CHIEF COMPLAINT: Hypotension, tachycardia

PRESENT ILLNESS: Ms. [**Known lastname 92802**] is a 63 year old lady with a history of
polycystic kidney disease and resulting nephrectomies and end
stage liver disease. She presented to the ED today at the
request of her nephrologist ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4883**]) after an episode of
hypotension to the 60s systolic yesterday at dialysis. The
patient reports consistently low blood pressures in ths 60s-100s
systolic. Of note, the patient was found to have a clot in her
RUE fistula yesterday morning and had temporary HD access placed
yesterday evening without complication.
In the ED, initial vs were: 97.9 120 60/p 22. A diagnostic
paracentesis was performed. The patient received a 250mL bolus
of NS for SBP in the 60s which did correct her to the 80s. She
also received Vancomycin and Ceftriaxone (1g each) and 10mg of
Decadron as a stress dose given her chronic steroid use.
Transfer vitals: VS: 120 72/48 22 100%RA
On arrival to the MICU, the patient appears quite comfortable.
She complains of some abdominal discomfort (therapeutic
paracentesis scheduled for today independently) and otherwise
denies chest pain, dyspnea greater than baseline, changes in her
chronically loose stools, or any symptoms of viral illness.
Per initial Nephrology notes, the patient is normally
hypotensive but has not been tachycardic in the past which
prompted their concern.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied cough, shortness of breath. Denied chest pain or
tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.

MEDICAL HISTORY: Past Medical History (Per OMR, confirmed with patient):
- [**Last Name (NamePattern1) 93249**] (autosomal dominant w renal/liver involvement, c/b [**Doctor Last Name **]

MEDICATION ON ADMISSION: Levothyroxine 112 mcg PO DAILY
Midodrine 5 mg PO BID
Fludrocortisone 0.1 mg PO DAILY
Clotrimazole 10 mg Troche 5X/DAY
Nephrocaps 1 mg PO Daily
Sevelamer HCl 800 mg PO TIDAC
Metoclopramide 5 mg PO TIDAC (three
Omeprazole 20 mg PO Daily
Nutren Renal 0.08 2kcal/mL liquid, 1 Can TID

ALLERGIES: Iodine; Iodine Containing / Trileptal / Dilantin

PHYSICAL EXAM: Vitals: T: 99.9 BP: 84/56 P: 119 R: 17 O2: 100% 2LNC
General: Alert, oriented, some discomfort on deep breathes
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, lying flat, could not easily evaluate JVP, no LAD

FAMILY HISTORY: Father and son with [**Name (NI) 18048**].
F - died in his 80s, [**Name (NI) 18048**] and prostate cancer
M - died at [**Age over 90 **] yrs of old age
Sister w [**Name (NI) 11398**].

SOCIAL HISTORY: Lives w husband in [**Name (NI) 86**]. Ambulates w cane. Worked as a city
planner.
Smoking: denies
EtOH: 1 glass of wine/day
Drugs: denies
Methicillin susceptible Staphylococcus aureus septicemia,End stage renal disease,Other suppurative peritonitis,Nutritional marasmus,Mechanical complication due to other implant and internal device, not elsewhere classified,Secondary hyperparathyroidism (of renal origin),Other forms of epilepsy and recurrent seizures, without mention of intractable epilepsy,Systolic heart failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Tachycardia, unspecified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in other specified places,Sepsis,Long-term (current) use of steroids,Other specified disorders of liver,Diarrhea,Other sequelae of chronic liver disease
Meth susc Staph aur sept,End stage renal disease,Suppurat peritonitis NEC,Nutritional marasmus,Malfunc oth device/graft,Sec hyperparathyrd-renal,Epilep NEC w/o intr epil,Systolic hrt failure NOS,Hyp kid NOS w cr kid V,Tachycardia NOS,Abn react-procedure NEC,Accident in place NEC,Sepsis,Long-term use steroids,Liver disorders NEC,Diarrhea,Oth sequela, chr liv dis
Admission Date:  [**2148-10-4**]              Discharge Date:   [**2148-10-23**]

Date of Birth:  [**2085-7-5**]             Sex:   F

Service: MEDICINE

Allergies:
Iodine; Iodine Containing / Trileptal / Dilantin

Attending:[**First Name3 (LF) 8388**]
Chief Complaint:
Hypotension, tachycardia

Major Surgical or Invasive Procedure:
Diagnostic Paracentesis
Therapeutic Paracentesis

History of Present Illness:
Ms. [**Known lastname 92802**] is a 63 year old lady with a history of
polycystic kidney disease and resulting nephrectomies and end
stage liver disease. She presented to the ED today at the
request of her nephrologist ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4883**]) after an episode of
hypotension to the 60s systolic yesterday at dialysis. The
patient reports consistently low blood pressures in ths 60s-100s
systolic. Of note, the patient was found to have a clot in her
RUE fistula yesterday morning and had temporary HD access placed
yesterday evening without complication.
In the ED, initial vs were: 97.9 120 60/p 22. A diagnostic
paracentesis was performed. The patient received a 250mL bolus
of NS for SBP in the 60s which did correct her to the 80s. She
also received Vancomycin and Ceftriaxone (1g each) and 10mg of
Decadron as a stress dose given her chronic steroid use.
Transfer vitals: VS: 120 72/48 22 100%RA
On arrival to the MICU, the patient appears quite comfortable.
She complains of some abdominal discomfort (therapeutic
paracentesis scheduled for today independently) and otherwise
denies chest pain, dyspnea greater than baseline, changes in her
chronically loose stools, or any symptoms of viral illness.
Per initial Nephrology notes, the patient is normally
hypotensive but has not been tachycardic in the past which
prompted their concern.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied cough, shortness of breath. Denied chest pain or
tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.


Past Medical History:
Past Medical History (Per OMR, confirmed with patient):
- [**Last Name (NamePattern1) 93249**] (autosomal dominant w renal/liver involvement, c/b [**Doctor Last Name **]

aneurysmal bleed and ESRD)
- multiple liver cysts
- ESRD [**1-1**] [**Month/Day (2) 18048**] now s/p bilateral nephrectomies
- subarachnoid hemorrhage 2/2 L MCA [**Doctor Last Name **] aneurysm s/p surgical

clipping c/b peri-operative hemorrhagic stroke resulting in
right hemiparesis([**2136**])
- HTN
- secondary hyperparathyroidism
- anemia
- acidosis
- nephrolithiasis
- stress fracture of the right ankle.
- seizure disorder


Social History:
Lives w husband in [**Name (NI) 86**]. Ambulates w cane. Worked as a city
planner.
Smoking: denies
EtOH: 1 glass of wine/day
Drugs: denies


Family History:
Father and son with [**Name (NI) 18048**].
F - died in his 80s, [**Name (NI) 18048**] and prostate cancer
M - died at [**Age over 90 **] yrs of old age
Sister w [**Name (NI) 11398**].


Physical Exam:
Vitals: T: 99.9 BP: 84/56 P: 119 R: 17 O2: 100% 2LNC
General: Alert, oriented, some discomfort on deep breathes
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, lying flat, could not easily evaluate JVP, no LAD

Lungs: Clear to auscultation anteriorly, difficulty with deep
inspiration, unable to sit patient up for sufficient exam
CV: S1 & S2 fast without murmur.
Abdomen: Distended, tense with signs of previous paracentesis.
Bowel sounds present. Prominent spleen and liver.
Ext: R Subclavian/IJ HD line in place, no peripheral edema.


Pertinent Results:
Admission labs:

[**2148-10-4**] 11:50AM   PLT COUNT-380
[**2148-10-4**] 11:50AM   NEUTS-89.6* LYMPHS-4.7* MONOS-5.4 EOS-0.1
BASOS-0.2
[**2148-10-4**] 11:50AM   WBC-8.9 RBC-3.55* HGB-9.8* HCT-34.1* MCV-96
MCH-27.6 MCHC-28.7* RDW-16.5*
[**2148-10-4**] 11:50AM   CK-MB-NotDone
[**2148-10-4**] 11:50AM   cTropnT-0.90*
[**2148-10-4**] 11:50AM   LIPASE-27
[**2148-10-4**] 11:50AM   ALT(SGPT)-18 AST(SGOT)-20 CK(CPK)-39 ALK
PHOS-168* TOT BILI-1.3
[**2148-10-4**] 11:50AM   estGFR-Using this
[**2148-10-4**] 11:50AM   GLUCOSE-111* UREA N-40* CREAT-3.6* SODIUM-139
POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-29 ANION GAP-19
[**2148-10-4**] 12:02PM   LACTATE-3.6*
[**2148-10-4**] 12:02PM   COMMENTS-GREEN TOP
[**2148-10-4**] 01:06PM   PT-15.6* PTT-33.2 INR(PT)-1.4*
[**2148-10-4**] 01:20PM ASCITES  WBC-9000* RBC-1100* POLYS-80*
LYMPHS-1* MONOS-0 MACROPHAG-19*
[**2148-10-4**] 01:20PM ASCITES  TOT PROT-2.7 GLUCOSE-71 LD(LDH)-171
ALBUMIN-1.5
[**2148-10-4**] 07:59PM   PT-17.3* PTT-33.3 INR(PT)-1.6*
[**2148-10-4**] 07:59PM   PLT COUNT-309
[**2148-10-4**] 07:59PM   WBC-7.2 RBC-2.69* HGB-7.6* HCT-25.3*# MCV-94
MCH-28.4 MCHC-30.1* RDW-17.8*
[**2148-10-4**] 07:59PM   ALBUMIN-4.9* CALCIUM-9.0 PHOSPHATE-3.5
MAGNESIUM-2.2
[**2148-10-4**] 07:59PM   CK-MB-4 cTropnT-0.62*
[**2148-10-4**] 07:59PM   GLUCOSE-125* UREA N-46* CREAT-3.9* SODIUM-138
POTASSIUM-4.4 CHLORIDE-92* TOTAL CO2-26 ANION GAP-24*
[**2148-10-4**] 10:55PM   HCT-25.8*
=
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DISCHARGE LABS
PITUITARY TSH
[**2148-10-22**] 07:20AM    26*
TSH ADDED 10;40AM
THYROID Free T4
[**2148-10-22**] 07:20AM    1.1

COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2148-10-23**] 07:00AM    14.7* 2.54* 7.1* 23.1* 91 27.9 30.7*
18.0* 379
RENAL & GLUCOSE     Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2148-10-23**] 07:00AM    108* 56* 4.1* 136 5.2* 95* 28 18

MICRO:

[**2148-10-4**] Blood culture: STAPH AUREUS COAG +.
         LINEZOLID :PENDING.
         DAPTOMYCIN : PENDING.
                              SENSITIVITIES: MIC expressed in
MCG/ML
                             STAPH AUREUS COAG +
                             |
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------   <=1 S
 Anaerobic Bottle Gram Stain (Final [**2148-10-5**]): GRAM POSITIVE
COCCI IN CLUSTERS.

-[**2148-10-4**] Peritoneal Fluid Culture:
GRAM STAIN (Final [**2148-10-4**]): 3+ PMNs. No microorganisms seen.
FLUID CULTURE (Final [**2148-10-7**]): STAPH AUREUS COAG +. SPARSE
GROWTH.
                              SENSITIVITIES: MIC expressed in
MCG/ML
                             STAPH AUREUS COAG +
                             |
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------   <=1 S
 ANAEROBIC CULTURE (Final [**2148-10-8**]):    NO ANAEROBES ISOLATED.

-[**2148-10-9**] Peritoneal Fluid:
GRAM STAIN (Final [**2148-10-9**]):
 4+   (>10 per 1000X FIELD):  POLYMORPHONUCLEAR LEUKOCYTES.
 2+   (1-5 per 1000X FIELD):  GRAM POSITIVE COCCI. IN PAIRS AND
CLUSTERS.
FLUID CULTURE (Final [**2148-10-12**]): STAPH AUREUS COAG +. SPARSE
GROWTH.
         SENSITIVITIES PERFORMED ON CULTURE # 284-9889S [**2148-10-4**].

ANAEROBIC CULTURE (Final [**2148-10-13**]):    NO ANAEROBES ISOLATED.

-[**2148-10-10**] Peritoneal Fluid:
GRAM STAIN (Final [**2148-10-10**]):
 4+   (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
 2+   (1-5 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS.
FLUID CULTURE (Final [**2148-10-13**]): STAPH AUREUS COAG +.    SPARSE
GROWTH.
         SENSITIVITIES PERFORMED ON CULTURE # 284-9889S [**2148-10-4**].

ANAEROBIC CULTURE (Final [**2148-10-14**]):    NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.

-[**2148-10-10**] Mycolytic Blood Culture:
BLOOD/FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary):    NO MYCOBACTERIA ISOLATED.

-[**2148-10-13**] Peritoneal Fluid:
GRAM STAIN (Final [**2148-10-13**]):
 4+   (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
 1+    (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS IN
CLUSTERS.
FLUID CULTURE (Final [**2148-10-16**]): STAPH AUREUS COAG +. RARE
GROWTH.
         SENSITIVITIES PERFORMED ON CULTURE # 285-6101S
[**2148-10-14**].
ANAEROBIC CULTURE (Final [**2148-10-17**]):    NO ANAEROBES ISOLATED

-[**2148-10-14**] Peritoneal Fluid:
GRAM STAIN (Final [**2148-10-14**]):
 4+   (>10 per 1000X FIELD):   POLYMORPHONUCLEAR LEUKOCYTES.
 1+    (<1 per 1000X FIELD):   GRAM POSITIVE COCCI. IN PAIRS.
FLUID CULTURE (Final [**2148-10-17**]): STAPH AUREUS COAG +. RARE
GROWTH.
         DAPTOMYCIN 0.5 MCG/ML = SENSITIVE BY E-TEST.
       SENSITIVITIES: MIC expressed in MCG/ML
                             STAPH AUREUS COAG +
                             |
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
LINEZOLID-------------     2 S
OXACILLIN-------------   =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------   <=1 S
ANAEROBIC CULTURE (Final [**2148-10-20**]):    NO ANAEROBES ISOLATED.

-[**2148-10-20**] Peritoneal Fluid:
GRAM STAIN (Final [**2148-10-20**]): 1+ PMNs (<1 per 1000X FIELD). NO
MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary):    NO GROWTH.
ANAEROBIC CULTURE (Preliminary):    NO GROWTH.

-[**10-12**], [**10-13**], [**10-14**] C. Diff toxins: Negative

=
=
=
=
=
=
=
=
=
================================================================

Imaging:
-[**2148-10-4**] CXR: No acute intrathoracic process.

-[**2148-10-7**] TTE : The left atrium and right atrium are normal in
cavity size. There is mild asymmetric left ventricular
hypertrophy with normal cavity size. There is mild to moderate
regional left ventricular systolic dysfunction with near
akinesis of the third of the ventricle with a small apical
aneurysm. The remaining segments are hyperdynamic (LVEF = 50-55
%). No intraventricualr thrombus is seen. There is valvular [**Male First Name (un) **]
with a severe (?>60mmHg) resting left ventricular outflow tract
obstruction. Right ventricular chamber size and free wall motion
are normal. The ascending aorta and aortic arch are mildly
dilated. The aortic valve leaflets (?#) appear structurally
normal with good leaflet excursion. The mitral valve leaflets
are not well seen. Mild (1+) mitral regurgitation is seen. There
is mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2148-8-2**],
regional left ventricular systolic dysfunction is now present
c/w ischemia. The heart rate is also much faster

-[**2148-10-9**] Upper Extremity Doppler U/S:Thrombosis of the right
upper extremity AV fistula, extending into the brachial vein. No
fluid collection.

-[**2148-10-14**] CT Abd/Pelvis w/o contrast: 1. Increasing large amount
of ascites with generalized anasarca.
2. Innumerable hepatic cysts nearly completely replacing the
hepatic
parenchyma and causing significant hepatic enlargement and
architectural
distortion. Overall, study limited due to absence of IV
contrast.
3. Interval reduction in the size of nephrectomy bed
collections, which are suboptimally seen due to lack of IV
contrast.

-[**2148-10-17**] WBC Scan: INTERPRETATION: Following the injection of
autologous white blood cells labeled with In-111, images of the
whole body were obtained. There is normal intense splenic
uptake. Tracer activity between the proximal lower extremities
are probably contamination. Uniform symmetric mild increase in
tracer uptake is seen in proximal upper and lower extremities,
consistent with expanded bone marrow in an activated
reticuloendothelial system.
  SPECT image of the segment of abdomen encompassing the liver
demonstrates markedly distorted and irregular uptake in a
polycystic liver, generally with increased tracer activities
corresponding to hepatic parenchyma and not the innumerable
cysts. Within the liver parenchyma there is heterogeneous uptake
with some regions showing more intense uptake than others. The
reason for this heterogeneity is not apparent. Again seen is
intense physiologic splenic uptake. Moderate ascites is present.

  IMPRESSION: No definite evidence of infected hepatic abscess


Brief Hospital Course:
A 63 year old lady with a history of bilateral nephrectomies
from polycystic kidney disease, end stage liver disease and
baseline hypotension presented with staph bacteremia and
peritonitis.

#. Staph bacteremia/peritonitis & sepsis: The patient was found
to have positive blood and peritoneal cultures fo Staph aureus.
She was treated with Vanc and Ceftriaxone and Albumin per
hepatology and infectious disease recommendations. Her initially
low blood pressures responded to fluids and albumin.  The
patient remained tachycardic due to under rescussitation given
her renal status.  She was continued on home florinef and
midodrine. A TTE revealed outflow tract obstruction and wall
motion abnormalities that were consistent with ischemia. She
remained tachycardic throughout admission.

[**Hospital Ward Name 121**] 10 Course: The patient was called out to the Hepatorenal
service on [**10-6**]. She was generally stable. She underwent
hemodialysis on [**10-7**], but ended up having a positive net fluid
balance. On [**10-8**], she went to the hemodialysis unit, where she
was found to be hypotensive with systolic BP in the 60's, and
tachycardic into the 120's. Cardiac enzymes included a flat CK
(MB not performed), and troponin of 0.35. EKG was unrevealing
for ischemic changes. She remained hypotensive in spite of IV
fluid boluses, and she was transferred to the MICU on [**10-8**]. As
before, she did not require vasopressors or mechanical
ventilation, and she was called back out to the floor on [**10-10**].

Back on the floor, the patient continued to have a peripheral
leukocytosis, the in the setting of known MRSA bacteremia and
peritoneal fluid infection. Her blood cultures were negative as
of [**10-7**], and her peritoneal fluid was negative for SBP and
cultures had no growth as of [**10-20**]. Per ID recommendations, the
patient was to continue taking vancomycin for four weeks
following her first negative peritoneal fluid culture. She also
was started on Bactrim DS per ID recs, to be given on dialysis
days, immediately after HD. She was instructed to follow up in
Infectious Disease clinic two weeks and four weeks after
discharge.

TTE performed on [**10-7**] revealed aneurysmal apical akinesis which
was not seen on a prior echo. In the setting of her admission
EKG changes and cardiac enzymes, it was believed that the
patient may have had an ischemic event prior to admission. She
was started on aspirin and atorvastatin. Beta blockers were not
given, since the patient seemed to require persistent
tachycardia to maintain her borderline low blood pressures. She
was discharged with instructions to continue taking the aspirin
and atorvastatin daily.

The patient's liver disease featured MELD scores in the high
20s. Her LFTs were generally stable. Her ascites reaccumulated
regularly, and she required several large-volume paracenteses.
She was never encephalopathic and did not experience any upper
or lower GI bleeding.

Her ESRD was managed with 3X/week dialysis, which she generally
tolerated well, but which was not always successful in removing
excess fluid, given the patient's consistently tenuous
hemodynamics. She was discharged with instructions to continue
her Tues/Thurs/Sat HD schedule.

Her TSH was found to be greatly elevated on [**10-22**]. Her diarrhea
was ruled out for C. Diff infection and she was given
loperamide, which may have had some modest benefit. It was also
believed that the frequent bowel movements may have been related
to side effects from her prolonged antibiotic use, as well as
her known intermittent rectal prolapse.

Moments before discharge, the patient was found to be febrile to
101.4. She denied fever, chills or any other symptoms. A
physical exam was negative for any localizing symptoms. Her line
looked good. The patient was told that we recommend that she
stay for a work up. She insisted that she be allowed to go. We
discharged her on 2 gm of Ceftriaxone IV daily.

**************
**************
TO FOLLOW UP
1) One febrile temperature prior to discharge with blood
cultures drawn and ceftriaxone started
2) TACHYCARDIA and ISCHEMIC SEQUELAE
3) Persistent Leukocytosis without Fever or source
4) Elevated TSH and Normal Free T4
**************
**************

Medications on Admission:
Levothyroxine 112 mcg PO DAILY
Midodrine 5 mg PO BID
Fludrocortisone 0.1 mg PO DAILY
Clotrimazole 10 mg Troche 5X/DAY
Nephrocaps 1 mg PO Daily
Sevelamer HCl 800 mg PO TIDAC
Metoclopramide 5 mg PO TIDAC (three
Omeprazole 20 mg PO Daily
Nutren Renal 0.08 2kcal/mL liquid, 1 Can TID

Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Take PRIOR to dialysis, on dialysis days.
4. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: Two (2)
Tablet PO 3X/WEEK (TU,TH,SA): Take on the days you have
dialysis, AFTER dialysis is complete.
Disp:*30 Tablet(s)* Refills:*0*
5. Midodrine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): Take PRIOR to dialysis, on dialysis days. Tablet(s)
6. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
five times a day.
7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
8. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times
a day).
11. Loperamide 2 mg Capsule Sig: [**12-1**] Capsules PO QID (4 times a
day) as needed for Diarrhea.
Disp:*60 Capsule(s)* Refills:*0*
12. Vancomycin 1,000 mg Recon Soln Sig: One (1) Dose Intravenous
3X/WEEK, with Dialysis for 4 weeks: You should receive this
medication with dialysis, and the dose will be based on your
blood vancomycin levels.
13. Outpatient Lab Work
[**10-27**], [**11-3**], [**11-10**], [**11-17**]
Please draw at Dialysis:
ALT, AST, Alkaline Phosphatase, Vanc Level, esr and crp
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]
All questions regarding outpatient antibiotics should be
directed to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**]

14. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO once a
day.
15. Ceftriaxone 2 gram Recon Soln Sig: One (1) unit Intravenous
once a day for 7 days: start on [**10-23**], pm.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
Polycystic liver disease
Polycystic kidney disease/End Stage Renal Disease
Gram Positive Sepsis
.
Secondary hyperparathyroidism
Anemia
Seizure disorder
Right upper extremity hemiparesis


Discharge Condition:
Medically stable for discharge to rehabilitation facility


Discharge Instructions:
Mrs [**Known lastname 92802**],

You were admitted to the hospital for low blood pressures and
high heart rate while undergoing hemodialysis. You had two stays
in the intensive care unit, for closer monitoring. You also
underwent several paracenteses to remove fluid from your
abdomen. This fluid was initially found to be infected, and you
had a blood infection as well; both infections were treated with
intravenous antibiotics, and you will have to complete a six
week course of vancomycin. You will also need to take another
antibiotic (Bactrim) with dialysis sessions.
.
You were evalutated by our physical therapists, who felt that
you would benefit from a brief stay in a rehabilitation
facility.
.
While hospitalized, you had an echocardiogram performed to
visualize your heart function. It showed areas of your heart
that were not pumping as effectively as your last echocardiogram
showed, in [**Month (only) **]. This was concerning for a possible episode
of interrupted blood flow to your heart muscle. For this reason
you were started on aspirin and atorvastatin, to protect your
heart. You should discuss this with your primary care physician
at your next visit, and also discuss the possibility of being
referred to a cardiologist.
.
We made the following changes to your medication regimen:
-Added ASPIRIN 81 mg by mouth, daily
-Added ATORVASTATIN 40 mg by mouth, daily
-Added SULFAMETHAZOLE-TRIMETHOPRIM Double Strength, 2 tabs to be
given on the days you have hemodialysis, AFTER your dialysis
sessions are complete
-Added VANCOMYCIN. You will continue receiving this with
dialysis through [**2148-11-17**]. The particular dose of
vancomycin that you receive on any will be based on your blood
vancomycin levels, as determined by blood tests.
- Added CEFTRIAXONE - new antibiotic
.
Please call your providers or return to the hospital immediately
if you experience any severe abdominal pain, nausea, vomiting,
fevers > 101 degrees, severe chest pain, shortness of breath,
lightheadedness, or any other concerning symptoms.

Followup Instructions:
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2148-10-29**] 2:20

INFECTIOUS DISEASE CLINIC: Please call ([**Telephone/Fax (1) 4170**] to
schedule an appointment. You should be seen there two weeks
after, and four weeks after discharge, to follow-up on the
infection you had in your blood and abdominal fluid.

PRIMARY CARE PHYSICIAN:
[**Name Initial (NameIs) 7274**]: [**Last Name (LF) 639**],[**First Name3 (LF) 640**] N.
Address: [**Street Address(2) 642**], [**Location (un) **],[**Numeric Identifier 643**]
Phone: [**Telephone/Fax (1) 93255**]
Fax: [**Telephone/Fax (1) 93256**]



Completed by:[**2148-10-24**]
{'Methicillin susceptible Staphylococcus aureus septicemia,End stage renal disease,Other suppurative peritonitis,Nutritional marasmus,Mechanical complication due to other implant and internal device, not elsewhere classified,Secondary hyperparathyroidism (of renal origin),Other forms of epilepsy and recurrent seizures, without mention of intractable epilepsy,Systolic heart failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Tachycardia, unspecified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in other specified places,Sepsis,Long-term (current) use of steroids,Other specified disorders of liver,Diarrhea,Other sequelae of chronic liver disease'}


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: Hypotension, tachycardia

PRESENT ILLNESS: Ms. [**Known lastname 92802**] is a 63 year old lady with a history of
polycystic kidney disease and resulting nephrectomies and end
stage liver disease. She presented to the ED today at the
request of her nephrologist ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4883**]) after an episode of
hypotension to the 60s systolic yesterday at dialysis. The
patient reports consistently low blood pressures in ths 60s-100s
systolic. Of note, the patient was found to have a clot in her
RUE fistula yesterday morning and had temporary HD access placed
yesterday evening without complication.
In the ED, initial vs were: 97.9 120 60/p 22. A diagnostic
paracentesis was performed. The patient received a 250mL bolus
of NS for SBP in the 60s which did correct her to the 80s. She
also received Vancomycin and Ceftriaxone (1g each) and 10mg of
Decadron as a stress dose given her chronic steroid use.
Transfer vitals: VS: 120 72/48 22 100%RA
On arrival to the MICU, the patient appears quite comfortable.
She complains of some abdominal discomfort (therapeutic
paracentesis scheduled for today independently) and otherwise
denies chest pain, dyspnea greater than baseline, changes in her
chronically loose stools, or any symptoms of viral illness.
Per initial Nephrology notes, the patient is normally
hypotensive but has not been tachycardic in the past which
prompted their concern.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied cough, shortness of breath. Denied chest pain or
tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.

MEDICAL HISTORY: Past Medical History (Per OMR, confirmed with patient):
- [**Last Name (NamePattern1) 93249**] (autosomal dominant w renal/liver involvement, c/b [**Doctor Last Name **]

MEDICATION ON ADMISSION: Levothyroxine 112 mcg PO DAILY
Midodrine 5 mg PO BID
Fludrocortisone 0.1 mg PO DAILY
Clotrimazole 10 mg Troche 5X/DAY
Nephrocaps 1 mg PO Daily
Sevelamer HCl 800 mg PO TIDAC
Metoclopramide 5 mg PO TIDAC (three
Omeprazole 20 mg PO Daily
Nutren Renal 0.08 2kcal/mL liquid, 1 Can TID

ALLERGIES: Iodine; Iodine Containing / Trileptal / Dilantin

PHYSICAL EXAM: Vitals: T: 99.9 BP: 84/56 P: 119 R: 17 O2: 100% 2LNC
General: Alert, oriented, some discomfort on deep breathes
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, lying flat, could not easily evaluate JVP, no LAD

FAMILY HISTORY: Father and son with [**Name (NI) 18048**].
F - died in his 80s, [**Name (NI) 18048**] and prostate cancer
M - died at [**Age over 90 **] yrs of old age
Sister w [**Name (NI) 11398**].

SOCIAL HISTORY: Lives w husband in [**Name (NI) 86**]. Ambulates w cane. Worked as a city
planner.
Smoking: denies
EtOH: 1 glass of wine/day
Drugs: denies 

### Response:
{'Methicillin susceptible Staphylococcus aureus septicemia,End stage renal disease,Other suppurative peritonitis,Nutritional marasmus,Mechanical complication due to other implant and internal device, not elsewhere classified,Secondary hyperparathyroidism (of renal origin),Other forms of epilepsy and recurrent seizures, without mention of intractable epilepsy,Systolic heart failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Tachycardia, unspecified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in other specified places,Sepsis,Long-term (current) use of steroids,Other specified disorders of liver,Diarrhea,Other sequelae of chronic liver disease'}
