CHIEF COMPLAINT: Back Pain

PRESENT ILLNESS: Pt is 67 y/o woman with PMH of CAD, last echo [**2172-12-22**] showing EF
60% with 13mm aortic valve with h/o aortic stenosis, HTN, Type
II DM complicated by diabetic neuropathy, retinopathy, h/o ESRD
on HD (three times per week, last dialyzed on [**2172-11-29**]), h/o L
fem-[**Doctor Last Name **] bypass s/p L BKA for severe PVD, h/o right heel foot
ulcer, h/o indwelling dialysis cathether growing MRSA recently
and subsequent left IJ placed for HD, h/o multiple line
infections and infections of dialysis catheter sites with MRSA,
who presented to [**Hospital3 **] on [**2172-12-12**] with CC of [**10-26**],
sharp, low back pain and fever.  Blood cultures drawn
demonstrated gram positive cocci in pairs and clusters.  A TEE
was attempted but she desatted and was felt to be 'unstable.'  A
TTE was inconclusive, but given her harsh systolic murmur and
blood cultures, was presumed to have endocarditis.  She was
started on Zithromax, and CTX originally on admission, and after
blood cultures came back positive on [**2172-12-20**], she was started on
IV vancomycin w/ d/c of zithromax.  It appears she was in the
ICU during her stay at [**Hospital1 46**] X 1 week then transferred to
medical floor.  Her back pain continued to worsen despite abx.
MRI of the spine revealed L3-L4 discitis, osteomyelitis with
epidural abscess and cauda equina compression with probable
multiple lumbar radiculopathy.  She was seen by NSGY who felt
her unstable to have the procedure done at [**Hospital3 3583**],
given her PMH.  Vascular surgery accepted her here at [**Hospital1 18**] for
transfer.  She was admitted yesterday to vascular service, made
NPO, IVF, Vanco X1, levoflox and metonidazole started, and spine
consulted with Dr. [**Last Name (STitle) 363**] attending.  Renal was also consulted,
and she was dialyzed on [**2172-12-29**].

MEDICAL HISTORY: 1. DM II w/retinopathy, neuropathy
2. HTN
3. AS (1.3 cm2)
4. h/o CAD with h/o "stents" though additional info in records,
EF 60%
5. PVD s/p L fem [**Doctor Last Name **] bypass and L BKA
6. ESRD on HD (Tue, Thurs, Sat) last HD today [**2173-1-8**]
7. h/o multiple line infections and infections of dialysis
catheter sites with MRSA
8. Hypercholesterolemia
9. Hyperthyroidism
10. Glaucoma

MEDICATION ON ADMISSION: 1. Rescula 1 drop each eye [**Hospital1 **]
2. Cosopt 1 drop each eye [**Hospital1 **]
3. Atenolol 25mg po qd
4. Cozaar 100mg po qd
5. Nifedipine 90mg po qd
6. Catapres
7. Renagel 800mg po with meals tid
8. Reglan 10mg po with meals tid
9. Lipitor 4mg po qd?
10. Nephrocaps

ALLERGIES: Tape

PHYSICAL EXAM: VS: Tmax 102 T BP 159/60 HR 90 R 19 O2 sat 100% 4L
GEN: Drowsy, shivering, diaphoretic, responds to questions, eyes
closed.
HEENT: PERRL. +catarats b/l, anicteric, moist/diaphoretic.
Neck: supple, unable to assess JVP
Chest: diffuse rhonchi, poor inspiratory effort
CVS: nl S1 S2, [**3-22**] harsh ESM radiates throughout, regular
rhythm.
Abd: obese, soft NT/ND, active BS
Ext: no edema, s/p L BKA. R foot warm, +heal ulcer with purulent
drainage
Neuro: drowsy but arousable, oriented to person/place, non focal

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Married, lives with husband. Non [**Name2 (NI) 1818**], no alcohol. No IVDA.
Methicillin susceptible Staphylococcus aureus septicemia,Acute osteomyelitis, other specified sites,Intraspinal abscess,Psoas muscle abscess,Ulcer of heel and midfoot,Cerebral embolism with cerebral infarction,End stage renal disease,Atrial fibrillation,Cellulitis and abscess of foot, except toes,Disseminated candidiasis,Congestive heart failure, unspecified,Pneumonia, organism unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Acute and subacute bacterial endocarditis,Hyperosmolality and/or hypernatremia,Severe sepsis,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Postmenopausal bleeding,Intervertebral disc disorder with myelopathy, lumbar region,Unspecified inflammatory spondylopathy,Cauda equina syndrome without mention of neurogenic bladder,Diarrhea,Below knee amputation status,Infection with microorganisms resistant to penicillins,Polyneuropathy in diabetes,Delirium due to conditions classified elsewhere
Meth susc Staph aur sept,Ac osteomyelitis NEC,Intraspinal abscess,Psoas muscle abscess,Ulcer of heel & midfoot,Crbl emblsm w infrct,End stage renal disease,Atrial fibrillation,Cellulitis of foot,Disseminated candidiasis,CHF NOS,Pneumonia, organism NOS,Hyp kid NOS w cr kid V,Ac/subac bact endocard,Hyperosmolality,Severe sepsis,DMII neuro nt st uncntrl,Postmenopausal bleeding,Lumb disc dis w myelopat,Inflam spondylopathy NOS,Cauda equina synd NOS,Diarrhea,Status amput below knee,Inf mcrg rstn pncllins,Neuropathy in diabetes,Delirium d/t other cond
Admission Date:  [**2172-12-29**]              Discharge Date:   [**2173-2-9**]

Date of Birth:  [**2105-1-30**]             Sex:   F

Service: MEDICINE

Allergies:
Tape

Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
Back Pain

Major Surgical or Invasive Procedure:
1. Temporary hemodyalysis line placement
2. Permanent hemodyalysis line placement
3. Endometrial Biopsy
4. Psoas abscess drainage
5. Epidural abscess resection and laminectomy
6. Central line placement
7. PICC lines placement

Patient still has Hemodyalysis line in place, not removed due to
comfort, if wanted can be removed.


History of Present Illness:
Pt is 67 y/o woman with PMH of CAD, last echo [**2172-12-22**] showing EF
60% with 13mm aortic valve with h/o aortic stenosis, HTN, Type
II DM complicated by diabetic neuropathy, retinopathy, h/o ESRD
on HD (three times per week, last dialyzed on [**2172-11-29**]), h/o L
fem-[**Doctor Last Name **] bypass s/p L BKA for severe PVD, h/o right heel foot
ulcer, h/o indwelling dialysis cathether growing MRSA recently
and subsequent left IJ placed for HD, h/o multiple line
infections and infections of dialysis catheter sites with MRSA,
who presented to [**Hospital3 **] on [**2172-12-12**] with CC of [**10-26**],
sharp, low back pain and fever.  Blood cultures drawn
demonstrated gram positive cocci in pairs and clusters.  A TEE
was attempted but she desatted and was felt to be 'unstable.'  A
TTE was inconclusive, but given her harsh systolic murmur and
blood cultures, was presumed to have endocarditis.  She was
started on Zithromax, and CTX originally on admission, and after
blood cultures came back positive on [**2172-12-20**], she was started on
IV vancomycin w/ d/c of zithromax.  It appears she was in the
ICU during her stay at [**Hospital1 46**] X 1 week then transferred to
medical floor.  Her back pain continued to worsen despite abx.
MRI of the spine revealed L3-L4 discitis, osteomyelitis with
epidural abscess and cauda equina compression with probable
multiple lumbar radiculopathy.  She was seen by NSGY who felt
her unstable to have the procedure done at [**Hospital3 3583**],
given her PMH.  Vascular surgery accepted her here at [**Hospital1 18**] for
transfer.  She was admitted yesterday to vascular service, made
NPO, IVF, Vanco X1, levoflox and metonidazole started, and spine
consulted with Dr. [**Last Name (STitle) 363**] attending.  Renal was also consulted,
and she was dialyzed on [**2172-12-29**].


Past Medical History:
1. DM II w/retinopathy, neuropathy
2. HTN
3. AS (1.3 cm2)
4. h/o CAD with h/o "stents" though additional info in records,
EF 60%
5. PVD s/p L fem [**Doctor Last Name **] bypass and L BKA
6. ESRD on HD (Tue, Thurs, Sat) last HD today [**2173-1-8**]
7. h/o multiple line infections and infections of dialysis
catheter sites with MRSA
8. Hypercholesterolemia
9. Hyperthyroidism
10. Glaucoma


Social History:
Married, lives with husband. Non [**Name2 (NI) 1818**], no alcohol. No IVDA.

Family History:
Non-contributory

Physical Exam:
VS: Tmax 102 T BP 159/60 HR 90 R 19 O2 sat 100% 4L
GEN: Drowsy, shivering, diaphoretic, responds to questions, eyes
closed.
HEENT: PERRL. +catarats b/l, anicteric, moist/diaphoretic.
Neck: supple, unable to assess JVP
Chest: diffuse rhonchi, poor inspiratory effort
CVS: nl S1 S2, [**3-22**] harsh ESM radiates throughout, regular
rhythm.
Abd: obese, soft NT/ND, active BS
Ext: no edema, s/p L BKA. R foot warm, +heal ulcer with purulent
drainage
Neuro: drowsy but arousable, oriented to person/place, non focal



Pertinent Results:
Upon Discharge:
[**2173-2-4**] 07:55AM BLOOD WBC-7.8 RBC-3.87* Hgb-11.5* Hct-33.9*
MCV-88 MCH-29.7 MCHC-34.0 RDW-15.6* Plt Ct-255
[**2173-2-4**] 07:55AM BLOOD Plt Ct-255
[**2173-2-4**] 07:55AM BLOOD Glucose-92 UreaN-14 Creat-3.3* Na-135
K-3.7 Cl-99 HCO3-26 AnGap-14
[**2173-2-4**] 07:55AM BLOOD Glucose-92 UreaN-14 Creat-3.3* Na-135
K-3.7 Cl-99 HCO3-26 AnGap-14
[**2173-2-4**] 07:55AM BLOOD Calcium-7.9* Phos-2.9 Mg-1.6
.
Upon Admission/Interval Data:
[**2173-1-31**] 05:29AM BLOOD Neuts-84.4* Bands-0 Lymphs-9.8* Monos-3.0
Eos-2.5 Baso-0.3
[**2173-1-31**] 05:29AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-OCCASIONAL
Macrocy-OCCASIONAL Microcy-1+ Polychr-2+ Tear Dr[**Last Name (STitle) 833**]
[**2173-1-31**] 05:29AM BLOOD ALT-9 AST-16 LD(LDH)-173 AlkPhos-71
TotBili-0.3
[**2173-2-4**] 07:55AM BLOOD Calcium-7.9* Phos-2.9 Mg-1.6
[**2172-12-30**] 07:37PM BLOOD %HbA1c-6.6* [Hgb]-DONE [A1c]-DONE
[**2173-1-7**] 03:10AM BLOOD Triglyc-83 HDL-28 CHOL/HD-2.7 LDLcalc-31
[**2173-1-10**] 05:30AM BLOOD TSH-6.6*
[**2173-1-10**] 05:30AM BLOOD T3-54* Free T4-0.9*
[**2172-12-30**] 06:55AM BLOOD WBC-13.9*# RBC-2.91*# Hgb-8.9*#
Hct-28.2*# MCV-97 MCH-30.5 MCHC-31.4 RDW-15.2 Plt Ct-417#
[**2172-12-30**] 09:15PM BLOOD Neuts-84.0* Lymphs-9.3* Monos-3.6 Eos-2.9
Baso-0.1
[**2172-12-30**] 09:15PM BLOOD Hypochr-2+ Macrocy-1+
[**2172-12-30**] 06:55AM BLOOD PT-13.9* PTT-23.7 INR(PT)-1.3
[**2172-12-30**] 06:55AM BLOOD Glucose-164* UreaN-49* Creat-5.2* Na-137
K-4.6 Cl-93* HCO3-28 AnGap-21*
[**2172-12-30**] 09:15PM BLOOD ALT-23 AST-32 LD(LDH)-209 AlkPhos-126*
TotBili-0.3
[**2172-12-30**] 06:55AM BLOOD Calcium-8.4 Phos-5.1* Mg-1.9
[**2172-12-30**] 09:15PM BLOOD calTIBC-105* VitB12-1534* Folate-GREATER
TH Ferritn-GREATER TH TRF-81*
.
Micro Data:

[**2173-1-1**] 3:15 pm ABSCESS      PSOAS MUSCLE ABSCESS.

                            **FINAL REPORT [**2173-1-5**]**

   GRAM STAIN (Final [**2173-1-1**]):
      2+   (1-5 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.

   WOUND CULTURE (Final [**2173-1-4**]):
      STAPH AUREUS COAG +.    SPARSE GROWTH OF TWO COLONIAL
MORPHOLOGIES.
         SENSITIVITIES PERFORMED ON CULTURE # 199-8937C
[**2172-12-31**].

   ANAEROBIC CULTURE (Final [**2173-1-5**]):    NO ANAEROBES ISOLATED.


[**2173-2-2**] 5:07 am BLOOD CULTURE

   AEROBIC BOTTLE (Final [**2173-2-6**]):
      REPORTED BY PHONE TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 102915**], RN @ FA11 [**Numeric Identifier 64343**] @
0609AM ON
      [**2173-2-4**].
      [**Female First Name (un) **] ALBICANS.

Imaging - see body of text (Hospital Course)
.
Recent Imaging:
CXR [**1-31**]:
1.  No evidence of pulmonary edema.
2.  Right middle and lower lobe opacities, which may relate to
pneumonia given the history of bacteremia.  Adjacent pleural
effusion.
3.  Right PICC line now terminates within the right subclavian
vein near junction with brachiocephalic vein.
.
CT head [**2083-1-29**]:
1.  No evidence of intracranial hemorrhage.
2.  Ongoing evolution of prior infarction in the right occipital
lobe.
3.  Questionable blurring of the [**Doctor Last Name 352**]-white matter
differentiation in the posterior right sylvian fissure, which
may represent an area of new acute infarction.
4.  Sinus disease
.
MRI head [**2173-1-30**]: Except for nonvisualization of the distal
portion of the right posterior cerebral artery, no other
abnormalities are seen on the MRA of the head.

Brief Hospital Course:
In summary, patient is a 67 y/o woman with hx of CAD (EF 60%),
AS (AV 1.3 cm2), HTN, DM2 c/b diabetic neuropathy, retinopathy,
h/o ESRD on HD, severe PVD s/p L BKA, admitted from OSH with
MRSA bacteremia [**2-18**] HD line infection, also with back pain and
fevers. Patient treated with Azithromycin and Ceftrixone then
changed to IV Vanco. Also ?BE given murmur on exam, TEE
inconclusive. Back pain persisted despite Antx treatment, MRI
performed which showed L3-L4 discitis, osteomyelitis w/epidural
abscess and cauda equina compression. Patient was then
transfered to [**Hospital1 18**] for further management, admitted to vascular
surgery, treated with IVF, Vanco, Levo, Flagyl, and spine
service consulted (Dr. [**Last Name (STitle) 363**]. Renal was also consulted, and
dialysis initiated. Ortho and general [**Doctor First Name **] were consulted for
her spinal abscess and psoas abscess respectively. Patient was
taken to the OR on [**12-31**] for a total laminectomy of L2, L3 and
L4, as I&D of epidural abscess, which later grew out coag
positive staph. On [**1-1**], IR drained the psoas abscess with
removal of 30cc of fluid, gram stain showing 2+PMNs, no bact,
culture growing rare gram positive cocci.
.
Patient then went into rapid a.fib on [**1-5**], HR 130-140s a/w
hypotension SBP 60s. No response to metoprolol; was bolused with
Amiodarone then started on gtt. She converted into sinus [**1-6**].
Overnight [**Date range (1) 84136**], she became confused and lethargic. Head
CT showed subacute right occipital stroke (new since [**12-30**]).
Patient was then transferred to the MICU for further management
and was continued on PO Amiodarone, Diltiazem po added for
better control. Patient remained stable and then transfered to
the medical floor.
.
On the floor, patient continued to make slow improvement, MS
improved gradually but generally drowsy but arousable. She
continued to have low grade temps, Vanco was continued for
approximately 30 days, then d/ced since multiple surveillance cx
negative, patient refusing TEE (although several prior negative
for BE), MRI showing continued resolution. Zosyn was added for
multiple decub ulcers. Also treated with course of Flagyl for
diarrhea. C.diff A/B negative, likely [**2-18**] to tube feeds. NGT
d/ed and patient eating soft foods with improved MS. Nutrition
continued to recommend TFs however patient and husband refusing
tube feeds. Patient experience several episodes of HA, but
refusing CT head wanting only symptomatic treatment. Other
issues on the floor included vaginal bleeding. GYN consulted for
MRI showing endometrial thickening/?lesion. Biopsy was
performed, results still pending.
.
On [**2173-1-30**] patient found unresponsive to voice/painful stimuli,
code blue called. VS HR 110, BP 120/60, RR 10. O2 sat 100% RA.
Patient given 0.4mg of narcan without repsonse. Glucose checked
and was noted to be 76, given amp of D50 also w/out response.
DDx at the time included CVA, infetion/meningitis,
toxic/metabolic insult, and seizure. Neuro consulted. CT head
performed which showed evolution of prior infarction in the
right occipital lobe and questionable blurring of the [**Doctor Last Name 352**]-white
matter differentiation in the posterior right sylvian fissure,
which may represent an area of new acute infarction. Patient
treated with Ativan 2mg and loaded with Dilantin 20mg/kg. MRI
also c/w stoke in evolution, no new CVA. CXR showing RML and RLL
opacities which could be c/w PNA given hx of bacteremia. Patient
also started to spike temps again and therefore treated with IV
Vanco, zosyn continued. Blood cx drawn from all lines, PICC
d/ced, new central line placed.
.
Patient's mental status improved back to baseline and then
called back out to floor. EEG performed on [**2173-2-1**]. Patient made
DNR/DNI given ongoing medical problems. family meeting on [**2-4**]
decided that the patient would become CMO and would go to
hospice. Patient was refusing further testing and treatement and
wanted to be made comfortable. Patient understood this decision
and so did her family. At this stage, one blood culture also
came back positive for yeast and the patient did not want
further treatement. Currently, patient is very comfortable and
resting without patient. All interventions were discontinued
including hemodyalysis and all central lines. Her HD catheter
remains since it was felt that it would be uncomfortable to
remove it. Over the next several days while awaiting hospice
placement, patient remained comfortable with stable vital signs,
responsive but generally drowsy.
.
In terms of her individual medical problems:
.
Sepsis. Currently afebrile however patient WBC count was
elevated during her last MICU stay. Multipe possible sources of
infection including line infection, reaccumulation in spine,
endocarditis, worsening decubitus ulcers. Patient s/p R
subclavian central line prior to transfer from MICU. R heal
ulcer now with frank pus ->XR not showing osteomyelitis. CXR
also showing new RML/RLL infiltrates. d/ced PICC, R subclavian
central line placed. Now all lines d/ced except for her
tunnelled HD lines. Her blood cx from [**2-2**] is growing [**Female First Name (un) **]
albicans. Patient was treated with a >25 day course of
vancomycin which was later d/ce once she was afebrile, WBC
within normal limits. She then became unresponse and went back
to the MICU where Vancomycing was added back. She received this
for a few more days until she was made CMO and all antibiotics
were d/ced. She was also on Zosyn for some time for her
decubitus ulcers.
.
Altered MS. [**Name13 (STitle) **] currently back to baseline, remains drowsy
but arousable. CT/MRI showing evolution of old CVA, no new
lesions. ?sepsis vs. hypoglycemia. EEG performed [**2173-2-1**] which
did not show any seizure activity.
.
Vaginal bleeding. s/p endometrial biopsy. Hct trending
downwards. Transfuse with HD for Hct >30 given hx of CAD.
Endometrial bx negative for malignancy, but +polyps.
.
ESRD on HD. Continue HD per renal recs. Permanent tunnelled line
placed [**1-28**]. She continued routine hemodyalsis until the
decision was made to discontinue dyalysis on [**2173-2-4**]..
.
A.fib with RVR. Remains borderline tachycardic in 90s. She was
intially treated with Amiodarone and diltiazem. This was later
discontinued.
.
DM2: Hypoglycemic over last few days, likely [**2-18**] to d/ce tube
feeds with suboptimal po intake. Was at one point requiring high
dose glargine and sliding scale insulin. Currently off all
insulin products.
.
Cardiovascular Disease. History of CAD, unclear if patient was
had PCI. No active issues. Continue ASA given risk of MI.
.
FEN: NGT d/ced [**1-27**], taking POs since but Nutrition recommending
supplementation, re-placement of tube. Patient refusing further
tube feeds. Continue PO intake as tolerated.
.
Communication: patient, husband [**Name (NI) 449**] [**Name (NI) **] ([**Telephone/Fax (1) 102916**])

Medications on Admission:
1. Rescula 1 drop each eye [**Hospital1 **]
2. Cosopt 1 drop each eye [**Hospital1 **]
3. Atenolol 25mg po qd
4. Cozaar 100mg po qd
5. Nifedipine 90mg po qd
6. Catapres
7. Renagel 800mg po with meals tid
8. Reglan 10mg po with meals tid
9. Lipitor 4mg po qd?
10. Nephrocaps

Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Morphine 10 mg/5 mL Solution Sig: [**1-18**]  PO Q4-6H (every 4 to 6
hours) as needed.
Disp:*qs qs* Refills:*0*
3. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.
Disp:*30 Tablet(s)* Refills:*2*
4. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours).
Disp:*120 Tablet(s)* Refills:*2*
5. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
6. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
7. Phenytoin 100 mg/4 mL Suspension Sig: One (1)  PO Q8H (every
8 hours).
8. Diphenhydramine HCl 12.5 mg/5 mL Elixir Sig: [**1-18**]  PO Q6H
(every 6 hours) as needed.
9. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H
(every 6 hours) as needed.
10. Dibucaine 1 % Ointment Sig: One (1) Appl Topical  [**Hospital1 **] (2
times a day) as needed.
11. Acetaminophen 160 mg/5 mL Solution Sig: [**1-18**]  PO Q4H (every 4
hours).


Discharge Disposition:
Extended Care

Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 731**] - [**Location (un) 3320**]

Discharge Diagnosis:
1. End stage renal disease on hemodyalysis
2. Atrial fibrillation with rapid ventricular rate
3. Epidural Abscess/Psoas abscess s/p resection and drainage
4. Diabetes Mellitus
5. Poor Nutrition
6. Vaginal bleeding s/p endometrial biopsy with endometrial
thickening on MRI, polyp found on biopsy
7. Occipital CVA
8. MRSA bacteremia
9. Chronic Diarrhea
10. Anemia
11. Sepsis/Fungemia


Discharge Condition:
Comfort Measures/DNR/DNI


Discharge Instructions:
Please take all medications as directed

Patient is comfort measures only, please provide symptom relief
with morphine liquid prn, ativan for anxiety, benadryl for
itching, tylenol #3 for pain.

Patient is also on liquid preparation of Phenytoin for seizure
prophylaxis

Followup Instructions:
none



Completed by:[**2173-2-9**]
{'Methicillin susceptible Staphylococcus aureus septicemia,Acute osteomyelitis, other specified sites,Intraspinal abscess,Psoas muscle abscess,Ulcer of heel and midfoot,Cerebral embolism with cerebral infarction,End stage renal disease,Atrial fibrillation,Cellulitis and abscess of foot, except toes,Disseminated candidiasis,Congestive heart failure, unspecified,Pneumonia, organism unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Acute and subacute bacterial endocarditis,Hyperosmolality and/or hypernatremia,Severe sepsis,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Postmenopausal bleeding,Intervertebral disc disorder with myelopathy, lumbar region,Unspecified inflammatory spondylopathy,Cauda equina syndrome without mention of neurogenic bladder,Diarrhea,Below knee amputation status,Infection with microorganisms resistant to penicillins,Polyneuropathy in diabetes,Delirium due to conditions classified elsewhere'}


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: Back Pain

PRESENT ILLNESS: Pt is 67 y/o woman with PMH of CAD, last echo [**2172-12-22**] showing EF
60% with 13mm aortic valve with h/o aortic stenosis, HTN, Type
II DM complicated by diabetic neuropathy, retinopathy, h/o ESRD
on HD (three times per week, last dialyzed on [**2172-11-29**]), h/o L
fem-[**Doctor Last Name **] bypass s/p L BKA for severe PVD, h/o right heel foot
ulcer, h/o indwelling dialysis cathether growing MRSA recently
and subsequent left IJ placed for HD, h/o multiple line
infections and infections of dialysis catheter sites with MRSA,
who presented to [**Hospital3 **] on [**2172-12-12**] with CC of [**10-26**],
sharp, low back pain and fever.  Blood cultures drawn
demonstrated gram positive cocci in pairs and clusters.  A TEE
was attempted but she desatted and was felt to be 'unstable.'  A
TTE was inconclusive, but given her harsh systolic murmur and
blood cultures, was presumed to have endocarditis.  She was
started on Zithromax, and CTX originally on admission, and after
blood cultures came back positive on [**2172-12-20**], she was started on
IV vancomycin w/ d/c of zithromax.  It appears she was in the
ICU during her stay at [**Hospital1 46**] X 1 week then transferred to
medical floor.  Her back pain continued to worsen despite abx.
MRI of the spine revealed L3-L4 discitis, osteomyelitis with
epidural abscess and cauda equina compression with probable
multiple lumbar radiculopathy.  She was seen by NSGY who felt
her unstable to have the procedure done at [**Hospital3 3583**],
given her PMH.  Vascular surgery accepted her here at [**Hospital1 18**] for
transfer.  She was admitted yesterday to vascular service, made
NPO, IVF, Vanco X1, levoflox and metonidazole started, and spine
consulted with Dr. [**Last Name (STitle) 363**] attending.  Renal was also consulted,
and she was dialyzed on [**2172-12-29**].

MEDICAL HISTORY: 1. DM II w/retinopathy, neuropathy
2. HTN
3. AS (1.3 cm2)
4. h/o CAD with h/o "stents" though additional info in records,
EF 60%
5. PVD s/p L fem [**Doctor Last Name **] bypass and L BKA
6. ESRD on HD (Tue, Thurs, Sat) last HD today [**2173-1-8**]
7. h/o multiple line infections and infections of dialysis
catheter sites with MRSA
8. Hypercholesterolemia
9. Hyperthyroidism
10. Glaucoma

MEDICATION ON ADMISSION: 1. Rescula 1 drop each eye [**Hospital1 **]
2. Cosopt 1 drop each eye [**Hospital1 **]
3. Atenolol 25mg po qd
4. Cozaar 100mg po qd
5. Nifedipine 90mg po qd
6. Catapres
7. Renagel 800mg po with meals tid
8. Reglan 10mg po with meals tid
9. Lipitor 4mg po qd?
10. Nephrocaps

ALLERGIES: Tape

PHYSICAL EXAM: VS: Tmax 102 T BP 159/60 HR 90 R 19 O2 sat 100% 4L
GEN: Drowsy, shivering, diaphoretic, responds to questions, eyes
closed.
HEENT: PERRL. +catarats b/l, anicteric, moist/diaphoretic.
Neck: supple, unable to assess JVP
Chest: diffuse rhonchi, poor inspiratory effort
CVS: nl S1 S2, [**3-22**] harsh ESM radiates throughout, regular
rhythm.
Abd: obese, soft NT/ND, active BS
Ext: no edema, s/p L BKA. R foot warm, +heal ulcer with purulent
drainage
Neuro: drowsy but arousable, oriented to person/place, non focal

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Married, lives with husband. Non [**Name2 (NI) 1818**], no alcohol. No IVDA. 

### Response:
{'Methicillin susceptible Staphylococcus aureus septicemia,Acute osteomyelitis, other specified sites,Intraspinal abscess,Psoas muscle abscess,Ulcer of heel and midfoot,Cerebral embolism with cerebral infarction,End stage renal disease,Atrial fibrillation,Cellulitis and abscess of foot, except toes,Disseminated candidiasis,Congestive heart failure, unspecified,Pneumonia, organism unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Acute and subacute bacterial endocarditis,Hyperosmolality and/or hypernatremia,Severe sepsis,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Postmenopausal bleeding,Intervertebral disc disorder with myelopathy, lumbar region,Unspecified inflammatory spondylopathy,Cauda equina syndrome without mention of neurogenic bladder,Diarrhea,Below knee amputation status,Infection with microorganisms resistant to penicillins,Polyneuropathy in diabetes,Delirium due to conditions classified elsewhere'}
