CHIEF COMPLAINT: Fever and Hypotension

PRESENT ILLNESS: 68 year old man with a past medical history significant for
diffuse large B-cell lymphoma, status post two cycles of R-CHOP,
who originally presented to [**Hospital1 18**] from rehab with fever, chills,
and malaise the day prior to admission. He had been feeling
relatively well over days prior to admission. He denied any
nausea, vomiting, diarrhea, or recent fever, but endorses slight
tenderness and redness over the PICC insertion site. Concerned
due to his previous medical history, his rehabilitation facility
sent the patient to the [**Hospital1 18**].
.
On presentation to the ED, patient was noted to have a
temperature of 101.7, heart rate of 115, blood pressure of
72/38, RR of 16, and oxygen saturation of 96%. He received
cefepime 2gm IV, vancomycin 1 gm IV, and Tylenol. His PICC line
was removed and sent for culture. Due to concern for hypotension
and sepsis, he was transferred to the ICU.
.
In the ICU, he was given IVFs to which his blood pressures
responded and have been stable in the 90s systolic (his
baseline).  Blood cultures from admission grew [**4-2**] pansensitive
staph aureus as well as [**2-2**] hafnia alvei which was sensitive to
ceftriaxone, thus he was started on nafcillin and ceftriaxone.
Source was thought to be his PICC line which, as above, was
removed on admission.  Cellulitis of the sking surrounding the
PICC was also noted.  Additionally, while in the ICU, he was
found to have a DVT right basilic vein extending to axillary
vein; for this he was started on heparin gtt with plan to
transition to coumadin.  Prior to his admission, he was being
treated for C. diff with PO vanco.  He has had persistent
diarrhea while here, C. diff was sent and was negative x3.  He
has, however, been continued on his PO vanco.
.
ROS:  Significant weight change from his baseline 175 to his
current 139 over the past year. He attributes this to poor
appetite [**1-31**] alcohol abuse.  Negative for chest pain, SOB

MEDICAL HISTORY: 1. Prostate cancer status post TURP and radiation per patient
2. [**Doctor Last Name 933**] disease treated with PTU/levoxyl
3. Hypertension
4. Hyperlipidemia
5. Alcohol abuse (last used 2 months ago)
6. Status subarachnoid hemorrhage and subdural hematoma
following an alcohol-related fall in [**4-5**].
7. Diffuse Large B-cell lymphoma, diagnosed [**2138-4-29**], now
receiving chemotherapy.
8. C. difficile colitis
9. VRE
10. Hyponatremia (SIADH)
.
Onc History: Pt initially presented to  [**Hospital3 46817**] in early [**Month (only) 547**] with cachexia, pour appetite, and right
hydronephrosis secondary to a testicular mass and
retroperitoneal
lymphadenopathy.  A biopsy showed diffuse large B-cell lymphoma
and he received two cycles of Rituxan-CHOP on [**2138-4-18**] and
[**2138-5-15**].

MEDICATION ON ADMISSION: -hexavitamin PO qd
-folic acid 1mg qd
-thiamine 100 mg qd
-protonix 40mg qd
-clotrimazole 1% topical q12hr
-levothyroxine 25 mcg qd
-nystatin 5cc PO q6hr swish and swallow
-triamcinolone 1% cream TP qd
-lovenox 40 mg SC qd
-allopurinol 200 qd
-tylenol 325mg PO q6hr PRN pain
-megestrol 40 mg qd prn
-lactulose 30 cc q6hr PRN
-colace 100 PO q12hr PRN
-zofran 4mg PO q8hr PRN
-dilaudid 4mg PO q4hr PRN
-calcium carbonate 1250 PO q12
-epogen 12,000 units SC qT,Th, Sa
-magnesium oxide 400 mg PO bid
-filgastrim 480 mcg q24 hr

ALLERGIES: Ciprofloxacin

PHYSICAL EXAM: Vital signs: T 98.6, HR 121, BP 108/36, RR 28, 97% on RA
General: Cachectic. In no apparent distress.
HEENT: Anicteric sclera. No oropharyngeal lesions. Poor
dentition. Slightly dry mucous membranes.
Neck: Supple. No JVD. No cervical lymphadenopathy.
Heart: Tachycardic. Normal S1 and S2. No murmurs, rubs, or
gallops appreciated.
Lungs: Clear to auscultation bilaterally. No crackles.
Abdomen: Soft. Hypoactive bowel sounds. Nontender throughout. No

FAMILY HISTORY: Brother with question of sudden cardiac death, second brother
with diabetes and coronary artery disease who died at age 57,
third brother with history of cerebrovascular accident.

SOCIAL HISTORY: Currently lives at rehabilitation center/nursing home. Prior to
[**5-5**] lived alone in [**Hospital3 4298**]. Separated from his wife.
[**Name (NI) **] a son who lives in [**Name (NI) 531**] and a daughter who lives in [**Location (un) 10054**]. Tobacco: 1.5 ppd X 50 years. Alcohol: Used to drink
[**12-31**] bottle of wine and four bottles of beer daily but stopped 2
months ago.  Denies illicit drugs.
Infection and inflammatory reaction due to other vascular device, implant, and graft,Intestinal infection due to Clostridium difficile,Other malignant lymphomas, lymph nodes of inguinal region and lower limb,Methicillin susceptible Staphylococcus aureus septicemia,Sepsis,Cellulitis and abscess of upper arm and forearm,Acute and subacute bacterial endocarditis,Neutropenia, unspecified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other disorders of neurohypophysis,Anemia in neoplastic disease,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Hypotension, unspecified,Unspecified acquired hypothyroidism,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site
React-oth vasc dev/graft,Int inf clstrdium dfcile,Lymphomas NEC inguin,Meth susc Staph aur sept,Sepsis,Cellulitis of arm,Ac/subac bact endocard,Neutropenia NOS,Abn react-procedure NEC,Neurohypophysis dis NEC,Anemia in neoplastic dis,Hyperlipidemia NEC/NOS,Hypertension NOS,Hypotension NOS,Hypothyroidism NOS,Mth sus Stph aur els/NOS
Admission Date:  [**2138-5-30**]              Discharge Date:   [**2138-6-8**]

Date of Birth:  [**2069-11-19**]             Sex:   M

Service: MEDICINE

Allergies:
Ciprofloxacin

Attending:[**Known firstname 3561**]
Chief Complaint:
Fever and Hypotension

Major Surgical or Invasive Procedure:
PICC line placement


History of Present Illness:
68 year old man with a past medical history significant for
diffuse large B-cell lymphoma, status post two cycles of R-CHOP,
who originally presented to [**Hospital1 18**] from rehab with fever, chills,
and malaise the day prior to admission. He had been feeling
relatively well over days prior to admission. He denied any
nausea, vomiting, diarrhea, or recent fever, but endorses slight
tenderness and redness over the PICC insertion site. Concerned
due to his previous medical history, his rehabilitation facility
sent the patient to the [**Hospital1 18**].
.
On presentation to the ED, patient was noted to have a
temperature of 101.7, heart rate of 115, blood pressure of
72/38, RR of 16, and oxygen saturation of 96%. He received
cefepime 2gm IV, vancomycin 1 gm IV, and Tylenol. His PICC line
was removed and sent for culture. Due to concern for hypotension
and sepsis, he was transferred to the ICU.
.
In the ICU, he was given IVFs to which his blood pressures
responded and have been stable in the 90s systolic (his
baseline).  Blood cultures from admission grew [**4-2**] pansensitive
staph aureus as well as [**2-2**] hafnia alvei which was sensitive to
ceftriaxone, thus he was started on nafcillin and ceftriaxone.
Source was thought to be his PICC line which, as above, was
removed on admission.  Cellulitis of the sking surrounding the
PICC was also noted.  Additionally, while in the ICU, he was
found to have a DVT right basilic vein extending to axillary
vein; for this he was started on heparin gtt with plan to
transition to coumadin.  Prior to his admission, he was being
treated for C. diff with PO vanco.  He has had persistent
diarrhea while here, C. diff was sent and was negative x3.  He
has, however, been continued on his PO vanco.
.
ROS:  Significant weight change from his baseline 175 to his
current 139 over the past year. He attributes this to poor
appetite [**1-31**] alcohol abuse.  Negative for chest pain, SOB

Past Medical History:
1. Prostate cancer status post TURP and radiation per patient
2. [**Doctor Last Name 933**] disease treated with PTU/levoxyl
3. Hypertension
4. Hyperlipidemia
5. Alcohol abuse (last used 2 months ago)
6. Status subarachnoid hemorrhage and subdural hematoma
following an alcohol-related fall in [**4-5**].
7. Diffuse Large B-cell lymphoma, diagnosed [**2138-4-29**], now
receiving chemotherapy.
8. C. difficile colitis
9. VRE
10. Hyponatremia (SIADH)
.
Onc History: Pt initially presented to  [**Hospital3 46817**] in early [**Month (only) 547**] with cachexia, pour appetite, and right
hydronephrosis secondary to a testicular mass and
retroperitoneal
lymphadenopathy.  A biopsy showed diffuse large B-cell lymphoma
and he received two cycles of Rituxan-CHOP on [**2138-4-18**] and
[**2138-5-15**].

Social History:
Currently lives at rehabilitation center/nursing home. Prior to
[**5-5**] lived alone in [**Hospital3 4298**]. Separated from his wife.
[**Name (NI) **] a son who lives in [**Name (NI) 531**] and a daughter who lives in [**Location (un) 10054**]. Tobacco: 1.5 ppd X 50 years. Alcohol: Used to drink
[**12-31**] bottle of wine and four bottles of beer daily but stopped 2
months ago.  Denies illicit drugs.

Family History:
Brother with question of sudden cardiac death, second brother
with diabetes and coronary artery disease who died at age 57,
third brother with history of cerebrovascular accident.

Physical Exam:
Vital signs: T 98.6, HR 121, BP 108/36, RR 28, 97% on RA
General: Cachectic. In no apparent distress.
HEENT: Anicteric sclera. No oropharyngeal lesions. Poor
dentition. Slightly dry mucous membranes.
Neck: Supple. No JVD. No cervical lymphadenopathy.
Heart: Tachycardic. Normal S1 and S2. No murmurs, rubs, or
gallops appreciated.
Lungs: Clear to auscultation bilaterally. No crackles.
Abdomen: Soft. Hypoactive bowel sounds. Nontender throughout. No

rebound or guarding.
Extremities: Warm and well perfused. 2+ radial pulses. No
peripheral edema appreciated.


Pertinent Results:
[**2138-5-30**] 09:10PM   PLT COUNT-392#
[**2138-5-30**] 09:10PM   HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-OCCASIONAL MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL
POLYCHROM-NORMAL BURR-OCCASIONAL
[**2138-5-30**] 09:10PM   NEUTS-77* BANDS-0 LYMPHS-15* MONOS-5 EOS-0
BASOS-0 ATYPS-3* METAS-0 MYELOS-0
[**2138-5-30**] 09:10PM   WBC-1.5* RBC-3.43* HGB-10.9* HCT-30.7* MCV-90
MCH-31.7 MCHC-35.5* RDW-17.9*
[**2138-5-30**] 09:10PM   LIPASE-14
[**2138-5-30**] 09:10PM   ALT(SGPT)-13 AST(SGOT)-12 ALK PHOS-68 TOT
BILI-0.6
[**2138-5-30**] 09:10PM   GLUCOSE-106* UREA N-10 CREAT-0.7 SODIUM-129*
POTASSIUM-4.0 CHLORIDE-93* TOTAL CO2-24 ANION GAP-16
[**2138-5-30**] 09:16PM   LACTATE-1.4
[**2138-5-30**] 09:50PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2138-5-30**] 09:50PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
.
pCXR [**2138-5-30**]: Single AP upright portable chest radiograph is
reviewed and compared to [**2138-5-14**]. Heart size is normal.
Mediastinal and hilar contours are unremarkable. Pulmonary
vasculature is not enlarged. There is no focal consolidation.
There is no significant amount of pleural fluid. There is no
pneumothorax
.
R upper ext u/s [**2138-6-1**]: Occlusive thrombus in the right basilic
vein extending into the axillary vein.
.
TTE [**2138-5-30**]: The left atrium is normal in size. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). The right ventricular cavity is mildly dilated.
Right ventricular systolic function is normal. The aortic valve
leaflets (3) are mildly thickened. No aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2138-2-27**],
there is no
significant change.
.
TEE [**2138-6-4**]: No spontaneous echo contrast or thrombus is seen in
the body of the left atrium/left atrial appendage or the body of
the right atrium/right atrial appendage. No atrial septal defect
is seen by 2D or color Doppler. A catheter is seen in the right
atrium coming in contact intermittently with the triscuspid
valve. No mobile elements are seen attached to the catheter.
There are simple atheroma in the ascending aorta. There are
simple atheroma in the aortic arch and descending thoracic
aorta. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No
vegetations are seen on the aortic valve. An eccentric jet of
probable mild aortic regurgitation is seen; however, given the
eccentric nature of this flow, cannot exclude the possibility of
a small aortic leaflet perforation. The mitral valve leaflets
are structurally normal. No mass or vegetation is seen on the
mitral valve. Mild to moderate ([**12-31**]+) mitral regurgitation is
seen. There is no pericardial effusion.
.
Left upper ext u/s [**2138-6-5**]: No evidence of DVT in the left upper
extremity.
.
Micro:
[**2138-5-30**], blood cultures 4/4 bottles:
      STAPH AUREUS COAG +.    FINAL SENSITIVITIES.
         Staphylococcus species may develop resistance during
prolonged
         therapy with quinolones.   Therefore, isolates that are
initially
         susceptible may become resistant within three to four
days after
         initiation of therapy.  Testing of repeat isolates may
be
         warranted.  PENICILLIN SENSITIVITY AVAILABLE ON
REQUEST.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
.
[**2138-5-30**], blood cultures 2/4 bottles:
       HAFNIA ALVEI.    FINAL SENSITIVITIES.
         Trimethoprim/Sulfa sensitivity testing available on
request.
      STAPH AUREUS COAG +.
         SENSITIVITIES PERFORMED ON CULTURE # 231-0361L [**2138-5-30**].

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             HAFNIA ALVEI
                             |
AMPICILLIN------------   <=2 R
AMPICILLIN/SULBACTAM--   <=2 R
CEFAZOLIN-------------  =>64 R
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CEFUROXIME------------     4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
IMIPENEM--------------   <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN----------   <=4 S
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------   <=1 S
.
PICC cath tip [**2138-5-30**]:
STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA----       S
.
Urine cx [**2138-5-30**]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES),
CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION.
.
[**2138-5-31**], blood cultures: 1/4 bottles with Staph Aureus
(sensitivies same as blood cx from [**2138-5-30**])
.
Blood cultures [**2138-6-1**], [**2138-6-3**], [**2139-6-8**]: NGTD
.
Stool: negative for Cdiff x 3, negative for O&P, stool culture
negative

Brief Hospital Course:
68 year old man with diffuse B cell lymphoma status post two
cycles of R-CHOP who presented with fever and hypotension in the
setting of infected PICC line.  He also was noted to have an
upper extremity DVT associated with the line.
.
1) Sepsis/Infected PICC/upper DVT:  He received IVFs in the ICU
and did not require pressers.  His PICC line was removed; blood
cultures and PICC catheter tip grew MSSA and Hafnia Alvei.  He
was given Nafcillin and Ceftriaxone.  R upper extremitiy u/s
revealed a DVT of the right basilic vein extending into the
axillary vein (this is where the old PICC had been).  He was
placed on a heparin drip.  Trans-thoracic and trans-esophageal
echos were done; neither revealed a vegetation but the TEE
showed an eccentric jet of aortic regurgitaion which could not
be ruled out as a manifestation of endocarditis.  ID was
consulted, and felt he should be treated for endocarditis.  The
Ceftriaxone should be given for a 2-week course (Hafnia Alvei is
not a common cause of endocarditis), and Nafcillin should be
given for 6 weeks (as MSSA commonly causes endocarditis).  He
will f/u with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from Infectious diseases on [**7-14**]
at 9:30am.  He will need weakly labs while on ABX, including CBC
w/diff, chemistry panel, LFTs.  These can be faxed to [**Hospital **] clinic
(Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) at fax # [**Telephone/Fax (1) 432**].

.
2) RUE DVT: At site of former PICC, U/S showed occlusive
thrombus in the right basilic vein extending into the axillary
vein.  He was on a heparin drip for 1 week.  Heparin was d/c'd
and no further anticoaggulation started for the following
reasons: The DVT was associated with a line that was removed,
and the patient has a h/o subdural & subarachnoid hemorrhage 3
months ago.
.
3) Diarrhea: The patient had recent C. diff infection for which
he was on PO vanco.  He continued to have loose stools.  C. diff
toxin was sent and was negative x4 during this admission.  Toxin
B sent.
- cont. PO vanco
- f/u C. diff toxin B
.
4) Diffuse large B cell lymphoma:  Received two cycles of R-CHOP
previously. Chemotherapy started in [**2138-3-30**].  He was on
allopurinol for tumor lysis and neupogen for cell count
enhancement.  Neupogen was d/c'd in the ICU when counts rose.
Due to the infection and possible endocarditis, his CHOP
chemotherapy will be held, but he was given 1 dose of Rituximab
while inpatient.  He will f/u with his outpatient Oncologist,
Dr. [**Last Name (STitle) 410**] one week after discharge.
.
5) [**Doctor Last Name 933**] Disease:  Followed by endocrine as an outpatient.  The
patient was continued on levothyroxine dose of 25mcg daily.   He
should f/u with his endocrinologist, Dr. [**First Name (STitle) **] as previously
scheduled.
.
6) Hyponatremia:  During previous hospitalization, patient was
noted to have low sodium level, thought to be secondary to
SIADH.  He received fluid resuscitation in the ICU initially.
After his sepsis physiology resolved, he was placed on a free
H2O restriction of 1500 ml.  His sodium was stable in the low
130s.
.
7) FEN:  Regular diet. Continued on multivitamins, thiamine,
folic acid. .
.
8) Prophylaxis:  Was given heparin gtt for DVT as above, then
ambulating.  Also given PPI and bowel regimen.
.
Code:  FULL.


Medications on Admission:
-hexavitamin PO qd
-folic acid 1mg qd
-thiamine 100 mg qd
-protonix 40mg qd
-clotrimazole 1% topical q12hr
-levothyroxine 25 mcg qd
-nystatin 5cc PO q6hr swish and swallow
-triamcinolone 1% cream TP qd
-lovenox 40 mg SC qd
-allopurinol 200 qd
-tylenol 325mg PO q6hr PRN pain
-megestrol 40 mg qd prn
-lactulose 30 cc q6hr PRN
-colace 100 PO q12hr PRN
-zofran 4mg PO q8hr PRN
-dilaudid 4mg PO q4hr PRN
-calcium carbonate 1250 PO q12
-epogen 12,000 units SC qT,Th, Sa
-magnesium oxide 400 mg PO bid
-filgastrim 480 mcg q24 hr

Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
5. CeftriaXONE 1 gm IV Q24H
6. Nafcillin 2 gm IV Q4H
7. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

10. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN.  Inspect site every shift.
11. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
13. Multivitamin,Tx-Minerals     Tablet Sig: One (1) Cap PO
DAILY (Daily).
14. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
17. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).


Discharge Disposition:
Extended Care

Facility:
N.E. [**Hospital **] Hospital

Discharge Diagnosis:
1. Sepsis secondary to infected PICC line and bacteremia
2. Right upper extremitiy DVT related to old PICC line
2. Endocarditis
3. Lymphoma


Discharge Condition:
Afebrile, stable


Discharge Instructions:
Please take your medications as prescribed.  You will not be
taking blood thinners.  Continue to take Ceftriaxone for 1 more
week (last full day is [**2138-6-15**]).  Continue to take Nafcillin for
5 more weeks (last day is [**2138-7-12**]).
.
You will need weakly labs while on antibiotics, including CBC
w/differential, chemistry panel, LFTs.  These can be faxed to [**Hospital **]
clinic (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) at fax # [**Telephone/Fax (1) 432**]
.
Call your doctor if you have fever, chills or any other symptom
that concerns you.

Followup Instructions:
- Please see Dr. [**Last Name (STitle) 410**]/Dr. [**First Name (STitle) **] on [**2138-6-16**] at 11AM.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3749**], MD: [**Telephone/Fax (1) 3241**] Date/Time:[**2138-6-16**]
11:00

- You are scheduled to follow up with the Infectious Diseases
team, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], as below.
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2138-7-14**] 9:30
- You are scheduled to see your endocrinologist, Dr. [**First Name (STitle) **].

Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1802**], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2138-6-20**]
11:00



Completed by:[**2138-6-9**]
{'Infection and inflammatory reaction due to other vascular device, implant, and graft,Intestinal infection due to Clostridium difficile,Other malignant lymphomas, lymph nodes of inguinal region and lower limb,Methicillin susceptible Staphylococcus aureus septicemia,Sepsis,Cellulitis and abscess of upper arm and forearm,Acute and subacute bacterial endocarditis,Neutropenia, unspecified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other disorders of neurohypophysis,Anemia in neoplastic disease,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Hypotension, unspecified,Unspecified acquired hypothyroidism,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: Fever and Hypotension

PRESENT ILLNESS: 68 year old man with a past medical history significant for
diffuse large B-cell lymphoma, status post two cycles of R-CHOP,
who originally presented to [**Hospital1 18**] from rehab with fever, chills,
and malaise the day prior to admission. He had been feeling
relatively well over days prior to admission. He denied any
nausea, vomiting, diarrhea, or recent fever, but endorses slight
tenderness and redness over the PICC insertion site. Concerned
due to his previous medical history, his rehabilitation facility
sent the patient to the [**Hospital1 18**].
.
On presentation to the ED, patient was noted to have a
temperature of 101.7, heart rate of 115, blood pressure of
72/38, RR of 16, and oxygen saturation of 96%. He received
cefepime 2gm IV, vancomycin 1 gm IV, and Tylenol. His PICC line
was removed and sent for culture. Due to concern for hypotension
and sepsis, he was transferred to the ICU.
.
In the ICU, he was given IVFs to which his blood pressures
responded and have been stable in the 90s systolic (his
baseline).  Blood cultures from admission grew [**4-2**] pansensitive
staph aureus as well as [**2-2**] hafnia alvei which was sensitive to
ceftriaxone, thus he was started on nafcillin and ceftriaxone.
Source was thought to be his PICC line which, as above, was
removed on admission.  Cellulitis of the sking surrounding the
PICC was also noted.  Additionally, while in the ICU, he was
found to have a DVT right basilic vein extending to axillary
vein; for this he was started on heparin gtt with plan to
transition to coumadin.  Prior to his admission, he was being
treated for C. diff with PO vanco.  He has had persistent
diarrhea while here, C. diff was sent and was negative x3.  He
has, however, been continued on his PO vanco.
.
ROS:  Significant weight change from his baseline 175 to his
current 139 over the past year. He attributes this to poor
appetite [**1-31**] alcohol abuse.  Negative for chest pain, SOB

MEDICAL HISTORY: 1. Prostate cancer status post TURP and radiation per patient
2. [**Doctor Last Name 933**] disease treated with PTU/levoxyl
3. Hypertension
4. Hyperlipidemia
5. Alcohol abuse (last used 2 months ago)
6. Status subarachnoid hemorrhage and subdural hematoma
following an alcohol-related fall in [**4-5**].
7. Diffuse Large B-cell lymphoma, diagnosed [**2138-4-29**], now
receiving chemotherapy.
8. C. difficile colitis
9. VRE
10. Hyponatremia (SIADH)
.
Onc History: Pt initially presented to  [**Hospital3 46817**] in early [**Month (only) 547**] with cachexia, pour appetite, and right
hydronephrosis secondary to a testicular mass and
retroperitoneal
lymphadenopathy.  A biopsy showed diffuse large B-cell lymphoma
and he received two cycles of Rituxan-CHOP on [**2138-4-18**] and
[**2138-5-15**].

MEDICATION ON ADMISSION: -hexavitamin PO qd
-folic acid 1mg qd
-thiamine 100 mg qd
-protonix 40mg qd
-clotrimazole 1% topical q12hr
-levothyroxine 25 mcg qd
-nystatin 5cc PO q6hr swish and swallow
-triamcinolone 1% cream TP qd
-lovenox 40 mg SC qd
-allopurinol 200 qd
-tylenol 325mg PO q6hr PRN pain
-megestrol 40 mg qd prn
-lactulose 30 cc q6hr PRN
-colace 100 PO q12hr PRN
-zofran 4mg PO q8hr PRN
-dilaudid 4mg PO q4hr PRN
-calcium carbonate 1250 PO q12
-epogen 12,000 units SC qT,Th, Sa
-magnesium oxide 400 mg PO bid
-filgastrim 480 mcg q24 hr

ALLERGIES: Ciprofloxacin

PHYSICAL EXAM: Vital signs: T 98.6, HR 121, BP 108/36, RR 28, 97% on RA
General: Cachectic. In no apparent distress.
HEENT: Anicteric sclera. No oropharyngeal lesions. Poor
dentition. Slightly dry mucous membranes.
Neck: Supple. No JVD. No cervical lymphadenopathy.
Heart: Tachycardic. Normal S1 and S2. No murmurs, rubs, or
gallops appreciated.
Lungs: Clear to auscultation bilaterally. No crackles.
Abdomen: Soft. Hypoactive bowel sounds. Nontender throughout. No

FAMILY HISTORY: Brother with question of sudden cardiac death, second brother
with diabetes and coronary artery disease who died at age 57,
third brother with history of cerebrovascular accident.

SOCIAL HISTORY: Currently lives at rehabilitation center/nursing home. Prior to
[**5-5**] lived alone in [**Hospital3 4298**]. Separated from his wife.
[**Name (NI) **] a son who lives in [**Name (NI) 531**] and a daughter who lives in [**Location (un) 10054**]. Tobacco: 1.5 ppd X 50 years. Alcohol: Used to drink
[**12-31**] bottle of wine and four bottles of beer daily but stopped 2
months ago.  Denies illicit drugs. 

### Response:
{'Infection and inflammatory reaction due to other vascular device, implant, and graft,Intestinal infection due to Clostridium difficile,Other malignant lymphomas, lymph nodes of inguinal region and lower limb,Methicillin susceptible Staphylococcus aureus septicemia,Sepsis,Cellulitis and abscess of upper arm and forearm,Acute and subacute bacterial endocarditis,Neutropenia, unspecified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other disorders of neurohypophysis,Anemia in neoplastic disease,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Hypotension, unspecified,Unspecified acquired hypothyroidism,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site'}
