CHIEF COMPLAINT: Hypotension

PRESENT ILLNESS: Ms. [**Known lastname 4636**] is a 71yo paraplegic female with PMH significant
for HTN, HLD, and chronic UTI's who is being transferred to the
MICU for management of hypotension. Per her son,
the patient's home nurse noted that she had a slight temperature
this morning. Her son noted that her appetite was poor and was
also incoherent. He also noted that her catheter contained urine
that was dark and concentrated. He immediately called 911. She
was then brought to [**Hospital1 18**] ED for further work-up. There is no
report of SOB, chest pain, abdominal pain, diarrhea, or
constipation. The son was also concerned that her catheter was
not working well and needed to be changed.
In the ED, initial vitals were T 102.2 BP 115/33 AR 105 RR 18 O2
sat 94% on 3L NC. She received Vancomycin 1gm IV, Zosyn 4.5gm
IV, and Tylenol 1gm. Her blood pressure dropped to 95/43 and
given lack of improvement after receiving 3L NS, she is being
transferred to the MICU for closer monitoring.

MEDICAL HISTORY: 1)Paraplegia [**1-5**] Anterior Spinal Infarct
2)Thoracic Aneurysm Repair ([**2128**])
3)Hx of LLL Collapse/PNA s/p mucous plug removal via
bronchoscopy
4)HTN
5)Hyperlipidemia
6)GERD
7)Suprapubic Catheter Placement / UTIs on Ppx Bactrim
8)Fecal Incontinence
9)Depression

MEDICATION ON ADMISSION: Gabapentin 900mg PO TID
Nortriptyline 50mg PO QHS
Bupropion 100mg PO BID
Pantoprazole 40mg PO daily
Aspirin 81mg PO daily
Colace 100mg PO BID
Zinc sulfate PO daily
Hexavitamin PO daily
Advair 250-50
Combivent MDI

ALLERGIES: Adhesive Tape

PHYSICAL EXAM: vitals T 95.8 BP 117/50 AR 65 RR 23 O2 sat 95% on 3L NC
Gen: Patient awake, responsive to commands
HEENT: MMM, PERRLA
Heart: RRR, no audible m,r,g
Lungs: CTAB, scattered crackles at posterior bases
Abdomen: Markedly distended but soft, NT, +BS
Extremities: 1+ bilateral edema, 2+ DP/PT pulses bilaterally;
large
ulcer approximately 6cm in diameter over L ischium that appears
to probe down to bone. She also has wound vac dressing in place
on left lower extremity.

FAMILY HISTORY: Son has DM

SOCIAL HISTORY: 58 year tobacco history, now smoking 3 cigarettes per day,
denies EthOH, denies drug abuse.  Widowed.  Has 3 sons.  She
lives alone in [**Hospital3 4634**].
Unspecified osteomyelitis, pelvic region and thigh,Encephalopathy, unspecified,Pressure ulcer, lower back,Paraplegia,Pathologic fracture of neck of femur,Chronic airway obstruction, not elsewhere classified,Neurogenic bladder NOS,Late effect of complications of surgical and medical care,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Urinary catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Mechanical complication due to urethral (indwelling) catheter,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Esophageal reflux,Depressive disorder, not elsewhere classified,Personal history of other diseases of circulatory system,Personal history, urinary (tract) infection
Osteomyelitis NOS-pelvis,Encephalopathy NOS,Pressure ulcer, low back,Paraplegia NOS,Path fx neck of femur,Chr airway obstruct NEC,Neurogenic bladder NOS,Late eff surg/med compl,Abn react-surg proc NEC,Abn react-urinary cath,Malfunc urethral cath,Hypertension NOS,Hyperlipidemia NEC/NOS,Esophageal reflux,Depressive disorder NEC,Hx-circulatory dis NEC,Personal history UTI
Admission Date:  [**2137-7-2**]              Discharge Date:   [**2137-7-9**]

Date of Birth:  [**2065-8-18**]             Sex:   F

Service: MEDICINE

Allergies:
Adhesive Tape

Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Hypotension

Major Surgical or Invasive Procedure:
RIJ placement

History of Present Illness:
Ms. [**Known lastname 4636**] is a 71yo paraplegic female with PMH significant
for HTN, HLD, and chronic UTI's who is being transferred to the
MICU for management of hypotension. Per her son,
the patient's home nurse noted that she had a slight temperature
this morning. Her son noted that her appetite was poor and was
also incoherent. He also noted that her catheter contained urine
that was dark and concentrated. He immediately called 911. She
was then brought to [**Hospital1 18**] ED for further work-up. There is no
report of SOB, chest pain, abdominal pain, diarrhea, or
constipation. The son was also concerned that her catheter was
not working well and needed to be changed.
In the ED, initial vitals were T 102.2 BP 115/33 AR 105 RR 18 O2
sat 94% on 3L NC. She received Vancomycin 1gm IV, Zosyn 4.5gm
IV, and Tylenol 1gm. Her blood pressure dropped to 95/43 and
given lack of improvement after receiving 3L NS, she is being
transferred to the MICU for closer monitoring.

Past Medical History:
1)Paraplegia [**1-5**] Anterior Spinal Infarct
2)Thoracic Aneurysm Repair ([**2128**])
3)Hx of LLL Collapse/PNA s/p mucous plug removal via
bronchoscopy
4)HTN
5)Hyperlipidemia
6)GERD
7)Suprapubic Catheter Placement / UTIs on Ppx Bactrim
8)Fecal Incontinence
9)Depression

Social History:
58 year tobacco history, now smoking 3 cigarettes per day,
denies EthOH, denies drug abuse.  Widowed.  Has 3 sons.  She
lives alone in [**Hospital3 4634**].

Family History:
Son has DM

Physical Exam:
vitals T 95.8 BP 117/50 AR 65 RR 23 O2 sat 95% on 3L NC
Gen: Patient awake, responsive to commands
HEENT: MMM, PERRLA
Heart: RRR, no audible m,r,g
Lungs: CTAB, scattered crackles at posterior bases
Abdomen: Markedly distended but soft, NT, +BS
Extremities: 1+ bilateral edema, 2+ DP/PT pulses bilaterally;
large
ulcer approximately 6cm in diameter over L ischium that appears
to probe down to bone. She also has wound vac dressing in place
on left lower extremity.


Pertinent Results:
[**2137-7-2**] 07:55PM   LACTATE-1.1
[**2137-7-2**] 07:57PM   WBC-14.0*# RBC-4.76 HGB-12.6 HCT-38.8 MCV-82
MCH-26.4* MCHC-32.4 RDW-15.9*
[**2137-7-2**] 07:57PM   CALCIUM-8.3* PHOSPHATE-3.1 MAGNESIUM-2.3
[**2137-7-2**] 07:57PM   GLUCOSE-120* UREA N-12 CREAT-0.5 SODIUM-138
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-24 ANION GAP-17
[**2137-7-2**] 08:00PM URINE  RBC-0 WBC-0-2 BACTERIA-MANY YEAST-NONE
EPI-0
[**2137-7-2**] 08:00PM URINE  BLOOD-NEG NITRITE-POS PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-9.0*
LEUK-MOD
[**2137-7-9**] 05:52AM BLOOD WBC-8.9 RBC-4.31 Hgb-11.3* Hct-36.0
MCV-84 MCH-26.1* MCHC-31.3 RDW-15.7* Plt Ct-427
[**2137-7-5**] 06:30AM BLOOD ESR-105*
[**2137-7-7**] 06:55AM BLOOD ESR-80*
[**2137-7-9**] 05:52AM BLOOD ESR-90*
[**2137-7-9**] 05:52AM BLOOD Glucose-114* UreaN-9 Creat-0.4 Na-143
K-4.1 Cl-104 HCO3-29 AnGap-14
[**2137-7-9**] 05:52AM BLOOD Albumin-3.2* Calcium-8.5 Phos-2.8 Mg-2.5
[**2137-7-8**] 07:05AM BLOOD CRP-123.6*
[**2137-7-9**] 05:52AM BLOOD CRP-101.0*

ECG: Sinus tachycardia. Left axis deviation. Left anterior
fascicular block. Diffuse non-diagnostic repolarization
abnormalities. Compared to the previous tracing of [**2136-9-12**]
heart rate has increased. Otherwise, no major change.
[**7-2**]: KUB Single AP abdominal radiograph obtained, however,
limited as only the superior portion of the abdomen imaged. The
imaged portion is obscured by overlying pannus, however, the
underlying bowel loops show a nonspecific bowel gas pattern with
mildly air-filled distended loops of colon. No intra-abdominal
free air. Multiple left-sided rib deformities are noted.
[**7-2**]: Single AP chest radiograph compared to [**2137-2-7**] show
slightly increased interstitial lung markings, which may
represent mild edema with areas of new patchy opacity in the
right lung base and left mid lung, which may represent
atelectasis although aspiration/pneumonia would be difficult to
exclude. There is no pneumothorax or pleural effusion. The
cardiomediastinal contour is unchanged. Again seen are multiple
left-sided rib deformities.

CT Head:
IMPRESSION:
1. No acute intracranial hemorrhage.
2. Moderate opacification from fluid versus mucosal thickening
in the
maxillary sinuses, not [**Last Name (LF) 4646**], [**First Name3 (LF) **] reflect
sinusitis, and
clinical correlation is recommended.

CTA Chest [**2137-7-6**]
IMPRESSION:
1. No evidence of pulmonary embolism or aortic dissection.
2. Mild cardiac decompensation with pulmonary vascular
congestion but no
alveolar edema. Small right pleural effusion.
3. Possible small airways infection in the right middle lobe.
4. Aneurysmal descending aorta, 4 cm. Descending aortic graft in
place
without complication.
5. Enlargement of the pulmonary arteries suggesting underlying
pulmonary
artery hypertension.

[**2137-7-7**] MRI HIP
FINDINGS:
Please note that due to hardware failure, the complete sequences
could not be obtained.
There is a comminuted left proximal femur intertrochanteric
fracture, with
coxa varus orientation. There is a large amount of marrow edema
within the
proximal femur. Marrow edema and a small fracture line also
extends into the femoral neck. However, the marrow signal in the
femoral head appears normal. There is a small left hip joint
effusion. The adjacent left acetabulum appears normal. There is
a large amount of surrounding muscular edema. Also noted is
abnormal marrow signal in bilateral ischial tuberosities, left
greater than right. These areas of abnormal marrow signal are
just deep to the bilateral decubitus ulcers. In the appropriate
clinical setting, these are consistent with osteomyelitis.
The right hip appears normal. There is no evidence of right hip
fracture.
A suprapubic catheter is present. There is a large amount of
pelvic
musculature atrophy, consistent with patient's history of
quadriplegia.
There are spinal cysts which are partially visualized on the T1
images in the sacral spine. Due to lack of T2-weighted images,
these cannot be further evaluated. Differential consideration
includes Tarlov cyst.

8/3 L HIP XR: IMPRESSION:
1. Comminuted intertrochanteric fracture of the proximal left
femur.

2. Sclerosis and osseous irregularity of the left ischial
tuberosity in the region of a vacuum drain is concerning for
osteomyelitis. Correlation with the recently performed MRI is
advised.

[**7-5**] R HIP XR: Markedly limited study without definite evidence
for acute bony injury or marked infection. If there is high
clinical concern, cross-sectional imaging is recommended. Due to
the patient's large size MRI may not be possible and CT scan may
be the best alternative.  (Per discussion with radiologist after
fracture seen on MR, fracture was previously visible on this
film as well, but was poor study)



Brief Hospital Course:
Ms. [**Known lastname 4636**] is a 71yo paraplegic female with PMH as listed
above who presents with transient hypotension and leukocytosis.

1)Hypotension: Patient initially found to be hypotensive with
SBP~90's despite receiving 3L NS. Her baseline SBP is between
110-120's. Upon transfer to the MICU, her BP stabilized. The
drop in her BP may have been early sepsis physiology given
fever, history of recurrent UTI's. She may also have some
underlying autonomic dysregulation given paraplegia. She was
started on Vancomycin and Zosyn given prior culture results
which grew E.coli and enterococcus. After transfer to the floor
on [**2137-7-4**] her BP remained stable SBP 110s-120s, no longer
requiring IVF.

2)Leukocytosis/fevers: Patient noted to have WBC~14.0 and
febrile on admission. Cxray was not very revealing. Her U/A was
positive for leukocytes and nitrites but no WBCs and urine cx
were negative. Plastic surgery was consulted to see patient
while she was in-house and recommended VAC dsg changes q MWF.
She continued to spike fevers until [**7-5**] on Vanc/Zosyn but
remained afebrile for the remainder of her hospital course.
Since her urine cultures and blood cultures were all negative,
we explored other etiologies for her fever. She had a CTA that
did not show a PE but did show possible PNA. She also had XRs of
her hips to look for osteomyelitis given B/L decubitus ulcers.
Initial XR was poor study. ESR was checked and was 105. MRI
showed abnormal marrow signal of B/L ischial tuberosities near
areas of decubitus ulcers c/w osteomyelitis. Zosyn was
discontinued, vancomycin was continued and Levofloxacin was
added for gram negative coverage for her osteo. She will need 6
week course (5 more weeks of antibiotics). She will also need
follow-up of inflammatory markers which trended down during
hospital stay.

3)Mental status changes: Per son, the patient was less coherent
on day of admission. This resolved rapidly with resolution of
hypotension and fever. CT head was negative.

4)Neurogenic bladder: Patient has chronic SP foley catheter
placement as a result of her paraplegia. The patient's son
reported that her foley was not working appropriately. Urology
was contact[**Name (NI) **] on floor and performed SP catheter change and
wound care was consulted for ostomy bag change around catheter.
She was also reporting increased bladder spasms since Baclofen
was originally held in MICU. Spasms resolved with restarting
Baclofen and she had decreased leaking around SP catheter after
catheter/bag change.

5)L trochanter ulcer: Patient is followed closely by plastic
surgery as an outpatient. She has a wound vac on her left lower
extremity. Wound care and plastic surgery were consulted and
changed VAC on MWF. She was continued on Zinc sulfate. When
findings of osteomyelitis were reported on MRI, plastics was
again contact[**Name (NI) **] and they did not feel that further debridement
was neccessary at that time. She will follow up in plastics
clinic. L buttock VAC dsg changes should continue qMWF.

6.) Left femur fracture: Incidentally, patient noted to have
comminuted L intertrochanteric femur fracture on MRI. She denied
any pain or h/o trauma. Imaging also commented on osteopenia.
She was started on calcium and vitamin D supplements as well as
Alendronate q week for atraumatic fracture. Ortho was consulted
and did not recommend surgery since she was non-weight bearing
on that leg and did not have pain. Could consider endocrine
workup and/or bone density scan as outpatient. She will follow
up in ortho clinic as outpatient.

7)GERD: Continued on Pantoprazole.

8)COPD: Pt reports she has "lung disease" but denies known h/o
COPD and PFTs in [**2128**] were normal. She required 3L O2 NC while
in hospital to maintain O2 sats around 94-95%. She reports that
she was intermittently on 3L O2 at home, but it was unclear who
started her home oxygen and what the original indication was.
She was continued on outpatient regimen of Advair and Combivent.
She has not seen a pulmonologist in the past, but follow up was
arranged for PFTs and an appointment was made with Dr. [**Last Name (STitle) **].

9)Depression: Outpatient regimen was initially held given mental
status. She was then re-started on Gabapentin, Nortriptyline,
and Bupropion.

10) Code: DNR/DNI

Medications on Admission:
Gabapentin 900mg PO TID
Nortriptyline 50mg PO QHS
Bupropion 100mg PO BID
Pantoprazole 40mg PO daily
Aspirin 81mg PO daily
Colace 100mg PO BID
Zinc sulfate PO daily
Hexavitamin PO daily
Advair 250-50
Combivent MDI


Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO Q8H
(every 8 hours).
3. Nortriptyline 25 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
4. Bupropion 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
[**12-5**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-5**]
aerosols Inhalation four times a day as needed for shortness of
breath or wheezing.
9. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO every six (6)
hours as needed for constipation.
10. Hexavitamin     Tablet Sig: One (1) Tablet PO once a day.
11. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
12. Baclofen 10 mg Tablet Sig: Four (4) Tablet PO TID (3 times a
day).
13. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 5 weeks: Do not take at the same time as
your zinc. .
Disp:*35 Tablet(s)* Refills:*0*
14. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours) for 5 weeks.
Disp:*70 * Refills:*0*
15. Sodium Hypochlorite 0.5 % Solution Sig: One (1) Appl
Miscellaneous ASDIR (AS DIRECTED).
16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
17. Saline Flush 0.9 % Syringe Sig: One (1)  Injection Per NEHT
protocol: Per NEHT protocol.
Disp:*30 * Refills:*2*
18. Heparin Flush 10 unit/mL Kit Sig: One (1)  Intravenous per
NEHT protocol: Per NEHT protocol.
Disp:*30 * Refills:*2*
19. Outpatient Lab Work
Please have CBC, BMP (including electrolytes and renal
function), Vancomycin trough level, ESR and CRP checked q week
on Wednesday or Thursday x 5 weeks. Fax results to Dr. [**Last Name (STitle) 1266**]
at [**Telephone/Fax (1) 4647**].
20. Home oxygen
Continue use of home oxygen. Patient previously on 3L of
supplementary oxygen at home. She should continue to use 3L of
oxygen via nasal cannula unless instructed not to by a
physician.
21. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
22. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
23. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QTHUR (every
Thursday) as needed for hip fx.
Disp:*4 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Company 1519**]/[**Hospital1 8**] VNA

Discharge Diagnosis:
Primary Diagnosis:
Osteomyelitis
Secondary Diagnosis
1. L proximal femur fx
2. T8 Paraplegia [**1-5**] Anterior Spinal Infarct [**2128**] surrounding
thoracic aneurysm repair
3. Thoracic Aneurysm Repair ([**2128**])
4. Hx of LLL Collapse/PNA s/p mucous plug removal via
bronchoscopy
5. HTN
6. Hyperlipidemia
7. GERD
8. Chronic Suprapubic Catheter
9. UTIs, was on Ppx Bactrim until [**5-14**]. Fecal Incontinence
11. Depression
12. ?COPD (PFTs normal [**2128**]), intermittently on 3L home O2,


Discharge Condition:
Hemodynamically stable, afebrile, normotensive


Discharge Instructions:
You were admitted to the hospital with fever, low blood
pressure, and confusion. This was most likely from an infection
of the bones in your hips. We also found that you have a
fracture of your left hip. You should not bear any weight on
this leg and should have a repeat X ray in approximately 6 weeks
to ensure that it is healing.

We made the following changes to your medications
1. We added Vancomycin 1g IV twice daily
2. We added Levofloxacin 500 mg PO daily
3. We added Calcium and Vitamin D supplements
4. We added Alendronate 75 mg PO q week

Please return to the ER or call your primary care physician if
you have fever >101, chills, shortness of breath, chest pain, or
pain in your hips.

Followup Instructions:
Please follow up with your primary care doctor Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **]. Call [**Telephone/Fax (1) 608**] if you have any questions. He will
see you at home. You should also have a repeat X ray of your
left hip to ensure continued resolution of hip fracture.

You will also need to have lab work done to follow safety labs
and inflammatory markers. This will be drawn by nurses in your
home.

Please follow up with Dr. [**First Name4 (NamePattern1) 4648**] [**Last Name (NamePattern1) **] in Pulmonary clinic. You
have an appointment on Wednesday [**8-7**] at 8am. Please
arrive at 7:30am to complete paperwork and have pulmonary
function tests prior to your visit.  Call [**Telephone/Fax (1) 612**] if you
have any questions or need to reschedule.

Please follow up with Dr. [**First Name (STitle) **] in plastic surgery/wound care
clinic on Friday [**7-19**] at 1:30pm. Call [**Telephone/Fax (1) 4649**] if you
have any questions or need to reschedule.

Please follow up with Dr. [**Last Name (STitle) **] in orthopedics clinic on
Thursday [**8-15**] at 10:00am. Call [**Telephone/Fax (1) 1228**] if you
have any questions or need to reschedule.
{'Unspecified osteomyelitis, pelvic region and thigh,Encephalopathy, unspecified,Pressure ulcer, lower back,Paraplegia,Pathologic fracture of neck of femur,Chronic airway obstruction, not elsewhere classified,Neurogenic bladder NOS,Late effect of complications of surgical and medical care,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Urinary catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Mechanical complication due to urethral (indwelling) catheter,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Esophageal reflux,Depressive disorder, not elsewhere classified,Personal history of other diseases of circulatory system,Personal history, urinary (tract) infection'}


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: Hypotension

PRESENT ILLNESS: Ms. [**Known lastname 4636**] is a 71yo paraplegic female with PMH significant
for HTN, HLD, and chronic UTI's who is being transferred to the
MICU for management of hypotension. Per her son,
the patient's home nurse noted that she had a slight temperature
this morning. Her son noted that her appetite was poor and was
also incoherent. He also noted that her catheter contained urine
that was dark and concentrated. He immediately called 911. She
was then brought to [**Hospital1 18**] ED for further work-up. There is no
report of SOB, chest pain, abdominal pain, diarrhea, or
constipation. The son was also concerned that her catheter was
not working well and needed to be changed.
In the ED, initial vitals were T 102.2 BP 115/33 AR 105 RR 18 O2
sat 94% on 3L NC. She received Vancomycin 1gm IV, Zosyn 4.5gm
IV, and Tylenol 1gm. Her blood pressure dropped to 95/43 and
given lack of improvement after receiving 3L NS, she is being
transferred to the MICU for closer monitoring.

MEDICAL HISTORY: 1)Paraplegia [**1-5**] Anterior Spinal Infarct
2)Thoracic Aneurysm Repair ([**2128**])
3)Hx of LLL Collapse/PNA s/p mucous plug removal via
bronchoscopy
4)HTN
5)Hyperlipidemia
6)GERD
7)Suprapubic Catheter Placement / UTIs on Ppx Bactrim
8)Fecal Incontinence
9)Depression

MEDICATION ON ADMISSION: Gabapentin 900mg PO TID
Nortriptyline 50mg PO QHS
Bupropion 100mg PO BID
Pantoprazole 40mg PO daily
Aspirin 81mg PO daily
Colace 100mg PO BID
Zinc sulfate PO daily
Hexavitamin PO daily
Advair 250-50
Combivent MDI

ALLERGIES: Adhesive Tape

PHYSICAL EXAM: vitals T 95.8 BP 117/50 AR 65 RR 23 O2 sat 95% on 3L NC
Gen: Patient awake, responsive to commands
HEENT: MMM, PERRLA
Heart: RRR, no audible m,r,g
Lungs: CTAB, scattered crackles at posterior bases
Abdomen: Markedly distended but soft, NT, +BS
Extremities: 1+ bilateral edema, 2+ DP/PT pulses bilaterally;
large
ulcer approximately 6cm in diameter over L ischium that appears
to probe down to bone. She also has wound vac dressing in place
on left lower extremity.

FAMILY HISTORY: Son has DM

SOCIAL HISTORY: 58 year tobacco history, now smoking 3 cigarettes per day,
denies EthOH, denies drug abuse.  Widowed.  Has 3 sons.  She
lives alone in [**Hospital3 4634**]. 

### Response:
{'Unspecified osteomyelitis, pelvic region and thigh,Encephalopathy, unspecified,Pressure ulcer, lower back,Paraplegia,Pathologic fracture of neck of femur,Chronic airway obstruction, not elsewhere classified,Neurogenic bladder NOS,Late effect of complications of surgical and medical care,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Urinary catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Mechanical complication due to urethral (indwelling) catheter,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Esophageal reflux,Depressive disorder, not elsewhere classified,Personal history of other diseases of circulatory system,Personal history, urinary (tract) infection'}
