CHIEF COMPLAINT: fevers, vomiting, AMS

PRESENT ILLNESS: History of Present Illness:  Mr. [**Known lastname 108855**] is an 84yo male with
history of CAD s/p stenting, CHF (EF 55%), Afib, prior cardiac
arrest and heart block s/p pacer/AICD placement, chronic trach,
and recent MRSA bacteremia on vancomycin who presents from rehab
with a one day history of fevers and vomiting, as well as AMS.
Patient has had several recent admissions, including admission
from [**Date range (1) 105469**] for PNA and MRSA bacteremia/sepsis.  Was
discharged to rehab on vanco, readmitted [**Date range (1) 20211**] for hematuria
and GI bleed (blood in ostomy bag), and again readmitted
[**Date range (1) 108857**] with persistent fevers and positive MRSA blood
cultures.  Source of MRSA bacteremia was unclear, and work-up
during that time included TTE/TEE negative for vegetations on
valves and cardiac pacer leads, and negative tagged WBC scan.
PICC was removed and replaced.  Patient discharged on planned 6
week course of vanco through [**2163-11-2**].  Hospital course also
notable for pseudomonas and klebsiella UTI, treated with 7 day
courses of cefepime and tobramycin.  Patient had Foley changed
during that admission.  Was discharged back to [**Hospital1 100**] Senior
Rehab.
.
Since discharge, has been noted to have worsening renal function
requiring nephrology consult, and in this setting his diuretic
regimen was held.  Also had increasing SOB requiring pulmonary
consult, with change in vent settings from pressure support to
AC mode.  Has had recurrent GI bleed requiring transfusion of 2
units pRBCs on [**2163-10-12**], and has been continued on PPI,
sucralfate, and iron supplementation.  Per report, usually
responds to wife, but was less responsive over past 1-2 days.
On day of admission had several episodes of vomiting, and per
wife was febrile to 101.  Sent to ED for further evaluation.
.
In the ED, initial VS were: 98.2 69 106/51 20 95% assist
control.  Labs notable for leukocytosis (WBC 14.2) with
neutrophil predominance, Hct 26.3 (stable), Na 127, Cr 3.5
(baseline 1.4), lactate 1.2.  UA suggestive of recurrent UTI.
CXR showed moderate pulmonary edema with bilateral pleural
effusions, and was similar to recent prior studies.  Given LUE
edema, ultrasound obtained which was negative for DVT.  Patient
received vancomycin and cefepime.  Also got ASA given elevated
trop of 0.2.  ECG showed paced rhythm.  Patient had 1L NS hung
prior to transfer.  VS prior to transfer 100.0 70, 112/82, 15,
99%.
.
On arrival to the MICU, patient nods yes when asked if he is in
pain, but he cannot localize the pain.  Appears comfortable when
resting in bed, though uncomfortable when examined.
.

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: Acetylcysteine 100mg TID intratracheal
Carvedilol 6.25mg [**Hospital1 **]
Citalopram 20mg daily
Docusate sodium 100mg [**Hospital1 **]
Ferrous sulfate elixir 325mg daily
Folic acid 1mg daily
Lidocaine patch daily
MVI daily
Omeprazole 20mg daily
Simethicone 80mg [**Hospital1 **]
Sucralfate 1gm TID
Fentanyl 12mcg patch Q72hrs
Acetaminophen 650mg Q6H prn pain
Albuterol inhaler 2 puffs Q4H prn SOB
Psyllium 1 teaspoon TID
Oxycodone 5mg Q4H prn pain

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

PHYSICAL EXAM: ADMISSION EXAM:
General: easily arousable to voice, frequently falls to sleep,
oriented to person and place, unable to assess if oriented to
time (could not interpret patient's answer), appears comfortable
at rest
HEENT: PERRL, EOMI, sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP 8-9cm, trach in place
CV: RRR, normal S1 + S2, II/VI holosystolic murmur loudest at
apex and radiating to axilla
Lungs: bilateral rhonchi with scattered crackles, no wheezing
Abdomen: bowel sounds present, soft, mildly distended, diffuse
mild  tenderness to palpation, suprapubic tenderness, ostomy bag
in place GU: foley in place
Ext: slighty cool, 2+ pulses, venous stasis changes, 2+ edema to
knees bilaterally

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.
Methicillin resistant Staphylococcus aureus septicemia,Pressure ulcer, stage IV,Urinary tract infection, site not specified,Hemorrhage of gastrointestinal tract, unspecified,Acute kidney failure, unspecified,Dependence on respirator, status,Hyposmolality and/or hyponatremia,Precipitous drop in hematocrit,Chronic diastolic heart failure,Chronic respiratory failure,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Thrombocytopenia, unspecified,Depressive disorder, not elsewhere classified,Other late effects of cerebrovascular disease,Percutaneous transluminal coronary angioplasty status,Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus,Automatic implantable cardiac defibrillator in situ,Personal history of sudden cardiac arrest,Tracheostomy status,Ileostomy status,Gastrostomy status,Personal history of irradiation, presenting hazards to health,Personal history of antineoplastic chemotherapy,Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus,Do not resuscitate status,Severe sepsis
MRSA septicemia,Pressure ulcer, stage IV,Urin tract infection NOS,Gastrointest hemorr NOS,Acute kidney failure NOS,Respirator depend status,Hyposmolality,Drop, hematocrit, precip,Chr diastolic hrt fail,Chronic respiratory fail,Atrial fibrillation,Crnry athrscl natve vssl,Thrombocytopenia NOS,Depressive disorder NEC,Late effect CV dis NEC,Status-post ptca,Hx-rectal & anal malign,Status autm crd dfbrltr,Hx sudden cardiac arrest,Tracheostomy status,Ileostomy status,Gastrostomy status,Hx of irradiation,Hx antineoplastic chemo,Meth resis Staph carrier,Do not resusctate status,Severe sepsis
Admission Date:  [**2163-10-14**]              Discharge Date:   [**2163-10-21**]

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

Service: MEDICINE

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

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
fevers, vomiting, AMS


Major Surgical or Invasive Procedure:
None


History of Present Illness:
History of Present Illness:  Mr. [**Known lastname 108855**] is an 84yo male with
history of CAD s/p stenting, CHF (EF 55%), Afib, prior cardiac
arrest and heart block s/p pacer/AICD placement, chronic trach,
and recent MRSA bacteremia on vancomycin who presents from rehab
with a one day history of fevers and vomiting, as well as AMS.
Patient has had several recent admissions, including admission
from [**Date range (1) 105469**] for PNA and MRSA bacteremia/sepsis.  Was
discharged to rehab on vanco, readmitted [**Date range (1) 20211**] for hematuria
and GI bleed (blood in ostomy bag), and again readmitted
[**Date range (1) 108857**] with persistent fevers and positive MRSA blood
cultures.  Source of MRSA bacteremia was unclear, and work-up
during that time included TTE/TEE negative for vegetations on
valves and cardiac pacer leads, and negative tagged WBC scan.
PICC was removed and replaced.  Patient discharged on planned 6
week course of vanco through [**2163-11-2**].  Hospital course also
notable for pseudomonas and klebsiella UTI, treated with 7 day
courses of cefepime and tobramycin.  Patient had Foley changed
during that admission.  Was discharged back to [**Hospital1 100**] Senior
Rehab.
.
Since discharge, has been noted to have worsening renal function
requiring nephrology consult, and in this setting his diuretic
regimen was held.  Also had increasing SOB requiring pulmonary
consult, with change in vent settings from pressure support to
AC mode.  Has had recurrent GI bleed requiring transfusion of 2
units pRBCs on [**2163-10-12**], and has been continued on PPI,
sucralfate, and iron supplementation.  Per report, usually
responds to wife, but was less responsive over past 1-2 days.
On day of admission had several episodes of vomiting, and per
wife was febrile to 101.  Sent to ED for further evaluation.
.
In the ED, initial VS were: 98.2 69 106/51 20 95% assist
control.  Labs notable for leukocytosis (WBC 14.2) with
neutrophil predominance, Hct 26.3 (stable), Na 127, Cr 3.5
(baseline 1.4), lactate 1.2.  UA suggestive of recurrent UTI.
CXR showed moderate pulmonary edema with bilateral pleural
effusions, and was similar to recent prior studies.  Given LUE
edema, ultrasound obtained which was negative for DVT.  Patient
received vancomycin and cefepime.  Also got ASA given elevated
trop of 0.2.  ECG showed paced rhythm.  Patient had 1L NS hung
prior to transfer.  VS prior to transfer 100.0 70, 112/82, 15,
99%.
.
On arrival to the MICU, patient nods yes when asked if he is in
pain, but he cannot localize the pain.  Appears comfortable when
resting in bed, though uncomfortable when examined.
.


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:
ADMISSION EXAM:
General: easily arousable to voice, frequently falls to sleep,
oriented to person and place, unable to assess if oriented to
time (could not interpret patient's answer), appears comfortable
at rest
HEENT: PERRL, EOMI, sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP 8-9cm, trach in place
CV: RRR, normal S1 + S2, II/VI holosystolic murmur loudest at
apex and radiating to axilla
Lungs: bilateral rhonchi with scattered crackles, no wheezing
Abdomen: bowel sounds present, soft, mildly distended, diffuse
mild  tenderness to palpation, suprapubic tenderness, ostomy bag
in place GU: foley in place
Ext: slighty cool, 2+ pulses, venous stasis changes, 2+ edema to
knees bilaterally

DISCHARGE EXAM
HEENT: PERRL, EOMI, sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP 8-9cm, trach in place
CV: RRR, normal S1 + S2, II/VI holosystolic murmur loudest at
apex and radiating to axilla
Lungs: bilateral rhonchi with scattered crackles, no wheezing
Abdomen: bowel sounds present, soft, mildly distended, diffuse
mild  tenderness to palpation, suprapubic tenderness, ostomy bag
in place GU: foley in place
Ext: slighty cool, 2+ pulses, venous stasis changes, 2+ edema to
knees bilaterally


Pertinent Results:
ADMISSION LABS
[**2163-10-14**] 06:25PM BLOOD WBC-14.2*# RBC-3.15* Hgb-8.9* Hct-26.3*
MCV-83 MCH-28.2 MCHC-33.8 RDW-15.4 Plt Ct-116*
[**2163-10-14**] 06:25PM BLOOD Neuts-82.8* Lymphs-6.4* Monos-10.2
Eos-0.3 Baso-0.4
[**2163-10-14**] 06:25PM BLOOD PT-16.7* PTT-35.8* INR(PT)-1.5*
[**2163-10-14**] 06:25PM BLOOD Glucose-108* UreaN-117* Creat-3.5*#
Na-127* K-4.5 Cl-85* HCO3-28 AnGap-19
[**2163-10-14**] 06:25PM BLOOD ALT-52* AST-65* AlkPhos-258* TotBili-1.7*
[**2163-10-15**] 02:26AM BLOOD Albumin-2.8* Calcium-8.4 Phos-3.5 Mg-2.2

DISCHARGE LABS
[**2163-10-21**] 03:32AM BLOOD WBC-4.9 RBC-2.90* Hgb-8.2* Hct-25.5*
MCV-88 MCH-28.2 MCHC-32.0 RDW-16.2* Plt Ct-108*
[**2163-10-19**] 12:11AM BLOOD PT-16.1* PTT-36.1* INR(PT)-1.4*
[**2163-10-21**] 03:32AM BLOOD Glucose-74 UreaN-96* Creat-2.7* Na-140
K-3.7 Cl-102 HCO3-23 AnGap-19
[**2163-10-20**] 03:02AM BLOOD CK(CPK)-21*
[**2163-10-21**] 03:32AM BLOOD Calcium-8.4 Phos-4.9* Mg-2.0

MICROBIOLOGY
[**10-14**] BLood Culture
   STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------   =>8 R
DAPTOMYCIN------------       S
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

[**10-14**] Urine Culture
   URINE CULTURE (Final [**2163-10-19**]):
      ENTEROCOCCUS SP..    >100,000 ORGANISMS/ML..
         Sensitivity testing performed by Sensititre.
         Daptomycin = 1 MCG /ML.
      YEAST.    10,000-100,000 ORGANISMS/ML..

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ENTEROCOCCUS SP.
                             |
AMPICILLIN------------     1 S
DAPTOMYCIN------------       S
LINEZOLID-------------     1 S
TETRACYCLINE----------  =>32 R
VANCOMYCIN------------  >256 R

[**10-15**] Sputum culture
[**2163-10-15**] 7:00 pm SPUTUM      Source: Endotracheal.

                            **FINAL REPORT [**2163-10-20**]**

   GRAM STAIN (Final [**2163-10-15**]):
      THIS IS A CORRECTED REPORT [**2163-10-16**] AT 3:00 PM.
      Reported to and read back by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 394**].
      >25 PMNs and <10 epithelial cells/100X field.
      4+   (>10 per 1000X FIELD):   GRAM NEGATIVE ROD(S).
      [**2163-10-16**] PREVIOUSLY REPORTED AS.
      <10 PMNs and >10 epithelial cells/100X field.
      4+   (>10 per 1000X FIELD):   GRAM NEGATIVE ROD(S).

   RESPIRATORY CULTURE (Final [**2163-10-20**]):
      Commensal Respiratory Flora Absent.
      PSEUDOMONAS AERUGINOSA.    HEAVY GROWTH.
         Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
         [**Last Name (NamePattern1) 3060**].
      KLEBSIELLA PNEUMONIAE.    SPARSE GROWTH.
         Piperacillin/tazobactam sensitivity testing available
on request.

                              SENSITIVITIES: MIC expressed in
MCG/ML

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

[**10-16**] Sputum
Time Taken Not Noted     Log-In Date/Time: [**2163-10-16**] 2:50 am
      SPUTUM

                            **FINAL REPORT [**2163-10-19**]**

   GRAM STAIN (Final [**2163-10-16**]):
      >25 PMNs and <10 epithelial cells/100X field.
      NO MICROORGANISMS SEEN.

   RESPIRATORY CULTURE (Final [**2163-10-19**]):
      RARE GROWTH Commensal Respiratory Flora.
      STAPH AUREUS COAG +.    RARE GROWTH.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations.

         Rifampin should not be used alone for therapy.
         This isolate is presumed to be resistant to clindamycin
based on
         the detection of inducible resistance .
      YEAST.    SPARSE GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------       R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S

[**10-19**] Urine Culture
[**2163-10-19**] 12:29 pm URINE      Source: Catheter.

                            **FINAL REPORT [**2163-10-20**]**

   URINE CULTURE (Final [**2163-10-20**]):
      YEAST.    10,000-100,000 ORGANISMS/ML..

[**10-15**] RUQ US
RIGHT UPPER QUADRANT ULTRASOUND: The liver is normal in
echotexture without focal lesions. There is no intrahepatic or
extrahepatic biliary ductal dilatation. The normal CBD measures
5 mm in diameter. Again noted is a large gallstone, measuring
2.7 cm, in the non-fully distended gallbladder. The gallbladder
wall is mildly thickened measuring up to 5 mm, nonspecific.
There is normal hepatopetal portal venous flow. The enlarged
spleen measures up to 16.6 cm. The visualized IVC, aorta and
pancreas are grossly unremarkable.  Trace ascites is noted.

IMPRESSION:
1. Known cholelithiasis.
2. Mildly thickened gallbladder wall, unchanged and
non-specific, could be
seen in right heart failure, hypoalbuminemia or other liver
disease. No
ultrasound findings to suggest acute cholecystitis.
3. Splenomegaly.

[**10-15**] LUE US
IMPRESSION: No DVT left upper extremity with a left basilic PICC
in place.

[**10-16**] G-tube check
REASON FOR EXAMINATION: Evaluation of the percutaneous
gastrostomy tube with bleeding and leakage throughout the tube.
AP radiograph of the abdomen after injection of contrast
material through the percutaneous gastrostomy is noted. The
contrast material is demonstrated in the stomach as well as in
the duodenum and jejunum. No definitive evidence of
extravasation is noted. If clinically warranted, correlation
with cross-sectional imaging might be considered.

Wound Care recomendations: Recommendations:

1. Follow pressure ulcer guidelines. Atmos Air. 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. LLE anterior excoriation - cover with Adaptic dressing, place

   4x4,and wrap with Kerlix. Secure with paper tape. Change
   daily.
5. No tape on skin.
6. Left Trochanter - apply Mepilex 4x4 to site, and change
   q3 days.
7. Cleanse scrotum and perineum area with Aloe Vesta foam
   cleanser daily. Pat dry.
8. Apply Critic Aid clear skin barrier ointment to scrotal
tissue
   to protect from fluid exposure daily. Elevate scrotum to
   assist with edema.
9. Waffles bilateral feet.
10. Apply Aquaphor ointment to dry intact skin daily from
    pharmacy daily.

Ostomy Care:  LLQ, 1 [**1-18**]", red, flush, os at center,
mucocutaneous junction
intact, peristomal skin intact with large parastomal hernia.
Pouched with [**First Name9 (NamePattern2) 93403**] [**Doctor Last Name **] [**Doctor Last Name **] one piece drainable, Dist #
[**Numeric Identifier 24338**], Man # [**Numeric Identifier 20839**]. No-sting barrier wipe, Dist # [**Numeric Identifier **], Man #
3344. Nursing staff to change pouch q Monday and Thursday while
her.


Brief Hospital Course:
84yo male with extensive cardiac PMH, recent MRSA bacteremia,
trach on chronic mechanical ventilation, and chronic foley
catheter with recent pseudomonal/klebsiella UTI, who presents
now from rehab with fever, leukocytosis, vomiting, and AMS in
setting enterococcus and yeast UTI, [**Last Name (un) **], MRSA bacteremia,
hematochezia, and Stage 4 sacral decubitus ulcer.
.
ACUTE ISSUES
#. MRSA Bacteremia:  Pt had recurrent MRSA bacteremia in the
settting of vancomycin treatment.  We are particularly concerned
about endocarditis from [**Last Name (un) 3941**] given the refractory nature.
However, removal of instrumentation is not an option per patietn
and family wishes.  Source of infection include sacral
decubitous ulcer, UTI, ventilation.  Pt does not have
leukocytosis or fever.  Chronic colonization likely.  Complete
bacterial clearance is unlikely in this setting.
OUTPATIENT ISSUES
- START Daptomycin indefinitely
- PICC line in place, routine care
.
#. GIB: Pt presented with HCT drop and Bright red blood through
ostomy.  He received a total of 3 units pRBC blood transfusion.
We temporarily stopped tube feeding the setting of GIB, and
discontinued his aspirin.  His HCT has been stable in the past
48 hours without transfusion.  GI has been consulted, and did
not feel that the benefit of osteostomy-scope outweighs its
risk.
OUTPATIENT ISSUES
- CONTINUE tube feeding as scheduled
- STOP aspirin and anti-platelets forever.
- START pantoprazole 40 mg iv bid
- CONTINUE ferrous sulfate, sucrafate
.
#. [**Last Name (un) **]: Pt presented with elevated Cr to 3.5 on admission with
anuria.  There was muddy brown cast on urine sedimentation,
concerning for ATN in the setting of sepsis and tobramycin
exposure.  We gave him gentle fluid challenge, and his urine
output recovered shortly afterwards.  His creatinine decreased
to 2.7 on the day of discharge.  This may or may not ever go
back down to his previous baseline.  Regardless, he's not anuric
and patient and family have refused initiation of dialysis.
OUTPATIENT ISSUES
- AVOID nephrotoxic medication
- DISCONTINUE Lisinopril
.
#. Hematuria and UTI:  Pt has indwelling foley catheter and
presented with hematuria and positive UA.  Urine culture was
notable for VRE, fungus.  We treated him with meropenem and
fluconazole while he was in the MICU.  He received bladder
irrigation for hematuria.  His hematuria resolved on the day of
discharge.  Pt was asymptomatic from his UTI.  We felt it is
impossible to completely treat his UTI.  We decided to
withdrawal treatment for now to minimize the hepatic and renal
drug intoxication.
.
#. Decubitus ulcer: Pt has a Stage 4 decubitus ulcer over sacrum
and left thigh.  The pain from decubitous ulcer is his major
concern while he was here.  He was seen by wound care.  They
advise supportive care.
OUTPATIENT ISSUES
- Pleae CHANGE BODY POSITION every 2 hours
- Please provide adequate pain management with lidocaine patch,
fentanyl, oxycodone.
.
#. Positive sputum culture: Pt has trach tube.  His sputum
culture grew multiresistant klebsiella and pseudomonas.  Pt
remained afebrile, no leukocytosis, left shift or increased
sputum production.  We felt the complete irradiation was unlikey
given his current clinical status and suspect he has permanent
colonization.
.
CHRONIC ISSUES
#. Chronic dCHF: Pt has diastolic CHF.  We continued his
beta-blocker for the need of rate control.  We held his
lisinopril in an hope of protecting his current kidney function.
 We held his aspirin in the setting of GI bleeding.  We felt
that active treatment for his CHF is less of a priority.
OUTPATIENT ISSUES
- DISCONTINUED Aspirin and all antiplatelet drugs
- DISCONTINUED Lisinopril
.
#. Atrial fibrillation: Pt is AV paced on telemetry. Not on
anticoagulation given history of GI bleeding.  Rate controlled
with carvedilol.
OUTPATIENT ISSUES
- Per our EP recommendation, they can disable the defibrillator
function, while still keep AV pacing, if there is a need in the
change of goal of care.
.
# Depression: Continue citalopram.
.
TRANSITIONAL ISSUES
Pt declared a code status of DNR/DNI.  Extensive discussion has
occurred between family and care provider team on goal of care.
In general, our understanding is that family would like
continued conservative treatment, with no invasive procedure,
including the use of pressors.  We have conveyed clearly to the
family that clinical improvement is unlikely in the current
situation.  Pt's family expressed concerns that patient has not
been getting enough comfort care (ie skin, wound, pain).
.
The wife has expressed continued frustration with being
transferred back and forth from rehab to the hospital.  We
assured her that the care provided to him at rehab is very good.
 In general, we'd try to limit the number of unecessary
hospitalizations.  We explained to the family, with the son
present in the room, that the patient's condition is stable, but
ultimately is declining.  We explicity told them that things are
probably as good as they'll ever be, and that in the future he
will have a slow and steady decline.  We are limited in
interventions that can be done here in hospital and have
conveyed that to his family.
.
.


Medications on Admission:
Acetylcysteine 100mg TID intratracheal
Carvedilol 6.25mg [**Hospital1 **]
Citalopram 20mg daily
Docusate sodium 100mg [**Hospital1 **]
Ferrous sulfate elixir 325mg daily
Folic acid 1mg daily
Lidocaine patch daily
MVI daily
Omeprazole 20mg daily
Simethicone 80mg [**Hospital1 **]
Sucralfate 1gm TID
Fentanyl 12mcg patch Q72hrs
Acetaminophen 650mg Q6H prn pain
Albuterol inhaler 2 puffs Q4H prn SOB
Psyllium 1 teaspoon TID
Oxycodone 5mg Q4H prn pain


Discharge Medications:
OxycoDONE (Immediate Release)  5-10 mg PO/NG Q4H:PRN pain hold
for sedation or RR <12
Citrate 25-50 mcg IV Q4H:PRN dressing changes
Albuterol Inhaler 6 PUFF IH Q4H:PRN shortness of breath,
wheezing
Pantoprazole 40 mg IV Q12H
Daptomycin 540 mg IV Q48H
Acetaminophen (Liquid) 650 mg PO/NG Q6H:PRN pain
Fentanyl Patch 12 mcg/hr TP Q72H last changed [**10-13**] @ 12:45
Sucralfate 1 gm PO/NG TID
Simethicone 80 mg PO/NG TID
Multivitamins 1 TAB PO/NG DAILY
Lidocaine 5% Patch 1 PTCH TD DAILY
FoLIC Acid 1 mg PO/NG DAILY
Ferrous Sulfate (Liquid) 300 mg PO/NG DAILY
Docusate Sodium (Liquid) 100 mg PO/NG [**Hospital1 **]
Citalopram 20 mg PO/NG DAILY
Carvedilol 6.25 mg PO/NG [**Hospital1 **]
MVI daily
Psyllium 1 teaspoon TID
Acetylcysteine 100mg TID intratracheal

Pt was administered the flu vaccine [**10-21**]

Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
MRSA bacteremia with likely pacemaker colonization, multiple
decubitus ulcers, ventilator dependence, acute kidney injury,
gastrointestinal bleeding, urinary tract infection, chronic
congestive heart failure.

Discharge Condition:
fair

Discharge Instructions:
Mr. [**Known lastname 108855**],

It was a pleasure taking care of you in the intensive care unit.
 As you know, the blood stream infection is probably chronic and
it would basically be impossible to cure of you that.  We
believe that your pacemaker is colonized with the bacteria, and
it would be impossible to remove it.  You also have a urinary
tract infection, and you were bleeding somewhere in your
intestines.  Fortunately the bleeding stopped.  You also have a
chronic heart failure, which you are aware.  Your kidney
insufficiency may resolve, but it may not.

You were also administered the flu vaccine while you were here.


Followup Instructions:
Continue with your regularly scheduled appointments as
previously scheduled.  There are no special appointments that
you need to make specifically in regard to your stay here.

You were administered the flu vaccine while you were here.

                             [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

Completed by:[**2163-10-22**]
{'Methicillin resistant Staphylococcus aureus septicemia,Pressure ulcer, stage IV,Urinary tract infection, site not specified,Hemorrhage of gastrointestinal tract, unspecified,Acute kidney failure, unspecified,Dependence on respirator, status,Hyposmolality and/or hyponatremia,Precipitous drop in hematocrit,Chronic diastolic heart failure,Chronic respiratory failure,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Thrombocytopenia, unspecified,Depressive disorder, not elsewhere classified,Other late effects of cerebrovascular disease,Percutaneous transluminal coronary angioplasty status,Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus,Automatic implantable cardiac defibrillator in situ,Personal history of sudden cardiac arrest,Tracheostomy status,Ileostomy status,Gastrostomy status,Personal history of irradiation, presenting hazards to health,Personal history of antineoplastic chemotherapy,Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus,Do not resuscitate status,Severe sepsis'}


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, vomiting, AMS

PRESENT ILLNESS: History of Present Illness:  Mr. [**Known lastname 108855**] is an 84yo male with
history of CAD s/p stenting, CHF (EF 55%), Afib, prior cardiac
arrest and heart block s/p pacer/AICD placement, chronic trach,
and recent MRSA bacteremia on vancomycin who presents from rehab
with a one day history of fevers and vomiting, as well as AMS.
Patient has had several recent admissions, including admission
from [**Date range (1) 105469**] for PNA and MRSA bacteremia/sepsis.  Was
discharged to rehab on vanco, readmitted [**Date range (1) 20211**] for hematuria
and GI bleed (blood in ostomy bag), and again readmitted
[**Date range (1) 108857**] with persistent fevers and positive MRSA blood
cultures.  Source of MRSA bacteremia was unclear, and work-up
during that time included TTE/TEE negative for vegetations on
valves and cardiac pacer leads, and negative tagged WBC scan.
PICC was removed and replaced.  Patient discharged on planned 6
week course of vanco through [**2163-11-2**].  Hospital course also
notable for pseudomonas and klebsiella UTI, treated with 7 day
courses of cefepime and tobramycin.  Patient had Foley changed
during that admission.  Was discharged back to [**Hospital1 100**] Senior
Rehab.
.
Since discharge, has been noted to have worsening renal function
requiring nephrology consult, and in this setting his diuretic
regimen was held.  Also had increasing SOB requiring pulmonary
consult, with change in vent settings from pressure support to
AC mode.  Has had recurrent GI bleed requiring transfusion of 2
units pRBCs on [**2163-10-12**], and has been continued on PPI,
sucralfate, and iron supplementation.  Per report, usually
responds to wife, but was less responsive over past 1-2 days.
On day of admission had several episodes of vomiting, and per
wife was febrile to 101.  Sent to ED for further evaluation.
.
In the ED, initial VS were: 98.2 69 106/51 20 95% assist
control.  Labs notable for leukocytosis (WBC 14.2) with
neutrophil predominance, Hct 26.3 (stable), Na 127, Cr 3.5
(baseline 1.4), lactate 1.2.  UA suggestive of recurrent UTI.
CXR showed moderate pulmonary edema with bilateral pleural
effusions, and was similar to recent prior studies.  Given LUE
edema, ultrasound obtained which was negative for DVT.  Patient
received vancomycin and cefepime.  Also got ASA given elevated
trop of 0.2.  ECG showed paced rhythm.  Patient had 1L NS hung
prior to transfer.  VS prior to transfer 100.0 70, 112/82, 15,
99%.
.
On arrival to the MICU, patient nods yes when asked if he is in
pain, but he cannot localize the pain.  Appears comfortable when
resting in bed, though uncomfortable when examined.
.

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: Acetylcysteine 100mg TID intratracheal
Carvedilol 6.25mg [**Hospital1 **]
Citalopram 20mg daily
Docusate sodium 100mg [**Hospital1 **]
Ferrous sulfate elixir 325mg daily
Folic acid 1mg daily
Lidocaine patch daily
MVI daily
Omeprazole 20mg daily
Simethicone 80mg [**Hospital1 **]
Sucralfate 1gm TID
Fentanyl 12mcg patch Q72hrs
Acetaminophen 650mg Q6H prn pain
Albuterol inhaler 2 puffs Q4H prn SOB
Psyllium 1 teaspoon TID
Oxycodone 5mg Q4H prn pain

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

PHYSICAL EXAM: ADMISSION EXAM:
General: easily arousable to voice, frequently falls to sleep,
oriented to person and place, unable to assess if oriented to
time (could not interpret patient's answer), appears comfortable
at rest
HEENT: PERRL, EOMI, sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP 8-9cm, trach in place
CV: RRR, normal S1 + S2, II/VI holosystolic murmur loudest at
apex and radiating to axilla
Lungs: bilateral rhonchi with scattered crackles, no wheezing
Abdomen: bowel sounds present, soft, mildly distended, diffuse
mild  tenderness to palpation, suprapubic tenderness, ostomy bag
in place GU: foley in place
Ext: slighty cool, 2+ pulses, venous stasis changes, 2+ edema to
knees bilaterally

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:
{'Methicillin resistant Staphylococcus aureus septicemia,Pressure ulcer, stage IV,Urinary tract infection, site not specified,Hemorrhage of gastrointestinal tract, unspecified,Acute kidney failure, unspecified,Dependence on respirator, status,Hyposmolality and/or hyponatremia,Precipitous drop in hematocrit,Chronic diastolic heart failure,Chronic respiratory failure,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Thrombocytopenia, unspecified,Depressive disorder, not elsewhere classified,Other late effects of cerebrovascular disease,Percutaneous transluminal coronary angioplasty status,Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus,Automatic implantable cardiac defibrillator in situ,Personal history of sudden cardiac arrest,Tracheostomy status,Ileostomy status,Gastrostomy status,Personal history of irradiation, presenting hazards to health,Personal history of antineoplastic chemotherapy,Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus,Do not resuscitate status,Severe sepsis'}
