CHIEF COMPLAINT: rigors, malaise

PRESENT ILLNESS: Patient is a 59 yo f with DM 2, HTN, diabetic neurogenic
osteoarthropathy foot who presents for fever/chills at home,
nausea and generalized malaise since monday.  On monday she had
a podiatric procedure with removal of macerated hypertrophied
tissue and slight extension of ulcer margins on left chronic
neuropathic ulcer.   Denies diarrhea, last bm yesterday.
Patient did have fatigue, decreased po's, headaches, "bone"
pain, increased bg as high as 500.  Denies diarrhea, urinary sx.

MEDICAL HISTORY: 1-DM 2 since [**2133**] on orals, followed by [**Last Name (un) 387**] but mostly by Dr.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], last aic 6.2, gets yearly eye exams
2-HTN
3-rheumatic fever at age 7 or 8
4-hypercholesterolemia
5-CAD nl ef, last cath [**11-26**]- complex disease of lad/d1,
significant disease of ramus

MEDICATION ON ADMISSION: Allopurinol 350 mg po qd
Ativan 2 mg qhs
Flexeril 10 mg [**Hospital1 **]
Zocor 80 mg qd
Lisinopril 5 mg qd
ASA
Tums
Glucophage 850 mg qam, 500mg XR qpm
Atenolol 25 mg qd
Glipizide 10 [**Hospital1 **]
AMbien
Plavix 75
Elavil 25 qhs
quinine 260 qhs prn

ALLERGIES: Gemfibrozil / Ranitidine / Aloe

PHYSICAL EXAM: PE: Tm 97.5 BP 96/50 P 82 O2 98% RA
Gen: no resp distress, shivering
HEENT: perrla, eomi, mm dry, neck supple, bleeding IJ site
Lungs: cta x 2
Heart: 2/6 sem, s1 s2 no m/r/g
Abd: obese, mildly tender diffusely, +bs
Ext: 1+ edema, bilateral foot deformities, ulcer on left foot
with drain, black area(foam per podiatry consult), clean ulcer
on right foot. warm feet b/l, decreased sensation to light touch
skin: no rashes
rectal: guaiac neg

FAMILY HISTORY: family hx of CAD, no dm or charcot

SOCIAL HISTORY: hx of domestic violence, denies smoking, drinking, lives alone,
daugher helps as she is chair bound since [**1-27**] (due to charcot
feet)
previously worked part time in flower shop
Methicillin susceptible Staphylococcus aureus septicemia,Septic shock,Ulcer of heel and midfoot,Acute kidney failure, unspecified,Acute osteomyelitis, ankle and foot,Cellulitis and abscess of foot, except toes,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Arthropathy associated with neurological disorders,Long-term (current) use of insulin,Unspecified essential hypertension,Other bone involvement in diseases classified elsewhere,Severe sepsis,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Anemia, unspecified
Meth susc Staph aur sept,Septic shock,Ulcer of heel & midfoot,Acute kidney failure NOS,Ac osteomyelitis-ankle,Cellulitis of foot,DMII neuro nt st uncntrl,Arthropathy w nerve dis,Long-term use of insulin,Hypertension NOS,Bone involv in oth dis,Severe sepsis,Crnry athrscl natve vssl,Hyperlipidemia NEC/NOS,Anemia NOS
Admission Date:  [**2147-5-4**]              Discharge Date:   [**2147-5-9**]

Date of Birth:  [**2087-5-24**]             Sex:   F

Service: MEDICINE

Allergies:
Gemfibrozil / Ranitidine / Aloe

Attending:[**First Name3 (LF) 22401**]
Chief Complaint:
rigors, malaise

Major Surgical or Invasive Procedure:
LIJ insertion

History of Present Illness:
Patient is a 59 yo f with DM 2, HTN, diabetic neurogenic
osteoarthropathy foot who presents for fever/chills at home,
nausea and generalized malaise since monday.  On monday she had
a podiatric procedure with removal of macerated hypertrophied
tissue and slight extension of ulcer margins on left chronic
neuropathic ulcer.   Denies diarrhea, last bm yesterday.
Patient did have fatigue, decreased po's, headaches, "bone"
pain, increased bg as high as 500.  Denies diarrhea, urinary sx.



Past Medical History:
1-DM 2 since [**2133**] on orals, followed by [**Last Name (un) 387**] but mostly by Dr.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], last aic 6.2, gets yearly eye exams
2-HTN
3-rheumatic fever at age 7 or 8
4-hypercholesterolemia
5-CAD nl ef, last cath [**11-26**]- complex disease of lad/d1,
significant disease of ramus


Social History:
hx of domestic violence, denies smoking, drinking, lives alone,
daugher helps as she is chair bound since [**1-27**] (due to charcot
feet)
previously worked part time in flower shop


Family History:
family hx of CAD, no dm or charcot

Physical Exam:
PE: Tm 97.5 BP 96/50 P 82 O2 98% RA
Gen: no resp distress, shivering
HEENT: perrla, eomi, mm dry, neck supple, bleeding IJ site
Lungs: cta x 2
Heart: 2/6 sem, s1 s2 no m/r/g
Abd: obese, mildly tender diffusely, +bs
Ext: 1+ edema, bilateral foot deformities, ulcer on left foot
with drain, black area(foam per podiatry consult), clean ulcer
on right foot. warm feet b/l, decreased sensation to light touch
skin: no rashes
rectal: guaiac neg


Pertinent Results:
[**2147-5-4**] 10:46PM   LACTATE-1.0
[**2147-5-4**] 09:30PM   CORTISOL-37.3*
[**2147-5-4**] 08:00PM URINE  HOURS-RANDOM CREAT-22 SODIUM-105
POTASSIUM-27
[**2147-5-4**] 08:00PM URINE  OSMOLAL-364
[**2147-5-4**] 08:00PM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2147-5-4**] 08:00PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2147-5-4**] 07:52PM   HGB-9.2* calcHCT-28 O2 SAT-70
[**2147-5-4**] 07:33PM   GLUCOSE-102 UREA N-23* CREAT-0.7 SODIUM-141
POTASSIUM-4.5 CHLORIDE-110* TOTAL CO2-18* ANION GAP-18
[**2147-5-4**] 07:33PM   ALT(SGPT)-11 AST(SGOT)-14 LD(LDH)-121 ALK
PHOS-70 AMYLASE-170* TOT BILI-0.2
[**2147-5-4**] 07:33PM   LIPASE-19
[**2147-5-4**] 07:33PM   ALBUMIN-3.4 CALCIUM-7.7* PHOSPHATE-2.8
MAGNESIUM-1.5* URIC ACID-3.3
[**2147-5-4**] 07:33PM   CORTISOL-18.7
[**2147-5-4**] 07:33PM   HCT-26.0*
[**2147-5-4**] 05:24PM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.005
[**2147-5-4**] 03:42PM   LACTATE-1.1
[**2147-5-4**] 03:42PM   HGB-8.9* calcHCT-27
[**2147-5-4**] 03:17PM   LACTATE-1.7
[**2147-5-4**] 12:29PM   NEUTS-88.7* BANDS-0 LYMPHS-7.7* MONOS-2.4
EOS-0.5 BASOS-0.6
[**2147-5-4**] 12:29PM   HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
[**2147-5-4**] 12:29PM   PT-13.4* PTT-31.6 INR(PT)-1.2*
[**2147-5-4**] 12:29PM   PLT SMR-NORMAL PLT COUNT-378.
Imaging:
CT LLE [**5-4**]:
New severe ulceration of the left foot with extension of gas
down to bone. Extensive destructive changes are seen adjacent to
this local area of gas that were present on prior study,
however, given ulceration, gas and soft tissue swelling, these
findings are concerning for osteomyelitis. Within the right
___destructive changes are present, however, no significant
ulcer and gas formation is identified. If there is further
clinical concern, recommend MRI.
.
CXR [**5-4**]:
IMPRESSION:
1. Left IJ catheter with tip in mid SVC.
2. No pneumothorax.
3. Mild opacification at right medial lung base may represent
atelectasis versus pneumonia. Lateral film is recommended for
further evaluation.
.
Echo [**5-5**]:
mild LAE, mild LVH, EF 60-65%, 2+TR, mod [**Last Name (un) 6879**] (35-55), no
effusion, no vegetations


Brief Hospital Course:
Briefly, this is a 59 yo f with DM 2, HTN, diabetic neurogenic
osteoarthropathy foot who presented with c/o fever, nausea, and
malaise for several days PTA.  On 4 days PTA pt had a podiatric
procedure with removal of macerated hypertrophied tissue and
slight extension of ulcer margins on left chronic neuropathic
ulcer.   Following that she experienced increased L foot pain.
The following day she developed nausea and fatigue.  On the
morning of admission the pt awoke with rigors and temp of 104.
Her FS was also up to 500. On admission the pt was hypotensive
to 54/38 with a lactate of 2.6.  She was started on Cefepime,
Vanc, and Flagyl to cover possible osteo.  In the MICU, the pt
was started on levophed gtt which was weaned off the same day.
She was also hydrated with 8 L NS.  CT of the pts LLE revealed
gas down to the pts L foot bone with destructive changes and
ulceration likely c/w osteomyelitis.  The pt was seen by
podiatry who feels the CT changes may be c/w either osteo or
charcot foot given no signs of infection on exam.  The pt also
was noted to be in ARF, which improved prior to transfer to the
floor.  She was found to have [**4-25**] blood cx growing MSSA, and
foot cx grew MSSA as well.
.
#s/p sepsis:  The most likely source was the pts foot ulcer,
which has grown MSSA and pseudomonas in the past. The also has
[**2-25**] blood cultures from [**5-4**] growing MSSA.  Her abdominal pain
resolved, and TTE was negative on [**5-5**] for any vegetations.
Following tranfer to the floor, the pts blood pressure remained
stable.  She was initially continued on cefepime, vanco, flagyl
to cover for potential pseudomonas, staph, and anaerobes in a
possible diabetic foot osteo (started [**5-4**]).  Per podiatry, the
changed seen on the CT of the pts L foot could be consistent
with either osteo or Charcot foot.  The pt is to have
reconstruction of her Charcot foot in several months.  She was
taken for debridement of her L foot and bone cultures were sent.

.
#L foot ulcer:  The pt was followed by podiatry.  CT of the L
foot revealed ulceration, gas and soft tissue swelling
concerning for osteomyelitis.  Per podiatry, these changes also
could be consistent with Charcot foot.  Her ulcer has grown MSSA
and pseudomonas in the past, so she was initially covered with
cefepime, vanc, and flagyl.  The podiatry team followed very
closely, and determined that she was clinically improving, with
well-appearing granulation tissue forming, and could e
dishcarged on oral antibiotics (levaquin) to be continued until
her reconstruction and follow up the following week.
.
#CARD/HTN/hyperlipidemia: She was continued on her ASA, plavix,
statin, and eventually her metoprolol and lisinopril were
restarted.  She was normotensive on discharge.
.
#[**Doctor First Name 48**]: Pts Cr on admission was 1.3, which decreased to 0.7 after
8 L of fluids.  Likely was prerenal in etiology.  Baseline Cr
was 0.6. She maintained good urine output during the admission.
.
#DM: The pts home po medications were held in the setting of
sepsis, but these were restarted following transfer to the
floor.   She had decent glycemic control while in the hospital.
.
#Anemia: The pts hct was 31 on admission and dropped to 23-24 on
subsequent days.  This was felt to be due to bleeding from her
central line site and fluid resuscitation. She was guaiac
negative, and her hct then remained stable.


Medications on Admission:
Allopurinol 350 mg po qd
Ativan 2 mg qhs
Flexeril 10 mg [**Hospital1 **]
Zocor 80 mg qd
Lisinopril 5 mg qd
ASA
Tums
Glucophage 850 mg qam, 500mg XR qpm
Atenolol 25 mg qd
Glipizide 10 [**Hospital1 **]
AMbien
Plavix 75
Elavil 25 qhs
quinine 260 qhs prn


Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection Q8H (every 8 hours).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Multivitamin     Capsule Sig: One (1) Cap PO DAILY (Daily).
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
8. Allopurinol 300 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical  [**Hospital1 **]
(2 times a day).
12. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed.
13. Quinine Sulfate 325 mg Capsule Sig: One (1) Capsule PO HS
(at bedtime) as needed.
14. Insulin Regular Human 100 unit/mL Solution Sig: One (1) unit
Injection ASDIR (AS DIRECTED).
15. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
16. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
17. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
18. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
19. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
20. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
21. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
22. Metformin 850 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
23. Metformin 500 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO QPM (once a day (in the
evening)).
24. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
25. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours): Please take until directed to stop by your
podiatrist.
Disp:*30 Tablet(s)* Refills:*0*
26. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).



Discharge Disposition:
Home With Service

Facility:
[**Hospital1 1559**] Home Care

Discharge Diagnosis:
Sepsis
Diabetes Mellitus type 2 with complications, poorly controlled
Charcot arthropathy
Cellulitis of foot
Hypertension
SECONDARY
Hyperlipidemia
Coronary artery disease


Discharge Condition:
Good, ambulating, tolerating PO, afebrile


Discharge Instructions:
If you experience high fevers, shaking chills, chest pain,
difficulty breathing, or any other concerning symtpom, please
seek immediate medical attention.

Please keep all follow up appointments.

You should continue to take levofloxacin as ordered indefinitely
until directed by podiatry.

Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2147-5-15**] 1:10
{'Methicillin susceptible Staphylococcus aureus septicemia,Septic shock,Ulcer of heel and midfoot,Acute kidney failure, unspecified,Acute osteomyelitis, ankle and foot,Cellulitis and abscess of foot, except toes,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Arthropathy associated with neurological disorders,Long-term (current) use of insulin,Unspecified essential hypertension,Other bone involvement in diseases classified elsewhere,Severe sepsis,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Anemia, unspecified'}


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: rigors, malaise

PRESENT ILLNESS: Patient is a 59 yo f with DM 2, HTN, diabetic neurogenic
osteoarthropathy foot who presents for fever/chills at home,
nausea and generalized malaise since monday.  On monday she had
a podiatric procedure with removal of macerated hypertrophied
tissue and slight extension of ulcer margins on left chronic
neuropathic ulcer.   Denies diarrhea, last bm yesterday.
Patient did have fatigue, decreased po's, headaches, "bone"
pain, increased bg as high as 500.  Denies diarrhea, urinary sx.

MEDICAL HISTORY: 1-DM 2 since [**2133**] on orals, followed by [**Last Name (un) 387**] but mostly by Dr.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], last aic 6.2, gets yearly eye exams
2-HTN
3-rheumatic fever at age 7 or 8
4-hypercholesterolemia
5-CAD nl ef, last cath [**11-26**]- complex disease of lad/d1,
significant disease of ramus

MEDICATION ON ADMISSION: Allopurinol 350 mg po qd
Ativan 2 mg qhs
Flexeril 10 mg [**Hospital1 **]
Zocor 80 mg qd
Lisinopril 5 mg qd
ASA
Tums
Glucophage 850 mg qam, 500mg XR qpm
Atenolol 25 mg qd
Glipizide 10 [**Hospital1 **]
AMbien
Plavix 75
Elavil 25 qhs
quinine 260 qhs prn

ALLERGIES: Gemfibrozil / Ranitidine / Aloe

PHYSICAL EXAM: PE: Tm 97.5 BP 96/50 P 82 O2 98% RA
Gen: no resp distress, shivering
HEENT: perrla, eomi, mm dry, neck supple, bleeding IJ site
Lungs: cta x 2
Heart: 2/6 sem, s1 s2 no m/r/g
Abd: obese, mildly tender diffusely, +bs
Ext: 1+ edema, bilateral foot deformities, ulcer on left foot
with drain, black area(foam per podiatry consult), clean ulcer
on right foot. warm feet b/l, decreased sensation to light touch
skin: no rashes
rectal: guaiac neg

FAMILY HISTORY: family hx of CAD, no dm or charcot

SOCIAL HISTORY: hx of domestic violence, denies smoking, drinking, lives alone,
daugher helps as she is chair bound since [**1-27**] (due to charcot
feet)
previously worked part time in flower shop 

### Response:
{'Methicillin susceptible Staphylococcus aureus septicemia,Septic shock,Ulcer of heel and midfoot,Acute kidney failure, unspecified,Acute osteomyelitis, ankle and foot,Cellulitis and abscess of foot, except toes,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Arthropathy associated with neurological disorders,Long-term (current) use of insulin,Unspecified essential hypertension,Other bone involvement in diseases classified elsewhere,Severe sepsis,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Anemia, unspecified'}
