CHIEF COMPLAINT: Hypotension

PRESENT ILLNESS: Mr. [**Known lastname 77792**] is a 75 with chronic respiratory failure s/p
tracheostomy, type II diabetes, peripheral vascular disease s/p
right BKA, CAD, atrial fibrillation, and ESRD on dialysis who
presented on [**2150-11-3**] from his chronic rehab facility with
hypotension to the 70s systolic with associated cough and sputum
production. Since [**2150-11-3**] he has had multiple ICU transfers for
hypotension and somnolence.
.
On DOA on [**2150-11-3**], he presented with BP of 50/33 and it was
presumed to be sepsis from large known sacral decubitus ulcer
which was felt to be infected.  He was admitted to the [**Hospital Unit Name 153**] for
concern for sepsis.  He was in the [**Hospital Unit Name 153**] from [**2150-11-3**] to
[**2150-11-26**]. In [**Hospital Unit Name 153**] he had a broad infectious workup.  Multiple
blood cultures were negative.  Both sputum and urine cultures
were positive for acinetobacter.  He was treated with a
prolonged course of daptomycin, meropenem and PO vancomycin.
Antibiotics were discontinued on [**2150-11-26**] prior to transfer to
the floor.  While in the ICU his blood pressures were
persistently in the 70s to 80s systolic but he was afebrile and
was noted to be mentating appropriately.  His blood pressures
were noted to be particularly sensitive to narcotic pain
medications. He was followed closely by the renal, infectious
disease and plastic surgery services.  He initially required
CVVH given his labile blood pressures but was ultimately
transitioned back to intermittent hemodialysis.  His back wound
was debrided on multiple occassions by plastic surgery.  His
back wound was noted to be consistently contaminated by fecal
material despite flexiseal use.  Diverting colostomy was
recommended but was declined by the patient.  He was transferred
to the floor on [**2150-11-26**] for further management.
.
On [**2150-11-29**] he was transferred back to the MICU for hypotension.
He was not febrile, new cultures failed to reveal a source. He
was started back on daptomycin, meropenem and PO vancomycin.  He
also received stress dose steroids. His hypotension resolved
with this regimen. He was transferred back to the floor with
blood pressures in the 90s to 110s systolic. The patient did
well on the floor until [**12-8**] when 2 hours after receiving 10 mg
oxycodone to control sacral decub pain in setting of dressing
change he became unresponsive.
Narcan did imporve his alertness but the medical staff was
unable to obtain reliable vital measurements and in setting of
worsening productive sputum and worsening leukocytosis, patient
was transferred to ICU were he was monitored for 2 days.  The
patient returned to the medicine floor on [**12-10**]. However, on
[**12-12**] he again became hypotensive and returned to the ICU, again
likely multifactorial. Midodrine was restarted and uptitrated to
15mg tid. He received one unit of PRBCs with hemodialysis for
colloid volume resuscitation. He was transferred back to the
floor on [**12-14**].
.
On review of systems he does not note any pain/discomfort
anywhere. He denies chest pain, shortness of breath, nausea,
vomiting, abdominal pain, dysuria, leg pain.

MEDICAL HISTORY: # DM2
# CRI (baseline 2.5)- recently started on HD
# CHF - EF 50-55% [**3-24**]
# Trached and Vent Dependent [**1-18**] PNA in [**12-24**]
hypercarbic/hypoxic respiratory failure, bronchoscopy on [**9-10**].
He diffuse airway edema consistent with volume overload. There
were no significant secretions and a full survey of the airways
reveals all airways were patent without any endobronchial
lesions. His trach was
felt to be in appropriate position without any obstruction.
There was no tracheobronchomalacia.
# PNA [**4-23**] (Stenotrophomonas - Bactrim sensitive)
and Acenitobacter ([**Last Name (un) 36**] to Unasyn, Gent and Tobra, resistant to

MEDICATION ON ADMISSION: epoetin alfa 20,000 units with HD
famiotidine 20mg daily
recent course with fluconazole/levoflox
metoprolol 12.5mg [**Hospital1 **]
zofran 4mg IV q6h prn nausea
percocet 5/325 mg 1-2 tabs, q4h prn pain
senna
sevelamer 800mg TID
simvastatin 10mg daily
vanco 1g with HD at [**Hospital1 **]

ALLERGIES: Penicillins / Sulfa (Sulfonamides)

PHYSICAL EXAM: Review of systems:
ROS is is negative except for what is mentioned in the HPI
.
EXAM
Vitals: 971., 115/40, 69, 16, 96%/40% FM
GEN: NAD, lying in bed, +trach, obese, awake, alert,
HEENT:PERRLA, EOMI, anicteric, MMM
neck: +trach in place, c/d/I, supple, unable to assess for JVP.

FAMILY HISTORY: Non-Contributory

SOCIAL HISTORY: Used to live with wife, who is HCP. Now at [**Hospital1 **].
Ulcer of heel and midfoot,Cardiac arrest,Severe sepsis,Morbid obesity,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Other specified forms of chronic ischemic heart disease,Anemia in chronic kidney disease,Unspecified disorder of plasma protein metabolism,Peripheral angiopathy in diseases classified elsewhere,Hyperpotassemia,Tracheostomy status,Below knee amputation status,Infection with microorganisms with resistance to multiple drugs,Unspecified septicemia,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Acute and chronic respiratory failure,Pneumonia due to Pseudomonas,Intestinal infection due to Clostridium difficile,Hemorrhage of gastrointestinal tract, unspecified,Acute kidney failure, unspecified,Unspecified osteomyelitis, other specified sites,Dependence on respirator, status,Pneumonitis due to inhalation of food or vomitus,Urinary tract infection, site not specified
Ulcer of heel & midfoot,Cardiac arrest,Severe sepsis,Morbid obesity,DMII renl nt st uncntrld,Chr ischemic hrt dis NEC,Anemia in chr kidney dis,Dis plas protein met NOS,Angiopathy in other dis,Hyperpotassemia,Tracheostomy status,Status amput below knee,Inf mcrg rstn oth drg ml,Septicemia NOS,End stage renal disease,Hyp kid NOS w cr kid V,Acute & chronc resp fail,Pseudomonal pneumonia,Int inf clstrdium dfcile,Gastrointest hemorr NOS,Acute kidney failure NOS,Osteomyelit NOS-oth site,Respirator depend status,Food/vomit pneumonitis,Urin tract infection NOS
Admission Date:  [**2150-11-3**]              Discharge Date:   [**2151-2-17**]

Date of Birth:  [**2075-1-1**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Sulfa (Sulfonamides)

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Hypotension

Major Surgical or Invasive Procedure:
Surgical Wound Debridement

History of Present Illness:
Mr. [**Known lastname 77792**] is a 75 with chronic respiratory failure s/p
tracheostomy, type II diabetes, peripheral vascular disease s/p
right BKA, CAD, atrial fibrillation, and ESRD on dialysis who
presented on [**2150-11-3**] from his chronic rehab facility with
hypotension to the 70s systolic with associated cough and sputum
production. Since [**2150-11-3**] he has had multiple ICU transfers for
hypotension and somnolence.
.
On DOA on [**2150-11-3**], he presented with BP of 50/33 and it was
presumed to be sepsis from large known sacral decubitus ulcer
which was felt to be infected.  He was admitted to the [**Hospital Unit Name 153**] for
concern for sepsis.  He was in the [**Hospital Unit Name 153**] from [**2150-11-3**] to
[**2150-11-26**]. In [**Hospital Unit Name 153**] he had a broad infectious workup.  Multiple
blood cultures were negative.  Both sputum and urine cultures
were positive for acinetobacter.  He was treated with a
prolonged course of daptomycin, meropenem and PO vancomycin.
Antibiotics were discontinued on [**2150-11-26**] prior to transfer to
the floor.  While in the ICU his blood pressures were
persistently in the 70s to 80s systolic but he was afebrile and
was noted to be mentating appropriately.  His blood pressures
were noted to be particularly sensitive to narcotic pain
medications. He was followed closely by the renal, infectious
disease and plastic surgery services.  He initially required
CVVH given his labile blood pressures but was ultimately
transitioned back to intermittent hemodialysis.  His back wound
was debrided on multiple occassions by plastic surgery.  His
back wound was noted to be consistently contaminated by fecal
material despite flexiseal use.  Diverting colostomy was
recommended but was declined by the patient.  He was transferred
to the floor on [**2150-11-26**] for further management.
.
On [**2150-11-29**] he was transferred back to the MICU for hypotension.
He was not febrile, new cultures failed to reveal a source. He
was started back on daptomycin, meropenem and PO vancomycin.  He
also received stress dose steroids. His hypotension resolved
with this regimen. He was transferred back to the floor with
blood pressures in the 90s to 110s systolic. The patient did
well on the floor until [**12-8**] when 2 hours after receiving 10 mg
oxycodone to control sacral decub pain in setting of dressing
change he became unresponsive.
Narcan did imporve his alertness but the medical staff was
unable to obtain reliable vital measurements and in setting of
worsening productive sputum and worsening leukocytosis, patient
was transferred to ICU were he was monitored for 2 days.  The
patient returned to the medicine floor on [**12-10**]. However, on
[**12-12**] he again became hypotensive and returned to the ICU, again
likely multifactorial. Midodrine was restarted and uptitrated to
15mg tid. He received one unit of PRBCs with hemodialysis for
colloid volume resuscitation. He was transferred back to the
floor on [**12-14**].
.
On review of systems he does not note any pain/discomfort
anywhere. He denies chest pain, shortness of breath, nausea,
vomiting, abdominal pain, dysuria, leg pain.

Past Medical History:
# DM2
# CRI (baseline 2.5)- recently started on HD
# CHF - EF 50-55% [**3-24**]
# Trached and Vent Dependent [**1-18**] PNA in [**12-24**]
hypercarbic/hypoxic respiratory failure, bronchoscopy on [**9-10**].
He diffuse airway edema consistent with volume overload. There
were no significant secretions and a full survey of the airways
reveals all airways were patent without any endobronchial
lesions. His trach was
felt to be in appropriate position without any obstruction.
There was no tracheobronchomalacia.
# PNA [**4-23**] (Stenotrophomonas - Bactrim sensitive)
and Acenitobacter ([**Last Name (un) 36**] to Unasyn, Gent and Tobra, resistant to

FQ, ceftaz, cefepime)
# MRSA PNA
# ESBL Klebsiella UTI [**3-24**]
# Morbid obesity
# Afib on Coumadin
# Hypercholesterolemia
# Coccyx Ulcers
# MGUS


Social History:
Used to live with wife, who is HCP. Now at [**Hospital1 **].


Family History:
Non-Contributory

Physical Exam:
Review of systems:
ROS is is negative except for what is mentioned in the HPI
.
EXAM
Vitals: 971., 115/40, 69, 16, 96%/40% FM
GEN: NAD, lying in bed, +trach, obese, awake, alert,
HEENT:PERRLA, EOMI, anicteric, MMM
neck: +trach in place, c/d/I, supple, unable to assess for JVP.

Chest/Pulmonary:b/l +poor respiratory effort, CTAB anteriorly.
R.sided HD catheter
Heart: s1s2 distant heart sounds, unable to appreciate m/r/g.
Abdomen: +bs, obese, soft, NT, ND
Ext: s/p R.BKA, wound at stub. L.leg dusky, dark in color, dry
skin, faint pulses. R.midline c/d/i. 3+body edema.
Back: +stage 4 sacral decub, with multiple surrounding decubs of
various stages. +evidence of zoster infection/dermatomal
vesicular rash.
Neuro: AOx3

Pertinent Results:
[**2150-12-14**] 03:04AM BLOOD WBC-21.3* RBC-2.72* Hgb-8.3* Hct-25.7*
MCV-95 MCH-30.4 MCHC-32.1 RDW-22.5* Plt Ct-232
[**2150-11-3**] 07:40PM BLOOD WBC-13.2*# RBC-3.27* Hgb-9.1* Hct-29.7*
MCV-91 MCH-27.8 MCHC-30.6* RDW-17.7* Plt Ct-415#
[**2150-12-14**] 03:04AM BLOOD PT-24.6* PTT-64.0* [**Month/Day/Year 263**](PT)-2.4*
[**2150-12-14**] 03:04AM BLOOD Glucose-74 UreaN-22* Creat-1.9*# Na-146*
K-3.3 Cl-110* HCO3-24 AnGap-15
[**2150-12-14**] 03:04AM BLOOD Calcium-8.8 Phos-2.1*# Mg-1.9
[**2150-12-13**] 08:28AM BLOOD Tobra-3.1*
.
CXR [**11-3**]
IMPRESSION: Cardiomegaly with bilateral small pleural effusions,
left greater than right. Retrocardiac opacity may represent a
combination of atelectasis and pleural effusions. Cannot rule
out pneumonia. Followup is recommended.
.
FOOT 2 VIEWS LEFT PORT Study Date of [**2150-11-4**] 10:04 AM
FINDINGS: No previous images. There has been resection of the
phalanges of
the fourth and fifth digits as well as a substantial portion of
the fifth
metatarsal in a patient with vascular calcification consistent
with diabetes. Specifically, no evidence of erosion of the
calcaneus, though there is evidence of an adjacent ulcer. Small
posterior calcaneal spur.
.
TTE (Complete) Done [**2150-11-9**]
The left atrial volume is increased. The left atrium is dilated.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Left ventricular systolic function is hyperdynamic (EF>75%).
Right ventricular chamber size and free wall motion are normal.
The aortic root is moderately dilated at the sinus level. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2150-4-4**],
mild symmetric LVH is present, left ventricular cavity size is
smaller and overall left ventricular systolic function has
improved. The degree of mitral regurgitation has increased
slightly. Moderate pulmonary artery systolic hypertension can be
seen on the current study.
.
[**2150-11-4**] 11:33 am SWAB      Source: Stool.
**FINAL REPORT [**2150-11-8**]**
R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final [**2150-11-8**]):
ENTEROCOCCUS SP..    MODERATE GROWTH.
SENSITIVITIES: MIC expressed in MCG/ML
ENTEROCOCCUS SP.
                             |
VANCOMYCIN------------  >256 R
.
[**2150-11-10**] 4:51 am MRSA SCREEN      Source: Nasal swab.
**FINAL REPORT [**2150-11-13**]**
   MRSA SCREEN (Final [**2150-11-13**]):
      POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations.

         Rifampin should not be used alone for therapy.
         SENSITIVITIES: MIC expressed in MCG/ML

_________________________________________________________
                             POSITIVE FOR METHICILLIN RESISTANT
STAPH AUREUS
                             |
CLINDAMYCIN-----------   =>8 R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
PENICILLIN G---------- =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------     2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------   <=1 S
.
[**2150-11-20**] 6:10 am SPUTUM      Source: Endotracheal.
   GRAM STAIN (Final [**2150-11-20**]):
      >25 PMNs and <10 epithelial cells/100X field.
      3+  (5-10 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.
      2+   (1-5 per 1000X FIELD):   GRAM NEGATIVE ROD(S).
      2+   (1-5 per 1000X FIELD):   GRAM NEGATIVE DIPLOCOCCI.
   RESPIRATORY CULTURE (Preliminary):
.
[**2150-11-29**] 7:49 pm SPUTUM      Source: Endotracheal.

                            **FINAL REPORT [**2150-12-3**]**

   GRAM STAIN (Final [**2150-11-29**]):
      >25 PMNs and <10 epithelial cells/100X field.
      4+   (>10 per 1000X FIELD):   GRAM NEGATIVE ROD(S).

   RESPIRATORY CULTURE (Final [**2150-12-3**]):
      SPARSE GROWTH OROPHARYNGEAL FLORA.
      ACINETOBACTER BAUMANNII COMPLEX.    MODERATE GROWTH.
         "Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
         used, since therapeutic efficacy relies on intrinsic
activity of
         the sulbactam component".
      PSEUDOMONAS AERUGINOSA.    MODERATE GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ACINETOBACTER BAUMANNII COMPLEX
                             |          PSEUDOMONAS AERUGINOSA
                             |          |
AMPICILLIN/SULBACTAM--     4 S
CEFEPIME--------------  =>64 R       32 R
CEFTAZIDIME-----------  =>64 R        4 S
CIPROFLOXACIN---------   =>4 R      =>4 R
GENTAMICIN------------  =>16 R        4 S
IMIPENEM--------------     8 I
MEROPENEM-------------             =>16 R
PIPERACILLIN----------               16 S
PIPERACILLIN/TAZO-----               32 S
TOBRAMYCIN------------     8 I      <=1 S
TRIMETHOPRIM/SULFA----  =>16 R
.
[**2150-12-12**] 11:48 am SPUTUM      Source: Endotracheal.

   GRAM STAIN (Final [**2150-12-12**]):
      >25 PMNs and <10 epithelial cells/100X field.
      3+  (5-10 per 1000X FIELD):   GRAM NEGATIVE ROD(S).
      1+    (<1 per 1000X FIELD):   GRAM POSITIVE ROD(S).
      1+    (<1 per 1000X FIELD):   GRAM NEGATIVE DIPLOCOCCI.

   RESPIRATORY CULTURE (Preliminary):
      OROPHARYNGEAL FLORA ABSENT.
      PSEUDOMONAS AERUGINOSA.    HEAVY GROWTH.
         COLISITIN AND TIGECYCLINE REQUESTED BY DR.[**Last Name (STitle) **].
[**Doctor Last Name **],[**2150-12-17**].
         COLISTIN AND  Tigecycline REQUEST SENT TO [**Hospital1 4534**]
[**2150-12-21**].
      ACINETOBACTER BAUMANNII COMPLEX.    HEAVY GROWTH.
         "Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
         used, since therapeutic efficacy relies on intrinsic
activity of
         the sulbactam component".
         TO ADD TIGECYCLINE ,DURAPENEM AND COLISTIN PER DR.
[**First Name (STitle) **] PAGER
         [**Numeric Identifier 36772**] [**2150-12-14**].
         DURAPENEM RESISTANT AT >32 MCG/ML  Sensitivity testing
performed
         by Etest.
         TIGECYCLINE AND COLISTIN SENT TO [**Hospital1 4534**] LABORATORIES FOR
         SENSITIVITY.
      PSEUDOMONAS AERUGINOSA.    HEAVY GROWTH.  SECOND
MORPHOLOGY.
         COLISTIN AND TIGECYCLINE REQUESTED BY DR. [**Last Name (STitle) **].
[**Doctor Last Name **],[**2150-12-17**].
         COLISTIN AND  Tigecycline REQUEST SENT TO [**Hospital1 4534**]
[**2150-12-21**].

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             PSEUDOMONAS AERUGINOSA
                             |          ACINETOBACTER BAUMANNII
COMPLEX
                             |          |          PSEUDOMONAS
AERUGINOSA
                             |          |          |
AMPICILLIN/SULBACTAM--             =>32 R
CEFEPIME--------------    32 R     =>64 R        8 S
CEFTAZIDIME-----------               32 R        4 S
CIPROFLOXACIN---------   =>4 R      =>4 R      =>4 R
GENTAMICIN------------     4 S        2 S        4 S
IMIPENEM--------------             =>16 R
MEROPENEM-------------  =>16 R                =>16 R
PIPERACILLIN----------    32 S                 <=4 S
PIPERACILLIN/TAZO-----    64 S                   8 S
TOBRAMYCIN------------   <=1 S      <=1 S      <=1 S
TRIMETHOPRIM/SULFA----                2 S

   LEGIONELLA CULTURE (Final [**2150-12-19**]):    NO LEGIONELLA
ISOLATED.

   FUNGAL CULTURE (Preliminary):
      YEAST.
.
[**2150-12-18**] 3:16 pm SPUTUM      Source: Endotracheal.

   GRAM STAIN (Final [**2150-12-21**]):
      >25 PMNs and <10 epithelial cells/100X field.
      2+   (1-5 per 1000X FIELD):   GRAM NEGATIVE ROD(S).
      1+    (<1 per 1000X FIELD):   BUDDING YEAST.

   RESPIRATORY CULTURE (Preliminary):

.

Brief Hospital Course:
Mr [**Known lastname 77792**] is a 76 year old man with a chronic trach, s/p multiple
admissions, End-stage renal disease, coronary artery disease,
atrial fibrillation, type two diabetes and a plasma cell
dyscrasia admitted originally with hypotension and sepsis from
an infected sacral decub with prolonged hospitalization course
involving multiple transfers back and forth between the ICU and
floor for hypercapneic respiratory failure secondary to narcotic
pain medication.
.
# Stage IV Decubitus Ulcer: Overall, the patient has a very
severe stage 4 sacral decubitus ulcer and multi-drug resistant
organisms. He completed a 6 week course of Meropenem on [**2151-1-11**]
for empiric coverage. A diverting colostomy was performed on
[**2151-1-6**] to prevent fecal contamination of the wound and to
facilitate any possible wound healing. For pain control during
wound dressing was managed with various regimens transitioned to
IV morphine eventually.

# Hypotension: Pt was noted to have a baseline of sBP in the 70s
to 80s. On his original day of admission it was thought that it
may be a component of sepsis however his BP has persisted even
with resolution of sepsis. Pt has been asymptomatic and
mentating well with his above noted systolic pressures. His
baseline low BP is most likely due to autonomic dysfunction
given his negative work up and lack of clinical findings.
[**Name (NI) **] pt did require intermittent low dose Levophed
as pt's BP was decreased to the mid 60s most likely secondary to
hypovolemia. Pt was started and continued on midodrine 15 mg po
tid. Throughout [**Month (only) 956**], BP's ranged from 60's/20's- 100's/40's
thought likley to be [**1-18**] chronic sepsis and autonomic
dysfuntion.

#Pseudomonal Pneumonia: The patient was diagnosed with a
possible drug-resistant pseudomonal pneumonia which was treated
with a 14 day course of tobramycin finishing [**12-22**]. Following
treatment pt showed a negative sputum culture on [**12-26**], pt has
not shown any positive blood cultures since admission.

# ESRD: Pt was briefly on CVVH for fluid removal for several
days in early [**Month (only) 956**]. Otherwise, he was maintained on MWF HD.
By the last week of [**Month (only) 956**], his pressures were unable to
tolerate fluid removal during HD.

# Presumed C.Diff: Pt was started empirically on PO Vancomycin
given his course on antibiotics, however they were discontinued
given lack of diarrhea and C. diff negative toxin assays.

# Chronic Respiratory Failure:  He has experienced several
transfers between floor status and the ICU for hypercapneic
respiratory failure. Pt is very sensitive to pain medication,
particularly Oxycodone. For his decub ulcer pain pt was trialed
on Oxycodone of 10mg and became somnelent. Pt has been
transitioned to Fentanyl patch 100mcg for baseline pain control
plus morphine for dressing changes. During [**Month (only) 956**], his
respiratory failure worstened and he was put on ventilator for
support.

# Coronary Artery Disease:  Last echocardiogram with preserved
ejection fraction.  Had troponin leak on admission which peaked
at 0.53. Pt was continued on simvastatin, his beta blockers were
held given his low pressures.

# Atrial Fibrillation: Pt's A. fib during hospitalization has
been rate controlled.  Due to his [**Country **] score 2 pt was continued
on Coumadin in house, given his supratherapeutic [**Country 263**] pt's
Coumadin was held. In early [**Month (only) 956**], coumadin was discontinued
all together due to his comorbid conditions and risk of bleeding
from multiple ulcers on feet and sacrum.

# Type II Diabetes: Pt has diabetes and has been noted to have
lower blood sugars following his surgery. His Lantus originally
at 28 was transitioned down to 15. Given his recent surgery it
was thought he most likely had some malabsorption from bowel
edema. Lantus was changed to 15units daily without any further
hypogycemia.

# Peripheral Vascular Disease:  s/p BKA on right with left heel
ulcer on leg. Also left second toe ulcer. Was followed by
vascular surgery.  Left amputation was considered given chronic
cyanosis but pt was too unstable for this.

# Plasma Cell Dyscrasia:  Known IgA kappa on electrophoresis,
bone marrow with 5-10% plasma cells.  Also with known
retroperitoneal mass s/p non-diagnostic FNA and needle core
biopsy indicating lymphoid tissue with quiescent germinal
centers.

# Pain Control:  Patient with significant pain from sacral
ulcer.  Unfortunately blood pressures and respiratory failure
occur with his narcotic use. Pain consult was obtained however
recommendations were not favourable given their side effects.
He is maintained on the fentanyl patch and trying out morphine
concentrate prn before dressing changes.

# Upper gastrointestinal bleeding:  Patient with guaiac positive
NG aspirates on [**11-24**].  He has had no subsequent gross bleeding
as well as no bleeding out of the ostomy. Following surgery pt's
Hct was noted to be 19 and he received 1u PRBC. He increased his
Hct appropriately and his subsequent Hcts were noted to be in
the mid 20s which is his baseline. Pt was continued on PPI
threrapy.

# Goals of care: [**2151-2-2**] a family meeting was held with ICU team
at which the family was informed that there were no further
medical or surgical options for treatment. Code status was
changed to DNR/DNI and it was made clear to the family that
CVVH, pressors or any escalation in care were not indicated. No
further cultures, radiologic studies were ordered. Pt continued
to get MWF blood draws prior to dialysis but pt quickly became
unable to tolerate fluid removal due to low BPs during dialysis.
Pain was controlled PRN and narcotics were not held in setting
of hypotension. On [**2151-2-16**] another conversation with the family
and the ICU team took place, at which time the family was
informed that Mr [**Known lastname 77795**] blood pressure would not tolerate
additional dialysis. The family decided that the pt would be
CMO, and a morphine drip was initiated. On [**2151-2-17**] at 11:45 pt
passed away from cardiac arrest.

Medications on Admission:
epoetin alfa 20,000 units with HD
famiotidine 20mg daily
recent course with fluconazole/levoflox
metoprolol 12.5mg [**Hospital1 **]
zofran 4mg IV q6h prn nausea
percocet 5/325 mg 1-2 tabs, q4h prn pain
senna
sevelamer 800mg TID
simvastatin 10mg daily
vanco 1g with HD at [**Hospital1 **]


Discharge Medications:
None

Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
End stage renal failure
Sepsis
Stage 4 Decubitus Ulcer
Upper GI Bleeding
Pneumonia
Hypoxemia
Hypotension
Altered Mental Status


Discharge Condition:
Deceased

Discharge Instructions:
None

Followup Instructions:
None


                             [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

Completed by:[**2151-2-18**]
{'Ulcer of heel and midfoot,Cardiac arrest,Severe sepsis,Morbid obesity,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Other specified forms of chronic ischemic heart disease,Anemia in chronic kidney disease,Unspecified disorder of plasma protein metabolism,Peripheral angiopathy in diseases classified elsewhere,Hyperpotassemia,Tracheostomy status,Below knee amputation status,Infection with microorganisms with resistance to multiple drugs,Unspecified septicemia,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Acute and chronic respiratory failure,Pneumonia due to Pseudomonas,Intestinal infection due to Clostridium difficile,Hemorrhage of gastrointestinal tract, unspecified,Acute kidney failure, unspecified,Unspecified osteomyelitis, other specified sites,Dependence on respirator, status,Pneumonitis due to inhalation of food or vomitus,Urinary tract infection, site not specified'}


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: Hypotension

PRESENT ILLNESS: Mr. [**Known lastname 77792**] is a 75 with chronic respiratory failure s/p
tracheostomy, type II diabetes, peripheral vascular disease s/p
right BKA, CAD, atrial fibrillation, and ESRD on dialysis who
presented on [**2150-11-3**] from his chronic rehab facility with
hypotension to the 70s systolic with associated cough and sputum
production. Since [**2150-11-3**] he has had multiple ICU transfers for
hypotension and somnolence.
.
On DOA on [**2150-11-3**], he presented with BP of 50/33 and it was
presumed to be sepsis from large known sacral decubitus ulcer
which was felt to be infected.  He was admitted to the [**Hospital Unit Name 153**] for
concern for sepsis.  He was in the [**Hospital Unit Name 153**] from [**2150-11-3**] to
[**2150-11-26**]. In [**Hospital Unit Name 153**] he had a broad infectious workup.  Multiple
blood cultures were negative.  Both sputum and urine cultures
were positive for acinetobacter.  He was treated with a
prolonged course of daptomycin, meropenem and PO vancomycin.
Antibiotics were discontinued on [**2150-11-26**] prior to transfer to
the floor.  While in the ICU his blood pressures were
persistently in the 70s to 80s systolic but he was afebrile and
was noted to be mentating appropriately.  His blood pressures
were noted to be particularly sensitive to narcotic pain
medications. He was followed closely by the renal, infectious
disease and plastic surgery services.  He initially required
CVVH given his labile blood pressures but was ultimately
transitioned back to intermittent hemodialysis.  His back wound
was debrided on multiple occassions by plastic surgery.  His
back wound was noted to be consistently contaminated by fecal
material despite flexiseal use.  Diverting colostomy was
recommended but was declined by the patient.  He was transferred
to the floor on [**2150-11-26**] for further management.
.
On [**2150-11-29**] he was transferred back to the MICU for hypotension.
He was not febrile, new cultures failed to reveal a source. He
was started back on daptomycin, meropenem and PO vancomycin.  He
also received stress dose steroids. His hypotension resolved
with this regimen. He was transferred back to the floor with
blood pressures in the 90s to 110s systolic. The patient did
well on the floor until [**12-8**] when 2 hours after receiving 10 mg
oxycodone to control sacral decub pain in setting of dressing
change he became unresponsive.
Narcan did imporve his alertness but the medical staff was
unable to obtain reliable vital measurements and in setting of
worsening productive sputum and worsening leukocytosis, patient
was transferred to ICU were he was monitored for 2 days.  The
patient returned to the medicine floor on [**12-10**]. However, on
[**12-12**] he again became hypotensive and returned to the ICU, again
likely multifactorial. Midodrine was restarted and uptitrated to
15mg tid. He received one unit of PRBCs with hemodialysis for
colloid volume resuscitation. He was transferred back to the
floor on [**12-14**].
.
On review of systems he does not note any pain/discomfort
anywhere. He denies chest pain, shortness of breath, nausea,
vomiting, abdominal pain, dysuria, leg pain.

MEDICAL HISTORY: # DM2
# CRI (baseline 2.5)- recently started on HD
# CHF - EF 50-55% [**3-24**]
# Trached and Vent Dependent [**1-18**] PNA in [**12-24**]
hypercarbic/hypoxic respiratory failure, bronchoscopy on [**9-10**].
He diffuse airway edema consistent with volume overload. There
were no significant secretions and a full survey of the airways
reveals all airways were patent without any endobronchial
lesions. His trach was
felt to be in appropriate position without any obstruction.
There was no tracheobronchomalacia.
# PNA [**4-23**] (Stenotrophomonas - Bactrim sensitive)
and Acenitobacter ([**Last Name (un) 36**] to Unasyn, Gent and Tobra, resistant to

MEDICATION ON ADMISSION: epoetin alfa 20,000 units with HD
famiotidine 20mg daily
recent course with fluconazole/levoflox
metoprolol 12.5mg [**Hospital1 **]
zofran 4mg IV q6h prn nausea
percocet 5/325 mg 1-2 tabs, q4h prn pain
senna
sevelamer 800mg TID
simvastatin 10mg daily
vanco 1g with HD at [**Hospital1 **]

ALLERGIES: Penicillins / Sulfa (Sulfonamides)

PHYSICAL EXAM: Review of systems:
ROS is is negative except for what is mentioned in the HPI
.
EXAM
Vitals: 971., 115/40, 69, 16, 96%/40% FM
GEN: NAD, lying in bed, +trach, obese, awake, alert,
HEENT:PERRLA, EOMI, anicteric, MMM
neck: +trach in place, c/d/I, supple, unable to assess for JVP.

FAMILY HISTORY: Non-Contributory

SOCIAL HISTORY: Used to live with wife, who is HCP. Now at [**Hospital1 **]. 

### Response:
{'Ulcer of heel and midfoot,Cardiac arrest,Severe sepsis,Morbid obesity,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Other specified forms of chronic ischemic heart disease,Anemia in chronic kidney disease,Unspecified disorder of plasma protein metabolism,Peripheral angiopathy in diseases classified elsewhere,Hyperpotassemia,Tracheostomy status,Below knee amputation status,Infection with microorganisms with resistance to multiple drugs,Unspecified septicemia,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Acute and chronic respiratory failure,Pneumonia due to Pseudomonas,Intestinal infection due to Clostridium difficile,Hemorrhage of gastrointestinal tract, unspecified,Acute kidney failure, unspecified,Unspecified osteomyelitis, other specified sites,Dependence on respirator, status,Pneumonitis due to inhalation of food or vomitus,Urinary tract infection, site not specified'}
