CHIEF COMPLAINT: Lethargy, txf from OSH with presumed urosepsis

PRESENT ILLNESS: Mr. [**Known lastname **] is a 46 year old male with multiple medical problems
pertinently including DM2 and morbid obesity, being transferred
from OSH with presumed urosepsis. He presented to [**Hospital1 **] [**Location (un) 620**] on
the morning of transfer c/o 3 days of increasing lethargy and
AMS. By his report he has been feeling "out of it" for the last
3 days, but can't quite articulate why. He says he's been very
weak and actually fell once, however on further questioning and
review of the notes this has been going on for months. He denies
any headache, photophobia, neck stiffness. ROS positive for
cough over the last week or so, occasionally productive of
sputum, as well as shortness of breath, however he says this is
also a chronic problem. Denies any fevers, chills, abdominal
pain. Has a chronic foley in place for about a year and denies
any pain at the foley site or change in urine color. His
colostomy output has not changed in consistency or quantity. He
is unsure if he has had any recent medication changes, and
mentions that he takes a lot of anti-anxiety medications.
.
At the OSH he was found to be virtually unresponsive,
hypotensive to the 80s systolic. ABG 7.36/64/95 on RA. WBC was
10, with a positive UA (+nitrite, +LE, 20-50 WBC, mod bact). He
received 2L NS, vanco/zosyn and was transported to [**Hospital1 18**].
.
On arrival in the ED here, systolics were 80-90 but improved
with 2 L IVF. He had a central line placed in R groin, however
has not required pressors.
.
On arrival to the [**Hospital Unit Name 153**] the patient's vitals were 97.1, HR 53, BP
158/103, RR 11, O2 100% on 4L NC. He was responsive, albeit
sluggish.
.
Of note, patient has been treated for numerous UTIs in the past,
most recently had proteus UTI in [**11-7**], sensitive to Augmentin
and cefuroxime. Has also had pseudomonal and klebsiella UTIs in
the last 1-2 years.

MEDICAL HISTORY: 1) DM2 diagnosed [**2114**] with triopathy: Creatinine has been as low
as 0.8 in the last couple of years, however widely fluctuant, as
high as 2 in the recent past. 0.9 in [**1-7**].
2) COPD, on home O2. Multiple episodes of respiratory failure
requiring intubation in recent years. Most recently, was
admitted in [**12-6**] with a perforated transverse colon requiring
partial colectomy and transverse colostomy. This course c/b
anticipated respiratory failure and anticipatory tracheostomy,
pseudomonal and MRSA PNA. Also with acalculous cholecystitis
requiring cholecystostomy tube. Had G-tube placed.
3) OSA on CPAP
3) VRE
4) s/p tracheostomy, as above in [**1-7**]
5) HTN
6) CHF: During hospitalization in [**10-20**] it was thought that
failure contributed to his respiratory failure. Last echo was in
[**12-6**] at which time LVEF thought to be roughly normal, however
very poor study and RV not visualized. Not on lasix.
7) Anemia of chronic disease, multiple transfusions in the past

MEDICATION ON ADMISSION: Paxil 40 mg [**Hospital1 **]
Neurontin 600 mg QID
Flonase 1 spray [**Hospital1 **]
Flovent 1 puff [**Hospital1 **]
Protonix 40 mg daily
Combivent 2 puffs [**Hospital1 **]
Reglan 10 mg TID
Lantus 44 units [**Hospital1 **]
Clonidine (Catapres) 6 mg [**Hospital1 **]?
Metoprolol 100 mg [**Hospital1 **]
Klonopin 2 mg TID
Lorazepam 2 mg daily
Xanax 1 mg TID
Astelin 1 spray [**Hospital1 **]
Lasix 40 mg [**Hospital1 **]

ALLERGIES: Cephalosporins / Morphine / Fentanyl

PHYSICAL EXAM: 97.1, HR 53, BP 158/103, RR 11, O2 100% on 4L NC
Gen: Morbidly obese caucasian male appearing slightly dyspneic
but otherwise comfortable.
MS: AAO x 3, responds to questions appropriately however very
slow to respond.
HEENT: PEARL, dry MM.
Neck: JVP unable to evaluate
Cor: RR, normal rate, distant HS
Lungs: Scattered expiratory wheezes anteriorly
Abd: NABS, soft, colostomy bag with brown stool, appears C/D/I,
second ostomy with gauze C/D/I.
Extr: RLE with erythematous plaque/patch circumferentially
around distal tibia (patient reports chronic), 2+ pitting and
weeping edema with a couple of vesicles. LLE s/p BKA, stump
covered with dressing. Extremities cold.
Neuro: Moves all extremities.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Lives home alone with VNA. Denies etoh. Remote cigar smoking, no
cigarettes. No IVDU or marijuana. Has 1 brother, [**Name (NI) **].
Disseminated candidiasis,Urinary tract infection, site not specified,Infection and inflammatory reaction due to indwelling urinary catheter,Opioid abuse, continuous,Acute kidney failure, unspecified,Chronic airway obstruction, not elsewhere classified,Congestive heart failure, unspecified,Retention of urine, unspecified,Hypotension, unspecified,Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Background diabetic retinopathy,Morbid obesity,Obstructive sleep apnea (adult)(pediatric),Depressive disorder, not elsewhere classified,Anemia of other chronic disease,Unspecified essential hypertension,Long-term (current) use of insulin,Colostomy status,Tracheostomy status,Below knee amputation status,Personal history of other diseases of circulatory system
Disseminated candidiasis,Urin tract infection NOS,React-indwell urin cath,Opioid abuse-continuous,Acute kidney failure NOS,Chr airway obstruct NEC,CHF NOS,Retention urine NOS,Hypotension NOS,Proteus infection NOS,DMII neuro nt st uncntrl,Neuropathy in diabetes,Nephritis NOS in oth dis,Diabetic retinopathy NOS,Morbid obesity,Obstructive sleep apnea,Depressive disorder NEC,Anemia-other chronic dis,Hypertension NOS,Long-term use of insulin,Colostomy status,Tracheostomy status,Status amput below knee,Hx-circulatory dis NEC
Admission Date:  [**2134-1-3**]              Discharge Date:   [**2134-1-13**]

Date of Birth:  [**2087-11-5**]             Sex:   M

Service: MEDICINE

Allergies:
Cephalosporins / Morphine / Fentanyl

Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Lethargy, txf from OSH with presumed urosepsis

Major Surgical or Invasive Procedure:
Left femoral line
foley catheter changed


History of Present Illness:
 Mr. [**Known lastname **] is a 46 year old male with multiple medical problems
pertinently including DM2 and morbid obesity, being transferred
from OSH with presumed urosepsis. He presented to [**Hospital1 **] [**Location (un) 620**] on
the morning of transfer c/o 3 days of increasing lethargy and
AMS. By his report he has been feeling "out of it" for the last
3 days, but can't quite articulate why. He says he's been very
weak and actually fell once, however on further questioning and
review of the notes this has been going on for months. He denies
any headache, photophobia, neck stiffness. ROS positive for
cough over the last week or so, occasionally productive of
sputum, as well as shortness of breath, however he says this is
also a chronic problem. Denies any fevers, chills, abdominal
pain. Has a chronic foley in place for about a year and denies
any pain at the foley site or change in urine color. His
colostomy output has not changed in consistency or quantity. He
is unsure if he has had any recent medication changes, and
mentions that he takes a lot of anti-anxiety medications.
.
At the OSH he was found to be virtually unresponsive,
hypotensive to the 80s systolic. ABG 7.36/64/95 on RA. WBC was
10, with a positive UA (+nitrite, +LE, 20-50 WBC, mod bact). He
received 2L NS, vanco/zosyn and was transported to [**Hospital1 18**].
.
On arrival in the ED here, systolics were 80-90 but improved
with 2 L IVF. He had a central line placed in R groin, however
has not required pressors.
.
On arrival to the [**Hospital Unit Name 153**] the patient's vitals were 97.1, HR 53, BP
158/103, RR 11, O2 100% on 4L NC. He was responsive, albeit
sluggish.
.
Of note, patient has been treated for numerous UTIs in the past,
most recently had proteus UTI in [**11-7**], sensitive to Augmentin
and cefuroxime. Has also had pseudomonal and klebsiella UTIs in
the last 1-2 years.


Past Medical History:
1) DM2 diagnosed [**2114**] with triopathy: Creatinine has been as low
as 0.8 in the last couple of years, however widely fluctuant, as
high as 2 in the recent past. 0.9 in [**1-7**].
2) COPD, on home O2. Multiple episodes of respiratory failure
requiring intubation in recent years. Most recently, was
admitted in [**12-6**] with a perforated transverse colon requiring
partial colectomy and transverse colostomy. This course c/b
anticipated respiratory failure and anticipatory tracheostomy,
pseudomonal and MRSA PNA. Also with acalculous cholecystitis
requiring cholecystostomy tube. Had G-tube placed.
3) OSA on CPAP
3) VRE
4) s/p tracheostomy, as above in [**1-7**]
5) HTN
6) CHF: During hospitalization in [**10-20**] it was thought that
failure contributed to his respiratory failure. Last echo was in
[**12-6**] at which time LVEF thought to be roughly normal, however
very poor study and RV not visualized. Not on lasix.
7) Anemia of chronic disease, multiple transfusions in the past

8) s/p BKA for chronic LE ulcer
9) TIA in [**2125**].
10) Difficult intubation; fiberoptic guidance in [**Month (only) 359**] of
[**2131**].
11) Urinary retention.
12) Osteoarthritis.
13) Depression.
14) C. Difficile in [**2129**].
15) Hypogonadism.
16) Morbid obesity
.
PAST SURGICAL HISTORY:
1. Bilateral carpal tunnel release in [**2123**].
2. Hydrocele repair in [**2126-4-3**].
3. Quadriceps tendon repair in [**2127**].
4. Status post partial resection of transverse colon, end
transverse colostomy, mucus fistula, jejunostomy tube and
percutaneous tracheostomy on [**2132-12-16**].


Social History:
Lives home alone with VNA. Denies etoh. Remote cigar smoking, no
cigarettes. No IVDU or marijuana. Has 1 brother, [**Name (NI) **].

Family History:
Non-contributory

Physical Exam:
 97.1, HR 53, BP 158/103, RR 11, O2 100% on 4L NC
Gen: Morbidly obese caucasian male appearing slightly dyspneic
but otherwise comfortable.
MS: AAO x 3, responds to questions appropriately however very
slow to respond.
HEENT: PEARL, dry MM.
Neck: JVP unable to evaluate
Cor: RR, normal rate, distant HS
Lungs: Scattered expiratory wheezes anteriorly
Abd: NABS, soft, colostomy bag with brown stool, appears C/D/I,
second ostomy with gauze C/D/I.
Extr: RLE with erythematous plaque/patch circumferentially
around distal tibia (patient reports chronic), 2+ pitting and
weeping edema with a couple of vesicles. LLE s/p BKA, stump
covered with dressing. Extremities cold.
Neuro: Moves all extremities.


Pertinent Results:
[**2134-1-3**] 09:56AM   GLUCOSE-72 UREA N-24* CREAT-1.2 SODIUM-144
POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-32 ANION GAP-9
[**2134-1-3**] 09:56AM   WBC-9.4 RBC-3.29* HGB-9.9* HCT-29.2* MCV-89
MCH-30.3 MCHC-34.1 RDW-15.8*
[**2134-1-3**] 09:56AM   NEUTS-74.6* BANDS-0 LYMPHS-18.6 MONOS-2.6
EOS-3.5 BASOS-0.7
[**2134-1-3**] 09:56AM   HYPOCHROM-OCCASIONAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-1+
STIPPLED-1+
[**2134-1-3**] 09:56AM   PLT COUNT-259
[**2134-1-3**] 09:56AM   PT-12.4 PTT-25.7 INR(PT)-1.0
[**2134-1-3**] 01:15AM URINE  HOURS-RANDOM
[**2134-1-3**] 01:15AM URINE  UHOLD-HOLD
[**2134-1-3**] 01:15AM URINE  COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.019
[**2134-1-3**] 01:15AM URINE  BLOOD-SM NITRITE-POS PROTEIN->300
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-9.0*
LEUK-MOD
[**2134-1-3**] 01:15AM URINE  RBC-1 WBC-1 BACTERIA-MANY YEAST-NONE
EPI-0
[**2134-1-3**] 01:15AM URINE  HYALINE-1*
[**2134-1-3**] 01:15AM URINE  3PHOSPHAT-MANY AMORPH-MOD
[**2134-1-3**] 01:08AM   LACTATE-1.3
[**2134-1-3**] 12:53AM   GLUCOSE-85 UREA N-28* CREAT-1.4* SODIUM-144
POTASSIUM-3.9 CHLORIDE-112* TOTAL CO2-28 ANION GAP-8
[**2134-1-3**] 12:53AM   CALCIUM-7.5* PHOSPHATE-2.4* MAGNESIUM-1.7
[**2134-1-3**] 12:53AM   WBC-8.3 RBC-2.89* HGB-9.2* HCT-25.0* MCV-87
MCH-31.8# MCHC-36.8*# RDW-15.2
[**2134-1-3**] 12:53AM   PT-13.4* PTT-26.2 INR(PT)-1.2
_
_
_
_
_
_
_
_
_
________________________________________________________________

CHEST (PORTABLE AP)  [**2134-1-3**] 6:27 AM

There is a tracheostomy tube. The cardiac silhouette is markedly
enlarged. There is blunting of both costophrenic angles, right
greater than left, consistent with pleural effusions. There is
no evidence for overt pulmonary edema or focal consolidation.





Brief Hospital Course:
46 year old male with DM2, morbid obesity, p/w hypotension,
positive UA, and presumed narcotics abuse.  These issues
resolved w/ decreased pain meds and fluid resuscitation.  New
finding of [**Female First Name (un) **] growing in blood cx taken [**2134-1-3**] and proteus
miribilis in urine - hemodynamically stable.
.
#) UTI: Has history of recurrent UTIs, resistant to multiple
antibiotics.  UA collected on [**1-3**] grew mixed flora - likely
fecal contaminants.  Repeat U/A after changing foley showed
proteus miribilis.  Started abx to treat given hx multiple UTIs
in this pt w/ diabetes and indwelling catheter.  Gave 5 days of
14 day course of cefpodoxime.  Discussed whether pt needed to
have foley in place - pt feels that he can't make it to the
bathroom in time and does not want to use urinal.  Risk of
recurrent infection was explained but pt wants to keep foley.
Condom cath not possible due to retracted penis.  He will need a
repeat U/A after completion of abx.
.
#) [**Female First Name (un) **] in blood cx:  [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 28631**] growing in 1
bottle from [**2134-1-3**]; uncertain whether cultures were taken prior
to fem line placement or after.  Repeat mycolytic cx sent and
LFTs normal - fluconazole started w/ 7 of 14 days remaining.
Ophtho consult to eval for chorioretinitis - no evidence of
fungemia.  Pt clinically stable at discharge and subsequent
cultures unrevealing thusfar.
.
#) pain control:  pt was taking MS contin 100mg tid at home, but
unclear why he has been taking this - possibly for multiple
chronic joint pain.  He was restarted on MS contin 15mg tid;
dose changed to [**Hospital1 **] and required only few additional doses of MS
IR.  He exhibited no signs of withdrawal during this admission.
He gave permission to contact Dr. [**Last Name (STitle) 24792**] who prescribes his
pain meds.  Also, SW [**First Name8 (NamePattern2) 7905**] [**Last Name (NamePattern1) **] spoke w/ his brother who is
concerned that pt is overmedicating himself at home.  Now, all
his providers - psychiatrist, pain MD [**First Name (Titles) **] [**Last Name (Titles) 3390**] all made aware of
his pain regimen and of each other.  Will send copy of discharge
summary to his providers; request that his [**Last Name (Titles) 3390**] address issue of
narcotics contract.
.
#) HTN: Intially hypotensive but responded w/ IVF resuscitation.
 Metoprolol was restarted at 25mg po bid - home dose is 100mg po
bid.  Titrated up to 75mg [**Hospital1 **] for persistently elevated BP but
dose limited by HR in 30s to 50s.  Also restarted clonidine
0.6mg po bid and added lisinopril.  BP was better controlled on
lisinopril 40mg but creatinine increasing so decreased dose to
30.  Considered MRA of renal arteries given resistance to
multiple hypertensive regimen, but unable to perform this study
due to pt's habitus.  We decided to continue medical management
at this time.  Added on amlodipine 10mg qd w/ BP ranging in 130s
to 140s prior to discharge.
.
#) ?hip dislocation: pt c/o persistent L hip pain and requesting
X-ray.  On exam, pt had full ROM and not tender at joint
insertion site.  Imaged both L hip and R shoulder - these did
not show evidence of fracture or dislocation.  Likely that pt is
deconditioned from prolonged hospitalization - he has not been
out of bed since admission.  Would work more aggressively w/ PT
to get him out of bed.
.
#) Confusion/lethargy: Patient clearly slow to respond to
questions, but is much more alert at discharge; reports
sluggishness at home.  Mental status clearer with time and
reduced narcotic dose.
.
#) Hypotension: Did not meet criteria for SIRS as WBC < [**Numeric Identifier 890**],
no fever, HR < 90, RR < 20, however did have mild leukocytosis
with positive UA, therefore presumed urosepsis at intial
presentation. However additioal history was obtained from pt's
brother of large amount of narcotics use to explain hypotension
and lethargy. Initially treated with broad spectrum ABX but then
held awaiting culture results. Hypotension resolved quickly with
IV fluids.
.
#) ARF: 1.4, up from 0.9 1 year ago. BUN also elevated, most
likely pre-renal in the setting of hypotension. Back to baseline
after IVF.
.
#) Anemia: Baseline appears to be around 29, currently 27,
however was 30 at OSH prior to fluids. No signs of active
bleeding. Guaiac negative ostomy output.
.
#) DM2: Good control w/ outpatient regimen of lantus 44 units
[**Hospital1 **], plus RISS.
.
#) PPx: Continued protonix. SC heparin. Bowel regimen.
.
#) FEN: diabetic diet.
.
#) Access: PIV; fem line in [**Hospital Unit Name 153**]
.
#) Code status: full - discussed w/ pt.  HCP is [**Name (NI) **] [**Name (NI) **],
his brother.

Medications on Admission:
Paxil 40 mg [**Hospital1 **]
Neurontin 600 mg QID
Flonase 1 spray [**Hospital1 **]
Flovent 1 puff [**Hospital1 **]
Protonix 40 mg daily
Combivent 2 puffs [**Hospital1 **]
Reglan 10 mg TID
Lantus 44 units [**Hospital1 **]
Clonidine (Catapres) 6 mg [**Hospital1 **]?
Metoprolol 100 mg [**Hospital1 **]
Klonopin 2 mg TID
Lorazepam 2 mg daily
Xanax 1 mg TID
Astelin 1 spray [**Hospital1 **]
Lasix 40 mg [**Hospital1 **]


Discharge Medications:
1. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig: One
(1) Spray Nasal [**Hospital1 **] (2 times a day).
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed.
8. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
9. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO tid prn.
10. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day) as needed.
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
12. Loratadine 10 mg Tablet Sig: One (1) Tablet PO qd ().
13. Clonidine 0.2 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
17. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
18. Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day) as needed.
19. Insulin Glargine 100 unit/mL Solution Sig: One (1)
Subcutaneous sliding scale: Please refer to insulin sliding
scale.
20. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
21. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to
6 hours) as needed.
22. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

23. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
24. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 10 days.
25. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 7 days.


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Healthcare Center - [**Location (un) 1110**]

Discharge Diagnosis:
Primary:
somnolence secondary to narcotics overuse
recurrent UTIs
hypertension
[**Female First Name (un) **] in blood culture
acute renal failure
.
DM2
COPD
OSA on CPAP
VRE
s/p tracheostomy, as above in [**1-7**]
CHF
Anemia of chronic disease
s/p BKA for chronic LE ulcer
Urinary retention
Depression
Morbid obesity


Discharge Condition:
stable


Discharge Instructions:
Please return for further care if you have fevers, chills,
dizziness, weakness, shortness of breath, chest pain, fainting,
sleepiness, or any other symptoms that are concerning to you.
.
Take all your medications only as directed.
.
Make sure to work with your physical therapist to make sure you
regain your former strength and mobility.
.
Keep you appointments as listed for you below.

Followup Instructions:
Eye clinic appointment at [**Last Name (un) **] [**Telephone/Fax (1) 28632**] or [**Hospital1 18**] [**Location (un) 442**]
eye clinic [**Telephone/Fax (1) 253**]



Completed by:[**2134-1-13**]
{'Disseminated candidiasis,Urinary tract infection, site not specified,Infection and inflammatory reaction due to indwelling urinary catheter,Opioid abuse, continuous,Acute kidney failure, unspecified,Chronic airway obstruction, not elsewhere classified,Congestive heart failure, unspecified,Retention of urine, unspecified,Hypotension, unspecified,Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Background diabetic retinopathy,Morbid obesity,Obstructive sleep apnea (adult)(pediatric),Depressive disorder, not elsewhere classified,Anemia of other chronic disease,Unspecified essential hypertension,Long-term (current) use of insulin,Colostomy status,Tracheostomy status,Below knee amputation status,Personal history of other diseases of circulatory system'}


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



### Clinical text :
CHIEF COMPLAINT: Lethargy, txf from OSH with presumed urosepsis

PRESENT ILLNESS: Mr. [**Known lastname **] is a 46 year old male with multiple medical problems
pertinently including DM2 and morbid obesity, being transferred
from OSH with presumed urosepsis. He presented to [**Hospital1 **] [**Location (un) 620**] on
the morning of transfer c/o 3 days of increasing lethargy and
AMS. By his report he has been feeling "out of it" for the last
3 days, but can't quite articulate why. He says he's been very
weak and actually fell once, however on further questioning and
review of the notes this has been going on for months. He denies
any headache, photophobia, neck stiffness. ROS positive for
cough over the last week or so, occasionally productive of
sputum, as well as shortness of breath, however he says this is
also a chronic problem. Denies any fevers, chills, abdominal
pain. Has a chronic foley in place for about a year and denies
any pain at the foley site or change in urine color. His
colostomy output has not changed in consistency or quantity. He
is unsure if he has had any recent medication changes, and
mentions that he takes a lot of anti-anxiety medications.
.
At the OSH he was found to be virtually unresponsive,
hypotensive to the 80s systolic. ABG 7.36/64/95 on RA. WBC was
10, with a positive UA (+nitrite, +LE, 20-50 WBC, mod bact). He
received 2L NS, vanco/zosyn and was transported to [**Hospital1 18**].
.
On arrival in the ED here, systolics were 80-90 but improved
with 2 L IVF. He had a central line placed in R groin, however
has not required pressors.
.
On arrival to the [**Hospital Unit Name 153**] the patient's vitals were 97.1, HR 53, BP
158/103, RR 11, O2 100% on 4L NC. He was responsive, albeit
sluggish.
.
Of note, patient has been treated for numerous UTIs in the past,
most recently had proteus UTI in [**11-7**], sensitive to Augmentin
and cefuroxime. Has also had pseudomonal and klebsiella UTIs in
the last 1-2 years.

MEDICAL HISTORY: 1) DM2 diagnosed [**2114**] with triopathy: Creatinine has been as low
as 0.8 in the last couple of years, however widely fluctuant, as
high as 2 in the recent past. 0.9 in [**1-7**].
2) COPD, on home O2. Multiple episodes of respiratory failure
requiring intubation in recent years. Most recently, was
admitted in [**12-6**] with a perforated transverse colon requiring
partial colectomy and transverse colostomy. This course c/b
anticipated respiratory failure and anticipatory tracheostomy,
pseudomonal and MRSA PNA. Also with acalculous cholecystitis
requiring cholecystostomy tube. Had G-tube placed.
3) OSA on CPAP
3) VRE
4) s/p tracheostomy, as above in [**1-7**]
5) HTN
6) CHF: During hospitalization in [**10-20**] it was thought that
failure contributed to his respiratory failure. Last echo was in
[**12-6**] at which time LVEF thought to be roughly normal, however
very poor study and RV not visualized. Not on lasix.
7) Anemia of chronic disease, multiple transfusions in the past

MEDICATION ON ADMISSION: Paxil 40 mg [**Hospital1 **]
Neurontin 600 mg QID
Flonase 1 spray [**Hospital1 **]
Flovent 1 puff [**Hospital1 **]
Protonix 40 mg daily
Combivent 2 puffs [**Hospital1 **]
Reglan 10 mg TID
Lantus 44 units [**Hospital1 **]
Clonidine (Catapres) 6 mg [**Hospital1 **]?
Metoprolol 100 mg [**Hospital1 **]
Klonopin 2 mg TID
Lorazepam 2 mg daily
Xanax 1 mg TID
Astelin 1 spray [**Hospital1 **]
Lasix 40 mg [**Hospital1 **]

ALLERGIES: Cephalosporins / Morphine / Fentanyl

PHYSICAL EXAM: 97.1, HR 53, BP 158/103, RR 11, O2 100% on 4L NC
Gen: Morbidly obese caucasian male appearing slightly dyspneic
but otherwise comfortable.
MS: AAO x 3, responds to questions appropriately however very
slow to respond.
HEENT: PEARL, dry MM.
Neck: JVP unable to evaluate
Cor: RR, normal rate, distant HS
Lungs: Scattered expiratory wheezes anteriorly
Abd: NABS, soft, colostomy bag with brown stool, appears C/D/I,
second ostomy with gauze C/D/I.
Extr: RLE with erythematous plaque/patch circumferentially
around distal tibia (patient reports chronic), 2+ pitting and
weeping edema with a couple of vesicles. LLE s/p BKA, stump
covered with dressing. Extremities cold.
Neuro: Moves all extremities.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Lives home alone with VNA. Denies etoh. Remote cigar smoking, no
cigarettes. No IVDU or marijuana. Has 1 brother, [**Name (NI) **]. 

### Response:
{'Disseminated candidiasis,Urinary tract infection, site not specified,Infection and inflammatory reaction due to indwelling urinary catheter,Opioid abuse, continuous,Acute kidney failure, unspecified,Chronic airway obstruction, not elsewhere classified,Congestive heart failure, unspecified,Retention of urine, unspecified,Hypotension, unspecified,Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Background diabetic retinopathy,Morbid obesity,Obstructive sleep apnea (adult)(pediatric),Depressive disorder, not elsewhere classified,Anemia of other chronic disease,Unspecified essential hypertension,Long-term (current) use of insulin,Colostomy status,Tracheostomy status,Below knee amputation status,Personal history of other diseases of circulatory system'}
