CHIEF COMPLAINT: Abdominal pain, diarrhea, found to have C.diff colitis.

PRESENT ILLNESS: Reason for MICU transfer: As per family request transfer from
[**Hospital6 **] MICU to [**Hospital1 18**].
.
History of Present Illness:  56 yo male with pmh significant for
HTN, HLD, alcohol abuse who was transferred from [**Hospital3 **] MICU for c-diff colitis.
.
Most of the information was obtained from family and records, pt
is drowsy. As per patient's family, he developed cough,
nausea/vomiting then diarrhea ~ 1week ago. He did not have
fever, chills or any other symptom. No blood or dark tarry
stools were noted. He had no recent travel, no unsual meals, no
sick contacts; although there is a day care at his work and he
plays with the children at times. He has been drinking 0.5 pint
of vodka or rum daily. He went to his PCP on [**Name9 (PRE) **], [**1-1**] and he
was treated with cipro. As per his family he continued to  have
diarrhea up to 30 episodes per day and he felt very ill. He went
to work, while he was at work he was found to be very pale, and
to be loosing his balance. His co-workers insisted that he went
to the ED. He called his PCP and went to [**Hospital3 **] ED.
.
He was admitted to South on [**1-3**]. His [**Month/Year (2) **] vitals were BP
90/54, HR 94, RR 16, sat 99% on RA. His labs were notable for:
Na 127, K 3.8, Cl 86, CO2 20, BUN of 47, Creat of 8.4, bili of
1.7, AST 181, ALT 57, alk phos 70, albumin of 3.2, and lipase of
160, WBC of 14.3, Hct 37.7, plat 131, CK 1548. His ABG at
[**Month/Year (2) **] 7.3/27/86/15.8. He was also noted to be oliguric. As
per [**Hospital3 **] note, pt was given several liters of fluid
(uncertain on amount) and started on Norepi. Despite fluid
resuscitation, his creatine remained high and UO was low. So, he
had temporary HD line placed and was started on HD. He had 3 L
of fluid removal today. His stool was + for Cdiff toxin and he
was started on Flagyl 500mg IV, vancomycin 250mg PO Q6hours. He
had ID, GI and surgery following him. As per notes he was not a
surgical candidate. His abdomen has become more distended and
his WBC increased from 14->13.2->18.6->21 then to 22K today. He
was also noted to be withdrawing from ETOH with tremors,
anxiety, confusion. As per [**Hospital3 **] notes, his last drink was
the day prior to [**Hospital3 **] on [**2114-12-31**]. He was started on Ativan
with CIWA scale. Prior to his transfer he was getting 2 mg of
Ativan for CIWA of 12.
.
On arrival to the MICU, pt is drowsy but easily arousable to
verbal stimuli. As per nursing staff, he received 2 mg of Ativan
prior to transfer. He appears comfortable. Does not increase
WOB. His abd is [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] and non-tender. He was accompanied
by his sister, who is a RN, and his 2 daughters
.
Review of systems:  As per HPI, pt lethargic and unable to
answer questions.

MEDICAL HISTORY: HTN was on lisinopril, HCTZ
HLD
Obesity
Depression
ETOH abuse

MEDICATION ON ADMISSION: 

ALLERGIES: Penicillins

PHYSICAL EXAM: [**Last Name (Titles) **] PE:
General: Drowsy, but easily arousable by verbal stimuli. He is
mumbling words, in NAD
HEENT: Sclera icteric, MM dry, oropharynx clear, PERRL
Neck: supple, JVP not elevated, no LAD
CV: RR tachy, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, diminished at bases,
no wheezes, rales, ronchi
Abdomen: very distended, tympanic, soft, non-tender, + hyper
active BS,
GU: foley- small amount of dark brown urine
Ext: warm, 2+ pulses, no clubbing, cyanosis, + trace edema
Neuro: Drowsy, easily arousable to verbal stimuli, no following
commands, moving all ext in bed. Mild tremor, no asterix.

FAMILY HISTORY: NC as per family.

SOCIAL HISTORY: Pt lives by himself, currently in a relationship.  His wife died
15 years prior.  He works as a facility manager in [**Hospital3 **].
He has 2 daughters. [**Name (NI) **] drinks 0.5 pints of vodka/rum per day (as
per family, he told the ED doctor [**First Name (Titles) **] [**Last Name (Titles) **]). Last drink was
prior to [**Last Name (Titles) **]. He does not smoke and as per family he does
not use any drugs.
Unspecified septicemia,Septic shock,Acute kidney failure with lesion of tubular necrosis,Acute and subacute necrosis of liver,Intestinal infection due to Clostridium difficile,Severe sepsis,Unspecified essential hypertension,Thrombocytopenia, unspecified,Alcohol abuse, unspecified,Other and unspecified hyperlipidemia
Septicemia NOS,Septic shock,Ac kidny fail, tubr necr,Acute necrosis of liver,Int inf clstrdium dfcile,Severe sepsis,Hypertension NOS,Thrombocytopenia NOS,Alcohol abuse-unspec,Hyperlipidemia NEC/NOS
[** **] Date:  [**2115-1-7**]              Discharge Date:   [**2115-1-23**]

Date of Birth:  [**2058-4-23**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Abdominal pain, diarrhea, found to have C.diff colitis.

Major Surgical or Invasive Procedure:
Hemodialysis x 3 sessions.
Tunneled line removal.
PICC line removal.


History of Present Illness:
Reason for MICU transfer: As per family request transfer from
[**Hospital6 **] MICU to [**Hospital1 18**].
.
History of Present Illness:  56 yo male with pmh significant for
HTN, HLD, alcohol abuse who was transferred from [**Hospital3 **] MICU for c-diff colitis.
.
Most of the information was obtained from family and records, pt
is drowsy. As per patient's family, he developed cough,
nausea/vomiting then diarrhea ~ 1week ago. He did not have
fever, chills or any other symptom. No blood or dark tarry
stools were noted. He had no recent travel, no unsual meals, no
sick contacts; although there is a day care at his work and he
plays with the children at times. He has been drinking 0.5 pint
of vodka or rum daily. He went to his PCP on [**Name9 (PRE) **], [**1-1**] and he
was treated with cipro. As per his family he continued to  have
diarrhea up to 30 episodes per day and he felt very ill. He went
to work, while he was at work he was found to be very pale, and
to be loosing his balance. His co-workers insisted that he went
to the ED. He called his PCP and went to [**Hospital3 **] ED.
.
He was admitted to South on [**1-3**]. His [**Month/Year (2) **] vitals were BP
90/54, HR 94, RR 16, sat 99% on RA. His labs were notable for:
Na 127, K 3.8, Cl 86, CO2 20, BUN of 47, Creat of 8.4, bili of
1.7, AST 181, ALT 57, alk phos 70, albumin of 3.2, and lipase of
160, WBC of 14.3, Hct 37.7, plat 131, CK 1548. His ABG at
[**Month/Year (2) **] 7.3/27/86/15.8. He was also noted to be oliguric. As
per [**Hospital3 **] note, pt was given several liters of fluid
(uncertain on amount) and started on Norepi. Despite fluid
resuscitation, his creatine remained high and UO was low. So, he
had temporary HD line placed and was started on HD. He had 3 L
of fluid removal today. His stool was + for Cdiff toxin and he
was started on Flagyl 500mg IV, vancomycin 250mg PO Q6hours. He
had ID, GI and surgery following him. As per notes he was not a
surgical candidate. His abdomen has become more distended and
his WBC increased from 14->13.2->18.6->21 then to 22K today. He
was also noted to be withdrawing from ETOH with tremors,
anxiety, confusion. As per [**Hospital3 **] notes, his last drink was
the day prior to [**Hospital3 **] on [**2114-12-31**]. He was started on Ativan
with CIWA scale. Prior to his transfer he was getting 2 mg of
Ativan for CIWA of 12.
.
On arrival to the MICU, pt is drowsy but easily arousable to
verbal stimuli. As per nursing staff, he received 2 mg of Ativan
prior to transfer. He appears comfortable. Does not increase
WOB. His abd is [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] and non-tender. He was accompanied
by his sister, who is a RN, and his 2 daughters
.
Review of systems:  As per HPI, pt lethargic and unable to
answer questions.

Past Medical History:
HTN was on lisinopril, HCTZ
HLD
Obesity
Depression
ETOH abuse


Social History:
Pt lives by himself, currently in a relationship.  His wife died
15 years prior.  He works as a facility manager in [**Hospital3 **].
He has 2 daughters. [**Name (NI) **] drinks 0.5 pints of vodka/rum per day (as
per family, he told the ED doctor [**First Name (Titles) **] [**Last Name (Titles) **]). Last drink was
prior to [**Last Name (Titles) **]. He does not smoke and as per family he does
not use any drugs.


Family History:
NC as per family.

Physical Exam:
[**Last Name (Titles) **] PE:
General: Drowsy, but easily arousable by verbal stimuli. He is
mumbling words, in NAD
HEENT: Sclera icteric, MM dry, oropharynx clear, PERRL
Neck: supple, JVP not elevated, no LAD
CV: RR tachy, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, diminished at bases,
no wheezes, rales, ronchi
Abdomen: very distended, tympanic, soft, non-tender, + hyper
active BS,
GU: foley- small amount of dark brown urine
Ext: warm, 2+ pulses, no clubbing, cyanosis, + trace edema
Neuro: Drowsy, easily arousable to verbal stimuli, no following
commands, moving all ext in bed. Mild tremor, no asterix.

DISCHARGE PE:
General: alert and oriented in NAD
HEENT: Sclera icteric, PERRL, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: CTAB, no wheezes, rales, ronchi
Abdomen: +BS, soft, NT, ND
Ext: warm, 2+ pulses, no clubbing, cyanosis, + trace edema

Pertinent Results:
[**Hospital **] HOSPITAL LABS: Na 127, K 3.8, Cl 86, CO2 20, BUN of 47,
Creat of 8.4, bili of 1.7, AST 181, ALT 57, alk phos 70, albumin
of 3.2, and lipase of 160, WBC of 14.3, Hct 37.7, plat 131, CK
1548. His ABG at [**Hospital **] 7.3/27/86/15.8. PT 15.5/INR 1.2/PTT
47.4

[**Hospital **] LABS:
[**2115-1-7**] 06:04PM BLOOD WBC-21.8* RBC-3.54* Hgb-11.8* Hct-36.2*
MCV-102* MCH-33.3* MCHC-32.7 RDW-15.4 Plt Ct-231
[**2115-1-7**] 06:04PM BLOOD Neuts-87.1* Lymphs-8.6* Monos-2.7 Eos-1.4
Baso-0.3
[**2115-1-10**] 04:42AM BLOOD Hypochr-OCCASIONAL Anisocy-1+
Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL Tear
Dr[**Last Name (STitle) **]1+
[**2115-1-7**] 06:04PM BLOOD PT-13.4* PTT-71.0* INR(PT)-1.2*
[**2115-1-7**] 06:04PM BLOOD Glucose-126* UreaN-30* Creat-5.3* Na-143
K-3.6 Cl-106 HCO3-26 AnGap-15
[**2115-1-7**] 06:04PM BLOOD ALT-88* AST-238* CK(CPK)-97 AlkPhos-177*
TotBili-1.6*
[**2115-1-7**] 06:04PM BLOOD Lipase-295*
[**2115-1-7**] 06:04PM BLOOD Albumin-2.9* Calcium-7.8* Phos-3.7 Mg-2.0
[**2115-1-8**] 03:09PM BLOOD Triglyc-65
[**2115-1-8**] 12:00AM BLOOD Type-ART pO2-103 pCO2-47* pH-7.32*
calTCO2-25 Base XS--2
[**2115-1-7**] 06:17PM BLOOD Lactate-1.5

LABS PRIOR TO DISCHARGE:
[**2115-1-23**] 04:56AM BLOOD WBC-10.5 RBC-2.52* Hgb-8.4* Hct-25.5*
MCV-101* MCH-33.4* MCHC-33.0 RDW-14.9 Plt Ct-314
[**2115-1-15**] 10:20AM BLOOD Neuts-83.2* Lymphs-9.9* Monos-4.9 Eos-1.2
Baso-0.8
[**2115-1-10**] 04:42AM BLOOD Neuts-86* Bands-11* Lymphs-2* Monos-0
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2115-1-23**] 04:56AM BLOOD PT-13.5* PTT-39.6* INR(PT)-1.3*
[**2115-1-23**] 04:56AM BLOOD Glucose-87 UreaN-8 Creat-0.7 Na-138 K-4.0
Cl-109* HCO3-23 AnGap-10
[**2115-1-23**] 04:56AM BLOOD ALT-92* AST-155* AlkPhos-115 TotBili-1.3
[**2115-1-21**] 06:02AM BLOOD ALT-114* AST-168* AlkPhos-140*
TotBili-1.2
[**2115-1-18**] 05:36AM BLOOD ALT-145* AST-223* AlkPhos-193*
TotBili-2.5*
[**2115-1-13**] 04:33AM BLOOD ALT-43* AST-103* LD(LDH)-361*
AlkPhos-142* TotBili-1.6* DirBili-0.9* IndBili-0.7
[**2115-1-23**] 04:56AM BLOOD Calcium-8.0* Phos-3.6 Mg-1.6
[**2115-1-8**] 09:36AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2115-1-8**] 09:36AM BLOOD HCV Ab-NEGATIVE
[**2115-1-14**] 06:30AM BLOOD HEPARIN DEPENDENT ANTIBODIES-

MICRO:
[**2115-1-10**] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER
CULTURE-FINAL; CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
[**2115-1-10**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2115-1-10**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2115-1-8**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2115-1-7**] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER
CULTURE-FINAL; CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
[**2115-1-7**] MRSA SCREEN MRSA SCREEN-FINAL
[**2115-1-7**] BLOOD CULTURE Blood Culture, Routine-FINAL

IMAGING:
[**2115-1-7**] CXR:  In comparison with the earlier study of this date,
there are
continued low lung volumes. Increased opacification at the left
base is
consistent with atelectasis and effusion. In the appropriate
clinical
setting, the possibility of supervening pneumonia would have to
be considered. Right IJ catheter tip is in the region of the
cavoatrial junction.  Nasogastric tube extends well into the
stomach.

[**2115-1-7**] KUB:  A nasogastric tube terminates in the distal
stomach or proximal duodenum. There is no free gas or
pneumatosis. There are multiple prominent air-filled loops of
small bowel throughout the central abdomen, findings which
suggest ileus. There is no non-surgical radiopaque
foreign body or soft tissue calcifications. Remnant barium is
present within the ascending colon.

[**2115-1-7**] RUQ U/S: Evaluation is limited due to body habitus.  The
liver is echogenic due to which may be due to fatty
infiltration. There are no focal hepatic lesions. There is no
intra- or extra-hepatic biliary
dilatation with the common bile duct measuring 3 mm. Small
amount of
perihepatic free fluid. The gallbladder is normal without
evidence of stones. The partially visualized right kidney is
normal. There is small amount of free fluid in the right lower
quadrant. The portal vein is patent. IMPRESSION: 1. Echogenic
liver may relate to fatty infiltration; other forms of more
advanced liver disease such as cirrhosis/fibrosis not excluded
on this study 2. No evidence of gallstones or acute
cholecystitis. 3. Small amount of free fluid.

[**2115-1-8**] TTE: The left atrium and right atrium are normal in
cavity size. Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion. IMPRESSION:
Normal global and regional biventricular systolic function. Mild
pulmonary Hypertension.

[**2115-1-8**] CT ABD/PELVIS: 1. Diffuse thickening and edema of the
large colon which would be in keeping with Clostridium difficile
colitis.
2. Moderate amount of intra-abdominal ascites. 3.
Hepatosteatosis with focal areas of increased fat deposition. 4.
Small bilateral pleural effusions with overlying left-sided
compressive atelectasis. 5. Gastric varices.

[**2115-1-12**] CT ABD/PELVIS: 1. Pancolitis with associated moderate
intra-abdominal and intrapelvic ascites. The overall appearance
is unchanged since the [**2115-1-8**] CT examination. No focal
collections or abscesses are detected. 2. Hypoenhancing right
hepatic lesion, which may reflect focal hepatic steatosis, but a
primary mass such as HCC cannot be excluded on this single-phase
study. Non-urgent evaluation with contrast-enhanced MRI or
multiphasic CT is recommended.  3. Small bilateral pleural
effusions, with adjacent compressive atelectasis. 4. Perigastric
and perisplenic varices.

[**2115-1-16**] CXR: In comparison with the study of [**1-10**], the
hemodialysis catheter has been removed and replaced by a right
subclavian PICC line that extends to the mid portion of the SVC.
The opacification at the left base has essentially cleared with
minimal residual atelectasis and blunting of the costophrenic
angle. The right base is essentially clear and there is no
evidence of vascular congestion.

Brief Hospital Course:
56 yo male with hx of HTN, HL, obesity, and ETOH abuse who
presented to OHS 4 days ago on [**1-3**] for nausea, vomiting, and
diarrhea and was found to be have [**Last Name (un) **] with anuria, and severe
c.diff colitis, transferred to [**Hospital1 18**] for further management.
.
# C.Diff Colitis: Risk factor was two days of cipro prior for a
GI bug prior to [**Hospital1 **].  Stool studies were not sent during
his GI bug.  He presented to the OSH with septic shock requiring
fluid and pressors, which were weaned off in 2 days.  His
abdomen was very distended at presentation, however it was soft
and non-tender.  His KUB showed dilated loops of bowel with air
fluid levels, but no free air.  Upon arrival to [**Hospital1 18**], his
vancomycin PO was increased from 250mg to 500mg, IV flagyl was
continued, and vancomycin enemas were started given concern for
decreased gut motility.  His white count continued to trend up
so flagyl was stopped and he was switched to tigecycline.
General surgery was also consulted but they did not recommend
surgery.  He had an NG tube placed which was draining bilous
drainage. He had negative stool cultures here. He had 1 + cdiff
PCR at the OHS.  He was improving clinically, but his WBC
continued to trend up peaking at 29K. ID recommended stopping
the Tigecycline since it could be affecting his gut flora. Po
and PR vancomycin were continued with recs to hold NG tube
suction for 1.5hours after. Fecal transplant was discussed, but
this was not pursued given patient's clinical improvement. He
had a repeat CT abd/pelvis that continued to show pancolitis
with associated moderate intraabdominal and intrapelvic ascites.
 His lactate was never elevated.  He required three HD sessions
at the OSH and three here at [**Hospital1 18**], then his Cr remained at or
below 1.0 since [**2115-1-19**].  IR removed his tunneled line.  He was
continued on vancomycin 500mg po q6hr until [**2115-1-22**] when the
dose was decreased to 125mg po q6hr, given literature showing
its equivalence.  His loose stools became more formed prior to
discharge, with fiber supplementation and BRAT diet.  Hygiene
and safety precautions to prevent cdiff infection were reviewed
with him prior to discharge.  He was also strongly encouraged to
take Florastor with any future course of antibiotics.
.
# Lower Extremity Swelling: Mr. [**Known lastname **] developed 3+ lower
extremity edema secondary to fluid resuscitation while in the
MICU.  He was started on Lasix 40mg po daily when his Cr fell
below 1.0.  His weight was 110.4kg on discharge with only trace
lower extremity edema.  His weight prior to [**Known lastname **] was 104kg.
.
# [**Last Name (un) **]: Presented with acute renal failure compliated by anuria.
This was likely secondary to poor renal perfusion from
hypovolemia secondary to diarrhea and hypotension secondary to
septic shock.  As per [**Hospital6 33**] notes, he received HD
3 times, most recently done on the day of transfer with 3L fluid
removal.  he had three sessions of HD at [**Hospital1 18**]. He was started
on CVVH and his renal fucntion started to improve.  He was given
lasix as above. Cr remained below 1.0 since [**2115-1-19**].
.
# Elevated LFT's, hypoalbuminemia, elevated INR: Patient has
been a heavy drinker for many years.  His elevated LFT's were
initally thought to be secondary to alcoholic hepatitis with a
discriminant function of 6.  US of liver/gallbladder showed
echogenic liver potentially related to fatty infiltration; but
could not exclude more advanced liver disease with cirrhosis or
fibrosis. His LFTs have been trending down but still not WNL,
and his synthetic function was also abnormal with elevated INR
and low albumin.  Hepatitis serologies were negative.  More
likely to explain his LFT's were his cdiff pancolitis infection.
 His elevated bili during this infection and findings of gastric
and splenic varices raise concern for cirrhosis.  He needs
outpatient follow up with liver for a liver biopsy.  He should
also be vaccinated against hepatitis A and B as an outpatient.
.
#Hypoenhancing right hepatic lesion: Found on CT abd/pelvis
which showed a hypoenhanncing hepatic lesion which may reflect
focal hepatic steatosis, but a primary mass such as HCC cannot
be excluded on this single-phase study. Non-urgent evaluation
with contrast-enhanced MRI or multiphasic CT is recommended,
particularly in the setting of alcohol abuse and potential
cirrhosis.
.
#Hypertension: Typically hypertensive, but was hypotensive
during [**Month/Day/Year **] with improvement to systolic 110s while on
lasix during last day of hospitalization.  His home
hydrochlorothiazide and lisinopril have been held.  These
medications will be restarted pending his outpatient pcp
[**Name Initial (PRE) 2742**].
.
#Thrombocytopenia:  Likely related to sepsis, but with concern
for cirrhosis this etiology must be ruled out.  Thrombocytopenia
resolved prior to discharge.
.
# ETOH abuse: Patient's last drink was on [**12-31**], the day prior
to hospitalization. [**Doctor Last Name 4866**] on 12 on CIWA at [**Doctor Last Name **] on
lorazepan 1-2mg IV. He did not withdraw.  Social work was
consulted. He has no desire to join AA but is amenable to
outpatient social work services for alcohol abuse.  These
resources were provided to him, as well as a list of AA meetings
in his area.
.
#Transitional Issues:
-Outpatient follow up with PCP
[**Name10 (NameIs) **] biopsy to rule out cirrhosis
-Contrast-enhanced MRI or multiphasic CT to rule out HCC
-Florastor for any future course of abx
-Code Status: Full Code (Confirmed)
-Contact: Daughter, [**First Name8 (NamePattern2) **] [**Name (NI) **], is his health care proxy:
[**Telephone/Fax (1) 91841**]/cell: [**Telephone/Fax (1) 91842**].  Sister, [**Name (NI) **] [**Name (NI) 438**]:
[**Telephone/Fax (1) 91843**].

Medications on [**Telephone/Fax (1) **]:
HCTZ 25mg once daily
Simvastatin 40mg Qday
Lisinopril 20mg
ASA 81mg daily


Discharge Medications:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
3. psyllium 1.7 g Wafer Sig: One (1) wafer PO DAILY (Daily) as
needed for diarrhea.
Disp:*15 wafers* Refills:*0*
4. Outpatient Lab Work
Please have CBC, Chem 7, and LFT's checked on Friday, [**1-25**], [**2114**].  Please have these faxed to Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 17664**].
5. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 22 doses.
Disp:*22 Capsule(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital3 **] VNA

Discharge Diagnosis:
Primary Diagnosis:
Clostridium Difficile Colitis
Septic shock
Anuric renal failure requiring hemodialysis

Secondary Diagnosis:
Hypertension
Hyperlipidemia
Alcohol Abuse


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Weight at discharge: 110.4 kg


Discharge Instructions:
It was a pleasure to take care of you here at the [**Hospital3 **]
[**Hospital 1225**] Medical Center.

You presented to an outside hospital after having had multiple
episodes of watery diarrhea, fevers, chills, and dehydration.
You were diagnosed with an infection called clostridium
difficile (C.diff) infection that caused low blood pressures.
Your kidneys also failed and you required several sessions of
dialysis - thankfully they recovered by themselves. You will
complete a 21 day course of vancomycin to treat your infection.

You may get this infection again.  Antibiotics make you at
higher risk for Cdiff infection.  Next time you take
antibiotics, you should also take the probiotic Florastor with
your antibiotic to help prevent repeat infection.  In addition,
warning signs of reinfection include fever, chills, abdominal
pain, diarrhea.  Please seek medical attention as soon as you
recognize any of these symptoms.  In order to prevent
reinfection or spread of infection, wash your hands after every
bathroom trip and before every meal.  Bathrooms that are shared
should be cleaned with diluted bleach.

While you were here you were seen by social to address your
alcoholism.  We encourage you to stop drinking alcohol
completely.  It was recommended that you seek out patient
treatment at one of the following out patient programs.  Please
call to make an intake appointment when you are ready to do so.

North River Counseling Inc
[**Street Address(2) 91844**]. [**Location (un) 17927**] [**Numeric Identifier 91845**]
[**Telephone/Fax (1) 91846**]

[**Hospital1 **]
[**Location (un) 91847**] [**Apartment Address(1) **]
[**Hospital1 392**] MA
[**Telephone/Fax (1) 91848**]

We have also provided you with a list of AA meetings if you
would like to participate.

If you have any questions or need further help please contact
the social worker you saw while you were here: [**Name (NI) 636**] [**Last Name (NamePattern1) 12471**],
LICSW [**Telephone/Fax (1) 57081**].

The following changes were made to your medication list:
START Vancomycin 125mg four times a day until [**2115-1-28**]
HOLD Hydrochlorothiazide and Lisinopril.  Your PCP may [**Name9 (PRE) **]
these medications at your next visit.
START psyllium wafers or fiber supplement at home to bulk up
your stools

Followup Instructions:
Please attend the following appointments:

Name: NP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**]
Location: [**Hospital3 **] MEDICAL CENTER
Address: [**State **]., [**Location (un) **],[**Numeric Identifier 85712**]
Phone: [**Telephone/Fax (1) 17663**]
Appointment: Friday [**2115-1-25**] 10:45am
*This is a follow up appointment for your hospitalization. You
will be reconnected with primary care physician after this
visit.
{'Unspecified septicemia,Septic shock,Acute kidney failure with lesion of tubular necrosis,Acute and subacute necrosis of liver,Intestinal infection due to Clostridium difficile,Severe sepsis,Unspecified essential hypertension,Thrombocytopenia, unspecified,Alcohol abuse, unspecified,Other and unspecified hyperlipidemia'}


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



### Clinical text :
CHIEF COMPLAINT: Abdominal pain, diarrhea, found to have C.diff colitis.

PRESENT ILLNESS: Reason for MICU transfer: As per family request transfer from
[**Hospital6 **] MICU to [**Hospital1 18**].
.
History of Present Illness:  56 yo male with pmh significant for
HTN, HLD, alcohol abuse who was transferred from [**Hospital3 **] MICU for c-diff colitis.
.
Most of the information was obtained from family and records, pt
is drowsy. As per patient's family, he developed cough,
nausea/vomiting then diarrhea ~ 1week ago. He did not have
fever, chills or any other symptom. No blood or dark tarry
stools were noted. He had no recent travel, no unsual meals, no
sick contacts; although there is a day care at his work and he
plays with the children at times. He has been drinking 0.5 pint
of vodka or rum daily. He went to his PCP on [**Name9 (PRE) **], [**1-1**] and he
was treated with cipro. As per his family he continued to  have
diarrhea up to 30 episodes per day and he felt very ill. He went
to work, while he was at work he was found to be very pale, and
to be loosing his balance. His co-workers insisted that he went
to the ED. He called his PCP and went to [**Hospital3 **] ED.
.
He was admitted to South on [**1-3**]. His [**Month/Year (2) **] vitals were BP
90/54, HR 94, RR 16, sat 99% on RA. His labs were notable for:
Na 127, K 3.8, Cl 86, CO2 20, BUN of 47, Creat of 8.4, bili of
1.7, AST 181, ALT 57, alk phos 70, albumin of 3.2, and lipase of
160, WBC of 14.3, Hct 37.7, plat 131, CK 1548. His ABG at
[**Month/Year (2) **] 7.3/27/86/15.8. He was also noted to be oliguric. As
per [**Hospital3 **] note, pt was given several liters of fluid
(uncertain on amount) and started on Norepi. Despite fluid
resuscitation, his creatine remained high and UO was low. So, he
had temporary HD line placed and was started on HD. He had 3 L
of fluid removal today. His stool was + for Cdiff toxin and he
was started on Flagyl 500mg IV, vancomycin 250mg PO Q6hours. He
had ID, GI and surgery following him. As per notes he was not a
surgical candidate. His abdomen has become more distended and
his WBC increased from 14->13.2->18.6->21 then to 22K today. He
was also noted to be withdrawing from ETOH with tremors,
anxiety, confusion. As per [**Hospital3 **] notes, his last drink was
the day prior to [**Hospital3 **] on [**2114-12-31**]. He was started on Ativan
with CIWA scale. Prior to his transfer he was getting 2 mg of
Ativan for CIWA of 12.
.
On arrival to the MICU, pt is drowsy but easily arousable to
verbal stimuli. As per nursing staff, he received 2 mg of Ativan
prior to transfer. He appears comfortable. Does not increase
WOB. His abd is [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] and non-tender. He was accompanied
by his sister, who is a RN, and his 2 daughters
.
Review of systems:  As per HPI, pt lethargic and unable to
answer questions.

MEDICAL HISTORY: HTN was on lisinopril, HCTZ
HLD
Obesity
Depression
ETOH abuse

MEDICATION ON ADMISSION: 

ALLERGIES: Penicillins

PHYSICAL EXAM: [**Last Name (Titles) **] PE:
General: Drowsy, but easily arousable by verbal stimuli. He is
mumbling words, in NAD
HEENT: Sclera icteric, MM dry, oropharynx clear, PERRL
Neck: supple, JVP not elevated, no LAD
CV: RR tachy, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, diminished at bases,
no wheezes, rales, ronchi
Abdomen: very distended, tympanic, soft, non-tender, + hyper
active BS,
GU: foley- small amount of dark brown urine
Ext: warm, 2+ pulses, no clubbing, cyanosis, + trace edema
Neuro: Drowsy, easily arousable to verbal stimuli, no following
commands, moving all ext in bed. Mild tremor, no asterix.

FAMILY HISTORY: NC as per family.

SOCIAL HISTORY: Pt lives by himself, currently in a relationship.  His wife died
15 years prior.  He works as a facility manager in [**Hospital3 **].
He has 2 daughters. [**Name (NI) **] drinks 0.5 pints of vodka/rum per day (as
per family, he told the ED doctor [**First Name (Titles) **] [**Last Name (Titles) **]). Last drink was
prior to [**Last Name (Titles) **]. He does not smoke and as per family he does
not use any drugs. 

### Response:
{'Unspecified septicemia,Septic shock,Acute kidney failure with lesion of tubular necrosis,Acute and subacute necrosis of liver,Intestinal infection due to Clostridium difficile,Severe sepsis,Unspecified essential hypertension,Thrombocytopenia, unspecified,Alcohol abuse, unspecified,Other and unspecified hyperlipidemia'}
