CHIEF COMPLAINT: Fever, hypotension

PRESENT ILLNESS: 68M with h/o t4 paraplegia x 2yrs, felt [**3-13**] "inflammatory spinal
disease", with a chronic indwelling foley, sacral decubitus
ulcers, presents to [**Hospital1 18**] from rehab after RN noted 1d of fever
(tmax 101.8).  [**Name8 (MD) **] RN caring for pt at rehab, pt noted some mild
abdominal discomfort (chronic), but otherwise denied any recent
symptoms of cough, n/v, constipation, rash.  Pt has been having
chronic diarrhea (x3/day, x2-3/night) for past 1yr, etiology
unclear.  [**Name2 (NI) 227**] persistent fevers x24hrs, pt was brought to
[**Hospital1 18**] ED.  [**Name8 (MD) **] RN BP prior to leaving rehab was 100/72.
.
Per pt, he notes chronic abdominal pain, "always there",
diffuse, sharp, sometimes awakening him from sleep, no relation
to food or BMs.  somewhat worse over the preceding 4 months, but
actually improving over the past few days.  At present, he
states his pain has completely resolved.   ROS otherwise
significant for +orthopnea, pt also notes nonproductive cough x
3 weeks, no flu sx (body aches, congestion, sore throat).  Pt
denies flut shot or pneumovax.  +sick contacts (lives in [**Hospital 100**]
Rehab).
.
Upon arrival in ED VS=100.4  100  87/51  12  95%RA.  UA was c/w
UTI, pt was started on vanco and zosyn, UCx and BCx sent.
sacral ulcers felt to be stage 4, no evidence of superinfection.
 BP initially responded to 3L IVF (99/53), however after 3rd
litre, BP down to 85/40, pt therefore received RIJ TLC, and
possibly an additional 1L IVF bolus, afterwhich BP improved to
115/70.  Pt was asymptomatic, mentating throughout without
specific complaints.
.
Pt also noted moderate abdominal tenderness.  CT ABD done which
showed no acute processes.  CXR unremarkable, EKG unremarkable
(old Q in III, ?mild ST changes V1).
.
Pt admitted to ICU for further monitoring given hypotension.
.

MEDICAL HISTORY: 1. Inflammatory disease of the spinal cord of uncertain
etiology.  MRA [**10-16**] negative for vascular malformation.  Initial
CSF analysis showed elevated protein (82) without oligoclonal
bands.  NMO blood titer negative, RPR negative, Lyme serology
negative, [**Doctor First Name **] negative, Ro and La negative, ACE level normal,
neuromyelitis IgG negative, ESR 70, CRP 66.8.  Ultimately
treated with broad spectrum antibiotics, corticosteroids (two
weeks of Solu-Medrol followed by a prednisone taper), and 5 days
of mannitol without improvement.  He is followed by neurology
for a dense paraplegia (T4) with neuropathic pain, restrictive
shoulder arthropathy, and a neurogenic bladder requiring a
chronic indwelling foley.
2. Chronic sacral decubitus ulcer, previously treated with a VAC
dressing
3. Multiple UTI (including Pseudomonas)
4. Pulmonary embolus [**11-15**] s/p IVC filter placement
5. Asthma
6. Two-vessel coronary artery disease s/p CABG 4-5 years ago
7. Systolic CHF (EF 25-30% on [**2-15**] TTE)
8. Repaired liver laceration
9. Chronic back pain
10. Vitiligo
11. Feeding tube
12. Depression
13. MRSA from sacral swab and sputum
14. Prior transient episodes of leg paralysis
15. Right frontal lobe brain lesion biopsied [**11-15**] and c/w
gliosis; resolved on repeat imaging
16. Abnormal visual evoked potentials

MEDICATION ON ADMISSION: vitamin c 500mg po qdaily
aspirin 81mg po qdaily
baclofen 5mg po tid
calcium carbonate 650mg po bid
citalopram 40mg po qdaily
pepcid 20mg po qdaily
advair 250/50 IH [**Hospital1 **]
gabapentin 400mg po bid
simethicone 80mg po tid
simvastatin 40mg po qdaily
tramadol 25mg po tid
ursodiol 300mg po qdaily
warfarin 3mg po qdaily
prostat 30ml oral [**Hospital1 **] (liquid protein supplement)
.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 96.6  85 105/66  15 100%2L
Gen: Well appearing male in NAD lying in bed.
HEENT: JVD <6-8cm, MMM, lips slightly pale.
Chest: CTA bilaterally, no w/r/r.
CV: RRR, physiologic splitting S2, no r/g.  3/6 SEM @ LSB.
Abd: Soft, nontender to deep palpation in all four quadrants,
distended, tympanic (?gas), negative murphys sign, well-healed
midline g-tube scar.
Extremities: Warm, well perfused, no C/C. [**2-10**]+ edema bilaterally
to knees.
Skin: Vitiligo on hands. Large round 6x4 cm diameter pressure
decubitus ulcer on sacrum and 4x3cm decub ulcer on left ischial
tuberosity.  Appears clean with granulation tissue in center, no
s/sx of infection.  no purulent drainage.
Neuro: CN grossly intact. A&O x 3, pleasantly conversant.

FAMILY HISTORY: No stroke, aneurysm, no seizure, no AAA.

SOCIAL HISTORY: He moved here from [**Country 3594**] (after living in many different
countries) in the [**2068**].  He is retired from a job in the
maritime industry.  Divorced 24 years ago.  Three children.
Quit smoking [**2076**].  Quit drinking [**2080**].  No history of illicit
drug use or abuse.
Infection and inflammatory reaction due to indwelling urinary catheter,Unspecified septicemia,Sepsis,Paraplegia,Pressure ulcer, lower back,Chronic systolic heart failure,Urinary tract infection, site not specified,Aortocoronary bypass status,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants
React-indwell urin cath,Septicemia NOS,Sepsis,Paraplegia NOS,Pressure ulcer, low back,Chr systolic hrt failure,Urin tract infection NOS,Aortocoronary bypass,Hx-ven thrombosis/embols,Long-term use anticoagul
Admission Date:  [**2106-4-6**]              Discharge Date:   [**2106-4-15**]

Date of Birth:  [**2038-4-1**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Fever, hypotension

Major Surgical or Invasive Procedure:
Bedside debridement of ulcerations by plastic surgery team


History of Present Illness:
68M with h/o t4 paraplegia x 2yrs, felt [**3-13**] "inflammatory spinal
disease", with a chronic indwelling foley, sacral decubitus
ulcers, presents to [**Hospital1 18**] from rehab after RN noted 1d of fever
(tmax 101.8).  [**Name8 (MD) **] RN caring for pt at rehab, pt noted some mild
abdominal discomfort (chronic), but otherwise denied any recent
symptoms of cough, n/v, constipation, rash.  Pt has been having
chronic diarrhea (x3/day, x2-3/night) for past 1yr, etiology
unclear.  [**Name2 (NI) 227**] persistent fevers x24hrs, pt was brought to
[**Hospital1 18**] ED.  [**Name8 (MD) **] RN BP prior to leaving rehab was 100/72.
.
Per pt, he notes chronic abdominal pain, "always there",
diffuse, sharp, sometimes awakening him from sleep, no relation
to food or BMs.  somewhat worse over the preceding 4 months, but
actually improving over the past few days.  At present, he
states his pain has completely resolved.   ROS otherwise
significant for +orthopnea, pt also notes nonproductive cough x
3 weeks, no flu sx (body aches, congestion, sore throat).  Pt
denies flut shot or pneumovax.  +sick contacts (lives in [**Hospital 100**]
Rehab).
.
Upon arrival in ED VS=100.4  100  87/51  12  95%RA.  UA was c/w
UTI, pt was started on vanco and zosyn, UCx and BCx sent.
sacral ulcers felt to be stage 4, no evidence of superinfection.
 BP initially responded to 3L IVF (99/53), however after 3rd
litre, BP down to 85/40, pt therefore received RIJ TLC, and
possibly an additional 1L IVF bolus, afterwhich BP improved to
115/70.  Pt was asymptomatic, mentating throughout without
specific complaints.
.
Pt also noted moderate abdominal tenderness.  CT ABD done which
showed no acute processes.  CXR unremarkable, EKG unremarkable
(old Q in III, ?mild ST changes V1).
.
Pt admitted to ICU for further monitoring given hypotension.
.

Past Medical History:
1. Inflammatory disease of the spinal cord of uncertain
etiology.  MRA [**10-16**] negative for vascular malformation.  Initial
CSF analysis showed elevated protein (82) without oligoclonal
bands.  NMO blood titer negative, RPR negative, Lyme serology
negative, [**Doctor First Name **] negative, Ro and La negative, ACE level normal,
neuromyelitis IgG negative, ESR 70, CRP 66.8.  Ultimately
treated with broad spectrum antibiotics, corticosteroids (two
weeks of Solu-Medrol followed by a prednisone taper), and 5 days
of mannitol without improvement.  He is followed by neurology
for a dense paraplegia (T4) with neuropathic pain, restrictive
shoulder arthropathy, and a neurogenic bladder requiring a
chronic indwelling foley.
2. Chronic sacral decubitus ulcer, previously treated with a VAC
dressing
3. Multiple UTI (including Pseudomonas)
4. Pulmonary embolus [**11-15**] s/p IVC filter placement
5. Asthma
6. Two-vessel coronary artery disease s/p CABG 4-5 years ago
7. Systolic CHF (EF 25-30% on [**2-15**] TTE)
8. Repaired liver laceration
9. Chronic back pain
10. Vitiligo
11. Feeding tube
12. Depression
13. MRSA from sacral swab and sputum
14. Prior transient episodes of leg paralysis
15. Right frontal lobe brain lesion biopsied [**11-15**] and c/w
gliosis; resolved on repeat imaging
16. Abnormal visual evoked potentials

Social History:
He moved here from [**Country 3594**] (after living in many different
countries) in the [**2068**].  He is retired from a job in the
maritime industry.  Divorced 24 years ago.  Three children.
Quit smoking [**2076**].  Quit drinking [**2080**].  No history of illicit
drug use or abuse.


Family History:
No stroke, aneurysm, no seizure, no AAA.

Physical Exam:
VS: 96.6  85 105/66  15 100%2L
Gen: Well appearing male in NAD lying in bed.
HEENT: JVD <6-8cm, MMM, lips slightly pale.
Chest: CTA bilaterally, no w/r/r.
CV: RRR, physiologic splitting S2, no r/g.  3/6 SEM @ LSB.
Abd: Soft, nontender to deep palpation in all four quadrants,
distended, tympanic (?gas), negative murphys sign, well-healed
midline g-tube scar.
Extremities: Warm, well perfused, no C/C. [**2-10**]+ edema bilaterally
to knees.
Skin: Vitiligo on hands. Large round 6x4 cm diameter pressure
decubitus ulcer on sacrum and 4x3cm decub ulcer on left ischial
tuberosity.  Appears clean with granulation tissue in center, no
s/sx of infection.  no purulent drainage.
Neuro: CN grossly intact. A&O x 3, pleasantly conversant.


Pertinent Results:
[**2106-4-5**] 11:50PM BLOOD WBC-9.08 RBC-4.37* Hgb-11.2* Hct-34.9*
MCV-80* MCH-25.6* MCHC-32.0 RDW-15.1
[**2106-4-8**] 04:47AM BLOOD WBC-6.7 RBC-3.49* Hgb-8.9* Hct-28.5*
MCV-82 MCH-25.6* MCHC-31.4 RDW-14.9
[**2106-4-5**] 11:50PM BLOOD Glucose-125* UreaN-11 Creat-0.5 Na-137
K-4.0 Cl-101 HCO3-27 AnGap-13
[**2106-4-8**] 04:47AM BLOOD Glucose-109* UreaN-5* Creat-0.4* Na-139
K-3.7 Cl-110* HCO3-23 AnGap-10
[**2106-4-6**] 10:27PM BLOOD CK-MB-5 cTropnT-0.08*
[**2106-4-6**] 08:11AM BLOOD cTropnT-0.08*
[**2106-4-5**] 11:50PM BLOOD CK-MB-NotDone cTropnT-0.09*
[**2106-4-8**] 04:47AM BLOOD Calcium-8.2* Phos-3.0 Mg-2.0
[**2106-4-6**] 12:05PM BLOOD Cortsol-15.3
[**2106-4-6**] 12:05PM BLOOD CRP-122.0*
[**2106-4-6**] 01:45PM BLOOD Lactate-1.4
[**2106-4-6**] 12:00PM BLOOD Lactate-0.7
[**2106-4-6**] 12:02AM BLOOD Lactate-1.7

CT ABD/Pelv [**2106-4-6**]:
1. Severe sacral and right ischial tuberosity decubitus ulcers.
2. No acute intra-abdominal inflammatory process.
3. Cholelithiasis.

CXR [**4-6**] Bedside frontal chest radiograph is compared to
[**2106-1-2**] and demonstrate clear lungs, normal pulmonary
vasculature, and no evidence for pleural effusions. The heart
and mediastinal contours, remarkable for tortuous aorta, are
stable. This patient is status post median sternotomy.

IMPRESSION: No acute cardiopulmonary process.

EKGs: NSR, essentially unchanged from prior tracings

WBC scan;

IMPRESSION: 1. Unchanged appearance of residual sacrum with
adjacent posterior
focal radiotracer uptake, again apparently within adjacent soft
tissues.
However, given the proximity of the uptake, bony involvement
with infection
cannot be excluded.
2. Similar sclerotic appearance of right lower ischium and
adjacent soft
tissue thickening. Although the CT appearance suggests chronic
osteomyelitis,
immediately adjacent radiotracer activity has resolved and the
bony abnormality
appears unchanged.
3. New cellulitis along the right lower buttock, at the
interface with the
thigh and inferior to the prior site of infection.
4. More extensive radiotracer uptake in the left lower buttock,
with fat
stranding on CT suggesting cellulitis. Although the soft tissue
abnormality
extends to the ischial tuberosity, there is no CT evidence of
bone destruction
or abnormal bony radiotracer uptake in this area.

[**2106-4-6**] 6:38 pm SWAB      Source: left ischial tuberosity.

                            **FINAL REPORT [**2106-4-10**]**

   GRAM STAIN (Final [**2106-4-6**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.

   WOUND CULTURE (Final [**2106-4-10**]):
      Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
      workup is performed appropriate to the isolates recovered
from the
      site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
      aureus and beta streptococcus).
      Susceptibility will be performed on P. aeruginosa and S.
aureus if
      sparse growth or greater.
      STAPH AUREUS COAG +.    SPARSE 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.
         Please contact the Microbiology Laboratory ([**8-/2404**])
immediately if
         sensitivity to clindamycin is required on this
patient's isolate.

                              SENSITIVITIES: MIC expressed in
MCG/ML

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

   ANAEROBIC CULTURE (Final [**2106-4-10**]):    NO ANAEROBES ISOLATED.






[**2106-4-6**] 6:38 pm SWAB      Source: sacral decubitus ulcer.

                            **FINAL REPORT [**2106-4-10**]**

   GRAM STAIN (Final [**2106-4-6**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.

   WOUND CULTURE (Final [**2106-4-10**]):
      ESCHERICHIA COLI.    RARE GROWTH.
      PSEUDOMONAS AERUGINOSA.    RARE GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ESCHERICHIA COLI
                             |          PSEUDOMONAS AERUGINOSA
                             |          |
AMPICILLIN------------   <=2 S
AMPICILLIN/SULBACTAM--   <=2 S
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S      <=1 S
CEFTAZIDIME-----------   <=1 S        4 S
CEFTRIAXONE-----------   <=1 S
CEFUROXIME------------     4 S
CIPROFLOXACIN---------   =>4 R   <=0.25 S
GENTAMICIN------------   <=1 S      <=1 S
MEROPENEM-------------<=0.25 S   <=0.25 S
PIPERACILLIN----------   <=4 S        8 S
PIPERACILLIN/TAZO-----   <=4 S        8 S
TOBRAMYCIN------------   <=1 S      <=1 S
TRIMETHOPRIM/SULFA----   <=1 S

   ANAEROBIC CULTURE (Final [**2106-4-10**]):    NO ANAEROBES ISOLATED.



Brief Hospital Course:
A/P: 67M h/o T4 paraplegia, recurrent UTIs [**3-13**] indwelling foley,
multiple stage 4 decubs was admitted to ICU initially with fever
to 101.8, transient hypotension that resolved with 3-4L IVF but
continued on sepsis protocol.
.
# FEVER - Felt due to UTI and or osteomyelitis.  Cx. all neg,
but swab suggested colonization with mrsa; also seen on swab,
pseudomonas and enterococcus.  Emperically treated with
vancomycin and zosyn given this information and prior culture
data that was reviewed here.  Tagged wbc scan as above.  Plastic
surgery consult evaluated wounds and felt that pt. did not have
evidence of osteomyelitis.  Plan two weeks of abx for empiric
treatment for complicated UTI.  Foley replaced.  Follow up with
[**Month/Day (2) **] arranged for evaluation for suprapubic catheter.  Follow
up with plastic surgery also arranged.
.
# HYPOTENSION - resolved with IVF and treatment of infection as
above.

# H/O PE - s/p IVC filter, INR elevated, so warfarin held, then
given 5 po vitamin K given sustained inr over 4.0.  INR came
down to 1.8 with this, so warfarin resumed.

Otherwise, home medication regimen continued in hospital for
other chronic medical issues as outlined in pmhx. and in
medication list below.

Medications on Admission:
vitamin c 500mg po qdaily
aspirin 81mg po qdaily
baclofen 5mg po tid
calcium carbonate 650mg po bid
citalopram 40mg po qdaily
pepcid 20mg po qdaily
advair 250/50 IH [**Hospital1 **]
gabapentin 400mg po bid
simethicone 80mg po tid
simvastatin 40mg po qdaily
tramadol 25mg po tid
ursodiol 300mg po qdaily
warfarin 3mg po qdaily
prostat 30ml oral [**Hospital1 **] (liquid protein supplement)
.


Discharge Medications:
1. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous Q 12H (Every 12 Hours) for 7 days. gram
2. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig:
One (1)  Intravenous Q8H (every 8 hours) for 7 days.
3. Sodium Hypochlorite 0.25 % Solution Sig: One (1) Appl
Miscellaneous ASDIR (AS DIRECTED) for 1 days: apply to ischial
wounds only, for one day ([**4-16**]) in [**Hospital1 **] wet to dry dsg changes.
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day).

6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
7. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) inhalation Inhalation [**Hospital1 **] (2 times a day).
9. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID (3 times a day) as needed.
11. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
13. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO QDAILY ().
14. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
15. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
16. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed.
17. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
18. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
19. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: [**2-10**] Tablet,
Rapid Dissolves PO Q8H (every 8 hours) as needed.
20. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
UTI with sepsis
Chronic sacral and ischial decubitus ulcerations
Chronic, systolic, heart failure
Hx. PE with SVC filter, on warfarin


Discharge Condition:
Stable


Discharge Instructions:
Return to the [**Hospital1 18**] Emergency Department for:

Fever
Hypotension

Followup Instructions:
Provider: [**Name10 (NameIs) **] SURGERY CLINIC Phone:[**Telephone/Fax (1) 4652**]
Date/Time:[**2106-4-23**] 1:30

For evaluation for suprapubic catheter placment:

Provider: [**Name10 (NameIs) **] UNIT Phone:[**Telephone/Fax (1) 164**] Date/Time:[**2106-4-28**]
9:30
{'Infection and inflammatory reaction due to indwelling urinary catheter,Unspecified septicemia,Sepsis,Paraplegia,Pressure ulcer, lower back,Chronic systolic heart failure,Urinary tract infection, site not specified,Aortocoronary bypass status,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants'}


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: Fever, hypotension

PRESENT ILLNESS: 68M with h/o t4 paraplegia x 2yrs, felt [**3-13**] "inflammatory spinal
disease", with a chronic indwelling foley, sacral decubitus
ulcers, presents to [**Hospital1 18**] from rehab after RN noted 1d of fever
(tmax 101.8).  [**Name8 (MD) **] RN caring for pt at rehab, pt noted some mild
abdominal discomfort (chronic), but otherwise denied any recent
symptoms of cough, n/v, constipation, rash.  Pt has been having
chronic diarrhea (x3/day, x2-3/night) for past 1yr, etiology
unclear.  [**Name2 (NI) 227**] persistent fevers x24hrs, pt was brought to
[**Hospital1 18**] ED.  [**Name8 (MD) **] RN BP prior to leaving rehab was 100/72.
.
Per pt, he notes chronic abdominal pain, "always there",
diffuse, sharp, sometimes awakening him from sleep, no relation
to food or BMs.  somewhat worse over the preceding 4 months, but
actually improving over the past few days.  At present, he
states his pain has completely resolved.   ROS otherwise
significant for +orthopnea, pt also notes nonproductive cough x
3 weeks, no flu sx (body aches, congestion, sore throat).  Pt
denies flut shot or pneumovax.  +sick contacts (lives in [**Hospital 100**]
Rehab).
.
Upon arrival in ED VS=100.4  100  87/51  12  95%RA.  UA was c/w
UTI, pt was started on vanco and zosyn, UCx and BCx sent.
sacral ulcers felt to be stage 4, no evidence of superinfection.
 BP initially responded to 3L IVF (99/53), however after 3rd
litre, BP down to 85/40, pt therefore received RIJ TLC, and
possibly an additional 1L IVF bolus, afterwhich BP improved to
115/70.  Pt was asymptomatic, mentating throughout without
specific complaints.
.
Pt also noted moderate abdominal tenderness.  CT ABD done which
showed no acute processes.  CXR unremarkable, EKG unremarkable
(old Q in III, ?mild ST changes V1).
.
Pt admitted to ICU for further monitoring given hypotension.
.

MEDICAL HISTORY: 1. Inflammatory disease of the spinal cord of uncertain
etiology.  MRA [**10-16**] negative for vascular malformation.  Initial
CSF analysis showed elevated protein (82) without oligoclonal
bands.  NMO blood titer negative, RPR negative, Lyme serology
negative, [**Doctor First Name **] negative, Ro and La negative, ACE level normal,
neuromyelitis IgG negative, ESR 70, CRP 66.8.  Ultimately
treated with broad spectrum antibiotics, corticosteroids (two
weeks of Solu-Medrol followed by a prednisone taper), and 5 days
of mannitol without improvement.  He is followed by neurology
for a dense paraplegia (T4) with neuropathic pain, restrictive
shoulder arthropathy, and a neurogenic bladder requiring a
chronic indwelling foley.
2. Chronic sacral decubitus ulcer, previously treated with a VAC
dressing
3. Multiple UTI (including Pseudomonas)
4. Pulmonary embolus [**11-15**] s/p IVC filter placement
5. Asthma
6. Two-vessel coronary artery disease s/p CABG 4-5 years ago
7. Systolic CHF (EF 25-30% on [**2-15**] TTE)
8. Repaired liver laceration
9. Chronic back pain
10. Vitiligo
11. Feeding tube
12. Depression
13. MRSA from sacral swab and sputum
14. Prior transient episodes of leg paralysis
15. Right frontal lobe brain lesion biopsied [**11-15**] and c/w
gliosis; resolved on repeat imaging
16. Abnormal visual evoked potentials

MEDICATION ON ADMISSION: vitamin c 500mg po qdaily
aspirin 81mg po qdaily
baclofen 5mg po tid
calcium carbonate 650mg po bid
citalopram 40mg po qdaily
pepcid 20mg po qdaily
advair 250/50 IH [**Hospital1 **]
gabapentin 400mg po bid
simethicone 80mg po tid
simvastatin 40mg po qdaily
tramadol 25mg po tid
ursodiol 300mg po qdaily
warfarin 3mg po qdaily
prostat 30ml oral [**Hospital1 **] (liquid protein supplement)
.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 96.6  85 105/66  15 100%2L
Gen: Well appearing male in NAD lying in bed.
HEENT: JVD <6-8cm, MMM, lips slightly pale.
Chest: CTA bilaterally, no w/r/r.
CV: RRR, physiologic splitting S2, no r/g.  3/6 SEM @ LSB.
Abd: Soft, nontender to deep palpation in all four quadrants,
distended, tympanic (?gas), negative murphys sign, well-healed
midline g-tube scar.
Extremities: Warm, well perfused, no C/C. [**2-10**]+ edema bilaterally
to knees.
Skin: Vitiligo on hands. Large round 6x4 cm diameter pressure
decubitus ulcer on sacrum and 4x3cm decub ulcer on left ischial
tuberosity.  Appears clean with granulation tissue in center, no
s/sx of infection.  no purulent drainage.
Neuro: CN grossly intact. A&O x 3, pleasantly conversant.

FAMILY HISTORY: No stroke, aneurysm, no seizure, no AAA.

SOCIAL HISTORY: He moved here from [**Country 3594**] (after living in many different
countries) in the [**2068**].  He is retired from a job in the
maritime industry.  Divorced 24 years ago.  Three children.
Quit smoking [**2076**].  Quit drinking [**2080**].  No history of illicit
drug use or abuse. 

### Response:
{'Infection and inflammatory reaction due to indwelling urinary catheter,Unspecified septicemia,Sepsis,Paraplegia,Pressure ulcer, lower back,Chronic systolic heart failure,Urinary tract infection, site not specified,Aortocoronary bypass status,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants'}
