CHIEF COMPLAINT: Lehargy/Weakness/Fever

PRESENT ILLNESS: 78 y/o Chinese male with ESRD, HTN, Afib, recently in a nursing
home after found to have T12 compression fracture, presents from
his nursing home with lethargy and weakness with fever on
[**2112-12-3**]. Pt presented to ED with fever and hypotension, and was
found to have bandemia of 17% with no clear source of infection.
He was initially empirically treated broadly with Ceftazadime
and vancomycin which was transitioned to unasyn and vancomycin
on admission to the ICU with the addition of steroids given
septic clinical picture.  A central line was placed and he was
given 3L NS prior to transfer to the ICU with improvement in BP
not requiring pressors.
.
Blood cx on [**12-3**] grew pansensative E. coli with no clear source
as UA was clear, CXR revealed no infiltrate and line site looked
clean. Steroids were not continued since [**Last Name (un) **] stim test was
negative. Antibiotics were weaned to Unasyn alone given only e.
coli grew in the blood cultures and follow-up cultures have been
negative with bandemia and fever resolved.
.
Pt had a mildly elevated Alk phos and GGT on admission so RUQ US
was obtained to look for a source of the GNR bactermia but there
were no signs of biliary obstruction or cholecystitis.  CT
abd/pelvis to r/o abdominal process as source of GNR bacteremia
was obtained which revealed ? ascending colitis.  Repeat imaging
then demonstrated ?transverse and left sided colitis could not
be excluded, thus colitis may represent his source of blood
seeding.
.
During his course on the floor, he was found to have a right
common femoral DVT.  He was transiently on heparin gtt, but
developed guaiac + stools and hematocrit drop requiring
transfusions with prbc x2.  Records from [**Hospital1 336**] reveal that he has
a h/o GI bleed from likely AVM source in past.  Heparin was
discontinued, GI was consulted and an IVC filter was placed.
.
78 year-old male with end-stage renal disease on hemodialysis,
hypertension, paroxysmal atrial fibrillation recently in a
nursing home because of a T12 compression fracture, presenting
from his nursing home with lethargy and weakness, decreased
appetite for several days with temperature to 101.
.
The patient's temperature was 103 rectally in the emergency
department. The patient was initially hypotensive to 82/40.
Laboratories were significant for lactate 2.7, 17% bandemia. A
right internal jugular central line was placed. The patient was
given three liters normal saline with improvement in systolic
blood pressures to 100s. Blood and urine cultures were sent and
he patient was started on Vancomycin and Ceftazidine. The
patient was initially given decadron as he had been recently on
prednisone. Head CT which showed a "hyperdense convexity along
the right frontal lobe measuring 3 mm thick which most likely
represents a small acute subdural hemorrhage."  Neurosurgery was
consulted, who stated that "there was a bone averaging at the
right frontal scull. No SDH."  Felt to be no neurosurgical
issue, transferred to MICU for further medical care.
.
On arrival to MICU, patient was normotensive to 124/75 with
heart rate 60. 2/2 blood culture bottles from admission grew
gram-negative rods. The source of the bacteremia was unclear.
Urinalysis and urine culture were negative. Chest X-ray was
negative for infection. Right upper quadrant ultrasound was
performed as the patient had elevated alkaline phosphatase and
GGT and showed no acute abdnormalities. Vancomycin and
Ceftazidine were discontinued and the patient was transferred to
the floor on Unasyn pending culture speciation.

MEDICAL HISTORY: 1. End-stage renal disease on dialysis (MoWeFr) via left-sided
AV fistula
2. Hypertension
3. Atrial fibrillation
4. Hypothyroidism
5. Anemia
6. Recent T12 compression fracture

MEDICATION ON ADMISSION: Amiodarone 200mg daily
Hydroxyzine 2.5mg daily
CaCO2 500g daily
Levothyroxine 100mcg daily
Isosorbide 30mg daily
Heparin SQ 5000 unit tid
Cacitriol 0.5mcg qweek (fri)
Lipitor 20mg daily
Toprol XL 25mg daily
Vitamin E 400 units daily
Nephrocaps 1mg daily
Prednisone 5mg daily
Duralgesic patch 50 mcg q72hrs to R chest
Megace ES 625/3 qd
Renagel 800mg tid with meals
Remeron 15mg qHS

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VITALS:  Temp 96.5, HR 60, BP 128/64, RR 14, O2 sat 98% on RA,
CVP 9-10.
GENERAL:  chinese male, comfortable appearing, lying in bed,
awake, interactive, confused.  Oriented to self, but not place
or time.
HEENT:  anicteric, mucous membranes dry
CHEST:  CTA b/l
HEART:  RRR nl s1, s2, II/VI SEM at LUSB
ABD:  +BS, soft, NT, ND, no guarding or rebound
EXT:  no edema, L arm AV fistula
NEURO:  CN II-XII intact, moves all extremities with 5/5
strength.

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: The patient is living at [**Hospital **] Health Center nursing home
after recent T12 fracture. The patient has a son living in the
area.
Bacteremia,End stage renal disease,Atrial fibrillation,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Pathologic fracture of vertebrae,Angiodysplasia of intestine with hemorrhage,Thrombocytopenia, unspecified,Hematoma complicating a procedure,Acute posthemorrhagic anemia,Unspecified acquired hypothyroidism,Other specified disorders of liver,Delirium due to conditions classified elsewhere
Bacteremia,End stage renal disease,Atrial fibrillation,Ac DVT/emb prox low ext,Path fx vertebrae,Angio intes w hmrhg,Thrombocytopenia NOS,Hematoma complic proc,Ac posthemorrhag anemia,Hypothyroidism NOS,Liver disorders NEC,Delirium d/t other cond
Name:  [**Known lastname 6291**],[**Known firstname 6320**] N.                   Unit No:   [**Numeric Identifier 6321**]

Admission Date:  [**2112-12-3**]              Discharge Date:   [**2113-1-3**]

Date of Birth:  [**2034-11-12**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 803**]
Addendum:
Patient is not being discharged on Dexamethasone. Please remove
from discharge summary.

Discharge Disposition:
Extended Care

Facility:
[**Hospital6 41**] - [**Location (un) 42**]

                             [**First Name11 (Name Pattern1) 153**] [**Last Name (NamePattern1) 811**] MD [**MD Number(2) 812**]

Completed by:[**2113-1-3**]

Admission Date:  [**2112-12-3**]              Discharge Date:   [**2113-1-3**]

Date of Birth:  [**2034-11-12**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
Lehargy/Weakness/Fever

Major Surgical or Invasive Procedure:
[**2112-12-20**]
1.  T12 transpedicular decompression of burst fracture and
    spinal cord compression.
2.  Harvest of bone marrow aspirate, right posterior superior
    iliac crest.
3.  Posterolateral arthrodesis T10-L2.
4.  Pedicle screw instrumentation segmental from T10-L2.


History of Present Illness:
78 y/o Chinese male with ESRD, HTN, Afib, recently in a nursing
home after found to have T12 compression fracture, presents from
his nursing home with lethargy and weakness with fever on
[**2112-12-3**]. Pt presented to ED with fever and hypotension, and was
found to have bandemia of 17% with no clear source of infection.
He was initially empirically treated broadly with Ceftazadime
and vancomycin which was transitioned to unasyn and vancomycin
on admission to the ICU with the addition of steroids given
septic clinical picture.  A central line was placed and he was
given 3L NS prior to transfer to the ICU with improvement in BP
not requiring pressors.
.
Blood cx on [**12-3**] grew pansensative E. coli with no clear source
as UA was clear, CXR revealed no infiltrate and line site looked
clean. Steroids were not continued since [**Last Name (un) **] stim test was
negative. Antibiotics were weaned to Unasyn alone given only e.
coli grew in the blood cultures and follow-up cultures have been
negative with bandemia and fever resolved.
.
Pt had a mildly elevated Alk phos and GGT on admission so RUQ US
was obtained to look for a source of the GNR bactermia but there
were no signs of biliary obstruction or cholecystitis.  CT
abd/pelvis to r/o abdominal process as source of GNR bacteremia
was obtained which revealed ? ascending colitis.  Repeat imaging
then demonstrated ?transverse and left sided colitis could not
be excluded, thus colitis may represent his source of blood
seeding.
.
During his course on the floor, he was found to have a right
common femoral DVT.  He was transiently on heparin gtt, but
developed guaiac + stools and hematocrit drop requiring
transfusions with prbc x2.  Records from [**Hospital1 336**] reveal that he has
a h/o GI bleed from likely AVM source in past.  Heparin was
discontinued, GI was consulted and an IVC filter was placed.
.
78 year-old male with end-stage renal disease on hemodialysis,
hypertension, paroxysmal atrial fibrillation recently in a
nursing home because of a T12 compression fracture, presenting
from his nursing home with lethargy and weakness, decreased
appetite for several days with temperature to 101.
.
The patient's temperature was 103 rectally in the emergency
department. The patient was initially hypotensive to 82/40.
Laboratories were significant for lactate 2.7, 17% bandemia. A
right internal jugular central line was placed. The patient was
given three liters normal saline with improvement in systolic
blood pressures to 100s. Blood and urine cultures were sent and
he patient was started on Vancomycin and Ceftazidine. The
patient was initially given decadron as he had been recently on
prednisone. Head CT which showed a "hyperdense convexity along
the right frontal lobe measuring 3 mm thick which most likely
represents a small acute subdural hemorrhage."  Neurosurgery was
consulted, who stated that "there was a bone averaging at the
right frontal scull. No SDH."  Felt to be no neurosurgical
issue, transferred to MICU for further medical care.
.
On arrival to MICU, patient was normotensive to 124/75 with
heart rate 60. 2/2 blood culture bottles from admission grew
gram-negative rods. The source of the bacteremia was unclear.
Urinalysis and urine culture were negative. Chest X-ray was
negative for infection. Right upper quadrant ultrasound was
performed as the patient had elevated alkaline phosphatase and
GGT and showed no acute abdnormalities. Vancomycin and
Ceftazidine were discontinued and the patient was transferred to
the floor on Unasyn pending culture speciation.

Past Medical History:
1. End-stage renal disease on dialysis (MoWeFr) via left-sided
AV fistula
2. Hypertension
3. Atrial fibrillation
4. Hypothyroidism
5. Anemia
6. Recent T12 compression fracture

Social History:
The patient is living at [**Hospital **] Health Center nursing home
after recent T12 fracture. The patient has a son living in the
area.

Family History:
Non-contributory.

Physical Exam:
VITALS:  Temp 96.5, HR 60, BP 128/64, RR 14, O2 sat 98% on RA,
CVP 9-10.
GENERAL:  chinese male, comfortable appearing, lying in bed,
awake, interactive, confused.  Oriented to self, but not place
or time.
HEENT:  anicteric, mucous membranes dry
CHEST:  CTA b/l
HEART:  RRR nl s1, s2, II/VI SEM at LUSB
ABD:  +BS, soft, NT, ND, no guarding or rebound
EXT:  no edema, L arm AV fistula
NEURO:  CN II-XII intact, moves all extremities with 5/5
strength.

Pertinent Results:
LABS: Lactate 2.7 to 1.1
PT: 15.4 PTT: 40.4 INR: 1.4
WBC 6.7 N:68 Band:17 L:11 M:4 E:0 Bas:0
HCT 29
PLT 163
CRP: 112.7
ALT: 51 AST: 91 AP: 229 Tbili: 2.0 Alb: 2.4 [**Doctor First Name **]: 18 Lip: 9
Anion Gap: 12
BUN 14 Cr 4.5

ECG: NSR at 63 with PR prolongation, nl axis, no Q waves, no
LVH, no ST changes.
.
U/A: 0-2 WBC, Tr leuk, neg nit
.
CXR: No evidence of PNA. Normal heart. Calcified and tortuous
aorta.
.
RUQ U/S: (wet read) Mild CBD dilatation to 7 mm (4mm is normal).
No u/s evidence of cholecystitis. No ascites in RUQ.
.
Head CT: 1. Hyperdense convexity along the right frontal lobe
measuring 3 mm thick which most likely represents a small acute
subdural hemorrhage.  No evidence for mass effect or shift of
normally midline structures.  Follow up head CT is recommended
to document interval change in [**6-9**] hours, or sooner if the
patient's mental status changes.
2.  Heavy atherosclerotic calcifications in the intracranial
vasculature as described above.
.
[**2112-12-26**] CT Abd:
COMPARISON:  Abdominal CT dated [**2112-12-11**].

FINDINGS:  The evaluation of abdominal organs and major vessels
are limited
due to lack of intravenous contrast [**Doctor Last Name 360**].  There is large
amount of free air
throughout the upper abdomen and pelvis, measuring approximately
[**3-21**] [**Doctor Last Name **], new
since prior study.  There is no area with concentrated
high-density oral
fluid-fluid level.  The liver is diffusely hypodense measuring
up to 78 [**Doctor Last Name **],
probably due to iodine accumulation with amiodarone.  Again note
is made of
multiple hypodense lesions in bilateral lobes of the liver,
measuring up to
1.6 cm in the right lobe, some of them abutting the liver
surface.  Evaluation
of these lesions is limited.  There is no definite intrahepatic
ductal
dilatation.  Gallbladder is unremarkable without evidence of
calcification.
Spleen, adrenal glands, pancreas are within normal limits.
Bilateral kidneys
are severely atrophic.  The patient is status post IVC placement
just inferior
to the renal veins.  The evaluation of small and large bowel is
limited
without oral contrast.  There is no significant dilatation or
obstruction. The
assessment of the wall thickening is difficult due to
surrounding ascites.

PELVIS:  Large amount of ascites new since prior studies is
noted, measuring
approximately [**5-11**] [**Doctor Last Name **].  There is no bowel dilatation.  The wall
of the
ascending colon is somewhat prominent which may be edematous,
however, the
evaluation is limited due to lack of oral contrast and
surrounding fluid.  The
appearance is overall unchanged since prior study.  There is no
significant
lymphadenopathy.

In the visualized portion of the lung bases, note is made of
bilateral pleural
effusion with collapse of the parenchyma, somewhat increased
since prior
study.  There is no suspicious mass or nodule in the visualized
portion of the
lung.

Again note is made of compression fracture of the T12, with
interval fixation
from T10-L2.

IMPRESSION:
1.  New large amount of ascites throughout the abdomen and
pelvis, measuring up to 20 [**Doctor Last Name **], without evidence of concentration
of high-density oral fluid-fluid levels.  Given the Hounsfield
unit, this is probably a simple fluid, however, in the setting
of anemia, hemorrhage component or abdominal bleed cannot be
totally excluded especially given that ascites is new. Clinical
correlation and close monitoring of the hematocrit level is
recommended.
2.  Limited study without intravenous contrast or oral contrast
[**Doctor Last Name 360**].
Somewhat prominent appearance of the ascending colon wall,
however, the
assessment is difficult with surrounding fluid.  The appearance
is overall
unchanged since prior study.
3.  Iodine accumulation of the liver with amiodarone.
4.  Multiple low-dense lesions in bilateral lobes of the liver,
overall
unchanged since prior study, some of which are abutting the
peripheral portion of the liver.
5.  Atrophic kidney.
6.  Interval posterior thoracolumbar fixation from T10-L2 with
compression
fracture of T12 with subcutaneous small fluid.
7.  Increased bilateral pleural effusion with collapsed lung in
the
visualized portion of lung bases.
.
[**2112-12-30**] Colonoscopy:
Mucosa: Diffuse abnormal vascularity with no bleeding was noted
in the cecum and proximal ascending colon. These findings are
compatible with angioectasias and the diffuse angioectasias
extending from the cecum into the first [**2-4**] folds of proximal
ascending colon. There was no active bleeding, but the process
was too diffuse to be treated endoscopically. Localized
scarring, mild ulceration, friability and mild erythema with no
bleeding were noted in the distal rectum. These findings are
compatible with previous proctitis and involved the rectum from
approximately 2 cm to 6 cm. Cold forceps biopsies were performed
for histology at the distal rectum.
.
Impression: Abnormal vascularity in the cecum and proximal
ascending colon compatible with angioectasias
Scarring, mild ulceration, friability and mild erythema in the
distal rectum compatible with previous proctitis (biopsy)
Otherwise normal colonoscopy to cecum
.
Recommendations: Follow-up biopsy results.
Obtain outside EGD and colonoscopy reports.
He may have some rectal bleeding after the biopsies.
His cecal and proximal ascending angioectasias will not be
amenable to endoscopic treatment since the process is so
diffuse. Definitive therapy would be a right hemi-colectomy


Brief Hospital Course:
78 year-old male with end-stage renal disease on hemodialysis,
hypertension, paroxysmal atrial fibrillation who presented with
fever and gram-negative rod bacteremia.
.
# Early Sepsis. The patient's temperature was 103 rectally in
the emergency department. The patient was initially hypotensive
to 82/40. Laboratories were significant for lactate 2.7, 17%
bandemia. A right internal jugular central line was placed. The
patient was given three liters normal saline with improvement in
systolic blood pressures to 120s on arrival to the MICU. Blood
and urine cultures were sent and he patient was started on
Vancomycin and Ceftazidine. The patient was initially given
decadron as he had been recently on prednisone; this was
discontinued as cortisol stimulation test showed an appropriate
response. The patient never required pressors. 2/2 blood culture
bottles from admission grew gram-negative rods. The source of
the bacteremia was unclear. Urinalysis and urine culture were
negative. Chest X-ray was negative for infection. Right upper
quadrant ultrasound was performed as the patient had elevated
alkaline phosphatase and GGT and showed no acute abdnormalities.
Vancomycin and Ceftazidine were discontinued and the patient was
transferred to the floor on Unasyn pending culture speciation.
Unasyn was discontinued and the patient was given a course of
ciprofloxacin once speciation and sensitivities had returned E.
coli, pan-sensitive.
.
# DVT: Right common femoral DVT was visualized [**12-8**] on imaging.
IVC filter was placed [**12-10**] as patient could not tolerate heparin
secondary to GI bleeding. In the future, heparin, coumadin, and
other anticoagulants should be avoided if possible to avoid GI
bleeding.
.
# Recent T12 Fracture. Records were obtained from [**Hospital1 336**] that
demonstrate that the patient was evaluated by neurosurgery who
did not feel the patient was a surgical candidate. The patient
was maintained on bedrest per [**Hospital1 336**] neurosurgical recommendation
until the patient has follow-up with neurosurgery. Neurosurgery
was consulted on this admission - MRI T10-S2 showed spinal cord
narrowing, edema. Patient underwent neurosurgical stablization
of the affected area. Neurosurgery continued to followup patient
and the followup L-spine film showed post-operative changes.
Neurosurgery removed staples on [**2112-1-4**].
.
# GI bleed: The patient had GI bleeding [**12-9**] which was felt
likely secondary to cecal AVM seen on [**Hospital1 336**] colonoscopy [**11-7**]. At
this time his anticoagulaion for DVT (heparin) was stopped, an
IVC filter was placed, and he was transfused 2 u PRBCs. He was
stable without bleeding until [**12-29**], when he again passed bright
red blood and clots. He was prepped and scoped at this time with
the finding of diffuse AVM at cecum and proximal colon (see
note). No active bleeding was seen. After the colonoscopy,
preventative surgery for the patient was discussed
(hemicolectomy), with the family opting for a more conservative
approach of following periodic hematocrits with transfusions as
needed.  The patient's hematocrit should be checked later this
week ([**2112-1-6**]) to ensure that it is stable. On discharge the
patient had baseline hematocrit ranging from 26-30.
.
# End-stage renal disease. The patient's renal failure is of an
unclear etiology. The patient was followed by renal throughtout
hospitalization. The patient was continued on hemodialysis per
MWF schedule. His next dialysis is due for Wednesday [**2113-1-4**]. In
addition, his renal medications were maintained. He has left arm
fistula.
.
# Liver cysts/ascites: HIs abdominal CT during his stay showed
persistent and stable liver hypodensities consistent w/ liver
cysts or hamartoma. His RUQ u/s on admission did not reveal
overt signs of cirrohsis. Not likely to be hepatocellular cancer
as his AFP was negative. His hepatitis B titer suggest that he
likely was exposed in the past but developed antibody to it. He
denies prior known history of hepatitis or alcohol history. He
should followup w/ liver specialist as outpatient and have
regular followup w/ AFP and RUQ us. In addition, a CT scan on
[**12-26**] demonstrated new accumulation of ascites, which similarly
should be evaluated by liver specialist.
.
# Hypothyroidism. The patient was seen by the endocrinology
service during his stay and briefly required corticosteroids
which were tapered before his discharge. His synthroid dose was
increased to 200mcg QD. He should have his thyroid levels
rechecked in two weeks time ([**2113-1-18**]) to assess whether his
synthroid dose needs to be decreased.
.
# Thrombocytopenia: The patient had unexplained thrombocytopenia
that developed during his hospital stay. He had negative
antibody screen for heparin induced thrombocytopenia and no
clear medication precipitants. His platelet count on discharge
was 80K. His exposure to heparin with PIV and PICC flushes
should be minimized and his platelet count should be checked
serially (next check [**2113-1-5**]).
.
# Atrial fibrillation: Patient now in NSR. Patient is not on
anticoagulation given history of GI bleed. He was continued on
amiodarone for rate control.
.
# Head CT. Pt had head CT which showed a "hyperdense convexity
along the right frontal lobe measuring 3 mm thick which most
likely represents a small acute subdural hemorrhage."
Neurosurgery was consulted and felt that the finding represented
"a bone averaging at the right frontal skull. No subdural
hematoma." The patient's neurologic exam remained nonfocal
throughoout hospitalization. On disharge, the patient felt to be
at his baseline mental status after discussion with his nursing
home. Repeat CT head showed the same findings; stable.
.
# FEN: Cardiac heart healthy pureed diet. Pills given with
puree. Can tolerate thin liquids.
.
# Access: The patient has a right PICC which was placed on
[**12-26**]. The PICC is being flushed with normal saline to minimize
exposure to heparin given the patient's unexplained
thrombocytopenia. The PICC should be removed at earliest
convenience: potentially on [**2113-1-5**] after recheck of hematocrit.
Given left arm fistula, patient has blood pressure measurements
on leg.
.
# PT: The patient requires daily physical therapy to improve his
strength.
.
# Code status: Full code. Contact: [**Name (NI) **] [**Telephone/Fax (1) 35421**].

Medications on Admission:
Amiodarone 200mg daily
Hydroxyzine 2.5mg daily
CaCO2 500g daily
Levothyroxine 100mcg daily
Isosorbide 30mg daily
Heparin SQ 5000 unit tid
Cacitriol 0.5mcg qweek (fri)
Lipitor 20mg daily
Toprol XL 25mg daily
Vitamin E 400 units daily
Nephrocaps 1mg daily
Prednisone 5mg daily
Duralgesic patch 50 mcg q72hrs to R chest
Megace ES 625/3 qd
Renagel 800mg tid with meals
Remeron 15mg qHS

Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO once a
week: q friday.
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. Megace ES 625 mg/5 mL Suspension Sig: Five (5) mL PO once a
day.
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
10. Dexamethasone 0.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Ammonium Lactate 12 % Lotion Sig: One (1) Appl Topical ASDIR
(AS DIRECTED).
13. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for nausea.
14. Sodium Chloride 0.9%  Flush 10 ml IV DAILY
Flush PICC with saline instead of heparin.
15. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
16. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
18. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
19. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
20. Renagel 800 mg Tablet Sig: One (1) Tablet PO three times a
day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Location (un) 86**]

Discharge Diagnosis:
Primary Diagnosis:
Gram negative rod bacteremia, likely gastrointestinal source

Secondary Diagnosis:
End stage renal disease on hemodialysis
Hypertension
Atrial Fibrillation
T12 compression fracture
liver cysts
thrombocytopenia


Discharge Condition:
Patient was in stable condition.
Able to sit, stand and participate in physical therapy with
assistance.


Discharge Instructions:
You were admitted to the hospital with an infection in your
bloodstream that was treated with antibiotics.
.
You had an IVC filter placed to prevent a clot from going to
your lungs.
.
You had a neurosurgery operation on your spine.
.
You should continue to receive dialysis and be followed by a
renal specialist for your end stage renal disease.
.
In the future, you should avoid "blood thinner" medications
(anticoagulants) because of the risk of GI bleeding, unless
specifically directed by your physician.
.
Please followup with the following specialist appointments:
liver, endocrine, and neurosurgery followup (see below).
.
Please make and appointment for followup with your primary care
physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 429**] [**Last Name (NamePattern1) **] once you are discharge.
.
Please call the phone number listed below for followup with
liver specialist for your liver abnormalities and ascites.
.
Please call your doctor or return to the ER if you have fevers,
chills, increased confusion, chest pain, shortness of breath,
worsening abdominal pain or other concerning symptoms.

Followup Instructions:
Please follow-up with your primary care doctor, Dr. [**First Name8 (NamePattern2) 429**] [**Last Name (NamePattern1) **],
in [**1-3**] weeks once you are discharged from . His phone number is
[**Telephone/Fax (1) 16171**].
.
You will need to follow-up with neurosurgery  on [**1-25**] at 10:45
am with Dr. [**Last Name (STitle) 548**] [**Telephone/Fax (1) 1669**]

please call for followup appointment with liver center
[**Telephone/Fax (1) 463**] for appointment in [**4-7**] weeks

Head CT at on [**1-31**] 11:30am at [**Hospital Ward Name 23**] [**Location (un) **] [**Telephone/Fax (1) 327**]

Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 23961**] for endocrinology, MD
Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2113-2-9**] 3:00



Completed by:[**2113-1-3**]
{'Bacteremia,End stage renal disease,Atrial fibrillation,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Pathologic fracture of vertebrae,Angiodysplasia of intestine with hemorrhage,Thrombocytopenia, unspecified,Hematoma complicating a procedure,Acute posthemorrhagic anemia,Unspecified acquired hypothyroidism,Other specified disorders of liver,Delirium due to conditions classified elsewhere'}


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: Lehargy/Weakness/Fever

PRESENT ILLNESS: 78 y/o Chinese male with ESRD, HTN, Afib, recently in a nursing
home after found to have T12 compression fracture, presents from
his nursing home with lethargy and weakness with fever on
[**2112-12-3**]. Pt presented to ED with fever and hypotension, and was
found to have bandemia of 17% with no clear source of infection.
He was initially empirically treated broadly with Ceftazadime
and vancomycin which was transitioned to unasyn and vancomycin
on admission to the ICU with the addition of steroids given
septic clinical picture.  A central line was placed and he was
given 3L NS prior to transfer to the ICU with improvement in BP
not requiring pressors.
.
Blood cx on [**12-3**] grew pansensative E. coli with no clear source
as UA was clear, CXR revealed no infiltrate and line site looked
clean. Steroids were not continued since [**Last Name (un) **] stim test was
negative. Antibiotics were weaned to Unasyn alone given only e.
coli grew in the blood cultures and follow-up cultures have been
negative with bandemia and fever resolved.
.
Pt had a mildly elevated Alk phos and GGT on admission so RUQ US
was obtained to look for a source of the GNR bactermia but there
were no signs of biliary obstruction or cholecystitis.  CT
abd/pelvis to r/o abdominal process as source of GNR bacteremia
was obtained which revealed ? ascending colitis.  Repeat imaging
then demonstrated ?transverse and left sided colitis could not
be excluded, thus colitis may represent his source of blood
seeding.
.
During his course on the floor, he was found to have a right
common femoral DVT.  He was transiently on heparin gtt, but
developed guaiac + stools and hematocrit drop requiring
transfusions with prbc x2.  Records from [**Hospital1 336**] reveal that he has
a h/o GI bleed from likely AVM source in past.  Heparin was
discontinued, GI was consulted and an IVC filter was placed.
.
78 year-old male with end-stage renal disease on hemodialysis,
hypertension, paroxysmal atrial fibrillation recently in a
nursing home because of a T12 compression fracture, presenting
from his nursing home with lethargy and weakness, decreased
appetite for several days with temperature to 101.
.
The patient's temperature was 103 rectally in the emergency
department. The patient was initially hypotensive to 82/40.
Laboratories were significant for lactate 2.7, 17% bandemia. A
right internal jugular central line was placed. The patient was
given three liters normal saline with improvement in systolic
blood pressures to 100s. Blood and urine cultures were sent and
he patient was started on Vancomycin and Ceftazidine. The
patient was initially given decadron as he had been recently on
prednisone. Head CT which showed a "hyperdense convexity along
the right frontal lobe measuring 3 mm thick which most likely
represents a small acute subdural hemorrhage."  Neurosurgery was
consulted, who stated that "there was a bone averaging at the
right frontal scull. No SDH."  Felt to be no neurosurgical
issue, transferred to MICU for further medical care.
.
On arrival to MICU, patient was normotensive to 124/75 with
heart rate 60. 2/2 blood culture bottles from admission grew
gram-negative rods. The source of the bacteremia was unclear.
Urinalysis and urine culture were negative. Chest X-ray was
negative for infection. Right upper quadrant ultrasound was
performed as the patient had elevated alkaline phosphatase and
GGT and showed no acute abdnormalities. Vancomycin and
Ceftazidine were discontinued and the patient was transferred to
the floor on Unasyn pending culture speciation.

MEDICAL HISTORY: 1. End-stage renal disease on dialysis (MoWeFr) via left-sided
AV fistula
2. Hypertension
3. Atrial fibrillation
4. Hypothyroidism
5. Anemia
6. Recent T12 compression fracture

MEDICATION ON ADMISSION: Amiodarone 200mg daily
Hydroxyzine 2.5mg daily
CaCO2 500g daily
Levothyroxine 100mcg daily
Isosorbide 30mg daily
Heparin SQ 5000 unit tid
Cacitriol 0.5mcg qweek (fri)
Lipitor 20mg daily
Toprol XL 25mg daily
Vitamin E 400 units daily
Nephrocaps 1mg daily
Prednisone 5mg daily
Duralgesic patch 50 mcg q72hrs to R chest
Megace ES 625/3 qd
Renagel 800mg tid with meals
Remeron 15mg qHS

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VITALS:  Temp 96.5, HR 60, BP 128/64, RR 14, O2 sat 98% on RA,
CVP 9-10.
GENERAL:  chinese male, comfortable appearing, lying in bed,
awake, interactive, confused.  Oriented to self, but not place
or time.
HEENT:  anicteric, mucous membranes dry
CHEST:  CTA b/l
HEART:  RRR nl s1, s2, II/VI SEM at LUSB
ABD:  +BS, soft, NT, ND, no guarding or rebound
EXT:  no edema, L arm AV fistula
NEURO:  CN II-XII intact, moves all extremities with 5/5
strength.

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: The patient is living at [**Hospital **] Health Center nursing home
after recent T12 fracture. The patient has a son living in the
area. 

### Response:
{'Bacteremia,End stage renal disease,Atrial fibrillation,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Pathologic fracture of vertebrae,Angiodysplasia of intestine with hemorrhage,Thrombocytopenia, unspecified,Hematoma complicating a procedure,Acute posthemorrhagic anemia,Unspecified acquired hypothyroidism,Other specified disorders of liver,Delirium due to conditions classified elsewhere'}
