CHIEF COMPLAINT: Transferred from OSH for sepsis and resp failure

PRESENT ILLNESS: Per OSH summary: 59 yo M who was admitted on [**2193-2-27**] with muscle
aches, nausea and vomiting for a few days. Pt had some trauma to
his right elbow against a rusted gas tank. Tetanus up to date.
ED course notable for hypotension, tachycardia and diaphoresis,
with fever to 101.7. CXR negative for infiltrate. Elbow x-ray
with soft tissue swelling. Joint tap revealed group A beta
strep, PCN sensitive. Initial labs with WBC 16.2, 80 % P, 13 %
bands. Vanc was started for ? of MRSA, unasyn and clindamycin
added. CE with CK 314, MB 5.2, trop I <0.03.
.
WBC increased to 17.9, 97% P, 36 % bands. Pt noted to have resp
acidosis on [**2-28**] (ABG 7.2/81) for which he was intubated. HR in
the 180's, pt pale and diaphroetic. D-dimer elevated, V/Q scan
normal.
.
On day of transfer pt taken to OR by Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 65850**] prior to
transfer. Wide debridement with irrigation with 4 L saline/abx;
wound was left open and packed with kerlex; no necrotizing
fascitis noted. Cultures taken, gram stain pending and will be
ready [**3-2**].
.
Enroute, [**Location (un) 7622**] crew stated that his HR post procedure was
elevated to 180's in AF. Sedation was manipulated from propofol
to fentanyl/versed (recieved 450 mg fentanyl, 450 mg versed).
Received 2 L NS enroute.
.
Transferred to [**Hospital1 18**] for further mgmt. On arrival, pt intubated
and sedated.

MEDICAL HISTORY: 1. HTN
2. Elevated cholesterol

MEDICATION ON ADMISSION: Meds at home:
ASA 81 mg qd
atenolol 25 mg qd
triameterene/HCTZ 25 mg qd
lipitor 10 mg qd
.
Meds in MICU:
Hydromorphone 1-4 mg IV Q2-3H:PRN for pain
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
Sliding Scale
Ipratropium Bromide Neb 1 NEB IH Q6H
Bisacodyl 10 mg PO/PR DAILY:PRN
Lansoprazole 15 mg NG DAILY
Chloral Hydrate 500 mg PO QHS:PRN insomnia
Metoprolol 12.5 mg PO BID
DiphenhydrAMINE HCl 25 mg IV Q6H:PRN
Docusate Sodium 100 mg PO BID
Penicillin G Potassium 3 MU IV Q4H
Haloperidol 2-5 mg IV TID:PRN
Heparin 5000 UNIT TID
Vancomycin HCl 1000 mg IV Q 12H

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 97.8 103/50 (0.1 levophed) CVP 7 120 (AF) AC, 600x21, 50% Fio2,
PIP 30, I/O:3.5 L + on transfer
intubated, sedated
PEERLA, anicteric
thick neck, right IJ in place
CTA bilaterally
RRR nl s1/s2 no m/r/g
obese soft NT/D +BS
warm ext., no edema
small petichial rash on leg and chest wall, blanching
right arm wrapped in bandage

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: nonsmoker, quit several years ago, married, fisherman
Toxic shock syndrome,Pyogenic arthritis, upper arm,Septic shock,Atrial fibrillation,Acute respiratory failure,Congestive heart failure, unspecified,Blood in stool,Acute vascular insufficiency of intestine,Acute kidney failure, unspecified,Streptococcal septicemia,Cellulitis and abscess of upper arm and forearm,Open wound of elbow, with tendon involvement,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group A,Severe sepsis,Olecranon bursitis,Infection with microorganisms resistant to penicillins,Infectious colitis, enteritis, and gastroenteritis,Delirium due to conditions classified elsewhere,Other accident caused by striking against or being struck accidentally by objects or persons,Accidents occurring in industrial places and premises
Toxic shock syndrome,Pyogen arthritis-up/arm,Septic shock,Atrial fibrillation,Acute respiratry failure,CHF NOS,Blood in stool,Ac vasc insuff intestine,Acute kidney failure NOS,Streptococcal septicemia,Cellulitis of arm,Opn wound elbow w tendon,Streptococcus group a,Severe sepsis,Olecranon bursitis,Inf mcrg rstn pncllins,Infectious enteritis NOS,Delirium d/t other cond,Obj w-w/o sub fall NEC,Acc on industr premises
Admission Date:  [**2193-3-1**]              Discharge Date:   [**2193-3-22**]

Date of Birth:  [**2134-1-11**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 4219**]
Chief Complaint:
Transferred from OSH for sepsis and resp failure

Major Surgical or Invasive Procedure:
- central venous access
- arterial line
- incision & drainage of R elbow in OR
- closure of R elbow wound
- extubation
- PICC line placement

History of Present Illness:
Per OSH summary: 59 yo M who was admitted on [**2193-2-27**] with muscle
aches, nausea and vomiting for a few days. Pt had some trauma to
his right elbow against a rusted gas tank. Tetanus up to date.
ED course notable for hypotension, tachycardia and diaphoresis,
with fever to 101.7. CXR negative for infiltrate. Elbow x-ray
with soft tissue swelling. Joint tap revealed group A beta
strep, PCN sensitive. Initial labs with WBC 16.2, 80 % P, 13 %
bands. Vanc was started for ? of MRSA, unasyn and clindamycin
added. CE with CK 314, MB 5.2, trop I <0.03.
.
WBC increased to 17.9, 97% P, 36 % bands. Pt noted to have resp
acidosis on [**2-28**] (ABG 7.2/81) for which he was intubated. HR in
the 180's, pt pale and diaphroetic. D-dimer elevated, V/Q scan
normal.
.
On day of transfer pt taken to OR by Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 65850**] prior to
transfer. Wide debridement with irrigation with 4 L saline/abx;
wound was left open and packed with kerlex; no necrotizing
fascitis noted. Cultures taken, gram stain pending and will be
ready [**3-2**].
.
Enroute, [**Location (un) 7622**] crew stated that his HR post procedure was
elevated to 180's in AF. Sedation was manipulated from propofol
to fentanyl/versed (recieved 450 mg fentanyl, 450 mg versed).
Received 2 L NS enroute.
.
Transferred to [**Hospital1 18**] for further mgmt. On arrival, pt intubated
and sedated.


Past Medical History:
1. HTN
2. Elevated cholesterol


Social History:
nonsmoker, quit several years ago, married, fisherman

Family History:
non-contributory

Physical Exam:
97.8 103/50 (0.1 levophed) CVP 7 120 (AF) AC, 600x21, 50% Fio2,
PIP 30, I/O:3.5 L + on transfer
intubated, sedated
PEERLA, anicteric
thick neck, right IJ in place
CTA bilaterally
RRR nl s1/s2 no m/r/g
obese soft NT/D +BS
warm ext., no edema
small petichial rash on leg and chest wall, blanching
right arm wrapped in bandage


Pertinent Results:
Labs on admission:
WBC 17.9, HCT 34.5, MCV 87, RDW 14.0, PLT 160
(DIFF: NEUTS-81* BANDS-5 LYMPHS-3* MONOS-9 METAS-2*)
PT 13.9*, PTT 29.6, INR(PT) 1.2*
Na 136, K 4.3, Cl 102, HCO3 24, BUN 57, Cr 3.2, Glu 195
ALT(SGPT) 34, AST(SGOT) 53*, LD(LDH) 247, AMYLASE 24, TBILI 0.8,
LIP 21
CALCIUM 7.2*, PHOSPHATE 2.7, MAGNESIUM 1.4*
CORTISOL 106.6*
Lactate 2.3
[**2193-3-1**] 11:42PM ABG: 7.24/26/103 on AC 600, PEEP 5, FiO2 50%
.
Labs on discharge:
WBC 8.8, Hct 27.1, MCV 90, plts 212
Na 139, K 3.8, Cl 105, HCO3 28, BUN 14, Cr 1.4, Glu 112
Ca 7.7, Mg 1.7, P 3.2
ALT 18, AST 28, Alk Phos 64, Tbili 0.2
INR 1.1
Urine eos negative
.
MICRO:
OSH data: [**2-27**] wound asp = grp A strep
OSH data: [**3-1**] wound cx = enterococcus D (vanc sensitive), MRSA

[**3-1**] - blood cx no growth
[**3-2**] - urine cx no growth
[**3-2**] - blood cx no growth
[**3-2**] - sputum cx [**10-9**] polys, <10 epis; no orgs; resp cx OP
flora absent, sparse growth yeast
[**3-3**] - blood cx no growth
[**3-5**] - swab cx gram stain no polys, no orgs; wound cx no growth,
anaerobes no growth
[**3-6**] - urine no growth
[**3-6**] - blood cx NGTD
[**3-6**] - sputum cx >25 PMNs, <10 epithelial cells/100X field.
1+ (<1 per 1000X field) BUDDING YEAST. Resp cx: OP flora absent,
sparse growth of yeast
[**3-10**] - stool cx C diff neg
[**3-12**] - tissue cx gram stain = no polys, no orgs; cx (broth only)
+ CNS; no anaerobes isolated
[**3-12**] - stool cx fecal, campylobacter, yersinia, vibrio, Ecoli
neg
[**3-13**] - stool cx C diff neg
[**3-13**] - blood cx NGTD
[**3-13**] - urine cx <10,000 org
[**3-16**] - stool cx C diff neg
[**3-17**] - C diff toxin B PENDING
.
IMAGING:
ECHO [**3-2**] - The left ventricular cavity size is normal. Left
ventricular systolic function appears grossly preserved/vigorous
but views are technically suboptimal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Right ventricular free wall motion appears
grossly preserved
in suboptimal views. The valves are not well visualized. No
significant mitral regurgitation is detected in suboptimal
views. There is a trivial/physiologic pericardial effusion.
.
CXR [**3-2**] - A single semierect AP view at 1100 hrs is compared to
a supine film earlier from the same day. The positions of the
right IJ and endotracheal tubes are unchanged. The distal tip of
the NG tube cannot be appreciated due to underpenetration of the
film. There is no evidence of pneumothorax.
.
CXR [**3-6**] - Mild failure and left lower lobe pneumonia.
.
CXR [**3-7**] - PICC overlies the right atrium and should be pulled
back 2-3 cm into the distal SVC. Findings discussed by telephone
with IV therapy in the morning of [**2193-3-7**].
.
CXR [**3-8**] - The heart size is normal. The mediastinal and hilar
contours are normal. There is a heterogeneous worsening opacity
in the left lower lobe indicative of pneumonia. The dense
opacity in the right lower lobe is likely due to overlying soft
tissue and unlikely due to pneumonia. Note that the left
costophrenic sulcus and lower lung is not included in the film.

.
CXR [**3-9**] - Improving aeration in both lung bases.
.
CXR [**3-13**] - Opacity in the right lower lobe, atelectasis vs.
consolidation. Small layering right pleural effusion.
.
ABD XR [**3-13**] - Normal gas pattern seen within the large bowel. No
evidence of megacolon.
.
ABD XR [**3-14**] - No abnormally dilated loops of small bowel are
seen. Normal gas pattern is seen within the large bowel. No
evidence of megacolon.
.
CT a/p [**3-14**] -
1. Atelectasis at the right lung base.
2. Small amount of ascites surrounding the liver.
3. Cholelithiasis without cholecystitis.
4. Mesenteric stranding and small pockets of mesenteric fluid in
the region of the distal small bowel with possible mild small
bowel wall thickening. In the clinical setting of the patient,
this is most likely due to an ischemic or infectious etiology.
Much less likely but included in the differential diagnosis
would be atypical Crohn's disease or lymphoma. The colon appears
unremarkable.
.
ECHO [**3-15**] - There is symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Left ventricular systolic function is
hyperdynamic (EF>75%). The right ventricular free wall is
hypertrophied. Right ventricular chamber size is normal. Right
ventricular systolic function is
normal. There is no pericardial effusion. Compared with the
findings of the prior study (images reviewed) of [**2193-3-2**],
probably no major change.
.
CXR [**3-17**] - Previous right pleural effusion has resolved. There is
no pulmonary edema or pneumonia. Aside from a band of
atelectasis in the right lower lobe, the lungs are clear. Heart
size is normal and the cardiomediastinal and hilar silhouettes
are unremarkable. Biapical pleural thickening is symmetric and
unchanged.


Brief Hospital Course:
Mr. [**Known lastname 65851**] is a 59 yo M with  HTN and hyperlipidemia who
presents to [**Hospital1 18**] with group A strep toxic shock syndrome from
an injury to his R elbow from a rusted gas tank.
.
# TOXIC SHOCK SYNDROME: Mr. [**Known lastname 65851**] was transferred from OSH
with a R elbow bursitis from grp A strep who was admitted s/p
debridement in OR with subsequent septic shock, respiratory
failure, and worsening renal failure. He was admitted to the ICU
and was intubated for respiratory distress. On arrival to the
MICU, the patient was without central venous access and required
vasopressors for hypotension. A TLC central line was placed
under U/S guidance. The patient was continued on penicillin G
and clindamycin (for 5 day course) was added per ID
recommendations. Mr. [**Known lastname 65851**] went to the OR on [**3-1**] and [**3-2**]
for incision and debridement of his right elbow with open
posterior and anterior wounds.  The patient was started on
vancomycin on [**3-4**] as wound fluid from the OSH grew enteroccus
(sensitive to vancomycin) and MRSA. On [**2193-3-5**], the patient
underwent incision, debridement, and closure of the anterior
elbow and a vacuum dressing was placed to posterior elbow. He
was then gradually weaned off pressors. He was extubated on [**3-7**]
without complications.  The patient's renal failure improved
(admission Cr was 3.2) thoroughout his stay in the MICU, likely
from the administration of aggressive IVF. On [**2193-3-9**], Mr.
[**Known lastname 65851**] was able to be transferred to the general medicine
[**Hospital1 **]. His hospital course was subsequently significant for
clinical evidence of volume overload for which he was diuresed
with IV lasix. His tachypnea was noted to improve with diuresis.
Hemodynamically, he remained stable and had no further signs of
septic shock. His arm wound was closed on [**2193-3-12**]. He was
continued on penicillin and vancomycin until [**2193-3-20**]. Vancomycin
troughs were drawn regularly in response to his improving
creatinine and its dosing was adjusted appropriately. Mr.
[**Known lastname 65851**] had several sets of surveillance cultures drawn and
all were negative. He had cultures taken from his R elbow in the
OR on [**3-12**] and coagulase negative staph was the only bacteria
that grew in the culture broth.
.
# TACHYCARDIA: Mr. [**Known lastname 65851**] was found to be in afib with RVR
on admission to the MICU. Upon transfer to the floor, he was
placed on telemetry for his GI bleeding and he was found to have
episodic bursts of tachycardia, though he always defended his
BP. EKG and tele strips were consistent with several types of
tachycardia, including sinus tach, afib, and possibly AVNRT. He
was started on a beta-blocker and the dose was titrated up until
it suppressed these episodes. Cardiology was curbsided about the
need for an anti-arrhythmic vs. increasing his beta-blockade and
recommended trying to increase his beta-blockade first before
committing the patient to a course of an anti-arrhythmic as it
was felt that his arrhythmia was likely related to his current
illness and may resolve over time. He was switched to oral
beta-blockers and did well. An ECHO was performed to evaluate
for atrial clot but no clot was seen. He was found to be
hyperdynamic, but did not have any focal wall motion
abnormalities. We attempted to scan his abdomen by MRA to look
for a mesenteric clot perhaps causing an ischemic colitis, but
due to his size and his bandaged arm, he was not able to fit
appropriately in the MRI scanner. He was discharged on
metoprolol 37.5mg PO TID. It was recommended that he follow-up
with his PCP upon discharge from rehab to have a repeat EKG and
colonoscopy. If the colonoscopy is negative for any bleed and he
is persistently in afib, he may need anticoagulation.
.
# HTN: He has HTN as an outpatient, for which he was on
atenolol. His beta-blocker was restarted upon his recovery from
the ICU. He was put on metoprolol because of its shorter
half-life and he tolerated this without any difficulty. His dose
was uptitrated to 37.5mg PO TID. His goal SBP was 120-140s in
order to adequately perfuse his bowel.
.
# RESPIRATORY FAILURE: Mr. [**Known lastname 65851**] was noted to be in
respiratory failure at the time of arrival to the hospital. He
was felt to be volume overloaded by exam and was diuresed with
20mg IV lasix. He was intubated and received at least 8L of IVF
over the course of his ICU stay. Once he was hemodynamically
stable, the the focus switched to diuresis and the team
attempted to keep him 1L negative daily until his dry weight was
achieved. On the floor, we attempted diuresis with frequent
doses of lasix 20mg IV, continually monitoring his Cr so as not
to worsen his renal failure. The pt was maintained on incentive
spirometry and nebulizers. His CXR showed interval improvement
of a patchy density in the left lower lobe concerning for
pneumonia. The CXR was also significant for prominent pulmonary
vasculature, consistent with mild congestive heart failure,
which improved over time. By time of discharge, he was breathing
at a RR of 18 and his room air sats were 96%.
.
# GUAIAC POSITIVE STOOL: Mr. [**Known lastname 65851**] began to have guaiac
positive stools upon transfer to the floor. The differential
diagnosis at the time included abx related diarrhea vs. C diff
vs. ischemic colitis. NG lavage was negative for blood. His
stools were liquid brown/yellow and were strongly heme positive.
A CT of his abdomen was performed and revealed ischemic vs.
infectious colitis at the distal small bowel. He was kept NPO,
Hct were monitored regularly and protonix was changed to IV BID.
His adbomen appeared distended at the time, but he did not have
any pain. Lactate was normal. GI and general surgery were
consulted and both advocated watchful waiting. Radiology
confirmed that the patient had dilated loops of colon, but not
toxic megacolon. He was started empirically on flagyl. He
continued to have guaiac positive stools throughout the
remainder of his hospital course. He required 1u pRBC
transfusion, after which his Hct remained stable at 28. C diff
was negative x3, but C diff toxin B was pending upon discharge.
His diet was advanced and his abdominal distension improved. The
most likely diagnosis was ischemic colitis either from his
hypotension in the ICU or from a clot due to his afib. The
frequency of his stools decreased prior to discharge and the
plan was to perform an outpatient colonoscopy approximately 6
weeks after discharge. He will continue on flagyl for a total of
6 additional days, to complete a course of empiric treatment for
C. diff.
.
# ARF: The pt was noted to have an elevated BUN/Cr on admission
in the setting of sepsis. The pt's renal failure gradually
resolved with treatment and was noted to be 1.4 on discharge.
This was felt to be his new baseline. The pt was also noted to
have positive urine eosinophils at the start of his antibiotic
treatment, so all potentially nephrotoxic agents were avoided
and his medications were renally dosed. Repeat checks of his
urine eosinophils were negative x2.
.
# HYPERGLYCEMIA: Mr. [**Known lastname 65851**] was noted to be hyperglycemic
on admission in the setting of sepsis. He was maintained on an
insulin drip in the ICU but insulin was discontinued once the
patient was transferred to the floor because of stable blood
glucose levels for 4 days.
.
# DELIRIUM: The pt was noted to have ICU delirium for which he
was treated with Haldol as needed. The pt was noted to have
improvement of his mental status after being transferred to the
[**Hospital1 **]. He had another brief episode of delirium while on the
floor, but did not require any medication for his symptoms. His
mental status improved on its own. He had no focal neuro
deficits at the time so no imaging was performed.
.
# ANEMIA: Mr. [**Known lastname 65851**] was anemic on admission, but he
continued to have guaiac positive stools throughout the second
half of his hospital stay. His Hct remained stable around 28 and
serial Hcts were monitored. It had originally been thought that
the drop from 34.5 to 28.3 was likely secondary to his ongoing
infection and a small amount of ongoing blood loss via VAC
dressing. However, it continued to drift downwards to 26 and he
was having frequent episodes of frankly bloody stool. He was
given 1u pRBC for a Hct of 26 and he tolerated this transfusion
well. His Hct then remained stable at 28 despite continued,
though less frequent, liquid guaiac positive stool. Further
workup of his anemia was not pursued as he had been given a
transfusion.
.
# AXILLARY RASHES: Treated with miconazole powder.
.
# FEN: His PO intake was poor while in the ICU. Once transferred
to the floor, his diet was advanced until he began having bloody
bowel movements, at which point he was made NPO with IVF only.
Once his hematocrit stabilized, his diet was advanced to clears
and then to regular. He was tolerating POs well prior to
discharge. He did not receive much IVF once on the floor.
Instead, we diuresed him as he was grossly volume overloaded and
hypoxic as a result. His electrolytes were checked regularly and
repleted as needed.
.
# PPx: Heparin sc, PPI. He had originally been on a bowel
regimen, but it was no longer needed upon discharge given his
loose stools.
.
# CODE: Full
.
# COMM: Was with his wife, [**Name (NI) 2127**]
.
# ACCESS: Had triple lumen central line while in the ICU. On the
floor, he had a PICC line in his L arm and peripheral IV on L
hand.
.
# DISPO: To acute rehab.


Medications on Admission:
Meds at home:
ASA 81 mg qd
atenolol 25 mg qd
triameterene/HCTZ 25 mg qd
lipitor 10 mg qd
.
Meds in MICU:
Hydromorphone 1-4 mg IV Q2-3H:PRN for pain
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
Sliding Scale
Ipratropium Bromide Neb 1 NEB IH Q6H
Bisacodyl 10 mg PO/PR DAILY:PRN
Lansoprazole 15 mg NG DAILY
Chloral Hydrate 500 mg PO QHS:PRN insomnia
Metoprolol 12.5 mg PO BID
DiphenhydrAMINE HCl 25 mg IV Q6H:PRN
Docusate Sodium 100 mg PO BID
Penicillin G Potassium 3 MU IV Q4H
Haloperidol 2-5 mg IV TID:PRN
Heparin 5000 UNIT TID
Vancomycin HCl 1000 mg IV Q 12H


Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 6 days.
6. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical  [**Hospital1 **]
(2 times a day): To axillas bilaterally.
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical  [**Hospital1 **]
(2 times a day) as needed for groin rash: To groin rash .
8. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Extended Care

Facility:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital Subacute Unit

Discharge Diagnosis:
Primary diagnosis:
Grp A strep infection in R elbow
Toxic shock syndrome
Acute renal failure
Paroxysmal atrial fibrillation/flutter
ICU delirium
.
Secondary diagnosis:
HTN
Hypercholesterolemia


Discharge Condition:
Good, afebrile, BP 118/68, HR 86, sats 95% on RA. Walking with
assistance, eating and drinking well.


Discharge Instructions:
Please call your PCP or go to the nearest ER if you develop any
of the following symptoms: fever, chills, headaches, chest pain,
palpitations, lightheadedness, dizziness, shortness of breath,
leg swelling, arm pain, arm swelling, persistent diarrhea,
bloody stools, or any other worrisome symptoms.
.
Please take all your medications as prescribed. Please continue
taking flagyl, an antibiotic for your loose stools, for an
additional 6 days.
.
Please keep all your follow-up appointments.

Followup Instructions:
Please follow up with your PCP [**Name Initial (PRE) 176**] 2 weeks of discharge from
rehab. Your PCP will need to recheck an EKG to see if you are
still in atrial fibrillation and, if so, will decide whether or
not to start anticoagulation.
.
Please follow-up with your orthopedist, Dr. [**Last Name (STitle) 1005**], on [**4-9**] at 10:30am. Please call his office at [**Telephone/Fax (1) 1228**] if you
have any questions or need to reschedule.
.
Please follow-up with a gastroenterologist for a repeat
colonoscopy. You can have your PCP refer you to one in your area
or you can return to [**Hospital1 18**]. The number for the GI department at
[**Hospital1 18**] is [**Telephone/Fax (1) 463**].


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4231**]
{'Toxic shock syndrome,Pyogenic arthritis, upper arm,Septic shock,Atrial fibrillation,Acute respiratory failure,Congestive heart failure, unspecified,Blood in stool,Acute vascular insufficiency of intestine,Acute kidney failure, unspecified,Streptococcal septicemia,Cellulitis and abscess of upper arm and forearm,Open wound of elbow, with tendon involvement,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group A,Severe sepsis,Olecranon bursitis,Infection with microorganisms resistant to penicillins,Infectious colitis, enteritis, and gastroenteritis,Delirium due to conditions classified elsewhere,Other accident caused by striking against or being struck accidentally by objects or persons,Accidents occurring in industrial places and premises'}


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: Transferred from OSH for sepsis and resp failure

PRESENT ILLNESS: Per OSH summary: 59 yo M who was admitted on [**2193-2-27**] with muscle
aches, nausea and vomiting for a few days. Pt had some trauma to
his right elbow against a rusted gas tank. Tetanus up to date.
ED course notable for hypotension, tachycardia and diaphoresis,
with fever to 101.7. CXR negative for infiltrate. Elbow x-ray
with soft tissue swelling. Joint tap revealed group A beta
strep, PCN sensitive. Initial labs with WBC 16.2, 80 % P, 13 %
bands. Vanc was started for ? of MRSA, unasyn and clindamycin
added. CE with CK 314, MB 5.2, trop I <0.03.
.
WBC increased to 17.9, 97% P, 36 % bands. Pt noted to have resp
acidosis on [**2-28**] (ABG 7.2/81) for which he was intubated. HR in
the 180's, pt pale and diaphroetic. D-dimer elevated, V/Q scan
normal.
.
On day of transfer pt taken to OR by Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 65850**] prior to
transfer. Wide debridement with irrigation with 4 L saline/abx;
wound was left open and packed with kerlex; no necrotizing
fascitis noted. Cultures taken, gram stain pending and will be
ready [**3-2**].
.
Enroute, [**Location (un) 7622**] crew stated that his HR post procedure was
elevated to 180's in AF. Sedation was manipulated from propofol
to fentanyl/versed (recieved 450 mg fentanyl, 450 mg versed).
Received 2 L NS enroute.
.
Transferred to [**Hospital1 18**] for further mgmt. On arrival, pt intubated
and sedated.

MEDICAL HISTORY: 1. HTN
2. Elevated cholesterol

MEDICATION ON ADMISSION: Meds at home:
ASA 81 mg qd
atenolol 25 mg qd
triameterene/HCTZ 25 mg qd
lipitor 10 mg qd
.
Meds in MICU:
Hydromorphone 1-4 mg IV Q2-3H:PRN for pain
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
Sliding Scale
Ipratropium Bromide Neb 1 NEB IH Q6H
Bisacodyl 10 mg PO/PR DAILY:PRN
Lansoprazole 15 mg NG DAILY
Chloral Hydrate 500 mg PO QHS:PRN insomnia
Metoprolol 12.5 mg PO BID
DiphenhydrAMINE HCl 25 mg IV Q6H:PRN
Docusate Sodium 100 mg PO BID
Penicillin G Potassium 3 MU IV Q4H
Haloperidol 2-5 mg IV TID:PRN
Heparin 5000 UNIT TID
Vancomycin HCl 1000 mg IV Q 12H

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 97.8 103/50 (0.1 levophed) CVP 7 120 (AF) AC, 600x21, 50% Fio2,
PIP 30, I/O:3.5 L + on transfer
intubated, sedated
PEERLA, anicteric
thick neck, right IJ in place
CTA bilaterally
RRR nl s1/s2 no m/r/g
obese soft NT/D +BS
warm ext., no edema
small petichial rash on leg and chest wall, blanching
right arm wrapped in bandage

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: nonsmoker, quit several years ago, married, fisherman 

### Response:
{'Toxic shock syndrome,Pyogenic arthritis, upper arm,Septic shock,Atrial fibrillation,Acute respiratory failure,Congestive heart failure, unspecified,Blood in stool,Acute vascular insufficiency of intestine,Acute kidney failure, unspecified,Streptococcal septicemia,Cellulitis and abscess of upper arm and forearm,Open wound of elbow, with tendon involvement,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group A,Severe sepsis,Olecranon bursitis,Infection with microorganisms resistant to penicillins,Infectious colitis, enteritis, and gastroenteritis,Delirium due to conditions classified elsewhere,Other accident caused by striking against or being struck accidentally by objects or persons,Accidents occurring in industrial places and premises'}
