CHIEF COMPLAINT: fever, back pain

PRESENT ILLNESS: Ms. [**Known firstname 1494**] [**Known lastname 41236**] is a 61-year old female with cervical and
lumbar laminectomy/fusion who presents with fever to 101.3
degrees and increased back pain.

MEDICAL HISTORY: Cervical and lumbar spondylosis.
- Anterior cervical corpectomy and fusion at C3 to C7 in
[**2173-11-23**].
- C7 through T1 laminectomies and partial laminectomy of C6 and
T2 on [**2176-4-23**]
- L4-L4 laminectomy in [**2166**].
- L2-S1 spinal fusion in [**2169**].
- L1 stimulator ? in [**2170**].
Osteoarthritis, status post bilateral shoulder surgery.
Hypertension
Hypercholesterolemia
Hypothyroidism

MEDICATION ON ADMISSION: 1. Atorvastatin 10 mg by mouth every day.
2. Amitriptyline 100 mg by mouth at hour of sleep.
3. Levothyroxine 125 mcg by mouth every day.
4. Docusate 100 mg by mouth twice per day.
5. Multivitamin one by mouth every day.
6. Calcium carbonate 1000 mg by mouth three times per day.
7. Atenolol 25 mg by mouth once per day.
8. Oxycodone 5 mg to 10 mg by mouth q.4h.
9. Zanaflex 2 mg by mouth three times per day.
10. Enteric coated aspirin 325 mg by mouth once per day.
11. Oxycodone 5 mg by mouth q.4-6h. as needed (for breakthrough
pain).
12. Celebrex 200 mg by mouth once per day.
13. Glucosamine 750 mg by mouth twice per day.
14. Fosamax 70 mg by mouth every week.
15. Diovan 80 mg by mouth once per day.

ALLERGIES: E-Mycin / Flagyl

PHYSICAL EXAM: V: Tm 103.0, 115/49, p87, spo2 97%
vent: AC 550x14/5/.5
ABG: 7.38/39/106
Gen: intubated, sedated
HEENT: no meningismus, no objective photophobia (per ortho),
NC/AT
lungs: CTA b
CV: s1/s2, rrr
abd: soft, nabs, nttp
ext: no edema, warm and dry, dp 2+
neuro: intubated and sedated

FAMILY HISTORY: She had a father with a transient ischemic
attack. Both parents have hypertension. There is no family
history of coronary artery disease or diabetes.

SOCIAL HISTORY: The patient has not smoked for the past 30
years. She has never had alcohol. Denies any history of
illicit drug use.
Other staphylococcal septicemia,Acute respiratory failure,Acute kidney failure, unspecified,Infection and inflammatory reaction due to nervous system device, implant, and graft,Other and unspecified disc disorder, lumbar region,Unspecified essential hypertension,Pure hypercholesterolemia,Unspecified acquired hypothyroidism,Other iatrogenic hypotension,Unspecified sedatives and hypnotics causing adverse effects in therapeutic use,Arthrodesis status
Staphylcocc septicem NEC,Acute respiratry failure,Acute kidney failure NOS,React-nerv sys dev/graft,Disc dis NEC/NOS-lumbar,Hypertension NOS,Pure hypercholesterolem,Hypothyroidism NOS,Iatrogenc hypotnsion NEC,Adv eff sedat/hypnot NOS,Arthrodesis status
Admission Date:  [**2178-3-4**]              Discharge Date:   [**2178-3-28**]

Date of Birth:  [**2115-4-1**]             Sex:   F

Service: MEDICINE

Allergies:
E-Mycin / Flagyl

Attending:[**First Name3 (LF) 689**]
Chief Complaint:
fever, back pain

Major Surgical or Invasive Procedure:
Central line placement-no complications. Placement of left
antecubital PICC line


History of Present Illness:
Ms. [**Known firstname 1494**] [**Known lastname 41236**] is a 61-year old female with cervical and
lumbar laminectomy/fusion who presents with fever to 101.3
degrees and increased back pain.

In the ED, she was initially scheduled for an MRI. She got
multiple doses of ativan, morphine, and haldol for sedation
before the study but had a near respiratory arrest. She was
intubated for increasing sedation for the MRI and put on
propofol and given a dose of vecuronium for paralysis before
MRI. The MRI preliminarily showed no abscess but was an
extrememly limited study. Orthopedics decided there was no role
for surgery at this time, so she was transferred to the MICU for
monitoring of this intubated patient.

Past Medical History:
Cervical and lumbar spondylosis.
- Anterior cervical corpectomy and fusion at C3 to C7 in
[**2173-11-23**].
- C7 through T1 laminectomies and partial laminectomy of C6 and
T2 on [**2176-4-23**]
- L4-L4 laminectomy in [**2166**].
- L2-S1 spinal fusion in [**2169**].
- L1 stimulator ? in [**2170**].
Osteoarthritis, status post bilateral shoulder surgery.
Hypertension
Hypercholesterolemia
Hypothyroidism


Social History:
The patient has not smoked for the past 30
years. She has never had alcohol. Denies any history of
illicit drug use.

Family History:
She had a father with a transient ischemic
attack. Both parents have hypertension. There is no family
history of coronary artery disease or diabetes.

Physical Exam:
V: Tm 103.0, 115/49, p87, spo2 97%
vent: AC 550x14/5/.5
ABG: 7.38/39/106
Gen: intubated, sedated
HEENT: no meningismus, no objective photophobia (per ortho),
NC/AT
lungs: CTA b
CV: s1/s2, rrr
abd: soft, nabs, nttp
ext: no edema, warm and dry, dp 2+
neuro: intubated and sedated


Pertinent Results:
[**2178-3-4**] 01:05PM   PT-11.3 PTT-21.1* INR(PT)-1.0
[**2178-3-4**] 11:35AM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2178-3-4**] 11:35AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2178-3-4**] 11:12AM   LACTATE-3.2*
[**2178-3-4**] 11:00AM   GLUCOSE-106* UREA N-33* CREAT-1.1 SODIUM-138
POTASSIUM-5.4* CHLORIDE-99 TOTAL CO2-25 ANION GAP-19
[**2178-3-4**] 11:00AM   CALCIUM-9.8 PHOSPHATE-4.1 MAGNESIUM-2.0
[**2178-3-4**] 11:00AM   CRP-34.2*
[**2178-3-4**] 11:00AM   WBC-17.4*# RBC-4.04* HGB-12.6 HCT-36.9 MCV-91
MCH-31.1 MCHC-34.1 RDW-14.0
[**2178-3-4**] 11:00AM   NEUTS-87.1* BANDS-0 LYMPHS-8.8* MONOS-3.2
EOS-0.8 BASOS-0.1
[**2178-3-4**] 11:00AM   HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2178-3-4**] 11:00AM   PLT SMR-NORMAL PLT COUNT-338
[**2178-3-4**] 11:00AM   SED RATE-22*
.
WBC scan: IMPRESSION:
Mild asymmetrical uptake at the lumbosacral junction and left
sacroiliac regionwhich could represent inflammation given
extensive changes seen on CT and MRI.
No definite source of infection is identified
.
LENI: IMPRESSION: No evidence of fempop DVT bilaterally.
.
ECHO: Conclusions:
1. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is normal (LVEF>55%).
2. Right ventricular chamber size and free wall motion are
normal.
3.There are simple atheroma in the descending thoracic aorta.
4.The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. No masses or vegetations are seen on the
aortic valve.
5.The mitral valve appears structurally normal with trivial
mitral
regurgitation. No mass or vegetation is seen on the mitral
valve.
6.There is no pericardial effusion.
.
CT spine: IMPRESSION: Stable appearance to multiple
abnormalities in the cervical spine as compared to [**2175**]. No
clear evidence of paraspinal abscesses.
.
MRI spine: IMPRESSION: Extremely limited exam. Multiple
abnormalities as described above, which do not appear to be new.
Superimposed acute inflammatory processes could be overlooked on
this study. If clinical concern persists, other imaging
modalities, such as a radionuclide scan, may be helpful for
further evaluation.
.
[**3-25**] MR spine -Somewhat motion limited study. No definite
evidence of alteration in appearance compared to the previous
examination of [**3-5**]. Persistent abnormalities in the lower
cervical, upper thoracic, lower thoracic, and upper lumbar
region.


Brief Hospital Course:
.
# Fever: Given her back pain and absence of other focus, there
was concern was for epidural abcess or spinal stimulator
infection. CT and MRI of spine were unrevealing although they
were limited studies as artifact from surgical hardware obscured
imaging. U/A was sterile. CXR showed no pneumonia despite repeat
studies. Blood cx drwan in ED eventually grew coag neg staph [**2-24**]
bottles. She was then started on Vancomycin and had persistent
fevers. ID consulted. Pt received ceftazidime ([**Date range (1) 59224**]),
vancomycin and gentamycin ([**Date range (1) 91453**]). Eventually all
antibiotics were discontinued except Vancomycin once
sensitivities were back. Surveillance blood cultures from [**3-16**],
[**3-17**] and [**3-22**] all grew coag negative staph but all with
different sensitivties with the [**3-17**] cultures growing 2
different morphologies. She has persistent fevers warrenting
further workup. Differential diagnosis also included viral
etiology, though no signs to suggest it and influenza a/b was
negative. TEE on [**3-6**] was negative for endocarditis. Pt had WBC
scan after MRI and CT scan negative which showed minimal uptake
at stimulator suggestive of inflammation but no evidence of
infection or abscess. Dr [**Last Name (STitle) 363**] from ortho spine felt that the
stimulator may be infected so she was taken to the OR for
removal of the battery pack of the stimulator and most of the
wires on [**3-19**] although grossly it didn't appeat infected.  LENI
were negative for infected thrombus. ID recommended a full 6
week course of vancomycin as there was no clear source of
infection. The possibility of drug fever was also raised due to
the possibility of the culture data being contaminant so on [**3-20**]
she was changed to daptomycin. Fevers improved over the next 48
hours. Repeat MRI on [**2178-3-24**] revealed continued discitis in L2-3
and L3-4 so plan was made to dicontinue PICC line and continue
Linezolid for the remainder of her 6 week course. Pt will
follow-up in [**Hospital **] clinic on [**4-13**].
.
# resp failure - intubated for CT and MRI and severe back pain
extubated after procedures. Pt likely over sedated for
procedures and intubated in the ED.
.
# hypotension -Due to oversedation during CT. Pt required
levophed for under 12 hours. Echo revealed EF>55% no WMA or
valvular dysfcn. Cortisol stimulation test was negative for
adrenal insuficiency and it resolved with fluids.
.
# Back pain: Was concerning for infection as pain seemed to be
worse than usual. Pain seemed to me paraspinal as pt had no
point tenderness. Pain service was consulted and started her on
Oxycontin to 20 TID with oxycodone 5mg PRN for breakthrough. She
was on tizanidine at home, which increased to 4mg on this
admission and then weaned back down as pain improved. PT was
consulted to assist with mobility and they felt the patient
would benefit from rehab. She was weaned down on amytriptylline
and tizanidine and topiramate was discontinued on discharge.
.
HTN:We continued her home BP meds but held her ACE-I due to low
SBP and bout of acute renal failure as below
.
#. hypothyroid: We continued replacement at 125mg qd but
increased dose to 150mcg since she reported this was her home
dose

.
# ARF-Pt had baseline creat 0.6 which increased to 1.2 with
decreased GFR with poor PO intake and hypotension. Urine
eosinophils were negative, FENa showed no prerenal state. Her
intermittent tachycardia suggested possible volume depletion
which  resolved with IVF. Her creat continued to improve with
holding ACE-I stopping vancomycin, and holdin NSAIDS so it
remained unclear which was the offending [**Doctor Last Name 360**].
.



Medications on Admission:
1. Atorvastatin 10 mg by mouth every day.
2. Amitriptyline 100 mg by mouth at hour of sleep.
3. Levothyroxine 125 mcg by mouth every day.
4. Docusate 100 mg by mouth twice per day.
5. Multivitamin one by mouth every day.
6. Calcium carbonate 1000 mg by mouth three times per day.
7. Atenolol 25 mg by mouth once per day.
8. Oxycodone 5 mg to 10 mg by mouth q.4h.
9. Zanaflex 2 mg by mouth three times per day.
10. Enteric coated aspirin 325 mg by mouth once per day.
11. Oxycodone 5 mg by mouth q.4-6h. as needed (for breakthrough
pain).
12. Celebrex 200 mg by mouth once per day.
13. Glucosamine 750 mg by mouth twice per day.
14. Fosamax 70 mg by mouth every week.
15. Diovan 80 mg by mouth once per day.


Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day): Until fully ambulatory.
.
2. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q4H (every
4 hours) as needed.
7. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical  QD (): 12 hours on
and 12 hours off. .
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q8H (every 8 hours).
12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
14. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
15. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 3 weeks: patient will have to have CBC checked q3d
while on this medication.
16. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical  [**Hospital1 **]
(2 times a day).
17. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).


Discharge Disposition:
Extended Care

Facility:
Meadowbrook - [**Location (un) 2624**]

Discharge Diagnosis:
Bacteremia
Discitis


Discharge Condition:
[**Name (NI) 97288**] pt with difficulty with ambulation and being discharged
to rehab for PT.


Discharge Instructions:
Pleae return to the hospital if you experience chest pain,
shortness of breath, dizziness/lightheadedness, severe
nausea/vomiting/diarrhea or any other severe symptoms. Please
call your doctor if you have any questions about your symptoms.

Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2178-4-30**] 2:10.

You schould call [**Telephone/Fax (1) 3329**] to confirm an appointment for [**4-1**] at 3pm with the covering doctor for Dr. [**Last Name (STitle) 931**] for post
hospitalization follow-up.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16881**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2178-4-13**] 10am

Please follow-up with Dr. [**Last Name (STitle) 363**] on Thursday [**4-9**] 4:30 pm and
can call [**Telephone/Fax (1) 3573**] to confirm the appointment.
{'Other staphylococcal septicemia,Acute respiratory failure,Acute kidney failure, unspecified,Infection and inflammatory reaction due to nervous system device, implant, and graft,Other and unspecified disc disorder, lumbar region,Unspecified essential hypertension,Pure hypercholesterolemia,Unspecified acquired hypothyroidism,Other iatrogenic hypotension,Unspecified sedatives and hypnotics causing adverse effects in therapeutic use,Arthrodesis status'}


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: fever, back pain

PRESENT ILLNESS: Ms. [**Known firstname 1494**] [**Known lastname 41236**] is a 61-year old female with cervical and
lumbar laminectomy/fusion who presents with fever to 101.3
degrees and increased back pain.

MEDICAL HISTORY: Cervical and lumbar spondylosis.
- Anterior cervical corpectomy and fusion at C3 to C7 in
[**2173-11-23**].
- C7 through T1 laminectomies and partial laminectomy of C6 and
T2 on [**2176-4-23**]
- L4-L4 laminectomy in [**2166**].
- L2-S1 spinal fusion in [**2169**].
- L1 stimulator ? in [**2170**].
Osteoarthritis, status post bilateral shoulder surgery.
Hypertension
Hypercholesterolemia
Hypothyroidism

MEDICATION ON ADMISSION: 1. Atorvastatin 10 mg by mouth every day.
2. Amitriptyline 100 mg by mouth at hour of sleep.
3. Levothyroxine 125 mcg by mouth every day.
4. Docusate 100 mg by mouth twice per day.
5. Multivitamin one by mouth every day.
6. Calcium carbonate 1000 mg by mouth three times per day.
7. Atenolol 25 mg by mouth once per day.
8. Oxycodone 5 mg to 10 mg by mouth q.4h.
9. Zanaflex 2 mg by mouth three times per day.
10. Enteric coated aspirin 325 mg by mouth once per day.
11. Oxycodone 5 mg by mouth q.4-6h. as needed (for breakthrough
pain).
12. Celebrex 200 mg by mouth once per day.
13. Glucosamine 750 mg by mouth twice per day.
14. Fosamax 70 mg by mouth every week.
15. Diovan 80 mg by mouth once per day.

ALLERGIES: E-Mycin / Flagyl

PHYSICAL EXAM: V: Tm 103.0, 115/49, p87, spo2 97%
vent: AC 550x14/5/.5
ABG: 7.38/39/106
Gen: intubated, sedated
HEENT: no meningismus, no objective photophobia (per ortho),
NC/AT
lungs: CTA b
CV: s1/s2, rrr
abd: soft, nabs, nttp
ext: no edema, warm and dry, dp 2+
neuro: intubated and sedated

FAMILY HISTORY: She had a father with a transient ischemic
attack. Both parents have hypertension. There is no family
history of coronary artery disease or diabetes.

SOCIAL HISTORY: The patient has not smoked for the past 30
years. She has never had alcohol. Denies any history of
illicit drug use. 

### Response:
{'Other staphylococcal septicemia,Acute respiratory failure,Acute kidney failure, unspecified,Infection and inflammatory reaction due to nervous system device, implant, and graft,Other and unspecified disc disorder, lumbar region,Unspecified essential hypertension,Pure hypercholesterolemia,Unspecified acquired hypothyroidism,Other iatrogenic hypotension,Unspecified sedatives and hypnotics causing adverse effects in therapeutic use,Arthrodesis status'}
