CHIEF COMPLAINT: Transferred from [**Hospital 4199**] Hospital for suspected T9-10 vertebral
osteomyelitis

PRESENT ILLNESS: Patient is a 67 year old Spanish-speaking female with h/o ESRD
on HD, CAD, h/o HIT, DM, s/p L BKA, and prior line infections
who is being transfered for possible vertebral osteomyelitis.

MEDICAL HISTORY: Hypertension
End Stage Renal Disease on dialysis T, TH, Sat, last session for
2 hours on [**2199-1-3**]
Peripheral Vascular Diseas, s/p left Below the Knee Amputation
Type 2 Diabetes Mellitus, insulin-dependent
Coronary Artery Disease s/p Myocardial Infarction in [**Male First Name (un) 1056**]
10 years ago, BMS placement in [**2197**]
Anemia
H/o Heparin-Induced Thrombocytopenia treated with argatroban and
h/o Deep vein Thrombosis (associated with line placement) in
[**9-12**], treated with coumadin x 1 month
Hypercholesterolemia
Obesity
Dibabetic Neuropathy in legs
H/o cholecystectomy [**2196**]
H/o appendectomy
Hypercalcemia
Groin line sepsis with stenotrophomonas in [**9-12**], MRSA line
infection [**9-9**]
R knee osteoarthritis
Left arm fistula [**9-/2198**], right arm fistula now occluded

MEDICATION ON ADMISSION: Amlodipine 10mg po daily
Cimetidine 20mg po daily
Florastor 250mg po daily
Folic Acid 1mg po daily
Insulin 32 units SC at bedtime plus RISS
Isosorbide Dinitrate 20mg po TID
Lipitor 20mg po daily
Lisinopril 5mg po daily
Toprol XL 200mg po daily
Nephrocaps 1mg po daily
Percocet 5/325 1 tab po q4h prn for pain
Renagel 800mg po TID
Sensipar 90mg po daily
Vancomycin 1gm IV with dialysis, last dose [**2199-1-3**]
Gabapentin 100mg po daily
*Stopped Plavix 75mg po daily for possible procedure

ALLERGIES: Heparin Agents / Aspirin / Albuterol

PHYSICAL EXAM: VITALS: T 97.6 HR 86 141/41 20 100% on 40% trach mask
GENERAL - elderly obese female, alert, responsive, makes eye
contact.  Does not respond to questions or commands, but
interacts.
HEENT - PERRL, EOMI, MMM
NECK - supple, tracheostomy in place
LUNGS - Decreased breath sounds at bases bilaterally, air
movement R > L.  Coarse rales more on left.
HEART - Regular rate and rhythm with 2/6 systolic murmur.
ABDOMEN - obese, + BS, soft, non-tender to palpation.  PEG tube
in place.
EXTREMITIES - Edematous bilaterally, [**1-5**]+.  1+ pedal pulses in
right foot, has left BKA.
NEURO: no sensation or movement of lower extremities.  Moves
upper extremities bilaterally and spontaneously, moves head,
mouths words (trach in place).  Clearly alert and responsive,
but does not repsond to commands, will occasionally respond to
questions.  Spanish-speaking only.
SKIN - multiple wounds, post-surgical and pressure wounds, as
detailed below.

FAMILY HISTORY: There is no family history of sudden death. Mother died of an MI

SOCIAL HISTORY: Social history is significant for the absence of current tobacco
use, quit smoking in [**2194**]. There is no history of alcohol abuse.
Lives at home with her husband, daughter, son and [**Name2 (NI) 802**]. She is
originally form [**Male First Name (un) 1056**]. She does not speak English.
Streptococcal septicemia,Septic shock,Acute kidney failure, unspecified,Intraspinal abscess,End stage renal disease,Pneumonia, organism unspecified,Encephalopathy, unspecified,Unspecified osteomyelitis, other specified sites,Paraplegia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Unspecified pleural effusion,Iatrogenic pneumothorax,Acute posthemorrhagic anemia,Other complications due to renal dialysis device, implant, and graft,Urinary tract infection, site not specified,Dependence on respirator, status,Severe sepsis,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Renal dialysis status,Atrial fibrillation,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status
Streptococcal septicemia,Septic shock,Acute kidney failure NOS,Intraspinal abscess,End stage renal disease,Pneumonia, organism NOS,Encephalopathy NOS,Osteomyelit NOS-oth site,Paraplegia NOS,Hyp kid NOS w cr kid V,Pleural effusion NOS,Iatrogenic pneumothorax,Ac posthemorrhag anemia,Comp-ren dialys dev/grft,Urin tract infection NOS,Respirator depend status,Severe sepsis,Enterococcus group d,Renal dialysis status,Atrial fibrillation,DMII neuro nt st uncntrl,Neuropathy in diabetes,Crnry athrscl natve vssl,Status-post ptca
Admission Date:  [**2199-1-3**]              Discharge Date:   [**2199-2-6**]

Date of Birth:  [**2131-8-19**]             Sex:   F

Service: MEDICINE

Allergies:
Heparin Agents / Aspirin / Albuterol

Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Transferred from [**Hospital 4199**] Hospital for suspected T9-10 vertebral
osteomyelitis

Major Surgical or Invasive Procedure:
1. Partial vertebrectomy at T7-T8.
2. Fusion T7-T8.
3. Incicison and drainage with debridement
4. Posterior T3-T12 fusion.
5. Incision and drainage of epidural abscess.
6. Bone graft.
7. Tracheostomy
8. Thoractomy and chest tube placement and removal
9. Percutaneous endoscopic gastrotomy tube placement

History of Present Illness:
Patient is a 67 year old Spanish-speaking female with h/o ESRD
on HD, CAD, h/o HIT, DM, s/p L BKA, and prior line infections
who is being transfered for possible vertebral osteomyelitis.

She was originally admitted to [**Hospital 4199**] Hospital from [**Date range (1) 81661**]
for abdominal pain and mental status changes.  She had an
abdominal CT negative for intraabdominal pathology but it showed
vertebral osteomyelitis.  Follow-up MRI showed T9-T10
osteomyelitis without evidence of cord compression on [**12-18**].
On comparison with prior images from [**11-12**], per report, it
appears that vertebral changes were present but not recognized
at the time.  Blood cultures grew enterococcus faecalis and she
was treated with vancomycin on dialysis days for a 14 day course
to end [**1-3**].  She had her HD catheter pulled [**12-23**].
Surveillance cultures have shown NGTD.  She had a negative PPD
and 3 negative AFB smears.  She had an attempted bone biopsy by
IR but no bone was recovered.  She was transferred "for further
evaluation of the osteomyelitis for possible fungal or
tuberculoid etiologies, if no improvement with the vancomycin."
Bone biopsy was done on [**12-27**] with inefficient yield for
diagnosis.  She was readmitted on [**1-1**] for recurrent abdominal
pain.

She is dialyzed T, Th, Sat and had a partial session on [**1-3**].
She has a left arm fistula that was used at the OSH for dialysis
but then clotted.  A second abdominal catheter was placed on
[**12-25**] for further access but per the dc summary, "it is felt
that this fistula should be left for further maturation."  Per
signout, "current HD access via right subclavian line, has
immature AVF in LUE."

On floor, she continues to complain of severe RUQ pain, worse
with movement and worse in the supine position.  She states it
radiates around her back on both sides when it gets severe.  She
states she's had it for two weeks, although the dc summary from
the OSH states several months.  Also complains of pain radiating
down her right leg of [**2-6**] weeks.  On further questioning, she
also endorsed lower extremity weakness for 4 days-1 week.

Denies fevers, chills, chest pain, shortness of breath, nausea,
or vomiting.  Had not had a bowel movement for several days at
OSH, previously had  diarrhea.  Does not urinate.

Past Medical History:
Hypertension
End Stage Renal Disease on dialysis T, TH, Sat, last session for
2 hours on [**2199-1-3**]
Peripheral Vascular Diseas, s/p left Below the Knee Amputation
Type 2 Diabetes Mellitus, insulin-dependent
Coronary Artery Disease s/p Myocardial Infarction in [**Male First Name (un) 1056**]
10 years ago, BMS placement in [**2197**]
Anemia
H/o Heparin-Induced Thrombocytopenia treated with argatroban and
h/o Deep vein Thrombosis (associated with line placement) in
[**9-12**], treated with coumadin x 1 month
Hypercholesterolemia
Obesity
Dibabetic Neuropathy in legs
H/o cholecystectomy [**2196**]
H/o appendectomy
Hypercalcemia
Groin line sepsis with stenotrophomonas in [**9-12**], MRSA line
infection [**9-9**]
R knee osteoarthritis
Left arm fistula [**9-/2198**], right arm fistula now occluded

Social History:
Social history is significant for the absence of current tobacco
use, quit smoking in [**2194**]. There is no history of alcohol abuse.
Lives at home with her husband, daughter, son and [**Name2 (NI) 802**]. She is
originally form [**Male First Name (un) 1056**]. She does not speak English.

Family History:
There is no family history of sudden death. Mother died of an MI

at 56 YO. Dad had a cardiovascular disease and died at [**Age over 90 **] YO of
"old age". One sister with HTN, one sister and one brother
healthy. [**Name2 (NI) **] history of cancer in the family.

Physical Exam:
VITALS: T 97.6 HR 86 141/41 20 100% on 40% trach mask
GENERAL - elderly obese female, alert, responsive, makes eye
contact.  Does not respond to questions or commands, but
interacts.
HEENT - PERRL, EOMI, MMM
NECK - supple, tracheostomy in place
LUNGS - Decreased breath sounds at bases bilaterally, air
movement R > L.  Coarse rales more on left.
HEART - Regular rate and rhythm with 2/6 systolic murmur.
ABDOMEN - obese, + BS, soft, non-tender to palpation.  PEG tube
in place.
EXTREMITIES - Edematous bilaterally, [**1-5**]+.  1+ pedal pulses in
right foot, has left BKA.
NEURO: no sensation or movement of lower extremities.  Moves
upper extremities bilaterally and spontaneously, moves head,
mouths words (trach in place).  Clearly alert and responsive,
but does not repsond to commands, will occasionally respond to
questions.  Spanish-speaking only.
SKIN - multiple wounds, post-surgical and pressure wounds, as
detailed below.

Trach: continues to have increase drainage peritube

G-tube: left ABD with moderate thick drainage from site, no
peritubular skin breakdown

Right axilla:  2 open sites, 1 x 1 cm yellow/red 50% each, wound
bed, 0.5 cm x 0.5 cm pink wound bed, wound edges are irregular,
no drainage, no s/s of infection,  other noted healed sites in
this area, undetermined etiology of wounds-possible friction

Right ABD: 2 ulcers now closed

Right lateral thigh:  2 unstageable pressure ulcers
1 x 3 cm yellow/black wound bed beginning to slough
7.5 x 1.5 cm necrotic black firm tissue beginning to slough at
proximal end and separate from wound edges.  There is a moderate
amount of yellow serous drainage.  There is no periwound
erythema, edema, induration or fluctuance.

Right lower leg just above ankle: intact darkly pigmented tissue
circumferentially in two linear configurations, ? etiology
no acute for s/s of infection

Left lateral chest tube site: closed

Left forearm/wrist: 0.5 x 1 cm dry yellow eschared site

Midline back vertebral incision: intact with steristrips in
place

Left thoracotomy incision: not approximated, 1 x 15 cm with
necrotic yellow black tissue in the wound bed, small amount of
yellow drainage with no odor, wound edges defined, no
surrounding
erythema, edema, or fluctuance

Inferior to left thoracotomy incision: 4 x 4.5 cm partial
thickness ulcer with 100% red wound bed improved maybe related
to
tape injury, wound edges are irregular, no s/s of infection

Left lateral back: 2.5 x 1 cm unstageable pressure ulcer with
50%
yellow/50% pink wound bed, irregular wound edges, no surrounding
s/s of infection

Left trochanter:  3 x 3.5 cm unstageable pressure ulcer, 100%
yellow fibrinous tissue, irregular wound edges, scant drainage
with no odor, periwound tissue intact with no induration, edema,
or fluctuance

Intergluteal tissue:  unchanged parital thickness ulcer with
100%
red wound bed and irregular wound edges most likely related to
moisture, appears to be healing

Perianal: anterior anus 1.5 x 0.2 cm, Stage II pressure ulcer
most likely from pressure of the FMS tubing.

Pertinent Results:
Admission Labs:
[**2199-1-3**] 07:55PM   WBC-9.2 RBC-3.09* HGB-9.0* HCT-29.4* MCV-95
MCH-29.1 MCHC-30.6* RDW-16.6*
[**2199-1-3**] 07:55PM   PLT COUNT-171
[**2199-1-3**] 07:55PM   GLUCOSE-125* UREA N-41* CREAT-5.2* SODIUM-137
POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-26 ANION GAP-14
[**2199-1-3**] 07:55PM   CALCIUM-10.1 PHOSPHATE-5.0* MAGNESIUM-2.3
[**2199-1-3**] 07:55PM   ALT(SGPT)-9 AST(SGOT)-12 ALK PHOS-112
AMYLASE-18 TOT BILI-0.3
[**2199-1-3**] 07:55PM   LIPASE-14
.
Studies:
.
MR CERVICAL, THORACIC AND LUMBAR SPINE WITHOUT AND WITH CONTRAST
[**2199-1-4**]
.
HISTORY: End-stage renal disease and known T9-10 vertebral
osteomyelitis, now with progressive lower extremity weakness and
incontinence.
.
Sagittal imaging was performed with long TR, long TE fast spin
echo, short TR, short TE spin echo, and STIR imaging. Axial
imaging was performed with short TR, short TE spin echo and long
TR, long TE spin echo technique. Due to the patient's renal
failure (EGFR of 8) informed consent was obtained before
administration of 20 cc of ProHance intravenous contrast.
Subsequently, sagittal and axial short TR, short TE imaging was
repeated. Comparison to an outside MR of the thoracic spine of
[**2198-12-18**].
.
FINDINGS: Again seen is evidence of discitis and osteomyelitis
centered at
T8-9. There is now a large, irregular, fluid collection at the
former
location of the intervertebral disc. There is extensive
enhancement around
the periphery of this abnormality. This enhancing fluid
collection extends
through the anterior cortex of the vertebral bodies and is
contiguous with a small amount of intraspinal epidural abnormal
enhancement. These findings suggest intraspinal extension of
infection with an epidural phlegmon. There is extensive
paraspinal soft tissue abnormality extending from T6 to T10.
This contains two focal non-enhancing areas that represent
abscess collections surrounded by extensive paraspinal phlegmon.
All of these changes appear to have progressed since the study
of [**12-18**]. Also seen are small bilateral pleural effusions.
These appear somewhat smaller than on the study of
[**12-18**].
.
The epidural material appears to encroach on the anterior aspect
of the spinal
cord and may cause some degree of cord compression. This is not
well
evaluated on this examination.
.
Incidentally noted is anterior subluxation of L4 on L5 on a
degenerative
basis.
.
CONCLUSION: Discitis and osteomyelitis with a large abscess
within the
vertebral column with extension anteriorly to the paravertebral
space and
posteriorly with at least a small intraspinal epidural phlegmon.
The images are severely degraded by motion artifact. However,
there appears to be edema
.
TRANS-THORACIC ECHOCARDIOGRAM, performed [**2199-1-28**]
.
The left atrium is mildly dilated. No left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). The
estimated right atrial pressure is 10-20mmHg. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). The estimated
cardiac index is normal (>=2.5L/min/m2). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets are mildly thickened (?#). There is mild aortic valve
stenosis (valve area 1.5cm2). No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
Compared with the prior study (images reviewed) of [**2199-1-9**], the
severity of aortic stenosis is higher, though may be related to
improved definitiion of the aortic velocity rather than a true
change.
.
HEAD CT, [**2199-1-29**]
.
IMPRESSION: Periventricular white matter and basal ganglia
hypodensities
likely represent chronic microvascular disease. However, given
the lack of
comparison studies, acute encephalopathy cannot be ruled out.
.
NECK CT, [**2199-1-29**]
.
IMPRESSION:
1. Status post T-spine fusion, with bilateral pleural effusions.

2. Paranasal sinus disease.
.
PORTABLE CHEST X-RAY, [**2199-2-1**] (most recent study)
.
IMPRESSION:
.
1) Marked volume loss in the left lower lobe, possibly from
mucous impaction or obstructing lesion given persistence of
atelectasis.

2) Large amount of at least partially loculated fluid in the
left lung.
.
CT T-SPINE, [**2199-1-9**]
.
IMPRESSION: Status post T8-T11 fusion with intervertebral body
cage. Marked
destruction of the T9 and T10 vertebral bodies and to a lesser
disc extent T8
and T11 reflect known osteomyelitis/discitis and partial
vertebrectomy.

.

[**2199-2-1**] 06:11AM BLOOD WBC-12.5* RBC-2.76* Hgb-8.3* Hct-26.5*
MCV-96 MCH-30.1 MCHC-31.3 RDW-16.4* Plt Ct-271
[**2199-1-30**] 07:32AM BLOOD WBC-9.8 RBC-2.16*# Hgb-6.5*# Hct-21.3*#
MCV-97 MCH-30.1 MCHC-31.2 RDW-16.0* Plt Ct-199
[**2199-1-28**] 06:30AM BLOOD WBC-11.5* RBC-2.38* Hgb-7.0* Hct-23.3*
MCV-98 MCH-29.5 MCHC-30.2* RDW-16.0* Plt Ct-194
[**2199-1-26**] 02:53AM BLOOD WBC-14.9* RBC-2.48* Hgb-7.2* Hct-24.0*
MCV-97 MCH-29.3 MCHC-30.2* RDW-15.7* Plt Ct-145*
[**2199-1-21**] 02:30PM BLOOD WBC-24.7* RBC-2.81* Hgb-8.3* Hct-26.9*
MCV-96 MCH-29.6 MCHC-31.0 RDW-16.1* Plt Ct-137*
[**2199-1-17**] 01:55AM BLOOD WBC-12.9* RBC-2.91* Hgb-8.8* Hct-27.1*
MCV-93 MCH-30.2 MCHC-32.4 RDW-16.6* Plt Ct-120*
[**2199-1-14**] 02:50AM BLOOD WBC-14.8* RBC-3.46* Hgb-10.7* Hct-30.8*
MCV-89 MCH-30.9 MCHC-34.7 RDW-16.1* Plt Ct-126*
[**2199-1-6**] 03:05AM BLOOD WBC-20.1* RBC-3.83* Hgb-11.3* Hct-34.8*
MCV-91 MCH-29.6 MCHC-32.6 RDW-16.8* Plt Ct-141*
[**2199-1-5**] 07:57PM BLOOD WBC-15.7*# RBC-3.26* Hgb-9.9* Hct-30.0*
MCV-92 MCH-30.2 MCHC-32.8 RDW-16.2* Plt Ct-151

Brief Hospital Course:
Patient is a 67 year old Spanish-speaking female with h/o ESRD
on HD, CAD, h/o HIT, DM, s/p L BKA, and prior line infections
who was transferred for vertebral osteomyelitis and epidural
abscess now status post incidion and drainage of abscess with
posterior fusion from T3-T12 with residual paraplegia.
.
The patient was transfered to the SICU on the Orthopaedic Spine
service on [**2199-1-13**] for management of her osteomyelitis and
epidural abscess.  Due to the unresolved paraplegia an IVC
filter was placed by the General Surgery service for DVT
prophylaxis given her history of heparin-induced
thrombocytopenia.
After her thoracotomy for her vertebrectomy she was noticed to
require additional respiratory support and a chest x-ray was
obtained.  An apical pneumothorax was identified and a chest
tube was placed. While in the SICU a PEG and trach were placed
due to inablility to wean off of the ventilator.  Pt had septic
physiology requiring three pressors for blood pressure support.
She developed a pneumonia and was placed on the antibiotics.
Her symptoms improved, however she developed a new atrial
fibrillation of unknown etiology.  She was started on amiodarone
and diltiazem with subsequent conversion to sinus where she
remained.
.
On [**1-26**] the patient was transfered back to the medical
service for continuing management of her multiple medical
issues.  The evening following the transfer her family members
noted that she had seemed less responsive over the course of the
day.  On initial exam she would make eye contact but was not
responding to commands or answering questions.  She was moving
her arms spontaneously.  Her oxygen saturation was 100%, and an
ABG drawn at that time showed no evidence of hypercarbia.  The
following morning she spiked a fever to 101 degrees, at which
point she was pan-cultured, and a chest x-ray showed worsening
consolidation, especially in the left lung.  Her antibiotic
coverage was broadened, and her mental status gradually improved
over the next several days.  She still remained intermittently
responsive to commands, but she would respond to family members,
and she began to move her upper extremities spontaneously.
.
#. Vertebral osteomyelitis: She presented with known vertebral
osteomyelitis and after having completed a 2 week course of
Vancomycin.  She continued to complain of RUQ abdominal pain
thought to be radicular in nature.  She also endorsed some lower
extremity weakness on admission and possible decreased
sensation.  She had an episode of stool incontinence overnight
the night of admission and an MRI was obtained that showed a
large abscess at T8-T9 within the vertebral column with
extension anteriorly to paravertebral space and posterially with
small epidural phlegmon.  There also appeared to be edema in
spinal cord at the level of the abscess.  She was taken to the
OR on [**2199-1-5**] and was treated initially with vancomycin and
ampicillin.  Patient had incision and drainage of her epidural
abscess, multiple thoractomies and posterior fusion from T3-T12.
 After growing VRE from blood on [**1-27**].  Pt was started on
linezolid and cefepime.  Flagyl was eventually added out of
concern for sinusitis.  Last day of cefepime [**2-6**].  Please see
full details under "Fevers" section.
.
#. ESRD on HD: She receives dialysis T, Th, Sat and had a
partial session on [**1-3**].  There were no signs of uremia on
admission.  She was dialyzed twice after undergoing MRI with
contrast in order to prevent NSF.
.
#. CAD: She had no symptoms on admission of CAD. Plavix was
stopped in preparation for a possible procedure.  She was
continued on metoprolol, Lipitor, and has an allergy to ASA.
.
#. Heparin-induced thrombocytopenia (HIT): She has a h/o HIT
with recent UE DVT due to line placement in [**9-12**].  Heparin
products were avoided during this admission.  She has a midline
that CANNOT be flushed with heparin.
.
# Fevers:
The infectious disease service had been following before
transfer to the medicine service, and they continued to follow
the patient after developing new fevers on [**1-27**].  At that
point she had two catheters in her left internal jugular vein -
one triple lumen catheter, and one HD catheter.  Cultures were
drawn from both catheters as well as peripherally.  Both of
these catheters were removed, and a temporary HD line was placed
with a VIP port for non-HD access.  Cultures drawn from the
earlier left IJ lines eventually grew out vancomycin resistant
enterococcus, which prompted the ID team to recommend Linezolid
for the bactermia and cefepime for hospital-acquired pneumonia
for antibiotic coverage.  She improved on this regimen over the
next several days, remaining afebrile, with improved mental
status.  She was transferred to the MICU for 2 days due to
nursing concerns and staffing issues, but then returned to the
medical floor.  During this time she also developed increased
secretions around the trach, which were thought to possibly
represent sinusitis (which was also noted on head CT) so she was
started on Flagyl as well for anaerobic coverage.  She continued
to improve, with clearance of further culture data, and within a
week she was stabilized and considered ready for transfer to
LTAC for continued care and rehab.
.
The infectious disease team recommended the following treatment
plan for discharge:
1. Cefepime for HAP, discontinued at discharge, on [**2199-2-6**]
2. Linezolid and Flagyl, to be continued until [**2199-2-12**]
3. Ampicillin, to be resumed on [**2199-2-12**] when stopping linezolid
and flagyl, and continued until [**2199-3-2**]
.
Until completion of ampicillin treatment, weekly labs should be
drawn (ESR, CRP, LFT's, CBC with diff) and faxed to the
infectious disease clinic at [**Telephone/Fax (1) 1419**].
.
# Altered mental status:
On transfer to the medical service, as noted above, she was
altered and minimally responsive, not moving her arms.  Her
neuro exam was limited due to her lack of alertness, but she was
also not moving her upper extremties, and not withdrawing to
pain.  With concern for possible spread of epidural abscess
and/or anoxic brain injury, a CT head/neck was obtained.  This
was a non-contrast CT, given her recent gadolinium exposure,
tenuous respiratory status, and inability to lie still.  We
could not give CT contrast due to lack of peripheral venous
access (this was attempted multiple times without success).
However, her mental status improved significantly with
antibiotics, and she regained movement in her arms as the
infection cleared.
.
# Respiratory status
The patient was noted to have a large left-sided pleural
effusion on CXR in addition to the new pneumonia.  It was
decided that with all of her comorbidities and recent
complications, that draining the effusion would be too
high-risk.  Her respiratory status remained stable after
antibiotic treatment, with decrease in secretions, stable
respiratory rate.  Her trach remains in place for now, to be
removed in the future if tolerated.  Pt has a large left-sided
pleural effusion that has been stable.
.
# ESRD on hemodialysis:
The patient remained on a Tuesday, Thursday, Saturday dialysis
schedule.  On Tuesday, [**2-5**] the HD catheter was not
functioning properly at dialysis, so TPA was left in the line
overnight, and HD was performed on Wednesday, [**2-6**] without
incident.  The plan per the renal team was to resume her
previous Tuesday/Thursday/Saturday schedule after transfer to
outside facility.  She was continued on her preadmission renal
medications.  Left upper extremity AV fistual clotted.
.
# Atrial fibrillation:
Shortly before transfer to the medicine service the patient was
noted to be in atrial fibrillation.  She was started on
amiodarone and diltiazem, with good control, and returned to
sinus rhythm.  The amiodarone was discontinued, and she was
maintained with good heart rate control on diltiazem at time of
discharge.  She was also started on coumadin for
anticoagulation.  It was decided to leave the IVC filter in
place, given risks of removal and lack of mobility in her future
course.  The coumadin dose was increased to 5 mg per day 2 days
before discharged, given subtherapeutic INR.  This dose may
require further adjustment pending INR trend.
.
# Type II Diabetes Mellitus:
Patient receives long-acting insulin qam in addition to sliding
scale qid.
.
# Vascular access:
Patient has a left upper extremity AV fistula that was used for
dialysis at the outside hospital but clotted prior to transfer.
As noted above, access was difficult throughout her hospital
course, and she had multiple temporary lines placed, avoiding
tunneled line placement due to active bacteremia.  However, a
tunneled left IJ dialysis line was placed by IR on [**Last Name (LF) 2974**], [**2-1**], along with a R-sided midline for use in continued antibiotic
treatment.  Heparing flushes SHOULD NOT be used.
.
# Pain control:
It is not clear exactly how much pain the patient has been
having, as she is not able to articulate how much or where her
pain is.  However, she does become noticeably calmer and more
comfortable with analgesia.  On discharge she was on a regimen
of oxycodone 5 mg per PEG tube Q 4 hours, with good effect.
.
# Nutrition:
The patient was kept on tube feeds at a goal rate of 25 cc/hour.
 She occasionally had residuals on routine checks, but mostly
her tube feeds have been running without incident.  Her abdomen
has consistently remained soft and non-tender.
.
# Wound care:
The patient has surgical wounds, as well as several pressure
wounds on her back and legs.  The wound care service was very
involved with her care, and provided recommendations for
continued wound care.  Please see the Page 1 for the specific
recommendations.
.
# Anemia - The patient's hematocrit remained low throughout the
hospitalization, requiring transfusions.  Likely combination of
ESRD, anemia of inflammation, combined with operative blood
loss.  Her hematocrit at time of discharge was stable.
.
# Goals of care:
The patient initially was DNR/DNI on admission, but this was
reversed before her surgical procedure.  After lengthy
discussions with the family, her code status was returned to
DNR/DNI after transfer back to the medicine service.  We
explained that the patient will likely require intensive
services indefinitely, and that she will probably never return
to her previous level of function.  Palliative care was also
consulted, and they explained that there are also comfort
measures available should the patient and her family be
interested in them in the future.  The family's current plan is
to transfer to a long term acute care facility for further rehab
and treatment.
.
The patient was discharged to LTAC on [**2199-2-6**].

Medications on Admission:
Amlodipine 10mg po daily
Cimetidine 20mg po daily
Florastor 250mg po daily
Folic Acid 1mg po daily
Insulin 32 units SC at bedtime plus RISS
Isosorbide Dinitrate 20mg po TID
Lipitor 20mg po daily
Lisinopril 5mg po daily
Toprol XL 200mg po daily
Nephrocaps 1mg po daily
Percocet 5/325 1 tab po q4h prn for pain
Renagel 800mg po TID
Sensipar 90mg po daily
Vancomycin 1gm IV with dialysis, last dose [**2199-1-3**]
Gabapentin 100mg po daily
*Stopped Plavix 75mg po daily for possible procedure

Discharge Medications:
1. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever.
4. Acetylcysteine 20 % (200 mg/mL) Solution Sig: 3-5 MLs
Miscellaneous Q6H (every 6 hours) as needed for Thick secretion.

5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash.
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for sob/wheeze.
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
11. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day) as needed for constipation.
12. Insulin Regular Human 100 unit/mL Solution Sig: see attached
insulin scale units Injection per attached regimen: Please give
insulin regimen as instructed on attached scale.
Disp:*qs * Refills:*2*
13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
14. Metoclopramide 5 mg/mL Solution Sig: Five (5) mg Injection
Q6H (every 6 hours).
15. Linezolid 600 mg/300 mL Parenteral Solution Sig: Six Hundred
(600) mg Intravenous Q12H (every 12 hours): to be continued
until [**2199-2-12**].
16. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) mg Intravenous Q8H (every 8 hours): to be
continued until [**2199-2-12**].  On dialysis days, please give
AFTER dialysis.
17. Oxycodone 5 mg/5 mL Solution Sig: Five (5) mg PO every [**4-9**]
hours as needed for pain: please hold for sedation, RR < 10.
18. Ampicillin Sodium 1 gram Recon Soln Sig: Two (2) grams
Intravenous every twelve (12) hours: Please give from [**2-12**]
to [**3-2**].  On dialysis days, please dose AFTER dialysis.
Disp:*qs * Refills:*2*


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 81662**] Med Ctr.

Discharge Diagnosis:
1. Thoracic osteomyelitis T9-10 with epidural abscess
2. Atrial fibrillation
3. Pneumonia
4. Apical pneumothorax
5. End stage renal disease
6. Post-operative fevers
7. Post-op acute blood loss anemia
8. Diabetes
9. Paraplegia
10. Heparin-induced thrombocytopenia


Discharge Condition:
Alert, responsive, mouths words but does not consistently
respond to questions or commands.  Moves both arms, but
paraplegic.


Discharge Instructions:
You have undergone the following operation: ANTERIOR/POSTERIOR
Thoracic debridement and fusion with instrumentation

Please engage in physical therapy as the patient can tolerate

You should take your antibiotics as prescribed for the full
course of treatment.  You will need to take Linezolid and Flagyl
until [**2-12**], then stop those antibiotics and start
ampicillin, from [**2-12**] through [**3-2**] (completing an
8 week course in total).

While taking antibiotics, you should have labs drawn once a
week, including ESR, CRP, LFT's, and CBC with diff.  These
results should be faxed to the infectious disease clinic office
at [**Hospital1 18**] - the fax number is [**Telephone/Fax (1) 1419**].

You should also continue your previous dialysis schedule, on
Tuesdays, Thursdays, and Saturdays, as coordinated by the renal
service.

Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 363**] in his clinic in 2 weeks.  Call
[**Telephone/Fax (1) **] for an appointment.

You should also followup with the infectious disease clinic
before you finish your course of antibiotics on [**3-2**].
You can call [**Telephone/Fax (1) 457**] to schedule an appointment.
{'Streptococcal septicemia,Septic shock,Acute kidney failure, unspecified,Intraspinal abscess,End stage renal disease,Pneumonia, organism unspecified,Encephalopathy, unspecified,Unspecified osteomyelitis, other specified sites,Paraplegia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Unspecified pleural effusion,Iatrogenic pneumothorax,Acute posthemorrhagic anemia,Other complications due to renal dialysis device, implant, and graft,Urinary tract infection, site not specified,Dependence on respirator, status,Severe sepsis,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Renal dialysis status,Atrial fibrillation,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: Transferred from [**Hospital 4199**] Hospital for suspected T9-10 vertebral
osteomyelitis

PRESENT ILLNESS: Patient is a 67 year old Spanish-speaking female with h/o ESRD
on HD, CAD, h/o HIT, DM, s/p L BKA, and prior line infections
who is being transfered for possible vertebral osteomyelitis.

MEDICAL HISTORY: Hypertension
End Stage Renal Disease on dialysis T, TH, Sat, last session for
2 hours on [**2199-1-3**]
Peripheral Vascular Diseas, s/p left Below the Knee Amputation
Type 2 Diabetes Mellitus, insulin-dependent
Coronary Artery Disease s/p Myocardial Infarction in [**Male First Name (un) 1056**]
10 years ago, BMS placement in [**2197**]
Anemia
H/o Heparin-Induced Thrombocytopenia treated with argatroban and
h/o Deep vein Thrombosis (associated with line placement) in
[**9-12**], treated with coumadin x 1 month
Hypercholesterolemia
Obesity
Dibabetic Neuropathy in legs
H/o cholecystectomy [**2196**]
H/o appendectomy
Hypercalcemia
Groin line sepsis with stenotrophomonas in [**9-12**], MRSA line
infection [**9-9**]
R knee osteoarthritis
Left arm fistula [**9-/2198**], right arm fistula now occluded

MEDICATION ON ADMISSION: Amlodipine 10mg po daily
Cimetidine 20mg po daily
Florastor 250mg po daily
Folic Acid 1mg po daily
Insulin 32 units SC at bedtime plus RISS
Isosorbide Dinitrate 20mg po TID
Lipitor 20mg po daily
Lisinopril 5mg po daily
Toprol XL 200mg po daily
Nephrocaps 1mg po daily
Percocet 5/325 1 tab po q4h prn for pain
Renagel 800mg po TID
Sensipar 90mg po daily
Vancomycin 1gm IV with dialysis, last dose [**2199-1-3**]
Gabapentin 100mg po daily
*Stopped Plavix 75mg po daily for possible procedure

ALLERGIES: Heparin Agents / Aspirin / Albuterol

PHYSICAL EXAM: VITALS: T 97.6 HR 86 141/41 20 100% on 40% trach mask
GENERAL - elderly obese female, alert, responsive, makes eye
contact.  Does not respond to questions or commands, but
interacts.
HEENT - PERRL, EOMI, MMM
NECK - supple, tracheostomy in place
LUNGS - Decreased breath sounds at bases bilaterally, air
movement R > L.  Coarse rales more on left.
HEART - Regular rate and rhythm with 2/6 systolic murmur.
ABDOMEN - obese, + BS, soft, non-tender to palpation.  PEG tube
in place.
EXTREMITIES - Edematous bilaterally, [**1-5**]+.  1+ pedal pulses in
right foot, has left BKA.
NEURO: no sensation or movement of lower extremities.  Moves
upper extremities bilaterally and spontaneously, moves head,
mouths words (trach in place).  Clearly alert and responsive,
but does not repsond to commands, will occasionally respond to
questions.  Spanish-speaking only.
SKIN - multiple wounds, post-surgical and pressure wounds, as
detailed below.

FAMILY HISTORY: There is no family history of sudden death. Mother died of an MI

SOCIAL HISTORY: Social history is significant for the absence of current tobacco
use, quit smoking in [**2194**]. There is no history of alcohol abuse.
Lives at home with her husband, daughter, son and [**Name2 (NI) 802**]. She is
originally form [**Male First Name (un) 1056**]. She does not speak English. 

### Response:
{'Streptococcal septicemia,Septic shock,Acute kidney failure, unspecified,Intraspinal abscess,End stage renal disease,Pneumonia, organism unspecified,Encephalopathy, unspecified,Unspecified osteomyelitis, other specified sites,Paraplegia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Unspecified pleural effusion,Iatrogenic pneumothorax,Acute posthemorrhagic anemia,Other complications due to renal dialysis device, implant, and graft,Urinary tract infection, site not specified,Dependence on respirator, status,Severe sepsis,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Renal dialysis status,Atrial fibrillation,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status'}
