CHIEF COMPLAINT: Fever

PRESENT ILLNESS: Mr. [**Known lastname 66189**] is a 72 yo male with ESRD on HD, IDDM, chronically
ventilated since prior CVA, who is transferred from [**Hospital 100**] Rehab
with fevers beginning on [**5-26**].  At [**Hospital 100**] Rehab he was started
empirically on PO metronidazole for suspected c. difficile
colitis, but all c. diff toxins returned negative.  Tmax was
101.2 on [**6-5**], and he was started empirically on vancomycin and
zosyn.  Since then, he has had persistent low-grade fevers of
99.4-100.2.  Urine, stool, and blood cultures have been no
growth to date.  Sputum cultures have repeated grown pseudomonas
aeurginosa (sensitive to zosyn, ceftaz; intermediate to
cefepime).  WBC increased from 9.8 on [**5-25**] to 23 on [**5-27**].  It
has subsequently remained elevated in the range of 14-19.

MEDICAL HISTORY: 1. Diabetes mellitus, Type II.  Diagnosed 40 years ago,
complicated by nephropathy, neuropathy (sensory and autonomic
leading to urinary retention) and retinopathy (s/p bilat
vitrectomies, L eye blindness).
2. ESRD secondary to diabetic nephropathy + chronic allograft
insufficiency s/p R cadaveric kidney transplant, complicated by
postinfectious GN (negative [**Doctor First Name **], ANCA, low complemt), signs of
chronic rejection (sclerotic glomeruli, interstitial fibrosis
3/[**2158**]).  On dialysis starting [**2148**].
3. Anemia
4. Hypertension
5. Neurogenic bladder
6. BPH s/p TURP [**2157**].
5. PVD s/p left popliteal-dorsalis pedis bypass with saphenous
vein graft
6. Chronic osteomyelitis of C-spine and bilateral feet, s/p
bilateral transmetatarsal amputations (R foot [**2145**], L foot
[**2157**]).
7. HSV stomatitis/genital
8. Recurrent UTI
9. s/p right MCA stroke [**1-19**]
10. blindness in right eye
11. Respiratory failure, chronically vented on CPAP 15/5, FiO2
35%

MEDICATION ON ADMISSION: Zosyn 2.25 grams q12 hours (start date [**6-5**])
Vancomycin 1 gram qHD M,Th,Sat
Acetic acid 1% irrigation daily
Combivent 6 puffs QID
ASA 81 mg daily
Lantus 7 un qHS
RISS
Lactobacillus 2 tab [**Hospital1 **]
Reglan 5 mg q8 hours
MVI 5 ml daily
Omeprazole 20 mg daily
Simvastatin 20 mg qHS
Codeine sulfate 7.5 mg q8 hours PRN
Lorazepam 0.25 mg q6 hours PRN
Zofran 4 mg IM PRN

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 98.1, BP 102/61, HR 90, RR 19, SpO2 99% on FiO2 35%
Gen: minimally responsive, grimacing to noxious stimuli
Neck: trach in place, no purulent secretions
CV: RRR, [**2-17**] murmur best auscultated at apex
Resp: lungs CTA
Abdomen: PEG clean, dry, intact; soft, + BS
Extrem: s/p bilateral partial foot amputations, diffuse muscle
wasting in lower extremities; scar tissue with functioning AV
fistula in LUE; midline in antecubital fossa of RUE; increased
rigidity of RUE; flacid LUE
Skin: full thickness decubitus ulcer covered with feces

FAMILY HISTORY: Mother and brother with DM Type 2.

SOCIAL HISTORY: Immigrated from [**Country **] in [**2141**].  Retired from being a civil
engineer at age 47 because of ??????health issues.??????  Currently lives
with wife and 38 [**Name2 (NI) **] daughter.  Denies alcohol, tobacco, drugs.
Glucocorticoid deficiency,Pressure ulcer, lower back,Chronic respiratory failure,Dependence on respirator, status,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Complications of transplanted kidney,Unspecified pleural effusion,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Background diabetic retinopathy,Neurogenic bladder NOS,Tracheostomy status,Unqualified visual loss, one eye,Old myocardial infarction,Aortocoronary bypass status,Carrier or suspected carrier of other specified bacterial diseases,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Peripheral vascular disease, unspecified
Glucocorticoid deficient,Pressure ulcer, low back,Chronic respiratory fail,Respirator depend status,Hyp kid NOS w cr kid V,End stage renal disease,Compl kidney transplant,Pleural effusion NOS,Late ef-hemplga side NOS,Abn react-org transplant,DMII renl nt st uncntrld,Neuropathy in diabetes,Diabetic retinopathy NOS,Neurogenic bladder NOS,Tracheostomy status,Visual loss, one eye NOS,Old myocardial infarct,Aortocoronary bypass,Bacteria dis carrier NEC,BPH w/o urinary obs/LUTS,Cholelithiasis NOS,Pseudomonas infect NOS,Periph vascular dis NOS
Admission Date:  [**2162-6-10**]              Discharge Date:   [**2162-6-17**]

Date of Birth:  [**2089-8-16**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Fever

Major Surgical or Invasive Procedure:
None

History of Present Illness:
Mr. [**Known lastname 66189**] is a 72 yo male with ESRD on HD, IDDM, chronically
ventilated since prior CVA, who is transferred from [**Hospital 100**] Rehab
with fevers beginning on [**5-26**].  At [**Hospital 100**] Rehab he was started
empirically on PO metronidazole for suspected c. difficile
colitis, but all c. diff toxins returned negative.  Tmax was
101.2 on [**6-5**], and he was started empirically on vancomycin and
zosyn.  Since then, he has had persistent low-grade fevers of
99.4-100.2.  Urine, stool, and blood cultures have been no
growth to date.  Sputum cultures have repeated grown pseudomonas
aeurginosa (sensitive to zosyn, ceftaz; intermediate to
cefepime).  WBC increased from 9.8 on [**5-25**] to 23 on [**5-27**].  It
has subsequently remained elevated in the range of 14-19.

In [**2161-12-12**], his functional status declined, had difficulty
walking and required transport to dialysis. He had heart attack
and underwent cabg at [**Hospital1 2177**] in [**2162-1-12**], post-operatively had
stroke, L sided hemiparesis but could still talk, though had
aphasia, went to [**Hospital1 **]. At [**Hospital1 **] developed sacral decubs,
developed sepsis in [**Month (only) 958**] and he want to [**Hospital1 2177**]. We was intubated
and septic in ICU at [**Hospital1 2177**] and the was discharged to [**Hospital 100**] Rehab
still requiring mechanical ventilation. He had a trach placed at
[**Hospital1 2177**]. At [**Hospital 100**] Rehab over the past months, he would nod his head
to queestion. Has not been able to talk.

Review of medical records revals a nonproductive cough and
minimal secretions from the trach.  There was no other report of
localizing symptoms.  [**Name8 (MD) **] RN, patient does not make urine but
has been straight-cathed daily to drain bladder pus.  Stools are
well-formed.

Past Medical History:
1. Diabetes mellitus, Type II.  Diagnosed 40 years ago,
complicated by nephropathy, neuropathy (sensory and autonomic
leading to urinary retention) and retinopathy (s/p bilat
vitrectomies, L eye blindness).
2. ESRD secondary to diabetic nephropathy + chronic allograft
insufficiency s/p R cadaveric kidney transplant, complicated by
postinfectious GN (negative [**Doctor First Name **], ANCA, low complemt), signs of
chronic rejection (sclerotic glomeruli, interstitial fibrosis
3/[**2158**]).  On dialysis starting [**2148**].
3. Anemia
4. Hypertension
5. Neurogenic bladder
6. BPH s/p TURP [**2157**].
5. PVD s/p left popliteal-dorsalis pedis bypass with saphenous
vein graft
6. Chronic osteomyelitis of C-spine and bilateral feet, s/p
bilateral transmetatarsal amputations (R foot [**2145**], L foot
[**2157**]).
7. HSV stomatitis/genital
8. Recurrent UTI
9. s/p right MCA stroke [**1-19**]
10. blindness in right eye
11. Respiratory failure, chronically vented on CPAP 15/5, FiO2
35%


Social History:
Immigrated from [**Country **] in [**2141**].  Retired from being a civil
engineer at age 47 because of ??????health issues.??????  Currently lives
with wife and 38 [**Name2 (NI) **] daughter.  Denies alcohol, tobacco, drugs.


Family History:
Mother and brother with DM Type 2.

Physical Exam:
VS: T 98.1, BP 102/61, HR 90, RR 19, SpO2 99% on FiO2 35%
Gen: minimally responsive, grimacing to noxious stimuli
Neck: trach in place, no purulent secretions
CV: RRR, [**2-17**] murmur best auscultated at apex
Resp: lungs CTA
Abdomen: PEG clean, dry, intact; soft, + BS
Extrem: s/p bilateral partial foot amputations, diffuse muscle
wasting in lower extremities; scar tissue with functioning AV
fistula in LUE; midline in antecubital fossa of RUE; increased
rigidity of RUE; flacid LUE
Skin: full thickness decubitus ulcer covered with feces


Pertinent Results:
[**2162-6-10**] 08:30PM BLOOD WBC-8.9# RBC-3.40* Hgb-10.3* Hct-32.8*
MCV-97 MCH-30.3 MCHC-31.5 RDW-17.4* Plt Ct-331#
[**2162-6-10**] 08:30PM BLOOD Neuts-77.2* Lymphs-14.1* Monos-3.7
Eos-4.5* Baso-0.5
[**2162-6-17**] 03:13AM BLOOD WBC-7.8 RBC-3.36* Hgb-10.5* Hct-32.8*
MCV-98 MCH-31.2 MCHC-32.0 RDW-17.2* Plt Ct-356
[**2162-6-10**] 08:30PM BLOOD PT-15.7* PTT-35.9* INR(PT)-1.4*
[**2162-6-10**] 08:30PM BLOOD Glucose-159* UreaN-37* Creat-2.3*# Na-141
K-3.9 Cl-103 HCO3-30 AnGap-12
[**2162-6-17**] 03:13AM BLOOD Glucose-223* UreaN-46* Creat-3.2* Na-137
K-4.1 Cl-99 HCO3-27 AnGap-15
[**2162-6-10**] 08:30PM BLOOD ALT-104* AST-173* AlkPhos-264*
TotBili-0.3
[**2162-6-15**] 05:27AM BLOOD ALT-37 AST-39 LD(LDH)-128 AlkPhos-161*
TotBili-0.3
[**2162-6-11**] 04:00AM BLOOD Lipase-12
[**2162-6-10**] 08:30PM BLOOD Albumin-2.6* Calcium-9.0 Phos-2.6* Mg-1.7
[**2162-6-17**] 03:13AM BLOOD Calcium-9.7 Phos-3.7 Mg-2.2
[**2162-6-14**] 05:38PM BLOOD Cortsol-5.6
[**2162-6-14**] 06:15PM BLOOD Cortsol-14.7
[**2162-6-14**] 06:45PM BLOOD Cortsol-16.3
[**2162-6-12**] 03:00AM BLOOD Vanco-25.9*
[**2162-6-15**] 05:27AM BLOOD Vanco-23.2*
[**2162-6-10**] 07:12PM BLOOD Type-ART PEEP-5 FiO2-35 pO2-42* pCO2-42
pH-7.49* calTCO2-33* Base XS-7 Vent-SPONTANEOU
[**2162-6-10**] 08:32PM BLOOD Type-ART Temp-37.8 PEEP-5 FiO2-35
pO2-118* pCO2-44 pH-7.47* calTCO2-33* Base XS-8
Intubat-INTUBATED Vent-SPONTANEOU
[**2162-6-12**] 03:10AM BLOOD Type-ART Temp-37.2 Rates-25/ Tidal V-500
PEEP-5 FiO2-35 pO2-125* pCO2-42 pH-7.44 calTCO2-29 Base XS-4
Intubat-INTUBATED Vent-IMV Comment-TRACH
[**2162-6-16**] 03:20AM BLOOD Type-ART pO2-116* pCO2-46* pH-7.43
calTCO2-32* Base XS-5 Intubat-INTUBATED
[**2162-6-10**] 07:12PM BLOOD Lactate-2.2*
[**2162-6-10**] 08:32PM BLOOD Lactate-1.3
[**2162-6-10**] 10:43PM BLOOD Lactate-1.0
[**2162-6-10**] 08:32PM BLOOD freeCa-1.17
.
MICROBIOLOGY:
[**2162-6-16**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
negative
[**2162-6-15**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
negative
[**2162-6-14**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2162-6-14**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2162-6-13**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2162-6-13**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2162-6-12**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2162-6-12**] URINE URINE CULTURE-FINAL no growth
[**2162-6-11**] BLOOD CULTURE Blood Culture, Routine-FINAL no growth
[**2162-6-10**] [**2162-6-10**] 6:30 pm SPUTUM      Source: Endotracheal.

   GRAM STAIN (Final [**2162-6-10**]):
      >25 PMNs and <10 epithelial cells/100X field.
      1+    (<1 per 1000X FIELD):   GRAM NEGATIVE ROD(S).

   RESPIRATORY CULTURE (Final [**2162-6-13**]):
      OROPHARYNGEAL FLORA ABSENT.
      PSEUDOMONAS AERUGINOSA.    SPARSE GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             PSEUDOMONAS AERUGINOSA
                             |
CEFEPIME--------------     8 S
CEFTAZIDIME-----------     4 S
CIPROFLOXACIN---------     2 I
GENTAMICIN------------     4 S
MEROPENEM-------------     1 S
PIPERACILLIN----------    32 S
PIPERACILLIN/TAZO-----    64 S
TOBRAMYCIN------------   <=1 S

   LEGIONELLA CULTURE (Final [**2162-6-17**]):    NO LEGIONELLA
ISOLATED.

   FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.

[**2162-6-10**] BLOOD CULTURE Blood Culture, Routine-no growth
.
CHEST (PORTABLE AP)  [**2162-6-10**] 6:53 PM
FINDINGS: No recent views for comparison. The patient has
undergone a CABG procedure with intact sternal sutures.
Tracheostomy tip lies approximately 3.3 cm above the carina.
Pacemaker device with single lead extending to the right
ventricle. No evidence of pneumothorax. Apical pleural
thickening is seen, as on the study of [**2160-6-27**]. There is some
haziness to the lower hemithoraces raising the possibility of
layering pleural effusion. Bibasilar atelectatic change is seen.
.
BILAT UP EXT VEINS US  [**2162-6-11**] 8:42 AM
CLINICAL HISTORY: Questionable right upper extremity DVT.
Evaluation of the deep venous system in the right upper
extremity was performed utilizing grayscale images, Doppler
flow, compression, and augmentation. There is mild eccentric
thickening in the wall of the right internal jugular vein which
raises a possibility of an element of chronic thrombosis in this
region. The right internal jugular vein, however, is patent and
compressible. The right subclavian, axillary, and brachial veins
are unremarkable. A PICC line is noted in the brachial vein.
Evaluation of the deep venous system in the left upper extremity
was also performed. The study demonstrates left internal
jugular, subclavian, axillary, and brachial veins to be patent.
There is a left-sided brachial AV fistula likely representing
patient's dialysis fistula. Note was made of thrombosis of the
left basilic vein, which is a superficial vein in the forearm.

IMPRESSION:
1. No evidence of acute DVT in either upper extremity.
2. Mild eccentric thickening in the right internal jugular vein
which may reflect a non-occlusive old/chronic thrombus.
3. Thrombosis of the left basilic vein which is a superficial
vein.
4. Left brachial arteriovenous dialysis fistula.

.
ABDOMEN U.S. (COMPLETE STUDY) PORT  [**2162-6-11**] 8:41 AM
IMPRESSION:
1. Cholelithiasis and minimal gallbladder wall thickening. Since
the gallbladder does not appear to be distended, these findings
are unlikely to reflect cholecystitis. If there is a clinical
concern for cystic duct obstruction, a nuclear HIDA scan can be
performed for further evaluation.
2. Incidental bilateral pleural effusions.
.
[**2162-6-11**] TTE
The left atrium is normal in size. The interatrial septum is
aneurysmal. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
masses or vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: No evidence of endocarditis. Normal global
biventricular systolic function. Mild mitral regurgitation.
Compared with the prior study (images reviewed) of [**2160-6-27**], an
interatrial shunt could not be demonstrated on the current
study. Pericardial effusion has resolved. The other findings are
similar.
.
CT CHEST W/O CONTRAST  [**2162-6-13**] 4:14 PM
IMPRESSION:
1. Large non-hemorrhagic non-loculated bilateral pleural
effusions. The effusions are symmetric in size bilaterally.
2. Gallstones. Possible cysts within the body and also within
the head and proximal tail of the pancreas, which could be
further assessed with MR of the abdomen.
3. Bilateral atrophic kidneys.
.
CHEST (PORTABLE AP)  [**2162-6-16**] 2:50 AM
The tracheostomy tip is at the midline, terminating 6.5 cm above
the carina. The pacemaker leads terminate in the right
ventricle, unchanged. The cardiomediastinal silhouette is
stable. There is no change in mild vascular enlargement and
large bilateral pleural effusions, right more than left, as well
as bibasilar areas of atelectasis.


Brief Hospital Course:
72 year old male with ESRD on HD, chronically ventilated since
prior CVA, who was transferred from [**Hospital 100**] Rehab with fevers
beginning on [**5-26**], course complicated by hypotension. Hospital
course by problem:
.
# Fevers/Hypotension/Adrenal Insufficiency: The patient remained
afebrile since admission. He was continued on vanc/zosyn which
had been started at his NH, and ciprofloxacin was added as he
was found to have a sacral ulcer contaminated with stool. He had
the area cleaned, a rectal tube placed to avoid contamination,
and the wound evaluated by wound nurse who recommended wund care
and dressing changes. Despite antibiotics, he remained
hypotensive, requiring IV pressors. Blood and stool culture data
were unrevealing (some blood cultures are still pending at time
of discharge). Sputum culture was positive for pseudomonas
though this was felt to be due to colonization. Chest xray and
CT did not suggest pneumonia. He does have chronic bilateral
effusions, not loculating, which had been tapped at his prior
hospitalization at [**Hospital1 2177**]. He had a TTE which was negative for
vegetation. He had a RUE US to evaluate for DVT as a possible
source of infection (given that he was noted to have a R SCV
clot on [**Hospital1 2177**] records) which was negative for DVT. His recurrent
intermittent fevers prior to admission were felt to most likely
be due to seeding of his sacral ulcer with stool. Given the
patient's persistent hypotension on broadspectrum antibiotics,
with no evidence of active infection, the patient had a cortisol
stimulation test which was consistent with adrenal insufficiency
(cortisol level 5, bumped to less than 19). He was started on
hydrocortisone [**6-14**] and subsequently remained stable off of IV
pressors, in fact becoming hypertensive to the SBP 170s.
Hydrocortisone was changed to prednisone 40mg daily on [**6-16**], to
begin a slow 2 week taper, with plan to repeat a cortisol
stimulation test as an outpatient. On [**6-16**] his antibiotics were
discontinued as he had completed a 10 day course of antibiotics
since his last febrile episode. He remained afebrile
subsequently for >24hrs.  His PCP should follow up on remaining
culture data and evaluate for ability to wean off of steroid
supplementation. A repeat cortisol stimulation test should be
performed in 2 weeks.
.
# HTN: The patient was hypertensive to SBPs 170s on [**6-17**]. He had
HD to remove 3L which brought his BP down to 146/61.
.
# Sacral decubitus ulcer: Ulcer was found to be contaminated
with feces, which is why he was treated with cipro. Rectal tube
was placed and wound evaluated by wound nurse. Please see wound
care instructions for further management. Continue rectal back
and q72h dressing changes.
.
# ESRD: Patient received HD according to his regular Tues,
Thurs, Sat schedule by AV fistula in LUE.
.
# Respiratory failure: Patient is chronically vented. He was
weaned to CPAP and PS with PEEP 5/ PS 5. He may tolerate a trial
of trach mask.
.
# DM2: He was continued pm Glargine qHS (increased to 14u due to
steroids) + RISS.  This may need to be adjusted as steroids are
weaned.
.
# FEN: He was continued on Nutren Renal @ 40 cc/hour.
.
# PPx: SQ heparin, PPI.
.
# Access: RUE midline inserted [**5-1**], changed [**6-5**].
.
# Code status: Full code, confirmed with HCP.
.
# Communication: HCP is daughter [**Name (NI) 4457**] [**Name (NI) 66189**] (daughter):
[**Telephone/Fax (1) 94885**].
Dispo: [**Hospital 100**] Rehab.


Medications on Admission:
Zosyn 2.25 grams q12 hours (start date [**6-5**])
Vancomycin 1 gram qHD M,Th,Sat
Acetic acid 1% irrigation daily
Combivent 6 puffs QID
ASA 81 mg daily
Lantus 7 un qHS
RISS
Lactobacillus 2 tab [**Hospital1 **]
Reglan 5 mg q8 hours
MVI 5 ml daily
Omeprazole 20 mg daily
Simvastatin 20 mg qHS
Codeine sulfate 7.5 mg q8 hours PRN
Lorazepam 0.25 mg q6 hours PRN
Zofran 4 mg IM PRN


Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) mL
Injection TID (3 times a day).
2. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day): only use if is on
mechanical ventilation.
3. Simvastatin 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Metoclopramide 10 mg Tablet [**Hospital1 **]: 0.5 Tablet PO TID (3 times a
day).
6. Therapeutic Multivitamin     Liquid [**Hospital1 **]: Five (5) ML PO DAILY
(Daily).
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [**Last Name (STitle) **]: Six
(6) Puff Inhalation Q4H (every 4 hours).
9. Insulin Glargine 100 unit/mL Cartridge [**Last Name (STitle) **]: Fifteen (15)
units Subcutaneous at bedtime.
10. Humalog 100 unit/mL Cartridge [**Last Name (STitle) **]: as directed as directed
Subcutaneous four times a day: glucose
0-60: give [**1-13**] amp D50; 61-180: give 0;
181-240: give 6 units;
241-320: give 8 units;
321-400: give 10 units;
>400: [**Name8 (MD) 138**] MD.
11. Prednisone 5 mg Tablet [**Name8 (MD) **]: as directed Tablet PO once a
day: [**6-18**], [**6-19**]: 40mg. [**6-20**], [**6-21**], [**6-22**], [**6-23**]: 30mg. [**6-24**], [**6-25**],
[**6-26**], [**6-27**]: 20mg. [**6-28**] change to 10mg daily, continue until
evaluated by PCP .


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
Primary
1. adrenal insufficiency
2. sacral pressure ulcer
3. end stage renal disease on hemodialysis

Secondary
1. hypertension
2. chronic respiratory failure
3. type 2 diabetes
4. chronic anemia
5. status post right MCA stroke


Discharge Condition:
able to open eyes, occasionally mouths words, squeezes hand
(inconsistently), afebrile, trached


Discharge Instructions:
You were admitted to the hospital for persistent low grade
fevers and hypotension. No source of infection was found,
however, it was felt that a possible source of infection was
your sacral ulcer which was found to be contaminated by stool.
You were continued on vanc/zosyn, and a third antibiotic,
ciprofloxacin was added to your regimen to cover for stool
organisms. You remained afebrile throughout your stay in the
hospital but you required IV pressors for several days despite
antibiotics. You had a cortisol stimulation test which showed
that you had adrenal insufficiency so you were started on high
dose hydrocortisone. After this your blood pressure remained
stable and you no longer required pressors. You were
transitioned to oral prednisone which should be tapered slowly
over 2 weeks as your blood pressure tolerates. You should follow
up with your PCP and have [**Name Initial (PRE) **] repeat cortisol stim test in 2
weeks. You completed a 10 day course of antibiotics which ended
[**6-16**] and remained afebrile.
.
You received hemodialysis according to your normal schedule.
.
Please continue to take your medications as prescribed. Continue
to go to your regularly scheduled dialysis sessions. Please
follow wound care instructions to maintain the area of your
ulcer clean and dry. Your CPAP settings were gradually weaned to
[**5-17**]. You may benefit from a trial of trach mask.
.
If you develop fever or any other concerning symptoms, please
call your doctor or come to the hospital.

Followup Instructions:
Continue hemodialysis on Tuesday, Thursday, Saturday schedule.
Repeat cortisol stimulation test in 2 weeks by PCP.


                             [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

Completed by:[**2162-6-17**]
{'Glucocorticoid deficiency,Pressure ulcer, lower back,Chronic respiratory failure,Dependence on respirator, status,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Complications of transplanted kidney,Unspecified pleural effusion,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Background diabetic retinopathy,Neurogenic bladder NOS,Tracheostomy status,Unqualified visual loss, one eye,Old myocardial infarction,Aortocoronary bypass status,Carrier or suspected carrier of other specified bacterial diseases,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Peripheral vascular disease, unspecified'}


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: Fever

PRESENT ILLNESS: Mr. [**Known lastname 66189**] is a 72 yo male with ESRD on HD, IDDM, chronically
ventilated since prior CVA, who is transferred from [**Hospital 100**] Rehab
with fevers beginning on [**5-26**].  At [**Hospital 100**] Rehab he was started
empirically on PO metronidazole for suspected c. difficile
colitis, but all c. diff toxins returned negative.  Tmax was
101.2 on [**6-5**], and he was started empirically on vancomycin and
zosyn.  Since then, he has had persistent low-grade fevers of
99.4-100.2.  Urine, stool, and blood cultures have been no
growth to date.  Sputum cultures have repeated grown pseudomonas
aeurginosa (sensitive to zosyn, ceftaz; intermediate to
cefepime).  WBC increased from 9.8 on [**5-25**] to 23 on [**5-27**].  It
has subsequently remained elevated in the range of 14-19.

MEDICAL HISTORY: 1. Diabetes mellitus, Type II.  Diagnosed 40 years ago,
complicated by nephropathy, neuropathy (sensory and autonomic
leading to urinary retention) and retinopathy (s/p bilat
vitrectomies, L eye blindness).
2. ESRD secondary to diabetic nephropathy + chronic allograft
insufficiency s/p R cadaveric kidney transplant, complicated by
postinfectious GN (negative [**Doctor First Name **], ANCA, low complemt), signs of
chronic rejection (sclerotic glomeruli, interstitial fibrosis
3/[**2158**]).  On dialysis starting [**2148**].
3. Anemia
4. Hypertension
5. Neurogenic bladder
6. BPH s/p TURP [**2157**].
5. PVD s/p left popliteal-dorsalis pedis bypass with saphenous
vein graft
6. Chronic osteomyelitis of C-spine and bilateral feet, s/p
bilateral transmetatarsal amputations (R foot [**2145**], L foot
[**2157**]).
7. HSV stomatitis/genital
8. Recurrent UTI
9. s/p right MCA stroke [**1-19**]
10. blindness in right eye
11. Respiratory failure, chronically vented on CPAP 15/5, FiO2
35%

MEDICATION ON ADMISSION: Zosyn 2.25 grams q12 hours (start date [**6-5**])
Vancomycin 1 gram qHD M,Th,Sat
Acetic acid 1% irrigation daily
Combivent 6 puffs QID
ASA 81 mg daily
Lantus 7 un qHS
RISS
Lactobacillus 2 tab [**Hospital1 **]
Reglan 5 mg q8 hours
MVI 5 ml daily
Omeprazole 20 mg daily
Simvastatin 20 mg qHS
Codeine sulfate 7.5 mg q8 hours PRN
Lorazepam 0.25 mg q6 hours PRN
Zofran 4 mg IM PRN

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 98.1, BP 102/61, HR 90, RR 19, SpO2 99% on FiO2 35%
Gen: minimally responsive, grimacing to noxious stimuli
Neck: trach in place, no purulent secretions
CV: RRR, [**2-17**] murmur best auscultated at apex
Resp: lungs CTA
Abdomen: PEG clean, dry, intact; soft, + BS
Extrem: s/p bilateral partial foot amputations, diffuse muscle
wasting in lower extremities; scar tissue with functioning AV
fistula in LUE; midline in antecubital fossa of RUE; increased
rigidity of RUE; flacid LUE
Skin: full thickness decubitus ulcer covered with feces

FAMILY HISTORY: Mother and brother with DM Type 2.

SOCIAL HISTORY: Immigrated from [**Country **] in [**2141**].  Retired from being a civil
engineer at age 47 because of ??????health issues.??????  Currently lives
with wife and 38 [**Name2 (NI) **] daughter.  Denies alcohol, tobacco, drugs. 

### Response:
{'Glucocorticoid deficiency,Pressure ulcer, lower back,Chronic respiratory failure,Dependence on respirator, status,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Complications of transplanted kidney,Unspecified pleural effusion,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Background diabetic retinopathy,Neurogenic bladder NOS,Tracheostomy status,Unqualified visual loss, one eye,Old myocardial infarction,Aortocoronary bypass status,Carrier or suspected carrier of other specified bacterial diseases,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Peripheral vascular disease, unspecified'}
