CHIEF COMPLAINT: sepsis, likely from osteomyletis of left heel

PRESENT ILLNESS: [**Age over 90 **] yo woman who lives in [**Location **] with Alzheimer's Dementia
(non-verbal at baseline) was admitted on [**8-28**] with sepsis of
unclear source. Cultures, Abd/Pelvic CT, CXR, and LP did not
reveal a source of infection, however, patient was noted to have
a chronic L heel ulcer that probed to bone.  In conjunction with
ESR of 100, the patient's sepsis was thought to be possibly due
to osteomyelitis.

MEDICAL HISTORY: 1) Alzheimer's dementia (non-verbal at baseline)
2) Urinary incontinence with indwelling Foley
3) GERD, PUD, esophagitis
4) Dysphagia s/p PEG
5) HTN
6) Hyperlipidemia
7) Tardive dyskinesia [**3-8**]/ haldol
8) Cataracts
9) Non-healing L heel ulcer
10)Anemia of chronic disease
11)s/p L hip ORIF
12)s/p TAH
13)Urosepsis [**5-9**] c/b CHF

MEDICATION ON ADMISSION: Duragesic patch
levoquin
lasix
prevacid
morphine
valproic acid
kaopectate
MOM
lactulose
albuterol
ipatromium

ALLERGIES: Haldol

PHYSICAL EXAM: VS:  BP  122 /80    HR:95  RR:20  T:6.1    99%O2 sat%
gen: NAD, overweight, non-verbal, elderly woman with dementia
HEENT:NCAT, PERLLA, anicteric, no conj injection, -JVD, -bruits,
good carotid pulses, -lymphadenopathy
lung: Crackles at bases
heart: RR, S1 and S2 wnl, -m/r/g
abd: +b/s, soft, non-tender, non-distended
extr:+trace dependent edema, -cyanosis
neuro:AOx3.  Baseline dementia.  Non-purposeful movements,
responsive to noxious stimuli.
skin: no jaundice, warm and dry
heel: decubitus ulcer Stage 3-4

FAMILY HISTORY: nc

SOCIAL HISTORY: The patient's son [**Name (NI) **] is involved with her care and was
aware of the hospital course.
Unspecified septicemia,Ulcer of heel and midfoot,Blood in stool,Unspecified pleural effusion,Subendocardial infarction, initial episode of care,Septic shock,Acute kidney failure, unspecified,Unspecified osteomyelitis, ankle and foot
Septicemia NOS,Ulcer of heel & midfoot,Blood in stool,Pleural effusion NOS,Subendo infarct, initial,Septic shock,Acute kidney failure NOS,Osteomyelitis NOS-ankle
Admission Date:  [**2106-8-28**]              Discharge Date:   [**2106-9-7**]


Service: MED

Allergies:
Haldol

Attending:[**First Name3 (LF) 18141**]
Chief Complaint:
sepsis, likely from osteomyletis of left heel

Major Surgical or Invasive Procedure:
A-line placement
R PICC line placement
L PICC line placement

History of Present Illness:
[**Age over 90 **] yo woman who lives in [**Location **] with Alzheimer's Dementia
(non-verbal at baseline) was admitted on [**8-28**] with sepsis of
unclear source. Cultures, Abd/Pelvic CT, CXR, and LP did not
reveal a source of infection, however, patient was noted to have
a chronic L heel ulcer that probed to bone.  In conjunction with
ESR of 100, the patient's sepsis was thought to be possibly due
to osteomyelitis.

In the ED she was tachypnic and hypotensive and was therefore
admitted to the MICU, intubated, and started on pressors.  She
was extubated on HD 4, and her cuff blood pressure was found to
be much lower than her arterial blood pressure measured via an
a-line, which was placed after aggressive fluid recusitation did
not improve her pressures.  The pressors were therefore
discontinued.

Her sepsis was initially treated empirically with broad-spectrum
abx in the ED/MICU, until cultures of L heel wound grew out MRSA
sensitive to vancomycin.  At that point, she was switched to
mom[**Name (NI) **] with vancomycin 1g q24 hours for a total duration of
six weeks. When she was stable for transfer she was moved to the
floor (on HD 5) for continued antibiotics and management.

On HD 5 a RUE DVT was discovered secondary to her right sided
PICC line; the PICC was removed, and patient anticoagulated
briefly until she developed guiac positive stools at which point
anticoagulation was discontinued.  A new left PICC line was
placed for continuation of her vancomycin.  Her HCTs remained
stable and she did not require transfusion.  The patient also
developed non tender blistering over her sacrum; a VZV DFA was
negative, and the blisters were treated with sterile dressings.
The remainder of the [**Hospital 228**] hospital course was unremarkable
and she was discharged on HD 10 to an extended care facility.


Past Medical History:
1) Alzheimer's dementia (non-verbal at baseline)
2) Urinary incontinence with indwelling Foley
3) GERD, PUD, esophagitis
4) Dysphagia s/p PEG
5) HTN
6) Hyperlipidemia
7) Tardive dyskinesia [**3-8**]/ haldol
8) Cataracts
9) Non-healing L heel ulcer
10)Anemia of chronic disease
11)s/p L hip ORIF
12)s/p TAH
13)Urosepsis [**5-9**] c/b CHF


Social History:
The patient's son [**Name (NI) **] is involved with her care and was
aware of the hospital course.

Family History:
nc

Physical Exam:
VS:  BP  122 /80    HR:95  RR:20  T:6.1    99%O2 sat%
gen: NAD, overweight, non-verbal, elderly woman with dementia
HEENT:NCAT, PERLLA, anicteric, no conj injection, -JVD, -bruits,
good carotid pulses, -lymphadenopathy
lung: Crackles at bases
heart: RR, S1 and S2 wnl, -m/r/g
abd: +b/s, soft, non-tender, non-distended
extr:+trace dependent edema, -cyanosis
neuro:AOx3.  Baseline dementia.  Non-purposeful movements,
responsive to noxious stimuli.
skin: no jaundice, warm and dry
heel: decubitus ulcer Stage 3-4

Pertinent Results:
[**2106-8-28**] 02:41PM   WBC-22.0*# RBC-4.10* HGB-12.4 HCT-38.9
MCV-95# MCH-30.3 MCHC-34.7 RDW-14.9
[**2106-8-28**] 02:41PM   NEUTS-80* BANDS-10* LYMPHS-4* MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2106-8-28**] 02:41PM   PLT COUNT-493*#
[**2106-8-28**] 02:41PM   PT-12.6 PTT-20.8* INR(PT)-1.0

UA/UCx and Bl Cx's wnl-no growth
L heel ulcer cultured MRSA
[**2106-8-28**] 05:50PM   GLUCOSE-234* UREA N-81* CREAT-1.1 SODIUM-156*
POTASSIUM-4.1 CHLORIDE-123* TOTAL CO2-21* ANION GAP-16
[**2106-8-28**] 05:50PM   ALT(SGPT)-40 AST(SGOT)-35 CK(CPK)-82 ALK
PHOS-70 AMYLASE-120* TOT BILI-0.3
[**2106-8-28**] 05:50PM   LIPASE-41

rule out MI:
[**2106-8-28**] 05:50PM   CK-MB-NotDone cTropnT-0.08*
[**2106-8-28**] 09:45PM   CK(CPK)-78
[**2106-8-28**] 09:45PM   CK-MB-5 cTropnT-0.07*

UE U/S:
IMPRESSION: Basilic vein thrombosis.
[**8-28**] CXR:IMPRESSION: Appropriate placement of endotracheal tube
and gastric tube. New
patchy opacities at the lung bases may represent changes from
aspiration,
given the recent development.

CT abd/pelvis
IMPRESSION:

1. Small bilateral pleural effusions with associated
atelectasis.
2. Small amount of nonspecific free fluid within the pelvis.
3. Distended gallbladder without percholecystic inflammatory
change and
without wall thickening.

Discharge ([**9-7**]) HCT=27.0
Discharge ([**9-7**]) BUN/Cr=11/0.5

VZV DFA ([**9-6**]) negative for VZV.

Brief Hospital Course:
1) Hypotension: Initial hypotension (with associated lactic
acidosis) likely due to hypovolemia (inadequate fluids with
aggressive diuresis) as well as sepsis. The difference in
readings between the cuff BP and the a-line BP suggest that her
hypotension was more transient than initailly thought.  A
cortisol stimulation test in the ICU was negative. Patient has
been adequately volume resuscitated per clinical signs such as
urine output since being on the floor.

2) Sepsis: Initially treated broadly, and switched to vancomycin
once C+S from L heel ulcer returned.  WBC trended down as of HD
6, patient did not have persistent fevers or other clinical
signs of infection, and she was discharged on day 6 of a 42 day
course of vancomycin 1g IV q24 hours.

3) Right Upper Extremity DVT: Thought to be PICC catheter
induced. The right sided catheter was discontined and a left
PICC was placed.  The patient was initially begun on a heparin
gtt, and coumadin was added the following day.  Both of these
medications were discontined when the patient was noted to have
guiac positive stools one day after initiation of warfarin
therapy.  Her hematocrit subsequently was stable, ranging
between 27-30, and transfusion was not required.

4) Hypoxemia: Etiology unclear; most likely diagnosis may have
been mild aspiration event. No evidence of pneumonia, CHF. On
discharge, patient was maintaining sats of 96% on 1 liter.

5) Hypernatremia: Initially Na=157.  Resolved after aggressive
hydration with normal saline. Likely due to hypovolemic
hypernatremia due to lack of free water access.

6) Anemia: Baseline Hct appears to likely range 27-30; stable on
discharge at 27.

7) Renal insufficiency: Most likely prerenal given elevated
BUN:Cr on admission. Once appropriately hydrated, excellent
urine output, discharge Creatinine was 0.5.

8) Delta MS: There was a question of a change in mental status
on admission.  Per son, patient was at her baseline.  However,
during hospitalization, Depakote and Ritalin were held.  She
remained non verbal and responsive to noxious stimuli throughout
her hospitalization.

9) NSTEMI: On admission the patient's, troponin was mildly
elevated (0.08, then 0.07), likely due to demand ischemia in
setting of hypotension and tachycardia. Her outpatient ASA was
continued, a beta-blocker was added when her BP would tolerate.

10) Pain Control: On fentanyl patch.

11) F/E/N: patient was well hydrated, potassium was repleted.
Tube feeds were continued, metoclopramide was continued. RISS
stopped on transfer to floor due to minimal insulin requirements
(4 units in 6 days).

12) Vaginal/perineal candidiasis: It was noted that patient had
[**Female First Name (un) **] infection on HD 6, she was treated with nystatin and
clotrimazole, both intravaginally.

13) Sacral blistering: DFA sent for VZV which was negative.
Blisters were treated with dressing changes and were stable.

14) Prophylaxis: SQ heparin and PPI were used for DVT and PUD
prophylaxis, respectively.

15) Code: Full code; patient's living will was faxed to hospital
on day of discharge.

16) Dispo: Discharged to [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **].

Medications on Admission:
Duragesic patch
levoquin
lasix
prevacid
morphine
valproic acid
kaopectate
MOM
lactulose
albuterol
ipatromium

Discharge Medications:
1. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
2. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
3. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO QD (once a day).
4. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO
QIDACHS (4 times a day (before meals and at bedtime)).
5. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1)  PO BID (2
times a day).
6. Nystatin 100,000 unit/mL Suspension Sig: One (1) Tablet PO HS
(at bedtime).
7. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Vaginal [**Hospital1 **] (2
times a day).
8. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl
Topical  PRN (as needed).
9. Vancomycin HCl 1000 mg IV Q24H
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1186**] - [**Location (un) 538**]

Discharge Diagnosis:
osteomylitis

Discharge Condition:
patient is hemodynamically stable, producing good urine output,
on six week course of vancomycin

Discharge Instructions:
Please continue the vancomycin for six weeks, on discharge from
[**Hospital1 18**] ([**2106-9-7**]), patient was on day 10/42.

Followup Instructions:
per physicians at ECF





Name:  [**Known lastname **],[**Known firstname 14865**]                     Unit No:   [**Numeric Identifier 14866**]

Admission Date:  [**2106-8-28**]              Discharge Date:   [**2106-9-7**]

Date of Birth:  [**2013-12-22**]             Sex:   F

Service: MED

Allergies:
Haldol

Attending:[**First Name3 (LF) 11107**]
Chief Complaint:
see discharge summary

Major Surgical or Invasive Procedure:
see dc

History of Present Illness:
see discharge summary

Past Medical History:
see discharge summary

Social History:
see dc

Family History:
see dc

Physical Exam:
see dc

Brief Hospital Course:
see dc

Medications on Admission:
see dc

Discharge Medications:
1. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
2. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
3. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO QD (once a day).
4. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO
QIDACHS (4 times a day (before meals and at bedtime)).
5. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1)  PO BID (2
times a day).
6. Nystatin 100,000 unit/mL Suspension Sig: One (1) Tablet PO HS
(at bedtime).
7. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Vaginal [**Hospital1 **] (2
times a day).
8. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl
Topical  PRN (as needed).
9. Vancomycin HCl 1000 mg IV Q24H
***Lasix was not restared****

Discharge Disposition:
Extended Care

Facility:
[**Hospital3 163**] - [**Location (un) 164**]

Discharge Diagnosis:
see dc

Discharge Condition:
see dc

Discharge Instructions:
see dc

Followup Instructions:
see dc

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 11108**] MD [**MD Number(2) 11109**]

Completed by:[**2106-9-7**]
{'Unspecified septicemia,Ulcer of heel and midfoot,Blood in stool,Unspecified pleural effusion,Subendocardial infarction, initial episode of care,Septic shock,Acute kidney failure, unspecified,Unspecified osteomyelitis, ankle and foot'}


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, likely from osteomyletis of left heel

PRESENT ILLNESS: [**Age over 90 **] yo woman who lives in [**Location **] with Alzheimer's Dementia
(non-verbal at baseline) was admitted on [**8-28**] with sepsis of
unclear source. Cultures, Abd/Pelvic CT, CXR, and LP did not
reveal a source of infection, however, patient was noted to have
a chronic L heel ulcer that probed to bone.  In conjunction with
ESR of 100, the patient's sepsis was thought to be possibly due
to osteomyelitis.

MEDICAL HISTORY: 1) Alzheimer's dementia (non-verbal at baseline)
2) Urinary incontinence with indwelling Foley
3) GERD, PUD, esophagitis
4) Dysphagia s/p PEG
5) HTN
6) Hyperlipidemia
7) Tardive dyskinesia [**3-8**]/ haldol
8) Cataracts
9) Non-healing L heel ulcer
10)Anemia of chronic disease
11)s/p L hip ORIF
12)s/p TAH
13)Urosepsis [**5-9**] c/b CHF

MEDICATION ON ADMISSION: Duragesic patch
levoquin
lasix
prevacid
morphine
valproic acid
kaopectate
MOM
lactulose
albuterol
ipatromium

ALLERGIES: Haldol

PHYSICAL EXAM: VS:  BP  122 /80    HR:95  RR:20  T:6.1    99%O2 sat%
gen: NAD, overweight, non-verbal, elderly woman with dementia
HEENT:NCAT, PERLLA, anicteric, no conj injection, -JVD, -bruits,
good carotid pulses, -lymphadenopathy
lung: Crackles at bases
heart: RR, S1 and S2 wnl, -m/r/g
abd: +b/s, soft, non-tender, non-distended
extr:+trace dependent edema, -cyanosis
neuro:AOx3.  Baseline dementia.  Non-purposeful movements,
responsive to noxious stimuli.
skin: no jaundice, warm and dry
heel: decubitus ulcer Stage 3-4

FAMILY HISTORY: nc

SOCIAL HISTORY: The patient's son [**Name (NI) **] is involved with her care and was
aware of the hospital course. 

### Response:
{'Unspecified septicemia,Ulcer of heel and midfoot,Blood in stool,Unspecified pleural effusion,Subendocardial infarction, initial episode of care,Septic shock,Acute kidney failure, unspecified,Unspecified osteomyelitis, ankle and foot'}
