CHIEF COMPLAINT: Sepsis

PRESENT ILLNESS: 31 y/o M with biliary atresia s/p liver [**Month/Day/Year **] at age 4
currently listed for liver/kidney [**Month/Day/Year **], ESRD on HD who was
transferred from OSH [**2135-11-12**] with fevers, tachycardia, and
abdominal pain. Patient reported diffuse abdominal pain, worse
in RUQ x 4 days that came on suddenly then radiated to right
chest. The day prior to transfer he had coffee-ground emesis and
black diarrhea. In the ED patient was tachycardic to 140-150s
with SBP 100's and spiked a fever to 102.4. Patient was
empirically started on vancomycin and zosyn. CXR demonstrated
bilateral effusions and no infiltrate. CTA torso demonstrated no
PE, but loculated ascites with mass effect, patent portal vein,
mod-large b/l pleural effusions and jejunal wall thickening of
unknown significance. Following 3L of IVFs patient remained
tachycardia and was consequently admitted to the MICU for
concern of sepsis.
.
During his MICU stay blood cultures returned positive for
klebsiella pneumoniae and consequently his HD line was removed.
Cultures were pan-sensitive consequently vanc/zosyn was narrowed
to ceftriaxone. Additional infectious work up included: negative
influenza, negative c. diff, negative SBP, negative urine
culture. Patient had no episodes of coffee ground emesis or
melena and HCT remained stable (hemoconcentrated on admission).
Tachycardia was an ongoing problem. The MICU team attempted
small boluses of fluid with only mild improvement in his HR.
Today 6 mg adenosine was given to investigate whether rhythm was
SVT but had no effect. During his admission the patient began
complaining of back pain and a MRI spine was ordered to rule out
epidural abscess prior to transfer.
.
Upon evaluation of the patient he states his abdominal pain has
completely resolved since admission. He denies any fevers,
chills, emesis or bloody bowel movements. He states his back
pain started on saturday ("after all the fluids") but has now
improved. The pain was [**4-3**] and non-localized ("my entire
back"). Patient describes difficulty ambulating due to lower
extremity edema only. No changes in his bowel movements (loose
at baseline). The patient is oriented x 3 and states he feels
much better than on admission.
.
Of note, patient was recently admitted [**10-3**] and diagnosed with
H1N1, SVT responsive to adenosine, multifocal PNA treated with
vancomycin, zosyn, and levofloxacin, possible sick euthyroid and
acute on chronic renal failure felt to be due to ATN requiring
HD and relisting for a kidney [**Month/Year (2) **].
.

MEDICAL HISTORY: -biliary Atresia s/p liver [**Month/Year (2) **] at age 4 (25 years ago)
-asthma, well-controlled
-right hip avascular necrosis, per ortho may need THR
-postinfectious glomerulonephritis s/p renal biopsy [**2135-5-24**]
showed IgG dominent exudative proliferative GN, c/w
postinfectious GN
-nephrotic syndrome (4.1g proteinuria), hypoalbuminemia
-small bowel resection

MEDICATION ON ADMISSION: asix 20mg PO daily
Lactulose 30-60cc PO QID
Reglan
Sucralfate
Tacrolimus 0.5mg PO BID
Oxycodone
Buproprion
Caltrate D
.
On transfer:
Metoprolol Tartrate 12.5 mg PO/NG [**Hospital1 **]
Adenosine 6 mg IV ONCE
Acetaminophen 500 mg PO/NG ONCE MR1
HYDROmorphone (Dilaudid) 0.2 mg IV Q6H:PRN pain
CeftriaXONE 1 gm IV Q24H
Tacrolimus 0.5 mg PO Q12H
Lidocaine 5% Patch 1 PTCH TD DAILY
OxycoDONE (Immediate Release) 5-10 mg PO/NG Q6H:PRN pain [**11-13**] @
Pantoprazole 40 mg PO Q12H
Sarna Lotion 1 Appl TP PRN Itching
Vitamin D 400 UNIT PO/NG DAILY
Calcium Carbonate 500 mg PO/NG DAILY
Sucralfate 1 gm PO QID
Metoclopramide 10 mg PO/IV QID:PRN nausea
Lactulose 30 mL PO/NG Q8H:PRN constipation

ALLERGIES: Ibuprofen

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
Vitals: Current: 99.4, HR 127, BP 132/89, RR 22, SaO2 98%
Last 24 hours: T 97-100.2, Tm 100.2; BP 104-145/66-90. HR
119-137 (with episodes into the 140s); RR 19-22; O2 93-97% on
RA.
GENERAL: Cachectic, comfortable, NAD
HEENT: MM dry, no LAD, neck supple
CARDIAC: Tachycardic, regular, No MRG
LUNG: Decreased breath sounds in bases bilaterally, no crackles,
wheezes.
ABDOMEN: Moderately distended, not tense, BS+, no tenderness. No
rebound or gaurding. Midline and RUQ surgical scar. Multiple
excoriations on abdomen.
EXT: 3+ pitting edema in LE's bilaterally (R > L)
NEURO: CNII-XII intact. Motor [**3-29**] upper and lower.
.

FAMILY HISTORY: NC

SOCIAL HISTORY: denies any tobacco, EtOH or illict drug use. Lives at home with
parents. Has one child with a prior girlfriend. Does not work.
Infection and inflammatory reaction due to other vascular device, implant, and graft,Other septicemia due to gram-negative organisms,End stage renal disease,Obstruction of bile duct,Liver replaced by transplant,Unspecified pleural effusion,Other ascites,Aseptic necrosis of head and neck of femur,Portal hypertension,Cellulitis and abscess of trunk,Kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Renal dialysis status,Awaiting organ transplant status,Other specified cardiac dysrhythmias,Asthma, unspecified type, unspecified,Anemia in chronic kidney disease,Unspecified pruritic disorder
React-oth vasc dev/graft,Gram-neg septicemia NEC,End stage renal disease,Obstruction of bile duct,Liver transplant status,Pleural effusion NOS,Ascites NEC,Aseptic necrosis femur,Portal hypertension,Cellulitis of trunk,Abn react-renal dialysis,Renal dialysis status,Await organ transplnt st,Cardiac dysrhythmias NEC,Asthma NOS,Anemia in chr kidney dis,Pruritic disorder NOS
Admission Date:  [**2135-11-12**]              Discharge Date:   [**2135-11-17**]

Date of Birth:  [**2104-8-11**]             Sex:   M

Service: MEDICINE

Allergies:
Ibuprofen

Attending:[**First Name3 (LF) 8388**]
Chief Complaint:
Sepsis

Major Surgical or Invasive Procedure:
HD line removal ([**2135-11-12**])
Temporary HD line placement ([**2135-11-15**])
Post-pyloric feeding tube placement ([**2135-11-16**])


History of Present Illness:
 31 y/o M with biliary atresia s/p liver [**Month/Day/Year **] at age 4
currently listed for liver/kidney [**Month/Day/Year **], ESRD on HD who was
transferred from OSH [**2135-11-12**] with fevers, tachycardia, and
abdominal pain. Patient reported diffuse abdominal pain, worse
in RUQ x 4 days that came on suddenly then radiated to right
chest. The day prior to transfer he had coffee-ground emesis and
black diarrhea. In the ED patient was tachycardic to 140-150s
with SBP 100's and spiked a fever to 102.4. Patient was
empirically started on vancomycin and zosyn. CXR demonstrated
bilateral effusions and no infiltrate. CTA torso demonstrated no
PE, but loculated ascites with mass effect, patent portal vein,
mod-large b/l pleural effusions and jejunal wall thickening of
unknown significance. Following 3L of IVFs patient remained
tachycardia and was consequently admitted to the MICU for
concern of sepsis.
.
During his MICU stay blood cultures returned positive for
klebsiella pneumoniae and consequently his HD line was removed.
Cultures were pan-sensitive consequently vanc/zosyn was narrowed
to ceftriaxone. Additional infectious work up included: negative
influenza, negative c. diff, negative SBP, negative urine
culture. Patient had no episodes of coffee ground emesis or
melena and HCT remained stable (hemoconcentrated on admission).
Tachycardia was an ongoing problem. The MICU team attempted
small boluses of fluid with only mild improvement in his HR.
Today 6 mg adenosine was given to investigate whether rhythm was
SVT but had no effect. During his admission the patient began
complaining of back pain and a MRI spine was ordered to rule out
epidural abscess prior to transfer.
.
Upon evaluation of the patient he states his abdominal pain has
completely resolved since admission. He denies any fevers,
chills, emesis or bloody bowel movements. He states his back
pain started on saturday ("after all the fluids") but has now
improved. The pain was [**4-3**] and non-localized ("my entire
back"). Patient describes difficulty ambulating due to lower
extremity edema only. No changes in his bowel movements (loose
at baseline). The patient is oriented x 3 and states he feels
much better than on admission.
.
Of note, patient was recently admitted [**10-3**] and diagnosed with
H1N1, SVT responsive to adenosine, multifocal PNA treated with
vancomycin, zosyn, and levofloxacin, possible sick euthyroid and
acute on chronic renal failure felt to be due to ATN requiring
HD and relisting for a kidney [**Month/Year (2) **].
.

Past Medical History:
-biliary Atresia s/p liver [**Month/Year (2) **] at age 4 (25 years ago)
-asthma, well-controlled
-right hip avascular necrosis, per ortho may need THR
-postinfectious glomerulonephritis s/p renal biopsy [**2135-5-24**]
showed IgG dominent exudative proliferative GN, c/w
postinfectious GN
-nephrotic syndrome (4.1g proteinuria), hypoalbuminemia
-small bowel resection


Social History:
denies any tobacco, EtOH or illict drug use. Lives at home with
parents. Has one child with a prior girlfriend. Does not work.


Family History:
NC

Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: Current: 99.4, HR 127, BP 132/89, RR 22, SaO2 98%
Last 24 hours: T 97-100.2, Tm 100.2; BP 104-145/66-90. HR
119-137 (with episodes into the 140s); RR 19-22; O2 93-97% on
RA.
GENERAL: Cachectic, comfortable, NAD
HEENT: MM dry, no LAD, neck supple
CARDIAC: Tachycardic, regular, No MRG
LUNG: Decreased breath sounds in bases bilaterally, no crackles,
wheezes.
ABDOMEN: Moderately distended, not tense, BS+, no tenderness. No
rebound or gaurding. Midline and RUQ surgical scar. Multiple
excoriations on abdomen.
EXT: 3+ pitting edema in LE's bilaterally (R > L)
NEURO: CNII-XII intact. Motor [**3-29**] upper and lower.
.

DISCHARGE
Vitals: Current: 99.0, tmax 99.7, HR 109-111, BP 114-126/74-78
(10-20 mmHg higher than yesterday), RR 20-22, SaO2 97%
IO Last 8 --> i = 240 ; o = 200
Last 24 --> i = 490 ; o = 200 + 4BM
Ultrafiltration - 2Litres negative
GENERAL: Cachectic, NAD
HEENT: MM dry, no LAD, neck supple
CARDIAC: Tachycardic, regular, No MRG
LUNG: Decreased breath sounds in bases bilaterally, no crackles,
wheezes.
ABDOMEN: distended, not tense, BS+, no tenderness. No rebound or
gaurding. Midline and RUQ surgical scar. Multiple excoriations
on abdomen.
EXT: 3+ pitting edema in LE's bilaterally, excoriations on arms
NEURO: CNII-XII intact. Motor [**3-29**] upper and lower.
SKIN: blanching erythema over left flank

Pertinent Results:
Admission
[**2135-11-12**] 06:30AM BLOOD WBC-9.5 RBC-4.13* Hgb-12.0* Hct-37.9*#
MCV-92 MCH-29.0 MCHC-31.6 RDW-17.7* Plt Ct-203
[**2135-11-12**] 06:30AM BLOOD Neuts-82* Bands-14* Lymphs-1* Monos-0
Eos-2 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2135-11-12**] 12:00PM BLOOD PT-15.2* PTT-32.7 INR(PT)-1.3*
[**2135-11-12**] 06:30PM BLOOD Glucose-108* UreaN-23* Creat-2.2* Na-133
K-4.1 Cl-107 HCO3-19* AnGap-11
[**2135-11-12**] 06:30AM BLOOD ALT-21 AST-63* CK(CPK)-84 AlkPhos-486*
TotBili-0.6
[**2135-11-12**] 06:25AM BLOOD Glucose-99 Lactate-2.2* Na-137 K-4.0
Cl-106

Discharge

[**2135-11-17**] 07:45AM BLOOD WBC-9.9 RBC-2.98* Hgb-8.4* Hct-26.8*
MCV-90 MCH-28.0 MCHC-31.2 RDW-17.9* Plt Ct-295
[**2135-11-17**] 08:45AM BLOOD PT-16.0* PTT-34.0 INR(PT)-1.4*
[**2135-11-17**] 04:45PM BLOOD Glucose-115* UreaN-10 Creat-1.4* Na-137
K-3.7 Cl-101 HCO3-30 AnGap-10
[**2135-11-17**] 04:45PM BLOOD Calcium-6.9* Phos-1.3* Mg-1.4*
[**2135-11-14**] 06:14AM BLOOD TSH-1.1
[**2135-11-14**] 06:14AM BLOOD Free T4-0.79*
[**2135-11-17**] 07:45AM BLOOD Vanco-17.0
[**2135-11-17**] 07:45AM BLOOD tacroFK-4.5*

Wound Culture
              STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------   0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S

Blood Culture
KLEBSIELLA PNEUMONIAE
                             |
AMPICILLIN/SULBACTAM--     4 S
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S

CT ABD/PELVIS
1. Severely limited study due to technique and timing of
contrast, for
evaluation for pulmonary embolism. No evidence of pulmonary
embolism in the
main or primary branches of the pulmonary artery.
2. Increased intra-abdominal ascites, with loculation and mass
effect on the intra-abdominal organs. Cirrhosis. Patent portal
vein. Perisplenic varices, compatible with portal hypertension.
3. Pulmonary edema. Moderate-to-large bilateral pleural
effusions with
associated atelectasis.
4. Two enlarged right internal mammary lymph nodes and right
greater than
left gynecomastia.
5. Mild jejunal wall thickening of unclear etiology. Eneteritis
is a
consideration. Some of these loops are mildly dilated but there
is not
obstruction.
6. Stable pneumobilia and mild common bile duct dilatation
status post
choledocojejunostomy.
7. Stable enlarged mesenteric lymph nodes.

MRI L AND T
IMPRESSION:
1. No abnormal bone marrow signal to suggest acute fracture or
osteomyelitis.
2. Bilateral L5 spondylolysis associated with proliferative bony
changes
extending into the right posterior epidural space at L4-5 which
combines with additional degenerative changes to create severe
canal narrowing.
3. Small bilateral fluid clefts at the level of spondylolysis
without a
drainable collection. Early infection within the posterior soft
tissues
cannot be fully excluded and continued followup is recommended.


Brief Hospital Course:
31 yo M w/ ESRD, ESLD s/p liver [**Month/Day/Year **] presented with
abdominal pain and tachycardia, found to have klebsiella
pneumoniae bacteremia, MSSA line site infection vs colonization
and, later cellulitis. He received ultrafiltration, HD, a
rational antibiotic regimen and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-intestinal tube for
feeding
.
# Klebsiella pneumoniae bacteremia
Presumably from his [**Last Name (NamePattern4) 2286**] line. It was pulled and replaced.
Ultimately he was discharged on Cefazolin 2 g qHD.
.
# Likely MSSA Line infection vs colonization: Pt had low grade
temperatures after transfer from MICU. His line site culture
grew MSSA and it was thought that his temperatures were related
to an untreated gram positive infection. After initiation of
cefazolin and vancomycin (below) were started, his temperature
normalized, his HR declined and his BP rose. Discharged on
Cefazolin.
.
# Rash: Discovered on Hospital day 3 and considered a cellulitis
with a hospital acquired pathogen that emerged despite
ceftriaxone. Discharged on vanc
.
# Atrial Tachycardia: Fluid unresponsive, normal TSH,
unresponsive to adenosine. Improved over time. Patient
discharged on 12.5 [**Hospital1 **] Metoprolol
.
# Lower back pain: Prior to transfer MICU team ordered MRI to
r/o epidural abscess. Unlikely based on improving back pain,
non-tender to palpation along spine, pain non-localized. No
deficits on neuro exam. L-spine wit severe DJD. Discharged on
lidocaine patches and oxycodone
.
#Pleural effusions: Albumin is less than 1 and ascites present.
Likely hepatic hydrothorax. Patient is responding to Abx,
unlikely effusions are infectious source. Patient breathing
comfortably on room air.
.
#ESLD: MELD 24 on [**11-16**]. SBP work-up negative. Persistent
concern for chronic rejection. Elevated INR may be partly
nutritional. A dobhoff was placed and the patient was discharged
with tube feeds at 45cc/hr. He was given phosphorus and
instructions for the prevention of refeeding syndome

#ESRD: [**12-27**] post-infectious glomerulonephritis, was started on HD
last admission due to ATN. Continue HD

TO BE FOLLOWED
1) Pt asked to see PCP every [**Month/Day (2) **] for MELD labs
2) Pt asked to have basic chemistries checked for surveillance
of refeeding syndrome

Medications on Admission:
asix 20mg PO daily
Lactulose 30-60cc PO QID
Reglan
Sucralfate
Tacrolimus 0.5mg PO BID
Oxycodone
Buproprion
Caltrate D
.
On transfer:
Metoprolol Tartrate 12.5 mg PO/NG [**Hospital1 **]
Adenosine 6 mg IV ONCE
Acetaminophen 500 mg PO/NG ONCE MR1
HYDROmorphone (Dilaudid) 0.2 mg IV Q6H:PRN pain
CeftriaXONE 1 gm IV Q24H
Tacrolimus 0.5 mg PO Q12H
Lidocaine 5% Patch 1 PTCH TD DAILY
OxycoDONE (Immediate Release) 5-10 mg PO/NG Q6H:PRN pain [**11-13**] @
Pantoprazole 40 mg PO Q12H
Sarna Lotion 1 Appl TP PRN Itching
Vitamin D 400 UNIT PO/NG DAILY
Calcium Carbonate 500 mg PO/NG DAILY
Sucralfate 1 gm PO QID
Metoclopramide 10 mg PO/IV QID:PRN nausea
Lactulose 30 mL PO/NG Q8H:PRN constipation

Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup Sig: 30-60 MLs PO four times a
day as needed for constipation.
2. Reglan 10 mg Tablet Sig: One (1) Tablet PO four times a day
as needed for nausea.
3. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
4. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
6. Caltrate-600 Plus Vitamin D3 600-400 mg-unit Tablet Sig: One
(1) Tablet PO twice a day.
7. Sarna Anti-Itch 0.5-0.5 % Lotion Sig: One (1) topical
application Topical four times a day as needed for itching.
8. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
9. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One
(1) Patch Topical once a day: Leave on for 12 hours, off for 12
hours.
Disp:*30 Patches* Refills:*2*
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
11. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg
Intravenous QHD: To be given at every Hemodialysis.
12. Cefazolin 1 gram Recon Soln Sig: Two (2) grams Intravenous
QHD: To be given at every Hemodialysis.
13. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
14. Outpatient Lab Work
Every [**Month/Year (2) 766**]. Check PT/INR, Sodium, Creatinine, Albumin and
bilirubin. Fax results to [**First Name8 (NamePattern2) 6177**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 697**].
15. Phos-NaK 280-160-250 mg Powder in Packet Sig: Two (2)
Pakcets PO twice a day.
Disp:*120 Packets* Refills:*2*
16. Outpatient Lab Work
Please check Chem 10 on Saturday [**11-19**] at HD and fax
results to [**Telephone/Fax (1) 697**]. Thanks.


Discharge Disposition:
Home With Service

Facility:
VNA of Southeastern Mass.

Discharge Diagnosis:
Primary Diagnoses:
1. Klebsiella septicemia
2. MSSA cellulitis at former HD line site
3. Hospital-acquired cellulitis of the back
4. Tachycardia
5. Severe spinal DJD and canal narrowing at L4-5
.
Secondary Diagnoses:
- Cirrhosis / ESLD
- ESRD on HD


Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Out of Bed with assistance to chair or
wheelchair


Discharge Instructions:
You were admitted to the MICU at [**Hospital1 18**] for abdominal pain, back
pain, bleeding, and sepsis, and you were found to have several
concurrent infections including Klebsiella bacteremia, MSSA
cellulitis from at the site of your hemodialysis catheter, and
back cellulitis that was thought to be hospital-acquired. You
were treated with IV Ceftriaxone for the Klebsiella bacteremia,
which was changed to Cefazolin with [**Hospital1 2286**], and then started
on Vancomycin with [**Hospital1 2286**] for treatment of your cellulitis.
You will continue to receive these medications for an additional
10 days, dosed each time at [**Hospital1 2286**]. Your hemodialysis line was
pulled and you were given a "line holiday" before it was
replaced. You received hemodialysis on your regular schedule, as
well as extra ultra-filtration given your fluid overload.
.
Given your bleeding your home Omeprazole was increased to twice
daily. You were also found to have severe degenerative joint
disease of the lumbar spine with severe spinal canal narrowing
on MRI that will need close follow-up of small bilateral fluid
clefts. You were started on a Lidoderm patch daily for control
of the back pain. Finally, your heart rate was found to be
elevated and you were started on a new medication called
Metoprolol to decrease the heart rate to the normal range.
.
MEDICATION CHANGES:
1. START Vancomycin 1gram IV at Hemodialysis x10 days
2. START Cefazolin 2grams IV at Hemodialysis x10 days
3. START Metoprolol 12.5mg by mouth twice daily
4. START Lidoderm patch daily for back pain
5. CHANGE Omeprazole to 40mg by mouth twice daily
.
Every [**Hospital1 766**] you must have labs drawn. You can do that here - at
the liver clinic - or at your PCP's office. Check PT/INR,
Sodium, Creatinine, Albumin and bilirubin. Fax results to
[**First Name8 (NamePattern2) 6177**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 697**].

Followup Instructions:
Provider: [**Name10 (NameIs) **],SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2135-11-19**]
12:00
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2135-11-23**] 9:00
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2136-1-16**] 9:00



Completed by:[**2135-11-18**]
{'Infection and inflammatory reaction due to other vascular device, implant, and graft,Other septicemia due to gram-negative organisms,End stage renal disease,Obstruction of bile duct,Liver replaced by transplant,Unspecified pleural effusion,Other ascites,Aseptic necrosis of head and neck of femur,Portal hypertension,Cellulitis and abscess of trunk,Kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Renal dialysis status,Awaiting organ transplant status,Other specified cardiac dysrhythmias,Asthma, unspecified type, unspecified,Anemia in chronic kidney disease,Unspecified pruritic disorder'}


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: Sepsis

PRESENT ILLNESS: 31 y/o M with biliary atresia s/p liver [**Month/Day/Year **] at age 4
currently listed for liver/kidney [**Month/Day/Year **], ESRD on HD who was
transferred from OSH [**2135-11-12**] with fevers, tachycardia, and
abdominal pain. Patient reported diffuse abdominal pain, worse
in RUQ x 4 days that came on suddenly then radiated to right
chest. The day prior to transfer he had coffee-ground emesis and
black diarrhea. In the ED patient was tachycardic to 140-150s
with SBP 100's and spiked a fever to 102.4. Patient was
empirically started on vancomycin and zosyn. CXR demonstrated
bilateral effusions and no infiltrate. CTA torso demonstrated no
PE, but loculated ascites with mass effect, patent portal vein,
mod-large b/l pleural effusions and jejunal wall thickening of
unknown significance. Following 3L of IVFs patient remained
tachycardia and was consequently admitted to the MICU for
concern of sepsis.
.
During his MICU stay blood cultures returned positive for
klebsiella pneumoniae and consequently his HD line was removed.
Cultures were pan-sensitive consequently vanc/zosyn was narrowed
to ceftriaxone. Additional infectious work up included: negative
influenza, negative c. diff, negative SBP, negative urine
culture. Patient had no episodes of coffee ground emesis or
melena and HCT remained stable (hemoconcentrated on admission).
Tachycardia was an ongoing problem. The MICU team attempted
small boluses of fluid with only mild improvement in his HR.
Today 6 mg adenosine was given to investigate whether rhythm was
SVT but had no effect. During his admission the patient began
complaining of back pain and a MRI spine was ordered to rule out
epidural abscess prior to transfer.
.
Upon evaluation of the patient he states his abdominal pain has
completely resolved since admission. He denies any fevers,
chills, emesis or bloody bowel movements. He states his back
pain started on saturday ("after all the fluids") but has now
improved. The pain was [**4-3**] and non-localized ("my entire
back"). Patient describes difficulty ambulating due to lower
extremity edema only. No changes in his bowel movements (loose
at baseline). The patient is oriented x 3 and states he feels
much better than on admission.
.
Of note, patient was recently admitted [**10-3**] and diagnosed with
H1N1, SVT responsive to adenosine, multifocal PNA treated with
vancomycin, zosyn, and levofloxacin, possible sick euthyroid and
acute on chronic renal failure felt to be due to ATN requiring
HD and relisting for a kidney [**Month/Year (2) **].
.

MEDICAL HISTORY: -biliary Atresia s/p liver [**Month/Year (2) **] at age 4 (25 years ago)
-asthma, well-controlled
-right hip avascular necrosis, per ortho may need THR
-postinfectious glomerulonephritis s/p renal biopsy [**2135-5-24**]
showed IgG dominent exudative proliferative GN, c/w
postinfectious GN
-nephrotic syndrome (4.1g proteinuria), hypoalbuminemia
-small bowel resection

MEDICATION ON ADMISSION: asix 20mg PO daily
Lactulose 30-60cc PO QID
Reglan
Sucralfate
Tacrolimus 0.5mg PO BID
Oxycodone
Buproprion
Caltrate D
.
On transfer:
Metoprolol Tartrate 12.5 mg PO/NG [**Hospital1 **]
Adenosine 6 mg IV ONCE
Acetaminophen 500 mg PO/NG ONCE MR1
HYDROmorphone (Dilaudid) 0.2 mg IV Q6H:PRN pain
CeftriaXONE 1 gm IV Q24H
Tacrolimus 0.5 mg PO Q12H
Lidocaine 5% Patch 1 PTCH TD DAILY
OxycoDONE (Immediate Release) 5-10 mg PO/NG Q6H:PRN pain [**11-13**] @
Pantoprazole 40 mg PO Q12H
Sarna Lotion 1 Appl TP PRN Itching
Vitamin D 400 UNIT PO/NG DAILY
Calcium Carbonate 500 mg PO/NG DAILY
Sucralfate 1 gm PO QID
Metoclopramide 10 mg PO/IV QID:PRN nausea
Lactulose 30 mL PO/NG Q8H:PRN constipation

ALLERGIES: Ibuprofen

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
Vitals: Current: 99.4, HR 127, BP 132/89, RR 22, SaO2 98%
Last 24 hours: T 97-100.2, Tm 100.2; BP 104-145/66-90. HR
119-137 (with episodes into the 140s); RR 19-22; O2 93-97% on
RA.
GENERAL: Cachectic, comfortable, NAD
HEENT: MM dry, no LAD, neck supple
CARDIAC: Tachycardic, regular, No MRG
LUNG: Decreased breath sounds in bases bilaterally, no crackles,
wheezes.
ABDOMEN: Moderately distended, not tense, BS+, no tenderness. No
rebound or gaurding. Midline and RUQ surgical scar. Multiple
excoriations on abdomen.
EXT: 3+ pitting edema in LE's bilaterally (R > L)
NEURO: CNII-XII intact. Motor [**3-29**] upper and lower.
.

FAMILY HISTORY: NC

SOCIAL HISTORY: denies any tobacco, EtOH or illict drug use. Lives at home with
parents. Has one child with a prior girlfriend. Does not work. 

### Response:
{'Infection and inflammatory reaction due to other vascular device, implant, and graft,Other septicemia due to gram-negative organisms,End stage renal disease,Obstruction of bile duct,Liver replaced by transplant,Unspecified pleural effusion,Other ascites,Aseptic necrosis of head and neck of femur,Portal hypertension,Cellulitis and abscess of trunk,Kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Renal dialysis status,Awaiting organ transplant status,Other specified cardiac dysrhythmias,Asthma, unspecified type, unspecified,Anemia in chronic kidney disease,Unspecified pruritic disorder'}
