CHIEF COMPLAINT: SEPSIS, HX NEC FASC

PRESENT ILLNESS: 62 yo man w/DM, HTN, recent admission for necrotizing fasciitis,
now readmitted with sepsis. During recent admission from [**11-18**]
to
[**2139-12-15**], pt had operative debridement of necrotizing fasciitis
of the LLE and groin on [**11-18**], as well as f/u bedside
debridements. He initially was started on zosyn, vanco, clinda,
and flagyl. [**11-18**] Intra-op tissue cultures grew coag neg staph
and pan-[**Last Name (un) 36**] E. Coli, and ABx narrowed to vanco & [**Last Name (un) 2830**]. Due to
cytopenias, switched to dapto & [**Last Name (un) 2830**], and completed total 21 day
course. [**12-1**] cath tip grew C. albicans. o/w multiple blood Cx
all negative. Hospital course c/b bilat PE resulting in
intubation, pt discharged on warfarin. Pt discharged to rehab on
[**12-15**] on VAC, with PICC in place, and off antibiotics. He was
originally scheduled for STSG surgery on [**2140-1-5**].

MEDICAL HISTORY: PAST MEDICAL/SURGICAL HISTORY:
*Nec fasc as above
*Diabetes mellitus type 2
*Asthma
*Bronchitis
*Hypertension
*Hyperlipidemia
*Obesity
*s/p knee surgery

MEDICATION ON ADMISSION: Lovastatin 20', Lisinopril 20', Metoprolol 25'', ISDN 30',
Albuterol, Ipatropium, Combivent, Glyburide 5AM, 2.5HS,
Omeprazole 40', Advair 250/50'', [**Doctor First Name **] 60'', Ibuprofen 800'',

ALLERGIES: All drug allergies previously recorded have been deleted

PHYSICAL EXAM: Tmax: 100.4  P: 95  R: 19  BP: 115/57 off pressors, O2Sat 100%
2L NC
General: obese man in NAD, speech fluent
HEENT: NCAT, PERRL, OP clear without exudates/lesions, lower lip
with crusted eschar ("cut myself shaving")
Neck: no LAD/JVD, R IJ CVL c/d/i
Lungs: CTA B
Heart: RRR, no m/r/g
Abdom: +BS, NT, ND, soft
Extrem:
*LLE edematous, warm, non-tender, diffuse erythema sparing knee
only, extending from toes to L flank.
*Ant thigh & groin wound with good granulation tissue, no pus,
good margins.
*RUE PICC no erythema
GU: Foley intact, groin with erythema
Neuro: MAE, PERRL
Skin: no other rash.

FAMILY HISTORY: NC

SOCIAL HISTORY: Arrived from rehab. Formerly lived alone. On disability.
Tob: quit 3 months ago after 54 yrs of smoking.
EtOH: quit 3 mo. ago
Other postoperative infection,Streptococcal septicemia,Sepsis,Cellulitis and abscess of leg, except foot,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic obstructive asthma, unspecified,Unspecified essential hypertension,Other and unspecified hyperlipidemia
Other postop infection,Streptococcal septicemia,Sepsis,Cellulitis of leg,DMII wo cmp nt st uncntr,Chronic obst asthma NOS,Hypertension NOS,Hyperlipidemia NEC/NOS
Admission Date:  [**2140-1-3**]              Discharge Date:   [**2140-1-11**]

Date of Birth:  [**2077-8-1**]             Sex:   M

Service: SURGERY

Allergies:
All drug allergies previously recorded have been deleted

Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
SEPSIS, HX NEC FASC

Major Surgical or Invasive Procedure:
None


History of Present Illness:
62 yo man w/DM, HTN, recent admission for necrotizing fasciitis,
now readmitted with sepsis. During recent admission from [**11-18**]
to
[**2139-12-15**], pt had operative debridement of necrotizing fasciitis
of the LLE and groin on [**11-18**], as well as f/u bedside
debridements. He initially was started on zosyn, vanco, clinda,
and flagyl. [**11-18**] Intra-op tissue cultures grew coag neg staph
and pan-[**Last Name (un) 36**] E. Coli, and ABx narrowed to vanco & [**Last Name (un) 2830**]. Due to
cytopenias, switched to dapto & [**Last Name (un) 2830**], and completed total 21 day
course. [**12-1**] cath tip grew C. albicans. o/w multiple blood Cx
all negative. Hospital course c/b bilat PE resulting in
intubation, pt discharged on warfarin. Pt discharged to rehab on
[**12-15**] on VAC, with PICC in place, and off antibiotics. He was
originally scheduled for STSG surgery on [**2140-1-5**].

On [**1-3**], at rehab, pt developed temp 101.2, BP 80/55, w/foul
smell from VAC (last changed 2 days ago), and erythema around
VAC
site. Pt presented to OSH, T 101, hypotensive despite 2L IVF,
36%
bands on manual diff, Rec'd vanco, clinda, levoflox, started on
pressors and transferred to [**Hospital1 18**]. CTA there neg for PE for w/u
of SOB. Per pt, had no pain on LLE, but redness that has
progressed over past 2 weeks.

On arrival here, T 97.3, still on pressors. Exam at that time
notable for foul odor, beefy soft tissue in wound, and light
crepitus over L med thigh. CT showed no gas or fluid collection.
Started empirically on meropenem, vancomycin, flagyl, and
fluconazole. Overnight, IJ CVL and R art line inserted. This AM,
weaned off pressors.


Past Medical History:
PAST MEDICAL/SURGICAL HISTORY:
*Nec fasc as above
*Diabetes mellitus type 2
*Asthma
*Bronchitis
*Hypertension
*Hyperlipidemia
*Obesity
*s/p knee surgery


Social History:
Arrived from rehab. Formerly lived alone. On disability.
Tob: quit 3 months ago after 54 yrs of smoking.
EtOH: quit 3 mo. ago


Family History:
NC

Physical Exam:
Tmax: 100.4  P: 95  R: 19  BP: 115/57 off pressors, O2Sat 100%
2L NC
General: obese man in NAD, speech fluent
HEENT: NCAT, PERRL, OP clear without exudates/lesions, lower lip
with crusted eschar ("cut myself shaving")
Neck: no LAD/JVD, R IJ CVL c/d/i
Lungs: CTA B
Heart: RRR, no m/r/g
Abdom: +BS, NT, ND, soft
Extrem:
*LLE edematous, warm, non-tender, diffuse erythema sparing knee
only, extending from toes to L flank.
*Ant thigh & groin wound with good granulation tissue, no pus,
good margins.
*RUE PICC no erythema
GU: Foley intact, groin with erythema
Neuro: MAE, PERRL
Skin: no other rash.


Pertinent Results:
[**2140-1-5**] 01:52AM BLOOD WBC-4.0 RBC-3.32* Hgb-10.8* Hct-29.8*
MCV-90 MCH-32.7* MCHC-36.5* RDW-15.5 Plt Ct-112*
[**2140-1-7**] 05:02AM BLOOD WBC-8.0# RBC-3.68* Hgb-11.5* Hct-32.8*
MCV-89 MCH-31.2 MCHC-34.9 RDW-15.4 Plt Ct-130*
[**2140-1-7**] 05:02AM BLOOD Glucose-53* UreaN-9 Creat-0.7 Na-139
K-4.1 Cl-106 HCO3-30 AnGap-7*
[**2140-1-4**] 01:20AM BLOOD ALT-34 AST-38 AlkPhos-54 TotBili-0.8
[**2140-1-7**] 05:02AM BLOOD Calcium-7.7* Phos-3.9 Mg-1.7
[**2140-1-6**] 06:06AM BLOOD Vanco-13.8
[**2140-1-3**] 07:31PM BLOOD Lactate-2.4*
[**2140-1-4**] 01:45AM BLOOD Lactate-1.3
.
Radiology Report CT PELVIS W/O CONTRAST Study Date of [**2140-1-3**]
7:53 PM
IMPRESSION:
1. Compared to prior exam, there is improved bibasilar
atelectasis and
resolution of small bilateral pleural effusions.
2. Post-surgical changes involving the left groin and
anterolateral thigh.
Extensive subcutaneous edema involving the postsurgical site and
extending
down the left leg to the ankle, which may be related ongoing
cellulitis. No discrete fluid collection or subcutaneous
emphysema.
.
[**2140-1-3**] 7:32 pm SWAB     Site: LEG      LEFT THIGH.
                            **FINAL REPORT [**2140-1-5**]**
   GRAM STAIN (Final [**2140-1-3**]):
      2+   (1-5 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      4+   (>10 per 1000X FIELD):   GRAM POSITIVE ROD(S).
      3+  (5-10 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS.
   WOUND CULTURE (Final [**2140-1-5**]):
      Due to mixed bacterial types (>=3) an abbreviated workup
is
      performed; P.aeruginosa, S.aureus and beta strep. are
reported if
      present. Susceptibility will be performed on P.aeruginosa
and
      S.aureus if sparse growth or greater..
      BETA STREPTOCOCCI, NOT GROUP A.    SPARSE GROWTH.
.
[**2140-1-4**] 7:00 pm CATHETER TIP-IV      Source: PICC.
      **FINAL REPORT [**2140-1-6**]**
      WOUND CULTURE (Final [**2140-1-6**]):
      BETA STREPTOCOCCUS GROUP C.    >15 colonies.
.
[**2140-1-9**] 02:33AM BLOOD PT-19.6* INR(PT)-1.8*
[**2140-1-10**] 04:23AM BLOOD PT-18.9* INR(PT)-1.7*
[**2140-1-11**] 04:41AM BLOOD PT-20.0* PTT-48.7* INR(PT)-1.9*
[**2140-1-8**] 04:41AM BLOOD Glucose-50* UreaN-9 Creat-0.7 Na-140
K-4.0 Cl-105 HCO3-30 AnGap-9

Brief Hospital Course:
This is a 62 yo w/DM, recent admit for nec fasc, who presents
with sepsis, GPC bacteremia, likely due to skin & soft tissue
infection of LLE and perineum. Given that organism (GPC in
chains, likely strep) has been isolated in blood, recommend
continuing meropenem and vancomycin for broad GPC/GNR coverage,
and adding clindamycin to optimize anti-toxin effect. Would stop
flagyl & fluconazole soon,
as meropenem covers anaerobes, and no evidence of fungal
infection.

His PICC, given demonstrated bacteremia, was removed and grew
BETA STREPTOCOCCUS GROUP C.

Sepsis: He was on pressors for hypotension. His initial exam was
notable for foul odor, beefy soft tissue in wound, and light
crepitus over L med thigh. CT showed no gas or fluid collection.
He continued on ABX as stated above. ID was consulted and
following along and eventually he was switched to Penicillin G
for 14 days. A new PICC was placed on HD 5 and he will complete
his ABX course at rehab.

Necrotizing Fasciitis: His LLE and Left groin continued with
dressing changes. The Celulitis improved and the wound was
healing with beefy, red granulation tissue. Plastics deffered
grafting at this time until the cellulitis resolved and he was
off antibiotics.

Heme: He was anticoagulated for history of PE. He was
supertherapeutic on admission and Coumadin was held and INR
drifted down to a therapeutic range. Coumadin was restarted when
appropriate.

Renal: His Lasix was restarted when appropriate to help with
diuresis.

He was discharge to rehab and will continue with ABX and PT.

Medications on Admission:
Lovastatin 20', Lisinopril 20', Metoprolol 25'', ISDN 30',
Albuterol, Ipatropium, Combivent, Glyburide 5AM, 2.5HS,
Omeprazole 40', Advair 250/50'', [**Doctor First Name **] 60'', Ibuprofen 800'',

Nicotine Patch


Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Glyburide 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
8. GlyBURIDE 2.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO once a day:
Monitor INR and adjust dose accordingly.
11. Penicillin G Potassium 20,000,000 unit Recon Soln Sig: 4
million  Units Injection Q4H (every 4 hours) for 8 days: 14 days
total. Stop [**2140-1-19**].
12. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 700**] - [**Location (un) 701**]

Discharge Diagnosis:
History of Necrotizing Fasciitis
Sepsis: Shortness of breath, Hypotension
Cellulitis


Discharge Condition:
Good


Discharge Instructions:
General:
* Please look at the wound site every day for signs of infection
(increased redness, swelling, odor, yellow or bloody discharge,
fever).
-Note color, consistency, and amount of fluid in drain. Call
doctor if amount increases significantly or changes in
character.
-Continue with VAC dressing changes every 3-4 days.
-Maintain the site clean, dry, and intact.
-Avoid swimming, baths, hot tubs-do not submerge yourself in
water.

*Please call your doctor or return to the ER for any of the
following:
* Increased pain, and erythema of your leg wound.
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.

* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.


Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8318**], MD Phone:[**Telephone/Fax (1) 2359**]
Date/Time:[**2140-1-20**] 9:15
Provider: [**Name10 (NameIs) **] SURGERY CLINIC Phone:[**Telephone/Fax (1) 4652**]
Date/Time:[**2140-1-15**] 1:30



Completed by:[**2140-1-11**]
{'Other postoperative infection,Streptococcal septicemia,Sepsis,Cellulitis and abscess of leg, except foot,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic obstructive asthma, unspecified,Unspecified essential hypertension,Other and unspecified hyperlipidemia'}


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: SEPSIS, HX NEC FASC

PRESENT ILLNESS: 62 yo man w/DM, HTN, recent admission for necrotizing fasciitis,
now readmitted with sepsis. During recent admission from [**11-18**]
to
[**2139-12-15**], pt had operative debridement of necrotizing fasciitis
of the LLE and groin on [**11-18**], as well as f/u bedside
debridements. He initially was started on zosyn, vanco, clinda,
and flagyl. [**11-18**] Intra-op tissue cultures grew coag neg staph
and pan-[**Last Name (un) 36**] E. Coli, and ABx narrowed to vanco & [**Last Name (un) 2830**]. Due to
cytopenias, switched to dapto & [**Last Name (un) 2830**], and completed total 21 day
course. [**12-1**] cath tip grew C. albicans. o/w multiple blood Cx
all negative. Hospital course c/b bilat PE resulting in
intubation, pt discharged on warfarin. Pt discharged to rehab on
[**12-15**] on VAC, with PICC in place, and off antibiotics. He was
originally scheduled for STSG surgery on [**2140-1-5**].

MEDICAL HISTORY: PAST MEDICAL/SURGICAL HISTORY:
*Nec fasc as above
*Diabetes mellitus type 2
*Asthma
*Bronchitis
*Hypertension
*Hyperlipidemia
*Obesity
*s/p knee surgery

MEDICATION ON ADMISSION: Lovastatin 20', Lisinopril 20', Metoprolol 25'', ISDN 30',
Albuterol, Ipatropium, Combivent, Glyburide 5AM, 2.5HS,
Omeprazole 40', Advair 250/50'', [**Doctor First Name **] 60'', Ibuprofen 800'',

ALLERGIES: All drug allergies previously recorded have been deleted

PHYSICAL EXAM: Tmax: 100.4  P: 95  R: 19  BP: 115/57 off pressors, O2Sat 100%
2L NC
General: obese man in NAD, speech fluent
HEENT: NCAT, PERRL, OP clear without exudates/lesions, lower lip
with crusted eschar ("cut myself shaving")
Neck: no LAD/JVD, R IJ CVL c/d/i
Lungs: CTA B
Heart: RRR, no m/r/g
Abdom: +BS, NT, ND, soft
Extrem:
*LLE edematous, warm, non-tender, diffuse erythema sparing knee
only, extending from toes to L flank.
*Ant thigh & groin wound with good granulation tissue, no pus,
good margins.
*RUE PICC no erythema
GU: Foley intact, groin with erythema
Neuro: MAE, PERRL
Skin: no other rash.

FAMILY HISTORY: NC

SOCIAL HISTORY: Arrived from rehab. Formerly lived alone. On disability.
Tob: quit 3 months ago after 54 yrs of smoking.
EtOH: quit 3 mo. ago 

### Response:
{'Other postoperative infection,Streptococcal septicemia,Sepsis,Cellulitis and abscess of leg, except foot,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic obstructive asthma, unspecified,Unspecified essential hypertension,Other and unspecified hyperlipidemia'}
