CHIEF COMPLAINT: Back pain

PRESENT ILLNESS: [**Known firstname 18882**] [**Known lastname 79357**] is an 83-year-old woman with a history of CLL
and is status post high grade MRSA bacteremia causing L5/S1
osteomyelitis with extension into epidural space, requiring
admission in [**4-23**]. The patient is now status post 6 weeks of
vancomycin and over 2 weeks of linezolid. She has had ongoing
low back and leg pain which has not improved. She was referred
by Dr. [**Last Name (STitle) 17444**] (ID) for further pain control and a repeat MRI. Her
last MRI was approximately 3 wks ago without significant change.

MEDICAL HISTORY: CLL
PVD s/p L [**Doctor Last Name **]/PT [**Name (NI) **] and L jump bypass from PT to plantar artery
CAD 3VD, s/p stent x2 [**10-21**]; p-MIBI [**1-23**] fixed, unchanged
moderate defect.
HTN
Dyslipidemia
Chronic right foot ulcer

MEDICATION ON ADMISSION: Plavix 75mg PO QD
Isosorbide Mononitrate 60 mg QD
Amlodipine 10mg QD
Besylate 10 mg QD
Quinapril 10 mg QD
ASA 325 mg QD
Protonix 40mg QD
Percocet prn
Lipitor 80mg QD
Metoprolol 75mg [**Hospital1 **]
Linezolid 600mg [**Hospital1 **]

ALLERGIES: Sulfonamides

PHYSICAL EXAM: VITALS: T=98.5, BP=121/88, HR=60, RR=16, O2=94% on RA
GEN: Pt moving and moaning, "I need more pain meds"
HEENT: Nonicteric, mucous membranes moist
CV: RRR, II/VI SEM
PULM/Back: CTA bilaterally; no spinal/paraspinal tenderness
ABD: Soft, NT, ND
EXT: No LE edema
NEURO: Uncooperative with exam; CN's intact, moving all 4
extremities with grossly normal strength/sensation; negative
straight leg raise

FAMILY HISTORY: NC

SOCIAL HISTORY: Widowed, lives alone, and has one daughter.  [**Name (NI) **] tobacco/alcohol.
 Had been independent with her ADLs prior to osteomyelitis.
Chronic osteomyelitis, other specified sites,Subendocardial infarction, initial episode of care,Chronic lymphoid leukemia, without mention of having achieved remission,Ulcer of other part of foot,Other complications due to other vascular device, implant, and graft,Arterial embolism and thrombosis of lower extremity,Thrombocytopenia, unspecified,Acute kidney failure with lesion of tubular necrosis,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Other and unspecified disc disorder, lumbar region,Unspecified essential hypertension,Atherosclerosis of native arteries of the extremities with ulceration,Other and unspecified hyperlipidemia,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Infection with microorganisms resistant to penicillins,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in other specified places,Other iatrogenic hypotension
Chr osteomyelit NEC,Subendo infarct, initial,Ch lym leuk wo achv rmsn,Ulcer other part of foot,Comp-oth vasc dev/graft,Lower extremity embolism,Thrombocytopenia NOS,Ac kidny fail, tubr necr,Crnry athrscl natve vssl,Status-post ptca,Disc dis NEC/NOS-lumbar,Hypertension NOS,Ath ext ntv art ulcrtion,Hyperlipidemia NEC/NOS,Mth sus Stph aur els/NOS,Inf mcrg rstn pncllins,Abn react-anastom/graft,Accident in place NEC,Iatrogenc hypotnsion NEC
Admission Date:  [**2154-6-20**]              Discharge Date:   [**2154-7-11**]


Service: MEDICINE

Allergies:
Sulfonamides

Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Back pain

Major Surgical or Invasive Procedure:
L5/S1 laminectomy

History of Present Illness:
[**Known firstname 18882**] [**Known lastname 79357**] is an 83-year-old woman with a history of CLL
and is status post high grade MRSA bacteremia causing L5/S1
osteomyelitis with extension into epidural space, requiring
admission in [**4-23**]. The patient is now status post 6 weeks of
vancomycin and over 2 weeks of linezolid. She has had ongoing
low back and leg pain which has not improved. She was referred
by Dr. [**Last Name (STitle) 17444**] (ID) for further pain control and a repeat MRI. Her
last MRI was approximately 3 wks ago without significant change.

The patient is unable to give an accurate history because "the
pain so bad, don't ask me any questions." She denies any chest
pain, SOB, or other symptoms. She relates pain "through my legs
and low back," which may have been worse over the past day or
so. She does not give a recent history of falls. She refuses to
answer any further questions.

In the ED, the patient had an L-MRI without significant change
from prior. She was given Dilaudid for pain control.

Past Medical History:
CLL
PVD s/p L [**Doctor Last Name **]/PT [**Name (NI) **] and L jump bypass from PT to plantar artery
CAD 3VD, s/p stent x2 [**10-21**]; p-MIBI [**1-23**] fixed, unchanged
moderate defect.
HTN
Dyslipidemia
Chronic right foot ulcer

Social History:
Widowed, lives alone, and has one daughter.  [**Name (NI) **] tobacco/alcohol.
 Had been independent with her ADLs prior to osteomyelitis.


Family History:
NC

Physical Exam:
VITALS: T=98.5, BP=121/88, HR=60, RR=16, O2=94% on RA
GEN: Pt moving and moaning, "I need more pain meds"
HEENT: Nonicteric, mucous membranes moist
CV: RRR, II/VI SEM
PULM/Back: CTA bilaterally; no spinal/paraspinal tenderness
ABD: Soft, NT, ND
EXT: No LE edema
NEURO: Uncooperative with exam; CN's intact, moving all 4
extremities with grossly normal strength/sensation; negative
straight leg raise

Pertinent Results:
WBC-66.5* RBC-3.76* Hgb-10.9* Hct-32.8* MCV-87 MCH-28.9
MCHC-33.1 RDW-14.9 Plt Ct-183
Neuts-10* Bands-2 Lymphs-86* Monos-1* Eos-0 Baso-0 Atyps-1*
Metas-0 Myelos-0 Other-0
Plt Smr-NORMAL Plt Ct-183
ESR-10
Glucose-99 UreaN-20 Creat-1.0 Na-138 K-4.2 Cl-103 HCO3-22
AnGap-17
Calcium-9.6 Phos-2.6* Mg-1.7

U/A: Sp [**Last Name (un) **] 1.015, pH 5.0, small leuks, 3 WBCs, otherwise
negative

Lumbar MRI on admission: IMPRESSION: Osteomyelitis and discitis
at L5-S1, with slight interval increase in irregularity and T2
hyperintensity within the L5-S1 disc space in comparison with
[**2154-5-7**]. Probable mild increase in enhancing epidural
soft tissue, posterior to L5 through S3 vertebrae without
evidence of canal stenosis. Persistent enhancing soft tissue
within the right psoas, anterior to the L5-S1 interspace, and
surrounding the L5 nerve roots bilaterally.

Angio [**7-4**]: Successful placement of a 40-cm total length right
basilic single lumen PICC with tip in the SVC

Brief Hospital Course:
1. L5/S1 Osteomyelitis: The patient was admitted for evaluation
and treatment of her severe low back pain. She was started on
opiate analgesia in addition to Neurontin. She was started on
Linezolid and then switched to Vancomycin IV for concern about
continuing osteomyelitis. Repeat lumbar MRI was performed and
compared with her study from six week prior; there was note of
continued osteomyelitis and discitis at L5-S1, with slight
interval increase in irregularity and T2 hyperintensity within
the L5-S1 disc space. There was probable mild increase in
enhancing epidural soft tissue, posterior to L5 through S3
vertebrae and persistent enhancing soft tissue within the right
psoas. ESR was 10. CRP was 0.82. Orthopedics and Infectious
Disease were consulted. It was determined that she would need
surgical debridement. Following cardiac clearance and
catheterization, she went to the OR and underwent a L5/S1
laminectomy on [**2154-7-1**]. Cultures from the site were obtained and
were negative except for trace growth of coag negative staph.
She was on antibiotics at the time of the surgery. The pathology
revealed bony changes consistent with chronic osteomyelitis.

Post surgery, she continued to note back pain. She was
maintained on vancomycin which was dosed by levels. A PICC line
was placed for long term IV antibiotic treatment. She will
likely require at least six weeks of antibiotics following
surgery. Her ID doctor, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17444**], wil contact her for a
follow-up appointment.

2. Acute renal failure: The patient's creatinine was 0.6 on
admission. She had a hypotensive episode prior to surgery which
resulted in a MICU admission. Her Cre rose at that time and it
was felt to be prerenal azotemia. Her creatinine then improved.
The day after her surgery, she was again noted to be
hypotensive. This was thought secondary to post-operative
hypovolemia. She received IV fluids with normalization of her
blood pressure. Her creatinine subsequently rose to a high of
1.6. This was thought to be secondary to ATN from her
hypotensive episode. Her ACE inhibitor was held. Her creatinine
slowly improved. Her ACEI was then restarted.

3. NSTEMI/CAD: Patient had known CAD. She also had a hypotensive
episode prior to surgery. During this time, she required MICU
admission for IV fluids and monitoring. She had a small NSTEMI
at that time. She was treated conservatively. When surgery was
deemed necessary cardiology was consulted for cardiac clearance.
She underwent persantine mibi which demonstarted a moderate
fixed inferior wall defect that was unchanged from prior study.
She also had global hypokinesis. Based on these results, the
patient went to cardiac catheterization. On cath, her RCA was
known to be proximally occluded, and thus was not selectively
engaged.  The LAD had patent proximal- to mid-vessel stents, and
mild diffuse disease up to 40% otherwise.  The Left circumflex
had a 40% proximal lesion, and was then occluded in the
mid-portion.  A large OM1 branch had a 50% lesion proximally.
There was a 15-mmHg gradient across the aortic valve during
simultaneous measurement of central arterial and LV pressures,
consistent with mild aortic stenosis. In all, she had Two VD,
patent LAD stents, and mild AS. No interventions were performed
ID had recommended that no stents be deployed as the plavix
requirement would have delayed her necessary back surgery. POBA
would have been performed, but there were no lesions amenable to
this treatment. The patient was restarted on her aspirin post
surgery.

4. Congestive heart failure: Following her surgery and her acute
renal failure episodes, the patient was noted to have worsening
oxygenation and she developed SOB. Chest x ray revealed
congestive heart failure. She was treated with lasix with
improvement in her breathing and oxygenation.

5. Peripheral vascular disease: the patient complained of severe
pain in her lower extremities. The etiology of which was not
clear. The nerve roots did not appear to be infringed upon on
her MRI. She has known severe PVD and is s/p left fem-[**Doctor Last Name **] bypass
graft. She has had problems since that time. Vascular surgery
was consulted to see if the PVD was contribing to her pain. They
felt that she continues to have severe PVD and requires
additional vascular interventions, but that her PVD was not the
etiology of her leg pain.

6. Back and lower extremity pain: the patient was noted to have
severe low back pain and bilateral lower extremity pain. The
etiology was not clear. It could not clearly be attributed to
the osteomyelitis or the PVD. She was maintained on fentanyl
patch, neurontin, and po opiates. This still only provided
moderate pain control. On  [**7-5**] she had acute change in mental
status and was arousable only to sternal rub. She had a head CT
that did not show a bleed. She was given narcan with some
improvement in her mental status. She slowly became more alert
and back to her baseline. The etiology of her depressed mental
status is likely multifactorial and included excessive sedation
from opiates and delirium. The fentanyl patch was decreased and
her po opiates were decreased.

7. CLL: The patient has a chronically elevated WBC count in the
20s. Heme/onc was consulted to ensure no additional treatment
was needed perioperatively. IVIG was considered, but given its
potential toxicities, it was held. Her CLL was not an active
issue during her hospitalization.

8. Hallucinations: In addition to her depressed mental status,
the patient suffered from hallucinations. She described seeing
bugs and other animals. These hallucinations were felt to be
opiate induced and improved with Haldol.

9. Anemia: The patient's hematocrit was noted to be dropping
post operatively. She required 4 units of PRBCs. A CT abdomen
was performed to exclude retroperitoneal bleed. This was
negative. She had trace OB positive stool from below. NG lavage
was negative. GI was consulted and EGD was considered, but was
deferred given her delerium. Hemolysis and DIC labs were
negative. The patient's blood counts then stabilized. The cause
of her drop in her hematocrit was not found. She should have a
colonoscopy as an outpatient if her clinical course goes well.

10. Thrombocytopenia: the patient's platelet counts dropped
during her admission. HIT antibody was sent and was negative.
Her platelet count then slightly improved. It was thought that
the Linezolid may have caused some of her thrombocytopenia.

11. Fevers: The patient had low-grade fevers post operatively.
She had chest x-rays which showed only CHF. Blood cultures were
negative. Urine culture demonstrated yeast, which was thought to
be contamination from tinea cruris. She was treated with topical
antifungal treatment for that as well as four days of po
fluconazole. She was also treated with cipro to complete an
8-day course for possible pneumonia.

12. Skin breakdown: The patient had mild skin breakdown on
sacrum and left elbow. Thought to be pressure-induced decubiti.
She was given an air mattress and wound care was consulted. She
had duoderms placed on her sacrum. She had had prophylaxis
instituted to prevent heel ulcerations as well.

13. Full code

Medications on Admission:
Plavix 75mg PO QD
Isosorbide Mononitrate 60 mg QD
Amlodipine 10mg QD
Besylate 10 mg QD
Quinapril 10 mg QD
ASA 325 mg QD
Protonix 40mg QD
Percocet prn
Lipitor 80mg QD
Metoprolol 75mg [**Hospital1 **]
Linezolid 600mg [**Hospital1 **]

Discharge Medications:
1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).

2. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed for constipation.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: 1.3333 Tablet,
Sublinguals Sublingual PRN (as needed) as needed for chest pain.

7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
10. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Quinapril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

13. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
14. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours) as needed for Leg/back pain.
15. Oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4-6H (every 4 to
6 hours) as needed: Hold for confusion/oversedation.
16. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
17. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical  [**Hospital1 **]
(2 times a day) as needed for Yeast in groin.
19. Vancomycin 1,000 mg Recon Soln Sig: Seven [**Age over 90 1230**]y
(750) mg Intravenous  once a day: Please check trough after 2nd
dose and fax to Dr. [**Last Name (STitle) 17444**] at [**Telephone/Fax (1) 1419**]. First dose given [**7-12**]
at noon.


Discharge Disposition:
Extended Care

Facility:
Bear [**Doctor Last Name **] Nursing Center - [**Location (un) 2199**]

Discharge Diagnosis:
L5/S1 osteomyelitis
Acute renal failure due to acute tubular necrosis
NSTEMI
CAD
CLL
Delerium
Sacral decubiti
CHF
PVD
Back and lower extremity pain
Anemia
Thrombocytopenia
Fevers of unclear etiology


Discharge Condition:
The patient is able to pivot with assistance. She is requiring
2L of oxygen at rest. She is alert with occasional confusion.

Discharge Instructions:
Multiple medication changes have been made, please see
accompanying medication sheet for accurate list.

Weigh yourself daily.
Adhere to 2 gram sodium/day diet.

Please return to the ED if you have fevers, chills, inability to
tolerate medications or if you have worsening weakness or
decreased sensation in your legs.

Followup Instructions:
-- You have an appointment with your orthopedic surgeon, Dr.
[**First Name8 (NamePattern2) **] [**Name (STitle) 1022**], [**Street Address(2) 96781**], [**Location (un) **], [**Location (un) **] [**Numeric Identifier 822**],
Phone: [**Telephone/Fax (1) 7807**]. Day/time: [**7-17**], 3:45 p.m.

-- You will need to follow up with your infectious disease
doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17444**], in four weeks. He will contact you with
appointment information. The [**Hospital **] Clinic's phone number is ([**Telephone/Fax (1) 10**].

-- Please call your PCP for an appointment one week after
leaving the rehab hospital.


Completed by:[**2154-7-11**]
{'Chronic osteomyelitis, other specified sites,Subendocardial infarction, initial episode of care,Chronic lymphoid leukemia, without mention of having achieved remission,Ulcer of other part of foot,Other complications due to other vascular device, implant, and graft,Arterial embolism and thrombosis of lower extremity,Thrombocytopenia, unspecified,Acute kidney failure with lesion of tubular necrosis,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Other and unspecified disc disorder, lumbar region,Unspecified essential hypertension,Atherosclerosis of native arteries of the extremities with ulceration,Other and unspecified hyperlipidemia,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Infection with microorganisms resistant to penicillins,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in other specified places,Other iatrogenic hypotension'}


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: Back pain

PRESENT ILLNESS: [**Known firstname 18882**] [**Known lastname 79357**] is an 83-year-old woman with a history of CLL
and is status post high grade MRSA bacteremia causing L5/S1
osteomyelitis with extension into epidural space, requiring
admission in [**4-23**]. The patient is now status post 6 weeks of
vancomycin and over 2 weeks of linezolid. She has had ongoing
low back and leg pain which has not improved. She was referred
by Dr. [**Last Name (STitle) 17444**] (ID) for further pain control and a repeat MRI. Her
last MRI was approximately 3 wks ago without significant change.

MEDICAL HISTORY: CLL
PVD s/p L [**Doctor Last Name **]/PT [**Name (NI) **] and L jump bypass from PT to plantar artery
CAD 3VD, s/p stent x2 [**10-21**]; p-MIBI [**1-23**] fixed, unchanged
moderate defect.
HTN
Dyslipidemia
Chronic right foot ulcer

MEDICATION ON ADMISSION: Plavix 75mg PO QD
Isosorbide Mononitrate 60 mg QD
Amlodipine 10mg QD
Besylate 10 mg QD
Quinapril 10 mg QD
ASA 325 mg QD
Protonix 40mg QD
Percocet prn
Lipitor 80mg QD
Metoprolol 75mg [**Hospital1 **]
Linezolid 600mg [**Hospital1 **]

ALLERGIES: Sulfonamides

PHYSICAL EXAM: VITALS: T=98.5, BP=121/88, HR=60, RR=16, O2=94% on RA
GEN: Pt moving and moaning, "I need more pain meds"
HEENT: Nonicteric, mucous membranes moist
CV: RRR, II/VI SEM
PULM/Back: CTA bilaterally; no spinal/paraspinal tenderness
ABD: Soft, NT, ND
EXT: No LE edema
NEURO: Uncooperative with exam; CN's intact, moving all 4
extremities with grossly normal strength/sensation; negative
straight leg raise

FAMILY HISTORY: NC

SOCIAL HISTORY: Widowed, lives alone, and has one daughter.  [**Name (NI) **] tobacco/alcohol.
 Had been independent with her ADLs prior to osteomyelitis. 

### Response:
{'Chronic osteomyelitis, other specified sites,Subendocardial infarction, initial episode of care,Chronic lymphoid leukemia, without mention of having achieved remission,Ulcer of other part of foot,Other complications due to other vascular device, implant, and graft,Arterial embolism and thrombosis of lower extremity,Thrombocytopenia, unspecified,Acute kidney failure with lesion of tubular necrosis,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Other and unspecified disc disorder, lumbar region,Unspecified essential hypertension,Atherosclerosis of native arteries of the extremities with ulceration,Other and unspecified hyperlipidemia,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Infection with microorganisms resistant to penicillins,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in other specified places,Other iatrogenic hypotension'}
