CHIEF COMPLAINT: Fevers and SOB

PRESENT ILLNESS: Ms. [**Known lastname 37559**] is a 54F with multiple medical problems, most s/f
ESRD on HD, and severe PVD c/b multiple stump infections with
highly resistant organisms who presented to the ED with fevers
to 101 for the past two days at her nursing home. Today she was
noted to be hypoxic to 85% on room air. ROS is notable for
generalized weakness, shortness of breath, nausea, and diarrhea.
She denies headache, sinus congestion, sore throat, or cough.
.

MEDICAL HISTORY: - Peripheral Vascular Disease s/p L SFA-DP bypass for L
gangrenous heel in [**2187**]; s/p R proximal SF-proximal AT bypass in
[**4-4**]; s/p multiple debridements of b/l LE for
infected/non-healing wounds; s/p L BKA [**12-6**], L AKA for
non-healing BKA ulcer (prior MRSA, VRE and MDR Klebsiella) [**1-6**]

MEDICATION ON ADMISSION: -1500mL fluid restriction
-CINACALCET 60mg daily
-HEPARIN 5000 units TID
-ISS
-METOCLOPRAMIDE 5mg with meals
-METOPROLOL tartrate 12.5mg [**Hospital1 **]
-MIRTAZAPINE 15mg QHS
-NEPHROCAPS daily
-SEVELAMER HCL 800MG three tabs TID
-SIMVASTATIN 10mg daily
-TRAMADOL 50mg [**Hospital1 **]
-ASPIRIN 81 mg daily
-Trazodone 25mg qhs prn
-Folic acid 1mg daily
-buproprion 75mg dialy
-bowel regimen

ALLERGIES: Lisinopril

PHYSICAL EXAM: per admitting team:
VITAL SIGNS:
T=100.7... BP=111/51... HR=82... RR=22... O2=94% on 4L
GENERAL: Obese african american female in NAD, having trouble
finishing sentences from shortness of breath.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: Obese, soft, NABS
EXTREMITIES: Left AKA c/d/i, no skin breakdown. RLE cool, with
good pulses. No edema or calf pain at that site.
SKIN: Stage II pressure ulcer on posterior aspect of left thigh,
appears new.
PSYCH: Listens and responds to questions appropriately, pleasant

FAMILY HISTORY: Mother died of stomach cancer in her 40s. Father had an unknown
cancer in his 70s. Stated that diabetes, high cholesterol, and
high blood pressure run in her family.

SOCIAL HISTORY: Admitted from rehab. Has two sisters, one daughter.  [**Name (NI) **] is
a former smoker with a 30 pack year history, quit 20 years ago.
Unspecified osteomyelitis, other specified sites,End stage renal disease,Bacteremia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Other and unspecified disc disorder, cervical region,Hyperpotassemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Anemia, unspecified,Thrombocytopenia, unspecified,Chronic airway obstruction, not elsewhere classified,Obstructive sleep apnea (adult)(pediatric),Below knee amputation status
Osteomyelit NOS-oth site,End stage renal disease,Bacteremia,Hyp kid NOS w cr kid V,MRSA elsewhere/NOS,Disc dis NEC/NOS-cerv,Hyperpotassemia,DMII wo cmp nt st uncntr,Anemia NOS,Thrombocytopenia NOS,Chr airway obstruct NEC,Obstructive sleep apnea,Status amput below knee
Admission Date:  [**2192-11-2**]              Discharge Date:   [**2192-11-21**]

Date of Birth:  [**2138-3-6**]             Sex:   F

Service: MEDICINE

Allergies:
Lisinopril

Attending:[**First Name3 (LF) 3283**]
Chief Complaint:
Fevers and SOB

Major Surgical or Invasive Procedure:
HD tunneled line removal
HD tunneled line placement
hemodialysis
TEE
Corpectomy anterior C4-C5


History of Present Illness:
Ms. [**Known lastname 37559**] is a 54F with multiple medical problems, most s/f
ESRD on HD, and severe PVD c/b multiple stump infections with
highly resistant organisms who presented to the ED with fevers
to 101 for the past two days at her nursing home. Today she was
noted to be hypoxic to 85% on room air. ROS is notable for
generalized weakness, shortness of breath, nausea, and diarrhea.
She denies headache, sinus congestion, sore throat, or cough.
.


Past Medical History:
- Peripheral Vascular Disease s/p L SFA-DP bypass for L
gangrenous heel in [**2187**]; s/p R proximal SF-proximal AT bypass in
[**4-4**]; s/p multiple debridements of b/l LE for
infected/non-healing wounds; s/p L BKA [**12-6**], L AKA for
non-healing BKA ulcer (prior MRSA, VRE and MDR Klebsiella) [**1-6**]

- Likely left AKA stump osteomyelitis requiring admission in
[**3-/2192**], on IV antibiotics, VAC dressing in place
- ESRD on HD. Last HD yesterday. Usually MWF schedule.
- HTN
- Diabetes Mellitus
- Renal Cell Carcinoma s/p right nephrectomy
- Obesity
- Depression
- s/p CCY
- Gastric Ulcer
- Obstructive Sleep Apnea. The patient reports that she used to
use a CPAP however her machine broke and she no longer uses it.

- Gastroparesis
- COPD on 3-4L NC baseline
- h/o ischemic colitis
- left adrenal adenoma


Social History:
Admitted from rehab. Has two sisters, one daughter.  [**Name (NI) **] is
a former smoker with a 30 pack year history, quit 20 years ago.


Family History:
Mother died of stomach cancer in her 40s. Father had an unknown
cancer in his 70s. Stated that diabetes, high cholesterol, and
high blood pressure run in her family.

Physical Exam:
per admitting team:
VITAL SIGNS:
T=100.7... BP=111/51... HR=82... RR=22... O2=94% on 4L
GENERAL: Obese african american female in NAD, having trouble
finishing sentences from shortness of breath.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: Obese, soft, NABS
EXTREMITIES: Left AKA c/d/i, no skin breakdown. RLE cool, with
good pulses. No edema or calf pain at that site.
SKIN: Stage II pressure ulcer on posterior aspect of left thigh,
appears new.
PSYCH: Listens and responds to questions appropriately, pleasant



Pertinent Results:
Admitting labs:
Trop-T: 0.14
CK: 97  MB: Notdone
.
133  93  31
--------------< 203
4.6  34  4.2
ALT: 25 AP: 154 Tbili: 0.5 Alb:
AST: 28 LDH: 263 Dbili:  TProt:
[**Doctor First Name **]: 57 Lip: 57
.
WBC: 5.8
HCT: 32
PLT: 97
N:81.1 L:10.3 M:7.6 E:0.5 Bas:0.5
.
Trends:
HCT stale 28-32
ALT and AST normal
.
Micro:
High Grade MRSA Bacteremia - last positive blood cx: [**11-13**]
Tissue from c-spine [**Doctor First Name **] grew MRSA
.
CT NECK:
IMPRESSION:
1. No focal signs of infection or abscess in the neck.
2. Probable small right pleural effusion.
CT Abdomen/Pelvis:
IMPRESSION:
1. No evidence of ischemia and no etiology for diffuse abdominal
pain.
2. Stable extensive vasculopathy.
3. Small right pleural effusion, perihepatic fluid, and
generalized anasarca without evidence of abscess.
TTE:
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality as the patient was difficult to
position. Suboptimal image quality - patient unable to
cooperate.
Conclusions
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. The right ventricular cavity is moderately dilated.
Free wall motion could not be assessed. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
[**11-9**] MRI C spine:
1. Confirming the suspicion of infectious phlegmon in the left
more than right ventral epidural space, extending over roughly 4
cm (CC), from the C3 through C6 level. Though there is no
specific evidence of liquefactive necrosis to suggest frank
abscess formation, such findings are unusual, in general, in the
cervical spine, and this study has poor contrast resolution.
2. Process is centered on the C3 through C5 vertebrae, which
demonstrate
abnormal signal and patchy heterogeneous enhancement after
contrast
administration, suggestive of vertebral osteomyelitis, with
probable component of discitis at the C4-5 level, at least.
There is also a prevertebral component to the phlegmon, as
demonstrated on the earlier study.
3. No cervical spinal cord signal abnormality at this time.
4 No other finding suspicious for osteomyelitis or epidural
abscess in the remainder of the cervical or thoracolumbar spine
(though the imaging is quite limited).
.
[**11-16**] C Spine CT:
Status post C4 and C5 vertebrectomy and anterior fusion with
normal alignment.


Brief Hospital Course:
54 year-old woman initially admitted w fever and found to have
persistent MRSA bacteremia.  Hospital course by problem:
.
1. Cervical osteomyelitis, MRSA bacteremia: She underwent spine
imaging and TEE.  Noted to have osteo of c-spine.  Her HD line
was pulled and she underwent a line holiday.  She was treated
with c4/5 corpectomy and c3-6 anterior fusion on [**11-15**] by spine
surgery.  The tissue grew MRSA.  Last positive blood cx was from
[**11-13**].  Patient will need the following:
- continue [**Location (un) **] J per spine team.  She may remove for shower
only
- continue IV vanco dosing w dialysis.  Continue rifampin [**Hospital1 **].
She will need 6 weeks of total therapy from [**11-15**] - [**12-27**].  She
will followup with the [**Hospital **] clinic.  She will need surveillance
labs sent WEEKLY to the [**Hospital **] clinic attng Dr. [**First Name (STitle) **] via f
[**Telephone/Fax (1) **]
- f/u with neurosurgery, Dr. [**Last Name (STitle) 548**], within the next 4-6 weeks.
- Please remove staples on [**11-23**] per neurosurgery team.
- continue surveillance blood cultures intermittently during HD
- oxycodone, tylenol, tramadol prn, lidocaine patch for pain
control
.
2. End-stage renal disease on HD: Continue HD T,Th,Sat as
scheduled.  She underwent line holiday with new HD line placed
in left IJ on [**11-19**].  She tolerated HD well with her new line
prior to discharge.  F/u with renal team.  Continue phos
binders.
.
3. Diabetes mellitus: continue outpt regimen of DM control
- metoclopramide for gastroparesis prn
.
4. Insomnia, depression
- continue bupropion, trazadone, mirtazapine,
.
5. Right eye pain - seen by ophthmo and dx w episcleritis during
hosp stay.  Received motrin 800mg q8h scheduled.  Had no eye
pain by discharge.  We recommend using motrin prn then
discontinuing it as tolerated.  She is at risk of GIB given her
renal disease so this should not be longterm med.
- she should f/u with Dr. [**First Name (STitle) **] in ophthmo in [**Last Name (un) **].
.
6. CAD, hypertension, hyperlipidemia
- continue metoprolol, statin; held ASA post-operatively
- restarted ASA 81mg on [**11-21**].  Ok per d/w neurosurgery
.
FEN. renal diet; sevelamer with meals when eating
Access. PIVx2, L subclavian CVL
- L subclavian CVL was removed on [**11-21**] prior to discharge to
rehab

Prophylaxis. HepSQ; bowel regimen
Code. Full


Medications on Admission:
-1500mL fluid restriction
-CINACALCET 60mg daily
-HEPARIN 5000 units TID
-ISS
-METOCLOPRAMIDE 5mg with meals
-METOPROLOL tartrate 12.5mg [**Hospital1 **]
-MIRTAZAPINE 15mg QHS
-NEPHROCAPS daily
-SEVELAMER HCL 800MG three tabs TID
-SIMVASTATIN 10mg daily
-TRAMADOL 50mg [**Hospital1 **]
-ASPIRIN 81 mg daily
-Trazodone 25mg qhs prn
-Folic acid 1mg daily
-buproprion 75mg dialy
-bowel regimen


Discharge Medications:
1. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
3. Insulin Lispro 100 unit/mL Solution Sig: variable units
Subcutaneous four times a day: routine insulin sliding scale.
4. Metoclopramide 5 mg Tablet Sig: One (1) Tablet PO four times
a day: w meals.
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
8. Sevelamer Carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
9. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO BID PRN () as
needed for pain.
11. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
12. Bupropion 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
15. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours): scheduled.
16. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for Episcleritis: continue prn x1 week then wean off.

17. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12h on,
12h off.
18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
19. Rifampin 150 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours): continue until [**12-28**].
20. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for neck pain: wean off as tolerated.
21. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous HD PROTOCOL (HD Protochol): give with HD per
protocol.  continue until [**12-28**].
22. home O2
continue home O2 as per previous
23. 1500ml fluid restriction
24. Outpatient Lab Work
Please obtain weekly LFTs, CBC, electrolytes and fax to [**Hospital **]
clinic attng Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 432**]
25. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.


Discharge Disposition:
Extended Care

Facility:
[**Location (un) **] nursing facility

Discharge Diagnosis:
Primary:
Cervical Discitis and osteomyelitis
MRSA bacteremia
ESRD on HD
Secondary:
Anemia chronic inflammation
PVD s/p L AKA
obesity hypoventilation syndrome
PUD


Discharge Condition:
Stable, on 3L O2


Discharge Instructions:
You came in with fevers and were found to have a MRSA
bacteremia.  The source was osteomyelitis of the cervical spine.
 You underwent spine surgery to remove the infection and your
blood cultures cleared.  You tolerated this procedure well.

It is very important that you stay on your antibiotics at least
until [**12-28**] or until told otherwise by your infectious
disease doctor.  You will be treated with vancomycin (with
dialysis) and rifampin (orally).

Please keep all followup appointments.  Please keep the neck
collar onn at ALL TIMES unless taking a shower.  Please return
if you experience fevers, chills, weakness, inability to eat,
chest pain, or trouble breathing.

??????	Do not smoke.
??????	Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery. When washing
be gentle. Do not scrub, and pat dry.

??????	No pulling up, lifting more than 10 lbs., or excessive bending
or twisting. Avoid vigorous pulling or tugging on your arms.
??????	Limit your use of stairs to 2-3 times per day.
??????	You are required to wear your cervical collar at all times,
except when showering

Your sutures should be removed from your neck on [**11-23**].  This
can be done by the rehab staff.

CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:

??????	Pain that is continually increasing or not relieved by pain
medicine.
??????	Any weakness, numbness, tingling in your extremities.
??????	Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
??????	Fever greater than or equal to 101?????? F.
??????	Any change in your bowel or bladder habits (such as loss of
bowl or urine control).


Followup Instructions:
Please followup with Dr. [**Last Name (STitle) 548**] in 6weeks. Please call for an
appointment [**Telephone/Fax (1) 2992**]

Please followup with Dr. [**First Name (STitle) **] in the [**Hospital **] clinic.  Call ([**Telephone/Fax (1) 10**] for an appointment.

Please have weekly LFTs, CBC, and electrolytes faxed to [**Hospital **]
clinic (attng Dr. [**First Name (STitle) **] via f: [**Telephone/Fax (1) **]

Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8145**], M.D. Date/Time:[**2193-1-3**] 10:10
{'Unspecified osteomyelitis, other specified sites,End stage renal disease,Bacteremia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Other and unspecified disc disorder, cervical region,Hyperpotassemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Anemia, unspecified,Thrombocytopenia, unspecified,Chronic airway obstruction, not elsewhere classified,Obstructive sleep apnea (adult)(pediatric),Below knee amputation 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: Fevers and SOB

PRESENT ILLNESS: Ms. [**Known lastname 37559**] is a 54F with multiple medical problems, most s/f
ESRD on HD, and severe PVD c/b multiple stump infections with
highly resistant organisms who presented to the ED with fevers
to 101 for the past two days at her nursing home. Today she was
noted to be hypoxic to 85% on room air. ROS is notable for
generalized weakness, shortness of breath, nausea, and diarrhea.
She denies headache, sinus congestion, sore throat, or cough.
.

MEDICAL HISTORY: - Peripheral Vascular Disease s/p L SFA-DP bypass for L
gangrenous heel in [**2187**]; s/p R proximal SF-proximal AT bypass in
[**4-4**]; s/p multiple debridements of b/l LE for
infected/non-healing wounds; s/p L BKA [**12-6**], L AKA for
non-healing BKA ulcer (prior MRSA, VRE and MDR Klebsiella) [**1-6**]

MEDICATION ON ADMISSION: -1500mL fluid restriction
-CINACALCET 60mg daily
-HEPARIN 5000 units TID
-ISS
-METOCLOPRAMIDE 5mg with meals
-METOPROLOL tartrate 12.5mg [**Hospital1 **]
-MIRTAZAPINE 15mg QHS
-NEPHROCAPS daily
-SEVELAMER HCL 800MG three tabs TID
-SIMVASTATIN 10mg daily
-TRAMADOL 50mg [**Hospital1 **]
-ASPIRIN 81 mg daily
-Trazodone 25mg qhs prn
-Folic acid 1mg daily
-buproprion 75mg dialy
-bowel regimen

ALLERGIES: Lisinopril

PHYSICAL EXAM: per admitting team:
VITAL SIGNS:
T=100.7... BP=111/51... HR=82... RR=22... O2=94% on 4L
GENERAL: Obese african american female in NAD, having trouble
finishing sentences from shortness of breath.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: Obese, soft, NABS
EXTREMITIES: Left AKA c/d/i, no skin breakdown. RLE cool, with
good pulses. No edema or calf pain at that site.
SKIN: Stage II pressure ulcer on posterior aspect of left thigh,
appears new.
PSYCH: Listens and responds to questions appropriately, pleasant

FAMILY HISTORY: Mother died of stomach cancer in her 40s. Father had an unknown
cancer in his 70s. Stated that diabetes, high cholesterol, and
high blood pressure run in her family.

SOCIAL HISTORY: Admitted from rehab. Has two sisters, one daughter.  [**Name (NI) **] is
a former smoker with a 30 pack year history, quit 20 years ago. 

### Response:
{'Unspecified osteomyelitis, other specified sites,End stage renal disease,Bacteremia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Other and unspecified disc disorder, cervical region,Hyperpotassemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Anemia, unspecified,Thrombocytopenia, unspecified,Chronic airway obstruction, not elsewhere classified,Obstructive sleep apnea (adult)(pediatric),Below knee amputation status'}
