CHIEF COMPLAINT: Sepsis and cellulitis

PRESENT ILLNESS: 75M with CAD s/p BMS, CHF, COPD, pleural effusions, PVD s/p
femeral endarterectomy and fem to posterior tibial bypass with
saphenous vein graft [**2125-5-28**] who was admitted [**8-4**] with a Right
Lower extremity MRSA surgical wound infection.

MEDICAL HISTORY: COPD (home O2)
CAD
Paroxysmal atrial fibrillation (anticoagulated)
PVD
H/O EtOH abuse
SIADH
Possible urinary retention
Coronary artery stenting, vessels unknown

MEDICATION ON ADMISSION: Coumadin 2.5 mg daily
lasix 40 mg daily
pravachol 40 mg daily
toprol xl 100 mg [**Hospital1 **]
cardizem 120 mg daily
Kcl 40 meq daily
flomax 0.4 mg daily
vitamin D
Advair 250/50 [**Hospital1 **]
xopenex
citracal

ALLERGIES: Vancomycin / Linezolid

PHYSICAL EXAM: On admittance
PE:
Gen: mild distress, diffuse erythema
HEENT: WNL
Chest: CTAB, A-fib
Abd: S/NT/ND
Ext: 5 cm open wound with purulent drainage on medial aspect of
right calf. blanching erythema from R toes to R thigh.
Skin:  Red, dry, peeling sking; pt arrived with several small
stg. decubitis on both buttocks; dry brittle nails
Pulses:       L     R
      Femoral   Mono  Mono
      [**Doctor Last Name **]       Mono
      DP        None  None
      PT        None  Mono
      Graft      -    Dop
      Radial    Dop   Palp

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives at home with wife.  The pt has been nearly immobilitezed
during his last 6 weeks at home with minmal ambulation.
Originally, pt was able to ambulate and take care of himself
before it became to painful to walk.
Smoker:  [**12-20**] PPD x 60 years, quit 4 mos ago
H/o alcoholism, pt now admits to drinking 1 12oz beer per night.
Methicillin resistant Staphylococcus aureus septicemia,Acute respiratory failure,Septic shock,Cellulitis and abscess of leg, except foot,Acute kidney failure, unspecified,Unspecified pleural effusion,Pneumonia due to Klebsiella pneumoniae,Ventilator associated pneumonia,Pneumonitis due to inhalation of food or vomitus,Subendocardial infarction, initial episode of care,Acute diastolic heart failure,Unspecified intestinal obstruction,Acute posthemorrhagic anemia,Urinary tract infection, site not specified,Atherosclerosis of native arteries of the extremities with gangrene,Severe sepsis,Pressure ulcer, buttock,Atrial fibrillation,Chronic airway obstruction, not elsewhere classified,Thrombocytopenia, unspecified,Unspecified acquired hypothyroidism,Dermatitis due to drugs and medicines taken internally
MRSA septicemia,Acute respiratry failure,Septic shock,Cellulitis of leg,Acute kidney failure NOS,Pleural effusion NOS,K. pneumoniae pneumonia,Ventltr assoc pneumonia,Food/vomit pneumonitis,Subendo infarct, initial,Ac diastolic hrt failure,Intestinal obstruct NOS,Ac posthemorrhag anemia,Urin tract infection NOS,Ath ext ntv art gngrene,Severe sepsis,Pressure ulcer, buttock,Atrial fibrillation,Chr airway obstruct NEC,Thrombocytopenia NOS,Hypothyroidism NOS,Drug dermatitis NOS
Admission Date:  [**2125-8-4**]              Discharge Date:   [**2125-11-19**]

Date of Birth:  [**2050-5-9**]             Sex:   M

Service: SURGERY

Allergies:
Vancomycin / Linezolid

Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Sepsis and cellulitis

Major Surgical or Invasive Procedure:
angio [**2125-8-17**]
rt. pig tail chest catheter placement [**2125-8-28**]
left pigtail catheter placement [**2125-9-7**]
Mechanical ventilation


History of Present Illness:
75M with CAD s/p BMS, CHF, COPD, pleural effusions, PVD s/p
femeral endarterectomy and fem to posterior tibial bypass with
saphenous vein graft [**2125-5-28**] who was admitted [**8-4**] with a Right
Lower extremity MRSA surgical wound infection.

Past Medical History:
COPD (home O2)
CAD
Paroxysmal atrial fibrillation (anticoagulated)
PVD
H/O EtOH abuse
SIADH
Possible urinary retention
Coronary artery stenting, vessels unknown

Social History:
Lives at home with wife.  The pt has been nearly immobilitezed
during his last 6 weeks at home with minmal ambulation.
Originally, pt was able to ambulate and take care of himself
before it became to painful to walk.
Smoker:  [**12-20**] PPD x 60 years, quit 4 mos ago
H/o alcoholism, pt now admits to drinking 1 12oz beer per night.



Family History:
NC

Physical Exam:
On admittance
PE:
Gen: mild distress, diffuse erythema
HEENT: WNL
Chest: CTAB, A-fib
Abd: S/NT/ND
Ext: 5 cm open wound with purulent drainage on medial aspect of
right calf. blanching erythema from R toes to R thigh.
Skin:  Red, dry, peeling sking; pt arrived with several small
stg. decubitis on both buttocks; dry brittle nails
Pulses:       L     R
      Femoral   Mono  Mono
      [**Doctor Last Name **]       Mono
      DP        None  None
      PT        None  Mono
      Graft      -    Dop
      Radial    Dop   Palp


Pertinent Results:
[**2125-8-4**] 11:08PM
URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013 BLOOD-MOD
NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG
UROBILNGN-NEG PH-5.0 LEUK-MOD RBC-0-2 WBC-[**5-29**]* BACTERIA-FEW
YEAST-MOD EPI-0 HYALINE-0-2

[**2125-8-4**] 09:00PM
GLUCOSE-69* UREA N-31* CREAT-1.5* SODIUM-126* POTASSIUM-5.7*
CHLORIDE-95* TOTAL CO2-23 ANION GAP-14 CK(CPK)-314* proBNP-5151*
CALCIUM-8.6 PHOSPHATE-3.5 MAGNESIUM-1.7

[**2125-8-4**] 09:00PM
WBC-16.8*# RBC-3.43* HGB-10.4* HCT-30.2* MCV-88 MCH-30.2
MCHC-34.3 RDW-14.8 NEUTS-80.9* LYMPHS-5.9* MONOS-3.7 EOS-9.4*
BASOS-0.1 PLT COUNT-441*# PT-39.8* PTT-38.1* INR(PT)-4.3*

[**2125-8-10**] TTE
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF>55%).
Regional left ventricular wall motion is normal. There is no
ventricular septal defect. The right ventricular cavity is
mildly dilated with borderline normal free wall function. The
ascending aorta is moderately dilated. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate ([**12-20**]+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.


CT CHEST [**2125-8-27**]
IMPRESSION:
1. Moderate-to-large bilateral pleural effusions, new compared
to [**2125-5-22**].
2. Right [**Doctor Last Name **] lobe consolidation consistent with pneumonia.
3. Mild-to-moderate pulmonary edema superimposed over diffuse
emphysema.
4. Large solitary left paratracheal lymph node.
5. No evidence of abscess or osteomyelitis.
6. Extensive vascular calcifications including coronary arteries
and great
vessels (arteries), aorta, iliac arteries, common femoral
arteries. Minimal
arterial flow diffusely through out lower extremities.
8. Atrophy of the left leg.
9. Focal aneurysmal dilation of right common femoral artery
where in-situ
saphenous bypass arises.

CT CHEST [**2125-9-6**]
CT CHEST WITHOUT CONTRAST: Since the prior CT, there has been
placement of a
right posterior pleural pigtail catheter which terminates in the
major fissure
at the base of the right lung. There is a moderate pneumothorax
including a
basal component and smaller component along the anterior
junction line and the
pleural catheter courses through the largest air pocket. The
fluid component
is also moderate in size and is mostly unloculated, but the
attenuation of the
adjacent pleura is increased which can be seen in empyema. This
becomes a
further possibility as there is a large airspace consolidation
in the right
lower lobe consistent with pneumonia

On the left, there is a moderate partially loculated pleural
effusion which is
relatively unchanged with the prior, with associated
atelectasis. There is
severe emphysema of both lungs and severe anasarca of the soft
tissues.

There is no pericardial effusion. Multiple enlarged mediastinal
lymph nodes,
largest 22-mm left paratracheal (2:23), are very slightly
enlarged and likely
reactive. There are severe coronary artery calcifications and
severe aortic
valvular calcifications. An NG tube is located in the stomach.
The patient
is not intubated. Right PICC tip terminates in the lower SVC.

Study is not tailored for subdiaphragmatic evaluation, but no
abnormality is
noted except for high attenuation of a medullary pyramid in the
right upper
renal pole. No suspicious lesions are identified in the bones.

In the bones, there are multiple anterior wedge deformities of
T6, T7, T8, T9,
and L1, all stable from [**2125-8-27**].

IMPRESSION:
1. Moderate right hydropneumothorax with large right lower lobe
pneumonia.
The pleural effusion may be empyema.
2. Stable partially loculated moderate left pleural effusion
with underlying
atelectasis.
3. Stable enlarged mediastinal adenopathy, which may be
reactive.
4. Severe anasarca.
5. Severe coronary artery and aortic valvular calcifications.

VIDEO OROPHARYNGEAL SWALLOW STUDY [**2125-10-18**]

This study was performed in conjunction with speech pathology
department.
Continuous fluoroscopic observation was provided during
administration of
pudding and nectar-thick consistencies. During initial
nectar-thick
administration in a more recumbent position, there was marked
premature
spillover and frank aspiration, which remained silent. Cough
reflex was
inadequate in clearing the aspirated material. Subsequent
delivery of pudding
and nectar-thick consistency redemonstrated prolonged transit
times of the
oral phase and decreased epiglottic deflection. A
mild-to-moderate residue
was also again noted within the valleculae and piriform sinuses.
While no
laryngeal penetration or aspiration was identified during
swallow, there
appeared to be at least episodes of laryngeal penetration after
swallow from
leftover residue within the piriform sinus. Patient's O2
saturations were
noted to transiently decrease during these episodes.

IMPRESSION:

Episodes of laryngeal penetration and aspiration as described
above.

Technically suboptimal study.
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are moderately
thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is mild
pulmonary artery systolic hypertension. There is an anterior
space which most likely represents a fat pad.

Compared with the prior study (images reviewed) of [**2125-8-10**],
right ventricular cavity size is smaller and the severity of
pulmonary artery systolic hypertension and tricuspid
regurgitation are reduced. Aortic regurgitation and mitral
regurgitation are not appreciated on the current study, but the
image quality is suboptimal and may not reflect a true change.

[**2125-11-8**].  RLE LENI.
IMPRESSION: Deep vein thrombosis of the right superficial
femoral vein.

[**2125-11-12**].  CT Chest.
IMPRESSION:
1. Abnormality on recent chest radiograph corresponds to an
enlarging
loculated left pleural effusion. There is no evidence of a
discrete lung
abscess in this region.
2. Persistent pneumonia in the right upper and right lower lobes
with likely necrotizing component in right lower lobe. Slight
improvement in right upper lobe since prior study.
3. New obstruction of airway proximal to the tracheostomy tube,
likely due to intraluminal secretions.
2. Mild hydrostatic edema superimposed on emphysema. Widespread
anasarca.

[**2125-10-6**] 10:00 am SPUTUM      Source: Endotracheal.

                            **FINAL REPORT [**2125-10-8**]**

   GRAM STAIN (Final [**2125-10-6**]):
      <10 PMNs and <10 epithelial cells/100X field.
      4+   (>10 per 1000X FIELD):   GRAM NEGATIVE ROD(S).
      3+  (5-10 per 1000X FIELD):   GRAM POSITIVE COCCI IN
PAIRS.
      QUALITY OF SPECIMEN CANNOT BE ASSESSED.

   RESPIRATORY CULTURE (Final [**2125-10-8**]):
      SPARSE GROWTH OROPHARYNGEAL FLORA.
      STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA.    MODERATE
GROWTH.
         IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 78211**]
         [**2125-10-3**].
      KLEBSIELLA PNEUMONIAE.    MODERATE GROWTH.
         IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 78211**]
         [**2125-10-3**].

[**2125-10-3**] 7:54 pm SPUTUM      Source: Endotracheal.

                            **FINAL REPORT [**2125-10-8**]**

   GRAM STAIN (Final [**2125-10-3**]):
      >25 PMNs and <10 epithelial cells/100X field.
      NO MICROORGANISMS SEEN.

   RESPIRATORY CULTURE (Final [**2125-10-8**]):
      OROPHARYNGEAL FLORA ABSENT.
      KLEBSIELLA PNEUMONIAE.    SPARSE GROWTH.
         gram stain reviewed: 3+  (5-10 per 1000X FIELD):   GRAM
NEGATIVE
         ROD(S).  were observed [**2125-10-5**].
      STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA.    SPARSE
GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             KLEBSIELLA PNEUMONIAE
                             |          STENOTROPHOMONAS
(XANTHOMONAS) MALTOPH
                             |          |
AMIKACIN--------------   <=2 S
AMPICILLIN/SULBACTAM--    16 I
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CEFUROXIME------------     8 S
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------     8 I
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------     8 I
TRIMETHOPRIM/SULFA----  =>16 R        2 S

[**2125-9-24**] 1:15 pm BRONCHOALVEOLAR LAVAGE      LLL SUPERIOR.

   GRAM STAIN (Final [**2125-9-24**]):
      3+  (5-10 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      2+   (1-5 per 1000X FIELD):   MULTIPLE ORGANISMS
CONSISTENT WITH
                                    OROPHARYNGEAL FLORA.
      SMEAR REVIEWED; RESULTS CONFIRMED.

   RESPIRATORY CULTURE (Final [**2125-9-26**]):
      OROPHARYNGEAL FLORA ABSENT.
      ACINETOBACTER BAUMANNII COMPLEX.    >100,000
ORGANISMS/ML..
         IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 78212**]
         ([**9-24**]).
      KLEBSIELLA PNEUMONIAE.    10,000-100,000 ORGANISMS/ML..
         IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 78212**]
         ([**9-24**]).

   FUNGAL CULTURE (Final [**2125-10-8**]):    NO FUNGUS ISOLATED.

   ACID FAST SMEAR (Final [**2125-9-25**]):
      NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.

   ACID FAST CULTURE (Preliminary):    NO MYCOBACTERIA ISOLATED.


[**2125-9-24**] 1:15 pm BRONCHIAL WASHINGS      WASH RIGHT ( RLL ).

                            **FINAL REPORT [**2125-9-29**]**

   GRAM STAIN (Final [**2125-9-24**]):
      4+   (>10 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      4+   (>10 per 1000X FIELD):   GRAM NEGATIVE ROD(S).

   RESPIRATORY CULTURE (Final [**2125-9-29**]):
      OROPHARYNGEAL FLORA ABSENT.
      Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
      workup will be performed appropriate to the isolates
recovered from
      this site.
      ACINETOBACTER BAUMANNII COMPLEX.    MODERATE GROWTH.
         "Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
         used, since therapeutic efficacy relies on intrinsic
activity of
         the sulbactam component".
      KLEBSIELLA PNEUMONIAE.    MODERATE GROWTH.
      NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA.    SPARSE
GROWTH.
         AMIKACIN >32 MCG/ML.
         CEFEPIME >16 MCG/ML.
         LEVOFLOXACIN <=2.0 MCG/ML.
         sensitivity testing performed by Microscan.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ACINETOBACTER BAUMANNII COMPLEX
                             |          KLEBSIELLA PNEUMONIAE
                             |          |
NON-FERMENTER, NOT PSEUDOMO
                             |          |          |
AMIKACIN--------------               16 S          R
AMPICILLIN/SULBACTAM--     8 S     =>32 R
CEFAZOLIN-------------             =>64 R
CEFEPIME--------------    32 R                     R
CEFTAZIDIME-----------  =>64 R     =>64 R        4 S
CEFTRIAXONE-----------                        =>32 R
CEFUROXIME------------             =>64 R
CIPROFLOXACIN---------   =>4 R      =>4 R        1 S
GENTAMICIN------------  =>16 R     =>16 R      =>8 R
IMIPENEM--------------     8 I                   4 S
LEVOFLOXACIN----------                             S
MEROPENEM-------------           <=0.25 S        2 S
PIPERACILLIN----------                        =>64 R
PIPERACILLIN/TAZO-----                8 S      <=8 S
TOBRAMYCIN------------     4 S     =>16 R      =>8 R
TRIMETHOPRIM/SULFA----   <=1 S     =>16 R      <=2 S

[**2125-9-19**] 4:38 pm PLEURAL FLUID

                            **FINAL REPORT [**2125-10-18**]**

   GRAM STAIN (Final [**2125-9-19**]):
      THIS IS A CORRECTED REPORT ([**2125-9-20**]).
      REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 78213**] @ 10:25 AM ON [**2125-9-20**].

      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      2+   (1-5 per 1000X FIELD):   GRAM NEGATIVE ROD(S).
                                   .
      PREVIOUSLY REPORTED AS.
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE COCCI IN PAIRS
([**2125-9-19**]).

   FLUID CULTURE (Final [**2125-9-23**]):
      ACINETOBACTER BAUMANNII COMPLEX.    MODERATE GROWTH.
         IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 78214**]
         ([**2125-9-18**]).
      KLEBSIELLA PNEUMONIAE.    MODERATE GROWTH.
         WARNING! This isolate is an extended-spectrum
beta-lactamase
         (ESBL) producer and should be considered resistant to
all
         penicillins, cephalosporins, and aztreonam. Consider
Infectious
         Disease consultation for serious infections caused by
         ESBL-producing species.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             KLEBSIELLA PNEUMONIAE
                             |
AMIKACIN--------------    16 S
AMPICILLIN/SULBACTAM--  =>32 R
CEFAZOLIN-------------  =>64 R
CEFEPIME--------------       R
CEFTAZIDIME-----------  =>64 R
CEFTRIAXONE-----------       R
CEFUROXIME------------  =>64 R
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------  =>16 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO-----     8 S
TOBRAMYCIN------------  =>16 R
TRIMETHOPRIM/SULFA----  =>16 R

   ANAEROBIC CULTURE (Final [**2125-9-23**]):    NO ANAEROBES ISOLATED.


   FUNGAL CULTURE (Final [**2125-10-18**]):    NO FUNGUS ISOLATED.

[**2125-9-18**] 1:27 pm PLEURAL FLUID

                            **FINAL REPORT [**2125-9-22**]**

   GRAM STAIN (Final [**2125-9-18**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      2+   (1-5 per 1000X FIELD):   GRAM NEGATIVE ROD(S).
      REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 78215**] AT 1725 ON [**2125-9-18**].

   FLUID CULTURE (Final [**2125-9-22**]):
      ACINETOBACTER BAUMANNII COMPLEX.    MODERATE GROWTH.
         "Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
         used, since therapeutic efficacy relies on intrinsic
activity of
         the sulbactam component".
      GRAM NEGATIVE ROD #2.    RARE GROWTH.
         IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 78216**]
         ([**2125-9-19**]).

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ACINETOBACTER BAUMANNII COMPLEX
                             |
AMPICILLIN/SULBACTAM--    16 I
CEFEPIME--------------    32 R
CEFTAZIDIME-----------  =>64 R
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------  =>16 R
IMIPENEM--------------  =>16 R
TOBRAMYCIN------------     8 I
TRIMETHOPRIM/SULFA----     2 S

   ANAEROBIC CULTURE (Final [**2125-9-22**]):    NO ANAEROBES ISOLATED.


[**2125-9-7**] 2:11 am SWAB      Source: CT site.

                            **FINAL REPORT [**2125-9-11**]**

   WOUND CULTURE (Final [**2125-9-11**]):
      ACINETOBACTER BAUMANNII COMPLEX.    MODERATE GROWTH.
         "Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
         used, since therapeutic efficacy relies on intrinsic
activity of
         the sulbactam component".
      KLEBSIELLA PNEUMONIAE.    MODERATE GROWTH.
         WARNING! This isolate is an extended-spectrum
beta-lactamase
         (ESBL) producer and should be considered resistant to
all
         penicillins, cephalosporins, and aztreonam. Consider
Infectious
         Disease consultation for serious infections caused by
         ESBL-producing species.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ACINETOBACTER BAUMANNII COMPLEX
                             |          KLEBSIELLA PNEUMONIAE
                             |          |
AMIKACIN--------------               16 S
AMPICILLIN/SULBACTAM--    16 I     =>32 R
CEFAZOLIN-------------             =>64 R
CEFEPIME--------------    32 R          R
CEFTAZIDIME-----------  =>64 R     =>64 R
CEFTRIAXONE-----------                  R
CEFUROXIME------------             =>64 R
CIPROFLOXACIN---------   =>4 R      =>4 R
GENTAMICIN------------  =>16 R     =>16 R
IMIPENEM--------------  =>16 R
MEROPENEM-------------           <=0.25 S
PIPERACILLIN/TAZO-----                8 S
TOBRAMYCIN------------     8 I     =>16 R
TRIMETHOPRIM/SULFA----   <=1 S     =>16 R

[**2125-8-5**] 5:03 am SWAB      Source: r groin.

                            **FINAL REPORT [**2125-8-8**]**

   WOUND CULTURE (Final [**2125-8-8**]):
      Due to mixed bacterial types (>=3) an abbreviated workup
is
      performed; P.aeruginosa, S.aureus and beta strep. are
reported if
      present. Susceptibility will be performed on P.aeruginosa
and
      S.aureus if sparse growth or greater..
      STAPH AUREUS COAG +.    MODERATE 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.

                              SENSITIVITIES: MIC expressed in
MCG/ML

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

[**2125-9-6**] 11:37 am PLEURAL FLUID

                            **FINAL REPORT [**2125-10-5**]**

   GRAM STAIN (Final [**2125-9-6**]):
      REPORTED BY PHONE TO DR. [**Last Name (STitle) 3172**] [**2125-9-6**] @ 1552..
      4+   (>10 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      4+   (>10 per 1000X FIELD):   GRAM NEGATIVE DIPLOCOCCI
(PROBABLE
      BIPOLAR STAINING GRAM NEGATIVE RODS).
      This is a concentrated smear made by cytospin method,
please refer to
      hematology for a quantitative white blood cell count..
      SMEAR REVIEWED; RESULTS CONFIRMED.

   FLUID CULTURE (Final [**2125-9-17**]):
      ACINETOBACTER BAUMANNII COMPLEX.    HEAVY GROWTH.
         "Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
         used, since therapeutic efficacy relies on intrinsic
activity of
         the sulbactam component".
         AMIKACIN AND COLISTIN REQUESTED BY DR.[**Last Name (STitle) **].
         SENT TO [**Hospital1 4534**] FOR COLISTIN SENSITIVITY.
         AMIKACIN sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
         COLISITIN = SENSITIVE AT <=2 MCG/ML , SENSITIVITIES
PERFORMED BY
         [**Hospital1 4534**] LABORATORIES.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ACINETOBACTER BAUMANNII COMPLEX
                             |
AMPICILLIN------------       R
AMPICILLIN/SULBACTAM--    16 I
CEFEPIME--------------  =>64 R
CEFTAZIDIME-----------  =>64 R
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------  =>16 R
IMIPENEM--------------  =>16 R
TOBRAMYCIN------------     8 I
TRIMETHOPRIM/SULFA----   <=1 S

   ANAEROBIC CULTURE (Final [**2125-9-10**]):    NO ANAEROBES ISOLATED.


   FUNGAL CULTURE (Final [**2125-10-5**]):    NO FUNGUS ISOLATED.

[**2125-10-18**] 04:39AM BLOOD WBC-13.5* RBC-3.42*# Hgb-10.6* Hct-31.9*#
MCV-93 MCH-30.9 MCHC-33.2 RDW-15.9* Plt Ct-804*
[**2125-8-4**] 09:00PM BLOOD WBC-16.8*# RBC-3.43* Hgb-10.4* Hct-30.2*
MCV-88 MCH-30.2 MCHC-34.3 RDW-14.8 Plt Ct-441*#
[**2125-10-18**] 04:39AM BLOOD Neuts-60.1 Lymphs-16.5* Monos-6.3
Eos-16.7* Baso-0.5
[**2125-9-27**] 04:15AM BLOOD Neuts-61.7 Lymphs-12.7* Monos-4.0
Eos-21.5* Baso-0.1
[**2125-10-18**] 04:39AM BLOOD PT-15.6* PTT-29.2 INR(PT)-1.4*
[**2125-8-14**] 09:30AM BLOOD PT-33.8* PTT-41.7* INR(PT)-3.5*
[**2125-9-24**] 07:17PM BLOOD Fibrino-312 D-Dimer-881*
[**2125-10-1**] 12:22AM BLOOD FDP-10-40*
[**2125-10-3**] 12:30AM BLOOD Ret Man-1.7*
[**2125-10-18**] 04:39AM BLOOD Glucose-86 UreaN-19 Creat-0.6 Na-133
K-4.8 Cl-99 HCO3-28 AnGap-11
[**2125-8-4**] 09:00PM BLOOD Glucose-69* UreaN-31* Creat-1.5* Na-126*
K-5.7* Cl-95* HCO3-23 AnGap-14
[**2125-10-8**] 09:08AM BLOOD CK(CPK)-18*
[**2125-8-7**] 11:30AM BLOOD ALT-30 AST-73* LD(LDH)-394* AlkPhos-52
Amylase-20 TotBili-0.5
[**2125-8-4**] 09:00PM BLOOD proBNP-5151*
[**2125-8-9**] 12:51PM BLOOD CK-MB-16* MB Indx-6.3* cTropnT-0.09*
[**2125-8-10**] 10:39AM BLOOD CK-MB-13* MB Indx-3.3 cTropnT-0.12*
[**2125-8-11**] 03:26AM BLOOD CK-MB-12* MB Indx-2.9 cTropnT-0.13*
[**2125-10-8**] 05:41PM BLOOD CK-MB-3 cTropnT-0.16*
[**2125-10-8**] 09:08AM BLOOD CK(CPK)-18*
[**2125-10-17**] 03:50AM BLOOD Calcium-9.0 Phos-4.2 Mg-2.1
[**2125-9-4**] 04:00AM BLOOD Ferritn-812*
[**2125-10-3**] 08:27PM BLOOD Hapto-222*
[**2125-8-7**] 08:55AM BLOOD TSH-3.3
[**2125-9-3**] 11:48AM BLOOD TSH-17*
[**2125-10-2**] 03:28AM BLOOD TSH-2.4
[**2125-10-2**] 03:28AM BLOOD T4-5.3
[**2125-9-13**] 04:32AM BLOOD T4-5.8 T3-52* calcTBG-0.96 TUptake-1.04
T4Index-6.0 Free T4-1.4
[**2125-10-7**] 05:25AM BLOOD Type-ART Temp-36.1 pO2-78* pCO2-49*
pH-7.47* calTCO2-37* Base XS-10
[**2125-10-5**] 04:31AM BLOOD Type-ART pO2-68* pCO2-61* pH-7.44
calTCO2-43* Base XS-13
[**2125-10-4**] 11:43AM BLOOD Type-ART Temp-35.9 FiO2-35 pO2-69*
pCO2-60* pH-7.40 calTCO2-39* Base XS-9 Intubat-INTUBATED
[**2125-10-4**] 04:13AM BLOOD Lactate-0.6

Brief Hospital Course:
In brief, this is a 75M with CAD s/p BMS, CHF, COPD, pleural
effusions, PVD s/p femeral endarterectomy and femoral to
posterior tibial bypass with saphenous vein graft [**2125-5-28**] who was
admitted [**8-4**] with a Right Lower extremity MRSA surgical wound
infection. He has had a complicated hospital course, summarized
as follows.
He was initially treated with Vancomycin, however, developed an
exfoliative rash to this medication. He completed a treatment
course with Linezolid and Unasyn. He developed pancytopenia
during this time. Hematology was consulted; it was thought to be
secondary to Linezolid. PF4Ab was negative for HIT. He also
developed acute renal failure and a NSTEMI during this time.

The patient developed increasing respiratory distress on [**8-26**];
eventually a respiratory code was called. He was found to be
unresponsive, with T = 92 degrees, BP 44/P, HR 82; he was
intubated. Nursing assessment at this time noted necrotic L
toes, necrotic calcaneous, as well as having thick bloody
secretions. His sputum ultimately grew Klebsiella. He was
treated initially with Daptomycin, Ceftazidime, and Fluconazole;
then Ceftriaxone alone from [**Date range (1) 78217**] then Meropenem started on
[**8-31**] (due to MIC levels) for a planned 10 day course (last day
planned as: [**9-6**]). A R pigtail chest tube was placed for his
pleural effusions. He was treated with stress dose steroids.
TFT's consistant with hypothyroid-- endocrine was consulted and
levothyroxine was started.

He was extubated on [**8-29**] and called out of the unit on [**8-30**]. He
was started on a heparin gtt on [**9-1**]. A L pigtail catheter
attempted but not able to be placed [**9-4**]; the R pigtail was
adjusted at that time.

On [**9-5**], the patient had an episode of respiratory distress with
hypertension to 190's/100's. He was reportedly "cyanotic" and
had blue fingertips, however, an O2 sat was unable to be
obtained. ABG around that time was 7.44/51/60/36. He was started
on a nonrebreather, given lasix/diamox and metoprolol. His
pigtail was TPA'd and put out several hundred cc's. His
respiratory status then improved and he was weaned to 2L NC. (Of
note, his I/Os were 1.6/.6 overnight).  On [**9-6**] he developed
fever and hypotension and was transferred to the MICU.

The following issues were addressed during his MICU course:

1. Sepsis: He grew acinetobacter from his pleural fluid (right).
 IP was consulted and a pigtail was placed on the left side; the
right pigtail continued to drain well. ID was consulted. He was
treated with Daptomycin/Meropenem. Unclear if acinetobacter was
a contaminant. Daptomycin was discontinued and he completed a
course of Meropenem to cover for Klebsiella Ventilator
Associated pneumonia.  He then developed another Klebsiella &
Acinetobacter pneumonia, so was treated with Meropenem/Bactrim
which was switched to Mereopenem/Cefepime when his acinetobacter
was found to be resistant to Bactrim.  He was on stress dose
steroids which were tapered and completed on [**11-13**].  He will
continue cefepime and meropenem until ???

2. Necrotic L foot: The patient requires a L AKA and a fem-fem
bypass.
Followed by vascular surgery and plan to take patient to OR when
medically clear. Cardiology saw patient and recommended stress
test prior to surgery. Plan is for patient to go to rehab to get
in better condition before undergoing vascular surgery.  He will
eventually followup with Dr. [**Last Name (STitle) 1391**].  Plavix was held, but
patient was started on pentoxyphyline and continued on aspirin.

3.Nutrition: The patient was on tube feeds throughout his
hospital stay.  He underwent several speech and swallow
evaluations and did not pass. Prior to discharge, he had an IR
guided PEG tube placed which is functioning well.  He had an
ileus for approximately 5 days which prevented him from getting
tube feeds.  He was started on an aggressive bowel regimen,
opioids were minimized, and patient was started on standing
reglan and hte ileus resolved.

4.Pain control: Patient was continuously experiencing intense
pain with any type of movement of his lower extremities.  He was
treated with gabapentin, oxycodone, and a fentanyl patch to
achieve ideal pain control.  He developed an ileus so pain
medications were weaned.  He was resumed on ultram and around
the clock tylenol.

5.Respiratory Status: Patient had a continued and persistent
hypercarbic respiratory acidosis, likely from underlying COPD,
and several episodes of pneumonia.  Tracheostomy was performed.
He was eventually weaned off the vent, with only intermittent
support on trach mask. Then over [**10-30**] developed
worsening infilatrates, reaccumulation of pleural fluid and
fever on Mereopenem/Cefepime.

6.Cellulitis: The patient developed a left knee cellulitis.
This was treated with daptomycin and ciprofloxacin for a total
of two weeks.  Daptomycin was chosen because the patient had a
history of MRSA infection and he had an allergy to vancomycin.
His antibiotics were stopped on [**10-17**].

7.Mental Status: The patient went through several weeks of being
quite sedated and unarousable.  This was evenually attributed to
the combination of high doses of tramadol and gabapentin.  His
gabpentin dosing was decreased and his tramadol was
discontinued.  The patient's mental status returned to him being
alert and interactive within two days of making these
interventions.

8.Congestive heart failure: The patient was total body fluid
overloaded.  He had marginal blood pressures and so was placed
on a lasix drip.  the patient diureses quite a bit, remaining on
the lasix drip for two weeks.  It was eventually discontinued
once his fluid status was optimized.  He still remains fluid
overloaded, but diuresis has not yet been initiated. Would
recommend diuresisi in the future.

9.NSTEMI: The patient was treated with metoprolol, aspirin.
Plavix was held due to coffee ground emesis from NGT.

10.Atrial Fibrilation: the patient was rate controlled with
metoprolol.  He was initially placed on heparin gtt, but this
was discontinued as he began to bleed from a coccygeal ulcer.
His HR was in the 90s at discharge in A. fib.

11.  RLE DVT.  Patient was initiated on lovenox when he was
found to have a RLE DVT.  He is currently getting bridged to
coumadin.  Hematocrit has been stable.

12.  Pleural effusion.  Patient has bilateral pleural effusion.
He underwent several thoracenteses during hospital stay. A
thoracentesis on [**2125-11-12**] was suggestive of empyema

Upper GU bleed: [**11-4**] stablized on proton pump inhibitor.

Medications on Admission:
Coumadin 2.5 mg daily
lasix 40 mg daily
pravachol 40 mg daily
toprol xl 100 mg [**Hospital1 **]
cardizem 120 mg daily
Kcl 40 meq daily
flomax 0.4 mg daily
vitamin D
Advair 250/50 [**Hospital1 **]
xopenex
citracal

Discharge Medications:
N/A

Discharge Disposition:
Expired

Facility:
[**Hospital3 105**] Northeast-[**Location (un) 86**]

Discharge Diagnosis:
Death
Septic shock
Respiratory arrest
Peripheral vascular disease with critical limb
ischemia/necrosis.
right lower extremity cellulitis/wound infection
Ventilator associated/hospital acquired pneumonia
delerium with agitation, etology multifactorial,resolved
drug eruption,resolving  with desqumation ? Bactrium ? Vanco,
improved
eosinophilia
Non ST elevation MI
left buttocks pressure decubitus Stg.[**12-20**],left heel decubitus
stage 1-2
history of MRSA
history of coronary artery disease, s/p PCI/stenting
atrial fibrillation
COPD
history of ETOH abuse
history of former tobacco use
history of hyponatremia-fluid restricted
acute blood loss anemia,on chronic, transfused
thrombocytopenia on linezolid with negative HIT
bone marrow suppression [**1-20**] linezolid
Urinary tract infection
bilateral pleural effusions
adrenal insuffiency- stress steroids
hypothyroid by thyroid function studies-synthroid
acute diastolic CHF


Discharge Condition:
Deceased

Discharge Instructions:
N/A

Followup Instructions:
N/A


Completed by:[**2126-5-10**]
{'Methicillin resistant Staphylococcus aureus septicemia,Acute respiratory failure,Septic shock,Cellulitis and abscess of leg, except foot,Acute kidney failure, unspecified,Unspecified pleural effusion,Pneumonia due to Klebsiella pneumoniae,Ventilator associated pneumonia,Pneumonitis due to inhalation of food or vomitus,Subendocardial infarction, initial episode of care,Acute diastolic heart failure,Unspecified intestinal obstruction,Acute posthemorrhagic anemia,Urinary tract infection, site not specified,Atherosclerosis of native arteries of the extremities with gangrene,Severe sepsis,Pressure ulcer, buttock,Atrial fibrillation,Chronic airway obstruction, not elsewhere classified,Thrombocytopenia, unspecified,Unspecified acquired hypothyroidism,Dermatitis due to drugs and medicines taken internally'}


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: Sepsis and cellulitis

PRESENT ILLNESS: 75M with CAD s/p BMS, CHF, COPD, pleural effusions, PVD s/p
femeral endarterectomy and fem to posterior tibial bypass with
saphenous vein graft [**2125-5-28**] who was admitted [**8-4**] with a Right
Lower extremity MRSA surgical wound infection.

MEDICAL HISTORY: COPD (home O2)
CAD
Paroxysmal atrial fibrillation (anticoagulated)
PVD
H/O EtOH abuse
SIADH
Possible urinary retention
Coronary artery stenting, vessels unknown

MEDICATION ON ADMISSION: Coumadin 2.5 mg daily
lasix 40 mg daily
pravachol 40 mg daily
toprol xl 100 mg [**Hospital1 **]
cardizem 120 mg daily
Kcl 40 meq daily
flomax 0.4 mg daily
vitamin D
Advair 250/50 [**Hospital1 **]
xopenex
citracal

ALLERGIES: Vancomycin / Linezolid

PHYSICAL EXAM: On admittance
PE:
Gen: mild distress, diffuse erythema
HEENT: WNL
Chest: CTAB, A-fib
Abd: S/NT/ND
Ext: 5 cm open wound with purulent drainage on medial aspect of
right calf. blanching erythema from R toes to R thigh.
Skin:  Red, dry, peeling sking; pt arrived with several small
stg. decubitis on both buttocks; dry brittle nails
Pulses:       L     R
      Femoral   Mono  Mono
      [**Doctor Last Name **]       Mono
      DP        None  None
      PT        None  Mono
      Graft      -    Dop
      Radial    Dop   Palp

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives at home with wife.  The pt has been nearly immobilitezed
during his last 6 weeks at home with minmal ambulation.
Originally, pt was able to ambulate and take care of himself
before it became to painful to walk.
Smoker:  [**12-20**] PPD x 60 years, quit 4 mos ago
H/o alcoholism, pt now admits to drinking 1 12oz beer per night. 

### Response:
{'Methicillin resistant Staphylococcus aureus septicemia,Acute respiratory failure,Septic shock,Cellulitis and abscess of leg, except foot,Acute kidney failure, unspecified,Unspecified pleural effusion,Pneumonia due to Klebsiella pneumoniae,Ventilator associated pneumonia,Pneumonitis due to inhalation of food or vomitus,Subendocardial infarction, initial episode of care,Acute diastolic heart failure,Unspecified intestinal obstruction,Acute posthemorrhagic anemia,Urinary tract infection, site not specified,Atherosclerosis of native arteries of the extremities with gangrene,Severe sepsis,Pressure ulcer, buttock,Atrial fibrillation,Chronic airway obstruction, not elsewhere classified,Thrombocytopenia, unspecified,Unspecified acquired hypothyroidism,Dermatitis due to drugs and medicines taken internally'}
