CHIEF COMPLAINT: CC: left calf infection

PRESENT ILLNESS: HPI:
Mr. [**Known lastname 39483**] is a 48 yo male with PMH of HIV, hepatitis C, and
h/o MSSA osteomyelitis following ORIF of left malleolus in [**3-15**]
who got an bug bite on his left posterior calf one week ago.  He
was seen at that time by his PCP who [**Name Initial (PRE) **] + D'd the wound and
started him on Cipro.  He is currently on day 7 of 10 of Cipro
and returned to PCP with fevers, chills and rigors.  Wound had
failed to improve on cipro and cultures returned with MRSA, so
he was prescribed doxycycline although he never took first dose.
After demonstrating chills/rigors at his PCP's office earlier
today, he was sent to the ED for further evaluation.
.
In the ED his vitals were T 104.1, HR 74, BP 95/62, and 96% on
room air.  His labs were notable for lactate of 3.5 and a WBC of
8.8 with 72.6% PMNs.  His blood pressure fell to 80/40 so a
right IJ Precept catheter was placed.  He was given 5L IVF and
started on vancomycin.  His blood pressure remained in 80s/30s
so norepinephrine was started with resultant blood pressures
with MAP > 65.
.
Upon arrival to [**Hospital Unit Name 153**], his vitals were T 104.1, HR 138, BP
128/74, RR 37, O2 sat of 92% on NRB.  Patient was alert and
oriented and reported that he was now short of breath after
laying flat in the ambulance. He denies any chest pain or prior
difficulty with his breathing.  He reported mild pruritus of the
LLE.  The levophed drip was subsequently stopped and patient was
given ethacrynic acid for diuresis as he has a sulfa alergy.
Otherwise, ROS was negative.
.

MEDICAL HISTORY: PMH:
- ankle fracture s/p ORIF of bimaleolar ankle infection in [**3-15**]
complicated by MSSA osteomyelitis requiring removal of hardware
in [**8-12**].  ? Treated with IV oxacillin for 3 weeks followed by PO
levofloxacin for 6 months.
- HIV positive for 20+ years, not on HAART for past 6-12 months,
last CD4 count on [**8-29**] was 173
- Hepatitis C
.

MEDICATION ON ADMISSION: MEDS:
Wellbutrin ER 200 mg [**Hospital1 **]
.

ALLERGIES: Sulfa (Sulfonamides) / Penicillins / Oxacillin / Vancomycin

PHYSICAL EXAM: PE:
VS:   T 104.1, HR 138, BP 128/74, RR 37 O2 sat of 92% on NRB
HEENT:  EOMI, o/p clear
CV: tachycardic, no murmurs/rubs/gallops
Pulm: tachypneic, increased work of breathing, crackles
bilaterally throughout entire lung fields, wheezes present
Abd: soft, Nontender, nondistended, bowel sounds present
Ext: no edema
Skin: left posterior calf 3 cm ulcer with surrounding eryethema,
warmth and tenderness (8 cm x 10 cm).
Neuro: AxOx3.  Cranial nerves grossly intact. Moving all
extremities without difficulty.
.

FAMILY HISTORY: FH: Noncontributory
.

SOCIAL HISTORY: SH:  Patient is a waiter.  He denies tobacco or alcohol use.
.
Unspecified septicemia,Human immunodeficiency virus [HIV] disease,Cellulitis and abscess of leg, except foot,Other pulmonary insufficiency, not elsewhere classified,Acute kidney failure, unspecified,Chronic hepatitis C without mention of hepatic coma,Depressive disorder, not elsewhere classified,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Infection with microorganisms resistant to penicillins,Diarrhea
Septicemia NOS,Human immuno virus dis,Cellulitis of leg,Other pulmonary insuff,Acute kidney failure NOS,Chrnc hpt C wo hpat coma,Depressive disorder NEC,Mth sus Stph aur els/NOS,Inf mcrg rstn pncllins,Diarrhea
Admission Date:  [**2140-10-26**]              Discharge Date:   [**2140-10-31**]

Date of Birth:  [**2092-4-30**]             Sex:   M

Service: MEDICINE

Allergies:
Sulfa (Sulfonamides) / Penicillins / Oxacillin / Vancomycin

Attending:[**First Name3 (LF) 545**]
Chief Complaint:
CC: left calf infection

Major Surgical or Invasive Procedure:
R IJ Line

History of Present Illness:
HPI:
Mr. [**Known lastname 39483**] is a 48 yo male with PMH of HIV, hepatitis C, and
h/o MSSA osteomyelitis following ORIF of left malleolus in [**3-15**]
who got an bug bite on his left posterior calf one week ago.  He
was seen at that time by his PCP who [**Name Initial (PRE) **] + D'd the wound and
started him on Cipro.  He is currently on day 7 of 10 of Cipro
and returned to PCP with fevers, chills and rigors.  Wound had
failed to improve on cipro and cultures returned with MRSA, so
he was prescribed doxycycline although he never took first dose.
After demonstrating chills/rigors at his PCP's office earlier
today, he was sent to the ED for further evaluation.
.
In the ED his vitals were T 104.1, HR 74, BP 95/62, and 96% on
room air.  His labs were notable for lactate of 3.5 and a WBC of
8.8 with 72.6% PMNs.  His blood pressure fell to 80/40 so a
right IJ Precept catheter was placed.  He was given 5L IVF and
started on vancomycin.  His blood pressure remained in 80s/30s
so norepinephrine was started with resultant blood pressures
with MAP > 65.
.
Upon arrival to [**Hospital Unit Name 153**], his vitals were T 104.1, HR 138, BP
128/74, RR 37, O2 sat of 92% on NRB.  Patient was alert and
oriented and reported that he was now short of breath after
laying flat in the ambulance. He denies any chest pain or prior
difficulty with his breathing.  He reported mild pruritus of the
LLE.  The levophed drip was subsequently stopped and patient was
given ethacrynic acid for diuresis as he has a sulfa alergy.
Otherwise, ROS was negative.
.


Past Medical History:
PMH:
- ankle fracture s/p ORIF of bimaleolar ankle infection in [**3-15**]
complicated by MSSA osteomyelitis requiring removal of hardware
in [**8-12**].  ? Treated with IV oxacillin for 3 weeks followed by PO
levofloxacin for 6 months.
- HIV positive for 20+ years, not on HAART for past 6-12 months,
last CD4 count on [**8-29**] was 173
- Hepatitis C
.


Social History:
SH:  Patient is a waiter.  He denies tobacco or alcohol use.
.


Family History:
FH: Noncontributory
.


Physical Exam:
PE:
VS:   T 104.1, HR 138, BP 128/74, RR 37 O2 sat of 92% on NRB
HEENT:  EOMI, o/p clear
CV: tachycardic, no murmurs/rubs/gallops
Pulm: tachypneic, increased work of breathing, crackles
bilaterally throughout entire lung fields, wheezes present
Abd: soft, Nontender, nondistended, bowel sounds present
Ext: no edema
Skin: left posterior calf 3 cm ulcer with surrounding eryethema,
warmth and tenderness (8 cm x 10 cm).
Neuro: AxOx3.  Cranial nerves grossly intact. Moving all
extremities without difficulty.
.


Pertinent Results:
Laboratories:
Hematology:
[**2140-10-26**] 03:43PM WBC-8.8# RBC-4.54* Hgb-14.6 Hct-39.2* MCV-86#
MCH-32.2* MCHC-37.3* RDW-12.6 Plt Ct-161 Neuts-72.6* Lymphs-23.1
Monos-1.9* Eos-2.3 Baso-0.1
.
[**2140-10-26**] 09:14PM WBC-7.1 RBC-4.08* Hgb-13.3* Hct-36.7* MCV-90
MCH-32.6* MCHC-36.2* RDW-11.8 Plt Ct-119* Neuts-54 Bands-35*
Lymphs-6* Monos-2 Eos-3 Baso-0 Atyps-0 Metas-0 Myelos-0
.
[**2140-10-26**] 09:14PM BLOOD PT-16.5* PTT-37.0* INR(PT)-1.5*
.
Chemistries:
[**2140-10-26**] 03:43PM BLOOD Glucose-93 UreaN-25* Creat-1.4* Na-131*
K-4.3 Cl-97 HCO3-20* AnGap-18 ALT-49* AST-94* AlkPhos-69
Amylase-118* TotBili-0.9 Lipase-26
.
Other:
[**2140-10-27**] 05:18PM BLOOD Fibrino-252#
[**2140-10-27**] 05:18PM BLOOD FDP-0-10
[**2140-10-26**] 03:43PM BLOOD CRP-17.9*
[**2140-10-26**] 03:43PM BLOOD Cortsol-36.4*
[**2140-10-26**] 03:54PM BLOOD Lactate-3.5*
[**2140-10-26**] 07:49PM BLOOD Glucose-77 Lactate-1.0
.
Micro:
[**2140-10-26**]: Blood cultures x 2 - Negative
[**2140-10-27**]: Blood cultures x 2 - Negative
[**2140-10-28**]: Catheter Tip culture - Negative
[**2140-10-27**]: C. diff negative
.
Imaging:
EKG: sinus tach at 130, normal axis, T wave flattening in
lateral leads compared to prior, no Q waves, no ST segment
changes
.
[**2140-10-26**] CXR.
1.  Right IJ central line positioned as described.
2.  Pulmonary vascular prominence, likely related to congestion.

.
Echocardiogram [**2140-10-27**]:
Conclusions:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 60%) There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is moderately dilated. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion. There is an
anterior space which most likely represents a fat pad.
<br>
<b>Discharge Labs:</b>
[**2140-10-31**] 06:45AM BLOOD WBC-5.1 RBC-3.98* Hgb-12.9* Hct-36.1*
MCV-91 MCH-32.4* MCHC-35.7* RDW-12.6 Plt Ct-160
[**2140-10-31**] 06:45AM BLOOD Neuts-10* Bands-0 Lymphs-63* Monos-19*
Eos-5* Baso-1 Atyps-2* Metas-0 Myelos-0
[**2140-10-31**] 06:45AM BLOOD Glucose-82 UreaN-15 Creat-0.9 Na-141
K-3.6 Cl-107 HCO3-27 AnGap-11
[**2140-10-31**] 06:45AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.0

Brief Hospital Course:
A/P:  Mr. [**Known lastname 39483**] is a 48 yo male with HIV, Hepatitis C, and
h/o MSSA osteomyelitis of left ankle s/p ORIF and removal of
hardware, now presents with sepsis secondary to left calf ulcer
and surrounding cellulitis.
.
# Shortness of breath:  Patient was transferred to the MICU
after he became acutely short of breath after receiving 5L of
IVF.  His CXR showed evidence of pulmonary edema.  The patient
received ethacrynic acid for diuresis as he has an allergy to
sulfa drugs with significant improvement.  Prior to arrival in
the MICU he had been weaned from a NRB mask to 2 L NC.  He
underwent echocardiogram on hospital day two to evaluate for
potential systolic dysfunction or valvular pathology which was
normal.  His oxygen saturations remained stable and he was
quickly weaned of oxygen.
.
#  Sepsis:  The patient presented with a known MRSA cellulitis
of his left leg.  On presentation to the emergency room the
patient was found to be febrile to 104 degrees with a 35%
bandemia, elevated lactate at 3.5 and hypotensive to the
80s/30s. In the emergency room he was started on vancomycin and
received 5L IVF with little improvement in his blood pressure.
He was transiently started on norepinephrine.  On arrival to the
[**Hospital Unit Name 153**] his blood pressure was in the 130s systolic and the
norepinephrine was quickly discontinued and he was actually
started on ethacrynic acid for diuresis.  He remained
hemodynamically stable for the remainder of his MICU course.
His lactate trended down with IVF.  His fevers improved.  His
cortisol was appropriately elevated and he did not receive
stress dose steroids.  He received one day of levofloxacin for
gram negative coverage but this was discontinued given rapid
clinical improvement.  On [**10-28**] his vancomycin was switched to
clindamycin after the patient developed a diffuse, erythematous,
pruritic rash.   He will complete a course of Clindamycin as an
outpatient.
.
# Acute renal failure:  On presentation the patient was found to
have an elevated creatinine at 1.4.  This rapidly improved to
his baseline of 0.8 with fluid hydration.  It was felt that his
renal failure was secondary to prerenal state in the setting of
hypotension and dehydration.
.
# Non-anion gap metabolic acidosis: On transfer to the MICU the
patient was found to have a non-anion gap metabolic acidosis
with a serum bicarbonate of 18.  It was thought that this was
most likely secondary to aggressive hydration with normal
saline.  This quickly improved after diuresis.
.
# Diffuse Rash: On hospital day 3 the patient was noted to
develop a diffuse, non-blanching, non-palpable purpuritic rash
located on the ventral surfaces of his arms and legs.  The
etiology of his rash is unclear.  Differential diagnosis
includes drug reaction to vancomycin or levofloxacin vs.
vaculitis vs. bleeding disorder.  His platelets have been
low-normal throughout this admission.  His coags have been
normal.  Rash improved after transfer to the floor.  Likely
etiology is Vancomycin, however patient has tolerated Vancomycin
in the past.
.
#  HIV.  Patient has had HIV for over 20 years.  Not currently
taking HAART.  Last CD4 count was 172 on [**2140-8-29**].
.
#  Hepatitis C.  AST (94) and ALT (49) are mildly elevated and
INR is now 1.5. AST was 89 and ALT was 70 on [**2140-8-29**]. This is
likely related to hepatitis C.  Unclear of status of hepatitis C
at present.  His transaminases have been stable.
.
#  Depression.  Continued on Wellbutrin.


Medications on Admission:
MEDS:
Wellbutrin ER 200 mg [**Hospital1 **]
.

Discharge Medications:
1. Bupropion 100 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO BID (2 times a day).
2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for pruritis.
Disp:*1 bottle* Refills:*0*
3. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q4H
(every 4 hours) as needed for itching.
Disp:*60 Tablet(s)* Refills:*0*
4. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours) for 6 days.
Disp:*48 Capsule(s)* Refills:*0*
5. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed for pain: Take with food.
Disp:*60 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
Lower Extremity Cellulitis
Sepsis secondary to above
Acute Renal Failure
Secondary:
HIV
Depression
Hepatitis C


Discharge Condition:
Afebrile, vital signs stable, ambulating w/o difficulty.


Discharge Instructions:
Please take all medications and complete the course of
antibiotics as prescribed.  You should follow up with your
primary doctor within 1 week.
.
Return to the emergency room for:
Worsening Rash
Fever


Followup Instructions:
PCP: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 571**] [**Telephone/Fax (1) 2393**].  Please call for f/u.
{'Unspecified septicemia,Human immunodeficiency virus [HIV] disease,Cellulitis and abscess of leg, except foot,Other pulmonary insufficiency, not elsewhere classified,Acute kidney failure, unspecified,Chronic hepatitis C without mention of hepatic coma,Depressive disorder, not elsewhere classified,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Infection with microorganisms resistant to penicillins,Diarrhea'}


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: CC: left calf infection

PRESENT ILLNESS: HPI:
Mr. [**Known lastname 39483**] is a 48 yo male with PMH of HIV, hepatitis C, and
h/o MSSA osteomyelitis following ORIF of left malleolus in [**3-15**]
who got an bug bite on his left posterior calf one week ago.  He
was seen at that time by his PCP who [**Name Initial (PRE) **] + D'd the wound and
started him on Cipro.  He is currently on day 7 of 10 of Cipro
and returned to PCP with fevers, chills and rigors.  Wound had
failed to improve on cipro and cultures returned with MRSA, so
he was prescribed doxycycline although he never took first dose.
After demonstrating chills/rigors at his PCP's office earlier
today, he was sent to the ED for further evaluation.
.
In the ED his vitals were T 104.1, HR 74, BP 95/62, and 96% on
room air.  His labs were notable for lactate of 3.5 and a WBC of
8.8 with 72.6% PMNs.  His blood pressure fell to 80/40 so a
right IJ Precept catheter was placed.  He was given 5L IVF and
started on vancomycin.  His blood pressure remained in 80s/30s
so norepinephrine was started with resultant blood pressures
with MAP > 65.
.
Upon arrival to [**Hospital Unit Name 153**], his vitals were T 104.1, HR 138, BP
128/74, RR 37, O2 sat of 92% on NRB.  Patient was alert and
oriented and reported that he was now short of breath after
laying flat in the ambulance. He denies any chest pain or prior
difficulty with his breathing.  He reported mild pruritus of the
LLE.  The levophed drip was subsequently stopped and patient was
given ethacrynic acid for diuresis as he has a sulfa alergy.
Otherwise, ROS was negative.
.

MEDICAL HISTORY: PMH:
- ankle fracture s/p ORIF of bimaleolar ankle infection in [**3-15**]
complicated by MSSA osteomyelitis requiring removal of hardware
in [**8-12**].  ? Treated with IV oxacillin for 3 weeks followed by PO
levofloxacin for 6 months.
- HIV positive for 20+ years, not on HAART for past 6-12 months,
last CD4 count on [**8-29**] was 173
- Hepatitis C
.

MEDICATION ON ADMISSION: MEDS:
Wellbutrin ER 200 mg [**Hospital1 **]
.

ALLERGIES: Sulfa (Sulfonamides) / Penicillins / Oxacillin / Vancomycin

PHYSICAL EXAM: PE:
VS:   T 104.1, HR 138, BP 128/74, RR 37 O2 sat of 92% on NRB
HEENT:  EOMI, o/p clear
CV: tachycardic, no murmurs/rubs/gallops
Pulm: tachypneic, increased work of breathing, crackles
bilaterally throughout entire lung fields, wheezes present
Abd: soft, Nontender, nondistended, bowel sounds present
Ext: no edema
Skin: left posterior calf 3 cm ulcer with surrounding eryethema,
warmth and tenderness (8 cm x 10 cm).
Neuro: AxOx3.  Cranial nerves grossly intact. Moving all
extremities without difficulty.
.

FAMILY HISTORY: FH: Noncontributory
.

SOCIAL HISTORY: SH:  Patient is a waiter.  He denies tobacco or alcohol use.
. 

### Response:
{'Unspecified septicemia,Human immunodeficiency virus [HIV] disease,Cellulitis and abscess of leg, except foot,Other pulmonary insufficiency, not elsewhere classified,Acute kidney failure, unspecified,Chronic hepatitis C without mention of hepatic coma,Depressive disorder, not elsewhere classified,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Infection with microorganisms resistant to penicillins,Diarrhea'}
