CHIEF COMPLAINT: Diarrhea with fever & tachycardia

PRESENT ILLNESS: An 82 year old [**First Name3 (LF) 595**] speaking woman recently discharged from
[**Hospital Ward Name 516**] for PNA returns with 3 days of diarrhea complicated
by tachycardia and fever as measured by her daughter/VNA. This
history is obtained from the patient's daughter and review of
medical records as communication with the patient is difficult
secondary to language and hearing difficulties.
.
BRIEF SUMMARY OF RECENT HOSPITALIZATION [**Date range (1) 108333**]:
The patient presented with hypoxic/hypercapnic respiratory
failure due to PNA with effusions attributed to diastolic heart
failure. She was admitted to the [**Hospital Unit Name 153**] and started on
Levoflox/Vanc to finish a 10 day Levofloxacin only course. The
patient experienced ? AMS but head CT was negative. Patient was
continued on Lovenox for chronic DVT h/o PE. Her cr remained at
1.8-2.4 during this admission. She developed a new wound
possibly from plexipulses and required extensive wound care for
multiple wounds. She was made DNR/DNI. The patient was D/C'd
home without mention of diarrhea.
.
Per the daughter, [**Name (NI) 108329**], the patient developed diarrhea during
her recent hospitalization that has persisted since discharge.
The patient had a "tought day" with some agitation and apparent
discomfort with breathing. The patient was eating but
"everything she ate caused loose stools" different from her
regular Crohn's flares. When [**Name (NI) 108329**] noted tachycardia and fever
accompanying the loose, yellow non-bloody stools with an
increasing O2 requirement, the patient was brought into the ED
.
In the ED, VS: 99.2 BP 103/53 HR 110, RR 24, 100% on 3L. Exam
revealed crackles and decreased BS. EKG showing RBBB with old
TWI in 3, sinus tach. CXR: resolving PNA. Received Vanco 1g &
fluids in ED.
.
On arrival to the floor, the patient is laying in bed and
reports that she is "fine." She complains of generalized chronic
weakness and has pain during wound dressing changes. Her
daughter relayed the history as above. The patient has a cough
productive of green sputum once on arrival. She has R sided
tremor.
.
ROS:
Significant for easy bruising, long standing vision & hearing
loss,
Denies headache, cough (except for above), SOB, chest pain,
abdominal pain, hematochezia, melena

MEDICAL HISTORY: PAST MEDICAL HISTORY:
-Anemia [**3-3**] CRI, chronic disease
-MDS dx 3 yrs ago
-Crohn's disease
-CAD s/p NSTEMI '[**89**]
-CRI w baseline Cr 1.5-1.8
-BL DVTs and saddle embolus in [**2190**], previously on warfarin now
on Lovenox
-Chronic BL LE edema
-Breast cancer s/p lumpectomy & XRT
-GERD
-Intracranial bleed and fx after pedestrian vs car 20 yrs ago
-Cataracts
-Venous stasis dermatitis
-Tinea pedis
-?Arrhythmia unspecified which daughter says is tx with
metoprolol
-dHF with EF 60-70%
.
PAST SURGICAL HISTORY:
-CCY 10 yrs ago
-Lumpectomy 13 yrs ago

MEDICATION ON ADMISSION: -Ciprofloxacin 250 mg [**Hospital1 **]: "Crohn's Ppx"
-Mesalamine 400mg 3 tab TID (pt usually only takes 3 tab QDAY)
-Prednisone 18 mg QDAY
-Omeprazole 20mg [**Hospital1 **]
-Metoprolol 12.5 mg QDAY
-Furosemide 10mg QOD
-Epogen 40,000 units QWEEK
-Lovenox 80mg syringe/70 units QDAY
-Alendronate 70mg QSATURDAY
-Calcium carbonate 500mg TID
-Folic acid 1 mg QDAY
-Vitamin B12 1cc QMONTH
-Vitamin D3 400 unit [**Unit Number **] tab QDAY
-APAP 500mg [**1-31**] tab QID PRN
-Albuterol 2.5mg neb QID PRN
-Camphor-Menthol 0.5-0.5 % Lotion TID PRN
-Triamcinolone cream PRN
-Miconazole cream PRN

ALLERGIES: Belladonna Alkaloids

PHYSICAL EXAM: VS: T BP 95/32 P 32 R 32 96% 3L
General: somnolent, but wakes to voice and responds to
questions; daughter at bedside
[**Name (NI) 4459**]: PERRL, NC/AT, conjunctival pallor, anicteric
Neck: no JVD appreciated
Lungs: bilaterla crackles while sitting up in bed
Cardiac: RRR, S1 S2, 2/6 SEM best at LUSB,
Abdomen: soft, non-tender, non-distended, +BS throughout
Extrem: [**3-4**]+ gross bilateral edema R>>L; dry dressings to both
legs, several healing skin tears over upper and lower
extremities
.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Married; lives with her husband who is demented, her daughter
[**Name (NI) 108329**], [**Name2 (NI) 108330**] husband and 6 [**Name2 (NI) **] granddaughter. Presently in
temporary housing while awaiting renovations on their [**Last Name (un) **]
which was damaged during a fire last winter. [**Last Name (un) 108329**] is the
caretaker for both of her parents. [**Last Name (un) 108329**] very stressed and
overwhelmed. Her mother-in-law in [**Name (NI) 4565**] died this past
month which required her husband to leave for [**Name (NI) 4565**]. She is
in the midst of trying to place her father in nursing care
facility and is quite guilty about this decision. Ms. [**Known lastname 108328**] [**Last Name (Titles) 108331**]y recieves near daily RN visits from Suburban Home Care.
[**Last Name (Titles) 108329**] is reliant on "sitters" to bring her mother to
appointments.
Pneumonitis due to inhalation of food or vomitus,Acute kidney failure with lesion of tubular necrosis,Acute respiratory failure,Chronic diastolic heart failure,Regional enteritis of unspecified site,Unspecified pleural effusion,Chronic kidney disease, Stage V,Cellulitis and abscess of leg, except foot,Osteoporosis, unspecified,Myelodysplastic syndrome, unspecified,Long-term (current) use of anticoagulants,Personal history of venous thrombosis and embolism,Diarrhea,Other specified disorders of skin,Hyperpotassemia,Esophageal reflux,Anemia in chronic kidney disease,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Personal history of malignant neoplasm of breast
Food/vomit pneumonitis,Ac kidny fail, tubr necr,Acute respiratry failure,Chr diastolic hrt fail,Regional enteritis NOS,Pleural effusion NOS,Chron kidney dis stage V,Cellulitis of leg,Osteoporosis NOS,Myelodysplastic synd NOS,Long-term use anticoagul,Hx-ven thrombosis/embols,Diarrhea,Skin disorders NEC,Hyperpotassemia,Esophageal reflux,Anemia in chr kidney dis,Crnry athrscl natve vssl,Old myocardial infarct,Hx of breast malignancy
Admission Date:  [**2194-3-24**]              Discharge Date:   [**2194-4-8**]

Date of Birth:  [**2112-2-19**]             Sex:   F

Service: MEDICINE

Allergies:
Belladonna Alkaloids

Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Diarrhea with fever & tachycardia

Major Surgical or Invasive Procedure:
blood transfusion


History of Present Illness:
An 82 year old [**First Name3 (LF) 595**] speaking woman recently discharged from
[**Hospital Ward Name 516**] for PNA returns with 3 days of diarrhea complicated
by tachycardia and fever as measured by her daughter/VNA. This
history is obtained from the patient's daughter and review of
medical records as communication with the patient is difficult
secondary to language and hearing difficulties.
.
BRIEF SUMMARY OF RECENT HOSPITALIZATION [**Date range (1) 108333**]:
The patient presented with hypoxic/hypercapnic respiratory
failure due to PNA with effusions attributed to diastolic heart
failure. She was admitted to the [**Hospital Unit Name 153**] and started on
Levoflox/Vanc to finish a 10 day Levofloxacin only course. The
patient experienced ? AMS but head CT was negative. Patient was
continued on Lovenox for chronic DVT h/o PE. Her cr remained at
1.8-2.4 during this admission. She developed a new wound
possibly from plexipulses and required extensive wound care for
multiple wounds. She was made DNR/DNI. The patient was D/C'd
home without mention of diarrhea.
.
Per the daughter, [**Name (NI) 108329**], the patient developed diarrhea during
her recent hospitalization that has persisted since discharge.
The patient had a "tought day" with some agitation and apparent
discomfort with breathing. The patient was eating but
"everything she ate caused loose stools" different from her
regular Crohn's flares. When [**Name (NI) 108329**] noted tachycardia and fever
accompanying the loose, yellow non-bloody stools with an
increasing O2 requirement, the patient was brought into the ED
.
In the ED, VS: 99.2 BP 103/53 HR 110, RR 24, 100% on 3L. Exam
revealed crackles and decreased BS. EKG showing RBBB with old
TWI in 3, sinus tach. CXR: resolving PNA. Received Vanco 1g &
fluids in ED.
.
On arrival to the floor, the patient is laying in bed and
reports that she is "fine." She complains of generalized chronic
weakness and has pain during wound dressing changes. Her
daughter relayed the history as above. The patient has a cough
productive of green sputum once on arrival. She has R sided
tremor.
.
ROS:
Significant for easy bruising, long standing vision & hearing
loss,
Denies headache, cough (except for above), SOB, chest pain,
abdominal pain, hematochezia, melena


Past Medical History:
PAST MEDICAL HISTORY:
-Anemia [**3-3**] CRI, chronic disease
-MDS dx 3 yrs ago
-Crohn's disease
-CAD s/p NSTEMI '[**89**]
-CRI w baseline Cr 1.5-1.8
-BL DVTs and saddle embolus in [**2190**], previously on warfarin now
on Lovenox
-Chronic BL LE edema
-Breast cancer s/p lumpectomy & XRT
-GERD
-Intracranial bleed and fx after pedestrian vs car 20 yrs ago
-Cataracts
-Venous stasis dermatitis
-Tinea pedis
-?Arrhythmia unspecified which daughter says is tx with
metoprolol
-dHF with EF 60-70%
.
PAST SURGICAL HISTORY:
-CCY 10 yrs ago
-Lumpectomy 13 yrs ago


Social History:
Married; lives with her husband who is demented, her daughter
[**Name (NI) 108329**], [**Name2 (NI) 108330**] husband and 6 [**Name2 (NI) **] granddaughter. Presently in
temporary housing while awaiting renovations on their [**Last Name (un) **]
which was damaged during a fire last winter. [**Last Name (un) 108329**] is the
caretaker for both of her parents. [**Last Name (un) 108329**] very stressed and
overwhelmed. Her mother-in-law in [**Name (NI) 4565**] died this past
month which required her husband to leave for [**Name (NI) 4565**]. She is
in the midst of trying to place her father in nursing care
facility and is quite guilty about this decision. Ms. [**Known lastname 108328**] [**Last Name (Titles) 108331**]y recieves near daily RN visits from Suburban Home Care.
[**Last Name (Titles) 108329**] is reliant on "sitters" to bring her mother to
appointments.

Family History:
non-contributory


Physical Exam:
VS: T BP 95/32 P 32 R 32 96% 3L
General: somnolent, but wakes to voice and responds to
questions; daughter at bedside
[**Name (NI) 4459**]: PERRL, NC/AT, conjunctival pallor, anicteric
Neck: no JVD appreciated
Lungs: bilaterla crackles while sitting up in bed
Cardiac: RRR, S1 S2, 2/6 SEM best at LUSB,
Abdomen: soft, non-tender, non-distended, +BS throughout
Extrem: [**3-4**]+ gross bilateral edema R>>L; dry dressings to both
legs, several healing skin tears over upper and lower
extremities
.


Pertinent Results:
[**2194-3-24**] 11:00PM   GLUCOSE-105 UREA N-34* CREAT-2.5* SODIUM-136
POTASSIUM-4.7 CHLORIDE-98 TOTAL CO2-33* ANION GAP-10
[**2194-3-24**] 11:00PM   CK(CPK)-11*
[**2194-3-24**] 11:00PM   CK-MB-NotDone cTropnT-0.07*
[**2194-3-24**] 11:00PM   ALBUMIN-3.1* CALCIUM-7.8* PHOSPHATE-4.3
MAGNESIUM-1.5*
[**2194-3-24**] 04:15PM URINE  HOURS-RANDOM UREA N-317 CREAT-58
SODIUM-77
[**2194-3-24**] 04:15PM URINE  UHOLD-HOLD
[**2194-3-24**] 04:15PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2194-3-24**] 04:15PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2194-3-24**] 04:15PM URINE  RBC-0-2 WBC-3 BACTERIA-OCC YEAST-NONE
EPI-0
[**2194-3-24**] 02:18PM   LACTATE-1.5
[**2194-3-24**] 01:10PM   GLUCOSE-88 UREA N-29* CREAT-2.4* SODIUM-139
POTASSIUM-4.7 CHLORIDE-99 TOTAL CO2-34* ANION GAP-11
[**2194-3-24**] 01:10PM   estGFR-Using this
[**2194-3-24**] 01:10PM   LD(LDH)-238 CK(CPK)-20*
[**2194-3-24**] 01:10PM   cTropnT-0.07*
[**2194-3-24**] 01:10PM   CK-MB-NotDone proBNP-1643*
[**2194-3-24**] 01:10PM   CALCIUM-8.0* PHOSPHATE-3.2 MAGNESIUM-1.6
[**2194-3-24**] 01:10PM   WBC-17.4*# RBC-2.68* HGB-9.9* HCT-30.9*
MCV-115* MCH-37.0* MCHC-32.1 RDW-19.3*
[**2194-3-24**] 01:10PM   NEUTS-89.6* LYMPHS-7.1* MONOS-2.6 EOS-0.4
BASOS-0.3
[**2194-3-24**] 01:10PM   HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
SCHISTOCY-OCCASIONAL STIPPLED-OCCASIONAL
[**2194-3-24**] 01:10PM   PLT COUNT-133*
[**2194-3-24**] 01:10PM   PT-12.3 PTT-29.7 INR(PT)-1.0

[**2194-4-8**] 05:56AM BLOOD Plt Smr-LOW Plt Ct-82*
[**2194-4-8**] 05:56AM BLOOD WBC-11.8* RBC-2.86* Hgb-9.6* Hct-29.5*
MCV-103* MCH-33.7* MCHC-32.6 RDW-18.8* Plt Ct-82*
[**2194-4-8**] 05:56AM BLOOD Glucose-110* UreaN-67* Creat-2.5* Na-143
K-5.2* Cl-109* HCO3-27 AnGap-12
[**2194-4-8**] 05:56AM BLOOD Calcium-7.9* Phos-3.9 Mg-1.6
MICROBIOLOGY:
MRSA negative
C.diff negative x2

IMAGING:
[**2194-4-7**] CXR: IMPRESSION:
1. New mild-to-moderate right pleural effusion.

2. Persistent moderate left pleural effusion and dense
retrocardiac opacity
which may represent left lower lobe collapse or, less likely,
consolidation.

[**2194-4-2**] UPPER EXT U/S: IMPRESSION:
1. No left upper extremity DVT.
2. Left thyroid cyst.


Brief Hospital Course:
An 82 year old lady with multiple medical problems recently
discharged for PNA presents with 3 days of diarrhea accompanied
by tachycardia & fever with concern for new left pneumonia
despite levaquin therapy. Her exam and appearance is concerning
for respiratory distress.
.
1) Pneumonia: The patient was found to have a new left sided
pneumonia, retrocardiac opacity and L pleural effusion on CXR
from either new process or aspiration. On admission to the
medicine service she was found to be in hypoxic/hypercarbic
respiratory failure and was transferred to the ICU. She was
started on vancomycin/zosyn 2 week course, albuterol and
ipratropium neb treatments and supplemental oxygen. IV fluids
were administered for her acute on chronic CKD (see below) which
may have lead to some pulmonary edema. Sputum culture was done
but did not reveal the source of her pneumonia. She completed
the course and her oxygen requirements improved. Lasix was held
in the setting of her ATN thus some fluid overload may be
present, and prior to discharge she was slowly restarted on
lasix for diuresis. She remained afebrile for the length of her
admission. Prior to discharge a repeat chest xray showed a
stable left-sided pleural effusion, new small right sided
pleural effusion (thought to be secondary to holding lasix for
hypotension for over a week), and stable retrocardiac opacity.
The patient was discharged on 2.5-3L of oxygen, with
saturdations 90-93%.

.
2) Diarrhea: This may have been the cause to the patient's
volume loss, leading to hypotension and eventually to ATN. While
initially guaiaic negative, it was felt to be due to antibiotic
use, infectious or Crohn's flare. She was c.diff negative x2.
Her poor po intake began to improve and her diarrhea, while
intermittent continued to be an issue. In the setting of
thrombocytopenia she had loose guaiac positive, dark/tarry
stools. It was unclear if this was a [**Name (NI) 4522**] flare of small
bleed from anticoagulation (on heparin at the time) or
thrombocytopenia. She was started on pulse dose steroids and
tapered down to prednisone 60mg daily. She is currently on a
taper. The GI service was consulted and felt that flexible
sigmoidoscopy may help elucidate whether there is new dysplasia
or worsening of her Crohn's. The patient's daughter and HCT did
not feel her mother could tolerate a procedure at this time and
opted for medical management. It remains unclear what caused her
diarrhea but it was encouraged that she maintain a lactose-free
diet as this was felt to exacerbate the issue. She will continue
her prednisone taper while at rehabilitation. She has a
follow-up appointment with Dr.[**Last Name (STitle) 3708**] after discharge. Given she
has been on steroids for many years, calcium and vitamin D
therapy was initiated during this hospitalization.

.
3) Diastolic Heart Failure: Her most recent echo suggests
hyperdynamic stiff ventricle as supported by elevated BNP, EF
70-80%. However this was done in the setting of what appeared to
be septic physiology. Her lasix and metoprolol were held on
admission for hypotension and renal failure. Lasix was restarted
prior to discharge for diuresis and improve her respiratory
status. Metoprolol should be restarted when appropriate, given
she is on a prednisone taper. Prior to discharge a transthoracic
echo was performed so that it can be used for comparison in the
future. The results will be pending after discharge and should
be followed-up at next PCP [**Name Initial (PRE) **]. Her weight on discharge was
77.8kg.

.
4) ATN/CKD: Patient at last discharge with creatinine of 2.4.
She was felt to be pre-renal given the diarrhea, which was
likely responsible for her elevated troponin on this admission.
Her creatinine rose to peak at 4.4. The nephrology service was
consulted and upon evaluation of her labs felt this was
consistent with ATN. Witholding lasix and gentle diuresis, the
patient's renal function improved. Her medications were renally
dosed and nephrotoxins avoided where possible. Urine output
improved and creatinine trended down to 2.5 prior to discharge
to rehabilitation.

.
5) Crohn's Disease: Initially the patient was continued on
prednisone 18mg daily as per her home regimen. However with
hypotension and respiratory failure, she was started on stress
dose regimen which was eventually tapered. She was switched from
IV to po prednisone and is currently on a long taper. As above,
she has an appointment with Dr. [**Last Name (STitle) 3708**] as an outpatient. She will
continue on prednisone, mesalamine and cipro twice daily to
prevent a flare.

.
6) MDS and Related Anemia: The patient is known to have chronic
anemia secondary to both MDS and CKD. She is followed as an
outpatient by hematology and received weekly Epogen treatment
prior to her multiple admission. She was transfused several
times  for hematocrit of 25. Prior to discharge she was also
given a one-time dose of 10,000U Epogen (slightly hypertensive
at the time, did not give full 40,000U dose). She has follow-up
with Dr.[**Last Name (STitle) **] in clinic to evaluate whether she should be
restarted on her Epogen treatments.

.
7) DVT/PE: Patient had chronic DVT/PE in the past for which she
was on lovenox, which was initially continued. In the setting of
acute renal failure she was switched to heparin for
approximately 2 days at which point her thrombocytopenia became
significantly worse (plt 49 at lowest). HIT antibodies were sent
and were negative. She was also found to have guaiac + stools
and tarry loose stools at times. Given her risk of bleeding
(anemia, thrombocytopenia) it was felt the risk of
anticoagulation was greater than the benefit, despite her
underlying PE/DVT history. The issue of anticoagulation should
be readdressed once her more pressing issues, namely
intermittent bloody stools and thrombocytopenia are resolved.
Lovenox was not restarted prior to discharge. Pneumoboot was
applied to the left arm once her skin and edema had healed.
Given her extensive upper extremity swelling of the L arm, an
upper extremity US was done to r/o DVT which was negative. Of
note, a thyroid cyst was identified on this study, which it
appears has been seen on prior imaging but should be further
evaluated if concerns arise in the future.

.
8) Hemorrhagic bullae s/p rupture: Much of this is likely due to
her years of steroid use. She has a variety of wounds from a
recent hospitalizations. Both wound care consult and vascular
surgery were asked to comment and felt surgical intervention or
debridement were not warranted, but good wound care and close
monitoring should be instituted. The patients legs were wrapped
daily, adaptec applied to wounds, and lotion applied to decrease
the risk of further skin tears. With time the swelling in her
arms and legs decreased, however her skin is very delicate and
good wound care practices need to be followed.

.
9) GERD: In the setting of guaiac positive stools she was
switched from omeprazole to protonix IV for two days while
concern for active bleed was ruled out. Once stable, she was
restarted on omeprazole 20mg twice daily.
.

10) Osteoporosis: Calcium and vitamin D were continued during
admission.

.
11) Nutrition: The patient has very poor appetite. She was NPO
for several days, and when she would eat, her diarrhea would
recur. Her diet was switched to lactose free and high calorie
supplements were provided.
.

12) Code: the patient's daughter and health care proxy confirmed
code as DNR/DNI


Medications on Admission:
-Ciprofloxacin 250 mg [**Hospital1 **]: "Crohn's Ppx"
-Mesalamine 400mg 3 tab TID (pt usually only takes 3 tab QDAY)
-Prednisone 18 mg QDAY
-Omeprazole 20mg [**Hospital1 **]
-Metoprolol 12.5 mg QDAY
-Furosemide 10mg QOD
-Epogen 40,000 units QWEEK
-Lovenox 80mg syringe/70 units QDAY
-Alendronate 70mg QSATURDAY
-Calcium carbonate 500mg TID
-Folic acid 1 mg QDAY
-Vitamin B12 1cc QMONTH
-Vitamin D3 400 unit [**Unit Number **] tab QDAY
-APAP 500mg [**1-31**] tab QID PRN
-Albuterol 2.5mg neb QID PRN
-Camphor-Menthol 0.5-0.5 % Lotion TID PRN
-Triamcinolone cream PRN
-Miconazole cream PRN


Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for Pain.
2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
3. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day).
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours).
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q2H (every 2 hours) as
needed for dyspnea.
8. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-31**] Sprays Nasal
TID (3 times a day) as needed.
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

11. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
12. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
13. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID (3 times a day).
14. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
15. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-31**]
Drops Ophthalmic PRN (as needed).
16. Prednisone 20 mg Tablet Sig: taper as below Tablet PO DAILY
(Daily): 60mg (3 tabs) daily for 4 days (start [**2194-4-8**]).
40mg (2 tabs) daily for 4 days.
20mg (1 tab) daily for 4 days .
17. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 1643**] center

Discharge Diagnosis:
Primary:
Pneumonia
Acute Tubular Necrosis of the kidney

Secondary:
Thrombocytopenia
Anemia
MDS


Discharge Condition:
hemodynamically stable and afebrile, 92% on 3L


Discharge Instructions:
You were admitted to the hospital for diarrhea and pneumonia.
You were found to be hypotensive (low blood pressure) and have
respiratory failure which required you to be admitted to the
ICU. You were treated with IV fluids and antibiotics. You
completed a two week course of antibiotics for your pneumonia.
For your diarrhea you were given pulse dose steroids and are now
on a taper of prednisone. Since you had bowel movements that
were positive for blood (guaiac positive) and your platelet
count became very low, your anticoagulation was stopped. Your
lasix was initially held as you were found to be in renal
failure, which is now resolving. Please make sure to discuss
with your doctor when it is appropriate for you to restart your
metoprolol and lovenox.

The following changes were made to your medications:
Your lovenox has been stopped.
Your metoprolol is being held- speak to your doctor to determine
when it is ok to restart this medication.
Calcium, vitamin D have been added to your regimen.

If you experience any shortness of breath, chest pains,
abdominal pains, fevers or chills, or any other concerning
symptoms please call your doctor or return to the emergency
room.


Followup Instructions:
Please make sure to follow-up with:
Primary care doctor: Dr.[**Last Name (STitle) 3357**] ([**Telephone/Fax (1) 4606**]on Thursday [**4-10**]
at 5:45pm

Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7290**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2194-4-24**]
10:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2194-4-29**] 3:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3014**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2194-4-29**]
3:30
{'Pneumonitis due to inhalation of food or vomitus,Acute kidney failure with lesion of tubular necrosis,Acute respiratory failure,Chronic diastolic heart failure,Regional enteritis of unspecified site,Unspecified pleural effusion,Chronic kidney disease, Stage V,Cellulitis and abscess of leg, except foot,Osteoporosis, unspecified,Myelodysplastic syndrome, unspecified,Long-term (current) use of anticoagulants,Personal history of venous thrombosis and embolism,Diarrhea,Other specified disorders of skin,Hyperpotassemia,Esophageal reflux,Anemia in chronic kidney disease,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Personal history of malignant neoplasm of breast'}


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: Diarrhea with fever & tachycardia

PRESENT ILLNESS: An 82 year old [**First Name3 (LF) 595**] speaking woman recently discharged from
[**Hospital Ward Name 516**] for PNA returns with 3 days of diarrhea complicated
by tachycardia and fever as measured by her daughter/VNA. This
history is obtained from the patient's daughter and review of
medical records as communication with the patient is difficult
secondary to language and hearing difficulties.
.
BRIEF SUMMARY OF RECENT HOSPITALIZATION [**Date range (1) 108333**]:
The patient presented with hypoxic/hypercapnic respiratory
failure due to PNA with effusions attributed to diastolic heart
failure. She was admitted to the [**Hospital Unit Name 153**] and started on
Levoflox/Vanc to finish a 10 day Levofloxacin only course. The
patient experienced ? AMS but head CT was negative. Patient was
continued on Lovenox for chronic DVT h/o PE. Her cr remained at
1.8-2.4 during this admission. She developed a new wound
possibly from plexipulses and required extensive wound care for
multiple wounds. She was made DNR/DNI. The patient was D/C'd
home without mention of diarrhea.
.
Per the daughter, [**Name (NI) 108329**], the patient developed diarrhea during
her recent hospitalization that has persisted since discharge.
The patient had a "tought day" with some agitation and apparent
discomfort with breathing. The patient was eating but
"everything she ate caused loose stools" different from her
regular Crohn's flares. When [**Name (NI) 108329**] noted tachycardia and fever
accompanying the loose, yellow non-bloody stools with an
increasing O2 requirement, the patient was brought into the ED
.
In the ED, VS: 99.2 BP 103/53 HR 110, RR 24, 100% on 3L. Exam
revealed crackles and decreased BS. EKG showing RBBB with old
TWI in 3, sinus tach. CXR: resolving PNA. Received Vanco 1g &
fluids in ED.
.
On arrival to the floor, the patient is laying in bed and
reports that she is "fine." She complains of generalized chronic
weakness and has pain during wound dressing changes. Her
daughter relayed the history as above. The patient has a cough
productive of green sputum once on arrival. She has R sided
tremor.
.
ROS:
Significant for easy bruising, long standing vision & hearing
loss,
Denies headache, cough (except for above), SOB, chest pain,
abdominal pain, hematochezia, melena

MEDICAL HISTORY: PAST MEDICAL HISTORY:
-Anemia [**3-3**] CRI, chronic disease
-MDS dx 3 yrs ago
-Crohn's disease
-CAD s/p NSTEMI '[**89**]
-CRI w baseline Cr 1.5-1.8
-BL DVTs and saddle embolus in [**2190**], previously on warfarin now
on Lovenox
-Chronic BL LE edema
-Breast cancer s/p lumpectomy & XRT
-GERD
-Intracranial bleed and fx after pedestrian vs car 20 yrs ago
-Cataracts
-Venous stasis dermatitis
-Tinea pedis
-?Arrhythmia unspecified which daughter says is tx with
metoprolol
-dHF with EF 60-70%
.
PAST SURGICAL HISTORY:
-CCY 10 yrs ago
-Lumpectomy 13 yrs ago

MEDICATION ON ADMISSION: -Ciprofloxacin 250 mg [**Hospital1 **]: "Crohn's Ppx"
-Mesalamine 400mg 3 tab TID (pt usually only takes 3 tab QDAY)
-Prednisone 18 mg QDAY
-Omeprazole 20mg [**Hospital1 **]
-Metoprolol 12.5 mg QDAY
-Furosemide 10mg QOD
-Epogen 40,000 units QWEEK
-Lovenox 80mg syringe/70 units QDAY
-Alendronate 70mg QSATURDAY
-Calcium carbonate 500mg TID
-Folic acid 1 mg QDAY
-Vitamin B12 1cc QMONTH
-Vitamin D3 400 unit [**Unit Number **] tab QDAY
-APAP 500mg [**1-31**] tab QID PRN
-Albuterol 2.5mg neb QID PRN
-Camphor-Menthol 0.5-0.5 % Lotion TID PRN
-Triamcinolone cream PRN
-Miconazole cream PRN

ALLERGIES: Belladonna Alkaloids

PHYSICAL EXAM: VS: T BP 95/32 P 32 R 32 96% 3L
General: somnolent, but wakes to voice and responds to
questions; daughter at bedside
[**Name (NI) 4459**]: PERRL, NC/AT, conjunctival pallor, anicteric
Neck: no JVD appreciated
Lungs: bilaterla crackles while sitting up in bed
Cardiac: RRR, S1 S2, 2/6 SEM best at LUSB,
Abdomen: soft, non-tender, non-distended, +BS throughout
Extrem: [**3-4**]+ gross bilateral edema R>>L; dry dressings to both
legs, several healing skin tears over upper and lower
extremities
.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Married; lives with her husband who is demented, her daughter
[**Name (NI) 108329**], [**Name2 (NI) 108330**] husband and 6 [**Name2 (NI) **] granddaughter. Presently in
temporary housing while awaiting renovations on their [**Last Name (un) **]
which was damaged during a fire last winter. [**Last Name (un) 108329**] is the
caretaker for both of her parents. [**Last Name (un) 108329**] very stressed and
overwhelmed. Her mother-in-law in [**Name (NI) 4565**] died this past
month which required her husband to leave for [**Name (NI) 4565**]. She is
in the midst of trying to place her father in nursing care
facility and is quite guilty about this decision. Ms. [**Known lastname 108328**] [**Last Name (Titles) 108331**]y recieves near daily RN visits from Suburban Home Care.
[**Last Name (Titles) 108329**] is reliant on "sitters" to bring her mother to
appointments. 

### Response:
{'Pneumonitis due to inhalation of food or vomitus,Acute kidney failure with lesion of tubular necrosis,Acute respiratory failure,Chronic diastolic heart failure,Regional enteritis of unspecified site,Unspecified pleural effusion,Chronic kidney disease, Stage V,Cellulitis and abscess of leg, except foot,Osteoporosis, unspecified,Myelodysplastic syndrome, unspecified,Long-term (current) use of anticoagulants,Personal history of venous thrombosis and embolism,Diarrhea,Other specified disorders of skin,Hyperpotassemia,Esophageal reflux,Anemia in chronic kidney disease,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Personal history of malignant neoplasm of breast'}
