CHIEF COMPLAINT: Abdominal pain

PRESENT ILLNESS: 68yo man with end-stage multiple sclerosis with [**Month/Day/Year **]
suprapubic foley comes in from [**Hospital3 2558**] with two days of
fevers and one day of abdominal pain and nausea. Yesterday he
had a fever to 102.  WBC of 14.6 with 89% PMN's.  Txfd to [**Hospital1 18**]
for further evaluation.
.
In the ED, initial vs were: T 98 P 91 BP 122/63 R 20 O2 sat
95%RA. UA positive large leuks, mod bact, 87 WBCs. CT abdomen
consistent with [**Last Name (un) 3696**] Syndrome and possible pyelo, ?
staghorn calculus. Surgery was consulted, who recommended
admission to medicine. Patient was febrile to 102 and was given
Tylenol and Vanc/Zosyn for broad coverage of pyelonephritis.
Given 2L fluids. There were problems with venous access -
anatomy made an IJ difficult (pt contracted), and two attempts
at a R subclavian were c/b air in the syringe, then arterial
puncture. Pressure held x15 minutes, no PTX on CXR. A right
femoral line was placed. Troponin 0.08 and pt had ? new Q waves
inferiorly in III/AVF with TWI in V2/V3, and rectal Aspirin
given.  Transferred to the floor
.
On the floor, the patient has [**4-21**] low pelvic abdominal pain.
[**Month/Year (2) 8304**] trouble clearing secretions.

MEDICAL HISTORY: 1. MS, endstage secondary progressive type.
1. Decubitus ulcer (healing).
2. History of lung aspiration and lung abscess.
3. Hypertension.
4. Gastroesophageal reflux.
5. Status post gastrostomy tube.
6. Status post suprapubic catheter.

MEDICATION ON ADMISSION: - oxybutynin ER 10mg daily
- simvastatin 80mg daily
- metoclopramide 5mg QID
- omeprazole 20mg daily
- provigil 200mg daily
- bisacodyl 10mg suppository QHS
- baclofen 10mg Q12am/12pm, 15mg Q6am/6pm
- natural balance tear drops 2 drops OU Q8hrs
- levothyroxine 50mcg daily
- acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for pain
- Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) enema Rectal
once a day as needed for constipation
- albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every six (6) hours as
needed for cough, wheezing, or shortness of breath
- ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for cough, wheezing, or
shortness of breath.
- multivitamin Liquid Sig: Fifteen (15) mL PO once a day.
- Guiatuss 100 mg/5 mL Liquid Sig: Ten (10) mL PO every six (6)
hours as needed for cough.
- Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) mL PO
once a day as needed for constipation.
- magnesium citrate Solution Sig: 0.5 bottle PO Monday,
Wednesday, Friday.
- Enulose 10 gram/15 mL Solution Sig: Fifteen (15) mL PO every
six (6) hours: given on Tuesday, Thursday, Saturday, Sunday.

ALLERGIES: Benzodiazepines / Augmentin

PHYSICAL EXAM: ADMISSION EXAM:
Vitals: T: 99 BP: 115/68 P: 79 R:21 O2: 97
General: Alert, oriented.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP difficult to assess
Lungs: Anterior/lateral auscultation has poor inspiratory effort
with coarse breath sounds and some rhonchi bilaterally.
CV: Distant heart sounds.  Regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Abdomen: Distended firm abdomen.  Tympanic to percussion.
G-tube in place as well as suprapubic catheter in place.  NT to
palpation.  No organomegaly appreciated.
GU: clear urine
Ext: Atrophic lower extremities.  Warm, well perfused, 1+
pulses, no clubbing, cyanosis or edema
Neuro:  Quadraplegic.  AOX3. Movement of right shoulder and can
move eyes.

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: Lives in Nursing Home at [**Hospital3 2558**], divorced, two children.
 Retired Biochemist.  Denies etoh/tobacco/drugs.
Infection and inflammatory reaction due to indwelling urinary catheter,Streptococcal septicemia,Severe sepsis,Septic shock,Pyelonephritis, unspecified,Other specified intestinal obstruction,Hydronephrosis,Multiple sclerosis,Neurogenic bladder NOS,Calculus of kidney,Unspecified essential hypertension,Atrial fibrillation,Esophageal reflux,Obstructive sleep apnea (adult)(pediatric)
React-indwell urin cath,Streptococcal septicemia,Severe sepsis,Septic shock,Pyelonephritis NOS,Intestinal obstruct NEC,Hydronephrosis,Multiple sclerosis,Neurogenic bladder NOS,Calculus of kidney,Hypertension NOS,Atrial fibrillation,Esophageal reflux,Obstructive sleep apnea
Admission Date:  [**2167-5-26**]              Discharge Date:   [**2167-6-2**]

Date of Birth:  [**2098-8-18**]             Sex:   M

Service: MEDICINE

Allergies:
Benzodiazepines / Augmentin

Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Abdominal pain


Major Surgical or Invasive Procedure:
Left-sided nephrostomy tube placement [**2167-5-28**]
PICC line placement


History of Present Illness:
68yo man with end-stage multiple sclerosis with [**Month/Day/Year **]
suprapubic foley comes in from [**Hospital3 2558**] with two days of
fevers and one day of abdominal pain and nausea. Yesterday he
had a fever to 102.  WBC of 14.6 with 89% PMN's.  Txfd to [**Hospital1 18**]
for further evaluation.
.
In the ED, initial vs were: T 98 P 91 BP 122/63 R 20 O2 sat
95%RA. UA positive large leuks, mod bact, 87 WBCs. CT abdomen
consistent with [**Last Name (un) 3696**] Syndrome and possible pyelo, ?
staghorn calculus. Surgery was consulted, who recommended
admission to medicine. Patient was febrile to 102 and was given
Tylenol and Vanc/Zosyn for broad coverage of pyelonephritis.
Given 2L fluids. There were problems with venous access -
anatomy made an IJ difficult (pt contracted), and two attempts
at a R subclavian were c/b air in the syringe, then arterial
puncture. Pressure held x15 minutes, no PTX on CXR. A right
femoral line was placed. Troponin 0.08 and pt had ? new Q waves
inferiorly in III/AVF with TWI in V2/V3, and rectal Aspirin
given.  Transferred to the floor
.
On the floor, the patient has [**4-21**] low pelvic abdominal pain.
[**Month/Year (2) 8304**] trouble clearing secretions.

Past Medical History:
1. MS, endstage secondary progressive type.
1. Decubitus ulcer (healing).
2. History of lung aspiration and lung abscess.
3. Hypertension.
4. Gastroesophageal reflux.
5. Status post gastrostomy tube.
6. Status post suprapubic catheter.


Social History:
Lives in Nursing Home at [**Hospital3 2558**], divorced, two children.
 Retired Biochemist.  Denies etoh/tobacco/drugs.


Family History:
Non-contributory.

Physical Exam:
ADMISSION EXAM:
Vitals: T: 99 BP: 115/68 P: 79 R:21 O2: 97
General: Alert, oriented.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP difficult to assess
Lungs: Anterior/lateral auscultation has poor inspiratory effort
with coarse breath sounds and some rhonchi bilaterally.
CV: Distant heart sounds.  Regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Abdomen: Distended firm abdomen.  Tympanic to percussion.
G-tube in place as well as suprapubic catheter in place.  NT to
palpation.  No organomegaly appreciated.
GU: clear urine
Ext: Atrophic lower extremities.  Warm, well perfused, 1+
pulses, no clubbing, cyanosis or edema
Neuro:  Quadraplegic.  AOX3. Movement of right shoulder and can
move eyes.

DISCHARGE EXAM: Generally unchanged from admission.  Abdomen
distended but soft, and non-tender with normoactive bowel
sounds.  Discharge VS: 98.5,  114/70, 78, 26, 93% RA.

Pertinent Results:
Admission Labs
[**2167-5-26**] 08:12PM URINE  HOURS-RANDOM
[**2167-5-26**] 08:12PM URINE  GR HOLD-HOLD
[**2167-5-26**] 08:12PM URINE  COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.033
[**2167-5-26**] 08:12PM URINE  BLOOD-SM  NITRITE-POS PROTEIN-100
GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-LG
[**2167-5-26**] 08:12PM URINE  RBC-9* WBC-87* BACTERIA-MOD YEAST-NONE
EPI-<1
[**2167-5-26**] 08:12PM URINE  HYALINE-1*
[**2167-5-26**] 08:12PM URINE  MUCOUS-RARE
[**2167-5-26**] 03:55PM   PT-12.3 PTT-25.5 INR(PT)-1.0
[**2167-5-26**] 03:28PM   LACTATE-1.9
[**2167-5-26**] 03:15PM   GLUCOSE-309* UREA N-24* CREAT-0.8 SODIUM-126*
POTASSIUM-4.2 CHLORIDE-89* TOTAL CO2-27 ANION GAP-14
[**2167-5-26**] 03:15PM   estGFR-Using this
[**2167-5-26**] 03:15PM   ALT(SGPT)-44* AST(SGOT)-19 CK(CPK)-33* ALK
PHOS-157* TOT BILI-0.8
[**2167-5-26**] 03:15PM   LIPASE-17
[**2167-5-26**] 03:15PM   cTropnT-0.08*
[**2167-5-26**] 03:15PM   CK-MB-2
[**2167-5-26**] 03:15PM   CALCIUM-8.5 PHOSPHATE-2.4* MAGNESIUM-2.3
[**2167-5-26**] 03:15PM   WBC-13.5* RBC-4.47* HGB-13.2* HCT-38.3*
MCV-86 MCH-29.6 MCHC-34.6 RDW-16.5*
[**2167-5-26**] 03:15PM   NEUTS-87.9* LYMPHS-7.6* MONOS-3.8 EOS-0.4
BASOS-0.4
[**2167-5-26**] 03:15PM   PLT COUNT-134*

OTHER PERTINENT LABS:
[**2167-5-31**] 04:00AM BLOOD ALT-58* AST-48* LD(LDH)-148 AlkPhos-256*
TotBili-0.7
[**2167-6-1**] 05:33AM BLOOD ALT-46* AST-27 LD(LDH)-135 AlkPhos-265*
TotBili-0.6
[**2167-5-26**] 03:15PM BLOOD cTropnT-0.08*
[**2167-5-27**] 12:38AM BLOOD cTropnT-0.11*
[**2167-5-27**] 07:56AM BLOOD CK-MB-2 cTropnT-0.14*
[**2167-5-27**] 03:11PM BLOOD CK-MB-3 cTropnT-0.09*
[**2167-5-30**] 03:50AM BLOOD CK-MB-2 cTropnT-0.04*
[**2167-6-1**] 05:33AM BLOOD Albumin-2.5* Calcium-8.0* Phos-2.7 Mg-1.8
[**2167-5-27**] 12:38AM BLOOD Osmolal-281
[**2167-6-1**] 05:33AM BLOOD Vanco-17.4

DISCHARGE LABS:
[**2167-6-2**] 04:37AM BLOOD WBC-9.4 RBC-3.46* Hgb-10.0* Hct-30.3*
MCV-88 MCH-29.1 MCHC-33.1 RDW-16.3* Plt Ct-211
[**2167-6-2**] 04:37AM BLOOD Glucose-160* UreaN-12 Creat-0.4* Na-141
K-4.4 Cl-102 HCO3-33* AnGap-10
[**2167-6-2**] 04:37AM BLOOD ALT-37 AST-17 AlkPhos-228* TotBili-0.5
[**2167-6-2**] 04:37AM BLOOD Calcium-8.3* Phos-2.6* Mg-1.8

MICROBIOLOGY:
Urine culture [**2167-5-26**]:
PROTEUS MIRABILIS
                             |          PROVIDENCIA STUARTII
                             |          |          MORGANELLA
MORGANII
                             |          |          |
ENTEROCOCCUS SP.
                             |          |          |          |
        ENTER
                             |          |          |          |
        |
AMIKACIN--------------     4 S        4 S
AMPICILLIN------------  =>32 R                            <=2 S
    <=2 S
AMPICILLIN/SULBACTAM--   <=2 S
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S      <=1 S       32 R
CEFTAZIDIME-----------   <=1 S      <=1 S     =>64 R
CEFTRIAXONE-----------   <=1 S      <=1 S     =>64 R
CIPROFLOXACIN---------     2 I      =>4 R        1 S
GENTAMICIN------------  =>16 R          S      <=1 S
MEROPENEM-------------<=0.25 S   <=0.25 S   <=0.25 S
NITROFURANTOIN--------              256 R      256 R     <=16 S
   <=16 S
TETRACYCLINE----------                                   =>16 R
   =>16 R
TOBRAMYCIN------------  =>16 R          I      <=1 S
TRIMETHOPRIM/SULFA----  =>16 R      <=1 S      <=1 S
VANCOMYCIN------------                                      1 S
      1 S
.
Blood culture [**2167-5-27**]: negative
Blood culture [**2167-5-27**]: GPCs in pairs and chains
Urine culture [**2167-5-29**]: negative

IMAGING:
CXR [**2167-5-26**]: 1. Bibasilar opacities could reflect aspiration or
atelectasis. 2. Right costophrenic angle blunting could reflect
pleural thickening given chronicity of appearance.

CT Abd/Pelvis [**2167-5-26**]:
1. Large staghorn calculus in the left renal pelvis, new from
[**2161**] CT.
Possible mild pyelitis though no overt signs of pyelonephritis.
Suprapubic
catheter in place with apparent bladder wall thickening,
correlate for
infection.
2. Mild dilation of the redundant sigmoid colon without distal
obstruction
-likely [**Last Name (un) **] syndrome. Mild fecal rectal impaction.
3. Stable hepatic hemangioma.
4. Bibasilar opacities in the lungs, likely [**Last Name (un) **] atelectasis
or
aspiration.

CXR [**2167-5-31**]: Interval changes suggest interval development of
CHF with
interstitial edema.

CXR [**2167-5-31**]: A right subclavian PICC line is present, tip over
distal SVC near SVC/RA junction. No pneumothorax is detected.
Otherwise, I doubt significant interval change.

UNILAT UP EXT VEINS US RIGHT [**2167-5-31**]: No evidence of DVT in the
right upper extremity.

TTE [**2167-6-1**]: The left atrium is moderately dilated. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Regional left ventricular wall
motion is normal. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse or
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is a very small pericardial effusion. The
effusion appears circumferential.

IMPRESSION: Suboptimal image quality. Preserved regional and
global biventricular systolic function. Very small
circumferential pericardial effusion.


Brief Hospital Course:
#) Sepsis Secondary to Pyelonephritis/Bacteremia:  Patient with
endstage MS [**First Name (Titles) **] [**Last Name (Titles) **] suprapubic cath presented with fevers,
tachycardia, and leukocytosis with dirty UA.  CT abdomen was
concerning for struvite stone in left kidney.  He was initially
admitted to MICU w/sepsis requiring fluid boluses and pressors,
and was empirically started on vancomycin/zosyn for broad
coverage. Stablizied and was off pressors since [**5-28**].  Urology
consulted with no recommendations for change in suprapubic
catheter exchange (recently replaced 2 weeks prior to
presentation per report), though did recommend percutaneous
nephrostomy tube placement.  Patient had IR placement of left
nephrostomy tube on [**2167-5-27**], and had adequate urostomy drainage
and improvement in hemodynamics/leukocytosis/fevers by post
intervention day 2.  Patient likely has colonization of
resistant bacteria from his [**Date Range **] suprapubic Foley, though
acute infection occurring now in setting of left kidney staghorn
calculus. Urine culture positive for Proteus mirabilis,
providencia stuartii, morganella morganii, and vanc-sensitive
enterococcus. Per Urology, would have high suspicion that
Proteus was responsible for much of acute infection, as this
bacteria is known to cause calculi. Patient was continued on
vanc/zosyn but was switched to vanc/ertapenem on [**2167-6-2**], and
per Urology recs patient should continue on this regimen through
Urology follow-up appt on [**2167-6-17**].  Will likely need surgical
management of left staghorn calculi at that time.  Left
nephrostomy tube should remain in place and open to drainage
until Urologyg follow-up.  Of note, blood cultures from [**2167-5-27**]
positive for GPCs in pairs and chains, though speciation still
pending at time of discharge.  TTE was suboptimal but did not
show evidence of vegetations.  Patient already on >2 week course
of broad spectrum abx.

#) Hypoxia: Patient not on O2 at baseline, though was requiring
5L NC suppplemental O2 on arrival to floor following ICU stay.
CXR [**5-31**] showed e/o effusions and interstitial edema, as well as
probable atalectasis.  Suspected volume overload following ICU
course with IVF and pressor administration in setting of sepsis.
 Echo showed preseved systolic function with EF >55. [**Month (only) 116**] also be
component of aspiration, and per speech and swallow evaluation
patient should only have ice chips with supervision, otherwise
strict NPO.  Patient diuresed with 20mg IV furosemide on [**6-1**],
and was net negative 2.1L with improvement in O2 sat to 93% on
RA.  O2 sats should be monitored on discharge, and patient
should continue on albuterol/ipratropium nebs Q6H prn
cough/wheeze/SOB.  Will require suctioning of secretions, and
should be NPO with all meds given via G-tube.

#) Apnea/Transient desaturation: Likely secondary to patient's
neuromuscular disease/MS and inability to clear secretions.
Patient failed multiple trials of CPAP while in the ICU, though
was able to tolerate CPAP on floor.  Will need outpatient sleep
study once discharged.

#) AFib with RVR: Patient with new onset AFib with RVR to 140s
in the setting of transient apnea and desaturations.  Patient
was started on metoprolol tartrate 12.5 TID.  His episodes
spontaneously resolved after 5-10 minutes, and he coverted back
to NSR.  For CHADS2 score 0-1, was started on aspirin 81 mg.
Echo showed moderate LA enlargement.

#) Abdominal pain/distention with 1 week's worth of
constipation: Imaging consistent with [**Last Name (un) 3696**] syndrome, which
can be a complication of multiple sclerosis as well as [**Last Name (un) **]
oxybutynin use.  DC'd anticholinergics and started aggressive
bowel regimen with good results. No evidence of perforation on
imaging.  Patient was not restarted on oxybutynin on discharge.


#) Positive troponin on admission: Likely strain as CK-MB was
flat. There are EKG changes relative to previous EKG from [**2160**],
but clinical picture more consistent with strain than ACS.  Echo
showed preserved systolic function.

#) Multiple sclerosis: Held oxybutynin per above but continued
baclofen.  Will need suctioning of oral secretions.

LABS/STUDIES PENDING AT TIME OF DISCHARGE:
Blood culture [**2167-5-27**]: speciation of GPCs

ISSUES REQUIRING FOLLOW-UP:
-Patient with new onset Afib this admission and was started on
metoprolol for rate control and ASA 81mg daily.  Will need
outpatiet follow-up
-Patient should continue on aggresive bowel regimen and discuss
with PCP whether he should restart oxybutynin
-Patient's FSBS were elevated this admission in setting of acute
infection, and should be monitored in outpatient setting
-Patient may benefit from outpatient sleep study given concern
for sleep apnea, may also benefit from CPAP at night if patient
will tolerate


Medications on Admission:
- oxybutynin ER 10mg daily
- simvastatin 80mg daily
- metoclopramide 5mg QID
- omeprazole 20mg daily
- provigil 200mg daily
- bisacodyl 10mg suppository QHS
- baclofen 10mg Q12am/12pm, 15mg Q6am/6pm
- natural balance tear drops 2 drops OU Q8hrs
- levothyroxine 50mcg daily
- acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for pain
- Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) enema Rectal
once a day as needed for constipation
- albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every six (6) hours as
needed for cough, wheezing, or shortness of breath
- ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for cough, wheezing, or
shortness of breath.
- multivitamin Liquid Sig: Fifteen (15) mL PO once a day.
- Guiatuss 100 mg/5 mL Liquid Sig: Ten (10) mL PO every six (6)
hours as needed for cough.
- Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) mL PO
once a day as needed for constipation.
- magnesium citrate Solution Sig: 0.5 bottle PO Monday,
Wednesday, Friday.
- Enulose 10 gram/15 mL Solution Sig: Fifteen (15) mL PO every
six (6) hours: given on Tuesday, Thursday, Saturday, Sunday.


Discharge Medications:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. metoclopramide 5 mg Tablet Sig: One (1) Tablet PO four times
a day.
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Provigil 200 mg Tablet Sig: One (1) Tablet PO once a day.
5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime).
6. baclofen 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): given at 12 AM and 12 PM.
7. baclofen 10 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day): given at 6 AM and 6 PM.
8. Natural Balance 0.4 % Drops Sig: Two (2) drop Ophthalmic
every eight (8) hours.
9. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for pain.
11. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) enema Rectal
once a day as needed for constipation.
12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every six (6) hours as
needed for cough, wheezing, or shortness of breath.
13. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for cough, wheezing, or
shortness of breath.
14. multivitamin     Liquid Sig: Fifteen (15) mL PO once a day.

15. Guiatuss 100 mg/5 mL Liquid Sig: Ten (10) mL PO every six
(6) hours as needed for cough.
16. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) mL
PO once a day as needed for constipation.
17. magnesium citrate     Solution Sig: 0.5 bottle PO Monday,
Wednesday, Friday.
18. Enulose 10 gram/15 mL Solution Sig: Fifteen (15) mL PO every
six (6) hours: given on Tuesday, Thursday, Saturday, Sunday.
19. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
20. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
21. ertapenem 1 gram Recon Soln Sig: One (1) gram Intravenous
daily () for 6 days.
22. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram
Intravenous Q 12H (Every 12 Hours) for 6 days.
23. PICC Line Orders
Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 2558**] - [**Location (un) **]

Discharge Diagnosis:
Primary: Sepsis secondary to pyelonephritis and bacteremia

Secondary: Multiple sclerosis, Pulmonary edema, Atrial
fibrillation, [**Last Name (un) **]??????s Syndrome


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.


Discharge Instructions:
Mr. [**Known lastname 9319**],

It was a pleasure taking care of you during your stay at [**Hospital1 18**].
You were initially admitted to the ICU with fevers and abdominal
pain.  We found you had a urinary tract infection/kidney
infection, due to a large stone in your left kidney.  You were
seen by the Urologists, who recommended you have a tube placed
to help drain urine from the left kidney while the stone is
causing an obstruction.

We started you on antibiotics, and gave you IV fluids and
medications to help raise your blood pressure.  You improved
with these treatments and were stable for transfer to the
medicine floor.

The urologists recommend you continue on IV antibiotics for
another 2 week course.  They will see you in the clinic after
the infection has resolved, to discuss what the next steps are
to treat the kidney stone.  The tube in your kidney will remain
in place until that appointment.

While you were here, you heart also went in and out of an
abnormal rhythm called atrial fibrillation.  We started you on
an aspirin, and also a medication to control your heart rate.

We made the following changes to your medications:
1. STARTED aspirin 81mg daily
2. STARTED metoprolol 12.5mg TID
3. STARTED vancomycin 1gm IV Q12H (through [**2167-6-17**])
4. STARTED ertapenem 1gm daily (through [**2167-6-17**])
5. STOPPED oxybutynin (please discuss whether you should restart
this medication with your PCP)

We did not make any other changes to your medications.  Please
continue to take them as you have been doing.

Followup Instructions:
Department: SURGICAL SPECIALTIES
When: WEDNESDAY [**2167-6-17**] at 9:00 AM
With: UROLOGY UNIT [**Telephone/Fax (1) 164**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Infection and inflammatory reaction due to indwelling urinary catheter,Streptococcal septicemia,Severe sepsis,Septic shock,Pyelonephritis, unspecified,Other specified intestinal obstruction,Hydronephrosis,Multiple sclerosis,Neurogenic bladder NOS,Calculus of kidney,Unspecified essential hypertension,Atrial fibrillation,Esophageal reflux,Obstructive sleep apnea (adult)(pediatric)'}


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: Abdominal pain

PRESENT ILLNESS: 68yo man with end-stage multiple sclerosis with [**Month/Day/Year **]
suprapubic foley comes in from [**Hospital3 2558**] with two days of
fevers and one day of abdominal pain and nausea. Yesterday he
had a fever to 102.  WBC of 14.6 with 89% PMN's.  Txfd to [**Hospital1 18**]
for further evaluation.
.
In the ED, initial vs were: T 98 P 91 BP 122/63 R 20 O2 sat
95%RA. UA positive large leuks, mod bact, 87 WBCs. CT abdomen
consistent with [**Last Name (un) 3696**] Syndrome and possible pyelo, ?
staghorn calculus. Surgery was consulted, who recommended
admission to medicine. Patient was febrile to 102 and was given
Tylenol and Vanc/Zosyn for broad coverage of pyelonephritis.
Given 2L fluids. There were problems with venous access -
anatomy made an IJ difficult (pt contracted), and two attempts
at a R subclavian were c/b air in the syringe, then arterial
puncture. Pressure held x15 minutes, no PTX on CXR. A right
femoral line was placed. Troponin 0.08 and pt had ? new Q waves
inferiorly in III/AVF with TWI in V2/V3, and rectal Aspirin
given.  Transferred to the floor
.
On the floor, the patient has [**4-21**] low pelvic abdominal pain.
[**Month/Year (2) 8304**] trouble clearing secretions.

MEDICAL HISTORY: 1. MS, endstage secondary progressive type.
1. Decubitus ulcer (healing).
2. History of lung aspiration and lung abscess.
3. Hypertension.
4. Gastroesophageal reflux.
5. Status post gastrostomy tube.
6. Status post suprapubic catheter.

MEDICATION ON ADMISSION: - oxybutynin ER 10mg daily
- simvastatin 80mg daily
- metoclopramide 5mg QID
- omeprazole 20mg daily
- provigil 200mg daily
- bisacodyl 10mg suppository QHS
- baclofen 10mg Q12am/12pm, 15mg Q6am/6pm
- natural balance tear drops 2 drops OU Q8hrs
- levothyroxine 50mcg daily
- acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for pain
- Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) enema Rectal
once a day as needed for constipation
- albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every six (6) hours as
needed for cough, wheezing, or shortness of breath
- ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for cough, wheezing, or
shortness of breath.
- multivitamin Liquid Sig: Fifteen (15) mL PO once a day.
- Guiatuss 100 mg/5 mL Liquid Sig: Ten (10) mL PO every six (6)
hours as needed for cough.
- Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) mL PO
once a day as needed for constipation.
- magnesium citrate Solution Sig: 0.5 bottle PO Monday,
Wednesday, Friday.
- Enulose 10 gram/15 mL Solution Sig: Fifteen (15) mL PO every
six (6) hours: given on Tuesday, Thursday, Saturday, Sunday.

ALLERGIES: Benzodiazepines / Augmentin

PHYSICAL EXAM: ADMISSION EXAM:
Vitals: T: 99 BP: 115/68 P: 79 R:21 O2: 97
General: Alert, oriented.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP difficult to assess
Lungs: Anterior/lateral auscultation has poor inspiratory effort
with coarse breath sounds and some rhonchi bilaterally.
CV: Distant heart sounds.  Regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Abdomen: Distended firm abdomen.  Tympanic to percussion.
G-tube in place as well as suprapubic catheter in place.  NT to
palpation.  No organomegaly appreciated.
GU: clear urine
Ext: Atrophic lower extremities.  Warm, well perfused, 1+
pulses, no clubbing, cyanosis or edema
Neuro:  Quadraplegic.  AOX3. Movement of right shoulder and can
move eyes.

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: Lives in Nursing Home at [**Hospital3 2558**], divorced, two children.
 Retired Biochemist.  Denies etoh/tobacco/drugs. 

### Response:
{'Infection and inflammatory reaction due to indwelling urinary catheter,Streptococcal septicemia,Severe sepsis,Septic shock,Pyelonephritis, unspecified,Other specified intestinal obstruction,Hydronephrosis,Multiple sclerosis,Neurogenic bladder NOS,Calculus of kidney,Unspecified essential hypertension,Atrial fibrillation,Esophageal reflux,Obstructive sleep apnea (adult)(pediatric)'}
