CHIEF COMPLAINT: Rigors

PRESENT ILLNESS: 68yo male with Downs Syndrome, [**Last Name (NamePattern4) 862**] disorder (last [**Last Name (NamePattern4) 862**]
[**4-/2145**]), urinary retention c/b CKD III due to urethral stricture
and neurogenic bladder, recurrent UTIs and HOCM (LVOT gradient
100mmHg) who is presenting after being seen in urology clinic
today, where [**Known lastname **] placement was unsuccessfully attempted for
PVR >1L. In clinic he was noted to have a UTI, and was sent home
with Cipro with plan for urethrotomy in the OR [**2146-1-28**]. However,
he never filled his prescription and was noted to be febrile and
rigoring at his group home. He was initially taken to [**Hospital1 3278**],
where he received a dose of Vanc, but his HCP requested transfer
to [**Hospital1 18**]. The patient's baseline state of function is very low;
but sister accompanied him to [**Hospital1 18**]. He cannot walk due to b/l
hip replacements and L hip osteomyelitis.
.
In the ED, initial VS were:
T 100.2 HR 93 BP 106/89 RR 16 O2 Sat 99% 4L Nasal Cannula
His BP was re-checked and found to be 88/49-->BP 58/66-->78/50.
IV NS was started with open, a L IJ was placed and Levophed gtt
was started. Blood and urine cultures were drawn (Vanc given at
[**Hospital1 3278**]) and the pt was started on Vanc/Zosyn. His BPs continued
to be low (65/35) and Dopamine was added, though he was not
maxed out on Levophed. Urology was consulted and placed a
suprapubic cathetar. Labs were notable for + UA, WBC 5.4 (20%
bands), INR 1.8, Cr 2.3 (baseline 1.3-1.8), HCT 29 (baseline in
low 30s) and Lactate 8.3. CXR showed no focal consolidation, EKG
showed new ST depressions II, V4-V6 as well LVH, which is
chronic. He received a total of 4L NS in the ED and was admitted
to the MICU.
.
On arrival to the MICU, initial VS were:
T 99.6 BP 104/34 HR 98 RR 21 O2 Sat 93% NC
He was making urine (500cc in bag) and mentating near his
baseline per sister, who accompanied him. An arterial line was
placed and Dopamine, Levophed, Neosynephrine and Vasopression
were required to keep MAP 65. SVO2 was 58, CVP was 5. NS was
given wide open. VBG was 7.15/46/40.

MEDICAL HISTORY: 1. Down syndrome
2. Mental retardation
3. NSETMI - recent DC on [**12-5**]
4. Hypercholesterolemia
5. s/p R hip replacement and no L hip
6. Osteoporosis
7. Seizures - generalized seizures
8. BPH
9. Hypothyroidism

MEDICATION ON ADMISSION: ATORVASTATIN [LIPITOR] - 80 mg Tablet - 1 Tablet(s) by mouth HS
(at bedtime)
BISMUTH TRIBROM-PETROLATUM,WH [XEROFORM PETROLATUM DRESSING] -
2" X 2" Bandage - use as directed in affected area
every 24 hours and as needed Dx:  decubitus ulcer
CICLOPIROX - 0.77 % Cream - Apply affected areas both feet twice
a day as directed.
CIPROFLOXACIN - 500 mg Tablet - 500 Tablet(s) by mouth twice a
day
DOUGHNUT CUSHION -   - use as directed once a day
FINASTERIDE - 5 mg Tablet - 1 Tablet(s) by mouth once a day
LEVETIRACETAM - 500 mg Tablet - 2 Tablet(s) by mouth twice   a
day
LEVOTHYROXINE - 137 mcg Tablet - 1 Tablet(s) by mouth qam
NYSTATIN - 100,000 unit/gram Powder - apply to left foot twice a
day
NYSTATIN - 100,000 unit/gram Cream - apply to affected area on
toes twice a day
OVERLAY FOR MATTRESS -   - use as directed once a day DX: Downs'
syndrome, wheel chair bound and decubitui.
PHENYTOIN SODIUM EXTENDED [DILANTIN KAPSEAL] - 100 mg Capsule -
take 1 Capsule(s) by mouth twice a day Brand name only-
medically
necessary - No Substitution
PHENYTOIN SODIUM EXTENDED [DILANTIN KAPSEAL] - 30 mg Capsule -
take 1 Capsule(s) by mouth twice a day Brand name only-
medically
necessary - No Substitution
TAMSULOSIN [FLOMAX] - 0.4 mg Capsule, Ext Release 24 hr - 1
(One)
Capsule(s) by mouth at bedtime
.
Medications - OTC
ACETAMINOPHEN -  (Dose adjustment - no new Rx) - 325 mg Tablet -
2 Tablet(s) by mouth every 4 hours as needed for mild pain
ALUM-MAG HYDROXIDE-SIMETH [MYLANTA] -  (Prescribed by Other
Provider) - Dosage uncertain
ASPIRIN [ENTERIC COATED ASPIRIN] - 81 mg Tablet, Delayed Release
(E.C.) - take 1 Tablet(s) by mouth once a day
CALCIUM CARBONATE [CALCIUM 500] - 500 mg (1,250 mg) Tablet - 2
tablets by mouth daily at 4 pm; do not provide at the same time
as his dilantin
CHOLECALCIFEROL (VITAMIN D3) - 1,000 unit Capsule - 1 Capsule(s)
by mouth daily (at 4 pm)
MENTHOL-ZINC OXIDE [MEDICATED BODY POWDER] - 0.15 %-1 % Powder -
apply topically once a day to mid thighs, and other irritated
skin
MULTIVITAMIN -   Tablet - 1 (One) Tablet(s) by mouth once a day
;
Multivitamin without calcium. Replaces rx dated [**2145-11-19**]
NEOMYCIN-BACITRACNZN-POLYMYXIN [NEOSPORIN] - 3.5 mg-400
unit-[**Unit Number **],000 unit/gram Ointment - as directed
PETROLATUM, WHITE-LANOLIN [VITAMIN A & D DIAPER RASH] -
Ointment - apply to affected area on buttocks twice a day and as
needed for moisture barrier protection

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Exam:
T 99.6 BP 104/34 HR 98 RR 21 O2 Sat 93% NC
General: Alert, anxious appearing, moderate distress
HEENT: Sclera anicteric, oropharynx clear, EOMI, PERRL
Neck: JVP below the clavicle
CV: Tachycardic, II/VI systolic murmur heard best at the apex,
no rubs or gallops
Lungs: Faint expiratory wheeze, otherwise CTAB, no increased WOB
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: suprapubic cathetar
Ext: cool, 1+ distal pulses
Skin: Mottling on the BLEs, BUEs and chest
Neuro: Alert, responds to yes/no questions, follows commands,
non verbal
.
Discharge Exam:
Expired

FAMILY HISTORY: There is no family history of premature coronary artery disease
or sudden death.

SOCIAL HISTORY: Lives in a group home - wheelchair bound.  [**First Name4 (NamePattern1) **] [**Known lastname 8389**] is the
HCP ([**Telephone/Fax (1) 21968**]).  No tobacco, EtOH or drug hx.
Unspecified septicemia,Septic shock,Acute respiratory failure,Defibrination syndrome,Subendocardial infarction, initial episode of care,Acute kidney failure with lesion of tubular necrosis,Acidosis,Urinary tract infection, site not specified,Hypertrophic obstructive cardiomyopathy,Severe sepsis,Thrombocytopenia, unspecified,Epilepsy, unspecified, without mention of intractable epilepsy,Urethral stricture, unspecified,Down's syndrome,Chronic kidney disease, Stage III (moderate),Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS),Retention of urine, unspecified,Unspecified acquired hypothyroidism,Neurogenic bladder NOS,Hip joint replacement,Osteoporosis, unspecified
Septicemia NOS,Septic shock,Acute respiratry failure,Defibrination syndrome,Subendo infarct, initial,Ac kidny fail, tubr necr,Acidosis,Urin tract infection NOS,Hyprtrophc obst cardiomy,Severe sepsis,Thrombocytopenia NOS,Epilep NOS w/o intr epil,Urethral stricture NOS,Down's syndrome,Chr kidney dis stage III,BPH w urinary obs/LUTS,Retention urine NOS,Hypothyroidism NOS,Neurogenic bladder NOS,Joint replaced hip,Osteoporosis NOS
Admission Date:  [**2146-1-26**]              Discharge Date:   [**2146-1-30**]

Date of Birth:  [**2078-9-26**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Rigors

Major Surgical or Invasive Procedure:
Intubation and Mechanical Ventilation
Central Venous Line Placement
Arterial Line Placement

History of Present Illness:
68yo male with Downs Syndrome, [**Last Name (NamePattern4) 862**] disorder (last [**Last Name (NamePattern4) 862**]
[**4-/2145**]), urinary retention c/b CKD III due to urethral stricture
and neurogenic bladder, recurrent UTIs and HOCM (LVOT gradient
100mmHg) who is presenting after being seen in urology clinic
today, where [**Known lastname **] placement was unsuccessfully attempted for
PVR >1L. In clinic he was noted to have a UTI, and was sent home
with Cipro with plan for urethrotomy in the OR [**2146-1-28**]. However,
he never filled his prescription and was noted to be febrile and
rigoring at his group home. He was initially taken to [**Hospital1 3278**],
where he received a dose of Vanc, but his HCP requested transfer
to [**Hospital1 18**]. The patient's baseline state of function is very low;
but sister accompanied him to [**Hospital1 18**]. He cannot walk due to b/l
hip replacements and L hip osteomyelitis.
.
In the ED, initial VS were:
T 100.2 HR 93 BP 106/89 RR 16 O2 Sat 99% 4L Nasal Cannula
His BP was re-checked and found to be 88/49-->BP 58/66-->78/50.
IV NS was started with open, a L IJ was placed and Levophed gtt
was started. Blood and urine cultures were drawn (Vanc given at
[**Hospital1 3278**]) and the pt was started on Vanc/Zosyn. His BPs continued
to be low (65/35) and Dopamine was added, though he was not
maxed out on Levophed. Urology was consulted and placed a
suprapubic cathetar. Labs were notable for + UA, WBC 5.4 (20%
bands), INR 1.8, Cr 2.3 (baseline 1.3-1.8), HCT 29 (baseline in
low 30s) and Lactate 8.3. CXR showed no focal consolidation, EKG
showed new ST depressions II, V4-V6 as well LVH, which is
chronic. He received a total of 4L NS in the ED and was admitted
to the MICU.
.
On arrival to the MICU, initial VS were:
T 99.6 BP 104/34 HR 98 RR 21 O2 Sat 93% NC
He was making urine (500cc in bag) and mentating near his
baseline per sister, who accompanied him. An arterial line was
placed and Dopamine, Levophed, Neosynephrine and Vasopression
were required to keep MAP 65. SVO2 was 58, CVP was 5. NS was
given wide open. VBG was 7.15/46/40.


Past Medical History:
1. Down syndrome
2. Mental retardation
3. NSETMI - recent DC on [**12-5**]
4. Hypercholesterolemia
5. s/p R hip replacement and no L hip
6. Osteoporosis
7. Seizures - generalized seizures
8. BPH
9. Hypothyroidism



Social History:
Lives in a group home - wheelchair bound.  [**First Name4 (NamePattern1) **] [**Known lastname 8389**] is the
HCP ([**Telephone/Fax (1) 21968**]).  No tobacco, EtOH or drug hx.


Family History:
There is no family history of premature coronary artery disease
or sudden death.

Physical Exam:
Admission Exam:
T 99.6 BP 104/34 HR 98 RR 21 O2 Sat 93% NC
General: Alert, anxious appearing, moderate distress
HEENT: Sclera anicteric, oropharynx clear, EOMI, PERRL
Neck: JVP below the clavicle
CV: Tachycardic, II/VI systolic murmur heard best at the apex,
no rubs or gallops
Lungs: Faint expiratory wheeze, otherwise CTAB, no increased WOB
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: suprapubic cathetar
Ext: cool, 1+ distal pulses
Skin: Mottling on the BLEs, BUEs and chest
Neuro: Alert, responds to yes/no questions, follows commands,
non verbal
.
Discharge Exam:
Expired


Pertinent Results:
Admission Labs:

[**2146-1-26**] 09:15PM BLOOD WBC-5.4 RBC-2.88* Hgb-9.8* Hct-29.2*
MCV-101* MCH-34.1* MCHC-33.6 RDW-14.7 Plt Ct-71*
[**2146-1-26**] 09:15PM BLOOD Neuts-76* Bands-20* Lymphs-2* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1* NRBC-2*
[**2146-1-26**] 09:15PM BLOOD Hypochr-NORMAL Anisocy-1+
Poiklo-OCCASIONAL Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL
Ovalocy-OCCASIONAL Burr-OCCASIONAL
[**2146-1-26**] 09:47PM BLOOD PT-19.2* PTT-46.8* INR(PT)-1.8*
[**2146-1-27**] 12:50AM BLOOD Fibrino-115*
[**2146-1-26**] 09:15PM BLOOD Glucose-109* UreaN-37* Creat-2.3* Na-139
K-3.7 Cl-105 HCO3-18* AnGap-20
[**2146-1-27**] 12:50AM BLOOD ALT-47* AST-71* LD(LDH)-418* CK(CPK)-655*
AlkPhos-68 TotBili-0.8
[**2146-1-27**] 12:50AM BLOOD CK-MB-23* MB Indx-3.5 cTropnT-0.34*
[**2146-1-27**] 12:50AM BLOOD Albumin-2.3* Calcium-6.1* Phos-2.6*
Mg-1.3*
[**2146-1-27**] 01:54PM BLOOD D-Dimer->[**Numeric Identifier 3652**]
[**2146-1-27**] 12:50AM BLOOD Cortsol-27.0*
[**2146-1-27**] 06:36AM BLOOD Phenyto-6.0* Phenyfr-PND
[**2146-1-27**] 01:06AM BLOOD Type-[**Last Name (un) **] Temp-37.6 pO2-40* pCO2-46*
pH-7.15* calTCO2-17* Base XS--13 Intubat-NOT INTUBA
[**2146-1-26**] 09:44PM BLOOD Lactate-8.3*
[**2146-1-27**] 01:06AM BLOOD freeCa-0.96*
.
TTE ([**2146-1-27**]): The left atrium is mildly dilated. There is
moderate symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). There is a moderate resting left
ventricular outflow tract obstruction (40 mmHg). The findings
are consistent with hypertrophic obstructive cardiomyopathy
(HOCM). Right ventricular chamber size and free wall motion are
normal. The diameters of aorta at the sinus, ascending and arch
levels are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. There is
systolic anterior motion of the mitral valve leaflets. A late
systolic jet of eccentric, moderate to severe (3+) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.

IMPRESSION: Hypertrophic obstructive cardiomyopathy with
moderate resting LVOT obstruction. Moderate to severe late
systolic functional mitral regurgitation. Moderate tricuspid
regurgitation. Mild pulmonary hypertension.
.
CXR ([**2146-1-27**]):
1. Left internal jugular catheter with tip in the region of the
junction of the left brachiocephalic vein and high superior vena
cava with possible hematoma along the medial left
brachiocephalic vein. Close clinical observation is recommended.

2. Mild to moderate pulmonary edema.
.
CXR ([**2146-1-27**]):
1. ET tube is 3.6 cm above the carina.
2. Increased atelectasis in the right upper lobe compared to the
prior
examination.
3. Stable consolidation in the right perihilar region, unchanged
from the
prior examination.
4. Mild-to-moderate pulmonary edema is unchanged from the prior
examination.
.
Abd Ultrasound ([**2146-1-28**]):
1. Small amount of ascites.
2. Partially imaged left pleural effusion.
3. Resolution of previously seen bilateral hydronephrosis.
4. No evidence of intra-abdominal abscess or renal stone.
.
Discharge Labs:
Pt made CMO, expired

Brief Hospital Course:
Primary Reason for Admission: 67 y/o man with fever, rigors,
positive UA and hypotension concerning for urosepsis admitted to
the MICU for hypotension.
.
Active Problems:
.
# Hypotension: Likely septic shock given elevated lactate,
rigors, fever and likely urinary source. On admission to the
MICU, Levophed, Vasopressin, Dopamine and Phenyleprine were
required to maintain MAP >65. The pt received aggressive IVF
recussittaion with NS; a total of 16L in the first 24 hours. He
also received 100mg IV Hydrocortisone x1 on admission for
refractory hypotension in the setting of septic shock. A random
cortisol was checked and was normal, and stress steroids were
discontinued. His urine cultures grew [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] and Proteus
Mirabilis, both sensitive to Meropenem, which he had been on for
3 days at the time of culture/sensitivity results. He contined
to require [**1-23**] pressors despite appropriate antibiotic therapy
and correction of acidosis. He was made CMO on [**2146-1-30**] and died
withing minutes of extubation and cessation of pressors.
.
# Respiratory Failure: Six hours after admission, the pt became
increaasingly acidotic and had increased WOB. He was unable to
mount a respiratory response to his metabolic acidosis and was
therefore intubated. He was started on ARDSNET protocol given
his pulmonary edema. He was terminally extubated on [**2146-1-30**] with
family at the bedside.
.
# NSTEMI: Troponinemia and ST depressions in V4-V6 are most
likely due to demand ischemia in the setting of hypotension and
known structural heart disease. His troponins and CKMB were
trended and contiunued to increase throughout the first 24 hours
of his hospital course (MB peak 42, Trop peak 2.06). TTE on HD 1
showed normal LV regional wall motion, severe MR, moderate TR
and mild pulmonary HTN. His home ASA was continued, no Heparin
or Plavix given.
.
# DIC: Thrombocytopenia likely consumptive in the setting of
septic shock. Given his elevated PT/PTT/INR, concern was for
DIC. Fibrinogen was low and fibrin degredation products were
high, consistent with DIC. He had intermittent bleeding from his
suprapubic cathetar, but otherwise had no bleeding; HCTs
remained stable. Hematology was asked to comment on
Cryoprecipitate tranfusion threshold and recommended giving
Cryoprecipitate for Fibrinogen <100. His fibrinogen was trended
and normalized. No blood/plasma products were given.
.
# Metabolic Acidosis: On admission, pt had an anion gap
acidosis, likely due to elevated lactate in the setting of
severe septic shock. Given aggressive IVF recussitation with NS,
pt also developed a non-gap hyperchloremic metabolic acidosis.
Mr [**Known lastname 8389**] was unable to mount an appropriate compensatory
respiratory response and was intubated for worsening acidosis.
He was also started on a NaHCO3 gtt and received intermittent
HCO3 ampules to stabilize his pH. By HD 3, his pH had
normalized.
.
# Fever: Pt was noted to be febrile in the ED and was started on
Vanc/Zosyn. Presumed source was GU tract given known UTI and
instrumentation of his urethra in [**Hospital 159**] clinic the day of
admission. Pt has grown Vanc sensitive Enterococcus in the past.
No clear pulmonary source, no other localizing complaints.
Antibiotics were broadened to Dapto/Meroprnem given his clinical
deterioration and increasing WBC count. Urine cultures grew E
coli and Proteus, both susceptible to Meropenem. Renal
ultrasound was negative for renal abscess. He defervesced by HD
#1 and his Dapto/[**Last Name (un) **] were continued until he was made CMO on
[**2146-1-30**].
.
# Acute on Chronic Renal Failure: Likely related to
hypoperfusion and septic shock.
His UOP was marginal throughout his course and renal was
consulted. Perparations were made for CVVH, which was never
initiated, as the pt was made CMO.
.
Chronic Problems:
.
# HOCM: Pt with known HOCM and significant LOVT gradient of
100mm Hg. As such, he is preload dependent, making aggressive
IVF recussitation all the more important to maintain adequate
perfusion.
.
# [**Date Range **] Disorder: No recent seizures (last [**4-/2145**]); there was
question of [**Year (4 digits) 862**] today at [**Hospital3 **] facility, but per
sister, was more likely rigors and not typical of his seizures.
- cont Dilantin 260mg po qday
- cont Levetiracetam 2000mg po qday
.
Transitional Issues: Pt expited at 12:20 with family at the
bedside within minutes of being made CMO. Family declined
autopsy.


Medications on Admission:
ATORVASTATIN [LIPITOR] - 80 mg Tablet - 1 Tablet(s) by mouth HS
(at bedtime)
BISMUTH TRIBROM-PETROLATUM,WH [XEROFORM PETROLATUM DRESSING] -
2" X 2" Bandage - use as directed in affected area
every 24 hours and as needed Dx:  decubitus ulcer
CICLOPIROX - 0.77 % Cream - Apply affected areas both feet twice
a day as directed.
CIPROFLOXACIN - 500 mg Tablet - 500 Tablet(s) by mouth twice a
day
DOUGHNUT CUSHION -   - use as directed once a day
FINASTERIDE - 5 mg Tablet - 1 Tablet(s) by mouth once a day
LEVETIRACETAM - 500 mg Tablet - 2 Tablet(s) by mouth twice   a
day
LEVOTHYROXINE - 137 mcg Tablet - 1 Tablet(s) by mouth qam
NYSTATIN - 100,000 unit/gram Powder - apply to left foot twice a
day
NYSTATIN - 100,000 unit/gram Cream - apply to affected area on
toes twice a day
OVERLAY FOR MATTRESS -   - use as directed once a day DX: Downs'
syndrome, wheel chair bound and decubitui.
PHENYTOIN SODIUM EXTENDED [DILANTIN KAPSEAL] - 100 mg Capsule -
take 1 Capsule(s) by mouth twice a day Brand name only-
medically
necessary - No Substitution
PHENYTOIN SODIUM EXTENDED [DILANTIN KAPSEAL] - 30 mg Capsule -
take 1 Capsule(s) by mouth twice a day Brand name only-
medically
necessary - No Substitution
TAMSULOSIN [FLOMAX] - 0.4 mg Capsule, Ext Release 24 hr - 1
(One)
Capsule(s) by mouth at bedtime
.
Medications - OTC
ACETAMINOPHEN -  (Dose adjustment - no new Rx) - 325 mg Tablet -
2 Tablet(s) by mouth every 4 hours as needed for mild pain
ALUM-MAG HYDROXIDE-SIMETH [MYLANTA] -  (Prescribed by Other
Provider) - Dosage uncertain
ASPIRIN [ENTERIC COATED ASPIRIN] - 81 mg Tablet, Delayed Release
(E.C.) - take 1 Tablet(s) by mouth once a day
CALCIUM CARBONATE [CALCIUM 500] - 500 mg (1,250 mg) Tablet - 2
tablets by mouth daily at 4 pm; do not provide at the same time
as his dilantin
CHOLECALCIFEROL (VITAMIN D3) - 1,000 unit Capsule - 1 Capsule(s)
by mouth daily (at 4 pm)
MENTHOL-ZINC OXIDE [MEDICATED BODY POWDER] - 0.15 %-1 % Powder -
apply topically once a day to mid thighs, and other irritated
skin
MULTIVITAMIN -   Tablet - 1 (One) Tablet(s) by mouth once a day
;
Multivitamin without calcium. Replaces rx dated [**2145-11-19**]
NEOMYCIN-BACITRACNZN-POLYMYXIN [NEOSPORIN] - 3.5 mg-400
unit-[**Unit Number **],000 unit/gram Ointment - as directed
PETROLATUM, WHITE-LANOLIN [VITAMIN A & D DIAPER RASH] -
Ointment - apply to affected area on buttocks twice a day and as
needed for moisture barrier protection


Discharge Medications:
Expired

Discharge Disposition:
Expired

Discharge Diagnosis:
Expired

Discharge Condition:
Expired

Discharge Instructions:
Expired

Followup Instructions:
Expired

                             [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
{"Unspecified septicemia,Septic shock,Acute respiratory failure,Defibrination syndrome,Subendocardial infarction, initial episode of care,Acute kidney failure with lesion of tubular necrosis,Acidosis,Urinary tract infection, site not specified,Hypertrophic obstructive cardiomyopathy,Severe sepsis,Thrombocytopenia, unspecified,Epilepsy, unspecified, without mention of intractable epilepsy,Urethral stricture, unspecified,Down's syndrome,Chronic kidney disease, Stage III (moderate),Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS),Retention of urine, unspecified,Unspecified acquired hypothyroidism,Neurogenic bladder NOS,Hip joint replacement,Osteoporosis, unspecified"}


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



### Clinical text :
CHIEF COMPLAINT: Rigors

PRESENT ILLNESS: 68yo male with Downs Syndrome, [**Last Name (NamePattern4) 862**] disorder (last [**Last Name (NamePattern4) 862**]
[**4-/2145**]), urinary retention c/b CKD III due to urethral stricture
and neurogenic bladder, recurrent UTIs and HOCM (LVOT gradient
100mmHg) who is presenting after being seen in urology clinic
today, where [**Known lastname **] placement was unsuccessfully attempted for
PVR >1L. In clinic he was noted to have a UTI, and was sent home
with Cipro with plan for urethrotomy in the OR [**2146-1-28**]. However,
he never filled his prescription and was noted to be febrile and
rigoring at his group home. He was initially taken to [**Hospital1 3278**],
where he received a dose of Vanc, but his HCP requested transfer
to [**Hospital1 18**]. The patient's baseline state of function is very low;
but sister accompanied him to [**Hospital1 18**]. He cannot walk due to b/l
hip replacements and L hip osteomyelitis.
.
In the ED, initial VS were:
T 100.2 HR 93 BP 106/89 RR 16 O2 Sat 99% 4L Nasal Cannula
His BP was re-checked and found to be 88/49-->BP 58/66-->78/50.
IV NS was started with open, a L IJ was placed and Levophed gtt
was started. Blood and urine cultures were drawn (Vanc given at
[**Hospital1 3278**]) and the pt was started on Vanc/Zosyn. His BPs continued
to be low (65/35) and Dopamine was added, though he was not
maxed out on Levophed. Urology was consulted and placed a
suprapubic cathetar. Labs were notable for + UA, WBC 5.4 (20%
bands), INR 1.8, Cr 2.3 (baseline 1.3-1.8), HCT 29 (baseline in
low 30s) and Lactate 8.3. CXR showed no focal consolidation, EKG
showed new ST depressions II, V4-V6 as well LVH, which is
chronic. He received a total of 4L NS in the ED and was admitted
to the MICU.
.
On arrival to the MICU, initial VS were:
T 99.6 BP 104/34 HR 98 RR 21 O2 Sat 93% NC
He was making urine (500cc in bag) and mentating near his
baseline per sister, who accompanied him. An arterial line was
placed and Dopamine, Levophed, Neosynephrine and Vasopression
were required to keep MAP 65. SVO2 was 58, CVP was 5. NS was
given wide open. VBG was 7.15/46/40.

MEDICAL HISTORY: 1. Down syndrome
2. Mental retardation
3. NSETMI - recent DC on [**12-5**]
4. Hypercholesterolemia
5. s/p R hip replacement and no L hip
6. Osteoporosis
7. Seizures - generalized seizures
8. BPH
9. Hypothyroidism

MEDICATION ON ADMISSION: ATORVASTATIN [LIPITOR] - 80 mg Tablet - 1 Tablet(s) by mouth HS
(at bedtime)
BISMUTH TRIBROM-PETROLATUM,WH [XEROFORM PETROLATUM DRESSING] -
2" X 2" Bandage - use as directed in affected area
every 24 hours and as needed Dx:  decubitus ulcer
CICLOPIROX - 0.77 % Cream - Apply affected areas both feet twice
a day as directed.
CIPROFLOXACIN - 500 mg Tablet - 500 Tablet(s) by mouth twice a
day
DOUGHNUT CUSHION -   - use as directed once a day
FINASTERIDE - 5 mg Tablet - 1 Tablet(s) by mouth once a day
LEVETIRACETAM - 500 mg Tablet - 2 Tablet(s) by mouth twice   a
day
LEVOTHYROXINE - 137 mcg Tablet - 1 Tablet(s) by mouth qam
NYSTATIN - 100,000 unit/gram Powder - apply to left foot twice a
day
NYSTATIN - 100,000 unit/gram Cream - apply to affected area on
toes twice a day
OVERLAY FOR MATTRESS -   - use as directed once a day DX: Downs'
syndrome, wheel chair bound and decubitui.
PHENYTOIN SODIUM EXTENDED [DILANTIN KAPSEAL] - 100 mg Capsule -
take 1 Capsule(s) by mouth twice a day Brand name only-
medically
necessary - No Substitution
PHENYTOIN SODIUM EXTENDED [DILANTIN KAPSEAL] - 30 mg Capsule -
take 1 Capsule(s) by mouth twice a day Brand name only-
medically
necessary - No Substitution
TAMSULOSIN [FLOMAX] - 0.4 mg Capsule, Ext Release 24 hr - 1
(One)
Capsule(s) by mouth at bedtime
.
Medications - OTC
ACETAMINOPHEN -  (Dose adjustment - no new Rx) - 325 mg Tablet -
2 Tablet(s) by mouth every 4 hours as needed for mild pain
ALUM-MAG HYDROXIDE-SIMETH [MYLANTA] -  (Prescribed by Other
Provider) - Dosage uncertain
ASPIRIN [ENTERIC COATED ASPIRIN] - 81 mg Tablet, Delayed Release
(E.C.) - take 1 Tablet(s) by mouth once a day
CALCIUM CARBONATE [CALCIUM 500] - 500 mg (1,250 mg) Tablet - 2
tablets by mouth daily at 4 pm; do not provide at the same time
as his dilantin
CHOLECALCIFEROL (VITAMIN D3) - 1,000 unit Capsule - 1 Capsule(s)
by mouth daily (at 4 pm)
MENTHOL-ZINC OXIDE [MEDICATED BODY POWDER] - 0.15 %-1 % Powder -
apply topically once a day to mid thighs, and other irritated
skin
MULTIVITAMIN -   Tablet - 1 (One) Tablet(s) by mouth once a day
;
Multivitamin without calcium. Replaces rx dated [**2145-11-19**]
NEOMYCIN-BACITRACNZN-POLYMYXIN [NEOSPORIN] - 3.5 mg-400
unit-[**Unit Number **],000 unit/gram Ointment - as directed
PETROLATUM, WHITE-LANOLIN [VITAMIN A & D DIAPER RASH] -
Ointment - apply to affected area on buttocks twice a day and as
needed for moisture barrier protection

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Exam:
T 99.6 BP 104/34 HR 98 RR 21 O2 Sat 93% NC
General: Alert, anxious appearing, moderate distress
HEENT: Sclera anicteric, oropharynx clear, EOMI, PERRL
Neck: JVP below the clavicle
CV: Tachycardic, II/VI systolic murmur heard best at the apex,
no rubs or gallops
Lungs: Faint expiratory wheeze, otherwise CTAB, no increased WOB
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: suprapubic cathetar
Ext: cool, 1+ distal pulses
Skin: Mottling on the BLEs, BUEs and chest
Neuro: Alert, responds to yes/no questions, follows commands,
non verbal
.
Discharge Exam:
Expired

FAMILY HISTORY: There is no family history of premature coronary artery disease
or sudden death.

SOCIAL HISTORY: Lives in a group home - wheelchair bound.  [**First Name4 (NamePattern1) **] [**Known lastname 8389**] is the
HCP ([**Telephone/Fax (1) 21968**]).  No tobacco, EtOH or drug hx. 

### Response:
{"Unspecified septicemia,Septic shock,Acute respiratory failure,Defibrination syndrome,Subendocardial infarction, initial episode of care,Acute kidney failure with lesion of tubular necrosis,Acidosis,Urinary tract infection, site not specified,Hypertrophic obstructive cardiomyopathy,Severe sepsis,Thrombocytopenia, unspecified,Epilepsy, unspecified, without mention of intractable epilepsy,Urethral stricture, unspecified,Down's syndrome,Chronic kidney disease, Stage III (moderate),Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS),Retention of urine, unspecified,Unspecified acquired hypothyroidism,Neurogenic bladder NOS,Hip joint replacement,Osteoporosis, unspecified"}
