CHIEF COMPLAINT: Bacteremia

PRESENT ILLNESS: 84 year old male with h/o CAD s/p stenting, systolic CHF
(EF40-45%), atrial fibrillation, h/o cardiac arrest with heart
block s/p AICD/pacemaker, trach/PEG, recent MRSA bacteremia, and
recent MICU admission for hematuria and GI bleed who presents
with fevers and baceteria.

MEDICAL HISTORY: Rectal cancer s/p excision and XRT ([**2157**])
CAD s/p stents (?[**2159**])
CVA in [**2150**] with residual right hand dysthesia
Complete heart block s/p pacemaker
H/o cardiac arrest (now with AICD)
GI bleed secondary to angiectasias in the duodenum ([**1-/2162**]) s/p
cauterization via EGD
Atrial fibrillation, not on [**Year (4 digits) **]
Systolic CHF (EF 40-45%)
S/p Fall with multiple rib fractures ([**2163-6-23**])
MICU admission [**Date range (1) 108856**]/[**2163**] for hemoptysis, bleeding from
trach
Abdominoperineal resection [**9-/2157**] w/ [**Doctor Last Name **]

MEDICATION ON ADMISSION: Acetaminophen 650mg po q4h prn pain
Lidocaine patch 5% TD daily
Trazodone 25mg po qhs prn insomnia
Citalopram 20mg po daily
Docusate 50mg po bid
Ferrous sulfate 300mg po daily
Folic acid 1mg po daily
Multivitamin 1 tab po daily
Omeprazole 20mg po daily
Albuterol sulfate 90mcg q4h prn SOB/wheeze
Simethicone 80mg po tid
Miconazole nitrate 2% application qhs
Oxycodone 5-10mg po q4h prn pain
Lasix 40mg po daily
Vancomycin 500mg IV q12h
Psyllium one packet po tid
Sucralfate 1gram po qid
Carvedilol 6.25mg po bid

ALLERGIES: Penicillins / Erythromycin Base / Streptomycin / Citric Acid /
Atenolol / Torsemide / Heparin Agents

PHYSICAL EXAM: On Admission:
Vitals: 97.7 70 108/49 18 100% AC 500x12, PEEP 5, FiO2 35%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, trach in place
with clear/white secretions
Neck: supple, no LAD
Lungs: Coarse rales at bases, no wheezes
CV: Regular rate and rhythm, normal S1 + S2, III/VI systolic
murmur at apex
Abdomen: soft, non-tender, distended, ostomy in place, bowel
sounds present, no rebound tenderness or guarding
GU: Foley in place
Skin: 3cm sacral decub without surrounding erythema.  PICC in
place on right arm, only mild redness at insertion.
Ext: Warm, well perfused with 2+ pitting edema, ulcerations on
bilateral shins

FAMILY HISTORY: Father died in 80s from MI. Mother died in 80s from PE. No
family history of colon, breast, uterine, or ovarian cancer. No
family history of seizures.

SOCIAL HISTORY: Resident of [**Hospital 100**] Rehab; previously had lived in [**Location 745**] with
his wife, now w some depression about moving out of their 42
year home. Has two children. Retired computer science professor.
Personal history of sudden cardiac arrest,Colostomy status,Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus,Personal history of irradiation, presenting hazards to health,Tracheostomy status,Gastrostomy status,History of fall,Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus,Sepsis,Methicillin resistant Staphylococcus aureus septicemia,Acute kidney failure, unspecified,Pressure ulcer, stage IV,Acute on chronic diastolic heart failure,Chronic respiratory failure,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Urinary tract infection, site not specified,Atrial fibrillation,Anemia, unspecified,Effusion of joint, lower leg,Automatic implantable cardiac defibrillator in situ,Percutaneous transluminal coronary angioplasty status
Hx sudden cardiac arrest,Colostomy status,Hx-rectal & anal malign,Hx of irradiation,Tracheostomy status,Gastrostomy status,Personal history of fall,Meth resis Staph carrier,Sepsis,MRSA septicemia,Acute kidney failure NOS,Pressure ulcer, stage IV,Ac on chr diast hrt fail,Chronic respiratory fail,Pseudomonas infect NOS,Urin tract infection NOS,Atrial fibrillation,Anemia NOS,Joint effusion-l/leg,Status autm crd dfbrltr,Status-post ptca
Admission Date:  [**2163-9-20**]              Discharge Date:   [**2163-9-30**]

Date of Birth:  [**2079-1-17**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Erythromycin Base / Streptomycin / Citric Acid /
Atenolol / Torsemide / Heparin Agents

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Bacteremia

Major Surgical or Invasive Procedure:
Transesophagealechocardiogram

History of Present Illness:
84 year old male with h/o CAD s/p stenting, systolic CHF
(EF40-45%), atrial fibrillation, h/o cardiac arrest with heart
block s/p AICD/pacemaker, trach/PEG, recent MRSA bacteremia, and
recent MICU admission for hematuria and GI bleed who presents
with fevers and baceteria.

He was recently admitted [**Date range (1) 105469**] for pneumonia and MRSA
bacteremia and sepsis.  Discharged on IV vancomycin which he has
been on since.  He was then readmitted [**9-10**] to [**9-12**] for
hematuria and blood from his colostomy bag felt to be secondary
to recent aspirin initiation.  He was discharged to [**Hospital 15159**] [**Hospital 100**]
Rehab.

He has had persistent fevers with Tm 101.5 and positive MRSA
blood cultures at rehab.  [**Hospital 4273**] cough, cold symptoms, nausea,
or vomiting.  Has had diarrhea over the last several days.
[**Hospital 4273**] CP or SOB.   His family reports that he was doing poorly
a few days ago but has turned around in the past few days.
[**Hospital 4273**] increasing secretions and he is vent-dependent.

In the ED, initial vitals were 98.8 70 120/52 96%.  He is being
admitted to the MICU for an endocarditis workup given history of
positive blood cultures.  Currently, he reports feeling tired
but otherwise okay.  Complains of pain in his back and his legs.

Review of systems:
(+) Per HPI
(-) [**Hospital 4273**] chills, night sweats, recent weight loss or gain.
[**Hospital 4273**] headache, sinus tenderness, rhinorrhea or congestion.
[**Hospital 4273**] cough, shortness of breath, or wheezing. [**Hospital 4273**] chest
pain, chest pressure, palpitations, or weakness. [**Hospital 4273**] nausea,
vomiting, constipation, abdominal pain, or changes in bowel
habits. [**Hospital 4273**] dysuria, frequency, or urgency. [**Hospital 4273**]
arthralgias or myalgias. [**Hospital 4273**] rashes or skin changes.

Past Medical History:
Rectal cancer s/p excision and XRT ([**2157**])
CAD s/p stents (?[**2159**])
CVA in [**2150**] with residual right hand dysthesia
Complete heart block s/p pacemaker
H/o cardiac arrest (now with AICD)
GI bleed secondary to angiectasias in the duodenum ([**1-/2162**]) s/p
cauterization via EGD
Atrial fibrillation, not on [**Year (4 digits) **]
Systolic CHF (EF 40-45%)
S/p Fall with multiple rib fractures ([**2163-6-23**])
MICU admission [**Date range (1) 108856**]/[**2163**] for hemoptysis, bleeding from
trach
Abdominoperineal resection [**9-/2157**] w/ [**Doctor Last Name **]


Social History:
Resident of [**Hospital 100**] Rehab; previously had lived in [**Location 745**] with
his wife, now w some depression about moving out of their 42
year home. Has two children. Retired computer science professor.

- Tobacco:  5 cigars daily for 30 years, quit [**2150**] s/p CVA
- Alcohol:  Previously [**1-16**] glasses/week, generally per wife
"affects him quite a bit," changing his mood and making him sick
- Illicits: [**Month/Day (2) 4273**]

Family History:
Father died in 80s from MI. Mother died in 80s from PE. No
family history of colon, breast, uterine, or ovarian cancer. No
family history of seizures.

Physical Exam:
On Admission:
Vitals: 97.7 70 108/49 18 100% AC 500x12, PEEP 5, FiO2 35%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, trach in place
with clear/white secretions
Neck: supple, no LAD
Lungs: Coarse rales at bases, no wheezes
CV: Regular rate and rhythm, normal S1 + S2, III/VI systolic
murmur at apex
Abdomen: soft, non-tender, distended, ostomy in place, bowel
sounds present, no rebound tenderness or guarding
GU: Foley in place
Skin: 3cm sacral decub without surrounding erythema.  PICC in
place on right arm, only mild redness at insertion.
Ext: Warm, well perfused with 2+ pitting edema, ulcerations on
bilateral shins

On discharge:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, trach in place
Neck: Supple, no LAD
Lungs: Coarse rales at bases, no wheezes
CV: Regular rate and rhythm, normal S1 + S2, III/VI systolic
murmur at apex
Abdomen: Soft, non-tender, distended, ostomy in place, bowel
sounds present, no rebound tenderness or guarding
GU: Foley in place
Skin: 3cm sacral decub without surrounding erythema.  PICC in
place on left.
Ext: Significant ulcerations on bilateral shins, some pain and
swelling of both knees that is stable

Pertinent Results:
Admission Labs:
[**2163-9-20**] 04:15PM   WBC-8.9 RBC-2.79* HGB-8.0* HCT-24.2* MCV-87
MCH-28.8 MCHC-33.3 RDW-15.8*
[**2163-9-20**] 04:15PM   NEUTS-80.3* LYMPHS-9.0* MONOS-9.9 EOS-0.5
BASOS-0.2
[**2163-9-20**] 04:15PM   PLT COUNT-168
[**2163-9-20**] 04:15PM   PT-15.8* PTT-30.4 INR(PT)-1.4*
[**2163-9-20**] 04:15PM   LIPASE-69*
[**2163-9-20**] 04:15PM   ALT(SGPT)-26 AST(SGOT)-96* ALK PHOS-266* TOT
BILI-1.1
[**2163-9-20**] 04:15PM   GLUCOSE-127* UREA N-70* CREAT-1.7* SODIUM-134
POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-27 ANION GAP-12
[**2163-9-20**] 05:00PM   COMMENTS-GREEN TOP

[**2163-9-20**] [**2163-9-20**] 4:15 pm BLOOD CULTURE
Blood Culture, Routine (Final [**2163-9-23**]):
      STAPH AUREUS COAG +.    FINAL SENSITIVITIES.
                              SENSITIVITIES: MIC expressed in
MCG/ML
                             STAPH AUREUS COAG +
CLINDAMYCIN-----------   =>8 R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------     2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S

[**2163-9-20**] 4:15 pm URINE     Site: CATHETER
   URINE CULTURE (Final [**2163-9-23**]):
      PSEUDOMONAS AERUGINOSA.    >100,000 ORGANISMS/ML..
         Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
         [**Last Name (NamePattern1) 3060**].
                              SENSITIVITIES: MIC expressed in
MCG/ML
                             PSEUDOMONAS AERUGINOSA
                             |
CEFEPIME--------------    16 I
CEFTAZIDIME-----------    32 R
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------     8 I
MEROPENEM-------------  =>16 R
PIPERACILLIN/TAZO-----       R
TOBRAMYCIN------------   <=1 S

[**2163-9-21**] 4:00 pm SWAB      Source: decubitus ulcer.
   GRAM STAIN (Final [**2163-9-21**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      1+    (<1 per 1000X FIELD):   GRAM NEGATIVE ROD(S).
   WOUND CULTURE (Final [**2163-9-24**]):
      PSEUDOMONAS AERUGINOSA.    SPARSE GROWTH.
         Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
         [**Last Name (NamePattern1) 3060**].
      ENTEROCOCCUS SP..    SPARSE GROWTH.
                              SENSITIVITIES: MIC expressed in
MCG/ML                             PSEUDOMONAS AERUGINOSA
                             |          ENTEROCOCCUS SP.
                             |          |
AMPICILLIN------------              <=2 S
CEFEPIME--------------    32 R
CEFTAZIDIME-----------  =>64 R
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------     8 I
LINEZOLID-------------                1 S
MEROPENEM-------------     8 I
PENICILLIN G----------                8 S
PIPERACILLIN/TAZO-----       R
TOBRAMYCIN------------   <=1 S
VANCOMYCIN------------             =>32 R

[**2163-9-22**] 2:51 pm URINE      Source: Catheter.
   URINE CULTURE (Final [**2163-9-25**]):
      PSEUDOMONAS AERUGINOSA.    >100,000 ORGANISMS/ML..
         Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
         [**Last Name (NamePattern1) 3060**].
      KLEBSIELLA PNEUMONIAE.    10,000-100,000 ORGANISMS/ML..
         Piperacillin/tazobactam sensitivity testing available
on request.
                              SENSITIVITIES: MIC expressed in
MCG/ML
                             PSEUDOMONAS AERUGINOSA
                             |          KLEBSIELLA PNEUMONIAE
                             |          |
AMPICILLIN/SULBACTAM--               16 I
CEFAZOLIN-------------             =>64 R
CEFEPIME--------------    16 I        2 S
CEFTAZIDIME-----------    16 I     =>64 R
CEFTRIAXONE-----------               16 R
CIPROFLOXACIN---------   =>4 R      =>4 R
GENTAMICIN------------     8 I      <=1 S
MEROPENEM-------------     8 I   <=0.25 S
NITROFURANTOIN--------            =>512 R
PIPERACILLIN/TAZO-----       R
TOBRAMYCIN------------   <=1 S     =>16 R
TRIMETHOPRIM/SULFA----              <=1 S

[**2163-9-21**] 3:54 am BLOOD CULTURE      Source: Line-midline.
   Blood Culture, Routine (Final [**2163-9-27**]):    NO GROWTH.

[**2163-9-22**] 3:00 am BLOOD CULTURE      FROM MIDLINE.
   Blood Culture, Routine (Final [**2163-9-28**]):    NO GROWTH.

[**2163-9-23**] 3:51 am BLOOD CULTURE: Pending

[**2163-9-24**] 3:51 am BLOOD CULTURE: Pending

Studies:

CXR [**2163-9-20**]: No significant change from [**2163-9-9**] radiograph, with
cardiomegaly, pulmonary vascular congestion and bilateral
pleural effusions again noted.  Left lower lobe opacity is
compatible with atelectasis and/or pneumonia.

TTE [**2163-9-21**]: The left atrium is moderately dilated. The left
atrium is elongated. The right atrium is moderately dilated.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. The right ventricular cavity is moderately dilated
There is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No masses or
vegetations are seen on the aortic valve. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve. An
eccentric, posteriorly directed jet of Moderate (2+) mitral
regurgitation is seen. Due to the eccentric nature of the
regurgitant jet, its severity may be significantly
underestimated (Coanda effect). Moderate [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion. Compared with
the prior study dated [**2163-9-8**] (images reviewed), the degree of
pulmonary pressures is much lower (likely underestimated as the
IVC was not well visualized). No vegetations or abscesses
visualized.

TEE [**2163-9-22**]: No vegetations seen on the cardiac leaflets. No mass
or vegetation seen on the cardiac wires. Simple atheroma aortic
arch. At least moderate in severity eccentric mitral
regurgitation. Moderate tricuspid regurgitation. Mild to
moderate pulmonary artery systolic hypertension.

BLE Ultrasound [**2163-9-24**]: Limited study demonstrates no evidence
of right or left lower extremity DVT.

CXR [**2163-9-25**]: As compared to the previous radiograph, the
position of the
tracheostomy tube and of the pacemaker wires is unchanged.
Unchanged moderate cardiomegaly with bilateral areas of
atelectasis and substantial enlargement of the vascular
structures at the lung hilus. Unchanged moderate pulmonary
edema. No newly appeared focal parenchymal opacities.

WBC scan [**2163-9-26**]: 1. Splenomegaly. 2. No focal source of
infection localized.

Bilateral UE ultrasound [**2163-9-28**]: No evidence of upper extremity
deep venous thrombosis.

Labs prior to discharge:
[**2163-9-29**] 02:57AM BLOOD WBC-7.1 RBC-2.89* Hgb-8.1* Hct-24.9*
MCV-86 MCH-28.0 MCHC-32.5 RDW-15.8* Plt Ct-154
[**2163-9-29**] 02:57AM BLOOD Neuts-75.9* Lymphs-11.7* Monos-10.6
Eos-1.2 Baso-0.5
[**2163-9-29**] 02:57AM BLOOD Glucose-154* UreaN-49* Creat-1.4* Na-135
K-3.5 Cl-96 HCO3-29 AnGap-14
[**2163-9-29**] 02:57AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.1
[**2163-9-29**] 11:06AM BLOOD Tobra-1.9*
[**2163-9-28**] 09:00PM BLOOD Tobra-2.5*
[**2163-9-28**] 04:03AM BLOOD Vanco-21.5*
[**2163-9-27**] 07:50PM BLOOD Vanco-21.7*
[**2163-9-28**] 02:07PM BLOOD Type-[**Last Name (un) **] Temp-37.4 Rates-/35 Tidal V-309
PEEP-5 FiO2-50 pO2-48* pCO2-42 pH-7.48* calTCO2-32* Base XS-6
Intubat-INTUBATED Vent-SPONTANEOU

Brief Hospital Course:
Primary Reason for Hospitalization: Mr. [**Known lastname 108855**] is a 84 year
old male with h/o CAD s/p stenting, systolic CHF (EF40-45%),
atrial fibrillation, h/o cardiac arrest with heart block s/p
AICD/pacemaker, trach/PEG, and recent ICU admission with GI
bleed, hematuria, and MRSA bacteremia, who presented from rehab
with fevers and persistent MRSA bacteremia while on vancomycin.

#. MRSA Bacteremia: The source of the patient's persistent
bacteremia was not found. He grew MRSA from multiple blood
cultures at rehab and also on initial presentation despite
appropriate vancomycin troughs. Multiple sources of persistent
seeding were considered. He had a TTE and TEE which were both
negative for vegetations and did not show any involvement of his
pacer leads. A tagged WBC scan was performed to look for occult
focus of infection which was negative. An upper extremity
ultrasound was also performed to look for possible infected clot
but was negative. His PICC line which had been recently replaced
at [**Hospital **] rehab was removed. A new one was not placed until he
had negative blood cultures.  He was continued on vancomycin and
dosing was changed to 1g q48h.  Further blood cultures were
negative.   Ultimately it was felt he likely has an endovascular
source but it was not found during this hospitalization.  He
should be continued on IV vancomycin for 6 weeks from the date
of his last positive blood culture, with last day [**2163-11-2**].

#. Pseudomonas and Klebsiella UTI: Given that he has an
indwelling foley it was suspected that this might be
colonization however his cultures were positive even after
changing his foley. He was found to have pseudomonas in his
urine as well as wound culture.  It was multidrug resistant
pseudomonas and he was treated with tobramycin for a seven day
course.  He needs one more dose of tobramycin 320mg IV x 1 when
trough < 1.  He also grew multidrug resistant klebsiella in his
urine and was started on a 7 day course of cefepime with last
day [**10-2**].

#. Fevers: He had fevers on admission felt to be related to his
MRSA bacteremia.  Other cultures returned positive as above.  He
also had a knee arthrocentesis which was not consistent with
septic arthritis.  His PICC was changed after a 24 hour line
holiday.  He was ruled out for C diff.

#. Acute renal failure: BUN/creatinine elevated to 70/1.7 on
admission felt to be related to ongoing infection and poor
forward floor from chronic systolic CHF.  His creatinine slowly
improved with diuresis.

#. Chronic respiratory failure: He was continued on mechanical
ventilation during this admission and was unable to be weaned to
trach mask for any length of time.  This was felt to be related
to chronic respiratory fatigue in addition to substantial
pulmonary edema.  Diuresis was difficult due to his large
obligate fluid intake, but was eventually acheived with lasix
80mg IV q6h plus metolazone 2.5mg po bid.  His metolazone may
need to be decreased over the next several days if he is
overdiuresed as he was on average 1L negative on this regimen
for the few days prior to discharge.  On the day of discharge,
he was on pressure support [**12-19**], PEEP 5, FiO2 50% with TV in the
300's.

#. Anemia: His hematocrit remained stable in the low 20's during
this admission.

#. Chronic Diastolic CHF: Has EF 55%. He was continued on his
home carvedilol.  His lisinopril has been on hold indefinitely
and was not restarted due to renal failure.  He was diuresed
with IV lasix and metolazone as above and will need his
creatinine and electrolytes monitored closely with ongoing
diuresis.

#. Sacral decubitus ulcer: Stage IV.  He was started on a
fentanyl patch and continued on prn oxycodone for pain control.

#. Atrial fibrillation: His heart rate and blood pressure
remained stable during this admission.  He is off
anticoagulation due to h/o GI bleeding and hemothorax.  He was
continued on carvedilol.

#. Wound care: He was evaluated by the wound care team who
recommended the following:
1. Follow pressure ulcer guidelines. First Step for fluid
management. Turn q 2 hours.
2. Cleanse wounds with commercial wound cleanser. Pat dry.
3. Apply Aquacel ag to sacrum wound, cover with 4x4's and soft
sorb dressing, secure with Medipore tape. Change daily.
4. BLE ulcerations - cover with Adaptic dressing, place 4x4 and
wrap with Kerlix. Secure with paper tape.
5. No tape on skin.
6. Mid upper back ulcer - Apply Mepilex 4x4 and change q3 days.
7. Mid lower back ulcer - apply DuoDerm wound gel to bed to
assist with autolytic debridement of yellow slough. Cover with
Mepilex 4x4 dressing, and change q 3 days.
8. Apply Critic Aid clear skin barrier ointment to scrotal
tissue to protect from fluid exposure daily. Elevate scrotum to
assess with edema.
9. Waffles bilateral feet.
10. Apply aloe vesta ointment to dry intact skin daily.
11. Support nutrition and hydration.

TRANSITIONAL ISSUES:
- Monitor I/O's closely and check electrolytes closely given
large doses of lasix and metolazone.  [**Month (only) 116**] need to back off on
metalazone if signs of overdiuresis.  However, would continue to
aim for -500cc daily I/O balance.
- Needs tobramycin trough drawn [**2163-10-1**] AM.  Give tobramycin
320mg IV x 1 when trough is <1.0.
- Continue vancomycin until [**2163-11-2**] for MRSA bacteremia.
Should have trough measured intermittently to assess for
appropriate dosing.
- Needs 2 more days of cefepime treatment
- Continue ventilator weaning and trach collar trials if
possible.  Diuresis should help with this.
- Please draw weekly labs: CBC/diff, chem-7, LFTs and fax to
Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**].  All questions
regarding outpatient antibiotics should be directed to the
when clinic is closed

Medications on Admission:
Acetaminophen 650mg po q4h prn pain
Lidocaine patch 5% TD daily
Trazodone 25mg po qhs prn insomnia
Citalopram 20mg po daily
Docusate 50mg po bid
Ferrous sulfate 300mg po daily
Folic acid 1mg po daily
Multivitamin 1 tab po daily
Omeprazole 20mg po daily
Albuterol sulfate 90mcg q4h prn SOB/wheeze
Simethicone 80mg po tid
Miconazole nitrate 2% application qhs
Oxycodone 5-10mg po q4h prn pain
Lasix 40mg po daily
Vancomycin 500mg IV q12h
Psyllium one packet po tid
Sucralfate 1gram po qid
Carvedilol 6.25mg po bid

Discharge Medications:
1. acetaminophen 650 mg/20.3 mL Solution [**Telephone/Fax (1) **]: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for pain, fever.
2. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Age over 90 **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
3. trazodone 50 mg Tablet [**Age over 90 **]: 0.5-1 Tablet PO at bedtime as
needed for insomnia.
4. citalopram 20 mg Tablet [**Age over 90 **]: One (1) Tablet PO DAILY (Daily).

5. docusate sodium 50 mg/5 mL Liquid [**Age over 90 **]: One Hundred (100) mg
PO twice a day: Hold for loose stools.
6. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid [**Age over 90 **]: Three
Hundred (300) mg PO once a day.
7. folic acid 1 mg Tablet [**Age over 90 **]: One (1) Tablet PO DAILY (Daily).

8. multivitamin     Tablet [**Age over 90 **]: One (1) Tablet PO DAILY (Daily).

9. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Age over 90 **]: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Age over 90 **]:
4-6 Puffs Inhalation Q4H (every 4 hours) as needed for sob,
wheeze.
11. simethicone 80 mg Tablet, Chewable [**Age over 90 **]: One (1) Tablet,
Chewable PO TID (3 times a day).
12. miconazole nitrate 2 % Powder [**Age over 90 **]: One (1) Appl Topical HS
(at bedtime) as needed for rash.
13. oxycodone 5 mg Tablet [**Age over 90 **]: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
14. fentanyl 12 mcg/hr Patch 72 hr [**Age over 90 **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
15. psyllium     Packet [**Age over 90 **]: One (1) Packet PO TID (3 times a
day).
16. sucralfate 1 gram Tablet [**Age over 90 **]: One (1) Tablet PO QID (4 times
a day).
17. carvedilol 6.25 mg Tablet [**Age over 90 **]: One (1) Tablet PO BID (2
times a day): Hold for SBP<100, HR<55.
18. cefepime 1 gram Recon Soln [**Age over 90 **]: One (1) gram Injection Q24H
(every 24 hours) for 2 days: Last day [**2163-10-2**].
19. vancomycin in D5W 1 gram/200 mL Piggyback [**Month/Day/Year **]: One (1) gram
Intravenous q48h: Until [**2163-11-2**].
20. furosemide 10 mg/mL Solution [**Year (4 digits) **]: Eighty (80) mg Injection
Q6H (every 6 hours).
21. metolazone 2.5 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO BID (2 times
a day): 30 minutes prior to Lasix dose.
22. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Year (4 digits) **]: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
23. tobramycin sulfate 40 mg/mL Solution [**Year (4 digits) **]: Three Hundred
Twenty (320) mg Injection ONCE (Once) for 1 doses: Give one dose
of 320mg when trough level < 1.0.


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
Primary Diagnosis:
MRSA bacteremia
Klebsiella and pseudomonas UTI
Chronic diastolic congestive heart failure
Respiratory failure

Secondary Diagnosis:
Coronary Artery Disease
Atrial fibrillation


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.


Discharge Instructions:
You were admitted to the hospital due to persistent fevers and a
bacterial infection in your blood.  You underwent multiple
studies to evaluate the source of your infection.  It does not
appear that your heart valves or your pacemaker are infected.
You were treated with antibiotics for your bloodstream
infection, as well as urinary and wound infections.  We also
tried to give you diuretics to help your breathing.

Changes to your medications:
Increased docusate to 100mg po bid
Increased albuterol to 4-6 puffs q4h prn SOB/wheeze
Start fentanyl patch 12mcg/hr TD q72h
Start cefepime 1g IV q24h for 2 more days, last day [**2163-10-2**]
Change vancomycin to 1g q48h, last day [**2163-11-2**]
Change furosemide to 80mg IV q6h
Add metolazone to 2.5mg po bid, 30 mins prior to lasix dose
Add tobramycin, needs one more dose of 320mg when trough <1.0

You should be weighed every day and the providers at rehab
should be notified if your weight goes up by more than 3 pounds.

Followup Instructions:
You have the following appointments scheduled:

Department: INFECTIOUS DISEASE
When: [**Month/Day/Year **] [**2163-10-14**] at 10:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: INFECTIOUS DISEASE
When: MONDAY [**2163-10-31**] at 9:30 AM
With: [**Name6 (MD) 14621**] [**Last Name (NamePattern4) 14622**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: GASTROENTEROLOGY
When: MONDAY [**2163-10-31**] at 1:15 PM
With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 463**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage
{'Personal history of sudden cardiac arrest,Colostomy status,Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus,Personal history of irradiation, presenting hazards to health,Tracheostomy status,Gastrostomy status,History of fall,Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus,Sepsis,Methicillin resistant Staphylococcus aureus septicemia,Acute kidney failure, unspecified,Pressure ulcer, stage IV,Acute on chronic diastolic heart failure,Chronic respiratory failure,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Urinary tract infection, site not specified,Atrial fibrillation,Anemia, unspecified,Effusion of joint, lower leg,Automatic implantable cardiac defibrillator in situ,Percutaneous transluminal coronary angioplasty status'}


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: Bacteremia

PRESENT ILLNESS: 84 year old male with h/o CAD s/p stenting, systolic CHF
(EF40-45%), atrial fibrillation, h/o cardiac arrest with heart
block s/p AICD/pacemaker, trach/PEG, recent MRSA bacteremia, and
recent MICU admission for hematuria and GI bleed who presents
with fevers and baceteria.

MEDICAL HISTORY: Rectal cancer s/p excision and XRT ([**2157**])
CAD s/p stents (?[**2159**])
CVA in [**2150**] with residual right hand dysthesia
Complete heart block s/p pacemaker
H/o cardiac arrest (now with AICD)
GI bleed secondary to angiectasias in the duodenum ([**1-/2162**]) s/p
cauterization via EGD
Atrial fibrillation, not on [**Year (4 digits) **]
Systolic CHF (EF 40-45%)
S/p Fall with multiple rib fractures ([**2163-6-23**])
MICU admission [**Date range (1) 108856**]/[**2163**] for hemoptysis, bleeding from
trach
Abdominoperineal resection [**9-/2157**] w/ [**Doctor Last Name **]

MEDICATION ON ADMISSION: Acetaminophen 650mg po q4h prn pain
Lidocaine patch 5% TD daily
Trazodone 25mg po qhs prn insomnia
Citalopram 20mg po daily
Docusate 50mg po bid
Ferrous sulfate 300mg po daily
Folic acid 1mg po daily
Multivitamin 1 tab po daily
Omeprazole 20mg po daily
Albuterol sulfate 90mcg q4h prn SOB/wheeze
Simethicone 80mg po tid
Miconazole nitrate 2% application qhs
Oxycodone 5-10mg po q4h prn pain
Lasix 40mg po daily
Vancomycin 500mg IV q12h
Psyllium one packet po tid
Sucralfate 1gram po qid
Carvedilol 6.25mg po bid

ALLERGIES: Penicillins / Erythromycin Base / Streptomycin / Citric Acid /
Atenolol / Torsemide / Heparin Agents

PHYSICAL EXAM: On Admission:
Vitals: 97.7 70 108/49 18 100% AC 500x12, PEEP 5, FiO2 35%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, trach in place
with clear/white secretions
Neck: supple, no LAD
Lungs: Coarse rales at bases, no wheezes
CV: Regular rate and rhythm, normal S1 + S2, III/VI systolic
murmur at apex
Abdomen: soft, non-tender, distended, ostomy in place, bowel
sounds present, no rebound tenderness or guarding
GU: Foley in place
Skin: 3cm sacral decub without surrounding erythema.  PICC in
place on right arm, only mild redness at insertion.
Ext: Warm, well perfused with 2+ pitting edema, ulcerations on
bilateral shins

FAMILY HISTORY: Father died in 80s from MI. Mother died in 80s from PE. No
family history of colon, breast, uterine, or ovarian cancer. No
family history of seizures.

SOCIAL HISTORY: Resident of [**Hospital 100**] Rehab; previously had lived in [**Location 745**] with
his wife, now w some depression about moving out of their 42
year home. Has two children. Retired computer science professor. 

### Response:
{'Personal history of sudden cardiac arrest,Colostomy status,Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus,Personal history of irradiation, presenting hazards to health,Tracheostomy status,Gastrostomy status,History of fall,Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus,Sepsis,Methicillin resistant Staphylococcus aureus septicemia,Acute kidney failure, unspecified,Pressure ulcer, stage IV,Acute on chronic diastolic heart failure,Chronic respiratory failure,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Urinary tract infection, site not specified,Atrial fibrillation,Anemia, unspecified,Effusion of joint, lower leg,Automatic implantable cardiac defibrillator in situ,Percutaneous transluminal coronary angioplasty status'}
