CHIEF COMPLAINT: Altered mental status, cough, diarrhea

PRESENT ILLNESS: Mr. [**Known lastname 66189**] is a 74M with an extensive past medical history, and
multiple recent hospitalizations for altered mental status and
Group B strep sepsis, who was recently discharged on [**11-26**] after
two serial hospitalizations for this. He was doing well after
discharge from the hospital on until Wednesday (two days PTA),
when he developed pain with his tube feeds, nausea, and
vomiting. His daughter reports that he would experience
abdominal pain soon after the onset of his tube feeds, which
would resolve soon after she shut them off. He vomited on
wednesday. Later that day at dialysis, he required supplemental
oxygen, which is new for him. On thursday, he developed a
productive cough, and was unable to clear his secreations.
Today, he developed worsening shortness of breath.
.
Review of systems is otherwise notable for bleedig (~1pint) from
his fistula, increased somnolence. She denies any fevers,
chills, sweats, skin rashes, diarrhea, or LE edema.
.
In the emergency department presenting vital signs were T=96.6,
BP=122/54, HR=72, O2sat=90%RA. On exam, he was initially
non-responsive to sternal rub, then became verbal during an
attempt at an ABG. Laboratory data is notable for mild
hypernatremia (147), elevated bicarb to 42 ([**Month/Year (2) 5348**] in the low
30s), HCT drop to 26.7 ([**Month/Year (2) 5348**] ~30), and a poistive UA. A CXR
was abnormal but unchanged with his known large right loculated
pleural effusion. A left sided IJ was placed as the patient has
limited access, blood cultures were drawn, and he recieved
Ceftriaxone and vancomycin for possible urine source vs.
aspiration PNA.

MEDICAL HISTORY: -CABG [**1-20**] after MI (at [**Hospital1 2177**]: LIMA to LAD, SVG to OM1, SVG to
PDA)
-Post-operative R.MCA CVA ~1wk after CABG-Pt with resultant
hemiplegia, aphasia, dsyphagia.
-Post-op large RUE DVT
-Status-post respiratory failure from CVA, now weaned of vent.
-Hypertension
-Peripheral vascular disease, status-post left
popliteal-dorsalis pedis bypass with saphenous vein graft
-S/p sepsis at [**Hospital1 **] in [**Month (only) 958**]
-Diabetes mellitus, Type II. Diagnosed 40 years ago, complicated
by nephropathy, neuropathy (sensory and autonomic leading to
urinary retention) and retinopathy (s/p bilat vitrectomies, L
eye blindness).
-ESRD initially secondary to diabetic nephropathy starting
dialysis in [**2148**].
- s/p chronic allograft insufficiency s/p R cadaveric kidney
transplant, complicated by postinfectious GN (negative [**Doctor First Name **],
ANCA, low complemt), signs of chronic rejection (sclerotic
glomeruli, interstitial fibrosis 3/[**2158**]).
-Chronic Anemia
-Neurogenic bladder
-BPH status-post TURP [**2157**].
-Chronic osteomyelitis of C-spine and bilateral feet, s/p
bilateral transmetatarsal amputations (R foot [**2145**], L foot
[**2157**]).
-HSV stomatitis/genital
-Recurrent UTI
-blindness in R eye following CVA (both eyes [**Year (4 digits) 11345**])
-Adrenal insufficiently diagnosed this year.
-PACER/ICD placed for CHB or mobitz II (records conflicting)

MEDICATION ON ADMISSION: Senna [**Hospital1 **] prn
Prednisone 5 mg daily
Lisinopril 5 mg daily
Lansoprazole 30 mg daily
Simvastatin 10 mg daily
Aspirin 81 mg daily
Simethicone 80 mg [**Hospital1 **]
Cefazolin 2g HD protocol until [**12-11**]
Insulin Glargine 12 units Qhs
Insulin Lispro sliding scale
Tube feeds: [**Month/Year (2) 94925**] renal full strength, 50cc/hr, 150cc q4H

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T=97.2 rectally... BP=125/60... HR=67... RR=20... O2=100% 2LNC
GENERAL: Somnolent, does not respond to voice, does respond to
sternal rub, but does not answer questions. Cold to touch.
[**First Name3 (LF) 4459**]: Right pupil reactive to light. Will not open his mouth
for exam.
CARDIAC: Bradycardic, with frequent PVCs. No murmurs. No JVD.
LUNGS: Moving air anteriorly. Decreased BS at right base.
ABDOMEN: [**First Name3 (LF) **] tube C/D/I, NABS, No wincing or guarding with deep
palpation. Non-distended
EXTREMITIES: Cool, with diminished pulses.

FAMILY HISTORY: Mother and brother with DM Type 2. He also has a cousin with
asthma and brother with lung cancer.

SOCIAL HISTORY: Originally from [**Country **], emigrated in [**2141**]. Retired civil
engineer. Lives at home with family, who provide chronic care.
At [**Year (4 digits) 5348**], is [**Last Name (LF) **], [**First Name3 (LF) 282**] tube dependent, and does verbalize
with his family. Prior ETOH and tobacco, not currently.
Neurosyphilis, unspecified,Acute respiratory failure,Toxic encephalopathy,Cardiac arrest,End stage renal disease,Anoxic brain damage,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Glucocorticoid deficiency,Urinary tract infection, site not specified,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Foreign body in other specified parts bronchus and lung,Other complications due to renal dialysis device, implant, and graft,Hyperosmolality and/or hypernatremia,Shock, unspecified,Other and unspecified coagulation defects,Candidiasis of mouth,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Dysphagia, unspecified,Peripheral vascular disease, unspecified,Background diabetic retinopathy,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Anemia, unspecified,Neurogenic bladder NOS,Cardiac pacemaker in situ,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Diabetes with ophthalmic manifestations, type II or unspecified type, uncontrolled,Foreign body accidentally entering other orifice,Carrier or suspected carrier of other specified infectious organism,Infection with microorganisms without mention of resistance to multiple drugs,Hypothermia not associated with low environmental temperature,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation
Neurosyphilis NOS,Acute respiratry failure,Toxic encephalopathy,Cardiac arrest,End stage renal disease,Anoxic brain damage,Hyp kid NOS w cr kid V,Glucocorticoid deficient,Urin tract infection NOS,Late ef-hemplga side NOS,FB trach/bronch/lung NEC,Comp-ren dialys dev/grft,Hyperosmolality,Shock NOS,Coagulat defect NEC/NOS,Thrush,Cor ath unsp vsl ntv/gft,Aortocoronary bypass,Dysphagia NOS,Periph vascular dis NOS,Diabetic retinopathy NOS,Nephritis NOS in oth dis,Anemia NOS,Neurogenic bladder NOS,Status cardiac pacemaker,Enterococcus group d,DMII ophth uncntrld,FB entering oth orifice,Carrier NEC,Inf mcr rst ot drg nt ml,Hypothrm-wo low env tmp,Abn react-anastom/graft
Admission Date:  [**2163-12-9**]              Discharge Date:   [**2164-1-5**]

Date of Birth:  [**2089-8-16**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 5608**]
Chief Complaint:
Altered mental status, cough, diarrhea

Major Surgical or Invasive Procedure:
Tracheostomy
Left AV fistula repair
Right femoral tunnelled dialysis line catheter placement


History of Present Illness:
Mr. [**Known lastname 66189**] is a 74M with an extensive past medical history, and
multiple recent hospitalizations for altered mental status and
Group B strep sepsis, who was recently discharged on [**11-26**] after
two serial hospitalizations for this. He was doing well after
discharge from the hospital on until Wednesday (two days PTA),
when he developed pain with his tube feeds, nausea, and
vomiting. His daughter reports that he would experience
abdominal pain soon after the onset of his tube feeds, which
would resolve soon after she shut them off. He vomited on
wednesday. Later that day at dialysis, he required supplemental
oxygen, which is new for him. On thursday, he developed a
productive cough, and was unable to clear his secreations.
Today, he developed worsening shortness of breath.
.
Review of systems is otherwise notable for bleedig (~1pint) from
his fistula, increased somnolence. She denies any fevers,
chills, sweats, skin rashes, diarrhea, or LE edema.
.
In the emergency department presenting vital signs were T=96.6,
BP=122/54, HR=72, O2sat=90%RA. On exam, he was initially
non-responsive to sternal rub, then became verbal during an
attempt at an ABG. Laboratory data is notable for mild
hypernatremia (147), elevated bicarb to 42 ([**Month/Year (2) 5348**] in the low
30s), HCT drop to 26.7 ([**Month/Year (2) 5348**] ~30), and a poistive UA. A CXR
was abnormal but unchanged with his known large right loculated
pleural effusion. A left sided IJ was placed as the patient has
limited access, blood cultures were drawn, and he recieved
Ceftriaxone and vancomycin for possible urine source vs.
aspiration PNA.


Past Medical History:
-CABG [**1-20**] after MI (at [**Hospital1 2177**]: LIMA to LAD, SVG to OM1, SVG to
PDA)
-Post-operative R.MCA CVA ~1wk after CABG-Pt with resultant
hemiplegia, aphasia, dsyphagia.
-Post-op large RUE DVT
-Status-post respiratory failure from CVA, now weaned of vent.
-Hypertension
-Peripheral vascular disease, status-post left
popliteal-dorsalis pedis bypass with saphenous vein graft
-S/p sepsis at [**Hospital1 **] in [**Month (only) 958**]
-Diabetes mellitus, Type II. Diagnosed 40 years ago, complicated
by nephropathy, neuropathy (sensory and autonomic leading to
urinary retention) and retinopathy (s/p bilat vitrectomies, L
eye blindness).
-ESRD initially secondary to diabetic nephropathy starting
dialysis in [**2148**].
- s/p chronic allograft insufficiency s/p R cadaveric kidney
transplant, complicated by postinfectious GN (negative [**Doctor First Name **],
ANCA, low complemt), signs of chronic rejection (sclerotic
glomeruli, interstitial fibrosis 3/[**2158**]).
-Chronic Anemia
-Neurogenic bladder
-BPH status-post TURP [**2157**].
-Chronic osteomyelitis of C-spine and bilateral feet, s/p
bilateral transmetatarsal amputations (R foot [**2145**], L foot
[**2157**]).
-HSV stomatitis/genital
-Recurrent UTI
-blindness in R eye following CVA (both eyes [**Year (4 digits) 11345**])
-Adrenal insufficiently diagnosed this year.
-PACER/ICD placed for CHB or mobitz II (records conflicting)

Social History:
Originally from [**Country **], emigrated in [**2141**]. Retired civil
engineer. Lives at home with family, who provide chronic care.
At [**Year (4 digits) 5348**], is [**Last Name (LF) **], [**First Name3 (LF) 282**] tube dependent, and does verbalize
with his family. Prior ETOH and tobacco, not currently.

Family History:
Mother and brother with DM Type 2. He also has a cousin with
asthma and brother with lung cancer.


Physical Exam:
T=97.2 rectally... BP=125/60... HR=67... RR=20... O2=100% 2LNC
GENERAL: Somnolent, does not respond to voice, does respond to
sternal rub, but does not answer questions. Cold to touch.
[**First Name3 (LF) 4459**]: Right pupil reactive to light. Will not open his mouth
for exam.
CARDIAC: Bradycardic, with frequent PVCs. No murmurs. No JVD.
LUNGS: Moving air anteriorly. Decreased BS at right base.
ABDOMEN: [**First Name3 (LF) **] tube C/D/I, NABS, No wincing or guarding with deep
palpation. Non-distended
EXTREMITIES: Cool, with diminished pulses.


Pertinent Results:
[**2163-12-9**] ADMISSION LABS:
WBC-5.0 RBC-2.82* Hgb-8.2* Hct-26.7* MCV-95 MCH-29.2 MCHC-30.8*
RDW-18.1* Plt Ct-232
Neuts-81.9* Lymphs-12.9* Monos-3.9 Eos-1.1 Baso-0.2
PT-15.6* PTT-50.4* INR(PT)-1.4*
Glucose-168* UreaN-27* Creat-3.1* Na-147* K-3.1* Cl-102 HCO3-42*
AnGap-6* Calcium-8.9 Phos-2.6* Mg-2.3
ALT-0 AST-8 LD(LDH)-105 CK(CPK)-8* AlkPhos-80 TotBili-0.2
Lipase-13
Lactate-1.1
.
Discharge labs:
[**2164-1-5**] 03:45AM BLOOD WBC-9.8 RBC-2.67* Hgb-8.3* Hct-26.8*
MCV-100* MCH-31.2 MCHC-31.2 RDW-21.4* Plt Ct-180
[**2164-1-5**] 03:45AM BLOOD PT-14.0* PTT-35.3* INR(PT)-1.2*
[**2164-1-5**] 03:45AM BLOOD Glucose-136* UreaN-27* Creat-2.2* Na-140
K-3.5 Cl-108 HCO3-24 AnGap-12
[**2163-12-30**] 07:28AM BLOOD ALT-24 AST-31 LD(LDH)-196 AlkPhos-122*
TotBili-0.2
[**2164-1-4**] 04:53AM BLOOD Calcium-8.7 Phos-2.7 Mg-1.8
[**2163-12-15**] 06:50AM BLOOD calTIBC-138* Ferritn-428* TRF-106*
[**2163-12-16**] 12:32PM BLOOD calTIBC-144* Ferritn-367 TRF-111*
[**2163-12-10**] 11:40AM BLOOD TSH-2.3
[**2163-12-20**] 04:09AM BLOOD Cortsol-7.3
[**2163-12-16**] 06:56PM BLOOD HIV Ab-NEGATIVE
[**2164-1-5**] 04:14AM BLOOD Type-ART Temp-36.7 Rates-/28 Tidal V-400
PEEP-5 FiO2-40 pO2-201* pCO2-38 pH-7.43 calTCO2-26 Base XS-1
-ASSIST/CON Intubat-INTUBATED
[**2164-1-3**] 07:55PM BLOOD Lactate-1.6
.
MICRO
[**2163-12-10**] 1:59 am URINE      Source: CVS.

                            **FINAL REPORT [**2163-12-13**]**

   URINE CULTURE (Final [**2163-12-13**]):
      ENTEROCOCCUS SP..    >100,000 ORGANISMS/ML..

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ENTEROCOCCUS SP.
                             |
AMPICILLIN------------  =>32 R
LINEZOLID-------------     2 S
NITROFURANTOIN--------    64 I
TETRACYCLINE----------  =>16 R
VANCOMYCIN------------  =>32 R
.
Time Taken Not Noted     Log-In Date/Time: [**2163-12-10**] 5:56 pm
      SEROLOGY/BLOOD      TAKEN FROM # 60614G.
.
[**2163-12-10**] 4:41 pm Rapid Respiratory Viral Screen & Culture
      Source: Nasopharyngeal swab.

                            **FINAL REPORT [**2163-12-12**]**

   Respiratory Viral Culture (Final [**2163-12-12**]):
      No respiratory viruses isolated.
      Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
      1,2 & 3, and Respiratory Syncytial Virus..
      Detection of viruses other than those listed above will
only be
      performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
      within 1 week if additional testing is needed.

   Respiratory Viral Antigen Screen (Final [**2163-12-10**]):
      Negative for Respiratory Viral Antigen.
      Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
      and RSV by immunofluorescence.
      Refer to respiratory viral culture for further
information.
.
                            **FINAL REPORT [**2163-12-22**]**

   RAPID PLASMA REAGIN TEST (Final [**2163-12-12**]):
      REACTIVE.
      Reference Range: Non-Reactive.

   QUANTITATIVE RPR (Final [**2163-12-22**]):
      REACTIVE AT A TITER OF 1:8.
      TEST PERFORMED BY STATE LAB.

   TREPONEMAL ANTIBODY TEST (Final [**2163-12-22**]):
      TP-PA REACTIVE.
      TEST PERFORMED BY STATE LAB.

.
[**2163-12-19**] 5:29 pm SPUTUM      Source: Endotracheal.

                            **FINAL REPORT [**2163-12-22**]**

   GRAM STAIN (Final [**2163-12-19**]):
      >25 PMNs and <10 epithelial cells/100X field.
      1+    (<1 per 1000X FIELD):   GRAM NEGATIVE ROD(S).

   RESPIRATORY CULTURE (Final [**2163-12-22**]):
      Commensal Respiratory Flora Absent.
      PSEUDOMONAS AERUGINOSA.    SPARSE GROWTH.
      KLEBSIELLA PNEUMONIAE.    RARE GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             PSEUDOMONAS AERUGINOSA
                             |          KLEBSIELLA PNEUMONIAE
                             |          |
AMPICILLIN/SULBACTAM--                4 S
CEFAZOLIN-------------              <=4 S
CEFEPIME--------------     4 S      <=1 S
CEFTAZIDIME-----------     4 S      <=1 S
CEFTRIAXONE-----------              <=1 S
CIPROFLOXACIN---------     2 I   <=0.25 S
GENTAMICIN------------     4 S      <=1 S
MEROPENEM-------------     1 S   <=0.25 S
PIPERACILLIN/TAZO-----    32 S      <=4 S
TOBRAMYCIN------------   <=1 S      <=1 S
TRIMETHOPRIM/SULFA----              <=1 S
.
[**2164-1-2**] 3:54 am STOOL     CONSISTENCY: SOFT

                            **FINAL REPORT [**2164-1-2**]**

   CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2164-1-2**]):
      Feces negative for C.difficile toxin A & B by EIA.
           (Reference Range-Negative).
.
[**2164-1-2**] 12:32 pm SPUTUM      Source: Endotracheal.

   GRAM STAIN (Final [**2164-1-2**]):
      >25 PMNs and <10 epithelial cells/100X field.
      4+   (>10 per 1000X FIELD):   GRAM NEGATIVE ROD(S).

   RESPIRATORY CULTURE (Preliminary):
      Commensal Respiratory Flora Absent.
      PSEUDOMONAS AERUGINOSA.    MODERATE GROWTH.
      GRAM NEGATIVE ROD #2.    MODERATE GROWTH.

.
CT Chest w/o [**2163-12-10**]
1. Reaccumulation of large right loculated pleural effusion,
simple in
attenuation. The pleura appears is smooth but thikc; evaluation
for infection
is limited without contrast.
2. Complete collapse of the right lower lobe and incomplete
collapse of the
right middle lobe.
3. Nodular consolidative opacity at the right apex raises the
possibility of
an infectious process.
4. Enlarged thyroid. Consider outpatient thyroid function tests
and
ultrasound if needed.
5. Atherosclerotic aortic and coronary artery calcifications.
6. Persistent cholelithiasis, atrophic kidneys and splenic
calcifications.

CT head w/o contrast [**2163-12-10**].

1. No acute intracranial hemorrhage. No mass effect. Stable
large territory
chronic infarction MR is more sensitive in the detection of
acute stroke. MR
[**First Name (Titles) 151**] [**Last Name (Titles) **] is more sensitive in the detection of sequelae
of intracranial
infarction.
2. Small amount of fluid in the right maxillary sinus raises the
possibility of sinusitis.

CT Head [**12-21**] w/o contrast:
1. No acute hemorrhage, mass effect, large mass, edema, or acute
infarction is noted.
2. Stable large region of cystic encephalomalacia and volume
loss, consistent with remote right MCA territorial infarction.
3. No pathologic enhancement.
.
EEG [**12-22**]:
This is an abnormal portable EEG due to slowing and
disorganization of the background rhythm and intermittent focal
slowing
in the left frontal and anterior sylvian regions. These findings

suggest a possible focus of subcortical dysfunction in this area
and an
underlying moderate to severe encephalopathy. Medications,
toxic/metabolic disturbances and infections are common causes.
There
were no epileptiform discharges or electrographic seizures seen
in this
recording.
.
CXR [**12-19**]:
As compared to the previous radiograph, there is now complete
opacification of the right hemithorax. The absence of
mediastinal shift to
the left suggests a combination of pleural effusion and
atelectasis. The left lung shows unchanged apical thickening and
a just minimal pleural effusion as well as a small retrocardiac
atelectasis. Focal parenchymal opacity suggesting pneumonia are
not present. The left-sided central venous access line has been
removed in the interval
.
CXR [**1-3**]:
The endotracheal tube measures 4.4 cm above the
carina. The right pleural effusion and partial collapse of the
right lung are unchanged since [**2164-1-2**]. The cardiac
and mediastinal silhouette is stable. The left lung is well
expanded. There is no pneumothorax. The right-sided pacemaker
and lead is unchanged in position.


Brief Hospital Course:
# Altered Mental Status: The patient was initially brought in to
be evaluated for possible confusion per his family. However on
further questioning, he initially appeared to be at his relative
[**Year (4 digits) 5348**] ([**Name2 (NI) 11345**], nearly deaf, left hemiplegia, intermittently
saying [**1-14**] words with signficant stimulation but rarely
oriented). An RPR was found to be mildy positive and
neurosyphyllis was thought to be possibly contributing to his
confusion. To this end a lumbar puncture under fluoroscopic
guidance was pursued. However, due to decompensation (see below)
the LP was not completed. Given the risk of a repeat LP, under
guidance from the infectious disease department, it was decided
to treat him for presumed neurosyphyllis. He received 2 weeks of
IV ceftriaxone, completed in house, with little improvement of
his mental status after his arrest. After his arrest, the
patients mental status became essentially unresponsive to any
stimuli. Repeat CT head and EEG showed no acute process. The
patient could not receive an MRI due to a pacemaker. In
consultation with neurology, his new [**Month/Day (2) 5348**] may be a result of
some anoxic brain injury.
.
# PEA arrest: The morning of his lumbar puncture, a CXR showed
complete opacification of his right lung, likely indicating a
significant mucous plug at that time. At [**Month/Day (2) 5348**], he has a
large, chronic, loculated pleural effusion that compresses most
of the right lung, leaving only a small section aerated. During
his lumbar puncture procedure, the patient suffered a PEA arrest
and was down for approximately 5 minutes. He was resuscitated
with CPR. As above, after the arrest, his mental status was
essentially unresponsive. His ability to protect his airway was
significantly decreased. After initial extubation after his
arrest, he required frequent nasal trumpet suctioning to prevent
recurrent mucous plugging. Even with frequent suctioning, he had
several further mucous plugging events with significant
desaturations requiring acute suction. The last such event was a
near respiratory arrest on the general medical floor requiring
re-intubation. After lengthy discussion with his family, it was
decided to place a tracheostomy to attempt to minimize further
mucous plugging events and ease suctioning, as he was having
significant nasopharyngeal trauma from NT suctioning. Hyocamine
tabs and mucomyst nebs were added to decrease and help clear
secretions. He will require frequent suctioning and close
monitoring of his airway to minimize further plugging events.
The family was made aware that the tracheostomy may not prevent
further events and that his overall mortality in the next year
is significant. They feel strongly that the patient would want
to continue living no matter what the cost. Extensive
discussions were held regarding goals of care and code status
with no change in his full code status. The family's overall
goal is to bring the patient home if at all possible.
.
# Respiratory Failure: As noted above, his last mucous plugging
event resulted in reintubation. He is in the process of weening
ventilatory support, currently on PS ventilation, 14/5, 40% with
good respiratory mechanics. His ventilatory support should
continue to be weened as tolerated with possible trach collar
soon. Of note, given his poor right lung, it is unlikely that
the patient will ever have a satisfactory RSBI. Sputum culture
from [**12-19**] grew pseudomonas and pan-sensitive klebsiella. The
patient had no evidence of actual pneumonia at that time. It was
felt that the pseudomonas was likely a colonizer given that the
exact same strain has been isolated from sputum cultures months
prior. The klebsiella was concurrently treated during his 2 week
course of ceftriaxone as above. Prior to discharge, a sputum
culture was growing pseudomonas and one other gram negative rod.
Again, he had no other clinical signs of pneumonia so new
antibiotics were not started. Further follow of sputum culture
should occur and if the patient decompensates, consideration of
antibiotics treating pseudomonas should occur.
.
# Pyuria: Patient had a grossly positive UA.  Ceftriaxone and
vancomycin were given initially. Piperacillin-tazobactam was
added and ceftriaxone discontinued when he became hypothermic
and altered requiring ICU transfer. He was ultimately found to
have a VRE urinary tract infection. He was treated with
linezolid, with a recommended course of 7 days. .
.
# Hypothermia: On the first hospital day the patient's
temperature dropped to <96 farenheit.  Other vital signs were
stable.  Given concominant leukopenia and positive UA, this was
concerning for sepsis.  Blood cultures were sent, and  warming
blankets were placed.  The patient was transferred to the
intensive care unit for closer monitoring in the setting of
likely sepsis, his antibiotic regimen was broadened to
vancomycin/zosyn. His hypothermia improved. He has been
hypothermic on his last several admissions. It may be that his
physiologic response to infection is hypothermia rather than
hyperthermia, or he is an outlier at the lower extreme of
temperature at [**Month/Day (4) 5348**]. On the floor after transfer out of the
ICU he initially needed a bearhugger to maintain temperatures
>96 and cultures done at that time were negative. He eventually
was able to maintain temperatures ranging 96-98 without the
assistance of a bear hugger.
.
#. ESRD:  Family reported episode of fistula bleeding the
previous day.  Pressure dressing was in place on admission. Hct
was decreased, possible secondary to this.  Transplant surgery
initially evaluated the fistula and determined that it was
functional and ready for use.  However, later on re-evaluation
transplant surgery felt that his fistula needed revision prior
to discharge. This was done and further hemodialysis should be
avoided from his fistula for 2 weeks from [**2164-1-2**]. A tunnelled
femoral HD line was placed for HD access until that time under
IR guidance.
Dialysis was continued MWF schedule. Midodrine was added to help
improve his BP prior to dialysis to assist with volume removal
and to combat possible autonomic dysfunction given wide swings
in blood pressure.
.
Enlarged Thyroid: He had chest imaging to evaluate pulmonary
function. An incidential finding of thyromegaly was noted. TFTs
are recommended as an outpatient.
.
#. Hypernatremia:  This was likely secondary to hypovolemia and
resolved.
.
#. Coronary artery disease: Aspirin, and simvastatin were
continued.
.
#. Hypertension:  Lisinopril was continued.
.
#. Type II DM:  Oral hypoglycemics were initially held and ISS
given, but restarted as his blood sugars became elevated. His
lantus was increased from 12 U QHS to 16 U QHS with effect.
.
.
#. Adrenal insufficiency- He is on 5mg prednisone daily at
[**Month/Day/Year 5348**]. There was an initial concern for sepsis, thus he got
high dose steroids,however [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim test was wnl. He was thus
tapered, and returned to his home dose of 5mg daily prior to
discharge.
.
#. Access:  He has poor vasculature. Initial PICC was placed
which was pulled back to midline prior to discharge as it was
coming out a little.
.
#. CODE STATUS: Full code  status was confirmed with the family.

Medications on Admission:
Senna [**Hospital1 **] prn
Prednisone 5 mg daily
Lisinopril 5 mg daily
Lansoprazole 30 mg daily
Simvastatin 10 mg daily
Aspirin 81 mg daily
Simethicone 80 mg [**Hospital1 **]
Cefazolin 2g HD protocol until [**12-11**]
Insulin Glargine 12 units Qhs
Insulin Lispro sliding scale
Tube feeds: [**Month/Year (2) 94925**] renal full strength, 50cc/hr, 150cc q4H

Discharge Medications:
1. Insulin Lispro 100 unit/mL Cartridge [**Month/Year (2) **]: Sliding Scale
Subcutaneous amount delivered depends on blood sugar.
2. [**Month/Year (2) **] renal full strength  [**Month/Year (2) **]: One [**Age over 90 1230**]y (150)
cc  every four (4) hours: at 50cc/hr.
3. B Complex Vitamins     Capsule [**Age over 90 **]: One (1) Cap PO DAILY
(Daily).
Disp:*30 Cap(s)* Refills:*2*
4. Folic Acid 1 mg Tablet [**Age over 90 **]: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Simvastatin 10 mg Tablet [**Age over 90 **]: One (1) Tablet PO DAILY
(Daily).
6. Folic Acid 1 mg Tablet [**Age over 90 **]: One (1) Tablet PO DAILY (Daily).

7. Ascorbic Acid 500 mg Tablet [**Age over 90 **]: One (1) Tablet PO BID (2
times a day).
8. Sodium Chloride 0.65 % Aerosol, Spray [**Age over 90 **]: [**1-14**] Sprays Nasal
TID (3 times a day) as needed for congestion.
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day (2) **]: One (1) neb Inhalation Q4H (every 4 hours) as
needed for SOB, wheeze.
10. Simethicone 80 mg Tablet, Chewable [**Month/Day (2) **]: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for nausea, high
residual.
11. B-Complex with Vitamin C     Tablet [**Month/Day (2) **]: One (1) Tablet PO
DAILY (Daily).
12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
13. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual [**Last Name (STitle) **]: One (1)
Tablet, Sublingual Sublingual QHS (once a day (at bedtime)).
14. Chlorhexidine Gluconate 0.12 % Mouthwash [**Last Name (STitle) **]: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day).
15. Midodrine 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a
day).
16. Acetylcysteine 20 % (200 mg/mL) Solution [**Hospital1 **]: Five (5) ML
Miscellaneous Q6H (every 6 hours) as needed for mucous.
17. Prednisone 10 mg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily).
18. Insulin Glargine 100 unit/mL Solution [**Hospital1 **]: Nineteen (19)
units Subcutaneous at bedtime.
19. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
20. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) ml
Injection [**Hospital1 **] (2 times a day).
21. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Mid-line, heparin dependent: Flush with 10 mL Normal Saline
followed by Heparin as above, daily and PRN per lumen.
22. Sodium Chloride 0.9%  Flush 10 mL IV PRN line flush
Mid-line, non-heparin dependent:    Flush with 10 mL Normal
Saline daily and PRN per lumen.
23. Fentanyl Citrate (PF) 50 mcg/mL Solution [**Hospital1 **]: 25-50 mcg
Injection Q2H (every 2 hours) as needed for pain, agitation.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]

Discharge Diagnosis:
Primary
Recurrent Urinary Tract Infection
Hypoxemic PEA arrest
Respiratory failure
Anoxic brain injury/altered mental status
Neurosyphillis
.
Secondary
End Stage Renal Disease
Diabetes
Hypertension
Peripheral Vascular Disease
Adrenal Insufficiency


Discharge Condition:
Hemodynamically stable
Tracheostomy in place, on PS ventilation 14/5, 40%
Non-responsive mental status (new [**Location (un) 5348**])
Afebrile


Discharge Instructions:
You were admitted to the hospital because you were confused, and
had also been having some vomiting, and bleeding from your
fistula. You were found to have an infection of your urine which
was treated with antibiotics. In the setting of working up your
confusion, a lumbar puncture was attempted. During this you had
low oxygen levels and your heart stopped. This was likely due to
mucous plugging. To attempt to prevent further plugging events,
a tracheostomy was performed. Your fistula was also surgically
repaired and a tunnelled dialysis catheter was placed in your
groin.
.
Please call your doctor or return to the hospital if you
experience confusion, shortness of breath, nausea, vomiting,
diarrhea, headache, fever, chills, changes in your bowel
movements, chest pain, or any other symptoms that are concerning
to you.

Followup Instructions:
.
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2164-1-12**] 2:40
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2164-1-12**] 3:00
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 1112**]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2164-1-12**] 3:00
{'Neurosyphilis, unspecified,Acute respiratory failure,Toxic encephalopathy,Cardiac arrest,End stage renal disease,Anoxic brain damage,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Glucocorticoid deficiency,Urinary tract infection, site not specified,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Foreign body in other specified parts bronchus and lung,Other complications due to renal dialysis device, implant, and graft,Hyperosmolality and/or hypernatremia,Shock, unspecified,Other and unspecified coagulation defects,Candidiasis of mouth,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Dysphagia, unspecified,Peripheral vascular disease, unspecified,Background diabetic retinopathy,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Anemia, unspecified,Neurogenic bladder NOS,Cardiac pacemaker in situ,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Diabetes with ophthalmic manifestations, type II or unspecified type, uncontrolled,Foreign body accidentally entering other orifice,Carrier or suspected carrier of other specified infectious organism,Infection with microorganisms without mention of resistance to multiple drugs,Hypothermia not associated with low environmental temperature,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}


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: Altered mental status, cough, diarrhea

PRESENT ILLNESS: Mr. [**Known lastname 66189**] is a 74M with an extensive past medical history, and
multiple recent hospitalizations for altered mental status and
Group B strep sepsis, who was recently discharged on [**11-26**] after
two serial hospitalizations for this. He was doing well after
discharge from the hospital on until Wednesday (two days PTA),
when he developed pain with his tube feeds, nausea, and
vomiting. His daughter reports that he would experience
abdominal pain soon after the onset of his tube feeds, which
would resolve soon after she shut them off. He vomited on
wednesday. Later that day at dialysis, he required supplemental
oxygen, which is new for him. On thursday, he developed a
productive cough, and was unable to clear his secreations.
Today, he developed worsening shortness of breath.
.
Review of systems is otherwise notable for bleedig (~1pint) from
his fistula, increased somnolence. She denies any fevers,
chills, sweats, skin rashes, diarrhea, or LE edema.
.
In the emergency department presenting vital signs were T=96.6,
BP=122/54, HR=72, O2sat=90%RA. On exam, he was initially
non-responsive to sternal rub, then became verbal during an
attempt at an ABG. Laboratory data is notable for mild
hypernatremia (147), elevated bicarb to 42 ([**Month/Year (2) 5348**] in the low
30s), HCT drop to 26.7 ([**Month/Year (2) 5348**] ~30), and a poistive UA. A CXR
was abnormal but unchanged with his known large right loculated
pleural effusion. A left sided IJ was placed as the patient has
limited access, blood cultures were drawn, and he recieved
Ceftriaxone and vancomycin for possible urine source vs.
aspiration PNA.

MEDICAL HISTORY: -CABG [**1-20**] after MI (at [**Hospital1 2177**]: LIMA to LAD, SVG to OM1, SVG to
PDA)
-Post-operative R.MCA CVA ~1wk after CABG-Pt with resultant
hemiplegia, aphasia, dsyphagia.
-Post-op large RUE DVT
-Status-post respiratory failure from CVA, now weaned of vent.
-Hypertension
-Peripheral vascular disease, status-post left
popliteal-dorsalis pedis bypass with saphenous vein graft
-S/p sepsis at [**Hospital1 **] in [**Month (only) 958**]
-Diabetes mellitus, Type II. Diagnosed 40 years ago, complicated
by nephropathy, neuropathy (sensory and autonomic leading to
urinary retention) and retinopathy (s/p bilat vitrectomies, L
eye blindness).
-ESRD initially secondary to diabetic nephropathy starting
dialysis in [**2148**].
- s/p chronic allograft insufficiency s/p R cadaveric kidney
transplant, complicated by postinfectious GN (negative [**Doctor First Name **],
ANCA, low complemt), signs of chronic rejection (sclerotic
glomeruli, interstitial fibrosis 3/[**2158**]).
-Chronic Anemia
-Neurogenic bladder
-BPH status-post TURP [**2157**].
-Chronic osteomyelitis of C-spine and bilateral feet, s/p
bilateral transmetatarsal amputations (R foot [**2145**], L foot
[**2157**]).
-HSV stomatitis/genital
-Recurrent UTI
-blindness in R eye following CVA (both eyes [**Year (4 digits) 11345**])
-Adrenal insufficiently diagnosed this year.
-PACER/ICD placed for CHB or mobitz II (records conflicting)

MEDICATION ON ADMISSION: Senna [**Hospital1 **] prn
Prednisone 5 mg daily
Lisinopril 5 mg daily
Lansoprazole 30 mg daily
Simvastatin 10 mg daily
Aspirin 81 mg daily
Simethicone 80 mg [**Hospital1 **]
Cefazolin 2g HD protocol until [**12-11**]
Insulin Glargine 12 units Qhs
Insulin Lispro sliding scale
Tube feeds: [**Month/Year (2) 94925**] renal full strength, 50cc/hr, 150cc q4H

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T=97.2 rectally... BP=125/60... HR=67... RR=20... O2=100% 2LNC
GENERAL: Somnolent, does not respond to voice, does respond to
sternal rub, but does not answer questions. Cold to touch.
[**First Name3 (LF) 4459**]: Right pupil reactive to light. Will not open his mouth
for exam.
CARDIAC: Bradycardic, with frequent PVCs. No murmurs. No JVD.
LUNGS: Moving air anteriorly. Decreased BS at right base.
ABDOMEN: [**First Name3 (LF) **] tube C/D/I, NABS, No wincing or guarding with deep
palpation. Non-distended
EXTREMITIES: Cool, with diminished pulses.

FAMILY HISTORY: Mother and brother with DM Type 2. He also has a cousin with
asthma and brother with lung cancer.

SOCIAL HISTORY: Originally from [**Country **], emigrated in [**2141**]. Retired civil
engineer. Lives at home with family, who provide chronic care.
At [**Year (4 digits) 5348**], is [**Last Name (LF) **], [**First Name3 (LF) 282**] tube dependent, and does verbalize
with his family. Prior ETOH and tobacco, not currently. 

### Response:
{'Neurosyphilis, unspecified,Acute respiratory failure,Toxic encephalopathy,Cardiac arrest,End stage renal disease,Anoxic brain damage,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Glucocorticoid deficiency,Urinary tract infection, site not specified,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Foreign body in other specified parts bronchus and lung,Other complications due to renal dialysis device, implant, and graft,Hyperosmolality and/or hypernatremia,Shock, unspecified,Other and unspecified coagulation defects,Candidiasis of mouth,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Dysphagia, unspecified,Peripheral vascular disease, unspecified,Background diabetic retinopathy,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Anemia, unspecified,Neurogenic bladder NOS,Cardiac pacemaker in situ,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Diabetes with ophthalmic manifestations, type II or unspecified type, uncontrolled,Foreign body accidentally entering other orifice,Carrier or suspected carrier of other specified infectious organism,Infection with microorganisms without mention of resistance to multiple drugs,Hypothermia not associated with low environmental temperature,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}
