CHIEF COMPLAINT: Orbital cellulitis

PRESENT ILLNESS: This is 47yo F with a history of HTN, CVA, Hep C, Anemia of
chronic disease, CRI, h/o renovascualr disease with L angio
stenting, renal osteodystrophy, depression, and
membranoproliferative glomerulonephritis who presented to OSH
for ankle pain and swelling, hypotension and syncope in PCPs
office.
.
The patient reports that three weeks prior to admission, she had
a frontal tooth replacement after an accident, and since that
dental procedure had intermittent fevers to 101.1 and drenching
night sweats at home, as well as difficulty swallowing. She
later developed right ankle pain, involvement of her Left ankle,
knee and R elbow so severe that she was confined to a
wheelchair, which was consistent with her prior gout flair. She
went to her PCP in [**State 2748**] with hopes of receiving a steroid
injection and was found to be hypotensive, and had a syncopal
episode. She was admitted on [**2194-2-27**] to [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 10315**]
Hospital in [**Location (un) 14078**], CT for the syncope eval.
.
At the OSH, her right ankle was aspirated, showing "rare WBC's,
no organisms, culture was negative," and she was started on high
dose steroids. Over 24 hours, she developed increasing swelling
in her left eye, so much that it was shut closed. Steroids were
increased and the patient's swelling and erythema progressed
over her ear, neck and had ecchymoses and drainage from eye. She
spiked to 103.3, was started initially on vanc/zosyn + acyclovir
and then switched to linezolid and meropenem. She was
subsequently transferred here. Blood and wound cultures were
positive for group a strep (strep pyogenes).

MEDICAL HISTORY: h/o nasal surgery
hepatitis C
MPGN
CKD
HTN
Sz secondary to poorly controlled HTN
depression
cryoblobulinemia
hyperuricemia
gout
Renal Artery Stenosis- s/p L sided stent placement

MEDICATION ON ADMISSION: MVI
zoloft
toprol xl 150 [**Hospital1 **]
prednisone 10 mg (last dose last week)
diovan/HCTZ 160/25 QD
allopurinol 150 QD
vicodin
torsemide 150 mg QD
ambien 10 HS
ropinerole 1 mg HS
flonase 2 sprays QD

ALLERGIES: Latex / Ivp Dye, Iodine Containing

PHYSICAL EXAM: Vitals: T 98.4, BP 140/80, 100, 22, 97%2L NC
Gen: ill-appearing, visibly uncomfortable, NAD
HEENT: deep erythematous L superior eyelid with massive, edema,
weeping clear yellow transudate with 3x2cm area of ecchymosis on
eyelid. Area of edema extending around the left ear with
deformity, and down left neck.
Neck: Diffuse tender LAD with multiple regional enlarged nodes L
> R.
CV: Irregularly Irregular, no MRG, JVP not visible.
CHEST: CTAB
Abd: mild soft tissue tenderness to left of umbilicus,
otherwise, soft, NT, ND, BS+
Extrem: no CCE, bilateral LE icthyosis, 2+ DP, PT pulses. L arm
tenderness near prior IV insertion site.

FAMILY HISTORY: Mother had DM, Father had HTN, she is one of 15 children (unsure
of other siblings health

SOCIAL HISTORY: lives with daughter and husband, has a dog. Denies tobacco/Etoh.
Has 2 other children. Born in [**Male First Name (un) 1056**], grew up in New
Jersey.
Abscess of eyelid,Acute kidney failure, unspecified,Chronic hepatitis C without mention of hepatic coma,Chronic kidney disease, unspecified,Bacteremia,Hypovolemia,Thrombocytopenia, unspecified,Orbital cellulitis,Anemia of other chronic disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Gout, unspecified,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group A,Atherosclerosis of renal artery,Atrial fibrillation
Abscess of eyelid,Acute kidney failure NOS,Chrnc hpt C wo hpat coma,Chronic kidney dis NOS,Bacteremia,Hypovolemia,Thrombocytopenia NOS,Orbital cellulitis,Anemia-other chronic dis,Hy kid NOS w cr kid I-IV,Gout NOS,Streptococcus group a,Renal artery atheroscler,Atrial fibrillation
Admission Date:  [**2194-3-4**]              Discharge Date:   [**2194-3-18**]

Date of Birth:  [**2146-7-20**]             Sex:   F

Service: MEDICINE

Allergies:
Latex / Ivp Dye, Iodine Containing

Attending:[**First Name3 (LF) 1974**]
Chief Complaint:
Orbital cellulitis

Major Surgical or Invasive Procedure:
none


History of Present Illness:
This is 47yo F with a history of HTN, CVA, Hep C, Anemia of
chronic disease, CRI, h/o renovascualr disease with L angio
stenting, renal osteodystrophy, depression, and
membranoproliferative glomerulonephritis who presented to OSH
for ankle pain and swelling, hypotension and syncope in PCPs
office.
.
The patient reports that three weeks prior to admission, she had
a frontal tooth replacement after an accident, and since that
dental procedure had intermittent fevers to 101.1 and drenching
night sweats at home, as well as difficulty swallowing. She
later developed right ankle pain, involvement of her Left ankle,
knee and R elbow so severe that she was confined to a
wheelchair, which was consistent with her prior gout flair. She
went to her PCP in [**State 2748**] with hopes of receiving a steroid
injection and was found to be hypotensive, and had a syncopal
episode. She was admitted on [**2194-2-27**] to [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 10315**]
Hospital in [**Location (un) 14078**], CT for the syncope eval.
.
At the OSH, her right ankle was aspirated, showing "rare WBC's,
no organisms, culture was negative," and she was started on high
dose steroids. Over 24 hours, she developed increasing swelling
in her left eye, so much that it was shut closed. Steroids were
increased and the patient's swelling and erythema progressed
over her ear, neck and had ecchymoses and drainage from eye. She
spiked to 103.3, was started initially on vanc/zosyn + acyclovir
and then switched to linezolid and meropenem. She was
subsequently transferred here. Blood and wound cultures were
positive for group a strep (strep pyogenes).

Patient was initially in ICU for several days before being
transferred to floor.


Past Medical History:
h/o nasal surgery
hepatitis C
MPGN
CKD
HTN
Sz secondary to poorly controlled HTN
depression
cryoblobulinemia
hyperuricemia
gout
Renal Artery Stenosis- s/p L sided stent placement


Social History:
lives with daughter and husband, has a dog. Denies tobacco/Etoh.
Has 2 other children. Born in [**Male First Name (un) 1056**], grew up in New
Jersey.

Family History:
Mother had DM, Father had HTN, she is one of 15 children (unsure
of other siblings health

Physical Exam:
Vitals: T 98.4, BP 140/80, 100, 22, 97%2L NC
Gen: ill-appearing, visibly uncomfortable, NAD
HEENT: deep erythematous L superior eyelid with massive, edema,
weeping clear yellow transudate with 3x2cm area of ecchymosis on
eyelid. Area of edema extending around the left ear with
deformity, and down left neck.
Neck: Diffuse tender LAD with multiple regional enlarged nodes L
> R.
CV: Irregularly Irregular, no MRG, JVP not visible.
CHEST: CTAB
Abd: mild soft tissue tenderness to left of umbilicus,
otherwise, soft, NT, ND, BS+
Extrem: no CCE, bilateral LE icthyosis, 2+ DP, PT pulses. L arm
tenderness near prior IV insertion site.


Pertinent Results:
OSH:  2/2 blood cx bottles + for Group A Strep, Wound Culture
positive for Group A strep.
.
.
[**2194-3-4**] 10:46PM   WBC-17.2* RBC-3.32* HGB-9.9* HCT-28.4* MCV-86
MCH-29.9 MCHC-34.9 RDW-13.9
[**2194-3-4**] 10:46PM   NEUTS-93* BANDS-3 LYMPHS-3* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2194-3-4**] 10:46PM   PLT SMR-VERY LOW PLT COUNT-71*
[**2194-3-4**] 10:46PM   ALT(SGPT)-23 AST(SGOT)-19 ALK PHOS-92 TOT
BILI-0.5
[**2194-3-4**] 10:46PM   GLUCOSE-149* UREA N-95* CREAT-2.1* SODIUM-140
POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-24 ANION GAP-15
[**2194-3-4**] 10:46PM   ALBUMIN-2.6* CALCIUM-8.5 PHOSPHATE-3.1
MAGNESIUM-3.2* IRON-58
.
.
[**2194-3-17**] 03:05AM BLOOD WBC-4.4 RBC-2.77* Hgb-8.7* Hct-25.1*
MCV-91 MCH-31.3 MCHC-34.5 RDW-14.5 Plt Ct-405
[**2194-3-17**] 03:05AM BLOOD UreaN-16 Creat-1.1
[**2194-3-17**] 03:05AM BLOOD ALT-18 AST-18
.
.
[**Month/Day/Year 4338**] ORBIT ([**3-14**]):
No significant change in the size of the abscess just lateral to
the left lateral rectus muscle.

Unchanged large superficial soft tissue abscess just inferior to
and lateral to the left orbit.

Unchanged appearance of the left periorbital pre- and
post-septal cellulitis.

Again, there is abnormally slow diffusion within the left optic
nerve (?ischemic optic neuritis).

Unchanged appearance of the left temporal mandibular joint with
enhancement and edema concerning for infection.
.
.

CT SINUS ([**3-10**]):
1. Left orbital and periorbital inflammatory changes, slightly
less extensive, compared to the prior study.
2. There is an increase in the opacification of the left
maxillary sinus.
3. Irregular left temporomandibular joint, with evidence of
prior surgery in this region. There has been no change since the
prior study. See above report for additional discussion.
.
CT CHEST:
1. No evidence of mediastinal mass.

2. Moderate pericardial effusion.

3. Noncalcified lower lobe nodules measuring up to 6 mm.
Statistically as an incidental finding, they are most likely
benign. However, if the patient has risk factors for neoplasm,
followup CT in six months may be helpful to confirm stability if
warranted clinically.


Brief Hospital Course:
1) Orbital cellulitis:
Unclear where this originated.  Likely progressed due to bolus
steroids for gout at outside hospital.  Treated with IV PCN and
clinda.  Oculoplastics, ENT, plastics, and ID all assisted with
management.  Oral surgery was consulted for possible seeding of
the TMJ given hardware from previous surgery.  By imaging, no
changes and clinically asymptomatic so this was not pursued
further.  With treatment of group A strep with PCN and clinda,
the cellulitis improved dramatically.  The swelling decreased
and an eschar was formed over the periorbital area. Pt had
intermittent sharp pain.  However, several repeat MRIs didn't
demonstrate worsening of infection.  Her pain was likely
neuropathic but resolved by several days prior to discharge.  1d
prior to discharge she was changed to PO amoxicillin.  She will
continue on this for at least 3 weeks with full duration to
determined at follow up with ID.  Per optho consulatation,
prognosis for return of vision in left eye extremely poor.  She
will continue to apply bacitracin ophthalmic to the entire area.
 She will follow-up with plastics for likely reconstruction, as
well as oculoplastics.  She will need repeat [**Month/Year (2) 4338**] orbit in [**11-26**]
weeks prior to f/u with ENT and ID.  All of these appointments
were arranged for her.
.
2) Anemia:
PT developed significant anemia, as low as 21 Hct.  No evidence
of bleeding, iron def, hemolysis.  Likely due to combination of
BM suppression from acute ilness and meds.  Hematocrit
stabilized with treatment of infection, discontinuation of
possible contributing medications (requip, hydral, and
valsartan), and initiation of epogen.  Patient will need
outpatient follow-up with hematology to discuss need for further
testing and long-term management.  Her Hct was in the mid 20s
for most of her hospital stay.  SPEP unremarkable.
.
3) Hypertension:
Valsartan discontinued due to risk of anemia.  Instead, started
lisinopril, amlodipine, and increased beta blocker.  Her BP
remained elevated but per pt better than baseline at home.  She
will continue to need uptitration of these meds as outpt.
.
4) Gout:
No symptoms on colchicine.   Allopurinol was not restarted at
this time, but can be once infectious issues are resolved.
.
5) PULM NODULES:
On chest CT, incidental finding of pulmonary nodules, likely
benign, but can be followed up in 6mo to demonstrate stability.
.
6) Acute renal failure:
On admission from OSH, pt's Cr was 2.1  Her baseline was not
known but with treatment of infection and hydration, improved to
1.1.  So she was in ARF likely from infection and hypovolemia.
.
7) Thrombocytopenia:
Plt dropped from 200s at OSH to around 50 in ICU here.  Concern
for HIT so all heparin was stopped.  HIT ab sent and negative x
2.  No evidence of DIC.  Platelets rebounded spontaneously
without any other intervention.


Medications on Admission:
MVI
zoloft
toprol xl 150 [**Hospital1 **]
prednisone 10 mg (last dose last week)
diovan/HCTZ 160/25 QD
allopurinol 150 QD
vicodin
torsemide 150 mg QD
ambien 10 HS
ropinerole 1 mg HS
flonase 2 sprays QD


Discharge Medications:
1. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a
day): take with 50mg tablet for total 150mg twice a day.
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*0*
2. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO twice a day: take with 100mg
tablet for total 150mg twice daily.
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*0*
3. Hexavitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).
4. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Epoetin Alfa 10,000 unit/mL Solution Sig: [**Numeric Identifier 961**] ([**Numeric Identifier 961**]) UNITS
Injection QMOWEFR (Monday -Wednesday-Friday).
Disp:*10 INJ* Refills:*0*
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
8. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed for insomnia.
9. Amoxicillin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 20 days.
Disp:*60 Capsule(s)* Refills:*0*
10. Bacitracin 500 unit/g Ointment Sig: One (1) Appl Ophthalmic
TID (3 times a day) for 3 weeks: left eye.
Disp:*QS * Refills:*0*
11. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**2-28**]
hours as needed for pain for 2 weeks.
Disp:*30 Tablet(s)* Refills:*0*
12. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Nasal 0.05 % Aerosol, Spray Sig: [**11-26**] sprays Nasal three
times a day for 1 months.
Disp:*QS * Refills:*0*
15. Outpatient Lab Work
Weekly CBC, chem-7, AST/ALT/alk phos/total bili starting week of
[**3-24**].  REsults faxed to Dr. [**First Name4 (NamePattern1) 4850**] [**Last Name (NamePattern1) **] (Infectious Diseases,
[**Hospital1 18**]) at [**Telephone/Fax (1) 1419**].


Discharge Disposition:
Home

Discharge Diagnosis:
PRIMARY:
orbital cellulitis, strep
anemia, NOS
hypertension

SECONDARY:
recent gout
hep c w/ h/o cryoglobulins - on plaquenil in past for this given
h/o kidney involvement
history of secondary hyperparathyroidism


Discharge Condition:
Good--afebrile, vital signs stable.


Discharge Instructions:
1. Take medications as prescribed.  Please note, some changes
made in your BP medications.
2.  Follow up as below.  Please make all the appointments and if
unable to do so contac the appropriate doctor.
3.  Sleep with head of bed elevated.  Use bacitracin ointment
liberally to the left eye.
4.  Please call your doctor or go to the emergency room if you
experience temperature > 100.5, worsening eye pain, worsening
swelling around your eye, diarrhea, vomiting/inability to take
your antibiotics, or other concerning symptoms.

Followup Instructions:
1.  Please call Dr. [**Last Name (STitle) 72399**] to schedule a follow up appointment
with her in [**11-26**] weeks for monitoring of BP, GOUT, ANEMIA and
other issues.

2.  ENT:  [**4-1**] at 2pm with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1837**] ([**Telephone/Fax (1) 72400**].
--You should have an [**Telephone/Fax (1) 4338**] of the eye and CT of the sinuses prior
to that visit.  They are scheduled as follows:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2194-3-29**] 11:15
[**Hospital Ward Name **] [**Location (un) 470**].
Provider: [**Name10 (NameIs) 4338**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2194-3-29**] 12:00  [**Hospital Ward Name **] basement.

3.  Provider: [**Name10 (NameIs) **] SURGERY CLINIC Phone:[**Telephone/Fax (1) 4652**]
Date/Time:[**2194-3-28**] 1:00.  [**Hospital **] Medical Building, [**Hospital Ward Name **].

4. INFECT DISEASE:  You have an appointment with Dr. [**First Name4 (NamePattern1) 4850**] [**Last Name (NamePattern1) **]
on [**4-3**] at 10am.  Please call ([**Telephone/Fax (1) 4170**] if there are any
problems.
[**Name (NI) **] will need weekly labs sent to Dr. [**First Name (STitle) **] at fax#[**Telephone/Fax (1) 1419**].
I have included prescription but please contact Dr. [**Last Name (STitle) 72401**] to
arrange the blood tests.

5. OCULOPLASTICS:  Dr. [**Last Name (STitle) 12044**] ([**Telephone/Fax (1) 12045**]) at [**Hospital 39111**] ([**Last Name (NamePattern1) **], [**Location (un) 453**]) on [**3-20**] at 2:30pm.

OTHER ISSUES:
You will need a follow up chest CT in 6 months to monitor
pulmonary nodules seen on CT here.  PLease ask Dr. [**Last Name (STitle) 72401**] to
set this up.
{'Abscess of eyelid,Acute kidney failure, unspecified,Chronic hepatitis C without mention of hepatic coma,Chronic kidney disease, unspecified,Bacteremia,Hypovolemia,Thrombocytopenia, unspecified,Orbital cellulitis,Anemia of other chronic disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Gout, unspecified,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group A,Atherosclerosis of renal artery,Atrial fibrillation'}


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: Orbital cellulitis

PRESENT ILLNESS: This is 47yo F with a history of HTN, CVA, Hep C, Anemia of
chronic disease, CRI, h/o renovascualr disease with L angio
stenting, renal osteodystrophy, depression, and
membranoproliferative glomerulonephritis who presented to OSH
for ankle pain and swelling, hypotension and syncope in PCPs
office.
.
The patient reports that three weeks prior to admission, she had
a frontal tooth replacement after an accident, and since that
dental procedure had intermittent fevers to 101.1 and drenching
night sweats at home, as well as difficulty swallowing. She
later developed right ankle pain, involvement of her Left ankle,
knee and R elbow so severe that she was confined to a
wheelchair, which was consistent with her prior gout flair. She
went to her PCP in [**State 2748**] with hopes of receiving a steroid
injection and was found to be hypotensive, and had a syncopal
episode. She was admitted on [**2194-2-27**] to [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 10315**]
Hospital in [**Location (un) 14078**], CT for the syncope eval.
.
At the OSH, her right ankle was aspirated, showing "rare WBC's,
no organisms, culture was negative," and she was started on high
dose steroids. Over 24 hours, she developed increasing swelling
in her left eye, so much that it was shut closed. Steroids were
increased and the patient's swelling and erythema progressed
over her ear, neck and had ecchymoses and drainage from eye. She
spiked to 103.3, was started initially on vanc/zosyn + acyclovir
and then switched to linezolid and meropenem. She was
subsequently transferred here. Blood and wound cultures were
positive for group a strep (strep pyogenes).

MEDICAL HISTORY: h/o nasal surgery
hepatitis C
MPGN
CKD
HTN
Sz secondary to poorly controlled HTN
depression
cryoblobulinemia
hyperuricemia
gout
Renal Artery Stenosis- s/p L sided stent placement

MEDICATION ON ADMISSION: MVI
zoloft
toprol xl 150 [**Hospital1 **]
prednisone 10 mg (last dose last week)
diovan/HCTZ 160/25 QD
allopurinol 150 QD
vicodin
torsemide 150 mg QD
ambien 10 HS
ropinerole 1 mg HS
flonase 2 sprays QD

ALLERGIES: Latex / Ivp Dye, Iodine Containing

PHYSICAL EXAM: Vitals: T 98.4, BP 140/80, 100, 22, 97%2L NC
Gen: ill-appearing, visibly uncomfortable, NAD
HEENT: deep erythematous L superior eyelid with massive, edema,
weeping clear yellow transudate with 3x2cm area of ecchymosis on
eyelid. Area of edema extending around the left ear with
deformity, and down left neck.
Neck: Diffuse tender LAD with multiple regional enlarged nodes L
> R.
CV: Irregularly Irregular, no MRG, JVP not visible.
CHEST: CTAB
Abd: mild soft tissue tenderness to left of umbilicus,
otherwise, soft, NT, ND, BS+
Extrem: no CCE, bilateral LE icthyosis, 2+ DP, PT pulses. L arm
tenderness near prior IV insertion site.

FAMILY HISTORY: Mother had DM, Father had HTN, she is one of 15 children (unsure
of other siblings health

SOCIAL HISTORY: lives with daughter and husband, has a dog. Denies tobacco/Etoh.
Has 2 other children. Born in [**Male First Name (un) 1056**], grew up in New
Jersey. 

### Response:
{'Abscess of eyelid,Acute kidney failure, unspecified,Chronic hepatitis C without mention of hepatic coma,Chronic kidney disease, unspecified,Bacteremia,Hypovolemia,Thrombocytopenia, unspecified,Orbital cellulitis,Anemia of other chronic disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Gout, unspecified,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group A,Atherosclerosis of renal artery,Atrial fibrillation'}
