CHIEF COMPLAINT: Chief Complaint: Vomiting, fever, hypotension

PRESENT ILLNESS: Ms. [**Known lastname **] is a 75 yo female with h/o DVT/PE, h/o necrotizing
fasciitis, COPD, recent cholecystectomy c/b biloma/sepsis
requiring ERCP and stone retrieval with stent placement.  She is
being transferred from [**Hospital3 **]1d s/p retrieval of
biliary stent with fevers, hypotension, and abdominal pain, and
vomiting.

MEDICAL HISTORY: -Necrotizing fasicitis right groin and pelvic area
-DVT/PE after necrotizing fasicitis of right groin six years ago
previously on warfarin but since stopped
-MVP
-Chronic constipation
-Non obstructive CAD: cath in [**2101**] with proximal calcification
in left coronary arteries. 30-40% stenosis in prox LAD, mild
osteal circ narrowing, 40% prox RCA stenosis. EF 50-55% with
apical hypokinesis. TTE in [**2103-5-13**] normal LV fxn, mod MR with
mild
-MVP, and trace TR
-Hyperlipidemia
-Osteoporosis
-COPD
-s/p CCY c/b biliary leak/biloma requiring ERCP and stone
retrieval with stent placement
-HTN

MEDICATION ON ADMISSION: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) inhalation Inhalation Q6H (every 6
hours) as needed for SOB.
4. ipratropium bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours) as needed for SOB.
5. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for dyspepsia.
6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for heartburn.
7. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) as needed for anxiety.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
10. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
11. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six

ALLERGIES: Penicillins / Sulfa(Sulfonamide Antibiotics) / latex / Warfarin

PHYSICAL EXAM: Admission physical exam:
Vitals: Tcurrent: 37.2 ??????C (99 ??????F) HR: 111 (106 - 130) bpm BP:
87/34(48) {87/34(48) - 107/65(74)} mmHg RR: 25 (25 - 34)
insp/min SpO2: 99%
General: Well-appearing patient sitting up in bed, alert and
interactive in NAD
HEENT: EOMI. PERRL. dry MM. OP without erythema, exudate, or
ulcerations
NECK: Supple, with RIJ in place
CV: Tachycardia. No M/R/G
Lungs: Nml work of breathing with no accessory muscle use. Late
inspiratory crackles at the bases bilaterally. No wheezes
bilaterally.
Abd: Ecchymosis in the lower abdomen bilaterally. BS+. Soft. ND.
TTP (deep palpation) in the lower quadrants bilaterally; mild
TTP in the RUQ. No rebound or guarding
Ext: Warm. No clubbing, cyanosis, or edema. No calf tenderness
bilaterally. No erythema of the LE bilaterally.
Neuro: CN 2-12 grossly intact bilaterally. Strength: [**5-17**] plantar
and dorsiflexion of the LE bilalerally. 5/5 strength through the
UE bilaterally. Sensation: To light touch intact through the LE
and UE bilaterally. Patient alert and oriented to person, place,
and time.

FAMILY HISTORY: No history of GB stones.

SOCIAL HISTORY: Married, stopped smoking in [**2086**]. 30-40 pack year. Social
drinking, 103 beverage during social setting. No drug use.
Currently in rehabilitation facility
Septicemia due to escherichia coli [E. coli],Septic shock,Subendocardial infarction, initial episode of care,Acute systolic heart failure,Hyposmolality and/or hyponatremia,Severe sepsis,Anemia, unspecified,Thrombocytopenia, unspecified,Other specified cardiac dysrhythmias,Chronic airway obstruction, not elsewhere classified,Mitral valve disorders,Other and unspecified hyperlipidemia,Osteoporosis, unspecified,Unspecified vitamin D deficiency,Postinflammatory pulmonary fibrosis,Coronary atherosclerosis of native coronary artery,Personal history of pulmonary embolism,Long-term (current) use of anticoagulants
E coli septicemia,Septic shock,Subendo infarct, initial,Ac systolic hrt failure,Hyposmolality,Severe sepsis,Anemia NOS,Thrombocytopenia NOS,Cardiac dysrhythmias NEC,Chr airway obstruct NEC,Mitral valve disorder,Hyperlipidemia NEC/NOS,Osteoporosis NOS,Vitamin D deficiency NOS,Postinflam pulm fibrosis,Crnry athrscl natve vssl,Hx pulmonary embolism,Long-term use anticoagul
Admission Date:  [**2104-7-20**]              Discharge Date:   [**2104-8-2**]

Date of Birth:  [**2028-9-6**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Sulfa(Sulfonamide Antibiotics) / latex / Warfarin

Attending:[**First Name3 (LF) 1436**]
Chief Complaint:
Chief Complaint: Vomiting, fever, hypotension

Reason for MICU transfer: Hypotension

Major Surgical or Invasive Procedure:
CVL placement
PICC line placement
Arterial line placement

History of Present Illness:
Ms. [**Known lastname **] is a 75 yo female with h/o DVT/PE, h/o necrotizing
fasciitis, COPD, recent cholecystectomy c/b biloma/sepsis
requiring ERCP and stone retrieval with stent placement.  She is
being transferred from [**Hospital3 **]1d s/p retrieval of
biliary stent with fevers, hypotension, and abdominal pain, and
vomiting.

She had a recent hospitalization at [**Hospital1 18**] from [**Date range (1) 62161**]
following a cholecystectomy at OSH for acute cholecystitis due
to the development of biliary leak/biloma, fevers, and
hypotension.  She was treated with antibiotics, IR drainage of
the biloma, ERCP with stone removal and stent placement. She
fared well and completed 10d of cipro/flagyl as an outpatient
completed on [**2104-6-28**].

Of note, since the patient has been at rehab facility, the
patient developed a PE after acutely complaining of shortness of
breath. She was evaluated at [**Hospital3 107616**] and reportedly
was found to have a PE on CTA of the chest. The patient was
started on coumadin and Lovenox shots. The patient has not been
taking Coumadin since Friday per her daugther's report in light
of procedure at [**Hospital1 18**] on Friday prior to presentation.

She had this biliary stent removed Friday prior to presentation
at [**Hospital1 18**]. She was eating and feeling well after the stent
removal on Friday. On Saturday, the patient was noted to have a
fever of 101.6 with chills as well as poor appetite. She denies
belly pain on Saturday AM. In the evening on Saturday, the
patient was noted to have another fever of 102 associated with
shaking as well as tachycardia of 100-130. She reports an
episode of bilious vomiting (non-bloody) and nausea as well. She
denies abdominal pain at the time. Of note, the patient reports
an episode of burning, right-sided chest pain associated with
shortness of breath that spontaneously came on and then
resolved. There was no radiation of the chest discomfort. She
denies further episodes of chest discomfort.

She was then taken to the OSH ED for further evaluation. She
presented to OSH ED, where note was made of an elevated troponin
?I to 0.43 without CP or EKG changes, and she was transferred
here for hypotension and further management in light of recent
procedure.

On arrival to the [**Hospital1 18**] emergency department, her initial vitals
were 98.2 110 86/57 16.  Leukocytosis to 12.6, lactate to 2.6,
hyponatremia and mild transaminitis were noted.  A right IJ
triple lumen was placed due to sepsis (well-placed on CXR), and
vancomycin and ceftriaxone were empirically administered for
septic shock. Norepinephrin gtt started.  She has remained
hypotensive with SBP 80-90 for roughly 3 hours.  2L NS were
administered and SBP increased to 80. Lowest recorded SBP in the
ED 79 per verbal sign out from ED resident. CXR without
pneumonia but mild pulmonary edema. Attempted to upload CT
images from OSH but was not an optimal study, so the patient
underwent a CT scan prior to transfer to the MICU.

On arrival to the MICU, the patient deniest abdominal pain,
nausea, and vomiting since arrival to the [**Hospital1 18**] ED.

Review of systems:
(+) Per HPI; Reports chronic, dry cough in AM; constipation
(-) Denies night sweats. Denies headache, sinus tenderness,
rhinorrhea or congestion. Denies shortness of breath, or
wheezing. Denies chest pressure, palpitations, or weakness.
Denies 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:
-Necrotizing fasicitis right groin and pelvic area
-DVT/PE after necrotizing fasicitis of right groin six years ago
previously on warfarin but since stopped
-MVP
-Chronic constipation
-Non obstructive CAD: cath in [**2101**] with proximal calcification
in left coronary arteries. 30-40% stenosis in prox LAD, mild
osteal circ narrowing, 40% prox RCA stenosis. EF 50-55% with
apical hypokinesis. TTE in [**2103-5-13**] normal LV fxn, mod MR with
mild
-MVP, and trace TR
-Hyperlipidemia
-Osteoporosis
-COPD
-s/p CCY c/b biliary leak/biloma requiring ERCP and stone
retrieval with stent placement
-HTN

Social History:
Married, stopped smoking in [**2086**]. 30-40 pack year. Social
drinking, 103 beverage during social setting. No drug use.
Currently in rehabilitation facility

Family History:
No history of GB stones.

Physical Exam:
Admission physical exam:
Vitals: Tcurrent: 37.2 ??????C (99 ??????F) HR: 111 (106 - 130) bpm BP:
87/34(48) {87/34(48) - 107/65(74)} mmHg RR: 25 (25 - 34)
insp/min SpO2: 99%
General: Well-appearing patient sitting up in bed, alert and
interactive in NAD
HEENT: EOMI. PERRL. dry MM. OP without erythema, exudate, or
ulcerations
NECK: Supple, with RIJ in place
CV: Tachycardia. No M/R/G
Lungs: Nml work of breathing with no accessory muscle use. Late
inspiratory crackles at the bases bilaterally. No wheezes
bilaterally.
Abd: Ecchymosis in the lower abdomen bilaterally. BS+. Soft. ND.
TTP (deep palpation) in the lower quadrants bilaterally; mild
TTP in the RUQ. No rebound or guarding
Ext: Warm. No clubbing, cyanosis, or edema. No calf tenderness
bilaterally. No erythema of the LE bilaterally.
Neuro: CN 2-12 grossly intact bilaterally. Strength: [**5-17**] plantar
and dorsiflexion of the LE bilalerally. 5/5 strength through the
UE bilaterally. Sensation: To light touch intact through the LE
and UE bilaterally. Patient alert and oriented to person, place,
and time.

DISCHARGE:
VITAL SIGNS: 97.3  84/42 (78-109/42-59)  100 (89-107)  20  87%
RA
I/O 1260/550, 52.4kg from 51.6kg yesterday
General: Alert, oriented, lying comfortably in bed, in no acute
distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP at 8-9cm, no LAD
CV: Regular rate and rhythm, S1 + S2 clear and of good quality,
no murmurs, rubs,  or gallops appreciated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally,
finger-to-nose intact

Pertinent Results:
Admission labs:

[**2104-7-20**] 07:10AM [**Month/Day/Year 3143**] WBC-12.6* RBC-3.32* Hgb-10.1* Hct-30.5*
MCV-92 MCH-30.3 MCHC-33.0 RDW-13.4 Plt Ct-137*#
[**2104-7-20**] 07:10AM [**Month/Day/Year 3143**] PT-20.8* PTT-30.1 INR(PT)-2.0*
[**2104-7-20**] 07:10AM [**Month/Day/Year 3143**] Glucose-138* UreaN-9 Creat-0.7 Na-131*
K-3.8 Cl-102 HCO3-17* AnGap-16
[**2104-7-20**] 07:10AM [**Month/Day/Year 3143**] ALT-88* AST-132* CK(CPK)-80 AlkPhos-91
TotBili-0.5
[**2104-7-21**] 02:05AM [**Month/Day/Year 3143**] Albumin-2.5* Calcium-6.9* Phos-2.2*
Mg-1.5*
[**2104-7-22**] 05:15AM [**Month/Day/Year 3143**] PTH-156*
[**2104-7-22**] 05:15AM [**Month/Day/Year 3143**] Cortsol-24.6* 25VitD-23*
[**2104-7-20**] 07:38AM [**Month/Day/Year 3143**] Lactate-2.3*

[**2104-7-22**] 03:58PM [**Month/Day/Year 3143**] HEPARIN DEPENDENT ANTIBODIES- Negative

Imaging:

CT OF THE CHEST:  The thyroid gland is normal.  There is no
axillary lymphadenopathy.  There is a right lower paratracheal
lymph node measuring 12 mm (series 2, image 17).  There is no
hilar lymphadenopathy.  There are mild-to-moderate
atherosclerotic calcifications of the thoracic aorta and
coronary arteries.  There is no pericardial and no pleural
effusion.

The airways are patent to a segmental level. Centrilobular and
paraseptal emphysema is seen with a peripheral bulla at the
right lung apex (series 2, image 9).  Diffuse fibrotic changes
are seen, predominantly at the lung bases. There is no focal
lung consolidation to suggest pneumonia.

A right IJ central line is seen ending at the mid SVC.

CT OF THE ABDOMEN: Multiple hypoattenuating liver lesions are
seen with Hounsfield unit measurements between 10 and 20, likely
representing simple cysts, however a very peripheral
hypoattenuating segment VI lesion is slightly more complex (se
2, im 54). No bile duct dilation. Prior cholecystectomy.

The pancreas and spleen are normal in size.  The right adrenal
gland is
prominent, possibly due to an adenoma.  The left adrenal gland
is normal.
A right extrarenal pelvis is seen.  There is no hydronephrosis,
and no
obstructive renal stones.

There is no retroperitoneal or mesenteric lymphadenopathy.
There is no free air and no free fluid. No fluid collections.
There are moderate-to-severe atherosclerotic calcifications of
the abdominal aorta and the iliac arteries.

The esophagus and stomach are unremarkable. The appeneix is
normal. The small and large bowel are nonobstructed.

CT OF THE PELVIS: There is large amount of stool in the rectum.
There is
moderate-to-severe sigmoid colon diverticulosis without evidence
of
diverticulitis.

A pessary is seen in the vagina. The ovaries are seen with a 1.7
cm cyst on the left ovary. The right ovary is normal and located
between the obturator muscle and the sigmoid colon (series 2,
image 92). There is no free fluid in the pelvis.

A Foley catheter is seen, redundant and curled in the bladder
and should be retracted by a few centimeters.  Postprocedural
air is seen in the urinary bladder.

BONES: There is mild anterolisthesis at L5.  There are no
suspicious lytic or sclerotic bony lesions.

IMPRESSION:
1.  Chronic interstitial lung disease, pulmonary fibrosis,
without evidence of focal consolidation to suggest pneumonia.
2.  Moderate paraseptal and centrilobular emphysema.
3.  Mediastinal lymphadenopathy, likely reacitve.
4.  No evidence of abdominal fluid collection.
5.  Hypoattenuating liver lesions, likely representing simple
cysts. Ultrasound is recommended for further workup.
6.  Redundant, curled up Foley catheter in the urinary bladder,
which should be retracted by a few centimeters.

RUQ Ultrasound:
FINDINGS:
The common bile duct measures between 6 and 7 mm, within normal
limits for the patient's age.  Multiple anechoic right and left
liver lobe cysts are seen.  A very small residual subhepatic
collection with echogenic debris measures 25 x 13 x 18 mm
(series 1, image 21).  The partially visualized pancreas is
normal.
IMPRESSION:
1.  No evidence of biliary dilatation.
2.  Simple liver cysts.
3.  Minimal residual complex subhepatic collection.

[**2104-7-21**] TTE:
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. There is moderate regional left
ventricular systolic dysfunction with severe hypokinesis of the
inferior and inferolateral walls and bassl 2/3rds of the
anterior wall. The remaining segments contract normally (LVEF =
30-35 %). The right ventricular cavity is moderately dilated
with focal hypokinesis of the apical 2/3rds of the free wall.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The descending thoracic aorta is mildly dilated. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are structurally
normal. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.

IMPRESSION: Normal left ventricular cavity size with extensive
regional systolic dysfunction c/w multivessel CAD (RCA and LAD
distribution). . Rigth ventricular free wall hypokinesis
suggestive of proximal RCA disease. Mild mitral regurgitation.

CLINICAL IMPLICATIONS:
The left ventricular ejection fraction is <40%, a threshold for
which the patient may benefit from a beta blocker and an ACE
inhibitor or [**Last Name (un) **].
Based on [**2099**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.

[**2104-7-29**] TTE:
Left ventricular wall thicknesses and cavity size are normal.
There is mild regional left ventricular systolic dysfunction
with hypokinesis of the mid- and distal anterior septum and mid-
inferior septum/inferolateral wall. The remaining segments
contract normally (LVEF = 40%). Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.

IMPRESSION: Mild regional left ventricular systolic dysfunction.


Compared with the prior study (images reviewed) of [**2104-7-21**],
overall LV systolic function has slightly improved. Regional
distribution of wall motion abnormalities is similar.

Microbiology:
[**2104-7-20**] 7:10 am [**Month/Day/Year 3143**] CULTURE

                            **FINAL REPORT [**2104-7-23**]**

   [**Month/Day/Year **] Culture, Routine (Final [**2104-7-23**]):
      ESCHERICHIA COLI.    FINAL SENSITIVITIES.
         Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
         [**Last Name (NamePattern1) 3060**].  CEFEPIME sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ESCHERICHIA COLI
                             |
AMPICILLIN------------  =>32 R
AMPICILLIN/SULBACTAM--     8 S
CEFAZOLIN-------------  =>64 R
CEFEPIME--------------     2 S
CEFTAZIDIME-----------    16 R
CEFTRIAXONE-----------  =>64 R
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO-----       S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S

   Anaerobic Bottle Gram Stain (Final [**2104-7-20**]):
      Reported to and read back by [**First Name5 (NamePattern1) 112132**] [**Last Name (NamePattern1) 112133**] @ 1020PM
[**2104-7-20**].
      GRAM NEGATIVE ROD(S).

   Aerobic Bottle Gram Stain (Final [**2104-7-20**]):    GRAM NEGATIVE
ROD(S).

[**2104-7-20**]- [**2104-7-23**]  [**Month/Day/Year 3143**] CULTURE      Source: Line-aline.

                            **FINAL REPORT**

   [**Month/Day/Year **] Culture, Routine (Final [**2104-7-29**]):    NO GROWTH.


Brief Hospital Course:
needs outpatient [**Last Name (un) **] given recent PE

75 yo female with h/o DVT/PE, h/o necrotizing fasciitis, COPD,
recent cholecystectomy c/b biloma/sepsis requiring ERCP and
stone retrieval with stent placement.  She was transferred from
[**Hospital3 **]1d s/p retrieval of biliary stent here at [**Hospital1 18**]
found to have ESBL Ecoli sepsis.  Hospital course c/b new WMA
and elevated troponins with concern for recent acute coronary
event.

ACTIVE ISSUES:

# SEPTIC SHOCK DUE TO ESBL: Initial [**Hospital1 **] culture revealed ESBL
E. Coli.  Likely etiology of the patient's sepsis is
translocation of gut flora in the setting of recent procedure
for stent removal. ERCP followed the patient through her MICU
course and there was no plan for intervention. Patient's [**Hospital1 **]
cultures remained NGTD, finalized. PICC line was placed for
outpatient antibiotic administration. She will need to complete
a full course of antiobitics with Meropenem for ESBL E. coli
bacteremia, which will end on [**2104-8-3**]. She will continue to be
managed at her nursing facility.

# DEMAND MYOCARDIAL INFARCTION: Patient has had cardiac
catheterization in the past with evidence of non-obstructive
disease (3 years ago). TTE with new left and right sided WMA.
Enzymes trended down.  Pt with likely demand infarct in setting
of sepsis requiring vasopressors. Repeat TTE showed stable WMA
with slightly improved ejection fraction. Cardiology was
consulted who followed the patient through her MICU stay. The
patient was ultimately not felt to have primary ACS.  As such,
there was not felt to be an indication for catheterization.  She
will follow-up for further evaluation and management with her
cardiologist. Although she is not symptomatic from a cardiac
standpoint (no symptoms to suggest angina), she may warrant an
outpatient stress test after discharge from her rehab facility.

# ACUTE SYSTOLIC HEART FAILURE: As a result of patient's septic
shock, she suffered a demand myocardial infarction with
resultant EF of 40% and focal wall motion abnormalities (from
outside facility report [**6-24**] showing EF 60%).  A repeat TTE on
resolution of sepsis showed persistent reduction in the patients
EF.  While she was in house, she was tried on a regimen of heart
failure medications, but her [**Month/Year (2) **] pressures was somewhat
limiting.  According to the patient and her daughter, her [**Name2 (NI) **]
pressure is in the 80s-90s at baseline.  Her lisinopril was
decreased to 2.5 mg daily.  On discharge she was given 6.25 mg
metoprolol tartrate [**Hospital1 **], which should be continued at rehab if
her vital signs allow.  Upon leaving the ICU, she did not
require lasix to maintain a euvolemic status, although she may
require this medication in the future. This should be decided in
conjuction with her primary cardiologist.

# HYPONATREMIA: The patient was transiently hyponatremic to 130.
 This improved after IVF administration.  Sodium was 134 on
discharge.

# PULMONARY EMBOLISM: Patient recently diagnosed w/ PE at OSH ED
after acutely developing shortness of breath at rehabilitation
facility. Patient was started on Lovenox, bridging to coumadin,
reportedly by the patient last taken 3 days prior to stent
removal. Patient was initially on heparin gtt during her
hospitalization, but her platelets acutely fell. She had
intermediate risk for HIT, so Hematology was consulted who
recommend starting argatroban and sending PF4 antibody. PF4
antibody was negative, so argatroban was discontinued and
Lovenox was restarted.  She was restarted on a coumadin on [**7-30**]
(5 mg QD).  She will need daily INR and readjustment of her
coumadin dosing to ensure she is within therapeutic range of INR
[**2-15**].

# ANEMIA: Remained stable without signs or symptoms of acute
bleeding.. Guaiac positive this admission. Initially on IV PPI,
which was then discontinued in light of stable HCTs. Will be
followed-up by PCP for consideration of colonoscopy.

# COUGH:  The patient's CT scan revealed diffuse fibrotic
changes concerning for possible interstitial lung disease. The
patient was also noted to desaturate to 77% on ambulation.  She
was scheduled for an oupatient pulmonology appointment and she
should have PFTs, lung volumes, and DFCO done at that time.  For
now, we achieved symptomatic control with cough suppressants.
Dry cough persisted in morning/night, likely involving
post-nasal drip. Nebulizers helped symptomatically. She will
continue with ipratropium at her nursing facility.

CHRONIC ISSUES:

# Vit D deficiency:  Low phosorous, high PTH. Patient initially
on standing phos repletion, which was discontinued with
initiation of Vit D [**Numeric Identifier 1871**] units weekly.

# HLD: Continued Pravastatin 40mg daily

# HTN: Held BB and ACEi in light of hypotension and pressor
requirement. Re-started at lower doses as documented above.

TRANSITIONAL ISSUES:

# PE: Lovenox, now bridging to coumadin. Needs INR with
follow-up for titration of coumadin. Was started on 5 mg
coumadin daily on [**2104-7-30**]. INR at discharge 1.6

# ? Pulmonary fibrosis: Will follow-up with pulmonology as
outpatient for work-up, which should include pulmonary function
tests, lung volumes, and DFCO.


Medications on Admission:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) inhalation Inhalation Q6H (every 6
hours) as needed for SOB.
4. ipratropium bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours) as needed for SOB.
5. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for dyspepsia.
6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for heartburn.
7. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) as needed for anxiety.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
10. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
11. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six

(6) hours as needed for fever or pain.
12. Zofran 8 mg Tablet Sig: One (1) Tablet PO every twelve (12)
hours as needed for nausea.
13. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours.


Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN fever or pain
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
5. Lisinopril 2.5 mg PO DAILY
please hold for SBP<90
6. Metoprolol Tartrate 12.5 mg PO BID
Please hold for SBP < 90 or HR < 60
7. Pravastatin 40 mg PO DAILY
8. Enoxaparin Sodium 60 mg SC Q12H
9. Meropenem 500 mg IV Q6H sepsis Duration: 2 Days
D1=[**7-21**]. Please give through the end of [**2104-8-3**].
10. Vitamin D 50,000 UNIT PO 1X/WEEK (TH)
11. Warfarin 5 mg PO DAYS ([**Doctor First Name **],MO,TU,WE,TH,FR,SA) PE
PLEASE BE SURE TO GIVE BRAND-NAME COUMADIN. PATIENT HAS ALLERGY
TO GENERIC WARFARIN.
12. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. OxycoDONE (Immediate Release)  5 mg PO Q6H:PRN severe pain
15. Ondansetron 8 mg PO Q8H:PRN nausea
16. Calcium Carbonate 500 mg PO QID:PRN heartburn
17. Aluminum-Magnesium Hydrox.-Simethicone 15-30 mL PO QID:PRN
heartburn
18. ALPRAZolam 0.25 mg PO BID:PRN anxiety


Discharge Disposition:
Extended Care

Facility:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 57850**] Healthcare Center - [**Location (un) **]

Discharge Diagnosis:
Acute systolic CHF
Demand myocardial infarction in setting of sepsis
Sepsis due to ESBL
Pulmonary embolism (stable diagnosis)
Sinus tachycardia
Interstitial lung disease
Hypertension


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


Discharge Instructions:
Dear Ms. [**Known lastname **],

It was a pleasure to take care of you during your
hospitalization. You were admitted after developing fevers and
an infection related to your gall bladder surgery. During your
stay, you were treated for this severe infection in the
Intensive Care Unit with antibiotics and medications to maintain
your [**Known lastname **] pressure. You improved well with this treatment and
were able to be transferred out of the ICU.

Since then, you have been managed with medications to keep your
[**Known lastname **] pressure and your heart rate stable. At this point, you
are now stable and safe enough to be discharged back to your
nursing facility. It will be important to continue taking your
medications as prescribed and letting your medical staff know if
you have any concerns or symptoms listed below. It will also be
important to see your doctors at the [**Name5 (PTitle) 4314**] listed below.

Followup Instructions:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) 1730**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital 46644**] MEDICAL ASSOCIATES-CARDIOLOGY
Address: ONE PARKWAY, [**Location (un) **],[**Numeric Identifier 75553**]
Phone: [**Telephone/Fax (1) 86181**]
Appt:  Friday, [**8-8**] at 11:15am

Also, an appointment with a Pulmonologist (lung doctor) at [**Hospital1 18**]
is in the process of being set up. You should call [**Telephone/Fax (1) 612**]
to confirm the date and time.
{'Septicemia due to escherichia coli [E. coli],Septic shock,Subendocardial infarction, initial episode of care,Acute systolic heart failure,Hyposmolality and/or hyponatremia,Severe sepsis,Anemia, unspecified,Thrombocytopenia, unspecified,Other specified cardiac dysrhythmias,Chronic airway obstruction, not elsewhere classified,Mitral valve disorders,Other and unspecified hyperlipidemia,Osteoporosis, unspecified,Unspecified vitamin D deficiency,Postinflammatory pulmonary fibrosis,Coronary atherosclerosis of native coronary artery,Personal history of pulmonary embolism,Long-term (current) use of anticoagulants'}


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: Chief Complaint: Vomiting, fever, hypotension

PRESENT ILLNESS: Ms. [**Known lastname **] is a 75 yo female with h/o DVT/PE, h/o necrotizing
fasciitis, COPD, recent cholecystectomy c/b biloma/sepsis
requiring ERCP and stone retrieval with stent placement.  She is
being transferred from [**Hospital3 **]1d s/p retrieval of
biliary stent with fevers, hypotension, and abdominal pain, and
vomiting.

MEDICAL HISTORY: -Necrotizing fasicitis right groin and pelvic area
-DVT/PE after necrotizing fasicitis of right groin six years ago
previously on warfarin but since stopped
-MVP
-Chronic constipation
-Non obstructive CAD: cath in [**2101**] with proximal calcification
in left coronary arteries. 30-40% stenosis in prox LAD, mild
osteal circ narrowing, 40% prox RCA stenosis. EF 50-55% with
apical hypokinesis. TTE in [**2103-5-13**] normal LV fxn, mod MR with
mild
-MVP, and trace TR
-Hyperlipidemia
-Osteoporosis
-COPD
-s/p CCY c/b biliary leak/biloma requiring ERCP and stone
retrieval with stent placement
-HTN

MEDICATION ON ADMISSION: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) inhalation Inhalation Q6H (every 6
hours) as needed for SOB.
4. ipratropium bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours) as needed for SOB.
5. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for dyspepsia.
6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for heartburn.
7. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) as needed for anxiety.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
10. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
11. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six

ALLERGIES: Penicillins / Sulfa(Sulfonamide Antibiotics) / latex / Warfarin

PHYSICAL EXAM: Admission physical exam:
Vitals: Tcurrent: 37.2 ??????C (99 ??????F) HR: 111 (106 - 130) bpm BP:
87/34(48) {87/34(48) - 107/65(74)} mmHg RR: 25 (25 - 34)
insp/min SpO2: 99%
General: Well-appearing patient sitting up in bed, alert and
interactive in NAD
HEENT: EOMI. PERRL. dry MM. OP without erythema, exudate, or
ulcerations
NECK: Supple, with RIJ in place
CV: Tachycardia. No M/R/G
Lungs: Nml work of breathing with no accessory muscle use. Late
inspiratory crackles at the bases bilaterally. No wheezes
bilaterally.
Abd: Ecchymosis in the lower abdomen bilaterally. BS+. Soft. ND.
TTP (deep palpation) in the lower quadrants bilaterally; mild
TTP in the RUQ. No rebound or guarding
Ext: Warm. No clubbing, cyanosis, or edema. No calf tenderness
bilaterally. No erythema of the LE bilaterally.
Neuro: CN 2-12 grossly intact bilaterally. Strength: [**5-17**] plantar
and dorsiflexion of the LE bilalerally. 5/5 strength through the
UE bilaterally. Sensation: To light touch intact through the LE
and UE bilaterally. Patient alert and oriented to person, place,
and time.

FAMILY HISTORY: No history of GB stones.

SOCIAL HISTORY: Married, stopped smoking in [**2086**]. 30-40 pack year. Social
drinking, 103 beverage during social setting. No drug use.
Currently in rehabilitation facility 

### Response:
{'Septicemia due to escherichia coli [E. coli],Septic shock,Subendocardial infarction, initial episode of care,Acute systolic heart failure,Hyposmolality and/or hyponatremia,Severe sepsis,Anemia, unspecified,Thrombocytopenia, unspecified,Other specified cardiac dysrhythmias,Chronic airway obstruction, not elsewhere classified,Mitral valve disorders,Other and unspecified hyperlipidemia,Osteoporosis, unspecified,Unspecified vitamin D deficiency,Postinflammatory pulmonary fibrosis,Coronary atherosclerosis of native coronary artery,Personal history of pulmonary embolism,Long-term (current) use of anticoagulants'}
