on the left malleolus which measures
approx. 1.5 x 0.8 cm.  There is undermining from [**5-8**] oclock,
0.5 cm.  The wound bed is 100% nonviable tissue and the bone is
palpable in the center of the wound bed.  The wound edges are
macerated and defined.  The periwound tissue is macerated and
erythemic, slight edema.  There is no induration, fluctuance or
crepitus.  R ankle is significant for displaced calcaneus bone.
+1 Ankle edema was noted on the right ankle.  Patient has had an
amputation of the right fifth toe.  Erythema is noted on both
shins extending from the ankle until 2 in below the knee. +1
DT/PT pulses. Palpable thrill over left arm AV fistula.
NEURO: PERRLA. CN II - XII intact.  Decreased vibration and
temperature sensation in stocking glove distribution.

FAMILY HISTORY: Father - Deceased with MI at 60
Sister - Breast cancer diagnosed at age 56.
Mother - 60s, CAD; diagnosed with breast cancer in her 30s.
Son with DM

SOCIAL HISTORY: The patient lives with her husband who is her primary caregiver.
 She denies past or present tobacco use.  She denies alcohol or
IV drug use.  Patient previously worked as a secretary.  She
endorses carbohydrate counting to control her diabetes and eats
a renal and cardiac friendly diet. 

### Response:
{'Other staphylococcal septicemia,Cellulitis and abscess of leg, except foot,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Congestive heart failure, unspecified,End stage renal disease,Ulcer of ankle,Infection and inflammatory reaction due to other vascular device, implant, and graft,Anemia in chronic kidney disease,Restless legs syndrome (RLS),Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Unspecified acquired hypothyroidism,Osteoporosis, unspecified,Other and unspecified hyperlipidemia,Old myocardial infarction,Other dependence on machines, supplemental oxygen,Aortocoronary bypass status'}
