CHIEF COMPLAINT: Transfer to [**Hospital1 18**] for PEG placement

PRESENT ILLNESS: 61 year-old male with longstanding DM type 1 with triopathy,
status post CRT [**2196**] (baseline creat 2.9-3.0 in [**3-/2203**]),
recurrent UTIs with MDR organisms, history of MRSA sepsis/osteo,
initially transferred on [**10-17**] from [**Hospital3 2737**] for PEG
placement.
*
He was originally admitted to [**Hospital1 **] on [**2203-10-4**] with mental
status changes. His w/u was remarkable for VRE UTI (only 1000
colonies) and a LLL pneumonia. He was initially started on
Cefepime, changed to Imipenem and Flagyl. A repeat urine culture
grew Burkholderia cepacia sensitive to Zosyn, and Zosyn therapy
was initiated on [**10-12**]. Blood cx negative. A follow-up CXR
showed resolution of his LLL pneumonia. A tagged WBC scan was
also performed and negative for infection. He remained
disoriented despite treatment of his infection, and he was felt
to be continually scratching his left biceps and having facial
twitching. Neurology was consulted. Head CT showed mild atrophy
but was otherwise negative. MRI showed marked atrophy, as well
as subtle changes in the posterior limb of the internal capsule
that could possibly represent small subacute punctate infarcts.
EEG was requested, but deferred [**12-29**] "scheduling difficulties".
Per neurology, Mr. [**Known lastname 1001**] was loaded with Dilantin for possible
seizure activity, with some subsequent improvement in his mental
status.
*
Still at the OSH, his Hct on admission was noted to be 25, and
he was transfused 2 units of PRBCs. He failed a bedside swallow
evaluation, and a barium swallow showed evidence of penetration
and aspiration. An NGT was placed. The patient reportedly did
not want a PEG tube, but was deemed incompetent to make
decisions by psychiatry. While in the hospital, he was begun on
Risperdal and Celexa was increased.
*
On the day of transfer ([**10-17**]), his lab work was remarkable for
a HCO3 drop 20-->15, with development of an anion gap acidosis.
He was started on IVF with dextrose, and given 1 amp of sodium
bicarbonate.  On arrival to [**Hospital1 18**], he was hemodynamically
stable. However, his initial lab work was remarkable for an
anion gap of 22, with HCO3 of 9, glucose of 362. ABG done
7.23/22/50 (?arterial). U/A positive for ketones.  Of note,
standing insulin had been held at outside hospital.  He was
given insulin SC X few doses, then started on insulin drip on
the floor on [**10-18**], along with IVF, with eventual closure of his
gap. Coincident with the metabolic derangements, however, he was
noted to have declining mental status (responsive only to pain
at time of transfer), and he was transferred to the MICU for
further care.
*
In the MICU, he was continued on the insulin drip overnight,
discontinued on [**10-19**] at 1000 after overlap with NPH. AG closed.
[**Last Name (un) **] consulted, with recommendation to start Lantus. Regarding
his mental status, neurology was consulted. LP was performed
with OP 9, WBC 4, RBC 0, TP 93, Gluc 145, gram stain negative,
cryptococcal antigen negative, cultures pending. He was loaded
with Dilantin on [**10-18**] at night pending EEG on [**10-19**].
Preliminary report negative for seizure activity. Per neurology,
Dilantin was tapered off.

MEDICAL HISTORY: 1. DM type 1 with triopathy
2. Status post cadaveric renal transplant in [**2196**]
3. Chronic renal insufficiency with baseline creatinine 2.9-3.0
in [**3-/2203**]
4. Peripheral neuropathy
6. Hypertension
7. CAD, LVEF >55% in [**3-/2203**]
8. GERD
9. Hypercholesterolemia
10. History of MRSA osteomyelitis/sepsis
11. History of recurrent UTIs with MDR organisms
*
Other past surgical history:
Status post right THR
Status post left BKA
Status post open chlecystectomy

MEDICATION ON ADMISSION: MEDS on admission to OSH (presumed)
Feosol 325 mg daily, Colace 100 mg daily, Senokot 1 tab qhs,
Flomax 0.4 mg qhd, Reglan 10 mg PO BID, Lopressor 75 mg twice
daily, Norvasc 10 mg daily, Plavix 75 mg daily, Nexium 40 mg
daily, Celexa 10 mg daily, Lasix 20 mg IV daily, Hydralazine 10
mg PO q6hours, Cefepime 1 gm IV daily, Prednisone 5 mg daily,
MVI daily, Tacrolimus 0.5 mg [**Hospital1 **], Heparin 5000 units SC BID
Humulin N 10 units qam, 5 units qhs
*
MEDS at time of transfer:
Rapamune 3 tabs 1 mg PO daily
Protonix 40 mg IV daily
Tacrolimmus 0.5 mg PO BID
Dilantin 300 mg PO qhs
Norvasc 10 mg PO QD
Zosyn 2.25 gm IV q6 hours (day 6 on transfer)
Lopressor 125 mg PO BID
Celexa 20 mg daily
Risperidone 0.5 mg PO BID
RISS
*
Current meds in MICU:
Metoprolol 75 mg PO BID
Pantoprazole 40 mg IV Q24H
Amlodipine 10 mg PO DAILY
Citalopram Hydrobromide 20 mg PO DAILY
Phenytoin 100 mg IV Q12H for 2 days, then 100 mg IV daily for 2
days
Daptomycin 300 mg IV Q48H day 2
Piperacillin-Tazobactam Na 2.25 gm IV Q6H
Docusate Sodium (Liquid) 100 mg PO BID
Epoetin Alfa 4000 UNIT SC QMOWEFR Start: HS
Senna 2 TAB PO BID:PRN
Folic Acid 1 mg IV DAILY
Sirolimus 3 mg PO DAILY
Heparin 5000 UNIT SC TID
Tacrolimus 1 mg PO BID renal transplant
Thiamine HCl 100 mg IV DAILY
Insulin SC
Glargine 10 units qhs (to receive first dose tonight)
*

ALLERGIES: Sulfamethoxazole/Trimethoprim / Aspirin

PHYSICAL EXAM: VITALS: Tm 99.2, Tc 98.9, HR 60s-70s, BP 120-170/50-60s, RR high
teens to low 20s, Sat 98-100% on RA.
I/O: + 450 last 24 hours, then + 1700 cc today
GEN: Caucasian male, in NAD. Answers questions, recognizes his
name, not oriented to place or time. Makes eye contact.
[**Name (NI) 4459**]: Pupils sluggish, reactive. Dry MM.
NECK: No cervical LN.
RESP: Limited examination, clear anteriorly.
CVS: RRR. Normal S1, S2.
GI: BS +. Soft, non-tender.
EXT: 2+ pedal edema RLE. Left BKA.
NEURO: Moves all 4 extremities.

FAMILY HISTORY: Mother with DM and PM and Father with PM

SOCIAL HISTORY: Widowed, ex-meat cutter, no TOB, no ETOH, no IVDU
Unspecified infectious and parasitic diseases,Diabetes with ketoacidosis, type I [juvenile type], not stated as uncontrolled,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Complications of transplanted kidney,Unspecified pleural effusion,Hematemesis,Hyperosmolality and/or hypernatremia,Hip joint replacement,Below knee amputation status,Unspecified essential hypertension,Unspecified disorder of skin and subcutaneous tissue
Infect/parasite dis NOS,DMI keto nt st uncntrld,Pneumonia, organism NOS,Urin tract infection NOS,Compl kidney transplant,Pleural effusion NOS,Hematemesis,Hyperosmolality,Joint replaced hip,Status amput below knee,Hypertension NOS,Skin disorder NOS
Admission Date:  [**2203-10-17**]              Discharge Date:   [**2203-11-7**]

Date of Birth:  [**2142-6-14**]             Sex:   M

Service: MEDICINE

Allergies:
Sulfamethoxazole/Trimethoprim / Aspirin

Attending:[**First Name3 (LF) 3624**]
Chief Complaint:
Transfer to [**Hospital1 18**] for PEG placement

Major Surgical or Invasive Procedure:
Placement of left subclavian central line (removed), and right
internal jugular central line (removed)

Right sided thoracentesis for pleural effusions


History of Present Illness:
61 year-old male with longstanding DM type 1 with triopathy,
status post CRT [**2196**] (baseline creat 2.9-3.0 in [**3-/2203**]),
recurrent UTIs with MDR organisms, history of MRSA sepsis/osteo,
initially transferred on [**10-17**] from [**Hospital3 2737**] for PEG
placement.
*
He was originally admitted to [**Hospital1 **] on [**2203-10-4**] with mental
status changes. His w/u was remarkable for VRE UTI (only 1000
colonies) and a LLL pneumonia. He was initially started on
Cefepime, changed to Imipenem and Flagyl. A repeat urine culture
grew Burkholderia cepacia sensitive to Zosyn, and Zosyn therapy
was initiated on [**10-12**]. Blood cx negative. A follow-up CXR
showed resolution of his LLL pneumonia. A tagged WBC scan was
also performed and negative for infection. He remained
disoriented despite treatment of his infection, and he was felt
to be continually scratching his left biceps and having facial
twitching. Neurology was consulted. Head CT showed mild atrophy
but was otherwise negative. MRI showed marked atrophy, as well
as subtle changes in the posterior limb of the internal capsule
that could possibly represent small subacute punctate infarcts.
EEG was requested, but deferred [**12-29**] "scheduling difficulties".
Per neurology, Mr. [**Known lastname 1001**] was loaded with Dilantin for possible
seizure activity, with some subsequent improvement in his mental
status.
*
Still at the OSH, his Hct on admission was noted to be 25, and
he was transfused 2 units of PRBCs. He failed a bedside swallow
evaluation, and a barium swallow showed evidence of penetration
and aspiration. An NGT was placed. The patient reportedly did
not want a PEG tube, but was deemed incompetent to make
decisions by psychiatry. While in the hospital, he was begun on
Risperdal and Celexa was increased.
*
On the day of transfer ([**10-17**]), his lab work was remarkable for
a HCO3 drop 20-->15, with development of an anion gap acidosis.
He was started on IVF with dextrose, and given 1 amp of sodium
bicarbonate.  On arrival to [**Hospital1 18**], he was hemodynamically
stable. However, his initial lab work was remarkable for an
anion gap of 22, with HCO3 of 9, glucose of 362. ABG done
7.23/22/50 (?arterial). U/A positive for ketones.  Of note,
standing insulin had been held at outside hospital.  He was
given insulin SC X few doses, then started on insulin drip on
the floor on [**10-18**], along with IVF, with eventual closure of his
gap. Coincident with the metabolic derangements, however, he was
noted to have declining mental status (responsive only to pain
at time of transfer), and he was transferred to the MICU for
further care.
*
In the MICU, he was continued on the insulin drip overnight,
discontinued on [**10-19**] at 1000 after overlap with NPH. AG closed.
[**Last Name (un) **] consulted, with recommendation to start Lantus. Regarding
his mental status, neurology was consulted. LP was performed
with OP 9, WBC 4, RBC 0, TP 93, Gluc 145, gram stain negative,
cryptococcal antigen negative, cultures pending. He was loaded
with Dilantin on [**10-18**] at night pending EEG on [**10-19**].
Preliminary report negative for seizure activity. Per neurology,
Dilantin was tapered off.

Past Medical History:
1. DM type 1 with triopathy
2. Status post cadaveric renal transplant in [**2196**]
3. Chronic renal insufficiency with baseline creatinine 2.9-3.0
in [**3-/2203**]
4. Peripheral neuropathy
6. Hypertension
7. CAD, LVEF >55% in [**3-/2203**]
8. GERD
9. Hypercholesterolemia
10. History of MRSA osteomyelitis/sepsis
11. History of recurrent UTIs with MDR organisms
*
Other past surgical history:
Status post right THR
Status post left BKA
Status post open chlecystectomy

Social History:
Widowed, ex-meat cutter, no TOB, no ETOH, no IVDU


Family History:
Mother with DM and PM and Father with PM


Physical Exam:
VITALS: Tm 99.2, Tc 98.9, HR 60s-70s, BP 120-170/50-60s, RR high
teens to low 20s, Sat 98-100% on RA.
I/O: + 450 last 24 hours, then + 1700 cc today
GEN: Caucasian male, in NAD. Answers questions, recognizes his
name, not oriented to place or time. Makes eye contact.
[**Name (NI) 4459**]: Pupils sluggish, reactive. Dry MM.
NECK: No cervical LN.
RESP: Limited examination, clear anteriorly.
CVS: RRR. Normal S1, S2.
GI: BS +. Soft, non-tender.
EXT: 2+ pedal edema RLE. Left BKA.
NEURO: Moves all 4 extremities.

Pertinent Results:
Micro:
[**2203-10-19**] BLOOD CULTURE x2 negative
[**2203-10-19**] CSF SPINAL FLUID GS negative, cultures negative
[**2203-10-19**] CSF CRYPTOCOCCAL ANTIGEN negative
[**2203-10-18**] BLOOD CULTURE x 4 bottles negative
*
Labs:
[**10-25**] Trop 0.14
[**10-26**] Trop 0.16  CK-MB 2
[**10-26**] Trop 0.16
[**10-27**]  Trop 0.20

Relevant imaging studies:
OSH:
CXR [**10-4**] with LLL pneumonia, resolved on CXR [**10-10**]
Tagged WBC scan negative
CT head: Atrophy, no focal disease
MRI head: MArked atrophic changes, possible subacute punctate
infarcts.
*
[**Hospital1 18**]:
[**10-18**] CXR: Probable bibasilar pneumonia
[**10-18**] Renal transplant U/S: Normal
[**10-19**] CT head: No intracranial hemorrhage. No major vascular
territorial infarction.
[**10-19**] EEG: Bursts of generalized slowing consistent with
encephalopathy. .
[**10-20**] MRI with gadolinium, stroke protocol: Mild-to-moderate
brain atrophy and a chronic lacune in the posterior limb of the
left internal capsule unchanged from the previous MRI of [**2202-3-31**].
There are no MRI signs of posterior encephalopathy seen. No mass
effect or hydrocephalus noted. No acute infarcts are seen.
[**10-24**] EGD: Gastric antrum, mucosal biopsy - negative for H.
pylori
[**10-27**] CT sinuses: No air-fluid levels to suggest acute
sinusitis. Mild mucosal thickening in the paranasal sinuses, as
described.
[**10-28**] V/Q Scan: Indeterminate lung scan. There are bilateral
areas of decreased perfusion within the lung bases,
asymmetrically with a larger defect on the right. Although the
pattern of this perfusion could be explained by bilateral
pleural effusion, in the face of these abnormalities, it is
difficult to exclude a pulmonary embolism.
[**10-31**] CT Chest without contrast: 1. Large bilateral pleural
effusions with associated compressive atelectasis that are
little changed when compared to [**2202-4-18**]. Otherwise, clear
lungs.  2. Slightly dilated esophagus  3. Dilatation of the
extrahepatic biliary system with a probable calcified filling
defect in the distal common duct. Clinical correlation is
advised.




Brief Hospital Course:
ASSESSMENT AND PLAN: 61 yo male with longstanding DM type 1 with
triopathy, s/p CRT in [**2196**] on immunosuppression, transferred
from OSH with UTI, change in mental status, in DKA. DKA
resolved. Also being anticoagulated for left DVT, likely PE.
Moderate to large pleural effusions bilaterally s/p right
thoracentesis.  Pt has had chronic complaints of chest pain x >1
month, with negative work-ups, pain likely due to combination of
costochondritis plus possible PE.  Pt also with UGIB,
esophagitis, duodenitis, duodenal ulcer not actively bleeding,
and Hct stable on anticoagulation. Treated for UTI with Zosyn,
however, pt found to have new UTI during admission with fever,
which was treated w/ Meropenem.
*
1) PE/DVT/Chest pain:
- Pt complaining of chest pain which he reports to have had for
greater than 1 month, pleuritic or with exertion.  EKGs showed
no changes from baseline, no ischemic changes. He had elevated
cardiac enzymes, which were felt to be secondary to his poor
renal clearance in addition to possible demand ischemia as they
were drawn during a period of anemia/UGIB.  He had lower
extremity dopplers which were positive for DVT in left
superficial femoral vein, extending to beginning of popliteal.
A V/Q scan was performed as the pt was unable to have a CTA due
to his renal status; however, the study was suboptimal, unable
to perform ventilation portion of study - on perfusion scan,
unable to visualize bases [**12-29**] bilateral pleural effusions,
therefore unable to r/o PE's.  The pt was started on Heparin;
Coumadin was started [**11-1**] at 3 mg, then increased to 5 mg to
reach therapeutic INR of 1.7.
- The patient also had bilateral pleural effusions which were
present on chest CT's from a year ago.  On [**2203-11-1**], an
ultrasound guided thoracentesis of right pleural effusion was
performed, 1.2L was removed.  Pleural fluid showed no PMN's or
organisms, LDH ratio indicative of transudative process, pleural
cx's NEGATIVE bacteria, fungus, AFB smear, and cytology NEGATIVE
for malignancy.
- Pt also had reproducible CP on palpation over sternum,
possible costochondritis.  Rib Xray [**10-31**] negative for fracture.
*
2) ID:  The patient completed 2 week course of Zosyn for UTI as
described above on [**10-22**].  However, the pt subsequently became
febrile [**10-25**] accompanied by change in mental status, increased
WBC - now has been afebrile with much improved mental status and
decreasing WBC.  Broad spectrum abx started [**10-27**], with
Vancomycin renally dosed (discontinued) and Zosyn; however,
[**10-26**] Urine Cx results + for non-fermenter not pseudomonas,
intermediate sensitivity to Zosyn, sensitive to Meropenem.
Ruled out for PNA, sinusitis, C. diff, line infection. Zosyn was
therefore discontinued, and pt was treated with Meropenem 500
[**Hospital1 **] IV x7 days, completed [**11-7**].  The patient also had yeast on
UA/UCx, and was started on Fluconazole [**11-5**] x ~10 day course.
The pt was subsequently afebrile with normal WBC, stable mental
status.
.
ID Work-up:
- Central line d/c'd [**10-27**], placed [**10-18**]; new RIJ placed [**10-26**].
- C.diff negative [**10-26**] - diarrhea, likely from GI blood.
- Blood cultures 11/22, 23 negative
- [**10-25**] KUB: No free air or obstruction
- [**10-27**] CXR: Small bilateral pleural effusions
- [**10-27**] CT Sinuses: No acute sinusitis; some paranasal sinus
thickening
- [**10-27**] Catheter tip: NO SIGNIFICANT GROWTH
- [**10-25**], 30 Blood cultures NO GROWTH
*
3) GI: Upper GI bleed coffee ground emesis [**10-22**], and again on
[**10-25**], requiring transfusions of PRBC's, total 4 units.  EGD was
performed [**10-24**], and showed esophagitis, duodenitis, duodenal
ulcer, no active bleeding.  An NGT was placed for gastric
decompression, d/c'd [**10-27**].  Hct stable on anticoagulation.
[**10-24**] EGD Biopsy negative for H. Pylori, Protonix PO BID,
Sucralfate QID.
- The pt also developed fleeting RUQ pain.  Incidental finding
on chest CT [**10-31**], showed dilatation of the extrahepatic biliary
system with a calcific density in the expected location of the
distal common duct.  RUQ resolved, LFT's and bilirubin normal
except for increased Alk Phos ([**10-18**] 208, [**11-3**] 439, [**11-4**] 452).
The pt may have some common bile duct stone/obstruction, given
CT finding, however, he has declined ERCP despite discussing
possibility for progression to infection.
*
4) DM type 1/DKA:
- DKA resolved. Basal insulin had been held at OSH (transferred
only on RISS). Pt's blood sugar was quite labile, fluctuating
depending upon PO status, infectious states, and had period of
both low FSG's to 30's necessitating D50, as well as
hyperglycemia to 477.  He had FSG's checked qACHS, and at 3AM.
His current regimen includes Glargine 18 u at NOON daily, as
well as sliding scale included.
*
5) Delta MS:
- The pt had an extensive work-up for initial changes in mental
status, including an EEG which showed no epileptiform activity,
LP with elevated protein and glucose, no evidence of infection,
normal OP, negative cultures, negative for CMV, [**Male First Name (un) 2326**] Virus, VZV.
MRI showed mild-to-moderate brain atrophy and a chronic lacune
in the
posterior limb of the left internal capsule unchanged from the
previous MRI of [**2202-3-31**], no MRI signs of posterior encephalopathy
seen, no mass effect or hydrocephalus noted, no acute infarcts.

- The pt's mental status changes were attributed to combination
of acute infection as well as hyperglycemia/DKA.  He
demonstrates mental status deterioration when febrile or
infected, and when blood sugars are either elevated or low.  The
pt now at his new baseline, is awake and alert, speaking
fluently, and cooperative with exam.
*
6) S/p renal transplant:
- The pt's immunosuppresion regimen was adjusted several times
during course of admission.  Regimen on discharge includes:
** Tacrolimus 1.5 mg [**Hospital1 **]
** Sirolimus 2 mg MWF, 1 mg TThSaSun
** Prednisone 4 mg qd
- The pt's Cr slightly increased during admission to peak of
2.9. This may have been in the context of taking sublingual
Tacrolimus while NPO, which per pharmacy causes greater
bioavailability of drug and possible renal effect.  Cr
subsequently decreased to 2.6. Medications were adjusted for
CrCl <30.
*
7) Heme/Anemia: Upper GI bleed, plus anemia of chronic disease.
Hct decreased acutely in context of coffee ground emesis, with
Hct down to low of 20; received 1 unit PRBC's [**10-22**] after
initial GIB, and an additional 3 units [**10-26**].  Pt was on Epogen,
decreased steadily from 8000 units 3X/week to [**2197**] units
3x/week. Hct remained stable for the last several weeks of
admission, even while therapeutic on anticoagulation.  Last Hct
prior to discharge was 36.2
*
8) FEN:
- Pt was initially NPO while he had initial mental status
changes.  However, after treatment for DKA/hyperglycemia and
infections, he passed a bedside speech and swallow with no
aspiration, was allowed to commence PO diet.
*
9) CV: Patient with HTN, CAD.
-Pt had elevated blood pressures during last few weeks of
admission.  Hydralazine had been d/c'd [**10-26**] and amlodipine
decreased to 5 qd in context of GI bleed and anemia.  However,
amlodipine was increased back to 10 as pt subsequently
hypertensive. Lasix 20 mg qd was also started [**11-3**] secondary to
HTN
*
10) DERM: The pt was seen by dermatology for a scaling plaque,
possible squamous cell CA on left temple.  Will need to schedule
excisional biopsy as outpatient in derm clinic [**Telephone/Fax (1) 1971**].
*
11) Psych:  Pt seen by psych consult [**10-31**] for possible
depression, no active suicidal ideation, but expressed desire to
not pursue major interventions to prolong life; he is not
denying any specific procedures at this time.  Per psychiatry,
pt does not appear to be suicidal, and his wishes to limit
invasive procedures is reasonable.  Celexa increased to 30 mg
qd.
*
12) PT/OT: Evaluated by PT/OT during admission, rehab
recommmended for ambulation and mobilization given left BKA,
deconditioning.


Medications on Admission:
MEDS on admission to OSH (presumed)
Feosol 325 mg daily, Colace 100 mg daily, Senokot 1 tab qhs,
Flomax 0.4 mg qhd, Reglan 10 mg PO BID, Lopressor 75 mg twice
daily, Norvasc 10 mg daily, Plavix 75 mg daily, Nexium 40 mg
daily, Celexa 10 mg daily, Lasix 20 mg IV daily, Hydralazine 10
mg PO q6hours, Cefepime 1 gm IV daily, Prednisone 5 mg daily,
MVI daily, Tacrolimus 0.5 mg [**Hospital1 **], Heparin 5000 units SC BID
Humulin N 10 units qam, 5 units qhs
*
MEDS at time of transfer:
Rapamune 3 tabs 1 mg PO daily
Protonix 40 mg IV daily
Tacrolimmus 0.5 mg PO BID
Dilantin 300 mg PO qhs
Norvasc 10 mg PO QD
Zosyn 2.25 gm IV q6 hours (day 6 on transfer)
Lopressor 125 mg PO BID
Celexa 20 mg daily
Risperidone 0.5 mg PO BID
RISS
*
Current meds in MICU:
Metoprolol 75 mg PO BID
Pantoprazole 40 mg IV Q24H
Amlodipine 10 mg PO DAILY
Citalopram Hydrobromide 20 mg PO DAILY
Phenytoin 100 mg IV Q12H for 2 days, then 100 mg IV daily for 2
days
Daptomycin 300 mg IV Q48H day 2
Piperacillin-Tazobactam Na 2.25 gm IV Q6H
Docusate Sodium (Liquid) 100 mg PO BID
Epoetin Alfa 4000 UNIT SC QMOWEFR Start: HS
Senna 2 TAB PO BID:PRN
Folic Acid 1 mg IV DAILY
Sirolimus 3 mg PO DAILY
Heparin 5000 UNIT SC TID
Tacrolimus 1 mg PO BID renal transplant
Thiamine HCl 100 mg IV DAILY
Insulin SC
Glargine 10 units qhs (to receive first dose tonight)
*


Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Therapeutic Multivitamin     Liquid Sig: One (1) Cap PO DAILY
(Daily).
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical  TID
(3 times a day) as needed for 1 weeks.
7. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
8. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).

9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
hold for SBP <110.
10. Codeine Sulfate 30 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed: please give 1/2 hr prior to PT.
11. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain.
14. Clotrimazole 1 % Cream Sig: One (1) Appl Topical  [**Hospital1 **] (2
times a day) for 1 weeks: perianal area.
15. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).

16. Sirolimus 1 mg Tablet Sig: Two (2) Tablet PO QMOWEFR (Monday
-Wednesday-Friday).
17. Sirolimus 1 mg Tablet Sig: One (1) Tablet PO QTUTHSA
([**Doctor First Name **],TU,TH,SA).
18. Tacrolimus 0.5 mg Capsule Sig: Three (3) Capsule PO BID (2
times a day).
19. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical  [**Hospital1 **]
(2 times a day) as needed.
20. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 1 weeks.
21. Insulin Glargine 100 unit/mL Solution Sig: One (1)
Subcutaneous once a day: 18 units Glargine at NOON daily.
22. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
23. Loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day) as needed.
24. Outpatient Lab Work
Please check Tacrolimus and Sirolimus levels q3 days, please
send results to transplant center at [**Telephone/Fax (1) 20303**] or
[**Telephone/Fax (1) 673**].

25. Outpatient Lab Work
Please check coags/INR twice weekly, and adjust Coumadin level
accordingly.
26. Epoetin Alfa 2,000 unit/mL Solution Sig: One (1)  Injection
QMOWEFR (Monday -Wednesday-Friday): [**2197**] u MWF.


Discharge Disposition:
Extended Care

Facility:
[**Hospital 20304**] Rehabilitation & Nursing Center - [**Location (un) 2498**]

Discharge Diagnosis:
Type I diabetes, cadaveric renal transplant, left DVT/?PE on
anticoagulation, pleural effusions, upper GI bleeds (resolved)
from esophagitis/duodenitis/duodenal ulcer, UTI and yeast in
urine


Discharge Condition:
Stable


Discharge Instructions:
Please continue taking your medications as written. Please call
your physician if you have any worsened chest pain, shortness of
breath, palpitations, cough, fever, urinary symptoms, vomiting
blood/"coffee ground" material, lightheadedness/dizziness,
confusion, other worrisome symptoms

Followup Instructions:
Please call Dr. [**Location (un) 20305**] for follow-up appointment once
discharged from Wedgemere [**Telephone/Fax (1) 20306**].

You will need your blood levels of Tacrolimus and Rapamycin
drawn every 3rd day, and results sent to Tranplant Center -
[**Telephone/Fax (3) 20307**]

Please call for an appointment to be seen in [**Hospital 2652**] clinic
after discharge from Wedgemere, for biopsy of lesion on left
temple, [**Telephone/Fax (1) 1971**]


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

Completed by:[**2203-11-7**]
{'Unspecified infectious and parasitic diseases,Diabetes with ketoacidosis, type I [juvenile type], not stated as uncontrolled,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Complications of transplanted kidney,Unspecified pleural effusion,Hematemesis,Hyperosmolality and/or hypernatremia,Hip joint replacement,Below knee amputation status,Unspecified essential hypertension,Unspecified disorder of skin and subcutaneous tissue'}


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: Transfer to [**Hospital1 18**] for PEG placement

PRESENT ILLNESS: 61 year-old male with longstanding DM type 1 with triopathy,
status post CRT [**2196**] (baseline creat 2.9-3.0 in [**3-/2203**]),
recurrent UTIs with MDR organisms, history of MRSA sepsis/osteo,
initially transferred on [**10-17**] from [**Hospital3 2737**] for PEG
placement.
*
He was originally admitted to [**Hospital1 **] on [**2203-10-4**] with mental
status changes. His w/u was remarkable for VRE UTI (only 1000
colonies) and a LLL pneumonia. He was initially started on
Cefepime, changed to Imipenem and Flagyl. A repeat urine culture
grew Burkholderia cepacia sensitive to Zosyn, and Zosyn therapy
was initiated on [**10-12**]. Blood cx negative. A follow-up CXR
showed resolution of his LLL pneumonia. A tagged WBC scan was
also performed and negative for infection. He remained
disoriented despite treatment of his infection, and he was felt
to be continually scratching his left biceps and having facial
twitching. Neurology was consulted. Head CT showed mild atrophy
but was otherwise negative. MRI showed marked atrophy, as well
as subtle changes in the posterior limb of the internal capsule
that could possibly represent small subacute punctate infarcts.
EEG was requested, but deferred [**12-29**] "scheduling difficulties".
Per neurology, Mr. [**Known lastname 1001**] was loaded with Dilantin for possible
seizure activity, with some subsequent improvement in his mental
status.
*
Still at the OSH, his Hct on admission was noted to be 25, and
he was transfused 2 units of PRBCs. He failed a bedside swallow
evaluation, and a barium swallow showed evidence of penetration
and aspiration. An NGT was placed. The patient reportedly did
not want a PEG tube, but was deemed incompetent to make
decisions by psychiatry. While in the hospital, he was begun on
Risperdal and Celexa was increased.
*
On the day of transfer ([**10-17**]), his lab work was remarkable for
a HCO3 drop 20-->15, with development of an anion gap acidosis.
He was started on IVF with dextrose, and given 1 amp of sodium
bicarbonate.  On arrival to [**Hospital1 18**], he was hemodynamically
stable. However, his initial lab work was remarkable for an
anion gap of 22, with HCO3 of 9, glucose of 362. ABG done
7.23/22/50 (?arterial). U/A positive for ketones.  Of note,
standing insulin had been held at outside hospital.  He was
given insulin SC X few doses, then started on insulin drip on
the floor on [**10-18**], along with IVF, with eventual closure of his
gap. Coincident with the metabolic derangements, however, he was
noted to have declining mental status (responsive only to pain
at time of transfer), and he was transferred to the MICU for
further care.
*
In the MICU, he was continued on the insulin drip overnight,
discontinued on [**10-19**] at 1000 after overlap with NPH. AG closed.
[**Last Name (un) **] consulted, with recommendation to start Lantus. Regarding
his mental status, neurology was consulted. LP was performed
with OP 9, WBC 4, RBC 0, TP 93, Gluc 145, gram stain negative,
cryptococcal antigen negative, cultures pending. He was loaded
with Dilantin on [**10-18**] at night pending EEG on [**10-19**].
Preliminary report negative for seizure activity. Per neurology,
Dilantin was tapered off.

MEDICAL HISTORY: 1. DM type 1 with triopathy
2. Status post cadaveric renal transplant in [**2196**]
3. Chronic renal insufficiency with baseline creatinine 2.9-3.0
in [**3-/2203**]
4. Peripheral neuropathy
6. Hypertension
7. CAD, LVEF >55% in [**3-/2203**]
8. GERD
9. Hypercholesterolemia
10. History of MRSA osteomyelitis/sepsis
11. History of recurrent UTIs with MDR organisms
*
Other past surgical history:
Status post right THR
Status post left BKA
Status post open chlecystectomy

MEDICATION ON ADMISSION: MEDS on admission to OSH (presumed)
Feosol 325 mg daily, Colace 100 mg daily, Senokot 1 tab qhs,
Flomax 0.4 mg qhd, Reglan 10 mg PO BID, Lopressor 75 mg twice
daily, Norvasc 10 mg daily, Plavix 75 mg daily, Nexium 40 mg
daily, Celexa 10 mg daily, Lasix 20 mg IV daily, Hydralazine 10
mg PO q6hours, Cefepime 1 gm IV daily, Prednisone 5 mg daily,
MVI daily, Tacrolimus 0.5 mg [**Hospital1 **], Heparin 5000 units SC BID
Humulin N 10 units qam, 5 units qhs
*
MEDS at time of transfer:
Rapamune 3 tabs 1 mg PO daily
Protonix 40 mg IV daily
Tacrolimmus 0.5 mg PO BID
Dilantin 300 mg PO qhs
Norvasc 10 mg PO QD
Zosyn 2.25 gm IV q6 hours (day 6 on transfer)
Lopressor 125 mg PO BID
Celexa 20 mg daily
Risperidone 0.5 mg PO BID
RISS
*
Current meds in MICU:
Metoprolol 75 mg PO BID
Pantoprazole 40 mg IV Q24H
Amlodipine 10 mg PO DAILY
Citalopram Hydrobromide 20 mg PO DAILY
Phenytoin 100 mg IV Q12H for 2 days, then 100 mg IV daily for 2
days
Daptomycin 300 mg IV Q48H day 2
Piperacillin-Tazobactam Na 2.25 gm IV Q6H
Docusate Sodium (Liquid) 100 mg PO BID
Epoetin Alfa 4000 UNIT SC QMOWEFR Start: HS
Senna 2 TAB PO BID:PRN
Folic Acid 1 mg IV DAILY
Sirolimus 3 mg PO DAILY
Heparin 5000 UNIT SC TID
Tacrolimus 1 mg PO BID renal transplant
Thiamine HCl 100 mg IV DAILY
Insulin SC
Glargine 10 units qhs (to receive first dose tonight)
*

ALLERGIES: Sulfamethoxazole/Trimethoprim / Aspirin

PHYSICAL EXAM: VITALS: Tm 99.2, Tc 98.9, HR 60s-70s, BP 120-170/50-60s, RR high
teens to low 20s, Sat 98-100% on RA.
I/O: + 450 last 24 hours, then + 1700 cc today
GEN: Caucasian male, in NAD. Answers questions, recognizes his
name, not oriented to place or time. Makes eye contact.
[**Name (NI) 4459**]: Pupils sluggish, reactive. Dry MM.
NECK: No cervical LN.
RESP: Limited examination, clear anteriorly.
CVS: RRR. Normal S1, S2.
GI: BS +. Soft, non-tender.
EXT: 2+ pedal edema RLE. Left BKA.
NEURO: Moves all 4 extremities.

FAMILY HISTORY: Mother with DM and PM and Father with PM

SOCIAL HISTORY: Widowed, ex-meat cutter, no TOB, no ETOH, no IVDU 

### Response:
{'Unspecified infectious and parasitic diseases,Diabetes with ketoacidosis, type I [juvenile type], not stated as uncontrolled,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Complications of transplanted kidney,Unspecified pleural effusion,Hematemesis,Hyperosmolality and/or hypernatremia,Hip joint replacement,Below knee amputation status,Unspecified essential hypertension,Unspecified disorder of skin and subcutaneous tissue'}
