CHIEF COMPLAINT: Transferred from OSH for Epidural/Abscess

PRESENT ILLNESS: 69yo M with PMH of ESRD on HD, DM, MVR, Afib, cirrhosis, and
prostate cancer, presented to OSH last week with LBP and LE
weakness, found to have a T5-6 epidural abscess with cord
compression on MRI and GPC bacteremia.  He was transferred to
[**Hospital1 18**] on [**2178-10-3**] and was taken that night to the OR for T5-6
laminectomy and drainage of abscess.  His tunneled HD cath was
removed and had a temporary femoral line placed today for HD.
He was also seen by Thoracic Surgery for anterior paraspinal
abscess, but no surgical intervention is necessary at this time.
 ID consulted and the organism is thought to most likely be
coag-neg. Staph. and source is thought to be his HD catheter.
Transferred to Medicine service for further workup of source
including TEE for endocarditis and CT abd/pelv.

MEDICAL HISTORY: ESRD, on dialysis
Atrial fibrillation, rate-controlled

MEDICATION ON ADMISSION: Unknown

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 98.2  HR 80  BP 116/64  RR 20  O2sat 93%RA
General- lying in bed, NAD, pleasant
HEENT- telangiectasias on face, sclerae anicteric, moist MM
Neck- no JVD
Pulm- CTAB
CV- irregularly irregular, 1/6 SEM heard best at LUSB
Abd- distended but soft, bulging flanks, nontender, no
peritoneal signs, NABS, no hepatomegaly, umbilical hernia easily
reducible and nontender
Back- dressing in place
Ext- no peripheral edema, +2 DP pulses
Neuro- able to move toes R>L, 4+/5 UE strength b/l, decreased
sensation to LT in upper thighs, no sensation to LT throughout
rest of legs

FAMILY HISTORY: NC

SOCIAL HISTORY: married, lives with wife who is debilitated by stroke, h/o EtOH
abuse- has not used since starting dialysis
Infection and inflammatory reaction due to other vascular device, implant, and graft,Methicillin susceptible Staphylococcus aureus septicemia,Intraspinal abscess,Acute osteomyelitis, other specified sites,End stage renal disease,Atrial fibrillation,Alcoholic cirrhosis of liver,Urinary tract infection, site not specified,Pressure ulcer, lower back,Other and unspecified coagulation defects,Mitral valve disorders,Acute respiratory failure,Hepatic encephalopathy,Severe sepsis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Pneumonitis due to inhalation of food or vomitus,Iron deficiency anemia secondary to blood loss (chronic),Thrombocytopenia, unspecified,Paraplegia,Intervertebral disc disorder with myelopathy, thoracic region,Delirium due to conditions classified elsewhere,Other and unspecified alcohol dependence, in remission,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Gastroparesis,Peripheral autonomic neuropathy in disorders classified elsewhere
React-oth vasc dev/graft,Meth susc Staph aur sept,Intraspinal abscess,Ac osteomyelitis NEC,End stage renal disease,Atrial fibrillation,Alcohol cirrhosis liver,Urin tract infection NOS,Pressure ulcer, low back,Coagulat defect NEC/NOS,Mitral valve disorder,Acute respiratry failure,Hepatic encephalopathy,Severe sepsis,Hyp kid NOS w cr kid V,Food/vomit pneumonitis,Chr blood loss anemia,Thrombocytopenia NOS,Paraplegia NOS,Thor disc dis w myelopat,Delirium d/t other cond,Alcoh dep NEC/NOS-remiss,DMII neuro nt st uncntrl,Gastroparesis,Aut neuropthy in oth dis
Admission Date:  [**2178-10-3**]              Discharge Date:   [**2178-11-14**]

Date of Birth:  [**2109-8-28**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 4219**]
Chief Complaint:
Transferred from OSH for Epidural/Abscess

Major Surgical or Invasive Procedure:
Evacuation of T5-T6 Epidural Hematoma/Abscess


History of Present Illness:
69yo M with PMH of ESRD on HD, DM, MVR, Afib, cirrhosis, and
prostate cancer, presented to OSH last week with LBP and LE
weakness, found to have a T5-6 epidural abscess with cord
compression on MRI and GPC bacteremia.  He was transferred to
[**Hospital1 18**] on [**2178-10-3**] and was taken that night to the OR for T5-6
laminectomy and drainage of abscess.  His tunneled HD cath was
removed and had a temporary femoral line placed today for HD.
He was also seen by Thoracic Surgery for anterior paraspinal
abscess, but no surgical intervention is necessary at this time.
 ID consulted and the organism is thought to most likely be
coag-neg. Staph. and source is thought to be his HD catheter.
Transferred to Medicine service for further workup of source
including TEE for endocarditis and CT abd/pelv.

Currently states he feels well, only complaint is mild pain in
his back.  He denies CP, SOB, abdominal pain, feeling feverish,
chills, headache, feeling confused, N/V, and LE pain.

Past Medical History:
ESRD, on dialysis
Atrial fibrillation, rate-controlled


Social History:
married, lives with wife who is debilitated by stroke, h/o EtOH
abuse- has not used since starting dialysis

Family History:
NC

Physical Exam:
T 98.2  HR 80  BP 116/64  RR 20  O2sat 93%RA
General- lying in bed, NAD, pleasant
HEENT- telangiectasias on face, sclerae anicteric, moist MM
Neck- no JVD
Pulm- CTAB
CV- irregularly irregular, 1/6 SEM heard best at LUSB
Abd- distended but soft, bulging flanks, nontender, no
peritoneal signs, NABS, no hepatomegaly, umbilical hernia easily
reducible and nontender
Back- dressing in place
Ext- no peripheral edema, +2 DP pulses
Neuro- able to move toes R>L, 4+/5 UE strength b/l, decreased
sensation to LT in upper thighs, no sensation to LT throughout
rest of legs


Pertinent Results:
Cultures:
[**2178-11-7**] Blood - pending
[**2178-11-6**] Blood - negative
[**2178-11-5**] Blood - negative
[**2178-10-29**] Blood - negative
[**2178-10-29**] Blood - negative
[**2178-10-29**] Urine - neagtive
[**2178-10-29**] Sputum - contaminated

Imaging:
[**2178-11-10**] CXR - Dense retrocardiac opacity, including a layering
pleural effusion as well, although an under lying consolidation
or atelectasis could be present. When clinically feasible, PA
and lateral could be helpful for further followup. The
appearance is unchanged, however.
[**2178-11-6**] Abdominal U/S - Massive ascites.  Left flank marked for
paracentesis.


Brief Hospital Course:
69yo M with ESRD on HD, MVR, Afib, and DM, p/w epidural abscess,
cord compression, and coag-neg Staph bacteremia, with drainage
with paraplegia.

1) Altered mental status:  On morning of [**10-8**], had [**Doctor Last Name 29943**] change
in personality and behavior, also with disorientation.  His
differential included CVA, subdural,
toxic-metabolic--hyponatremia, elevated ammonia, infection
(bacteremia, SBP).  Psych consult saw the patient and deemed him
incompetent to make medical decisions secondary to delirium.
Later in the morning was more oriented, and noted to be
primarily angry and doubtful of his diagnosis.  His orientation
and attention was intact.  Labs were negative for electrolyte
abnormalities, leukocytosis, elevated ammonia.  Neurology
consult recommended EEG, continued toxic-metabolic w/u, MRI head
to look for CVA, MRI C/T/L spine to eval for persistent/new
abscess.  His EEG was consistent with encephalopathy.  He had a
diagnostic paracentesis that was negative for SBP.  He was found
to have a FQ-resistant E. coli UTI, and was put on ceftriaxone
to complete a 14d course.  Multiple attempts were made to get
the MRI, but he was unable to tolerate the study.  It was
performed on [**10-20**] and showed a recurrent T5-T6 epidural abscess
with destruction of the T5 and T6 vertebrae, and a question of
lumbar discitis.  His MRI head showed an old cerebellar and
chronic microvascular infarcts, but no new infarcts.  He
continued to have attentional deficit and intermittent
disorientation to place and time.  He was taken to the OR for
debridement and fusion of his T5-T6 vertebrae.  The patient
continued to be intermittently delirius after surgery.

2) Epidural abscess: He was transferred to Medicine s/p drainage
of his posterior fluid collection.  The abscess fluid culture
grew coag-neg Staph and he was maintained on vancomycin to treat
his bacteremia and osteomyelitis, with the intention of treating
for 6 weeks.  His most likely source was thought to be his HD
line, and it was removed.  He also had cord compression with
paraplegia as a result of the abscess.  Thoracic [**Doctor First Name **] was
initially consulted and stated there was no evidence for
discrete anterior paraspinal abscess, so no indication for
surgical intervention.  Blood cultures here were negative, as
was the cath tip culture negative.  A TTE showed no visible
endocarditis.  A TEE was not performed as his antibiotic course
would adequately treat for endocarditis.  A recurrent abscess
with osteomyelitis was found on MRI as stated above.  He also
had the possibility of lumbar discitis that appeared to be new
when compared to his OSH MRI, and would have developed while he
was on vancomycin.  ID recommended no change in his antibiotics
until after surgery.  Dr. [**Last Name (STitle) 363**] came and spoke with the patient
and his family and it was decided that no further surgical
intervention was warranted.  Further surgery to stabalize his
back was risky and painful.  The patient decline and elected to
be fitted for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] brace.

3) ESRD: He started HD several months ago and had a tunneled
line placed at that time.  It was pulled this admission as it
was thought to likely be the source of his bacteremia, and
ultimately his epidural abscess.  He initially had a temporary
femoral catheter placed, which was later pulled and a new
tunneled line was placed by IR.  He was maintained on his MWF
schedule, had temporary femoral catheter pulled on [**10-7**].  He was
followed by Renal throughout his stay.

4) Afib: He is rate-controlled on diltiazem, digoxin, and
metoprolol as an outpatient.  He stated he had not been on
anticoagulation for several years per the patient.  Further
history was obtained from his wife, who stated he had a severe
upper GI bleed a year and a half ago, and also had multiple
falls over the past several years.  He was well rate-controlled
throughout his stay.  He was maintained on beta blockade
perioperatively.

5) Respiratory Distress - On [**10-29**] pt was noted to be tachypneic
at 36/m w/ O2 sat 90% 4L/m NC which prompted a trigger. He was
treated w/ O2 by NRB, w/ sat increasing to 98%. Suctioning
returned copious thick secretions, and O2 sat improved to 98% on
4L/m, but pt remained tachypneic w/ increasing confusion. CXR
demonstrated LLL infiltrate, unchanged from recent imaging.
Patient transferred to MICU for closer monitoring and frequent
suctioning. Patient was transferred back to regular medical
floor after improved respiratory and mental status. Patient no
longer having copious secretions and is not requiring frequent
suctioning. Now with O2 sats in high 90's on RA. Mental status
has also improved.

6) Questionable PEA Arrest - On [**2178-11-5**] a code blue was called
on the patient and he was transferred to the ICU for a
questionable PEA arrest.  Patient improved rapidly after event,
not likely PEA given recovery without need for intervention.
Possibly a mucus plug or aspiration causing an hypoxic arrest.
Of note, he has had multiple aspiration events in the past. PE
causing PEA possible but less likely given rapid improvement and
lack of hypoxia. Possible that he had a bradycardic event as he
had recently had long pauses and been taken off diltiazem and
BB. However, in stable Afib on telemetry overnight. Cardiac
enzymes stable so not likely MI. The patient was transferred
back to the general medical floor.

6) Cirrhosis/Ascites: Likely secondary to alcohol abuse.  His
PT/INR was slightly elevated, and his albumin was low.  He was
not on SBP prophylaxis as an outpatient.  No SBP on his
diagnostic paracentesis.  He was treated empirically with
lactulose after he was found to be delirious.  His history of GI
bleed should be confirmed with his PCP as may be an indication
for SBP prophylaxis as an outpatient.

7) MV repair:  He is s/p a MV repair in [**2159**] per the patient.
His TTE showed an annuloplasty ring.  A TEE to look for
endocarditis was not performed as his osteomyelitis antibiotic
course would adequately treat endocarditis.

8) Anemia: Hct was stable throughout his admission.  His stools
were guaiac negative.

Code status: After the patient returned to the medical floor
from the ICU for the 2nd time during his admission, a family
meeting was held to address goals of care as his overall medical
condition remained tenuous.  At the first meeting, the patient
and family decided that the patient would be DNR/DNI (consistent
with the patient statements to multiple family members in the
past).  Over the next few days, the patient continued to express
wishes to stop dialysis and all other tests.  Another family
meeting was held including the presence of the patient, and it
was decided that the patient would be CMO (including stopping
dilaysis).  The patient was made CMO on [**2178-11-11**] and passed away
on [**2178-11-14**].


Medications on Admission:
Unknown

Discharge Medications:
Expired on [**2178-11-14**]

Discharge Disposition:
Extended Care

Discharge Diagnosis:
Expired on [**2178-11-14**]

Discharge Condition:
Expired on [**2178-11-14**]


Discharge Instructions:
Expired on [**2178-11-14**]

Followup Instructions:
Expired on [**2178-11-14**]

                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4231**]
{'Infection and inflammatory reaction due to other vascular device, implant, and graft,Methicillin susceptible Staphylococcus aureus septicemia,Intraspinal abscess,Acute osteomyelitis, other specified sites,End stage renal disease,Atrial fibrillation,Alcoholic cirrhosis of liver,Urinary tract infection, site not specified,Pressure ulcer, lower back,Other and unspecified coagulation defects,Mitral valve disorders,Acute respiratory failure,Hepatic encephalopathy,Severe sepsis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Pneumonitis due to inhalation of food or vomitus,Iron deficiency anemia secondary to blood loss (chronic),Thrombocytopenia, unspecified,Paraplegia,Intervertebral disc disorder with myelopathy, thoracic region,Delirium due to conditions classified elsewhere,Other and unspecified alcohol dependence, in remission,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Gastroparesis,Peripheral autonomic neuropathy in disorders classified elsewhere'}


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



### Clinical text :
CHIEF COMPLAINT: Transferred from OSH for Epidural/Abscess

PRESENT ILLNESS: 69yo M with PMH of ESRD on HD, DM, MVR, Afib, cirrhosis, and
prostate cancer, presented to OSH last week with LBP and LE
weakness, found to have a T5-6 epidural abscess with cord
compression on MRI and GPC bacteremia.  He was transferred to
[**Hospital1 18**] on [**2178-10-3**] and was taken that night to the OR for T5-6
laminectomy and drainage of abscess.  His tunneled HD cath was
removed and had a temporary femoral line placed today for HD.
He was also seen by Thoracic Surgery for anterior paraspinal
abscess, but no surgical intervention is necessary at this time.
 ID consulted and the organism is thought to most likely be
coag-neg. Staph. and source is thought to be his HD catheter.
Transferred to Medicine service for further workup of source
including TEE for endocarditis and CT abd/pelv.

MEDICAL HISTORY: ESRD, on dialysis
Atrial fibrillation, rate-controlled

MEDICATION ON ADMISSION: Unknown

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 98.2  HR 80  BP 116/64  RR 20  O2sat 93%RA
General- lying in bed, NAD, pleasant
HEENT- telangiectasias on face, sclerae anicteric, moist MM
Neck- no JVD
Pulm- CTAB
CV- irregularly irregular, 1/6 SEM heard best at LUSB
Abd- distended but soft, bulging flanks, nontender, no
peritoneal signs, NABS, no hepatomegaly, umbilical hernia easily
reducible and nontender
Back- dressing in place
Ext- no peripheral edema, +2 DP pulses
Neuro- able to move toes R>L, 4+/5 UE strength b/l, decreased
sensation to LT in upper thighs, no sensation to LT throughout
rest of legs

FAMILY HISTORY: NC

SOCIAL HISTORY: married, lives with wife who is debilitated by stroke, h/o EtOH
abuse- has not used since starting dialysis 

### Response:
{'Infection and inflammatory reaction due to other vascular device, implant, and graft,Methicillin susceptible Staphylococcus aureus septicemia,Intraspinal abscess,Acute osteomyelitis, other specified sites,End stage renal disease,Atrial fibrillation,Alcoholic cirrhosis of liver,Urinary tract infection, site not specified,Pressure ulcer, lower back,Other and unspecified coagulation defects,Mitral valve disorders,Acute respiratory failure,Hepatic encephalopathy,Severe sepsis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Pneumonitis due to inhalation of food or vomitus,Iron deficiency anemia secondary to blood loss (chronic),Thrombocytopenia, unspecified,Paraplegia,Intervertebral disc disorder with myelopathy, thoracic region,Delirium due to conditions classified elsewhere,Other and unspecified alcohol dependence, in remission,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Gastroparesis,Peripheral autonomic neuropathy in disorders classified elsewhere'}
