CHIEF COMPLAINT: chest pain, shortness of breath, rigors

PRESENT ILLNESS: This is a 62 year old female with history of recent NSTEMI, type
II diabetes mellitus, s/p revision Charcot LLE([**9-29**]) prior
pseudomonas, and MRSA infections that presents with left lower
extremity plantar purulent ulceration, chest pain, and rigors.
The patient reported that she was recently discharged from rehab
on [**1-14**], and on [**1-19**] noticed a pin-sized hole with bloody
discharge at the site of her prior Charcot surgery. That night
the pt reported + nightsweats, frontal headaches, chills, and
shortness of breath.

MEDICAL HISTORY: # Coronary artery disease status post myocardial infarction x 4
per patient with multiple PCIs in [**2131**], performed at [**Hospital3 15054**],
anatomy unknown)
# s/p Removal of external fixator left foot ([**2149-12-30**])
# s/p Bilateral Charcot reconstruction [**2149-10-14**]
# H/o MRSA ([**2149-10-14**]) from skin wounds
# H/o Pseudomonas ([**2149-7-31**]) from skin wounds
# Diabetes mellitus, type 2, since [**2133**]
# Hypercholesterolemia
# Hypertension
# Neuropathy
# B/l charcot s/p RLE recon ([**1-28**])
# H/o sepsis, in MICU [**4-/2147**]
# Rheumatic fever at age 7 or 8

MEDICATION ON ADMISSION: ASA 81 mg PO Daily
Vitamin C 500mg [**Hospital1 **]
Metoprolol (Dose Unknown)
Calcium Carbonate 500mg [**Hospital1 **]
Colace
Glipizide 5mg PO Daily
Lactulose 30mL q6hr PRN
Lorazepam 2mg qhs PRN
Magnesium Oxide 140mg [**Hospital1 **]
Glucophage 850mg QAM
Glucophage XR QHS
MVI
Quinine Sulfate 325mg QHS
Senna 2 Tabs PO Daily
Vitamin D 400mg PO Daily
Vitamin E
Zinc Sulfate
Motrin 800mg PO TID PRN
Allopurinol 100mg PO Daily
Fluvastatin 80mg PO QHS
Oxycodone (Dose Unknown)
Protonix
Nitro Glycerin SL

ALLERGIES: Gemfibrozil / Ranitidine / Aloe / Lipitor / Avandia

PHYSICAL EXAM: PHYSICAL EXAM ON ADMISSION:
Vitals: T: 98.6 BP: 102/43 HR: 96 RR: 16 96% 2L NC
GEN: Caucasian female, obese, NAD, Sitting upright speaking in
full sentences
HEENT: PERRL, EOMI, Sclera Anicteric, MMM, OP Clear
NECK: LIJ in place, Obese neck, unappreciable neck veins,
carotid pulses brisk,  no cervical lymphadenopathy, trachea
midline
COR: S1 S2, [**2-27**] ejection murmur radiating to axilla,  radial
pulses +2
PULM: Lungs CTAB,no wheezes or crackles
ABD: Soft, Obese, NT, ND, +BS, no HSM, no masses
EXT: Left plantar wound packed, approximately 0.5 cm vertical
incision. Draining both purulent, and serosangionous fluid. Left
medial plantar ulceration granulation tissue at the base without
drainage. No crepitus appreciated.
NEURO: AOx3. Moving all 4 extremities. Strength 5/5 in upper and
lower extremities.
SKIN: Without rashes.

FAMILY HISTORY: Family H/O CAD; no Family H/O DM or Charcot joints

SOCIAL HISTORY: Is divorced and lives by herself in [**Hospital1 1559**], MA. [**Name (NI) **]
mother lives nearby and helps out. Patient has one daughter who
also helps her. Denies smoking or drinking.
Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft,Methicillin resistant Staphylococcus aureus septicemia,Severe sepsis,Acute kidney failure, unspecified,Ulcer of other part of foot,Diabetes with neurological manifestations, type II or unspecified type, uncontrolled,Polyneuropathy in diabetes,Iron deficiency anemia, unspecified,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Unspecified essential hypertension,Pure hypercholesterolemia,Calculus of kidney
React-oth int ortho dev,MRSA septicemia,Severe sepsis,Acute kidney failure NOS,Ulcer other part of foot,DMII neuro uncntrld,Neuropathy in diabetes,Iron defic anemia NOS,Crnry athrscl natve vssl,Old myocardial infarct,Hypertension NOS,Pure hypercholesterolem,Calculus of kidney
Admission Date:  [**2150-1-21**]              Discharge Date:   [**2150-1-30**]

Date of Birth:  [**2087-5-24**]             Sex:   F

Service: MEDICINE

Allergies:
Gemfibrozil / Ranitidine / Aloe / Lipitor / Avandia

Attending:[**First Name3 (LF) 4365**]
Chief Complaint:
chest pain, shortness of breath, rigors

Major Surgical or Invasive Procedure:
Incision and Drainage of left foot ulcer
Central venous line placement
Left foot hardware removal and wash out
PICC line placement

History of Present Illness:
This is a 62 year old female with history of recent NSTEMI, type
II diabetes mellitus, s/p revision Charcot LLE([**9-29**]) prior
pseudomonas, and MRSA infections that presents with left lower
extremity plantar purulent ulceration, chest pain, and rigors.
The patient reported that she was recently discharged from rehab
on [**1-14**], and on [**1-19**] noticed a pin-sized hole with bloody
discharge at the site of her prior Charcot surgery. That night
the pt reported + nightsweats, frontal headaches, chills, and
shortness of breath.

In the ED, her initial vitals were 97.7 88/38 96 16 96%RA. The
patients blood pressure subsequently fell to 70/50, with a HR in
70s. The pt received 3L NS with BP improvement to 110/50 with
her heart rate in the 80s. A LIJ was placed and the pt was given
ASA, Vanc, Zosyn. Podiatry was called for incision and drainage
of noted left foot ulcer.

The patient denied any fevers, chills, nausea, vomiting,
abdominal pain, diarrhea, constipation, melena, hematochezia,
orthopnea, lower extremity, cough, urinary frequency, urgency,
dysuria, lightheadedness, focal weakness, vision changes, rash
or skin changes.

Past Medical History:
# Coronary artery disease status post myocardial infarction x 4
per patient with multiple PCIs in [**2131**], performed at [**Hospital3 15054**],
anatomy unknown)
# s/p Removal of external fixator left foot ([**2149-12-30**])
# s/p Bilateral Charcot reconstruction [**2149-10-14**]
# H/o MRSA ([**2149-10-14**]) from skin wounds
# H/o Pseudomonas ([**2149-7-31**]) from skin wounds
# Diabetes mellitus, type 2, since [**2133**]
# Hypercholesterolemia
# Hypertension
# Neuropathy
# B/l charcot s/p RLE recon ([**1-28**])
# H/o sepsis, in MICU [**4-/2147**]
# Rheumatic fever at age 7 or 8


Social History:
Is divorced and lives by herself in [**Hospital1 1559**], MA. [**Name (NI) **]
mother lives nearby and helps out. Patient has one daughter who
also helps her. Denies smoking or drinking.


Family History:
Family H/O CAD; no Family H/O DM or Charcot joints

Physical Exam:
PHYSICAL EXAM ON ADMISSION:
Vitals: T: 98.6 BP: 102/43 HR: 96 RR: 16 96% 2L NC
GEN: Caucasian female, obese, NAD, Sitting upright speaking in
full sentences
HEENT: PERRL, EOMI, Sclera Anicteric, MMM, OP Clear
NECK: LIJ in place, Obese neck, unappreciable neck veins,
carotid pulses brisk,  no cervical lymphadenopathy, trachea
midline
COR: S1 S2, [**2-27**] ejection murmur radiating to axilla,  radial
pulses +2
PULM: Lungs CTAB,no wheezes or crackles
ABD: Soft, Obese, NT, ND, +BS, no HSM, no masses
EXT: Left plantar wound packed, approximately 0.5 cm vertical
incision. Draining both purulent, and serosangionous fluid. Left
medial plantar ulceration granulation tissue at the base without
drainage. No crepitus appreciated.
NEURO: AOx3. Moving all 4 extremities. Strength 5/5 in upper and
lower extremities.
SKIN: Without rashes.

Pertinent Results:
LABS ON ADMISSION:

[**2150-1-21**] 03:00PM BLOOD WBC-12.3*# RBC-3.69* Hgb-10.0* Hct-30.3*
MCV-82 MCH-27.0 MCHC-32.9 RDW-16.7* Plt Ct-294
[**2150-1-21**] 03:00PM BLOOD Neuts-87.0* Lymphs-8.5* Monos-3.2 Eos-1.0
Baso-0.2
[**2150-1-21**] 03:00PM BLOOD Glucose-255* UreaN-18 Creat-1.2* Na-135
K-3.6 Cl-103 HCO3-18* AnGap-18
[**2150-1-21**] 08:46PM BLOOD Calcium-7.5* Phos-2.8# Mg-1.5*
[**2150-1-21**] 03:09PM BLOOD Glucose-136* Lactate-3.4* Na-136 K-3.6
Cl-102 calHCO3-18*

CARDIAC ENZYMES:
[**2150-1-21**] 03:00PM BLOOD cTropnT-0.02*
[**2150-1-22**] 06:13AM BLOOD CK-MB-2 cTropnT-0.01

INFLAMMATORY MARKERS:

[**2150-1-27**] 05:22AM BLOOD ESR-142*
[**2150-1-26**] 04:40AM BLOOD CRP-123.3*
[**2150-1-27**] 05:22AM BLOOD CRP-83.5*

LABS ON DISCHARGE:
[**2150-1-29**] 06:32AM
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
6.7 3.01* 8.3* 24.6* 82 27.5 33.6 16.8* 450*
[**2150-1-29**] 06:32AM
Glucose UreaN Creat Na K Cl HCO3 AnGap
218* 19 1.6* 139 4.5 105 25 14
Vanco
[**2150-1-29**] 06:32AM 22.3*

----------
MICROBIOLOGY:
[**2150-1-21**] 3:00 pm BLOOD CULTURE      #1.

                            **FINAL REPORT [**2150-1-24**]**

   Blood Culture, Routine (Final [**2150-1-24**]):
      STAPH AUREUS COAG +.    FINAL SENSITIVITIES.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations
Rifampin
         should not be used alone for therapy.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------   =>8 R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
PENICILLIN G---------- =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------     2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------   <=1 S
-------------------\\\\\\\\\\\\\\\\
[**2150-1-21**] 4:05 pm BLOOD CULTURE      #2.

                            **FINAL REPORT [**2150-1-24**]**

   Blood Culture, Routine (Final [**2150-1-24**]):
      STAPH AUREUS COAG +.
         SENSITIVITIES PERFORMED ON CULTURE # 264-7543R
[**2150-1-21**].

   Anaerobic Bottle Gram Stain (Final [**2150-1-22**]):
      GRAM POSITIVE COCCI IN CLUSTERS.

   Aerobic Bottle Gram Stain (Final [**2150-1-23**]):
      GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
--------------------
Blood Cultures Negative [**1-22**], [**1-23**], [**1-24**]
--------------------
[**2150-1-23**] 12:30 pm SWAB      LEFT FOOT.

                            **FINAL REPORT [**2150-1-27**]**

   GRAM STAIN (Final [**2150-1-23**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      NO MICROORGANISMS SEEN.
      SMEAR REVIEWED; RESULTS CONFIRMED.

   WOUND CULTURE (Final [**2150-1-27**]):
      Due to mixed bacterial types (>=3) an abbreviated workup
is
      performed; P.aeruginosa, S.aureus and beta strep. are
reported if
      present. Susceptibility will be performed on P.aeruginosa
and
      S.aureus if sparse growth or greater..
      STAPH AUREUS COAG +.    MODERATE GROWTH.
         SENSITIVITIES PERFORMED ON CULTURE # 264-7759R
([**2150-1-21**]).
      PSEUDOMONAS AERUGINOSA.    RARE GROWTH.

   ANAEROBIC CULTURE (Final [**2150-1-27**]):    NO ANAEROBES ISOLATED.


[**2150-1-26**] 3:54 pm CATHETER TIP-IV      Source: Left IJ.

                            **FINAL REPORT [**2150-1-29**]**

   WOUND CULTURE (Final [**2150-1-29**]):
      STAPHYLOCOCCUS, COAGULASE NEGATIVE.    >15 colonies.
         COAG NEG STAPH does NOT require contact precautions,
regardless of
         resistance Oxacillin RESISTANT Staphylococci MUST be
reported as
         also RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations
Rifampin
         should not be used alone for therapy.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPHYLOCOCCUS, COAGULASE NEGATIVE
                             |
CLINDAMYCIN-----------   =>8 R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------     8 I
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
PENICILLIN G---------- =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
VANCOMYCIN------------     2 S
ECG [**2150-1-21**]
Sinus rhythm. There are Q waves in the inferior leads consistent
with prior
inferior myocardial infarction. There are Q waves in the
anterior leads
consistent with prior myocardial infarction. Low voltage in the
precordial
leads. Compared to the previous tracing there is no significant
change.

ECHO [**2150-1-23**]
IMPRESSION: No obvious masses/vegetations seen suggestive of
endocarditis. Moderate aortic stenosis. Normal left ventricular
systolic function, EF >55%. The right ventricle appears mildly
depressed with depressed free wall contractility (the base
contracts normally).

TEE [**2150-1-28**]: Impression: No mass/thrombus seen in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
No valvular mass/vegetation seen. Mild (1+) aortic
regurgitation. Moderate (2+) mitral regurgitation. Overall LVEF
is normal.
--------------------
IMAGING STUDIES:

Left Foot XRay 3 Views:
IMPRESSION:
1. No definite new areas of cortical destruction to suggest
osteomyelitis.
2. Status post Charcot reconstruction without evidence of
hardware failure or change in alignment.
3. Diffuse soft tissue swelling about the foot and ankle. No
soft tissue gas identified.

MRI Right Calf [**2150-1-27**]
IMPRESSION:

1. No evidence for osteomyelitis.

2. Focal defect in cortex of anterior mid shaft tibia, likely
due to prior
instrumentation. Please correlate clinically.

3. Diffuse muscle atrophy, greatest in tibialis anterior.

4. Achilles tendon thickening.


Brief Hospital Course:
This is a 62 year-old female with a history of type II diabetes
mellitus, bilateral charcot joints with recent LLE
reconstruction who presents with a draining ulcer on her left
foot and hypotension who was found to have MRSA bacteremia and
and required LLE hardware removal.

# Sepsis/Hypotension:  The patient presented with tachycardia,
leukocytosis and hypotension. She was found to be bacteremic and
suspected source was a left foot ulcer at her previous surgical
site that was incised and debrided of purulent material upon
admission by podiatry. She was initially admitted to the MICU
where she received IVF and required pressors for only a few
hours. She was started on Vancomycin and Zosyn for empiric
coverage. Her vital signs stabilized with these interventions.
She went to the OR for LLE harware removal where she had a screw
removed and washout. Following this procedure patient's vital
signs remained stable and she was transferred to the floor.

#MRSA Bacteremia/Osteomyelitis (MRSA + Pseudomonas): MRSA
bacteremia likely secondary to chronic ulcerations of the left
plantar foot. Blood cultures from [**1-21**] grew MRSA. Wound culture
from left lower extremity (intraoperative) also positive for
MRSA and Pseudomonas. Patient had both a TTE and TEE to rule out
endocarditis.  Patient followed by infectious disease service
during this hospitalization. As noted above, patient was
initially started on a course of Vancomycin, Zosyn and Cipro.
Zosyn stopped after 5 days and patient continued on
Vancomycin/Cipro.  Cipro was stopped after 8 days and switched
to meropenem giving finding on R calf MRI that showed tendon
thickening. Surveillance cultures from [**1-22**], [**1-23**], and [**1-24**] all
negative. Patient's CRP trending down. On discharge, she
remained afebrile, stable hemodynamics, left foot with two clean
surgical sites without erythema. Patient will require a 6 week
course of antibiotics (starting [**2150-1-23**]) given osteomyelitis and
high grade bacteremia. She will be discharged on vancomycin 1
gram Q24hrs for MRSA and meropenem 1 gram Q12 hours (may need to
be adjusted as renal function improves) for pseudomonas. The
last dose both BOTH medications is [**2150-3-5**]. Patient should have
the following laboratory monitoring: CBC/diff, chem 7, LFTs,
ESR/CRP, vancomycin trough weekly. Creatinine and vancomycin
trough should be checked within a couple days of discharge. All
laboratory results should be faxed to Infectious disease RNs at
([**Telephone/Fax (1) 432**]. All questions regarding outpatient antibiotics
should be directed to the infectious disease RNs at
Patient has a follow up appointment in infectious disease clinic
on [**2150-2-20**] with Dr. [**Last Name (STitle) 111**].

# Left Lower Extremity Hardware Removal: Patient taken to OR by
podiatry on [**2150-1-23**]. The lateral screw was removed and the site
was debrided and irrigated. The wounds were initially left open
and packed. These wounds were closed at the bedside on [**2150-1-27**].
Patient's has not complained of significant pain post-op.
Patient will require daily dressing changes to LLE. Patient is
to avoid weight bearing on the LLE for at least 3 weeks. She
should follow up with Dr.[**Last Name (STitle) **] in podiatry clinic on [**2150-2-5**].

# Right Lower Extremity Shin Ulcer: Pt noted to have ulcer where
external fixator had been in place. An MRI of this area did not
indicate evidence of osteomyelitis.

# Type II Diabetes Mellitus: Prior to hospitalization patient on
regimen consisting of metformin and glyburide, though for the
past few months was only taking glyburide. Her most recent
Hgba1C of 7.9 in [**2149-9-22**]. Glipizide held while an
inpatient. Patient started on Lantus in addition to an insulin
sliding scale given to finger stick blood sugars in the
200's-400's. Given difficulty controlling blood sugars in spite
of titrating up lantus Josline endocrinology service consulted.
At time of discharge patient on Lantus 30 units qHs and the
humalog sliding scale attached to this discharge summary. It is
likely that the patient's lantus will continue to be titrated to
achieve adequate glycemic control. She is scheduled to follow up
at [**Hospital **] Clinic with Dr. [**First Name (STitle) 7582**] on [**2150-4-8**].

# Acute Renal Failure: Following surgery patient's creatine
increased to as high as 2.2 likely secondary to transient
hypotension with operative anesthesia. Creatinine continues to
improve and is 1.6 at time of discharge. As noted above, her
creatinine should be rechecked within a few days of discharge
and weekly thereafter.

# Coronary Artery Disease: Stable during this admission. Given
patient presented with chest pain she was ruled out for ACS with
two sets of negative cardiac enzymes. ECG unchanged. She was
continued on aspirin, statin, plavix. Her metoprolol was held on
admission due to hypotension and restarted at time of discharge
(this medication had been started on a previous admission-she
was previously on atenolol).

# Nephrolithiasis: Stable during this admission. Patient was on
a dose of Allopurinol 350 mg daily which was decreased to 150 mg
daily. Can titrate backup to 350 mg daily and renal function
improves.

Patient was a FULL code during this admission.


Medications on Admission:
ASA 81 mg PO Daily
Vitamin C 500mg [**Hospital1 **]
Metoprolol (Dose Unknown)
Calcium Carbonate 500mg [**Hospital1 **]
Colace
Glipizide 5mg PO Daily
Lactulose 30mL q6hr PRN
Lorazepam 2mg qhs PRN
Magnesium Oxide 140mg [**Hospital1 **]
Glucophage 850mg QAM
Glucophage XR QHS
MVI
Quinine Sulfate 325mg QHS
Senna 2 Tabs PO Daily
Vitamin D 400mg PO Daily
Vitamin E
Zinc Sulfate
Motrin 800mg PO TID PRN
Allopurinol 100mg PO Daily
Fluvastatin 80mg PO QHS
Oxycodone (Dose Unknown)
Protonix
Nitro Glycerin SL


Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
10. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection Q8H (every 8 hours).
13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
14. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
16. Sodium Chloride 0.9%  Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
17. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
18. Lantus 100 unit/mL Solution Sig: Thirty (30)  Subcutaneous
at bedtime.
19. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous per sliding scale attached.
20. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO
twice a day.
21. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
22. Magnesium Oxide 140 mg Capsule Sig: Two (2) Capsule PO twice
a day.
23. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual as needed as needed for chest pain.
24. Meropenem 1 gram Recon Soln Sig: 1g  Intravenous every eight
(8) hours: last dose on [**2150-3-5**].
25. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).

26. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
27. Vancomycin 1,000 mg Recon Soln Sig: One (1)  Intravenous
every twenty-four(24) hours: last dose on [**2150-3-5**].


Discharge Disposition:
Extended Care

Facility:
holy trinity

Discharge Diagnosis:
Primary: Methicillin Resistant Staphylococcus aureus bacteremia,
Osteomyelitis, Acute renal failure, status post hardware removal
in left lower extremity
Secondary: Type II Diabetes Mellitus, Coronary Artery Disease


Discharge Condition:
stable


Discharge Instructions:
You were admitted to the hospital because you were found to have
a low blood pressure in the emergency department. You were
admitted to the ICU where you received intravenous fluids,
medications to support your blood pressure and intravenous
antibiotics. You were determined to have a bacterial infection
in your blood stream which was likely caused by an infection
that started in your left foot. You went to the operating room
and had hardware removed from your left lower extremity.
Intra-operative cultures confirmed that your have a bacterial
infection in your left foot. Your vital signs stabilized
following surgery and continuation of antibiotics and you were
able to be transferred to a medical floor. You will need to
complete a total of 6 week course of antibiotics for this
infection. You have follow up scheduled with an infectious
disease doctor as listed below.

In regards to your left foot, you cannot weight bear for a
minimum of 3 weeks. You have an appointment to follow up with
your podiatrist, Dr. [**Last Name (STitle) **] 1 week after discharge.

During your hospitalization your blood sugars were found to be
very high. You were seen by the endocrinology service from
[**Last Name (un) **] and you were started on a new regimen with both long and
short acting insulin. It is very important to control your blood
sugars. You have an appoinment to follow up at the [**Hospital **] Clinic
in [**Location (un) 86**].

You have been started on the following NEW medications:
-Lantus: this is a long acting insulin that you should take
before bedtime
-Humalog sliding scale: this is short acting insulin. You will
need to check your blood sugar before meals and give yourself
insulin injections based on the sliding scale (you have been on
a sliding scale in the past)
-Meropenem: this is an antibiotic for your bone infection
-Vancomycin: this is an antibiotic for your blood infection
-Oxycodone: this is a pain medication. you should not drive or
operate heavy machinery while taking this medication.

The following CHANGES were made to your antibiotic regimen:
-Allopurinol was decreased from 350 mg daily to 150 mg daily
given your current kidney function. Your doctor will let you
know when it is safe to increase the dose.

If you experience fevers, chills, chest pain, shortness of
breath, drainage from your surgical site or worsening pain in
your left lower leg please contact your primary care physician
or go to the emergency department for evaluation.

Followup Instructions:
Provider: [**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) 15351**], DPM (podiatrist) Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2150-2-5**] 4:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (infectious disease)
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2150-2-20**] 11:00

You are also scheduled to see Dr. [**First Name (STitle) **] (endocrinologist) at
[**Last Name (un) **] Diabetes Center on [**2150-4-8**] at 12:00. You can try and call
the office to see if there are cancellation so that you could be
seen sooner. The office number is [**Telephone/Fax (1) 2384**]

You should follow up with your primary care physician [**Name Initial (PRE) 176**] [**1-23**]
weeks following discharge from rehab.



Completed by:[**2150-1-30**]
{'Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft,Methicillin resistant Staphylococcus aureus septicemia,Severe sepsis,Acute kidney failure, unspecified,Ulcer of other part of foot,Diabetes with neurological manifestations, type II or unspecified type, uncontrolled,Polyneuropathy in diabetes,Iron deficiency anemia, unspecified,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Unspecified essential hypertension,Pure hypercholesterolemia,Calculus of kidney'}


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: chest pain, shortness of breath, rigors

PRESENT ILLNESS: This is a 62 year old female with history of recent NSTEMI, type
II diabetes mellitus, s/p revision Charcot LLE([**9-29**]) prior
pseudomonas, and MRSA infections that presents with left lower
extremity plantar purulent ulceration, chest pain, and rigors.
The patient reported that she was recently discharged from rehab
on [**1-14**], and on [**1-19**] noticed a pin-sized hole with bloody
discharge at the site of her prior Charcot surgery. That night
the pt reported + nightsweats, frontal headaches, chills, and
shortness of breath.

MEDICAL HISTORY: # Coronary artery disease status post myocardial infarction x 4
per patient with multiple PCIs in [**2131**], performed at [**Hospital3 15054**],
anatomy unknown)
# s/p Removal of external fixator left foot ([**2149-12-30**])
# s/p Bilateral Charcot reconstruction [**2149-10-14**]
# H/o MRSA ([**2149-10-14**]) from skin wounds
# H/o Pseudomonas ([**2149-7-31**]) from skin wounds
# Diabetes mellitus, type 2, since [**2133**]
# Hypercholesterolemia
# Hypertension
# Neuropathy
# B/l charcot s/p RLE recon ([**1-28**])
# H/o sepsis, in MICU [**4-/2147**]
# Rheumatic fever at age 7 or 8

MEDICATION ON ADMISSION: ASA 81 mg PO Daily
Vitamin C 500mg [**Hospital1 **]
Metoprolol (Dose Unknown)
Calcium Carbonate 500mg [**Hospital1 **]
Colace
Glipizide 5mg PO Daily
Lactulose 30mL q6hr PRN
Lorazepam 2mg qhs PRN
Magnesium Oxide 140mg [**Hospital1 **]
Glucophage 850mg QAM
Glucophage XR QHS
MVI
Quinine Sulfate 325mg QHS
Senna 2 Tabs PO Daily
Vitamin D 400mg PO Daily
Vitamin E
Zinc Sulfate
Motrin 800mg PO TID PRN
Allopurinol 100mg PO Daily
Fluvastatin 80mg PO QHS
Oxycodone (Dose Unknown)
Protonix
Nitro Glycerin SL

ALLERGIES: Gemfibrozil / Ranitidine / Aloe / Lipitor / Avandia

PHYSICAL EXAM: PHYSICAL EXAM ON ADMISSION:
Vitals: T: 98.6 BP: 102/43 HR: 96 RR: 16 96% 2L NC
GEN: Caucasian female, obese, NAD, Sitting upright speaking in
full sentences
HEENT: PERRL, EOMI, Sclera Anicteric, MMM, OP Clear
NECK: LIJ in place, Obese neck, unappreciable neck veins,
carotid pulses brisk,  no cervical lymphadenopathy, trachea
midline
COR: S1 S2, [**2-27**] ejection murmur radiating to axilla,  radial
pulses +2
PULM: Lungs CTAB,no wheezes or crackles
ABD: Soft, Obese, NT, ND, +BS, no HSM, no masses
EXT: Left plantar wound packed, approximately 0.5 cm vertical
incision. Draining both purulent, and serosangionous fluid. Left
medial plantar ulceration granulation tissue at the base without
drainage. No crepitus appreciated.
NEURO: AOx3. Moving all 4 extremities. Strength 5/5 in upper and
lower extremities.
SKIN: Without rashes.

FAMILY HISTORY: Family H/O CAD; no Family H/O DM or Charcot joints

SOCIAL HISTORY: Is divorced and lives by herself in [**Hospital1 1559**], MA. [**Name (NI) **]
mother lives nearby and helps out. Patient has one daughter who
also helps her. Denies smoking or drinking. 

### Response:
{'Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft,Methicillin resistant Staphylococcus aureus septicemia,Severe sepsis,Acute kidney failure, unspecified,Ulcer of other part of foot,Diabetes with neurological manifestations, type II or unspecified type, uncontrolled,Polyneuropathy in diabetes,Iron deficiency anemia, unspecified,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Unspecified essential hypertension,Pure hypercholesterolemia,Calculus of kidney'}
