CHIEF COMPLAINT: Weakness

PRESENT ILLNESS: Mr. [**Known lastname **] is an 83 y/oM with diabetes and reportedly labile
sugars recently, also recently s/p ORIF after fall in [**3-24**] and
recent admission from [**Date range (3) 17395**] for urosepsis at [**Hospital3 **],
who was transferred from his nursing unit at Life Care Center of
[**Location (un) 5165**] to the [**Hospital1 18**] ED today for weakness and fatigue. His
family felt that he had been doing poorly over the last several
days with labile blood sugars ranging by report from 60s to over
400 on his regimen of NPH and novolog sliding scale.  He had
also increasing confusion over the last several days as well. He
was scheduled for TURP today for his BPH (has indwelling foley)
but this was cancelled and he was transferred at family request
to [**Hospital1 18**].

MEDICAL HISTORY: Hip Fracture s/p ORIF [**2183-4-11**] with intramedullary rod
h/o T 12 compression fracture and C6-C7 disk protrusion
ANEMIA
DIABETES MELLITUS
HYPOTHYROIDISM
HYPERCHOLESTEROLEMIA
XEROROSIS
LUNG NODULE
HYPERTENSION

MEDICATION ON ADMISSION: iron 325mg po daily
sliding scale novolog QID 200-300 1 unit [**Unit Number **]-400 2 units >400 3
units
NPH 5 units at 9pm, 10 units at 8:30am
oyster calcium 500mg [**Hospital1 **]
flomax 0.4mg PO qHS
synthroid 50mcg qAM
colace 100mg PO BID
MVI with minerals qAM
Vitamin c 500mg daily
zinc 220mg daily
prilosec 20mg po daily
Cozaar 100mg qd

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission Exam
General Appearance: No(t) Well nourished, Thin
Eyes / Conjunctiva: PERRL
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Not assessed),
(Left DP pulse: Not assessed)
Respiratory / Chest: (Breath Sounds: Clear : , No(t) Crackles :
)
Abdominal: Soft
Extremities: Right: Absent, Left: Absent
Musculoskeletal: No(t) Unable to stand
Skin:  Dry. Left clavicular head has superficial
redness/tenderness.
Neurologic: Attentive, Responds to: Not assessed, Oriented (to):
person initially (hospital vs. shopping center, knew day was
thursday but not year). This improved after 1 hr, Movement: Not
assessed, Tone: Not assessed

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: Tobacco: Former smoker
Alcohol: none per d/c
Was living in [**Hospital 5165**] Living Center prior to admission
WWII Veteran-was gunner onboard merchant vessels from [**2117**] to
[**2120**]
Bacteremia,Other pulmonary embolism and infarction,Unspecified infective arthritis, other specified sites,Urinary tract infection, site not specified,Hemorrhage of gastrointestinal tract, unspecified,Diabetes with ketoacidosis, type II or unspecified type, uncontrolled,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Anemia, unspecified,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Unspecified acquired hypothyroidism,Pure hypercholesterolemia,Unspecified essential hypertension,Pressure ulcer, lower back
Bacteremia,Pulm embol/infarct NEC,Inf arthrit NOS-oth site,Urin tract infection NOS,Gastrointest hemorr NOS,DMII ketoacd uncontrold,MRSA elsewhere/NOS,Anemia NOS,BPH w/o urinary obs/LUTS,Hypothyroidism NOS,Pure hypercholesterolem,Hypertension NOS,Pressure ulcer, low back
Admission Date:  [**2183-6-5**]              Discharge Date:   [**2183-6-23**]

Date of Birth:  [**2099-12-6**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 358**]
Chief Complaint:
Weakness

Major Surgical or Invasive Procedure:
Transesophageal Echocardiography


History of Present Illness:
Mr. [**Known lastname **] is an 83 y/oM with diabetes and reportedly labile
sugars recently, also recently s/p ORIF after fall in [**3-24**] and
recent admission from [**Date range (3) 17395**] for urosepsis at [**Hospital3 **],
who was transferred from his nursing unit at Life Care Center of
[**Location (un) 5165**] to the [**Hospital1 18**] ED today for weakness and fatigue. His
family felt that he had been doing poorly over the last several
days with labile blood sugars ranging by report from 60s to over
400 on his regimen of NPH and novolog sliding scale.  He had
also increasing confusion over the last several days as well. He
was scheduled for TURP today for his BPH (has indwelling foley)
but this was cancelled and he was transferred at family request
to [**Hospital1 18**].

His recent hospitalization sepsis in the above dates was notable
per discharge summary for ??????Urosepsis with methicillin-reisistant
staphylococcus aureus bacteremia?????? and r/o endocarditis and
seeding of right hip. He was found to have MRSA in his urine
culture, and then [**2-19**] blood culture bottles were MRSA as well.
He underwent TEE which had a question of an old aortic anterior
leaflet vegetation, and subsequently underwent TEE which showed
no evidence of valvular lesions. The treating team noted in
their d/c summary that they believed he had a MRSA UTI with
blood seeding secondary to urinary retention. He was treated
with vancomycin. His creatinine prior discharge was 1.7, and was
started on linezolid IV for ten days, completing a course of
antibiotics on [**2183-5-13**].

He was on lovenox previously, but this had been discontinued at
the rehab.

He presented to the [**Hospital1 18**] ED where his vitals at triage were  T
97.8 HR 72 BP 132/78 RR 18 O2 Sat 98% on Room Air.  He was found
to be in DKA/HONK, and after cultures was started on
vanc/ceftriaxone empirically.

He was found to have a melanotic bowel movement in the ED
(confirmed guaiac positive). GI was consulted to see him, but as
he remained hemodynically stable, an immediate scope was not
planned. NG lavage was attempted but unsuccessful in the ED.


Past Medical History:
Hip Fracture s/p ORIF [**2183-4-11**] with intramedullary rod
h/o T 12 compression fracture and C6-C7 disk protrusion
ANEMIA
DIABETES MELLITUS
HYPOTHYROIDISM
HYPERCHOLESTEROLEMIA
XEROROSIS
LUNG NODULE
HYPERTENSION

Needs outpt cysto, TURP


Social History:
Tobacco: Former smoker
Alcohol: none per d/c
Was living in [**Hospital 5165**] Living Center prior to admission
WWII Veteran-was gunner onboard merchant vessels from [**2117**] to
[**2120**]


Family History:
noncontributory

Physical Exam:
Admission Exam
General Appearance: No(t) Well nourished, Thin
Eyes / Conjunctiva: PERRL
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Not assessed),
(Left DP pulse: Not assessed)
Respiratory / Chest: (Breath Sounds: Clear : , No(t) Crackles :
)
Abdominal: Soft
Extremities: Right: Absent, Left: Absent
Musculoskeletal: No(t) Unable to stand
Skin:  Dry. Left clavicular head has superficial
redness/tenderness.
Neurologic: Attentive, Responds to: Not assessed, Oriented (to):
person initially (hospital vs. shopping center, knew day was
thursday but not year). This improved after 1 hr, Movement: Not
assessed, Tone: Not assessed

Discharge Exam
afebrile, VSS
Gen -- very thin, frail eldelry male
HEENT -- anicteric, op clear, edentulous, dentures present
Heart -- regular
Lungs -- clear
Abd - soft, benign, +BS
Ext -- no edema, right antecubital PICC in place without
erethyma or exudate
Skin -- stage II sacral decubitus ulcer


Pertinent Results:
[**2183-6-5**] 11:35AM   GLUCOSE-641* UREA N-28* CREAT-1.1 SODIUM-134
POTASSIUM-5.1 CHLORIDE-96 TOTAL CO2-16* ANION GAP-27*
[**2183-6-5**] 11:35AM   CK(CPK)-17*
[**2183-6-5**] 11:35AM   CK-MB-NotDone cTropnT-<0.01
[**2183-6-5**] 11:35AM   CALCIUM-8.7 PHOSPHATE-3.1 MAGNESIUM-1.9
[**2183-6-5**] 11:35AM   WBC-13.1*# RBC-3.17*# HGB-9.1*# HCT-28.7*#
MCV-90 MCH-28.7 MCHC-31.7 RDW-16.2*
[**2183-6-5**] 11:35AM   NEUTS-93.6* LYMPHS-4.0* MONOS-2.1 EOS-0.1
BASOS-0.2
[**2183-6-5**] 11:35AM   PLT COUNT-408
[**2183-6-5**] 11:35AM   PT-17.0* PTT-52.0* INR(PT)-1.5*
[**2183-6-5**] 11:35AM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.029
[**2183-6-5**] 11:35AM URINE  BLOOD-MOD NITRITE-POS PROTEIN-NEG
GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2183-6-5**] 11:35AM URINE  RBC-[**3-20**]* WBC-[**12-5**]* BACTERIA-MOD
YEAST-NONE EPI-0

Neck, soft tissue ultrasound [**6-6**]:
1.5 x 0.8 x 0.5 cm echopenic lesion over the left clavicular
head most likely represent a synovial fluid pocket/cyst, less
likely a lymph node. Followup imaging can be performed as
clinically indicated.

LENIs [**6-6**]:
No evidence of DVT in the bilateral lower extremities.

Hip films [**6-6**]: The patient is status post ORIF of an
intratrochanteric fracture of the left femur. The fracture is
comminuted. The hardware is intact. There is no evidence for
loosening or fracture of the hardware.

Left knee [**6-6**]: A portable lateral film is provided of the left
knee. This demonstrates hardware in adequate position. There is
no evidence of loosening. No osteolytic changes are seen.
--------
[**2183-6-8**] CT Left shoulder: IMPRESSION:

1. No obvious left shoulder effusion or bony abnormality
involving the left
shoulder, aside from minor degenerative change.

2. Relatively large pulmonary artery embolus involving the left
main
pulmonary artery and branches to the left upper lobe and lingula
and left
lower lobe.

3. Minimal fluid in the left sternoclavicular joint. Nearby soft
tissue
calcification could represent chondrocalcinosis. Finding
described on recent
ultrasound is not definitively identified, but might not be
appreciated on
this exam due to resolution and artifact from nearby bone.
-------
MRI Cervical and Thoracic Spine:
IMPRESSION: Study somewhat limited by lack of contrast. Possible
discitis
osteomyelitis at T12 and the adjacent endplates. There is
epidural soft
tissue at T11-T12 contiguous with the disc , which may represent
a focal disc herniation, although the possibility of a tiny
epidural abscess cannot be excluded. There is mild focal
kyphotic angulation at this level. However, evaluation is
limited due to lack of gadolinium and motion degradation on the
axial images through this region.

There is abnormal signal within the C3 and adjacent C4 vertebral
bodies.
Findings most likely related to DJD but possibility of infection
cannot be
entirely excluded.

Moderate cervical spondylosis as detailed above.
------

TEE:  No atrial septal defect is seen by 2D or color Doppler.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) are mildly thickened. There are
filamentous strands on the tip of the right coronary cusp
measuring 0.6cm x 0.2cm most consistent with Lambl's excresences
(normal variant), but cannot exclude endocarditis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve.
Trivial mitral regurgitation is seen. No masses or vegetations
are seen on the tricuspid valve.. No masses or vegetations are
seen on the pulmonic valve. There is no pericardial effusion.

Impression: Filamentous strand on the aortic valve most
consistent with Lambl's excresence (normal variant), but cannot
exclude endocarditis.
---------
CT Scan Pelvis and Abdomen:
CT ABDOMEN WITH CONTRAST: Moderate right and small left pleural
effusions are
new since [**2181**] with associated bibasilar atelectasis. A 2-mm
right lower lobe
nodule (2:3) is stable since [**2181**]. Pleural calcifications are
seen
bilaterally. The cardiac apex is unremarkable. The stomach,
proximal small
bowel, spleen, adrenal glands, and kidneys, are unremarkable.
Clips in the
gallbladder fossa are likely related to previous
cholecystectomy. The
pancreas is thin and atrophic and otherwise unremarkable. The
distal common
bile duct is slightly prominent given the patient's age,
measuring 10 mm
(2:25). The liver contains a focal hypodensity in segment 4A
measuring 7 mm
thickness and too small to characterize. There is no free gas or
fluid in the
abdomen, though note is made of edema suggesting third-spacing
of fluid. There
is no retroperitoneal or mesenteric lymphadenopathy.

CT PELVIS WITH CONTRAST: The rectum contains a large amount of
stool and
otherwise the rectum and colon are unremarkable. The urinary
bladder contains
a moderate amount of gas related to the Foley catheter which is
in place.
Debris is seen settling dependently in the bladder. The prostate
is enlarged
and measures 63 x 52 x 63mm. There is no inguinal or pelvic
lymphadenopathy.
There is no free gas or fluid in the pelvis.

OSSEOUS FINDINGS: Left hip fracture and hardware are similar to
that
cataloged on [**2183-6-6**]. Otherwise, there is no suspicious
sclerotic or lytic
lesion. Multilevel degenerative changes noted, including
anterior wedge
compression deformity of the T12 vertebral body with
approximately 50% of loss
of height anteriorly.

IMPRESSION:
1. Right greater than left, small bilateral pleural effusions.
2. Enlarged prostate.
3. Debris seen dependently in the bladder. Non-specific on
imaging and may
represent small amount of blood. Recommend correlation to
urinalysis.
4. Left hip hardware and fractures as detailed on the dedicated
CT from
[**2183-6-6**].
5. Compression deformity of T12 of unknown chronicity.
------
[**2183-6-19**] CT chest, for eval of L SC joint
FINDINGS: The airways are patent to the segmental levels. There
is marked
loss of volume in the right middle lobe. In the right middle
lobe, there are
bronchiectasis and calcified granulomas. Two 2-mm lung nodules
in the RML are
stable since in [**2180**]. In the right middle lobe, surrounding the
largest
calcified granuloma, soft tissue abnormality measures 12 mm, was
9 mm. I
believe the increase in size is given the increase in loss of
volume in the
right middle lobe compared to prior studies, but followup in six
months is
recommended to assess stability. Bronchiectasis and bronchial
wall thickening
is also present in the lower lobes bilaterally. Small bilateral
pleural
effusions are layering and non-hemorrhagic. Calcified pleural
plaques are
noted bilaterally. Bibasilar atelectases are greater in the left
base in the
dependent portions. Elongated nodular opacity in the left lower
lobe, series
4, image 168, is likely an area of small atelectasis. There is
mild
centrilobular emphysema, predominating in the upper lobes. 3-mm
nodule in the
left upper lobe (4:135), is stable since [**2180**]. 2-mm nodule in
the upper lobe,
(4:124), is stable since [**2180**]. 7 x 4 mm nodule, left upper lobe
superior
segment, series 4, image 168, is unchanged from prior.
Consolidation is in
the lingula. 2-mm subpleural nodule is in the right lower lobe,
is unchanged,
(4:197). There are no new lung nodules.

Mild aortic calcification is of unknown hemodynamic
significance. Coronary
calcification is in the LAD. Cardiac size is normal. There are
no enlarged
mediastinal, hilar, or axillary lymph nodes. There is no
pericardial
effusion.

This examination is not tailored for subdiaphragmatic
evaluation. The upper
abdomen is unremarkable.

Right PICC tip is in the lower SVC.

There is no abscess or osseous erosion. Very mild soft tissue
swelling
overlying the left sternoclavicular joint. There is minimal
asymmetry with
slight increased bony sclerosis about the left sternoclavicular
joint compared
to the right, best seen on sagittal images (401b:18).

Compression fracture is at T12.

IMPRESSION: No definite abscess or osseous erosion around the
left
sternoclavicular joint. Given uptake on indium-111 scan in the
region of the
left sternoclavicular joint, query septic joint or
osteomyelitis. This should
be correlated clinically.
----
[**2183-6-18**] tagged WBC nuclear scan
INTERPRETATION:
Following the injection of autologous white blood cells labeled
with
Tc-[**Age over 90 **]m/In-111, an image of the whole body was obtained,
demonstrating increased
asymmetric activity at the left sternoclavicular junction,
corresponding to the
known supraclavicular fluid collection, now concerning for an
abscess.

The mild activity in the liver and the high activity in the
spleen are normal.
Non-specific, mild, asymmetric increased activities are noted in
the right
hemipelvis, in the anterior view. SPECT-CT images in the pelvis
were obtained
for further evaluation.

SPECT-CT images from the lower abdomen to the pelvic symphysis
were obtained,
but revealed no abnormal activities. Borderline enlarged
inguinal nodes are
identified, but none demonstrate abnormal tracer activities.

IMPRESSION: Abnormal increased focal tracer activity projected
onto the left
sternoclavicular junction, corresponding to the known left
supraclavicular fluid
collection. Findings consistent with an abscess.

------
[**2183-6-5**] 11:35 am URINE     Site: CATHETER

                            **FINAL REPORT [**2183-6-8**]**

   URINE CULTURE (Final [**2183-6-8**]):
      PSEUDOMONAS AERUGINOSA.    >100,000 ORGANISMS/ML..
         Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
         [**Last Name (NamePattern1) 3060**].

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             PSEUDOMONAS AERUGINOSA
                             |
AMIKACIN--------------    16 S
CEFEPIME--------------    16 I
CEFTAZIDIME-----------    16 I
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------  =>16 R
MEROPENEM-------------  =>16 R
PIPERACILLIN----------       R
PIPERACILLIN/TAZO-----    64 S
TOBRAMYCIN------------  =>16 R

------
Blood cultures from [**6-5**] thru [**6-13**] all grew coag positive staph
aureus with following sensitivites:
                             STAPH AUREUS COAG +
                             |
DAPTOMYCIN------------       S
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
LINEZOLID-------------     4 S
OXACILLIN-------------   =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------     2 S

Blood cultures from [**6-14**] thru current have been no growth to
date.



Brief Hospital Course:
Mr. [**Known lastname **] is a n 83M w/ DM2, HTN, BPH w/ chronic indwelling
Foley, left hip ORIF in [**3-24**], recent urosepsis/MRSA bacteremia
presents from rehab with DKA and now w/ MRSA bacteremia who was
treated initially treated in the ICU for his DKA which resolved
fairly quickly and was subsequently transferred in stable
condition to the floor.

His prolonged course and treatment are as follows.

#  Diabetic Ketoacidosis: After insulin/glucose overnight the
patient was no longer in DKA.  His anion gap resolved, blood
sugars fell into the normal range.  His NPH and HISS were
continued, and although initially poorly controlled, have
stabilized on the current regimen.

#  GIB: In the ICU had melanotic stool.  GI consulted and given
stable hematocrit did not intervene.  He is recommended to
follow up for possible EGD/[**Last Name (un) **] as an outpatient when stable,
finished treatment for bacteremia.

# MRSA Bacteremia: Etiology uncertain, although endocarditis was
initially suspected.  He had recent MRSA bacteremia in [**4-24**],
treated at OSH. TTE showed possible old vegetation on aortic
valve and a mass on the mitral valve, but subsequent TEE was
negative and he was treated with a 10 day course of antibiotics.

After admission here, repeat TTE and TEE were negative for
vegetation.  Given his persistent, high grade bacteremia, a site
of seeding was suspected.  He does have left hip hardware, but
imaging did not show evidence of infection.  On exam, he had a
very erythematous, tender left sternoclavicular joint.  Imaging
by ultrasound initially was suspicious for fluid collection,
however CT scan of the area did not show a drainable collection.
 Thoracic surgery was consulted to discuss aspiration and/or
debridement, as this was felt to be the source of his persistent
bacteremia.  Given his frail state, treatment with IV vancomycin
without debridement was felt to be the best conservative course.
 His bacteremia cleared, last positive culture [**6-13**], and the L
SC joint appearance (erythema and tenderness) improved as well.
 In additional workup, a tagged WBC scan showed increased uptake
at the left sternoclavicular joint concerning for an abscess.
Repeat CT of the area failed to demonstrate a clear abscess, but
had no bony destruction.  No intervention was recomended by
thoracic surgery and interventional radiology.  He was started
on Vancomycin and should be continued on this antibiotic for 6
WEEK course from [**2183-6-14**].  End date [**2183-7-25**].  Follow up with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 18**] recommended, they will call for follow up
date/time.

# Incidental PE: Found on CT of left shoulder.  Lovenox bridging
to warfarin goal INR [**2-18**].

# UTI versus colonization, pseudomonas: Foley was changed on
admission. He was treated with ciprofloxacin until cultures
showed pseudomonas, so this was changed to Zosyn, but
senstivities revealed multi-drug resistance, sensitive only to
amikacin. Given that it was unclear if this organism was causing
symptoms and may have been a colonizer in his indwelling Foley,
Zosyn was stopped and a repeat urine culture was sent from the
new Foley that continued to grow Pseudomonas.  He had improved
clinically, however, so this was considered chronic
colonization. His Foley was changed a second time two weeks
later and repeat urine culture showed persistant pseudomonas.
ID recommended a one week course of tetracycline.
.
#. Decubitus Ulcer ?????? stage II ulcer on admission.  Received
daily wound care, will need continued precautions and wound care
on discharge.


Medications on Admission:
iron 325mg po daily
sliding scale novolog QID 200-300 1 unit [**Unit Number **]-400 2 units >400 3
units
NPH 5 units at 9pm, 10 units at 8:30am
oyster calcium 500mg [**Hospital1 **]
flomax 0.4mg PO qHS
synthroid 50mcg qAM
colace 100mg PO BID
MVI with minerals qAM
Vitamin c 500mg daily
zinc 220mg daily
prilosec 20mg po daily
Cozaar 100mg qd

Discharge Medications:
1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for left shoulder pain.
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
6. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for prevent constipation.
8. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO PRN: prior to
PT/OT.
9. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO once a day.
10. Calcium 500 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO
twice a day.
11. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO PRN as needed for
constipation.
12. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
13. Tetracycline 250 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) for 6 days. Capsule(s)
14. Vancomycin 500 mg Recon Soln Sig: Three (3) Recon Soln
Intravenous Q 24H (Every 24 Hours) for 5 weeks: end date
[**2183-7-25**].
15. Sodium Chloride 0.9 % 0.9 % Syringe Sig: 1-2 MLs Injection
twice a day as needed for line flush.
16. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twelve
(12) units Subcutaneous qAM.
17. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Five
(5) units Subcutaneous qPM.
18. Insulin Lispro 100 unit/mL Cartridge Sig: One (1) units
Subcutaneous qAC and qHS: by sliding scale attached.
19. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO once a
day.
20. Warfarin 2 mg Tablet Sig: One (1) Tablet PO at bedtime.
21. Lovenox 80 mg/0.8 mL Syringe Sig: Seventy (70) mg
Subcutaneous every twelve (12) hours for 2 days: until INR
theraputic at 2-3.


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
1. MRSA Bacteremia, left sternoclavicular joint infection
2. pulmonary embolus
3. DMII
4. HTN
5. BPH, chronic foley
6. UTI, pseudomonas


Discharge Condition:


Stable to extended care facility for ongoing treatment of
bacteremia, chronic left shoulder pain, left rib pain, right
PICC in place.


Discharge Instructions:
You were admitted to the hospital for complications related to
your diabetes and were found to have an infection of your blood.
 You are currently being treated with IV vancomycin for an
infection in your blood stream, and will need 6 weeks of this
medicine.

You are being discharged to extended care facility ([**Hospital1 **]) so
that you may continue to receive IV antibiotics, physical
therapy, and close observation of your condition.

If you have fever, chills, altered mental status, oozing or
redness from your PICC line, chest pain, shortness of breath, or
any other concers, please call your primary physician or return
to the emergency department.

Followup Instructions:
Please keep the following appointments.

Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15048**], MD Phone:[**Telephone/Fax (1) 9347**]
Date/Time:[**2183-7-28**] 9:15
{'Bacteremia,Other pulmonary embolism and infarction,Unspecified infective arthritis, other specified sites,Urinary tract infection, site not specified,Hemorrhage of gastrointestinal tract, unspecified,Diabetes with ketoacidosis, type II or unspecified type, uncontrolled,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Anemia, unspecified,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Unspecified acquired hypothyroidism,Pure hypercholesterolemia,Unspecified essential hypertension,Pressure ulcer, lower back'}


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: Weakness

PRESENT ILLNESS: Mr. [**Known lastname **] is an 83 y/oM with diabetes and reportedly labile
sugars recently, also recently s/p ORIF after fall in [**3-24**] and
recent admission from [**Date range (3) 17395**] for urosepsis at [**Hospital3 **],
who was transferred from his nursing unit at Life Care Center of
[**Location (un) 5165**] to the [**Hospital1 18**] ED today for weakness and fatigue. His
family felt that he had been doing poorly over the last several
days with labile blood sugars ranging by report from 60s to over
400 on his regimen of NPH and novolog sliding scale.  He had
also increasing confusion over the last several days as well. He
was scheduled for TURP today for his BPH (has indwelling foley)
but this was cancelled and he was transferred at family request
to [**Hospital1 18**].

MEDICAL HISTORY: Hip Fracture s/p ORIF [**2183-4-11**] with intramedullary rod
h/o T 12 compression fracture and C6-C7 disk protrusion
ANEMIA
DIABETES MELLITUS
HYPOTHYROIDISM
HYPERCHOLESTEROLEMIA
XEROROSIS
LUNG NODULE
HYPERTENSION

MEDICATION ON ADMISSION: iron 325mg po daily
sliding scale novolog QID 200-300 1 unit [**Unit Number **]-400 2 units >400 3
units
NPH 5 units at 9pm, 10 units at 8:30am
oyster calcium 500mg [**Hospital1 **]
flomax 0.4mg PO qHS
synthroid 50mcg qAM
colace 100mg PO BID
MVI with minerals qAM
Vitamin c 500mg daily
zinc 220mg daily
prilosec 20mg po daily
Cozaar 100mg qd

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission Exam
General Appearance: No(t) Well nourished, Thin
Eyes / Conjunctiva: PERRL
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Not assessed),
(Left DP pulse: Not assessed)
Respiratory / Chest: (Breath Sounds: Clear : , No(t) Crackles :
)
Abdominal: Soft
Extremities: Right: Absent, Left: Absent
Musculoskeletal: No(t) Unable to stand
Skin:  Dry. Left clavicular head has superficial
redness/tenderness.
Neurologic: Attentive, Responds to: Not assessed, Oriented (to):
person initially (hospital vs. shopping center, knew day was
thursday but not year). This improved after 1 hr, Movement: Not
assessed, Tone: Not assessed

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: Tobacco: Former smoker
Alcohol: none per d/c
Was living in [**Hospital 5165**] Living Center prior to admission
WWII Veteran-was gunner onboard merchant vessels from [**2117**] to
[**2120**] 

### Response:
{'Bacteremia,Other pulmonary embolism and infarction,Unspecified infective arthritis, other specified sites,Urinary tract infection, site not specified,Hemorrhage of gastrointestinal tract, unspecified,Diabetes with ketoacidosis, type II or unspecified type, uncontrolled,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Anemia, unspecified,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Unspecified acquired hypothyroidism,Pure hypercholesterolemia,Unspecified essential hypertension,Pressure ulcer, lower back'}
