CHIEF COMPLAINT: fevers, hypotension

PRESENT ILLNESS: [**Age over 90 **]-year-old female with past medical history of ESRD on HD,
pulmonary hypertension, chronic diastolic heart failure presents
with fevers and respiratory distress.
.
Per notes and history from family, the patient had been doing
well until 5-6 days prior to presentation. At that time the
patient developed a "cough and a cold". They note a
non-productive cough without fevers, chills or night sweats. At
that time she was noted to have "some rhonchi" per HD nurse. The
patient was thought to have a viral URI. Over the last few days
the patient has been feeling worse and has had poor PO intake.
She went to dialysis on the day of presentation and completed
hemodyalysis. Upon returning home she became more lethargic. Her
temperature and SaO2 were checked and were 101.5 and 85% on
room-air, respectively.
.
She presented to the emergency department with initial vitals of
T 101.5, HR 70, BP 133/60, RR 40 and SaO2 92% on NRB. The
patient was intubated for respiratory distress. WBC was 12.3.
CXR showed LLL opacity and patchy right pulmonary opacities.
Given clinical picture the patient was started on vancomycin,
cefepime and levofloxacin. After Versed bolus patient became
hypotensive and was started on levophed with placement of triple
lumen catheter.
.
Currently, the patient is sedated and intubated.
.
Review of Systems: Unable to obtain from patient.

MEDICAL HISTORY: - ESRD on T/Th/Sat HD followed by Dr. [**Last Name (STitle) 118**] at [**Location (un) **] [**Location (un) **]

MEDICATION ON ADMISSION: albuterol sulfate 2.5 mg/3 mL (0.083 %) neb [**Hospital1 **] PRN
albuterol sulfate [ProAir HFA] 90 mcg HFA Inh 1 puffs inhaled
[**Hospital1 **] prn
Anastrozole (dosage uncertain)
atorvastatin 10 mg PO daily
azithromycin [Zithromax Z-Pak] 250mg PO daily x5 days (500mg on
Day 1)
B complex-vitamin C-folic acid [Renal Caps] 1 mg PO daily
bupropion HCl 75 mg Tablet [**12-3**] tab in AM, [**12-3**] tab at noon PO
daily
calcium acetate 667 mg PO every other day
citalopram 10 mg PO daily
epoetin alfa 40,000 unit inj q two weeks
hydrocortisone acetate 25 mg Suppository [**Hospital1 **] prn hemorrhoids
levothyroxine 50 mcg PO daily
lidocaine 5 % (700 mg/patch) Adhesive Patch 1 daily
nystatin 100,000 apply to rash under breast [**Hospital1 **]
oxycodone 5-10mg liquid PO q4hours
pantoprazole 40 mg PO BID
polyethylene glycol 3350 [Miralax] 100 % Powder 1 tablespoon
Powder(s) by mouth daily
pregabalin [Lyrica] 25 mg Capsule PO 3 days per week
temazepam 15 mg PO qhs
tramadol 25mg PO BID prn pain
warfarin 2 mg PO daily
acetaminophen 650 mg PO TID
ergocalciferol 400 unit PO daily

ALLERGIES: Penicillins / Sulfa (Sulfonamide Antibiotics) / Tetracycline
Analogues

PHYSICAL EXAM: VS: Temp: 99.5 BP: 109/48 HR: 63 RR: 19 O2sat: 100% AC 500 14
FIO2 .50
GEN: sedated, responsive to voice, elderly
HEENT: PERRL, intubated, ETT with some bright red blood, no LAD,
no JVD
Resp: Coarse breath sounds bilateral, anterior exam, bilat
crackles, limited exam
CV: RR, II/VI murmur difficult to hear with vent, S1 and S2 wnl,
no r/g appreciated
ABD: nd, +b/s, soft, no masses or hepatosplenomegaly appreciated
EXT: wwp, cool feet/hands, [**12-3**]+ peripheral edema
SKIN: thin skin with multiple tears, lesion around anus
NEURO: Sedated, pupils as above

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives at home in [**Location (un) 10059**]. She has a high school education and
was a businesswoman. She is a widow. She does not smoke and she
does not drink alcohol. She has 24 hour care at home.
Unspecified septicemia,Acute respiratory failure,Pneumonia, organism unspecified,End stage renal disease,Toxic encephalopathy,Septic shock,Chronic diastolic heart failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Secondary malignant neoplasm of bone and bone marrow,Intestinal infection due to Clostridium difficile,Do not resuscitate status,Renal dialysis status,Atrial fibrillation,Other chronic pulmonary heart diseases,Unspecified acquired hypothyroidism,Anemia, unspecified,Constipation, unspecified,Pressure ulcer, lower back,Personal history of malignant neoplasm of breast,Cardiac pacemaker in situ,Long-term (current) use of anticoagulants,Foreign body in larynx,Inhalation and ingestion of other object causing obstruction of respiratory tract or suffocation,Accidents occurring in residential institution,Thrombocytopenia, unspecified,Severe sepsis
Septicemia NOS,Acute respiratry failure,Pneumonia, organism NOS,End stage renal disease,Toxic encephalopathy,Septic shock,Chr diastolic hrt fail,Hyp kid NOS w cr kid V,Secondary malig neo bone,Int inf clstrdium dfcile,Do not resusctate status,Renal dialysis status,Atrial fibrillation,Chr pulmon heart dis NEC,Hypothyroidism NOS,Anemia NOS,Constipation NOS,Pressure ulcer, low back,Hx of breast malignancy,Status cardiac pacemaker,Long-term use anticoagul,Foreign body in larynx,Resp obstr-inhal obj NEC,Accid in resident instit,Thrombocytopenia NOS,Severe sepsis
Admission Date:  [**2186-12-25**]              Discharge Date:   [**2187-1-15**]


Service: MEDICINE

Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Tetracycline
Analogues

Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
fevers, hypotension

Major Surgical or Invasive Procedure:
intubation
extubation
placement of central line
removal of central line
removal of tunneled HD line and placement of a temporary HD line

removal of temporary HD line and placement of a new tunneled
line

History of Present Illness:
[**Age over 90 **]-year-old female with past medical history of ESRD on HD,
pulmonary hypertension, chronic diastolic heart failure presents
with fevers and respiratory distress.
.
Per notes and history from family, the patient had been doing
well until 5-6 days prior to presentation. At that time the
patient developed a "cough and a cold". They note a
non-productive cough without fevers, chills or night sweats. At
that time she was noted to have "some rhonchi" per HD nurse. The
patient was thought to have a viral URI. Over the last few days
the patient has been feeling worse and has had poor PO intake.
She went to dialysis on the day of presentation and completed
hemodyalysis. Upon returning home she became more lethargic. Her
temperature and SaO2 were checked and were 101.5 and 85% on
room-air, respectively.
.
She presented to the emergency department with initial vitals of
T 101.5, HR 70, BP 133/60, RR 40 and SaO2 92% on NRB. The
patient was intubated for respiratory distress. WBC was 12.3.
CXR showed LLL opacity and patchy right pulmonary opacities.
Given clinical picture the patient was started on vancomycin,
cefepime and levofloxacin. After Versed bolus patient became
hypotensive and was started on levophed with placement of triple
lumen catheter.
.
Currently, the patient is sedated and intubated.
.
Review of Systems: Unable to obtain from patient.


Past Medical History:
- ESRD on T/Th/Sat HD followed by Dr. [**Last Name (STitle) 118**] at [**Location (un) **] [**Location (un) **]

- metastatic breast carcinoma
- afib on coumadin
- tachy/brady syndrome s/p PPM [**2172**]
- chronic diastolic dysfunction with EF 65%, 4+ TR, 2+ MR
- hypothyroidism
- HTN
- anemia (baseline ~34)
- gout
- moderate pulmonary hypertension
- IBS
- h/o diverticulosis
- squamous cell carcinoma of left shin and neck, s/p radiation
in [**2183**]
- "multiple other basal cell and squamous cell carcinomas
treated with surgery"
- Post herpetic neuralgia
- osteoporosous
- h/o right hip fracture requiring total hip replacement in
[**2183-11-1**]
- right inguinal herniorrhaphy in [**2180**]


Social History:
Lives at home in [**Location (un) 10059**]. She has a high school education and
was a businesswoman. She is a widow. She does not smoke and she
does not drink alcohol. She has 24 hour care at home.


Family History:
NC

Physical Exam:
VS: Temp: 99.5 BP: 109/48 HR: 63 RR: 19 O2sat: 100% AC 500 14
FIO2 .50
GEN: sedated, responsive to voice, elderly
HEENT: PERRL, intubated, ETT with some bright red blood, no LAD,
no JVD
Resp: Coarse breath sounds bilateral, anterior exam, bilat
crackles, limited exam
CV: RR, II/VI murmur difficult to hear with vent, S1 and S2 wnl,
no r/g appreciated
ABD: nd, +b/s, soft, no masses or hepatosplenomegaly appreciated
EXT: wwp, cool feet/hands, [**12-3**]+ peripheral edema
SKIN: thin skin with multiple tears, lesion around anus
NEURO: Sedated, pupils as above


Pertinent Results:
LABS ON ADMISSION:
wbc 12.3, hct 37.5, plt 181
na 140, k 5.0, cl 97, hco3 28, bun 18, cr 2.6, gluc 176
lft peak: (3 days after admission) alt 304, ast 719, ldh 707

LABS ON DISCHARGE:
wbc 11.1, hct 34.3, plt 66
na 138, k 5.3, cl 99, hco3 25, bun 82, cr 4.7, gluc 152
lfts alt 17, ast 42, ldh 601, alk phos 103, tbili 0.7

* will attach lab printout for more detail.

Micro:
[**2187-1-15**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-PENDING
[**2187-1-9**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL -[**2187-1-6**] STOOL CLOSTRIDIUM DIFFICILE
TOXIN A & B TEST-FINAL -
[**2187-1-3**] CATHETER TIP-IV WOUND CULTURE-FINAL -
[**2187-1-2**] CATHETER TIP-IV WOUND CULTURE-FINAL -
[**2187-1-2**] CATHETER TIP-IV WOUND CULTURE-FINAL -
[**2187-1-2**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL {STAPH AUREUS COAG +}
      |
CLINDAMYCIN-----------       R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------     1 S
[**2187-1-2**] BLOOD CULTURE Blood Culture, Routine-FINAL
-
[**2187-1-2**] BLOOD CULTURE Blood Culture, Routine-FINAL
-
[**2186-12-29**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL -
[**2186-12-29**] BLOOD CULTURE Blood Culture, Routine-FINAL
-
[**2186-12-29**] BLOOD CULTURE Blood Culture, Routine-FINAL
-
[**2186-12-28**] BLOOD CULTURE Blood Culture, Routine-FINAL
-
[**2186-12-28**] CATHETER TIP-IV WOUND CULTURE-FINAL -
[**2186-12-28**] BLOOD CULTURE Blood Culture, Routine-FINAL
-
[**2186-12-28**] BLOOD CULTURE Blood Culture, Routine-FINAL
-
[**2186-12-27**] BLOOD CULTURE Blood Culture, Routine-FINAL
-[**2186-12-26**] Influenza A/B by DFA DIRECT INFLUENZA A
ANTIGEN TEST-FINAL; DIRECT INFLUENZA B ANTIGEN TEST-FINAL -
[**2186-12-26**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL; LEGIONELLA CULTURE-FINAL -
[**2186-12-26**] BLOOD CULTURE Blood Culture, Routine-FINAL
-
[**2186-12-26**] BLOOD CULTURE Blood Culture, Routine-FINAL
-
[**2186-12-26**] BLOOD CULTURE Blood Culture, Routine-FINAL
-
[**2186-12-26**] BLOOD CULTURE Blood Culture, Routine-FINAL
-
[**2186-12-25**] BLOOD CULTURE Blood Culture, Routine-FINAL
-[**2186-12-25**] BLOOD CULTURE Blood Culture, Routine-FINAL
-

Imaging:
[**1-8**] CXR: NG tube tip is in the stomach. The central venous line
tip is at the proximal right atrium. The pacemaker leads
terminate in the expected location of right atrium and
ventricle. There is no change in the cardiomediastinal
silhouette, left retrocardiac consolidation which in part is
representing atelectasis as well as pulmonary edema. No
pneumothorax is seen.

(Multiple other CXRs for line placement - all similar).

[**12-31**] RUQ u/s: IMPRESSION: Normal gallbladder without stones,
with normal caliber common bile duct.

[**12-29**] CT torso: IMPRESSION:
1. No clear source of the patient's sepsis. Interval bilateral
pleural
effusions with associated atelectasis. No evidence of focal
infiltration to suggest pneumonia.
2. No evidence of intra-abdominal abscess, bowel obstruction or
fluid
collection.
3. Soft tissue mass with lysis of the anterior left acetabulum
as well as
soft tissue mass arising from the right pleura with associated
destruction in the posterolateral right fifth rib.
4. Multiple healed right-sided rib fractures.
5. Punctate, non-obstructing bilateral renal calculi.

[**12-28**] ECHO: Conclusions
The left atrium is mildly dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity is unusually small. Overall
left ventricular systolic function is low normal (LVEF 50%). The
right ventricular free wall is hypertrophied. The right
ventricular cavity is dilated with depressed free wall
contractility. There is abnormal septal motion/position
consistent with right ventricular pressure/volume overload.
There are three aortic valve leaflets. The aortic valve leaflets
are moderately thickened. There is a minimally increased
gradient consistent with minimal aortic valve stenosis. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. There is
severe mitral annular calcification. Trivial mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The left ventricular inflow pattern suggests a restrictive
filling abnormality, with elevated left atrial pressure. The
tricuspid valve leaflets are mildly thickened. The tricuspid
valve leaflets fail to fully coapt. The supporting structures of
the tricuspid valve are thickened/fibrotic. Moderate to severe
[3+] tricuspid regurgitation is seen. [Due to acoustic
shadowing, the severity of tricuspid regurgitation may be
significantly UNDERestimated.] There is moderate pulmonary
artery systolic hypertension. The main pulmonary artery is
dilated. The branch pulmonary arteries are dilated. There is no
pericardial effusion.

[**12-26**] Hip Xray: IMPRESSION: Enlarging metastasis left hemipelvis.

[**12-25**] CXR: IMPRESSION:
1. Low lung volumes. Mild pulmonary vascular congestion and
stable
cardiomegaly.
2. Blunting of the left costophrenic angle is chronic and may be
due to
prominent paracardiac fat pad, although a trace effusion cannot
be entirely excluded.




Brief Hospital Course:
[**Age over 90 **]-year-old female with ESRD on HD, pHTN, dCHF, presents with
fevers, respiratory distress and hypotension of unknown etiology
now resolved, although with persistent delerium.
.
# Hypotension: Unclear etiology. All infectious workup was
negative except for MRSA in a sputum culture.  Pt was initially
on pressors for a prolonged period of time, then was eventually
weaned off of them.  Pt was still requiring vasopressin
especially with dialysis sessions. Pt was emperically treated
with 14 day course of vanc as well as an 8 day course of
Meropenem for pneumonia and question of a line infection. TTE
was performed which showed EF of 50% and no obvious vegetations.
 Pt was started on Hydrocortisone, which was gradually tapered
off.  Pt was also started on Midodrine as well as
Fludricortisone for further BP support.  The fludricotisone was
stopped as she was continuing to retain fluid.  Currently, pt is
normotensive, off all pressors but still taking midodrine TID.
Her BPs range in the 90s-100s, and dip into the 80s during HD.
Pt remains afebrile, with no leukocytosis without signs of
infection.  Her WBC was 11 on discharge, which has been around 9
or 10 since admission, but there are no signs of infection.
.
# Hypoxic respiratory failure: Pt presented to the emergency
department with respiratory distress and was satting 92% on NRB.
The patient was intubated.  Etiology was unclear, pneumonia vs
volume overload.  Pt was dialysed to maintain a euvolemic state.
 Pt was treated emperically for a possible pneumonia with
Vanc/[**Last Name (un) **] though all cultures were negative and CXR without
clear evidence of consolidation.  Pt was eventually extubated
and her respiratory status consistently imrpoved to now only on
2L NC.  She still appears volume overload with peripheral edema,
and HD is trying to remove fluid as blood pressure tolerates.
.
# ESRD: Pt is on hemodialysis as an outpt, followed by Dr.
[**Last Name (STitle) 118**].  Renal followed pt closely and did HD as needed.  Pt was
also on CVVH at times to get fluid off as pt was often fluid
overloaded.  Pt's tunneled HD line was removed though low
suspicion of a line infection.  A temporary HD line was placed,
and a few days later that was removed and a new HD tunneled line
was placed.  All cultures were negative. Pt is currently on a
MWF HD schedule.  She has dialysis [**12-15**] (the day of discharge).
They recommended to consider giving albumin if hypotensive
during dialysis for BP support. She is newly on nephrocaps as a
vitamin supplement.
.
# Diarrhea: Pt had diarrhea, likely secondary to antibiotics.
Tube feeds may have been contributing. There was no evidence of
C. Difficile infection.  The symptoms are gradually improving
with addition of banana flakes in tube feeds, per Nutrition.
She is sensitive to constipation medications and one dose of
senna seemed to have given her diarrhea.  On the day of
discharge, she had a c.diff test pending because of this
diarrhea.  Her WBC were 11, which was only slightly above
baseline.  The c.diff will be back tomorrow which we will follow
up and call [**Hospital 100**] Rehab if it is positive.
.
# Delirium/pain control: Pt was intially sedated while
intubated.  After extubation, pt mental status was slow to
improve.  Gradually though, pt has become more communicative.
This was likely [**1-3**] to prologed ICU stay.  Continue to orient
often, minimize lines, avoid sedating medications.  Pt was on
Buproprion, which was later discontinued as it was giving no
benefit.  Pt was also receiving Zyprexa PRN, which was then
discontinued due to concern that it may be adversly affecting
her mental status.  Pt does get frequent Oxycodone for pain
control, which may be currently contributing to her mental
status.  Her pain is usually in her R breast.  Her family refers
to it as zoster pain, but there is a metastatic breast cancer
mass on the rib in that area, which is likely the cause of the
pain.  [**Female First Name (un) 1634**] was consulted to help manage pain control and
delerium. We put her on standing acetaminophen. We decided to
continue her oxycodone on an as needed basis for now.  It may
need to be increased for comfort if her family tolerates
somewhat increased sedation.  We think delerium will hopefully
clear with time and better sleep cycle.  Of note, on her home
meds, lyrica and her temazepam were stopped to see if her mental
status would improve. It will likely be helpful to seek the aid
of palliative care in the future to help manage pain and keep
balance between pain and the side effects of pain meds.
.
# Thrombocytopenia: Unclear etiology. H2 blocker was
discontinued.  [**Month (only) 116**] have nbeen secondary to vanco.  HIT antibody
was sent and was negative.  Plts now stable with no signs of
bleeding.
.
# Transaminitis: Pt noted to have a rise in her LFTs.  Unclear
etiology. RUQ u/s was negative.  LFTs gradually improved and
have nearly normalized now.  [**Month (only) 116**] have been secondary to mild
shock liver in setting of initial hypotension.
.
# Hyperglycemia: Pt had elevated sugars, especially in the
setting of steroids for her hypotension.  Pt was maintained on
an insulin sliding scale.  Pt was also started on NPH 12 units
qAM, 10units qHS but was weaned down to no standing long acting
insulin.  She is now just on a regular insulin sliding scale.
.
# Nutrition: An NGT was placed and tube feeds were started to
give pt nutrition during this long ICU course.  Pt is tolerating
the tube feeds realtively well with low residuals.  Pt did have
diarrhea, thus banana flakes were added. As pt's mental status
continues to improve, speech and swallow is evaluating pt,
however, most recently recommeded that pt remain NPO for now.
.
# Atrial fibrillation/Tachy/Brady syndrome: Pt was
supratherapeutic on Coumadin intially.  Couamdin was held.  INR
trended down appropriatly and Coumadin was restarted.  Pt was
not bridged as the anti-coagulation was for Afib.  Currently, pt
is on 1.5mg daily.  She is in normal sinus rhythm with heart
rates in the 80s-90s on discharge.  Rate control was not given
because of her low blood pressures.
.
# Chronic diastolic CHF: Pt is getting UF with HD.  No evidence
of heart failure seen in her respiratory status, but is
anasarcic.
.
# Metastatic breast carcinoma: Pt is s/p palliative radiation to
hip, is followed by an oncologist at [**Hospital1 2025**] but currently off
treatment due to GI intolerance.  Hip films on admission showed
enlarged hip metastasis but causing no pain or discomfort
currently.  She also has a rib met seen on CT chest.  Her pain
regimen is with oxycodone as above.
.
# Skin impairments: Pt has very sensitive skin, with multiple
skin tears.  Pt also has a stage II ulcer on coccyx.  Pt also
had an incident of contrast infiltration into left arm, which
she is recovering from.  Pt has appropriate wound care with
dressing changes.  She also has a fungal rash around her
fingernails for which she is on antifungal powder.
.
# Hypothyroidism: we continued her levothyroxine.
.
# Hemorrhoids: bothered her while she was here, was treated with
tucks pads; she had no bleeding problems while here.

Pt was intially full code, however after extubation and after
much discussion with pt's daughter [**Name (NI) **] [**Name (NI) 99825**] (HCP), pt was
made DNR/DNI.  We suggested palliative care briefly to the
family, but they were resistant to having them see her at this
time.

*** ADDENDUM:
The morning after the patient was discharged, the lab called to
report a positive c.diff sample.  [**Hospital 100**] Rehab was contact[**Name (NI) **]
[**12-16**] at 730 am and informed of the results.  Told to call Dr.
[**First Name (STitle) 3441**] back with questions.

Medications on Admission:
albuterol sulfate 2.5 mg/3 mL (0.083 %) neb [**Hospital1 **] PRN
albuterol sulfate [ProAir HFA] 90 mcg HFA Inh 1 puffs inhaled
[**Hospital1 **] prn
Anastrozole (dosage uncertain)
atorvastatin 10 mg PO daily
azithromycin [Zithromax Z-Pak] 250mg PO daily x5 days (500mg on
Day 1)
B complex-vitamin C-folic acid [Renal Caps] 1 mg PO daily
bupropion HCl 75 mg Tablet [**12-3**] tab in AM, [**12-3**] tab at noon PO
daily
calcium acetate 667 mg PO every other day
citalopram 10 mg PO daily
epoetin alfa 40,000 unit inj q two weeks
hydrocortisone acetate 25 mg Suppository [**Hospital1 **] prn hemorrhoids
levothyroxine 50 mcg PO daily
lidocaine 5 % (700 mg/patch) Adhesive Patch 1 daily
nystatin 100,000 apply to rash under breast [**Hospital1 **]
oxycodone 5-10mg liquid PO q4hours
pantoprazole 40 mg PO BID
polyethylene glycol 3350 [Miralax] 100 % Powder 1 tablespoon
Powder(s) by mouth daily
pregabalin [Lyrica] 25 mg Capsule PO 3 days per week
temazepam 15 mg PO qhs
tramadol 25mg PO BID prn pain
warfarin 2 mg PO daily
acetaminophen 650 mg PO TID
ergocalciferol 400 unit PO daily

Discharge Medications:
1. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for chronic pain.
3. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**12-3**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for SOB/wheezing.
5. midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
6. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. triamcinolone acetonide 0.025 % Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day): apply to rash around fingers.
8. oxycodone 5 mg/5 mL Solution Sig: Two (2) ml PO Q2H (every 2
hours) as needed for pain: hold for sedation.
9. therapeutic multivitamin     Liquid Sig: Five (5) ML PO DAILY
(Daily).
10. warfarin 1 mg Tablet Sig: 1.5 Tablets PO Once Daily at 4 PM.

11. ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for fungal rash: appply to rash around
fingernails.
12. pramoxine-mineral oil-zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal PRN (as needed) as needed for pain.
13. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for fungal rash.
14. Normal Saline Flush 0.9 % Syringe Sig: One (1) syringe
Injection PRN as needed for to flush line.
15. insulin regular human 100 unit/mL Solution Sig: One (1) unit
Injection ASDIR (AS DIRECTED): sliding scale is attached.
16. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.

17. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO three
times a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
Primary Diagnosis:
Sepsis
Respiratory Failure
Pneumonia
ESRD on HD
Delerium
Metastatic breast cancer (to rib/hip)
Afib on Coumadin

Secondary diagnosis:
Hypothyroidism
Diastolic CHF
Anemia


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.


Discharge Instructions:
You were admitted to the hospital with low blood pressure and
respiratory distress.  You were treated for pnuemonia and a line
infection with a course of antibiotics.  During your initial
presentation, you required intubation and special medications to
keep your blood pressure up.  Eventually, your breathing
improved and you were able to be extubated.  We changed your
lines to help facilitate improvement of your line infection.
You were getting dialysis while here because of your renal
disease.

You continue to have intermittent low blood pressures.  We tried
oral medications to help you.  We will keep you on midodrine for
this reason.  Dialysis will continue to try to keep getting
excess fluid off as your blood pressure tolerates.

You also continue to have some confusion.  This is likely
related to ICU delerium and all the medications you had that
have sedating side effects.  We are trying to find a balance
between pain control and confusion, and have you on oxycodone
for now.

Other problems included diarrhea, which was likely related to
antibiotics and the tube feeds.  You need to continue the tube
feeds until your swallowing improves.  You also had elevated
liver enzymes, which were likely related to your low blood
pressures.  They were better when you were discharged.  Your
platelets were also low, likely from the acute illness.  They
were stable on discharge.  You also had some sleeping problems.
We had stopped your tempazepam and lyrica because you were too
sleepy at times.

The changes to your medications at this time are:
- stopped lyrica and tempazepam
- stopped wellbutrin
- stopped atorvastatin (because of your liver)
- stopped protonix (because of your platelets)
- changed coumadin from 2 mg to 1.5 mg (your inr was 2.0 on
discharge)
- started insulin for high blood sugars
- started midodrine for low blood pressures


Followup Instructions:
Please follow up with your rehab doctors.  You can make
appointments to see your primary care doctor once you are well
enough to go home after rehab.

Please follow up with the following appointments:
Department: CARDIAC SERVICES
When: TUESDAY [**2187-3-20**] at 3:30 PM
With:  DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: CARDIAC SERVICES
When: TUESDAY [**2187-3-20**] at 4:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage



Completed by:[**2187-1-16**]
{'Unspecified septicemia,Acute respiratory failure,Pneumonia, organism unspecified,End stage renal disease,Toxic encephalopathy,Septic shock,Chronic diastolic heart failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Secondary malignant neoplasm of bone and bone marrow,Intestinal infection due to Clostridium difficile,Do not resuscitate status,Renal dialysis status,Atrial fibrillation,Other chronic pulmonary heart diseases,Unspecified acquired hypothyroidism,Anemia, unspecified,Constipation, unspecified,Pressure ulcer, lower back,Personal history of malignant neoplasm of breast,Cardiac pacemaker in situ,Long-term (current) use of anticoagulants,Foreign body in larynx,Inhalation and ingestion of other object causing obstruction of respiratory tract or suffocation,Accidents occurring in residential institution,Thrombocytopenia, unspecified,Severe sepsis'}


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, hypotension

PRESENT ILLNESS: [**Age over 90 **]-year-old female with past medical history of ESRD on HD,
pulmonary hypertension, chronic diastolic heart failure presents
with fevers and respiratory distress.
.
Per notes and history from family, the patient had been doing
well until 5-6 days prior to presentation. At that time the
patient developed a "cough and a cold". They note a
non-productive cough without fevers, chills or night sweats. At
that time she was noted to have "some rhonchi" per HD nurse. The
patient was thought to have a viral URI. Over the last few days
the patient has been feeling worse and has had poor PO intake.
She went to dialysis on the day of presentation and completed
hemodyalysis. Upon returning home she became more lethargic. Her
temperature and SaO2 were checked and were 101.5 and 85% on
room-air, respectively.
.
She presented to the emergency department with initial vitals of
T 101.5, HR 70, BP 133/60, RR 40 and SaO2 92% on NRB. The
patient was intubated for respiratory distress. WBC was 12.3.
CXR showed LLL opacity and patchy right pulmonary opacities.
Given clinical picture the patient was started on vancomycin,
cefepime and levofloxacin. After Versed bolus patient became
hypotensive and was started on levophed with placement of triple
lumen catheter.
.
Currently, the patient is sedated and intubated.
.
Review of Systems: Unable to obtain from patient.

MEDICAL HISTORY: - ESRD on T/Th/Sat HD followed by Dr. [**Last Name (STitle) 118**] at [**Location (un) **] [**Location (un) **]

MEDICATION ON ADMISSION: albuterol sulfate 2.5 mg/3 mL (0.083 %) neb [**Hospital1 **] PRN
albuterol sulfate [ProAir HFA] 90 mcg HFA Inh 1 puffs inhaled
[**Hospital1 **] prn
Anastrozole (dosage uncertain)
atorvastatin 10 mg PO daily
azithromycin [Zithromax Z-Pak] 250mg PO daily x5 days (500mg on
Day 1)
B complex-vitamin C-folic acid [Renal Caps] 1 mg PO daily
bupropion HCl 75 mg Tablet [**12-3**] tab in AM, [**12-3**] tab at noon PO
daily
calcium acetate 667 mg PO every other day
citalopram 10 mg PO daily
epoetin alfa 40,000 unit inj q two weeks
hydrocortisone acetate 25 mg Suppository [**Hospital1 **] prn hemorrhoids
levothyroxine 50 mcg PO daily
lidocaine 5 % (700 mg/patch) Adhesive Patch 1 daily
nystatin 100,000 apply to rash under breast [**Hospital1 **]
oxycodone 5-10mg liquid PO q4hours
pantoprazole 40 mg PO BID
polyethylene glycol 3350 [Miralax] 100 % Powder 1 tablespoon
Powder(s) by mouth daily
pregabalin [Lyrica] 25 mg Capsule PO 3 days per week
temazepam 15 mg PO qhs
tramadol 25mg PO BID prn pain
warfarin 2 mg PO daily
acetaminophen 650 mg PO TID
ergocalciferol 400 unit PO daily

ALLERGIES: Penicillins / Sulfa (Sulfonamide Antibiotics) / Tetracycline
Analogues

PHYSICAL EXAM: VS: Temp: 99.5 BP: 109/48 HR: 63 RR: 19 O2sat: 100% AC 500 14
FIO2 .50
GEN: sedated, responsive to voice, elderly
HEENT: PERRL, intubated, ETT with some bright red blood, no LAD,
no JVD
Resp: Coarse breath sounds bilateral, anterior exam, bilat
crackles, limited exam
CV: RR, II/VI murmur difficult to hear with vent, S1 and S2 wnl,
no r/g appreciated
ABD: nd, +b/s, soft, no masses or hepatosplenomegaly appreciated
EXT: wwp, cool feet/hands, [**12-3**]+ peripheral edema
SKIN: thin skin with multiple tears, lesion around anus
NEURO: Sedated, pupils as above

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives at home in [**Location (un) 10059**]. She has a high school education and
was a businesswoman. She is a widow. She does not smoke and she
does not drink alcohol. She has 24 hour care at home. 

### Response:
{'Unspecified septicemia,Acute respiratory failure,Pneumonia, organism unspecified,End stage renal disease,Toxic encephalopathy,Septic shock,Chronic diastolic heart failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Secondary malignant neoplasm of bone and bone marrow,Intestinal infection due to Clostridium difficile,Do not resuscitate status,Renal dialysis status,Atrial fibrillation,Other chronic pulmonary heart diseases,Unspecified acquired hypothyroidism,Anemia, unspecified,Constipation, unspecified,Pressure ulcer, lower back,Personal history of malignant neoplasm of breast,Cardiac pacemaker in situ,Long-term (current) use of anticoagulants,Foreign body in larynx,Inhalation and ingestion of other object causing obstruction of respiratory tract or suffocation,Accidents occurring in residential institution,Thrombocytopenia, unspecified,Severe sepsis'}
