CHIEF COMPLAINT: Fevers, rigors

PRESENT ILLNESS: 39 year old male with a history of end-stage renal disease of
unknown etiology on HD, HTN, prior history of Hodgkin's disease,
gout, peptic ulcer disease, hypothyroidism, depression
presenting with fevers after right subclavian HD line was placed
by transplant surgery 2 days prior to admission.  Mr [**Known lastname **] went
for his first HD treatment after new line placement 1 day prior
to admission with temps to 101; he also developed rigors this
morning and presented to [**Hospital3 **].  His fever climbed to
103 and was given vancomycin, blood cultures from his HD line,
and was given fluid boluses and was then transferred to [**Hospital1 18**]
given that his nephrologist and transplant team are here.  In
the [**Hospital1 18**] ED, his heart rates were in the 130s with a rectal
temperature of 104; he was visibly in rigors and not endorsing
any pain otherwise.  He received tylenol and ativan for his
rigors; Zosyn was added on to his vancomycin.  Transplant team
pulled his HD line and tip was sent for culture.  An EKG done in
the ED showed ST elevations in AVF and lead III with ST
depressions in V1 and V2 however these resolved on repeat EKG; 1
set of troponins was elevated to 5.8 with no prior troponins to
compare to; CK-MB was of normal fraction.  Cards was consulted
and they felt the troponin elevation was in the setting of
chronic renal failure and demand ischemia in setting of
tachycardia.  1 aspirin was given.  They did not recommend
anticoagulation in setting of demand.  IV vancomycin was redosed
and 2 L of IV fluids were given.  Vitals in the ED were: 102.6,
HR 125, BP 132/58, RR 28, satting 96% RA.

MEDICAL HISTORY: 1. Chronic renal failure, Cr baseline 2.5 - followed by Dr.
[**Last Name (STitle) 8605**] at [**Hospital3 **]. No kidney biopsy.
2. Hypertension.
3. Hodgkin's disease s/p chemotherapy with [**Doctor First Name **] and radiation
4. [**First Name9 (NamePattern2) 7816**] [**Location (un) **] - reportedly as a result of chemo treatment -
left him with numbness below the waist.
5. Depression with one prior psych hospitalization.
6. H/o suicidal attempt with narcotics overdose
7. Left eye blindness evaluated in ED on [**2101-9-25**] with
?functional overlay
8. Back pain - right flank pain requiring chronic narcotics (as
per pt). Unknown etiology.
9. Hypothyroidism.
10. Gout.
11. ? [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear
12. post radiation pancreatitis
13. chronic anemia

MEDICATION ON ADMISSION: 1.  albuterol
2.  allopurinol 50 mg daily
3.  nephrocaps 1 caps daily
4.  calcium acetate 667 mg daily
5.  citalopram 40 mg daily
6.  vicodin
7.  levothyroxine 112 mcg daily
8.  morphine 30 mg daily
9.  pantoprazole 40 mg daily
10. trazodone 50 mg qhs
11. venlafaxine 150 mg daily
12. coumadin 7.5/5 alternating
13. colace
14. senna

ALLERGIES: Percocet / Erythromycin Base / A.C.E Inhibitors / Nsaids

PHYSICAL EXAM: Admission Physical Exam:
VS HR 120s BP 119/63, 92% RA, RR 20, temp 100.9
GEN: In NAD, lying in bed
HEENT: Anicteric, oropharynx clear
Cardiac: Tachycardic, no murmurs appreciable
Chest: old suture evident from prior line placement
Pulm: clear in anterior fields
Abd: soft and nontender
Ext: No edema noted
.
Discharge Physical Exam:
VS: Tm/Tc:99.2, BP:128-138/86-99, HR:108-116, RR:20, S02:99%RA
Gen: lying in bed, comfortable-apparing
Cardiac: muffled S1 and S2, RRR, 3/6 systolic murmur at the apex
as well as LLSB, cardiac friction rub present
Lungs: crackles at the bases but otherwise clear
Abdomen: mod firm and distended, two incision sites in RLQ and
LLQ show staples in place without drainage, minimal tenderness
around RLQ incision
UE: significant erythema and swelling in LUE
LE: 2+ DP, radial pulses, trace swelling in bilat LE

FAMILY HISTORY: Father - s/p renal transplant ?hypertensive nephropathy
Mother - Depression and alcohol dependence
Two sons (ages 2 and 15) with renal dysplasia
No history of deafness or cystic kidney disease

SOCIAL HISTORY: Pt lives with his wife and his children. He is on disability.
Used to work as EMT.  Pt denies tobacco, alcohol or illicit drug
Infection and inflammatory reaction due to other vascular device, implant, and graft,End stage renal disease,Psoas muscle abscess,Hemoperitoneum (nontraumatic),Subendocardial infarction, initial episode of care,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic pancreatitis,Acute infective polyneuritis,Bacteremia,Unspecified disease of pericardium,Primary hypercoagulable state,Pyogenic arthritis, pelvic region and thigh,Acute posthemorrhagic anemia,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in other specified places,Unspecified acquired hypothyroidism,Profound impairment, one eye, impairment level not further specified,Personal history of hodgkin's disease,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Gout, unspecified,Depressive disorder, not elsewhere classified,Tachycardia, unspecified
React-oth vasc dev/graft,End stage renal disease,Psoas muscle abscess,Hemoperitoneum,Subendo infarct, initial,Hyp kid NOS w cr kid V,Chronic pancreatitis,Ac infect polyneuritis,Bacteremia,Pericardial disease NOS,Prim hypercoagulable st,Pyogen arthritis-pelvis,Ac posthemorrhag anemia,Mth sus Stph aur els/NOS,Abn react-renal dialysis,Accident in place NEC,Hypothyroidism NOS,Blindness, one eye,Hx-hodgkin's disease,Adv eff antineoplastic,Gout NOS,Depressive disorder NEC,Tachycardia NOS
Admission Date:  [**2107-9-29**]              Discharge Date:   [**2107-11-1**]

Date of Birth:  [**2068-7-20**]             Sex:   M

Service: MEDICINE

Allergies:
Percocet / Erythromycin Base / A.C.E Inhibitors / Nsaids

Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Fevers, rigors

Major Surgical or Invasive Procedure:
1. Dialysis
2. Bilateral hematoma and right lower quadrant hematoma incision
and drainage
3. Left arm PICC placement

History of Present Illness:
39 year old male with a history of end-stage renal disease of
unknown etiology on HD, HTN, prior history of Hodgkin's disease,
gout, peptic ulcer disease, hypothyroidism, depression
presenting with fevers after right subclavian HD line was placed
by transplant surgery 2 days prior to admission.  Mr [**Known lastname **] went
for his first HD treatment after new line placement 1 day prior
to admission with temps to 101; he also developed rigors this
morning and presented to [**Hospital3 **].  His fever climbed to
103 and was given vancomycin, blood cultures from his HD line,
and was given fluid boluses and was then transferred to [**Hospital1 18**]
given that his nephrologist and transplant team are here.  In
the [**Hospital1 18**] ED, his heart rates were in the 130s with a rectal
temperature of 104; he was visibly in rigors and not endorsing
any pain otherwise.  He received tylenol and ativan for his
rigors; Zosyn was added on to his vancomycin.  Transplant team
pulled his HD line and tip was sent for culture.  An EKG done in
the ED showed ST elevations in AVF and lead III with ST
depressions in V1 and V2 however these resolved on repeat EKG; 1
set of troponins was elevated to 5.8 with no prior troponins to
compare to; CK-MB was of normal fraction.  Cards was consulted
and they felt the troponin elevation was in the setting of
chronic renal failure and demand ischemia in setting of
tachycardia.  1 aspirin was given.  They did not recommend
anticoagulation in setting of demand.  IV vancomycin was redosed
and 2 L of IV fluids were given.  Vitals in the ED were: 102.6,
HR 125, BP 132/58, RR 28, satting 96% RA.

Past Medical History:
1. Chronic renal failure, Cr baseline 2.5 - followed by Dr.
[**Last Name (STitle) 8605**] at [**Hospital3 **]. No kidney biopsy.
2. Hypertension.
3. Hodgkin's disease s/p chemotherapy with [**Doctor First Name **] and radiation
4. [**First Name9 (NamePattern2) 7816**] [**Location (un) **] - reportedly as a result of chemo treatment -
left him with numbness below the waist.
5. Depression with one prior psych hospitalization.
6. H/o suicidal attempt with narcotics overdose
7. Left eye blindness evaluated in ED on [**2101-9-25**] with
?functional overlay
8. Back pain - right flank pain requiring chronic narcotics (as
per pt). Unknown etiology.
9. Hypothyroidism.
10. Gout.
11. ? [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear
12. post radiation pancreatitis
13. chronic anemia

Social History:
Pt lives with his wife and his children. He is on disability.
Used to work as EMT.  Pt denies tobacco, alcohol or illicit drug

use.

Family History:
Father - s/p renal transplant ?hypertensive nephropathy
Mother - Depression and alcohol dependence
Two sons (ages 2 and 15) with renal dysplasia
No history of deafness or cystic kidney disease

Physical Exam:
Admission Physical Exam:
VS HR 120s BP 119/63, 92% RA, RR 20, temp 100.9
GEN: In NAD, lying in bed
HEENT: Anicteric, oropharynx clear
Cardiac: Tachycardic, no murmurs appreciable
Chest: old suture evident from prior line placement
Pulm: clear in anterior fields
Abd: soft and nontender
Ext: No edema noted
.
Discharge Physical Exam:
VS: Tm/Tc:99.2, BP:128-138/86-99, HR:108-116, RR:20, S02:99%RA
Gen: lying in bed, comfortable-apparing
Cardiac: muffled S1 and S2, RRR, 3/6 systolic murmur at the apex
as well as LLSB, cardiac friction rub present
Lungs: crackles at the bases but otherwise clear
Abdomen: mod firm and distended, two incision sites in RLQ and
LLQ show staples in place without drainage, minimal tenderness
around RLQ incision
UE: significant erythema and swelling in LUE
LE: 2+ DP, radial pulses, trace swelling in bilat LE

Pertinent Results:
Admission Results([**9-29**]):
CBC: WBC-17.8*# RBC-3.66* Hgb-10.4* Hct-33.0* MCV-90 MCH-28.3
MCHC-31.4 RDW-18.1* Plt Ct-262 Neuts-93.7* Lymphs-3.5* Monos-2.0
Eos-0.5 Baso-0.3
Coags: PT-24.8* PTT-29.4 INR(PT)-2.4*
Chem: Glucose-95 UreaN-44* Creat-6.7* Na-136 K-4.8 Cl-93*
HCO3-25 AnGap-23*
LFTS: ALT-40 AST-51* CK(CPK)-286 AlkPhos-123 TotBili-0.5
Lytes: Calcium-7.9* Phos-1.7*# Mg-1.5*
Abx: Vanco-16.9
Lactate-2.7*
.
Cardiac Markers:
[**2107-9-29**] 07:58PM BLOOD cTropnT-5.86*
[**2107-9-30**] 02:42AM BLOOD CK-MB-11* MB Indx-0.6 cTropnT-5.32*
[**2107-9-30**] 10:37AM BLOOD CK-MB-9 cTropnT-5.11*
[**2107-10-1**] 08:00PM BLOOD CK-MB-6 cTropnT-4.88*
[**2107-10-2**] 06:55AM BLOOD CK-MB-7 cTropnT-4.31*
[**2107-10-4**] 01:01PM BLOOD CK-MB-3 cTropnT-2.80*
[**2107-10-4**] 09:51PM BLOOD CK-MB-3 cTropnT-2.56*
[**2107-10-5**] 05:12AM BLOOD CK-MB-2 cTropnT-2.68*
[**2107-10-14**] 10:27AM BLOOD CK-MB-4 cTropnT-1.49*
[**2107-10-15**] 04:36AM BLOOD CK-MB-3 cTropnT-1.35*
[**2107-10-16**] 06:40AM BLOOD CK-MB-3 cTropnT-1.22*
[**2107-10-17**] 05:59AM BLOOD CK-MB-3 cTropnT-1.00*
.
Relevant Results:
[**2107-10-6**] 04:55AM BLOOD ESR-131*
[**2107-10-6**] 04:55AM BLOOD CRP-43.5*
[**2107-10-5**] 03:15PM BLOOD ACA IgG-5.4 ACA IgM-15.0*
[**2107-10-9**] 05:30AM BLOOD ACA IgG-7.3 ACA IgM-12.8*
[**2107-10-9**] 05:30AM BLOOD Lupus-POS
[**2107-9-29**] 07:58PM BLOOD Lipase-23
[**2107-10-6**] 04:55AM BLOOD Lipase-125*
[**2107-10-10**] 08:20AM BLOOD Lipase-232*
[**2107-10-9**] 05:30AM BLOOD Hapto-398*
[**2107-10-6**] 04:55AM BLOOD %HbA1c-5.4 eAG-108
[**2107-10-6**] 04:55AM BLOOD Triglyc-198* HDL-15 CHOL/HD-7.7
LDLcalc-60
[**2107-10-14**] 10:27AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HAV
Ab-POSITIVE
[**2107-10-14**] 10:27AM BLOOD HCV Ab-NEGATIVE
.
Micro:
[**2107-9-29**] 7:58 pm BLOOD CULTURE      #1.

                            **FINAL REPORT [**2107-10-2**]**

   Blood Culture, Routine (Final [**2107-10-2**]):
      STAPH AUREUS COAG +.
         Consultations with ID are recommended for all blood
cultures
         positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.

         FINAL SENSITIVITIES.
         Staphylococcus species may develop resistance during
prolonged
         therapy with quinolones.   Therefore, isolates that are
initially
         susceptible may become resistant within three to four
days after
         initiation of therapy.  Testing of repeat isolates may
be
         warranted.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------  0.25 S
OXACILLIN-------------   0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S

   Aerobic Bottle Gram Stain (Final [**2107-9-30**]):
      REPORTED BY PHONE TO [**First Name8 (NamePattern2) 12708**] [**Last Name (un) 12707**] AT 14:35PM ON
[**2107-9-30**].
      GRAM POSITIVE COCCI IN CLUSTERS.

   Anaerobic Bottle Gram Stain (Final [**2107-9-30**]):
      GRAM POSITIVE COCCI IN CLUSTERS.
.
[**2107-9-29**] 10:15 pm CATHETER TIP-IV      AEROBIC/ANAEROBIC.

                            **FINAL REPORT [**2107-10-2**]**

   WOUND CULTURE (Final [**2107-10-2**]):
      STAPH AUREUS COAG +.    >15 colonies.
         Staphylococcus species may develop resistance during
prolonged
         therapy with quinolones.   Therefore, isolates that are
initially
         susceptible may become resistant within three to four
days after
         initiation of therapy.  Testing of repeat isolates may
be
         warranted.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------  0.25 S
OXACILLIN-------------   0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
.
Cardiology:
TTE ([**9-30**]):
The left atrium is elongated. The right atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. LV systolic function
appears depressed (ejection fraction 30 percent) secondary to
severe hypokinesis of the inferior septum, inferior free wall,
and posterior wall. There is no ventricular septal defect. Right
ventricular chamber size is normal. with depressed free wall
contractility. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis. No
masses or vegetations are seen on the aortic valve, but cannot
be fully excluded due to suboptimal image quality. Mild (1+)
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. No masses or vegetations are seen on
the mitral valve, but cannot be fully excluded due to suboptimal
image quality. No masses or vegetations are seen on the
tricuspid valve, but cannot be fully excluded due to suboptimal
image quality. No masses or vegetations are seen on the pulmonic
valve, but cannot be fully excluded due to suboptimal image
quality. There is no pericardial effusion.

IMPRESSION: no obvious vegetation, but suboptimal study
.
TEE ([**10-5**]):
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion. No
masses or vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. No mass or vegetation is seen on the mitral
valve. Mild (1+) mitral regurgitation is seen. No vegetations or
abscess. Normal biventricular systolic function. Mild mitral
regurgitation
.
Radiology:
U/S R HD graft ([**9-30**]):
Patent right upper extremity AV graft with no stenosis, no
evidence of abscess.
.
U/S RUE and R IJ ([**10-4**]):
Nonocclusive thrombus seen in the mid right internal jugular
vein. No evidence of perigraft abscess of HD graft.
.
U/S bilateral Hips ([**10-8**]):
No hip joint effusion on the left or right side. Slight
asymmetry of psoas
muscle on the right, suspicious for a psoas/paraspinal process.
.
MRI bilateral/thighs ([**10-8**]):
1. Bilateral heterogeneous fluid collections in the iliacus
muscles, most
consistent with abscesses, right greater than left. Fluid-fluid
levels with
areas of T1 hyperintensity suggest the presence of internal
hemorrhage and/or proteinaceous debris. Collection on the right
extends into the iliopsoas bursa, with associated myositis, and
small area of focal fluid near the rectus femoris origin.
2. No evidence of hip effusions
.
CT of pelvis ([**10-10**]):
1. Large right and small left iliac muscle abscess with
percutaneous drain in place on the right.
2. Right iliac abscess extends inferiorly distal to the inguinal
ligament but does not reach the iliopsoas insertion site at the
lesser trochanter.
3. Left iliac muscle abscess ends about 2 cm distal to the
inguinal ligament.
.
CT of pelvis ([**10-12**]):
1. Right iliopsoas pigtail catheter removal and subsequent
washout, now with packing/surgicell/gauze in place and a skin
staple closure over it - this was confirmed with the description
in the operative note as well as with [**Doctor First Name **] [**Doctor Last Name **] at 17:00
on [**2107-10-12**].
2. Right subcutaneous fat fluid collection with air-fluid level
and
hematocrit suggestive of hematoma.
3. Extensive subcutaneous gas - likely postoperative, although
gas-producing infection cannot be ruled out.
.
Pelvic Arteriogram ([**10-13**]):
Pelvic arteriograms without signs of active bleeding. No
embolization was performed.
.
L Groin U/S ([**10-18**]):
There is a 3.3 x 1.9 x 1.3 cm collection with a fluid-fluid
level
within the left groin, suggestive of a hematoma. There is no
internal
vascularity. There is no connection with the underlying vessels.
The
underlying left common femoral artery and vein demonstrate
normal waveforms
and are patent.
.
Abd U/S ([**10-19**]):
Multiple superficial hypoechoic fluid collections in the right
lower quadrant adjacent to the incision, one of which measures 7
cm with
complex features, located above the right inguinal fold, raising
question of abscess. This site has been marked for possible
aspiration, although not
definitely amenable to drainage given internal echoes.
.
Abd CT ([**10-20**]):
1. Two fluid collections in the right anterior abdominal wall,
one may be
residual hematoma, the other may be fluid, infection is not
excluded.
2. Multiple locules of air within the right iliacus muscle, some
of which may be post-operative, the remaining may be related to
surgical packing with Surgicel. A small amount of air may be
intraperitoneal.
3. Persistent large amount of air in the anterior abdominal
wall, fascititis is not excluded.
4. Heterogeneous attenuation of the left iliacus muscle may
reflect residual hematoma at the site but no locules of air
within the left iliacus.
5. Small amount of free fluid within the pelvis.
.
MRV Chest Without Contrast ([**10-24**]):
1. No findings of SVC thrombosis. No contrast was administered
due to
diminished GFR.
2. Reidentification of nonocclusive chronic appearing thrombosis
in the mid right jugular vein, better appreciated on the
previously performed ultrasound.
3. Moderate left pleural effusion and pericardial effusion.
.
Abdominal Ultrasound ([**10-24**]):
A 9-cm fluid collection in the subcutaneous fat of the right
lower quadrant.
.
TTE ([**10-25**]):
The left atrium is normal in size. The estimated right atrial
pressure is 10-15mmHg. Left ventricular wall thicknesses and
cavity size are normal. There is moderate regional left
ventricular systolic dysfunction with basal to mid akinesis of
the inferior wall. There is mild hypokinesis of the remaining
segments (LVEF = 30-35 %). The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size is normal. with
mild global free wall hypokinesis. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are structurally normal. Mild (1+) mitral regurgitation is seen.
The pulmonary artery systolic pressure could not be determined.
There is a moderate sized pericardial effusion. No right
ventricular diastolic collapse is seen. There is brief right
atrial diastolic collapse. There is significant, accentuated
respiratory variation in mitral/tricuspid valve inflows,
consistent with impaired ventricular filling. Compared with the
prior study (images reviewed) of [**2107-9-30**], there is a moderate
sized pericardial effusion without frank tamponade.
.
EKG ([**10-25**]):
Sinus tachycardia. Left bundle-branch block. Since the previous
tracing
of [**2107-10-14**] there is probably no significant change.
.
TTE ([**10-28**]):
The left atrium is mildly dilated. The estimated right atrial
pressure is 10-20mmHg. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. There is
moderate to severe global left ventricular hypokinesis (LVEF =
30 %). Right ventricular chamber size is normal. with depressed
free wall contractility. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is a
moderate sized pericardial effusion. There are no
echocardiographic signs of tamponade. No right ventricular
diastolic collapse is seen. There is brief right atrial
diastolic invagination. Compared with the findings of the prior
study (images reviewed) of [**2107-10-25**], the pericardial
effusion is slightly smaller.
.
TTE ([**11-1**]):
The estimated right atrial pressure is 0-10mmHg. There is mild
regional left ventricular systolic dysfunction with basal to mid
inferoseptal, inferior, and inferolateral hypokinesis. Overall
left ventricular systolic function is mildly depressed (LVEF= 45
%). Right ventricular chamber size is normal. with borderline
normal free wall function. There is a moderate sized pericardial
effusion. No right ventricular diastolic collapse is seen. There
is brief right atrial diastolic collapse. There is significant,
accentuated respiratory variation in mitral/tricuspid valve
inflows, consistent with impaired ventricular filling. Compared
with the prior study (images reviewed) of [**2107-10-28**], the
pericardial effusion size is similar without tamponade. The left
ventricular systolic function may be slightly improved.
.
Upper Extremity US with Doppler ([**10-31**]): Short segment of
nonocclusive thrombus along the left basilic PICC in the upper
arm.
.
Discharge Labs:
.
[**2107-11-1**] 06:24AM BLOOD WBC-7.9 RBC-2.86* Hgb-8.1* Hct-25.8*
MCV-90 MCH-28.5 MCHC-31.6 RDW-19.4* Plt Ct-329
[**2107-11-1**] 06:24AM BLOOD PT-17.4* PTT-28.7 INR(PT)-1.6*
[**2107-11-1**] 06:24AM BLOOD Glucose-81 UreaN-24* Creat-4.9*# Na-133
K-4.0 Cl-94* HCO3-31 AnGap-12
[**2107-11-1**] 06:24AM BLOOD Calcium-7.9* Phos-4.0 Mg-2.0

Brief Hospital Course:
39 year-old with a complicated medical history including prior
Hodgkins, HTN, PUD, hypothyroidism, depression, hx of lupus
anticoagulant requring warfarin use, and ESRD of unclear
etiology on [**Hospital **] transferred from OSH to [**Hospital1 18**] ED on [**2107-9-29**]. Two
days prior to presentation, the patient had a right IJ tunneled
HD line placed (placed by Dr. [**First Name (STitle) **], Transplant Surgery). One
day prior to presentation, went to HD with fevers 101. Had
rigors morning of presentation on [**9-29**], and went to [**Hospital1 9191**].
.
# MSSA Line Sepsis:
Patient was initially admitted directly to the MICU for concern
of line sepsis in the setting of fevers and rigors. Transplant
surgery was notified and removed newly placed subclavian line.
OSH Blood cultures grew Staph aureus and patient was started on
Vancomycin while sensitivities were pending. Blood cultures at
[**Hospital1 18**] were taken prior to antibiotic administration. These
cultures also grew gram positive cocci. Patient continued to
spike intermittent fevers. Surveillance cultures were taken
daily while in the MICU. A TTE was completed and did not
indicate any valvular abnormalities, however, it did show focal
areas of hypokinesis and a depressed EF as noted below. TEE was
arranged with cardiology and showed no vegetations. On day of
transfer to floor, patient was also started on nafcillin as
cultures came back MSSA. Plan was complete a 6 week course of
antibiotics for MSSA bacteremia with nafcillin being used while
in hospital and then transition to cefazolin with hemodialysis
once patient was discharged. As noted below abx were changed for
10 days to emperic Vanco/cefepime due to concerns for thigh and
abdominal abscess but patient was transitioned back to
nafcillin, ciprofloxacin and flagyl once the culture data from
these thigh/abdomen collections was negative. The patient was
transitioned from Nafcillin to Cefazolin prior to discharge.
Cefazolin, Ciprofloxacin and Flagyl were to be continued until
[**11-11**]. Cefazolin to be given with HD, 2 grams on Monday and
Wednesday and 3 g on Friday. [**Hospital1 700**] was
contact[**Name (NI) **] directly regarding the Cefazolin as it was left out of
his discharge medication list.
.
# Pericardial Effusion:
Patient had MRV of chest to evaluate for clot burden which
revealed an incidental pericardial effusion. Pulsus physiology
was difficult to detect as patient had AV graft in right
extremity and a PICC line in his left extremity. A TTE was
subsequently perfromed to characterize the effusion more
carefully and revealed a 2 cm pericardial effusion without
evidence of tamponade though brief right atrial collapse was
noted. A repeat TTE 72 hours later revealed a slightly smaller
effusion with only right atrial involution appreciated. A third
TTE was performed on the day of discharge, approximately 96
houurs later, which again showed a slightly smaller pericardial
effusion with noted brief right atrial diastolic collapse. A
copy of the most recent TTE report was sent with the patient at
[**Location (un) **] [**Hospital1 **] to communicate with him regarding follow up. The
patient is to have repeat TTEs on [**11-18**] and [**11-30**]. A
follow up cardiology appointment was made for the patient on
[**12-1**].
.
#. Troponin Leak:
On admission, patient had EKG changes concerning for cardiac
ischemia. Initial troponins were elevated although CK-MB was
within normal limits. Cardiology was notified in the ED and said
that the troponin level was consistent with ESRD and demand
ischemia (as patient was tachycardic for a prolonged period).
However, TTE demonstrated inferior wall hypokinesis with EF of
30% which made it appear that the patient had a cardiac event
prior to admission and still had elevated troponins from this
event because of no renal clearance. Pt was started on full
strength ASA, high dose atorvastatin, beta-blocker, and kept on
heparin drip which had already been started for below
coagulation issues. Cardiology initially planned to perform
cardiac catheterization during his hospitalization, but TEE done
to evaluate for endocarditis a few days after initially TTE no
longer showed evidence of hypokinetic wall segments and showed
and EF >50% bringing back to the forefront the idea that perhaps
the patient had not had a cardiac event and had merely spilled
troponins in the setting of some coronary disease exacerbated by
tachycardia, septic physiology and ESRD. Decision was made for
no coronary intervention and atorvastatin dose was decreased in
setting of elevated LFTs. Troponins continued to slowly trend
down although never really resolved during the hospitalization,
likely secondary to his ESRD. Late in this [**Hospital 228**] hospital
course, the troponins were no longer followed. Heparin was
stopped as patient developed hematomas as per below and it was
felt that the risk to bleeding was more significant that risk of
clotting. TTEs were performed per above. The last TTE on day of
discharge revealed an EF of 45%. Cardiology follow up per above.

.
#. ESRD:
Renal was notified upon admission and patient received a line
holiday while in the MICU receiving abx. Electrolytes were
monitored. Plan was for patient to restart normal MWF schedule
using mature graft of R upper extremity. However, PTT was >150
on morning of planned graft access and infectious disease was
also concerned about the possibility that graft infected in the
setting of bacteremia. As a result, a temporary L subclavian
tunneled HD catheter was placed by IR and used for two HD
sessions while PTT was brought under better control and U/S of R
vascular graft was done to r/o infection. U/S showed no evidence
of perigraft abscess of fluid collection so graft was used for
HD starting on [**2107-10-7**]. Temporary HD line was removed after
successful use of the graft. Pt was continued on MWF HD schedule
for throughout his hospitalization. Antibiotics to be given at
HD after discharge as per above.
.
#. Coagulopathy:
At time of admission pt was on therapeutic warfarin with
presenting INR of 2.4. Per patient report he was on this
medication because of anti-phospholipid hypercoag state that had
been discovered at [**Location (un) 95377**] hospital as part of a work-up
to determine why he kept clotting off HD access grafts/fistulas.
Pt warfarin was held at presentation to [**Hospital1 18**] because of need
for multiple procedures and pt was placed on heparin gtt. This
was continued through much of hospitalization but pt still
developed multiple thrombotic complications. In the ICU,
difficulty threading a L IJ line led team to believe there must
be a clot in the L IJ. Additionally, a non-occlusive thrombus in
R IJ at site of recent central line was found on u/s ([**10-4**]). Pt
later developed significant R hip/thigh pain with some swelling.
Ultra-sound of the area showed and asymmetry that was suspicious
for a psoas/paraspinal process. As a result, f/u MRI of the R
hip/thigh was performed and showed bilateral heterogeneous fluid
collections in the iliacus muscles, most consistent with
abscesses, right greater than left. Fluid-fluid levels with
areas of T1 hyperintensity suggest the presence of internal
hemorrhage and/or proteinaceous debris. Collection on the right
extends into the iliopsoas bursa, with associated myositis, and
small area of focal fluid near the rectus femoris origin.
Because patient was febrile with significant pain in the area CT
guided IR drainage of R thigh abscesses were performed on [**10-8**]
with drain placed in the R side. A follow-up CT on [**10-10**] showed
persistence of fluid and in light of continuing fevers and
concern for permanent neurologic damage to nerve structures in
the area, orthopedic surgery took pt to the OR [**10-11**] to debride
the abscesses. During surgery these were found to be hematomas
(R>L). From the OR, pt was transferred to the TSICU due to
hypotension (SBP down to the 70's) and complications from
bleeding which continued to ooze during surgery preventing
initial closure of the wound. In the TSICU, Mr. [**Known lastname **] was
placed on peripheral pressors initially due to access issues and
was also transfused blood products due to hct drop and
hypotension. Also, he had an elevated white count and fevers.
Left femoral line was placed on [**2107-10-12**]. Additionally, was
switched from nafcillin to vancomycin/cefepime on [**10-12**], with
suggestion of a 8 day course. Switch made at ID's suggestion due
to concern of possible infected hematomas at sites of abscesses
- these abx continued until [**10-23**], slightly longer than
initially planned because concern for a wound infection had
developed in the interim as noted below. Pressors d/c'd morning
of [**2107-10-13**], and the pt's VS remained stable and afebrile. Had
pelvic arteriograms performed to assess for possible bleeds,
which were negative. Went back to the OR on [**10-13**] to have
packing removed from washout on [**10-11**]. Cultures ultimately
negative from this source and hematomas seemed to have
spontaneously formed while on heparin gtt. Pt was transfered
back to the floor but shortly thereafter developed pain in L
groin and significant RLQ pain with surrounding skin erythema,
induration, and dusky changes. Ultra-sound of L groin showed a
small hematoma which had formed at site of femoral line removal
the day before. There was no vessel aneurysm and the hematoma
was not connected to other vascular structures so since small no
intervention was undertaken. Ultra-sound of abdomen showed
multiple superficial hypoechoic fluid collections in the
rightnlower quadrant adjacent to the recent surgical incision,
one of which measured 7 cm withcomplex features, located above
the right inguinal fold, raising question of abscess. A CT of
abdomen with contrast showed two fluid collections in R ant
abdominal wall, one likely hematoma with the other containing
fluid that could not have infection excluded. Because pt has
having recurrence of fever spikes there was concern for
post-surgical abscess, orthopedics took pt back to the OR on
[**10-21**] for I&D of the wound and found it to be a hematoma, not
abscess. Cultures were sent, but like previous hematoma,
cultures remained negatived. The heparin gtt was eventually
disconinued as the risk of bleeding was considered greater than
the risk of clotting. Hematology was consulted as an inpatient
but had low suspicion for a hypercoaguable state. The patient
was discharged with the contact information to make a follow up
appointment so that his possible anti-phospholipid syndrome
could be evaluated more appropriately as an outpatient.
.
#. Pain control:
Pt with significant pain control issues during hospitalization,
mostly related to pain at sites of various hematoma formations.
Initially pain was controlled with IV morphine but this was
ultimately changed to dilaudid because of pt's poor renal
function. Dilaudid PCA was initiated when difficulty controlling
pain with IV pushes. Pt then started on long acting oxycontin
which was uptitrated in effort to provide more consistent pain
control. Dilaudid PCA weaned as long-acting POs uptitrated and
pt ultimately transitioned over to PO dilaudid for breakthrough
pain as better control was achieved. The patient was eventually
transitioned to Oxycontin for pain control. The patient reported
significantly improved pain late in his hospital course.
.
#. Left Upper Extremity Thrombosis: The day prior to discharge
the patient had left upper extremity swelling and mild surround
erythema. An US was ordered for evaluation of a thrombosis and
revealed a short segment of nonocclusive thrombus along the left
basilic PICC in the upper arm. Per report good flow was noted
around the PICC line. The PICC line was pulled as it was
considered the most likely source of the thrombosis. No
anticoagulation was persued due to above issues and due to its
non-occlusive nature and thought that it would resolve after the
PICC line was removed.

Medications on Admission:
1.  albuterol
2.  allopurinol 50 mg daily
3.  nephrocaps 1 caps daily
4.  calcium acetate 667 mg daily
5.  citalopram 40 mg daily
6.  vicodin
7.  levothyroxine 112 mcg daily
8.  morphine 30 mg daily
9.  pantoprazole 40 mg daily
10. trazodone 50 mg qhs
11. venlafaxine 150 mg daily
12. coumadin 7.5/5 alternating
13. colace
14. senna

Discharge Disposition:
Extended Care

Facility:
[**Hospital1 700**] - [**Location (un) 701**]

Discharge Diagnosis:
Primary Diagnosis:
MSSA (Methicillin-Sensitive Staphylococcus Aureus) Bacteremia
Bilateral Psoas and Right Lower Quadrant Hematomas
Pericardial Effusion
Myocardial Ischemia
.
Secondary Diagnoses:
End-Stage Renal Disease
Possible Lupus Anticoagulant/Anti-Phospholipid Antibody Syndrome


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
Mr. [**Known lastname **]:
.
You were admitted to [**Hospital1 18**] with a bloodstream infection that was
most likely from your tunneled HD line. Blood cultures revealed
a bacteria called Staphylococcus aureus that was sensitive to
the antibiotic Nafcillin. You were treated with Nafcillin
throughout most of your stay but were transitioned to Cefazolin
prior to discharge. You will need to continue Cefazolin as
instructed below. On admission to the hospital you were also on
Coumadin for a possible diagnosis of anti-phospholipid antibody
syndrome. As you subsequently developed several hematomas during
your hospitalization, this medication was discontinued and the
Hematology service was consulted. The diagnosis of
anti-phospholipid antibody syndrome is difficult to make as an
inpatient. You will need to follow up with the Hematology
department as an outpatient and the information has been
provided below.
.
The following changes were made to your medications.
.
1. Start Cefazolin 2 grams with hemodialysis on Mondays and
Wednesdays and 3 grams with hemodialysis on Fridays. You will
need this antibiotic for a total of two weeks from [**10-28**]. Stop
this medication on [**11-11**].
2. Stop taking Vancomycin which you were admitted on from the
outside hospital.
3. Your Senna was increased from 1 tablet by mouth twice a day
for constipation to 2 tablets twice a day for constipation.
4. Stop taking the Cefazolin that you were admitted on and
continue as directed above.
5. Stop taking Morphine sulfate 2-4 mg intravenously every four
hours for pain.
6. Start taking Oxycontin 100 mg by mouth every 12 hours.
7. Start taking Docusate sodium 100 mg by mouth twice a day for
constipation.
8. Start taking Atorvastatin 40 mg by mouth once a day for
hyperlipidemia.
9. Start taking Ciprofloxacin 500 mg by mouth once a day for 10
days. Start this medication on [**11-2**] and stop on [**11-11**].
10. Start taking Metronidazole 500 mg by mouth every eight hours
for 10 days. You will need one dose the evening of [**11-1**].
Otherwise, you will need to take this medication three times a
day from [**11-2**] to [**11-11**].
11. Start taking Trazodone 50 mg by mouth at night as needed for
insomnia.
12. Start taking Nephrocaps (B complex-Vitamin C-Folic acid)   1
tab by mouth daily.
13. Start taking Calcium acetate 667 mg. Take two capsules three
times a day with meals.
14. Start taking Sevelamer carbonate 800 mg. Take one tablet by
mouth three times a day with meals.
15. Start taking Nitroglycerin 0.3 mg tablets. Take one tablet
every five minutes as needed for chest pain. Do not exceed 3
tablets in a 15 minute period.
16. Given the severity of your renal failure, you will also need
to receive Epoetin Alfa with dialysis. This medication will not
appear on your medication list in the following documents as it
was dosed and administered according to [**Hospital1 18**] protocols.
.
No other changes were made to your other medications while in
the hospital and you should continue taking all other
medications as previously prescribed.


Followup Instructions:
Please keep all follow up appointments as below:
.
1. Please call the Hematology-Oncology department at ([**Telephone/Fax (1) 15761**] to establish a follow-up appointment in the Hemostasis
and [**Hospital 17902**] clinic for further evaluation of the possible
anti-phospholipid antibody syndrome.
.
2. Please call the Orthopedics Department at ([**Telephone/Fax (1) 2007**] to
make a follow-up appointment. The appointment should be for
approximately one month from the date of discharge and should be
made with the [**Doctor Last Name **], the nurse practitioner.
.
3. Please keep the Infectious Disease appointment as below:
.
Department: INFECTIOUS DISEASE
When: MONDAY [**2107-11-14**] at 9:00 AM
With: [**First Name4 (NamePattern1) 2482**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage
.
Below are instructions for the labs that will need to be sent to
the Infectious Disease Department prior to your appintment on
[**2107-11-14**].
.
OUTPATIENT ANTIBIOTIC REGIMEN AND PROJECTED DURATION:
[**Doctor Last Name **] and DOSE:
Cefazolin 2g with dialysis on Mo, We; 3g with dialysis on Friday
Start date: [**2107-10-28**]
Stop date: [**2107-11-11**]
.
REQUIRED LABORATORY MONITORING:
LAB TESTS: CBC, Bun, Crea, LFTs, ESR and CRP
FREQUENCY: Qweekly
.
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]
.
4. Patient will need weekly monitoring of his pericardial
effusion with a Transthoracic Echocardiogram. Please communicate
this information to the MD.



Completed by:[**2107-11-8**]
{"Infection and inflammatory reaction due to other vascular device, implant, and graft,End stage renal disease,Psoas muscle abscess,Hemoperitoneum (nontraumatic),Subendocardial infarction, initial episode of care,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic pancreatitis,Acute infective polyneuritis,Bacteremia,Unspecified disease of pericardium,Primary hypercoagulable state,Pyogenic arthritis, pelvic region and thigh,Acute posthemorrhagic anemia,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in other specified places,Unspecified acquired hypothyroidism,Profound impairment, one eye, impairment level not further specified,Personal history of hodgkin's disease,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Gout, unspecified,Depressive disorder, not elsewhere classified,Tachycardia, unspecified"}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: Fevers, rigors

PRESENT ILLNESS: 39 year old male with a history of end-stage renal disease of
unknown etiology on HD, HTN, prior history of Hodgkin's disease,
gout, peptic ulcer disease, hypothyroidism, depression
presenting with fevers after right subclavian HD line was placed
by transplant surgery 2 days prior to admission.  Mr [**Known lastname **] went
for his first HD treatment after new line placement 1 day prior
to admission with temps to 101; he also developed rigors this
morning and presented to [**Hospital3 **].  His fever climbed to
103 and was given vancomycin, blood cultures from his HD line,
and was given fluid boluses and was then transferred to [**Hospital1 18**]
given that his nephrologist and transplant team are here.  In
the [**Hospital1 18**] ED, his heart rates were in the 130s with a rectal
temperature of 104; he was visibly in rigors and not endorsing
any pain otherwise.  He received tylenol and ativan for his
rigors; Zosyn was added on to his vancomycin.  Transplant team
pulled his HD line and tip was sent for culture.  An EKG done in
the ED showed ST elevations in AVF and lead III with ST
depressions in V1 and V2 however these resolved on repeat EKG; 1
set of troponins was elevated to 5.8 with no prior troponins to
compare to; CK-MB was of normal fraction.  Cards was consulted
and they felt the troponin elevation was in the setting of
chronic renal failure and demand ischemia in setting of
tachycardia.  1 aspirin was given.  They did not recommend
anticoagulation in setting of demand.  IV vancomycin was redosed
and 2 L of IV fluids were given.  Vitals in the ED were: 102.6,
HR 125, BP 132/58, RR 28, satting 96% RA.

MEDICAL HISTORY: 1. Chronic renal failure, Cr baseline 2.5 - followed by Dr.
[**Last Name (STitle) 8605**] at [**Hospital3 **]. No kidney biopsy.
2. Hypertension.
3. Hodgkin's disease s/p chemotherapy with [**Doctor First Name **] and radiation
4. [**First Name9 (NamePattern2) 7816**] [**Location (un) **] - reportedly as a result of chemo treatment -
left him with numbness below the waist.
5. Depression with one prior psych hospitalization.
6. H/o suicidal attempt with narcotics overdose
7. Left eye blindness evaluated in ED on [**2101-9-25**] with
?functional overlay
8. Back pain - right flank pain requiring chronic narcotics (as
per pt). Unknown etiology.
9. Hypothyroidism.
10. Gout.
11. ? [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear
12. post radiation pancreatitis
13. chronic anemia

MEDICATION ON ADMISSION: 1.  albuterol
2.  allopurinol 50 mg daily
3.  nephrocaps 1 caps daily
4.  calcium acetate 667 mg daily
5.  citalopram 40 mg daily
6.  vicodin
7.  levothyroxine 112 mcg daily
8.  morphine 30 mg daily
9.  pantoprazole 40 mg daily
10. trazodone 50 mg qhs
11. venlafaxine 150 mg daily
12. coumadin 7.5/5 alternating
13. colace
14. senna

ALLERGIES: Percocet / Erythromycin Base / A.C.E Inhibitors / Nsaids

PHYSICAL EXAM: Admission Physical Exam:
VS HR 120s BP 119/63, 92% RA, RR 20, temp 100.9
GEN: In NAD, lying in bed
HEENT: Anicteric, oropharynx clear
Cardiac: Tachycardic, no murmurs appreciable
Chest: old suture evident from prior line placement
Pulm: clear in anterior fields
Abd: soft and nontender
Ext: No edema noted
.
Discharge Physical Exam:
VS: Tm/Tc:99.2, BP:128-138/86-99, HR:108-116, RR:20, S02:99%RA
Gen: lying in bed, comfortable-apparing
Cardiac: muffled S1 and S2, RRR, 3/6 systolic murmur at the apex
as well as LLSB, cardiac friction rub present
Lungs: crackles at the bases but otherwise clear
Abdomen: mod firm and distended, two incision sites in RLQ and
LLQ show staples in place without drainage, minimal tenderness
around RLQ incision
UE: significant erythema and swelling in LUE
LE: 2+ DP, radial pulses, trace swelling in bilat LE

FAMILY HISTORY: Father - s/p renal transplant ?hypertensive nephropathy
Mother - Depression and alcohol dependence
Two sons (ages 2 and 15) with renal dysplasia
No history of deafness or cystic kidney disease

SOCIAL HISTORY: Pt lives with his wife and his children. He is on disability.
Used to work as EMT.  Pt denies tobacco, alcohol or illicit drug 

### Response:
{"Infection and inflammatory reaction due to other vascular device, implant, and graft,End stage renal disease,Psoas muscle abscess,Hemoperitoneum (nontraumatic),Subendocardial infarction, initial episode of care,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic pancreatitis,Acute infective polyneuritis,Bacteremia,Unspecified disease of pericardium,Primary hypercoagulable state,Pyogenic arthritis, pelvic region and thigh,Acute posthemorrhagic anemia,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in other specified places,Unspecified acquired hypothyroidism,Profound impairment, one eye, impairment level not further specified,Personal history of hodgkin's disease,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Gout, unspecified,Depressive disorder, not elsewhere classified,Tachycardia, unspecified"}
