CHIEF COMPLAINT: Nausea, vomiting and chills

PRESENT ILLNESS: 82 y/o M w/CAD, CHF, HTN, who was in his USOH until 2 days prior
to admission when he awoke at 5AM with shaking chills. He then
began to have nausea with vomiting and later on profuse
diarrhea. Apparently the patient had been having decreased PO
intake for a couple of days prior to this episode. Patient
states that he had some minor abdominal pain, epigastric in
location. He says that the chills he experienced lasted for one
hour and then resolved. Patient denies any hematemesis or BRBPR.
No sick contacts although patient has 9 grandchildren who visit.
The night before he ate take out chicken, however other family
members ate the same food and did not have similar symptoms.
.
ROS: Positive for chronic joint pain, walks with a cane. Denies
any chest pain, occasionally has palpitations, has anxiety at
times. His ET is limited by joint pain but can walk to end of
room without SOB. He says that his legs are always slightly
swollen, not worse at present, sleeps in hospital bed at home
with raised hed, denies PND, gets up fequently to urinate at
night. Denies headache. +fatigue, decreased energy.

MEDICAL HISTORY: 1. CAD, cath 5 years ago at NEBH (cardiologist [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **])
2. CHF, TTE [**3-6**] w/depressed EF
3. Hypertension, per daughter pt's bp usually 90s-100s on meds
4. Severe Lumbar Spinal stenosis, mild cervical stenosis
5. Sleep apnea, on 2L home O2 at night
6. Afib, s/p DCCV which failed, now rate controlled, not
anticoagulated secondary to fall risk
7. Arthritis
8. Gout
9. COPD? No PFTs

MEDICATION ON ADMISSION: Crestor 5 mg daily
Niaspan 500 mg daily
Colchicine 0.6 mg daily
Sonata 5 mg daily
Digitek 125 mcg daily
Carbidopa 25/100 3x/day
Aspirin 81 mg daily
Glipizide 5 mg [**Hospital1 **]
Lisinopril 5 mg daily
Sotalol 80 mg qam, 40 mg qpm
Potassium 20 meq daily
[**Doctor First Name **] 180 mg daily
Lasix 80 mg qod
Doxepin 25 mg prn itching

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T: 97.6 P: 61 BP: 100/60 R: 18 O2 sat 97% on 2L FS 183
Gen: Elderly man, lying in bed, NAD
HEENT: EOM full, anicteric, L facial droop (old) moist, OP clear

FAMILY HISTORY: HTN, CAD, CVA

SOCIAL HISTORY: Lives with 2 daughter who look after him, wife deceased, has 9
grandchildren, moved to the US from [**Country 4754**] in [**2064**]. Worked at
Sears [**Last Name (un) 40191**] as a firefighter for 41 years, now retired. Has 5
children who all live in the Northeast, lives in [**Location (un) 538**].
Widowed. No tobacco or alcohol x 50 years.
Septicemia due to escherichia coli [E. coli],Atrial fibrillation,Obstructive chronic bronchitis with (acute) exacerbation,Acute kidney failure, unspecified,Dehydration,Septic shock,Other pulmonary insufficiency, not elsewhere classified,Severe sepsis,Long-term (current) use of steroids,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Paralysis agitans
E coli septicemia,Atrial fibrillation,Obs chr bronc w(ac) exac,Acute kidney failure NOS,Dehydration,Septic shock,Other pulmonary insuff,Severe sepsis,Long-term use steroids,DMII wo cmp nt st uncntr,Paralysis agitans
Name:  [**Known lastname 1385**],[**Known firstname **]                Unit No:   [**Numeric Identifier 7235**]

Admission Date:  [**2122-12-23**]              Discharge Date:   [**2123-1-1**]

Date of Birth:  [**2040-6-26**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 276**]
Addendum:
Microbiology Data:
Urine cultures 11/23, [**12-25**] - NO GROWTH
.
Blood cultures 11/23:
 **FINAL REPORT [**2122-12-29**]**

   AEROBIC BOTTLE (Final [**2122-12-29**]):    NO GROWTH.

   ANAEROBIC BOTTLE (Final [**2122-12-25**]):
      REPORTED BY PHONE TO [**First Name8 (NamePattern2) 194**] [**Last Name (NamePattern1) **] @ [**2047**] [**2122-12-23**].
      ESCHERICHIA COLI.    FINAL SENSITIVITIES.
         Trimethoprim/Sulfa sensitivity testing available on
request.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ESCHERICHIA COLI
                             |
AMPICILLIN------------  =>32 R
AMPICILLIN/SULBACTAM--    16 I
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CEFUROXIME------------     4 S
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------  =>16 R
IMIPENEM--------------   <=1 S
LEVOFLOXACIN----------   =>8 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------     4 S
.
Blood Cultures 11/25 - NO GROWTH
.
Stool Cultures 11/30 - negative for c. diff

Discharge Disposition:
Extended Care

Facility:
[**Hospital1 170**] Senior Healthcare - [**Location (un) 171**]

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 284**] MD [**MD Number(1) 285**]

Completed by:[**2123-1-1**]

Admission Date:  [**2122-12-23**]              Discharge Date:   [**2123-1-1**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Nausea, vomiting and chills

Major Surgical or Invasive Procedure:
Central Line placement
Midline IV placement

History of Present Illness:
82 y/o M w/CAD, CHF, HTN, who was in his USOH until 2 days prior
to admission when he awoke at 5AM with shaking chills. He then
began to have nausea with vomiting and later on profuse
diarrhea. Apparently the patient had been having decreased PO
intake for a couple of days prior to this episode. Patient
states that he had some minor abdominal pain, epigastric in
location. He says that the chills he experienced lasted for one
hour and then resolved. Patient denies any hematemesis or BRBPR.
No sick contacts although patient has 9 grandchildren who visit.
The night before he ate take out chicken, however other family
members ate the same food and did not have similar symptoms.
.
ROS: Positive for chronic joint pain, walks with a cane. Denies
any chest pain, occasionally has palpitations, has anxiety at
times. His ET is limited by joint pain but can walk to end of
room without SOB. He says that his legs are always slightly
swollen, not worse at present, sleeps in hospital bed at home
with raised hed, denies PND, gets up fequently to urinate at
night. Denies headache. +fatigue, decreased energy.


Past Medical History:
1. CAD, cath 5 years ago at NEBH (cardiologist [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **])
2. CHF, TTE [**3-6**] w/depressed EF
3. Hypertension, per daughter pt's bp usually 90s-100s on meds
4. Severe Lumbar Spinal stenosis, mild cervical stenosis
5. Sleep apnea, on 2L home O2 at night
6. Afib, s/p DCCV which failed, now rate controlled, not
anticoagulated secondary to fall risk
7. Arthritis
8. Gout
9. COPD? No PFTs


Social History:
Lives with 2 daughter who look after him, wife deceased, has 9
grandchildren, moved to the US from [**Country 4754**] in [**2064**]. Worked at
Sears [**Last Name (un) 40191**] as a firefighter for 41 years, now retired. Has 5
children who all live in the Northeast, lives in [**Location (un) 538**].
Widowed. No tobacco or alcohol x 50 years.

Family History:
HTN, CAD, CVA

Physical Exam:
VS: T: 97.6 P: 61 BP: 100/60 R: 18 O2 sat 97% on 2L FS 183
Gen: Elderly man, lying in bed, NAD
HEENT: EOM full, anicteric, L facial droop (old) moist, OP clear

Neck: supple, JVP flat
Chest: Diffuse scattered wheezines, crackles at lower bases b/l

CV: nl S1 S2, regular, no m/r/g
Abd: obese, soft, nt/nd. +bs. no palpable hepatosplenomegaly.
Ext: 2+ pedal edema to upper calf, warm and dry, 2+ dp pulses
b/l


Pertinent Results:
On Admission:
[**2122-12-23**] 12:40AM   PLT COUNT-167
[**2122-12-23**] 12:40AM   NEUTS-82* BANDS-14* LYMPHS-2* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2122-12-23**] 12:40AM   WBC-19.0*# RBC-4.83 HGB-15.8 HCT-44.5 MCV-92
MCH-32.7* MCHC-35.5* RDW-13.8
[**2122-12-23**] 12:40AM   DIGOXIN-0.5*
[**2122-12-23**] 12:40AM   CORTISOL-36.5*
[**2122-12-23**] 12:40AM   GLUCOSE-178* UREA N-29* CREAT-1.9* SODIUM-136
POTASSIUM-4.7 CHLORIDE-97 TOTAL CO2-21* ANION GAP-23*
[**2122-12-23**] 12:51AM   LACTATE-3.7*
[**2122-12-23**] 12:51AM   COMMENTS-GREEN TOP
[**2122-12-23**] 02:45AM   PT-14.5* PTT-31.4 INR(PT)-1.4
[**2122-12-23**] 02:45AM   PLT COUNT-159
[**2122-12-23**] 02:45AM   NEUTS-83* BANDS-12* LYMPHS-1* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2122-12-23**] 02:45AM   WBC-18.9* RBC-4.55* HGB-14.7 HCT-41.6 MCV-92
MCH-32.3* MCHC-35.3* RDW-13.8
[**2122-12-23**] 02:45AM   CRP-189.1*
[**2122-12-23**] 02:45AM   CORTISOL-218.9*
[**2122-12-23**] 02:45AM   ALBUMIN-3.8 CALCIUM-8.6 PHOSPHATE-2.3*#
MAGNESIUM-1.4*
[**2122-12-23**] 02:45AM   CK-MB-2 cTropnT-0.03* proBNP-2335*
[**2122-12-23**] 02:45AM   LIPASE-19
[**2122-12-23**] 02:45AM   ALT(SGPT)-30 AST(SGOT)-25 CK(CPK)-265* ALK
PHOS-73 TOT BILI-1.2
[**2122-12-23**] 02:45AM   GLUCOSE-212* UREA N-30* CREAT-1.8* SODIUM-133
POTASSIUM-5.1 CHLORIDE-98 TOTAL CO2-20* ANION GAP-20
[**2122-12-23**] 02:54AM URINE  RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2122-12-23**] 02:54AM URINE  BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2122-12-23**] 02:54AM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.023
[**2122-12-23**] 03:02AM   LACTATE-2.7*
[**2122-12-23**] 03:02AM   COMMENTS-GREEN TOP
[**2122-12-23**] 05:26AM   LACTATE-2.2*
[**2122-12-23**] 05:26AM   COMMENTS-GREEN TOP
[**2122-12-23**] 08:00AM   CK-MB-3 cTropnT-0.02*
[**2122-12-23**] 08:00AM   CK(CPK)-246*
[**2122-12-23**] 02:26PM   CK-MB-4
[**2122-12-23**] 02:26PM   CK(CPK)-300*
[**2122-12-23**] 02:26PM   GLUCOSE-278* UREA N-27* CREAT-1.6* SODIUM-136
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-20* ANION GAP-17
[**2122-12-23**] 02:37PM   cTropnT-0.01
.
Upon discharge/other relevant labs:
[**2123-1-1**] 06:18AM BLOOD WBC-23.0* RBC-4.01* Hgb-13.1* Hct-36.9*
MCV-92 MCH-32.5* MCHC-35.4* RDW-13.5 Plt Ct-254
[**2123-1-1**] 06:18AM BLOOD Plt Ct-254
[**2122-12-31**] 06:08AM BLOOD Glucose-79 UreaN-30* Creat-1.2 Na-137
K-4.0 Cl-98 HCO3-26 AnGap-17
[**2122-12-24**] 04:24AM BLOOD LD(LDH)-195
[**2122-12-23**] 02:26PM BLOOD CK(CPK)-300*
[**2122-12-23**] 08:00AM BLOOD CK(CPK)-246*
[**2122-12-23**] 02:45AM BLOOD ALT-30 AST-25 CK(CPK)-265* AlkPhos-73
TotBili-1.2
[**2122-12-23**] 02:45AM BLOOD CK-MB-2 cTropnT-0.03* proBNP-2335*
[**2122-12-23**] 02:37PM BLOOD cTropnT-0.01
[**2122-12-23**] 08:00AM BLOOD CK-MB-3 cTropnT-0.02*
[**2122-12-30**] 06:25AM BLOOD Calcium-8.4 Phos-3.3 Mg-1.8 UricAcd-9.5*
[**2122-12-23**] 02:45AM BLOOD CRP-189.1*
[**2122-12-23**] 12:40AM BLOOD Digoxin-0.5*
[**2122-12-25**] 01:47AM BLOOD Type-ART Temp-38.6 pO2-71* pCO2-32*
pH-7.46* calHCO3-23 Base XS-0 Intubat-NOT INTUBA
[**2122-12-25**] 01:47AM BLOOD Lactate-1.9
.
Microbiology:

Imaging:
[**12-23**] CXR: Portable supine AP radiograph of the chest is
reviewed, and compared to previous study at 1:09 a.m. The right
subclavian IV catheter terminates in the right atrium. No
pneumothorax is identified. The lung volume is small with
continued slight elevation of the right hemidiaphragm. The heart
is normal in size. Again, note is made of tortuosity of the
thoracic aorta. IMPRESSION: No pneumothorax.
.
[**12-23**] KUB: No evidence for small-bowel obstruction. Limited
study, which cannot rule out the presence of free air. If of
clinical concern, would repeat examination.
.
[**12-23**] CT Abdomen: 1. Distended gallbladder likely containing
gallstones or sludge without evidence for cholecystitis. 2. No
evidence for intra-abdominal or intrapelvic bowel abnormality
including colitis or diverticulitis. 3. Diverticulosis without
evidence for diverticulitis.
4. Low-density lesions within the liver and bilateral kidneys
likely representing cysts. These foci could be definitively
characterized with ultrasound if clinically indicated.
.
[**12-23**] EGK: Atrial fibrillation with a mean ventricular response,
rate approximately 115. Inferior myocardial infarction.
Non-diagnostic T wave flattening in the lateral leads. Compared
to the previous tracing of [**2121-3-24**] cardiac now atrial
fibrillation.
[**12-25**] EKG: Atrial fibrillation Old inferior infarct Low QRS
voltages in precordial leads Since last ECG, ventricular
response slower
.
CXR [**12-25**]: The exam is unchanged. Lung volumes are small. Right
subclavian IV catheter tip overlies the SVC. Pneumothoraces
present. Patchy atelectasis unchanged, no infiltrates. Heart
size and mediastinal contour within normal.
.
Renal Ultrasound [**12-29**]: The left kidney measures 13.7 cm. The
right kidney measures 14.7 cm. There is no evidence of
perinephric fluid or abscess. In the right kidney there are four
cysts identified, as seen on prior CT exam from [**2122-12-23**]. The
simple cysts range in size from approximately 4 cm to 7 cm in
diameter. In the left kidney there are multiple subcentimeter
simple cysts along with a large 3.5 x 3.7 x 4.2 cm simple cyst
seen in the mid to lower pole. The bladder is full and
unremarkable


Brief Hospital Course:
Mr. [**Known lastname **] is an 82 yo gentleman with CAD, CHF, ?COPD, A.
Fib/flutter admitted with E.coli sepsis and rapid atrial
fibrillation. The patient was initially managed in the MICU for
24 hrs with central line placement and IVF resuscitation. He was
then transferred to the regular medical floor once stabilized.
Initially the patient was doing very well on the floor, sitting
in chair [**Location (un) 1131**], heart rate well controlled on digoxin only
(sotalol held in setting of relative hypotension on admission).
Blood cultures returned positive for gram negative rods
resistant to quinolones and therefore his antibiotics were
changed from Levofloxacin/Flagyl/Ampicillin antibiotics to
Ceftriaxone mid afternoon. Patient also noted to be
intermittently wheezing, started on Albuterol/Atrovent nebs and
given 2x 40 IV lasix for fluid overload on exam. Overnight,
patient spiked temp to 101.6 and went into rapid A. fib with
rates in 140s, BP 100/67, given IV diltiazem 10 mg x 2 then 30
mg PO with persistent elevation in HR ranging 120-130s. The
patient was transferred back to the MICU for management of his
rapid A.fib and sepsis.
.
In the MICU, patient treated with Ceftriaxone initially. Blood
cultures came back positive for E.coli. Patient remained his
blood pressures, no evidence of septic shock. Eventually
antibiotics were tailored further and he was transferred to the
medical floor once again, this time on IV Cefazolin (Ancef). His
central line d/ced prior to transfer.
.
Rapid A. Fib: Patient was taking Sotalol/Dig at home, not on any
anticoagulation. He required IV diltiazem in ED for rapid rate.
Upon transfer to the floor, patient was initially maintained on
Digoxin w/out restarting sotalol for concerns of borderline low
BP. His HR was well controlled in the 80s. Dig level 0.5 on
admission. Patient later went into rapid afib the same evening
in setting of fever spike requiring IV diltiazem. He was started
on IV diltiazem->PO with improvement in HR control while in the
MICU. Patient also restarted on sotalol which was eventually
increased to 80 mg daily for optimal control. His current
regimen for HR control includes Sotalol 80 mg [**Hospital1 **] and Diltiazem
300 mg daily sustained release, Digoxin is discontinued. Patient
was also started on anticoagulation for A.fib with coumadin. He
is currently on 3 mg of coumadin daily. His INR must be checked
and reported to his PCP (as outlined in the discharge plan) in
case adjustments must be made. Patient was monitored on
telemetry throughout his stay in hospital.
.
E. Coli Sepsis: Blood cx growing E.coli sensitive to
Cephalosporins, resistant to quinolones, likely source is GI
given hx of N/V/D although unclear. [**Name2 (NI) **] clear source on abdominal
CT such as cholecystitis, diverticulitis. Patient was initially
treated with broad coverage with Ampicillin/Flagyl/Levofloxacin.
He was changed to IV Ceftriaxone and then Cefazolin once the
sensitivities were available. Patient is now afebrile x several
days, WBC was generally trending down from admission 18->12 but
later increased to >20 in setting of gouty flare and in setting
of increases steroids. He is discharge with negative urine/blood
cultures, afebrile, HR well controlled and generally feeling
much better. He should continue narrow spectrum antibiotic
coverage with Cefazolin IV to complete a 14 day course.
Infectious disease felt that the patient should be treated with
IV antibiotics for 14 days since PO antibiotics will likely not
be adequate for this type of infection. Renal son[**Name (NI) **] was also
performed to r/out any other potential source such as a
perinephric abscess, this was negative. Of note, patient
developed one episode of diarrhea on [**12-30**] which resolved
spontaneously. His stool is negative for C.diff and he has not
had any abdominal pain/discomfort to date.
.
?COPD. Patient noted to be wheezing upon transfer to the floor.
He does not have a documented diagnosis of COPD, no PFTs on
record. It was unclear whether this was a COPD flare vs. cardiac
wheezing given that the patient required aggressive fluid
hydration in the MICU. The patient as treated with
Albuterol/Atrovent nebulizers with improvement. He was also
diuresed with IV lasix 40 mg [**Hospital1 **] and then put on lasix PO 80 QOD
then daily. He is discharged on 80 mg of lasix daily. He
diureses well with this dose. Of note, the patient was also
started on prednisone for presumed COPD and due to ongoing
wheezing. He is discharged on 20 mg of prednisone for COPD and
concomitant gouty flare. Steroids should be tapered over the
next 12 days. Patient also received a 5 day course of
Azithromycin for presumed COPD exacerbation.
.
Acute Renal Insufficiency: Patient has a baseline creatinine of
1.3-1.5 on prior visits in [**2121**]. On admission his Cr was 1.9
which has trended down to 1.2 on discharge. Likely prerenal
secondary to volume depletion from vomiting/diarrhea, was fluid
resuscitated in MICU and later diuresed on the floor. Currently
patient appears euvolemic with trace pedal edema. His
medications were renally dosed throughout this admission.
.
CAD/CHF: Patient has a depressed EF on echo in [**2121**], %EF not
reported. Upon initial transfer to floor the patient appeared
fluid overloaded s/p fluid resuscitation in MICU. Patient had
elevated JVP, 2+ pitting edema, wheezing with crackles. Cardiac
enzymes were negative x 3 on admission. Question of
subendocardial ischemia in setting of hypotension based on
subtle EKG changes in ST-T segments. BNP elevated on admission
as well. Patient required diuresis with IV lasix initially and
is not maintained on PO lasix. He is currently euvolemic per
exam and stabilized on his current regimen. He should be
continued on ASA, Statin. He is currently not on an ACEI (defer
to Dr. [**Last Name (STitle) **] his PCP and cardiologist), likely because he does not
have a depressed EF.
.
Gout. Patient has a history of gout in the past. He developed a
gouty attack in his right foot on [**12-29**] and then in his left
elbow on [**12-31**]. He was treated with Ibuprofen 600 mg x 2
intially and then placed on Indomethacin 25 mg TID with some
relief. His steroids were also increased to 20 mg daily. He was
not treated with Colchicine which he has taken in the past due
to one episode of diarrhea and the potential to cause stomach
upset with this medication. This medication can be restarted in
the future as per the PCP. [**Name10 (NameIs) **] should also be on prophylaxis with
Allopurinol in the future once he is over this acute flare.
.
Diabetes: Patient is usually managed on oral medication as an
outpatient. He requires coverage with regular insulin sliding
scale while on steroids. The regular insulin sliding scale can
be discontinued once he is off steroids. He is also discharged
on Glipizide which he was taking prior to admission. This
medication was discontinued while in hospital and he was
maintained on a sliding scale regimen with good control.
.
FEN: Cardiac/diabetic diet; No standing IVF; electrolytes were
monitored and replaced as needed.
.
Prophylaxis: SQ heparin, bowel regimen, PPI (only while on
steroids, can be d/ced afterwards)
.
Code: Full. Confirmed with patient.

Medications on Admission:
Crestor 5 mg daily
Niaspan 500 mg daily
Colchicine 0.6 mg daily
Sonata 5 mg daily
Digitek 125 mcg daily
Carbidopa 25/100 3x/day
Aspirin 81 mg daily
Glipizide 5 mg [**Hospital1 **]
Lisinopril 5 mg daily
Sotalol 80 mg qam, 40 mg qpm
Potassium 20 meq daily
[**Doctor First Name **] 180 mg daily
Lasix 80 mg qod
Doxepin 25 mg prn itching


Discharge Medications:
1. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Diltiazem HCl 300 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
3. Cefazolin 1 g Piggyback Sig: One (1) Piggyback Intravenous
Q12H (every 12 hours) for 10 days.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. Indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) for 5 days.
7. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 10 days: Please give 20 mg daily x 4 days then 10 mg daily
for 4 days then 5 mg for 4 days.
8. Heparin Flush CVL  (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN.  Inspect site every shift
9. Albuterol Sulfate 0.083 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical  QID
(4 times a day) as needed.
11. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
12. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. Sonata 5 mg Capsule Sig: One (1) Capsule PO at bedtime.
14. Insulin Regular Human 100 unit/mL Cartridge Sig: One (1)
Injection as directed on flow sheet for 12 days.
15. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours).
16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
17. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
19. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
20. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
21. Niaspan 500 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day.
22. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **] Senior Healthcare - [**Location (un) 1887**]

Discharge Diagnosis:
1. E. coli sepsis
2. Rapid atrial fibrillation


Discharge Condition:
Good - breathing comfortably, afebrile, heart rate well
controlled


Discharge Instructions:
Please take all medications as directed

Please ensure that you follow up with your primary care doctor
(see below) as indicated by his PCP.

Please check INR on Saturday [**2123-1-2**] and Monday [**2123-1-4**] and
then weekly INR - patient recently started on coumadin, please
forward results to PCP listed below who will make adjustments to
his medication if necessary:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
One [**Location (un) **] Place, [**Apartment Address(1) 19746**]
([**Telephone/Fax (1) 5455**] ext:[**Numeric Identifier 40192**]
Pager: [**Pager number 40193**]
[**University/College 40194**]
.
Please follow up with other appointments as listed below.
.
Please return to the hospital if you have any fevers, chills,
nausea/vomiting, elevated heart rate or any other complaints

Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6855**], M.D. Date/Time:[**2123-2-18**] 10:00

Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
One [**Location (un) **] Place, [**Apartment Address(1) 19746**]
([**Telephone/Fax (1) 5455**] ext:[**Numeric Identifier 40192**]
Pager: [**Pager number 40193**]
[**University/College 40194**]



Completed by:[**2123-1-1**]
{'Septicemia due to escherichia coli [E. coli],Atrial fibrillation,Obstructive chronic bronchitis with (acute) exacerbation,Acute kidney failure, unspecified,Dehydration,Septic shock,Other pulmonary insufficiency, not elsewhere classified,Severe sepsis,Long-term (current) use of steroids,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Paralysis agitans'}


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: Nausea, vomiting and chills

PRESENT ILLNESS: 82 y/o M w/CAD, CHF, HTN, who was in his USOH until 2 days prior
to admission when he awoke at 5AM with shaking chills. He then
began to have nausea with vomiting and later on profuse
diarrhea. Apparently the patient had been having decreased PO
intake for a couple of days prior to this episode. Patient
states that he had some minor abdominal pain, epigastric in
location. He says that the chills he experienced lasted for one
hour and then resolved. Patient denies any hematemesis or BRBPR.
No sick contacts although patient has 9 grandchildren who visit.
The night before he ate take out chicken, however other family
members ate the same food and did not have similar symptoms.
.
ROS: Positive for chronic joint pain, walks with a cane. Denies
any chest pain, occasionally has palpitations, has anxiety at
times. His ET is limited by joint pain but can walk to end of
room without SOB. He says that his legs are always slightly
swollen, not worse at present, sleeps in hospital bed at home
with raised hed, denies PND, gets up fequently to urinate at
night. Denies headache. +fatigue, decreased energy.

MEDICAL HISTORY: 1. CAD, cath 5 years ago at NEBH (cardiologist [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **])
2. CHF, TTE [**3-6**] w/depressed EF
3. Hypertension, per daughter pt's bp usually 90s-100s on meds
4. Severe Lumbar Spinal stenosis, mild cervical stenosis
5. Sleep apnea, on 2L home O2 at night
6. Afib, s/p DCCV which failed, now rate controlled, not
anticoagulated secondary to fall risk
7. Arthritis
8. Gout
9. COPD? No PFTs

MEDICATION ON ADMISSION: Crestor 5 mg daily
Niaspan 500 mg daily
Colchicine 0.6 mg daily
Sonata 5 mg daily
Digitek 125 mcg daily
Carbidopa 25/100 3x/day
Aspirin 81 mg daily
Glipizide 5 mg [**Hospital1 **]
Lisinopril 5 mg daily
Sotalol 80 mg qam, 40 mg qpm
Potassium 20 meq daily
[**Doctor First Name **] 180 mg daily
Lasix 80 mg qod
Doxepin 25 mg prn itching

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T: 97.6 P: 61 BP: 100/60 R: 18 O2 sat 97% on 2L FS 183
Gen: Elderly man, lying in bed, NAD
HEENT: EOM full, anicteric, L facial droop (old) moist, OP clear

FAMILY HISTORY: HTN, CAD, CVA

SOCIAL HISTORY: Lives with 2 daughter who look after him, wife deceased, has 9
grandchildren, moved to the US from [**Country 4754**] in [**2064**]. Worked at
Sears [**Last Name (un) 40191**] as a firefighter for 41 years, now retired. Has 5
children who all live in the Northeast, lives in [**Location (un) 538**].
Widowed. No tobacco or alcohol x 50 years. 

### Response:
{'Septicemia due to escherichia coli [E. coli],Atrial fibrillation,Obstructive chronic bronchitis with (acute) exacerbation,Acute kidney failure, unspecified,Dehydration,Septic shock,Other pulmonary insufficiency, not elsewhere classified,Severe sepsis,Long-term (current) use of steroids,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Paralysis agitans'}
