CHIEF COMPLAINT: Lethargy, leukocytosis, hypotension

PRESENT ILLNESS: 48 year old female with ESRD on HD (M,W,F), Hepatitis B on
antiviral treatment, recent long complicated admission
[**Date range (1) 17651**]/[**2168**] for complications of PEG placement on [**2168-1-6**] with
abdominal wall abscess s/p exlap, closure of gastrostomy and peg
removal, I&D abd wall abscess x3/necrotizing fascitis with wound
vac, who was at rehab and was started for treatment for positive
cdiff on [**3-30**] and sent in for increased leukocytosis to 25 and
lethargy on PO vanco and flagyl.
.
She was at [**Hospital3 **] with PICC line for antibiotics,
tunneled catheter for HD and abd wound. Per rehab pt was pos of
C-diff on [**3-30**] with WBC of 16.9 and was started on Flagyl but
became nauseous and vomited while taking and was changed to
vanco 250mg QID on [**4-1**]. On day of admission, patient with
lethargy, and increased WBC to 25.9 and T99.2 at rehab.
.
Initials vitals in the ED were VS/100.7 HR52 BP84/48 RR14 100%
on RA. Received 2L IVF. Persistently hyopotensive. Right fem
line placed, refused IJ, and started on levophed at 0.05. Has R
PICC and R tunnelled HD line not obviously infected. Getting
levophed at 0.05. CT abdomen prelim read showed new splenic
infarct, ? colitis. Right lung consolidation icnreased. Right
thigh ? abscess but no TTP. Also given vanc/zosyn. Labs
significant for WBC 25.7 with 73N, 2 bands, ALT: 46 AP: 344
Tbili: 11.7 AST: 140 Dbili: 7.3, INR 1.4, Hct 32.2. EKG with
sinus bradycardia. Seen by surgery who recommended broad
antibiotic coverage including antifungal coverage, serial
abdominal exams. Renal made aware. On transfer, vitals were HR54
BP99/55 RR16 100% on 2L NC.
.
On arrival to the ICU, patient was sleepy but not in any
localized pain. States she has baseline nonfocal leg pain,
denies SOB, chest pain, abdominal pain. States she has been
having diarrhea for more than one week which has been unchanged.

MEDICAL HISTORY: - ESRD due to diabetes, on MWF HD at [**Hospital1 1474**] center being
evaluated for renal transplant, hemodialysis since [**2167-3-2**]
- chronic HBV infection with associated autoimmune
cholangiopathy that has responded to prednisone in past, also
being evaluated for liver transplant
- HTN
- Diabetes complicated by neuropathy, nephropathy, retinopathy
- Chronic diarrhea/weight loss/malabsorption
- h/o CVA: Residual L-sided weakness most pronounced in leg,
hand
coordination/strength; uses walker to ambulate
- s/p Surgical procedures during last hospital stay - s/p
multiple courses of antibiotics including Linezolid discontinued
on [**3-3**] after a 24 day course, Fluconazole discontinued on [**3-3**]
after a 23 day course and completed meropenem day [**10-9**] on [**3-10**]
for Pseudomonas,
Enterococcus, E. Coli and [**Female First Name (un) **] infection.
[**2168-3-2**] PICC and Tunneled HD cath
[**2168-2-15**] I+D abdominal wound
[**2168-2-13**] I+D abdominal wall infection
[**2168-2-5**] I+D abdominal wall abscess
[**2168-1-28**] Ex-Lap, gastrostomy closure, umbo hernia, I&D abscess
[**2168-1-21**] Abdominal Wall Abscess Drainage, IR

MEDICATION ON ADMISSION: - Vancomycin 250mg PO QID
- Ursodiol 250mg TID
- Entecavir 1mg Tablet PO 1X/WEEK (FR)
- SC heparin 5000 units [**Hospital1 **]
- Glargine insulin 10units QHS
- Lispro insulin sliding scale
- Lisinopril 20mg daily
- Loperamide 2mg before meals and at bedtime
- Medium Chain Triglycerides 7.7 kcal/mL (15)ML PO TID
- Metoprolol Tartrate 25 mg [**Hospital1 **]
- Nephplex tablet PO daily
- Pantoprazole 40 mg XR daily
- Tenofovir Disoproxil Fumarate 300 mg PO 1X/WEEK (FR)
-Lipase-Protease-Amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: Four (4) Cap PO TID W/MEALS Please
give 1 capsule before, 2 capsule during, and 1 capsule after
meals and snacks.
- Lactulose 20gm PO daily prn
- Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H prn pain,
1mg IV Q6hr prn breakthrough pain
- Ativan 0.5mg PO TID prn anxiety, nausea, dizziness
- Zofran 4mg IV Q8hr prn nausea
- Timolol maleate eye drops 1 drop both eyes [**Hospital1 **]
- Anusol ointment TID prn rectal pain
- Opium tincture 10 drops Q4hrs prn diarrhea
- Glucagon prn hypoglycemia
- s/p prednisone taper

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T:96.7 BP:117/63 P:62 R:19 18 O2:98% on RA
General: Haitian woman, responding appropriately to questions,
AOx3, low energy
[**Year (4 digits) 4459**] - PERRL, EOMI, sclerae icteric with subungual icterus
NECK - Supple, no JVD
LUNGS - Decreased BS at bases, good air movement otherwise with
no wheezes or crackles
HEART - PMI non-displaced, RRR, loud holosystolic murmur heard
throughout precordium, nl S1-S2
CHEST: R tunnelled HD catheter in place, dressing in place, no
erythema or tenderness at site
ABDOMEN - + BS, wound vac in place over recent I&D site across R
abdomen. Large midline vertical incision scar. TTP in R quadrant
without rebound or guarding
EXTREMITIES - 2+ edema bilaterally with fluid with 2+ peripheral
pulses (radials, DPs). Tender in all areas, no area of
fluctuance or erythema in right thigh. R femoral line in place
and R PICC line in place
NEURO - +asterixis

FAMILY HISTORY: Father died of complications from diabetes. Mother also
diabetic. Otherwise no known illness in family including no
known renal/liver disease.

SOCIAL HISTORY: Prior to rehab, lived with her mother and daughter (15) and son
(12). Not married. Born in [**Country 2045**] but moved to the US in [**2144**].
Has been out
of work since her stroke and has both VNA and home health aide
to assist her at home with ADLs and meds.
Other and unspecified infection due to central venous catheter,Disseminated candidiasis,Septic shock,End stage renal disease,Portal vein thrombosis,Acute respiratory failure,Encephalopathy, unspecified,Severe sepsis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta,Intestinal infection due to Clostridium difficile,Other complications due to other vascular device, implant, and graft,Acute venous embolism and thrombosis of subclavian veins,Unspecified protein-calorie malnutrition,Cholangitis,Other ascites,Unspecified pleural effusion,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Renal dialysis status,Background diabetic retinopathy,Polyneuropathy in diabetes,Anemia in chronic kidney disease
Oth/uns inf-cen ven cath,Disseminated candidiasis,Septic shock,End stage renal disease,Portal vein thrombosis,Acute respiratry failure,Encephalopathy NOS,Severe sepsis,Hyp kid NOS w cr kid V,Hpt B chrn wo cm wo dlta,Int inf clstrdium dfcile,Comp-oth vasc dev/graft,Ac embl subclav veins,Protein-cal malnutr NOS,Cholangitis,Ascites NEC,Pleural effusion NOS,Abn react-procedure NEC,DMII renl nt st uncntrld,Renal dialysis status,Diabetic retinopathy NOS,Neuropathy in diabetes,Anemia in chr kidney dis
Admission Date:  [**2168-4-5**]              Discharge Date:   [**2168-4-25**]

Date of Birth:  [**2119-5-26**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 5608**]
Chief Complaint:
Lethargy, leukocytosis, hypotension

Major Surgical or Invasive Procedure:
Diagnostic paracentesis

History of Present Illness:
48 year old female with ESRD on HD (M,W,F), Hepatitis B on
antiviral treatment, recent long complicated admission
[**Date range (1) 17651**]/[**2168**] for complications of PEG placement on [**2168-1-6**] with
abdominal wall abscess s/p exlap, closure of gastrostomy and peg
removal, I&D abd wall abscess x3/necrotizing fascitis with wound
vac, who was at rehab and was started for treatment for positive
cdiff on [**3-30**] and sent in for increased leukocytosis to 25 and
lethargy on PO vanco and flagyl.
.
She was at [**Hospital3 **] with PICC line for antibiotics,
tunneled catheter for HD and abd wound. Per rehab pt was pos of
C-diff on [**3-30**] with WBC of 16.9 and was started on Flagyl but
became nauseous and vomited while taking and was changed to
vanco 250mg QID on [**4-1**]. On day of admission, patient with
lethargy, and increased WBC to 25.9 and T99.2 at rehab.
.
Initials vitals in the ED were VS/100.7 HR52 BP84/48 RR14 100%
on RA. Received 2L IVF. Persistently hyopotensive. Right fem
line placed, refused IJ, and started on levophed at 0.05. Has R
PICC and R tunnelled HD line not obviously infected. Getting
levophed at 0.05. CT abdomen prelim read showed new splenic
infarct, ? colitis. Right lung consolidation icnreased. Right
thigh ? abscess but no TTP. Also given vanc/zosyn. Labs
significant for WBC 25.7 with 73N, 2 bands, ALT: 46 AP: 344
Tbili: 11.7 AST: 140 Dbili: 7.3, INR 1.4, Hct 32.2. EKG with
sinus bradycardia. Seen by surgery who recommended broad
antibiotic coverage including antifungal coverage, serial
abdominal exams. Renal made aware. On transfer, vitals were HR54
BP99/55 RR16 100% on 2L NC.
.
On arrival to the ICU, patient was sleepy but not in any
localized pain. States she has baseline nonfocal leg pain,
denies SOB, chest pain, abdominal pain. States she has been
having diarrhea for more than one week which has been unchanged.


Past Medical History:
- ESRD due to diabetes, on MWF HD at [**Hospital1 1474**] center being
evaluated for renal transplant, hemodialysis since [**2167-3-2**]
- chronic HBV infection with associated autoimmune
cholangiopathy that has responded to prednisone in past, also
being evaluated for liver transplant
- HTN
- Diabetes complicated by neuropathy, nephropathy, retinopathy
- Chronic diarrhea/weight loss/malabsorption
- h/o CVA: Residual L-sided weakness most pronounced in leg,
hand
coordination/strength; uses walker to ambulate
- s/p Surgical procedures during last hospital stay - s/p
multiple courses of antibiotics including Linezolid discontinued
on [**3-3**] after a 24 day course, Fluconazole discontinued on [**3-3**]
after a 23 day course and completed meropenem day [**10-9**] on [**3-10**]
for Pseudomonas,
Enterococcus, E. Coli and [**Female First Name (un) **] infection.
[**2168-3-2**] PICC and Tunneled HD cath
[**2168-2-15**] I+D abdominal wound
[**2168-2-13**] I+D abdominal wall infection
[**2168-2-5**] I+D abdominal wall abscess
[**2168-1-28**] Ex-Lap, gastrostomy closure, umbo hernia, I&D abscess
[**2168-1-21**] Abdominal Wall Abscess Drainage, IR


Social History:
Prior to rehab, lived with her mother and daughter (15) and son
(12). Not married. Born in [**Country 2045**] but moved to the US in [**2144**].
Has been out
of work since her stroke and has both VNA and home health aide
to assist her at home with ADLs and meds.

Family History:
Father died of complications from diabetes. Mother also
diabetic. Otherwise no known illness in family including no
known renal/liver disease.

Physical Exam:
Vitals: T:96.7 BP:117/63 P:62 R:19 18 O2:98% on RA
General: Haitian woman, responding appropriately to questions,
AOx3, low energy
[**Year (4 digits) 4459**] - PERRL, EOMI, sclerae icteric with subungual icterus
NECK - Supple, no JVD
LUNGS - Decreased BS at bases, good air movement otherwise with
no wheezes or crackles
HEART - PMI non-displaced, RRR, loud holosystolic murmur heard
throughout precordium, nl S1-S2
CHEST: R tunnelled HD catheter in place, dressing in place, no
erythema or tenderness at site
ABDOMEN - + BS, wound vac in place over recent I&D site across R
abdomen. Large midline vertical incision scar. TTP in R quadrant
without rebound or guarding
EXTREMITIES - 2+ edema bilaterally with fluid with 2+ peripheral
pulses (radials, DPs). Tender in all areas, no area of
fluctuance or erythema in right thigh. R femoral line in place
and R PICC line in place
NEURO - +asterixis

Pertinent Results:
[**2168-4-25**] 12:14PM BLOOD WBC-22.8* RBC-2.75* Hgb-7.1* Hct-23.8*
MCV-87 MCH-26.0* MCHC-30.1* RDW-24.1* Plt Ct-331
[**2168-4-25**] 05:48AM BLOOD Neuts-91* Bands-0 Lymphs-7* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2168-4-25**] 12:14PM BLOOD PT-15.8* PTT-66.0* INR(PT)-1.4*
[**2168-4-25**] 12:14PM BLOOD Glucose-152* UreaN-4* Creat-0.6 Na-131*
K-4.6 Cl-110* HCO3-16* AnGap-10
[**2168-4-25**] 05:48AM BLOOD ALT-13 AST-51* AlkPhos-299* TotBili-8.2*
[**2168-4-25**] 12:14PM BLOOD Calcium-8.0* Phos-1.2* Mg-2.4
[**2168-4-25**] 05:48AM BLOOD calTIBC-186* Ferritn-310* TRF-143*
[**2168-4-7**] 02:44AM BLOOD Triglyc-130
[**2168-4-7**] 02:44AM BLOOD TSH-0.61
[**2168-4-15**] 04:24AM BLOOD Cortsol-26.6*

Brief Hospital Course:
48 year old female with ESRD on HD, Chronic HBV, on wound vac
for abdominal wall abscess s/p exlap, closure of gastrostomy and
peg removal, I&D abd wall abscess x3/necrotizing fascitis and
recent E.Coli, [**Female First Name (un) 564**], and Pseudomonas bacteremia, with recent
diagnosis/initiation of treatment for positive cdiff admitted
for septic shock.

* Candidemia
Patient was empirically started on micafungin on admission due
for concern for possible PICC-associated fungal infection given
concomitant TPN. Of note, her beta glucan on admission was quite
high, though there were no prior values from her prior admission
for comparison. Micafungin was discontinued given initial
clinical stability and known C difficile colitis as explanation
for leukocytosis. However, off antifungals on the medical floor,
she developed high grade fevers. Multiple sets of blood cultures
ultimately returned positive for C. glabrate, confirmed to be
fluconazole sensitive. Her existing HD catheter and PICC line
were removed and subsequently no further blood cultures grew
yeast. TEE showed no evidence of endocarditis, and opthalmology
exam showed no eye involvement. This extended course was chosen
given her existing clots and potential for having seeded these
in setting of candidemia. Examination of a thigh fluid
collection, ascites, and pleural effusion revealed no active
infection at these sites.

* Unresponsive episodes
Patient experienced multiple episodes of unresponsiveness
throughout the hospitalization. Initially there was some
question as to whether these might be seizure-related given her
prior CVA and treatment with antimicrobials known to lower the
seizure threshold (meropenem). However EEG showed no evidence of
seizure activity and neurology consultants felt no additional
workup was required. They felt she likely has some degree of
autonomic dysfunction in the setting of her diabetes and this
could explain these episodes. MRI/MRV was done to look for
fungal CNS disease and cerebral sinus thrombosis respectively,
but showed no acute process.

* C. difficile colitis
Patient diagnosed with this at her rehab facility. Of note, she
does have a history of chronic diarrhea worked up extensively by
GI and felt to be secondary to pancreatic insufficiency. She was
initially treated wtih vancomycin and metronidazole,
subsequently narrowed down to PO vancomycin alone.

* Aspiration
Patient had a witnessed aspiration on [**4-23**] in the setting of one
of her bradycardic and hypotensive episodes. She was empirically
started on vancomycin and meropenem and reintubated.

* Portal venous thrombosis
Patient's admission abdominal imaging showed a portal venous
clot which appeared new from 3/[**2168**]. She was started on heparin
consequently.

* Abdominal wound
She continued care with a wound vac. Her wound was felt to be
healing well and was followed regularly by plastic surgery.

* Nutrition
Patient's TPN was held in the setting of her systemic fungal
infection. She had a Dophoff placed and was started on enteral
feeding.

* Autoimmune cholangiopathy and hepatitis B
She continued on prednisone at the hepatology service's
recommendation, along with tenofovir and entecavir. She will
require close liver followup on discharge.

* ESRD on HD
Patient was maintained on CVVH in the ICU. She has a new HD line
placed.

* Goals of Care
Ultimately goals of care were addressed with family members. The
decision was made to extubate and change goals to comfort
measures only. Shortly after extubation, patient passed away on
[**4-25**].

Medications on Admission:
- Vancomycin 250mg PO QID
- Ursodiol 250mg TID
- Entecavir 1mg Tablet PO 1X/WEEK (FR)
- SC heparin 5000 units [**Hospital1 **]
- Glargine insulin 10units QHS
- Lispro insulin sliding scale
- Lisinopril 20mg daily
- Loperamide 2mg before meals and at bedtime
- Medium Chain Triglycerides 7.7 kcal/mL (15)ML PO TID
- Metoprolol Tartrate 25 mg [**Hospital1 **]
- Nephplex tablet PO daily
- Pantoprazole 40 mg XR daily
- Tenofovir Disoproxil Fumarate 300 mg PO 1X/WEEK (FR)
-Lipase-Protease-Amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: Four (4) Cap PO TID W/MEALS Please
give 1 capsule before, 2 capsule during, and 1 capsule after
meals and snacks.
- Lactulose 20gm PO daily prn
- Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H prn pain,
1mg IV Q6hr prn breakthrough pain
- Ativan 0.5mg PO TID prn anxiety, nausea, dizziness
- Zofran 4mg IV Q8hr prn nausea
- Timolol maleate eye drops 1 drop both eyes [**Hospital1 **]
- Anusol ointment TID prn rectal pain
- Opium tincture 10 drops Q4hrs prn diarrhea
- Glucagon prn hypoglycemia
- s/p prednisone taper

Discharge Medications:
Deceased.

Discharge Disposition:
Expired

Discharge Diagnosis:
Deceased.

Discharge Condition:
Deceased.

Discharge Instructions:
Deceased.

Followup Instructions:
Deceased.


Completed by:[**2168-4-26**]
{'Other and unspecified infection due to central venous catheter,Disseminated candidiasis,Septic shock,End stage renal disease,Portal vein thrombosis,Acute respiratory failure,Encephalopathy, unspecified,Severe sepsis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta,Intestinal infection due to Clostridium difficile,Other complications due to other vascular device, implant, and graft,Acute venous embolism and thrombosis of subclavian veins,Unspecified protein-calorie malnutrition,Cholangitis,Other ascites,Unspecified pleural effusion,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Renal dialysis status,Background diabetic retinopathy,Polyneuropathy in diabetes,Anemia in chronic kidney disease'}


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: Lethargy, leukocytosis, hypotension

PRESENT ILLNESS: 48 year old female with ESRD on HD (M,W,F), Hepatitis B on
antiviral treatment, recent long complicated admission
[**Date range (1) 17651**]/[**2168**] for complications of PEG placement on [**2168-1-6**] with
abdominal wall abscess s/p exlap, closure of gastrostomy and peg
removal, I&D abd wall abscess x3/necrotizing fascitis with wound
vac, who was at rehab and was started for treatment for positive
cdiff on [**3-30**] and sent in for increased leukocytosis to 25 and
lethargy on PO vanco and flagyl.
.
She was at [**Hospital3 **] with PICC line for antibiotics,
tunneled catheter for HD and abd wound. Per rehab pt was pos of
C-diff on [**3-30**] with WBC of 16.9 and was started on Flagyl but
became nauseous and vomited while taking and was changed to
vanco 250mg QID on [**4-1**]. On day of admission, patient with
lethargy, and increased WBC to 25.9 and T99.2 at rehab.
.
Initials vitals in the ED were VS/100.7 HR52 BP84/48 RR14 100%
on RA. Received 2L IVF. Persistently hyopotensive. Right fem
line placed, refused IJ, and started on levophed at 0.05. Has R
PICC and R tunnelled HD line not obviously infected. Getting
levophed at 0.05. CT abdomen prelim read showed new splenic
infarct, ? colitis. Right lung consolidation icnreased. Right
thigh ? abscess but no TTP. Also given vanc/zosyn. Labs
significant for WBC 25.7 with 73N, 2 bands, ALT: 46 AP: 344
Tbili: 11.7 AST: 140 Dbili: 7.3, INR 1.4, Hct 32.2. EKG with
sinus bradycardia. Seen by surgery who recommended broad
antibiotic coverage including antifungal coverage, serial
abdominal exams. Renal made aware. On transfer, vitals were HR54
BP99/55 RR16 100% on 2L NC.
.
On arrival to the ICU, patient was sleepy but not in any
localized pain. States she has baseline nonfocal leg pain,
denies SOB, chest pain, abdominal pain. States she has been
having diarrhea for more than one week which has been unchanged.

MEDICAL HISTORY: - ESRD due to diabetes, on MWF HD at [**Hospital1 1474**] center being
evaluated for renal transplant, hemodialysis since [**2167-3-2**]
- chronic HBV infection with associated autoimmune
cholangiopathy that has responded to prednisone in past, also
being evaluated for liver transplant
- HTN
- Diabetes complicated by neuropathy, nephropathy, retinopathy
- Chronic diarrhea/weight loss/malabsorption
- h/o CVA: Residual L-sided weakness most pronounced in leg,
hand
coordination/strength; uses walker to ambulate
- s/p Surgical procedures during last hospital stay - s/p
multiple courses of antibiotics including Linezolid discontinued
on [**3-3**] after a 24 day course, Fluconazole discontinued on [**3-3**]
after a 23 day course and completed meropenem day [**10-9**] on [**3-10**]
for Pseudomonas,
Enterococcus, E. Coli and [**Female First Name (un) **] infection.
[**2168-3-2**] PICC and Tunneled HD cath
[**2168-2-15**] I+D abdominal wound
[**2168-2-13**] I+D abdominal wall infection
[**2168-2-5**] I+D abdominal wall abscess
[**2168-1-28**] Ex-Lap, gastrostomy closure, umbo hernia, I&D abscess
[**2168-1-21**] Abdominal Wall Abscess Drainage, IR

MEDICATION ON ADMISSION: - Vancomycin 250mg PO QID
- Ursodiol 250mg TID
- Entecavir 1mg Tablet PO 1X/WEEK (FR)
- SC heparin 5000 units [**Hospital1 **]
- Glargine insulin 10units QHS
- Lispro insulin sliding scale
- Lisinopril 20mg daily
- Loperamide 2mg before meals and at bedtime
- Medium Chain Triglycerides 7.7 kcal/mL (15)ML PO TID
- Metoprolol Tartrate 25 mg [**Hospital1 **]
- Nephplex tablet PO daily
- Pantoprazole 40 mg XR daily
- Tenofovir Disoproxil Fumarate 300 mg PO 1X/WEEK (FR)
-Lipase-Protease-Amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: Four (4) Cap PO TID W/MEALS Please
give 1 capsule before, 2 capsule during, and 1 capsule after
meals and snacks.
- Lactulose 20gm PO daily prn
- Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H prn pain,
1mg IV Q6hr prn breakthrough pain
- Ativan 0.5mg PO TID prn anxiety, nausea, dizziness
- Zofran 4mg IV Q8hr prn nausea
- Timolol maleate eye drops 1 drop both eyes [**Hospital1 **]
- Anusol ointment TID prn rectal pain
- Opium tincture 10 drops Q4hrs prn diarrhea
- Glucagon prn hypoglycemia
- s/p prednisone taper

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T:96.7 BP:117/63 P:62 R:19 18 O2:98% on RA
General: Haitian woman, responding appropriately to questions,
AOx3, low energy
[**Year (4 digits) 4459**] - PERRL, EOMI, sclerae icteric with subungual icterus
NECK - Supple, no JVD
LUNGS - Decreased BS at bases, good air movement otherwise with
no wheezes or crackles
HEART - PMI non-displaced, RRR, loud holosystolic murmur heard
throughout precordium, nl S1-S2
CHEST: R tunnelled HD catheter in place, dressing in place, no
erythema or tenderness at site
ABDOMEN - + BS, wound vac in place over recent I&D site across R
abdomen. Large midline vertical incision scar. TTP in R quadrant
without rebound or guarding
EXTREMITIES - 2+ edema bilaterally with fluid with 2+ peripheral
pulses (radials, DPs). Tender in all areas, no area of
fluctuance or erythema in right thigh. R femoral line in place
and R PICC line in place
NEURO - +asterixis

FAMILY HISTORY: Father died of complications from diabetes. Mother also
diabetic. Otherwise no known illness in family including no
known renal/liver disease.

SOCIAL HISTORY: Prior to rehab, lived with her mother and daughter (15) and son
(12). Not married. Born in [**Country 2045**] but moved to the US in [**2144**].
Has been out
of work since her stroke and has both VNA and home health aide
to assist her at home with ADLs and meds. 

### Response:
{'Other and unspecified infection due to central venous catheter,Disseminated candidiasis,Septic shock,End stage renal disease,Portal vein thrombosis,Acute respiratory failure,Encephalopathy, unspecified,Severe sepsis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta,Intestinal infection due to Clostridium difficile,Other complications due to other vascular device, implant, and graft,Acute venous embolism and thrombosis of subclavian veins,Unspecified protein-calorie malnutrition,Cholangitis,Other ascites,Unspecified pleural effusion,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Renal dialysis status,Background diabetic retinopathy,Polyneuropathy in diabetes,Anemia in chronic kidney disease'}
