CHIEF COMPLAINT: Shortness of breath

PRESENT ILLNESS: Ms [**Known lastname 24166**] is a 54 y/o F with hx of long-standing T1DM,
long-standing tobacco abuse (recently quit) and chronic
osteomyelitis of the foot who came to the ED after calling EMS
for experiencing acute-onset shortness of breath while lying in
bed at home.  She denied chest pain or palpitations.  She was
found by EMS to be hypoxic to 70s on room air, with increased
work of breathing and tachycardia to the 110s.  She was given
nebulizers en route to the ED, without significant improvement.

MEDICAL HISTORY: per d/c summary [**2119-11-18**], confirmed with patient
- DM1 - insulin dependent, poorly controlled HBA1c 12%, managed
by
[**Last Name (un) **] Dr. [**First Name (STitle) **]
- DM associated neuropathy
- HTN
- HLD - LDL 102 in [**2112**]
- Back pain s/p fall
- History of osteomyelitis left hallux s/p ulcer infection
debridement [**4-/2119**] and again 12/[**2118**].
- Trigger release right index and long fingers [**6-/2118**]
- s/p Left first toe and ray amputation [**2119-11-15**]- Dr.
[**Last Name (STitle) **]

MEDICATION ON ADMISSION: AMLODIPINE - 5 mg daily
CIPROFLOXACIN - 500 mg [**Hospital1 **]
INSULIN GLARGINE [LANTUS] - 15 units at bedtime
INSULIN LISPRO [HUMALOG] - SS scale
LIDOCAINE - 5 % (700 mg/patch) Adhesive Patch, Medicated - 1
once a day as needed for back pain
METOPROLOL SUCCINATE [TOPROL XL] - 50 mg daily
MOXIFLOXACIN [AVELOX] - 400 mg daily
VANCOMYCIN - 1.25 grams Q24hrs
ASPIRIN 325 mg daily

ALLERGIES: Bactrim / daptomycin

PHYSICAL EXAM: Admission Physical Exam:
General: Alert, oriented, no acute distress, speaking in full
sentences
HEENT: Sclera anicteric, mild conjunctival injection, MMM,
oropharynx clear, EOMI
Neck: supple, JVP @8 cm H20, no LAD
CV: Tachycardic, regular, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Decreased breath sounds throughout.  No wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ radial/DP/PT pulses bilaterally, no
clubbing, cyanosis or edema.  S/p left toe amp, no erythema or
purulence
Neuro: 5/5 strength upper/lower extremities, grossly normal
sensation, 2+ reflexes bilaterally, gait deferred

FAMILY HISTORY: per d/c summary [**2119-11-18**]
Mother with DM2 and CVA, father died of MI at age 76, siblings
all healthy

SOCIAL HISTORY: per d/c summary [**2119-11-18**]
Lives with husband, no children. Works as staff assistant at
[**University/College **] [**Location (un) **]. Smokes 2 cig/day, has been smoking for 20
years used to smoke 1ppd. No ETOH or IVDA.
Acute diastolic heart failure,Acute kidney failure, unspecified,Diabetes with ketoacidosis, type I [juvenile type], uncontrolled,Hyposmolality and/or hyponatremia,Chronic osteomyelitis, ankle and foot,Other acute and subacute forms of ischemic heart disease, other,Unspecified essential hypertension,Polyneuropathy in diabetes,Long-term (current) use of insulin,Other bone involvement in diseases classified elsewhere,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Other and unspecified hyperlipidemia,Personal history of tobacco use,Anemia, unspecified,Other nonspecific abnormal serum enzyme levels,Other and unspecified disc disorder, thoracic region,Anxiety state, unspecified,Nausea with vomiting
Ac diastolic hrt failure,Acute kidney failure NOS,DMI ketoacd uncontrold,Hyposmolality,Chr osteomyelit-ankle,Ac ischemic hrt dis NEC,Hypertension NOS,Neuropathy in diabetes,Long-term use of insulin,Bone involv in oth dis,MRSA elsewhere/NOS,Hyperlipidemia NEC/NOS,History of tobacco use,Anemia NOS,Abn serum enzy level NEC,Disc dis NEC/NOS-thorac,Anxiety state NOS,Nausea with vomiting
Admission Date:  [**2119-12-6**]              Discharge Date:   [**2119-12-12**]

Date of Birth:  [**2065-11-1**]             Sex:   F

Service: MEDICINE

Allergies:
Bactrim / daptomycin

Attending:[**First Name3 (LF) 2291**]
Chief Complaint:
Shortness of breath

Major Surgical or Invasive Procedure:
None


History of Present Illness:
Ms [**Known lastname 24166**] is a 54 y/o F with hx of long-standing T1DM,
long-standing tobacco abuse (recently quit) and chronic
osteomyelitis of the foot who came to the ED after calling EMS
for experiencing acute-onset shortness of breath while lying in
bed at home.  She denied chest pain or palpitations.  She was
found by EMS to be hypoxic to 70s on room air, with increased
work of breathing and tachycardia to the 110s.  She was given
nebulizers en route to the ED, without significant improvement.

In the ED, initial VS were: 99.2 120 216/80 32 92% with neb.
Exam notable for respiratory distress with accessory muscle use
and decreased breath sounds bilaterally with expiratory wheeze.
Labs revealed anemia slightly below baseline, normal WBC count,
hyperglycemia > 600, hyponatremia, mild anion gap metabolic
acidosis, normal cardiac biomarkers, and BNP 2500.  ECG
demonstrated sinus tachycardia @ 141 bpm with lateral ST
depressions.  CXR showed vascular prominence and cephalization
of the vessels, with LLL consolidation.  The pt was given
increasing amounts of supplemental O2 but remained hypoxic; she
was started on CPAP with improvement in O2 sats and respiratory
rate.  Her hypertension was treated with nitro gtt.  She was
started on heparin gtt for empiric treatment of ACS and PE.  She
was given 8 units regular insulin; fingerstick was not
rechecked.  Bedside echo did not reveal ventricular dysfunction
or tamponade.  Pt was given 20 mg IV furosemide.  Vitals prior
to transfer were HR 120, RR 18, BP 165/62 O2 100% on CPAP.

On arrival to the MICU, she reports significant relief in
regards to her breathing.  She denies cough, fever, sick
contacts. She has never experienced similar symptoms.  Her last
fingerstick check was with breakfast yesterday, when it was 101.

Of note, the patient was seen in the [**Hospital1 18**] ED yesterday
afternoon, after her outpatient provider referred her for
nausea, vomiting, and lateral ECG changes. She had two negative
troponins and no stress test, and was discharged home.

Past Medical History:
per d/c summary [**2119-11-18**], confirmed with patient
- DM1 - insulin dependent, poorly controlled HBA1c 12%, managed
by
[**Last Name (un) **] Dr. [**First Name (STitle) **]
- DM associated neuropathy
- HTN
- HLD - LDL 102 in [**2112**]
- Back pain s/p fall
- History of osteomyelitis left hallux s/p ulcer infection
debridement [**4-/2119**] and again 12/[**2118**].
- Trigger release right index and long fingers [**6-/2118**]
- s/p Left first toe and ray amputation [**2119-11-15**]- Dr.
[**Last Name (STitle) **]

Social History:
per d/c summary [**2119-11-18**]
Lives with husband, no children. Works as staff assistant at
[**University/College **] [**Location (un) **]. Smokes 2 cig/day, has been smoking for 20
years used to smoke 1ppd. No ETOH or IVDA.


Family History:
per d/c summary [**2119-11-18**]
Mother with DM2 and CVA, father died of MI at age 76, siblings
all healthy

Physical Exam:
Admission Physical Exam:
General: Alert, oriented, no acute distress, speaking in full
sentences
HEENT: Sclera anicteric, mild conjunctival injection, MMM,
oropharynx clear, EOMI
Neck: supple, JVP @8 cm H20, no LAD
CV: Tachycardic, regular, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Decreased breath sounds throughout.  No wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ radial/DP/PT pulses bilaterally, no
clubbing, cyanosis or edema.  S/p left toe amp, no erythema or
purulence
Neuro: 5/5 strength upper/lower extremities, grossly normal
sensation, 2+ reflexes bilaterally, gait deferred

Physical Exam on discharge:
VS: Tmax 99.3 Tc 99 BP 147/80(142/63-167/68) p 79 (79-84) 20 95
% RA
General: Alert, oriented, no acute distress, speaking in full
sentences
HEENT: Sclera anicteric, mild conjunctival injection, MMM,
oropharynx clear, EOMI
Neck: supple, no LAD
CV: Regular, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Decreased breath sounds throughout. No wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ radial/DP pulses bilaterally, no
clubbing, cyanosis or edema. S/p left toe amp with bandage in
place
Neuro: 5/5 strength upper/lower extremities, grossly normal
sensation

Pertinent Results:
Labs on admission:

[**2119-12-6**] 12:10AM   ALBUMIN-3.6 CALCIUM-8.4 PHOSPHATE-4.3
MAGNESIUM-1.9
[**2119-12-6**] 12:10AM   proBNP-2459*
[**2119-12-6**] 12:10AM   cTropnT-0.02*
[**2119-12-6**] 12:10AM   ALT(SGPT)-26 AST(SGOT)-21 CK(CPK)-49 ALK
PHOS-637* TOT BILI-0.4
[**2119-12-6**] 12:10AM   GLUCOSE-619* UREA N-28* CREAT-1.8*
SODIUM-127* POTASSIUM-4.8 CHLORIDE-93* TOTAL CO2-19* ANION
GAP-20
[**2119-12-6**] 12:13AM   LACTATE-2.5*
[**2119-12-6**] 04:54AM   RET AUT-1.6
[**2119-12-6**] 04:54AM   PT-13.5* PTT-76.5* INR(PT)-1.3*
[**2119-12-6**] 04:54AM   PLT COUNT-234
[**2119-12-6**] 04:54AM   WBC-5.4 RBC-2.68* HGB-7.4* HCT-22.7* MCV-85
MCH-27.6 MCHC-32.7 RDW-14.3
[**2119-12-6**] 04:54AM   WBC-5.4 RBC-2.68* HGB-7.4* HCT-22.7* MCV-85
MCH-27.6 MCHC-32.7 RDW-14.3
[**2119-12-6**] 04:54AM   CALCIUM-8.1* PHOSPHATE-4.1 MAGNESIUM-1.8
[**2119-12-6**] 04:54AM   CK-MB-3 cTropnT-0.07*
[**2119-12-6**] 05:02AM   LACTATE-2.4*
[**2119-12-6**] 11:27AM   CK-MB-4 cTropnT-0.12*
[**2119-12-6**] 11:27AM   CK(CPK)-59
[**2119-12-6**] 02:14PM   GLUCOSE-175* UREA N-31* CREAT-1.9*
SODIUM-130* POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-21* ANION GAP-15
[**2119-12-6**] 07:49PM   PT-12.0 PTT-43.8* INR(PT)-1.1
[**2119-12-6**] 07:53PM   CK-MB-3 cTropnT-0.12*
[**2119-12-6**] 07:53PM   CK(CPK)-46

ECHO [**2119-12-6**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). The right ventricular cavity is
mildly dilated with normal free wall contractility. The number
of aortic valve leaflets cannot be determined. The aortic valve
leaflets are mildly thickened (?#). There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is an anterior
space which most likely represents a prominent fat pad.

IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. Technically suboptimal to exclude focal wall
motion abnormality. Mild mitral regurgitation. Mild right
ventricular dilation with normal function.  Compared with the
prior study (images reviewed) of [**2119-11-16**], estimated pulmonary
artery pressure is mildly elevated (previously undetermined).

CT chest w/o contrast [**2119-12-6**]:
1. Lytic process T2 vertebral body and small associated
paravertebral soft
tissue mass could be infectious or malignant. Dedicated neuro
imaging
recommended for assessment of the spinal canal.
2. Moderate left and small right nonhemorrhagic layering pleural
effusions
may have increased slightly since [**19**]:00 a.m. No evidence of
extensive
pneumonia, but small areas of infection could be missed given
the large scale
left lower lobe atelectasis and smaller atelectasis at the right
base.
3. Numerous borderline bilateral axillary lymph nodes and
possibly in the
left hilus, and less extensive lymph node enlargement in the
mediastinum.

MRI w/o contrast [**2119-12-7**]:
Compression fracture of T2 with signal abnormalities involving
the adjacent T1/T2 and T2/T3 intervertebral disc spaces and T1
as well as T3 enplates. Small contiguous anterior paraspinous
soft tissue component.
Differential diagnosis includes osteomyelitis or, far less
likely, metastatic process.

There is no evidence of cord compression or epidural abscess in
this
non-enhanced exam.

RUQ ultrasound with dopplers:
1. Low volume, nondistended gallbladder containing sludge and
small,
[**Doctor Last Name 5691**]-like stones. Nonspecific gallbladder wall thickening and
pericholecystic fluid. In combination with lack of elevated
white blood cell count, ultrasound findings are not suspicious
for acute cholecystitis.
2. Moderate bilateral pleural effusions.

Labs on discharge:

[**2119-12-12**] 06:35AM BLOOD WBC-6.5 RBC-2.91* Hgb-8.0* Hct-23.7*
MCV-82 MCH-27.5 MCHC-33.7 RDW-14.3 Plt Ct-341
[**2119-12-12**] 06:35AM BLOOD Glucose-65* UreaN-22* Creat-1.0 Na-133
K-4.3 Cl-105 HCO3-21* AnGap-11
[**2119-12-12**] 06:35AM BLOOD AlkPhos-98
[**2119-12-12**] 06:35AM BLOOD Calcium-7.9* Phos-3.1 Mg-2.1

Brief Hospital Course:
This is a 54-year-old female with hx T1DM, tobacco abuse,
osteomyelitis of left foot on chronic antibiotics, recent ED
visit for nausea/vomiting and ECG changes, admitted with acute
onset pulmonary edema, hypertensive crisis, and mild diabetic
ketoacidosis.

Active Issues:

# Flash pulmonary edema:  The patient was admitted to the MICU
with flash pulmonary edema in the setting of hypertensive
urgency.  She did have a troponin rise that peaked at 0.12
without MB elevation.  The patient was started on a heparin drip
for possibility of ACS versus pulmonary embolism.  She was
unable to undergo CTA for PE secondary to acute kidney injury.
The patient underwent a transthoracic ECHO that showed a normal
ejection fraction, left ventricular hypertrophy, and could not
exclude a wall motion defect.  She was started on BIPAP and
diuresed with initial good response.  BIPAP was subsequently
removed in the ICU and diuresis was continued.  She was
transferred to the cardiology wards.  On the floor, the patient
continued to diurese well with normalization of her oxygen
saturation on room air.  Heparin drip was stopped upon transfer
to the floor due to low likelhood of acute coronary syndrome and
pulmonary embolism (given rapid improvement in A-A gradient).
Ms. [**Known lastname 24166**] was continued on aspirin, statin, and beta
blocker.  She was discharged on lasix 20 mg daily.

# Elevated troponin: On admission, troponin rose from 0.02 and
peaked at 0.12 without elevation in CK-MB.  She was initially
started on a heparin drip for ACS, but the heparin drip was
discontinued as elevated troponin was likely related to demand
ischemia in setting of hypertensive urgency, flash pulmonary
edema, and tachycardia. ECG did show rate-related ST depressions
in V4-V6.  The patient remained chest pain free throughout
admission.  She was started on aspirin, a statin, and continued
on home metoprolol.  Her home valsartan was held given acute
kidney injury.  The patient should undergo cardiac cath as an
outpatient with improvement in her renal function.  A repeat
echocardiogram should also be performed in follow-up.

# Hypertension: The patient was admitted with hypertensive
urgency to 216/80 complicated by flash pulmonary edema.  She was
initially started on a nitro drip, that was weaned in the ICU.
She was continued on home amlodipine initially, increased to 10
mg daily before discharge.  Home metoprolol was titrated up to
150mg [**Hospital1 **] for blood pressure control.  Valsartan was held in the
setting of acute kidney injury until the day of discharge when
her creatinine decreased to 1.0.  The cause of hypertensive
urgency is unclear, but may relate to poorly controlled type 1
diabetes.

# DM1/Hyperglycemia: Glucose >600 on admission, with mild anion
gap acidosis (gap 15).  The patient was briefly placed on an
insulin drip, and then transitioned to her home insulin regimen
with closure of her anion gap.  Precipitant for hyperglycemia
was unclear, though potential etiologies include insulin
nonadherence (patient unclear if took med and does not remember
sliding scale), infection (possible infectious diarrhea, chronic
osteomyeltis), or flash pulmonary edema.  The patient was seen
by [**Last Name (un) **], who made changes to her home sliding scale.  With
inpatient adherence to her insulin sliding scale, glycemic
control improved.

# Nausea/vomiting:  The patient was admitted with 5 days of
nausea.  On admission, she began to also experience non-bloody
diarrhea.  The patient was seen by infectious disease for
possible antibiotic side effect for cause of her symptoms.
Stool studies were negative for infectious diarrhea.  The
patient was given zofran as needed for nausea, which
significantly improved before discharge.

# Pleural effusions: Noted on CXR and CT scan.  Likely secondary
to flash pulmonary edema.  No evidence of pneumonia - patient
did not had any cough or CP, and did not have a leukocytosis.
As patient had concerning T2 lesion on CT scan, there was
concern for malignant effusions.  Interventional pulmonary was
consulted for possible thoracentesis; however, further diuresis
was recommended as onset and appearance of effusions on imaging
makes them less likely malignancy.  On day 4 of admission,
effusions began to improve with diuresis.

# [**Last Name (un) **]: The patient has had an elevated creatinine (as high as
2.2) since the end of [**Month (only) **] (baseline Cr 0.9-1.1).  Recent
renal ultrasound was negative for hydronephrosis. Recent
SPEP/UPEP negative.  [**Last Name (un) **] likely represents prerenal azotemia
from poor forward flow, as the patient's creatinine began to
improve with diuresis.  Due to [**Last Name (un) **], the patient's valsartan was
held until discharge when her creatinine decreased to 1.0.

# MRSA Osteomyelitis: Per patient, wound healing well with
regular dressing changes by VNA. She is followed closely by
outpatient ID, on vancomycin.  The patient's vancomycin was
discontinued by outpatient ID physician on the day of admission
for possible drug reaction (vanco as source of nausea).  She
received one dose of daptomycin, and developed a drug rash.
Daptomycin was discontinued and the patient was resumed on
vancomycin.  The patient was followed by inpatient infectious
disease throughout admission.

# T2 Lytic lesion:  On CT scan, the patient was incidentally
noted to have a large, concerning lesion that takes up much of
T2 vertebral body.  The patient underwent thoracic MRI that
revealed associated compression fracture with the T2 lesion and
soft tissue changes in T1-T3.  The patient was seen by
infectious disease, who felt the lesion was in fact consistent
with vertebral osteomyelitis.  They recommended follow up
imaging in [**1-28**] weeks to look at interval chane in the lesion.
If at that time there is no interval change, IR-guided biopsy
should be considered.

# Normocytic anemia: Hct trending down over recent admissions.
Iron studies c/w anemia of chronic inflammation. B12 and folate
WNL. Recent SPEP/UPEP negative. Labs not suggestive of
hemolysis.  Hematocrit was trended throughout admission.

# Hyponatremia: The patient was admitted with hyponatremia to
130 (baseline normal).  Hyponatremia likely hypervolemic,
secondary to fluid overload, as it improved to baseline with
diuresis.

# Hyperlipidemia: Patient not on medication as outpatient, but
has been started on pravavastatin this admission given cardiac
risk factors.

# Elevated AlkPhos: The patient was admitted with elevated alk
phos and GGT, likely secondary to hepatic source.  She underwent
a right upper quadrant ultrasound that showed mild gallbladder
sludge, but was otherwise normal.  No evidence of congestive
hepatopathy, as AST and ALT normal.  AST had decreased to normal
before discharge.

# Anxiety regarding multiple new diagnoses:  Patient very
anxious about recent dyspnea and multiple recent
hospitalizations.  She was followed by social work throughout
admission.

Transitional Issues:

-Pt was full code for this admission

-Pt will be followed by [**Hospital 4898**] clinic for her osteomyelitis and
follow up lumbar spine CT scan

-Pt should be considered for an outpatient catherization based
on her troponin bump and new diagnosis of congestive heart
failure

Medications on Admission:
AMLODIPINE - 5 mg daily
CIPROFLOXACIN - 500 mg [**Hospital1 **]
INSULIN GLARGINE [LANTUS] - 15 units at bedtime
INSULIN LISPRO [HUMALOG] - SS scale
LIDOCAINE - 5 % (700 mg/patch) Adhesive Patch, Medicated - 1
once a day as needed for back pain
METOPROLOL SUCCINATE [TOPROL XL] - 50 mg daily
MOXIFLOXACIN [AVELOX] - 400 mg daily
VANCOMYCIN - 1.25 grams Q24hrs
ASPIRIN 325 mg daily

Discharge Medications:
1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
2. insulin glargine 100 unit/mL Solution Sig: Nineteen (19)
units Subcutaneous at bedtime.
3. insulin lispro 100 unit/mL Solution Sig: please take as
directed on sliding scale Subcutaneous -.
4. lidocaine  Topical
5. metoprolol tartrate 50 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*0*
6. vancomycin in D5W 1 gram/200 mL Piggyback Sig: Seven Hundred
Fifty (750) mg Intravenous Q 24H (Every 24 Hours).
Disp:*30 gram* Refills:*2*
7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Outpatient Lab Work
1.Please check CBC, BMP and LFT's, ESR and CRP once a week and
fax results to infectious disease clinic at [**Telephone/Fax (1) 1419**], attn:
Dr. [**Last Name (STitle) **]

2. Please check a vancomycin trough level on [**2119-12-14**] and fax
results to infectious disease clinic at [**Telephone/Fax (1) 1419**], attn: Dr.
[**Last Name (STitle) **]

11. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
Home Solutions

Discharge Diagnosis:
Primary:
- Acute Diastolic Heart Failure
- Osteomyelitis
- Hypertension
- Acute Kidney Injury

Secondary:
- Diabetes Mellitus type 1


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
Mrs. [**Known lastname 24166**],

It was a pleasure taking of you during your hospitalization at
[**Hospital1 69**].  You were admitted with
shortness of breath.  This is the result of heart failure.  You
were treated with removing fluid from your lungs and controlling
your blood pressure.  You will need to follow-up with a
cardiologist who can continue to monitor this.

We continued treating your foot infection with IV antibiotics.
We discovered that you had an area in your spine that most
likely is also an infection.  In order to make sure that it
improves with your antibiotics (and isn't something besides an
infection, like malignancy) you will need to have a repeat MRI
in [**1-28**] weeks to evaluate for improvement of the lesion.  If it
is not improved then a biopsy will likely need to be performed.

You are now ready for discharge home.

PLEASE NOTE THE FOLLOWING MEDICATION CHANGES:
- STARTED VALSARTAN 80 MG DAILY FOR HIGH BLOOD PRESSURE
- STARTED PRAVASTATIN 20 MG DAILY FOR HIGH CHOLESTEROL
- STARTED FUROSEMIDE (LASIX) 20 MG DAILY FOR INCREASED FLUID
- INCREASED AMLODIPINE TO 10 MG DAILY FOR HIGH BLOOD PRESSURE
- INCREASED METOPROLOL TO 150 MG TWICE A DAY FOR HIGH BLOOD
PRESSURE
- INCREASED INSULIN GLARGINE TO 19 UNITS AT BEDTIME FOR HIGH
BLOOD SUGAR
- INCREASED SLIDING SCLAE HUMALOG (PLEASE SEE ATTACHED SHEET)
- DECREASED VANCOMYCIN TO 750 MG DAILY FOR INFECTION
- STOPPED CIPROFLOXACIN 500 MG TWICE A DAY
- STOPPED MOXIFLOXACIN 400 MG DAILY

Followup Instructions:
Department: INFECTIOUS DISEASE
When: MONDAY [**2119-12-25**] at 10:30 AM
With: [**Name6 (MD) 14621**] [**Last Name (NamePattern4) 14622**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: [**Hospital3 249**]
When: [**Hospital3 **] [**2119-12-15**] at 1:50 PM
With: [**Doctor First Name 306**] C-[**Name Initial (MD) **] [**Name8 (MD) 308**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: CARDIAC SERVICES
When: THURSDAY [**2119-12-28**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: PODIATRY
When: MONDAY [**2120-1-1**] at 2:50 PM
With: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST     Best Parking: [**Street Address(1) 592**] Garage
{'Acute diastolic heart failure,Acute kidney failure, unspecified,Diabetes with ketoacidosis, type I [juvenile type], uncontrolled,Hyposmolality and/or hyponatremia,Chronic osteomyelitis, ankle and foot,Other acute and subacute forms of ischemic heart disease, other,Unspecified essential hypertension,Polyneuropathy in diabetes,Long-term (current) use of insulin,Other bone involvement in diseases classified elsewhere,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Other and unspecified hyperlipidemia,Personal history of tobacco use,Anemia, unspecified,Other nonspecific abnormal serum enzyme levels,Other and unspecified disc disorder, thoracic region,Anxiety state, unspecified,Nausea with vomiting'}


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: Shortness of breath

PRESENT ILLNESS: Ms [**Known lastname 24166**] is a 54 y/o F with hx of long-standing T1DM,
long-standing tobacco abuse (recently quit) and chronic
osteomyelitis of the foot who came to the ED after calling EMS
for experiencing acute-onset shortness of breath while lying in
bed at home.  She denied chest pain or palpitations.  She was
found by EMS to be hypoxic to 70s on room air, with increased
work of breathing and tachycardia to the 110s.  She was given
nebulizers en route to the ED, without significant improvement.

MEDICAL HISTORY: per d/c summary [**2119-11-18**], confirmed with patient
- DM1 - insulin dependent, poorly controlled HBA1c 12%, managed
by
[**Last Name (un) **] Dr. [**First Name (STitle) **]
- DM associated neuropathy
- HTN
- HLD - LDL 102 in [**2112**]
- Back pain s/p fall
- History of osteomyelitis left hallux s/p ulcer infection
debridement [**4-/2119**] and again 12/[**2118**].
- Trigger release right index and long fingers [**6-/2118**]
- s/p Left first toe and ray amputation [**2119-11-15**]- Dr.
[**Last Name (STitle) **]

MEDICATION ON ADMISSION: AMLODIPINE - 5 mg daily
CIPROFLOXACIN - 500 mg [**Hospital1 **]
INSULIN GLARGINE [LANTUS] - 15 units at bedtime
INSULIN LISPRO [HUMALOG] - SS scale
LIDOCAINE - 5 % (700 mg/patch) Adhesive Patch, Medicated - 1
once a day as needed for back pain
METOPROLOL SUCCINATE [TOPROL XL] - 50 mg daily
MOXIFLOXACIN [AVELOX] - 400 mg daily
VANCOMYCIN - 1.25 grams Q24hrs
ASPIRIN 325 mg daily

ALLERGIES: Bactrim / daptomycin

PHYSICAL EXAM: Admission Physical Exam:
General: Alert, oriented, no acute distress, speaking in full
sentences
HEENT: Sclera anicteric, mild conjunctival injection, MMM,
oropharynx clear, EOMI
Neck: supple, JVP @8 cm H20, no LAD
CV: Tachycardic, regular, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Decreased breath sounds throughout.  No wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ radial/DP/PT pulses bilaterally, no
clubbing, cyanosis or edema.  S/p left toe amp, no erythema or
purulence
Neuro: 5/5 strength upper/lower extremities, grossly normal
sensation, 2+ reflexes bilaterally, gait deferred

FAMILY HISTORY: per d/c summary [**2119-11-18**]
Mother with DM2 and CVA, father died of MI at age 76, siblings
all healthy

SOCIAL HISTORY: per d/c summary [**2119-11-18**]
Lives with husband, no children. Works as staff assistant at
[**University/College **] [**Location (un) **]. Smokes 2 cig/day, has been smoking for 20
years used to smoke 1ppd. No ETOH or IVDA. 

### Response:
{'Acute diastolic heart failure,Acute kidney failure, unspecified,Diabetes with ketoacidosis, type I [juvenile type], uncontrolled,Hyposmolality and/or hyponatremia,Chronic osteomyelitis, ankle and foot,Other acute and subacute forms of ischemic heart disease, other,Unspecified essential hypertension,Polyneuropathy in diabetes,Long-term (current) use of insulin,Other bone involvement in diseases classified elsewhere,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Other and unspecified hyperlipidemia,Personal history of tobacco use,Anemia, unspecified,Other nonspecific abnormal serum enzyme levels,Other and unspecified disc disorder, thoracic region,Anxiety state, unspecified,Nausea with vomiting'}
