CHIEF COMPLAINT: Right septic ankle

PRESENT ILLNESS: 58 yo male with hx of ESRD on HD, s/p L BKA and type II DM with
frequent right foot infections who was noted to be somnolent at
Rehab and finger stick was noted to be 20.  Pt got D5H2O with
resolution of MS, and pt was brought to [**Hospital1 18**] where he was noted
to be hypotensive into the 80's.  Pt was clinically hypovolemic
and pt was given 4 L NS in ER with persistent hypotension and pt
was started on 5 mcg of levophed.  Sepsis protocol was initiated
and pt received vanc, levo, and flagyl without a clear
infectious sourse.

MEDICAL HISTORY: ESRD on HD
Hx of thrombosed RUQ AV fistula s/p thrombectomy [**12-28**]
s/p left IJ permacath placement
Type II DM
Hep B
HTN
Ischemic colitis w/ GI bleed
TB
s/p L BKA
Multiple right foot infections-last admission with right fool
amputation recommended.  infected with staph bacteremia.  tx
with vanc + ceftaz.
Hx of substance abuse
CHF EF 55% Diastolic dysfunction
VRE, MRSA
Hx of chronic pain
Right shoulder pain
Anemia of chronic disease
Constipation

MEDICATION ON ADMISSION: Norvasc 10 mg po qd
MVI
Folate 1 mg
Renagel 800 mg po tid
NPH 40 unit pm 60 unit am
RISS
Epogen 30,000 units 3x/week
Vicodin PRN
ASA 81 mg qd
Coumadin 1 mg po qd
Protonix 40 mg po qd
Neurontin 100 mg po bid
Methadone 100 mg po qd

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On admission
VS: T 101 BP 97/40 HR 105 RR 14 O2sat 95% RA
GEN: A+O x3,
HEENT: nc/at, PERRL, EOMI, mucous membranes, no JVD
Cor: tachycardia, regular rhythm, nl S1, S2, no
murmurs/rubs/gallops
Lungs: bilateral crackles
Abdomen: +BS, soft, NTND, no rebound
Ext: s/p L BKA, right ankle with erythema, warmth, and effusion
on lateral maleoulus.  Chronic anatomical joint changes.  Right
arm with fistula, no drainage.
Neuro: alert and oriented x3, CN II-XII intact.  Strengths
grossly intact.  Sensation intact at lower extremity to light
touch and pain.

FAMILY HISTORY: unknown

SOCIAL HISTORY: unknown
Unspecified septicemia,Cellulitis and abscess of leg, except foot,Atherosclerosis of native arteries of the extremities with gangrene,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic hepatitis C without mention of hepatic coma,Pyogenic arthritis, ankle and foot,Sepsis,Chronic osteomyelitis, ankle and foot,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled
Septicemia NOS,Cellulitis of leg,Ath ext ntv art gngrene,Hyp kid NOS w cr kid V,Chrnc hpt C wo hpat coma,Pyogen arthritis-ankle,Sepsis,Chr osteomyelit-ankle,DMII renl nt st uncntrld
Admission Date:  [**2184-8-10**]              Discharge Date:   [**2184-9-2**]

Date of Birth:  [**2125-5-16**]             Sex:   M

Service: VSURG

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Right septic ankle

Major Surgical or Invasive Procedure:
I+D of R ankle
right below knee amputation [**2184-8-25**]
Permcath replacement [**2184-9-1**]


History of Present Illness:
58 yo male with hx of ESRD on HD, s/p L BKA and type II DM with
frequent right foot infections who was noted to be somnolent at
Rehab and finger stick was noted to be 20.  Pt got D5H2O with
resolution of MS, and pt was brought to [**Hospital1 18**] where he was noted
to be hypotensive into the 80's.  Pt was clinically hypovolemic
and pt was given 4 L NS in ER with persistent hypotension and pt
was started on 5 mcg of levophed.  Sepsis protocol was initiated
and pt received vanc, levo, and flagyl without a clear
infectious sourse.

Upon questioning, pt denies fevers, though noted upon exam to be
febrile at 102, no cough, no flank pain, no dysruria,
nodiarrhea, no pururlent discharge from the right foot.  Pt has
a history of sepsis from his right foot MRSA and pseudomonas on
[**2184-6-24**].  At that time, podiatry recommended R BKA secondary to
very poor perfusion, but pt refused AMA given that he already
has L AKA.  Prior to admisiion, pt denied right foot pain,
erythema, or discomofrt when walking, good range of motion.  In
ER, MICU team noted right large effusion at the medial and
lateral malleolus with warmth.  10 cc of gross pus was drained
and sent for a culture.  Patient was then trasnfered to MICU for
sepsis treatment.

Past Medical History:
ESRD on HD
Hx of thrombosed RUQ AV fistula s/p thrombectomy [**12-28**]
s/p left IJ permacath placement
Type II DM
Hep B
HTN
Ischemic colitis w/ GI bleed
TB
s/p L BKA
Multiple right foot infections-last admission with right fool
amputation recommended.  infected with staph bacteremia.  tx
with vanc + ceftaz.
Hx of substance abuse
CHF EF 55% Diastolic dysfunction
VRE, MRSA
Hx of chronic pain
Right shoulder pain
Anemia of chronic disease
Constipation

Social History:
unknown

Family History:
unknown

Physical Exam:
On admission
VS: T 101 BP 97/40 HR 105 RR 14 O2sat 95% RA
GEN: A+O x3,
HEENT: nc/at, PERRL, EOMI, mucous membranes, no JVD
Cor: tachycardia, regular rhythm, nl S1, S2, no
murmurs/rubs/gallops
Lungs: bilateral crackles
Abdomen: +BS, soft, NTND, no rebound
Ext: s/p L BKA, right ankle with erythema, warmth, and effusion
on lateral maleoulus.  Chronic anatomical joint changes.  Right
arm with fistula, no drainage.
Neuro: alert and oriented x3, CN II-XII intact.  Strengths
grossly intact.  Sensation intact at lower extremity to light
touch and pain.

Pertinent Results:
[**2184-8-10**] 05:26PM   HCT-25.7*
[**2184-8-10**] 03:00PM JOINT FLUID  WBC-[**Numeric Identifier 101058**]* RBC-[**Numeric Identifier 16351**]* POLYS-98*
LYMPHS-1 MONOS-1
[**2184-8-10**] 02:53PM   K+-4.5
[**2184-8-10**] 02:12PM   TYPE-[**Last Name (un) **]
[**2184-8-10**] 02:00PM   CRP-17.86*
[**2184-8-10**] 12:30PM   ALT(SGPT)-35 AST(SGOT)-148* ALK PHOS-200*
AMYLASE-194* TOT BILI-1.0
[**2184-8-10**] 12:30PM   CALCIUM-8.8 PHOSPHATE-4.7*# MAGNESIUM-2.2
[**2184-8-10**] 12:30PM   CRP-18.86*
[**2184-8-10**] 12:30PM   WBC-8.7 RBC-3.70* HGB-10.1* HCT-32.4* MCV-88
MCH-27.3 MCHC-31.1 RDW-17.8*
[**2184-8-10**] 12:30PM   PLT SMR-NORMAL PLT COUNT-263
[**2184-8-9**] 06:30AM   PT-23.9* INR(PT)-3.6

Brief Hospital Course:
1)Foot infection: Patient was initially brought to ER with
increased somulence, decreased finger stick of 20, fever 102,
SBP in 80's and was noted to have large effusion at the right
medial/lateral malleolus with warmth.  Initially 10 cc of pus
was drained and was empirically started on vancomycin,
levofloxacin, and flagyl.  He was sent to MICU and was on
pressors transiently.  Right ankle pus showed 119,500 WBC with
98% PMNs, and pt was seen by podiatry on admission.
Recommendation of BKA was made since this infection could be
life threatening.  Patient adamantly refused for BKA, and thus
patient was taken to the OR by the podiatry on [**8-11**] for incision
and drainage.  Antibiotic was changed to vancomycin, zosyn, and
gentamycin.  The foot aspirate from the ED showed MRSA and
Proteus mirabilis.  The blood culture also grew MRSA, proteus
mirabilis, and enterococcus faecalis.  The swab/tissue culture
from [**8-11**] I+D also showing same microorganisms.  Patient's Hct
has dropped several times requiring transfusion with the source
of bleed being post-I&D foot wound.  The wound has been treated
temporarily with antibiotics and dressing change with 1/4
strength betadine.  Infectious disease was consulted and
recommended 14 day course of Vancomycin (dosed by level) and
Zosyn, and then additional 10 day course of vanc/zosyn after the
BKA if he were to have one.  Patient was initially hesitant to
undergo BKA but finally agreed to do so.

2)ESRD: Patient has ESRD and requiring frequent HD.  Patient's
phosphate level was elevated, so Renagel was increased to 2 gm
tid.  Patient showed signs of mild fluid overload (bibasilar
crackles) but was dialyzed frequently before developing SOB.

3)DM: Patient's glucose level has been during the hospital
course.  AM NPH insulin dose was changed from 60 units to 72
units.

4)CAD: Patient was started on metoprolol 50 mg [**Hospital1 **] to maintain
his BP below 140.  Patient's aspirin dose was halved before the
surgery.
[**8-25**] s/p right below knee amputation. Transfered to VAscular
service postoperatively.
Transfused 1 unit PRBC"S for Hct. 27 post transfusion HCt
30.3-28.3 hyperkalemia treated with insluin glucose IV.Transfer
from PACU to VICU.
[**8-26**] requird additional hemodialysis for persistant hyperkalemia
of 6.7. No ekg changes.Transfered to floor.
[**2184-8-27**] pain thearphy consulted Diludid PCA dosing increased and
neurotin dsing with improved pain control.
[**2184-8-28**] Pain regiment continued with satisfactory pain control.
[**2184-8-29**] transfused 1.5 units PRBC for HCt of 24.post transfusion
HCT. 27.4
[**2184-8-30**] transfused 2 uniits PRBC's antibiotic discontinued.
Continued on PCA.d/c femoral line.Temperature max 101.3 to99.6
WBC 8.1 diff pending blood and ulrine cultures pending. Chest
xray pending.postransfusin HCt. 32.2
[**2184-8-31**] OD with edema and lid crusting and mild scleral
ejection.Eye care started.
selvimer dose increased from 800mgm tid to 1600 tid .Will need
percath placed prior to discharged.
[**2184-8-31**] PICC line placement in interventional radology
[**2184-9-1**] discharge


Medications on Admission:
Norvasc 10 mg po qd
MVI
Folate 1 mg
Renagel 800 mg po tid
NPH 40 unit pm 60 unit am
RISS
Epogen 30,000 units 3x/week
Vicodin PRN
ASA 81 mg qd
Coumadin 1 mg po qd
Protonix 40 mg po qd
Neurontin 100 mg po bid
Methadone 100 mg po qd

Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
2. Multivitamin     Capsule Sig: One (1) Cap PO QD (once a day).

3. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).

5. Methadone HCl 40 mg Tablet, Soluble Sig: 2.5 Tablet, Solubles
PO QD (once a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for breakthrough pain only.

9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
10. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QAM AND
QNOON ().
11. Epoetin Alfa 10,000 unit/mL Solution Sig: as directed
Injection ASDIR (AS DIRECTED).
12. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: as
directed  Subcutaneous twice a day: Breakfast 60u
Dinner    40u.
13. Insulin Regular Human 100 unit/mL Solution Sig: as directed
Injection every six (6) hours: regular insulin sliding scale:
 glucoses <150/ no insulin
glucose 151-200/2u
glucoses 201-250/4u
glucoses 251-300/6u
glucoses>300 [**Name8 (MD) 138**] Md. .


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Location (un) 86**]

Discharge Diagnosis:
sepsis
right ankle infection
End stage renal disease on hemodialysis
diabetes mellitus type 2
secondary diagnosis:
thrombosed A_V fistula s/p thrombectomy [**12-28**]
Hepatitis B
hypertension
Ischemic colitis with GI bleed
history TB
history of substance abuse
history of chronic pain
history of  congestive heart failure. EF 55% with diastolic
dysfunction
history of VRE
history of MRSA
history of lanemia of chronic disease


Discharge Condition:
stable

Followup Instructions:
Dr. [**Last Name (STitle) **] 2-3 weeks. call for appointment. [**Telephone/Fax (1) 1241**]



Completed by:[**2184-11-16**]
{'Unspecified septicemia,Cellulitis and abscess of leg, except foot,Atherosclerosis of native arteries of the extremities with gangrene,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic hepatitis C without mention of hepatic coma,Pyogenic arthritis, ankle and foot,Sepsis,Chronic osteomyelitis, ankle and foot,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled'}


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: Right septic ankle

PRESENT ILLNESS: 58 yo male with hx of ESRD on HD, s/p L BKA and type II DM with
frequent right foot infections who was noted to be somnolent at
Rehab and finger stick was noted to be 20.  Pt got D5H2O with
resolution of MS, and pt was brought to [**Hospital1 18**] where he was noted
to be hypotensive into the 80's.  Pt was clinically hypovolemic
and pt was given 4 L NS in ER with persistent hypotension and pt
was started on 5 mcg of levophed.  Sepsis protocol was initiated
and pt received vanc, levo, and flagyl without a clear
infectious sourse.

MEDICAL HISTORY: ESRD on HD
Hx of thrombosed RUQ AV fistula s/p thrombectomy [**12-28**]
s/p left IJ permacath placement
Type II DM
Hep B
HTN
Ischemic colitis w/ GI bleed
TB
s/p L BKA
Multiple right foot infections-last admission with right fool
amputation recommended.  infected with staph bacteremia.  tx
with vanc + ceftaz.
Hx of substance abuse
CHF EF 55% Diastolic dysfunction
VRE, MRSA
Hx of chronic pain
Right shoulder pain
Anemia of chronic disease
Constipation

MEDICATION ON ADMISSION: Norvasc 10 mg po qd
MVI
Folate 1 mg
Renagel 800 mg po tid
NPH 40 unit pm 60 unit am
RISS
Epogen 30,000 units 3x/week
Vicodin PRN
ASA 81 mg qd
Coumadin 1 mg po qd
Protonix 40 mg po qd
Neurontin 100 mg po bid
Methadone 100 mg po qd

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On admission
VS: T 101 BP 97/40 HR 105 RR 14 O2sat 95% RA
GEN: A+O x3,
HEENT: nc/at, PERRL, EOMI, mucous membranes, no JVD
Cor: tachycardia, regular rhythm, nl S1, S2, no
murmurs/rubs/gallops
Lungs: bilateral crackles
Abdomen: +BS, soft, NTND, no rebound
Ext: s/p L BKA, right ankle with erythema, warmth, and effusion
on lateral maleoulus.  Chronic anatomical joint changes.  Right
arm with fistula, no drainage.
Neuro: alert and oriented x3, CN II-XII intact.  Strengths
grossly intact.  Sensation intact at lower extremity to light
touch and pain.

FAMILY HISTORY: unknown

SOCIAL HISTORY: unknown 

### Response:
{'Unspecified septicemia,Cellulitis and abscess of leg, except foot,Atherosclerosis of native arteries of the extremities with gangrene,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic hepatitis C without mention of hepatic coma,Pyogenic arthritis, ankle and foot,Sepsis,Chronic osteomyelitis, ankle and foot,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled'}
