CHIEF COMPLAINT: Right leg pain

PRESENT ILLNESS: Ms. [**Known lastname 37559**] is a 55 yo W with PMH of ESRD on HD, PVD, DM, renal
cell ca, presents with RLE pain x 1 week, n/v and abdominal
tenderness. She reports sharp pain in ankle, toes, calf and knee
for approx. 1 week. Nothing improves or exacerbates symptoms.
She notes some swelling throughout but denies joint swelling or
redness. No fevers or chills. She has not had similar symptoms
in the past. No trauma to the area. She is non ambulatory at
baseline. Pt presented to ED from nursing home for further
evaluation.

MEDICAL HISTORY: -Peripheral vascular disease s/p left SFA-DP bypass in [**2187**] for
gangrenous heel, s/p R proximal SF-proximal AT bypass in [**4-4**],
s/p L BKA in [**1-6**] for non-healing ulcer
- Left stump osteomyelitis in [**4-5**] treated with vanco/[**Last Name (un) 2830**] from
[**Date range (1) 101854**]
- H/o MRSA vertebral osteomyelitis with MRSA bacteremia
- ESRD on HD - TTSat schedule per nephrology ED note
- HTN
- CAD s/p NSTEMI
- Diabetes Mellitus
- Renal Cell Carcinoma s/p right nephrectomy
- Obesity
- Depression
- s/p CCY
- Gastric Ulcer
- Obstructive Sleep Apnea.
- Gastroparesis
- COPD on 3-4L NC baseline
- H/o ischemic colitis
- Left adrenal adenoma

MEDICATION ON ADMISSION: Lactulose 30 mg prn
Seroquel 25 mg q 12 hour
Sensipar 60 mg daily
Renagel 2400 TIDWF
Zemplar 4 mcg MWF IV
Nitropaste prn
Novolog sliding scale
HSQ
Senokot 1 [**Hospital1 **]
Reglan 5 mg TID
Nexium 20 mg daily
Colace 100 mg daily
Zocor 10 mg daily
Lopressor 12.5 q 12 hours
Lovenox 40 mg daily
Aranesp 100 Mo
Remeron 15 mg qhs
Duralgesic 75 mcq q3day
Aspirin 81 daily
Nephrocaps 1 daily
Ambien 5 mg
Ultram 50 [**Hospital1 **]
Perocet 2 tabs q6hours
Neuronitn 300mg prn
Insulin Novolog 8, 8, and 10 units before meals and sliding
scale.
Paricalcitol 6 mg q HD

ALLERGIES: Lisinopril

PHYSICAL EXAM: VS: T sys 140 w/ doppler HR 54 100% RA
Gen: Pleasant obese african american female in NAD
HEENT: PERRL, EOMI, o/p clear
CV: RRR, distant heart sounds
Pulm: CTABL no w/r/r
Abd: obese, soft, NT, ND; old surgical scar well healed in RLQ
Ext: L BKA; RLE with 1+ pitting edema; dopplerable DP pulse
Neuro: alert and oriented x 3, moving all extremities, CNs [**1-10**]
intact; no focal deficits
SKIN: intertriginous erythema
GYN: firm purulent abscess over right labia

FAMILY HISTORY: Mother died of stomach cancer in her 40s. Father had an unknown
cancer in his 70s. Stated that diabetes, high cholesterol, and
high blood pressure run in her family.

SOCIAL HISTORY: Admitted from nursing home. Has two sisters, one daughter.
[**Name (NI) **] is a former smoker with a 30 pack year history, quit 20
years ago.
Septicemia due to gram-negative organism, unspecified,Septic shock,Encephalopathy, unspecified,End stage renal disease,Atherosclerosis of native arteries of the extremities with gangrene,Acute osteomyelitis, ankle and foot,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Acidosis,Other complications due to other vascular device, implant, and graft,Severe sepsis,Diabetes with peripheral circulatory disorders, type II or unspecified type, uncontrolled,Renal dialysis status,Gastroparesis,Other specified cardiac dysrhythmias,Obstructive sleep apnea (adult)(pediatric),Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Depressive disorder, not elsewhere classified
Gram-neg septicemia NOS,Septic shock,Encephalopathy NOS,End stage renal disease,Ath ext ntv art gngrene,Ac osteomyelitis-ankle,Hyp kid NOS w cr kid V,Acidosis,Comp-oth vasc dev/graft,Severe sepsis,DMII circ uncntrld,Renal dialysis status,Gastroparesis,Cardiac dysrhythmias NEC,Obstructive sleep apnea,Crnry athrscl natve vssl,Old myocardial infarct,Depressive disorder NEC
Admission Date:  [**2193-8-7**]              Discharge Date:   [**2193-8-28**]

Date of Birth:  [**2138-3-6**]             Sex:   F

Service: MEDICINE

Allergies:
Lisinopril

Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Right leg pain

Major Surgical or Invasive Procedure:
R BKA [**8-27**]
PICC
triple lumen Left IJ CVL

History of Present Illness:
Ms. [**Known lastname 37559**] is a 55 yo W with PMH of ESRD on HD, PVD, DM, renal
cell ca, presents with RLE pain x 1 week, n/v and abdominal
tenderness. She reports sharp pain in ankle, toes, calf and knee
for approx. 1 week. Nothing improves or exacerbates symptoms.
She notes some swelling throughout but denies joint swelling or
redness. No fevers or chills. She has not had similar symptoms
in the past. No trauma to the area. She is non ambulatory at
baseline. Pt presented to ED from nursing home for further
evaluation.

Also reports nausea and vomiting x1 day. Took compazine in AM
which improved symptoms. No abdominal pain or diarrhea. Has been
eating per baseline.
In the ED, VS: 98/51 58 15 98 RA. She had XR lower leg, CT
abd/pelvis negative for abnormalities. CXR without infiltrate.
BP was in the 100s. EKG was without ischemic changes. BP ranging
from sys 60-100s. Received approximately 750cc NS in ED.
Received vanco and zosyn for concern for sepsis. Received
dilaudid 2mg PO x 1 with some relief. Compazine before arrival.
Wears O2 at baseline.
ROS: Rash on bilateral flanks and abscess in groin


Past Medical History:
-Peripheral vascular disease s/p left SFA-DP bypass in [**2187**] for
gangrenous heel, s/p R proximal SF-proximal AT bypass in [**4-4**],
s/p L BKA in [**1-6**] for non-healing ulcer
- Left stump osteomyelitis in [**4-5**] treated with vanco/[**Last Name (un) 2830**] from
[**Date range (1) 101854**]
- H/o MRSA vertebral osteomyelitis with MRSA bacteremia
- ESRD on HD - TTSat schedule per nephrology ED note
- HTN
- CAD s/p NSTEMI
- Diabetes Mellitus
- Renal Cell Carcinoma s/p right nephrectomy
- Obesity
- Depression
- s/p CCY
- Gastric Ulcer
- Obstructive Sleep Apnea.
- Gastroparesis
- COPD on 3-4L NC baseline
- H/o ischemic colitis
- Left adrenal adenoma


Social History:
Admitted from nursing home. Has two sisters, one daughter.
[**Name (NI) **] is a former smoker with a 30 pack year history, quit 20
years ago.

Family History:
Mother died of stomach cancer in her 40s. Father had an unknown
cancer in his 70s. Stated that diabetes, high cholesterol, and
high blood pressure run in her family.


Physical Exam:
VS: T sys 140 w/ doppler HR 54 100% RA
Gen: Pleasant obese african american female in NAD
HEENT: PERRL, EOMI, o/p clear
CV: RRR, distant heart sounds
Pulm: CTABL no w/r/r
Abd: obese, soft, NT, ND; old surgical scar well healed in RLQ
Ext: L BKA; RLE with 1+ pitting edema; dopplerable DP pulse
Neuro: alert and oriented x 3, moving all extremities, CNs [**1-10**]
intact; no focal deficits
SKIN: intertriginous erythema
GYN: firm purulent abscess over right labia


Pertinent Results:
LABS:
[**2193-8-7**] 01:35PM BLOOD WBC-9.1# RBC-3.30* Hgb-10.1* Hct-33.1*
MCV-100* MCH-30.6 MCHC-30.5* RDW-16.0* Plt Ct-136*
[**2193-8-7**] 01:35PM BLOOD Neuts-83.9* Lymphs-13.3* Monos-2.6
Eos-0.1 Baso-0.2
[**2193-8-7**] 01:35PM BLOOD Glucose-131* UreaN-28* Creat-4.8* Na-142
K-3.6 Cl-101 HCO3-28 AnGap-17
[**2193-8-7**] 01:35PM BLOOD CK(CPK)-35
[**2193-8-7**] 01:35PM BLOOD cTropnT-0.27*
[**2193-8-7**] 10:02PM BLOOD CK-MB-3 cTropnT-0.24*
[**2193-8-8**] 05:01AM BLOOD CK-MB-NotDone cTropnT-0.24*
[**2193-8-8**] 05:01AM BLOOD Calcium-7.9* Phos-5.9* Mg-1.8
[**2193-8-7**] 01:44PM BLOOD Lactate-2.0

STUDIES:
Right Tib/Fib/Knee Xray: IMPRESSION: = 1. Diffuse severe
osteopenia, making evaluation for subtle fracture suboptimal.
Given this, no evidence of acute fracture. No dislocation or
suprapatellar joint effusion.

Doppler LE- Right: IMPRESSION: No evidence of DVT.

CTA Abdomen: IMPRESSION: 1. No evidence of acute mesenteric
ischemia or ischemic colitis. 2. Nonspecific cecal thickening;
consider correlation with colonoscopy. 3. Stable extensive
vascular calcifications. 4. Stable 1 cm enhancing splenic
lesion, may represent hemangioma or hamartoma.

Graft Duplex Ultrasound: The patient's prior right-sided lower
extremity graft is not visualized, the native superficial
femoral artery on the right is visualized with a monophasic
waveform indicating distal ischemia. Please note, these findings
are similar to a prior exam of [**2191-7-4**].

CT Head: No hemorrhage, no acute intracranial pathology.
.
Echo [**8-28**] There is severe regional left ventricular systolic
dysfunction with severe hypokinesis/akinesis of the distal half
of the left ventricle. The right ventricular cavity is markedly
dilated with severe global free wall hypokinesis (with
perservation of the very base of the right ventricle). There is
abnormal septal motion/position. The aortic valve leaflets (3)
are mildly thickened. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. Moderate to
severe [3+] tricuspid regurgitation is seen. There is at least
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.

Compared with the prior study (images reviewed) of [**2193-8-15**] and
[**2193-2-22**], the right ventricular function is similar with
increased severity of tricuspid regurgitation. The left
ventricular systolic function has worsened.
.
[**2193-8-25**] 5:02 am BLOOD CULTURE      Source: Line-picc.

   Blood Culture, Routine (Preliminary):
      GRAM NEGATIVE ROD(S).    OF TWO COLONIAL MORPHOLOGIES.
      GRAM NEGATIVE ROD #2.    POSSIBLE SECOND MORPHOLOGY.

   Aerobic Bottle Gram Stain (Final [**2193-8-26**]):
      REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 0314 ON [**8-26**] - [**Numeric Identifier 100088**].
      GRAM NEGATIVE ROD(S).

   Anaerobic Bottle Gram Stain (Final [**2193-8-26**]):    GRAM
NEGATIVE ROD(S).


Brief Hospital Course:
Ms. [**Known lastname 37559**] is a 54 yo female with ESRD on HD, HTN, DM, OSA,
COPD, obesity, PVD admitted for right lower extremity pain,
hypotension at dialysis and somnolence.

#. Hypotension: Patient noted to be hypotensive on arrival to ED
though asymptomatic. Accurate blood pressures are difficult to
attain given patient's obesity and vascular disease. On initial
arrival to the MICU, her blood pressure was manually
140/doppler.  However, automatic readings were much lower. It is
unclear whether this was a true episode of hypotension or
whether measurements were not accurate.  She had occasional
episodes of hypotension with SBP's in the 80's that seemed to
occur after hemodialysis.  Her blood pressure returned to [**Location 213**]
range with 500cc boluses of normal saline.  She also had
episodes of hypertension with SBP's measured in the 200-300
range.  However, it was not clear if these readings were
accurate and the patient remained asymptomatic throughout these
episodes.  She was continued on metoprolol throughout the
hospitalization, although this was held on days that she was
dialyzed. O

#. Leg pain: She presented with 1 week of right lower extremity
pain without history of trauma and without evidence of DVT on
ultrasound.  She was initially managed with percocet for pain,
which caused her to become sleepy if given more than one tab at
a time.  As she has a graft in this leg, vascular surgery was
consulted for possible arterial occlusion.  A graft duplex study
showed no flow in her prior graft, and she was started on a
heparin drip.  She then underwent RLE angiogram which showed
some flow through her graft, and vascular surgery felt that
arterial occlusion was unlikely to be causing her symptoms.
Therefore, her pain was attributed to diabetic neuropathy.  Her
dose of gabapentin was increased, and she was given lidoderm
patches for her foot daily.  She was also started on keppra for
neuropathic pain.  Her pain remained uncontrolled.  She then
developed skin breakdown on the dorsum of her toes.  Her toes
began to appear infected with purulent, malodorous drainage and
she was treated with IV Vancomycin and Unasyn.  Vascular surgery
was reconsulted and felt it was most likely a diabetic ulcer.
Amputation was considered.

#. Episodes of decreased responsiveness: She had multiple
episodes of increased somnolence during her hospital stay.  She
was minimally responsive to sternal rub during these episodes
but would wake up to noxious stimuli (such as getting stuck for
an arterial blood gas).  She had a head CT and MRI which showed
no acute process.  Neurology was consulted due to concern for
possible seizures vs other neurological process.  They felt that
her episodes were not likely seizures and could represent
syncopal episodes or arrhythmias.  She was monitored on
telemetry and no events were noted.  Her blood sugars were in
the normal range during these episodes.  They were ultimately
thought to be a combination of pain, sedating medications,
depression, and possibly occult infection.  Her seroquel was
decreased, narcotics were stopped, and her reglan was
discontinued.  She continued to be somnolent at times and this
was of unclear etiology.

#. Hearing difficulty: She had episodes of decreased hearing
during hospitalization.  During the first episode, there was
some concern for an acute bleed in her head as she had recently
been started on a heparin drip.  A stat head CT was done which
showed no acute intracranial process or bleed.  It was felt that
her hearing difficulty was likely related to earwax obstruction
or congestion.  Her ears were cleaned out with liquid colace and
curettes and her hearing slightly improved but she continued to
have bilateral hearing difficulty.  It was arranged for her to
have an audiology evaluation while an inpatient.

#. Bacteremia: She had one positive blood culture that grew
Coagulase-negative Staph aureus.  She was started on vancomycin
for treatment but no immediate clinical improvement was noted.
It is unclear whether this positive blood culture was a
contaminant.  She subsequently grew GNR in her blood.

#. CAD: She had an elevated troponin on admission, but her ECG
was at baseline.  Her troponin increased during her hospital
stay and there was concern for a cardiovascular cause of her
episodes of decreased responsiveness.  Her ECG showed some ST-T
changes.  Cardiology was consulted who felt that her troponin
elevation was due to her renal disease and she did not likely
have an acute event while in the hospital.  She had a repeat TTE
which was a limited study due to lack of patient cooperation.
However, it showed new wall motion abnormalities compared to
previous.  Cardiology felt that the timeline of these
abnormalities could not be determined and recommended
conservative managemend with statin, aspirin, and beta blocker.
She also had been on Plavix on admission for a recent NSTEMI and
they recommended continuing this treatment.

#. Nausea/Vomiting: She has a history of gastroparesis and had a
short episode of nausea and vomiting prior to presentation.  CT
abdomen showed no acute pathology.  She was given reglan to
increase motility and her symptoms improved.  However, reglan
was later discontinued due to concern for contributing to her
episodes of decreased responsiveness.  She had one subsequent
episode of vomiting after her family brought her a large meal
from McDonald's.

#. Diabetes: She was placed on a diabetic diet and an insulin
sliding scale without complication.

#. ESRD on HD: She continued on hemodialysis on Tues, Thurs, Sat
while in the hospital.  She refused one dialysis session and
dialysis was delayed without complication.

#. COPD: On 3-4L NC at home, continued as needed although she
did not typically require oxygen supplementation and her O2 sats
were 93-94% RA.

#. OSA: Patient refused CPAP multiple times during her
hospitalization, but did wear it on some nights.

#. Depression: Continued on seroquel and remeron.  Her seroquel
dose was decreased due to concern that it was sedating her and
contributing to her episodes of decreased responsiveness.

#. MICU TRANSFER. Ms. [**Known lastname 37559**] was transfered to the MICU for
decreased mentation and difficulty measuring blood pressures in
the setting of GNR bacteremia.  Arterial catheterization
confirmed hypotension, and her shock was treated with
vasopressors and fluid resuscitation.  The source of infection
was believed to be her Right foot with wet gangrene. She was
covered broadly with Gent/[**Last Name (un) **]/Vanc. Vascular took patient to OR
for right BKA.

However her lactate continued to climb and she became
progressively hypotensive requiring multiple vasopressors for
blood pressure support. An echocardiogram showed both RV
hypokinesis and LV hypokinesis.  Given a known RIJ clot, a
lactate that had risen above 7, and prior history of ischemic
colitis, differential included pulmonary embolism, ischemic
bowel, and myocardial ischemia.  She was taken emergently for CT
scan to evaluate for PE and ischemic bowel, but arrested during
the scan.  Family was brought into the arrest with the support
of social work. CT was negative for PE and ischemic bowel, and
cardiology was consulted for consideration of cath.  With full
ACLS, she had return of spontaneous circulation and was brought
back to the ICU. However, she again arrested and was unable to
be resuscitated.

Medications on Admission:
Lactulose 30 mg prn
Seroquel 25 mg q 12 hour
Sensipar 60 mg daily
Renagel 2400 TIDWF
Zemplar 4 mcg MWF IV
Nitropaste prn
Novolog sliding scale
HSQ
Senokot 1 [**Hospital1 **]
Reglan 5 mg TID
Nexium 20 mg daily
Colace 100 mg daily
Zocor 10 mg daily
Lopressor 12.5 q 12 hours
Lovenox 40 mg daily
Aranesp 100 Mo
Remeron 15 mg qhs
Duralgesic 75 mcq q3day
Aspirin 81 daily
Nephrocaps 1 daily
Ambien 5 mg
Ultram 50 [**Hospital1 **]
Perocet 2 tabs q6hours
Neuronitn 300mg prn
Insulin Novolog 8, 8, and 10 units before meals and sliding
scale.
Paricalcitol 6 mg q HD


Discharge Medications:
expired

Discharge Disposition:
Expired

Discharge Diagnosis:
expired

Discharge Condition:
expired

Discharge Instructions:
expired

Followup Instructions:
expired

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]

Completed by:[**2193-8-29**]
{'Septicemia due to gram-negative organism, unspecified,Septic shock,Encephalopathy, unspecified,End stage renal disease,Atherosclerosis of native arteries of the extremities with gangrene,Acute osteomyelitis, ankle and foot,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Acidosis,Other complications due to other vascular device, implant, and graft,Severe sepsis,Diabetes with peripheral circulatory disorders, type II or unspecified type, uncontrolled,Renal dialysis status,Gastroparesis,Other specified cardiac dysrhythmias,Obstructive sleep apnea (adult)(pediatric),Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Depressive disorder, not elsewhere classified'}


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: Right leg pain

PRESENT ILLNESS: Ms. [**Known lastname 37559**] is a 55 yo W with PMH of ESRD on HD, PVD, DM, renal
cell ca, presents with RLE pain x 1 week, n/v and abdominal
tenderness. She reports sharp pain in ankle, toes, calf and knee
for approx. 1 week. Nothing improves or exacerbates symptoms.
She notes some swelling throughout but denies joint swelling or
redness. No fevers or chills. She has not had similar symptoms
in the past. No trauma to the area. She is non ambulatory at
baseline. Pt presented to ED from nursing home for further
evaluation.

MEDICAL HISTORY: -Peripheral vascular disease s/p left SFA-DP bypass in [**2187**] for
gangrenous heel, s/p R proximal SF-proximal AT bypass in [**4-4**],
s/p L BKA in [**1-6**] for non-healing ulcer
- Left stump osteomyelitis in [**4-5**] treated with vanco/[**Last Name (un) 2830**] from
[**Date range (1) 101854**]
- H/o MRSA vertebral osteomyelitis with MRSA bacteremia
- ESRD on HD - TTSat schedule per nephrology ED note
- HTN
- CAD s/p NSTEMI
- Diabetes Mellitus
- Renal Cell Carcinoma s/p right nephrectomy
- Obesity
- Depression
- s/p CCY
- Gastric Ulcer
- Obstructive Sleep Apnea.
- Gastroparesis
- COPD on 3-4L NC baseline
- H/o ischemic colitis
- Left adrenal adenoma

MEDICATION ON ADMISSION: Lactulose 30 mg prn
Seroquel 25 mg q 12 hour
Sensipar 60 mg daily
Renagel 2400 TIDWF
Zemplar 4 mcg MWF IV
Nitropaste prn
Novolog sliding scale
HSQ
Senokot 1 [**Hospital1 **]
Reglan 5 mg TID
Nexium 20 mg daily
Colace 100 mg daily
Zocor 10 mg daily
Lopressor 12.5 q 12 hours
Lovenox 40 mg daily
Aranesp 100 Mo
Remeron 15 mg qhs
Duralgesic 75 mcq q3day
Aspirin 81 daily
Nephrocaps 1 daily
Ambien 5 mg
Ultram 50 [**Hospital1 **]
Perocet 2 tabs q6hours
Neuronitn 300mg prn
Insulin Novolog 8, 8, and 10 units before meals and sliding
scale.
Paricalcitol 6 mg q HD

ALLERGIES: Lisinopril

PHYSICAL EXAM: VS: T sys 140 w/ doppler HR 54 100% RA
Gen: Pleasant obese african american female in NAD
HEENT: PERRL, EOMI, o/p clear
CV: RRR, distant heart sounds
Pulm: CTABL no w/r/r
Abd: obese, soft, NT, ND; old surgical scar well healed in RLQ
Ext: L BKA; RLE with 1+ pitting edema; dopplerable DP pulse
Neuro: alert and oriented x 3, moving all extremities, CNs [**1-10**]
intact; no focal deficits
SKIN: intertriginous erythema
GYN: firm purulent abscess over right labia

FAMILY HISTORY: Mother died of stomach cancer in her 40s. Father had an unknown
cancer in his 70s. Stated that diabetes, high cholesterol, and
high blood pressure run in her family.

SOCIAL HISTORY: Admitted from nursing home. Has two sisters, one daughter.
[**Name (NI) **] is a former smoker with a 30 pack year history, quit 20
years ago. 

### Response:
{'Septicemia due to gram-negative organism, unspecified,Septic shock,Encephalopathy, unspecified,End stage renal disease,Atherosclerosis of native arteries of the extremities with gangrene,Acute osteomyelitis, ankle and foot,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Acidosis,Other complications due to other vascular device, implant, and graft,Severe sepsis,Diabetes with peripheral circulatory disorders, type II or unspecified type, uncontrolled,Renal dialysis status,Gastroparesis,Other specified cardiac dysrhythmias,Obstructive sleep apnea (adult)(pediatric),Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Depressive disorder, not elsewhere classified'}
