CHIEF COMPLAINT: Hypoglycemia

PRESENT ILLNESS: Reliability: Patient was AAOx3 however did endorse seeing an
"extra man" in the room when asked how many persons where
present in room. History also obtained from patient's wife and
medical records from rehab and [**Hospital3 **] ED.
.
Patient is 68-year-old male with ESRD status post cadaver kidney
transplant in [**2130**] on tacrolimus/prednisone, type 1 diabetes,
CAD status post CABG x4, PVD status post right popliteal stent
and 2nd right toe amputation in addition to history of MRSA
osteomyelitis,
chronic lower extremity nonhealing ulcers, history of multiple
DVTs on Coumadin with IVC filter, diastolic heart failure,
multiple prior C. difficile episodes in [**2135**], [**2138**], and [**4-/2140**]
among other conditions that presents from rehab with confusion
and low oxygen saturation.
.
Patient was recently admitted to [**Hospital1 18**] in [**2140-4-29**] for
nausea/vomiting with eating with GI work-up revealing
gastroparesis and C. difficile diarrhea treated with PO
vancomycin.
.
At some point, he was admitted to rehab for PT/OT. His rehab
course was complicated by pneumonia and urinary tract infection
(no culture data available), which were treated with a 7-day
course of Ceftin (course was started around [**2140-6-30**]). The
patient required about 2-3 L NC while he had pneumonia.
.
He was in his otherwise normal state of health at rehab until
about 2-3 days ago when he needed nebulizer treatments on Friday
and also developed supplemental oxygen requirement on Saturday
similar to what he needed when he had pneumonia about 3-4 weeks
ago. His wife also stated that at baseline his mental status has
been AAOx3 but he does seem forgetful with hallucinations (e.g.
little kid hiding in the corner) with any illness and
dehydration. Of note, he had a CXR on [**2140-7-14**] that was compared
to his prior chest x-ray showing clearing of bilateral
infiltrates and pneumonia - namely the prominent right perihilar
infiltrate and small left perihilar infiltrate.
.
At the Guardian [**Name (NI) **] rehab, BLS placed him on 100 % NRB for
hypoxemia (unknown number) with O2 sat in 90s.
.
He was taken to [**Hospital3 **] ED where he was thought to be "really
confused" with no focal neurological deficits or post-ictal
state. His O2 sat was low as well (unknown number). He received
500 cc of fluid and a ? dose of Ceftin. He was transferred to
[**Hospital1 18**] given that he received a transplant here.
.
VS prior to transfer from [**Hospital3 **] ED were T 98.8 BP 124/62 HR
71 RR 22 Glc 169
.
In the ED, initial VS were: Triage 17:52 0 97.2 52 90/46 16 98%
4L
.
He arrived to [**Hospital1 18**] ED with relative hypotension with blood
pressures of 90/40, saturating 96% on 2 L nasal cannula with
diffuse crackles and wheezes on his lung fields.
.
Of note, recent BP in clinic per [**Hospital1 581**] are 88/60, 102/82,
92/52, 118/80 from past 2 years. BP at rehab on [**2140-5-6**] was
121/80.
.
BP remained stable in ER, required 2 L NC throughout ER course.
.
Labs were performed
- WBC 3.7 Hgb 8.2 (of note baseline ~ 10) Plt 253 with Diff N
70.9 L 16.5 E 6.6
- INR 2.8 (in setting of coumadin therapy) PTT 44.3
- Na 139 K 5.2 Cl 111 HCO3 23 BUN 17 Cr 1.6 (Cr 1.1-1.2) Glc 83
- cTropnT 0.07
- UA Nit neg pH 6 LE Mod WBC > 182 bacteria many Epi 0 cast Gr
13
.
Diagnostic testing was performed:
- ECG: Sinus bradycardia at 52 bpm, NA, NI except QTc 502 ms, no
ST/T changes or STEMI. Low voltage I, II, III, aVR, aVL, aVF.
Compared to prior dated [**2140-1-25**], rhythm is NSR at 87 bpm, QTc
427 ms
- CXR (prelim): layering effusion, scarring atelectasis in lower
base. Cardiomediastinal unchanged. IVC filter seen.
Impression: Bilateral pleural effusions and cephalization,
post-surgical changes in right lung without definite
consolidation.
.
He was given:
- hydrocortisone 100 mg IV x 1 for stress dose steroids
- cefepime 2 gm IV and vancomycin 1000 mg IV
- 2 L NS with urine output of 95 mL
.
VS on transfer: 18:38 53 100/41 17 97% on 2 L NC
.
On arrival to the MICU, the patient was AAOx3 but thought that
another man was standing behind me - which was not true. He was
also noted that have Tax 94. Urine output was poor, and he
received 2 L NS bolus.
.
He denies any localizing complaints such as cough, abdominal
pain, dysuria although does admit to low oxygen levels.
.
Review of systems:
(+) Per HPI; fatigue, shortness of breath x 2 weeks, worsened
over last week
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.

MEDICAL HISTORY: -DVT (multiple) s/p IVC filter [**3-/2134**] on coumadin for life
-CAD s/p CABG and MI; s/p stents
-Chronic dCHF
-HTN
-DM1 with retinopathy, neuropathy, ESRD, R charcot foot in [**2125**]
-s/p cadaveric renal transplant in [**9-/2131**] on prednisone and
tacrolimus
-ORIF right arm
-chronic foot ulcer
-amputated right toe
-MRSA right foot with osteomyelitis
-C diff colitis [**5-6**]
-cryptococcal pna in [**4-3**], now on fluconazole suppressive
therapy
-lung nodules
-PVD
-GERD
-b/l cataract surgery,
-s/p [**Doctor Last Name **] artery angioplasty in [**6-4**]
-cellulitis
-chronic osteomyelitis followed in ID clinico
-Anemia
-Arteriogram showing R fem/tib and L tib dz and [**Date Range 1106**] plans
to consider intervention as outpatient.

MEDICATION ON ADMISSION: Preadmissions medications listed are incomplete and require
futher investigation.  Information was obtained from
Family/[**Name (NI) 31571**] rehab list.
1. Amlodipine 5 mg PO DAILY
hold for sbp<100 or hr<60
2. Clopidogrel 75 mg PO DAILY
3. Fluconazole 200 mg PO Q24H
4. Glargine 15 Units Bedtime
Insulin SC Sliding Scale using novolog Insulin
5. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
hodl for sbp<100 or hr<60
6. Metoprolol Tartrate 50 mg PO BID
hold for sbp<100 or hr<60
7. Mirtazapine 7.5 mg PO HS
8. PredniSONE 5 mg PO DAILY
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
10. Tacrolimus 0.5 mg PO Q12H
11. Travatan Z *NF* (travoprost) 0.004 % OS qday
12. Tamsulosin 0.4 mg PO HS
13. Actonel *NF* (risedronate) 35 mg Oral q Sunday
14. Nitroglycerin SL 0.3 mg SL PRN chest pain
15. Senna with Docusate Sodium *NF* (sennosides-docusate sodium)
8.6-50 mg Oral qhs
16. Ascorbic Acid 500 mg PO BID
17. Multivitamins 1 TAB PO DAILY
18. Acetaminophen 650 mg PO Q4H:PRN pain
do not exceed 4 g in 24 hour period
19. Aspirin 81 mg PO DAILY
20. Atorvastatin 80 mg PO DAILY
21. Pantoprazole 20 mg PO Q12H
22. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/hwheezing
23. Warfarin 1 mg PO DAILY16

ALLERGIES: Tegaderm Frame Style / Prinivil / Reglan / Levofloxacin

PHYSICAL EXAM: Admission PE:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, shoddy lymphadenopathy of
anterior cervical chain, more prominent on left than right
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: decreased inspiratory effort, mild rhonchi at right base,
however difficult to appreciate given limited exam.
Abdomen: distended, non-tender, difficult to appreciate
organomegaly given firmness of abdomen.
GU: no foley
Ext: multiple ulcers over LE bilaterally in various stages of
healing, 2+ edema of LE b/l, multiple scars present, amputation
of digits present.
Neuro: grossly normal sensation, non focal exam

FAMILY HISTORY: FAMILY HISTORY:
DM type II in father and paternal grandfather. Mother had "heart

SOCIAL HISTORY: SOCIAL HISTORY
-Lives w/ wifw, has 3 children
-Tobacco history: Former smoker, 2ppd for many years
-ETOH: Infrequent now that in [**Hospital1 1501**]
-Illicit drugs: None
-uses wheelchair for ambulation
.
Unspecified septicemia,Acute kidney failure with lesion of tubular necrosis,Toxic encephalopathy,Pressure ulcer, stage III,Complications of transplanted kidney,Chronic diastolic heart failure,Urinary tract infection, site not specified,Long-term (current) use of insulin,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Peripheral vascular disease, unspecified,Other toe(s) amputation status,Personal history of venous thrombosis and embolism,Diabetes with ophthalmic manifestations, type I [juvenile type], not stated as uncontrolled,Background diabetic retinopathy,Polyneuropathy in diabetes,Esophageal reflux,Personal history of tobacco use,Sepsis,Anemia in chronic kidney disease,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS)
Septicemia NOS,Ac kidny fail, tubr necr,Toxic encephalopathy,Pressure ulcer,stage III,Compl kidney transplant,Chr diastolic hrt fail,Urin tract infection NOS,Long-term use of insulin,Abn react-org transplant,Cor ath unsp vsl ntv/gft,Aortocoronary bypass,Periph vascular dis NOS,Status amput othr toe(s),Hx-ven thrombosis/embols,DMI ophth nt st uncntrld,Diabetic retinopathy NOS,Neuropathy in diabetes,Esophageal reflux,History of tobacco use,Sepsis,Anemia in chr kidney dis,BPH w/o urinary obs/LUTS
Admission Date:  [**2140-7-21**]              Discharge Date:   [**2140-7-27**]

Date of Birth:  [**2071-10-10**]             Sex:   M

Service: MEDICINE

Allergies:
Tegaderm Frame Style / Prinivil / Reglan / Levofloxacin

Attending:[**First Name3 (LF) 3624**]
Chief Complaint:
Hypoglycemia

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Reliability: Patient was AAOx3 however did endorse seeing an
"extra man" in the room when asked how many persons where
present in room. History also obtained from patient's wife and
medical records from rehab and [**Hospital3 **] ED.
.
Patient is 68-year-old male with ESRD status post cadaver kidney
transplant in [**2130**] on tacrolimus/prednisone, type 1 diabetes,
CAD status post CABG x4, PVD status post right popliteal stent
and 2nd right toe amputation in addition to history of MRSA
osteomyelitis,
chronic lower extremity nonhealing ulcers, history of multiple
DVTs on Coumadin with IVC filter, diastolic heart failure,
multiple prior C. difficile episodes in [**2135**], [**2138**], and [**4-/2140**]
among other conditions that presents from rehab with confusion
and low oxygen saturation.
.
Patient was recently admitted to [**Hospital1 18**] in [**2140-4-29**] for
nausea/vomiting with eating with GI work-up revealing
gastroparesis and C. difficile diarrhea treated with PO
vancomycin.
.
At some point, he was admitted to rehab for PT/OT. His rehab
course was complicated by pneumonia and urinary tract infection
(no culture data available), which were treated with a 7-day
course of Ceftin (course was started around [**2140-6-30**]). The
patient required about 2-3 L NC while he had pneumonia.
.
He was in his otherwise normal state of health at rehab until
about 2-3 days ago when he needed nebulizer treatments on Friday
and also developed supplemental oxygen requirement on Saturday
similar to what he needed when he had pneumonia about 3-4 weeks
ago. His wife also stated that at baseline his mental status has
been AAOx3 but he does seem forgetful with hallucinations (e.g.
little kid hiding in the corner) with any illness and
dehydration. Of note, he had a CXR on [**2140-7-14**] that was compared
to his prior chest x-ray showing clearing of bilateral
infiltrates and pneumonia - namely the prominent right perihilar
infiltrate and small left perihilar infiltrate.
.
At the Guardian [**Name (NI) **] rehab, BLS placed him on 100 % NRB for
hypoxemia (unknown number) with O2 sat in 90s.
.
He was taken to [**Hospital3 **] ED where he was thought to be "really
confused" with no focal neurological deficits or post-ictal
state. His O2 sat was low as well (unknown number). He received
500 cc of fluid and a ? dose of Ceftin. He was transferred to
[**Hospital1 18**] given that he received a transplant here.
.
VS prior to transfer from [**Hospital3 **] ED were T 98.8 BP 124/62 HR
71 RR 22 Glc 169
.
In the ED, initial VS were: Triage 17:52 0 97.2 52 90/46 16 98%
4L
.
He arrived to [**Hospital1 18**] ED with relative hypotension with blood
pressures of 90/40, saturating 96% on 2 L nasal cannula with
diffuse crackles and wheezes on his lung fields.
.
Of note, recent BP in clinic per [**Hospital1 581**] are 88/60, 102/82,
92/52, 118/80 from past 2 years. BP at rehab on [**2140-5-6**] was
121/80.
.
BP remained stable in ER, required 2 L NC throughout ER course.
.
Labs were performed
- WBC 3.7 Hgb 8.2 (of note baseline ~ 10) Plt 253 with Diff N
70.9 L 16.5 E 6.6
- INR 2.8 (in setting of coumadin therapy) PTT 44.3
- Na 139 K 5.2 Cl 111 HCO3 23 BUN 17 Cr 1.6 (Cr 1.1-1.2) Glc 83
- cTropnT 0.07
- UA Nit neg pH 6 LE Mod WBC > 182 bacteria many Epi 0 cast Gr
13
.
Diagnostic testing was performed:
- ECG: Sinus bradycardia at 52 bpm, NA, NI except QTc 502 ms, no
ST/T changes or STEMI. Low voltage I, II, III, aVR, aVL, aVF.
Compared to prior dated [**2140-1-25**], rhythm is NSR at 87 bpm, QTc
427 ms
- CXR (prelim): layering effusion, scarring atelectasis in lower
base. Cardiomediastinal unchanged. IVC filter seen.
Impression: Bilateral pleural effusions and cephalization,
post-surgical changes in right lung without definite
consolidation.
.
He was given:
- hydrocortisone 100 mg IV x 1 for stress dose steroids
- cefepime 2 gm IV and vancomycin 1000 mg IV
- 2 L NS with urine output of 95 mL
.
VS on transfer: 18:38 53 100/41 17 97% on 2 L NC
.
On arrival to the MICU, the patient was AAOx3 but thought that
another man was standing behind me - which was not true. He was
also noted that have Tax 94. Urine output was poor, and he
received 2 L NS bolus.
.
He denies any localizing complaints such as cough, abdominal
pain, dysuria although does admit to low oxygen levels.
.
Review of systems:
(+) Per HPI; fatigue, shortness of breath x 2 weeks, worsened
over last week
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.

Past Medical History:
-DVT (multiple) s/p IVC filter [**3-/2134**] on coumadin for life
-CAD s/p CABG and MI; s/p stents
-Chronic dCHF
-HTN
-DM1 with retinopathy, neuropathy, ESRD, R charcot foot in [**2125**]
-s/p cadaveric renal transplant in [**9-/2131**] on prednisone and
tacrolimus
-ORIF right arm
-chronic foot ulcer
-amputated right toe
-MRSA right foot with osteomyelitis
-C diff colitis [**5-6**]
-cryptococcal pna in [**4-3**], now on fluconazole suppressive
therapy
-lung nodules
-PVD
-GERD
-b/l cataract surgery,
-s/p [**Doctor Last Name **] artery angioplasty in [**6-4**]
-cellulitis
-chronic osteomyelitis followed in ID clinico
-Anemia
-Arteriogram showing R fem/tib and L tib dz and [**Date Range 1106**] plans
to consider intervention as outpatient.

Social History:
SOCIAL HISTORY
-Lives w/ wifw, has 3 children
-Tobacco history: Former smoker, 2ppd for many years
-ETOH: Infrequent now that in [**Hospital1 1501**]
-Illicit drugs: None
-uses wheelchair for ambulation
.


Family History:
FAMILY HISTORY:
DM type II in father and paternal grandfather. Mother had "heart

disease".


Physical Exam:
Admission PE:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, shoddy lymphadenopathy of
anterior cervical chain, more prominent on left than right
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: decreased inspiratory effort, mild rhonchi at right base,
however difficult to appreciate given limited exam.
Abdomen: distended, non-tender, difficult to appreciate
organomegaly given firmness of abdomen.
GU: no foley
Ext: multiple ulcers over LE bilaterally in various stages of
healing, 2+ edema of LE b/l, multiple scars present, amputation
of digits present.
Neuro: grossly normal sensation, non focal exam

Discharge PE:
VS: T 98, Tm 98.3, 60-70s, 120-140s/50-70s, 18-20, 98-100% RA
Glucose: 117-207
General: Alert, oriented, in NAD
HEENT: some bloody appearance to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2281**]
CV: RRR, no murmurs
Lungs: Inspiratory rales at L base, otherwise CTAB
Abdomen: soft, non-tender, nondistended, +BS
Ext: multiple ulcers over LE bilaterally in various stages of
healing with dressing in place


Pertinent Results:
ADMISSION LABS
[**2140-7-21**] 07:33PM URINE  HOURS-RANDOM UREA N-517 CREAT-240
SODIUM-69 POTASSIUM-98 CHLORIDE-43
[**2140-7-21**] 07:33PM URINE  OSMOLAL-576
[**2140-7-21**] 06:40PM URINE  BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-MOD
[**2140-7-21**] 06:40PM URINE  RBC-2 WBC->182* BACTERIA-MANY YEAST-NONE
EPI-0
[**2140-7-21**] 06:30PM   LACTATE-1.2
[**2140-7-21**] 06:26PM   GLUCOSE-86 UREA N-17 CREAT-1.6* SODIUM-139
POTASSIUM-5.2* CHLORIDE-111* TOTAL CO2-23 ANION GAP-10
[**2140-7-21**] 06:26PM   cTropnT-0.07*
[**2140-7-21**] 06:26PM   TSH-8.9*
[**2140-7-21**] 06:26PM   CORTISOL-6.9
[**2140-7-21**] 06:26PM   WBC-3.7* RBC-3.36* HGB-8.2* HCT-26.7* MCV-80*
MCH-24.5* MCHC-30.7* RDW-15.6*
[**2140-7-21**] 06:26PM   NEUTS-70.9* LYMPHS-16.5* MONOS-5.8 EOS-6.6*
BASOS-0.3
[**2140-7-21**] 06:26PM   PLT COUNT-253
[**2140-7-21**] 06:26PM   PT-29.4* PTT-44.3* INR(PT)-2.8*

Micro:
ucx [**2140-7-21**]:
 ESCHERICHIA COLI
                             |
AMPICILLIN------------  =>32 R
AMPICILLIN/SULBACTAM--    16 I
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN--------  <=16 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----  =>16 R

urine legionella Ag: neg
CMV viral load undetectable

CXR [**2140-7-21**]:
Bilateral pleural effusions and pulmonary [**Month/Day/Year 1106**] congestion.
Post-surgical changes seen in the right lung

TTE [**2140-7-22**]:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 65%). However, the inferior wall may be mildly
hypokinetic. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.

Transplant renal U/S [**2140-7-22**]:
1.  Interval increase in elevated intrarenal resistive indices
with no
discernable antegrade diastolic flow noted throughout.  In
addition, there is a notable increase in peak systolic velocity
of main renal artery with normal waveforms and velocity
identified in the left iliac artery. No stenosis identified.
2. Extensive transplanted interlobar renal artery and main renal
artery
calcifications.
3. No hydronephrosis, masses, or perinephric fluid collection
evident.

Discharge Labs:
[**2140-7-27**] 05:55AM BLOOD WBC-4.6 RBC-3.92* Hgb-9.4* Hct-31.0*
MCV-79* MCH-24.1* MCHC-30.3* RDW-15.4 Plt Ct-276
[**2140-7-27**] 05:55AM BLOOD PT-24.7* PTT-44.3* INR(PT)-2.4*
[**2140-7-27**] 05:55AM BLOOD Glucose-152* UreaN-14 Creat-1.1 Na-139
K-4.8 Cl-110* HCO3-24 AnGap-10
[**2140-7-26**] 06:05AM BLOOD ALT-19 AST-29 LD(LDH)-180 AlkPhos-207*
TotBili-0.1
[**2140-7-27**] 05:55AM BLOOD Calcium-8.1* Phos-2.6* Mg-1.6

Brief Hospital Course:
68-year-old male with ESRD status post cadaver kidney transplant
in [**2130**] on tacrolimus/prednisone, DM1, CAD s/p MI and CABG, PVD
with chronic lower extremity nonhealing ulcers, history of
multiple DVTs on coumadin, diastolic heart failuire among other
conditions that presents with confusion, low oxygenation
saturations, acute renal failure, and relative hypotension
concerning for sepsis from a urinary source.
.
Acute diagnoses:
#Sepsis from UTI source: Patient is immunocompromised in setting
of kidney transplant and presents with leukopenia, hypothermia
in setting of positive UA/UCx suggestive of sepsis from a
urinary source. Prior urine culture data suggestive of E. coli
and Proteus that are resistant to certain drug classes. CXR
without consolidation.  Host factors include immunosuppresion
with tacrolimus/prednisone, HCAP exposure. On presentation, pt
met SIRS criteria, with lactate elevation and [**Last Name (un) **].  He was
treated with fluid resuscitation and empiric abx (Vanc/Zosyn).
MICU COURSE: patient was admitted to the MICU for respiratory
distress and relative hypotension in setting of Sepsis of
urinary source and [**Last Name (un) **] possibly [**12-31**] renal transplant failure. Pt
on vanc/cefepime during MICU adm. Pt had improvement in his
respiratory status and was hemodynamically stable at the time of
transfer from the MICU. Transitioned to IV ceftriaxone. Ucx grew
e coli. Blood cultures were negative. Pt transitioned to PO
cefpodoxime [**7-25**] with plan for 14d course total of ABX to end
[**2140-8-4**].
.
# Dyspnea/hypoxia: Patient is reporting a subacute course of
dyspnea with acute flare starting on admission with new O2
requirements. Although immobile, he is low-risk (1.3%) based on
[**Doctor Last Name 3012**] score. Troponin - and ECG with no acute changes. BNP
elevated, JVD, volume up on exam. Appears patient was right
sided volume overloaded and improved with some diuresis.
Secondary consideration would include diaphragmatic contribution
given prior RUL resection with volume loss.  TTE with no changes
from prior.  In MICU, pt did not require ventilatory (invasive
or non-invasive) assistance. Respiratory status improved and pt
satting 98-100% RA.
.
# Status post kidney transplant with acute renal failure: Pt's
allograft function was compromised on admission given recent
baseline Cr 1.1-1.2, rehab lab on [**2140-7-20**] Cr 1.4, and admission
Cr 1.6. His urine output had been marginal. Admission urinalysis
showing protein 100 with last UA in [**5-10**] showing trace protein.
FeUrea 20.27, prerenal. UA shows granular casts. He may have
hypotension that has lead to ATN. Urine eosinophils are negative
speaking against AIN in setting of mild peripheral eosinophilia.
Secondary consideration is tacrolimus vasoconstriction also
contributing to ? ATN picture. Creatinine has downtrended after
fluid resuscitation. UCx positive as above. Lasix 40mg QD
restarted [**7-24**]. Renal ultrasound generally unremarkable
.
# Pressure Ulcers: Multiple pressures ulcers: R lateral tibia
(full thickness), R heal (originally Stage III), L Lateral foot
(healing stage III-IV). Wound care consulted and patient treated
per their recs: Remove pressure from area, constant
repositioning, waffle boots at all times. He has stage I sacral
ulcer and multiple areas of skin breakdown in lower extremities.
Sacral coccygeal area blanchable
.
# Immunosuppression: Continued tacrolimus and prednisone.
Continued bactrim ppx. Followed daily tac levels with goal
trough between [**3-4**].
.
# Acute toxic-metabolic encephalopathy: home mirtazapine held;
vitamin B12, RPR, TSH was elevated however T4 was within normal
limits. BK virus undetected
.
# Microcytic, Hypochromic anemia: Admission Hgb is 8.2 (of note
baseline ~ 10). Fe studies c/w anemia of chronic disease (low
Fe, low transferrin and TIBC, normal ferritin). Last EGD and
colonoscopy were in [**2136**] with polyps in the sigmoid colon
(polypectomy) and mild-moderate gastritis (biopsy).  H/H stable.
Pt initially on Fe supplementation, but discontinued for iron
studies that seemed more c/w anemia of chronic disease.
.
# Prolonged QTc and Sinus bradycardia: QTc noted to be 502 ms [**First Name (Titles) **] [**Last Name (Titles) **]n ECG. Resolving bradycardia. On telemetry. Resolved
(QTc down to 430 and no longer bradycardic).
.
# History of multiple DVT. INR max was 6.3 on [**7-26**]. Most likely
nutritional deficiency from poor PO intake in the setting of ABX
use. Patient has a history of difficult to control INR levels.
No documented dose of coumadin since [**7-22**]. LFTs WNL. Pt given 5
mg PO vit K. INR down to 2.4 on day of discharge. Pt to resume
coumadin at dose of 0.5mg daily with close INR monitoring.
.
# CAD s/p CABG and MI s/p stents
- continue plavix/aspirin, atorvastatin
- hold other anti-ischemic regimen
.
# T1DM: pt with hypoglycemia with bld glucose down to 50s.
Lantus decreased to 8, then 4 units with stable blood glucose in
the 100s. Discharged pt on 6u QHS and would continue to monitor
and adjust as needed. He was also continued on a humalog sliding
scale.
.
# History of cryptococcal pneumonia: continued fluconazole
suppressive therapy
.
# BPH: tamsulosin held, will restart on discharge
.
# HTN: pt restarted on reduced dose of metoprolol. Pt discharged
with plan to restart amlodipine at rehab as BPs improved during
hospitalization. Pt discharged off imdur.
.
Transitional Issues:
# Full Code
# Pt will return to rehab.

Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation.  Information was obtained from
Family/[**Name (NI) 31571**] rehab list.
1. Amlodipine 5 mg PO DAILY
hold for sbp<100 or hr<60
2. Clopidogrel 75 mg PO DAILY
3. Fluconazole 200 mg PO Q24H
4. Glargine 15 Units Bedtime
Insulin SC Sliding Scale using novolog Insulin
5. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
hodl for sbp<100 or hr<60
6. Metoprolol Tartrate 50 mg PO BID
hold for sbp<100 or hr<60
7. Mirtazapine 7.5 mg PO HS
8. PredniSONE 5 mg PO DAILY
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
10. Tacrolimus 0.5 mg PO Q12H
11. Travatan Z *NF* (travoprost) 0.004 % OS qday
12. Tamsulosin 0.4 mg PO HS
13. Actonel *NF* (risedronate) 35 mg Oral q Sunday
14. Nitroglycerin SL 0.3 mg SL PRN chest pain
15. Senna with Docusate Sodium *NF* (sennosides-docusate sodium)
8.6-50 mg Oral qhs
16. Ascorbic Acid 500 mg PO BID
17. Multivitamins 1 TAB PO DAILY
18. Acetaminophen 650 mg PO Q4H:PRN pain
do not exceed 4 g in 24 hour period
19. Aspirin 81 mg PO DAILY
20. Atorvastatin 80 mg PO DAILY
21. Pantoprazole 20 mg PO Q12H
22. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/hwheezing
23. Warfarin 1 mg PO DAILY16


Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain
do not exceed 4 g in 24 hour period
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/hwheezing
3. Ascorbic Acid 500 mg PO BID
4. Atorvastatin 80 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Fluconazole 200 mg PO Q24H
7. Multivitamins 1 TAB PO DAILY
8. PredniSONE 5 mg PO DAILY
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
10. Tacrolimus 0.5 mg PO Q12H
11. Travatan Z *NF* (travoprost) 0.004 % OS qday
12. Cefpodoxime Proxetil 100 mg PO Q12H
Total of 14 days (to end [**8-4**])
13. Furosemide 40 mg PO DAILY
14. Pantoprazole 20 mg PO Q12H
15. Senna with Docusate Sodium *NF* (sennosides-docusate sodium)
8.6-50 mg Oral qhs
16. Tamsulosin 0.4 mg PO HS
17. Nitroglycerin SL 0.3 mg SL PRN chest pain
18. Mirtazapine 7.5 mg PO HS
19. Aspirin 81 mg PO DAILY
20. Actonel *NF* (risedronate) 35 mg ORAL Q SUNDAY
21. Metoprolol Tartrate 25 mg PO BID
hold for SBP < 100 or HR < 60
22. Miconazole 2% Cream 1 Appl TP [**Hospital1 **] perineum
23. Warfarin 0.5 mg PO DAILY16
24. Glargine 6 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
25. Amlodipine 5 mg PO DAILY
hold for sbp<100 or hr<60


Discharge Disposition:
Extended Care

Facility:
Guardian [**Name (NI) **] - [**Name (NI) 1474**]

Discharge Diagnosis:
Primary Diagnosis
Sepsis
Urinary Tract Infection
Acute Renal failure

Secondary Diagnosis
History of renal transplant
Coronary Artery Disease

Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Mr [**Known lastname **],

It was a pleasure participating in your care while you were
admitted to [**Hospital1 69**].  As you know
you were admitted because you were confused with worsening of
your renal function. You were found to have an infection in your
urinary tract that was likely causing your symptoms. You were
given antibiotics through the IV and then converted to pills.
You symptoms improved but you will need to continue taking
antibiotics for 8 more days (last dose [**2140-8-4**]).  Your INR was
also elevated so we held your blood thinner.  This will need to
restarted once this number improves.

We made the following changes to your medications
1. START Cefpodoxime for 8 more days
2. STOP fludrocortisone
3. STOP isosorbide mononitrate
4. DECREASE metoprolol to 25 mg twice a day
5. DECREASE lantus to 6 units at night
6. DECREASE warfarin to 0.5mg daily

You should continue to take all other medications as instructed.


Followup Instructions:
Please discuss with the staff at the facility a follow up
appointment with your PCP below when you are ready for
discharge.
Name: [**Doctor Last Name **] [**Last Name (NamePattern4) 31572**],MD
Location: [**Hospital3 249**]
[**Hospital1 **]/EAST
Address: [**Location (un) **], E/CC-6, [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2010**]

Department: NEUROLOGY
When: TUESDAY [**2140-8-9**] at 1 PM
With: [**Doctor Last Name 640**] [**Doctor First Name 747**] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 1844**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: TRANSPLANT CENTER
When: TUESDAY [**2140-8-16**] at 10:00 AM
With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage


                             [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]

Completed by:[**2140-7-27**]
{'Unspecified septicemia,Acute kidney failure with lesion of tubular necrosis,Toxic encephalopathy,Pressure ulcer, stage III,Complications of transplanted kidney,Chronic diastolic heart failure,Urinary tract infection, site not specified,Long-term (current) use of insulin,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Peripheral vascular disease, unspecified,Other toe(s) amputation status,Personal history of venous thrombosis and embolism,Diabetes with ophthalmic manifestations, type I [juvenile type], not stated as uncontrolled,Background diabetic retinopathy,Polyneuropathy in diabetes,Esophageal reflux,Personal history of tobacco use,Sepsis,Anemia in chronic kidney disease,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS)'}


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: Hypoglycemia

PRESENT ILLNESS: Reliability: Patient was AAOx3 however did endorse seeing an
"extra man" in the room when asked how many persons where
present in room. History also obtained from patient's wife and
medical records from rehab and [**Hospital3 **] ED.
.
Patient is 68-year-old male with ESRD status post cadaver kidney
transplant in [**2130**] on tacrolimus/prednisone, type 1 diabetes,
CAD status post CABG x4, PVD status post right popliteal stent
and 2nd right toe amputation in addition to history of MRSA
osteomyelitis,
chronic lower extremity nonhealing ulcers, history of multiple
DVTs on Coumadin with IVC filter, diastolic heart failure,
multiple prior C. difficile episodes in [**2135**], [**2138**], and [**4-/2140**]
among other conditions that presents from rehab with confusion
and low oxygen saturation.
.
Patient was recently admitted to [**Hospital1 18**] in [**2140-4-29**] for
nausea/vomiting with eating with GI work-up revealing
gastroparesis and C. difficile diarrhea treated with PO
vancomycin.
.
At some point, he was admitted to rehab for PT/OT. His rehab
course was complicated by pneumonia and urinary tract infection
(no culture data available), which were treated with a 7-day
course of Ceftin (course was started around [**2140-6-30**]). The
patient required about 2-3 L NC while he had pneumonia.
.
He was in his otherwise normal state of health at rehab until
about 2-3 days ago when he needed nebulizer treatments on Friday
and also developed supplemental oxygen requirement on Saturday
similar to what he needed when he had pneumonia about 3-4 weeks
ago. His wife also stated that at baseline his mental status has
been AAOx3 but he does seem forgetful with hallucinations (e.g.
little kid hiding in the corner) with any illness and
dehydration. Of note, he had a CXR on [**2140-7-14**] that was compared
to his prior chest x-ray showing clearing of bilateral
infiltrates and pneumonia - namely the prominent right perihilar
infiltrate and small left perihilar infiltrate.
.
At the Guardian [**Name (NI) **] rehab, BLS placed him on 100 % NRB for
hypoxemia (unknown number) with O2 sat in 90s.
.
He was taken to [**Hospital3 **] ED where he was thought to be "really
confused" with no focal neurological deficits or post-ictal
state. His O2 sat was low as well (unknown number). He received
500 cc of fluid and a ? dose of Ceftin. He was transferred to
[**Hospital1 18**] given that he received a transplant here.
.
VS prior to transfer from [**Hospital3 **] ED were T 98.8 BP 124/62 HR
71 RR 22 Glc 169
.
In the ED, initial VS were: Triage 17:52 0 97.2 52 90/46 16 98%
4L
.
He arrived to [**Hospital1 18**] ED with relative hypotension with blood
pressures of 90/40, saturating 96% on 2 L nasal cannula with
diffuse crackles and wheezes on his lung fields.
.
Of note, recent BP in clinic per [**Hospital1 581**] are 88/60, 102/82,
92/52, 118/80 from past 2 years. BP at rehab on [**2140-5-6**] was
121/80.
.
BP remained stable in ER, required 2 L NC throughout ER course.
.
Labs were performed
- WBC 3.7 Hgb 8.2 (of note baseline ~ 10) Plt 253 with Diff N
70.9 L 16.5 E 6.6
- INR 2.8 (in setting of coumadin therapy) PTT 44.3
- Na 139 K 5.2 Cl 111 HCO3 23 BUN 17 Cr 1.6 (Cr 1.1-1.2) Glc 83
- cTropnT 0.07
- UA Nit neg pH 6 LE Mod WBC > 182 bacteria many Epi 0 cast Gr
13
.
Diagnostic testing was performed:
- ECG: Sinus bradycardia at 52 bpm, NA, NI except QTc 502 ms, no
ST/T changes or STEMI. Low voltage I, II, III, aVR, aVL, aVF.
Compared to prior dated [**2140-1-25**], rhythm is NSR at 87 bpm, QTc
427 ms
- CXR (prelim): layering effusion, scarring atelectasis in lower
base. Cardiomediastinal unchanged. IVC filter seen.
Impression: Bilateral pleural effusions and cephalization,
post-surgical changes in right lung without definite
consolidation.
.
He was given:
- hydrocortisone 100 mg IV x 1 for stress dose steroids
- cefepime 2 gm IV and vancomycin 1000 mg IV
- 2 L NS with urine output of 95 mL
.
VS on transfer: 18:38 53 100/41 17 97% on 2 L NC
.
On arrival to the MICU, the patient was AAOx3 but thought that
another man was standing behind me - which was not true. He was
also noted that have Tax 94. Urine output was poor, and he
received 2 L NS bolus.
.
He denies any localizing complaints such as cough, abdominal
pain, dysuria although does admit to low oxygen levels.
.
Review of systems:
(+) Per HPI; fatigue, shortness of breath x 2 weeks, worsened
over last week
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.

MEDICAL HISTORY: -DVT (multiple) s/p IVC filter [**3-/2134**] on coumadin for life
-CAD s/p CABG and MI; s/p stents
-Chronic dCHF
-HTN
-DM1 with retinopathy, neuropathy, ESRD, R charcot foot in [**2125**]
-s/p cadaveric renal transplant in [**9-/2131**] on prednisone and
tacrolimus
-ORIF right arm
-chronic foot ulcer
-amputated right toe
-MRSA right foot with osteomyelitis
-C diff colitis [**5-6**]
-cryptococcal pna in [**4-3**], now on fluconazole suppressive
therapy
-lung nodules
-PVD
-GERD
-b/l cataract surgery,
-s/p [**Doctor Last Name **] artery angioplasty in [**6-4**]
-cellulitis
-chronic osteomyelitis followed in ID clinico
-Anemia
-Arteriogram showing R fem/tib and L tib dz and [**Date Range 1106**] plans
to consider intervention as outpatient.

MEDICATION ON ADMISSION: Preadmissions medications listed are incomplete and require
futher investigation.  Information was obtained from
Family/[**Name (NI) 31571**] rehab list.
1. Amlodipine 5 mg PO DAILY
hold for sbp<100 or hr<60
2. Clopidogrel 75 mg PO DAILY
3. Fluconazole 200 mg PO Q24H
4. Glargine 15 Units Bedtime
Insulin SC Sliding Scale using novolog Insulin
5. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
hodl for sbp<100 or hr<60
6. Metoprolol Tartrate 50 mg PO BID
hold for sbp<100 or hr<60
7. Mirtazapine 7.5 mg PO HS
8. PredniSONE 5 mg PO DAILY
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
10. Tacrolimus 0.5 mg PO Q12H
11. Travatan Z *NF* (travoprost) 0.004 % OS qday
12. Tamsulosin 0.4 mg PO HS
13. Actonel *NF* (risedronate) 35 mg Oral q Sunday
14. Nitroglycerin SL 0.3 mg SL PRN chest pain
15. Senna with Docusate Sodium *NF* (sennosides-docusate sodium)
8.6-50 mg Oral qhs
16. Ascorbic Acid 500 mg PO BID
17. Multivitamins 1 TAB PO DAILY
18. Acetaminophen 650 mg PO Q4H:PRN pain
do not exceed 4 g in 24 hour period
19. Aspirin 81 mg PO DAILY
20. Atorvastatin 80 mg PO DAILY
21. Pantoprazole 20 mg PO Q12H
22. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/hwheezing
23. Warfarin 1 mg PO DAILY16

ALLERGIES: Tegaderm Frame Style / Prinivil / Reglan / Levofloxacin

PHYSICAL EXAM: Admission PE:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, shoddy lymphadenopathy of
anterior cervical chain, more prominent on left than right
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: decreased inspiratory effort, mild rhonchi at right base,
however difficult to appreciate given limited exam.
Abdomen: distended, non-tender, difficult to appreciate
organomegaly given firmness of abdomen.
GU: no foley
Ext: multiple ulcers over LE bilaterally in various stages of
healing, 2+ edema of LE b/l, multiple scars present, amputation
of digits present.
Neuro: grossly normal sensation, non focal exam

FAMILY HISTORY: FAMILY HISTORY:
DM type II in father and paternal grandfather. Mother had "heart

SOCIAL HISTORY: SOCIAL HISTORY
-Lives w/ wifw, has 3 children
-Tobacco history: Former smoker, 2ppd for many years
-ETOH: Infrequent now that in [**Hospital1 1501**]
-Illicit drugs: None
-uses wheelchair for ambulation
. 

### Response:
{'Unspecified septicemia,Acute kidney failure with lesion of tubular necrosis,Toxic encephalopathy,Pressure ulcer, stage III,Complications of transplanted kidney,Chronic diastolic heart failure,Urinary tract infection, site not specified,Long-term (current) use of insulin,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Peripheral vascular disease, unspecified,Other toe(s) amputation status,Personal history of venous thrombosis and embolism,Diabetes with ophthalmic manifestations, type I [juvenile type], not stated as uncontrolled,Background diabetic retinopathy,Polyneuropathy in diabetes,Esophageal reflux,Personal history of tobacco use,Sepsis,Anemia in chronic kidney disease,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS)'}
