CHIEF COMPLAINT: Sepsis

PRESENT ILLNESS: 57 yo M recent discharge from [**Hospital1 18**] to rehab, now returns with
tachycardia, hypotension and increasing lethargy/malaise and
increasing WBC. Pt is positive for C diff, on PO Flagyl. En
route to [**Hospital1 18**], BP dropped to 70s so diverted to [**Hospital1 **],
where better access was obtained and an a-line was placed. He
received 3500cc crystalloid with improvement in his BP and he
was transferred to [**Hospital1 18**].

MEDICAL HISTORY: ++ Pneumonia
 - [**2114-1-15**]
 - respiratory failure, intubation, tracheostomy
++ Acalculous cholecystitis
 - percutaneous cholecystostomy tube [**2114-2-21**]
 - percutaneous tube dislodgement --> fever leukocytosis [**2114-3-12**]
 - fever leukocytosis --> ERCP ([**First Name4 (NamePattern1) 3075**] [**Last Name (NamePattern1) 3549**]) w/ stent [**2114-4-9**]
 - open cholecystectomy @ [**Hospital1 18**] [**2114-4-17**]
++ Diabetes mellitus, insulin dependent
++ Atrial fibrillation
++ Congestive heart failure
++ Chronic renal insufficiency
++ MRSA
++ CDiff
++ hx ESBL-Klebs

MEDICATION ON ADMISSION: - Vanco 125 Po q 6
- Heparin 500 TID
- Famotidine 20 [**Hospital1 **]
- albuterol neb prn
- humalog SS
- Sotalol AF 80 [**2-16**] tab [**Hospital1 **]
- MVI
- Citalopram 20 2 tabs qd
- zinc 220 po qd
- vit c 500 SR [**Hospital1 **]
- tylenol 325 q 4-6 prn
- glargine 20 units qhs
- alprazolam 1mg [**Hospital1 **] prn
- oxycodone 5mg q 4-6 prn
- cipro 1 tab po BID

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM
VS: 96.7   81    136/61     18    100% on AC
Gen: Chronically ill appearing
[**Month (only) 4459**]: PERRL
Neck: trach in place
Heart: s1s2 RRR
Pulm: Coarse BS bilaterally
Abd: +BS, soft, mild TTP diffusely,
Ext: trace edema
Back: + sacral decubiti, packed
Rectal: Guaiac negative brown stool
Neuro: alert, awake, follows commands, MAE

FAMILY HISTORY: Mother healthy; father with MI.

SOCIAL HISTORY: Rehab since admission in [**Month (only) 1096**].  Used to live with his
children, Taxi driver, Divorced, 2 children.
Unspecified septicemia,Septic shock,Intestinal infection due to Clostridium difficile,Chronic respiratory failure,Urinary tract infection, site not specified,Other complications due to other vascular device, implant, and graft,Pressure ulcer, stage IV,Severe sepsis,Congestive heart failure, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Atrial fibrillation,Tracheostomy status,Gastrostomy status,Personal history, urinary (tract) infection,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Long-term (current) use of insulin,Obstructive sleep apnea (adult)(pediatric),Chronic kidney disease, unspecified,Anemia, unspecified,Personal history of Methicillin resistant Staphylococcus aureus,Other acquired absence of organ,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation
Septicemia NOS,Septic shock,Int inf clstrdium dfcile,Chronic respiratory fail,Urin tract infection NOS,Comp-oth vasc dev/graft,Pressure ulcer, stage IV,Severe sepsis,CHF NOS,DMII wo cmp nt st uncntr,Atrial fibrillation,Tracheostomy status,Gastrostomy status,Personal history UTI,Pseudomonas infect NOS,Long-term use of insulin,Obstructive sleep apnea,Chronic kidney dis NOS,Anemia NOS,Hx Methicln resist Staph,Acq absence of organ NEC,Abn react-artif implant
Admission Date:  [**2114-5-11**]              Discharge Date:   [**2114-5-17**]

Date of Birth:  [**2056-11-6**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 552**]
Chief Complaint:
Sepsis

Major Surgical or Invasive Procedure:
Central line placement x2 (femoral and R subclavian)
PICC placment and repositioning

History of Present Illness:
57 yo M recent discharge from [**Hospital1 18**] to rehab, now returns with
tachycardia, hypotension and increasing lethargy/malaise and
increasing WBC. Pt is positive for C diff, on PO Flagyl. En
route to [**Hospital1 18**], BP dropped to 70s so diverted to [**Hospital1 **],
where better access was obtained and an a-line was placed. He
received 3500cc crystalloid with improvement in his BP and he
was transferred to [**Hospital1 18**].

Recent admission [**4-27**] to this hospital with fever, leukocytosis
and hypotension, eventually dx'd with C diff and placed on PO
VAnco. Urine cx returned yesterday with pseudomonas resistant to
Cipro.

In the ED here, VS: 97.9, 100/44, 76, 16, 100% A femoral CVL was
placed. Levophed was started. He received Vanco, Zosyn, and
Flagyl after cx obtained.

On arrival to the MICU pt indicates that he feels better.

Past Medical History:
++ Pneumonia
 - [**2114-1-15**]
 - respiratory failure, intubation, tracheostomy
++ Acalculous cholecystitis
 - percutaneous cholecystostomy tube [**2114-2-21**]
 - percutaneous tube dislodgement --> fever leukocytosis [**2114-3-12**]
 - fever leukocytosis --> ERCP ([**First Name4 (NamePattern1) 3075**] [**Last Name (NamePattern1) 3549**]) w/ stent [**2114-4-9**]
 - open cholecystectomy @ [**Hospital1 18**] [**2114-4-17**]
++ Diabetes mellitus, insulin dependent
++ Atrial fibrillation
++ Congestive heart failure
++ Chronic renal insufficiency
++ MRSA
++ CDiff
++ hx ESBL-Klebs

Past Surgery History
- trach/EG
- cholecystostomy tube on [**2-21**], Tube replaced on [**3-12**]

Social History:
Rehab since admission in [**Month (only) 1096**].  Used to live with his
children, Taxi driver, Divorced, 2 children.


Family History:
Mother healthy; father with MI.

Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 96.7   81    136/61     18    100% on AC
Gen: Chronically ill appearing
[**Month (only) 4459**]: PERRL
Neck: trach in place
Heart: s1s2 RRR
Pulm: Coarse BS bilaterally
Abd: +BS, soft, mild TTP diffusely,
Ext: trace edema
Back: + sacral decubiti, packed
Rectal: Guaiac negative brown stool
Neuro: alert, awake, follows commands, MAE

Pertinent Results:
ADMISSION LABS:

[**2114-5-10**] 11:00PM   WBC-21.1* RBC-2.89* HGB-8.5* HCT-26.5* MCV-92
MCH-29.4 MCHC-32.1 RDW-15.0
[**2114-5-10**] 11:00PM   NEUTS-89.7* LYMPHS-5.1* MONOS-1.6* EOS-3.3
BASOS-0.3
[**2114-5-10**] 11:00PM   GLUCOSE-261* UREA N-26* CREAT-1.2 SODIUM-135
POTASSIUM-4.7 CHLORIDE-98 TOTAL CO2-27 ANION GAP-15
[**2114-5-10**] 11:35PM   GLUCOSE-245* LACTATE-2.2* NA+-134* K+-4.7
CL--98* TCO2-28
[**2114-5-10**] 11:00PM   ALT(SGPT)-24 AST(SGOT)-46* CK(CPK)-24* ALK
PHOS-391* TOT BILI-0.3
[**2114-5-10**] 11:00PM   LIPASE-8
[**2114-5-10**] 11:00PM   TOT PROT-5.6* CALCIUM-7.9* PHOSPHATE-3.8
MAGNESIUM-1.7
[**2114-5-10**] 11:00PM   PT-15.7* PTT-40.6* INR(PT)-1.4*

WBC trend:
[**2114-5-11**] 03:36AM BLOOD WBC-27.1* RBC-2.74* Hgb-7.9* Hct-25.1*
MCV-92 MCH-28.9 MCHC-31.6 RDW-14.7 Plt Ct-245
[**2114-5-12**] 04:22AM BLOOD WBC-14.5* RBC-2.88* Hgb-8.2* Hct-25.7*
MCV-89 MCH-28.5 MCHC-32.0 RDW-15.5 Plt Ct-195
[**2114-5-13**] 05:48AM BLOOD WBC-10.2 RBC-2.79* Hgb-8.2* Hct-24.9*
MCV-90 MCH-29.3 MCHC-32.7 RDW-15.7* Plt Ct-182
[**2114-5-14**] 06:40AM BLOOD WBC-12.5* RBC-3.13* Hgb-9.3* Hct-27.8*
MCV-89 MCH-29.7 MCHC-33.4 RDW-15.4 Plt Ct-193
[**2114-5-15**] 05:50AM BLOOD WBC-12.0* RBC-3.42* Hgb-9.8* Hct-30.9*
MCV-91 MCH-28.7 MCHC-31.7 RDW-15.2 Plt Ct-208

Discharge labs:

Hematology
  COMPLETE BLOOD COUNT WBC RBC  Hgb   Hct  MCV MCH  MCHC RDW
PltCt
[**2114-5-17**] 07:46AM    9.6 3.07* 9.3* 27.1* 88 30.2 34.3 15.8*
196
[**2114-5-17**] 07:46AM        PT, PTT, INR, Plt Ct: 14.5*, 39.4*,
1.3*, 196
Chemistry
  RENAL & GLUCOSE    Glucose UreaN Creat  Na   K   Cl HCO3 AnGap

[**2114-5-17**] 09:41AM    136*   11    0.4*  138 3.3 107 25     9

Micro:
[**2114-5-12**] 5:44 pm SPUTUM      Source: Endotracheal.
                            **FINAL REPORT [**2114-5-14**]**

   GRAM STAIN (Final [**2114-5-12**]):
      <10 PMNs and <10 epithelial cells/100X field.
      NO MICROORGANISMS SEEN.
      QUALITY OF SPECIMEN CANNOT BE ASSESSED.

   RESPIRATORY CULTURE (Final [**2114-5-14**]):
      OROPHARYNGEAL FLORA ABSENT.
      YEAST.    RARE GROWTH.
.
[**2114-5-10**] 11:00 pm BLOOD CULTURE     Site: ARM

                            **FINAL REPORT [**2114-5-16**]**

   Blood Culture, Routine (Final [**2114-5-16**]):    NO GROWTH.
.
[**2114-5-10**] 11:45 pm BLOOD CULTURE     Site: CENTRAL LINE
      CENTRAL LINE-X2.

   Blood Culture, Routine (Pending):
.
[**2114-5-11**] 12:45 am URINE     Site: CATHETER

                            **FINAL REPORT [**2114-5-12**]**

   URINE CULTURE (Final [**2114-5-12**]):    NO GROWTH.
.
Radiographic studies:
.
[**5-11**] CT chest/abd/pelvis:
IMPRESSION:
1. No cause for the patient's sepsis identified. No
intra-abdominal or
intrapelvic abscess. No evidence of pneumonia.

2. Small bilateral pleural effusions and bibasilar atelectasis.

3. Sacral decubitus ulcer with slightly increased gas in the
subcutaneous
tissues to the right of the coccyx. It is unclear if this
increased gas is
related to progressive infection or manipulation/debridement.
Clinical
correlation is recommended.
.
PORTABLE CHEST, [**2114-5-12**]

COMPARISON: Comparison study of one day earlier.

INDICATION: Possible pneumonia.

FINDINGS: Indwelling devices are in standard position, and
cardiomediastinal contours are unchanged. Lower lung volumes
result in crowding of bronchovascular structures, limiting
assessment of volume status of the patient. Increasing patchy
opacities at both bases may be due to atelectasis, but attention
to these areas on repeat radiograph with improved inspiratory
level may be helpful. Left-sided loculated fluid versus pleural
thickening is unchanged.
.
HISTORY: 57-year-old man, now status post placement of new PICC
line, assess
for placement.

COMPARISON: [**2114-5-12**].

AP PORTABLE CHEST RADIOGRAPH:

The left-sided PICC line is seen curled around in the axillory
region.

The right subclavian central venous line is in unchanged
position with the tip at the mid SVC. The patient is status post
tracheostomy, but the apparatus is seen without apparent
complications. There is persistent low lung volume, with
appearance of crowding of bronchovascular structures. The
previously noted left side opacity is unchanged and also
suggestion of left- sided fluid vs. pleural thickening.

LEFT UPPER EXTREMITY DUPLEX ULTRASOUND DATED [**2114-5-16**]:
IMPRESSION: Thrombosis of the cephalic vein in the region of the
existing PICC line. No deep venous thrombosis.


Brief Hospital Course:
57M with MMP returning from rehab with rising WBC and hypoTN,
concerning for sepsis.

# Hypotension: Most likely cause in setting of leukocytosis and
recent infections is recurrence of sepsis (most likely urine,
but other possible sources include c diff, pneumonia, sacral
decubiti). No evidence of cardiogenic shock [**3-19**] cardiac ischemia
based on 12-lead; no indication of hemorrhage (guaiac neg).  In
the ED had right femoral line placed, was volume resuscitated
and started on Levophed.  Upon arrival in the ICU, he was
continued on volume resuscitation and he pressors were ulimately
weaned the day of admission.  Given his history of Cipro
resistent Pseudomonas and ESBL Klebsiella, he was empirically
started on Meropenum / Vancomycin with Flagyl given history of
C.diff.  On [**5-11**], a right subclavian line was placed and a CT
Torso was obtained to evaluate for potential source but was
unrevealing.  Once hemodynamically stable, he was transferred to
the floor for continued care. Patient remained stable on the
floor. Sputum culture showed yeast, all other cultures negative.
Plastic surgery examined sacral wound and felt was healing well,
unlikely source of infection. IV Vanco was d/c. IV flagyl also
d/c after pt had decreased
BM and WBC remained around 12 and patient remained afebrile with
stable vital signs.

# CDiff: CDiff pos x3 during last admission. Pt started on IV
flagyl upon admission in setting of sepsis, which was D/C on
[**5-15**]. At time of d/c the patient is not having any diarrhea. Pt
remains on PO vanco and should do so until 2 weeks after d/c
meropenem.  If diarrhea continues at this point, repeat CDiff
studies and additional stool studies may be warrented.

# Urinary Tract Infection:  Prior culture from last
hospitalization revealed Pseudomonas, resistant to Cipro, which
is what the patient had been sent to rehab on. New urine culture
was sent and he was changed to Meropenem which should be
continued to complete a 14 day course. His foley was d/c on
anticipation of d/c because patient AAOx3 and states able to use
urinal.

# Respiratory Failure:  Upon admisison, was placed on AC
ventilation in ED, but patient stated he is not vent-dependent.
He was quickly transitioned to pressure support settings and
then back to his home trach mask.  Upon transfer from MICU, pt
had a Speech and Swallow evaluation for both diet modifications
and pass??????-muir valve evaluation. Patient tolerated PMV and his
diet was advanced as per SS recommendations. He developed a
productive cough while on the floor and was started on chest PT
and guaiffenesin syrup, along with his albuterol nebs and
ipratroprium MDI. Pt has been 97-100% on TM for several days
before d/c.

# Atrial Fibrillation: Upon admission was in sinus and on
Sotalol.  Sotolol was initially held given hypotension, but was
restarted [**5-12**]. Records obtained from initial hospitalization in
[**1-22**] at [**Hospital 498**] hospital indicated that patient had a single
isolated episode of afib w/RVR in the setting of complicated
pneumonia w/demand ischemia which resolved on Carizem drip. Pt
had been on Warfarin on d/c from [**Hospital1 498**] but was taken off at some
point between his d/c on [**3-2**] and his admission to [**Hospital1 18**] in
early [**Month (only) 958**], likely for surgical interventions for his
cholecystitis. After speaking with the family, it appeared that
the patient actually had had several periods of atrial
fibrillation including after cardioversion. With this additional
history, we made the decision to start the patient on Coumadin
at 5mg per day with a Lovenox bridge, which was started at 100
Q12h. He will need his INR checked and his coumadin level
adjusted accordingly. The patient should have cardiology f/u at
some point to further address this issue as well as consider an
outpatient stress test when clinically improved (based on echo
during prior admission which showed mild LV dysfunction).

# Sacral decubiti: Currently receiving dressing changes TID at
rehab. Underwent debridement in early [**Month (only) 958**].  Per prior Plastics
recommendations, patient was continued on wound care TID and
placed on a KinAir bed. Patient was evaluated by the PRS service
after transfer to the floor who recommended [**Hospital1 **] wet to dry
dressing changes, nutritional optimizaiton, frequent turning,
and f/u at PRS resident clinic in 2 months for re-evaluation.
They did not feel that his ulcer was a source of infection and
felt that it appeared to be healing well.

# Diabetes Mellitus: On Lantus and ISS as an outpatient.  Lantus
held on admission while holding tubefeeds.  Started on insulin
gtt for glucose control, which was then discontinued once his
condition improved.  On [**5-12**], his Glargine was restarted. It was
increased from 20U QHS to 25U QHS on [**5-15**] after several high BS
(mostly low to mid 200's) requiring ISS coverage.

# FEN: the patient was started on TF until evaluated by S&S on
[**5-14**] who recommended a modified diet and instructions regarding
feeding including: 1:1 observation, sitting upright while
eating, single cup sips only Consistency: Pureed (dysphagia);
Nectar prethickened liquids, Pills via PEG. PMV in place for all
POs. When he is taking adequate POs the patient's TF may be d/c.

# IV access: the patient initially had a femoral line placed in
the ED which was switched for a R subclavian in the MICU which
was switched for a L PICC line on the floor on [**5-15**]. An US was
performed for concern for DVT in the LUE which was positive for
thrombosis in the cephalic vein (in which the catheter was
placed).  The L sided PICC was pulled and a R sided PICC was
placed. At this point his R subclavian line was pulled by IR.
The decision was made not to anticoagulate the patient for the
cephalic vein thrombosis as it is not considered a DVT, however,
the patient was placed on therapeutic Lovenox as a bridge to
anticoagulation with Coumadin for his Atrial fibrillation.

# Code - FULL CODE


Medications on Admission:
- Vanco 125 Po q 6
- Heparin 500 TID
- Famotidine 20 [**Hospital1 **]
- albuterol neb prn
- humalog SS
- Sotalol AF 80 [**2-16**] tab [**Hospital1 **]
- MVI
- Citalopram 20 2 tabs qd
- zinc 220 po qd
- vit c 500 SR [**Hospital1 **]
- tylenol 325 q 4-6 prn
- glargine 20 units qhs
- alprazolam 1mg [**Hospital1 **] prn
- oxycodone 5mg q 4-6 prn
- cipro 1 tab po BID

Discharge Medications:
1. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
2. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): please continue for 2 weeks after patient completes
course of meropenem.
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day) as needed for shortness of
breath or wheezing.
5. Ascorbic Acid 90 mg/mL Drops Sig: One (1)  PO BID (2 times a
day).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
7. Sotalol 80 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).

8. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
9. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
10. Insulin Glargine 100 unit/mL Solution Sig: Twenty Five (25)
units Subcutaneous at bedtime.
11. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: Five
(5) ML Intravenous PRN (as needed) as needed for line flush.
12. Meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg
Intravenous Q6H (every 6 hours) for 9 days: needs 8 more days to
complete 14 day course.
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
14. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Enoxaparin 100 mg/mL Syringe Sig: One (1) ml Subcutaneous
Q12H (every 12 hours): Lovenox as bridge for anticoagulation
with Coumadin - can d/c once therapeutic on Coumadin. ml
16. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]

Discharge Diagnosis:
Sepsis


Discharge Condition:
stable


Discharge Instructions:
Please continue your Meropenem for 9 more days to complete a 14
day course for your urinary tract infection. Continue taking
your oral vancomycin for 2 weeks after the Meropenem is
finished. If you continue to have diarrhea, your providers
should re-check a CDiff test and my want to consider sending
additional stool studies.

We have started you on aspirin to reduce your risk of stroke and
heart attack. Please take this as directed. After reviewing your
records and speaking with your family we have decided to start
you on a blood thinning medication to prevent a stroke from your
atrial fibrillation. You will need to have your INR (blood test)
checked frequently while you are at your rehabilitation
facility.

Please continue wet to dry dressings twice daily for your wound.
Stay off your back as much as possible to help this wound to
heal.

Please continue to follow the dietary restrictions recommended
by speech and swallow:
1. PO intake of nectar thick liquids and puree.
2. Pills crushed with puree or via PEG tube.
3. 1:1 supervision with all POs.
4. PMV in place for ALL POs.
5. a) Strict 1:1 supervision
   b) Sit fully upright for all POs.
   c) No consecutive sips of liquid - single sips via CUP only.
      No straws.
   e) Alternate between each bite and sip
6. Q6 oral care.
7. Patient awaiting d/c to rehab and recommend continued
monitoring and dysphagia therapy. Suggest an instrumental
evaluation (MBS) prior to upgrading patient's diet, [**3-19**] h/o
silent aspiration of thin liquids.

Please continue to work with a social worker once at [**Name (NI) **] to
help you cope through this difficult time.

Please take your medications as prescribed. Please return to the
ED if you develop fevers, chills, are vomiting and unable to
tolerate POs, chest pain, shortness of breath, or any other
concerns.


Followup Instructions:
Please call the plastic surgery clinic at [**Telephone/Fax (1) 4652**] to
schedule a follow up appointment in resident clinic in 2 months.


We have scheduled an appointment for your with your surgeon, Dr
[**Last Name (STitle) 468**] because you missed your appointment during this visit.
Your new appointment is for [**Last Name (LF) 766**], [**5-28**] at 11:45. You can
call [**Telephone/Fax (1) 2835**] if you need to reschedule this appointment.

Please also keep your appoinment with Dr [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] On
[**2114-6-8**] ay 10:00. Please call [**Telephone/Fax (1) 22**] if you need to
reschedule this appointment.





Name:  [**Known lastname 12990**],[**Known firstname **]                      Unit No:   [**Numeric Identifier 12991**]

Admission Date:  [**2114-5-11**]              Discharge Date:   [**2114-5-17**]

Date of Birth:  [**2056-11-6**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 5420**]
Addendum:
Upon d/c it was recognized that a foley had been re-placed by
the night team after the d/c summary was written that the
catheter had been d/c. I called [**Hospital3 **] and spoke with RN
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12992**] regarding this issue and recommended that in
light of the recent severe UTI the patient should not have an
indwelling catheter. She said she would pass this on to the
physician.

Discharge Disposition:
Extended Care

Facility:
[**Hospital6 2876**] - [**Location (un) 3542**]

                             [**Name6 (MD) **] [**Last Name (NamePattern4) 5421**] MD [**MD Number(2) 5422**]

Completed by:[**2114-5-17**]
{'Unspecified septicemia,Septic shock,Intestinal infection due to Clostridium difficile,Chronic respiratory failure,Urinary tract infection, site not specified,Other complications due to other vascular device, implant, and graft,Pressure ulcer, stage IV,Severe sepsis,Congestive heart failure, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Atrial fibrillation,Tracheostomy status,Gastrostomy status,Personal history, urinary (tract) infection,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Long-term (current) use of insulin,Obstructive sleep apnea (adult)(pediatric),Chronic kidney disease, unspecified,Anemia, unspecified,Personal history of Methicillin resistant Staphylococcus aureus,Other acquired absence of organ,Surgical operation with implant of artificial internal device 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: Sepsis

PRESENT ILLNESS: 57 yo M recent discharge from [**Hospital1 18**] to rehab, now returns with
tachycardia, hypotension and increasing lethargy/malaise and
increasing WBC. Pt is positive for C diff, on PO Flagyl. En
route to [**Hospital1 18**], BP dropped to 70s so diverted to [**Hospital1 **],
where better access was obtained and an a-line was placed. He
received 3500cc crystalloid with improvement in his BP and he
was transferred to [**Hospital1 18**].

MEDICAL HISTORY: ++ Pneumonia
 - [**2114-1-15**]
 - respiratory failure, intubation, tracheostomy
++ Acalculous cholecystitis
 - percutaneous cholecystostomy tube [**2114-2-21**]
 - percutaneous tube dislodgement --> fever leukocytosis [**2114-3-12**]
 - fever leukocytosis --> ERCP ([**First Name4 (NamePattern1) 3075**] [**Last Name (NamePattern1) 3549**]) w/ stent [**2114-4-9**]
 - open cholecystectomy @ [**Hospital1 18**] [**2114-4-17**]
++ Diabetes mellitus, insulin dependent
++ Atrial fibrillation
++ Congestive heart failure
++ Chronic renal insufficiency
++ MRSA
++ CDiff
++ hx ESBL-Klebs

MEDICATION ON ADMISSION: - Vanco 125 Po q 6
- Heparin 500 TID
- Famotidine 20 [**Hospital1 **]
- albuterol neb prn
- humalog SS
- Sotalol AF 80 [**2-16**] tab [**Hospital1 **]
- MVI
- Citalopram 20 2 tabs qd
- zinc 220 po qd
- vit c 500 SR [**Hospital1 **]
- tylenol 325 q 4-6 prn
- glargine 20 units qhs
- alprazolam 1mg [**Hospital1 **] prn
- oxycodone 5mg q 4-6 prn
- cipro 1 tab po BID

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM
VS: 96.7   81    136/61     18    100% on AC
Gen: Chronically ill appearing
[**Month (only) 4459**]: PERRL
Neck: trach in place
Heart: s1s2 RRR
Pulm: Coarse BS bilaterally
Abd: +BS, soft, mild TTP diffusely,
Ext: trace edema
Back: + sacral decubiti, packed
Rectal: Guaiac negative brown stool
Neuro: alert, awake, follows commands, MAE

FAMILY HISTORY: Mother healthy; father with MI.

SOCIAL HISTORY: Rehab since admission in [**Month (only) 1096**].  Used to live with his
children, Taxi driver, Divorced, 2 children. 

### Response:
{'Unspecified septicemia,Septic shock,Intestinal infection due to Clostridium difficile,Chronic respiratory failure,Urinary tract infection, site not specified,Other complications due to other vascular device, implant, and graft,Pressure ulcer, stage IV,Severe sepsis,Congestive heart failure, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Atrial fibrillation,Tracheostomy status,Gastrostomy status,Personal history, urinary (tract) infection,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Long-term (current) use of insulin,Obstructive sleep apnea (adult)(pediatric),Chronic kidney disease, unspecified,Anemia, unspecified,Personal history of Methicillin resistant Staphylococcus aureus,Other acquired absence of organ,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation'}
