CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 69-year-old
female with diabetes, chronic renal insufficiency, coronary
artery disease, systolic congestive heart failure with an
ejection fraction of 20%, chronic atrial fibrillation,
chronic anemia, and blindness, who was treated for
necrotizing fascitis with multi-organ dysfunction.

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Necrotizing fasciitis,Acute respiratory failure,Other septicemia due to gram-negative organisms,Acute kidney failure, unspecified,Cerebral artery occlusion, unspecified with cerebral infarction,Acute myocardial infarction of unspecified site, initial episode of care,Unspecified gastritis and gastroduodenitis, with hemorrhage,Congestive heart failure, unspecified,Pneumonia due to Klebsiella pneumoniae
Necrotizing fasciitis,Acute respiratry failure,Gram-neg septicemia NEC,Acute kidney failure NOS,Crbl art ocl NOS w infrc,AMI NOS, initial,Gstr/ddnts NOS w hmrhg,CHF NOS,K. pneumoniae pneumonia
Admission Date:  [**2180-6-19**]       Discharge Date:  [**2180-8-9**]

Date of Birth:   [**2110-9-11**]       Sex:  F

Service:

HISTORY OF PRESENT ILLNESS:  The patient is a 69-year-old
female with diabetes, chronic renal insufficiency, coronary
artery disease, systolic congestive heart failure with an
ejection fraction of 20%, chronic atrial fibrillation,
chronic anemia, and blindness, who was treated for
necrotizing fascitis with multi-organ dysfunction.

The patient was admitted to [**Hospital6 2018**] on [**2180-6-19**], with the complaint of severe left
leg pain for the prior two weeks.  Of note, she noted prior
poor p.o. intake for approximately one week and recently had
her p.o. Lasix dose increased as an outpatient for worsened
lower extremity edema.

On presentation, the left leg slightly edematous, painful,
and warm, with ................... to exam findings.  In the
Emergency Department, she was afebrile.  She had a negative
leni.  She had multiple laboratory abnormalities including
white blood cell measuring 58,000, with bandemia to 15%.
Hematocrit was low at 19, and creatinine was 5.9, with
bicarbonate of 13, and anion gap of 20.  Lactate level
measured 7.6.  She was also hypoglycemic to the 50s which was
refractory to D50 administration and eventually declined to
the 20s and as low as 7.  There was no history of sulfa nor
Metformin use.  She received MS04 for pain, packed red blood
cells, and over the course of her Emergency Department stay,
there was an acute decline in her mental status.  A head CT
was negative for bleeding.  She received a dose of
Levofloxacin.

On arrival to the MICU, the patient was changed to Kefzol and
later switched to Clindamycin and Vancomycin.  The patient
continued to decline and was noted to exhibit Kussmaul
respirations.  She was ultimately intubated for airway
protection and work of breathing.  She had a documented
fingerstick of less than 20.  She became hypotensive
requiring fluid boluses and ultimately pressor support with
Phenylephrine.  Her urine output was minimal.  A PA catheter
was placed showing a CBP of 34, PA of 51/34, cardiac output
of 2.5, SVR of [**2095**], MVO2 of 28%.  CKs rose to greater than
1000, with relatively low MBs, and troponin was 3.9.  She was
started on Dobutamine with improvement in her cardiac index
and MVO2, as was improved in urine output.

................... consultation was obtained with an initial
impression that she did not have involvement of the deep
tissues but rather this was a superficial process.

The patient underwent CT imaging of the leg without contrast
which revealed no direct evidence of fasciitis; however, over
the following day, she began to develop ...................,
and the leg appeared more dusky.  She became hypothermic.
She was started on Xigriss given the clinical evidence for
infection, hypotension, and end-organ hypoperfusion,
consistent with severe sepsis.  She was later proven to be
................... and was started on ...................
replacement therapy.  Fluid was culture from the bolus
lesions which proved positive for group A strep.  Skin biopsy
was obtained by Dermatology which was consistent for a
leukocyclastic vasculitis.

Ultimately Surgery was reconsulted, and the patient underwent
above-knee amputation on [**6-29**] with an immediate
postoperative complicated by wound bleeding and hypotension.
The wound was left open ..................., a Vac dressing
was applied which was changed every three days by Vascular
Surgery.  The wound was felt to be granulating well.

The patient was subsequently noted to have a left groin
hematoma, possibly from a previous line attempt.  The
hematoma was monitored by Vascular Surgery and was felt to
stabilize.  There was no felt to be no indication for
evacuation.  Ultrasound revealed no pseudoaneurysm.
Sanguinous drainage and skin breakdown was noted from the
area of the hematoma.  It was recommended that
................... ointment be applied to the skin overlying
the hematoma.

The patient's Intensive Care Unit stay was further
complicated by Klebsiella oxytoca sepsis.  This was treated
with a 21-day course of Meropenem.  In addition, she was
treated for infection with strep stenotrophamonas with
Bactrim isolated from stump wound culture on [**7-21**].

While in the Intensive Care Unit, the patient was noted to
have seizure activity.  EEG showed nonspecific diffuse wave
slowing.  Head imaging revealed the presence of recent left
middle cerebral artery stroke, ...................  The
patient was followed by the Neurology Service who recommended
that she start on Phenytoin.  She ...................
profound hypoglycemia, as well as stroke.  She was aphasic.
She did arouse to tactile stimulation.  She was noted to have
intermittent eye opening to voice.

Her family primary care physician followed her through her
hospitalization.  She has made a promising recovery and is
hopeful further ...................  Interestingly the
patient was noted to have an elevated PTT throughout the
hospital stay.  She was found to have lupus anticoagulant;
however, efforts toward any coagulation has been difficult,
with her intermittent melena throughout her hospital course.
She has undergone periodic transfusions with packed RBCs.
The patient received and EGD and colonoscopy which revealed
diffuse hemorrhagic gastritis.  No sites of lower GI bleed
were identified.  The patient was placed on Protonix 40 mg IV
b.i.d., as well as Carafate per recommendation of the
Gastroenterology Service.  It was recommended that she
maintain off all anticoagulants and ...................
agents presently.

The patient was successfully extubated in [**Month (only) 216**] and
transferred to the Medical Floor.  She has been hemodialysis
as a result of her critical illness and is currently
undergoing a regimen of Monday, Wednesday, and Friday,
three-times-a-week dialysis.  She has been tolerating this
well.  A tunnel catheter was placed in the right internal
jugular vein on [**7-17**].

Since extubation, the patient has been requiring intermittent
suction of copious respiratory secretions.  She maintains
oxygen saturations in the mid 90s without supplemental
oxygen.  On [**8-1**], the patient was noted to develop a
right leukocytosis in the 20,000 range, but she remained
afebrile.  ................... placement was empirically
increased.  She has remained hemodynamically stable.
Pseudomonas aeruginosa pansensitive was isolated from the
sputum, and the patient was started on Zosyn.  She had
left-sided pleural effusion that has been further evaluated
in the Intensive Care Unit.  A thoracentesis was performed on
[**8-5**] with an exudate of 1.3 L, with .................
7.45.  Chest x-ray performed subsequently revealed no obvious
infiltrate.  Blood cultures from ................... on
[**8-4**] showed ................... Staphylococcus,
enterococcus ................... in 2 out of 6 bottles.  It
was suspected that there may be a contaminant.  Blood
cultures from both a left upper extremity PICC line and her
PermCath showed no growth to date.  Blood cultures on
[**8-6**] through [**8-7**] showed no growth to date.
It was recommended that she be maintained on Zosyn through
[**8-15**] to treat both Pseudomonas tracheal bronchitis,
as well as possible enterococcus infection.  There is low
suspicion for the latter.

The patient was maintained on tube feeds through a
percutaneously placed GJ tube.  She has been tolerating the
tube feeds well.  The patient will subsequently be discharged
through a rehabilitation facility.  Several family meetings
occurred throughout the patient's hospitalization.  The
family is aware of her critical illness and guarded
prognosis.  THE PATIENT IS FULL CODE in accordance with their
wishes.

DISCHARGE MEDICATIONS: Tube feeds, FS Promote with fiber at
65 cc/hr, Reglan 10 mg p.o. t.i.d., Protonix 40 mg IV b.i.d.,
Dulcolax 5 mg p.o. q.d. p.r.n., Synthroid 37.5 mcg p.o. q.d.,
Prednisone 20 mg p.o. q.d. tapered to 10 mg daily within a
one-week period, Dilantin 150 mg p.o. b.i.d., Tylenol 650 mg
p.o. q.i.d., Insulin sliding scale, Sulcrafate 1 g GJ tube 4
times a day, Humalog Insulin sliding scale, Zosyn 2.25 mcg IV
q.8 hours through [**2180-8-15**], Mucomyst nebs every 6
hours p.r.n., ................... 10 mg p.o. q.d., TUMS 500
mg p.o. 3 times a day, Silvadene 1% ointment to skin of her
hematoma, Albuterol nebs q.4-6 hours p.r.n., Nephrocaps 1
p.o. q.d., Nystatin mouth rinse b.i.d., Epogen 4000 U at
every hemodialysis session, Zemproar 2 mg IV at hemodialysis.

Additional recommendations that if over the 1-2 months the
patient has no active infections, the patient should undergo
ACT challenge to reassess the dosage ................... the
necessity for the Prednisone for adrenal insufficiency.

DISCHARGE DIAGNOSIS:
1.  Necrotizing fascitis.
2.  Group A streptococcus.
3.  Status post left above-knee-amputation on [**6-29**].
4.  Klebsiella oxytoca sepsis.
5.  End-stage renal disease, now on hemodialysis.
6.  ................... Vascular coagulation, resolved.
7.  Hemorrhagic gastritis.
8.  Grade 2 internal hemorrhoids, nonbleeding.
9.  Episode of profound hypoglycemia.
10. Diabetes mellitus.
11. Adrenal insufficiency.
12. Hypothyroidism.
13. Left MCA stroke.
14. Seizure disorder on Phenytoin.
15. Pseudomonas treated bronchitis.
16. Lupus anticoagulant, likely anti...................
syndrome.
17. Ischemic cardiomyopathy with an ejection fraction of 15%.
18. Mitral regurgitation, moderate.
19. Left groin hematoma.

CONDITION ON DISCHARGE:  Guarded.

DISCHARGE STATUS:  Discharge to rehabilitation facility.






                            [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12157**], M.D.  [**MD Number(1) 12158**]

Dictated By:[**Last Name (NamePattern1) 32393**]
MEDQUIST36

D:  [**2180-8-9**]  20:10
T:  [**2180-8-9**]  20:19
JOB#:  [**Job Number 32394**]
{'Necrotizing fasciitis,Acute respiratory failure,Other septicemia due to gram-negative organisms,Acute kidney failure, unspecified,Cerebral artery occlusion, unspecified with cerebral infarction,Acute myocardial infarction of unspecified site, initial episode of care,Unspecified gastritis and gastroduodenitis, with hemorrhage,Congestive heart failure, unspecified,Pneumonia due to Klebsiella pneumoniae'}


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: 

PRESENT ILLNESS: The patient is a 69-year-old
female with diabetes, chronic renal insufficiency, coronary
artery disease, systolic congestive heart failure with an
ejection fraction of 20%, chronic atrial fibrillation,
chronic anemia, and blindness, who was treated for
necrotizing fascitis with multi-organ dysfunction.

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Necrotizing fasciitis,Acute respiratory failure,Other septicemia due to gram-negative organisms,Acute kidney failure, unspecified,Cerebral artery occlusion, unspecified with cerebral infarction,Acute myocardial infarction of unspecified site, initial episode of care,Unspecified gastritis and gastroduodenitis, with hemorrhage,Congestive heart failure, unspecified,Pneumonia due to Klebsiella pneumoniae'}
