CHIEF COMPLAINT: ARF, acidemia, Respiratory failure, hypotension

PRESENT ILLNESS: 46 yo m s/p CRT, hypertension, known to the MICU team after he
was recently admitted with respiratory distress and hypotension,
found to have likely MSSA pna complicated by septic shock who
now returns to the ICU with melena and a hematocrit drop.
.
Briefly, the patient [**Hospital 106884**] transferred from an OSH after
he presented with tachycardia and hypotension following
approximately one week of dry cough and URI symptoms. He was
intubated due to respiratory failure (unclear if
hypoxic/hypercarbic). Additionally, noted to be in acute on
chronic renal failure. He was treated for possible cardiogenic
shock (given troponin leak, and renal failure) and diuresed. The
patient transferred to the [**Hospital1 18**] ICU on [**2179-12-22**] with
respiratory failure, ARF, and vasopresser dependent hypotension.
He was felt to likely be in septic shock in the setting of a
PNA. He was started on stress dose steroids and
vancomycin/zosyn. Patient was titrated off pressers within the
first 24 hours. Bronchoscopy on [**12-23**] showed edematous airways
and scant purulent sputum in the LUL. BAL samples grew MSSA from
2 samples (Moraxella from one). Blood cultures from [**12-22**] grew
out coag neg staph, 2 different species, from 1 from each of 6
bottles. 1 bottle also grew Peptostreptococcus. Extubated on
[**12-25**] without complications. Maintained on CVVHD
(anuric/oliguric). Initially treated with vancomycin and zosyn
until [**12-27**], changed to nafcillin. Clindamycin added [**12-28**].
.
He was subsequently transferred to the floor on [**12-29**] where he
developed a low grade fever to 100.5 and initially had low grade
diarrhea (not tested for fecal occult blood at that time. On
[**12-30**] he was febrile to 101.0 and had onset of "explosive" bowel
movement which was noted to be melanotic (and FOBT positive).
CBC that morning showed an 8 pt hematocrit drop. By report, the
patient had coffee grounds draining NGT following intubation at
OSH. Patient denied abdominal pain and denied
fevers/post-prandial abd pain/n/v/d prior to hospitalization.
Other than the development of diarrhea and fever over 30 hours
prior to MICU transfer, the patient had been asymptomatic. He
also denied LH/CP/SOB.
.
In the MICU, he had an EGD which revealed normal mucosa in the
esophagus; Thick gastric folds; ulcers in the duodenal bulb and
second part of the duodenum (thermal therapy, injection);
Otherwise normal EGD to second part of the duodenum. He received
12 units of blood and his HCT finally stabilized 28-30 s/p
cauterization. Renal evaluated him and decided on HD for [**1-2**].
Wound cultures on the L subclavian tunnelled cath were sent for
concern of infected site. Dilt and BB were restarted.

MEDICAL HISTORY: Renal Transplant 16 yrs ago on immunosuppresants
-HTN poorly controlled
-Anemia on procrit
-Chronic Allograft Nephropathy baseline Cr 4.2 ([**2179-1-10**])

MEDICATION ON ADMISSION: -Lisinopril 20mg qd
-Aronesp 40mg SQ QOWeek
-Fosamax 5mg qd
-MVI
-Cellcept 250mg [**Hospital1 **]
-Pravachol 10mg qhs
-Prednisone 10mg QOD
-Prograf 2mg [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 97.3 103/37 81 11 93% AC 700x14 PEEP 5 FiO2 1.0
GEN: Intubated, sedated
HEENT: ETT in place, R-SVC in place, no cervical LAD, pinpoint
pupils, anicteric sclera
RESP: Course BS throughout L BS>R, no wheezing
CV: Reg Nml S1,S2 2/6 SEM throughout precordium
ABD: Soft ND/NT, +BS, black/coffee ground material from NGT
EXT: No peripheral edema, slight mottling of LE toes b/l
NEURO: hyporeflexia, sedated

FAMILY HISTORY: unknown

SOCIAL HISTORY: lives with 2 children and mother
Other staphylococcal septicemia,Complications of transplanted kidney,Acute kidney failure, unspecified,Acute respiratory failure,Methicillin susceptible pneumonia due to Staphylococcus aureus,Septic shock,Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Atrial fibrillation,Subendocardial infarction, initial episode of care,Severe sepsis,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Anemia in chronic kidney disease,Dermatitis due to drugs and medicines taken internally,Unspecified disease of pericardium
Staphylcocc septicem NEC,Compl kidney transplant,Acute kidney failure NOS,Acute respiratry failure,Meth sus pneum d/t Staph,Septic shock,Chr duoden ulcer w hem,Atrial fibrillation,Subendo infarct, initial,Severe sepsis,Abn react-org transplant,Anemia in chr kidney dis,Drug dermatitis NOS,Pericardial disease NOS
Admission Date:  [**2179-12-22**]              Discharge Date:   [**2180-1-8**]

Date of Birth:  [**2133-12-20**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3624**]
Chief Complaint:
ARF, acidemia, Respiratory failure, hypotension

Major Surgical or Invasive Procedure:
Hemodialysis
Central line placement and removal
Tunnelled hemodialysis catheter placement
Peripherally inserted central catheter
Intubation and subsequent extubation
Endoscopy
Bronchial lavage


History of Present Illness:
46 yo m s/p CRT, hypertension, known to the MICU team after he
was recently admitted with respiratory distress and hypotension,
found to have likely MSSA pna complicated by septic shock who
now returns to the ICU with melena and a hematocrit drop.
.
Briefly, the patient [**Hospital 106884**] transferred from an OSH after
he presented with tachycardia and hypotension following
approximately one week of dry cough and URI symptoms. He was
intubated due to respiratory failure (unclear if
hypoxic/hypercarbic). Additionally, noted to be in acute on
chronic renal failure. He was treated for possible cardiogenic
shock (given troponin leak, and renal failure) and diuresed. The
patient transferred to the [**Hospital1 18**] ICU on [**2179-12-22**] with
respiratory failure, ARF, and vasopresser dependent hypotension.
He was felt to likely be in septic shock in the setting of a
PNA. He was started on stress dose steroids and
vancomycin/zosyn. Patient was titrated off pressers within the
first 24 hours. Bronchoscopy on [**12-23**] showed edematous airways
and scant purulent sputum in the LUL. BAL samples grew MSSA from
2 samples (Moraxella from one). Blood cultures from [**12-22**] grew
out coag neg staph, 2 different species, from 1 from each of 6
bottles. 1 bottle also grew Peptostreptococcus. Extubated on
[**12-25**] without complications. Maintained on CVVHD
(anuric/oliguric). Initially treated with vancomycin and zosyn
until [**12-27**], changed to nafcillin. Clindamycin added [**12-28**].
.
He was subsequently transferred to the floor on [**12-29**] where he
developed a low grade fever to 100.5 and initially had low grade
diarrhea (not tested for fecal occult blood at that time. On
[**12-30**] he was febrile to 101.0 and had onset of "explosive" bowel
movement which was noted to be melanotic (and FOBT positive).
CBC that morning showed an 8 pt hematocrit drop. By report, the
patient had coffee grounds draining NGT following intubation at
OSH. Patient denied abdominal pain and denied
fevers/post-prandial abd pain/n/v/d prior to hospitalization.
Other than the development of diarrhea and fever over 30 hours
prior to MICU transfer, the patient had been asymptomatic. He
also denied LH/CP/SOB.
.
In the MICU, he had an EGD which revealed normal mucosa in the
esophagus; Thick gastric folds; ulcers in the duodenal bulb and
second part of the duodenum (thermal therapy, injection);
Otherwise normal EGD to second part of the duodenum. He received
12 units of blood and his HCT finally stabilized 28-30 s/p
cauterization. Renal evaluated him and decided on HD for [**1-2**].
Wound cultures on the L subclavian tunnelled cath were sent for
concern of infected site. Dilt and BB were restarted.


Past Medical History:
Renal Transplant 16 yrs ago on immunosuppresants
-HTN poorly controlled
-Anemia on procrit
-Chronic Allograft Nephropathy baseline Cr 4.2 ([**2179-1-10**])


Social History:
lives with 2 children and mother

Family History:
unknown

Physical Exam:
VS: 97.3 103/37 81 11 93% AC 700x14 PEEP 5 FiO2 1.0
GEN: Intubated, sedated
HEENT: ETT in place, R-SVC in place, no cervical LAD, pinpoint
pupils, anicteric sclera
RESP: Course BS throughout L BS>R, no wheezing
CV: Reg Nml S1,S2 2/6 SEM throughout precordium
ABD: Soft ND/NT, +BS, black/coffee ground material from NGT
EXT: No peripheral edema, slight mottling of LE toes b/l
NEURO: hyporeflexia, sedated


Pertinent Results:
OSH
ABG-7.14/30.2/103/10.8
Tn-I:.05 (nml.01-.04)
131  92  160          Alb 2.9; Alk phos 140; LDH 1760; AST 22;
ALT 27
--------------<160    CK 2445
3.2  10  25.2

45.4>----<726
     23.0

[**Hospital1 18**] ADMISSION LABS:
--See Below
.

[**2179-12-22**] 04:34PM BLOOD WBC-52.9*# RBC-2.96* Hgb-7.9*# Hct-25.0*
MCV-85 MCH-26.9* MCHC-31.8 RDW-16.9* Plt Ct-820*#
[**2179-12-22**] 04:34PM BLOOD Neuts-97* Bands-1 Lymphs-0 Monos-2 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2179-12-22**] 04:34PM BLOOD Glucose-231* UreaN-197* Creat-22.0*#
Na-134 K-3.7 Cl-94* HCO3-8* AnGap-36*
[**2179-12-22**] 04:34PM BLOOD ALT-14 AST-26 LD(LDH)-717* AlkPhos-167*
Amylase-71 TotBili-0.4
[**2179-12-22**] 04:34PM BLOOD Lipase-109*
[**2179-12-22**] 04:34PM BLOOD CK-MB-13* cTropnT-0.12*
[**2179-12-22**] 04:34PM BLOOD Albumin-2.8* Calcium-4.1* Phos-17.3*#
Mg-2.4
[**2179-12-22**] 04:34PM BLOOD Osmolal-352*
[**2179-12-22**] 04:34PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2179-12-22**] 11:49PM BLOOD Type-ART Temp-36.2 Rates-14/5 Tidal V-700
PEEP-10 FiO2-100 pO2-120* pCO2-44 pH-7.00* calTCO2-12* Base
XS--20 AADO2-563 REQ O2-91 -ASSIST/CON Intubat-INTUBATED
.
Microbiology:
* Blood culture ([**12-22**]): Peptostreptococcus, coag negative staph
(2 different colonies)
* Blood cultures ([**12-27**], [**12-30**], [**12-31**], [**1-2**], [**1-3**], [**1-4**],
[**1-5**]): Negative
* Blood culture ([**1-6**]): No growth to date
* Catheter tip ([**12-30**], [**1-8**]): Negative
* Sputum ([**12-23**]): Coag positive staph (oxacillin sensitive)
* CMV antibody ([**12-23**]): POSITIVE FOR CMV IgG ANTIBODY BY EIA .
87 AU/ML
* CMV viral load ([**12-23**]): negative
* EBV IgG positive, IgM negative ([**12-23**])
* BAL ([**12-23**]): GRAM STAIN (Final [**2179-12-23**]):
      2+   (1-5 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      1+    (<1 per 1000X FIELD):   GRAM NEGATIVE DIPLOCOCCI.

   RESPIRATORY CULTURE (Final [**2179-12-26**]):
      OROPHARYNGEAL FLORA ABSENT.
      STAPH AUREUS COAG +.
         10,000-100,000 ORGANISMS/ML. OF TWO COLONIAL
MORPHOLOGIES.
         Staphylococcus species may develop resistance during
prolonged
         therapy with quinolones.   Therefore, isolates that are
initially
         susceptible may become resistant within three to four
days after
         initiation of therapy.  Testing of repeat isolates may
be
         warranted.
         MORAXELLA CATARRHALIS.    ~[**2173**]/ML.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------   0.5 S
PENICILLIN------------ =>0.5 R

   LEGIONELLA CULTURE (Final [**2179-12-31**]):    NO LEGIONELLA
ISOLATED.
   IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII (Final
[**2179-12-24**]):
      PNEUMOCYSTIS CARINII NOT SEEN.
   FUNGAL CULTURE (Final [**2180-1-5**]):    NO FUNGUS ISOLATED.
   ACID FAST SMEAR (Final [**2179-12-24**]):
      NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
* Rapid Respiratory Viral Antigen Test (Final [**2179-12-24**]):
      Respiratory viral antigens not detected.
      CULTURE CONFIRMATION PENDING.
      SPECIMEN SCREENED FOR: ADENO,PARAINFLUENZA 1,2,3 INFLUENZA
A,B AND
      RSV.
* Urinary legionella antigen ([**12-24**]): Negative
* H. pylori ([**12-30**]): Negative
* Stool culture ([**12-28**], [**12-30**]): Negative for shigella,
salmonella, campylobacter
* Stool negative for C. diff X 3
* Left IJ HD cath site ([**1-1**]): 2+ PMNs, but culture negative to
date
* Cytology from BAL: Negative for malignant cells.
.
Radiology/studies:
* EKG ([**12-22**]): Poor quality tracing. Probable atrial
fibrillation with a rapid ventricular response. Since the
previous tracing of [**2175-9-12**] atrial fibrillation is new. QRS
voltage in the precordial leads may be increased. Clinical
correlation is suggested.
* EKG ([**12-24**]): Atrial fib with RVR then repeated with controlled
ventricular rate then repeated again with sinus rhythm
* EKG ([**12-25**]): Atrial flutter
* EKG ([**12-30**]): Sinus rhythm. Since the previous tracing of
[**2180-1-4**] T wave inversions in the anterolateral leads are seen
consistent with anterior ischemia or non-Q wave myocardial
infarction.
* Abdominal US ([**12-23**]): No cholelithiasis or son[**Name (NI) 493**] signs
of acute cholecystitis.
* ECHO ([**12-23**]): The left atrium is moderately dilated. The right
atrium is moderately dilated. No atrial septal defect is seen by
2D or color Doppler. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic (EF
70-80%). There is a mild resting left ventricular outflow tract
obstruction. A mid-cavitary gradient is identified. Right
ventricular chamber size and free wall motion are normal. The
aortic root is moderately dilated. The ascending aorta is
moderately dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. There is mild
systolic anterior motion of the mitral valve leaflets. Mild to
moderate ([**1-11**]+) mitral regurgitation is seen. The mitral
regurgitation jet is eccentric (posterior directed). The timing
of the mitral regurgitation is late systolic. The tricuspid
valve leaflets are mildly thickened. There is mild  pulmonary
artery systolic hypertension. There is a small posterior
pericardial effusion. There are no echocardiographic signs of
tamponade.  Compared with the findings of the prior report
(images unavailable for review) of [**2176-1-25**], the left
ventricle is now hyperdynamic, with a resting left ventricular
outflow tract gradient.
* CT Chest without contrast ([**12-28**]): 1. Moderate amount of
pericardial effusion, which may have restrictive physiology. 2.
Bilateral pleural effusion, moderate. 3. Scattered areas of
ground glass, predominantly in the right lung which most likely
represent viral infection, aspiraation is less likely.
* ECHO ([**12-30**]): The left ventricular cavity size is normal.
Overall left ventricular systolic function is normal (LVEF 70%).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. There is a small pericardial effusion.
There are no echocardiographic signs of tamponade. Compared with
the findings of the prior study (images reviewed) of [**12-23**]

[**2179**], the pericardial effusion may be slightly larger (but still
small); no evidence of cardiac tamponade.
* CT chest with contrast ([**1-2**]): 1. Moderate amount of
pericardial effusion, slightly increased, which may have
restrictive physiology. 2. Marked decrease in pleural effusion,
now smaller in size, and improvement in the scattered areas of
ground-glass most likely due to resolution or improvement in
viral infection. The aspiration etiology is less likely. 3.
Cholelythiasis with no cholecystitis.
* Lung scan ([**1-3**]):  Normal lung scan. No evidence for PE.
* ECHO ([**1-4**]): The estimated right atrial pressure is
11-15mmHg. Left ventricular wall thickness, cavity size, and
systolic function are normal (LVEF 70%). Right ventricular
chamber size and free wall motion are normal. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. There is a small to moderate sized pericardial
effusion subtending the basal posterolateral wall and right
atrial free wall. There are no echocardiographic signs of
tamponade. No right atrial or right ventricular diastolic
collapse is seen.  Compared with the findings of the prior study
(images reviewed) of [**2179-12-30**], the pericardial effusion
is somewhat further increased in size, but still with no
evidence of cardiac tamponade.
.
Labs at discharge:
WBC 9.9, Hgb 10.6, Hct 30.4, Plt 203


Brief Hospital Course:
46 yo m s/p CRT, htn, known to the MICU team after he was
recently admitted with respiratory distress and hypotension,
found to have likely MSSA pna complicated by septic shock who
now returns to the ICU with melena and a hematocrit drop.
.
Briefly, the patient [**Hospital 106884**] transferred from an OSH after
he presented with tachycardia and hypotension following
approximately one week of dry cough and URI symptoms. He was
intubated due to respiratory failure (unclear if
hypoxic/hypercarbic). Additionally, noted to be in acute on
chronic renal failure. He was treated for possible cardiogenic
shock (given troponin leak, and renal failure) and diuresed. The
patient transferred to the [**Hospital1 18**] ICU on [**2179-12-22**] with
respiratory failure, ARF, and vasopresser dependent hypotension.
He was felt to likely be in septic shock in the setting of a
PNA. He was started on stress dose steroids and
vancomycin/zosyn. Patient was titrated off pressers within the
first 24 hours. Bronchoscopy on [**12-23**] showed edematous airways
and scant purulent sputum in the LUL. BAL samples grew MSSA from
2 samples (Moraxella from one). Blood cultures from [**12-22**] grew
out coag neg staph, 2 different species, from 1 from each of 6
bottles. 1 bottle also grew Peptostreptococcus. Extubated on
[**12-25**] without complications. Maintained on CVVHD
(anuric/oliguric). Initially treated with vancomycin and zosyn
until [**12-27**], changed to nafcillin. Clindamycin added [**12-28**].
.
He was subsequently transferred to the floor on [**12-29**] where he
developed a low grade fever to 100.5 and initially had low grade
diarrhea (not tested for fecal occult blood at that time. On
[**12-30**] he was febrile to 101.0 and had onset of "explosive" bowel
movement which was noted to be melanotic (and FOBT positive).
CBC that morning showed an 8 pt hematocrit drop. By report, the
patient had coffee grounds draining NGT following intubation at
OSH. Patient denied abdominal pain and denied
fevers/post-prandial abd pain/n/v/d prior to hospitalization.
Other than the development of diarrhea and fever over 30 hours
prior to MICU transfer, the patient had been asymptomatic. He
also denied LH/CP/SOB.
.
In the MICU, he had an EGD which revealed normal mucosa in the
esophagus; Thick gastric folds; ulcers in the duodenal bulb and
second part of the duodenum (thermal therapy, injection);
Otherwise normal EGD to second part of the duodenum.  He
received 12 units of blood and his HCT finally stabilized 28-30
s/p cauterization.  Renal evaluated him and decided on HD for
[**1-2**].  Wound cultures on the L subclavian tunnelled cath were
sent for concern of infected site.  Dilt and BB were restarted.
.
On the floor, he continued to spike fevers daily.  The ID and
renal team's followed closely.  Tacrolimus was weaned in setting
of graft failure.  The right IJ was pulled.  Multiple cultures
showed no subsequent growth.  As of [**1-4**], the following
represents active issues:
.
A/P: 46 yo m w/ a h/o CRT and chronic graft rejection, admitted
with hypotension and PNA, stable s/p cauderization for ulcers
causing melana and hematocrit drop, now with persistent fevers
of unknown etiology.
.
#) ID - The patient had known coag neg staph bacteremia (2
distinct species) and Peptostreptococcus bacteremia with last
positive blood culture [**12-22**].  Of note, he had post-viral MSSA
PNA with respiratory failure that has resolved.   CT Chest [**1-2**]
revealed ? worsening pericardial effusion (see below).
Pericarditis was considered but the patient did not have any EKG
changes consistent with this.  Overall, his fever curve
decreased and at the time of discharge, he had not had a fever >
100.5 in over 24 hours.
- Zosyn was discontinued on [**1-4**] and vancomycin discontinued on
[**1-5**].
- The patient was discharged on Bactrim SS 1 TAB PO 3X WEEK for
Ppx while on steroids. He was instructed to return to the ER or
call his doctor should he have any temperature over 100.5. His
PICC line was removed prior to discharge as he was not going
home on any antibiotics; he does still have his tunnelled HD
catheter in place.
.
#) Pericardial Effusion - This was questionably worsening per CT
scans. However, the patient had 2 echos revealing pericardial
effusion without any echocardiographic signs of tamponade.
.
#) Melena - This was asymptomatic prior to presentation while
hospitalized. EGD showed multiple duodenal ulcers and a pyloric
channel ulcer (treated with BiCAP and epi on [**12-29**]). H. pylori
serology neg. His hematocrit remained stable post-procedure. He
was discharged on [**Hospital1 **] proton pump inhibitor.
.
#) Rash - The patient was noted to have a diffuse erythematous
rash, primarily on his back and trunk. He was evaluated by
Dermatology who felt that the rash could be consistent with a
drug rash. However, as the rash was not bothersome to the
patient in any way and seemed to be resolving (potentially since
discontinuing antibiotics), they did not recommend any specific
treatment. They specifically did not believe that his rash was
in any way related to his ongoing fevers. Please see their note
in OMR for further details.
.
#) Acute on chronic renal failure- Acute on chronic allograft
failure with initiation of hemodialysis while hospitalized. The
patient did have some recovery of his urine output following his
ICU stay. This could represent some graft recovery. However, the
patient is planned to continue hemodialysis as an outpatient
with his first appointment on Tuesday, [**1-11**]. He is to
continue his tacrolimus at 0.5 mg [**Hospital1 **] and prednisone at 10 mg
every other day for now.
- He was dialyzed on the morning of discharge without
complication.
.
#) Afib/flutter- The patient was restarted on diltiazem and BB
on [**12-31**]. He remained in sinus rhythm. His primary doctor could
consider changing to once daily dosing as an outpatient.
.
#) FEN - He tolerated a low sodium, 1 g phosphorus diet while
hospitalized.
.
#) Ppx - He was maintained on a [**Hospital1 **] PPI as above. He had
pneumoboots but was ambulatory prior to discharge.
.
#) Code full
.
#) Access- L PICC (removed prior to discharge), L SC tunneled HD
catheter intact at discharge.

Medications on Admission:
-Lisinopril 20mg qd
-Aronesp 40mg SQ QOWeek
-Fosamax 5mg qd
-MVI
-Cellcept 250mg [**Hospital1 **]
-Pravachol 10mg qhs
-Prednisone 10mg QOD
-Prograf 2mg [**Hospital1 **]


Discharge Medications:
1. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Prednisone 10 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
Disp:*20 Tablet(s)* Refills:*0*
3. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*0*
4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) treatment
Inhalation Q4H (every 4 hours) as needed.
Disp:*QS one month treatment* Refills:*0*
6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
Disp:*30 Tablet(s)* Refills:*0*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatment
Inhalation Q6H (every 6 hours) as needed.
Disp:*QS one month treatment* Refills:*0*
9. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
11. nebulizer machine
Nebulizer machine for nebulizer treatments.


Discharge Disposition:
Home

Discharge Diagnosis:
Acute on chronic renal failure
coagulase negative staphylococcal bacteremia, resolved
Community acquired pneumonia, resolved
Gastrointestinal bleeding, resolved
Duodenal ulcers status post thermal therapy/injection
Pericardial effusion

Secondary:
Status post cadaveric renal transplant
Hypertension
Anemia


Discharge Condition:
Afebrile, normotensive, comfortable on room air


Discharge Instructions:
Please take all medications as prescribed. Please call your
doctor or return to the emergency room should you develop any of
the following symptoms: fever > 101, chills, nausea or vomiting
with inability to keep down liquids or medications, vomiting
blood or blood in your stool, palpitations, dizziness or passing
out.

Please follow up with your already-scheduled dialysis
appointment next Tuesday. You will receive your erythropoietin
at dialysis.

Please call Dr. [**Last Name (STitle) **] should you have any problems in the interim.

Followup Instructions:
Please have your next outpatient dialysis on Tuesday, [**2180-1-11**], at
[**Location (un) 3320**].

Please make an appointment to see Dr. [**Last Name (STitle) **] within the next [**1-11**]
weeks. His office can be reached at [**Telephone/Fax (1) 250**].

Please keep these already scheduled appointments. Call the
office if there is a problem with the appointment date/time.

Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2180-1-31**] 11:30
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2180-2-8**] 8:50


                             [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]

Completed by:[**2180-1-11**]
{'Other staphylococcal septicemia,Complications of transplanted kidney,Acute kidney failure, unspecified,Acute respiratory failure,Methicillin susceptible pneumonia due to Staphylococcus aureus,Septic shock,Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Atrial fibrillation,Subendocardial infarction, initial episode of care,Severe sepsis,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Anemia in chronic kidney disease,Dermatitis due to drugs and medicines taken internally,Unspecified disease of pericardium'}


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: ARF, acidemia, Respiratory failure, hypotension

PRESENT ILLNESS: 46 yo m s/p CRT, hypertension, known to the MICU team after he
was recently admitted with respiratory distress and hypotension,
found to have likely MSSA pna complicated by septic shock who
now returns to the ICU with melena and a hematocrit drop.
.
Briefly, the patient [**Hospital 106884**] transferred from an OSH after
he presented with tachycardia and hypotension following
approximately one week of dry cough and URI symptoms. He was
intubated due to respiratory failure (unclear if
hypoxic/hypercarbic). Additionally, noted to be in acute on
chronic renal failure. He was treated for possible cardiogenic
shock (given troponin leak, and renal failure) and diuresed. The
patient transferred to the [**Hospital1 18**] ICU on [**2179-12-22**] with
respiratory failure, ARF, and vasopresser dependent hypotension.
He was felt to likely be in septic shock in the setting of a
PNA. He was started on stress dose steroids and
vancomycin/zosyn. Patient was titrated off pressers within the
first 24 hours. Bronchoscopy on [**12-23**] showed edematous airways
and scant purulent sputum in the LUL. BAL samples grew MSSA from
2 samples (Moraxella from one). Blood cultures from [**12-22**] grew
out coag neg staph, 2 different species, from 1 from each of 6
bottles. 1 bottle also grew Peptostreptococcus. Extubated on
[**12-25**] without complications. Maintained on CVVHD
(anuric/oliguric). Initially treated with vancomycin and zosyn
until [**12-27**], changed to nafcillin. Clindamycin added [**12-28**].
.
He was subsequently transferred to the floor on [**12-29**] where he
developed a low grade fever to 100.5 and initially had low grade
diarrhea (not tested for fecal occult blood at that time. On
[**12-30**] he was febrile to 101.0 and had onset of "explosive" bowel
movement which was noted to be melanotic (and FOBT positive).
CBC that morning showed an 8 pt hematocrit drop. By report, the
patient had coffee grounds draining NGT following intubation at
OSH. Patient denied abdominal pain and denied
fevers/post-prandial abd pain/n/v/d prior to hospitalization.
Other than the development of diarrhea and fever over 30 hours
prior to MICU transfer, the patient had been asymptomatic. He
also denied LH/CP/SOB.
.
In the MICU, he had an EGD which revealed normal mucosa in the
esophagus; Thick gastric folds; ulcers in the duodenal bulb and
second part of the duodenum (thermal therapy, injection);
Otherwise normal EGD to second part of the duodenum. He received
12 units of blood and his HCT finally stabilized 28-30 s/p
cauterization. Renal evaluated him and decided on HD for [**1-2**].
Wound cultures on the L subclavian tunnelled cath were sent for
concern of infected site. Dilt and BB were restarted.

MEDICAL HISTORY: Renal Transplant 16 yrs ago on immunosuppresants
-HTN poorly controlled
-Anemia on procrit
-Chronic Allograft Nephropathy baseline Cr 4.2 ([**2179-1-10**])

MEDICATION ON ADMISSION: -Lisinopril 20mg qd
-Aronesp 40mg SQ QOWeek
-Fosamax 5mg qd
-MVI
-Cellcept 250mg [**Hospital1 **]
-Pravachol 10mg qhs
-Prednisone 10mg QOD
-Prograf 2mg [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 97.3 103/37 81 11 93% AC 700x14 PEEP 5 FiO2 1.0
GEN: Intubated, sedated
HEENT: ETT in place, R-SVC in place, no cervical LAD, pinpoint
pupils, anicteric sclera
RESP: Course BS throughout L BS>R, no wheezing
CV: Reg Nml S1,S2 2/6 SEM throughout precordium
ABD: Soft ND/NT, +BS, black/coffee ground material from NGT
EXT: No peripheral edema, slight mottling of LE toes b/l
NEURO: hyporeflexia, sedated

FAMILY HISTORY: unknown

SOCIAL HISTORY: lives with 2 children and mother 

### Response:
{'Other staphylococcal septicemia,Complications of transplanted kidney,Acute kidney failure, unspecified,Acute respiratory failure,Methicillin susceptible pneumonia due to Staphylococcus aureus,Septic shock,Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Atrial fibrillation,Subendocardial infarction, initial episode of care,Severe sepsis,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Anemia in chronic kidney disease,Dermatitis due to drugs and medicines taken internally,Unspecified disease of pericardium'}
