CHIEF COMPLAINT: Fever, Shortness of Breath, Sepsis

PRESENT ILLNESS: 63 year old woman with a history of [**Doctor First Name 39850**] status post
neck surgery 1 yr ago, trach collar dependent, who presents with
one day of fever to 103.8, increased SOB and increased
secretions. Patient's daughter states that the patient vomited
once earlier, but it may have been respiratory secretions.  She
denies known sick contacts.  [**Name (NI) **] associated diarrhea, abd pain or
rash. Of note, patient has had recurrent UTIs and a MRSA
pneumonia in past. Also, is on coumadin for history of left
upper extremity DVT.
.
In the ED, initial VS were:  T 101.8 HR 119 BP 104/38 RR 22 O2
sat 100% 15L.  Patient's temperature peaked at 103.8 in the ED.
She was placed on nonrebreather to trach for dyspnea and
secretions, and saturated 100%. On exam, patient was noted to
have rhonchi bilat. No abdominal tenderness, normal skin exam.
Patient has chronic Foley and urine was sent for UA, urine cx.
Labs were notable for WBC 25.3, Na 128, lactate 2, Hct 28 (close
to baseline). UA was positive for infection.  CXR with no clear
consolidation. Pt was started on Cefepime, Vanc, Levofloxacin
for UTI and possible pneumonia. She was given about 900cc NS.
She was transferred to the MICU for respiratory status.  On
transfer, VS were: Temperature 101.2 ??????F (38.4 ??????C). Pulse 117.
Respiratory Rate 21. Blood Pressure 171/70. O2 Saturation 97. O2
Flow humidified 02. Pain Level 0.
.
On arrival to the MICU, the patient was tachypneic, slightly
diaphoretic, but not in any distress.  She was on humidified O2
via trach collar, complaining of bilateral arm pain c/w
contracture pain.

MEDICAL HISTORY: C5 [**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 39850**]
Chronic respiratory failure with trach
s/p C6 corpectomy and ACDF C7T1 c allograft and plate c/b CSF
leak
Stage II pressure ulcers
MRSA/Hflu Ventilator-associated Pneumonia
Left upper extremity Deep vein thrombosis (DVT)
Neurogenic bowel
Neurogenic bladder
h/o Hypertension (HTN)
h/o Myocardia Infarction in 03 s/p BMS to LCcx
Diabetes Mellitus (diet controlled)
hypercholesterolemia
s/p TAH-BSO [**2146**]
hypotension, on florinef/MICU and glycopyrrelate
history of pan-sensitive respiratory pseudomonas

MEDICATION ON ADMISSION: -baclofen 20mg @ 0600 and 1200, 30mg @ [**2156**]
-gabapentin 800mg @ 0800, 400mg @ 1200, 800mg @ [**2156**]
-hydroxyzine 50mg (25cc of 10mg/5cc) q4h prn anxiety
-ipratropium-albuterol [DuoNeb] q4h prn dyspnea/wheezing
-lisinopril 5 mg daily
-morphine 10 mg/5 mL Solution 5-10ml G(s) PO q6h PRN pain
-nitroglycerin 0.4 mg SL q5-10 minutes x 3 PRN chest pain
-omeprazole magnesium [Prilosec] 20mg/5mL oral suspension daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM:
Vitals: T: 100.2 BP: 149/47 P: 104 R: 20 O2: 93% trach collar
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, increased oral secretions, [**Name (NI) 3899**], ptosis
L>R, baseline
Neck: supple, JVP not elevated, no LAD, there is a trach-collar
in place
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops, 2+ pulses throughout
Lungs: Diminished excursion, diffuse wheezes without focal
rhonchi or rales, no accessory muscle use.  the patient is
tachypneic
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, there is a feeding tube present
GU: foley present
Ext: Arms warm/well-perfused, legs cool, 2+ pulses in all
extremities, no clubbing, cyanosis or edema; there is a 22GA
peripheral IV in the right wrist
Neuro: Answers questions appropriately and clearly, insensate
lower extremities, normal sensation BUE, contractures present
BUE
.
DISCHARGE EXAM:
Vitals:  98.1  122/50  65  20  100% TM
General: Alert, oriented, answers appropriately, comfortable
HEENT: Sclera anicteric, [**Name (NI) 3899**]
Neck: supple, JVP not elevated, no LAD, trach-collar in place;
left PICC line in place - non-erythematous, no drainage,
non-tender to palpation
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops, 2+ pulses
throughout
Lungs: Diminished excursion, no accessory muscle use, lungs
clear to auscultation, no crackles or rales
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, feeding tube in place, no pus draining
GU: suprapubic foley in place, no surrounding erythema
Ext: Warm/well-perfused, 2+ pulses in all extremities, 1+ edema
to ankle; no clubbing, cyanosis or edema
Neuro: Answers questions appropriately and clearly, normal
sensation BUE, decreseased but sensation present in BLE, cannot
move UE or LE

FAMILY HISTORY: Hypertension

SOCIAL HISTORY: Drugs: None
Tobacco: prior (30-40 years) 1+ pack/day smoker
Alcohol: None
Other: used to work as [**Hospital1 112**] clerk
Septicemia due to gram-negative organism, unspecified,Quadriplegia, unspecified,Urinary tract infection, site not specified,Chronic respiratory failure,Neurogenic bowel,Hyposmolality and/or hyponatremia,Sepsis,Acute upper respiratory infections of unspecified site,Late effect of spinal cord injury,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Tracheostomy status,Gastrostomy status,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants,Neurogenic bladder NOS,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Old myocardial infarction,Unspecified essential hypertension,Anemia, unspecified,Pressure ulcer, lower back
Gram-neg septicemia NOS,Quadriplegia, unspecifd,Urin tract infection NOS,Chronic respiratory fail,Neurogenic bowel,Hyposmolality,Sepsis,Acute uri NOS,Late eff spinal cord inj,Abn react-surg proc NEC,Tracheostomy status,Gastrostomy status,Hx-ven thrombosis/embols,Long-term use anticoagul,Neurogenic bladder NOS,Crnry athrscl natve vssl,Status-post ptca,Old myocardial infarct,Hypertension NOS,Anemia NOS,Pressure ulcer, low back
Admission Date:  [**2168-6-30**]              Discharge Date:   [**2168-7-12**]

Date of Birth:  [**2105-6-17**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Doctor First Name 2080**]
Chief Complaint:
Fever, Shortness of Breath, Sepsis

Major Surgical or Invasive Procedure:
Left PICC line placement


History of Present Illness:
63 year old woman with a history of [**Doctor First Name 39850**] status post
neck surgery 1 yr ago, trach collar dependent, who presents with
one day of fever to 103.8, increased SOB and increased
secretions. Patient's daughter states that the patient vomited
once earlier, but it may have been respiratory secretions.  She
denies known sick contacts.  [**Name (NI) **] associated diarrhea, abd pain or
rash. Of note, patient has had recurrent UTIs and a MRSA
pneumonia in past. Also, is on coumadin for history of left
upper extremity DVT.
.
In the ED, initial VS were:  T 101.8 HR 119 BP 104/38 RR 22 O2
sat 100% 15L.  Patient's temperature peaked at 103.8 in the ED.
She was placed on nonrebreather to trach for dyspnea and
secretions, and saturated 100%. On exam, patient was noted to
have rhonchi bilat. No abdominal tenderness, normal skin exam.
Patient has chronic Foley and urine was sent for UA, urine cx.
Labs were notable for WBC 25.3, Na 128, lactate 2, Hct 28 (close
to baseline). UA was positive for infection.  CXR with no clear
consolidation. Pt was started on Cefepime, Vanc, Levofloxacin
for UTI and possible pneumonia. She was given about 900cc NS.
She was transferred to the MICU for respiratory status.  On
transfer, VS were: Temperature 101.2 ??????F (38.4 ??????C). Pulse 117.
Respiratory Rate 21. Blood Pressure 171/70. O2 Saturation 97. O2
Flow humidified 02. Pain Level 0.
.
On arrival to the MICU, the patient was tachypneic, slightly
diaphoretic, but not in any distress.  She was on humidified O2
via trach collar, complaining of bilateral arm pain c/w
contracture pain.

Past Medical History:
C5 [**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 39850**]
Chronic respiratory failure with trach
s/p C6 corpectomy and ACDF C7T1 c allograft and plate c/b CSF
leak
Stage II pressure ulcers
MRSA/Hflu Ventilator-associated Pneumonia
Left upper extremity Deep vein thrombosis (DVT)
Neurogenic bowel
Neurogenic bladder
h/o Hypertension (HTN)
h/o Myocardia Infarction in 03 s/p BMS to LCcx
Diabetes Mellitus (diet controlled)
hypercholesterolemia
s/p TAH-BSO [**2146**]
hypotension, on florinef/MICU and glycopyrrelate
history of pan-sensitive respiratory pseudomonas

Social History:
Drugs: None
Tobacco: prior (30-40 years) 1+ pack/day smoker
Alcohol: None
Other: used to work as [**Hospital1 112**] clerk


Family History:
Hypertension

Physical Exam:
ADMISSION EXAM:
Vitals: T: 100.2 BP: 149/47 P: 104 R: 20 O2: 93% trach collar
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, increased oral secretions, [**Name (NI) 3899**], ptosis
L>R, baseline
Neck: supple, JVP not elevated, no LAD, there is a trach-collar
in place
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops, 2+ pulses throughout
Lungs: Diminished excursion, diffuse wheezes without focal
rhonchi or rales, no accessory muscle use.  the patient is
tachypneic
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, there is a feeding tube present
GU: foley present
Ext: Arms warm/well-perfused, legs cool, 2+ pulses in all
extremities, no clubbing, cyanosis or edema; there is a 22GA
peripheral IV in the right wrist
Neuro: Answers questions appropriately and clearly, insensate
lower extremities, normal sensation BUE, contractures present
BUE
.
DISCHARGE EXAM:
Vitals:  98.1  122/50  65  20  100% TM
General: Alert, oriented, answers appropriately, comfortable
HEENT: Sclera anicteric, [**Name (NI) 3899**]
Neck: supple, JVP not elevated, no LAD, trach-collar in place;
left PICC line in place - non-erythematous, no drainage,
non-tender to palpation
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops, 2+ pulses
throughout
Lungs: Diminished excursion, no accessory muscle use, lungs
clear to auscultation, no crackles or rales
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, feeding tube in place, no pus draining
GU: suprapubic foley in place, no surrounding erythema
Ext: Warm/well-perfused, 2+ pulses in all extremities, 1+ edema
to ankle; no clubbing, cyanosis or edema
Neuro: Answers questions appropriately and clearly, normal
sensation BUE, decreseased but sensation present in BLE, cannot
move UE or LE

Pertinent Results:
ADMISSION LABS:
[**2168-6-30**] 03:00PM BLOOD WBC-25.3*# RBC-3.40* Hgb-8.7* Hct-28.5*
MCV-84 MCH-25.5* MCHC-30.4* RDW-13.6 Plt Ct-294
[**2168-6-30**] 03:00PM BLOOD Neuts-90.5* Lymphs-4.7* Monos-4.0 Eos-0.5
Baso-0.3
[**2168-6-30**] 03:00PM BLOOD Plt Ct-294
[**2168-6-30**] 03:00PM BLOOD Glucose-140* UreaN-16 Creat-0.4 Na-128*
K-4.5 Cl-93* HCO3-22 AnGap-18
[**2168-6-30**] 03:05PM BLOOD Lactate-2.0
.
DISCHARGE LABS [**2168-7-12**] 07:40AM:
WBC-8.5 RBC-3.16* Hgb-8.0* Hct-26.6* MCV-84 MCH-25.2* MCHC-29.9*
RDW-15.2 Plt Ct-249
PT-16.9* PTT-60.6* INR(PT)-1.6*
Glucose-134* UreaN-13 Creat-0.3* Na-141 K-4.2 Cl-108 HCO3-25
AnGap-12
Calcium-8.9 Phos-2.8 Mg-2.1
Vanco-24.5*
.
MICROBIOLOGY:
Urine culture [**6-30**]:  MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES),
CONSISTENT WITH FECAL CONTAMINATION.
.
Sputum culture [**6-30**]:
   GRAM STAIN (Final [**2168-7-1**]):
      >25 PMNs and <10 epithelial cells/100X field.
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.
      1+    (<1 per 1000X FIELD):   GRAM NEGATIVE ROD(S).
   RESPIRATORY CULTURE (Final [**2168-7-3**]):
Due to mixed bacterial types ( >= 3 colony types) an abbreviated
workup will be performed appropriate to the isolates recovered
from this site.  UNABLE TO R/O PATHOGENS DUE TO OVERGROWTH OF
SWARMING PROTEUS SPP. Unable to definitively determine the
presence or absence of commensal respiratory flora.
.
Blood culture [**7-3**]: Negative
Urine culture [**7-3**]: Negative
.
Blood culture [**7-7**] x 2: Negative
Urine culture [**7-7**]: Negative
.
CATHETER TIP-IV: (Final [**2168-7-10**]):    No significant growth.
.
IMAGING:
[**6-30**] CXR:
SINGLE PORTABLE VIEW OF THE CHEST:  Opacification of left
hemidiaphragm, downward displacement of the major fissure is
compatible with patient's known chronic left lower lobe
collapse.  No new focal consolidation is seen to suggest
pneumonia.  There is no pleural effusion or pneumothorax.
Anterior cervical fusion hardware, a percutaneous gastrostomy
tube and tracheostomy collar are noted. Cardiac and mediastinal
contours are unchanged.
IMPRESSION:  No acute cardiopulmonary process.
.
Left UE ultrasound [**2168-7-1**]:
IMPRESSION:  No evidence of deep vein thrombosis in the left
arm.
.
CXR [**2168-7-3**]:
FINDINGS:  There is a right-sided central venous catheter with
the distal lead tip in the distal SVC appropriately sited.
There are no pneumothoraces. Lungs are grossly clear.  There is
some atelectasis at the left lung base. The heart size is within
normal limits.
.
CXR [**2168-7-8**]: PICC placement.
1.  Placement of a double-lumen Power PICC line into the distal
superior vena cava via the left cephalic vein.
2.  The line is ready to use.

Brief Hospital Course:
63 year old woman with a history of [**Month/Day/Year 39850**] status post
neck surgery 1 year ago, trach collar dependent, admitted with
fever to 103.8F and increased secretions.
.
# Sepsis due to HCAP:  Patient admitted to the MICU with fevers
to 103.8 and increased secretions.  She was started on cefepime,
vancomycin, and Levaquin to cover for HCAP and possible UTI.
Fever resolved and the patient was transferred to the floor.
She underwent sputum cultures 5/24 that grew gram positive
cocci, but serial chest X-rays negative for pneumonia.  Urine
culture also positive for > 3 types of bacteria in the setting
of chronic suprapubic catheter.  Once fevers resolved and WBC
count normalized on [**7-2**], the patient was transitioned to PO
ciprofloxacin and linezolid.  However, she spiked a fever to 101
and became hypotensive on [**7-3**].  Subclavian line was placed and
she was resumed on vanc/cefepime (Day 1 - [**2168-6-30**]) for urinary
and respiratory sources of infection.  Given decompensation with
transition from cefepime to ciprofloxacin, the patient was
thought to have a possible gram negative infection as the
culprit for her decompensation.  Vancomycin was discontinued for
36 hours, and the patient again spiked a fever.  The patient was
resumed on vancomycin on [**7-7**].  A picc line was placed and the
subclavian was removed.  The patient will complete a 14 day
course of vancomycin and cefepime as an outpatient.  Cefepime
course will complete [**2168-7-14**].  Vancomycin course will complete
[**2168-7-21**].
.
# Left upper extremity DVT/history of pulmonary embolism:
Patient had DVT/PE in [**9-/2167**] off coumadin.  Requires life-long
anticoagulation [**3-10**] immobility from [**Month/Day (2) 39850**].  INR 2.0 on
admission. Warfarin continued. A left-upper extremity ultrasound
was negative for ongoing clot, so her left extremity can be used
for IV lines/draws.  Warfarin was briefly held during admission
for central line placement.  Despite promptly resuming this
medication, her INR trended down to 1.2.  She was started on a
lovenox bridge.  The patient should undergo daily INR checks,
and stop lovenox bridge once therapeutic on coumadin (INR >
2.0).
.
# history of CAD s/p NSTEMI with stent: Patient without chest
pain throughout admission.  She was continued on home ASA,
statin, lisinopril.  On [**2168-7-10**], the patient underwent EKG that
showed inverted T waves in the lateral precordial leads.  The
patient was asymptomatic at that time.  Cardiac enzymes x 2
negative.  Repeat EKG at a slower heart rate (65 rather than 95)
showed normalization of her EKG to baseline.  The patient likely
has rate-related change secondary to history of CAD.  She will
follow up with Dr. [**Last Name (STitle) **], cardiology, as an outpatient.
.
# HTN: Chronic.  Lisinopril briefly held on admission, then
resumed with stabilization on the floor.  She remained
normotensive for much of admission.
.
# [**Last Name (STitle) **] with spasticity: Tizanidine initially held, but
then restarted after levofloxacin was stopped. The patient was
continued on home tramadol, morphine, baclofen, gabapentin.
=======================
TRANSITIONAL ISSUES:
-code status: Full Code
-Patient to complete 14-day courses of vancomycin and cefepime.
Cefepime course will complete [**2168-7-14**].  Vancomycin course will
complete [**2168-7-21**].
-Please check vancomycin trough [**2168-7-15**].  Adjust dose
accordingly.
-Patient on lovenox bridge, as INR 1.6 at the time of discharge.
 Monitor daily INRs.  Stop lovenox when INR > 2.0 on coumadin.

Medications on Admission:
-baclofen 20mg @ 0600 and 1200, 30mg @ [**2156**]
-gabapentin 800mg @ 0800, 400mg @ 1200, 800mg @ [**2156**]
-hydroxyzine 50mg (25cc of 10mg/5cc) q4h prn anxiety
-ipratropium-albuterol [DuoNeb] q4h prn dyspnea/wheezing
-lisinopril 5 mg daily
-morphine 10 mg/5 mL Solution 5-10ml G(s) PO q6h PRN pain
-nitroglycerin 0.4 mg SL q5-10 minutes x 3 PRN chest pain
-omeprazole magnesium [Prilosec] 20mg/5mL oral suspension daily

-simvastatin 20 mg once a day
-tizanidine 4-6 mg tid PRN muscle spasm
-tramadol 50-100 q4-6h PRN pain
-warfarin 2mg MF, 4mg all other days PO@1600
-acetaminophen 650mg qid PRN pain
-aspirin 81 mg once a day
-[Calcium 600 + D(3)] 600 mg-400 unit twice a day
-docusate sodium 60 mg/15 mL Syrup 25 ml G tube twice a day
-docusate sodium [Enemeez] 283 mg Enema daily PRN constipation

-inulin [Metamucil Clear-Natural (inul)] 5 gram/5.8 gram Powder
1 tsp by mouth up to three times daily
-nutritional supplement 6 cans(s) per G-Tube--once a day

Discharge Medications:
1. baclofen 10 mg Tablet [**Year (4 digits) **]: Two (2) Tablet PO q6am, q12pm.
2. baclofen 10 mg Tablet [**Year (4 digits) **]: Three (3) Tablet PO q8pm.
3. gabapentin 250 mg/5 mL Solution [**Year (4 digits) **]: Eight Hundred (800) mg
PO q 8am and 8pm.
4. gabapentin 250 mg/5 mL Solution [**Year (4 digits) **]: Four Hundred (400) mg PO
NOON (At Noon).
5. hydroxyzine HCl 10 mg/5 mL Syrup [**Year (4 digits) **]: Fifty (50) mg PO every
four (4) hours as needed for anxiety.
6. ipratropium bromide 0.02 % Solution [**Year (4 digits) **]: One (1) inhalation
Inhalation Q4H (every 4 hours) as needed for dyspnea/wheezing:
please give as duoneb with albuterol .
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Year (4 digits) **]: One (1) inhalation Inhalation Q4H (every 4
hours) as needed for dyspnea/wheezing: please give as duoneb
with ipratropium .
8. lisinopril 5 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily).

9. morphine 10 mg/5 mL Solution [**Year (4 digits) **]: 10-20 mg PO Q6H (every 6
hours) as needed for pain.
10. nitroglycerin 0.4 mg Tablet, Sublingual [**Year (4 digits) **]: One (1) SL
Sublingual q5 minutes x 3 as needed for chest pain: call your
doctor if you take this medication.
11. omeprazole magnesium 10 mg Susp,Delayed Release for Recon
[**Year (4 digits) **]: Twenty (20) mg PO once a day.
12. simvastatin 20 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO at bedtime.

13. tizanidine 2 mg Tablet [**Year (4 digits) **]: 4-6 mg PO TID (3 times a day) as
needed for muscle spasm.
14. tramadol 50 mg Tablet [**Year (4 digits) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
15. warfarin 2 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO q mon, fri.
16. warfarin 2 mg Tablet [**Year (4 digits) **]: Two (2) Tablet PO q sun, tues,
wed, thurs, sat.
17. acetaminophen 650 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO four
times a day as needed for pain.
18. aspirin 81 mg Tablet, Chewable [**Year (4 digits) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
19. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet [**Year (4 digits) **]: One
(1) Tablet PO twice a day.
20. docusate sodium 60 mg/15 mL Syrup [**Year (4 digits) **]: Twenty Five (25) mL
PO twice a day: per G tube.
21. docusate sodium 283 mg Enema [**Year (4 digits) **]: One (1) enema Rectal once
a day as needed for constipation.
22. cefepime 2 gram Recon Soln [**Year (4 digits) **]: Two (2) grams Injection Q8H
(every 8 hours) for 5 days.
23. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid [**Year (4 digits) **]: Three
Hundred (300) mg PO once a day.
24. heparin, porcine (PF) 10 unit/mL Syringe [**Year (4 digits) **]: One (1) ML
Intravenous PRN (as needed) as needed for line flush: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN.

25. enoxaparin 80 mg/0.8 mL Syringe [**Year (4 digits) **]: Eighty (80) mg
Subcutaneous Q12H (every 12 hours): discontinue when INR > 2.0.

26. metoprolol tartrate 25 mg Tablet [**Year (4 digits) **]: 0.5 Tablet PO BID (2
times a day).
27. vancomycin 750 mg Recon Soln [**Year (4 digits) **]: Seven [**Age over 90 1230**]y (750)
mg Intravenous twice a day for 9 days: please check vanco trough
after 4th dose.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **] at [**Hospital 1263**] Hospital in [**Location (un) 686**]

Discharge Diagnosis:
Primary diagnosis: urinary tract infection, upper respiratory
infection, fever
Secondary diagnosis:  history of deep vein thrombosis/pulmonary
embolism; history of coronary artery disease


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.


Discharge Instructions:
Ms. [**Known lastname 105209**],
.
You were admitted to the hospital with fevers and increased
secretions.  You underwent a thorough infectious evaluation, and
were found to have a likely upper respiratory infection and
urinary tract infection as the source of your fevers.  You were
started on two antibiotics, called vancomycin and cefepime.  We
attempted to transition you to antibiotics by mouth for your
infection, but you began to experience fevers again.  You were
discharged to rehab with a special IV in place to continue
antibiotics for a total 14 day course.
.
During your admission, you were resumed on metoprolol for
optimal management of your heart disease.
.
MEDICATIONS CHANGED THIS ADMISSION
START metoprolol 12.5 mg twice a day
START cefepime 2 grams IV every 8 hours for 2 days (last day
[**2168-7-14**])
START vancomycin 750 mg IV twice a day for 9 days (last day
[**2168-7-21**])
START lovenox 80 mg twice a day until INR > 2.0

Followup Instructions:
Please follow up with your primary care physician on discharge
from rehab.  [**Last Name (LF) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 2010**]
.
Department: CARDIAC SERVICES
When: FRIDAY [**2168-7-29**] at 10:40 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Septicemia due to gram-negative organism, unspecified,Quadriplegia, unspecified,Urinary tract infection, site not specified,Chronic respiratory failure,Neurogenic bowel,Hyposmolality and/or hyponatremia,Sepsis,Acute upper respiratory infections of unspecified site,Late effect of spinal cord injury,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Tracheostomy status,Gastrostomy status,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants,Neurogenic bladder NOS,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Old myocardial infarction,Unspecified essential hypertension,Anemia, unspecified,Pressure ulcer, lower back'}


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, Shortness of Breath, Sepsis

PRESENT ILLNESS: 63 year old woman with a history of [**Doctor First Name 39850**] status post
neck surgery 1 yr ago, trach collar dependent, who presents with
one day of fever to 103.8, increased SOB and increased
secretions. Patient's daughter states that the patient vomited
once earlier, but it may have been respiratory secretions.  She
denies known sick contacts.  [**Name (NI) **] associated diarrhea, abd pain or
rash. Of note, patient has had recurrent UTIs and a MRSA
pneumonia in past. Also, is on coumadin for history of left
upper extremity DVT.
.
In the ED, initial VS were:  T 101.8 HR 119 BP 104/38 RR 22 O2
sat 100% 15L.  Patient's temperature peaked at 103.8 in the ED.
She was placed on nonrebreather to trach for dyspnea and
secretions, and saturated 100%. On exam, patient was noted to
have rhonchi bilat. No abdominal tenderness, normal skin exam.
Patient has chronic Foley and urine was sent for UA, urine cx.
Labs were notable for WBC 25.3, Na 128, lactate 2, Hct 28 (close
to baseline). UA was positive for infection.  CXR with no clear
consolidation. Pt was started on Cefepime, Vanc, Levofloxacin
for UTI and possible pneumonia. She was given about 900cc NS.
She was transferred to the MICU for respiratory status.  On
transfer, VS were: Temperature 101.2 ??????F (38.4 ??????C). Pulse 117.
Respiratory Rate 21. Blood Pressure 171/70. O2 Saturation 97. O2
Flow humidified 02. Pain Level 0.
.
On arrival to the MICU, the patient was tachypneic, slightly
diaphoretic, but not in any distress.  She was on humidified O2
via trach collar, complaining of bilateral arm pain c/w
contracture pain.

MEDICAL HISTORY: C5 [**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 39850**]
Chronic respiratory failure with trach
s/p C6 corpectomy and ACDF C7T1 c allograft and plate c/b CSF
leak
Stage II pressure ulcers
MRSA/Hflu Ventilator-associated Pneumonia
Left upper extremity Deep vein thrombosis (DVT)
Neurogenic bowel
Neurogenic bladder
h/o Hypertension (HTN)
h/o Myocardia Infarction in 03 s/p BMS to LCcx
Diabetes Mellitus (diet controlled)
hypercholesterolemia
s/p TAH-BSO [**2146**]
hypotension, on florinef/MICU and glycopyrrelate
history of pan-sensitive respiratory pseudomonas

MEDICATION ON ADMISSION: -baclofen 20mg @ 0600 and 1200, 30mg @ [**2156**]
-gabapentin 800mg @ 0800, 400mg @ 1200, 800mg @ [**2156**]
-hydroxyzine 50mg (25cc of 10mg/5cc) q4h prn anxiety
-ipratropium-albuterol [DuoNeb] q4h prn dyspnea/wheezing
-lisinopril 5 mg daily
-morphine 10 mg/5 mL Solution 5-10ml G(s) PO q6h PRN pain
-nitroglycerin 0.4 mg SL q5-10 minutes x 3 PRN chest pain
-omeprazole magnesium [Prilosec] 20mg/5mL oral suspension daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM:
Vitals: T: 100.2 BP: 149/47 P: 104 R: 20 O2: 93% trach collar
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, increased oral secretions, [**Name (NI) 3899**], ptosis
L>R, baseline
Neck: supple, JVP not elevated, no LAD, there is a trach-collar
in place
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops, 2+ pulses throughout
Lungs: Diminished excursion, diffuse wheezes without focal
rhonchi or rales, no accessory muscle use.  the patient is
tachypneic
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, there is a feeding tube present
GU: foley present
Ext: Arms warm/well-perfused, legs cool, 2+ pulses in all
extremities, no clubbing, cyanosis or edema; there is a 22GA
peripheral IV in the right wrist
Neuro: Answers questions appropriately and clearly, insensate
lower extremities, normal sensation BUE, contractures present
BUE
.
DISCHARGE EXAM:
Vitals:  98.1  122/50  65  20  100% TM
General: Alert, oriented, answers appropriately, comfortable
HEENT: Sclera anicteric, [**Name (NI) 3899**]
Neck: supple, JVP not elevated, no LAD, trach-collar in place;
left PICC line in place - non-erythematous, no drainage,
non-tender to palpation
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops, 2+ pulses
throughout
Lungs: Diminished excursion, no accessory muscle use, lungs
clear to auscultation, no crackles or rales
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, feeding tube in place, no pus draining
GU: suprapubic foley in place, no surrounding erythema
Ext: Warm/well-perfused, 2+ pulses in all extremities, 1+ edema
to ankle; no clubbing, cyanosis or edema
Neuro: Answers questions appropriately and clearly, normal
sensation BUE, decreseased but sensation present in BLE, cannot
move UE or LE

FAMILY HISTORY: Hypertension

SOCIAL HISTORY: Drugs: None
Tobacco: prior (30-40 years) 1+ pack/day smoker
Alcohol: None
Other: used to work as [**Hospital1 112**] clerk 

### Response:
{'Septicemia due to gram-negative organism, unspecified,Quadriplegia, unspecified,Urinary tract infection, site not specified,Chronic respiratory failure,Neurogenic bowel,Hyposmolality and/or hyponatremia,Sepsis,Acute upper respiratory infections of unspecified site,Late effect of spinal cord injury,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Tracheostomy status,Gastrostomy status,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants,Neurogenic bladder NOS,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Old myocardial infarction,Unspecified essential hypertension,Anemia, unspecified,Pressure ulcer, lower back'}
